Optiflow ADU Case Study Booklet Rev C

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Case Studies

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1. Treatment of chest trauma patient with rib fractures using nasal

high flow therapy with Optiflow™

CASE STUDY

SUBMITTED BY

Treatment of chest trauma patient with rib fractures

using nasal high flow therapy with Optiflow™

André Beaumont, RRT (Hon), BSc, MSc (Cand)

York Hospital

Toronto, Ontario

Canada

INTRODUCTION

There are fractures of the right transverse processes of T3

The patient involved in this case study is a

and T5 to T11. There is a comminuted fracture of the left

65 year old man who fell backwards 10 to 15 feet while

scapular spine and there is also a comminuted fracture of the

pruning fruit trees. The fall is not thought to have any

right scapula involving the body as well as the glenoid with

underlying health-related causes. He was transported to the

extension into the glenohumeral joint. There is a moderate

Emergency Department (ER) of York Central Hospital on

amount of right-sided subcutaneous emphysema and a small

May 19, 2009. Upon examination, the patient exhibited

right-sided pneumothorax measuring maximally 17mm at the

obvious back pain and difficulty breathing with no concurrent

right base anteriorly. There is a small right hemothorax and

neck pain. There was no loss of consciousness and no

mild patchy opacity in the right lung dependently, most likely

obvious neurological deficits and vital signs were stable on

representing atelectasis although a degree of pulmonary

admission. Past medical history includes hyper-

contusion cannot be completely excluded. Tracheobronchial

cholesterolemia, hypertension, atrial fibrillation and

tree and left lung are clear. No evidence of mediastinal

obstructive sleep apnea.

hematoma. No evidence of free intraperitoneal fluid or air. No

obvious evidence of intra-abdominal injury within the limits of

Initial chest X-ray results exhibited fractures to the right third

an uninfused study. At this point the patient was admitted to

to eighth rib and subcutaneous emphysema with no obvious

a medical bed and analgesics were provided for pain control

pneumothorax. Radiological findings of a subsequent CT of

and to prevent chest splinting.

the chest, abdomen and pelvis are outlined in the following

report:

CLINICAL COURSE

Non-contrast chest abdomen and pelvis - There are fractures

The patient tolerated general analgesics and prophylactic

of the right third through 10th ribs, several with displacement.

antibiotics for roughly 24 hours before becoming increasingly

short of breath, diaphoretic and hypoxic. Internal medicine

determined that this gentleman was likely to face impending

respiratory failure due to pulmonary complications of his fall

including pulmonary contusions, atelectasis, pneumonia and

a worsening right-sided pneumo/hemothora breathing. The

patient had a 90% Oxygen Saturation on 4 L/min O2 via

nasal prongs at this time and was breathing 35 to 45 breaths

per minute. The patient was transferred to the Intensive Care

Unit (ICU) for a thoracic epidural insertion to be followed by a

right sided chest tube insertion. A quandary arose in

determining how best to support this patients respiratory

efforts during the epidural insertion and possibly beyond.

Case Study submitted to Fisher & Paykel Healthcare Ltd

185047492 Rev C

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Since it appeared that conventional oxygen delivery systems

injury. Length of stay and the cost of admission, particularly

were not enough, invasive and noninvasive options were

in the ICU, were likely significantly decreased since

examined. Optiflow was currently on trial at this institution

intubation and invasive ventilation along with concurrent

and the author suggested using it as a test during the

sedation were not required. The alternative supportive

procedure with invasive ventilation as a back-up in the event

equipment available, namely the Respironics Vision BiPAP,

of further respiratory failure.

required the use of a full face mask. This interface would limit

the patient’s ability to both speak and ingest fluids only

The Optiflow was applied at 40% oxygen with a flow of 35

L/min using the large bore nasal cannula. The humidifier was

set to the non-invasive mode. The patient was then assisted

into a sitting position whereby the epidural could be inserted.

After both the epidural and the Optiflow application the

patient’s work of breathing and respiratory distress

decreased dramatically. The respiratory rate dropped from

42 to 23 /min. A chest tube was then inserted into the fourth

intercostal space. Over the course of the subsequent night,

the epidural level was titrated upwards to better control the

patient’s pain and Levophed was started to control a lowered

blood pressure.

during opportunities where it was felt safe to remove the

mask for short periods of time. A further ongoing

complication with the full face mask BiPAP is the pressure

damage caused by long term use on the face. Since the

Optiflow is a flow generator, not a pressure generator, and

since the interface utilized was a type of wide bore nasal

cannula, the patient comfort was improved over traditional

noninvasive means.

The sole major complaint of the patient regarding his

respiratory status was the dryness he developed in his mouth

- this, in spite of using a Fisher & Paykel Healthcare

humidifier in-line with the Optiflow. Of note is that the

By the following morning the patient’s status had improved

humidifier was set to the traditional noninvasive mode of

and this trend would continue for the next seven days while

humidification which drops the overall temperature felt at the

remaining on the Optiflow for the duration. The patient was

interface. Since so little of the interface is in contact with

able to ingest fluids and oral medications with no noticeable

facial skin, it may have served better to try the system using

problems and was able to speak coherently with staff and

the invasive humidification setting.

family members. Staff and family noted also that the patient

Overall, the Optiflow system served this trauma patient very

did not appear to significantly snore or obstruct his airway

well and the eventual outcome could not have been better,

while sleeping in spite of previously being diagnosed as

considering the circumstances surrounding the injury and

having obstructive sleep apnea. The sole complaint voiced

treatment.

by this particular patient is the noticeable drying of the oropharynx while wearing the Optiflow for such a long duration.

Disclaimer: Any clinical opinions in this Case are the opinions of the

contributing author and are given for information purposes only. The clinical

opinions are not intended as and do not substitute medical advice.

DISCUSSION

Traumatic chest injuries such as suffered by the patient in

this case study often run a complicated course. Because of

the pulmonary contusions and pain, these patients frequently

develop atelectasis and pneumonias requiring more invasive

ventilatory care. In the case of this patient, the Optiflow used

in conjunction with excellent pain control and prophylactic

antibiotics led to the best possible outcome for his chest

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2. Heated Humidification and Optiflow™

CASE STUDY

SUBMITTED BY

Heated Humidification and Optiflow™:

The future of effective, high flow nasal oxygen

therapy

Gerald Chanques, MD, PhD, Anesthesiologist & ICU Doctor

Samir Jaber, MD, PhD, Professor and Chairman of Anesthesiology & Critical

Care Medicine.

Department of Anesthesiology & Critical Care Medicine. University of

Montpellier Saint Eloi Hospital, France

National Institute of Health and Medical Research (INSERM)

U1046 (Physiology & Experimental Medicine)

University of Montpellier Arnaud de Villeneuve Hospital, France

BACKGROUND

Pain and discomfort are associated with an increased

morbidity in critically ill patients



Critically ill patients hospitalized in an Intensive Care

FIRST STUDY – FACEMASK OXYGEN WITH ADDED

HUMIDIFICATION



oxygen therapy when delivered by a facemask in 30

consecutive ICU patients (70% surgical).The median

oxygen flow rate was 8 5-11 L/min3.

Unit (ICU) frequently report pain and discomfort.



The causes of the pain and discomfort may be related

to a patient’s medical history and or to the procedures



The oxygen was humidified - either by a bubble

humidifier or a heated humidifier (MR850; Fisher &

Paykel Healthcare, Auckland, New-Zealand). The

humidifiers were randomly assigned and changed

every 24 hours for 48-72 hours using a crossover

design.



Evaluation of the discomfort symptom data, such as

dryness of the upper airway mucosa or pain, was

blinded.



In addition we performed a bench test study, using

psychometric methods to measure the hygrometric

properties of oxygen when humidified with either the

bubble or the heated humidifier or without any

humidification device. The mean absolute humidity

was two times greater with the heated humidifier than

with the bubble humidifier.

and devices they encounter1.



