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Objectives: To evaluate the safety and feasibility of high flow oxygen therapy (HFOT), and to record SpO2 and desaturation episodes in dogs and cats receiving HFOT or conventional oxygen therapy (COT) during bronchoscopy ± bronchoalveolar lavage (BAL). Materials and methods: Dogs and cats undergoing bronchoscopy ± BAL between January and May 2023 were included in the study. Patients were randomly allocated to two groups: HFOT (HFOT group; two cats and four dogs) and COT (COT group; one cat and five dogs). HFOT and COT were started at the beginning of the bronchoscopy. HFOT was delivered with a gas flow rate of 1 L/kg/min at an FiO2 of 100% and a temperature of 34°C (pediatric mode) or 37°C (adult mode). COT was delivered through the working channel of the bronchoscope at a rate of 1.5 L/min. The safety and feasibility of HFOT were assessed, and peripheral oxygen saturation (SpO2) was measured by pulse oximetry every 30 s throughout the procedure. Measurements and main results: HFOT was feasible and safe in both dogs and cats with no complications reported. While there was no significant difference in the number of desaturation episodes (SpO2 < 94%) between the two groups, none of the patients in the HFOT group experienced severe desaturation (SpO2 < 90%). In contrast, two patients in the COT group had an SpO2 < 90%. Mean SpO2 was significantly higher in the HFOT group compared to the COT group at T0 (98%± 2% vs. 94± 2%), T0.5 (98%± 2% vs. 94%± 3%) and T1 (98%± 2% vs. 94%± 4%). Conclusion: To the authors' knowledge, this is the largest study conducted to date using HFOT during bronchoscopy in dogs and cats. Our results suggest that HFOT is feasible and safe during bronchoscopy ± BAL. Furthermore, HFOT may reduce the risk of desaturation episodes in dogs and cats undergoing bronchoscopy and BAL. [ABSTRACT FROM AUTHOR]

ObjectivesTo evaluate the safety and feasibility of high flow oxygen therapy (HFOT), and to record SpO2 and desaturation episodes in dogs and cats receiving HFOT or conventional oxygen therapy (COT) during bronchoscopy ± bronchoalveolar lavage (BAL).Materials and methodsDogs and cats undergoing bronchoscopy ± BAL between January and May 2023 were included in the study. Patients were randomly allocated to two groups: HFOT (HFOT group; two cats and four dogs) and COT (COT group; one cat and five dogs). HFOT and COT were started at the beginning of the bronchoscopy. HFOT was delivered with a gas flow rate of 1 L/kg/min at an FiO2 of 100% and a temperature of 34°C (pediatric mode) or 37°C (adult mode). COT was delivered through the working channel of the bronchoscope at a rate of 1.5 L/min. The safety and feasibility of HFOT were assessed, and peripheral oxygen saturation (SpO2) was measured by pulse oximetry every 30 s throughout the procedure.Measurements and main resultsHFOT was feasible and safe in both dogs and cats with no complications reported. While there was no significant difference in the number of desaturation episodes (SpO2

Acute dyspnea represents one of the most frequent symptoms leading to emergency room evaluation. Its significant prognostic value warrants a careful evaluation. The differential diagnosis of dyspnea is complex due to the lack of specificity and the loose association between its intensity and the severity of the underlying pathological condition. The initial assessment of dyspnea calls for prompt diagnostic evaluation and identification of optimal monitoring strategy and provides information useful to allocate the patient to the most appropriate setting of care. In recent years, accumulating evidence indicated that lung ultrasound, along with echocardiography, represents the first rapid and non-invasive line of assessment that accurately differentiates heart, lung or extra-pulmonary involvement in patients with dyspnea. Moreover, non-invasive respiratory support modalities such as high-flow nasal oxygen and continuous positive airway pressure have aroused major clinical interest, in light of their efficacy and practicality to treat patients with dyspnea requiring ventilatory support, without using invasive mechanical ventilation. This clinical review is focused on the pathophysiology of acute dyspnea, on its clinical presentation and evaluation, including ultrasound-based diagnostic workup, and on available non-invasive modalities of respiratory support that may be required in patients with acute dyspnea secondary or associated with respiratory failure. [ABSTRACT FROM AUTHOR]

