High-flow nasal cannula oxygen therapy versus noninvasive ventilation in acute respiratory failure related to suspected or confirmed acute heart failure: a systematic review with meta-analysis.

The objective of this review is to compare high-flow nasal cannula (HFNC) oxygen (High flow oxygen) and noninvasive ventilation (NIV) for the management of acute respiratory failure secondary to suspected or confirmed acute heart failure (AHF). A comprehensive and relevant literature search of MEDLINE, Web of Science, and the Cochrane Library was conducted using Medical Subject Heading and Free text terms from January 2010 to March 2024. All randomized clinical trials and observational retrospective and prospective studies reporting adult patients with acute respiratory failure due to suspected or confirmed AHF and comparing HFNC to NIV were included. Primary outcome included treatment failure, as a composite outcome including early termination to the allocated treatment, need for in-hospital intubation or mortality, or the definition used in the study for treatment failure if adequate. Secondary outcomes included change in respiratory rate and dyspnea intensity after treatment initiation, patient comfort, invasive mechanical ventilation requirement, and day-30 mortality. Six of the 802 identified studies were selected for final analysis, including 572 patients (221 assigned to high flow and 351 to NIV). Treatment failure rate was 20% and 13% in the high flow oxygen and NIV groups, respectively [estimated odds ratio (OR): 1.7, 95% confidence interval (95% CI): 0.9-3.1] in randomized studies and 34% and 16% in the high flow oxygen and NIV groups, respectively (OR: 3.1, 95% CI: 0.7-13.5), in observational studies. Tracheal intubation requirement was 7% and 5% of patients in the HFNC and NIV groups, respectively (OR: 1.4, 95% CI: 0.5-3.5) in randomized studies, and 20% and 9% in the high flow oxygen and NIV group, respectively (OR: 2.1, 95% CI: 0.5-9.4) in observational studies. Mortality was 13% and 8% in the high flow oxygen and the NIV groups, respectively (OR: 1.8, 95% CI: 0.8-1.1) in randomized studies and 14% and 9% in the high flow oxygen and the NIV groups, respectively (OR: 1.4, 95% CI: 0.5-3.7) in observational studies. Compared with NIV, high flow oxygen was not associated with a higher risk of treatment failure during initial management of patients with acute respiratory failure related to suspected or confirmed AHF.

Protect peripheral intravenous catheters: a study protocol for a randomised controlled trial of a novel antimicrobial dressing for peripheral intravenous catheters (ProP trial).

INTRODUCTION: Peripheral intravenous catheters (PIVCs) are the most commonly used vascular access device in hospitalised patients. Yet PIVCs may be complicated by local or systemic infections leading to increased healthcare costs. Chlorhexidine gluconate (CHG)-impregnated dressings may help reduce PIVC-related infectious complications but have not yet been evaluated. We hypothesise an impregnated CHG transparent dressing, in comparison to standard polyurethane dressing, will be safe, effective and cost-effective in protecting against PIVC-related infectious complications and phlebitis. METHODS AND ANALYSIS: The ProP trial is a multicentre, superiority, randomised clinical and cost-effectiveness trial with internal pilot, conducted across three centres in Australia and France. Patients (adults and children aged ≥6 years) requiring one PIVC for ≥48 hours are eligible. We will exclude patients with emergent PIVCs, known CHG allergy, skin injury at site of insertion or previous trial enrolment. Patients will be randomised to 3M Tegaderm Antimicrobial IV Advanced Securement dressing or standard care group. For the internal pilot, 300 patients will be enrolled to test protocol feasibility (eligibility, recruitment, retention, protocol fidelity, missing data and satisfaction of participants and staff), primary endpoint for internal pilot, assessed by independent data safety monitoring committee. Clinical outcomes will not be reviewed. Following feasibility assessment, the remaining 2624 (1312 per trial arm) patients will be enrolled following the same methods. The primary endpoint is a composite of catheter-related infectious complications and phlebitis. Recruitment began on 3 May 2023. ETHICS AND DISSEMINATION: The protocol was approved by Ouest I ethic committee in France and by The Queensland Children's Hospital Human Research Ethics Committee in Australia. The findings will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT05741866.

High-flow nasal cannula oxygen versus noninvasive ventilation for the management of acute cardiogenic pulmonary edema: a randomized controlled pilot study.

