RESUMO
BACKGROUND: An estimated 20% of emergency department (ED) patients require respiratory support (RS). Evidence suggests that nasal high flow (NHF) reduces RS need. AIMS: This review compared NHF to conventional oxygen therapy (COT) or noninvasive ventilation (NIV) in adult ED patients. METHOD: The systematic review (SR) and meta-analysis (MA) methods reflect the Cochrane Collaboration methodology. Six databases were searched for randomized controlled trials (RCTs) comparing NHF to COT or NIV use in the ED. Three summary estimates were reported: (1) need to escalate care, (2) mortality, and (3) adverse events (AEs). RESULTS: This SR and MA included 18 RCTs (n = 1874 participants). Two of the five MA conclusions were statistically significant. Compared with COT, NHF reduced the risk of escalation by 45% (RR 0.55; 95% CI [0.33, 0.92], p = .02, NNT = 32); however, no statistically significant differences in risk of mortality (RR 1.02; 95% CI [0.68, 1.54]; p = .91) and AE (RR 0.98; 95% CI [0.61, 1.59]; p = .94) outcomes were found. Compared with NIV, NHF increased the risk of escalation by 60% (RR 1.60; 95% CI [1.10, 2.33]; p = .01); mortality risk was not statistically significant (RR 1.23, 95% CI [0.78, 1.95]; p = .37). LINKING EVIDENCE TO ACTION: Evidence-based decision-making regarding RS in the ED is challenging. ED clinicians have at times had to rely on non-ED evidence to support their practice. Compared with COT, NHF was seen to be superior and reduced the risk of escalation. Conversely, for this same outcome, NIV was superior to NHF. However, substantial clinical heterogeneity was seen in the NIV delivered. Research considering NHF versus NIV is needed. COVID-19 has exposed the research gaps and slowed the progress of ED research.
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Serviço Hospitalar de Emergência , Humanos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Serviço Hospitalar de Emergência/organização & administração , Ventilação não Invasiva/métodos , Ventilação não Invasiva/normas , Terapia Respiratória/métodos , Terapia Respiratória/normas , Oxigenoterapia/métodos , Oxigenoterapia/normas , Oxigenoterapia/estatística & dados numéricosRESUMO
Rationale: When compared with VenturiMask after extubation, high-flow nasal oxygen provides physiological advantages. Objectives: To establish whether high-flow oxygen prevents endotracheal reintubation in hypoxemic patients after extubation, compared with VenturiMask. Methods: In this multicenter randomized trial, 494 patients exhibiting PaO2:FiO2 ratio ⩽ 300 mm Hg after extubation were randomly assigned to receive high-flow or VenturiMask oxygen, with the possibility to apply rescue noninvasive ventilation before reintubation. High-flow use in the VenturiMask group was not permitted. Measurements and Main Results: The primary outcome was the rate of reintubation within 72 hours according to predefined criteria, which were validated a posteriori by an independent adjudication committee. Main secondary outcomes included reintubation rate at 28 days and the need for rescue noninvasive ventilation according to predefined criteria. After intubation criteria validation (n = 492 patients), 32 patients (13%) in the high-flow group and 27 patients (11%) in the VenturiMask group required reintubation at 72 hours (unadjusted odds ratio, 1.26 [95% confidence interval (CI), 0.70-2.26]; P = 0.49). At 28 days, the rate of reintubation was 21% in the high-flow group and 23% in the VenturiMask group (adjusted hazard ratio, 0.89 [95% CI, 0.60-1.31]; P = 0.55). The need for rescue noninvasive ventilation was significantly lower in the high-flow group than in the VenturiMask group: at 72 hours, 8% versus 17% (adjusted hazard ratio, 0.39 [95% CI, 0.22-0.71]; P = 0.002) and at 28 days, 12% versus 21% (adjusted hazard ratio, 0.52 [95% CI, 0.32-0.83]; P = 0.007). Conclusions: Reintubation rate did not significantly differ between patients treated with VenturiMask or high-flow oxygen after extubation. High-flow oxygen yielded less frequent use of rescue noninvasive ventilation. Clinical trial registered with www.clinicaltrials.gov (NCT02107183).
