High Flow Nasal Oxygen for Severe Hypoxemia: Oxygenation Response and Outcome in COVID-19 Patients

Abstract Background Critically ill patients with obesity may have an increased risk of difficult intubation and subsequent severe hypoxemia. We hypothesized that pre-oxygenation with noninvasive ventilation before intubation as compared with high-flow nasal cannula oxygen may decrease the risk of severe hypoxemia in patients with obesity. Methods Post hoc subgroup analysis of critically ill patients with obesity (body mass index ≥ 30 kg·m−2) from a multicenter randomized controlled trial comparing preoxygenation with noninvasive ventilation and high-flow nasal oxygen before intubation of patients with acute hypoxemic respiratory failure (PaO2/FiO2 < 300 mm Hg). The primary outcome was the occurrence of severe hypoxemia (pulse oximetry < 80%) during the intubation procedure. Results Among the 313 patients included in the original trial, 91 (29%) had obesity with a mean body mass index of 35 ± 5 kg·m−2. Patients with obesity were more likely to experience an episode of severe hypoxemia during intubation procedure than patients without obesity: 34% (31/91) vs. 22% (49/222); difference, 12%; 95% CI 1 to 23%; P = 0.03. Among patients with obesity, 40 received preoxygenation with noninvasive ventilation and 51 with high-flow nasal oxygen. Severe hypoxemia occurred in 15 patients (37%) with noninvasive ventilation and 16 patients (31%) with high-flow nasal oxygen (difference, 6%; 95% CI − 13 to 25%; P = 0.54). The lowest pulse oximetry values during intubation procedure were 87% [interquartile range, 77–93] with noninvasive ventilation and 86% [78–92] with high-flow nasal oxygen (P = 0.98). After multivariable analysis, factors independently associated with severe hypoxemia in patients with obesity were intubation difficulty scale > 5 points and respiratory primary failure as reason for admission. Conclusions Patients with obesity and acute hypoxemic respiratory failure had an increased risk of severe hypoxemia during intubation procedure as compared to patients without obesity. However, preoxygenation with noninvasive ventilation may not reduce this risk compared with high-flow nasal oxygen. Trial registration Clinical trial number: NCT02668458 (http://www.clinicaltrials.gov)

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Effects of high-flow oxygen therapy on patients with hypoxemia after extubation and predictors of reintubation: a retrospective study based on the MIMIC-IV database

BMC Pulmonary Medicine ◽

10.1186/s12890-021-01526-2 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Taotao Liu ◽

Qinyu Zhao ◽

Bin Du

Keyword(s):

Mechanical Ventilation ◽

Treatment Group ◽

Medical Information ◽

Characteristic Curve ◽

Oxygenation Index ◽

High Flow ◽

Control Group ◽

Severe Hypoxemia ◽

High Flow Oxygen ◽

Weaning Failure

Abstract Background To investigate the indications for high-flow nasal cannula oxygen (HFNC) therapy in patients with hypoxemia during ventilator weaning and to explore the predictors of reintubation when treatment fails. Methods Adult patients with hypoxemia weaning from mechanical ventilation were identified from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. The patients were assigned to the treatment group or control group according to whether they were receiving HFNC or non-invasive ventilation (NIV) after extubation. The 28-day mortality and 28-day reintubation rates were compared between the two groups after Propensity score matching (PSM). The predictor for reintubation was formulated according to the risk factors with the XGBoost algorithm. The areas under the receiver operating characteristic curve (AUC) was calculated for reintubation prediction according to values at 4 h after extubation, which was compared with the ratio of SpO2/FiO2 to respiratory rate (ROX index). Results A total of 524,520 medical records were screened, and 801 patients with moderate or severe hypoxemia when undergoing mechanical ventilation weaning were included (100 < PaO2/FiO2 ≤ 300 mmHg), including 358 patients who received HFNC therapy after extubation in the treatment group. There were 315 patients with severe hypoxemia (100 < PaO2/FiO2 ≤ 200 mmHg) before extubation, and 190 patients remained in the treatment group with median oxygenation index 166[157,180] mmHg after PSM. There were no significant differences in the 28-day reintubation rate or 28-day mortality between the two groups with moderate or severe hypoxemia (all P > 0.05). Then HR/SpO2 was formulated as a predictor for 48-h reintubation according to the important features predicting weaning failure. According to values at 4 h after extubation, the AUC of HR/SpO2 was 0.657, which was larger than that of ROX index (0.583). When the HR/SpO2 reached 1.2 at 4 h after extubation, the specificity for 48-h reintubation prediction was 93%. Conclusions The treatment effect of HFNC therapy is not inferior to that of NIV, even on patients with oxygenation index from 160 to 180 mmHg when weaning from ventilator. HR/SpO2 is more early and accurate in predicting HFNC failure than ROX index.

