What Do You Mean a High Flow Nasal Cannula

1
What Do You Mean a High Flow Nasal Cannula?

• Presented By
• Michael Portzline BS, RRT, CPFT
• Sales Manager, Medical Support Products, Inc.
• Diane Tattersall, RRT
• Clinical Product Specialist, Vapotherm, Inc.

2
Low Flow and High Flow Defined

• Low Flow- delivers 100 oxygen (diluted by room
  air) at flows that are less than the patients
  inspiratory flowrate
• High Flow-delivers a prescribed gas mixture at
  flowrates that exceed patient demand
• Reference AARC CPG Oxygen Therapy for Adults
  in the Acute Care Facility

3
This is not the right kind of high flow or
humidification?
4
Oxygenation Where have we come from?
5
Oxygenation Where have we come from?

• Nasal Cannula- up to 6-8 lpm with inadequate
  humidification and fluctuation of FiO2
• High flow venturi mask to deliver up to 50
  without adequate humidification and often wont
  meet demand
• Partial or non-rebreathing masks with poor
  tolerance and inadequate humidification and
  varying FiO2
• Introduction of CPAP or BiPAP systems to assist
  with oxygenation but with poor deliveries of
  accurate FiO2 and no true account for heat and
  humidification
• When all else fails-intubation and ventilation

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Humidification Where have we come from?
7
Other Ways to Humidify
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Humidification Where have we come from?

• Bubble Humidifiers that produce little to no true
  humidification
• Aerosol generators that can cause more infection
  and irritation risks than humidification
• Heated humidifiers that often harbor infection
  and require some form of drainage from rainout
• HME devices that work only if your patient can
  provide their own adequate humidification without
  secretion problems
• Mist tents that are harder to keep the patient in
  than humidify and vary in FiO2 delivery

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There is Good News

• There is a better product to provide accurate
  oxygenation and complete humidification to your
  patients!

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The New Way to Oxygenate and Humidify Vapotherm
2000i
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What is Vapotherm?

• Vapotherm is the power of flow
• Its patented membrane technology makes flows of
  1-40 lpm possible
• It delivers water vapor at BTPS with almost 100
  relative humidity
• Temperature range from 33-43 degrees Celcius

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Delivery Thermodynamics

• Triple Lumen delivery tube
• Minimal heat loss
• Short nasal cannula

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The Vapor Transfer Cartridge

• Patented vapor-transfer technology
• Allows molecular vapor to pass without direct
  contact between delivery gas water
• Filters at 0.01 micron- Tested against
  Brovindimonus Diminuta- Nelson Study
• Humidifies gas up to 55 mg/L/H2O

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Humidity vs Temperature
Water content of air at 100 relative humidity
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Vapotherm Operation
Water Reservoir
Vapor Transfer Cartridge
Water Heater
Water Pump
Heated Delivery Tube
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The Simple Message
The gas is saturated and warmed to body
temperature, therefore the patients airway is
not cooled or dried Flow does not create high
airway pressure .Therefore, high flow is easily
tolerated.
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Areas of Use

• ICU
• Emergency
• PICU
• NICU
• Pulmonary Rehab
• Post Surgical Care
• LTAC
• Homecare

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Clinical Applications

• COPD
• Pulmonary Fibrosis
• CHF
• Asthma
• Rhinitis, Sinusitis
• Respiratory Muscle Fatigue due to increased WOB
• Croup, Epiglottitis
• Cystic Fibrosis
• Body core rewarming
• Post Extubation- adult and infant
• NICU- alternative to NCPAP
• Mucociliary Clearance and Airway Irritation

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Indications For Use

• Any patient who is non-compliant or not
  clinically improving with conventional high-flow
  mask therapy.
• Patients requiring supplemental heat humidity
  for artificial airways
• Post extubation support or weaning from NPPV
• Spontaneously breathing newborns who are
  requiring supplemental oxygen therapy who are
  failing conventional modalities. It has been
  used in place of NCPAP.

