Talking All Things Cardiopulm
This podcast is designed to discuss heart and lung conditions, treatment interventions, research, current trends, expert opinions and patient experiences.The goal is to learn, inspire and bring Cardiopulm to the forefront of conversation.
Talking All Things Cardiopulm
Episode 84: Breaking Down High-Flow O2 Devices
In today’s episode, we break down 3 of the most common high-flow oxygen devices that you may see in the hospital setting: typical high-flow nasal cannula, venturi mask, and heated high-flow nasal cannula devices. Each device varies on the level of flow and FiO2 available, as well as, how the FiO2 is achieved. Each device also has pros and cons for choice of use.
Join me today, as we discuss the difference between the more common high-flow oxygen devices available.
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Welcome to Talking All Things Cardiopulm. I am your host, r Rachel Barisi, physical therapist and board-certified cardiopulmonary clinical specialist. This podcast is designed to discuss heart and lung conditions, treatment interventions, research, current trends, expert opinions and patient experiences. The goal is to learn, inspire and bring cardiopalm to the forefront of conversation. Thanks for joining me today, and let's get after it. Before we jump into today's episode, let me take a moment to introduce Jane, the clinic management software and EMR that I use in my practice.
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Rachele Burriesci:All right, good morning. I'm recording earlier than I normally do and I'm hoping Rem doesn't have a breakdown upstairs so I'm going to apologize ahead of time if she starts barking, but I'm going to hope that we can hold off just in time. We have a fun week planned. This is Nikki's birthday week, so she has a few days off kind of in between, which has been awesome, and I actually had a Sunday available, which is always fun. So happy birthday, nikki. This is one of those things that she likes to do is round up in age, so I actually am always confused about how old she is. She's been calling herself I'm going to get it wrong now she's been calling herself 42 for like I don't know two years maybe, and I think she's turning 42 this year. I have to go ahead and do the math. I'm pretty sure that is correct, but you never know with her, because she's turning 42 this year. I have to go ahead and do the math. I'm pretty sure that is correct, but you never know with her because she's always rounding up. It takes a minute, so nothing huge planned, but hoping to actually spend some quality time and not do projects. But we have a weather delay anyway. We've had quite a bit of rain, so not quite sure if we're going to get anything done this week. But that's okay as well. We're getting close. I'll give you the update when we're done, all right.
Rachele Burriesci:So I wanted to jump in and talk about high flow devices. Last week I kind of went on my rant about nomenclature and I'm still there because it really has been a little bit more laborious to find a very simple piece of information that is indeed updated. And I am finding that the high flow nasal cannula terminology is becoming more and more common when discussing heated high flow nasal cannula. So I'm only going to discuss three types of high flow devices today just to kind of give you a general introduction and idea of how they work, and then I may in the future do more deep dive into those specific devices to get a little bit more nitty gritty and how they work and maybe what patient population you might see them in. So, first and foremost, when we're talking about high flow devices, what we're discussing basically is something that has what is called a fixed performance, a little bit more precise FiO2 delivery at a higher flow rate to essentially cover the patient's inspiratory demand. So when we're above 20 liters per minute we have the ability to actually provide more demand than the patient is doing on their own and typically when we're using these types of devices they might have a higher inspiratory demand due to hypoxemia, increased respiratory rate and such. So the three devices that I do want to talk about is the typical high flow nasal cannula I think that's how I'm going to try to keep it separate Air entrainment mask, specifically the Venturi mask, and the heated high flow nasal cannula system, which there are actually a few of them to pick from, but we'll kind of just give a little general information about them.
Rachele Burriesci:So the typical high flow nasal cannula is one of those things that you'll see in the hospital setting and maybe even in home health and maybe even in a skilled facility to provide a little bit more FiO2 and flow rate to the patient. It's the perfect device for the patient who has kind of outrun the standard nasal cannula of six liters. It's super versatile. It's very comfortable for the patient who has kind of outrun the standard nasal cannula of six liters. It's super versatile, it's very comfortable for the patient. They're able to speak, eat cough, all those things without a mask in front of their face. It's pretty well tolerated and it has great variability.
