Use Of High-flow Oxygen Therapy Research Articles

High-flow oxygen therapy for ventilator weaning patients with tracheostomy cannula

Introduction. To date, information of the use of high-flow oxygen therapy (HFOT) in patients with tracheostomy cannulas is limited. The use of HFOT in this group of patients at the ventilator weaning may improve outcomes.Objective. Improving results of treatment of patients with tracheostomy cannulas with hypoxemic ARF of various origin through the use of HFOT at the ventilator weaning after prolonged mechanical ventilation (MV).Materials and methods. The prospective open cohort study included 50 patients aged 45 (from 37 to 57) years, the duration of invasive mechanical ventilation was 8.68 ± 3.83 days. Patients were randomized into two groups: in group A, weaning from the respirator was performed through a combination of traditional low-flow oxygen therapy (LFO) and assisted modes of MV; in group B – through a combination of HFOT and assisted modes of MV. The groups compared gas exchange rates, the duration of weaning from the respirator, the incidence of complications (pulmonary and extrapulmonary), the duration of treatment, mortality in the ICU and in the hospital. In all patients, the most significant predictors of in-hospital mortality were analyzed.Results. The use of HFOT in patients in group B revealed significant benefits in terms of the studied parameters in the early and late stages of the study. Mortality in the groups did not differ. The most significant risk factors for in-hospital mortality were cannulation after transfer from the OR (OR = 9,667; 95% CI: 2.414–38,713; p = 0,001).Conclusions. The use of HFOT in patients with tracheostomy cannulas is more clinically effective than COT. Risk factors assessment in every patient will allow optimal use HFOT.

The effects of high-flow oxygen therapy on mortality in patients with COVID-19.

High-flow oxygen therapy (HFOT) has been successful in treating acute hypoxic respiratory failure (AHRF) and acute respiratory distress syndrome (ARDS). Successful treatment with noninvasive ventilation and avoidance of mechanical ventilation (MV) has been associated with decreased mortality and positive patient outcomes. It is unclear whether the evidence supports the use of HFOT to treat coronavirus disease 2019 (COVID-19)-induced AHRF and ARDS. To determine whether the use of HFOT decreases the need for intubation or decreases mortality compared with MV in patients with AHRF due to COVID-19. A literature search was conducted in March 2022 using CINAHL, Embase, PubMed, and Scopus bibliographic databases. Ten studies comparing HFOT and MV in COVID-19 respiratory failure met inclusion criteria. Nine studies found a statistically significant reduction in the need for intubation; eight studies found significantly decreased morality in patients who received HFOT. Study design and methodologies limited the findings. Based on the available evidence, the use of HFOT positively affected mortality and incidence of the need for intubation and MV. Further research needs to be conducted before HFOT is adopted as the standard of care for COVID-19-induced AHRF and ARDS. Nurse practitioners should be informed regarding the various respiratory support modalities and evaluate risk versus benefit when caring for patients with COVID-19-induced AHRF and ARDS.

Association between prehospital medication and fatal outcomes in a cohort of hospitalized patients due to coronavirus disease-2019 in a referral hospital in Peru

BackgroundTo explore the association between the use of prehospital medications and the development of fatal outcomes in patients who required hospitalization due to coronavirus disease-2019 (COVID-19). MethodsThis retrospective cohort study included adult patients who were hospitalized due to COVID-19. Demographic, clinical, and laboratory data, prehospital medication history, and fatal outcome development (use of high-flow oxygen therapy, intensive care unit [ICU] admission, or mortality) were extracted from the medical records of patients who were admitted due to COVID-19 to the Carlos Seguín Escobedo National Hospital of Arequipa, Peru during July to September 2021, the period after the second wave of COVID-19 cases in Peru. Survival was analyzed using the Cox proportional hazards model, and crude hazard ratios and adjusted hazard ratios (aHR) with their respective 95% confidence intervals (95% CI) were calculated. ResultsA total of 192 patients were evaluated, of whom 62% were males and 46.9% did not require oxygen support at admission. Additionally, 64.6% used nonsteroidal anti-inflammatory drugs, 35.4% used corticosteroids, 28.1% used macrolides or ceftriaxone, 24.5% used ivermectin, and 21.9% used warfarin before hospitalization. Of the patients, 30.2% developed a fatal outcome during follow-up. The multivariate analysis revealed that prehospital corticosteroid use was independently associated with the fatal outcome due to COVID-19 with an aHR = 5.29 (95%CI: 1.63–17.2). ConclusionPrehospital corticosteroid use was associated with a 5-fold increased risk of fatal outcome development.

