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Respir Care. 2018 Mar;63(3):259-266. doi: 10.4187/respcare.05793. Epub 2017 Dec 5.

Proactive Use of High-Flow Nasal Cannula With Critically Ill Subjects.

Author information

1
Department of Respiratory Therapy, UnityPoint Health, Des Moines, Iowa.
2
Department of Respiratory Therapy, UnityPoint Health, Des Moines, Iowa. He is now affiliated with Inova Fairfax, Falls Church, VA.
3
Department of Trauma Services, UnityPoint Health, Des Moines, Iowa sarah.spilman@unitypoint.org.
4
Department of Pulmonology and Critical Care, The Iowa Clinic, and with the Department of Pulmonology and Critical Care, UnityPoint Health, Des Moines, Iowa.
5
Department of Trauma Surgery, The Iowa Clinic, and with the Department of Trauma Services, UnityPoint Health, Des Moines, Iowa.
6
Department of Trauma Surgery, The Iowa Clinic. She is now affiliated with Sanford Medical Center, Fargo, ND.

Abstract

INTRODUCTION:

It has been suggested that use of a high-flow nasal cannula (HFNC) could be a first-line therapy for patients with acute hypoxic respiratory failure. The purpose of this study was to determine if protocolized use of HFNC decreases unplanned intubation and adverse outcomes in an ICU population.

METHODS:

The study was a prospective evaluation of 2 cohorts who received HFNC per protocol. Control groups were retrospective selections of subjects who received HFNC in the pre-protocol period. Cohort 1 (n = 88) received mechanical ventilation for ≥ 24 h and was extubated directly to HFNC following strict protocol criteria. Cohort 2 (n = 83) were placed on HFNC when oxygen requirements escalated (>4 L/min).

RESULTS:

Cohort 1 did not differ from its control group in mortality, hospital stay, or ICU days, but there were significant decreases in incidence of Gram-negative pulmonary infection (30% vs 9%, P = .001) and use of bronchodilator therapy (81% vs 61%, P = .008). Failed extubation rates were nearly identical across groups, but time to re-intubation was shorter in the protocol group (24 vs 13 h, P = .19). Cohort 2 did not differ significantly from its control group in intubation rates or mortality, but subjects managed by protocol experienced significant decreases in ICU days (4 vs 3 d, P = .03) and hospital days (12 vs 8 d, P = .007). There was a trend toward fewer hours on HFNC (33 vs 24 h, P = .10) and faster time to intubation when HFNC failed (19 vs 9 h, P = .08).

CONCLUSIONS:

Extubation to HFNC led to a significant decrease in pulmonary infections and bronchodilator therapy in Cohort 1 but did not reduce length of stay or rates of failed extubation. When HFNC was used early and per protocol (Cohort 2), ICU and hospital lengths of stay were reduced and HFNC was initiated more quickly when the need for respiratory support escalated.

KEYWORDS:

high-flow nasal cannula; mechanical ventilation; postextubation management; pulmonary infection; re-intubation; respiratory failure

Comment in

PMID:
29208754
DOI:
10.4187/respcare.05793

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