2Conflict of InterestI have no real or perceived conflict of interest that relates to this presentation. Any use of brand names is not in any way meant to be an endorsement of a specific product, but to merely illustrate a point of emphasis.2
3Objectives Learning objectives for this presentation: Describe the technological elements of High Flow Oxygen Delivery System.Define the clinical end-points when utilizing High Flow Oxygen Delivery System.Review outcome data and case scenarios with High Flow Oxygen utilization.Directions: please state 2-3 objectives that you wish to accomplish with your presentation. Please use action verbs when developing your objectives.Goals:To allow attendees to evaluate whether or not you communicated your chosen topic effectivelyTo provide attendees with information about why your topic should be of importance to them (the WIFM: what’s in it for me?)3
4What is High Flow Oxygen (HFO2) An oxygen delivery system which blends oxygen/air from 35%-100%Can be administered via wide bore nasal cannula or trach adapter up to 60 L/min.Provides humidity enriched oxygen therapy for patients in mild to moderate respiratory distress.HF02 does not augment tidal volume and thus does not facilitate CO2 removal.It is not a substitute for NIPPV in an acute crisis.However, it may provide a bridge from NIPPV to conventional oxygen delivery devices and also may give some patients NIPPV free hours.
5High Flows Oxygen Benefits – There are five key benefits:Delivers a high FIO2 accuratelyMeets the patient’s ventilatory demandsProvides patient comfortProvides a modest amount of positive airway pressureOptimizes mucociliary clearance
6How is High Flow Oxygen Delivered? A combination of:Molecular high humidification delivery systemAn air/oxygen blenderFlowmeterVia nasal cannula or trach tube adaptor
21Advantages of HFO2PATIENTCLINICIANComfortable oxygen delivery, reducing the likelihood of treatment failureLess attendance time assisting uncomfortable patientsCan continue to eat, drink, talk and sleepNo need to change between multiple oxygen delivery devices and interfaces A broad range of flows and oxygen concentrations can be delivered, providing both versatility and continuity of care as patients wean or their condition becomes more acuteIncreased confidence in the actual fraction of inspired oxygen (FiO2) being delivered to the patient
22Easier oral care, maintaining the moisture in the oral mucosa May displace the need for noninvasive or invasive ventilation through better patient toleranceEasier oral care, maintaining the moisture in the oral mucosaBetter secretion clearance, reducing the risk of respiratory infectionMay be used to wean patients off noninvasive or invasive ventilation
24High Flows of Oxygen Delivered Through Nasal Cannula The combination of nasal cannula and optimal humidity enables comfortable delivery of high flowsPatientcomfortOptimizedpatientoutcomesPatientcompliance
27Why Improvement in Oxygenation? Guaranteed FI02 deliveredVentilatory demands met“Back pressure CPAP”-Every ten liters of flow approximately1 cm of CPAP is generated!-Maximum of 5-6cm CPAP can be achieved.
28Meeting patient’s inspiratory flow demand No ambiententrainment
39SpO2 MonitoringA SpO2 monitor is to be utilized for ALL HFO2 patients and low SpO2 alarm must be set 2% below the physician ordered desired Sp02.The high respiratory rate alarm must also be set per physician order on the appropriate bedside monitor.
