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In a hospital setting, the supply and utilisation of oxygen are crucial for high-quality healthcare. This quality improvement project aimed to increase the rate of timely and safe oxygen delivery from 30% to 75% at Wallaga University Comprehensive Specialized Hospital from 1 January to 30 June 2024.Using the Plan-Do-Study-Act (PDSA) cycle, the project team identified root causes through fishbone and driver diagrams. Key interventions included staff orientation on safe handling of oxygen devices, clear job descriptions for compliance, improved handover processes between shifts, regular maintenance and inventory checks, increasing the number of oxygen cylinders, using hospital vehicles for transport and establishing a communication system with suppliers for timely requests.Results showed that the inventory of regular oxygen delivery devices improved to 76%, with equipment checks conducted 65% of the time. Emergency preparedness reached 20%, and onsite training for staff achieved 75%. Oxygen usage monitoring was nearly perfect at 99%, with delivery times reduced to 1 day for 70% of orders. A standard protocol for oxygen supply and use was established, resulting in a significant increase in timely and safe oxygen delivery from 30% to 75%.This project effectively optimised oxygen supply management, highlighting the importance of proactive management, communication and continuous monitoring in building a reliable oxygen therapy service. Improvements in inventory management and delivery efficiency were facilitated by a dedicated dashboard, standardised operating procedures and comprehensive staff training., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Background: Gastrointestinal endoscopy with sedation is frequently complicated by hypoxemia. Nasal cannulas have limitations in eliminating hypoxemia. We hypothesized that the combination of nasal clips and nasal cannulas would improve the inspired oxygen concentrations and prevent hypoxemia compared with the use of nasal cannulas alone., Methods: A total of 600 adult patients were randomly assigned to receive supplemental oxygen through single-lumen nasal cannulas or through the combination of nasal clips and nasal cannulas. The primary outcome was the incidence of hypoxemia. Additionally, subclinical respiratory depression and severe hypoxemia, duration of hypoxemia, lowest SpO 2 level, measures to increase oxygen saturation level, and adverse events such as cough and hiccups were compared as secondary outcomes., Results: Three hundred patients in the nasal clip group and 296 patients in the nasal cannula group were included in the intention-to-treat analysis. Nasal clips significantly decreased the incidence of hypoxemia from 25.0-17.7%(RR = 0.707, 95% CI = 0.516 to 0.967, P = 0.029). The median and interquartile range of lowest SpO 2 in the nasal clip group (96 [92 to 98]) was significantly greater than that in the nasal cannula group (95 [89 to 97]; median difference = 1.000, 95% CI = 0.000 to 2.000, P = 0.004). No significant differences were found between the two groups in subclinical respiratory depression or severe hypoxemia, duration of hypoxemia, adverse events or measures taken to increase oxygen saturation., Conclusions: The combination of nasal clips and cannulas reduces hypoxemia during gastrointestinal endoscopy with sedation, demonstrating a significant advantage over the sole use of nasal cannulas, with tolerable adverse events., Trial Registration: Chinese Clinical Trial Registry (ChiCTR2200065407)., Competing Interests: Declarations. Ethics approval and consent to participate: This study was approved by the Medical Ethics Committee of Taizhou Enze Medical Centre (Group) Enze Hospital, Taizhou, Zhejiang, China (approval no. K20220307) on 28 March 2022. All participants provided written informed consent before participation. The trial followed the Consolidated Standards of Reporting Trials (CONSORT) reporting guidelines and was registered before patient recruitment at the Chinese Clinical Trial Registry (registration no. ChiCTR2200065407; date of registration: November 4, 2022). Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Objective: To identify predictive factors for failure in the installation of high-flow nasal cannulas in children diagnosed with acute viral bronchiolitis under 24 months of age admitted to the pediatric intensive care unit., Methods: This work was a retrospective single-center cohort study conducted from March 2018 to July 2023 involving infants under 24 months of age who were diagnosed with acute viral bronchiolitis and who received high-flow nasal cannulas upon admission to the pediatric intensive care unit. Patients were categorized into two groups, the Success Group and Failure Group, on the basis of high-flow nasal cannula therapy efficacy. The primary outcome was treatment failure, which was defined as the transition to invasive or noninvasive ventilation. The analyzed variables included age, sex, weight, high-flow nasal cannula parameters, vital signs, risk factors, comorbidities, and imaging. Acute viral bronchiolitis severity was assessed using the Wood-Downes Scale, and functional status was assessed via the Functional Status Scale, both of which were administered by trained physiotherapists., Results: In total, 162 infants with acute viral bronchiolitis used high-flow nasal cannulas, with 17.28% experiencing treatment failure. The significant differences between the Failure and Success Groups included age (p = 0.001), weight (p = 0.002), bronchiolitis severity (p = 0.004), initial high-flow nasal cannula flow (p = 0.001), and duration of use (p = 0.000). The cutoff values for initial flow (≤ 12L/min), weight (≤ 5kg), and Wood-Downes score (≥ 9 points) were determined from the ROC curves. Initial flow ≤ 12L/min was the most predictive for failure (AUC = 0.71; 95%CI: 0.61 - 0.84; p = 0.001). Multivariate analysis indicated that weight was a protective factor (RR = 0.87; 95%CI: 0.78 - 0.98), duration of use reduced the risk of failure (RR = 0.49; 95%CI: 0.38 - 0.64; p = 0.000), and Wood-Downes score was not significant (RR = 1.04; 95%CI: 0.95 - 1.14; p = 0.427). Weight explained 84.7% of the variation in initial flow., Conclusion: Risk factors for high-flow nasal cannula therapy failure in bronchiolitis patients include younger age, consequently lower weight, and a lower initial flow rate.

Objectives: High velocity therapy (HVT), a form of high-flow oxygen therapy, utilizing a small-bore nasal cannula has been widely used in acute care settings. A new dual-prong (newDP) cannula made using more comfortable material and a single-prong (SP) cannula were evaluated to compare comfort and functionality as measured by relief of dyspnea of patients with chronic obstructive pulmonary disease (COPD) receiving HVT therapy., Design: Randomized crossover evaluation., Setting: Outpatient and in patient critical care setting., Patients: Patients with hypercapnic COPD presenting with dyspnea above baseline., Interventions: HVT therapy was provided using an existing HVT dual-prong nasal cannula (traditional) to determine the most efficacious flow rate. Patients were then randomized to receive either the newDP cannula, or the SP cannula, and retitrated for optimal flow rate. During each session of therapy, Rated Perceived Dyspnea (RPD) scores, vital signs, transcutaneous carbon dioxide partial pressure (PTCco2) levels, and clinician/ patient perceptions were documented., Measurements and Main Results: Of 31 enrolled, 26 patients completed the trial. The median flow rate that relieved dyspnea for the traditional, newDP, and SP cannulas were 25 L/min (20-30 L/min), 25 L/min (19.1-30 L/min), and 15 L/min (13-17 L/min), respectively. The change in RPD from baseline for traditional, newDP, and SP were -1 (-1 to 0), -1 (-2 to -1), and -1 (-2 to -1). Change in RPD from baseline for newDP and SP compared with the traditional cannula was significantly different (p = 0.044 and p = 0.01, respectively). Changes in vital signs and PTCco2 were similar between the three cannula types compared with baseline. The SP cannula provided comparable therapeutic efficacy at significantly lower flow rates (traditional vs. SP; p < 0.0001 and newDP vs. SP; p < 0.0001)., Conclusions: The new cannula designs provided comparable relief of dyspnea. The single-prong cannula provided comparable efficacy at significantly lower flow rates (traditional vs. SP; p < 0.0001 and newDP vs. SP; p < 0.0001). The use of a single-prong cannula with HVT warrants further study., Competing Interests: Ms. Bergeski, Mr. Dungan, and Dr. Volakis were employed by Vapotherm (Exeter, NH) during the trial period. Mr. Dungan received a consultant from Vapotherm; he holds multiple patents on high-velocity nasal cannula, high-flow nasal cannula, ventilation, and diagnostic technologies. Dr. Whittle is employed by Vapotherm presently. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Background: Acute respiratory failure is common occurrence in critical care, with varying causes, depending on case mix of the ICU. High flow nasal cannula (HFNC) is commonly utilized in both adult and pediatric population. However, traditionally, neurologically ill patients have been considered unsuitable for HFNC due to poor sensorium and risk of aspiration. Therefore, we conducted a study to assess the effectiveness of HFNC in Neuro ICU., Methodology: We did a prospective observational study on all adult patients requiring HFNC during their stay in Neuro ICU. Primary aim of the study was to find common indications for use of HFNC in neuro ICU. The secondary objective was to observe if HFNC could prevent re-intubation. The various other factors studied included age, gender, diagnosis (traumatic brain injury, postoperative neurosurgical condition or other neurological conditions), GCS score, HFNC settings, duration and cost of HFNC therapy., Results: During the period from January 1, 2021- 23, out of 1825 patients admitted to neuro ICU, 98 required HFNC therapy. Mean age was 43.3 years (range 18-85), 75.5% of which were males. Utilization rate of HFNC was 5.3%. HFNC was more commonly used for non-trauma patients, most often to reduce work of breathing following extubation (85%). HFNC helped prevent the need for re-intubation in 76.5% of patients with a failure rate of 23.5% across all subgroups of patients in neuro ICU. Requirements for higher flow rate and FiO 2 were significant predictors of HFNC failure. The mean cost of HFNC usage accounted for only 5.6% of the total inpatient bill., Conclusion: In neurocritical care, the causes of extubation failures and hypoxemia, differ significantly from other ICUs. In our study, HFNC was used most often to reduce work of breathing following extubation and was useful in preventing re-intubation. The use of HFNC did not significantly increase the cost of healthcare., Competing Interests: Declarations. Human ethics and consent to participate: Ethical clearance for the study was obtained from the institutional review board of Christian Medical College Vellore with a waiver of consent (IRB Min No: 14383 dated 22.12.2021) for the study titled “Exploring the effectiveness of High-Flow Nasal Cannula in the Neurointensive Care Unit: A prospective observational study” in accordance with the Institute’s ethical standards on human experimentation and with the Helsinki declaration of 1975. Consent to participate: Was waived by the Institutional review board as there was no change in existing practice of management. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Background: The Rapid-O2 oxygen insufflation device® (Rapid-O2) was designed primarily for rescue oxygenation in cannot intubate, cannot oxygenate (CICO) events; thus, hypercapnia is inevitable. Rapid-O2 was modified to enhance ventilation using the Venturi effect during expiration., Methods: To determine the most effective combination of inner catheters (20 gauge [G], 18 G, 16 G, 14 G, and 2-mm inner diameter [ID] transtracheal catheter [TTC]) and insufflation catheters (16 G, 14 G, and 2-mm ID TTC) for achieving optimum ventilation, insufflating and expiratory flows were measured at an oxygen flow rate of 15 L/min. The insufflating and expiratory pressures were measured at 6-15 L/min. The flows and pressures were measured using a gas flow analyzer. The insufflating and expiratory times were measured using a trachea-lung model to obtain minute volumes. To assess the improvement by modifying the Rapid-O2, minute volumes were measured using the Rapid-O2., Results: The most appropriate inner catheter was 18 G. The insufflating pressures ranged from 97 (2-mm ID TTC) to 377 cmH2O (16 G) at 15 L/min. During expiration, similar negative pressures of 50 cmH2O were measured in the insufflation catheters at 15 L/min. At lung compliance of 100 ml/cmH2O, the minute volumes through a 2-mm ID and 14 G insufflation catheters were 7.0 and 5.37 L/min, respectively, at 15 L/min. The minute volumes were significantly greater in modified Rapid-O2., Conclusions: Modified Rapid-O2 provided sufficient minute volumes in adults using a 14 G or 2-mm ID insufflation catheter at 15 L/min, demonstrating its potential for ventilation in CICO events.