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High Flow Setup
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High Flow Applications 5-40 lpm
Winning By A Nose Abstract by John Walsh CRT,
Northwest Community Hospital, Arlington Heights,
IL
Advance for Respiratory CarePractitioners April
22, 2002
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Treatment of Acute Hypoxia in CHF

• 10 hypoxic patients, receiving O2 by
  non-rebreather mask at 15 lpm. Treated in
  emergency room with Vapotherm at 20 - 40 lpm 100
  O2 by nasal cannula.
• Recorded
• Respiratory rate (0, 15, 30 min)
• Heart rate (0, 10 min)
• SpO2 (0, 10 min)

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CHF- Oxygen Saturation
24
CHF - Respiratory Rate
25
Melanie Guerrero, MD Walter Reed Medical Center,
Washington DC
Vapotherm Can Be as Effective as Non-Rebreather
Systems for Oxygen Delivery
October 2003 Issue of Chest
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Guerero Study Vapotherm vs NRB

• 14 Male patients 12 COPD, 2 Pulmonary Fibrosis
• Baseline ABG and at 60 min. after administration
  of device
• Vapotherm run at 40 lpm, NRB at 100
• PaO2 increased from 68 to 389 with NRB and from
  68 to 375 with Vapotherm
• PCO2 or pH unaltered
• Conclusion Vapotherm as effective as NRB and
  allows more flexibility to the patient

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Vapotherm in Respiratory Insufficiency

• Lesley Manning, RRT, Memorial Health University
  Medical Center, Savannah, Georgia
• Respiratory Care, November 2004
• Post Pneumonectomy patient with post-op pulmonary
  edema, decreased SaO2, increased RR and dyspnea
• Aerosol mask to NRB with no change
• Placed on Vapotherm (20 lpm) within 15 min FiO2
  decreased to 40, normalized RR and improved
  dyspnea. Weaned to traditional NC in 48 hours

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Is it CPAP?
Pharyngeal pressure recordings from normal
subject at 0, 20 and 36 lpm nasal air flow.
At flow rates greater than 20 lpm, pharyngeal
pressure is positive even during inspiration.
Mean airway pressure increases only slightly, but
there may be a significant level of PEEP at the
highest flow rates.
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Nasal flow and inspiratory work
Tracheal pressure recorded via tracheal cannula.
The shaded area was integrated to calculate
inspiratory work.
Inspiratory work at nasal flow rates from 10 to
36 lpm
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Oxygen Delivery with Vapotherm without a Blender
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Tiep Study
High Flow Nasal Oxygen vs. High Flow Mask
Oxygen Tracheal O2 Concentrations Using a Head
Extension Airway Model Published in Respiratory
Care Journal September, 2002 Brian Tiep, M.D.
Mary Barnett, RN
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Tiep Barnett Introduction

• The non-rebreather mask has been the standard for
  high flow O2. However, it is not always reliable
  in providing a target FIO2 and it limits patient
  comfort and ability to eat and communicate.
• Recently, Vapotherm has developed a high flow
  oxygen delivery system in which the oxygen is
  warmed and humidified providing comfortable
  nasal flows up to 40 L/m.
• The present study was designed to measure oxygen
  concentrations achievable via Vapotherm versus
  the mask and to trace the delivery flow through a
  model of the upper airways.

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Tiep Barnett Methods

• An upper airway head extension model was used to
  trace flow of ultrasonic mist and measure
  tracheal gas exchange. Breathing through the
  models mouthpiece located at the tracheal
  junction, enables tracheal gas concentrations to
  be measured. Also, by following the ultrasonic
  mist we were able to trace flow patterns in the
  upper airways.
• We measured O2, CO2 and air-flow in a normal
  subject breathing consistent and controlled
  breaths at a rate of 20 breaths/min with the
  model wearing the nasal cannula vs mask. O2 was
  delivered at 10, 15, 20, and 30 L/m through each
  device.

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Tiep Barnett Results O2 Storage

• High mask flow, impeded by pressure at the mouth
  - stores less O2 in the upper airways during
  exhalation

• High nasal flow, unimpeded at mouth, fills the
  upper airways storing O2 during exhalation

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Ultrasonic Flow NC vs. Mask
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Tiep Barnett Results FiO2

• Peak FIO2 as measured at the beginning of
  inspiration via nasal cannula and mask.

