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Al Nufaiei ZF, Al Zhranei RM. High-Flow Nasal Cannula Oxygen Therapy versus Non-Invasive Ventilation in patients at very high risk for extubating failure: A systematic review of randomized controlled trials. PLoS One 2024; 19:e0299693. [PMID: 38568930 PMCID: PMC10990192 DOI: 10.1371/journal.pone.0299693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 02/15/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Mechanical ventilation is commonly used for managing respiratory failure in chronic obstructive pulmonary disease (COPD) patients, but weaning patients off ventilator support can be challenging and associated with complications. While many patients respond well to Non-invasive ventilation (NIV), a significant proportion may not respond as favourably. We aimed to assess whether high-flow nasal cannula (HFNC) is equally effective as NIV in reducing extubation failure among previously intubated COPD patients. METHODS This systematic review was carried out in line with PRISMA guidelines We searched PubMed, Scopus, Web of Science, and Cochrane library from inception until February 15, 2023. Randomized Clinical Trials (RCTs) of adults at high risk for extubating failure were included. We examined the use of HFNC as the intervention and NIV as the comparator. Our outcome of interest included, reintubation rate, length of hospital or intensive care unit (ICU) stay, adverse events, and time to reintubation. The Cochrane risk-of-bias tool was used for randomized trials to assess risk of bias. RESULTS We identified 348 citations, 11 of which were included, representing 2,666 patients. The trials indicate that HFNC is comparable to NIV in preventing reintubation after extubating in COPD patients. In comparison to NIV, HFNC also produced improved tolerance, comfort, and less complications such as airway care interventions. NIV with active humification may be more effective that HFNC in avoiding reintubation in patients who are at extremely high risk for extubating failure. CONCLUSION The inconclusive nature of emerging evidence highlights the need for additional studies to establish the efficacy and suitability of HFNC as an alternative to NIV for previously intubated COPD patients. Clinicians should consider the available options and individualize their approach based on patient characteristics. Future research should focus on addressing these gaps in knowledge to guide clinical decision-making and optimize outcomes for this patient population.
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Affiliation(s)
- Ziyad F. Al Nufaiei
- College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
- Ministry of the National Guard—Health Affairs, Jeddah, Saudi Arabia
| | - Raid M. Al Zhranei
- College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
- Ministry of the National Guard—Health Affairs, Jeddah, Saudi Arabia
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Zhou SJ, Chen XH, Liu YY, Chen Q, Zheng YR, Zhang QL. Comparison of high-flow nasal cannula oxygenation and non-invasive ventilation for postoperative pediatric cardiac surgery: a meta-analysis. BMC Pulm Med 2024; 24:92. [PMID: 38383357 PMCID: PMC10882916 DOI: 10.1186/s12890-024-02901-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 02/08/2024] [Indexed: 02/23/2024] Open
Abstract
OBJECTIVE To evaluate the efficacy of high-flow nasal cannula oxygenation (HFNC) versus non-invasive ventilation (NIV) in pediatric patients post-congenital heart surgery (CHS) through a meta-analysis. METHODS A comprehensive literature search was conducted across the Chinese biomedical literature database, Vip database, CNKI, Wanfang, PubMed, Embase, Cochrane Library, and Web of Science until December 20, 2022. We selected RCTs or cohort studies that met inclusion criteria for a meta-analysis using RevMan 5.4 software. RESULTS Our search yielded five publications, comprised of one randomized controlled trial and four cohort studies. Meta-analysis revealed a significant reduction in reintubation rates in children post-CHS treated with HFNC as compared to NIV [RR = 0.36, 95%CI(0.25 ~ 0.53), P < 0.00001]. There was also a notable reduction in the duration of ICU stay [MD = -4.75, 95%CI (-9.38 ~ -0.12), P = 0.04]. No statistically significant differences were observed between HFNC and NIV in terms of duration of mechanical ventilation, 24 h PaO2, and PaCO2 post-treatment (P > 0.05). Furthermore, both groups showed no significant difference in the duration of extracorporeal circulation [MD = -8.27, 95%CI(-17.16 ~ 0.62), P = 0.07]. CONCLUSIONS For pediatric patients post-CHS, HFNC appears to be more effective than NIV in reducing reintubation rates and shortening the CICU stay.
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Affiliation(s)
- Si-Jia Zhou
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Xiu-Hua Chen
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Ying-Ying Liu
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Qiang Chen
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Yi-Rong Zheng
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China.
| | - Qi-Liang Zhang
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China.
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3
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Kuitunen I, Salmi H, Wärnhjelm E, Näse-Ståhlhammar S, Kiviranta P. High-flow nasal cannula use in pediatric patients for other indications than acute bronchiolitis-a scoping review of randomized controlled trials. Eur J Pediatr 2024; 183:863-874. [PMID: 37962672 PMCID: PMC10912153 DOI: 10.1007/s00431-023-05234-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 09/06/2023] [Accepted: 09/19/2023] [Indexed: 11/15/2023]
Abstract
The objective of the study is to summarize current literature on high-flow nasal cannula (HFNC) use for different indications in pediatric patient excluding acute bronchiolitis and neonatal care. The study design is a systematic scoping review. Pubmed, Scopus, and Web of Science databases were searched in February, 2023. All abstracts and full texts were screened by two independent reviewers. Randomized controlled trials focusing on HFNC use in pediatric patients (age < 18 years) were included. Studies focusing on acute bronchiolitis and neonatal respiratory conditions were excluded. Study quality was assessed by Cochrane risk of bias 2.0 tool. The main outcomes are patient groups and indications, key outcomes, and risk of bias. After screening 1276 abstracts, we included 22 full reports. Risk of bias was low in 11 and high in 5 studies. We identified three patient groups where HFNC has been studied: first, children requiring primary respiratory support for acute respiratory failure; second, perioperative use for either intraprocedural oxygenation or postoperative respiratory support; and third, post-extubation care in pediatric intensive care for other than postoperative patients. Clinical and laboratory parameters were assessed as key outcomes. None of the studies analyzed cost-effectiveness.Conclusion: This systematic scoping review provides an overview of current evidence for HFNC use in pediatric patients. Future studies should aim for better quality and include economic evaluation with cost-effectiveness analysis.Protocol registration: Protocol has been published https://osf.io/a3y46/ .
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Affiliation(s)
- Ilari Kuitunen
- Institute of Clinical Medicine and Department of Pediatrics, University of Eastern Finland, Puijonlaaksontie 2, 70210, Kuopio, Finland.
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland.
| | - Heli Salmi
- Department of Pediatrics, Helsinki Childrens Hospital, Helsinki, Finland
| | - Elina Wärnhjelm
- Department of Anesthesiology, Helsinki Childrens Hospital, Helsinki, Finland
| | | | - Panu Kiviranta
- Institute of Clinical Medicine and Department of Pediatrics, University of Eastern Finland, Puijonlaaksontie 2, 70210, Kuopio, Finland
- Finnish Medical Society Duodecim, Helsinki, Finland
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Mukherjee D, Mukherjee R. High-Flow Nasal Cannula Oxygen Therapy in the Management of Respiratory Failure: A Review. Cureus 2023; 15:e50738. [PMID: 38111819 PMCID: PMC10727693 DOI: 10.7759/cureus.50738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2023] [Indexed: 12/20/2023] Open
Abstract
High-flow nasal cannula (HFNC) oxygen therapy is gaining traction globally as a treatment for respiratory failure. There are several physiological benefits, and there is a growing body of evidence showing improved quality of life and patient comfort with HFNC, both in acute and home settings. Due to the increased burden of long-term respiratory conditions such as chronic obstructive pulmonary disease (COPD) on healthcare systems worldwide, the role of ward-based and post-discharge interventions in the prevention of hospital readmissions is an area of increasing interest. In this narrative review, we outline the physiological effects of HFNC and assess its applications in both the hospital and home settings for acute and chronic respiratory failure. We also consider the evidence of non-invasive ventilation (NIV) versus HFNC in the hospital setting and the application of HFNC at home in stable hypercapnic respiratory failure to improve the quality of life and prevent readmissions. We also look at applications of HFNC in specific circumstances, such as the perioperative period, emergency department, and acute (mainly critical care) setting including in immunocompromised patients and palliative care.
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Affiliation(s)
- Deyashini Mukherjee
- General Internal Medicine, University Hospitals Coventry and Warwickshire, Coventry, GBR
| | - Rahul Mukherjee
- Respiratory Medicine and Physiology, Birmingham Heartlands Hospital, Birmingham, GBR
- Pulmonology, Institute of Clinical Sciences, University of Birmingham, Birmingham, GBR
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5
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Jiang L, Zhang H. The association between time definition of reintubation and patient outcomes in critically ill patients: several topics should be noticed. Crit Care 2023; 27:395. [PMID: 37845741 PMCID: PMC10577911 DOI: 10.1186/s13054-023-04680-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 10/07/2023] [Indexed: 10/18/2023] Open
Affiliation(s)
- Libing Jiang
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, 310009, China.
| | - Hongyu Zhang
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine, Key Laboratory of The Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, 310009, China
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Suclupe S, Efrain Pantoja Bustillos P, Bracchiglione J, Requeijo C, Salas-Gama K, Solà I, Merchán-Galvis A, Uya Muntaña J, Robleda G, Martinez-Zapata MJ. Effectiveness of nonpharmacological interventions to prevent adverse events in the intensive care unit: A review of systematic reviews. Aust Crit Care 2023; 36:902-914. [PMID: 36572576 DOI: 10.1016/j.aucc.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 11/09/2022] [Accepted: 11/12/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Different types of interventions have been assessed for the prevention of adverse events. However, determining which patient-safety practice is most effective can be challenging when there is no systematised evidence synthesis. An overview following the best methodological standards can provide the best reliable integrative evidence. OBJECTIVES The objective of this study was to provide an overview of effectiveness nonpharmacological interventions aimed at preventing adverse events in the intensive care unit. METHODS A review of systematic reviews (SRs) was conducted according to the Cochrane Handbook and PRISMA recommendations. PubMed, CINAHL, and Cochrane Library were searched for SRs published until March 2022. Two reviewers independently assessed the study's quality, using AMSTAR-2, and extracted data on intervention characteristics and effect on prevention of adverse events. RESULTS Thirty-seven SRs were included, and 27 nonpharmacological interventions were identified to prevent 11 adverse events. Most of the reviews had critically low methodological quality. Among all the identified interventions, subglottic secretion drainage, semirecumbent position, and kinetic bed therapy were effective in preventing ventilator-associated pneumonia; the use of earplugs, early mobilisation, family participation, and music in reducing delirium; physical rehabilitation in improving muscle strength; use of respiratory support in preventing reintubation; the use of a computerised physician order entry system in reducing risk of medication errors; and the use of heated water humidifier was effective in reducing artificial airway occlusion. CONCLUSIONS Some nonpharmacological interventions reduced adverse events in the intensive care setting. These findings should be interpreted carefully due to the low methodological quality. SRs on preventing adverse events in the intensive care unit should adhere to quality assessment tools so that best evidence can be used in decision-making.
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Affiliation(s)
- Stefanie Suclupe
- Universitat Autònoma de Barcelona, Spain; Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Spain.
| | | | - Javier Bracchiglione
- Universitat Autònoma de Barcelona, Spain; Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Spain; Interdisciplinary Centre for Health Studies (CIESAL), Universidad de Valparaíso, Chile
| | - Carolina Requeijo
- Epidemiology and Public Health Department, Hospital de La Santa Creu I Sant Pau, Institut de Recerca IIB Sant Pau, Barcelona, Spain
| | - Karla Salas-Gama
- Universitat Autònoma de Barcelona, Spain; Vall D'Hebron University Hospital, Barcelona, Spain
| | - Ivan Solà
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Spain; Epidemiology and Public Health Department, Hospital de La Santa Creu I Sant Pau, Institut de Recerca IIB Sant Pau, Barcelona, Spain; CIBER of Epidemiology and Public Health (CIBERESP), Spain
| | - Angela Merchán-Galvis
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Spain; Department of Social Medicine and Family Health, Universidad Del Cauca, Colombia
| | - Jaume Uya Muntaña
- Hospital Universitario de Bellvitge, Instituto Català de Salut, Nursing Research Group, Bellvitge Institute for Biomedical Research, Spain
| | - Gemma Robleda
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Spain; Nursing School of Barcelona, Campus Docent Sant Joan de Déu-Private Foundation, University of Barcelona, Spain
| | - Maria Jose Martinez-Zapata
- Universitat Autònoma de Barcelona, Spain; Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), Spain; CIBER of Epidemiology and Public Health (CIBERESP), Spain
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7
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Cheng K, Li W, Lu Y, Wu H, Zhou J. Effect of modified high-flow oxygen therapy on positive end-expiratory pressure and end-expiratory lung volume based on simulated lung platform. Heliyon 2023; 9:e19119. [PMID: 37636410 PMCID: PMC10450983 DOI: 10.1016/j.heliyon.2023.e19119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 08/09/2023] [Accepted: 08/11/2023] [Indexed: 08/29/2023] Open
Abstract
Objective The aim of this study was to assess the effect of modified high-flow oxygen therapy on end-expiratory lung volume (EELV) and positive end-expiratory pressure (PEEP) in tracheotomized patients with normal pulmonary, acute hypoxic respiratory failure (AHRF) or chronic obstructive pulmonary disease (COPD). Methods A ventilator and an artificial lung model were used to simulate the normal or strong inspiratory effort state of normal lung, AHRF and COPD patients. The traditional high-flow respiratory humidification therapy device connected with a standard interface (group A), and the modified therapy device added two types of resistance valves (group B, inner diameter 7.7 mm, length 24.0 mm; group C, inner diameter 7.7 mm, length 34.0 mm) to the exhalation end of the standard interface. The changes of end-expiratory lung volume (ΔEELV) and PEEP with the increase of flow rate (10 L/min, 20 L/min, 30 L/min, 40 L/min, 50 L/min, 60 L/min) in the three groups was recorded. Results Under simulated conditions of normal lung, AHRF and COPD, as the flow rate increased by using the modified therapy device, the PEEP values in all groups showed an exponential increasing trend, and the ΔEELV also increased accordingly. In addition, under the same flow rate level, the PEEP values of the two modified high-flow oxygen therapies (Group B and Group C) were significantly higher than those of the standard high-flow oxygen therapy (Group A) (p < 0.05). In the normal lung model with normal or strong inspiratory effort, and in the AHRF or COPD model with strong inspiratory effort, when the flow rate was higher than 30 L/min, the PEEP levels of Group B were significantly lower than those of Group C (p < 0.05). In the AHRF model with normal inspiratory effort, when the flow rate was between 10 L/min and 60 L/min, the PEEP levels of Group B were significantly lower than those of Group C (p < 0.05). Moreover, in the COPD model with normal inspiratory effort, the PEEP levels of Group B were significantly lower than that of Group C only when the flow rate was 60 L/min (p < 0.05). Conclusion The addition of different types of resistance valves to the high-flow exhalation end may be a feasible solution to improve the clinical efficacy of tracheotomized high-flow oxygen therapy.
