neonatal high flow nasal cannula bradley a. yoder, md professor of pediatrics division of...
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Neonatal High Flow Nasal Cannula
Bradley A. Yoder, MDProfessor of Pediatrics
Division of NeonatologyUniversity of Utah School of Medicine
Towards A Clinical Practice Guideline
Disclosure Statement
I have received research and/or travel compensation as a consultant to
Drager MedicalFisher & Paykel
Vapotherm& Ikaria
Objectives
Recognize Detrimental Approaches
Suggest Clinical Guidelines
Identify Areas for Further Research
Contributing Consultants• Clare Collins, MBChB, PhD, FRACP. Department of Paediatrics, Mercy
Hospital for Women, Melbourne, AU ([email protected])
• Kevin Ives, MBBChir, , MD, FRCPCH. Dept of Neonatology, John Radcliffe Hospital, Oxford, UK ([email protected])
• Brett Manley, MB BS (Hons.), PhD, FRACP. Consultant Neonatologist Neonatal Services and Newborn Research Centre, Royal Women's Hospital Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, AU ([email protected])
• Michael McQueen, MD, MBA, FAAP. Neonatology, Banner Health System, Phoenix, AZ, USA ([email protected])
• Bradley A. Yoder, MD, FAAP. Division of Neonatology, University of Utah School of Medicine, SLC, UT, USA ([email protected])
Why Do We Need
Practice Guidelines?
Why Do We Need Practice Guidelines?
• HHFNC universally available in US NICU’s
• Expanding international use
• Increasing pediatric & adult use
• Only a few RCT’s have been completed
• Guidelines generally improve outcomes
• Assist in identifying areas to improve
HHHFNC - Mechanisms of ActionMechanism Process References
Gascondition
Reduced metabolic work
Maintain epithelial integrity
Improved lung mechanics
Greenspan, JPeds 1991Williams, CCM 1996Waugh, RespCare 2004Schiffmann, RCCNA 2006Chidekel, PulmMed 2012
Pressure Minimal if: small NC coupled w/ large nasal interface
Increases EELV
Saslow, J Perinatol 2006Kubicka, Peds 2008Wilkinson, J Perinatol 2008Frizzola, PedsPulm 2011Sivieri, PedsPulm 2012Collins, JPaedsChildH 2013Hough, PedsCCM 2014
Flow Dead space gas washout Inspiratory resistance Augment tidal volume Off-loads diaphragm activity
Shepard, ARRD 1990Dewan, Chest 1994Frizzola, PedsPulm 2011Rubin, PedsCCM 2014Pham, PedsPulm 2014
HHHFNC Randomized Clinical Trials• Post-extubation HHHFNC v CPAP - preemies < 32 wks
– C Collins (Melbourne, AU; n=132)
• Post-extubation HHHFNC v CPAP - preemies < 32 wks– B Manley (Melbourne, AU; n= 300)
• Post-extubation HHHFNC v CPAP – Liu C (China; n= 255)
• Comparison of HHHFNC to Nasal CPAP in Neonates– B Yoder (University of Utah, n = 432; 150 < 32 wks)
• Initial Rx for RDS HHHFNC v CPAP - preemies < 35 wks– A Kugelman (Haifa, Israel; n=76)
Summary of Current RCT’s
HHHFNC:• ~ 1200 infants in 5 trials
• Similar failure rates as nCPAP
• As applied, no evidence for increased adverse events….particularly air leaks
• Does not extend O2 use or hospital stay
• Primarily relates to post-extubation use
Issues in Clinical Care• Cannula to nares ratio
• Gas egress
• Temp & humidity
• Initial Flow Rate
• Escalation/weaning flow
• NG v OG tube
• PO feeding on HFNC
MUST maintain a leak at the nose
avoids excessive pressure generation
allows nasopharyngeal ‘washout’
more comfort & less nasal trauma
Keep temperature close to 37o C
