High flow, low results: The limits of high flow nasal cannula in the treatment of bronchiolitis.

Bronchiolitis continues to be the most common cause of hospitalization in the first year of life. We continue to search for the remedy that will improve symptoms, shorten hospitalization and prevent worsening of disease. Although initially thought to be a promising therapy, large randomized controlled trials show us that high flow nasal cannula (HFNC) use is not that remedy. These trials show no major differences in duration of hospital stay, intensive care unit (ICU) admission rates, duration of stay in the ICU, duration of oxygen therapy, intubation rates, heart rate, respiratory rate or comfort scores. Additionally, practices regarding initiation, flow rates and weaning continue to vary from institution to institution and there are currently no agreed upon indications for its use. This reveals the need for evidence based guidelines on HFNC use in bronchiolitis.

Estrategias de destete y desmonte de cánula nasal de alto flujo en adultos / Adult High-Flow Nasal Cannula Weaning and Disassembly Strategies

Introducción: La cánula nasal de alto flujo es un sistema que utiliza una mezcla de aire-oxígeno humidificado y calentado con un caudal de hasta 70 litros por minuto. Es utilizada mayoritariamente en la insuficiencia respiratoria aguda de origen hipoxémico, donde ha demostrado brindar mayor comodidad y poder resolutivo de la hipoxemia, en comparación con la oxigenoterapia convencional. Aunque se conocen sus indicaciones y estrategia de seguimiento, en la práctica clínica no es claro su proceso de destete/desmonte. Objetivo: Identificar en la bibliografía la literatura existente acerca de estrategias de destete/desmonte de la cánula nasal de alto flujo en adultos. Métodos: Se realizó una revisión bibliográfica en las bases de datos del portal regional de la BVS, PubMed, Web Of Science, Scopus y Google scholar, sin límite de tiempo y es- tructurando una ecuación PIO con palabras clave y operadores booleanos. Se asumieron artículos publicados en inglés y español, texto completo. Resultados: En la bibliografía, aún se reporta discrepancia en el proceso de destete y desmonte de la cánula nasal de alto flujo, pero en la mayoría de los estudios encontrados en esta revisión se propone disminuir la FiO2 primero de forma gradual (5-10%) hasta valores de 30-50% y, posteriormente, el flujo. Para desmontarla, se podría considerar tener una FiO2 entre 30-50%, flujo entre 20-30 litros por minuto, SaO2 >92%, con adecuada mecánica respiratoria y estado de conciencia. Conclusión: Aún no existe unanimidad en el proceso de destete/desmonte en la cánula nasal de alto flujo en el paciente adulto.

Introduction: The high-flow nasal cannula is a system that uses a humidified and heated air-oxygen mixture with a flow rate of up to 70 liters per minute. It is mostly used in acute respiratory failure of hypoxemic origin, where it has been shown to provide greater comfort and resolving power of hypoxemia, compared to conventional oxygen therapy. Although its indications and follow-up strategy are known, in clinical practice the weaning/weaning process is not clear. Objective: To identify in the bibliography the existing literature on weaning/ weaning strategies of high-flow nasal cannula in adults. Methods: A bibliographic review was carried out in the databases of the regional portal of the BVS, PubMed, Web Of Science, Scopus and Google scholar, without time limit and structuring a PIO equation with keywords and boléan connectors. Articles published in English and Spanish, full text, were assumed. Results: The literature still reports discrepancy in the process of weaning and disassembling the high-flow nasal cannula, but most of the studies found in this review propose to decrease the FiO2 first gradually (5-10%) to values of 30-50% and then the flow. To dismantle it, one could consider having a FiO2 between 30-50%, flow between 20-30 liters per minute, SaO2 >92%, with adequate respiratory mechanics and state of consciousness. Conclusion: There is still no unanimity on the weaning/weaning process in the high- flow nasal cannula in the adult patient.

Role of High Flow Nasal Cannula as a Novel Therapy for Treatment of Severe Obstructive Sleep Apnea in a Child With Neuroendocrine Hyperplasia of Infancy: A Case Report and Review of Literature.

Neuroendocrine hyperplasia of infancy is a rare form of pediatric interstitial lung disease presenting with hypoxemia, tachypnea, retractions, and persistent pulmonary crackles in the first year of life. As these children frequently require supplemental oxygen therapy and demonstrate nighttime hypoxemia, there is a concern for an increased prevalence of sleep-disordered breathing in this population, including obstructive sleep apnea. As untreated sleep-disordered breathing is associated with adverse developmental outcomes for children, it is essential to promptly diagnose and treat. However, treatment of obstructive sleep apnea is often challenging in children. In this report, we describe a case of a child diagnosed with neuroendocrine hyperplasia of infancy at 12 months of age who was subsequently found to have severe obstructive sleep apnea that persisted despite adenotonsillectomy. As continuous positive airway pressure was not well tolerated, the patient was initiated on a high-flow nasal cannula at nighttime, which resulted in improvement of his sleep apnea and daytime functioning with better adherence to treatment. Our case illustrates the importance of screening for sleep-disordered breathing in patients with neuroendocrine hyperplasia of infancy, as well as the utility of a high-flow nasal cannula as a novel, effective treatment for pediatric obstructive sleep apnea.