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Affiliation(s)
- Kunming Cheng
- Department of Intensive Care Unit, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Wanqing Li
- Department of Operating Room, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, China
| | - Yanqiu Lu
- Department of Intensive Care Unit, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Haiyang Wu
- Department of Clinical College of Neurology, Neurosurgery and Neurorehabilitation, Tianjin Medical University, Tianjin, China
| | - Jianxin Zhou
- Department of Critical Care Unit, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100070, China
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Boscolo A, Pettenuzzo T, Sella N, Zatta M, Salvagno M, Tassone M, Pretto C, Peralta A, Muraro L, Zarantonello F, Bruni A, Geraldini F, De Cassai A, Navalesi P. Noninvasive respiratory support after extubation: a systematic review and network meta-analysis. Eur Respir Rev 2023; 32:32/168/220196. [PMID: 37019458 PMCID: PMC10074166 DOI: 10.1183/16000617.0196-2022] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 12/08/2022] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND The effect of noninvasive respiratory support (NRS), including high-flow nasal oxygen, bi-level positive airway pressure and continuous positive airway pressure (noninvasive ventilation (NIV)), for preventing and treating post-extubation respiratory failure is still unclear. Our objective was to assess the effects of NRS on post-extubation respiratory failure, defined as re-intubation secondary to post-extubation respiratory failure (primary outcome). Secondary outcomes included the incidence of ventilator-associated pneumonia (VAP), discomfort, intensive care unit (ICU) and hospital mortality, ICU and hospital length of stay (LOS), and time to re-intubation. Subgroup analyses considered "prophylactic" versus "therapeutic" NRS application and subpopulations (high-risk, low-risk, post-surgical and hypoxaemic patients). METHODS We undertook a systematic review and network meta-analysis (Research Registry: reviewregistry1435). PubMed, Embase, CENTRAL, Scopus and Web of Science were searched (from inception until 22 June 2022). Randomised controlled trials (RCTs) investigating the use of NRS after extubation in ICU adult patients were included. RESULTS 32 RCTs entered the quantitative analysis (5063 patients). Compared with conventional oxygen therapy, NRS overall reduced re-intubations and VAP (moderate certainty). NIV decreased hospital mortality (moderate certainty), and hospital and ICU LOS (low and very low certainty, respectively), and increased discomfort (moderate certainty). Prophylactic NRS did not prevent extubation failure in low-risk or hypoxaemic patients. CONCLUSION Prophylactic NRS may reduce the rate of post-extubation respiratory failure in ICU patients.
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Affiliation(s)
- Annalisa Boscolo
- Department of Medicine (DIMED), University of Padua, Padova, Italy
- Institute of Anaesthesia and Intensive Care, Padua University Hospital, Padova, Italy
- These authors contributed equally to this work
| | - Tommaso Pettenuzzo
- Institute of Anaesthesia and Intensive Care, Padua University Hospital, Padova, Italy
- These authors contributed equally to this work
| | - Nicolò Sella
- Institute of Anaesthesia and Intensive Care, Padua University Hospital, Padova, Italy
| | - Matteo Zatta
- Department of Medicine (DIMED), University of Padua, Padova, Italy
| | - Michele Salvagno
- Department of Medicine (DIMED), University of Padua, Padova, Italy
| | - Martina Tassone
- Department of Medicine (DIMED), University of Padua, Padova, Italy
| | - Chiara Pretto
- Department of Medicine (DIMED), University of Padua, Padova, Italy
| | - Arianna Peralta
- Institute of Anaesthesia and Intensive Care, Padua University Hospital, Padova, Italy
| | - Luisa Muraro
- Institute of Anaesthesia and Intensive Care, Padua University Hospital, Padova, Italy
| | | | - Andrea Bruni
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Federico Geraldini
- Institute of Anaesthesia and Intensive Care, Padua University Hospital, Padova, Italy
| | - Alessandro De Cassai
- Institute of Anaesthesia and Intensive Care, Padua University Hospital, Padova, Italy
| | - Paolo Navalesi
- Department of Medicine (DIMED), University of Padua, Padova, Italy
- Institute of Anaesthesia and Intensive Care, Padua University Hospital, Padova, Italy
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Chan KC, Yang TX, Khu KF, So CV. High-flow Nasal Cannula versus Conventional Ventilation in Laryngeal Surgery: A Systematic Review and Meta-analysis. Cureus 2023; 15:e38611. [PMID: 37284366 PMCID: PMC10239706 DOI: 10.7759/cureus.38611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2023] [Indexed: 06/08/2023] Open
Abstract
High-flow nasal cannula (HFNC) is an emerging option for maintaining oxygenation in patients undergoing laryngeal surgery, as an alternative to traditional tracheal ventilation and jet ventilation (JV). However, the data on its safety and efficacy is sparse. This study aims to aggregate the current data and compares the use of HFNC with tracheal intubation and jet ventilation in adult patients undergoing laryngeal surgery. We searched PubMed, MEDLINE (Medical Literature Analysis and Retrieval System Online, or MEDLARS Online), Embase (Excerpta Medica Database), Google Scholar, Cochrane Library, and Web of Science. Both observational studies and prospective comparative studies were included. Risk of bias was appraised with the Cochrane Collaboration Risk of Bias in Non-Randomized Studies - of Interventions (ROBINS-I) or RoB2 tools and the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for case series. Data were extracted and tabulated as a systematic review. Summary statistics were performed. Meta-analyses and trial sequential analyses of the comparative studies were performed. Forty-three studies (14 HFNC, 22 JV, and seven comparative studies) with 8064 patients were included. In the meta-analysis of comparative studies, the duration of surgery was significantly reduced in the THRIVE (Transnasal Humidified Rapid-Insufflation Ventilatory Exchange) group, but the number of desaturations, need for rescue intervention, and peak end-tidal CO2 were significantly increased compared to the conventional ventilation group. The evidence was of moderate certainty and there was no evidence of publication bias. In conclusion, HFNC may be as effective as tracheal intubation in oxygenation during laryngeal surgery in selected adult patients and reduces the duration of surgery but conventional ventilation with tracheal intubation may be safer. The safety of JV was comparable to HFNC.
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Affiliation(s)
- Kai Chun Chan
- Department of Anaesthesiology and Operating Theatre Services, Queen Elizabeth Hospital, Kowloon, HKG
| | - Timothy Xianyi Yang
- Department of Anaesthesiology and Operating Theatre Services, Queen Elizabeth Hospital, Kowloon, HKG
| | - Kin Fai Khu
- Department of Anaesthesiology, Princess Margaret Hospital, Kowloon, HKG
| | - Ching Vincent So
- Department of Anaesthesiology, Queen Mary Hospital, Hong Kong Island, HKG
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10
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Wyatt KD, Goel NN, Whittle JS. Recent advances in the use of high flow nasal oxygen therapies. Front Med (Lausanne) 2022; 9:1017965. [PMID: 36300187 PMCID: PMC9589055 DOI: 10.3389/fmed.2022.1017965] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 09/26/2022] [Indexed: 11/23/2022] Open
Abstract
High flow nasal oxygen is a relatively new option for treating patients with respiratory failure, which decreases work of breathing, improves tidal volume, and modestly increases positive end expiratory pressure. Despite well-described physiologic benefits, the clinical impact of high flow nasal oxygen is still under investigation. In this article, we review the most recent findings on the clinical efficacy of high flow nasal oxygen in Type I, II, III, and IV respiratory failure within adult and pediatric patients. Additionally, we discuss studies across clinical settings, including emergency departments, intensive care units, outpatient, and procedural settings.
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Affiliation(s)
- Kara D. Wyatt
- Scientific Consultant, Chattanooga, TN, United States
| | - Neha N. Goel
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Jessica S. Whittle
- Department of Emergency Medicine, University of Tennessee, Chattanooga, TN, United States
- Vapotherm, Inc., Exeter, NH, United States
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11
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Yao X, Wang J, Lu Y, Huang X, Du X, Sun F, Zhao Y, Xie F, Wang D, Liu C. Prediction and prognosis of reintubation after surgery for Stanford type A aortic dissection. Front Cardiovasc Med 2022; 9:1004005. [PMID: 36299868 PMCID: PMC9592067 DOI: 10.3389/fcvm.2022.1004005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/21/2022] [Indexed: 01/28/2023] Open
Abstract
Background Reintubation is a serious adverse respiratory event after Stanford type A aortic dissection surgery (AADS), however, published studies focused on reintubation after AADS are very limited worldwide. The objectives of the current study were to establish an early risk prediction model for reintubation after AADS and to clarify its relationship with short-term and long-term prognosis. Methods Patients undergoing AADS between 2016–2019 in a single institution were identified and divided into two groups based on whether reintubation was performed. Independent predictors were identified by univariable and multivariable analysis and a clinical prediction model was then established. Internal validation was performed using bootstrap method with 1,000 replications. The relationship between reintubation and clinical outcomes was determined by univariable and propensity score matching analysis. Results Reintubation were performed in 72 of the 492 included patients (14.6%). Three preoperative and one intraoperative predictors for reintubation were identified by multivariable analysis, including older age, smoking history, renal insufficiency and transfusion of intraoperative red blood cells. The model established using the above four predictors showed moderate discrimination (AUC = 0.753, 95% CI, [0.695–0.811]), good calibration (Hosmer-Lemeshow χ2 value = 3.282, P = 0.915) and clinical utility. Risk stratification was performed and three risk intervals were identified. Reintubation was closely associated with poorer in-hospital outcomes, however, no statistically significant association between reintubation and long-term outcomes has been observed in patients who were discharged successfully after surgery. Conclusions The requirement of reintubation after AADS is prevalent, closely related to adverse in-hospital outcomes, but there is no statistically significant association between reintubation and long-term outcomes. Predictors were identified and a risk model predicting reintubation was established, which may have clinical utility in early individualized risk assessment and targeted intervention.
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Affiliation(s)
- Xingxing Yao
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jin Wang
- Department of Cardiology, The Sixth People's Hospital of Luohe, Luohe, China
| | - Yang Lu
- Department of Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiaofan Huang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xinling Du
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fuqiang Sun
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yangchao Zhao
- Department of Extracorporeal Life Support Center, Department of Cardiac Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China,Yangchao Zhao
| | - Fei Xie
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China,Fei Xie
| | - Dashuai Wang
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China,Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China,*Correspondence: Dashuai Wang
| | - Chao Liu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China,Chao Liu
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Kumar A, Joshi S, Tiwari N, Kumar V, Ramamurthy H, Kumar G, Sharma V. Comparative evaluation of high-flow nasal cannula oxygenation vs nasal intermittent ventilation in postoperative paediatric patients operated for acyanotic congenital cardiac defects. Med J Armed Forces India 2022; 78:454-462. [PMID: 36267502 PMCID: PMC9577337 DOI: 10.1016/j.mjafi.2021.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/03/2021] [Indexed: 10/20/2022] Open
Abstract
Background This study aimed to compare high-flow nasal cannula (HFNC) oxygenation vs nasal intermittent ventilation (NIV) oxygenation for respiratory care after extubation in postoperative paediatric cardiac patients. Methods This study was a randomised controlled trial. One hundred twenty-one paediatric patients with acyanotic congenital heart disease undergoing corrective cardiac surgery on cardiopulmonary bypass were included in the study. Patients were randomised to receive either HFNC (AIRVO) or NIV (RAM Cannula) postextubation. Arterial blood gas was analysed at different time points perioperatively. Results Patients in both the groups were matched with respect to diagnosis and demographic profiles. Baseline hemodynamic and respiratory parameters were also similar in both the groups. Patients in HFNC/AIRVO group did not show improved carbon dioxide (CO2) washout but showed improved pO2 and pO2/FiO2 ratio immediate postextubation. Reintubation rate and other intensive care unit (ICU) complications were similar in both the groups. Conclusion Postcardiopulmonary bypass respiratory complications in paediatric patients with congenital acyanotic heart disease can be minimised with newer oxygen therapy devices such as AIRVO (HFNC) or RAM cannula (NIV). In comparison between these two, AIRVO did not show improved CO2 washout over RAM cannula; however, it did provide better oxygenation as measured by pO2 in arterial blood and pO2/FiO2 ratio immediate postextubation. Also, long-term results such as duration of mechanical ventilation and ICU stay were not affected by the choice of device.
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Affiliation(s)
- Alok Kumar
- Classified Specialist (Anaesthesia & Cardio-Thoracic Anaesthesia), Army Hospital (R&R), New Delhi, India
| | - Saajan Joshi
- Senior Advisor (Anaesthesia) & Trained in Paediatric Anaesthesia, Army Hospital (R&R), New Delhi, India
| | - Nikhil Tiwari
- Senior Advisor (Surgery) & Cardio-Thoracic Surgeon, Army Hospital (R&R), New Delhi, India
| | - Vivek Kumar
- Classified Specialist (Paediatric) & Trained in Paediatric Cardiology, Army Hospital (R&R), New Delhi, India
| | - H.R. Ramamurthy
- Senior Advisor (Paediatric) & Trained in Paediatric Cardiology, Army Hospital (R&R), New Delhi, India
| | - Gaurav Kumar
- Senior Consultant (Paediatric Cardiac Surgery), Fortis Hospital, Delhi, India
| | - Vipul Sharma
- Professor (Cardiac Anaesthesia), Dr. D.Y. Patil Medical College, Pune, India
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Zhang X, Fan A, Liu Y, Wei L. Humidified versus nonhumidified low-flow oxygen therapy in children with Pierre-Robin syndrome: A randomized controlled trial. Medicine (Baltimore) 2022; 101:e30329. [PMID: 36197167 PMCID: PMC9509148 DOI: 10.1097/md.0000000000030329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Humidification is an important process in clinical oxygen therapy. We aimed to evaluate the effects and safety of humidified versus nonhumidified low-flow oxygen therapy in children with Pierre-Robin syndrome. METHODS This study was an open-label, single-centered randomized controlled trial (RCT) with a parallel group design. The study protocol has been registered in Chinese Clinical Trial Registry (ChiCTR1900021584). The children were randomized to the humidified versus nonhumidified groups. Average arterial oxygen partial pressure (PaO2) and carbon dioxide partial pressure (PaCO2), incidence of ventilator-associated pneumonia (VAP), nasal cavity dryness, nasal mucosal bleeding and bacterial contamination of the humidified bottle, the cost of nasal oxygen therapy and duration of intensive care unit (ICU) stay were analyzed. RESULTS A total of 213 children with Pierre-Robin syndrome were included. There were no significant differences in the gender, age, weight, prematurity, duration of anesthesia and surgery duration of mandibular traction between humidified group and nonhumidified group (all P > .05). No significant differences in the average arterial PaO2 and PaCO2 level on the postoperative day 1, 2, and ICU discharge between humidified group and nonhumidified group were found (all P > .05). There were no significant differences in the incidence of nasal cavity dryness, nasal mucosal bleeding, bacterial contamination and VAP, the duration of ICU stay between humidified group and nonhumidified group (all P > .05). The cost of nasal oxygen therapy in the humidified group was significantly less than that of nonhumidified group (P = .013). CONCLUSIONS Humidifying the oxygen with cold sterile water in the low-flow oxygen therapy in children may be not necessary. Future RCTs with lager sample size and rigorous design are warranted to further elucidate the effects and safety of humidified versus nonhumidified low-flow oxygen therapy.