BACKGROUND: The spontaneous breathing trial (SBT) is the final step of weaning from invasive mechanical ventilation. An SBT is aimed at predicting work of breathing (WOB) after extubation and, most importantly, a patient's eligibility for extubation. The optimal SBT modality remains debated. A high-flow oxygen (HFO) has been tested during SBT in clinical study only, which is why no definite conclusion can be drawn on its physiologic effects on the endotracheal tube. Our objective was to assess, on a bench, inspiratory tidal volume (VT), total PEEP, and WOB across 3 different SBT modalities: T-piece, 40 L/min HFO, and 60 L/min HFO. METHODS: A test lung model was set with 3 conditions of resistance and linear compliance, 3 inspiratory efforts (low, normal, and high), each at 2 breathing frequencies (low and high for 20 and 30 breaths/min, respectively). Pairwise comparisons and a quasi-Poisson generalized linear model that compared SBT modalities were performed. RESULTS: Inspiratory VT, total PEEP, and WOB differed from one SBT modality to another. Inspiratory VT remained higher with the T-piece than in the HFO independent of the mechanical condition, effort intensity, and breathing frequency (P < .001 in each comparison). WOB adjusted by the inspiratory VT was significantly lower during SBT performed with an HFO than when performed with the T-piece (P < .001 in each comparison). The total PEEP was significantly higher in the HFO at 60 L/min than in the other modalities (P < .001). The end points were significantly influenced by breathing frequency, effort intensity, and mechanical condition. CONCLUSIONS: With the same effort intensity and breathing frequency, inspiratory VT was higher in the T-piece than in the other modalities. Compared with the T-piece, WOB was significantly lower in the HFO condition and higher flow was a benefit. Based on the results of the present study, the HFO as an SBT modality would seem to require clinical testing. [ABSTRACT FROM AUTHOR]

BackgroundThe use of high flow oxygen therapy (HFOT) has significantly escalated during the COVID-19 pandemic. HFOT can be delivered through both dedicated devices and ICU ventilators. HFOT can be administered to a patient via a nasal cannula (NC). In intubated patients, a tracheal cannula (TC) is used instead. In this study, we aim to compare the work of breathing (WOB) using a TC or NC and to explore whether differences exist among HFOT devices.MethodsSeven HFOT devices (three dedicated and four ICU ventilators) were connected to a manikin head (Laerdal Medical) through a NC (Optiflow 3S, large size, Fisher and Paykel Healthcare) or a TC (OPT 970 Optiflow+, Fisher and Paykel Healthcare). Each device was also attached to a manikin head that was connected to a lung simulator (ASL5000, Ingmar Medical), set at 40 ml/cmH2O compliance, 10 cmH2O/L/s resistance, and sinusoidal inspiratory effort (muscular pressure 10 cmH2O, rate 30 breaths/min). HFOT was delivered at 40 L/min and at 21% inspired oxygen fraction. The total WOB per breath and its resistive and elastic components were automatically analyzed breath by breath over the last 20 breaths by using Campbell's diagram.ResultsThe WOB and its resistive and elastic components were significantly lower with the TC than with the NC for every device, and systematically lower with the reference device than with others. These differences were, however, very small and may be not clinically relevant.ConclusionThe WOB is lower with the TC than with the NC and with the reference device, compared with the most recent devices.

The typical approach to management of respiratory distress is focused on oxygen supplementation. However, additional oxygen alone does not improve outcomes, particularly in critically ill patients. Instead, supplemental oxygen can be associated with increased morbidities. We present the hypothesis that clinicians should focus on reducing the work of breathing early in the course of critical illness. Rather than simply supplementing oxygen, newer technologies including high flow nasal oxygen, may be utilized to increase the efficiency of gas exchange. By reducing the work of breathing, the cardiac workload can be reduced, thus relieving some excess physiologic stress and supporting the critically ill patient. To illustrate this point, we provided three clinical cases of respiratory failure from non-pulmonary origins; all cases displayed hemodynamic improvement due to reducing the work of breathing through high-velocity therapy prior to receiving definitive therapy for underlying pathologies.

