Elsevier

Journal of Critical Care

Volume 27, Issue 5, October 2012, Pages 434-439
Journal of Critical Care

Infection/Respiratory
High-flow nasal therapy in adults with severe acute respiratory infection: A cohort study in patients with 2009 influenza A/H1N1v

https://doi.org/10.1016/j.jcrc.2012.04.006Get rights and content

Abstract

Purpose

The experience with high-flow nasal cannula (HFNC) oxygen therapy in severe acute respiratory infection (SARI) is limited. The objective was to assess the effectiveness of HFNC oxygen therapy in adult patients with SARI by confirmed 2009 influenza A/H1N1v infection (by real-time reverse transcription polymerase chain reaction testing).

Material and Methods

A single-center post hoc analysis of a cohort of intensive care unit patients admitted with SARI due to 2009 Influenza A/H1N1v was done. High-flow nasal cannula (Optiflow; Fisher & Paykel, Auckland, New Zealand) was indicated in the presence of acute respiratory failure when the patient was unable to maintain a pulse oxymetry more than 92% with more than 9 L/min of oxygen using a standard face mask conventional delivery systems. Nonresponders were defined by their need of subsequent mechanical ventilation.

Results

Twenty-five nonintubated adult patients were admitted for SARI (21 pneumonia). Twenty were unable to maintain pulse oxymetry more than 92% with conventional oxygen administration and required HFNC O2 therapy, which was successful in 9 (45%). All 8 patients on vasopressors required intubation within 24 hours. After 6 hours of HFNC O2 therapy, nonresponders presented a lower Pao2/fraction of inspired oxygen (median, 135 [interquartile range, 84-210] vs 73 [56-81] mm Hg P < .05) and needed higher oxygen flow rate. No secondary infections were reported in health care workers. No nosocomial pneumonia occurred during HFNC O2 therapy.

Conclusion

High-flow nasal cannula O2 therapy appears to be an innovative and effective modality for early treatment of adults with SARI.

Introduction

Severe acute respiratory infection (SARI) due to pandemic 2009 influenza A/H1N1v infection was characterized by a rapid acute respiratory failure (ARF), preceded by 3 to 5 days of flu-like symptoms. Data from large cohorts during the pandemic period indicated that 30% of all hospital-admitted patients required intensive care unit (ICU) admission with more than 60% of them being subsequently mechanically ventilated [1], [2].

High-flow nasal cannula (HFNC) O2 therapy is the newest and least known noninvasive option for the clinical management of patients with ARF. Current heated/humidified high flow (up to 50 L/min) devices have achieved a great degree of efficacy and comfort in delivering high-flow oxygen compared with conventional oxygen therapy [3]. Furthermore, improvement in oxygenation with HFNC has been described in patients with mild to severe ARF [3], [4], [5]. For these reasons and the comfort provided to the patient, HFNC O2 therapy appears to be an innovative modality for early treatment of adult patients with severe ARF. Although it has the potential to reduce the need of mechanical ventilation (MV), its indications remain speculative. Information on SARI due to influenza A/H1N1v is limited to 5 patients [4].

Our hypothesis was that HFNC O2 therapy could be an efficient noninvasive intervention and that it might alleviate the need for MV in some patients with SARI. To evaluate this hypothesis, the clinical course of nonintubated patients with SARI was recorded, with specific focus on those receiving HFNC O2 therapy who were also compared with control patients already mechanically ventilated on admission. Primary end points were the need for MV and ICU mortality. Secondary objectives of the analysis were to identify a subset of patients most likely to benefit from HFNC O2 therapy and to anticipate outcomes.

Section snippets

Methods

This study represents a post hoc analysis of a prospectively assessed cohort of adult patients admitted with ARF due to 2009 influenza A/H1N1v infection (in the general ICU of Vall d'Hebron University Hospital in Barcelona, a large tertiary university hospital) from September 1, 2009, to January 31, 2011. Patients reported in this study were also reported to a large national registry, which received ethics board approval in July 2009 (ref. 07/J23). Informed consent was waived because of the

Results

Thirty-five adult patients with confirmed 2009 influenza A/H1N1v infections required ICU admission because of SARI with severe hypoxemia or acute respiratory distress syndrome. All patients received oral oseltamivir and parenteral antibiotics. Ten patients (28.6%) already required intubation before ICU admission. Data for intubated patients were compared with patients requiring HFNC O2 treatment. High-flow nasal cannula O2 therapy patients were significantly younger (37 [29-47] vs 50 [44-56]

Discussion

This is the first study reporting HFNC used in a series of adult patients as early therapy for severe ARF caused by 2009 influenza A/H1N1v infection. Our findings suggest that all patients with inotropes required intubation. Furthermore, patients without cardiovascular compromise and an RR above 30 breaths per minute on conventional oxygen therapy, upon ICU admission, may benefit of a HFNC trial. Six hours after onset of treatment, failing patients demonstrated worse oxygenation (Pao2/Fio2 < 100

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Conflicts of interest: Dr Masclans and Dr Roca have received honoraria as lecture fees from Fisher & Paykel. This study has been funded in part with CIBERES funding (PCI Neumonia) and AGAUR (2009SGR01226). Fisher & Paykel did not have access to the manuscript and have not participated neither in the study design or interpretation of results. Dr Pérez, Dr Poulakou, Dr Souto, Dr Laborda, Dr Balcells, and Dr Rello have no conflict of interest to disclose.

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