high flow therapy (hft) in the pediatric population
TRANSCRIPT
High Flow Therapy: Definitions
- Flow rate that exceeds patient flow demands at various minute volumes●A method to achieve actual FiO2 of 1●Eliminate entrainment of ambient air
- Accomplished in the nasopharynx only with proper gas conditioning●Conventional cannula therapy limited by nasal damage●HFT becomes more than oxygen therapy
- Combination of technologies to achieve optimal temperature, humidity and flow rate at the point of delivery
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Continuum of Care: Old Model
5
General 02Therapy
Acu
ity
Choice of Therapy
General 02Therapy
Bi-Level
MechanicalVentilation
CPAP
Rescue Weaning
Bi-LevelCPAP
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Continuum of Care: New Model
6
General 02Therapy
Acu
ity
Choice of Therapy
General 02Therapy
Bi-Level
MechanicalVentilation
CPAP
High Flow Therapy
Rescue Weaning
Bi-Level
CPAP
Control the Factors that Matter…
Combination of proprietary technology to achieve optimal:
Flow Fi02 Temperature Humidity
at the point of delivery.
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High Flow Therapy: Mechanisms of Action
Humidify / Warm Airways
Supports Inspiration
Flush Dead Space
●CO2 Elimination●Oxygen Efficiency
●Cannula Flow > inspiratory●Work of Breathing
●Mobilization of Secretions●Nasal comfort
Humidify / Warm Airways
●Nasopharynx is highly efficient at conditioning inspiratory gas
●Anatomical Structure
●Mucosal Architecture
Inspiratory Gas Conditioning
Conditioning Prevents Injury
Inadequate warming and humidification can cause:
● Thickened Secretions
● Decreased mucocilliary action
● Thermal challenge
● Bloody secretions
● Lung atelectasis
Humidify / Warm Airways
Pulmonary Physiology
VentilationOxygenation
PiO2 ~150 mmHg
PAO2 ~100 mmHg
PaO2 ~95 mmHg
PiCO2 ~0 mmHg
PACO2 ~40 mmHg
PaCO2 ~40 mmHg
Ambient Air
Alveolar
Blood
● High nasal flow, unimpeded at mouth, fills the upper
airways – storing O2 during exhalation and flushing CO2
● High nasal flow, unimpeded at mouth, fills the upper
airways – storing O2 during exhalation and flushing CO2
Flush Dead Space & Support Inspiration
● High mask flow, impeded by pressure at the mouth - stores less
O2 in the upper airways during exhalation and adds prosthetic
dead space
● High mask flow, impeded by pressure at the mouth - stores less
O2 in the upper airways during exhalation and adds prosthetic
dead spaceTiep, et al: Resp Care, 2002: High Flow Nasal vs High Flow Mask oxygen delivery: Tracheal Gas Concentrations Through an airway model
Dead space washout● Supports CO2 ventilation● Enhances oxygenation
Matched inspiratory flow ● Attenuates nasopharyngeal resistance
Adequate gas conditioning● Improves conductance and compliance● Reduces energy cost of gas conditioning
Mechanism of Action for HFT
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Mechanisms by Application
Oxygen Flush Humidity Mild Pressure
RSV
CF
RDS
Asthma
HFT DOES NOT TREAT A DISEASE, THE MECHANISMS TREAT SYMPTOMS
Here are merely a few pediatric 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?
Is Cannula Size Important?
Platform A Platform BPremature 1.5 2.4
Neonatal 1.5 2.4
Infant 1.9 2.7
Intermediate Infant
1.9 2.7
Pediatric 2.7 3.7
Calculating Flows
Tidal Volume 6-8 ml/kg
PEDS: VT are less, but rates are much greater
Breaths per Minute
Infant (0 – 1 yr) 30 - 60
Toddler (1 - 3 yrs) 24 - 40
Preschooler (3 - 6 yrs) 22 - 34
School Age (6 – 12 yrs)
18 - 30
Adolescent (12 – 18 yrs)
12 - 16
Flow Requirements: Pediatrics
Younger than 6 yrs, more like an infant
Older that 6 yrs, more like an adult
Numa and Newth, 1996
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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
Clinical References
●Spentzas et al. - J Intensive Care Med 2009;24:323-8
- Children w/ Respiratory Distress treated with High Flow Nasal Cannula, Published 2009. Paper showing the pronounced physiologic improvements in 46 pediatric patients at Le Bonheur Children’s Hospital, Memphis, Tn. University of Tennessee Critical Care Division.
●Byerly et al. - Burns 2006;32:121-5
- Demonstrates what effect the humidification can have on airway function, although they also reinforce the physiologic impact that flush and pressure have on respiratory function with RDS.
●Hasani et al. - Chron Respir Dis 2008: 5, 81-6
- Although derived from adult patients, it shows mucocilliary clearance functions are dramatically improved with heated, humidified high flow cannula treatment. Patients with RSV and CF should be considered when looking at these results.
Precision Flow® Overview
Precision Flow® Integrates Humidification and Gas Blending in One Device
Precision Flow® Integrates Humidification and Gas Blending in One Device
• Flow, FiO2, Temperature All In One
• One Control, Easy To Use
• Smart Technology
• Robust Design w/ Limited Maintenance
• Audio/Visual Alarm Functionality
• Quick Start Up
• No Disinfecting
Main Unit - Front Panel
Run, Standby ButtonAlarm Mute and
Display Dim
Temperature Display
Setting Control Knob
Flow Display Oxygen Display
Safety Features
System Fault Alarm
Water Out Alarm
Blocked Tube Alarm
Gas Supply Fault
Battery Low, Charging
Cartridge Fault
Disposable Water Path Fault or Absent
High and Low Cartridge Indicators
Disposable Patient Circuit (DPC)
The Precision Flow™ Disposable Patient Circuit (DPC) Consists of
Three Components: 1. Disposable Water Path (DWP)
2. Vapor Transfer Cartridge (VTC)
3. Patient Delivery Tube
30 Day on Single Patient
Available Low or High Flow Kits Impeller
Heater Plate
Sensors
Filter Membrane
Delivery Tube
Cartridge
WaterSpike
Precision Flow® Overview
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
Indications for Use: 5-20Lpm
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