Pilot Study of High-flow Humidified Nasal Oxygen During Breaks From Noninvasive Ventilation

Not Applicable

Completed

Conditions: Acute Respiratory Failure
Treatment With Noninvasive Positive Pressure Ventilation

Interventions: Device: Standard oxygen therapy
Device: High-flow humidified nasal oxygen delivery system

Registration Number: NCT01925534

Lead Sponsor: Tufts Medical Center

Brief Summary: The purpose of this study is to assess whether Optiflow, a high-flow humidified oxygen delivery system, is superior to standard oxygen therapy during breaks off noninvasive ventilation in patients affected by acute respiratory failure and in respiratory distress. The investigators anticipate that the Optiflow will provide oxygen more effectively, be more comfortable and permit longer breaks off NIV, shortening the total duration of NIV.

Detailed Description: Background: Noninvasive ventilation (NIV) provides respiratory support to many patients affected by acute respiratory failure. This treatment, compared to invasive mechanical ventilation, allows patients to take intermittent breaks during which oxygen therapy is provided through a nasal cannula or mask. During these breaks, the lack of ventilator support may predispose to respiratory distress, retention of CO2 and oxygen desaturation. Optiflow is a nasal humidified (37◦C, 44mg/L H2O) high-flow (up to 60 L/min) therapy which can provide greater support than standard oxygen therapy during the breaks from NIV.

Aim of the study is to evaluate Optiflow as an alternative to standard oxygen therapy during breaks from NIV in patients with acute respiratory failure. The investigators hypothesize tha Optiflow will reduce the total length of stay on NIV, and increase the comfort and length of the breaks. Also, the investigators anticipate that it will reduce respiratory rate, accessory muscle use and dyspnea score compared to standard oxygen therapy.

Experimental design Prospective open-label, parallel, randomized (1:1) controlled study, with a target enrollment of 70.

Study procedures Enrolled patients receiving NIV will be randomized into two arms; a treatment group which will receive Optiflow during breaks and a control arm which will receive standard oxygen therapy during breaks. In both cases, FiO2 will be titrated to maintain oxygen saturation above 90%. The necessity of breaks will be determined together with the patients (talk, eat, medication, communicate with family, inability to tolerate the interface), and the need to resume NIV will be based on clinical data, such as dyspnea, respiratory rate, heart rate, blood pressure, oxygen saturation, transcutaneous carbon dioxide (CO2) and patients' desire.

Recorded data: The investigators will record demographic baseline data; Glasgow Coma Scale, respiratory and heart rate, blood pressure, dyspnea score, accessory muscle use, and comfort score at randomization, at the end of each NIV session and NIV break; the length of each NIV session and break; the medications administered and all the arterial blood gases (ABG) on a daily basis. Moreover the investigators will record the NIV parameters and inspired oxygen fraction (FiO2) at each session and break.

Risks: The investigators don't anticipate any significant risks related to the study procedures and equipment. Some patients may not tolerate the Optiflow and some patients may fail NIV and require intubation.

Recruitment & Eligibility

Status: COMPLETED

Sex: All

Target Recruitment: 47

Inclusion Criteria

Patients of 18 or more years of age treated with Bipap or CPAP as per hospital protocol, with an underlying clinical diagnosis of acute respiratory failure.
Patients that, prior to administration of NIV, had persistent respiratory acidosis with a pH <7.35 and arterial CO2 > 45 mmHg despite controlled oxygen therapy and standard medical management i.e. bronchodilators, corticosteroids and antibiotics, or
Patients with hypoxemic respiratory failure with a PaO2/FiO2 ratio < 300 and respiratory rate ≥ 24.
Anticipated duration on NIV of at least 24 hrs

Exclusion criteria:

Usual contraindications to NIV
Respiratory arrest
Unable to fit mask
Medically unstable or multiple organ failure or unstable coronary disease
Agitated or uncooperative
Unable to protect airways
Swallowing difficulties
Excessive secretions not managed by clearance techniques
Recent upper airway or gastro-intestinal surgery
Facial deformity or previous head and neck surgery
Undrained pneumothorax
NIV failure within first 2 hours (either intolerance or requirement for intubation)
Managed for greater than 48 hours on NIV prior to randomization
Disorientation, confusion, unable to rate comfort or dyspnea
Expected to require NIV for fewer than 24 hrs from the time of enrollment
Patient previously in study
Patients on CPAP nighttime only due to OSA

Withdrawal/Termination criteria:

Patients will be withdrawn from the study when NIV fails and/or the patient is intubated.

Exclusion Criteria

Not provided

Study & Design

Study Type: INTERVENTIONAL

Study Design: PARALLEL

Arm && Interventions

Group	Intervention	Description
Oxygen therapy	Standard oxygen therapy	Standard oxygen therapy
Optiflow	High-flow humidified nasal oxygen delivery system	High-flow humidified nasal oxygen delivery system

Primary Outcome Measures

Name	Time	Method
Length of Stay on Noninvasive Ventilation (NIV)	Day 1-7	The investigator will measure the total time on NIV in day(s), hours and minutes. This is done by having nursing staff note times of NIV start to finish of each session of NIV. They were added to get cumulative time.

Secondary Outcome Measures

Name	Time	Method
Need for Intubation	Days 2-10	Count of participants who underwent endotracheal intubation
Ease of Eating	Day 1-4	difficulty eating using patient rating on a visual analog scale of 0 for easy eating and 4 for difficult eating. Results tabulated as number of patients finding it easy to eat (Score of 0-1)
Assessment of Respiratory Rate During Break	day 1-4	Evaluation of respiratory rate. This was counted for a minute at bedside at start and finish of break.
Oxygen Saturation During Breaks	day 1-4	Using pulse oximetry (SpO2) at beginning and end of breaks
Patients' Comfort	Day 2-4	Using a visual analogue scale (VAS). Patients rate how comfortable they felt on a 1 to 10 scale with 10 being most comfortable and 1 being the least comfortable.
Length of Breaks From NIV	Day 4-10	This is done by having nursing staff note times of break start (off NIV) to start of next session of NIV in minutes. Subgroup analysis was performed to assess differences between hypercapnic and hypoxemic patients, not observed in terms of time spent on or off NIV.

Trial Locations

Locations (2): Intensive Care Unit and Intermediate Care Unit, Tufts Medical Center
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Boston, Massachusetts, United States
Intensive Care Unit, Winchester Hospital
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Winchester, Massachusetts, United States