High Flow Nasal Cannula to Prevent Intubation in ARF

Alexandre Biasi Cavalcanti Director - HCor Research Institute – São Paulo

HCor ICU

BRICNet – Brazilian Intensive Care Network

Conflicts of Interests Disclosure

My institution receives support for clinical trials from Baxter

(donation of IV fluids), Fisher & Paykel (equipment and supplies)

and Bactiguard (funding and catheters).

Objectives

• Efficacy in patients with ARF to avoid intubation• Hypoxemic

• Immunocompromised

• COPD

• Cardiogenic pulmonary edema

Physiologic effects of HFNC compared to conventional O2

• Improved oxygenation

• Increased CO2 clearance

• Less inspiratory effort and work of breathing

• Small positive airway pressure

• Better secretion clearance (proper gas humification & temperature)

• Comfort: communication, less anxiety/claustrophobia

• Lower risk of P-SILI: lower Delta PL, less inhomogeneity (increased FRC)

Objectives

• Efficacy in patients with ARF to avoid intubation• Hypoxemic

• Immunocompromised

• COPD

• Cardiogenic pulmonary edema

N Engl J Med 2015;372:2185-9

FLORALI

313 ICU patients with hypoxemic ARF.

All criteria <3 hours:

• PaO2/FIO2 <300

• Resp rate ≥ 25

• PaCO2 ≤ 45

106 HFNC 96 standard

oxygen

111 standard

oxygen

N Engl J Med 2015;372:2185-9

N Engl J Med 2015;372:2185-9

P for interaction = 0.01

High flow nasal cannula compared with conventional oxygen therapy for acute

hypoxemic respiratory failure: a systematic review and meta-analysis

Intensive Care Med. 2019;45:563-572GRADE quality of evidence: Low (imprecision and ROB)

Objectives

• Efficacy in patients with ARF to avoid intubation• Hypoxemic

• Immunocompromised

• COPD

• Cardiogenic pulmonary edema

Effect of High-Flow Nasal Oxygen vs Standard Oxygen on 28-Day Mortality in Immunocompromised Patients With ARF

776 adults

• Acute respiratory failure

• PaO2 <60mmHg, or SpO2 <90% on room air, or tachypnea >30/min, or labored breathing or respiratory distress;

• AND need for oxygen 6 L/min

• Immunosuppression:• use of long-term (>3 months) or high-dose (>0.5mg/kg/d) steroids,

• use of other immunosuppressant drugs,

• solid organ transplantation

• solid tumor requiring chemotherapy in the last 5 years,

• hematologic malignancy

• primary immune deficiency (AIDS was excluded)

JAMA. 2018; 320 (20): 2099-2107

HFNCConventional O2

Effect of High-Flow Nasal Oxygen vs Standard Oxygen on 28-Day Mortality in Immunocompromised Patients With ARF

JAMA. 2018; 320 (20): 2099-2107

High Flow Nasal Therapy in Immunocompromised Patients with Acute Respiratory Failure: a Systematic Review and Meta-analysis

Cortegiani et al. J Crit Care. 2019;50:250-256.

Need for Invasive MV

Objectives

• Physiology

• Efficacy in patients with ARF to avoid intubation• Hypoxemic

• Immunocompromised

• COPD

• Cardiogenic pulmonary edema

High flow through nasal cannula in exacerbated COPD patients: a systematic review

Pulmonology 2019; epub

5 studies

• 2 parallel RCT

• 3 cross-over RCT

198 patients

High flow through nasal cannula in exacerbated COPD patients: a systematic review

Pulmonology 2019; epub

HFNC vs Low-flow O2 HFNC vs NIV

CO2 ↔️ ↔️

Respiratory

rate↔️ ↔️

Work of

breathing↓ ↔️

Comfort ↔️ or ↑ ↑

Ann Emerg Med. 2018; 72:73-83

204 patients with acute respiratory failure (requiring

NIV) in the emergency department

116 HFNC 112 NIV

104 analyzed 100 analyzed

12 excluded 12 excluded

Ann Emerg Med. 2018; 72:73-83

Ann Emerg Med. 2018; 72:73-83*non-inferiority margin 15%

Objectives

• Physiology

• Efficacy in patients with ARF to avoid intubation• Hypoxemic

• Immunocompromised

• COPD

• Cardiogenic pulmonary edema

HVNI vs NIPPV in the treatment of Acute Decompensated Heart Failure: subgroup analysis of a multi-center trial in the ED

Haywood et al. Am J Emerg Med. 2019. epub

Haywood et al. Am J Emerg Med. 2019. epub

Statistical Plan

Trial adaptive design:

• Allows non-inferiority and superiority decisions to be made at the group level. • Groups can be discontinued – predictive enrichment

• Borrows information about effect size across groups with a hierarchical model.• The hierarchical model allows dynamic borrowing of information

between groups (more borrowing when the groups are consistent).

Intensive Care Med (2015) 41:623–632

Failure of high-flow nasal cannula therapy may delay intubation and increase mortality

Intensive Care Med (2015) 41:623–632

Failure of high-flow nasal cannula therapy may delay intubation and increase mortality

An index combining respiratory rate and oxygenation to

predict outcome of nasal high flow therapy

Am J Respir Crit Care Med 2019;199:1368-76.

ROX =𝑆𝑃𝑂2: 𝐹𝐼𝑂2𝑅𝑒𝑠𝑝 𝑟𝑎𝑡𝑒

An index combining respiratory rate and oxygenation to

predict outcome of nasal high flow therapy

AJRCCM. 2018 epub

Take home messages

• HFNC is possibly superior to conventional oxygen therapy to prevent intubation in acute hypoxemic respiratory failure (maybe also against NIV) and immunocompromised patients

• Initial evidence for hypercapnic COPD suggesting HFNC might be good alternative to NIV

• Little evidence for cardiogenic pulmonary edema

• ROX index is helpful to identify patients who will fail HFNC

Alexandre Biasi Cavalcanti

abiasi@hcor.com.br