BACKGROUND: Whether high-flow nasal oxygen can improve clinical signs of acute respiratory failure in acute heart failure (AHF) is uncertain. OBJECTIVE: To compare the effect of high-flow oxygen with noninvasive ventilation (NIV) on respiratory rate in patients admitted to an emergency department (ED) for AHF-related acute respiratory failure. DESIGN, SETTINGS AND PARTICIPANTS: Multicenter, randomized pilot study in three French EDs. Adult patients with acute respiratory failure due to suspected AHF were included. Key exclusion criteria were urgent need for intubation, Glasgow Coma Scale <13 points or hemodynamic instability. INTERVENTION: Patients were randomly assigned to receive high-flow oxygen (minimum 50 l/min) or noninvasive bilevel positive pressure ventilation. OUTCOMES MEASURE: The primary outcome was change in respiratory rate within the first hour of treatment and was analyzed with a linear mixed model. Secondary outcomes included changes in pulse oximetry, heart rate, blood pressure, blood gas samples, comfort, treatment failure and mortality. MAIN RESULTS: Among the 145 eligible patients in the three participating centers, 60 patients were included in the analysis [median age 86 (interquartile range (IQR), 90; 92) years]. There was a median respiratory rate of 30.5 (IQR, 28; 33) and 29.5 (IQR, 27; 35) breaths/min in the high-flow oxygen and NIV groups respectively, with a median change of -10 (IQR, -12; -8) with high-flow nasal oxygen and -7 (IQR, -11; -5) breaths/min with NIV [estimated difference -2.6 breaths/min (95% confidence interval (CI), -0.5-5.7), P  = 0.052] at 60 min. There was a median SpO 2 of 95 (IQR, 92; 97) and 96 (IQR, 93; 97) in the high-flow oxygen and NIV groups respectively, with a median change at 60 min of 2 (IQR, 0; 5) with high-flow nasal oxygen and 2 (IQR, -1; 5) % with NIV [estimated difference 0.8% (95% CI, -1.1-2.8), P  = 0.60]. PaO 2 , PaCO 2 and pH did not differ at 1 h between groups, nor did treatment failure, intubation and mortality rates. CONCLUSION: In this pilot study, we did not observe a statistically significant difference in changes in respiratory rate among patients with acute respiratory failure due to AHF and managed with high-flow oxygen or NIV. However, the point estimate and its large confidence interval may suggest a benefit of high-flow oxygen. TRIAL REGISTRATION: NCT04971213 ( https://clinicaltrials.gov ).

Cost-effectiveness analysis of bundled innovative devices versus standard approach in the prevention of unscheduled peripheral venous catheters removal due to complications in France.

The objective of the study was to perform a cost-effectiveness analysis of bundled devices (BDs) versus standard devices (SDs) for the prevention of unscheduled peripheral venous catheter (PVC) removal due to complication from a French investigator-initiated, open-label, single center, randomized-controlled, two-by-two factorial trial (CLEAN-3 study). A 14-day time non homogeneous semi-markovian model was performed to be fitted to longitudinal individual patient data from CLEAN-3 database. This model includes five health states and eight transitional events; a base case scenario, two scenario analyses and bootstrap sensitivity analyses were performed. The cost-effectiveness criterion was the cost per patient with unscheduled PVC removal avoided. 989 adult (age≥18 years) patients were analyzed to compare the BDs group (494 patients), and the SDs group (495 patients). The assessed intervention was a combination of closed integrated catheters, positive displacement needleless-connectors, disinfecting caps, and single-use prefilled flush syringes compared with the use of open catheters and three-way stopcocks for treatment administration. For the base case scenario, an unscheduled 1st PVC removal before discharge was significantly more frequent in the SDs group (235 patients (47.5%) in the SDs group and 172 patients (34.8%) in the BDs group, p = 0.00006). After adjustment for 1st catheter time, the number of patients with unscheduled PVC removal per day was of 16 (95%CI: 15; 18) patients (out of 100) in the BDs group and of 26 (95%CI: 24; 28) patients (out of 100) in the SDs group. The mean cost per patient (adjusted on catheter-time) was of €144 (95%CI: €135-€154) for patients in the SDs group versus €102 (95%CI: €95-€109) for patients in the BDs group; the mean saving per patient was of €42 (95%CI: €32-€54). As a consequence, the assessed BDs strategy was less costly and more effective than the SDs strategy. Trail registration: CLEAN-3 study is registered with ClinicalTrials.gov, NCT03757143.