Sunday, March 8, 2015

High-flow nasal cannulas: Not yet ready for ED use.

What is high-flow nasal cannula (HFNC) therapy, and, more importantly, does it work? A recent segment on EM:RAP went into a fair amount of detail about the putative mechanism, so I’ll leave that alone.

What that segment left out, though, was any discussion of the published evidence pointing to the benefit of HFNC. And indeed, while there are a lot of anecdotal reports and personal testimonials, the actual data hasn’t been clearly discussed. Here’s a quick review of what we currently know.

1. Preterm infants


Although the “diet-PEEP” argument would suggest that HFNC might have a large role in tiny patients, it isn’t clear that HFNC helps prevent intubation in preemies. A Cochrane review suggested that using HFNC post-extubation, instead of CPAP, might lead to higher re-intubation rates. An RCT that was conducted after that review, however, found that HFNC was roughly equivalent to nasal CPAP for respiratory support in this age group. Data from other recent trials haven’t been as convincing, though, and many neonatologists still find the evidence “insufficient” to use HFNC in place of more established therapies

2. Infants


It may help prevent intubation of little kids with bronchiolitis, although the data is weak. The two most relevant studies were retrospective chart reviews, using a before-and-after design, looking at overall rates for intubation in the time period after HFNC was introduced to the pediatric service. Nonetheless, McKiernan found that intubation rates for bronchiolitis dropped from 23 % to 9%, and Schibler found the rate plummeted for 37% to 7%!
McKiernan 2010
This may end up being one of the best-supported roles for HFNC, and high-quality studies are in progress that could help clarify the issue.

3. Adults


The initial trials in adults have demonstrated modest improvements in oxygenation, but haven't studied patient oriented-outcomes. For example, one study found that oxygenation mildly increased after HFNC initiation, but no control group was used.

Sztrymf 2012

In one controlled trial, versus face mask, fewer desaturations were seen with HFNC. Despite this, there was no statistical difference in the use of rescue CPAP/BiPAP. A few other studies have further noted that HFNC seems to be more comfortable than CPAP.

A single-author review, otherwise very bullish on HFNC therapy, conceded: “although some clinicians may have the impression that in some instances, use of HFNC has avoided intubation, this has not been shown in a controlled trial.”

The largest current review on the use of HFNC concludes that (my emphasis):
“While theoretical advantages exist over standard nasal cannula and face mask oxygen, current evidence does not definitively demonstrate superiority to other methods of respiratory support. Few studies have focused on clinical outcomes beyond common respiratory parameters. Given the potential lack of consistency of positive pressure generated with current HFNC systems, NIV such as CPAP and bilevel positive airway pressure should still be considered first line therapy in moderately distressed patients in whom supplementation oxygen is insufficient and when a consistent positive pressure is indicated.”

Bringing it home!

Being an “early-adopter” is cool – if you’re lining up to get the new iPhone or Zune! In medicine, however, it doesn’t often pay to jump on a bandwagon before the data is in. (Want to buy some Xigris cheap?) We are being encouraged to try a new therapy that uses proprietary (proprietary = $) devices, with soft indications, scant evidence, but with touted outcomes such as “improved comfort,” instead of mortality or rates of intubation. We should be cautious.

Particularly concerning is the uncritical enthusiasm for the use of this device in situations that either clearly call for other therapies, or for no therapy. For example, some describe the utility of HFNC in patients who are “extremely hypoxic,” but there is little evidence that HFNC improves outcomes in this population.

HFNC is probably more useful for precisely titrating FIO2 in the (mythical?) CO2 retainer. But if there is a concern about the PaCO2, why not use a proven therapy like NPPV that we know saves lives?

Lastly, some clinicians promote the use of HFNC for CHF, since there is (wink, wink) a “PEEP component,” but that’s a patient who needs CPAP or BiPAP as well, since we already have proven a mortality benefit in that population as well.

Sure, you can relax, talk with family, and eat while wearing HFNC, but if you are so dead set on wolfing down a sandwich, you probably don’t need an expensive, unproven therapy. You need 2 liters per minute, and a floor bed!

19 comments:


  1. Why do some clinicians insist on waiting for a collection of randomized prospective studies before adopting any new therapy? I understand EBM, and I know that for outcomes I cannot follow in the ED itself, I need to rely on good evidence based studies, many with large numbers of patients. However, for a therapy in which I can see a response myself in the department, I should be able to form my own opinion. Recognizing that the risks of confirmation bias can be controlled for by using objective measures, there is no reason to wait for a Cochrane review before trying a new therapy like High Flow Nasal Cannula.

