Humidified High Flow Oxygen Therapy

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Humidified High Flow Oxygen Therapy

• Clinical Application
• Ken Miller, MEd-RRT-NPS
• Educational/Research Coordinator
• Respiratory Care
• LVHN

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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.

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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.

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What is High FlowOxygen (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.

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High Flows Oxygen Benefits

• There are five key benefits
• Delivers a high FIO2 accurately
• Meets the patients ventilatory demands
• Provides patient comfort
• Provides a modest amount of positive airway
  pressure
• Optimizes mucociliary clearance

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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

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High flow cannula
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The prongs are wide bore dispersing the flow as
it enters the nares and reduces the jetting
effect associated with standard nasal cannula
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Trach adapter
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Vent Tie-II Utilized for securing
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Max Venturi
Oxygen analyzer
Allows for independent control of oxygen and
flow
FIO2 control
Flow rate control
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850 Humidifier provides molecular humidification
Set a non-invasive mode via cannula
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Warm Unit for a Minimal of 5!!!
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Complete High Flow Oxygen System set up
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Other High Flow Systems
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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
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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 No need to change between multiple oxygen delivery devices and interfaces 
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 Increased confidence in the actual fraction of inspired oxygen (FiO2) being delivered to the patient
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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 risk of respiratory infection May be used to wean patients off noninvasive or invasive ventilation  
May be used to wean patients off noninvasive or invasive ventilation  
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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
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Octoberfest Party Last Year!!!
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I hoping next years Octoberfest?)
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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.

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Meeting patients inspiratory flow demand
No ambient entrainment
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Face-mask oxygen delivery vs High Flow Oxygen
Approximately 1 cm/h20 of back pressure CPAP
per every ten liters of flow
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HFO can not help here!!!
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Adequate hydration
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Inadequate humification ?
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Ordering of Optiflow
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Where to Start High Flow Oxygen
FI02 70 40 lpm
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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.

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Weaning of HFO2

• Titrate to 40 oxygen
• Reduce Flow to 20-30LPM
• Transition to nasal cannula

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Does this really work???
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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.

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Clinical Indications
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2009-2011
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New Data 2011-12
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ICU LOS 2011-2012
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Hypothesis

• HFO may reduce escalation of therapy in specific
  patient populations that exhibit certain clinical
  and demographic characteristics

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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

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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

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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 long-term therapy1

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Results

• All variables which were found to be
  statistically different (plt0.05) 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(p0.023) 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
  (p0.001).
• 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 (p0.001) times more likely to
  be a success.

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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
  co-morbidity 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.

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High Flow Oxygen Results2011-2012
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High Flow Oxygen ResultsIndications2011-2012
Oxygenation NIPPV Free Vent Liberation WOB Secretions Palliative
294 30 42 57 49 77
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HFO ResultsOutcomes2012
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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.
  oroca_at_ir.vhebron.net
• 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.

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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 comfortPalliative Care

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Nurses reaction when I bring new technology
into her room!!
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Liberation Following ProlongVentilatory 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 gt60 to
  maintain a Sp02gt88. Several bronchoscopies were
  performed to address mucus plugging and maintain
  a patent airway.

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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/t-tube. During the breathing trials
the patients 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 gt60. 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.
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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 re-intubation
  within six hours, secondary to excessive work of
  breathing and hypoxemia.

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• 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
  maintainedgt93 and work of breathing was minimal,
  secretion removal was adequate. The patient was
  transferred to medical-surgical unit within
  twenty-four hours.

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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 de-saturation 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 long-term skilled care
  facility.

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Post ExtubationPulmonary 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 patients nares set at 50
  lpm and 50, extubated was performed and the
  clinical course remained stable.

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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.

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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 patients 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.

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High-flow Oxygen System
Clinical Indications Met?
1
Warm Unit for 5 Set FIO2 to Maintain Sp02gt93 Set
LPM 40LPM
2
Maintain Current Settings
Increase FI02 or Liter flow
Sp02gt93
Sp02gt93
Yes
No
3
No
Yes
Is Patients Inspiratory Flow Met?
Maintain Current Settings
Increase Flow to 50-60LPM
Is Patients Inspiratory Flow Met?
Yes
No
4
6
No
7
Yes
Re-assess for other clinical interventions
Clinical Status Stable?
Clinical Status Stable?
Maintain/wean Current Settings
Yes
Transferred From Critical Care
No
No
5
Yes
Place on Conventional Oxygen System
Maintain/wean Current Settings
FIO2lt 60 Flowlt40Lpm
8
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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
  patients inspiratory flow demands
• Easy to administer and maintain
• Patient comfort

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Unanswered Questions!!!

• HFO effect on mortality?
• Its effect on ICU duration in a randomized
  controlled study?
• Can it be used safely during an acute crisis in
  medical-surgical patient population?

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Thank You Any Questions
Kenneth Miller MEd, RRT-ACCS, RRT-NPS
Respiratory Care LVHN 610-402-5772 Kenneth.miller
_at_lvhn.org