Rachele Burriesci:So, from what I have seen in clinic primarily and I actually have one device in front of me here the typical high flow nasal cannula that we might think of is a simple device that looks like a regular nasal cannula for the most part. It typically has green tubing and the biggest difference is that we have a much wider variability. So we can go from one to 15 liters of flow and the FiO2 range varies, based on what I have seen, between 24% to 75%. I've seen as high as 80. I don't have a updated number for that, so I'm going to keep it around that. 75, 80% on the high point. These are great. They give you a lot of variability. When you're exercising with patients who might desaturate during your session, always make sure that you're monitoring your SpO2 throughout. Always check your devices, make sure that you're at the appropriate flow rate, also that you have good connection and there's not a lot of air leak. The reason why these devices don't technically go up to 100%, even though in theory, mathematically, it might seem that it could is because when the patient is breathing, they're also breathing room air and so there's a lot of mixing of air. So although this is considered a high flow nasal cannula, the precision of the FiO2 is still not as precise as some of the others. So I would call this a lower level and based on definition kind of flirts that line.
Rachele Burriesci:The next one I want to talk about is the Venturi mask, and I love this device. I think this was probably the one of the most used devices I used when I was in Michigan, because it gave precision to FiO2. And these devices typically have what's called an entrainment attachment, so there's some sort of valve attached to the mask itself. This is an all-in-one, so if you're on YouTube you can see a picture. I'll post this on Instagram as well. Essentially, the entrainment device is built into the mask and all you have to do is actually turn it to achieve the appropriate FIO2 based on the amount of flow that is provided, and this one tells you on the mask itself how many liters for what device for what FIO2. My apologies. So at three liters you can get 24%. If you click it to the next one, at three liters you can get up to 26%, and then at six, it goes up to 28 and 30% and if you go on the backside, this one goes up to 15 liters flow, which will achieve an FiO2 of 50%. So the entrainment mass again have some variability, usually somewhere between 24% and 50%. That top range might change pending the manufacturer that you're using. I believe the highest I have seen is 55%, maybe 60%. These are getting more common. I think they're a little bit easier in the sense that it's an all-in-one device.
Rachele Burriesci:You don't have to carry multiple valves, and I actually don't have my other Venturi available, but essentially I have one kind of here. They have these little entrainment valves that are separate, so they're usually different colors. There's usually like four or five of them. In theory, you would have to have these little valves with you in order to up titrate. So the entrainment mask allow for higher precision of FiO2 delivered based on the size of the valve holes that are created. So essentially there's this nozzle that creates a drag force between room air being pulled in and the flow from the oxygen into basically a jet nozzle maybe a transducer could be another word that's used and essentially the valve entrainment creates the precision of FiO2 based on the size that is available. Okay, so it basically allows a certain amount of oxygen from room air, the flow from the oxygen system into the valve, and that provides said precision.
Rachele Burriesci:These are really great. They typically work with a face mask, but they also have the ability to attach to a trach collar. So a lot of my patients when I was in Michigan who had trachs, we would utilize the Venturi to the trach to basically allow precision with exercise. So these are nice. The big con to the Venturi mask obviously you only have so much FiO2, right. Con to the Venturi mask obviously you only have so much FiO2, right. You're still only getting around 50% at its highest. But it is more precise. So you know exactly what you're giving to the patient and you can document that appropriately. So whatever FiO2 that is prescribed via the mask, based on their level of performance, based on their SpO2, you can determine yes, they are at an FiO2 of 40%, maintaining an SpO2 within goal, and then, if they were desaturating at all, you still have room to up titrate if needed, but you still max out, right, there's still an end to that. So the entrainment masks are really nice because it gives a little bit more precision to the FiO2 that's being delivered. The flow rates go up to technically 15 liters. So again, from a definition perspective, it's again kind of on the border like the typical high flow nasal cannula, but super nice.
Rachele Burriesci:One of the cons, I think, for the patients is that it's also typically a face mask and so if you're exercising this may be more uncomfortable. There's a lot more skin breakdown with the face mask coverings. The plastic is soft in comparison but against your skin can really start to cause some breakdown. So comfort is one of those things that can be a con for that one. And then the range of FiO2, right, if you only go up to 50%, you still need a backup device. So if I was working with a patient with a Venturi and we were exercising and we are utilizing some of those higher FiO2 range same thing I'd probably want a non-rebreather nearby as a just-in-case for either recovery or if we have an increase in desaturation with whatever activity that we're doing.
