Caracterización de pacientes en cuidado intensivo que usaron cánula nasal de alto flujo en un hospital de alta complejidad
Introducción: La cánula nasal de alto flujo (CNAF) es una herramienta no invasiva utilizada en pacientes críticos con hipoxemia severa. Métodos: Estudio descriptivo retrospectivo realizado en una cohorte de 127 pacientes adultos atendidos en una unidad de cuidados intensivos en Medellín, Colombia, d...
- Autores:
-
Duque Jiménez, Carlos Alberto
Pineda Parada, Jonathan Antonio
Vásquez Taborda, Adriana María
- Tipo de recurso:
- Tesis
- Fecha de publicación:
- 2025
- Institución:
- Universidad de Antioquia
- Repositorio:
- Repositorio UdeA
- Idioma:
- spa
- OAI Identifier:
- oai:bibliotecadigital.udea.edu.co:10495/47462
- Acceso en línea:
- https://hdl.handle.net/10495/47462
- Palabra clave:
- Cuidados críticos
Critical care
Insuficiencia respiratoria
Respiratory insufficiency
Terapia por inhalación de oxígeno
Oxygen inhalation therapy
Cánula
Cannula
Terapia con oxígeno a altos flujos
https://id.nlm.nih.gov/mesh/D003422
https://id.nlm.nih.gov/mesh/D012131
https://id.nlm.nih.gov/mesh/D010102
https://id.nlm.nih.gov/mesh/D000072601
ODS 3: Salud y bienestar. Garantizar una vida sana y promover el bienestar de todos a todas las edades
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- embargoedAccess
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- http://creativecommons.org/licenses/by-nc-sa/4.0/
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Caracterización de pacientes en cuidado intensivo que usaron cánula nasal de alto flujo en un hospital de alta complejidad |
| dc.title.translated.none.fl_str_mv |
Characterization of patients in intensive care who used high-flow nasal cannula in a high-complexity hospital |
| title |
Caracterización de pacientes en cuidado intensivo que usaron cánula nasal de alto flujo en un hospital de alta complejidad |
| spellingShingle |
Caracterización de pacientes en cuidado intensivo que usaron cánula nasal de alto flujo en un hospital de alta complejidad Cuidados críticos Critical care Insuficiencia respiratoria Respiratory insufficiency Terapia por inhalación de oxígeno Oxygen inhalation therapy Cánula Cannula Terapia con oxígeno a altos flujos https://id.nlm.nih.gov/mesh/D003422 https://id.nlm.nih.gov/mesh/D012131 https://id.nlm.nih.gov/mesh/D010102 https://id.nlm.nih.gov/mesh/D000072601 ODS 3: Salud y bienestar. Garantizar una vida sana y promover el bienestar de todos a todas las edades |
| title_short |
Caracterización de pacientes en cuidado intensivo que usaron cánula nasal de alto flujo en un hospital de alta complejidad |
| title_full |
Caracterización de pacientes en cuidado intensivo que usaron cánula nasal de alto flujo en un hospital de alta complejidad |
| title_fullStr |
Caracterización de pacientes en cuidado intensivo que usaron cánula nasal de alto flujo en un hospital de alta complejidad |
| title_full_unstemmed |
Caracterización de pacientes en cuidado intensivo que usaron cánula nasal de alto flujo en un hospital de alta complejidad |
| title_sort |
Caracterización de pacientes en cuidado intensivo que usaron cánula nasal de alto flujo en un hospital de alta complejidad |
| dc.creator.fl_str_mv |
Duque Jiménez, Carlos Alberto Pineda Parada, Jonathan Antonio Vásquez Taborda, Adriana María |
| dc.contributor.advisor.none.fl_str_mv |
Arroyave Páramo, Héctor Darío Palacio Sánchez, Andrés Felipe Villada Ochoa, Oscar Alonso |
| dc.contributor.author.none.fl_str_mv |
Duque Jiménez, Carlos Alberto Pineda Parada, Jonathan Antonio Vásquez Taborda, Adriana María |
| dc.contributor.jury.none.fl_str_mv |
