Invasive high-flow oxygen therapy and invasive-noninvasive ventilation sequential strategies for chronic obstructive pulmonary disease patients with severe respiratory failure: a randomized controlled trial_Chinese Journal of Respiratory and Critical Care Medicine

Authors：

CAO Peng ¹ , LING Bingyu ¹ , XU Yan ¹ , WANG Bingxia ¹ , SHAN Xueqin ¹ , WANG Yunyun ¹ , XU Jun ² , ZHU Qingcheng ¹ ,  TAN Dingyu ¹

1. Emergency Department, Clinical Medical College of Yangzhou University, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu 225001, P. R. China;
2. Department of Emergency, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, P. R. China;

Corresponding?author：

TAN Dingyu, Email: webtan1981@gmail.com

Keywords：

Chronic obstructive pulmonary diseases; Respiratory failure; High-flow nasal cannula oxygen therapy; Non-invasive ventilation; Pulmonary infection control window

DOI：

10.7507/1671-6205.202006053

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Objective To compare the therapeutic effects of invasive-high-flow oxygen therapy (HFNC) and invasive-non-invasive ventilation (NIV) sequential strategies on severe respiratory failure caused by chronic obstructive pulmonary disease (COPD), and explore the feasibility of HFNC after extubation from invasive ventilation for COPD patients with severe respiratory failure.Methods From October 2017 to October 2019, COPD patients with type Ⅱ respiratory failure who received invasive ventilation were randomly assigned to a HFNC group and a NIV group at 1: 1 in intensive care unit (ICU), when pulmonary infection control window appeared after treatments. The patients in the HFNC group received HFNC, while the patients in the NIV group received NIV after extubation. The primary endpoint was treatment failure rate. The secondary endpoints were blood gas analysis and vital signs at 1 hour, 24 hours, and 48 hours after extubation, total respiratory support time after extubation, daily airway care interventions, comfort scores, and incidence of nasal and facial skin lesions, ICU length of stay, total length of stay and 28-day mortality after extubation.Results One hundred and twelve patients were randomly assigned to the HFNC group and the NIV group. After secondary exclusion, 53 patients and 52 patients in the HFNC group and the NIV group were included in the analysis respectively. The treatment failure rate in the HFNC group was 22.6%, which was lower than the 28.8% in the NIV group. The risk difference of the failure rate between the two groups was –6.2% (95%CI –22.47 - 10.43, P=0.509), which was significantly lower than the non-inferior effect of 9%. Analysis of the causes of treatment failure showed that treatment intolerance in the HFNC group was significantly lower than that in the NIV group, with a risk difference of –38.4% (95%CI –62.5 - –3.6, P=0.043). One hour after extubation, the respiratory rate of both groups increased higher than the baseline level before extubation (P<0.05). 24 hours after extubation, the respiratory rate in the HFNC group decreased to the baseline level, but the respiratory rate in the NIV group was still higher than the baseline level, and the respiratory rate in the HFNC group was lower than that in the NIV group [(19.1±3.8) vs. (21.7±4.5) times per minute, P<0.05]. 48 hours after extubation, the respiratory rates in the two groups were not significantly different from their baseline levels. The average daily airway care intervention in the NIV group was 9 (5 - 12) times, which was significantly higher than the 5 (4 - 7) times in the HFNC group (P=0.006). The comfort score of the HFNC group was significantly higher than that of the NIV group (8.6±3.2 vs. 5.7±2.8, P= 0.022), while the incidence of nasal and facial skin lesions in the HFNC group was significantly lower than that in the NIV group (0 vs. 9.6%, P=0.027). There was no significant difference in dyspnea score, length of stay and 28-day mortality between the two groups.Conclusions The efficacy of invasive-HFNC sequential treatment on COPD with severe respiratory failure is not inferior to that of invasive-NIV sequential strategy. The two groups have similar treatment failure rates, and HFNC has better comfort and treatment tolerance.

