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High-flow nasal cannula oxygen in patients with haematological malignancy: a retrospective observational study

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Abstract

Patients with haematological malignancies (HM) face high rates of intensive care unit (ICU) admission and mortality. High-flow nasal cannula oxygen (HFNCO) is increasingly used to support HM patients in ward settings, but there is limited evidence on the safety and efficacy of HFNCO in this group. We retrospectively reviewed all HM patients receiving ward-based HFNCO, supervised by a critical care outreach service (CCOS), from January 2014 to January 2019. We included 130 consecutive patients. Forty-three (33.1%) were weaned off HFNCO without ICU admission. Eighty-seven (66.9%) were admitted to ICU, 20 (23.3%) required non-invasive and 34 (39.5%) invasive mechanical ventilation. ICU and hospital mortality were 42% and 55% respectively. Initial FiO2 < 0.4 (OR 0.27, 95% CI 0.09–0.81, p = 0.019) and HFNCO use on the ward > 1 day (OR 0.16, 95% CI 0.04, 0.59, p = 0.006) were associated with reduced likelihood for ICU admission. Invasive ventilation was associated with reduced survival (OR 0.27, 95%CI 0.1–0.7, p = 0.007). No significant adverse events were reported. HM patients receiving ward-based HFNCO have higher rates of ICU admission, but comparable hospital mortality to those requiring CCOS review without respiratory support. Results should be interpreted cautiously, as the model proposed depends on the existence of CCOS.

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Data availability

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

ARF:

Acute respiratory failure

CPR:

Cardiopulmonary resuscitation

CCOS:

Critical care outreach service

EoL:

End of life

FiO2:

Fraction of inspired oxygen

GvHD:

Graft vs host disease

HCTCI:

Hematopoietic cell transplantation-comorbidity index

HFNCO:

High-flow nasal cannula oxygen

HM:

Haematological malignancy

HR:

Hazard ratio

HSCT:

Haematopoietic stem cell transplant

ICU:

Intensive care unit

IMV:

Invasive mechanical ventilation

NIV:

Non-invasive ventilation

PEEP:

Positive end-expiratory pressure

TEP:

Treatment escalation plan

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Author information

Authors and Affiliations

  1. University College Hospital NHS Foundation Trust, 235 Euston Rd, Bloomsbury, London, NW1 2BU, UK

    Simon Tetlow

  2. Royal Brompton Hospital, Sydney St, Chelsea, London, SW3 6NP, UK

    Rathai Anandanadesan

  3. Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK

    Leila Taheri

  4. School of Medicine, Aristotle University of Thessaloniki, University Campus, 54124, Thessaloniki, Greece

    Eirini Pagkalidou

  5. Department of Haematological Medicine, King’s College Hospital, Denmark Hill, Brixton, London, SE5 9RS, UK

    Hugues De Lavallade

  6. Department of Critical Care, King’s College Hospital, Denmark Hill, Brixton, London, SE5 9RS, UK

    Victoria Metaxa

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  1. Simon Tetlow
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  2. Rathai Anandanadesan
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  3. Leila Taheri
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  4. Eirini Pagkalidou
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Contributions

ST conceptualized the project along with VM, designed the data collection methodology, led the data collection, and was a major contributor in writing and editing the manuscript. RA contributed to the data collection, curated the data, and was a major contributor in writing and editing the manuscript. LT contributed to the data collection, curated the data, and contributed to writing and editing the manuscript. EP performed statistical analysis on the data. H De L assisted in conceptualizing the project, and contributed towards writing and editing the manuscript. VM conceptualized the project along with ST, supervised the project, and was a major contributor in writing and editing the manuscript. All authors have read and approved the final manuscript.

Corresponding author

Correspondence to Simon Tetlow.

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Ethics approval

The study was endorsed by the King’s College Hospital Service Evaluation Committee as a Quality Improvement Project (ref. number KCC31032019TUO) and Research Ethics Committee approval was not deemed necessary.

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Not applicable.

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The authors declare no competing interests.

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Appendix

Appendix

Critical care outreach service at King’s College Hospital

The CCOS in the hospital gets involved in patient care either by direct referral from the ward teams or by responding to an increased National Early Warning Score (NEWS; see below in Supplement). For scores > 4 the ward medical team is asked to review the patient, whereas if the score is > 6, the CCOS is alerted and a prompt review of the patient is carried out. Involvement of the team occurs either with a telephone call from the ward clinicians or with an electronic alert on the portable devices they are carrying (Ascom MycoTM Smartphone, Sweden). Depending on the initial assessment, the patient’s co-morbidities and the clinical trajectory, the team either gives advice to the ward staff or intervenes and gets directly involved in patient care. The latter consists of a range of actions, including advice on fluid and electrolyte management; diagnostic procedures; initiation of non-invasive respiratory support via application of HFNCO or continuous positive airway pressure (CPAP) or transfer to ICU. HFNCO is delivered by the Fisher & Paykel Optiflow system, using the MR850 respiratory humidifier with MR290 chamber; RT241 heated delivery tubing, and RT033 or RT044 small or wide bore nasal cannulae (Fisher & Paykel Healthcare, Auckland, New Zealand). When the intervention is indicated, the initial standard settings are oxygen flow 60 L/min and adequate FiO2 to achieve SpO2 > 94%. In both situations, hourly monitoring and regular medical and nursing reviews are instituted until symptom resolution or decision to escalate treatment and ICU transfer Table 6. 

Table 6 The NEWS scoring system. National Early Warning Score
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Tetlow, S., Anandanadesan, R., Taheri, L. et al. High-flow nasal cannula oxygen in patients with haematological malignancy: a retrospective observational study. Ann Hematol 101, 1191–1199 (2022). https://doi.org/10.1007/s00277-022-04824-9

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  • DOI: https://doi.org/10.1007/s00277-022-04824-9

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