Facial fire with use of high-flow nasal oxygen during laser surgery.

Use of high-flow nasal oxygen to enable apnoeic oxygenation during tubeless airway surgery is well-established. The use of an ignition source in this oxygen-rich environment increases the risk of surgical fire. We present a case of facial fire secondary to the use of carbon dioxide laser and high-flow nasal oxygen during a surgical procedure for subglottic stenosis. The incident occurred when the laser was being tested near the patient, resulting in superficial burns to the patient's face and neck. The airway was unaffected and the burns were managed conservatively. This case highlights important safety consideration for the use of an ignition source in the presence of high-flow nasal oxygen and the role of human factors and in-built risk mitigation features.

Comparison of Modified ROX Index Score and ROX Index Score for Early Prediction of High Flow Nasal Oxygen Therapy Outcome in Patients with Acute Respiratory Failure: A Prospective Observational Cohort Study.

Background: We compared the modified ROX index and ROX index scores in earlier predictions of high-flow nasal oxygen (HFNO) therapy outcomes in patients with acute respiratory failure. Methods: We conducted a prospective observational study on 151 acute respiratory failure patients initiated on HFNO therapy. The primary objective of this research was to compare the modified ROX index and ROX index to investigate which score predicted HFNO treatment outcome earlier. Results: The modified ROX index score had better predictive power than the ROX score at different time points, especially one hour following the start of HFNO therapy (AUC 0.790; 95% CI: 0.717-0.863; p < 0.001). For the ROX Index at 1 hour, the ideal cut-off value for HFNO outcome was 4.36 (sensitivity: 72.6%, specificity: 53.9%), and for the modified ROX index at 1 hour, it was 4.63 (sensitivity: 74.2%, specificity: 69.7%). The presence of various comorbidities didn't show any change in ROX-HR cut-off values. Conclusion: The modified ROX index is a better predictor of the success of HFNO therapy than the ROX index. Furthermore, the presence of any comorbidities did not affect modified ROX index cut-off values or the outcome of HFNO therapy. How to cite this article: Sarkar AG, Sharma A, Kothari N, Goyal S, Meshram T, Kumari K, et al. Comparison of Modified ROX Index Score and ROX Index Score for Early Prediction of High Flow Nasal Oxygen Therapy Outcome in Patients with Acute Respiratory Failure: A Prospective Observational Cohort Study. Indian J Crit Care Med 2024;28(9):842-846.

Outcome of Early Initiation of High-flow Nasal Oxygen Therapy among Pneumonia Patients Presenting with Acute Hypoxemic Respiratory Failure.

Background: High-flow nasal oxygen (HFNO) therapy is an upcoming and beneficial modality for patients with acute hypoxemic respiratory failure (AHRF). Objectives: To evaluate whether early use of HFNO in pneumonia patients with AHRF can reduce the need for invasive ventilation. Patients and methods: In this prospective, randomized controlled trial, 160 patients who fulfilled the criteria were included. The patient's characteristics, sequential organ failure assessment score, and simplified acute physiology score were recorded. Respiratory rate (RR), and oxygenation parameters (PaO2/FiO2), and RR-oxygenation index at selected time intervals were collected and analyzed. The primary outcome was the number of patients who needed intubation. Secondary outcomes included length of intensive care unit (ICU) and hospital stay and mortality at day 28. Results: The rate of intubation was not statistically significant between the two groups 15 vs 18.7%; difference 3.7% [(95% confidence interval (CI): 2.5-5.7%]. In 48-hour time periods, the mean PaO2/FiO2 ratio was significantly increased in the HFNO group compared with the non-invasive ventilation (NIV) group. The RRs and heart rate (HR) showed a significant decrease in the HFNO group.The length of ICU and hospital stays was not different between both groups. No significant differences were found in mortality rates between the HFNO and NIV groups 9 (11.2%) and 10 (12.5%), with 1.3% (95% CI: 0.7-3.8%) (p = 0.21). Multivariate analysis demonstrated that low baseline PaO2/FiO2, Respiratory rate-oxygenation index (ROX index) ≤ 5.4 measured at 12 hour and high severity scores were independent risk factors for intubation. Conclusion: Treatment with HFNO did not reduce the need for intubation among patients with pneumonia-induced AHRF, despite the improved PaO2/FiO2 observed with HFNO compared with NIV. Clinical trial no: NCT05809089. How to cite this article: Magdy DM. Outcome of Early Initiation of High-flow Nasal Oxygen Therapy among Pneumonia Patients Presenting with Acute Hypoxemic Respiratory Failure. Indian J Crit Care Med 2024;28(8):753-759.

