Conflict of Interest€¦ · mortality, IVH, NEC, PVL, surfactant, etc. ... Former 28 week preemie...
Transcript of Conflict of Interest€¦ · mortality, IVH, NEC, PVL, surfactant, etc. ... Former 28 week preemie...
Neo
nata
l Hea
ted
Hig
h Fl
ow N
asal
C
annu
la: J
ust S
ay N
o or
Go
with
th
e Fl
ow?
Rob
DiB
lasi
RR
T-N
PS, F
AAR
C
Prog
ram
Man
ager
Res
earc
h/Q
I, R
espi
rato
ry T
hera
py
Prin
cipl
e In
vest
igat
or, S
eattl
e C
hild
ren’
s R
esea
rch
Inst
itute
Con
flict
of I
nter
est
I hav
e re
ceiv
ed re
sear
ch fu
nds a
nd/o
r spe
aker
ho
nora
ria fr
om th
e fo
llow
man
ufac
ture
rs:
•Va
poth
erm
•
Neo
tech
•
Drae
ger M
edic
al
•M
allin
ckro
dt M
edic
al
•Ae
roge
n Ph
arm
a •
Chie
si Ph
arm
a
Obj
ectiv
es
Lear
ning
obj
ectiv
es fo
r thi
s pre
sent
atio
n:
•Re
view
theo
retic
func
tiona
l diff
eren
ces b
etw
een
Nas
al C
PAP
and
high
flow
nas
al c
annu
la (H
FNC)
•
Expl
ore
phys
iolo
gic
data
com
parin
g HF
NC
to o
ther
no
ninv
asiv
e st
rate
gies
•
Disc
uss c
linic
al d
ata
rela
ted
to H
FNC
use
in
neon
ates
•
Dete
rmin
e be
st p
ract
ice
for H
FNC
man
agem
ent
and
wea
ning
Hea
ted
and
Hum
idifi
ed H
igh
Flow
Nas
al
Can
nula
(HFN
C)
CO
2
CO
2
+ +
+
+ + +
+ +
+
+ +
+ +
+ +
•H
FNC
pro
vide
s a
mon
opha
sic
oxyg
en fl
ow
•he
ated
and
hum
idifi
ed
(100
% B
TPS)
•
“Ope
n S
yste
m” r
esul
ting
in
leak
s •
Impr
oves
oxy
gena
tion:
•
↑PaO
2 (F
iO2)
, hum
idity
, PE
EP
•Im
prov
es v
entil
atio
n •↓P
aCO
2, ↑V
T , ↓
RR
and
VE
•↓
CO
2 reb
reat
hing
from
an
atom
ic d
eads
pace
•
Indi
cate
d th
erap
eutic
flow
se
tting
cur
rent
ly u
nkno
wn
HFN
C In
terfa
ces
may
be
mor
e co
mfo
rtabl
e th
an N
-CPA
P
Pho
tos
Cou
rtesy
of R
ose
DeC
lerk
, Ver
mon
t Oxf
ord
and
Loui
se O
wen
G
ollg
her e
t al.,
Am
J R
esp.
and
Crit
. Car
e M
ed, 2
017
HFN
C In
terfa
ces
may
be
mor
e co
mfo
rtabl
e th
an N
-CPA
P
Pho
tos
Cou
rtesy
of R
ose
DeC
lerk
, Ver
mon
t Oxf
ord
and
Loui
se O
wen
Perc
eive
d lim
itatio
ns o
f HFN
C
•Pr
essu
re is
hig
hly
varia
ble
and
cann
ot b
e m
easu
red
or re
gula
ted
•Th
ere
are
no a
larm
s w
ith m
ost H
FNC
sys
tem
s
•D
iste
ndin
g ai
rway
pre
ssur
e ge
nera
ted
by H
FNC
m
ay le
ad to
lung
inju
ry (o
vere
xpan
sion
or
atel
ecta
sis)
and
con
tribu
te to
the
deve
lopm
ent o
f BP
D in
infa
nts
•In
abilit
y to
sel
ect p
rope
rly s
ized
pro
ngs
coul
d in
crea
se ri
sk fo
r VIL
I and
gas
tric
insu
fflat
ion
Airw
ay In
jury
with
Nas
al C
PAP
•C
PAP
use
may
: •
Incr
ease
the
risk
for t
issu
e ne
cros
is,
nasa
l ste
nosi
s, d
efor
mity
, and
PnT
x •
Incr
ease
d ne
ed fo
r sed
atio
n •
Inte
rface
may
impa
ct b
ondi
ng, s
uck
feed
ing,
and
pos
ition
ing
•R
epor
ted
adva
ntag
es o
f HFN
C o
ver
CPA
P:
•R
educ
ed ra
tes
of n
asal
trau
ma
•
Red
uced
infa
nt p
ain
scor
es a
nd
stre
ss
•Pr
efer
red
by p
aren
ts a
nd n
ursi
ng
staf
f •
Less
PnT
x
Phys
ic o
f Gas
Flo
w: N
CPA
P
DiB
lasi
,. R
esp.
