Sequential Application of Oxygen Therapy Via High-Flow Nasal Cannula and Noninvasive Ventilation in Acute Respiratory Failure: An Observational Pilot Study

Abstract

BACKGROUND:The aim of this study was to evaluate the clinical efficacy of humidified oxygen via high-flow nasal cannula (HFNC) alternating with noninvasive ventilation (NIV) in acute hypoxemic respiratory failure (AHRF). METHODS: We performed a prospective observational study in a 12-bed ICU of a university hospital. All subjects with a P aO 2 /F IO 2 of < 300 mm Hg with standard mask oxygen and a breathing frequency of > 30 breaths/min or signs of respiratory distress were included and treated with HFNC first and then NIV. Ventilatory parameters, blood gases, and tolerance were recorded during 2 consecutive sessions of NIV and HFNC. Outcome was assessed after continuation of this noninvasive strategy. RESULTS: Twenty-eight subjects with AHRF were studied, including 23 (82%) with ARDS. Compared with standard oxygen therapy, P aO 2 significantly increased from 83 (68 -97) mm Hg to 108 (83-140) mm Hg using HFNC and to 125 (97-200) mm Hg using NIV (P < .01), whereas breathing frequency significantly decreased. HFNC was significantly better tolerated than NIV, with a lower score on the visual analog scale. The nonintubated subjects received HFNC for 75 (27-127) h and NIV for 23 (8 -31) h. Intubation was required in 10 of 28 subjects (36%), including 8 of 23 subjects with ARDS (35%). After HFNC initiation, a breathing frequency of > 30 breaths/min was an early factor associated with intubation. CONCLUSIONS: HFNC was better tolerated than NIV and allowed for significant improvement in oxygenation and tachypnea compared with standard oxygen therapy in subjects with AHRF, a large majority of whom had ARDS. Thus, HFNC may be used between NIV sessions to avoid marked impairment of oxygenation. Key words: acute respiratory failure; acute respiratory distress syndrome (ARDS); noninvasive ventilation; nasal high-flow oxygen therapy; intensive care unit (ICU). [Respir Care 2015;60(2):170 -178.

High-flow nasal oxygen therapy and noninvasive ventilation in the management of acute hypoxemic respiratory failure

“…In a pilot study successively assessing standard oxygen, HFNC and NIV in patients with ARF, PaO 2 increased from standard oxygen to HFNC without changes in PaO 2 /FiO 2 ratio (17). This suggests that oxygenation improvement was mainly due to increased FiO 2 .…”

“…However, clinical studies have shown less improvement in oxygenation with HFNC than with NIV, probably due to lower impact of the PEEP effect with HFNC than with NIV (10,17). In a pilot study successively assessing standard oxygen, HFNC and NIV in patients with ARF, PaO 2 increased from standard oxygen to HFNC without changes in PaO 2 /FiO 2 ratio (17).…”

“…Standard oxygen through face mask provides non-humidified or under-humidified cold gas that dries the upper airway and leads to reduced patient comfort, even when a bubble humidifier is used (30). Most studies have reported better comfort and dyspnea feeling with HFNC than with standard oxygen through a mask or NIV (10,17,(31)(32)(33) with subsequently improved compliance (34).…”

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J‐SSCG2016)

“…Since the establishment of the new definition of ARDS in 2012, the concept of initiating therapeutic interventions according to disease severity was introduced,35, 185 and numerous reports have been made in recent years describing the clinical utility of techniques such as oxygen therapy in mild ARDS cases, oxygen therapy administered via high‐flow nasal cannula (high‐flow nasal therapy), and noninvasive positive pressure ventilation 186, 187, 188, 189. Administering oxygen in some form to sepsis patients presenting with hypoxemia is widely practiced, and while this approach is believed to help prevent the onset of acute respiratory failure leading to ARDS, there is currently no clear supporting evidence.…”

Improvements in intensive care units

“…The hazard ratio for death at 90 days was 2.01 (95% confidence interval (CI), 1.01 to 3.99) with standard oxygen versus high-flow oxygen (p=0.046) and 2.50 (95% CI, 1.31 to 4.78) with NIMV versus high-flow oxygen (p=0.006).Intubation rates were not significantly different among three groups (38% in the high flow O 2 group, 47% in the low flow O 2 group and 50% in the NIMV group [11].A prospective trial in patients with hypoxemic respiratory failure, HFOS applied sequentially with non-invasive mechanical ventilation (NIMV) and shown that HFOS improved oxygenation but not as much as NIMV compared to standard oxygen therapy [12].…”