P O I N T

by Armstrong Medical

Peri-Operative Insufflatory Nasal Therapy

Helping prevent peri-operative pulmonary complications

Clinical Summary

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• High BMI• Emergency intubations• Difficult intubations• Critically ill

HIGH RISK PATIENTS

Securing an artificial airway remains a hazardous procedure during the induction of anaesthesia.

There is a positive correlation between obesity and difficult intubation, while critically ill patients can desaturate in as little as 30 seconds (1).

Pre-oxygenation is delivered to prolong the apneic window, during which nitrogen is washed out of the lungs and alveoli are filled with oxygen.

Studies suggest 3 minutes pre-oxygenation with 100% oxygen can result in absorption atelectasis of up to 5% lung volume (2) .

POST-OP RECOVERY

OPERATING ROOMS

Pre-op

Hypoxia; a peri-operative riskPulmonary complications significantly contribute to peri-operative morbidity, mortality and increased hospital stay (9).

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Patients with respiratory disease have an increased chance of developing complications peri-operatively.

For certain patients, regional anaesthesia supplemented by sedation is chosen to avoid the pulmonary complications of general anaesthesia (3).

Sedation does have risks, notably respiratory depression (4). All sedatives and opioids have the potential to depress central hypercapnic and/or peripheral hypoxemic drives (5).

Bronchoscopy is one of the most common procedures performed under sedation. In addition to the effects of sedation, the bronchoscope also takes up to 10–15% of the tracheal lumen, resulting in increased work of breathing and decreased PaO2

(6).

Post-operative pulmonary complications (PPC) are linked to increased length of stay and mortality.

Post-operative atelectasis occurs in 90% of patients and accounts for as much as 20% lung volume (2).

Anaesthesia and surgery compromise optimal secretion clearance. The ability to generate expiratory forces is hindered in the post-op

patient by reduced tidal volume caused by atelectasis or pain.

Obese patients are further susceptible to PPC as they consume approximately 25% more oxygen than non-obese subjects, lung compliance is decreased by approximately 25% and FRC reduced by approximately one third (7).

POST-OP RECOVERY

OPERATING ROOMSIntra-op

Post-op

HIGHEST RISK OF PPC

Cardiac 39.6%

Abdominal 7.2%Thoracic 31.4% (8)

Cardiac, Thoracic and Abdominal surgery present the highest risk of PPC (8).

Adjustable flow rates

Integrated O2 analayser

Ultra-PEP therapy

AquaVENT®Humidification

Adjustable FiO2

POINT Features

AquaNASE® high flow cannula

What’s the POINT?Pulmonary complications may present at any stage of the patient’s peri-operative experience. Appropriate interventions can minimise these risks in the pre, intra and post-operative periods (9).

POINT delivers humidified high flow therapy to support your patient during the peri-operative period.

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Why choose POINT?

Pre-op

• Increased and accurate pre-oxygenation

• Increased apneic window for management of difficult airways

Intra-op

• Apneic oxygenation during ENT surgery

• Respiratory support during procedural sedation

Post -op

• Reversal of anaesthesia induced atelectasis

• Improved secretion clearance

POINT Applications

READY TO USE

• POINT system does not require decontamination between patients

• POINT starter Flowkit protected by BioCote®, for rapid set up when required

• Rapid heat humidification chamber, achieves optimal temperature quicker

• Portable for use during transport

IMPROVED CONTROL

• Accurate FiO2, higher flow rates reduce dilution from room air

• Adjustable FiO2, reducing concerns over O2 toxicity or absorption atelectasis

• Adjustable flow rates for nasal cannula (60L/min) and face mask CPAP (>60L/min)

• Humidification improves patient comfort and secretion clearance

• Ultra-PEP aids improved FRC and secretion clearance5

Alveolar recruitment

Studies have demonstrated variable PEEP is achieved (2-7cmH2O) with Nasal High Flow (NHF) (13). For some patients variable PEEP may not be adequate and continuous pressure is required.

Continuous and measured PEEP may be achieved using a combination of NHF and Ultra-PEP or mask CPAP.

Mask CPAP treats or prevents atelectasis by delivering a flow rate equal to the patient’s Peak Inspiratory Requirement (PIR), maintaining the desired pressure throughout the respiratory cycle.

First described in 1959 as Aventilatory Mass Flow (AVMF) (11) this physiological phenomenon describes apneic oxygenation.

During apnea, external respiration ceases. Diffusion of oxygen from alveoli to capillaries (a) continues as normal (250mL/min) while CO2 from the capillaries into the alveoli decreases to 20mL/min (b).

