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Terapi Oksigen Nasal aliran-cepat pada perawatan intensif

dan anaesthesia
T. Renda1,*, A. Corrado2, G. Iskandar3, G. Pelaia4, K. Abdalla5 and P. Navalesi5

Oxygen therapy is first-line treatment for hypoxaemic acute respiratory failure (ARF).
High-flow nasal oxygen therapy (HFNO) represents an alternative to conventional
oxygen therapy. HFNO provides humidified, titrated oxygen therapy matching or even
exceeding the patients’ inspiratory demand. The application of HFNO is becoming
widespread in Intensive Care Units (ICUs), favoured by increasing evidence based on
numerous studies supporting its efficacy. The mechanisms of action and physiological
effects of HFNO are not yet fully understood. Pharyngeal dead space washout, decrease
in airway resistance, generation of a positive end-expiratory pressure, and enhanced
delivery of oxygen are all alleged to be potential mechanisms. The emerging evidence
suggests that HFNO is effective in improving oxygenation in most patients with
hypoxaemic ARF of different aetiologies. Notwithstanding the potential benefit of
HFNO in the management of hypoxaemia, further large cohort studies are necessary to
clarify the indications, contraindications and factors associated with HFNO failure.
HFNO may also be valuable in reducing the need for tracheal intubation in the
management of post-extubation ARF. In addition, HFNO has been proposed to limit
oxygen desaturation by prolonging apnoeic oxygenation during intubation both in ICUs
and operating theatres.

Kata kunci: oxygen inhalation therapies; perioperative care; respiratory insufficiency

Oxygen therapy is first-line treatment in over recent decades, such as low-flow

the management of hypoxaemic acute systems (nasal cannula, simple
respiratory failure (ARF). Different facemask, non-rebreathing reservoir
oxygen devices have become available
mask) and high-flow systems (Venturi A device utilizing the Venturi
mask). effect based on the Bernoulli principle,
The choice of a specific device in the so-called Venturi mask, in part
the management of ARF is based on the overcomes these limitations. Compared
severity of the hypoxaemia, the with low-flow systems, this device
underlying mechanisms, and the delivers higher flow rates (30-50 total
patient’s breathing pattern and litres min-1 of air and oxygen) with
tolerance.1 In hypoxaemic patients with FIO2 ranging from 24% to 60%.
respiratory distress, who tend to breathe Nonetheless, with this device, the FIO2
with an open mouth, oxygen therapy is is limited to a nominal 60%: the
usually delivered via a facemask humidification of the inhaled gas
covering both the nose and mouth, rather remains problematic because of the
than through a nasal cannula. Critically insufficient humidification of oxygen by
ill patients often require high-flow standard bubble humidifiers. This leads
devices to meet their oxygen needs.2 In to dryness of the airway mucosa and
fact, in tachypnoeic patients with ARF, discomfort.5,6
the peak inspiratory flow rate is usually High-flow nasal oxygen therapy
high and often exceeds the oxygen flow (HFNO) is an innovative high-
delivered by the traditional oxygen flowsystem that allows for delivering up
devices.3,4 A high respiratory rate can to 60 litres min-1 of heated and fully
generate significant entrainment of room humidified gas with a FIO2 ranging
air in the mask and dilution of the between 21% and 100%. Recent trials
inspired oxygen with an insufficient conducted in Intensive Care Unit (ICU)
oxygen concentration. The suboptimal settings indicate that compared with
humidification of the inhaled oxygen conventional oxygen therapy, HFNO
provided by standard bubble achieves better oxygenation,6e9 as well
humidifiers5 and the limited and as improving patient comfort.6,7,10,11
unknown inspiratory oxygen fraction Nevertheless, indications and
(FIo2) delivery are additional drawbacks contraindications for HFNO use in
of these devices. critically ill patients
have not yet been fully established and administering of FIO2 up to 100%. The
there are currently few indications. physiological effects and action
In this narrative review, we aim mechanisms of HFNO6,10,12e21 are
to: (1) describe the potential applications illustrated in Table 1.
