High-Flow Oxygen through Nasal Cannula in
Acute Hypoxemic Respiratory Failure
Jean-Pierre Frat, M.D., Arnaud W. Thille, M.D., Ph.D., Alain Mercat, M.D., Ph.D.,
Christophe Girault, M.D., Ph.D., Stephanie Ragot, Pharm.D., Ph.D.,
Sebastien Perbet, M.D., Gwenael Prat, M.D., Thierry Boulain, M.D.,
Elise Morawiec, M.D., Alice Cottereau, M.D., Jerome Devaquet, M.D.,
Saad Nseir, M.D., Ph.D., Keyvan Razazi, M.D., Jean-Paul Mira, M.D., Ph.D.,
Laurent Argaud, M.D., Ph.D., Jean-Charles Chakarian, M.D.,
Jean-Damien Ricard, M.D., Ph.D., Xavier Wittebole, M.D., Stephanie Chevalier, M.D.,
Alexandre Herbland, M.D., Muriel Fartoukh, M.D., Ph.D.,
Jean-Michel Constantin, M.D., Ph.D., Jean-Marie Tonnelier, M.D., Marc Pierrot, M.D.,
Armelle Mathonnet, M.D., Gaetan Beduneau, M.D., Celine Deletage-Metreau, Ph.D.,
Jean-Christophe M. Richard, M.D., Ph.D., Laurent Brochard, M.D.,
and Rene Robert, M.D., Ph.D., for the FLORALI Study Group and the REVA Network*
May 17, 2015, at NEJM.org
R4 김형오
Introduction
• High-flow oxygen therapy
– Nasal cannula
– Heated / humidified oxygen delivered to the nose at high flow
rates
– Lowering physiological dead space by flushing expired CO2
– Lowering work of breathing
• Shown to result in better comfort and oxygenation
than standard oxygen therapy delivered through a face
mask in patients with acute respiratory failure of
various origins
Introduction
• Noninvasive positive pressure ventilation
– Intubation / mortality need reduction
• COPE AE, cardiogenic pulmonary edema
– Decrease in work of breathing
– Improvement in gas exchange
• But data on the overall effects of noninvasive
ventilation with respect to the prevention of intubation
and improvement in outcome are conflicting in
patients with acute hypoxemic respiratory failure
Objective
• To compare High-flow oxygen therapy with
noninvasive ventilation or standard oxygen
therapy among patients with acute hypoxemic
respiratory failure
Methods
• Patients
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23 ICUs in France and Belgium
18 years old or older
Respiratory rate of more than 25 breaths/min
PaO2/FiO2 ≤ 300mmHg
• While patient was breathing oxygen at a flow rate of 10L/min or
more for least 15 minutes
– PaCO2 ≤ 45mmHg
– Absence of clinical history of underlying chronic respiratory
failure
Methods
• Exclusion criteria
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–
–
–
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PaCO2 > 45mmHg
Asthma / COPD acute exacerbation
Cardiogenic pulmonary edema
Severe neutropenia
Hemodynamic instability
Vasopressor usage
Glasgow Coma Scale of 12 points or less
Urgent need for endotracheal intubation
DNR
Methods
• Standard oxygen group
–
–
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Nonrebreather face mask, 10L/min or more
Rate adjusted, target SpO2 92% or more
Measured by pulse oximetry
Until the patient recoverd or was intubated
Methods
• High flow oxygen group
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Oxygen passed through a heated humidifier
Large-bore binasal prongs
50L/min gas flow with FiO2 1.0 at initiation
FiO2 adjusted, target SpO2 92% or more
Applied at least 2 subsequent days
Methods
• Noninvasive-ventilation group
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Through a face mask
Pressure support applied in a noninvasive ventilation mode
Tidal volume 7~10mL/Kg targeted of predicted body weight
Initial PEEP 2~10cmH2O
Minimal duration of 8 hrs/d for at least 2 subsequent days
Methods
• Primary outcome
– Endotracheal intubation within 28 days
• Hemodynamic instability
• Deterioration of neurologic status
• Signs of worsening respiratory failure
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40/min ≤ RR
High respiratory muscle workload
Development of large amount of secretion
Acidosis with pH of less than 7.35
SpO2 less than 90% for more than 5 minutes without technical dysfunction
• Secondary outcome
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Mortality in the ICU
Mortality at 90 days
Number of ventilation free days : day 1~ day 28
Duration of ICU stay
50%
47%
38%
Discussion
• Strengths
– Multicenter design and sealed randomization to the
assigned strategy
– Prespecified intubation criteria
– Complete follow up at 90 days
• Limitations
– Intubation rate in the overall population
• Low power to detect a significant between-group
difference
– PaO2:FiO2 ≤ 200mmHg subgroup difference significance
Conclusion
• Treatment with high flow oxygen improved the
survival rate among patients with acute
hypoxemic respiratory failure
• No difference in the primary outcome was
observed with high flow oxygen therapy as
compared with standard oxygen therapy or
noninvasive ventilation