High-Flow Nasal Cannula for Avoiding Intubation?

 

Citation: Ni YN, Luo J, Yu H, et al. Can high-flow nasal cannula reduce the rate of endotracheal intubation in adult patients with acute respiratory failure compared with conventional oxygen therapy and noninvasive positive pressure ventilation? A systematic review and meta-analysis. Chest. 2017

 

What We Already Know: High flow nasal cannula (HFNC) may be beneficial in hypoxemic respiratory failure and is well-tolerated. A meta-analysis by Monro-Somerville et al has compared HFNC and usual care (i.e. nasal cannula or non-invasive ventilation) to find no difference in mortality or intubation.1 Furthermore, HFNC improves dyspnea and comfort scores.

 

Why This Study is Important: Current practice in the ED is to consider techniques of delayed sequence intubation (DSI) to enable tolerance of non-invasive ventilation (NIV). This meta-analysis provides a non-inferiority analysis evaluating intubation rates, length of stay and mortality comparing HFNC and NIV. Though the etiology of respiratory failure was not known in the raw data, the non-inferiority analysis of the study show how HFNC may be beneficial in acute respiratory failure when NIV is not tolerated.

 

Brief Overview: In 18 studies comparing HFNC alone with NIV or conventional oxygen therapy (COT), a total of 3,881 patients (from a variety of practice environments) were analyzed for differences in intubation, ICU mortality, and length of stay. Between HFNC and NIV, no statistically significant difference was found for ICU mortality and intubation rates; however, there was significant statistical heterogeneity.

 

Limitations: There was significant heterogeneity possibly secondary to the lack of raw information; specifically, there was not data on the underlying cause of the respiratory failure. The study populations varied and included perioperative or cardiothoracic surgery patients in addition to ED patients. Furthermore, blinding interventions is obviously difficult to perform.

 

Take Home Points: Despite significant heterogeneity, the analysis found that HFNC had benefit in avoiding intubation compared to COT. No difference was found in intubation rates when comparing HFNC and NIV. It may be worth an attempt at high flow nasal cannula to avoid intubation rather than conventional oxygen therapy in patients not able to tolerate NIV.

 

Thanks to Zack Kuschner for the academic discussion on the topic and to Jackie Paulis for the artistic inspiration. Happy St. Patrick’s Day!

 

References

  1. Monro-Somerville T, Sim M, Ruddy J, Vilas M, Gillies MA. The Effect of High-Flow Nasal Cannula Oxygen Therapy on Mortality and Intubation Rate in Acute Respiratory Failure: A Systematic Review and Meta-Analysis. Crit Care Med. 2017;45(4):e449-e456.