of HFNO in different settings, and (2) The administration of HFNO
provide practical indications and requires the following: high pressure
recommendations for facilitating HFNO sources of oxygen and air, an air-oxygen
use. We performed a broad search in blender or a high-flow ’Venturi’ system
PubMed National Library and Embase (which permits delivery of an accurate
using the keywords ’high flow nasal’ or FIO2 between 21% and 100%), a
’high flow oxygen’, limiting our search humidifying and heating system for
to adult patients and journals published conditioning the gas to optimal
in English, without any limits to the type temperature (37 0C) and humidity (44mg
of publication. We retrieved 155 studies, H2O litres-1), a sterile water reservoir, a
and selected those we considered most non-condensing circuitry, and an
appropriate and relevant for our interface.
purposes. Overall, the authors of this The two most widely marketed
review article are familiar with all the HFNO systems are the Precision Flow
applications of HFNO described and, by Vapotherm and Optiflow by Fisher &
therefore, their comments are based both Pykel Healthcare Ltd. (as shown in Fig.
on interpretation of the available 1A and B, respectively). Vapotherm
evidence and personal experience. Precision Flow incorporates the air-
oxygen blender and oxygen analyser in
Sistem Pemberian Oksigen Nasal the humidifier. The flow rate reaches 40
Aliran Tinggi: Karakteristik Teknis litres min-1. This device contains a
Utama cartridge system using membrane
HFNO allows for delivering up to 60 technology for water vapour transfer. As
litres min-1 of gas at 370 C and with an a result, water vapour diffuses into the
absolute humidity of 44 mg H2O litres- inspiratory stream while heating the gas
. In contrast with all the other systems to the preset temperature (generally
for oxygen therapy, HFNO enables the 370C). Moreover, the system utilizes
triple lumen ’jacketed’ tubing and a Several studies in adult patients
dedicated nasal cannula to maintain the demonstrate beneficial effects in terms
temperature while minimizing of reduction of respiratory rate and
condensation.13 Fisher & Pykel dyspnoea, greater comfort and improved
Optiflow consists of a heated humidifier oxygenation [expressed as either partial
with a hotplate and a disposable water pressure of oxygen in arterial blood
chamber analogous to those used for (PaO2) or arterial peripheral oxygen
mechanical ventilation. It also includes a saturation (SaO2), and reduction of
heated inspiratory circuit that avoids accessory muscles recruitment].7,8,11
heat loss and condensation, a high flow HFNO is generally well tolerated. The
airoxygen proportional valve, an oxygen rarely reported discomfort was caused
analyser and a nasal cannula that come by rather mild side-effects, such as nasal
in different sizes.22 The flow rate mucosa lesions,7
delivered by the system achieves 60 feeling hot,7,28-30 noise31 and
litres min-1.22,23 High flow by Optiflow dislocation of the cannula.6
can also be delivered by mixing oxygen Contraindications to HFNO in adults
and compressed air through two have not been reported. Severe nasal
independent wall outlets connected by a obstruction, copious nose bleeding,
Ytube or through a mechanical recent nasal trauma or surgery represent
ventilator.24 Devices for environments potential contraindications for the
at a lower healthcare level have also application of HFNO. The strengths and
been developed. Flowrest (Vapotherm) drawbacks of HFNO are reported in
and the AIRVO 2 (Fisher & Pykel) Table 2. Worth noting, compared with
deliver high-flow gas mixing oxygen non-invasive ventilation (NIV), HFNO
and room air by means of a turbine.24,25 is much easier to implement, requiring
minor technical skills, training and
Bukti Terkini dan Aplikasi Klinis nursing workload. Some practical
information to facilitate implementation
HFNO has been increasingly used to and use of HFNO is provided in Table 3.