The net effect is a decrease in lung volume and alveolar pressure. This pressure gradient creates aventilatory mass flow from the nasopharynx to the alveoli in the presence of a patent airway (12).

Apneic oxygenation

Physiology of POINTPOINT provides 5 physiological benefits to support your patient during the peri-operative period.

• Apneic oxygenation• Alveolar recruitment• Maintained mucocillary function• Nasopharyngeal dead space washout • Accurate FiO2

a

b

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High flow oxygen therapy delivered via nasal prongs can reduce the patient’s dead space by up to one third in adults.

This decreases rebreathing of CO2 and improves alveolar ventilation for patients in which tidal volume has decreased (10).

Nasopharyngeal dead space washout

Tv AvRR Mv

500ml 12 6000ml 4200ml

Tv AvRR Mv

150ml 40 6000ml

Deadspace

150ml

Deadspace

150ml

Alveolar ventilation in healthy patients

Alveolar ventilation in respiratory distress

Tv RR Mv

150ml 40 6000ml 2000ml

Deadspace

100ml

Av

Alveolar ventilation in nasal high �ow

Heated and humidified oxygen therapy ensures patient comfort and compliance to achieve the physiological benefits at higher flow rates.

Post-operatively, humidification plays a crucial role in maintaining effective secretion clearance, preventing mucous plugging, atelectasis, infection and subsequent complications.

Maintained mucociliary function

Flow rates closer to the patient’s PIR reduce entrainment of room air and the subsequent dilution of FiO2

(14).

The POINT system allows adjustment of FiO2 to address concerns of absorption atelectasis associated with higher oxygen concentrations.

Accurate FiO2

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PEEP versus CPAP; what’s the difference?

PEEP & CPAP are often mistaken as one and the same therapy. Defining the difference helps us understand the benefits and limitations of each therapy.

POINT Plus(CPAP)

• PAP is any pressure applied to the airways above atmospheric pressure.

• PEEP refers to the positive airway pressure at the end of expiration only. During inspiration the pressure will drop below the PEEP level.

• CPAP refers to the PEEP pressure being maintained during the entire respiratory cycle (inspiration and expiration).

• To prevent a drop of pressure during the respiratory cycle the flow rate must exceed the patient’s peak inspiratory flow rate. In respiratory distress PIR may range from 60-120L/min.

NORMAL BREATHING

NHF PEEP

CPAP

1cmH2O

2cmH2O

5cmH2O

7cmH2O

10cmH2O

TIME

PRES

SURE

-2cmH2O

Post-operative therapiesStudies have demonstrated variable PEEP (2-7cmH2O) can be achieved with Nasal High Flow (13). Variable factors include flow rate, size of prongs in relation to the nares and mouth or nose breathing. The PEEP is pressure due to the resistance generated by the continuous administration of high flow of gas (60L/min).

For some patients variable PEEP provided by NHF may not be adequate and high flow CPAP with a face mask is required.

COUSSA M et al (16) observed in morbidly obese patients that 10cmH2O of CPAP during the induction of anaesthesia decreased the amount of atelectasis.

A study of 200 patients by SQUADRONE V et al demonstrated CPAP reduced post-op rates of intubation, ICU length of stay and pneumonia rates (15).

Armstrong Medical’s POINT and FD140 systems provide quick and simple escalation from NHF (PEEP) to full mask CPAP.

Atelectasis is present in 90% of patients post-op and is associated with increased rates of post-operative pulmonary complications. Atelectasis promotes bacterial growth in the lung (15) increasing the risk of post-operative pneumonia.

Compression of lung tissue -There is a correlation between body mass index (BMI) and atelectasis, with morbid obesity accompanied by an increased amount of atelectasis.

Patient position - The resting lung volume (functional residual capacity, FRC) is reduced by 0.7-0.8L by changing the body position from upright to supine with a further decrease by 0.4-0.5L with the induction of general anaesthesia.

Absorption atelectasis behind closed airways - A drop in FRC promotes closure of airways. Gas will be absorbed in alveoli behind the closed or intermittently closed airways, eventually leading to collapse.

Reduction in alveolar surfactant due to the lack of intermittent deep breaths during mechanical ventilation. Decreased surfactant results in reduced alveolar stability and may contribute to airway closure (3).

Mucous plugging - Anaesthesia may adversely affect the lungs’ defence mechanisms, impairing the ability to cough and suppressing mucociliary clearance, leading to post-operative mucous plugging.

