High-Flow Nasal Cannula and in-line aerosolised bronchodilator delivery during severe exacerbation of asthma in adults: A feasibility Observational Study.

BACKGROUND: Asthma is a common chronic respiratory disease affecting 1-29% of the population in different countries. Exacerbations represent a change in symptoms and lung function from the patient's usual condition that requires emergency department (ED) admission. Recently, the use of a High-Flow Nasal Cannula (HFNC) plus an in-line vibrating mesh nebulizer (VMN) for aerosol drug delivery has been advocated in clinical practice. Thus, this pilot observational study aims to investigate the feasibility of HFNC treatment with VMN for in-line bronchodilator delivery in patients with severe asthma. METHODS: This study was conducted from May 2022 to May 2023. Subjects ≥ 18 years old with a previous diagnosis of asthma who were admitted to the ED during severe exacerbation were included. The primary endpoint was the change in peak expiratory flow ratio (PEFR) after 2-h of treatment with bronchodilator delivered by HFNC with in-line VMN. Additional outcomes were changes in forced expiratory volume in 1 second (FEV1) and clinical variables before treatment. RESULTS: 30 patients mean age of 43 (SD ± 16) years, mostly female (67%) were studied. A significant change in PEFR (147 ± 31 L/m vs. 220 ± 38 L/m; p < 0.001) was observed after treatment with HFNC and in-line VMN with significant improvement in clinical variables. And no subjects required invasive mechanical ventilation (IMV) during the study. CONCLUSIONS: HFNC treatment with in-line VMN for bronchodilator delivery appears feasible and safe for patients with severe asthma exacerbation. These preliminary promising results should be confirmed with appropriately large-designed studies.

Terapia de alto flujo en pacientes con traqueostomía. Una revisión narrativa / High-Flow Therapy in Tracheostomized Patients. A Narrative Review

La terapia de alto flujo se ha popularizado durante los últimos años, basada en sus efectos fisiológicos, la entrega de una fracción inspirada de oxígeno segura y estable, sumada al flujo calefaccionado y humidificado, lo que hizo posible su utilización en distintos escenarios. Sin embargo, los estudios que muestran estos beneficios y efectos se han realizado, principalmente, con el empleo de una cánula nasal; mientras que las características de esta terapia en los pacientes traqueostomizados no se ha desarrollado suficientemente. Proponemos aquí una revisión narrativa con las características más salientes de la terapia de alto flujo en este subgrupo de pacientes.

High-flow therapy has become popular in recent years, based on its physiological effects, the delivery of a safe and stable inspired fraction of oxygen, combined with heated and humidified flow, which made its use possible in different scenarios. However, studies demonstrating these benefits and effects have been mainly conducted using a nasal cannula, while the characteristics of this therapy in tracheostomized patients have not been sufficiently developed. We propose a narrative review highlighting the most relevant characteristics of high-flow therapy in this subgroup of patients.

Lung ultrasound score predicts outcomes in patients with acute respiratory failure secondary to COVID-19 treated with non-invasive respiratory support: a prospective cohort study.

BACKGROUND: Lung ultrasound has demonstrated its usefulness in several respiratory diseases management. One derived score, the Lung Ultrasound (LUS) score, is considered a good outcome predictor in patients with Acute Respiratory Failure (ARF). Nevertheless, it has not been tested in patients undergoing non-invasive respiratory support (NIRS). Taking this into account, the aim of this study is to evaluate LUS score as a predictor of 90-day mortality, ETI (Endotracheal intubation) and HFNC (High Flow Nasal Cannula) failure in patients with ARF due to COVID-19 admitted to a Respiratory Intermediate Care Unit (RICU) for NIRS management. RESULTS: One hundred one patients were admitted to the RICU during the study period. Among these 76% were males and the median age was 55 (45-64) years. Initial ARF management started with HFNC, the next step was the use of Continuous Positive Airway Pressure (CPAP) devices and the last intervention was ETI and Intensive Care Unit (ICU) admission. Of the total study population, CPAP was required in 40%, ETI in 26%, while 15% died. By means of a ROC analysis, a LUS ≥ 25 points was identified as the cut-off point for mortality(AUC 0.81, OR 1.40, 95% CI 1.14 to 1.71; p < 0.001), ETI (AUC 0.83, OR 1.43, 95% CI 1.20 to 1.70; p < 0.001) and HFNC failure (AUC 0.75, OR 1.25, 95% CI 1.12 to 1.41; p < 0.001). Kaplan-Meier survival curves also identified LUS ≥ 25 as a predictor of 90-days mortality (HR 4.16, 95% CI 1.27-13.6) and 30 days ETI as well. CONCLUSION: In our study, a ≥ 25 point cut-off of the Lung Ultrasound Score was identified as a good outcome prediction factor for 90-days mortality, ETI and HFNC failure in a COVID-19 ARF patients cohort treated in a RICU. Considering that LUS score is easy to calculate, a multicenter study to confirm our findings should be performed.

Utilización de soportes respiratorios no invasivos post extubación en pacientes adultos críticos: revisión narrativa SRNI post extubación en adultos críticos / Use of Non-Invasive Respiratory Support in Critically Ill Patients Post-Extubation: a Narrative Review NIRS Post-Extubation in Critically Ill Adults

La tasa de reintubación orotraqueal luego de la extubación se registra entre un 10 a 20%. La aplicación de soportes respiratorios no-invasivos (SRNI) posterior a la extuba-ción como cánula nasal de alto-flujo, ventilación no invasiva (dos niveles de presión) y presión positiva continua en la vía aérea demostraron ser seguras y efectivas post ex-tubación. El período pre-destete representa un momento crucial en el manejo de los pa-cientes críticos ya que el fracaso de la extubación, definido como la necesidad de reintu-bación dentro de los 2 a 7 días, demostró peores resultados al aumentar la mortalidad entre un 25-50%. Esta situación conlleva al requerimiento de ventilación mecánica prolongada, neumonía asociada a la ventilación mecánica y estancias prolongadas de internación. Por lo tanto, es esencial identificar a los pacientes que se beneficiarán utilizando SRNI post extubación.

The rate of re-intubation after extubation is recorded at 10-20%. The use of non-invasive respiratory support (NIRS) post-extubation such as high-flow nasal cannula, non-invasive ventilation (bilevel pressure) and continuous positive airway pressure (CPAP) have been shown to be safe and effective post-extubation. The pre-weaning period represents a crucial time in the management of critically ill patients, as extubation failure, defined as the need for reintubation within 2-7 days, showed worse outcomes with mortality increasing by 25-50%. This situation leads to the requirement for prolonged mechanical ventilation, ventilator-associated pneumonia and long lengths of hospital stay. Therefore, it is essential to identify patients who will benefit from NIRS post extubation.