High Flow Nasal Oxygen in acute respiratory failure

common 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 um 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] ocean 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 um through managing a dignified death be [Music] 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 is [Music] [Music] i'm a critical care nurse i'm proud to work together with other professions as a multidisciplinary team to fight covet 19. together we are intensive care i am an anesthesiologist and i am proud to be an intensivist together we are fighting kovid 19. together we are intensive care medicine i am a critical care nurse and perfusionist i am proud to work in the intensive care unit we are working together to fight coveting and together we are intensive paramedicine i am internist and i am proud to be an intensivist the intensivists are working together to fight covet 19. together we are intensive care medicine [Music] good afternoon everybody we are delighted to host you today in this webinar that uh that will discuss the specific role of non-invasive ventilation with focus on high flow nasal cannula have a uh a group of fantastic speakers today and with no further ado let me ask my co-host dr frat if you can first introduce the speaker thank you very much sharon it's my pleasure to to present roshberg working in hamilton canada department of medicine and critical clinical epidemiology and biostatistics at mcmaster university and he is an expert on meta-analysis he published many meta-analysis and also many guidelines on the use of niv and recently on the use of high-flow natal oxygen therapy thank you bram to start this session and you have 15 minutes thank you jp and sharon for the kind introduction and it's absolutely my pleasure to be presenting today on high flow nasal cannula and acute respiratory failure specifically discussing what the guidelines say in terms of declarations i should mention i treat patients with acute hypoxemic respiratory failure i am an adult intensivist i do work as a methodologist for a number of national and international organizations and was the methodologist for the european society high flow guideline which we'll talk more about no other academic or financial conflicts of interest to report this is the guideline that came out just in the last few months we addressed four pico questions as part of this four clinical questions uh the use of high flow in the setting of hypoxemia post extubation peri intubation and in the post-operative setting and it is for these four indications that we'll discuss some of the evidence and recommendations a little bit more we were fortunate enough to actually publish each of these meta-analysis as standalone publications in icm ccm or chest which was an added benefit here and provide more details around some of the evidence summaries before i get into some of the details i thought just for a moment it might be interesting to discuss how the generation of guidelines in producing trustworthy guidelines has evolved over the last 10 or 15 years and really with the publication of this guideline we can trust from the institute of medicine a lot of these main tenants came to light conflict of interest management is crucial both academic and financial and this guideline was no different we had very strict rules in terms of reporting and who could be involved in which questions having a representative panel including multi-disciplinary stakeholders is crucial to make sure that all viewpoints are heard coming up with questions prioritizing outcomes ahead of time also crucial as you've seen each of the questions is addressed with a standalone systematic review meta-analysis we rate the certainty of evidence for each of these outcomes and questions in addition to considering the evidence we also consider the ben the balance between benefits and harms the quality of the evidence individual patient values and preferences costs resources these are all combined when and considered when coming up with the recommendations themselves and they lead to clear actionable guidance for clinicians that's ultimately the most important and to do this all using a very transparent process we're left with either a strong or weak or conditional recommendation strong recommendations identify the fact that most well-informed patients would choose this course of action as opposed to conditional or weak and those are synonymous a conditional and weak recommendation are equivalent and here recognizes that the majority of patients well-informed patients would choose the recommended course of action but there might be a minority or at least a large minority of patients that would choose otherwise and and here it's where the benefit and harms more closely balance each other all right let's get into the meat of the recommendations and let's start with acute hypoxemic respiratory failure this is the summarized evidence across all randomized controlled trials looking at the role of high flow in hypoxemic respiratory failure and you can see for example for mortality for randomized control trials including 1400 patients address this outcome and looking at the pooled risk ratio 0.94 fairly difficult to make any uh assessment in terms of conclusions for mortality with wide confidence intervals that go from .67 to 1.31 so a fairly uncertain effect on mortality but our best guess is no real difference however when we look at intubation you can see reported across seven rcts 1600 patients and a statistically significant reduction in intubation in those that used or were randomized to high flow as compared to standard of care this based on low certainty evidence you can see the upper end of the confidence interval approaches one or no effect but certainly our best guess is that the use of high flow in patients with de novo hypoxemic respiratory failure reduces intubation certainly consistent with what i see at the bedside as well i i think with the increasing use and high flow in the last five or ten years it feels like we're probably intubating less patient reported dyspnea reported in five rcts may be lower in those that are randomized to high flow although you can see wide confidence intervals and there's pathophysiologic rationale why patients with high flow might feel less short of breath and in so much that we're able to more closely match their inspiratory demands that you know when patients come in with dyspnea they're sucking back and and hoping for flows in the range of sometimes up to 80 to 100 liters per minute and standard oxygen therapy often not able to match those inspiratory demands whereas high flow that can achieve flows in the range of 60 to 70 liters per minute probably more able to match those inspiratory demands and therefore help alleviate that feeling of dyspnea we looked at complications and they were very heterogeneously reported and difficult to to summarize quantitatively but no difference between groups some have suggested that there could be harm in using high flow especially early on in these patients in so much that we might be delaying intubation and those that inevitably end up still requiring intubation and might this delay be associated with worse outcomes and this group from south korea examined this exact question using a retrospective observational design 175 patients and they looked at patients that ultimately ended up failing high flow requiring intubation and compared those that failed early versus those that failed late wondering if if perhaps in this subset that are destined to fail high flow could the delay enacted with high flow lead to harm and they did see an increase in icu mortality