Car
e Jo
urna
l, 20
16
Hig
h Fl
ow N
asal
Can
nula
Fl
ow R
ate>
2 L
/min
; mon
opha
sic
flow
CO
2
CO
2
+ +
+
+ + +
+ +
+
+ +
+ +
+ +
Pho
to c
ourte
sy o
f Tom
Mill
er P
hD
Eve
rybo
dy S
eem
s to
Be
Goi
ng W
ith th
e Fl
ow…
.
It is
Bei
ng U
sed
to T
reat
a
Num
ber o
f Mal
adie
s…
Is it
pos
sibl
e th
at it
is b
eing
app
lied
whe
n it
is n
ot
alw
ays
nece
ssar
ily in
dica
ted?
No
one
Know
s W
hat t
he F
low
Sho
uld
Be
Set
At…
024681012
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Apr-14
Jun-14
Aug-14
Oct-14
Dec-14
Feb-15
Apr-15
% of All Pt Days with HFNC in Use
THE
QU
ESTI
ON
: Ove
rutil
izat
ion
of H
FNC
?
•W
hat l
evel
of s
uppo
rt is
pro
vide
d w
ith H
FNC
? •
Are
ther
e ph
ysio
logi
c be
nefit
s w
ith H
FNC
? •
A m
anag
emen
t pro
toco
l in
the
US
is
none
xist
ent
(Infa
nt th
roug
h A
dult)
Tran
slat
iona
l Res
earc
h Q
uest
ions
•D
oes
HFN
C p
rovi
de p
ress
ure
sim
ilar t
o C
PAP?
•
Doe
s H
FNC
redu
ced
exha
led
CO
2re
-bre
athi
ng fr
om th
e an
atom
ic d
eads
pace
? •
Are
ther
e di
ffere
nces
in th
e le
vel o
f CO
2w
asho
ut re
late
d to
di
ffere
nt p
atie
nt s
izes
? •
Wha
t hap
pens
to p
ress
ures
and
CO
2 with
mou
th
open
/clo
sed?
•
Can
thes
e ef
fect
s be
stu
died
in a
ben
ch m
odel
or h
uman
s?
•C
an H
FNC
use
affe
ct o
utco
mes
in o
ur p
atie
nt p
opul
atio
n th
at a
re d
iffer
ent f
rom
oth
er n
onin
vasi
ve fo
rms
of s
uppo
rt?
Nie
lsen
et a
l., In
Pre
ss R
espi
rato
ry C
are
Jour
nal,
2017
End-
Expi
rato
ry P
ress
ures
Niel
sen
et a
l., In
Pre
ss R
espi
rato
ry C
are
Jour
nal,
2017
End
expi
rato
ry p
ress
ure
with
HFN
C
Iyer
et a
l., R
espi
rato
ry C
are
Jour
nal,
2016
Flow
Effe
cts:
End
-Tid
al C
O2
(alv
eola
r ve
ntila
tion)
2L:2
6.3±
2.7
2L: 3
5.4±
1.7
2L: 5
.3±1
.3
2 L:
10.
4±1.
6
4 L:
7.2
±0.9
4
L: 1
9.1±
0.7
6 L:
7.6
±2.1
Flow
Effe
cts I
nsp.
