High-Flow Nasal Cannula Oxygen Therapy versus Non-Invasive Ventilation for AECOPD Patients After Extubation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

[High-flow nasal oxygen therapy and hypercapnic acute respiratory failure]

Humidified high-flow nasal oxygen therapy (HFNO) has, in recent years, come to assume a key role in the management of hypoxemic acute respiratory failure (ARF). While non-invasive ventilation (NIV) currently represents the first-line ventilatory strategy in patients exhibiting hypercapnic ARF, the operating principles and physiological effects of HFNO could be interesting and useful in the initial management of hypercapnic ARF and/or after extubation, particularly in acute exacerbations of chronic obstructive pulmonary disease. Under these conditions, HFNO could be used either alone continuously or in combination with NIV during breaks in spontaneous breathing, depending on the severity and etiology of the underlying hypercapnic ARF.

High-Flow Nasal Cannula Oxygen Therapy versus Non-Invasive Ventilation in patients at very high risk for extubating failure: A systematic review of randomized controlled trials

BACKGROUND

Mechanical ventilation is commonly used for managing respiratory failure in chronic obstructive pulmonary disease (COPD) patients, but weaning patients off ventilator support can be challenging and associated with complications. While many patients respond well to Non-invasive ventilation (NIV), a significant proportion may not respond as favourably. We aimed to assess whether high-flow nasal cannula (HFNC) is equally effective as NIV in reducing extubation failure among previously intubated COPD patients.

METHODS

This systematic review was carried out in line with PRISMA guidelines We searched PubMed, Scopus, Web of Science, and Cochrane library from inception until February 15, 2023. Randomized Clinical Trials (RCTs) of adults at high risk for extubating failure were included. We examined the use of HFNC as the intervention and NIV as the comparator. Our outcome of interest included, reintubation rate, length of hospital or intensive care unit (ICU) stay, adverse events, and time to reintubation. The Cochrane risk-of-bias tool was used for randomized trials to assess risk of bias.

RESULTS

We identified 348 citations, 11 of which were included, representing 2,666 patients. The trials indicate that HFNC is comparable to NIV in preventing reintubation after extubating in COPD patients. In comparison to NIV, HFNC also produced improved tolerance, comfort, and less complications such as airway care interventions. NIV with active humification may be more effective that HFNC in avoiding reintubation in patients who are at extremely high risk for extubating failure.

CONCLUSION

The inconclusive nature of emerging evidence highlights the need for additional studies to establish the efficacy and suitability of HFNC as an alternative to NIV for previously intubated COPD patients. Clinicians should consider the available options and individualize their approach based on patient characteristics. Future research should focus on addressing these gaps in knowledge to guide clinical decision-making and optimize outcomes for this patient population.

Construction and validation of nomogram prediction model for risk of acute heart failure in patients with acute exacerbation of chronic obstructive pulmonary disease

To investigate the influencing factors of in-hospital acute heart failure (AHF) in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD), and to construct and validate a risk prediction nomogram model. Three Hundred Thirty patients with AECOPD admitted to our hospital from June 2020 to June 2023 were retrospectively analyzed as a training set for the construction of the model. Three Hundred Twenty-five AECOPD patients admitted to the Second People's Hospital of Hefei from 2006 to June 2023 were also collected as the validation set for the validation of the model. A nomogram model was constructed to predict the risk of nosocomial AHF in patients with AECOPD, and C-index and receiver operating characteristic curve were drawn to assess the predictive predictive efficacy of the model. Model fit was evaluated by Hosmer-Lemeshow test, calibration curve was drawn to evaluate the calibration of the model; decision curve was drawn to analyze the net benefit rate of this nomogram model. Multivariate logistic regression analysis indicated that body mass index, mmRC grade, neutrophils, lymphocytes, hemoglobin, creatinine, PO2, PCO2, and Homocysteine were independent risk factors for in-hospital AHF in patients with AECOPD. To construct a nomogram model for risk prediction of in-hospital AHF in patients with AECOPD. The C-index of the training set was 0.949 (95% CI: 0.91-0.961); the C-index of the validation set was 0.936 (95% CI: 0.911-0.961) suggesting good model discrimination. The receiver operating characteristic curve calculated area under curve for the training set was 0.949 (95% CI: 0.928-0.97); area under curve for the validation set was 0.936 (95% CI: 0.91-0.961) suggesting good model accuracy. The results of Hosmer-Lemeshoe goodness-of-fit test and calibration curve analysis showed that the calibration curve of this nomogram model was close to the ideal curve. The clinical decision curve also showed good clinical net benefit of the nomogram model. Body mass index, mmRC grade, neutrophils, lymphocytes, hemoglobin, creatinine, PO2, PCO2, and Homocysteine are risk factors for in-hospital AHF in AECOPD patients, and nomogram models constructed based on the above factors have some predictive value for in-hospital AHF in AECOPD patients. It is also vital for nursing staff to strengthen nursing care.

