High Flow Therapy (HFT) in the Pediatric Population

Agenda

• HFT Clinical Review

• Precision Flow Overview

• 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™

5-20Lpm

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 spaceTiep, 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 for HFT

21

Mechanisms by Application

Oxygen Flush Humidity Mild Pressure

RSV

CF

RDS

Asthma

HFT DOES NOT TREAT A DISEASE, THE MECHANISMS TREAT SYMPTOMS

Here are merely a few pediatric 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?

Is Cannula Size Important?

Platform A Platform BPremature 1.5 2.4

Neonatal 1.5 2.4

Infant 1.9 2.7

Intermediate Infant

1.9 2.7

Pediatric 2.7 3.7

Calculating Minimal Flow

Extrapolated from equations in Mosby’s Respiratory Care Equipment, 7th Ed.

Calculating Flows

Tidal Volume 6-8 ml/kg

PEDS: VT are less, but rates are much greater

Breaths per Minute

Infant (0 – 1 yr) 30 - 60

Toddler (1 - 3 yrs) 24 - 40

Preschooler (3 - 6 yrs) 22 - 34

School Age (6 – 12 yrs)

18 - 30

Adolescent (12 – 18 yrs)

12 - 16

Flow Requirements: Pediatrics

Younger than 6 yrs, more like an infant

Older that 6 yrs, more like an adult

Numa and Newth, 1996

25

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

●Spentzas et al. - J Intensive Care Med 2009;24:323-8

- Children w/ Respiratory Distress treated with High Flow Nasal Cannula, Published 2009. Paper showing the pronounced physiologic improvements in 46 pediatric patients at Le Bonheur Children’s Hospital, Memphis, Tn. University of Tennessee Critical Care Division.

●Byerly et al. - Burns 2006;32:121-5

- Demonstrates what effect the humidification can have on airway function, although they also reinforce the physiologic impact that flush and pressure have on respiratory function with RDS.

●Hasani et al. - Chron Respir Dis 2008: 5, 81-6

- Although derived from adult patients, it shows mucocilliary clearance functions are dramatically improved with heated, humidified high flow cannula treatment. Patients with RSV and CF should be considered when looking at these results.

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 Precision Flow™ 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

Indications for Use: 5-20Lpm

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

Q & A