High-Flow Nasal Cannula Oxygen in Patients with Acute Respiratory Failure and Do-Not-Intubate or Do-Not-Resuscitate Orders: A Systematic Review

Effect of high flow nasal oxygen on inspiratory effort of patients with acute hypoxic respiratory failure and do not intubate orders

High flow nasal oxygen (HFNO) is recommended as a first-line respiratory support during acute hypoxic respiratory failure (AHRF) and represents a proportionate treatment option for patients with do not intubate (DNI) orders. The aim of the study is to assess the effect of HFNO on inspiratory effort as assessed by esophageal manometry in a population of DNI patients suffering from AHRF. Patients with AHRF and DNI orders admitted to Respiratory intermediate Care Unit between January 1st, 2018 and May 31st, 2023 to receive HFNO and subjected to esophageal manometry were enrolled. Esophageal pressure swing (ΔPes), clinical variables before and after 2 h of HFNO and clinical outcome (including HFNO failure) were collected and compared as appropriate. The change in physiological and clinical parameters according to the intensity of baseline breathing effort was assessed and the correlation between baseline ΔPes values and the relative change in breathing effort and clinical variables after 2 h of HFNO was explored. Eighty-two consecutive patients were enrolled according to sample size calculation. Two hours after HFNO start, patients presented significant improvement in ΔPes (12 VS 16 cmH2O, p < 0.0001), respiratory rate (RR) (22 VS 28 bpm, p < 0.0001), PaO2/FiO2 (133 VS 126 mmHg, p < 0.0001), Heart rate, Acidosis, Consciousness, Oxygenation and respiratory rate (HACOR) score, (4 VS 6, p < 0.0001), Respiratory rate Oxygenation (ROX) index (8.5 VS 6.1, p < 0.0001) and BORG (1 VS 4, p < 000.1). Patients with baseline ΔPes below 20 cmH2O where those who improved all the explored variables, while patients with baseline ΔPes above 30 cmH2O did not report significant changes in physiological or clinical features. A significant correlation was found between baseline ΔPes values and after 2 h of HFNO (R2 = 0.9, p < 0.0001). ΔPes change 2 h after HFNO significantly correlated with change in BORG (p < 0.0001), ROX index (p < 0.0001), HACOR score (p < 0.001) and RR (p < 0.001). In DNI patients with AHRF, HFNO was effective in reducing breathing effort and improving respiratory and clinical variables only for those patients with not excessive inspiratory effort.

High-Flow Nasal Cannula Oxygen Therapy in the Management of Respiratory Failure: A Review

High-flow nasal cannula (HFNC) oxygen therapy is gaining traction globally as a treatment for respiratory failure. There are several physiological benefits, and there is a growing body of evidence showing improved quality of life and patient comfort with HFNC, both in acute and home settings. Due to the increased burden of long-term respiratory conditions such as chronic obstructive pulmonary disease (COPD) on healthcare systems worldwide, the role of ward-based and post-discharge interventions in the prevention of hospital readmissions is an area of increasing interest. In this narrative review, we outline the physiological effects of HFNC and assess its applications in both the hospital and home settings for acute and chronic respiratory failure. We also consider the evidence of non-invasive ventilation (NIV) versus HFNC in the hospital setting and the application of HFNC at home in stable hypercapnic respiratory failure to improve the quality of life and prevent readmissions. We also look at applications of HFNC in specific circumstances, such as the perioperative period, emergency department, and acute (mainly critical care) setting including in immunocompromised patients and palliative care.

