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 Experts on Air

High flow nasal cannula therapy: Daily practice tips

Experts on air - High flow nasal cannula therapy Experts on air - High flow nasal cannula therapy

In our first webinar series, five international experts discussed various aspects of treating patients with high flow nasal cannula therapy (HFNC) (Also known as high flow oxygen therapy. This terminology can be used interchangeably with high flow nasal cannula therapyA​). They looked at some of the challenges you might face and offered their tips and tricks for best practice to improve patient outcomes.

Video recordings. Watch the sessions

Experts On Air - Right patient, right treatment, right time? How to use HFOT guidelines

Right patient, right treatment, right time? How to use HFOT guidelines

Sharon Einav and Tommaso Mauri.

 

Before initiating HFNC therapy, we need to identify the patient’s criteria and adapt treatment based on clinical guidelines. This webinar looked at the different types of patients and how they can benefit from this therapy.

Experts On Air - How to optimize HFNC therapy settings - Input from physiological studies

How to optimize HFNC therapy settings. Input from physiological studies

Tommaso Mauri and Jens Bräunlich.

 

In order to improve physiology and outcomes of patients supported by HFNC, it is crucial to adjust the flow rate, FiO2, temperature, and cannula size based on target physiological variables such as respiratory effort, ROX index, respiratory rate, etc., as well as on patient comfort. We focused on how to optimize HFNC this physiology-based approach.

Experts On Air - How to monitor patients during nasal HFNC therapy

How to monitor patients. During nasal HFNC therapy

Oriol Roca and Sharon Einav.

 

To better understand the progress of nasal high flow nasal cannula therapy it is essential to monitor the patient's respiratory parameters such as oxygenation and RR. In this session, we covered different aspects of respiratory monitoring and explain how they could be used at the bedside.

Experts On Air - Intubation in hypoxemic respiratory failure: Does time matter?

Intubation in hypoxemic respiratory failure: Does time matter?

Jean-Damien Ricard and Tommaso Mauri.

 

The point in time at which a critically ill patient is intubated can play an important role in their survival, especially in those with hypoxemic respiratory failure. In this webinar, we talked about when to intubate patients undergoing HFNC therapy and which parameters should be taken into consideration.

Experts On Air - HFNC in hypercapnic respiratory failure

HFNC. In hypercapnic respiratory failure

Jens Bräunlich and Tommaso Mauri.

 

The latest studies indicate that HFNC may have beneficial effects on patients with hypercapnia. In this webinar, we reviewed the effects this therapy may have on these patients and how to approach their treatment.

Experts On Air - HFNC outside of critical care

HFNC. Outside of critical care

Jean-Damien Ricard and Oriol Roca.

 

The COVID-19 pandemic has seen HFNC therapy become more and more relevant in various departments, including emergency care, pediatrics, and general patient wards. In this webinar, we looked at where this therapy could be initiated to achieve better patient outcomes.

Experts On Air: Ask the experts

Ask the experts. Questions and answers

Q&A 1. Right patient, right treatment, right time? How to use HFOT guidelines

There is currently no known protocol for congenital heart surgery

There is no formal protocol for weaning. (See the next webinar on February 24 about optimizing HFOT settings).

Data is clear on the benefit of CPAP, there is not enough literature on HFNO.

 

(a) In high risk/obese patients particularly after chest surgery and abdominal surgery. Also consider ENT if there are secretions. (b) There could be a possible issue with pressure on surgical sutures with NIV if it was gastric surgery. (c)  In failed HFNO, heart failure patients. You could also alternate HFNO with NIV. 

Prevention : HFNC is good for comfort and maybe shortened stays. Treatment:  This is unclear (not enough patients). NIV shows benefit but there is not enough head-to-head data.

There are three papers showing the cost-effectiveness of HFNC. It is obviously not for indiscriminate use.  For pediatrics, there is also literature justifying the use of HFNO for bronchiolitis: Buendía JA, Acuña-Cordero R, Rodriguez-Martinez CE. The cost-utility of early use of high-flow nasal cannula in bronchiolitis. Health Econ Rev. 2021;11(1):41. Published 2021 Oct 28. doi:10.1186/s13561-021-00339-71​, Buendía JA, Acuña-Cordero R, Rodriguez-Martinez CE. Budget impact analysis of high-flow nasal cannula for infant bronchiolitis: the Colombian National Health System perspective. Curr Med Res Opin. 2021;37(9):1627-1632. doi:10.1080/03007995.2021.19433422​, Heikkilä P, Forma L, Korppi M. High-flow oxygen therapy is more cost-effective for bronchiolitis than standard treatment-A decision-tree analysis. Pediatr Pulmonol. 2016;51(12):1393-1402. doi:10.1002/ppul.234673

There is also some cost-utility work on HFNO for COPD use at home which appears quite convincing: Sørensen SS, Storgaard LH, Weinreich UM. Cost-Effectiveness of Domiciliary High Flow Nasal Cannula Treatment in COPD Patients with Chronic Respiratory Failure. Clinicoecon Outcomes Res. 2021;13:553-564. Published 2021 Jun 18. doi:10.2147/CEOR.S3125234​.

Contraindications: Patient not awake / nobody to see/montior the patient (no alarms).

Mainly delayed intubation; possible P-SILI as well.

Not at all. The advantage of HFO is in the high flows. Hence, if there is no respiratory distress (i.e., low flows) and supplementation up to an FiO2 of 0.5-0.6 suffices, there is no need.

There are no RCTs but there are several interesting studies thus far:

COVID-ICU group, for the REVA network, COVID-ICU investigators. Benefits and risks of noninvasive oxygenation strategy in COVID-19: a multicenter, prospective cohort study (COVID-ICU) in 137 hospitals. Crit Care. 2021;25(1):421. Published 2021 Dec 8. doi:10.1186/s13054-021-03784-25​: “In patients with COVID-19, HFNC was associated with a reduction in oxygenation failure without improvement in 90-day mortality, whereas NIV was associated with a higher mortality in these patients. “

Ranieri VM, Tonetti T, Navalesi P, et al. High-Flow Nasal Oxygen for Severe Hypoxemia: Oxygenation Response and Outcome in Patients with COVID-19. Am J Respir Crit Care Med. 2022;205(4):431-439. doi:10.1164/rccm.202109-2163OC6​: “We analyzed 184 and 131 patients receiving HFNO or NIV, respectively. 112 HFNO, and 69 NIV patients transitioned to IMV. 104 (92.9%) HFNO patients and 66 (95.7%) NIV patients continued to have PaO2/FiO2 ≤300 under IMV…. Overall mortality was 19.0% (35/184) and 24.4% (32/131) for HFNO and NIV, respectively (p=0.2479).”

Perkins GD, Ji C, Connolly BA, et al. Effect of Noninvasive Respiratory Strategies on Intubation or Mortality Among Patients With Acute Hypoxemic Respiratory Failure and COVID-19: The RECOVERY-RS Randomized Clinical Trial. JAMA. 2022;327(6):546-558. doi:10.1001/jama.2022.00287​: “Among patients with acute hypoxemic respiratory failure due to COVID-19, an initial strategy of CPAP significantly reduced the risk of tracheal intubation or mortality compared with conventional oxygen therapy, but there was no significant difference between an initial strategy of HFNO compared with conventional oxygen therapy. The study may have been underpowered for the comparison of HFNO vs conventional oxygen therapy.”
This may be better than immediately intubating these patients…

Definitely yes, although the literature is still not sufficiently strong. There are no RCTs but there are several interesting studies thus far (see answer to previous question).

