Dataset Information

High-flow nasal cannula oxygen therapy decreases postextubation neuroventilatory drive and work of breathing in patients with chronic obstructive pulmonary disease.

ABSTRACT:

Background

The physiological effects of high-flow nasal cannula O₂ therapy (HFNC) have been evaluated mainly in patients with hypoxemic respiratory failure. In this study, we compared the effects of HFNC and conventional low-flow O₂ therapy on the neuroventilatory drive and work of breathing postextubation in patients with a background of chronic obstructive pulmonary disease (COPD) who had received mechanical ventilation for hypercapnic respiratory failure.

Methods

This was a single center, unblinded, cross-over study on 14 postextubation COPD patients who were recovering from an episode of acute hypercapnic respiratory failure of various etiologies. After extubation, each patient received two 1-h periods of HFNC (HFNC1 and HFNC2) alternated with 1 h of conventional low-flow O₂ therapy via a face mask. The inspiratory fraction of oxygen was titrated to achieve an arterial O₂ saturation target of 88-92%. Gas exchange, breathing pattern, neuroventilatory drive (electrical diaphragmatic activity (EAdi)) and work of breathing (inspiratory trans-diaphragmatic pressure-time product per minute (PTP_DI/min)) were recorded.

Results

EAdi peak increased from a mean (±SD) of 15.4 ± 6.4 to 23.6 ± 10.5 ?V switching from HFNC1 to conventional O₂, and then returned to 15.2 ± 6.4 ?V during HFNC2 (conventional O₂: p?DI/min increased from 135 ± 60 to 211 ± 70 cmH₂O/s/min, and then decreased again during HFNC2 to 132 ± 56 (conventional O₂: p?ConclusionsIn patients with COPD, the application of HFNC postextubation significantly decreased the neuroventilatory drive and work of breathing compared with conventional O₂ therapy.

SUBMITTER: Di Mussi R

PROVIDER: S-EPMC6091018 | biostudies-literature | 2018 Aug

REPOSITORIES: biostudies-literature

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Publications

High-flow nasal cannula oxygen therapy decreases postextubation neuroventilatory drive and work of breathing in patients with chronic obstructive pulmonary disease.

Di Mussi Rosa R Spadaro Savino S Stripoli Tania T Volta Carlo Alberto CA Trerotoli Paolo P Pierucci Paola P Staffieri Francesco F Bruno Francesco F Camporota Luigi L Grasso Salvatore S

Critical care (London, England) 20180802 1

<h4>Background</h4>The physiological effects of high-flow nasal cannula O<sub>2</sub> therapy (HFNC) have been evaluated mainly in patients with hypoxemic respiratory failure. In this study, we compared the effects of HFNC and conventional low-flow O<sub>2</sub> therapy on the neuroventilatory drive and work of breathing postextubation in patients with a background of chronic obstructive pulmonary disease (COPD) who had received mechanical ventilation for hypercapnic respiratory failure.<h4>Meth ...[more]

PMID: 30071876

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Project description:BACKGROUND:Postextubation high-flow nasal cannula (HFNC) is used as a support therapy in high-risk patients in ICU. This study aimed to determine the effects of HFNC therapy on lung recruitment and overdistension assessed by electrical impedance tomography (EIT). METHODS:Twenty-four patients who received HFNC within 24?h after extubation were prospectively enrolled in this study. EIT was used to monitor regional lung ventilation distributions at baseline (conventional oxygen therapy) and three flow rate levels of HFNC therapy (20, 40, and 60?L/min). Change of end-expiratory lung impedance (?EELI), regional recruitment (recruited-pixels) and overdistension (overdistended-pixels), and lung strain change were determined by EIT. EIT images were equally divided into four ventral-to-dorsal horizontal regions of interest (ROIs 1, 2, 3, and 4). "Overdistension-by HFNC" due to HFNC is defined as an increase of overdistened-pixels >?10 than baseline. Patients were divided into two groups: (1) high potential of recruitment (HPR), recruited-pixels >?10 pixels at 60?L/min than baseline, and (2) low potential of recruitment (LPR), recruited-pixels <?10 pixels at 60?L/min than baseline. RESULTS:When the flow rate gradually increased from baseline to 60?L/min, a significant and consistent increasing trend of global ?EELI (%) (p?<?0.0001), recruited-pixels (p?<?0.001), and overdistended-pixels (p?=?0.101) was observed. Moreover, the increase of ?EELI was mainly distributed in ROI2 (p?=?0.001) and ROI3 (p?<?0.0001). The HPR group (13/24 patients) had significantly higher recruited-pixels than the LPR group (11/24 patients) at 20, 40, and 60?L/min. There were no significant differences in PaO2/FiO2, ?EELI (%), and overdistention pixels between the two groups. The HPR group had 13 patients in which no one had "overdistension-by HFNC", and the LPR group had 11 patients in which 4 patients had "overdistension-by HFNC" (0/13 vs. 4/11, p?=?0.017). CONCLUSIONS:Using EIT could identify diverse effects of HFNC on lung regional ventilation in postextubation situations. Further study is required to validate using "HFNC effect" based on lung recruitment and overdistension by EIT in clinical practice. TRIAL REGISTRATION:The study was retrospectively registered at www.clinicaltrials.gov (no. NCT04245241).

