PARIS - High Flow Trials Bronchiolittis

How Does High Flow
Treatment Work?
Time for a change in Paradigm?
Paediatric View of High Flow Nasal Cannula Therapy
in Bronchiolitis-a PARIS High Flow Trial
A/Prof Andreas Schibler
University of Queensland
Paediatric Critical Care Research Group (PCCRG)
Lady Cilento Children’s Hospital
Brisbane, QLD, Australia
Objective
Pressure
Oxygen
Work
of
Breathing
Conflict of Interest Declaration:
Swiss Precision
Studies funded by National Health Medical Research
Council Australia, Heart Foundation, ANZ Trustee,
QEMRF, Preston James Fund, Intensive Care
Foundation, Welcome Trust UK, travel expenses for
conferences paid by Maquet, Draeger, Visasys,
Fisher&Paykel, no personal COI
Oxygen Requirement
in presence of Lung Disease
What does the clinician need to know?
•
Is a Function of Alveolar Surface
- Size of the Lung, Atelectasis and Consolidation
•
Is a Function of Shunt Fraction
- ventilation-perfusion mismatch
•
Is a Function of Ventilation Inhomogeneity
- affected by Physiological Dead Space
and preferential ventilation
•
Is a Function of Alveolar-Capillary Membrane
- Aa-Gradient
Responds to CPAP
Responds to O2
1986
The Birth of High Flow
2001
Frey and Shann.
Oxygen administration in infants
Arch Dis Child fetal Neonatal Ed 2003;88F84-F88
2006
Saslow et al.
Work of breathing using high-flow nasal cannula in preterm infants
J Perinatology 2006;26:476-480
3 large RCT in preterm infants post extubation for RDS (2013)
High Flow is non-inferior to nCPAP
n ~ 900 infants
2015:Current intubation rate ~3-5%
PICU admission fro Bronchiolitis in Australia and New Zealand
Admission Rate per 100,000
700
600
500
400
300
200
100
0
1
2
3
4
5
6
7
8
9
10
Neonatal
28 days to <90 days
90 days to <1 year
1 year to <2 years
11
12
13
Risk adjusted Odds Ratio for Intubation of
infants with Bronchiolitis
Odds Ratio
2
1
0.5
0.25
What is High Flow Nasal
Cannula oxygen therapy?
• No clear definition
• High Flow Nasal Cannula (HFNC) therapy is anything if:
• flow rates >2L/min in infants and
• flow rates ranges from 0.5 to 2L/kg/min in paediatrics
• with or without fraction inspired oxygen
• Maximal flow rate capped at 8L/min in the past (manufacturing
limitations)
• Heated and Humidified gas (undisputed benefits)
• Blended oxygen
Most accepted definition in bronchiolitis is:
Flow rate titrated for body weight at 2L/kg/min for infants under
12mths with bronchiolitis
improves lung volume, decreases
electrical activity of the diaphragm and reduces WOB measured by
oesophagus pressures. (Pham et al)
Differences in tidal breathing between infants with chronic lung diseases and healthy controls
Schmalisch BMC Pediatrics 2005
Why should we use 2L/kg/min?
Table 3
Comparison of TB parameters between both patient groups ordered according to the p-value of the ANOVA
(Presented are group means ± SD, statistically significant p-values after Bonferroni correction (p < 0.0028) are
printed in bold)
Parameter
Healthy neonates (n = 48)
CLD infants (n = 48)
p-value CLD
tI(s)
RR (min-1)
0.65 ± 0.14
39.2 ± 8.6
0.45 ± 0.11
55.4 ± 14.2
p < 0.0001
p < 0.0001
(PTIF+PTEF)/VT (s-1)
0.27 ± 0.06
0.37 ± 0.09
p < 0.0001
tE (s)
VT/tI(mL·s-1·kg-1)
0.98 ± 0.24
8.9 ± 2.2
0.72 ± 0.22
11.6 ± 2.8
p < 0.0001
p < 0.0001
V'E(mL·min-1·kg-1)
215 ± 51.7
276 ± 76.8
p < 0.0001
TIF 50 (L·min-1·kg-1)
0.75 ± 0.21
0.98 ± 0.26
p < 0.0001
PTIF (L·min-1·kg-1)
0.83 ± 0.20
1.05 ± 0.28
p < 0.0001
5.25 ± 3.66
1.05
± 0.28
p =p0.0001
< 0.0001
0.64 ± 0.19
0.82 ± 0.29
p = 0.0006
-1-2·kg-1-1
PTEF/t
))
PTEF (L·s·kg
PTIF
(L·min
PTEF (L·min-1·kg-1)
tptef
(s)*)
2.90±± 0.20
1.68
0.83
0.24 ± 0.09
0.18 ± 0.11
p = 0.001
TEF75 (L·min-1·kg-1)
