David P Yamane, Christopher W Jones, R Gentry Wilkerson, Joshua J Oliver, Soroush Shahamatdar, Aditya Loganathan, Taylor Bolden, Ryan Heidish, Connor L Kelly, Amy Bergeski, Jessica S Whittle, George C Dungan, Richard Maisiak, Andrew C Meltzer
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We aimed to determine whether high-velocity nasal insufflation (HVNI) is noninferior to NiPPV in relieving dyspnea within 4 h in ED patients with acute hypercapnic respiratory failure.</p><p><strong>Methods: </strong>This randomized control trial was conducted in seven EDs in the United States. Symptomatic patients with suspected COPD, partial pressure of carbon dioxide (pCO<sub>2</sub>) ≥ 60 mm Hg, and venous pH 7.0-7.35 were randomized to receive HVNI (n = 36) or NiPPV (n = 32). The primary outcome was dyspnea severity 4 h after the initiation of study intervention, as measured by the Borg score. Secondary outcomes included vital signs, oxygen saturation, venous pCO<sub>2</sub>, venous pH, patient discomfort level, and need for endotracheal intubation.</p><p><strong>Results: </strong>Sixty-eight patients were randomized between November 5, 2020, and May 10, 2023 (mean age 65.6 years; 47% women). The initial pCO<sub>2</sub> was 77.7 ± 13.6 mm Hg versus 76.5 ± 13.6 mm Hg and the initial venous pH was 7.27 ± 0.063 versus 7.27 ± 0.043 in the HVNI and NiPPV groups, respectively. Dyspnea was similar in the HVNI and NiPPV groups at baseline (dyspnea scale score 5.4 ± 2.93 and 5.6 ± 2.41) and HVNI was noninferior to NiPPV at the following time points: 30 min (3.97 ± 2.82 and 4.54 ± 1.65, p = 0.006), 60 min (3.09 ± 2.70 and 4.07 ± 1.77, p < 0.001), and 4 h (3.17 ± 2.59 and 3.34 ± 2.04, p = 0.03). At 4 h, there was no difference between the groups in the pCO<sub>2</sub> mm Hg (68.76 and 67.29, p = 0.63). Patients reported better overall comfort levels in the HVNI group at 30 min, 60 min, and 4 h (p = 0.003).</p><p><strong>Conclusions: </strong>In participants with symptomatic COPD, HVNI was noninferior to NiPPV in relieving dyspnea 4 h after therapy initiation. 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Noninvasive positive pressure ventilation (NiPPV) is commonly used to help relieve symptoms but is limited due to patient intolerance. We aimed to determine whether high-velocity nasal insufflation (HVNI) is noninferior to NiPPV in relieving dyspnea within 4 h in ED patients with acute hypercapnic respiratory failure.</p><p><strong>Methods: </strong>This randomized control trial was conducted in seven EDs in the United States. Symptomatic patients with suspected COPD, partial pressure of carbon dioxide (pCO<sub>2</sub>) ≥ 60 mm Hg, and venous pH 7.0-7.35 were randomized to receive HVNI (n = 36) or NiPPV (n = 32). The primary outcome was dyspnea severity 4 h after the initiation of study intervention, as measured by the Borg score. Secondary outcomes included vital signs, oxygen saturation, venous pCO<sub>2</sub>, venous pH, patient discomfort level, and need for endotracheal intubation.</p><p><strong>Results: </strong>Sixty-eight patients were randomized between November 5, 2020, and May 10, 2023 (mean age 65.6 years; 47% women). The initial pCO<sub>2</sub> was 77.7 ± 13.6 mm Hg versus 76.5 ± 13.6 mm Hg and the initial venous pH was 7.27 ± 0.063 versus 7.27 ± 0.043 in the HVNI and NiPPV groups, respectively. Dyspnea was similar in the HVNI and NiPPV groups at baseline (dyspnea scale score 5.4 ± 2.93 and 5.6 ± 2.41) and HVNI was noninferior to NiPPV at the following time points: 30 min (3.97 ± 2.82 and 4.54 ± 1.65, p = 0.006), 60 min (3.09 ± 2.70 and 4.07 ± 1.77, p < 0.001), and 4 h (3.17 ± 2.59 and 3.34 ± 2.04, p = 0.03). At 4 h, there was no difference between the groups in the pCO<sub>2</sub> mm Hg (68.76 and 67.29, p = 0.63). 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引用次数: 0
摘要