ICU stressors have been associated with an increased

morbidity, and are partially explained by an increased

stress response, deterioration in quality of life and bad

memories.

Discomfort is a consequence of Oxygen therapy

delivered by a face mask

We studied discomfort associated with conventional

Oxygen therapy is a common treatment for ICU patients who

suffer from organ dysfunction. Non-intubated critically ill

patients commonly receive oxygen therapy above 4 L/min via

a facemask. For decades, facemasks have been chosen in

preference to nasal cannula partially because patients with

acute respiratory failure prefer to breathe through an open

mouth rather than their nose. Additionally oxygen flow rates

are limited when using a standard non-humidified nasal

cannula. The delivery of higher flows of oxygen by facemask

frequently causes discomfort.

MISSION:

We have been working to reduce pain, discomfort and

neuropsychological disorders in our medical-surgical

ICU for 10 years. We have found that strategies to

reduce pain and discomfort were associated with an

improvement of ICU outcomes2.

Case Study submitted to Fisher & Paykel Healthcare Ltd

185047492 Rev C

RESULTS

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In this first study we have shown that intensity of

symptoms was less prevalent when oxygen therapy was

humidified using a heated humidifier .



Using a 0-10 visual numeric scale, the dryness of the

upper airway mucosa was significantly lower when a

heated humidifier was used (3.1 [1.7 to 4.8] vs. 4.8 [2.0

to 6.4], P< 0.01).



The decrease of discomfort seen was associated more

with mouth and throat dryness.

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



In addition to the impact of discomfort, psychological

issues and morbidity - without humidification, oxygen

therapy could also impair the airway mucosa leading to

mucus plugging and infections.

More than half (56%) of patients experienced

moderate-to-severe discomfort symptoms regardless

of the humidification device used.



This is especially of interest in the less severe ICU patients

who require oxygen therapy, whatever the flow.

No significant difference in facial heat sensation was

observed between the two humidification devices.



Conclusion 2: Patients don’t have to remove the

oxygen therapy to drink and eat.

On the last day of the study, patient preference was

significantly higher for the heated humidifier than for

the bubble humidifier.

CONCLUSION:

Effective humidification decreases the discomfort

associated with oxygen therapy.

ONGOING STUDY: HUMIDIFIED OXYGEN THERAPY

WITH OPTIFLOW NASAL CANNULA

Because all our mechanical ventilators are fitted with a

heated humidifier, the routine use of this equipment has been

facilitated in all ICU patients for oxygen therapy after

extubation, or between non-invasive ventilation sessions,

without any further cost implication.

In addition, we have progressively introduced the high flow

nasal cannula Optiflow as a standard oxygen interface for all

our ICU patients whatever the required oxygen flow rate. Our

intuition was that Optiflow could provide several advantages

including being an effective treatment with minimal

associated discomfort compared to facemasks.

Conclusion 1: Healthcare providers and family

members are able to see the entire patient’s face.

In patients unable to communicate, the observation of the

patient’s face is of particular importance for an accurate

observation of pain behavior. Consequently, we

constructed a dedicated pain assessment tool for non4.

intubated ICU patients Careful assessment of pain in ICU

patients is associated with positive outcomes2. Moreover,

for ICU patients able to communicate, speech and

language therapists also recommend the careful

observation of the face including cheek, mouth and lips.

This improves the effectiveness of patient’s

communication, which is frequently altered in critical illness.

Conclusion 3: Optiflow allows immediate oxygen

therapy without any interruption after removal of the

tracheal tube (extubation).

Extubation is a critical situation associated with a risk of

desaturation due to a variety of causes, such as airway

narrowing, pain and cough. Moreover, disruption of oxygen

therapy may occur during the time of switching from the

tracheal tube to the placement of the facemask in case of

sustained cough or agitation. Optiflow can be safely placed

and connected to oxygen before removal of the

endotracheal tube, to avoid any disruption of oxygen

therapy during this critical procedure.

Conclusion 4: Optiflow can be used at a variety of

flow ranges from moderate to very high oxygen.

The use of standard nasal cannula for non-humidified

oxygen therapy less than 4 L/min is feasible and

recommended; the use of heated humidified oxygen

therapy with Optiflow is feasible and safe within a large

range of oxygen flow from 4 L/min up to 60L/min. We

currently use either a standard oxygen flow meter, which

delivers an accurate oxygen flow up to 30 L/min, or a

dedicated mixed oxygen/air flow meter when an oxygen

flow above 30 L/min is needed.

COMPARISON: OPTIFLOW COMPARED TO OTHER

OXYGEN THERAPY DEVICES



We compared the oxygen therapy characteristics of

Optiflow to the reference facemask with reservoir bag

for high-flow oxygen therapy and to the ContinuousPositive-Airway-Pressure Boussignac CPAP using a

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dedicated facemask .



This cross-over study was performed in 10 recovery

patients weaned from a tracheotomy-tube and

randomized to one of three devices, three oxygen flowrates (15, 30 and 45 L/min) and two airway-tightness

conditions (open and closed mouth), i.e. 18 tested

conditions.



Airway-pressures and inspired fraction of oxygen

(FiO2) were measured for the first time inside the

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

trachea using a tracheal catheter inserted through the

hole of the tracheotomy tube after removal.

CONCLUSION:

The clinician should choose the technique best-

Comfort was evaluated as previously described.

adapted to the patient’s condition and requirements.

RESULTS



We found that Optiflow provided a tracheal end3-6

expiratory pressure of 5

cm H2O at 30 L/min

oxygen-flow and mouth closed.



This positive airway pressure was higher than the

reservoir-bag-facemask, and lower than the

Boussignac CPAP, which was the only device

generating a Continuous-Positive-Airway-Pressure,

irrespective of the inspiration or the expiration, or the

opening of the mouth.



On the other hand, FiO2 and comfort levels were

higher for the Optiflow than for the Boussignac CPAP

and did not significantly differ from the reference highflow facemask with reservoir.

THE FUTURE: COULD WE USE OPTIFLOW IN ALL

ICU PATIENTS REQUIRING AN OXYGEN FLOW

ABOVE 4 L/MIN?

We have shown that the use of Optiflow at high oxygen flows

provided similar tracheal FiO2 when compared to the

reference facemask with reservoir bag. This finding, in

addition to the number of other potential advantages for ICU

patients (communication, activities of daily living), allows the

utilization of Optiflow for a large range of heated humidified

oxygen flow needs. A broad application of Optiflow for

oxygen therapy, whatever the oxygen flow rate, seems to be

feasible in the ICU setting. However, the benefit of this

implementation needs to be evaluated in terms of both its

advantages and cost-effectiveness.

REFERENCES

1.

Chanques G, Sebbane M, Barbotte E, Viel E, Eledjam JJ, Jaber S: A prospective study of pain at rest: incidence

and characteristics of an unrecognized symptom in surgical and trauma versus medical intensive care unit

patients. Anesthesiology 2007, 107(5):858-860.

2.

Chanques G, Jaber S, Barbotte E, Violet S, Sebbane M, Perrigault P, Mann C, Lefrant J, Eledjam J: Impact of

systematic evaluation of pain and agitation in an intensive care unit. Crit Care Med 2006, 34(6):1691-1699.

3.

Chanques G, Constantin JM, Sauter M, Jung B, Sebbane M, Verzilli D, Lefrant JY, Jaber S: Discomfort associated

with underhumidified high-flow oxygen therapy in critically ill patients. Intensive Care Med 2009, 35(6):996-1003.

4.

Chanques G, Payen JF, Mercier G, de Lattre S, Viel E, Jung B, Cissé M, Lefrant JY, Jaber S: Assessing pain in nonintubated critically ill patients unable to self-report: an adaptation of the Behavioral Pain Scale. Intensive Care

Med 2009, 35:2060-2067.

5.