CO
2 (d
eads
pace
)
Pre-
term
: Vap
othe
rm 8
L/m
in
Term
: Vap
othe
rm 8
L/m
in
Adul
t: Va
poth
erm
40
L/m
in
"Whe
re th
ere
is n
o st
anda
rd, t
here
can
be n
o im
prov
emen
t"
-Tai
ichi
Ohn
o
Prot
ocol
Dev
elop
men
t
Age
Gro
upD
efin
ition
of H
FNC
*
Acut
e C
are
Min
imum
H
FNC
Flo
w R
ate
(bro
nchi
oliti
s pa
thw
ay)
Acut
e C
are
Max
imum
H
FNC
Flo
w R
ate
IC
U M
axim
um H
FNC
Flo
w R
ates
Flow
Rat
e (L
/min
)
Estim
ated
PE
EP
(cm
H2O
)
HFN
C
min
imum
(L
/min
)
Estim
ated
PEEP
(cm
H20
)
HFN
C
max
imum
(L
/min
)
Estim
ated
PE
EP
(cm
H2O
)
HFN
C
max
imum
(L
/min
)
Estim
ated
PE
EP (c
m H
2O)
0-90
d3
2 3
2 4
3 8
10
91d-
6mo
4 <1
4<1
6 2
106
>6m
o-1y
r 5
<15
<18
2 12
-20
4-10
>1 y
r-2y
r 6
<25
<110
3 15
-20
6-10
>2yr
-8yr
6
<16
<112
2 15
-20
4-6
>8yr
s8
<18
<115
2 15
-30
4-12
PEEP
val
ues
are
estim
ated
at e
ach
HFN
C s
ettin
gs u
sing
a s
pont
aneo
usly
bre
athi
ng lu
ng m
odel
and
3D
ana
tom
ic a
irway
with
Vap
othe
rm
devi
ce.
*
HFN
C d
efin
ition
bas
ed o
n es
timat
ed in
spira
tory
flow
for a
vera
ge w
eigh
t in
term
infa
nt th
roug
h ad
oles
cent
pat
ient
s; p
atie
nts
who
are
no
t on
the
bron
chio
litis
pat
hway
and
are
rece
ivin
g flo
w b
elow
that
def
ined
as
HFN
C fo
r age
may
be
cand
idat
es fo
r wea
ning
/ di
scon
tinua
tion
and
shou
ld b
e di
scus
sed
with
med
ical
team
; pat
ient
s re
quiri
ng o
xyge
n af
ter H
FNC
sho
uld
be s
uppo
rted
with
a N
C a
ttach
ed to
an
oxyg
en fl
ow
met
er (w
ithou
t ble
nder
) bef
ore
acut
e ca
re tr
ansf
er.
Is C
O2 r
espo
nse
betw
een
HFN
C, N
CPAP
, and
NIV
Di
ffere
nt?
Muk
erji
et a
l. J P
erin
atol
. 201
5
↓28
%
↓44
%
↓15
%
↓35
%
Clin
ical
Out
com
es: C
ompa
ring
HFN
C to
NIV
•H
FNC
doe
sno
t pro
vide
insp
irato
ry p
ress
ure
but
CO
2 pur
ging
dur
ing
inha
latio
n an
d ex
hala
tion
may
pr
ovid
e a
sim
ilar v
entil
atio
n ef
fect
as
NIV
•
HH
HFN
C m
aybe
as
effe
ctiv
e as
NIP
PV in
pr
even
ting
endo
trach
eal v
entil
atio
n in
the
prim
ary
treat
men
t of R
DS
in p
rem
atur
e in
fant
s
•N
eona
tes
Kug
lem
an,P
eds
Pul
m, 2
016;
Lav
azar
ri 20
16, J
amaP
edia
trics
•Ad
ults
NiY
N, C
hest
. 201
7, N
agat
a K
, Res
pira
tory
Car
e 20
15
NO
doc
umen
ted
airw
ay In
jury
or p
neum
otho
rax
-.20 .2.4.6.81
1.2
NC
PAP-
NIM
V PE
R P
T D
AY
HH
FNC
PER
PT
DAY
IN
VASI
VE V
ENTS
PER
PT
DAY
2016
2015
2014
2013
2012
↓57%
↓36%
↑58%
2016
2015
2014
2013
2012
2016
2015
2014
2013
2012
HFN
C U
se a
t SC
H: A
Sna
p Sh
ot fr
om th
e N
ICU
% c
hang
e ba
sed
on m
ean
valu
es
Total Days of Therapy/Total Patient Days
Shor
t-ter
m p
hysi
olog
ic o
utco
mes
: WO
B
Neu
th e
t al.,
Ped
s P
ulm
46:
67-7
4 (2
011)
Shor
t-ter
m P
hysi
olog
ic S
tudi
es: r
ecru
itmen
t
Clin
ical
Que
stio
ns
•C
an H
FNC
be
used
saf
ely
and
effe
ctiv
ely
as a
n al
tern
ativ
e to
N-C
PAP
in te
rm a
nd p
re-te
rm
infa
nts
as a
n in
itial
form
of s
uppo
rt or
follo
win
g ex
tuba
tion?
