optiflow_adu_case_study_booklet_rev_c.pdf
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Case Studies
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Table of Contents
1. Treatment of chest trauma patient with rib fractures using NHF therapy with Optiflow
(Beaumont, Canada)
2. Heated humidification and Optiflow: The future of effective, high flow nasal oxygen
therapy (Chanques, France)
3. The application of Optiflow in conjunction with The Breather and Passey-Muir valve in the
difficult-to-wean patients with a tracheostomy (Dungo-Sales, Canada)
4. The application of Optiflow in weaning from tracheostomy (Dungo-Sales, Canada)
5. A new standard of oxygen therapy using Optiflow humidified nasal cannula (Fealy,
Australia)
6. One therapy, two applications, three positive outcomes with Optiflow (Graham, USA)
7. Type II respiratory failure management with Optiflow (Harvey, Scotland)
8. Optiflow improves thoraco-abdominal asynchrony as demonstrated by Respiratory
Inductive Plethysmography (Itagaki, Japan)
9. Pre-oxygenation prior to induction of anesthesia with Optiflow (Larsson, Sweden)
10. Treatment of a cardiac patient pre and post-extubation with Optiflow (Malone, Canada)
11. Treatment of cardiac insufficiency and hypoxemia with Optiflow (Prus, USA)
12. Economic and patient benefits revealed (Whitten, USA)
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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
5
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
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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.
Case Study submitted to Fisher & Paykel Healthcare Ltd
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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
185047492 Rev C
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.