Use Of High-flow Nasal Cannula Therapy Research Articles

Hospital Oxygen Supply Overwhelmed Due to COVID-19: When Demand Exceeds Supply.

During the first wave of COVID-19, we experienced problems with our hospital oxygen supply system. This study aimed to analyze factors that stressed this system and rethink the design criteria of the gas pipeline system considering the varying oxygen demand. A retrospective study was conducted to describe problems that occurred at different stages in the oxygen supply system at our hospital due to increases in oxygen use in general, and the creation of an intermediate respiratory care unit (IRCU) and use of high-flow nasal cannula (HFNC) in particular. Herein, the characteristics and design criteria of the medical gas pipeline system are analyzed, and the steps taken to avoid future problems are outlined. Increases in oxygen use were observed at times of maximum occupancy, and these created vulnerabilities in the oxygen supply due to insufficient capacity in terms of cryogenic tanks, evaporators, and the piping network. The peak consumption was 3 times higher than the peak in the preceding 4 years. The use of HFNC therapy aggravated the problem; IRCU use accounting for as much as two-fifths of the total across the hospital. Steps taken subsequently prevented the recurrence of vulnerabilities. The design criteria for storage and distribution networks of medical gases in hospitals need to be revised considering new parameters for their implementation and the use of HFNC therapy in an IRCU. In particular, the cryogenic tanks, evaporators, and piping network for hospital wards are critical.

High-Flow Nasal Cannula System in Respiratory Failure Associated with Interstitial Lung Diseases: A Systematic Review and Narrative Synthesis.

Background: High-flow nasal cannula (HFNC) therapy has emerged as a promising treatment modality for interstitial lung disease (ILD)-related respiratory failure. This systematic review aims to evaluate the efficacy and safety of HFNC therapy in patients with ILDs. Methods: A comprehensive literature search was conducted using major electronic databases to identify relevant studies investigating the use of HFNC therapy in ILD patients with respiratory failure. Outcome measures of interest included improvements in oxygenation, dyspnea relief, respiratory rate control, hospital length of stay, and mortality. Results: Twelve studies were analyzed with an overall population of 715 patients included. Idiopathic Pulmonary Fibrosis (IPF) was the most prevalent type of ILD. Evaluated clinical settings were acute (7 studies), chronic (2 studies), and end-stage (3 studies) ILDs. The HFNC as a support for acute respiratory failure seems not inferior to non-invasive ventilation while offering better comfort and patient's perception. Poor data are available about use in chronic/long-term or rehabilitative settings. In end of life/palliative care, an HFNC might improve quality of life. Despite the promising results, further research is warranted to establish optimal HFNC protocols, identify patient subgroups most likely to benefit, and explore long-term outcomes. Conclusions: Overall, the HFNC appears to be a valuable therapeutic option for managing respiratory failure in ILD patients, offering potential improvements in oxygenation and symptom relief.

High-Flow Nasal Cannula Versus Nasal Prong Bubble Continuous Positive Airway Pressure in Children With Moderate to Severe Acute Bronchiolitis: A Randomized Controlled Trial.

To compare high-flow nasal cannula (HFNC) versus nasal prong bubble continuous positive airway pressure (b-CPAP) in children with moderate to severe acute bronchiolitis. A randomized controlled trial was carried out from August 2019 to February 2022. (Clinical Trials Registry of India number CTRI/2019/07/020402). Pediatric emergency ward and ICU within a tertiary care center in India. Children 1-23 months old with moderate to severe acute bronchiolitis. Comparison of HFNC with b-CPAP, using a primary outcome of treatment failure within 24 hours of randomization, as defined by any of: 1) a 1-point increase in modified Wood's clinical asthma score (m-WCAS) above baseline, 2) a rise in respiratory rate (RR) greater than 10 per minute from baseline, and 3) escalation in respiratory support. The secondary outcomes were success rate after crossover, if any, need for mechanical ventilation (invasive/noninvasive), local skin lesions, length of hospital stay, and complications. In 118 children analyzed by intention-to-treat, HFNC ( n = 59) versus b-CPAP ( n = 59) was associated with a lower failure rate (23.7% vs. 42.4%; relative risk [95% CI], RR 0.56 [95% CI, 0.32-0.97], p = 0.031). The Cox proportion model confirmed a lower hazard of treatment failure in the HFNC group (adjusted hazard ratio 0.48 [95% CI, 0.25-0.94], p = 0.032). No crossover was noted. A lower proportion escalated to noninvasive ventilation in the HFNC group (15.3%) versus the b-CPAP group (15.3% vs. 39% [RR 0.39 (95% CI, 0.20-0.77)], p = 0.004). The HFNC group had a longer median (interquartile range) duration of oxygen therapy (4 [3-6] vs. 3 [3-5] d; p = 0.012) and hospital stay (6 [5-8.5] vs. 5 [4-7] d, p = 0.021). No significant difference was noted in other secondary outcomes. In children aged one to 23 months with moderate to severe acute bronchiolitis, the use of HFNC therapy as opposed to b-CPAP for early respiratory support is associated with a lower failure rate and, secondarily, a lower risk of escalation to mechanical ventilation.

