Flow Nasal Cannula Oxygen Therapy Research Articles

The post ICU trajectory: Post acute and post ICU nutritional care

ICU survivors are growing but a persistent physical and mental disability may occur. The patients discharged from ICU are frequently malnourished and their medical nutritional support is impaired by oral intake limitation due to respiratory support such as non invasive ventilation or high flow nasal cannula oxygen therapy, dysphagia and difficulties to determine energy and protein targets. ICU acquired weakness must be recognized and could be minimized by better energy intake determined by indirect calorimetry, optimal protein intake and physical activity. Early physical activity has become a pivotal element of the improvement of the physical and cognitive condition in the post ICU.

What barriers do paediatric nurses encounter when attempting to wean paediatric patients off humidified high flow nasal cannula oxygen therapy? A qualitative study

PurposeThis study aimed to explore nurse perceptions of barriers and facilitators to weaning humidified high flow nasal cannula (HHFNC) in Australian paediatric settings. Design and methodsA qualitative descriptive two phased study was conducted across Australia. Purposeful sampling and snowballing technique were used to recruit nurses with the study advertised widely on social media nursing groups. Phase One data collection was via a survey with open and closed ended questions, and Phase Two via semi-structured interviews. Data were analysed using descriptive statistics (Phase One) and thematic analysis (Phase One and Two) to identify themes and patterns in the narrative. ResultsPhase one: 36(56.25 %) participants identified their workplace had clear guidelines, 57(89.06 %) received education on HHFNC and 34(57.63 %) experienced barriers when weaning. Three themes and nine subthemes were identified i) variable clinical process for weaning HHFNC, ii) knowledge and skills and iii) clinical observation and assessment of the child. Phase two: four themes and nine subthemes were identified, i) ‘There doesn't seem to be any pattern’: no evidence to guide practice, ii) Nursing and medical led weaning, iii) Knowledge and skills and iv) Family centred approaches to weaning. ConclusionsCurrent research on HHFNC does not consider best practice for weaning. This study identified barriers as inconsistency in weaning practice and availability of guidelines and facilitators were a robust education program and confidence in weaning. Multidisciplinary team need to collaborate to determine standardised weaning practice. Practice ImplicationsFurther research is essential to determine best practice weaning methods and inform national/international guidelines.

The impact of pulmonary tuberculosis on SARS-CoV-2 infection: a nationwide cohort study.

The interaction between COVID-19 and tuberculosis (TB) is not yet fully understood, and large-scale research on the mortality outcome of such dual infection has been limited. This study aimed to investigate the impact of PTB on mortality among patients with COVID-19 within a Korean population by conducting an extensive analysis of a nationwide large dataset. We investigated the mortality and disease severity among COVID-19 patients who had PTB in South Korea. This study analyzed 462,444 out of 566,494 COVID-19 patients identified between January 2020 and December 2021. A total of 203 COVID-19 with PTB patients and 812 matched COVID-19 without PTB were analyzed using 1:4 propensity score matching. COVID-19 patients with PTB exhibited higher in-hospital mortality (odds ratio (OR) 3.02, 95% confidence interval (CI) 1.45-6.27, p-value = 0.003) and were at increased risk of requiring conventional oxygen therapy (OR 1.57, 95% CI 1.10-2.25, p-value = 0.013) as well as high flow nasal cannula (HFNC) or noninvasive ventilation (NIV) oxygen therapy (OR 1.91, 95 CI 1.10-3.32, p-value = 0.022) compared to those without PTB. Compared to matched COVID-19 without PTB, co-infected patients showed increased mortality rates across various timeframes, including during hospitalization, and at 30 day and 90 day intervals. In-hospital mortality rates were particularly elevated among women, individuals with malignancy, and those with lower incomes. Furthermore, the increased in-hospital mortality among PTB patients persisted irrespective of the timing of TB diagnosis or vaccination status against COVID-19. We suggest that physicians be aware of the risk of mortality and severity among COVID-19 patients with PTB; coinfection with COVID-19 is a critical situation that remains to be further explored and needs more attention in countries with an intermediate to high PTB burden.

