HFNC vs. BVM for Pre-oxygenation prior to intubation

A sentinel event is one where, amongst other different outcomes, leads to death. In critical care, anesthesia, and emergency medicine, we often deal with emergent airways on patients who are on the brink of death unless we intervene expediently. Despite having performed many intubations in my young career, I have the utmost respect for every airway. Any one of them can become at catastrophe at any time. If you're not prepared and thinking two steps ahead, you're honestly not adequately trained. If you haven't been burned before, you have not performed sufficient procedures to truly be proficient. Please don't take offense by that, it's just the name of the game. In residency I made sure to hunt down every single airway possible. In med school I hung out with the anesthesiologists to attempt to intubate their patients prior to surgery. Some of the ED attendings during residency had my number and would page/text me to perform the procedure to provide me with more experience. In fellowship I would love to tag along with the anesthesia residents on the "airway team" and go intubate patients throughout the hospital.

A way to mitigate the risk of patient demise is to attempt to pre-oxygenate your patients as much as possible prior to intubation. There are many strategies to do this, a NRB, BVM, NIV, and HFNC which will all deliver 100% FiO2. A regular nasal cannula won't really cut it on the sick patients. Remember, one needs to be prepared for catastrophe to occur on EVERY AIRWAY. This RCT from 2015 which is completely free compared in 40 pts the strategy of pre-oxygenating the patients with either HFNC of BVM prior to intubation. There were largely no significant differences between the two groups in their outcomes, but they did find one significant difference that really caught my eye. The SpO2 dropped significantly in the one minute of apnea after induction in the group that was preoxygenated with the BVM (p=0.001). Sure, that didn't change the outcomes overall in these 40 patients which is admittedly a small sample size, but it only takes one airway to become a true disaster where the patient develops anoxic brain injury or even dies during the intubation due to hypoxia. That would be a sentinel event that will keep you up at night. I do not wish that on anyone. Please be careful with your airway out there. The most important skill is knowing how to bag your patient. You should also be trained in how to cut the neck so that when it does happen, and I wish you never have to go through this yourself, you don't freeze.

-EJ



Link to Article

FREE FULL PDF

Simon M, Wachs C, Braune S, Heer G de, Frings D, Kluge S. High-flow nasal cannula versus bag-valve-mask for preoxygenation before intubation in subjects with hypoxemic respiratory failure. Respiratory Care 2016;61:1160–7.

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HFNC: Does it Ventilate COPD Patients?

I've reviewed numerous mechanisms of action and functions of High Flow Nasal Cannula (HFNC) but I haven't touch on whether or not it works to help ventilate patients. I have discussed in the mechanisms of action that it does wash out the CO2 from the dead space in the nasopharynx, oropharynx, etc, but does that show a numerical decrease in the PCO2? The studies I had reviewed prior to this one weren't promising. 

One of the indirect ways that HFNC can bring down CO2 is by bringing down the patients respiratory rate. There's plenty of data to support the decrease in the respiratory rate. Since the person isn't breathing as hard nor as fast, less CO2 is produced. Less CO2 is produced means the patients needs to be ventilated less. Things get better. Prior to this study, though, the data just wasn't there to show that this actually happened in a statistically significant way. I've said this before and I'll say this again, I will not recommend HFNC to a patient with a COPD patient sucking wind in the ED with an exacerbation that has a gas that looks like 7.06/96/66. That patient either needs some non-invasive ventilation with a very close eye or the endotracheal tube.

In this study they placed COPD patients, not in exacerbation, on HFNC and measured a number of parameters but you and I are here for the CO2. Patients had their PCO2 measured at baseline, on 20L HFNC, and at 30L HFNC. At 20L the PCO2 was at approximately 91 (plus or minus 6.7)% of their baseline and at 30L their PCO2 was at approximately 87.4 (plus or minus 6.2) % of their baseline. That data was statistically significant.

This may be completely out of bounds but if we can (although I probably shouldn't) extrapolate that to a patient with a PCO2 of 60, 20L should bring them down to approximately 54.6 and 30L down to 52.4. Something is better than nothing and if you can hold the patient over while they get their steroids and nebulizations, it may be worth a try in the real world.