Yes, we use a specific connector for tracheostomy. Only in monitored areas. Not for patients who need suction more than 2 or more times each nursing shift (>twice in 8 hours).

Over COT and before NIV for all patients except heart failure.

Possibly looking forward there may be ways to identify these patients based on their aeration distributions (CT) and WOB (EiT). We are not there yet.

Helmet is the interface, not the mode of ventilation. Use of a helmet interface requires experience. We use it for patients who are cooperative and alternate it with HFNO since it limits communication and feeding.  

In terms of mode, BiPAP definitely first line only for pulmonary edema (heart failure). An interesting paper on helmet vs. HFNO for heart failure  (single center about 200 patients): Osman A, Via G, Sallehuddin RM, et al. Helmet continuous positive airway pressure vs. high flow nasal cannula oxygen in acute cardiogenic pulmonary oedema: a randomized controlled trial. Eur Heart J Acute Cardiovasc Care. 2021;10(10):1103-1111. doi:10.1093/ehjacc/zuab0788

For COVID: 110 patients: Grieco DL, Menga LS, Cesarano M, et al. Effect of Helmet Noninvasive Ventilation vs High-Flow Nasal Oxygen on Days Free of Respiratory Support in Patients With COVID-19 and Moderate to Severe Hypoxemic Respiratory Failure: The HENIVOT Randomized Clinical Trial. JAMA. 2021;325(17):1731-1743. doi:10.1001/jama.2021.46829

Among patients with COVID-19 and moderate to severe hypoxemia, treatment with helmet noninvasive ventilation, compared with high-flow nasal oxygen, resulted in no significant difference in the number of days free of respiratory support within 28 days.

We alternate based on the patients tolerance and response.

BiPAP definitely.

The problem is that mean apnea times in the studies for the metaanalysis were <2 minutes and even <1 in critical care patients. Also, most patients included in these studies were not with severe hypoxia, no data on difficult intubations, not enough on obesity (one study) and not on preganacy. So overall I agree with your clinical impression and we use it during intubations of patients with hypoxemia in our ICU.

There may be P-SILI with HFNO as well but this is vey diffucult to measure clinically. There is direct evidence of this in only neonatal cases with baro/volutrauma but we must assume the possibility exists in adults too.

At least 30 liters per minute. (See the upcoming webinar on optimizing HFOT settings on February 24.)

Q&A 2. How to optimize HFOT settings - Input from physiological studies

Weaning from HFNC should be gradual as this is a potent non invasive support. FiO2 could be the first setting to decrease, while flow can be safely reduced after FiO2 becomes <50%. When FiO2 is <40% with flow <40 l/min, transition to standard oxygen, for example to discharge the patient from the ICU. This could be attempted with 2 hours of close monitoring.

See above.

The paper mentioned in my talk by Pinkham et al. is very recent and confirms values between 2 and 5 cmH2O (Pinkham M, Tatkov S. Effect of flow and cannula size on generated pressure during nasal high flow. Crit Care. 2020;24(1):248. Published 2020 May 24. doi:10.1186/s13054-020-02980-w10​).

I would be careful, for the study in Crit Care 2020 on flows > 60 l/min we used 2 humidifiers. 

See above.

We do use HFNC with NGT, usually smaller cannula, being careful of accurate positioning and checking from time to time. 

Aerosol shouldn't be an issue, HFNC can even grant improved delivery to the distal airways, see Reminiac F, Vecellio L, Bodet-Contentin L, et al. Nasal high-flow bronchodilator nebulization: a randomized cross-over study. Ann Intensive Care. 2018;8(1):128. Published 2018 Dec 20. doi:10.1186/s13613-018-0473-811​.

Yes, if the high flow is connected to a mask you just give a lot of oxygen, probably lose both PEEP effect (no occlusion of the nares) and CO2 washout (no direct flow in the upper airways), I would avoid that.

No, CO2 clearance is not affected as long as there is a circulation of gas, open mouth and venturi effect may reduce tha alveolar FiO2 and the PEEP effect, determining worsening oxygenation.

 

We normally use EIT by continuous monitoring of end-expiratory impedance before and after start of HFNC.

Q&A 3. How to monitor patients during nasal HFOT

OSI is the oxygenation saturation index. Is is normally defined as [Fio2 × mean airway pressure × 100)/oxygen saturation by pulse oximetry (Spo2)] and predicts outcomes of mechanically ventilated patients. In the case of HFNC patients, MAP may be estimated by the level of flow delivered, but no data is available about its utility.

There is probably no single variable that reflects the response to the treatment. I think that different things happen when the patient is doing well: oxygenation improvement, decrease in respiratory rate, relief in dyspnea feeling… Regarding the right flow, we know that most of the effects are flow-dependent and, therefore, when we start the treatment in paitents with acute hypoxemic respiratory failure, we try to use the highest tolerated flow. However, we can't start with 60Lpm as the patient does not tolerate it. So we start with 40Lpm and once the patient is used to receiving this amount of flow, we can progressively increase up to 60Lpm. This increase can usually be made in the first 30 minutes of treatment.

(Editor's note: "aspects" has been understood as "variables" for the purposes of this answer) Clinical examination, respiratory rate, use of accessory muscles, thoraco-abdominal asynchrony, SpO2, FiO2

There is no specific timeframe for expected improvement. However, it is true that some thresholds of different variables have been described as predictors of HFNC failure at different time-points.  

The use of accessory muscles suggests that the inspiratory effort is excessive. Similarly, low PaCO2 or a negative swing in CVP could also suggest the same. (Please also see the second webinar for an answer to this question.)

I do not wait. If the patient is not responding to the treatment, I try to increase the flow up to the maximum tolerated. And if the patient is still not responding, one would need to escalate the treatment. 

The evidence is sometimes controversial because the criteria for intubation may vary a lot between different countries, hospitals or even doctors in the same ICU. Thus, some studies compared early versus delayed intubation taking the time of ICU admission as moment 0. The majority of them have shown that earlier intubation is associated with better outcomes. In other words, delayed intubation may be associated with increased mortality. 

My suggestion would be not to base the decision of intubating a patient based only on a number. The clinical examination of the patient is extremely important. The ROX may help you to decide if the patient is doing well or not, as you can repeat the measurement several times. The benefit of the ROX is that it is based on physiological variables that determine the outcome (need for intubation). We proposed an algorithm that may help in a review in ICM with Jean-Damien Ricard in 2020 that we are now testing in a RCT.

 

In our clinical practice we rarely do it. There is a good correlation between SpO2 and PaO2 if you keep the SpO2 < 98%. 

These patients usually need lower flows and benefit more from active humidification that improves secretion clearance. But I would base my decisions in the same way as for HFNC patients. 

As commented before, I would never make a decision based on just a number. I think that the ROX value should be combined with the clinical examination of the patient.

Q&A 4. Intubation in hypoxemic respiratory failure: Does time matter?