High-flow nasal oxygen therapy in patients after esophageal interventions: аdvantages and disadvantages

BACKGROUND: Pulmonary complications in patients who underwent esophagectomy with one-stage esophagoplasty are a frequent cause of death in the intensive care unit (ICU). However, the use of noninvasive ventilation (NIV) in these patients is not indicated because of the failure of esophagogastric anastomosis. Compared with NIV and standard oxygen therapy, high-flow oxygen therapy (HFOT) reduces the rate of transfer to mechanical ventilation (MV) in the case of acute respiratory failure.
 AIM: This study aimed to assess the clinical advantages and disadvantages of HFOT in patients with respiratory failure after esophagectomy.
 MATERIALS AND METHODS: Ninety patients with esophagectomy were examined. Two groups were formed by randomization: group 1 (n=45) with standard respiratory therapy, incentive spirometry, and nasal oxygen therapy with NIV sessions and low end-expiratory pressure (up to 6 mmHg) and group 2 (n=45) with HFOT. Therapy parameters were selected according to oxygenation (PaO2/FiО2) and saturation (SaО2) index values. Parameter changes, session duration, patients tolerance to respiratory therapy methods (from 1 to 10 points), dynamics of chest X-ray pattern, and duration of treatment in ICU were analyzed.
 RESULTS: The advantages of HFOT were the absence of discomfort during the session, possibility to decrease O2 flow required for an adequate level of oxygenation, high flow with controlled O2 fraction allowed to reach target values of oxygenation index, decreased frequency of patients transfer to MV, and time spent in ICU.
 CONCLUSIONS: The use of HFOT is justified as part of the complex respiratory therapy in patients with moderate respiratory failure. In patients with severe respiratory failure, HFOT is an alternative to other high-flow techniques and NIV. The choice between these methods should be individualized and depend on the patients condition and ventilation requirement.

Performance of Invasive Mode in Different Heated Humidification Systems With High-Flow Nasal Cannula.

Oxygen therapy via high-flow nasal cannula generates physiologic changes that impact ventilatory variables of patients. However, we know that there are detrimental effects on airway mucosa related to inhalation of gases. The objective of this study was to evaluate the performance in terms of absolute humidity, relative humidity, and temperature of different brands of heated humidifiers and circuits in the invasive mode during the use of high-flow oxygen therapy in flows between 30 and 100 L/min. A prospective observational study conducted at the Sanatorio Anchorena equipment analysis laboratory; September 5 to October 20, 2019. A statistically significant interaction was found among the programmed flows and the different combinations of devices and circuits for the delivery of absolute humidity (P < .001). An effect of flow on delivered absolute humidity was found, regardless of the equipment and circuit combination (P < .001). However, in the invasive mode, the combination of the Fisher&Paykel MR850 heated humidifier with the Medtronic-Dar circuit, the Intersurgical circuit, and the AquaVENT circuit always reached or achieved absolute humidity values > 33 mg/L, even at flows up to 100 L/min. The combination of the Flexicare FL9000 heated humidifier with the Fisher&Paykel RT202 circuit, the Fisher&Paykel Evaqua 2 circuit, the Flexicare circuit, the AquaVENT circuit, and the GGM circuit achieved similar results. The mean (SD) of absolute humidity delivered in the invasive mode (36.2 ± 5.9 mg/L) was higher compared with the noninvasive mode (26.8 ± 7.2 mg/L) (P < .001), regardless of circuit and programmed flows. When heated humidifiers were used in the invasive mode for high-flow oxygen therapy, absolute humidity depended not only on the heated humidifiers and the combination of circuits but also on the programmed flow, especially at flows > 50 L/min. Moreover, the heated humidifiers exhibited different behaviors, in some cases inefficient, in delivering adequate humidification. However, some equipment improved performance when set to the invasive mode.

Outcomes of 2111 COVID-19 Hospitalized Patients Treated with Hydroxychloroquine/Azithromycin and Other Regimens in Marseille, France, 2020: A Monocentric Retrospective Analysis.

