Lamb Keith D, Spilman Sarah K, Oetting Trevor W, Jackson Julie A, Trump Matthew W, Sahr Sheryl M
Department of Respiratory Therapy, UnityPoint Health, Des Moines, Iowa.
Department of Respiratory Therapy, UnityPoint Health, Des Moines, Iowa. He is now affiliated with Inova Fairfax, Falls Church, VA.
Respir Care. 2018 Mar;63(3):259-266. doi: 10.4187/respcare.05793. Epub 2017 Dec 5.
It has been suggested that use of a high-flow nasal cannula (HFNC) could be a first-line therapy for patients with acute hypoxic respiratory failure. The purpose of this study was to determine if protocolized use of HFNC decreases unplanned intubation and adverse outcomes in an ICU population.
The study was a prospective evaluation of 2 cohorts who received HFNC per protocol. Control groups were retrospective selections of subjects who received HFNC in the pre-protocol period. Cohort 1 ( = 88) received mechanical ventilation for ≥ 24 h and was extubated directly to HFNC following strict protocol criteria. Cohort 2 ( = 83) were placed on HFNC when oxygen requirements escalated (>4 L/min).
Cohort 1 did not differ from its control group in mortality, hospital stay, or ICU days, but there were significant decreases in incidence of Gram-negative pulmonary infection (30% vs 9%, = .001) and use of bronchodilator therapy (81% vs 61%, = .008). Failed extubation rates were nearly identical across groups, but time to re-intubation was shorter in the protocol group (24 vs 13 h, = .19). Cohort 2 did not differ significantly from its control group in intubation rates or mortality, but subjects managed by protocol experienced significant decreases in ICU days (4 vs 3 d, = .03) and hospital days (12 vs 8 d, = .007). There was a trend toward fewer hours on HFNC (33 vs 24 h, = .10) and faster time to intubation when HFNC failed (19 vs 9 h, = .08).
Extubation to HFNC led to a significant decrease in pulmonary infections and bronchodilator therapy in Cohort 1 but did not reduce length of stay or rates of failed extubation. When HFNC was used early and per protocol (Cohort 2), ICU and hospital lengths of stay were reduced and HFNC was initiated more quickly when the need for respiratory support escalated.
有人提出，使用高流量鼻导管（HFNC）可能是急性低氧性呼吸衰竭患者的一线治疗方法。本研究的目的是确定按照方案使用HFNC是否能降低重症监护病房（ICU）患者的非计划性插管率和不良结局。
本研究是对两个按照方案接受HFNC治疗的队列进行的前瞻性评估。对照组是回顾性选取的在方案制定前接受HFNC治疗的受试者。队列1（n = 88）接受机械通气≥24小时，并在严格按照方案标准直接拔管后使用HFNC。队列2（n = 83）在氧气需求增加（>4 L/分钟）时使用HFNC。
队列1在死亡率、住院时间或ICU住院天数方面与其对照组无差异，但革兰氏阴性肺部感染的发生率（30%对9%，P = .001）和支气管扩张剂治疗的使用率（81%对61%，P = .008）显著降低。各组的拔管失败率几乎相同，但方案组的再次插管时间较短（24对13小时，P = .19）。队列2在插管率或死亡率方面与其对照组无显著差异，但按照方案管理的受试者在ICU住院天数（4对3天，P = .03）和住院天数（12对8天，P = .007）方面显著减少。使用HFNC的时间有减少的趋势（33对24小时，P = .10），并且在HFNC失败时插管时间更快（19对9小时，P = .08）。
在队列1中，拔管后使用HFNC导致肺部感染和支气管扩张剂治疗显著减少，但并未缩短住院时间或降低拔管失败率。当早期按照方案使用HFNC时（队列2），ICU和住院时间缩短，并且在呼吸支持需求增加时更快地开始使用HFNC。
