Quelle est la place de l'Optiflow aux urgences ? Où en est-on des études cliniques ? Peut-on traiter les patients des urgences comme ceux de réanimation avec l'oxygénation haut-débit ? De nouvelles perspectives avec l'Optiflow ?

1. Nicolas PESCHANSKI
MD, PhD – CHI Eure-Seine Evreux
MEDECINE d’urgence

2. Consultant
Congrès/Symposiums
Investigateur
Congrès/Symposiums

3. Principes

4. Heated-Humidified HFNO
➚ 60 l/min
FiO2 > 90% Effet PEP 2-3 cmH2O

5. High-Flow Nasal Ox
Concept
1985

6. 1986-1991
Animal

7. NICU
2001

8. 2009

10. IRA

11. Effets sur 48 heures auprès de 40 patients dont 20 avec pneumonies
IRA

12. Effets sur 48 heures auprès de 40 patients dont 20 avec pneumonies
IRA

13. IRA

14. IRA

15. Etat de l’Art

16. IRA
Ni YN, et al. CHEST 2017; 151(4):764-775Ni YN, et al. Chest 2017;151(4):764-75

17. HDN versus Oxy. Conv. (COT)
HDN versus VNI
Pneumopathies
IRA

18. ?

19. Spoletini G, et al. Chest. 2015;148(1):253-61
Effets bénéfiques…

20. Spoletini G, et al. Chest. 2015;148(1):253-61
Pratique clinique…

21. Sztrymf et al. Int Care Med. 2011
Rittayamai et al. Respir Care. 2014
Lenglet et al. Respir Care. 2012
Rittayamai et al. Respir Care. 2015
Etat de l’art…

22. Transposer…?

23. Spoletini G, et al. Chest. 2015;148(1):253-61
Transposer…?

24. État de l’art Urgences

25. HFNCO2 = 998
HFNCO2 + Trials = 160
HFNCO2 + Trials + Urgences = 24
HFNCO2 + RCT + Urgences (Adultes) = 6
HFNCO2 + Urgences + Guidelines = 1 (Inde)

26. Quels Critères ?
RCT

27. Lenglet H, et al. Respir Care 2012;57(11):1873-8.
Pneumonia was the most common reason for
oxygen therapy (9/17)
HFNC is possible in the ED, and it alleviated
dyspnea and improved respiratory parameters in
subjects with acute hypoxemic respiratory failure.
Humidified High Flow Nasal Oxygen During
Respiratory Failure in the Emergency Department:
Feasibility and Efficacy
Pionniers…

28. HOT-ER Jones PG et al. Respir Care 2016

29. HOT-ER
Jones PG et al. Respir Care 2016
CONCLUSIONS: HFNC was not shown to reduce the need for mechanical ventilation
in the emergency department for subjects with acute respiratory distress compared with
standard O2, although it was safe and may reduce the need for escalation of oxygen
therapy within the first 24 h of admission
C’est de l’Urgence !!