Chanques G, Riboulet F, M S, Jung B, Prades A, Gallia F, Futier E, Constantin JM, Matecki S, Jaber S: High-FlowNasal-Cannula (new Optiflow™ system) versus Boussignac-Continuous-Positive-Airway-Pressure In IntensiveCare-Unit Patients: A Cross-Over Physiological Study. Annual Congress of the American Thoracic Society, San

Francisco, 2012.

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3. The Application of Optiflow™ in Conjunction with the Breather® and

Passey-Muir® Valve in the Difficult-to-Wean Patient with a

Tracheostomy

CASE STUDY

SUBMITTED BY

Optiflow™ Nasal High Flow

Michelle Dungo-Sales, BSc, RRT

St Paul’s Hospital

Vancouver, B.C, Canada

BACKGROUND



17 AUG: A tracheostomy was performed in the OR

The patient presented in this case study is a 54 year old man

and a #6 Shiley tracheostomy inserted. The patient

transferred to the ICU on July 23 with sepsis secondary to a

was mechanically ventilated on pressure support for

perforated abdominal viscous post-gastric tube insertion in

a short time.

the operating room (OR). The patient was intubated upon



ventilation and started on T-piece trials.

admission for airway protection for a decreased level of

consciousness. PMHx: Advanced HIV (new diagnosis with

19 AUG: The patient weaned from mechanical



20 AUG: The patient was corked for the first time

CD4 count of 50), previous mycobacterium avium complex

(with a plastic cap placed on the end of the inner

(MAC) and pneumocystis carinii pneumonia (PCP), spastic

cannula as a weaning trial) and tolerated about 3.5

paraplegia secondary to viral transverse myelitis from

hours before desaturating and then requiring lots of

varicella zoster, multifactorial cognitive impairment and TB

suctioning via the tracheostomy. Patient was then

meningitis.

placed on Optiflow via a T-piece at FiO2=0.30 at a

flow rate of 40 L/min. Optiflow therapy was

CLINICAL COURSE

maintained for the next few days, with the patient

requiring less suctioning.



23 JUL: The patient was intubated.



24 JUL: The patient was extubated after one day.



26 JUL: The patient was started on Optiflow at

to #4 Shiley cuffless and the patient was corked on

FiO2=0.35 via HFNC at a flow rate of 40 L/min to

room air.

provide humidity to assist with secretion clearance.







24 AUG: The patient had multiple desaturations;

The patient required frequent naso/orotracheal

therefore the tracheostomy was uncorked and he

suction to clear secretions as he did not have a

was placed back on Optiflow via a T-piece at

consistently effective cough.

FiO2=0.40.

After three days of Optiflow treatment, the patient



next two weeks, he required naso/orotracheal

27 AUG: The tracheostomy tube was displaced

interstitially twice and required reinsertion.

weaned to nasal prongs and then room air. For the



23 AUG: ENT service downsized the tracheostomy



28 AUG: The patient was managing secretions

suction about once a day.

independently with Optiflow as secretions were

12 AUG: ENT were consulted and determined

noticeably thinner. His tracheostomy tube was

some atrophy to vocal cord and filler was injected

corked and switched to Optiflow via a nasal

into cords. A tracheostomy for bronchial hygiene

cannulae (HFNC).

was proposed after discussion with the team.



29 AUG: The patient’s tracheostomy was

decannulated.

Case Study submitted to Fisher & Paykel Healthcare Ltd

185047492 Rev C

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



30 AUG: The patient required nasotracheal

Corking trials were re-initiated in mid-October. During the

suctioning for desaturations due to retained

period his tracheostomy was corked, Optiflow was used via

pulmonary secretions.

NC at FiO2=0.30.

31 AUG: ENT reinserted the tracheostomy (a #5

cuffless, distal extended length Shiley as regular

because a #4 Shiley was too short for the patient’s



14 OCT: Corking trials were re-initiated.



22 OCT: After being corked for about nine hours,

the patient had plugged off his left lung. Corking

anatomy) for bronchial toilet and Optiflow was

restarted via a T-piece at FiO2=0.30 and a flow rate

of 40 L/min.

trials were stopped after this event.



7 NOV: Corking trials were restarted with the use of

Optiflow via NC and when uncorked, the patient

Over the next two months, the patient was initiated on

several corking trials with the use of Optiflow via NC but was

was on a T-piece via Optiflow.



not able to sustain corking due to retained secretions. His

corked but occasionally still required suctioning

cough was inconsistent and he had also plugged off his

whole left lung due to mucous plugging on more than one

through the tracheostomy.



occasion.

The team's plan was to cork patient for extended

period due to the previous failed decannulation and

an inconsistent cough which required suctioning.

Despite an injection of vocal cord filler by ENT for unilateral

vocal cord atrophy, the patient was still unable to speak in

12 NOV: The patient was able to tolerate 14 hours



13 NOV – 6 DEC: The patient was corked during

more than a whisper. Speech language pathology (SLP) was

the day and uncorked overnight and Optiflow was

involved in his care to improve voice quality using

still used via NC and a T-piece.

strengthening exercises. Minimal improvement was noted



7 DEC: The patient was transferred to the ICU due

after weeks of speech language therapy. The patient

to impending hypoxic respiratory failure. He was on

continued to receive nutrition via a percutaneous endoscopic

maximum FiO2 via Optiflow with satisfactory SpO 2

gastrostomy (PEG) tube. He was also started on anti-

readings. Respiratory failure was determined to be

retrovirals for his HIV. The patient was cachectic and unable

again due to mucous plugging.

to sit in a wheelchair for long periods of time. This was due to



8 DEC: The patient was transferred from the ICU

his ongoing hip and back pain; therefore he remained in bed

back to the HIV ward and it was recommended that

for most of the day. The patient lacked any leg strength to

he should not be corked and would likely be a

support his own weight and this motor loss was deemed to

chronic tracheostomy patient.

be irreversible via MRI. (The MRI showed progressive,



21 DEC: ENT removed granuloma tissue from the

atrophic changes in the spinal cord with the evolution of

tracheostomy site and it was suggested by

basal ganglia infarcts.) After a multi-disciplinary meeting was

pharmacy to try glycopyrollate to thin pulmonary

held, it was decided to send a request for assessment and

secretions.

placement at a long-term facility able to accommodate a

patient with a tracheostomy. He was put on a waitlist for

placement. During this time, the patient was left on Optiflow

at FiO2=0.30 via a T-piece and still required lots of suctioning

through his tracheostomy. His cough continued to remain

inconsistent.

No further corking trials were attempted until the end of

January, when the patient was stable. He required

minimal suctioning and his cough was noticeably

improved and effective. The patient had developed

upper body strength and was able to help assist in his

bed transfers. He had also gained much-needed weight.

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The patient was able to tolerate longer periods in his

facility on July 30. He still had a PEG on discharge with

wheelchair, which improved his overall respiratory

the plan to remove it in a few weeks but was eating full

mechanics and secretion clearance.

meals and taking oral medications.

Our department consulted with other disciplines involved

in his care, such as nursing, SLP, physiotherapy and

occupational therapy. A team meeting was held with all

disciplines and the primary care team (the HIV team) to

discuss progress and a care plan while awaiting transfer

to a long-term facility. It was apparent that the patient

was making progress from all fronts. Our department

and SLP suggested restarting corking trials but this time

using a Passey-Muir® valve (PMV) in conjunction with

Optiflow. The use of the PMV would enable resensitizing of the upper airway and strengthening of the

muscles involved in respiration and swallowing. SLP

also suggested trying “The Breather®” device in

conjunction with the PMV. The Breather® is a device that

is used to assist in lung expansion, coughing and

secretion clearance by having the patient use a

mouthpiece attached to a device with a variable

resistance. The patient was started on a slow, PMV

corking and weaning trial. Optiflow therapy was

maintained at all times, including during the PMV trials.

