Presentation on theme: "High Flow Therapy (HFT)"— Presentation transcript:
1High Flow Therapy (HFT) Adult PopulationBrief introduction---”Hello Everyone, I’m **, a Clinical Specialist for Vapotherm---and the focus off today’s talk is on high flow therapy and our technology, and adult applications.Nursing Educational Series
2Agenda Respiratory Patient Tx Model ( Old & New ) Review of High Flow Therapy (HFT®)Clinical Applications & BenefitsPrecision Flow® DemonstrationQ & AThe goal of the presentation is to:- Outline the Mechanisms of Action of how High Flow Therapy----what is happening physiologically and anatomically-Describe how HFT fits into the continuum of respiratory care- Discuss Patient Application----what types of patients will benefit from this therapy.- Provide a brief overview of key research=Overview Vapotherm approach to HFT and demonstrate Precision Flow- Questions and Answers
3Oxygen Therapy -vs- Ventilation Oxygen Therapy Goals –1. Correct hypoxemia2. Decrease symptoms associated with hypoxemia3. Decrease workload on cardiopulmonary systemN.I.V.Therapy Goals –1. Improve Gaseous Exchange (02-CO2)2. Decrease intrapulmonary Shunt3. Assist the Pt’s Spontaneous Respiratory Effort & Alleviate Dyspnea4. Reduce Work of Breathing5. Avoid Intubation & VentilationThe current model in treating a respiratory compromised patient was to initiate, depending on the acuity of the patient, one of many types of oxygen devices (low or high flow). If the patient digressed, the next option is some sort of pressure therapy, officially known as Non Invasive Ventilation, or more commonly known as BiPap. (Or NCPAP if in NICU)However, it has become more understood that typically these oxygen devices, especially high flow masks, generally do not fully support the patient as anticipated. Take for example a non-rebreather mask, thought to deliver 100% O2, research has shown time and time again, it typically only delivers 60-70% Fi02. When this fails, the physician makes the jump to NIV to support the patient, but as you can see the goals between these two therapies are completely different and in some cases maybe over kill for a patient who simply cannot oxygenate.Question: How often is Bipap being used to oxygenate your patients when they will not tolerate or benefit from a mask?
4Continuum of Care: Old Model RescueWeaningAcuityMechanicalVentilationBi-LevelBi-LevelCPAPCPAPThrough the progression of respiratory insufficiency, multiple therapies are initiated in an effort the alleviate symptoms and subsequently attempt to avoid more invasive therapies, such as mechanical ventilation. Arguably, there is a gap between the ability of simple oxygen to correct the problem and the initiation of pressure support therapies that take at least some control over respiratory volumes during breathing. These early pressure therapies induce anxiety and are very unpleasant for a patient, which can worsen their status by causing harder breathing in an already delicate balance of distress vs. fatigue. And, it’s not until bi-level therapy is initiated that an effect on CO2 can be anticipated.Note that the curve for extuabtion/weaning is not a mirror image of the rescue curve. Once a clinician has full control over a patient’s respiration, the decision to extubate becomes challenging. You have to consider questions such as, “Have the patient's lungs improved to a point where they can oxygenate without requiring extreme physical work effort?,” and “Does the patient have the muscular integrity to support their own ventilatory needs?” In this regard, and considering the hazards of re-intubation, the clinician typically does not take high risks on extubating prematurely. A patient is typically extubated when their respiratory parameters indicate that they are well enough to need only minimal support, so the relative acuity scale shifts downward; however, it is still likely that simple oxygen therapy will, at least initially, not be enough.General 02TherapyGeneral 02TherapyChoice of Therapy44
5Continuum of Care: Old Model Low FlowCannulaOxygen MaskCPAP / Bi-LevelMechanicalVentilationFlows limited to 1 – 5LpmHigher Fi02AchievedPressure SupportPatient Completely VentilatedFi02 typically< .40Easily ToleratedPoorly ToleratedClaustrophobiaCannot Eat, Take MedsOff more than OnTight Fitting MaskNot well toleratedOver UtilizedUsed when Patients Fail CPAP/ BiPAPSome Patients Hard To WeanInvasive55
6What if there was a therapy that was a bridge between Continuum of CareWhat if there was a therapy that was a bridge between02 Therapy and Bi-Level?