30. OAP cardiogénique
Makdee O, et al. Ann Emerg Med. 2017;70(4):465-472
VS.

31. OAP cardiogénique
Makdee O, et al. Ann Emerg Med. 2017;70(4):465-472

32. Dyspnée & Hypoxémie
Rittayamai N, et al. Respir Care 2015;60(10):1377–1382
Use of High-Flow Nasal Cannula for Acute Dyspnea and Hypoxemia
in the Emergency Department
Nuttapol Rittayamai MD, Jamsak Tscheikuna MD, Nattakarn Praphruetkit MD, and
Sunthorn Kijpinyochai MD
BACKGROUND: Acute dyspnea and hypoxemia are 2 of the most common problems in the
emergency room. Oxygen therapy is an essential supportive treatment to correct these issues. In this
study, we investigated the physiologic effects of high-flow nasal oxygen cannula (HFNC) compared
with conventional oxygen therapy (COT) in subjects with acute dyspnea and hypoxemia in the
emergency room. METHODS: A prospective randomized comparative study was conducted in the
emergency department of a university hospital. Forty subjects were randomized to receive HFNC
or COT for 1 h. The primary outcome was level of dyspnea, and secondary outcomes included
change in breathing frequency, subject comfort, adverse events, and rate of hospitalization.
RESULTS: Common causes of acute dyspnea and hypoxemia were congestive heart failure, asthma
exacerbation, COPD exacerbation, and pneumonia. HFNC significantly improved dyspnea (2.0 ؎ 1.8
vs 3.8 ؎ 2.3, P ‫؍‬ .01) and subject comfort (1.6 ؎ 1.7 vs 3.7 ؎ 2.4, P ‫؍‬ .01) compared with COT.
No statistically significant difference in breathing frequency was found between the 2 groups at
the end of the study. HFNC was well tolerated, and no serious adverse events were found. The
rate of hospitalization in the HFNC group was lower than in the COT group, but there was no
statistically significant difference (50% vs 65%, P ‫؍‬ .34). CONCLUSIONS: HFNC improved
dyspnea and comfort in subjects presenting with acute dyspnea and hypoxemia in the emer-
gency department. HFNC may benefit patients requiring oxygen therapy in the emergency
room. Key words: high-flow nasal oxygen cannula; oxygen therapy; dyspnea; hypoxemia; emergency
room. [Respir Care 2015;60(10):1377–1382. © 2015 Daedalus Enterprises]
Introduction monia, and exacerbation of chronic obstructive airway dis-
thermore, Schwabbauer et
cantly reduced dyspnea an
with noninvasive ventilatio
respiratory failure. In addi
study tolerated HFNC ver
events occurred during the
jects who received HFNC
talization, but this was not
icant.
Improvement of dyspnea
several mechanisms, includ
subjects’ demand,13 decreas
low levels of positive airw
racoabdominal synchrony,2
cosal dryness with heated-
. 2. Change in level of dyspnea assessed using a numerical
ng scale (0–10) between high-flow nasal cannula (HFNC) and
Mean arterial pressure, mean Ϯ SD mm Hg 100.4 Ϯ 22.9 1
Heart rate, mean Ϯ SD beats/min 93.5 Ϯ 16.2 1
pO2
, mean Ϯ SD % 85.9 Ϯ 9.0
C ϭ high-flow nasal oxygen cannula
ϭ conventional oxygen therapy
were less sick compared with the subjects in the above-
mentioned studies. Thus, appropriate selection and fre-
quent re-evaluation of patients during HFNC use will help
to improve outcomes, particularly in the emergency de-
partment.
This study has some limitations. First, there was a 1.5-h
delay on average between the screening period and proto-
col initiation. Second, we did not measure delivered FIO2
in the COT group because this technique was difficult to
perform in the emergency department. Third, arterial blood
gases were not measured during the study. This was an
important limitation for comparing gas exchange between
the 2 groups and the potential changes in PaCO2
from ox-
ygen therapy, particularly in subjects with COPD.
Conclusions
In conclusion, HFNC resulted in less dyspnea and better
comfort in comparison with COT in subjects presenting to
the emergency department with acute dyspnea and hypox-
emia. This device may benefit patients requiring oxygen
therapy in the emergency department.
RESPIRATORY CARE • OCTOBER 2015 VOL 60 NO 10

33. Pathologies -> IRA
ICC BPCO
IRC Asthme
HTAP SAOS…
PAC
SICA
EP
SCA
…
Wilt TJ, et al. Ann Intern Med. 2007;147:639–53.

34. IRA
Durey A, et al . Am J Emerg Med. 2017;70(4):465-472

35. IRA
Durey A, et al . Am J Emerg Med. 2017;70(4):465-472
In our study, cardiogenic pulmonary edema was observed more frequently
in the success group and the finding of bilateral pulmonary infiltrates on
chest X-ray was more common in the success group as well.
Whereas, the percentage of pneumonia was higher in the failure group.