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Ventilação não Invasiva , Insuficiência Respiratória , Humanos , Extubação , Insuficiência Respiratória/terapia , Oxigenoterapia/efeitos adversos , Intubação Intratraqueal , Oxigênio/uso terapêuticoRESUMO
BACKGROUND: Nasal high flow (NHF) may reduce hypoxia and hypercapnia during an endoscopic retrograde cholangiopancreatography (ERCP) procedure under sedation. The authors tested a hypothesis that NHF with room air during ERCP may prevent intraoperative hypercapnia and hypoxemia. METHODS: In the prospective, open-label, single-center, clinical trial, 75 patients undergoing ERCP performed with moderate sedation were randomized to receive NHF with room air (40 to 60 L/min, n = 37) or low-flow O2 via a nasal cannula (1 to 2 L/min, n = 38) during the procedure. Transcutaneous CO2, peripheral arterial O2 saturation, a dose of administered sedative and analgesics were measured. RESULTS: The primary outcome was the incidence of marked hypercapnia during an ERCP procedure under sedation observed in 1 patient (2.7%) in the NHF group and in 7 patients (18.4%) in the LFO group; statistical significance was found in the risk difference (-15.7%, 95% CI -29.1 - -2.4, p = 0.021) but not in the risk ratio (0.15, 95% CI 0.02 - 1.13, p = 0.066). In secondary outcome analysis, the mean time-weighted total PtcCO2 was 47.2 mmHg in the NHF group and 48.2 mmHg in the LFO group, with no significant difference (-0.97, 95% CI -3.35 - 1.41, p = 0.421). The duration of hypercapnia did not differ markedly between the two groups either [median (range) in the NHF group: 7 (0 - 99); median (range) in the LFO group: 14.5 (0 - 206); p = 0.313] and the occurrence of hypoxemia during an ERCP procedure under sedation was observed in 3 patients (8.1%) in the NHF group and 2 patients (5.3%) in the LFO group, with no significant difference (p = 0.674). CONCLUSIONS: Respiratory support by NHF with room air did not reduce marked hypercapnia during ERCP under sedation relative to LFO. There was no significant difference in the occurrence of hypoxemia between the groups that may indicate an improvement of gas exchanges by NHF. TRIAL REGISTRATION: jRCTs072190021 . The full date of first registration on jRCT: August 26, 2019.
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Colangiopancreatografia Retrógrada Endoscópica , Sedação Consciente , Humanos , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Hipercapnia/prevenção & controle , Estudos Prospectivos , Hipóxia/etiologia , Hipóxia/prevenção & controle , OxigênioRESUMO
BACKGROUND: We aimed to assess the efficacy of a closed-loop oxygen control in critically ill patients with moderate to severe acute hypoxemic respiratory failure (AHRF) treated with high flow nasal oxygen (HFNO). METHODS: In this single-centre, single-blinded, randomized crossover study, adult patients with moderate to severe AHRF who were treated with HFNO (flow rate ≥ 40 L/min with FiO2 ≥ 0.30) were randomly assigned to start with a 4-h period of closed-loop oxygen control or 4-h period of manual oxygen titration, after which each patient was switched to the alternate therapy. The primary outcome was the percentage of time spent in the individualized optimal SpO2 range. RESULTS: Forty-five patients were included. Patients spent more time in the optimal SpO2 range with closed-loop oxygen control compared with manual titrations of oxygen (96.5 [93.5 to 98.9] % vs. 89 [77.4 to 95.9] %; p < 0.0001) (difference estimate, 10.4 (95% confidence interval 5.2 to 17.2). Patients spent less time in the suboptimal range during closed-loop oxygen control, both above and below the cut-offs of the optimal SpO2 range, and less time above the suboptimal range. Fewer number of manual adjustments per hour were needed with closed-loop oxygen control. The number of events of SpO2 < 88% and < 85% were not significantly different between groups. CONCLUSIONS: Closed-loop oxygen control improves oxygen administration in patients with moderate-to-severe AHRF treated with HFNO, increasing the percentage of time in the optimal oxygenation range and decreasing the workload of healthcare personnel. These results are especially relevant in a context of limited oxygen supply and high medical demand, such as the COVID-19 pandemic. Trial registration The HILOOP study was registered at www. CLINICALTRIALS: gov under the identifier NCT04965844 .
