High Flow Nasal Oxygen (HFNO): a standard of care for COVID-19 patients and beyond?

[Music] foreign [Music] states [Music] [Applause] [Music] [Applause] [Music] um [Music] [Music] fair and what scares me is that making those decisions and making those wrong decisions and the realization that that decision uh of that decision in three four weeks time where you end up having a patient who in effect can be crippled by life-sustaining therapy which may not have been in their best interests or their family's best interests and that still scares me and i think it scares a lot of colleagues but intense care is much more multidisciplinary now and i think that has helped our decision making and has reduced that fear factor honesty and humility go a long way and most patients and relatives understand that we're also human and mistakes can happen and should be openly discussed [Music] uh media auction together with my colleagues in particular the nursing colleagues we arranged a wedding for a patient who was at the end of his life and had decided to marry his long-term partner before he later died and it was very moving to be part of this very special event in the intensive care unit it's a real privilege to be able to support a patient and their family through that um what i hope is the worst thing that ever happens to them in their lives to to be able to support them through that hopefully to recovery or to support them through managing a dignified death most by [Music] a intensive care medicine allows me to learn something new every day so every day i need colleagues and i hear of their new technologies new advances and progress in their particular specialty but most importantly every day is a different day with new challenges and i enjoy the interaction with my colleagues and most importantly with patients and their relatives so it is a provides a great variety it's different every day and it's a specialty where progress is made on a on a regular basis um [Music] [Music] so i am a full-time intensivist and proud to be one we're all working together in a multi-disciplinary fashion to fight covid 19. together we are intensive care medicine hello i am internal medicine specialist and i am proud to be an intensivist we intensified start working hard to fight for kobe 19. together we are intensive care medicine thank you i am the editor of the intensive care medicine journal i am proud to be an intensivist we are working together to fight cove 19 and to take care also of non-convict patients together we are intensive care medicine i'm a nephrologist and i'm proud to be an intensivist we intensivists are working together to fight corvette corvit-19 together we are intensive care medicine i'm anesthetist and i'm proud to be an intensivist we intensivist are working together to fight covey 19 together we are intersecting good afternoon and welcome good afternoon everyone acicm uh webinar on iphone as oxygen for coin 19 and beyond and thank you for to massimo for supporting this webinar i am salvatore majora professor anesthesiology and critical medicine and chair of departmental necessity and critical care and the hospital kitty italy and it's my pleasure to co-share this session with professor rossello from fojo italy thank you thank you thank you nice to meet you and thank you for joining us um in this afternoon uh for this live where we were not all can explain uh between us all the effects related to the use of high flow natural oxygen uh and kavin and beyond so thank you for joining us okay so the the this webinar will be very charged of many many informations uh uh from different perspective and i suggest not to lose for the time to go in uh in the uh directly in the in the topics so michaela yes yeah it's with my great honor to introduce you one of the pioneer in terms of a non-invasive ventilation and use of age polynomial oxygen so professor majora uh is going to give us a beautiful view from his point of view about non-invasive respiratory support in covet 19 patients please professor thank you thank you michaela for a nice word so in the next few minutes i will talk about the use of non-invasive respiratory support and covenanting patients these are my conflicts of interest i received lecture free from dragon media on g healthcare so when we talk about kobe 19 patients we're talking with patients about patients who present the hospital very often with interstitial pneumonia with this ground glass opacity and sometimes associated with the aerial lung collapse from a clinical point of view these patients present with severe apoxemia not associated with dyspnea intake and this is why it has been called silent hypoxemia hypoxia and with normal respiratory mechanics and later on this picture may evolve to severe refractory epoxymia eventually associated with dyspnea tachypnea use of accessory respiratory muscle strong respiratory effort and impairment of respiratory mechanics now these patients particularly at the beginning of this of the disease course uh are often treated with non-invasive respiratory supports and we have several forms of non-invasive respiratory support technique to be used in these patients and in this slide i show you [Music] here the the the airway pressure tracing and the eye flow tracing with different techniques as compared to spontaneous breeding with standard oxygen for example we have the nazi flow technique where we set very high gas flow and with this technique we we can generate a modest level of peep then we have other form of non-invasive respiratory technique like cpap where we set one single level of pressure around which the patient the patient breathes or non-invasive ventilation with two level of pressure peep and pressure support to further support the respiratory muscle and this technique may be used with different interfaces face mask or the element now what we know about the use of these technique uh techniques in covenanting patients well we have several guidelines which then have been issued at global and european level and as you can see uh all the guidelines in some way supports the use of all this technique in general very weak or conditional recommendation and however most of this recommendation comes from the evidence collected in patients with apoxemia before covenanting pandemic so if we look at the uh the current guidelines that you use of this technique for example concerning nazareth flow we can see from meta-analysis or perform on different study on the use of nasal flow in hypoxiamic patients not necessarily covenanting patients that this technique does not improve mortality but significantly is associated with significant reduction in the intubation rate and based on this consideration the recent guidelines about the use of nasal flow in hypoxiamic respiratory failure recommending using this technique as compared to standard oxygen for patients uh with hypoxiamic respiratory failure this was a strong recommendation what about non-invasive ventilation where here the available results showing uh are more conflicting and in indeed uh meta-analysis shows no effect on non-invasive ventilation as compared to standard oxygen uh both own mortality and on intubation rate and for this reason the actual guidelines uh do not offer any recommendation but use of nav in these patients so i think