High Flow Nasal Cannula in Children During Sleep. Brian McGinley M.D. Associate Professor of Pediatrics University of Utah

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1 High Flow Nasal Cannula in Children During Sleep Brian McGinley M.D. Associate Professor of Pediatrics University of Utah

2 Disclosures Conflicts of Interest: None Will discuss a product that is commercially available, not yet FDA approved for sleep apnea

3 Objectives: Review the effect of high flow nasal cannula on sleep disordered breathing in children. Discuss the Mechanism of Action of high flow cannula on breathing during sleep. Review the use of High Flow Nasal Cannula in children with Cystic Fibrosis.

4 Ventilatory Control

5 AASM -Hypoventilation in Children during Sleep CO 2 > than 50 mmhg for 25% of TST Children with OSA are at increased risk for peri operative morbidity if RDI>24 events/hr, SpO2 < 80%, or CO 2 is > 60 mmhg Does not discriminate between EtCO 2 /TcCO 2 Journal of Clinical Sleep Medicine 8(5):

6 Background pco = k * 2 VCO V A 2 Want to but can t breathe Can but won t breathe

7 Upper Airway Patency Apnea Rus Flow- Limitation P N = 0 Pph = -10 P N = +5 Pph= -5 P N < Pcrit Pcrit = +1 Pcrit > Pph P N > Pcrit Pcrit = +1 Pcrit > Pph Normal Breathing Vimax = (P N Pcrit)/R N R Pus = +15 Pph= +5 P N > Pcrit Pcrit= +1 Pph > Pcrit V = (P N Pph)/R Adapted from Gold et al. Chest 1996;10:

8 Want to but can t breath Neuromuscular/skeletal disease, Morbid Obesity, Pulmonary and cardiovascular diseases, Obstructive Sleep Apnea 12 year old with achondroplasia RDI =112 events/hour

9 OSA Pharyngeal collapse

10 Waterfall Analogue What determines the amount of Airflow? P US Nasal P CRIT Tracheal P CRIT P US UPSTREAM SEGMENT COLLAPSIBLE COLLAPSIBLE P DS DOWNSTREAM SEGMENT Constant/fixed inspiratory Airflow P DS

11 Inspiratory Airflow Limitation Flow is independent of Downstream Pressure Flow (ml/s) P ES (cmh 2 O)

12 Therapy for OSA Change Nasal or Critical Pressure

13 Sullivan CE, Lancet CPAP

14 Waterfall Analogue Flow Depends on the Upstream Pressure and Pcrit P US Effect of CPAP P CRIT 1 cmh 2 O Pn increase V I by 50 ml/s Peff = Pcrit + 8 cmh 2 O Normal Inspiratory Airflow > 400 ml/s P DS

15 High Nasal Flow Therapy 1. Effect on sleep disordered breathing in children. 2. Mechanism of Action 3. High Flow Nasal Cannula and Pulmonary disease Preliminary data in children with CF

16 Treatment with Nasal Insufflation (TNI) Warm (30-32 O C) Humidified (90-95 % relative Humidity) 20 L/min Two overnight polysomnograms One night OFF TNI One night ON TNI Random order

17 Children on CPAP Patient ID Anthropometrics Gender Mean SEM Age (yrs) Height (cm) Weight (kg) BMI (kg/m 2) BMI z score Previous Treatment CPAP Pressure (cm H 2 O) Adenotonsillectomy Disordered Breathing Indices AHI Total (events/hr) SpO 2 nadir (%) Peak CO 2 (mm Hg) % TST CO 2 > 50 mm Hg Daytime Symptoms

18 Children on CPAP Patient ID Anthropometrics Gender Mean SEM Age (yrs) Height (cm) Weight (kg) BMI (kg/m 2) BMI z score Previous Treatment CPAP Pressure (cm H 2 O) Adenotonsillectomy Disordered Breathing Indices AHI Total (events/hr) SpO 2 nadir (%) Peak CO 2 (mm Hg) % TST CO 2 > 50 mm Hg Daytime Symptoms

19 Children on CPAP Patient ID Anthropometrics Gender Mean SEM Age (yrs) Height (cm) Weight (kg) BMI (kg/m 2) BMI z score Previous Treatment CPAP Pressure (cm H 2 O) Adenotonsillectomy Disordered Breathing Indices AHI Total (events/hr) SpO 2 nadir (%) Peak CO 2 (mm Hg) % TST CO 2 > 50 mm Hg Daytime Symptoms

20 HNFT in Children McGinley B, Pediatrics. 2009; 124(1):

21 Sleep Disordered Breathing Responses to HFNC Pediatrics Jul;124(1):179-88

22 Respiratory Responses to HFNC during NREM TNI Off TNI On SpO 2 (%) Expiration Airflow NREM Inspiration Thorax Inspiration Expiration 5 seconds 5 seconds HNFT reduced respiratory load with inspiratory flow limitation McGinley B et al, Pediatrics. 2009

23 Effect of TNI on Sleep Disordered Breathing during NREM sleep Pediatrics Jul;124(1):179-88

24 High Nasal Flow Therapy 1. Effect on sleep disordered breathing in children. 2. Mechanism of Action 3. High Flow Nasal Cannula and Pulmonary disease Preliminary data in children with CF

25 HFNC in Apneic Children on CPAP TNI Off TNI Expiration Airflow (ml/s) Inspiration P SG (cm H 2 O) McGinley et al Pediatrics 2009

26 Effects on Ventilation pco = k * 2 VCO V A 2

27 Acute HFNC Trials during NREM

28 Panel A Arousals EOG EEG EMG Effect on Ventilation OFF (SNORING) TNI ON OFF (SNORING) Flow (L/min) 0 RC Abd SaO 2 (%) tc-co 2 (mmhg) Panel B Respiratory Rate Minute Ventilation (L/min) CO 2 (mmhg) WAKE OFF TNI OFF WAKE OFF TNI OFF WAKE OFF TNI OFF

29 Effects of TNI on Ventilation

30 High Flow Nasal Cannula HIGH NASAL AIRFLOW

31 Summary In children with stable inspiratory flow limitation, TNI increased respiratory efficiency through either: 1. Decreased dead space ventilation 2. Decreased CO 2 production during sleep.

