Editorial
High-flow nasal cannula oxygenation for everyone? Not so fast!
¿Oxigenación con cánula nasal de alto flujo para todos? ¡No tan rápido!
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"tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "391" "paginaFinal" => "393" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "J. Mayordomo-Colunga, A. Medina" "autores" => array:2 [ 0 => array:3 [ "nombre" => "J." "apellidos" => "Mayordomo-Colunga" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 1 => array:4 [ "nombre" => "A." "apellidos" => "Medina" "email" => array:1 [ 0 => "amedinavillanueva@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Sección de Cuidados Intensivos Pediátricos, Hospital Universitario Central de Asturias, Oviedo, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "CIBER-Enfermedades Respiratorias, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Oxigenación con cánula nasal de alto flujo para todos? ¡No tan rápido!" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1223 "Ancho" => 1651 "Tamanyo" => 144825 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Indifference ROPE zone [δL, δU] and corresponding conclusions for Hernández et al.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a> clinical trial based on the location of the 95% posterior credible difference interval for each scenario.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">High-flow nasal cannula (HFNC) therapy is being increasingly used in adult and paediatric patients. It delivers a heated and humidified mixture of air and oxygen utilising a flow superior than the patient's demand, thus providing a quite stable fraction of inspired oxygen. The mode of action is not fully understood, and some mechanisms suggested include dead space carbon dioxide washout and ‘some’ positive end-expiratory pressure (PEEP).<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Asthmatic exacerbation is a frequent cause of admission in paediatric wards, and also in paediatric intensive care units (PICUs). Non-invasive ventilation (NIV) has been suggested as a useful tool in order to improve patients with severe asthmatic exacerbations, thus avoiding intubation. Although this use is still controversial, many intensive care units worldwide have included NIV as part of the cornerstone treatment in refractory status asthmaticus.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">2,3</span></a> External PEEP or expiratory positive airway pressure, may decrease the dynamic expiratory collapse, reducing the occurrence of air trapping, and therefore, of intrinsic PEEP. This may relieve the uploading of respiratory muscles while maintaining patency of smaller airways. Inspiratory positive airway pressure, ideally delivered as synchronised pressure support, may help inspiratory muscles to counteract airflow limitation and chest wall overstretching, improving tidal volumes.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The study by Pilar et al.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a> suggests that NIV is far more effective than HFNC in severe asthmatic exacerbations: 22/22 were successfully treated using NIV while 8/20 who were previously being treated with HFNC then had to be treated with NIV, and those 8 patients also avoided tracheal intubation with NIV. According to these results, HFNC seems to be cost-ineffective and therefore, the use of HFNC in severe asthmatic exacerbations would be inacceptable. We have had the opportunity to look at the economic data from Cruces University Hospital in order to analyse cost-effectiveness of HFNC and NIV according to Pilar et al. results.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">6</span></a> The cost of a mean admission per day of an asthmatic patient in the PICU is € 1575.85 plus the cost of consumables (we considered the cost per patient of the multiuser total face mask – reused up to 10 times – and that children who fail HFNC will have required both materials; HFNC and NIV). Considering the HFNC rate of failure in the present study (40%), we have elaborated a decision tree using the rolling-back method (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). According to this decision tree, if NIV is used as the first option, the expected cost is € 2804, while if HFNC is chosen; the expected cost is € 4167. The cost of each patient treated successfully with HFNC is € 2970 (60% of the patients), while the cost of a patient who had to be treated with NIV after failing on HFNC is € 5963.