A pediatric case developing critical abdominal distension caused by a combination of humidified high-flow nasal cannula oxygen therapy and nasal airway

The effect of mechanical ventilation compared to high-flow nasal cannula on gastric residual volume and reflux events using novel automated technology

BACKGROUND & AIM

High flow nasal cannula (HFNC) oxygen therapy is frequently used following extubation. A case report, utilizing an innovative medical technology (The smART + Platform, ART MEDICAL Ltd., Netanya, Israel) that enables the detection of gastric refluxes and gastric residual volumes (GRV), has suggested that HFNC may be associated with increased reflux events and GRV. This study measured reflux events and GRV using smART+ in mechanically ventilated patients before and after extubation while they were receiving HFNC therapy. We aim to show if there is a significant difference in reflux events and GRV between HFNC users and mechanically ventilated patients.

METHODS

This is a post hoc analysis examines data of a randomized controlled trial (RCT) involving critically ill adult patients who received enteral nutrition through the smART + Platform. The study was approved by the local ethics committee. We compared the frequency and amplitude of reflux events and GRV in mechanically ventilated patients. These parameters were assessed both 3 h before extubation and subsequently after extubation when the patients were connected to HFNC. Patients served as their own controls. To evaluate the differences between the pre- and post-extubation measurements, we applied a parametric paired t-test.

RESULTS

Ten patients (mean age of 58 years; mean APACHE II score 22; mean 3.9 days of mechanical ventilation) were included. Three hours prior extubation the mean GRV was 4.1 ml/h compared to 14.03 ml/h on HFNC (p = 0.004). The mean frequency of major reflux events was 2.33/h in ventilated patients versus 4.4/h in the HFNC patients (p = 0.73). The mean frequency of major reflux events was 9.17/h in ventilated patients versus 9.83/h in HFNC patients (p = 0.14).

CONCLUSIONS

Leveraging the smART + Platform, we demonstrated that the use of HFNC significantly increases GRV compared with patients on mechanical ventilation and may increase the frequency of major reflux events, thereby increasing the risk of aspiration. Further studies are required to support our conclusions.

Gastric Insufflation with High Flow Nasal Oxygen Therapy in Adult Patients Admitted to Intensive Care Unit: An Observational Study

Background

With the provision of a small positive end-expiratory pressure (PEEP) effect, high-flow nasal oxygen (HFNO) therapy carries a risk of stomach distension. The present study was conducted to find out the air leak in the gastric antrum leading to gastric distension in adult patients with acute respiratory failure receiving HFNO therapy.

Materials and methods

Adult patients with early hypoxemic respiratory failure requiring HFNO therapy were enrolled in this trial. Before initiation of HFNO therapy, baseline gastric volume (GV) and the average number of peristaltic contractions over one minute were measured using ultrasound. Once the patient was stabilized on HFNO therapy, a 2nd, 3rd, and 4th ultrasound scans were acquired at 10, 20, and 30 minutes respectively. Vitals and blood gas values were recorded at the baseline and after 30 min of initiation of HFNO therapy. Patient comfort, duration of HFNO therapy, and outcome were also recorded.

Results

The GV at 10, 20, and 30 minutes were significantly larger (p < 0.001) compared to baseline. This increase in GV was associated with a significantly increased number of peristaltic contractions and had a significant positive correlation with the HFNO flow (r = 0.541; p < 0.001). The HFNO therapy was well tolerated by most of the patients and led to a significant improvement in the vitals and blood gas parameters at 30 minutes after initiation of HFNO therapy.

Conclusion

In adult patients with hypoxemic respiratory failure, the use of HFNO therapy produces gas leaks into the stomach leading to increased gastric volume. The gastric distension increases the peristaltic contraction and higher flows result in more distension.

How to cite this article

Ramachandran A, Bhatia P, Mohammed S, Kamal M, Chhabra S, Paliwal B. Gastric Insufflation with High Flow Nasal Oxygen Therapy in Adult Patients Admitted to Intensive Care Unit: An Observational Study. Indian J Crit Care Med 2024;28(4):393-398.

Factors associated with failure of using high flow nasal cannula in children

INTRODUCTION

High flow nasal cannula (HFNC) has significantly success in treating acute respiratory distress while HFNC failure dramatically increases mortality and morbidity.

