Today we have a brief discussion on the new hottie in the respiratory care world, High-Flow Nasal Cannulae
Check Out Critical Care Horizons
Critical Care Horizons published its first articles this week, with a further article due out in the next few days.
How do these Bad Boys Work?
- Best Review by Ward et al.
- Review from an RT Journal
- LitFL CCC Entry
- Josh Farkas has a great post on sole use of high-flow NC
- Gastric rupture following nasopharyngeal catheter oxygen delivery-a report of two cases
- Some of the Devices: Optiflow, Vapotherm
THRIVE
Miguel-Montanes Study
PREOXYFLOW
and the response from the FOAM World
- PulmCrit
- The Bottom Line Review
FLORALI
Update:
- This trial demonstrates that in poor mental status, Nasal Facemask rather than Full Facemask led to better outcomes (Crit Care. 2013; 17(6): R300)
- John Greenwood, editor of the CCProject, adds this great comment:
Hey Scott,
Great summary and review as always. I've seen a worrisome trend of people citing FLORALI to justify HFNC as a reasonable strategy for pts with hypoxic RF rather than (in my opinion) what should probably be a tool used as bridge during intubation planning. Consider adding this study (http://www.ncbi.nlm.nih.gov/
pubmed/25691263) to your pack. Just out of curiosity, are there any specific patients you are maintaining on HFNC?
If I may, here's my own little rant about the FLORALI study (STRANGE subtleties in protocol)
1. HFNC was not used as a treatment option for all-comers w/ hypoxic respiratory failure. There were significant exclusion criteria & none of the enrolled patients had chronic lung disease (including COPD) and had no other organ dysfunction. These were only pts with PURE, single organ failure (hypoxic RF) and nothing else…
2. The authors targeted 7-10 cc/kg TV with their NIPPV which may have resulted in additional lung injury as the editorial noted, but I suspect the authors may have chosen this to avoid causing any hypercapnea associated with LTVV. Unfortunately this arm was doomed from the get go I think – especially since almost 25% had unilateral lung disease on presentation.
3. Not only was there a significant amount of therapy crossover between the NIPPV and HFNC arms, but the therapies weren't even independent of each other! 2/3 arms were actually HFNC arms, one of them just had intermittent/scheduled NIPPV sessions!!
Anyways, appreciate all the hard work. Keep it up. Happy Independence Day.
- This study shows that the size of the nasal interface definitely matters (Crit Care 2020;24:248)
Additional New Information
Fantastic Review on High Flow NC Therapy
More on EMCrit
- PulmCrit- Does the HIGH trial debunk high-flow nasal cannula?(Opens in a new browser tab)
- Pneumonia, BiPAP, secretions, and HFNC: New lessons from FLORALI(Opens in a new browser tab)
- Preoxygenation, Reoxygenation and Deoxygenation(Opens in a new browser tab)
- PulmCrit- Mastering the dark arts of BiPAP & HFNC
Additional Resources
You Need an EMCrit Membership to see this content. Login here if you already have one.
- EMCrit 373 – Mike Weinstock with another Critical Care Bounceback: “Asymptomatic Hypertension” - April 18, 2024
- EMCrit Wee – Ross Prager on 10 Heuristics for the New ICU Attending - April 13, 2024
- EMCrit 372 – FoundStab Intubation SOP - April 5, 2024
Nice discussion of the nuts and bolts of HFNO2. I could never wrap my head around the insane flow rates but now it makes more sense (they are not getting those flow rates!)
Regarding SMACC and powerpoint: when one prepares for a lecture as you did the slides become less important and may even detract. I was in the audience to hear you speak. Your message came through incredibly clear. If you had no slides at all I bet the lecture would have been just as good if not better. Thank you for the amazing presentations.
Thanks Cliff! The wee will discuss this, but no slides would have been absolutely fine–would not have caused any problem. But having slides but not knowing whether or not you were on the right one without looking down the whole time was actually quite bad and tough to lead to the same lecture quality. I will be recording it as a podcast–I promise you it will be a better lecture when the slides work.