Background: Oxygen therapy is critical and vital treatment for hypoxemia and respiratory distress, however, access to reliable oxygen systems remains limited in SSA. Despite WHO initiatives that distributed over 30,000 OC oxygen concentrators worldwide, SSA faces significant challenges related to their maintenance and use, due to harsh environmental conditions, technical skill shortages and inadequate infrastructure. This review aims to systematically identify and assess the literature on OC design adaptations, maintenance challenges, and knowledge gaps in SSA, providing actionable recommendations to inform innovative and context-sensitive solutions to improve healthcare delivery in the region., Methods: The study focused on medical oxygen concentrators in SSA countries. It was conducted by following the PRISMA statement and searching three databases, i.e., Scopus, PubMed, and Web of Science, for publications in the period 2001-2023, using the search terms: oxygen concentrator, therapy, cylinder, plant, supply, delivery, and availability, design, and maintenance. The screening process involved evaluating manuscripts based on their titles, abstracts and full texts, based on specific inclusion and exclusion criteria. The extracted information included the author's publication year, country, study aim, and key findings., Results: Overall, 1,057 papers were returned for our analysis, of which 20 met the inclusion criteria. These studies primarily examined the design, availability and cost-effectiveness of oxygen concentrators compared to cylinders, revealing a significant supply and demand gap for these devices in SSA. It also illustrated how the environmental challenges impacted the devices durability, highlighting the need for more locally adapted resilient solutions. Solar-powered systems provide a sustainable option in areas with unstable power supplies, although initial costs remain high. Robust maintenance strategies, capacity building and strict procurement protocols proved essential to ensuring equipment long-term functionality., Conclusion: This review synthesized and critically assessed the current in the body of literature, enabling highlighting valuable insights for innovators and stakeholders with an interest in enhancing the oxygen availability in SSA. It highlighted a pressing need for improved healthcare infrastructure investment, context-aware OC design and novel standards and regulatory frameworks to support frugal innovation., Competing Interests: Declarations. Ethics approval and consent to participate: Not applicable. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Background: Literature regarding the advantages of HFNC in infants for ensuring oxygen supply after non-cardiac surgery is insufficient. The purpose of our study is to compare COT vs. HFNC on postoperative outcomes in infants undergoing non-cardiac surgery. We hypothesize that prophylactic use of HFNC after non-cardiac surgery in infants would reduce the incidence of post-anesthesia hypoxemia and could also be adapted as first-line oxygen therapy after non-cardiac surgery., Methods: This is a superior, single-blind, randomized controlled study. A total of 394 infants undergoing general anesthesia will be randomly assigned to accept COT or HFNC in a 1:1 ratio. The primary outcome is the rate of desaturation post-extubation. Secondary outcomes include the rate of mild upper airway obstruction, the rate of severe respiratory depression, the rate of transfer to PICU, duration of oxygen therapy, length of PACU stay, the time to reach full enteral feeding, and postoperative adverse events, including nasal injury, agitation, vomiting, and unplanned secondary surgery related to the initial surgery., Discussion: This is the first randomized controlled trial to explore the advantages of HFNC in infants to ensure oxygen supply after non-cardiac surgery. If favorable evidence is obtained, HFNC could be adopted as first-line oxygen therapy for infants following non-cardiac surgery., Trial Registration: The trial was registered at https://www.chictr.org.cn (Registration number: ChiCTR2400081600, Date: March 6, 2024)., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2025 Zhang et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background/purpose: The use of high-flow nasal cannulas (HFNC) in patients admitted to the pediatric intensive care unit (PICU) has gradually increased worldwide; however, details on clinical efficacy remain limited in Taiwan. Therefore, we explored the clinical characteristics and outcomes of pediatric patients using HFNC in the PICU., Methods: Medical records were retrospectively collected from pediatric patients (aged <18 years) who received HFNC support from December 2021 to January 2023 in the PICU of a medical center. Outcome parameters included treatment failure (defined as increased respiratory support to advanced non-invasive ventilators or intubations), duration of support from HFNC, and changes in clinical parameters after initiating HFNC., Results: A total of 261 episodes of HFNC use were included, with a failure rate of 24.5% and a median support length of 4 days. Multivariable analysis showed that infant age (adjusted odds ratio [aOR]: 2.1, p = 0.02) and accompanying complex chronic disease (aOR: 4.4, p = 0.014) were risk factors for treatment failure and a diagnosis of asthma or bronchiolitis had a lower hazard of treatment failure (aOR: 0.29, p = 0.025) than other diagnoses did. Improvements in clinical parameters, including pulse rate, respiratory rate, SpO 2 , and CO 2 levels, were observed 24 h after the initiation of HFNC., Conclusion: The application of HFNC in the PICU in Taiwan is effective but should be performed with care in infants with accompanying complex chronic diseases. In addition to low treatment failure, HFNC utilizations stabilized the clinical parameters of children with asthma/bronchiolitis within one day., Competing Interests: Declaration of competing interest Jeng-Hung Wu and En-Ting Wu participated in speakers bureaus of Fisher and Paykel., (Copyright © 2024 Formosan Medical Association. Published by Elsevier B.V. All rights reserved.)

Background: High-flow nasal cannula (HFNC) therapy has gained popularity in the pediatric intensive care unit (PICU). However, the nationwide effect of HFNC on mechanical ventilation duration has not been studied., Methods: We retrospectively analyzed pediatric patients (28 days to 17 years old) admitted to tertiary ICUs for respiratory support from 2012 to 2019 using the Korean National Health Insurance database. Pre-/post-HFNC periods were defined as the 12 months before and after the application of HFNC in any hospital, respectively, allowing a 6-month transition period. Mechanical ventilation duration and ventilator-free days during these two periods were compared using a multivariable regression model., Results: Using data from 46 hospitals, 4,705 and 4,864 respective pre-/post-HFNC period patients were evaluated. During the post-HFNC period, 14.8% of patients were treated by HFNC, and 67.1% were treated using invasive mechanical ventilation. In adjusted analysis, mechanical ventilation duration was reduced by 0.99 days (confidence interval [CI]: -1.86, -0.12). The duration was significantly reduced by 17.81 days (CI: -35.46, -0.16) among patients whose ventilation duration was longer than 28 days. In subgroup analysis, mechanical ventilation duration was reduced by 1.49 days (CI: -2.78, -0.19) in the overall surgical group and 6.71 days (CI: -11.71, - 1.71) in the neurologic subgroup. Ventilator-free days were increased only in the overall surgical group, by 0.31 days (CI: 0.01, 0.61)., Conclusions: Application of HFNC to PICU patients could reduce mechanical ventilation duration, especially in patients requiring prolonged mechanical ventilator support or in post-operative patients., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Choi et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: High flow nasal cannula therapy (HFNC) and continuous positive airway pressure (CPAP) are two widely used modes of non-invasive respiratory support in paediatric critical care units. The FIRST-ABC randomised controlled trials (RCTs) evaluated the clinical and cost-effectiveness of HFNC compared with CPAP in two distinct critical care populations: acutely ill children ('step-up' RCT) and extubated children ('step-down' RCT). Clinical effectiveness findings (time to liberation from all forms of respiratory support) showed that HFNC was non-inferior to CPAP in the step-up RCT, but failed to meet non-inferiority criteria in the step-down RCT. This study evaluates the cost-effectiveness of HFNC versus CPAP., Methods: All-cause mortality, health-related Quality of Life (HrQoL), and costs up to six months were reported using FIRST-ABC RCTs data. HrQoL was measured with the age-appropriate Paediatric Quality of Life Generic Core Scales questionnaire and mapped onto the Child Health Utility 9D index score at six months. Quality-Adjusted Life Years (QALYs) were estimated by combining HrQoL with mortality. Costs at six months were calculated by measuring and valuing healthcare resources used in paediatric critical care units, general medical wards and wider health service. The cost-effectiveness analysis used regression methods to report the cost-effectiveness of HFNC versus CPAP at six months and summarised the uncertainties around the incremental cost-effectiveness results., Results: In both RCTs, the incremental QALYs at six months were similar between the randomised groups. The estimated incremental cost at six months was - £4565 (95% CI - £11,499 to £2368) and - £5702 (95% CI - £11,328 to - £75) for step-down and step-up RCT, respectively. The incremental net benefits of HFNC versus CPAP in step-down RCT and step-up RCT were £4388 (95% CI - £2551 to £11,327) and £5628 (95% CI - £8 to £11,264) respectively. The cost-effectiveness results were surrounded by considerable uncertainties. The results were similar across most pre-specified subgroups, and the base case results were robust to alternative assumptions., Conclusions: HFNC compared to CPAP as non-invasive respiratory support for critically-ill children in paediatric critical care units reduces mean costs and is relatively cost-effective overall and for key subgroups, although there is considerable statistical uncertainty surrounding this result., Competing Interests: Declarations. Ethical approval and consent to participate: The FIRST-ABC master protocol was approved by the East of England–Cambridge South Research Ethics Committee (19/EE/0185) and the UK Health Research Authority (IRAS 260536). The trial was registered with the International Standard Randomised Controlled Trial Number (ISRCTN) Registry (ISRCTN60048867). Written informed consent was obtained from parents/legal guardians of each trial participant. Consent for publication: Not applicable. Competing interests: The authors report funding from the National Institute for Health and Social Care Research (NIHR) Health Technology Assessment Programme to their institutions for the work presented in the manuscript. KR is Director of the NIHR Health and Social Care Delivery Research Programme., (© 2024. The Author(s).)

