Transcript Blood Transfusion in the Newborn

Neonatal High Flow Nasal Cannula
Towards A Clinical Practice Guideline
Bradley A. Yoder, MD
Professor of Pediatrics
Division of Neonatology
University of Utah School of Medicine
Disclosure Statement
I have received research and/or travel
compensation as a consultant to
Drager Medical
Fisher & Paykel
Vapotherm
& Ikaria
Objectives
Recognize Detrimental Approaches
Suggest Clinical Guidelines
Identify Areas for Further Research
Contributing Consultants
• Clare Collins, MBChB, PhD, FRACP. Department of Paediatrics, Mercy
Hospital for Women, Melbourne, AU ([email protected])
• Kevin Ives, MBBChir, , MD, FRCPCH. Dept of Neonatology, John
Radcliffe Hospital, Oxford, UK ([email protected])
• Brett Manley, MB BS (Hons.), PhD, FRACP. Consultant Neonatologist
Neonatal Services and Newborn Research Centre, Royal Women's
Hospital Department of Obstetrics and Gynaecology, The University
of Melbourne, Melbourne, AU ([email protected])
• Michael McQueen, MD, MBA, FAAP. Neonatology, Banner Health
System, Phoenix, AZ, USA ([email protected])
• Bradley A. Yoder, MD, FAAP. Division of Neonatology, University of
Utah School of Medicine, SLC, UT, USA ([email protected])
Why Do We Need
Practice Guidelines?
Why Do We Need Practice Guidelines?
• HHFNC universally available in US NICU’s
• Expanding international use
• Increasing pediatric & adult use
• Only a few RCT’s have been completed
• Guidelines generally improve outcomes
• Assist in identifying areas to improve
HHHFNC - Mechanisms of Action
Mechanism
Process
References
Gas
condition
Reduced metabolic work
Greenspan, JPeds 1991
Williams, CCM 1996
Waugh, RespCare 2004
Schiffmann, RCCNA 2006
Chidekel, PulmMed 2012
Maintain epithelial integrity
Improved lung mechanics
Pressure
Minimal if:
small NC coupled w/ large
nasal interface
Increases EELV
Flow
Dead space gas washout
Inspiratory resistance
Augment tidal volume
Off-loads diaphragm activity
Saslow, J Perinatol 2006
Kubicka, Peds 2008
Wilkinson, J Perinatol 2008
Frizzola, PedsPulm 2011
Sivieri, PedsPulm 2012
Collins, JPaedsChildH 2013
Hough, PedsCCM 2014
Shepard, ARRD 1990
Dewan, Chest 1994
Frizzola, PedsPulm 2011
Rubin, PedsCCM 2014
Pham, PedsPulm 2014
HHHFNC Randomized Clinical Trials
• Post-extubation HHHFNC v CPAP - preemies < 32 wks
– C Collins (Melbourne, AU; n=132)
• Post-extubation HHHFNC v CPAP - preemies < 32 wks
– B Manley (Melbourne, AU; n= 300)
• Post-extubation HHHFNC v CPAP
– Liu C (China; n= 255)
• Comparison of HHHFNC to Nasal CPAP in Neonates
– B Yoder (University of Utah, n = 432; 150 < 32 wks)
• Initial Rx for RDS HHHFNC v CPAP - preemies < 35 wks
– A Kugelman (Haifa, Israel; n=76)
Summary of Current RCT’s
HHHFNC:
• ~ 1200 infants in 5 trials
• Similar failure rates as nCPAP
• As applied, no evidence for increased adverse
events….particularly air leaks
• Does not extend O2 use or hospital stay
• Primarily relates to post-extubation use
Issues in Clinical Care
• Cannula to nares ratio
• Gas egress
• Temp & humidity
• Initial Flow Rate
• Escalation/weaning flow
• NG v OG tube
• PO feeding on HFNC
Initial Set-up
• MUST maintain a leak at the nose
– avoids excessive pressure generation
– allows nasopharyngeal ‘washout’
– more comfort & less nasal trauma
• Keep temperature close to 37o C
