What's new at the ERS 2020 International Congress about the rol of HFNC in COPD Patients

The ERS 2020 International Congress was to be held in Viena last 5-9 september 2020, but COVID-19 pandemic has conditioned its transformation in a Virtual ERS International Congress, an event which also marked ERS's 30th year. The congress has been a success with more than 33.000 delegates attending the specially designed online platform over the course of this three-day event. During the congress it has been presented more than 450 scientific and educational sessions. Now we have to wait to the next ERS 2021 International Congress, that will be held, hopefully, in Barcelona.

Several Posters and Oral presentations related to high flow therapy (HFNC) have been presented in the ERS Congress. In this occasion, we are going to focus in those that have discussed the rol of HFNC in COPD patients. Let's see them grouped by topics.

1. HFNC at home in COPD patients.

There has been presented 3 posters, two of them talking about COPD patients with chronic hypoxic respiratory failure and the another one focused in chronic hypercapnic failure. All have shown positive results.

Assessment of health-related quality of life and hospital admission costs of domiciliary High-Flow nasal cannula treatment for severe COPD with chronic hypoxic failure, from Sabrina Storgaard Sørensen, Ulla Møller Weinreich, Line Hust Storgaard.

Introduction: Domiciliary High Flow Nasal Cannula (HFNC) has been shown to reduce days of hospitalization in COPD-patients with chronic hypoxic failure (CHF).

Aim: To evaluate development in health-related quality of life (HRQoL) and costs related to hospital admissions in HNFC treated COPD patients with CHF compared to controls.

Method: In a cohort of 200 COPD patients randomized equally into usual care ± HFNC, complete HRQoL data, judged by St. Georg Respiratory Questionnaire (SGRQ), were available in 140 patients (66 HFNC and 74 controls). The SGRQ data were used to predict EQ-5D utility values using a validated algorithm developed by Starkie et al. Based on this, Quality-Adjusted Life-Years (QALYs) were calculated, and QALYs were corrected for baseline HRQoL and days of treatment.The cost of hospital admission due to COPD exacerbation (AECOPD) was calculated for the same 140 patients during the study period using mean daily admission costs. The cost was corrected for cost of AECOPD admissions in the year prior to inclusion and days of treatment. Costs were valued in British Pounds (£) at price level 2019.

Results: HNFC treatment resulted in a QALY improvement of 0.045 (95% CI -0.017; 0.107) and a mean decrease in cost of £ -1290 (95% CI -2710; 131) per patient. No statistically significant differences were observed.

Conclusion:HNFC treatment led to a gain in QALYs and resulted in savings in hospital admission costs when compared to usual care. Further analysis will reveal whether HNFC for COPD patients with CHR is a cost-effective treatment when considering all relevant cost categories.

COPD patients’ experience of long-term domestic oxygen-enriched nasal high flow treatment: A qualitative study, from Line Storgaard, Ulla Weinreich, Birgitte S. Laursen.

Background: Little is known about COPD patients experience with home based health treatments, which are currently rapidly evolving. A previous randomized controlled trial investigated the use of long-term oxygen enriched high flow nasal cannula (HFNC) treatment at home.

Aim: To explore COPD patients’ experience using home HFNC treatment.

Methods: Patients in this qualitative study were included from the previous RCT. All patients used long-term oxygen therapy and HFNC, the latter as a primarily nocturnal add-on. Data were collected using semi-structured interviews focused on four themes: “Description of daily use”, “Experienced changes”, “Treatment benefits and disadvantages” and “User-friendliness”. The interviewer played an encouraging, non-normative neutral facilitator role in order to give the participants possibility to explain themselves as fully as possible.

Results: Participants were recruited until themes were saturated. A total of 12 patients (5 males, 7 females) and 8 relatives participated. Six themes were identified as important to patient adherence: Perceived lower work of breathing; reduced symptoms; improved quality of sleep; increased activity of daily living; feeling safe; technology use.

Conclusion: The results increase our knowledge of patient experience of using HFNC for home treatment, which improved the patients’ experience through reducing symptoms and increase the activity of daily living. Furthermore, they substantiate the necessity of perceived usefulness and ease of use as important factors for adherence to treatment.

Nasal High-flow Versus Non-invasive Ventilation In Patients With Chronic Hypercapnic COPD, from Jens Bräunlich, Dominic Dellweg, Andreas Bastian, Torsten Blum, Stephan Budweiser, Winfried Randerath, Dora Triché, Martin Bachmann, Christian Kähler, Abdel Hakim Bayarassou, Irmhild Mäder, Jens Geiseler, David Petroff, Hubert Wirtz.

