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 Experts On Air

La HFOT más allá de la UCI

Seminario web 6
1. Using the HFOT guidelines 2. Optimizing HFOT settings 3. Monitoring patients on HFOT 4. Intubation in hypoxemic respiratory failure 5. HFOT in hypercapnic respiratory failure 6. HFOT beyond the ICU
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6.  HFOT beyond the ICU (Experts on Air)

HFOT beyond the ICU
Speaker: Jean‑Damien Ricard; Interviewer: Oriol Roca

The COVID-19 pandemic has seen high flow oxygen therapy become more and more relevant in various departments, including emergency care, and pediatric and general patient wards. In this webinar, we looked at where this therapy could be initiated to achieve better patient outcomes.

Experts On Air is a free series of live Zoom events on different aspects of a central topic. Events are approximately 30 minutes in duration and feature a presentation by a speaker together with questions from an interviewer. Want to join the next live session? Click here for more information: https://www.hamilton-medical.com/Landing-pages/Experts-on-Air.html

For more information on this past webinar, including questions not answered during the event, click here: https://www.hamilton-medical.com/Landing-pages/Experts-on-Air/High-flow-nasal-cannula-therapy.html
34 minutes
EN
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1.  Using the HFOT guidelines

35 minutes
EN
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2.  Optimizing HFOT settings

30 minutes
EN
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3.  Monitoring patients on HFOT

35 minutes
EN
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4.  Intubation in hypoxemic respiratory failure

29 minutes
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5.  HFOT in hypercapnic respiratory failure

30 minutes
EN

Preguntas y respuestas del seminario web 6

En mi UCI, utilizamos flujo alto nasal en pacientes con COVID‑19 durante las sucesivas oleadas en salas sin presión negativa y sin que se presentaran casos de contaminación del personal. Así que la respuesta, en mi opinión, es sí, se puede utilizar flujo alto nasal en salas sin presión negativa, siempre que el personal esté debidamente equipado con EPP.

(Nota del editor: Esta pregunta se interpretó de esta forma: «¿Qué parámetros de seguridad deben observarse cuando se utiliza HFOT fuera de la UCI?». No hay una respuesta definitiva a esa pregunta, porque depende de factores como la distancia a la UCI donde se administre el flujo alto nasal, la formación del personal para administrar y monitorizar el flujo alto nasal en pacientes con insuficiencia respiratoria aguda, de si estos pacientes tendrán una medición continua de la SpO2 o no, etc. Dicho esto, creo que la FiO2 debería limitarse y no superar el 60 %; la SpO2 no debería estar por debajo del 92 % al 94 %, y la frecuencia respiratoria no debería superar un valor de 25 a 28. Si los pacientes se encuentran fuera de uno de estos objetivos, se debe llamar a un médico de la UCI para que los evalúe.  

No tengo datos ni experiencia personal. Mi opinión es que, si no hay opción de suministro eléctrico, será problemático no tener humidificación. Si se contara con una batería externa y tuviera autonomía para todo el tiempo de vuelo, no vería razones «técnicas» por las que tal dispositivo no pudiera funcionar durante un vuelo en helicóptero. (Nota del editor: Que sepamos, en este momento no hay ningún dispositivo de humidificación disponible que esté aprobado para el traslado).

El índice ROX se estableció y validó en pacientes adultos (mayores de 18 años) con insuficiencia respiratoria hipoxémica aguda relacionada con neumonía. Tiene sentido aplicarlo a pacientes más jóvenes cuyas características fisiológicas sean similares a las de un paciente adulto. Conozco al menos una publicación en la que se estableció la puntuación ROX en una población pediátrica: Yildizdas D, Yontem A, Iplik G, Horoz OO, Ekinci F. Predicting nasal high‑flow therapy failure by pediatric respiratory rate‑oxygenation index and pediatric respiratory rate‑oxygenation index variation in children. Eur J Pediatr. 2021;180(4):1099‑1106. doi:10.1007/s00431‑020‑03847‑61​.