ObjectivesWe evaluated the 6-week mortality of SARS-CoV-2 hospitalized patients treated using a standardized protocol in 2020 in Marseille, France.MethodsA retrospective monocentric cohort study was conducted in the standard hospital wards at the Institut Hospitalo-Universitaire Méditerranée Infection, between March and December 2020 in adults with SARS-CoV-2 PCR-proven infection.ResultsOf the 2111 hospitalized patients (median age, 67 [IQR 55–79] years; 1154 [54.7%] men), 271 were transferred to the intensive care unit (12.8%) and 239 died (11.3%; the mean age of patients who died was 81.2 (±9.9)). Treatment with hydroxychloroquine plus azithromycin (HCQ-AZ), used in 1270 patients, was an independent protective factor against death (0.68 [0.52 – 0.88]). This effect was consistent for all subgroups of age, comorbidities, severity of the disease and comedications with zinc or corticosteroids. Zinc was independently protective against death (0.39 [0.23 – 0.67]), in a subgroup analysis of patients treated with HCQ-AZ without dexamethasone. The use of high-flow oxygen therapy in elderly patients who were not eligible for intensive care unit transfer saved 19 patients (33.9%).ConclusionsIn our 2020 cohort, treating COVID-19 with HCQ-AZ was associated with lower mortality. These results need to be analyzed in the context of academic discussions about observational studies versus randomized clinical trials. More data will deserve to be analyzed in the SARS-Cov 2 variants, vaccination and post-vaccination era.

Treatment with Non-invasive respiratory support in severe COVID-19: Clinical effectiveness observational study

Introduction: The study aimed to analyse the clinical response and short-term outcomes with the use of high-flow oxygen therapy (HFOT), non-invasive mechanical ventilation (NIMV) with bilevel positive airway pressure, or continuous positive airway pressure (CPAP) in severe COVID-19 patients. Methods: We conducted an observational, prospective, single-center study, approved by Ethics Committee of “Instituto de Investigación Sanitaria Fundación Jiménez Díaz” (EO102-20-HRJC). We included a total of 130 patients ≥18 years-old, with proved SARS-CoV-2 infection and secondary Acute Respiratory Failure (ARF) that required treatment with Non-invasive Respiratory Support (NIRS). We collected data about population demographic characteristics, clinical factors, and evolution during the incoming. A baseline of patients treated with HFO, CPAP and NIMV were compared with one-way ANOVA test, while categorical variables were expressed as numbers and percentages and were compared using the chi-square test or Fisher’s exact test when appropriate. Results: The cohort was distributed as follows: CPAP 54.6% (n = 71), NIMV 30% (n = 39), HFO 15.4% (n = 20). There were no differences between NIRS subgroups regarding age, comorbidity, or functional status. At the beginning of NIRS treatment, PaO2/FiO2 value was 149.3 ± 69.7. After 24 hours, PaO2/FiO2 was significantly higher in the CPAP group (CPAP vs NIMV, p-value = 0.0042; CPAP vs HFO, p-value = 0.000169). The overall ICU admission evaded rate was 69.1% and TF rate was 43.8%, without differences between the three therapies (p-value = 0.281). The mortality rate was 37.2%, without significant differences between subgroups. Conclusions: Our data suggest that CPAP versus treatment with NIMV or HFO improves PaO2/FiO2 rate in severe ARF patients, significantly reducing ICU admission. No differences were observed in mortality or therapeutic failure.

Coronavirus Disease 2019 (COVID-19) in Solid Organ Transplant Recipients: A Case-Control Study.

BackgroundIt is unclear whether solid organ transplant (SOT) patients have more severe coronavirus disease 2019 (COVID-19) and worse outcome than the general population.Material/MethodsWe conducted a case-control study on 32 SOT recipients and 84 non-SOT controls matched for age and sex admitted for confirmed COVID-19. The primary endpoint was in-hospital all-cause mortality rate. Secondary endpoints included severe acute respiratory distress syndrome (ARDS), use of high-flow oxygen therapy, and length of hospital stay.ResultsThe median (IQR) Charlson comorbidity index (CCI) at admission was significantly higher in SOT recipients (6 (3–8) vs 3 (2–4); P<0.01). Fever was less frequent in SOT recipients (78% vs 94%, P=0.01). SOT recipients had a higher median SaO2/FiO2 at admission (452 [443–462] vs 443 [419–452], P<0.01) and reached the worst SaO2/FiO2 value later during hospitalization 15 (10–21) vs 11 (9–14) days, P=0.01). Both groups had a similar severe ARDS rate during hospitalization (33% vs 28%) (p=0.59). There were no significant differences during hospitalization in terms of highest level of respiratory support needed, or length of hospital stay: 8.5 (5.5–21) vs 11.5 (6.5–16.5) days; P=0.34) in SOT recipients when compared to controls. In-hospital all-cause mortality rates were significantly higher in SOT recipients (21.9% vs 4.7%, P<0.01; OR 1.08; 95% CI 0.10–10.98), but among patients who died, median CCI was similar between groups (8 [6–8] vs 7 [6–8]).ConclusionsIn our experience, hospitalized SOT recipients for COVID-19 had higher in-hospital mortality compared to non-SOT patients, probably due to the greater number of underlying comorbidities, and not directly related to chronic immunosuppression.

