Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome associated with COVID-19: An Emulated Target Trial Analysis.

RATIONALE: Whether COVID patients may benefit from extracorporeal membrane oxygenation (ECMO) compared with conventional invasive mechanical ventilation (IMV) remains unknown. OBJECTIVES: To estimate the effect of ECMO on 90-Day mortality vs IMV only Methods: Among 4,244 critically ill adult patients with COVID-19 included in a multicenter cohort study, we emulated a target trial comparing the treatment strategies of initiating ECMO vs. no ECMO within 7 days of IMV in patients with severe acute respiratory distress syndrome (PaO2/FiO2 <80 or PaCO2 ≥60 mmHg). We controlled for confounding using a multivariable Cox model based on predefined variables. MAIN RESULTS: 1,235 patients met the full eligibility criteria for the emulated trial, among whom 164 patients initiated ECMO. The ECMO strategy had a higher survival probability at Day-7 from the onset of eligibility criteria (87% vs 83%, risk difference: 4%, 95% CI 0;9%) which decreased during follow-up (survival at Day-90: 63% vs 65%, risk difference: -2%, 95% CI -10;5%). However, ECMO was associated with higher survival when performed in high-volume ECMO centers or in regions where a specific ECMO network organization was set up to handle high demand, and when initiated within the first 4 days of MV and in profoundly hypoxemic patients. CONCLUSIONS: In an emulated trial based on a nationwide COVID-19 cohort, we found differential survival over time of an ECMO compared with a no-ECMO strategy. However, ECMO was consistently associated with better outcomes when performed in high-volume centers and in regions with ECMO capacities specifically organized to handle high demand. This article is open access and distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0/)

Impact clinique des techniques non-invasives d'oxygénation au cours de l'insuffisance respiratoire aiguë

Standard oxygen, high-flow nasal oxygen therapy (HFNO) and non-invasive ventilation (NIV), and are three strategies of oxygenation usually applied in the ICU for patients with acute hypoxemic respiratory failure. However, it is not well established which technique is better to avoid intubation and thus the related morbidity and mortality, but also which one can secure intubation procedure in case of failure. Objectives: To conduct clinical studies in patients with acute hypoxemic respiratory failure: 1- to compare oxygen strategies including standard oxygen, HFNO, or NIV (associated with HFNO) in terms of intubation and mortality rates; 2- to determine factors associated with oxygen strategies failure, i.e. intubation and mortality; 3- to determine which technique of pre-oxygenation best decreases the risk of severe hypoxemia during intubation procedure before invasive ventilation. Methods: 1- feasibility and efficiency of the association of NIV/HFNO (HFNO interspaced between NIV sessions) were validated in a first clinical study conducted in patients with acute hypoxemic respiratory failure; 2- Impact on prognosis of standard oxygen, HFNO, association of NIV/HFNO were compared in multicenter randomized controlled trial in the same population; 3- factors associated with intubation and mortality were determined in a post-hoc analysis; 4- efficiency of NIV and HFNO during pre-oxygenation were compared in a multicenter randomized controlled trial in patients requiring intubation during the management of acute hypoxemic respiratory failure. Results: In patients treated for acute hypoxemic respiratory failure, HFNO has shown 1- beneficial respiratory effects, with an increase in PaO2, decrease in respiratory rate, as compared to standard oxygen; 2- a better prognosis in terms of mortality and intubation as compared to standard oxygen and NIV; 3- factors associated with intubation and mortality after NIV treatment included high tidal volume generated by patients within the first hours of NIV initiation; 4- pre-oxygenation by NIV before intubation of patients with acute hypoxemic respiratory failure decreased the risk of severe hypoxemia during the intubation procedure as compared pre-oxygenation with HFNO. Conclusions: Patients with acute hypoxemic respiratory failure seem to benefit of a first line treatment with HFNO in terms of mortality and intubation as compared standard oxygen and NIV. However, NIV has a place in these patients during pre-oxygenation before intubation to secure intubation procedure by decreasing the risk of severe hypoxemia.L’oxygénothérapie conventionnelle, l’oxygénothérapie nasale à haut débit (OHD, et la ventilation non-invasive (VNI), sont les trois techniques d’oxygénation disponibles en réanimation dans la prise en charge des patients en insuffisance respiratoire aiguë hypoxémique. Cependant, la place de chacune n’est pas clairement déterminée pour éviter l’intubation, ainsi la morbidité et mortalité associées à la ventilation invasive, ou encore en cas d’échec pour sécuriser la procédure d’intubation. Objectifs : Conduire des études cliniques chez des patients avec une insuffisance respiratoire aiguë hypoxémique pour: 1- déterminer la stratégie d’oxygénation non-invasive la plus efficace sur l’intubation et la mortalité ; 2- déterminer les facteurs associés à l’échec de chacune des techniques d’oxygénation ; 3- déterminer la technique de pré-oxygénation la plus efficace pour diminuer le risque d’hypoxémie sévère lors de la procédure d’intubation trachéale en cas de recours à la ventilation invasive. Méthodes : 1- Une première étude pilote a évaluée la faisabilité de l’utilisation de l’OHD entre les séances de VNI, chez les patients en insuffisance respiratoire aigüe hypoxémique ; 2- Un grand essai clinique randomisé a comparé les trois stratégies d’oxygénation sur le pronostic dans la même population de patients; 3- Une analyse post-hoc a déterminé les facteurs associés à l’intubation et à la mortalité avec chacune des trois stratégies d’oxygénation; 4- Un nouvel essai clinique randomisé a comparé l’efficacité de la pré-oxygénation par VNI et OHD chez des patients nécessitant un intubation lors de la prise en charge d’une insuffisance respiratoire hypoxémique. Résultats : Chez les patients avec une insuffisance respiratoire aiguë hypoxémique : 1- l’OHD permettait une baisse significative de la fréquence respiratoire et l’amélioration de l’oxygénation comparée à l’oxygène standard, qui restait cependant inférieure à la VNI 2- l’OHD permettait une amélioration de la mortalité comparativement à toutes les autres techniques et une diminution du recours à l’intubation chez les patients les plus sévères; 3- des volumes courants excessifs 1 heure après la mise en route de la VNI était associés à une augmentation du risque, ce qui pourrait expliquer des effets délétères de la VNI; 4- La pré-oxygénation avant intubation par VNI diminuait le risque de survenue d’hypoxémie sévère comparativement à une pré-oxygénation par OHD. Conclusions : Les patients avec une insuffisance respiratoire aiguë hypoxémique semblent avoir un meilleur pronostic après un traitement de première ligne par OHD en termes de mortalité et d’intubation, comparativement à l’oxygénothérapie conventionnelle et à la VNI. Cependant, la VNI garde une place au cours de la pré-oxygénation avant ventilation invasive, pour sécuriser la procédure d’intubation et diminuer le risque d’épisodes d’hypoxémie sévère

