High-flow nasal oxygen versus noninvasive ventilation in adult patients with cystic fibrosis: a randomized crossover physiological study

Michael C Sklar, Martin Dres, Nuttapol Rittayamai, Brent West, Domenico Luca Grieco, Irene Telias, Detajin Junhasavasdikul, Michela Rauseo, Tai Pham, Fabiana Madotto, Carolyn Campbell, Elizabeth Tullis, Laurent Brochard, Michael C Sklar, Martin Dres, Nuttapol Rittayamai, Brent West, Domenico Luca Grieco, Irene Telias, Detajin Junhasavasdikul, Michela Rauseo, Tai Pham, Fabiana Madotto, Carolyn Campbell, Elizabeth Tullis, Laurent Brochard

Abstract

Background: Noninvasive ventilation (NIV) is the first-line treatment of adult patients with exacerbations of cystic fibrosis (CF). High-flow nasal oxygen therapy (HFNT) might benefit patients with hypoxemia and can reduce physiological dead space. We hypothesized that HFNT and NIV would similarly reduce work of breathing and improving breathing pattern in CF patients. Our objective was to compare the effects of HFNT versus NIV in terms of work of breathing, assessed noninvasively by the thickening fraction of the diaphragm (TFdi, measured with ultrasound), breathing pattern, transcutaneous CO2 (PtcCO2), hemodynamics, dyspnea and comfort.

Methods: Adult CF patients who had been stabilized after requiring ventilatory support for a few days were enrolled and ventilated with HFNT and NIV for 30 min in crossover random order.

Results: Fifteen patients were enrolled. Compared to baseline, HFNT, but not NIV, reduced respiratory rate (by 3 breaths/min, p = 0.01) and minute ventilation (by 2 L/min, p = 0.01). Patients also took slightly larger tidal volumes with HFNT compared to NIV (p = 0.02). TFdi per breath was similar under the two techniques and did not change from baseline. MAP increased from baseline with NIV and compared to HFNT (p ≤ 0.01). Comfort was poorer with the application of both HFNT and NIV than baseline. No differences were found for heart rate, SpO2, PtcCO2 or dyspnea.

Conclusions: In adult CF patients stabilized after indication for ventilatory support, HFNT and NIV have similar effects on diaphragmatic work per breath, but high-flow therapy confers additional physiological benefits by decreasing respiratory rate and minute ventilation.

Clinical trial registration: Ethics Committee of St. Michael's Hospital (REB #14-338) and clinicaltrial.gov (NCT02262871).

Figures

Fig. 1
Fig. 1
Study design. Fifteen cystic fibrosis patients were oxygenated with high-flow nasal cannula and noninvasive ventilation for 30 min each in random order with a 10-min washout period after each device use. All measurements were taken at baseline and after 25 min on each device. HFNT high-flow nasal therapy, NIV noninvasive ventilation
Fig. 2
Fig. 2
Individual patient changes in diaphragm thickening fraction. No significant change in diaphragm thickening fraction was observed between baseline conditions or after each device, n = 15
Fig. 3
Fig. 3
Individual patient changes in respiratory variables. a HFNT significantly reduced respiratory rate compared to baseline and b significantly increased tidal volume when compared to NIV, c HFNT significantly reduced minute ventilation compared to baseline conditions, d no differences were observed for PtcCO2, *p < 0.05 (versus baseline). HFNT high-flow nasal therapy, NIV noninvasive ventilation, PtcCO2 transcutaneous carbon dioxide, n = 15
Fig. 4
Fig. 4
Individual patient changes in symptom scores, n = 15, with some symptom scores overlapping. a Dyspnea scores were unchanged between baseline conditions and the use of either HFNT or NIV. b Compared to baseline conditions, both NIV and HFNT reduced comfort scores, *p < 0.05 (versus baseline), HFNT high-flow nasal therapy, NIV noninvasive ventilation. Dyspnea and comfort scores: (dyspnea: 0 = no dyspnea, 10 = maximal dyspnea. Comfort: 0 = maximal discomfort, 10 = very comfortable), n = 15

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