High Flow, High Hope: HFNO in Acute Hypoxemic Respiratory Failure.

How to cite this article: Pachisia AV, Govil D. High Flow, High Hope: HFNO in Acute Hypoxemic Respiratory Failure. Indian J Crit Care Med 2024;28(8):726-728.

Pre-oxygenation using high flow humidified nasal oxygen or face mask oxygen in pregnant people - a prospective randomised controlled crossover non-inferiority study (The HINOP2 study).

BACKGROUND: Airway guidelines recommend pre-oxygenation of obstetric patients to an end tidal oxygen concentration (etO2) ≥90%. High flow nasal oxygen (HFNO) achieves this in 60% of pregnant people. However face mask (FM) pre-oxygenation also may not achieve this target in all patients. In this study we determined whether HFNO pre-oxygenation is non-inferior to FM pre-oxygenation. METHODS: This randomised controlled crossover non-inferiority trial was conducted on healthy participants of gestational age ≥37 weeks in a simulated environment. Participants underwent pre-oxygenation for three minutes with HFNO and FM oxygen in randomised order. HFNO was delivered at a maximal flow of 70 l.min-1 and FM oxygen at 10 l.min-1. The primary outcome was etO2 on first expired breath after pre-oxygenation. Non-inferiority was defined as a mean difference in first etO2 between groups of ≤5%. RESULTS: Seventy participants were randomised with 62 analysed. Age (mean (SD)), gestation (median (IQR)), and body mass index (median (IQR)), were 34.7 (4.6) years, 39 (38.4, 39.4) weeks, 29 (26.6, 32.4) kg.m-2 respectively. First etO2 after HFNO pre-oxygenation was greater than after FM pre-oxygenation (HFNO pre-oxygenation mean (SD) 90.2 (3.9)% versus FM pre-oxygenation 88.7 (3.0)%; mean difference = 1.45%, 95% CI 0.19 to 2.72%; p = 0.025. Forty-four (71%) participants achieved ≥90% first etO2 concentration after HFNO pre-oxygenation versus 27 (44%) after FM pre-oxygenation (p = 0.002). CONCLUSIONS: In this cohort of pregnant people at term in a simulated environment, pre-oxygenation with HFNO was not inferior to FM pre-oxygenation. FM pre-oxygenation did not achieve pre-oxygenation targets in over 50% of participants.

Implementing High-Flow Nasal Oxygen Therapy in Medical Wards: A Scoping Review to Understand Hospital Protocols and Procedures.

Acute hypoxemic respiratory failure (ARF) is a common cause for hospital admission. High-flow nasal oxygen (HFNO) is increasingly used as a first-line treatment for patients with ARF, including in medical wards. Clinical guidance is crucial when providing HFNO, and health services use local health guidance documents (LHGDs) to achieve this. It is unknown what hospital LHGDs recommend regarding ward administration of HFNO. This study examined Australian hospitals' LHGDs regarding ward-based HFNO administration to determine content that may affect safe delivery. A scoping review was undertaken on 2 May 2022 and updated on 29 January 2024 to identify public hospitals' LHGDs regarding delivery of HFNO to adults with ARF in medical wards in two Australian states. Data were extracted and analysed regarding HFNO initiation, monitoring, maintenance and weaning, and management of clinical deterioration. Of the twenty-six included LHGDs, five documents referenced Australian Oxygen Guidelines. Twenty LHGDs did not define a threshold level of hypoxaemia where HFNO use was recommended over conventional oxygen therapy. Thirteen did not provide target oxygen saturation ranges whilst utilising HFNO. Recommendations varied regarding maximal levels of inspired oxygen and flow rates in the medical ward. Eight LHGDs did not specify any system to identify and manage deteriorating patients. Five LHGDs did not provide guidance for weaning patients from HFNO. There was substantial variation in the LHGDs regarding HFNO care for adult patients with ARF in Australian hospitals. These findings have implications for the delivery of high-quality, safe clinical care in hospitals.

[High-flow nasal oxygen therapy and hypercapnic acute respiratory failure]. / Oxygénothérapie nasale à haut débit et insuffisance respiratoire aiguë hypercapnique.