7Continuum of Care: New Model RescueWeaningAcuityMechanicalVentilationBi-LevelBi-LevelCPAPCPAPHigh FlowTherapyHigh Flow Therapy fills that gap, where a patient has not truly reached insufficiency and can be supported by a little more help than just some oxygen. This is valuable in both rescue and weaning paradigms.However, this is not to say that CPAP and Bi-PAP don’t have a roll. In a rescue scenario, when a patient’s disease exacerbation progresses to the point where they are experiencing de-recruitment of lung tissue and/or no longer have the physical stamina to draw in adequate breath volumes, then pressure support is needed. In weaning, it is always desirable to have minimally invasive pressure support available if it can mean avoiding re-intubation. Plus, in scenarios such as following thoracic surgery, the pressure support is critical for acting against pulmonary edema. Therefore, CPAP and Bi-PAP will certainly always play critical rolls in the clinician’s armamentarium.General 02TherapyGeneral 02TherapyChoice of Therapy77
8High Flow Therapy: Precision Flow Via Nasal Cannula5 – 40 LpmPrecision Flow ®Precise Temperature,Blending, & Flow-Humidification with no RainoutPatient’s Demands Met-Easily Tolerated by Patient-Higher Fi02s than a Mask- Audible AlarmsThe tools for delivery of heated, humidified repsiratory gas support range from a nasal cannula to a transtracheal cather. The table above discussses the tools, application and value of these interfaces.88
9High Flow Therapy: Definitions Flow rate that exceeds patient flow demands at various minute volumesA method to achieve actual FiO2 of 1Eliminate entrainment of ambient air- Accomplished in the nasopharynx only with proper gas conditioningConventional cannula therapy limited by nasal damageHFT becomes more than oxygen therapyCombination of technologies to achieve optimal temperature, humidity and flow rate at the point of deliveryLet’s start out with “What is High Flow Therapy”. Simply put, and by definition of the AARC, high flow therapy is defined as flow rates that meet or exceed the patients inspiratory demand at various minute volumes.In practice, HFT via nasal cannula is the application of conditioned breathing gas delivery to effect washout of the nasopharyngeal dead-space and support breathing effort.Optimal outcomes with high flow therapy can only be accomplished with ideal conditioning of breathing gases, which is gas delivered at body temperature, and saturated with water vapor. With proper conditioning, higher gas flows can be used while avoiding mucosal damage, and provide optimal outcomes in the manner of improved respiratory efficiency with respect to both oxygenation and carbon dioxide ventilation.It is only recently with a combination of new technologies in delivering heated/humidified breathing gases to patients that High Flow Therapy via nasal cannula has accomplished this. So, where do we start?
10at the point of delivery. Control the Factors that Matter…Combination of proprietary technology to achieve optimal:FlowFi02TemperatureHumidityat the point of delivery.So, what is required of a device to meet patient’s needs to deliver a safe and effective modality that makes an oxygen delivery system a more aggressive mode of therapy and enables to you to achieve better outcomes on higher acuity patients? Most importantly, how do we increase the success rate of optimal patient outcomes by decreasing the need for more invasive therapies?INDIVIDUAL control of four primary factors which allows for oxygen therapy to be delivered at higher flow rates, thus allowing a simple therapy to function as a more aggressive modality: Flow, FiO2, Temperature and Humidity. As a clinician is able to individually AND most importantly, independently control those four factors, simple oxygen therapy evolves into a high flow, more effective yet least invasive therapeutic modality. As this simple therapy evolves, optimal patient outcomes become apparent.
11High Flow Therapy: Mechanisms of Action Humidify / Warm AirwaysMobilization of SecretionsNasal comfortFlush Dead SpaceCO2 EliminationOxygen EfficiencyWhy is it important to condition the gas to body temperature, pressure saturated? To accomplish the true mechanism of action of High Flow Therapy. Although some may believe that high flow therapy is unregulated CPAP due to the fact that some pressure inevitably develops, we believe it is not the most critical mechanism of action:Remember earlier we defined what high flow therapy was; not a few extra liters, but rather a flow rate that exceeds patient demand. This creates a number of very important physiologic scenarios which elevates a nasal cannula to a more aggressive form of therapeutic modalities:Flush dead space and therefore remove CO2 as well as making oxygen delivery more efficiency by way of an internal reservoirSupport inspiration by providing flow. This eliminates the inertia of gas movement through the resistance offered by the nasopharynx and allow for greater inspiratory flow for the same work effortThe gas conditioning that allows for HFT, also has it own impact on the mechanics of the lungs and airways, which include improving lung compliance and reducing airway resistance. Secretion mobilization is another important outcome of warm, saturated breathing gas delivery.Supports InspirationCannula Flow > inspiratoryWork of Breathing11111111
12Mechanisms: Humidity Anatomical Structure Mucosal Architecture Inspiratory Gas ConditioningNasopharynx is highly efficient at conditioning inspiratory gasAnatomical StructureMucosal ArchitectureHowever, before we start flushing the nasopharynx and support the WOB demands of our patients, we must first overcome meeting its efficiency at warming and humidifying inspiratory gas. Delivering high flows without matching BTPS could cause damage and expedite a disease state.This efficiency is a result of both the large surface area created by the anatomical structure of the nasal cavity and the conchae, which brings the gas in close proximity to the walls of the cavity.And of course, the architecture of the mucosal tissue…
13Conditioning Prevents Injury Mechanisms: HumidityConditioning Prevents InjuryInadequate warming and humidification can cause:Thickened SecretionsDecreased mucocilliary actionThermal challengeBloody secretionsLung atelectasisNo matter what the device, oxygen concentration or liter flow, humidification is critical for safe and effective delivery of respiratory gas. The lack of humidity can cause:Thickened secretions – resulting in plugged airwaysDecrease in mucocilliary action – hampering clearance of debrisThermal challenge to the upper airway to adequately heat and humidify the gas – leading to excess energy expenditure and dehydration.Bloody secretions – as a result of cellular damageAlso, later stages of progression may include atelectasis in the lung.All of these symptoms contribute towards the patient possibly requiring more invasive therapies, such as CPAP/BiPaP or ultimately, intubation!
