2. Heated Humidified HighFlow Nasal Cannulae
(HHHFNC)
does it have a place in NICU
routine work?

3. Heated Humidified High-Flow Nasa
-Flow
in the
beginning, it
was the flow

4. Bonnaire E: Inhalations of oxygen in the newborn. Arch
Pediatr. 8:769 1891
by dr M Osama Hussein

5. Doctor Bonnaire, a French obstetrician, wrote the first article describing
the use of oxygen for premature infants by Tarnier at 1889
by dr M Osama Hussein

6. 1907 – A. Lane invented
nasal catheter
1919 – L. Hill
developed O2
tent
1920 - O2
therapy became
routine for “sick
new born”

7. Nasal cannula
Low flow systems
Nasopharyngeal
cannula
O2
Oxygen mask
High flow
systems
Enclosure system
Oxygen hood
Oxygen Liter/ min
FLOW

8. • Patrick Bouvier Kennedy dies of respiratory distress
syndrome (RDS), 34 weeks gestation, birthweight 2100
gms.
• Maria Delivoria-Papadopoulos
First successful ventilation of a preterm infant with hyaline •
membrane disease (Assisted ventilation in terminal hyaline
membrane disease. Arch. Dis. Child., 39:481-484, 1964

9. PARAMETERS OF VENTILATORS
(keyboard of ventilation)
FiO2
 Flow
 Inspiratory pressure
 End expiratory pressure
 Timing
 Rate
by dr M Osama Hussein

10. Parameters of assisted ventilation
 Free flow oxygen ( FiO2 + Flow)
 Assisted ventilation
1. Positive pressure ventilation(FiO2 + Flow +
Inspiratory pressure + End expiratory pressure +
Time of inspiration+ Rate)
Manual
Mechanical
2. CPAP (FiO2 + Flow + End expiratory pressure)
by dr M Osama Hussein

11. • Patrick Bouvier Kennedy dies of respiratory distress
syndrome (RDS), 34 weeks gestation, birthweight 2100
gms.
• Maria Delivoria-Papadopoulos
First successful ventilation of a preterm infant with hyaline •
membrane disease (Assisted ventilation in terminal hyaline
membrane disease. Arch. Dis. Child., 39:481-484, 1964
Gregory
Use of continuous positive airway pressure
(CPAP) for respiratory distress syndrome (RDS)
by dr M Osama Hussein

13. CPAP Provided by G. Gregory
by dr M Osama Hussein

14. • Sreenan et al. (2001) found that a PEEP of 6 cmH2O
could be reliable delivered to neonates using a high
flow nasal cannula & that was proved to be useful in
the management of apnea of prematurity
• Frey and Shann (2003) showed that nasal cannula flows
greater than 0.5 lpm resulted in positive end-expiratory
pressure (PEEP) when cannulas with a diameter of 3
mm were utilized
• Saslow et al. (2006) found that high flow nasal cannula
delivered CPAP & was useful to reduce work of
breathing in preterm infants
by dr M Osama Hussein

15. The use of high-flow nasal cannulae is an alternative
means of providing noninvasive respiratory support to
very preterm infants. Such cannulae deliver heated and
humidified gas at flow rates of more than 1 liter per
minute through small binasal prongs. Because high-flow
nasal cannulae have a simpler interface with the infant
and smaller prongs than nasal CPAP, the cannulae are
perceived as easier to use, more comfortable for the
infant, and advantageous for mother–infant bonding
(Hough JL, et al, J Paediatr Child Health, 2012).
by dr M Osama Hussein

16. The use of high-flow nasal cannulae is increasingly
popular for noninvasive respiratory support in neonatal
intensive care units around the world (Manley BJ, et
al, J Paediatr Child Health, 2012)
by dr M Osama Hussein

17. HHHFNC is a widely used modality in UK neonatal units.
Its current use appears to be without clear criteria and
mostly based on individual preference. Ojha S, et al,
Acta Paediatr. 2013
by dr M Osama Hussein

18. The use of high-flow nasal cannulae is an increasingly
popular alternative to nasal continuous positive airway
pressure (CPAP) for noninvasive respiratory support of
very preterm infants (gestational age, <32 weeks) after
extubation. (Nath P, et al, Pediatr Int, 2010)
The efficacy of high-flow nasal cannulae is similar to that
of CPAP as respiratory support for very preterm infants
after extubation Manley, et al. N Engl J Med 2013)
by dr M Osama Hussein