Citation： CAO Peng, LING Bingyu, XU Yan, WANG Bingxia, SHAN Xueqin, WANG Yunyun, XU Jun, ZHU Qingcheng, TAN Dingyu. Invasive high-flow oxygen therapy and invasive-noninvasive ventilation sequential strategies for chronic obstructive pulmonary disease patients with severe respiratory failure: a randomized controlled trial. Chinese Journal of Respiratory and Critical Care Medicine, 2021, 20(6): 388-395. doi: 10.7507/1671-6205.202006053 Copy

1.	Lv YY, Lv QR, Lv QC, et al. Pulmonary infection control window as a switching point for sequential ventilation in the treatment of COPD patients: a meta-analysis. Int J Chron Obstruct Pulmon Dis, 2017, 12: 1255-1267.
2.	Song YL, Chen RC, Zhan QY, et al. The optimum timing to wean invasive ventilation for patients with AECOPD or COPD with pulmonary infection. Int J Chron Obstruct Pulmon Dis, 2016, 11: 535-542.
3.	Esteban A, Ferguson ND, Meade MO, et al. Evolution of mechanical ventilation in response to clinical research. Am J Respir Crit Care Med, 2008, 177(2): 170-177.
4.	Rochwerg B, Einav S, Chaudhuri D, et al. The role for high flow nasal cannula as a respiratory support strategy in adults: a clinical practice guideline. Intensive Care Med, 2020, 46(12): 2226-2237.
5.	Ni YN, Luo J, Yu H, et al. Can high‐flow nasal cannula reduce the rate of reintubation in adult patients after extubation? A meta‐analysis. BMC Pulm Med, 2017, 17(1): 142.
6.	中華醫學會呼吸病學分會慢性阻塞性肺疾病學組. 慢性阻塞性肺疾病診治指南(2013年修訂版). 中華結核和呼吸雜志, 2013, 36(4): 255-264.
7.	Borg G. Perceived exertion as an indicator of somatic stress. Scand J Rehabil Med, 1970, 2: 92-98.
8.	Osadnik CR, Tee VS, Carson-Chahhoud KV, et al. Non-invasive ventilation for the management of acute hypercapnic respiratory failure due to exacerbation of chronic obstructive pulmonary disease. Cochrane Database Syst Rev, 2017, 7: CD004104.
9.	Hernández G, Vaquero C, Colinas L, et al. Effect of postextubation high-flow nasal cannula vs noninvasive ventilation on reintubation and postextubation respiratory failure in high-risk patients: a randomized clinical trial. JAMA, 2016, 316(15): 1565-1574.
10.	Stéphan F, Barrucand B, Petit P, et al. High-flow nasal oxygen vs noninvasive positive airway pressure in hypoxemic patients after cardiothoracic surgery: a randomized clinical trial. JAMA, 2015, ; 313(23): 2331-2339.
11.	Br?unlich J, Wirtz H. Nasal high-flow in acute hypercapnic exacerbation of COPD. Int J Chron Obstruct Pulmon Dis, 2018, 13: 3895-3897.
12.	Yuste ME, Moreno O1, Narbona S, et al. Efficacy and safety of high-flow nasal cannula oxygen therapy in moderate acute hypercapnic respiratory failure. Rev Bras Ter Intensiva, 2019, 31(2): 156-163.