Rachele Burriesci:But the air entrainment masks pulling different levels of air from room, air and oxygen flow to provide precision in documentation and delivery to your patient, which is really nice. So those are the two high flow devices that as a physical therapist, you have the ability to titrate. Now, again, regardless, if you have the ability to titrate, whether it's in your state practice act that you can titrate based on an SpO2 goal order. It's really important that if you have never used a device, that you get the correct training on utilizing those devices. If you're in the hospital setting and you're new, maybe the physical therapy department has educational materials or an in-service to help provide said education. Or maybe this would be a great time to have interdisciplinary communication, maybe have RTs come in and give an in-service on oxygen devices that are available in that specific setting, because every single hospital that you go to, because every single hospital that you go to, every single setting that you go to, has different devices available.
Rachele Burriesci:Based on where I was previously, where I am now, there's differences in the type of device. There's differences in the manufacturers and also just in what's available. Right, I really don't see OxyMask anymore. I just haven't seen it in a while. Could I get it? Potentially, does it have any benefit over the others? Maybe not. Right From like an FIO2 range, you can argue that maybe a Venturi mask would be more precise compared to an OxyMask and still get the same level of support.
Rachele Burriesci:So why one place would have one versus the other could be pros and cons, could be financial, could be contracts with different companies. Either way, you want to know what is available in your setting to maximize your patient's outcomes with exercise, especially if they are desaturating, if they are requiring higher levels of oxygen. But in the high flow device world the typical high flow nasal cannula, which is the green tubing that goes up to 15 liters you can titrate as a PT if you have that education to do so. Same is true for the Venturi mask. Again, if you are using the Venturi mask that has the multiple valves, then you have to make sure that you have the multiple valves during your session in order to titrate. So in one of the places that I worked in Michigan, the patients came down to the gym, even in the acute care setting, and if they were on a Venturi mask I would have to call up to the nursing staff to make sure that they send the other valves down with them. Because if we're exercising and we need to up titrate, if I don't have those valves I can't up titrate that mask, right, you can't just up the oxygen flow meter. It's not going to make a difference because the valve is what's helping to basically utilize the air that's being delivered to create this precise FIO2. So there is some cons to that, which is why the Venturi mask that's kind of built in that you just twist to what you need, is super beneficial in those situations. I'm actually surprised that the small valve ones haven't gone out of style for that reason. Whether they get lost, they get left somewhere, you forget to bring them. I think the built-in one is just superior in that kind of way. But I am curious if there's any change in precision, which I don't know. I didn't read anything about that, but it is something to consider. I'm assuming precision side-by-side is probably pretty close, but it's super easy if it's just kind of built in to the mask itself, all right.
Rachele Burriesci:So now we're going to talk about the last of the high flows. Like I said, this isn't a comprehensive list. There are different manufacturers, there are different brands available. There are other high flow devices, especially in the pediatric case incubators, hoods, oxygen tents, things like that. I don't work with those specific devices so I'm not going to discuss them on this podcast, but maybe we'll get someone in the pediatric world to kind of fill us in on those as well.
Rachele Burriesci:But I think one of the most eye-opening things when I was, you know, checking in on updates on FiO2 and flow rates for these devices was the nomenclature of the high flow nasal cannula systems. And what I would consider as a heated high flow nasal cannula system is in research, in the literature, in multiple textbooks and trust me when I say I have multiple textbooks lined up to just like check my sources here Everyone calls these heated high flow systems high flow nasal cannula. So it's one of those things where I think in clinic you are conditioned to hear certain things and then when you start kind of digging into the literature, you can either find discrepancies in terminology or you know it's just not called that sometimes in clinics. So if I'm the only one in this boat, apologies for the multiple rants on it, but I was actually very surprised by this. So when we're talking about high flow nasal cannula systems, a lot of times we're talking about heated high flow nasal cannula systems. These are more high level devices with very precise FiO2 delivery as well as flow delivery, as well as humidification as well as heat.