treat hypoxaemia in spontaneously
breathing, critically ill patients.26,27
Gagal Napas Akut Hipoksemia (de single-centre study by the same authors,
novo) which included 38 ICU patients with
hypoxaemic ARF, HFNO improved
Several studies have shown that HFNO oxygenation, while also reducing
is superior to conventional forms of respiratory rate, dyspnoea,
oxygen administration in improving supraclavicular retraction and thoraco-
arterial oxygenation and patient abdominal asynchrony.8 They also
comfort, while reducing respiratory rate, found
dyspnoea and clinical signs of that lack of improvement in
respiratory distress. oxygenation, persistence of tachypnoea
Roca and colleagues7 first and thoraco-abdominal asynchrony 30
described a significant improvement in min after HFNO initiation were early
oxygenation in 20 ICU adult patients indicators of HFNO failure.8 Rello and
with hypoxaemic ARF, as assessed by colleagues32 evaluated HFNO in a
both SaO2 and PaO2 , respiratory rate, cohort of 35 ICU patients with severe
dyspnoea and comfort, in a study acute respiratory infection as a result of
comparing 30 one-minute trials of A/ H1N1 influenza. Standard oxygen
HFNO and conventional oxygen therapy therapy failed in 30 patients; 10 of them
via facemask at an estimated FIO2 required immediate intubation, while 20
>50%. received HFNO, which was successful
Sztrymf and colleagues11 used in nine patients (45%).
HFNO as rescue therapy in a prospective Two studies compared HFNO
observational study in ARF patients with with both standard oxygen therapy and
persistent hypoxaemia after one hour of NIV.33,34 Schwabbauer and
conventional oxygen therapy and colleagues33 investigated the short-term
without indications for immediate effects of HFNO (flow 55 litres min-1
tracheal intubation. and FIO2 60%), as compared with
HFNO was applied for a median time of oxygen administration via Venturi mask
26.5 (17-121) h, and was generally well (flow 15 litres min-1 and FIO260%) and
tolerated, thus avoiding intubation in NIV [FIO2 60%, positive end-
70% of patients.11 In a pilot prospective expiratory pressure (PEEP) 5 cm H2O,
tidal volume 6-8 ml kg-1 of ideal body endpoint) was lower among patients
weight] in 14 patients with mild- treated with HFNO than among those
tomoderate hypoxaemic ARF. PaO2 receiving conventional oxygen or NIV
was significantly higher with NIV, as (38% vs 47% and 50%, respectively),
opposed to both standard oxygen but these differences did not achieve
therapy (P<0.001) and HFNO (P<0.01), statistical significance (P= 0.18). In a
and with HFNO compared with standard post hoc analysis including 238 patients
oxygen therapy (P<0.01), while who on enrolment had severe
dyspnoea was lower with HFNO, as hypoxaemia, as defined by PaO2 =FIO2
opposed to NIV (P<0.05).33 ratio < 26.7 kPa, intubation turned out to
Frat and colleagues34 conducted be less likely to occur in the HFNO
a prospective, randomized, controlled group than in the two other groups
multicentre open-label trial including (P=0.009). HFNO significantly
310 patients admitted to 23 French ICUs improved two secondary outcomes, the
for hypoxaemic ARF (PaO2 =FIO2 ratio ventilator-free days at day 28 and 90 day
< 40kPa), predominantly because of mortality, compared with both standard
pneumonia. oxygen (P¼0.046) and NIV
Patients were randomized to receive (P¼0.006).34 The reason why HFNO
either standard oxygen through a reduced 90 day mortality is not entirely
facemask, HFNO or NIV.34 The clear.
