WAAGBali conference

AnaesthetistsIntensivists

ENT surgeonsEmergency Physicians

Difficult case presentationDiscussion and debate on difficult airways

A few useful case presentationsSome good workshops

High Flow Nasal Cannula

High Flow Nasal Cannula

To 70 l/minFiO2 adjustable

High Flow Nasal Cannula

Humidified and warmed

High Flow Nasal CannulaKeeps mouth and eyes

clearNo wedgies please

High flow oxygen humidified therapy is intended to:

• Eliminate most of the anatomic dead space and

reduce CO2 rebreathing

• Create a reservoir with high FiO2 in the nasal cavity

High flow oxygen humidified therapy is intended to:

• Improve gas exchange via CPAP effect

– reducing atelectasis

– reducing ventilation-perfusion mismatch

• 7cm H2O positive pressure (avoid tight nares seal)

• 2cm when the mouth is open

High flow oxygen humidified therapy is intended to:

• Significantly reduce the work of breathing

• Improved compliance with more comfort

– Compared to NIV mask

THRIVE by Patel et al 2015

• Increases apnoea times in patients with difficult airways

• 25 patients• Mallampati 3, direct laryngoscopy 3• 12 obese, 9 had stridor• Given jaw thrust• Median apnoea time 14 minutes (5-65)• No patient desaturated (<90%)

THRIVE by Patel et al 2015

• Increases apnoea times in patients with difficult airways

• 25 patients• Mallampati 3, direct laryngoscopy 3• 12 obese, 9 had stridor• Median apnoea time 14 minutes (5-65)• No patient desaturated (<90%)

Normal lungsDifficult airways

Increase apnoea time

FLORALI by Frat et al 2015• Multicenter open label randomised trial• 310 hypoxaemic patients• Intubation rate difference did not reach significance (P=0.18)

– 38% HFNC, – 47% standard group,– 50% NIV group

• Post hoc analysis showed it did reach significance in the more severe group (238 patients).

• There was a significant difference in 90 day mortality in favour of HFNC.

FLORALI by Frat et al 2015• Multicenter open label randomised trial• 310 hypoxaemic patients• Intubation rate difference did not reach significance (P=0.18)

– 38% HFNC, – 47% standard group,– 50% NIV group

• Post hoc analysis showed it did reach significance in the more severe group (238 patients).

• There was a significant difference in 90 day mortality in favour of HFNC.

Abnormal lungsMay reduce need to

intubateImproves 90 day

mortality

ICU preox by Miguel-Montanes et al 2015

• Sequential observational• NRBM then HFLC• 100 patients• Median lowest SpO2 in NRBM 94%• Median lowest SpO2 in HFLC 100%• P <0.0001• Patients with NRBM had more episodes of

severe hypoxaemia (2% vs 14%, p = 0.03)

ICU preox by Miguel-Montanes et al 2015

• Sequential observational• NRBM then HFLC• 100 patients• Median lowest SpO2 in NRBM 94%• Median lowest SpO2 in HFLC 100%• P <0.0001• Patients with NRBM had more episodes of

severe hypoxaemia (2% vs 14%, p = 0.03)

Abnormal lungs Preoxygenation

Reduces hypoxaemia

PREOXYFLOW by Vourc’h et al 2015

• Multicentre randomised 119 patients• ICU pts requiring intubation for severe

hypoxaemia• RCT HFNC vs 15L/min via face mask 100% FiO2

• No difference in median lowest saturation• Scott’s take – HFNC group entraining air via mouth– No jaw thrust in HFNC group

PREOXYFLOW by Vourc’h et al 2015

• Multicentre randomised 119 patients• ICU pts requiring intubation for severe

hypoxaemia• RCT HFNC vs 15L/min via face mask• No difference in median lowest saturation

Abnormal lungs PreoxygenationNo difference

HFNC may delay intubation and increase mortality by Kang et al 2015

• 175 patients• 130 intubated before 48 hours HFNC• 45 intubated after 48 hours HFNC• Early intubation group had lower mortality

HFNC may delay intubation and increase mortality by Kang et al 2015

• 175 patients• 130 intubated before 48 hours HFNC• 45 intubated after 48 hours HFNC• Early intubation group had lower mortalityAbnormal lungs

Delayed intubation patients

may do worse

HFNC in hypoxaemia in EDRittayamai et al 2015

• Prospective randomised to HFNC vs COT• Improved dyspnoea and subject discomfort• No major adverse effects

HFNC in hypoxaemia in EDRittayamai et al 2015

• Prospective randomised to HFNC vs COT• Improved dyspnoea and subject discomfort• No major adverse effectsDoesn’t seem to do harm

in EDAppears to help relieve

distress / discomfort

When should we use it in ED?

• In those distressed by dyspnoea and hypoxaemia, but not for intubation and for comfort measures.

• Those with airway issues or mild hypoxaemia who require sedation for a brief procedure

• In those with mild respiratory distress who don’t need intubation and probably don’t need NIV but do need a bit of respiratory support

When should we use it in ED?

• In those distressed by dyspnoea and hypoxaemia, but not for intubation and for comfort measures.

• Those with airway issues or mild hypoxaemia who require sedation for a brief procedure

• In those with mild respiratory distress who don’t need intubation and probably don’t need NIV but do need a bit of respiratory support

Comfort in palliation with hypoxia / respiratory distress

When should we use it in ED?

• In those distressed by dyspnoea and hypoxaemia, but not for intubation and for comfort measures.

• Those with airway issues or mild hypoxaemia who require sedation for a brief procedure

• In those with mild respiratory distress who don’t need intubation and probably don’t need NIV but do need a bit of respiratory support

Apnoeic oxygenation during brief procedures in those at risk

Maintain jaw thrust

Hospital wide - TOE, BAL, endoscopy…

When should we use it in ED?

• In those distressed by dyspnoea and hypoxaemia, but not for intubation and for comfort measures.

• Those with airway issues or mild hypoxaemia who require sedation for a brief procedure

• In those with mild respiratory distress who don’t need intubation and probably don’t need NIV but do need a bit of respiratory support

Mild respiratory distress and hypoxia

No evidence for CO2 retainers - It is not BiPAP

When should we use it in ED?

• Children– More widely used– Respiratory distress

• Bronchiolitis, pneumonia, CCF• Respiratory support to children with neuromuscular

disease• Apnoea of prematurity• Post extubation• Weaning CPAP / BiPAP

• 2L per kg per minute for first 10kg + 0.5L/kg/min above that– max 50L/min