heated humified high flow nasal cannula, does it have a rule in nicu routine care?
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Heated Humidified High-Flow Nasal Cannulae
(HHHFNC)does it have a place in
NICU routine work?
in the beginning, it was the flow
Heated Humidified High-Flow Nasal Cannulae -Flow
Bonnaire E: Inhalations of oxygen in the newborn. Arch Pediatr. 8:769 1891
by dr M Osama Hussein
Doctor Bonnaire, a French obstetrician, wrote the first article describing the use of oxygen for premature infants by Tarnier at 1889
by dr M Osama Hussein
1907 – A. Lane invented nasal catheter
1919 – L. Hill developed O2
tent
1920 - O2 therapy became routine for “sick
new born”
O2
Low flow systems
Nasal cannula
Nasopharyngeal cannula
High flow systems
Oxygen mask
Enclosure systemOxygen hood
Oxygen Liter/ minFLOW
1963• Patrick Bouvier Kennedy dies of respiratory distress
syndrome (RDS), 34 weeks gestation, birthweight 2100 gms.
1963• Maria Delivoria-Papadopoulos
•First successful ventilation of a preterm infant with hyaline membrane disease (Assisted ventilation in terminal hyaline
membrane disease. Arch. Dis. Child., 39:481-484, 1964
FiO2
Flow
Inspiratory pressure
End expiratory pressure
Timing
Rate
PARAMETERS OF VENTILATORS (keyboard of ventilation)
by dr M Osama Hussein
Free flow oxygen
Assisted ventilation
1. Positive pressure ventilation
Manual
Mechanical
2. CPAP
( FiO2 + Flow)
(FiO2 + Flow + Inspiratory pressure + End expiratory pressure + Time of inspiration+ Rate)
(FiO2 + Flow + End expiratory pressure)
Parameters of assisted ventilation
by dr M Osama Hussein
1963• Patrick Bouvier Kennedy dies of respiratory distress
syndrome (RDS), 34 weeks gestation, birthweight 2100 gms.
1963• Maria Delivoria-Papadopoulos
•First successful ventilation of a preterm infant with hyaline membrane disease (Assisted ventilation in terminal hyaline
membrane disease. Arch. Dis. Child., 39:481-484, 1964
1971GregoryUse of continuous positive airway pressure (CPAP) for respiratory distress syndrome (RDS)
by dr M Osama Hussein
CPAP Provided by G. Gregoryby dr M Osama Hussein
• Sreenan et al. (2001) found that a PEEP of 6 cmH2O could be reliable delivered to neonates using a high flow nasal cannula & that was proved to be useful in the management of apnea of prematurity
• Frey and Shann (2003) showed that nasal cannula flows greater than 0.5 lpm resulted in positive end-expiratory pressure (PEEP) when cannulas with a diameter of 3 mm were utilized
• Saslow et al. (2006) found that high flow nasal cannula delivered CPAP & was useful to reduce work of breathing in preterm infants
by dr M Osama Hussein
The use of high-flow nasal cannulae is an alternative means of providing noninvasive respiratory support to very preterm infants. Such cannulae deliver heated and humidified gas at flow rates of more than 1 liter per minute through small binasal prongs. Because high-flow nasal cannulae have a simpler interface with the infant and smaller prongs than nasal CPAP, the cannulae are perceived as easier to use, more comfortable for the infant, and advantageous for mother–infant bonding (Hough JL, et al, J Paediatr Child Health, 2012).