36. NEXT ?

37. Pré-Ox

38. Pré-oxygénation Réa
CONCLUSIONS
Compared to HFFM, HFNC as a preoxygenation device did not
reduce the lowest level of desaturation

39. CONCLUSIONS
A novel strategy for preoxygenation in hypoxaemic patients, adding HFNC for apnoeic
oxygenation to NIV prior to orotracheal intubation, may be more effective in reducing
the severity of oxygen desaturation than the reference method using NIV alone.
Pré-oxygénation Réa

40. Papazian L. et al. ICM 2016
Indications Urgences ?

41. On y travaille…
Hayes-Bradley C, et al. An Emerg Med 2016
Efficacy of Nasal Cannula Oxygen as a
Preoxygenation Adjunct in Emergency
Airway Management
Clare Hayes-Bradley, BSc, MBBS*; Anthony Lewis, MBBCh, PhD; Brian Burns, MBBCh, MSc; Matt Miller, MBChB
*Corresponding Author. E-mail: clarehayesbradley@yahoo.com, Twitter: @ClareHBradley.
Study objective: Although preoxygenation for emergency airway management is usually performed with nonrebreather
face masks or bag-valve-mask devices, some clinicians also deliver supplemental high-flow oxygen by nasal cannula.
We aim to measure the efficacy of supplemental nasal cannula oxygen delivery to conventional bag-valve-mask and
nonrebreather face mask preoxygenation both with and without a simulated face mask leak.
Methods: We conducted a randomized crossover trial using healthy volunteers. We randomized subjects to
preoxygenation with bag-valve-mask or nonrebreather face mask. In random sequence, subjects underwent 3-minute
trials of preoxygenation with oxygen through mask alone at 15 L/min, oxygen through mask at 15 L/min with standardized
leak, oxygen through mask at 15 L/minþoxygen through nasal cannula at 10 L/min, and oxygen through mask at 15 L/
minþoxygen through nasal cannula at 10 L/min with standardized leak. The primaryoutcome was single-breath exhalation
end-tidal oxygen (ETO2). We compared ETO2 between preoxygenation modalities, using nonparametric techniques.
Results: We enrolled 60 subjects (30 nonrebreather face mask and 30 bag-valve-mask). In scenarios without a mask
leak, ETO2 was similar between bag-valve-mask and bag-valve-maskþnasal cannula (mean 79% versus 75%; difference
–3%; 95% confidence interval [CI] –8% to 1%). In bag-valve-mask scenarios with a mask leak, ETO2 was higher for bag-
valve-maskþnasal cannula than bag-valve-mask alone (mean 66% versus 41%; difference 25%; 95% CI 21% to 29%).
ETO2 was higher for nonrebreather face maskþnasal cannula than nonrebreather face mask (mean 67% versus 52%;
difference 15%; 95% CI 12% to 18%). In nonrebreather face mask scenarios with a mask leak, ETO2 was higher for
nonrebreather face maskþnasal cannula than nonrebreather face mask (mean 65% versus 48%; difference 17%; 95%
CI 13% to 20%).
Conclusion: Although not aiding bag-valve-mask preoxygenation with a good mask seal, supplemental nasal cannula
oxygen improved preoxygenation efficacy in the presence of a bag-valve-mask mask leak. Supplemental nasal cannula
oxygen improved nonrebreather face mask preoxygenation both with and without a mask leak. Supplemental nasal
AIRWAY/ORIGINAL RESEARCH
What this study adds to our knowledge
In this randomized trial on 60 healthy volunteers,
nasal cannula oxygen at 10 L/min improved end-tidal
oxygen levels with nonrebreather mask,
nonrebreather with a mask leak, and bag-valve-mask
with a mask leak. Addition of nasal cannula did not
improve end-tidal oxygen with well-sealed bag-valve-
mask.
How this is relevant to clinical practice
Although requiring validation in clinical emergency
department patients, supplemental nasal cannula
oxygen may aid emergency airway management
preoxygenation efforts.

42. INDICATIONS
Hypoxie
OAPc Pré-Ox

43. Améliorations des échanges gazeux
Critères !!!

44. Fréquence respiratoire
SpO2
Gaz du sang artériel
Mesurer

45. Echelle de dyspnée
EVA « confort »
Taux d’abandon
Evaluer

46. Nouveau mode d’oxygénation
sans intubation
ni trachéotomie
Comparer Gold Standard ?

47. Questions ?
Nicolas PESCHANSKI
Urgences Adultes – SAMU 27
CHI
Eure-Seine
@DocNikko