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Affiliation(s)
- Xin Zhang
- Surgical Intensive Care Unit, Children’s Hospital of Nanjing Medical University, Nanjing City, Jiangsu Province, China
| | - Aijuan Fan
- Surgical Intensive Care Unit, Children’s Hospital of Nanjing Medical University, Nanjing City, Jiangsu Province, China
| | - Yingfei Liu
- Surgical Intensive Care Unit, Children’s Hospital of Nanjing Medical University, Nanjing City, Jiangsu Province, China
| | - Li Wei
- Surgical Intensive Care Unit, Children’s Hospital of Nanjing Medical University, Nanjing City, Jiangsu Province, China
- * Correspondence: Li Wei, Surgical Intensive Care Unit, Children’s Hospital of Nanjing Medical University, No. 72 Guangzhou Road, Gulou District, Nanjing City, Jiangsu Province, China (e-mail: )
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Vieira F, Bezerra FS, Coudroy R, Schreiber A, Telias I, Dubo S, Cavalot G, Pereira SM, Piraino T, Brochard LJ. High Flow Nasal Cannula compared to Continuous Positive Airway Pressure: a bench and physiological study. J Appl Physiol (1985) 2022; 132:1580-1590. [PMID: 35511720 DOI: 10.1152/japplphysiol.00416.2021] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 04/04/2022] [Accepted: 05/01/2022] [Indexed: 11/22/2022] Open
Abstract
High-flow nasal cannula (HFNC) is extensively used for acute respiratory failure. However, questions remain regarding its physiological effects. We explored 1) whether HFNC produced similar effects to continuous positive airway pressure (CPAP); 2) possible explanations of respiratory rate changes; 3) the effects of mouth opening. Two studies were conducted: a bench study using a manikin's head with lungs connected to a breathing simulator while delivering HFNC flow rates from 0 to 60L/min; a physiological cross-over study in 10 healthy volunteers receiving HFNC (20 to 60L/min) with the mouth open or closed and CPAP 4cmH2O delivered through face-mask. Nasopharyngeal and esophageal pressures were measured; tidal volume and flow were estimated using calibrated electrical impedance tomography. In the bench study, nasopharyngeal pressure at end-expiration reached 4cmH2O with HFNC at 60L/min, while tidal volume decreased with increasing flow. In volunteers with HFNC at 60L/min, nasopharyngeal pressure reached 6.8cmH2O with mouth closed and 0.8cmH2O with mouth open; p<0.001. When increasing HFNC flow, respiratory rate decreased by lengthening expiratory time, tidal volume did not change, and effort decreased (pressure-time product of the respiratory muscles); at 40L/min, effort was equivalent between CPAP and HFNC40L/min and became lower at 60L/min (p=0.045). During HFNC with mouth closed, and not during CPAP, resistance to breathing was increased, mostly during expiration. In conclusion, mouth closure during HFNC induces a positive nasopharyngeal pressure proportional to flow rate and an increase in expiratory resistance that might explain the prolonged expiration and reduction in respiratory rate and effort, and contribute to physiological benefits.
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Affiliation(s)
- Fernando Vieira
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
| | | | - Remi Coudroy
- INSERM CIC 1402, ALIVE group, University of Poitiers, Poitiers, France
| | - Annia Schreiber
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Irene Telias
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Sebastian Dubo
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
| | - Giulia Cavalot
- Department of Emergency Medicine, Ospedale San Giovanni Bosco, Turin, Italy
| | - Sergio Martins Pereira
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
| | - Thomas Piraino
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
| | - Laurent Jean Brochard
- Keenan Research Centre for Biomedical Research, University of Toronto, Toronto, Ontario, Canada
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15
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Cui N, Yan X, Zhang Y, Chen D, Zhang H, Zheng Q, Jin J. Non-Pharmacological Interventions for Minimizing Physical Restraints Use in Intensive Care Units: An Umbrella Review. Front Med (Lausanne) 2022; 9:806945. [PMID: 35573001 PMCID: PMC9091438 DOI: 10.3389/fmed.2022.806945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 03/29/2022] [Indexed: 01/08/2023] Open
Abstract
Background There is a relationship between the application of physical restraints and negative physiological and psychological effects on critically ill patients. Many organizations have supported and advocated minimizing the use of physical restraints. However, it is still common practice in many countries to apply physical restraints to patients in intensive care. Objective This study aimed to assess the effectiveness of various non-pharmacological interventions used to minimize physical restraints in intensive care units and provide a supplement to the evidence summary for physical restraints guideline adaptation. Methods Based on the methodology of umbrella review, electronic databases, including Cochrane Database of Systematic Reviews, Joanna Briggs Institute Database of Systematic Reviews and Implementation Reports, MEDLINE, EMBASE, CINAHL, Web of Science, PsycInfo/Psyc Articles/Psychology and Behavioral Science Collection, China National Knowledge Infrastructure, SinoMed, and Wanfang Data, were searched to identify systematic reviews published from January 2016 to December 2020. Two independent reviewers undertook screening, data extraction, and quality appraisal. The methodological quality of systematic reviews was evaluated by AMSTAR 2. Evidence quality of each intervention was assessed according to GRADE. The corrected covered area was calculated as a measure of overlap. Results A total of 47 systematic reviews were included in the umbrella review, of which six were evaluated as high quality, five were of moderate quality, and the rest were of low or critically low quality. The corrected covered area range was from 0.0 to 0.269, which indicated that there was mild overlap between systematic reviews. The included systematic reviews evaluated various types of non-pharmacological interventions for minimizing physical restraints in intensive care units, which included multicomponent interventions involving healthcare professionals' education, family engagement/support, specific consultations and communication, rehabilitation and mobilization (rehabilitation techniques, early mobilization, inspiratory muscle training), interventions related to reducing the duration of mechanical ventilation (weaning modes or protocols, ventilator bundle or cough augmentation techniques, early tracheostomy, high-flow nasal cannula), and management of specific symptoms (delirium, agitation, pain, and sleep disturbances). Conclusion The number of systematic reviews related to physical restraints was limited. Multicomponent interventions involving healthcare professionals' education may be the most direct non-pharmacological intervention for minimizing physical restraints use in intensive care units. However, the quality of evidence was very low, and conclusions should be taken with caution. Policymakers should consider incorporating non-pharmacological interventions related to family engagement/support, specific consultations and communication, rehabilitation and mobilization, interventions related to reducing the duration of mechanical ventilation, and management of specific symptoms as part of the physical restraints minimization bundle. All the evidence contained in the umbrella review provides a supplement to the evidence summary for physical restraints guideline adaptation. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=242586, identifier: CRD42021242586.
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Affiliation(s)
- Nianqi Cui
- Department of Nursing, The Second Affiliated Hospital Zhejiang University School of Medicine (SAHZU), Hangzhou, China
| | - Xiaoli Yan
- Health Management Center, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yuping Zhang
- Department of Nursing, The Second Affiliated Hospital Zhejiang University School of Medicine (SAHZU), Hangzhou, China
| | - Dandan Chen
- Faculty of Nursing, Zhejiang University School of Medicine, Hangzhou, China
| | - Hui Zhang
- Faculty of Nursing, Zhejiang University School of Medicine, Hangzhou, China
| | - Qiong Zheng
- Faculty of Nursing, Zhejiang University School of Medicine, Hangzhou, China
| | - Jingfen Jin
- Department of Nursing, The Second Affiliated Hospital Zhejiang University School of Medicine (SAHZU), Hangzhou, China
- Key Laboratory of the Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, China
- Changxing Branch Hospital of SAHZU, Huzhou, China
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Joffe A, Barnes CR. Extubation of the potentially difficult airway in the intensive care unit. Curr Opin Anaesthesiol 2022; 35:122-129. [PMID: 35191402 DOI: 10.1097/aco.0000000000001119] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Extubation in the intensive care unit (ICU) is associated with a failure rate requiring reintubation in 10-20% patients further associated with significant morbidity and mortality. This review serves to highlight recent advancements and guidance on approaching extubation for patients at risk for difficult or failed extubation (DFE). RECENT FINDINGS Recent literature including closed claim analysis, meta-analyses, and national society guidelines demonstrate that extubation in the ICU remains an at-risk time for patients. Identifiable strategies aimed at optimizing respiratory mechanics, patient comorbidities, and airway protection, as well as preparing an extubation strategy have been described as potential methods to decrease occurrence of DFE. SUMMARY Extubation in the ICU remains an elective decision and patients found to be at risk should be further optimized and planning undertaken prior to proceeding. Extubation for the at-risk patient should be operationalized utilizing easily reproducible strategies, with airway experts present to guide decision making and assist in reintubation if needed.
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Affiliation(s)
- Aaron Joffe
- Department of Anesthesiology & Pain Medicine, Harborview Medical Center, Seattle, Washington
- Banner MD Anderson Cancer Center, Gilbert, Arizona, USA
| | - Christopher R Barnes
- Department of Anesthesiology & Pain Medicine, Harborview Medical Center, Seattle, Washington
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Park S. High-flow nasal cannula for respiratory failure in adult patients. Acute Crit Care 2022; 36:275-285. [PMID: 35263823 PMCID: PMC8907461 DOI: 10.4266/acc.2021.01571] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 11/25/2021] [Indexed: 11/30/2022] Open
Abstract
The high-flow nasal cannula (HFNC) has been recently used in several clinical settings for oxygenation in adults. In particular, the advantages of HFNC compared with low-flow oxygen systems or non-invasive ventilation include enhanced comfort, increased humidification of secretions to facilitate expectoration, washout of nasopharyngeal dead space to improve the efficiency of ventilation, provision of a small positive end-inspiratory pressure effect, and fixed and rapid delivery of an accurate fraction of inspired oxygen (FiO2) by minimizing the entrainment of room air. HFNC has been successfully used in critically ill patients with several conditions, such as hypoxemic respiratory failure, hypercapneic respiratory failure (exacerbation of chronic obstructive lung disease), post-extubation respiratory failure, pre-intubation oxygenation, and others. However, the indications are not absolute, and much of the proven benefit remains subjective and physiologic. This review discusses the practical application and clinical uses of HFNC in adults, including its unique respiratory physiologic effects, device settings, and clinical indications.
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Affiliation(s)
- SeungYong Park
- Division of Respiratory, Allergy and Critical Care Medicine, Department of Internal Medicine, Jeonbuk National University Medical School, Jeonju, Korea
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18
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Park S. Treatment of acute respiratory failure: high-flow nasal cannula. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2022. [DOI: 10.5124/jkma.2022.65.3.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: High-flow nasal cannulas (HFNCs) have recently been used for several conditions, such as hypoxemic respiratory failure, hypercapnic respiratory failure, post-extubation respiratory failure, and preintubation oxygenation, in critically ill patients.Current Concepts: The advantages of HFNC compared with those of low-flow oxygen systems or noninvasive ventilation include enhanced comfort, increased humidification of secretions to facilitate expectoration, washout of the nasopharyngeal dead space to improve ventilation efficiency, provisioning for low positive end-inspiratory pressure effect, and fixed and rapid delivery of accurate fraction of inspired oxygen by minimizing the entrainment of room air. However, the indications are not absolute, with much of the proven benefit being subjective and physiologic.Discussion and Conclusion: The goal of this review is to discuss the practical application and clinical uses of HFNCs in patients with acute respiratory failure, highlighting its unique respiratory and physiologic effects, device settings, and clinical indications.
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Hung KC, Chang YJ, Chen IW, Soong TC, Ho CN, Hsing CH, Chu CC, Chen JY, Sun CK. Efficacy of high flow nasal oxygenation against hypoxemia in sedated patients receiving gastrointestinal endoscopic procedures: A systematic review and meta-analysis. J Clin Anesth 2022; 77:110651. [PMID: 35030538 DOI: 10.1016/j.jclinane.2022.110651] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 12/18/2021] [Accepted: 01/05/2022] [Indexed: 12/20/2022]
Abstract
STUDY OBJECTIVE To evaluate the impact of high flow nasal oxygenation (HFNO) on the risk of hypoxemia during gastrointestinal endoscopic procedures (GEPs) under sedation. DESIGN Meta-analysis of randomized controlled trials. SETTING Gastrointestinal endoscopy. INTERVENTION HFNO. PATIENTS Adults patients undergoing GEPs under sedation. MEASUREMENTS The primary outcome was risk of hypoxemia, while the secondary outcomes included risks of severe hypoxemia, hypercapnia, need for jaw thrust or other airway interventions, and procedural interruption as well as procedure time, minimum SpO2, and level of carbon dioxide (CO2). Analyses based on age, gender, flow rate, risk status of patients were performed to investigate subgroup effects. RESULTS Medline, Google scholar, Cochrane Library, and EMBASE databases were searched from inception to July 2021. Seven randomized controlled trials (RCTs) involving 2998 patients published from 2019 to 2021 were included. All GEPs were performed under propofol sedation. Pooled results revealed significantly lower risks of hypoxemia [relative risk (RR) = 0.31, 95% CI:0.13-0.75; 2998 patients], severe hypoxemia (RR = 0.38, 95% CI:0.2-0.74; 2766 patients), other airway interventions (RR = 0.34, 95% CI:0.22-0.52; 2736 patients), procedural interruption (RR = 0.12, 95% CI:0.02-0.64, 451 patients) and a lower CO2 level [standard mean difference (MD) = -0.21, 95% CI: -0.4 to -0.03; 458 patients] in HFNO group compared to control group. Subgroup analysis focusing on risk of hypoxemia showed no significant subgroup effects, indicating consistent benefits of HFNO in different clinical settings. There were no difference in minimum SpO2 (p = 0.06; 262 patients), risk of hypercapnia (p = 0.09; 393 patients), need for jaw thrust (p = 0.28; 2256 patients), and procedure time (p = 0.41, 1004 patients) between the two groups. CONCLUSION Our results demonstrated the efficacy of high flow nasal oxygenation for reducing the risk of hypoxemia in patients receiving elective gastrointestinal endoscopic procedures under sedation. Further studies are warranted to verify its cost-effectiveness in the gastrointestinal endoscopy setting.
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Affiliation(s)
- Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan; Department of Hospital and Health Care Administration, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, Tainan City, Taiwan
| | - Ying-Jen Chang
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan; Department of Recreation and Health-Care Management, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, Tainan City, Taiwan
| | - I-Wen Chen
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Tien-Chou Soong
- Department of Weight Loss and Health Management Center, E-DA Dachang Hospital, Kaohsiung City, Taiwan; Department of Asia Obesity Medical Research Center, E-DA Hospital, Kaohsiung City, Taiwan; College of Medicine, I-Shou University, Kaohsiung City, Taiwan
| | - Chun-Ning Ho
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Chung-Hsi Hsing
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan; Department of Medical Research, Chi-Mei Medical Center, Tainan City, Taiwan
| | - Chin-Chen Chu
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Jen-Yin Chen
- Department of Anesthesiology, Chi Mei Medical Center, Tainan City, Taiwan
| | - Cheuk-Kwan Sun
- College of Medicine, I-Shou University, Kaohsiung City, Taiwan; Department of Emergency Medicine, E-Da Hospital, Kaohsiung City, Taiwan.