Respiratory Syncytial Virus Infections in Pediatric Intensive Care: Association of Sociodemographic Data and Clinical Outcomes with Viral and Bacterial Co-infections.

The aim of the study was to evaluate respiratory syncytial virus (RSV) infections in cases followed in the pediatric intensive care unit (PICU). The study was designed as a prospective cohort in 6 PICUs. There were 3 groups: only RSV (+), RSV (v+) who were positive for another viral agent(s) in addition to RSV, and RSV (b+) who were positive for a bacterial agent(s) in addition to RSV. A total of 119 cases were included in the study, 67 (56.3%) of whom were male. The RSV (+) group had a lower pH compared to the other groups and a higher rate of acute bronc hiolitis/bronchitis diagnoses compared to the RSV (v+) group. The RSV (v+) group had higher bicarbonate levels, higher creatinine levels, longer hospital stays, and higher Pediatric Risk of Mortality-3 scores (PRISM-3) compared to the RSV (+) group. Cases with RSV (b+) were younger and also had lower body weight compared to the other groups. Furthermore, the RSV (b+) group had higher C-reactive protein and Procalcitonin (PCT) levels and higher rates of High Flow Nasal Cannula-Oxygen Therapy (HFNC-OT) use. Multiple linear regression analysis revealed that PRISM-3 score, PCT levels, Pediatric Acute Respiratory Distress Syndrome diagnoses, inhaled steroid use, chronic illness status, and heart rate on admission were associated with the length of stay in the PICU. High flow nasal cannula-oxygen therapy continues to be the most frequently preferred respiratory support method in RSV infections. Viral infections accompanying RSV can increase the severity of the disease.

Role of High flow Nasal Cannula Oxygen Therapy Versus Non-Invasive Ventilation in the Management of Acute Respiratory Failure

Role of High flow Nasal Cannula Oxygen Therapy Versus Non-Invasive Ventilation in the Management of Acute Respiratory Failure

High Flow Nasal Cannula Oxygen Therapy (HFNC) With Different Temperatures in COVID-19 Patients: A Randomized Clinical Trial

Background: The effect of using high flow oxygen delivery through the nasal cannula (HFNC) in COVID-19 patients has been associated with different results. This study aimed to evaluate the effect of different HFNC temperatures in COVID-19 patients. Methods: Patients were randomly divided into three groups under high current oxygenation with temperatures of 31, 34, and 37. Except for the temperature, other device settings were set equally. After 24 hours, clinical conditions were on the agenda and compared with the conditions before the intervention. Results: Fever, sore throat, malaise, diarrhea in patients of 31 degree group and indicators of nausea, cough, body pain, headache have changed the most in 37 degree group. Abdominal pain has shown the greatest change in the 34 degree group. PR, DBP, and SpO2 indices changed the most at 31 degrees and RR and SBP at 37 degrees. PR, RR, SBP and SPO2 indices showed significant values in intra-group comparison, and in inter-group comparison, only PR, RR indices had significant differences. In intra-group analysis, PaCO2, WBC, CRP, ESR and ferritin had significant changes, and in inter-group comparison, none of the indicators had significant differences. Conclusion: Based on the results of the present study, reducing the temperature in the use of HFNC can improve the clinical conditions of patients with COVID-19.

High Flow Nasal Cannula Versus Conventional Oxygen Therapy and Incidence of Post-Extubation Airway Obstruction in PICU: An Open-Label Randomized Controlled Trial (HiFloCOT-PICU Trial).