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Epoprostenol Delivered via High Flow Nasal Cannula for ICU Subjects with Severe Hypoxemia Comorbid with Pulmonary Hypertension or Right Heart Dysfunction

Pharmaceutics ◽

10.3390/pharmaceutics11060281 ◽

2019 ◽

Vol 11 (6) ◽

pp. 281 ◽

Cited By ~ 7

Author(s):

Jie Li ◽

Lauren J. Harnois ◽

Bethelhem Markos ◽

Keith M. Roberts ◽

Salma Al Homoud ◽

...

Keyword(s):

Pulmonary Hypertension ◽

High Flow ◽

Nasal Cannula ◽

Apache Ii Score ◽

High Flow Nasal Cannula ◽

Severe Hypoxemia ◽

Right Heart ◽

Heart Dysfunction ◽

Institutional Review ◽

Right Heart Dysfunction

Inhaled epoprostenol (iEPO) has been utilized to improve oxygenation in mechanically ventilated subjects with severe hypoxemia, but the evidence for iEPO via high-flow nasal cannula (HFNC) is rare. Following approval by the institutional review board, this retrospective cohort study evaluated subjects who received iEPO via HFNC for more than 30 min to treat severe hypoxemia comorbid with pulmonary hypertension or right heart dysfunction between July 2015 and April 2018. A total of 11 subjects were enrolled in the study of whom 4 were male (36.4%), age 57.5 ± 22.1 years, and APACHE II score at ICU admission was 18.5 ± 5.7. Ten subjects had more than three chronic heart or lung comorbidities; seven of them used home oxygen. After inhaling epoprostenol, subjects’ SpO2/FIO2 ratio improved from 107.5 ± 26.3 to 125.5 ± 31.6 (p = 0.026) within 30–60 min. Five subjects (45.5%) had SpO2/FIO2 improvement >20%, which was considered as a positive response. Heart rate, blood pressure, and respiratory rate were not significantly different. Seven subjects did not require intubation, and seven subjects were discharged home. This retrospective study demonstrated the feasibility of iEPO via HFNC in improving oxygenation. Careful titration of flow while evaluating subjects’ response may help identify responders and avoid delaying other interventions. This study supports the need for a larger prospective randomized control trial to further evaluate the efficacy of iEPO via HFNC in improving outcomes.

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Effects of high-flow oxygen therapy on patients with hypoxemia after extubation and predictors of reintubation: a retrospective study based on the MIMIC-IV database

10.21203/rs.3.rs-133541/v1 ◽

2020 ◽

Author(s):

Taotao Liu ◽

Qinyu Zhao ◽

Bin Du

Keyword(s):

Mechanical Ventilation ◽

Treatment Group ◽

Medical Information ◽

Characteristic Curve ◽

Oxygenation Index ◽

High Flow ◽

Control Group ◽

Severe Hypoxemia ◽

High Flow Oxygen ◽

Weaning Failure

Abstract Purpose To investigate the indications for high-flow nasal cannula oxygen (HFNC) therapy in patients with hypoxemia during ventilator weaning and to explore the predictors of reintubation when treatment fails. Methods Adult patients with hypoxemia weaning from mechanical ventilation were identified from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. The patients were assigned to the treatment group or control group according to whether they were receiving HFNC or non-invasive ventilation (NIV) after extubation. The 28-day mortality and 28-day reintubation rates were compared between the two groups after Propensity score matching (PSM). The predictor for reintubation was formulated according to the risk factors with the XGBoost algorithm. The areas under the receiver operating characteristic curve (AUC) was calculated for reintubation prediction according to values at 4 hours after extubation, which was compared with the ratio of SpO2/FiO2 to respiratory rate (ROX index). Results A total of 524520 medical records were screened, and 801 patients with moderate or severe hypoxemia when undergoing mechanical ventilation weaning were included (100 < PaO2/FiO2 ≤ 300 mmHg), including 358 patients who received HFNC therapy after extubation in the treatment group. There were 315 patients with severe hypoxemia (100 < PaO2/FiO2 ≤ 200 mmHg) before extubation, and 190 patients remained in the treatment group with median oxygenation index 166[157,180] mmHg after PSM. There were no significant differences in the 28-day reintubation rate or 28-day mortality between the two groups with moderate or severe hypoxemia (all P > 0.05). Then HR/SpO2 was formulated as a predictor for 48-hour reintubation according to the important features predicting weaning failure. According to values at 4 hours after extubation, the AUC of HR/SpO2 was 0.657, which was larger than that of ROX index (0.583). When the HR/SpO2 reached 1.2 at 4 hours after extubation, the specificity for 48-hour reintubation prediction was 93%. Conclusions The treatment effect of HFNC therapy is not inferior to that of NIV, even on patients with oxygenation index from 160 to 180 mmHg when weaning from ventilator. HR/SpO2 is more early and accurate in predicting HFNC failure than ROX index.