    So does HFNC therapy work. Hell yes. We are just finishing our worst RSV season in years. Every EBM study ever written on bronchiolitis has stated nothing works for this disease. Not hypertonic saline, not nebulized epinephrine, not albuterol, nothing. But this season we used HFNC and found for the first time a therapy that did work. Infants and toddlers with retractions severe enough to reach their thoracic vertebrae, respiratory rates in the 80s and 90’s and ronchi, rales and wheezes in all fields were placed on HFNC. Within minutes respiratory rates dropped to the 40’s, sats increased and retractions improved. By 2 hours most of these kids had clear breath sounds. Now before you tell me this is confirmation bias, I will tell you in 36 years I have tried everything in these children and nothing has worked. More importantly, I had the same expectations of all of those therapies as I had for HFNC and was not deluded by any confirmation bias into thinking I was making these children better. The nurses, myself and the most skeptical, late adopters in our department have all reported the same experiences with the HFNC.

    I have had similar experiences with adult patients (with the exception of CHF, BiPAP still works better in them).

    So here is my question. On your next shift if a mom brings in a struggling 8 month old with severe respiratory distress and obvious bronchiolitis are you going to do nothing, which is what the EBM literature recommends or are you going to try HFNC on the recommendation of some very experienced clinicians?


    Alfred Sacchetti, MD
    Emergency Department
    Voice: 856-757-3803

    ReplyDelete
    Replies
    1. So happy right now.Words are not enough to thank you Dr.Chukwu madu herbal home, for healing me of the deadly disease that have been disturbing me for 9 years now, I have promise to share testimony about you if you are really able to cure me of my HSV2 which you really cured. I am here to tell the whole world that there are real powerful herbal doctor who can cure any disease because i am a living testimony to your work. You have wiped away the shame on my face and brought Joy back to my life that i have wish for over 9 years now. I was reading a testimony in a forum of a lady who said you cured her from the deadly Herpes Simplex virus, and i never believed not until i gave you a try and you really cured me. You are really a God sent to people and i will continue to spread the good thing you are doing to other people in the world who might also be having same problem cause i know you will also be of help. Anyone who is suffering from any kinds of disease should contact this great herbal Man called Dr.Chukwu madu on his email[ dr.chukwumaduherbalhome@gmail.com] . or call his mobile number or whatsapp him  +2347030936239,
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    2. Do anyone still doubt natural herbs? I've seen the great importance of natural herbs and the wonderful work they have done in people's lives. I wonder why people still spend their money on injections and drugs each time they are sick. Natural herbs can cure all kinds of illness including herpes, diabetes, asthma, HIV, HSV1&2, hepatitis, HPV etc. I've seen it with my own eyes. I was cured from Herpes and HPV and my aunt and her husband were cured from Hiv too by DR. Chukwu madu herbs. He uses natural herbs to cure different kind of virus. Dr. CHUKWU,prove to the world that natural herbs can cure all illness and he cured countless people using herbs. I know is hard to believe but am a living testimony. I was diagnose of Herpes and HPV in 2016 and i believe there is cure even when the doctors said there is no cure yet. I strongly believe in herbs and i came across a comment on a blog written by Lisa Pierre, saying she was cured from HERPES by Dr. CHUKWU MADU and i contacted his herbal hom on the email that was provided on the comment and order one for myself and he send it to me through UPS and gave me instructions on how to use it and after i finish taken it i went for checkup and the result shows am Herpes and HPV NEGATIVE. The doctor said that the virus is completely gone from my body. There is no harm trying herbs it work perfectly and it has no effect. You can contact Dr. CHUKWU MADU to get yours.. His email is dr.chukwumaduherbalhome@gmail.com.
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    3. Am Laura Mildred by name, i was diagnosed with Herpes 4 years ago i lived in pain with the knowledge that i wasn't going to ever be well again i contacted so many herbal doctors on this issue and wasted a large sum of money but my condition never got better i was determined to get my life back so one day i saw Mr. Morrison Hansen post on how Dr. Emu saved him from Herpes with herbal medicine i contacted Dr. Emu on his Email: Emutemple@gmail.com we spoke on the issue i told him all that i went through and he told me not to worry that everything will be fine again so he prepared the medicine and send it to me and told me how to use it, after 14 days of usage I went to see the doctor for test,then the result was negative, am the happiest woman on earth now thanks to Dr. Emu God bless you. Email him at: Emutemple@gmail.com Whats-app or Call him: +2347012841542 

      Delete
  2. As I noted above, the (quite messy) data on HFNC use in bronchiolitis suggests that HFNC could be an effective tool where, indeed, very little else works. I look forward to seeing the better-controlled trials, and I hope that it shows a benefit!