strengths of this study rely on the well- As tidal volumes on average
matched baseline characteristics of the exceeded 9ml kg-1 of predicted body
three groups, the randomization within weight, the authors hypothesize an
three hours after the patient’s eligibility, increased risk of ventilator-induced lung
the well-defined pre-established criteria injury with NIV.35,36
for intubation, the exclusion of patients The use of HFNO has been reported in
with associated hypercapnia or a history 45 patients with Acute Respiratory
of chronic respiratory failure, as well as Distress Syndrome (ARDS) classified as
those with acute cardiogenic pulmonary severe (33% of patients), moderate
oedema or severe neutropenia.34 The (38%) and mild (29%),37 according to
rate of tracheal intubation (primary the Berlin Definition.38 Median values
of the Simplified Acute Physiology NIV may play a role in the treatment of
Score II, PaO2 =FIO2 ratio and mild ARDS, providing an algorithm for
respiratory rate were 36 (24-44), 12.26 the practical use of both techniques in
(11.8-27.79) kPa and 34 (30-40) breaths these patients. They also highlighted that
min-1, respectively. The main cause of patients should be monitored very
ARF determining ICU admission was closely in ICU settings with special
pneumonia (82%) and 44% of patients attention paid during the first two hours,
had at least one additional organ failure. and suggested that intubation be
Forty per cent of patients required promptly applied whenever further
intubation.37 deterioration occurs or an additional
A prospective observational organ fails.40
study evaluated the sequential use of Inappropriate use of HFNO may
HFNO and NIV, applied for 16 and 8 h lead to delayed intubation with adverse
day-1, respectively, in 28 hypoxaemic outcomes. In a retrospective
patients, 23 (82%) of whom with observational study on critically ill adult
ARDS.39 The sequential treatment patients, Kang and colleagues41 report a
significantly increased PaO2 and series of HFNO failures leading to
decreased respiratory rate, compared intubation. Based on the time lag
with previously administered standard between commencement of HFNO and
oxygen therapy. HFNO was better intubation, HFNO failures were
tolerated than NIV. Ten patients (36%), considered early or late (i.e. before and
including eight individuals with ARDS, after 48 h, respectively). The most
required intubation. In the patients who common aetiologies were de nouo ARF
were not intubated, HFNO and NIV (33.1%) and acute on chronic respiratory
were delivered for a median time of 75 failure (35.6%) in the early and late
(27-127) and 23 (8-31) h, respectively. HFNO failure groups, respectively.
The authors concluded that using HFNO Intubation following early failure was
between NIV sessions avoids associated with lower ICU mortality,
deterioration of oxygenation.39 improved weaning and extubation
Demoule and colleagues40 outcomes, with more ventilator-free
recently suggested that both HFNO and days, indicating that delaying intubation
leads to adverse hospital outcomes. The positive pressure produced by HFNO at
authors attributed this to an increased end-expiration determines effective lung
risk of respiratory muscle failure and recruitment. Escalating to either non-
cardiac dysfunction because of invasive continuous positive airway
prolonged ineffective ventilation.41 pressure (CPAP) alone, in order to
They reported that early indicators of improve functional residual capacity, or
HFNO failure could be lack of associated with inspiratory pressure
improvement in oxygenation and support, also reducing the breathing
persistence of tachypnoea, as defined by effort, may be helpful in patients whose
a respiratory rate higher than 30 breaths hypoxaemia is strongly dependent on
min-1 and thoraco-abdominal alveolar collapse.
asynchrony 30 min after HFNO
initiation.8,39 Other factors associated Gagal Napas Post Ekstubasi
with failure are shock requiring
administration of vasopressors, a Sepsis- Immediate post-extubation is a crucial
related Organ Failure Assessment moment in the transition from
(SOFA) score of 4 or more, an Acute mechanical ventilation to spontaneous
Physiology and Chronic Health breathing. By guaranteeing adequate
Evaluation II (APACHE II) >12 on oxygenation, facilitating expectoration
admission and a PaO2=FIO2 ratio <13.3 and reducing the breathing effort, HFNO
kPa after 6 h of treatment.32,37 has the potential to prevent post-
Overall, the data provided by the extubation respiratory failure and
available studies indicate that HFNO thereby avoid re-intubation.
