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Pretalli JB, Parmentier AL, Mauny F, Desmettre T, Marjanovic N, Capellier G, Khoury A. Efficacy of high-flow nasal oxygen therapy started in the emergency room versus conventional oxygen therapy in patients with acute hypoxaemic respiratory distress: protocol for a French multicentric, prospective, open and randomised superiority study protocol (HIFLOWED). BMJ Open 2024; 14:e083262. [PMID: 39160110 PMCID: PMC11337659 DOI: 10.1136/bmjopen-2023-083262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 07/23/2024] [Indexed: 08/21/2024] Open
Abstract
INTRODUCTION Acute respiratory failure is a life-threatening condition frequently found in the emergency department. High-flow nasal oxygen (HFNO) is increasingly used in emergency departments for patients with hypoxaemic acute respiratory failure. However, despite the increasing number of studies, its potential advantages regarding the need for therapeutic escalation and mortality have not been precisely evaluated. Our objective is to compare conventional oxygen therapy to HFNO when they are initiated during the first hour following the patient's arrival at the emergency department, with the hypothesis that HFNO would reduce the need for ventilatory therapy escalation. METHODS AND ANALYSIS This is a multicentric, prospective, open and randomised superiority study. 500 inpatients will be randomised (1:1) to receive conventional oxygen therapy or HNFO. The primary outcome is a failure in the oxygen therapy defined as the need for a therapeutic escalation within 4 hours after therapy initiation. ETHICS AND DISSEMINATION The study has been submitted and approved by the Comité de Protection des Personnes Nord Ouest IV (20 October 2020). As required, a notification was sent to the Agence nationale de sécurité du médicament et des produits de santé (22 October 2020). The research results will be published in peer-reviewed publications and presented at international conferences. TRIAL REGISTRATION NUMBER NCT04607967.
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Affiliation(s)
- Jean Baptiste Pretalli
- Department of Emergency Medicine and Critical Care, Besançon University Hospital, Besançon, France
- Inserm CIC 1431, CHU Besançon, Besançon, France
| | | | | | - Thibaut Desmettre
- Department of Emergency Medicine and Critical Care, Besançon University Hospital, Besançon, France
| | - Nicolas Marjanovic
- Department of Emergency Medicine, Poitiers University Hospital, Poitiers, France
| | - Gilles Capellier
- Department of Emergency Medicine and Critical Care, Besançon University Hospital, Besançon, France
| | - Abdo Khoury
- Department of Emergency Medicine and Critical Care, Besançon University Hospital, Besançon, France
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Ai T, Zhang Z, Tan Z, Shi Z, Li H, Zhang S, Zhao X, Yao Y, Li W, Gao Y, Zhu M. Modified Respiratory Rate Oxygenation Index: An Early Warning Index for the Need of Intubation in COVID-19 Patients with High-Flow Nasal Cannula Therapy. J Emerg Med 2023; 65:e93-e100. [PMID: 37479639 PMCID: PMC10212589 DOI: 10.1016/j.jemermed.2023.04.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 04/21/2023] [Accepted: 04/25/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND High-flow nasal cannula oxygen therapy (HFNC) is recommended for patients with COVID-19. However, the increasing use of HFNC brings a risk of delayed intubation. The optimal timing of switching from HFNC to invasive mechanical ventilation (IMV) remains unclear. An effective predictor is needed to assist in deciding on the timing of intubation. Respiratory rate and oxygenation (ROX) index, defined as (SpO2/FiO2) / respiratory rate, has already shown good diagnostic accuracy. Modified ROX (mROX) index, defined as (PaO2 /FiO2) / respiratory rate, might be better than the ROX index in predicting HFNC failure. OBJECTIVE The aim was to evaluate the predictive value of mROX for HFNC failure in patients with COVID-19. METHODS Severe or critical patients with COVID-19 treated with HFNC were enrolled in two clinical centers. Laboratory indicators, respiratory parameters, and mROX index at 0 h and 2 h after initial HFNC were collected. Based on the need for IMV after HFNC initiation, the patients were divided into an HFNC failure group and an HFNC success group. The predictive value of mROX index for IMV was evaluated by the area under the receiver operating characteristic curve (AUROC) and logistic regression analysis. We performed Kaplan-Meier survival analysis using the log-rank test. RESULTS Sixty patients with COVID-19 (mean ± SD age, 62.8 ± 14.1 years; 42 patients were male) receiving HFNC were evaluated, including 18 critical and 42 severe cases. A total of 33 patients had hypertension; 14 had diabetes; 17 had chronic cardiac disease; 11 had chronic lung disease; 13 had chronic kidney disease; and 17 had a history of stroke. The AUROC of mROX index at 2 h was superior to that of other respiratory parameters to predict the need for IMV (0.959; p < 0.001). At the mROX index cutoff point of 4.45, predicting HFNC failure reached the optimal threshold, with specificity of 94% and sensitivity of 92%. Logistic regression analysis showed that 2-h mROX index < 4.45 was a protective factor for IMV (odd radio 0.18; 95% CI 0.05-0.64; p = 0.008). In the HFNC failure group, the median time from HFNC to IMV was 22.5 h. The 28-day mortality of the late intubation patients (≥ 22.5 h) was higher than that of the early intubation patients (< 22.5 h) (53.8% vs. 8.3%; p = 0.023). CONCLUSIONS mROX at 2 h is a good early warning index of the need for IMV in patients with COVID-19 after HFNC initiation. Early intubation may lead to better survival in patients with 2-h mROX index < 4.45.
