NIV VERSUS HFNC FOR HYPOXIC

RESPIRATORY FAILURE
Terrence Shenfield MS, RRT-ACCS, RPFT, NPS, AE-C
HFNC OR NIV-
WHICH IS
BETTER?
Describe Describe what is Hypoxic Respiratory Failure

Describe Describe
HRF
the Role of NIV in the management of

Describe Describe how to use the HACOR tool Objectives

Describe Describe the risk factors of NIV

Describe Describe the role of HFNC in HRF

 COCHRANE REVIEW FOR
NON-INVASIVE OR CPAP FOR
No articles are
BREATHING SUPPORT IN found or studies to
ADULT INTENSIVE CARE support its use
PATIENTS
 ■ Acute hypoxemic respiratory
failure usually refers to a
What is patient with an increased
breathing frequency and low
hypoxic oxygen saturation
■ PaO2/FIO2 while receiving
respiratory supplemental oxygen (eg,
breathing frequency of 25
failure breaths/min with a
PaO2/FIO2 of less than 300
mm Hg).
 NIV has long been known as an effective treatment for acute
hypercapnic respiratory failure secondary to COPD.

Review of NIV as a general approach to managing respiratory failure in

the Evidence the absence of hypercapnia has shown mixed results in
patients with hypoxemic respiratory failure.

for NIV for

Hypoxic Specific etiologies have since been studied, such as acute
cardiogenic pulmonary edema, immunosuppression,
postoperative management, community-acquired pneumonia
Respiratory (CAP), postextubation management, and acute lung injury and
ARDS, with mixed results
Failure The heterogeneity among studies precluded any
recommendation for the routine use of NIV in patients with
acute hypoxemic respiratory failure.
 American Thoracic Society/European Respiratory Society
guidelines provide no recommendation for the use of NIV
in the management of de novo hypoxemic respiratory
failure.

Clinical De novo hypoxemic respiratory failure refers to acute

Practice hypoxemic respiratory failure in the absence of underlying
chronic lung disease or cardiac failure.
Guidelines
For example
PaO2 /FIO2 < 200 mm Hg, and breathing
frequencies 30 breaths/min, and could involve many
potential causes of acute hypoxemic respiratory failure
(eg, sepsis, atelectasis, pneumonia).
 Cardiogenic pulmonary
edema, postoperative
Known patients, and trauma patients
benefits of
NIV for
hypoxic Largest study to date found no
respiratory difference in the intubation
failure rate or mortality when
comparing NIV, CPAP, or
standard oxygen therapy.
 Evidence for using NIV in the postoperative setting is
moderate for specific patients after lung resection and after
abdominal surgery.

Known Lung resection subjects had a significantly reduced need for

intubation and hospital mortality

benefits of Subjects after abdominal surgery had significantly lower

NIV for
intubation rates with NIV and lower (but not significant) 90-d
mortality.

hypoxic In trauma patients it is specific to patients with chest trauma.

respiratory Pooled analysis found lower intubation rates, lower mortality,

failure less nosocomial pneumonia, and a shorter ICU length of stay
when using NIV.
Cardiogenic pulmonary edema can benefit from either CPAP or
NIV
When Benefit Is Less
Clear
■ Risk of NIV failing in patients with acute hypoxemic
respiratory failure is well described in the literature
– Failure rates 25-87%
■ Clinicians should take a judicious approach when
choosing NIV to treat acute hypoxemic respiratory
failure
■ How do you determine that your therapy is failing?
RISK
FACTORS FOR
NIV FAILING
PaO2 / FIO2

■ Most commonly used variable for

determination of hypoxemia
■ Used in classifying ALI and ARDS
■ Most studies found through multivariate
analyses that a PaO2 /FIO2 of 150 mm Hg
at baseline and up to 1 h after NIV initiation
predicts NIV failure.
■ More recent study found a PaO2 /FIO2 of
200 mm Hg to also be predictive of failure,
particularly in acute hypoxemic respiratory
failure in subjects treated with NIV
 Severity scores available to clinicians to
assess the overall condition of the
patient
Simplified Acute Physiology Score II

Severity
Scores Sequential Organ Failure Assessment

Acute Physiology and Chronic Health

Evaluation II
Tidal Volume

■ Single limb NIV circuits tidal volume may not be accurate due to
leaks
■ Dual limb circuits are better
■ Exhaled tidal volume of 9.5 mL/kg of predicted body weight
predicted NIV failure with a sensitivity and specificity of 82% and
87%, respectively
■ Tidal volume 9 mL/kg of predicted body weight at 1 h was
associated with the need for intubation
■ This may be due to the difficulty in controlling the underlying
respiratory drive of patients in acute hypoxemic respiratory failure
Community Acquired Pneumonia

■ Pneumonia is a very big risk factor

for NIV failure
■ NIV failure if the infiltrates found on
chest radiograph worsen in the 24 h
after treatment with NIV
■ Delaying intubation in this group
increases mortality
Acute Respiratory Distress Syndrome

