Domiciliary High-Flow Nasal Cannula Oxygen Therapy for Patients with Stable Hypercapnic Chronic Obstructive Pulmonary Disease. A Multicenter Randomized Crossover Trial

Thoracic Society of Australia and New Zealand clinical practice guideline on adult home oxygen therapy

This Thoracic Society of Australia and New Zealand Guideline on the provision of home oxygen therapy in adults updates a previous Guideline from 2015. The Guideline is based upon a systematic review and meta-analysis of literature to September 2022 and the strength of recommendations is based on GRADE methodology. Long-term oxygen therapy (LTOT) is recommended for its mortality benefit for patients with COPD and other chronic respiratory diseases who have consistent evidence of significant hypoxaemia at rest (PaO2 ≤ 55 mm Hg or PaO2 ≤59 mm Hg in the presence of hypoxaemic sequalae) while in a stable state. Evidence does not support the use of LTOT for patients with COPD who have moderate hypoxaemia or isolated nocturnal hypoxaemia. In the absence of hypoxaemia, there is no evidence that oxygen provides greater palliation of breathlessness than air. Evidence does not support the use of supplemental oxygen therapy during pulmonary rehabilitation in those with COPD and exertional desaturation but normal resting arterial blood gases. Both positive and negative effects of LTOT have been described, including on quality of life. Education about how and when to use oxygen therapy in order to maximize its benefits, including the use of different delivery devices, expectations and limitations of therapy and information about hazards and risks associated with its use are key when embarking upon this treatment.

The Role of High Flow Nasal Therapy in Chronic Respiratory Failure

High-flow nasal therapy (HFNT) has an increasing role in the management of acute hypoxic respiratory failure. Due to its tolerable interface and ease of use, its role in chronic hypercapnic respiratory failure (CHRF) is emerging. This article examines the literature to date surrounding the short and long-term mechanisms of HFNT in sleep and wakefulness of CHRF patients. It is likely HFNT will have an increasing role in those patients intolerant of non-invasive ventilation.

Effectiveness, Adherence and Safety of Home High Flow Nasal Cannula in Chronic Respiratory Disease and Respiratory Insufficiency: A Systematic Review

INTRODUCTION

The effectiveness of home high flow nasal cannula (HFNC) for the treatment of chronic respiratory failure in patients with chronic respiratory diseases (CRDs) has not been summarized. We aimed to conduct a systematic review of the effectiveness, adherence, and safety of HFNC in the long-term treatment of patients with chronic respiratory diseases and respiratory failure.

METHODS

A systematic review was conducted. PubMed, Web of science, and SCOPUS were search up to August 2023. Long-term HFNC studies (≥4 weeks) reporting dyspnea; exacerbations, hospitalizations; peripheral oxygen saturation (SpO2), comfort; patient experience, health-related quality of life or partial pressure of carbon dioxide (paCO2) were included.

RESULTS

Thirteen articles (701 patients) based on 10 studies were selected: randomized control trials (n=3), randomized crossover trials (n=2), crossover (n=3) and retrospective (n=2) studies. COPD (n=6), bronchiectasis (n=2), COPD/bronchiectasis (n=1) and ILD (n=1) were the underlined CRDs. HFNC reduced exacerbations when compared to usual care/home respiratory therapies (n=6). Quality of life outcomes were also in favor of HFNC in patients with COPD and bronchiectasis (n=6). HFNC had significant effects on hospitalizations, paCO2, and lung function. Adherence ranged from 5.2 to 8.6h/day (n=5). Three studies reported no events, 3 non-serious events and 2 no differences compared with other home respiratory therapies.

CONCLUSIONS

HFNC seems more effective than usual care or other home respiratory therapies in reducing exacerbations and improving quality of life in patients with COPD and bronchiectasis, while presenting good adherence and being safe. Its apparently superior effectiveness needs to be better studied in future real-world pragmatic trials.

Treatment Recommendation for Dyspnea in Patients with Advanced Disease: Revised Clinical Guidelines from the Japanese Society for Palliative Medicine

Dyspnea is one of the most common and distressing symptoms in patients with cancer and noncancer advanced diseases. The Japanese Society for Palliative Medicine revised previous guidelines for the management of respiratory symptoms in patients with cancer and newly developed clinical guidelines for managing dyspnea in patients with advanced disease, based on the result of systematic reviews for each clinical question and consensus among experts. We describe the recommendations of the guidelines as well as provide insights into the reasoning behind the recommendations and their development process. There has been a paucity of evidence regarding the interventions for dyspnea in patients with advanced disease. Thus, more clinical research that includes not only randomized controlled trials but also real-world observational studies is warranted.

The benefits and drawbacks of home oxygen therapy for COPD: what's next?

INTRODUCTION

Home oxygen therapy is one of the few interventions that can improve survival in patients with chronic obstructive pulmonary disease (COPD) when administered appropriately, although it may cause side effects and be an unnecessary burden for some patients.

AREAS COVERED

This narrative review summarizes the current literature on the assessment of hypoxemia, different types of home oxygen therapy, potential beneficial and adverse effects, and emerging research on home oxygen therapy in COPD. A literature search was performed using MEDLINE and EMBASE up to January 2024, with additional articles being identified through clinical guidelines.

EXPERT OPINION

Hypoxemia is common in patients with more severe COPD. Long-term oxygen therapy is established to prolong survival in patients with chronic severe resting hypoxemia. Conversely, in the absence of chronic severe resting hypoxemia, home oxygen therapy has an unclear or conflicting evidence base, including for palliation of breathlessness, and is generally not recommended. However, beneficial effects in some patients cannot be precluded. Evidence is emerging on the optimal daily duration of oxygen use, the role of high-flow and auto-titrated oxygen therapy, improved informed decision-making, and telemonitoring. Further research is needed to validate novel oxygen delivery systems and monitoring tools and establish long-term effects of ambulatory oxygen therapy in COPD.

ERS International Congress 2023: highlights from the Respiratory Intensive Care Assembly

Early career members of Assembly 2 (Respiratory Intensive Care) attended the 2023 European Respiratory Society International Congress in Milan, Italy. The conference covered acute and chronic respiratory failure. Sessions of interest to our assembly members and to those interested in respiratory critical care are summarised in this article and include the latest updates in respiratory intensive care, in particular acute respiratory distress syndrome and mechanical ventilation.

The Role of High-Flow Nasal Cannula Oxygen Therapy in Exercise Testing and Pulmonary Rehabilitation: A Review of the Current Literature

High-flow nasal cannula (HFNC) has recently emerged as a crucial therapeutic strategy for hypoxemic patients both in acute and chronic settings. Indeed, HFNC therapy is able to deliver higher fractions of inspired oxygen (FiO2) with a heated and humidified gas flow ranging from 20 up to 60 L per minute, in a more comfortable way for the patient in comparison with Conventional Oxygen Therapy (COT). In fact, the flow keeps the epithelium of the airways adequately moisturized, thus positively affecting the mucus clearance. Finally, the flow is able to wash out the carbon dioxide in the dead space of the airways; this is also enhanced by a modest positive end-expiratory pressure (PEEP) effect. Recent evidence has shown applications of HFNC in exercise training and chronic settings with promising results. In this narrative review, we explored how HFNC might contribute to enhancing outcomes of exercise training and pulmonary rehabilitation among patients dealing with chronic obstructive pulmonary disease, interstitial lung diseases, and lung cancer.

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.

Home high flow nasal cannula for chronic hypercapnic respiratory failure in COPD: A systematic review and meta-analysis

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) with chronic hypercapnia is usually treated with non-invasive ventilation (NIV). High flow nasal cannula (HFNC) may be an appropriate alternative. However, the efficacy of HFNC in COPD patients with chronic hypercapnia is yet to be optimally summarized.

METHODS

We conducted a systematic review and meta-analysis using random effects with inverse variance methods. Randomized controlled trials involving adult COPD patients initiated on HFNC for at least one month were included. Outcomes of interest were all-cause mortality, acute exacerbations, hospitalizations, and change in St. George Respiratory Questionnaire (SGRQ). We assessed the risk of bias using ROB 2.0 and assessed the quality of the evidence using GRADE.

RESULTS

We included four randomized trials involving 440 patients. HFNC probably reduces acute exacerbations compared to standard care (RR 0.77 [95 % CI 0.66 to 0.89]; moderate certainty), suggesting 69 fewer acute exacerbations per 1000 patients. HFNC may reduce hospital admissions (RR 0.87 [95 % CI 0.69 to 1.09]; low certainty) and may lower the SGRQ score (MD 8.12 units lower [95 % CI 13.30 to 2.95 lower]; low certainty). However, HFNC may have no effect on mortality (RR 1.22 [95 % CI 0.64 to 2.35]; low certainty).

CONCLUSION

HFNC probably reduces acute exacerbations and might reduce hospital admissions in COPD patients with chronic hypercapnia. However, its effect on mortality is uncertain. Future larger RCTs with longer follow-up periods are recommended to provide more robust evidence on the efficacy of HFNC in patients with COPD.