To study the impact of high flow nasal cannula (HFNC) vs. conventional oxygen therapy (COT) (by simple nasal cannula) as respiratory support after extubation on the rates of post-extubation airway obstruction (PEAO) among mechanically ventilated critically ill children. This open-label randomized controlled trial was conducted in pediatric intensive care unit (PICU) of a tertiary care teaching hospital in North India over a period of 7 mo (11 August 2021 to 10 March 2022). Children aged 3 mo to 12 y who required invasive mechanical ventilation for > 72h and had passed spontaneous breathing trial (ready for extubation) were enrolled and randomized by computer generated block randomization to receive HFNC or COT after extubation. Primary outcome was rate of PEAO (assessed by modified Westley croup score, mWCS) within 48h of extubation; and secondary outcomes were rate and number of adrenaline nebulization, treatment failure (requiring escalation of respiratory support), extubation failure, adverse events, and length of PICU stay in two groups. During the study period, 116 children were enrolled (58 each in HFNC and COT groups). There was no difference in rate of PEAO (55% vs. 51.7%, respectively), need of adrenaline nebulization, extubation failure, adverse events, and duration of PICU stay in two groups. However, the HFNC group had significantly lower rates of treatment failure (27.6% vs. 48.3%, p = 0.02). The rate of PEAO was similar in HFNC and COT groups. However, HFNC group had significantly lower rate of treatment failure requiring escalation of respiratory support.

High flow Nasal Cannula oxygen therapy: the Columbus egg that helps us understand the clinical meaning of dyspnea.

High flow Nasal Cannula oxygen therapy: the Columbus egg that helps us understand the clinical meaning of dyspnea.

High flow nasal cannula oxygen therapy versus non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease with acute-moderate hypercapnic respiratory failure: a randomized controlled non-inferiority trial

BackgroundAlthough cumulative studies have demonstrated a beneficial effect of high-flow nasal cannula oxygen (HFNC) in acute hypercapnic respiratory failure, randomized trials to compare HFNC with non-invasive ventilation (NIV) as initial treatment in acute exacerbations of chronic obstructive pulmonary disease (AECOPD) patients with acute-moderate hypercapnic respiratory failure are limited. The aim of this randomized, open label, non-inferiority trial was to compare treatment failure rates between HFNC and NIV in such patients.MethodsPatients diagnosed with AECOPD with a baseline arterial blood gas pH between 7.25 and 7.35 and PaCO2 ≥ 50 mmHg admitted to two intensive care units (ICUs) at a large tertiary academic teaching hospital between March 2018 and December 2022 were randomly assigned to HFNC or NIV. The primary endpoint was the rate of treatment failure, defined as endotracheal intubation or a switch to the other study treatment modality. Secondary endpoints were rates of intubation or treatment change, blood gas values, vital signs at one, 12, and 48 h, 28-day mortality, as well as ICU and hospital lengths of stay.Results225 total patients (113 in the HFNC group and 112 in the NIV group) were included in the intention-to-treat analysis. The failure rate of the HFNC group was 25.7%, while the NIV group was 14.3%. The failure rate risk difference between the two groups was 11.38% (95% CI 0.25–21.20, P = 0.033), which was higher than the non-inferiority cut-off of 9%. In the per-protocol analysis, treatment failure occurred in 28 of 110 patients (25.5%) in the HFNC group and 15 of 109 patients (13.8%) in the NIV group (risk difference, 11.69%; 95% CI 0.48–22.60). The intubation rate in the HFNC group was higher than in the NIV group (14.2% vs 5.4%, P = 0.026). The treatment switch rate, ICU and hospital length of stay or 28-day mortality in the HFNC group were not statistically different from the NIV group (all P > 0.05).ConclusionHFNC was not shown to be non-inferior to NIV and resulted in a higher incidence of treatment failure than NIV when used as the initial respiratory support for AECOPD patients with acute-moderate hypercapnic respiratory failure.Trial registration: chictr.org (ChiCTR1800014553). Registered 21 January 2018, http://www.chictr.org.cn

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

Background & aimHigh 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 a significant difference in reflux events and GRV between HFNC users and mechanically ventilated patients. MethodsThis 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 three hours 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. ResultsTen patients (mean age of 58 years; mean APACHE II score 22; mean 3.9 days 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). ConclusionsLeveraging 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 risk of aspiration. Further studies are required to support our conclusions.

Nutrition during noninvasive respiratory support.

