PONE-D-24-02817Noninvasive vs invasive respiratory support for patients with acute hypoxemic respiratory failurePLOS ONE

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This work was supported by an Emergency Medicine Foundation grant sponsored by Fisher & Paykel, and in part by the National Science Foundation under grant #1838745 and the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number 5T32HL007955. Neither funding agency or sponsor was involved in the design or conduct of the study or interpretation and presentation of the results. 

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Additional Editor Comments:

Dear Authors

This retrospective study on patients with acute hypoxemic respiratroy support who were treated as first with invasive or noninvasive ventilation answered to may interesting questions It is well designed and written and brings some interesting answers to yours questions. Both reviewers are of the same opinion as meed but found somme issues to be discussed or elaborated.

I'm looking forward hearing from you soon.

Kind regards.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Mosier and co-authors explored the outcomes of patients affected by acute hypoxemic respiratory failure treated with NIRS (noninvasive respiratory supports) compared to patients initially treated with IMV (invasive mechanical ventilation). They found that initial treatment with NIRS is not associated with a reduced in-hospital death when compared to IMV, but NIRS treatment is associated with a higher likelihood of earlier hospital discharge.

The authors should be commended for the work they have performed. However, I believe that there is a major issue to resolve:

It is not clear if cases analyzed are “de novo acute hypoxemic respiratory failure”, exacerbations or a mix of cases. In the introduction section authors correctly referred to the use of NIRS in acute exacerbation of COPD or acute cardiogenic pulmonary oedema, and in “de novo” hypoxemic respiratory failure (lines 94-99, page 3). However, having a look at data presented in table 1, it comes out that the median pH of the included population is 7.31 (IMV) and 7.33 (NIV). This potentially correlates with the level of CO2 found (46 vs 53). Taking into account that bicarbonate levels were pretty normal or even higher in the noninvasive group, this means that most of the patients were affected already by a chronic respiratory condition. Indeed, 78% and 16% in IMV and 85% and 18% in noninvasive group were respectively COPD or obese. Surprisingly, only 0% was affected by acute respiratory conditions as influenza, and no ARDS patients were enlisted in the retrieved data.

In conclusion, it seems that there is no distinction between de novo and acute exacerbations of chronic condition, and that the majority of this cohort of patients analyzed is affected by exacerbation of chronic condition. I believe that this distinction and a subanalysis of specific populations should also be considered (obesity, COPD, etc).

Reviewer #2: This is an interesting retrospective comparison of in-hospital mortality and the discharge alive of patients with acute respiratory failure treated initially either with noninvasive respiratory support or with invasive mechanical ventilation and deserves to be published. Noninvasive respiratory was associated with more discharges alive, but no reduction in in-hospital mortality at the expense of the high-flow nasal oxygen (HFNO) therapy group. Due to the retrospective nature of the study, treatment with NHFO was problematic and inadequate in relation to the need for respiratory support. Thus, the results do not reflect the actual effectiveness of NHO therapy. It is true, however, that the data comes from real life, even from the pre-Covid-19 period. In addition to the benefits of HFNO in preventing intubation, prior studies have already demonstated the deleterous effect with inadequate use of HFNO. Meanwhile, the knowledge and the way of using NHFO has improved. The authors have already discussed in details the limitations of the study. One of the important issues is the imbalance of the groups. HFNO was the ceiling treatment for terminal-stage diseased patients irrespective of the severity of respiratory failure. Thus, the inclusion criteria for NIPPV group and HFNO group differ significantly as does the outcome.

The authors should address the perspectives of the study in discussion: When is it safe to start HFNO in acute respiratory failure? When to escalate from HFNO to NIPPV or to MV? Is a stepwise approach the right one?

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Reviewer #1: No

Reviewer #2: No

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Noninvasive vs invasive respiratory support for patients with acute hypoxemic respiratory failure

PONE-D-24-02817R1

Dear Dr. Mosier,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Stefan Grosek, Ph.D., M.D.,

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: (No Response)

Reviewer #2: All the questions were adequately answered. There are no concerns regarding publication ethics and research ethics

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Andreja Sinkovič

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