Humidified high-flow nasal oxygen therapy (HFNO) has, in recent years, come to assume a key role in the management of hypoxemic acute respiratory failure (ARF). While non-invasive ventilation (NIV) currently represents the first-line ventilatory strategy in patients exhibiting hypercapnic ARF, the operating principles and physiological effects of HFNO could be interesting and useful in the initial management of hypercapnic ARF and/or after extubation, particularly in acute exacerbations of chronic obstructive pulmonary disease. Under these conditions, HFNO could be used either alone continuously or in combination with NIV during breaks in spontaneous breathing, depending on the severity and etiology of the underlying hypercapnic ARF.

Airway fire with use of diathermy in conjunction with high-flow nasal oxygen.

Operating theatre fires are rare but can result in significant morbidity. A 76-year-old male with complex airway disease sustained superficial facial burns during an elective airway debulking procedure. His airway was being managed with high-flow nasal oxygen at 70 l.min-1 and FiO2 1.0 delivered by Optiflow™ (Fisher and Paykel Healthcare Limited, Auckland, New Zealand). When suction monopolar diathermy was used to excise hyperkeratotic tissue beside his epiglottis, an arc was created to the tip of the suspension laryngoscope, followed by a jet of flame as the Optiflow circuit ignited. This resulted in burns to the patient's face and shoulder. He required admission to the intensive care unit and had a complicated postoperative course that included the need for surgical tracheostomy to facilitate weaning from mechanical ventilation. This case highlights the dangers of using high-flow nasal oxygen alongside an ignition source.

Case series of dogs with blastomycosis managed with high-flow nasal oxygen therapy (2019-2023): 19 cases.

Objective: To describe the clinical presentation, progression, treatment, and outcome of dogs with blastomycosis treated with high-flow nasal oxygen therapy (HFNOT). Design: Retrospective case review. Setting: University veterinary teaching hospital. Animals: Nineteen client-owned dogs with strongly suspected or confirmed blastomycosis treated with HFNOT. Measurements and main results: The medical records of dogs with strongly suspected or confirmed blastomycosis between October 2019 and May 2023 that received HFNOT were evaluated. Nineteen dogs were included. Nine dogs were started directly on high-flow nasal oxygen therapy. The remaining 10 dogs first received traditional oxygen therapy and were then transitioned to HFNOT 3-142 h later. Of the 19 dogs, 1 survived to discharge from hospital, 12 were euthanized due to progression of disease, and 6 died during the hospitalization period. Conclusions and clinical importance: The prognosis for survival of dogs with severe blastomycosis requiring therapy beyond traditional oxygen methods was poor to grave in this population. This is the first known documented report of HFNOT use in dogs with confirmed or suspected blastomycosis.

Effectiveness of early high-flow nasal oxygen therapy after extubation of patients in the intensive care unit.

PURPOSE: This study aimed to evaluate the impact of early high-flow nasal oxygen (HFNO) therapy initiation using a pre-determined respiratory rate­oxygenation (ROX) index on reducing reintubation rates and duration of intensive care unit (ICU) stay in post-extubated patients. MATERIALS AND METHODS: We enrolled a total of 145 extubated patients (mean age: 67.1 ± 12.9 years; sex: 96 male and 49 female; acute physiology and chronic health evaluation II score: 18.4 ± 6.8 points) classified into two groups: 71 patients admitted to the ICU before establishing extubation criteria and 74 patients after criteria implementation, over a 6-month period. We compared the HFNO reintubation rates and ROX index at 2 h post-extubation before and after implementing early HFNO criteria. RESULTS: The utilization rate of HFNO pre- and post-establishment of early HFNO criteria did not differ significantly (19.7% vs. 17.6%). However, the reintubation rate significantly decreased (11.3% vs. 4.1%, P < 0.05) with early HFNO use. Additionally, significant differences were observed in the total intubation period (5.2 ± 7.0 vs. 2.5 ± 2.7 days, P < 0.05) and ICU duration (8.6 ± 9.7 vs. 5.8 ± 5.6 days, P < 0.05). CONCLUSIONS: Early initiation of HFNO guided by the ROX index threshold post-extubation in patients admitted to ICU is associated with reduced reintubation rates and shorter ICU stays.

Trophic Nutrition in ICU Patients Undergoing High-Flow Oxygen Therapy and/or Noninvasive Mechanical Ventilation: The Nutri-Trophic Study.