Many observational studies have suggested that NHF prevents intubation. The clinical impression was unequivocally demonstrated in a large randomized trial (Frat JP, Thille AW, Mercat A, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med. 2015;372(23):2185-2196. doi:10.1056/NEJMoa150332612​). In this study, patients at greater risk of intubation (i.e., those with PaO2/FiO2 below 200) and who received NHF were significantly less intubated than those who received either NIV or standard oxygen. More recently, several studies performed in Covid-related ARDS have confirmed the prevention of intubation with the use of NHF (COVID-ICU group, for the REVA network, COVID-ICU investigators. Benefits and risks of noninvasive oxygenation strategy in COVID-19: a multicenter, prospective cohort study (COVID-ICU) in 137 hospitals. Crit Care. 2021;25(1):421. Published 2021 Dec 8. doi:10.1186/s13054-021-03784-213​, ​Ospina-Tascón GA, Calderón-Tapia LE, García AF, et al. Effect of High-Flow Oxygen Therapy vs Conventional Oxygen Therapy on Invasive Mechanical Ventilation and Clinical Recovery in Patients With Severe COVID-19: A Randomized Clinical Trial [published correction appears in JAMA. 2022 Mar 15;327(11):1093]. JAMA. 2021;326(21):2161-2171. doi:10.1001/jama.2021.2071414​).

Of note, the data is less conclusive in patients with hematological or oncological disorders.
 

If the question is interpreted as "Is it reasonable to start NHF and perhaps escalate to invasive ventilation in a patient beyond 65 years", the answer is yes, but patients and family must be informed that the prognosis is much less favorable than in younger patients. My bias is that intubation should be discussed on an individual basis above 70-75, depending on the presence of comorbodities and the fitness of the patient before being infected by Covid.

Yes, for at least two reasons. First, although there is - at a cohort level - a relationship between the importance of lung involvement and outcome, on an individual basis, we have sometimes had very rapid recovery despite an initial unfavorable radiological assessment. Second, the radiological phenotype also plays a role (we had the impression that very diffuse ground glass was less "bad" than consolidation display). And finally, even if the patient is at high risk of intubation, NHF can be initiated and will help preoxygenate the patient, and will serve as apneic oxygenation during laryngoscopy.  

I don't yet have any personal experience with 100 l/min. My bias is that because there is a linear relationship between flow and both positive pressure and deadspace washout, this suggests that beneficial effects of NHF are more important at 100 l/min than at 60. Obviously, the question of tolerance is a key issue. We need more data on the tolerance of these very high flows.

This is a vast question and whole consensus conferences have been dedicated to this unique question. Bear in mind several facts: 1) there is no 100%-sure test or group of parameters that predict safe extubation; 2) reintubation will occur in 10%-20% of patients; 3) unplanned extubation does not systematically lead to reintubation (only 40% approx.). That means we as clinicians must stay very humble as to our capacity to predict extubation outcome. Always perform either a T-piece trial or minimal pressure support spontaneous breathing trial. When to start these trials? Partial or complete resolution of the cause that led to intubation. Hemodynamic stability without vasopressors, FiO2 < 40%, PEEP < 5, no or little neurological and cognitive impairment, appropriate cough, no or little muscle weakness. 

Q&A 5. HFNC in hypercapnic respiratory failure

There could be two possible reasons: 1. It could be an optimized ventilation and endobronchial humidity, which leads to reduced triggering of an ECOPD 2. Prevention of symptoms worsening in the case of exacerbation onset.

After some more clinical studies about efficiency this could be the next step to optimize NHF therapy.

We have the same experience.

Q&A 6. HFNC outside of critical care

In my ICU, we performed nasal high flow in Covid-19 patients throughout all the consecutive surges in rooms without negative pressure without experiencing staff contamination. So the answer, in my opinion, is yes, nasal high flow can be performed in a room without negative pressure, provided staff is properly equipped with PPE.

(Editor's note: This question was interpreted as "What safety parameters should be observed when using HFOT outside of the ICU?"). Tthere is no definite answer to that question, because it depends on how far from the ICU nasal high flow is performed, how well the staff is trained to perform and monitor nasal high flow in patients with acute respiratory failure, if these patients will have continuous measurment of SpO2 or not, etc. Having said this, I believe FiO2 should be limited, and not exceed 60%; SpO2 should not be below 92-94% ; respiratory rate no greater than 25-28. if patients are out of one of these targets, then an ICU physician should be called to assess these patients  

I have no personal data or experience. My bias is that if there is no possiblity of electric supply, then it will be problematic to not have any humidification. If an external battery was available and it covered the entire flight time, then I would see no "technical" reasons why such a device could not be operated during a helictopter flight  (Editor's note: To our knowledge, there is currently no humidification device available that is approved for transport.)

The Rox index was established and validated in adult (over 18 yo) patients with pneumonia-related acute hypoxemic respiratory failure. It makes sense to apply it to younger patients whose physiological characteristics are similar to those of adult patients. I'm aware of at least one publication in which the Rox score was established in a pediatric population: Yildizdas D, Yontem A, Iplik G, Horoz OO, Ekinci F. Predicting nasal high-flow therapy failure by pediatric respiratory rate-oxygenation index and pediatric respiratory rate-oxygenation index variation in children. Eur J Pediatr. 2021;180(4):1099-1106. doi:10.1007/s00431-020-03847-615​.

Several studies have shown that use of nasal high flow reduced the intubation rate in children admitted for respiratory failure due to bronchiolitis: Franklin D, Babl FE, Schlapbach LJ, et al. A Randomized Trial of High-Flow Oxygen Therapy in Infants with Bronchiolitis. N Engl J Med. 2018;378(12):1121-1131. doi:10.1056/NEJMoa171485516​ and Schibler A, Pham TM, Dunster KR, et al. Reduced intubation rates for infants after introduction of high-flow nasal prong oxygen delivery. Intensive Care Med. 2011;37(5):847-852. doi:10.1007/s00134-011-2177-517​.

There is no similar data in adults, most probably because the clinical entity of bronchiolitis in adults is less defined and hence much less frequent.

Disclaimer

The contents of this page are for informational purposes only and are not intended to be a substitute for professional training or for standard treatment guidelines in your facility. The responses to the questions on this page were prepared by the respective webinar's speaker;  any recommendations made here with respect to clinical practice or the use of specific products, technology, or therapies represent the personal opinion of the speaker only, and may not be considered as official recommendations made by Hamilton Medical AG. Hamilton Medical AG provides no warranty with respect to the information contained ion this page and reliance on any part of this information is solely at your own risk.

References

  1. 1. Buendía JA, Acuña-Cordero R, Rodriguez-Martinez CE. The cost-utility of early use of high-flow nasal cannula in bronchiolitis. Health Econ Rev. 2021;11(1):41. Published 2021 Oct 28. doi:10.1186/s13561-021-00339-7
  2. 2. Buendía JA, Acuña-Cordero R, Rodriguez-Martinez CE. Budget impact analysis of high-flow nasal cannula for infant bronchiolitis: the Colombian National Health System perspective. Curr Med Res Opin. 2021;37(9):1627-1632. doi:10.1080/03007995.2021.1943342
  3. 3. Heikkilä P, Forma L, Korppi M. High-flow oxygen therapy is more cost-effective for bronchiolitis than standard treatment-A decision-tree analysis. Pediatr Pulmonol. 2016;51(12):1393-1402. doi:10.1002/ppul.23467
  4. 4. Sørensen SS, Storgaard LH, Weinreich UM. Cost-Effectiveness of Domiciliary High Flow Nasal Cannula Treatment in COPD Patients with Chronic Respiratory Failure. Clinicoecon Outcomes Res. 2021;13:553-564. Published 2021 Jun 18. doi:10.2147/CEOR.S312523
  5. 5. COVID-ICU group, for the REVA network, COVID-ICU investigators. Benefits and risks of noninvasive oxygenation strategy in COVID-19: a multicenter, prospective cohort study (COVID-ICU) in 137 hospitals. Crit Care. 2021;25(1):421. Published 2021 Dec 8. doi:10.1186/s13054-021-03784-2
  6. 6. Ranieri VM, Tonetti T, Navalesi P, et al. High-Flow Nasal Oxygen for Severe Hypoxemia: Oxygenation Response and Outcome in Patients with COVID-19. Am J Respir Crit Care Med. 2022;205(4):431-439. doi:10.1164/rccm.202109-2163OC
  7. 7. Perkins GD, Ji C, Connolly BA, et al. Effect of Noninvasive Respiratory Strategies on Intubation or Mortality Among Patients With Acute Hypoxemic Respiratory Failure and COVID-19: The RECOVERY-RS Randomized Clinical Trial. JAMA. 2022;327(6):546-558. doi:10.1001/jama.2022.0028
  8. 8. Osman A, Via G, Sallehuddin RM, et al. Helmet continuous positive airway pressure vs. high flow nasal cannula oxygen in acute cardiogenic pulmonary oedema: a randomized controlled trial. Eur Heart J Acute Cardiovasc Care. 2021;10(10):1103-1111. doi:10.1093/ehjacc/zuab078