Helicopter Air Transport of a Patient Using High Flow Nasal Cannula: A Case Report

The classic out-of-hospital approach to a patient with severe acute respiratory failure involves both orotracheal intubation and invasive mechanical ventilation. The use of non-invasive methods for respiratory support has been shown to be beneficial in managing both acute and chronic respiratory failure. However, its use had not been previously considered for air medical transport due to concerns related to airway safety during flight, limited oxygen availability, and limited experience in this setting. We describe the successful inter-hospital helicopter transport of a patient with end-stage lung disease to a transplantation unit while utilizing a high-flow oxygen cannula, which was performed without significant complications. Our successful case report raises the possibility that high-flow nasal cannulas may be safely employed in the management of respiratory failure in specific patient populations during air medical transport.

Comparison of High-Flow Nasal Cannula with Conventional Oxygen Therapy in Patients with Hypercapnic Chronic Obstructive Pulmonary Disease: A Systematic Review and Meta-Analysis

Purpose

This study aimed to evaluate the clinical outcomes of high-flow nasal cannula (HFNC) compared with conventional oxygen therapy (COT) in patients with hypercapnic chronic obstructive pulmonary disease (COPD), including arterial partial pressure of carbon dioxide (PaCO₂), arterial partial pressure of oxygen (PaO₂), respiratory rate (RR), treatment failure, exacerbation rates, adverse events and comfort evaluation.

Patients and Methods

PubMed, EMBASE and the Cochrane Library were retrieved from inception to September 30, 2022. Eligible trials were randomized controlled trials and crossover studies comparing HFNC and COT in hypercapnic COPD patients. Continuous variables were reported as mean and standard derivation and calculated by weighted mean differences (MD), while dichotomous variables were shown as frequency and proportion and calculated by odds ratio (OR), with the 95% confidence intervals (Cl). Statistical analysis was performed using RevMan 5.4 software.

Results

Eight studies were included, five with acute hypercapnia and three with chronic hypercapnia. In acute hypercapnic COPD, short-term HFNC reduced PaCO₂ (MD -1.55, 95% CI: -2.85 to -0.25, I² = 0%, p <0.05) and treatment failure (OR 0.54, 95% CI: 0.33 to 0.88, I² = 0%, p<0.05), but there were no significant differences in PaO₂ (MD -0.36, 95% CI: -2.23 to 1.52, I² = 45%, p=0.71) and RR (MD -1.07, 95% CI: -2.44 to 0.29, I² = 72%, p=0.12). In chronic hypercapnic COPD, HFNC may reduce COPD exacerbation rates, but there was no advantage in improving PaCO₂ (MD -1.21, 95% CI: -3.81 to 1.39, I² = 0%, p=0.36) and PaO₂ (MD 2.81, 95% CI: -1.39 to 7.02, I² = 0%, p=0.19).

Conclusion

Compared with COT, short-term HFNC reduced PaCO₂ and the need for escalating respiratory support in acute hypercapnic COPD, whereas long-term HFNC reduced COPD exacerbations rates in chronic hypercapnia. HFNC has great potential for treating hypercapnic COPD.

Home High-Flow Therapy in Patients with Chronic Respiratory Diseases: Physiological Rationale and Clinical Results

High-flow therapy (HFT) is the administration of gas flows above 15 L/min. It is a non-invasive respiratory support that delivers heated (up to 38 °C), humidified (100% Relative Humidity, RH; 44 mg H2O/L Absolute Humidity, AH), oxygen-enriched air when necessary, through a nasal cannula or a tracheostomy interface. Over the last few years, the use of HFT in critically ill hypoxemic adults has increased. Although the clinical benefit of home high-flow therapy (HHFT) remains unclear, some research findings would support the use of HHFT in chronic respiratory diseases. The aim of this review is to describe the HFT physiological principles and summarize the published clinical findings. Finally, we will discuss the differences between hospital and home implementation, as well as the various devices available for HHFT application.

High Flow Nasal Cannula in Patients With Cancer at the End of Life

CONTEXT

High flow nasal cannula (HFNC) is frequently used to manage dyspnea in patients with cancer near the end of life. Because HFNC is restricted to the in-patient setting, patients on HFNC need to be liberated from it to be discharged from the hospital.

OBJECTIVES

The purpose of this study is to assess the rate of successful liberation from HFNC in a palliative and supportive care unit (PSCU).

METHODS

The study is a retrospective chart review of all 374 adult patients with cancer on HFNC admitted to a palliative and supportive care unit at a tertiary medical center from January 1, 2018 to December 31, 2020. We determined the proportion of patients who were liberated from HFNC (by day three and overall) and the proportion of patients discharged alive.

RESULTS

The mean age of the patients was 64, 54% were male and 73% were white. Only 16% (95% CI: 13-20) of the patients were discharged alive. Liberation from HFNC by day three and overall was accomplished in 23% and 25% of the patients respectively. Comparing the patients who could be liberated from HFNC vs. those who could not by day three, 38% vs. 9% were discharged alive respectively; and overall, 62% vs. 1% respectively (P < 0.001 in both cases).

CONCLUSION

Only a minority of patients with cancer at the end of life can be liberated from HFNC, and only a minority are discharged alive. This information is important when discussing goals of care with patients and their families before initiating HFNC.

The use of high-flow nasal cannula in patients with chronic obstructive pulmonary disease under exacerbation and stable phases: A systematic review and meta-analysis

BACKGROUND

High-flow nasal cannula (HFNC) has been increasingly utilized in patients with chronic obstructive pulmonary disease (COPD); however, the effects on reducing the need for intubation or reintubation remain unclear.

OBJECTIVES

We aimed to investigate whether HFNC therapy was superior to conventional oxygen therapy (COT) or noninvasive ventilation (NIV) in patients with COPD.

METHODS

A literature search was performed in electronic databases until October 1st, 2022. The primary outcome was the need for intubation/reintubation. All analyses were performed using R (version 4.0.3) and STATA SE (version 15.1).

RESULTS

When HFNC therapy was compared with NIV in patients with COPD under initial respiratory support and postextubation, no significant differences were found in the risk of intubation (RR 0.84, 95% CI 0.36 to 1.98) and reintubation (RR 1.35, 95% CI 0.73 to 2.50). Compared to NIV, HFNC therapy did not decrease the partial pressure of carbon dioxide or increase the partial pressure of oxygen to the fraction of inspired oxygen. However, HFNC therapy was associated with a lower incidence of skin breakdown (RR 0.52, 95% CI 0.39 to 0.69) and a higher comfort score (SMD 0.90, 95% CI 0.60 to 1.20) than NIV. When HFNC therapy was compared with COT during initial respiratory treatment for COPD exacerbation, a lower risk of treatment failure was found (RR 0.58, 95% CI 0.37 to 0.89). When HFNC therapy was compared with long-term oxygen therapy, quality of life (measured by SGRQ-C) was significantly improved (SMD -0.42, 95% CI -0.69 to -0.14).

CONCLUSION

HFNC therapy might be used as an alternative to NIV for COPD exacerbation with mild-moderate hypercapnia under close monitoring and is a potential domiciliary treatment for stable COPD.

The Danish respiratory society guideline for long-term high flow nasal cannula treatment, with or without supplementary oxygen

Introduction

Long-term High Flow Nasal Cannula (LT-HFNC), defined as High Flow Nasal Cannula treatment provided to patients with chronic pulmonary conditions during stable phases, has emerged as a home treatment in different categories of patients with chronic lung diseases in recent years.

Methods

This paper summarizes the physiological effects of LT-HFNC and evaluates the clinical knowledge to date about treatment in patients with chronic obstructive lung disease, interstitial lung disease and bronchiectasis. The guideline is translated and summarized in this paper and presented unabridged as an appendix to the paper.

Results

The paper describes the working process behind the Danish Respiratory Society's National guideline for treatment of stable disease, which has been written to support clinicians in both evidence-based decision making and practical issues concerning the treatment.

Long-Term Domiciliary High-Flow Nasal Therapy in Patients with Bronchiectasis: A Preliminary Retrospective Observational Case-Control Study

High-flow nasal therapy (HFNT) provides several pathophysiological benefits in chronic respiratory disorders. We aimed to evaluate the effectiveness of long-term HFNT in patients with bronchiectasis (BE).

METHODS

This is a retrospective bicentric case-control study of outpatients with BE on optimized medical treatment with a severe exacerbation requiring hospitalization in the previous year. Patients on long-term home HFNT (cases) and patients on optimized medical treatment alone (controls) were matched by age, sex, bronchiectasis severity index, and exacerbations in the previous year. Data on BE exacerbations, hospitalizations/year, mucus features, respiratory symptoms, and pulmonary function were collected. The primary outcome was the change from baseline in the exacerbation rates at 12 months between groups.

RESULTS

20 patients in the HFNT group and 20 controls were included. A significant reduction in exacerbations [-1.9 (-2.8 to -0.9), p = 0.0005] and hospitalizations [-0.7 (-1.1 to -0.3), p = 0.0006] was found in the HFNT group vs controls. A slight improvement in pulmonary function [FEV₁% +6,1% (+1% to +11.3%) (p = 0.0219), FVC% +4.6% (+0.8% to +8.3%) (p = 0.0188) and FEF_25-75% +13.4 (+11 to +15.9) (p = 0.0189) was also found in the HFNT group compared to controls.

