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

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  • This is a trash bag with gas inflow. It was closed loosely about the neck and pressure could be maintained easily and constantly. This was about the 5th or 6th patient we treated.
  • Heated humified high flow nasal cannula, does it have a rule in NICU routine care?

    1. 1. Heated Humidified HighFlow Nasal Cannulae (HHHFNC) does it have a place in NICU routine work?
    2. 2. Heated Humidified High-Flow Nasa -Flow in the beginning, it was the flow
    3. 3. Bonnaire E: Inhalations of oxygen in the newborn. Arch Pediatr. 8:769 1891 by dr M Osama Hussein
    4. 4. 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
    5. 5. 1907 – A. Lane invented nasal catheter 1919 – L. Hill developed O2 tent 1920 - O2 therapy became routine for “sick new born”
    6. 6. Nasal cannula Low flow systems Nasopharyngeal cannula O2 Oxygen mask High flow systems Enclosure system Oxygen hood Oxygen Liter/ min FLOW
    7. 7. • Patrick Bouvier Kennedy dies of respiratory distress syndrome (RDS), 34 weeks gestation, birthweight 2100 gms. • 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
    8. 8. PARAMETERS OF VENTILATORS (keyboard of ventilation) FiO2  Flow  Inspiratory pressure  End expiratory pressure  Timing  Rate by dr M Osama Hussein
    9. 9. Parameters of assisted ventilation  Free flow oxygen ( FiO2 + Flow)  Assisted ventilation 1. Positive pressure ventilation(FiO2 + Flow + Inspiratory pressure + End expiratory pressure + Time of inspiration+ Rate) Manual Mechanical 2. CPAP (FiO2 + Flow + End expiratory pressure) by dr M Osama Hussein
    10. 10. • Patrick Bouvier Kennedy dies of respiratory distress syndrome (RDS), 34 weeks gestation, birthweight 2100 gms. • 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 Gregory Use of continuous positive airway pressure (CPAP) for respiratory distress syndrome (RDS) by dr M Osama Hussein
    11. 11. CPAP Provided by G. Gregory by dr M Osama Hussein
    12. 12. • 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
    13. 13. 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
    14. 14. 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
    15. 15. 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
    16. 16. 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
    17. 17. HHHFNC and NCPAP produced similar rates of extubation failure. Collins CL, et al, j peds.2012 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 by dr M Osama Hussein
    18. 18. Unlike NCPAP, HHFNC does not seem to increase the risk of nasal trauma and appears to improve costeffectiveness whilst producing otherwise equal respiratory and non-respiratory outcomes. FernandezAlvarez JR. Eur J Pediatr. 2013 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 by dr M Osama Hussein
    19. 19. 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
    20. 20. 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
    21. 21. 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
    22. 22. 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
    23. 23. 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
    24. 24. Ram cannula Nasal cannula by dr M Osama Hussein
    25. 25. 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
    26. 26. 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
    27. 27. 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 apnea o Delivery room care? by dr M Osama Hussein
    28. 28. 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
    29. 29. Vapotherm (VT) 2000i (Vapotherm Inc., Stevensville, MD, USA) Optiflow™ | Fisher & Paykel Healthcare by dr M Osama Hussein
    30. 30. by dr M Osama Hussein
    31. 31. Thank you See you in Port said fifth neonatology conference October 2014

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