Transcript burns

HFNO
George Tay Robin Holland
Robina Hospital
4.4.11
Declaration of Conflict of interest
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I have bought my sister a F&P washing machine once
No other connection with F&P
George?
Picture of HFNO
Picture of HFNO
setup
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Flows 45-60 L/min
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Humidified warmed T 37
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Heated circuit to avoid rain out
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Variable oxygen / air
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Silastic prongs
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Provides 3-8 cmH2O pressure in pharynx
background
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No flow sensors in nose
Paediatrics have used nasal cpap extensively esp neonates
used for ventilation with nasal catheters/ET tubes
Provides some CPAP with mouth closed
Better tolerated over longer terms
Suitable for medical ward use
Allows oral nutrition altho bubbling out tetrapacks
will change current practice of respiratory failure….
Or is that just hyperbole
Talk structure
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Information on early use in particular paeds
Physiology papers flow and pressure measure
Current use papers cardiac surgery
Comparison to cpap
Future research
Predominately australian data to be presented
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Perhaps robina audit data do you think george?
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use
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Resp failure
CHF
Asthma
Palliative care for respiratory distress
Minimally invasive high oxygen provision
Preparation for intubation
Not let the sun go down twice on NIV
The current view is short term use of NIV before intubation or limitation
studies
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Cardiac surgery patients
Intensive care respiratory failure ie CAL APO
Post extubation
Palliative care patients
contraindications
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Unconscious patient
High Aspiration Risk
Facial trauma
Basal skull fracture
Tracheostomy
Pneumothorax
Neonates use
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Heated Humidified High-Flow Nasal Cannula Therapy: Yet Another Way to Deliver Continuous Positive
Airway Pressure?
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Zuzanna J. Kubicka, MDa, Joseph Limauro, RRTb, Robert A. Darnall, MDa,c
a Departments of Pediatrics
b Respiratory Therapy
c Physiology, Dartmouth Medical School and Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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OBJECTIVE. The goal was to estimate the level of delivered continuous positive airway pressure by measuring
oral cavity pressure with the mouth closed in infants of various weights and ages treated with heated, humidified
high-flow nasal cannula at flow rates of 1–5 L/minute. We hypothesized that clinically relevant levels of
continuous positive airway pressure would not be achieved if a nasal leak is maintained.
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METHODS. After performing bench measurements and demonstrating that oral cavity pressure closely
approximated levels of traditionally applied nasal continuous positive airway pressure, we successfully measured
oral cavity pressure during heated, humidified, high-flow nasal cannula treatment in 27 infants. Small (outer
diameter: 0.2 cm) cannulae were used for all infants, and flow rates were left as ordered by providers.
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RESULTS. Bench measurements showed that, for any given leak size, there was a nearly linear relationship
between flow rate and pressure. The highest pressure achieved was 4.5 cmH2O (flow rate: 8 L/minute; leak: 3
mm). In our study infants (postmenstrual age: 29.1–44.7 weeks; weight: 835–3735 g; flow rate: 1–5 L/minute), no
pressure was generated with the mouth open at any flow rate. With the mouth closed, the oral cavity pressure
was related to both flow rate and weight. For infants of 1500 g, there was a linear relationship between flow rate
and oral cavity pressure.
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CONCLUSIONS. Oral cavity pressure can estimate the level of continuous positive airway pressure. Continuous
positive airway pressure generated with heated, humidified, high-flow nasal cannula treatment depends on the
flow rate and weight. Only in the smallest infants with the highest flow rates, with the mouth fully closed, can
clinically significant but unpredictable levels of continuous positive airway pressure be achieved. We conclude that
heated, humidified high-flow nasal cannula should not be used as a replacement for delivering continuous
positive airway pressure.
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Pediatrics. 2008 Jan;121(1):82-8
vapotherm
vapotherm
Early paeds cpap use in icu
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Comparison of Humidified High Flow Nasal Cannula to Nasal CPAP in
Neonates (HHFNC)
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This study is currently recruiting participants.