CONCLUSIONS

In this preliminary study, long-term domiciliary HFNT improved the clinical course of patients with BE.

Home High-Flow Nasal Cannula Oxygen Therapy for Stable Hypercapnic COPD: A Randomized Clinical Trial

Rationale: The long-term effects of using a high-flow nasal cannula for chronic hypercapnic respiratory failure caused by chronic obstructive pulmonary disease remain unclear. Objectives: To assess whether long-term high-flow nasal cannula use reduces the number of exacerbations and improves other physiological parameters in patients with chronic hypercapnic respiratory failure caused by chronic obstructive pulmonary disease. Methods: We enrolled 104 participants (aged ⩾40 yr) with daytime hypercapnia (Global Initiative for Chronic Obstructive Lung Disease stages 2-4) receiving long-term oxygen therapy (⩾16 h/d for ⩾1 mo) and randomly assigned them to high-flow nasal cannula/long-term oxygen therapy and long-term oxygen therapy groups. The primary endpoint was the moderate or severe exacerbation rate. We compared changes from baseline in arterial blood gas values, peripheral oxygen saturation, pulmonary function, health-related quality-of-life scores, and the 6-minute-walk test. Measurements and Main Results: High-flow nasal cannula use significantly reduced the rate of moderate/severe exacerbations (unadjusted mean count 1.0 vs. 2.5, a ratio of the adjusted mean count between groups [95% confidence interval] of 2.85 [1.48-5.47]) and prolonged the duration without moderate or severe exacerbations. The median time to first moderate or severe exacerbation in the long-term oxygen therapy group was 25 (14.1-47.4) weeks; this was not reached in the high-flow nasal cannula/long-term oxygen therapy group. High-flow nasal cannula use significantly improved health-related quality of life scores, peripheral oxygen saturation, and specific pulmonary function parameters. No safety concerns were identified. Conclusions: A high-flow nasal cannula is a reasonable therapeutic option for patients with stable hypercapnic chronic obstructive pulmonary disease and a history of exacerbations. Clinical trial registered with www.umin/ac.jp (UMIN000028581) and www.clinicaltrials.gov (NCT03282019).

An Analysis of the Effect of Noninvasive Positive Pressure Ventilation on Patients with Respiratory Failure Complicated by Diabetes Mellitus

Objective

To observe the clinical effectiveness of noninvasive positive pressure ventilation in patients with respiratory failure complicated by diabetes.

Methods

From May 2021 to May 2022, 90 patients with respiratory failure complicated by diabetes treated in our hospital were recruited and randomly assigned to receive either medication (control group) or noninvasive positive pressure ventilation (study group), with 45 patients in each group. The clinical endpoint was therapeutic outcomes.

Results

Noninvasive positive pressure ventilation resulted in significantly lower Self-Rating Anxiety Scale (SAS) and Self-Rating Depression Scale (SDS) scores versus medications (P < 0.05). Patients with noninvasive positive pressure ventilation showed better pulmonary function indices versus those with medications (P > 0.05). There was no significant difference in arterial oxygen (PaO₂), carbon dioxide partial pressure (PaCO₂), and arterial oxygen pressure/inspired fraction of O₂ (PaO₂/FiO₂) between the two groups prior to the intervention (P > 0.05). However, patients in the study group had significantly elevated PaO₂ and PaO₂/FiO₂ and lower PaCO₂ levels than those in the control group (P < 0.05). Following the intervention, noninvasive positive pressure ventilation resulted in significantly lower inflammatory factor levels versus medications (P > 0.05). After the intervention, markedly better glucose control was observed in the study group versus the control group (P < 0.05). The incidence of complications in the control group was 2.38%, which was significantly lower than that of the control group (16.67) (P < 0.05).

Conclusion

Noninvasive positive pressure ventilation effectively suppresses the inflammatory response, improves the blood gas analysis index, and eliminates the negative emotions of patients, thereby maintaining hemodynamic stability and improving clinical efficacy with a better safety profile. Further studies are recommended prior to clinical promotion.

Acute and long-term management of severe bronchiectasis with high flow nasal therapy: A case report

Bronchiectasis (BE) is a long-term, chronic lung condition featured by widened and scarred airways. These can alter the physiological mucociliary clearance, making it difficult to clear mucus and microorganisms, leading to frequent exacerbations. High flow nasal therapy (HFNT) is a noninvasive respiratory support that delivers heated and humidified gas eventually enriched with oxygen, through a nasal cannula.  Humidification is crucial for adequate airways mucociliary clearance, improving ciliary function and consequently reducing airways inflammation and recurrent infections. HFNT has been mostly used in patients with acute hypoxemic respiratory failure and in selected patients with chronic respiratory failure due to COPD. Still, evidence about its use in acute and long-term home setting in patients with clinically relevant BE are lacking. We report a case of severe widespread BE, already on top medical therapy and pulmonary rehabilitation, still suffering from difficult mucus expectoration and recurrent exacerbations, who has been additionally treated with HFNT, both in hospital and domiciliary, reporting significant improvements on relevant clinical and patient-centered outcomes. Thus, HFNT may confer additional benefits as an add-on treatment of patients with severe BE and respiratory failure.

Hospital Cost Savings for Sequential COPD Patients Receiving Domiciliary Nasal High Flow Therapy

Purpose

To estimate the 5-year budget impact to Aotearoa New Zealand (NZ) hospitals of domiciliary nasal high flow (NHF) therapy to patients with chronic obstructive pulmonary disease (COPD) who require long term oxygen therapy.

Methods

Hospital admission counts along with length of stay were obtained from hospital records of 200 COPD patients enrolled in a 12-month randomized clinical trial of NHF in Denmark, both over a 12-month baseline and then in the study period while on randomized treatment (control or NHF). NZ costings from similar COPD patients were estimated using data from Middlemore Hospital, Auckland and were applied to the Danish trial. The budget impact of NHF was estimated over the predicted 5-year lifetime of the device when used by patients sequentially.

Results

Fifty-five of 100 patients in the NHF group and 44 of 100 patients in the control group were admitted to hospital with a respiratory diagnosis during the baseline year. They had 108 admissions in the treatment group vs 89 in the control group, with 632 vs 438 days in hospital, and modeled annual costs of $9443 vs $6512 per patient, respectively. During the study period there were 38 vs 44 patients with 67 vs 80 admissions and 302 vs 526 days in hospital, at a modeled annual cost of $6961 vs $9565 per patient respectively. Taking into account capital expenditure and running costs, this resulted in cost savings of $5535 per patient-year (95% CI, -$36 to -$11,034). With 90% usage over the estimated five-year lifetime of the NHF device, amortized capital costs of $594 per year and annual running costs of $662, we estimate a 5-year undiscounted cost saving per NHF device of $18,626 ($16,934 when discounted to net present value at 5% per annum). There would still be annual cost savings over a wide range of assumptions.

Conclusion

Domiciliary NHF therapy for patients with severe COPD has the potential to provide substantial hospital cost savings over the five-year lifetime of the NHF device.

High-flow nasal cannula improves respiratory impedance evaluated by impulse oscillometry in chronic obstructive pulmonary disease patients: a randomised controlled trial

Non-pharmacological treatment with high-flow nasal cannula (HFNC) may play a vital role in treatment of patients with chronic obstructive pulmonary disease (COPD). To evaluate the efficacy of HFNC, impulse oscillation system (IOS) is a new noninvasive technique in measuring the impedance of different portions of lungs. It shows higher sensitivity in contrast to conventional pulmonary function tests (PFT). However, whether IOS is an appropriate technique to evaluate the efficacy of HFNC in improving the impedance of small airways or peripheral lung in patients with COPD is still unclear. We enrolled 26 stable COPD participants randomised into two groups receiving HFNC or nasal cannula (NC) for 10 min followed by a 4-week washout period and crossover alternatively. IOS was used to detect the difference of respiratory impedance after HFNC or NC interventions. IOS parameters, PFT results, transcutaneous partial pressure of carbon dioxide, peripheral oxygen saturation, body temperature, respiratory rate, pulse rate, and blood pressure at the time of pre-HFNC, post-HFNC, pre-NC, and post-NC, were collected and analysed using SPSS (version 25.0, IBM, Armonk, NY, USA). The IOS measurement indicated that HFNC significantly improved R5, R5% predicted, R5–R20, X5-predicted, and Fres compared with NC, whereas no significant difference was observed through the PFT measurement. The beneficial effect of HFNC in improving small airway resistance and peripheral lung reactance compared with that of NC in patients with stable COPD was confirmed through IOS measurement.

Trial registration: ClinicalTrials.gov NCT05130112 22/11/2021.

High-flow nasal cannula versus conventional oxygen therapy in acute COPD exacerbation with mild hypercapnia: a multicenter randomized controlled trial

Background

High-flow nasal cannula (HFNC) can improve ventilatory function in patients with acute COPD exacerbation. However, its effect on clinical outcomes remains uncertain.

