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Vol. 40. Issue 9.
Pages 703-705 (September 2021)
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Vol. 40. Issue 9.
Pages 703-705 (September 2021)
Letter to the Editor
Open Access
Prognostic impact of high flow nasal cannula compared to noninvasive positive-pressure ventilation in the treatment of acute pulmonary edema
Impacto prognóstico da cânula nasal de alto fluxo em comparação com a ventilação por pressão positiva não invasiva no tratamento de edema agudo de pulmão
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Williams Hinojosaa,
Corresponding author
williams_hinojosa@hotmail.com

Corresponding author.
, Carolina Iglesiasa, Silvio Veraa, Marta Marcosa, Aitor Uribarrib, Itziar Gómezb, Gemma Pastorb
a Cardiology Department, Hospital Clínico Universitario, Valladolid, Spain
b CIBERCV, Cardiology Department, Hospital Clínico Universitario, Valladolid, Spain
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Tables (2)
Table 1. Baseline characteristics of the patients according to the modality of noninvasive ventilation therapy.
Table 2. Primary and secondary ends point comparing noninvasive positive-pressure ventilation and high flow nasal cannula.
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Dear Editor,

The use of non-invasive mechanical ventilation (NIMV) reduces the rate of intubation and mortality in patients with acute pulmonary edema (APE).1 High flow nasal cannula oxygen (HFNC) may offer an alternative to ventilatory support in patients with APE2,3 with theoretical advantages related to patient adaptation, comfort and less of a need for staff training to achieve optimal therapy. However, clinical efficacy and safety of HFNC compared to NIMV in APE is not well established.

We performed a prospective, observational study between November 2018 and January 2020. Forty-seven patients with criteria of non-hypercapnic APE were classified into two groups according to the initial therapy: Continuous positive airway pressure (CPAP)/NIPPV versus HFNC. The selected ventilatory therapy was at the discretion of the treating clinician and patients with cardiogenic shock, hemodynamic instability, hypercapnic respiratory failure (partial pressure of carbon dioxide >45 mmHg) were excluded. The device used for NIMV ventilation was a V V60® (Philips, Respironics Inc, MA, USA), whereas for HFNC therapy an Airvo™ 2 (Fisher & Paykel Healthcare, East Tamaki, New Zealand) was used. Primary composite endpoint was death or need for orotracheal intubation within 30 days after admission. The secondary endpoints were length of hospital stay, admission to the critical care unit and composite of orotracheal intubation/change of therapy secondary to respiratory worsening.

The mean age was 68.8±13.1 years, 83% male. Twenty-eight (59.6%) patients received HFNC and 19 (40.4%) NIPPV-CPAP as initial treatment for APE. De novo acute heart failure (HF) was the initial presentation in 76.6% and 61.7% was secondary to acute coronary syndrome. Disease severity at admission was similar in both groups (Table 1). In patients treated with HFNC, initial flow was 44.3±22.7 L/min and 37°C. In the case of CPAP treatment, the initial pressure was 7±2 cmH20 and in NIPPV patients, the inspiratory pressure was 14±4 and expiratory 6±2 cmH20.

Table 1.

Baseline characteristics of the patients according to the modality of noninvasive ventilation therapy.

Characteristic  Global populationn=47  CPAP/NIPPVn=19  HFNCn=28  p value 
Age (years)  68.6±16.49  70.42±11.56  67±14.74  0.451 
Male gender (%)  83.0  78.9  85.7  0.697 
Diabetes (%)  46.8  68.4  32.1  0.014 
Hypertension (%)  76.0  89.5  67.9  0.159 
COPD (%)  12.8  21.1  7.1  0.204 
OSAS (%)  4.3  5.3  3.6  0.999 
Previous cardiac surgery (%)  19.1  21.1  17.9  0.999 
Ischemic heart disease (%)  34.0  36.8  32.1  0.739 
Chronic kidney failure (%)  14.9  21.4  10.7  0.417 
Valvular heart disease (%)  36.2  36.8  35.7  0.937 
AF (%)  12.8  15.8  10.7  0.674 
Admission characteristics
Pulse rate (beats/min)  97.8±16.5  103.1±27.7  94.2±25.5  0.269 
Systolic BP mmHg  120±30.4  125.3±37.04  117.5±25.31  0.391 
Diastolic BP mmHg  71.04±16.6  75.1±20.6  68.2±12.87  0.164 
Respiratory rate (breaths/min)  28.6±4.3  28.4±5.7  27.74±3.23  0.843 
Peripheral oxygen saturation %  89.7±5.7  89.6±5.6  89.8±5.1  0.935 
Apache II score  15.16±6.41  15.34±5.31  15.05±7.11  0.889 
Etiology of heart failure
ACS (%)  12 (61.7)  17 (63.2)  60.7  0.866 
STEMI (%)  42.4  42.1  3.1  0.847 
NSTEMI (%)  19.3  21.1  17.9  0.999 
Syntax score  21.0±10.6  20.04±12.2  21.71±9.5  0.687 
Valve disease (%)  4 (8.5)  1 (5.3)  3 (10.7)  0.638 
Arrhythmia (%)  3 (6.4)  2 (7.1)  1 (5.3)  0.946 
Hypertensive crisis (%)  3 (6.4)  1 (3.6)  2 (10.5)  0.557 
Chronic HF (%)  11(23.4)  5 (26.3)  6 (21.4)  0.737 
Aortic dissection (%)  1 (2,1)  0.0  1 (3.6)  0.999 
LVEF  37.4±11.3  33.8±9.7  39.9±11.9  0.074 
Treatment in first 24 hours
Furosemide (%)  42 (95.5)  19(100.0)  26(92.0)  0.498 
Mean dose 24 hours (mg)  168.4±136.3  136.84±82.3  193.5±164.7  0.100 
Hydric balance first 24 hours (L)  -2.9±2.3  -1.8±1.5  -2.2±2.1  0.498 
Nitroglycerin (%)  23(52.3)  9(47.4)  14(56.0)  0.570 
Mean dose 24 hours mg/kg/min  37.3±60.5  51.2±90  27±23  0.953 
Thiazides (%)  5 (11.4)  2 (10.5)  3 (12.0)  0.999 
CRRT (%)  3 (6.8)  1 (5.3)  2 (8.0)  0.999 