The respiratory therapists, SLPs, and nursing staff

communicated when the PMV would be placed in situ

during the day so that “Breather” therapy would occur at

the time the patient was having a PMV trial and sitting

up in his wheelchair. He tolerated using the PMV during

daytime hours (about 12 to 14 hours) in about a month

and a half. Over this period, the patient received SLP

therapy during the weekdays with remarkable progress.

He was now able to talk at an audible level with the PMV

and it was suggested by SLP that a Modified Barium

Swallow test be repeated (he had failed this previously).

The patient now rarely required any suctioning through

his tracheostomy. He passed his swallow test and was

started on a thickened diet in addition to his gastric tube

feeds. The patient eventually decannulated requiring no

supplemental oxygen and transferred to a long-term

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4. The Application of OptiflowTM in Weaning from Tracheostomy

CASE STUDY

SUBMITTED BY

Optiflow™ Nasal High Flow

Michelle Dungo-Sales, BSc, RRT

St Paul’s Hospital

Vancouver, B.C, Canada

INTRODUCTION

that day and a #6 Shiley cuffed tracheostomy was surgically

The patient presented in this case study is a 73-year-old

inserted. The patient was weaned from mechanical

Chinese-speaking gentleman with a diagnosis of

ventilation and placed on Optiflow via T-piece at FiO2=0.30

hyperparathyroidism secondary to chronic renal failure. The

and flow rate of 35L/min minute from June 6 to June 12. The

patient has an extensive past medical history that includes

humidity provided by the application of Optiflow assisted in

COPD, previous left pneumonectomy secondary to a

the management of thick secretions that were present. On

necrotizing pneumonia, two previous tracheostomies and

June 12, ENT changed the tracheostomy to a #6 Shiley

end-stage renal disease, requiring hemodialysis three times

cuffless type and Optiflow was discontinued and the patient

a week.

was placed on humidified O2 via a Thera-Mist® nebulizer at

FiO2=0.36 via a T-piece as it was felt that secretions were

The patient underwent surgery for a subtotal

thin, mucoid and his cough had improved. The patient was

parathyroidectomy on May 26, 2011. On post-op day four,

further downsized to a #4 Shiley, cuffless tracheostomy on

May 30, whilst on the surgical ward, a CODE BLUE was

June 13 as he remained stridorous when the tracheostomy

called for impending hypoxic respiratory failure. The patient

opening was finger-occluded with the #6 Shiley in situ.

was difficult to intubate (with a Grade III classification where

only the epiglottis is visualized during direct laryngoscopy)

Tracheostomy corking trials1 were initiated on June 14 and

due to the presence of airway swelling. Three attempts were

the patient tolerated approximately 15 hours and SpO 2

made before he was successfully intubated with a #7.5 oral

maintained between 88 and 92% on 3 to 4 L/min via nasal

endotracheal tube (OETT) and transferred to the ICU for

prongs. The next day, the patient was transferred to the

mechanical ventilation.

medical ward but became acutely hypoxic. It was believed

that the hypoxic episode was due to mucous plugging after

CLINICAL COURSE

only being transferred from the ICU within the last 24 hours.

The patient was diagnosed and treated for aspiration

As a result, the patient was restarted on the Thera-Mist®

pneumonia and weaned to minimal ventilatory support. On

nebulizer via tracheostomy mask at FiO 2=0.36 for humidity.

June 5, after about six days of ventilatory support, the

He required frequent tracheostomy suctioning of thick

decision was made to perform a trial extubation using a tube

secretions and plugs for almost two weeks. The patient was

exchanger (airway exchange catheter) with an anesthesia

eventually decannulated on June 24 after tolerating

and ENT physician at the bedside. Once the OETT was

tracheostomy corking for 24 hours whilst requiring no

removed, the patient’s airway was examined by ENT via

suction. The following day, during hemodialysis, he became

bronchoscope and it was decided to re-intubate him with a

severely hypoxic with increased work of breathing. It was

#7.0 OETT. The patient was then scheduled for a

identified that this episode was caused by mucous plugging.

tracheostomy insertion in the operating room (OR) due to the

1

high risk of complications. The patient went to the OR later

Case Study submitted to Fisher & Paykel Healthcare Ltd

185047492 Rev C

Corking trials: a procedure whereby the tracheostomy opening is capped

for a period of time to assess whether the patient still requires the

tracheostomy tube.

Page 12

It was decided to re-insert a tracheostomy size #4 Shiley

the strength of his cough. This patient may well have been

cuffless to allow for secretion management and the patient

discharged to a long-term care facility with a home

®

was placed on an AirLife nebulizer for humidity with

tracheostomy had our facility not have trialled Optiflow on our

FiO2=0.28. Nebulized hypertonic saline was added to the

medical ward. This use of Optiflow on the medical ward was

patient’s list of regular respiratory medications. On July 14, a

the first application used outside of a critical care area at our

multi-disciplinary meeting including a Respiratory Therapy

facility. The patient was happily discharged home after being

was held. The plan was to discharge the patient either to

in hospital for just over two months, without a tracheostomy

their home if he was able to be decannulated or transferred

and without supplemental oxygen.

to a care facility as the family voiced that they were unable to

manage a tracheostomy. During the meeting a plan was

established to: keep attempting corking trials, re-initiate

Optiflow for secretion management and continue and

encourage mobilization. The next day, the patient was

initiated on Optiflow at FiO2=0.30 at a flow rate of 35 L/min in

accordance with the care plan with the trach interface. From

July 15 to 18, he was maintained on Optiflow at FiO2=0.30,

flow rate of 35 L/min for 24 hours a day, and on July 19,

corking trials were initiated. During these trials, the patient

was switched to the nasal prong interface on Optiflow at the

same FiO2. During this time, his cough and mobility

improved. The patient was decannulated on July 25 while

Optiflow was continued via nasal interface for a few more

days. On August 3, he was discharged home without the

tracheostomy.

DISCUSSION

This case study demonstrates that the use of Optiflow may

have played an important role in aiding a patient with a

tracheostomy to manage thick secretions and eventually

wean off the tracheostomy after a previously failed

decannulation. Optiflow was used for approximately two

consecutive weeks with both the T-piece and nasal interface.

During this time the patient was encouraged to cough and

clear his own secretions and mobilize with family and the

physiotherapist daily. After the application of Optiflow,

pulmonary secretions were noticeably thinner and easier to

manage and clear by the patient. He did not have any acute

episodes of hypoxia during this period. The patient’s overall

exercise tolerance and independence improved as well as

Page 13

5. A new standard of oxygen therapy using an Optiflow™ humidified

nasal cannula

CASE STUDY

SUBMITTED BY

Optiflow™ humidified nasal cannula

Nigel Fealy, Clinical Nurse Educator

Department of Intensive Care,

Austin Hospital Melbourne, Australia

The ICU staff realized that while Optiflow was first introduced

INTRODUCTION

to provide comfortable and effective high flow oxygen

In December 2011, the Intensive Care Department at Austin

delivery, it was just as effective at low flows. Standardizing

Hospital in Melbourne, Australia implemented a policy of

with Optiflow would provide continuity of high quality care

always extubating patients onto an Optiflow humidified nasal

and eliminate the hidden costs associated with supporting a

cannula. The policy was designed to further improve oxygen

diverse range of equipment.

therapy while reducing waste and minimizing the investment

in unproductive inventory. Within six months the use of

Optiflow had spread to wards throughout the hospital.

Austin Hospital has 400 acute beds and a 20 bed intensive

care unit (ICU). Optiflow was initially used within the ICU to

provide comfortable and effective high flow oxygen therapy

“Now, we simply extubate onto Optiflow and as the patient

gets better we can decrease the flows close to levels that of

basic nasal prongs. But if they get sicker we can escalate up

the tree and we don‟t have to change the device,” says Nigel.

