Introduction. High flow nasal cannula oxygen therapy (HFNC) has become frequent in the treatment of patients with acute hypoxemic respiratory failure. Methods. Eleven patients with acute exacerbation of fibrotic interstitial lung disease (ILD) were treated with HFNC after failure of conventional therapy (SatO2< 90% offering 100% FiO2 by non-rebreathing mask or noninvasive ventilation). Results. Ten patients had success with HFNC (not requiring orotracheal intubation) during emergency department admission. HFNC significantly improves clinical variables after 2h: respiratory rate decreased from 33 ± 6 breaths/min to 23 ± 3 breaths/min; PaO2 increased from 48.7 (38 - 59)mmHg to 81.1 (76 - 90) mmHg; PaO2/FiO2 ratio increased from 102.4 ± 32.2 to 136.6 ± 29.4; SatO2 increased from 85 (66 - 92)% to 96 ± (95 - 97)%. HFNC could be an effective alternative in the treatment of acute respiratory failure from acute exacerbations of fibrotic ILD

Balzan, Fernanda Machado

Catarino, Bruna Maciel

moretti Jr, Joares Luiz

Pacheco, Eder Chaves

Savi, Augusto

Vieira, Fernando Nataniel

English

Introduction. High flow nasal cannula oxygen therapy (HFNC) has become frequent in the treatment of patients with acute hypoxemic respiratory failure. Methods. Eleven patients with acute exacerbation of fibrotic interstitial lung disease (ILD) were treated with HFNC after failure of conventional therapy (SatO2&lt; 90% offering 100% FiO2 by non-rebreathing mask or noninvasive ventilation). Results. Ten patients had success with HFNC (not requiring orotracheal intubation) during emergency department admission. HFNC significantly improves clinical variables after 2h: respiratory rate decreased from 33 ± 6 breaths/min to 23 ± 3 breaths/min; PaO2 increased from 48.7 (38 - 59)mmHg to 81.1 (76 - 90) mmHg; PaO2/FiO2 ratio increased from 102.4 ± 32.2 to 136.6 ± 29.4; SatO2 increased from 85 (66 - 92)% to 96 ± (95 - 97)%. HFNC could be an effective alternative in the treatment of acute respiratory failure from acute exacerbations of fibrotic ILD