The use of noninvasive techniques [noninvasive ventilation (NIV) or high flow nasal cannula (HFNC) oxygen therapy] to support oxygenation and/or ventilation in patients with respiratory failure has become widespread, even more so since the coronavirus disease 2019 pandemic. The use of these modalities may impair the patient's ability to eat. "To breath or to eat" may become a dilemma. In this review, we identify the patients at risk of malnutrition that require medical nutritional therapy and understand the mechanisms of function of the devices to better give adapted nutritional indications for noninvasive ventilation or high flow nasal cannula. The Global Leadership Initiative for Malnutrition has been validated in the Intensive Care setting and can be used in patients requiring NIV. Many patients are underfed when receiving noninvasive ventilation therapies. HFNC may impair the swallowing ability and increase dysphagia while NIV may improve the swallowing reflexes. New technology preventing reflux and ensuring enteral feeding efficacy may increase the medical nutrition therapy safety and provide near-target energy and protein provision. The patient requiring noninvasive ventilation presents one of the most challenging nutritional challenges. The main steps to improve nutrition administration are to assess nutritional status, evaluate the presence of dysphagia, choose the most adequate tool of respiratory support, and adapt nutritional therapy (oral, enteral, or parenteral) accordingly.

Nutrition therapy in non-intubated patients with acute respiratory failure: a narrative review.

Non-invasive ventilation use is increasing in patients from acute respiratory failure. However, nutritional assessment and medical nutritional therapy are often missed and patients may be frequently underfed. This review evaluates the tools for nutritional screening and assessment, assesses the use of medical nutritional therapy in various techniques of non invasive ventilation and suggested tools to improve this therapy. A review of the literature was performed to evaluate the tools available to define malnutrition and determine the energy needs of patients requiring non invasive ventilation. Energy and protein intake was assessed in 16 recent papers. High Flow Nasal Cannula Oxygen therapy and non invasive ventilation using mask were described and nutritional therapy determined in each condition. A better determination of malnutrition, a more adequate energy requirement and an improved energy and protein administration are required in patients with acute respiratory failure treated with non invasive ventilation.

Clinical research progress in non-invasive positive pressure ventilation in 2023

Non-invasive positive pressure ventilation (NPPV) is a widely used method of providing respiratory support in a variety of clinical settings, including emergency departments, general wards, and intensive care units. The relevant research articles on NPPV published between 1st October 2022 and 30th September 2023 were retrieved from Medline and reviewed. In the management of acute respiratory failure (ARF) associated with COVID-19, studies have highlighted the significant influence of regional economic status on the choice of respiratory support strategies. It has been observed that NPPV is more suitable for patients with mild to moderate acute respiratory distress syndrome (ARDS) than for those with severe ARDS, as the latter group has an increased risk of delayed intubation. In addition, patients with severe dyspnea tended to benefit more from NPPV compared with high flow nasal cannula (HFNC) and conventional oxygen therapy, with a reduced risk of self-induced lung injury. For non-COVID-19-related ARF, research shows no significant differences in mortality and intubation rates between HFNC and NPPV in patients with hypercapnic ARF. The updated HACOR score and ROX score have been validated to have a high predictive value for clinical outcomes in patients receiving NPPV for hypoxemic ARF. With regard to weaning from invasive mechanical ventilation, immediate application of NPPV after extubation showed a lower mortality rate compared to continued invasive weaning. Moreover, NPPV with active humidification significantly decreased the reintubation rate within 7 days after extubation compared with HFNC. The choice between using NPPV and HFNC should be based on the specific etiology of the patient's condition. The potential effect of noninvasive high-frequency oscillatory ventilation on CO2 clearance was also investigated.