    I don’t think any working EM physician requires an RCT or a Cochrane review to justify every intervention. Our world “in the pit” is too messy to survive as EBM absolutists, and so I think that the “some clinicians” argument is a bit of a straw-man. Evidence doesn’t have to be based in double-blind, multicenter RCTs to be valid, but it ought to be a little better than what we have now for the utility of HFNC in COPD, asthma, CHF, or other hypoxic or hypercarbic causes of respiratory failure. As it stands, the evidence from modestly well-done studies shows only tepid benefit (e.g. “improved comfort”) in adults. Surely that evidence should outweigh case studies and anecdotes?

    For every clinician who you might describe as a forward-thinking “early-adopter,” I can point to another clinician who jumped on a bandwagon too soon. Did your hospital purchase a bunch of Edwards catheters for sepsis care, or expensive devices for inducing hypothermia after cardiac arrest? Did your pharmacy purchase a bunch of Xigris or nesiritide that gathered dust before being withdrawn from the market place? Following the latest fad can make you a pioneer, or it can hurt patients and cost big $$.

    So, if we already have therapies with proven benefit, why change to something new, with only “Mikey likes it” levels of evidence?

    ReplyDelete
  3. Sorry gotta disagree strongly. All of the examples you cite contained outcomes that could not be observed in the ED. As a result clinicians needed to rely on evidence based medicine for guidance. HFNC has an outcome that is immediately observable to the treating clinician. You are looking at the patient, if you close the laryngoscope and put the intubation cart away the treatment worked.

    You condemn the early adopters but you ignore all those conservative docs who waited before adopting therapies that turned out to be much more superior to existing treatments.

    How do you regard those ED docs who held off adopting BIPAP for years waiting for the RCT’s to convince them it was a good therapy. How do you justify the unnecessary intubations with all the procedural complications, ventilator associated pneumonias and ICU admissions. If you waited for ED studies to prove the value of propofol sedation you subjected patients to increased complications with less effective agents and prolonged ED stretcher times. Even something as simple at using wire guided pig tail catheters for pneumonthoracies has yet to undergo a RCT, yet every progressive department has adopted them over the traditional formal chest tubes in these patients.

    Here is the bottom line. You can be wrong as an early adopter if a therapy turns out to be ineffective. You can be wrong for waiting too long to adopt a much more effective therapy. For me the real error is to condemn a new therapy with outcomes observable in the ED without ever trying it. Until you have used HFNC in a pulmonary fibrosis patient to avoid an intubation or in a tiring infant with bronchiolitis you really cannot condemn the therapy. There is no reason anyone reading this blog cannot take this modality and use it for themselves.

    Like Mikey, you just might like it.

    ReplyDelete
  4. This comment has been removed by the author.

    ReplyDelete
  5. You don't need a randomized control trial to dictate all you management. You can still look out the outcome of the patient in front of you. High Flow Nasal Cannula is inexpensive, clinically effective and provides improved comfort beyond simply avoiding intubations. As those old enough to remember Mikey, "Try it, you'll like it"

    ReplyDelete
  6. I am bold enough among many others to state that there is now a potent cure to this sickness but many are unaware of it. I discovered that I was infected with the virus 3 months ago, after a medical check-up. My doctor told me and I was shocked, confused and felt like my world has crumbled. I was dying slowly due to the announcement of my medical practitioner but he assured me that I could leave a normal life if I took my medications (as there was no medically known cure to Herpes). I went from churches to churches but soon found that my case needed urgent attention as I was growing lean due to fear of dying anytime soon. In a bid to look for a lasting solution to my predicament, I sought for solutions from the herbal world. I went online and searched for every powerful trado-medical practitioner that I could severe, cos I heard that the African Herbs had a cure to the Herpes syndrome. It was after a little time searching the web that I came across one Dr Itua(A powerful African Herbal Doctor), who offered to help me at a monetary fee. I had to comply as this was my final bus-stop to receiving a perfect healing. My last resolve was to take my life by myself, should this plan fail. At last it worked out well. He gave me some steps to follow and I meticulously carried out all his instructions. Last month, to be precise, I went back to the hospital to conduct another test and to my amazement, the results showed that negative,Dr Itua Can As Well Cure The Following Desease…Cancer,Hiv,Herpes, Hepatitis B,Liver Inflammatory,Diabetis,Fribroid, Dercum,Get Your Ex Back, You can free yourself of this Herpes virus by consulting this great African Herbal Doctor via this e-mail: drituaherbalcenter@gmail.com or call and whatsapp him on +2348149277967 He will help you and his herb medication is sure. he has the cure on all disease .You can talk to me on INSTAGRAM..tashamoore219....