plays a significant role in the treatment Tiruvoipati and colleagues42
of hypoxaemic (de novo) ARF, offering compared HFNO and highflow oxygen
the chance to improve oxygenation in via facemask in 50 patients randomized
patients who do not respond to forms of to receive either high-flow oxygen via
conventional oxygen therapy, primarily facemask followed by HFNO or HFNO
by reducing room-air entrainment and and then high-flow oxygen via
washing out the anatomical dead space. facemask, 30 min after extubation. The
It is unlikely, however, that the small gas flow rate (30 litres min-1) and FIO2
(of 30-40%) were maintained through a non-re-breathing facemask.
throughout the entire study period and HFNO resulted in a higher PaO2 /FIO2
during the stabilization period. ratio, more ventilator-free days and
Oxygenation was no different in either fewer patients requiring re-intubation.
of the devices, while HFNO resulted in Mortality and length of ICU stay were
being better tolerated (P=0.01).42 no different between the two groups.43
In a randomized cross-over study A randomized open-label bi-
conducted in a respiratory ICU, 70 centre trial compared HFNO with
extubated patients were randomly standard oxygen via Venturi mask after
allocated to either HFNO for 30 min extubation in 105 adults with a
followed by standard oxygen therapy via PaO2/FIO2 ratio <40 kPa at the end of
a non-re-breathing facemask for a the spontaneous breathing trial.6 For the
further 30 min or by standard oxygen same FIO2 after extubation, patients
therapy followed by HFNO, both for 30 treated with HFNO showed better
min.30 The gas flowrates averaged 36.8 oxygenation than those treated with
litres min-1 in the HFNO group and 8.0 standard oxygen and this effect lasted up
litres min-1 in the group receiving to 48 h. Moreover, the patients receiving
standard oxygen. HFNO significantly HFNO, compared with those treated
improved dyspnoea (P=0.04), with a Venturi mask, showed a reduction
respiratory rate (P=0.009) and heart rate in respiratory rate and PaCO , which
(P=0.006), compared with standard achieved statistical significance three
oxygen therapy. Most subjects (88.2%) hours after extubation; in addition, they
preferred HFNO to conventional oxygen experienced less discomfort because of
therapy.30 the interface. Fewer patients required
Brotfain and colleagues43 NIV (P=0.04) or re-intubation (P<0.01)
retrospectively analysed 67 in the HFNO group, suggesting a
mechanically ventilated patients over a potential role of HFNO in preventing
one year period, comparing a group of extubation failure.6
34 patients who underwent HFNO after Recently, Hernandez and
extubation with a group of 33 patients colleagues44 conducted a multicentre
receiving standard oxygen therapy randomized clinical trial in seven
Spanish ICUs aimed at determining The same authors found that
whether HFNO is superior to standard HFNO is not inferior to NIV in
oxygen therapy, delivered either through preventing post-extubation respiratory
a nasal cannula or a nonrebreathing failure (26.9 vs 39.8%, risk difference
facemask, for preventing re-intubation 12.9%; 95% CI, 6.6% to ∞) and re-
in mechanically ventilated patients at intubation (22.8 vs 19.1%, risk
low risk of extubation failure. Five difference -3.7%; 95% CI, -9.1% to ∞)
hundred and twenty-seven patients were in a later randomized controlled trial
randomized to receive either HFNO including 604 patients at a high risk of
(n=264) or conventional oxygen therapy extubation failure, defined as age >65 yr,
(n=263) for 24 h after planned APACHE II score >12 at extubation,
extubation. Low risk for reintubation BMI >30 kgm-2, difficult management
was defined as age <65 yr, APACHE II of secretions, difficult or prolonged
score <12 at extubation, BMI <30kg weaning, more than one comorbidity,
me2, adequate secretion management, heart failure as a primary indication for
simple weaning, a maximum of one mechanical ventilation, moderate-to-
single comorbidity, and absence of heart severe COPD, airway patency problems
failure, chronic obstructive pulmonary or prolonged mechanical ventilation.45
disease (COPD), airway patency Considering the demonstrated
problems and previous prolonged advantages over standard oxygen
mechanical ventilation. The occurrence therapy (i.e. improved oxygenation,
of post-extubation respiratory failure better comfort and a reduced risk of
within 72 h was lower in the HFNO dislocation), and the potential for
group (8.3%) than in the controls facilitating expectoration and reducing
(14.4%) (P=0.03). The re-intubation rate the work of breathing, HFNO should
was also significantly reduced by HFNO now be considered as standard treatment
(4.9%), compared with the controls after extubation of all ICU patients,
(12.2%) (P=0.004), while the time though some, especially those who are
before re-intubation was similar in both hypercapnic at extubation46 might
groups.44 benefit from NIV for preventing post-
extubation respiratory failure.47
and reducing the need for re-intubation
Acute cardiogenic pulmonary edema after major surgery.50,51 Nonetheless,
By improving oxygenation while these forms of ventilatory assistance
reducing cardiac afterload through the could be limited by logistic problems in
generation of a low intrathoracic the recovery room of the operating
positive pressure, HFNO might also be theatre and by patient intolerance.
