High Flow Nasal Cannula Therapy: A Simple and Effective

HighFlowNasalCannulaTherapy:ASimpleandEffectiveModalityPresentedby:MeaganN.Dubosky,MS,RRT-ACCS,NPS,AE-CManager,RespiratoryCare&PulmonaryRehabServicesRushOakParkHospital,Chicago,ILAssistantProfessor,RushUniversity,Chicago,IL

ThisprogramissponsoredbyTeleflexIncorporated.MC-002628

OurSponsor

KelliMcGrew,MS,RRTManager,ClinicalSupport&EducationTeleflex,Respiratory

OurModerator

DavidLVines,MHS,RRT,FAARCChair,DepartmentofCardiopulmonaryScienceRushUniversity,Chicago,IL

OurSpeaker

MeaganDubosky,MS,RRT-ACCS,NPS,AE-CAssistantProfessorDept.ofCardiopulmonarySciences,CollegeofHealthSciencesRushUniversity,Chicago,IL

Ms.Dubosky disclosedthefollowingrelationships:• Aerogen (Research)• Halyard(Research&Consulting)

• Nooff-labeluseofproductsarediscussedinthiswebinar.• ThispresentationissponsoredandfundedbyTeleflex.

Mr.Vinesdisclosedthefollowingrelationship:• Teleflex (Consulting)

Disclosures

ContinuingEducation(CNEandCRCE)

• Thisactivityhasbeenapprovedfor1.0contacthourofCRCEandCNEbytheAARCandCaliforniaBoardofNursingandtheFloridaBoardofNursing.

• Attheendofthiswebinar,youcanobtainthosecontinuingeducationcreditsbyloggingontowww.saxetesting.com/cf.TheURLtobeprovidedattheendofthiswebinar.

• Completethepost-testandevaluationform.• Uponsuccessfulsubmission,youwillbeabletoprintyourcertificateof

completion.Accreditation• AmericanAssociationforRespiratoryCare,9425N.MacArthurBlvd.,

Suite100,Irving,TX75063.• Provider(SaxeCommunications)isapprovedbytheCaliforniaBoardof

RegisteredNursing.Provider#14477andFloridaBoardofNursingProvider#50-17032

HighFlowNasalCannulaTherapy:ASimpleandEffectiveModalityPresentedby:MeaganN.Dubosky,MS,RRT-ACCS,NPS,AE-CManager,RespiratoryCare&PulmonaryRehabServicesRushOakParkHospital,Chicago,ILAssistantProfessor,RushUniversity,Chicago,IL

Attheendofthispresentationyouwillbeableto:

1. ExplainthepotentialmechanismsofactionofHFNC.

2. DiscussHFNCuseinvariouspatientconditions.

3. DescribetherecommendedapplicationandmanagementofHFNC.

LearningObjectives

• ReverseHypoxemia• MaintainaPaO2ofatleast60mmHg

• Decreaseworkofbreathing

• Decreasecardiacworkload

RobertL.WilkinsEgan'sFundamentalsofRespiratoryCare,9thEdition.Mosby,2009.WillBeachey RespiratoryCareAnatomyandPhysiology,2nd Edition.Mosby,2007

3MainGoalsOfOxygenTherapy

Indications• Documentedhypoxemia

• PaO2 <60orSaO2 <90%insubjectsbreathingroomairorwithvaluesbelowdesirablerangeforspecificclinicalsituation.

• Anacutecaresituationinwhichhypoxemiaissuspected

• SevereTrauma• AcuteM.I.• Short-termtherapyorsurgicalintervention

RESPIRATORYCARE•JUNE2002VOL47NO6

AARCCPG:OxygenTherapyforAdultsintheAcuteCareFacility

• LowFiO2• Hypoventilation• V/QMismatch• AnatomicShunt• DiffusionImpairment


CausesofHypoxemia1.Reducedpartialpressureofoxygenintheinspiredair.

2.Alveolarhypoventilation

3.Ventilationperfusionmismatch4.Shunt(intracardiac orintrapulmonary)5.Impairedalveolar-capillarydiffusion

5MainCausesofHypoxemia

ImagecourtesyofTeleflex.

Oxygentherapyiseffective!

Examples:• COPD• Fibrosis• Asthma• Pneumonia• P.E.• Pulm HTN


V/QMismatch:Themostcommonculpritofhypoxemia

Respondspoorlytooxygentherapy

• Severeshunting/absenceofventilation• Large#alveolicollapsedorfluidfilled

GOAL:Re-establishventilationwithoutinjuringthelungordecreasingdeliverytothetissues…

1.Increaseoxygencontent2.Maintaincardiacoutput

RefractoryHypoxemia

ClinicalPresentation

• IncreasedWOB• Cough• Dyspnealevel

(BORG)• Pale• Tachypnea• Tachycardia• Desaturating

• ChestPain• Producing

Sputum• Tripodding• Abnormal

BreathSounds• Disoriented• Headaches

3P’sofDeviceSelection

Purpose

Patient

Performance

OxygenDeliverySystems

LowFlow• Variableperformance• Providesupplemental

oxygenNasalCannula,Simplemask,NRB

HighFlow• Fixedperformance• Meetsorexceedspatient’sinspiratorydemandsAir-entrainmentmask/nebulizers,HFNC

RobertL.WilkinsEgan'sFundamentalsofRespiratoryCare,9thEdition.Mosby,2009.