Abstract Objective All respiratory care represents some risk of becoming an aerosol‐generating procedure (AGP) during COVID‐19 patient management. Personal protective equipment (PPE) and environmental control/engineering is advised. High velocity nasal insufflation (HVNI) and high flow nasal cannula (HFNC) deliver high flow oxygen (HFO) therapy, established as a competent means of supporting oxygenation for acute respiratory distress patients, including that precipitated by COVID‐19. Although unlikely to present a disproportionate particle dispersal risk, AGP from HFO continues to be a concern. Previously, we published a preliminary model. Here, we present a subsequent highresolution simulation (higher complexity/reliability) to provide a more accurate and precise particle characterization on the effect of surgical masks on patients during HVNI, low‐flow oxygen therapy (LFO2), and tidal breathing. Methods This in silico modeling study of HVNI, LFO2, and tidal breathing presents ANSYS fluent computational fluid dynamics simulations that evaluate the effect of Type I surgical mask use over patient face on particle/droplet behavior. Results This in silico modeling simulation study of HVNI (40 L min−1) with a simulated surgical mask suggests 88.8% capture of exhaled particulate mass in the mask, compared to 77.4% in LFO2 (6 L min−1) capture, with particle distribution escaping to the room (> 1 m from face) lower for HVNI+Mask versus LFO2+Mask (8.23% vs 17.2%). The overwhelming proportion of particulate escape was associated with mask‐fit designed model gaps. Particle dispersion was associated with lower velocity. Conclusions These simulations suggest employing a surgical mask over the HVNI interface may be useful in reduction of particulate mass distribution associated with AGPs.

Abstract Background Pneumocystis jirovecii pneumonia (PJP) remains a severe disease associated with high rates of invasive mechanical ventilation (MV) and mortality. The objectives of this study were to assess early risk factors for severe PJP and 90-day mortality, including the broncho-alveolar lavage fluid cytology profiles at diagnosis. Methods We prospectively enrolled all patients meeting pre-defined diagnostic criteria for PJP admitted at Nantes university hospital, France, from January 2012 to January 2017. Diagnostic criteria for PJP were typical clinical features with microbiological confirmation of P. jirovecii cysts by direct examination or a positive specific quantitative real-time polymerase chain reaction (PCR) assay. Severe PJP was defined as hypoxemic acute respiratory failure requiring high-flow nasal oxygen with at least 50% FiO2, non-invasive ventilation, or MV. Results Of 2446 respiratory samples investigated during the study period, 514 from 430 patients were positive for P. jirovecii. Of these 430 patients, 107 met criteria for PJP and were included in the study, 53 (49.5%) patients had severe PJP, including 30 who required MV. All patients were immunocompromised with haematological malignancy ranking first (n = 37, 35%), followed by solid organ transplantation (n = 27, 25%), HIV-infection (n = 21, 20%), systemic diseases (n = 13, 12%), solid tumors (n = 12, 11%) and primary immunodeficiency (n = 6, 8%). By multivariate analysis, factors independently associated with severity were older age (OR, 3.36; 95% CI 1.4–8.5; p

Nasal high flow (NHF) has gained popularity among intensivists to manage patients with acute respiratory failure. An important literature has accompanied this evolution. In this review, an international panel of experts assessed potential benefits of NHF in different areas of acute respiratory failure management. Analyses of the physiological effects of NHF indicate flow-dependent improvement in various respiratory function parameters. These beneficial effects allow some patients with severe acute hypoxemic respiratory failure to avoid intubation and improve their outcome. They require close monitoring to not delay intubation. Such a delay may worsen outcome. The ROX index may help clinicians decide when to intubate. In immunocompromised patients, NHF reduces the need for intubation but does not impact mortality. Beneficial physiological effects of NHF have also been reported in patients with chronic respiratory failure, suggesting a possible indication in acute hypercapnic respiratory failure. When intubation is required, NHF can be used to pre-oxygenate patients either alone or in combination with non-invasive ventilation (NIV). Similarly, NHF reduces reintubation alone in low-risk patients and in combination with NIV in high-risk patients. NHF may be used in the emergency department in patients who would not be offered intubation and can be better tolerated than NIV. [ABSTRACT FROM AUTHOR]

Objective: To study the curative efficacy of continuous blood filtration combined with high flow oxygen uptake in the treatment of severe acute respiratory syndrome and its effects on the inflammatory factors. Methods: 60 cases of patients with severe acute respiratory syndrome admitted to our hospital from February 2013 to February 2016 were selected and divided into the observation group (n=30) and the control group (n=30) by random number table method. The observation group was treated with continuous hemofiltration combined with high flow oxygen, while the control group was treated with continuous hemofiltration. Clinical efficacy,arterial partial oxygen pressure (PaO2), arterial partial carbon dioxide pressure (PaCO2), oxygenation index, hydrogen ion concentration index (pH), respiratory rate (RR), heart rate (HR), serum c-reactive protein (CRP), interleukin-6 (il-6), interleukin-8 (il-8), and tumor necrosis factor (TNF-α) were compared between the two groups. Results: After treatment, the effective rate of observation group was 76.67%, which was significantly higher than that of the control group (50.00%, P<0.05). After treatment, the PaO2, PaCO2, oxygenation index, pH value, RR and HR in both groups were significantly improved compared with those before treatment. The PaO2 and oxygenation index in the observation group were significantly higher than those in the control group, and the levels of PaCO2, pH value,RR, HR, serum CRP, IL-6, IL-8 and TNF-α were significantly lower than those in the control group (P<0.05). During the treatment, the total incidence of adverse reactions in the observation group (10.00%) was significantly lower than that in the control group (36.67%,P<0.05). One case died in the observation group (3.33%), and six cases died in the control group (20.00%). The fatality rate of the observation group was significantly lower than that of the control group (P<0.05). Conclusion: The clinical efficacy and safety of continuous hemofiltration combined with high-flow oxygen inhalation in the treatment of patients with severe acute respiratory syndrome are significantly better than that of continuous hemofiltration alone, which may be related to the effective reduction of inflammatory reactions. [ABSTRACT FROM AUTHOR]

