Scientific Letter
Combination Therapy in Patients with Acute Respiratory Failure: High-Flow Nasal Cannula and Non-Invasive Mechanical Ventilation
Terapia combinada en pacientes con insuficiencia respiratoria aguda: alto flujo por cánula nasal y ventilación mecánica no invasiva
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These patients are usually reconnected to the respirator, depriving them of their periods of rest from NIMV. We report the case of a patient with acute respiratory failure who used high-flow nasal cannula (HFNC) as an alternative therapy during the periods of disconnection from NIMV.</p><p id="par0010" class="elsevierStylePara elsevierViewall">This was an 83-year-old woman, with a diagnosis of hypoventilation-obesity syndrome, receiving night-time NIMV. She had a giant umbilical hernia that caused significant ventilatory compromise. She attended the emergency room due to dyspnea and a low level of consciousness, blood pressure: 158/86<span class="elsevierStyleHsp" style=""></span>mmHg, heart rate: 86<span class="elsevierStyleHsp" style=""></span>bpm; breathing rate: 32<span class="elsevierStyleHsp" style=""></span>breaths/min; SatO<span class="elsevierStyleInf">2</span> 86%, with O<span class="elsevierStyleInf">2</span> at 6<span class="elsevierStyleHsp" style=""></span>bpm and a Glasgow score of 10. Physical examination was significant for peripheral cyanosis, tachypnea, and abdominal breathing. Pulmonary auscultation revealed bilateral crackles and rhonchi. Clinical laboratory tests were significant for BNP 241<span class="elsevierStyleHsp" style=""></span>mg/dl and leukocytes: 10<span class="elsevierStyleHsp" style=""></span>400 (neutrophils: 70.6%). PCR for influenza type A-H1 subtype was positive. Arterial blood gases showed a pH of 7.07; <span class="elsevierStyleItalic">p</span>O<span class="elsevierStyleInf">2</span>: 38<span class="elsevierStyleHsp" style=""></span>mmHg; <span class="elsevierStyleItalic">p</span>CO<span class="elsevierStyleInf">2</span>: 107<span class="elsevierStyleHsp" style=""></span>mmHg; HCO<span class="elsevierStyleInf">3</span>: 31<span class="elsevierStyleHsp" style=""></span>mg/dl. Chest X-ray revealed right basal opacity with blunting of the left costophrenic angle. The principal diagnosis was acute respiratory failure with severe respiratory acidosis due to viral pneumonia caused by type A-H1 influenza. NIMV began with a V60 respirator in ST mode, regulated with IPAP 21<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O, EPAP 10<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O, and a back-up breath rate of 16<span class="elsevierStyleHsp" style=""></span>breaths/min. Clinical assessment carried out at 1<span class="elsevierStyleHsp" style=""></span>h showed an improved level of consciousness (Glasgow 14), respiration (25<span class="elsevierStyleHsp" style=""></span>breaths/min) and arterial blood gases (pH: 7.18<span class="elsevierStyleHsp" style=""></span>mmHg; <span class="elsevierStyleItalic">p</span>CO<span class="elsevierStyleInf">2</span>: 82<span class="elsevierStyleHsp" style=""></span>mmHg; <span class="elsevierStyleItalic">p</span>O<span class="elsevierStyleInf">2</span>: 65<span class="elsevierStyleHsp" style=""></span>mmHg; HCO<span class="elsevierStyleInf">3</span>: 30<span class="elsevierStyleHsp" style=""></span>mg/dl; FiO<span class="elsevierStyleInf">2</span>: 35%; alveolar arterial O<span class="elsevierStyleInf">2</span> gradient: 64.5). Arterial blood gas at 6<span class="elsevierStyleHsp" style=""></span>h showed pH: 7.33 (2) 78<span class="elsevierStyleHsp" style=""></span>mmHg; <span class="elsevierStyleItalic">p</span>CO<span class="elsevierStyleInf">2</span>: 50<span class="elsevierStyleHsp" style=""></span>mmHg; HCO<span class="elsevierStyleInf">3</span>: 26.4; FiO<span class="elsevierStyleInf">2</span>: 35%; alveolar arterial O<span class="elsevierStyleInf">2</span> gradient: 91.5. The patient was admitted to the respiratory observation area, and prescribed NIMV in shifts. During the first attempt at disconnection from NIMV using a Venturi mask at 35%, the patient developed significant work of breathing, respiratory rate 40<span class="elsevierStyleHsp" style=""></span>breaths/min, and arterial O<span class="elsevierStyleInf">2</span> saturation (SpO<span class="elsevierStyleInf">2</span>) 70%, so we decided to use HFNC at 60<span class="elsevierStyleHsp" style=""></span>l/min with FiO<span class="elsevierStyleInf">2</span> of 50%. The patient improved and recovered the level of comfort she had experienced with NIMV; her respiration rate normalized and SpO<span class="elsevierStyleInf">2</span> stabilized at 93%. The patient continued to alternate between NIMV and HFNC during hospital admission until discharge 8 days later. Arterial blood gases at discharge were pH 7.45, <span class="elsevierStyleItalic">p</span>CO<span class="elsevierStyleInf">2</span> 42<span class="elsevierStyleHsp" style=""></span>mmHg, <span class="elsevierStyleItalic">p</span>O<span class="elsevierStyleInf">2</span> 57<span class="elsevierStyleHsp" style=""></span>mmHg, and HCO<span class="elsevierStyleInf">3</span> 29.2<span class="elsevierStyleHsp" style=""></span>mg/dl. Chest X-ray showed that the radiological infiltrate had disappeared. The patient continued to receive domiciliary NIMV at night and during the day after eating, as she had done before admission.