Heated and humidified high-flow nasal cannula (HFNC) is a widely used form of respiratory support; however, data regarding optimal flows for a given patient size or disease state are lacking. A comprehensive study of the physiologic effects of HFNC is needed to better understand the mechanisms of action. The objective of the current study was to quantify the effect of HFNC settings in age-specific, anatomically correct nasal airways and spontaneously breathing lung models. We hypothesized that there is an effect of flow on pressure and ventilation.
METHODS:
Three-dimensionally printed upper airway models of a preterm neonate, term neonate, toddler, small child, and adult were affixed to the ASL 5000 test lung to simulate spontaneous breathing with age-appropriate normal ventilation parameters. CO2 was introduced to simulate profound hypercapneic respiratory failure with an end-tidal partial pressure of carbon dioxide (PETCO2) of 90 ± 1 mm Hg. Two commercially available HFNC systems were applied to the airway models, and PEEP, inspired CO2, and exhaled CO2 (PETCO2) were recorded for 6 min across a range of flow.
RESULTS:
Increasing HFNC flow provided a non-linear increase in PEEP in closed-mouth models, with maximum tested flows generating 6 cm H2O in the preterm neonate to 20 cm H2O in the small child. Importantly, PEEP decreased by approximately 50% in open-mouth models. Increasing HFNC flow improved expiratory CO2 elimination to a certain point, above which continued increases in flow had minimal additional effect. This change point ranged from 4 L/min in the preterm neonate to 10 L/min in the small child.
CONCLUSIONS:
These findings may help clinicians understand the effects of HFNC at different settings and may inform management guidelines for patients with respiratory failure.
WilkinsonD, AndersenC, O'DonnellCPF, De PaoliAG, ManleyBJ. High flow nasal cannula for respiratory support in preterm infants. Cochrane Database Syst Rev, 2016;(2):CD006405.
2.
BeggsS, WongZH, KaulS, OgdenKJ, WaltersJAE. High-flow nasal cannula therapy for infants with bronchiolitis. Cochrane Database Syst Rev, 2014(1):CD009609.
3.
NishimuraM. High-flow nasal cannula oxygen therapy in adults: physiological benefits, indication, clinical benefits, and adverse effects. Respir Care, 2016; 61(4):529–541.
4.
MessikaJ, Ben AhmedK, GaudryS, Miguel-MontanesR, RafatC, SztrymfB, et al. Use of high-flow nasal cannula oxygen therapy in subjects with ARDS: a 1-year observational study. Respir Care, 2015; 60(2):162–169.
5.
FratJP, ThilleAW, MercatA, GiraultC, RagotS, PerbetS, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med, 2015; 372(23):2185–2196.
6.
CollinsCL, HolbertonJR, BarfieldC, DavisPG. A randomized controlled trial to compare heated humidified high-flow nasal cannulae with nasal continuous positive airway pressure postextubation in premature infants. J Pediatr, 2013; 162(5):949–954.e1.
7.
MetgeP, GrimaldiC, HassidS, ThomachotL, LoundouA, MartinC, MichelF. Comparison of a high-flow humidified nasal cannula to nasal continuous positive airway pressure in children with acute bronchiolitis: experience in a pediatric intensive care unit. Eur J Pediatr, 2014; 173(7):953–958.
8.
SimMA, DeanP, KinsellaJ, BlackR, CarterR, HughesM. Performance of oxygen delivery devices when the breathing pattern of respiratory failure is simulated. Anaesthesia, 2008; 63(9):938–940.
9.
LuoJC, LuMS, ZhaoZH, JiangW, XuB, WengL, et al. Positive End-Expiratory pressure effect of 3 high-flow nasal cannula devices. Respir Care, 2017; 62(7):888–895.
10.
FrizzolaM, MillerTL, RodriguezME, ZhuY, RojasJ, HesekA, et al. High-flow nasal cannula: impact on oxygenation and ventilation in an acute lung injury model. Pediatr Pulmonol, 2011; 46(1):67–74.