Verified by University of Utah, September 2010
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First Received: January 24, 2008 Last Updated: September 14,
2010 History of Changes
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Sponsor: University of Utah Collaborator: Intermountain Health Care, Inc.
Information provided by: University of UtahClinicalTrials.gov Identifier:
NCT00609882
Early paeds cpap use in icu
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Primary Outcome Measures:
Compare extubation success rate, defined as % infants remaining
extubated for > 72 hrs, among infants managed with HHFNC versus nCPAP
Time Frame: 72 hrs
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Secondary Outcome Measures:
Compare frequency of significant apnea after extubation to HHFNC v CPAP
Time Frame: 7 days
Compare total duration of ventilator, positive pressure (CPAP and/or
HHFNC), and oxygen use up to the time of discharge from the NICU
Time Frame: 3 months
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Compare incidence of potential adverse effects associated with the use of
nasal CPAP and HHFNC including pulmonary air leaks, nasal deformities,
feeding intolerance, necrotizing enterocolitis, intestinal perforation and BPD
Time Frame: 3 months
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Compare weight gain and the time to establish full enteral feeds (> 120
ml/kg/d) between infants on HHFNC v CPAP Time Frame: 3 months
Early paeds cpap use in icu
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Arms
nCPAP post extubation 4-8cmH2O
HHNFC post extubation 4-8cmH2O
Estimated Enrollment:420
Study Start Date:December 2007Estimated
Study Completion Date:July 2011
Estimated Primary Completion Date:July 2011
Early paeds cpap use in icu
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Inclusion Criteria:
Birth weight > 1000 grams and > 27 weeks gestation
Candidate for non-invasive respiratory support as a result of:
 an intention to manage the infant with non-invasive (no endotracheal
tube) respiratory support from birth initiated in the first 24 hours of life
 an intention to extubate an infant being managed with intubated
respiratory support to non-invasive support
Exclusion Criteria:
Birth weight < 1000 grams
Estimated gestation < 29 weeks
Participation in a concurrent study that prohibits the use of HHFNC
Active air leak syndrome
Infants with abnormalities of the upper and lower airways; such as PierreRobin, Treacher-Collins, Goldenhar, choanal atresia or stenosis, cleft lip
and/or palate, or
Infants with significant abdominal or respiratory malformations including
tracheo-esophageal fistula, intestinal atresia, omphalocele, gastroschisis,
and congenital diaphragmatic hernia.
Adult use
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High flow nasal oxygen generates positive airway pressure in adult volunteers
Groves N Tobin A
Intensive Care Unit St. Vincent's Hospital Melbourne Australia [email protected]
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INTRODUCTION: The use of non-invasive ventilation (NIV) as an alternative to intubation in
respiratory failure is associated with better outcomes in certain conditions. NIV is often
poorly tolerated by patients hence precipitating the need for invasive ventilation. High flow
nasal (HFN) oxygen delivery is a potential alternative to NIV as it delivers air and oxygen
via a humidified circuit at flows greater than those traditionally used with a nasal interface.
BODY: Studies of paediatric patient using high flow nasal oxygen therapy have been
shown to have similar efficacy as nasal continuous positive airway pressure (CPAP).
Although the degree of positive pressure and the effect of different flow rates on positive
pressure generation have not been well defined or studied in the adult intensive care
population. St. Vincent's Health Human Research and Ethics Committee granted approval
to this study and also awarded a $3000 grant. Volunteers were fitted with the Fisher &
Paykel high flow nasal interface (RT034) and pharyngeal pressures were recorded with
flows from 0 to 60L/min. Expiratory pressures with the mouth closed were higher than
those with the mouth open and this was statistically significant (<0.001). Expiratory
pressures were higher with the mouth closed and were statistically different (p<0.001).
EPPs were higher amongst female subjects compared to male subjects and were
statistically different between genders for both open (p<0.05) and closed (p<0.001)
measurements.
