The impact of high flow nasal oxygen in the immunocompromised critically ill: A systematic review and meta-analysis
CCCF ePoster library. Mohamed A. Oct 3, 2017; 198122; 53
Dr. Alaa Mohamed
Dr. Alaa Mohamed
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The impact of high flow nasal oxygen in the immunocompromised critically ill: A systematic review and meta-analysis

Michael C. Sklar MD,Alaa Mohamed MD, Ani Orchanian-Cheff BA, MISt, Lorenzo Del Sorbo MD, Sangeeta Mehta  MD, Laveena Munshi MD, MSc

Interdepartmental Division of Critical Care Medicine, Sinai Health System, University Health Network, University of Toronto, Ontario, Canada



 Background: Mortality in immunocompromised patients with respiratory failure presenting to the intensive care unit (ICU) remains high. Those requiring invasive mechanical ventilation are subject to an increased mortality risk. High-flow nasal-cannula has been proposed to be a superior modality of oxygen support and may have a role in preventing invasive mechanical ventilation; however, its role in this population is not clearly defined.
Objectives: To evaluate the effectiveness of high-flow nasal-cannula compared to other modalities of oxygen support (face mask or non-invasive ventilation) in immunocompromised patients with acute respiratory failure
Methods: We systematically searched the major medical databases to identify all publications reporting the use of HFNC. We included any observational studies describing the use of HFNC in IC patients and randomized controlled trials (RCTs) that further compared HFNC to either face mask (FM) oxygen or non-invasive ventilation (NIV) amongst IC patients.  We looked at clinical and physiological efficacy across this population and meta-analyzed rates of invasive mechanical ventilation (IMV) and respiratory rate from the RCTs. 
Results: Of 3099 studies reviewed, 6 met our inclusion criteria. We included 3 observational studies and 3 randomized controlled trials (428 patients).  Hematologic malignancy was the leading etiology of immunosuppression (60%) and pneumonia the leading cause of respiratory failure (52%). Thirty-four percent of high-flow nasal-cannula patients subsequently required invasive mechanical ventilation.  Two randomized trials compared high-flow nasal-cannula to face mask, demonstrating no difference in rates of invasive mechanical ventilation (Risk ratio (RR) 1.03, 95% CI 0.41-2.61, I2=52%). High-flow nasal-cannula compared to non-invasive ventilation (1 randomized trial and 1 observational study with propensity-score matching) was associated with a decreased need for invasive mechanical ventilation (RR 0.54, 95% CI 0.35-0.84, I2=0%) and with reduced intensive care unit mortality (RR 0.40, 95% CI 0.22-0.70, I2 = 0%). One possible explanation for this finding of benefit of high flow nasal cannula compared specifically to non-invasive ventilation but not face mask, could be the pressure levels generated in non-invasive compared to pressure transmitted via high flow nasal cannula. During non-invasive ventilation, patients may generate tidal volumes that are above those considered lung protective (>8ml/kg).
Conclusions: There is a limited body of evidence to guide oxygen therapy in hypoxemic immunocompromised patients.  The current studies suggest that high-flow nasal-cannula may be associated with reduced need for invasive mechanical ventilation and improved survival when compared to non-invasive ventilation but not when compared to face mask oxygen. The data to date is intriguing but limited and these findings are meant to be hypothesis generating. More research in supportive oxygen therapies are needed for this population.

    Text Box: The Effect of HFNC vs FM on the need for IMV
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