Nasal high flow oxygen therapy in hospitalised neonatal foals.

Respiratory disease is common in critically ill neonatal foals. Traditional oxygen therapy (TOT) with nasal insufflation of oxygen is often used to provide first-line respiratory support. Mechanical ventilation is used in foals which require a greater level of support but requires specialist expertise and can be associated with significant complications. Non-invasive ventilation (NIV) enables a greater level of respiratory support without the need for intubation. High flow oxygen therapy (HFOT) is a mode of NIV commonly used in human intensive care. To describe the use of HFOT in hospitalised neonatal foals. Retrospective case series. Hospital records of neonatal foals admitted between 2018 and 2019 that received treatment with HFOT were reviewed. Clinical data and complications were recorded. Fourteen foals were identified and the median duration of use was 43hours (range 2-93hours) with a median flow rate of 0.7L/kg/min (range 0.42-1.67). Ten foals survived to discharge. No significant complications associated with the technique were recorded. A small study population which was retrospectively reviewed. This study provides preliminary information about the clinical use of HFOT in neonatal foals. The technique was well tolerated and no significant adverse effects were noted. However, further study is required to evaluate efficacy.

Неинвазивная вентиляция легких (лекция)

В лекции освещены вопросы step by step респираторной терапии у больных с острой дыхательной дисфункцией (ОДД). Первым шагом в лечении больных с ОДД (при отсутствии показаний к инвазивной механической вентиляции легких) является использование высокопоточной оксигенации (ВПО) и неинвазивной вентиляции легких (НИВЛ). По сравнению с инвазивной механической вентиляцией легких эти технологии имеют определенные преимущества. Они не приводят к вентилятор-ассоциированному повреждению легких, вентилятор-ассоциированной диафрагмальной дисфункции и не вызывают вентилятор-ассоциированной пневмонии. НИВЛ обеспечивает определенная концентрация кислорода на вдохе (FiO2) в сочетании с умеренным давлением в конце выдоха (РЕЕР)/постоянным положительным давлением в дыхательных путях (СРАР) и инспираторным давлением. В отличие от оксигенации через лицевую маску или носовые канюли она уменьшает возможность экспираторного закрытия мелких дыхательных путей, предупреждает коллапс альвеол и возможность возникновения ателектазов. Преимуществом НИВЛ в сравнении со стандартной оксигенотерапией через лицевую маску/носовые канюли можно считать то, что она обеспечивает умеренный уровень РЕЕР/СРАР, который уменьшает пред- и постнагрузку левого желудочка. Это имеет особенное значение у больных с острой левожелудочковой недостаточностью или отеком легких. Главным условием успешного проведения НИВЛ является наличие адекватного сознания у больного. В основе клинической эффективности ВПО лежит возможность создания большой скорости потока газа (до 60 л/мин). Такая скорость потока (которая равна или даже больше скорости потока при вдохе больного) минимизирует «примешивание» комнатного воздуха и разрешает поддерживать на вдохе высокую FiO2. Принципиально важно наличие возможности методом step by step регулировать скорость потока и температуры, точное измерение FiO2. Современные системы ВПО имеют специальные контуры из полупроницаемых материалов, которые не допускают образования конденсата и имеют оригинальные носовые или трахеостомические канюли.