13.	Lee MK, Choi J, Park B, et al. High flow nasal cannulae oxygen therapy in acute-moderate hypercapnic respiratory failure. Clin Respir J, 2018, 12(6): 2046-2056.
14.	談定玉, 凌冰玉, 孫家艷, 等. 經鼻高流量氧療與無創正壓通氣比較治療慢性阻塞性肺疾病合并中度呼吸衰竭的觀察性隊列研究. 中華急診醫學雜志, 2018, 27(4): 361-366.
15.	Thille AW, Coudroy R, Nay MA, et al. Non-invasive ventilation alternating with high-flow nasal oxygen versus high-flow nasal oxygen alone after extubation in COPD patients: a post hoc analysis of a randomized controlled trial. Ann Intensive Care, 2021, 11(1): 30.
16.	Fricke K, Tatkov S, Domanski U, et al. Nasal high flow reduces hypercapnia by clearance of anatomical dead space in a COPD patient. Respir Med Case Rep, 2016, 19: 115-117.
17.	Parke RL, Eccleston ML, Mcguinness SP. The effects of flow on airway pressure during nasal high-flow oxygen therapy. Respir Care, 2011, 56(8): 1151-1155.
18.	Di Mussi R, Spadaro S, Stripoli T, et al. High-flow nasal cannula oxygen therapy decreases postextubation neuroventilatory drive and work of breathing in patients with chronic obstructive pulmonary disease. Crit Care, 2018, 22(1): 180.
19.	Jing G, Li J, Hao D, et al. Comparison of high flow nasal cannula with noninvasive ventilation in chronic obstructive pulmonary disease patients with hypercapnia in preventing postextubation respiratory failure: A pilot randomized controlled trial. Res Nurs Health, 2019, 42(3): 217-225.
20.	Cortegiani A, Longhini F, Fabiana Madotto F, et al. High flow nasal therapy versus noninvasive ventilation as initial ventilatory strategy in COPD exacerbation: a multicenter non-inferiority randomized trial. Crit Care, 2020, 24(1): 692.
21.	張京臣, 吳逢選, 孟琳琳, 等. 慢性阻塞性肺疾病患者拔管后序貫經鼻高流量氧療的效果和安全性. 中華醫學雜志, 2018, 98(2): 109-112.
22.	劉景剛, 楊圣強, 袁繼印, 等. 經鼻高流量氧療序貫治療慢性阻塞性肺疾病機械通氣患者的臨床研究. 中華急診醫學雜志, 2019, 28(4): 459-555.
23.	於江泉, 鄭瑞強, 朱進, 等. 經鼻高流量氧療在慢性阻塞性肺疾病急性加重患者有創呼吸機序貫治療中的臨床效果. 中華重癥醫學電子雜志, 2019, 5(3): 213-218.
24.	Delclaux C, L'Her E, Alberti C, et al. Treatment of acute hypoxemic nonhypercapnic respiratory insufficiency with continuous positive airway pressure delivered by a face mask: a randomized controlled trial. JAMA, 2000, 284(18): 2352-2360.
25.	Doshi P, Whittle JS, Bublewicz M, et al. High‐velocity nasal insufflation in the treatment of respiratory failure: a randomized clinical trial. Ann Emerg Med, 2018, 72(1): 73-83.
26.	Sun J, Li Y, Ling B, et al. High flow nasal cannula oxygen therapy versus non-invasive ventilation for chronic obstructive pulmonary disease with acute-moderate hypercapnic respiratory failure: an observational cohort study. Int J Chron Obstruct Pulmon Dis, 2019, 14: 1229-1237.