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Interhospital transfer of COVID-19 patients treated with high-flow nasal oxygen therapy

International Journal of Emergency Medicine ◽

10.1186/s12245-021-00385-2 ◽

2021 ◽

Vol 14 (1) ◽

Author(s):

Elophe Dubie ◽

François Morin ◽

Dominique Savary ◽

Amaury Serruys ◽

Pascal Usseglio

Keyword(s):

Intensive Care ◽

Prospective Observational Study ◽

Care Service ◽

High Flow ◽

High Flow Nasal Cannula ◽

Severe Hypoxemia ◽

Interhospital Transfer ◽

Early Intubation ◽

Second Wave ◽

Very High

AbstractAt the start of the COVID-19 pandemic, early intubation was recommended on the basis of worldwide observations of severe hypoxemia. However, some patients were ultimately able to benefit from high-flow nasal cannula (HFNC) and thus avoid intubation. During the “second wave” (September to December 2020 in France), some emergency departments implemented HFNC in patients with severe COVID-19. The question then arose regarding the transfer of these most serious patients to intensive care units (ICU) and of the respiratory modalities to be used during this transfer. To assess the feasibility of interhospital transfers of COVID-19 patients needing HFNC, we conducted a bi-centric prospective observational study of all medical transfers of patients needing HFNC with the Chambéry and Angers (France) mobile emergency and intensive care service (SMUR) during the “second wave” of the COVID-19 pandemic in France. Analysis of these 42 patients showed no significant variation in the respiratory requirements during the transfer. Overall, 52% of patients were intubated during their stay in ICU, including three patients intubated before or during transfer. Interhospital transfer with HFNC is very high-risk, and intubation remains indicated in the most unstable patients. However, 48% of patients benefited from HFNC and were thus able to avoid intubation during their transfer and ICU stay; for these patients, intubation would probably have been indicated in the absence of available HFNC techniques.

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Prone positioning in high-flow nasal cannula for COVID-19 patients with severe hypoxemia: a pilot study

Annals of Translational Medicine ◽

10.21037/atm-20-3005 ◽

2020 ◽

Vol 8 (9) ◽

pp. 598-598 ◽

Cited By ~ 5

Author(s):

Guo-Wei Tu ◽

You-Xia Liao ◽

Qing-Yun Li ◽

Hui Dong ◽

Lu-Yu Yang ◽

...

Keyword(s):

Pilot Study ◽

High Flow ◽

Nasal Cannula ◽

Prone Positioning ◽

High Flow Nasal Cannula ◽

Severe Hypoxemia

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Comparison of hypoxemia, intubation procedure, and complications for non-invasive ventilation against high-flow nasal cannula oxygen therapy for patients with acute hypoxemic respiratory failure: a non-randomized retrospective analysis for effectiveness and safety (NIVaHIC-aHRF)

BMC Emergency Medicine ◽

10.1186/s12873-021-00402-w ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Chao Zhang ◽

Min Ou

Keyword(s):

Respiratory Failure ◽

Oxygen Therapy ◽

High Flow ◽

Severe Hypoxia ◽

Invasive Ventilation ◽

Severe Hypoxemia ◽

Non Invasive ◽

Non Invasive Ventilation ◽

High Flow Oxygen ◽

Intubation Procedure

Abstract Background Optimization of preoxygenation procedure can help to secure the method of intubation by reducing the risks of severe hypoxemia and other problems. There is confusion for efficacy of non-invasive ventilation compared to high-flow oxygen therapy regarding occurrence of severe hypoxemia during the intubation procedure. The purpose of the study was to compare the difference between noninvasive ventilation and high flow oxygen therapy to prevent desaturation during laryngoscopy. Methods Patients underwent high-flow nasal cannula oxygen therapy (HCO cohort, n = 161) or non-invasive ventilation procedure (NIV cohort, n = 154) for oxygenation and ventilation due to acute hypoxemic respiratory failure in the intensive care unit. Data before preoxygenation, preoxygenation, intubation, laryngoscopy, and complications of patients due to tracheal intubation were retrospectively collected and analyzed. Results There was no difference between both cohorts for the demographical and clinical conditions of the patients before preoxygenation (p > 0.05 for all parameters), numbers of patients with severe hypoxia during the intubation procedure (35 vs. 45, p = 0.303), the time duration of laryngoscopy (p = 0.847), number of laryngoscopies attempts (p = 0.804), and immediate and late complications during the intubation procedure. The values of pulse oximetry were reported higher for patients of NIV cohort than those of HCO cohort during preoxygenation. Fewer numbers of patients were reported with severe hypoxia among patients of the NIV cohort than those of the HCO cohort (24 vs., 40, p = 0.042) who have moderate-to-severe hypoxemia (partial pressure of arterial oxygen to fraction of inspired oxygen ratio ≤ 200 mmHg) before preoxygenation. The most common complications were hypertension, pulmonary aspiration, and increased 30-day mortality. Conclusions When compared, there was no difference between non-invasive ventilation technique and high-flow oxygen therapy to minimize severe hypoxia prior to laryngoscopy and endotracheal intubation in patients with acute respiratory failure.