- EJ



Bräunlich J, Köhler M, Wirtz H. Nasal highflow improves ventilation in patients with COPD. International Journal of Chronic Obstructive Pulmonary Disease. 2016;1077-1085.

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High Flow Nasal Cannula in Acute Decompensated Heart Failure data leaves much to be desired.

Fortunately in the critical ill population, we do not necessarily have to abide by the saying that "if all you have is a hammer, everything looks like a nail". What I'm referring to is regarding utilizing high-flow nasal cannula in acute heart failure exacerbations. I already dissected how HFNC generated a "PEEP" equivalent airway pressure and the data behind that statement. The amount of PEEP varies and it drops by a statistically significant difference if the patient has their mouth open. If a patient presents to the emergency department, or someone gets overzealous with maintenance fluids, with an acute heart failure exacerbation, there is data that I will be reviewing here where HFNC is an option. But let's be honest with ourselves, though, non-invasive ventilation (colloquially known as BiPAP, although CPAP has data for working as well) is the better option because it provides positive airway pressure more reliably that HFNC. Sometimes these patients just need the ventilator as well. All three studies are FREE that I am going to be reviewing here and I recommend you read them for yourself rather than trusting my takedown of them. That's your disclaimer.

The first study published in 2011 out of Spain was a look at just 5 patients. I know, don't fall off of your seat. I can't criticize because I don't do any research outside of read other peoples research. One needs to remember that in 2011 the HFNC systems were not readily available for historical context. These 5 patients were treated in the emergency department with NIV and then I guess they were diuresed aggressively there. Why do I guess? Well the study does not report the BNP nor the achieved diuresis in these 5 patients. Big weakness in the study. They looked at a multitude of parameters that would be standard for a study of this nature, i.e. to see if HFNC is better than the other oxygen devices, but there are big problems. You see, the authors looked at the parameters before HFNC and then 24 hours AFTER HFNC. What they don't say is how much the patients were diuresed in the interim. Of course the PaO2 is going to improve. Of course the dyspnea is going to improve. Of course the respiratory rate is going to improve! Anyway, this is a study worth sticking in our back pockets to know it happened and move forward.

The second study by Roca also out of Spain in 2013 wanted to assess if HFNC helped with the hemodynamic parameters. They hypothesized that HFNC in patients with heart failure could be associated with a decrease in preload without changing the cardiac output. To look at this, patients got sequential echo's to assess cardiac function. Pretty good setup if you ask me. The 10 patients enrolled in this study were all stable. Therefore the data needs to be extrapolated to the sick patients. They did a baseline TTE on these patients, then hooked them up to the HFNC system at 20L, checked an echo, then at 40L of flow, and checked an echo. They did all sort of echocardiographic wizardry to obtain their results. They found that HFNC may be associated with a decrease in preload justified by the lack of IVC collapse on inspiration without any changes to cardiac function. IVC measurements are their own can of worms when used for resuscitation but this is very standardized and methodical. The most interesting finding that I enjoyed was the decrease in respiratory rate noted by these patients. At baseline, their RR was 23 breaths per minute. At 20L this fell to 17 bpm. At 40L this fell to 13 bpm. Cool stuff! Note that the patients were receiving just flow in this study as the FiO2 was set to 21% (room air). The authors chose to not use patients in acute decompensated heart failure for this study as there would have been too much variability in the subjects themselves along with their responses to the treatments interfering with to the measures. Obviously if they dump out a liter due to furosemide their hemodynamic parameters are going to change and it'll mask out the effect of the HFNC or provide confounders.