Enteral nutrition (EN) therapy in ICU patients requiring oxygen therapy with high-flow nasal cannula (HFNC) and/or noninvasive mechanical ventilation (NIMV) is controversial. A prospective, cohort, observational, and multicenter study was conducted in 10 ICUs in Spain to analyze the 90-day mortality, tolerance, side effects, and infectious complications of trophic EN in patients requiring HFNC therapy and/or NIVM. A total of 149 patients were enrolled. The mean age, severity scores, tracheobronchitis, bacteremia, and antimicrobial therapy were significantly higher in deceased than in living patients (p < 0.05), and the mortality rate was 14.8%. A total of 110 patients received oral trophic feedings, 36 patients received nasogastric tube feedings (NGFs), and 3 received mixed feedings. Trophic EN was discontinued in only ten (14.9%) patients because of feeding-related complications. The variables selected for the multivariate logistic regression on feeding discontinuation were SOFA upon admission (OR per unit = 1.461) and urea (OR per mg/dL = 1.029). There were no significant differences in the development of new infections according to the route of EN administration. Early trophic feeding administered to patients with acute respiratory failure requiring noninvasive ventilation is safe and feasible, and is associated with few dietary and infectious complications in a mortality, setting comparable to similar studies.

Effects of non-invasive respiratory support in post-operative patients: a systematic review and network meta-analysis.

BACKGROUND: Re-intubation secondary to post-extubation respiratory failure in post-operative patients is associated with increased patient morbidity and mortality. Non-invasive respiratory support (NRS) alternative to conventional oxygen therapy (COT), i.e., high-flow nasal oxygen, continuous positive airway pressure, and non-invasive ventilation (NIV), has been proposed to prevent or treat post-extubation respiratory failure. Aim of the present study is assessing the effects of NRS application, compared to COT, on the re-intubation rate (primary outcome), and time to re-intubation, incidence of nosocomial pneumonia, patient discomfort, intensive care unit (ICU) and hospital length of stay, and mortality (secondary outcomes) in adult patients extubated after surgery. METHODS: A systematic review and network meta-analysis of randomized and non-randomized controlled trials. A search from Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials, and Web of Science from inception until February 2, 2024 was performed. RESULTS: Thirty-three studies (11,292 patients) were included. Among all NRS modalities, only NIV reduced the re-intubation rate, compared to COT (odds ratio 0.49, 95% confidence interval 0.28; 0.87, p = 0.015, I2 = 60.5%, low certainty of evidence). In particular, this effect was observed in patients receiving NIV for treatment, while not for prevention, of post-extubation respiratory failure, and in patients at high, while not low, risk of post-extubation respiratory failure. NIV reduced the rate of nosocomial pneumonia, ICU length of stay, and ICU, hospital, and long-term mortality, while not worsening patient discomfort. CONCLUSIONS: In post-operative patients receiving NRS after extubation, NIV reduced the rate of re-intubation, compared to COT, when used for treatment of post-extubation respiratory failure and in patients at high risk of post-extubation respiratory failure.

Use of THRIVE for Apneic Oxygenation in Transoral Laser Microlaryngeal Surgery: A Scoping Review.

OBJECTIVES: Trans-nasal humidified rapid insufflation ventilatory exchange (THRIVE) has demonstrated utility in extending the apneic window in the perioperative setting. Its benefits in facilitating tubeless anesthesia are recognized during elective laryngotracheal surgeries. The use of THRIVE and administering higher fractional inspired oxygen concentrations in laser laryngeal surgery (LLS) remains controversial due to the theoretical risk of airway fires. A scoping review of the literature describing institutional experiences with THRIVE during LLS was conducted. DATA SOURCES AND REVIEW METHODS: A systematic scoping review of the literature was performed including PubMed, Medline, Embase, Scopus, JBI EBP Database, and Cochrane Library from inception to April 2023. RESULTS: From the 472 articles identified in our review, nine articles were included representing 271 cases. THRIVE was used for preoxygenation and to maintain apneic oxygenation during LLS. Different institutional practices related to THRIVE parameters and intraoperative modifications during lasing were described in the literature, including cessation of THRIVE, reduction of FiO2 to 30%, and continuous 100% FiO2 oxygenation. One study described a brief ignition of the coating of a KTP laser fiber without injury to the patient. No adverse patient outcomes have been documented in the literature with THRIVE during LLS. CONCLUSION: THRIVE is a safe and effective form of tubeless anesthesia and apneic oxygenation during LLS, with no adverse patient safety events reported in the literature. Key determinants to maintain safety include optimal patient and team selection, effective surgeon-anesthetist cooperation, and institutional protocols that govern intraoperative practice. Laryngoscope, 2024.