    ReplyDelete
    Replies
    1. Do anyone still doubt natural herbs? I've seen the great importance of natural herbs and the wonderful work they have done in people's lives. I wonder why people still spend their money on injections and drugs each time they are sick. Natural herbs can cure all kinds of illness including herpes, diabetes, asthma, HIV, HSV1&2, hepatitis, HPV etc. I've seen it with my own eyes. I was cured from Herpes and HPV and my aunt and her husband were cured from Hiv too by DR. Chukwu madu herbs. He uses natural herbs to cure different kind of virus. Dr. CHUKWU,prove to the world that natural herbs can cure all illness and he cured countless people using herbs. I know is hard to believe but am a living testimony. I was diagnose of Herpes and HPV in 2016 and i believe there is cure even when the doctors said there is no cure yet. I strongly believe in herbs and i came across a comment on a blog written by Lisa Pierre, saying she was cured from HERPES by Dr. CHUKWU MADU and i contacted his herbal hom on the email that was provided on the comment and order one for myself and he send it to me through UPS and gave me instructions on how to use it and after i finish taken it i went for checkup and the result shows am Herpes and HPV NEGATIVE. The doctor said that the virus is completely gone from my body. There is no harm trying herbs it work perfectly and it has no effect. You can contact Dr. CHUKWU MADU to get yours.. His email is dr.chukwumaduherbalhome@gmail.com.
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      Delete
  7. Irrespective of receiving daily oral or future injectable depot therapies, these require health care visits for medication and monitoring of safety and response. If patients are treated early enough, before a lot of immune system damage has occurred, life expectancy is close to normal, as long as they remain on successful treatment. However, when patients stop therapy, virus rebounds to high levels in most patients, sometimes associated with severe illness because i have gone through this and even an increased risk of death. The aim of “cure”is ongoing but i still do believe my government made millions of ARV drugs instead of finding a cure. for ongoing therapy and monitoring. ARV alone cannot cure HIV as among the cells that are infected are very long-living CD4 memory cells and possibly other cells that act as long-term reservoirs. HIV can hide in these cells without being detected by the body’s immune system. Therefore even when ART completely blocks subsequent rounds of infection of cells, reservoirs that have been infected before therapy initiation persist and from these reservoirs HIV rebounds if therapy is stopped. “Cure” could either mean an eradication cure, which means to completely rid the body of reservoir virus or a functional HIV cure, where HIV may remain in reservoir cells but rebound to high levels is prevented after therapy interruption.Dr Itua Herbal Medicine makes me believes there is a hope for people suffering from,Parkinson's disease,Schizophrenia,Lung Cancer,Breast Cancer,Colo-Rectal Cancer,Blood Cancer,Prostate Cancer,Scoliosis,Fibromyalgia,Fluoroquinolone Toxicity
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    ReplyDelete
  8. I am so happy that i got cured from herpes virus 1&2 after i have suffered from this virus for over 3 years. I have been using drugs to suppress it,i got introduced to doc tor razor by a friend of mine who knew i was herpes positive, she believes in herbs, and i have full doubt on her idea to try out herbal medicine. I contacted the doctor and told him what i was passing through, so he promised he was going to get me cured completely. I am so glad that after applying doctor razor herbal remedy for 18 days there is no trace of the virus in my body as confirmed by the results given to me by the medical hospital,where i conducted my test. I am so grateful Doctor Razor. For those who are in same situation just like i was, you can reach out to doctor razor on email : drrazorherbalhome@gmail.com , WhatsApp or Call him on +2349065420442. Please share as received, so multitude can be saved from this virus

    ReplyDelete
  9. I Can't still believe that i got cured from Genital Herpes through herbal treatment from Dr Aizonofe herb who I met through the internet, I actually couldn't believe it at first because it sounded impossible to me knowing how far I have gone just to get rid of it. Dr Aizonofe herb send me his medicine which I took as instructed and here I am living a happy life once again, a big thanks to Dr Aizonofe herb, I am sure there are many herbal doctors out there but Dr Aizonofe herb did it for me, contact him draizonofeherb@gmail.com , also call or whatsApp him on +2348136785562

