Tuesday, 26 May 2015

High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. NEJM May 2015.

High flow oxygen through nasal cannula has been widely used in the past decade (including in Westmead Hospital) despite the lack of evidence to support its use. This method provides a high concentration of heated and humidified oxygen through a nasal cannula, with flow rates from 40 to 60 litres per minute that generate low levels of PEEP. It is thought to be more comfortable for the patient and it also increase excretion of carbon dioxide.  This multicentre randomised trial is the first of its kind to demonstrate the effectiveness of high-flow oxygen therapy. 310 patients with acute nonhypercapnic hypoxemic respiratory failure were randomised to receive high-flow oxygen therapy, standard oxygen therapy through face mask or non-invasive positive-pressure ventilation. The primary outcome, the rate of endotracheal intubation, was lower among patients treated with high-flow oxygen than among those who received standard oxygen therapy or noninvasive ventilation, but the rates did not differ significantly (38% vs. 47% and 50%, respectively) (P = 0.18). However, in a post hoc adjusted analysis that included the 238 patients with severe initial hypoxemia (Pao2 :Fio2, ≤200 mm Hg), the intubation rate was significantly lower among patients who received highflow oxygen than among patients in the other two groups (P = 0.009). In the entire cohort of 310 patients, the highflow delivery mode significantly increased the number of ventilator-free days and also reduced 90-day mortality, as compared with standard oxygen therapy alone (P = 0.046) or noninvasive ventilation (P = 0.006). An editorial emphasising the significance of this finding is also available in this issue of NEJM.

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