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COVID-19 , Insuficiência Respiratória , Adulto , COVID-19/terapia , Cânula , Estudos Cross-Over , Humanos , Hipóxia/etiologia , Hipóxia/terapia , Oxigênio/uso terapêutico , Oxigenoterapia/métodos , Pandemias , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/terapiaRESUMO
BACKGROUND: For children and adults, the standard treatment for obstructive sleep apnea is the delivery of continuous positive airway pressure (CPAP). Though effective, CPAP masks can be uncomfortable to patients, contributing to adherence concerns. Recently, nasal high flow (NHF) therapy has been investigated as an alternative, especially in CPAP-intolerant children. The present study aimed to compare and contrast the positive airway pressures and expired gas washout generated by NHF versus CPAP in child nasal airway replicas. METHODS: NHF therapy was investigated at a flow rate of 20 L/min and compared to CPAP at 5 cmH2O and 10 cmH2O for 10 nasal airway replicas, built from computed tomography scans of children aged 4-8 years. NHF was delivered with three different high flow nasal cannula models provided by the same manufacturer, and CPAP was delivered with a sealed nasal mask. Tidal breathing through each replica was imposed using a lung simulator, and airway pressure at the trachea was recorded over time. For expired gas washout measurements, carbon dioxide was injected at the lung simulator, and end-tidal carbon dioxide (EtCO2) was measured at the trachea. Changes in EtCO2 compared to baseline values (no intervention) were assessed. RESULTS: NHF therapy generated an average positive end-expiratory pressure (PEEP) of 5.17 ± 2.09 cmH2O (mean ± SD, n = 10), similar to PEEP of 4.95 ± 0.03 cmH2O generated by nominally 5 cmH2O CPAP. Variation in tracheal pressure was higher between airway replicas for NHF compared to CPAP. EtCO2 decreased from baseline during administration of NHF, whereas it increased during CPAP. No statistical difference in tracheal pressure nor EtCO2 was found between the three high flow nasal cannulas. CONCLUSION: In child airway replicas, NHF at 20 L/min generated average PEEP similar to CPAP at 5 cm H2O. Variation in tracheal pressure was higher between airway replicas for NHF than for CPAP. The delivery of NHF yielded expired gas washout, whereas CPAP impeded expired gas washout due to the increased dead space of the sealed mask.
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Cânula , Dióxido de Carbono/análise , Pressão Positiva Contínua nas Vias Aéreas/métodos , Respiração , Apneia Obstrutiva do Sono/terapia , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Apneia Obstrutiva do Sono/metabolismo , Apneia Obstrutiva do Sono/fisiopatologia , TraqueiaRESUMO
PURPOSE: In neuromuscular disorders (NMD), inspiratory muscle weakness may cause sleep-related hypoventilation requiring non-invasive ventilation (NIV). Alternatively, nasal high flow therapy (NHF) may ameliorate mild nocturnal hypercapnia (NH) through washout of anatomical dead space and generation of positive airway pressure. Ventilatory support by NIV or NHF might have favourable short-term effects on sympathovagal balance (SVB). This study comparatively investigated the effects of NHF and NIV on sleep-related breathing and SVB in NMD patients with evolving NH. METHODS: Transcutaneous CO2 (ptcCO2), peripheral oxygen saturation (SpO2), sleep outcomes and SVB (spectral analysis of heart rate, diastolic blood pressure variability) along with haemodynamic measures (cardiac index, total peripheral resistance index) were evaluated overnight in 17 patients. Polysomnographies (PSG) were randomly split into equal parts with no treatment, NIV and NHF at different flow rates (20 l/min vs. 50 l/min). In-depth analysis of SVB and haemodynamics was performed on 10-min segments of stable N2 sleep taken from each intervention. RESULTS: Compared with no treatment, NHF20 and NHF50 did not significantly change ptcCO2, SpO2 or the apnea hypopnea index (AHI). NHF50 was poorly tolerated. In contrast, NIV significantly improved both gas exchange and AHI without adversely affecting sleep. During daytime, NHF20 and NHF50 had neutral effects on ventilation and oxygenation whereas NIV improved ptcCO2 and SpO2. Effects of NIV and NHF on SVB and haemodynamics were neutral during both night and daytime. CONCLUSIONS: NHF does not correct sleep-disordered breathing in NMD patients with NH. Both NHF and NIV exert no immediate effects on SVB.
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Pressão Sanguínea/fisiologia , Frequência Cardíaca/fisiologia , Hipercapnia/fisiopatologia , Hipercapnia/terapia , Doenças Neuromusculares/fisiopatologia , Oxigenoterapia/métodos , Sono/fisiologia , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ventilação não Invasiva , Polissonografia , Resultado do TratamentoRESUMO
BACKGROUND: In precapillary pulmonary hypertension (PH), nasal high flow therapy (NHF) may favorably alter sympathovagal balance (SVB) and sleep-related breathing through washout of anatomical dead space and alleviation of obstructive sleep apnea (OSA) due to generation of positive airway pressure. OBJECTIVES: To investigate the effects of NHF on SVB, sleep, and OSA in patients with PH, and compare them with those of positive airway pressure therapy (PAP). METHODS: Twelve patients with PH (Nice class I or IV) and confirmed OSA underwent full polysomnography, and noninvasive monitoring of SVB parameters (spectral analysis of heart rate, diastolic blood pressure variability). Study nights were randomly split into four 2-h segments with no treatment, PAP, NHF 20 L/min, or NHF 50 L/min. In-depth SVB analysis was conducted on 10-min epochs during daytime and stable N2 sleep at nighttime. RESULTS: At daytime and compared with no treatment, NHF20 and NHF50 were associated with a flow-dependent increase in peripheral oxygen saturation but a shift in SVB towards increased sympathetic drive. At nighttime, NHF20 was associated with increased parasympathetic drive and improvements in sleep efficiency, but did not alter OSA severity. NHF50 was poorly tolerated. PAP therapy improved OSA but had heterogenous effects on SVB and neutral effects on sleep outcomes. Hemodynamic effects were neutral for all interventions. CONCLUSIONS: In sleeping PH patients with OSA NHF20 but not NHF50 leads to decreased sympathetic drive likely due to washout of anatomical dead space. NHF was not effective in lowering the apnea-hypopnoea index and NHF50 was poorly tolerated.