“In short, we can use Optiflow until they‟re discharged from

the ICU.”

up to 60L/min. The wider benefits and versatile flow rates of

Ensuring a smooth transition

Optiflow soon became apparent, making it an ideal solution

Each bay in the ICU was equipped with two 30L/min flow

for the medical staff‟s desire to improve respiratory care. The

meters (one for air and the other for oxygen) and dual-flow

majority of ICU patients at Austin Hospital are post-surgical,

adaptors. Humidifiers, chambers and heated delivery tubes

so extubation was the logical point at which to begin

were standardized (in this case with the F&P MR850

standardizing.

system) allowing a straightforward transition to an Optiflow

nasal cannula on extubation.

CLINICAL COURSE

Austin Hospital ICU has about 230 nurses on staff. Some

Historically the ICU nurses would select the most appropriate

piece of oxygen equipment from what was available at the

time. This could result in the use of a simple mask, basic

nasal prongs, a re-breather mask or an air entrainer kit.

work only one day a week while others are full time. With

the equipment in place, ICU educators and F&P

representatives were on site at the beginning of every shift

for a week. Staff were shown how to assemble the

“Often we were extubating patients from a ventilated circuit to

equipment and provided with a guide that included set up

a whole new air entrainer kit. When their oxygen was OK

flows. The ICU educators also developed policies and

they‟d go to a simple mask and then maybe basic nasal

protocols for using Optiflow.

prongs,” explains Nigel. “So they‟d often have four or five

“We just went for one full week, Monday through to Sunday

versions of oxygen therapy while in the ICU. Instead of using

every shift and captured 80% to 90% of the staff,” explains

all those pieces of equipment, we were looking for something

Nigel. “It also meant that if anyone said „hang on I thought I

that covered the entire range.”

Case Study submitted to Fisher & Paykel Healthcare Ltd

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had it but now that I‟m using it I‟ve got a couple of

Page 14

questions‟ one of us was immediately available to provide

Patients help to drive change

the answers.”

With Optiflow patients can eat, talk and sleep without

Discharging to the ward on Optiflow

interrupting their therapy. There‟s no doubt they‟re more

With the ICU‟s inventory simplified to one device for non-

comfortable and compliant on Optiflow.

invasive oxygen delivery, patients are discharged to the

“When we had them on face masks and the humidification

ward on Optiflow. ICU nurses simply wean patients down to

was done properly they sometimes complained it was too

flow rates that are within the wards‟ capabilities. The ward

hot on their face,” explains Nigel. “With Optiflow they don‟t

staff can then decide whether to continue delivering

have that claustrophobic feeling of gas forcing into their

humidified gas through the Optiflow nasal cannula or switch

face. They‟re just more comfortable.”

the patient to another device.

Once patients have experienced Optiflow the message is

Changing early perceptions on the ward

clear. As Nigel explains, when you put a patient back onto

With the ICU standardized to Optiflow, a comprehensive

a mask they typically say something like „Hang on a

training program began for staff on the wards. Part of the

minute. I was quite happy with that other thing. It was

challenge was overcoming the perception that Optiflow was

comfortable. Why do I have to go back to this mask? I don‟t

a high flow ICU device that should only be used on high

want it on my face‟.

acuity patients.

“In nearly every other facet of medicine we have embraced

“Initially there was a feeling that if you had more patients on

technology, yet as a profession we‟re still putting masks on

Optiflow in your ward it meant you must have more really

people,” says Nigel.

high acuity patients,” says Nigel. “To change this, we

simply gave nursing staff the facts and let them come to

their own conclusions. We believe there is good evidence

that effective humidification is important even if the patient

is only needing a couple of liters per minute.”

Optiflow is now at home on the wards

The ICU liaison nurses also did an immense job in

assisting with the transition to build confidence with

Optiflow on the wards. Once ward staff realized that you

can use Optiflow at low flows, they understood that the

Through a series of workshops, the hospital‟s clinical nurse

device was more about providing effective and comfortable

educators were introduced to the reasons for the ICU‟s

humidification and not just for high acuity patients. As a

decision to standardize. They also learned about the

result, they‟ve taken to Optiflow quite quickly.

benefits of warm humidified respiratory care and how to

use an Optiflow device. At the same time, ward managers

“Our cardiothoracic and liver transplant wards were the first

were engaged to check that appropriate gas supply fittings

two that really took it up easily,” explains Nigel. “That

were in place. The educators then ran training programs for

translated to most wards in the hospital within just six

their own nursing staff.

months. The wards adapted to the change a lot quicker

“Some of our ward educators had previously worked in the

ICU. So from their background they were saying, „listen

guys this is really simple it‟s not that big a deal‟,” explains

Nigel.

than we thought they would.”

DISCUSSION

Standardizing with Optiflow at Austin Hospital was quite

straightforward, but according to Nigel that was because of

the approach they took. He believes the vital success factors

are:

Page 15

•

Having the full support of medical staff, the medical

director and ICU consultants

•

Identifying two or three ICU nurses to champion the

change, be visible reference points and respond to any

challenges

•

Checking that all equipment is in place before making

the change

•

Fully supporting ICU staff through a concentrated oneweek changeover

•

Discharging to the ward on Optiflow and enabling ward

staff to make an informed choice about the most

suitable ongoing therapy

SUMMARY

By implementing a policy to standardize to Optiflow the

Austin Hospital has simplified its oxygen therapy treatment.

This has resulted in the following benefits:

•

All patients can receive humidified medical gasses

comfortably through a nasal cannula

•

The ability of Optiflow to operate over a wide range of

low and high flows has meant that caregivers do not

need to change the device as a patient‟s condition

changes

•

Patients comply better with their therapy so there is less

demand on caregivers

•

The hospital has been able to rationalize its inventory

and help reduce waste

Optiflow‟s success in the ICU has now spread to the wards

and an intensive training program has helped to ensure

that staff are comfortable with the change and that a

consistent high standard of care is delivered.

Page 16

6. One Therapy, Two Applications,

Three Positive Outcomes with Optiflow™

CASE STUDY

SUBMITTED BY

One Therapy, Two Applications,

Three Positive Outcomes with OptiflowTM

Brenda Graham, RRT

Brigham & Women’s Hospital

Boston, MA

INTRODUCTION

Patient found with SaO2 in mid 70’s, changed to 100% non-

I am a Respiratory Therapist in a very busy 777 bed major

rebreather mask and transferred to MICU. On admission,

medical center.

placed on High Flow mask at 30 L/min, SaO2: 90 – 92%.

I have an active role in all of our ICU settings. You are about

Patient complained of dry mouth, presented increased

to meet two very different patients…

anxiety, often taking mask off for a break; SaO2 dipping to 62

– 78%. Patient appeared dusky.

Patient #1 (16 MAY 2009)

Presented as a 78 years old, 68kg female with severe

21 MAY: Patient changed to Optiflow System at 45 L/min

dyspnea/hypoxia, (most likely due to significant pulmonary

at 100% O2, SaO2 increased to 91%. Patient reported she

hypertension). Medical History includes chronic atrial

did not like the mask and was overall more comfortable on

fibrillations, hypotension, anal CA, and coronary artery

Optiflow cannula. Patient is Do Not Intubate / Do Not

disease. On admission, worsening shortness of breath for

Resuscitate status, however, may consider intubation if

several days. Over the prior week, started using O2 at

there is a real chance for improvement. PFT’s (previously

home at 2 to 3 L/min nasal cannula, achieving SaO2 of

technically limited): severe restrictive process and 40% of

90%. Social: lives alone, 40 pack/year smoking history: quit

predicted values. Chest CT 5/20 was negative for

12 years ago. Next of kin: one sister. Exam: chest-kyphotic,

Pulmonary Embolism. Venous Blood Gas: 5/20 7.41, CO 2 -

breath sounds = bilateral crackels/rales ½ way up. 2-3 +

55, O2 – 32, SO2 57%; ECHO: 5/20 reveals Pulmonary

pitting edema of lower extremities, using accessory

Artery Systolic Pressure of 100, Right Ventricular strain as

muscles to breath. SaO2 dipping to low 80’s with activity or

well as under-filled Left Ventrical; CXR: 5/21 reveals severe

talking.

alveolar edema and effusions, worse since prior study.