that we should consider a couple of uh issues to better understand uh what kind of support to apply and how to choose the right support and right patients and the one first issue is the severity of patients uh for example based on oxygenation or the potential ratio for example in this study which was a secondary analysis of the lung safe study which was a very large study about the ventilatory management of patients with ilds both with non-invasive and invasive uh mechanical ventilation this this analysis was a focus in patient treated with non-invasive ventilation and uh what these analyses show is that uh while in the less severe patients those with a future fetal ratio greater than 150 there was no difference in outcome in this case survival between non-invasive ventilation and invasive mechanical ventilation in the more severe patients survival was lower with nfv essentially the same was shown also with dustless flow for example these a very small retrospective study uh performing covenanting patients in china and again also for this technique you can see that the failure rate was different based on baseline purity ratio with a very high failure rate greater than 60 percent in in the less severe and essentially no failure rate in the uh in the less severe so one thing that we can see is that we we can say for uh from this data is that both nav and nasal flow may be safely applied in the less severe patients those let's say with the peer 250 ratio uh greater than 150 but we must be much more cautious uh in the most severe patients another issue concerning specifically non-invasive ventilation concerns the interface that we use for apply this technique and for example we know from this study by patel and co-workers that the use of helmet non-invasive ventilation as compared with the face mask non-invasive ventilation inpatient severe yes was associated with a decrease in intubation rate and an improvement in survival so there is a difference between interface and from a technical standpoint the most striking difference between these two interface uh the nav technique with these two interface was the level of applied people which was significantly higher where the element would with the face mask was not possible to to set very high peak because of patient's intolerance and accessory leak now uh applying high peep with helmet which is also in general more comfortable for patients so uh these uh allows to apply this high level of peep for for a longer period of time as compared to face mic applying this high level people may have beneficial effects not only in terms of improvement in oxygenation but also in decreasing the additional lung injury that can be produced by the strong patient's effort leading to the so-called patients have reflected like injury in this study for example uh the researchers uh compare the effect of spontaneous breathing with high level of peep or with low level of peep so during non-invasive ventilation but in animals and in patients what they found that that when spontaneous bleeding was associated with high level of peep the level of the uh respirat the inspiratory effect was lower as compared to low peep so stronger effort with low pip as compared to ip and this was true in animals and in patients and was associated also with a decrease in the inflammation observed in the caudal and dorsal zone with low peep and this you can see with ip was prevented so the beneficial effect of ip may be in terms of improvement oxygenation but also rendering the spontaneous effort less injuries and uh very recently this network meta-analysis suggested that in general non-invasive form of respiratory support may be beneficial in apoxiamic respiratory failure of course with difference between the different technique probably an advantage of helmet and evs compared to face mask nib and that nasally flow but in particular with in this meta-analysis what what was clear is that was there was no direct comp comparison between helmet non-invasive ventilation and nasolabial flow oxygen based on this data together with domenico grieco which is the the the principal investigator of these studies and also other studies and massive montanelli from from rome who designed a first physiological study to compare uh nasal flow and helmet non-invasive inflation in 50 patients with severe apoxiam respiratory failure and 130 to 50 ratio and these were applied for too short period of 60 minutes applied in random order and uh the main endpoint were oxygenation in terms of pure 2 future ratio as you can see without manual invasive ventilation oxygenation was better but also this was associated with a decrease in the expiratory effort uh respiratory rate and dyspnea more evident with helmet nav as compared with nasally flow interestingly what we found is that the decrease in the inspiratory effort obtained with the helmet non-invasive ventilation as compared with another flow was stronger was strongly associated but it was strongly dependent but the the intensity of the inspiratory effort with nasal flow so if the patients showed a very strong effort applying the helmet was able to significantly reduce this effort and this was associated also with a decrease in transformative pressure while if the patients with nasal flow have very low uh uh inspiratory effort so no effort no no real uh patients less severe there was less effects beneficial effects in uh reducing these periodontal effects we helmet even an increase in transparent air pressure so the the conclusion of the study was that nav may be probably more effective than as a flow but especially in patients more severe oxygenation impairment and more uh vigorous inspiratory effort based on the results of this physiological study uh we designed a multi-central and romance control trial denial trial which has been published always with the domenico first auto and massimo antonelli from rome which was published few days ago in drama and this study compared again in patients in approximate patients with moderate to severe hypoxamid patients in four icu in italy you compare uh helmet nav and nasally flow and the the included patients were very severe with an average p250 ratio 100 and respiratory rate 28 and nozzle flow was set at the maximum gas flow and loaded by the equipment we use 60 liter per minutes the primary outcome with this study was the median number of days free of respiratory support within 28 days after enrollment and with this we meant days free of any form of respiratory support both non-invasive support and invasive support concerning the helmet this is the setting we use with the quite high level of peep 10 to 12 the same pressure with pressure support so air mat was used with a ventilator able to deliver pressure support ventilation with two level of pressure a very fast pressurization time very sensitive inspiratory trigger and this was the setting and concerning the primary outcome uh there was no difference in term of respiratory support three days between the two techniques however uh among the secondary pre-specified secondary outcome we we look also at the need for intubation we found a significantly reduction in of rate from 50 to 30 percent without mental illness inflation as compared to another flow and the cause of intubation were also significantly different