11.
ParkeRL, BlochA, McGuinnessSP. Effect of very-high-flow nasal therapy on airway pressure and end-expiratory lung impedance in healthy volunteers. Respir Care, 2015; 60(10):1397–1403.
12.
SivieriEM, GerdesJS, AbbasiS. Effect of HFNC flow rate, cannula size, and nares diameter on generated airway pressures: an in vitro study. Pediatr Pulmonol, 2013; 48(5):506–514.
13.
VargasF, Saint-LegerM, BoyerA, BuiNH, HilbertG. Physiologic effects of high-flow nasal cannula oxygen in critical care subjects. Respir Care, 2015; 60(10):1369–1376.
14.
DysartK, MillerTL, WolfsonMR, ShafferTH. Research in high flow therapy: mechanisms of action. Respir Med, 2009; 103(10):1400–1405.
15.
MauriT, TurriniC, EroniaN, GrasselliG, VoltaCA, BellaniG, PesentiA. Physiologic effects of high-flow nasal cannula in acute hypoxemic respiratory failure. Am J Respir Crit Care Med, 2017; 195(9):1207–1215.
16.
YoungquistTM, RichardsonCP, DiblasiRM. Effects of condensate in the exhalation limb of neonatal circuits on airway pressure during bubble CPAP. Respir Care, 2013; 58(11):1840–1846.
17.
WuG, WollenA, DiBlasiRM, HimleyS, SaxonE, AustinG, et al. Reservoir cannulas for pediatric oxygen therapy: a proof-of-concept study. Int J Pediatr, 2016; 2016:9214389.
18.
DiBlasiRM, CoppoloDP, NagelMW, DoyleCC, AvvakoumovaVI, AliRS, MitchellJP. A novel, versatile valved holding chamber for delivering inhaled medications to neonates and small children: laboratory simulation of delivery options. Respir Care, 2010; 55(4):419–426.
19.
NumaAH, NewthCJ. Anatomic dead space in infants and children. J Appl Physiol, 1996; 80(5):1485–1489.
20.
DiBlasiRM, CrotwellDN, ShenS, ZhengJ, FinkJB, YungD. Iloprost drug delivery during infant conventional and high-frequency oscillatory ventilation. Pulm Circ, 2016; 6(1):63–69.
21.
CoffeyPS, SaxonEA, NarayananI, DiBlasiRM. Performance and acceptability of two self-inflating bag-mask neonatal resuscitator designs. Respir Care, 2015; 60(9):1227–1237.
22.
PoliJA, RichardsonCP, DiBlasiRM. Volume oscillations delivered to a lung model using 4 different bubble CPAP systems. Respir Care, 2015; 60(3):371–381.
23.
HsiaD, DiBlasiRM, RichardsonP, CrotwellD, DebleyJ, CarterE. The effects of flexible bronchoscopy on mechanical ventilation in a pediatric lung model. Chest, 2009; 135(1):33–40.
24.
StrieglAM, ReddingGJ, DiblasiR, CrotwellD, SalyerJ, CarterER. Use of a lung model to assess mechanical in-exsufflator therapy in infants with tracheostomy. Pediatr Pulmonol, 2011; 46(3):211–217.
25.
FranklinD, DalzielS, SchlapbachLJ, BablFE, OakleyE, CraigSS, et al. Early high flow nasal cannula therapy in bronchiolitis, a prospective randomised control trial (protocol): a Paediatric Acute Respiratory Intervention Study (PARIS). BMC Pediatr, 2015; 15:183.
26.
R Development Core Team. R: a language and environment for statistical computing. 2008; http://www.r-project.org.
27.
MuggeoVM, AtkinsDC, GallopRJ, DimidjianS. Segmented mixed models with random changepoints: a maximum likelihood approach with application to treatment for depression study. Stat Model Soc, 2014; 14(4):293–313.