32 High Nasal Flow Therapy 1. Effect on sleep disordered breathing in children. 2. Mechanism of Action 3. High Flow Nasal Cannula and Pulmonary disease Preliminary data in children with CF

33 Cystic Fibrosis 20 year-old male F508del homozygous Pancreatic insufficiency CF-related liver disease and cirrhosis CF-related diabetes on insulin

34 Lung Function FEV1-pred (L) /22/03 08/22/04 08/22/05 08/22/06 08/22/07 08/22/08 08/22/09 08/22/10 08/22/11

35 Lung Function FEV1 (L) FEV1-pred (L) /22/03 08/22/04 08/22/05 08/22/06 08/22/07 08/22/08 08/22/09 08/22/10 08/22/11

36 Lung function FEV1 (L) FEV1-pred (L) /25/12 02/25/12 03/25/12 04/25/12 05/25/12 06/25/12 07/25/12 08/25/12 09/25/12 10/25/12

37 Clinic Visit 9/20/2012 FEV1: 1.55L (33.4%-predicted) Exhausted Difficult attending to conversation in clinic Mother talking for him Poor sleep Snoring Excessive daytime sleepiness Did not feel refreshed in the morning

38 NREM Sleep on O2 3 LPM Respiratory rate (20-24/min) Increased respiratory effort Event rate underestimated SDB - events not meeting criteria

39 REM- Severe OSA on O2 3 LPM

40 Treatment Plan BiPAP - non compliant, cited the mask Alternative: Nasal insufflation via nasal cannula (HNFT) -Warm and humidified air at high flow (20 LPM) -Efficacious for OSA in children -May improve secretions -Using sleep to provide lung protective therapy

41 Sleep Study Results on Treatment Baseline (3 LPM O 2 ) HFNT 20 LPM +2L O 2 NREM REM Total AHI SaO 2 (Bsl) 91% 88% 89% NREM REM Total AHI SaO 2 (Bsl) 91% 88% 89% SaO 2 (min) 82% 78% 78% SaO 2 (min) 85% 77% 77%

42 Ten subjects (37-75yrs) High nasal Flow Therapy 3 hours per day Optiflow (30 L/min)

43 Rea et al, 2009 RCT: HNFT vs. Control, 2 hours/day, wakefulness Severe COPD, Bronchiectasis (n=108, 60 HNFT, 48 Control)

44 Preliminary Data Ventilatory loads are increased in CF during sleep WAKE BSL 15 Sec 15 Sec EOG EEG 100 SaO 2 (%) 90 TcCO Flow (L/min) 0 Effort f: 24/min V I : 7.0 L/min f: 28/min V I : 8.0 L/min

45 Preliminary Data NI reduces ventilatory loads in CF patients during sleep

46 HNFT reduces energy expenditure EOG EEG EMG Airflow 70 EE 50 (kcal/h) 30 off HFNI off HFNI Normal: 19yrs, BMI 19 HFNI reduces EE by kcal/night off CF:? 30-50% reduction in Ventilation could reduce EE by kcal/night

47 Overall Concept utilize sleep to prevent pulmonary cachexia

48 How much weight change can we expect? Primary Snoring and Growth Failure in a Patient With Cystic Fibrosis MacDonald KD et al Respiratory Care 2009

49 Patient Follow Up Clinic visit on 11/29/12 Loves the AIRVO Improved AM sputum production More daytime energy No longer on daytime oxygen Better mood Playing video games until midnight

50 Lung function Initiated AIRVO on 10/26/12 FEV 1 : 1.4 L (29.8%-predicted) FEV1 (L) FEV1-pred (L) 0 01/25/12 02/25/12 03/25/12 04/25/12 05/25/12 06/25/12 07/25/12 08/25/12 09/25/12 10/25/12 5 Clinic visit on 11/29/12 FEV 1 : 2.1 L (45.9%-predicted) FEV1 (L) FEV1-pred (L) /25/12 02/25/12 03/25/12 04/25/12 05/25/12 06/25/12 07/25/12 08/25/12 09/25/12 10/25/12 11/25/12

51 Implications 1. TNI might provide an alternative to surgery and CPAP for children. 2. TNI may also have a role in treating hypercapnic respiratory diseases in children (Cystic Fibrosis, Neuromuscular Disease). 3. TNI can be used to manipulate upper airway obstruction to assess the impact of inspiratory flow limitation on the co-morbid outcomes associated with sleep disordered breathing.

52 Acknowledgments Johns Hopkins Sleep Medicine Hartmut Schneider M.D. PhD Ann Halbower M.D. Alan Schwartz M.D. Philip Smith M.D. Susheel Patil M.D Jason Kirkness PhD Seleon GmbH, Germany HL Johns Hopkins Pediatric Clinical Research Unit

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