Nasal High Flow Use in COPD Patients with Hypercapnic Respiratory Failure: Treatment Algorithm &amp; Review of the Literature

Pantazopoulos, Ioannis; Daniil, Zoi; Moylan, Melanie; Gourgoulianis, Konstantinos; Chalkias, Athanasios; Zakynthinos, Spyros; Ischaki, Eleni

doi:10.1080/15412555.2020.1715361

Cited by 19 publications

(18 citation statements)

References 70 publications

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“…In non-randomized trials, HFNT showed to be equivalent to NIV in avoiding intubation in mild-to-moderate AECOPD patients with respiratory acidosis with similar failure rates, but with better comfort and fewer complications for the patients using HFNT [ 21 , 22 ]. Thus, there is a reasonable physiological and clinical rationale for using HFNT in AECOPD, but its efficacy and safety are unclear [ 23 ].…”

Section: Introductionmentioning

confidence: 99%

High flow nasal therapy versus noninvasive ventilation as initial ventilatory strategy in COPD exacerbation: a multicenter non-inferiority randomized trial

et al. 2020

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Background The efficacy and safety of high flow nasal therapy (HFNT) in patients with acute hypercapnic exacerbation of chronic obstructive pulmonary disease (AECOPD) are unclear. Our aim was to evaluate the short-term effect of HFNT versus NIV in patients with mild-to-moderate AECOPD, with the hypothesis that HFNT is non-inferior to NIV on CO2 clearance after 2 h of treatment. Methods We performed a multicenter, non-inferiority randomized trial comparing HFNT and noninvasive ventilation (NIV) in nine centers in Italy. Patients were eligible if presented with mild-to-moderate AECOPD (arterial pH 7.25–7.35, PaCO2 ≥ 55 mmHg before ventilator support). Primary endpoint was the mean difference of PaCO2 from baseline to 2 h (non-inferiority margin 10 mmHg) in the per-protocol analysis. Main secondary endpoints were non-inferiority of HFNT to NIV in reducing PaCO2 at 6 h in the per-protocol and intention-to-treat analysis and rate of treatment changes. Results Seventy-nine patients were analyzed (80 patients randomized). Mean differences for PaCO2 reduction from baseline to 2 h were − 6.8 mmHg (± 8.7) in the HFNT and − 9.5 mmHg (± 8.5) in the NIV group (p = 0.404). By 6 h, 32% of patients (13 out of 40) in the HFNT group switched to NIV and one to invasive ventilation. HFNT was statistically non-inferior to NIV since the 95% confidence interval (CI) upper boundary of absolute difference in mean PaCO2 reduction did not reach the non-inferiority margin of 10 mmHg (absolute difference 2.7 mmHg; 1-sided 95% CI 6.1; p = 0.0003). Both treatments had a significant effect on PaCO2 reductions over time, and trends were similar between groups. Similar results were found in both per-protocol at 6 h and intention-to-treat analysis. Conclusions HFNT was statistically non-inferior to NIV as initial ventilatory support in decreasing PaCO2 after 2 h of treatment in patients with mild-to-moderate AECOPD, considering a non-inferiority margin of 10 mmHg. However, 32% of patients receiving HFNT required NIV by 6 h. Further trials with superiority design should evaluate efficacy toward stronger patient-related outcomes and safety of HFNT in AECOPD. Trial registration: The study was prospectively registered on December 12, 2017, in ClinicalTrials.gov (NCT03370666).