and a decrease in ventilator-free days in those in the delayed arms suggesting that there could be some harm especially in those that inevitably end up requiring invasive mechanical ventilation in delaying things however obviously given the design there's confounding at play here and this requires further evaluation in larger prospective studies despite this the guideline panel when weighing those benefits a decrease in intubation compared to the harms felt like the benefits far outweighed any potential harms and made a strong recommendation for using high flow nasal cannula in patients with hypoxemic respiratory failure it was felt that high flow is relatively safe the largest complication described is usually nosebleeds from interruption of the nasal mucosa with the high flows but this is often compensated by using a humidified circuit we did find one cost effectiveness study that suggested actually cost savings with high flow despite the resource costs with purchasing the units this decrease in intubation and decrease with days requiring ventilatory support and icu support translated into net savings a lot has been made of the role of high flow in patients with covid and i think you're going to hear about this more soon in one of the subsequent lectures there's concerns about risk of aerosolization however i was involved with this review published in the canadian journal of anesthesia found seven eligible studies looking at healthy adults simulators and those with gram-negative pneumonia and at least from this review found no increased risk of aerosolization or risk healthcare workers when using high flow in patients with covet moving on from hypoxemic respiratory failure what about using high flow in the post-operative setting we found six or seven randomized control trials that specifically looked at this all studies used high flow in the setting of prophylaxis for post-operative respiratory failure rather than treatment and all studies specifically looked at high-risk surgeries surgeries like cardiac or thoracic surgeries and they dichotomize patients into those that were high risk those that were obese had a high aeroscout score or had underlying lung disease as opposed to patients that were at average risk and this is the need this forest plot summarizes the need for reintubation postoperatively and you can see that there appears to be benefits in those that were high risk which is not seen in average risk patients i do want to alert you to the fact that the numbers uh in terms of reintubation are rare so although it seems like there's benefit the number of events are quite small and weighing these pros and cons the guideline panel ultimately decided to make a conditional or weak recommendation for using high-flow nasal cannula post-op cardiac thoracic surgery specifically in patients that were high-risk or obese for a lot of the reasons that i've already mentioned one of the other benefits of using high flow in this population for prophylaxis as opposed to non-invasive positive pressure ventilation is that it doesn't necessarily always mandate a post-op icu admission and some of these patients may be able to be managed on a step down floor or on the ward thereby preserving resources as well the third question looked at the role of high flow in the peri intubation timing specifically looking at high flow for pre-oxygenation before intubation but also the benefits of high flow is that they can stay on even during intubation itself often not getting in the way of direct or video laryngoscopy we found 10 rcts that looked at high flow specifically in the setting 2200 patients five of these rcts were in perioperative patients undergoing intubation all high-risk surgical settings and five of these rcts were in critically ill hypoxemic patients looking at the peri intubation timing all of the interventions amongst these studies looked at as i said high flow both for pre-oxygenation three to seven minutes prior to intubation and also left on during intubation in terms of comparison seven of the randomized control trials compared high flow to face mask or bag mask whereas three of the rcts compared high flow to non-invasive ventilation and when we look at the incidence of peri-intubation hypoxia which is highlighted in this forest plot no matter whether we look at icu patients or perioperative patients it does not seem like the use of high flow here decreases the risk for peri intubation hypoxia and therefore the guideline panel actually made no recommendation for the setting of using high flow peri intubation some in the panel felt like we should still make a conditional recommendation for using and the panel was relatively split but ultimately with no evidence of benefits we ended with no recommendation i.e allowing clinicians to work as as they want to although we did recognize that perhaps for those that are already on high flow which we've already committed the resources and the costs it certainly would be reasonable to leave the high flow on their face during the time of intubation we'll move on to the last question that was addressed by this guideline the role of high flow in the post extubation setting we found eight randomized control trials summarizing sixteen hundred patients that looked at high flow post extubation i should mention that all of these looked at a high flow for prophylaxis for post extubation respiratory failure similar to the post-operative setting and none of them looked at the treatment of established post-extubation respiratory failure and amongst these eight rcts they were relatively dichotomized three of them looked at high-risk patients in which had one of these features that are listed and all three of these high-risk studies compared versus niv there were also five rcts that looked at low or unspecified risk patients in the post excavation timing and these five rcts and low risk patients compared high flow to conventional oxygen therapy and dichotomizing these results based on those that were compared to standard o2 and low risk as opposed to those that were high risk and compared to niv you can see benefit in high flow compared to standard oxygen therapy across the low risk population and no difference between high flow and niv in the post exhibition period and those that were high risk there were no differences in the other outcomes for either the high risk or the low risk population however probably not surprised to hear that high flow is generally better tolerated and more comfortable than non-invasive ventilation based on moderate certainty and so uh the guideline panel in looking at this data suggested using high flow compared to standard oxygen therapy following extubation for patients who are intubated more than 24 hours and have any single high risk feature at the same time they said for patients who clinicians would normally extubate to non-invasive positive pressure ventilation we suggested continuing non-invasive positive pressure ventilation as opposed to high flow and these were both conditional recommendations why did we say only those intubated more than 24 hours or with any single high risk feature if the benefit was seen in all low risk patients well it comes down to the absolute risk and the costs and resources that are are included for patients that are only very briefly intubated less than 24 hours and without any high risk features even a relative reduction in reintubation of 0.46 translates to a very small absolute reduction and reintubation with high flow and when you're talking about such a low absolute reduction makes you wonder whether the costs and resources associated with this are worthwhile however when you start looking at