The third and last study I'm going to share with you all today comes from our colleagues in South Korea who performed a retrospective cohort analysis where patients were divided into a HFNC group or an intubation group after oxygenation with a facemask at a flow rate of 10L/min or more. These authors jumped on the opportunity to look at this data as they hadn't seen any published data about using HFNC in patients with acute heart failure exacerbations. They looked at approximately 5 years of data to place 73 patients in the intubation group and 76 patients in the HFNC group. Since this was a retrospective study, the decision as to what arm the patients fell in was at the discretion of the physician at bedside. The authors are just looking back in time at why they decided to do it and how the patients did. It seems as if they ignored the NIV data. I could be wrong. The baseline characteristics of the two arms were similar with nothing too eye catching. These patients were looked at for 6 hours. There were no statistically significant changes in the physiologic responses between the two groups. There was also no difference in the clinical outcomes between the two groups. This oddly, in my opinion, includes vasopressor/ionotrope use. I mention this because patients who are intubated typically have sedation. Also, the medications utilized for intubation could have an effect on hemodynamic parameters that are not noted here. It's just something that, from a personal experience standpoint, has me a bit curious. The p-value for that is 0.051. If the sample size would've been larger, I'm sure that would've been a notable difference. The authors noted all these limitations to their study and agree that what we really need is a prospective, multicentered, randomized, controlled trial. I agree

To conclude, I think the best we have right now in the absence of concrete data is clinical judgment, my favorite. One could try to place the patient on HFNC to either keep them away from the ventilator or even keep them from being annoyed by the CPAP/BiPAP mask which is typically uncomfortable, limits the ability to eat, speak, and other fun activities. If it fails, it fails. Your RT may be a little annoyed at you and may say "I told you so", but ultimately we have to do what's best for the patient. Thoughts? Please read these articles for yourself. A hat tip to all the authors. 

- EJ





Link to Abstract

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Link to Abstract

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High-flow Nasal Cannula: What is it?

High-flow nasal cannula oxygen therapy in adults

Some of you have asked what I mean every time I post something regarding high flow nasal cannula. Let's start by defining the flow in the different oxygen devices. Regular nasal cannula provides between 1-6 liters of flow. A simple face mask can get you flows between 6-10L/min. Venti masks, aka Venturi masks can get you flow rates between 4-8L/min. The best you can potentially do with a non-high flow device is the non-rebreather which can generate a flow rate of 10-15L/min. Just so we are all clear, every time I see a patient on a non-rebreather my senses step up to the next level. To me, that thing strapped on a patients face means that a decision needs to be made stat as the person who placed it on their face needs a second opinion. It's time to either place the patient on HFNC, BiPAP, intubate, or my favorite, they just panicked and didn't know what to do. It happens.

I like the image in particular because it is not signaling any machine in particular. There are a number of different companies who make these devices and I do not know the nitty gritty as to what differentiates them. I just know I love the technology. Would you all like for me to make a YouTube video where I break down the mechanisms of action of the device?

This article is a good review for the time, published in 2015, with the data that existed at the moment. The author reviews the physiologic effects, discusses the dead space washout, the PEEP effect, the benefits of heat and humidification. In addition, they discuss clinical uses such as both hypoxemic and hypercapnic respiratory failure, pre-intubation, post-extubation, sleep apnea, heart failure, and others.

It's definitely worth a quick read.

-EJ








Nishimura, M. (2015). High-flow nasal cannula oxygen therapy in adults. Journal of Intensive Care, 3(1).

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HFNC/High Flow Nasal Cannula: A beautiful image of the mechanisms of action

Not Just Oxygen? Mechanisms of Benefit from High-Flow Nasal Cannula in Hypoxemic Respiratory Failure.




Link to Abstract

Link to Image

Goligher, E. C., Slutsky, A. S. (2017). Not Just Oxygen? Mechanisms of Benefit from High-Flow Nasal Cannula in Hypoxemic Respiratory Failure. American Journal of Respiratory and Critical Care Medicine, 195(9), 1128–1131.
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HFNC/ High Flow Nasal Cannula in the Emergency Department: Can it avoid intubations?