1. Lv YY, Lv QR, Lv QC, et al. Pulmonary infection control window as a switching point for sequential ventilation in the treatment of COPD patients: a meta-analysis. Int J Chron Obstruct Pulmon Dis, 2017, 12: 1255-1267.
2. Song YL, Chen RC, Zhan QY, et al. The optimum timing to wean invasive ventilation for patients with AECOPD or COPD with pulmonary infection. Int J Chron Obstruct Pulmon Dis, 2016, 11: 535-542.
3. Esteban A, Ferguson ND, Meade MO, et al. Evolution of mechanical ventilation in response to clinical research. Am J Respir Crit Care Med, 2008, 177(2): 170-177.
4. Rochwerg B, Einav S, Chaudhuri D, et al. The role for high flow nasal cannula as a respiratory support strategy in adults: a clinical practice guideline. Intensive Care Med, 2020, 46(12): 2226-2237.
5. Ni YN, Luo J, Yu H, et al. Can high‐flow nasal cannula reduce the rate of reintubation in adult patients after extubation? A meta‐analysis. BMC Pulm Med, 2017, 17(1): 142.
6. 中華醫學會呼吸病學分會慢性阻塞性肺疾病學組. 慢性阻塞性肺疾病診治指南(2013年修訂版). 中華結核和呼吸雜志, 2013, 36(4): 255-264.
7. Borg G. Perceived exertion as an indicator of somatic stress. Scand J Rehabil Med, 1970, 2: 92-98.
8. Osadnik CR, Tee VS, Carson-Chahhoud KV, et al. Non-invasive ventilation for the management of acute hypercapnic respiratory failure due to exacerbation of chronic obstructive pulmonary disease. Cochrane Database Syst Rev, 2017, 7: CD004104.
9. Hernández G, Vaquero C, Colinas L, et al. Effect of postextubation high-flow nasal cannula vs noninvasive ventilation on reintubation and postextubation respiratory failure in high-risk patients: a randomized clinical trial. JAMA, 2016, 316(15): 1565-1574.
10. Stéphan F, Barrucand B, Petit P, et al. High-flow nasal oxygen vs noninvasive positive airway pressure in hypoxemic patients after cardiothoracic surgery: a randomized clinical trial. JAMA, 2015, ; 313(23): 2331-2339.
11. Br?unlich J, Wirtz H. Nasal high-flow in acute hypercapnic exacerbation of COPD. Int J Chron Obstruct Pulmon Dis, 2018, 13: 3895-3897.
12. Yuste ME, Moreno O1, Narbona S, et al. Efficacy and safety of high-flow nasal cannula oxygen therapy in moderate acute hypercapnic respiratory failure. Rev Bras Ter Intensiva, 2019, 31(2): 156-163.
13. Lee MK, Choi J, Park B, et al. High flow nasal cannulae oxygen therapy in acute-moderate hypercapnic respiratory failure. Clin Respir J, 2018, 12(6): 2046-2056.
14. 談定玉, 凌冰玉, 孫家艷, 等. 經鼻高流量氧療與無創正壓通氣比較治療慢性阻塞性肺疾病合并中度呼吸衰竭的觀察性隊列研究. 中華急診醫學雜志, 2018, 27(4): 361-366.
15. Thille AW, Coudroy R, Nay MA, et al. Non-invasive ventilation alternating with high-flow nasal oxygen versus high-flow nasal oxygen alone after extubation in COPD patients: a post hoc analysis of a randomized controlled trial. Ann Intensive Care, 2021, 11(1): 30.
16. Fricke K, Tatkov S, Domanski U, et al. Nasal high flow reduces hypercapnia by clearance of anatomical dead space in a COPD patient. Respir Med Case Rep, 2016, 19: 115-117.
17. Parke RL, Eccleston ML, Mcguinness SP. The effects of flow on airway pressure during nasal high-flow oxygen therapy. Respir Care, 2011, 56(8): 1151-1155.
18. Di Mussi R, Spadaro S, Stripoli T, et al. High-flow nasal cannula oxygen therapy decreases postextubation neuroventilatory drive and work of breathing in patients with chronic obstructive pulmonary disease. Crit Care, 2018, 22(1): 180.
19. Jing G, Li J, Hao D, et al. Comparison of high flow nasal cannula with noninvasive ventilation in chronic obstructive pulmonary disease patients with hypercapnia in preventing postextubation respiratory failure: A pilot randomized controlled trial. Res Nurs Health, 2019, 42(3): 217-225.
20. Cortegiani A, Longhini F, Fabiana Madotto F, et al. High flow nasal therapy versus noninvasive ventilation as initial ventilatory strategy in COPD exacerbation: a multicenter non-inferiority randomized trial. Crit Care, 2020, 24(1): 692.
21. 張京臣, 吳逢選, 孟琳琳, 等. 慢性阻塞性肺疾病患者拔管后序貫經鼻高流量氧療的效果和安全性. 中華醫學雜志, 2018, 98(2): 109-112.
22. 劉景剛, 楊圣強, 袁繼印, 等. 經鼻高流量氧療序貫治療慢性阻塞性肺疾病機械通氣患者的臨床研究. 中華急診醫學雜志, 2019, 28(4): 459-555.
23. 於江泉, 鄭瑞強, 朱進, 等. 經鼻高流量氧療在慢性阻塞性肺疾病急性加重患者有創呼吸機序貫治療中的臨床效果. 中華重癥醫學電子雜志, 2019, 5(3): 213-218.
24. Delclaux C, L'Her E, Alberti C, et al. Treatment of acute hypoxemic nonhypercapnic respiratory insufficiency with continuous positive airway pressure delivered by a face mask: a randomized controlled trial. JAMA, 2000, 284(18): 2352-2360.
25. Doshi P, Whittle JS, Bublewicz M, et al. High‐velocity nasal insufflation in the treatment of respiratory failure: a randomized clinical trial. Ann Emerg Med, 2018, 72(1): 73-83.
26. Sun J, Li Y, Ling B, et al. High flow nasal cannula oxygen therapy versus non-invasive ventilation for chronic obstructive pulmonary disease with acute-moderate hypercapnic respiratory failure: an observational cohort study. Int J Chron Obstruct Pulmon Dis, 2019, 14: 1229-1237.

Chinese Journal of Respiratory and Critical Care Medicine

Invasive high-flow oxygen therapy and invasive-noninvasive ventilation sequential strategies for chronic obstructive pulmonary disease patients with severe respiratory failure: a randomized controlled trial

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