5/17/ UCSF Benioff Children's Hospital Oakland

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1 UCSF Benioff Children's Hospital Oakland 1

2 USCF Benioff Children's Hospital San Francisco 50 Years of the Nasal Cannula Presented by: Katie Sabato, MS RRT Director of Respiratory Care and Pulmonary Function UCSF Benioff Children's Hospital Oakland 2

3 Rubber Catheter 1908 Arbuthnot Lane 3

4 Candles burn for Moms in heaven Discovery of Oxygen Oxygen needed a simple device that would allow delivery to patients. If Necessity is the mother of invention 4

5 Nasal Cannula (n) a device who unconditionally provides support for millions to build strength and heal hearts. It has provided wonderful success stories, some think, miracles. The nasal cannula is the backbone to a very rewarding and successful profession. Most common treatment given in hospitals in the developed world is? 5

6 Rubber Catheter 1908 Arbuthnot Lane 1930 Stainless Steel Nasal Inhaler 6

7 Nasal Cannula 1946 Wilford Jones 618,570. Respiratory appliances. BRITISH OXYGEN CO., Ltd., and JONES, W. Nov. 5, 1946, No [Class 81 (ii)] A nasal inhalation apparatus for oxygen &c. comprises a tubular bridge piece 10 adapted to bear against the upper lips and a catheter tube or tubes 12 projecting therefrom to be inserted in the nasal passage, the gas supply conduits 13, 14 to the bridge piece being axially extensible and adap. ted to encircle the head and serve as the sole support for the device. The bridge piece is curved to conform with the upper jaw and the gas supply conduits are secured together by a sliding fastener 15. Nasal Cannula (1946) and Inhalation Therapy (1946) 1943 Edwin R. Levine, MD, establishes a primitive inhalation therapy program using on the job trained technicians to manage post surgical patients at Michael Reese Hospital in Chicago Dr. Levine s students and other interested doctors, nurses, and oxygen orderlies meet at the University of Chicago Hospital to form the July Inhalation Therapy Association (ITA) The ITA is formally chartered as a not for profit entity in the state of Illinois. The new Association boasts 59 members, 17 of whom are from various Apr religious orders. Albert Andrews, MD, outlines the structure and purpose of a hospital based inhalation therapy department in his book, Manual of Oxygen Therapy 1947 Techniques. Which came first? Oxygen Mask Oxygen Tents Nasal Cannula Oxygen Hoods Oxygen Catheter 7

8 1917 Haldane s 1 st Oxygen Mask Oxygen Tents

9 Oxygen Hoods and on Attention focuses on the actual prongs cannula 1956 Hudson and Salter 1960 Ensuring full freedom keeping the cannula as much out of the way Two tip styles designed to deliver maximum volume of oxygen with out drying and burning Straight tip vents 9

10 Nasal catheter for glasses 1987 Current Oxy View built into frames Uni flow cannula 10

11 Nasal Cannula and End Tidal CO2 Monitoring 11

12 Evidence Based Indications: Nasal Cannula with Oxygen A PaO 2 of 60 mm Hg is often set as a reasonable goal in the initial treatment of arterial hypoxemia.! Accepted indications for short term oxygen therapy include acute hypoxemia, cardiac and respiratory arrest and low cardiac output with metabolic acidosis. Questionable indications for which supplemental oxygen is used clinically, but for which there is little supporting data, include uncomplicated acute myocardial infarction, dyspnea without hypoxemia, sickle cell crisis and angina. It provides comfort and an inconsistent low level of oxygen for patients who have chronic stable medical conditions Long Term Oxygen Therapy via Nasal Cannula Long-term oxygen therapy (LTOT) increases survival and improves the quality of life of hypoxemic patients with chronic obstructive pulmonary disease (COPD). Such is evidenced based Each year, approximately one million patients receive LTOT through Medicare. The cost of LTOT is increasing at an annual rate of nearly 13%. 12

13 RESERVOIR CANNULAS Reservoir cannulas are oxygen-conserving devices. They store 20 ml of oxygen during exhalation and make that oxygen available for the beginning of the next inhalation. They require one half to one fourth the flow rate of standard cannulas at settings of 0.5 to 2 L/min. 4, 7 These devices are available in 2 configurations: the Oxymizer and the Oxymizer Pendant. Providing long term oxygen therapy via nasal cannula How does Pulse Dose work? When inhaling, your diaphragm moves down and causes a drop in pressure in the lungs. Air flows in through the nose and mouth to equalize the pressure. This negative pressure is also present at the nose and mouth during inhalation. This pressure signal travels through the nasal cannula to a pressure sensor in the Pulse Dose conserving device. An electronic circuit then opens an electrical valve to deliver a precisely metered dose of oxygen. When the valve is closed, the sensor is ready to detect the next inhalation. Overuse of IPPB become an embarrassment to the profession Foundations of Respiratory Care By the 1970s the necessity of these devices came "under scrutiny" by insurance companies who had to flip the bill. They claimed there was no proof the treatments did any good, and they were too expensive. Such scrutiny was validated by researchers who proved by scientific evidence the following: IPPB therapy deposit 32% less of aerosolized medicine to the lungs than a simple aerosol treatment. Benefit from the therapy were also proven to be short lived, lasting less than an hour. Inventive spirometers were equally as effective in preventing and treating postoperative atelectasis (4) Until you re willing to look foolish, you ll never have the possibility of being great. -Cher 13

