Use of High-Flow Nasal Cannula for Acute Dyspnea and Hypoxemia in the Emergency Department

Abstract

BACKGROUND: Acute dyspnea and hypoxemia are 2 of the most common problems in the emergency room. Oxygen therapy is an essential supportive treatment to correct these issues. In this study, we investigated the physiologic effects of high-flow nasal oxygen cannula (HFNC) compared with conventional oxygen therapy (COT) in subjects with acute dyspnea and hypoxemia in the emergency room. METHODS: A prospective randomized comparative study was conducted in the emergency department of a university hospital. Forty subjects were randomized to receive HFNC or COT for 1 h. The primary outcome was level of dyspnea, and secondary outcomes included change in breathing frequency, subject comfort, adverse events, and rate of hospitalization. RESULTS: Common causes of acute dyspnea and hypoxemia were congestive heart failure, asthma exacerbation, COPD exacerbation, and pneumonia. HFNC significantly improved dyspnea (2.0 ؎ 1.8 vs 3.8 ؎ 2.3, P ‫؍‬ .01) and subject comfort (1.6 ؎ 1.7 vs 3.7 ؎ 2.4, P ‫؍‬ .01) compared with COT. No statistically significant difference in breathing frequency was found between the 2 groups at the end of the study. HFNC was well tolerated, and no serious adverse events were found. The rate of hospitalization in the HFNC group was lower than in the COT group, but there was no statistically significant difference (50% vs 65%, P ‫؍‬ .34). CONCLUSIONS: HFNC improved dyspnea and comfort in subjects presenting with acute dyspnea and hypoxemia in the emergency department. HFNC may benefit patients requiring oxygen therapy in the emergency room.

High-Flow Nasal Cannula Oxygen Therapy in Adults: Physiological Benefits, Indication, Clinical Benefits, and Adverse Effects

“…40 HFNC has also been applied to patients with mild to moderate hypoxemic respiratory failure in a cardiothoracic ICU 12 and emergency room. 69,82,83 HFNC can be regarded as a first-line treatment for patients with mild to moderate hypoxemic ARF.…”

A Skeptical Perspective on High-Flow Nasal Cannula in the Treatment of Acute Hypoxemic Respiratory Failure

“…The latter may be due to a lack of predefined discontinuation criteria, distraction and/or missed cues, inexperience with the device and its use, or a desire to avoid escalation due to patient or provider bias. The current studies by Nagata et al, 7 Gaunt et al, 8 Rittayamai et al, 9 and Vargas et al 10 failed to define such abandonment criteria, and in particular, Rittayamai et al 9 acknowledge several such limitations of their study. First, a median 1.5 h elapsed between recognition and implementation of HFNC or conventional oxygen therapy.…”

“…HFNC addresses these shortcomings through delivery of high flow (30 -60 L/min) heated and humidified gas at a constant F IO 2 via a wide-bore nasal interface. 3 Its comfort has been wellestablished, including in the current study of emergency department subjects by Rittayamai et al, 9 and correlates with patient compliance.…”

“…However, the limited patient population, comparatively disparate mortality in the shock subgroups, and the non-protective ventilation strategy (average tidal volume [V T ] in excess of 9 mL/kg) in the NIV group preclude a definitive conclusion from these results. In this issue of RESPIRATORY CARE, 5 original research articles by Nagata et al, 7 Gaunt et al, 8 Rittayamai et al, 9 Vargas et al, 10 and Parke et al 11 explore aspects of HFNC ranging from the physiologic basis for its use to the comparative risks, benefits, and clinical efficacy of conventional oxygen therapy, NIV, and HFNC in the acute care setting. In the end, and in the context of conflicting end points, such as length of stay, ventilator-free days, and mortality, prudence suggests a skeptical interpretation of appropriate use for HFNC in patients experiencing acute hypoxemic, non-hypercapnic respiratory failure.…”

High-Flow Nasal Cannula Support Therapy: New Insights and Improving Performance

“…HFNC was also usually better tolerated than NIV, although NIV obtained greater improvements in oxygenation [13,14]. In addition, HFNC has been used in small cohorts of patients with acute respiratory failure in the emergency department [15,16] and even in 150 children less than 2 years old during interhospital transport [17]. The effects on oxygenation and rates of intubation reported in all these studies are similar to those found when HFNC has been used in patients with acute respiratory failure admitted to critical care areas, suggesting that, with adequate monitoring, HFNC can be safely used outside the critical care setting.…”