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Table of Contents
LETTER TO EDITOR
Year : 2020  |  Volume : 22  |  Issue : 3  |  Page : 191-192

Safety comparison between high-flow nasal cannula and noninvasive positive pressure ventilation for coronavirus disease 2019 patients


1 Department of Anaesthesiology and Critical Care, Maulana Azad Medical College, New Delhi, India
2 Department of Anaesthesiology and Intensive Care, Maulana Azad Medical College, New Delhi, India

Date of Submission05-Aug-2020
Date of Acceptance09-Aug-2020
Date of Web Publication31-Dec-2020

Correspondence Address:
Dr. Deepak Kumar
Type-2, Sector-C/241, Albert Square, New Delhi - 110 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ejop.ejop_95_20

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How to cite this article:
Kumar D, Kumar A, Kohli A. Safety comparison between high-flow nasal cannula and noninvasive positive pressure ventilation for coronavirus disease 2019 patients. Eurasian J Pulmonol 2020;22:191-2

How to cite this URL:
Kumar D, Kumar A, Kohli A. Safety comparison between high-flow nasal cannula and noninvasive positive pressure ventilation for coronavirus disease 2019 patients. Eurasian J Pulmonol [serial online] 2020 [cited 2021 Jan 16];22:191-2. Available from: https://www.eurasianjpulmonol.com/text.asp?2020/22/3/191/305722



Dear Editor,

We have read with great interest the surviving sepsis campaign: Guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19).[1] There is still long debate on the recommendation to use high-flow nasal cannula (HFNC) over noninvasive positive pressure ventilation (NIPPV). We agree that HFNC has demonstrated reduced 90-day mortality compared to NIPPV in patients with acute hypoxemic respiratory failure.[2] This lower mortality observed in the HFNC may have resulted from the cumulative effects of less intubation, particularly in patients with severe hypoxemia (PaO2:FiO2 ≤ 200 mm Hg), as compared with other patients. Various studies have shown NIPPV has been demonstrated to have increased risk of aerosolized transmission to health care workers.[3] Presently, it is known that COVID-19 (SARS-CoV-2) compared to SARS-CoV-1 remains viable in aerosols for at least 3 h with a marginal reduction in infectious titer from 103.5 to 102.7 TCID50 per liter of air.[4] Similarly, it showed higher stability on plastic and stainless steel than on copper and cardboard, with virus viability seen up to 72 h on these surfaces.[4] This provides a concerning phenomenon for both HFNC and NIPPV as both plastic interface (plastic cannula in HFNC and plastic disposable mask in NIPPV) with potential for aerosolization. An important difference is that the NIPPV interface provides a potential closed system (which may be advantageous), whereas HFNC allows patients to frequently touch their faces, eyes with continuous exposure to droplets, potentially increasing transmission to inanimate surfaces and hospital workers. However, Leung et al., in 2019, found that HFNC use was not associated with increased air or contact surface for bacterial contamination compared to simple oxygen masks in critically ill patients.[5] Unfortunately, viruses were not included in this study. Likewise, the term “aerosol” is a misnomer as it is well described that larger particle droplets can remain longer in circulation if ambient airflows (as in HFNC) sustain the infectious suspension for a longer duration. In addition, there are various other advantages of HFNC as many studies reported that early application of prone position with HFNC therapy, especially in patients with moderate acute respiratory distress syndrome (ARDS), may help avoid intubation but not in the several ARDS group.[6] The only known retrospective study evaluating SARS development in hospital workers conducted before the widespread use of HFNC showing that development of SARS occurred in tracheal intubation (35%), 38% (NIPPV) and HFNC 8%,[3] this suggests that both noninvasive (including HFNC) and invasive ventilation approaches carry significant risk. Undeniably, in these patients, HFNC provides more comfort and likely improved compliance. However, since the data regarding transmission are unclear, we suggest, in addition to a negative pressure room, reverse isolation protection efforts with patients on HFNC wearing an N-95 mask over the nasal interface or a contained respiratory hood will further decrease the aerosol production and provide better fitting of nasal cannula.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Alhazzani W, Moller MH, Arabi YM, Loeb M, Gong MN, Fan E. Surviving sepsis campaign: Guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19). Intensive Care Med 2020;46:854-87.  Back to cited text no. 1
    
2.
Frat JP, Thille AW, Mercat A, Girault C, Ragot S, Perbet S, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med 2015;372:2185-96.  Back to cited text no. 2
    
3.
Raboud J, Shigayeva A, McGeer A, Bontovics E, Chapman M, Gravel D, et al. Risk factors for SARS transmission from patients requiring intubation: A multicentre investigation in Toronto, Canada. PLoS One 2010;5:e10717.  Back to cited text no. 3
    
4.
van Doremalen N, Bushmaker T, Morris DH, Holbrook MG, Gamble A, Williamson BN, et al. Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1. N Engl J Med 2020;382:1564-7.  Back to cited text no. 4
    
5.
Leung CC, Joynt GM, Gomersall CD, Wong WT, Lee A, Ling L, et al. Comparison of high-flow nasal cannula versus oxygen face mask for environmental bacterial contamination in critically ill pneumonia patients: A randomized controlled crossover trial. J Hosp Infect 2019;101:84-7.  Back to cited text no. 5
    
6.
Ding L, Wang L, Ma W, He H. Efficacy and safety of early prone positioning combined with HFNC or NIV in moderate to severe ARDS: A multi-center prospective cohort study. Crit Care 2020;24:28.  Back to cited text no. 6
    




 

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