Inselspital Universitätsklinik für Anästhesiologie und Schmerztherapie. 73. Berner Anästhesie-Symposium Mittwoch, 15. November 2017 Kinderanästhesie

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1 Inselspital Universitätsklinik für Anästhesiologie und Schmerztherapie 73. Berner Anästhesie-Symposium Mittwoch, 15. November 2017 Kinderanästhesie HFNC Von Spontanatmung bis zur apnoischen Oxygenierung Referat von: Dr. med. Thomas Riva Inselspital, Bern HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

2 Dept. Anaesthesia and Pain Therapy, University Hospital Bern HFNC From spontaneous breathing to apnoeic oxygenation Dr. med. T. Riva I received materials for research from Fisher & Paykel and Radiometer

3 High-Flow nasal cannula therapy Developed in NICU as CPAPalternative for apnea of prematurity (Sreenan 2001) HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

4 Nasal prongs HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

5 HFNC O 2 -flow between 4 and 70 l/min Titration of O 2 -concentration (FiO 2 ) O 2 is humidified and heated Prevention of naso-pulmonary broncho-constrictoric reflex by cold and dry oxygen 1 Reduction of inflammatory irritations of the mucosa 1. Fontanari P. Changes in airway resistance induced by nasal inhalation of cold dry, dry, or moist air in normal individuals. J Appl Physiol 1996; 81: HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

6 HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

7 ICU Indications Respiratory distress syndrome, apnea of prematurity or postextubation support in preterm infants 1 RSV-Bronchiolitis (reduction of intubation s rate from 37% to 7%) 2 Acute respiratory failure (asthma, pneumonia and croup) 3 Postextubation stridor 4 1. Yoder BA, Pediatrics 2013 May;131(5), Wilkinson D, Cochrane Database of Systematic Reviews Schibler, Intensive Care Med (2011) 37: Wing R, Pediatr Emerg Care 2012;28: Byerly F, Burns 2006;32:121 5 HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

8 HFNC/THRIVE physiology Match of the inspiratory demand inspiratory resistance and metabolic work reduction Provide positive distending pressure for lung recruitment In RSV a mean pharyngeal pressure of 4 cm H 2 O with 2 L/kg/min 1 Turbulence & washout of nasopharyngeal deadspace improvement of alveolar ventilation 1. Milesi C, Intensive Care Med. 2013;39: HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

9 Match of inspiratory demand P.Ramnarayan, A Schibler ICM 2017 Schmalisch BMC Pediatrics 2005 PIF (L/kg/min) 3 2,5 Arjan B.Te Pas Pediatric Research 2009 HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

10 Physiology: inspiratory effort and work of breathing Pediatr Pulmonol. 2015;50: HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

11 Premature neonates 15 premature, 29 weeks GA A Lampland HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

12 7 HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

13 Electrical Impedance Tomography (EIT) images from a post-cardiac surgical patient British Journal of Anaesthesia 107 (6): (2011) From HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

14 Washout of nasopharyngeal deadspace Möller W et al. Nasal high flow reduces dead space. J Appl Physiol 122: , 2017 HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

15 Apneic Oxygenation Volhard (1908) and Meltzer (1909) Conditio sine qua non: Open Airway, O 2 reaches alveoli, air can escape Draper (1947) O2 gradient between upper airway & alveolus Must have: circulation, patent airway & denitrogenation of the respiratory tract HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

16 Apneic Oxygenation HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

17 Problem: increase in sympathetic activity Tenney, Anesthesiology 1956 (Hunde & Katzen) hypercapnia as cause for hypertony Gentz, J Clin Anesth 1998 CO 2 -increase of 8-9 mmhg in 1 st min, following minutes: 3mm Hg/min Stock et al, J Clin Anesth, 1989 CO 2 -increase of 12 mmhg in 1 st min, following minutes: 3-4 mm Hg/min HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

18 Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

19 Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) 25 patients in apnea Apnea time 5-65 minutes No desaturation <90% 0.16 kpa/min > 0.4 kpa/min Oxygenation & Ventilation: End-etCO 2 mean 58mmHg (114 after 65 min) CO 2 -increase 1 mm Hg/min (vs. 3mmHg/min) HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

20 THRIVE - Indications Surgery requiring apnea improvement of surgical (laryngeal surgery/microwave ablation) conditions/ respiratory pause Intubation (+ difficult intubation scenarios) enhancement of security and training conditions for trainees Procedural sedation gain of safety Postextubation support of preterm/toddlers Prevention of desaturation HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

