Heated humified high flow nasal cannula, does it have a rule in NICU routine care?

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