Background: Despite the encouraging results of noninvasive ventilation (NIV) in chronic hypercapnic COPD patients, it is also evident that some patients do not tolerate NIV or do not benefit from it. We conducted a study in which COPD patients with stable, chronic hypercapnia were treated with NIV and nasal high-flow (NHF) to compare effectiveness. Methods: In a multi-centered, randomized, controlled, cross-over design, patients received 6 weeks of NHF ventilation followed by 6 weeks of NIV ventilation or vice-versa (TIBICO) between 2011 and 2016. COPD patients with stable daytime hypercapnia (pCO2≥50 mmHg) were recruited from 13 German centers. The primary endpoint was pCO2 changes from baseline blood gas, lung function, quality of life (QoL), the 6 min walking test, and duration of device use were secondary endpoints. Results: A total of 102 patients (mean±SD) age 65.3±9.3 years, 61% females, body mass index 23.1±4.8 kg/m,2 90% GOLD D, pCO2 56.5±5.4 mmHg were randomized. PCO2 levels decreased by 4.7% (n=94; full analysis set; 95% CI 1.8–7.5, P=0.002) using NHF and 7.1% (95% CI 4.1–10.1, P<0.001) from baseline using NIV (indistinguishable to intention-to-treat analysis). The difference of pCO2 changes between the two devices was −1.4 mmHg (95% CI −3.1–0.4, P=0.12). Both devices had positive impact on blood gases and respiratory scores (St. George’s Respiratory Questionnaire, Severe Respiratory Insufficiency Questionnaire). Conclusions: NHF may constitute an alternative to NIV in COPD patients with stable chronic hypercapnia, eg, those not tolerating or rejecting NIV with respect to pCO2 reduction and improvement in QoL.

2. HFNC during exercise in COPD patients

Use of HFNC during exercise in COPD patients have been an important topic in the ERS Congress. Three posters have shown us that HFNC improves the endurance, performance, desaturation and symptoms in COPD patients.

Effects of high flow nasal cannula during exercise in COPD patients with exercise induced desaturation, from Natthawan Sanguanwong, Nareerat Sae-Eao, Anan Ananpipatkul, Dittapol Muntham, Worawan Sirichana.

Introduction: Chronic obstructive pulmonary disease(COPD) with exercise induced desaturation (EID) have poor prognosis. Pathophysiology of EID is increased dead space ventilation. High flow nasal cannula(HFNC) was shown to reduce dead space and delivered constant FiO2. Added HFNC during exercise could improve exercise training in COPD with EID.

Aims: To compare the effects of supplemental HFNC, oxygen cannula(OC) and without oxygen(control) during exercise in COPD patients with EID.

Methods: We performed a randomized crossover study in stable COPD patients with EID. Subjects were assigned to wear HFNC, OC or no oxygen supplement during constant work rate(WR) exercise testing on cycle ergometer. Work rate was set at 70% of maximum WR derived from a maximum incremental exercise test. Each test was randomly sequenced of device selection and performed on separate day. HFNC was set to deliver flow rate 60 Lpm, FiO2 0.4 and OC was set at 6 Lpm during exercise. We recorded exercise endurance time(Tex), time to desaturation(Tdsat) and rate perceived dyspnea(RPE). We used mixed effect linear regression model to compare between 3 groups.

Results: Thirteen subjects were enrolled. Mean±SD age was 71.3±9.1 years and FEV1 66.4±19.5% predicted. Tex of HFNC and OC tests were 793.4±270.2vs768.3±265.4 sec compare to control 698.6±299.9 sec (p=0.12 and p= 0.25). Both HFNC and OC tests had longer Tdsat than control, 793.4±270.2vs675.7±288.5 and 364.7±339.8sec respectively, (p=0.008 and p=0.03). At iso-time, differences of RPE were not significantly reduced.

Conclusions: HFNC and oxygen cannula slightly improved exercise endurance time in COPD patients with EID and lengthen time to desaturation during exercise.

Comparisons of effects of high-flow and nasal cannula oxygen on exercise performance in patients with COPD, from Yen-Huey Chen, Shiao-Lan Cheng, Huang-Pin Wu, Hui-Ling Lin.

Aims: High flow nasal cannula (HFNC) washout the anatomical dead space, permitting a higher fraction of minute ventilation to participate in gas pulmonary exchanges. Supplemental oxygen has been shown to improve the clinical outcomes in patients with chronic obstructive pulmonary disease (COPD). The purpose of this study was to evaluate the effect of HFNC on hemodynamic and tissue oxygenation during exercise.

