What Do You Mean a High Flow Nasal Cannula - PowerPoint PPT Presentation

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What Do You Mean a High Flow Nasal Cannula

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Guerero Study: Vapotherm vs NRB. 14 Male patients: 12 COPD, 2 Pulmonary Fibrosis ... method for providing respiratory support for the spontaneously breathing patient ... – PowerPoint PPT presentation

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Title: What Do You Mean a High Flow Nasal Cannula


1
What Do You Mean a High Flow Nasal Cannula?
  • Presented By
  • Michael Portzline BS, RRT, CPFT
  • Sales Manager, Medical Support Products, Inc.
  • Diane Tattersall, RRT
  • Clinical Product Specialist, Vapotherm, Inc.

2
Low Flow and High Flow Defined
  • Low Flow- delivers 100 oxygen (diluted by room
    air) at flows that are less than the patients
    inspiratory flowrate
  • High Flow-delivers a prescribed gas mixture at
    flowrates that exceed patient demand
  • Reference AARC CPG Oxygen Therapy for Adults
    in the Acute Care Facility

3
This is not the right kind of high flow or
humidification?
4
Oxygenation Where have we come from?
5
Oxygenation Where have we come from?
  • Nasal Cannula- up to 6-8 lpm with inadequate
    humidification and fluctuation of FiO2
  • High flow venturi mask to deliver up to 50
    without adequate humidification and often wont
    meet demand
  • Partial or non-rebreathing masks with poor
    tolerance and inadequate humidification and
    varying FiO2
  • Introduction of CPAP or BiPAP systems to assist
    with oxygenation but with poor deliveries of
    accurate FiO2 and no true account for heat and
    humidification
  • When all else fails-intubation and ventilation

6
Humidification Where have we come from?
7
Other Ways to Humidify
8
Humidification Where have we come from?
  • Bubble Humidifiers that produce little to no true
    humidification
  • Aerosol generators that can cause more infection
    and irritation risks than humidification
  • Heated humidifiers that often harbor infection
    and require some form of drainage from rainout
  • HME devices that work only if your patient can
    provide their own adequate humidification without
    secretion problems
  • Mist tents that are harder to keep the patient in
    than humidify and vary in FiO2 delivery

9
There is Good News
  • There is a better product to provide accurate
    oxygenation and complete humidification to your
    patients!

10
The New Way to Oxygenate and Humidify Vapotherm
2000i
11
What is Vapotherm?
  • Vapotherm is the power of flow
  • Its patented membrane technology makes flows of
    1-40 lpm possible
  • It delivers water vapor at BTPS with almost 100
    relative humidity
  • Temperature range from 33-43 degrees Celcius

12
Delivery Thermodynamics
  • Triple Lumen delivery tube
  • Minimal heat loss
  • Short nasal cannula

13
The Vapor Transfer Cartridge
  • Patented vapor-transfer technology
  • Allows molecular vapor to pass without direct
    contact between delivery gas water
  • Filters at 0.01 micron- Tested against
    Brovindimonus Diminuta- Nelson Study
  • Humidifies gas up to 55 mg/L/H2O

14
Humidity vs Temperature
Water content of air at 100 relative humidity
15
Vapotherm Operation
Water Reservoir
Vapor Transfer Cartridge
Water Heater
Water Pump
Heated Delivery Tube
16
The Simple Message
The gas is saturated and warmed to body
temperature, therefore the patients airway is
not cooled or dried Flow does not create high
airway pressure .Therefore, high flow is easily
tolerated.
17
Areas of Use
  • ICU
  • Emergency
  • PICU
  • NICU
  • Pulmonary Rehab
  • Post Surgical Care
  • LTAC
  • Homecare

18
Clinical Applications
  • COPD
  • Pulmonary Fibrosis
  • CHF
  • Asthma
  • Rhinitis, Sinusitis
  • Respiratory Muscle Fatigue due to increased WOB
  • Croup, Epiglottitis
  • Cystic Fibrosis
  • Body core rewarming
  • Post Extubation- adult and infant
  • NICU- alternative to NCPAP
  • Mucociliary Clearance and Airway Irritation

19
Indications For Use
  • Any patient who is non-compliant or not
    clinically improving with conventional high-flow
    mask therapy.
  • Patients requiring supplemental heat humidity
    for artificial airways
  • Post extubation support or weaning from NPPV
  • Spontaneously breathing newborns who are
    requiring supplemental oxygen therapy who are
    failing conventional modalities. It has been
    used in place of NCPAP.