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Affiliation(s)
- Tianyi Ai
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhiyun Zhang
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhangjun Tan
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhiqiang Shi
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Hui Li
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Shuyi Zhang
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xianyuan Zhao
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yulong Yao
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wen Li
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yuan Gao
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
| | - Mingli Zhu
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Oxygénothérapie à haut débit nasal dans l’insuffisance respiratoire aiguë hypoxémique. Rev Mal Respir 2022; 39:607-617. [DOI: 10.1016/j.rmr.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 05/24/2022] [Indexed: 11/18/2022]
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Tetlow S, Anandanadesan R, Taheri L, Pagkalidou E, De Lavallade H, Metaxa V. High-flow nasal cannula oxygen in patients with haematological malignancy: a retrospective observational study. Ann Hematol 2022; 101:1191-1199. [PMID: 35394147 DOI: 10.1007/s00277-022-04824-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 03/21/2022] [Indexed: 01/05/2023]
Abstract
Patients with haematological malignancies (HM) face high rates of intensive care unit (ICU) admission and mortality. High-flow nasal cannula oxygen (HFNCO) is increasingly used to support HM patients in ward settings, but there is limited evidence on the safety and efficacy of HFNCO in this group. We retrospectively reviewed all HM patients receiving ward-based HFNCO, supervised by a critical care outreach service (CCOS), from January 2014 to January 2019. We included 130 consecutive patients. Forty-three (33.1%) were weaned off HFNCO without ICU admission. Eighty-seven (66.9%) were admitted to ICU, 20 (23.3%) required non-invasive and 34 (39.5%) invasive mechanical ventilation. ICU and hospital mortality were 42% and 55% respectively. Initial FiO2 < 0.4 (OR 0.27, 95% CI 0.09-0.81, p = 0.019) and HFNCO use on the ward > 1 day (OR 0.16, 95% CI 0.04, 0.59, p = 0.006) were associated with reduced likelihood for ICU admission. Invasive ventilation was associated with reduced survival (OR 0.27, 95%CI 0.1-0.7, p = 0.007). No significant adverse events were reported. HM patients receiving ward-based HFNCO have higher rates of ICU admission, but comparable hospital mortality to those requiring CCOS review without respiratory support. Results should be interpreted cautiously, as the model proposed depends on the existence of CCOS.
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Affiliation(s)
- Simon Tetlow
- University College Hospital NHS Foundation Trust, 235 Euston Rd, Bloomsbury, London, NW1 2BU, UK.
| | | | - Leila Taheri
- Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Eirini Pagkalidou
- School of Medicine, Aristotle University of Thessaloniki, University Campus, 54124, Thessaloniki, Greece
| | - Hugues De Lavallade
- Department of Haematological Medicine, King's College Hospital, Denmark Hill, Brixton, London, SE5 9RS, UK
| | - Victoria Metaxa
- Department of Critical Care, King's College Hospital, Denmark Hill, Brixton, London, SE5 9RS, UK
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Liu J, Li D, Luo L, Liu Z, Li X, Qiao L. Analysis of risk factors for the failure of respiratory support with high-flow nasal cannula oxygen therapy in children with acute respiratory dysfunction: A case-control study. Front Pediatr 2022; 10:979944. [PMID: 36081624 PMCID: PMC9445578 DOI: 10.3389/fped.2022.979944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 08/05/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Evidence-based clinical practice guidelines regarding high-flow nasal cannula (HFNC) use for respiratory support in critically ill children are lacking. Therefore, we aimed to determine the risk factors for early HFNC failure to reduce the failure rate and prevent adverse consequences of HFNC failure in children with acute respiratory dysfunction. METHODS Demographic and laboratory data were compared among patients, admitted to the pediatric intensive care unit between January 2017 and December 2018, who were included in a retrospective cohort study. Univariate and multivariate analyses were performed to determine risk factors for eventual entry into the predictive model for early HFNC failure and to perform an external validation study in a prospective observational cohort study from January to February 2019. Further, the association of clinical indices and trends pre- and post-treatment with HFNC treatment success or failure in these patients was dynamically observed. RESULTS In total, 348 pediatric patients were included, of these 282 (81.0%) were included in the retrospective cohort study; HFNC success was observed in 182 patients (64.5%), HFNC 0-24 h failure in 74 patients (26.2%), and HFNC 24-48 h failure in 26 patients (9.2%). HFNC 24 h failure was significantly associated with the pediatric risk of mortality (PRISM) III score [odds ratio, 1.391; 95% confidence interval (CI): 1.249-1.550], arterial partial pressure of carbon dioxide-to-arterial partial pressure of oxygen (PaCO2/PaO2) ratio (odds ratio, 38.397; 95% CI: 6.410-230.013), and respiratory rate-oxygenation (ROX) index (odds ratio, 0.751; 95% CI: 0.616-0.915). The discriminating cutoff point for the new scoring system based on the three risk factors for HFNC 24 h failure was ≥ 2.0 points, with an area under the receiver operating characteristic curve of 0.794 (95% CI, 0.729-0.859, P < 0.001), sensitivity of 68%, and specificity of 79%; similar values were noted on applying the model to the prospective observational cohort comprising 66 patients (AUC = 0.717, 95% CI, 0.675-0.758, sensitivity 83%, specificity 44%, P = 0.009). In this prospective cohort, 11 patients with HFNC failure had an upward trend in PaCO2/PaO2 ratio and downward trends in respiratory failure index (P/F ratio) and ROX index; however, opposite directions of change were observed in 55 patients with HFNC success. Furthermore, the fractional changes (FCs) in PaCO2/PaO2 ratio, P/F ratio, percutaneous oxygen saturation-to-fraction of inspired oxygen (S/F) ratio, and ROX index at 2 h post-HFNC therapy onset were statistically significant between the two groups (all, P < 0.05). CONCLUSION In the pediatric patients with acute respiratory insufficiency, pre-treatment PRISM III score, PaCO2/PaO2 ratio, and ROX index were risk factors for HFNC 24 h failure, and the direction and magnitude of changes in the PaCO2/PaO2 ratio, P/F ratio, and ROX index before and 2 h after HFNC treatment were warning indicators for HFNC 24 h failure. Further close monitoring should be considered for patients with these conditions.
