Neonatal High Flow Nasal Cannula

Bradley A. Yoder, MDProfessor of Pediatrics

Division of NeonatologyUniversity of Utah School of Medicine

Towards A Clinical Practice Guideline

Disclosure Statement

I have received research and/or travel compensation as a consultant to

Drager MedicalFisher & Paykel

Vapotherm& Ikaria

Objectives

Recognize Detrimental Approaches

Suggest Clinical Guidelines

Identify Areas for Further Research

Contributing Consultants• Clare Collins, MBChB, PhD, FRACP. Department of Paediatrics, Mercy

Hospital for Women, Melbourne, AU (CCollins@mercy.com.au)

• Kevin Ives, MBBChir, , MD, FRCPCH. Dept of Neonatology, John Radcliffe Hospital, Oxford, UK (Kevin.Ives@nhs.net)

• Brett Manley, MB BS (Hons.), PhD, FRACP. Consultant Neonatologist Neonatal Services and Newborn Research Centre, Royal Women's Hospital Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, AU (Brett.Manley@thewomens.org.au)

• Michael McQueen, MD, MBA, FAAP. Neonatology, Banner Health System, Phoenix, AZ, USA (Michael.McQueen@bannerhealth.com)

• Bradley A. Yoder, MD, FAAP. Division of Neonatology, University of Utah School of Medicine, SLC, UT, USA (bradley.yoder@hsc.utah.edu)

Why Do We Need

Practice Guidelines?

Why Do We Need Practice Guidelines?

• HHFNC universally available in US NICU’s

• Expanding international use

• Increasing pediatric & adult use

• Only a few RCT’s have been completed

• Guidelines generally improve outcomes

• Assist in identifying areas to improve

HHHFNC - Mechanisms of ActionMechanism Process References

Gascondition

Reduced metabolic work

Maintain epithelial integrity

Improved lung mechanics

Greenspan, JPeds 1991Williams, CCM 1996Waugh, RespCare 2004Schiffmann, RCCNA 2006Chidekel, PulmMed 2012

Pressure Minimal if: small NC coupled w/ large nasal interface

Increases EELV

Saslow, J Perinatol 2006Kubicka, Peds 2008Wilkinson, J Perinatol 2008Frizzola, PedsPulm 2011Sivieri, PedsPulm 2012Collins, JPaedsChildH 2013Hough, PedsCCM 2014

Flow Dead space gas washout Inspiratory resistance Augment tidal volume Off-loads diaphragm activity

Shepard, ARRD 1990Dewan, Chest 1994Frizzola, PedsPulm 2011Rubin, PedsCCM 2014Pham, PedsPulm 2014

HHHFNC Randomized Clinical Trials• Post-extubation HHHFNC v CPAP - preemies < 32 wks

– C Collins (Melbourne, AU; n=132)

• Post-extubation HHHFNC v CPAP - preemies < 32 wks– B Manley (Melbourne, AU; n= 300)

• Post-extubation HHHFNC v CPAP – Liu C (China; n= 255)

• Comparison of HHHFNC to Nasal CPAP in Neonates– B Yoder (University of Utah, n = 432; 150 < 32 wks)

• Initial Rx for RDS HHHFNC v CPAP - preemies < 35 wks– A Kugelman (Haifa, Israel; n=76)

Summary of Current RCT’s

HHHFNC:• ~ 1200 infants in 5 trials

• Similar failure rates as nCPAP

• As applied, no evidence for increased adverse events….particularly air leaks

• Does not extend O2 use or hospital stay

• Primarily relates to post-extubation use

Issues in Clinical Care• Cannula to nares ratio

• Gas egress

• Temp & humidity

• Initial Flow Rate

• Escalation/weaning flow

• NG v OG tube

• PO feeding on HFNC

MUST maintain a leak at the nose

avoids excessive pressure generation

allows nasopharyngeal ‘washout’

more comfort & less nasal trauma

Keep temperature close to 37o C

Position tubing down & away from baby

minimize fluid into the nares/airway

reduces risk for pressure injuries

INITIAL SET-UP

Occlusive NC

Non-occlusive NC

Only use heated and humidified systems

Typical peak inspiratory flow ~ 1 lpm, thus when flow > wt in kg, set FiO2 = delivered FiO2