Prognosis reported as poor, not responding to diuretics, no

Patient #2 (12 DEC 2009)

further interventions available, focus will now be on comfort

Presented as a 76 years old, 86kg male admitted to SICU

measures only. Patient was given morphine for air hunger,

post scheduled abdominal aortic aneurism repair

all other medications discontinued that weren’t contributing

(diagnosed in 2007). Medical history includes: COPD,

to comfort, patient treated symptomatically. Time of death

hypertension, dyspnea on exertion, mild AS, dyslipidemia,

was 22 May.

nd

home O2 at 2 L/min cannula. Social: retired, lives alone,

four children. (+) daily etoh use, 100 pack/year smoking

Patient #2: 13 MAY

history: quit last year. Exam: (limited) breaths sounds =

Post-op day 1: Patient was extubated at 11am. Patient was

clear bilaterally, mildly obese, vital signs stable. Pre-op

noted to have a decline in mental status, worsening

FEV1 on 4/9 = 53% of predicted.

hypercarbia despite BiPAP trial and gastric distension.

CLINICAL COURSE

Patient #1 (19 MAY)

14 MAY: Patient required reintubation and ventilation at

1pm. Patient remained intubated as evolving ileus was

worked up, complicated by post-op delirium vs. etoh detox.

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Page 17

16 MAY: Patient self-extubated requiring immediate

requiring a tracheostomy, resulting in increased medical

reintubation resulting in PEA arrest.

expenses and lengthening his ICU stay.

20 MAY: CXR reveals mild pulmonary edema unchanged

In closing, “One therapy” (the Optiflow System), “two

with small stable right pleural effusion and cardiomegaly.

applications”, (Patient #1 and #2) and “three positive

After five days of hypotension and volume resuscitation,

outcomes”; finally a comfortable bridge that meets patients’

st

patient extubated for third time, straight to BiPAP on 21

requirements, leaving the third positive outcome, a happy

May. Patient became agitated and non-compliant,

smiling Respiratory Care Practitioner.

constantly trying to remove mask, ABG = 7.45, CO2 55,

PO2 55, Resp Rate of 34. On 5/22, 3:00 pm, patient

changed to Optiflow at 100% O2 and 50 LPM, ABG = 7.47,

CO2 55, PO2 85, 97% SaO2. At 3:40pm, decreased O2 to

55% and flow to 25 LPM, ABG = 7.40, CO 2 62, PO2 103,

Disclaimer: Any clinical opinions in this Case Study are the opinions of

the contributing author and are given for information purposes only. The

clinical opinions are not intended as and do not substitute medical

advice.

REFERENCES

SaO2 98%. Patient stated, “This is much better, keep that

1.

Chest / 135/ 1/ Jan; 2009

space mask away”. It was decided on physician rounds that

2.

Breen CM, Abernethy AP, Abbott KH,

J Gen Intern Med 2004: 32:638-643

if patient required reintubation, that a tracheostomy with

plug will follow. Respiratory team then worked diligently to

wean Optiflow until patient was able to tolerate his home O 2

requirements of 2 L/min cannula with SaO2 of 95%. This

patient was last seen ambulating with 1 assist, stopping to

talk with anyone in sight.

3 JUN: Patient was discharged to rehab.

DISCUSSION

Death in the ICU is common. Approximately 20% of all

deaths in the United States now occur after admission to an

ICU. Many, if not most deaths are preceded by a decision to

1

withhold life-sustaining treatments . Healthcare practitioners’

focus is being re-directed in relieving pain and suffering or

allowing the patient to die from underlying illness. We are

2

then faced with a common challenge of palliative ICU care .

Patient #1 was allowed to die with dignity. The Optiflow

System was the only system that provided comfort to this

patient while meeting her oxygen requirements. In meeting

with the chaplain, as well as the patient’s sister, it was

discussed that the last 30 hours of her life were comfortable

and at peace. Patient #2 has a very complex and long ICU

stay. Had the Optiflow System not been available, I feel this

patient would have been re-intubated for the fourth time

Page 18

7. Type II respiratory failure management with Optiflow™

CASE STUDY

Type II respiratory failure management with Optiflow

SUBMITTED BY

TM

Laura Harvey

MHDU, Crosshouse Hospital

Kilmarnock, Ayrshire

Scotland

improvement was noted, but she still had a respiratory

INTRODUCTION

acidosis.

A 72 year old patient was admitted to Medical HDU with an

infective exacerbation of COPD. On admission, her arterial

blood gases indicated she was in Hypercapnic Failure

(previously known as Type 2 respiratory Failure). She had a

marked respiratory acidosis and acute hypoxemia. She had

The flow rate on the NHF was increased to 50L/min and

ABGs were rechecked in two hours. These showed

continued improvement so a decision was made to continue

NHF therapy and reassess in 12 hours.

been commenced on bi-level ventilation in the Emergency

The patient continued to improve on the NHF therapy and

Department but she was non-compliant, prior to transfer it

she was very comfortable using it. She was able to eat, drink

had been removed. She had an extensive medical history

and chat to staff and visitors. The increased flow decreased

with advanced COPD (Cor Pulmonale) and pulmonary

her work of breathing and over a 36 hour period her arterial

hypertension causing right sided heart failure.

blood gases corrected as her infective exacerbation began to

She had numerous previous admissions with respiratory

failure that required non-invasive ventilation (bi-level

ventilation). However during her last couple of admissions

she had been reluctant to comply with the bi-level ventilation

citing the mask was making her feel “claustrophobic”.

respond to treatment. The flow rate of the NHF was gradually

reduced until it reached 20L/min. At that stage the oxygen

concentration was reduced to 28%. The patient’s

improvement was maintained and she was transferred to a

medical ward for discharge planning 24 hours after the

completion of NHF therapy.

CLINICAL COURSE

DISCUSSION

When the patient was transferred to Medical HDU, the staff

In this case, Optiflow facilitated better preoxygenation than

attempted to persuade the patient to allow them to start bi-

the standard tight-fitting face mask. Use of the standard

level ventilation but she insisted she did not want the

mask was not an option because of the patient’s underlying

therapy. At this time, her saturation levels were only being

claustrophobia. This patient tolerated Optiflow without

maintained in the high 70’s and her respiratory rate was 35 to

reporting any problems. In similar cases the normal default is

45 breaths per minute. She was peripherally cyanosed,

to run oxygen over the patient’s mouth and nose whilst

visibly short of breath and unable to complete full sentences.

allowing the patient to hold the bag-mask himself/herself.

At this point, the decision was made to commence the

patient on OptiflowTM Nasal High Flow Therapy (NHF) at a

high flow rates and a lower oxygen concentration. The NHF

was started at 40L/min and 40% oxygen. Within 10 minutes

her work of breathing had reduced and her saturation was in

the mid to high 80’s. After two hours of NHF her ABGs

(arterial blood gases) were checked and a slight

Case Study submitted to Fisher & Paykel Healthcare Ltd

185047492 Rev C

The patient was successfully discharged 7 days after initial

presentation and she was particularly impressed with the

NHF therapy. She found it more comfortable than the mask

used in NIV and stated she would happily use it again if the

need arose.

Disclaimer: Any clinical opinions in this Case Study are the opinions of the

contributing author and are given for information purposes only. The clinical

opinions are not intended as and do not substitute medical advice.

Page 19

8. Optiflow™ improves thoraco-abdominal asynchrony as

demonstrated by Respiratory Inductive Plethysmography (RIP)

CASE STUDY

SUBMITTED BY

Optiflow™ improves thoraco-abdominal asynchrony as

demonstrated by Respiratory Inductive Plethysmography (RIP).

Taiga Itagaki, M.D.