patients that were intubated longer than 24 hours and the risk of reintubation starts to increase especially with risk features that same relative reduction in reintubation with high flow translates into a larger absolute reduction and therefore probably more justifiable to entail the resources and costs associated with using high flow in this setting there's likely no doubt that there is a role for high flow and and probably under used in this setting around extubation i appreciate your time and attention and i will step away i think for the next speaker now thank you very much thank you bram it's a great presentation i think we will have there is a question but we will ask you the this question at the end of the session so now so i will continue with the introduction of the second speaker we are honored to have here uh professor sheila miatra professor miyatra is a professor of intensive care at the tata memorial hospital in mumbai in india she's president of the aaaid which is the all india difficult airway association she chairs the intensive care committee of the wfsa and she recently led a global delphi on the management of cov19 related um acute respiratory failure in critical care which was published sorry in critical care uh we're delighted to have you here sheila and the stage is yours thank you very much uh sharon for that kind of invitation uh greetings from india at the outset i'd like to thank the european society of intensive care medicine for having me here and i will be speaking about high flow nasal cannula oxygen strategies for use and patients and i will restrict my presentation to severe covert 19 uh patients and uh professor roschberg has already set the stage by talking about the perioperative uh indications of using high flow nasal cannula oxygen i'd like to declare that i have no conflict of interest academic or financial related to this presentation now when we have patients who come to the intensive care unit with acute hypoxic respiratory failure we either give them oxygen conventional oxygen therapy or we use non-invasive ventilation or high flow nasal cannula oxygen or sometimes even a helmet depending upon the availability so recently uh in the intensive care unit along with intensive care medicine along with audre de jong and jonathan casey we wrote this article on focus on non-invasive respiratory support before and after mechanical ventilation and professor roschberg has very beautifully uh given you all the evidence for the perioperative rule use and uh this is summarized very nicely in this uh cartoon uh the indications for initial auction strategies during tracheal intubation and after extubation as he's already outlined uh high from nasal cannula oxygen is superior to conventional oxygen therapy in patients with acute hypoxia respiratory failure uh well between nib and hfno uh there is um you know the trial from uh professor frat has shown no difference however in the subgroup of patients uh using high from nasal cannula oxygen they were increased 90 day benefit in 90 day mortality so that's why we are considering high flow nasal cannula oxygen more and more uh in these patients who present with acute hypoxia respiratory failure as far as during tracheal intubation uh in patients with moderate to severe hypoxemia especially in patients with p2f ratio less than 200 there is a benefit of using non-invasive ventilation and professor rashford has already talked about the benefits of ethnic oxidation that you can achieve using high flow nasal cannula oxygen because you can not only use it for pre-oxygenation during tracheal intubation but also can continue it during attempts at intubation and we've already got the study in any gm from jonathan casey showing the benefits of gentle mask ventilation during this procedure coming to after extubation there is a role as uh professor rashford has already mentioned for high flow nasal cannula oxygen and niv but only in high risk patients so we already know about uh the benefits of high flow nasal uh can uh cannula oxygen in patients who present with acute hypoxemic respiratory failure in uh in the ico and we're using a lot routinely to prevent uh you know intubations prevent patients going on mechanical ventilation so what is different in uh covadine teen patients they present to icu with acute hypoxic respiratory failure and they will need intubation so high flow can actually prevent uh many of these patients from getting uh intubated and should be extensively used so why do we have these reservations so if you look at high flow nasal cannula oxygen in coffee patients when you you start this therapy of hfido you're usually looking at patient benefit but inside with the sars cover 2 virus we're also concerned about risk of infection to the health care provider so this has really have concerns not only about the patient benefit but we're also trying to balance this against the healthcare workers safety so this has led to concerns because high from nasal cannula oxygen this high flow heated humidified oxygen that's going to the patient is considered as an aerosol generating procedure so are we exposing our healthcare workers uh to get infected uh with saskovictu while using this therapy should we be through using this therapy at all was really the question in the beginning of the pandemic so this is a study that was published in the european journal of uh respiratory uh care journal in 2019 and they did a very elegant study and this is of course not in covet patients it's a simulation based study and they use smoke and they looked at exhaled air dispersion during high flow days with candlestick therapy and they compared this with uh cpap using different different types of uh you know nasal prongs and they looked at uh different types simulated different types of lung injury both normal lungs mild and a different severity and they use high flow at different flows so hfno at 10 liters at 30 liters and 60 liters very interesting study stimulus simulated study and what did they find they found that when you use a high flow at rates um like 60 flow rate both in normal and mild disease compared to at flows of 30 and 10 there was a significantly higher exhale dispersion distance in and this was a distance median distance and mean millimeters so this led to concerns that probably even if we use hyphen nasal cannula oxygen we should probably limit the flow that we're using so early in the pandemic due to the hypothetic risk of transmission to healthcare workers at the beginning experts recommended uh either restricting the use of hypernal candle oxygen or if at all it was used limiting the flow rate to less than 13 critically ill patients now this recommendation uh led to intensivists uh either not using it or adopting an early intubation strategy because they were limited by the flow uh into early intubation was also practice for other concerns related to the pathology of the disease so the risk of bio aerosol dispersion associated with high flu nasal candle oxygen has since then been questioned and this is another very elegant study that compares high flow nasal cannula oxygen with a oxygen mask and looks at environmental bacterial contamination now this was not done in uh covert 19 patients but this was done in patients with bacterial pneumonias and this was a randomized uh crossover trial it was a non-inferiority trial done in a small number of patients and they looked at the environmental contamination using bacterial tray plates and also air sampling and very interesting findings um so they looked at the gram negative bacteria and the total bacteria count at day one day two and day five and if you notice that there was no