Scientific Letter
High-flow nasal cannula oxygen for reverting severe acute exacerbation of chronic obstructive pulmonary disease: A case report
Oxigenoterapia de alto flujo con cánula nasal en el tratamiento de la exacerbación de la enfermedad pulmonar obstructiva crónica: informe de un caso
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Plotnikow, A.W. Thille, D. Vasquez, R. Pratto, P. Desmery" "autores" => array:5 [ 0 => array:4 [ "nombre" => "G." "apellidos" => "Plotnikow" "email" => array:1 [ 0 => "gplotnikow@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A.W." "apellidos" => "Thille" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "D." "apellidos" => "Vasquez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "R." 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As., Argentina" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Université de Poitiers, Poitiers, France" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Centre Hospitalier Universitaire de Poitiers, Poitiers, France" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Oxigenoterapia de alto flujo con cánula nasal en el tratamiento de la exacerbación de la enfermedad pulmonar obstructiva crónica: informe de un caso" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">High-flow nasal cannula (HFNC) oxygen therapy is a recent technique enabling delivery of high flow rate (up to 70<span class="elsevierStyleHsp" style=""></span>L/min) of gas heated and humidified as in physiological conditions. This strategy of oxygenation could be beneficial in ICU patients to avoid intubation in those with acute hypoxemic respiratory failure.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> The high-flow rate of gas continuously delivered in the airways may generate positive end-expiratory pressure (PEEP) effect<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> and a washout of dead space, flushing carbon dioxide (CO<span class="elsevierStyleInf">2</span>) out of the upper airways.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> This phenomenon may help to improve alveolar ventilation and to reduce work of breathing.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> To date, no study has been conducted to assess HFNC in acute hypercapnic respiratory failure. We report here the case of a 72-year-old male admitted to ICU for acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD) successfully treated with HFNC after failure of noninvasive ventilation (NIV).</p><p id="par0010" class="elsevierStylePara elsevierViewall">The history of this patient smoker with severe COPD (stage IV according to the GOLD classification) began 3 days prior to his admission with breathlessness worsening, fever and purulent cough. Clinical findings on admission to emergency department included signs of respiratory distress with a respiratory rate at 28 breaths/min and activation of accessory respiratory muscles. His temperature was 38.2<span class="elsevierStyleHsp" style=""></span>°C, heart rate 110 beats/min, blood arterial pressure 140/70<span class="elsevierStyleHsp" style=""></span>mmHg, without signs of congestive heart failure. He was stuporous as indicated by a Kelly–Matthay score of 4. Auscultation revealed crackles over the right side of the chest. Arterial blood gas values on admission revealed respiratory acidosis with pH 7.27 and PaCO<span class="elsevierStyleInf">2</span> 89<span class="elsevierStyleHsp" style=""></span>mmHg, and PaO<span class="elsevierStyleInf">2</span> was 45<span class="elsevierStyleHsp" style=""></span>mmHg on room air. Chest computed tomography (CT) with angiogram was negative for pulmonary embolism and revealed right baseline infiltrates. The bacterial sputum culture and virology studies were negative. The diagnosis of acute exacerbation of COPD was retained and he received inhaled bronchodilators, systemic steroids, Ampicillin-Sulbactam plus Clarithromycin and Oseltamivir. Given the severity, he was rapidly admitted to the ICU to start NIV. Large leaks immediately occurred after NIV initiation probably because of his facial anatomy characterized by retrognathia, very thin and bearded. Given the difficulties to carry out NIV, three different masks and two types of ventilators were tested to ensure patient–ventilator interaction and alveolar ventilation. The first blood gas in ICU revealed worsening of hypercapnia, reaching 91<span class="elsevierStyleHsp" style=""></span>mmHg (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) using pressure-support 10<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O, PEEP 8<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O, tidal volume 