Author: Alexander Petti, PGY-2
Background:
- Dyspnea and acute respiratory failure is one of the top 5 reasons patient come to the ED.
- High flow NC, unlike regular NC can provide up to 100% FIO2.
- It also includes a mild distending pressure and improved bentiatoin effusion by way of extrathoracic dead space clearance.
- Evidence has been shown effect in hypoxic respiratory failure, but not in the undifferentiated respiratory failure pt.
Article Reviewed:
- Doshi et al. High Velocity Nasal Insufflation in the treatment of respiratory failure: A randomized clinical trial
Population:
- Undifferentiated respiratory failure in the ED
Clinical Question:
- Assess the ability of high velocity nasal insufflation to support patients with undifferentiated respiratory failure in the ED who require ventilator support, a non-inferiorority trail comparing to NIV PPV
Outcomes:
- Primary:
- Therapy failure at 72 hours
- Secondary:
- Patient tolerabilty,
- Alleviation of distress,
- Time to Intubation,
- Physician perception
- Intervention:
- High Flow NC 35L/M and FIO2 1.0
- Control:
- BIPAP 10/5
- Design:
- Randomized controlled
- Excluded:
- Suspected drug overdose,
- Cardiovascular instability,
- End stage CA,
- Life expectancy less than 6 months,
- GCS <9,
- Cardiac or respiratory arrest on arrival,
- Need for intubation,
- Suspected CVA,
- Suspected STEMI,
- Increased risk for pulmonary aspiration, agitation or uncooperativeness.
Primary Results:
- HFNC non inferior to NIV PPV
Critical Findings:
Strengths:
- Asks a clinically important, patient centered question
- Multicenter, study which increases external validity
- Baseline characteristics were similar between groups
- Reasons for arm failure or intubation well documented
Limitations:
- Cannot blind patient or clinician to treatment arm
- Half of eligible pts not enrolled due to lack of research team
- Non-inferiority trial
- Small overall sample size
- No patient comfort measures
- Did not look at blood gases
- Cross over if arm failure, needed due to safety
Discussion:
- HFNC is non-inferior to to NIV PPV for the ED patients with undifferentiated respiratory failure, with a trend towards less intubations and non-inferior to arm failure.
- Author’s Conclusion:
- “The principal finding of this study demonstrates that high-velocity nasal insufflation is non-inferior to noninvasive positive-pressure ventilation for the treatment of adult ED patients with respiratory failure from various causes. The most meaningful outcome is avoidance of intubation, however, the model also evaluated the failure rate for patients to continue receiving their assigned noninvasive therapy.”
- Our Conclusion:
- This study shows that HFNI is non-inferior to NIVPPV. However, there needs to be a superiority trail or use of specific conditions.
- Potential impact to current practices:
- More use of HFNI instead of NIVPPV
- Or if your patient cannot tolerate NIVPPV, can try HFNC before jumping to intubation