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High Flow Oxygen Therapy

High Flow Oxygen Therapy (HFOT), particularly when delivered by nasal cannula (HFNC) has revolutionized the management of the patient with hypoxic respiratory failure - in particular in those patients whose lung pathology has plateaued or those resposive to medical treatment (antibiotics, steroids etc). High flow systems have been available for decades - they involve the use of a high pressure oxygen source, and oxygen air blender (air can be entrained into this device), a high flow flowmeter, a humidifier, a heated delivery tube and a delivery device: CPAP mask, T-Piece with PEEP valve, Tracheostomy or specially designed nasal cannula. In this tutorial I describe the various devices configurations that are available - ranging from very straightforward standalone machines, to full mechanical ventilators. Regardless of device the major goal is to deliver sufficient flow to meet patient demand - resolving the problem of peak flow and separating out the FiO2 from the flow rate. I postulate that, at flows in excess of 30L per minute, and depending on the diameter of the nasal cannula, the patient's anatomy and whether the mouth is open (and by how much!) - the patient likely receives a couple of cmH2O of pressure support and 3-5cmH2O of PEEP. So it represents mild CPAP (certainly a CPAP device delivering high flow at 5cmH2O will outperform HFNC). There is a dearth of non industry funded data on how HFOT may benefit the patient. Certainly these devices are very effective at targeting SpO2 and reducing the work of breathing. Certainly they increase non hypoxic apneic duration. Conversely - purported impacts on dead space washout, alveolar ventilation and CO2 clearance are currently unproven. I describe how this may work in the tutorial, but point out that this is principally a belief not a fact. HFNO may also improve mucociliary clearance - due to the high flow of humidified gas passing into the airways. In the second part of the tutorial I talk about how HFOT should be used in clinical practice and the scenarios in which it is beneficial (hypoxemia, weaning and liberation) and when it is not (hypercarbic respiratory failure, post op respiratory failure secondary to atelectasis). ‪@ccmtutorials‬ www.ccmtutorials.org Description: 00:00 Beginning and Introduction 00:40 Review of Previous Tutorial 01:30 Contents of This Tutorial 01:45 We Need to Talk About Flow Again (conjecture about flow and pressure in HFOT) 07:50 The Basics of High Flow Systems 09:45 High Flow Nasal Oxygen Therapy (HFNOT) 10:35 The Airvo Type System 12:15 Air Entrainment (Hamilton Ventilator) 12:55 High Flow through a Mechanical Ventilator 14:10 A Simple High Flow System that Blends High Pressure Oxygen and Air 15:00 Goals of High Flow Oxygen Therapy (treatment of hypoxemia / reduced work of breathing) 16:30 How Does HFOT work? 18:15 HFOT and Oxygenation and Ventilation (includes unproven hypothesis) 20:15 HFOT and Carbon Dioxide Removal (contains unproven hypothesis) 25:15 HFNO Apnea and Carbon Dioxide 26:10 HFOT and Mucociliary Clearance 27:00 Using High Flow Oxygen Therapy (example Trish in MAU) 28:00 HFOT Therapeutic Strategy in Acute Hypoxic Respiratory Failure (AHRF) 31:00 HFOT in Hypercarbic (type II) Respiratory Failure 32:50 HFOT in Postoperative Respiratory Failure (hypoventilation and atelectasis) 34:45 Indications and Contraindications to HFOT 35:47 HFOT in Ventilator Liberation 37:30 Review of This Tutorial 39:00 Preview of Next Tutorial