20
High Flow Setup
21
High Flow Applications 5-40 lpm
Winning By A Nose Abstract by John Walsh CRT,
Northwest Community Hospital, Arlington Heights,
IL
Advance for Respiratory CarePractitioners April
22, 2002
22
Treatment of Acute Hypoxia in CHF
  • 10 hypoxic patients, receiving O2 by
    non-rebreather mask at 15 lpm. Treated in
    emergency room with Vapotherm at 20 - 40 lpm 100
    O2 by nasal cannula.
  • Recorded
  • Respiratory rate (0, 15, 30 min)
  • Heart rate (0, 10 min)
  • SpO2 (0, 10 min)

23
CHF- Oxygen Saturation
24
CHF - Respiratory Rate
25
Melanie Guerrero, MD Walter Reed Medical Center,
Washington DC
Vapotherm Can Be as Effective as Non-Rebreather
Systems for Oxygen Delivery
October 2003 Issue of Chest
26
Guerero Study Vapotherm vs NRB
  • 14 Male patients 12 COPD, 2 Pulmonary Fibrosis
  • Baseline ABG and at 60 min. after administration
    of device
  • Vapotherm run at 40 lpm, NRB at 100
  • PaO2 increased from 68 to 389 with NRB and from
    68 to 375 with Vapotherm
  • PCO2 or pH unaltered
  • Conclusion Vapotherm as effective as NRB and
    allows more flexibility to the patient

27
Vapotherm in Respiratory Insufficiency
  • Lesley Manning, RRT, Memorial Health University
    Medical Center, Savannah, Georgia
  • Respiratory Care, November 2004
  • Post Pneumonectomy patient with post-op pulmonary
    edema, decreased SaO2, increased RR and dyspnea
  • Aerosol mask to NRB with no change
  • Placed on Vapotherm (20 lpm) within 15 min FiO2
    decreased to 40, normalized RR and improved
    dyspnea. Weaned to traditional NC in 48 hours

28
Is it CPAP?
Pharyngeal pressure recordings from normal
subject at 0, 20 and 36 lpm nasal air flow.
At flow rates greater than 20 lpm, pharyngeal
pressure is positive even during inspiration.
Mean airway pressure increases only slightly, but
there may be a significant level of PEEP at the
highest flow rates.
29
Nasal flow and inspiratory work
Tracheal pressure recorded via tracheal cannula.
The shaded area was integrated to calculate
inspiratory work.
Inspiratory work at nasal flow rates from 10 to
36 lpm
30
Oxygen Delivery with Vapotherm without a Blender
31
Tiep Study
High Flow Nasal Oxygen vs. High Flow Mask
Oxygen Tracheal O2 Concentrations Using a Head
Extension Airway Model Published in Respiratory
Care Journal September, 2002 Brian Tiep, M.D.
Mary Barnett, RN
32
Tiep Barnett Introduction
  • The non-rebreather mask has been the standard for
    high flow O2. However, it is not always reliable
    in providing a target FIO2 and it limits patient
    comfort and ability to eat and communicate.
  • Recently, Vapotherm has developed a high flow
    oxygen delivery system in which the oxygen is
    warmed and humidified providing comfortable
    nasal flows up to 40 L/m.
  • The present study was designed to measure oxygen
    concentrations achievable via Vapotherm versus
    the mask and to trace the delivery flow through a
    model of the upper airways.

33
Tiep Barnett Methods
  • An upper airway head extension model was used to
    trace flow of ultrasonic mist and measure
    tracheal gas exchange. Breathing through the
    models mouthpiece located at the tracheal
    junction, enables tracheal gas concentrations to
    be measured. Also, by following the ultrasonic
    mist we were able to trace flow patterns in the
    upper airways.
  • We measured O2, CO2 and air-flow in a normal
    subject breathing consistent and controlled
    breaths at a rate of 20 breaths/min with the
    model wearing the nasal cannula vs mask. O2 was
    delivered at 10, 15, 20, and 30 L/m through each
    device.

34
Tiep Barnett Results O2 Storage
  • High mask flow, impeded by pressure at the mouth
    - stores less O2 in the upper airways during
    exhalation
  • High nasal flow, unimpeded at mouth, fills the
    upper airways storing O2 during exhalation

35
Ultrasonic Flow NC vs. Mask
36
Tiep Barnett Results FiO2
  • Peak FIO2 as measured at the beginning of
    inspiration via nasal cannula and mask.