520<span class="elsevierStyleHsp" style=""></span>ml. Due to persistent major leaks and a poor adherence, NIV was stopped and replaced by HFNC with a flow of 50<span class="elsevierStyleHsp" style=""></span>L/min and FiO<span class="elsevierStyleInf">2</span> of 45% through an ICU ventilator (Dräger Evita XL, Lübeck, Germany) and a heated humidifier (Fisher & Paykel, Auckland, New Zealand). <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarizes the patient's evolution over time. The first blood gas 1<span class="elsevierStyleHsp" style=""></span>h after initiation of HFNC showed a significant decrease in PaCO<span class="elsevierStyleInf">2</span>. Respiratory acidosis and altered consciousness were normalized 24<span class="elsevierStyleHsp" style=""></span>h after the use of HFNC. Oxygen was switched from HFNC to standard nasal prong 3 days after ICU admission. He was transferred to the ward the same day and discharged to home on oxygen therapy 11 days after hospital admission.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">There is strong evidence that the use of noninvasive ventilation (NIV) as first-line therapy is beneficial in patients with severe exacerbation of COPD in as much as it reduces endotracheal intubation and mortality.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Air leaks are frequent during NIV and may impair its efficiency, by reducing patient tolerance and by promoting numerous patient–ventilator asynchronies.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> In the present case report, several interfaces and types of ventilators were tested due to patient's anatomic characteristics and poor tolerance.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> None of these options allowed acceptance of the patient, resulting in progression of hypercapnia and reduced level of consciousness, both being 2 strong factors of NIV failure,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> which led us to use an alternative method in order to avoid endotracheal intubation. Therefore, we decided to switch for the use of HFNC whereas his PaCO<span class="elsevierStyleInf">2</span> reached 91<span class="elsevierStyleHsp" style=""></span>mmHg.</p><p id="par0020" class="elsevierStylePara elsevierViewall">To date, only one case report has proposed HFNC as an alternative method in a patient who did not tolerate any NIV, reporting better tolerance and good results with the use of the cannula (i.e. a decrease in PaCO<span class="elsevierStyleInf">2</span> and a progressive correction of acidosis).<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Unlike our, the authors delivered high-flow through a dedicated device (Optiflow<span class="elsevierStyleSup">®</span>, Fisher&Paykel, New Zealand) with flow of 60<span class="elsevierStyleHsp" style=""></span>L/m and a FiO<span class="elsevierStyleInf">2</span> of 60% in a patient with relatively low PaCO<span class="elsevierStyleInf">2</span> levels that rose overtime.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> By contrast, we delivered high-flow through an ICU ventilator (Dräger Evita XL, Lübeck, Germany) in a patient with hypercapnia exceeding 90<span class="elsevierStyleHsp" style=""></span>mmHg at time of HFNC initiation.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Although HFNC does not offer pressure support, the high flow generates PEEP and provides continuous washout of dead space in the airways. These 2 mechanisms were probably the most effective to improve alveolar ventilation in our patient. Parke et al. measured nasopharyngeal pressure in patients at different levels of flow using HFNC and found a PEEP level ranging from 2 to 4<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O with a gas flow rate of 50<span class="elsevierStyleHsp" style=""></span>L/min.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Although the PEEP level seems only moderate, this PEEP effect could help to improve gas exchange and to decrease work of breathing in patients, as with CPAP in patients with intrinsic PEEP.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> The high-flow rate of gas continuously delivered in the airways may also generate a washout of dead space from the pharynx into the bronchi, flushing carbon dioxide (CO<span class="elsevierStyleInf">2</span>) out of the upper airways.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> This phenomenon may help to improve alveolar ventilation and to reduce work of breathing.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> As compared to NIV, severe studies have found that the patients had less discomfort and less breathlessness with HFNC.