Methods: This was a prospective randomized crossover study. Patients with a diagnosis of COPD (n=15) performed two constant load exercise tests at 75% of maximum workload achieved at a previous incremental exercise test on cycle-ergometer with HFNC (HFNC) test and without HFNC (Control) test. During the exercise tests, the vital signs and hemodynamic parameters were continuously monitored. The cerebral and skeletal muscle oxygenation was measured by near-infrared spectroscopy.

Results: The exercise duration in the HFNC test (962.9±281.7 sec) was significantly longer than that in the Control test (823.9±184.9 sec) (p<0.001). At the end of the exercise test, there was no significant difference in the hemodynamics status between HFNC and Control test (p>0.05). The change of cerebral deoxygenated hemoglobin in the HFNC test (-1.8±2.1um) was significantly lower compared with the Control test (0.4±4.3 um) (p<0.05).

Conclusion: The HFNC improves exercise duration in COPD patients. This effect may be associated with the improvement in cerebral oxygenation.

Effect of High-Flow Oxygen on Exercise Performance In COPD. A Randomized Crossover Trial, from Konstantinos Bitos, Michael Furian, Laura Mayer, Simon Rafael Schneider, Simone Buenzli, Maamed Mademilov, Ulan Sheraliev, Ainura K. Abdraeva , Shaira Aydaralieva, Aybermet Myratbekova, Talantbek M. Sooronbaev, Silvia Ulrich, Konrad Ernst Bloch.

Background: High-flow oxygen therapy (HFOT) provides oxygen-enriched, humidified, heated air at high flow rates. It could be an alternative to low-flow oxygen therapy via nasal cannula (LFOT), which is commonly used by patients with chronic obstructive pulmonary disease (COPD) during endurance training in pulmonary rehabilitation. We hypothesized that HFOT improves exercise endurance in COPD patients compared to LFOT.

Methods: Patients with stable, moderate to severe COPD with resting pulse oximetry (SpO2) ≥92% performed two cycle constant work-rate exercise tests to exhaustion at 75% of their maximum work-rate on two different days, using first LFOT (3L/min), then HFOT (60L/min, FiO2 0.45), or vice versa, according to a randomized, crossover design. The primary outcome was the difference in endurance time between therapies. Secondary outcomes were respiratory rate, SpO2, heart rate, arterial blood gases and dyspnea.

Results: 79 patients, mean±SD aged 58±9years, FEV1 63±9%predicted were randomized and included in the intention-to-treat analysis. Endurance time improved under HFOT versus LFOT by a mean of 85s (95%CI: 7 to 164), corresponding to an increase of 13% (95%CI: 1 to 28). Under HFOT, patients had lower respiratory rate and higher SpO2 at isotime; at end-exercise under HFOT, SpO2 remained higher, 1.9% (1.5 to 2.3), and dyspnea sensation was lower, -0.8 points Borg CR10-scale (-1.2 to -0.3), compared to LFOT.

Conclusions: HFOT improved endurance time in patients with stable, moderate to severe COPD by improving arterial oxygenation, respiratory rate and dyspnea compared to LFOT. Therefore, HFOT is promising for enhancing exercise performance in COPD. (ClinicalTrials.gov, NCT03955770).

3. HFNC and sleep apnea.

One study have shown us how HFNC is effective in reducing nocturnal apneas and improving oxygenation in patients with severe COPD and mild-moderate OSA.

High flow-nasal cannula oxygen treatment in patients with concomitant severe chronic obstructive pulmonary diseases and mild-moderate sleep apnea (overlap syndrome), from Lucia Spicuzza, Raffaele Campisi, Claudia Crimi, Stefano Alia, Marialuisa Giuffrida, Nunzio Crimi.

High-flow nasal cannula oxygen treatment (HFNC) has several physiological benefits in respiratory failure due to chronic obstructive pulmonary diseases (COPD). In addition, the small positive pressure generated at the naso-pharinx tract may counteract obstructive apneas. This study aimed to evaluate the effect of HFNC in patients with overlap syndrome (OS) consisting in severe COPD and mild-moderate obstructive sleep apnea (OSA). 17 patients (8 males, BMI35±7, age75±9 yrs, FEV1 % 45±12) with OS and chronic or nocturnal respiratory failure were included. Among these, there were also patients with apnea-hypopnea index (AHI) >15 who refused continuous positive pressure ventilation (CPAP). We performed a nocturnal polygraphy at baseline (if not hypoxemic during the day), during conventional oxygen treatment (COT) and during HFNC at the same set FiO2 (mean value 27%). Mean PaO2 or PaCO2 at baseline were 60±8 and 45±5 mmHg. Both treatments improved, to different extent, nocturnal oxygenation, but only HFNC reduced significantly the apnea-hypopnea index (AHI), nocturnal parameters changed as follows:

All values with HFNC were significant vs COT and baseline. There was no changes in PaO2 or PaCO2 in the morning after each treatment. We conclude that HFNC oxygen treatment is effective in reducing nocturnal apneas and improving oxygenation in patients with severe COPD and mild-moderate OSA compared to COT. HFNC may also be a chance in patients refusing CPAP.