Randomized Controlled Trial of Humidified High-Flow Nasal Oxygen for Acute Respiratory Distress in the Emergency Department: The HOT-ER Study

This study was the first randomized control trial looking at whether high-flow nasal cannula (HFNC) decreases the need for mechanical ventilation in the emergency department. In addition they looked at emergency department and hospital lengths of stays, 90 day mortality, adverse effects in the hospital, and patient experience. I sympathize for the authors of this study because their abstract shows results that my not in fact be true. I state this because, although the study took over two years to complete, they did not collect sufficient patients to demonstrate an effect on their primary outcome which was a need for mechanical ventilation. Unfortunately, they needed 900 based on post-hoc analysis and obtained 322 patients. It would have taken them approximately 6 years to get this trial done. Sigh. The other caveat to this trial is that the sickest patients were plucked out by the physicians after recruitment because they wanted to proceed with NIV/BiPAP before even trying HFNC. I can't say I blame them. I treat patients and trials be damned if my clinical judgement is telling me to do something. That's another reason why I am not in academics nor do I do research. Patients also just weren't that sick. If you're an ER doctor, could you imagine the acuity if you just intubate 7.2% of patients in respiratory failure on standard oxygen therapy? That means these patients weren't that sick. I mean, the intubation rates for all comers in patients who are on HFNC in subsequent studies flirts with 30%. Please don't quote me on that number but I believe it to be accurate based on my prior research. I can just imagine how many clinicians would irresponsibly read through the abstract and say, HFNC is not good and just throw away the technology ignoring the benefits. Then you have to fight against their cognitive dissonance to make them change their practice. That's enough for today on this study. Thanks for checking it out.
A 🎩 tip to the authors

-EJ




Jones PG, Kamona S, Doran O, Sawtell F, Wilsher M. Randomized controlled trial of humidified high-flow nasal oxygen for acute respiratory distress in the emergency department: the HOT-ER Study. Respir Care 2016;61:291–299.

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HFNC: The Physiologic Effects

Physiologic Effects of High-Flow Nasal Cannula in Acute Hypoxemic Respiratory Failure

I have extensively covered high flow nasal cannula, HFNC on this page due to a talk I'm creating on the matter. We've witnessed it first hand keep patients off of the ventilator. This article published in the American Journal of Respiratory and Critical Care Medicine, which as an aside is the highest impact factor publication in the Critical Care world, looked at 15 patients to determine the physiologic effects of the HFNC system. The reason why they performed the study was because those physiologic effects that we all know are beneficial were just not defined at the time of the publication. The ambitious authors wanted to go ahead and define them. Although this study was published in May 2017, one can grasp more or less the time it takes to get one of these important studies published by noting that it was initially submitted in May 2016. Imagine having this data and not being able to get it out. I would lose my mind.
The authors used patients with a P/F ratio of less than or equal to 300. They performed a number of measurements which I will not cover here for the sake of it being Sunday morning and you do not want to be put into another nap.
In a quick and dirty recap, here are their findings:
1. less inspiratory effort
2. lighter metabolic work of breathing
3. less minute ventilation (due to decreased respiratory rate)
4. improved oxygenation
5. no change in PCO2 nor pH
6. increased lung volume in dependent and non-dependent lung regions
- this may be a huge key towards understanding the possible PEEP that the HFNC system may provide. The authors state that increasing the EELI with an improvement in oxygenation while not having a change in tidal volume may explain the PEEP effect
There are other findings which I will defer to the authors to describe in the article. Check it out in the link below.

- EJ






Link to Abstract

Mauri, T., Turrini, C., Eronia, N., Grasselli, G., Volta, C. A., Bellani, G., & Pesenti, A. (2017). Physiologic Effects of High-Flow Nasal Cannula in Acute Hypoxemic Respiratory Failure. American Journal of Respiratory and Critical Care Medicine, 195(9), 1207–1215.

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BiPAP (NIV) vs. High Flow Nasal Cannula

High-flow nasal cannula oxygen therapy in patients undergoing thoracic surgery: current evidence and practice

Always give credit when credit is due and cite your sources. The article below isn't free, but if you can get your hands on it, it has some really nice tables. In particular, there is one table where they compare non-invasive ventilation to high-flow nasal cannula with regards to comfort, airway pressure and PEEP (see more on my post about that yesterday), anatomical dead space, CO2 washout, mucociliary function, pulmonary effects, extra pulmonary effects, skin breakdown and sores. It's worth checking out if you have access to this journal.