FIO2
30
20
15
10
N M
N M
N M
N M
37
Tiep Barnett Conclusions
Conclusions High flow nasal cannula delivery is
more efficacious than the non-rebreather mask at
equivalent flows, due to O2 storage in the upper
airways during exhalation poised for delivery
upon the next inhalation in addition to the
continuous supply flow. High flow nasal O2 can
be an effective option for patients with high
flow requirements. Clinical studies are
recommended to evaluate the impact of high flow,
warmed and humidified O2 following extubation,
during sleep, and in the management of
exacerbations.
38
Key Reference Studies (Hi Flow)
  • Tiep Barnett, High flow nasal cannula vs high
    flow mask, Respiratory Care Journal. Proved nasal
    cannula as good or better in measured FiO2 vs non
    re-breather mask.
  • Malinowski, Oxygen concentrations via nasal
    cannula at high flows, Respiratory Care Journal.
    Validated Vapotherm system as a high flow system
    in O2 delivery
  • Walsh, Winning By a Nose, Advance for RTs, 8 out
    8 patients presented in the Emergency Room
    produced significant improvements in O2 sats
    within 10 minutes, with improved patient comfort
    and a fall in breathing rate.
  • Guerero, Vapotherm Can Be as Effective as NRB in
    Delivery of High Flow Oxygen, Chest. Vapotherm as
    effective as NRB
  • Additional studies are published on the web site
    www.vtherm.com

39
Low Flow Setup
40
Low Flow Application (1-8 lpm)
  • Existing users/clinical community requested that
    Vapotherm develop a low flow system to provide
    heat, humidity and flow for NICU use
  • 10 of all births require breathing assistance
  • Trend is towards moderate flows via cannula vs.
    long term NCPAP
  • Deficit in current technology that will
    adequately heat and humidify gases safely and
    effectively in the NICU.

41
Low Flow Application
  • Delivers flows between 1-8Lpm via Nasal Cannula
  • Temperature between 33-43C
  • 95-100 constant humidity delivered to patient
  • Interfaces with Premie (lt700 grams), Neonate
    (700-1100 grams), and Infant (gt1100 grams)
    cannulas

42
NICU/Nursery Indications
  • Blood tinged secretions or upper airway trauma
    due to moderate flows through a nasal cannula
  • Prevention of potential facial trauma or other
    contraindications associated with NCPAP
  • Shortening weaning cycle for spontaneously
    breathing infants who are not tolerating NCPAP

43
Shyan Sun, M.D. and Robert Tero, RRT, Saint
Barnabus Medical Center, Livingston, NJ
  • Safety and Efficacy of the Vapotherm 2000i in
    the Neonatal Population
  • Abstract in the November 2004 Issue of the
    Respiratory Care Journal

44
Sun Tero
  • Looked at 109 neonates on Vapotherm from
    2002-2003 (2070 days or 5.7 years of therapy time
    equiv)
  • Babies weighing from under 500g to over 1500g
  • Average time of Vapotherm 30 days in 2002 and 18
    days in 2003
  • Vapotherm used either as primary treatment for
    respiratory distress in lieu of NCPAP or in post
    extubation in place of NCPAP
  • Results found no evidence of barotrauma, CPAP
    belly, nosocomial infection or nasal plugging
  • No nasal trauma in flows between 2-8 lpm (nasal
    cannula diameter is 2 mm)
  • Conclusion Vapotherm is a safe and effective
    adjunct to support infants with respiratory
    compromise

45
Key Reference Studies (Low Flow)
  • Sun Tero, Safety and Efficacy of the Vapotherm
    2000i in the Neonatal Population in Respiratory
    Care Journal. Proved that Vapotherm was a safe
    and effective therapy for babies with respiratory
    compromise.
  • Walsh, Comparison of Vapotherm 2000i with a
    bubble humidifier for humidifying flow through an
    infant nasal cannula in Respiratory Care Journal.
    Proved that the Vapotherm was superior to a
    bubble humidifier in preventing water deficit.
  • Sanchez Sabato, Very High Flow Nasal Cannula-
    Alternative to NCPAP in Select ICN Patients? In
    Respiratory Care Journal. Proved that in 7
    babies, the vapotherm was better tolerated with
    better results than NCPAP.
  • Additional studies are published on the web site
    www.vtherm.com

46
Case Study CMC Scranton Baby P
  • History 26 week, 942 g male born to a 22 yr
    old, single, white primipara who was GBS positive
    and treated with steroids and antibiotics prior
    to delivery. (Ruptured membranes since 18 wk)
  • Early Presentation Born via caesarean for
    bleeding due to ruptured placentae. Baby P
    presented with respiratory distress secondary to
    hypoplastic lungs and anemia secondary to
    abruptio placentae.
  • Treatment Course First Week
  • Conventional ventilation with SIMV and 90-100
    oxygen
  • Antibiotics
  • Curosurf (3 doses)
  • Cardioechogram revealed patent ductus arteriosus
  • Treatment Course Second Week
  • HFOV
  • Indomethacin for PDA
  • Vancomycin, Cefotaxime for positive blood and
    sputum cultures
  • Received multiple blood and platelets
    transfusions for anemia