Background: In immunocompromised patients with acute hypoxemic respiratory failure (ARF), initial management aims primarily to avoid invasive mechanical ventilation (IMV).Methods: To assess the impact of initial management on IMV and mortality rates, we performed a multinational observational prospective cohort study in 16 countries (68 centers).Results: A total of 1611 patients were enrolled (hematological malignancies 51.9%, solid tumors 35.2%, systemic diseases 17.3%, and solid organ transplantation 8.8%). The main ARF etiologies were bacterial (29.5%), viral (15.4%), and fungal infections (14.7%), or undetermined (13.2%). On admission, 915 (56.8%) patients were not intubated. They received standard oxygen (N = 496, 53.9%), high-flow oxygen (HFNC, N = 187, 20.3%), noninvasive ventilation (NIV, N = 153, 17.2%), and NIV + HFNC (N = 79, 8.6%). Factors associated with IMV included age (hazard ratio = 0.92/year, 95% CI 0.86-0.99), day-1 SOFA (1.09/point, 1.06-1.13), day-1 PaO2/FiO2 (1.47, 1.05-2.07), ARF etiology (Pneumocystis jirovecii pneumonia (2.11, 1.42-3.14), invasive pulmonary aspergillosis (1.85, 1.21-2.85), and undetermined cause (1.46, 1.09-1.98). After propensity score matching, HFNC, but not NIV, had an effect on IMV rate (HR = 0.77, 95% CI 0.59-1.00, p = 0.05). ICU, hospital, and day-90 mortality rates were 32.4, 44.1, and 56.4%, respectively. Factors independently associated with hospital mortality included age (odds ratio = 1.18/year, 1.09-1.27), direct admission to the ICU (0.69, 0.54-0.87), day-1 SOFA excluding respiratory score (1.12/point, 1.08-1.16), PaO2/FiO2 < 100 (1.60, 1.03-2.48), and undetermined ARF etiology (1.43, 1.04-1.97). Initial oxygenation strategy did not affect mortality; however, IMV was associated with mortality, the odds ratio depending on IMV conditions: NIV + HFNC failure (2.31, 1.09-4.91), first-line IMV (2.55, 1.94-3.29), NIV failure (3.65, 2.05-6.53), standard oxygen failure (4.16, 2.91-5.93), and HFNC failure (5.54, 3.27-9.38).Conclusion: HFNC has an effect on intubation but not on mortality rates. Failure to identify ARF etiology is associated with higher rates of both intubation and mortality. This suggests that in addition to selecting the appropriate oxygenation device, clinicians should strive to identify the etiology of ARF. [ABSTRACT FROM AUTHOR]

Background Whilst research demonstrates the benefits of nasal high flow oxygen in the intensive care setting, limited literature exists on its benefits in ward patients. Objectives This study evaluated the use of nasal high flow oxygen in adult ward patients with respiratory failure or at risk of respiratory deterioration. Primary outcome was an improvement in pulmonary function as indicated by decreases in respiratory and heart rates and an increase in arterial oxygen saturation via pulse oximetry . Research methodology Using a prospective observational research design, purposeful sampling recruited 67 adult ward patients receiving nasal high flow oxygen between May and July 2015 (inclusive). All recruited patients were included in the data analysis. Results The median age was 71.0 years (q25, q75 = 58.0, 78.0) and most patients were medical specialty patients ( n = 46, 68.7%). After commencing nasal high flow oxygen, respiratory rate ( t = 2.79, p = <0.01) and heart rate ( t = 2.23, p = 0.03) decreased and arterial oxygen saturation via pulse oximetry increased ( t = 4.08, p = <0.001). Conclusion Nasal high flow oxygen appears effective in a selective group of ward patients with respiratory failure, or at risk of respiratory deterioration, and may reduce demand on critical care beds; this warrants further research. [ABSTRACT FROM AUTHOR]