40Weaning of HFO2 Titrate to 40% oxygen Reduce Flow to 20-30LPM Transition to nasal cannula
47HypothesisHFO may reduce escalation of therapy in specific patient populations that exhibit certain clinical and demographic characteristics
48Relevance to PracticeAid clinical decision making as to whether or not HFO is the best option for a specific patientInitiate HFO on patients that display characteristics deemed successfulNot consider HFO for patients that display characteristics deemed unsuccessfulEffective and efficient use of respiratory technology
49Study Design Retrospective observational study Analyzed data on patients at LVHN who were placed on HFO from May 21, 2011 to May 21, 2012Sample size: 137 patientsPatients less than 18-years-old were excludedPatients on HFO were identified from a daily report received by respiratory therapyElectronic medical record was used to gather demographic and clinical information regarding these patients
50MethodsPatients were separated into two groups: patients who were successful on HFO and patients who were notSuccess was defined as de-escalation in care, meaning the patient maintained clinical end-points on HFO or conventional oxygen delivery systemsFailure was defined as escalation in care, meaning that in order to maintain desired clinical end-points either NIPPV or mechanical ventilation had to be institutedIf a patient was on HFO for more than 72 hours they were counted as a failure because HFO is not indicated to be a long-term therapy1
51ResultsAll variables which were found to be statistically different (p<0.05) between the two groups were included in the logistic regression model.Patients who had a previously existing co-morbidity of pulmonary disease were 5.81(p=0.023) times more likely to fail on HFO compared to patients who did not have a previously existing co-morbidity of pulmonary disease.For every one day increase in ICU length-of-stay the odds of failing on HFO increased by 1.14 (p=0.001).Compared to those who were on HFO for 0 to 4 hours, those who were on HFO for greater than 16 hours were (p=0.001) times more likely to be a success.
52Interpretation/Conclusion Patients who stay in the ICU for a longer period of time may be more likely to fail on HFO because these individuals tend to be sicker.Those who are going to fail on HFO are more likely to do so in the first sixteen hours, therefore, these hours are crucial for the patient.Patients who have a previously existing co-morbidity of pulmonary disease are more likely to fail on HFO.Patients who succeed on HFO spend an average of 7.63 days in the ICU compared to days for patients who fail.
56Literature OutcomesHigh-flow oxygen therapy in acute respiratory failure.Roca O, Riera J, Torres F, Masclans JR.Servei de Medicina Intensiva (Area General), Hospital Universitari Vall d'Hebron, Passeig Vall d'Hebron , Barcelona, Spain.CONCLUSIONS:HFNC was better tolerated and more comfortable than face mask. HFNC was associated with better oxygenation and lower respiratory rate. HFNC could have an important role in the treatment of patients with acute respiratory failure.High-Flow Oxygen Administration by Nasal Cannula for Adult and Perinatal PatientsJeffrey J Ward MEd RRT FAARC:The HFNC can effectively be used to treat patients withmoderate levels of hypoxemic respiratory failure.HFNC could be considered as an initial appliance incertain settings (eg, ED), as flow could be titrated basedon response over a full range without having to changeto other devices.
57Case ScenariosPost liberation from long-duration Mechanical VentilationInability to administer mask either for high flow Oxygen Delivery or NIPPV secondary to facial surgical graftBridge therapy from NIPPV to conventional Oxygen AdministrationIn lieu of CPAP InterventionNitric Oxide/Heliox AdministrationPost extubation Pulmonary EdemaPatient comfort—Palliative Care
58Nurse’s reaction when I bring new technology intoher room!!
59Liberation Following Prolong Ventilatory Support A twenty-seven year old female was admitted to our ICU for Pneumonia and Sepsis. She developed full-blown ARDS and required full ventilatory support for fifty-two days.She received a tracheostomy on day thirty-two and required prolonged periods of FIO2 >60% to maintain a Sp02>88%. Several bronchoscopies were performed to address mucus plugging and maintain a patent airway.
60She was slowly transition to partial ventilatory support and then attempts were made to conduct spontaneous breathing trials (SBT) via conventional high flow oxygen system utilizing a trach mask/t-tube. During the breathing trials the patient’s respiratory rate and heart rate increased above clinical end-points and a paradoxical breathing pattern with associated wheezing was noted. Secretion removal was also problematic, requiring frequent suctioning. Periods of desaturation were noted requiring titration of oxygen delivery >60%.After four days of failed SBTs the patient was placed HFO2 via trach adapter. After institution of this oxygen and humidification delivery system, periods of desaturations were absent and work of breathing was reduced. Stable hemodynamics and airway patency were maintained. The patient remained liberated from mechanical ventilation and was transferred to a long-term care facility.