Clinical impact of noninvasive oxygenation strategies in acute respiratory failure

L’oxygénothérapie conventionnelle, l’oxygénothérapie nasale à haut débit (OHD, et la ventilation non-invasive (VNI), sont les trois techniques d’oxygénation disponibles en réanimation dans la prise en charge des patients en insuffisance respiratoire aiguë hypoxémique. Cependant, la place de chacune n’est pas clairement déterminée pour éviter l’intubation, ainsi la morbidité et mortalité associées à la ventilation invasive, ou encore en cas d’échec pour sécuriser la procédure d’intubation. Objectifs : Conduire des études cliniques chez des patients avec une insuffisance respiratoire aiguë hypoxémique pour: 1- déterminer la stratégie d’oxygénation non-invasive la plus efficace sur l’intubation et la mortalité ; 2- déterminer les facteurs associés à l’échec de chacune des techniques d’oxygénation ; 3- déterminer la technique de pré-oxygénation la plus efficace pour diminuer le risque d’hypoxémie sévère lors de la procédure d’intubation trachéale en cas de recours à la ventilation invasive. Méthodes : 1- Une première étude pilote a évaluée la faisabilité de l’utilisation de l’OHD entre les séances de VNI, chez les patients en insuffisance respiratoire aigüe hypoxémique ; 2- Un grand essai clinique randomisé a comparé les trois stratégies d’oxygénation sur le pronostic dans la même population de patients; 3- Une analyse post-hoc a déterminé les facteurs associés à l’intubation et à la mortalité avec chacune des trois stratégies d’oxygénation; 4- Un nouvel essai clinique randomisé a comparé l’efficacité de la pré-oxygénation par VNI et OHD chez des patients nécessitant un intubation lors de la prise en charge d’une insuffisance respiratoire hypoxémique. Résultats : Chez les patients avec une insuffisance respiratoire aiguë hypoxémique : 1- l’OHD permettait une baisse significative de la fréquence respiratoire et l’amélioration de l’oxygénation comparée à l’oxygène standard, qui restait cependant inférieure à la VNI 2- l’OHD permettait une amélioration de la mortalité comparativement à toutes les autres techniques et une diminution du recours à l’intubation chez les patients les plus sévères; 3- des volumes courants excessifs 1 heure après la mise en route de la VNI était associés à une augmentation du risque, ce qui pourrait expliquer des effets délétères de la VNI; 4- La pré-oxygénation avant intubation par VNI diminuait le risque de survenue d’hypoxémie sévère comparativement à une pré-oxygénation par OHD. Conclusions : Les patients avec une insuffisance respiratoire aiguë hypoxémique semblent avoir un meilleur pronostic après un traitement de première ligne par OHD en termes de mortalité et d’intubation, comparativement à l’oxygénothérapie conventionnelle et à la VNI. Cependant, la VNI garde une place au cours de la pré-oxygénation avant ventilation invasive, pour sécuriser la procédure d’intubation et diminuer le risque d’épisodes d’hypoxémie sévère.Standard oxygen, high-flow nasal oxygen therapy (HFNO) and non-invasive ventilation (NIV), and are three strategies of oxygenation usually applied in the ICU for patients with acute hypoxemic respiratory failure. However, it is not well established which technique is better to avoid intubation and thus the related morbidity and mortality, but also which one can secure intubation procedure in case of failure. Objectives: To conduct clinical studies in patients with acute hypoxemic respiratory failure: 1- to compare oxygen strategies including standard oxygen, HFNO, or NIV (associated with HFNO) in terms of intubation and mortality rates; 2- to determine factors associated with oxygen strategies failure, i.e. intubation and mortality; 3- to determine which technique of pre-oxygenation best decreases the risk of severe hypoxemia during intubation procedure before invasive ventilation. Methods: 1- feasibility and efficiency of the association of NIV/HFNO (HFNO interspaced between NIV sessions) were validated in a first clinical study conducted in patients with acute hypoxemic respiratory failure; 2- Impact on prognosis of standard oxygen, HFNO, association of NIV/HFNO were compared in multicenter randomized controlled trial in the same population; 3- factors associated with intubation and mortality were determined in a post-hoc analysis; 4- efficiency of NIV and HFNO during pre-oxygenation were compared in a multicenter randomized controlled trial in patients requiring intubation during the management of acute hypoxemic respiratory failure. Results: In patients treated for acute hypoxemic respiratory failure, HFNO has shown 1- beneficial respiratory effects, with an increase in PaO2, decrease in respiratory rate, as compared to standard oxygen; 2- a better prognosis in terms of mortality and intubation as compared to standard oxygen and NIV; 3- factors associated with intubation and mortality after NIV treatment included high tidal volume generated by patients within the first hours of NIV initiation; 4- pre-oxygenation by NIV before intubation of patients with acute hypoxemic respiratory failure decreased the risk of severe hypoxemia during the intubation procedure as compared pre-oxygenation with HFNO. Conclusions: Patients with acute hypoxemic respiratory failure seem to benefit of a first line treatment with HFNO in terms of mortality and intubation as compared standard oxygen and NIV. However, NIV has a place in these patients during pre-oxygenation before intubation to secure intubation procedure by decreasing the risk of severe hypoxemia