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Original Articlehttps://doi.org/10.22491/2357-9730.98187ISSN 2357-9730http://seer.ufrgs.br/hcpa 33Clin Biomed Res. 2020;40(1):33-3633HigH-flow nasal cannula oxygen tHerapy in acute respiratory failure due to acute exacerbation of fibrotic interstitial lung diseaseFernanda Machado Balzan1, Eder Chaves Pacheco2, Fernando Nataniel Vieira1, Joares Luiz Moretti Júnior1,  Bruna Maciel Catarino1, Augusto Savi Mail11 Serviço de Fisioterapia, Hospital de Clínicas de Porto Alegre (HCPA).  Porto Alegre, RS, Brasil.2 Laboratório de Pneumologia LIM-09, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP). São Paulo, SP, Brasil.Corresponding author:Augusto Savi Mailasavi@hcpa.edu.brHospital de Clínicas de  Porto Alegre (HCPA)Rua Ramiro Barcelos, 2350.90035-903, Porto Alegre, RS, Brasil.ABSTRACTHigh flow nasal cannula oxygen therapy (HFNC) has become frequent in the treatment of patients with acute hypoxemic respiratory failure. Methods. Eleven patients with acute exacerbation of fibrotic interstitial lung disease (ILD) were treated with HFNC after failure of conventional therapy (SatO2 < 90% offering 100% FiO2 by non-rebreathing mask or noninvasive ventilation). Ten patients had success with HFNC (not requiring orotracheal intubation) during emergency department admission. HFNC significantly improves clinical variables after 2h: respiratory rate decreased from 33 ± 6 breaths/min to 23 ± 3 breaths/min; PaO2 increased from 48.7 (38-59) mmHg to 81.1 (76-90) mmHg; PaO2/FiO2 ratio increased from 102.4 ± 32.2 to 136.6 ± 29.4; SatO2 increased from 85 (66-92)% to 96 ± (95-97)%. HFNC could be an effective alternative in the treatment of acute respiratory failure from acute exacerbations of fibrotic ILD.Keywords: Respiratory failure; interstitial lung disease; high flow nasal cannulaFibrotic interstitial lung diseases (ILDs) represent a pathologically heterogeneous group of diseases in which impaired tissue oxygen delivery occurs. ILDs involve interstitial pulmonary histologic abnormalities that lead to profound impairment of lung physiology and function. Gas exchange is impaired secondary to V/Q mismatching, shunting, and decreased diffusion across the abnormal interstitium1. Acute exacerbation of fibrotic ILD is a leading cause of death, often complicated by severe hypoxemia2,3.Noninvasive ventilation (NIV) has been a viable option as it results in better patient survival and lower high-care unit use4. However, the increased work of breathing due to decreased lung compliance may be an important factor for poor NIV tolerance in these patients during acute exacerbations5. High-flow nasal cannula oxygen therapy (HFNC) provides an alternative to conventional oxygen therapy whereby heated and humidified oxygen is delivered to the nose at high flow rates and the fraction of inspired oxygen (FiO2) can be adjusted by changing the fraction of oxygen in the driving gas6-9. HFNC has been commonly used in the treatment of patients with acute hypoxemic respiratory failure as it results in greater comfort and oxygenation than standard oxygen therapy delivered through a face mask, also helping decrease the work of breathing6.HFNC might potentially be an alternative to conventional oxygen therapy in patients requiring both high flows and high oxygen concentrations, such as patients with acute exacerbation of fibrotic ILD, to correct hypoxemia and control dyspnea; however, evidence is still scarce7. In this prospective analysis, we assessed short-term effects (need for endotracheal intubation, clinical outcomes, arterial blood gases, and length of hospital stay) in patients with acute respiratory failure due to acute exacerbation of fibrotic ILD in the emergency department (ED).METHODSWe enrolled 11 patients with acute respiratory failure due to acute exacerbation of fibrotic ILD diagnosed by clinical, physiological, and high-Balzan et al.http://seer.ufrgs.br/hcpaClin Biomed Res 2020;40(1)34resolution computed tomography criteria. This study was conducted in the ED of a university hospital between December 2016 and October 2017. The primary outcome was the proportion of patients who required endotracheal intubation despite HFNC therapy, and secondary outcomes were arterial blood gases, Borg scale, and improvement in vital signs. The study was approved by the Institutional Ethics Committee of our hospital and patients consented to participate.All patients were treated with HFNC after failure of conventional therapy, defined as arterial oxygen saturation (SaO2) < 90% with non-rebreathing mask and/or NIV or if conventional therapy was not tolerated.HFNC was delivered using an Optiflow nasal interface and circuit connected to a heated humidifier (MR730; Fisher & Paykel Healthcare, Auckland, New Zealand) with flow generated through a mechanical ventilator with oxygen therapy software (EVITA XL, Dräger, Lübeck, Germany). This system delivers oxygen at a maximum flow of 50 L/min. Data were collected before and 2 hours after HFNC and included respiratory rate (RR), heart rate (HR), arterial oxygen saturation by pulse oximetry (SpO2), arterial blood gases as arterial partial pressure of oxygen (PaO2), arterial partial pressure of carbon dioxide (PaCO2), ratio of PaO2 to the fraction of inspired oxygen (FiO2), and subjective dyspnea (Borg scale, 0 = no dyspnea to 10 = maximum dyspnea).Need for intubation was defined as RR > 40 breaths/min, signs of high respiratory muscle workload, and SpO2 < 90% with FiO2 1.0.HFNC was started in all patients with the flow set at 50 L/min and FiO2 to maintain SpO2 > 90% and according to the patient’s comfort and vital signs. Weaning started after improvement of the patient’s initial condition with reduction of FiO2 up to 40% and flow in steps of 5 L/min until reaching 15 L/min.Data are expressed in mean and standard deviation and median and interquartile range (25th-75th percentiles). The Shapiro-Wilk test was used to determine the normality of data