14 The Personal Oxygen Bar Modeled after oxygen bars found in resorts and spas, this is the personal oxygen bar that increases the concentration of oxygen you breathe by 43% (from 21% to 30%), helping you to achieve a sense of calm to facilitate relaxation. 14

15 Transpirator Respiratory Therapy Units for Horses 1985 Method and apparatus for pulmonary and cardiovascular conditioning of race horses and competition animals A high humidity method and an apparatus are described which are useful for conditioning a pulmonary and/or a cardiovascular system in a large animal. The method broadly comprises delivering a humidified air stream at a dew point temperature greater than the environmental ambient dew point temperature to an animal's respiratory tract. 15

16 Respiratory Units for Horses And the mother of our equipment gives us a miracle First Heated High Flow Nasal Cannula 16

17 Vapotherm Model 2000i 1997 Bill Niland and Jun Cortez Heated Humidified High Flow Nasal Cannula PubMed search will yield > 600 references / few high quality Acute Hypoxemic Respiratory Failure Acute Respiratory Failure with hypercapnia Pneumonia and COPD Pediatric Emergency Department for Respiratory Distress CPAP intolerant kids with OSA Reduce rates of reintubation small study prevented intubation( Taft and Hill) Supportive for Do not intubate patients Enhanced exercise tolerance for asthma and COPD Preconditioning of lungs prior to surgery Great up to date review on Heated Humidified High Flow Nasal Cannula High Flow Nasal Cannula : Where does it fit? David J Dries Respiratory Care March 2018,63 (3)

18 Amazing But wait there is more that Mom can do Deliver Heliox Nitric Oxide Deliver Aerosolized drugs Lower the flow better deposition 18

19 KS1 NO We need HHHFNC ED NURSE = RCP So what does this all mean? Mom can sure do a lot! Clinical evidence : large random controlled studies are needed Cost effective HHHNC is not cheap / can use of it decrease hospital cost over other devices Application How to determine flow rate objective symptoms or body weight Safe use Got to assure we do not prolong patient stays and or mask unlaying critical pathology early identification of clinical detrition Risks with HHHFNC It is n from NIV NIV does have all the inherent risks associated with lung damage ( TV stretch VILI) what are the risks with HHHFNC???? Why/ How does HHHFNC work Proposed Enhanced precise oxygen delivery Adequate flow reduces work of breathing Washout of the anatomic dead space removing the built up CO2 in the upper airway Helps with lung mucociliary clearance Ciliary activity is maintained Elimination of the effects of cooling and drying Reduced heat loss Elimination of the metabolic cost of cool gas conditioning Higher flow on the expiratory phase offers resistance to exhalation back pressure similar to nasal CPAP 19

20 Slide 55 KS1 Katie Sabato, 2/26/2017

21 Airway Hydration HHHNC end expiratory pressure and enhance tidal volumes 20

22 It is not just a simple nasal cannula Fit of the actual prongs is crucial Size to circumference of the nares Respect and critical assessment and Oxygen is a drug and any amount > 60% carries risks Multiple toxicities lung damage oxidative stress lung fibrosis atelectasis Any amount of time oxygen is higher than 60% can cause harm 100% > 12 hours 80% > 24 hours 60% > 36 hours UCSF Children's Benioff Childrens Oakland Respect for Heated High Flow Nasal Cannula 20 years invested first abstract 2004 Focus is on cost effective safe positive patient outcome RT driven clinical pathways Floors and ED 21

23 UCSF Children s Oakland Major Accomplishments with HHHNC A respect for Respiratory Care Practitioners and their ability to direct cost effective care with the customer first! 52 % of the time a high acuity respiratory patient is placed on HHHFNC patient is able to be treated effectively (3.2 days) in the acute care N=302 patients in last 16 months 22

24 Put your own oxygen mask on first, whether it s on a plane, at home or anywhere in life. - Ellen Delap 23

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26 Been here? 25

27 Modes of respiratory therapy based on clinical impressions and not on scientific clinical research and review 26

28 What flows should I use with pediatric patients? 27

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