Lack of Benefit of High Flow Nasal Oxygen Therapy as Ceiling of Treatment for Severe COVID-19 Pneumonitis in Elderly Frail Patients: A Single Centre Observational Study

Fatema Merchant#, 1, Akash Mavilakandy#, 1, Harvinder S. Virk#, 2, Sajid Khan1, Georgios Tsaknis1, Muhammad Naeem1, Srikumar Mallik1, Kirsty Datson1, Raja Reddy1, *
1 Respiratory Medicine, Kettering General Hospital NHS Foundation Trust, Kettering, UK
2 Respiratory Sciences Department, University of Leicester, Glenfield Hospital, Leicester, UK

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© 2022 Merchant et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

* Address correspondence to this author at the Respiratory Medicine, Kettering General Hospital NHS Foundation Trust, Kettering, UK E-mails:,
# These authors contributed equally to this work



Severe COVID-19 pneumonitis in elderly frail patients is associated with poor outcomes, and therefore invasive mechanical ventilation is often deemed an inappropriate course of action. Some evidence suggests high-flow nasal oxygen (HFNO) may prevent the need for invasive ventilation in other groups of patients, but whether it is an appropriate ceiling of care for older frail patients is unknown.


We retrospectively identified patients with severe COVID-19 pneumonitis requiring FiO2>60% who were deemed inappropriate for invasive ventilation or non-invasive continuous positive airway pressure ventilation (CPAP). Our local protocol based on national guidance suggested these patients should be considered for HFNO. We observed whether the patients received HFNO or standard oxygen therapy (SOT) and compared mortality and survival time in these groups.


We identified 81 patients meeting the inclusion criteria. From this group, 24 received HFNO and 57 received SOT. The HFNO group was similar in age, BMI and co-morbidities to the SOT group but less frail, as determined by the Clinical Frailty Scale (CFS). All 24 patients that received HFNO died in comparison to 46 patients (80.7%) in the SOT group. Mortality in the HFNO group was significantly higher than in the SOT group.


Elderly frail patients with severe COVID-19 pneumonitis deemed inappropriate for invasive ventilation and did not benefit from HFNO. Further, HFNO may have been associated with harm in this group.

Keywords: COVID-19, Ventilation, HFNO group, Patients, SOT, CPAP.