distribution of the variables, and those with normal distribution were compared by the t-test. The level of significance was set at p ≤ 0.05.RESULTSEleven patients (7 women) were included in the study (Table 1). The mean hospital stay was 17.1 ± 8.4 days, and total in-hospital mortality was 54%. Patients’ vital signs and arterial blood gases improved (Figure 1). One patient (9.1%) required orotracheal intubation in the ED for increased ventilatory effort and desaturation even after the start of HFNC therapy.2001751501251007550Pre PostPaO2/FiO2 ratio7,8pH7,67,47,27,0Pre PostRR (breaths/min)403020100Pre Post35PaCO2(mm Hg)454030Pre Post10090807060Pre PostSpO2(%)1086420Pre PostDyspnea (BORG scale)Figure 1: Changes in pH (A), RR (B), PaCO2 (C), PaO2/FiO2 ratio (D), SpO2 (E) and dyspnea (F) before and after 2 hours high flow nasal cannula (HFNC). Lines represent median +/- standard error. *P < 0.01 comparing before and after HFNC. PCO2, arterial carbon dioxide pressure; PaO2, arterial oxygen pressure; FiO2, inspired oxygen fraction; SpO2, pulse oximetry; subjective dyspnea scale Borg.High-flow nasal cannula and fibrotic lung diseasehttp://seer.ufrgs.br/hcpa Clin Biomed Res 2020;40(1) 35Table 1: Baseline characteristics of patientsCharacteristic ResultAge, mean ± SD (yr) 63 ± 8.6Women , No. (%) 7 (63.6)BMI, mean ± SD (kg/m2) 27.2 ± 4.1TLC, % of predicted 59 ± 8.8FVC, % of predicted 48 ± 9.8Comorbidities, No. (%)Arterial hypertension 3 (27)Diabetes mellitus 3 (27)COPD 1 (9)Asthma 1 (9)Heart failure 1 (9)Previous use of home oxygen, No. (%) 2 (18)SD: standard deviation. BMI: body mass index. TLC: total lung capacity. FVC: forced vital capacity. COPD: chronic obstructive pulmonary disease.REFERENCES1. Raghu G, Brown KK. Interstitial lung disease: clinical evaluation and keys to an accurate diagnosis. Clin Chest Med. 2004;25(3):409-19.2.  Ryerson CJ, Cottin V, Brown KK, Collard HR. Acute exacerbation of idiopathic pulmonary fibrosis: shifting the paradigm. Eur Respir J. 2015;46(2):512-20.3.  Horio, Y, Takihara T, Niimi K, Komatsu M, Sato M, Tanaka J, et al. High-flow nasal cannula oxygen therapy for acute exacerbation of interstitial pneumonia: A case series. Respir Investig. 2016;54(2):125-9.4.  Tomii K, Tachikawa R, Chin K, Murase K, Handa T, Mishima M, Ishihara K. Role of non-invasive ventilation in managing life-threatening acute exacerbation of interstitial pneumonia. Intern Med. 2010;49(14):1341-7.5.  Vianello A, Arcaro G, Battistella L, Pipitone E, Vio S, Concas A, et al. Noninvasive ventilation in the event of acute respiratory failure in patients with idiopathic pulmonary fibrosis. J Crit Care. 2014;29(4):562-7.6.  Frat JP, Thille AW, Mercat A, Girault C, Ragot S, Perbet S, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med. 2015;372(23):2185-96.7.  Faverio P, De Giacomi F, Sardella L, Fiorentino G, Carone M, Salerno F,  et al. Management of acute respiratory DISCUSSIONThis study showed a low intubation rate in patients with acute exacerbation of fibrotic ILD using HFNC. HFNC also improved PaO2/FiO2 ratio and RR with a corresponding lower sensation of dyspnea. These short-term findings may suggest the use of HFNC as an alternative method in this group of patients in the ED.The decrease in RR with the use of HFNC leads to a consequent decrease in ventilatory effort. This effect may be related to the low positive expiratory pressure generated by the flow of the therapy and may also be related to the improvement in ventilation-perfusion matching8,9.One study investigating the physiological effects of HFNC in patients with acute hypoxemic respiratory failure reported that HFNC delivered at increasing flow rates linearly improves respiratory drive, end-expiratory lung volume, lung mechanics, and oxygenation, while effort and minute ventilation decrease in an exponential manner10. These results contribute to understanding why patients with acute exacerbation of fibrotic ILD in this study had a reduction in ventilatory effort after 2 hours of HFNC therapy. HFNC may be more suitable for the management of acute respiratory failure due to acute exacerbation of fibrotic ILD in which higher positive end-expiratory pressure and/or ventilatory support is required3.Our study has some limitations. The level of patient comfort in relation to HFNC therapy was not evaluated, and future clinical trials enrolling a larger number of patients need to be developed to confirm our findings. In addition, despite the low rate of orotracheal intubation in the ED, we observed a high in-hospital mortality rate, which may be associated with the severity of disease in our patients.CONCLUSIONThe present results suggest that HFNC may be an effective alternative in the treatment of acute respiratory failure due to acute exacerbation of fibrotic ILD, especially in the ED.Balzan et al.http://seer.ufrgs.br/hcpaClin Biomed Res 2020;40(1)36failure in interstitial lung diseases: overview and clinical insights. BMC Pulm Med. 2018;18(1):70.8.  Mauri T, Turrini C, Eronia N, Grasselli G, Volta CA, Bellani G, Pesenti A. Physiologic effects of high flow nasal cannula in acute hypoxemic respiratory failure. AM J Respir Crit Care Med. 2017;195(9):1207-15.9.  Parke RL, McGuinnes SP. Pressures delivered by nasal high flow oxygen during all phases of the respiratory cycle. Respir Care. 2013;58(10):1621-4.10.  Mauri T, Alban L, Turrini C, Cambiaghi B, Carlesso E, Taccone P, et al. Optimum support by high-flow nasal cannula in acute hypoxemic respiratory failure: effects of increasing flow rates. Intensive Care Med. 2017;43(10):1453-63.Received: Nov 14, 2019Accepted: Mar 8, 2020

High flow nasal cannula oxygen therapy in acute respiratory failure from acute exacerbation of fibrotic interstitial lung disease

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High flow nasal cannula oxygen therapy in acute respiratory failure from acute exacerbation of fibrotic interstitial lung disease

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