1. High Flow Therapy (HFT) NICU Population Nursing Educational Series

2. Agenda Respiratory Patient Tx Model ( Old & New ) Review of High Flow Therapy (HFT ® ) Clinical Applications & Benefits Precision Flow® Demonstration Q & A

3. Oxygen Therapy -vs- Ventilation Oxygen Therapy Goals – - 1. Correct hypoxemia - 2. Decrease symptoms associated with hypoxemia - 3. Decrease workload on cardiopulmonary system N.I.V. Therapy Goals (NCPAP) – - 1. Improve Gaseous Exchange (02-CO2) - 2. Decrease intrapulmonary Shunt - 3. Assist the Pt’s Spontaneous Respiratory Effort & Alleviate Dyspnea - 4. Reduce Work of Breathing - 5. Avoid Intubation & Ventilation

4. 44 Continuum of Care: Old Model 4 General 02 Therapy Acuity Choice of Therapy General 02 Therapy Bi-Level Mechanical Ventilation CPAP Rescue Weaning Bi-Level CPAP

5. Continuum of Care: Old Model 5 Low Flow Humidified Cannula Oxygen HoodCPAP / Bi-Level Mechanical Ventilation Flows limited to 1 – 3Lpm Higher Fi02 Achieved Pressure Support Patient Completely Ventilated Nice Interface Rainout an Issue Heated Wire Hard to Humidify Patient Must Remain in Hood Tight Fitting Adverse Affects Cumbersom Used when Patients Fail CPAP/ BiPAP Invasive

6. Continuum of Care What if there was a therapy that was a bridge between 02 Therapy and Bi-Level?

7. 77 Continuum of Care: New Model 7 General 02 Therapy Acuity Choice of Therapy General 02 Therapy Bi-Level Mechanical Ventilation CPAP High Flow Therapy Rescue Weaning Bi-Level CPAP

8. High Flow Therapy: Precision Flow 8 High Flow Therapy Via Nasal Cannula 1- 8 Lpm 5 – 40 Lpm Precision Flow ® -Precise Temperature, Blending, & Flow -Humidification with no Rainout -Patient’s Demands Met -Easily Tolerated by Patient -Higher Fi02s than a Mask -Audible Alarms

9. High Flow Therapy: Definitions - Flow rate that exceeds patient flow demands at various minute volumes ● A method to achieve actual FiO2 of 1 ● Eliminate entrainment of ambient air - Accomplished in the nasopharynx only with proper gas conditioning ● Conventional cannula therapy limited by nasal damage ● HFT becomes more than oxygen therapy - Combination of technologies to achieve optimal temperature, humidity and flow rate at the point of delivery

10. Control the Factors that Matter… Combination of proprietary technology to achieve optimal:  Flow  Fi02  Temperature  Humidity at the point of delivery.

11. 11 High Flow Therapy: Mechanisms of Action Humidify / Warm AirwaysSupports Inspiration Flush Dead Space ● CO 2 Elimination ● Oxygen Efficiency ● Cannula Flow > inspiratory ● Work of Breathing ● Mobilization of Secretions ● Nasal comfort

12. Mechanisms: Humidity ● Nasopharynx is h ighly efficient at conditioning inspiratory gas ● Anatomical Structure ● Mucosal Architecture Inspiratory Gas Conditioning

13. Conditioning Prevents Injury Inadequate warming and humidification can cause: ● Thickened Secretions ● Decreased mucocilliary action ● Thermal challenge ● Bloody secretions ● Lung atelectasis Mechanisms: Humidity

14. ● Williams et al, 1996, Crit Care Med 24(11): 1920-9 Why BTPS?

