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Review
. 2024 Oct 18;14(1):158.
doi: 10.1186/s13613-024-01389-w.

Oxygen therapy and noninvasive respiratory supports in acute hypoxemic respiratory failure: a narrative review

Arnaud W Thille  1   2 , Frédéric Balen  3   4 , Guillaume Carteaux  5   6   7 , Tahar Chouihed  8   9 , Jean-Pierre Frat  10   11 , Christophe Girault  12 , Erwan L'Her  13 , Nicolas Marjanovic  11   14 , Mai-Anh Nay  15 , Patrick Ray  16 , Matthieu Reffienna  17 , Leo Retenauer  18 , Antoine Roch  19 , Guillaume Thiery  20   21 , Jennifer Truchot  22
Affiliations
Review

Oxygen therapy and noninvasive respiratory supports in acute hypoxemic respiratory failure: a narrative review

Arnaud W Thille et al. Ann Intensive Care. .

Abstract

Background: This narrative review was written by an expert panel to the members of the jury to help in the development of clinical practice guidelines on oxygen therapy.

Results: According to the expert panel, acute hypoxemic respiratory failure was defined as PaO2 < 60 mm Hg or SpO2 < 90% on room air, or PaO2/FiO2 ≤ 300 mm Hg. Supplemental oxygen should be administered according to the monitoring of SpO2, with the aim at maintaining SpO2 above 92% and below 98%. Noninvasive respiratory supports are generally reserved for the most hypoxemic patients with the aim of relieving dyspnea. High-flow nasal cannula oxygen (HFNC) seems superior to conventional oxygen therapy (COT) as a means of avoiding intubation and may therefore be should probably be used as a first-line noninvasive respiratory support in patients requiring more than 6 L/min of oxygen or PaO2/FiO2 ≤ 200 mm Hg and a respiratory rate above 25 breaths/minute or clinical signs of respiratory distress, but with no benefits on mortality. Continuous positive airway pressure (CPAP) cannot currently be recommended as a first-line noninvasive respiratory support, since its beneficial effects on intubation remain uncertain. Despite older studies favoring noninvasive ventilation (NIV) over COT, recent clinical trials fail to show beneficial effects with NIV compared to HFNC. Therefore, there is no evidence to support the use of NIV or CPAP as first-line treatment if HFNC is available. Clinical trials do not support the hypothesis that noninvasive respiratory supports may lead to late intubation. The potential benefits of awake prone positioning on the risk of intubation in patients with COVID-19 cannot be extrapolated to patients with another etiology.

Conclusions: Whereas oxygen supplementation should be initiated for patients with acute hypoxemic respiratory failure defined as PaO2 below 60 mm Hg or SpO2 < 90% on room air, HFNC should be the first-line noninvasive respiratory support in patients with PaO2/FiO2 ≤ 200 mm Hg with increased respiratory rate. Further studies are needed to assess the potential benefits of CPAP, NIV through a helmet and awake prone position in patients with acute hypoxemic respiratory failure not related to COVID-19.

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Conflict of interest statement

AWT, MAN, JPF received fees from Fisher&Paykel (travel expense coverage to attend scientific meetings and payments for lectures). GC received personal fees from Air Liquide Medical System, GE Healthcare, Dräger, Fisher&Paykel, Medtronic and Lowenstein.

References

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