Transcript Lehigh Valley Health Network - Focus on Respiratory Care & Sleep

Humidified High Flow Oxygen
Therapy
Clinical Application
Ken Miller, MEd-RRT-NPS
Educational/Research Coordinator
Respiratory Care
LVHN
Conflict of Interest
I 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.
Objectives
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.
What 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.
High Flows Oxygen Benefits
– There are five key benefits:
– Delivers a high FIO2 accurately
– Meets the patient’s ventilatory
demands
– Provides patient comfort
– Provides a modest amount of positive
airway pressure
– Optimizes mucociliary clearance
How is High Flow Oxygen
Delivered?
■
A combination of:
– Molecular high humidification delivery
system
– An air/oxygen blender
– Flowmeter
– Via nasal cannula or trach tube adaptor
High flow cannula
The prongs are wide bore dispersing the flow as it enters the nares
and reduces the jetting effect associated with standard nasal cannula
Trach adapter
Vent Tie-II
Utilized for securing
Max Venturi
Allows for
independent
control of
oxygen
and flow
Oxygen analyzer
FIO2 control
Flow
rate
control
850 Humidifier
provides
molecular humidification
Set a non-invasive
mode
via cannula
Warm Unit for a Minimal of 5’!!!
Complete
High Flow
Oxygen System
set up
Other High Flow Systems
Were Does the Clinician Intervene
with HFO2 in the Care Cycle?
Invasive
ventilation
HF02
Non-invasive
ventilation
Face
mask oxygen
Humidity therapy
HF02
Nasal cannula
Advantages of HFO2
PATIENT
CLINICIAN
Comfortable oxygen
delivery, reducing the
likelihood of treatment
failure
Less attendance time assisting uncomfortable
patients
Can continue to eat,
drink, talk and sleep
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 acute
No need to change between multiple oxygen
delivery devices and interfaces
Increased confidence in the actual fraction of
inspired oxygen (FiO2) being delivered to the
patient
May displace the need
for noninvasive
or invasive ventilation
through better patient
tolerance
Easier oral care, maintaining the moisture in
the oral mucosa
Better secretion
clearance, reducing the
May be used to wean patients off
risk of respiratory
noninvasive or invasive ventilation
infection
High Flows of Oxygen Delivered
Through Nasal Cannula
■
The combination of nasal cannula and
optimal humidity enables comfortable
delivery of high flows
Patient
comfort
Optimized
patient
outcomes
Patient
compliance
Octoberfest Party Last Year!!!
hoping next
year’s
Octoberfest::)
I
Why Improvement in
Oxygenation?
■
Guaranteed FI02 delivered
■ Ventilatory demands met
■ “Back pressure CPAP”
-Every ten liters of flow approximately
1 cm of CPAP is generated!
-Maximum of 5-6cm CPAP can be
achieved.
Meeting patient’s inspiratory flow demand
No ambient
entrainment
Face-mask oxygen delivery vs
High Flow Oxygen
Approximately 1 cm/h20 of “back pressure CPAP” per every
ten liters of flow
HFO can not help here!!!
Adequate hydration
Inadequate humification :
Where to Start High Flow
Oxygen
70%
FI02
40 lpm
SpO2 Monitoring
■
■
A 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.
Weaning of HFO2
■
■
■
Titrate to 40% oxygen
Reduce Flow to 20-30LPM
Transition to nasal cannula
Does this really work???
Outcomes
■
■
Sixty patients were
placed on HFNC from
July 1, 2009 to Dec 31,
2009 in MSICU.
In the HFNC that did
not required therapy
escalation had a 11.5
duration in MSICU
compared to 19.5 who
did.