Methods

This randomized controlled trial was conducted from July 2017 to December 2020 in 16 tertiary hospitals in China. Patients with acute COPD exacerbation with mild hypercapnia (pH ≥ 7.35 and arterial partial pressure of carbon dioxide > 45 mmHg) were randomly assigned to either HFNC or conventional oxygen therapy. The primary outcome was the proportion of patients who met the criteria for intubation during hospitalization. Secondary outcomes included treatment failure (intolerance and need for non-invasive or invasive ventilation), length of hospital stay, hospital cost, mortality, and readmission at day 90.

Results

Among 337 randomized patients (median age, 70.0 years; 280 men [83.1%]; median pH 7.399; arterial partial pressure of carbon dioxide 51 mmHg), 330 completed the trial. 4/158 patients on HFNC and 1/172 patient on conventional oxygen therapy met the criteria for intubation (P = 0.198). Patients progressed to NPPV in both groups were comparable (15 [9.5%] in the HFNC group vs. 22 [12.8%] in the conventional oxygen therapy group; P = 0.343). Compared with conventional oxygen therapy, HFNC yielded a significantly longer median length of hospital stay (9.0 [interquartile range, 7.0–13.0] vs. 8.0 [interquartile range, 7.0–11.0] days) and a higher median hospital cost (approximately $2298 [interquartile range, $1613–$3782] vs. $2005 [interquartile range, $1439–$2968]). There were no significant differences in other secondary outcomes between groups.

Conclusions

In this multi-center randomized controlled study, HFNC compared to conventional oxygen therapy did not reduce need for intubation among acute COPD exacerbation patients with mild hypercapnia. The future studies should focus on patients with acute COPD exacerbation with respiratory acidosis (pH < 7.35). However, because the primary outcome rate was well below expected, the study was underpowered to show a meaningful difference between the two treatment groups.

Trial registration: NCT03003559. Registered on December 28, 2016.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-03973-7.

Nasal High Flow Therapy For Symptom Management in People Receiving Palliative Care

For patients with chronic non-malignant lung disease, severe chronic breathlessness can significantly impact quality of life, causing significant disability, distress, social isolation, and recurrent hospital admissions. Caregivers for people with challenging symptoms, such as severe breathlessness, are also profoundly impacted. Despite increasing research focused on breathlessness over recent years, this symptom remains extremely difficult to manage, with no effective treatment that completely relieves breathlessness. A new potential treatment for relieving breathlessness in patients at home is nasal high flow (NHF) therapy. NHF therapy is a respiratory support system that delivers heated, humidified air (together with oxygen if required) with flows of up to 60 L/min. This case describes a patient with very severe chronic obstructive pulmonary disease who received domiciliary NHF therapy (approximately 8 hours/day, flow rate of 20 L/min) over twelve months with good effect for the relief of severe chronic breathlessness. We discuss the management principles for severe chronic breathlessness, the physiological effects of NHF therapy and the evidence for long-term use in the community setting. With the support of respiratory and palliative care clinicians together, domiciliary NHF therapy has great potential for improving current symptom management approaches in people with life-limiting illnesses.

High Flow Nasal Cannula Decreased Pulmonary Complications in Neurologically Critically Ill Patients

Objective: Pulmonary complications could badly affect the recovery of neurological function and neurological prognosis of neurological critically ill patients. This study evaluated the effect of high-flow nasal cannula (HFNC) therapy on decreasing pulmonary complications in neurologically critically ill patients.

Patients and Methods: The patients admitted to the intensive care unit (ICU) with serious neurological disease and receiving oxygen therapy were retrospectively reviewed (Ethical No. IRB2021-YX-001). Patients were divided into the HFNC group and the conventional oxygen therapy (COT) group. We analyzed the data within these two groups, including patients’ baseline data, short-term outcomes of respiratory complications, general outcomes including hospital stay, ICU stay and mortality, and neurological functions. To analyze the relevant factors, we performed multivariable logistic regression analysis.

Results: A total of 283 patients met the criteria, including 164 cases in the HFNC group and 119 cases in the COT group. The HFNC group had remarkably less mechanical ventilation requirement with lower phlegm viscosity. Even more, ICU stay and total hospital stay were significantly shortened in the HNFC group.

Conclusion: HFNC decreased pulmonary complications in neurologically critically ill patients and improved recovery of neurological function and neurological prognosis.

The effect of domiciliary high flow nasal cannula treatment on dyspnea and walking distance in patients with interstitial lung disease - A pilot study

INTRODUCTION

Interstitial Lung Diseases (ILD) affect the lung parenchyma and are often complicated by respiratory failure (RF) and impaired physical activity. High Flow Nasal Cannula (HFNC) has proved effective in other disease entities with RF. The aim of this study is to investigate the effect of domiciliary HFNC in ILD on dyspnea and walking distance.

METHODS

A 6 weeks cross-over study with domiciliary HFNC-treatment/6 weeks' observation in ILD-patients requiring ambulatory oxygen therapy or with newly prescribed (within 12 months) long term oxygen therapy. Patients were advised to use HFNC 8 h/day, recommended night-time use. Body phletysmography; 6-min walk test (6MWT) including BORG-score, oxygen saturation (SO2) at start, minimum SO2 and time to recovery after 6MWT; arterial blood gasses; modified Medical Research Council (mMRC)-score; quality of life, by the St George Respiratory Questionnaire (SGRQ) and QoS, by the Richards-Campbell Sleep Questionnaire (RCSQ) were investigated at baseline; six weeks and 12 weeks.

RESULTS

10 patients were included; one later withdrew consent. Patients used HFNC between 8-<1 h/day. There were no differences in lung function; blood gasses; SGRQ or RCSQ over the observational period). Walking distance improved significantly (393-441 m p = 0.049) as did time to recovery (3.4-2-2 min, p = 0.001). When correcting for HFNC use (hours/day) significant improvement was also seen in mMRC-score (p = 0.035) and minimum saturation during 6MWT (p = 0.01).

CONCLUSION

Despite a very heterogenous group and no effect on quality of life and -sleep, the study indicates an improvement in dyspnea and physical ability of HFNC in ILD patients.

Effects of high-flow nasal cannula with oxygen on self-paced exercise performance in COPD: A randomized cross-over trial

INTRODUCTION

Studies have demonstrated that noninvasive ventilation improves exercise intolerance in patients with chronic obstructive pulmonary disease (COPD). The role of heated humidified high-flow nasal cannula (HFNC) therapy in patients with COPD on self-paced exercise performance remains unclear. Therefore, the purpose of the present study was to determine whether HFNC-aided supplemental oxygen during a 6-minute walk test (6MWT) would change self-paced exercise performance and cardiopulmonary outcomes in patients with stable COPD.

METHODS

A single-site, cross-over trial was conducted in a pulmonary rehabilitation outpatient department. This study enrolled 30 stable COPD patients without disability. The participants with and without HFNC performed 6MWTs on 2 consecutive days. Outcomes were the distance walked in the 6MWT, physiological, and cardiopulmonary parameters.

RESULTS

Those performing HFNC-aided walking exhibited a longer walking distance than those performing unaided walking. The mean difference in meters walked between the HFNC-aided and unaided walking scenarios was 27.3 ± 35.6 m (95% CI: 14.4-40.5 m). The energy expenditure index was significantly lower when walking was aided by HHHNFC rather than unaided (median: 1.21 beats/m walked vs median: 1.37 beats/m walked, P < .001). However, there were no differences in transcutaneous carbon dioxide tension between HHHNFC and non-HHHNFC patients.

CONCLUSION

Walking distance and arterial oxygen saturation improved in stable COPD patients receiving HFNC with additional oxygen support. However, HFNC did not affect transcutaneous carbon dioxide tension and the self-reported dyspnea score during the walking test. The present study demonstrated the feasibility and safety of using HFNC in self-paced exercise.

TRIAL REGISTRATION

NCT03863821.

The efficacy and safety of high-flow nasal cannula therapy in patients with COPD and type II respiratory failure: a meta-analysis and systematic review

Background

High-flow nasal cannula (HFNC) and noninvasive ventilation (NIV) have been used for the treatment of COPD and respiratory failure in clinical settings. We aimed to evaluate the efficacy and safety of HFNC therapy in patients with COPD and type II respiratory failure, to provide evidence to the clinical COPD management.

Methods

We searched Cochrane et al. databases up to Dec 31, 2020 for randomized controlled trials (RCTs) on the use of HFNC therapy in patients with COPD and type II respiratory failure. Two researchers independently screened the literature according to the inclusion and exclusion criteria, and evaluated the quality of the literature and extracted data. We used Revman5.3 software for statistical analysis of collected data.

Results

A total of 6 RCTs involving 525 COPD and type II respiratory failure patients. Meta-analyses indicated that compared with NIV, HFNC could significantly reduce PaCO₂ level (MD = − 2.64, 95% CI (− 3.12 to − 2.15)), length of hospital stay ((MD = – 1.19, 95 CI (− 2.23 to − 0.05)), the incidence of nasal facial skin breakdown ((OR = 0.11, 95% CI (0.03–0.41)). And there were no significant differences between the two groups in PaO₂ ((MD = 2.92, 95% CI (− 0.05 to 5.90)), incidence of tracheal intubation ((OR = 0.74, 95% CI (0.34–1.59)) and mortality (OR = 0.77, 95% CI (0.28–2.11)).