The use of high-flow oxygen therapy delivered via Airvo™ in the acute setting over a six-month period: A clinical perspective

Since 2010 the benefits of high-flow oxygen therapy (HFOT) have been realised both in the acute clinical setting and for chronic long-term conditions. Independent control of flow, inspired oxygen and humidification, and reports of good patient tolerance, makes it a favourable treatment option. A service review looking at the use of HFOT delivered via Airvo™ (Fisher and Paykel) was completed over a six-month period in the acute clinical environment in a small tertiary hospital in New Zealand. It was used on the critical care unit, but its use focused primarily at ward level to determine which patients could benefit from it and to indicate where it could be safely delivered. Data was collected on patient diagnosis, clinical indications, respiratory rate, oxygen percentage and mode of delivery prior to using high-flow, initial HFOT settings and highest settings throughout treatment, number of HFOT treatment days and clinical outcome. In this report, clinical observations showed that for those patients who have secretion retention, atelectasis, increased work of breathing, and increasing oxygen requirements, HFOT is an appropriate treatment option especially in those patients who are not reliant on high levels of positive end expiratory pressure (PEEP). It also demonstrated that HFOT via Airvo™ can be safely implemented in ward settings for a variety of clinical conditions. Recommendations for future work includes the collection of qualitative data on patient comfort and compliance with HFOT in addition to information on clinician confidence in setting up and weaning patients from the device.

Respiratory and pharmacological management in severe acute bronchiolitis: Were clinical guidelines not written for critical care?

PurposeThe treatment applied for children admitted to the pediatric intensive care unit (PICU) for severe acute bronchiolitis may differ from general recommendations. The first objective of our study was to describe the treatments offered to these children in a Spanish tertiary PICU. The second objective was to analyse the changes in management derived from the publication of the American Academy of Pediatrics (AAP) bronchiolitis guideline in 2014. MethodsThis was a retrospective–prospective observational study conducted during two epidemic waves (2014–2015 and 2015–2016). The AAP guidelines were distributed and taught to PICU staff between both epidemic waves. ResultsA total of 138 children were enrolled (78 male). In the first period, 78 children were enrolled. The median age was 1.8 months (IQR 1.1–3.6). There were no differences between the management in the two periods, except for the use of high-flow oxygen therapy (HFOT); its use increased in the second period. Overall, 83% of patients received non-invasive ventilation or HFOT. Children older than 12 months received HFOT exclusively. In comparison, continuous positive airway pressure and bi-level positive airway pressure were used less during the period 2015–2016 (P=0.036). Regarding pharmacological therapy, 70% of patients received antibiotics, 23% steroids, 33% salbutamol, 31% adrenaline, and 7% hypertonic saline. The mortality rate was zero. ConclusionsOur PICU did not follow the AAP recommendations. There were no differences between the two periods, except in the use of HFOT. All children older than 12 months received HFOT exclusively. The rate of using invasive mechanical ventilation was also low.

Preventive use of respiratory support after scheduled extubation in critically ill medical patients\u2014a network meta-analysis of randomized controlled trials

BackgroundRespiratory support has been increasingly used after extubation for the prevention of re-intubation and improvement of prognosis in critically ill medical patients. However, the optimal respiratory support method is still under debate. This network meta-analysis (NMA) aims to evaluate the comparative effectiveness of various respiratory support methods used for preventive purposes after scheduled extubation in critically ill medical patients.MethodsA systematic database search was performed from inception to December 19, 2019, for randomized controlled trials (RCTs) that compared a preventive use of different respiratory support methods, including conventional oxygen therapy (COT), noninvasive ventilation (NIV), high-flow oxygen therapy (HFOT), and combinational use of HFOT and NIV (HFOT+NIV), after planned extubation in adult critically ill medical patients. Study selection, data extraction, and quality assessments were performed in duplicate. The primary outcomes included re-intubation rate and short-term mortality.ResultsSeventeen RCTs comprising 3341 participants with 4 comparisons were included. Compared with COT, NIV significantly reduced the re-intubation rate [risk ratio (RR) 0.55, 95% confidence interval (CI) 0.39 to 0.77; moderate quality of evidence] and short-term mortality (RR 0.66, 95% CI 0.48 to 0.91; moderate quality of evidence). Compared to COT, HFOT had a beneficial effect on the re-intubation rate (RR 0.55, 95% CI 0.35 to 0.86; moderate quality of evidence) but no effect on short-term mortality (RR 0.79, 95% CI 0.56 to 1.12; low quality of evidence). No significant difference in the re-intubation rate or short-term mortality was found among NIV, HFOT, and HFOT+NIV. The treatment rankings based on the surface under the cumulative ranking curve (SUCRA) from best to worst for re-intubation rate were HFOT+NIV (95.1%), NIV (53.4%), HFOT (51.2%), and COT (0.3%), and the rankings for short-term mortality were NIV (91.0%), HFOT (54.3%), HFOT+NIV (43.7%), and COT (11.1%). Sensitivity analyses of trials with a high risk of extubation failure for the primary outcomes indicated that the SUCRA rankings were comparable to those of the primary analysis.ConclusionsAfter scheduled extubation, the preventive use of NIV is probably the most effective respiratory support method for comprehensively preventing re-intubation and short-term death in critically ill medical patients, especially those with a high risk of extubation failure.

