High Flow Nasal High Flow Nasal Cannula for Patient Care Cannula for Patient Care

Units- ACHUnits- ACH

ACH Hospital Pediatrics Fall ACH Hospital Pediatrics Fall RetreatRetreat

September 16/17 2011September 16/17 2011

Oxygen Delivery SystemsOxygen Delivery Systems Blow byBlow by Nasal cannulaNasal cannula

Low-flow- Low-flow- 1-4 LPM delivers 25-40% FiO2 (limit flow to 2 LPM in infants)1-4 LPM delivers 25-40% FiO2 (limit flow to 2 LPM in infants) High-flow-High-flow- delivers heated and humidified O2 - up to 8LPM (infants); up to 40 delivers heated and humidified O2 - up to 8LPM (infants); up to 40

LPM (children/adults); may be better tolerated than O2 by face maskLPM (children/adults); may be better tolerated than O2 by face mask MasksMasks

Simple – flow rates: Simple – flow rates: 5-10 LPM delivers 35-50% FiO2 (unreliably)5-10 LPM delivers 35-50% FiO2 (unreliably) Partial rebreathing- Partial rebreathing- flow rates 10-12 LPM delivers 50-60% FiO2flow rates 10-12 LPM delivers 50-60% FiO2 Nonrebreathing- Nonrebreathing- flow rates of 10-15 LPM delivers FiO2 up to 95%flow rates of 10-15 LPM delivers FiO2 up to 95%

Enclosure systemsEnclosure systems Hoods Hoods – flow rates 10-15 LPM delivers FiO2 of 80-90 %– flow rates 10-15 LPM delivers FiO2 of 80-90 % Tents Tents – using high flow rates can deliver up to 50% FiO2– using high flow rates can deliver up to 50% FiO2

Ventilation bagsVentilation bags Self-inflatingSelf-inflating Flow-inflatingFlow-inflating

High Flow Nasal Cannula High Flow Nasal Cannula (HFNC)(HFNC)

Key benefits over nasal prongs:Key benefits over nasal prongs:1.1. Delivery of up to 100% oxygen more accuratelyDelivery of up to 100% oxygen more accurately2.2. Anatomical dead space flushedAnatomical dead space flushed3.3. Providing warmed + humidified gas reduces Providing warmed + humidified gas reduces

metabolic work (in adults estimated at 156 cal/min)metabolic work (in adults estimated at 156 cal/min)4.4. Providing warmed + humidified gas improves Providing warmed + humidified gas improves

conductance and pulmonary complianceconductance and pulmonary compliance5.5. Positive airway pressure throughout the respiratory Positive airway pressure throughout the respiratory

cycle cycle • Overcomes inspiratory resistance Overcomes inspiratory resistance • MayMay be able to provide positive distending pressure for be able to provide positive distending pressure for

lung recruitment lung recruitment (up to 5-6 cm H2O- depending on mouth open (up to 5-6 cm H2O- depending on mouth open and leak in very small infants) – and leak in very small infants) – unreliably!!!unreliably!!!

6.6. Potentially aids in mucociliary clearancePotentially aids in mucociliary clearance

Uses in PediatricsUses in Pediatrics

• • RDS of prematurityRDS of prematurity• • BronchiolitisBronchiolitis• • Apnea of prematurityApnea of prematurity• • Chronic Lung DiseaseChronic Lung Disease• • Infants susceptible to nasal trauma/maintaining Infants susceptible to nasal trauma/maintaining

mucosal integritymucosal integrity• • Infants weaning from invasive ventilation and Infants weaning from invasive ventilation and

CPAPCPAP

*Indications for use are non-specific; no formal *Indications for use are non-specific; no formal recommendations are available for specific clinical indicationsrecommendations are available for specific clinical indications

““Criteria” for useCriteria” for use

Effective spontaneous respiratory effortEffective spontaneous respiratory effort

Requirement for moderate to high Requirement for moderate to high amounts of oxygen when NP or facial amounts of oxygen when NP or facial mask not amenablemask not amenable