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Liu J, Li D, Luo L, Liu Z, Li X, Qiao L. Analysis of risk factors for the failure of respiratory support with high-flow nasal cannula oxygen therapy in children with acute respiratory dysfunction: A case-control study. Front Pediatr 2022; 10:979944. [PMID: 36081624 PMCID: PMC9445578 DOI: 10.3389/fped.2022.979944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 08/05/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Evidence-based clinical practice guidelines regarding high-flow nasal cannula (HFNC) use for respiratory support in critically ill children are lacking. Therefore, we aimed to determine the risk factors for early HFNC failure to reduce the failure rate and prevent adverse consequences of HFNC failure in children with acute respiratory dysfunction. METHODS Demographic and laboratory data were compared among patients, admitted to the pediatric intensive care unit between January 2017 and December 2018, who were included in a retrospective cohort study. Univariate and multivariate analyses were performed to determine risk factors for eventual entry into the predictive model for early HFNC failure and to perform an external validation study in a prospective observational cohort study from January to February 2019. Further, the association of clinical indices and trends pre- and post-treatment with HFNC treatment success or failure in these patients was dynamically observed. RESULTS In total, 348 pediatric patients were included, of these 282 (81.0%) were included in the retrospective cohort study; HFNC success was observed in 182 patients (64.5%), HFNC 0-24 h failure in 74 patients (26.2%), and HFNC 24-48 h failure in 26 patients (9.2%). HFNC 24 h failure was significantly associated with the pediatric risk of mortality (PRISM) III score [odds ratio, 1.391; 95% confidence interval (CI): 1.249-1.550], arterial partial pressure of carbon dioxide-to-arterial partial pressure of oxygen (PaCO2/PaO2) ratio (odds ratio, 38.397; 95% CI: 6.410-230.013), and respiratory rate-oxygenation (ROX) index (odds ratio, 0.751; 95% CI: 0.616-0.915). The discriminating cutoff point for the new scoring system based on the three risk factors for HFNC 24 h failure was ≥ 2.0 points, with an area under the receiver operating characteristic curve of 0.794 (95% CI, 0.729-0.859, P < 0.001), sensitivity of 68%, and specificity of 79%; similar values were noted on applying the model to the prospective observational cohort comprising 66 patients (AUC = 0.717, 95% CI, 0.675-0.758, sensitivity 83%, specificity 44%, P = 0.009). In this prospective cohort, 11 patients with HFNC failure had an upward trend in PaCO2/PaO2 ratio and downward trends in respiratory failure index (P/F ratio) and ROX index; however, opposite directions of change were observed in 55 patients with HFNC success. Furthermore, the fractional changes (FCs) in PaCO2/PaO2 ratio, P/F ratio, percutaneous oxygen saturation-to-fraction of inspired oxygen (S/F) ratio, and ROX index at 2 h post-HFNC therapy onset were statistically significant between the two groups (all, P < 0.05). CONCLUSION In the pediatric patients with acute respiratory insufficiency, pre-treatment PRISM III score, PaCO2/PaO2 ratio, and ROX index were risk factors for HFNC 24 h failure, and the direction and magnitude of changes in the PaCO2/PaO2 ratio, P/F ratio, and ROX index before and 2 h after HFNC treatment were warning indicators for HFNC 24 h failure. Further close monitoring should be considered for patients with these conditions.
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Affiliation(s)
- Jie Liu
- Department of Pediatric Intensive Care Unit, West China Second Universal Hospital, Sichuan University, Chengdu, China.,NHC Key Laboratory of Chronobiology (Sichuan University), Ministry of Education, Chengdu, China
| | - Deyuan Li
- Department of Pediatric Intensive Care Unit, West China Second Universal Hospital, Sichuan University, Chengdu, China.,NHC Key Laboratory of Chronobiology (Sichuan University), Ministry of Education, Chengdu, China
| | - Lili Luo
- Department of Pediatric Intensive Care Unit, West China Second Universal Hospital, Sichuan University, Chengdu, China.,NHC Key Laboratory of Chronobiology (Sichuan University), Ministry of Education, Chengdu, China
| | - Zhongqiang Liu
- Department of Pediatric Intensive Care Unit, West China Second Universal Hospital, Sichuan University, Chengdu, China.,NHC Key Laboratory of Chronobiology (Sichuan University), Ministry of Education, Chengdu, China
| | - Xiaoqing Li
- Department of Pediatric Intensive Care Unit, West China Second Universal Hospital, Sichuan University, Chengdu, China.,NHC Key Laboratory of Chronobiology (Sichuan University), Ministry of Education, Chengdu, China
| | - Lina Qiao
- Department of Pediatric Intensive Care Unit, West China Second Universal Hospital, Sichuan University, Chengdu, China.,NHC Key Laboratory of Chronobiology (Sichuan University), Ministry of Education, Chengdu, China
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21
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Xu SX, Wu CS, Liu SY, Lu X. High-flow nasal cannula oxygen therapy and noninvasive ventilation for preventing extubation failure during weaning from mechanical ventilation assessed by lung ultrasound score: A single-center randomized study. World J Emerg Med 2021; 12:274-280. [PMID: 34512823 DOI: 10.5847/wjem.j.1920-8642.2021.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 06/26/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND We sought to demonstrate the superiority of a targeted therapy strategy involving high-flow nasal cannula oxygen (HFNCO2) therapy and noninvasive ventilation (NIV) using lung ultrasound score (LUS) in comparison with standard care among patients in the intensive care unit (ICU) who undergo successful weaning to decrease the incidence of extubation failure at both 48 hours and seven days. METHODS During the study period, 98 patients were enrolled in the study, including 49 in the control group and 49 in the treatment group. Patients in the control group and patients with an LUS score <14 points (at low risk of extubation failure) in the treatment group were extubated and received standard preventive care without NIV or HFNCO2. Patients with an LUS score ≥14 points (at high risk of extubation failure) in the treatment group were extubated with a second review of the therapeutic optimization to identify and address any persisting risk factors for postextubation respiratory distress; patients received HFNCO2 therapy combined with sessions of preventive NIV (4-8 hours per day for 4-8 sessions total) for the first 48 hours after extubation. RESULTS In the control group, 13 patients had the LUS scores ≥14 points, while 36 patients had scores <14 points. In the treatment group, 16 patients had the LUS scores ≥14 points, while 33 patients had scores <14 points. Among patients with the LUS score ≥14 points, the extubation failure rate within 48 hours was 30.8% in the control group and 12.5% in the treatment group, constituting a statistically significant difference (P<0.05). Conversely, among patients with an LUS score <14 points, 13.9% in the control group and 9.1% in the treatment group experienced extubation failure (P=0.61). The length of ICU stay (9.4±3.1 days vs. 7.2±2.4 days) was significantly different and the re-intubation rate (at 48 hours: 18.4% vs. 10.2%; seven days: 22.4% vs. 12.2%) significantly varied between the two groups (P<0.05). There was no significant difference in the 28-day mortality rate (6.1% vs. 8.2%) between the control and treatment groups. CONCLUSIONS Among high-risk adults being weaned from mechanical ventilation and assessed by LUS, the NIV+HFNCO2 protocol does not lessen the mortality rate but reduce the length of ICU stay, the rate of extubation failure at both 48 hours and seven days.
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Affiliation(s)
- Shan-Xiang Xu
- Emergency Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Chun-Shuang Wu
- Emergency Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Shao-Yun Liu
- Emergency Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Xiao Lu
- Emergency Department, the Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou 310009, China
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22
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Guo K, Liu G, Wang W, Guo G, Liu Q. Effects of high-flow nasal oxygen cannula versus other noninvasive ventilation in extubated patients: a systematic review and meta-analysis of randomized controlled trials. Expert Rev Respir Med 2021; 16:109-119. [PMID: 34348551 DOI: 10.1080/17476348.2021.1964363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES A systematic review and meta-analysis were performed to compare the effects of high-flow nasal oxygen cannula (HFNC) and noninvasive ventilation (NIV) in extubated patients with respiratory insufficiency. METHODS The Cochrane Library, PubMed, and ClinicalTrials.gov were searched from inception to 28 February 2021, to identify randomized controlled trials. The primary outcome was reintubation within 24-72 hours after a planned extubation. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. RESULTS Six articles with1746 patients were included. The effect of HFNC on the reintubation rate was noninferior to that of NIV (OR = 1.11, 95% CI: 0.85-1.44). The rate of treatment failure was 20.40% with HFNC versus 20.92% with NIV; this difference was nonsignificant (OR = 0.97, 95% CI: 0.72-1.32, P = 0.85). HFNC reduced the rates of skin lesion occurrence (10.28% versus 23.82%, OR = 0.37, 95% CI: 0.26-0.53, P < 0.00001) and post-extubation respiratory failure (23.76% versus 25.56%, OR = 0.64, 95% CI: 0.46-0.88, P = 0.006), compared with NIV. CONCLUSIONS In extubated patients, HFNC was noninferior to NIV in the rate of reintubation and treatment failure. Compared with NIV, HFNC decreased the occurrence of skin lesions and post-extubation respiratory failure.
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Affiliation(s)
- Kaiyuan Guo
- Department of 2018 Grade Clinical Medicine, Medical College of Zhengzhou University, Zhengzhou, PR China
| | - Gang Liu
- Department of Emergency Intensive Care Ward, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, PR China
| | - Wei Wang
- Department of Clinical Evaluation, Henan Medical Association, Zhengzhou, PR China
| | - Guancheng Guo
- Department of Emergency Intensive Care Ward, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, PR China
| | - Qi Liu
- Department of Emergency Intensive Care Ward, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, PR China.,Department of Translational Medicine Center, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, PR China.,Department of Henan Medical Key Laboratory of Emergency and Trauma Research, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, PR China
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An Integrated Model including the ROX Index to Predict the Success of High-Flow Nasal Cannula Use after Planned Extubation: A Retrospective Observational Cohort Study. J Clin Med 2021; 10:jcm10163513. [PMID: 34441809 PMCID: PMC8397019 DOI: 10.3390/jcm10163513] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 11/17/2022] Open
Abstract
High-flow nasal cannula (HFNC) therapy is commonly used to prevent reintubation after planned extubation. In clinical practice, there are no appropriate tools to evaluate whether HFNC therapy was successful or failed after planned extubation. In this retrospective observational study, we investigated whether the use of the ROX index was appropriate to differentiate between HFNC success and failure within 72 h after extubation and to develop an integrated model including the ROX index to improve the prediction of HFNC success in patients receiving HFNC therapy after planned extubation. Of 276 patients, 50 patients (18.1%) were reintubated within 72 h of extubation. ROX index values of >8.7 at 2 h, >8.7 at 6 h, and >10.4 at 12 h after HFNC therapy were all meaningful predictors of HFNC success in extubated patients. In addition, the integrated model including the ROX index had a better predictive capability for HFNC success than the ROX index alone. In conclusion, the ROX index at 2, 6, and 12 h could be applied to extubated patients to predict HFNC success after planned extubation. To improve its predictive power, we should also consider an integrated model consisting of the ROX index, sex, body mass index, and the total duration of ventilator care.
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24
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High-Flow Nasal Cannula Compared With Conventional Oxygen Therapy or Noninvasive Ventilation Immediately Postextubation: A Systematic Review and Meta-Analysis. Crit Care Med 2021; 48:e1129-e1136. [PMID: 32947472 DOI: 10.1097/ccm.0000000000004576] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Reintubation after failed extubation is associated with increased mortality and longer hospital length of stay. Noninvasive oxygenation modalities may prevent reintubation. We conducted a systematic review and meta-analysis to determine the safety and efficacy of high-flow nasal cannula after extubation in critically ill adults. DATA SOURCES We searched MEDLINE, EMBASE, and Web of Science. STUDY SELECTION We included randomized controlled trials comparing high-flow nasal cannula to other noninvasive methods of oxygen delivery after extubation in critically ill adults. DATA EXTRACTION We included the following outcomes: reintubation, postextubation respiratory failure, mortality, use of noninvasive ventilation, ICU and hospital length of stay, complications, and comfort. DATA SYNTHESIS We included eight randomized controlled trials (n = 1,594 patients). Compared with conventional oxygen therapy, high-flow nasal cannula decreased reintubation (relative risk, 0.46; 95% CI, 0.30-0.70; moderate certainty) and postextubation respiratory failure (relative risk, 0.52; 95% CI, 0.30-0.91; very low certainty), but had no effect on mortality (relative risk, 0.93; 95% CI, 0.57-1.52; moderate certainty), or ICU length of stay (mean difference, 0.05 d fewer; 95% CI, 0.83 d fewer to 0.73 d more; high certainty). High-flow nasal cannula may decrease use of noninvasive ventilation (relative risk, 0.64; 95% CI, 0.34-1.22; moderate certainty) and hospital length of stay (mean difference, 0.98 d fewer; 95% CI, 2.16 d fewer to 0.21 d more; moderate certainty) compared with conventional oxygen therapy, however, certainty was limited by imprecision. Compared with noninvasive ventilation, high-flow nasal cannula had no effect on reintubation (relative risk, 1.16; 95% CI, 0.86-1.57; low certainty), mortality (relative risk, 1.12; 95% CI, 0.82-1.53; moderate certainty), or postextubation respiratory failure (relative risk, 0.82; 95% CI, 0.48-1.41; very low certainty). High-flow nasal cannula may reduce ICU length of stay (moderate certainty) and hospital length of stay (moderate certainty) compared with noninvasive ventilation. CONCLUSIONS High-flow nasal cannula reduces reintubation compared with conventional oxygen therapy, but not compared with noninvasive ventilation after extubation.
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25
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Yan C, Zhang J, Wu Y, Yao J, Li J, Zhang X, Cheng Y, Liu X, Yi J, Lin D, Yu S, Guo M, Lu L, Cheng W, He P. Effect of High-Flow Nasal Cannula for Hypoxemia Following Sun's Procedure in Acute Aortic Dissection Type a Patients. Front Surg 2021; 8:630624. [PMID: 34026812 PMCID: PMC8138463 DOI: 10.3389/fsurg.2021.630624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 02/10/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Patients with acute aortic dissection type A (AADA) often have hypoxemia (partial pressure of oxygen [PaO2]/fraction of inspired oxygen [FiO2] <300 mmHg) before weaning in the intensive care unit (ICU). This study compared the efficacy of high-flow nasal cannula (HFNC) with that of conventional oxygen therapy (COT) in patients with AADA following Sun's procedure. Methods: The medical records of 87 adult patients with AADA who underwent Sun's procedure and met the inclusion criteria (PaO2/FiO2 <300 mmHg before weaning) were retrospectively analyzed. After surgery, 41 patients were treated with HFNC and 46 were treated with COT. The oxygenation level, FiO2, partial pressure of carbon dioxide, heart rate, respiratory rate, subjective discomfort, and reintubation rate were recorded. The difference in lung volume loss between the HFNC and COT groups was assessed using the radiological atelectasis score (chest radiograph) or calculated from three-dimensional (3D) reconstructed computed tomography (CT) images. Results: From day 1 to day 5 after weaning, there was no significant difference in PaO2/FiO2 between the HFNC and COT groups, although the FiO2 was significantly lower in the HFNC group than in the COT group (P < 0.05). Further studies indicated that the percentage of lung volume loss (pleural effusion and/or pulmonary atelectasis) by 3D reconstruction of CT images at 4–8 days post-operation was significantly lower in the HFNC group (P < 0.05). The subjective experience of breathing discomfort, reintubation rate, and length of stay in the ICU were significantly reduced in the HFNC group (P < 0.05). There was no significant difference in readmission to the ICU and in-hospital mortality between the two groups. Conclusions: HFNC can be used as an effective oxygen therapy for AADA patients with hypoxemia after Sun's procedure.