difference when hyphen nasal cannula was used uh compared to conventional oxygen therapy in terms of the contamination with the gram-negative bacteria at various decisions or even the uh air pollution so uh high flow nasal cannula and doctor rashford has already alluded to this and this was a systematic review that was done uh for the who and professor rushwork was a part of this systematic review where they looked at the effectiveness of the aerosolization the dispersion and the infection transmission and this was a small number of studies only seven studies three were in mannequins three were done in covid patients and one was this study in bacterial pneumonia and what they found was uh definitely there was a benefit with use of hyphenase can oxygen to reduce the need for invasive mechanical ventilation in these patients but there was very low certainty uh you know the uncertain findings with regard to droplet dispersion and aerosol generation so nothing to recommend that there would be these concerns if you used uh you know different flows and whether we should or should not be using it so no real concerns shown of course these were small uh studies mannequin studies but this meta-analysis did not show any difference now uh there's uncertainty about whether this is an aerosol generating uh uh you know where it generates aerosol and at what distance and however we do wear our personal protective equipment and over time we've begun to realize that perhaps if there is a benefit to patients with covet 19 and we could avoid incubations that known benefits non-covet patients uh why don't we use it and we know that appropriate pve should protect us so more and more confidence has come in using these non-invasive uh therapies that were presumed to be aerosol generating now um other this is a very interesting study that i found in the annals of intensive care and this is from a group of french intensivists and what they did is they put surgical mask on top of the high flow nasal cannula oxygen and they showed that it could improve the oxygenation in critically ill patients and these patients who present with hypoxomic respiratory failure so very interesting study they looked at just using high flow nasal cannula oxygen and using hfno with a surgical mask and they compared different aspects the pao2 the sao2 spo2 the p to f ratio and they also looked at the partial pressure of carbon dioxide because they would be concerned that there would be an increase in these levels and very interesting whatever concerns were expressed were not really realized and their study shows that a surgical mask when it's placed over the patient's face was already treated with a high flow nasal cannula device would actually avoid offer an advantage in terms of oxygenation in covert patients and this oxygenation improvement is also associated neither with a clinically significant change in uh the partial pressure of carbon dioxide and nor were there any uh sort of subjective patient complaints and this was a review that was published in uh critical care very recently and they have looked at practical strategies to reduce the nosocomial transmission to healthcare professionals providing respiratory care with covid19 and they've looked at the various strategies which uh put the healthcare worker at risk and if you look at high flow nasal canada oxygen they've said the recommendation they've made is that you should have a proper fitting nasal cannula and you should and you should try to place a surgical or a procedure mask over the high fly nasal cannula to prevent further transmission or risk to the healthcare workers now what evidence do we have for the use of high flow nasal cannula in covid19 patients uh in the intensive care unit now this is a very elegant study using high flow nasal therapy to avoid invasive mechanical ventilation and this was done in covid pneumonia this was a study it was a retrospective study done quite early in the pandemic published analysis of intensive care and done by a french group and here they compared standard oxygen therapy versus uh high flow nasal cannula therapy and this was a retrospective study and the primary endpoint was to look at invasive mechanical ventilation and as you can see there was a difference in the primary outcome between the use of hypernasal canal oxygen and standard option therapy when looking at invasive mechanical ventilation but this was a small study and a retrospective study and it showed that high flow nasal candle oxygen covered 19 patients with acute respiratory failure was associated with a lower risk for invasive mechanical ventilation another uh study that was performed uh by um alexandra de mol at all and this was published as a letter in the blue journal high flow nasal cannula oxygen critically ill patients and here this was again a retrospective study and they looked at 379 patients in the intensive care unit and they compared those who received high flow nasal cannula versus those who did not receive hyphenase in canada and this study it was a propensity score matched analysis were done and they this on the x-axis as you can see these were the days since icu admission and this was the proportion of uh the events uh leading to invasive mechanical ventilation which as you can see were much higher in the patient in which high from nasal cannula oxygen was not used now this was another study from a professor artigras and using high flow nasal cannula in patients with covid19 and this was a prospectively done study and they looked at high flow nasal cannula and early intubation and compared uh these two and these were patients who presented to the intensive care unit who are on oxygen therapy not ventilated and they looked at intubation within the first 24 hours this again was a propensity math study and finally they were able to get a matching in 561 patients in both the arms and uh their primary outcome was ventilator free days and the length of icu stay and there was a significantly uh lesser more number of ventilator-free days and lesser stay in icu in the patients who were in the high flow diesel cannula oxygen group so they concluded that the use of hyphen nasal cannula upon iso admission in adult patients with covet 19 may lead to an increase in ventilator-free days and a reduction in isolant of stay when compared to early initiation of mechanical ventilation now these were small studies retrospective studies one prospective study now do we have any data on what are the predictors of failure when you use hyphen nasal cannula oxygen therapy with acute respiratory failure because this is very important uh information and this was again an observation study but a multicentric study done in spanish 36 spanish and honduran uh intensive care units and they screened over a thousand patients 259 patients were finally included and 140 of them were not included and 119 patients were intubated and these were patients who received high flow nasal cannula oxygen and when they did a regression analysis to look at what were the predictors of failure in these patients who received hypernasal cannula oxygen uh it was the non-respiratory surface core and also the rocks rocks indrex which is the ratio of the p2f ratio divided by the respiratory rate and they had a cutoff value of 3.5 so these seem to be the predictors of failure when hyphen nasal cannula oxygen was used in covet 19 patients so small studies retrospective studies prospective studies with propensity matching done but no uh respective randomized controlled trials and uh this kind of limited data leaves us uh you know really asking as to what is the role of high flow nasal cannula oxygen and very recently