Background: Nasal continuous positive airway pressure (NCPAP) is widely used for premature infants with respiratory distress syndrome (RDS). A high-flow nasal cannula (HFNC) provides positive end-expiratory pressure using high-flow oxygen; however, the variability in distending pressure is a primary concern. This study evaluated the feasibility and safety of a newly designed protocol for NCPAP weaning with cyclic HFNC use for premature infants., Methods: Premature infants with RDS using NCPAP support who were ready for weaning were enrolled. The weaning protocol used cyclic NCPAP with HFNC every 3 h for 3 days in the neonatal intensive care unit. The heart rate (HR), respiratory rate (RR), pulse oximetry (SpO 2 ), transcutaneous carbon dioxide (PtcCO 2 ), and cerebral tissue oxygen saturation (StO 2 ) at the end of NCPAP with HFNC support were recorded once daily for 3 days., Results: From June 2019 to April 2021, 46 premature infants (27 male, 19 female) were enrolled. The mean gestational age and birth body weight were 28.7 ± 2.6 weeks and 1181 ± 354 g, respectively. No statistically significant differences in the HR, RR, SpO 2 , and cerebral StO 2 during NCPAP weaning with HFNC were observed. However, the mean PtcCO 2 with NCPAP was statistically significantly lower than that with HFNC (46.9 ± 6.0 mmHg vs. 47.9 ± 6.4 mmHg, P = 0.02)., Conclusions: The feasibility and safety of the NCPAP weaning protocol with cyclic HFNC for premature infants are acceptable in this preliminary study. Due to the limited number of participants, further studies are required for more comprehensive analysis., Trial Registration: This prospective observational case study was approved by the Human Experiment and Ethics Committee of our hospital (approval number: KMUHIRB-SV(I)-20180059; approval date: January 11, 2019)., Competing Interests: Declarations Ethics approval and consent to participate This prospective observational case study was approved by the Human Experiment and Ethics Committee of our hospital (approval number: KMUHIRB-SV(I)-20180059; approval date: January 11, 2019). All experiments were performed in accordance with relevant guidelines and regulations. Written informed consent was obtained from the parents of the included premature infants. Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Chronic obstructive pulmonary disease (COPD) is one of the most common clinical respiratory illnesses, defined by permanent pathological deterioration that leads to respiratory failure. Regarding COPD treatment, oxygen therapy is very important. Non-invasive positive pressure ventilation (NPPV) is a technique for non-invasive mechanical ventilation that enables patients to get positive pressure support without the need of an artificial airway. Instead, it merely employs the mask by covering the mouth and nose, or simply the nose of patients. NPPV has been shown to be beneficial for COPD patients experiencing respiratory failure. High-flow nasal cannula (HFNC) oxygen therapy shows some advantages, including the reduction of anatomical dead space, the prompt correction of low oxygen levels as well as the improvement of patients' tolerance. Owing to its continuous progress, ventilation technology strongly improves COPD treatment. In this study, the authors analyze the application of NPPV and HFNC in COPD so as to provide recommendations for mechanical ventilation treatment., Competing Interests: Yuting Wang and Yan Liu are co-first authors for this study. The authors report no conflicts of interest in this work., (© 2024 Wang et al.)

Background: Chronic respiratory diseases (CRDs) affect at least 545 million people globally, leading to symptoms such as dyspnoea, fatigue and limited physical activity. Pulmonary rehabilitation (PR) programmes aim to improve the exercise capacity and quality of life of patients with CRD through exercise training. High-flow nasal cannula (HFNC) therapy shows potential as an adjunct treatment during exercise, but its effects on CRD populations are unclear. The purpose of this systematic review was to evaluate the effects of HFNC during exercise in people with CRD., Methods: A systematic review was conducted and eight databases and other resources were searched from inception (28 June 2022) to 4 April 2023. Studies that used adult patients with CRD and randomised controlled trial that compared the effect of HFNC versus standard care (conventional oxygen therapy or room air) during exercise were included. Two authors independently selected trials, extracted the data, assessed risks of bias and employed the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach to judging the certainty of evidence. We pooled trials using random-effect models and inverse variance estimation., Results: Seventeen studies (n=8406) were included in the review (570 patients). The evidence suggests that HFNC increases exercise time after multiple training sessions (weighted mean difference (WMD)=160.58 s; 95% 95% CI=67.32-253.83, 2 studies) and increase after a single session (WMD=72.10 s; 95% CI=28.95-115.24, 11 studies). HFNC may result in little improvements in secondary outcomes (quality of life, dyspnoea, comfort, complications and adherence)., Discussion: The evidence suggests that HFNC may increase functional exercise capacity and positively enhance secondary outcomes. Continued research is justified to elucidate the role of HFNC in PR during exercise training., Prospero Registration Number: CRD42022336263., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Tracheostomized patients undergoing liberation from mechanical ventilation (MV) are exposed to the ambient environment through humidified air, potentially heightening aerosol particle dispersion. This study was designed to evaluate the patterns of aerosol dispersion during spontaneous breathing trials in such patients weaning from prolonged MV., Methods: Particle Number Concentrations (PNC) at varying distances from tracheostomized patients in a specialized weaning unit were quantified using low-cost particle sensors, calibrated against a Condensation Particle Counter. Different oxygen delivery methods, including T-piece and collar mask both with the humidifier or with a small volume nebulizer (SVN), and simple collar mask, were employed. The PNC at various distances and across different oxygen devices were compared using the Kruskal-Wallis test., Results: Of nine patients receiving prolonged MV, five underwent major surgery, and eight were successfully weaned from ventilation. PNCs at distances ranging from 30 cm to 300 cm showed no significant disparity (H(4) = 8.993, p = 0.061). However, significant differences in PNC were noted among oxygen delivery methods, with Bonferroni-adjusted pairwise comparisons highlighting differences between T-piece or collar mask with SVN and other devices., Conclusion: Aerosol dispersion within 300 cm of the patient was not significantly different, while the nebulization significantly enhances ambient aerosol dispersion in tracheostomized patients on prolonged MV., Competing Interests: Declaration of competing interest None, (Copyright © 2024 Formosan Medical Association. Published by Elsevier B.V. All rights reserved.)

The newly developed portable oxygen concentrator with an auto-demand oxygen delivery system (auto-DODS) automatically switches between 3 sensitivities according to the negative pressure gradient of inhalation and supplies oxygen only during inhalation. The aim of this study was to verify the effectiveness and safety of auto-demand devices compared with a continuous flow oxygen concentrator, during sleep, in a randomized crossover noninferiority trial. We alternatively used an auto-DODS or a continuous-flow oxygen concentrator, all night on separate days for HOT (Home Oxygen Therapy) patients with nocturnal hypoxemic symptoms. The primary endpoints were the mean value of oxygen saturation (SpO 2 ) over the total sleep time. The secondary endpoints included the efficacy endpoints and the safety endpoints. Regarding the primary endpoint, the difference in SpO 2 between the auto-DODS and continuous flow was 0.835%. Since the upper limit of this difference did not exceed 2.8, which was set as the noninferiority margin, it was shown that the auto-DODS did not reduce SpO 2 by at least 2.8% on average compared to continuous flow. No equipment failure or exacerbation of disease was observed, confirming the safety of the auto-DODS during the night., (© 2024. The Author(s).)

Objective: A high-flow nasal cannula is a practical and safe instrument that can be used for children with asthma exacerbation and promotes beneficial outcomes such as improved asthma severity scores and reduced hospitalization durations, salbutamol use, and oxygen use. To evaluate and compare the efficacy of high-flow nasal cannula treatment and that of bilevel positive airway pressure treatment as respiratory physiotherapy interventions for pediatric patients who are hospitalized because of asthma exacerbation., Methods: During a randomized clinical trial, treatment was performed using a high-flow nasal cannula and bilevel positive airway pressure for hospitalized children with asthma. After randomization, data regarding lung function, vital signs, and severity scores (pulmonary index, pediatric asthma severity, and pediatric asthma scores) were collected., Results: Fifty patients were included in this study (25 in the Bilevel Group and 25 in the high-flow nasal cannula group). After 45 minutes of therapy, an improvement in the forced expiratory volume in 1 second was observed. The high-flow nasal cannula group required fewer days of oxygen (O2) use, used fewer bronchodilators (number of salbutamol puffs), and required shorter hospitalization periods than the Bilevel Group (6.1±1.9 versus 4.3±1.3 days; 95% confidence interval, -5.0 to -0.6)., Conclusion: A high-flow nasal cannula is a viable option for the treatment of asthma exacerbation because it can reduce the hospitalization period and the need for O2 and bronchodilators. Additionally, it is a safe and comfortable treatment modality that is as effective as bilevel positive airway pressure.ClinicalTrials.gov Identifier: NCT04033666.

