HighFlowNasalCannulaTherapy:ASimpleandEffectiveModalityPresentedby:MeaganN.Dubosky,MS,RRT-ACCS,NPS,AE-CManager,RespiratoryCare&PulmonaryRehabServicesRushOakParkHospital,Chicago,ILAssistantProfessor,RushUniversity,Chicago,IL
ThisprogramissponsoredbyTeleflexIncorporated.MC-002628
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
RobertL.WilkinsEgan'sFundamentalsofRespiratoryCare,9thEdition.Mosby,2009.WillBeachey RespiratoryCareAnatomyandPhysiology,2nd Edition.Mosby,2007
CausesofHypoxemia1.Reducedpartialpressureofoxygenintheinspiredair.
2.Alveolarhypoventilation
3.Ventilationperfusionmismatch4.Shunt(intracardiac orintrapulmonary)5.Impairedalveolar-capillarydiffusion
5MainCausesofHypoxemia
ImagecourtesyofTeleflex.
Oxygentherapyiseffective!
Examples:• COPD• Fibrosis• Asthma• Pneumonia• P.E.• Pulm HTN
RobertL.WilkinsEgan'sFundamentalsofRespiratoryCare,9thEdition.Mosby,2009.WillBeachey RespiratoryCareAnatomyandPhysiology,2nd Edition.Mosby,2007
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
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?
RobertL.WilkinsEgan'sFundamentalsofRespiratoryCare,9thEdition.Mosby,2009.
Performance
Oxygen1. Howmuchoxygencanthedevicedeliver?2. DoestheFiO2 varyorstaythesameifpatientchanges
demand?
RobertL.WilkinsEgan'sFundamentalsofRespiratoryCare,9thEdition.Mosby,2009.
Performance
HighFlowDeviceQualification-
“Systemshouldprovideatleast60L/mintotalflow.Averageadultpeakinspiratoryflowduringtidalventilationisapprox.3xVE.20L/minisclosetotheupperlimitofsustainableVEforthosewhoareill.3x20,or60L/min,shouldsufficeinmostsituations.”
RobertL.WilkinsEgan'sFundamentalsofRespiratoryCare,9thEdition.Mosby,2009.
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.
HFNC:MechanismsofAction
Flushingofanatomicaldeadspace
• WashoutofexpiredCO2 thoughttobeprimarymechanismcontributingtosuccess
• Moreoxygenparticipatesingasexchange– thuslowerVEneeds
• Multipleclinicaltrials&animalstudies↓PaCO2NormalizedVt andVE↓Deadspace
ImagecourtesyofTeleflex
HFNC:MechanismsofAction
2.Meetingflowdemands
• Meetsorexceedsinspiratoryflowdemands
• AllowsmorepreciseFiO2delivery• Entrainmentofairoccurs
withALLoxygendeliverydevices
• MinimizedwithHFNC• Closedmouthbest
Spoletini G.Chest2015;148(1):253-261.Volsko TA.EquipmentforRespiratoryCare.Burlington,MA:JonesandBartlett;2014.
PhotocourtesyofTeleflexMedical
HFNC:MechanismsofAction
3.Maximizinglungmechanics(heat&humidity)
• GasConditioning&Comfort• Secretionclearanceandpatientcomfort.• ShiftinISB• Discomfort&Pain
HFNC:MechanismsofAction
4.Improvesmetabolicexpenditure
• Meetsflowdemands- decreasingenergyusedinresistiveWOB• ↑RR=moretimeworking
• Nasalpassageheats&humidifieswell(normalconditions)• Systemstressed-cold,drymedicalgas.• Requiresenergytoraisethetemperaturebreathedin.
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
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