Prone Positioning Is Safe and May Reduce the Rate of Intubation in Selected COVID-19 Patients Receiving High-Flow Nasal Oxygen Therapy

Background: Patients with COVID-19 may experience hypoxemic Acute Respiratory Failure (hARF) requiring O2-therapy by High-Flow Nasal Cannula (HFNO). Although Prone Positioning (PP) may improve oxygenation in COVID-19 non-intubated patients, the results on its clinical efficacy are controversial. The present study aims to prospectively investigate whether PP may reduce the need for endotracheal intubation (ETI) in patients with COVID-19 receiving HFNO. Methods: All consecutive unselected adult patients with bilateral lung opacities on chest X-ray receiving HFNO after admission to a SARS-CoV-2 Respiratory Intermediate Care Unit (RICU) were considered eligible. Patients who successfully passed an initial PP trial (success group) underwent PP for periods ≥ 2 h twice a day, while receiving HFNO. The study’s primary endpoint was the intubation rate during the stay in the RICU. Results: Ninety-three patients were included in the study. PP was feasible and safe in 50 (54%) patients. Sixteen (17.2%) patients received ETI and 27 (29%) escalated respiratory support, resulting in a mortality rate of 9/93 (9.7%). The length of hospital stay was 18 (6–75) days. In 41/50 (80%) of subjects who passed the trial and underwent PP, its use was associated with clinical benefit and survival without escalation of therapy. Conclusions: PP is feasible and safe in over 50% of COVID-19 patients receiving HFNO for hARF. Randomized trials are required to confirm that PP has the potential to reduce intubation rate.

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A case of subcutaneous emphysema/mediastinal emphysema during the use of humidified high-flow nasal cannula

JA Clinical Reports ◽

10.1186/s40981-019-0305-3 ◽

2019 ◽

Vol 5 (1) ◽

Cited By ~ 2

Author(s):

Shota Sonobe ◽

Satoki Inoue ◽

Tadashi Nishiwada ◽

Junji Egawa ◽

Masahiko Kawaguchi

Keyword(s):

Subcutaneous Emphysema ◽

Oxygen Therapy ◽

High Flow ◽

Nasal Cannula ◽

High Flow Nasal Cannula ◽

Respiratory Condition ◽

Case Presentation ◽

X Ray ◽

Chest X Ray ◽

High Flows

Abstract Background Heated, humidified, high-flow nasal cannula (HHFNC) oxygen therapy allows optimal humidification of inspired gas at high flows and creates a distending pressure similar to nasal continuous positive airway pressure [1]. It has been safely used in adults with moderate hypoxemia with few complications [2, 3]. Hereby, we report serious complications occurred during HHFNC oxygen therapy. Case presentation A 53-year-old female with hemophagocytic lymphohistiocytosis (HLH) was admitted to the intensive care unit because of respiratory failure. After weaning from mechanical ventilation which lasted for 2 weeks, HHFNC therapy at 40 L/min with an FiO2 of 0.5 was started for hypoxemia. Four days later, dyspnea and hypoxemia occurred and chest X-ray and CT scan revealed localized pneumothorax, subcutaneous emphysema, and massive pneumomediastinum. After cessation of HHFNC, respiratory condition improved. Conclusion Subcutaneous emphysema, pneumothorax, and pneumomediastinum should be notified as a serious complication during HHFNC therapy.

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High-flow nasal cannula oxygen therapy is superior to conventional oxygen therapy but not to noninvasive mechanical ventilation on intubation rate: a systematic review and meta-analysis

Critical Care ◽

10.1186/s13054-017-1760-8 ◽

2017 ◽

Vol 21 (1) ◽

Cited By ~ 38

Author(s):

Huiying Zhao ◽

Huixia Wang ◽

Feng Sun ◽

Shan Lyu ◽

Youzhong An

Keyword(s):

Systematic Review ◽

Mechanical Ventilation ◽

Oxygen Therapy ◽

Meta Analysis ◽

High Flow ◽

Nasal Cannula ◽

Intubation Rate ◽

Noninvasive Mechanical Ventilation ◽

High Flow Nasal Cannula

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High-Flow Nasal Cannula and Prone Positioning in Awake Patients with COVID-19 Related Respiratory Failure: An Observational Study.