47
Case Study CMC Scranton Baby P
  • Treatment Course Cont
  • HFOV till day 23 then returned to conventional
    vent
  • Continued on antibiotics and antifungals
  • Nutrition supported by hyperal and breast milk
  • Tranferred to CHOP on day 38 for ligation of PDA
  • While at CHOP received HFOV and nitric due to
    poor oxygenation
  • Also received chronic diuretic and bronchodilator
    therapy
  • Tranferred back to CMC after 47 days at CHOP with
    poor prognosis for life
  • Family informed, baptized
  • Extubated and placed on CPAP on day 115 due to
    desaturations and presumed ETT blockage with no
    clinical improvement
  • Placed on Vapotherm at 6 lpm and 86 FiO2,
    Immediately began to show clinical improvement.
    Began to interact with mother, received both
    physical and occupational therapy.
  • Discharged to home at 172 days on the Vapotherm
    at 5 lpm
  • Still alive and residing in a Pediatric Care
    Facility in PA

48
Miracle Baby Lucas Goes Home
Copied from Vapotherm Customer Newsletter, March
2005
49
Other Vapotherm Setups
  • Humidified trach collar or mask therapy
  • Homecare Setup
  • 25 lpm compressor
  • carry stand
  • titration wye for additional oxygen via
    concentrator or liquid O2 system

50
What about Other High Flow Devices
The Salter Labs high-flow cannula and humidifier
combination (Courtesy Salter Labs, Arvin,
California).
Fisher Paykel MR850 Humidification Systemwith
high flow NC
Hudson The Comfort Flo Humidification system
51
Conclusions
  • Vapotherm is a safe and effective method for
    providing respiratory support for the
    spontaneously breathing patient
  • The only FDA cleared device for providing high
    flows to neonates through a cannula
  • The Vapotherm is a device with easy setup and
    operation that provides patient comfort and
    compliance through 100 relative humidity at body
    temperature
  • In terms of Safety
  • Non-invasive flow device
  • No heated wire circuits and no water loss
  • Filter technology provides a highly effective
    barrier to infection
  • Eliminates nasal breakdown, thickening of
    secretions and other adverse effects associated
    with pressure devices
  • Vapotherm makes for happier and healthier
    patients

52
Who Would You Rather Have as a Patient?
NCPAP Baby!
Vapotherm Baby!
53
Post Test
  • True or False (Please Circle Correct Answer)
  • 1. The reason we have been unable to use high
    flows from a nasal cannula in the past has
  • been due to inadequate ways of humidifying.

    True or False
  • 2. The vapor transfer cartridge is designed to
    filter bacteria as small as 3 microns in size.
    True or False
  • 3. The adult high flow cartridge has a range of
    flow between 5-40 lpm.
    True or False
  • 4. The blocked tube alarm will occur if flow is
    lost to the unit.
    True or False
  • 5. One indication that you have a bad cartridge
    is constant bubbling in the water bag.
    True or False
  • 6. The cartridge inside the Vapotherm unit must
    be replaced between patients.
    True or False
  • 7. Weaning FiO2 not flow should be the first step
    in weaning from vapotherm.
    True or False
  • 8. In studies comparing the Vapotherm to other
    high flow devices, the Vapotherm
  • showed equal to or higher SpO2s.

    True or
    False
  • True or False (Please Circle Correct Answer)
  • 1. The reason we have been unable to use high
    flows from a nasal cannula in the past has
  • been due to inadequate ways of humidifying.

    True or False
  • 2. The vapor transfer cartridge is designed to
    filter bacteria as small as 3 microns in size.
    True or False
  • 3. The adult high flow cartridge has a range of
    flow between 5-40 lpm.
    True or False
  • 4. The blocked tube alarm will occur if flow is
    lost to the unit.
    True or False
  • 5. One indication that you have a bad cartridge
    is constant bubbling in the air release cap.
    True or False
  • 6. The cartridge inside the Vapotherm unit must
    be replaced between patients.
    True or False
  • 7. Weaning FiO2 not flow should be the first step
    in weaning from vapotherm.
    True or False
  • 8. In studies comparing the Vapotherm to other
    high flow devices, the Vapotherm
  • showed equal to or higher SpO2s.

    True or
    False
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