4. HFNC in COPD exacerbations

Two studies have discussed the rol of HNFC in COPD exacerbations, showing good results comparing to NIV.

Comparison of high-flow oxygenation to noninvasive ventilation in COPD exacerbation, from Atefeh Fakharian, Abbas Rezaee, Hamidreza Jamaati, Esmail Eidani, Atefeh Abedini, Fariba Ghorbani.

Objectives: To compare the therapeutic effects of high-flow oxygen Therapy (HFT) and noninvasive ventilation (NIV) for stabilizing chronic obstructive pulmonary disease during exacerbation.

Methods: In this randomized clinical trial at Masih Daneshvari hospital, between July 2019 and Oct 2019, 30 COPD patients in the exacerbation were divided into two groups, N= 15. By a simple randomized allocation, patients receive either NIV or HFT for one hour and following a washout period of 30 minutes, they switched to the other treatment option. Arterial Blood Gas Parameters, as well as Respiratory Rate (RR), Dyspnea Score, Heart Rate (HR) and Oxygen Saturation (SO2), were compared before and after the intervention and between groups.

Results: Baseline patient characteristics were similar in two groups. Pre and post analysis revealed that in both groups, RR, Dyspnea Score, HR, SO2, and PCO2 improved significantly. After the first intervention, there was no difference in all parameters between groups except for SO2 which was significantly higher in HFT (%92.1± 1) than that of NIV (%89± 1), p=0.001. Likewise, following the washout period, patients in HFT and NIV had a dyspnea score of 1.93± 0.7 and 2.73±0.9 respectively, p=0.01. Similarly, the pattern of RR-change was the same as dyspnea. The final improvement in dyspnea score was observed in the patients who received HFT as the first intervention. No side effects were reported.

Conclusion: HFT is feasible for patients with COPD exacerbation and appears to be superior to NIV for reducing dyspnea score and improving respiratory distress.

Effectiveness of high flow oxygen therapy (HFNC) in hypercapnic respiratory failure, from Antonio Di Sorbo, Mariano Mazza, Assunta Micco, Angelo Romano, Gaetano Beatrice, Mario Del Donno

Introduction: High-flow nasal cannula (HFNC) oxygen therapy in acute hypoxic respiratory failure is generally used. However, evidence to support the use of HFNC in acute respiratory failure (ARF) with hypercapnia is limited.

The aim of this study is to evaluate the efficacy of HFNC in improving the blood values of pO2, pCO2 and pH, in patients with hypercapnic respiratory failure secondary to exacerbated COPD.

Materials and methods: In this retrospective study, we included 36 patients (22 male, 14 female, age 66.5 ± 10.5) admitted to our Department for hypercapnic respiratory failure secondary to COPD exacerbated, treated with HFNC, from June 2017 to December 2019.

Results: The preliminary data obtained from the observed patients showed: an improvement in the average values of pO2 (52.2 ± 4.8 vs 69.7 ± 5), pCO2 (56.1 ± 12.2 vs 44.1 ± 5,5) and pH (7.34 ± 0.05 vs 7.38 ± 0.05) at discharge, using HFNC with flow 39.4 ± 4 l/min, T 34 ° C ± 2, FiO2 30 ± 6%, daily use equal to 7.5 ± 1 hours/day and a duration of hospitalization equal to 7.4 ± 1.8 days.

Conclusions: From our preliminary data, we can conclude that in patients with hypercapnic respiratory failure secondary to exacerbated COPD, continuous therapy with HFNC shows a significant improvement in the average values of the blood levels of pO2, pCO2 and pH and represents a valid therapeutic option beyond to the pharmacological one. Therapy is also more accepted in terms of compliance and individual comfort than NIV. In the future, the HFNC therapy could be considered a useful option to the recommended basic treatment, in patients with hypoxemic-hypercapnic respiratory failure, especially in non-compliant patients with NIV treatment.

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