Causes of atelectasis

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Codes

Ordering InformationCode Description Box Qty

AMHO1509/030 Heated Humidified Oxygen System complete with AquaNASE® Nasal Cannula and bacterial viral breathing filter

10

AMHO1509/008 AquaVENT® Heated Humidified Oxygen System complete with AquaNASE® Nasal Cannula 10

AMPT1001/002 Ultra-PEP Exerciser with manometer 20

AMCPUK01258 CPAP adaptor kit 20

AMNS1004 AquaNASE® Nasal High Flow System (4mm) 30

AMNS1005 AquaNASE® Nasal High Flow System (5mm) 30

AMNS1006 AquaNASE® Nasal High Flow System (6mm) 30

*Pressure respiratory rate and apnoea alarms

60 min internal battery life

Max flow rate CPAP 140L/min, NHF60l/min

POINT Range

*Optional pressure measurement

Integral digital oxygen display

120L/min flow

MaxVenturiTM 120

FD140

Both MaxVenturiTM 120 and FD140 are supplied

with AquaVENT® heater humidifier

AquaVENT® heater humidifier*For transition from NHF to CPAP, adequate flow rates and pressure measurement are essential.

1. GREGORETTI C, PELOSI P, (2010) A physiologically oriented approach to the perioperative period: the role of the anaesthesiologist, Best Practice & Research Clinical Anaesthesiology 24 (2), vii-viii

2. MORAN C, KARALAPILLAI D, DARVALL J, NANUAN A, (2014) Is it time for apnoeic oxygenation during endotracheal intubation in critically ill patients, Critical care and resuscitation 16 (3), 233-5

3. HEDENSTIERNA G, EDMARK L, (2010) Mechanisms of atelectasis in the perioperative period, Best Practice & Research Clinical Anaesthesiology 24, 157-169

4. MERCER M, (2000) Anaesthesia for the patient with respiratory disease, Update in Anaesthia 12, 1-3

5. HÖHENER D, BLUMENTHAL S, BORGEAT A, (2008) Sedation and regional anaesthesia in the adult patient, British Journal of Anaesthesia 100 (1), 8–16

6. BECKER DE, HAAS DA, (2007) Management of Complications During Moderate and Deep Sedation: Respiratory and Cardiovascular Considerations, Anesthesia Progress 54 (2), 59–69

7. DIAB S, FRASER JF, (2014) Maintaining Oxygenation Successfully with High Flow Nasal Cannula during Diagnostic Bronchoscopy on a Postoperative Lung Transplant Patient in the Intensive Care, Case Reports in Critical Care 198262

8. PELOSI P, GREGORETTI C, (2010) Perioperative management of obese patients, Best Practice & Research Clinical Anaesthesiology 24, 211–225

9. CANET J et al, (2010) Prediction of postoperative pulmonary complications in a population – based surgical cohort, Anaesthesiology 113, 1-6

10. MOLLER et al, (2015) Nasal high flow clears anatomical dead space in upper airway models, Journal of Applied Physiology 118, 1525–1532

11. BARTLETT R G et al, (1959) Demonstration of aventilatory mass flow during ventilation and apnea in man, Journal of Applied Physiology 4 (1), 97-101

12. PATEL A, NOUAEI SAR, (2015) Transnasal Humidified Rapid Insuflation Ventilatory exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways, Anesthesia 70, 323-329

13. PARKE et al, (2009) Nasal high flow therapy delivers low level positive airway pressure, British journal of Anaesthesia 103 (6), 886-90

14. GOTERA C, LOBATO D, PINTO T, WINCK JC, (2013) Clinical evidence on high flow oxygen therapy and active humidication in adults, Pneumologia 19(5), 217-227

15. SQUADRONE V et al, (2005) Continuous Positive Airway Pressure for Treatment of Postoperative Hypoxemia, JAMA, 293 (5), 589-595

16. COUSSA M et al, (2004) Prevention of Atelectasis Formation During the Induction of General Anesthesia in Morbidly Obese Patients, Anesthia Analgesia 98, 1491–5

References

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Distributed by:

Armstrong manufacture a complete range of disposable respiratory products

for anaesthesia and critical care applications. For supply of these products or any

product within the Armstrong range, please contact your local representative.

Armstrong Medical Wattstown Business Park Newbridge Road Coleraine BT52 1BS Northern Ireland T +44 (0) 28 7035 6029 F +44 (0) 28 7035 6875 E info@armstrongmedical.net W www.armstrongmedical.net

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