by dr M Osama Hussein
The use of high-flow nasal cannulae is increasingly popular for noninvasive respiratory support in neonatal intensive care units around the world (Manley BJ, et al, J Paediatr Child Health, 2012)
by dr M Osama Hussein
HHHFNC is a widely used modality in UK neonatal units. Its current use appears to be without clear criteria and mostly based on individual preference. Ojha S, et al, Acta Paediatr. 2013
by dr M Osama Hussein
The use of high-flow nasal cannulae is an increasingly popular alternative to nasal continuous positive airway pressure (CPAP) for noninvasive respiratory support of very preterm infants (gestational age, <32 weeks) after extubation. (Nath P, et al, Pediatr Int, 2010)
The efficacy of high-flow nasal cannulae is similar to that of CPAP as respiratory support for very preterm infants after extubation Manley, et al. N Engl J Med 2013)
by dr M Osama Hussein
Among infants ≥28 weeks' gestational age, HHHFNC appears to have similar efficacy and safety to nCPAP when applied immediately postextubation or early as initial noninvasive support for respiratory dysfunction. Yoder BA, et al. Pediatrics. 2013
HFNC can improve dyspnea and physiologic parameters in extubated subjects, including respiratory rate and heart rate when compared with conventional oxygen therapy. This device may have a potential role after endotracheal extubation. Rittayamai N, Respir Care. 2013
HHHFNC and NCPAP produced similar rates of extubation failure. Collins CL, et al, j peds.2012
by dr M Osama Hussein
HHHFNC resulted in significantly less nasal trauma in the first 7 days post-extubation than NCPAP and was most significant in infants <28 weeks of gestation. The use of protective dressings was not associated with decreased nasal trauma for infants on NCPAP. Collins CL et al, Eur J Pediatr. 2014
Unlike NCPAP, HHFNC does not seem to increase the risk of nasal trauma and appears to improve cost-effectiveness whilst producing otherwise equal respiratory and non-respiratory outcomes. Fernandez-Alvarez JR. Eur J Pediatr. 2013
by dr M Osama Hussein
There’s no difference in patient comfort with HHHFNC versus NCPAP. However, parents preferred HHHFNC, and during HHHFNC respiratory rate was lower than during NCPAP. Klingenberg C, Arch Dis Child Fetal Neonatal Ed. 2013
by dr M Osama Hussein
Increasing flow rates of HHHFNC therapy are associated with linear increases in NP pressures in bronchiolitis patients. Larger studies are needed to assess the clinical efficacy of HHHFNC therapy in bronchiolitis. Arora B et al, Pediatr Emerg Care. 2012
HFNP therapy has dramatically changed ventilatory practice in infants <24 months of age, and appears to reduce the need for intubation in infants with viral bronchiolitis. Schibler A, Intensive Care Med, 2011
by dr M Osama Hussein
High-flow nasal cannula used early in the development of pediatric acute respiratory insufficiency(ARI )is associated with a decreased the need for intubation and mechanical ventilation. Wing R et al, Pediatr Emerg Care. 2012
by dr M Osama Hussein
Implementation of the RAM Cannula guidelines resulted in a decrease in ventilator days, decrease in rate of endotracheal intubation, and length of stay (LOS) . RAM Cannula guidelines allow our PICU to standardize care and provide a comfortable interface for our patients. AAP, Shari Toomey, 2013
by dr M Osama Hussein
Nasal interfaces commonly used for NCPAP or NIPPV include short binasal prongs, naso-pharyngeal prongs, and nasal masks. These interfaces are difficult to secure, which may further limit the handling of sick patients, and are also associated with a high incidence of nasal injuries, nasal cannula (RAM Nasal Cannula) were used to provide NCPAP as well as NIPPV in the delivery room and in the NICU in over 500 patients, for over 5,000 days with an extremely low incidence of nasal injuries. Ramanathan, J Pulmon Resp Med, 2013
by dr M Osama Hussein
Ram cannula Nasal cannulaby dr M Osama Hussein
Side effects?
• Most concern is related to air leak syndrome complicating high-flow nasal cannula therapy, Hegde & Prodhan ,Pediatrics. 2013
by dr M Osama Hussein
Non invasive ventilation interfaces
High flow nasal cannula systems are increasingly adopted
because of the ease of use Vapotherm, Fisher Paykel HFNC
However, these HFNC systems have no ability to measure
or limit the pressure delivered to the baby There are no pop-off valves in these systems
Only pop-off is at 20 PSI to protect the device and not to protect
the baby
Can generate significant amount of distending pressures at the
nasal interface
Air leaks have been reported
by dr M Osama Hussein
Indications
o To facilitate extubation of mechanically ventilated neonates
o As a primary mode of support for neonates with respiratory distress
o Infants with moderate-to-severe apneao Delivery room care?
by dr M Osama Hussein
Criteria to start HHHFNC
o If an infant has any of the following:
o Respiratory rate >60 breaths/minute
o Moderate to severe grunting
o Respiratory retraction
o Oxygen saturation <90% (preductal)
o Frequent apnea
by dr M Osama Hussein
by dr M Osama Hussein
Vapotherm (VT) 2000i (Vapotherm Inc., Stevensville, MD, USA)
Optiflow™ | Fisher & Paykel Healthcare
by dr M Osama Hussein
Thank youSee you in
Port said fifth neonatology conference
October 2014