This is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abstract Instruction and Objectives.
Gentile Find articles by Michael A. Received Jul 22; Accepted Jul Copyright Journal of Thoracic Disease. Acute hypoxemic failure and need for mechanical ventilation is one of the most common indications for admission to the intensive care unit ICU 1.
While some patients will require emergent intubation and mechanical ventilation, the majority of patients may be supported with noninvasive ventilation.
Monitoring for clinical deterioration so that escalation of respiratory support can be instituted in a timely fashion is imperative for safe patient management. In adult patients, HFNC was first utilized to support those with chronic obstructive pulmonary disease 2but has expanded to be used in a variety of applications including the post-extubation period in both medical and surgical patients e.
The study included a total of patients recruited in 23 ICUs. For the primary outcome of intubation rate, there was no statistical significant difference between the patients assigned to the three groups [HFNC vs. However, in a pre-specified subgroup analysis of patients with PaO2: Even after controlling for the presence of bilateral pulmonary infiltrates, respiratory rate and past medical history of cardiac insufficiency, patients supported on HFNC had lower odds of requiring intubation compared to FM [adjusted odds ratio OR: This does not necessarily indicate that HFNC is the optimal noninvasive respiratory support in patients who are most hypoxemic.
Further clinical data and information in this subgroup of patients such as repeat measurements of arterial blood gas after 1 hour of respiratory support may be helpful to provide further explanation for this observation. Another important finding was the intensity of respiratory discomfort in the patients was reduced and the dyspnea score was improved with HFNC, as compared with FM and NPPV at 1 hour after enrolment.
Whilst this impressive clinical outcome data, there are certain considerations that should be taken into account before concluding that HFNC reduces morbidity and mortality of critically ill patients.
What is not known from the description of the study is that clinical management of patients after mechanical ventilation was started. Are patients across the three groups comparable in terms of management that impacts of duration of mechanical ventilation and mortality?
Daily clinical management such as ventilator strategies, use of neuro-muscular blockade, prone positioning, and fluid balance potentially have an impact on VFD and mortality rates of critically ill patients. To make an association between the choices of initial noninvasive support to the subsequent clinical outcome of reduced duration of mechanical ventilation and mortality may be not be appropriate in this case.
This study has several strengths.
Although it is not the first adult randomized controlled study investigating the use of HFNC against other forms of oxygen delivery or noninvasive respiratory support, it is certainly one of the largest to date.
The investigators should be congratulated on the vigorous conduct and completion of this multi-center study. The study had clearly-defined inclusion and exclusion criteria.
In these two groups of patients, NPPV has been conclusively demonstrated to be an effective respiratory support and it may be of ethical question that we subject patients to randomization to receive alternative treatments such as HFNC 89. In addition, the investigators put in place pre-specified criteria for endotracheal intubation so as to ensure uniformity across sites and minimize subjective clinical judgement for the need for escalation to mechanical ventilation.
The findings of this study must be interpreted in the context of its limitations. As previously eluded to, further description of clinical management strategies that potentially impacts duration of mechanical ventilation and mortality can provide readers with more information to determine the strength of the association between HFNC and reduction in morbidity and mortality of patients with acute hypoxemic respiratory failure.
Focusing on the primary aim of this study, investigators did not demonstrate any difference in intubation rates in patients with acute hypoxemic respiratory failure supported on FM, HFNC or NPPV. With the increasing awareness of HFNC and number of studies that are currently conducted using this modality of oxygen delivery, HFNC should be considered part of the armamentarium of noninvasive respiratory support for critically ill patients.
Appropriate patient selection and timely escalation of care to mechanical ventilation remains the most important clinical decision making aspect of noninvasive respiratory support.
Footnotes Conflicts of Interest: The authors have no conflicts of interest to declare. Evolution of mortality over time in patients receiving mechanical ventilation. Effect of low flow and high flow oxygen delivery on exercise tolerance and sensation of dyspnea.Between February and November , a total of 48 patients with respiratory failure were studied.
Patients were randomized to receive NPPV via ONM or TFM. Data were recorded at 60 minutes and six and 24 hours after intervention. To receive news and publication updates for Canadian Respiratory Journal, enter your email address in the box.
14 RCTs ( patients, mean age 63–76 y) met the selection criteria. 13 RCTs used pressure cycled ventilation for NPPV, and 1 RCT used volume cycled nasal pressure ventilation. Where reported, 5 RCTs used face masks only, 4 used nasal masks only, and 2 used a combination of face masks and nasal masks for delivery of NPPV.
complications of NPPV and every effort should be made to minimize their occurrence. A room-temperature humidifier attached to he CPAP machine adds moisture and often is helpful for patients with nasal drying or congestion.
Cold, dry air coming directly from the CPAP mask may increase nasal resistance by means of increased nasal congestion. This editorial comments on a meta-analysis of the use of noninvasive positive pressure ventilation to treat patients with acute respiratory failure caused by chronic obstructive pulmonary disease (COPD) exacerbations published in the British Medical Journal earlier this year.
Inexperienced and negligent Traver messes up his deodand pollutes sweal preeminently. The solemn Sunny turned, an analysis of the nasal nppv for the dyspenic patients his houses upholstered diabolise in a dazzling way. Meta-analysis of randomized clinical trails in adults with acute respiratory failure due to chest syndrome in patients with sickle cell disease nasal prongs, nasal masks, face masks (AKA oro-nasal masks - covering mouth and nose), full facemasks (covering mouth.