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Affiliation(s)
- Jie Liu
- Department of Pediatric Intensive Care Unit, West China Second Universal Hospital, Sichuan University, Chengdu, China.,NHC Key Laboratory of Chronobiology (Sichuan University), Ministry of Education, Chengdu, China
| | - Deyuan Li
- Department of Pediatric Intensive Care Unit, West China Second Universal Hospital, Sichuan University, Chengdu, China.,NHC Key Laboratory of Chronobiology (Sichuan University), Ministry of Education, Chengdu, China
| | - Lili Luo
- Department of Pediatric Intensive Care Unit, West China Second Universal Hospital, Sichuan University, Chengdu, China.,NHC Key Laboratory of Chronobiology (Sichuan University), Ministry of Education, Chengdu, China
| | - Zhongqiang Liu
- Department of Pediatric Intensive Care Unit, West China Second Universal Hospital, Sichuan University, Chengdu, China.,NHC Key Laboratory of Chronobiology (Sichuan University), Ministry of Education, Chengdu, China
| | - Xiaoqing Li
- Department of Pediatric Intensive Care Unit, West China Second Universal Hospital, Sichuan University, Chengdu, China.,NHC Key Laboratory of Chronobiology (Sichuan University), Ministry of Education, Chengdu, China
| | - Lina Qiao
- Department of Pediatric Intensive Care Unit, West China Second Universal Hospital, Sichuan University, Chengdu, China.,NHC Key Laboratory of Chronobiology (Sichuan University), Ministry of Education, Chengdu, China
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Giugliano-Jaramillo C, León J, Enriquez C, Keymer JE, Pérez-Araos R. High Flow Nasal Cannula as Support in Immunocompromised Patients with Acute Respiratory Failure: A Retrospective Study. Open Respir Med J 2021. [DOI: 10.2174/1874306402115010061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction:
High Flow Nasal Cannula (HFNC) is a novel technique for respiratory support that improves oxygenation. In some patients, it may reduce the work of breathing. In immunocompromised patients with Acute Respiratory Failure (ARF), Non-Invasive Ventilation (NIV) is the main support recommended strategy, since invasive mechanical ventilation could increase mortality rates. NIV used for more than 48 hours may be associated with increased in-hospital mortality and hospital length of stay. Therefore HFNC seems like a respiratory support alternative.
Objective:
To describe clinical outcomes of immunocompromised patients with ARF HFNC-supported.
Methods:
Retrospective study in patients admitted with ARF and HFNC-supported. 25 adult patients were included, 21 pharmacologically and 4 non- pharmacologically immunosuppressed. Median age of the patients was 64 [60-76] years, APACHE II 15 [11-19], and PaO2:FiO2 218 [165-248]. Demographic information, origin of immunosuppression, Respiratory Rate (RR), Heart Rate (HR), Mean Arterial Pressure (MAP), oxygen saturation (SpO2) and PaO2:FiO2 ratio were extracted from clinical records of our HFNC local protocol. Data acquisition was performed before and after the first 24 hours of connection. In addition, the need for greater ventilatory support after HFNC, orotracheal intubation, in-hospital mortality and 90 days out-patients’ mortality was recorded.
Results:
Mean RR before the connection was 25±22 breaths/min and 22±4 breaths/min after the first 24 hours of HFNC use (95% CI; p=0.02). HR mean before connection to HFNC was 96±22 beats/min, and after, it was 86±15 beats/min (95%CI; p=0.008). Previous mean MAP was 86±15 mmHg, and after HFNC, it was 80±12 mmHg (95%CI; p=0.09); mean SpO2 after was 93±5% and before it was 95±4% (95% CI; p=0.13); and previous PaO2:FiO2 mean was 219±66, and after it was 324±110 (95%CI; p=0.52). In-hospital mortality was 28% and 90 days out-patients’ mortality was 32%.
Conclusion:
HFNC in immunosuppressed ARF subjects significantly decreases HR and RR, being apparently an effective alternative to decrease work of breathing. In-hospital mortality in ARF immunosuppressed patients was high even though respiratory support was used. Better studies are needed to define the role of HFNC-support in ARF.
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7
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Baldomero AK, Melzer AC, Greer N, Majeski BN, MacDonald R, Linskens EJ, Wilt TJ. Effectiveness and Harms of High-Flow Nasal Oxygen for Acute Respiratory Failure: An Evidence Report for a Clinical Guideline From the American College of Physicians. Ann Intern Med 2021; 174:952-966. [PMID: 33900793 PMCID: PMC8292205 DOI: 10.7326/m20-4675] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Use of high-flow nasal oxygen (HFNO) for treatment of adults with acute respiratory failure (ARF) has increased. PURPOSE To assess HFNO versus noninvasive ventilation (NIV) or conventional oxygen therapy (COT) for ARF in hospitalized adults. DATA SOURCES English-language searches of MEDLINE, Embase, CINAHL, and Cochrane Library from January 2000 to July 2020; systematic review reference lists. STUDY SELECTION 29 randomized controlled trials evaluated HFNO versus NIV (k = 11) or COT (k = 21). DATA EXTRACTION Data extraction by a single investigator was verified by a second, 2 investigators assessed risk of bias, and evidence certainty was determined by consensus. DATA SYNTHESIS Results are reported separately for HFNO versus NIV, for HFNO versus COT, and by initial or postextubation management. Compared with NIV, HFNO may reduce all-cause mortality, intubation, and hospital-acquired pneumonia and improve patient comfort in initial ARF management (low-certainty evidence) but not in postextubation management. Compared with COT, HFNO may reduce reintubation and improve patient comfort in postextubation ARF management (low-certainty evidence). LIMITATIONS Trials varied in populations enrolled, ARF causes, and treatment protocols. Trial design, sample size, duration of treatment and follow-up, and results reporting were often insufficient to adequately assess many outcomes. Protocols, clinician and health system training, cost, and resource use were poorly characterized. CONCLUSION Compared with NIV, HFNO as initial ARF management may improve several clinical outcomes. Compared with COT, HFNO as postextubation management may reduce reintubations and improve patient comfort; HFNO resulted in fewer harms than NIV or COT. Broad applicability, including required clinician and health system experience and resource use, is not well known. PRIMARY FUNDING SOURCE American College of Physicians. (PROSPERO: CRD42019146691).