Rachele Burriesci:There are multiple types of devices on the market that provide this type of support. One is called the Vapotherm. That one came out in 2008. We have the Telflex Comfort Flow that came out in 2006, as well as the Fisher Paykel Optiflow Airvo, which also came out in 2006. So these devices are different manufacturers that fall under this type of device. It's a heated high flow system. They each work a little bit different in how they deliver, but the idea is pretty similar. These systems cannot be titrated by a physical therapist, from what I understand, unless you have been formally trained and checked off on this. Anytime I have worked with these patients over the last 10 to 12 years, rt is providing the titration if needed. So if your patient is on a heated high flow system, you definitely want to collaborate with RT to either co-treat together or be nearby if desaturation occurs so that they can help titrate flow and or FiO2.
Rachele Burriesci:So these devices typically have a gas flow generator, they typically have a heated humidifier and they typically have some sort of heated circuit in their overall interface. How they actually create the system is where the manufacturers differ a little bit. So the VapoTherm allows for 1 to 40 liters per minute of flow and they can achieve up to 0.90 FiO2, or 90%, and they have a specifically designed nasal cannula. For their device as well. They require the high flow air, the oxygen tube blender and a flow meter in order to kind of create this support. They also have a vapor transfer cartridge, and so this is a high efficiency heated humidification system. It allows water vapor to be added to the oxygen flow through a semi-permeable membrane, and so essentially their humidification system is a little bit different than the Airvo system.
Rachele Burriesci:What is understood about these devices is that they can provide a much higher level of flow, typically around 40 to 60 liters of flow. Right, I just said the Vapotherm goes up to 40, both the Comfort Flow and the Airvo go up to 60. That higher level of flow allows to basically override the inspiratory demand of the patient. It actually helps wash out some of the dead space from that demand, and so those higher flow rates is where we can get more support in these devices.
Rachele Burriesci:The heated part is really for comfort, and so, based on the literature, how it's heated really doesn't matter, just that it is heated. And so, at these higher level flow rates, the heated systems help with comfort for the patient. They can tolerate those higher flows with said heat. Typically the heat goes up to around 37 degrees Celsius, pretty much matching body temp. This is typically considered a comfortable level for patients. There was one article that said patients prefer a slightly lower temp at 31 degrees, but there was basically a oh, use your word there were two groups. One had 31 degrees Celsius, one had 37 degrees Celsius and whatever the flow rate was I think they had two different flow rates, I think it was 30 and 60 or 40 and 60. And pretty much across the board, most patients felt the most comfort at the lower temps. But again, it really depends on the manufacturer and what is recommended for these devices. From my understanding, the air voze are set at 37 degrees, but there might be some adjustment available. Pediatric patients also have different recommendations based on this, recommendations based on this. So the heated part of the systems is really for comfort.
Rachele Burriesci:Humidification also falls in that as well. Basically, per research, right around the four liter mark. Anything above it, it really dries patients out. So anytime you have oxygen being delivered at greater than four liters per minute, flow humidification is recommended. Now the difference between these heated high flow systems and a regular typical high flow or any other humidification is bubbler humidification versus built-in humidification system. In comparison between the bubbler and these heated high flow humidification systems, the heated high humidification systems are more tolerated.
Rachele Burriesci:Whether it's how it's being delivered, the comfort of the device that's being worn, the humidification overall from a comfort perspective is typically better for these heated, high flow systems. Whether it's a combination of the heat and humidification seems to be part of the process. But each one of these systems, whether it's the Vapotherm, the Comfort Flow or the Aerovo, have a heat exchange device that differ in how it's put into the system, humidification and then higher levels of flow rate. The comfort flow can deliver flows between two and 60 liters, again heated, humidified, through, again, a nasal cannula type interface. It's equipped with a sterile concha thermo Neptune heated humidifier with sterile water. So again, it's just how it's performing the same level of support, just with a different type of interface. The comfort flow has this ability to help minimize risk with bacteria growth and cross-contamination with that type of system that they created.
Rachele Burriesci:And then the Erivo, in my opinion is probably the most common. This is the one I have seen the most in clinic in two different states. Back in Michigan I think they were on the Erivo 1., now it's Erivo 2. The company behind that seems to be the Fisher and Paykel Optiflow AirVo2. They go hand in hand. Again, they can provide two to 60 liters of support.