Factors influencing health professionals' use of high-flow nasal cannula therapy for infants with bronchiolitis - A qualitative study.

To explore the factors influencing the use of high-flow nasal cannula (HFNC) therapy for infants with bronchiolitis. Qualitative approach using semi-structured interviews. The semi-structured interviews (face-to-face or virtual) were conducted between September 2020 and February 2021. Deductive content analysis was used to map key influencing factors for use of HFNC therapy to the Theoretical Domains Framework (TDF). Nineteen interviews were undertaken before reaching thematic saturation (7 nurses, 12 doctors) in emergency departments and paediatric wards from four purposively selected hospitals in Australia and New Zealand. Influencing factors were mapped to eight domains in the TDF with 21 themes identified. Main findings included: (1) Health professionals' expectations of HFNC therapy on patient deterioration, work of breathing and oxygenation; (2) Staff emotions relating to concern and anxiety about deterioration and "need to do something"; (3) Social influences from other health professionals and parents and (4) Environmental factors relating to logistics of care and patient transfer considerations. These factors, combined with the ready availability of HFNC equipment and health professionals having the required skills to administer the therapy, contributed to its initiation. Individual/personal and contextual/environmental factors contribute to the use of HFNC therapy for infants with bronchiolitis. It is evident these influences contribute substantially to increased use, despite evidence-based guidelines recommending a more nuanced approach to this therapy. These findings will inform a targeted implementation intervention to promote evidence-based use of HFNC therapy in infants with bronchiolitis.

High-Flow Nasal Cannula Therapy for Respiratory Support in Adult Intensive Care Unit Patients