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CONCLUSION: This study has demonstrated that high flow nasal therapy is associated
with the generation of significant positive airway pressure in volunteers. In conclusion
there is a degree of CPAP generated with the HFN therapy, which is flow dependent and
also dependent on whether the person is breathing with mouth open or closed
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Aust Crit Care. 2007 Nov;20(4):126-31. Epub 2007 Oct 10.
Adult use
Universitätsklinikum Leipzig
Adult use
Adult use
Adult use
Adult use
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So let us go to the clinical situation
Cardiac surgery adults
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HIGH FLOW NASAL OXYGEN THERAPY DELIVERS LOW LEVEL POSITIVE PRESSURE IN A STUDY OF 15
POST OPERATIVE CARDIAC PATIENTS
R. Parke1, M. Eccleston1, S. McGuinness1, C. Gerard2
Cardiothoracic and Vascular Intensive Care Unit, Auckland District Health Board and Fisher and Paykel
Healthcare, New Zealand
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Background: This investigation follows a study in healthy volunteers, where a low level of positive airway
pressure was measured in subjects who were receiving high flow nasal oxygen therapy (1). A descriptive study
was therefore carried out to determine whether similar results would be obtained in a patient population.
Methods: 15 cardio surgical patients were consented pre-operatively. During the post-operative period a 10F
catheter was inserted into the hypopharyngeal space, via the nose, whilst participants were still sedated and
ventilated. Measurements were then performed once the participant was awake and extubated. Placement of the
hypopharyngeal catheter was confirmed at this time using end tidal CO2 monitoring. Measurements were
performed with both a nasal interface (Fisher and Paykel Optiflow™ system) and standard face mask at gas flow =
35Lpm. Measurements were recorded with mouth open and mouth closed. The hypopharyngeal pressures were
recorded over one minute of breathing. The mean airway pressure was determined by averaging the peak
pressure from each breath over a one minute period. This allowed the entire pressure profile of each breath to be
included within the mean airway pressure calculation.
Results: n=15. Average age = 63 years (41 – 79); average height = 175.4cms (156 – 186); average weight =
85.7kg (67 – 107). 86% (n=13) male.
At 35 Lpm with mouth closed, the Optiflow™ system with nasal interface delivered mean airway pressures of 2.70
cmH2O. Other results are described in table 1:
Conclusion: This study demonstrates that a low level of positive pressure is delivered using high flow nasal
oxygen therapy, at 35Lpm of gas flow, in cardiac surgical patients. This is consistent with the results obtained in
healthy volunteers. Further studies into high flow nasal oxygen therapy and its clinical applications are
recommended.
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Respiratory Care 2007
the science journal of the american association of respiratory care
Cardiac surgery in adult icu
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Nasal high-flow therapy delivers low level positive airway pressure
R. Parke1,*, S. McGuinness1M. Eccleston2,†
+ Author Affiliations
1Cardiothoracic and Vascular Intensive Care Unit, Level 4, Building 32, Auckland City Hospital, Private Bag 92024, Auckland 1010,
New Zealand
2Fisher and Paykel Healthcare, 1 Maurice Paykel Place, East Tamaki, Auckland, New Zealand
*Corresponding author. E-mail: [email protected]
Accepted August 18, 2009.
Abstract
Background The aim of this prospective study was to determine whether a level of positive airway pressure was generated in
participants receiving nasal high flow (NHF) delivered by the Optiflow™ system (Fisher and Paykel Healthcare Ltd, Auckland, New
Zealand) in a cardiothoracic and vascular intensive care unit (ICU).
Methods Nasopharyngeal airway pressure was measured in 15 postoperative cardiac surgery adult patients who received both NHF and
standard facemask therapy at a flow rate of 35 litre min−1. Measurements were repeated in the open mouth and closed mouth positions.
Mean airway pressure was determined by averaging the pressures at the peak of inspiration of each breath within a 1 min period, allowing
the entire pressure profile of each breath to be included within the calculation.
Results Low level positive pressure was demonstrated with NHF at 35 litre min−1 with mouth closed when compared with a facemask.
NHF generated a mean nasopharyngeal airway pressure of mean (sd) 2.7 (1.04) cm H2O with the mouth closed. Airway pressure was
significantly higher when breathing with mouth closed compared with mouth open (P≤0.0001).