 

  1. 9. Grieco DL, Menga LS, Cesarano M, et al. Effect of Helmet Noninvasive Ventilation vs High-Flow Nasal Oxygen on Days Free of Respiratory Support in Patients With COVID-19 and Moderate to Severe Hypoxemic Respiratory Failure: The HENIVOT Randomized Clinical Trial. JAMA. 2021;325(17):1731-1743. doi:10.1001/jama.2021.4682
  2. 10. Pinkham M, Tatkov S. Effect of flow and cannula size on generated pressure during nasal high flow. Crit Care. 2020;24(1):248. Published 2020 May 24. doi:10.1186/s13054-020-02980-w
  3. 11. Reminiac F, Vecellio L, Bodet-Contentin L, et al. Nasal high-flow bronchodilator nebulization: a randomized cross-over study. Ann Intensive Care. 2018;8(1):128. Published 2018 Dec 20. doi:10.1186/s13613-018-0473-8
  4. 12. Frat JP, Thille AW, Mercat A, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med. 2015;372(23):2185-2196. doi:10.1056/NEJMoa1503326
  5. 14. Ospina-Tascón GA, Calderón-Tapia LE, García AF, et al. Effect of High-Flow Oxygen Therapy vs Conventional Oxygen Therapy on Invasive Mechanical Ventilation and Clinical Recovery in Patients With Severe COVID-19: A Randomized Clinical Trial [published correction appears in JAMA. 2022 Mar 15;327(11):1093]. JAMA. 2021;326(21):2161-2171. doi:10.1001/jama.2021.20714
  6. 15. Yildizdas D, Yontem A, Iplik G, Horoz OO, Ekinci F. Predicting nasal high-flow therapy failure by pediatric respiratory rate-oxygenation index and pediatric respiratory rate-oxygenation index variation in children. Eur J Pediatr. 2021;180(4):1099-1106. doi:10.1007/s00431-020-03847-6
  7. 16. Franklin D, Babl FE, Schlapbach LJ, et al. A Randomized Trial of High-Flow Oxygen Therapy in Infants with Bronchiolitis. N Engl J Med. 2018;378(12):1121-1131. doi:10.1056/NEJMoa1714855
  8. 17. Schibler A, Pham TM, Dunster KR, et al. Reduced intubation rates for infants after introduction of high-flow nasal prong oxygen delivery. Intensive Care Med. 2011;37(5):847-852. doi:10.1007/s00134-011-2177-5

Footnotes

  • A. Also known as high flow oxygen therapy. This terminology can be used interchangeably with high flow nasal cannula therapy.

 

The cost-utility of early use of high-flow nasal cannula in bronchiolitis.

Buendía JA, Acuña-Cordero R, Rodriguez-Martinez CE. The cost-utility of early use of high-flow nasal cannula in bronchiolitis. Health Econ Rev. 2021;11(1):41. Published 2021 Oct 28. doi:10.1186/s13561-021-00339-7



BACKGROUND

High-flow nasal cannula (HFNC) oxygen is a non-invasive ventilation system that was introduced as an alternative to CPAP (continuous positive airway pressure), with a marked increase in its use in pediatric care settings. This study aimed to evaluate the cost-effectiveness of early use of HFNC compared to oxygen by nasal cannula in an infant with bronchiolitis in the emergency setting.

METHODS

A decision tree model was used to estimate the cost-effectiveness of HFNC compared with oxygen by nasal cannula (control strategy) in an infant with bronchiolitis in the emergency setting. Cost data were obtained from a retrospective study on bronchiolitis from tertiary centers in Rionegro, Colombia, while utilities were collected from the literature.

RESULTS

The QALYs per patient calculated in the base-case model were 0.9141 (95% CI 0.913-0.915) in the HFNC and 0.9105 (95% CI 0.910-0.911) in control group. The cost per patient was US$368 (95% CI US$ 323-411) in HFNC and US$441 (95% CI US$ 384-498) per patient in the control group.

CONCLUSIONS

HFNC was cost-effective HFNC compared to oxygen by nasal cannula in an infant with bronchiolitis in the emergency setting. The use of this technology in emergency settings will allow a more efficient use of resources, especially in low-resource countries with high prevalence of bronchiolitis .

Budget impact analysis of high-flow nasal cannula for infant bronchiolitis: the Colombian National Health System perspective.

Buendía JA, Acuña-Cordero R, Rodriguez-Martinez CE. Budget impact analysis of high-flow nasal cannula for infant bronchiolitis: the Colombian National Health System perspective. Curr Med Res Opin. 2021;37(9):1627-1632. doi:10.1080/03007995.2021.1943342



BACKGROUND

High-flow nasal cannula is a non-invasive ventilation system that was introduced as an alternative to continuous positive airway pressure), with a marked increase in its use in pediatric care settings. However, the expected budget impact of this intervention has not been explicitly estimated. This study aimed to evaluate the budget impact of the high-flow nasal cannula for acute bronchiolitis in Colombia.

METHODS

A budget impact analysis was performed to evaluate the potential financial impact deriving from high-flow nasal cannula during 2020. The analysis considered a 5-year time horizon and Colombian National Health System perspective. The incremental budget impact was calculated by subtracting the cost of the new treatment, in which a high-flow nasal cannula is reimbursed, from the cost of the conventional treatment without a high-flow nasal cannula (supplemental oxygen through a nasal cannula up to a maximum of 2 liters per minute). Univariate one-way sensitivity analyses were performed.

RESULTS

In the base-case analysis the 5-year costs associated with high-flow nasal cannula and no- high-flow nasal cannula were estimated to be US$159,585,618 and US$172,751,689 respectively, indicating savings for Colombian National Health equal to US$13,166,071 if the high-flow nasal cannula is adopted for the routine management of patients with acute bronchiolitis. This result was robust in univariate sensitivity one-way analysis.

CONCLUSION

High-flow nasal cannula was cost-saving in emergency settings for treating infants with acute bronchiolitis. This evidence can be used by decision-makers in our country to improve clinical practice guidelines and should be replicated to validate their results in other middle-income countries.

High-flow oxygen therapy is more cost-effective for bronchiolitis than standard treatment-A decision-tree analysis.