ACS: acute coronary syndrome; AF: atrial fibrillation; BP: blood pressure, CCRT: continuous renal replacement therapy; COPD: chronic obstructive pulmonary disease; CPAP: continuous positive airway pressure; HF: heart failure; HFNC: high flow nasal cannula; LVEF: left ventricular ejection fraction. MCS: mechanical circulatory support, NIPPV: noninvasive positive-pressure ventilation; OSAS: obstructive sleep apnea syndrome, STEMI: ST elevation myocardial infarction. NSTMI: non ST elevation myocardial infarction.

There was no significant difference in 30-day mortality or combined objective of death/intubation in HFNC vs. NIMV (21.5 vs. 15.8 p=0.72) and (37.0 vs. 21.1% p=0.24). However the failure of therapy, defined as the combined objective of intubation or change of therapy due to respiratory worsening, was more frequent in the HFNC group (40.7 vs. 15.8 p=0.07). In-hospital or coronary care unit long stay was no different between both groups (Table 2).

Table 2.

Primary and secondary ends point comparing noninvasive positive-pressure ventilation and high flow nasal cannula.

Variable  Overall(n=47)  CPAP/NIPPVn=19  HFNCn=28  p value 
Death at 30 days (%)  19.1  15.8  21.5  0.72 
Respiratory infection after 48 hours of admission (%)  15.2  26.3  7.4  0.10 
Intubation at 30 days (%)  23.9  15.8  29.6  0.32 
Death or intubation 30 days (%)  30.4  21.1  37.0  0.24 
Intubation or change therapy for worsening RD (%)  30.4  40.7  15.8  0.07 
Length hospital stay (days)  11.8±10.9  12.06±9.6  11.7±11.8  0.65 
Length critical care unit stay (days)  5.87±6.8  6.9±7.2  5.1±6.5  0.24 

CPAP: continuous positive airway pressure; HFNC: high flow nasal cannula; RD: respiratory distress; NIPPV: noninvasive positive-pressure ventilation.

In this study, HFNC was not associated with increased 30-day mortality in patients with non-hypercapnic APE, but was associated with non-significant increase in treatment failure secondary to respiratory worsening. These findings could be explained for several reasons related to the physiological effects of positive end-expiratory pressure (PEEP) over compliance, alveolar recruitment, decrease of left ventricular afterload and right ventricular preload.4,5 Although HFNC seems to have an impact on RV preload, PEEP is often inconsistent, depending on the flow delivered and patient collaboration. This effect could explain that despite the good results in hypoxemic respiratory failure of other causes,5 it has no benefit in APE.6 Although the use of HFNC possibly does not provide benefits in the treatment of APE over NIMV, it could have better results in decompensated HF over conventional oxygen2,3,6 or in weaning from NIMV therapy. Randomized studies are needed.

Conflicts of interest

None declared.

References
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N. Berbenetz, Y. Wang, J. Brown, et al.
Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary edema.
Cochrane Database Syst Rev, 4 (2019), pp. CD005351
[2]
O. Makdee, A. Monsomboon, U. Surabenjawong, et al.
High-flow nasal cannula versus conventional oxygen therapy in emergency department patients with cardiogenic pulmonary edema: a randomized controlled trial.
Ann Emerg Med, 70 (2017),
[3]
D.R. Ko, J. Beom, H. Lee, et al.
Benefits of high-flow nasal cannula therapy for acute pulmonary edema in patients with heart failure in the emergency department: a prospective multi-center randomized controlled trial.
J Clin Med, 9 (2020), pp. 1937
[4]
C.L. Alviar, P.E. Miller, D. Mcareavey, ACC Critical Care Cardiology Working Group, et al.
Positive pressure ventilation in the cardiac intensive care unit.
J Am Coll Cardiol, 72 (2018), pp. 1532-1553
[5]
P. Doshi, J.S. Whittle, M. Bublewicz, et al.
High-velocity nasal insufflation in the treatment of respiratory failure: a randomized clinical trial.
Ann Emerg Med, 72 (2018), pp. 73-83
[6]
Y. Koga, K. Kaneda, N. Fujii, et al.
Comparison of high-flow nasal cannula oxygen therapy and non-invasive ventilation as first-line therapy in respiratory failure: a multicenter retrospective study.
Acute Med Surg, 7 (2020), pp. e461
Copyright © 2021. Sociedade Portuguesa de Cardiologia
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