14Why BTPS? Mechanisms: Humidity Importantly, it is critical that HFT via nasal cannula be done with optimal warming and humidification. The level of flow that brings therapeutic benefit beyond simple oxygen supplementation, can support nasal mucosal function if the humidification is correct, but overwhelm nasal mucosa if humidification is inadequate.This graph from Williams and colleagues shows how important proper humidification is to proper mucosal function. Significant deviations from BTPS on the x axis, which is 44 mg/l of water vapor, results in thick secretions and decreases in mucus transport velocity shown in the y axis. When the nasal mucosa is overwhelmed, the results can be cell damage contributing to lung injury seen as atelectasis.Williams et al, 1996, Crit Care Med 24(11):
15Mechanisms: Humidity (How We Do It) Vapor Transfer Cartridge:Key to efficient, high performance humidification and gas conditioningAlso serves as filter--pore size much smaller than 0.05 micronsPatient Delivery Tube:Patented triple lumen designDesign prevents rain-outKeeps gas conditioned out to patientSafer than traditional heater wire design
16Flush Dead Space & Support Inspiration Mechanisms: Physiology & Dead SpaceFlush Dead Space & Support InspirationNow that we have adequately conditioned the gas – we can look at the other mechanisms. Most importantly is the elimination of anatomical dead space by flushing out end-expiratory gas during expiration so each subsequent breath contains more fresh gas and less end-expiratory gas.
17Pulmonary Physiology and Dead Space Although related to a decrease in respiratory efficiency, anatomical dead space is essential for at lease two functions: 1) the nasopharyngeal area is responsible for gas conditioning to insure that the gas reaching the viscera is at body temperature and saturated, ….
18Pulmonary Physiology and Dead Space …. and 2) the large airways conduct the gas to the thorax and distribute it to the lung regions.
19Pulmonary Pathophysiology Now when we think about pulmonary pathophysiology, physiologic dead space in the lungs should normally be very small. However, with progressing lung disease, physiologic dead space increases as a result of increasing ventilation-perfusion mismatch secondary to dysfunctional alveolar units or gas trapping in obstructive diseases. Therefore, respiratory efficiency is reduced in cases of disease and patients need to work harder to keep alveolar gas concentrations adequate.
20Pulmonary Pathophysiology Eliminating nasopharyngeal dead space by flushing with fresh gas makes breathing more efficient even under normal conditions in healthy people.In this regard, flushing nasopharyngeal dead space can counterbalance physiologic dead space, effectively raising the threshold were patients may succumb to disease and require more invasive ventilatory support.Importantly, HFT does not treat disease, but rather improves respiratory efficiency related to dead space, allowing for more functional reserve.