10.21203/rs.3.rs-1023023/v1 ◽

2021 ◽

Author(s):

Fekri Abroug ◽

Zeineb Hammouda ◽

Manel Lahmar ◽

Wiem Nouira ◽

Syrine Maatouk ◽

...

Keyword(s):

Logistic Regression ◽

Observational Study ◽

Prone Position ◽

Supine Position ◽

Early Response ◽

High Flow ◽

Nasal Cannula ◽

Youden Index ◽

Prone Positioning ◽

High Flow Nasal Cannula

Abstract Background: We report an observational study on the use of High-flow nasal cannula (HFNC) and awake prone position in patients with Covid-19 related severe ARF.Methods: chart analysis of consecutive patients with confirmed Covid-19 and severe ARF (PaO2/FiO2 ratio <150) who received HFNC. Patients were systematically encouraged to lie in the prone position if tolerated. We calculated initial ROX index (the ratio of SpO2/FIO2 to respiratory rate) while in supine position and at the end of the first HFNC session whether in prone or supine position, and their difference (delta ROX). The success/failure of HFNC (need for intubation) was recorded. Predictors of HFNC failure were identified using ROC curve and logistic regression.Results: HFNC was administered to 213 out of 360 patients with COVID-19 related severe ARF (71% male, median age:59 years (IQR:50-68), median PaO2/FIO2: 104(73-143). At the start of HFNC, median ROX index was 4(3.4-5). Among included patients, 178 (83.5%) could tolerate prone position and had a median of 4.4(2-6) prone sessions during a median of 10(4-16) hours/day each, for a median of 4(2-7) days. Overall, HFNC failure occurred in 61 patients (28.1%) with similar proportions in patients who had HFNC in prone position and in patients who did not tolerate prone position (29% and 26%, respectively; relative risk:1.14. 95%CI:0.62-2.1). In the prediction of HFNC outcome, AUC was highest for delta ROX (AUC=0.83); AUC for baseline ROX (0.71), PaO2/FiO2 (0.73), and SpO2 (0.67), were significantly lower. The delta ROX cut-off ≤1.8 had the best Youden index indicating the best combination of sensitivity (0.89) and specificity (0.61) with a PLR (2.33) and a NLR (0.17) to predict HFNC failure. Logistic regression disclosed the following predictors of HFNC failure: delta ROX: RR=0.44, 95%CI=0.32-0.62; p-0.0001); baseline ROX index: RR=0.58, 95% CI:0.39-0.85, p=0.005); SOFA score (RR=1.6 for each point; 95%CI: 1.1-2.2, p=0.007); and PaO2/FiO2 at admission: RR=0.96, 95%CI=0.94-0.99). Prone position was not related to HFNC success.CONCLUSION: Awake HFNC in prone position is feasible in most patients with severe hypoxemic COVID-19. Indicators of ARF severity and the early response to HFNC, rather than prone position are independently associated with HFNC outcome.

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Use of Dexmedetomidine in Early Prone Positioning Combined With High-Flow Nasal Cannula and Non-Invasive Positive Pressure Ventilation in a COVID-19 Positive Patient

Cureus ◽

10.7759/cureus.10430 ◽

2020 ◽

Author(s):

Elis M Cruz Salcedo ◽

Lyd-Marie Rodriguez ◽

Jay Patel ◽

Andrew R Seevaratnam

Keyword(s):

Positive Pressure Ventilation ◽

High Flow ◽

Nasal Cannula ◽

Positive Patient ◽

Positive Pressure ◽

Prone Positioning ◽

High Flow Nasal Cannula ◽

Non Invasive

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Prone positioning combined with high-flow nasal cannula in severe noninfectious ARDS

Critical Care ◽

10.1186/s13054-020-2821-y ◽

2020 ◽

Vol 24 (1) ◽

Cited By ~ 16

Author(s):

Orlando R. Pérez-Nieto ◽

Manuel A. Guerrero-Gutiérrez ◽

Ernesto Deloya-Tomas ◽

Silvio A. Ñamendys-Silva

Keyword(s):

High Flow ◽

Nasal Cannula ◽

Prone Positioning ◽

High Flow Nasal Cannula

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The Impact of High-Flow Nasal Cannula on the Outcome of Immunocompromised Patients with Acute Respiratory Failure: A Systematic Review and Meta-Analysis

Medicina ◽

10.3390/medicina55100693 ◽

2019 ◽

Vol 55 (10) ◽

pp. 693 ◽

Cited By ~ 4

Author(s):

Cheng ◽

Chang ◽

Wang ◽

Hsiao ◽

Lai ◽

...