Heikkilä P, Forma L, Korppi M. High-flow oxygen therapy is more cost-effective for bronchiolitis than standard treatment-A decision-tree analysis. Pediatr Pulmonol. 2016;51(12):1393-1402. doi:10.1002/ppul.23467

We evaluated the cost-effectiveness of high-flow nasal cannula (HFNC) to provide additional oxygen for infants with bronchiolitis, compared to standard low-flow therapy. The cost-effectiveness was evaluated by decision analyses, using decision tree modeling, and was based on real costs from our recently published retrospective case-control study. The data on the effectiveness of HFNC treatment were collected from earlier published retrospective studies, using admission rates to pediatric intensive care units (PICU). The analyses in the study showed that the expected treatment costs of each episode of infant bronchiolitis varied between €1,312-2,644 ($1,786-3,600) in the HFNC group and €1,598-3,764 ($2,175-5,125) in the standard treatment group. The PICU admission rates and consequential costs were lower for HFNC than for standard treatment. HFNC treatment proved more cost-effective than standard treatment in all the baseline analyses and was also more cost-effective in the sensitivity analyses, except for in the worst-case scenario analysis. In conclusion, our modeling demonstrated that HFNC was strongly cost-effective for infant bronchiolitis, compared to standard treatment because it was both more effective and less expensive. Thus, if children hospitalized for bronchiolitis need oxygen, it should be delivered as HFNC treatment. Pediatr Pulmonol. 2016;51:1393-1402. © 2016 Wiley Periodicals, Inc.

Cost-Effectiveness of Domiciliary High Flow Nasal Cannula Treatment in COPD Patients with Chronic Respiratory Failure.

Sørensen SS, Storgaard LH, Weinreich UM. Cost-Effectiveness of Domiciliary High Flow Nasal Cannula Treatment in COPD Patients with Chronic Respiratory Failure. Clinicoecon Outcomes Res. 2021;13:553-564. Published 2021 Jun 18. doi:10.2147/CEOR.S312523



PURPOSE

To evaluate the cost-effectiveness of long-term domiciliary high flow nasal cannula (HFNC) treatment in COPD patients with chronic respiratory failure.

PATIENTS AND METHODS

A cohort of 200 COPD patients were equally randomized into usual care ± HFNC and followed for 12 months. The outcome of the analysis was the incremental cost per quality-adjusted life-year (QALY) gained, and the analysis was conducted from a healthcare sector perspective. Data on the patients' health-related quality of life (HRQoL), gathered throughout the trial using the St. George's Respiratory Questionnaire (SGRQ), was converted into EQ-5D-3L health state utility values. Costs were estimated using Danish registers and valued in British pounds (£) at price level 2019. Scenario analyses and probabilistic sensitivity analyses were conducted to assess the uncertainty of the results.

RESULTS

The adjusted mean difference in QALYs between the HFNC group and the control group was 0.059 (95% CI: 0.017; 0.101), and the adjusted mean difference in total costs was £212 (95% CI: -1572; 1995). The analysis resulted in an incremental cost-effectiveness ratio (ICER) of £3605 per QALY gained. At threshold values of £20.000-30.000 per QALY gained, the intervention had an 83-92% probability of being cost-effective. The scenario analyses all revealed ICERs below the set threshold value and demonstrated the robustness of the main result.

CONCLUSION

This is the first cost-effectiveness study on domiciliary HFNC in Europe. The findings demonstrate that long-term domiciliary HFNC treatment is very likely to be a cost-effective addition to usual care for COPD patients with chronic respiratory failure. The results must be interpreted in light of the uncertainty associated with the indirect estimation of health state utilities.

Benefits and risks of noninvasive oxygenation strategy in COVID-19: a multicenter, prospective cohort study (COVID-ICU) in 137 hospitals.

COVID-ICU group, for the REVA network, COVID-ICU investigators. Benefits and risks of noninvasive oxygenation strategy in COVID-19: a multicenter, prospective cohort study (COVID-ICU) in 137 hospitals. Crit Care. 2021;25(1):421. Published 2021 Dec 8. doi:10.1186/s13054-021-03784-2



RATIONAL

To evaluate the respective impact of standard oxygen, high-flow nasal cannula (HFNC) and noninvasive ventilation (NIV) on oxygenation failure rate and mortality in COVID-19 patients admitted to intensive care units (ICUs).

METHODS

Multicenter, prospective cohort study (COVID-ICU) in 137 hospitals in France, Belgium, and Switzerland. Demographic, clinical, respiratory support, oxygenation failure, and survival data were collected. Oxygenation failure was defined as either intubation or death in the ICU without intubation. Variables independently associated with oxygenation failure and Day-90 mortality were assessed using multivariate logistic regression.

RESULTS

From February 25 to May 4, 2020, 4754 patients were admitted in ICU. Of these, 1491 patients were not intubated on the day of ICU admission and received standard oxygen therapy (51%), HFNC (38%), or NIV (11%) (P < 0.001). Oxygenation failure occurred in 739 (50%) patients (678 intubation and 61 death). For standard oxygen, HFNC, and NIV, oxygenation failure rate was 49%, 48%, and 60% (P < 0.001). By multivariate analysis, HFNC (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.36-0.99, P = 0.013) but not NIV (OR 1.57, 95% CI 0.78-3.21) was associated with a reduction in oxygenation failure). Overall 90-day mortality was 21%. By multivariable analysis, HFNC was not associated with a change in mortality (OR 0.90, 95% CI 0.61-1.33), while NIV was associated with increased mortality (OR 2.75, 95% CI 1.79-4.21, P < 0.001).

CONCLUSION

In patients with COVID-19, HFNC was associated with a reduction in oxygenation failure without improvement in 90-day mortality, whereas NIV was associated with a higher mortality in these patients. Randomized controlled trials are needed.

High-Flow Nasal Oxygen for Severe Hypoxemia: Oxygenation Response and Outcome in Patients with COVID-19.

Ranieri VM, Tonetti T, Navalesi P, et al. High-Flow Nasal Oxygen for Severe Hypoxemia: Oxygenation Response and Outcome in Patients with COVID-19. Am J Respir Crit Care Med. 2022;205(4):431-439. doi:10.1164/rccm.202109-2163OC

Rationale: The "Berlin definition" of acute respiratory distress syndrome (ARDS) does not allow inclusion of patients receiving high-flow nasal oxygen (HFNO). However, several articles have proposed that criteria for defining ARDS should be broadened to allow inclusion of patients receiving HFNO. Objectives: To compare the proportion of patients fulfilling ARDS criteria during HFNO and soon after intubation, and 28-day mortality between patients treated exclusively with HFNO and patients transitioned from HFNO to invasive mechanical ventilation (IMV). Methods: From previously published studies, we analyzed patients with coronavirus disease (COVID-19) who had PaO2/FiO2 of ⩽300 while treated with ⩾40 L/min HFNO, or noninvasive ventilation (NIV) with positive end-expiratory pressure of ⩾5 cm H2O (comparator). In patients transitioned from HFNO/NIV to invasive mechanical ventilation (IMV), we compared ARDS severity during HFNO/NIV and soon after IMV. We compared 28-day mortality in patients treated exclusively with HFNO/NIV versus patients transitioned to IMV. Measurements and Main Results: We analyzed 184 and 131 patients receiving HFNO or NIV, respectively. A total of 112 HFNO and 69 NIV patients transitioned to IMV. Of those, 104 (92.9%) patients on HFNO and 66 (95.7%) on NIV continued to have PaO2/FiO2 ⩽300 under IMV. Twenty-eight-day mortality in patients who remained on HFNO was 4.2% (3/72), whereas in patients transitioned from HFNO to IMV, it was 28.6% (32/112) (P < 0.001). Twenty-eight-day mortality in patients who remained on NIV was 1.6% (1/62), whereas in patients who transitioned from NIV to IMV, it was 44.9% (31/69) (P < 0.001). Overall mortality was 19.0% (35/184) and 24.4% (32/131) for HFNO and NIV, respectively (P = 0.2479). Conclusions: Broadening the ARDS definition to include patients on HFNO with PaO2/FiO2 ⩽300 may identify patients at earlier stages of disease but with lower mortality.