Introduction: The effectiveness of home high flow nasal cannula (HFNC) for the treatment of chronic respiratory failure in patients with chronic respiratory diseases (CRDs) has not been summarized. We aimed to conduct a systematic review of the effectiveness, adherence, and safety of HFNC in the long-term treatment of patients with chronic respiratory diseases and respiratory failure., Methods: A systematic review was conducted. PubMed, Web of science, and SCOPUS were search up to August 2023. Long-term HFNC studies (≥4 weeks) reporting dyspnea; exacerbations, hospitalizations; peripheral oxygen saturation (SpO 2 ), comfort; patient experience, health-related quality of life or partial pressure of carbon dioxide (paCO 2 ) were included., Results: Thirteen articles (701 patients) based on 10 studies were selected: randomized control trials (n=3), randomized crossover trials (n=2), crossover (n=3) and retrospective (n=2) studies. COPD (n=6), bronchiectasis (n=2), COPD/bronchiectasis (n=1) and ILD (n=1) were the underlined CRDs. HFNC reduced exacerbations when compared to usual care/home respiratory therapies (n=6). Quality of life outcomes were also in favor of HFNC in patients with COPD and bronchiectasis (n=6). HFNC had significant effects on hospitalizations, paCO 2 , and lung function. Adherence ranged from 5.2 to 8.6h/day (n=5). Three studies reported no events, 3 non-serious events and 2 no differences compared with other home respiratory therapies., Conclusions: HFNC seems more effective than usual care or other home respiratory therapies in reducing exacerbations and improving quality of life in patients with COPD and bronchiectasis, while presenting good adherence and being safe. Its apparently superior effectiveness needs to be better studied in future real-world pragmatic trials., (Copyright © 2024 The Authors. Published by Elsevier España, S.L.U. All rights reserved.)

Objective: This study aims to evaluate the performance of the fabian-Predictive-Intelligent-Control-of-Oxygenation (PRICO) system for automated control of the fraction of inspired oxygen (FiO 2 )., Design: Multicentre randomised cross-over study., Setting: Five neonatal intensive care units experienced with automated control of FiO 2 and the fabian ventilator., Patients: 39 infants: median gestational age of 27 weeks (IQR: 26-30), postnatal age 7 days (IQR: 2-17), weight 1120 g (IQR: 915-1588), FiO 2 0.32 (IQR: 0.22-0.43) receiving both non-invasive (27) and invasive (12) respiratory support., Intervention: Randomised sequential 24-hour periods of automated and manual FiO 2 control., Main Outcome Measures: Proportion (%) of time in normoxaemia (90%-95% with FiO 2 >0.21 and 90%-100% when FiO 2 =0.21) was the primary endpoint. Secondary endpoints were severe hypoxaemia (<80%) and severe hyperoxaemia (>98% with FiO 2 >0.21) and prevalence of episodes ≥60 s at these two SpO 2 extremes., Results: During automated control, subjects spent more time in normoxaemia (74%±22% vs 51%±22%, p<0.001) with less time above and below (<90% (9%±8% vs 12%±11%, p<0.001) and >95% with FiO 2 >0.21 (16%±19% vs 35%±24%) p<0.001). They spent less time in severe hyperoxaemia (1% (0%-3.5%) vs 5% (1%-10%), p<0.001) but exposure to severe hypoxaemia was low in both arms and not different. The differences in prolonged episodes of SpO 2 were consistent with the times at extremes., Conclusions: This study demonstrates the ability of the PRICO automated oxygen control algorithm to improve the maintenance of SpO 2 in normoxaemia and to avoid hyperoxaemia without increasing hypoxaemia., Competing Interests: Competing interests: All the authors or their institutions received funding for this and additional projects from Vyaire Medical., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To assess whether the respiratory oxygenation index (ROX index) measured after the start of high-flow nasal cannula oxygen therapy can help identify the need for intubation in patients with acute respiratory failure due to coronavirus disease 2019., Methods: This retrospective, observational, multicenter study was conducted at the intensive care units of six Brazilian hospitals from March to December 2020. The primary outcome was the need for intubation up to 7 days after starting the high-flow nasal cannula., Results: A total of 444 patients were included in the study, and 261 (58.7%) were subjected to intubation. An analysis of the area under the receiver operating characteristic curve (AUROC) showed that the ability to discriminate between successful and failed high-flow nasal cannula oxygen therapy within 7 days was greater for the ROX index measured at 24 hours (AUROC 0.80; 95%CI 0.76 - 0.84). The median interval between high-flow nasal cannula initiation and intubation was 24 hours (24 - 72), and the most accurate predictor of intubation obtained before 24 hours was the ROX index measured at 12 hours (AUROC 0.75; 95%CI 0.70 - 0.79). Kaplan-Meier curves revealed a greater probability of intubation within 7 days in patients with a ROX index ≤ 5.54 at 12 hours (hazard ratio 3.07; 95%CI 2.24 - 4.20) and ≤ 5.96 at 24 hours (hazard ratio 5.15; 95%CI 3.65 - 7.27)., Conclusion: The ROX index can aid in the early identification of patients with acute respiratory failure due to COVID-19 who will progress to the failure of high-flow nasal cannula supportive therapy and the need for intubation.

Importance: Patients presenting to the emergency department (ED) with hypoxemia often have mixed or uncertain causes of respiratory failure. The optimal treatment for such patients is unclear. Both high-flow nasal cannula (HFNC) and noninvasive ventilation (NIV) are used., Objectives: We sought to compare the effectiveness of initial treatment with HFNC versus NIV for acute hypoxemic respiratory failure., Design Setting and Participants: We conducted a retrospective cohort study of patients with acute hypoxemic respiratory failure treated with HFNC or NIV within 24 hours of arrival to the University of Michigan adult ED from January 2018 to December 2022. We matched patients 1:1 using a propensity score for odds of receiving NIV., Main Outcomes and Measures: The primary outcome was major adverse pulmonary events (28-d mortality, ventilator-free days, noninvasive respiratory support hours) calculated using a win ratio., Results: A total of 1154 patients were included. Seven hundred twenty-six (62.9%) received HFNC and 428 (37.1%) received NIV. We propensity score matched 668 of 1154 (57.9%) patients. Patients on NIV versus HFNC had lower 28-day mortality (16.5% vs. 23.4%, p = 0.033) and required noninvasive treatment for fewer hours (median 7.5 vs. 13.5, p < 0.001), but had no difference in ventilator-free days (median [interquartile range]: 28 [26, 28] vs. 28 [10.5, 28], p = 0.199). Win ratio for composite major adverse pulmonary events favored NIV (1.38; 95% CI, 1.15-1.65; p < 0.001)., Conclusions and Relevance: In this observational study of patients with acute hypoxemic respiratory failure, initial treatment with NIV compared with HFNC was associated with lower mortality and fewer composite major pulmonary adverse events calculated using a win ratio. These findings underscore the need for randomized controlled trials to further understand the impact of noninvasive respiratory support strategies., Competing Interests: Dr. Munroe was supported by grant number T32 HL 007749 (Multidisciplinary Training Program in Lung Disease), grant number F32 HL 172463 and grant number L30 HL 170379 (Loan Repayment Award) from the National Institutes of Health (NIH) and the National Heart, Lung, and Blood Institute (NHLBI). This work was also supported in part by a grant from NIH (NINDS and NHLBI) for infrastructure for the Clinical Coordinating Center for the Strategies to Innovate EmeRgENcy Care Clinical Trials Network—2U24NS100659. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. This article does not represent the views of the Department of Veterans Affairs or the U.S. government. Dr. Mosier has received travel support from Fisher & Paykel. The remaining authors have disclosed that they do not have any potential conflicts of interest.

Background: During neonatal and paediatric high-flow nasal cannula therapy, optimising the flow setting is crucial for favourable physiological and clinical outcomes. However, considerable variability exists in clinical practice regarding initial flows and subsequent adjustments for these patients. Our review aimed to summarise the impact of various flows during high-flow nasal cannula treatment in neonates and children., Methods: Two investigators independently searched PubMed, Embase, Web of Science, Scopus and Cochrane for in vitro and in vivo studies published in English before 30 April 2023. Studies enrolling adults (≥18 years) or those using a single flow setting were excluded. Data extraction and risk of bias assessments were performed independently by two investigators. The study protocol was prospectively registered with PROSPERO (CRD42022345419)., Results: 38 406 studies were identified, with 44 included. In vitro studies explored flow settings' effects on airway pressures, humidity and carbon dioxide clearance; all were flow-dependent. Observational clinical studies consistently reported that higher flows led to increased pharyngeal pressure and potentially increased intrathoracic airway pressure (especially among neonates), improved oxygenation, and reduced respiratory rate and work of breathing up to a certain threshold. Three randomised controlled trials found no significant differences in treatment failure among different flow settings. Flow impacts exhibited significant heterogeneity among different patients., Conclusion: Individualising flow settings in neonates and young children requires consideration of the patient's peak inspiratory flow, respiratory rate, heart rate, tolerance, work of breathing and lung aeration for optimal care., Competing Interests: Conflict of interest: J. Li discloses research funding from Fisher & Paykel Healthcare Ltd, Aerogen Ltd, the American Association for Respiratory Care and the Rice Foundation; and speaker fees from the American Association for Respiratory Care, Aerogen Ltd, Heyer Ltd, Vincent Medical and Fisher & Paykel Healthcare Ltd. A.G. Miller discloses relationships with Saxe Communications, S2N Health and Fisher & Paykel. A.T. Rotta discloses relationships with Breas US and Elsevier. Both J. Li and A.G. Miller serve as section editors for Respiratory Care. The other authors have no conflict of interest to disclose., (Copyright ©The authors 2024.)

