High-flow nasal cannula oxygen therapy to treat acute respiratory failure in patients with acute exacerbation of idiopathic pulmonary fibrosis

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Abstract

Background:

Some patients with idiopathic pulmonary fibrosis (IPF) develop acute exacerbation (AE-IPF) leading to severe acute respiratory failure (ARF); despite conventional supportive therapy, the mortality rate remains extremely high. The aim of this study was to assess how a treatment algorithm incorporating high-flow nasal cannula (HFNC) oxygen therapy affects the short-term mortality of patients with AE-IPF who develop ARF.

Method and design:

A retrospective cohort analysis was conducted.

Patients and interventions:

The study consisted of 17 patients with AE-IPF admitted to a respiratory intensive care unit (RICU) for ARF managed using a treatment algorithm incorporating HFNC. The outcome measure was mortality rate during their stay in the RICU.

Results:

Implementation of the treatment algorithm led to a successful outcome in nine patients and to a negative one in eight patients (47.1%) who died within 39 days of being admitted to the RICU. The survival rate was 70.6% (±0.1 %) at 15 days, 52.9% (±0.1%) at 30 days, 35.3% (±0.1%) at 90 days, and 15.6% (±9.73 %) at 365 days. Overall, 4 out of 10 patients who did not respond to conventional oxygen therapy showed a satisfactory response to HFNC.

Conclusions:

Short-term mortality fell to below 50% when a treatment algorithm incorporating HFNC was implemented in a group of patients with AE-IPF admitted to a RICU for ARF. Patients not responding to conventional oxygen therapy seemed to benefit from HFNC.

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Most cited references 31

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A multidimensional index and staging system for idiopathic pulmonary fibrosis.

Brett Ley, Christopher J Ryerson, Eric Vittinghoff … (2012)

Idiopathic pulmonary fibrosis (IPF) is a progressive fibrotic lung disease with an overall poor prognosis. A simple-to-use staging system for IPF may improve prognostication, help guide management, and facilitate research. To develop a multidimensional prognostic staging system for IPF by using commonly measured clinical and physiologic variables. A clinical prediction model was developed and validated by using retrospective data from 3 large, geographically distinct cohorts. Interstitial lung disease referral centers in California, Minnesota, and Italy. 228 patients with IPF at the University of California, San Francisco (derivation cohort), and 330 patients at the Mayo Clinic and Morgagni-Pierantoni Hospital (validation cohort). The primary outcome was mortality, treating transplantation as a competing risk. Model discrimination was assessed by the c-index, and calibration was assessed by comparing predicted and observed cumulative mortality at 1, 2, and 3 years. Four variables were included in the final model: gender (G), age (A), and 2 lung physiology variables (P) (FVC and Dlco). A model using continuous predictors (GAP calculator) and a simple point-scoring system (GAP index) performed similarly in derivation (c-index of 70.8 and 69.3, respectively) and validation (c-index of 69.1 and 68.7, respectively). Three stages (stages I, II, and III) were identified based on the GAP index with 1-year mortality of 6%, 16%, and 39%, respectively. The GAP models performed similarly in pooled follow-up visits (c-index ≥71.9). Patients were drawn from academic centers and analyzed retrospectively. The GAP models use commonly measured clinical and physiologic variables to predict mortality in patients with IPF.

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Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008

R Phillip Dellinger, Mitchell Levy, Jean M. Carlet … (2007)