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Affiliation(s)
- Arianne K Baldomero
- Minneapolis Veterans Affairs Health Care System and University of Minnesota, Minneapolis, Minnesota (A.K.B., A.C.M.)
| | - Anne C Melzer
- Minneapolis Veterans Affairs Health Care System and University of Minnesota, Minneapolis, Minnesota (A.K.B., A.C.M.)
| | - Nancy Greer
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota (N.G., B.N.M., R.M., E.J.L.)
| | - Brittany N Majeski
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota (N.G., B.N.M., R.M., E.J.L.)
| | - Roderick MacDonald
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota (N.G., B.N.M., R.M., E.J.L.)
| | - Eric J Linskens
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota (N.G., B.N.M., R.M., E.J.L.)
| | - Timothy J Wilt
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, and University of Minnesota, Minneapolis, Minnesota (T.J.W.)
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El-Goly AMM. Lines of Treatment of COVID-19 Infection. COVID-19 INFECTIONS AND PREGNANCY 2021. [PMCID: PMC8298380 DOI: 10.1016/b978-0-323-90595-4.00002-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Xu J, Yu Y, Liu J. Acute Hypoxemic Respiratory Failure in Immunocompromised Patients: Taking Aggressive Measures to Identify Etiology. Front Med (Lausanne) 2020; 7:433. [PMID: 33015081 PMCID: PMC7511656 DOI: 10.3389/fmed.2020.00433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 07/06/2020] [Indexed: 02/05/2023] Open
Affiliation(s)
- Jing Xu
- Department of Critical Care Medicine, School of Medicine, Rui Jin Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yuetian Yu
- Department of Critical Care Medicine, School of Medicine, Ren Ji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jialin Liu
- Department of Critical Care Medicine, School of Medicine, Rui Jin Hospital, Shanghai Jiao Tong University, Shanghai, China
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Yao W, Wang T, Jiang B, Gao F, Wang L, Zheng H, Xiao W, Yao S, Mei W, Chen X, Luo A, Sun L, Cook T, Behringer E, Huitink JM, Wong DT, Lane-Fall M, McNarry AF, McGuire B, Higgs A, Shah A, Patel A, Zuo M, Ma W, Xue Z, Zhang LM, Li W, Wang Y, Hagberg C, O'Sullivan EP, Fleisher LA, Wei H. Emergency tracheal intubation in 202 patients with COVID-19 in Wuhan, China: lessons learnt and international expert recommendations. Br J Anaesth 2020; 125:e28-e37. [PMID: 32312571 PMCID: PMC7151238 DOI: 10.1016/j.bja.2020.03.026] [Citation(s) in RCA: 216] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 03/31/2020] [Accepted: 03/31/2020] [Indexed: 02/07/2023] Open
Abstract
Tracheal intubation in coronavirus disease 2019 (COVID-19) patients creates a risk to physiologically compromised patients and to attending healthcare providers. Clinical information on airway management and expert recommendations in these patients are urgently needed. By analysing a two-centre retrospective observational case series from Wuhan, China, a panel of international airway management experts discussed the results and formulated consensus recommendations for the management of tracheal intubation in COVID-19 patients. Of 202 COVID-19 patients undergoing emergency tracheal intubation, most were males (n=136; 67.3%) and aged 65 yr or more (n=128; 63.4%). Most patients (n=152; 75.2%) were hypoxaemic (Sao2 <90%) before intubation. Personal protective equipment was worn by all intubating healthcare workers. Rapid sequence induction (RSI) or modified RSI was used with an intubation success rate of 89.1% on the first attempt and 100% overall. Hypoxaemia (Sao2 <90%) was common during intubation (n=148; 73.3%). Hypotension (arterial pressure <90/60 mm Hg) occurred in 36 (17.8%) patients during and 45 (22.3%) after intubation with cardiac arrest in four (2.0%). Pneumothorax occurred in 12 (5.9%) patients and death within 24 h in 21 (10.4%). Up to 14 days post-procedure, there was no evidence of cross infection in the anaesthesiologists who intubated the COVID-19 patients. Based on clinical information and expert recommendation, we propose detailed planning, strategy, and methods for tracheal intubation in COVID-19 patients.
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Affiliation(s)
- Wenlong Yao
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tingting Wang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Bailin Jiang
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA,Department of Anesthesiology, Peking University People's Hospital, Beijing, China
| | - Feng Gao
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Li Wang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hongbo Zheng
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Weimin Xiao
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shanglong Yao
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Mei
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiangdong Chen
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China,Corresponding author.
| | - Ailin Luo
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China,Corresponding authors.
| | - Liang Sun
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA,Department of Anesthesiology, Peking University People's Hospital, Beijing, China
| | - Tim Cook
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
| | - Elizabeth Behringer
- Division of Cardiovascular Surgery and Critical Care, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | | | - David T. Wong
- Department of Anaesthesia, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Meghan Lane-Fall
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Barry McGuire
- Department of Anaesthesia, Ninewells Hospital, Dundee, UK
| | - Andrew Higgs
- Department of Anaesthesia and Intensive Care Medicine, Warrington and Halton Hospitals, Warrington, UK
| | - Amit Shah
- Department of Anesthesiology, Kailash Cancer Hospital and Research Center, Muni Seva Ashram, Goraj, India
| | - Anil Patel
- Department of Anaesthesiology, Royal National Throat, Nose and Ear Hospital, London, UK
| | - Mingzhang Zuo
- Department of Anesthesiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Wuhua Ma
- Department of Anesthesiology, First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, China
| | - Zhanggang Xue
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Li-Ming Zhang
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh Medical Center (UPMC) and University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Wenxian Li
- Department of Anesthesiology, Eye, Ear, Nose and Throat Hospital of Fudan University, Shanghai, China
| | - Yong Wang
- Department of Anesthesiology, First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, China
| | - Carin Hagberg
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ellen P. O'Sullivan
- Department of Anaesthesia and Intensive Care Medicine, St James's Hospital, Dublin, Ireland
| | - Lee A. Fleisher
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Huafeng Wei
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA,Corresponding author.