Clinical characteristics and mortality prediction of patients admitted to the Hong Kong East Cluster intensive care units in the COVID‐19 fifth wave

AbstractIntroductionCOVID‐19 has been threatening global public health since 2019. To address the overwhelming caseload, several tools were developed to predict prognosis and aid triage of critically ill patients for intensive care. Currently, there is a lack of local data on the validity of such tools.ObjectiveThe objective of this study is to identify the predictors of intensive care unit (ICU) mortality in COVID‐19 patients in Hong Kong and externally validate the different scoring systems.MethodsA retrospective cohort analysis of patients admitted to the HKEC ICUs from 1 January 2022 to 30 April 2022 was performed. We collected data on patient demographics, vaccination status, laboratory parameters, and clinical outcomes including need for organ support and mortality. Clinical severities were estimated by Sequential Organ Failure Score, 4C Mortality Score, COVID‐Gram score, and Acute Physiology and Chronic Health Evaluation (APACHE) IV score based on the original studies. Comparison between individual scoring systems' performance on hospital mortality was conducted and summarized.ResultsIn these four months, 137 patients with COVID‐19 admitted to ICUs of Ruttonjee Hospital and Pamela Youde Nethersole Eastern Hospital were recruited. 64 patients (46.7%) were admitted for COVID‐19 related respiratory failure, among which mortality was 66.7%. The overall hospital and ICU mortality were 21.9% and 13.1%, respectively. Invasive mechanical ventilation (IMV) (OR 3.221, p 0.034), high flow nasal cannula (HFNC) oxygen therapy (OR 3.107, p 0.039), and higher APACHE IV score (OR 1.043, p < 0.001) were independent predictors of hospital mortality using multivariate analysis. The scoring systems had good performance in mortality prediction in our population. The APACHE IV score (AUROC 0.79, 95% CI 0.698–0.894) and 4C Mortality Score (AUROC 0.751, 95% CI 0.657–0.844) outperformed other scoring systems in predicting hospital mortality.ConclusionIn patients with COVID‐19, the use of IMV or HFNC and APACHE IV score were independent risk factors for hospital mortality. The APACHE IV and the 4C Mortality Score were most useful in our population for predicting ICU and hospital mortality.

Effects of Training on High Flow Nasal Cannula Oxygen Therapy on Pediatric Nurses’ Knowledge Levels: A Randomized Controlled Study

Effects of Training on High Flow Nasal Cannula Oxygen Therapy on Pediatric Nurses’ Knowledge Levels: A Randomized Controlled Study

Clinical study of NFNC in the treatment of acute exacerbation chronic obstructive pulmonary disease patients with respiratory failure

BACKGROUND Most patients with acute exacerbation chronic obstructive pulmonary disease (AECOPD) have respiratory failure that necessitates active correction and the improvement of oxygenation is particularly important during treatment. High flow nasal cannula (HFNC) oxygen therapy is a non-invasive respiratory aid that is widely used in the clinic that improves oxygenation state, reduces dead space ventilation and breathing effort, protects the loss of cilia in the airways, and improves patient comfort. AIM To compare HFNC and non-invasive positive pressure ventilation in the treatment of patients with AECOPD. METHODS Eighty AECOPD patients were included in the study. The patients were in the intensive care department of our hospital from October 2019 to October 2021. The patients were divided into the control and treatment groups according to the different treatment methods with 40 patients in each group. Differences in patient comfort, blood gas analysis and infection indices were analyzed between the two groups. RESULTS After treatment, symptoms including nasal, throat and chest discomfort were significantly lower in the treatment group compared to the control group on the 3rd and 5th days (P < 0.05). Before treatment, the PaO2, PaO2/FiO2, PaCO2, and SaO2 in the two groups of patients were not significantly different (P > 0.05). After treatment, the same indicators were significantly improved in both patient groups but had improved more in the treatment group compared to the control group (P < 0.05). After treatment, the white blood cell count, and the levels of C-reactive protein and calcitonin in patients in the treatment group were significantly higher compared to patients in the control group (P < 0.05). CONCLUSION HFNC treatment can improve the ventilation of AECOPD patients whilst also improving patient comfort, and reducing complications. HFNC is a clinically valuable technique for the treatment of AECOPD.

