Communication in critical care tracheostomy patients dependent upon cuff inflation: A scoping review.

OBJECTIVES: The aim of this study was to synthesise the evidence concerning communication in critically ill tracheostomy patients dependent on cuff inflation. The aim was to identify the psychological impact on patients awake and alert with tracheostomies but unable to speak; strategies utilised to enable communication and facilitators and barriers for the success of these strategies. REVIEW METHOD USED: This scoping review was conducted using the Joanna Briggs Institute framework and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. DATA SOURCES: CINAHL, Embase, Medline, and Web of Science were searched from 1st January 2000 to 30th September 2023 and supplemented with hand searching of references from included studies. REVIEW METHODS: Studies were eligible if they addressed the psychological impact of voicelessness and/or the structure, process, and outcomes of augmentative and alternative communication (AAC) systems, in addition to facilitators and barriers to effectiveness. The population of interest included critically ill tracheostomy patients dependent on cuff inflation, their families, and healthcare workers. Screening and data extraction were undertaken by two reviewers independently. Data analysis involved descriptive statistics and content analysis. RESULTS: A total of 23 studies met the inclusion criteria: 11 were qualitative, nine were quantitative, and three were mixed-methods studies. Voicelessness elicited negative emotions, predominantly frustration. AAC systems, encompassing unaided and aided (low-tech and high-tech) methods, presented both advantages and drawbacks. High-tech strategies held promise for patients with physical limitations. Patients equally appreciated the support offered through unaided strategies, including eye contact and touch. Facilitating factors included speech therapy involvement and assessment. Patient-related challenges were the most frequent barriers. CONCLUSION: Facilitating meaningful communication for critically ill tracheostomy patients dependent on cuff inflation is of paramount psychological significance. Whilst AAC systems are practicable, they are not without limitations, implying the absence of a universally applicable solution. This underscores the importance of continuous evaluation, reinforced by a multidisciplinary team. REVIEW PROTOCOL REGISTERED: 27 July 2022. REVIEW REGISTRATION: Open Science Framework Registries: https://osf.io/kbrjn/.

International Survey of High-Flow Nasal Therapy Use for Respiratory Failure in Adult Patients.

(1) Background: High-flow nasal therapy (HFNT) has shown several benefits in addressing respiratory failure. However, the quality of evidence and the guidance for safe practice are lacking. This survey aimed to understand HFNT practice and the needs of the clinical community to support safe practice. (2) Method: A survey questionnaire was developed and distributed to relevant healthcare professionals through national networks in the UK, USA and Canada; responses were collected between October 2020 and April 2021. (3) Results: In the UK and Canada, HFNT was used in 95% of hospitals, with the highest use being in the emergency department. HNFT was widely used outside of a critical care setting. HFNT was mostly used to treat acute type 1 respiratory failure (98%), followed by acute type 2 respiratory failure and chronic respiratory failure. Guideline development was felt to be important (96%) and urgent (81%). Auditing of practice was lacking in 71% of hospitals. In the USA, HFNT was broadly similar to UK and Canadian practice. (4) Conclusions: The survey results reveal several key points: (a) HFNT is used in clinical conditions with limited evidence; (b) there is a lack of auditing; (c) it is used in wards that may not have the appropriate skill mix; and (d) there is a lack of guidance for HFNT use.

High flow nasal oxygen for acute type two respiratory failure: a systematic review.

Background: Acute type two respiratory failure (AT2RF) is characterized by high carbon dioxide levels (PaCO 2 >6kPa). Non-invasive ventilation (NIV), the current standard of care, has a high failure rate. High flow nasal therapy (HFNT) has potential additional benefits such as CO 2 clearance, the ability to communicate and comfort. The primary aim of this systematic review is to determine whether HFNT in AT2RF improves 1) PaCO 2, 2) clinical and patient-centred outcomes and 3) to assess potential harms. Methods: We searched EMBASE, MEDLINE and CENTRAL  (January 1999-January 2021). Randomised controlled trials (RCTs) and cohort studies comparing HFNT with low flow nasal oxygen (LFO) or NIV were included. Two authors independently assessed studies for eligibility, data extraction and risk of bias. We used Cochrane risk of bias tool for RCTs and Ottawa-Newcastle scale for cohort studies. Results: From 727 publications reviewed, four RCTs and one cohort study (n=425) were included. In three trials of HFNT vs NIV, comparing PaCO 2 (kPa) at last follow-up time point, there was a significant reduction at four hours (1 RCT; HFNT median 6.7, IQR 5.6 - 7.7 vs NIV median 7.6, IQR 6.3 - 9.3) and no significant difference at  24-hours or five days. Comparing HFNT with LFO, there was no significant difference at 30-minutes. There was no difference in intubation or mortality. Conclusions: This review identified a small number of studies with low to very low certainty of evidence. A reduction of PaCO 2 at an early time point of four hours post-intervention was demonstrated in one small RCT. Significant limitations of the included studies were lack of adequately powered outcomes and clinically relevant time-points and small sample size. Accordingly, systematic review cannot recommend the use of HFNT as the initial management strategy for AT2RF and trials adequately powered to detect clinical and patient-relevant outcomes are urgently warranted.

High-flow nasal cannula therapy for initial oxygen administration in acute hypercapnic respiratory failure: study protocol of randomised controlled unblinded trial.

INTRODUCTION: Acute respiratory failure is a common clinical condition accounting for nearly 116 000 admissions in the UK hospitals. Acute type 2 respiratory failure is also called acute hypercapnic respiratory failure (AHRF) and characterised by an elevated arterial CO2 level of >6 kPa due to pump failure. Acute exacerbation of chronic obstructive pulmonary disease is the most common cause of AHRF. High-flow nasal therapy (HFNT) is a new oxygen delivery system that uses an oxygen-air blender to deliver flow rates of up to 60 L/min. The gas is delivered humidified and heated to the patient via wide-bore nasal cannula. METHODS AND ANALYSIS: We hypothesised that HFNC as the initial oxygen administration method will reduce the number of patients with AHRF requiring non-invasive ventilation in patients at 6 hours post intervention when compared with low-flow nasal oxygen (LFO). A randomised single-centre unblinded controlled trial is designed to test our hypothesis. The trial will compare two oxygen administration methods, HFNT versus LFO. Patients will be randomised to one of the two arms if they fulfil the eligibility criteria. The sample size is 82 adult patients (41 HFNT and 41 LFO) presenting to the emergency department. ETHICS AND DISSEMINATION: Ethical approval was obtained from the Office for Research Ethics Committees Northern Ireland (REC reference: 20/NI/0049). Dissemination will be achieved in several ways: (1) the findings will be presented at national and international meetings with open-access abstracts online and (2) in accordance with the open-access policies proposed by the leading research funding bodies we aim to publish the findings in high-quality peer-reviewed open-access journals. TRIAL REGISTRATION NUMBER: The trial was prospectively registered at the clinicaltrials.gov registry (NCT04640948) on 20 November 2020.