Oxygen Therapy: Systems and Indications in the Pediatric and Adult Population

Hypoxemia is defined as the decrease in arterial partial pressure of oxygen (PaO2) below 80 mmHg. One of the ways to alleviate this condition is through oxygen therapy, which consists of administering oxygen at a concentration higher than atmospheric. This therapy is indicated in various pathologies and is aimed to treat hypoxemia and reduce the patient's myocardial demand and respiratory effort. Classically, this treatment has been carried out using low-flow systems, in which the inspiratory fraction of oxygen (FiO2) cannot be regulated. However, an increase in the use of high-flow oxygen therapy (HFO) has been observed in recent years. These systems allow for greater patient comfort as well as more precise regulation of the FiO2. The purpose of this article is to review respiratory physiology to understand respiratory failure from a clinical and pathophysiological point of view. Likewise, the different oxygen therapy systems most widely used are discussed, as well as their indications for acute and chronic pathologies, both in the pediatric and adult populations.

Comparative analysis of the use of high-flow and traditional oxygen therapy in patients with severe community-acquired pneumonia. An experimental and clinical study

Introduction. In patients with spontaneous breathing and respiratory failure, various methods of delivering the gas mixture to the respiratory tract have been developed. The use of high-flow oxygen therapy is alternative standard oxygen therapy. Objectives. Experimental study of the effects of high-flow oxygen therapy and evaluation of its clinical effectiveness in comparison with traditional oxygen therapy in patients with severe community-acquired pneumonia. Materials and Methods. During the experimental stage of the study, the level of mean airway pressure was determined depending on the flow of the gas mixture using a lung model with parameters of biomechanics of respiration. During the clinical stage, a comparative analysis of the effectiveness of respiratory support in groups of patients with severe community-acquired pneumonia using high-flow and traditional oxygen therapy was carried out. Results. During experimental study, flow of gas mixture 30 l/min was determined, at which mean airway pressure registered on models of healthy lungs and lungs with modified respiratory biomechanics significantly increases. During the clinical phase of the study, a statistically significant decrease in the frequency of initiation of artificial (invasive and non-invasive) lung ventilation, an increase in oxygenation (saturation hemoglobin with oxygen, partial pressure oxygen in arterial blood) and partial pressure carbon dioxide with simultaneous decrease in respiratory rate. Conclusion. The value of gas flow over 30 l/min has significant effect on the recorded mean airway pressure calculated using models of lungs in experiment. However, clinical significance of this indicator is not clinically significant. The use of high-flow oxygen therapy in patients with severe community-acquired pneumonia in comparison with standard method reduces the frequency use of ventilation (invasive and non-invasive) with a significant increase in oxygenation indicators. This reduces hyperventilation, which is confirmed by a significant increase in partial pressure carbon dioxide and a decrease in respiratory rate.

Center effect in intubation risk in critically ill immunocompromised patients with acute hypoxemic respiratory failure