Position tubing down & away from baby
minimize fluid into the nares/airway
reduces risk for pressure injuries
INITIAL SET-UP
Occlusive NC
Non-occlusive NC
Only use heated and humidified systems
Typical peak inspiratory flow ~ 1 lpm, thus when flow > wt in kg, set FiO2 = delivered FiO2
HFNC is a non-invasive Rx: treat it like CPAP
titrate FiO2 first, then flow rate
if an infant needs > 50-60% oxygen D modes
know when to bail (apnea, acidosis, hypoxia.…)
CRITICAL POINTS
Indications for HHHFNC
• Post-extubation support for preterm infants– Current evidence shows equivalence to CPAP
– Data is limited for infants born < 26 weeks’ GA
• Infants stable on CPAP, where HFNC therapy may be preferred– A variety of reasons may be offered including ease
of care, neuro-developmental, nasal trauma, other
Unproven Benefit
• As primary support for RDS or other acute neonatal respiratory disorder
– Lack of evidence from RCT’s
– But empirically used by many centers
Management of Flow Rate
• Criteria for escalation:– FiO2– Respiratory rate– RDS score/WOB– Radiograph
• Initiating flow: – Dependent on size &/or
gestation– Dependent on 1o v 2o Rx– Dependent on current
Paw/FiO2
• Approach to weaning:– Time on HF– FiO2– Respiratory exam
Management of HHHFNC Therapy
Weight EGA CurrentRx Mode
Current PAW
CurrentFiO2
Resp Rate
Time On
Exam RDS-S
Initial flow rate
N = 4Y = 1 N = 5 N = 5 N = 3
Y = 2N = 1Y = 4 Y = 5 N = 4
Y = 1 Y = 5
Flow Escalation N = 5 N = 5 N = 5 N = 5 Y = 5 Y = 5 N = 2
Y = 3 Y = 5
WeaningFlow
N = 1Y = 4
N = 1Y = 4 N = 5 N = 5 Y = 5 N = 1
Y = 4 Y = 5 Y = 5
The majority of consultants use the infants underlying clinical
condition, rather than weight or gestation, to manage HHHFNC
What criteria do you use in initiatingHHHFNC therapy in neonates?
Initiating HHHFNC
Flow Rate “A” “B” “C” “D” “E”
Current weight
< 1000 g1000-2000 g
> 2000 g
5-7 lpm 3-5 lpm 5-8 lpm 8 lpm 4-6 lpm all wts 4-6 lpm all wts all wts all wts 4-8 lpm
Postnatal age
< 24 hrs< 7 days
other
5-7 lpm all Same 5-8 lpm all 8 lpm all 4-6 lpm all as above
Prior Rx mode
HFVSIMVCPAPOther
NO Same 5-8 lpm 8 lpm Same as 6-7 lpm as above; 5-8 lpm for all above;5-7 lpm includes Rarely Occ <28 wk Don’t use CPAP HFV may go NIMV/CPAP
FiO2< 40%< 30%
RA
7-8 lpm by 1 lpm 7-8 lpm 8 lpm 6-8 lpm if5-7 lpm Same 5-8 lpm for all FiO2 > 40%5-7 lpm as above otherwise 4-6 lpm
PAW< 8 cm H2O< 6 cm H2O
other
6-8 lpm Same Same 8 lpm 4-6 lpm all5-7 lpm as above for all for all typically notOnly @ CPAP < 7 Same successful if > 9-10
Other 7-8 lpm if Flow need based WOB on all of above
Initiation of HHHFNC Therapy
Weight FiO2 PAW
Initial flow rate
“A” 5-7 lpm @ any weight
“B” Varies by wt 3-8 lpm
“C” 5-8 lpm @ any weight
“D” 8 lpm @ any weight
“E” 4-6 lpm @ any weight
Increase for > 30%
Increase for > 30%
Increase for > 30%
Always start at 8 lpm
Increase for > 30%
Increase for > 6-7 cm H2O
Same as for weight
Same as for weight
Always start at 8 lpm
Same; poor success rate if > 9-10 at extubation
Gestation & postnatal age not a factor
Use only heated/humidified systems
Use NC sized to allow ready egress of gas
Start at 5-8 lpm no evidence comparing starting flow ratesconsider increased flow based on FiO2/Paw/WOB
CONSENSUS RECOMMENDATIONSINITIATING HIGH FLOW
What criteria do you use in escalatingHHHFNC therapy in neonates?