i'm all i'm sure you've all seen this paper that's published in jama and this is from professor antonelli and his group and this has compared the effect of helmet non-invasive ventilation with high flow nasal cancer oxygen and looked at the respiratory free uh day support in the intensive care unit and this was in moderate to severe hypoxic respiratory failure and their primary outcome was days free of respiratory support and a very nice elaborate protocol that they used and when they looked compared hyphen nasal cannula oxygen with um non-with helmet non-invasive ventilation and when you look at the primary endpoint respiratory support free days there was really no uh difference between the uh two interventions and the authors concluded that in critically ill patients with moderate to severe hypoxemic respiratory failure due to covert 19 the helmet non-invasive uh ventilation compared to a high flow diesel cannibal oxygen resulted in no significant difference in the number of days of respiratory support within 28 days for these patients of course the helmet may not be available across the globe and that gives you some confidence that there is a good role for using high flow nasal candle auction uh in these patients with uh covet 19. so looking at the kind of studies that are available very small studies no randomized controlled trials small studies retrospective prospective studies but with propensity matching uh we thought why don't we do a delphi on the uh use of hyphenase and cannula oxygen uh and um you know try to establish what the exact role of high flow nasal candle oxygen should be in patients with uh covid uh 19 and we did this expert consensus statement using this delphi process and professor enov and professor jaber are part of this delphi process so i was very i'm very proud to have led this expert consensus statement uh this delphi process that was published in critical care in march along with dr prashant nasa and the team steering committee and 39 international experts and very good geographical distribution of these experts uh 20 countries six continents uh just in brief we did had multiple choice questions like scale questions and we used liked statements more than 70 was considered as consensus and for multiple choice questions more than 80 and we also assess stability between the last two rounds and uh based on this we were able to achieve over 73 consensus in the management of acute respiratory failure and based on our statements we were able to produce 20 clinical practice uh statements and i'll just talk about the uh statements on high flow nasal cannula therapy what was the consensus among the experts and they accepted that high flow nasal therapy should be considered as an alternative strategy for oxygen support and in brackets is the percentage of consensus high flow nasal cannula therapy should be used in patients who are unable to maintain saturation more than 90 using oxygen delivery through a venturi mask and also may be used in patients with increasing oxygen requirements and uh you may need to uh this therapy may avoid the need for trigger intubation in uh and invasive mechanical ventilation so in conclusion i'd like to say that high from nasal therapy should be considered as an alternate strategy for auction support in covet 19 patients and these concerns about transmission of infection uh has not really been established and this should not limit the use nor the flow uh the flow that you're using for hyphen nasal cannula oxygen and we have preliminary data that shows that high flow nasal oxygen in these patients reduces the need for invasive mechanical ventilation can lead to increase in ventilator free days and a reduction in the icu length of strain with no if uh apparent effect on mortality of course we need future studies to confirm these findings because the data is very limited uh strategies to reduce the infection for the healthcare workers should include the appropriate use of personal protective equipment a properly fitted nasal cannula and also wearing a surgical mask over the nasal cannula thank you very much for your attention thank you very much professor miatra for a fascinating talk very important one at this time we are particularly grateful for your having found the time to do this talk given the difficult uh circumstances in your country it's very much appreciated and we will have questions for you at the end so please wait um and jean-pierre would you like to continue with introducing the next speaker yeah thank you sherrod so now uh i'm very pleased to introduce samia jaber a french guy working at montpellier in south of france very nice place he's working in the department of anesthesiology and internship care and he has a lot of publication and ventilation about airway management and also non-invasive support thank you samir you have 15 minutes thank you everybody thank you jean-pierre thank you sharon i'm very happy to be with you first of all i want to thank shayla as said by sharon in this very difficult situation in india of all what happened and i want to say to her we are all with all the people in india in this very bad situation uh i will try to focus mainly my talk on the perioperative on post operative my conflict interest i'm a consultant with honorarium with the facial pace company and i have no difficulty to say what i want to say with fashion pacquiao because they never influenced my different talk since more than 10 years this is my objective during the next 15 minutes the question is which ventilatory support could be used after surgery now actually we have the possibility to use as said previously non-invasive ventilation using icu or home or dedicated niv ventilator i can use an iev or cpap on ventilator and now more recently as presented first by bram in the first talk we can use high flow oxygen the rep sorry because during my talk sometimes you will see some slide with high flow oxygen therapy and other with hopki flow with the cold name of fascia pica that is exactly the same for discussion just five minutes to recall some physiological point of view for the more young people that's what uh what are the main ventilatory support especially after surgery or after distribution to prevent reintubation or to trade first of all this is the airway pressure in yellow you having why the flow this is actually you're on my spontaneous breathing ventilation this is my breathing pattern as you know you are a sinister downflow with uh zero centimeter prisminus one sentiment of water in the mouth so when you use uh you applied a positive and expiratory pressure as you see for example eight centimeter of water which called continuous perceived every pressure when it's used alone called cpap and it's called pip when it comes with another positive money you have also a synonym flow and you just have the difference that you not reach zero but you stay at eight centimeter of water at end of expiratory pressure so what is non-invasive classical ventilation is when you applied another positive pressure with a dynamic one which is called almost often driving positive pressure you know here we unciflated seven centimeter of water often called pressure support ventilation then you have seven plus eight it's uh 15 sentiment of water positive and expiratory pressure in all in the algorithm at the end of inspiration so it's often called non-invasive ventilation by pop or psv pre-speed and the difference is it's that is active non-passive like cpap because you need to deliver a pressure this it's deliver a very decelerating flow because it's more physiological and as you know at the start of inspiratory you have the maximum flow that what we use