beneficial in acute cardiogenic Moreover, the occurrence of gastric
pulmonary oedema. Carratala Perales distension may further
and colleagues28 report the cases of five decreasefunctional residual lung
patients with acute cardiogenic capacity orbecontraindicated because of
pulmonary oedema and refractory the site of surgery. Indeed, when these
hypoxaemia despite NIV who were drawbacks limit the use of CPAP and
successfully treated with HFNO, NIV, HFNO might in principle offer
showing significant improvement after potential therapeutic advantages
24 h of treatment. In the absence of any compared with standard oxygen
studies comparing HFNO with treatment.14,15,17,18,52 Unfortunately,
noninvasive CPAP, the latter remains however, the evidence available does
the treatment of choice for hypoxaemic not confirm this assumption.
patients with acute cardiogenic Parke and colleagues29
pulmonary oedema. compared the prophylactic use of HFNO
us standard oxygen in 340 patients after
Hypoxemia pasca bedah elective cardiac surgery and found that
Postoperative hypoxaemia and the former was not associated with
respiratory complications increase improved postoperative oxygenation,
morbidity, mortality, ICU and length of compared with standard oxygen therapy.
hospitalization. 48,49 Standard oxygen Nonetheless, HFNO significantly
therapy may not be effective in lowered PaCO2 four and 24 h after
correcting hypoxaemia. Conversely, extubation and reduced the requirement
non-invasive CPAP and NIV have for escalation to other forms of
proved to be effective in maintaining respiratory support. 29 Corley and
lung volume, improving oxygenation colleagues53 found that prophylactic
HFNO after extubation in obese patients breakdown was significantly more
who underwent cardiac surgery, neither frequent with BiPAP after 24 h.55 It
improved oxygenation, respiratory rate remains unclear, however, whether or
or dyspnoea, nor did it reduce the need not both HFNO and BiPAP are superior
for escalation of respiratory support, to standard oxygen therapy.
compared with standard oxygen therapy.