Effect of Noninvasive Respiratory Strategies on Intubation or Mortality Among Patients With Acute Hypoxemic Respiratory Failure and COVID-19: The RECOVERY-RS Randomized Clinical Trial.

Perkins GD, Ji C, Connolly BA, et al. Effect of Noninvasive Respiratory Strategies on Intubation or Mortality Among Patients With Acute Hypoxemic Respiratory Failure and COVID-19: The RECOVERY-RS Randomized Clinical Trial. JAMA. 2022;327(6):546-558. doi:10.1001/jama.2022.0028



Importance

Continuous positive airway pressure (CPAP) and high-flow nasal oxygen (HFNO) have been recommended for acute hypoxemic respiratory failure in patients with COVID-19. Uncertainty exists regarding the effectiveness and safety of these noninvasive respiratory strategies.

Objective

To determine whether either CPAP or HFNO, compared with conventional oxygen therapy, improves clinical outcomes in hospitalized patients with COVID-19-related acute hypoxemic respiratory failure.

Design, Setting, and Participants

A parallel group, adaptive, randomized clinical trial of 1273 hospitalized adults with COVID-19-related acute hypoxemic respiratory failure. The trial was conducted between April 6, 2020, and May 3, 2021, across 48 acute care hospitals in the UK and Jersey. Final follow-up occurred on June 20, 2021.

Interventions

Adult patients were randomized to receive CPAP (n = 380), HFNO (n = 418), or conventional oxygen therapy (n = 475).

Main Outcomes and Measures

The primary outcome was a composite of tracheal intubation or mortality within 30 days.

Results

The trial was stopped prematurely due to declining COVID-19 case numbers in the UK and the end of the funded recruitment period. Of the 1273 randomized patients (mean age, 57.4 [95% CI, 56.7 to 58.1] years; 66% male; 65% White race), primary outcome data were available for 1260. Crossover between interventions occurred in 17.1% of participants (15.3% in the CPAP group, 11.5% in the HFNO group, and 23.6% in the conventional oxygen therapy group). The requirement for tracheal intubation or mortality within 30 days was significantly lower with CPAP (36.3%; 137 of 377 participants) vs conventional oxygen therapy (44.4%; 158 of 356 participants) (absolute difference, -8% [95% CI, -15% to -1%], P = .03), but was not significantly different with HFNO (44.3%; 184 of 415 participants) vs conventional oxygen therapy (45.1%; 166 of 368 participants) (absolute difference, -1% [95% CI, -8% to 6%], P = .83). Adverse events occurred in 34.2% (130/380) of participants in the CPAP group, 20.6% (86/418) in the HFNO group, and 13.9% (66/475) in the conventional oxygen therapy group.

Conclusions and Relevance

Among patients with acute hypoxemic respiratory failure due to COVID-19, an initial strategy of CPAP significantly reduced the risk of tracheal intubation or mortality compared with conventional oxygen therapy, but there was no significant difference between an initial strategy of HFNO compared with conventional oxygen therapy. The study may have been underpowered for the comparison of HFNO vs conventional oxygen therapy, and early study termination and crossover among the groups should be considered when interpreting the findings.

Trial Registration

isrctn.org Identifier: ISRCTN16912075.

Helmet continuous positive airway pressure vs. high flow nasal cannula oxygen in acute cardiogenic pulmonary oedema: a randomized controlled trial.

Osman A, Via G, Sallehuddin RM, et al. Helmet continuous positive airway pressure vs. high flow nasal cannula oxygen in acute cardiogenic pulmonary oedema: a randomized controlled trial. Eur Heart J Acute Cardiovasc Care. 2021;10(10):1103-1111. doi:10.1093/ehjacc/zuab078



AIMS

Non-invasive ventilation represents an established treatment for acute cardiogenic pulmonary oedema (ACPO) although no data regarding the best ventilatory strategy are available. We aimed to compare the effectiveness of helmet CPAP (hCPAP) and high flow nasal cannula (HFNC) in the early treatment of ACPO.

METHODS AND RESULTS

Single-centre randomized controlled trial of patients admitted to the emergency department due to ACPO with hypoxemia and dyspnoea on face mask oxygen therapy. Patients were randomly assigned with a 1:1 ratio to receive hCPAP or HFNC and FiO2 set to achieve an arterial oxygen saturation >94%. The primary outcome was a reduction in respiratory rate; secondary outcomes included changes in heart rate, PaO2/FiO2 ratio, Heart rate, Acidosis, Consciousness, Oxygenation, and Respiratory rate (HACOR) score, Dyspnoea Scale, and intubation rate. Data were collected before hCPAP/HFNC placement and after 1 h of treatment. Amongst 188 patients randomized, hCPAP was more effective than HFNC in reducing respiratory rate [-12 (95% CI; 11-13) vs. -9 (95% CI; 8-10), P < 0.001] and was associated with greater heart rate reduction [-20 (95% CI; 17-23) vs. -15 (95% CI; 12-18), P = 0.042], P/F ratio improvement [+149 (95% CI; 135-163) vs. +120 (95% CI; 107-132), P = 0.003] as well as in HACOR scores [6 (0-12) vs. 4 (2-9), P < 0.001] and Dyspnoea Scale [4 (1-7) vs. 3.5 (1-6), P = 0.003]. No differences in intubation rate were noted (P = 0.321).

CONCLUSION

Amongst patients with ACPO, hCPAP resulted in a greater short-term improvement in respiratory and hemodynamic parameters as compared with HFNC.

TRIAL REGISTRATION

Clinical trial submission: NMRR-17-1839-36966 (IIR). Registry name: Medical Research and Ethics Committee of Malaysia Ministry of Health. Clinicaltrials.gov identifier: NCT04005092. URL registry: https://clinicaltrials.gov/ct2/show/NCT04005092.

Effect of Helmet Noninvasive Ventilation vs High-Flow Nasal Oxygen on Days Free of Respiratory Support in Patients With COVID-19 and Moderate to Severe Hypoxemic Respiratory Failure: The HENIVOT Randomized Clinical Trial.

Grieco DL, Menga LS, Cesarano M, et al. Effect of Helmet Noninvasive Ventilation vs High-Flow Nasal Oxygen on Days Free of Respiratory Support in Patients With COVID-19 and Moderate to Severe Hypoxemic Respiratory Failure: The HENIVOT Randomized Clinical Trial. JAMA. 2021;325(17):1731-1743. doi:10.1001/jama.2021.4682



Importance

High-flow nasal oxygen is recommended as initial treatment for acute hypoxemic respiratory failure and is widely applied in patients with COVID-19.

Objective

To assess whether helmet noninvasive ventilation can increase the days free of respiratory support in patients with COVID-19 compared with high-flow nasal oxygen alone.

Design, Setting, and Participants

Multicenter randomized clinical trial in 4 intensive care units (ICUs) in Italy between October and December 2020, end of follow-up February 11, 2021, including 109 patients with COVID-19 and moderate to severe hypoxemic respiratory failure (ratio of partial pressure of arterial oxygen to fraction of inspired oxygen ≤200).