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Although these studies assessed comfort in hypoxemic patients we believe that these findings may be extrapolated to hypercapnic patients.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The use of HFNC under strict clinical monitoring in an acute care facility could be an alternative treatment option instead of endotracheal intubation after NIV failure in COPD patients with acute hypercapnia.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0035" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Ventilatory support \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Hospital admission \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">ICU (1<span class="elsevierStyleHsp" style=""></span>h) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">ICU (2<span class="elsevierStyleHsp" style=""></span>h) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">ICU (12<span class="elsevierStyleHsp" style=""></span>h) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">ICU (24<span class="elsevierStyleHsp" style=""></span>h) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">ICU (48<span class="elsevierStyleHsp" style=""></span>h) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">ICU (60<span class="elsevierStyleHsp" style=""></span>h) \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Spontaneous \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">NIV face mask \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">HFNC \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">HFNC \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">HFNC \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">HFNC \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Nasal prong O<span class="elsevierStyleInf">2</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">FiO<span class="elsevierStyleInf">2</span> (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3<span class="elsevierStyleHsp" style=""></span>L/m \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">pH \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.32 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.37 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.44 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.41 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleBold">PaCO</span><span class="elsevierStyleInf"><span class="elsevierStyleBold">2</span></span><span class="elsevierStyleBold">(mmHg)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleBold">89</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleBold">91</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleBold">83</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleBold">78</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleBold">66</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleBold">61</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><span class="elsevierStyleBold">63</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PaO<span class="elsevierStyleInf">2</span> (mmHg) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">73 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">63 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">64 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">83 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">HCO<span class="elsevierStyleInf">3</span> (mEq/L) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">40.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">42.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">44.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">42 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">40.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">39.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">EB (mEq/L) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SaO<span class="elsevierStyleInf">2</span> (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">91 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">96 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Respiratory rate (breaths/min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28–30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Accessory muscles \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kelly–Matthay score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1601468.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Summary of the main clinical changes, arterial blood gases and ventilator support for a hypercapnic patient using high flow nasal cannula.