High Flow Therapy (HFT) in the Adult Population. Agenda High Flow Mechanisms of Action Clinical...
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Transcript of High Flow Therapy (HFT) in the Adult Population. Agenda High Flow Mechanisms of Action Clinical...
High Flow Therapy (HFT) in the Adult Population
Agenda
• High Flow Mechanisms of Action
• Clinical Application and Research
• 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™
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
66
Continuum of Care: New Model
6
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
Humidify / Warm Airways
●Nasopharynx is highly efficient at conditioning inspiratory gas
●Anatomical Structure
●Mucosal Architecture
Inspiratory Gas Conditioning
Humidify / Warm Airways
Conditioning Prevents Injury
Inadequate warming and humidification can cause:
● Thickened Secretions
● Decreased mucocilliary action
● Thermal challenge
● Bloody secretions
● Lung atelectasis
Humidify / Warm Airways
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
●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 space
Tiep, 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 Review
21
Mechanisms by Application
Oxygen Flush Humidity Mild Pressure
COPD
Fibrosis
Asthma
CHF
HFT DOES NOT TREAT A DISEASE, THE MECHANISMS TREAT SYMPTOMS
Here are merely a few 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?
22
The Interface…Delivering the Flow
Platform “A” Platform “B”
Textbook Adult Values:Tidal volume = 500mlBreathing rate = 12 / minInspiratory fraction = 0.3
Spontaneous Inspiratory Flow avg. = 20 lpm+ what is the peak flow?+ Are they larger?+ Are they breathing heavy?
Calculating Minimal Flow
Err Aggressively…but within reason
AARC Definition….
……flows that exceed patient demand at various minute volumes.
Calculating Minimal Flow
Extrapolated from equations in Mosby’s Respiratory Care Equipment, 7th Ed.
Flow Requirements: Adults
Inhalation:
RR = 12+
Tidal Volume = 500ml
Inspiratory time fraction = 0.3 (~1.5 sec)
= 25 - 35 LPM
25
Exhalation:
Expiratory time = ~3.5 sec
Extrathoracic dead space = 0.8 ml/kg (~50 ml)
Inhalation flow is 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
Clinical References
●Calvano et al. - Respir Care 2008; 53(12):1739-43.
- HFT stabilizes end-stage respiratory failure patient on HFT just to make her comfortable when she refused intubation and biPAP.
●Dewan & Bell. - Chest 1994;105:1061-5
- Oxygenation improved but also work tolerance and reduced dyspnea with high flow cannula
●Hasani et al. - Chron Respir Dis 2008: 5, 81-6
- Showed that mucocilliary functions are actually improved with BTPS humidification
●Chatila et al. - Chest 2004;126:1108-15
- Temple Lung Center in Philadelphia showed in COPDers that with Vapotherm blood O2 and
CO2 improves as did work performance.
●Dysart et al. - Respir Med 2009;103:1400-5
- Summarizations of the Mechanisms of Action of HFT
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 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:
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
Q & A