López García, David Andrés Zapata Aristizábal, Felipe Santiago |
| dc.subject.decs.none.fl_str_mv |
Cuidados críticos Critical care Insuficiencia respiratoria Respiratory insufficiency Terapia por inhalación de oxígeno Oxygen inhalation therapy Cánula Cannula |
| topic |
Cuidados críticos Critical care Insuficiencia respiratoria Respiratory insufficiency Terapia por inhalación de oxígeno Oxygen inhalation therapy Cánula Cannula Terapia con oxígeno a altos flujos https://id.nlm.nih.gov/mesh/D003422 https://id.nlm.nih.gov/mesh/D012131 https://id.nlm.nih.gov/mesh/D010102 https://id.nlm.nih.gov/mesh/D000072601 ODS 3: Salud y bienestar. Garantizar una vida sana y promover el bienestar de todos a todas las edades |
| dc.subject.proposal.spa.fl_str_mv |
Terapia con oxígeno a altos flujos |
| dc.subject.meshuri.none.fl_str_mv |
https://id.nlm.nih.gov/mesh/D003422 https://id.nlm.nih.gov/mesh/D012131 https://id.nlm.nih.gov/mesh/D010102 https://id.nlm.nih.gov/mesh/D000072601 |
| dc.subject.ods.none.fl_str_mv |
ODS 3: Salud y bienestar. Garantizar una vida sana y promover el bienestar de todos a todas las edades |
| description |
Introducción: La cánula nasal de alto flujo (CNAF) es una herramienta no invasiva utilizada en pacientes críticos con hipoxemia severa. Métodos: Estudio descriptivo retrospectivo realizado en una cohorte de 127 pacientes adultos atendidos en una unidad de cuidados intensivos en Medellín, Colombia, durante el año 2023. Se evaluaron las indicaciones clínicas para el uso de CNAF, cambios en variables fisiológicas, necesidad de intubación y mortalidad. Resultados: Las principales indicaciones fueron insuficiencia respiratoria aguda severa (IRAS) por neumonía (31,5 %, n = 40), exacerbación de EPOC (16,7 %, n = 21), SDRA (11,8 %, n = 15) e inmunosupresión (10,2 %, n = 13). Se observó una reducción significativa de la frecuencia respiratoria tras 12 horas de terapia (mediana: 24 a 19,5 rpm; p < 0,001). El 22,2 % de los pacientes presentó fracaso con CNAF. No hubo diferencias significativas en la necesidad de intubación entre las distintas indicaciones clínicas (p = 0,17). La mortalidad hospitalaria global fue del 28,3 %, con mayor incidencia en el subgrupo con neumonía (p = 0,02). El índice de ROX fue más alto en el postoperatorio de cirugía cardíaca (p = 0,012), y la PaO₂/FiO₂ mejoró significativamente en casos de edema agudo de pulmón cardiogénico (p = 0,018). Conclusiones: La CNAF se usó con mayor frecuencia en IRAS por neumonía. Globalmente, se asoció con mejoría en parámetros de oxigenación y ventilación, permitiendo asociar su uso a una evolución clínica favorable en ciertos subgrupos de pacientes críticos. |
| publishDate |
2025 |
| dc.date.accessioned.none.fl_str_mv |
2025-09-30T15:02:01Z |
| dc.date.issued.none.fl_str_mv |
2025 |
| dc.date.available.none.fl_str_mv |
2027-09-30 |
| dc.type.none.fl_str_mv |
Trabajo de grado - Especialización |
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http://purl.org/coar/resource_type/c_46ec |
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Other |
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https://hdl.handle.net/10495/47462 |
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https://hdl.handle.net/10495/47462 |
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spa |
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spa |