Hi Scott, I was also in Audience at SMACC and your endearing and classy adaptation to the AV Charlie Foxtrot was totally cool. Thanks for all your work in preparing this talk, and I really felt for you not being able to deliver it with all the bells and whistles. BUT you handled it in a amusing and extemporaneously professional way and we all were with you. VIVA la FOAM. Many thanks from someone who has become a better Doctor for all your your effortsover these recent years, with or with out slides with videos clips.
Cheers, Renee
Ta, Renee
So just to be clear, do you see HFNC as an asset or should we not be using it? I’m just a little unclear as to whether or not you think HFNC is even worth using. I’ve been using it in the ED for about a month for hypoxic patients and it seems to work well especially for those with asthma. Maybe it’s just another case of positive thinking after I’ve told the patients they are receiving the latest and greatest oxygen therapies in the respiratory world. I’d like to hear your thoughts.
Rick, RRT
Love it to extubate onto directly in a patient I’m worried about. And I use it in a patient I want NIPPV on, but they won’t tolerate it.
My assumption has always been that most of the time, most of the oxygen is indeed leaking around the nose and only during inspiration are you getting a significant fraction of it. It seems valid that we don’t know exactly what that fraction is, of course. But then, we rarely have a full understanding of the physiology behind any intervention, leaving us looking at the patient to see how they are doing (just like with fluids in sepsis?).
absolutely
At our ICU we use the optiflow HFNC. Most of the time it is used while we watch the patient for days tire, weaken and become more distressed. As they deteriorate to the point of peri-arrest usually with a PaO2 40, on 100% O2, 60l gas flow, they are reluctantly intubated. this normally occurs 20minutes before shift handover.
The rationale: “sometimes you can get away without intubating them”.
Sorry typo, this should of read:
…usually with a PaO2 40, on 100% O2, 60l gas flow…
See John Greenwood’s article above, it supports your experience
sorry, i just read my edit, i think something is happening to “less than” signs as it keeps removing them, i was trying to say pao2 less than 8 and a resp rate greeter than 40.( and an LLS score of 1)
Scott, I would like to share the understanding from a respiratory therapist with HF NC. Prong size/fitting is essential to optimal performance of any of the devices. Prongs are to occlude no more than 1/2 the inner diameter of the nare to allow for escape of any “back pressure” that could be transmitted to the lung if the mouth is closed to avoid barotrauma. All of the commercial devices have a built in pop-off valve pre-set at 40cmH20 that provide additional safety to the patient. The high flow within the airways creates a turbulent gas flow within the large airways… Read more »
Carrie, You are a superstar–that is perfect!
Had the THRIVE author give us rounds today..he’s talking of apnoea times of >1 hour with no additional ventilation for some super complex ENT procedures, and has some videos showing his results…blew my mind…get him on the show!
v. cool
Hey Scott, Great summary and review as always. I’ve seen a worrisome trend of people citing FLORALI to justify HFNC as a reasonable strategy for pts with hypoxic RF rather than (in my opinion) what should probably be a tool used as bridge during intubation planning. Consider adding this study (http://www.ncbi.nlm.nih.gov/pubmed/25691263) to your pack. Just out of curiosity, are there any specific patients you are maintaining on HFNC? If I may, here’s my own little rant about the FLORALI study (STRANGE subtleties in protocol) 1. HFNC was not used as a treatment option for all-comers w/ hypoxic respiratory failure. There… Read more »
John’s comments added to the post above
Friction loss. Your firefighters will understand.
hi scott thanks again for the great review, as usual … My concens about FOLRALI trial: 1. The standard mask flow is much lower compared to high-flow nasal cannula (HFNC); I believe that this is a bias, and Venturi mask should have been used instead 2. Why the authors did not chose to compare HFNC with CPAP that is as simple, and has been shown to increase oxygenation (1,2), and decrease ETI criteria (3); in this way they should have finally answered the question whether flow or PEEP count 3. Primary outcome was not met; ETI decreased significantly only in… Read more »
agree with you on all points–writing an article for Annals of EM saying the same