The ATS settles how to choose between high-flow oxygen, CPAP and non-invasive ventilation

The edition in brief

The American Thoracic Society has published the first guideline covering the whole range of non-invasive respiratory support in acute respiratory failure, using GRADE methodology across four questions. For acute hypoxaemic respiratory failure it makes a strong recommendation for high-flow nasal cannula and a conditional recommendation for non-invasive ventilation or CPAP, with close monitoring for escalation. For acute hypercapnic failure it makes a strong recommendation for non-invasive ventilation to reduce mortality and intubation, and conditionally allows high-flow only where hypercapnia is less severe and acidaemia mild — pH above 7.25 — and escalation is immediately available. It strongly recommends high-flow or non-invasive ventilation for preoxygenation before intubation, and suggests high-flow for low-risk and non-invasive ventilation for high-risk patients after extubation. A prespecified pooled analysis of ALIENTO and ARNASA, 2,682 participants with COPD and frequent exacerbations, found astegolimab every two weeks reduced moderate or severe exacerbations by 15% (rate ratio 0.85, 95% CI 0.76 to 0.96), with severe exacerbations down 32% (rate ratio 0.68, 95% CI 0.52 to 0.87). Participants were enrolled irrespective of eosinophil count. A pooled analysis of BOREAS and NOTUS found dupilumab reduced emergency department visits and hospital admissions by 38% and systemic corticosteroid use for severe exacerbations by 42%, in patients with eosinophils of 300 cells per microlitre or above. SNaPP randomised 3,498 surgical patients and found sugammadex reduced postoperative pulmonary complications or death from 21.5% to 19.0%. EMBARC data from 19,324 patients show bronchiectasis exacerbation risk rises continuously with each prior event, with no threshold.