•
Shor
t-ter
m p
ulm
onar
y ph
ysio
logi
c ou
tcom
es (W
OB,
ga
s ex
chan
ge, A
OP,
and
lung
recr
uitm
ent)
•M
orbi
dity
/mor
talit
y (D
eath
, BPD
, oth
er c
ompl
icat
ions
) •
Nas
al a
irway
inju
ry
•Pn
eum
otho
rax
HFN
C in
Pre
mat
ure
Infa
nts
Follo
win
g Ex
tuba
tion
•Fo
llow
ing
extu
batio
n (6
stu
dies
,n=9
34),
no d
iffer
ence
s be
twee
n H
FNC
and
CPA
P:
•de
ath
or C
LD
•ra
te o
f tre
atm
ent f
ailu
re o
r rei
ntub
atio
n
•In
fant
s ra
ndom
ized
to H
FNC
had
low
er n
asal
trau
ma
and
pneu
mot
hora
x
•Su
bgro
up a
naly
sis
foun
d no
diff
eren
ce in
the
rate
of t
he p
rimar
y ou
tcom
es b
etw
een
HFN
C a
nd C
PAP
in p
rete
rm in
fant
s in
diff
eren
t ge
stat
iona
l age
sub
grou
ps, s
mal
l num
ber i
nfan
ts <
1200
gra
ms
•Fo
r inf
ants
wea
ning
from
non
-inva
sive
resp
irato
ry s
uppo
rt (C
PAP)
, tw
o st
udie
s (n
=149
) fou
nd th
at p
rete
rm in
fant
s ra
ndom
ized
to H
FNC
ha
d a
redu
ced
dura
tion
of h
ospi
taliz
atio
n co
mpa
red
with
infa
nts
who
re
mai
ned
on C
PAP
•R
CT
- HFN
C n
onin
ferio
r to
CPA
P as
prim
ary
resp
irato
ry
supp
ort f
or p
rete
rm in
fant
s (g
esta
tiona
l age
, ≥28
wee
ks 0
da
ys) w
ith e
arly
RD
S•
HFN
C g
roup
rece
ived
an
initi
al g
as fl
ow o
f 6 to
8 L
/min
from
ei
ther
the
Opt
iflow
Jun
ior (
F&P
Hea
lthca
re) o
r Pre
cisi
on
Flow
(Vap
othe
rm)d
evic
e w
ith c
ross
over
to N
-CPA
P (9
4% v
s 6%
) •
Nas
al C
PAP
grou
p re
ceiv
ed 6
-8 c
mH
2O u
sing
thre
e di
ffere
nt
kind
s of
N-C
PAP
Rob
erts
et a
l., N
EJM
, 201
6
The
“HIP
STE
R T
rial”
Out
com
es
•St
udy
stop
ped
afte
r tw
o ye
ars;
HFN
C=2
78 a
nd C
PAP=
286
•Tr
eatm
ent f
ailu
re (F
iO2
>0.4
0) w
ithin
72
hour
s af
ter r
ando
miz
atio
n w
as g
reat
er (2
5.5%
) in
the
HFN
C th
an N
-CPA
P gr
oup
(13.
