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High-flow nasal cannula and noninvasive ventilation: effects on alveolar recruitment and overdistension

Amandeep S. Saini, Simon Meredith, Antonio M. Esquinas, Bushra A. Mina
ERJ Open Research 2022 8: 00127-2022; DOI: 10.1183/23120541.00127-2022
Amandeep S. Saini
1Dept of Medicine, Lenox Hill Hospital/Northwell Health, New York, NY, USA
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  • For correspondence: asaininy@gmail.com
Simon Meredith
2Dept of Pulmonary and Critical Care Medicine, Lenox Hill Hospital/Northwell Health, New York, NY, USA
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Antonio M. Esquinas
3Intensive Care Unit, Hospital Morales Meseguer, Murcia, Spain
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Bushra A. Mina
2Dept of Pulmonary and Critical Care Medicine, Lenox Hill Hospital/Northwell Health, New York, NY, USA
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Abstract

Both high-flow nasal cannula and noninvasive ventilation are subject to pulmonary complications https://bit.ly/3jFCSG9

To the Editor:

We have read with great interest a study recently published in ERJ Open Research that analysed the ability of high-flow nasal cannula (HFNC) and noninvasive ventilation (NIV) to induce pulmonary expansion in acute hypoxaemic respiratory failure [1]. We would like to congratulate Artaud-Macari et al. [1] for their interesting observation using end-expiratory electrical lung impedance as a measuring tool. NIV certainly affects both dependent and non-dependent lung regions, which could increase tidal volume (VT) to >9.5 mL per kg predicted body weight and potentially exacerbate acute hypoxaemic respiratory failure. The authors concluded that, compared to NIV, HFNC contributes to lower risk of overdistension and fewer deleterious effects on global and regional VT, because the end-expiratory electrical lung impedance does not increase in non-dependent regions. Other studies, however, argue that HFNC may have similar negative effects to NIV, supported by four well-known determinants, as follows.

First, VT and flow rate have relative proportional inter-relationships. Despite the respiratory rate and primary patient modality (mouth versus nose breathing) being possible confounders, VT still increases proportionally with gas flow under HFNC, with p-values as low as 0.001 [2, 3]. As such, one can presume that higher levels of VT and flow rate may induce overdistension and barotrauma.

Secondly, while HFNC could have a protective effect compared to NIV, the negative swings in pleural pressure secondary to spontaneous inspiratory efforts can contribute to patient self-inflicted lung injury [4]. In the study by Artaud-Macari et al. [1], the HFNC setting was delivered at a constant flow rate of 50 L·min−1. However, previous studies considered an optimal HFNC rate of 60 L·min−1, given that there were reduced indices of respiratory effort in adult patients recovering from acute hypoxaemic respiratory failure [5].

Thirdly, during spontaneous breathing, both the VT and inspiratory flow vary, and when HFNC flow is less than patient inspiratory flow, the patient will inspire atmospheric air. Alternatively, when HFNC flow is sufficiently high, the absolute humidity of inspired gas is unlikely to be a problem. Conditioning of the gas minimises airway constriction, reduces work of breathing, improves mucociliary function, facilitates secretion clearance and decreases the incidence of atelectasis, thereby improving the ventilation/perfusion ratio and overall oxygenation [6].

Finally, the Pendelluft phenomenon also has an effect on VT. The phenomenon is defined as the displacement of gas from a more recruited non-dependent lung region to a less recruited dependent lung region. Gas flow from the dependent to the non-dependent region is essential in Pendelluft, but the severity of this phenomenon is not always proportional to gas flow. The severity increases as differences in plateau pressure levels increase between the non-dependent and dependent regions, and is amplified by differences in their lung mechanics [7].

Flow rate, negative pleural pressure swing, spontaneous inspiratory effort and the Pendelluft phenomenon are important determinants in HFNC complications. We are not fully convinced that HFNC has a greater protective effect compared to NIV relative to lung injury, and suggest that more research is needed to confirm the findings reported by Artaud-Macari et al. [1].

Footnotes

  • Provenance: Submitted article, peer reviewed.

  • Conflict of interest: None declared.

  • Received March 12, 2022.
  • Accepted April 6, 2022.
  • Copyright ©The authors 2022
http://creativecommons.org/licenses/by-nc/4.0/

This version is distributed under the terms of the Creative Commons Attribution Non-Commercial Licence 4.0. For commercial reproduction rights and permissions contact permissions{at}ersnet.org

References

  1. ↵
    1. Artaud-Macari E,
    2. Bubenheim M,
    3. Le Bouar G, et al.
    High-flow oxygen therapy versus noninvasive ventilation: a randomised physiological crossover study of alveolar recruitment in acute respiratory failure. ERJ Open Res 2021; 7: 00373-2021. doi:10.1183/23120541.00373-2021
    OpenUrlAbstract/FREE Full Text
  2. ↵
    1. L'Her E,
    2. Nazir S,
    3. Pateau V, et al.
    Accuracy of noncontact surface imaging for tidal volume and respiratory rate measurements in the ICU. J Clin Monit Comput 2021; in press [https://doi.org/10.1007/s10877-021-00708-x].
  3. ↵
    1. Le Moigne G,
    2. Nazir S,
    3. Pateau V, et al.
    Noninvasive tidal volume measurements, using a time-of-flight camera, under high-flow nasal cannula – a physiological evaluation, in healthy volunteers. Crit Care Med 2022; 50: e61–e70. doi:10.1097/CCM.0000000000005183
    OpenUrl
  4. ↵
    1. Grieco DL,
    2. Menga LS,
    3. Eleuteri D, et al.
    Patient self-inflicted lung injury: implications for acute hypoxemic respiratory failure and ARDS patients on non-invasive support. Minerva Anestesiol 2019; 85: 1014–1023. doi:10.23736/S0375-9393.19.13418-9
    OpenUrl
  5. ↵
    1. Delorme M,
    2. Bouchard PA,
    3. Simon M, et al.
    Effects of high-flow nasal cannula on the work of breathing in patients recovering from acute respiratory failure. Crit Care Med 2017; 45: 1981–1988. doi:10.1097/CCM.0000000000002693
    OpenUrlPubMed
  6. ↵
    1. Nishimura M
    . High-flow nasal cannula oxygen therapy in adults: physiological benefits, indication, clinical benefits, and adverse effects. Respir Care 2016; 61: 529–541. doi:10.4187/respcare.04577
    OpenUrlAbstract/FREE Full Text
  7. ↵
    1. Enokidani Y,
    2. Uchiyama A,
    3. Yoshida T, et al.
    Effects of ventilatory settings on Pendelluft phenomenon during mechanical ventilation. Respir Care 2021; 66: 1–10. doi:10.4187/respcare.07880
    OpenUrlAbstract/FREE Full Text
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High-flow nasal cannula and noninvasive ventilation: effects on alveolar recruitment and overdistension
Amandeep S. Saini, Simon Meredith, Antonio M. Esquinas, Bushra A. Mina
ERJ Open Research Apr 2022, 8 (2) 00127-2022; DOI: 10.1183/23120541.00127-2022

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High-flow nasal cannula and noninvasive ventilation: effects on alveolar recruitment and overdistension
Amandeep S. Saini, Simon Meredith, Antonio M. Esquinas, Bushra A. Mina
ERJ Open Research Apr 2022, 8 (2) 00127-2022; DOI: 10.1183/23120541.00127-2022
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