Conclusions

HFNC is more advantageous over NIV in the treatment of COPD and type II respiratory failure. Future studies with larger sample size and strict design are needed to further elucidate the role of HFNC in COPD and respiratory failure.

Bronchodilator Delivery via High-Flow Nasal Cannula: A Randomized Controlled Trial to Compare the Effects of Gas Flows

(1) Background: Aerosol delivery via high-flow nasal cannula (HFNC) has attracted increasing clinical interest. In vitro studies report that the ratio of HFNC gas flow to patient inspiratory flow (GF:IF) is a key factor in the efficiency of trans-nasal aerosol delivery. (2) Methods: In a randomized controlled trial, patients with a history of COPD or asthma and documented positive responses to inhaled bronchodilators in an outpatient pulmonary function laboratory were recruited. Subjects were randomized to receive inhalation at gas flow ratio settings of: GF:IF = 0.5, GF:IF = 1.0, or GF = 50 L/min. Subjects were assigned to inhale saline (control) followed by salbutamol via HFNC with cumulative doses of 0.5 mg, 1.5 mg, 3.5 mg, and 7.5 mg. Spirometry was performed at baseline and 10-12 min after each inhalation. (3) Results: 75 subjects (49 asthma and 26 COPD) demonstrating bronchodilator response were enrolled. Per the robust ATS/ERS criteria no difference was observed between flows, however using the criteria of post-bronchodilator forced expiratory volume in the first second (FEV₁) reaching the screening post-bronchodilator FEV₁ with salbutamol, a higher percentage of subjects receiving GF:IF = 0.5 met the criteria at a cumulative dose of 1.5 mg than those receiving GF:IF = 1.0, and GF = 50 L/min (64% vs. 29% vs. 27%, respectively, p = 0.011). Similarly at 3.5 mg (88% vs. 54% vs. 46%, respectively, p = 0.005). The effective dose at GF:IF = 0.5 was 1.5 mg while for GF = 50 L/min it was 3.5 mg. (4) Conclusions: During salbutamol delivery via HFNC, cumulative doses of 1.5 mg to 3.5 mg resulted in effective bronchodilation. Applying the robust ATS/ERS criteria no difference was observed between the flows, however using the more sensitive criteria of subjects reaching post screening FEV₁ to salbutamol via HFNC, a higher number of subjects responded to the doses of 0.5 mg and 1.5 mg when HFNC gas flow was set at 50% of patient peak inspiratory flow.

Update on guidelines for the treatment of COPD in Taiwan using evidence and GRADE system-based recommendations

Chronic obstructive pulmonary disease (COPD) has significant contributions to morbidity and mortality world-wide. Early symptoms of COPD are not readily distinguishable, resulting in a low rate of diagnosis and intervention. Different guidelines and recommendatations for the diagnosis and treatment of COPD exist globally. The first edition of clinical practice guidelines for COPD was published in 2016 by the Ministry of Health and Welfare in Taiwan in collaboration with the Taiwan evidence-based medicine association and Cochrane Taiwan, and was revised in 2019 in order to update recent diagnostic and therapeutic modalities for COPD and its acute exacerbation. This revised guideline covered a range of topics highlighted in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) report, including strategies for the diagnosis, assessment, monitoring, and management of stable COPD and exacerbations, with particular focus on evidence from Taiwan. The recommendations included in the revised guideline were formed based on a comprehensive systematic review or meta-analysis of specific clinical issues identified by an expert panel that surveyed relevant scientific evidence in the literature and guidelines published by the clinical communities and organizations nationally and internationally. The guidelines and recommendations are applicable to the clinical settings in Taiwan. We expect this revised guideline to facilitate the diagnosis, treatment and management of patients with COPD by physicians and health care professionals in Taiwan. Adaptations of the materials included herein for educational and training purposes is encouraged.

Efficacy of High-Flow Nasal Cannula Oxygen Therapy in Patients with Mild Hypercapnia

Objectives

To investigate the indications of high-flow nasal cannula (HFNC) oxygen therapy among patients with mild hypercapnia and to explore the predictors of intubation when HFNC fails.

Methods

This retrospective study was conducted based on the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Adult patients with mild hypercapnia (45 < PaCO₂ ≤ 60 mmHg) received either HFNC or non-invasive ventilation (NIV) oxygen therapy. Propensity score matching (PSM) was implemented to increase between-group comparability. The Kaplan–Meier method was used to estimate overall survival and cumulative intubation rates, while 28-day mortality and 48-h and 28-day intubation rates were compared using the Chi-squared test. The predictive performances of HR/SpO₂ and the ROX index (the ratio of SpO₂/FiO₂ to respiratory rate) at 4 h were assessed regarding HFNC failure, which was determined if intubation was given within 48 h after the initiation of oxygen therapy. The area under the receiver operating characteristic curve (AUC) for HR/SpO₂ and the ROX index were calculated and compared.

Results

A total of 524,520 inpatient hospitalization records were screened, 106 patients in HFNC group and 106 patients in NIV group were successfully matched. No significant difference in 48-h intubation rate between the HFNC group (the treatment group) and the NIV group (the control group) (14.2% vs. 8.5%, p = 0.278); patients receiving HFNC had higher 28-day intubation rate (26.4% vs. 14.2%, p = 0.029), higher 28-day mortality (17.9% vs. 8.5%, p = 0.043), and longer ICU length of stay (4.4 vs. 3.3 days, p = 0.019), compared to those of NIV group. The AUC of HR/SpO₂ at 4 h after the initiation of HFNC yielded around 0.660 for predicting 48-h intubation, greater than that of the ROX index with an AUC of 0.589 (p < 0.01).

Conclusion

Patients with impending respiratory failure had lower intubation rate, shorter ICU length of stay, and lower mortality when treated mild hypercapnia with NIV over HFNC. As opposed to the ROX index, a modest, yet improved predictive performance is demonstrated using HR/SpO₂ in predicting the failure of HFNC among these patients.

Effect of high-flow nasal cannula oxygen therapy in patients with chronic obstructive pulmonary disease: A meta-analysis

BACKGROUND

High-flow nasal cannula oxygen therapy reduces the arterial partial pressure of carbon dioxide and acute exacerbation but does not increase exercise capacity or decrease hospitalisation or mortality. The study aimed to test the hypothesis that in chronic obstructive pulmonary disease patients, the use of high-flow nasal cannula decreases arterial partial pressure of carbon dioxide and increases the partial pressure of oxygen and 6-min walking distance.

METHODS

PubMed, Embase and the Cochrane library were searched for eligible studies published from database inception to November 2020 (Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist). The primary outcomes were partial pressure of carbon dioxide and partial pressure of oxygen, and the secondary outcomes were transcutaneous partial pressure of carbon dioxide and 6-min walking distance.

RESULTS

Nine studies (680 patients) were included. high-flow nasal cannula did not decrease partial pressure of carbon dioxide compared with the control interventions (mean difference = -0.81, 95% confidence interval: -2.68 to 1.06, p = .395; I²  = 42.9%, p_{heterogeneity}  = .105). high-flow nasal cannula decreased partial pressure of carbon dioxide compared with long-term oxygen therapy (mean difference = -3.25, 95% confidence interval: -5.65 to -0.85, p = .008; I²  = 0%, p_{heterogeneity}   = .375); no difference was observed for the control modalities. high-flow nasal cannula resulted in better partial pressure of carbon dioxide compared with control interventions in hypoxemic patients (mean difference = -2.59, 95% confidence interval: -4.82 to -0.35, p = .023; I²  = 32.5%, p_{heterogeneity}  = .224), but not in other types of patients. high-flow nasal cannula did not increase partial pressure of oxygen compared with the control interventions (mean difference = 1.17, 95% confidence interval: -1.50 to 3.83, p = .390; I²  = 0%, p_{heterogeneity}  = .660). high-flow nasal cannula decreased transcutaneous carbon dioxide tension (transcutaneous partial pressure of carbon dioxide) compared with the control interventions (mean difference = 2.37, 95% confidence interval: 0.07-4.68, p = .044; I²  = 8.7%, p_{heterogeneity}   = .295). high-flow nasal cannula increased 6-min walking distance compared with the control interventions (mean difference = 18.22, 95% confidence interval: 0.86-,35.57, p = .040; I²  = 0%, p_{heterogeneity}  = .918). The sensitivity analyses showed that the results were robust.

CONCLUSIONS

High-flow nasal cannula did not significantly decrease partial pressure of carbon dioxide or increase partial pressure of oxygen in chronic obstructive pulmonary disease patients, which is different from the previous meta-analysis, but it decreases transcutaneous partial pressure of carbon dioxide and increased 6-min walking distance.

RELEVANCE TO CLINICAL PRACTICE

This meta-analysis shows that in patients with chronic obstructive pulmonary disease, high-flow nasal cannula improves both transcutaneous partial pressure of carbon dioxide and 6-min walking distance, suggesting the high-flow nasal cannula has benefits in the management of chronic obstructive pulmonary disease. Considering that the literature suggests no impact of high-flow nasal cannula on hospitalisation and mortality, the benefits of high-flow nasal cannula might be limited to the patients who survive the chronic obstructive pulmonary disease events. Still, the global impact of high-flow nasal cannula on the quality of life of patients with chronic obstructive pulmonary disease should be examined.

