Haut debit nasal ou BiPAP? Laurent Brochard Toronto

Haut debit nasal ou BiPAP? Laurent Brochard Toronto

Conflicts of interest Our clinical research laboratory has received research grants for clinical trials from the following companies: General Electric (FRC); educational tool (EELV and recruitment) Respironics (NIV) Fisher Paykel (Optiflow) Covidien (PAV+) Dräger (SmartCare)

Outcomes of Non-invasive Ventilation for Acute Exacerbations of COPD in the United States, 1998-2008 7,511,267 admissions for acute exacerbations occurred from 1998-2008 Chandra et al. AJRCCM 2

Mortality Demoule A et al ICM 2006

PaO2/FiO2 Respiratory mechanics Time window NIV May prevent or be useless ETI Dangerous Severity window May help May help or worsen Insufficient or risky Needed Time (hours/days) Brochard et al. Semin Resp Med. 2014

Définitions de l Humidité 44 mg/l (cap. maxi.) Condensation Humidité Absolue = 44 mg/l Humidité Relative = 100 % Humidité Absolue = 30 mg/l Humidité Relative = 100% 30mg/L (cap. maxi.) 37 C Refroidissement du gaz 30 C

Ventilation spontanée Ventilation invasive Ventilation non invasive AIR AMBIANT ~22 C ~10 mg/l ~50% HR GAZ SECS TURBINE ~ 22 C ~ 22 C ~0 mg/l ~0 à 10 mg/l ~0% HR ~0 à 50% HR 37 C, 44 mgh 2 O /l, 100%HR HUMIDIFICATION DES GAZ IMPERATIVE HUMIDIFICATION DES GAZ?

Washout of nasopharyngeal dead space The high gas flow decreases the upper airway dead space like trans-tracheal airway insufflation High Gas Flow

Resp Care 2012

NHF vs low flow O2: improved gas exchange and comfort 20 hypoxemic pts (SpO2<96% with FiO2 50%) Venturi Mask vs NHF for 30 min 8 7 6 5 4 3 2 1 0 Dyspnea FM * 10 * 10 * 8 8 NHF 6 4 2 0 Mouth Dryness FM NHF 6 4 2 0 Overall Comfort FM NHF 30 25 20 15 10 5 0 Resp. Rate 140 * * 120 Gas exchange 100 80 60 40 20 0 FM NHF FM NHF PaO2 PaCO2 Roca O, et al. Respir Care 2010;55:408-413

NHF in the ED 17 pts with hypoxemic ARF & dyspnea Before NHF After 1h NHF Borg scale 6 3 * VAS dyspnea 7 3 * RR, b/min 28 25 * SpO2, % 90 97 * NHF is feasible in the ED, and it alleviated dyspnea and improved respiratory parameters in subjects with hypoxemic ARF Lenglet H et al. Respir Care 2012;57:1873 1878

NHF in hypoxemic ARF 38 pts with ARF receiving NHF for 48h; 9 pts (24%) were intubated Intubated pts ( at 1h): - RR (30 vs 24 b/m) - SpO2 (96 vs 98%) - P/F ratio (91 vs 201) - T/A asynchrony (75 vs 10% pts) Sztrymf et al. Intensive Care Med 2011;37:1780 1786

NHF vs mask HF: improved success rate & compliance 60 pts with mild to moderate hypoxemic ARF High-flow face mask vs NHF for 24 h Fewer desaturations with NHF (15 vs 26) Parke R, et al. Respir Care 2011;56:265-70

NHF vs face mask after extubation 17 pts after extubation NHF vs non-rebreathing face mask for 30 Rittayamai N, et al. Respir Care 2014;59:485 490

Nasal High-Flow oxygen therapy after extubation No. 197 Assessed for Eligibility No. 92 Excluded No. 68 Not Meeting Inclusion Criteria* No. 24 Refused to Participate No. 105 Randomized No. 53 Assigned to Receive NHF No. 53 Received NHF as Assigned No. 52 Assigned to Receive Venturi mask No. 52 Received Venturi mask as Assigned No. 53 Included in Analysis No. 52 Included in Analysis No. 4 Post-Extubation Respiratory Failure No. 18 Post-Extubation Respiratory Failure No. 2 NIV No. 2 direct Intubation No. 8 NIV No. 10 direct Intubation No. 2 Success No. 7 Success No. 1 Intubation Maggiore SM et al. AJRCCM 2014;190:282-288

Nasal High-Flow oxygen therapy after extubation Maggiore SM et al. AJRCCM 2014;190:282-288

Nasal High-Flow oxygen therapy after extubation * ** * ** * * * NHF Venturi mask N intervention 48 49 49 48 47 40 37 N intervention 48 49 49 48 47 40 37 N control 45 42 40 34 33 26 23 N control 45 42 40 34 33 26 23 Maggiore SM et al. AJRCCM 2014;190:282-288

Nasal High-Flow oxygen therapy after extubation With NHF: Fewer pts with interface displacements (32% vs 56%, p=0.01) Fewer pts with oxygen desaturations (40% vs 75%, p<0.01) Maggiore SM et al. AJRCCM 2014;190:282-288

The RINO Trial (ReINtubation rate after Oxygen therapy) Multicenter, randomized, controlled, phase III, open trial (NCT02107183) 500 patients Nasal high-flow vs Venturi mask after extubation Study hypothesis: using Optiflow for delivering oxygen therapy after extubation may reduce the extubation failure rate and the need for reintubation as compared with the Venturi mask

Flowchart of the study 03/06/2014 Salvatore M. Maggiore 31

Conclusions (I) Available data suggest that NHF is an effective method for delivering oxygen therapy: better than conventional, low-flow devices in terms of gas exchange, respiratory rate, and comfort safer than face mask, with less interface displacement and less oxygen desaturations NHF may play a role in protecting extubation and might improve clinical outcomes in patients with hypoxemic respiratory failure

Conclusions (II) Humidification is important in airway management High flow systems may provide optimal humidification and may reduce dead space These well tolerated systems may become the first line therapy in hypoxemic respiratory failure