High-Flow Oxygen Therapy vs. Non-Invasive ventilation: Insights from the Renovate Trial
For years, the medical community has debated the optimal treatment for patients in respiratory distress: high-flow oxygen therapy (HTO) or non-invasive ventilation (NIV). The Renovate trial, a groundbreaking study conducted across 33 Brazilian hospitals, has shed new light on this critical issue. According to Professor Marc Leone, vice-president of the french Society of Anesthesia and Resuscitation (Sfar), “The Renovate trial addresses a debate that has been going on for several years on the choice of high-flow oxygen therapy or non-invasive ventilation for patients in respiratory distress.”
The study, which included 1,766 adult patients, aimed to determine whether HTO was non-inferior to NIV in preventing endotracheal intubation or death within seven days. Patients were categorized into five groups: non-immune deficient hypoxemic patients, immunodeficient hypoxemics, those with chronic obstructive pulmonary disease (COPD) exacerbation, cardiogenic pulmonary edema (CPO), and hypoxemic COVID-19 patients.
A More Cozy Option
Table of Contents
- A More Cozy Option
- Key Findings Across Patient Subgroups
- Future research Needed
- Summary of Key Findings
- High-Flow Oxygen Therapy: A Game-Changer in Respiratory Distress Management
- High-Flow Oxygen Therapy vs. Non-Invasive Ventilation: Key Insights
- Advantages of High-Flow Oxygen Therapy
- Limitations and Future Research
- Key Takeaways
- Summary of Key Findings
- Conclusion
High-flow oxygen therapy, which delivers warmed and humidified oxygen, has become a popular supportive therapy, especially during the COVID-19 pandemic. “High-flow oxygen therapy, compared to conventional oxygen therapy, provides warmed and humidified oxygen.It has the advantage of recruiting alveoli in the lung,” explains Professor Leone. Additionally, HTO offers greater patient comfort, allowing individuals to “eat, drink, and speak more easily than with NIV.”
The trial’s results, published in JAMA, revealed that 39% of the HTO group experienced intubation or death within seven days, compared to 38.1% in the NIV group. the incidence of severe adverse events was similar between the two groups, and there was no significant difference in 28-day mortality rates. However, patient comfort was notably higher in the HTO group.
Key Findings Across Patient Subgroups
The study found that HTO was non-inferior to NIV for most patient subgroups:
- Non-immune deficient hypoxemic patients: 32.5% vs. 33.1%
- COPD exacerbation: 28.6% vs. 26.2%
- Cardiogenic pulmonary edema: 10.3% vs. 21.3%
- Hypoxemic COVID-19 patients: 51.3% vs.47%
However, HTO was less effective for immunocompromised hypoxemic patients, with 57.1% experiencing intubation or death within seven days compared to 36.4% in the NIV group.
Future research Needed
While the Renovate trial provides valuable insights, the authors emphasize the need for further research. The small sample sizes in certain subgroups—such as COPD (n = 77), immunocompromised (n = 50), and CPO (n = 272) patients—highlight the necessity for larger, more focused studies.
Summary of Key Findings
| Patient Subgroup | HTO Intubation/Death Rate | NIV Intubation/Death Rate | Non-Inferiority Margin |
|————————————|——————————-|——————————-|—————————-|
| Non-immune deficient hypoxemic | 32.5% | 33.1% | 0.999 |
| COPD exacerbation | 28.6% | 26.2% | 0.992 |
| Cardiogenic pulmonary edema | 10.3% | 21.3% | 0.997 |
| Hypoxemic COVID-19 patients | 51.3% | 47% | 0.997 |
| Immunocompromised hypoxemic | 57.1% | 36.4% | 0.989 |
The Renovate trial underscores the potential of high-flow oxygen therapy as a viable alternative to non-invasive ventilation for most patients in respiratory distress. However, immunocompromised individuals may still benefit more from NIV.As Professor Leone aptly notes, “The results indicate that there is no additional risk, apart from for the immunocompromised, in putting patients on high flow.”
For more detailed findings, explore the full study published in JAMA.
High-Flow Oxygen Therapy: A Game-Changer in Respiratory Distress Management
Recent studies have sparked a significant shift in the approach to treating respiratory distress, particularly in patients with conditions like COPD, OPC, and acute hypoxemic episodes. According to Professor Marc Leone of North Hospital, AP-HM, “quite surprisingly, subgroup comparisons even show that high flow is slightly better than NIV in hypercapnic patients, that is to say those with COPD or OPC, in whom NIV is usually favored.” This revelation challenges the long-standing preference for non-invasive ventilation (NIV) in such cases.
Traditionally, NIV has been the go-to treatment for respiratory distress caused by exacerbations of COPD and cardiogenic pulmonary edema. However, as the Brazilian team points out, “if the recommendations today indicate the use of NIV for respiratory distress caused by exacerbations of COPD and cardiogenic pulmonary edema, they were in fact based on a comparison of NIV with conventional oxygen therapy.” This raises questions about whether high-flow oxygen therapy (OHD) might be a more effective alternative.
OHD has already gained traction in treating acute hypoxemic episodes, including in immunocompromised patients and those with COVID-19. “OHD is preferred over low flow to treat patients with an acute hypoxemic episode, also including the immunocompromised and Covid-19,” notes Professor Leone.
Practical Implications for Clinicians
For healthcare teams proficient in both techniques, the choice between OHD and NIV can be tailored to patient comfort and tolerance. “This is not the first study to present such results,” says Professor Leone. “Thus, for teams mastering both techniques, the choice can be made based on patient comfort and tolerance.For others,there is no danger in putting a patient in respiratory distress on high-flow oxygen therapy.”