What is the effectiveness of high-flow nasal cannula (HFNC) therapy compared with standard oxygen therapy, noninvasive ventilation, or noninvasive positive pressure (NIPPV) ventilation for respiratory support in adults in the intensive care unit?Critically ill patients are at high risk for severe hypoxemia that can lead to significant tissue damage and death if not corrected. Supplemental oxygen can be delivered via multiple methods, including mechanical ventilation, noninvasive ventilation, NIPPV, HFNC therapy, and low-flow nasal cannula (LFNC) therapy.1 Up to 40% of all patients admitted to the intensive care unit (ICU) receive mechanical ventilation; although this method is often necessary, it presents risks and potential complications, including trauma to the pulmonary system and increased mortality.2,3To avoid these complications, the use of alternative methods of respiratory support that can provide adequate oxygen levels is often considered. Use of LFNC therapy can be helpful but often cannot provide a sufficiently high level of oxygen for critically ill patients. However, HFNC therapy can provide high levels of oxygen, and its use in the ICU has been growing in recent years.4High-flow nasal cannula therapy delivers heated and humidified oxygen via the nose at high flow rates of up to 60 L/min. The high flow rates produce low levels of positive pressure in the upper airways, which can clear out expired carbon dioxide, leading to reduced work of breathing and decreased respiratory rate.5 Noninvasive positive pressure ventilation, which refers primarily to continuous positive airway pressure or bilevel positive airway pressure ventilation, can be used when patients require high levels of supplemental oxygen and need some level of mechanical support. The oxygen is delivered via a tight-fitting mask, typically over the nose, mouth, or both; this mask can be uncomfortable and make it difficult to maintain adequate positioning.6The purpose of this review was to compare the efficacy and safety of HFNC therapy with those of the other common noninvasive respiratory support methods in the ICU setting.This summary was based on an update to a previously published systematic review conducted in 2017.7 As new evidence on a topic becomes available, updates are necessary to account for the results that the new evidence presents. This update, conducted by Lewis et al,8 included 31 randomized controlled trials comprising 5136 adult participants. The authors of this review investigated several outcomes, with the primary ones being treatment failure (need to escalate to invasive ventilation), in-hospital mortality, and adverse events (pneumonia).The authors independently assessed the risk of bias for each study, including selection, performance, detection, attrition, reporting, and publication biases. They resolved any disagreements by reviewing the data together and through discussion.Lewis et al8 used risk ratios (RRs) with 95% CIs for dichotomous outcomes as measures of treatment effect between various comparisons and outcomes. They used the internationally approved Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to determine the certainty of evidence—high, moderate, low, or very low—for each outcome9: This review showed that, overall, there was little or no difference in the evidence when comparing HFNC use with standard oxygen therapy or NIPPV in the outcomes explored. There was low-certainty evidence showing that HFNC therapy may lead to less treatment failure compared with standard oxygen therapy, with the classification of low certainty based on heterogeneity (differences in how the studies were conducted) and an unclear risk of bias in the studies.Currently, more than 50 studies are being conducted on the use of HFNC therapy; this high level of research activity is likely related to the increase in the use of HFNC therapy resulting from the COVID-19 pandemic. Upon publication, these studies can be added to the evaluation to provide additional guidance.The evidence from this systematic review can affect the decisions of clinical care teams when they are creating treatment plans for critically ill patients. Advocating for the best evidence-based treatment remains an important part of the role of critical care nurses. We must always consider the best available evidence and understand the feasibility, appropriateness, meaningfulness, and effectiveness of any intervention to determine whether it is suitable to implement in our individual context.

High-flow nasal cannula versus noninvasive ventilation in patients with COVID-19: a systematic review and meta-analysis.

Background:During the novel coronavirus disease 2019 (COVID-19) pandemic raging around the world, the effectiveness of respiratory support treatment has dominated people’s field of vision. This study aimed to compare the effectiveness and value of high-flow nasal cannula (HFNC) with noninvasive ventilation (NIV) for COVID-19 patients.Methods:A comprehensive systematic review via PubMed, Web of Science, Cochrane, Scopus, WHO database, China Biology Medicine Disc (SINOMED), and China National Knowledge Infrastructure (CNKI) databases was conducted, followed by meta-analysis. RevMan 5.4 was used to analyze the results and risk of bias. The primary outcome is the number of deaths at day 28. The secondary outcomes are the occurrence of invasive mechanical ventilation (IMV), the number of deaths (no time-limited), length of intensive care unit (ICU) and hospital stay, ventilator-free days, and oxygenation index [partial pressure of arterial oxygen (PaO2)/fraction of inhaled oxygen (FiO2)] at 24 h.Results:In total, nine studies [one randomized controlled trial (RCT), seven retrospective studies, and one prospective study] totaling 1582 patients were enrolled in the meta-analysis. The results showed that the incidence of IMV, number of deaths (no time-limited), and length of ICU stay were not statistically significant in the HFNC group compared with the NIV group (ps = 0.71, 0.31, and 0.33, respectively). Whereas the HFNC group performed significant advantages in terms of the number of deaths at day 28, length of hospital stay and oxygenation index (p < 0.05). Only in the ventilator-free days did NIV show advantages over the HFNC group (p < 0.0001).Conclusion:For COVID-19 patients, the use of HFNC therapy is associated with the reduction of the number of deaths at day 28 and length of hospital stay, and can significantly improve oxygenation index (PaO2/FiO2) at 24 h. However, there was no favorable between the HFNC and NIV groups in the occurrence of IMV. NIV group was superior only in terms of ventilator-free days.

Velocity-based target flow rate for high-flow nasal cannula oxygen therapy.