Background: Exercise-induced O 2 desaturation contributes to dyspnea and exercise intolerance in various respiratory diseases. This study assessed whether automated O 2 titration was superior to fixed-flow O 2 to improve exertional dyspnea and walking exercise endurance. We also aimed at evaluating possible additive effects of high-flow nasal cannula coupled with automated O 2 titration on these outcomes., Methods: Subjects with chronic respiratory diseases and exercise-induced desaturation performed a 3-min constant-speed shuttle test (CSST) and an endurance shuttle walking test (ESWT) with either (1) fixed-flow O 2 , (2) automated O 2 titration targeting an S pO 2 of 94% (± 2%), and (3) automated O 2 titration + high-flow nasal cannula according to a randomized sequence. The main outcome was Borg dyspnea score at the end of the 3-min CSST. Secondary outcomes included endurance time and dyspnea during ESWT and oxygenation status during exercise., Results: Ten subjects with COPD, 10 with interstitial lung disease, 5 with pulmonary hypertension, and 3 with cystic fibrosis completed the study. Compared to fixed-flow O 2 , automated O 2 titration did not reduce dyspnea at the end of the 3-min CSST. Endurance time during the ESWT was prolonged with automated O 2 titration (mean difference 298 [95% CI 205-391] s, P < .001), and dyspnea at isotime was reduced. No further improvement was noted when high-flow nasal cannula was added to automated O 2 titration. Compared to fixed-flow O 2 , O 2 flows were higher with automated O 2 titration, resulting in better oxygenation., Conclusions: Automated O 2 titration was superior to fixed-flow O 2 to alleviate dyspnea and improve exercise endurance during the ESWT in subjects with a variety of chronic respiratory diseases. Adding high-flow nasal cannula to automated O 2 titration provided no further benefits., Competing Interests: Drs Dion, Bilodeau, Lellouche, and Maltais are shareholders of OxyNov, the maker of FreeO2. Dr Lellouche is co-founder of OxyNov. The remaining authors have disclosed no conflicts of interest., (Copyright © 2024 by Daedalus Enterprises.)

Background: The application of a surgical face mask over oxygen delivery devices is now a widespread recommendation in the setting of the Coronavirus disease pandemic. This addition is designed to reduce droplet spread, but this also changes the nature of these devices, and may alter the amount of oxygen delivered to a patient. This research investigated how placing a surgical face mask over both a simple plastic mask ("Hudson mask") and nasal cannula altered the concentration of available oxygen measured at the nares., Methods: We measured the inspired and end-tidal oxygen concentrations of five healthy non-smoking volunteers. Oxygen was delivered via nasal cannula and also a simple plastic face mask, at flow rates of 2, 4, 6 and 8 l per minute, with and without an overlying surgical face mask., Results: Adding a surgical mask over nasal cannula caused an appreciable rise in the end-tidal oxygen concentrations at all the measured oxygen flow rates 2, 4, 6, 8 L/minute. With the Hudson mask, there was a rise in oxygen concentration at 4 and 6 L/minute. For example, at a flow rate of 4 l/min via nasal cannula, available oxygen concentration increased from 24 to 36%, and via the Hudson mask the concentration rose from 27 to 38%., Conclusions: The addition of a surgical face mask over both nasal cannula and a Hudson mask resulted in an increased available oxygen concentration. This may be valuable where more advanced oxygen devices are not available, or alternatively providing adequate supplemental oxygen at lower flow rates and thus making critical savings in oxygen usage., (© 2022. The Author(s).)

Background: Experimental and pilot clinical data suggest that spontaneously breathing patients with sepsis and septic shock may present increased respiratory drive and effort, even in the absence of pulmonary infection. The study hypothesis was that respiratory drive and effort may be increased in septic patients and correlated with extrapulmonary determinant and that high-flow nasal cannula may modulate drive and effort., Methods: Twenty-five nonintubated patients with extrapulmonary sepsis or septic shock were enrolled. Each patient underwent three consecutive steps: low-flow oxygen at baseline, high-flow nasal cannula, and then low-flow oxygen again. Arterial blood gases, esophageal pressure, and electrical impedance tomography data were recorded toward the end of each step. Respiratory effort was measured as the negative swing of esophageal pressure (ΔPes); drive was quantified as the change in esophageal pressure during the first 500 ms from start of inspiration (P0.5). Dynamic lung compliance was calculated as the tidal volume measured by electrical impedance tomography, divided by ΔPes. The results are presented as medians [25th to 75th percentile]., Results: Thirteen patients (52%) were in septic shock. The Sequential Organ Failure Assessment score was 5 [4 to 9]. During low-flow oxygen at baseline, respiratory drive and effort were elevated and significantly correlated with arterial lactate (r = 0.46, P = 0.034) and inversely with dynamic lung compliance (r = -0.735, P < 0.001). Noninvasive support by high-flow nasal cannula induced a significant decrease of respiratory drive (P0.5: 6.0 [4.4 to 9.0] vs. 4.3 [3.5 to 6.6] vs. 6.6 [4.9 to 10.7] cm H2O, P < 0.001) and effort (ΔPes: 8.0 [6.0 to 11.5] vs. 5.5 [4.5 to 8.0] vs. 7.5 [6.0 to 12.6] cm H2O, P < 0.001). Oxygenation and arterial carbon dioxide levels remained stable during all study phases., Conclusions: Patients with sepsis and septic shock of extrapulmonary origin present elevated respiratory drive and effort, which can be effectively reduced by high-flow nasal cannula., (Copyright © 2021, the American Society of Anesthesiologists. All Rights Reserved.)

During flexible fiberoptic bronchoscopy (FOB) the arterial partial pressure of oxygen can drop, increasing the risk for respiratory failure. To avoid desaturation episodes during the procedure several oxygenation strategies have been proposed, including conventional oxygen therapy (COT), high flow nasal cannula (HFNC), continuous positive airway pressure (CPAP) and non-invasive ventilation (NIV). By a review of the current literature, we merely describe the clinical practice of oxygen therapies during FOB. We also conducted a pooled data analysis with respect to oxygenation outcomes, comparing HFNC with COT and NIV, separately. COT showed its benefits in patients undergoing FOB for broncho-alveolar lavage (BAL) or brushing for cytology, in those with peripheral arterial oxyhemoglobin saturation < 93% prior to the procedure or affected by obstructive disorder. HFNC is preferable over COT in patients with mild to moderate acute respiratory failure (ARF) undergoing FOB, by improving oxygen saturation and decreasing the episodes of desaturation. On the opposite, CPAP and NIV guarantee improved oxygenation outcomes as compared to HFNC, and they should be preferred in patients with more severe hypoxemic ARF during FOB., (© 2021. The Author(s).)

Introduction: : When using portable oxygen, a demand oxygen delivery system (DODS), which senses the beginning of inhalation and delivers a bolus of oxygen, is often used. However, conventional DODS may not supply sufficient oxygen when reduced tidal flow fails to trigger the flow sensor. Recently, "auto-DODS," which detects the negative pressure of inhalation and switches among 3 trigger sensitivity levels (standard, high, and extra high), has been developed to improve the efficacy of oxygenation. An auto-DODS can also supply pulsed-flow oxygen when it detects apnea, whereas a conventional DODS has only standard sensitivity. This randomized, open-label, crossover pilot study compared the performance of an auto-DODS with that of a conventional DODS., Methods: : We recruited patients with chronic obstructive pulmonary disease (COPD) or interstitial pneumonia receiving long-term oxygen therapy. Interventions were performed on 2 different days for each participant. On each day, an auto-DODS or a conventional DODS were tested at rest for 30 minutes and during the 6-minute walk test. The primary outcome was mean oxygen saturation (SpO2). Secondary outcomes were the ratios of time for each sensitivity level and pulsed-flow oxygen when using the auto-DODS, total time desaturated below SpO2 90%, percentage of time desaturated below SpO2 90%, minimum SpO2, mean and maximum pulse rate, six-minute walk distance, recovery time after 6-minute walk test, modified Borg scale, comfort, and discomfort index., Results: : When using the auto-DODS at rest, a high or extra high sensitivity level was observed in addition to standard sensitivity in 6 of 8 participants. During the 6-minute walk test, only standard sensitivity was observed in 6 participants. Mean SpO2 differences between the auto-DODS and conventional DODS at rest and during the 6-minute walk test were -0.6 [-4.5, 3.4] and 0.0 [-2.5, 2.5] ([95% confidence interval]), respectively, neither of which were significant (P = .73 and P = .99). There were no significant differences in secondary outcomes. There were no adverse events when using the auto-DODS., Conclusions: : This study showed that the auto-DODS did not show superiority in oxygenation either at rest or during exercise compared to a conventional DODS. The auto-DODS was shown to supply oxygen safely and detect inhalations with various trigger sensitivities., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: The dead space washout and provision of some level of positive airway pressure by nasal high-flow (NHF) cannula could improve the efficiency of ventilation, oxygenation and maintenance of the upper airway in patients undergoing deep sedation. This study aimed to compare the incidences of events represented oxygenation and ventilation, i.e. desaturation and upper airway obstruction, and arterial blood gas (ABG) levels between using NHF cannula and conventional nasal cannula (NC2) during deep sedation of adult surgical patients., Methods: In this prospective randomized single-blinded study, the patients who were 20-80 years old, ASA physical status of 1 to 3, scheduled for surgery under intravenous sedation (IVS) were included. The patients were randomly divided into two groups, i.e., NC2 or NHF groups. Propofol infusion was given to maintain deep sedation. The desaturation (SpO 2  < 92%) and upper airway obstruction events (presence of snoring with paradoxical breathing) after application of NC2 or NHF were observed and collected. Other outcomes included interventions during IVS, such as jaw lifting or airway instrument insertion, mouth dryness, and post- ABG analyses were also collected and compared., Results: Thirty-six patients undergoing endovascular surgery were randomized into NC2 or NHF groups (18 in each group). No patients dropped out of the study. There were no significant differences in age, sex, ASA physical status, pre-sedation and pre-application of NC2 and NHF ABG analyses (PaO 2 , SaO 2 , pH, PaCO 2 , and PaO 2 /FiO 2 ). NHF group had significantly lower in the incidence of desaturation [5 (27.78%) vs 13 (72.22%), p = 0.008], upper airway obstruction [4 (22.22%) vs 13 (72.22%), p = 0.003], and airway maneuver [6 (33.33%) vs 13 (72.22%), p = 0.019] than NC2 group. There were no differences in the ABG analyses after oxygen supplementation and no significant differences in mouth dryness between groups., Conclusion: The use of NHF cannula in patients undergoing endovascular surgery under deep sedation reduced desaturation events and required fewer airway interventions than NC2 with no difference in arterial blood gas analyses and mouth dryness., (© 2021. The Author(s).)

