High Flow Therapy (HFT) in the Neonatal Population

High Flow Therapy (HFT) in the Neonatal Population

Agenda

• HFT Clinical Review

• Precision Flow® Overview

• Precision Flow® Demonstration

• Q & A

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

Flow First™

1-8Lpm

4

HFT Clinical Review

55

Continuum of Care: Old Model

5

General 02Therapy

Acu

ity

Choice of Therapy

General 02Therapy

Bi-Level

MechanicalVentilation

CPAP

Rescue Weaning

Bi-LevelCPAP

Continuum of Care: New Model

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.

88

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


●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


Inspiratory Gas Conditioning

●Williams et al, 1996, Crit Care Med 24(11): 1920-9

Why BTPS?

Flush Dead Space & Support Inspiration

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

Pulmonary Physiology and Dead Space

Pulmonary Physiology and Dead Space

Pulmonary Pathophysiology

Pulmonary Pathophysiology

3

● 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

What About Pressure?

●Pressure determined by primarily by leak (Kahn at al, Pediatr Res 2007)- Infant anatomical size – passage through nasopharynx- Size ratio between nares and prongs – back flush

●Inadvertent CPAP with conventional nasal cannula (Locke et al, Pediatrics 1993) - Smaller (2 cm OD) prongs negate pressure

- Occluded only 50% of the nares- Larger (3 cm OD) prongs generate pressure

●Intentional CPAP with conventional nasal cannula (Sreenan et al, Pediatrics 2001)- Snug prongs- Mouth held closed- Up to 8 cmH2O with 3 lpm

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Mechanisms by Application

Neonataes /Infants

Oxygen Flush Humidity Mild Pressure

IRDS

RSV

Brochiolitis (also seen in

Peds)

HFT DOES NOT TREAT A DISEASE, THE MECHANISMS TREAT SYMPTOMS

Here are a few general 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?

What Else About Pressure?

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 Minimal Flow

Extrapolated from equations in Mosby’s Respiratory Care Equipment, 7th Ed.

Calculating Flows

Tidal Volume 4-6 ml/kg

Neonates: 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: Infants

Inhalation:

RR = 60 - 70+

Tidal Volume = 4-6 ml/kg

Inspiratory time fraction = 0.3 – 0.5 (<0.3 sec)

< 2 LPM (in most cases)

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Exhalation:

Expiratory time = < 0.6 sec

Extrathoracic dead space = 2.6 ml/kg

Inhalation flow is NOT sufficient

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

●Dysart et al. - Respir Med 2009;103:1400-5 - The combination of flow dynamics and gas conditioning offer a number of mechanisms

that impart impressive clinical outcomes

●Woodhead et al. - J Perinatol 2006;26:481-5 - Showed that the nasal mucosa is preserved because of the Vapotherm conditioning and

this allowed these authors to avert intubation.

●Holleman-Duray et al. - J Perinatol 2007;27:776-81 - At Loyola showed they were able to extubate from greater vent setting by using

Vapotherm. There is some mild pressure, and a growing number of studies have confirmed this.

●Saslow et al. - J Perinatol 2006;26:476-80 - were they showed the distending pressure to be not more than with a CPAP of

6. But, you can’t compare HFT directly to CPAP because there are other mechanisms at play such as the elimination of dead space.

●Lampland et al. - J Pediatr 2009;154:177-82 - Compared to a CPAP of 6cmH20 the babies were doing just as well with high

HFT setting that generated just about half of the airway pressure.

More Clinical References

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: It All Comes Down To This

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: 1-8 Lpm

Indications:● Spontaneously breathing patients who are requiring supplemental

oxygen therapy

● Any patient who is on oxygen that is: 1. Not compliant, 2. not improving, 3. Or has an increase in work of breathing

● Post extubation support or weaning from NCPAP

● Patients requiring supplemental heat & humidity for artificial airways

Contraindications:

●Patients not spontaneously breathing●Patients that have a deviated septum

Q & A

Documents

High Flow Therapy (HFT) in the Neonatal Population