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Background Non-invasive ventilation (NIV) remains the gold-standard therapy for acidotic acute hypercapnic respiratory failure (AHRF) in COPD, but around 20% of patients are unable to tolerate it. In the event of NIV failure, invasive ventilation (IMV) is only rarely offered, and in-hospital mortality exceeds 40%. Currently, excluding IMV no proven therapy exists beyond controlled oxygen and supportive medical care. Nasal High Flow Therapy (NHFT) improves survival in hypoxic respiratory failure and improves gas exchange in AHRF, but there is no robust evidence for improved survival in NIV-intolerant patients with COPD. NHFT is increasingly used in this setting without RCT data. If practice becomes entrenched, clinical equipoise may be lost undermining the feasibility of a future trial. A similar trajectory occurred in early UK experience with NIV, where uncontrolled implementation without adequate evidence or governance led to unexpectedly high mortality and delayed service reform. (National COPD Audit 2003).Aims We conducted a survey among 16 respiratory clinicians experienced in NIV/RSU care to understand; (a) need for a trial, (b) current NHFT use, (c) feasibility, (d) trial design, (e) appropriate endpoints.Results All (n=16) agreed there is immediate need for a trial and 15 were willing to participate. A traditional RCT was deemed unfeasible due to the time-critical nature of intervention. Strong support was expressed for a Cluster RCT, randomising centres rather than individual patients. Considering the potential benefit and recruitment challenges, 70% favoured powering the trial to detect a 15% absolute 30 day mortality reduction, balancing clinical relevance with recruitment feasibility. 2 centres reported potential reservations/barriers to participation due to entrenched NHFT use and loss of equipoise. One centre was already using NHFT in NIV intolerant patients.Conclusions There is an urgent need to evaluate NHFT in this high-risk, under-researched group. A cluster RCT, powered for a 30 day mortality, is feasible, but must be undertaken before widespread adoption makes such a study untenable.