• Position tubing down & away from baby
– minimize fluid into the nares/airway
– reduces risk for pressure injuries
Occlusive NC
Non-occlusive NC
Critical Points
• Only use heated and humidified systems
• Typical peak inspiratory flow ~ 1 lpm, thus
when flow > wt in kg, set FiO2 = delivered FiO2
• HFNC is a non-invasive Rx: treat it like CPAP
– titrate FiO2 first, then flow rate
– if an infant needs > 50-60% oxygen  D modes
– know when to bail (apnea, acidosis, hypoxia.…)
Indications for HHHFNC
• Post-extubation support for preterm infants
– Current evidence shows equivalence to CPAP
– Data is limited for infants born < 26 weeks’ GA
• Infants stable on CPAP, where HFNC therapy
may be preferred
– A variety of reasons may be offered including ease
of care, neuro-developmental, nasal trauma, other
Unproven Benefit
• As primary support for RDS or other acute
neonatal respiratory disorder
– Lack of evidence from RCT’s
– But empirically used by many centers
Management of Flow Rate
• Initiating flow:
– Dependent on size &/or
gestation
– Dependent on 1o v 2o Rx
– Dependent on current
Paw/FiO2
• Approach to weaning:
– Time on HF
– FiO2
– Respiratory exam
• Criteria for escalation:
–
–
–
–
FiO2
Respiratory rate
RDS score/WOB
Radiograph
Management of HHHFNC Therapy
Weight
EGA
Current
Rx Mode
Current
PAW
Current
FiO2
Resp
Rate
Time
On
Exam
RDS-S
Initial flow
rate
N=4
Y=1
N=5
N=5
N=3
Y=2
N=1
Y=4
Y=5
N=4
Y=1
Y=5
Flow
Escalation
N=5
N=5
N=5
N=5
Y=5
Y=5
N=2
Y=3
Y=5
Weaning
Flow
N=1
Y=4
N=1
Y=4
N=5
N=5
Y=5
N=1
Y=4 Y=5
Y=5
The majority of consultants use the infants underlying clinical
condition, rather than weight or gestation, to manage HHHFNC
What criteria do you use in initiating
HHHFNC therapy in neonates?
Initiating
HHHFNC
Flow Rate
“C”
“A”
“B”
< 1000 g
1000-2000 g
> 2000 g
5-7 lpm
3-5 lpm
4-6 lpm
4-8 lpm
5-8 lpm
8 lpm
4-6 lpm
all wts
all wts
all wts
< 24 hrs
< 7 days
other
5-7 lpm all
Same
as above
5-8 lpm all
HFV
SIMV
CPAP
Other
NO
6-7 lpm
5-7 lpm
Same
as above;
includes
HFV
5-8 lpm
5-8 lpm
Rarely
8 lpm
for all
Occ <28 wk
may go NIMV/CPAP
FiO2
< 40%
< 30%
RA
7-8 lpm
5-7 lpm
5-7 lpm
by 1 lpm
Same
as above
7-8 lpm
5-8 lpm
8 lpm
for all
6-8 lpm if
FiO2 > 40%
otherwise 4-6 lpm
PAW
< 8 cm H2O
< 6 cm H2O
other
Same
for all
8 lpm
for all
4-6 lpm all
typically not
successful if > 9-10
Current
weight
Postnatal
age
Prior Rx
mode
Other
all wts
6-8 lpm
Same
5-7 lpm
as above
Only @ CPAP < 7 Same
7-8 lpm if
WOB
“D”
8 lpm all
“E”
4-6 lpm all
Same as
above;
Don’t use CPAP
Flow need based
on all of above
Initiation of HHHFNC Therapy
Initial
flow
rate
Weight
FiO2
PAW
“A” 5-7 lpm @ any weight
Increase for > 30%
Increase for > 6-7 cm H2O
“B” Varies by wt 3-8 lpm
Increase for > 30%
Same as for weight
“C” 5-8 lpm @ any weight
Increase for > 30%
Same as for weight
“D” 8 lpm @ any weight
Always start at 8 lpm
Always start at 8 lpm
“E” 4-6 lpm @ any weight
Increase for > 30%
Same; poor success rate
if > 9-10 at extubation
Gestation & postnatal age not a factor
Consensus Recommendations
Initiating High Flow
• Use only heated/humidified systems
• Use NC sized to allow ready egress of gas
• Start at 5-8 lpm
– no evidence comparing starting flow rates
– consider increased flow based on FiO2/Paw/WOB
What criteria do you use in escalating
HHHFNC therapy in neonates?
