Vapotherm high velocity therapy is an attractive alternative to traditional noninvasive positive pressure ventilation (NiPPV) for respiratory distress. This approach — which is a form of Mask-Free NIV® — redefines the notion that ventilatory support requires a mask-and-pressure-based mechanism of action. High velocity therapy, uses a primarily flush-based mechanism and a comfortable cannula interface to provide ventilatory support. Some clinicians wonder just how effective such a device could be in treating moderate to severe hypercapnic patients.
A new study published in Critical Care Explorations by Plotnikow and colleagues continues to answer that question with additional evidence for the clinical efficacy of high velocity therapy in COPD patients with moderate to severe hypercapnic respiratory failure (median baseline PaCO2 > 57 mmHg.)
The Patient Population
Plotnikow and colleagues conducted a multi-center, prospective, observational pilot study to evaluate the effect of high velocity therapy as first-line ventilatory support in enrolled COPD patients with acute hypercapnic respiratory failure. They enrolled 40 patients, ages 68±10 years, with 25 of them (62.5%) being classified as having severe COPD (see Table 1).
Table 1: Patient Characteristics
|Moderate n (%)||9 (22.5)|
|Severe n (%)||25 (62.5)|
|Very Severe n (%)||6 (15)|
Outcomes & Conclusion
Once patients were admitted to the ICU with a diagnosis of hypercapnic acute respiratory failure (PaCO2 > 45 mmHg and pH < 7.35), Vapotherm high velocity therapy was applied as a first-line ventilatory support therapy. Each patient’s baseline vitals were taken prior to therapy initiation and then measured again after an hour. Table 2 shows the average outcomes of all patients.
Table 2: Clinical & Blood Gas Data after 1-Hour of High Velocity Therapy
|Clinical Variable||Baseline||1 Hour of High Velocity Therapy||P Value|
|Respiratory Rate (breaths per minute)||29||21||p<0.001|
|Accessory Muscle Use (%)||90||37||p<0.001|
|Thoracoabdominal asynchrony (%)||35||7||p<0.001|
|SaO2 (%)||92%||No significant change||N.S.|
|PaO2 (mmHg)||67.5 mmHg (59.9-76.5)||No significant change||N.S.|
About 17% (n=7) of patients failed on high velocity therapy. This proportion of therapy failures is similar to the proportion reported to fail on noninvasive positive pressure ventilation among a similar patient population. The authors observed that changes after the first hour of therapy of pH, respiratory rate, and PaCO2 were potential outcome predictors in these patients. Those who didn’t show positive trends in these parameters within that first hour were likely to fail on high velocity therapy.
Overall, the authors conclude that Vapotherm high velocity therapy was an effective tool for reducing respiratory rate in these COPD patients with acute hypercapnic respiratory failure.
Previous Studies Show Similar Favorable Outcomes
This observational pilot study conclusion is in line with previous data from a randomized controlled trial conducted by Doshi and colleagues. The Doshi trial compared the efficacy of NiPPV and high velocity therapy in all-comer adults in an emergency department setting and found the two therapies to have similar outcomes. A subgroup analysis of just the COPD /hypercapnic population from that larger randomized trial also found that high velocity therapy had similar outcomes to NiPPV when treating hypercapnia. While the Doshi trial showed comparable efficacy between the two modalities, physicians rated high velocity therapy more favorably when it came to physician perception of patient response, patient comfort, and simplicity of use, as seen in Figures 1-3.
Figure 1: Patient Response
Figure 2: Patient Comfort
Figure 3: Simplicity of Use
Vapotherm high velocity therapy is not intended to provide total ventilatory support.
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 Brochard L, Mancebo J, Wysocki M, et al. Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med 1995; 333: 817-822.
 Doshi P, Whittle JS, Bublewicz M, et al. High-Velocity Nasal Insufflation in the Treatment of Respiratory Failure: A Randomized Clinical Trial. Ann Emerg Med. 2018;72(1):73-83 e75.
 Doshi P, Whittle JS, Dungan G et al, The ventilatory effect of high velocity nasal insufflation compared to noninvasive positive-pressure ventilation in the treatment of hypercapneic respiratory failure: A subgroup analysisLung. 2020 Apr 6. https://doi.org/10.1016/j.hrtlng.2020.03.008