OxygenDeliverySystems

PerformanceQuestions…

Oxygen1. Howmuchoxygencanthedevicedeliver?2. DoestheFiO2 varyorstaythesameifpatient

demandchanges?

Flow1. Ifinspiratorydemandishigherthanthedevice,will

entrainingroomaircausedesaturation?2. DoesthepatienthavesignsofincreasedWOB?


Performance

Oxygen1. Howmuchoxygencanthedevicedeliver?2. DoestheFiO2 varyorstaythesameifpatientchanges

demand?


Performance

HighFlowDeviceQualification-

“Systemshouldprovideatleast60L/mintotalflow.Averageadultpeakinspiratoryflowduringtidalventilationisapprox.3xVE.20L/minisclosetotheupperlimitofsustainableVEforthosewhoareill.3x20,or60L/min,shouldsufficeinmostsituations.”


HeatedHighFlowNasalCannula(HFNC)

Simple• Flowrates16-60L/min• FiO2 from0.21to1.0• Activehumidity• Temperaturecontrol

Benefits• Comfort=Compliance• Talk,eat,drink

PhotocourtesyofTeleflex

HFNC:MechanismsofAction

4KeyPrinciples

1. Flushingofanatomicaldeadspace

2. Meetingflowdemands

3. Maximizinglungmechanics(heat&humidity)

4. Improvesmetabolicexpenditure(WOB)

Schwabbauer N.BMCAnesthesiol 2014;14:66-2253-14-66.eCollection 2014.Spoletini G,Chest2015;148(1):253-261DysartK.Respir Med2009;103(10):1400-1405.FratJP.Respir Care2015;60(2):170-178.


Flushingofanatomicaldeadspace

• WashoutofexpiredCO2 thoughttobeprimarymechanismcontributingtosuccess

• Moreoxygenparticipatesingasexchange– thuslowerVEneeds

• Multipleclinicaltrials&animalstudies↓PaCO2NormalizedVt andVE↓Deadspace

ImagecourtesyofTeleflex


2.Meetingflowdemands

• Meetsorexceedsinspiratoryflowdemands

• AllowsmorepreciseFiO2delivery• Entrainmentofairoccurs

withALLoxygendeliverydevices

• MinimizedwithHFNC• Closedmouthbest

Spoletini G.Chest2015;148(1):253-261.Volsko TA.EquipmentforRespiratoryCare.Burlington,MA:JonesandBartlett;2014.

PhotocourtesyofTeleflexMedical


3.Maximizinglungmechanics(heat&humidity)

• GasConditioning&Comfort• Secretionclearanceandpatientcomfort.• ShiftinISB• Discomfort&Pain


4.Improvesmetabolicexpenditure

• Meetsflowdemands- decreasingenergyusedinresistiveWOB• ↑RR=moretimeworking

• Nasalpassageheats&humidifieswell(normalconditions)• Systemstressed-cold,drymedicalgas.• Requiresenergytoraisethetemperaturebreathedin.

HFNCIndications

AcuteHypoxemicRespiratoryFailure(AHRF)

Fratetal.NEngl JMed2015• N=310• >60%w/CAP,nonehypercarbia,

allhypoxemicresp fail• Randomized(1:1:1):HFNC,NPPV,

orstandardoxygendelivery• Intubationratedidnot

differbetween3groups(trendedlowerinHFNC)

• HFNCgroup- lower90-daymortality

• Morevent-freedays• Lessrespiratorydiscomfort

Fratetal.NEngl JMed2015

0

0.2

0.4

0.6

0.8

1

1.2

0 20 40 60 80 100

CumulativeProb

abilityofS

urvival

DAYSSINCEENROLLMENT

KAPLAN-MEIERPLOTOFTHEPROBABLILITYOFSURVIVALFROM

RANDOMIZATIONTODAY90

NIV SOT HFNC

PostCardiothoracicSurgery

TraditionallysupportedbyNPPVtopreventre-intubation(Grade2)

-Approx.20%fail

StephanFetal.JAMA2015• N=830,randomized• NPPVvs.HFNC• Hypoxemiapostsurgery

• Reintubation ratessimilar(13.7%vs.14%)• ICUmortalitysimilar(5.5%vs.6.8%)

StephanFetal.JAMA2015

Post-Extubation

Henandez etal.JAMA2016• N=527,multicenterRCT• HFNC(264)orconventionaloxygentherapy(263)- 24hours• Lowriskforreintubation,fulfilledextubation criteria