Objective To provide an update to the original Surviving Sepsis Campaign clinical management guidelines, “Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock,” published in 2004. Design Modified Delphi method with a consensus conference of 55 international experts, several subsequent meetings of subgroups and key individuals, teleconferences, and electronic-based discussion among subgroups and among the entire committee. This process was conducted independently of any industry funding. Methods We used the GRADE system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations. A strong recommendation [1] indicates that an intervention's desirable effects clearly outweigh its undesirable effects (risk, burden, cost), or clearly do not. Weak recommendations [2] indicate that the tradeoff between desirable and undesirable effects is less clear. The grade of strong or weak is considered of greater clinical importance than a difference in letter level of quality of evidence. In areas without complete agreement, a formal process of resolution was developed and applied. Recommendations are grouped into those directly targeting severe sepsis, recommendations targeting general care of the critically ill patient that are considered high priority in severe sepsis, and pediatric considerations. Results Key recommendations, listed by category, include: early goal-directed resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures prior to antibiotic therapy (1C); imaging studies performed promptly to confirm potential source of infection (1C); administration of broad-spectrum antibiotic therapy within 1 hr of diagnosis of septic shock (1B) and severe sepsis without septic shock (1D); reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage, when appropriate (1C); a usual 7–10 days of antibiotic therapy guided by clinical response (1D); source control with attention to the balance of risks and benefits of the chosen method (1C); administration of either crystalloid or colloid fluid resuscitation (1B); fluid challenge to restore mean circulating filling pressure (1C); reduction in rate of fluid administration with rising filing pressures and no improvement in tissue perfusion (1D); vasopressor preference for norepinephrine or dopamine to maintain an initial target of mean arterial pressure ≥ 65 mm Hg (1C); dobutamine inotropic therapy when cardiac output remains low despite fluid resuscitation and combined inotropic/vasopressor therapy (1C); stress-dose steroid therapy given only in septic shock after blood pressure is identified to be poorly responsive to fluid and vasopressor therapy (2C); recombinant activated protein C in patients with severe sepsis and clinical assessment of high risk for death (2B except 2C for post-operative patients). In the absence of tissue hypoperfusion, coronary artery disease, or acute hemorrhage, target a hemoglobin of 7–9 g/dL (1B); a low tidal volume (1B) and limitation of inspiratory plateau pressure strategy (1C) for acute lung injury (ALI)/acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure in acute lung injury (1C); head of bed elevation in mechanically ventilated patients unless contraindicated (1B); avoiding routine use of pulmonary artery catheters in ALI/ARDS (1A); to decrease days of mechanical ventilation and ICU length of stay, a conservative fluid strategy for patients with established ALI/ARDS who are not in shock (1C); protocols for weaning and sedation/analgesia (1B); using either intermittent bolus sedation or continuous infusion sedation with daily interruptions or lightening (1B); avoidance of neuromuscular blockers, if at all possible (1B); institution of glycemic control (1B) targeting a blood glucose < 150 mg/dL after initial stabilization ( 2C ); equivalency of continuous veno-veno hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1A); use of stress ulcer prophylaxis to prevent upper GI bleeding using H2 blockers (1A) or proton pump inhibitors (1B); and consideration of limitation of support where appropriate (1D). Recommendations specific to pediatric severe sepsis include: greater use of physical examination therapeutic end points (2C); dopamine as the first drug of choice for hypotension (2C); steroids only in children with suspected or proven adrenal insufficiency (2C); a recommendation against the use of recombinant activated protein C in children (1B). Conclusion There was strong agreement among a large cohort of international experts regarding many level 1 recommendations for the best current care of patients with severe sepsis. Evidenced-based recommendations regarding the acute management of sepsis and septic shock are the first step toward improved outcomes for this important group of critically ill patients.

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Acute exacerbation of idiopathic pulmonary fibrosis: incidence, risk factors and outcome.

J. W. Song, S-B. Hong, C.-M. Lim … (2011)

Although acute exacerbation of idiopathic pulmonary fibrosis (IPF) has become well recognised, the reported incidence and outcomes are highly variable, and risk factors are unknown. The aim of this study was to estimate the incidence, risk factors and impact of acute exacerbations, and other known causes of rapid deterioration. This was a retrospective review of 461 patients with IPF (269 cases were biopsy-proven). The median follow-up period was 22.9 months. Rapid deterioration requiring hospitalisation occurred in 163 (35.4%) patients, with multiple episodes in 42 patients. Acute exacerbation was the most frequent cause (55.2%), followed by infection. The 1- and 3-yr incidences of acute exacerbation were 14.2 and 20.7%, respectively. Never having smoked and low forced vital capacity (FVC) were significant risk factors. The in-hospital mortality rate was 50.0%, and the 1- and 5-yr survival rates from the initial diagnosis were 56.2 and 18.4%, respectively. Acute exacerbation was a significant predictor of poor survival after the initial diagnosis, along with increased age, low FVC and diffusing capacity of the lung for carbon monoxide, and steroid use with or without cytotoxic therapy. 1- and 3-yr incidences of acute exacerbation were 14.2 and 20.7%, respectively. Never having smoked and low FVC were risk factors. Acute exacerbation had a serious impact on the overall survival of the patients with IPF.

