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Journal Club April 2023 v2

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42 views32 pages

Journal Club April 2023 v2

Thank you for the summary. I appreciate you taking the time to discuss these important topics.

Uploaded by

Gail Drescher
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPT, PDF, TXT or read online on Scribd
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Journal Club – Post-Extubation Non-invasive

Respiratory Support (NRS)


Disclosures

• Technical Editor at the Respiratory Care Journal


• Consultant Speaker for Boehringer Ingelheim
• Science Writer at ICF
Extubation to HFNC v NIV in Obese Subjects

http://www.thelancet.com/respiratory (2023)
Study Questions

• The type of question determines the study design that


should be used to answer the question.
– These features increase the quality of the study; designs
without these features are more subject to bias.
Types of Study Questions

• Therapy/Prevention/Intervention
• Diagnosis/Diagnostic Tests
• Etiology/Harm/Risk Factors/Mechanism of Disease
Prognosis Descriptive/Prevalence Systematic Reviews
Economic Evaluations
Therapy/Intervention/Prevention Study

 A study intended to evaluate the safety,


efficacy, or effectiveness of an intervention,
including educational or behavioral
interventions
 Could include healthy people, patients, or
health care providers as subjects
 Includes studies labeled as pilot, phase 2,
preliminary or feasibility study

Hulley textbook, Chapters 10 & 11, (Clinical Trials)


Friedman LM et al. Fundamentals of Clinical Trials, 3rd ed, Springer,1998.
Jadad A. Randomized Controlled Trials: A User’s Guide, BMJ Books, 1998.
CRCA Lectures: 11/28/07, 12/5/07, 12/12/07 (from Clinical Trial Design Course)
Stating the Question/Hypothesis

• A research idea (for an observational or intervention


study) should be structured into a well-built clinical
research question or hypothesis with the following
PICO components:
– Population of interest
– Intervention to be tested
– Comparison strategy
– Outcome(s)

Richardson WS et al. The well built clinical question: a key to evidence-based decisions.
ACP Journal Club. 1995; 123(3):A12-3.
CRCA Lectures: 11/7/07 (Interventional Studies); 9/3/03 (Observational Studies)
PICO – Extubation to HFNC v NIV in Obese
Subjects
• Population - Obese patients
• Intervention – RCT comparing NIV to oxygen therapy (HFNC and COT)
• Outcomes –
– Primary –Treatment failure within 72 h
– Composite:
» Reintubation
» Switch to other study treatment
» Premature study-treatment discontinuation
– Secondary - Incidence of acute respiratory failure within 7 d post extubation
• P/F ratio
• Organ failure
• ICU & Hospital ICU
• Mortality
Randomized Controlled Trial (RCT)

• Prospective study to measure


effectiveness
• Selection Bias
– Eliminates the ability to assign
patients to a treatment based on the
clinician’s assessment of whether the
patient will benefit or not.
• Control group for comparison
– Limitations:
• Cost
• Generalizability
• Loss to follow-up
Methods

• RCT >980 obese subjects


• Mean BMI ≈ 35 kg/m2
• Two randomizations:
– 1st – NIV v O2 therapy
– 2nd – Type of O2 therapy
• NIV alternating w/ HFNC compared to COT/HFNC
(Oxygen group) alone.
Application of NRS

• NIV • O2 Therapy
– NIV 30 min post extub
– EPAP – 10 cm H20
– HFNC – 24 h
– PS – to obtain: • 50 L/min
• RR 20-30 breaths/min • FIO2 titrated to SpO2 ≥ 94%
• VT 6-8 mL/kg/IBW – SOT
– Duration:
• 30-60 minutes throughout
the first 24 h – cumulative
time of at least 4 h
• Alternating with either
HFNC or SOT
Pulse Oximetry – Oxygenation Targets

• GC and critically-ill patients:


– SpO2 recommendations for adults 94-98%
– 88-93% in critically-ill patients requiring FIO2 ≥ .70
• COPD:
– 88-92%
Pulse Oximetry – Oxygenation Targets
Study Flow Chart
Baseline Comparison

