OptiTHO: Early Non-invasive Ventilation and High-flow Nasal Oxygen Therapy for Preventing Delayed Respiratory Failure in Hypoxemic Blunt Chest Trauma Patients.
Study Details
Study Description
Brief Summary
In blunt chest trauma patients without immediate life-threatening conditions, delayed respiratory failure and need for mechanical ventilation may still occur in 12 to 40% of patients, depending on the severity of the trauma, the preexisting conditions and the intensity of initial management.
In this context, non-invasive ventilation (NIV) is recommended in hypoxemic chest trauma patients, defined as a PaO2/FiO2 ratio < 200 mmHg. However, there is a large heterogeneity among studies regarding the severity of injuries, the degree of hypoxemia and the timing of enrollment. The interest of a preventive strategy during the early phase of blunt chest trauma, before the occurrence of respiratory distress or severe hypoxemia, is not formally established in the literature. Moreover, high-flow nasal oxygen therapy (HFNC-O2) appears to be a reliable and better tolerated alternative to conventional oxygen therapy (COT), associated with a significant reduction in intubation rate in hypoxemic patients.
Two NIV strategies are compared:
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In the experimental strategy, NIV is performed after inclusion in patients with moderate hypoxemia, defined by a PaO2/FiO2 ratio < 300 mmHg. The minimally required duration of NIV was 4 hours per day for at least 2 calendar days.
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In the control group, patients receive oxygen from nasal cannula or high concentration oxygen mask according to the FiO2 needed to achieve SpO2 > 92%. NIV is initiated only in patients having PaO2/FiO2 ratio < 200 mmHg under COT.
Investigators hypothesized that an early strategy associating HFNC-O2 and preventive NIV in hypoxemic blunt chest trauma patients may reduce the need for mechanical ventilation compared to the recommended strategy associating COT and late NIV.
Condition or Disease | Intervention/Treatment | Phase |
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N/A |
Study Design
Arms and Interventions
Arm | Intervention/Treatment |
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Experimental: An "early" NIV strategy associated with HFNC-O2
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Combination Product: Preventive strategy
In the experimental strategy, NIV is performed after inclusion in patients with moderate hypoxemia, defined by a PaO2/FiO2 ratio < 300 mmHg. The minimally required duration of NIV was 4 hours per day for at least 2 calendar days. The daily duration of NIV can be increased at the discretion of the physician in patients with signs of delayed respiratory failure under HFNC-O2 and improving under NIV. Beyond the first 48 hours, NIV and HFNC-O2 can be stopped and the patient switched to COT if respiratory rate < 25/min and SpO2 > 92% under FiO2 < 30% for at least 6 hours.
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Active Comparator: A "late" NIV strategy associated with COT
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Combination Product: Standard of care
In the control group, patients receive oxygen from nasal cannula or high concentration oxygen mask according to the FiO2 needed to achieve SpO2 > 92%. NIV is initiated only in patients having PaO2/FiO2 ratio < 200 mmHg under COT. A trial of curative NIV is allowed at the discretion of the physician in patients who have signs of delayed respiratory failure and no other organ dysfunction. The non-improvement of respiratory conditions after 1 hour of NIV, the NIV-dependence (≥ 12 consecutive hours) or NIV-intolerance should be considered as criteria for endotracheal intubation.
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Outcome Measures
Primary Outcome Measures
- Necessity to perform endotracheal intubation [Up to 14 days after randomization]
To ensure the consistency of indications across sites and reduce the risk of delayed intubation, the following criteria for endotracheal intubation must be used (only one criterion is needed): cardiac arrest or significant hemodynamic instability, deterioration of neurologic status, signs of persisting or worsening respiratory failure as defined by at least two of the following criteria: respiratory rate of more than 35 breaths per minute, lack of improvement in signs of high respiratory-muscle workload, development of copious tracheal secretions, signs of respiratory exhaustion (pH <7.32 or PaCO2 > 50 mmHg), major hypoxemia (PaO2/FiO2 ratio <100 or SpO2 <92% for more than 5 minutes).