this mod in nav this and where we can place high flow this is my personal point of view and high flow is between standard oxygen and cpap not exactly a cpap or pip one because in reality you stand down at zero at end but expiration but it's like a cpap a light cpap because you can deliver two to four sentiment of water at an expiration in the majority of the cast but not more so what can imagine the approach as said that brown first told you have a curative one on the profile active or preventive one creative application of anterior support is when acute respiratory failure is present and the objective is in this situation to avoid intubation and contrary to prophylactic or preventive is to try to avoid the occurrence on acute respiratory failure in patient without acute respiratory failure many in present at high risk that's why when you look uh the different for example meta analysis you will see that we classified the patient at high risk or low to moderate risk obviously you have a reason because it's not very strict and for each situation each indication you have you can use a low pressure which is optiflow because you have very low uh positive and expiratory pressure you can use a real cpap which can reach more than 10 or 50 centimeters of water and you can use a non-invasive ventilation mainly when you have an hypercapnia associated to hypoxalia just a small publicity for the journal is you can read the last number of intensive care medicine journal in december when you have all what every physician should know an acute respiratory failure on mechanical ventilation and you have several paper on high flow especially as you see this by brown brush well who manages this very nice clinical practice guidelines and other by jean america and all the specialists the experts in the world participated to this you have i you have to read these nice guidelines produced by the [Music] european society of uh intensive care and anastasia uh leading by by mark leon and cheryl as you see and you can find some recommendation uh according the evidence as you see you have low quality evidence to suggest the use of ash high flow oxygen for hypoxamic after cardiac surgery but you have you see here the recommendations also are weak for other situations but we will discuss this situation this is the same slide showing first by uh brahm in the first tool that you can have three figures in the original paper you will see that in high-risk population you don't have less escalation of respiratory support however in the average risk population you have some benefit in favors of high flow oxygen therapy so just the progress to use the high flow you can for me it's more easy to uh to always separate the free function of the ventilation system that the airway system the gas action that is the lying function gas exchange and the muscle pump that is mainly the muscles the diaphragm so what are the action of the high flow oxygen mainly in using high fio2 in gas exchange you have the effect of the cpap pip light even it's a very low less than 5 centimeter between 2 to 4 but it's sometimes efficient and this could be also affect the diaphragm mobility and in my point of view also you have an effect never reported but now we are going in montpelier study to evaluate the effect of upper airways because we observe it in our practice meaning after surgery in obese or in patient in person is a care like that like cpap especially in patients with in obese patients with obstructive sleep apnea you can have the same effect that the cpap and maybe you can limit it the the decrease of the upper airway diameter in this situation maybe it also participated to the effects that you observe obviously you have for me it's the main action is the conditioning of the gas mainly the humidification and the heat which allows better uh mucociliary clearance and in my point of view this is probably the main action that we observe it will observe the positive effect in this situation this is my personal point of view obviously we can discuss this one the second objective one is the dates paid washout which could be very benefit in some patients especially in some hypercapnic patients or observative patient then you have the addition of all of this physiological effect you could improve the comfort of the patient and the results are the decrease of inspiratory effort mainly by decreasing the work of breathing this was clearly and nicely reported in this uh paper that presented first uh leading by jean damier and gonzalo hernandez which explained the different mechanisms that are presented to you in this right this is the same one you can see you have probably five major effects which could explain but probably the minification could explain why in high flow oxygen very high you have the positive effect is to understand why we could use this in the first operative period this slide summarized the main modification of respirative function as you see which leading uh restrictive syndrome all the association of these and a diaphragm dysfunction with a hypothesis this is a vicious circle as you see which leading to hypoxia with respiratory failure and ammonia which could worsen by the food overload during surgery and during the anesthesia management the consequences of a postoperative pulmonary complication as you see you have an increase of mortality patients with acute respiratory failure after surgery reported here seven sixty percent of mortality in comparison to zero point three percent uh with patient patient without nuclear respiratory fever that our challenge is to avoid the this complication after surgery this is like to summarize a different strategy from the left to the right you have standard oxygenation you see here very low oxygen therapy the high mass concentration the high flow oxygen and the different strategy of high flow cpap by papa navy and at the end unfortunately intubation for invasive ventilation so the paper this uh by leading by abram as you can see uh abram presented us the five and the four main recommendation and we'll focus on this uh surgery part and then you see the abdominal cardiac and thoracic this is my with my friend emmanuel fiti we published recently the pub ventilation it's the approach that we should avoid the complication after surgery by using positive pressure from the beginning the pre-operative intraoperative and post-operative and reported the effect of non-invasive ventilation by the never study we showed that the niv could decrease the rate of reintubation in patients who developed acute respiratory failure after abdominal surgery you can see here we decrease by 30 the rate of reintubation so what about the prevention of hypoxemia after surgery we performed with our group the opera study opera study leading by uh emmanuel treaty and our colleagues is to evaluate high flow oxygen to prevent hypoxemia in abdominal surgery you see here um the criteria we anticipate duration of surgery at least two hours or more we not included the obese patient and the emergency surgery in this situation and the primary outcome was the hypoxania one hour of extubation and at the end of allocated treatment the secondary outcomes are the classical ones however so sorry the results are totally non-significant between the two groups that mean between high flow oxygen therapy and standard oxygen therapy in terms of occurrence of postoperative hypoxemia and the same is true for the post-operative complication so it's really we were disappointed and the same is true as you see for all the different secondary outcomes so it was a negative study why it not works one hypothesis is that the patient who have not received the no