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.P. Frat" 1 => "A.W. Thille" 2 => "A. Mercat" 3 => "C. Girault" 4 => "S. Ragot" 5 => "S. Perbet" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa1503326" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2015" "volumen" => "372" "paginaInicial" => "2185" "paginaFinal" => "2196" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25981908" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0060" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The effects of flow on airway pressure during nasal high-flow oxygen therapy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R.L. Parke" 1 => "M.L. Eccleston" 2 => "S.P. McGuinness" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4187/respcare.01106" "Revista" => array:6 [ "tituloSerie" => "Respir Care" "fecha" => "2011" "volumen" => "56" "paginaInicial" => "1151" "paginaFinal" => "1155" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21496369" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0065" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nasal high flow clears anatomical dead space in upper airway models" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "W. Möller" 1 => "G. Celik" 2 => "S. Feng" 3 => "P. Bartenstein" 4 => "G. Meyer" 5 => "E. Oliver" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1152/japplphysiol.00934.2014" "Revista" => array:7 [ "tituloSerie" => "J Appl Physiol" "fecha" => "2015" "volumen" => "118" "paginaInicial" => "1525" "paginaFinal" => "1532" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25882385" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0140673613623776" "estado" => "S300" "issn" => "01406736" ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0070" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The role of high flow oxygen therapy in acute respiratory failure" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.R. Masclans" 1 => "P. Pérez-Terán" 2 => "O. Roca" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.medin.2015.05.009" "Revista" => array:6 [ "tituloSerie" => "Med Intensiva" "fecha" => "2015" "volumen" => "39" "paginaInicial" => "505" "paginaFinal" => "515" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26429697" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0075" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Which patients with acute exacerbation of chronic obstructive pulmonary disease benefit from noninvasive positive-pressure ventilation. A systematic review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S.P. Keenan" 1 => "T. Sinuff" 2 => "D.J. Cook" 3 => "N.S. Hill" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Intern Med" "fecha" => "2003" "volumen" => "138" "paginaInicial" => "861" "paginaFinal" => "870" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12779296" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0080" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Patient–ventilator asynchrony during non-invasive ventilation for acute respiratory failure: a multicenter study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L. Vignaux" 1 => "F. Vargas" 2 => "J. Roeseler" 3 => "D. Tassaux" 4 => "A.W. Thille" 5 => "M.P. Kossowsky" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00134-009-1416-5" "Revista" => array:6 [ "tituloSerie" => "Intensive Care Med" "fecha" => "2009" "volumen" => "35" "paginaInicial" => "840" "paginaFinal" => "846" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19183949" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0085" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Patient–ventilator asynchrony during noninvasive ventilation: a bench and clinical study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G. Carteaux" 1 => "A. Lyazidi" 2 => "A. Cordoba-Izquierdo" 3 => "L. Vignaux" 4 => "P. Jolliet" 5 => "A.W. Thille" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.11-2279" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2012" "volumen" => "142" "paginaInicial" => "367" "paginaFinal" => "376" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22406958" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0090" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A chart of failure risk for noninvasive ventilation in patients with COPD exacerbation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Confalonieri" 1 => "G. Garuti" 2 => "M.S. Cattaruzza" 3 => "J.F. Osborn" 4 => "M. Antonelli" 5 => "G. Conti" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/09031936.05.00085304" "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2005" "volumen" => "25" "paginaInicial" => "348" "paginaFinal" => "355" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15684302" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0095" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "1914.e1-2" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "High-flow