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High Flow Therapy (HFT) PICU Population Nursing Educational Series

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Agenda Respiratory Patient Tx Model ( Old & New ) Review of High Flow Therapy (HFT ) Clinical Applications & Benefits Precision Flow Demonstration Q & A

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Oxygen Therapy -vs- Ventilation Oxygen Therapy Goals - 1. Correct hypoxemia - 2. Decrease symptoms associated with hypoxemia - 3. Decrease workload on cardiopulmonary system N.I.V.Therapy Goals - 1. Improve Gaseous Exchange (02-CO2) - 2. Decrease intrapulmonary Shunt - 3. Assist the Pts Spontaneous Respiratory Effort & Alleviate Dyspnea - 4. Reduce Work of Breathing - 5. Avoid Intubation & Ventilation

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44 Continuum of Care: Old Model 4 General 02 Therapy Acuity Choice of Therapy General 02 Therapy Bi-Level Mechanical Ventilation CPAP Rescue Weaning Bi-Level CPAP

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Continuum of Care: Old Model 5 Low Flow Cannula Oxygen MaskCPAP / Bi-Level Mechanical Ventilation Flows limited to 1 5Lpm Higher Fi02 Achieved Pressure Support Patient Completely Ventilated Fi02 typically

11 High Flow Therapy: Mechanisms of Action Humidify / Warm AirwaysSupports Inspiration Flush Dead Space CO 2 Elimination Oxygen Efficiency Cannula Flow > inspiratory Work of Breathing Mobilization of Secretions Nasal comfort

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Mechanisms: Humidity Nasopharynx is h ighly efficient at conditioning inspiratory gas Anatomical Structure Mucosal Architecture Inspiratory Gas Conditioning

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Conditioning Prevents Injury Inadequate warming and humidification can cause: Thickened Secretions Decreased mucocilliary action Thermal challenge Bloody secretions Lung atelectasis Mechanisms: Humidity

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Williams et al, 1996, Crit Care Med 24(11): 1920-9 Why BTPS?

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Vapor Transfer Cartridge: Key to efficient, high performance humidification and gas conditioning Also serves as filter--pore size much smaller than 0.05 microns Patient Delivery Tube: Patented triple lumen design Design prevents rain-out Keeps gas conditioned out to patient Safer than traditional heater wire design Mechanisms: Humidity (How We Do It)

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Flush Dead Space & Support Inspiration Mechanisms: Physiology & Dead Space

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Pulmonary Physiology and Dead Space

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Pulmonary Pathophysiology

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21 Mechanisms: Standard Oxygen Therapy

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High nasal flow, unimpeded at mouth, fills the upper airways storing O 2 during exhalation and flushing CO2 Flush Dead Space & Support Inspiration High mask flow, impeded by pressure at the mouth - stores less O 2 in the upper airways during exhalation and adds prosthetic dead space Tiep, et al: Resp Care, 2002: High Flow Nasal vs High Flow Mask oxygen delivery: Tracheal Gas Concentrations Through an airway model

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23 Mechanisms: High Flow Therapy HFT Therapeutic Flow Ranges > 4Lpm Neonate > 10Lpm Pediatric

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Dead space washout Supports CO 2 ventilation Enhances oxygenation Matches inspiratory flow Attenuates nasopharyngeal resistance Adequate gas conditioning Improves conductance and compliance Reduces energy cost of gas conditioning Mechanism of Action Review

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HFT Clinical Review Clinical Applications & Benefits

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Flow First Early Intervention Is The Key 26 HFT Clinical Review

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Indications for Use: Indications: Spontaneously breathing patients who are requiring supplemental oxygen therapy Any patient who is on an oxygen mask that is: 1. Not compliant, 2. not improving, 3. Or has an increase in work of breathing Post- extubation support or weaning from NPPV Patients requiring supplemental heat & humidity for artificial airways Contraindications: Patients not spontaneously breathing Patients that have a deviated septum Patients with severe facial trauma or disfigurement

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28 Mechanisms by Application OxygenFlushHumidityMild Pressure RSV CF RDS Asthma HFT DOES NOT TREAT A DISEASE, THE MECHANISMS TREAT SYMPTOMS These are some sample disease states and how the mechanisms of action treat the symptoms. Can you think of other respiratory insufficiencies where the symptoms can be treated by HFT?

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Is Cannula Size Important? Platform APlatform B Premature1.52.4 Neonatal1.52.4 Infant1.92.7 Intermediate Infant 1.92.7 Pediatric2.73.7

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HFT Conclusions Patient Care Aspects Easy Interface Nasal Cannula - No Tight Fitting Prongs to Fit - No Leaks to Worry About - Patient Can Bond with Parent (Kangaroo Care) - Patient Can Nurse Ability to Control Factors Independently - Can Deliver Temp, Flow, Fi02 to Meet Patients Exact Needs - Can Deliver High Flow and Low Fi02 to Chronic Patients

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HFT Conclusions Patient Care Aspects Ability to Provide Adequate Humidity - No Risk of Lung Injury - Minimal Rainout in Circuit - Safe to Use in Heated Environments Low Maintenance While on Patient - No Masks to Keep Tight - No Rainout in Patient Delivery Tube - Circuit Good for 30days LOS - Easy to Read Display - Audible Alarms

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Q & A