Letter to the Editor
Reply to “Pulmonary toxicity by oxygen and COVID-19”
Respuesta a «Toxicidad pulmonar por oxígeno y COVID-19»
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Belenguer-Muncharaz, H. Hernández-Garcés" "autores" => array:2 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Belenguer-Muncharaz" "email" => array:1 [ 0 => "belengueralberto8@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" ] ] ] 1 => array:3 [ "nombre" => "H." "apellidos" => "Hernández-Garcés" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario Dr. Peset, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad Predepartamental Medicina, Facultad de Ciencias de la Salud, Universitat Jaume I (UJI), Castelló de la Plana, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Respuesta a «Toxicidad pulmonar por oxígeno y COVID-19»" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We read with great interest the letter in which the authors talk about the deleterious effect of using a high fraction of inspired oxygen (FiO<span class="elsevierStyleInf">2</span>) in patients with acute respiratory distress syndrome (ARDS) due pneumonia caused by SARS-CoV-2 where they advocate for the use of continuous positive airway pressure (CPAP) to reduce the high FiO<span class="elsevierStyleInf">2</span> used in high-flow nasal oxygen (HFNO) therapy.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We agree with the authors when they talk about planning CPAP or non-invasive ventilation (NIV) as an alternative to HFNO. However, clinical practice guidelines say otherwise and they recommend HFNO and choose invasive mechanical ventilation (IMV) in cases of failed HFNO.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Based on these recommendations,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> a Spanish multicenter registry (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>876 patients) showed a wide use of HFNO (49%) vs NIV, and CPAP (<5% in both modalities). We should mention the high rate of failure in the HFNO group (60%) with mortality rates > 30% in patients who required intubation.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The efficacy of NIV in SARS-CoV-2-induced pneumonia was demonstrated in an Italian multicenter registry (N<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>110 patients) that compared the NIV-helmet to HFNO. Although the registry primary endpoint—ventilation-free days (20 days vs 18 days, <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.26)—was not achieved the NIV group had lower rates of intubation on day 28 vs the HFNO group [28% vs 51%; OR, 0.37 (0.17−0.82), <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.02]. At the same time, the NIV-helmet had better oxygenation, and less dyspnea compared to the HFNO group.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Consistent with one of the arguments that support the use of HFNO,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> the patients’ tolerance was higher with HFNO compared to NIV.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Similarly, in our series of 27 hypoxemic patients due to SARS-CoV-2-induced pneumonia, NIV was used as the first-line therapy in 21 patients (80.8%) basically with NIV specific ventilators in CPAP mode. CPAP failed in 10 patients (48%) with an associated mortality rate of 50%. No health personnel became infected in relation to the NIV as opposed to what has been reported in the clinical practice guidelines.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Therefore, based on these guidelines,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> we believe that the HFNO plays a key role in the early ventilatory therapy of hypoxemic patients. Unfortunately, the rate of failure in hypoxemic patients is high,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> which may have overestimated the true efficacy of HFNO in advanced stages of ARDS. Like the authors say, a high FiO<span class="elsevierStyleInf">2</span> in HFNO added to the pulmonary damage caused by the virus worsens ARDS, and eventually leads to IMV.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> On the contrary, results from the latest clinical trials,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and observational studies<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> pave the way for the safe use of NIV in its different modes (CPAP or NIV) by applying positive end-expiratory pressure (PEEP) that recruits the damaged lung, which allows reaching a non-detrimental FiO<span class="elsevierStyleInf">2</span><a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> while avoiding IMV and its deleterious effect.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,5</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Belenguer-Muncharaz A, Hernández-Garcés H. Respuesta a «Toxicidad pulmonar por oxígeno y COVID-19». Med Intensiva. 2022;46:354.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Toxicidad pulmonar por oxígeno y COVID-19" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. León-Jiménez" 1 => "E. Vázquez-Gandullo" 2 => "F. Montoro-Ballesteros" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.medin.2021.04.008" "Revista" => array:2 [ "tituloSerie" => "Med Intensiva" "fecha" => "2020" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "W. Alhazzani" 1 => "M.H. Møller" 2 => "Y.M. Arabi" 3 => "M. Loeb" 4 => "M.N. Gong" 5 => "E. 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Bitondo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jama.2021.4682" "Revista" => array:7 [ "tituloSerie" => "JAMA" "fecha" => "2021" "volumen" => "325" "paginaInicial" => "1731" "paginaFinal" => "1743" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/33764378" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0015028207000696" "estado" => "S300" "issn" => "00150282" ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Eficacia de la ventilación no invasiva en pacientes ingresados por neumonía por SARS-CoV-2 en una unidad de cuidados intensivos" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A. Belenguer-Muncharaz" 1 => "H. Hernández-Garcés" 2 => "C. López-Chicote" 3 => "S. Ribes-García" 4 => "J. Ochagavía-Barbarín" 5 => "R. Zaragoza-Crespo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.medin.2020.08.011" "Revista" => array:2 [ "tituloSerie" => "Med Intensiva" "fecha" => "2020" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735727/0000004600000006/v1_202206091533/S2173572722000789/v1_202206091533/en/main.assets" "Apartado" => array:4 [ "identificador" => "64604" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735727/0000004600000006/v1_202206091533/S2173572722000789/v1_202206091533/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572722000789?idApp=WMIE" ]
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