62Inability to Administer Mask Either for High Flow Oxygen Delivery or BIPAP Secondary to Facial Surgical GraftA thirty-nine year old male received a right superficial parotidectomy modified neck dissection for dermatofibrosarcoma. The operative procedure lasted fourteen hours and the patient was chemically paralyzed for medical stability and required mechanical ventilation for five days.During the ventilatory duration, the patient developed pneumonia which was resolved with antibiotic administration. The patient was extubated on day six but required re-intubation within six hours, secondary to excessive work of breathing and hypoxemia.
63High flow oxygen administration or non-invasive positive pressure ventilation were not options secondary to the location and fragile state of the facial skin graft.Mechanical ventilation was continued for an additional five days.The patient was then extubated and placed on HFNC, set at fifty percent oxygen and with a flow of thirty liters per minute. SpO2 was maintained>93% and work of breathing was minimal, secretion removal was adequate. The patient was transferred to medical-surgical unit within twenty-four hours.
64Bridge Therapy from NIPPV to Conventional Oxygen Administration An eighty-two year old female was placed on NIPPV for Respiratory Failure. Attempts to wean off NIPPV failed secondary to de-saturation and increased WOB.HFNC was placed on the patient at 60% and 40LPM, SPO2 was maintained and the patient remained NIPPV until discharge to a long-term skilled care facility.
65Post Extubation Pulmonary Edema A thirty-two year old male was admitted for bacterial pneumonia who required mechanical ventilation for seven days. Decision was made to attempt ventilatory liberation, weaning parameters were adequate however cardiac function was marginal. Decision was made to extubate, which was performed. Within two minutes post extubation the patient develop acute pulmonary edema and had to be re-intubated and ventilated.Post forty eight hours post extubation failure the decision again was made to attempt ventilatory liberation. At this point to minimize the lost of positive pressure post extubation, HFNC was placed in the patient’s nares set at 50 lpm and 50%, extubated was performed and the clinical course remained stable.
67HFNC Via HelioxSeventy-one year old patient admitted with a laryngeal tumor was placed on NIPPV along with Heliox.Patient vomited multiple times and mask compliance was marginal associated with desaturation and increased work of breathing.Patient was placed on HFNC via Heliox gas exchange stabilized and patient compliance was adhere to.
68Patient ComfortA fifty-five year old female was admitted for aortic value insufficiency a with a history if idiopathic pulmonary fibrosis. The patient under went aortic value repair.Post operatively she had multiple bouts of respiratory failure and required prolong mechanical ventilation. She was transited to NIPPV post ventilatory liberation and required its utilization for prolonged periods of time.To enhance the patient’s ability to communicate to her family and to have longer durations of BIPAP free-time to enjoy her meals HFNC was instituted. Post HFNC , NIPPV utilization was been reduced to hours of sleep only.
70High-flow Oxygen System ClinicalIndicationsMet?1Warm Unit for 5’Set FIO2to MaintainSp02>93%Set LPM 40LPM2IncreaseFI02 orLiter flowMaintainCurrentSettingsSp02>93%Sp02>93%YesNo3NoYesIs Patient’sInspiratory FlowMet?Is Patient’sInspiratory FlowMet?IncreaseFlow to50-60LPMMaintainCurrentSettingsNoYes46No7YesRe-assessfor otherclinicalinterventionsClinical StatusStable?Clinical StatusStable?Maintain/weanCurrentSettingsNoYesTransferredFromCritical CareNo5YesPlace onConventionalOxygen SystemMaintain/weanCurrentSettingsFIO2< 60%Flow<40Lpm8
71HFO2Provides wide range of precise FIO2 delivery for many patient populationsEnhances muco-kinesisProvides a pseudo-CPAPMaintains sufficient flow to maintain the patient’s inspiratory flow demandsEasy to administer and maintainPatient comfort
72Unanswered Questions!!!HFO effect on mortality?It’s effect on ICU duration in a randomized controlled study?Can it be used safely during an acute crisis in medical-surgical patient population?
73Thank You Any Questions Kenneth Miller MEd, RRT-ACCS, RRT-NPS Respiratory CareLVHN