Effect of budesonide/glycopyrrolate/formoterol fumarate metered dose inhaler combined with nasal high-flow nasal cannula on elderly patients with COPD and respiratory failure

Objective

To explore the clinical effect of budesonide/glycopyrrolate/formoterol fumarate metered dose inhaler (BGF MDI) combined with high-flow nasal cannula (HFNC) in the treatment of elderly patients with chronic obstructive pulmonary disease (COPD) and respiratory failure.

Methods

The clinical records of 94 elderly patients with COPD and respiratory failure who were treated in Yongkang First People's Hospital from February 2022 to January 2023 were retrospectively selected. Among them, 46 patients received HFNC alone (Control-group) and 48 patients received HFNC combined with BGF MDI (Study-group). The treatment effect, arterial blood gas status, pulmonary function, and acute physiology and chronic health evaluation (APACHE) II score before and after treatment were analyzed in both groups.

Results

The total efficacy of treatment in the Study-group (95.8%) was higher than that in the Control-group (78.3%) (P<0.05). After treatment, the partial pressure of arterial carbon dioxide (PaCO2), residual volume, and APACHE II scores in the two groups decreased compared to those before treatment, with the Study-group lower overall. However, arterial oxygen saturation (SaO2), oxygen partial pressure (PaO2), the percentage of peak expiratory flow (PEF), and forced expiratory volume in one second (FEV1) as percent of predicted (%FEV1) were higher than before treatment, and higher in the Study-group (P<0.05).

Conclusions

Compared with HFNC alone, BGF MDI combined with HFNC can effectively regulate the arterial blood gas status of elderly patients with COPD and respiratory failure, restore pulmonary function, and improve the overall treatment effect.

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.

Efficacy of treatment with N-acetylcysteine inhalation for AECOPD: A propensity-score-matched cohort study

INTRODUCTION

N-acetylcysteine (NAC) prevents acute exacerbations of chronic obstructive pulmonary disease (AECOPD). However, the value of NAC inhalation in the treatment of patients with AECOPD is still poorly understood. The study was conducted to evaluate the efficacy of NAC inhalation in AECOPD patients requiring hospitalization.

METHODS

In this single institutional, retrospective cohort study, all patients with AECOPD requiring hospitalization between January 2021 and January 2022 were included. Patients were divided into NAC group and Non-NAC group according to whether being treated with NAC inhalation and were matched using the propensity score. The primary outcome was a composite of progression to ventilation requirement, in-hospital mortality and readmission for AECOPD within 30 days. The effect on the mean hospitalized days, blood gas indexes and the incidence rate of adverse drug events were compared between the two groups.

RESULTS

Ninety-six patients in the NAC group were matched with 96 patients in the Non-NAC group. The differences in the primary composite end point (NAC group vs Non-NAC group, 5.2% vs 16.7%; P = 0.011) were significant. The median time to discharge was shorter in the NAC group (8.3 vs. 9.1 days, P = 0.030). The NAC group presented a larger increase in partial pressure of arterial oxygen (Pa O2 ) and a higher ratio of self-reported symptomatic improvement from admission to day 5. There was no definite difference between the two groups in the frequency of adverse event.

CONCLUSION

NAC inhalation is associated with an improved clinical outcome. A further study should be conducted to confirm the clinical usefulness of NAC inhalation in AECOPD patients.

