Scientific letter
The science of truth
La ciencia de la verdad
a Internal Medicine Service and Critical Patient Unit, Viña del Mar, Chile
b Respiratory Therapy UC-Christus Health Network Clinical Hospital, School of Kinesiology, Faculty of Rehabilitation, Andres Bello University, Santiago, Chile
c Central University Hospital of Asturias, Oviedo, Spain
d Hospital Universitari i Politècnic La Fe, València, Spain
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Marin-Corral, S. Pascual-Guardia, R. Muñoz-Bermúdez, A. Salazar-Degracia, C. Climent, C. Vilà-Vilardell, M. Acer, M. Picornell, M.I. Restrepo, J.R. Masclans, F. Álvarez-Lerma" "autores" => array:11 [ 0 => array:2 [ "nombre" => "J." "apellidos" => "Marin-Corral" ] 1 => array:2 [ "nombre" => "S." "apellidos" => "Pascual-Guardia" ] 2 => array:2 [ "nombre" => "R." "apellidos" => "Muñoz-Bermúdez" ] 3 => array:2 [ "nombre" => "A." "apellidos" => "Salazar-Degracia" ] 4 => array:2 [ "nombre" => "C." "apellidos" => "Climent" ] 5 => array:2 [ "nombre" => "C." "apellidos" => "Vilà-Vilardell" ] 6 => array:2 [ "nombre" => "M." "apellidos" => "Acer" ] 7 => array:2 [ "nombre" => "M." "apellidos" => "Picornell" ] 8 => array:2 [ "nombre" => "M.I." "apellidos" => "Restrepo" ] 9 => array:2 [ "nombre" => "J.R." "apellidos" => "Masclans" ] 10 => array:2 [ "nombre" => "F." "apellidos" => "Álvarez-Lerma" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569121000772?idApp=WMIE" "url" => "/02105691/0000004600000004/v1_202203261024/S0210569121000772/v1_202203261024/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Scientific letter</span>" "titulo" => "The science of truth" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:1 [ "paginaInicial" => "224" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "A. Fajardo, R. Adasme, A. Medina, V. Modesto i Alapont" "autores" => array:4 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Fajardo" "email" => array:1 [ 0 => "drauriopiotr@gmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">1</span>" "identificador" => "fn0005" ] ] ] 1 => array:3 [ "nombre" => "R." "apellidos" => "Adasme" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">1</span>" "identificador" => "fn0005" ] ] ] 2 => array:3 [ "nombre" => "A." 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"apellidos" => "Modesto i Alapont" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">1</span>" "identificador" => "fn0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Internal Medicine Service and Critical Patient Unit, Viña del Mar, Chile" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Respiratory Therapy UC-Christus Health Network Clinical Hospital, School of Kinesiology, Faculty of Rehabilitation, Andres Bello University, Santiago, Chile" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Central University Hospital of Asturias, Oviedo, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Hospital Universitari i Politècnic La Fe, València, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La ciencia de la verdad" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We have read the article “<span class="elsevierStyleItalic">High flow nasal cannula useful for severe SARS-CoV-2 pneumonia</span>”<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">1</span></a> and we believe that what the authors claim is not supported by the data and analysis they provide. The article describes the use of HFNO with an initial requirement of 100% FiO<span class="elsevierStyleInf">2</span>. These are therefore patients with severe ARDS, which clinical practice guidelines prescribes intubation, invasive mechanical ventilation (IMV) and even prone position.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">2</span></a> Maintaining non-invasive support in these patients causes more mortality than performing IMV.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">3</span></a> This simple statement has not yet been able to be experimentally refuted.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Being a retrospective study, the cause–effect relationship regarding the efficacy of a treatment (HFNO) vs. another (IMV) cannot be rigorously argued if it is not demonstrated that the two cohorts (with and without treatment) were similar before applying the respective treatments. The authors do not present a table showing the distribution of the covariates in both cohorts before the treatment was applied. And therefore, we do not know the confounding factors that should have been controlled for in the analysis.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We did find some data that makes us believe that IMV was applied to patients with a higher probability of dying. Thus, they indicate that “<span class="elsevierStyleItalic">patients were placed in HFNO if they had ventilatory failure”,</span> but that “<span class="elsevierStyleItalic">patients that had severely altered consciousness at admission, severe work of breathing (exhaustion), or shock were placed on invasive mechanical ventilation”.