Secondary Outcome Measures
- PaO2/FiO2 ratio [every 6 hours during the first 48 hours after randomization]
- Respiratory rate [every 6 hours during the first 48 hours after randomization]
- Dyspnea score [every 6 hours during the first 48 hours after randomization]
Dyspnea score : +2 = significant improvement; +1 = slight improvement; 0 = no change; -1 = slight deterioration ; -2 = significant deterioration
- ICU and hospital length of stay [Up to 14 days after randomization]
- ICU or in-hospital mortality [Up to 14 days after randomization]
- Number of ventilator free-days [Up to 14 days after randomization]
Days alive and without invasive or non-invasive mechanical ventilation
Eligibility Criteria
Criteria
Inclusion Criteria:
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Patient admitted in intensive care unit within 48 hours after a high-risk blunt chest trauma, defined by a TTS (Thorax Trauma Severity) score ≥ 8.
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Hypoxemia defined by a PaO2/FiO2 ratio < 300, and the absence of hypercapnia (PaCO2 < 45 mmHg).
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Without indication of endotracheal intubation at inclusion.
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Affiliated person or beneficiary of a social security scheme.
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Free, informed and written consent signed by the participant and the investigator (at the latest on the day of inclusion and before any examination required by the research).
Exclusion Criteria:
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Criteria relating to formal indication to NIV: Exacerbation of underlying chronic respiratory disease, cardiogenic pulmonary edema, severe neutropenia.
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Criteria relating to contraindications to NIV: Hemodynamic instability, Glasgow Coma Scale score ≤ 12 or excessive agitation, or other contraindications to non-invasive ventilation (active gastrointestinal bleeding, low level of consciousness, multiorgan failure, airway patency problems, lack of cooperation or hemodynamic instability).
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Associated traumatic lesions entailing particular risks: severe brain injury, complex facial trauma, tetraplegia, tracheobronchial or esophageal injuries, thoracic or abdominal trauma with indication for surgery by thoracotomy or laparotomy.
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Criteria relating to the regulation: A do-not-intubate order and a decision not to participate, persons placed under judicial protection, persons participating in another research including a period of exclusion still in course, severely altered physical and/or psychological health which, according to the investigator, could affect the participant's compliance of the study.
Contacts and Locations
Locations
Site | City | State | Country | Postal Code | |
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1 | CHU Amiens-Picardie | Amiens | France | 80054 | |
2 | CH d'Annecy | Annecy | France | ||
3 | CHU de Bordeaux | Bordeaux | France | 33076 | |
4 | CHU de Clermont-Ferrand | Clermont-Ferrand | France | 63003 | |
5 | APHP - Hôpital Beaujon | Clichy | France | 92110 | |
6 | AP-HM - Hôpital de la Timone | Marseille | France | 13385 | |
7 | CHU de Nîmes | Nîmes | France | 30029 | |
8 | CH de Pau | Pau | France | 64000 | |
9 | HCL - Hôpital Lyon Sud | Pierre-Bénite | France | 69495 | |
10 | CHU de Poitiers | Poitiers | France | 86021 | |
11 | CHU de Saint Etienne | Saint-Priest-en-Jarez | France | 42270 | |
12 | CHU de Strasbourg - Hôpital Civil | Strasbourg | France | 67091 | |
13 | CHU de Strasbourg -Hôpital de Hautepierre | Strasbourg | France | 67200 | |
14 | Hôpital Robert Picqué | Villenave-d'Ornon | France | 33882 |
Sponsors and Collaborators
- University Hospital, Bordeaux
Investigators
- Study Chair: Antoine BENARD, MD, Unité de Soutien Méthodologique à la Recherche Clinique et Epidémiologique (USMR) du CHU de Bordeaux
Study Documents (Full-Text)
None provided.More Information
Publications
None provided.- CHUBX 2018/62