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Affiliation(s)
- ChaoJun Yan
- Cardiac Surgery Department, Southwest Hospital, Army Medical University, Chongqing, China
| | - Jianrong Zhang
- Cardiac Surgery Department, Three Gorges Hospital, Chongqing University, Chongqing, China
| | - Yi Wu
- Institute of Digital Medicine, College of Biomedical Engineering and Medical Imaging, Army Medical University, Chongqing, China
| | - Jie Yao
- Institute of Digital Medicine, College of Biomedical Engineering and Medical Imaging, Army Medical University, Chongqing, China
| | - Jun Li
- Cardiac Surgery Department, Southwest Hospital, Army Medical University, Chongqing, China
| | - Xianpu Zhang
- Cardiac Surgery Department, Southwest Hospital, Army Medical University, Chongqing, China
| | - Yongbo Cheng
- Cardiac Surgery Department, Southwest Hospital, Army Medical University, Chongqing, China
| | - Xin Liu
- Cardiac Surgery Department, Southwest Hospital, Army Medical University, Chongqing, China
| | - Jianguang Yi
- Cardiac Surgery Department, Southwest Hospital, Army Medical University, Chongqing, China
| | - Deqin Lin
- Cardiac Surgery Department, Southwest Hospital, Army Medical University, Chongqing, China
| | - Sanjiu Yu
- Cardiac Surgery Department, Southwest Hospital, Army Medical University, Chongqing, China
| | - Mei Guo
- Cardiac Surgery Department, Southwest Hospital, Army Medical University, Chongqing, China
| | - Liuhong Lu
- Institute of Digital Medicine, College of Biomedical Engineering and Medical Imaging, Army Medical University, Chongqing, China
| | - Wei Cheng
- Cardiac Surgery Department, Southwest Hospital, Army Medical University, Chongqing, China
| | - Ping He
- Cardiac Surgery Department, Southwest Hospital, Army Medical University, Chongqing, China
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Gulla KM, Kabra SK, Lodha R. Feasibility of Pediatric Non-Invasive Respiratory Support in Low- and Middle-Income Countries. Indian Pediatr 2021. [PMID: 33941707 PMCID: PMC8639409 DOI: 10.1007/s13312-021-2377-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Non-Invasive respiratory support can be viewed as mechanical respiratory support without endotracheal intubation and it includes continuous positive airway pressure, bi-level positive airway pressure, high flow nasal cannula, and non-invasive positive pressure ventilation. Over past few years, non-invasive respiratory support is getting more popular across pediatric intensive care units for acute respiratory failure as well as for long-term ventilation support at home. It reduces the need for invasive mechanical ventilation, decreases the risk of nosocomial pneumonia as well as mortality in selected pediatric and adult population. Unfortunately, majority of available studies on non-invasive respiratory support have been conducted in high-income countries, which are different from low-and middle-income countries (LMICs) in terms of resources, manpower, and the disease profile. Hence, we need to consider disease profile, severity at hospital presentation, availability of age-appropriate equipment, ability of healthcare professionals to manage patients on non-invasive respiratory support, and cost-benefit ratio. In view of the relatively high cost of equipment, there is a need to innovate to develop indigenous kits/devices with available resources in LMICs to reduce the cost and potentially benefit health system. In this review, we highlight the role of non-invasive respiratory support in different clinical conditions, practical problems encountered in LMICs setting, and few indigenous techniques to provide non-invasive respiratory support.
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Yasuda H, Okano H, Mayumi T, Narita C, Onodera Y, Nakane M, Shime N. Post-extubation oxygenation strategies in acute respiratory failure: a systematic review and network meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:135. [PMID: 33836812 PMCID: PMC8034160 DOI: 10.1186/s13054-021-03550-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 03/23/2021] [Indexed: 02/06/2023]
Abstract
Background High-flow nasal cannula oxygenation (HFNC) and noninvasive positive-pressure ventilation (NPPV) possibly decrease tracheal reintubation rates better than conventional oxygen therapy (COT); however, few large-scale studies have compared HFNC and NPPV. We conducted a network meta-analysis (NMA) to compare the effectiveness of three post-extubation respiratory support devices (HFNC, NPPV, and COT) in reducing the mortality and reintubation risk. Methods The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and Ichushi databases were searched. COT, NPPV, and HFNC use were assessed in patients who were aged ≥ 16 years, underwent invasive mechanical ventilation for > 12 h for acute respiratory failure, and were scheduled for extubation after spontaneous breathing trials. The GRADE Working Group Approach was performed using a frequentist-based approach with multivariate random-effect meta-analysis. Short-term mortality and reintubation and post-extubation respiratory failure rates were compared. Results After evaluating 4631 records, 15 studies and 2600 patients were included. The main cause of acute hypoxic respiratory failure was pneumonia. Although NPPV/HFNC use did not significantly lower the mortality risk (relative risk [95% confidence interval] 0.75 [0.53–1.06] and 0.92 [0.67–1.27]; low and moderate certainty, respectively), HFNC use significantly lowered the reintubation risk (0.54 [0.32–0.89]; high certainty) compared to COT use. The associations of mortality with NPPV and HFNC use with respect to either outcome did not differ significantly (short-term mortality and reintubation, relative risk [95% confidence interval] 0.81 [0.61–1.08] and 1.02 [0.53–1.97]; moderate and very low certainty, respectively). Conclusion NPPV or HFNC use may not reduce the risk of short-term mortality; however, they may reduce the risk of endotracheal reintubation. Trial registration number and date of registration PROSPERO (registration number: CRD42020139112, 01/21/2020). Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03550-4.
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Affiliation(s)
- Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847, Amanuma-cho, Oomiya-ku, Saitama-shi, Saitama, 330-8503, Japan. .,Department of Clinical Research Education and Training Unit, Keio University Hospital Clinical and Translational Research Center (CTR), 35, Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Hiromu Okano
- Department of Critical and Emergency Medicine, National Hospital Organization Yokohama Medical Center, 2-60-3, Harajyuku, Totsuka-ku, Yokohama-shi, Kanagawa, 245-8575, Japan
| | - Takuya Mayumi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kanazawa University, 1-13, Takaramachi, Kanazawa-shi, Ishikawa, 920-0934, Japan
| | - Chihiro Narita
- Department of Emergency Medicine, Shizuoka General Hospital, 1-27-4, Kitaandou, Aoi-ku, Shizuoka-shi, Shizuoka, 420-8527, Japan
| | - Yu Onodera
- Department of Anesthesiology, Yamagata University Faculty of Medicine, 2-2-2, Iidanishi, Yamagata-shi, Yamagata, 990-2331, Japan
| | - Masaki Nakane
- Department of Emergency and Critical Care Medicine, Yamagata University Hospital, 2-2-2, Iidanishi, Yamagata-shi, Yamagata, 990-2331, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Postgraduate School of Medical Science, Hiroshima University Hospital, 3-2-1, Kasumi, Minami-ku, Hiroshima-shi, Hiroshima, 734-8551, Japan
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Gershengorn HB, Hu Y, Chen JT, Hsieh SJ, Dong J, Gong MN, Chan CW. The Impact of High-Flow Nasal Cannula Use on Patient Mortality and the Availability of Mechanical Ventilators in COVID-19. Ann Am Thorac Soc 2021; 18:623-631. [PMID: 33049156 PMCID: PMC8009000 DOI: 10.1513/annalsats.202007-803oc] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 10/13/2020] [Indexed: 12/26/2022] Open
Abstract
Rationale: How to provide advanced respiratory support for coronavirus disease (COVID-19) to maximize population-level survival while optimizing mechanical ventilator access is unknown.Objectives: To evaluate the use of high-flow nasal cannula for COVID-19 on population-level mortality and ventilator availability.Methods: We constructed dynamical (deterministic) simulation models of high-flow nasal cannula and mechanical ventilation use for COVID-19 in the United States. Model parameters were estimated through consensus based on published literature, local data, and experience. We had the following two outcomes: 1) cumulative number of deaths and 2) days without any available ventilators. We assessed the impact of various policies for the use of high-flow nasal cannula (with or without "early intubation") versus a scenario in which high-flow nasal cannula was unavailable.Results: The policy associated with the fewest deaths and the least time without available ventilators combined the use of high-flow nasal cannula for patients not urgently needing ventilators with the use of early mechanical ventilation for these patients when at least 10% of ventilator supply was not in use. At the national level, this strategy resulted in 10,000-40,000 fewer deaths than if high-flow nasal cannula were not available. In addition, with moderate national ventilator capacity (30,000-45,000 ventilators), this strategy led to up to 25 (11.8%) fewer days without available ventilators. For a 250-bed hospital with 100 mechanical ventilators, the availability of 13, 20, or 33 high-flow nasal cannulas prevented 81, 102, and 130 deaths, respectively.Conclusions: The use of high-flow nasal cannula coupled with early mechanical ventilation when supply is sufficient results in fewer deaths and greater ventilator availability.
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Affiliation(s)
- Hayley B. Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Miami Miller School of Medicine, Miami, Florida
- Division of Critical Care Medicine and
| | - Yue Hu
- Division of Decision, Risk, and Operations, Columbia University Business School, New York, New York; and
| | | | - S. Jean Hsieh
- Division of Pulmonary, Critical Care, and Sleep Medicine, Mount Sinai School of Medicine, New York, New York
| | - Jing Dong
- Division of Decision, Risk, and Operations, Columbia University Business School, New York, New York; and
| | - Michelle Ng Gong
- Division of Critical Care Medicine and
- Division of Pulmonary and Critical Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Carri W. Chan
- Division of Decision, Risk, and Operations, Columbia University Business School, New York, New York; and
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Lewis SR, Baker PE, Parker R, Smith AF. High-flow nasal cannulae for respiratory support in adult intensive care patients. Cochrane Database Syst Rev 2021; 3:CD010172. [PMID: 33661521 PMCID: PMC8094160 DOI: 10.1002/14651858.cd010172.pub3] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND High-flow nasal cannulae (HFNC) deliver high flows of blended humidified air and oxygen via wide-bore nasal cannulae and may be useful in providing respiratory support for adults experiencing acute respiratory failure, or at risk of acute respiratory failure, in the intensive care unit (ICU). This is an update of an earlier version of the review. OBJECTIVES To assess the effectiveness of HFNC compared to standard oxygen therapy, or non-invasive ventilation (NIV) or non-invasive positive pressure ventilation (NIPPV), for respiratory support in adults in the ICU. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, Web of Science, and the Cochrane COVID-19 Register (17 April 2020), clinical trial registers (6 April 2020) and conducted forward and backward citation searches. SELECTION CRITERIA We included randomized controlled studies (RCTs) with a parallel-group or cross-over design comparing HFNC use versus other types of non-invasive respiratory support (standard oxygen therapy via nasal cannulae or mask; or NIV or NIPPV which included continuous positive airway pressure and bilevel positive airway pressure) in adults admitted to the ICU. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as expected by Cochrane. MAIN RESULTS We included 31 studies (22 parallel-group and nine cross-over designs) with 5136 participants; this update included 20 new studies. Twenty-one studies compared HFNC with standard oxygen therapy, and 13 compared HFNC with NIV or NIPPV; three studies included both comparisons. We found 51 ongoing studies (estimated 12,807 participants), and 19 studies awaiting classification for which we could not ascertain study eligibility information. In 18 studies, treatment was initiated after extubation. In the remaining studies, participants were not previously mechanically ventilated. HFNC versus standard oxygen therapy HFNC may lead to less treatment failure as indicated by escalation to alternative types of oxygen therapy (risk ratio (RR) 0.62, 95% confidence interval (CI) 0.45 to 0.86; 15 studies, 3044 participants; low-certainty evidence). HFNC probably makes little or no difference in mortality when compared with standard oxygen therapy (RR 0.96, 95% CI 0.82 to 1.11; 11 studies, 2673 participants; moderate-certainty evidence). HFNC probably results in little or no difference to cases of pneumonia (RR 0.72, 95% CI 0.48 to 1.09; 4 studies, 1057 participants; moderate-certainty evidence), and we were uncertain of its effect on nasal mucosa or skin trauma (RR 3.66, 95% CI 0.43 to 31.48; 2 studies, 617 participants; very low-certainty evidence). We found low-certainty evidence that HFNC may make little or no difference to the length of ICU stay according to the type of respiratory support used (MD 0.12 days, 95% CI -0.03 to 0.27; 7 studies, 1014 participants). We are uncertain whether HFNC made any difference to the ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO2/FiO2) within 24 hours of treatment (MD 10.34 mmHg, 95% CI -17.31 to 38; 5 studies, 600 participants; very low-certainty evidence). We are uncertain whether HFNC made any difference to short-term comfort (MD 0.31, 95% CI -0.60 to 1.22; 4 studies, 662 participants, very low-certainty evidence), or to long-term comfort (MD 0.59, 95% CI -2.29 to 3.47; 2 studies, 445 participants, very low-certainty evidence). HFNC versus NIV or NIPPV We found no evidence of a difference between groups in treatment failure when HFNC were used post-extubation or without prior use of mechanical ventilation (RR 0.98, 95% CI 0.78 to 1.22; 5 studies, 1758 participants; low-certainty evidence), or in-hospital mortality (RR 0.92, 95% CI 0.64 to 1.31; 5 studies, 1758 participants; low-certainty evidence). We are very uncertain about the effect of using HFNC on incidence of pneumonia (RR 0.51, 95% CI 0.17 to 1.52; 3 studies, 1750 participants; very low-certainty evidence), and HFNC may result in little or no difference to barotrauma (RR 1.15, 95% CI 0.42 to 3.14; 1 study, 830 participants; low-certainty evidence). HFNC may make little or no difference to the length of ICU stay (MD -0.72 days, 95% CI -2.85 to 1.42; 2 studies, 246 participants; low-certainty evidence). The ratio of PaO2/FiO2 may be lower up to 24 hours with HFNC use (MD -58.10 mmHg, 95% CI -71.68 to -44.51; 3 studies, 1086 participants; low-certainty evidence). We are uncertain whether HFNC improved short-term comfort when measured using comfort scores (MD 1.33, 95% CI 0.74 to 1.92; 2 studies, 258 participants) and responses to questionnaires (RR 1.30, 95% CI 1.10 to 1.53; 1 study, 168 participants); evidence for short-term comfort was very low certainty. No studies reported on nasal mucosa or skin trauma. AUTHORS' CONCLUSIONS HFNC may lead to less treatment failure when compared to standard oxygen therapy, but probably makes little or no difference to treatment failure when compared to NIV or NIPPV. For most other review outcomes, we found no evidence of a difference in effect. However, the evidence was often of low or very low certainty. We found a large number of ongoing studies; including these in future updates could increase the certainty or may alter the direction of these effects.