HFNC is a non-invasive Rx: treat it like CPAP

titrate FiO2 first, then flow rate

if an infant needs > 50-60% oxygen D modes

know when to bail (apnea, acidosis, hypoxia.…)

CRITICAL POINTS

Indications for HHHFNC

• Post-extubation support for preterm infants– Current evidence shows equivalence to CPAP

– Data is limited for infants born < 26 weeks’ GA

• Infants stable on CPAP, where HFNC therapy may be preferred– A variety of reasons may be offered including ease

of care, neuro-developmental, nasal trauma, other

Unproven Benefit

• As primary support for RDS or other acute neonatal respiratory disorder

– Lack of evidence from RCT’s

– But empirically used by many centers

Management of Flow Rate

• Criteria for escalation:– FiO2– Respiratory rate– RDS score/WOB– Radiograph

• Initiating flow: – Dependent on size &/or

gestation– Dependent on 1o v 2o Rx– Dependent on current

Paw/FiO2

• Approach to weaning:– Time on HF– FiO2– Respiratory exam

Management of HHHFNC Therapy

Weight EGA CurrentRx Mode

Current PAW

CurrentFiO2

Resp Rate

Time On

Exam RDS-S

Initial flow rate

N = 4Y = 1 N = 5 N = 5 N = 3

Y = 2N = 1Y = 4 Y = 5 N = 4

Y = 1 Y = 5

Flow Escalation N = 5 N = 5 N = 5 N = 5 Y = 5 Y = 5 N = 2

Y = 3 Y = 5

WeaningFlow

N = 1Y = 4

N = 1Y = 4 N = 5 N = 5 Y = 5 N = 1

Y = 4 Y = 5 Y = 5

The majority of consultants use the infants underlying clinical

condition, rather than weight or gestation, to manage HHHFNC

What criteria do you use in initiatingHHHFNC therapy in neonates?

Initiating HHHFNC

Flow Rate “A” “B” “C” “D” “E”

Current weight

< 1000 g1000-2000 g

> 2000 g

5-7 lpm 3-5 lpm 5-8 lpm 8 lpm 4-6 lpm all wts 4-6 lpm all wts all wts all wts 4-8 lpm

Postnatal age

< 24 hrs< 7 days

other

5-7 lpm all Same 5-8 lpm all 8 lpm all 4-6 lpm all as above

Prior Rx mode

HFVSIMVCPAPOther

NO Same 5-8 lpm 8 lpm Same as 6-7 lpm as above; 5-8 lpm for all above;5-7 lpm includes Rarely Occ <28 wk Don’t use CPAP HFV may go NIMV/CPAP

FiO2< 40%< 30%

RA

7-8 lpm by 1 lpm 7-8 lpm 8 lpm 6-8 lpm if5-7 lpm Same 5-8 lpm for all FiO2 > 40%5-7 lpm as above otherwise 4-6 lpm

PAW< 8 cm H2O< 6 cm H2O

other

6-8 lpm Same Same 8 lpm 4-6 lpm all5-7 lpm as above for all for all typically notOnly @ CPAP < 7 Same successful if > 9-10

Other 7-8 lpm if Flow need based WOB on all of above

Initiation of HHHFNC Therapy

Weight FiO2 PAW

Initial flow rate

“A” 5-7 lpm @ any weight

“B” Varies by wt 3-8 lpm

“C” 5-8 lpm @ any weight

“D” 8 lpm @ any weight

“E” 4-6 lpm @ any weight

Increase for > 30%

Increase for > 30%

Increase for > 30%

Always start at 8 lpm

Increase for > 30%

Increase for > 6-7 cm H2O

Same as for weight

Same as for weight

Always start at 8 lpm

Same; poor success rate if > 9-10 at extubation

Gestation & postnatal age not a factor

Use only heated/humidified systems

Use NC sized to allow ready egress of gas

Start at 5-8 lpm no evidence comparing starting flow ratesconsider increased flow based on FiO2/Paw/WOB

CONSENSUS RECOMMENDATIONSINITIATING HIGH FLOW

What criteria do you use in escalatingHHHFNC therapy in neonates?