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Conclusions This study demonstrated that a low level of positive pressure was generated with NHF at 35 litre min−1 of gas flow. This is
consistent with results obtained in healthy volunteers.
Australian Clinical Trials Registry www.actr.org.au ACTRN012606000139572.
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Br J Anaesth. 2009 December; 103(6): 886–890
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Cardiac surgery adults
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Does the use of high flow nasal oxygen therapy improve lung function after open heart surgery in obese
patients?
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Direct extubation onto high flow nasal prongs post cardiac surgery versus standard treatment in patients with a
BMI = 30: A randomised controlled trial
Funding year: 2010
Amount funded: $59,574
Lead researcher:
Ms Amanda Corley RN BN GradCert Hsci
Research team:
Dr Adrian Barnett BSc(Hon) PhD
Assoc. Prof. John Fraser MBChB, MRCP, FRCA, FFARCSI, FJFICM
Miss Amy Spooner RN BN Grad Cert Crit Care, Grad Dip Crit Care
Location of research:
The Prince Charles Hospital, Chermside
Project description:
Open heart surgery is being performed on increasing numbers of obese patients. Almost a third of patients
undergoing open heart surgery are classified as obese. It is known that these patients are more prone to post
operative complications, particularly lung collapse and that they recover more slowly from these complications.
This increase in complications and slower recovery leads to longer intensive care unit and hospital stays. Our
previous research has shown that high flow nasal prongs (HFNP) create positive airway pressure and that patients
who are obese benefit even more from the positive effects of HFNP. Our study also showed that the patients'
oxygen levels improved and their breathing felt more comfortable with the HFNP. Therefore, it is necessary that we
further investigate the effects of HFNP on obese patients after cardiac surgery, in an attempt to reduce
complications, particularly lung collapse.
Case report pulmonary fibrosis
Adult icu use
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What is the evidence for the use of high flow nasal cannula oxygen in adult patients admitted to
critical care units? A systematic review.
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Kernick J, Magarey J.Discipline of Nursing, The University of Adelaide, Adelaide, SA 5005, Australia.
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BACKGROUND: Humidified high flow nasal cannula oxygen therapy is increasingly available in
Australian adult intensive care units. Its use in paediatric populations has been extensively
studied and has shown positive effects however its clinical effectiveness in adults has not been
established.
PURPOSE: A systematic review of the literature was conducted to critique current evidence,
inform nursing practice and make recommendations for nursing research.
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METHODS: An extensive search strategy identified clinical studies comparing standard oxygen
therapy with high flow therapy in critical care units. Two reviewers independently assessed
articles for eligibility, methodological quality and inclusion. Outcomes of interest included
oxygenation, ventilation, work of breathing, positive airway pressure, patient comfort and long
term effect. A narrative synthesis was conducted to describe the emerging evidence.
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FINDINGS: Eight studies were included for review. All were abstracts or poster presentations
from scientific meetings therefore the quality of data available for analysis was poor. Findings
indicated there was preliminary evidence to support the use of high flow therapy to optimise
oxygenation in adults. This therapy may reduce the effort of breathing and provide augmented
airway pressures. Patients described the therapy as comfortable. No definitive evidence
supported the claim that ventilation is improved or conclusively demonstrated a long-term
effect.
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CONCLUSION: Humidified high flow nasal cannula may be used as an intermediate therapy to
improve oxygenation in adult critical care patients. Further research is required to determine
the duration of effect of the therapy, identify the patient population for whom it is most
beneficial and evaluate long-term outcomes; to enable definitive recommendations for practice
to be made.
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Aust Crit Care. 2010 May;23(2):53-70. Epub 2010 Mar 5
Comparison HFNO to HF Face mask after extubation
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High-flow nasal oxygen vs high-flow face mask: A randomized crossover trial in extubated patients
Ravindranath Tiruvoipati , a, , David Lewisa, Kavi Hajia and John Bothaa
Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria 3199, Australia
Available online 24 September 2009.