21 Surgery requiring apnea (laryngeal surgery, microwave ablation) HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

22 General anaesthesia for laryngeal surgery flexible bronchoscopy after inhalational induction and maintenance with Sevoflurane via an endoscopy mask Remi-Perfusor 0,3 ug/kg/min and Propofol Perfusor 25 mg/kg/h Intubation with Vygon/Portex if < 3 kg Intubation with Microcuff if > 3 kg Patel et al, Can J Anaesth 1994,771-4 Due to larger MV:FRC-Ratio short apnea HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

23 HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

24 Pediatric Anesthesia 27 (2017) HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

25 Early experience with THRIVE for pediatric endoscopic airway surgery HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

26 HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

27 Patients Intervention Weight (kg) Apnea cycles Apnea time (min/seconds) tcco 2 before tcco 2 after Minimal SpO 2 kpa CO 2 /min Patient 1 Laryngeal dilatation and endoscopic cricoid split with CO 2 -laser + posterior expansion 6.7 HFNC 100% No desat HFNC 30% No desat. 0.6 Patient 2 MLS Debridement 16.0 HFNC 100% 6 00 NA NA No desat MLS + Debridement 12.3 HFNC 100% 8 01 No desat. 0.3 HFNC 100% No desat Patient 3 MLS +Debridement 12.4 HFNC 100% No desat HFNC 100% No desat MLS + Debridement 12.8 HFNC 100% No desat. 0.3 MLS +Debridement 13.0 HFNC 100% No desat. 0.2 MLS +Debridement 15.0 HFNC 100% No desat Patient 4 MLS +Laryngeal bougienage 72.0 HFNC 100% No desat HFNC 100% No desat Patient 5 MLS and Cleft repair with CO 2 -laser 3.9 HFNC 30% No desat 0.23 HFNC 30% No desat 0.24 HFNC 100% % 0.32 Patient 6 MLS/Supraglottoplasty with CO 2 -laser 16 HFNC 30% No desat. 0.5 HFNC 30% No desat HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

28 Improvement of oxygenation during intubation HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

29 Time to desaturation after preoxygenation Benumof JL, Dagg R, Benumof R. Critical hemoglobin desaturation will occur before return to an unparalyzed state following 1 mg/kg intravenous succinylcholine. Anesthesiology 1997; 87:979 HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

30 High Flow Nasal Cannula Therapy Spoletini, CHEST 2015 Effect like CPAP Heinrich, J Obes Bariatrics 2014 Intubation bariatric patients Mask 12 l/min vs. CPAP (peep 7 FiO2 100%) vs. HFNCT (FiO2 100%) po2 250 vs 370mmHg HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

31 HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

32 HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

33 Goal of the study Evaluate the apnea time until deoxygenation occurs using: Ø low-flow (0.2 L/kg/min with 100% oxygen) Ø two different concentrations for the high-flow (2L/kg/min) oxygen therapy (i-thrive): 30% oxygen vs. 100% oxygen. Evaluate the increase of CO 2 for the different flow regimens Evaluate whether or not air is entering in the stomach during high-flow therapy (using abdominal ultrasound) and if a pneumothorax ever occurs HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

34 Methods 60 children, ASA 1&2, 10-20kg with legal guardians providing written informed consent Exclusion criteria: known or suspected difficult intubation, oxygen dependency, congenital heart or lung disease, obesity BMI>30kg/m 2 and high aspiration risk Scheduled for elective surgery requiring general anaesthesia Randomized to different O 2 -regimens during apnoea after induction: 1. low-flow nasal cannula therapy 100% oxygen at 0.2L/kg/min 2. high-flow (i-thrive) 100% oxygen at 2.0 L/kg/min 3. high-flow (i-thrive) 30% oxygen at 2.0 L/kg/min Standardized anaesthesia (incl. neuromonitoring) & neuromuscular blockade After assuring proper mask ventilation & transcutaneous (tc) CO 2 of mmhg ( kpa) apnea started according to randomization HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