[The role of the physiotherapist in the assessment and management of dyspnea]

The role of the physiotherapist in the assessment and management of dyspnea. Dyspnea is the most common symptom in cardio-respiratory diseases. Recently improved comprehension of dyspnea mechanisms have underlined the need for three-faceted assessment. The three key aspects correspond to the "breathing, thinking, functioning" clinical model, which proposes a multidimensional - respiratory, emotional and functional - approach. Before initiating treatment, it is essential for several reasons to assess each specific case, determining the type of dyspnea affecting the patient, appraising the impact of shortness of breath, and estimating the effectiveness of the treatment applied. The physiotherapist has a major role to assume in the care of dyspneic patients, not only in assessment followed by treatment but also as a major collaborator in a multidisciplinary team, especially with regard to pulmonary rehabilitation. The aim of this review is to inventory the existing assessment tools and the possible physiotherapies for dyspnea, using a holistic approach designed to facilitate the choice of techniques and to improve quality of care by fully addressing the patient's needs.

Fluid resuscitation of at least 30 mL/kg was not associated with decreased mortality in patients with infection, signs of hypoperfusion, and a do-not-intubate order

Aim

Administration of at least 30 mL/kg of fluid as fluid resuscitation is recommended for patients with sepsis and signs of hypoperfusion. However, it is not clear whether this is appropriate for patients with a do‐not‐intubate (DNI) order. This study evaluated the association between volume of fluid resuscitation and outcomes in patients with infection, signs of hypoperfusion, and a DNI order in an emergency department.

Methods

This was a single‐center retrospective cohort study. We classified the infected patients with signs of hypoperfusion and a DNI order seen in our emergency department between April 1, 2015 and November 31, 2020 into the standard fluid resuscitation group (≥30 mL/kg) and the restricted fluid resuscitation group (<30 mL/kg). We compared with in‐hospital mortality and the rate of discharge to home in two groups.

Results

Of 367 patients, 149 received standard fluid resuscitation and 218 received restricted fluid resuscitation. In‐hospital mortality was similar in each group (40/149 and 62/218, respectively). Standard fluid resuscitation was not associated with in‐hospital mortality (adjusted odds ratio [aOR], 1.05; 95% confidence interval [CI], 0.62–1.77, P = 0.86), but was associated with a significantly lower rate of discharge to home (aOR, 0.55; 95% CI, 0.30–0.98, P = 0.043). There was no significant difference in respiratory rate or need for oxygen therapy post‐resuscitation between the two groups.

Conclusion

This study suggests that fluid resuscitation may be not beneficial for infected patients with signs of hypoperfusion and a DNI order. Further studies should be conducted on the options for resuscitation management for these patients.

Noninvasive respiratory supports for the relief of terminal breathlessness

PURPOSE OF REVIEW

Breathlessness is a common symptom in patients with respiratory failure in the terminal phase of their illness. Noninvasive methods of oxygen delivery are frequently used in the palliative setting. We review the evidence supporting noninvasive respiratory supports for the relief of terminal breathlessness in those with life-limiting illnesses.

RECENT FINDINGS

There is limited evidence to support the use of supplemental oxygen for patients without hypoxia. It is unclear whether the symptomatic benefit of oxygen therapy relates to the oxygen delivery and/or airflow across the nasal mucosa. Early trials suggest that high-flow nasal cannula (HFNC) oxygen therapy improves breathlessness at rest and on exertion for patients with cancer. Noninvasive ventilation (NIV) also appears to improve breathlessness in the palliative setting; however, potential harms include facial pressure injuries, claustrophobia and anxiety. Goals of care should be explicitly discussed and frequently reviewed given that these interventions have the potential for harm and can be challenging to withdraw.

SUMMARY

HFNC oxygen therapy and NIV appear to reduce breathlessness in the palliative setting. Further high-quality trials are needed to confirm the symptomatic benefits of noninvasive respiratory supports on breathlessness for patients with cancer.

Nasal high flow oxygen therapy during acute admissions or periods of worsening symptoms

PURPOSE OF REVIEW

Nasal high flow therapy (NHF) is increasingly used in acute care settings. In this review, we consider recent advances in the utilization of NHF in chronic obstructive pulmonary disease (COPD), terminal cancer and symptom management. Considerations around NHF use during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic are also discussed.

