Comparison of hypoxemia, intubation procedure, and complications for non-invasive ventilation against high-flow nasal cannula oxygen therapy for patients with acute hypoxemic respiratory failure: a non-randomized retrospective analysis for effectiveness and safety (NIVaHIC-aHRF)

Prevalence of peri-intubation major adverse events among critically ill patients: A systematic review and meta analysis

BACKGROUND

Peri-intubation major adverse events (MAEs) are potentially preventable and associated with poor patient outcomes. Critically ill patients intubated in Emergency Departments, Intensive Care Units or medical wards are at particularly high risk for MAEs. Understanding the prevalence and risk factors for MAEs can help physicians anticipate and prepare for the physiologically difficult airway.

METHODS

We searched PubMed, Scopus, and Embase for prospective and retrospective observational studies and randomized control trials (RCTs) reporting peri-intubation MAEs in intubations occurring outside the operating room (OR) or post-anesthesia care unit (PACU). Our primary outcome was any peri-intubation MAE, defined as any hypoxia, hypotension/cardiovascular collapse, or cardiac arrest. Esophageal intubation and failure to achieve first-pass success were not considered MAEs. Secondary outcomes were prevalence of hypoxia, cardiac arrest, and cardiovascular collapse. We performed random-effects meta-analysis to identify the prevalence of each outcome and moderator analyses and meta-regressions to identify risk factors. We assessed studies' quality using the Cochrane Risk of Bias 2 tool and the Newcastle-Ottawa Scale.

RESULTS

We included 44 articles and 34,357 intubations. Peri-intubation MAEs were identified in 30.5% of intubations (95% CI 25-37%). MAEs were more common in the intensive care unit (ICU; 41%, 95% CI 33-49%) than the Emergency Department (ED; 17%, 95% CI 12-24%). Intubation for hemodynamic instability was associated with higher rates of MAEs, while intubation for airway protection was associated with lower rates of MAEs. Fifteen percent (15%, 95% CI 11.5-19%) of intubations were complicated by hypoxia, 2% (95% CI 1-3.5%) by cardiac arrest, and 18% (95% CI 13-23%) by cardiovascular collapse.

CONCLUSIONS

Almost one in three patients intubated outside the OR and PACU experience a peri-intubation MAE. Patients intubated in the ICU and those with pre-existing hemodynamic compromise are at highest risk. Resuscitation should be considered an integral part of all intubations, particularly in high-risk patients.

Comparison of the effect of Continuous Positive Airway Pressure (CPAP) and Bi-Level Positive Airway Pressure (BiPAP) on hemodynamic parameters in Covid-19 patients: A clinical trial

BACKGROUND

The most prevalent clinical sign for COVID-19 patients are respiratory diseases such that the criteria for clinical screening and care of the patients in most countries, including Iran, are based on the three primary symptoms, i.e., fever, cough, shortness of breath, or difficulty breathing. The purpose of the current study was to compare the effect of continuous positive airway pressure and bi-level positive airway pressure on hemodynamic parameters in COVID-19 patients.

MATERIALS AND METHODS

It was a clinical trial conducted on 46 COVID-19 patients admitted to Imam Hassan Hospital in Bojnourd in 2022. This study included patients selected through convenient sampling and then through Permuted block randomization, who were assigned to continuous positive airway pressure (CPAP), and Bi-Level Positive Airway Pressure (BiPAP) groups. Patients were compared in terms of the severity of their COVID-19 disease in both groups and were divided equally in each disease severity. After determining their type of respiratory aid use, the patient's hemodynamic status (systolic blood pressure, diastolic blood pressure, pulse, arterial oxygen saturation, and temperature) was examined beforehand, immediately after 1 hour, 6 hours, and then daily up to 3 days of CPAP/BiPAP at a specific time. Data collection tools were demographic data questionnaires and information on patients' diseases. A checklist was also used to record the main variables of the research. The collected data were put into SPSS software version 19. To analyze the data, the Kolmogorov-Smirnov normality test was used to evaluate the normality of quantitative variables. As a result, it was found that the data had a normal distribution. Repeated measures of ANOVA and independent t-tests were employed to compare quantitative variables in the two groups at different times. In this study, a significance level of 0.05 was considered.

