Randomized Controlled Trial of Humidified High-Flow Nasal Oxygen for Acute Respiratory Distress in the Emergency Department: The HOT-ER Study

BACKGROUND: Humidified high-flow nasal cannula (HFNC) is a novel method of oxygen delivery with increasing use in emergency departments and intensive care settings despite little evidence' showing benefit over standard oxygen delivery,methods (standard O-2). The aim of this study was to determine whether HFNC compared with standard O-2 given to subjects in acute respiratory distress would reduce the need for noninvasive ventilation or invasive ventilation. METHODS: This was a pragmatic open randomized controlled trial in adult subjects with hypoxia and tachypnea presenting to a tertiary academic hospital emergency department. The primary outcome was the need for mechanical ventilation in the emergency department. RESULTS: We screened 1,287 patients, 322 met entry criteria and 19 were excluded from analysis. Of these, 165 randomized to HFNC and 138 to standard O-2 were analyzed. Baseline characteristics were similar. In the HFNC group, 3.6% (95% CI 1.5-7.9%) versus 7.2% (95% CI 3.8-13%) in the standard O-2 group required mechanical ventilation in the emergency department (P = .16), and 5.5% (95% CI 2.8-10.2%) in HFNC versus 11.6% (95% CI 7.2-18.1%) in the standard O-2 group required mechanical ventilation within 24 h of admission (P = .053). There was no difference in mortality or stay. Adverse effects were infrequent; however, fewer subjects in the HFNC group had a fall in Glasgow coma score due to CO2 retention, 0% (95% CI 0-3%) versus 2.2% (95% CI 0.4-6%). One in 12 subjects did not tolerate HFNC. CONCLUSIONS: HFNC was not shown to reduce the need for mechanical ventilation in the emergency department for subjects with acute respiratory distress compared with standard O-2, although it was safe and may reduce the need for escalation of oxygen therapy within the first 24 h of admission. (C) 2016 Daedalus Enterprises