RECENT FINDINGS

NHF enables humidification and high flows to be provided together with titrated, supplemental oxygen therapy. Compared to conventional oxygen therapy, NHF improves respiratory physiology by reducing workload, enhancing muco-ciliary clearance and improving dead space washout. Some studies suggest that early use of NHF in people being cared for in the emergency department leads to lower rates of invasive ventilation and noninvasive ventilation. There is also emerging evidence for NHF use in people with COPD and chronic respiratory failure, and in palliative care. NHF is comfortable, well-tolerated and safe for use in the management of breathlessness in people with cancer. NHF can be delivered by face mask to patients with SARS-CoV-2 infection, to ease the burden on critical care resources.

SUMMARY

The evidence base for NHF is rapidly growing and offers promise in relieving troublesome symptoms and for people receiving palliative care.

Clinical therapeutic effects of high-flow nasal oxygen therapy in patients with acute exacerbation of chronic obstructive pulmonary disease: A protocol for systematic review and meta-analysis

BACKGROUND

For patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) complicated by respiratory acidosis, noninvasive ventilation therapy is thought to be the first-line treatment. In patients with AECOPD, the effect of high-flow nasal oxygen therapy is not well studied. In this study, the existing data will be synthesized to obtain an effective rate of movement of nasal oxygen therapy in patients with AECOPD.

METHODS

Using PubMed, EMBASE, Cochrane Library, Web of Science, Scopus, a systematic search will be undertaken to identify randomized controlled trails (RCTs) on the clinical therapeutic effects of rate of movement of nasal oxygen therapy in patients with AECOPD without language constraints from their onset to November 2020. To classify potentially qualifying tests, we will also review Google Scholar, ClinicalTrials.gov, and the reference lists of included studies. Two independent reviewers will review inclusion trials and execute data extraction. Research bias and quality will be measured using the Cochrane Collaboration Bias Method 2.0. The findings of the analysis will be pooled using a formula of fixed-effects or random-effects. We will address any dispute by dialogue, and cases of disagreement will be mediated by a third author.

RESULTS

The current research will examine the clinical therapeutic results of patients with AECOPD with rate of movement of nasal oxygen therapy.

CONCLUSION

To assess the efficacy of rate of movement of nasal oxygen therapy in patients with AECOPD, the present analysis would provide consistent facts.

OSF REGISTRATION NUMBER

November 18, 2020.osf.io/umd48. (https://osf.io/umd48/).

High-flow therapy: physiological effects and clinical applications

Humidified high-flow therapy (HFT) is a noninvasive respiratory therapy, typically delivered through a nasal cannula interface, which delivers a stable fraction of inspired oxygen (F_IO2) at flow rates of up to 60 L·min⁻¹. It is well-tolerated, simple to set up and ideally applied at 37°C to permit optimal humidification of inspired gas. Flow rate and F_IO2 should be selected based on patients' inspiratory effort and severity of hypoxaemia. HFT yields beneficial physiological effects, including improved mucociliary clearance, enhanced dead space washout and optimisation of pulmonary mechanics. Robust evidence supports its application in the critical care setting (treatment of acute hypoxaemic respiratory failure and prevention of post-extubation respiratory failure) and emerging data supports HFT use during bronchoscopy, intubation and breaks from noninvasive ventilation or continuous positive airway pressure. There are limited data on HFT use in patients with hypercapnic respiratory failure, as an adjunct to pulmonary rehabilitation and in the palliative care setting, and further research is needed to validate the findings of small studies. The COVID-19 pandemic raises questions regarding HFT efficacy in COVID-19-related hypoxaemic respiratory failure and concerns regarding aerosolisation of respiratory droplets. Clinical trials are ongoing and healthcare professionals should implement strict precautions to mitigate the risk of nosocomial transmission.

Humidified high-flow therapy is a well-tolerated method of delivering a stable F_IO2 at flow rates up to 60 L/min. It improves secretion clearance, dead space washout and pulmonary mechanics and is an effective treatment in hypoxaemic respiratory failurehttps://bit.ly/35Hvjrj