Varios estudios han demostrado que el uso de flujo nasal alto reduce la tasa de intubación en pacientes pediátricos ingresados por insuficiencia respiratoria debida a bronquiolitis: Franklin D, Babl FE, Schlapbach LJ, et al. A Randomized Trial of High‑Flow Oxygen Therapy in Infants with Bronchiolitis. N Engl J Med. 2018;378(12):1121‑1131. doi:10.1056/NEJMoa17148552​ and Schibler A, Pham TM, Dunster KR, et al. Reduced intubation rates for infants after introduction of high‑flow nasal prong oxygen delivery. Intensive Care Med. 2011;37(5):847‑852. doi:10.1007/s00134‑011‑2177‑53​.

No existen datos similares en adultos, probablemente porque la entidad clínica de la bronquiolitis en adultos está menos definida y, por tanto, es mucho menos frecuente.

Exención de responsabilidad

El contenido de esta página solo tiene fines informativos y no pretende sustituir a la formación profesional ni las pautas de tratamiento estándar de su centro. Las respuestas a las preguntas que aparecen en esta página fueron elaboradas por el ponente del seminario web correspondiente;  toda recomendación que se haga aquí con respecto a la práctica clínica o al uso de productos, dispositivos o tratamientos específicos únicamente constituye la opinión personal del ponente y no se puede considerar una recomendación oficial hecha por Hamilton Medical AG. Hamilton Medical no ofrece ninguna garantía con respecto a la información contenida en esta página y, si utiliza cualquier parte de esta información, lo hará únicamente bajo su propia responsabilidad.

Referencias

  1. 1. Yildizdas D, Yontem A, Iplik G, Horoz OO, Ekinci F. Predicting nasal high‑flow therapy failure by pediatric respiratory rate‑oxygenation index and pediatric respiratory rate‑oxygenation index variation in children. Eur J Pediatr. 2021;180(4):1099‑1106. doi:10.1007/s00431‑020‑03847‑6
  2. 2. Franklin D, Babl FE, Schlapbach LJ, et al. A Randomized Trial of High‑Flow Oxygen Therapy in Infants with Bronchiolitis. N Engl J Med. 2018;378(12):1121‑1131. doi:10.1056/NEJMoa1714855

 

  1. 3. Schibler A, Pham TM, Dunster KR, et al. Reduced intubation rates for infants after introduction of high‑flow nasal prong oxygen delivery. Intensive Care Med. 2011;37(5):847‑852. doi:10.1007/s00134‑011‑2177‑5

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Predicting nasal high‑flow therapy failure by pediatric respiratory rate‑oxygenation index and pediatric respiratory rate‑oxygenation index variation in children.

Yildizdas D, Yontem A, Iplik G, Horoz OO, Ekinci F. Predicting nasal high‑flow therapy failure by pediatric respiratory rate‑oxygenation index and pediatric respiratory rate‑oxygenation index variation in children. Eur J Pediatr. 2021;180(4):1099‑1106. doi:10.1007/s00431‑020‑03847‑6

The primary objective of this study was to evaluate whether pediatric respiratory rate‑oxygenation index (p‑ROXI) and variation in p‑ROXI (p‑ROXV) can serve as objective markers in children with high‑flow nasal cannula (HFNC) failure. In this prospective, single‑center observational study, all patients who received HFNC therapy in the general pediatrics ward, pediatric intensive care unit, and the pediatric emergency department were included. High‑flow nasal cannula success was achieved for 116 (88.5%) patients. At 24 h, if both p‑ROXI and p‑ROXV values were above the cutoff point (≥ 66.7 and ≥ 24.0, respectively), HFNC failure was 1.9% and 40.6% if both were below their values (p < 0.001). At 48 h of HFNC initiation, if both p‑ROXI and p‑ROXV values were above the cutoff point (≥ 65.1 and ≥ 24.6, respectively), HFNC failure was 0.0%; if both were below these values, HFNC failure was 100% (p < 0.001).Conclusion: We observed that these parameters can be used as good markers in pediatric clinics to predict the risk of HFNC failure in patients with acute respiratory failure. What is Known: • Optimal timing for transitions between invasive and noninvasive ventilation strategies is of significant importance. • The complexity of data requires an objective marker that can be evaluated quickly and easily at the patient's bedside for predicting HFNC failure in children with acute respiratory failure. What is New: • Our data showed that combining p‑ROXI and p‑ROXV can be successful in predicting HFNC failure at 24 and 48 h of therapy.