Summary Objective The aim of this study was to determine the role that heated, humidified high-flow nasal oxygen (HHHFNO) plays in the adult ED with particular focus on the indications and outcomes of use. Methods An explorative study was undertaken using retrospective chart review to identify characteristics of adult patients who received HHHFNO in a tertiary adult ED between January and December 2014. Results Thirty-nine patients were identified as having received HHHFNO during the study period with a range of indications for this use. No clear guidelines existed for initiation of this use. Two patients failed on HHHFNO therapy, requiring increased respiratory support; twenty-seven patients were admitted to hospital with HHHFNO still being delivered and seven patients were successfully treated with HHHFNO in the ED. The use of HHHFNO was associated with a 4.91 bpm (95% CI 2.23–7.59; P = 0.001) decrease in mean RR and an 11.26 bpm (95% CI 4.62–17.90; P = 0.002) decrease in mean HR from baseline at 120 min of use. Hypercapnic patients showed a significant decrease in mean PaCO 2 levels after one hour of HHHFNO use (70.33 mmHg (SD 19.63) vs. 55.00 mmHg (SD 13.28), P = 0.041) with no change in PaCO 2 levels in patients who were not hypercapnic prior to HHHFNO use (PaCO 2 32.71 mmHg (SD 5.28) vs. 32.38 mmHg (SD 3.70), P = 0.919). Conclusions HHHFNO is currently being used as a device for supplemental oxygen delivery within the adult Emergency Department; however, further research is needed in this area to quantify its use in many of the indications seen. [ABSTRACT FROM AUTHOR]

Abstract: Context: Dyspnea is one of the most distressing symptoms for cancer patients. The role of high-flow oxygen (HFO) and bilevel positive airway pressure (BiPAP) in the palliation of dyspnea has not been well characterized. Objectives: To determine the feasibility of conducting a randomized trial of HFO and BiPAP in cancer patients and examine the changes in dyspnea, physiologic parameters, and adverse effects with these modalities. Methods: In this randomized study (ClinicalTrials.gov Identifier: NCT01518140), we assigned hospitalized patients with advanced cancer and persistent dyspnea to either HFO or BiPAP for two hours. We assessed dyspnea with a numeric rating scale (NRS) and modified Borg scale (MBS) before and after the intervention. We also documented vital signs, transcutaneous carbon dioxide, and adverse effects. Results: Thirty patients were enrolled (1:1 ratio) and 23 (77%) completed the assigned intervention. HFO was associated with improvements in both NRS (mean 1.9; 95% CI 0.4–3.4; P = 0.02) and MBS (mean 2.1; 95% CI 0.6–3.5; P = 0.007). BiPAP also was associated with improvements in NRS (mean 3.2; 95% CI 1.3–5.1; P = 0.004) and MBS (mean 1.5; 95% CI −0.3, 3.2; P = 0.13). There were no significant differences between HFO and BiPAP in dyspnea NRS (P = 0.14) and MBS (P = 0.47). Oxygen saturation improved with HFO (93% vs. 99%; P = 0.003), and respiratory rate had a nonstatistically significant decrease with both interventions (HFO −3, P = 0.11; BiPAP −2, P = 0.11). No significant adverse effects were observed. Conclusion: HFO and BiPAP alleviated dyspnea, improved physiologic parameters, and were safe. Our results justify larger randomized controlled trials to confirm these findings. [Copyright &y& Elsevier]

Background: Vapotherm 2000i® is a non-invasive high-flow respiratory support system used mainly in the treatment of type 1 respiratory failure. It uses a mixture of oxygen and air to deliver a set concentration via nasal cannula (or tracheostomy mask). The advantage of this system is the high humidity achieved using the integral heated water system. The system has been used in neonatal practice as a replacement for conventional continuous positive airway pressure (CPAP) but there is little published research within the adult setting about its use. Aim: This study discusses the indications for the use of this non-invasive high-flow respiratory support system, the system set up, the benefits and complications of the system. Audit design: An audit of 72 patients was undertaken within the Surgical High Dependency Unit that collected data on the types of patient receiving the therapy, its effectiveness and patient experience. Audit findings: The audit demonstrated reduced respiratory rate and improvement in oxygenation for treated patients. Conclusion: A non-invasive high-flow respiratory support system can be effective at improving oxygenation in hypoxic patients. Patients were generally satisfied with the system and the system seems suitable for use in an adult surgical high dependency setting. [ABSTRACT FROM AUTHOR]