positive pressure during surgery cannot be treated by high flow student because to avoid or to reopen um athletic disease we need high pressure more than five to six centimeters that means that's why we use non-invasive ventilation to open their body however for those who received the standard positive pressure during surgery that's called the improved strategy have a better outcome so what about thoracic surgery we have this a nice study from our friend francois stefan in from in paris who performed a high flow oxygen therapy versus non-invasive after cardiothoracic surgery and this study was a positive one because it's a non-affirmative study because you see this kaplan miracle is absolutely similar with similar reintubation rates using either non-invasive ventilation or high-flow oxygen therapy and in the group of obese patients the same is true in this strategy so my this is my last before last slide my take home message is always in front of poster participatory failure please eliminate before everything a surgical complication and if you have a clinical clinical and gas exchange improvement you can continue to apply high flow oxygen therapy however if you have no clinical and gas exchange improvement please stop and probably incubate the patient or use another strategy such as invasive ventilation finally my take-home message are the following three points as i said post-operative acute respiratory failure the main message please always eliminate surgical complications that mean you need to have a ct scan to eliminate a complication and to consider reoperation the second high flow in selected past participation could be proposed we have today strong evidence of safety then i have at first land therapy to prevent autotreat hypoxemia or as an alternative to cpap or bypass as reported in cardiothoracic surgery mainly by the study of francois stefan finally please like other strategy of non-invasive ventilation high flow should not delay the time of reintubation thank you for your attention thank you samia for this very amazing presentation with so much figures so perhaps sharon you can start with the first question yes so we've been receiving questions from the audience and we too have questions it depends on the amount of time that we will have uh i'd like to start with uh dr miyatra um we received the same question twice from two different people regarding the effect of face mask uh surgical mask on top of the high flow nasal cannula do you have any uh thoughts on why it increases fio2 or white increases perhaps po2 and any infectious issues right actually um that was a very i found that very interesting because i thought the idea of putting a mask over the hyphenaser cannula was basically what uh to you know avoid transmission or whatever aerosol was generated to the stuff but an interesting finding or maybe it was just an association was there's also increase in the saturation and also no increase uh significant increase in the paco2 so i i mean the authors also haven't given a definitive explanation for this but uh definitely from an infection standpoint i would say that um we cannot swear and say that there is no aerosol generation of course we have our ppe as a frontline i mean final kind of thing to protect us nevertheless if some putting a mask over the hyphen nasal cannula auction doesn't produce any adverse events why not do that if there's an additional protection against aerosol generation thank you um unless jean-pierre you want to ask something i also have a question uh to bram about peri intubation um yes ask a question to sami or about please do please please do first samia to at you for for conclusion you said that you can use a high flow as an alternative to to to niv does that mean that your first treatment will be niv for this patient and how long you you you use the this oxygen support in your patient or through your study you you report it thank you jean-pierre for this question in our practice we use both that means you use mainly after abdominal surgery in intensive care or in post anesthetic care non-invasive ventilation to prevent atelectasis or to treat because non-invasive ventilation deliver high array pressure you know that means you use at least five to six centimeter of pip and we use at least four to six centimeter of pressure support ventilation this is absolutely necessary to reopen the the the lung in some cases of athletic disease because we reported that high flow oxygen could not reopen the alveoli because to reopen clothes alveoli we need more than two or three sentiment for the whole lung there but we use high flow oxygen therapy for all the patients between the non-invasive trial we use preventive non-invasive trial in all our abdominal surgery because in ico we receive the high risk abdominal surgery the other goes to not in icu they go to the wards so we our approach is to probably use both not contradictory i think they are not we should not consider competition between non-invasive and high flow it's approximately synergic we use in our practice preventive nav trial at five to six hours per day by trials of 30 minutes like in physiotherapy and when the patient tolerated because sometimes the patient is not in [Music] acute respiratory failure or don't have dyspnea we try to explain to the patient that it's like physiotherapy kinsey therapy but it's better accepted you applied a short session many times a day yes it's it's better accepted than long session we in fact in our practice is around 25 minutes started from 10 minutes to one hour depending the tolerance of the patient and the civility that's why i said we can always set preventive curative but in the real life it's sometimes gray zone we have a lot of liver transplantation patients we can start with them it's very epic patient no problem and the at the start of the encore now for example at the end of the night you have a patient with respiratory distress and the same patient could be prophylactic grison and unfortunately curative situation okay thank you samia yes we have a couple of very interesting practical questions from the audience so we'll skip mine and we'll go to the audience's practical questions one that i found particularly interesting is how you handle gas swallowing and stomach dilation or is there any level or specific level of peep or pressure that you would put an ng tube in and the second one and if you could answer both this is to all the speakers um how do the how do i know whether to increase the fio2 or the um or the flow particularly in covid 19 patients if anybody has any idea how to respond to these it would be great so let's start with uh samia do you want to perhaps respond to the ng my question i want to be uh some courtesy for sheila i prefer sheila start for the last question but okay so ladies okay i will address the second question uh if i may so uh regarding um you know titrating the flow and uh if i i mean the fio2 a lot of times people think this moves in parallel but actually you have to set them independently so i would set the fio2 based on my target saturation that i want to achieve and of course i'm not aiming for 100 saturation i'm okay if they are setting above 90. so i would titrate uh the fio2 to these level to the level of saturation that i aim to achieve and uh regarding the flow i would look at the patient's work of breathing the respiratory distress so initially of course you have to start with a much uh you know you start with a high fio2 and you come down to your targets you know come down with the fio2 regarding the flow you have to start with a lower flow because this is not well uh tolerated though you're giving heated humidified oxygen