early non-invasive ventilation and high-flow nasal oxygen therapy for preventing delayed respiratory failure in hypoxemic blunt chest trauma patients.

Conditions: Chest Injuries; Respiratory Failure

Summary: in blunt chest trauma patients without immediate life-threatening conditions, delayed respiratory failure and need for mechanical ventilation may still occur in 12 to 40% of patients, depending on the severity of the trauma, the preexisting conditions and the intensity of initial management. in this context, non-invasive ventilation (niv) is recommended in hypoxemic chest trauma patients, defined as a pao2/fio2 ratio \< 200 mmhg. however, there is a large heterogeneity among studies regarding the severity of injuries, the degree of hypoxemia and the timing of enrollment. the interest of a preventive strategy during the early phase of blunt chest trauma, before the occurrence of respiratory distress or severe hypoxemia, is not formally established in the literature. moreover, high-flow nasal oxygen therapy (hfnc-o2) appears to be a reliable and better tolerated alternative to conventional oxygen therapy (cot), associated with a significant reduction in intubation rate in hypoxemic patients. two niv strategies are compared: 1. in the experimental strategy, niv is performed after inclusion in patients with moderate hypoxemia, defined by a pao2/fio2 ratio \< 300 mmhg. the minimally required duration of niv was 4 hours per day for at least 2 calendar days. 2. in the control group, patients receive oxygen from nasal cannula or high concentration oxygen mask according to the fio2 needed to achieve spo2 \> 92%. niv is initiated only in patients having pao2/fio2 ratio \< 200 mmhg under cot. investigators hypothesized that an early strategy associating hfnc-o2 and preventive niv in hypoxemic blunt chest trauma patients may reduce the need for mechanical ventilation compared to the recommended strategy associating cot and late niv.


Eligibility criteria:
inclusion criteria: * patient admitted in intensive care unit within 48 hours after a high-risk blunt chest trauma, defined by a tts (thorax trauma severity) score ≥ 8. * hypoxemia defined by a pao2/fio2 ratio \< 300, and the absence of hypercapnia (paco2 \< 45 mmhg). * without indication of endotracheal intubation at inclusion. * affiliated person or beneficiary of a social security scheme. * free, informed and written consent signed by the participant and the investigator (at the latest on the day of inclusion and before any examination required by the research). exclusion criteria: * criteria relating to formal indication to niv: exacerbation of underlying chronic respiratory disease, cardiogenic pulmonary edema, severe neutropenia. * criteria relating to contraindications to niv: hemodynamic instability, glasgow coma scale score ≤ 12 or excessive agitation, or other contraindications to non-invasive ventilation (active gastrointestinal bleeding, low level of consciousness, multiorgan failure, airway patency problems, lack of cooperation or hemodynamic instability). * associated traumatic lesions entailing particular risks: severe brain injury, complex facial trauma, tetraplegia, tracheobronchial or esophageal injuries, thoracic or abdominal trauma with indication for surgery by thoracotomy or laparotomy. * criteria relating to the regulation: a do-not-intubate order and a decision not to participate, persons placed under judicial protection, persons participating in another research including a period of exclusion still in course, severely altered physical and/or psychological health which, according to the investigator, could affect the participant's compliance of the study.

Keywords: chest trauma respiratory failure noninvasive ventilation high-flow nasal oxygen therapy