20
18
16
14
12
10
8
6
4
2
0
HFNC
BPAP/
Vent
Clinical Indications
45
40
35
30
25
20
15
10
5
0
Oxygenation
Ventilatory demands
Humidification
st
O
Optiflow Diagnosis
eu
m
on
ia
M
ISC
DX
Re
sp
M
is c
Pn
p
Bu
rn
Tr
au
m
a/
Po
PD
CH
F
CO
Number of Patients
2009-2011
Patient Diagnosis
80
60
40
20
0
New Data 2011-12
120
100
80
60
40
20
0
Total
Oxygen
Trach
Oxygen
BIPAP/Vent
ICU LOS 2011-2012
18
16
14
12
Oxygen
BIPAP
Vent
10
8
6
4
2
0
ICU stay
Hypothesis
■
HFO may reduce escalation of therapy
in specific patient populations that
exhibit certain clinical and demographic
characteristics
Relevance to Practice
■
■
■
■
Aid clinical decision making as to
whether or not HFO is the best option
for a specific patient
Initiate HFO on patients that display
characteristics deemed successful
Not consider HFO for patients that
display characteristics deemed
unsuccessful
Effective and efficient use of respiratory
technology
Study Design
■
■
■
■
■
■
Retrospective observational study
Analyzed data on patients at LVHN who were placed
on HFO from May 21, 2011 to May 21, 2012
Sample size: 137 patients
Patients less than 18-years-old were excluded
Patients on HFO were identified from a daily report
received by respiratory therapy
Electronic medical record was used to gather
demographic and clinical information regarding these
patients
Methods
■
Patients were separated into two groups:
patients who were successful on HFO and
patients who were not
■ Success was defined as de-escalation in
care, meaning the patient maintained clinical
end-points on HFO or conventional oxygen
delivery systems
■ Failure was defined as escalation in care,
meaning that in order to maintain desired
clinical end-points either NIPPV or
mechanical ventilation had to be instituted
■ If a patient was on HFO for more than 72
hours they were counted as a failure
because HFO is not indicated to be a longterm therapy1
Results
■
■
■
■
All 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 13.11 (p=0.001) times more likely to be
a success.
Interpretation/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 comorbidity 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
14.83 days for patients who fail.
High Flow Oxygen Results
2011-2012
600
500
400
300
200
100
0
Total
NC
Trach
High Flow Oxygen Results
Indications
2011-2012
Oxygenation NIPPV
Free
Vent
Liberation
WOB
Secretions
Palliative
294
42
57
49
77
30
HFO Results
Outcomes
2012
350
300
250
200
150
100
50
0
Oxygen
NIPPV
Mech Vent
Comfort
Literature Outcomes
■
High-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 119-129, 08035 Barcelona, Spain. [email protected]
■ 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
Patients
Jeffrey J Ward MEd RRT FAARC:
■ The HFNC can effectively be used to treat patients with
moderate levels of hypoxemic respiratory failure.
HFNC could be considered as an initial appliance in
certain settings (eg, ED), as flow could be titrated based
on response over a full range without having to change
to other devices.
Case Scenarios
■
■
■
■
■
■
■
Post liberation from long-duration Mechanical
Ventilation
Inability to administer mask either for high flow
Oxygen Delivery or NIPPV secondary to facial
surgical graft
Bridge therapy from NIPPV to conventional
Oxygen Administration
In lieu of CPAP Intervention
Nitric Oxide/Heliox Administration
Post extubation Pulmonary Edema
Patient comfort—Palliative Care
Nurse’s reaction
when I
bring new
technology into
her room!!
Liberation 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.
She 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/ttube. 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.
Inability to Administer Mask Either for High
Flow Oxygen Delivery or BIPAP Secondary to
Facial Surgical Graft
■
A 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 reintubation within six hours, secondary to
excessive work of breathing and hypoxemia.
High
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 twentyfour hours.
Bridge 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 desaturation 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 longterm skilled care facility.
Post 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.
HFNC Via Heliox
■
■
■
Seventy-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.
Patient Comfort
■
■
■
A 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.
High-flow Oxygen System
Clinical
Indications
Met?
1
Warm Unit for 5’
Set FIO2
to Maintain
Sp02>93%
Set LPM 40LPM
Increase
FI02 or
Liter flow
Sp02>93%
Yes
Sp02>93%
3
Increase
Flow to
50-60LPM
No
Is Patient’s
Inspiratory Flow
Met?
Yes
Maintain/wean
Current
Settings
No
Maintain
Current
Settings
Yes
4
No
Clinical Status
Stable?
Maintain
Current
Settings
Yes
No
No
Is Patient’s
Inspiratory Flow
Met?
Yes
2
Re-assess
for other
clinical
interventions
No
Clinical Status
Stable?
6
Maintain/wean
Current
Settings
Yes
5
Place on
Conventional
Oxygen System
8
7
Transferred
From
Critical Care
FIO2< 60%
Flow<40Lpm
HFO2
■
■
■
■
■
■
Provides wide range of precise FIO2
delivery for many patient populations
Enhances muco-kinesis
Provides a pseudo-CPAP
Maintains sufficient flow to maintain the
patient’s inspiratory flow demands
Easy to administer and maintain
Patient comfort
Unanswered 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?
■
Kenneth Miller MEd, RRT-ACCS, RRT-NPS
Respiratory Care
LVHN
610-402-5772
[email protected]