Emergency and Critical Care Medicine, Tokushima

University Hospital,

Tokushima, Japan.

BACKGROUND

reflecting thoraco-abdominal asynchrony improved

Optiflow delivers a positive oropharyngeal airway pressure

considerably with Optiflow (Figure 2).

which may improve oxygenation. However, it is unclear if

Optiflow improves thoraco-abdominal asynchrony. The

SUMMARY

degree of thoraco-abdominal synchrony reflects respiratory

This case suggests that improvements in thoraco-abdominal

pattern and work of breathing. This case study describes the

asynchrony can be accomplished with the use of Optiflow

use of Respiratory Inductive Plethysmography (RIP) to

therapy.

monitor the effects that the use of Optiflow has on the

respiratory pattern of a post-operative patient.

A CASE

A 73 year old man was admitted to intensive care unit (ICU)

after thoracic surgery. The operation was uneventful, and he

was extubated in the operating room. Initially oxygen was

administered via a standard face mask at flow of 5 L/min.

Oxygen was then delivered at 35% via Optiflow at a flow rate

of 40 L/min. He was discharged ICU without any requirement

for oxygen therapy one day post-surgery.

THORACO-ABDOMINAL MOVEMENT

Two RIP transducer bands were placed around the rib cage

and the abdomen (Figure 1). We measured the movement of

the rib cage and the abdomen using RIP before and after the

initiation of Optiflow.

MAJOR FINDINGS

Respiratory rate decreased from 23 BPM to 17 BPM after

Optiflow was initiated. Blood pressure, heart rate, SpO 2, pH

and PaCO2 were all improved or maintained after the

initiation of Optiflow from 156/77 mmHg to 127/63 mmHg, 87

BPM to 88 BPM, 100% to 100%, 7.40 to 7.41 and 38.1

mmHg to 38.7 mmHg, respectively. Two parameters

Case Study submitted to Fisher & Paykel Healthcare Ltd

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Figure 1: Example of the RIP transducer bands in place on a

patient receiving Optiflow (not reporting case)

Page 20

Figure 2A: The motion of the rib cage (RC), the abdomen (AB), and their sum signal (SUM). SUM represents tidal volume (VT).

Maximum compartmental amplitude (MCA) is the sum of the maximal peak-to-trough amplitudes of RC and AB excursion. MCA/VT

approached to 1.0 after Optiflow (figure 2A).

Figure 2B: On Konno-Mead plot by plotting abdominal motion against rib cage motion, phase angle ( θ) is calculated according to a

-1

formula θ=sin (M/S). Asynchrony produces wide open loop and increased phase angle. This patient showed marked reduction of

phase angle with Optiflow (figure 2B).

Page 21

9. Pre-oxygenation prior to induction of anesthesia with Optiflow™

CASE STUDY

SUBMITTED BY

Pre-oxygenation prior to induction of anesthesia with Optiflow™

Anders Larsson

Consultant, Medical Director, Anesthesia

Gävle Hospital

Gävle, Sweden

INTRODUCTION

A 37 year old woman with a BMI of 40 was listed for elective

laparoscopic gastric bypass due to obesity. The patient had a

previous surgical history of tonsillectomy and laparotomy for

ectopic pregnancy. Her co-morbidities included: asthma,

fibromyalgia, claustrophobia, depression, tinnitus and panic

attacks. Her current medication included: Citalopram,

Zopiclone, Alvedon and Diclofenac.

replaced with a tight-fitting face mask, and 8ml of Esmeron

10 mg/ml was given via I.V. After two minutes of mask

ventilation tracheal intubation was performed. The patient

had preoperative oxygen saturation of 96%; following

commencement of Optiflow pre-oxygenation, oxygen

saturation rose to 99%.These saturations were maintained

throughout induction of anesthesia and until tracheal

intubation was performed.

During the preoperative assessment, the patient stated that

she becomes panicky when breathing through a face mask

prior to anesthesia.

The laparoscopic gastric bypass was performed without

complications. On waking and removal of the endotracheal

tube the patient developed laryngospasm and desaturated to

CLINICAL COURSE

40%, a small quantity of rose-colored foam was seen in the

Given the patient’s history of panic attacks and previous

mouth. Within two minutes the laryngospasm resolved

traumatic experiences during pre-oxygenation with a tight-

spontaneously and oxygen saturation increased to 94% a

fitting face-mask, the plan was to pre-oxygenate using

tight-fitting face mask delivering Fi02 1.0 was applied. The

Optiflow. During the preoperative assessment the patient

patient was then transferred to a post-operative recovery

was informed of this plan.

ward. Optiflow was set up at Fi02 0.6 and a flow rate of 40

L/min on recovery ward and attached to the patient when she

Optiflow was set to deliver Fi02 1.0 at a flow rate of 40 L/min.

Optiflow nasal cannula was placed on the patient for the ten

minutes prior to induction of anesthesia. The patient tolerated

the nasal cannula very well and reported no discomfort or

anxiety. Prior to induction of anesthesia, the patient received

intravenous (I.V.) Robinul 0.2 mg and Dridol 1 mg. Ten

minutes after Optiflow commencement, Ultiva target-

arrived. Optiflow was used for six hours on the recovery ward

and the Fi02 gradually reduced. After six hours on the

recovery ward the patient was mobilized and Optiflow was

replaced with 2L oxygen via nasal prongs and intermittent

use of PEEP. The patient was transferred to the general

ward on the day after surgery.

controlled infusion was started and the patient was

DISCUSSION

encouraged to breathe deeply. When the patient experienced

In this case Optiflow facilitated better pre-oxygenation than

flushing and dizziness, 2.0 ml of Ultiva 50 micrograms/ml

the standard tight-fitting face mask. Use of the standard

was given via I.V. and a target-controlled Propofol infusion

mask was not an option because of the patient’s underlying

was started. After 17ml of Propofol 10 mg/ml had been

claustrophobia. This patient tolerated Optiflow without

administered the patient became apnoeic and lost her blink

reporting any problems. In similar cases the normal default is

reflex. At this time the Optiflow nasal cannula was

to run oxygen over the patient’s mouth and nose whilst

allowing the patient to hold the bag-mask himself/herself.

Case Study submitted to Fisher & Paykel Healthcare Ltd

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Page 22

Following removal of the tracheal tube, laryngospasm and

early pulmonary edema (both anesthetic complications)

were evident. These complications required a prolonged

stay on the recovery ward. The patient remained on the

recovery ward for 16 hours compared with the anticipated

four hours.

Optiflow was used for six hours on the recovery ward since

the alternative would otherwise have been a tight-fitting

CPAP mask. In a subsequent telephone conversation with

the patient she stated that she experienced no discomfort

either on induction of anesthesia or postoperatively and

that she was very satisfied at having avoided using the

tight-fitting mask.

This case demonstrated effective pre-oxygenation prior to

surgery, despite intense fear of a tight-fitting face mask.

The subsequent benefit of being able to manage the

patient’s labored breathing postoperatively, due to an

unforeseen airway complication, without a tight-fitting

CPAP mask was probably also highly significant.

Disclaimer: Any clinical opinions in this Case Study are the opinions of the

contributing author and are given for information purposes only. The clinical

opinions are not intended as and do not substitute medical advice.

Page 23

10.Treatment of a cardiac patient pre and post-extubation with

Optiflow™ High Flow Nasal Cannulae

CASE STUDY

SUBMITTED BY

Optiflow™ Nasal High Flow

Julie Malone, BHSc, RRT

Toronto General Hospital, University Health Network

Toronto, Ontario, Canada

BACKGROUND

CPAP/BiPAP and high-flow oxygen. His blood pressure was

being controlled by Hydralizine, Terazosin, Nipride and

A 46 year old male patient transferred to the Cardiac Care

Nitroglycerine.