Switches in non-invasive respiratory support strategies during acute hypoxemic respiratory failure: Need to monitoring from a retrospective observational study

Objective 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. Design Retrospective, single-center observational study. Setting Intensive Care Medicine. Patients AHRF patients (cardiac origin and respiratory acidosis excluded) underwent combined NIRS therapies such as non-invasive-ventilation (NIV) and High-Flow-Nasal-Cannula (HFNC). Interventions 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. Results 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). Conclusions 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. ... (AU)

Objetivo 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). Diseño Estudio observacional retrospectivo unicéntrico. Ámbito Cuidados Intensivos. Pacientes Pacientes con IRAH (excluyendo causa cardíaca y acidosis respiratoria) que recibieron tanto ventilación-no-invasiva (VNI) como cánula-nasal-de-alto-flujo (CNAF). Intervenciones 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. Resultados 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). Conclusiones 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 ... (AU)

Rehabilitación Respiratoria con cánula nasal de alto flujo en pacientes con enfermedades respiratorias crónicas / Respiratory Rehabilitation with high-flow nasal cannula in patients with chronic respiratory diseases / Reabilitação Respiratória com cânula nasal de alto fluxo em doentes com doença respiratória crónica

Las enfermedades respiratorias crónicas, se incrementan a nivel mundial, destacándose EPOC, fibrosis pulmonar, bronquiectasia y sumándose la condición post COVID-19 asociadas a las vías respiratorias. Objetivo. Determinar los efectos de la rehabilitación respiratoria con cánula nasal de alto flujo en pacientes con enfermedades respiratorias crónicas. Material y método. Estudio realizado en un hospital militar peruano a una muestra constituida por 115 pacientes, quienes ingresaron a un programa de Rehabilitación Respiratoria de 12 semanas con la asistencia de la Cánula de alto flujo durante cada sesión y evaluados al inicio y al final mediante el test de pararse y sentarse en un minuto. El diseño fue pre experimental con pre y post test, corte longitudinal, de tipo aplicada. Se obtuvo la media y desviación estándar y se realizó la prueba de rangos con signo de Wilcoxon, se consideró una significancia del 95% y un valor p<0,05 como estadísticamente significativo. Resultados. La media de la edad fue de 58,30 ± 8,17; el 62,6% fue hombres y 37,4% mujeres; los pacientes con condición Post COVID-19 fueron el 71.30%, seguidos de fibrosis pulmonar con 12,17%; con 7,16±1,24 (p<0,000), en el número de repeticiones mediante pararse y sentarse durante un minuto, lo que mejoró principalmente la fatiga muscular (p<0,003). Conclusiones. Se determina como cambio, que se duplica lo mínimamente significativo mediante la prueba de pararse y sentarse durante un minuto. Además, se evidencia mejor respuesta al ejercicio, con menor disnea y fatiga muscular, por efecto de la presión positiva de la cánula de alto flujo.

Chronic respiratory diseases are increasing worldwide, with COPD, pulmonary fibrosis, bronchiectasis and post COVID-19 conditions associated with the respiratory tract standing out. Objective. To determine the effects of respiratory rehabilitation with high-flow nasal cannula in patients with chronic respiratory diseases. Method. Study carried out in a Peruvian military hospital on a sample of 115 patients, who entered a 12-week Respiratory Rehabilitation program with the assistance of the high-flow nasal cannula during each session and evaluated at the beginning and at the end by means of the test of standing up and sitting down in one minute. The design was pre-experimental with pre- and post-test, longitudinal cut, applied type. The mean and standard deviation were obtained and the Wilcoxon signed-rank test was performed, a significance of 95% and a value p<0.05 was considered statistically significant. Results. The mean age was 58.30±8.17; 62.6% were male and 37.4% female; patients with Post COVID-19 condition were 71.30%, followed by pulmonary fibrosis with 12.17%; with 7.16±1.24 (p<0.000), in the number of repetitions by standing and sitting for one minute, which mainly improved muscle fatigue (p<0.003). Conclusions. It is determined as a change, that the minimally significant is duplicated by the test of standing and sitting for one minute. In addition, a better response to exercise is evidenced, with less dyspnea and muscle fatigue, due to the effect of the positive pressure of the high flow cannula.

As doenças respiratórias crónicas estão a aumentar em todo o mundo, com destaque para a DPOC, a fibrose pulmonar, as bronquiectasias e as doenças pós-COVID-19 associadas ao trato respiratório. Objetivo. Determinar os efeitos da reabilitação respiratória com cânula nasal de alto fluxo em doentes com doenças respiratórias crónicas. Método. Estudo realizado num hospital militar peruano com uma amostra de 115 pacientes, que entraram num programa de Reabilitação Respiratória de 12 semanas com a assistência da cânula nasal de alto fluxo durante cada sessão e avaliados no início e no fim através do teste de sentar e levantar de um minuto. O delineamento foi pré-experimental com pré e pós-teste, longitudinal, do tipo aplicado. Obteve-se média e desvio padrão e realizou-se o teste de Wilcoxon signed-rank, com 95% de significância e valor de p < 0,05 foi considerado estatisticamente significativo. Resultados. A média de idade foi de 58,30±8,17; 62,6% eram do sexo masculino e 37,4% do sexo feminino; pacientes com quadro pós COVID-19 foram 71,30%, seguido de fibrose pulmonar com 12,17%; com 7,16±1,24 (p<0,000), no número de repetições em pé e sentado por um minuto, que melhorou principalmente a fadiga muscular (p<0,003). Conclusões. Determina-se como mudança, que o minimamente significativo é duplicado pelo teste de estar de pé e sentado durante um minuto. Além disso, evidencia-se uma melhor resposta ao exercício, com menos dispneia e fadiga muscular, devido ao efeito da pressão positiva da cânula de alto fluxo.