3 vs
25
.5%
; P<0
.001
) •
Leng
th o
f sup
port
and
oxyg
en re
quire
men
t gre
ater
in H
FNC
gro
up
•N
o di
ffere
nce
in in
tuba
tion
rate
s at
72
hour
s (1
5.5
vs 1
1.5)
, BPD
, m
orta
lity,
IVH
, NEC
, PVL
, sur
fact
ant,
etc.
•
Urg
ent n
eed
for i
ntub
atio
n oc
curre
d m
ore
frequ
ently
in th
e C
PAP
grou
p th
an H
FNC
gro
up (1
8.4%
vs.
5.6
%, P
= 0
.03)
•
Nas
al tr
aum
a (8
.3 v
s 18
.5%
; P<0
.001
) and
pne
umot
hora
x an
d ai
r-le
ak lo
wer
(0 v
s 6%
; P<0
.02)
dur
ing
HFN
C th
an N
-CPA
P
Rob
erts
et a
l., N
EJM
, 201
6
HFN
C U
se In
BPD
•Pr
actic
es a
re d
ispa
rate
nat
iona
lly a
nd s
ome
do n
ot u
se
HFN
C b
ecau
se th
ey a
re n
ot a
ble
to g
o ho
me
with
it
•W
eani
ng a
t SC
H is
clin
ical
ly-b
ased
: •
Trac
heom
alac
ia o
r oth
er a
irway
ano
mal
ies
(obs
truct
ion)
•
Gas
Exc
hang
e: s
erum
CO
2an
d H
CO
3-
•R
R a
nd W
OB
•Ju
dici
ous
redu
ctio
ns in
flow
(~0.
5 to
1 L
/min
/wk)
•W
eani
ng H
FNC
coi
ncid
es w
ith s
tero
id w
ean
HFN
C U
se In
BPD
•Fo
rmer
28
wee
k pr
eem
ie
with
sev
ere
BPD
adm
itted
fo
r vira
l bro
nchi
oliti
s •
Rec
eivi
ng 7
L/m
in H
FNC
•
Enro
lled
in H
FNC
stu
dy
•N
o Ai
rway
Ano
mal
ies
or
TBM
Phys
iolo
gic
Effe
cts
of H
FNC
in B
PD
DiB
lasi
et a
l.,U
npub
lishe
d D
ata
Car
diac
Pat
ient
s: A
sen
sitiv
e Pa
tient
Pop
ulat
ion
Shi
oji e
t al.,
Jou
rnal
of I
nten
sive
Car
e 20
17
Post
-ext
ubat
ion
HFN
C vs
NIM
V (in
fant
s)
Age
2 m
onth
s (0.
5, 4
) M
ale
(%)
22 (5
2%)
Ethn
icity
Hisp
anic
26
(61%
)
W
hite
14
(33%
)
O
ther
3
(6%
) W
eigh
t (ra
nge)
3.
6 kg
(2.2
-9.6
) Re
ason
for i
ntub
atio
n
Cong
enita
l Hea
rt D
iseas
e Su
rger
y (%
) 30
(71%
)
Re
spira
tory
Fai
lure
(%)
10 (2
3%)
Leng
th o
f Mec
hani
cal V
entil
atio
n (r
ange
) 7
days
(2-3
0)
Leng
th o
f Non
inva
sive
Vent
ilatio
n (r
ange
) 1
(0.2
-29
days
)
Ran
dom
ized
cro
ss o
ver t
rial a
fter e
xtub
atio
n (n
=42)
Kam
erka
r et a
l., J
Pedi
atr 2
017
No
diffe
renc
e in
effo
rt o
f bre
athi
ng b
etw
een
HFN
C an
d N
IMV,
rega
rdle
ss o
f flo
w ra
te
or in
spira
tory
pre
ssur
e (K
rusk
al-W
allis
AN
OVA
P = .1
5). Ka
mer
kar e
t al.,
J Pe
diat
r 201
7 N
ewbo
rn in
fant
s -6
mon
ths (
70%
with
CHD
)
HFN
C U
se In
Bro
nchi
oliti
s
•C
ochr
ane
Met
a-an
alys
is
(201
4):
•Th
ere