19. HHHFNC and NCPAP produced similar rates of extubation failure.
Collins CL, et al, j peds.2012
Among infants ≥28 weeks' gestational age, HHHFNC appears to
have similar efficacy and safety to nCPAP when applied
immediately postextubation or early as initial noninvasive
support for respiratory dysfunction. Yoder BA, et al.
Pediatrics. 2013
HFNC can improve dyspnea and physiologic parameters in
extubated subjects, including respiratory rate and heart rate
when compared with conventional oxygen therapy. This device
may have a potential role after endotracheal extubation.
Rittayamai N, Respir Care. 2013
by dr M Osama Hussein

20. Unlike NCPAP, HHFNC does not seem to increase the
risk of nasal trauma and appears to improve costeffectiveness whilst producing otherwise equal
respiratory and non-respiratory outcomes. FernandezAlvarez JR. Eur J Pediatr. 2013
HHHFNC resulted in significantly less nasal trauma in the
first 7 days post-extubation than NCPAP and was most
significant in infants <28 weeks of gestation. The use of
protective dressings was not associated with decreased
nasal trauma for infants on NCPAP. Collins CL et al, Eur J
Pediatr. 2014
by dr M Osama Hussein

21. There’s no difference in patient comfort
with HHHFNC versus NCPAP. However, parents
preferred HHHFNC, and during HHHFNC respiratory rate
was lower than during NCPAP. Klingenberg C, Arch Dis
Child Fetal Neonatal Ed. 2013
by dr M Osama Hussein

22. Increasing flow rates of HHHFNC therapy are associated
with linear increases in NP pressures in bronchiolitis
patients. Larger studies are needed to assess the clinical
efficacy of HHHFNC therapy in bronchiolitis. Arora B et
al, Pediatr Emerg Care. 2012
HFNP therapy has dramatically changed ventilatory
practice in infants <24 months of age, and appears to
reduce the need for intubation in infants with viral
bronchiolitis. Schibler A, Intensive Care Med, 2011
by dr M Osama Hussein

23. High-flow nasal cannula used early in the development
of pediatric acute respiratory insufficiency(ARI )is
associated with a decreased the need for intubation
and mechanical ventilation. Wing R et al, Pediatr Emerg
Care. 2012
by dr M Osama Hussein

24. Implementation of the RAM Cannula guidelines
resulted in a decrease in ventilator days, decrease in
rate of endotracheal intubation, and length of stay
(LOS) . RAM Cannula guidelines allow our PICU to
standardize care and provide a comfortable interface for
our patients. AAP, Shari Toomey, 2013
by dr M Osama Hussein

25. Nasal interfaces commonly used for NCPAP or NIPPV
include short binasal prongs, naso-pharyngeal
prongs, and nasal masks. These interfaces are difficult
to secure, which may further limit the handling of sick
patients, and are also associated with a high incidence
of nasal injuries, nasal cannula (RAM Nasal Cannula)
were used to provide NCPAP as well as NIPPV in the
delivery room and in the NICU in over 500 patients, for
over 5,000 days with an extremely low incidence of
nasal injuries. Ramanathan, J Pulmon Resp Med, 2013
by dr M Osama Hussein

26. Ram cannula
Nasal cannula
by dr M Osama Hussein

27. Side effects?
• Most concern is related to air leak syndrome
complicating high-flow nasal cannula therapy, Hegde
& Prodhan ,Pediatrics. 2013
by dr M Osama Hussein

28. Non invasive ventilation interfaces
 High flow nasal cannula systems are increasingly
adopted because of the ease of use
 Vapotherm, Fisher Paykel HFNC
 However, these HFNC systems have no ability to
measure or limit the pressure delivered to the baby
 There are no pop-off valves in these systems
 Only pop-off is at 20 PSI to protect the device and not to
protect the baby
 Can generate significant amount of distending pressures
at the nasal interface
 Air leaks have been reported
by dr M Osama Hussein

29. Indications
o To facilitate extubation of mechanically
ventilated neonates
o As a primary mode of support for neonates
with respiratory distress
o Infants with moderate-to-severe apnea
o Delivery room care?
by dr M Osama Hussein

31. Criteria to start HHHFNC
o If an infant has any of the following:
o Respiratory rate >60 breaths/minute
o Moderate to severe grunting
o Respiratory retraction
o Oxygen saturation <90% (preductal)
o Frequent apnea
by dr M Osama Hussein

32. Vapotherm (VT) 2000i (Vapotherm Inc., Stevensville, MD, USA)
Optiflow™ | Fisher & Paykel Healthcare
by dr M Osama Hussein

33. by dr M Osama Hussein

37. Thank you
See you in
Port said fifth neonatology
conference
October 2014