Nasal high flow oxygen therapy in the ward setting · via AIRVO™ used in wards since 2009 •Currently used in all acute wards across hospital. Rationale for use beyond ICU •

Alison Pirret NP, PhDCritical Care Complex Middlemore Hospital

School of Nursing Massey UniversityNew Zealand

Nasal high flow oxygen therapy in the ward setting

Conflicts of Interest

• Financially supported by Fisher & Paykal to attend this meeting.

• No other conflicts of interest to declare.

NHFProvides heated and humidified

gas

Delivers at a high flow rate (up to 60LPM)

• Low levels of dynamic positive pressure

• Can adjust FiO2 (.21-1.0)

• Decreases dead space in upper airway

• Reduces work of breathing

Evidence for NHF

Does NHF have a place beyond ICU?

Number of ICU beds per 100,000 population

Coun

try

Murthy & Wunsch 2012 Critical Care, 16, 218

Is NHF safe in the ward setting?

Matthay MA. New Engl J Med 2015;372:2225-6.

Is NHF effective in the adult ward setting?

Application of NHF beyond ICU

• Long hx of using high flow oxygen in ICU – mask then optiflow™ nasal prongs in 2004

• NHF (optiflow™ system) via AIRVO™ used in wards since 2009

• Currently used in all acute wards across hospital

Rationale for use beyond ICU

• Patients can eat & drink

• Comfortable

• Can talk & be understood

• Receive benefits of NHF • therapy

– ? contributed to ↓ ICU/HDU admission

Our setting

• Middlemore Hospital, Auckland, NZ

• Tertiary metropolitan hospital

• 990 beds

• Critical Care Complex– 12 ICU beds– 6 HDU beds– 2 tier 24/7 emergency

response system

Two tier emergency response system

• EWSS

• Nurse led 24/7 Patient at risk team (PART)

• Physician led 24/7 medical emergency team

Pirret AM1,2, Takerei SF1, Matheson CL3, Kelly M1, Strickland W1, Harford J1, Jepsen NE3, Welsh LJ3, Allan CPA3.

1. Critical Care Complex, Mddlemore Hospital, Auckland.

2. School of Nursing, Massey University, New Zealand.3. Physiotherapist Services, Middlemore Hospital,

Auckland.

Study design/aim

• Prospective observational design

• To evaluate the use of NHF oxygen in adult ward patients with with respiratory failure or at risk of respiratory deterioration

• Identify difference in patient characteristics between PART and physiotherapist groups.

Study outcomes

• Primary outcome

– Improvement in pulmonary function as indicated by:

• ↓ respiratory rate• ↓ heart rate • ↑ SpO2

• Secondary outcomes

– Improvements in:• ↓ dyspnoea• ↑ sputum clearance

67 patients

NHF prescribing clinician

• PART team n=30 (42.9%)

• Physiotherapist n=30 (42.9%)

• Other n=10 (14.2%)

Variable (Total number) Number (percentage)

Mean (M) & SD (± )or Median (Mdn) & percentiles(q25, q75)

Age Mdn =71 years (58.00, 78.00)

Gender MaleFemale

41 (61.2%)26 (38.8%)

Specialty MedicalSurgical

46 (68.7%)21 (31.3%)

Number of Comorbidities M=3.03±1.89

SOFA score M=3.16±1.86

SpO2/FiO2 ratio 308.92±87.41

Demographics

No significant differences between PART & physiotherapists patient groups

Conditions requiring NHF

0

5

10

15

20

25

Condition

Total frequency

PART

Physiotherapists

Freq

uenc

y

Primary outcomes

0102030405060708090

100

RR HR SpO2

Pre NHF

Post NHF

t=2.79p=0.007

Parameter

Valu

e

t=2.23p=0.03 t=4.08

p=<0.001

Pre-post timeMdn=20.0 (q25, q75=15.0, 30.0) minutes

Over next 14.21±7.88 hours ↓ RR (F=11.64, p=<0.01)↑ SpO2 (F=5.43, p=0.007)

