Elsevier

Journal of Critical Care

Volume 25, Issue 3, September 2010, Pages 463-468
Journal of Critical Care

Respiratory/Ventilation
High-flow nasal oxygen vs high-flow face mask: A randomized crossover trial in extubated patients

https://doi.org/10.1016/j.jcrc.2009.06.050Get rights and content

Abstract

Purpose

Oxygen delivery after extubation is critical to maintain adequate oxygenation and to avoid reintubation. The delivery of oxygen in such situations is usually by high-flow face mask (HFFM). Yet, this may be uncomfortable for some patients. A recent advance in oxygen delivery technology is high-flow nasal prongs (HFNP). There are no randomized trials comparing these 2 modes.

Methods

Patients were randomized to either protocol A (n = 25; HFFM followed by HFNP) or protocol B (n = 25; HFNP followed by HFFM) after a stabilization period of 30 minutes after extubation. The primary objective was to compare the efficacy of HFNP to HFFM in maintaining gas exchange as measured by arterial blood gas. Secondary objective was to compare the relative effects on heart rate, blood pressure, respiratory rate, comfort, and tolerance.

Results

Patients in both protocols were comparable in terms of age, demographic, and physiologic variables including arterial blood gas, blood pressure, heart rate, respiratory rate, Glasgow Coma Score, sedation, and Acute Physiology and Chronic Health Evaluation (APACHE) III scores. There was no significant difference in gas exchange, respiratory rate, or hemodynamics. There was a significant difference (P = .01) in tolerance, with nasal prongs being well tolerated. There was a trend (P = .09) toward better patient comfort with HFNP.

Conclusions

High-flow nasal prongs are as effective as HFFM in delivering oxygen to extubated patients who require high-flow oxygen. The tolerance of HFNP was significantly better than in HFFM.

Introduction

Optimal oxygen delivery after extubation is critical to maintain adequate oxygenation and avoid reintubation. The delivery of oxygen in such situations is usually by high-flow face mask (HFFM). Although face masks are used commonly and are effective, some patients find these masks to be uncomfortable and claustrophobic, leading to frequent removal [1]. Furthermore, it is difficult to communicate and eat while receiving oxygen through face masks [2]. Face masks are often displaced, particularly, while the patients are sleeping [3], [4]. All these factors can potentially lead to inadequate delivery of the prescribed oxygen with the associated complications.

The other commonly used oxygen delivery system is nasal cannula. Nasal cannulas have several potential advantages over a face mask. They are generally better tolerated than face masks [2]. They do not interfere with eating or drinking, allow patients to talk without removal, and do not cause claustrophobia. Nasal cannulas have been found to be more comfortable than face masks [5]. Given these advantages, it is not surprising that most patients prefer nasal cannulas than face masks [6]. In spite of this, there are concerns that nasal cannulas may not deliver adequate oxygen in “mouth breathers” [1]. Moreover, nasal cannulas are traditionally used only in situations where the required oxygen delivery is not more than 4 L/min because of the potential drying of the nasal mucosa [7].

A recent advance in oxygen delivery technology is the high-flow nasal prongs (HFNP; Fisher and Paykel Healthcare, Auckland, New Zealand). These can deliver up to 50 L/min of warm and humidified oxygen similar to HFFM. Humidification prevents the nasal mucosa from drying up. In addition, HFNP were also shown to generate a significant positive airway pressure [8], which could further aid in improving oxygenation. High-flow nasal prongs have been used and validated in the neonatal population [9], [10], [11]. A few small studies have also reported on their usefulness in the adult population [8], [12], but, to date, there is no randomized evaluation of their efficacy in adult patients.

The primary objective of this study was to compare the relative efficacy of HFNP with HFFM in maintaining gas exchange. Secondary objective included the comparison of relative effects of the 2 delivery modes on heart rate, blood pressure, respiratory rate, patient comfort, and tolerance.

Section snippets

Ethics and enrollment procedure

Ethical approval was obtained from the Human Research Ethics Committee for Clinical Research at Peninsula Health. The family/next of kin of the potential participant was first presented with an information leaflet. After the family had read and understood the information pertaining to the study, researchers approached them for assent for the enrollment of patients into the trial. Further explanation and clarifications were provided at this stage.

Participant eligibility

All adult patients (>18 years) with family to

Results

Fifty patients were recruited with 25 patients each randomized to protocol A or B.

Eight patients were excluded from the final analysis (4 patients met exit criteria, and complete data were missing in 4 patients). As shown in Table 3, both groups were comparable in terms of age, sex, diagnoses, numbers of hours ventilated before extubation, GCS, sedation, and APACHE III scores at randomization. After stabilization of 30 minutes, the gas exchange and other physiologic parameters were comparable (

Discussion

Our study reveals that HFNP are comparable with HFFM in terms of providing adequate gas exchange. High-flow nasal prongs were tolerated better than HFFM, and there was a trend toward better patient comfort with the use of HFNP that did not reach statistical significance.

The use of high-flow nasal oxygen has been studied mostly in neonatal patients [9], [10], [11]. Studies evaluating high-flow humidified oxygen therapy in neonatal patients claim it to be associated with improved respiratory

Conclusions

High-flow nasal prongs were found to be as effective as HFFM in delivering oxygen in extubated patients who require high flow. Patient tolerance of HFNP was significantly better than that in HFFM.

Acknowledgments

The authors would like to thank Nina Fowler, Laurel Walker, Jodi Vuat, Naomi Pratt, and all our ICU staff for their help in this study and also Fisher and Paykel Healthcare for supporting this study.

References (16)

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