Helmet CPAP (H-CPAP) has been recommended in many guidelines as a noninvasive respiratory support during COVID-19 pandemic in many countries around the world. It has the least amount of particle dispersion and air contamination among all noninvasive devices and may mitigate the ICU bed shortage during a COVID surge as well as a decreased need for intubation/mechanical ventilation. It can be attached to many oxygen delivery sources. The MaxVenturi setup is preferred as it allows for natural humidification, low noise burden, and easy transition to HFNC during breaks and it is the recommended transport set-up. The patients can safely be proned with the helmet. It can also be used to wean the patients from invasive mechanical ventilation. Our article reviews in depth the pathophysiology of COVID-19 ARDS, provides rationale of using H-CPAP, suggests a respiratory failure algorithm, guides through its setup and discusses the issues and concerns around using it., (Published by Elsevier España, S.L.U.)

Rationale: Respiratory muscle paralysis due to low cervical spinal cord injury (CSCI) can lead to dysphagia. Noninvasive positive airway pressure (PAP) therapy can effectively treat this type of dysphagia. High-flow nasal cannula (HFNC) oxygen therapy can generate a low level of positive airway pressure resembling PAP therapy, it may improve the dysphagia., Patient Concerns: The patient was an 87-year-old man without preexisting dysphagia. He suffered a CSCI due to a dislocated C5/6 fracture, without brain injury, and underwent emergency surgery. Postoperatively (day 2), he complained of dysphagia, and the intervention was initiated., Diagnosis: Based on clinical findings, dysphagia in this case, may have arisen due to impaired coordination between breathing and swallowing, which typically occurs in patients with CSCI who have reduced forced vital capacity., Interventions: HFNC oxygen therapy was started immediately after the surgery, and swallowing rehabilitation was started on Day 2. Indirect therapy (without food) and direct therapy (with food) were applied in stages. HFNC oxygen therapy appeared to be effective because swallowing function temporarily decreased when the HFNC oxygen therapy was changed to nasal canula oxygen therapy., Outcomes: Swallowing function of the patient improved and he did not develop aspiration pneumonia., Lessons: HFNC oxygen therapy improved swallowing function in a patient with dysphagia associated with respiratory-muscle paralysis following a CSCI. It may have prolonged the apnea tolerance time during swallowing and may have improved the timing of swallowing. HFNC oxygen therapy can facilitate both indirect and direct early swallowing therapy to restore both swallowing and respiratory function., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Hypoxemic respiratory failure is a common manifestation of COVID-19 pneumonia. Early in the COVID-19 pandemic, patients with hypoxemic respiratory failure were, at times, being intubated earlier than normal; in part because the options of heated humidified high flow nasal cannula (HFNC) and non-invasive ventilation (NIV) were considered potentially inadequate and to increase risk of virus aerosolization. To understand the benefits and factors that predict success and failure of HFNC in this population, we evaluated data from the first 30 sequential patients admitted with COVID-19 pneumonia to our center who were managed with HFNC. We conducted Cox Proportional Hazards regression models to evaluate the factors associated with high flow nasal cannula failure (outcome variable), using time to intubation (censoring variable), while adjusting for comorbidities and immunosuppression. In the majority of our patients (76.7%), the use of HFNC failed and the patients were ultimately placed on mechanical ventilation. Those at increased risk of failure had a higher sequential organ failure assessment score, and at least one comorbidity or history of immunosuppression. Our data suggest that high flow nasal cannula may have a role in some patients with COVID-19 presenting with hypoxemic respiratory failure, but careful patient selection is the likely key to its success., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: General anesthesia-induced atelectasis is common, and persistent postoperative atelectasis is associated with pulmonary complications. We aimed to evaluate the preventive effects of a high-flow nasal cannula (HFNC) on postoperative atelectasis and respiratory complications in infants and small children., Methods: In this prospective randomized controlled trial, children (≤2 years) receiving general anesthesia (>2 hours) were randomized into the control and HFNC groups. At the end of the surgery, the first lung ultrasound evaluation was performed in both groups. In the postanesthetic care unit (PACU), the control group received conventional oxygen therapy, while the HFNC group received oxygen via HFNC, with a flow rate of 2 L kg-1 min-1. Before discharge to the ward, a second lung ultrasound examination was performed. The primary outcome was the lung ultrasound score at PACU discharge. The secondary outcomes included the lung ultrasound score at the end of surgery, the incidence of significant atelectasis at PACU discharge, and other postoperative outcomes., Results: Lung ultrasound score and the incidence of atelectasis at the end of surgery did not differ significantly between the control (n = 38) and HFNC (n = 40) groups. After staying in the PACU, both groups showed a reduced lung ultrasound score and atelectasis incidence. However, the HFNC group had a significantly lower consolidation score than the control group (0; interquartile range [IQR] = 0-1 vs 3; IQR = 2-4; P< .001). Additionally, none of the patients had significant atelectasis in the HFNC group, compared to 6 patients in the control group (0% vs 15.8%; odds ratio [OR] = 0.444; 95% confidence interval for OR, 0.343-0.575; P = .011). Incidence of desaturation (oxygen saturation [Spo2] ≤ 95%), postoperative complications, and the length of hospital stay did not differ between the groups., Conclusions: Preventive use of HFNC after surgery improves the lung ultrasound score and reduces postoperative atelectasis compared to conventional oxygen therapy in infants and small children., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 International Anesthesia Research Society.)

Background: We aimed to determine whether high-flow nasal oxygen could reduce the incidence of decreased peripheral oxygen saturation (SpO 2 ) compared with standard oxygen in patients at risk of hypoxaemia undergoing gastrointestinal endoscopy under deep sedation., Methods: This was a multicentre, randomised controlled trial with blinded assessment of the primary outcome evaluating high-flow nasal oxygen (gas flow 70 L min -1 , inspired oxygen fraction 0.50) or standard oxygen delivered via nasal cannula or face mask (6 L min -1 ) or nasopharyngeal tube (5 L min -1 ) in patients at risk of hypoxaemia (i.e. >60 yr old, or with underlying cardiac or respiratory disease, or with ASA physical status >1, or with obesity or sleep apnoea syndrome) undergoing gastrointestinal endoscopy. The primary endpoint was the incidence of SpO 2 ≤92%. Secondary outcomes included prolonged or severe desaturations, need for manoeuvres to maintain free upper airways, and other adverse events., Results: In 379 patients, a decrease in SpO 2 ≤92% occurred in 9.4% (18/191) for the high-flow nasal oxygen group, and 33.5% (63/188) for the standard oxygen groups (adjusted absolute risk difference, -23.4% [95% confidence interval (CI), -28.9 to -16.7]; P<0.001). Prolonged desaturation (>1 min) and manoeuvres to maintain free upper airways were less frequent in the high-flow nasal oxygen group than in the standard oxygen group (7.3% vs 14.9%, P=.02, and 11.1% vs 32.4%, P<0.001)., Conclusions: In patients at risk of hypoxaemia undergoing gastrointestinal endoscopy under deep sedation, use of high-flow nasal oxygen significantly reduced the incidence of peripheral oxygen desaturation., Clinical Trial Registration: NCT03829293., (Copyright © 2021 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.)

Coronavirus disease-2019 (COVID-19) has rapidly spread worldwide and causes high mortality of elderly patients. High-flow nasal cannula therapy (HFNC) is an oxygen delivery method for severely ill patients. We retrospectively analyzed the course of illness and outcomes in 110 elderly COVID-19 patients (≥65 years) treated with HFNC from 6 hospitals. 38 patients received HFNC (200 mmHg < PaO 2 /FiO 2 ≤ 300 mmHg, early HFNC group), and 72 patients received HFNC (100 mmHg < PaO 2 /FiO 2 ≤ 200 mmHg, late HFNC group). There were no significant differences of sequential organ failure assessment (SOFA) scores and APECH II scores between early and late HFNC group on admission. Compared with the late HFNC group, patients in the early HFNC group had a lower likelihood of developing severe acute respiratory distress syndrome (ARDS), longer time from illness onset to severe ARDS and shorter duration of viral shedding after illness onset, as well as shorter lengths of ICU and hospital stay. 24 patients died during hospitalization, of whom 22 deaths (30.6%) were in the late HFNC group and 2 (5.3%) in the early HFNC group. The present study suggested that the outcomes were better in severely ill elderly patients with COVID-19 receiving early compared to late HFNC.