uh with the less patients undergoing intubation with helmets because of hypoxemia respiratory muscle fatigue and worsening of dyspnea and also another press piece of eye outcome was the invasive ventilation three days which was significantly higher with element non-invasive incubation as compared to a nasal eye flow so of course one important thing could be to identify a subgroup of patients who can then may benefit the most from elementary and met non-invasive ventilation so we look at this index this core the oxygenation to the spinae score which is the po2 ratio divide this pnear with the most severe patients having a lower score higher score identifying less severe patients and we divided the population of the animal trial in in the less severe with the score greater than 30 or more severe when the score was below 30 and what we found is that in the less severe patients according to the score there was no difference in the information rate between these two techniques however in the most severe we found the uh greatest benefit of n-met non-invasive ventilation reducing the intubation rate which was in this case significantly lower so in conclusion i would say that uh both nozzle and flow and the ip and vase ventilation are probably the technique of choice for the non-invasive respiratory support in epoxying patients uh probably the non-invasive ventilation may be more beneficial in the most severe patients because in these patients may especially in these patients may reduce the intubation rate but in any case with any form of respiratory support i would like to say that it is extremely important a careful monitoring not to delay intubation and the institution of protective ventilation and i thank you very much for your attention okay so um after that i don't know if me michaela want to present also the second speaker and then we have a question and answer a discussion at the end of the tree presentation um otherwise i will do uh it is my pleasure to introduce john brownlick for the second presentation uh and the giants will talk about [Music] lose flowing copd patients patients acute hypoxia and crystalline failure giants uh come from the icu of the university hospital in leitzig in germany jones yes yes okay thank you very much for this kind introduction my name is since brony from germany i want to speak or highlight some aspects of the benefits of nasal high flow in copd patients and acute hypoxamic respiratory failure these are my conflict of interest in this presentation the research of nasal high flow especially for acute hyperxemic respiratory failure goes apart i think so 10 years ago one of the first papers about this topic came from spain from oil rocker in 2010 and he compared in this first study face mass with oxygen and the nasal hive flu and acute respiratory failure on only a low count of patients and these were patients with a high respiratory rate of 28 this was the baseline and in hypoxemia and they found in his study that nasal high flow is better if his can reduce the respiratory rate in these patients compared to oxygen face mass and has also an impact to the oxygenation measured in pao2 in this study from 227 to 77 mm mercury this was the first study would have shown the impact of nasal high flow and acute hypoxemic respiratory failure and a little bit later five years later jean-pierre frat you all know this study very good in investigated 300 patients with acute hypoxiamin respiratory failure and with in the mainly part of them the with pneumonia and they randomized these patients to a nasal high flow group to a standard oxygen group and non-invasive ventilation group when you see in this slide this is very severe oxygenation impairments in these patients and with a very high i have not shown here respiratory rate and the primary outcome of the study was the incidence of intubation and the whole group of these 300 patients they found no difference between non-invasive ventilation the standard oxygen and the nasal high flow but in the soup group with a higher impairment of oxygenation below 200 millimeter hg they found the benefit of nasal high flow in terms of intubation compared to non-invasive ventilation and standard oxygen and as a secondary outcome they investigated the probability of survival and they found that nasal high flow is able to improve the survival in these very severe and sick patients and as you have seen in the presentation by sabato maturi you can also see here nasal high flow is able to prevent invasive mechanical ventilation in a number needed to treat from 28 compared to oxygen and i think it is very clear that nasal high flow is able to prevent intubation after we have seen all the studies in the last year and these meta-analysis was published 2020 and i show you uh something about the results of this study without the helmet non-invasive ventilation this was shown by professor much sure here you can see non-invasive ventilation with the nasal high flow with the compar in the comparison of all-cause mortality and intubation rate and you can see nasal high flow is not able to reduce the mortality compared to non-invasive ventilation but both oxygenation strategies or support strategies can reduce the need for intubation as we have shown in this life before but very interesting in this work is the fact if you look at the sensitivity analysis especially for the oil course mortality in these patients you found if you exclude patients with copd no benefits on neutrality in terms of you use non-invasive ventilation and in this case if you exclude especially these patients you have no difference in mortality between nasal high flow and non-invasive ventilation so in fact in acute proximity respiratory failure could be the same in our patients and as also shown in the presentation before nasal high flow is the strong recombinated therapy in hypoxamic acute respiratory failure today but in my own research over the last year it was interesting for me to understand why nasal high flow is able to support ventilation auto bettering exaggeration and one idea of why nasal hive law is able to do this is that nasal high flow have a small increase in airway pressure there is a alveolar recruitment human organization of the areola ventilation and therefore an improvement in oxygenation but i think this is not the all uh tune in in all cases if you show on the left side you see compared non-invasive ventilation to nasal high flow with different flows that needs a high flow if you measure the mean airway pressure is very lower than in non-invasive ventilation if you open the mouse or nasal high flow is also not able to get such a high pressure like an enclosed system like non-invasive ventilation but their nasal high flow is able to increase the anti-exploratory lung volume and have a small peep effect in these patients but not the same like in closed system and if you compare non-invasive ventilation in your mind with nasal high flow you have very different pressure cycles especially if you use non-invasive ventilation you can increase the pressure in the inspiratory cycle and you have a small peep or a higher peep in the expiratory cycle this is not the same if you use a nasal high flow device if you in inspire your air in the inspiration cycle your pressure is very low in in the expiration you