The aim of this study was to assess retrospectively whether the average inspiratory flow velocity-based initial flow rate in high-flow nasal cannula (HFNC) therapy could be well tolerated and safely used for infants and children hospitalized with moderate to severe respiratory failure. Thirty-three patients without underlying diseases (22 males; 67%), hospitalized to receive HFNC therapy for infection-related respiratory failure, were analyzed. The median age was 2months (interquartile range, 1month to 1year). Patients with dyspnea and carbon dioxide partial pressure (pCO2 ) >50mmHg or venous blood pH <7.320, combined with pulse oximetry arterial oxygen saturation <92%, were included. We set target flow rates calculated from the average inspiratory flow velocity, starting at the actual initial flow rates, and these were subsequently adjusted if necessary. One patient could not tolerate the cannula. Of the remaining 32 patients, 81% (n = 26) had an actual initial flow rate within 1 L of the target flow rate; these patients were evaluated for changes in the fraction of inspired oxygen (FITarget flow rate tableO2 ), pH, and pCO2 values after 24h. Three patients required a higher fraction of inspired oxygen, one showed a persistent pH < 7.320, and seven exhibited pCO2 >50mmHg. No patient required non-invasive positive-pressure ventilation, and one required intubation. Pneumothorax was not reported in any patient. The average inspiratory flow velocity-based initial flow rate was well-tolerated without sedation, and there were no severe complications. Starting at this flow rate would improve the use of HFNC therapy in the pediatric ward, possibly reducing the need for more invasive modes of ventilation.

Predicting use of high-flow nasal cannula therapy following extubation in paediatrics.

High-flow nasal cannula (HFNC) therapy is widely used for respiratory support within paediatrics, most commonly used as a supportive measure in acute respiratory failure, aiming to avoid invasive mechanical ventilation (IMV). It is increasingly being used following extubation of critically ill children potentially at a higher risk of requiring re-intubation. Less data indicate the use for post-extubation HFNC therapy or possible clinical outcomes of this therapy. To identify reasons for, and variables to predict, the use of HFNC therapy post-extubation. This was a retrospective case-control study. All children admitted to a nine-bedded regional paediatric intensive care unit requiring IMV between 18 December 2017 and 28 November 2018 were identified. The demographic data and bedside clinical and laboratory variables of the patients requiring HFNC therapy were compared with those who did not require HFNC. There was no statistical difference in the median age and weight of children receiving HFNC therapy post-extubation compared with children not receiving it. In a logistic regression model, the highest ventilation (peak inspiratory pressure) and oxygen requirements in the first 24 hours of admission, along with the presence of comorbidity and use of HFNC therapy prior to intubation, predicted the use of HFNC following extubation, (r2 0.42, area under the receiver operating curve 0.843, P < .0001). The direct correlation between high initial ventilatory requirements and pre-existing comorbidity was significant for the use of post-extubation HFNC therapy. This may be useful to stratify children in the use of HFNC therapy post-extubation in the critically ill population. This study provides evidence that it may be possible to predict the use of HFNC therapy post-extubation. Avoiding unnecessary use of this therapy improves patient care while providing a positive economic impact.

High-flow nasal cannula therapies for respiratory management in pediatric patients.

High-flow nasal cannula (HFNC) oxygen therapy is a non-invasive form of respiratory support that is rapidly being taken up in pediatric intensive care units (PICU). For infants with bronchiolitis, who are the largest non-elective source of admissions to a PICU, there is some evidence that using HFNC therapy reduces the need for intubation and mechanical ventilation. The aim of this review article is to explore, describe, critique and add to the evidence surrounding the use of HFNC therapy in the pediatric population for the management of respiratory distress.

Early high flow nasal cannula therapy in bronchiolitis, a prospective randomised control trial (protocol): A Paediatric Acute Respiratory Intervention Study (PARIS).

