A change from high-flow to titrated oxygen therapy in the prehospital setting is associated with lower mortality in COPD patients with acute exacerbations: an observational cohort study

Background: The aim of this study was to investigate 30-day mortality for COPD patients treated by ambulances in the period before and after implementation of a pre-hospital oxygen protocol. Methods: Prehospital High-flow oxygen was used from April to September 2012 and titrated oxygen from April to September 2013. Primary outcome was 30-day mortality. Results: 707 patients were included; 209 in the high-flow group and 498 in the titration group. Of these, 56 and 132 arrived with acute exacerbation (AE). Overall 30-day mortality was 11.5% vs. 9.4% (p=0.41), respectively. For patients with AE, it was 19.6% vs. 4.6% (p=0.001). Conclusion: Change of treatment protocol is associated with a lower 30-day mortality for patients registered with acute exacerbation, but not for all COPD patients.

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Prone positioning of patients with moderate hypoxia due to COVID-19: A multicenter pragmatic randomized trial [COVID-PRONE]

10.1101/2021.11.05.21264590 ◽

2021 ◽

Author(s):

Mike Fralick ◽

Michael Colacci ◽

Laveena Munshi ◽

Kevin Venus ◽

Lee Fidler ◽

...

Keyword(s):

Respiratory Failure ◽

Critically Ill ◽

Median Time ◽

Critically Ill Patients ◽

Primary Outcome ◽

Standard Of Care ◽

High Flow ◽

Hospital Death ◽

Prone Positioning ◽

High Flow Oxygen

What is already known on this topic: Prone positioning is considered standard of care for mechanically ventilated patients who have severe acute respiratory distress syndrome. Recent data suggest prone positioning is beneficial for patients with COVID-19 who are requiring high flow oxygen. It is unknown of prone positioning is beneficial for patients not on high flow oxygen. What this study adds: Prone positioning is generally not well tolerated and innovative approaches are needed to improve adherence. Clinical and physiologic outcomes were not improved with prone positioning among hypoxic but not critically ill patients hospitalized with COVID-19. Objectives: To assess the effectiveness of prone positioning to reduce the risk of death or respiratory failure in non-critically ill patients hospitalized with COVID-19 Design: Pragmatic randomized clinical trial of prone positioning of patients hospitalized with COVID-19 across 15 hospitals in Canada and the United States from May 2020 until May 2021. Settings: Patients were eligible is they had a laboratory-confirmed or a clinically highly suspected diagnosis of COVID-19, required supplemental oxygen (up to 50% fraction of inspired oxygen [FiO2]), and were able to independently prone with verbal instruction. (NCT04383613). Main Outcome Measures: The primary outcome was a composite of in-hospital death, mechanical ventilation, or worsening respiratory failure defined as requiring at least 60% FiO2 for at least 24 hours. Secondary outcomes included the change in the ratio of oxygen saturation to FiO2 (S/F ratio). Results: A total of 248 patients were included. The trial was stopped early on the basis of futility for the pre-specified primary outcome. The median time from hospital admission until randomization was 1 day, the median age of patients was 56 years (interquartile range [IQR] 45,65), 36% were female, and 90% of patients were receiving oxygen via nasal prongs at the time of randomization. The median time spent prone in the first 72 hours was 6 hours total (IQR 1.5,12.8) for the prone arm compared to 0 hours (0,2) in the control arm. The risk of the primary outcome was similar between the prone group (18 [14.3%] events) and the standard care group (17 [13.9%] events), odds ratio 0.92 (95% CI 0.44 to 1.92). The change in the S/F ratio after 72 hours was similar for patients randomized to prone compared to standard of care. Conclusion: Among hypoxic but not critically patients with COVID-19 in hospital, a multifaceted intervention to increase prone positioning did not improve outcomes. Adherence to prone positioning was poor, despite multiple efforts. Subsequent trials of prone positioning should aim to develop strategies to improve adherence to awake prone positioning.

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High-flow oxygen nasal cannula for treating acute bronchiolitis in infants: A systematic review and meta-analysis

Medwave ◽

10.5867/medwave.2021.04.8190 ◽

2021 ◽

Vol 21 (04) ◽

pp. e8190-e8190

Author(s):

Fernando Tortosa ◽

Ariel Izcovich ◽

Gabriela Carrasco ◽

Gabriela Varone ◽

Pedro Haluska ◽

...