is not well tolerated by the patient and then you gradually increase uh the patient the floor to match uh you know the patient's comfort level so i look at how uh you know what is a destiny distress what is the work of breathing and i increase the flow uh just enough to make the patient uh comfortable now in the covet era you know we are concerned about giving high flows of course so you don't have to keep everyone at 60 floors i come down on the floor if i see the patient is comfortable at 40 and 30 i come down to lower flows uh and also uh presently in india we're facing a shortage of oxygen so we're trying to come down on the floors as far as possible but of course giving the patient uh what the what he needs so oxygen conservation is not very a strength of the high flow nasal cannula yes i can report our practice and my personal recommendation today we initially start by the application of the florally protocol this is absolutely the recommendation initially the recommendation protocol made by jean-pierre in the first landmark study but now and as said by sheila the tolerance it's very poor in post-partisan so my position is now to always put the fio2 setting to 1 to 100 percent this is our practice and to always just decrease the flow because the flow sometimes more than 13 or 14 in our patient is not well tolerated so and moreover i don't believe personally about the cpap effect i don't believe it i i believe that it's very small positive pressure we performed several study and we shared we showed that the mouth open you never you never have more than two or maximum three centimeters of water in all the situation so in my point of view the effect of pip it's very very low in my point of view i this is something that i showed and that's why we prefer to use high fio2 and to benefit of the humidification and heat oxygen therapy and we decrease more and more and it's better psychologically for the nurse on the doctor to have a lower flow uh with a fiot one this is our position maybe it's totally open i know that ram you have another position but it's very interesting that they think to discuss this point of between pragmatic bedside practice and some literature point of view i i think it does depend uh there's great perspective and i certainly agree and i think that there is a little bit difference between patient populations as well you know perhaps in the post-operative setting they don't tolerate the high flows as well but my experience sometimes in those that come in quite hypoxic and air-hungry is that being able to titrate up those flows is what actually helps address dyspnea and and better matching those uh inspiratory demands especially in patients that are so uh dyspnic and breathing in a rate in the 40s or 50s uh i get more sometimes i put it on just for flow they might not be actually hypoxic or that high degree of hypoxia but by titrating up the flows i'm able to deal with the dyspnea and buy me some time to evaluate to see whether they would need to proceed to intubation or not so i do think that there's a little bit of some type of patience and tight trade ability yeah well probably both you have the fio2 effect and that more you increase the fio2 more you increase the real oxygen delivery in the trachea as you know because in the very acute cr patient with a high oxygen demand with having the high demand you have you need to have a high inspiratory flow and then you never reach more than 80 percent in the real life of fiu2 in the alveoli that's probably why in this very sick patient as you the very sick hypoxemic patient it's better to a rated high flow than the other one you're right about the selection of the population thank you um i don't know if we have enough time for more questions or i can ask a question for sheila what is now in india because we are very it's it's hard for us to see what we see the television every every night every evening we see what happened in india and we are very sorry for what happened and what is the main practice in the icu or in the personality care what is the main ventilatory support today so first i just like to say don't go by just what you see in the media things are pretty much under control now but across the country we've become very conscious about oxygen conservation and we're not uh we're taking all kinds of measures to limit the use of oxygen so it's not that we're saying don't use hyphen nasal candle oxygen but we're trying to say you know use it if only if you absolutely need to use it and if at all you can come down on the floors come down on the floors at the earliest you know don't just keep everyone on 60 floor if you can manage with 30 floor 40 flow uh you know we're checking for leaks we're not giving trying to target 100 saturations so various measures are being taken not only in areas where they're shortaged but even where there isn't shortage acknowledging the fact that we have a huge number of patients who are coming into the icu it's almost like a tsunami you know large numbers so we're very conscious about this and trying to limit the oxygen that we are using thank you so we perhaps the last question sharon if you agree about um the use of high flow prolonged high flow therapy and the the problematic of oxygen toxicity i think there is no data about that but perhaps you can answer to to this question high flow high prolonged high flow and oxygen toxicity brahms in methanol is this other study you you made did you find something about that yeah unfortunately there at least in our reviews no although you know we focused especially for the guidelines more on patient important outcomes and we did look at mortality at 30 days for a lot of these interventions especially in hypoxemic respiratory failure we looked at icu length of stay we looked at duration of respiratory support and certainly if you expected with prolonging high fio2 therapies with high flow and oxygen toxicity increase free radical production and and harm via these pathways you might expect impact on some of these these patient important outcomes like mortality at 30 days hospital mortality duration of icu and we did not see any harm in terms of looking at these so not to say that it's not a risk i certainly worry with setting such high fio2s over a prolonged period of time but it doesn't at least from a meta-analysis and evidence-summary perspective translate into those patient important outcomes at least based on the data we have thank you i don't know if my colleagues want to add anything else maybe we will have more data in the next two years by the mega rocks studio the mega rocks studio is a studio leading by the onsic group which will include forty thousand forty thousand patients with liberal versus restrictive oxygen but include all patients that mean acute respiratory failure and patient without and we will see a prolonged effect of this this is crazy study we have to see the results about it next month i uh you should all expect to see the results of the prism trial which is coming out 4 000 patients randomized to cpap very interesting results um we should all look forward to that i can't tell you you can read the discussion so um thanks uh uh jean-pierre could you perhaps uh say thanks on our behalf to everybody uh for me it was a great pleasure to be with you guys here and with a great audience and uh please thank you everybody for this all your presentation and i hope that that will help everybody to to use high flow or other oxygen support and yeah great talks everybody and great audience thank you thank you goodbye you

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Length: 79min 50sec (4790 seconds)

Published: Thu Apr 29 2021