Escalating HHHFNC

Increase in Flow Rate “A” “B” “C” “D” “E”

Current weight

< 1000 g1000-2000 g

> 2000 g

Don’t use Don’t use Don’t use Don’t use Don’t use

Postnatal age

< 24 hrs< 7 days

other

Don’t use Don’t use Don’t use Don’t u se Don’t use

FiO2

< 40%< 30%> 21%

> 30% use by 1-2 lpm by 1 lpm If FiO2 by 1-2 lpm 7-8 lpm if > 30% as FiO2 flow back if > 40% by 1 lpm to 8 lpm

Resp rate< 60

60-80> 80

As above only if > 60 by 1 lpm by 1 lpm by 1 lpm for FiO2 only if signs by 1 lpm by 1-2 lpm by 1 lpm WOB/distress

RDS score or WOB Specify by 1 lpm by 1-2 lpm by 1 lpm As above As above

Time on HHFNC

< 6 hrs< 12 hrs> 12 hrs> 24 hrs

other

No time Same as Same As above Do not use limit “A” Don’t wait more time epochs D to CPAP than 1-2 hrs to Consider Depends on babyif HFNC = 8 lpm escalate to D to CPAP Do not use CPAP & concerns CPAP/NIMV or NIMV Occ use BiPAP

Don’t exceed 8 lpm flow in neonates

Increase flow for: WOB Respiratory rate FiO2

Don’t delay in escalating flow

Change to CPAP/NIMV if not improving

CONSENSUS RECOMMENDATIONSESCALATING HIGH FLOW

What criteria do you use in escalatingHHHFNC therapy in neonates?

Escalating HHHFNC

Increase in Flow Rate “A” “B” “C” “D” “E”

Current weight

< 1000 g1000-2000 g

> 2000 g

Don’t use Don’t use Don’t use Don’t use Don’t use

Postnatal age

< 24 hrs< 7 days

other

Don’t use Don’t use Don’t use Don’t u se Don’t use

FiO2

< 40%< 30%> 21%

> 30% use by 1-2 lpm by 1 lpm If FiO2 by 1-2 lpm 7-8 lpm if > 30% as FiO2 flow back if > 40% by 1 lpm to 8 lpm

Resp rate< 60

60-80> 80

As above only if > 60 by 1 lpm by 1 lpm by 1 lpm for FiO2 only if signs by 1 lpm by 1-2 lpm by 1 lpm WOB/distress

RDS score or WOB Specify by 1 lpm by 1-2 lpm by 1 lpm As above As above

Time on HHFNC

< 6 hrs< 12 hrs> 12 hrs> 24 hrs

other

No time Same as Same As above Do not use limit “A” Don’t wait more time epochs D to CPAP than 1-2 hrs to Consider Depends on babyif HFNC = 8 lpm escalate to D to CPAP Do not use CPAP & concerns CPAP/NIMV or NIMV Occ use BiPAP

What criteria do you use in weaningHHHFNC therapy in neonates?