nasal cannula oxygen supply as treatment in hypercapnic respiratory failure: a case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "V. Lepere" 1 => "J. Messika" 2 => "B. La Combe" 3 => "J.D. Ricard" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Am J Emerg Med" "fecha" => "2016" "volumen" => "34" "itemHostRev" => array:3 [ "pii" => "S0140673614604098" "estado" => "S300" "issn" => "01406736" ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0100" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Continuous positive airway pressure reduces work of breathing and dyspnea during weaning from mechanical ventilation in severe chronic obstructive pulmonary disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "B.J. Petrof" 1 => "M. Legare" 2 => "P. Goldberg" 3 => "J. Milic-Emili" 4 => "S.B. Gottfried" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/ajrccm/141.2.281" "Revista" => array:6 [ "tituloSerie" => "Am Rev Respir. Dis." "fecha" => "1990" "volumen" => "141" "paginaInicial" => "281" "paginaFinal" => "289" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2405757" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/02105691/0000004100000009/v1_201711250711/S0210569116302637/v1_201711250711/en/main.assets" "Apartado" => array:4 [ "identificador" => "19505" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Cartas Científicas" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/02105691/0000004100000009/v1_201711250711/S0210569116302637/v1_201711250711/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569116302637?idApp=WMIE" ]
| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 6 | 7 | 13 |
| 2024 Octubre | 105 | 55 | 160 |
| 2024 Septiembre | 113 | 39 | 152 |
| 2024 Agosto | 127 | 71 | 198 |
| 2024 Julio | 121 | 52 | 173 |
| 2024 Junio | 117 | 63 | 180 |
| 2024 Mayo | 74 | 56 | 130 |
| 2024 Abril | 75 | 52 | 127 |
| 2024 Marzo | 72 | 25 | 97 |
| 2024 Febrero | 49 | 34 | 83 |
| 2024 Enero | 39 | 35 | 74 |
| 2023 Diciembre | 51 | 36 | 87 |
| 2023 Noviembre | 42 | 52 | 94 |
| 2023 Octubre | 48 | 57 | 105 |
| 2023 Septiembre | 38 | 50 | 88 |
| 2023 Agosto | 39 | 10 | 49 |
| 2023 Julio | 71 | 31 | 102 |
| 2023 Junio | 66 | 18 | 84 |
| 2023 Mayo | 48 | 34 | 82 |
| 2023 Abril | 38 | 26 | 64 |
| 2023 Marzo | 63 | 55 | 118 |
| 2023 Febrero | 64 | 38 | 102 |
| 2023 Enero | 27 | 19 | 46 |
| 2022 Diciembre | 70 | 50 | 120 |
| 2022 Noviembre | 57 | 42 | 99 |
| 2022 Octubre | 69 | 54 | 123 |
| 2022 Septiembre | 87 | 48 | 135 |
| 2022 Agosto | 70 | 66 | 136 |
| 2022 Julio | 64 | 50 | 114 |
| 2022 Junio | 84 | 32 | 116 |
| 2022 Mayo | 63 | 48 | 111 |
| 2022 Abril | 54 | 55 | 109 |
| 2022 Marzo | 67 | 71 | 138 |
| 2022 Febrero | 47 | 57 | 104 |
| 2022 Enero | 58 | 64 | 122 |
| 2021 Diciembre | 89 | 62 | 151 |
| 2021 Noviembre | 66 | 64 | 130 |
| 2021 Octubre | 82 | 80 | 162 |
| 2021 Septiembre | 44 | 44 | 88 |
| 2021 Agosto | 54 | 65 | 119 |
| 2021 Julio | 44 | 39 | 83 |
| 2021 Junio | 51 | 52 | 103 |
| 2021 Mayo | 117 | 87 | 204 |
| 2021 Abril | 156 | 105 | 261 |
| 2021 Marzo | 158 | 77 | 235 |
| 2021 Febrero | 144 | 55 | 199 |
| 2021 Enero | 98 | 48 | 146 |
| 2020 Diciembre | 82 | 44 | 126 |
| 2020 Noviembre | 77 | 39 | 116 |
| 2020 Octubre | 78 | 47 | 125 |
| 2020 Septiembre | 52 | 47 | 99 |
| 2020 Agosto | 34 | 27 | 61 |
| 2020 Julio | 42 | 36 | 78 |
| 2020 Junio | 58 | 30 | 88 |
| 2020 Mayo | 38 | 29 | 67 |
| 2020 Abril | 38 | 27 | 65 |
| 2020 Marzo | 44 | 28 | 72 |
| 2020 Febrero | 168 | 44 | 212 |
| 2020 Enero | 53 | 53 | 106 |
| 2019 Diciembre | 120 | 38 | 158 |
| 2019 Noviembre | 139 | 35 | 174 |
| 2019 Octubre | 166 | 33 | 199 |
| 2019 Septiembre | 68 | 47 | 115 |
| 2019 Agosto | 60 | 39 | 99 |
| 2019 Julio | 59 | 33 | 92 |
| 2019 Junio | 49 | 28 | 77 |
| 2019 Mayo | 91 | 58 | 149 |
| 2019 Abril | 47 | 26 | 73 |
| 2019 Marzo | 72 | 45 | 117 |
| 2019 Febrero | 66 | 46 | 112 |
| 2019 Enero | 69 | 60 | 129 |
| 2018 Diciembre | 159 | 78 | 237 |
| 2018 Noviembre | 202 | 165 | 367 |
| 2018 Octubre | 120 | 56 | 176 |
| 2018 Septiembre | 62 | 20 | 82 |
| 2018 Agosto | 53 | 32 | 85 |
| 2018 Julio | 42 | 23 | 65 |
| 2018 Junio | 60 | 31 | 91 |
| 2018 Mayo | 29 | 16 | 45 |
| 2018 Abril | 56 | 22 | 78 |
| 2018 Marzo | 19 | 11 | 30 |
| 2018 Febrero | 11 | 14 | 25 |
| 2018 Enero | 7 | 11 | 18 |
| 2017 Diciembre | 15 | 25 | 40 |
| 2017 Noviembre | 5 | 8 | 13 |
| 2017 Julio | 0 | 1 | 1 |
| 2017 Mayo | 0 | 1 | 1 |
| 2017 Marzo | 0 | 1 | 1 |
| 2017 Febrero | 0 | 2 | 2 |
| 2017 Enero | 0 | 2 | 2 |
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