FIO2
30
20
15
10
N M
N M
N M
N M
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Tiep Barnett Conclusions
Conclusions High flow nasal cannula delivery is
more efficacious than the non-rebreather mask at
equivalent flows, due to O2 storage in the upper
airways during exhalation poised for delivery
upon the next inhalation in addition to the
continuous supply flow. High flow nasal O2 can
be an effective option for patients with high
flow requirements. Clinical studies are
recommended to evaluate the impact of high flow,
warmed and humidified O2 following extubation,
during sleep, and in the management of
exacerbations.
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Key Reference Studies (Hi Flow)

• Tiep Barnett, High flow nasal cannula vs high
  flow mask, Respiratory Care Journal. Proved nasal
  cannula as good or better in measured FiO2 vs non
  re-breather mask.
• Malinowski, Oxygen concentrations via nasal
  cannula at high flows, Respiratory Care Journal.
  Validated Vapotherm system as a high flow system
  in O2 delivery
• Walsh, Winning By a Nose, Advance for RTs, 8 out
  8 patients presented in the Emergency Room
  produced significant improvements in O2 sats
  within 10 minutes, with improved patient comfort
  and a fall in breathing rate.
• Guerero, Vapotherm Can Be as Effective as NRB in
  Delivery of High Flow Oxygen, Chest. Vapotherm as
  effective as NRB
• Additional studies are published on the web site
  www.vtherm.com

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Low Flow Setup
40
Low Flow Application (1-8 lpm)

• Existing users/clinical community requested that
  Vapotherm develop a low flow system to provide
  heat, humidity and flow for NICU use
• 10 of all births require breathing assistance
• Trend is towards moderate flows via cannula vs.
  long term NCPAP
• Deficit in current technology that will
  adequately heat and humidify gases safely and
  effectively in the NICU.

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Low Flow Application

• Delivers flows between 1-8Lpm via Nasal Cannula
• Temperature between 33-43C
• 95-100 constant humidity delivered to patient
• Interfaces with Premie (lt700 grams), Neonate
  (700-1100 grams), and Infant (gt1100 grams)
  cannulas

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NICU/Nursery Indications

• Blood tinged secretions or upper airway trauma
  due to moderate flows through a nasal cannula
• Prevention of potential facial trauma or other
  contraindications associated with NCPAP
• Shortening weaning cycle for spontaneously
  breathing infants who are not tolerating NCPAP

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Shyan Sun, M.D. and Robert Tero, RRT, Saint
Barnabus Medical Center, Livingston, NJ

• Safety and Efficacy of the Vapotherm 2000i in
  the Neonatal Population
• Abstract in the November 2004 Issue of the
  Respiratory Care Journal

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Sun Tero

• Looked at 109 neonates on Vapotherm from
  2002-2003 (2070 days or 5.7 years of therapy time
  equiv)
• Babies weighing from under 500g to over 1500g
• Average time of Vapotherm 30 days in 2002 and 18
  days in 2003
• Vapotherm used either as primary treatment for
  respiratory distress in lieu of NCPAP or in post
  extubation in place of NCPAP
• Results found no evidence of barotrauma, CPAP
  belly, nosocomial infection or nasal plugging
• No nasal trauma in flows between 2-8 lpm (nasal
  cannula diameter is 2 mm)
• Conclusion Vapotherm is a safe and effective
  adjunct to support infants with respiratory
  compromise

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Key Reference Studies (Low Flow)

• Sun Tero, Safety and Efficacy of the Vapotherm
  2000i in the Neonatal Population in Respiratory
  Care Journal. Proved that Vapotherm was a safe
  and effective therapy for babies with respiratory
  compromise.
• Walsh, Comparison of Vapotherm 2000i with a
  bubble humidifier for humidifying flow through an
  infant nasal cannula in Respiratory Care Journal.
  Proved that the Vapotherm was superior to a
  bubble humidifier in preventing water deficit.
• Sanchez Sabato, Very High Flow Nasal Cannula-
  Alternative to NCPAP in Select ICN Patients? In
  Respiratory Care Journal. Proved that in 7
  babies, the vapotherm was better tolerated with
  better results than NCPAP.
• Additional studies are published on the web site
  www.vtherm.com

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Case Study CMC Scranton Baby P

• History 26 week, 942 g male born to a 22 yr
  old, single, white primipara who was GBS positive
  and treated with steroids and antibiotics prior
  to delivery. (Ruptured membranes since 18 wk)
• Early Presentation Born via caesarean for
  bleeding due to ruptured placentae. Baby P
  presented with respiratory distress secondary to
  hypoplastic lungs and anemia secondary to
  abruptio placentae.
• Treatment Course First Week
• Conventional ventilation with SIMV and 90-100
  oxygen
• Antibiotics
• Curosurf (3 doses)
• Cardioechogram revealed patent ductus arteriosus
• Treatment Course Second Week
• HFOV
• Indomethacin for PDA
• Vancomycin, Cefotaxime for positive blood and
  sputum cultures
• Received multiple blood and platelets
  transfusions for anemia