Weaning HHHFNC

Decrease in Flow Rate “A” “B” “C” “D” “E”

Current weight

< 1000 g1000-2000 g

> 2000 g

Wean qod q 12-24 hrs qod if Keep 8 lpm 0.5 lpm q D q 12-24 hrs < 1500 g til > 1 kg 1 lpm q DWean q12 q 4-12 hrs 1-2 kg by 1 lpm q 24 1 lpm prn > 2 kg as tolerated

Postnatal age

< 24 hrs< 7 days

other

Don’t use Wean as NO As above Don’t use above unless “bigger” baby

FiO2< 40%< 30%

RA

No wean Same Same As above if 0.5 lpm if CLDif > 30-35% FiO2 stable otherwise as & < 40% above for WT

Resp rate< 60

60-80> 80

No wean Same Same No wean No wean if RR>60 if > 80 if > 80

RDS score or WOB

Specify No wean Same Same Same SameDecreased WOB & FiO2 drive weaning more rapidly among larger infants

Stick to slower wean for smaller/younger infantsTime on HHFNC

< 6-12 hrs> 12 hrs> 24 hrs

other

If “quick” recover Same Same Not a Not a from RDS WOB more a factor factor factorFor ELBW p-ext than time except for ELBWwean qod if FiO2 > 25%

Wean the FiO2 first, then the gas flowSimilar to CPAP; to at least < 35%, probably < 30%

Review at least every 12-24 hrs to determine if flow rate can be weaned or discontinued

May be able to wean infants > 2 kg more quickly

Wean by 0.5 - 1 lpm decrements

CONSENSUS RECOMMENDATIONSWEANING HIGH FLOW

Stopping HHHFNC TherapyWeight EGA Postnatal Age

“A” 4 lpm *

“B” 1-2 lpm @ < 1000g; 2-3 lpm at higher weights

“C” 3 lpm - “smaller” babies

“D” 4 lpm *

“E” 2-3 lpm for VLBWI, prefer to “dry” low-flow NC

“A” Rarely < 4 lpm w/ BPD

“B” Same as weight

“C” 3-4 lpm if larger/older

“D” Same as weight

“E” Same as weight

“A” Same as weight

“B” Same as weight

“C” Expect “smaller” on 3-5 lpm for 2-3 wks

“D” Same as weight

“E” Same as weight

* 1o related to funding issues

Preferably stable > 24 hrs, FiO2 < 30% and normal WOB/RR

There is no consensus on when to D/C HF

No studies comparing effect or outcomes related to D/C HFNC at different support levels

Recommendations vary from 1 – 4 lpmCenters vary by weight of infant Also variation related to support for BPD

CONSENSUS RECOMMENDATIONSDISCONTINUING HIGH FLOW

CONSENSUS !THIS WOULD WORK A LOT BETTER IF YOU’D JUST AGREE WITH ME

Consensus on HHHFNC: A Tale of Two NICU’sPreferred Non-Invasive Approach by NICU RN’s

24-wk, 500g 26-wk, 750 g 28-wk, 1200g 30-wk, 1500g0

10

20

30

40

50

60

70

80

90

100

CPAP-Au CPAP-UK HHHFNC-Au HHHFNC-UK

Au data from Roberts CT, J Paeds Child Health 2014; UK data from K Ives, unpublished

TheFuture

Challenges are what make life interesting ……

…… overcoming them is what makes life meaningful

Joshua J. Marine

Future Studies• Additional large RCTs are needed:

– to evaluate HHHFNC use in ELBWIs

– to compare different HHHFNC devices

– to evaluate various approaches to HHHFNC

– to assess economic impact of HHHFNC

– to address specific respiratory conditions

– other

V I G I L A N C EYou can’t see it if you don’t stay awake

SUMMARY

• HHHFNC is in wide clinical use

• RCT’s support HHHFNC as safe, effective alternative to nCPAP at the time of extubation

• Additional RCT’s are needed to study HHHFNC as 1o therapy & related to flow management

• Except for stopping, there is moderate consensus in the management of HHHFNC

Contributing Consultants• Clare Collins, MBChB, PhD, FRACP.

Mercy Hospital for Women, Melbourne, AU

• Kevin Ives, MBBChir, , MD, FRCPCH. John Radcliffe Hospital, Oxford, UK

• Brett Manley, MB BS (Hons.), PhD, FRACP. The University of Melbourne, Melbourne, AU

• Michael McQueen, MD, MBA, FAAP. Banner Health System, Phoenix, AZ, USA

??