Interventions

Participants were randomly assigned to receive continuous treatment with helmet noninvasive ventilation (positive end-expiratory pressure, 10-12 cm H2O; pressure support, 10-12 cm H2O) for at least 48 hours eventually followed by high-flow nasal oxygen (n = 54) or high-flow oxygen alone (60 L/min) (n = 55).

Main Outcomes and Measures

The primary outcome was the number of days free of respiratory support within 28 days after enrollment. Secondary outcomes included the proportion of patients who required endotracheal intubation within 28 days from study enrollment, the number of days free of invasive mechanical ventilation at day 28, the number of days free of invasive mechanical ventilation at day 60, in-ICU mortality, in-hospital mortality, 28-day mortality, 60-day mortality, ICU length of stay, and hospital length of stay.

Results

Among 110 patients who were randomized, 109 (99%) completed the trial (median age, 65 years [interquartile range {IQR}, 55-70]; 21 women [19%]). The median days free of respiratory support within 28 days after randomization were 20 (IQR, 0-25) in the helmet group and 18 (IQR, 0-22) in the high-flow nasal oxygen group, a difference that was not statistically significant (mean difference, 2 days [95% CI, -2 to 6]; P = .26). Of 9 prespecified secondary outcomes reported, 7 showed no significant difference. The rate of endotracheal intubation was significantly lower in the helmet group than in the high-flow nasal oxygen group (30% vs 51%; difference, -21% [95% CI, -38% to -3%]; P = .03). The median number of days free of invasive mechanical ventilation within 28 days was significantly higher in the helmet group than in the high-flow nasal oxygen group (28 [IQR, 13-28] vs 25 [IQR 4-28]; mean difference, 3 days [95% CI, 0-7]; P = .04). The rate of in-hospital mortality was 24% in the helmet group and 25% in the high-flow nasal oxygen group (absolute difference, -1% [95% CI, -17% to 15%]; P > .99).

Conclusions and Relevance

Among patients with COVID-19 and moderate to severe hypoxemia, treatment with helmet noninvasive ventilation, compared with high-flow nasal oxygen, resulted in no significant difference in the number of days free of respiratory support within 28 days. Further research is warranted to determine effects on other outcomes, including the need for endotracheal intubation.

Trial Registration

ClinicalTrials.gov Identifier: NCT04502576.

Effect of flow and cannula size on generated pressure during nasal high flow.

Pinkham M, Tatkov S. Effect of flow and cannula size on generated pressure during nasal high flow. Crit Care. 2020;24(1):248. Published 2020 May 24. doi:10.1186/s13054-020-02980-w

Nasal high-flow bronchodilator nebulization: a randomized cross-over study.

Reminiac F, Vecellio L, Bodet-Contentin L, et al. Nasal high-flow bronchodilator nebulization: a randomized cross-over study. Ann Intensive Care. 2018;8(1):128. Published 2018 Dec 20. doi:10.1186/s13613-018-0473-8



BACKGROUND

There is an absence of controlled clinical data showing bronchodilation effectiveness after nebulization via nasal high-flow therapy circuits.

RESULTS

Twenty-five patients with reversible airflow obstruction received, in a randomized order: (1) 2.5 mg albuterol delivered via a jet nebulizer with a facial mask; (2) 2.5 mg albuterol delivered via a vibrating mesh nebulizer placed downstream of a nasal high-flow humidification chamber (30 L/min and 37 °C); and (3) nasal high-flow therapy without nebulization. All three conditions induced significant individual increases in forced expiratory volume in one second (FEV1) compared to baseline. The median change was similar after facial mask nebulization [+ 350 mL (+ 180; + 550); + 18% (+ 8; + 30)] and nasal high flow with nebulization [+ 330 mL (+ 140; + 390); + 16% (+ 5; + 24)], p = 0.11. However, it was significantly lower after nasal high-flow therapy without nebulization [+ 50 mL (- 10; + 220); + 3% (- 1; + 8)], p = 0.0009. FEV1 increases after facial mask and nasal high-flow nebulization as well as residual volume decreases were well correlated (p < 0.0001 and p = 0.01). Both techniques showed good agreement in terms of airflow obstruction reversibility (kappa 0.60).

CONCLUSION

Albuterol vibrating mesh nebulization within a nasal high-flow circuit induces similar bronchodilation to standard facial mask jet nebulization. Beyond pharmacological bronchodilation, nasal high flow by itself may induce small but significant bronchodilation.

High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure.

Frat JP, Thille AW, Mercat A, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med. 2015;372(23):2185-2196. doi:10.1056/NEJMoa1503326



BACKGROUND

Whether noninvasive ventilation should be administered in patients with acute hypoxemic respiratory failure is debated. Therapy with high-flow oxygen through a nasal cannula may offer an alternative in patients with hypoxemia.

METHODS

We performed a multicenter, open-label trial in which we randomly assigned patients without hypercapnia who had acute hypoxemic respiratory failure and a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen of 300 mm Hg or less to high-flow oxygen therapy, standard oxygen therapy delivered through a face mask, or noninvasive positive-pressure ventilation. The primary outcome was the proportion of patients intubated at day 28; secondary outcomes included all-cause mortality in the intensive care unit and at 90 days and the number of ventilator-free days at day 28.

RESULTS

A total of 310 patients were included in the analyses. The intubation rate (primary outcome) was 38% (40 of 106 patients) in the high-flow-oxygen group, 47% (44 of 94) in the standard group, and 50% (55 of 110) in the noninvasive-ventilation group (P=0.18 for all comparisons). The number of ventilator-free days at day 28 was significantly higher in the high-flow-oxygen group (24±8 days, vs. 22±10 in the standard-oxygen group and 19±12 in the noninvasive-ventilation group; P=0.02 for all comparisons). The hazard ratio for death at 90 days was 2.01 (95% confidence interval [CI], 1.01 to 3.99) with standard oxygen versus high-flow oxygen (P=0.046) and 2.50 (95% CI, 1.31 to 4.78) with noninvasive ventilation versus high-flow oxygen (P=0.006).

CONCLUSIONS

In patients with nonhypercapnic acute hypoxemic respiratory failure, treatment with high-flow oxygen, standard oxygen, or noninvasive ventilation did not result in significantly different intubation rates. There was a significant difference in favor of high-flow oxygen in 90-day mortality. (Funded by the Programme Hospitalier de Recherche Clinique Interrégional 2010 of the French Ministry of Health; FLORALI ClinicalTrials.gov number, NCT01320384.).

Effect of High-Flow Oxygen Therapy vs Conventional Oxygen Therapy on Invasive Mechanical Ventilation and Clinical Recovery in Patients With Severe COVID-19: A Randomized Clinical Trial.

Ospina-Tascón GA, Calderón-Tapia LE, García AF, et al. Effect of High-Flow Oxygen Therapy vs Conventional Oxygen Therapy on Invasive Mechanical Ventilation and Clinical Recovery in Patients With Severe COVID-19: A Randomized Clinical Trial [published correction appears in JAMA. 2022 Mar 15;327(11):1093]. JAMA. 2021;326(21):2161-2171. doi:10.1001/jama.2021.20714



IMPORTANCE

The effect of high-flow oxygen therapy vs conventional oxygen therapy has not been established in the setting of severe COVID-19.

OBJECTIVE

To determine the effect of high-flow oxygen therapy through a nasal cannula compared with conventional oxygen therapy on need for endotracheal intubation and clinical recovery in severe COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

Randomized, open-label clinical trial conducted in emergency and intensive care units in 3 hospitals in Colombia. A total of 220 adults with respiratory distress and a ratio of partial pressure of arterial oxygen to fraction of inspired oxygen of less than 200 due to COVID-19 were randomized from August 2020 to January 2021, with last follow-up on February 10, 2021.