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Affiliation(s)
- Sharon R Lewis
- Lancaster Patient Safety Research Unit, Royal Lancaster Infirmary, Lancaster, UK
| | - Philip E Baker
- Academic Centre, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Roses Parker
- Cochrane MOSS Network, c/o Cochrane Pain Palliative and Supportive Care Group, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Andrew F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
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Lewis K, Piticaru J, Chaudhuri D, Basmaji J, Fan E, Møller MH, Devlin JW, Alhazzani W. Safety and Efficacy of Dexmedetomidine in Acutely Ill Adults Requiring Noninvasive Ventilation: A Systematic Review and Meta-analysis of Randomized Trials. Chest 2021; 159:2274-2288. [PMID: 33434496 DOI: 10.1016/j.chest.2020.12.052] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/24/2020] [Accepted: 12/26/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Although clinical studies have evaluated dexmedetomidine as a strategy to improve noninvasive ventilation (NIV) comfort and tolerance in patients with acute respiratory failure (ARF), their results have not been summarized. RESEARCH QUESTION Does dexmedetomidine, when compared with another sedative or placebo, reduce the risk of delirium, mortality, need for intubation and mechanical ventilation, or ICU length of stay (LOS) in adults with ARF initiated on NIV in the ICU? STUDY DESIGN AND METHODS We electronically searched MEDLINE, EMBASE, and the Cochrane Library from inception through July 31, 2020, for randomized clinical trials (RCTs). We calculated pooled relative risks (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes with the corresponding 95% CIs using a random-effect model. RESULTS Twelve RCTs were included in our final analysis (n = 738 patients). The use of dexmedetomidine, compared with other sedation strategies or placebo, reduced the risk of intubation (RR, 0.54; 95% CI, 0.41-0.71; moderate certainty), delirium (RR, 0.34; 95% CI, 0.22-0.54; moderate certainty), and ICU LOS (MD, -2.40 days; 95% CI, -3.51 to -1.29 days; low certainty). Use of dexmedetomidine was associated with an increased risk of bradycardia (RR, 2.80; 95% CI, 1.92-4.07; moderate certainty) and hypotension (RR, 1.98; 95% CI, 1.32-2.98; moderate certainty). INTERPRETATION Compared with any sedation strategy or placebo, dexmedetomidine reduced the risk of delirium and the need for mechanical ventilation while increasing the risk of bradycardia and hypotension. The results are limited by imprecision, and further large RCTs are needed. TRIAL REGISTRY PROSPERO; No.: 175086; URL: www.crd.york.ac.uk/prospero/.
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Affiliation(s)
- Kimberley Lewis
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Joshua Piticaru
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - John Basmaji
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Morten Hylander Møller
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, MA; Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA
| | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
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Yang PL, Yu JQ, Chen HB. High-flow nasal cannula for acute exacerbation of chronic obstructive pulmonary disease: A systematic review and meta-analysis. Heart Lung 2020; 50:252-261. [PMID: 33359930 DOI: 10.1016/j.hrtlng.2020.12.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 12/09/2020] [Accepted: 12/16/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND The evidence for the safety of high-flow nasal cannula (HFNC) in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients is conflicting. OBJECTIVES To evaluate the intubation and mortality risks of HFNC compared to non-invasive ventilation (NIV) and conventional oxygen therapy (COT) for AECOPD patients. METHODS A search of electronic databases was performed. Studies that used HFNC to treat AECOPD patients were identified. RESULTS Seven RCTs and one observational study were included. There were no differences in intubation risk (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.49 to 1.78, p = 0.84, very low certainty) and mortality risk (RR 0.91, 95% CI 0.46 to 1.79, p = 0.77, very low certainty) for HFNC compared with NIV. No data were available for intubation or mortality risk for HFNC compared with COT. CONCLUSION For AECOPD patients, low-quality evidence indicates that HFNC does not increase intubation and mortality risks compared to NIV.
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Affiliation(s)
- Peng-Lei Yang
- Graduate school of Dalian Medical University, Dalian, Liaoning province, China; Department of Critical Care Medicine, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu Province, China.
| | - Jiang-Quan Yu
- Department of Critical Care Medicine, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu Province, China; Clinical Medical College of Yangzhou University, Yangzhou, Jiangsu Province, China.
| | - Han-Bing Chen
- Graduate school of Dalian Medical University, Dalian, Liaoning province, China; Department of Critical Care Medicine, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu Province, China.
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High-Flow Nasal Cannula in the Immediate Postoperative Period. Chest 2020; 158:1934-1946. [DOI: 10.1016/j.chest.2020.06.038] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 05/08/2020] [Accepted: 06/05/2020] [Indexed: 02/06/2023] Open
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Ko RE, Park C, Nam J, Ko MG, Na SJ, Ahn JH, Carriere KC, Jeon K. Effect of post-extubation high-flow nasal cannula on reintubation in elderly patients: a retrospective propensity score-matched cohort study. Ther Adv Respir Dis 2020; 14:1753466620968497. [PMID: 33121395 PMCID: PMC7607726 DOI: 10.1177/1753466620968497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Studies of mechanically ventilated patients with a low risk of reintubation have suggested that the use of high-flow nasal cannula (HFNC) oxygen therapy reduces the risk of reintubation compared with conventional oxygen therapy (COT). However, the effect of HFNC following extubation in elderly patients with a high risk of reintubation remains unclear. Methods: All consecutive medical intensive care unit (ICU) patients aged >65 years who were mechanically ventilated for >24 h were prospectively registered between July 2017 and June 2018. Control was obtained from a historical database of patients attending the same ICU from January 2012 to December 2013. A total of 152 patients who underwent HFNC after planned extubation according to institutional protocols (HFNC group) were compared with a propensity-matched historical control group who underwent COT (n = 175, COT group). The primary outcome was the proportion of reintubated patients within 48 h after planned extubation. Results: One hundred patients from the HFNC group and 129 patients from the COT group were matched by a propensity score that reflected the probability of receiving HFNC, and all variables were well matched. Post-extubation respiratory failure (41.0% versus 33.3%, p = 0.291) and reintubation rate within 48 h (16.0% versus 11.6%, p = 0.436) did not differ between the HFNC and COT groups. However, decreased levels of consciousness as a sign of post-extubation respiratory failure (27.0% versus 11.7%, p = 0.007) were significantly increased in the HFNC group compared with the COT group. Conclusion: Among elderly patients who underwent planned extubation, HFNC was not associated with a decrease in the risk of reintubation. Further prospective study evaluating the clinical benefits of post-extubation HFNC in elderly patients is needed. The reviews of this paper are available via the supplemental material section.
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Affiliation(s)
- Ryoung-Eun Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chul Park
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Division of Pulmonary Medicine, Department of Internal Medicine, Wonkwang University Hospital, 895 Muwang-ro, Iksan, Republic of Korea
| | - Jimyoung Nam
- Intensive Care Unit Nursing Department, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Myeong Gyun Ko
- Intensive Care Unit Nursing Department, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joong Hyun Ahn
- Biostatistics and Clinical Epidemiology Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Keumhee C Carriere
- Biostatistics and Clinical Epidemiology Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.,Department of Mathematical and Statistical Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Kyeongman Jeon
- Department of Critical Care Medicine and Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Republic of Korea
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Agarwal A, Basmaji J, Muttalib F, Granton D, Chaudhuri D, Chetan D, Hu M, Fernando SM, Honarmand K, Bakaa L, Brar S, Rochwerg B, Adhikari NK, Lamontagne F, Murthy S, Hui DSC, Gomersall C, Mubareka S, Diaz JV, Burns KEA, Couban R, Ibrahim Q, Guyatt GH, Vandvik PO. High-flow nasal cannula for acute hypoxemic respiratory failure in patients with COVID-19: systematic reviews of effectiveness and its risks of aerosolization, dispersion, and infection transmission. Can J Anaesth 2020; 67:1217-1248. [PMID: 32542464 PMCID: PMC7294988 DOI: 10.1007/s12630-020-01740-2] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 05/20/2020] [Accepted: 05/20/2020] [Indexed: 01/03/2023] Open
Abstract
PURPOSE We conducted two World Health Organization-commissioned reviews to inform use of high-flow nasal cannula (HFNC) in patients with coronavirus disease (COVID-19). We synthesized the evidence regarding efficacy and safety (review 1), as well as risks of droplet dispersion, aerosol generation, and associated transmission (review 2) of viral products. SOURCE Literature searches were performed in Ovid MEDLINE, Embase, Web of Science, Chinese databases, and medRxiv. Review 1: we synthesized results from randomized-controlled trials (RCTs) comparing HFNC to conventional oxygen therapy (COT) in critically ill patients with acute hypoxemic respiratory failure. Review 2: we narratively summarized findings from studies evaluating droplet dispersion, aerosol generation, or infection transmission associated with HFNC. For both reviews, paired reviewers independently conducted screening, data extraction, and risk of bias assessment. We evaluated certainty of evidence using GRADE methodology. PRINCIPAL FINDINGS No eligible studies included COVID-19 patients. Review 1: 12 RCTs (n = 1,989 patients) provided low-certainty evidence that HFNC may reduce invasive ventilation (relative risk [RR], 0.85; 95% confidence interval [CI], 0.74 to 0.99) and escalation of oxygen therapy (RR, 0.71; 95% CI, 0.51 to 0.98) in patients with respiratory failure. Results provided no support for differences in mortality (moderate certainty), or in-hospital or intensive care length of stay (moderate and low certainty, respectively). Review 2: four studies evaluating droplet dispersion and three evaluating aerosol generation and dispersion provided very low certainty evidence. Two simulation studies and a crossover study showed mixed findings regarding the effect of HFNC on droplet dispersion. Although two simulation studies reported no associated increase in aerosol dispersion, one reported that higher flow rates were associated with increased regions of aerosol density. CONCLUSIONS High-flow nasal cannula may reduce the need for invasive ventilation and escalation of therapy compared with COT in COVID-19 patients with acute hypoxemic respiratory failure. This benefit must be balanced against the unknown risk of airborne transmission.
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Affiliation(s)
- Arnav Agarwal
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - John Basmaji
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Fiona Muttalib
- Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada
| | - David Granton
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Devin Chetan
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
- Division of Cardiology, Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Malini Hu
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kimia Honarmand
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Schulich School of Medicine and Dentistry, Department of Medicine, Western University, London, ON, Canada
| | - Layla Bakaa
- Honours Life Sciences Program, Faculty of Science, McMaster University, Hamilton, ON, Canada
| | - Sonia Brar
- School of Medicine and Biomedical Sciences, University of Buffalo, Buffalo, NY, USA
| | - Bram Rochwerg
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Neill K Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Francois Lamontagne
- Université de Sherbrooke, Sherbrooke, Canada
- Centre de recherche du CHU de Sherbrooke, Sherbrooke, QC, Canada
| | - Srinivas Murthy
- BC Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - David S C Hui
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, Hong Kong, SAR, China
- Stanley Ho, Center for Emerging Infectious Diseases, The Chinese University of Hong Kong, Shatin, Hong Kong, SAR, China
| | - Charles Gomersall
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Samira Mubareka
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Janet V Diaz
- Pacific Medical Center, San Francisco, CA, USA
- World Health Organization, Geneva, Switzerland
| | - Karen E A Burns
- Unity Health Toronto - St. Michael's Hospital, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, Toronto, ON, Canada
| | - Rachel Couban
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada
| | - Quazi Ibrahim
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
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Ervin JN, Rentes VC, Dibble ER, Sjoding MW, Iwashyna TJ, Hough CL, Ng Gong M, Sales AE. Evidence-Based Practices for Acute Respiratory Failure and Acute Respiratory Distress Syndrome: A Systematic Review of Reviews. Chest 2020; 158:2381-2393. [PMID: 32682771 PMCID: PMC7768938 DOI: 10.1016/j.chest.2020.06.080] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 06/03/2020] [Accepted: 06/25/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND The recent pandemic highlights the essential nature of optimizing the use of invasive mechanical ventilation (IMV) in complex critical care settings. This review of reviews maps evidence-based practices (EBPs) that are associated with better outcomes among adult patients with acute respiratory failure or ARDS on the continuum of care, from intubation to liberation. RESEARCH QUESTION What EPBs are recommended to reduce the duration of IMV and mortality rate among patients with acute respiratory failure/ARDS? STUDY DESIGN AND METHODS We identified an initial set of reports that links EBPs to mortality rates and/or duration of IMV. We conducted a review of reviews, focusing on preappraised guidelines, meta-analyses, and systematic reviews. We searched Scopus, CINAHL, and PubMed from January 2016 to January 2019 for additional evidence that has not yet been incorporated into current guidelines. RESULTS Our initial search produced 61 publications that contained 42 EBPs. We excluded 42 manuscripts during the data extraction process, primarily because they were not associated with improved patient outcomes. The remaining 19 preappraised guidelines, meta-analyses, and systematic reviews met our full inclusion criteria and spanned the continuum of IMV care from intubation to liberation. These contained 20 EBPs, a majority of which were supported with moderate levels of evidence. Of these, six EBPs focused on intubation and escalation of care, such as ventilator management and synchrony; ten EBPs reduced complications associated with IMV, which included spontaneous awakening and breathing trials and early mobility protocols; and four EBPs promoted timely extubation and postextubation recovery. INTERPRETATION This review describes EBPs that are associated with fewer ventilator days and/or lower mortality rates among patients who received IMV for acute respiratory failure/ARDS. Many of these EBPs are connected across the care continuum, which indicates the need to promote and assess effective implementation jointly, rather than individually.
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Affiliation(s)
- Jennifer N Ervin
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI.
| | - Victor C Rentes
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI
| | - Emily R Dibble
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI; College of Human Ecology, Cornell University, Ithaca, NY
| | - Michael W Sjoding
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; University of Michigan, Ann Arbor, MI
| | - Theodore J Iwashyna
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; University of Michigan, Ann Arbor, MI; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Catherine L Hough
- Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University, Portland, OR
| | - Michelle Ng Gong
- Department of Medicine, Divisions of Critical Care Medicine and Pulmonary Medicine, Montefiore Health System, Albert Einstein College of Medicine, Bronx, NY
| | - Anne E Sales
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI
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High-Flow Nasal Cannula versus Noninvasive Positive Pressure Ventilation in Patients with Heart Failure after Extubation: An Observational Cohort Study. Can Respir J 2020; 2020:6736475. [PMID: 32714476 PMCID: PMC7354657 DOI: 10.1155/2020/6736475] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 04/24/2020] [Accepted: 05/06/2020] [Indexed: 11/18/2022] Open
Abstract
Noninvasive positive pressure ventilation (NPPV) has been widely applied in patients with high-risk extubation failure, including heart failure. High-flow nasal cannula (HFNC) has been demonstrated to benefit patients with heart failure by reducing cardiac preload. This study aimed to compare the effectiveness of HFNC to NPPV for preventing extubation failure in patients with heart failure. This 3-year retrospective and single-center cohort study included patients with heart failure with left ventricular ejection fraction <50% who received prophylactic HFNC or NPPV after scheduled extubation from January 2015 to January 2018 from a medical center with four adult intensive care units. Demographics, comorbidities, diagnosis, and weaning status were collected. The primary outcome was treatment failure within 72 hours after extubation, which was defined as escalation to NPPV or reintubation in the HFNC group and was defined as requiring reintubation in the NPPV group. Secondary outcomes were reintubation within 72 hours, reintubation, duration of stay, and mortality during the intensive care unit and hospital stay. Of the 104 patients analyzed, characteristics of 58 patients in the HFNC group and 46 patients in the NPPV group were compared. The treatment failure within 72 hours in the two groups was not significantly different (25.9% vs 13%, p=0.106). Hypoxemic respiratory failure related treatment failure was significantly higher in the HFNC group. Prophylactic HFNC as first-line therapy had a comparable rate of reintubation within 72 hours to the prophylactic NPPV alone (17.2% vs 13%, p=0.556). Other secondary outcomes were similar between the two groups. Among patients with heart failure, HFNC was not inferior to NPPV for preventing extubation failure and reintubation. However, in case of an impending respiratory failure, selective patients may benefit from rescue NPPV.