Escalating
HHHFNC
“A”
“B”
Increase in Flow Rate
“C”
< 1000 g
1000-2000 g
> 2000 g
Don’t use
Don’t use
Don’t use
Don’t use
Don’t use
< 24 hrs
< 7 days
other
Don’t use
Don’t use
Don’t use
Don’t u se
Don’t use
FiO2
< 40%
< 30%
> 21%
> 30% use
7-8 lpm
by 1 lpm
by 1-2 lpm
if > 30%
by 1 lpm
as FiO2
Resp rate
< 60
60-80
> 80
by 1 lpm
by 1 lpm
by 1 lpm
by 1-2 lpm
by 1 lpm
by 1 lpm
RDS score
or WOB
Specify
by 1 lpm
by 1-2 lpm
by 1 lpm
Current
weight
Postnatal
age
Time on
HHFNC
< 6 hrs
< 12 hrs
> 12 hrs
> 24 hrs
other
No time
Same as
limit
“A”
D to CPAP
if HFNC = 8 lpm
& concerns
Same
Don’t wait more
than 1-2 hrs to
escalate to
CPAP/NIMV
“D”
“E”
If FiO2
flow back
to 8 lpm
by 1-2 lpm
if > 40%
As above
for FiO2
only if > 60
only if signs
WOB/distress
As above
As above
As above
Do not use
time epochs
Depends on baby
Do not use CPAP
Occ use BiPAP
Consider
D to CPAP
or NIMV
Consensus Recommendations
Escalating High Flow
• Don’t exceed 8 lpm flow in neonates
• Increase flow for:
–
–
–
WOB
Respiratory rate
FiO2
• Don’t delay in escalating flow
• Change to CPAP/NIMV if not improving
What criteria do you use in escalating
HHHFNC therapy in neonates?
Escalating
HHHFNC
“A”
“B”
Increase in Flow Rate
“C”
< 1000 g
1000-2000 g
> 2000 g
Don’t use
Don’t use
Don’t use
Don’t use
Don’t use
< 24 hrs
< 7 days
other
Don’t use
Don’t use
Don’t use
Don’t u se
Don’t use
FiO2
< 40%
< 30%
> 21%
> 30% use
7-8 lpm
by 1 lpm
by 1-2 lpm
if > 30%
by 1 lpm
as FiO2
Resp rate
< 60
60-80
> 80
by 1 lpm
by 1 lpm
by 1 lpm
by 1-2 lpm
by 1 lpm
by 1 lpm
RDS score
or WOB
Specify
by 1 lpm
by 1-2 lpm
by 1 lpm
Current
weight
Postnatal
age
Time on
HHFNC
< 6 hrs
< 12 hrs
> 12 hrs
> 24 hrs
other
No time
Same as
limit
“A”
D to CPAP
if HFNC = 8 lpm
& concerns
Same
Don’t wait more
than 1-2 hrs to
escalate to
CPAP/NIMV
“D”
“E”
If FiO2
flow back
to 8 lpm
by 1-2 lpm
if > 40%
As above
for FiO2
only if > 60
only if signs
WOB/distress
As above
As above
As above
Do not use
time epochs
Depends on baby
Do not use CPAP
Occ use BiPAP
Consider
D to CPAP
or NIMV
What criteria do you use in weaning
HHHFNC therapy in neonates?
