High flow oxygen by nasal cannula for hypoxemic respiratory failure
” High-Flow Oxygen through Nasal Cannula in Acute Hypoxemic Respiratory Failure” Frat et al, June 2015 New England Journal of Medicine
The idea: Do all patients with non-traumatic respiratory distress require the same treatment? Early in the evaluation of the patient with respiratory distress Emergency Medicine doctors frequently reach for non-invasive positive pressure ventilation (bipap). For hypercapnia and pulmonary edema this is a well-studied and well-accepted rescue that may often delay or negate a patient’s need for intubation and invasive ventilation. New research evaluates whether this is the best approach for all etiologies of respiratory distress.
The study: A multi-center, randomized prospective trial for patients in 23 ICUs in France with hypoxemic respiratory failure comparing high flow oxygen, standard face mask and non-invasive positive pressure ventilation. Primary outcome was proportion of patients intubated at day 28; secondary outcomes were all-cause mortality at 90 days and number of ventilator-free days by day 28.
Results: For non-hypercapneic, hypoxemic respiratory failure treatment with high-flow oxygen did not decrease intubation rates. There was, however a significant decrease in all cause mortality at 90 days. The clinically significant hazard ratio for death at 90 days was 2.01 (P=0.046) with standard oxygen vs high flow and 2.5 (P=0.006) with bipap vs high flow.
The takeaway: For the patient with isolated hypoxic respiratory failure (pneumonia, non-pulmonary sepsis, drowning) this study shows high flow oxygen improves all cause mortality and decreases patient discomfort. Talk to your respiratory therapists about the best and fastest way to order high flow in your Emergency Department.