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Pressão Sanguínea/fisiologia , Frequência Cardíaca/fisiologia , Hipertensão Pulmonar/terapia , Oxigenoterapia/métodos , Apneia Obstrutiva do Sono/terapia , Sono/fisiologia , Idoso , Feminino , Humanos , Hipertensão Pulmonar/fisiopatologia , Masculino , Pessoa de Meia-Idade , Polissonografia , Apneia Obstrutiva do Sono/fisiopatologia , Resultado do TratamentoRESUMO
AIM: This study reviews clinical outcomes after initiating a routine policy of preterm respiratory stabilisation using nasal high flow (HF) in the delivery room (DR). METHOD: This was a retrospective observational cohort study in a single-centre neonatal intensive care unit and included all neonates born before 32 weeks of gestation between 1 April 2015 and 31 March 2020. Stabilisation measures and outcomes were recorded including oxygen requirements, admission temperature, surfactant administration, invasive ventilation within 72 h of birth, bronchopulmonary dysplasia (BPD) and death. RESULTS: There were 491 eligible babies during the 5-year epoch. 292 were stabilised using HF in the DR. The median admission temperature in babies transferred on HF was 36.8°C, and the median FiO2 at admission was 25%. 45% of these infants received surfactant. At 72 postnatal hours, 78% were either sustained on HF or were either self-ventilating in air (SVIA) or receiving low-flow nasal cannula (LFNC) respiratory support. 27% were intubated within 7 days. At 36 weeks postmenstrual age, 36% of survivors had BPD. CONCLUSION: We have demonstrated that preterm babies <32 weeks can be effectively stabilised on HF in the DR.
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Displasia Broncopulmonar , Surfactantes Pulmonares , Adulto , Displasia Broncopulmonar/epidemiologia , Displasia Broncopulmonar/terapia , Estudos de Coortes , Salas de Parto , Feminino , Idade Gestacional , Humanos , Lactente , Recém-Nascido , Recém-Nascido Prematuro , Gravidez , Estudos RetrospectivosRESUMO
OBJECTIVE: To identify predictors and outcomes of early intubation in preterm infants with respiratory distress, and predictors of need for brief respiratory support (≤1 day). STUDY DESIGN: Secondary analysis of data from a randomized trial comparing nasal high-flow with continuous positive airway pressure as primary respiratory support in preterm infants born at 28-36 weeks of gestation. Intubation was assessed within 72 hours of randomization. RESULTS: There were 564 included infants with a mean (SD) gestational age of 32.0 (2.2) weeks and birth weight 1744 (589) g; 76 infants (13.5%) received early intubation. On multivariable analysis, lower gestational age and higher pre-randomization fraction of inspired oxygen (FiO2) predicted intubation. A test based on gestational age of <30 weeks and an FiO2 of ≥0.30 produced a likelihood ratio of 9.1. Intubation was associated with prolonged duration of respiratory support and supplemental oxygen, with pneumothorax and nasal trauma, and in infants born at <32 weeks of gestational, with bronchopulmonary dysplasia and patent ductus arteriosus requiring treatment. Greater gestational age and lower FiO2 predicted the need for ≤1 day of respiratory support. A test based on a gestational age of ≥34 weeks and an FiO2 of 0.21 produced a likelihood ratio of 4.7. CONCLUSIONS: In preterm infants 28-36 week of gestation receiving primary noninvasive respiratory support, lower gestational age, and higher FiO2 predicted need for intubation within 72 hours. Intubation was associated with adverse respiratory outcomes. Greater gestational age and lower FiO2 predicted need for ≤1 day of respiratory support. It may be reasonable to defer the use of respiratory support in more mature infants with low FiO2 requirements. TRIAL REGISTRATION AUSTRALIAN NEW ZEALAND CLINICAL TRIALS REGISTRY: ACTRN12613000303741.
