FROM CHEST

In patients with acute respiratory failure, high-flow nasal cannula (HFNC) is more reliable than is conventional oxygen therapy at reducing rates of endotracheal intubation, although no significant difference was found when HFNC was compared with noninvasive positive pressure ventilation, a new study found.

An increasing awareness of the high rate of adverse events and mortality rates associated with invasive mechanical ventilation in hospitals has led to a rise in the use of noninvasive positive pressure ventilation (NIPPV). While this has effectively cut the use of conventional oxygen therapy (COT), its application in clinical practice is limited by a host of complications such as interface intolerance, skin damage, and other hazards. HFNC, because of its demonstrated efficacy and relatively easier application, and better tolerance in patients, also has been gaining popularity. Despite the known benefits HFNC, this therapy is not given to all adults with acute respiratory failure (ARF). This may be due to the lack of consistency in data regarding how HFNC’s effectiveness at decreasing intubation and reintubation rates compares with COT’s and NIPPV’s.

Researchers in China conducted a meta-analysis and systematic review of all superiority and nonsuperiority data on the outcomes of using HFNC, COT, and NIPPV to treat ARF. Their examination included 18 trials comprising 3,881 patients, which compared the results of receiving HFNC with the results of receiving NIPPV or COT. The study is published in CHEST ( 10.1016/j.chest.2017.01.004 ).

The investigators concluded that HFNC was associated with significantly lower rates of the need for endotracheal intubation, compared with COT (P = .01). When HFNC was compared with NIPPV, however, the rates of patients needing intubation were not statistically different from each other (P = .16). HFNC was not associated with significant improvements in mortality rates or lengths of stay in the intensive care units, when compared with both COT and NIPPV.

According to the researchers’ subgroup analysis conducted of HFNC in 2,741 patients following extubation, those patients who received HFNC had a significantly lower reintubation rate than that of those who received COT (OR = 0.39, P = .0003). In this analysis, again, no significant differences in outcomes were seen between patients who received HFNC and NIPPV (OR = 1.07, P = .60)

Bin-Miao Liang, MD, PhD, a researcher in the department of respiratory and critical care medicine at Sichuan University in China, and coauthors noted that “concomitant complications such as acute kidney dysfunction and cardiac impairment may contribute to ICU mortality and ICU [lengths-of-stay] besides respiratory status itself.” Factors such as available beds, a patient’s insurance status, and other resources may also have impacted outcomes, they said.

The researchers wrote that they found “[significant] statistical heterogeneity” in the rates of endotracheal intubation and ICU mortality between HFNC and NIPPV. A lack of raw data, which prevented a subanalysis of individual respiratory failure from being performed, is one possible cause of the statistical heterogeneity, the authors concluded.

China-Japan Friendship Hospital is continuing the search for more data on the success rates of HFNC and NIPPV at reducing intubation and mortality rates. The hospital is sponsoring a multicenter, randomized, noninferiority trial titled, “High Flow Nasal Cannula vs. NPPV in Moderate Chronic Obstructive Pulmonary Disease Exacerbation,” according to ClinicalTrials.gov. No results were available for this trial as of Feb. 6.

None of the authors had relevant disclosures.

wmcknight@frontlinemedcom.com

On Twitter @whitneymcknight

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