Keyword(s):

Systematic Review ◽

Confidence Interval ◽

Treatment Failure ◽

Meta Analysis ◽

High Flow ◽

Nasal Cannula ◽

Low Flow ◽

Acute Bronchiolitis ◽

High Flow Oxygen ◽

Flow Group

Introduction Oxygen therapy through a high-flow nasal cannula is thought to improve the work of breathing and the comfort of patients with acute bronchiolitis. It is widely used in hospital wards and critical care of pediatric patients. However, there is uncertainty on the magnitude of the effect on critical and important outcomes in these patients. Objectives The objective of this review is to evaluate the available evidence on the use of oxygen administered through high-flow cannula versus low-flow oxygen for the treatment of acute bronchiolitis in children under two years of age. Methodology We carried out a systematic review and a meta-analysis following the PRISMA standards for reporting. The search was carried out in electronic databases by two researchers independently. The evidence was summarized using the GRADE methodology. Results Six randomized and non-randomized clinical trials were included, including 1867 individuals younger than 24 months of age with acute bronchiolitis in pediatric emergency, hospitalization, and intensive care services. Mortality was not reported in the included studies. Treatment failure occurred in 108/933 in the high flow group and 233/934 in the low flow group (relative risk: 0.46; 95% confidence interval: 0.35 to 0.62), which shows 11.7% less treatment failure (95% confidence interval between 7.9% and 14.5% less) in the high flow group with a number needed to treat of 7.5 (95% confidence interval 6 to 10) with moderate certainty in the evidence. Conclusion The use of humidified and heated oxygen with high flow compared to oxygen at low flow is probably associated with decreased treatment failure in children younger than two years with acute bronchiolitis. There is uncertainty about the effect on hospitalization days and clinical progression.

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First-line oxygen therapy with high-flow in bronchiolitis is not cost saving for the health service

Archives of Disease in Childhood ◽

10.1136/archdischild-2019-318427 ◽

2020 ◽

Vol 105 (10) ◽

pp. 975-980

Author(s):

Vijay S Gc ◽

Donna Franklin ◽

Jennifer A Whitty ◽

Stuart R Dalziel ◽

Franz E Babl ◽

...

Keyword(s):

Cost Saving ◽

Oxygen Therapy ◽

High Flow ◽

First Line ◽

First Line Therapy ◽

Line Therapy ◽

High Flow Oxygen ◽

Flow Group ◽

Intervention Costs ◽

The Cost

BackgroundBronchiolitis is the most common reason for hospital admission in infants. High-flow oxygen therapy has emerged as a new treatment; however, the cost-effectiveness of using it as first-line therapy is unknown.ObjectiveTo compare the cost of providing high-flow therapy as a first-line therapy compared with rescue therapy after failure of standard oxygen in the management of bronchiolitis.MethodsA within-trial economic evaluation from the health service perspective using data from a multicentre randomised controlled trial for hypoxic infants (≤12 months) admitted to hospital with bronchiolitis in Australia and New Zealand. Intervention costs, length of hospital and intensive care stay and associated costs were compared for infants who received first-line treatment with high-flow therapy (early high-flow, n=739) or for infants who received standard oxygen and optional rescue high-flow (rescue high-flow, n=733). Costs were applied using Australian costing sources and are reported in 2016–2017 AU$.ResultsThe incremental cost to avoid one treatment failure was AU$1778 (95% credible interval (CrI) 207 to 7096). Mean cost of bronchiolitis treatment including intervention costs and costs associated with length of stay was AU$420 (95% CrI −176 to 1002) higher per infant in the early high-flow group compared with the rescue high-flow group. There was an 8% (95% CrI 7.5 to 8.6) likelihood of the early high-flow oxygen therapy being cost saving.ConclusionsThe use of high-flow oxygen as initial therapy for respiratory failure in infants with bronchiolitis is unlikely to be cost saving to the health system, compared with standard oxygen therapy with rescue high-flow.

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Poractant Alfa Versus Beractant for Neonatal Respiratory Distress Syndrome: A Retrospective Cost Analysis

The Journal of Pediatric Pharmacology and Therapeutics ◽

10.5863/1551-6776-23.5.367 ◽

2018 ◽

Vol 23 (5) ◽

pp. 367-371

Author(s):

Sara Brown ◽

Jeff Hurren ◽

Heidi Sartori

Keyword(s):

Primary Outcome ◽

Distress Syndrome ◽

Pulmonary Hemorrhage ◽

Length Of Hospital Stay ◽

Medication Cost ◽

Neonatal Respiratory Distress ◽

Before And After ◽

Observational Cohort ◽

Baseline Characteristics ◽

Retrospective Observational Cohort Study

OBJECTIVES The objectives of this study were to determine the average medication cost per patient of poractant alfa and beractant, and to compare the outcomes of treatment with these agents. METHODS We conducted a retrospective, observational, cohort study of patients who received surfactant, before and after an institutional formulary change from beractant to poractant alfa. The primary outcome was the average medication cost per case. Secondary measures were clinical outcomes, including duration of respiratory support, length of hospital stay, and the occurrence of complications. RESULTS A total of 114 patients were enrolled; 38 were treated with poractant alfa and 76 patients were treated with beractant. Baseline characteristics were similar between groups. The average medication cost per patient was $1756.44 ± $1030.06 and $1329.78 ± $705.64 for poractant alfa and beractant, respectively (p = 0.011). Patients treated with poractant alfa had a shorter length of stay (45.0 ± 30.5 days) than patients treated with beractant (65.1 ± 37.1 days) (p = 0.010). Rates of pneumothoraces, pulmonary hemorrhage, necrotizing enterocolitis, intraventricular hemorrhage, and mortality did not differ significantly between groups. CONCLUSIONS We found an unanticipated increase in drug cost with poractant alfa compared to beractant.

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