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Several paediatric publications have suggested that HFNC oxygenation is a promising tool. Heikkila et al. have recently published an interesting cost-effectiveness paper about the use of HFNC in bronchiolitis, reporting that this therapy was cost-effective mainly due to a reduction in the need for PICU admissions.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a> These authors used earlier published retrospective studies in order to know the admission rate to PICU. This is a source of possible bias, as admission criteria may differ significantly among PICUs as well as intubation criteria, suggested by a strikingly high intubation rate of 37% in one of the studies.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Chisti et al. reported in a randomised controlled trial in children with pneumonia and hypoxaemia a mortality of 4% in children receiving bubble CPAP, 15% in children receiving low-flow oxygen therapy, and 13% in children receiving HFNC.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">9</span></a> The subgroup analysis of this study has shown that these differences in mortality were significant when comparing CPAP and HFNC groups.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In regards to the use of HFNC after extubation in adult patients, two recent studies by Hernández et al. compared HFNC and conventional oxygen therapy in patients at low risk of reintubation,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a> and HFNC and NIV in patients at high risk of reintubation.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a> Authors conclude that HFNC is more effective than conventional oxygen therapy<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a> and non-inferior to NIV in terms of rates of reintubation.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In the first study, several intubations were prevented with the use of HFNC (NNT<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>14), although there were no differences regarding length of stay and mortality<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">11</span></a>; furthermore, the number of patients who would not have needed reintubation with the use of NIV is not known. Performing a decision analysis according to costs, the most adequate decision would be to use standard low-flow oxygen. Considering the NNT (NNT<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>14; 95%CI: 8–40) and that the cost gap of € 123.88 per patient (€ 125 per HFNC, minus € 1.12 per nasal prongs), we can estimate that the Incremental Cost-Effectiveness Ratio is € 1734.32 (95%CI: 991 to € 4955.2) per avoided intubation, which would imply an economic burden.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The second study by Hernández et al.,<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a> concludes non inferiority of HFNC compared to NIV. We performed a robust Bayesian analysis, through 10,000 Monte Carlo Markov Chain simulations in a conjugated beta-binomial model, based on the data used by these authors in order to calculate the sample size for their study: NIV reintubation rate ranging from 9 to 32%; noninferiority margin for HFNC group 10%; and baseline intubation rate 20–25%. Bayesian priors used in our analysis are as follows: (a) reference (objective): Jeffrey's prior (Beta [0.5; 0.5]) for both groups; (b) sceptic on HFNC: it considers 9% reintubation rate with NIV (Beta [27; 273]) and 20% reintubation rate with HFNC (Beta [60; 240]); and (c) enthusiastic on HFNC: it considers 32% reintubation rate with NIV (Beta [96; 204]) and 20% reintubation rate with HFNC (Beta [60; 240]). Interpreting the results within the original framework of Freedman et al. discussed in the work by Spiegelhalter et al.,<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">13</span></a> we have 3 different scenarios:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0045" class="elsevierStylePara elsevierViewall">Reference scenario: there is a 2.8% probability that NIV is superior, 97.2% probability of equivalence, and 0% probability that HFNC is superior.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall">Sceptic on HFNC scenario: there is a 9.9% probability that NIV is superior, 90.1% probability of equivalence, and 0% probability that HFNC is superior.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0055" class="elsevierStylePara elsevierViewall">Enthusiastic on HFNC scenario: there is a 0% probability that NIV is superior, 99.4% probability of equivalence, and 0.6% probability that HFNC is superior.