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1. Vo P, Kharasch VS. Respiratory Failure. Pediatrics In Review [Internet]. 2014 Nov 1;35(11):476–86. 2. Ling RR, Ponnapa Reddy M, Subramaniam A, Moran B, Ramanathan K, Ramanan M, et al. Epidemiology of acute hypoxaemic respiratory failure in Australian and New Zealand intensive care units during 2005–2022. A binational, registry-based study. Intensive Care Med. 2024 Nov;50(11):1861-72. 3. Franca SA, Toufen C, Hovnanian ALD, Albuquerque ALP, Borges ER, Pizzo VRP, et al. The epidemiology of acute respiratory failure in hospitalized patients: A Brazilian prospective cohort study. Journal of Critical Care. 2011 Jun;26(3):330.e1-330.e8. 4. Díaz Lobato S, García González JL. Oxigenoterapia en situaciones de urgencia y urgencia. En: Giner Donaire J, Chiner Vives E, coordinadores. Manual SEPAR de procedimientos. Sistemas de oxigenoterapia. Barcelona: Respira; 2014. p. 44-62.68. 5. Dueñas Castell C, Mejía Bermúdez J, Coronel C, Ortiz Ruiz G. Insuficiencia respiratoria aguda. Acta Colombiana de Cuidado Intensivo. 2016 Jun;16:1-24. 6. Velasco Sanz TR, Sánchez De La Ventana AB. La oxigenoterapia de alto flujo con cánula nasal en pacientes críticos. Estudio prospectivo. Enfermería Intensiva. 2014 Oct;25(4):131-6. 7. Dysart K, Miller TL, Wolfson MR, Shaffer TH. Research in high flow therapy: mechanisms of action. Respir Med. 2009 Oct;103(10):1400-5. doi: 10.1016/j.rmed.2009.04.007. Epub 2009 May 21. 8. Riera J, Pérez P, Cortés J, Roca O, Masclans JR, Rello J. Effect of high-flow nasal cannula and body position on end-expiratory lung volume: a cohort study using electrical impedance tomography. Respir Care. 2013 Apr;58(4):589-96. 9. Corley A, Caruana LR, Barnett AG, Tronstad O, Fraser JF. Oxygen delivery through high-flow nasal cannulae increase end-expiratory lung volume and reduce respiratory rate in post-cardiac surgical patients. Br J Anaesth. 2011 Dec;107(6):998-1004. 10. Roca O, Pérez-Terán P, Masclans JR, Pérez L, Galve E, Evangelista A, Rello J. Patients with New York Heart Association class III heart failure may benefit with high flow nasal cannula supportive therapy: high flow nasal cannula in heart failure. J Crit Care. 2013 Oct;28(5):741-6. 11. Salah B, Dinh Xuan AT, Fouilladieu JL, Lockhart A, Regnard J. Nasal mucociliary transport in healthy subjects is slower when breathing dry air. Eur Respir J. 1988 Oct;1(9):852-5. 12. Sim MA, Dean P, Kinsella J, Black R, Carter R, Hughes M. Performance of oxygen delivery devices when the breathing pattern of respiratory failure is simulated. Anaesthesia. 2008 Sep;63(9):938-40. 13. Oczkowski S, Ergan B, Bos L, Chatwin M, Ferrer M, Gregoretti C, Heunks L, Frat JP, Longhini F, Nava S, Navalesi P, Ozsancak Uğurlu A, Pisani L, Renda T, Thille AW, Winck JC, Windisch W, Tonia T, Boyd J, Sotgiu G, Scala R. ERS clinical practice guidelines: high-flow nasal cannula in acute respiratory failure. Eur Respir J. 2022 Apr 14;59(4):2101574. 14. Frat JP, Thille AW, Mercat A, Girault C, Ragot S, Perbet S, et al. High flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med. 2015;372:2185 96. 15. Messika J, Ben Ahmed K, Gaudry S, Miguel Montanes R, Rafat C, Sztrymf B, et al. Use of high flow nasal cannula oxygen therapy in subjects with ARDS: A 1 year observational study. Respir Care. 2015;60:162 9. 16. Kreitmann L, Helms J, Martin-Loeches I, Salluh J, Poulakou G, Pène F, Nseir S. ICU-acquired infections in immunocompromised patients. Intensive Care Med. 2024 Jan 10. 17. Keenan SP, Sinuff T, Burns KE, Muscedere J, Kutsogiannis J, Mehta S, et al. Clinical practice guidelines for the use of noninvasive positive pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting. CMAJ. 2011;183:E195 214. 18. Antonelli M, Conti G, Bufi M, Costa MG, Lappa A, Rocco M, et al. Noninvasive ventilation for treatment of acute respiratory failure in patients undergoing solid organ transplantation: A randomized trial. JAMA. 2000;283:235 41. 19. Hilbert G, Gruson D, Vargas F, Valentino R, Gbikpi Benissan G, Dupon M, et al. Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure. N Engl J Med. 2001;344:481 7. 20. Frat JP, Ragot S, Girault C, Perbet S, Prat G, Boulain T, et al. Effect of non invasive oxygenation strategies in immunocompromised patients with severe acute respiratory failure: A post hoc analysis of a randomized trial. Lancet Respir Med. 2016;4:646 52. 21. Ni YN, Luo J, Yu H, Liu D, Liang BM, Yao R, et al. Can high flow nasal cannula reduce the rate of reintubation in adult patients after extubation? A meta analysis. BMC Pulm Med. 2017;17:142. 22. Yan L, Lu Y, Deng M, Zhang Q, Bian Y, Zhou X, Hou G. Efficacy of high-flow nasal cannula in patients with acute heart failure: a systematic review and meta-analysis. BMC Pulm Med. 2023 Nov 28;23(1):476. 23. Huang Y, Lei W, Zhang W, Huang JA. High-Flow Nasal Cannula in Hypercapnic Respiratory Failure: A Systematic Review and Meta-Analysis. Can Respir J. 2020 Oct 29;2020:7406457. 24. Frat JP, Brugiere B, Ragot S, Chatellier D, Veinstein A, Goudet V, Coudroy R, Petitpas F, Robert R, Thille AW, Girault C. Sequential application of oxygen therapy via high-flow nasal cannula and noninvasive ventilation in acute respiratory failure: an observational pilot study. Respir Care. 2015 Feb;60(2):170-8. 25. Poletini G, Mega C, Pisani L, Alotaibi M, Khoja A, Price LL, Blasi F, Nava S, Hill NS. High-flow nasal therapy vs standard oxygen during breaks off noninvasive ventilation for acute respiratory failure: A pilot randomized controlled trial. J Crit Care. 2018 Dec;48:418-425. 26. Roca O, Caralt B, Messika J, Samper M, Sztrymf B, Hernández G, García-de-Acilu M, Frat JP, Masclans JR, Ricard JD. An Index Combining Respiratory Rate and Oxygenation to Predict Outcome of Nasal High-Flow Therapy. Am J Respir Crit Care Med. 2019 Jun 1;199(11):1368-1376. 27. Mauri T, Spinelli E, Scotti E, Turrini C, Mascarin G, Grafoni M, et al. Noninvasive support strategies for patients with acute respiratory failure secondary to pneumonia. Intensive Care Med. 2016;42(5):673-82. 28. Roca O, Pérez-Terán P, Masclans JR. High-flow oxygen therapy in acute respiratory failure. Respir Care. 2010;55(4):408–413. 29. Sztrymf B, Messika J, Bertrand F, Dreyfuss D, Ricard JD. Beneficial effects of humidified high-flow nasal oxygen in critical care patients with severe community-acquired pneumonia. J Crit Care. 2012;27(3):324.e9–324.e13. 30. Thille AW, Muller G, Gacouin A, Coudroy R, Decavèle M, Sonneville R, et al. Effect of postextubation high-flow nasal oxygen with noninvasive ventilation vs high-flow nasal oxygen alone on reintubation among patients at high risk of extubation failure: a randomized clinical trial. JAMA. 2019;322(15):1465–75. doi:10.1001/jama.2019.14901. 31. Veenstra P, Veeger NJGM, Koppers RJH, Duiverman ML, Van Geffen WH. High-flow nasal cannula oxygen therapy for admitted COPD-patients. A retrospective cohort study. Chen RJ, editor. PLoS ONE. 2022 Oct 5;17(10):e0272372. 32. Xu Z, Zhu L, Zhan J, Feng H, Deana C, Vetrugno L, et al. Effect of high-flow nasal cannula oxygen therapy in combination with non-invasive ventilation on critically ill patients with acute respiratory failure: a retrospective study. J Thorac Dis. 2023 Dec;15(12):6821-30. 33. Osadnik CR, Tee VS, Carson-Chahhoud KV, Picot J, Wedzicha JA, Smith BJ. Non-invasive ventilation for the management of acute hypercapnic respiratory failure due to exacerbation of chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews [Internet]. 2017 Jul 13 [cited 2025 Mar 30];2017(7). Available from: http://doi.wiley.com/10.1002/14651858.CD004104.pub4. 