■ LUNG SAFE study published evidence that NIV is commonly used in patients who
meet criteria for ARDS
■ As expected, increasing ARDS severity (measured by PaO2 /FIO2 ) resulted in an
increased risk of NIV failure.
■ Patients with PaO2 /FIO2 150 mm Hg had higher ICU mortality when treated with
NIV compared with subjects treated with invasive ventilation
■ Most common NIV interface used in clinical practice to treat acute hypoxemic
respiratory failure is an oronasal mask which commonly leads to failure
■ Helmet mask have shown improved outcomes related to the ability to deliver and
maintain higher levels of PEEP, improved patient tolerance, or longer sessions of NIV
Immunosuppression

■ For patients with immunosuppression and who

present with respiratory failure, clinical guidelines
have recommended using NIV as a preference over
invasive ventilation
■ Patients with de novo respiratory failure,
immunosuppression has been associated with a
risk of NIV therapy failing
■ Perhaps HFNC may benefit this patient population
The HACOR Score

■ Validated tool used to determine probability of NIV

failure
■ Heart rate, acidosis, consciousness, oxygenation,
and respiratory rate
■ A HACOR score of 5 after 1 h of NIV treatment had a
diagnostic accuracy to predict NIV failure of 81.8%
and higher hospital mortality
 RISK OF
HIGHER
MORTALITY
NIV Failure

■ Monitoring patients with acute hypoxemic

respiratory failure
■ Do not delay intubation for patient who fail NIV
■ Studies show delays result in increased mortality
Delaying Intubation

■ Timing to intubation can be life saving

■ If kept on NIV too long hoping for a better outcome it
has been shown to increase mortality
■ Careful attention to patient selection and monitoring
for risk factors of NIV failure should be a priority
■ Use HACOR score for timing to intubate
NIV Settings and Equipment

Upper limit of EPAP/PEEP

Application of higher
in most studies of NIV,
Positive pressure should expiratory positive airway
particularly those that
be individualized for each pressure (EPAP/PEEP)
involve acute hypoxemic
patient may improve oxygenation
respiratory failure, is no
in a patient
higher than 10 cm H2O

Humidification has been

Maintain higher levels of
shown to improve
PEEP with the helmet
comfort and tolerance of
interface
therapy
THE ROLE OF
HFNC
 ■ Conclusion

Cochrane review for – We were not able to

collect enough

High-flow nasal evidence from good

cannula for
breathing support in
quality studies to
determine whether
HFNC offer a safe and
effective way of
delivering respiratory
support for adults in

adult intensive care the ICU.

patients
HFNC for Hypoxic
Respiratory
Failure
■ Management of acute
hypoxemic respiratory failure
has gained tremendous
popularity
■ FLORALI study compared the
use of HFNC, NIV, and standard
oxygen therapy in subjects with
acute hypoxemic respiratory
failure
– 90-day mortality was lower with
HFNC
HFNC for Hypoxic
Respiratory Failure

■ Doshi et al published a randomized

noninferiority trial of 204 subjects that
compared HFNC with NIV and found HFNC
to be noninferior for the treatment of acute
respiratory failure
– However, in this study, there was a
significant amount of crossover from HFNC
to NIV
– Currently, there is insufficient evidence to
support using HFNC instead of NIV to treat
all forms of respiratory failure

■ FLORALI trial demonstrated that subjects

with immunosuppression had better
outcomes (lower intubation and lower
mortality) when randomized to HFNC than
those randomized to NIV
 NIV in the general management of acute hypoxemic
respiratory failure lacks clinical practice guidelines

Avoiding intubation by using NIV is an important factor

Experienced clinicians choose to manage a patient in

Summary acute hypoxemic respiratory failure with NIV, then risk
factors need to be observed

HFNC has an increasing amount of supportive data,

particularly in patients when NIV recommendations
are lacking

HFNC is more effective than NIV in the management

of acute hypoxemic respiratory failure and patients
who are immunosuppressed
Reference

■ Frat, J. P., Ragot, S., Coudroy, R., Constantin, J. M., Girault, C., Prat, G., ... & Thille,
A. W. (2018). Predictors of intubation in patients with acute hypoxemic respiratory
failure treated with a noninvasive oxygenation strategy. Critical care medicine, 46(2),
208-215.
■ Grieco, D. L., Menga, L. S., Raggi, V., Bongiovanni, F., Anzellotti, G. M., Tanzarella,
E. S., ... & Antonelli, M. (2020). Physiological comparison of high-flow nasal cannula
and helmet noninvasive ventilation in acute hypoxemic respiratory failure. American
journal of respiratory and critical care medicine, 201(3), 303-312.
■ Zayed, Y., Barbarawi, M., Kheiri, B., Haykal, T., Chahine, A., Rashdan, L., ... &
Seedahmed, E. (2019). Initial noninvasive oxygenation strategies in subjects with de
novo acute hypoxemic respiratory failure. Respiratory Care, 64(11), 1433-1444.