Predictors of Length of Stay, Mortality and Rehospitalization in COPD Patients: A Retrospective Cohort Study

Chronic obstructive pulmonary disease (COPD) is a highly prevalent chronic lung disease that has a significant impact on individuals and healthcare systems worldwide. This study aimed to identify factors that predict the length of a hospital stay (LOHS), one-year mortality, and rehospitalization within 6 months in patients admitted for acute exacerbation of COPD (AECOPD). A retrospective cohort study was conducted using data from 170 patients admitted to a district general hospital in Switzerland between January 2019 and February 2020. Sociodemographic and health-related variables measured at admission were analyzed as potential predictors. Multivariable zero-truncated negative binomial and logistic regression analyses were performed to assess the risk factors for LOHS (primary endpoint), mortality, and rehospitalization. The results show that an indication for oxygen supplementation was the only significant predictor of LOHS. In the logistic regression analysis, older age, COPD severity stages GOLD III and IV, active cancer and arrhythmias were associated with higher mortality, whereas rehabilitation after discharge was associated with lower mortality. There were no significant associations regarding rehospitalization. This study identified routinely available predictors for LOHS and mortality, which may further advance our understanding of AECOPD and thereby improve patient management, discharge planning, and hospital costs. The protective effect of rehabilitation after hospitalization regarding lower mortality warrants further confirmation and may improve the comprehensive management of patients with AECOPD.

Post-extubation high-flow nasal cannula oxygen therapy <em>versus</em> non-invasive ventilation in chronic obstructive pulmonary disease with hypercapnic respiratory failure

The sequential use of non-invasive ventilation (NIV) for weaning in hypercapnic respiratory failure patients is a recommended practice. However, the effectiveness of weaning on High flow nasal cannula (HFNC) is unclear. Chronic obstructive pulmonary disease patients with hypercapnic respiratory failure who received invasive ventilation were screened for enrolment. This study was a single-centre, prospective, randomized comparative study. The primary outcome was treatment failure within 72 hours after extubation. Patients who were screened positive for extubation were enrolled in the study and randomized into the HFNC group and NIV group using a computer-generated simple randomization chart. The treatment failure was defined as a return to invasive mechanical ventilation, or a switch in respiratory support modality (i.e., changing from HFNC to NIV or from NIV to HFNC). Of 72 patients, 62 patients were included in the study. Treatment failure occurred in 8 patients (26.67 %) in HFNC group and 8 patients in NIV group (25%) (p=0.881). The mean duration of ICU stay in HFNC group was 5.47±2.26 days and 6.56±3.39 in NIV group (p=0.376). In the current study, HFNC was non-inferior to NIV in preventing post-extubation respiratory failure in COPD patients, while HFNC had better treatment tolerance.

Exacerbations of COPD

COPD exacerbations are associated with significant morbidity, mortality, and increased health care expenditures. The recently published Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommendations have further refined the definition of an exacerbation. A better understanding of the risk factors associated with the development of an exacerbation exists, and improvements are being made in earlier detection approaches. Pharmacologic treatment strategies have been the cornerstone of effective therapy. In addition, both pharmacologic and non-pharmacologic strategies have been proven successful in the prevention of future exacerbations. Newer technologies, including the use of artificial intelligence and wearable monitoring devices, are now being used to help in the earlier detection of exacerbations. Such preventive and earlier detection strategies can help to develop a more personalized care model and improve outcomes for patients with COPD.

A Novel Metabolic Score for Predicting the Acute Exacerbation in Patients with Chronic Obstructive Pulmonary Disease

Background

Chronic obstructive pulmonary disease (COPD) has higher mortality when developing to acute exacerbation (AECOPD); hence, the early intervention of COPD is critical for preventing AECOPD. Exploring the serum metabolites associated with acute exacerbation in patients with COPD will contribute to the early intervention of COPD.

Methods

In the study, a non-targeted metabolomics strategy combined with multivariate statistical methods was performed to explore the metabolic profiling of COPD developing acute exacerbation, to screen the potential metabolites associated with AECOPD and to analyze the potential value of these metabolites in predicting the development of COPD.