Escalating HHHFNC
Increase in Flow Rate “A” “B” “C” “D” “E”
Current weight
< 1000 g1000-2000 g
> 2000 g
Don’t use Don’t use Don’t use Don’t use Don’t use
Postnatal age
< 24 hrs< 7 days
other
Don’t use Don’t use Don’t use Don’t u se Don’t use
FiO2
< 40%< 30%> 21%
> 30% use by 1-2 lpm by 1 lpm If FiO2 by 1-2 lpm 7-8 lpm if > 30% as FiO2 flow back if > 40% by 1 lpm to 8 lpm
Resp rate< 60
60-80> 80
As above only if > 60 by 1 lpm by 1 lpm by 1 lpm for FiO2 only if signs by 1 lpm by 1-2 lpm by 1 lpm WOB/distress
RDS score or WOB Specify by 1 lpm by 1-2 lpm by 1 lpm As above As above
Time on HHFNC
< 6 hrs< 12 hrs> 12 hrs> 24 hrs
other
No time Same as Same As above Do not use limit “A” Don’t wait more time epochs D to CPAP than 1-2 hrs to Consider Depends on babyif HFNC = 8 lpm escalate to D to CPAP Do not use CPAP & concerns CPAP/NIMV or NIMV Occ use BiPAP
Don’t exceed 8 lpm flow in neonates
Increase flow for: WOB Respiratory rate FiO2
Don’t delay in escalating flow
Change to CPAP/NIMV if not improving
CONSENSUS RECOMMENDATIONSESCALATING HIGH FLOW
What criteria do you use in escalatingHHHFNC therapy in neonates?
Escalating HHHFNC
Increase in Flow Rate “A” “B” “C” “D” “E”
Current weight
< 1000 g1000-2000 g
> 2000 g
Don’t use Don’t use Don’t use Don’t use Don’t use
Postnatal age
< 24 hrs< 7 days
other
Don’t use Don’t use Don’t use Don’t u se Don’t use
FiO2
< 40%< 30%> 21%
> 30% use by 1-2 lpm by 1 lpm If FiO2 by 1-2 lpm 7-8 lpm if > 30% as FiO2 flow back if > 40% by 1 lpm to 8 lpm
Resp rate< 60
60-80> 80
As above only if > 60 by 1 lpm by 1 lpm by 1 lpm for FiO2 only if signs by 1 lpm by 1-2 lpm by 1 lpm WOB/distress
RDS score or WOB Specify by 1 lpm by 1-2 lpm by 1 lpm As above As above
Time on HHFNC
< 6 hrs< 12 hrs> 12 hrs> 24 hrs
other
No time Same as Same As above Do not use limit “A” Don’t wait more time epochs D to CPAP than 1-2 hrs to Consider Depends on babyif HFNC = 8 lpm escalate to D to CPAP Do not use CPAP & concerns CPAP/NIMV or NIMV Occ use BiPAP
What criteria do you use in weaningHHHFNC therapy in neonates?