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Pressão Positiva Contínua nas Vias Aéreas , Intubação Intratraqueal , Ventilação não Invasiva , Síndrome do Desconforto Respiratório do Recém-Nascido/terapia , Pressão Positiva Contínua nas Vias Aéreas/efeitos adversos , Feminino , Idade Gestacional , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Intubação Intratraqueal/efeitos adversos , Masculino , Prognóstico , Estudos Prospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Nasal high flow delivered at flow rates higher than 60 L/min in patients with acute hypoxemic respiratory failure might be associated with improved physiological effects. However, poor comfort might limit feasibility of its clinical use. METHODS: We performed a prospective randomized cross-over physiological study on 12 ICU patients with acute hypoxemic respiratory failure. Patients underwent three steps at the following gas flow: 0.5 L/kg PBW/min, 1 L/kg PBW/min, and 1.5 L/kg PBW/min in random order for 20 min. Temperature and FiO2 remained unchanged. Toward the end of each phase, we collected arterial blood gases, lung volumes, and regional distribution of ventilation assessed by electrical impedance tomography (EIT), and comfort. RESULTS: In five patients, the etiology was pulmonary; infective disease characterized seven patients; median PaO2/FiO2 at enrollment was 213 [IQR 136-232]. The range of flow rate during NHF 1.5 was 75-120 L/min. PaO2/FiO2 increased with flow, albeit non significantly (p = 0.064), PaCO2 and arterial pH remained stable (p = 0.108 and p = 0.105). Respiratory rate decreased at higher flow rates (p = 0.014). Inhomogeneity of ventilation decreased significantly at higher flows (p = 0.004) and lung volume at end-expiration significantly increased (p = 0.007), but mostly in the non-dependent regions. Comfort was significantly poorer during the step performed at the highest flow (p < 0.001). CONCLUSIONS: NHF delivered at rates higher than 60 L/min in critically ill patients with acute hypoxemic respiratory failure is associated with reduced respiratory rate, increased lung homogeneity, and additional positive pressure effect, but also with worse comfort.
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Administração Intranasal/métodos , Oxigênio/administração & dosagem , Insuficiência Respiratória/tratamento farmacológico , Administração Intranasal/instrumentação , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Índice de Massa Corporal , Dióxido de Carbono/análise , Dióxido de Carbono/sangue , Feminino , Humanos , Itália , Masculino , Pessoa de Meia-Idade , Escores de Disfunção Orgânica , Oxigênio/análise , Estudos Prospectivos , Insuficiência Respiratória/fisiopatologia , Escore Fisiológico Agudo SimplificadoRESUMO
Nasal high-flow therapy (NHFT) is an upcoming treatment for chronic obstructive pulmonary disease (COPD) patients. It supplies heated, humidified, and, desirably, oxygen-enriched air through a nasal cannula at flow rates up to 60 L/min. Several studies examined the effect of NHFT in COPD patients, but a clear overview is lacking. The present review aimed to give an overview of the clinical evidence of NHFT in 3 aspects of COPD care: long-term use in stable COPD patients, use for treatment of COPD exacerbations, and use during exercise therapy in COPD. For each topic, a specific literature search was performed up to December 9, 2019. Studies show promising results, with most evidence for its long-term use in hypoxemic COPD patients that frequently exacerbate, and very limited evidence for its use during COPD exacerbations or as a worthwhile adjunct to exercise training. More evidence is therefore needed to know how to incorporate NHFT in standard clinical practice.
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Duração da Terapia , Hipercapnia/terapia , Hipóxia/terapia , Oxigenoterapia/métodos , Doença Pulmonar Obstrutiva Crônica/terapia , Insuficiência Respiratória/terapia , Cânula , Progressão da Doença , Prática Clínica Baseada em Evidências , Terapia por Exercício/métodos , Humanos , Ventilação não Invasiva/métodos , Oxigenoterapia/instrumentaçãoRESUMO
Rationale: One important concern during high-flow nasal cannula (HFNC) therapy in patients with acute hypoxemic respiratory failure is to not delay intubation. Objectives: To validate the diagnostic accuracy of an index (termed ROX and defined as the ratio of oxygen saturation as measured by pulse oximetry/FiO2 to respiratory rate) for determining HFNC outcome (need or not for intubation). Methods: This was a 2-year multicenter prospective observational cohort study including patients with pneumonia treated with HFNC. Identification was through Cox proportional hazards modeling of ROX association with HFNC outcome. The most specific cutoff of the ROX index to predict HFNC failure and success was assessed. Measurements and Main Results: Among the 191 patients treated with HFNC in the validation cohort, 68 (35.6%) required intubation. The prediction accuracy of the ROX index increased over time (area under the receiver operating characteristic curve: 2 h, 0.679; 6 h, 0.703; 12 h, 0.759). ROX greater than or equal to 4.88 measured at 2 (hazard ratio, 0.434; 95% confidence interval, 0.264-0.715; P = 0.001), 6 (hazard ratio, 0.304; 95% confidence interval, 0.182-0.509; P < 0.001), or 12 hours (hazard ratio, 0.291; 95% confidence interval, 0.161-0.524; P < 0.001) after HFNC initiation was consistently associated with a lower risk for intubation. A ROX less than 2.85, less than 3.47, and less than 3.85 at 2, 6, and 12 hours of HFNC initiation, respectively, were predictors of HFNC failure. Patients who failed presented a lower increase in the values of the ROX index over the 12 hours. Among components of the index, oxygen saturation as measured by pulse oximetry/FiO2 had a greater weight than respiratory rate. Conclusions: In patients with pneumonia with acute respiratory failure treated with HFNC, ROX is an index that can help identify those patients with low and those with high risk for intubation. Clinical trial registered with www.clinicaltrials.gov (NCT02845128).