- EJ

Link to Abstract

Wittenstein, J., Ball, L., Pelosi, P.; Gama de Abreu, M. (2018). High-flow nasal cannula oxygen therapy in patients undergoing thoracic surgery. Current Opinion in Anaesthesiology, 1.

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Do Not Resuscitate/Do Not Intubate does NOT mean Do Not Do Anything.

Nasal high flow oxygen therapy in do-not-intubate patients with hypoxemic respiratory distress

This topic is very dear to me because I am a huuuuuuuge proponent for appropriate end of life care. I'm an Intensivist after all and people unfortunately die on my service. We all are going to have our day. My goal with the patients I take care of is to make their passing to the next life as comfortable as possible with as much love surrounding the individual as humanly possible. It irks me at times when clinicians write patients off just because they have a DNR/DNI order written. For the non-medical people around here that means do not resuscitate/do not intubate. Also, what are you doing around here? Those patients also need our best efforts as they are already cognizant of their impending mortality. That usually means their friends and family members are also aware and would rather be around when the inevitable to all of us occurs and they pass. In this article, the authors attempted to avoid utilizing non-invasive ventilation, or as most of us just call it, BiPAP, by placing patients on high flow nasal cannula. Small study, 50 patients. Can you imagine the difficulty in enrolling patients into a study like this? It must have been quite challenging. In short, although mortality in hospital was appropriately high, they found that they were able to avoid placing patients on BiPAP in 82% of patients. To me, this is particularly important because that means these patients were able to comfort eat, speak to their families, say their goodbyes, give them unobstructed hugs (due to the BiPAP mask), kisses, and smiles without a NIV mask in the way. The decreased RR as a clinician to me is significant because if there's one thing that makes me uncomfortable, it's a patient who is in frank respiratory distress sucking wind to survive. A respiratory rate decrease from 30.6 to 24.7 is something I'd take any day. This is something I do in my practice. I was very happy to run into their article and find some data to support what I anecdotally believed.

A hat tip to the authors.

-EJ

Peters S, Holets S, Gay P. Nasal high flow oxygen therapy in do-not-intubate patients with hypoxemic respiratory distress. Respir Care. 2013 ; 58(4): 597-600.

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HFNC/High Flow Nasal Cannual vs. Conventional Oxygen Therapy vs. Non-Invasive Positive Pressure Ventilation

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

I need help with this. Is it me or is this an apples to oranges study? I ask that because the authors compared high flow nasal cannula to conventional oxygen therapy and then they compared HFNC to NIPPV. Okay, the COT versus HFNC is an easy one to settle. Fewer people are going to be intubated if they’re on HFNC, all comers. But the caveats kick in when the authors compare HFNC to NIPPV which many of you know as BiPAP. My issue is because they included patients who were having acute exacerbations of COPD, acute cardiogenic pulmonary edema, asthma exacerbations, and ARDS in the HFNC vs NIV arm of the study. It is my opinion that that’s a bit ridiculous bc we know (and knew in 2017 when this study was published) that those patient populations more often than not need more support than what HFNC can provide. I will say there is data for HFNC in all those settings, but not enough to prove a benefit to NIV. Can you chime in below with your thoughts? I don’t think they should have looked at all comers for HFNC. Taking it by disease processes which other authors have done would yield actual real world results. These devices need to be carefully tailored to the patients you are treating. I’m more than willing to change my mind but I need help. Thanks.  

-EJ

Link to abstract

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High Flow Nasal Cannula: Does my patient with pneumonia need to be intubated?

The article I'm referencing in this post is titled: An Index Combining Respiratory Rate and Oxygenation to Predict Outcome of Nasal High-Flow Therapy. It was published in the American Journal of Respiratory and Critical Care Medicine in June of 2019. 

