Noninvasive ventilation (NIV) is the recommended ventilatory support for acute cardiogenic pulmonary edema (CPE) associated with acute respiratory failure or hypercapnia. High-flow nasal cannula (HFNC) has emerged as an alternative to NIV in acute hypoxemic respiratory failure. We aimed to assess the efficacy of HFNC on early changes in and respiratory parameters in patients in the emergency department with acute hypercapnic CPE and to compare it to NIV.
METHODS:
We conducted a prospective observational study in consecutive emergency department patients with acute hypercapnic CPE. Subjects received either HFNC or NIV, according to the attending emergency physician's expertise in HFNC. The primary outcome was change in after treatment for 1 h. Secondary outcomes were change in pH, breathing frequency, signs of work of breathing, and comparisons to NIV.
RESULTS:
Twenty-seven subjects with a discharge diagnosis of hypercapnic CPE were analyzed. Subjects had a median age of 87 y (interquartile range [IQR] 78–93); 37% were male. Twelve (44%) received HFNC, and 15 (56%) received NIV. Median of changes in from baseline to after 1 h of treatment were 7 mm Hg (IQR 4–11, P = .002) for HFNC and 3 mm Hg (IQR 1–8, P = .02) for NIV, with no between-group difference. pH, breathing frequency and signs of work of breathing also improved after both HFNC and NIV.
CONCLUSIONS:
This preliminary study suggests that HFNC treatment for 1 h improves and respiratory parameters in subjects with hypercapnic acute CPE in a manner that is comparable to NIV. Further studies are needed to assess HFNC as a possible alternative to NIV in early management of acute hypercapnic respiratory failure of cardiogenic origin. (ClinicalTrials.gov registration NCT03883555.)
LaribiS, KeijzersG, van MeerO, KlimS, MotiejunaiteJ, KuanWS, et al. Epidemiology of patients presenting with dyspnea to emergency departments in Europe and the Asia-Pacific region. Eur J Emerg Med, 2019; 26(5):345–349.
2.
AbermanA, FulopM. The metabolic and respiratory acidosis of acute pulmonary edema. Ann Intern Med, 1972; 76(2):173–184.
3.
ContouD, FragnoliC, Córdoba-IzquierdoA, BoissierF, Brun-BuissonC, ThilleAW. Severe but not mild hypercapnia affects the outcome in patients with severe cardiogenic pulmonary edema treated by non-invasive ventilation. Ann Intensive Care, 2015; 5(1):55.
4.
KonishiM, AkiyamaE, SuzukiH, IwahashiN, MaejimaN, TsukaharaK, et al. Hypercapnia in patients with acute heart failure. ESC Heart Fail, 2015; 2(1):12–19.
5.
ContouD, FragnoliC, Córdoba-IzquierdoA, BoissierF, Brun-BuissonC, ThilleAW. Noninvasive ventilation for acute hypercapnic respiratory failure: intubation rate in an experienced unit. Respir Care, 2013; 58(12):2045–2052.
6.
MasipJ, PeacockWF, PriceS, CullenL, Martin-SanchezFJ, SeferovicP, et al. Indications and practical approach to non-invasive ventilation in acute heart failure. Eur Heart J, 2018; 39(1):17–25.
7.
MasipJ, RoqueM, SánchezB, FernándezR, SubiranaM, ExpósitoJA. Noninvasive ventilation in acute cardiogenic pulmonary edema: systematic review and meta-analysis. JAMA, 2005; 294(24):3124–3130.
8.
PonikowskiP, VoorsAA, AnkerSD, BuenoH, ClelandJGF, CoatsAJS, et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: the task force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC), developed with the special contribution of the Heart Failure Association (HFA) of the ESC. Eur Heart J, 2016; 37(27):2129–2200.
9.
RochwergB, BrochardL, ElliottMW, HessD, HillNS, NavaS, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J, 2017; 50(2):1602426.
10.
TallmanTA, PeacockWF, EmermanCL, LopatinM, BlickerJZ, WeberJ, et al. Noninvasive ventilation outcomes in 2,430 acute decompensated heart failure patients: an ADHERE Registry Analysis. Acad Emerg Med, 2008; 15(4):355–362.
11.
BerstenAD, HoltAW, VedigAE, SkowronskiGA, BaggoleyCJ. Treatment of severe cardiogenic pulmonary edema with continuous positive airway pressure delivered by face mask. N Engl J Med, 1991; 325(26):1825–1830.
FratJP, ThilleAW, MercatA, GiraultC, RagotS, PerbetS, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med, 2015; 372(23):2185–2196.
15.
MöllerW, CelikG, FengS, BartensteinP, MeyerG, OliverE, et al. Nasal high flow clears anatomical dead space in upper airway models. J Appl Physiol (1985), 2015; 118(12):1525–1532.