Background: There is a limited evidence for humidified high-flow nasal cannula (HHFNC) use on inter-hospital transport. Despite this, its use during transport is increasing in children with respiratory distress worldwide. In 2015 HHFNC was implemented on a specialized pediatric retrieval team serving for Victoria. The aim of this study is to investigate the effect of the HHFNC implementation on the retrieval team on the paediatric intensive care unit (PICU) length of stay and respiratory support use., Methods: We performed a cohort study using a comparative interrupted time-series approach controlling for patient and temporal covariates, and population-adjusted analysis. We studied 3022 children admitted to a PICU in Victoria with respiratory distress January 2010-December 2019. Patients were divided in pre-intervention era (2010-2014) and post-intervention era (2015-2019)., Results: 1006 children following interhospital transport and 2016 non-transport children were included. Median (IQR) age was 1.4 (0.7-4.5) years. Pneumonia (39.1%) and bronchiolitis (34.3%) were common. On retrieval, HHFNC was used in 5.0% (21/420) and 45.9% (269/586) in pre- and post-intervention era. In an unadjusted model, median (IQR) PICU length of stay was 2.2 (1.1-4.2) and 1.7 (0.9-3.2) days in the pre- and post-intervention era in transported children while the figures were 2.4 (1.3-4.9) and 2.1 (1.2-4.5) days in non-transport children. In the multivariable regression model, the intervention was associated with the reduced PICU length of stay (ratio 0.64, 95% confidential interval 0.49-0.83, p = 0.001) with the predicted reduction of PICU length of stay being - 10.6 h (95% confidential interval - 16.9 to - 4.3 h), and decreased respiratory support use (- 25.1 h, 95% confidential interval - 47.9 to - 2.3 h, p = 0.03). Sensitivity analyses including a model excluding less severe children showed similar results. In population-adjusted analyses, respiratory support use decreased from 4837 to 3477 person-hour per year in transported children over the study era, while the reduction was 594 (from 9553 to 8959) person-hour per year in non-transport children. With regard to the safety, there were no escalations of respiratory support mode during interhospital transport., Conclusions: The implementation of HHFNC on interhospital transport was associated with the reduced PICU length of stay and respiratory support use among PICU admissions with respiratory distress.

Importance: Pneumonia is the leading cause of childhood mortality worldwide. Severe pneumonia associated with hypoxemia requires oxygen therapy; however, access remains unreliable in low- and middle-income countries. Solar-powered oxygen delivery (solar-powered O2) has been shown to be a safe and effective technology for delivering medical oxygen. Examining the cost-effectiveness of this innovation is critical for guiding implementation in low-resource settings., Objective: To determine the cost-effectiveness of solar-powered O2 for treating children in low-resource settings with severe pneumonia who require oxygen therapy., Design, Setting, and Participants: An economic evaluation study of solar-powered O2 was conducted from January 12, 2020, to February 27, 2021, in compliance with the World Health Organization Choosing Interventions That Are Cost-Effective (WHO-CHOICE) guidelines. Using existing literature, plausible ranges for component costs of solar-powered O2 were determined in order to calculate the expected total cost of implementation. The costs of implementing solar-powered O2 at a single health facility in low- and middle-income countries was analyzed for pediatric patients younger than 5 years who required supplemental oxygen., Exposures: Treatment with solar-powered O2., Main Outcomes and Measures: The incremental cost-effectiveness ratio (ICER) of solar-powered O2 was calculated as the additional cost per disability-adjusted life-year (DALY) saved. Sensitivity of the ICER to uncertainties of input parameters was assessed through univariate and probabilistic sensitivity analyses., Results: The ICER of solar-powered O2 was estimated to be $20 (US dollars) per DALY saved (95% CI, $2.83-$206) relative to the null case (no oxygen). Costs of solar-powered O2 were alternatively quantified as $26 per patient treated and $542 per life saved. Univariate sensitivity analysis found that the ICER was most sensitive to the volume of pediatric pneumonia admissions and the case fatality rate. The ICER was insensitive to component costs of solar-powered O2 systems. In secondary analyses, solar-powered O2 was cost-effective relative to grid-powered concentrators (ICER $140 per DALY saved) and cost-saving relative to fuel generator-powered concentrators (cost saving of $7120)., Conclusions and Relevance: The results of this economic evaluation suggest that solar-powered O2 is a cost-effective solution for treating hypoxemia in young children in low- and middle-income countries, relative to no oxygen. Future implementation should prioritize sites with high rates of pediatric pneumonia admissions and mortality. This study provides economic support for expansion of solar-powered O2 and further assessment of its efficacy and mortality benefit.

Background: High-flow nasal cannula (HFNC) oxygen therapy has been recommended for use in coronavirus disease 2019 (COVID-19) patients with acute respiratory failure and many other clinical conditions. HFNC devices produced by different manufacturers may have varied performance. Whether there is a difference in these devices and the extent of the differences in performance remain unknown., Methods: Four HFNC devices (AIRVO 2, TNI softFlow 50, HUMID-BH, and OH-70C) and a ventilator with an HFNC module (bellavista 1000) were evaluated. The flow was set at 20, 25, 30, 35, 40, 45, 50, 60, 70, and 80 L/min, and the FiO 2 was set at 21%, 26%, 30%, 35%, 40%, 45%, 50%, 60%, 70%, 80%, and 90%. Then, one side of the cannulas was clipped to simulate the compression, bending, or blocking of the nasal cannulas. The flow and FiO 2 of the delivered gas were recorded and compared among settings and devices., Results: The actual-flow and actual-FiO 2 delivered by different settings and devices varied. AIRVO 2 had superior performance in flow and FiO 2 accuracy. bellavista 1000 and OH-70C had good performance in the accuracy of actual-flows and actual-FiO 2, respectively. bellavista 1000 and HUMID-BH had a larger flow range from 10 to 80 L/min, but only bellavista 1000 could provide a stable flow with an excessive resistance up to 60 L/min. TNI softFlow 50 had the best flow compensation and could provide sufficient flow with excessive resistance at 20-50 L/min., Conclusions: The variation in flow, FiO 2 settings, and devices could influence the actual-flow and actual-FiO 2 delivered. AIRVO 2 and OH-70C showed better FiO 2 accuracy. TNI softFlow 50, bellavista 1000, and HUMID-BH could lower the risk of insufficient flow support due to accidental compression or blocking of the cannulas. In addition, ventilators with HFNC modules provided comparable flow and FiO 2 and could be an alternative to standalone HFNC devices., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2021 Yuyan Zhou et al.)

Introduction: Efforts to meet increased oxygen demands in COVID-19 patients are a priority in averting mechanical ventilation (MV), associated with high mortality approaching 76.4-97.2%. Novel methods of oxygen delivery could mitigate that risk. Oxygen hoods/helmets may improve: O 2 -saturation (SaO2), reduce in-hospital mechanical ventilation and mortality rates, and reduce length of hospitalization in hypoxic Covid-19 patients failing on conventional high-flow oxygen delivery systems., Methods: DesignProspective Controlled Cohort Study. SettingSingle Center. ParticipantsAll patients admitted with a diagnosis of COVID-19 were reviewed and 136/347 patients met inclusion criteria. Study period3/6/2020 to 5/1/2020. 136 participants completed the study with known status for all outcome measures. Intervention or exposureOxygen hoods/helmets as compared to conventional high-flow oxygen delivery systems., Main Outcome(s) and Measure(s): 1) Pre and post change in oxygen saturation (SaO 2 ). 2) In-hospital Mechanical Ventilation (MV). 3) In-hospital Mortality. 4) Length of hospitalization., Results: 136 patients including 58-intervention and 78-control patients were studied. Age, gender, and other demographics/prognostic indicators were comparable between cohorts. Oxygen hoods averted imminent or immediate intubation/MV in all 58 COVID-19 patients failing on conventional high-flow oxygen delivery systems with a mean improvement in SaO 2 of 8.8%, p < 0.001. MV rates were observed to be higher in the control 37/78 (47.4%) as compared to the intervention cohort 23/58 (39.7%), a difference of 7.7%, a 27% risk reduction, not statistically significant, OR 95%CI 0.73 (0.37-1.5). Mortality rates were observed higher in the control 54/78 (69.2%) as compared to the intervention cohort 36/58 (62.1%), a difference of 7.1%, a 27% risk reduction, not statistically significant OR 95%CI 0.73 (0.36-1.5)., Conclusion: Oxygen hoods demonstrate improvement in SaO 2 for patients failing on conventional high-flow oxygen-delivery systems and prevented imminent mechanical ventilation. In-hospital mechanical ventilation and mortality rates were reduced with the use of oxygen hoods but not found to be statistically significant. The oxygen hood is a safe, effective oxygen-delivery system which may reduce intubation/MV and mortality rates. Their use should be considered in treating hypoxic COVID-19 patients. Further research is warranted., Trial Registration: ClinicalTrials.gov Identifier: NCT04407260., (Copyright © 2021. Published by Elsevier Ltd.)

Dyspnoea is a cardinal symptom of fibrotic interstitial lung disease (ILD), with a lack of proven effective therapies. With emerging evidence of the role of facial and nasal airflow for relieving breathlessness, this pilot study was conducted to examine the feasibility of conducting a clinical trial of a handheld fan (HHF) for dyspnoea management in patients with fibrotic ILD. In this mixed-methods, randomised, assessor-blinded, controlled trial, 30 participants with fibrotic ILD who were dyspnoeic with a modified Medical Research Council Dyspnoea grade ≥ 2 were randomised to a HHF for symptom control or no intervention for 2 weeks. Primary outcomes were trial feasibility, change in Dyspnoea-12 scores at Week 2, and participants' perspectives on using a HHF for dyspnoea management. Study recruitment was completed within nine months at a single site. Successful assessor blinding was achieved in the fan group [Bang's Blinding Index - 0.08 (95% CI - 0.45, 0.30)] but not the control group [0.47 (0.12, 0.81)]. There were no significant between-group differences for the change in Dyspnoea-12 or secondary efficacy outcomes. During qualitative interviews, participants reported that using the HHF relieved breathlessness and provided relaxation, despite initial scepticism about its therapeutic benefit. Oxygen-experienced participants described the HHF being easier to use, but not as effective for symptomatic relief, compared to oxygen therapy. Our results confirmed the feasibility of a clinical trial of a HHF in fibrotic ILD. There was a high level of patient acceptance of a HHF for managing dyspnoea, with patients reporting both symptomatic benefits and ease of use.