• No differences between
subjects for significant
potential confounders:
– Demographics
– Co-morbidities
– Reason for ICU admission
– Reason for Intubation
Explanation of Terms

• P Value – Probability that the observed


difference occurred by chance
• Power
– How many subjects are needed to
answer the research question
• Type I error – conclude there was a
difference when there wasn’t
• Type II error – accept null
hypothesis that there was no
difference when there was
• Odds Ratio & Confidence Interval
– Magnitude of effect
– Measure of association between an
exposure and an outcome
Results cont…
Results cont…
Results – Cumulative Incidence of Treatment
Failure
Results cont...
Mechanics of Breathing in Obesity

• Reduced lung volumes


• Impaired airway stability
– Small airway collapse
• Impaired diaphragmatic
excursion
• OHS
– BMI > 30/kg m2
– Awake hypercapnia
HFNC v COT in Obese Subjects

• Low-Flow v HFNC
BJA: British Journal of Anaesthesia, Volume 107, Issue 6, December 2011, Pages
– 22 patients 998–1004,

– Studied lung volumes via electrical impedance


tomography
HFNC Guidelines in ARF

• Recommendations:
– HFNC over COT and NIV in AHRF
– HFNC over COT during NIV breaks
– HFNC OR COT in low/mod or high-risk post-op
patients
High-risk Patients:
– HFNC over COT in non-surgical patients at low/mod •Advanced age
risk of extubation failure •Hypercapneic during
– NIV over HFNC in non-surgical patients at high SBT
risk of extubation failure
•Chronic cardiac or
– Trial of NIV prior to HFNC in COPD patients with
acute hypercapneic respiratory failure respiratory disorders
https://erj.ersjournals.com/content/erj/early/2021/09/29/13993003.01574-2021.full.pdf •Airway patency
HIGH WEAN

• Multicenter RCT,
N=641
– High risk - > 65 y & h/o
cardiac or pulm dz
• Reintubation
– 11.8% HFNC+NIV vs
18.2% HFNC alone
• Post-extub RF
– 21% HFNC+NIV vs
29% HFNC alone
Sub-analysis of HIGH WEAN Subjects

• Categorized patients by weight class:


HFNC vs NIV

JAMA. 2016;316(15):1565-1574
• Multicenter RCT – 3 ICUs
• N=604 high-risk patients:
HFNC was non-inferior to
– > 65 y NIV in preventing 72 h
– HF as primary indication for intubation reintubation
– High acuity
– BMI > 30
– Airway patency issues
– Difficult or prolonged weaning
– 2 or more comorbidities
Effects of Positive Pressure Ventilation on the Heart

↑ ITP → ↑ RAP which ↓ venous return → ↓ RV preload & ↑ RV


afterload → ↓ LAP & PVC → ↓ LV preload → ↓ CO

PEEP augments CO by ↓
LV afterload → ↑ CO
Take-Away’s

• Conclusion
– For routine post-extubation management - NIV rotating with HFNC is better than
standard oxygen therapy alone in a mixed group of critically-ill obese patients.
– HFNC should not replace NIV for preventing reintubation in critically ill obese patients.
– Most of the difference in the primary outcome was due to patients on SOT switching to
NIV.
– Less treatment failure with NIV + HFNC
• Lower percent of chronic respiratory failure or COPD patients in this study
• Limitations
– 50% of subjects enrolled at 6/39 centers
– Unblinded design
– Lack of systematic SBT
– Inclusion/exclusion criteria were broad
Other Topics Discussed….
Selecting & Sizing the NIV Mask

Look for where


Dedicated color hits
below the lip ICU Vents
NIV Vents
HFNC and Epoprostenol Delivery

Drug delivery is
dependent on
infusion pump
flow and gas flow
Questions???
1 MD/DC Society CEU to be distributed by email
(Please sign-in and provide best address on sheet to receive credit )

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