Utilización de soportes respiratorios no invasivos post extubación en pacientes adultos críticos: revisión narrativa SRNI post extubación en adultos críticos / Use of Non-Invasive Respiratory Support in Critically Ill Patients Post-Extubation: a Narrative Review NIRS Post-Extubation in Critically Ill Adults

La tasa de reintubación orotraqueal luego de la extubación se registra entre un 10 a 20%. La aplicación de soportes respiratorios no-invasivos (SRNI) posterior a la extuba-ción como cánula nasal de alto-flujo, ventilación no invasiva (dos niveles de presión) y presión positiva continua en la vía aérea demostraron ser seguras y efectivas post ex-tubación. El período pre-destete representa un momento crucial en el manejo de los pa-cientes críticos ya que el fracaso de la extubación, definido como la necesidad de reintu-bación dentro de los 2 a 7 días, demostró peores resultados al aumentar la mortalidad entre un 25-50%. Esta situación conlleva al requerimiento de ventilación mecánica prolongada, neumonía asociada a la ventilación mecánica y estancias prolongadas de internación. Por lo tanto, es esencial identificar a los pacientes que se beneficiarán utilizando SRNI post extubación.

The rate of re-intubation after extubation is recorded at 10-20%. The use of non-invasive respiratory support (NIRS) post-extubation such as high-flow nasal cannula, non-invasive ventilation (bilevel pressure) and continuous positive airway pressure (CPAP) have been shown to be safe and effective post-extubation. The pre-weaning period represents a crucial time in the management of critically ill patients, as extubation failure, defined as the need for reintubation within 2-7 days, showed worse outcomes with mortality increasing by 25-50%. This situation leads to the requirement for prolonged mechanical ventilation, ventilator-associated pneumonia and long lengths of hospital stay. Therefore, it is essential to identify patients who will benefit from NIRS post extubation.

Cánula Nasal de Alto Flujo Asimétrica: una Revisión Narrativa / Asymmetrical High Flow Nasal Cannula: a Narrative Review

Los sistemas de Cánula nasal de alto flujo (CNAF) han sido ampliamente utilizados en el campo clínico como soporte no invasivo en el manejo de la falla respiratoria aguda (sobre todo hipoxémica) y cuidados post extubación. Clínica y fisiológicamente, las cánulas nasales de alto flujo son capaces de entregar un flujo de oxigeno alto que, debido a que ese gas se encuentra optimamente humidificado y calefaccionado, permite una mejor tolerancia por parte del paciente al ser comparada con las cánulas de oxigeno tradicionales. Por otra parte, este alto. Flujo es capaz de generar una presión positiva al final de la espiración (CPAP) en la vía área y favorecer tanto en barrido de dióxido de carbono (CO2) desde la vía aérea superior, lo que disminuye el trabajo respiratorio del paciente y mejora su confort.. Sin embargo; aún existe un alto porcentaje de pacientes que fracasan la terapia con CNAF y requiere soportes mas complejos como la ventilación mecánica, ya sea imvasiva o no. Estos resultados con la terapia CNAF pueden ser influidos por aspectos técnicos como, por ejemplo, la turbulencia que pueden generar estos sistemas a nivel de la región nasal. Por esta razón se han desarrollado nuevas tecnologías en el diseño y uso de interfaces para suministrar este alto flujo. Una de estas innovaciones es el uso de cánulas asimétricas, las que potencian los beneficios fisiológicos que entrega una cánula de alto flujo convencional. La presente revisión pretende exponer las principales diferencias que presenta el sistema de alto flujo convencional versus la nueva interface asimétrica.

High-flow nasal cannula (HFNC) systems have been widely used in the clinical field as non-invasive support in the management of acute respiratory failure (especially hypoxemic) and post-extubation care. Clinically and physiologically, high flow nasal cannulas are capable of delivering a high flow of oxygen which, because this gas is optimally humidified and heated, allows better tolerance by the patient when compared to traditional oxygen cannulas. . On the other hand, this high. Flow is capable of generating positive pressure at the end of expiration (CPAP) in the airway and favoring the sweep of carbon dioxide (CO2) from the upper airway, which reduces the patient's respiratory work and improves their comfort. .. However; There is still a high percentage of patients who fail therapy with HFNC and require more complex supports such as mechanical ventilation, whether invasive or not. These results with HFNC therapy can be influenced by technical aspects such as, for example, the turbulence that these systems can generate in the nasal region. For this reason, new technologies have been developed in the design and use of interfaces to provide this high flow. One of these innovations is the use of asymmetric cannulas, which enhance the physiological benefits provided by a conventional high-flow cannula. The present review aims to expose the main differences that the conventional high flow system presents versus the new asymmetric interface.

RAM Cannula Versus Bi-Nasal Prongs as Respiratory Device Interfaces in Neonates of Thirty-Two or More Weeks of Gestation With Respiratory Distress: The First "ProRAM" Randomized Trial Report.