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Author and article information

Contributors

Andrea Vianello:

ORCID: https://orcid.org/0000-0002-8790-6029

Giovanna Arcaro

Beatrice Molena

Cristian Turato

Fausto Braccioni

Luciana Paladini

Stefania Vio

Silvia Ferrarese

Piera Peditto

Federico Gallan

Marina Saetta

Journal

Journal ID (nlm-ta): Ther Adv Respir Dis

Journal ID (iso-abbrev): Ther Adv Respir Dis

Journal ID (publisher-id): TAR

Journal ID (hwp): sptar

Title: Therapeutic Advances in Respiratory Disease

Publisher: SAGE Publications (Sage UK: London, England )

ISSN (Print): 1753-4658

ISSN (Electronic): 1753-4666

Publication date (Electronic): 06 June 2019

Publication date Collection: Jan-Dec 2019

Volume: 13

Electronic Location Identifier: 1753466619847130

Affiliations

[1-1753466619847130]U.O. Fisiopatologia Respiratoria, Azienda Ospedaliera di Padova, Via Giustiniani 2, 35128 Padova, Italy

[2-1753466619847130]Department of Cardiological, Thoracic and Vascular Sciences, University of Padova, Padova, Italy

[3-1753466619847130]Department of Cardiological, Thoracic and Vascular Sciences, University of Padova, Padova, Italy

[4-1753466619847130]Veneto Institute of Oncology IOV, IRCCS, Padova, Italy

[5-1753466619847130]Department of Cardiological, Thoracic and Vascular Sciences, University of Padova, Padova, Italy

[6-1753466619847130]Department of Cardiological, Thoracic and Vascular Sciences, University of Padova, Padova, Italy

[7-1753466619847130]Department of Radiology, University of Padova, Padova, Italy

[8-1753466619847130]Department of Cardiological, Thoracic and Vascular Sciences, University of Padova, Padova, Italy

[9-1753466619847130]Department of Cardiological, Thoracic and Vascular Sciences, University of Padova, Padova, Italy

[10-1753466619847130]Department of Cardiological, Thoracic and Vascular Sciences, University of Padova, Padova, Italy

[11-1753466619847130]Department of Cardiological, Thoracic and Vascular Sciences, University of Padova, Padova, Italy

Author notes

[*] andrea.vianello@ 123456aopd.veneto.it

Author information

Andrea Vianello https://orcid.org/0000-0002-8790-6029

Article

Publisher ID: 10.1177_1753466619847130

DOI: 10.1177/1753466619847130

PMC ID: 6557021

PubMed ID: 31170875

SO-VID: fb74f47d-0b5f-4963-a08a-c0c2688d2ecb

License:

This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License ( http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( https://us.sagepub.com/en-us/nam/open-access-at-sage).

History

Date received : 23 December 2018

Date accepted : 29 March 2019

Custom metadata

cover-date January-December 2019

Keywords: acute respiratory failure,high-flow nasal cannula,idiopathic pulmonary fibrosis,non-invasive mechanical ventilation

Data availability:

Keywords: acute respiratory failure, high-flow nasal cannula, idiopathic pulmonary fibrosis, non-invasive mechanical ventilation

High-flow nasal cannula oxygen therapy to treat acute respiratory failure in patients with acute exacerbation of idiopathic pulmonary fibrosis

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Abstract

Background:

Method and design:

Patients and interventions:

Results:

Conclusions:

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Most cited references 31

A multidimensional index and staging system for idiopathic pulmonary fibrosis.

Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008

Acute exacerbation of idiopathic pulmonary fibrosis: incidence, risk factors and outcome.

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