背景：急诊科慢性阻塞性肺疾病（COPD）的急性加重包括呼吸困难、咳嗽和胸部不适；频繁的恶化与死亡率增加和生活质量下降有关。无创正压通气（NiPPV）通常用于帮助缓解症状，但由于患者不耐受而受到限制。我们的目的是确定高速鼻灌气（HVNI）在缓解急性高碳酸血症性呼吸衰竭ED患者4小时内的呼吸困难方面是否优于NiPPV。方法：该随机对照试验在美国的7个急诊科进行。有症状的疑似COPD患者，二氧化碳分压(pCO2)≥60 mm Hg，静脉pH 7.0 ~ 7.35随机分为HVNI组（n = 36）和NiPPV组（n = 32）。主要终点是研究干预开始后4小时的呼吸困难严重程度，以Borg评分衡量。次要结局包括生命体征、血氧饱和度、静脉二氧化碳分压、静脉pH值、患者不适程度和是否需要气管插管。结果：68例患者在2020年11月5日至2023年5月10日期间随机分组(平均年龄65.6岁；47%的女性)。HVNI组和NiPPV组初始pCO2分别为77.7±13.6 mm Hg和76.5±13.6 mm Hg，初始静脉pH分别为7.27±0.063和7.27±0.043。HVNI组和NiPPV组在基线时的呼吸困难相似（呼吸困难量表评分分别为5.4±2.93和5.6±2.41），HVNI组在以下时间点的呼吸困难不低于NiPPV: 30分钟（3.97±2.82和4.54±1.65,p = 0.006）， 60分钟(3.09±2.70和4.07±1.77,p 2 mm Hg（68.76和67.29,p = 0.63）。HVNI组患者在30分钟、60分钟和4小时时报告的总体舒适度更好（p = 0.003）。结论：在有症状的COPD患者中，HVNI在治疗开始4小时后缓解呼吸困难的效果不逊于NiPPV。HVNI可能是一些在急诊科经历慢性阻塞性肺病中度急性加重的患者的合理治疗选择。
High-velocity nasal insufflation versus noninvasive positive pressure ventilation for moderate acute exacerbation of chronic obstructive pulmonary disease in the emergency department: A randomized clinical trial.
Background: Acute exacerbations of chronic obstructive pulmonary disease (COPD) in the emergency department (ED) involve dyspnea, cough, and chest discomfort; frequent exacerbations are associated with increased mortality and reduced quality of life. Noninvasive positive pressure ventilation (NiPPV) is commonly used to help relieve symptoms but is limited due to patient intolerance. We aimed to determine whether high-velocity nasal insufflation (HVNI) is noninferior to NiPPV in relieving dyspnea within 4 h in ED patients with acute hypercapnic respiratory failure.
Methods: This randomized control trial was conducted in seven EDs in the United States. Symptomatic patients with suspected COPD, partial pressure of carbon dioxide (pCO2) ≥ 60 mm Hg, and venous pH 7.0-7.35 were randomized to receive HVNI (n = 36) or NiPPV (n = 32). The primary outcome was dyspnea severity 4 h after the initiation of study intervention, as measured by the Borg score. Secondary outcomes included vital signs, oxygen saturation, venous pCO2, venous pH, patient discomfort level, and need for endotracheal intubation.
Results: Sixty-eight patients were randomized between November 5, 2020, and May 10, 2023 (mean age 65.6 years; 47% women). The initial pCO2 was 77.7 ± 13.6 mm Hg versus 76.5 ± 13.6 mm Hg and the initial venous pH was 7.27 ± 0.063 versus 7.27 ± 0.043 in the HVNI and NiPPV groups, respectively. Dyspnea was similar in the HVNI and NiPPV groups at baseline (dyspnea scale score 5.4 ± 2.93 and 5.6 ± 2.41) and HVNI was noninferior to NiPPV at the following time points: 30 min (3.97 ± 2.82 and 4.54 ± 1.65, p = 0.006), 60 min (3.09 ± 2.70 and 4.07 ± 1.77, p < 0.001), and 4 h (3.17 ± 2.59 and 3.34 ± 2.04, p = 0.03). At 4 h, there was no difference between the groups in the pCO2 mm Hg (68.76 and 67.29, p = 0.63). Patients reported better overall comfort levels in the HVNI group at 30 min, 60 min, and 4 h (p = 0.003).
Conclusions: In participants with symptomatic COPD, HVNI was noninferior to NiPPV in relieving dyspnea 4 h after therapy initiation. HVNI may be a reasonable treatment option for some patients experiencing moderate acute exacerbations of COPD in the ED.
期刊介绍：
Academic Emergency Medicine (AEM) is the official monthly publication of the Society for Academic Emergency Medicine (SAEM) and publishes information relevant to the practice, educational advancements, and investigation of emergency medicine. It is the second-largest peer-reviewed scientific journal in the specialty of emergency medicine.
The goal of AEM is to advance the science, education, and clinical practice of emergency medicine, to serve as a voice for the academic emergency medicine community, and to promote SAEM''s goals and objectives. Members and non-members worldwide depend on this journal for translational medicine relevant to emergency medicine, as well as for clinical news, case studies and more.
Each issue contains information relevant to the research, educational advancements, and practice in emergency medicine. Subject matter is diverse, including preclinical studies, clinical topics, health policy, and educational methods. The research of SAEM members contributes significantly to the scientific content and development of the journal.
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