34. Hernández G, Vaquerizo Alonso C, González-Castro A, García de Acilu M, Pérez LC, Rodríguez ML, et al. Effect of Postextubation High-Flow Nasal Cannula Therapy on Reintubation and Mortality in Adults With a High Risk for Extubation Failure: A Multicenter Randomized Clinical Trial. JAMA. 2016 Oct 18;316(15):1565–74. 35. Mariani J, Macchia A, Belziti C, Deabreu M, Gagliardi J, Doval H, et al. Noninvasive ventilation in acute cardiogenic pulmonary edema: a meta-analysis of randomized controlled trials. J Card Fail. 2011 Oct;17(10):850-9. 36. Adi Osman M, Via G, Roslanuddin MMS, Azma HA, Sow KF, Azlizawati A, et al. Helmet continuous positive airway pressure vs. high flow nasal cannula oxygen in acute cardiogenic pulmonary oedema: a randomized controlled trial. Eur Heart J Acute Cardiovasc Care. 2021 Dec;10(10):1103–1111. 37. Stephan F, Boyer A, Ricard JD, Buczinski B, Ercole A, Hubloue I, et al. High-Flow Nasal Oxygen Therapy Is Associated With a Lower Rate of Escalation of Respiratory Support in Critically Ill Patients Compared With Conventional Oxygen Therapy. JAMA. 2015 Jun 23-30;313(23):2331–9. 38. Carrillo A, Gonzalez-Diaz G, Ferrer M, Martinez-Oñate M, Vargas M, Ramirez P, et al. Non-invasive ventilation in community-acquired pneumonia and severe acute respiratory failure. Intensive Care Med. 2012 Mar;38(3):458-66. 39. Esteban A, Frutos-Vivar F, Ferguson ND, Arabi YM, Baigorri F, Quintana M, et al. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med. 2004 Jun 3;350(24):2452-60. 40. Kang BJ, Koh Y, Lim CM, Huh JW, Baek S, Han M, et al. Failure of high-flow nasal cannula therapy may delay intubation and increase mortality. Intensive Care Med. 2015 Apr;41(4):623-32. |
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Medellín |
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Universidad de Antioquia |
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Especialización en Medicina Crítica y Cuidados Intensivos |
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Departamento de Cirugía |
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Medellín, Colombia |
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Facultad de Medicina |
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Arroyave Páramo, Héctor DaríoPalacio Sánchez, Andrés FelipeVillada Ochoa, Oscar AlonsoDuque Jiménez, Carlos AlbertoPineda Parada, Jonathan AntonioVásquez Taborda, Adriana MaríaLópez García, David AndrésZapata Aristizábal, Felipe Santiago2023Lat: 06 15 00 N degrees minutes Lat: 6.2500 decimal degrees Long: 075 36 00 W degrees minutes Long: -75.6000 decimal degreeshttp://vocab.getty.edu/page/tgn/7005073Medellín2025-09-30T15:02:01Z2027-09-302025https://hdl.handle.net/10495/47462Introducción: La cánula nasal de alto flujo (CNAF) es una herramienta no invasiva utilizada en pacientes críticos con hipoxemia severa. Métodos: Estudio descriptivo retrospectivo realizado en una cohorte de 127 pacientes adultos atendidos en una unidad de cuidados intensivos en Medellín, Colombia, durante el año 2023. Se evaluaron las indicaciones clínicas para el uso de CNAF, cambios en variables fisiológicas, necesidad de intubación y mortalidad. Resultados: Las principales indicaciones fueron insuficiencia respiratoria aguda severa (IRAS) por neumonía (31,5 %, n = 40), exacerbación de EPOC (16,7 %, n = 21), SDRA (11,8 %, n = 15) e inmunosupresión (10,2 %, n = 13). Se observó una reducción significativa de la frecuencia respiratoria tras 12 horas de terapia (mediana: 24 a 19,5 rpm; p < 0,001). El 22,2 % de los pacientes presentó fracaso con CNAF. No hubo diferencias significativas en la necesidad de intubación entre las distintas indicaciones clínicas (p = 0,17). La mortalidad hospitalaria global