INTERVENTIONS

Patients were randomly assigned to receive high-flow oxygen through a nasal cannula (n = 109) or conventional oxygen therapy (n = 111).

MAIN OUTCOMES AND MEASURES

The co-primary outcomes were need for intubation and time to clinical recovery until day 28 as assessed by a 7-category ordinal scale (range, 1-7, with higher scores indicating a worse condition). Effects of treatments were calculated with a Cox proportional hazards model adjusted for hypoxemia severity, age, and comorbidities.

RESULTS

Among 220 randomized patients, 199 were included in the analysis (median age, 60 years; n = 65 women [32.7%]). Intubation occurred in 34 (34.3%) randomized to high-flow oxygen therapy and in 51 (51.0%) randomized to conventional oxygen therapy (hazard ratio, 0.62; 95% CI, 0.39-0.96; P = .03). The median time to clinical recovery within 28 days was 11 (IQR, 9-14) days in patients randomized to high-flow oxygen therapy vs 14 (IQR, 11-19) days in those randomized to conventional oxygen therapy (hazard ratio, 1.39; 95% CI, 1.00-1.92; P = .047). Suspected bacterial pneumonia occurred in 13 patients (13.1%) randomized to high-flow oxygen and in 17 (17.0%) of those randomized to conventional oxygen therapy, while bacteremia was detected in 7 (7.1%) vs 11 (11.0%), respectively.

CONCLUSIONS AND RELEVANCE

Among patients with severe COVID-19, use of high-flow oxygen through a nasal cannula significantly decreased need for mechanical ventilation support and time to clinical recovery compared with conventional low-flow oxygen therapy.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04609462.

Predicting nasal high-flow therapy failure by pediatric respiratory rate-oxygenation index and pediatric respiratory rate-oxygenation index variation in children.

Yildizdas D, Yontem A, Iplik G, Horoz OO, Ekinci F. Predicting nasal high-flow therapy failure by pediatric respiratory rate-oxygenation index and pediatric respiratory rate-oxygenation index variation in children. Eur J Pediatr. 2021;180(4):1099-1106. doi:10.1007/s00431-020-03847-6

The primary objective of this study was to evaluate whether pediatric respiratory rate-oxygenation index (p-ROXI) and variation in p-ROXI (p-ROXV) can serve as objective markers in children with high-flow nasal cannula (HFNC) failure. In this prospective, single-center observational study, all patients who received HFNC therapy in the general pediatrics ward, pediatric intensive care unit, and the pediatric emergency department were included. High-flow nasal cannula success was achieved for 116 (88.5%) patients. At 24 h, if both p-ROXI and p-ROXV values were above the cutoff point (≥ 66.7 and ≥ 24.0, respectively), HFNC failure was 1.9% and 40.6% if both were below their values (p < 0.001). At 48 h of HFNC initiation, if both p-ROXI and p-ROXV values were above the cutoff point (≥ 65.1 and ≥ 24.6, respectively), HFNC failure was 0.0%; if both were below these values, HFNC failure was 100% (p < 0.001).Conclusion: We observed that these parameters can be used as good markers in pediatric clinics to predict the risk of HFNC failure in patients with acute respiratory failure. What is Known: • Optimal timing for transitions between invasive and noninvasive ventilation strategies is of significant importance. • The complexity of data requires an objective marker that can be evaluated quickly and easily at the patient's bedside for predicting HFNC failure in children with acute respiratory failure. What is New: • Our data showed that combining p-ROXI and p-ROXV can be successful in predicting HFNC failure at 24 and 48 h of therapy.

A Randomized Trial of High-Flow Oxygen Therapy in Infants with Bronchiolitis.

Franklin D, Babl FE, Schlapbach LJ, et al. A Randomized Trial of High-Flow Oxygen Therapy in Infants with Bronchiolitis. N Engl J Med. 2018;378(12):1121-1131. doi:10.1056/NEJMoa1714855



BACKGROUND

High-flow oxygen therapy through a nasal cannula has been increasingly used in infants with bronchiolitis, despite limited high-quality evidence of its efficacy. The efficacy of high-flow oxygen therapy through a nasal cannula in settings other than intensive care units (ICUs) is unclear.

METHODS

In this multicenter, randomized, controlled trial, we assigned infants younger than 12 months of age who had bronchiolitis and a need for supplemental oxygen therapy to receive either high-flow oxygen therapy (high-flow group) or standard oxygen therapy (standard-therapy group). Infants in the standard-therapy group could receive rescue high-flow oxygen therapy if their condition met criteria for treatment failure. The primary outcome was escalation of care due to treatment failure (defined as meeting ≥3 of 4 clinical criteria: persistent tachycardia, tachypnea, hypoxemia, and medical review triggered by a hospital early-warning tool). Secondary outcomes included duration of hospital stay, duration of oxygen therapy, and rates of transfer to a tertiary hospital, ICU admission, intubation, and adverse events.

RESULTS

The analyses included 1472 patients. The percentage of infants receiving escalation of care was 12% (87 of 739 infants) in the high-flow group, as compared with 23% (167 of 733) in the standard-therapy group (risk difference, -11 percentage points; 95% confidence interval, -15 to -7; P<0.001). No significant differences were observed in the duration of hospital stay or the duration of oxygen therapy. In each group, one case of pneumothorax (<1% of infants) occurred. Among the 167 infants in the standard-therapy group who had treatment failure, 102 (61%) had a response to high-flow rescue therapy.

CONCLUSIONS

Among infants with bronchiolitis who were treated outside an ICU, those who received high-flow oxygen therapy had significantly lower rates of escalation of care due to treatment failure than those in the group that received standard oxygen therapy. (Funded by the National Health and Medical Research Council and others; Australian and New Zealand Clinical Trials Registry number, ACTRN12613000388718 .).

Reduced intubation rates for infants after introduction of high-flow nasal prong oxygen delivery.

Schibler A, Pham TM, Dunster KR, et al. Reduced intubation rates for infants after introduction of high-flow nasal prong oxygen delivery. Intensive Care Med. 2011;37(5):847-852. doi:10.1007/s00134-011-2177-5



PURPOSE

To describe the change in ventilatory practice in a tertiary paediatric intensive care unit (PICU) in the 5-year period after the introduction of high-flow nasal prong (HFNP) therapy in infants <24 months of age. Additionally, to identify the patient subgroups on HFNP requiring escalation of therapy to either other non-invasive or invasive ventilation, and to identify any adverse events associated with HFNP therapy.

METHODS

The study was a retrospective chart review of infants <24 months of age admitted to our PICU for HFNP therapy. Data was also extracted from both the local database and the Australian New Zealand paediatric intensive care (ANZPIC) registry for all infants admitted with bronchiolitis.

RESULTS

Between January 2005 and December 2009, a total of 298 infants <24 months of age received HFNP therapy. Overall, 36 infants (12%) required escalation to invasive ventilation. In the subgroup with a primary diagnosis of viral bronchiolitis (n = 167, 56%), only 6 (4%) required escalation to invasive ventilation. The rate of intubation in infants with viral bronchiolitis reduced from 37% to 7% over the observation period corresponding with an increase in the use of HFNP therapy. No adverse events were identified with the use of HFNP therapy.

CONCLUSION

HFNP therapy has dramatically changed ventilatory practice in infants <24 months of age in our institution, and appears to reduce the need for intubation in infants with viral bronchiolitis.