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Characterizations of High Flow Nasal Cannula Use in a Teaching Community Hospital in New York City
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A5102 - Characterizations of High Flow Nasal Cannula Use in a Teaching Community Hospital in New York City
Author Block: E. L. Altschul1, Y. Mogilevskaya2, A. Schwab3, B. A. Mina1; 1Pulmonary and Critical Care Medicine, Northwell Health Lenox Hill Hospital, New York, NY, United States, 2Internal Medicine, Northwell Health Lenox Hill Hospital, New York, NY, United States, 3Internal Medicine, Northwell Health Forest Hills Hospital, Queens, NY, United States.
Rationale: High flow nasal cannula (HFNC) has become a prevalent method of oxygen delivery for patients at risk for respiratory decompensation given its ability to provide flow rates up to 60L/min and oxygen concentration up to 100%. In our hospital, there is no protocol on the initiation or weaning of HFNC. We aimed to define the characteristics for successful use of HFNC in a community teaching hospital.
Methods: We performed a two month retrospective chart review on patients admitted to the medical service; including the medical intensive care unit (ICU), regional, and telemetry floors; with an order for HFNC. We assessed length of time on HFNC, advancement to noninvasive positive pressure ventilation (NIPPV) or mechanical ventilation (MV), and indications. Flow rates and FiO2 levels were followed to determine how patients weaned from HFNC.
Results: For the months of November and December, 47 charts were reviewed. The average length of time on HFNC was 4.17 days, with a median of 3 days. The written indications for HFNC were work of breathing (42%), and hypoxia (26%), and weaning from mechanical ventilation (MV; 26%). Of the 12 patients extubated to HFNC, 25% required re-intubation. Those placed directly on HFNC had 13% progression to MV, most commonly due to mucus plugging and hypercapnia, and 11% progressed to NIPPV due to worsening pneumonia and tachypnea. We found no correlation between failure of HFNC and markers of disease (ie lactic acidosis, AKI, LACE score). Palliative use was seen in patients who died in the hospital or were discharged to hospice (28%). There was no clear documentation of titration for patients on HFNC.
Discussion: HFNC has been proven to be at least as effective as NIPPV for managing hypoxic respiratory failure. Recent data has demonstrated a benefit in hypercapnic respiratory failure for acute and post extubation management. Our hospital, patients were successfully placed on HFNC for respiratory distress and post extubation management; 87% and 75% respectively. The common reasons for failure, hypercapnia and mucus plugging, may help residents determine which method of respiratory support is most appropriate. Lastly, it was commonly used in palliation likely because the device allows more interaction with family members, palliative feeds, and comfort. Appropriate placement of HFNC may improve if a weaning protocol is developed for housestaff education. Future studies are needed to determine a HFNC weaning process and compare extubation to various modalities to determine which patients would benefit from HFNC.
Author Block: E. L. Altschul1, Y. Mogilevskaya2, A. Schwab3, B. A. Mina1; 1Pulmonary and Critical Care Medicine, Northwell Health Lenox Hill Hospital, New York, NY, United States, 2Internal Medicine, Northwell Health Lenox Hill Hospital, New York, NY, United States, 3Internal Medicine, Northwell Health Forest Hills Hospital, Queens, NY, United States.
Rationale: High flow nasal cannula (HFNC) has become a prevalent method of oxygen delivery for patients at risk for respiratory decompensation given its ability to provide flow rates up to 60L/min and oxygen concentration up to 100%. In our hospital, there is no protocol on the initiation or weaning of HFNC. We aimed to define the characteristics for successful use of HFNC in a community teaching hospital.
Methods: We performed a two month retrospective chart review on patients admitted to the medical service; including the medical intensive care unit (ICU), regional, and telemetry floors; with an order for HFNC. We assessed length of time on HFNC, advancement to noninvasive positive pressure ventilation (NIPPV) or mechanical ventilation (MV), and indications. Flow rates and FiO2 levels were followed to determine how patients weaned from HFNC.
Results: For the months of November and December, 47 charts were reviewed. The average length of time on HFNC was 4.17 days, with a median of 3 days. The written indications for HFNC were work of breathing (42%), and hypoxia (26%), and weaning from mechanical ventilation (MV; 26%). Of the 12 patients extubated to HFNC, 25% required re-intubation. Those placed directly on HFNC had 13% progression to MV, most commonly due to mucus plugging and hypercapnia, and 11% progressed to NIPPV due to worsening pneumonia and tachypnea. We found no correlation between failure of HFNC and markers of disease (ie lactic acidosis, AKI, LACE score). Palliative use was seen in patients who died in the hospital or were discharged to hospice (28%). There was no clear documentation of titration for patients on HFNC.
Discussion: HFNC has been proven to be at least as effective as NIPPV for managing hypoxic respiratory failure. Recent data has demonstrated a benefit in hypercapnic respiratory failure for acute and post extubation management. Our hospital, patients were successfully placed on HFNC for respiratory distress and post extubation management; 87% and 75% respectively. The common reasons for failure, hypercapnia and mucus plugging, may help residents determine which method of respiratory support is most appropriate. Lastly, it was commonly used in palliation likely because the device allows more interaction with family members, palliative feeds, and comfort. Appropriate placement of HFNC may improve if a weaning protocol is developed for housestaff education. Future studies are needed to determine a HFNC weaning process and compare extubation to various modalities to determine which patients would benefit from HFNC.
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