have a higher pressure so a small peep because you breath against the flow of the nasal high flow device this is a very important difference in my opinion that means if you need a higher airway pressure in your patient for instance with a sleep apnea or something else you should use a closed system like non-invasive ventilation and perhaps not nasal high flow device but this is only a part of our patients there is also another idea why nasal high flow is able to bettering the oxygenation in our patients if you think on your patients with a high respiratory rate with acute hypoxemic respiratory failure these patients include a lot of air with a lot of flow in their nose or on their mouths and the flow can be up to 150 liter per minute and if you use a low flow oxygen device in your nose you have an in occlusion of a non-oxygenated air from the room and if you have a higher flow and high respiratory rate you have a lot of non-oxygenated air and your feu2 in your airways is lower if you use the nasal high fluid device you include in these patients 40 50 or 60 liter per minute with oxygenated air and the additional room air who comes in is much lower therefore you have a better oxygenation during use of a nasal high-flow device because of the lesser admixture of non-oxygenated room air and i think this is a rare very important mechanism and you can see this also in this study i have assumed you know shown you the the clinical data from uh oreo rocker i've showed you before in this aviva study from rockstar from 2007 if you have a higher respiratory rate and and you compare this with oxygenation divided with a low flow oxygen your device your nasal hyphae device is able to stabilize the oxygenation in higher respiratory rate and that's why the oxygenation additional to the increase in end exploratory lung might be better when you can see if you see all the studies who have good data for this fact you see if you use the nasal high flow and measure the oxygenation in this patient you have better outcomes and an improvement of nasal high flow if you use this in higher respiratory rates there are some additional effects especially interesting acute hypoxemic respiratory failure but also interesting if you use the nasal high flow as a respiratory support device especially in copd patients it's the second part of my speech you see you can increase the tidal volume in these patients this means you have not only recruitment you have in these patients also you have a very low tidal volume if they have an uh hyper captaining and a half and decrease in in muscle in in breathing muscle you can increase the tidal volume in your patient because you can support these breathing in these patients and also in consequence of this the respiratory rate decreases in our patient the calculated minute volume is the same if you use a nasal high flow device and you can support very good the respiratory stress in your copd patients and this might be also a benefit if a patient with copd will have a higher dead space ventilation because of the muscle weakness in his disease you can reduce the dead space ventilation if you include your high flow your volume in the patients in every inspiratory cycle therefore your audio law ventilation might be better if you have no um not to use a high power to overwhelming the dead space ventilation or patients and this is a beneficial effect who can support ventilation in our cbd patients in all this leads to a reduced walk of breathing this is a very simple picture there are a lot of very good papers in the past published and you see here compared in copd patients to oxygen that nasal high flow is able to decrease the work of breathing in the obd patient but also in patients with acute hypoxamic respiratory failure there is also a very important effect from the nasal hyphen is so called washout effect of the aries this washout is not limited on the upper arrest this is also in the lower areas i have seen in the in the past and this is a very simple experiment we have used the nasal prongs in our knees on both knees on one years and also this with different flow rates and if you increase the flow rate from 20 to 30 liter per minute you can decrease the pco2 measured in cabin arterial blood and if you use the nasal hive with a higher leak it's the same like you can open the mouth you have a better decrease in pco2 and if you additional and this means than our d then you can increase the flow and you have also an additional effect and the best effect of decrease of plco2 and this is the function of the wash out of the areas in your ins by expired gas in your airways and there is another very important effect of a nasal high flow device if you introduce your warmth and humidified air in your airways this is very good for the comfort for this patient is good for the tolerance with such a higher flow like 50 or 60 mil per minute but in the other hand there is also an effect on your movement of your cereal in your airways and you have battering in some inflammatory processes this is a a little bit older study from kilgo and you see on the left side if you look at the movement of this area in your areas if your temperature in the areas or humidification goes down from 37 to 30 you can see the movement of your zero is not so good and the clearing end of your airways is not so good if you use a cold and not humidification device or oxygen and if you look at some data from copd our own group looked since 2012 in a study in patients with chronic hypercapnic copd and for the decrease of pco2 this was our first way before we can use a nasal high flow device in acute hypercapnic copd patients we proved this in chronic hypercapnia we randomized our patients to two allocations to the first allocation was to use the nasal hypha device for six weeks and then switch to non-invasive ventilation when the other group started with non-invasive ventilation and switch to a nasal hyper device and we recruited 102 patients on the primary end point was the pco2 change from baseline and the secondary endpoints maya lung function quality of life very important in treatment of patients with chronic hypercapnia with non-invasive ventilation and we found in our study a very clear sign nasal high flow was not inferior in case of the primary endpoint the reduction of pco2 you see this in this waterfall plot and the other part is the nasal high flow and the lower part is non-invasive ventilation and we found also no difference in terms of quality of life so we think nasal high flow is able to support patients with chronic hypercapnic copd and there is also another interesting study also in stable patients for your interest from denmark this is not the moon landing this is the the plan for the randomization of this patient in our location they gave 100 patients nasal high flu device at home and the other patients and standard oxygen this were partly hypoxamic patients and hypercapnic patients and monitored this patient for an exacerbation and the patients were at six months in the hospital and on the other wizards there had a telephone contact and they found that the nasal high flow is able to reduce the exacerbations per year and this was also true in the hypercapnic group this was published in this year this subgroup analysis and therefore i think nasal high