BackgroundAcute respiratory failure is the leading reason for intensive care unit (ICU) admission in immunocompromised patients, and the need for invasive mechanical ventilation has become a major clinical endpoint in randomized controlled trials (RCTs). However, data are lacking on whether intubation is an objective criteria that is used unbiasedly across centers. This study explores how this outcome varies across ICUs.MethodsHierarchical models and permutation procedures for testing multiple random effects were applied on both data from an observational cohort (the TRIAL-OH study: 703 patients, 17 ICUs) and a randomized controlled trial (the HIGH trial: 776 patients, 31 ICUs) to characterize ICU variation in intubation risk across centers.ResultsThe crude intubation rate varied across ICUs from 29 to 80% in the observational cohort and from 0 to 86% in the RCT. This center effect on the mean ICU intubation rate was statistically significant, even after adjustment on individual patient characteristics (observational cohort: p value = 0.013, median OR 1.48 [1.30–1.72]; RCT: p value 0.004, median OR 1.51 [1.36–1.68]). Two ICU-level characteristics were associated with intubation risk (the annual rate of intubation procedure per center and the time from respiratory symptoms to ICU admission) and could partly explain this center effect. In the RCT that controlled for the use of high-flow oxygen therapy, we did not find significant variation in the effect of oxygenation strategy on intubation risk across centers, despite a significant variation in the need for invasive mechanical ventilation.ConclusionIntubation rates varied considerably among ICUs, even after adjustment on individual characteristics.

Clinical parameters alerting treatment failure in critical patients with high-flow oxygen therapy

To describe the clinical outcomes of critically unwell patients using high-flow oxygen therapy (HFOT) and establish clinical parameters that identify high-risk patients likely to fail or deteriorate on HFOT. We conducted a retrospective observational study on the use of HFOT (Optiflow; Fisher &

The Effectiveness of High-Flow Oxygen Therapy and the Fascinating Song of the Sirens

This Viewpoint describes the evidence supporting the use of high-flow oxygen therapy in pediatric patients with bronchiolitis, with remarks associating this unproven therapy with characters from the Odyssey, by Homer.

Noninvasive ventilation as acute therapy.

Noninvasive ventilation (NIV) is widely used in ICU patients to treat or to prevent acute respiratory failure. Whereas its physiological effects are clearly beneficial in hypercapnic patients, it could be deleterious in hypoxemic patients without hypercapnia. NIV should be cautiously used in patients with de-novo respiratory failure, the vast majority of whom meet the criteria for acute respiratory distress syndrome. Spontaneous breathing with high tidal volumes may worsen lung injury in these patients, and recent findings suggest that NIV may increase the risk of mortality. Even though high-flow oxygen therapy is increasingly applied in this context, NIV remains recommended for management of immunocompromised patients with acute respiratory failure. NIV should be the first-line oxygenation strategy in patients with acute hypercapnic respiratory failure when pH is equal to or below 7.35. Prophylactic NIV prevents respiratory failure after extubation of patients at high risk of reintubation. Most previous studies have compared NIV with standard oxygen, and recent recommendations have been established from these findings. Given the growing use of high-flow oxygen therapy, new studies are needed to compare NIV versus high-flow oxygen therapy so as to better define the appropriate indications for each treatment.

Efficacy and safety of nasal high-flow oxygen in COPD patients

BackgroundNasal high-flow oxygen therapy (HFOT) is a novel treatment option for patients suffering from acute or chronic respiratory failure. Aim of our study was to compare safety and efficacy of HFOT with those of conventional oxygen treatment (COT) in normo- and hypercapnic COPD patients.MethodsA single cohort of 77 clinically stable hypoxemic patients with an indication for long-term oxygen treatment (LTOT) with or without hypercapnia successively received COT and HFOT for 60 min each, including oxygen adaption and separated by a 30 min washout phase.ResultsHFOT was well-tolerated in all patients. A significant decrease in PaCO2 was observed during oxygen adaption of HFOT, and increased PaO2 coincided with significantly increased SpO2 and decreased AaDO2 during both treatment phases. Even at a flow rate of 15 L/min, oxygen requirement delivered as air mixture by HFOT tended to be lower than that of COT (2.2 L/min). Not only was no increase in static or dynamic lung volumes observed during HFOT, but even was a significant reduction of residual lung volume measured in 36 patients (28%).ConclusionsThus, short-term use of HFOT is safe in both normocapnic and hypercapnic COPD patients. Lower oxygen levels were effective in correcting hypoxemic respiratory failure and reducing hypercapnia, leading to a reduced amount of oxygen consumption. Long-term studies are needed to assess safety, tolerability, and clinical efficacy of HFOT.Trial registrationClinicalTrials.gov NCT01686893 13.09.2012 retrospectively registered (STIT-1) and NCT01693146 14.09.2012 retrospectively registered (STIT-2). Studies were approved by the local ethics committee (Ethikkommission der Medizinischen Universität Innsbruck, Studienkennzahl UN3547, Sitzungsnummer 274/4.19).