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

Feb-12

Apr-12

Jun-12

Aug-12

Oct-12

Dec-12

Feb-13

Apr-13

Jun-13

Aug-13

Oct-13

Dec-13

Feb-14

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?