| | - collaboratorsPengZhiyong21LiangHansheng22NishikawaKoji23Department of Critical Care Medicine, Zhongnan Hospital, Wuhan University, Wuhan, ChinaDepartment of Anesthesiology, Peking University People’s Hospital, Beijing, ChinaDepartment of Anesthesiology and Operating Room, General Sagami Kosei Hospital, Kanagawa, Japan
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11
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Goh KJ, Chai HZ, Ong TH, Sewa DW, Phua GC, Tan QL. Early prediction of high flow nasal cannula therapy outcomes using a modified ROX index incorporating heart rate. J Intensive Care 2020; 8:41. [PMID: 32587703 PMCID: PMC7310118 DOI: 10.1186/s40560-020-00458-z] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 06/10/2020] [Indexed: 12/21/2022] Open
Abstract
Background The ROX index (ratio of pulse oximetry/FIO2 to respiratory rate) has been validated to predict high flow nasal cannula therapy (HFNC) outcomes in patients with pneumonia. We evaluated a modified ROX index incorporating heart rate (HR) in patients initiated on HFNC for acute hypoxemic respiratory failure and as a preventative treatment following planned extubation. Methods We performed a prospective observational cohort study of 145 patients treated with HFNC. ROX-HR index was defined as the ratio of ROX index over HR (beats/min), multiplied by a factor of 100. Evaluation was performed using area under the receiving operating characteristic curve (AUROC) and cutoffs assessed for prediction of HFNC failure: defined as the need for mechanical ventilation. Results Ninety-nine (68.3%) and 46 (31.7%) patients were initiated on HFNC for acute hypoxemic respiratory failure and following a planned extubation, respectively. The majority (86.9%) of patients had pneumonia as a primary diagnosis, and 85 (56.6%) patients were immunocompromised. Sixty-one (42.1%) patients required intubation (HFNC failure). Amongst patients on HFNC for acute respiratory failure, HFNC failure was associated with a lower ROX and ROX-HR index recorded at time points between 1 and 48 h. Within the first 12 h, both indices performed with the highest AUROC at 10 h as follows: 0.723 (95% CI 0.605–0.840) and 0.739 (95% CI 0.626–0.853) for the ROX and ROX-HR index respectively. A ROX-HR index of > 6.80 was significantly associated with a lower risk of HFNC failure (hazard ratio 0.301 (95% CI 0.143–0.663)) at 10 h. This association was also observed at 2, 6, 18, and 24h, even with correction for potential confounding factors. For HFNC initiated post-extubation, only the ROX-HR index remained significantly associated with HFNC failure at all recorded time points between 1 and 24 h. A ROX-HR > 8.00 at 10 h was significantly associated with a lower risk of HFNC failure (hazard ratio 0.176 (95% CI 0.051–0.604)). Conclusion While validation studies are required, the ROX-HR index appears to be a promising tool for early identification of treatment failure in patients initiated on HFNC for acute hypoxemic respiratory failure or as a preventative treatment after a planned extubation.
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Affiliation(s)
- Ken Junyang Goh
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, 20 College Road, Singapore, 169856 Singapore
| | - Hui Zhong Chai
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, 20 College Road, Singapore, 169856 Singapore
| | - Thun How Ong
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, 20 College Road, Singapore, 169856 Singapore.,Duke-National University of Singapore Graduate Medical School, Singapore, Singapore
| | - Duu Wen Sewa
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, 20 College Road, Singapore, 169856 Singapore
| | - Ghee Chee Phua
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, 20 College Road, Singapore, 169856 Singapore.,Duke-National University of Singapore Graduate Medical School, Singapore, Singapore
| | - Qiao Li Tan
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, 20 College Road, Singapore, 169856 Singapore
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12
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Wang Y, Ni Y, Sun J, Liang Z. Use of High-Flow Nasal Cannula for Immunocompromise and Acute Respiratory Failure: A Systematic Review and Meta-Analysis. J Emerg Med 2020; 58:413-423. [PMID: 32220545 DOI: 10.1016/j.jemermed.2020.01.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 01/10/2020] [Accepted: 01/20/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute respiratory failure (ARF) is a common cause of emergency department (ED) and intensive care unit (ICU) admissions. High-flow nasal cannula oxygen therapy (HFNC) is widely used for patients with ARF. OBJECTIVE Our aim was to evaluate the latest evidence regarding the application of HFNC in immunocompromised patients with ARF. METHODS We searched PubMed, Embase, and Cochrane databases from inception to January 2019. The primary outcome was short-term mortality and the secondary outcomes were intubation rate and length of ICU stay. RESULTS Eight studies involving 2,179 immunocompromised subjects with ARF were included. No significant differences for short-term mortality were observed when comparing HFNC with conventional oxygen therapy (COT) (risk ratio [RR] 0.89; 95% confidence interval [CI] 0.73 to 1.09; p = 0.25, I2 = 47%) and with noninvasive ventilation (NIV) (RR 0.66; 95% CI 0.37 to 1.18; p = 0.16, I2 = 58%). Lower intubation rates were found when comparing HFNC with COT (RR 0.89; 95% CI 0.80 to 0.99; p = 0.03, I2 = 0%) and no significant difference was found between HFNC and NIV (RR 0.74; 95% CI 0.46 to 1.19; p = 0.22, I2 = 67%). The length of ICU stay was similar when comparing HFNC with COT (mean difference [MD] 0.59; 95% CI -1.68 to 2.85; p = 0.61, I2 = 56%), but was significantly shorter when HFNC was compared with NIV (MD -2.13; 95% CI -3.98 to -0.29; p = 0.02, I2 = 0%). CONCLUSIONS There was no significant difference in short-term mortality with use of HFNC when compared with COT or NIV for immunocompromised patients with ARF. A lower intubation rate than COT and a shorter length of ICU stay than NIV were observed in the HFNC group.