Cost-Effectiveness of Domiciliary High Flow Nasal Cannula Treatment in COPD Patients with Chronic Respiratory Failure

PURPOSE

To evaluate the cost-effectiveness of long-term domiciliary high flow nasal cannula (HFNC) treatment in COPD patients with chronic respiratory failure.

PATIENTS AND METHODS

A cohort of 200 COPD patients were equally randomized into usual care ± HFNC and followed for 12 months. The outcome of the analysis was the incremental cost per quality-adjusted life-year (QALY) gained, and the analysis was conducted from a healthcare sector perspective. Data on the patients' health-related quality of life (HRQoL), gathered throughout the trial using the St. George's Respiratory Questionnaire (SGRQ), was converted into EQ-5D-3L health state utility values. Costs were estimated using Danish registers and valued in British pounds (£) at price level 2019. Scenario analyses and probabilistic sensitivity analyses were conducted to assess the uncertainty of the results.

RESULTS

The adjusted mean difference in QALYs between the HFNC group and the control group was 0.059 (95% CI: 0.017; 0.101), and the adjusted mean difference in total costs was £212 (95% CI: -1572; 1995). The analysis resulted in an incremental cost-effectiveness ratio (ICER) of £3605 per QALY gained. At threshold values of £20.000-30.000 per QALY gained, the intervention had an 83-92% probability of being cost-effective. The scenario analyses all revealed ICERs below the set threshold value and demonstrated the robustness of the main result.

CONCLUSION

This is the first cost-effectiveness study on domiciliary HFNC in Europe. The findings demonstrate that long-term domiciliary HFNC treatment is very likely to be a cost-effective addition to usual care for COPD patients with chronic respiratory failure. The results must be interpreted in light of the uncertainty associated with the indirect estimation of health state utilities.

Safety and efficacy of high flow nasal cannula therapy in acute hypercapnic respiratory failure - a retrospective audit

BACKGROUND

While the role of high flow nasal cannulae (HFNC) in the management of respiratory failure continues to expand, few studies describe its use in acute hypercapnic respiratory failure.

AIMS

In this retrospective study we assessed the safety and efficacy of HFNC for treatment of acute hypercapnic respiratory failure.

METHODS

Admissions with acute hypercapnic respiratory failure to a thoracic medicine unit at a tertiary centre between January and August 2018 were included if treated with either HFNC or non-invasive ventilation (NIV). The primary outcome was post-treatment change in arterial pCO₂ . Demographics, comorbidities, length of stay, readmission rate and mortality were also collected.

RESULTS

64 patients were identified, comprising 69 presentations grouped according to initial treatment: HFNC (n=24) or NIV (n=45). Patients in the NIV group had more severe blood gas derangement. In both groups, mean arterial pCO₂ improved significantly (-10 (95% CI: -14 to -6) mmHg) from baseline with no evidence of a differential effect between groups. Six (25%) patients were transitioned from HFNC to NIV, of whom 3 had comorbid obesity and 2 had sleep disordered breathing. No significant differences in hospital length of stay, 30-day readmission rate or 90-day mortality were observed.

CONCLUSIONS

HFNC may be a reasonable initial treatment for patients with mild acute hypercapnic respiratory failure who do not have comorbid obesity or sleep disordered breathing. Prospective study may help identify clinical factors or phenotypes predictive of success with this treatment modality. This article is protected by copyright. All rights reserved.

Anesthetic management of a patient with Freeman-Sheldon syndrome undergoing oral surgery: A case report

In the anesthetic management in this case was how to manage the patient without causing respiratory depression and respiratory muscle fatigue.

Acute Responses to Oxygen Delivery via High Flow Nasal Cannula in Patients with Severe Chronic Obstructive Pulmonary Disease-HFNC and Severe COPD

Differences in oxygen delivery methods to treat hypoxemia have the potential to worsen CO₂ retention in chronic obstructive lung disease (COPD). Oxygen administration using high flow nasal cannula (HFNC) has multiple physiological benefits in treating respiratory failure including reductions in PaCO₂ in a flow-dependent manner. We hypothesized that patients with COPD would develop worsening hypercapnia if oxygen fraction was increased without increasing flow rate. We evaluated the acute response to HFNC in subjects with severe COPD when flow remained constant and inspired oxygen was increased. In total, 11 subjects with severe COPD (FEV1 < 50%) on supplemental oxygen with baseline normocapnia (PaCO₂ < 45 mm Hg; n = 5) and hypercapnia (PaCO₂ ≥ 45 mm Hg; n = 6) were studied. Arterial blood gas responses were studied at three timepoints: Baseline, HFNC at a flow rate of 30 L/min at resting oxygen supplementation for 1 h, and FiO₂ 30% above baseline with the same flow rate for the next hour. The primary endpoint was the change in PaCO₂ from baseline. No significant changes in PaCO₂ were noted in response to HFNC applied at baseline FiO₂ in the normocapnic and hypercapnic group. At HFNC with FiO₂ 30% above baseline, the normocapnic group did not show a change in PaCO₂ (baseline: 38.9 ± 1.8 mm Hg; HFNC at higher FiO₂: 38.8 ± 3.1 mm Hg; p = 0.93), but the hypercapnic group demonstrated significant increase in PaCO₂ (baseline: 58.2 ± 9.3 mm Hg; HFNC at higher FiO₂: 63.3 ± 10.9 mm Hg; p = 0.025). We observed worsening hypercapnia in severe COPD patients and baseline hypercapnia who received increased oxygen fraction when flow remained constant. These data show the need for careful titration of oxygen therapy in COPD patients, particularly those with baseline hypercapnia when flow rate is unchanged.

The role of high-flow nasal therapy in bronchiectasis: a post hoc analysis

High-flow nasal therapy (HFNT) is a gas delivery system that provides heated and humidified air or supplemental oxygen by nasal cannula. The role of HFNT in airways disease has primarily focused on COPD. Studies in patients with COPD have demonstrated improvement in quality-of-life scores and reduced acute exacerbations with HFNT use [1, 2].

High-flow nasal therapy significantly reduces exacerbation rates and improves quality of life in patients with stable bronchiectasis. High-flow nasal therapy is therefore a potential treatment option for patients with bronchiectasis.https://bit.ly/2JFXuQc

High-flow nasal cannula oxygen versus conventional oxygen for hypercapnic chronic obstructive pulmonary disease: A meta-analysis of randomized controlled trials

INTRODUCTION

Low-concentration oxygen is an established way for the treatment of chronic obstructive pulmonary disease (COPD) with Type II respiratory failure. Hypercapnia can complicate both COPD exacerbations and stable COPD. Treating with noninvasive ventilation (NIV) can reduce carbon dioxide tension in arterial (PaCO₂ ) in hypercapnic COPD. As an open system, high-flow nasal cannula oxygen (HFNC) is easy to tolerate and use. More researches are needed to focus on how HFNC is used to treat COPD patients with hypercapnic respiratory failure.

METHODS

The Cochrane Library, Medline, EMBASE, and CINAHL database were retrieved from inception to October 2019. Eligible trials were clinical randomized controlled trials comparing the effects of HFNC and conventional oxygen on hypercapnic COPD patients. Two researchers assessed the quality of each study and extracted the data into RevMan 5.3 independently. The primary outcome was PaCO₂ and the secondary outcome was PaO₂ .

RESULTS

Four RCTs with 329 patients were included. The research results indicated that PaCO₂ in the HFNC group was similar to the conventional oxygen group. No significant difference were observed in PaCO₂ (MD -0.98, CI: -2.67 to 0.71, Z = 1.14, p = 0.25) and PaO₂ (MD -0.72, CI: -6.99 to 5.55, Z = 0.23, p = 0.82) between the HFNC group and conventional oxygen group.

CONCLUSIONS

Our meta-analysis showed no difference in PO₂ and PCO₂ between the HFNC and conventional oxygen. But we should treat this conclusion with caution because the number of studies and participants is small and, there is heterogeneity in the PaO₂ and PCO₂ measurements between stable and AECOPD.

High-Flow Nasal Cannula Therapy for Exertional Dyspnea in Patients with Cancer: A Pilot Randomized Clinical Trial

BACKGROUND

Exertional dyspnea is common in patients with cancer and limits their function. The impact of high-flow nasal cannula on exertional dyspnea in nonhypoxemic patients is unclear. In this double-blind, parallel-group, randomized trial, we assessed the effect of flow rate (high vs. low) and gas (oxygen vs. air) on exertional dyspnea in nonhypoxemic patients with cancer.

PATIENTS AND METHODS

Patients with cancer with oxygen saturation >90% at rest and exertion completed incremental and constant work (80% maximal) cycle ergometry while breathing low-flow air at 2 L/minute. They were then randomized to receive high-flow oxygen, high-flow air, low-flow oxygen, or low-flow air while performing symptom-limited endurance cycle ergometry at 80% maximal. The primary outcome was modified 0-10 Borg dyspnea intensity scale at isotime. Secondary outcomes included dyspnea unpleasantness, exercise time, and adverse events.