    ReplyDelete
  10. So happy right now.Words are not enough to thank you Dr.Chukwu madu herbal home, for healing me of the deadly disease that have been disturbing me for 9 years now, I have promise to share testimony about you if you are really able to cure me of my HSV2 which you really cured. I am here to tell the whole world that there are real powerful herbal doctor who can cure any disease because i am a living testimony to your work. You have wiped away the shame on my face and brought Joy back to my life that i have wish for over 9 years now. I was reading a testimony in a forum of a lady who said you cured her from the deadly Herpes Simplex virus, and i never believed not until i gave you a try and you really cured me. You are really a God sent to people and i will continue to spread the good thing you are doing to other people in the world who might also be having same problem cause i know you will also be of help. Anyone who is suffering from any kinds of disease should contact this great herbal Man called Dr.Chukwu madu on his email[ dr.chukwumaduherbalhome@gmail.com] . or call his mobile number or whatsapp him  +2347030936239,
    and get your problem solved. 

    ReplyDelete
  11. Do anyone still doubt natural herbs? I've seen the great importance of natural herbs and the wonderful work they have done in people's lives. I wonder why people still spend their money on injections and drugs each time they are sick. Natural herbs can cure all kinds of illness including herpes, diabetes, asthma, HIV, HSV1&2, hepatitis, HPV etc. I've seen it with my own eyes. I was cured from Herpes and HPV and my aunt and her husband were cured from Hiv too by DR. Chukwu madu herbs. He uses natural herbs to cure different kind of virus. Dr. CHUKWU,prove to the world that natural herbs can cure all illness and he cured countless people using herbs. I know is hard to believe but am a living testimony. I was diagnose of Herpes and HPV in 2016 and i believe there is cure even when the doctors said there is no cure yet. I strongly believe in herbs and i came across a comment on a blog written by Lisa Pierre, saying she was cured from HERPES by Dr. CHUKWU MADU and i contacted his herbal hom on the email that was provided on the comment and order one for myself and he send it to me through UPS and gave me instructions on how to use it and after i finish taken it i went for checkup and the result shows am Herpes and HPV NEGATIVE. The doctor said that the virus is completely gone from my body. There is no harm trying herbs it work perfectly and it has no effect. You can contact Dr. CHUKWU MADU to get yours.. His email is dr.chukwumaduherbalhome@gmail.com.
    WhatsApp +2347030936239.

    ReplyDelete
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    ReplyDelete
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    ReplyDelete
  14. There is no other way to get the body of herpes virus other than detoxification using natural diet or pure herbs. The health industry is a billion dollars industry - which is why the big pharmaceuticals sued Dr. Sebi the moment he discovered a 1-Week CURE FOR HERPES (Oral and Genital). Most diseases are acquired by what you eat. Even when infected by someone, it thrives because your body is receptive and filled with mucus. No disease can survive in an electric filled body. What you eat will determine how you live, how you behave, and even how it relates to you. Detoxification is the heart of ridding the body of the herpes virus. There is no other way to bring the necessary result. There are three ways to achieve this; Stop putting acidic foods into the body - if possible eat only alkaline diet, Fast daily before eating if possible for a year, Cleanse the body of toxins and acids with Nze Njoku Herbal Formula (Which also increases oxygen to cells). Feed the body with the right nutrients to repair, rebuild, and strengthen it at a cellular level and watch the body heal itself.

    Some may wonder, how long is one expected to maintain such a diet and what herbs can help you achieve all these within few weeks?

    Nze Njoku Herbal Home provides all the
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    ReplyDelete
  15. I’d recommend using Dr. Utu Herbal Cure topically for instant pain and itch relief as well as accelerated healing of lesions and permanently stopping oral and genital herpes virus outbreaks. I have tried just about everything from acyclovir suppressive therapy to different natural oils, extracts, and other natural methods, some of which are EXTREMELY painful and exacerbate the problem (i.e. apple cider vinegar!). While vitamin E oil and suppressive therapy worked well for me, when I became pregnant I went back to trying to find a herbal cure. I was using vitamin E oil topically for a while but it was thin and difficult to use and only seemed to prevent further outbreaks rather than getting rid of it. I contacted Dr. Utu Herbal Cure through my friend. To my surprise, I could tell my outbreak was starting to heal within only a few hours! No more itching or pain! Dr. Utu Herbal Cure that I used was liquid herbs in bottles, so it was very easy to use. It simply whiffs, but it works so I don’t care! The best part is I successfully delivered a herpes-free attractive daughter without further medicines. Anyone who has tried Dr. Utu Herbal Cure knows just how quickly those treatments can add up. So give it a try! Anyone can reach Dr. Utu through
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    ReplyDelete