Background: Using bilateral short nasal prongs as an interface for noninvasive respiratory support is challenging, and it is associated with nasal injury. We aimed to compare RAM cannula with nasal prongs in delivering noninvasive ventilation to newborn infants. Methods: This is a single-center randomized trial (trial registry: ISRCTN10561691). The setting involves a tertiary neonatal unit with a capacity of 30 beds and more than 13 years of experience in neonatal noninvasive ventilation. We included 50 infants born at ≥ 32 weeks of gestation, who had respiratory distress at birth. We excluded those with major congenital anomalies and those who required intubation in the delivery room. Primary outcomes were intubation rate and use of noninvasive positive-pressure ventilation (NIPPV); other outcomes included air leak and nasal injury rate. The infants were assigned using randomly generated numbers into bi-nasal prong and RAM canula groups in a 1:1 ratio. Results: Two and four babies in the RAM and prong groups, respectively, were upgraded to NIPPV (P = 0.600). One versus no baby in the RAM vs. prong groups was intubated (P = 1.000). Newborns in the prong group required oxygen support for a longer period (mean duration: 154.6 ± 255.2 h) than those in the RAM group (40.7 ± 72.6 h, P = 0.030). None of the patients in the RAM group had traumatic nasal injury compared to five babies in the prong group (P = 0.050). Four babies in our study developed air leaks, with two in each group. Conclusions: The use of RAM cannula in delivering noninvasive ventilation to newborns ≥ 32 weeks of age did not affect the noninvasive ventilation failure rate or incidence of air leak. The use was associated with a shorter duration of respiratory support and a reduced risk of nasal septal injury.

Intraoperative high flow oxygen therapy for tubeless anaesthesia in thoracoscopic surgery.

Tubeless anaesthesia has become widespread in videothoracoscopic surgery, even in major procedures such as lobectomies. There are several advantages in avoiding general anaesthesia and one-lung mechanical ventilation, such as faster recovery and shorter hospital stays. However, hypoxaemia and hypercapnia are the most reported causes of conversion to general anaesthesia. High Flow Oxygen Therapy (HFOT) generates flow-dependent positive end-expiratory pressure, improves oxygenation and also carbon dioxide washout by flow-dependent dead space flushing. For this reason, intraoperative HFOT may reduce the rate of conversion to general anaesthesia. We report our experience with intraoperative HFOT in a 71-year-old female with lung adenocarcinoma undergoing VATS upper left lobectomy.

Switches in non-invasive respiratory support strategies during acute hypoxemic respiratory failure: Need to monitoring from a retrospective observational study.

OBJECTIVE: 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. DESIGN: Retrospective, single-center observational study. SETTING: Intensive Care Medicine. PATIENTS: AHRF patients (cardiac origin and respiratory acidosis excluded) underwent combined NIRS therapies such as non-invasive-ventilation (NIV) and High-Flow-Nasal-Cannula (HFNC). INTERVENTIONS: 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. RESULTS: 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). CONCLUSIONS: 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.

High-flow nasal cannula and non-invasive mechanical ventilation in pediatric asthma exacerbation: two-year prospective observational study in intensive care.

BACKGROUND: Asthma is a common cause of admission to the pediatric intensive care unit (PICU). We described and analyzed the therapies applied to children admitted to a tertiary PICU because of asthma. Later, we evaluated high-flow nasal cannula (HFNC) use in these patients and compared their evolution and complications with those who received non-invasive ventilation. METHODS: We conducted a prospective observational study (October 2017-October 2019). Collected data: epidemiological, clinical, respiratory support therapy needed, complementary tests, and PICU and hospital stay. Patients were divided into three groups: (1) only HFNC; (2) HFNC and non-invasive mechanical ventilation (NIMV); and (3) only NIMV. RESULTS: Seventy-six patients were included (39 female). The median age was 2 years and 1 month. The median pulmonary score was 5. The median PICU stay was 3 days, and the hospital stay was 6 days. Children with HNFC only (56/76) had fewer PICU days (p = 0.025) and did not require NIMV (6/76). Children with HFNC had a higher oxygen saturation/fraction of inspired oxygen ratio ratio (p = 0.025) and lower PCO2 (p = 0.032). In the group receiving both therapies (14/76), NIMV was used first in all cases. No epidemiologic or clinical differences were found among groups. CONCLUSION: HFNC was a safe approach that did not increase the number of PICU or hospital days. On admission, normal initial blood gases and the absence of high oxygen requirements were useful in selecting responders to HFNC. Further randomized and multicenter clinical trials are needed to verify these data.