RESULTS

Seventy-four patients were enrolled, and 44 completed the study (mean age 63; 41% female). Compared with low-flow air at baseline, dyspnea intensity was significantly lower at isotime with high-flow oxygen (mean change, -1.1; 95% confidence interval [CI], -2.1, -0.12) and low-flow oxygen (-1.83; 95% CI, -2.7, -0.9), but not high-flow air (-0.2; 95% CI, -0.97, 0.6) or low-flow air (-0.5; 95% CI, -1.3, 0.4). Compared with low-flow air, high-flow oxygen also resulted in significantly longer exercise time (difference + 2.5 minutes, p = .009), but not low-flow oxygen (+0.39 minutes, p = .65) or high-flow air (+0.63 minutes, p = .48). The interventions were well tolerated without significant adverse effects.

CONCLUSION

Our preliminary findings support that high-flow oxygen improved both exertional dyspnea and exercise duration in nonhypoxemic patients with cancer. (ClinicalTrials.gov ID: NCT02357134).

IMPLICATIONS FOR PRACTICE

In this four-arm, double-blind, randomized clinical trial examining the role of high-flow nasal cannula on exertional dyspnea in patients with cancer without hypoxemia, high-flow oxygen, but not high-flow air, resulted in significantly lower dyspnea scores and longer exercise time. High-flow oxygen delivered by high-flow nasal cannula devices may improve clinically relevant outcomes even in patients without hypoxemia.

High-Flow Nasal Cannula for Chronic Obstructive Pulmonary Disease with Acute Compensated Hypercapnic Respiratory Failure: A Randomized, Controlled Trial

Introduction

Currently, there is a lack of evidence on the utilization of high-flow nasal cannula (HFNC) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) accompanied by hypercapnic respiratory failure. We aimed to explore the efficacy and safety of HFNC compared with conventional oxygen therapy (COT) in such patients.

Methods

This was a prospective, randomized, controlled trial. Patients with AECOPD with a baseline arterial blood gas pH ≥7.35, PaO₂ <60 mmHg, and PaCO₂ >45 mmHg were enrolled. The primary endpoint was treatment failure, which needs mechanical ventilation.

Results

A total of 320 patients were randomized to either the HFNC group (n = 160) or the COT group (n = 160). Sixteen (10.0%) patients in the HFNC group had treatment failure during hospitalization, which was significantly lower than the COT group figure of 31 (19.4%) patients (p = 0.026). Twenty-four hours after recruitment, the PaCO₂ of the HFNC group was lower than that of the COT group (54.1 ± 9.79 mmHg vs 56.9 ± 10.1 mmHg, p = 0.030). PaCO₂ higher than 59 mmHg after HFNC for 24 h was identified as an independent risk factor for treatment failure [OR 1.078, 95% CI 1.006–1.154, p = 0.032].

Conclusion

In AECOPD patients with acute compensated hypercapnic respiratory failure, HFNC improved the prognosis compared with COT. Therefore, HFNC might be considered for first-line oxygen therapy in select patients.

Trial Registration Number

ClinicalTrials.Gov: NCT02439333.

Development in PaCO2 over 12 months in patients with COPD with persistent hypercapnic respiratory failure treated with high-flow nasal cannula-post-hoc analysis from a randomised controlled trial

INTRODUCTION

Persistent hypercapnic failure in chronic obstructive pulmonary disease (COPD) is associated with poor prognosis. Long-term home non-invasive ventilation is recommended for patients with PaCO2 >7.0 kPa. Domiciliary high-flow nasal cannula (HFNC) reduces PaCO2 in short-term studies. This post-hoc analysis examines the effect of HFNC on PaCO2 levels, exacerbations and admissions in patients with COPD with persistent hypercapnic and hypoxic failures.

METHODS

The original trial included 74 long-term oxygen-treated patients (31 HFNC treated/43 controls) with persistent hypercapnic failure (PaCO2 >6 kPa) who completed the 12-month study period. Baseline data included age, sex, blood gases, exacerbations and hospital admissions in the previous year. Data on blood gases were also recorded at 6 and 12 months for all patients. In addition, acute changes in blood gases after 30 min of HFNC use at site visits were examined, as were exacerbations and hospital admissions during study.

RESULTS

Patients were comparable at baseline. After 12 months there was a 1.3% decrease in PaCO2 in patients using HFNC and a 7% increase in controls before HFNC use on site (p=0.003). After 30 min of HFNC at visits PaCO2 changed significantly, with comparable reductions, at 0, 6 and 12 months, including for controls who tried HFNC at study end (p<0.001). The exacerbation rate increased, compared with 12 months prestudy, by 2.2/year for controls (p<0.001) and 0.15/year for HFNC-treated patients (p=0.661). Hospital admission rates increased in the control group,+0.3/year from prestudy (p=0.180), And decreased by 0.67/year (p=0.013)for HFNC-treated patients.

CONCLUSION

This post-hoc analysis indicates that HFNC stabilises patients with COPD with persistent hypoxic and hypercapnic failures, in terms of PaCO2, exacerbations and number of hospitalisations, whereas those not receiving HFNC worsened. This suggests that HFNC is a possible treatment for patients with persistent hypercapnic COPD.

End-of-life home care of an interstitial pneumonia patient supported by high-flow nasal cannula therapy: A case report

BACKGROUND

High-flow nasal cannula (HFNC) therapy and morphine continuous subcutaneous infusion (CSI) have been used to ameliorate dyspnea in non-cancer patients with end-stage respiratory diseases, including chronic obstructive pulmonary disease and interstitial pneumonia, primarily in hospital settings. However, it is rare to perform home-based medical treatment using these. We observe a case to assess the feasibility of this treatment strategy.

CASE SUMMARY

Here, we report a case of a 75-year-old man who was diagnosed with interstitial pneumonia 11 years ago and was successfully nursed at home during his terminal phase for over 10 mo without hospitalization, by introducing domiciliary uses of HFNC and morphine CSI with a patient-controlled analgesia device.

CONCLUSION

Active utilization of HFNC and morphine CSI with patient-controlled analgesia device would substantiate successful end-of-life palliative home care of idiopathic interstitial pneumonia patients.

Efficiency of High-Flow Nasal Cannula on Pulmonary Rehabilitation in COPD Patients: A Meta-Analysis

Introduction

The clinical benefit of high-flow nasal cannula (HFNC) on factors related to pulmonary rehabilitation in chronic obstructive pulmonary disease (COPD) patients remains unclear. This meta-analysis aimed at synthesizing the available evidence on the efficacy of HFNC on exercise capacity, lung function, and other factors related to pulmonary rehabilitation in COPD patients.

Methods

Electronic databases (MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science) were searched for randomized trials comparing with conventional oxygen therapy (COT) or noninvasive ventilation (NIV). Primary outcomes were respiratory rate, FEV1, tidal volume, oxygen partial pressure, total score of St. George's respiratory questionnaire, 6-minute walk test, and exercise endurance time.

Results

Ten trials met the criteria for inclusion. Combined data from six studies showed that HFNC showed a lower respiratory rate in COPD patients [mean difference -1.27 (95% CI: -1.65–(-0.89)]. Combined data from three studies showed a lower forced expiratory volume in one second (FEV1) in the group of HFNC. No difference in tidal volume was showed between the HFNC and control groups in COPD patients. No significant oxygen improvement between the HFNC groups and control groups. The total score of St. George's respiratory questionnaire was improved by the subgroup analysis of HFNC versus COT but no NIV. Two multicenter RCTs showed the six-minute walk test, and statistical results showed that the length of the six-minute walk capacity was increased after usage of HFNC compared to the control group [mean difference -8.65 (95% CI: -9.12–(-8.19)]. No increase of exercise capacity after usage of HFNC (mean difference -12.65).

Conclusion

In the first meta-analysis of the area, the current evidence did not show so much positive effect on tidal volume or oxygen improvement in COPD patients. Length of the six-minute walk capacity was increased after using HFNC, while other pulmonary rehabilitation parameters, namely, the score of St. George's respiratory questionnaire and exercise capacity show no increase in the group of HFNC. The variance in the quality of the evidence included in this meta-analysis highlights the need for this evidence to be followed up with further high-quality and more randomized trials.

Nasal high-flow oxygen versus noninvasive ventilation in acute exacerbation of COPD: protocol for a randomised noninferiority clinical trial

Background

Noninvasive ventilation (NIV) is considered as the first-line treatment for acute exacerbation of COPD (AECOPD) complicated by respiratory acidosis. Recent studies demonstrate a role of nasal high-flow oxygen (NHF) in AECOPD as an alternative treatment in patients intolerant to NIV or with contraindications to it.

Aim

The study aimed to evaluate whether NHF respiratory support is noninferior compared to NIV in respect to treatment failure, defined as need for intubation or change to alternative treatment group, in patients with AECOPD and mild-to-moderate acute or acute-on-chronic hypercapnic respiratory failure.