16.
MöllerW, FengS, DomanskiU, FrankeKJ, CelikG, BartensteinP, et al. Nasal high flow reduces dead space. J Appl Physiol (1985), 2017; 122(1):191–197.
ParkeRL, EcclestonML, McGuinnessSP. The effects of flow on airway pressure during nasal high-flow oxygen therapy. Respir Care, 2011; 56(8):1151–1155.
19.
FratJP, BrugiereB, RagotS, ChatellierD, VeinsteinA, GoudetV, et al. Sequential application of oxygen therapy via high-flow nasal cannula and noninvasive ventilation in acute respiratory failure: an observational pilot study. Respir Care, 2015; 60(2):170–178.
20.
CorleyA, RickardCM, AitkenLM, JohnstonA, BarnettA, FraserJF, et al. High-flow nasal cannulae for respiratory support in adult intensive care patients. Cochrane Database Syst Rev, 2017; 5:CD010172.
21.
RochwergB, GrantonD, WangDX, HelvizY, EinavS, FratJP, et al. 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(5):563–572.
22.
NiYN, LuoJ, YuH, LiuD, NiZ, ChengJ, 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; 151(4):764–775.
23.
Beng LeongL, Wei MingN, Wei FengL. High flow nasal cannula oxygen versus noninvasive ventilation in adult acute respiratory failure: a systematic review of randomized-controlled trials. Eur J Emerg Med, 2019; 26(1):9–18.
24.
FratJP, JolyF, ThilleAW. Noninvasive ventilation versus oxygen therapy in patients with acute respiratory failure. Curr Opin Anaesthesiol, 2019; 32(2):150–155.
25.
LengletH, SztrymfB, LeroyC, BrunP, DreyfussD, RicardJD. Humidified high flow nasal oxygen during respiratory failure in the emergency department: feasibility and efficacy. Respir Care, 2012; 57(11):1873–1878.
26.
MacéJ, MarjanovicN, FaranpourF, MimozO, FrerebeauM, VioleauM, et al. Early high-flow nasal cannula oxygen therapy in adults with acute hypoxemic respiratory failure in the ED: a before-after study. Am J Emerg Med, 2019; 37(11):2091–2096.
27.
RittayamaiN, TscheikunaJ, PraphruetkitN, KijpinyochaiS. Use of high-flow nasal cannula for acute dyspnea and hypoxemia in the emergency department. Respir Care, 2015; 60(10):1377–1382.
28.
JonesPG, KamonaS, DoranO, SawtellF, WilsherM. 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(3):291–299.
29.
DoshiP, WhittleJS, BublewiczM, KearneyJ, AsheT, GrahamR, et al. High-velocity nasal insufflation in the treatment of respiratory failure: a randomized clinical trial. Ann Emerg Med, 2018; 72(1):73–83.
30.
HaywoodST, WhittleJS, VolakisLI, DunganG2nd, BublewiczM, KearneyJ, et al. HVNI vs NIPPV in the treatment of acute decompensated heart failure: subgroup analysis of a multi-center trial in the ED. Am J Emerg Med, 2019; 37(11):2084–2090.
31.
MakdeeO, MonsomboonA, SurabenjawongU, PraphruetkitN, ChaisirinW, ChakornT, et al. High-flow nasal cannula versus conventional oxygen therapy in emergency department patients with cardiogenic pulmonary edema: a randomized controlled trial. Ann Emerg Med, 2017; 70(4):465–472.
32.
JeongJH, KimDH, KimSC, KangC, LeeSH, KangTS, et al. Changes in arterial blood gases after use of high-flow nasal cannula therapy in the ED. Am J Emerg Med, 2015; 33(10):1344–1349.
33.
KimES, LeeH, KimSJ, ParkJ, LeeYJ, ParkJS, et al. Effectiveness of high-flow nasal cannula oxygen therapy for acute respiratory failure with hypercapnia. J Thorac Dis, 2018; 10(2):882–888.
34.
BraunlichJ, KohlerM, WirtzH. Nasal high flow improves ventilation in patients with COPD. Int J Chron Obstruct Pulmon Dis, 2016; 11:1077–1085.
35.
ParkeRL, McGuinnessSP. Pressures delivered by nasal high flow oxygen during all phases of the respiratory cycle. Respir Care, 2013; 58(10):1621–1624.
36.
ThilleAW, JolyF, MarjanovicN, FratJP. High-flow oxygen therapy for the management of patients with acute exacerbation of cystic fibrosis. Ann Transl Med, 2018; 6:S113.
37.
SklarMC, DresM, RittayamaiN, WestB, GriecoDL, TeliasI, et al. High-flow nasal oxygen versus noninvasive ventilation in adult patients with cystic fibrosis: a randomized crossover physiological study. Ann Intensive Care, 2018; 8(1):85.