We see this every day in the intensive care unit. A patient with pneumonia sucking wind. Tachypenic. Slightly altered. Requiring a bunch of oxygen. Should we intubate them and place them on mechanical ventilation, or should we give them a shot and see if they fly on high flow nasal cannula? The data for pneumonia and using BiPAP isn't there so that's not an option. Side note, check the FLORALI trial which I posted on my site as it has some of the same researchers on the matter. I really really don't want to have to intubate the patient with all the risks and complications known to go with that unless it's really really needed. In a joking manner, we all think we're big shots and can call it just by seeing it. You know the type, I am the same way. I can tell a patient needs to be intubated as soon as I lay eyes on them. Big shot. Yep. This is true, or is it? We also know that delaying intubation is far worse for patient populations that just intubating them early on. What ends up happening is that once you finally go ahead and proceed with intubation after the patient has been developing more and more fatigue, you notice that you're in deep poop when the induction agents destroy your patients hemodynamics. Start bolusing fluids. Place a central line and start vasopressors. Death spiral ensues. If this hasn't happened to you in your career, you haven't been working long enough. 

What if there was a tool to help us with this decision? Wouldn't that be great? How about a tool so simple that all you need is a pulse oximeter, a HFNC setup telling you the FiO2 being delivered to the patient, and a set of eyeballs to count a patients respiratory rate (because we all know that whatever device measures RR on the monitor is inaccurate and showing "apneic" more often than it should). Well, we're all in luck! These authors came up with the ROX index which is (SpO2/FiO2)/RR. SpO2 is the number you get from the pulse oximeter and it's on the monitor. It should be entered as a whole number. FiO2 is entered as a decimal. For example room air is 21% so 0.21. RR is, well, respiratory rate. Based on the data provided in this article, it should be a statistically significant prediction of whether your patient is going to be intubated or not. Hopefully the delay of mechanical ventilation we all are dreading should be avoided. This should also help you make the decision to just intubate the person before you leave your partner who is working the opposite shift with an airway dump, one of the worst kinds of dumps. 

I am not going to go deep into the data of this study because this team knows what they are doing far better than I ever will and the truth is that the abstract here is a pretty darn good representation of what is within the bulk of the text. I am curious, however, of why the article was published in its "in press" format in December of 2018 and was not fully released until June 2019. So many people could have benefitted from it. 

Also, a little tidbit that you may or may not have known. The journal where this was published, the American Journal of Respiratory and Critical Care Medicine is the high ranked journal for Critical Care Medicine based on Impact Factor. Don't know what Impact Factor is? You should definitely check it out because it evaluates the quality of the journal. That will keep you from making a mistake that I made where I showed my Program Director in residency an article from this small European journal something about atrial fibrillation and then he proceeded to make fun of me and showed me where to look up the actual data on afib, the American Heart Association Guidelines. Anyway, that's enough of a rant. Enjoy the article and until next time! 

ADDENDUM: Someone who follows my on instagram named Jessie just opened my eyes to a use case for this ROX index that I hadn't thought of before. It could potentially be used to help either alert or calm nurses and respiratory therapists regarding the potential decline of a patient who is on HFNC either in a step-down/PCU/intermediate unit. It could be an objective piece of data that they could provide to physicians to provide evidence that the patient needs to be transferred to the intensive care unit for intubation or that the patient is deteriorating. Wow! I feel silly that I had not thought of that myself but I'm glad she reached out and pointed it out to me. Thanks Jessie! 

-EJ




Link to the Abstract

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HFNC vs. conventional oxygen after extubatio

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One of the dreaded things in Critical Care is to extubate someone and see that they’re not flying. It makes you question yourself; your judgement, assessments. It makes you self conscious. Will families may lose trust in you, and most importantly: are you causing harm to your patients? I’ve had just 6 reintubations in my 2 years out of training but that is considered too few as the reintubation rate should be 10-15%. Otherwise you’re not being aggressive enough. I don’t even check blood gases before I pull the tube. Needless to say, my kickass RT’s know that for the questionable pts, I want the #BiPAP or #HFNC at the bedside when we pull the tube. Sometimes hooked up and ready to go, sometimes outside the room to “ward off evil spirits”. I have a plan A, B, and C ready to go before I reintubate. My empiric data, otherwise worthless, shows that HFNC does help prevent reintubation. This meta-analysis says different. My bias, admittedly, says the conclusion has some limitations, and if you seek you shall find. This is an issue with meta analyses, the heterogeneity. You’re trying to compare apples and oranges regarding different studies and the authors did the best they could with statistical gymnastics that I don’t quite understand to make apple pie with an orange flavored crust. It just didn’t work out to show certain endpoints bc the included studies were just too different. Does that means that HFNC really doesn’t help avoid reintubations? Nope. It just means we need more data. A big 🎩 tip to the authors. 