Weaning
HHHFNC
Current
weight
“A”
“B”
Decrease in Flow Rate
“C”
< 1000 g
1000-2000 g
> 2000 g
Wean qod
< 24 hrs
< 7 days
other
Don’t use
Wean as
above
NO
unless
“bigger” baby
As above
No wean
if > 30-35%
Same
Same
FiO2
< 40%
< 30%
RA
As above if
FiO2 stable
& < 40%
No wean
if RR>60
Same
Same
Resp rate
< 60
60-80
> 80
Postnatal
age
RDS score
or WOB
Time on
HHFNC
Specify
< 6-12 hrs
> 12 hrs
> 24 hrs
other
Wean q12
q 12-24 hrs
q 12-24 hrs
q 4-12 hrs
qod if
< 1500 g
“D”
Keep 8 lpm
til > 1 kg
1-2 kg by 1 lpm q 24
> 2 kg as tolerated
No wean
if > 80
“E”
0.5 lpm q D
1 lpm q D
1 lpm prn
Don’t use
0.5 lpm if CLD
otherwise as
above for WT
No wean
if > 80
No wean
Same
Same
Same
Same
Decreased WOB & FiO2 drive weaning more rapidly among larger infants
Stick to slower wean for smaller/younger infants
If “quick” recover Same
Same
from RDS
WOB more a factor
For ELBW p-ext than time except for ELBW
wean qod if FiO2 > 25%
Not a
factor
Not a
factor
Consensus Recommendations
Weaning High Flow
• Wean the FiO2 first, then the gas flow
– Similar to CPAP; to at least < 35%, probably < 30%
• Review at least every 12-24 hrs to determine if
flow rate can be weaned or discontinued
– May be able to wean infants > 2 kg more quickly
• Wean by 0.5 - 1 lpm decrements
Stopping HHHFNC Therapy
Weight
EGA
Postnatal Age
“A” 4 lpm *
“A” Rarely < 4 lpm w/ BPD “A” Same as weight
“B” 1-2 lpm @ < 1000g;
2-3 lpm at higher weights
“B” Same as weight
“C” 3 lpm - “smaller” babies
“C” 3-4 lpm if larger/older “C” Expect “smaller”
on 3-5 lpm for 2-3 wks
“D” 4 lpm *
“D” Same as weight
“D” Same as weight
“E” 2-3 lpm for VLBWI,
prefer to “dry” low-flow NC
“E” Same as weight
“E” Same as weight
“B” Same as weight
Preferably stable > 24 hrs, FiO2 < 30% and normal WOB/RR
* 1o related to funding issues
Consensus Recommendations
Discontinuing High Flow
• There is no consensus on when to D/C HF
• No studies comparing effect or outcomes
related to D/C HFNC at different support levels
• Recommendations vary from 1 – 4 lpm
– Centers vary by weight of infant
– Also variation related to support for BPD
CONSENSUS !
THIS WOULD WORK A LOT BETTER IF YOU’D JUST AGREE WITH ME
Consensus on HHHFNC: A Tale of Two NICU’s
Preferred Non-Invasive Approach by NICU RN’s
CPAP-Au
CPAP-UK
HHHFNC-Au
HHHFNC-UK
100
90
80
70
60
50
40
30
20
10
0
24-wk, 500g
26-wk, 750 g
28-wk, 1200g
30-wk, 1500g
Au data from Roberts CT, J Paeds Child Health 2014; UK data from K Ives, unpublished
The
Future
Challenges are what make life
interesting ……
…… overcoming them is what
makes life meaningful
Joshua J. Marine
Future Studies
• Additional large RCTs are needed:
– to evaluate HHHFNC use in ELBWIs
– to compare different HHHFNC devices
– to evaluate various approaches to HHHFNC
– to assess economic impact of HHHFNC
– to address specific respiratory conditions
– other
VIGILANCE
You can’t see it if you don’t stay awake
SUMMARY
• HHHFNC is in wide clinical use
• RCT’s support HHHFNC as safe, effective
alternative to nCPAP at the time of extubation
• Additional RCT’s are needed to study HHHFNC
as 1o therapy & related to flow management
• Except for stopping, there is moderate
consensus in the management of HHHFNC
Contributing Consultants
• Clare Collins, MBChB, PhD, FRACP.
Mercy Hospital for Women, Melbourne, AU
• Kevin Ives, MBBChir, , MD, FRCPCH.
John Radcliffe Hospital, Oxford, UK
• Brett Manley, MB BS (Hons.), PhD, FRACP.
The University of Melbourne, Melbourne, AU
• Michael McQueen, MD, MBA, FAAP.
Banner Health System, Phoenix, AZ, USA
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