flow is not only a good support of breathing in the obd patient but it can also reduce the exacerbation rate perhaps because of the humidification of the airways and the first data on patients with acute hypercapnic copd comes from our group on the left side you see the whole group of these patients with hypercapnia and on the right side you can see the oxydotic patients and especially on the right side we used at the first line in this patient there were no randomization no control group we used non-invasive ventilation all these patients had an intolerance of non-invasive ventilation in for many reasons and after that we used the nasal high flow device and we have shown in this observational study that the ph was decreasing after two or four hours and the pco2 was decreasing in our group and this i think was a good sign to make some more studies in this topic and one very important topic a study comes from italy published in 2020 there were randomized 80 patients with a hypercapnic acidotic acute exacerbation of copd and 40 patients went to the nasal hyphal group and the other patients were treated with non-invasive ventilation and the pco2 as the primary outcome parameter was measured two hours after randomization and use of the different devices and they found an intentional treat analyzes no difference between nasal high flow and non-invasive ventilation as a consequence all over the world there are some groups who look now for the use of nasal high flow in the strong recommended area of non-invasive ventilation the acute oxidative hypercapnic exacerbation of copd and want to prove the theory that nasal high flow is able to support also our patients compared to non-invasive ventilation and we have also today we get the um go from the attic committee to start our study supported by the german government to use nasal high flow compared to non-invasive ventilation for 27 hours this is the primary endpoint the switch of the devices is a combined unemployed debt and the use of an additional support or intubation this will start today and we want to include 700 patients in our analysis i hope we will have some answers for this topic and therefore i want to thank you very much for your attention in this topic and i gave back to professor mature for the next speaker thank you thank you very much jones for this very comprehensive very nice review on the topic and now we should move on and it's again my pleasure to introduce professor roseau we'll talk about the use of nozzle flow in the incubation phase both for pre-intubation and pair intubation and impulse distribution phase michaela it's up to you um switch to the mind can you stretch your okay thank you so much for the for the introduction for the presentation also uh for this beautiful talk so uh going deep on the on the mechanism which is the most um fascinating thing about eye flow natural oxygen uh as you can see um in this wonderful drawing by edward gallagher uh published on the blue journal in 2017 there's a huge amount of mechanism that actually all together can give an improved clinical outcome in the patient undergoing a trial of age flow natural oxygen and as you can see um the mechanism are so wide that is the reason why um the panel of experts published these these guidelines related to the importance and the the evidence based in terms of clinical application of the ae flow nasal cannula and so um in my talk we will try to figure out what's uh important and if there's any um clinical point of view for which we should or we should not uh apply iphone as well oxygen in the period period intubation and in the past exhibition period so uh what the the panel made for what regard but the peer intubation period is almost clear with mother entertainment um and what they say is that sorry oh okay can you see can you still see the presentation okay okay okay um and so what they say for the for the peer intuition period with moderate certainty is not recommendation and let's see why um so in this uh in this trial um as you can see uh published in 2016 and respiratory care a group of 40 patients has been analyzed and um the the authors of this study they compared and the uh the level of spo2 in the peer intubation period um when comparing the uh the application on iphone as a cannula to the bag about mask and what they found was really interesting because as you can see uh from the results there was no actually um difference between the two treatments so that's what they showed and also in terms of oxygenation um and so they say for hypoxemics respiratory failure uh there's no difference if you apply h1na cannula or if you do pre-oxygenation uh with a big mask bulb so uh no change in terms of of spo2 so the lowest level of spo2 reached in the pre-op pre-op oxygenation period was exactly the same again another wonderful job in this beautiful trial of the 313 patient analyzed in which they compared the non-invasive ventilation versus eyeflow natural cannula during the period intubation for the ethnic oxygenation within patients with acute epoxymic failure it's being said that for what regard the guidelines the panel made an observation for these uh for the peer intubation period of about ten trials five of them were on respiratory acute respiratory failure the other five were um in india so during general anesthesia so what they regard this uh this job what they found was that in the overall population which is figure a there was no difference in term of the of spo2 so the lowest level of sp2 was exactly the same when going from non-embedded ventilation or h clones or cannula but if you observe a figure b um in figure a was the overall population with acute respiratory failure and the pf ratio below 300 millimeters of mercury um while in the in in figure b they actually evaluated the behavior of the patient in terms of the lowest spu2 level for a patient with acute respiratory failure and a pf ratio below 200. and so there was a little bit lower level in terms of spo2 after the in the period intubation period for whatever that p a patient treated with age flow nasal oxygen but in the overall population there was actually no difference again uh another study of 124 patients in which they uh compared the effects of iphone as of samuel during endotracheal intubation when compared to face mask and as you can see for what regard the lowest level of spo2 during the very intubation period also in this uh in this study also in this trial there was no actually difference so uh it was exactly the same as you can see for what regard the two groups in terms of the statistical analysis again another study 184 patients in which they compare the nasal eye flow again with a a back bulb mask in critically ill patients and so also in this uh uh also in this study there was no statistically different and so the treatment was exactly the same and it was no statistically different uh in terms of lowest ssp2 uh between the two groups so the iso group and the standard math group um and then as you can see uh it's exactly the same for what regard uh this kind of population um the last trial that i would like to uh to point to the uh and with you to focus the attention on is this beautiful trial the optimist trial with 49 patients analyzed in which as you can see it's a beautiful study uh in which uh