Characteristics and outcome of patients set up on high-flow oxygen therapy at home

Indications and evidence for domiciliary noninvasive ventilation

INTRODUCTION

Home noninvasive ventilation (HNIV) has expanded globally, with a greater evidence base for its use. HNIV improves multiple patient related outcomes in patients with chronic hypercapnic respiratory failure. Obesity hypoventilation syndrome (OHS) is rapidly taking over as the primary indication for HNIV and COPD patients who overlap with obstructive sleep apnea hypoventilation syndromes (OSAHS) and are increasingly recognized but add to the complexity of HNIV prescribing. Optimal settings vary for differing diseases, with higher inspiratory pressures often required in those with OHS and COPD, yet which settings translate into greatest patient benefit remains unknown.

AREAS COVERED

We cover the evidence base underpinning the common indications for HNIV in COPD, OHS, neuromuscular disease (NMD), and chest wall disease (CWD) and highlight common HNIV modes used.

EXPERT OPINION

Active screening for nocturnal hypoventilation in OHS and COPD may be important to guide earlier ventilation. Further research on which HNIV modalities best improve patient related outcomes and the right time for initiation in different patient phenotypes is rapidly needed. Worldwide, clinical research trials should aim to bridge the gap by reporting on patient-related outcomes and cost effectiveness in real-world populations to best understand the true benefit of HNIV amongst heterogenous patient populations.

Expanded central role of the respiratory physiotherapists in the community setting

The development of community hubs through the Slaintecare initiative will rely on respiratory physiotherapists and clinical nurse specialists for the management of chronic respiratory diseases. The role of the respiratory physiotherapist has evolved dramatically over the last decade. We review the increasing scope of practice of the physiotherapist and the evidence base for same. We pay particular attention to the role of the physiotherapist in areas such as pulmonary rehabilitation, sputum clearance, neuromuscular disease, chronic respiratory failure, ambulatory oxygen assessments and dysfunctional breathing. We give an in depth review of sputum clearance techniques. We also address areas of potential future expansion for the role of the physiotherapist such as prescription and initiation of non-invasive ventilation.

Home High-Flow Therapy in Patients with Chronic Respiratory Diseases: Physiological Rationale and Clinical Results

High-flow therapy (HFT) is the administration of gas flows above 15 L/min. It is a non-invasive respiratory support that delivers heated (up to 38 °C), humidified (100% Relative Humidity, RH; 44 mg H2O/L Absolute Humidity, AH), oxygen-enriched air when necessary, through a nasal cannula or a tracheostomy interface. Over the last few years, the use of HFT in critically ill hypoxemic adults has increased. Although the clinical benefit of home high-flow therapy (HHFT) remains unclear, some research findings would support the use of HHFT in chronic respiratory diseases. The aim of this review is to describe the HFT physiological principles and summarize the published clinical findings. Finally, we will discuss the differences between hospital and home implementation, as well as the various devices available for HHFT application.

Hygrometric Performances of Different High-Flow Nasal Cannula Devices: Bench Evaluation and Clinical Tolerance

BACKGROUND

High-flow nasal cannula (HFNC) is increasingly used for the management of respiratory failure. Settings include [Formula: see text], total gas flow, and temperature target. Resulting absolute humidity (AH) at the nasal cannula may affect clinical tolerance, and optimal settings with respect to hygrometry remain poorly documented.

METHODS

A bench study was designed to assess AH delivered by 4 HFNC devices (Optiflow, Airvo 2, Precision Flow, and Hydrate) according to flow, ambient temperature, and other available settings. Clinical tolerance of different levels of hygrometry (20, 30, and 40 mg H₂O/L) was evaluated in 15 healthy volunteers.

RESULTS

With [Formula: see text] set at 1.0, normal ambient temperature, and settings made accordingly to the manufacturers' recommendations, mean ± SD AH was 42.2 ± 3.1, 39.5 ± 1.8, 35.7 ± 2.0, and 32.9 ± 2.7 mg H₂O/L for the Airvo 2, Optiflow, Hydrate, and Precision Flow, respectively, (P < .001). AH dropped from -3.5 to -10.7 mg H₂O/L (P <. 001) with high ambient temperature, except for the Precision Flow. Increasing flow did not significantly affect AH except for the Precision Flow (from 36.4 ± 1.6 to 29.8 ± 0.2 mg H₂O/L at 10 and 40 L/min, respectively, [P < .001]). The lowest AH was encountered with the Optiflow set with noninvasive ventilation (NIV) mode, without compensation algorithm, and at high ambient temperature (14.2 ± 1.5 mg H₂O/L). In studied subjects, AH significantly affected breathing comfort, reduced from 7.0 ± 1.0 to 3.0 ± 2.0 at 40 and 20 mg H₂O/L, respectively, (P < .001). Comfort was similar at 30 and 40 mg H₂O/L.