Methods

We designed a multicentre, prospective, randomised trial on patients with AECOPD, who have pH<7.35 but >7.25 and P_aCO2 >45 mmHg, in whom NIV is indicated as a first-line treatment. According to power analysis, 498 participants will be required for establishing noninferiority of NHF compared to NIV. Patients will be randomly assigned to receive NIV or NHF. Treatment will be adjusted to maintain S_pO2 between 88%–92% for both groups. Arterial blood gases, respiratory variables, comfort, dyspnoea score and any pulmonary or extrapulmonary complications will be assessed at baseline, before treatment initiation, and at 1, 2, 4, 6, 12, 24, 48 h, then once daily from day 3 to patient discharge, intubation or death.

Conclusion

Given the increasing number of studies demonstrating the physiological effects of NHF in COPD patients, we hypothesise that NHF respiratory support will be noninferior to NIV in patients with AECOPD and mild-to-moderate acute or acute on chronic hypercapnic respiratory failure.

Nasal high-flow oxygen could be an effective alternative to NIV respiratory support for patients with mild-to-moderate #AECOPD, especially for those who do not tolerate or have contraindications for NIVhttps://bit.ly/3bgxDYx

Tolerability and Safety of High-Flow Nasal Therapy in Patients Hospitalized with an Exacerbation of COPD

BACKGROUND

The effect of high-flow nasal therapy (HFNT) in individuals with an exacerbation of chronic obstructive pulmonary disease (COPD) and hypercapnia is not well studied. We assessed patient tolerance and impact of air-gas therapy delivered by humidified HFNT (20-35 L/min) on gas exchange in hypercapnic COPD patients during hospitalization for COPD exacerbation. We hypothesized that HFNT use would be safe and well tolerated in individuals hospitalized for COPD exacerbation regardless of the degree of hypercapnia.

METHODS

Patients hospitalized for a COPD exacerbation were included if they were hypercapnic (arterial partial pressure of carbon dioxide [PaCO2] > 45 mmHg), ≥ 10 pack-year history, and agreed to treatment with HFNT, along with daily arterial blood gas (ABG) samples and bedside spirometry. They were placed on a HFNT system following admission for at least 3 days with an air-gas blend to maintain a flow rate between 20-35 L/min and fraction of inspired oxygen (FiO2) titrated to keep oxygen saturation (SaO2) values > 90%. Patient tolerance of HFNT and evidence of clinical deterioration as defined by worsening hypoxia or hypercapnia was the primary endpoint.

RESULTS

Ten consecutive patients participated in the study. The patients had frequent prior exacerbations, were hypercapnic, dyspneic, and gas trapped. Participants received an air-gas flow rate (median [interquartile range (IQR)] 25 (IQR 20-30) L/min and FiO2 of 30 (IQR 30-30) %. There was no increase in PaCO2- levels (p = 0.26) or dyspnea (Borg scale, p= 0.52) while using HFNT. No patient discontinued HFNT, had further decompensation, required non-invasive ventilation or intubation during the study period.

CONCLUSION

In a pilot study, patients experiencing a severe COPD exacerbation were able to tolerate continuous HFNT safely regardless of degree of hypercapnia.

Efficacy of nasal high flow therapy on the coordination between breathing and swallowing of saliva during daytime nap in chronic obstructive pulmonary disease patients: A single center, randomized crossover controlled study

BACKGROUND

There are some clinical reports on dysphagia in patients with chronic obstructive pulmonary disease (COPD); however, its pathophysiology remains largely unknown.Changes in respiratory function occur in patients with COPD causing a decrease in tidal volume and an increase in respiratory rate (tachypnea). In addition, it leads to lack of coordination between respiration and swallowing.A new treatment called nasal high flow (NHF) has been introduced for patients with COPD, replacing the traditional non-invasive ventilation (NIV) procedure. The NHF therapy involves inhalation of high flow of humidified air, which reduces respiratory effort in patients with COPD. Furthermore, NHF therapy facilitates swallowing of saliva even during respiratory management. A recent clinical study reported that high-flow nasal cannula oxygen therapy for 6 weeks improved the health-related quality of life and reduced hypercapnia in patients with stable COPD. Taken together, NHF therapy is gaining attention in the clinical management of patients with COPD.Therefore, in this study, we aim to examine the efficacy of NHF therapy on the coordination between breathing and swallowing of saliva during daytime nap in patients with COPD.

METHODS/DESIGN

This open-label, investigator-initiated, single center study will evaluate the efficacy of NHF therapy on the coordination between breathing and swallowing of saliva during the daytime nap in COPD patients with forced expiratory volume in 1 second (FEV1%) of <70% during treatment at the Nagasaki University Hospital Respiratory Rehabilitation Center. Evaluations will be performed during the 90 to 180 minute "daytime nap" in the measurement room of the hospital. The primary endpoint will be the rate of appearance of the expiratory phase after swallowing of saliva and the frequency of swallowing during the measurement period.

DISCUSSION

The purpose of this study is to obtain evidence regarding the utility of NHF as a potential therapeutic device for COPD patients to prevent aspiration of saliva during the sleep stage of daytime nap. The utility will be assessed by comparing the decrease in incidence rates of the expiratory phase after swallowing of saliva in the NHF device group and the control group, wherein this device was not used.

High-Flow Oxygen Therapy During Exercise Training in Patients With Chronic Obstructive Pulmonary Disease and Chronic Hypoxemia: A Multicenter Randomized Controlled Trial

OBJECTIVE

The study aimed to evaluate whether high-flow oxygen therapy (HFOT) during training was more effective than oxygen in improving exercise capacity in hypoxemic chronic obstructive pulmonary disease (COPD).

METHODS

A total of 171 patients with COPD and chronic hypoxemia were consecutively recruited in 8 rehabilitation hospitals in a randomized controlled trial. Cycle-ergometer exercise training was used in 20 supervised sessions at iso inspiratory oxygen fraction in both groups. Pre- and post-training endurance time (Tlim), 6-minute walking distance (6MWD), respiratory and limb muscle strength, arterial blood gases, Barthel Index, Barthel Dyspnea Index, COPD Assessment Test, Maugeri Respiratory Failure questionnaire, and patient satisfaction were evaluated.

RESULTS

Due to 15.4% and 24.1% dropout rates, 71 and 66 patients were analyzed in HFOT and Venturi mask (V-mask) groups, respectively. Exercise capacity significantly improved after training in both groups with similar patient satisfaction. Between-group difference in post-training improvement in 6MWD (mean: 17.14 m; 95% CI = 0.87 to 33.43 m) but not in Tlim (mean: 141.85 seconds; 95% CI = -18.72 to 302.42 seconds) was significantly higher in HFOT. The minimal clinically important difference of Tlim was reached by 47% of patients in the V-mask group and 56% of patients in the HFOT group, whereas the minimal clinically important difference of 6MWD was reached by 51% of patients in the V-mask group and 69% of patients in the HFOT group, respectively.

CONCLUSION

In patients with hypoxemic COPD, exercise training is effective in improving exercise capacity.

IMPACT STATEMENT

The addition of HFOT during exercise training is not more effective than oxygen through V-mask in improving endurance time, the primary outcome, whereas it is more effective in improving walking distance.

Treatment of severe stable COPD: the multidimensional approach of treatable traits

Now that additional treatment options for severe chronic obstructive pulmonary disease (COPD) have emerged in recent years, patients with severe COPD should not be left in the rather hopeless situation of "there is nothing to improve" any more. Inertia or fatalism is a disservice to our patients. Ranging from advanced care planning to quite intense and demanding therapies such as multidisciplinary pulmonary rehabilitation, (endoscopic) lung volume reduction, chronic noninvasive ventilation and lung transplantation, caregivers should try to provide a personalised treatment for every severe COPD patient. In this review, we aim to describe the multidimensional approach to these patients at our centre along the lines of treatable traits leading to specific additional treatment modalities on top of standard care.

High-flow nasal cannula oxygen therapy as an emerging option for respiratory failure: the present and the future

Conventional oxygen therapy (COT) and noninvasive ventilation (NIV) have been considered for decades as frontline treatment for acute or chronic respiratory failure. However, COT can be insufficient in severe hypoxaemia whereas NIV, although highly effective, is poorly tolerated by patients and its use requires a specific expertise. High-flow nasal cannula (HFNC) is an emerging technique, designed to provide oxygen at high flows with an optimal degree of heat and humidification, which is well tolerated and easy to use in all clinical settings. Physiologically, HFNC reduces the anatomical dead space and improves carbon dioxide wash-out, reduces the work of breathing, and generates a positive end-expiratory pressure and a constant fraction of inspired oxygen. Clinically, HFNC effectively reduces dyspnoea and improves oxygenation in respiratory failure from a variety of aetiologies, thus avoiding escalation to more invasive supports. In recent years it has been adopted to treat de novo hypoxaemic respiratory failure, exacerbation of chronic obstructive pulmonary disease (COPD), postintubation hypoxaemia and used for palliative respiratory care. While the use of HFNC in acute respiratory failure is now routine as an alternative to COT and sometimes NIV, new potential applications in patients with chronic respiratory diseases (e.g. domiciliary treatment of patients with stable COPD), are currently under evaluation and will become a topic of great interest in the coming years.