because of the apneic oxygenation even from the the use of icelanders of cannula um the two groups of 49 patients so 24 25 were actually um compared but with a different uh with a different friend one group was the treatment together with high flonase and niv versus uh nid alone as you can see there was actually a statistical difference in terms of minimal sptos po2 value and so the group with niv alone at a worse um spo2 value when compared to the group that actually uh used both uh nab and um iphone nasal cannula and so that's why uh for the peer intuition period this is the uh the idea given from the from the panel for the pay intuition period but let's see what what what was the the suggestion made from the panel for what regard the post extubation period so the panel said following excavation with moderator sanity conditional recommendation so it's a little bit different let's see uh starting from this beautiful job prop from professor maggiore published in 2014 on the blue journal in which they actually um compared the assets of i flow or nasal cannula versus venturi mask oxygen period for what regard the epoch exhibition period and so what they found as you can see is that in terms of oxygenation actually um given the period of observation 72 hours actually after the 30 the 24th hour there was actually a better oxygenation from patients going from a patient with a fullness or cannula enough of it to too conventional with them to remask oxygenation and plus there was a better saturation and also a better outcome in terms also of comfort and dyspnea in this kind of patient again always talking about respiratory rate comfort of the patient and also immunodynamic parameters such as heart rate this is a beautiful study of 17 patients by the group of the professor rita yamai in which they actually evaluated the difference in terms of post excubation going from high flow natural cannula versus cot conventional um oxygen therapy and they found a superiority um in terms of the comfort of the patient and respiratory rate and a better heart rate suppression using age glonass or cannula in the process of excavation period still um jama 2016 uh this beautiful of 527 patients of the of the group in which they evaluated the effects of plus exhibition eiffel nasal cannula versus cot circumventional oxygen therapy but in low risk patients and what they found was that as you can see there was actually a difference a statistical difference which was in favor of high flow and other oxygen when compared to conventional oxygen in terms of percentage of intubation uh and it was statistically significant um what it was uh uh another point uh the the the same group collided a little bit later so from april 2016 to october 2016 was the application of iceland or cannula versus this time nid but instead of low-risk patient this time was on iverse patient and so lower expression was co2 versus high flow iris patient with niv versus uh iflaw um and in the trial uh what they what the what the authors showed was the unknown inferiority um results in terms of the comparison between the two treatments and so they differentiate the the population which is the same thing that is enlightened in the in the panel from the expert uh when going from the the two uh type of treatment so uh either for non-embedded ventilation and icelandic or cannula so non-inferiority or eye flow and also no difference uh uh when evaluating the mortality comparison between the two treatment again another study which was on high flow nasal cannula to prevent post-extubation respiratory failure again in high risk patients and so uh what they saw was that was uh actually um they couldn't find um a success or either not success because the the the comparison between the two grouping 155 patients um and like that there was no statistical significance between the two and also from uh from uh from what regard all the other outcome bibles there was actually no difference at all so giving uh the data came in from the the panel of experts uh just to summarize we can say that for the peer intuition period uh the panel of experts made no recommendation for the use of age clonaze of cannula in the peer intuition period for patients who are already receiving age fluency or cannula the panel suggested in teenage foreign cannula during the intubation but with moderate that sad and conditional recommendation while for what regards post extubation respiratory failure the recommendation from the expert says that uh age flow as compared to coc follow and extubation it depends also from how many hours the patient is excavated so for patients undergoing a an intubation of probably 24 hours is fine but that they they they wanted to point out the attention on the fact that respiratory failure and patient with respiratory failure are different based on of course from the the pf at the the baseline and so uh if the patient are incubated for more than 24 hours and have an iris feature um is a conditional recommendation with moderate certainty evidence but for patients that already the clinician would put on niv ppv um the panel suggests to continue to use an ippb uh as opposed to h flow nasal oxygen without with the low certainty evidence and that conditional recommendation thank you so much for your attention thank you thank you michaela for this really nice and exhaustive presentation so i will now will discuss some questions or coming from sem tv and from social media and there are a few questions for example concerning uh i i think that there is one question which is important very actual uh cons concerning the pandemic and and the question is if uh just for sparing oxygen nav could be more uh interesting than nasally flow the concern is the co the oxygen conformation with nasal flow as compared to nav and uh i could say my experience and of course the first consideration is that we in the pandemic we should use what we have and what we know uh of course with the eye flow if we use very high flow rate six liter per minute uh of pure oxygen we can have a very uh large uh consumer we can consume much very high very high quantity of oxygen uh i and with nav maybe could be could be it could be better wha what what is your experience with that what do you think about this michaela jones do you have any comment on this issue i agree with you uh either for what regard patient in the icu but also patient on board so based also um on on how the patient is going and also based on what clinician are more um more practical with i would suggest the same uh as you say from your experience so is the pandemic there's a an emergency ongoing and and you have um not too much time to titrate uh and also to keep an eye on the oxygenation of the patient so uh probably i would suggest to choose what the the clinician is uh is more familiar with one comment about the the oxygen consumption i think in general you must admixture more oxygen if you have higher flow rates with a nasal high flow device this is in general the theory i think so but in the clinical practice i have also looked for a idea there are some opinions about you can spear some oxygen in some patients it is not really clear you have some patients where you must use a lot of oxygen if you're using a hyperbolic device especially in a higher flow rate but in some