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Alison Pirret NP, PhDCritical Care Complex Middlemore Hospital
School of Nursing Massey UniversityNew Zealand
Nasal high flow oxygen therapy in the ward setting
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Conflicts of Interest
• Financially supported by Fisher & Paykal to attend this meeting.
• No other conflicts of interest to declare.
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NHFProvides heated and humidified
gas
Delivers at a high flow rate (up to 60LPM)
• Low levels of dynamic positive pressure
• Can adjust FiO2 (.21-1.0)
• Decreases dead space in upper airway
• Reduces work of breathing
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Evidence for NHF
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Does NHF have a place beyond ICU?
Number of ICU beds per 100,000 population
Coun
try
Murthy & Wunsch 2012 Critical Care, 16, 218
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Is NHF safe in the ward setting?
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Matthay MA. New Engl J Med 2015;372:2225-6.
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Is NHF effective in the adult ward setting?
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Application of NHF beyond ICU
• Long hx of using high flow oxygen in ICU – mask then optiflow™ nasal prongs in 2004
• NHF (optiflow™ system) via AIRVO™ used in wards since 2009
• Currently used in all acute wards across hospital
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Rationale for use beyond ICU
• Patients can eat & drink
• Comfortable
• Can talk & be understood
• Receive benefits of NHF • therapy
– ? contributed to ↓ ICU/HDU admission
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Our setting
• Middlemore Hospital, Auckland, NZ
• Tertiary metropolitan hospital
• 990 beds
• Critical Care Complex– 12 ICU beds– 6 HDU beds– 2 tier 24/7 emergency
response system
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Two tier emergency response system
• EWSS
• Nurse led 24/7 Patient at risk team (PART)
• Physician led 24/7 medical emergency team
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Pirret AM1,2, Takerei SF1, Matheson CL3, Kelly M1, Strickland W1, Harford J1, Jepsen NE3, Welsh LJ3, Allan CPA3.
1. Critical Care Complex, Mddlemore Hospital, Auckland.
2. School of Nursing, Massey University, New Zealand.3. Physiotherapist Services, Middlemore Hospital,
Auckland.
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Study design/aim
• Prospective observational design
• To evaluate the use of NHF oxygen in adult ward patients with with respiratory failure or at risk of respiratory deterioration
• Identify difference in patient characteristics between PART and physiotherapist groups.
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Study outcomes
• Primary outcome
– Improvement in pulmonary function as indicated by:
• ↓ respiratory rate• ↓ heart rate • ↑ SpO2
• Secondary outcomes
– Improvements in:• ↓ dyspnoea• ↑ sputum clearance
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67 patients
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NHF prescribing clinician
• PART team n=30 (42.9%)
• Physiotherapist n=30 (42.9%)
• Other n=10 (14.2%)
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Variable (Total number) Number (percentage)
Mean (M) & SD (± )or Median (Mdn) & percentiles(q25, q75)
Age Mdn =71 years (58.00, 78.00)
Gender MaleFemale
41 (61.2%)26 (38.8%)
Specialty MedicalSurgical
46 (68.7%)21 (31.3%)
Number of Comorbidities M=3.03±1.89
SOFA score M=3.16±1.86
SpO2/FiO2 ratio 308.92±87.41
Demographics
No significant differences between PART & physiotherapists patient groups
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Conditions requiring NHF
0
5
10
15
20
25
Condition
Total frequency
PART
Physiotherapists
Freq
uenc
y
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Primary outcomes
0102030405060708090
100
RR HR SpO2
Pre NHF
Post NHF
t=2.79p=0.007
Parameter
Valu
e
t=2.23p=0.03 t=4.08
p=<0.001
Pre-post timeMdn=20.0 (q25, q75=15.0, 30.0) minutes
Over next 14.21±7.88 hours ↓ RR (F=11.64, p=<0.01)↑ SpO2 (F=5.43, p=0.007)
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PART & physiotherapists primary outcomes
0102030405060708090
100
RR HR SpO2
PART Pre NHFPART post NHFPhysio pre NHFPhysio post NHF
PART: t=2.49, p=0.02 Physio: t=1.51, p=0.14
Parameter
Valu
e
PART: t=3.03, p=0.005Physio: t=0.92, p=0.37
PART: t=4.12, p=<0.001Physio: t=4.12, p=0.21
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Secondary outcomes
Variable Statistical test
Dyspnoea pre NHF oxygenDyspnoea post NHF oxygen
N=38 (56.7%)N=32 (47.8%
p=0.45
Mixed logistic regression over time OR=0.64,p=0.0005
Sputum retention pre NHF oxygenSputum retention post NHF oxygen
N=38 (56.7%)N=40 (59.7%)
p=0.63
Mixed logistic regression OR=1.13,p=0.25
No pre and post improvements in PART or physiotherapist groups
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Reason for stopping NHF
Reason Frequency (percent)
Total group(N=67)
PART (n=30)
Physiotherapist(n=27)
Clinically improved 46 (68.7%) 22 (73.3%) 16 (59.3%)
Therapy not tolerated 6 (9.0%) 1 (3.3%) 4 (14.8%)
Patient palliated or died 5 (7.5%) 1 (3.3%) 4 (14.8%)
Transferred to ICU 3 (4.5%) 2 (6.0%) 1 (3.7%)
Transferred to HDU 3 (4.5%) 3 (10.0%) 0Place on another NHF device
2 (3.0%) 0 2 (7.4%)
Required ward NIV 2 (3.0%) 1 (3.3%) 0
Too hot (n=3)Confusion (n=2)Other (n=1)
ICU• Community acquired pneumonia (81yrs)• Complex bowel surgery-leak• Gangrenous cholecystitis
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2.36
0.33
1.58
0.12 0.10
2.64
1.57
0.00
1.00
2.00
3.00
Leng
th o
f tim
e on
NHF
(Day
s)
Reason for stopping NHF (Mdn)
Time on NHFMdn=2.03 (q25, q75=0.89-3.16) days
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NHF settings
Variable FiO2M or Mdn (q25, q75)
Flow rate LPM SpO2 /FiO2 ratio
Clinically improved (n=46)
0.28 (0.25, 0.39) 35.0 (30.0, 35.0) 316.39±85.04
Not tolerated (n=6) 0.28 (0.25, 0.30) 30.83±3.76 334.16±89.76
Transferred to ICU (n=3)
0.40 (0.31, 0.43) 30.0 (0.30, 0.33) 227.50 (q25, q75=214.84, 342.32)
Transferred to HDU (n=3)
0.44 (0.43, 0.49) 40.0 (35.0, 40.0) 200.89±28.51
Palliated/died (n=5) 0.25 (0.25, 0.38) 30.0 (30.0, 30.0) 301.78±86.0
Ward NIV (n=2)Other NHF (n=2)
0.35±0.1734±0.02
20.0±0.032.5±3.5
304.35±147.57266.07±12.63
Flow Mdn =30.0 (q25, q75=30.0-35.0FiO2 M=0.33±0.10
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Hospital LOS & mortality
Variable Total group (N=67)Mdn (q25, q75)
PART(n=30)Mdn (q25, q75)
Physiotherapists(n=27)Mdn (q25, q75)
Statistical test
Hospital lengthof stay
8.5 (5.0, 30.9) days
7.5 (4.0, 13.0) days
12.88 (5.0, 12.0) days
U=354.0p=0.41
Survivedhospital stay
n=60 (89.6%) n=28 (93.3%) n=23 (85.2%) FET p=0.40
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Limitations
• Single site observational study
• Not randomised/blinded
• Small numbers
• Used successfully – PART & MET