Treatment Failure Less Likely With HFNC Than NIV Among Patients With COPD, Study Finds

New study findings are supporting the use of high-flow nasal cannula (HFNC) in patients with chronic obstructive pulmonary disease (COPD) who have hypercapnic respiratory failure, with results demonstrating that HFNC after extubation led to a lower risk of treatment failure than non-invasive ventilation (NIV).

The randomized study, which looked at the outcomes of 86 patients receiving either HFNC or NIV, found a treatment failure risk difference of 5.8%, with a treatment failure rate of 22.7% among the 44 patients receiving HFNC and a treatment failure rate of 28.6% among the 42 patients receiving NIV. Treatment failure was defined as reintubation or switching to another treatment.

HFNC oxygen therapy is a new type of respiratory support system, but it is increasingly being used as a method to prevent post-extubation hypoxemic respiratory failure and reintubation. However, until this study, there’s been little evidence has on whether the treatment is a viable option for COPD patients with hypercapnic respiratory failure—a common but serious complication of the disease—after intubation. According to the researchers, HFNC supplies high flow mixed gases through special nasal prongs at a sufficient temperature and humidity for patient comfort.

The researchers of the study compared the effectiveness of HFNC with NIV, which has been touted as a way to reduce the duration of invasive ventilation typically required for severe cases of acute hypercapnic respiratory failure by using a pulmonary infection control window as the switching point.

“The success of NIV is closely related to the experience and abilities of the treating medical staff, the level of education and compliance of patients, and the performance of the NIV device,” explained the researchers. “Due primarily to poor patient tolerance, NIV fails in approximately 15 to 25% of patients, potentially leading to endotracheal intubation. For post-extubation patients with COPD who cannot tolerate NIV or have contraindications to NIV, alternative respiratory support methods are urgently needed.”

In addition to carrying a lower risk of treatment failure, HFNC was also found to be more comfortable for patients. When analyzing the reasons for treatment failure, the researchers found significantly lower treatment intolerance among patients receiving NIV, resulting in a risk difference of –50.0%. Among the 6 patients in the NIV group who experienced intolerance, there were feelings of claustrophobia, excessive air flow or pressure, breathlessness, and headache.

The researchers also observed significantly less airway care interventions and cases of nasofacial skin breakdown when patients were treated with HFNC, which they credited to the treatment’s nasal plug design and better comfort. There was an average number of 6 daily airway care interventions for patients receiving HFNC compared to an average number of 7 daily interventions for patients receiving NIV.

“Due to intolerance, drinking and eating, sputum clearance, communication, discomfort, or displacement of the NIV mask, NIV patients frequently remove their masks and significantly increase the nursing workload,” noted the researchers. “Patients in the HFNC group were not restricted by respiratory support in eating, drinking, and communicating.”

An hour following extubation, the mean respiratory rates for both groups of patients was faster than baseline levels. A day after patients were extubated, the respiratory rates of patients receiving HFNC returned to baseline levels; however, levels were still higher among patients receiving NIV. Two days later, both groups had respiratory levels comparable to those at baseline.

Reference

Tan D, Walline J, Ling B, et al. High-flow nasal cannula oxygen therapy versus non-invasive ventilation for chronic obstructive pulmonary disease patients after extubation: a multicenter, randomized controlled trial. Critical Care. Published online August 6, 2020. doi:10.1186/s13054-020-03214-9