is in
suffi
cien
t evi
denc
e to
det
erm
ine
the
effe
ctiv
enes
s of
HFN
C th
erap
y fo
r tre
atin
g in
fant
s w
ith b
ronc
hiol
itis
•“A
bsen
ce o
f evi
denc
e m
ay n
ot
be e
vide
nce
of a
bsen
ce”
•Sh
ort-t
erm
phy
siol
ogic
stu
dies
ha
ve s
how
n im
prov
ed g
as
exch
ange
and
redu
ced
WO
B
HFN
C U
tiliz
atio
n in
Pat
ient
s w
ith B
ronc
hiol
itis
HFN
C M
anag
emen
t Gui
delin
es
Jour
nal o
f Per
inat
olog
y 20
17
"Whe
re th
ere
is n
o st
anda
rd, t
here
can
be n
o im
prov
emen
t"
-Tai
ichi
Ohn
o
Prot
ocol
Dev
elop
men
t
Age
Gro
upD
efin
ition
of H
FNC
*
Acut
e C
are
Min
imum
H
FNC
Flo
w R
ate
(bro
nchi
oliti
s pa
thw
ay)
Acut
e C
are
Max
imum
H
FNC
Flo
w R
ate
IC
U M
axim
um H
FNC
Flo
w R
ates
Flow
Rat
e (L
/min
)
Estim
ated
PE
EP
(cm
H2O
)
HFN
C
min
imum
(L
/min
)
Estim
ated
PEEP
(cm
H20
)
HFN
C
max
imum
(L
/min
)
Estim
ated
PE
EP
(cm
H2O
)
HFN
C
max
imum
(L
/min
)
Estim
ated
PE
EP (c
m H
2O)
0-90
d3
2 3
2 4
3 8
10
91d-
6mo
4 <1
4<1
6 2
106
>6m
o-1y
r 5
<15
<18
2 12
-20
4-10
>1 y
r-2y
r 6
<25
<110
3 15
-20
6-10
>2yr
-8yr
6
<16
<112
2 15
-20
4-6
>8yr
s8
<18
<115
2 15
-30
4-12
PEEP
val
ues
are
estim
ated
at e
ach
HFN
C s
ettin
gs u
sing
a s
pont
aneo
usly
bre
athi
ng lu
ng m
odel
and
3D
ana
tom
ic a
irway
with
Vap
othe
rm
devi
ce.
*
HFN
C d
efin
ition
bas
ed o
n es
timat
ed in
spira
tory
flow
for a
vera
ge w
eigh
t in
term
infa
nt th
roug
h ad
oles
cent
pat
ient
s; p
atie
nts
who
are
no
t on
the
bron
chio
litis
pat
hway
and
are
rece
ivin
g flo
w b
elow
that
def
ined
as
HFN
C fo
r age
may
be
cand
idat
es fo
r wea
ning
/ di
scon
tinua
tion
and
shou
ld b
e di
scus
sed
with
med
ical
team
; pat
ient
s re
quiri
ng o
xyge
n af
ter H
FNC
sho
uld
be s
uppo
rted
with
a N
C a
ttach
ed to
an
oxyg
en fl
ow
met
er (w
ithou
t ble
nder
) bef
ore
acut
e ca
re tr
ansf
er.
0%1%2%3%4%5%6%7%8%9%10%
11%
12%
13%
14%
Jan-13Feb-13Mar-13Apr-13
May-13Jun-13Jul-13
Aug-13Sep-13Oct-13Nov-13Dec-13Jan-14Feb-14Mar-14Apr-14
May-14Jun-14Jul-14
Aug-14Sep-14Oct-14Nov-14Dec-14Jan-15Feb-15Mar-15Apr-15
May-15Jun-15Jul-15
Aug-15Sep-15Oct-15Nov-15Dec-15Jan-16Feb-16Mar-16Apr-16
May-16Jun-16Jul-16
Aug-16Sep-16Oct-16Nov-16Dec-16Jan-17Feb-17
PERCENT OF PT DAYS ON HFNC
PERC
ENT
OF
PT D
AYS
ON
HFN
C Is
it a
ll ho
t air?