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Vol. 48. Issue 4.
Pages 200-210 (April 2024)
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Vol. 48. Issue 4.
Pages 200-210 (April 2024)
Original article
Switches in non-invasive respiratory support strategies during acute hypoxemic respiratory failure: Need to monitoring from a retrospective observational study
Francisco José Parrilla-Gómeza,b,1,
Corresponding author

Corresponding author: Critical Care Department, Hospital del Mar, Passeig Marítim 25-29, E-08003 Barcelona, Spain.
, Judith Marin-Corrala,c,1, Andrea Castellví-Fonta, Purificación Pérez-Terána,b, Lucía Picazoa, Jorge Ravelo-Barbaa, Marta Campano-Garcíaa, Olimpia Festad, Marcos Restrepoc,e,1, Joan Ramón Masclansa,b,1
a Critical Care Department, Hospital del Mar de Barcelona. Critical illness research group (GREPAC), Hospital del Mar Research Institute (IMIM)
b Department of Medicine and Life Sciences (MELIS), UPF, Barcelona, Spain
c Division of Pulmonary & Critical Care Medicine, University of Texas Health San Antonio, San Antonio, San Antonio, TX, USA
d Anaesthesia and Reanimation Department, Hospital General de Sant Boi, Barcelona, Spain
e Division of Pulmonary Diseases & Critical Care Medicine, South Texas Veterans Health Care System, San Antonio, TX, USA
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Tables (2)
Table 1. Patients characteristics in both study groups.
Table 2. NIRS switches characteristics and patients' characteristics at starting of first and second NIRS in both study groups.
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Additional material (4)

To explore combined non-invasive-respiratory-support (NIRS) patterns, reasons for NIRS switching, and their potential impact on clinical outcomes in acute-hypoxemic-respiratory-failure (AHRF) patients.


Retrospective, single-center observational study.


Intensive Care Medicine.


AHRF patients (cardiac origin and respiratory acidosis excluded) underwent combined NIRS therapies such as non-invasive-ventilation (NIV) and High-Flow-Nasal-Cannula (HFNC).


Patients were classified based on the first NIRS switch performed (HFNC-to-NIV or NIV-to-HFNC), and further specific NIRS switching strategies (NIV trial-like vs. Non-NIV trial-like and single vs. multiples switches) were independently evaluated.

Main variables of interest

Reasons for switching, NIRS failure and mortality rates.


A total of 63 patients with AHRF were included, receiving combined NIRS, 58.7% classified in the HFNC-to-NIV group and 41.3% in the NIV-to-HFNC group. Reason for switching from HFNC to NIV was AHRF worsening (100%), while from NIV to HFNC was respiratory improvement (76.9%). NIRS failure rates were higher in the HFNC-to-NIV than in NIV-to-HFNC group (81% vs. 35%, p < 0.001). Among HFNC-to-NIV patients, there was no difference in the failure rate between the NIV trial-like and non-NIV trial-like groups (86% vs. 78%, p = 0.575) but the mortality rate was significantly lower in NIV trial-like group (14% vs. 52%, p = 0.02). Among NIV to HFNC patients, NIV failure was lower in the single switch group compared to the multiple switches group (15% vs. 53%, p = 0.039), with a shorter length of stay (5 [2–8] vs. 12 [8–30] days, p = 0.001).


NIRS combination is used in real life and both switches’ strategies, HFNC to NIV and NIV to HFNC, are common in AHRF management. Transitioning from HFNC to NIV is suggested as a therapeutic escalation and in this context performance of a NIV-trial could be beneficial. Conversely, switching from NIV to HFNC is suggested as a de-escalation strategy that is deemed safe if there is no NIRS failure.

Non-invasive respiratory support
Acute hypoxemic respiratory failure
Non-invasive ventilation
High Flow Nasal Cannula
NIRS patterns
Switching strategies
Acute respiratory failure

Explorar los patrones combinados de soporte-respiratorio-no-invasivo (SRNI), las razones para cambiar de SRNI y su potencial impacto en los resultados clínicos en pacientes con insuficiencia-respiratoria-aguda-hipoxémica (IRAH).


Estudio observacional retrospectivo unicéntrico.


Cuidados Intensivos.


Pacientes con IRAH (excluyendo causa cardíaca y acidosis respiratoria) que recibieron tanto ventilación-no-invasiva (VNI) como cánula-nasal-de-alto-flujo (CNAF).


Se categorizó a los pacientes según el primer cambio de SRNI realizado (CNAF-to-VNI o VNI-to-CNAF) y se evaluaron estrategias específicas de SRNI (VNI trial-like vs. Non-VNI trial-like y cambio único vs. múltiples cambios de NIRS) de manera independiente.

Variables de interés principales

Razones para el cambio, así como las tasas de fracaso de SRNI y la mortalidad.


Un total de 63 pacientes recibieron SRNI combinado, 58,7% clasificados en el grupo CNAF-to-VNI y 41,3% en el grupo VNI-to-CNAF. Los cambios de CNAF a VNI ocurrieron por empeoramiento de la IRHA (100%) y de VNI a CNAF por mejora respiratoria (76.9%). Las tasas de fracaso de SRNI fueron mayores de CNAF a VNI que de VNI a CNAF (81% vs. 35%, p < 0.001). Dentro de los pacientes de CNAF a VNI, no hubo diferencia en las tasas de fracaso entre los grupos VNI trial-like y no-VNI trial-like (86% vs. 78%, p = 0.575), pero la mortalidad fue menor en el grupo VNI trial-like (14% vs. 52%, p = 0.02). Dentro de los pacientes de VNI a CNAF, el fracaso de VNI fue menor en grupo de cambio único vs. múltiple (15% vs. 53%, p = 0.039).


Los cambios de estrategia de SRNI son comunes en el manejo clínico diario de la IRHA. El cambio de CNAF a VNI impresiona de ser una escalada terapéutica y en este contexto la realización de un VNI-trial puede ser beneficioso. Al contrario, cambiar de VNI a CNAF impresiona de ser una desescalada terapéutica y parece segura si no hay fracaso del SRNI.

Palabras clave:
Soporte respiratorio no invasivo
Ventilación mecánica no invasiva
Cánula nasal de alto flujo
Síndrome de distres respiratorio agudo
Insuficiencia respiratoria aguda


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