Oxygénothérapie à haut débit nasale associée à la ventilation non invasive dans l'insuffisance respiratoire aiguë hypoxémique de l'adulte (Etude prospective observationnelle OVALI)

POITIERS-BU Médecine pharmacie (861942103) / SudocSudocFranceF

High-flow nasal cannula oxygen therapy in acute hypoxemic respiratory failure and COVID-19-related respiratory failure

Although standard oxygen face masks are first-line therapy for patients with acute hypoxemic respiratory failure, high-flow nasal cannula oxygen therapy has gained major popularity in intensive care units. The physiological effects of high-flow oxygen counterbalance the physiological consequences of acute hypoxemic respiratory failure by lessening the deleterious effects of intense and prolonged inspiratory efforts generated by patients. Its simplicity of application for physicians and nurses and its comfort for patients are other arguments for its use in this setting. Although clinical studies have reported a decreased risk of intubation with high-flow oxygen compared with standard oxygen, its survival benefit is uncertain. A more precise definition of acute hypoxemic respiratory failure, including a classification of severity based on oxygenation levels, is needed to better compare the efficiencies of different non-invasive oxygenation support methods (standard oxygen, high-flow oxygen, and non-invasive ventilation). Additionally, the respective role of each non-invasive oxygenation support method needs to be established through further clinical trials in acute hypoxemic respiratory failure, especially in severe forms

High-flow nasal cannula oxygen therapy in acute respiratory failure at Emergency Departments: A systematic review

International audienceObjectives: The use of high-flow oxygen therapy (HFOT) through nasal cannula for the management of acute respiratory failure at the emergency department (ED) has been only sparsely studied. We conducted a systematic review of randomized-controlled and quasi-experimental studies comparing the early use of HFOT versus conventional oxygen therapy (COT) in patients with acute respiratory failure admitted to EDs.Methods: A systematic research of literature was carried out for all published control trials comparing HFOT with COT in adult patients admitted in EDs. Eligible data were extracted from Medline, Embase, Pascal, Web of Science and the Cochrane database. The primary outcome was the need for mechanical ventilation, i.e. intubation or non-invasive ventilation as rescue therapy. Secondary outcomes included respiratory rate, dyspnea level, ED length of stay, intubation and mortality.Results: Out of 1829 studies screened, five studies including 673 patients were retained in the analysis (350 patients treated with HFOT and 323 treated with COT). The need for mechanical ventilation was similar in both treatments (RR = 0.75; 95% CI 0.41 to 1.35; P = 0.31; I2 = 16%). Respiratory rate was lower with HFOT (Mean difference (MD) = -3.14 breaths/min; 95% CI = -4.9 to -1.4; P < 0.001; I2 = 39%), whereas sensation of dyspnea did not differ. (MD = -1.04; 95% CI = -2.29 to -0.22; P = 0.08; I2 = 67%). ED length of stay and mortality were similar between groups.Conclusion: The early use of HFOT in patients admitted to an ED for acute respiratory failure did not reduce the need for mechanical ventilation as compared to COT. However, HFOT decreased respiratory rate.Registration: PROSPERO ID CRD4201912569