Project description:BackgroundOptimal flow settings during high-flow nasal cannula (HFNC) therapy are unknown. We investigated the optimal flow settings during HFNC therapy based on breathing pattern and tidal inspiratory flows in patients with acute hypoxemic respiratory failure (AHRF).MethodsWe conducted a prospective clinical study in adult hypoxemic patients treated by HFNC with a fraction of inspired oxygen (FIO2) ≥ 0.4. Patient's peak tidal inspiratory flow (PTIF) was measured and HFNC flows were set to match individual PTIF and then increased by 10 L/min every 5-10 min up to 60 L/min. FIO2 was titrated to maintain pulse oximetry (SpO2) of 90-97%. SpO2/FIO2, respiratory rate (RR), ROX index [(SpO2/FIO2)/RR], and patient comfort were recorded after 5-10 min on each setting. We also conducted an in vitro study to explore the relationship between the HFNC flows and the tracheal FIO2, peak inspiratory and expiratory pressures.ResultsForty-nine patients aged 58.0 (SD 14.1) years were enrolled. At enrollment, HFNC flow was set at 45 (38, 50) L/min, with an FIO2 at 0.62 (0.16) to obtain an SpO2/FIO2 of 160 (40). Mean PTIF was 34 (9) L/min. An increase in HFNC flows up to two times of the individual patient's PTIF, incrementally improved oxygenation but the ROX index plateaued with HFNC flows of 1.34-1.67 times the individual PTIF. In the in vitro study, when the HFNC flow was set higher than PTIF, tracheal peak inspiratory and expiratory pressures increased as HFNC flow increased but the FIO2 did not change.ConclusionMean PTIF values in most patients with AHRF were between 30 and 40 L/min. We observed improvement in oxygenation with HFNC flows set above patient PTIF. Thus, a pragmatic approach to set optimal flows in patients with AHRF would be to initiate HFNC flow at 40 L/min and titrate the flow based on improvement in ROX index and patient tolerance.Trial registrationClinicalTrials.gov (NCT03738345). Registered on November 13th, 2018. https://clinicaltrials.gov/ct2/show/NCT03738345?term=NCT03738345&draw=2&rank=1.

Project description:ObjectivesTo 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.MethodsThis 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 non-invasive 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 and 48-h and 28-day intubation rates were compared using the Chi-squared test. The predictive performances of HR/SpO2 and the ROX index (the ratio of SpO2/FiO2 to respiratory rate) at 4 h were assessed regarding HFNC failure, which was determined if intubation was given within 48 h 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.ResultsA 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-h intubation rate between the HFNC group (the treatment group) and the NIV group (the control 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), and 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 h after the initiation of HFNC yielded around 0.660 for predicting 48-h intubation, greater than that of the ROX index with an AUC of 0.589 (p < 0.01).ConclusionPatients with impending respiratory failure had lower intubation rate, shorter ICU length of stay, and lower mortality when treated mild hypercapnia with NIV over HFNC. 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.

Dataset Information

High-flow nasal cannula oxygen therapy decreases postextubation neuroventilatory drive and work of breathing in patients with chronic obstructive pulmonary disease.

Background

Methods

Results

Publications

High-flow nasal cannula oxygen therapy decreases postextubation neuroventilatory drive and work of breathing in patients with chronic obstructive pulmonary disease.

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