Unit at Toronto General Hospital with a Type B Dissection

(Subclavian to Common Iliac 3.8 cm in length). He had

Three days later the patient was not tolerating BiPAP, having

experienced searing chest pain whilst golfing and had gone

periods of retching, general discomfort and nose bleeds. The

to a local emergency room. The patient was flown to Toronto

respiratory therapist decided to place him on the Optiflow

General Hospital where he had previously undergone an AV

Nasal High Flow to increase his degree of comfort while

Sparing in 2011. He presented on 5 L/min nasal prongs with

providing appropriate levels of oxygen and humidity.

an initial Arterial Blood Gas (ABG): 7.44/31/71/21/92. He

Settings: 100% oxygen, 55 L/min flow. ABG

experienced no shortness of breath, and had only mild chest

7.48/41/105/30/98. The patient was very happy to have the

pain. The initial treatment plan was to control his blood

Optiflow system started as he could eat while on this therapy,

pressure with Labetalol and Nipride. The patient had a past

which is not possible with BiPAP. The patient continued to

medical history of Marfans syndrome, hypertension,

show infiltrates and atelectasis on chest x-ray and seemed to

hyperlipidemia and obesity.

be volume overloaded. Continuing aggressive diuresis,

incentive spirometry and alternating between Optiflow and

CLINICAL COURSE

BiPAP, oxygen levels were able to be weaned down to 70%

The next day, post admission, the patient had increasing

with BiPAP being discontinued five days later.

oxygenation issues, including hypoxia and increased work of

breathing; his respiratory rate was in the high 20’s and he

was placed on 95% FiO2 high-flow oxygen. His ABG was

7.44/27/72/18/92. A cardiac ECHO was performed with

results showing a normal right ventricle, no pericardial

effusion and a dilated IVC of 2.5 cm. The physician ordered a

2-hour bi-level positive airway pressure (BiPAP) trial but the

patient was switched to continuous positive airway pressure

(CPAP) 5 cmH2O with 100% oxygen due to a high minute

volume of > 40 liters (L) and a high tidal volume of > 2 L

(ABG results: 7.41/21/298/19/100). The patient was started

on Piptazo empirically as he was mildly febrile (38.1 °C); a

chest x-ray showed infiltrates in his right lower lobe, and he

was commenced on a Lasix infusion for fluid overload. The

patient continued on a treatment plan alternating between

Case Study submitted to Fisher & Paykel Healthcare Ltd

185047492 Rev C

Two weeks after the initial hypoxic event, the patient

complained of blurred vision and was significantly confused

compared to during previous days. He had continued on the

Optiflow system with 80% oxygen and 55 L/min flow. The

patient presented as volume depleted with a low CVP, low

wedge pressure and minimal edema but continued to have

persistent pulmonary infiltrates on chest x-ray. On

auscultation, air entry was decreased with fine crackles

throughout lung fields. The patient developed a fever of 39.4

°C and was requiring frequent suctioning. The Respirology

team was consulted and a decision made to intubate to

facilitate a bronchoscopy. The patient was a difficult

intubation, requiring multiple attempts using a MAC 4 and

cricoid pressure. Bronchoscopy results showed friable

airways along with a large quantity of thick white secretions.

Page 24

Bronchoalveolar lavage (BAL) samples obtained at the time

improved the patient's outcome but also reduced the cost of

were negative for infection. The Respirology team

his stay in hospital.

discontinued the Hydralizine as it was suspected as being a

possible cause of the acute pneumonitis. They

recommended a lung biopsy but this was put on hold due to

the patient being too high-risk to undergo such a procedure

at the time.

The patient was briefly ventilated on Pressure Control, but

was quickly weaned to Pressure Support of 5 cmH2O, PEEP

of 10 cmH2O, 60% oxygen.

Over a period of four days the patient was weaned to

minimal settings and extubated directly to the Optiflow. He

was placed on 50% oxygen with a flow of 50 L/min and within

24 hours was weaned to 40% oxygen and a flow of 30 L/min.

The patient was placed on nasal prongs and transferred out

of the CCU. He was discharged home two weeks later on

room air, with his acute pneumonitis resolved and his blood

pressure under control.

DISCUSSION

Overall, this case was aided by the use of the Optiflow

system which should have been initiated as soon as the

initial hypoxic event took place. The high humidity and the

improved comfort level experienced by the patient while on

Optiflow allowed him to tolerate the periods of BiPAP that

were needed to keep the patient from being intubated. The

break periods from the BiPAP helped with pressure damage

from the full face mask as this patient required the use of

non-invasive ventilation for a significant period of time.

Though the patient ended up requiring a brief period of

mechanical ventilation post bronchoscopy, he was able to

avoid intubation for almost two weeks after the initial hypoxic

event which I attribute to the Optiflow system. The high flows

provided by the Optiflow helped with atelectasis which had

been a problem throughout the patient's ICU stay. By use of

this treatment directly after extubation the patient was able to

be quickly weaned and sent to a ward. This not only

Page 25

11.Treatment of cardiac insufficiency and hypoxemia with Optiflow™

Case Study

Submitted By

Treatment of Cardiac Insufficiency and

Hypoxemia with OptiflowTM

Michael Prus, MSA, RRT, CTTS Director

Respiratory Therapy

Good Samaritan Hospital

Suffern, NY 10901

rhythm and rate, blood pressure was normal. The patient

INTRODUCTION

stated that previous chest pain had resolved and that he felt

A patient with cardiomyopathy, cardiac failure and awaiting a

more comfortable. The patient remained on Optiflow for two

heart transplant was treated with a balloon pump to assist

weeks then transitioned to a venti-mask and was discharged

their insufficient cardiac output. Oxygen saturation was

home.

maintained in the low 90’s with a non-rebreather mask at 12

L/min of oxygen.

The patient stated that, “Optiflow significantly decreased his

chest pain and made breathing easier.” He told his physician,

The patient had a recent history of chest pain, tachycardia,

nurses, and RT staff that, “the new device saved him from

low blood pressure, and dyspnea. The Physician decided to

being placed on that other breathing machine.”

remove balloon pump after a positive response to

medications, however the patients’ oxygenation then became

DISCUSSION

a significant challenge. The patient had a standing order for

With this patient it was evident that Optiflow High Flow

bi-level ventilation.

Cannulas allowed us to effectively meet this very ill patient’s

oxygen requirements. We did not have to resort to bi-level

CLINICAL COURSE

ventilation or invasive ventilation. This therefore meant that

When the balloon pump was removed, oxygenation became

the patient did not have to suffer the consequences and

more difficult to accomplish, we could only maintain SaO 2 at

complications associated with escalation of therapy.

85% whilst using a non-rebreather mask at 12 L/min and an

oxygen cannula at 5 L/min.

In the short term our specific concerns for this patient were to

meet his oxygen requirements and relieve his work of

An order was in place for this patient to receive bi-level

breathing. We observed the added benefits of decreased

ventilation following balloon pump removal, but the patient’s

heart rate and a return to normal blood pressure.

issues were related to oxygenation, alone their PaCO2

remained within normal ranges. The patient had also been

noncompliant with previous attempts at bi-level ventilation

The patient was very satisfied with the therapy as he felt a

significant relief of his chest pain and his work of breathing.

He was very grateful for the support Optiflow gave him.

despite various attempts and trials of interface alternatives.

The patients’ oxygenation issues persisted without

Disclaimer: Any clinical opinions in this Case Study are the opinions of the

improvement in SaO2. The Respiratory Therapist made a

recommendation to the Physician to use Optiflow

TM

(High

Flow Nasal Cannula) instead of BiPAP. The Patient was then

placed on Optiflow cannula with a flow of 40 L/min and a

FiO2 of 1.0. Within the first half hour the patient’s SaO 2

increased to 94% then to 97% and subsequently to 100%

thereafter. Heart rate returned within a normal range for both

Case Study submitted to Fisher & Paykel Healthcare Ltd

185047492 Rev C

contributing author and are given for information purposes only. The clinical

opinions are not intended as and do not substitute medical advice.