Effectiveness of preoxygenation strategies: a systematic review and network meta-analysis.

BACKGROUND: Preoxygenation is universally recommended before induction of general anaesthesia to prolong safe apnoea time. The optimal technique for preoxygenation is unclear. We conducted a systematic review to determine the preoxygenation technique associated with the greatest effectiveness in adult patients having general anaesthesia. METHODS: We searched six databases for randomised controlled trials of patients aged ≥16 yr, receiving general anaesthesia in any setting and comparing different preoxygenation techniques and methods. Our primary effectiveness outcome was safe apnoea time, and secondary outcomes included incidence of arterial oxygen desaturation; lowest SpO2 during airway management; time to end-tidal oxygen concentration of 90%; and [Formula: see text] and [Formula: see text] at the end of preoxygenation. We assessed the quality of evidence according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) recommendations. RESULTS: We included 52 studies of 3914 patients. High-flow nasal oxygen with patients in a head-up position was most likely to be associated with a prolonged safe apnoea time when compared with other strategies, with a mean difference (95% credible interval) of 291 (138-456) s and 203 (79-343) s compared with preoxygenation with a facemask in the supine and head-up positions, respectively. Subgroup analysis of studies without apnoeic oxygenation also showed high-flow nasal oxygen in the head-up position as the highest ranked technique, with a statistically significantly delayed mean difference (95% credible interval) safe apnoea time compared with facemask in supine and head-up positions of 222 (63-378) s and 139 (15-262) s, respectively. High-flow nasal oxygen was also the highest ranked technique for increased [Formula: see text] at the end of preoxygenation. However, the incidence of arterial desaturation was less likely to occur when a facemask with pressure support was used compared with other techniques, and [Formula: see text] was most likely to be lowest when preoxygenation took place with patients deep breathing in a supine position. CONCLUSIONS: Preoxygenation of adults before induction of general anaesthesia was most effective in terms of safe apnoea time when performed with high-flow nasal oxygen with patients in the head-up position in comparison with facemask alone. Also, high-flow nasal oxygen in the head-up position is likely to be the most effective technique to prolong safe apnoea time among those evaluated. Clinicians should consider this technique and patient position in routine practice. SYSTEMATIC REVIEW PROTOCOL: PROSPERO CRD42022326046.

New Treatment Modality for Burn Injury-Related Acute Respiratory Distress Syndrome: High-Flow Nasal Oxygen Therapy in Major Burns.

Pulmonary insufficiency is the primary cause of death in cases of major burns accompanied by inhalation damage. It is important to consider the impact on the face and neck in flame burns. Early implementation of bronchial hygiene measures and oxygenation treatment in inhalation injury can reduce mortality. This case series presents the effects of high-flow nasal oxygen (HFNO) application on patient outcomes in major burns and inhalation injury. This report discusses 3 different patients. One patient, a 29-year-old male with 35% TBSA burns, received HFNO treatment for inhalation injury on the sixth day after the trauma. After 72 hours of HFNO application, the patient's pulmonary symptoms improved. The second patient had 60% TBSA burns and developed respiratory distress symptoms on the fifth day after the trauma. After 7 days of HFNO application, all symptoms and findings of acute respiratory distress syndrome (ARDS) were resolved. HFNO has been used for the treatment of ARDS related to major burn (60% of burned TBSA) in a 28-year-old patient, and improvement was achieved. The use of HFNO in pulmonary insufficiency among burn patients has not been reported previously. This series of patient cases demonstrates the successful application of HFNO in treating inhalation injury and burn-related ARDS. However, further clinical studies are necessary to increase its clinical utilization.

High-Flow Nasal Oxygen versus Conventional Nasal Cannula in Preventing Hypoxemia in Elderly Patients Undergoing Gastroscopy with Sedation: A Randomized Controlled Trial.