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Gasometria , Cateterismo/normas , Técnicas e Procedimentos Diagnósticos/normas , Oxigenação por Membrana Extracorpórea/normas , Oxigenoterapia/normas , Pneumonia/terapia , Taxa Respiratória , Idoso , Estudos de Coortes , Confiabilidade dos Dados , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ventilação não Invasiva/normas , Guias de Prática Clínica como Assunto , Estudos ProspectivosRESUMO
Nasal high flow (NHF) therapy has recently gained attention as a new respiratory support system and is increasingly being utilized in every day clinical practice. Recent studies suggest that it may also be effective in patients with hypercapnia and suggest NHF as a possible alternative for patients who cannot tolerate standard noninvasive ventilation. The present review discusses the mechanisms of action that make NHF potentially suitable for chronic obstructive pulmonary disease (COPD) patients and evaluates the current evidence of NHF use for treatment of stable hypercapnic COPD patients as well as acute hypercapnic exacerbation of COPD. An algorithm is also proposed for the clinical application of NHF in patients with acute hypercapnic exacerbation of COPD, based on current literature.
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Algoritmos , Hipercapnia/terapia , Oxigenoterapia/métodos , Doença Pulmonar Obstrutiva Crônica/terapia , Insuficiência Respiratória/terapia , Cânula , Humanos , Ventilação não Invasiva/métodos , Doença Pulmonar Obstrutiva Crônica/fisiopatologiaRESUMO
Little is known about chronic obstructive pulmonary disease (COPD) patients experience with home-based health treatments, which are currently rapidly evolving. A previous randomized controlled trial investigated the use of long-term oxygen enriched high flow nasal cannula (HFNC) treatment at home. The aim of this study was to explore COPD patients' experience using home HFNC treatment. Patients in this qualitative study were included from the previous RCT. All patients used long-term oxygen therapy and HFNC, the latter as a primarily nocturnal add-on. Data were collected using semi-structured interviews focused on four themes: 'Description of daily use', 'Experienced changes', 'Treatment benefits and disadvantages' and 'User-friendliness'. The interviewer played an encouraging, non-normative neutral facilitator role in order to give the participants possibility to explain themselves as fully as possible. Participants were recruited until themes were saturated. A total of 12 patients (5 males, 7 females) and 8 relatives participated. Six themes were identified as important to patient adherence: Perceived lower work of breathing; reduced symptoms; improved quality of sleep; increased activity of daily living; feeling safe; technology use. The results increase our knowledge of patient experience of using HFNC for home treatment, which improved the patients' experience through reducing symptoms and increase the activity of daily living. Furthermore, they substantiate the necessity of perceived usefulness and ease of use as important factors for adherence to treatment.
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Oxigenoterapia , Cooperação do Paciente/psicologia , Doença Pulmonar Obstrutiva Crônica/terapia , Autocuidado/psicologia , Atividades Cotidianas , Idoso , Idoso de 80 Anos ou mais , Cânula , Feminino , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Oxigenoterapia/instrumentação , Doença Pulmonar Obstrutiva Crônica/complicações , Pesquisa Qualitativa , Ensaios Clínicos Controlados Aleatórios como Assunto , Sono , Tecnologia , Trabalho RespiratórioRESUMO
Objective: To explore the observation and nursing of patients with acute mass asphyxia poisoning with pulmonary bullae treated by nasal high-flow humidification and oxygen therapy. Methods: Review and summarize the data of 5 patients with acute mass asphyxial gas poisoning with pulmonary vesicles who were admitted to the department of toxicology of this hospital in June 2019 and received nasal high-flow humidification and oxygen therapy. The oxygenation index, airway humidification and prognosis were observed. Results: All the 5 patients were successfully transferred to nasal catheter for oxygen inhalation after nasal high-flow humidification and orygen therapy without intubation. When discharged from the hospital without oxygen, pH: 7.36-7.42, PO(2):82-106 mmHg, PCO(2):32-39 mmHg. All the white blood cells and myocardial enzymes were normal, and there was no brain injury, perinasal skin damage and abdominal distension. Conclusion: Nasal high-flow humidification and oxygen therapy can effectively improve the efficacy of oxygen therapy for patients with acute mass asphyxial gas poisoning with pulmonary vacuoles.