Keyword(s):

Respiratory Failure ◽

Acute Respiratory Failure ◽

Meta Analysis ◽

High Flow ◽

Nasal Cannula ◽

Immunocompromised Patients ◽

Intubation Rate ◽

High Flow Nasal Cannula ◽

Control Groups ◽

And Control

Background and objectives: High-flow nasal cannula (HFNC) can be used as a respiratory support strategy for patients with acute respiratory failure (ARF). However, no clear evidence exists to support or oppose HFNC use in immunocompromised patients. Thus, this meta-analysis aims to assess the effects of HFNC, compared to conventional oxygen therapy (COT) and noninvasive ventilation (NIV), on the outcomes in immunocompromised patients with ARF. The Pubmed, Embase and Cochrane databases were searched up to November 2018. Materials and Methods: Only clinical studies comparing the effect of HFNC with COT or NIV for immunocompromised patients with ARF were included. The outcome included the rate of intubation, mortality and length of stay (LOS). Results: A total of eight studies involving 1433 immunocompromised patients with ARF were enrolled. The pooled analysis showed that HFNC was significantly associated with a reduced intubation rate (risk ratio (RR), 0.83; 95% confidence interval (CI), 0.74–0.94, I2 = 0%). Among subgroup analysis, HFNC was associated with a lower intubation rate than COT (RR, 0.86; 95% CI, 0.75–0.95, I2 = 0%) and NIV (RR, 0.59; 95% CI, 0.40–0.86, I2 = 0%), respectively. However, there was no significant difference between HFNC and control groups in terms of 28-day mortality (RR, 0.78; 95% CI, 0.58–1.04, I2 = 48%), and intensive care unit (ICU) mortality (RR, 0.87; 95% CI, 0.73–1.05, I2 = 57%). The ICU and hospital LOS were similar between HFNC and control groups (ICU LOS: mean difference, 0.49 days; 95% CI, −0.25–1.23, I2 = 69%; hospital LOS: mean difference, −0.12 days; 95% CI, −1.86–1.61, I2 = 64%). Conclusions: Use of HFNC may decrease the intubation rate in immunocompromised patients with ARF compared with the control group, including COT and NIV. However, HFNC could not provide additional survival benefit or shorten the LOS. Further large, randomized controlled trials are needed to confirm these findings.

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High-flow nasal cannula oxygen therapy to treat patients with hypoxemic acute respiratory failure consequent to SARS-CoV-2 infection

Thorax ◽

10.1136/thoraxjnl-2020-214993 ◽

2020 ◽

Vol 75 (11) ◽

pp. 998-1000 ◽

Cited By ~ 6

Author(s):

Andrea Vianello ◽

Giovanna Arcaro ◽

Beatrice Molena ◽

Cristian Turato ◽

Andi Sukthi ◽

...

Keyword(s):

Respiratory Failure ◽

Acute Respiratory Failure ◽

High Flow ◽

Nasal Cannula ◽

High Flow Nasal Cannula ◽

C Reactive Protein ◽

Reactive Protein ◽

Non Invasive ◽

Non Invasive Ventilation ◽

Hypoxemic Acute Respiratory Failure

This observational study aims to assess the outcome and safety of O2-therapy by high-flow nasal cannula (HFNC) in 28 consecutive patients with severe hypoxemic acute respiratory failure (hARF) consequent to SARS-CoV-2 infection, unresponsive to conventional O2-therapy. Nineteen patients had a positive response. Nine patients required escalation of treatment to non-invasive ventilation (five subsequently intubated). None of the staff had a positive swab testing during the study period and the following 14 days. Severity of hypoxemia and C reactive protein level were correlated with HFNC failure. These data suggest HFNC to be a safe treatment for less severe patients with SARS-CoV-2 hARF and efficacy will need to be assessed as part of a clinical trial.

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Efficacy of High-flow Nasal Cannula Oxygen Therapy in Patients with Mild Hypercapnia

10.21203/rs.3.rs-616727/v1 ◽

2021 ◽

Author(s):

Lingling Su ◽

Qinyu Zhao ◽

Taotao Liu ◽

Yujun Xu ◽

Weichun Li ◽

...