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Affiliation(s)
- Yiwei Wang
- Department of Respiratory and Critical Care Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China
| | - Yuenan Ni
- Department of Respiratory and Critical Care Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China
| | - Jikui Sun
- State Key Laboratory of Oral Diseases, West China School of Stomatology, Sichuan University, Chengdu, China
| | - Zongan Liang
- Department of Respiratory and Critical Care Medicine, West China Hospital, West China School of Medicine, Sichuan University, Chengdu, China
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13
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Noninvasive approach for de novo acute hypoxemic respiratory failure: noninvasive ventilation, high-flow nasal cannula, both or none? Curr Opin Crit Care 2020; 25:54-62. [PMID: 30516585 DOI: 10.1097/mcc.0000000000000570] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW To summarize the recent evidence regarding the use of noninvasive strategies for de novo acute hypoxemic respiratory failure (AHRF). RECENT FINDINGS New guidelines for the use of noninvasive ventilation (NIV) in acute respiratory failure have been published. In parallel, high-flow nasal cannula (HFNC) is an emerging noninvasive strategy for AHRF patients. Although some have cautioned against the use of NIV in AHRF, new encouraging data about the use of a helmet interface for NIV in acute respiratory distress syndrome may overcome the limitations of facemask NIV. SUMMARY In the last two decades, the use of NIV and HFNC in patients with AHRF has considerably expanded, changing the paradigm of management of AHRF. Choice of each technique should be based according to centre experience and patient tolerability. However, when using noninvasive strategies for AHRF, it is crucial to predefine specific criteria for intubation and monitor patients closely for early detection of clinical deterioration to avoid delayed intubation.
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14
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Satici C, López-Padilla D, Schreiber A, Kharat A, Swingwood E, Pisani L, Patout M, Bos LD, Scala R, Schultz MJ, Heunks L. ERS International Congress, Madrid, 2019: highlights from the Respiratory Intensive Care Assembly. ERJ Open Res 2020; 6:00331-2019. [PMID: 32166088 PMCID: PMC7061203 DOI: 10.1183/23120541.00331-2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 01/23/2020] [Indexed: 12/19/2022] Open
Abstract
The Respiratory Intensive Care Assembly of the European Respiratory Society is delighted to present the highlights from the 2019 International Congress in Madrid, Spain. We have selected four sessions that discussed recent advances in a wide range of topics: from acute respiratory failure to cough augmentation in neuromuscular disorders and from extra-corporeal life support to difficult ventilator weaning. The subjects are summarised by early career members in close collaboration with the Assembly leadership. We aim to give the reader an update on the most important developments discussed at the conference. Each session is further summarised into a short list of take-home messages.
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Affiliation(s)
- Celal Satici
- Respiratory Medicine, Istanbul Gaziosmanpasa Training and Research Hospital, Health Science University, Istanbul, Turkey
| | - Daniel López-Padilla
- Respiratory Dept, Gregorio Marañón University Hospital, Spanish Sleep Network, Madrid, Spain
| | - Annia Schreiber
- Interdepartmental Division of Critical Care, University of Toronto, Unity Health Toronto (St Michael's Hospital) and the Li Ka Shing Knowledge Institute, Toronto, Canada
| | - Aileen Kharat
- Pulmonology Dept, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Ema Swingwood
- University Hospitals Bristol NHS Foundation Trust, Adult Therapy Services, Bristol Royal Infirmary, Bristol, UK
| | - Luigi Pisani
- Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Lieuwe D. Bos
- Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
- Respiratory Medicine, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Raffaele Scala
- Pulmonology and Respiratory Intensive Care Unit, S. Donato Hospital, Arezzo, Italy
| | - Marcus J. Schultz
- Intensive Care, Amsterdam UMC, Location AMC, University of Amsterdam, Amsterdam, the Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Leo Heunks
- Intensive Care, Amsterdam UMC, Location VUmc, Amsterdam, the Netherlands
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15
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Mansfield DR. Nasal high‐flow therapy: Established roles and emerging opportunities. Respirology 2019; 24:1039-1041. [DOI: 10.1111/resp.13677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 07/28/2019] [Indexed: 11/30/2022]
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16
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Cheng LC, Chang SP, Wang JJ, Hsiao SY, Lai CC, Chao CM. The Impact of High-Flow Nasal Cannula on the Outcome of Immunocompromised Patients with Acute Respiratory Failure: A Systematic Review and Meta-Analysis. MEDICINA (KAUNAS, LITHUANIA) 2019; 55:E693. [PMID: 31623276 PMCID: PMC6843566 DOI: 10.3390/medicina55100693] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 10/09/2019] [Accepted: 10/15/2019] [Indexed: 12/24/2022]
Abstract
Background and objectives: High-flow nasal cannula (HFNC) can be used as a respiratory support strategy for patients with acute respiratory failure (ARF). However, no clear evidence exists to support or oppose HFNC use in immunocompromised patients. Thus, this meta-analysis aims to assess the effects of HFNC, compared to conventional oxygen therapy (COT) and noninvasive ventilation (NIV), on the outcomes in immunocompromised patients with ARF. The Pubmed, Embase and Cochrane databases were searched up to November 2018. Materials and Methods: Only clinical studies comparing the effect of HFNC with COT or NIV for immunocompromised patients with ARF were included. The outcome included the rate of intubation, mortality and length of stay (LOS). Results: A total of eight studies involving 1433 immunocompromised patients with ARF were enrolled. The pooled analysis showed that HFNC was significantly associated with a reduced intubation rate (risk ratio (RR), 0.83; 95% confidence interval (CI), 0.74-0.94, I2 = 0%). Among subgroup analysis, HFNC was associated with a lower intubation rate than COT (RR, 0.86; 95% CI, 0.75-0.95, I2 = 0%) and NIV (RR, 0.59; 95% CI, 0.40-0.86, I2 = 0%), respectively. However, there was no significant difference between HFNC and control groups in terms of 28-day mortality (RR, 0.78; 95% CI, 0.58-1.04, I2 = 48%), and intensive care unit (ICU) mortality (RR, 0.87; 95% CI, 0.73-1.05, I2 = 57%). The ICU and hospital LOS were similar between HFNC and control groups (ICU LOS: mean difference, 0.49 days; 95% CI, -0.25-1.23, I2 = 69%; hospital LOS: mean difference, -0.12 days; 95% CI, -1.86-1.61, I2 = 64%). Conclusions: Use of HFNC may decrease the intubation rate in immunocompromised patients with ARF compared with the control group, including COT and NIV. However, HFNC could not provide additional survival benefit or shorten the LOS. Further large, randomized controlled trials are needed to confirm these findings.