fue del 28,3 %, con mayor incidencia en el subgrupo con neumonía (p = 0,02). El índice de ROX fue más alto en el postoperatorio de cirugía cardíaca (p = 0,012), y la PaO₂/FiO₂ mejoró significativamente en casos de edema agudo de pulmón cardiogénico (p = 0,018). Conclusiones: La CNAF se usó con mayor frecuencia en IRAS por neumonía. Globalmente, se asoció con mejoría en parámetros de oxigenación y ventilación, permitiendo asociar su uso a una evolución clínica favorable en ciertos subgrupos de pacientes críticos.EspecializaciónEspecialista en Medicina Crítica y Cuidados Intensivos21 páginasapplication/pdfspaUniversidad de AntioquiaEspecialización en Medicina Crítica y Cuidados IntensivosDepartamento de CirugíaMedellín, ColombiaFacultad de MedicinaCampus en el Área de la saludhttp://creativecommons.org/licenses/by-nc-sa/4.0/info:eu-repo/semantics/embargoedAccessAttribution-NonCommercial-ShareAlike 4.0 Internationalhttp://purl.org/coar/access_right/c_f1cfCaracterización de pacientes en cuidado intensivo que usaron cánula nasal de alto flujo en un hospital de alta complejidadCharacterization of patients in intensive care who used high-flow nasal cannula in a high-complexity hospitalTrabajo de grado - Especializaciónhttp://purl.org/coar/resource_type/c_46ecOtherhttp://purl.org/coar/version/c_b1a7d7d4d402bcceinfo:eu-repo/semantics/otherinfo:eu-repo/semantics/draft1. Vo P, Kharasch VS. Respiratory Failure. Pediatrics In Review [Internet]. 2014 Nov 1;35(11):476–86.2. Ling RR, Ponnapa Reddy M, Subramaniam A, Moran B, Ramanathan K, Ramanan M, et al. Epidemiology of acute hypoxaemic respiratory failure in Australian and New Zealand intensive care units during 2005–2022. A binational, registry-based study. Intensive Care Med. 2024 Nov;50(11):1861-72.3. Franca SA, Toufen C, Hovnanian ALD, Albuquerque ALP, Borges ER, Pizzo VRP, et al. The epidemiology of acute respiratory failure in hospitalized patients: A Brazilian prospective cohort study. Journal of Critical Care. 2011 Jun;26(3):330.e1-330.e8.4. Díaz Lobato S, García González JL. Oxigenoterapia en situaciones de urgencia y urgencia. En: Giner Donaire J, Chiner Vives E, coordinadores. Manual SEPAR de procedimientos. Sistemas de oxigenoterapia. Barcelona: Respira; 2014. p. 44-62.68.5. Dueñas Castell C, Mejía Bermúdez J, Coronel C, Ortiz Ruiz G. Insuficiencia respiratoria aguda. Acta Colombiana de Cuidado Intensivo. 2016 Jun;16:1-24.6. Velasco Sanz TR, Sánchez De La Ventana AB. La oxigenoterapia de alto flujo con cánula nasal en pacientes críticos. Estudio prospectivo. Enfermería Intensiva. 2014 Oct;25(4):131-6.7. Dysart K, Miller TL, Wolfson MR, Shaffer TH. Research in high flow therapy: mechanisms of action. Respir Med. 2009 Oct;103(10):1400-5. doi: 10.1016/j.rmed.2009.04.007. Epub 2009 May 21.8. Riera J, Pérez P, Cortés J, Roca O, Masclans JR, Rello J. Effect of high-flow nasal cannula and body position on end-expiratory lung volume: a cohort study using electrical impedance tomography. Respir Care. 2013 Apr;58(4):589-96.9. Corley A, Caruana LR, Barnett AG, Tronstad O, Fraser JF. Oxygen delivery through high-flow nasal cannulae increase end-expiratory lung volume and reduce respiratory rate in post-cardiac surgical patients. Br J Anaesth. 2011 Dec;107(6):998-1004.10. Roca O, Pérez-Terán P, Masclans JR, Pérez L, Galve E, Evangelista A, Rello J. Patients with New York Heart Association class III heart failure may benefit with high flow nasal cannula supportive therapy: high flow nasal cannula in heart failure. J Crit Care. 2013 Oct;28(5):741-6.11. Salah B, Dinh Xuan AT, Fouilladieu JL, Lockhart A, Regnard J. Nasal mucociliary transport in healthy subjects is slower when breathing dry air. Eur Respir J. 1988 Oct;1(9):852-5.12. Sim MA, Dean P, Kinsella J, Black R, Carter R, Hughes M. Performance of oxygen delivery devices when the breathing pattern of respiratory failure is simulated. Anaesthesia. 