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Case Study CMC Scranton Baby P

• Treatment Course Cont
• HFOV till day 23 then returned to conventional
  vent
• Continued on antibiotics and antifungals
• Nutrition supported by hyperal and breast milk
• Tranferred to CHOP on day 38 for ligation of PDA
• While at CHOP received HFOV and nitric due to
  poor oxygenation
• Also received chronic diuretic and bronchodilator
  therapy
• Tranferred back to CMC after 47 days at CHOP with
  poor prognosis for life
• Family informed, baptized
• Extubated and placed on CPAP on day 115 due to
  desaturations and presumed ETT blockage with no
  clinical improvement
• Placed on Vapotherm at 6 lpm and 86 FiO2,
  Immediately began to show clinical improvement.
  Began to interact with mother, received both
  physical and occupational therapy.
• Discharged to home at 172 days on the Vapotherm
  at 5 lpm
• Still alive and residing in a Pediatric Care
  Facility in PA

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Miracle Baby Lucas Goes Home
Copied from Vapotherm Customer Newsletter, March
2005
49
Other Vapotherm Setups

• Humidified trach collar or mask therapy
• Homecare Setup
• 25 lpm compressor
• carry stand
• titration wye for additional oxygen via
  concentrator or liquid O2 system

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What about Other High Flow Devices
The Salter Labs high-flow cannula and humidifier
combination (Courtesy Salter Labs, Arvin,
California).
Fisher Paykel MR850 Humidification Systemwith
high flow NC
Hudson The Comfort Flo Humidification system
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Conclusions

• Vapotherm is a safe and effective method for
  providing respiratory support for the
  spontaneously breathing patient
• The only FDA cleared device for providing high
  flows to neonates through a cannula
• The Vapotherm is a device with easy setup and
  operation that provides patient comfort and
  compliance through 100 relative humidity at body
  temperature
• In terms of Safety
• Non-invasive flow device
• No heated wire circuits and no water loss
• Filter technology provides a highly effective
  barrier to infection
• Eliminates nasal breakdown, thickening of
  secretions and other adverse effects associated
  with pressure devices
• Vapotherm makes for happier and healthier
  patients

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Who Would You Rather Have as a Patient?
NCPAP Baby!
Vapotherm Baby!
53
Post Test

• True or False (Please Circle Correct Answer)
• 1. The reason we have been unable to use high
  flows from a nasal cannula in the past has
• been due to inadequate ways of humidifying.
  
  True or False
• 2. The vapor transfer cartridge is designed to
  filter bacteria as small as 3 microns in size.
  True or False
• 3. The adult high flow cartridge has a range of
  flow between 5-40 lpm.
  True or False
• 4. The blocked tube alarm will occur if flow is
  lost to the unit.
  True or False
• 5. One indication that you have a bad cartridge
  is constant bubbling in the water bag.
  True or False
• 6. The cartridge inside the Vapotherm unit must
  be replaced between patients.
  True or False
• 7. Weaning FiO2 not flow should be the first step
  in weaning from vapotherm.
  True or False
• 8. In studies comparing the Vapotherm to other
  high flow devices, the Vapotherm
• showed equal to or higher SpO2s.
  
  True or
  False

• True or False (Please Circle Correct Answer)
• 1. The reason we have been unable to use high
  flows from a nasal cannula in the past has
• been due to inadequate ways of humidifying.
  
  True or False
• 2. The vapor transfer cartridge is designed to
  filter bacteria as small as 3 microns in size.
  True or False
• 3. The adult high flow cartridge has a range of
  flow between 5-40 lpm.
  True or False
• 4. The blocked tube alarm will occur if flow is
  lost to the unit.
  True or False
• 5. One indication that you have a bad cartridge
  is constant bubbling in the air release cap.
  True or False
• 6. The cartridge inside the Vapotherm unit must
  be replaced between patients.
  True or False
• 7. Weaning FiO2 not flow should be the first step
  in weaning from vapotherm.
  True or False
• 8. In studies comparing the Vapotherm to other
  high flow devices, the Vapotherm
• showed equal to or higher SpO2s.
  
  True or
  False