Increased access to reliable medical oxygen would reduce the global burden of pneumonia. Oxygen concentrators have been shown to be an effective solution, however they have significant drawbacks when used in low-resource environments where pneumonia burden is the heaviest. Low quality grid power can damage oxygen concentrators and blackouts can prevent at-risk patients from receiving continual oxygen therapy. Gaps in prescribed oxygen flow can result in acquired brain injuries, extended hypoxemia and death. The FREO2 Low-Pressure Oxygen Storage (LPOS) system consists of a suite of improvements to a standard oxygen concentrator which address these limitations. This study reports the technical results of a field trial of the system in Mbarara, Uganda. During this trial, oxygen supplied from the LPOS system was distributed to four beds in the paediatric ward of Mbarara Regional Referral Hospital. Over a three-month period, medical-grade oxygen was made available to patients 100% of the time. This period was sufficient to quantify the ability of the LPOS system to deal with blackouts, maintenance, and an unscheduled repair to the LPOS store., Competing Interests: During the period of the trial described in this manuscript, authors KR and JB were employees of FREO2 Foundation Australia Ltd, a not-for-profit company aiming to reduce health inequalities around provision of medical grade oxygen in low-resource environments. Authors DP, BS and RR are directors and co-founders of FREO2 Foundation Australia Ltd. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Background: High-flow nasal cannulae (HFNC) deliver high flows of blended humidified air and oxygen via wide-bore nasal cannulae and may be useful in providing respiratory support for adults experiencing acute respiratory failure, or at risk of acute respiratory failure, in the intensive care unit (ICU). This is an update of an earlier version of the review., Objectives: To assess the effectiveness of HFNC compared to standard oxygen therapy, or non-invasive ventilation (NIV) or non-invasive positive pressure ventilation (NIPPV), for respiratory support in adults in the ICU., Search Methods: We searched CENTRAL, MEDLINE, Embase, CINAHL, Web of Science, and the Cochrane COVID-19 Register (17 April 2020), clinical trial registers (6 April 2020) and conducted forward and backward citation searches., Selection Criteria: We included randomized controlled studies (RCTs) with a parallel-group or cross-over design comparing HFNC use versus other types of non-invasive respiratory support (standard oxygen therapy via nasal cannulae or mask; or NIV or NIPPV which included continuous positive airway pressure and bilevel positive airway pressure) in adults admitted to the ICU., Data Collection and Analysis: We used standard methodological procedures as expected by Cochrane., Main Results: We included 31 studies (22 parallel-group and nine cross-over designs) with 5136 participants; this update included 20 new studies. Twenty-one studies compared HFNC with standard oxygen therapy, and 13 compared HFNC with NIV or NIPPV; three studies included both comparisons. We found 51 ongoing studies (estimated 12,807 participants), and 19 studies awaiting classification for which we could not ascertain study eligibility information. In 18 studies, treatment was initiated after extubation. In the remaining studies, participants were not previously mechanically ventilated. HFNC versus standard oxygen therapy HFNC may lead to less treatment failure as indicated by escalation to alternative types of oxygen therapy (risk ratio (RR) 0.62, 95% confidence interval (CI) 0.45 to 0.86; 15 studies, 3044 participants; low-certainty evidence). HFNC probably makes little or no difference in mortality when compared with standard oxygen therapy (RR 0.96, 95% CI 0.82 to 1.11; 11 studies, 2673 participants; moderate-certainty evidence). HFNC probably results in little or no difference to cases of pneumonia (RR 0.72, 95% CI 0.48 to 1.09; 4 studies, 1057 participants; moderate-certainty evidence), and we were uncertain of its effect on nasal mucosa or skin trauma (RR 3.66, 95% CI 0.43 to 31.48; 2 studies, 617 participants; very low-certainty evidence). We found low-certainty evidence that HFNC may make little or no difference to the length of ICU stay according to the type of respiratory support used (MD 0.12 days, 95% CI -0.03 to 0.27; 7 studies, 1014 participants). We are uncertain whether HFNC made any difference to the ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO 2 /FiO 2 ) within 24 hours of treatment (MD 10.34 mmHg, 95% CI -17.31 to 38; 5 studies, 600 participants; very low-certainty evidence). We are uncertain whether HFNC made any difference to short-term comfort (MD 0.31, 95% CI -0.60 to 1.22; 4 studies, 662 participants, very low-certainty evidence), or to long-term comfort (MD 0.59, 95% CI -2.29 to 3.47; 2 studies, 445 participants, very low-certainty evidence). HFNC versus NIV or NIPPV We found no evidence of a difference between groups in treatment failure when HFNC were used post-extubation or without prior use of mechanical ventilation (RR 0.98, 95% CI 0.78 to 1.22; 5 studies, 1758 participants; low-certainty evidence), or in-hospital mortality (RR 0.92, 95% CI 0.64 to 1.31; 5 studies, 1758 participants; low-certainty evidence). We are very uncertain about the effect of using HFNC on incidence of pneumonia (RR 0.51, 95% CI 0.17 to 1.52; 3 studies, 1750 participants; very low-certainty evidence), and HFNC may result in little or no difference to barotrauma (RR 1.15, 95% CI 0.42 to 3.14; 1 study, 830 participants; low-certainty evidence). HFNC may make little or no difference to the length of ICU stay (MD -0.72 days, 95% CI -2.85 to 1.42; 2 studies, 246 participants; low-certainty evidence). The ratio of PaO 2 /FiO 2 may be lower up to 24 hours with HFNC use (MD -58.10 mmHg, 95% CI -71.68 to -44.51; 3 studies, 1086 participants; low-certainty evidence). We are uncertain whether HFNC improved short-term comfort when measured using comfort scores (MD 1.33, 95% CI 0.74 to 1.92; 2 studies, 258 participants) and responses to questionnaires (RR 1.30, 95% CI 1.10 to 1.53; 1 study, 168 participants); evidence for short-term comfort was very low certainty. No studies reported on nasal mucosa or skin trauma., Authors' Conclusions: HFNC may lead to less treatment failure when compared to standard oxygen therapy, but probably makes little or no difference to treatment failure when compared to NIV or NIPPV. For most other review outcomes, we found no evidence of a difference in effect. However, the evidence was often of low or very low certainty. We found a large number of ongoing studies; including these in future updates could increase the certainty or may alter the direction of these effects., (Copyright © 2021 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Background: Over 6 million esophagogastroduodenoscopy (EGD) procedures are performed in the United States each year. Patients having anesthesia for advanced EGD procedures, such as interventional procedures, are at high risk for hypoxemia., Methods: Our primary study aim was to evaluate whether high-flow nasal cannula (HFNC) oxygen reduces the incidence of hypoxemia during anesthesia for advanced EGD. Secondarily, we studied whether HFNC oxygen reduces hypercarbia or hypotension. After obtaining written informed consent, adults having anesthesia for advanced EGD, expected to last longer than 15 minutes, were randomly assigned to receive HFNC oxygen or standard nasal cannula (SNC) oxygen. The primary outcome was occurrence of one or more hypoxemia events during anesthesia, defined by arterial oxygen saturation <92% for at least 15 consecutive seconds. Secondary outcomes were occurrence of one or more hypercarbia or hypotension events. A hypercarbia event was defined by a transcutaneous CO2 measurement 20 mm Hg or more above baseline, and a hypotension event was defined by a mean arterial blood pressure measurement 25% or more below baseline., Results: Two hundred seventy-one adult patients were enrolled and randomized, and 262 patients completed study procedures. Eight randomized patients did not complete study procedures due to changes in their anesthesia or endoscopy plan. One patient was excluded from analysis because their procedure was aborted after 1 minute. Patients who received HFNC oxygen (N = 132) had a significantly lower incidence of hypoxemia than those who received SNC oxygen (N = 130; 21.2% vs 33.1%; hazard ratio [HR] = 0.59 [95% confidence interval {CI}, 0.36-0.95]; P = .03). There was no difference in the incidence of hypercarbia or hypotension between the groups. The HR for hypercarbia with HFNC oxygen was 1.29 (95% CI, 0.89-1.88; P = .17), and the HR for hypotension was 1.25 (95% CI, 0.86-1.82; P = .25)., Conclusions: HFNC oxygen reduces the incidence of hypoxemia during anesthesia for advanced EGD and may offer an opportunity to enhance patient safety during these procedures., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 International Anesthesia Research Society.)

Background: All of the existing medication and surgical therapies currently cannot completely inhibit intracerebral hemorrhage (ICH)-mediated brain damage, resulting in disability in different degrees in the involved patients. Normobaric oxygenation (NBO) was reported attenuating ischemic brain injury. Herein, we aimed to explore the safety and efficacy of NBO on rescuing the damaged brain tissues secondary to acute ICH, especially those in the perihematoma area being threatened by ischemia and hypoxia., Methods: A total of 150 patients confirmed as acute spontaneous ICH by computed tomography (CT) within 6 h after symptoms onset, will enroll in this study after signing the informed consent, and enter into the NBO group or control group randomly according to a random number. In the NBO group, patients will inhale high-flow oxygen (8 L/min, 1 h each time for 6 cycles daily) and intake low-flow oxygen (2 L/min) in intermittent periods by mask for a total of 7 days. While in the control group, patients will breathe in only low-flow oxygen (2 L/min) by mask for 7 consecutive days. Computed tomography and perfusion (CT/CTP) will be used to evaluate cerebral perfusion status and brain edema. CT and CTP maps in the two groups at baseline and day 7 and 14 after NBO or low-flow oxygen control will be compared. The primary endpoint is mRS at both Day14 post-ICH and the end of the 3rd month follow-up. The secondary endpoints include NIHSS and plasma biomarkers at baseline and Day-1, 7, and 14 after treatment, as well as the NIHSS at the end of the 3rd month post-ICH and the incidence of bleeding recurrence and the mortalities within 3 months post-ICH., Discussion: This study will provide preliminary clinical evidence about the safety and efficacy of NBO on correcting acute ICH and explore some mechanisms accordingly, to offer reference for larger clinical trials in the future., Trial Registration: ClinicalTrials.gov NCT04144868 . Retrospectively registered on October 29, 2019.