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Abstract
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Purpose
Oxygen delivery after extubation is critical to maintain adequate oxygenation and to avoid reintubation. The
delivery of oxygen in such situations is usually by high-flow face mask (HFFM). Yet, this may be uncomfortable for
some patients. A recent advance in oxygen delivery technology is high-flow nasal prongs (HFNP). There are no
randomized trials comparing these 2 modes.
Methods
Patients were randomized to either protocol A (n = 25; HFFM followed by HFNP) or protocol B (n = 25; HFNP
followed by HFFM) after a stabilization period of 30 minutes after extubation. The primary objective was to
compare the efficacy of HFNP to HFFM in maintaining gas exchange as measured by arterial blood gas.
Secondary objective was to compare the relative effects on heart rate, blood pressure, respiratory rate, comfort,
and tolerance.
Results
Patients in both protocols were comparable in terms of age, demographic, and physiologic variables including
arterial blood gas, blood pressure, heart rate, respiratory rate, Glasgow Coma Score, sedation, and Acute
Physiology and Chronic Health Evaluation (APACHE) III scores. There was no significant difference in gas
exchange, respiratory rate, or hemodynamics. There was a significant difference (P = .01) in tolerance, with nasal
prongs being well tolerated. There was a trend (P = .09) toward better patient comfort with HFNP.
Conclusions
High-flow nasal prongs are as effective as HFFM in delivering oxygen to extubated patients who require high-flow
oxygen. The tolerance of HFNP was significantly better than in HFFM.
Comparison HFNO to CPAP
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Physiologic Effects of High Flow Nasal Therapy in Patients With Acute
Hypoxemic Respiratory Failure (OPTIFLOW)
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This study is currently recruiting participants.
Verified by University Hospital, Bordeaux, December 2010
First Received: January 18, 2010 Last Updated: December 8,
2010 History of Changes
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Sponsor: University Hospital, Bordeaux Information provided by: University
Hospital, BordeauxClinicalTrials.gov Identifier: NCT01056952
Vue-aerienne-Bordeaux-CHU
centre Hospitalier Universitaire
Comparison HFNO to CPAP Bordeaux
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Two arms HFNO then CPAP
and CPAP then HFNO
Three interventions standard O2 CPAP 7.5cmH2O HFNO 40L/min
Comparison HFNO to CPAP Bordeaux
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Inclusion Criteria:
Acute respiratory insufficiency, defined as the PaO2/FIO2 ratio of 300 mm Hg or less after
breathing oxygen
The presence of lung infiltrates on a posteroanterior chest radiograph
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Exclusion Criteria:
Face or cranial trauma or surgery
Patients younger than 18 years
History of COPD
Acute respiratory acidosis (defined as a pH <7.30 and a PaCO2 >50 mm Hg)
Hemodynamic instability with arterial pressure < 90mmHg
Respiratory instability with PaO2/FiO2<100mmHg
ventricular arrhythmias
Excess respiratory secretions.
Upper gastrointestinal bleeding
Recent gastric or oesophageal surgery
Tracheostomy or other airways disorders
Pneumothorax
Contraindication of gastric probe insertion
Impossibility to insert the oesophageal probe
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Probably intensive care in major hospital
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Comparison HFNO to CPAP Bordeaux
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Primary Outcome Measures:
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Inspiratory muscle effort : oesophageal pressure (Poes) and the
oesophageal pressure time product (PTPoes)
Time Frame: Every 30 minutes for 90 minutes
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Secondary Outcome Measures:
Gas exchange :PaO2/FiO2 ratio
Time Frame: Every 30 minutes for 90 minutes
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Comfort assessed using a five-item semi quantitative scale
Time Frame: Every 30 minutes for 90 minutes
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Dyspnea assessed using a visual analogic scale
Time Frame: Every 30 minutes for 90 minutes
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HFNO in CAL Ambrock Hagen
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Transnasal Insufflation (TNI) and Chronic Obstructive Pulmonary Disease
(TNICOPD)
This study has been completed.