Weaning HHHFNC
Decrease in Flow Rate “A” “B” “C” “D” “E”
Current weight
< 1000 g1000-2000 g
> 2000 g
Wean qod q 12-24 hrs qod if Keep 8 lpm 0.5 lpm q D q 12-24 hrs < 1500 g til > 1 kg 1 lpm q DWean q12 q 4-12 hrs 1-2 kg by 1 lpm q 24 1 lpm prn > 2 kg as tolerated
Postnatal age
< 24 hrs< 7 days
other
Don’t use Wean as NO As above Don’t use above unless “bigger” baby
FiO2< 40%< 30%
RA
No wean Same Same As above if 0.5 lpm if CLDif > 30-35% FiO2 stable otherwise as & < 40% above for WT
Resp rate< 60
60-80> 80
No wean Same Same No wean No wean if RR>60 if > 80 if > 80
RDS score or WOB
Specify No wean Same Same Same SameDecreased WOB & FiO2 drive weaning more rapidly among larger infants
Stick to slower wean for smaller/younger infantsTime on HHFNC
< 6-12 hrs> 12 hrs> 24 hrs
other
If “quick” recover Same Same Not a Not a from RDS WOB more a factor factor factorFor ELBW p-ext than time except for ELBWwean qod if FiO2 > 25%
Wean the FiO2 first, then the gas flowSimilar to CPAP; to at least < 35%, probably < 30%
Review at least every 12-24 hrs to determine if flow rate can be weaned or discontinued
May be able to wean infants > 2 kg more quickly
Wean by 0.5 - 1 lpm decrements
CONSENSUS RECOMMENDATIONSWEANING HIGH FLOW
Stopping HHHFNC TherapyWeight EGA Postnatal Age
“A” 4 lpm *
“B” 1-2 lpm @ < 1000g; 2-3 lpm at higher weights
“C” 3 lpm - “smaller” babies
“D” 4 lpm *
“E” 2-3 lpm for VLBWI, prefer to “dry” low-flow NC
“A” Rarely < 4 lpm w/ BPD
“B” Same as weight
“C” 3-4 lpm if larger/older
“D” Same as weight
“E” Same as weight
“A” Same as weight
“B” Same as weight
“C” Expect “smaller” on 3-5 lpm for 2-3 wks
“D” Same as weight
“E” Same as weight
* 1o related to funding issues
Preferably stable > 24 hrs, FiO2 < 30% and normal WOB/RR
There is no consensus on when to D/C HF
No studies comparing effect or outcomes related to D/C HFNC at different support levels
Recommendations vary from 1 – 4 lpmCenters vary by weight of infant Also variation related to support for BPD
CONSENSUS RECOMMENDATIONSDISCONTINUING HIGH FLOW
CONSENSUS !THIS WOULD WORK A LOT BETTER IF YOU’D JUST AGREE WITH ME
Consensus on HHHFNC: A Tale of Two NICU’sPreferred Non-Invasive Approach by NICU RN’s
24-wk, 500g 26-wk, 750 g 28-wk, 1200g 30-wk, 1500g0
10
20
30
40
50
60
70
80
90
100
CPAP-Au CPAP-UK HHHFNC-Au HHHFNC-UK
Au data from Roberts CT, J Paeds Child Health 2014; UK data from K Ives, unpublished
TheFuture
Challenges are what make life interesting ……
…… overcoming them is what makes life meaningful
Joshua J. Marine
Future Studies• Additional large RCTs are needed:
– to evaluate HHHFNC use in ELBWIs
– to compare different HHHFNC devices
– to evaluate various approaches to HHHFNC
– to assess economic impact of HHHFNC
– to address specific respiratory conditions
– other
V I G I L A N C EYou can’t see it if you don’t stay awake
SUMMARY
• HHHFNC is in wide clinical use
• RCT’s support HHHFNC as safe, effective alternative to nCPAP at the time of extubation
• Additional RCT’s are needed to study HHHFNC as 1o therapy & related to flow management
• Except for stopping, there is moderate consensus in the management of HHHFNC
Contributing Consultants• Clare Collins, MBChB, PhD, FRACP.
Mercy Hospital for Women, Melbourne, AU
• Kevin Ives, MBBChir, , MD, FRCPCH. John Radcliffe Hospital, Oxford, UK
• Brett Manley, MB BS (Hons.), PhD, FRACP. The University of Melbourne, Melbourne, AU
• Michael McQueen, MD, MBA, FAAP. Banner Health System, Phoenix, AZ, USA
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