2008 Sep;63(9):938-40.13. Oczkowski S, Ergan B, Bos L, Chatwin M, Ferrer M, Gregoretti C, Heunks L, Frat JP, Longhini F, Nava S, Navalesi P, Ozsancak Uğurlu A, Pisani L, Renda T, Thille AW, Winck JC, Windisch W, Tonia T, Boyd J, Sotgiu G, Scala R. ERS clinical practice guidelines: high-flow nasal cannula in acute respiratory failure. Eur Respir J. 2022 Apr 14;59(4):2101574.14. Frat JP, Thille AW, Mercat A, Girault C, Ragot S, Perbet S, et al. High flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med. 2015;372:2185 96.15. Messika J, Ben Ahmed K, Gaudry S, Miguel Montanes R, Rafat C, Sztrymf B, et al. Use of high flow nasal cannula oxygen therapy in subjects with ARDS: A 1 year observational study. Respir Care. 2015;60:162 9.16. Kreitmann L, Helms J, Martin-Loeches I, Salluh J, Poulakou G, Pène F, Nseir S. ICU-acquired infections in immunocompromised patients. Intensive Care Med. 2024 Jan 10.17. Keenan SP, Sinuff T, Burns KE, Muscedere J, Kutsogiannis J, Mehta S, et al. Clinical practice guidelines for the use of noninvasive positive pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting. CMAJ. 2011;183:E195 214.18. Antonelli M, Conti G, Bufi M, Costa MG, Lappa A, Rocco M, et al. Noninvasive ventilation for treatment of acute respiratory failure in patients undergoing solid organ transplantation: A randomized trial. JAMA. 2000;283:235 41.19. Hilbert G, Gruson D, Vargas F, Valentino R, Gbikpi Benissan G, Dupon M, et al. Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure. N Engl J Med. 2001;344:481 7.20. Frat JP, Ragot S, Girault C, Perbet S, Prat G, Boulain T, et al. Effect of non invasive oxygenation strategies in immunocompromised patients with severe acute respiratory failure: A post hoc analysis of a randomized trial. Lancet Respir Med. 2016;4:646 52.21. Ni YN, Luo J, Yu H, Liu D, Liang BM, Yao R, et al. Can high flow nasal cannula reduce the rate of reintubation in adult patients after extubation? A meta analysis. BMC Pulm Med. 2017;17:142.22. Yan L, Lu Y, Deng M, Zhang Q, Bian Y, Zhou X, Hou G. Efficacy of high-flow nasal cannula in patients with acute heart failure: a systematic review and meta-analysis. BMC Pulm Med. 2023 Nov 28;23(1):476.23. Huang Y, Lei W, Zhang W, Huang JA. High-Flow Nasal Cannula in Hypercapnic Respiratory Failure: A Systematic Review and Meta-Analysis. Can Respir J. 2020 Oct 29;2020:7406457.24. Frat JP, Brugiere B, Ragot S, Chatellier D, Veinstein A, Goudet V, Coudroy R, Petitpas F, Robert R, Thille AW, Girault C. Sequential application of oxygen therapy via high-flow nasal cannula and noninvasive ventilation in acute respiratory failure: an observational pilot study. Respir Care. 2015 Feb;60(2):170-8.25. Poletini G, Mega C, Pisani L, Alotaibi M, Khoja A, Price LL, Blasi F, Nava S, Hill NS. High-flow nasal therapy vs standard oxygen during breaks off noninvasive ventilation for acute respiratory failure: A pilot randomized controlled trial. J Crit Care. 2018 Dec;48:418-425.26. Roca O, Caralt B, Messika J, Samper M, Sztrymf B, Hernández G, García-de-Acilu M, Frat JP, Masclans JR, Ricard JD. An Index Combining Respiratory Rate and Oxygenation to Predict Outcome of Nasal High-Flow Therapy. Am J Respir Crit Care Med. 2019 Jun 1;199(11):1368-1376.27. Mauri T, Spinelli E, Scotti E, Turrini C, Mascarin G, Grafoni M, et al. Noninvasive support strategies for patients with acute respiratory failure secondary to pneumonia. Intensive Care Med. 