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Nam H, Cho JH, Park TS, Kim SW, Kang HK, Shin YM, Hwang JJ, Lee K, Ha JH, Lee YS, Chang Y, Park S. Non-invasive ventilation for acute respiratory failure: pressure support ventilation vs. pressure-controlled ventilation. J Thorac Dis 2020; 12:2553-2562. [PMID: 32642163 PMCID: PMC7330335 DOI: 10.21037/jtd.2020.03.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Background The best ventilator mode for patients receiving non-invasive ventilation (NIV) has not been clarified. This study compared the effectiveness of two pressure-targeted modes, i.e., pressure support ventilation (PSV) and pressure-controlled ventilation (PCV), in patients receiving NIV. Methods This was a prospective multicentre observational study of NIV use for acute respiratory failure (ARF) in adult patients. We compared the two pressure-targeted modes in terms of NIV success and complication rates. Results Among 176 patients receiving NIV, 88 patients were included in the study (PCV mode, n=29; PSV mode, n=59). The study population had a median age of 73.0 years and median body mass index of 20.8 kg/m2. The applied inspiratory positive airway pressure (IPAP) was higher in patients with PCV than in those with PSV [18.0 cmH2O (15.0–20.5 cmH2O) vs. 15.0 cmH2O (12.0–17.0 cmH2O), respectively, P=0.001]. More patients with PCV received sedatives and experienced dry mouth than those with PSV; however, the incidences of large leaks were low in both groups (n=5 vs. n=2, respectively). With regard to NIV outcomes, 24 (27.2%) patients experienced NIV failure and 13 (14.8%) died in hospital. PSV mode was a significant factor for NIV success [odds ratio (OR), 2.303; 95% confidence interval (CI), 1.216 to 4.360] in multivariate analyses and this association remained significant in a 1:1 matched cohort (n=29 per group). Conclusions In contrast to PCV mode, PSV mode was significantly associated with NIV success in the intensive care unit setting, particularly when large leaks were not a major concern. Nevertheless, further well-designed multicenter, protocol-driven randomized controlled trials are warranted.
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Affiliation(s)
- Hyunseung Nam
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Jae Hwa Cho
- Department Internal Medicine, Gangnam Severance Hospital, College of Medicine, Yonsei University, Seoul, Korea
| | - Tai Sun Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Sei Won Kim
- Department of Pulmonary, Critical Care and Sleep Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyung Koo Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - Yoon Mi Shin
- Department of Pulmonary and Critical Care Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Jae Joon Hwang
- Department of Pulmonary and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Kwangha Lee
- Department of Internal Medicine, Pusan National University Hospital, Busan, Korea
| | - Jick Hwan Ha
- Department of Pulmonary and Critical Care Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Inchoen, Korea
| | - Young Seok Lee
- Department of Pulmonary and Critical Care Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Youjin Chang
- Department of Pulmonary and Critical Care Medicine, Inje University Paik Hospital, Seoul, Korea
| | - Sunghoon Park
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
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Noninvasive respiratory support in the hypoxaemic peri-operative/periprocedural patient: a joint ESA/ESICM guideline. Intensive Care Med 2020; 46:697-713. [PMID: 32157356 PMCID: PMC7223056 DOI: 10.1007/s00134-020-05948-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 01/22/2020] [Indexed: 12/12/2022]
Abstract
Hypoxaemia is a potential life-threatening yet common complication in the peri-operative and periprocedural patient (e.g. during an invasive procedure at risk of deterioration of gas exchange, such as bronchoscopy). The European Society of Anaesthesiology (ESA) and the European Society of Intensive Care Medicine (ESICM) developed guidelines for the use of noninvasive respiratory support techniques in the hypoxaemic patient in the peri-operative and periprocedural period. The panel outlined five clinical questions regarding treatment with noninvasive respiratory support techniques [conventional oxygen therapy (COT), high flow nasal cannula, noninvasive positive pressure ventilation (NIPPV) and continuous positive airway pressure (CPAP)] for hypoxaemic patients with acute peri-operative/periprocedural respiratory failure. The goal was to assess the available literature on the various noninvasive respiratory support techniques, specifically studies that included adult participants with hypoxaemia in the peri-operative/periprocedural period. The literature search strategy was developed by a Cochrane Anaesthesia and Intensive Care trial search specialist in close collaboration with the panel members and the ESA group methodologist. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to assess the level of evidence and to grade recommendations. The final process was then validated by both ESA and ESICM scientific committees. Among 19 recommendations, the two grade 1B recommendations state that: in the peri-operative/periprocedural hypoxaemic patient, the use of either NIPPV or CPAP (based on local expertise) is preferred to COT for improvement of oxygenation; and that the panel suggests using NIPPV or CPAP immediately post-extubation for hypoxaemic patients at risk of developing acute respiratory failure after abdominal surgery.
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Mansfield DR. Nasal high‐flow therapy: Established roles and emerging opportunities. Respirology 2019; 24:1039-1041. [DOI: 10.1111/resp.13677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 07/28/2019] [Indexed: 11/30/2022]
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Lu Z, Chang W, Meng SS, Zhang X, Xie J, Xu JY, Qiu H, Yang Y, Guo F. Effect of high-flow nasal cannula oxygen therapy compared with conventional oxygen therapy in postoperative patients: a systematic review and meta-analysis. BMJ Open 2019; 9:e027523. [PMID: 31377696 PMCID: PMC6687012 DOI: 10.1136/bmjopen-2018-027523] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE To evaluate the effect of high-flow nasal cannula oxygen therapy (HFNC) versus conventional oxygen therapy (COT) on the reintubation rate, rate of escalation of respiratory support and clinical outcomes in postextubation adult surgical patients. DESIGN Systematic review and meta-analysis of published literature. DATA SOURCES PubMed, Embase, the Cochrane Library, Web of Science, China National Knowledge Index and Wan fang databases were searched up to August 2018. ELIGIBILITY CRITERIA Studies in postoperative adult surgical patients (≥18 years), receiving HFNC or COT applied immediately after extubation that reported reintubation, escalation of respiratory support, postoperative pulmonary complications (PPCs) and mortality were eligible for inclusion. DATA EXTRACTION AND SYNTHESIS The following data were extracted from the included studies: first author's name, year of publication, study population, country of origin, study design, number of patients, patients' baseline characteristics and outcomes. Associations were evaluated using risk ratio (RR) and 95% CIs. RESULTS This meta-analysis included 10 studies (1327 patients). HFNC significantly reduced the reintubation rate (RR 0.38, 95% CI 0.23 to 0.61, p<0.0001) and rate of escalation of respiratory support (RR 0.43, 95% CI 0.26 to 0.73, p=0.002) in postextubation surgical patients compared with COT. There were no differences in the incidence of PPCs (RR 0.87, 95% CI 0.70 to 1.08, p=0.21) or mortality (RR 0.45, 95% CI 0.16 to 1.29, p=0.14). CONCLUSION HFNC is associated with a significantly lower reintubation rate and rate of escalation of respiratory support compared with COT in postextubation adult surgical patients, but there is no difference in the incidence of PPCs or mortality. More well-designed, large randomised controlled trials are needed to determine the subpopulation of patients who are most likely to benefit from HFNC therapy.
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Affiliation(s)
- Zhonghua Lu
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Wei Chang
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Shan-Shan Meng
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Xiwen Zhang
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Jianfeng Xie
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Jing-Yuan Xu
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Haibo Qiu
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yi Yang
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Fengmei Guo
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
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Norkienė I, d'Espiney R, Martin-Lazaro JF. Effectiveness of high-flow nasal oxygen therapy in management of acute hypoxemic and hypercapnic respiratory failure. Acta Med Litu 2019; 26:46-50. [PMID: 31281216 DOI: 10.6001/actamedica.v26i1.3955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background High-flow nasal oxygen therapy (HFNOT) therapy has been increasingly used in patients with acute hypoxemic (Type I) respiratory failure (RF). Meanwhile indications and clinical effectiveness of HFNOT in patients with hypercapnic (Type II) RF remain controversial. The aim of our study was to evaluate the outcomes of primary HFTNOT in patients with hypoxemic and hypercapnic RF. Materials and methods We conducted a retrospective observational study of patients diagnosed with severe community acquired pneumonia (CAP), who required HFNC oxygen therapy for hypoxemia. Primary end-point was intubation or escalation to NIV rate after HFNOT. The secondary endpoint was the 30-day mortality after an admission regardless of the cause. Results Analysis was conducted on all 51 (n = 51) patients. Of these, 32 (63%) were diagnosed with Type I RF and 19 (37%) with Type II RF. The partial pressure of arterial carbon dioxide (PaCO2) in Type I RF patients was 34.05 mmHg at admission and decreased to 33.07 mmHg after 1 hour of HFNOT. In patients with Type II RF PaCO2 decreased from 56.47 to 54.97 mmHg. In Type I RF successful outcome was achieved in 25 patients (78%) compared to 11 patients (58%) with Type II RF. Escalation was required in seven patients with Type I RF and eight patients in Type II group. There were no mortalities in our population group. Conclusions Our data suggest that HFNOT can be effectively used in Type I and Type II RF. Clinicians should be cautious identifying patients at risk of escalation. A larger population group study is needed to identify predictors of HFNOT failure.
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Affiliation(s)
- Ieva Norkienė
- Intensive Care Unit, Newham University Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Raquel d'Espiney
- Intensive Care Unit, Newham University Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Juan F Martin-Lazaro
- Intensive Care Unit, Newham University Hospital, Barts Health NHS Trust, London, United Kingdom
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Rochwerg B, Granton D, Wang DX, Helviz Y, Einav S, Frat JP, Mekontso-Dessap A, Schreiber A, Azoulay E, Mercat A, Demoule A, Lemiale V, Pesenti A, Riviello ED, Mauri T, Mancebo J, Brochard L, Burns K. High flow nasal cannula compared with conventional oxygen therapy for acute hypoxemic respiratory failure: a systematic review and meta-analysis. Intensive Care Med 2019; 45:563-572. [PMID: 30888444 DOI: 10.1007/s00134-019-05590-5] [Citation(s) in RCA: 138] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 02/28/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND This systematic review and meta-analysis summarizes the safety and efficacy of high flow nasal cannula (HFNC) in patients with acute hypoxemic respiratory failure. METHODS We performed a comprehensive search of MEDLINE, EMBASE, and Web of Science. We identified randomized controlled trials that compared HFNC to conventional oxygen therapy. We pooled data and report summary estimates of effect using relative risk for dichotomous outcomes and mean difference or standardized mean difference for continuous outcomes, with 95% confidence intervals. We assessed risk of bias of included studies using the Cochrane tool and certainty in pooled effect estimates using GRADE methods. RESULTS We included 9 RCTs (n = 2093 patients). We found no difference in mortality in patients treated with HFNC (relative risk [RR] 0.94, 95% confidence interval [CI] 0.67-1.31, moderate certainty) compared to conventional oxygen therapy. We found a decreased risk of requiring intubation (RR 0.85, 95% CI 0.74-0.99) or escalation of oxygen therapy (defined as crossover to HFNC in the control group, or initiation of non-invasive ventilation or invasive mechanical ventilation in either group) favouring HFNC-treated patients (RR 0.71, 95% CI 0.51-0.98), although certainty in both outcomes was low due to imprecision and issues related to risk of bias. HFNC had no effect on intensive care unit length of stay (mean difference [MD] 1.38 days more, 95% CI 0.90 days fewer to 3.66 days more, low certainty), hospital length of stay (MD 0.85 days fewer, 95% CI 2.07 days fewer to 0.37 days more, moderate certainty), patient reported comfort (SMD 0.12 lower, 95% CI 0.61 lower to 0.37 higher, very low certainty) or patient reported dyspnea (standardized mean difference [SMD] 0.16 lower, 95% CI 1.10 lower to 1.42 higher, low certainty). Complications of treatment were variably reported amongst included studies, but little harm was associated with HFNC use. CONCLUSION In patients with acute hypoxemic respiratory failure, HFNC may decrease the need for tracheal intubation without impacting mortality.
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Affiliation(s)
- B Rochwerg
- Michael G. De Groote School of Medicine, McMaster University, Hamilton, ON, Canada. .,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada. .,Department of Medicine, Division of Critical Care, Juravinski Hospital, 711 Concession St, Hamilton, ON, L8V 1C3, Canada.
| | - D Granton
- Michael G. De Groote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - D X Wang
- Schulich School of Medicine, Western University, London, ON, Canada
| | - Y Helviz
- General Intensive Care Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - S Einav
- General Intensive Care Unit, Shaare Zedek Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - J P Frat
- CHU de Poitiers, Médecine Intensive Réanimation, Poitiers, France.,INSERM, CIC-1402, équipe ALIVE, Poitiers, France.,Faculté de Médecine et de Pharmacie de Poitiers, Université de Poitiers, Poitiers, France
| | - A Mekontso-Dessap
- Hôpitaux Universitaires Henri Mondor, Créteil, France.,Université Paris, Créteil, France
| | - A Schreiber
- Department of Medicine, Division of Respirology, University Health Network, Toronto, ON, Canada
| | - E Azoulay
- Hôpital Saint-Louis, Paris, France.,Center of Epidemiology and Biostatistics, Paris Diderot Sorbonne University, Paris, France
| | - A Mercat
- Département de Médecine Intensive-Réanimation, CHU d'Angers, Université d'Angers, Angers, France
| | - A Demoule
- Service de Pneumologie et Réanimation Médicale du Département R3S, AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Paris, France.,Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, INSERM, UMRS1158, Paris, France
| | - V Lemiale
- Hôpital Saint-Louis, Paris, France.,Center of Epidemiology and Biostatistics, Paris Diderot Sorbonne University, Paris, France
| | - A Pesenti
- Università degli Studi di Milano, Dipartimento di Fisopatologia Medico-Chirurgica e dei Trapianti, Milan, Italy.,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - E D Riviello
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - T Mauri
- Università degli Studi di Milano, Dipartimento di Fisopatologia Medico-Chirurgica e dei Trapianti, Milan, Italy.,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - J Mancebo
- Servei de Medicina Intensiva, Hospital Universitari Sant Pau, Barcelona, Spain
| | - L Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - K Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
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Lee M, Kim JH, Jeong IB, Son JW, Na MJ, Kwon SJ. Protecting Postextubation Respiratory Failure and Reintubation by High-Flow Nasal Cannula Compared to Low-Flow Oxygen System: Single Center Retrospective Study and Literature Review. Acute Crit Care 2019; 34:60-70. [PMID: 31723906 PMCID: PMC6849042 DOI: 10.4266/acc.2018.00311] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 02/02/2019] [Accepted: 02/21/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Use of a high-flow nasal cannula (HFNC) reduced postextubation respiratory failure (PERF) and reintubation rate compared to use of a low-flow oxygen system (LFOS) in low-risk patients. However, no obvious conclusion was reached for high-risk patients. Here, we sought to present the current status of HFNC use as adjunctive oxygen therapy in a clinical setting and to elucidate the nature of the protective effect following extubation. METHODS The medical records of 855 patients who were admitted to the intensive care unit of single university hospital during a period of 5.5 years were analyzed retrospectively, with only 118 patients ultimately included in the present research. The baseline characteristics of these patients and the occurrence of PERF and reintubation along with physiologic changes were analyzed. RESULTS Eighty-four patients underwent HFNC, and the remaining 34 patients underwent conventional LFOS after extubation. Physicians preferred HFNC to LFOS in the face of high-risk features including old age, neurologic disease, moderate to severe chronic obstructive pulmonary disease, a long duration of mechanical ventilation, low baseline arterial partial pressure of oxygen to fraction of inspired oxygen ratio, and a high baseline alveolar-arterial oxygen difference. The reintubation rate at 72 hours after extubation was not different (9.5% vs. 8.8%; P=1.000). Hypoxic respiratory failure was slightly higher in the nonreintubation group than in the reintubation group (31.9% vs. 6.7%; P=0.058). Regarding physiologic effects, heart rate was only stabilized after 24 hours of extubation in the HFNC group. CONCLUSIONS No difference was found in the occurrence of PERF and reintubation between both groups. It is worth noting that similar PERF and reintubation ratios were shown in the HFNC group in those with certain exacerbating risk factors versus not. Caution is needed regarding delayed reintubation in the HFNC group.
