1. 15/12/2022
www.brn.cat
BRN Trustees:
Unidades de Cuidados Respiratorios
Intermedios (UCRIs)
Chairs: Dr. Miquel Ferrer (H. Clínic), Dr. Manel Luján (H. Parc Taulí)
Speakers: Dra. Marina Galdeano (H. Germans Trias), Dr. Miquel Ferrer
(H. Clínic), Dra. Elena Prina (H. de Sabadell), Dr. Carlos Ferrando (H.
Clínic)

2. 15/12/2022
Alto flujo nasal en la insuficiencia respiratoria aguda.
Presentación de las últimas guías.
Dr. Miquel Ferrer
UVIR, Servei de Pneumologia, Institut Clínic de Respiratori, Clinic Barcelona, IDIBAPS,
CibeRes, Universitat de Barcelona.
E-mail: miferrer@clinic.cat
BRN Trustees:
Unidades de Cuidados Respiratorios Intermedios (UCRIs)

3. High Flow Nasal Therapy
Minimal flow: 40 L/min
(40-60)

4.  HFNC has become a frequently used non-invasive respiratory support in
acute settings
• Evidence supporting its use has only recently emerged
 Limited evidence on the most appropriate NIRS in different ARF scenarios
• HFNC is more comfortable and tolerated compared to COT and NIV
• Lower ability than NIV to unload respiratory muscles in ARF
• Prolonging NIRS in patients failing with either HFNC and NIV may result
in delayed intubation and worsen hospital mortality
 These guidelines provide evidence-based recommendations for the use of
HFNC alongside other NIRS forms in adults with ARF

5. Composition of the task force panel:
 18 clinicians with expertise in respiratory and acute care
medicine
• Leadership: 2 clinical chairs
 The methodology team
 ERS methodologist with experience in guidelines
development using GRADE methodology
 ELF representative for patient’s perspective

6. • Estimate of effect per outcome
• Quality of evidence per outcome
• RCTs start from high quality,
observational studies from low
• 5 factors that might result in rating
quality down (risk of bias, inconsistency,
indirectness, imprecision, publication
bias)
• 3 factors that might result in rating up
observational studies (large effect, dose-
response, antagonistic bias)
• Rate overall quality of evidence across
outcomes
The GRADE approach
Grading of Recommendations, Assessment, Development and Evaluation

7. PICO QUESTIONS
Ask an answerable question! Formulate the
questions/ outcomes to facilitate your search and
the management of your results
Use the PICO format
• Population
• Intervention
• Comparison
• Outcome
7
Populations:
1.Acute hypoxemic respiratory failure
2.Post-operative after extubation
3.Non-surgical after extubation
4.Acute hypercapnic respiratory failure
Interventions:
1.HFNC
2.HFNC during breaks from NIV
Comparisons:
1. NIV
2. COT
Outcomes:
1. Mortality (early, late)
2. Intubation
3. Escalation to NIV
4. Length of stay (ICU, hospital)
5. Comfort, dyspnoea
6. Blood gases (PaO2, PaCO2,..)
7. Respiratory rate

8. Recommendation 1: HFNC vs COT in hypoxemic respiratory failure

9. Recommendation 1: HFNC vs COT in hypoxemic respiratory failure

10. Recommendation 1: HFNC vs COT in hypoxemic respiratory failure

11. Recommendation 2: HFNC vs NIV in hypoxemic respiratory failure

12. Recommendation 2: HFNC vs NIV in hypoxemic respiratory failure

13. Recommendation 3: HFNC or COT during breaks from NIV in hypoxemic ARF
Spoletini G et al. J Crit Care 2018; 48: 418–25
Change in Respiratory Rate
Change in Dyspnoea Score
Change in Comfort Score

14. Recommendation 4: HFNC vs. COT in post-operative patients

15. Recommendation 4: HFNC vs. COT in post-operative patients

16. Recommendation 5: HFNC vs. NIV in post-operative patients

17. Recommendation 6: HFNC vs. COT to prevent extubation failure in
non-surgical patients

18. Recommendation 6: HFNC vs. COT to prevent extubation failure in
non-surgical patients

19. Recommendation 7: HFNC vs. NIV to prevent extubation failure in
non-surgical patients

20. Recommendation 7: HFNC vs. NIV to prevent extubation failure in
non-surgical patients

21. Recommendation 8: HFNC vs. NIV in hypercapnic respiratory failure

22. Recommendation 8: HFNC vs. NIV in hypercapnic respiratory failure

23. PICO questions Recommmendations Certainty of Evidence
1. HFNC or COT in AHRF? Use of HFNC over COT in AHRF Conditional
recommendation
Moderate certainty of
evidence
2. HFNC or NIV in AHRF? Use of HFNC over NIV in AHRF Conditional
recommendation
Very low certainty of
evidence
3.HFNC or COT during breaks
from NIV in AHRF?
Use of HFNC over COT during
breaks from NIV AHRF
Conditional
recommendation
Low certainty of
evidence
4. HFNC or COT in post-
operative patients after
extubation?
Use of either COT or HFNC in
post-operative patients at low risk
of respiratory complications
Conditional
recommendation
Low certainty of
evidence
5. HFNC or NIV in post-operative
patients after extubation?
Use of either HFNC or NIV in post-
operative patients at high risk of
respiratory complications
Conditional
recommendation
Low certainty of
evidence
6. HFNC or COT in nonsurgical
patients after extubation?
Use of HFNC over COT in
nonsurgical patients after
extubation
Conditional
recommendation
Low certainty of
evidence
7. HFNC or NIV in nonsurgical
patients after extubation?
Use of NIV over HFNC for patients
at high risk of extubation failure,
unless contraindications to NIV
Conditional
recommendation
Moderate certainty of
evidence
8. HFNC or NIV in acute
hypercapnic respiratory failure?
A trial of NIV prior to use of HFNC
in COPD and acute hypercapnic
respiratory failure
Conditional
recommendation
Low certainty of
evidence