Background: We aimed to compare the prevention of hypoxemia using High-flow nasal oxygen (HFNO) or regular nasal tubing (CNC) in elderly patients undergoing gastroscopy with sedation. Methods: This study was a prospective, randomized, controlled trial conducted at a single center. We included elective patients aged 65 and above who were undergoing gastroscopy with sedation. In the intervention group (HFNO), we set the oxygen flow rate to 60 liters per minute with an oxygen fraction (FiO2) of 0.6, while in the control group (CNC), it was 6 liters per minute. The primary outcome was the occurrence of hypoxemia (defined as Spo2 < 90%). Results: A total of 125 participants were enrolled (HFNO group: n = 63; CNC group: n = 62). The occurrence of hypoxemia was found to be significantly lower in the HFNO group compared to the CNC group (3.2% vs. 22.6%, p = 0.001). Additionally, a significantly shorter duration of low oxygen levels was observed in the HFNO group [0.0 seconds (0.0-13.0)] compared to the CNC group [0.0 seconds (0.0-124.0), p<0.001]. Moreover, a higher minimum Spo2 value was achieved in the HFNO group [99.0% (98.0-100.0) vs. 96.5% (91.0-99.0), p < 0.001], and a shorter recovery time was recorded [0.5 minutes (0.0-0.5) vs. 0.5 minutes (0.0-1.0), p = 0.016] in comparison to the CNC group. There were no differences in terms of comfort level [0 (0-4) vs. 0 (0-5), p = 0.268] between the two groups. Conclusions: The HFNO system was determined to be a safe and highly effective method for oxygen delivery, leading to a reduction in the occurrence of hypoxemia in elderly patients undergoing gastroscopy with sedation. It is recommended that HFNO be considered as the standard approach for management in this population.

Acute Respiratory Failure From Early Pandemic COVID-19: Noninvasive Respiratory Support vs Mechanical Ventilation.

BACKGROUND: The optimal strategy for initial respiratory support in patients with respiratory failure associated with COVID-19 is unclear, and the initial strategy may affect outcomes. RESEARCH QUESTION: Which initial respiratory support strategy is associated with improved outcomes in patients with COVID-19 with acute respiratory failure? STUDY DESIGN AND METHODS: All patients with COVID-19 requiring respiratory support and admitted to a large health care network were eligible for inclusion. We compared patients treated initially with noninvasive respiratory support (NIRS; noninvasive positive pressure ventilation by facemask or high-flow nasal oxygen) with patients treated initially with invasive mechanical ventilation (IMV). The primary outcome was time to in-hospital death analyzed using an inverse probability of treatment weighted Cox model adjusted for potential confounders. Secondary outcomes included unweighted and weighted assessments of mortality, lengths of stay (ICU and hospital), and time to intubation. RESULTS: Nearly one-half of the 2,354 patients (47%) who met inclusion criteria received IMV first, and 53% received initial NIRS. Overall, in-hospital mortality was 38% (37% for IMV and 39% for NIRS). Initial NIRS was associated with an increased hazard of death compared with initial IMV (hazard ratio, 1.42; 95% CI, 1.03-1.94), but also an increased hazard of leaving the hospital sooner that waned with time (noninvasive support by time interaction: hazard ratio, 0.97; 95% CI, 0.95-0.98). INTERPRETATION: Patients with COVID-19 with acute hypoxemic respiratory failure initially treated with NIRS showed an increased hazard of in-hospital death.

Comparison between high-flow nasal oxygen (HFNO) alternated with non-invasive ventilation (NIV) and HFNO and NIV alone in patients with COVID-19: a retrospective cohort study.

