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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Currently&#44; high-flow nasal cannula therapy &#40;HFNC&#41; is considered as a non-invasive respiratory support therapy suitable for patients experiencing both hypoxemic and hypercapnic respiratory failure&#46; At first glance&#44; setting HFNC seems to be very simple to use&#46; The main menu of the HFNC devices offers only three key parameters&#58; flow&#44; temperature and FiO<span class="elsevierStyleInf">2</span>&#46; However&#44; several studies have also shown us that setting HFNC may not be as simple as it initially seems&#44; opening the door to defining HFNC ventilatory modalities similar to those used in non-invasive ventilation&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We could categorize the HFNC effects into three groups&#58; 1&#46; humidification and warming effects&#44; which are common to all HFNC patients&#44; impacting mucociliary clearance&#44; patient comfort and tolerance&#44; 2&#46; airway pressurization effects&#44; particularly significant for hypoxemic ARF patients&#44; and 3&#46; CO<span class="elsevierStyleInf">2</span> washout effects&#44; relevant for hypercapnic ARF patients&#46; Can HFNC settings be customized to prioritize certain mechanisms over others&#63; Existing evidence suggests that customization is feasible&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">From the beginnings of HFNC&#44; it has been clear that there is a direct correlation between the administered flow rate and the resultant airway pressure&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> However&#44; factors beyond flow rate can also influence pressurization&#46; The first one is related to the degree of elastance of the rib cage &#40;with a constant flow&#44; elastance that determines the airway pressure&#41;&#46; Secondly&#44; the size of the cannula &#40;larger cannulas covering a larger nares surface area increase airway pressure<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a>&#41;&#46; Thirdly&#44; the patient&#39;s breathing pattern &#40;the pressure is higher with mouth-closed breathing<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a>&#41;&#46; Fourthly&#44; the type of gas used &#40;lower-density inspired gas as helium&#8211;oxygen mixture&#44; leads to lower airway pressure<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a>&#41;&#46; Finally&#44; the airway access &#40;pressure is lower when HFNC is administered through tracheostomy vs nasal cannula&#41;&#46; Studies conducted during the COVID-19 pandemic have also highlighted additional HFNC optimization techniques&#44; including prone maneuvers and surgical mask placement&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Conversely&#44; certain circumstances enhance CO<span class="elsevierStyleInf">2</span> washout&#46; Different studies have shown that CO<span class="elsevierStyleInf">2</span> washout increase when the patient breathes with an open mouth<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> or when smaller cannulas leave more space in the nostrils&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> It is worth noting that the density of the inspired gas&#44; whether it is ambient air&#44; O<span class="elsevierStyleInf">2</span> or a helium&#8211;O<span class="elsevierStyleInf">2</span> mixture&#44; does not alter CO<span class="elsevierStyleInf">2</span> washout&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In summary&#44; we could clearly differentiate three ventilatory strategies or modalities when setting up a HFNC &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; In hypoxemic ARF patients it would be advisable to use high-flow rates and cannulas covering more than 50&#37; of the nares&#44; encourage mouth-closed breathing&#44; avoid low-density gases&#44; and consider mask placement and prone maneuvers for oxygenation&#46; In hypercapnic ARF patients&#44; lower flow rates and cannulas that occlude less than 50&#37; of the nares should be more appropriate&#46; Advise open-mouth breathing and consider low-density gas mixtures if needed&#46; Finally&#44; for patients with compromised mucociliar clearance&#44; high flows are unnecessary&#44; and the focus should primarily be on gas humidification and warming&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">To our knowledge&#44; this is the first time that ventilatory modalities applied to HFNC have been described&#46; Future studies are necessary to enhance our understanding of HFNC and the impact of different HFNC settings on clinical outcomes&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of Interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors do not have any conflict of interest related to this manuscript&#46;</p></span></span>"
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Letter to the Director
High-flow Nasal Cannula Ventilatory Modalities
Salvador Díaz Lobatoa,
Corresponding author
sdiazlobato@gmail.com

Corresponding author.
, José Manuel Carratalá Peralesb, Guillermo Montielc, José Miguel Alonso Íñigod
a HLA Hospital Universitario Moncloa, Universidad Europea, Nippon Gases Healthcare, Madrid, Spain
b Unidad de Corta Estancia, Servicio de Urgencias, Hospital General de Alicante, Spain
c Servicio de Anestesiología y Reanimación, Hospital Universitario y Politécnico La Fe, Valencia, Spain
d Servicio de Neumonología, Hospital J.A. Fernández, Buenos Aires, Argentina

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