21Mechanisms: Standard Oxygen Therapy However, because the lung are a visceral organ that surrounds the heart and comes in direct contact with the body’s entire circulating blood volume, gas entering the lungs needs to be warmed, humidified and cleaned prior to reaching the alveoli.2121
22Flush Dead Space & Support Inspiration Here is a look in a clinical model where a nasal cannula (on the left), at high flows, flushes out the dead space as opposed to a mask (on the right) which acts as an external reservoir and the patient’s inspiratory demand determines if the delivered gas arrives into the airway.High mask flow, impeded by pressure at the mouth - stores less O2 in the upper airways during exhalation and adds prosthetic dead spaceHigh nasal flow, unimpeded at mouth, fills the upper airways – storing O2 during exhalation and flushing CO2Tiep, et al: Resp Care, 2002: High Flow Nasal vs High Flow Mask oxygen delivery: Tracheal Gas Concentrations Through an airway model
23Illustrates HFT Therapeutic Flow Ranges: Mechanisms: High Flow TherapyIllustrates HFT Therapeutic Flow Ranges:25-35LpmPrecise gas warming and humidification is critical to support effective use of High Flow Therapy via nasal cannula. This animation shows how HFT purges that end-expiratory gas from the nasopharyngeal dead space during expiration to facilitate ventilation of CO2, and how each subsequent breath contains more fresh gas from this internal reservoir during inspiration, making oxygenation more efficient.Typically this occurs in the adult patient at flow rates of 25Lpm or more.2323
24Mechanism of Action Review Dead space washoutSupports CO2 ventilationEnhances oxygenationMatched inspiratory flowAttenuates nasopharyngeal resistanceAdequate gas conditioningImproves conductance and complianceReduces energy cost of gas conditioningSo lets review the mechanisms by which HFT works.When appropriately conditioned, the use of high flows of respiratory gases does not overwhelm the mucosa and facilitates addition mechanism beyond basic oxygen therapy.Research is now demonstrating that among these mechanisms are:Dead space washout, which supports CO2 ventilation as well as oxygenationMatched or exceeded inspiratory flow which attenuates nasopharyngeal resistance and facilitates inspiration effortAdequate gas conditioning which improves pulmonary mechanical parameters and reduces the energy cost of gas conditioning
26Flow First™ Early Intervention Is The Key HFT Clinical ReviewFlow First™ Early Intervention Is The KeyTo start, many clinicians believe that high flow should be the first intervention a respiratory clinician makes when the situation calls for respiratory support for a spontaneously breathing patient. This means flow first in rescue situations in the ER or ICU, Flow first in maintenance situations, and flow first in weaning.Clinically, it also means that high flow therapy allows the clinician to utilize flow, ahead of Fi02 to manage patients. This Flow First concept will become clear as we progress through this presentation.
27Indications for Use: Indications: Contraindications: Spontaneously breathing patients who are requiring supplemental oxygen therapyAny patient who is on an oxygen mask that is: 1. Not compliant, 2. not improving, 3. Or has an increase in work of breathingPost- extubation support or weaning from NPPVPatients requiring supplemental heat & humidity for artificial airwaysSo we read the literal indications for use from the 510 k (FDA), which means Vapotherm is indicated for what is really a broad range of applications. So what does that mean in terms of patient selectionFirst, indications include-Spontaneously breathing patients who are requiring supplemental oxygen therapy-Any patient who is on an oxygen mask that is: 1. Not compliant, 2. Not improving, 3. Or has an increase in work of breathing-Post extubation support or weaning from NPPV-Patients requiring supplemental heat & humidity for artificial airwaysOn the flip side, there are actually not many contraindications.-Patients not spontaneously breathing-Patients that have a deviated septum-Patients with severe facial trauma or disfigurementThese indications are general, without being case specific to alleviate any potential off-labeling (such as we cure RSV). Also it keeps the possibilities wide open.Contraindications:Patients not spontaneously breathingPatients that have a deviated septumPatients with severe facial trauma or disfigurement
28Mechanisms by Application HFT DOES NOT TREAT A DISEASE, THE MECHANISMS TREAT SYMPTOMSOxygenFlushHumidityMild PressureCOPDFibrosisAsthmaCHFIts importantly to understand that HFT, like other forms of respiratory support, does not treat a disease, but it impacts symptoms. Much in the same way your cold medicine suppresses sneezing while the cold virus runs is course. Within various disease states, the combination of mechanisms that are most impactful vary based on the symptoms that are characteristic of that disease. Here is an example of how various mechanisms come into play during some of the major adult respiratory disease states.Here are a sample of some disease states and how the mechanisms of action treat the symptoms.Can you think of other respiratory insufficiencies where the symptoms can be treated by HFT?
29HFT Conclusions – Patient Care Aspects Non-invasive Interface – Nasal CannulaNo Masks to FitNo Leaks to Worry AboutPatient Can Eat, Talk, Take MedsAbility to Control Factors IndependentlyCan Deliver Temp, Flow, Fi02 to Meet Patients Exact NeedsCan Deliver High Flow and Low Fi02 for “Retainers”
30HFT Conclusions – Patient Care Aspects Ability to Oxygenate Better than a MaskNo Need to Use Pressure Devices Just to Oxygenate PatientsExcellent Weaning Tool for Patients on BiPAPCan Be Used on Multiple DiagnosisUsed to Treat Entire Spectrum of Respiratory Compromised PatientsMouth Breathers & Difficult to Treat PatientsLow Maintenance While on PatientNo Masks to Keep TightNo Rainout in Patient Delivery TubeCircuit Good for 30days LOSEasy to Read Display