Results

Serum lysine, glutamine, 3-hydroxybutyrate, pyruvate and glutamate levels were significantly higher, while 1-methylhistidine, isoleucine, choline, valine, alanine, histidine and leucine levels were significantly lower in AECOPD patients, compared with stable COPD patients after normalization based on the healthy controls. Moreover, eight metabolic pathways were significantly altered (P<0.05) in the serum of AECOPD patients compared with the stable COPD population, including purine metabolism, glutamine and glutamate metabolism, arginine biosynthesis, butyrate metabolism, ketone body synthesis and degradation, and linoleic acid metabolism. In addition, the correlation analysis between metabolites and AECOPD patients demonstrated that an M-score based on a weighted sum of concentrations of four metabolites including pyruvate, isoleucine, 1-methylhistidine and glutamine were significantly associated with the acute exacerbation of pulmonary ventilation function in COPD patients.

Conclusion

Altogether, the metabolite score based on a weighted sum of concentrations of four serum metabolites was associated with an increased risk of COPD developing acute exacerbation, which will provide a new insight for the understanding of COPD development.

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 effects of flow settings during high-flow nasal cannula support for adult subjects: a systematic review

BACKGROUND

During high-flow nasal cannula (HFNC) therapy, flow plays a crucial role in the physiological effects. However, there is no consensus on the initial flow settings and subsequent titration. Thus, we aimed to systematically synthesize the effects of flows during HFNC treatment.

METHODS

In this systematic review, two investigators independently searched PubMed, Embase, Web of Science, Scopus, and Cochrane for in vitro and in vivo studies investigating the effects of flows in HFNC treatment published in English before July 10, 2022. We excluded studies that investigated the pediatric population (< 18 years) or used only one flow. Two investigators independently extracted the data and assessed the risk of bias. The study protocol was prospectively registered with PROSPERO, CRD42022345419.

RESULTS

In total, 32,543 studies were identified, and 44 were included. In vitro studies evaluated the effects of flow settings on the fraction of inspired oxygen (F_IO₂), positive end-expiratory pressure, and carbon dioxide (CO₂) washout. These effects are flow-dependent and are maximized when the flow exceeds the patient peak inspiratory flow, which varies between patients and disease conditions. In vivo studies report that higher flows result in improved oxygenation and dead space washout and can reduce work of breathing. Higher flows also lead to alveolar overdistention in non-dependent lung regions and patient discomfort. The impact of flows on different patients is largely heterogeneous.

INTERPRETATION

Individualizing flow settings during HFNC treatment is necessary, and titrating flow based on clinical findings like oxygenation, respiratory rates, ROX index, and patient comfort is a pragmatic way forward.

High-flow nasal cannula oxygen therapy is superior to conventional oxygen therapy in intensive care unit patients after extubation

BACKGROUND

Optimal oxygen supply is the cornerstone of the management of critically ill patients after extubation. High flow oxygen system is an alternative to standard oxygen therapy. This research explored the efficacy of high-flow nasal cannula (HFNC) oxygen therapy in patients after extubation in the intensive care unit (ICU).

METHOD

We retrospectively analyzed critically ill patients admitted to the ICU and subjected to HFNC or conventional oxygen therapy from January 2018 to June 2022 at the Suzhou Hospital of Integrated Traditional Chinese and Western Medicine. Blood gas analysis, a cough and sputum assessment, and cardiovascular function examinations were performed to evaluate the effect of HFNC oxygen therapy on patients. Also, the 28-d mortality rate, reintubation rate and incidence of respiratory failure were analyzed to evaluate whether HFNC oxygen therapy could improve patients' outcome.

RESULTS

In patients who received HFNC oxygen therapy, the partial pressure of oxygen and oxygenation index increased, and the respiratory rate decreased. HFNC oxygen therapy improved the patients' ability to cough up sputum and promoted the expulsion of sputum. In terms of cardiovascular function, patients who received HFNC oxygen therapy had a significant improvement in heart rate, but there was no real effect on patients' arterial pressure. There was no significant difference in the rates of reintubation (P = 0.202), 28-d mortality (P = 0.558) or respiratory failure (P = 0.677) between patients who received different oxygen therapies including HFNC oxygen therapy.

CONCLUSION

HFNC oxygen therapy improves the respiratory function of patients after extubation in their ICU and improves their coughing ability.