BackgroundBronchiolitis imposes the largest health care burden on non-elective paediatric hospital admissions worldwide, with up to 15 % of cases requiring admission to intensive care. A number of previous studies have failed to show benefit of pharmaceutical treatment in respect to length of stay, reduction in PICU admission rates or intubation frequency. The early use of non-invasive respiratory support devices in less intensive scenarios to facilitate earlier respiratory support may have an impact on outcome by avoiding progression of the disease process. High Flow Nasal Cannula (HFNC) therapy has emerged as a new method to provide humidified air flow to deliver a non-invasive form of positive pressure support with titratable oxygen fraction. There is a lack of high-grade evidence on use of HFNC therapy in bronchiolitis.Methods/DesignProspective multi-centre randomised trial comparing standard treatment (standard subnasal oxygen) and High Flow Nasal Cannula therapy in infants with bronchiolitis admitted to 17 hospitals emergency departments and wards in Australia and New Zealand, including 12 non-tertiary regional/metropolitan and 5 tertiary centres. The primary outcome is treatment failure; defined as meeting three out of four pre-specified failure criteria requiring escalation of treatment or higher level of care; i) heart rate remains unchanged or increased compared to admission/enrolment observations, ii) respiratory rate remains unchanged or increased compared to admission/enrolment observations, iii) oxygen requirement in HFNC therapy arm exceeds FiO2 ≥ 40 % to maintain SpO2 ≥ 92 % (or ≥94 %) or oxygen requirement in standard subnasal oxygen therapy arm exceeds >2L/min to maintain SpO2 ≥ 92 % (or ≥94 %), and iv) hospital internal Early Warning Tool calls for medical review and escalation of care. Secondary outcomes include transfer to tertiary institution, admission to intensive care, length of stay, length of oxygen treatment, need for non-invasive/invasive ventilation, intubation, adverse events, and cost.DiscussionThis large multicenter randomised trial will allow the definitive assessment of the efficacy of HFNC therapy as compared to standard subnasal oxygen in the treatment of bronchiolitis.Trial registrationThe trial is registered with the Australian and New Zealand Clinical Trials Registry ACTRN12613000388718 (registered on 10 April 2013).

The Use of Bubble CPAP and Humidified High Flow Nasal Cannula Oxygen Therapy in Children with Severe Pneumonia and Hypoxemia: A Systematic Review of the Evidence

Background: Among children with severe pneumonia hypoxemia is the commonest complication leading to death. Some children will have both type I (hypoxemic) and type II (hypercarbic) respiratory failure. Together this accounts for high case-fatality rates in most populations with severe pneumonia. Standard oxygen supplementation by nasal prongs (low flow) can be lifesaving, but is not always sufficient to manage respiratory failure. In recent years continuous positive airway pressure (CPAP) has been used to relieve hypoxemia and reduce the work of breathing. There are several ways to give positive airway pressure; one is bubble CPAP (BCPAP), another is high flow nasal cannula (HFNC) oxygen therapy.Objective: To review the evidence for using BCPAP, and HFNC therapy in children with severe pneumonia and hypoxemia, particularly the experience of these therapies in developing countries.Methods: Two of our study investigators independently conducted searches of the existing literature in PUBMED in October 2014 to identify reports focusing on the use of BCPAP or HFNC therapy in children with severe pneumonia and hypoxemia, as defined by the World Health Organization.Results: 13 relevant studies were identified. Ten evaluated the efficacy of BCPAP among 3164 children, and three described the same for HFNC in 255 children. In all studies the entry criteria was severe respiratory distress. The study methodologies, the outcomes recorded and results were heterogeneous. The age range of the children in the studies was from the immediate newborn period on day 1 of life up to the age of 12 years. However, we evaluated the outcome of our review in two aged categories and found: children 0-28 days for 8 studies and &gt; 28 days for 2 studies. In 3 studies of children aged 0-28 days and 2 studies of older children had clinical features consistent with severe pneumonia and those who among them were treated with immediate BCPAP therapy had better outcome (p&lt;0.01 or CI &lt; 1) compared to those who were treated with delayed BCPAP, or historical control one each, or standard flow flow (LF) oxygen therapy (in two studies). Primary outcomes were comparable between BCPAP and ventilator driven CPAP in three studies and between BCPAP and low flow oxygen or variable flow nasal CPAP in two studies (95% CI contain 1) of children aged 0-28 days. Children treated with HFNC compared to those who did not receive HFNC in three relevant studies, all of them in older children had better outcome (p&lt;0.05).Conclusion: Studies of BCPAP and HFNC are heterogeneous with different populations, comparators, outcome measures and results. However limited studies suggest that BCPAP may be effective in managing respiratory distress and hypoxemia in developing countries, although evidence is not overwhelming. Studies of the use of HFNC therapy are more limited and do not allow firm conclusions to be made. Most studies of BCPAP and HFNC have been done in neonates with respiratory distress, and studies outside this age group, where the predominant pathologies are bacterial pneumonia, sepsis and viral bronchiolitis are needed.Bangladesh Crit Care J September 2014; 2 (2): 71-78