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Section: Introductionmentioning

confidence: 99%

High flow nasal therapy versus noninvasive ventilation as initial ventilatory strategy in COPD exacerbation: a multicenter non-inferiority randomized trial

et al. 2020

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“…Any further changes of expiratory positive airway pressure and inspiratory positive airway pressure will be made according to patient's vital signs/monitoring data and the attending physician's instruction. Study group 2 will receive NHF therapy with the initial setting of flow at 50–60 L·min −1 , temperature at 37°C and F IO 2 adjusted to maintain S pO 2 between 88–92% [ 19 ]. The NHF device and consumables will be the same in all centres (AIRVO 2, Fisher & Paykel Healthcare Ltd., Auckland, New Zealand).…”

Section: Methodsmentioning

confidence: 99%

“…Optimal setting is defined as the ideal setting regulated by the attending physician for each patient. The cut-off values of the examined physiologic parameters are S pO 2 <88% not corrected with supplemental oxygen, respiratory rate >35 breaths·min −1 , thoraco-abdominal asynchrony and auxiliary respiratory muscle use, worsening of hypercapnia and acidaemia, indicating further respiratory muscle fatigue and sequential organ failure assessment score >4 [ 19 ]. Patients presenting with or developing respiratory arrest, gasping respiration, pH<7.15, signs of low cardiac output or presence of exclusion criteria (severe facial deformity, facial burns or fixed upper airway obstruction) will be immediately intubated and ventilated.…”

Section: Methodsmentioning

confidence: 99%

“…The intervals of these decrements will be based on the patient's above mentioned clinical and physiological parameters. When the patient is stable for 1–2 h with minimal or no supplemental oxygen while S pO 2 remains >88–92% and flow rate <15 L·min −1 , NHF will be stopped and a Venturi mask or nasal prongs will be provided, if supplementary oxygen is still needed [ 9 , 19 , 23 ].…”

Section: Methodsmentioning

confidence: 99%

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

Papalampidou

Bibaki²,

Boutlas

et al. 2020

ERJ Open Res

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BackgroundNoninvasive 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.AimThe 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.MethodsWe designed a multicentre, prospective, randomised trial on patients with AECOPD, who have pH<7.35 but >7.25 and PaCO2 >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 SpO2 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.ConclusionGiven 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.

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“…However, the efficacy is sometimes limited by patients’ poor adherence. In such cases, nasal high flow may be an alternative means for palliative purposes, but further studies are needed to verify its safety and efficacy [ 83 ].…”

Section: Obstructive Sleep Apneamentioning

confidence: 99%

Comorbid Conditions in Chronic Obstructive Pulmonary Disease: Potential Therapeutic Targets for Unmet Needs

Matsunaga

Harada

Suizu

et al. 2020

JCM

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The management of chronic obstructive pulmonary disease (COPD) has improved significantly due to advances in therapeutic agents, but it has also become apparent that there are issues that remain difficult to solve with the current treatment algorithm. COPD patients face a number of unmet needs concerning symptoms, exacerbations, and physical inactivity. There are various risk factors and triggers for these unmet needs, which can be roughly divided into two categories. One is the usual clinical characteristics for COPD patients, and the other is specific clinical characteristics in patients with comorbid conditions, such as asthma, cardiovascular disease, and bronchiectasis. These comorbidities, which are also associated with the diversity of COPD, can cause unmet needs resistance to usual care. However, treatable conditions that are not recognized as therapeutic targets may be latent in patients with COPD. We again realized that treatable traits should be assessed and treated as early as possible. In this article, we categorize potential therapeutic targets from the viewpoint of pulmonary and systemic comorbid conditions, and address recent data concerning the pathophysiological link with COPD and the impact of intervention on comorbid conditions in order to obtain evidence that could enable us to provide personalized COPD management.

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Nasal High Flow Use in COPD Patients with Hypercapnic Respiratory Failure: Treatment Algorithm & Review of the Literature

Cited by 19 publications

References 70 publications

High flow nasal therapy versus noninvasive ventilation as initial ventilatory strategy in COPD exacerbation: a multicenter non-inferiority randomized trial

High flow nasal therapy versus noninvasive ventilation as initial ventilatory strategy in COPD exacerbation: a multicenter non-inferiority randomized trial

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

Comorbid Conditions in Chronic Obstructive Pulmonary Disease: Potential Therapeutic Targets for Unmet Needs

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