INTRODUCCIÓN: El asma es una causa frecuente de ingreso en la unidad de cuidados intensivos pediátricos (UCIP). En este, cuadro el uso de cánula nasal de alto flujo (CNAF) se ha visto extendido. En este trabajo se describe el tratamiento global en la UCIP ante el ingreso por asma en un hospital monográfico pediátrico y se evalúa la respuesta al uso de la CNAF, comparando la evolución de los pacientes con aquellos que recibieron ventilación no invasiva (VNI). MÉTODOS: Se llevó a cabo un estudio observacional prospectivo (de octubre del 2017 a octubre del 2019). Se describieron epidemiología, clínica, tratamiento y soporte respiratorio. Para la comparación se crearon tres grupos de pacientes: 1) solo CNAF; 2) CNAF y VNI; y 3) solo VNI. RESULTADOS: Se incluyeron 76 pacientes. La mediana de edad fue de dos años y un mes; la mediana de índice pulmonar fue 5. La mediana de ingreso en UCIP fue de tres días y de ingreso hospitalario, seis días. Los niños con solo CNAF (56/76) mostraron menos días de UCIP (p = 0.025) y no requirieron VNI (6/76). También mostraron mayor SatO2/FiO2 (saturación de oxígeno/fracción de oxígeno inspirado) (p = 0.025) y menor nivel de PCO2 (presión parcial de CO2) (p = 0.032). La VNI se utilizó primero siempre en el grupo que recibió ambas modalidades (14/76). No se encontraron diferencias epidemiológicas o clínicas entre grupos. CONCLUSIONES: En nuestra serie, el uso de CNAF no aumentó los días de ingreso en la UCIP ni de hospital. Tampoco requirió cambio a VNI. Al ingreso, una gasometría normal y bajo requerimiento de oxígeno permitieron seleccionar a los pacientes respondedores. Se necesitan más ensayos multicéntricos clínicos aleatorizados para verificar estos datos.

High-flow nasal cannula and non-invasive mechanical ventilation in pediatric asthma exacerbation: two-year prospective observational study in intensive care / Cánula nasal de alto flujo y ventilación no invasiva en asma pediátrico grave: estudio observacional prospectivo de dos años de duración en cuidados intensivos

Abstract Background: Asthma is a common cause of admission to the pediatric intensive care unit (PICU). We described and analyzed the therapies applied to children admitted to a tertiary PICU because of asthma. Later, we evaluated high-flow nasal cannula (HFNC) use in these patients and compared their evolution and complications with those who received non-invasive ventilation. Methods: We conducted a prospective observational study (October 2017-October 2019). Collected data: epidemiological, clinical, respiratory support therapy needed, complementary tests, and PICU and hospital stay. Patients were divided into three groups: (1) only HFNC; (2) HFNC and non-invasive mechanical ventilation (NIMV); and (3) only NIMV. Results: Seventy-six patients were included (39 female). The median age was 2 years and 1 month. The median pulmonary score was 5. The median PICU stay was 3 days, and the hospital stay was 6 days. Children with HNFC only (56/76) had fewer PICU days (p = 0.025) and did not require NIMV (6/76). Children with HFNC had a higher oxygen saturation/fraction of inspired oxygen ratio ratio (p = 0.025) and lower PCO2 (p = 0.032). In the group receiving both therapies (14/76), NIMV was used first in all cases. No epidemiologic or clinical differences were found among groups. Conclusion: HFNC was a safe approach that did not increase the number of PICU or hospital days. On admission, normal initial blood gases and the absence of high oxygen requirements were useful in selecting responders to HFNC. Further randomized and multicenter clinical trials are needed to verify these data.

Resumen Introducción: El asma es una causa frecuente de ingreso en la unidad de cuidados intensivos pediátricos (UCIP). En este, cuadro el uso de cánula nasal de alto flujo (CNAF) se ha visto extendido. En este trabajo se describe el tratamiento global en la UCIP ante el ingreso por asma en un hospital monográfico pediátrico y se evalúa la respuesta al uso de la CNAF, comparando la evolución de los pacientes con aquellos que recibieron ventilación no invasiva (VNI). Métodos: Se llevó a cabo un estudio observacional prospectivo (de octubre del 2017 a octubre del 2019). Se describieron epidemiología, clínica, tratamiento y soporte respiratorio. Para la comparación se crearon tres grupos de pacientes: 1) solo CNAF; 2) CNAF y VNI; y 3) solo VNI. Resultados: Se incluyeron 76 pacientes. La mediana de edad fue de dos años y un mes; la mediana de índice pulmonar fue 5. La mediana de ingreso en UCIP fue de tres días y de ingreso hospitalario, seis días. Los niños con solo CNAF (56/76) mostraron menos días de UCIP (p = 0.025) y no requirieron VNI (6/76). También mostraron mayor SatO2/FiO2 (saturación de oxígeno/fracción de oxígeno inspirado) (p = 0.025) y menor nivel de PCO2 (presión parcial de CO2) (p = 0.032). La VNI se utilizó primero siempre en el grupo que recibió ambas modalidades (14/76). No se encontraron diferencias epidemiológicas o clínicas entre grupos. Conclusiones: En nuestra serie, el uso de CNAF no aumentó los días de ingreso en la UCIP ni de hospital. Tampoco requirió cambio a VNI. Al ingreso, una gasometría normal y bajo requerimiento de oxígeno permitieron seleccionar a los pacientes respondedores. Se necesitan más ensayos multicéntricos clínicos aleatorizados para verificar estos datos.