0.60 ± 0.20
0.76 ± 0.29
p = 0.003
TEF50 (L·min-1·kg-1)
0.52 ± 0.17
0.66 ± 0.25
p = 0.003
TEF25 (L·min-1·kg-1)
0.38 ± 0.11
0.46 ± 0.16
p = 0.006
Vptef (mL/kg)*)
VT (mL·kg-1)
VPTEF/VT(%)*)
tPTEF/tE (%)*)
1.68 ± 0.52
5.57 ± 1.06
29.4 ± 6.6%
25.8 ± 9.7%
1.37 ± 0.44
5.15 ± 1.35
27.2 ± 6.1%
23.2 ± 7.8%
p = 0.006
p = 0.09
p = 0.13
p = 0.20
*)Loops
with flow limitations, grunting or other deformations were excluded from the evaluation (6 controls, 8 CLD
infants)
Abbreviations: tI,E-inspiratory, expiratory time, RR-respiratory rate, PTIF, PTEF-peak tidal inspiratory and expiratory
flow, VT-tidal volume, TIF 50-tidal inspiratory flow when 50% of VT is inspired, TEF 75, TEF 50, TEF 25-expiratory flow
when 75%, 50% and 25% of tidal volume remains in the lung, V' E-minute ventilation, tPTEF,VPTEF-time and volume to
peak tidal expiratory flow
Schmalisch et al. BMC Pediatrics 2005 5:36 doi:10.1186/1471-2431-5-36
Physiological Evidence
Plausible cause relationship of High Flow
Pharynx Pressure
PEEP
Milesi C. Intensive Care Med 2013
~ 1.6 L/kg/min
Inspiratory
Aid
High Flow Setup
2 L/kg/min
Blended O2/Air
Heated, Humidified
Infant Oxygen Cannula
BC2745
HFNC during interhospital Transport
children < 2 years of age
Figure 1: High-flow nasal prong system used for retrievals of critically ill children. 1, nasal
cannulae; 2, distal temperature probe; 3, tubing; 4, heated humidifier, 5, oximeter, 6, flow-meter
with ventouri blender, 7, ambient air entry port through air filter, 8, Pressurized O 2 access
How does HFNC compare to CPAP?
Early Intervention
Intubation – Ventilation - Pressure Injury
Doing less
Surfactant
plus Ventilation
Surfactant
plus CPAP
CPAP
32-36 weeks
26-32 weeks
23-24 gestational week survival on
CPAP only
Neonatal Respiratory Distress
Research
Delivery Room
Neonatal Intensive Care Unit
Progression of Disease
Acute Respiratory Distress
Research
Progression of Disease
Emergency Department
Operating Theatre
Hospital Ward
Intensive Care Unit
Acute Respiratory Distress
Research
Progression of Disease
Emergency Department
Operating Theatre
Hospital Ward
Intensive Care Unit
Primary
Outcome
Study Protocol
Responder
HFNC
2L/kg/min
Inclusion Criteria
* Bronchiolitis
* SpO2 <92/94%%
* < 12mths
Transfer
Non-Responder
Responder
Control
Responder
Non-Responder
HFNC
2L/kg/min
Non-Responder
Criteria for non-responder:
RR, HR and EWT unchanged after 120-180 min
Transfer
CPAP
WOB
FiO2
Control
Humidification
Standardization
Evidence
-
+
ACKNOWLEDGMENTS Collin Myers
PARIS Study Group
Donna Franklin
Sue Moloney
Tom Hurley
David Levitt
Marlon Radcliffe
Vishal Kapoor
John Waugh
John Coghlan
John Gavranich
David McMaster
Jan Cullen
Luregn Schlapbach
Christian Stocker
Adrian Mattke
Lee O’Malley
Trang Pham
Geraldine Corcoran
Debbie Long
Tara Williams
Kimble Dunster
John Fraser
Tom Riedel
PREDICT Study Group
Stuart Dalziel
Franz Babl
Ed Oakley
Jocelyn Neutze
Simon Craig
Kam Sinn
Jeremy Furyk
Natalie Phillips
Inclusion Criteria:
1. Infants < 12 mths (corrected age) requiring
admission to your hospital
2. Diagnosed with Bronchiolitis (viral illness
characterised by coryzal symptoms for 1-3days,
then worsens on days 3-5, with increased work of
breathing and auscultatory findings of possible
crackles and wheeze)
3. Oxygen requirement with SpO2 <94% in room air
If oxygen in ambulance - turn off briefly to assess
SpO2 in room air.
Exclusion criteria:
• Upper airway obstruction
• Apnoeas
• Craniofacial malformation
• Critically ill and immediate need for Intubation and
Ventilation or NIV
• Basal skull Fracture
• Trauma
• Decreased level of consciousness
• Cyanotic Heart Disease
• Home Oxygen therapy