Keyword(s):

Oxygen Therapy ◽

Medical Information ◽

Characteristic Curve ◽

Predictive Performance ◽

High Flow ◽

Nasal Cannula ◽

Intubation Rate ◽

High Flow Nasal Cannula ◽

Inpatient Hospitalization ◽

Significant Difference

Abstract Objectives: To investigate the indications of high-flow nasal cannula (HFNC) oxygen therapy among patients with mild hypercapnia and to explore the predictors of intubation when HFNC fails.Methods: This retrospective study was conducted based on the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Adult patients with mild hypercapnia (45<PaCO2≤60 mmHg) received either HFNC or noninvasive ventilation (NIV) oxygen therapy. Propensity score matching (PSM) was implemented to increase between-group comparability. The Kaplan-Meier method was used to estimate overall survival and cumulative intubation rates, while 28-day mortality, 48-hour and 28-day intubation rates were compared using the Chi-square test. The predictive performances of HR/SpO2 and the ROX index (the ratio of SpO2/FiO2 to respiratory rate) at 4 hours were assessed regarding HFNC failure, which was determined if intubation was given within 48 hours after the initiation of oxygen therapy. The area under the receiver operating characteristic curve (AUC) for HR/SpO2 and the ROX index were calculated and compared.Results: A total of 524,520 inpatient hospitalization records were screened, 106 patients in HFNC group and 106 patients in NIV group were successfully matched. No significant difference in 48-hour intubation rate between the HFNC group and the NIV group (14.2% vs. 8.5%, P=0.278); patients receiving HFNC had higher 28-day intubation rate (26.4% vs. 14.2%, P=0.029), higher 28-day mortality (17.9% vs. 8.5%, P=0.043), longer ICU length of stay (4.4 vs. 3.3 days, P=0.019), compared to those of NIV group. The AUC of HR/SpO2 at 4 hours after the initiation of HFNC yielded around 0.660 for predicting 48-hour intubation, greater than that of the ROX index with an AUC of 0.589 (P<0.01).Conclusions: HFNC therapy cannot completely replace NIV for patients with mild hypercapnia. As opposed to the ROX index, a modest, yet improved predictive performance is demonstrated using HR/SpO2 in predicting the failure of HFNC among these patients.

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Simple predictive models identify patients with COVID-19 pneumonia and poor prognosis

PLoS ONE ◽

10.1371/journal.pone.0244627 ◽

2020 ◽

Vol 15 (12) ◽

pp. e0244627

Author(s):

Mar Riveiro-Barciela ◽

Moisés Labrador-Horrillo ◽

Laura Camps-Relats ◽

Didac González-Sans ◽

Meritxell Ventura-Cots ◽

...

Keyword(s):

Predictive Models ◽

Poor Prognosis ◽

High Flow ◽

X Ray ◽

Inflammatory Parameters ◽

High Flow Oxygen ◽

Patients At Risk ◽

Chest X Ray ◽

Bootstrap Replication

Background and aims Identification of SARS-CoV-2-infected patients at high-risk of poor prognosis is crucial. We aimed to establish predictive models for COVID-19 pneumonia severity in hospitalized patients. Methods Retrospective study of 430 patients admitted in Vall d’Hebron Hospital (Barcelona) between 03-12-2020 and 04-28-2020 due to COVID-19 pneumonia. Two models to identify the patients who required high-flow-oxygen-support were generated, one using baseline data and another with also follow-up analytical results. Calibration was performed by a 1000-bootstrap replication model. Results 249 were male, mean age 57.9 years. Overall, 135 (31.4%) required high-flow-oxygen-support. The baseline predictive model showed a ROC of 0.800 based on: SpO2/FiO2 (adjusted Hazard Ratio-aHR = 8), chest x-ray (aHR = 4), prior immunosuppressive therapy (aHR = 4), obesity (aHR = 2), IL-6 (aHR = 2), platelets (aHR = 0.5). The cut-off of 11 presented a specificity of 94.8%. The second model included changes on the analytical parameters: ferritin (aHR = 7.5 if ≥200ng/mL) and IL-6 (aHR = 18 if ≥64pg/mL) plus chest x-ray (aHR = 2) showing a ROC of 0.877. The cut-off of 12 exhibited a negative predictive value of 92%. Conclusions SpO2/FiO2 and chest x-ray on admission or changes on inflammatory parameters as IL-6 and ferritin allow us early identification of COVID-19 patients at risk of high-flow-oxygen-support that may benefit from a more intensive disease management.

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