PART & physiotherapists primary outcomes

0102030405060708090

100

RR HR SpO2

PART Pre NHFPART post NHFPhysio pre NHFPhysio post NHF

PART: t=2.49, p=0.02 Physio: t=1.51, p=0.14

Parameter

Valu

e

PART: t=3.03, p=0.005Physio: t=0.92, p=0.37

PART: t=4.12, p=<0.001Physio: t=4.12, p=0.21

Secondary outcomes

Variable Statistical test

Dyspnoea pre NHF oxygenDyspnoea post NHF oxygen

N=38 (56.7%)N=32 (47.8%

p=0.45

Mixed logistic regression over time OR=0.64,p=0.0005

Sputum retention pre NHF oxygenSputum retention post NHF oxygen

N=38 (56.7%)N=40 (59.7%)

p=0.63

Mixed logistic regression OR=1.13,p=0.25

No pre and post improvements in PART or physiotherapist groups

Reason for stopping NHF

Reason Frequency (percent)

Total group(N=67)

PART (n=30)

Physiotherapist(n=27)

Clinically improved 46 (68.7%) 22 (73.3%) 16 (59.3%)

Therapy not tolerated 6 (9.0%) 1 (3.3%) 4 (14.8%)

Patient palliated or died 5 (7.5%) 1 (3.3%) 4 (14.8%)

Transferred to ICU 3 (4.5%) 2 (6.0%) 1 (3.7%)

Transferred to HDU 3 (4.5%) 3 (10.0%) 0Place on another NHF device

2 (3.0%) 0 2 (7.4%)

Required ward NIV 2 (3.0%) 1 (3.3%) 0

Too hot (n=3)Confusion (n=2)Other (n=1)

ICU• Community acquired pneumonia (81yrs)• Complex bowel surgery-leak• Gangrenous cholecystitis

2.36

0.33

1.58

0.12 0.10

2.64

1.57

0.00

1.00

2.00

3.00

Leng

th o

f tim

e on

NHF

(Day

s)

Reason for stopping NHF (Mdn)

Time on NHFMdn=2.03 (q25, q75=0.89-3.16) days

NHF settings

Variable FiO2M or Mdn (q25, q75)

Flow rate LPM SpO2 /FiO2 ratio

Clinically improved (n=46)

0.28 (0.25, 0.39) 35.0 (30.0, 35.0) 316.39±85.04

Not tolerated (n=6) 0.28 (0.25, 0.30) 30.83±3.76 334.16±89.76

Transferred to ICU (n=3)

0.40 (0.31, 0.43) 30.0 (0.30, 0.33) 227.50 (q25, q75=214.84, 342.32)

Transferred to HDU (n=3)

0.44 (0.43, 0.49) 40.0 (35.0, 40.0) 200.89±28.51

Palliated/died (n=5) 0.25 (0.25, 0.38) 30.0 (30.0, 30.0) 301.78±86.0

Ward NIV (n=2)Other NHF (n=2)

0.35±0.1734±0.02

20.0±0.032.5±3.5

304.35±147.57266.07±12.63

Flow Mdn =30.0 (q25, q75=30.0-35.0FiO2 M=0.33±0.10

Hospital LOS & mortality

Variable Total group (N=67)Mdn (q25, q75)

PART(n=30)Mdn (q25, q75)

Physiotherapists(n=27)Mdn (q25, q75)

Statistical test

Hospital lengthof stay

8.5 (5.0, 30.9) days

7.5 (4.0, 13.0) days

12.88 (5.0, 12.0) days

U=354.0p=0.41

Survivedhospital stay

n=60 (89.6%) n=28 (93.3%) n=23 (85.2%) FET p=0.40

Limitations

• Single site observational study

• Not randomised/blinded

• Small numbers

• Used successfully – PART & MET