First Received: March 19, 2010 Last Updated: September 29, 2010 Sponsor:
Helios Klinik Ambrock Information provided by: Helios Klinik Ambrock
ClinicalTrials.gov Identifier: NCT01090544
The purpose of this study is to determine wether transnasal insufflation as an
alternate form of breathing support for COPD patients will lead to improvement of
their medical condition.
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Condition Intervention Chronic Obstructive Pulmonary Disease (COPD)
Device: Nasal Insufflation
Study Type:Interventional Study Design:Control: Uncontrolled
Endpoint Classification: Efficacy Study
Intervention Model: Single Group Assignment
Masking: Open Label
Primary Purpose: TreatmentOfficial Title:Transnasal Insufflation for Patients With
COPD GOLD IV and Hypercapnia
HFNO in CAL Ambrock Hagen
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Primary Outcome Measures:
partial pressure of carbon dioxide (PaCO2) decrease Time Frame: 3 hours
PaCO2 is measured before and after applying TNI, and a PaCO2 decrease is
supposed to be assessed.
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Secondary Outcome Measures:
Breathing Frequency Time Frame: 3 hours
Breathing Frequency is supposed to decrease under TNI treatment
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Enrollment:21Study Start Date:December 2009
Study Completion Date:September 2010Primary Completion Date:June 2010
Intervention Details:
Device: Nasal Insufflation Breathing therapy
Other Name: TNI 20 oxy
Transnasal insufflation device
• Picture of tni
HFNO in CAL Ambrock Hagen
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Detailed Description: Chronic obstructive pulmonary disease (COPD) is a slowly proceeding
lung disease which basic pathophysiologic mechanisms are only partly understood so far and
which is difficult to access with a pharmacological or sundry approach besides smoking cessation.
Average life expectancy is clearly limited especially in advanced stages with respiratory
insufficiency . Based on different smaller surveys long-term oxygen treatment is classified to be
the routine in COPD treatment when patients develop hypoxemia.
The primary application of non-invasive ventilation Routine is the treatment for COPD patients
with acute respiratory decompensation and developing hypoxemia and respiratory acidosis,
because it reduces the acute mortality as various prospective randomized studies showed.
On the other side there are no distinct informations and data about the initiation of a nocturnal
positive pressure breathing therapy when chronic hypercapnia appear in progression of COPD.
Nocturnal positive pressure therapy appliqued with a mask can be assumed to be the routine
treatment for neuromuscular and restrictive thorax diseases, because nocturnal ventilation results
in a distinct increase of life expectancy.
In contrast data about positive pressure therapy at COPD are inconsistent and initiation of
nocturnal breathing therapy is practised in many places, but is scientifically not confirmed yet.
It is known from various other studies with other patient collectives with nocturnal positive
pressure therapy, like patients with obstructive sleep apnoea syndrome, that only 50 to 70% of
those patients are using their therapy constantly. Daily practice shows that patients with chronic
hypercapnia based on COPD are even harder to accustom oneself to a nocturnal breathing
therapy than patients with restrictive lung diseases or patients with obstructive sleep apnoea
syndrome.
Reasons for that are not known, but maybe the significant lung distension or increased
appearance of depressive or anxiety disorders of COPD patients are responsible for that.
Perhaps patients do not feel a subjective improvement of their medical condition and don't accept
a tight closing mask at nights.
As a result an alternate form of breathing support would be desirable.
HFNO in CAL Ambrock Hagen
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Eligibility
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Ages Eligible for Study:
18 Years to 85 Years
Genders Eligible for Study: Both
Accepts Healthy Volunteers: No
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Inclusion Criteria:
COPD GOLD IV
PCO2 > 50 mmHg
competent patients
stable respiratory situation
Exclusion Criteria:
serious acute diseases
hypercapnic decompensation pH < 7,30
Osa paper
summary
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HFNO is a new modality that is under investigation for clinical utility
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It seems to provide a little cpap but is better tolerated over long term use
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It may displace previous use of CPAP and invasive ventilation
Key references F and P