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A Rationale for Use of High Flow Nasal Cannula for Select Patients With Suspected or Confirmed Severe Acute Respiratory Syndrome Coronavirus-2 Infection

Journal of Intensive Care Medicine ◽

10.1177/0885066620956630 ◽

2020 ◽

Vol 36 (1) ◽

pp. 9-17

Author(s):

Dante A. Suffredini ◽

Michael G. Allison

Keyword(s):

Respiratory Failure ◽

Healthcare Workers ◽

High Flow ◽

Nasal Cannula ◽

The Novel ◽

High Flow Nasal Cannula ◽

Severe Hypoxemia ◽

Hypoxemic Respiratory Failure ◽

Viral Particles ◽

High Concentrations

Infection with the novel 2019 coronavirus (SARS-CoV-2) is associated with the development of a viral pneumonia with severe hypoxemia and respiratory failure. In many cases these patients will require mechanical ventilation; but in others the severity of disease is significantly less and may not need invasive support. High flow nasal cannula (HFNC) is a widely used modality of delivering high concentrations of oxygen and airflow to patients with hypoxemic respiratory failure, but its use in patients with SARS-CoV-2 is poorly described. Concerns with use of HFNC have arisen including aerosolization of viral particles to healthcare workers (HCW) to delaying intubation and potentially worsening of outcomes. However, use of HFNC in other coronavirus pandemics and previous experimental evidence suggest HFNC is low risk and may be effective in select patients infected with SARS-CoV-2. With the significant increase in resource utilization in care of patients with SARS-CoV-2, identification of those that may benefit from HFNC allowing allocation of ventilators to those more critically ill is of significant importance. In this manuscript, we review pertinent literature regarding the use of HFNC in the current SARS-CoV-2 pandemic and address many concerns regarding its use.

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Effects of high-flow oxygen therapy on patients with hypoxemia after extubation and predictors of reintubation: a retrospective study based on the MIMIC-IV database

10.21203/rs.3.rs-133541/v2 ◽

2021 ◽

Author(s):

Taotao Liu ◽

Qinyu Zhao ◽

Bin Du

Keyword(s):

Mechanical Ventilation ◽

Treatment Group ◽

Medical Information ◽

Characteristic Curve ◽

Oxygenation Index ◽

High Flow ◽

Control Group ◽

Severe Hypoxemia ◽

High Flow Oxygen ◽

Weaning Failure

Abstract Purpose: To investigate the indications for high-flow nasal cannula oxygen (HFNC) therapy in patients with hypoxemia during ventilator weaning and to explore the predictors of reintubation when treatment fails.Methods: Adult patients with hypoxemia weaning from mechanical ventilation were identified from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. The patients were assigned to the treatment group or control group according to whether they were receiving HFNC or non-invasive ventilation (NIV) after extubation. The 28-day mortality and 28-day reintubation rates were compared between the two groups after Propensity score matching (PSM). The predictor for reintubation was formulated according to the risk factors with the XGBoost algorithm. The areas under the receiver operating characteristic curve (AUC) was calculated for reintubation prediction according to values at 4 hours after extubation, which was compared with the ratio of SpO2/FiO2 to respiratory rate (ROX index).Results: A total of 524520 medical records were screened, and 801 patients with moderate or severe hypoxemia when undergoing mechanical ventilation weaning were included (100<PaO2/FiO2≤300 mmHg), including 358 patients who received HFNC therapy after extubation in the treatment group. There were 315 patients with severe hypoxemia (100<PaO2/FiO2≤200 mmHg) before extubation, and 190 patients remained in the treatment group with median oxygenation index 166[157,180] mmHg after PSM. There were no significant differences in the 28-day reintubation rate or 28-day mortality between the two groups with moderate or severe hypoxemia (all P>0.05). Then HR/SpO2 was formulated as a predictor for 48-hour reintubation according to the important features predicting weaning failure. According to values at 4 hours after extubation, the AUC of HR/SpO2 was 0.657, which was larger than that of ROX index (0.583). When the HR/SpO2 reached 1.2 at 4 hours after extubation, the specificity for 48-hour reintubation prediction was 93%. Conclusions: The treatment effect of HFNC therapy is not inferior to that of NIV, even on patients with oxygenation index from 160 to 180 mmHg when weaning from ventilator. HR/SpO2 is more early and accurate in predicting HFNC failure than ROX index.

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