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Affiliation(s)
- Minhyeok Lee
- Division of Respiratory and Critical Care Medicine, Department of Internal Medicine, Konyang University Hospital, Daejeon, Korea
- The 2nd Infantry Division of Republic of Korea Army, Yanggu, Korea
| | - Ji Hye Kim
- Division of Respiratory and Critical Care Medicine, Department of Internal Medicine, Konyang University Hospital, Daejeon, Korea
| | - In Beom Jeong
- Division of Respiratory and Critical Care Medicine, Department of Internal Medicine, Konyang University Hospital, Daejeon, Korea
| | - Ji Woong Son
- Division of Respiratory and Critical Care Medicine, Department of Internal Medicine, Konyang University Hospital, Daejeon, Korea
| | - Moon Jun Na
- Division of Respiratory and Critical Care Medicine, Department of Internal Medicine, Konyang University Hospital, Daejeon, Korea
| | - Sun Jung Kwon
- Division of Respiratory and Critical Care Medicine, Department of Internal Medicine, Konyang University Hospital, Daejeon, Korea
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Lockstone J, Boden I, Robertson IK, Story D, Denehy L, Parry SM. Non-Invasive Positive airway Pressure thErapy to Reduce Postoperative Lung complications following Upper abdominal Surgery (NIPPER PLUS): protocol for a single-centre, pilot, randomised controlled trial. BMJ Open 2019; 9:e023139. [PMID: 30782696 PMCID: PMC6340066 DOI: 10.1136/bmjopen-2018-023139] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 08/18/2018] [Accepted: 11/23/2018] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Postoperative pulmonary complications (PPCs) are a common serious complication following upper abdominal surgery leading to significant consequences including increased mortality, hospital costs and prolonged hospitalisation. The primary objective of this study is to detect whether there is a possible signal towards PPC reduction with the use of additional intermittent non-invasive ventilation (NIV) compared with continuous high-flow nasal oxygen therapy alone following high-risk elective upper abdominal surgery. Secondary objectives are to measure feasibility of: (1) trial conduct and design and (2) physiotherapy-led NIV and a high-flow nasal oxygen therapy protocol, safety of NIV and to provide preliminary costs of care information of NIV and high-flow nasal oxygen therapy. METHODS AND ANALYSIS This is a single-centre, parallel group, assessor blinded, pilot, randomised trial, with 130 high-risk upper abdominal surgery patients randomly assigned via concealed allocation to either (1) usual care of continuous high-flow nasal oxygen therapy for 48 hours following extubation or (2) usual care plus five additional 30 min physiotherapy-led NIV sessions within the first two postoperative days. Both groups receive standardised preoperative physiotherapy and postoperative early ambulation. No additional respiratory physiotherapy is provided to either group. Outcome measures will assess incidence of PPC within the first 14 postoperative days, recruitment ability, physiotherapy-led NIV and high-flow nasal oxygen therapy protocol adherence, adverse events relating to NIV delivery and costs of providing a physiotherapy-led NIV and a high-flow nasal oxygen therapy service following upper abdominal surgery. ETHICS AND DISSEMINATION Ethics approval has been obtained from the relevant institution and results will be published to inform future multicentre trials. TRIAL REGISTRATION NUMBER ACTRN12617000269336; Pre-results.
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Affiliation(s)
- Jane Lockstone
- Department of Physiotherapy, Launceston General Hospital, Launceston, Tasmania, Australia
- Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ianthe Boden
- Department of Physiotherapy, Launceston General Hospital, Launceston, Tasmania, Australia
- Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - Iain K Robertson
- School of Health Sciences, University of Tasmania, Launceston, Tasmania, Australia
| | - David Story
- Anaesthesia Perioperative and Pain Medicine Unit, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Linda Denehy
- Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - Selina M Parry
- Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
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Xu Z, Li Y, Zhou J, Li X, Huang Y, Liu X, Burns KEA, Zhong N, Zhang H. High-flow nasal cannula in adults with acute respiratory failure and after extubation: a systematic review and meta-analysis. Respir Res 2018; 19:202. [PMID: 30326893 PMCID: PMC6192218 DOI: 10.1186/s12931-018-0908-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 10/07/2018] [Indexed: 12/16/2022] Open
Abstract
Background High-flow nasal cannula (HFNC) can be used as an initial support strategy for patients with acute respiratory failure (ARF) and after extubation. However, no clear evidence exists to support or oppose HFNC use in clinical practice. We summarized the effects of HFNC, compared to conventional oxygen therapy (COT) and noninvasive ventilation (NIV), on important outcomes including treatment failure and intubation/reintubation rates in adult patients with ARF and after extubation. Methods We searched 4 electronic databases (Pubmed, EMBASE, Scopus, and Web of Science) to identify randomized controlled trials (RCTs) comparing the effects of HFNC with either COT or NIV on rates of 1) treatment failure and 2) intubation/reintubation in adult critically ill patients. Results We identified 18 RCTs (n = 4251 patients) in pooled analyses. As a primary mode of support, HFNC treatment reduced the risk of treatment failure [Odds Ratio (OR) 0.65; 95% confidence interval (CI) 0.43–0.98; p = 0.04; I2 = 32%] but had no effect on preventing intubation (OR, 0.74; 95%CI 0.45–1.21; p = 0.23; I2 = 0%) compared to COT. When used after extubation, HFNC (vs. COT) treatment significantly decreased reintubation rate (OR 0.46; 95%CI 0.33–0.63; p < 0.00001; I2 = 30%) and extubation failure (OR 0.43; 95%CI 0.25–0.73; p = 0.002; I2 = 66%). Compared to NIV, HFNC significantly reduced intubation rate (OR 0.57; 95%CI 0.36–0.92; p = 0.02; I2 = 0%) when used as initial support, but did no favorably impact clinical outcomes post extubation in few trials. Conclusions HFNC was superior to COT in reducing treatment failure when used as a primary support strategy and in reducing rates of extubation failure and reintubation when used after extubation. In few trials, HFNC reduced intubation rate compared to NIV when used as initial support but demonstrated no beneficial effects after extubation. Electronic supplementary material The online version of this article (10.1186/s12931-018-0908-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Zhiheng Xu
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute for Respiratory Health, Guangzhou, China.,Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yimin Li
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute for Respiratory Health, Guangzhou, China.,Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Jianmeng Zhou
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute for Respiratory Health, Guangzhou, China
| | - Xi Li
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute for Respiratory Health, Guangzhou, China.,Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yongbo Huang
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute for Respiratory Health, Guangzhou, China.,Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Xiaoqing Liu
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute for Respiratory Health, Guangzhou, China
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada. .,The Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, M5B1W8, Canada. .,Departments of Anesthesia and Physiology, University of Toronto, Toronto, ON, Canada.
| | - Nanshan Zhong
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute for Respiratory Health, Guangzhou, China
| | - Haibo Zhang
- State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory Disease, Guangzhou Institute for Respiratory Health, Guangzhou, China. .,Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China. .,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada. .,The Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, M5B1W8, Canada. .,Departments of Anesthesia and Physiology, University of Toronto, Toronto, ON, Canada.
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Corley A, Rickard CM, Aitken LM, Johnston A, Barnett A, Fraser JF, Lewis SR, Smith AF. High-flow nasal cannulae for respiratory support in adult intensive care patients. Cochrane Database Syst Rev 2017; 5:CD010172. [PMID: 28555461 PMCID: PMC6481761 DOI: 10.1002/14651858.cd010172.pub2] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND High-flow nasal cannulae (HFNC) deliver high flows of blended humidified air and oxygen via wide-bore nasal cannulae and may be useful in providing respiratory support for adult patients experiencing acute respiratory failure in the intensive care unit (ICU). OBJECTIVES We evaluated studies that included participants 16 years of age and older who were admitted to the ICU and required treatment with HFNC. We assessed the safety and efficacy of HFNC compared with comparator interventions in terms of treatment failure, mortality, adverse events, duration of respiratory support, hospital and ICU length of stay, respiratory effects, patient-reported outcomes, and costs of treatment. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 3), MEDLINE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Web of Science, proceedings from four conferences, and clinical trials registries; and we handsearched reference lists of relevant studies. We conducted searches from January 2000 to March 2016 and reran the searches in December 2016. We added four new studies of potential interest to a list of 'Studies awaiting classification' and will incorporate them into formal review findings during the review update. SELECTION CRITERIA We included randomized controlled studies with a parallel or cross-over design comparing HFNC use in adult ICU patients versus other forms of non-invasive respiratory support (low-flow oxygen via nasal cannulae or mask, continuous positive airway pressure (CPAP), and bilevel positive airway pressure (BiPAP)). DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion, extracted data, and assessed risk of bias. MAIN RESULTS We included 11 studies with 1972 participants. Participants in six studies had respiratory failure, and in five studies required oxygen therapy after extubation. Ten studies compared HFNC versus low-flow oxygen devices; one of these also compared HFNC versus CPAP, and another compared HFNC versus BiPAP alone. Most studies reported randomization and allocation concealment inadequately and provided inconsistent details of outcome assessor blinding. We did not combine data for CPAP and BiPAP comparisons with data for low-flow oxygen devices; study data were insufficient for separate analysis of CPAP and BiPAP for most outcomes. For the primary outcomes of treatment failure (1066 participants; six studies) and mortality (755 participants; three studies), investigators found no differences between HFNC and low-flow oxygen therapies (risk ratio (RR), Mantel-Haenszel (MH), random-effects 0.79, 95% confidence interval (CI) 0.49 to 1.27; and RR, MH, random-effects 0.63, 95% CI 0.38 to 1.06, respectively). We used the GRADE approach to downgrade the certainty of this evidence to low because of study risks of bias and different participant indications. Reported adverse events included nosocomial pneumonia, oxygen desaturation, visits to general practitioner for respiratory complications, pneumothorax, acute pseudo-obstruction, cardiac dysrhythmia, septic shock, and cardiorespiratory arrest. However, single studies reported adverse events, and we could not combine these findings; one study reported fewer episodes of oxygen desaturation with HFNC but no differences in all other reported adverse events. We downgraded the certainty of evidence for adverse events to low because of limited data. Researchers noted no differences in ICU length of stay (mean difference (MD), inverse variance (IV), random-effects 0.15, 95% CI -0.03 to 0.34; four studies; 770 participants), and we downgraded quality to low because of study risks of bias and different participant indications. We found no differences in oxygenation variables: partial pressure of arterial oxygen (PaO2)/fraction of inspired oxygen (FiO2) (MD, IV, random-effects 7.31, 95% CI -23.69 to 41.31; four studies; 510 participants); PaO2 (MD, IV, random-effects 2.79, 95% CI -5.47 to 11.05; three studies; 355 participants); and oxygen saturation (SpO2) up to 24 hours (MD, IV, random-effects 0.72, 95% CI -0.73 to 2.17; four studies; 512 participants). Data from two studies showed that oxygen saturation measured after 24 hours was improved among those treated with HFNC (MD, IV, random-effects 1.28, 95% CI 0.02 to 2.55; 445 participants), but this difference was small and was not clinically significant. Along with concern about risks of bias and differences in participant indications, review authors noted a high level of unexplained statistical heterogeneity in oxygenation effect estimates, and we downgraded the quality of evidence to very low. Meta-analysis of three comparable studies showed no differences in carbon dioxide clearance among those treated with HFNC (MD, IV, random-effects -0.75, 95% CI -2.04 to 0.55; three studies; 590 participants). Two studies reported no differences in atelectasis; we did not combine these findings. Data from six studies (867 participants) comparing HFNC versus low-flow oxygen showed no differences in respiratory rates up to 24 hours according to type of oxygen delivery device (MD, IV, random-effects -1.51, 95% CI -3.36 to 0.35), and no difference after 24 hours (MD, IV, random-effects -2.71, 95% CI -7.12 to 1.70; two studies; 445 participants). Improvement in respiratory rates when HFNC was compared with CPAP or BiPAP was not clinically important (MD, IV, random-effects -0.89, 95% CI -1.74 to -0.05; two studies; 834 participants). Results showed no differences in patient-reported measures of comfort according to oxygen delivery devices in the short term (MD, IV, random-effects 0.14, 95% CI -0.65 to 0.93; three studies; 462 participants) and in the long term (MD, IV, random-effects -0.36, 95% CI -3.70 to 2.98; two studies; 445 participants); we downgraded the certainty of this evidence to low. Six studies measured dyspnoea on incomparable scales, yielding inconsistent study data. No study in this review provided data on positive end-expiratory pressure measured at the pharyngeal level, work of breathing, or cost comparisons of treatment. AUTHORS' CONCLUSIONS We were unable to demonstrate whether HFNC was a more effective or safe oxygen delivery device compared with other oxygenation devices in adult ICU patients. Meta-analysis could be performed for few studies for each outcome, and data for comparisons with CPAP or BiPAP were very limited. In addition, we identified some risks of bias among included studies, differences in patient groups, and high levels of statistical heterogeneity for some outcomes, leading to uncertainty regarding the results of our analysis. Consequently, evidence is insufficient to show whether HFNC provides safe and efficacious respiratory support for adult ICU patients.
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Affiliation(s)
- Amanda Corley
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Level 5, CSB, Rode Rd, Chermside, Queensland, Australia, 4032
- National Centre of Research Excellence in Nursing, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | - Claire M Rickard
- National Centre of Research Excellence in Nursing, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
| | - Leanne M Aitken
- National Centre of Research Excellence in Nursing, Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
- Intensive Care Unit, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Queensland, Australia, 4102
- School of Health Sciences, City, University of London, London, UK
| | - Amy Johnston
- School of Nursing and Midwifery, Menzies Health Institute Queensland, and Department of Emergency Medicine, Gold Coast Health, Southport, Queensland, Australia, 4215
| | - Adrian Barnett
- Institute of Health and Biomedical Innovation, School of Public Health and Social Work, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove, Queensland, Australia, 4059
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital and University of Queensland, Level 5, CSB, Rode Rd, Chermside, Queensland, Australia, 4032
| | - Sharon R Lewis
- Patient Safety Research Department, Royal Lancaster Infirmary, Pointer Court 1, Ashton Road, Lancaster, UK, LA1 4RP
| | - Andrew F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Ashton Road, Lancaster, Lancashire, UK, LA1 4RP
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