Uso de cánula nasal de alto flujo artesanal como oxigenoterapia en insuficiencia respiratoria por COVID-19 / Use of artisanal high flow nasal cannula as oxygen therapy in respiratory failure due to COVID-19

Los riesgos asociados a la neumonía por (SARS-CoV-2) es la generación de insuficiencia respiratoria secundaria que en algunos casos desencadenara al tan temido síndrome de distres respiratorio (SDRA); Informes sobre atención clínica, indican que tiene una incidencia (SDRA) de 3-10 % con necesidad de Asistencia Respiratoria Mecánica (ARM) en pacientes hospitalizados; por lo que dispositivos de oxigenación no invasivos siguen siendo una opción atractiva, de forma inicial. Caso clínico: mujer de 47 años con insuficiencia respiratoria secundario a neumonía por COVID-19, por la gravedad se indica su ingreso a terapia intensiva, pero por razones de falta de unidad es manejada en unidad respiratoria, con el uso de dispositivos de oxigenación de armado ARTESAL, de manera exitosa, con la utilización de CNAF-artesanal, se pretende mejorar el trabajo respiratorio, índices de oxigenación, mientras se da tratamiento a la infección por el COVID-19; el objetivo del presente caso es reportar el presente caso con evolución favorable a la literatura disponible. Discusión: El uso de terapia de oxigenación con dispositivo de Cánula Nasal de Alto Flujo, aún no ha sido normatizado en pacientes con COVID-19, pero existe evidencia clínica sobre los efectos beneficiosos en la insuficiencia respiratoria en neonatos mas no en adultos. Conclusión: El uso temprano de la CNAF-artesanal en la insuficiencia respiratoria resulta muy atractivo, más aún con dispositivo de confección artesanal, da una opción más al paciente fuera de UTI, pudiendo apoyar en evitar la intubación y su ingreso a ventilación mecánica.

The risks associated with pneumonia (SARS-CoV-2) is the generation of secondary respiratory failure that in some cases will trigger the much feared respiratory distress syndrome (ARDS); Reports on clinical care indicate that it has an incidence (ARDS) of 3-10% with the need for Mechanical Respiratory Assistance (ARM) in hospitalized patients; so non-invasive oxygenation devices remain an attractive option, initially. Clinical case: a 47-year-old woman with respiratory failure secondary to covid-19 pneumonia. Due to the severity, her admission to intensive care is indicated, but for reasons of lack of unity, she is managed in a common room, with the use of high-pressure oxygenation devices. ARTISAL assembly, successfully, with the use of CNAF-artisanal, is intended to improve the work of breathing, and oxygenation indices, while treating the infection by COVID-19; The objective of this case is to report the present case with a favorable evolution based on the available literature. Discussion: The use of oxygenation therapy with a High Flow Nasal Cannula device has not yet been standardized in patients with COVID-19, but there is clinical evidence on the beneficial effects in respiratory failure in neonates but not in adults. Conclusion: The early use of the artisan HFNC in respiratory failure is very attractive, even more so with an artisanal device, it gives the patient another option outside the ICU, being able to help avoid intubation and admission to mechanical ventilation.

Origen y evolución de una vía aérea permeable / The origin and evolution of a permeable airway

Resumen: A través de los siglos hemos descubierto la importancia de mantener permeable y segura la vía aérea. Desde Hipócrates en la antigua Grecia, hasta el siglo XX en oriente y occidente, se ha continuado con el desarrollo de herramientas que faciliten esta cotidiana tarea por lo que, con esta revisión sistemática, se establecieron como objetivos exponer el origen y los antecedentes del tubo endotraqueal, cánula orofaríngea y laringoscopio, así como discutir su utilidad en la práctica anestésica-quirúrgica, a través del tiempo hasta hoy en día.

Abstract: Over the centuries, we have discovered the importance of preserving a safe permeable airway. From Hippocrates in ancient Greece to the 20th century in the East and West, the development of multiple tools that enable this task continues through time, which is why with this systematic review we aim to uncover the origin and historical background of the endotracheal tube, the oropharyngeal cannula and the laryngoscope, discussing their effectiveness in the anesthetic-surgical practice over years to the present day.

Cánula nasal de alto flujo en pacientes críticos: una revisión narrativa / High Flow Nasal Cannula in Critically Ill Patients: a Narrative Review

La cánula nasal de alto flujo se ha convertido en una de las principales estrategias de soporte ventilatorio no invasivo en la insuficiencia respiratoria aguda hipoxémica, principalmente después de la pandemia de COVID-19. Sin embargo, su uso se extiende más allá de este escenario y abarca diferentes condiciones clínicas como el período postextubación, período postquirúrgico, insuficiencia respiratoria hipercápnica y soporte vital en pacientes inmunodeprimidos, trasplantados u oncológicos. Los manuscritos que avalan su aplicación han sido ampliamente difundidos y el grado de evidencia es lo suficientemente alto como para recomendar su uso. Por tanto, es necesario destacar sus efectos fisiológicos como el confort, una fracción inspirada de oxígeno precisa, el lavado de CO2 o la optimización del volumen pulmonar de fin de espiración para comprender su mecanismo de acción y mejorar los resultados de los pacientes. El objetivo de esta revisión narrativa es ofrecer un resumen breve y conciso de los efectos y beneficios de aplicar esta terapia en diferentes escenarios clínicos sin la estructura rígida de una revisión sistemática. Con base en estas líneas, el lector curioso puede ampliar la evidencia científica que avala el empleo de la cánula nasal de alto flujo en cada escenario particular. (AU);

