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Giulia Spoletini, MD; Nicholas S. Hill, MD, FCCP
Author and Funding Information

From the Department of Pathophysiology and Transplantation (Dr Spoletini), Università degli Studi di Milano, IRCCS Fondazione Ospedale Maggiore Policlinico Cà Granda; and the Division of Pulmonary, Critical Care and Sleep Medicine (Drs Spoletini and Hill), Tufts Medical Center.

CORRESPONDENCE TO: Nicholas S. Hill, MD, FCCP, Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, 800 Washington St, #257, Boston, MA 02111; e-mail: nhill@tuftsmedicalcenter.org


CONFLICT OF INTEREST: N. S. H. has served on the Medical Advisory Board and received consulting fees from Fisher Paykel and has also received consulting fees from Vapotherm. None declared (G. S.).

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(4):e127-e128. doi:10.1378/chest.15-1463
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To the Editor:

We thank Drs Díaz-Lobato and Mayoralas Alises for their interest in our review in CHEST1 on the mechanisms and potential applications of heated and humidified high-flow nasal oxygen (HFNO) in adults and for asking us to better clarify our empirical recommendations on the use of HFNO on general wards. In our review, we recommended that “until the safety of HFNC [high-flow nasal cannula] can be established in various settings,…use on regular wards should be discouraged, especially in patients with severe hypoxemia who are prone to severe oxygen desaturations if disconnected.”1 This recommendation was based on our belief that in the absence of data demonstrating the safety of HFNO on general wards, we should recommend caution. To date, only case series and a few retrospective and prospective observational studies have examined the use of HFNO on general wards and have reported no major complications.2,3

A study by Kang et al4 raises concerns about managing patients in a less intensively monitored setting. In this study, 275 of 616 patients treated with HFNO failed and required intubation. Patients with “delayed” intubation (after 48 h) had a lower eventual weaning rate and a higher mortality than those who failed earlier. The authors suggested that the time to intubation may have been inappropriately prolonged, leading to the worse outcome.

Thus, we still recommend that patients prone to severe oxygen desaturations should be watched closely in ICUs or intermediate care units, with a plan to escalate to noninvasive ventilation or intubation without undue delay if they deteriorate. However, we agree with Drs Díaz-Lobato and Mayoralas Alises that the device itself should not be the main determinant when deciding where to treat patients; rather, it should be the severity and stability of the patient’s condition. If patients are cooperative, have no more than moderate hypoxemia, and are otherwise stable, they could probably be managed safely on a general ward. However, in the absence of studies establishing the safety of managing such patients on a general ward, we recommend that physicians err on the side of caution and monitor sicker patients being treated with HFNO in a higher intensity unit until they are clinically stable.

References

Spoletini G, Alotaibi M, Blasi F, Hill NS. Heated humidified high-flow nasal oxygen in adults: mechanism of action and clinical implications. Chest. 2015;148(1):253-261. [CrossRef] [PubMed]
 
Ward JJ. High-flow oxygen administration by nasal cannula for adult and perinatal patients. Respir Care. 2013;58(1):98-122. [CrossRef] [PubMed]
 
Epstein AS, Hartridge-Lambert SK, Ramaker JS, Voigt LP, Portlock CS. Humidified high-flow nasal oxygen utilization in patients with cancer at Memorial Sloan-Kettering Cancer Center. J Palliat Med. 2011;14(7):835-839. [CrossRef] [PubMed]
 
Kang BJ, Koh Y, Lim CM, et al. Failure of high-flow nasal cannula therapy may delay intubation and increase mortality. Intensive Care Med. 2015;41(4):623-632. [CrossRef] [PubMed]
 

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References

Spoletini G, Alotaibi M, Blasi F, Hill NS. Heated humidified high-flow nasal oxygen in adults: mechanism of action and clinical implications. Chest. 2015;148(1):253-261. [CrossRef] [PubMed]
 
Ward JJ. High-flow oxygen administration by nasal cannula for adult and perinatal patients. Respir Care. 2013;58(1):98-122. [CrossRef] [PubMed]
 
Epstein AS, Hartridge-Lambert SK, Ramaker JS, Voigt LP, Portlock CS. Humidified high-flow nasal oxygen utilization in patients with cancer at Memorial Sloan-Kettering Cancer Center. J Palliat Med. 2011;14(7):835-839. [CrossRef] [PubMed]
 
Kang BJ, Koh Y, Lim CM, et al. Failure of high-flow nasal cannula therapy may delay intubation and increase mortality. Intensive Care Med. 2015;41(4):623-632. [CrossRef] [PubMed]
 
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