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 Experts on Air

Using HFOT outside critical care. Is it feasible?

Webinar #6
1. Using the HFOT guidelines 2. Optimizing HFOT settings 3. Monitoring during HFOT 4. Intubation in hypoxemic respiratory failure 5. HFOT in hypercapnic respiratory failure 6. HFOT outside critical care
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6.  Using HFOT outside critical care (Experts on Air)

Series 1, webinar 6: High flow oxygen therapy (HFOT)
HFOT outside of critical care
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.
35 minutes
EN
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1.  Using the HFOT guidelines

36 minutes
EN
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Video

2.  Optimizing HFOT settings

31 minutes
EN
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Video

3.  Monitoring during HFOT

37 minutes
EN
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4.  Intubation in hypoxemic respiratory failure

30 minutes
EN
Experts-Air_HFNC_Hypercapnic-respiratory-failure_youtube
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5.  HFOT in hypercapnic respiratory failure

31 minutes
EN

Q&A Webinar #6.

In my ICU, we performed nasal high flow in Covid-19 patients throughout all the consecutive surges in rooms without negative pressure without experiencing staff contamination. So the answer, in my opinion, is yes, nasal high flow can be performed in a room without negative pressure, provided staff is properly equipped with PPE.

(Editor's note: This question was interpreted as "What safety parameters should be observed when using HFOT outside of the ICU?"). Tthere is no definite answer to that question, because it depends on how far from the ICU nasal high flow is performed, how well the staff is trained to perform and monitor nasal high flow in patients with acute respiratory failure, if these patients will have continuous measurment of SpO2 or not, etc. Having said this, I believe FiO2 should be limited, and not exceed 60%; SpO2 should not be below 92-94% ; respiratory rate no greater than 25-28. if patients are out of one of these targets, then an ICU physician should be called to assess these patients  

I have no personal data or experience. My bias is that if there is no possiblity of electric supply, then it will be problematic to not have any humidification. If an external battery was available and it covered the entire flight time, then I would see no "technical" reasons why such a device could not be operated during a helictopter flight  (Editor's note: To our knowledge, there is currently no humidification device available that is approved for transport.)

The Rox index was established and validated in adult (over 18 yo) patients with pneumonia-related acute hypoxemic respiratory failure. It makes sense to apply it to younger patients whose physiological characteristics are similar to those of adult patients. I'm aware of at least one publication in which the Rox score was established in a pediatric population: 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​.

Several studies have shown that use of nasal high flow reduced the intubation rate in children admitted for respiratory failure due to 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/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​.

There is no similar data in adults, most probably because the clinical entity of bronchiolitis in adults is less defined and hence much less frequent.

Disclaimer

The contents of this page are for informational purposes only and are not intended to be a substitute for professional training or for standard treatment guidelines in your facility. The responses to the questions on this page were prepared by the respective webinar's speaker;  any recommendations made here with respect to clinical practice or the use of specific products, technology, or therapies represent the personal opinion of the speaker only, and may not be considered as official recommendations made by Hamilton Medical AG. Hamilton Medical AG provides no warranty with respect to the information contained ion this page and reliance on any part of this information is solely at your own risk.

Bibliografia

  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

Note

 

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.