High-Velocity Nasal Insufflation in the Treatment of Respiratory Failure

A Randomized Clinical Trial

Pratik Doshi, Jessica Whittle, Michael Bublewicz, Joseph Kearney, Terrell Ashe, Russell Graham, Suesann Salazar, Terry W. Ellis, Dianna Maynard, Rose Dennis, April Tillotson, Mandy Hill, Misha Granado, Nancy Gordon, Charles Dunlap, Sheldon Spivey, Thomas L. Miller

Research output: Contribution to journalArticle

7 Citations (Scopus)

Abstract

Study objective: We compare high-velocity nasal insufflation, a form of high-flow nasal cannula, with noninvasive positive-pressure ventilation in the treatment of undifferentiated respiratory failure with respect to therapy failure, as indicated by requirement for endotracheal intubation or cross over to the alternative therapy. Methods: This was a multicenter, randomized trial of adults presenting to the emergency department (ED) with respiratory failure requiring noninvasive positive-pressure ventilation. Patients were randomly assigned to high-velocity nasal insufflation (initial flow 35 L/min; temperature 35°C (95°F) to 37°C (98.6°F); FiO2 1.0) or noninvasive positive-pressure ventilation using an oronasal mask (inspiratory positive airway pressure 10 cm H2O; expiratory positive airway pressure 5 cm H2O). The primary outcome was therapy failure at 72 hours after enrollment. A subjective outcome of crossover was allowed as a risk mitigation to support deferment of informed consent. Noninferiority margins were set at 15 and 20 percentage points, respectively. Results: A total of 204 patients were enrolled and included in the analysis, randomized to high-velocity nasal insufflation (104) and noninvasive positive-pressure ventilation (100). The intubation rate (high-velocity nasal insufflation=7%; noninvasive positive-pressure ventilation=13%; risk difference=–6%; 95% confidence interval –14% to 2%) and any failure of the assigned arm (high-velocity nasal insufflation=26%; noninvasive positive-pressure ventilation=17%; risk difference 9%; confidence interval –2% to 20%) at 72 hours met noninferiority. The effect on PCO2 over time was similar in the entire study population and in patients with baseline hypercapnia. Vital signs and blood gas analyses improved similarly over time. The primary limitation was the technical inability to blind the clinical team. Conclusion: High-velocity nasal insufflation is noninferior to noninvasive positive-pressure ventilation for the treatment of undifferentiated respiratory failure in adult patients presenting to the ED.

Original languageEnglish (US)
Pages (from-to)73-83.e5
JournalAnnals of Emergency Medicine
Volume72
Issue number1
DOIs
StatePublished - Jul 1 2018

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Insufflation
Positive-Pressure Respiration
Treatment Failure
Nose
Respiratory Insufficiency
Randomized Controlled Trials
Hospital Emergency Service
Confidence Intervals
Pressure
Blood Gas Analysis
Intratracheal Intubation
Hypercapnia
Vital Signs
Therapeutics
Complementary Therapies
Masks
Informed Consent
Intubation
Multicenter Studies
Temperature

All Science Journal Classification (ASJC) codes

  • Emergency Medicine

Cite this

High-Velocity Nasal Insufflation in the Treatment of Respiratory Failure : A Randomized Clinical Trial. / Doshi, Pratik; Whittle, Jessica; Bublewicz, Michael; Kearney, Joseph; Ashe, Terrell; Graham, Russell; Salazar, Suesann; Ellis, Terry W.; Maynard, Dianna; Dennis, Rose; Tillotson, April; Hill, Mandy; Granado, Misha; Gordon, Nancy; Dunlap, Charles; Spivey, Sheldon; Miller, Thomas L.

In: Annals of Emergency Medicine, Vol. 72, No. 1, 01.07.2018, p. 73-83.e5.

Research output: Contribution to journalArticle

Doshi, P, Whittle, J, Bublewicz, M, Kearney, J, Ashe, T, Graham, R, Salazar, S, Ellis, TW, Maynard, D, Dennis, R, Tillotson, A, Hill, M, Granado, M, Gordon, N, Dunlap, C, Spivey, S & Miller, TL 2018, 'High-Velocity Nasal Insufflation in the Treatment of Respiratory Failure: A Randomized Clinical Trial', Annals of Emergency Medicine, vol. 72, no. 1, pp. 73-83.e5. https://doi.org/10.1016/j.annemergmed.2017.12.006
Doshi, Pratik ; Whittle, Jessica ; Bublewicz, Michael ; Kearney, Joseph ; Ashe, Terrell ; Graham, Russell ; Salazar, Suesann ; Ellis, Terry W. ; Maynard, Dianna ; Dennis, Rose ; Tillotson, April ; Hill, Mandy ; Granado, Misha ; Gordon, Nancy ; Dunlap, Charles ; Spivey, Sheldon ; Miller, Thomas L. / High-Velocity Nasal Insufflation in the Treatment of Respiratory Failure : A Randomized Clinical Trial. In: Annals of Emergency Medicine. 2018 ; Vol. 72, No. 1. pp. 73-83.e5.
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abstract = "Study objective: We compare high-velocity nasal insufflation, a form of high-flow nasal cannula, with noninvasive positive-pressure ventilation in the treatment of undifferentiated respiratory failure with respect to therapy failure, as indicated by requirement for endotracheal intubation or cross over to the alternative therapy. Methods: This was a multicenter, randomized trial of adults presenting to the emergency department (ED) with respiratory failure requiring noninvasive positive-pressure ventilation. Patients were randomly assigned to high-velocity nasal insufflation (initial flow 35 L/min; temperature 35°C (95°F) to 37°C (98.6°F); FiO2 1.0) or noninvasive positive-pressure ventilation using an oronasal mask (inspiratory positive airway pressure 10 cm H2O; expiratory positive airway pressure 5 cm H2O). The primary outcome was therapy failure at 72 hours after enrollment. A subjective outcome of crossover was allowed as a risk mitigation to support deferment of informed consent. Noninferiority margins were set at 15 and 20 percentage points, respectively. Results: A total of 204 patients were enrolled and included in the analysis, randomized to high-velocity nasal insufflation (104) and noninvasive positive-pressure ventilation (100). The intubation rate (high-velocity nasal insufflation=7{\%}; noninvasive positive-pressure ventilation=13{\%}; risk difference=–6{\%}; 95{\%} confidence interval –14{\%} to 2{\%}) and any failure of the assigned arm (high-velocity nasal insufflation=26{\%}; noninvasive positive-pressure ventilation=17{\%}; risk difference 9{\%}; confidence interval –2{\%} to 20{\%}) at 72 hours met noninferiority. The effect on PCO2 over time was similar in the entire study population and in patients with baseline hypercapnia. Vital signs and blood gas analyses improved similarly over time. The primary limitation was the technical inability to blind the clinical team. Conclusion: High-velocity nasal insufflation is noninferior to noninvasive positive-pressure ventilation for the treatment of undifferentiated respiratory failure in adult patients presenting to the ED.",
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AU - Ashe, Terrell

AU - Graham, Russell

AU - Salazar, Suesann

AU - Ellis, Terry W.

AU - Maynard, Dianna

AU - Dennis, Rose

AU - Tillotson, April

AU - Hill, Mandy

AU - Granado, Misha

AU - Gordon, Nancy

AU - Dunlap, Charles

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