</span> Survival of (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>30) patients who received IMV was 42.2%. And of those (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>60) who received HFNO at some point in their evolution, 35 (58%) could be weaned from HFNO and went home, but in 25 (42%) of them the treatment failed. Of these, 24 had to be intubated and 13 finally died (21.67% mortality).</p><p id="par0020" class="elsevierStylePara elsevierViewall">The patients where HFNO failed (Tables 1 and 2) were much more severe than those where it worked. So, since the assignment of patients to treatments was not random, it is logical to deduce that the IMV had to deal with the most seriously ill. This is clearly a co-intervention bias. And despite this, we can calculate that the IMV was quite effective, in the sense of achieving the objective for which it was administered. Since IMV was applied to 30<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>24<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>54 patients, with a total of 17<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>13<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>30 deaths, it worked in more than 55.56% of the patients where it was applied. HFNO only fulfilled its function in 58% of the patients where it was used, and who were the healthiest. Using a beta-binomial Bayesian model, and a non-informative a priori distribution, the probability (rational belief) that IMV fulfills its function better than HFNO is 61.8%.</p><p id="par0025" class="elsevierStylePara elsevierViewall">So, to our knowledge, statements such as “We show evidence of the utility of HFNO in severe covid-19 patients that required ICU admission for the treatment of severe respiratory failure. We achieved a high survival and posterior discharge rate” are far from having endured a rigorous experimental rebuttal and must still remain in the degree of belief.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethics approval and consent to participate</span><p id="par0030" class="elsevierStylePara elsevierViewall">Consent for publication, availability of data and material: Not applicable.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Authors’ contribution</span><p id="par0035" class="elsevierStylePara elsevierViewall">All authors contributed equally to this manuscript.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Funding</span><p id="par0040" class="elsevierStylePara elsevierViewall">Not applicable.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflict of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare no competing interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Ethics approval and consent to participate" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Authors’ contribution" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Funding" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of interest" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:3 [ "etiqueta" => "1" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">WeVent: International Mechanical Ventilation Group.</p>" "identificador" => "fn0005" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0020" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Ángel Mejía V, Isaza D, Fernández Turizo M. High flow nasal cannula useful for severe SARSs-CoV-2 pneumonia, Med Intens. <a target="_blank" href="https://doi.org/10.1016/j.medin.2021.01.002">https://doi.org/10.1016/j.medin.2021.01.002</a>." ] ] ] 1 => array:3 [ "identificador" => "bib0025" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Potentially modifiable factors contributing to outcome from acute respiratory distress syndrome: the LUNG SAFE study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Laffey" 1 => "G. Bellani" 2 => "T. Pham" 3 => "E. Fan" 4 => "F. Madotto" 5 => "E.K. Bajwa" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00134-016-4571-5" "Revista" => array:6 [ "tituloSerie" => "Intensive Care Med" "fecha" => "2016" "volumen" => "42" "paginaInicial" => "1865" "paginaFinal" => "1876" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27757516" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0030" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Noninvasive ventilation of patients with acute respiratory distress syndrome insights from the LUNG SAFE study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G. Bellani" 1 => "J.G. Laffey" 2 => "T. Pham" 3 => "F. Madotto" 4 => "E. Fan" 5 => "L. Brochard" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/rccm.201606-1306OC" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2017" "volumen" => "195" "paginaInicial" => "67" "paginaFinal" => "77" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27753501" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/02105691/0000004600000004/v1_202203261024/S0210569121000735/v1_202203261024/en/main.assets" "Apartado" => array:4 [ "identificador" => "53" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Cartas científicas" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/02105691/0000004600000004/v1_202203261024/S0210569121000735/v1_202203261024/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569121000735?idApp=WMIE" ]
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