High-flow nasal cannula has become one of the main strategies for non-invasive ventilatory support in hypoxemic acute respiratory failure, mainly after the COVID-19 pandemic. However, its use extends beyond this scenario and covers different clinical conditions such as the post-extubation period, post-surgical period, hypercapnic respiratory failure and life support in immunosuppressed, trasplant or cancer patients. Manuscripts that support its application have been widely disseminated and the degree of evidence is high enough to recommend its use. Therefore, it is necessary to highlight its physiological effects such as comfort, precise fraction of inspiratory oxygen, CO2 lavage or optimize end-expiratory lung volume to understand its mechanism of action and improve patients' outcomes. The objective of this narrative review is to offer a brief and concise summary of the benefits of applying this therapy in different clinical scenarios without the rigid structure of a systematic review. Based on these lines, the curious reader can expand the scientific evidence that supports the use of the high-flow nasal cannula in each particular scenario. (AU);

Avaliação do uso de estratégias não invasivas em pacientes com insuficiência respiratória por COVID-19 / Evaluation of the use of non-invasive strategies in patients with respiratory failure by COVID-19

Introdução: Durante a pandemia de COVID-19, tornou-se necessário o uso de estratégias no tratamento dos pacientes que evoluem com insuficiência respiratória aguda. Objetivo: Avaliar o uso de estratégias não invasivas no desfecho de pacientes com insuficiência respiratória aguda ou crônica agudizada por COVID-19. Métodos: Pesquisa de caráter observacional e retrospectivo por meio da coleta de dados em prontuário eletrônico com pacientes submetidos ao uso de cânula nasal de alto fluxo (CNAF) e/ou ventilação mecânica não invasiva (VNI). Resultados: 81 pacientes, sendo 70,4% (57) do sexo masculino, com 56,5 ± 14,6 anos. 49,4% (40) dos indivíduos fizeram uso de CNAF e VNI, 9,9% (8) e 40,7% (33) apenas VNI ou CNAF, respectivamente. O tempo médio de uso da CNAF foi de 4,4 ± 3,7 dias e de VNI foi de 2,7 ± 3,4 dias. Observou-se que 43 (53,1%) dos pacientes pesquisados evoluíram para intubação orotraqueal (IOT) e 40 (49,4%) para óbito. Destes, 22 encontravam-se em IOT. Houve diferença estatística quando comparados idade entre os grupos IOT e não IOT, 60,5 ± 13,9 anos vs 52,1 ± 14,2 anos (p = 0,012), respectivamente. Conclusão: O uso de VNI e/ou CNAF pode ser considerado como alternativa no tratamento de pacientes com COVID-19. Contudo, os diversos fatores intrínsecos e extrínsecos ao paciente ainda contribuem para a alta taxa de IOT e de mortalidade.

High flow nasal oxygen and awake prone positioning - Two allies against COVID-19: A systematic review.

INTRODUCTION: Severe acute respiratory distress syndrome coronavirus disease-2 (SARS-CoV-2) can lead to acute hypoxemic respiratory failure (AHRF) with possible multisystemic involvement. Ventilation/perfusion mismatch and shunt increase are critical determinants of hypoxemia. Understanding hypoxemia and the mechanisms involved in its genesis is essential to determine the optimal therapeutic strategy. High flow nasal oxygen (HFNO) and awake prone positioning (APP) in patients with COVID-19 AHRF showed promising benefits. The aim of this systematic review was to depict current situation around the combined use of HFNO and APP in patients with COVID-19 AHRF. Particularly, to investigate and report the pathophysiological rationale for adopting this strategy and to evaluate the (1) criteria for initiation, (2) timing, monitoring and discontinuation, and to assess the (3) impact of HFNO/ APP on outcome. METHODS: We performed a systematic search collecting the articles present in PubMed, Scopus, EMBASE, and Cochrane databases with the following keywords: COVID-19 pneumonia, high flow nasal oxygen, awake prone position ventilation. RESULTS: Thirteen studies displayed inclusion criteria and were included, accounting for 1242 patients who received HFNO/ APP. The combination of HFNO/ APP has an encouraging pathophysiological rationale for implementing this technique. The recognition of patients who can benefit from HFNO/ APP is difficult and there are no validated protocols to start, monitoring, and discontinue HFNO/ APP therapy. The most used method to monitor the efficacy and failure of this combined technique are oxygenation indexes, but discontinuation techniques are inconsistently and poorly described limiting possible generatability. Finally, this technique provided no clear benefits on outcome. CONCLUSIONS: Our systematic search provided positive feedbacks for improving the utilization of this combination technique, although we still need further investigation about methods to guide timing, management, and discontinuation, and to assess the intervention effect on outcome.

Left Atrial Veno-Arterial Extracorporeal Membrane Oxygenation Case Series: A Single-Center Experience.

INTRODUCTION: We aimed to review the characteristics and outcomes of left atrial veno-arterial extra corporeal membrane oxygenation (LAVA ECMO) at our institution over a 4-y period from 2017 to 2020. METHODS: Among 227 adult patients who received VA ECMO support from January 2017 to December 2020, we reviewed 33 of these who underwent transseptal cannulation and were converted to LAVA ECMO. The timing of transseptal cannulation, either at initiation of VA ECMO (n = 25) or with a later transseptal cannulation to treat complications of left ventricular (LV) distention while on VA ECMO (n = 8), was reviewed. The clinical characteristics, indications, echocardiography data, and outcomes were assessed. RESULTS: Duration of LAVA ECMO support ranged from 1 to 13 d, with a median of 5 d. Successful weaning from the LAVA ECMO circuit was achieved for 15 patients (45%). The in-hospital mortality rate was 66%. There were 11 patients (33%) who survived to be discharged from the hospital. CONCLUSIONS: LV distention is a known complication of VA ECMO and impedes the recovery of the heart. LAVA ECMO provides a novel approach to treating LV distention. Additionally, our review shows that this modality may be used as a bridge to durable mechanical circulatory support, cardiac transplantation, or recovery.