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Affiliation(s)
- Li-Chin Cheng
- Divisin of Colorectal Surgery, Department of Surgery, Chi Mei Medical Center, Tainan 71004, Taiwan.
| | | | - Jian-Jhong Wang
- Division of Nephrology, Department of Internal Medicine, Chi Mei Medical Center, Chiali 72263, Taiwan.
| | - Sheng-Yen Hsiao
- Department of Internal Medicine, Chi Mei Medical Center, Liouying, 73657, Taiwan.
| | - Chih-Cheng Lai
- Department of Internal Medicine, Kaohsiung Veterans General Hospital, Tainan Branch, Tainan 71051, Taiwan.
| | - Chien-Ming Chao
- Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying, 73657, Taiwan.
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17
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Allan PA, Litton E. Reducing Respiratory Complications After Cardiac Surgery. J Cardiothorac Vasc Anesth 2019; 34:166-167. [PMID: 31395412 DOI: 10.1053/j.jvca.2019.07.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 07/08/2019] [Indexed: 11/11/2022]
Affiliation(s)
| | - Edward Litton
- Fiona Stanley Hospital, Perth, WA, Australia; St. John of God Subiaco Hospital, Perth, WA, Australia
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18
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Baker K, Greaves T, Fraser JF. How to use humidified high-flow nasal cannula in breathless adults in the emergency department. Emerg Med Australas 2019; 31:863-868. [PMID: 31389171 DOI: 10.1111/1742-6723.13372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 07/11/2019] [Accepted: 07/15/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Kylie Baker
- Emergency Department, Ipswich Hospital, Ipswich, Queensland, Australia
| | - Tanya Greaves
- Emergency Department, Ipswich Hospital, Ipswich, Queensland, Australia
| | - John F Fraser
- The University of Queensland and Adult Intensive Care Service, Prince Charles Hospital, Brisbane, Queensland, Australia.,St Andrew's War Memorial Hospital, Brisbane, Queensland, Australia
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19
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Boccatonda A, Groff P. High-flow nasal cannula oxygenation utilization in respiratory failure. Eur J Intern Med 2019; 64:10-14. [PMID: 31029547 DOI: 10.1016/j.ejim.2019.04.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 04/09/2019] [Accepted: 04/19/2019] [Indexed: 10/27/2022]
Abstract
High flow nasal cannula (HFNC) represents a new oxygenation system to be used in the treatment of respiratory emergencies. During HFNC therapy, the active humidification and air heating system allow the patient to tolerate higher flows by favouring physiologic mucociliary clearance and improving fluidity of respiratory secretions. Following this, FiO2 values are more stable and reliable, by reducing losses and minimizing ambient air entrainment. Several clinical trials in acute respiratory failure patients have suggested lower rate of invasive mechanical ventilation, improved comfort and enhanced survival by early HFNC utilization in comparison with conventional oxygen therapy (COT) or non-invasive ventilation (NIV). This review aims to summarize the main evidences on the use of HFNC in the acute setting and its major indications.
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Affiliation(s)
- Andrea Boccatonda
- Department of Internal Medicine, "G. d'Annunzio" University, Chieti, Italy.
| | - Paolo Groff
- Emergency Department, "Santa Maria della Misericordia" Hospital, Perugia, Italy
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20
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Zayed Y, Banifadel M, Barbarawi M, Kheiri B, Chahine A, Rashdan L, Haykal T, Samji V, Armstrong E, Bachuwa G, Al-Sanouri I, Seedahmed E, Hernandez DA. Noninvasive Oxygenation Strategies in Immunocompromised Patients With Acute Hypoxemic Respiratory Failure: A Pairwise and Network Meta-Analysis of Randomized Controlled Trials. J Intensive Care Med 2019; 35:1216-1225. [PMID: 31046545 DOI: 10.1177/0885066619844713] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Acute hypoxemic respiratory failure (AHRF) is a leading cause of intensive care unit (ICU) admission among immunocompromised patients. Invasive mechanical ventilation is associated with increased morbidity and mortality. OBJECTIVE To evaluate the efficacy of various oxygenation strategies including noninvasive ventilation (NIV), high-flow nasal cannula (HFNC), and conventional oxygen therapy in immunocompromised patients with AHRF. METHODS Electronic databases including PubMed, Embase, and the Cochrane Library were reviewed from inception to December 2018. We included all randomized controlled trials (RCTs) comparing different modalities of initial oxygenation strategies in immunocompromised patients with AHRF. Our primary outcome was the need for intubation and invasive mechanical ventilation while secondary outcomes were ICU acquired infections and short- and long-term mortality. Data were extracted separately and independently by 2 reviewers. We performed a Bayesian network meta-analysis to calculate odds ratio (OR) and Bayesian 95% credible intervals (CrIs). RESULTS Nine RCTs were included (1570 patients, mean age 61.1 ± 13.8 years with 64% male). Noninvasive ventilation was associated with a significantly reduced intubation rate compared with standard oxygen therapy (OR: 0.53; 95% CrI: 0.26-0.91). There were no significant reductions of intubation between NIV versus HFNC (OR: 0.83; 95% CrI: 0.35-2.11) or HFNC versus standard oxygen therapy (OR: 0.65; 95% CrI: 0.26-1.24). There were no significant differences between all groups regarding short-term (28-day or ICU) mortality or long-term (90-day or hospital) mortality or ICU-acquired infections (P > 0.05). CONCLUSION Among immunocompromised patients with AHRF, NIV was associated with a significant reduction of intubation compared with standard oxygen therapy. There were no significant differences among all oxygenation strategies regarding mortality and ICU-acquired infections.