• Reintubation w/in72hr.lessinHFNC• 13(4.9%)vs.32(12.2%)p=.004

• Postextubation Resp FailurelessinHFNC• 22(8.3%)vs.38(14.4%)p=.03

Maggioreetal.AmJRespir Crit CareMed2014• N=105,RCT• Mech vent>24hrs,passedSBT,P/F<300.• HFNC(n=53)vs.VenturiMask(n=52)

• HFNCbetteroxygenationforthesamesetFiO2• HFNCassociatedbettercomfort,↓desats &interfacedisplacements,

↓reintubationrate Henandez etal.JAMA2016Maggioreetal.AmJRespir Crit CareMed2014

Do-Not-Intubate(DNI)

NPPVcommoninDNIwithresp failurePetersetal.Respir Care2013• N=50exploredefficacy(pulm fibrosis,pneumonia,

COPD,cancer,hematologicmalignancy,CHF)• Saturationswentfrom89.1%to94.7%(p<.001)• RR30.6breaths/minto24.7(p<.001)• 9(18%)escalatedtoNIV• Concluded- HFNCprovidesadequate

oxygenationinDNIComfort.Abilitytospeakanddrink.Lessintrusive.

Petersetal.Respir Care2013

HeartFailure

AssociatedAHRFandpooroutcomes• TraditionallyNPPV

↑oxygenation,↑intrathoracicpressure,↓WOB,↓preload

Rocaetal.JCrit Care2013• N=10,sequentialintervention,prospective• NYHAclassIII,EF≤45%• TEEmeasureinsp collapseofIVC(surrogateforpreload)• HFNConroomairatnoflow,20L/min,40L/min

• Collapse↓- noflow(37%),20L/min(28%),40L/min(21%)

• ChangesreversiblewithwithdrawalofHFNC• RR↓-noflow(23bpm),20L/min(17bpm),40L/min

(13bpm)

Rocaetal.JCrit Care2013

COPD

Braunlich etal.Int JChron ObstructDis2016

• N=19,interventionalclinicalstudy• AIM:characterizeflow-dependentchangesinMAP,Vt,RR,

pCO2 atdifferentflowrates(20,30,40,50L/min)comparedtoCPAPandnBiPAP• HFNChadminorincreaseMAP• Vt ↑,RR↓,VE↓• Hypercapniadecreasedw/↑flow• Dyspneaimproved

Braunlich etal.Int JChron ObstructDis2016Fraseretal.Thorax2016

COPDContinued

Fraseretal.Thorax2016• N=30male,randomizedcrossover• Assessed:short=termphysioresponsecomparingLTOT

(2-4L/min)vsHFNC(30L/min)• HFNCvsLTOT

• TcCO2 (43.3vs46.7mmHg,p<0.001)• TcO2 (97.1vs101.2mmHg,p=0.01)• RR(15.4vs19.2bpm,/<0.001)• Vt (.50vs.40,p=0.003)• EELV(174%vs113%,p<0.001)– relativechangefrom

baseline

Braunlich etal.Int JChron ObstructDis2016Fraseretal.Thorax2016

Other…

Dataalsoexistssupportingusein

• IPF

• EmergencyDepartments

• Bronchoscopy

• Qualityoflife

ClinicalApplication

Nasalprongsizing

• Usesizingtool

• Manufacturersguidelines

• Typically:diameter½sizeof

patient’snostril

PhotocourtesyofTeleflexMedical

ClinicalApplication

Flowrates• Start(30-50L/min)• TitrateresponsetoRR/WOBOxygen• Startat100%• Titratetargetingsaturationgoal(92-98%)COPD• Startat50%orless• Titratetargetingsaturationgoal(90-92%)

AdditionalEducationalOpportunities

Self-studyCRCE/CNEpublicationprovidesanin-depthreviewandexpertpaneldiscussion

Availableonlineatwww.clinicalfoundations.org

ContinuingEducation(CNEandCRCE)

• Thisactivityhasbeenapprovedfor1.0contacthourofCRCEandCNEbytheAARCandCaliforniaBoardofNursingandtheFloridaBoardofNursing.

• Attheendofthiswebinar,youcanobtainthosecontinuingeducationcreditsbyloggingontowww.saxetesting.com/cf

• Completethepost-testandevaluationform.• Uponsuccessfulsubmission,youwillbeabletoprintyourcertificateof

completion.Accreditation• AmericanAssociationforRespiratoryCare,9425N.MacArthurBlvd.,Suite

100,Irving,TX75063.• Provider(SaxeCommunications)isapprovedbytheCaliforniaBoardof

RegisteredNursing.Provider#14477andFloridaBoardofNursingProvider#50-17032

Questions

On-demandWebinar

• Thiswebinarwillbeavailableon-demandatwww.clinicalfoundations.org inabout10days

• APDFoftheslidescanbedownloadedatthattime

Documents

High Flow Nasal Cannula Therapy: A Simple and Effective