In 220 patients receiving lung-protective Pilihan tidak intubasi dan perawatan
ventilation during major abdominal paliatif
surgery, when compared with standard In some terminally ill patients with
oxygen therapy, the early preventive dyspnoea, NIV may reduce
application of HFNO after extubation breathlessness.56 Patients with a do-not-
failed to improve hypoxaemia, the intubate order may also receive NIV as
occurrence of postoperative pulmonary ceiling treatment of intervening ARF.57
complications within 7 days after If proved capable of providing similar
surgery, duration of hospital stay or in- symptom relief, HFNO could be an
hospital mortality.54 additional means for the management of
The BiPOP Study, a non- these patients. In fact, HFNO can be
inferiority trial performed in postcardiac delivered continuously for protracted
surgery patients with overt post- periods with few side-effects, which
extubation ARF or deemed at risk of might allow more effective symptom
extubation failure because of pre- palliation. In keeping with this premise,
existing risk factors, enrolled 830 Peters and colleagues9 applied HFNO
patients to randomly receive either before proceeding with NIV, if needed,
HFNO at a flow rate of 50 litres min-1 in 50 patients aged between 27 and 96
(n=414) or bilevel positive airway and admittedtoa medicalICUwithARFof
pressure (BiPAP) via full facemask for different etiologies and a do-not intubate
at least four hours a day (n=416).55 The order. Several patients suffered from
authors found HFNO not to be inferior end-stage pulmonary fibrosis,
to BiPAP (risk difference 0.9%, malignancies and COPD.9 Mean SaO2
P=0.003) in terms of ICU mortality and improved from 89.1 to 94.7% (P<0.001)
number of nurse interventions. Skin and the respiratory rate decreased from
30.6 to 24.7 breaths min-1 (P<0.001). associated with jawt hrust may extend
Only 18% of patients progressed to NIV, the safe apnoeic window, which could
while 82% were managed with HFNO possibly change the nature of difficult
alone, for a median duration of 30 h.9 intubations from a hurried to a smooth
Further studies are necessary to confirm event. THRIVE was evaluated in 25
these encouraging preliminary results. patients with known or anticipated
difficult airways undergoing general
Prosedur dalam anesthesia dan anaesthesia for hypopharyngeal or

perawatan intensif laryngotracheal surgery.59 HFNO was

administered at 70 litres min-1 for 10
Preoksigenasi dan manajemen jalan
min with head elevation to 400 before
napas pada kamar operasi
intubation, then decreased to 200 after
Pre-oxygenation techniques aim at
induction for laryngoscopy. HFNO was
improving patient safety for intubation
maintained until a definitive airway was
in the operating theatre. In patients with
established. The median apnoea time
known or anticipated difficult airways,
was 14min, and no patient experienced
awake fibre-optic intubation is
desaturation below 90%.59 More
commonly performed, which exposes
recently, a randomized controlled trial
the patient to a high
compared THRIVE with facemask pre-
risk of hypoxaemia, despite
oxygenation in 40 patients undergoing
supplemental standard oxygen
emergency surgery. Arterial blood gases
administration. In 50 patients
were not significantly different between
undergoing awake fibre-optic intubation
treatments and controls. No airway
because of anticipated difficult airways,
rescue manoeuvres were needed, and
HFNO improved oxygenation, patient
there were no differences in the number
tolerance and safety of the procedure, as
of laryngoscopy attempts between the
demonstrated by fewer episodes of
two groups. Nonetheless, in the
THRIVE group the mean (SD) apnoea
Transnasal Humidified Rapid-
time 248 (71s), was significantly longer
Insufflation Ventilatory Exchange
than in the controls 123 (55s)
(THRIVE) administered by HFNO
(P<0.001).60 As a result of the fact that
compared with standard techniques of after’ study compared standard pre-
pre-oxygenation, HFNO offers greater oxygenation with HFNO for tracheal
advantages without any side-effects in intubation.62 During an initial ’control’
patients with known or anticipated period, all patients were intubated
difficult airways, we believe that all following the standard pre-oxygenation
operating theatres should have access to procedure. In the ’change of practice’
this technique. period, HFNO at 60 litres min-1 was
applied to all patients requiring
Preoksigenasi dan barisan cepat dari intubation. HFNO significantly
intubasi pada ICU improved oxygenation and reduced the
In critically ill patients, tracheal occurrence of severe hypoxaemia
intubation can be complicated by compared with standard
adverse effects, oxygen desaturation preoxygenation.62 Nevertheless, these
being one of the most common, which positive results in favour of HFNO were