RESULTS

There was a significant difference in terms of systolic blood pressure, diastolic blood pressure, respiration rate, pulse rate, oxygen saturation, and temperature in the two groups of patients at 1 day, 2 days, and 3 days after use (P < 0.05).

CONCLUSION

The results displayed better performance of CPAP than BiPAP in the parameters of systolic blood pressure, diastolic blood pressure, respiration rate, pulse rate, oxygen saturation, and temperature in COVID-19 patients. Therefore, in necessary cases, it is recommended to use a CPAP mask.

Effectiveness of high-flow nasal cannula therapy on clinical outcomes in adults with COVID-19: A systematic review

Introduction/Background

Coronavirus disease 2019 (COVID-19) has high transmissibility and mortality rates. High-flow nasal cannula therapy (HFNC) might reduce the need for orotracheal intubation, easing the burden on the health system caused by COVID-19. The objective of the present study was to examine the effectiveness of HFNC in adult patients hospitalized with COVID-19. Specifically, the present study explores the effects of HFNC on rates of mortality, intubation and intensive care units (ICU) length of stay. The present study also seeks to define predictors of success and failure of HFNC.

Methods

A systematic literature search was conducted in the PubMed, EMBASE and SCOPUS databases, and the study was prepared according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study quality was assessed using the National Heart, Lung, and Blood Institute's Study Quality Assessment Tools.

Results

The search identified 1,476 unique titles; 95 articles received full-text reviews and 40 studies were included in this review. HFNC was associated with a reduction in the rate of orotracheal intubation, notably when compared to conventional oxygen therapy. Studies reported inconsistency in whether HFNC reduced ICU length of stay or mortality rates. Among the predictors of HFNC failure/success, a ratio of oxygen saturation index of approximately 5 or more was associated with HFNC success.

Conclusion

In adult patients hospitalized with COVID-19, HFNC may prove effective in reducing the rate of orotracheal intubation. The ratio of the oxygen saturation index was the parameter most examined as a predictor of HFNC success. Low-level research designs, inherent study weaknesses and inconsistent findings made it impossible to conclude whether HFNC reduces ICU length of stay or mortality. Future studies should employ higher level research designs.

Prediction of high-flow nasal cannula outcomes at the early phase using the modified respiratory rate oxygenation index

BACKGROUND

This study was designed to explore the early predictive value of the respiratory rate oxygenation (ROX) index modified by PaO₂ (mROX) in high-flow nasal cannula (HFNC) therapy in patients with acute hypoxemia respiratory failure (AHRF).

METHOD

Seventy-five patients with AHRF treated with HFNC were retrospectively reviewed. Respiratory parameters at baseline and 2 h after HFNC initiation were analyzed. The predictive value of the ROX (ratio of pulse oximetry/FIO₂ to respiratory rate) and mROX (ratio of arterial oxygen /FIO₂ to respiratory rate) indices with two variations by adding heart rate to each index (ROX-HR and mROX-HR) was evaluated.

RESULTS

HFNC therapy failed in 24 patients, who had significantly higher intensive care unit (ICU) mortality and longer ICU stay. Both the ROX and mROX indices at 2 h after HFNC initiation can predict the risk of intubation after HFNC. Two hours after HFNC initiation, the mROX index had a higher area under the receiver operating characteristic curve (AUROC) for predicting HFNC success than the ROX index. Besides, baseline mROX index of greater than 7.1 showed a specificity of 100% for HFNC success.

CONCLUSION

The mROX index may be a suitable predictor of HFNC therapy outcomes at the early phase in patients with AHRF.