The Effect of High-flow Nasal Cannula Oxygen for Dyspnea in Patients with Advanced Disease: Systematic Review

Objective: To evaluate the efficacy of high-flow nasal cannula oxygen (HFNC) for dyspnea in patients with advanced disease. Methods: A literature search was conducted using MEDLINE, Cochrane Library, EMBASE, and Ichu-shi Web. Inclusion criteria were: 1) randomized controlled trials evaluating the effect of HFNC on dyspnea; 2) aged 18 years or older with advanced disease with hypoxemia; 3) control group was conventional oxygen therapy or noninvasive positive pressure ventilation. Exclusion criteria were: 1) patients in intensive care unit, 2) weaning from ventilator. Results: Six studies (4 from database searches, and 2 from hand searches) were included. In the 2 studies evaluating short-term intervention, one showed HFNC was more efficacious, and the other conventional oxygen was more efficacious. In the 2 studies evaluating long-term interventions: one showed HFNC was more efficacious, and the other showed no significant difference. In the 2 studies evaluating the intervention during exercise, one showed HFNC was more efficacious, and the other showed no significant difference. Conclusion: HFNC may be effective for dyspnea in patients with advanced disease associated with hypoxemia.

Análisis de la experiencia del uso de cánula nasal de alto flujo como terapéutica en neumonía por SARS-CoV-2 / Analysis of the experience of the use of high-flow nasal cannula as therapeutics in SARS-CoV-2 pneumonia

Introducción: Durante la pandemia por SARS-CoV-2, la cánula nasal de alto flujo (CNAF) se usó como soporte en espera de Unidad de terapia intensiva (UTI) o como alternativa a la ventilación invasiva. Objetivos: Primario: Determinar si la cánula nasal de alto flujo evita la intubación oro traqueal. Secundarios: Analizar predictores de éxito al inicio de la cánula nasal de alto flujo y análisis descriptivo de la muestra. Materiales y métodos: Estudio observacional descriptivo retrospectivo. Se incluyeron pacientes mayores de 16 años positivos para SARS-CoV-2, atendidos en guardia y unidad de terapia intensiva, que utilizaron cánula nasal de alto flujo entre octubre de 2020 y marzo 2021. Se recolectaron datos en planillas individuales, analizadas por un profesional externo. Resultados: Se incluyeron en el trabajo 72 pacientes (de 16 a 88 años), 20 mujeres y 52 hombres. El 50 % de la muestra evitó la intubación orotraqueal. El IROX inicio grupo "éxito" vs. grupo "fracaso", p = 0,006. Comparación Irox 12 h grupo "éxito" vs. grupo "fracaso" p < 0,001. Comparación "tiempo desde ingreso a inicio de cánula nasal de alto flujo" grupo "éxito" vs. grupo "fracaso", p = 0,133. Comparación "Delta IROX" grupo "éxito" vs grupo "fracaso" p = 0,092. Conclusión: Se evitó la intubación orotraqueal en el 50 % de los casos. El IROX de inicio y el IROX a las 12 h del uso de cánula nasal de alto flujo fue estadísticamente significativo, lo que es un buen predictor del éxito en esta población. La fecha de inicio de síntomas y el uso de cánula nasal de alto flujo y el delta del IROX durante las pri meras 12 h no fue estadísticamente significativo para el éxito de la terapia. Estos datos son una herramienta útil con el objeto de generar protocolos de selección de pacientes para esta patología.

Introduction: During the SARS-CoV-2 pandemic, the high flow nasal cannula (HFNC) was used as support while waiting for the Intensive Care Unit (ICU) or as an alternative to invasive ventilation. The objective of this work is the description and analysis of the use of CNAF in our population. Objectives: Primary: Determine if HFNC prevents orotracheal intubation. Secondary: Analyze predictors of success at the start of CNAF and a descriptive analysis of the sample Materials and method: Retrospective descriptive observational study. Patients over 16 years of age positive for SARS-CoV-2, treated in Guard and ICU were included. who used CNAF between October 2020 and March 2021 Data was collected in individual forms, analyzed by an external professional. Results: The study included 72 patients (16 to 88 years old), 20 women and 52 men; 50 % of the sample avoided orotracheal intubation. Start IROX, group "success" vs. group "failure" p = 0.006. Comparison Irox.12 h group "success" vs. group "failure" p < 0.001. Comparison "Time from admission to start of CNAF" group "success" vs. group "failure" p = 0.133. Comparison "Delta IROX" group "success" vs. group "failure" p = 0.092. Conclusion: HFNC avoided orotracheal intubation in the 50 % of the cases. The initial IROX and the IROX 12 hours after the use of HFNC were statistically significant, which is a good predictor of success in this population. The date of onset of symptoms and the use of FNAF and IROX delta during the first 12 hours were not statistically significant for the success of the therapy. These data are a useful tool for generating patient selection protocols for this pathology.