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Asfixia , Oxigênio , Vesícula , Gasometria , Humanos , OxigenoterapiaRESUMO
Bronchiolitis is a common viral disease that significantly affects infants less than 12â¯months of age. The purpose of this review is to present a review of the current knowledge of the uses of respiratory support in the management of infants with bronchiolitis presenting to hospital. We electronically searched MEDLINE, Cochrane, CINAHL and EMBASE (inception to 25th March 2018), to manually search for clinical trials that address the management strategies for respiratory support of infants with bronchiolitis. We identified 120 papers who met the inclusion criteria, of which 33 papers were relevant for this review with only nine randomized controlled trials. This review demonstrated that non-invasive respiratory support reduced the need for escalation of therapy, particularly the proportion of intubations required for infants with bronchiolitis. Additionally, clear economic benefits have been demonstrated when non-invasive ventilation has been used. The potential early use of non-invasive respiratory supports such as nasal high flow therapy and non-invasive ventilation may have an impact on health care costs and reduction in ICU admissions and intubation rates. High-grade evidence demonstrates safety and quality of high flow therapy in general ward settings.
Assuntos
Bronquiolite Viral/terapia , Pressão Positiva Contínua nas Vias Aéreas/métodos , Ventilação não Invasiva/métodos , Insuficiência Respiratória/terapia , Humanos , Lactente , Recém-Nascido , Intubação Intratraqueal/métodos , Oxigenoterapia/métodos , Respiração Artificial/métodosRESUMO
BACKGROUND AND OBJECTIVE: We hypothesized that by reducing respiratory work and improving gas exchange, nasal high flow (NHF) would improve exercise tolerance in patients with chronic obstructive pulmonary disease (COPD) following respiratory exacerbation. METHODS: This was a monocentric, randomized, controlled crossover study. Patients with severe to very severe COPD carried out two high-intensity constant work-rate exercise tests (CWRET) with and without NHF on two consecutive days. The primary outcome was the mean difference in endurance time between both conditions. The secondary aims included vastus lateralis oxygenation (StO2 ), dyspnoea, leg discomfort, maximal inspiratory pressure (MIP), transcutaneous CO2 pressure (PtcCO2 ), respiratory rate (RR), heart rate (HR) and pulsed O2 saturation (SpO2 ), as well as the patients' opinions of the device. RESULTS: A total of 19 patients were included (mean forced expiratory volume in 1 s = 28.7 ± 10.8%, age = 62.1 ± 9.1 years). No significant differences in endurance time during the CWRET were found between the two test conditions (-66.58 (95% CI: -155.9 to 22.7) s, P = 0.12). StO2 , PtCO2 and HR were reduced at the end of the exercise with NHF (-2.1% (95% CI: -4.3 to -0.0); -1.3 mm Hg (95% CI: -2.5 to -0.2); -2.7 bpm (95% CI: -5.0 to -0.5), respectively, P ≤ 0.05). No significant differences were found for any of the other secondary outcomes. Half of the patients evaluated the device as being moderately to very uncomfortable. CONCLUSION: NHF during exercise did not increase endurance time in patients with COPD following exacerbation. CLINICAL TRIAL REGISTRATION: NCT03058081 at clinicaltrials.gov.
