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Summary: Back to basics with newer technology: should we focus on reducing work of breathing earlier?

Topic: Work of Breathing

Sciarretta C, Greenberg J, Wyatt KD & Whittle JS. Back to basics with newer technology: should we focus on reducing work of breathing earlier? Frontiers in Medicine 2022; https://doi.org/10.3389/fmed.2022.1070517 

Sciarretta et al., in a published perspective article, illustrate three cases of respiratory failure from non-pulmonary origins; all cases displayed hemodynamic improvement (of vital signs and lactate levels) due to reducing the work of breathing through high-velocity therapy prior to receiving definitive therapy for underlying pathologies.  The clinical cases described illustrate the concept that clinicians should consider respiratory support early in the care of patients with evidence of increased work of breathing, even if the underlying cause is not pulmonary in origin and/or there is no overt hypoxemia or hypercapnia.  

  • Case #1:  A 23-year-old female with diabetes mellitus type-1 presented to the Emergency Department(ED) with abdominal pain, vomiting, dyspnea and a measured blood glucose of 1,608 mg/dL. The patient’s respiratory rate(RR) and serum lactate decreased within 10 minutes following application of high velocity therapy at 40L/min; RR reduced from 36 breaths per minute to 25 breaths per minute while the lactate dropped from 8.6 mmol/L to 4.5 mmol/L.  The authors note that supporting the patient’s respiratory effort and reducing work of breathing using high velocity therapy stabilized the patient’s clinical situation, which allowed the clinical team to focus on source control. 
  • Case #2: A 51-year-old female with alcoholic cirrhosis with hematemesis and abdominal distension presented to the ED. In this case, the patient’s RR and serum lactate decreased within 10-15 minutes following application of high velocity therapy at 40L/min; RR reduced from 35 breaths per minute to 23 breaths per minute while the lactate dropped from 11 mmol/L to 8 mmol/L. These clinical parameters improvements occurred prior to definitive therapy for esophageal and gastric varices. 
  • Case #3: A 38-year-old male presented to the ED with hypertension, type 2 diabetes mellitus, heart failure with preserved ejection fraction (HFpEF), sleep-disordered breathing (combined obstructive sleep apnea and obesity hypoventilation syndrome), and severe obesity (BMI > 60) with confusion. In this case, the patient’s RR and serum lactate decreased within 10-15 minutes following application of high velocity therapy at 40L min; RR reduced from 28 breaths per minute to 23 breaths per minute while the lactate dropped from 4.8 mmol/L to 2.2 mmol/L. These improvements in clinical parameters all occurred prior to the initiation of definitive therapy. 

Demonstrated by the case study examples, the authors suggest that signs of increased work of breathing should be more readily considered to be an early warning sign for the decompensation of hospitalized patients. It is recommended to begin to equate clinical signs of increased work of breathing (increased respiratory rate, accessory muscle use, assumed body position) with the need to initiate gentle supportive therapy. If possible, this intervention should occur even prior to obvious severe acidosis. 

Early intervention with high flow nasal oxygen (HFNO) is a non-invasive way to improve gas exchange, supporting the correction of metabolic acidosis as well as offloading the percentage of cardiac output that is being utilized for breathing.  The authors note this concept warrants further study to identify appropriate patient populations and treatment strategies as well as to characterize potential clinical and economic impacts. 

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