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Affiliation(s)
- Yazan Zayed
- Internal Medicine Department, 3361Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Momen Banifadel
- Internal Medicine Department, 89021University of Toledo, Toledo, OH, USA
| | - Mahmoud Barbarawi
- Internal Medicine Department, 3361Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Babikir Kheiri
- Internal Medicine Department, 3361Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Adam Chahine
- Internal Medicine Department, 3361Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Laith Rashdan
- Internal Medicine Department, 3361Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Tarek Haykal
- Internal Medicine Department, 3361Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Varun Samji
- Internal Medicine Department, 3361Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Emily Armstrong
- Internal Medicine Department, 3361Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Ghassan Bachuwa
- Internal Medicine Department, 3361Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Ibrahim Al-Sanouri
- Pulmonary and Critical Care Department, 3361Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Elfateh Seedahmed
- Pulmonary and Critical Care Department, 3361Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Dawn-Alita Hernandez
- Pulmonary and Critical Care Department, 89021University of Toledo, Toledo, OH, USA
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21
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Cortegiani A, Crimi C, Sanfilippo F, Noto A, Di Falco D, Grasselli G, Gregoretti C, Giarratano A. High flow nasal therapy in immunocompromised patients with acute respiratory failure: A systematic review and meta-analysis. J Crit Care 2018; 50:250-256. [PMID: 30622042 DOI: 10.1016/j.jcrc.2018.12.015] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 12/27/2018] [Accepted: 12/27/2018] [Indexed: 01/08/2023]
Abstract
PURPOSE The role of high-flow nasal therapy (HFNT) as compared to conventional oxygen therapy (COT) in immunocompromised patients admitted to intensive care unit (ICU) with acute respiratory failure (ARF) remains unclear. We conducted a systematic review and meta-analysis in order to address this issue. METHODS We searched PubMed, Medline and Embase until November 7th, 2018. Randomized controlled trials (RCTs), non-randomized prospective and retrospective evidence were selected. Observational studies were considered for sensitivity analysis. Primary outcome was mortality rate; intubation rate was a secondary outcome. RESULTS We included four studies in the primary analysis: one RCT, two RCT's post-hoc analyses and one retrospective study. We found no significant difference in short-term mortality comparing HFNT vs. COT: 1) ICU: n = 872 patients, odds ratio (OR) = 0.80 [0.44,1.45], p = 0.46, I2 = 30%, p = 0.24; 2) 28-day: n = 996 patients, OR = 0.79 [0.45,1.38], p = 0.40, I2 = 52%, p = 0.12). Conversely, we found a reduction of intubation rate in the HFNT group (n = 1052 patients, OR = 0.74 [0.55,0.98], p = 0.03, I2 = 7%, p = 0.36). The inclusion of one observational study for sensitivity analysis did not grossly change results. CONCLUSIONS We found no benefit of HFNT over COT on mortality in immunocompromised patients with ARF. However, HFNT was associated with a lower intubation rate warranting further research.
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Affiliation(s)
- Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy.
| | - Claudia Crimi
- Respiratory Medicine Unit, AOU "Policlinico-Vittorio Emanuele", Catania, Italy
| | - Filippo Sanfilippo
- Department of Anesthesia and Intensive Care, AOU Policlinico Vittorio Emanuele, Catania, Italy
| | - Alberto Noto
- Anesthesia and Intensive Care Unit, AOU Policinico "G. Martino", Messina, Italy
| | - Davide Di Falco
- Department of Anesthesia and Intensive Care, School of Anesthesia and Intensive Care, University of Catania, 95100 Catania, Italy
| | - Giacomo Grasselli
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Via Festa del Perdono 1, 20122, Milan, Italy
| | - Cesare Gregoretti
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
| | - Antonino Giarratano
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
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22
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Brunot V, Larcher R, Amalric M, Platon L, Tudesq JJ, Besnard N, Daubin D, Corne P, Jung B, Klouche K. Prise en charge du transplanté rénal en réanimation. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
La transplantation rénale est la thérapeutique de choix de l’insuffisance rénale chronique au stade ultime, son usage est de plus en plus large. Les progrès réalisés dans les traitements immunosuppresseurs ont permis une amélioration de la durée de vie du greffon, mais au prix d’une augmentation des complications cardiovasculaires et infectieuses. Environ 5 % des transplantés rénaux présentent des complications sévères qui nécessitent une prise en charge intensive. Elles sont principalement de cause infectieuse et dominées par la défaillance respiratoire aiguë. L’insuffisance rénale aiguë est commune, elle affecte la fonction du greffon à court et long termes. La prise en charge en réanimation de ces complications doit prendre en compte le terrain particulier du transplanté rénal et les effets délétères de l’immunosuppression, condition nécessaire à une amélioration de la mortalité qui reste à plus de 30 %.
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23
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Dugan KC, Hall JB, Patel BK. High-Flow Nasal Oxygen-The Pendulum Continues to Swing in the Assessment of Critical Care Technology. JAMA 2018; 320:2083-2084. [PMID: 30357275 DOI: 10.1001/jama.2018.14287] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Karen C Dugan
- Department of Medicine, University of Chicago, Chicago, Illinois
| | - Jesse B Hall
- Section of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, Illinois
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24
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Scala R, Pisani L. Noninvasive ventilation in acute respiratory failure: which recipe for success? Eur Respir Rev 2018; 27:27/149/180029. [DOI: 10.1183/16000617.0029-2018] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 04/16/2018] [Indexed: 12/12/2022] Open
Abstract
Noninvasive positive-pressure ventilation (NPPV) to treat acute respiratory failure has expanded tremendously over the world in terms of the spectrum of diseases that can be successfully managed, the locations of its application and achievable goals.The turning point for the successful expansion of NPPV is its ability to achieve the same physiological effects as invasive mechanical ventilation with the avoidance of the life-threatening risks correlated with the use of an artificial airway.Cardiorespiratory arrest, extreme psychomotor agitation, severe haemodynamic instability, nonhypercapnic coma and multiple organ failure are absolute contraindications for NPPV. Moreover, pitfalls of NPPV reduce its rate of success; consistently, a clear plan of what to do in case of NPPV failure should be considered, especially for patients managed in unprotected setting. NPPV failure is likely to be reduced by the application of integrated therapeutic tools in selected patients handled by expert teams.In conclusion, NPPV has to be considered as a rational art and not just as an application of science, which requires the ability of clinicians to both choose case-by-case the best “ingredients” for a “successful recipe” (i.e.patient selection, interface, ventilator, interface,etc.) and to avoid a delayed intubation if the ventilation attempt fails.
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