SARS-CoV-2 pneumonia and Eisenmenger’s Syndrome: doubling the challenge

Eisenmenger’s syndrome (ES) is the most severe phenotype of pulmonary arterial hypertension (PAH) secondary to congenital heart disease. In these cases, a significant systemic-to-pulmonary (left-to-right) shunting triggers the development of pulmonary vascular disease (PVD) and pulmonary hypertension. In cases of acute hypoxemic respiratory failure in patients with ES, high flow nasal cannula (HFNC) oxygen therapy should be considered as a first-line approach in order to avoid pulmonary complications and right ventricular overload related to positive pressure ventilation. Here, we report a case of HFNC use in a patient with COVID-19 infection and ES.

The Momentum Battle in an Upper Airway During High Flow Nasal Cannula Oxygen Therapy

Abstract Two types of high flow nasal cannula (HFNC) oxygen therapy were tested using computational models of the human upper airway to investigate cannula geometry's effect on CO2 flush. Models were run with a generic HFNC geometry, two High Velocity Nasal Insufflation (HVNI) cannula geometries, and without any cannula, each for open and closed mouth patient scenarios. For the open mouth scenario, models included either an inflamed left nasal passageway or a healthy (uninflamed) left nasal passageway. With a healthy left nasal passageway and open mouth, the CO2 remaining in the airway at end-exhale was 1.88 mg and 1.84 mg for the HVNI cannulas, 2.56 mg for HFNC, and 10.0 mg for the model with no cannula. With an inflamed left nasal passageway and open mouth, the CO2 remaining was 1.97 mg, 1.95 mg, 4.24 mg, and 10.5 mg for the same sequence of therapy types. For the closed mouth models, the distinction between therapy types was negligible. It was found that the higher momentum from the HVNI cannulas created a higher resistance against the infiltration of exhaled CO2 into the upper airway. The HVNI cannulas also began flushing the airway (reducing total CO2 mass) earlier in the exhalation cycle than both the HFNC and no-cannula models. The higher resistance to expiratory flow entering the upper airway and earlier transition to flush led to HVNI therapy having the lowest values of CO2 remaining in the airway.

Performance of the ROX index in predicting high flow nasal cannula failure in COVID-19 patients: a systematic review and meta-analysis

COVID-19 patients with acute hypoxemic respiratory failure (AHRF) benefit from high flow nasal cannula (HFNC) oxygen therapy. However, delays in initiating invasive ventilation after HFNC failure are associated with poorer outcomes. The respiratory oxygenation (ROX) index, combining SpO2/FiO2 and respiratory rate, can predict HFNC failure. This meta-analysis evaluated the optimal ROX index cut-offs in predicting HFNC failure among COVID-19 patients at different measurement timings and clinical settings. Three databases were searched for eligible papers. From each study, we reconstructed the confusion matrices at different cut-offs, fitted linear mixed models to estimate the ROX index distribution function, and derived the area under the summary receiver operator characteristic curve (sAUC) and optimal cut-offs to predict HFNC failure. 24 studies containing 4790 patients were included. Overall sAUC was 0.771 (95% CI: 0.666–0.847) (optimal cut-off: 5.23, sensitivity: 0.732, specificity: 0.690). The cut-off values to achieve 80%, 90% sensitivity, 80%, 90% specificity were 5.70, 6.69, 4.45, 3.37, respectively. We stratified the analysis by ROX measurement time and estimated optimal cut-offs and cut-offs to achieve 80% sensitivity and specificity. For 2–6 h and 6–12 h post-HFNC initiation, we propose the use of 80% specific cut-offs to rule in HFNC failure of < 5.33 and < 3.69, respectively. For 12–24 h post-HFNC initiation, we propose the use of the 80% sensitive cut-off of > 6.07 to rule out HFNC failure. Our analysis confirms the overall utility of the ROX index in risk stratification of COVID-19 patients with AHRF receiving HFNC and provides potentially useful cut-offs for different times from HFNC initiation.

High flow nasal cannula for respiratory support in term infants.

High flow nasal cannula for respiratory support in term infants.