BACKGROUND: Non-invasive respiratory support (conventional oxygen therapy [COT], non-invasive ventilation [NIV], high-flow nasal oxygen [HFNO], and NIV alternated with HFNO [NIV + HFNO] may reduce the need for invasive mechanical ventilation (IMV) in patients with COVID-19. The outcome of patients treated non-invasively depends on clinical severity at admission. We assessed the need for IMV according to NIV, HFNO, and NIV + HFNO in patients with COVID-19 according to disease severity and evaluated in-hospital survival rates and hospital and intensive care unit (ICU) lengths of stay. METHODS: This cohort study was conducted using data collected between March 2020 and July 2021. Patients ≥ 18 years admitted to the ICU with a diagnosis of COVID-19 were included. Patients hospitalized for < 3 days, receiving therapy (COT, NIV, HFNO, or NIV + HFNO) for < 48 h, pregnant, and with no primary outcome data were excluded. The COT group was used as reference for multivariate Cox regression model adjustment. RESULTS: Of 1371 patients screened, 958 were eligible: 692 (72.2%) on COT, 92 (9.6%) on NIV, 31 (3.2%) on HFNO, and 143 (14.9%) on NIV + HFNO. The results for the patients in each group were as follows: median age (interquartile range): NIV (64 [49-79] years), HFNO (62 [55-70] years), NIV + HFNO (62 [48-72] years) (p = 0.615); heart failure: NIV (54.5%), HFNO (36.3%), NIV + HFNO (9%) (p = 0.003); diabetes mellitus: HFNO (17.6%), NIV + HFNO (44.7%) (p = 0.048). > 50% lung damage on chest computed tomography (CT): NIV (13.3%), HFNO (15%), NIV + HFNO (71.6%) (p = 0.038); SpO2/FiO2: NIV (271 [118-365] mmHg), HFNO (317 [254-420] mmHg), NIV + HFNO (229 [102-317] mmHg) (p = 0.001); rate of IMV: NIV (26.1%, p = 0.002), HFNO (22.6%, p = 0.023), NIV + HFNO (46.8%); survival rate: HFNO (83.9%), NIV + HFNO (63.6%) (p = 0.027); ICU length of stay: NIV (8.5 [5-14] days), NIV + HFNO (15 [10-25] days (p < 0.001); hospital length of stay: NIV (13 [10-21] days), NIV + HFNO (20 [15-30] days) (p < 0.001). After adjusting for comorbidities, chest CT score and SpO2/FiO2, the risk of IMV in patients on NIV + HFNO remained high (hazard ratio, 1.88; 95% confidence interval, 1.17-3.04). CONCLUSIONS: In patients with COVID-19, NIV alternating with HFNO was associated with a higher rate of IMV independent of the presence of comorbidities, chest CT score and SpO2/FiO2. Trial registration ClinicalTrials.gov identifier: NCT05579080.

Trans-nasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) and its Utility in Otolaryngology, Head and Neck Surgery: A Literature Review.

High-flow nasal oxygen (HFNO) therapy is extensively used in critical care units for spontaneously breathing patients. Trans-nasal humidified rapid insufflation ventilatory exchange (THRIVE) is a method of apnoeic oxygenation with continuous nasal delivery of warmed, humidified oxygen at high-flow rates up to 70L/min. THRIVE extends the apnoeic window before desaturation occurs so that tubeless anaesthesia is possible. The advent of THRIVE has had a monumental impact on anaesthetic practice, with a diverse range of clinical applications and it has been incorporated into difficult airway guidelines. THRIVE has many applications in otolaryngology and head and neck surgery. It is used as a pre-oxygenation tool during induction in both anticipated and unanticipated difficult airway scenarios and as a method of oxygenation for tubeless anaesthesia in elective laryngotracheal and hypopharyngeal surgeries and during emergence from anaesthesia. In this scoping review of the literature, we aim to provide an overview on the utility of THRIVE in otolaryngology, including the underlying physiologic principles, current indications and limitations, and its feasibility and safety in different surgical contexts and specific population groups.

Analysis of therapeutic effects on type II respiratory failure and impact on blood gas changes: high-flow nasal oxygen therapy vs. non-invasive positive pressure ventilation.

OBJECTIVE: To evaluate the efficacy of high-flow nasal oxygen therapy (HFNO) vs. non-invasive positive pressure ventilation (NIPPV) in type II respiratory failure, and analyze their impact on blood gas parameters. METHODS: A retrospective analysis of 110 cases of type II respiratory failure treated from April 2021 to March 2023 categorized patients into control (NIPPV, n=50) and observation (HFNO, n=60) groups. Both groups received comprehensive nursing interventions. Treatment outcomes, respiratory and hemodynamic parameters, blood gas parameters, and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were compared before and 48 hours after treatment. Additionally, the complication rates and independent risk factors affecting prognosis were analyzed. RESULTS: The observation group exhibited superior treatment efficacy compared to the control group (P=0.001). Both groups showed significant improvements in APACHE II scores and respiratory, hemodynamic, and blood gas parameters after treatment (P<0.001), with the observation group experiencing more pronounced improvements (P<0.001). The observation group also had a lower incidence of complications than the control group (P=0.013). Logistic regression identified PaCO2 and treatment protocol as independent risk factors affecting adverse outcomes (P<0.05). CONCLUSION: HFNO demonstrates superior therapeutic efficacy in type II respiratory failure, significantly improving blood gas parameters with a high level of safety, supporting its clinical applicability.