CO2 elimination maintainedCO2 elimination maintained

CPAP vs HFNCCPAP vs HFNC

3 key problems with CPAP making HFNC 3 key problems with CPAP making HFNC attractive:attractive:

1.1. Mechanical difficulties of maintaining CPAP Mechanical difficulties of maintaining CPAP apparatus in noseapparatus in nose

2.2. CPAP commonly causes nasal septum CPAP commonly causes nasal septum traumatrauma

3.3. CPAP is tightly affixed to nose and face- CPAP is tightly affixed to nose and face- causes intolerance with patient movement, causes intolerance with patient movement, trauma, need for sedation, etc. trauma, need for sedation, etc.

Consider HFNC a bridge between Low Consider HFNC a bridge between Low Flow NP and CPAPFlow NP and CPAP

While HFNC While HFNC maymay provide some positive provide some positive pressure, it is pressure, it is notnot regulated and highly regulated and highly variablevariable

((butbut give HFNC the “respect” given to non- give HFNC the “respect” given to non-invasive modes of ventilation)invasive modes of ventilation)

Basic Set-upBasic Set-up

Potential ComplicationsPotential Complications Respiratory FailureRespiratory Failure Excessive condensation in the tubingExcessive condensation in the tubing Aspiration (above/below)Aspiration (above/below) Potential for infectionPotential for infection Barotrauma with unmeasured CPAPBarotrauma with unmeasured CPAP PneumothoraxPneumothorax Subcutaneous scalp emphysema, pnemo-Subcutaneous scalp emphysema, pnemo-

orbitis, pneumocephalus has been described in orbitis, pneumocephalus has been described in one neonate on HFNCone neonate on HFNC

Pulmonary hemorrhage Pulmonary hemorrhage Nasal septal damageNasal septal damage

Other considerations

Need for NG to decompress stomach

Ability to orally feed

Nare occlusion

Guidelines for HFNC Use At Guidelines for HFNC Use At ACHACH

Will be initiated and stabilized in PICU/NICU Will be initiated and stabilized in PICU/NICU prior to transfer to Unit 2prior to transfer to Unit 2

Currently only being used for patients with Currently only being used for patients with chronicchronic oxygen needs and/or craniofacial oxygen needs and/or craniofacial anomaliesanomalies

Patients on HFNC Patients on HFNC MUSTMUST be on CRM be on CRM Patients will go to Unit 2, Yellow Hallway Patients will go to Unit 2, Yellow Hallway

and preferably Purple Teamand preferably Purple Team Respirology consult is mandatoryRespirology consult is mandatory

Guidelines cont’dGuidelines cont’d

RT to assess the patient RT to assess the patient AT MINIMUMAT MINIMUM of of q4hq4h

RN to assess the patient RN to assess the patient AT MINIMUMAT MINIMUM of of q4h (alternating q2h with RT assessment)q4h (alternating q2h with RT assessment)

Orders for HFNC must include: Flow rate Orders for HFNC must include: Flow rate and FiO2and FiO2

Signage will be placed at the bedside of Signage will be placed at the bedside of these patients by RTthese patients by RT

Weaning can only be ordered by Weaning can only be ordered by Respirology and Hospital PediatricsRespirology and Hospital Pediatrics

Weaning of HFNCWeaning of HFNC Indications:Indications:

Once patient FiO2 is <40%Once patient FiO2 is <40% Disease process is improvingDisease process is improving

Order can be specific or written “as tolerated” Order can be specific or written “as tolerated” must be in discussion with Hospital Pediatrician and must be in discussion with Hospital Pediatrician and

Respirology Respirology Drop flow in increments of 1-2 LPMDrop flow in increments of 1-2 LPM

<6 mos of age: once flow is 2 LPM consider changing to <6 mos of age: once flow is 2 LPM consider changing to regular nasal prongsregular nasal prongs

> 6 mos of age: once clow is 3 LPM consider changing to > 6 mos of age: once clow is 3 LPM consider changing to regular nasal prongsregular nasal prongs

QUESTIONS??QUESTIONS??