A Randomized Trial of High‑Flow Oxygen Therapy in Infants with Bronchiolitis.

Franklin D, Babl FE, Schlapbach LJ, et al. A Randomized Trial of High‑Flow Oxygen Therapy in Infants with Bronchiolitis. N Engl J Med. 2018;378(12):1121‑1131. doi:10.1056/NEJMoa1714855



BACKGROUND

High‑flow oxygen therapy through a nasal cannula has been increasingly used in infants with bronchiolitis, despite limited high‑quality evidence of its efficacy. The efficacy of high‑flow oxygen therapy through a nasal cannula in settings other than intensive care units (ICUs) is unclear.

METHODS

In this multicenter, randomized, controlled trial, we assigned infants younger than 12 months of age who had bronchiolitis and a need for supplemental oxygen therapy to receive either high-flow oxygen therapy (high-flow group) or standard oxygen therapy (standard-therapy group). Infants in the standard-therapy group could receive rescue high-flow oxygen therapy if their condition met criteria for treatment failure. The primary outcome was escalation of care due to treatment failure (defined as meeting ≥3 of 4 clinical criteria: persistent tachycardia, tachypnea, hypoxemia, and medical review triggered by a hospital early-warning tool). Secondary outcomes included duration of hospital stay, duration of oxygen therapy, and rates of transfer to a tertiary hospital, ICU admission, intubation, and adverse events.

RESULTS

The analyses included 1472 patients. The percentage of infants receiving escalation of care was 12% (87 of 739 infants) in the high-flow group, as compared with 23% (167 of 733) in the standard-therapy group (risk difference, -11 percentage points; 95% confidence interval, -15 to -7; P<0.001). No significant differences were observed in the duration of hospital stay or the duration of oxygen therapy. In each group, one case of pneumothorax (<1% of infants) occurred. Among the 167 infants in the standard-therapy group who had treatment failure, 102 (61%) had a response to high-flow rescue therapy.

CONCLUSIONS

Among infants with bronchiolitis who were treated outside an ICU, those who received high-flow oxygen therapy had significantly lower rates of escalation of care due to treatment failure than those in the group that received standard oxygen therapy. (Funded by the National Health and Medical Research Council and others; Australian and New Zealand Clinical Trials Registry number, ACTRN12613000388718 .).

Reduced intubation rates for infants after introduction of high‑flow nasal prong oxygen delivery.

Schibler A, Pham TM, Dunster KR, et al. Reduced intubation rates for infants after introduction of high‑flow nasal prong oxygen delivery. Intensive Care Med. 2011;37(5):847‑852. doi:10.1007/s00134‑011‑2177‑5



PURPOSE

To describe the change in ventilatory practice in a tertiary paediatric intensive care unit (PICU) in the 5‑year period after the introduction of high‑flow nasal prong (HFNP) therapy in infants <24 months of age. Additionally, to identify the patient subgroups on HFNP requiring escalation of therapy to either other non‑invasive or invasive ventilation, and to identify any adverse events associated with HFNP therapy.

METHODS

The study was a retrospective chart review of infants <24 months of age admitted to our PICU for HFNP therapy. Data was also extracted from both the local database and the Australian New Zealand paediatric intensive care (ANZPIC) registry for all infants admitted with bronchiolitis.

RESULTS

Between January 2005 and December 2009, a total of 298 infants <24 months of age received HFNP therapy. Overall, 36 infants (12%) required escalation to invasive ventilation. In the subgroup with a primary diagnosis of viral bronchiolitis (n = 167, 56%), only 6 (4%) required escalation to invasive ventilation. The rate of intubation in infants with viral bronchiolitis reduced from 37% to 7% over the observation period corresponding with an increase in the use of HFNP therapy. No adverse events were identified with the use of HFNP therapy.

CONCLUSION

HFNP therapy has dramatically changed ventilatory practice in infants <24 months of age in our institution, and appears to reduce the need for intubation in infants with viral bronchiolitis.