35 Primary Outcome: Apnoea Time (from start of apnoea to 95% SaO 2 -desaturation) 6.9 ( ) 7.6 ( ) 3.0 ( ) *Kruskal Wallis. Post hoc pairwise comparison with Mann Whitney and Bonferroni correction, p = for 0.2l/kg, 100% vs. 2.0l/kg, 100%, p <0.001 for 0.2l/kg, 100% vs. 2l/kg, 30%, and p = <0.001 for 2.0l/kg, 100% vs. 2l/kg, 30%. Two patients from the group 0.2l/kg, 100% have no data for primary outcome, because the intervention had to be ended because of technical failure and diaphragmatic respiration. Apnea time, min - mean (interquartile range) HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

36 Secondary outcome: increase of CO 2 22 Low-flow 100% O 2 0.2L/kg/min, n=18 i-thrive 100% O 2 2.0L/kg/min, n =20 i-thrive 30% O 2 2.0L/kg/min, n =20 p-value Rate of CO 2 - increase, kpa/min 0.57 ( ) 0.55 ( ) 0.60 ( ) Rate of CO 2 - increase, mmhg 4.28 ( ) 4.13 ( ) 4.50 ( ) mean (interquartile range) HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

37 Secondary Outcome: Safety Outcomes No pneumothorax or gastric gas insufflation detected by ultrasound Termination criteria: 1. apnea-duration > 10 min 2. tcco 2 rising to 65mmHg (8.7kPa) 3. SpO 2 < 95% Termination criteria reached, n (%) Low-flow 100% O 2 0.2/kg/min, n=18 i-thrive 100% O 2 2.0L/kg/min, n =20 i-thrive 30% O 2 2.0L/kg/min, n =20 Apnoea time of 10 minutes 2 (11) 4 (20) 0 (0) tcco 2 65 mmhg 13 (72) 16 (80) 0 (0) SpO 2 95% 3 (17) 0 (0) 20 (100) HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

38 Effect of reduced humidity on mucociliary transport Tatkov et al From HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

39 Procedural sedation HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

40 Procedural sedation Prevents hypoxaemia and maintains adequate oxygenation of tissues and vital organs A positive distending pressure of 4-8 cm H 2 O is achieved, improving functional residual capacity Reduces work of breathing HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

41 Sago, J Oral Maxillofac Surg Patienten unter Sedation 5 vs. 30 vs. 50 L/min O 2 HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

42 World J Gastroenterol Dec 21; 22(47): HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

43 Postextubation support HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

44 HFNC in PACU/Postextubation support Ensure adequate clearance of secretions and limit the adverse events of hypothermia and insensible water loss by use of optimal humidification. Using humidified gas keeps mucus more fluid and aids airway recovery (eg, after surgery) Reduces respiratory rate and the work of breathing less dyspnea Prevents excessive CO 2 accumulation Ease of set-up easier to fit a nasal cannula than an oxygen mask Low level of patient compliance needed (sedation possible but not required) Very comfortable and allows children to communicate and feed HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

45 Hemodynamic and respiratory parameters before and after HFNCT HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

46 Pediatric OSA 13-59% of overweight children Diagnosed by parent hx or sleep study Mild Moderate Severe (If apnea is seen after small dosages of opioids, the child should be treated as having severe OSA) Diminished ventilatory response to CO2 A fraction of children with OSA shows an increased sensitivity to both the analgetic and the respiratory depressant effect of opioids HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

47 Pediatric OSA Type I Type II Tonsillar and Adenoid Hypertrophy Obese HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

48 Flow HFNC in PACU Flow and Weaning Weight HFNC Flow rate Comments Circuit to use kg 2L/kg/min Max 25 L/min Paed circuit kg 30 L/min Adult circuit kg 35L/min Adult circuit kg 40 L/min Adult circuit >50 kg L/min Adult circuit Weaning Ø wean the FiO2 to < 30% Ø Reduce flow to 5 L/min, change to low flow 100% oxygen (1 to 2L/min) HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

49 Learning points Lower FiO 2 during airway management is not recommended CO 2 -clearance with flow up to 4L/kg/min needs future investigation In low-resource settings 100% low-flow O 2 -delivery represent a feasible option (prevention of hypoxemia during intubation) HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

50 Learning points THRIVE is more beneficial due to humidification of airway mucosa Improved safety during procedural sedation Airway surgery - our surgeons are enthusiastic!! But HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

51 Learning points You MUST have a patent airway In apnea, once desaturation starts, you need a Plan B HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

52 HFNCT From spontaneous breathing to apnoeic oxygenation - Dr. med. T. Riva 73. BAS

53 PODCAST 2017, Universität Bern