15. Vapor Transfer Cartridge: ● Key to efficient, high performance humidification and gas conditioning ● Also serves as filter--pore size much smaller than 0.05 microns Patient Delivery Tube: ● Patented triple lumen design ● Design prevents rain-out ● Keeps gas conditioned out to patient ● Safer than traditional heater wire design Mechanisms: Humidity (How We Do It)

16. Flush Dead Space & Support Inspiration Mechanisms: Physiology & Dead Space

17. Pulmonary Physiology and Dead Space

19. Pulmonary Pathophysiology

21. 21 Mechanisms: Standard Oxygen Therapy

22. ● High nasal flow, unimpeded at mouth, fills the upper airways – storing O 2 during exhalation and flushing CO2 Flush Dead Space & Support Inspiration ● High mask flow, impeded by pressure at the mouth - stores less O 2 in the upper airways during exhalation and adds prosthetic dead space Tiep, et al: Resp Care, 2002: High Flow Nasal vs High Flow Mask oxygen delivery: Tracheal Gas Concentrations Through an airway model

23. 23 Mechanisms: High Flow Therapy HFT Therapeutic Flow Range > 4Lpm

24. Dead space washout ● Supports CO 2 ventilation ● Enhances oxygenation Matches inspiratory flow ● Attenuates nasopharyngeal resistance Adequate gas conditioning ● Improves conductance and compliance ● Reduces energy cost of gas conditioning Mechanism of Action Review

25. HFT Clinical Review Clinical Applications & Benefits

26. Flow First ™ Early Intervention Is The Key 26 HFT Clinical Review

27. Indications for Use: Indications: ● Spontaneously breathing patients who are requiring supplemental oxygen therapy over 1Lpm ● Any patient who is on an oxygen mask that is: 1. Not compliant, 2. not improving, 3. Or has an increase in work of breathing ● Post- extubation support or weaning from NPPV / NCPAP ● Patients requiring supplemental heat & humidity for artificial airways Contraindications: ● Patients not spontaneously breathing ● Patients that have a deviated septum ● Patients with severe facial trauma or disfigurement

28. 28 Mechanisms by Application Neonataes /Infants OxygenFlushHumidityMild Pressure IRDS RSV Brochiolitis (also seen in Peds) HFT DOES NOT TREAT A DISEASE, THE MECHANISMS TREAT SYMPTOMS These are some sample disease states and how the mechanisms of action treat the symptoms. Can you think of other respiratory insufficiencies where the symptoms can be treated by HFT?

29. What About Pressure? ● Pressure determined by primarily by leak (Kahn at al, Pediatr Res 2007) - Infant anatomical size – passage through nasopharynx - Size ratio between nares and prongs – back flush ● Inadvertent CPAP with conventional nasal cannula (Locke et al, Pediatrics 1993) - Smaller (2 cm OD) prongs negate pressure - Occluded only 50% of the nares - Larger (3 cm OD) prongs generate pressure ● Intentional CPAP with conventional nasal cannula (Sreenan et al, Pediatrics 2001) - Snug prongs - Mouth held closed - Up to 8 cmH 2 O with 3 lpm

30. What Else About Pressure? Platform APlatform B Premature1.52.4 Neonatal1.52.4 Infant1.92.7 Intermediate Infant1.92.7 Pediatric2.73.7

31. HFT Conclusions – Patient Care Aspects ● Easy Interface – Nasal Cannula - No Tight Fitting Prongs to Fit - No Leaks to Worry About - Patient Can Bond with Parent (Kangaroo Care) - Patient Can Nurse ● Ability to Control Factors Independently - Can Deliver Temp, Flow, Fi02 to Meet Patients Exact Needs - Can Deliver High Flow and Low Fi02 to Chronic Patients - Audible Alarms ELBW Infant being Kangaroo’d by Dad on a Precision Flow

32. HFT Conclusions – Patient Care Aspects ● Ability to Provide Adequate Humidity - No Risk of Lung Injury - Minimal Rainout in Circuit - Safe to Use in Heated Environments ● Low Maintenance While on Patient - No Masks to Keep Tight - No Rainout in Patient Delivery Tube - Circuit Good for 30days LOS - Easy to Read Display

33. Q & A