patients this is beneficial and support the respiratory the respiration that you can use a little bit lower oxygen in my personal clinical practice i see this very often there is no no rule that you can spear or oxygen or not but in general i think the idea could be correct i mean and please no no i was just thinking about the fact that uh maybe because of the the stable fio2 that you can administer with hpl network oxygen um it could be also an advantage from this point of view so okay there is also another question about how to set gas flow with another flow uh with the inpatients economy 19 my personal opinion is that in patients in general with apoxiam respiratory failure and coming antenna is not an exception i would start always with the highest six little per minutes and then i would eventually decrease the flow based on patient comforts what do you think about this yeah i totally agree yeah chance for you the same i start off with 40 liter per minute to to introduce the patients to the therapy but i go also to 60 billion per minute of course okay uh there is also another another question about uh which comes from social media about the duration of the nasola flow therapy for how long we can use this therapy uh and uh if particularly in cognitive patients there are risk of a crowned use of an isolated flow in in the question was mentioned particularly the risk of fibrosis i do not think that there is any risk of increa increasing risk of fibroids with the nasal flow but there are any risk of coming from a pro-launched use of nasal flow and for how long have you used this device in hypoxamic patients or covenanting patients for my opinion there is no problem to use nasal hyphae very wrong we look after some days to wean patients from nasal high fluid before of comfort reasons and the most reasons and the more patients said to me no i want to use nasal high flow once again and if you can good oxygenate the patients with a low oxygen flow it's the right time to to end the use of a nasal high flow device on the other way if you use the rocks index to predict your success of a nasal high flow device you should use the rocks index to have no delay of the intubation process please miguel no no don't worry don't worry go for it so we agree that's the the point uh personally i have used also in the past the nazi flow for days uh for many days without any risk so i would say that from this point of view i do not think that this therapy is uh [Music] able to increase the risk because of launched use there is a another question concerning combination therapy for example a couple of questions one is combining if there can be many any benefit combining nozzle flow with a simple face mask that's on uh adson mask uh not in my opinion but i want i would like to have also your uh your advice on this issue yeah i agree with you i don't know the question to use the nasal high flow with what kind of mask with atsun mask the simple face mask yeah okay okay simple phase mask for for for conventional i think this makes no sense okay so we agree on that while another question is concerning the combination of nasally flow the combination of nasal flow with the nav in cova 19 patients so what i could say is that there is one report uh in which nasa live flow was combined with helmet cpap and the combination was able to a little bit combine the advantage of being over having a high another gas flow with the advantage of setting a high level of pip because we know that with nazareth flow the level of pressure peep that we can generate is quite modest if we combine we can increase the level of peep do you have any experience or any other comment or data i would say that i i i should say that i i have never used this combination because it is quite complex for now and i think that we could probably choose the different technique if we need different effects but so my experience is also is only based on a single report i know from the literature do you have some experience on this or you have any comment on this [Music] on this use of muscle flow combined with other technique we uh saw in in our iq uh in this period of uh pandemic what we are doing is that uh when patients are on on uh on on cpap for instance and we want them we want to allow them to to eat sometimes we bridge therapy on age flow nasal oxygen and so usually we use to alternate the technique so we go from cpap to h clone of oxygen during the feeding period and then we go back to cpap so this is my experience for now this is also our experience but this is different this different [Music] than combining the two technique together uh again i i know that has been described it could be it could have an advantage but for now we have no really clinical reports saying more than this more than physiological effects for now the technique is so complex combining the two together that probably the advantages are not so counterbalanced by the complexity of the technique um there are also a question concerning risk of nazi flow a few comments were interested in knowing if giving 60 liter per minutes may be really protective for the lung the question was if this is gentle for the lung or it can be associated with some form of trauma not necessarily in the lung but also in the hard way not for what i know at least has not been described from a clinical point of view i do not have experience in that sense in meaning that i do not believe that there are any physiological reason why 60 liter per minute may be deleterious and generally especially for the several epoxiemic patients this is quite well tolerated [Music] michaela jones do you have an experience with the risk related to the use of eye flow through the nose for the our way and the lung okay no so the question is clearly no there is uh also one uh question about use of nasal flow and saline hypoxia um and we know that saline epoxy is due to the fact that there is a dissociation between between hypoxemia that can be also severe without dyspnea without a major impairment respiratory mechanics and we know that and this is why we have silent hypoxia and we have dyspnea only when hypoxemia become very very severe below let's say 30 millimeter of mercury and this is associated generally with an increase in co2 in the in the very late phase of acute respiratory failure apoxamic respiratory failure so uh the the robin as a flow for silent epoxy is just to correct a hypoxemia as any other device oxygenation device so maybe maybe better as we we have seen that simple oxygen and at least comparable to other non-invasive technique your experience in this i think also in this situation it is very important to to support the ventilation because of this effect not only to correct the hypoxemia to prevent an increase in hypercapnia this is more beneficial because of the isoflow compared to standard oxygen there is a question that i think is more for you gents is the replace for another flow at home for copd patients i think that your presentation is already uh at least in part answer to this question but would you like to add something else on this question the the role of nazareth at home in copd patients yes in my opinion it's could play a role because of we want to correct the hypercapnia in our patient we want to decrease exacerbation votes was shown in studies