</p></li></ul></p><p id="par0060" class="elsevierStylePara elsevierViewall">Therefore, in all 3 scenarios, the most probable interval is equivalence, with 99.4% of posterior credibility in the enthusiastic on HFNC scenario, 97.2% in the reference scenario, and 90.1% in the sceptic on HFNC scenario. So, robust Bayesian analysis reveals that only the enthusiastic prior of HFNC may consider that HFNC is superior to NIV (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), but with a scarce 0.6% probability.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">As a conclusion, considering that most PICUs and adult intensive care units have NIV devices, and that HFNC does not seem to be superior to NIV in many clinical scenarios, the cost of acquiring HFNC devices is not currently justified. Further clinical and cost-effectiveness studies are warranted.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 438 "Ancho" => 1649 "Tamanyo" => 71554 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Decision-tree analysis based on Pilar et al. study.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">7</span></a></p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1223 "Ancho" => 1651 "Tamanyo" => 144825 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Indifference ROPE zone [δL, δU] and corresponding conclusions for Hernández et al.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">12</span></a> clinical trial based on the location of the 95% posterior credible difference interval for each scenario.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:13 [ 0 => array:3 [ "identificador" => "bib0070" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Use of high flow nasal cannula in critically ill infants, children, and adults: a critical review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J.H. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 19 | 16 | 35 |
| 2024 September | 55 | 32 | 87 |
| 2024 August | 53 | 39 | 92 |
| 2024 July | 74 | 28 | 102 |
| 2024 June | 65 | 46 | 111 |
| 2024 May | 38 | 29 | 67 |
| 2024 April | 69 | 47 | 116 |
| 2024 March | 61 | 26 | 87 |
| 2024 February | 66 | 46 | 112 |
| 2024 January | 59 | 37 | 96 |
| 2023 December | 64 | 35 | 99 |
| 2023 November | 103 | 49 | 152 |
| 2023 October | 69 | 40 | 109 |
| 2023 September | 61 | 38 | 99 |
| 2023 August | 45 | 23 | 68 |
| 2023 July | 56 | 26 | 82 |
| 2023 June | 53 | 26 | 79 |
| 2023 May | 72 | 34 | 106 |
| 2023 April | 60 | 28 | 88 |
| 2023 March | 134 | 40 | 174 |
| 2023 February | 84 | 29 | 113 |
| 2023 January | 86 | 22 | 108 |
| 2022 December | 104 | 42 | 146 |
| 2022 November | 109 | 50 | 159 |
| 2022 October | 105 | 52 | 157 |
| 2022 September | 88 | 32 | 120 |
| 2022 August | 59 | 41 | 100 |
| 2022 July | 77 | 45 | 122 |
| 2022 June | 68 | 30 | 98 |
| 2022 May | 61 | 43 | 104 |
| 2022 April | 63 | 46 | 109 |
| 2022 March | 109 | 57 | 166 |
| 2022 February | 108 | 52 | 160 |
| 2022 January | 114 | 34 | 148 |
| 2021 December | 83 | 61 | 144 |
| 2021 November | 85 | 38 | 123 |
| 2021 October | 176 | 71 | 247 |
| 2021 September | 78 | 44 | 122 |
| 2021 August | 53 | 38 | 91 |
| 2021 July | 31 | 29 | 60 |
| 2021 June | 58 | 37 | 95 |
| 2021 May | 105 | 48 | 153 |
| 2021 April | 257 | 89 | 346 |
| 2021 March | 153 | 40 | 193 |
| 2021 February | 144 | 31 | 175 |
| 2021 January | 172 | 30 | 202 |
| 2020 December | 116 | 20 | 136 |
| 2020 November | 116 | 32 | 148 |
| 2020 October | 82 | 34 | 116 |
| 2020 September | 76 | 30 | 106 |
| 2020 August | 41 | 20 | 61 |
| 2020 July | 53 | 21 | 74 |
| 2020 June | 45 | 20 | 65 |
| 2020 May | 45 | 17 | 62 |
| 2020 April | 55 | 33 | 88 |
| 2020 March | 35 | 25 | 60 |
| 2020 February | 56 | 28 | 84 |
| 2020 January | 26 | 22 | 48 |
| 2019 December | 37 | 17 | 54 |
| 2019 November | 38 | 38 | 76 |
| 2019 October | 35 | 26 | 61 |
| 2019 September | 29 | 26 | 55 |
| 2019 August | 26 | 21 | 47 |
| 2019 July | 25 | 21 | 46 |
| 2019 June | 15 | 15 | 30 |
| 2019 May | 57 | 27 | 84 |
| 2019 April | 23 | 23 | 46 |
| 2019 March | 19 | 25 | 44 |
| 2019 February | 28 | 33 | 61 |
| 2019 January | 32 | 35 | 67 |
| 2018 December | 74 | 36 | 110 |
| 2018 November | 82 | 37 | 119 |
| 2018 October | 73 | 18 | 91 |
| 2018 September | 60 | 9 | 69 |
| 2018 August | 58 | 8 | 66 |
| 2018 July | 44 | 15 | 59 |
| 2018 June | 45 | 10 | 55 |
| 2018 May | 19 | 6 | 25 |
| 2018 April | 33 | 11 | 44 |
| 2018 March | 45 | 13 | 58 |
| 2018 February | 36 | 8 | 44 |
| 2018 January | 1 | 0 | 1 |
| 2017 December | 1 | 1 | 2 |
| 2017 November | 1 | 1 | 2 |
| 2017 October | 1 | 0 | 1 |
| 2017 September | 1 | 3 | 4 |
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