Thread by @WellingtonICU

Here is this week's @WellingtonICU #Twitterjournalclub prepared by Rosanna Rahman. We are so committed, we don't even stop for #SMACC
thelancet.com/journals/lanre…

Patients with acute hypoxemic respiratory failure (PaO2:FiO2 ratio ≤300mmHg) frequently require intubation in the intensive care unit.

Rapid sequence intubation (RSI) in the acute setting is associated with a high risk of life-threatening complications. Severe hypoxaemia (SpO2<80% for ≥5sec) occurs in 20-25% of patients and is associated with hypoxia-driven cardiac arrest.

Previous studies have found both high-flow oxygen therapy (HFOT) and non-invasive ventilation (NIV) during the preoxygenation stage of intubation to be superior to holding a mask in reducing risk of severe hypoxaemia.

The FLORALI-2 trial was a multicentre, non-blinded, open-label, parallel-group randomised, controlled trial of NIV versus HFOT for preoxygenation prior to intubation in patients with acute hypoxemic respiratory failure.

Twenty-eight intensive care units in France intubated 2079 patients between April 15th, 2016 and January 8th 2017. 313 patients met all inclusion criteria for the intention-to-treat analysis. 142 were randomised in to the NIV arm and 171 in to the HFOT arm.

Inclusion criteria included age >18 years, respiratory rate >25 bpm or increased work of breathing and (PaO2:FiO2 ratio ≤300mmHg).

Exclusion criteria included consent not given or withdrawn, intubation for cardiac arrest, Glasgow coma score <8, contraindications to NIV (e.g. facial fracture), pregnancy/breastfeeding, being under legal protection, pulse oximetry not available or data not recorded.

Preoxygenation was done with the patient recumbent at 30◦ and the clinician performing a jaw thrust to maintain a patent airway.

Patients received either NIV via a face mask and pressure support ventilation (expired tidal volume 6-8mL/kg of predicted bodyweight, PEEP 5cm H2O and FiO2 1.0) or HFOT via binasal prongs (humidified flow 60L/min, FiO2 1.0).

Only HFOT was continued during laryngoscopy.

The primary outcome was an episode of severe hypoxaemia between the beginning of RSI and 5min after confirmation of tracheal intubation by capnography. Secondary outcomes included SpO2 at the end of preoxygenation and the lowest value during the intubation period.

Serious adverse events included peri-RSI cardiac arrest, ventilator-acquired pneumonia, length of stay in ICU and mortality at day 28.

There were no statistically significant differences in patient demographics, primary or secondary outcomes or serious adverse events between NIV and HFOT arms.

A significant interaction between PaO2:FiO2 ratio at enrolment and treatment arm with respect to the primary outcome was found (p=0.003). Therefore, the results were reanalysed in two subgroups: patients with moderate-to-severe (PaO2:FiO2 ≤200) or mild (PaO2:FiO2 >200) hypoxemia

In patients with moderate-to-severe hypoxemia at enrolment, the risk of severe hypoxemia during intubation was lower with NIV than HFOT after adjustment for PaO2 at randomisation (p=0.0459).

In the moderate-to-severe subgroup, the NIV arm also demonstrated higher pulse oximetry readings at the end preoxygenation (p=0.02) and a higher average “lowest” pulse oximetry during intubation (p=0.02).

No statistical adjustments were made for multiple comparisons, therefore all subgroup analyses should be considered observational.

The secondary analysis was suggestive of a benefit to using NIV for preoxygenation in patients with moderate-to-severe hypoxemia. However, the generlisability of the findings may be limited given the high number of patients that did not meet the study inclusion criteria.

There is also arguably little clinical significance of the results as oxygenation strategy had no effect on mortality or other patient-important outcomes, regardless of patient subgroup.

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