we have no information about mortality this informations are lacking we do it in this way if the patients have no tolerance of non-invasive ventilation we try with the same outcome parameters a trial of nasal high flow and if you have a benefit we bring the patient with the nasal high flow at home thank you there is another question uh which is concerning the use of non-invasive respiratory techniques in cognitive patients or apoxamic patients if understand correctly the question is that uh it if nazi flow fails is it better to intubate directly the patients or uh there is room for trying another technique for non-invasive respiratory support this is a good very good question because we are really confronted in uh quite often in this video with this issue i think that uh if the patient is strictly monitored and intubation is available uh ready ready available and if we have experience with non-invasive ventilation we can do a trial of nav before intubation also trying to understand why nasally flow has failed a trial meaning uh 30 minutes one hour and just take a look what is going on concerning oxygenation uh respiratory effort intensity of respiratory effort and dyspnea and respiratory rate and so um [Music] otherwise if we are in less safe context maybe it could be better to introduce directly to the patient what do you think about this yeah i agree with you i think the same i mean if you have the the opportunity to monitor the patient uh uh and the patient is not far from the intensivists which can actually look at the rocks index or either evaluate some other signs of inspiratory effort then maybe i would give a trial otherwise go straight to intubation i think also the decision must be case-based okay okay is there a role for the roxy index in the in this context yes i would say yes of course i will remember the roxy index is the rash of sp02fu2 divided by the respiratory rate and [Music] it has been validated for uh intubation for trying to identify patients who is going to fail with another flow with the value of the when this value especially is below 2.85 after the first two hour or likely higher after six hour and also it is important to look at the trend and it has been shown shown also that a gas flow challenge uh the modification of the rocks index with the gas flow challenge may also help in identifying the patients that are at higher risk of intubation uh there is another question just one second because i need to to reddit uh concerning the risk of [Music] of the there is one question concerning the oxygen toxicity when using 100 pure oxygen both with nasal flow and with nav of course there is a risk but that's the reason why we need also always to balance benefit from risk and we need to have a target of oxygenation which is uh the the minimum acceptable uh usually we we say between 1996 of uh situation and 50 55 to a 80 po2 and so we we need to optimize the oxygen uh the fu2 based on a quite modest uh oxygenation target and also there is another question concerning the use of nasally flow for winning [Music] for mechanical ventilation in patients with tracheostomy so do you have any experience with that no i think i haven't experienced we have published that on this but they're they're only a future they want to there are only a few informations about this topic you have published such a study yeah i think this is a question for you yeah yes i would like to have also your opinion in the study we published we look at the effect the physiological effect of high flow delivery through the tracheostomy is compared on to standard muscle flow and what we found is that the physiological effects are modest with iflow because it's an open circuit and there are only modest physiological effects present when we apply the highest level of gas flow 50 liter per minute in our study in this case we have a small amount of pressure generated into the always small improvement in oxygenation respiratory rate but these effects are clearly much less important than those seen with the standard muscle flow however there is also some uh importance concerning to the delivery of humidity in the airway and we have a recent publication on new england journal medicine in which they have used this technique of high flow delivery through the tracheostomy for optimizing humidity and they compare intermittent high flow uh with the intermittent closure of the tracheostomy uh as a way to win from the uh from the tracheal as compared to continuous application of of the high flow and counting the number of suction needed uh as a way to to drive winning and they found that the continuous application i flow uh was better that intermittent use and a periodic closing of the tracheostomy so i think that there is a role not necessarily for not necessarily for the physiological effect which are different as compared to nasal flow but also because of improved improvement in gas conditioning to the to the to the trachea i think that maybe we have we have late now but we have room for one last question uh uh can we use nasality flowing patients who do not cooperate with nasal breathing and keep their mouth open what is your experience i think yes if you need not such a high peep you can use nasal high flow in this patient it's very comfortable of course it it is still meaning what what you want in this patient if you want to oxygenate if you want to wash out more co2 you can use nasal high flow and it's equal that the mouth is open this is no problem it's again it could be beneficial in some patients i remember my patients with cystic fibrosis have not tolerate non-invasive ventilation and have a very high hypercapnia we use the nasal high flow on both nostrils the same what i say in my speech and then we use it in only one nose trail and the hypercapnia decreased in this patient it can be beneficial especially also in this patient but if you on the other hand need a high pressure like a very obese patient with a sleep apnea and the sleep apnea is the problem in this patient you use a pressure in a closed system in my opinion that's why i cannot clog our clothes out that nasal hypo cannot be beneficial in non-cooperative patients miguel any anything to add no i'm good thanks i would say that at the end we could say that we are quite lucky in this period because a difference from previous year we have increased our armamentarium of non-invasive technique or respiratory support and i think that we should increase our knowledge of this different technique in order to uh also understanding the physiological effect in order to choose the right technique for the right patients at our time and uh finally to deliver personalized uh respiratory support um with this consideration i think that we should close i would like to thank you all uh all of you all the speakers uh my co-chair michaela rousseau and all of you the audience of this uh nice webinar we hope that you find this uh interesting and we like also to thank you massimo for the support they give to the for the realization of this of this webinar so i think that we can close and i thank you again all and goodbye thank you bye [Music] [Music] [Music] [Music] [Music] [Music] [Music] [Music] you

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Length: 94min 20sec (5660 seconds)

Published: Thu Apr 22 2021