Assuntos
Teste de Esforço/métodos , Tolerância ao Exercício , Oxigenoterapia , Doença Pulmonar Obstrutiva Crônica , Monitorização Transcutânea dos Gases Sanguíneos , Cânula , Estudos Cross-Over , Feminino , Volume Expiratório Forçado , Humanos , Masculino , Pessoa de Meia-Idade , Oxigenoterapia/instrumentação , Oxigenoterapia/métodos , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Doença Pulmonar Obstrutiva Crônica/terapia , Testes de Função Respiratória/métodos , Exacerbação dos Sintomas , Resultado do TratamentoRESUMO
BACKGROUND: There has been increasing interest in transnasal pulmonary aerosol administration, but the dose-response relationship has not been reported. OBJECTIVES: To determine the accumulative bronchodilator dose at which patients with stable mild-to-moderate asthma and chronic obstructive pulmonary disease (COPD) achieve similar spirometry responses before and after bronchodilator tests using albuterol via a metered dose inhaler with a valved holding chamber (MDI + VHC). METHOD: Adult patients who met ATS/ERS criteria for bronchodilator responses in pulmonary function laboratory were recruited and consented to participate. After a washout period, patients received escalating doubling dosages (0.5, 1, 2, and 4 mg) of albuterol in a total volume of 2 mL delivered by vibrating mesh nebulizer via a nasal cannula at 37°C with a flow rate of 15-20 L/min using a Venturi air entrainment device. Spirometry was measured at baseline and after each dose. Titration was stopped when an additional forced expiratory volume in 1 second (FEV1) improvement was <5%. RESULTS: 42 patients (16 males) with stable mild-to-moderate asthma (n = 29) and COPD (n = 13) were enrolled. FEV1 increment after a cumulative dose of 1.5 mg of albuterol via nasal cannula at 15-20 L/min was similar to 4 actuations of MDI + VHC (0.34 ± 0.18 vs. 0.34 ± 0.12 L, p = 0.878). Using ATS/ERS criteria of the bronchodilator test, 33.3% (14/42) and 69% (29/42) of patients responded to 0.5 and 1.5 mg of albuterol, respectively. CONCLUSIONS: With a nasal cannula at 15-20 L/min, transnasal pulmonary delivery of 1.5 mg albuterol resulted in similar bronchodilator response as 4 actuations of MDI + VHC.
Assuntos
Albuterol/administração & dosagem , Asma/tratamento farmacológico , Broncodilatadores/administração & dosagem , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Adulto , Feminino , Humanos , Masculino , Inaladores Dosimetrados , Pessoa de Meia-Idade , EspirometriaRESUMO
BACKGROUND: Aerosol delivery through a nasal high flow (NHF) system is attractive for clinicians as it allows for simultaneous administration of oxygen and inhalable drugs. However, delivering a fine particle fraction (FPF, particle wt. fraction < 5.0 µm) of drugs into the lungs has been very challenging, with highest value of only 8%. Here, we aim to develop an efficient nose-to-lung delivery system capable of delivering improved quantities (FPF > 16%) of dry powder aerosols to the lungs via an NHF system. METHODS: We evaluated the FPF of spray-dried mannitol with leucine with a next generation impactor connected to a nasopharyngeal outlet of an adult nasal airway replica. In addition, we investigated the influence of different dispersion (20-30 L/min) and inspiratory (20-40 L/min) flow rates, on FPF. RESULTS: We found an FPF of 32% with dispersion flow rate at 25 L/min and inspiratory flow rate at 40 L/min. The lowest FPF (21%) obtained was at the dispersion flow rate at 30 L/min and inspiratory flow rate at 30 L/min. A higher inspiratory flow rate was generally associated with a higher FPF. The nasal cannula accounted for most loss of aerosols. CONCLUSIONS: In conclusion, delivering a third of inhalable powder to the lungs is possible in vitro through an NHF system using a low dispersion airflow and a highly dispersible powder. Our results may lay the foundation for clinical evaluation of powder aerosol delivery to the lungs during NHF therapy in humans.
Assuntos
Aerossóis/administração & dosagem , Leucina/administração & dosagem , Manitol/administração & dosagem , Oxigenoterapia/métodos , Pós/administração & dosagem , Administração por Inalação , Cânula , Humanos , Técnicas In Vitro , Modelos Anatômicos , Nebulizadores e Vaporizadores , Tamanho da Partícula , Ventilação PulmonarRESUMO
AIM: This study compared how non-invasive respiratory support (NRS) was provided in neonatal units in Italy and the UK. METHODS: An NRS questionnaire was sent to tertiary neonatal centres, identified by national societies, from November 2015 to May 2016. RESULTS: Responses were received from 49/57 (86%) UK units and 103/115 (90%) Italian units. NRS was started in the delivery room by 61% of UK units and 85% of Italian units. In neonatal intensive care units, 33% of UK units used nasal high-flow therapy (HFT) as primary support, compared to 3% in Italy. Nasal continuous positive airway pressure (CPAP) was used in 57% of UK units and 90% of Italian units. The commonest starting flow rate on nasal HFT for term and preterm infants was 6 L/min in the UK, while Italian units mainly used this flow for term infants. In the UK, 67% of units decreased nasal HFT by 1 L/min per day. In Italy, infants on nasal CPAP were weaned by 1 cm H2 O per day in 39% of units. CONCLUSION: The way that NRS was managed for very preterm infants differed between the UK and Italy, reflecting a lack of evidence on optimal NRS and the use of local protocols.