OBJECTIVE

To describe factors associated with failure of HFNC use in children.

METHODS

We performed a retrospective observational study using demographic and laboratory findings. We compared clinical and laboratory variables in both successful and failed HFNC groups. The correlations between factors and HFNC failure were constructed by binary logistic regression analysis.

RESULTS

Between August 2016 and May 2018, 250 children receiving HFNC (median age 16 months; range 1-228 months, male 50.8%) were enrolled. Pneumonia was the most common cause of respiratory distress, and the median length of stay (LOS) in hospital was 11 days. HFNC failure was found 16.4% while HFNC complication was 4.8% including epistaxis, pressure sore, and gastric distension. Based on multivariable logistic regression analysis, factors associated with HFNC failure were children with congenital heart disease comorbidity (p = 0.005), HFNC use with maximum FiO₂  > 0.6 (p = 0.021), lobar infiltration on chest X-ray (p = 0.012), the reduction of heart rate, and respiratory rate <20% after 1 h of HFNC use (p = 0.001 and p = 0.001, respectively).

CONCLUSION

HFNC is feasible to use for children with respiratory distress; however, patients with congenital heart disease, using HFNC with FiO₂  > 0.6, lobar infiltration on chest X-ray should be closely monitored. Heart rate and respiratory rate are important parameters in addition to clinical assessment for evaluating HFNC failure in children.

The role for high flow nasal cannula as a respiratory support strategy in adults: a clinical practice guideline

Purpose

High flow nasal cannula (HFNC) is a relatively recent respiratory support technique which delivers high flow, heated and humidified controlled concentration of oxygen via the nasal route. Recently, its use has increased for a variety of clinical indications. To guide clinical practice, we developed evidence-based recommendations regarding use of HFNC in various clinical settings.

Methods

We formed a guideline panel composed of clinicians, methodologists and experts in respiratory medicine. Using GRADE, the panel developed recommendations for four actionable questions.

Results

The guideline panel made a strong recommendation for HFNC in hypoxemic respiratory failure compared to conventional oxygen therapy (COT) (moderate certainty), a conditional recommendation for HFNC following extubation (moderate certainty), no recommendation regarding HFNC in the peri-intubation period (moderate certainty), and a conditional recommendation for postoperative HFNC in high risk and/or obese patients following cardiac or thoracic surgery (moderate certainty).

Conclusions

This clinical practice guideline synthesizes current best-evidence into four recommendations for HFNC use in patients with hypoxemic respiratory failure, following extubation, in the peri-intubation period, and postoperatively for bedside clinicians.

Electronic supplementary material

The online version of this article (10.1007/s00134-020-06312-y) contains supplementary material, which is available to authorized users.

High-flow nasal cannula vs standard respiratory care in pediatric procedural sedation: A randomized controlled pilot trial

INTRODUCTION

Respiratory instability is frequently observed during pediatric procedural sedation. The aim of this trial was to estimate the impact of high-flow nasal cannula (HFNC) therapy on respiratory stability during sedation for upper gastrointestinal tract endoscopy in children.

METHODS

Prospective randomized controlled non-blinded single-center pilot trial. Children were randomly allocated to receive either HFNC (2 L/kg/min) or low-flow nasal oxygen cannula (LFNC, standard care). FiO₂ was titrated to maintain SpO₂ 94% to 98% in both groups. Primary outcome was the number of events of respiratory instability defined by prespecified criteria (hypoxia, hypercapnia, apnea). Secondary outcomes included type and duration of events, number of interventions to regain respiratory stability and cumulative doses of medication.

RESULTS

Fifty children (mean age, 12.3 ± 3.1 years) were enrolled and treated with HFNC (n = 25) or LFNC (n = 25). Patient and intervention characteristics were not different in the two study groups, including total oxygen flow rate. Mean (SD) number of respiratory events in the HFNC group was 2.0 ± 1.9 events compared to 2.0 ± 1.4 events in the LFNC group (P = .65; 95% CI of difference, -1.0 to 1.0). There was no difference for any secondary outcome criteria, percentage of patients for any outcome criteria and no difference in the number of respiratory events or airway management maneuvers per patient between treatment groups.

CONCLUSIONS

HFNC did not increase respiratory stability in sedated children undergoing upper gastrointestinal tract endoscopy compared to LFNC.