HFNO

1. HFNO George Tay Robin Holland Robina Hospital 4.4.11

2. Declaration of Conflict of interest • I have bought my sister a F&P washing machine once • No other connection with F&P • George?

3. Picture of HFNO

4. Picture of HFNO

5. setup • Flows 45-60 L/min • Humidified warmed T 37 • Heated circuit to avoid rain out • Variable oxygen / air • Silastic prongs • Provides 3-8 cmH2O pressure in pharynx

6. background • 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

7. Talk structure • 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 • Perhaps robina audit data do you think george?

8. use • 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

9. studies • Cardiac surgery patients • Intensive care respiratory failure ie CAL APO • Post extubation • Palliative care patients

10. contraindications • Unconscious patient • High Aspiration Risk • Facial trauma • Basal skull fracture • Tracheostomy • Pneumothorax

11. Neonates use • Heated Humidified High-Flow Nasal Cannula Therapy: Yet Another Way to Deliver Continuous Positive Airway Pressure? • Zuzanna J. Kubicka, MDa, Joseph Limauro, RRTb, Robert A. Darnall, MDa,c • a Departments of Pediatricsb Respiratory Therapyc Physiology, Dartmouth Medical School and Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire • 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-flownasal 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. • 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-flownasal 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. • 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. • CONCLUSIONS. Oral cavity pressure can estimate the level of continuous positive airway pressure. Continuous positive airway pressure generated with heated, humidified, high-flownasal 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-flownasal cannula should not be used as a replacement for delivering continuous positive airway pressure. • Pediatrics. 2008 Jan;121(1):82-8

12. vapotherm

13. vapotherm

14. Early paeds cpap use in icu • Comparison of Humidified High Flow Nasal Cannula to Nasal CPAP in Neonates (HHFNC) • This study is currently recruiting participants. • Verified by University of Utah, September 2010 • First Received: January 24, 2008   Last Updated: September 14, 2010   History of Changes • Sponsor: University of Utah Collaborator: Intermountain Health Care, Inc.Information provided by: University of UtahClinicalTrials.gov Identifier: NCT00609882

15. Early paeds cpap use in icu • 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  • 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 • 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  • 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 

16. Early paeds cpap use in icu • 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

17. Early paeds cpap use in icu • 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 Pierre- Robin, 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.

18. Adult use • High flow nasal oxygen generates positive airway pressure in adult volunteers • Groves NTobin A • Intensive Care Unit St. Vincent's Hospital Melbourne Australia groves.nicole@gmail.com • 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. • 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 • Aust Crit Care. 2007 Nov;20(4):126-31. Epub 2007 Oct 10.

19. Adult use

20. Universitätsklinikum Leipzig

21. Adult use

22. Adult use

23. Adult use

24. Adult use • So let us go to the clinical situation

25. Cardiac surgery adults • 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 • 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. • Respiratory Care 2007 the science journal of the american association of respiratory care

26. Cardiac surgery in adult icu • 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: rparke@adhb.govt.nz • 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). • 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. • Br J Anaesth. 2009 December; 103(6): 886–890

27. Cardiac surgery adults • Does the use of high flow nasal oxygen therapy improve lung function after open heart surgery in obese patients? • 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: 2010Amount funded: $59,574Lead researcher:Ms Amanda Corley RN BN GradCert HsciResearch team: Dr Adrian Barnett BSc(Hon) PhDAssoc. Prof. John Fraser MBChB, MRCP, FRCA, FFARCSI, FJFICMMiss 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.

28. Case report pulmonary fibrosis

29. Adult icu use • What is the evidence for the use of high flow nasal cannula oxygen in adult patients admitted to critical care units? A systematic review. • Kernick J, Magarey J.Discipline of Nursing, The University of Adelaide, Adelaide, SA 5005, Australia. • 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. • 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. • 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. • 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. • Aust Crit Care. 2010 May;23(2):53-70. Epub 2010 Mar 5

30. Comparison HFNO to HF Face mask after extubation • 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. • Abstract • 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.

31. Comparison HFNO to CPAP • Physiologic Effects of High Flow Nasal Therapy in Patients With Acute Hypoxemic Respiratory Failure (OPTIFLOW) • 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 • Sponsor: University Hospital, Bordeaux Information provided by: University Hospital, BordeauxClinicalTrials.gov Identifier: NCT01056952

32. Vue-aerienne-Bordeaux-CHU centre Hospitalier Universitaire

33. Comparison HFNO to CPAP Bordeaux • Two arms HFNO then CPAP and CPAP then HFNO • Three interventions standard O2 CPAP 7.5cmH2O HFNO 40L/min

34. Comparison HFNO to CPAP Bordeaux • 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 • 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 • Probably intensive care in major hospital

35. Comparison HFNO to CPAP Bordeaux • Primary Outcome Measures: • Inspiratory muscle effort : oesophageal pressure (Poes) and the oesophageal pressure time product (PTPoes) • Time Frame: Every 30 minutes for 90 minutes  • Secondary Outcome Measures: • Gas exchange :PaO2/FiO2 ratio • Time Frame: Every 30 minutes for 90 minutes  • Comfort assessed using a five-item semi quantitative scale Time Frame: Every 30 minutes for 90 minutes  • Dyspnea assessed using a visual analogic scale • Time Frame: Every 30 minutes for 90 minutes 

36. HFNO in CAL Ambrock Hagen • 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. • ConditionInterventionChronic Obstructive Pulmonary Disease (COPD)Device: Nasal InsufflationStudy Type:Interventional Study Design:Control: UncontrolledEndpoint Classification: Efficacy StudyIntervention Model: Single Group AssignmentMasking: Open LabelPrimary Purpose: TreatmentOfficial Title:Transnasal Insufflation for Patients With COPD GOLD IV and Hypercapnia

38. HFNO in CAL Ambrock Hagen • 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. • Secondary Outcome Measures: • Breathing Frequency  Time Frame: 3 hours • Breathing Frequency is supposed to decrease under TNI treatment • 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

39. Transnasal insufflation device • Picture of tni

40. HFNO in CAL Ambrock Hagen • 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.

41. HFNO in CAL Ambrock Hagen • Eligibility • Ages Eligible for Study:   18 Years to 85 Years • Genders Eligible for Study:   Both • Accepts Healthy Volunteers:   No • Inclusion Criteria: • COPD GOLD IV • PCO2 > 50 mmHg • competent patients • stable respiratory situation • Exclusion Criteria: • serious acute diseases • hypercapnic decompensation pH < 7,30

42. Osa paper

43. summary • HFNO is a new modality that is under investigation for clinical utility • It seems to provide a little cpap but is better tolerated over long term use • It may displace previous use of CPAP and invasive ventilation

44. Key references F and P