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High-Flow Nasal Cannula Therapy in Do-Not-Intubate Patients With Hypoxemic Respiratory Distress

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High flow nasal cannulae oxygen therapy in acute-moderate hypercapnic respiratory failure

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High-Flow Nasal Cannula in Acute Hypoxemic Respiratory Failure: A Review of the FLORALI Trial

High-Flow Oxygen through Nasal Cannula in Acute Hypoxemic Respiratory Failure

I first shared this article in June of 2019 on Instagram when my account had a mere 2500 followers. Since then the amount of followers to my account have skyrocketed and I could not have done it without the help of each and every one of you who find value in what I do.
As an aside, many of you know I'm preparing a lecture on high-flow nasal cannula and non-invasive ventilation. This article is one of the landmark trials in the HFNC literature and it's worth revisiting in greater detail. After all, I wasn't taking articles apart in as much depth several months ago as I am now. The name by which this study is commonly referred to is the FLORALI trial, as in high FLow Oxygen therapy in Resuscitation of patients with Acute Lung Injury. Witty, huh? The authors had noted that there weren't any studies looking at non-invasive ventilation in patients who were in acute hypoxemic respiratory failure that were not hypercapnic. They went ahead to detail all the beneficial effects of HFNC which I have beat you all over the head with on this medium. They went ahead and designed a prospective, multicenter, randomized, controlled trial to see which worked best to avoid intubations and improve outcomes in patients who were in hypoxemic respiratory failure: NIV, HFNC, or standard oxygen therapy which I will herein refer to as SOT.
They chose to enroll patients who were sick, but not too sick. After all, you need to enroll patients and keep them safe at the same time. If you choose patients who are too sick, then clinicians aren't going to follow the study protocol. They had a strict protocol as well to intubate patients so that patients wouldn't be left lingering without being intubated. After all, there is clear data that if you wait too long to intubate, patients do poorly and there is increased mortality. They included patients who were hypoxemic with a PF ratio < 300, needing a flow of 10L, a PaCO2 < 45 (so no COPD exacerbation patients here) and no chronic respiratory failure. Asthmatics were also excluded, as well as cardiogenic pulmonary edema, use of vasopressors, and hemodynamic instability. They had other parameters but you can check out the article for yourself.
Patients were randomized at 1:1:1 for SOT (nonrebreather at flow of 10L), HFNC (50L of flow and FiO2 titrated), and NIV (pressure support titrated to obtain a tidal volume of 7-10cc/kg ideal body weight and a PEEP between 2-10cmH2O).
When you look at the characteristics of the patients enrolled, and they enrolled 310 of them, the vast majority had pneumonia with a predominance of community acquired followed by healthcare associated pneumonia.
The primary outcome was rates of intubation. There was no difference if you just look at the direct comparison p-value of 0.18. When you look at the patients who had a PF ratio less than 200, though, the patients with HFNC did MUCH better with p-value of 0.009. This is your indication, team! You have someone with pneumonia, don't put the on NIV when HFNC may work better!
Fewer patients died in the ICU if they were to receive HFNC versus the other two (p=0.047).
There was also improved 90 day survival in the HFNC group (p=0.02). This was enough info, and more in the article that you really should read for yourself, to convince many ED and ICU practitioners that HFNC is the way to go in this patient population. Check the article out for yourself!

- EJ





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Frat JP, Thille AW, Mercat A, Girault C, Ragot S, Perbet S, et al.; FLORALI Study Group; REVA Network. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med 2015;372:2185–2196.

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Can high-flow nasal cannula reduce the rate of reintubation in adult patients after extubation? A meta-analysis

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Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.