CONCLUSIONS

When used according to manufacturer's recommendations and at normal ambient temperature, all the HFNC devices evaluated achieved satisfactory hygrometric output with respect to breathing comfort evaluated in healthy subjects (≥ 30 mg H₂O/L). Substantial differences exist between devices, and optimal knowledge of their working principles is required as inappropriate usage may dramatically alter efficacy and clinical tolerance.

The pattern of hospital-community-home (HCH) nursing in tracheostomy patients with severe traumatic brain injury: Is it feasible?

BACKGROUND

Tracheostomy is very common in patients with severe traumatic brain injury (TBI), long-term nursing care are needed for those patients. We aimed to evaluate the effects of hospital-community-home (HCH) nursing in those patients.

METHODS

This study was a before-after study design. Patients were divided into control groups (traditional nursing care) and HCH group(HCH nursing care). Tracheostomy patients with severe TBI needing long-term care were included. All patients underwent a two-month long follow-up. Glasgow coma score (GCS), Karnofsky, Self-Anxiety Scale (SAS) from caregiver and Barthel assessment at the discharge and two months after discharge were evaluated. The tracheostomy-related complications were recorded and compared.

RESULTS

A total of 60 patients were included. There were no significant differences between the two groups in the GCS, Karnofsky, SAS from caregiver and Barthel index at discharge((all P > .05); the GCS, Karnofsky and Barthel index were all significantly increased after two-month follow-up for the two groups (all P < .05), and the GCS, Karnofsky and Barthel index at two-month follow-up in HCH group were significantly higher than that of the control group(all P < .05), but the SAS from caregiver at two-month follow-up in HCH group was significantly less than that of the control group(P = .009). The incidence of block of artificial tracheal cannula and readmission in HCH group were significant less than that of control group (all P < .05).

CONCLUSION

HCH nursing care is feasible in tracheostomy patients with severe TBI, future studies are needed to further evaluate the role of HCH nursing care.

End-of-life home care of an interstitial pneumonia patient supported by high-flow nasal cannula therapy: A case report

BACKGROUND

High-flow nasal cannula (HFNC) therapy and morphine continuous subcutaneous infusion (CSI) have been used to ameliorate dyspnea in non-cancer patients with end-stage respiratory diseases, including chronic obstructive pulmonary disease and interstitial pneumonia, primarily in hospital settings. However, it is rare to perform home-based medical treatment using these. We observe a case to assess the feasibility of this treatment strategy.

CASE SUMMARY

Here, we report a case of a 75-year-old man who was diagnosed with interstitial pneumonia 11 years ago and was successfully nursed at home during his terminal phase for over 10 mo without hospitalization, by introducing domiciliary uses of HFNC and morphine CSI with a patient-controlled analgesia device.

CONCLUSION

Active utilization of HFNC and morphine CSI with patient-controlled analgesia device would substantiate successful end-of-life palliative home care of idiopathic interstitial pneumonia patients.

High-flow nasal cannula oxygen therapy as an emerging option for respiratory failure: the present and the future

Conventional oxygen therapy (COT) and noninvasive ventilation (NIV) have been considered for decades as frontline treatment for acute or chronic respiratory failure. However, COT can be insufficient in severe hypoxaemia whereas NIV, although highly effective, is poorly tolerated by patients and its use requires a specific expertise. High-flow nasal cannula (HFNC) is an emerging technique, designed to provide oxygen at high flows with an optimal degree of heat and humidification, which is well tolerated and easy to use in all clinical settings. Physiologically, HFNC reduces the anatomical dead space and improves carbon dioxide wash-out, reduces the work of breathing, and generates a positive end-expiratory pressure and a constant fraction of inspired oxygen. Clinically, HFNC effectively reduces dyspnoea and improves oxygenation in respiratory failure from a variety of aetiologies, thus avoiding escalation to more invasive supports. In recent years it has been adopted to treat de novo hypoxaemic respiratory failure, exacerbation of chronic obstructive pulmonary disease (COPD), postintubation hypoxaemia and used for palliative respiratory care. While the use of HFNC in acute respiratory failure is now routine as an alternative to COT and sometimes NIV, new potential applications in patients with chronic respiratory diseases (e.g. domiciliary treatment of patients with stable COPD), are currently under evaluation and will become a topic of great interest in the coming years.