High flow nasal cannula: a new option in treatment of acute hypoxemic respiratory failure
Medicina d’Emergenza ed Urgenza Università La Sapienza Roma
One of the major feature of HFNC is the great tolerance and grade of comfort of patients compared to both conventional oxygen therapy (COT)11 and NIV12. In the last few years several studies investigated clinical applications of HFNC: acute hypoxemic respiratory failure (AhRF)13,14,15, hypercapnic non acidotic respiratory failure16, OSAS17, pre oxygenation before orotracheal intubation (IOT)18,19 and peri-procedural oxygenation20. Among them, the most promising seems to be the treatment of de novo AhRF; favorable evidences have been reported even in ARDS due to influenza H1N121, 22.
Currently, most of the available data come from Intensive Care Units (ICUs) even though successful results and good compliance among physicians have been reported in the Emergency Department too23, 24.
Despite the majority of studies have compared HFNC to COT, the advantage of the former has never been assessed so far.
However, some authors claim that HFNC may be superior in terms of IOT rate even if no difference was found in relation to mortality25. On the other hand, other works suggest that no difference exists between HFNC and COT even with respect to the IOT rate26.
Few works comparing HFNC to NIV in AhRF are currently available: only three of them are multicentric randomized clinical trials (RCT)27, 28, 29. The FLORALI is the only RCT conducted within several ICUs, randomly assigning HFNC, COT or bilevel NIV up to 300 patients with AhRF. Although no difference was found relatively to the proportion of patient intubated, except in the PaO2/FiO2 < 200 mmHg sub-group post hoc analysis27, a significant survival benefit has been reported among patients who were receiving HFNC therapy.
According to current scientific evidence, there are not enough data to consider HFNC superior than NIV or COT in the treatment of AhRF. Therefore it is not possible to give any univocal recommendation on the use of one specific technique31. However, some authors believe that HFNC should be considered as the first-line treatment option prior to NIV in AhRF management30, since such strategies could be similar to NIV in terms of IOT rate but is definitively more tolerated 12. Hence, others multicentric RCT are required, but certainly HFNC may assume an important role in treatment of de novo AhRF on the future.
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