may cause cardiac arrest in spite of not subsequently confirmed in two
preintubation oxygenation.61 In current randomized trials including 119 and 150
standard practice, preoxygenation critically ill patients.63,64
before tracheal intubation is performed Currently, pre-oxygenation with
with a high FIO2 using an oxygen bag HFNO for rapid sequence intubation in
reservoir connected to a facemask. the ICU does not appear to add
Pre-oxygenation can be significant benefits compared with
improved by NIV.61 This technique standard procedures and therefore it
may however result in being difficult cannot be recommended. Worth noting,
within the context of pending intubation, however, in both of these studies,
and impossible during laryngoscopy. patients with Grade 4 glottis exposure on
HFNO has the potential to maintain the Cormack-Lehane scale,63 and those
oxygenation during laryngoscopy, in at risk of prolonged intubation time
this way guaranteeing high-flow apnoeic because of abnormal airway anatomy
oxygenation. In 101 ICU patients with and requiring video laryngoscopy,64
mild-to-moderate hypoxaemia, a were excluded. Whether or not this sub-
nonrandomized prospective ’before- group of patients could benefit from
HFNO consequently remains to be patients to receive either 40 litres min-1
clarified. via Venturi mask (V40), or HFNO at 40
Jaber and colleagues65 recently litres min-1 (N40) or 60 litres min-1
proposed the combination of HFNO for (N60). The duration of the procedure
apnoeic oxygenation with NIV prior to was similar in the three groups, likewise
intubation and this turned out to be more the FIO2 (0.50) and the amount of
effective than NIV alone in reducing the midazolam (4mg) administered. Arterial
severity of oxygen desaturation. blood gases and cardiovascular variables
were sampled before the procedure
Administrasi oksigen selama while breathing room air, at the end of
prosedur invasif procedure (T1) with FIO2 50%, and 10
min after bronchoscopy (T2). At T1,
Invasive procedures, such as fibre-optic N60 resulted in the highest PaO2, PaO2
bronchoscopy, transoe-sophageal /FIO2 ratio and SaO2 , as opposed to
echocardiography or digestive tract both N40 and V40.69
endoscopy, may precipitate or further A prospective randomized trial
deteriorate hypoxaemia. Similar to was conducted to compare HFNO with
CPAP and NIV, HFNO has the potential NIV in 40 patients undergoing fibre-
to improve safety.21,66,67 optic bronchoscopy and
Lomas and colleagues68 first bronchoalveolar lavage, with a PaO2
reported the case of a patient with /FIO2 ratio <40kPa before initiating the
myasthenia gravis and severe ARF, procedure.70 NIV resulted in better
because of muscle weakness and oxygenation than HFNO throughout the
bilateral atelectasis, who underwent study period. Heart rate, mean arterial
fibre-optic bronchoscopy with HFNO. pressure, respiratory rate and the need
The bronchoscopy was well tolerated, for intubation were similar in both
although the patient finally needed groups. Two patients in the HFNO group
tracheal intubation because of were unable to complete the procedure
respiratory muscle failure.68 as a result of a worsening of the
Lucangelo and colleagues69 hypoxaemia.70
randomized 45 mildly hypoxaemic
Penelitian masa depan HFNO also fails.17,40 Compared with
Randomized multicentre trials and large standard techniques, HFNO improves
cohort studies need to be conducted to safety in patients with known or
investigate the effectiveness of HFNO in anticipated difficult airways undergoing
specific aetiologies of acute respiratory elective intubation, and it may help in
failure, as well as the optimal flow rate avoiding or limiting hypoxaemia during
titration in different patients, and the invasive diagnostic procedures, making
proper timing for switching to it advisable for operating theatres to
conventional oxygen therapy. The role have access to this technique.
of HFNO should be better clarified with
respect to rapid sequence intubation in
critically ill patients at risk of prolonged
intubation time because of difficult Kontribusi penulis
airways.71 Finally, cost effectiveness
analyses of the different HFNO Contributed to the conception of the
applications are also deemed necessary review article, acquisition of data
for appropriate use of this technique. (literature search), drafting of the article
and critical revision, and they hereby
Kesimpulan give final approval of the version to be
Several studies indicate that HFNO is submitted and any revisions: all authors.
more effective than conventional
oxygen therapy in improving
oxygenation in patients with
hypoxaemic ARF. The patients most
likely to benefit from HFNO are those
with mild-to-moderate forms of
hypoxaemic ARF. A stepwise approach
has been proposed, which reserves
HFNO for patients in whom standard
oxygen fails and escalating to NIV prior
to invasive mechanical ventilation if