28.
HoughJL, PhamTM, SchiblerA. Physiologic effect of high-flow nasal cannula in infants with bronchiolitis. Pediatr Crit Care Med, 2014; 15(5):e214–e219.
29.
UrbanoJ, del CastilloJ, López-HerceJ, GallardoJA, SolanaMJ, CarrilloÁ. High-flow oxygen therapy: pressure analysis in a pediatric airway model. Respir Care, 2012; 57(5):721–726.
30.
GrovesN, TobinA. High flow nasal oxygen generates positive airway pressure in adult volunteers. Aust Crit Care, 2007; 20(4):126–131.
31.
RitchieJE, WilliamsAB, GerardC, HockeyH. Evaluation of a humidified nasal high-flow oxygen system using oxygraphy, capnography and measurement of upper airway pressures. Anaesth Intensive Care, 2011; 39(6):1103–1110.
32.
CorleyA, CaruanaLR, BarnettAG, TronstadO, FraserJF. Oxygen delivery through high-flow nasal cannulae increase end-expiratory lung volume and reduce respiratory rate in post-cardiac surgical patients. Br J Anaesth, 2011; 107(6):998–1004.
33.
KumarH, SpenceCJ, TawhaiMH. Modeling the pharyngeal pressure during adult nasal high flow therapy. Respir Physiol Neurobiol, 2015; 219:51–57.
34.
HasanRA, HabibRH. Effects of flow rate and airleak at the nares and mouth opening on positive distending pressure delivery using commercially available high-flow nasal cannula systems: a lung model study. Pediatr Crit Care Med, 2011; 12(1):e29–e33.
35.
SaslowJG, AghaiZH, NakhlaTA, HartJJ, LawryshR, StahlGE, PyonKH. Work of breathing using high-flow nasal cannula in preterm infants. J Perinatol, 2006; 26(8):476–480.
36.
LamplandAL, PlummB, MeyersPA, WorwaCT, MammelMC. Observational study of humidified high-flow nasal cannula compared with nasal continuous positive airway pressure. J Pediatr, 2009; 154(2):177–182.
37.
MillerTL, SaberiB, SaberiS. Computational fluid dynamics modeling of extrathoracic airway flush: evaluation of high flow nasal cannula design elements. J Pulm Respir Med, 2016; 6(5):1–7. doi: 10.4172/2161-105X.1000376.
38.
JeongJH, KimDH, KimSC, KangC, LeeSH, KangTS, et al. Changes in arterial blood gases after use of high-flow nasal cannula therapy in the ED. Am J Emerg Med, 2015; 33(10):1344–1349.
39.
MöllerW, CelikG, FengS, BartensteinP, MeyerG, OliverE, et al. Nasal high flow clears anatomical dead space in upper airway models. J Appl Physiol, 2015; 118(12):1525–1532.
40.
FrickeK, TatkovS, DomanskiU, FrankeKJ, NiliusG, SchneiderH. Nasal high flow reduces hypercapnia by clearance of anatomical dead space in a COPD patient. Respir Med Case Rep, 2016; 19:115–117.
41.
SivieriEM, FogliaEE, AbbasiS. Carbon dioxide washout during high flow nasal cannula versus nasal CPAP support: an in vitro study. Pediatr Pulmonol, 2017:52(6):792–798.
42.
KugelmanA, RiskinA, SaidW, ShorisI, MorF, BaderD. A randomized pilot study comparing heated humidified high-flow nasal cannulae with NIPPV for RDS. Pediatr Pulmonol, 2015; 50(6):576–583.
43.
NagataK, MorimotoT, FujimotoD, OtoshiT, NakagawaA, OtsukaK, et al. Efficacy of high-flow nasal cannula therapy in acute hypoxemic respiratory failure: decreased use of mechanical ventilation. Respir Care, 2015; 60(10):1390–1396.