</p><p id="par0015" class="elsevierStylePara elsevierViewall">This was a patient with acute respiratory failure and severe respiratory acidosis due to viral pneumonia caused by influenza A-H1, in which the use of HFNC allowed the patient to take NIMV rest periods without undue stress. HFNC has proven to be useful in the treatment of patients with hypoxemic respiratory failure, and evidence is emerging to suggest its usefulness in hypercapnic respiratory failure.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> It has multiple mechanisms of action, of which the most important are its ability to increase alveolar recruitment, improve the ventilatory pattern, generate a positive expiratory pressure, and flush CO<span class="elsevierStyleInf">2</span> from the dead space.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> By supplying the gas at a temperature of 37<span class="elsevierStyleHsp" style=""></span>°<span class="elsevierStyleSmallCaps">C</span> and 100% humidity, HFNC is better tolerated and more comfortable for the patient.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> Numerous studies have demonstrated a significant reduction in respiratory rate, heart rate, dyspnea score, supraclavicular and thoracoabdominal retraction, and asynchrony, and a significant improvement in SpO<span class="elsevierStyleInf">2</span> in patients with acute hypoxemic respiratory failure treated with HFNC.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> In COPD patients with hypercapnia, HFNC improves the effectiveness of breathing, reduces pCO<span class="elsevierStyleInf">2</span>, work of breathing, and rapid, shallow breathing index, as an indicator of respiratory work load.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">There are few publications on the outcomes of combined therapy with NFNC and NIMV. Frat et al.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> published a prospective observational study in which they alternated the use of NFNC and NIMV in subjects with acute hypoxemic respiratory failure, the majority of which met criteria for ARDS. Compared with conventional oxygen therapy, the use of HFNC improved oxygenation levels and symptoms of respiratory distress. Despite a lower impact on oxygenation compared with NIMV, HFNC was better tolerated. The study concluded that this technique can be used as a bridge between NIMV sessions. Spoletini et al.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> subsequently published a review of the mechanisms of action and the clinical implications of HFNC. Among the potential clinical applications, they highlighted its use during NIMV rest periods, thanks to the physiological and subjective benefits, and its advantages over conventional oxygen therapy.</p><p id="par0025" class="elsevierStylePara elsevierViewall">HFNC and NIMV may be complementary techniques in the management of patients with acute respiratory failure. The combined use of NIMV and HFNC offers advantages over conventional NIMV oxygen therapy in more severe and unstable cases, as was the case in our patient. Studies are needed to address the role of NIMV-HFNC combination therapy in patients with acute respiratory failure.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Segovia B, Velasco D, Jaureguizar Oriol A, Díaz Lobato S. Terapia combinada en pacientes con insuficiencia respiratoria aguda: alto flujo por cánula nasal y ventilación mecánica no invasiva. Arch Bronconeumol. 2019;55:166–167.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Noninvasive mechanical ventilation in acute ventilatory failure: rationale and current applications" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "A.M. Esquinas" 1 => "M.O. Benhamou" 2 => "A.J. Glossop" 3 => "B. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 0 | 2 |
| 2024 October | 78 | 26 | 104 |
| 2024 September | 47 | 13 | 60 |
| 2024 August | 80 | 42 | 122 |
| 2024 July | 66 | 29 | 95 |
| 2024 June | 63 | 23 | 86 |
| 2024 May | 81 | 34 | 115 |
| 2024 April | 62 | 26 | 88 |
| 2024 March | 83 | 28 | 111 |
| 2024 February | 79 | 29 | 108 |
| 2024 January | 0 | 1 | 1 |
| 2023 March | 13 | 9 | 22 |
| 2023 February | 52 | 26 | 78 |
| 2023 January | 55 | 36 | 91 |
| 2022 December | 70 | 34 | 104 |
| 2022 November | 77 | 56 | 133 |
| 2022 October | 80 | 40 | 120 |
| 2022 September | 57 | 37 | 94 |
| 2022 August | 55 | 47 | 102 |
| 2022 July | 47 | 68 | 115 |
| 2022 June | 56 | 38 | 94 |
| 2022 May | 59 | 49 | 108 |
| 2022 April | 59 | 27 | 86 |
| 2022 March | 83 | 47 | 130 |
| 2022 February | 91 | 44 | 135 |
| 2022 January | 131 | 58 | 189 |
| 2021 December | 80 | 50 | 130 |
| 2021 November | 53 | 44 | 97 |
| 2021 October | 62 | 63 | 125 |
| 2021 September | 59 | 39 | 98 |
| 2021 August | 51 | 53 | 104 |
| 2021 July | 31 | 29 | 60 |
| 2021 June | 52 | 38 | 90 |
| 2021 May | 58 | 39 | 97 |
| 2021 April | 109 | 105 | 214 |
| 2021 March | 55 | 32 | 87 |
| 2020 May | 0 | 2 | 2 |
| 2020 March | 16 | 10 | 26 |
| 2020 February | 51 | 24 | 75 |
| 2020 January | 71 | 17 | 88 |
| 2019 December | 45 | 15 | 60 |
| 2019 November | 23 | 18 | 41 |
| 2019 October | 27 | 17 | 44 |
| 2019 September | 28 | 14 | 42 |
| 2019 August | 1 | 4 | 5 |
| 2019 March | 1 | 4 | 5 |
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