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WAAGBali conference
AnaesthetistsIntensivists
ENT surgeonsEmergency Physicians
Difficult case presentationDiscussion and debate on difficult airways
A few useful case presentationsSome good workshops
High Flow Nasal Cannula
High Flow Nasal Cannula
To 70 l/minFiO2 adjustable
High Flow Nasal Cannula
Humidified and warmed
High Flow Nasal CannulaKeeps mouth and eyes
clearNo wedgies please
High flow oxygen humidified therapy is intended to:
• Eliminate most of the anatomic dead space and
reduce CO2 rebreathing
• Create a reservoir with high FiO2 in the nasal cavity
High flow oxygen humidified therapy is intended to:
• Improve gas exchange via CPAP effect
– reducing atelectasis
– reducing ventilation-perfusion mismatch
• 7cm H2O positive pressure (avoid tight nares seal)
• 2cm when the mouth is open
High flow oxygen humidified therapy is intended to:
• Significantly reduce the work of breathing
• Improved compliance with more comfort
– Compared to NIV mask
THRIVE by Patel et al 2015
• Increases apnoea times in patients with difficult airways
• 25 patients• Mallampati 3, direct laryngoscopy 3• 12 obese, 9 had stridor• Given jaw thrust• Median apnoea time 14 minutes (5-65)• No patient desaturated (<90%)
THRIVE by Patel et al 2015
• Increases apnoea times in patients with difficult airways
• 25 patients• Mallampati 3, direct laryngoscopy 3• 12 obese, 9 had stridor• Median apnoea time 14 minutes (5-65)• No patient desaturated (<90%)
Normal lungsDifficult airways
Increase apnoea time
FLORALI by Frat et al 2015• Multicenter open label randomised trial• 310 hypoxaemic patients• Intubation rate difference did not reach significance (P=0.18)
– 38% HFNC, – 47% standard group,– 50% NIV group
• Post hoc analysis showed it did reach significance in the more severe group (238 patients).
• There was a significant difference in 90 day mortality in favour of HFNC.
FLORALI by Frat et al 2015• Multicenter open label randomised trial• 310 hypoxaemic patients• Intubation rate difference did not reach significance (P=0.18)
– 38% HFNC, – 47% standard group,– 50% NIV group
• Post hoc analysis showed it did reach significance in the more severe group (238 patients).
• There was a significant difference in 90 day mortality in favour of HFNC.
Abnormal lungsMay reduce need to
intubateImproves 90 day
mortality
ICU preox by Miguel-Montanes et al 2015
• Sequential observational• NRBM then HFLC• 100 patients• Median lowest SpO2 in NRBM 94%• Median lowest SpO2 in HFLC 100%• P <0.0001• Patients with NRBM had more episodes of
severe hypoxaemia (2% vs 14%, p = 0.03)
ICU preox by Miguel-Montanes et al 2015
• Sequential observational• NRBM then HFLC• 100 patients• Median lowest SpO2 in NRBM 94%• Median lowest SpO2 in HFLC 100%• P <0.0001• Patients with NRBM had more episodes of
severe hypoxaemia (2% vs 14%, p = 0.03)
Abnormal lungs Preoxygenation
Reduces hypoxaemia
PREOXYFLOW by Vourc’h et al 2015
• Multicentre randomised 119 patients• ICU pts requiring intubation for severe
hypoxaemia• RCT HFNC vs 15L/min via face mask 100% FiO2
• No difference in median lowest saturation• Scott’s take – HFNC group entraining air via mouth– No jaw thrust in HFNC group
PREOXYFLOW by Vourc’h et al 2015
• Multicentre randomised 119 patients• ICU pts requiring intubation for severe
hypoxaemia• RCT HFNC vs 15L/min via face mask• No difference in median lowest saturation
Abnormal lungs PreoxygenationNo difference
HFNC may delay intubation and increase mortality by Kang et al 2015
• 175 patients• 130 intubated before 48 hours HFNC• 45 intubated after 48 hours HFNC• Early intubation group had lower mortality
HFNC may delay intubation and increase mortality by Kang et al 2015
• 175 patients• 130 intubated before 48 hours HFNC• 45 intubated after 48 hours HFNC• Early intubation group had lower mortalityAbnormal lungs
Delayed intubation patients
may do worse
HFNC in hypoxaemia in EDRittayamai et al 2015
• Prospective randomised to HFNC vs COT• Improved dyspnoea and subject discomfort• No major adverse effects
HFNC in hypoxaemia in EDRittayamai et al 2015
• Prospective randomised to HFNC vs COT• Improved dyspnoea and subject discomfort• No major adverse effectsDoesn’t seem to do harm
in EDAppears to help relieve
distress / discomfort
When should we use it in ED?
• In those distressed by dyspnoea and hypoxaemia, but not for intubation and for comfort measures.
• Those with airway issues or mild hypoxaemia who require sedation for a brief procedure
• In those with mild respiratory distress who don’t need intubation and probably don’t need NIV but do need a bit of respiratory support
When should we use it in ED?
• In those distressed by dyspnoea and hypoxaemia, but not for intubation and for comfort measures.
• Those with airway issues or mild hypoxaemia who require sedation for a brief procedure
• In those with mild respiratory distress who don’t need intubation and probably don’t need NIV but do need a bit of respiratory support
Comfort in palliation with hypoxia / respiratory distress
When should we use it in ED?
• In those distressed by dyspnoea and hypoxaemia, but not for intubation and for comfort measures.
• Those with airway issues or mild hypoxaemia who require sedation for a brief procedure
• In those with mild respiratory distress who don’t need intubation and probably don’t need NIV but do need a bit of respiratory support
Apnoeic oxygenation during brief procedures in those at risk
Maintain jaw thrust
Hospital wide - TOE, BAL, endoscopy…
When should we use it in ED?
• In those distressed by dyspnoea and hypoxaemia, but not for intubation and for comfort measures.
• Those with airway issues or mild hypoxaemia who require sedation for a brief procedure
• In those with mild respiratory distress who don’t need intubation and probably don’t need NIV but do need a bit of respiratory support
Mild respiratory distress and hypoxia
No evidence for CO2 retainers - It is not BiPAP
When should we use it in ED?
• Children– More widely used– Respiratory distress
• Bronchiolitis, pneumonia, CCF• Respiratory support to children with neuromuscular
disease• Apnoea of prematurity• Post extubation• Weaning CPAP / BiPAP
• 2L per kg per minute for first 10kg + 0.5L/kg/min above that– max 50L/min