NIV, while effective, is a more complex procedure requiring specialized expertise and significant medical and paramedical resources. “In addition, for the patient, NIV can be more uncomfortable and impose variations in respiratory pressure,” adds Professor Leone.
A Safe Transition Therapy
In their editorial published in JAMA, Professors Jean-Pierre Frat and Arnaud Thille, along with Dr. Sylvain Le pape from Poitiers University Hospital,offer a nuanced viewpoint. “Rather than suggesting that OHD can universally replace NIV for all etiologies of respiratory distress,” they argue, “these results indicate that initiating treatment with OHD is generally not harmful.”
They emphasize that OHD provides clinicians with valuable time to diagnose and determine the underlying cause of respiratory distress before selecting the most appropriate treatment.“This interpretation provides data giving clinicians time to make a diagnosis and find the cause of respiratory distress before choosing the most appropriate option,” they explain.They describe OHD as a “safe transition therapy.”
Key Comparisons: OHD vs. NIV
| Aspect | High-Flow Oxygen Therapy (OHD) | Non-Invasive Ventilation (NIV) |
|————————–|————————————|————————————|
| Patient Comfort | Generally more comfortable | Can be uncomfortable |
| Technical complexity | Less complex | Requires expertise |
| Resource Intensity | Lower | Higher |
| Preferred For | Acute hypoxemic episodes, COPD | COPD, cardiogenic pulmonary edema |
Conclusion
The growing body of evidence suggests that high-flow oxygen therapy is not only a viable alternative to NIV but may even offer superior outcomes in certain patient subgroups. As Professor Leone succinctly puts it, “There is no danger in putting a patient in respiratory distress on high-flow oxygen therapy.” For clinicians,this means greater adaptability and the ability to prioritize patient comfort and safety while managing respiratory distress effectively.
For further insights, explore the full study in JAMA and the accompanying editorial by Professors Frat, Thille, and Dr.Le Pape.
With acute hypoxemic respiratory failure,” explains Professor Leone. The ability of HTO to deliver warmed and humidified oxygen, improve alveolar recruitment, and enhance patient comfort has made it a compelling option in clinical practice.
High-Flow Oxygen Therapy vs. Non-Invasive Ventilation: Key Insights
The Renovate trial compared high-flow oxygen therapy (HTO) with non-invasive ventilation (NIV) in preventing endotracheal intubation or death within seven days across various patient subgroups. The study included 1,766 adult patients categorized into five groups:
- Non-immune deficient hypoxemic patients
- Immunodeficient hypoxemic patients
- Patients with COPD exacerbation
- Patients with cardiogenic pulmonary edema (CPO)
- Hypoxemic COVID-19 patients
Key Findings:
- Overall outcomes:
– 39% of the HTO group experienced intubation or death within seven days, compared to 38.1% in the NIV group.
– No significant difference in 28-day mortality rates or severe adverse events was observed.
– HTO was associated with significantly greater patient comfort.
- Subgroup Analysis:
– Non-immune deficient hypoxemic patients: 32.5% (HTO) vs. 33.1% (NIV)
– COPD exacerbation: 28.6% (HTO) vs. 26.2% (NIV)
– Cardiogenic pulmonary edema: 10.3% (HTO) vs. 21.3% (NIV)
– Hypoxemic COVID-19 patients: 51.3% (HTO) vs. 47% (NIV)
– Immunocompromised hypoxemic patients: 57.1% (HTO) vs. 36.4% (NIV)
HTO demonstrated non-inferiority to NIV in most subgroups,except for immunocompromised patients,were NIV was more effective.
Advantages of High-Flow Oxygen Therapy
- Improved Comfort: Patients can eat, drink, and speak more easily compared to NIV.
- Alveolar Recruitment: Warmed and humidified oxygen helps recruit alveoli, improving oxygenation.
- Less Invasive: HTO avoids the discomfort and complications associated with NIV masks.
Limitations and Future Research
While the trial provides valuable insights, certain limitations, such as small sample sizes in specific subgroups (e.g., COPD, immunocompromised, CPO), highlight the need for further research. larger, more focused studies are necessary to confirm these findings and refine clinical guidelines.
Key Takeaways
- HTO is a viable alternative to NIV for most patients with respiratory distress, offering comparable outcomes and superior comfort.
- Immunocompromised patients may still benefit more from NIV.
- The results challenge traditional preferences for NIV in hypercapnic patients, suggesting HTO could be equally effective or superior in some cases.
Summary of Key Findings
| Patient subgroup | HTO Intubation/Death Rate | NIV Intubation/Death Rate | non-Inferiority Margin |
|————————————|——————————-|——————————-|—————————-|
| Non-immune deficient hypoxemic | 32.5% | 33.1% | 0.999 |
| COPD exacerbation | 28.6% | 26.2% | 0.992 |
| Cardiogenic pulmonary edema | 10.3% | 21.3% | 0.997 |
| Hypoxemic COVID-19 patients | 51.3% | 47% | 0.997 |
| Immunocompromised hypoxemic | 57.1% | 36.4% | 0.989 |
Conclusion
The Renovate trial highlights the potential of high-flow oxygen therapy as a comfortable and effective alternative to non-invasive ventilation for most patients in respiratory distress. Though, immunocompromised patients may still derive greater benefit from NIV. As Professor Leone notes, “There is no additional risk, apart from for the immunocompromised, in putting patients on high flow.”
For more detailed findings, explore the full study published in JAMA.