2016;42(5):673-82.28. Roca O, Pérez-Terán P, Masclans JR. High-flow oxygen therapy in acute respiratory failure. Respir Care. 2010;55(4):408–413.29. Sztrymf B, Messika J, Bertrand F, Dreyfuss D, Ricard JD. Beneficial effects of humidified high-flow nasal oxygen in critical care patients with severe community-acquired pneumonia. J Crit Care. 2012;27(3):324.e9–324.e13.30. Thille AW, Muller G, Gacouin A, Coudroy R, Decavèle M, Sonneville R, et al. Effect of postextubation high-flow nasal oxygen with noninvasive ventilation vs high-flow nasal oxygen alone on reintubation among patients at high risk of extubation failure: a randomized clinical trial. JAMA. 2019;322(15):1465–75. doi:10.1001/jama.2019.14901.31. Veenstra P, Veeger NJGM, Koppers RJH, Duiverman ML, Van Geffen WH. High-flow nasal cannula oxygen therapy for admitted COPD-patients. A retrospective cohort study. Chen RJ, editor. PLoS ONE. 2022 Oct 5;17(10):e0272372.32. Xu Z, Zhu L, Zhan J, Feng H, Deana C, Vetrugno L, et al. Effect of high-flow nasal cannula oxygen therapy in combination with non-invasive ventilation on critically ill patients with acute respiratory failure: a retrospective study. J Thorac Dis. 2023 Dec;15(12):6821-30.33. Osadnik CR, Tee VS, Carson-Chahhoud KV, Picot J, Wedzicha JA, Smith BJ. Non-invasive ventilation for the management of acute hypercapnic respiratory failure due to exacerbation of chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews [Internet]. 2017 Jul 13 [cited 2025 Mar 30];2017(7). Available from: http://doi.wiley.com/10.1002/14651858.CD004104.pub4.34. Hernández G, Vaquerizo Alonso C, González-Castro A, García de Acilu M, Pérez LC, Rodríguez ML, et al. Effect of Postextubation High-Flow Nasal Cannula Therapy on Reintubation and Mortality in Adults With a High Risk for Extubation Failure: A Multicenter Randomized Clinical Trial. JAMA. 2016 Oct 18;316(15):1565–74.35. Mariani J, Macchia A, Belziti C, Deabreu M, Gagliardi J, Doval H, et al. Noninvasive ventilation in acute cardiogenic pulmonary edema: a meta-analysis of randomized controlled trials. J Card Fail. 2011 Oct;17(10):850-9.36. Adi Osman M, Via G, Roslanuddin MMS, Azma HA, Sow KF, Azlizawati A, et al. Helmet continuous positive airway pressure vs. high flow nasal cannula oxygen in acute cardiogenic pulmonary oedema: a randomized controlled trial. Eur Heart J Acute Cardiovasc Care. 2021 Dec;10(10):1103–1111.37. Stephan F, Boyer A, Ricard JD, Buczinski B, Ercole A, Hubloue I, et al. High-Flow Nasal Oxygen Therapy Is Associated With a Lower Rate of Escalation of Respiratory Support in Critically Ill Patients Compared With Conventional Oxygen Therapy. JAMA. 2015 Jun 23-30;313(23):2331–9.38. Carrillo A, Gonzalez-Diaz G, Ferrer M, Martinez-Oñate M, Vargas M, Ramirez P, et al. Non-invasive ventilation in community-acquired pneumonia and severe acute respiratory failure. Intensive Care Med. 2012 Mar;38(3):458-66.39. Esteban A, Frutos-Vivar F, Ferguson ND, Arabi YM, Baigorri F, Quintana M, et al. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med. 2004 Jun 3;350(24):2452-60.40. Kang BJ, Koh Y, Lim CM, Huh JW, Baek S, Han M, et al. Failure of high-flow nasal cannula therapy may delay intubation and increase mortality. Intensive Care Med. 2015 Apr;41(4):623-32.Cuidados críticosCritical careInsuficiencia respiratoriaRespiratory insufficiencyTerapia por inhalación de oxígenoOxygen inhalation therapyCánulaCannulaTerapia con oxígeno a altos flujoshttps://id.nlm.nih.gov/mesh/D003422https://id.nlm.nih.gov/mesh/D012131https://id.nlm.nih.gov/mesh/D010102https://id.nlm.nih.gov/mesh/D000072601ODS 3: Salud y bienestar. 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