As doctors brace for second wave of COVID-19, they have a new approach: High-flow nasal cannula

Treatment of COVID-19 has been a medical puzzle for front-line doctors largely learning about the disease in real-time without proven protocols. During the first crush of COVID-19, physicians in the U.S. relied heavily on mechanical ventilation to rescue oxygen-starved patients.

Patients with COVID-19 can struggle to get enough oxygen due to the severe lung damage caused by the virus, explained Scott Kopec, a pulmonology and critical care physician and former director of the pulmonary and critical care fellowship program at the University of Massachusetts. Mechanical ventilation offers breathing support via a tube placed down the windpipe into the lungs.

As doctors got a crash course in the new disease, their stance on ventilators began to evolve.

Ventilators are suggested for the most severe cases where complete assisted breathing is necessary. But a less intrusive form of oxygen delivery -- "high-flow nasal cannula” -- is showing positive results.

While in the beginning days of COVID-19 early ventilator use was considered a best practice, the complexity of the disease made ventilator use challenging.

Despite doctors' best efforts, survival statistics for COVID-19 patients on ventilators told a grim story: only about a third survived, according to the Intensive Care National Audit and Research Centre.

With the help of patient data from around the world, the approach to COVID-19 respiratory failure evolved and using a ventilator early fell out of favor.

"The most important part of practicing good medicine is to follow the science and being flexible to change when the data shows it will save lives," said Ashely Alker, an emergency medicine physician and chief medical media officer of Doctorpedia.

High-flow nasal cannula (HFNC) was already available and started to show positive results. It's breathing support system that delivers oxygen at a high flow rate and it soon became the preferred first choice of the Society for Critical Care Medicine. An HFNC device straps around the head and inserts a plastic prong into each nostril through which oxygen flows -- quite different from mechanical ventilation that pushes air directly into the lungs.

And while high-flow nasal cannula cannot completely take over a person's breathing like a ventilator, it's less invasive, has fewer dangerous complications and is sometimes enough breathing support for a patient to recover. In a study of critically ill patients with COVID-19 in Chongqing, China, high-flow nasal cannula effectively avoided ventilator use for the majority of patients.

“The data offered new solutions," said Alker.

The shift away from early ventilator use was a timely development as national ventilator shortages became critical. But some manufacturers of high-flow nasal cannula faced a dilemma.

Hospitals across the globe were suddenly ordering high flow nasal cannula and manufacturers struggled to keep up with sudden worldwide demand.

“We were just inundated," said Joe Army, president and CEO of Vapotherm, one company that manufactures high-flow nasal cannula units.

With COVID-19 hospitalizations rising in some states and the possibility of a second wave on the horizon, high-flow nasal cannula manufacturers are preparing.

WestMed, another manufacturer of high-flow nasal cannula, says on its website that the need for its devices is at an "all-time high" and that "additional manufacturing capacity has been added and our production facilities are now running 24/7."

Vapotherm, meanwhile, is expanding its New Hampshire facility to scale up manufacturing capacity to 20 times pre-COVID-19 levels, creating up to 350 new jobs. In May it entered a $9.9 million blanket purchase agreement with the U.S Department of Defense to supply high-flow nasal cannula units to the nation's 51 Department of Defense hospitals.

“We don't have a point of view around, you know, if there is going to be a second wave or not. I am hoping desperately that as a people we will find a vaccine for this, but I think it's foolish on our part to plan for that," Army said. "If hospitals around the world experience another surge, we are prepared to take care of them.”

If or when a second COVID-19 wave comes, physicians will once again let science and data be their guide.

Nancy A. Anoruo, MD, MPH, is an internal medicine physician, public health scientist and contributor/journalist for ABC News Medical Unit.