Rachele Burriesci:The nasal cannula has a flexible wide bore nasal cannula device and I have one here if you are on YouTube, so just a little bit different. In the actual nasal cannula tubing we have a wide bore system attached to it. It looks visually different than the typical high flow right Different devices, different nasal cannulas attached. It's got that corrugated tubing attached for the humidification system. It has an entrainment port. Again, it's attached to an external oxygen flow. It has an O2 analyzer attached to it to help monitor precise FiO2 being delivered and it has the ability to basically support higher levels of flow, higher levels of FiO2, close to 100% and humidification as well as heat in that comfort support level that the patient tends to like better.
Rachele Burriesci:The research is really supporting their use and I have to even say in the last two or three years I have seen more use of the heated high flow systems like Aerofo, more prophylactically right. Typically, when we saw them in years past it was in situations where the patient's super hy DNI maybe they're trying to prevent intubation, but it was in those more severe hypoxemic patients. That is still the case, but you're seeing them more prophylactically. In the last year, I have to say I have seen the use of airvo devices heated high flow devices post-extubation prophylactically not because a patient post-extubation prophylactically not because a patient didn't tolerate extubation, just prophylactically more consistently In the last year I have to say I've seen that quite a bit. The research supports this. The research says that if patients are extubated to a heated high flow device like Airvo that there is less risk for re intubation. So you're seeing it more post-operatively, post-cardiac surgeries, post-thoracic surgeries. So that seems to be a higher, more common device that's being used, more common device that's being used even outside of the severe hypoxemia. But research is showing that it does help prevent re-intubation and so I would assume to see this more commonly.
Rachele Burriesci:The high flow really allows to provide a higher level support for the patient, helps basically generate this washout effect to eliminate anatomic dead space in the upper lobes, helps with better oxygen exchange, better tolerated from the patient. So there's a number of different things in the physiologic perspective that makes these devices more optimal compared to a low flow device like a non-rebreather, so to speak, even if they're providing high levels of oxygen both. I think one of the big things also is low flow versus high flow is that it's not low FiO2 versus high FiO2. The low flow devices can provide pretty high levels of FiO2, but the precision is less because a lot of times you have room air being incorporated into those devices. These heated high flow devices are very specific, give a lot of ability to titrate liters of flow versus FiO2, versus humidification versus heat independently, and so that allows for a little bit more precision in what is being delivered to said patient. But again, if you're working with a patient who is on a heated high flow, you definitely want to know what FIO2 that they're on, what their goals of care are, what level of tolerance they have to even mobility in the bed and desaturation. And this is definitely one of those times that if you're working with a patient with a high level device that you coordinate with your team and try to co-treat this patient, because the patient's going to have a better outcome overall If you can titrate in the moment as a patient starts to desaturate, versus having to wait to then get a person to assist is always ideal. So if you do have a patient who's on a heated high flow system and they have been desaturating even with, say, bed mobility or anything that they might be doing in a low level situation, then you definitely want to co-treat this person. But great device. I think we're going to see a lot more of it in the future and improvements to it.
Rachele Burriesci:My understanding is that typically with these high flow devices, even though they have the ability to provide two to 60 liters, we're not using those low level flow rates for this type of device. They typically start around the 20 and 35 liters of flow with support, which makes sense because the reason that you're using it is really to help assist. So lots of benefits with these devices. But again, if you're working with them, you might want to co-treat with your RT because this would be a great way to really have that interdisciplinary support to help optimize patient outcome. But the high flow nasal cannula the typical one is this guy you have the ability to titrate that. You have up to 15 liters of flow to kind of work with with around an FiO2 75%. These tend to be more common again in the last five years. I feel like they're easier to get. They're more commonly used with patients requiring high levels of support and they have great variability right. So if you're working with a patient and they're desaturating with exercise, you have the ability to kind of move to what the patient needs with just this device.
Rachele Burriesci:And then the Venturi. I love the Venturi. I'm a little bit biased. I really use this device a ton in Michigan. It allows for some more precision, especially because it's a mask. You're going to get a little less variability and you have the idea of how much FiO2 that patient's actually being delivered with the level of activity that you're doing. But it has some cons. You have to have the valves available. You tap out around 50%-ish pending your manufacturer, and so you still might need a backup device for that patient. All right, I think that's all I have for you today. I'm probably going to go into each one a little bit more in detail in the future, but I hope this was a good starting point, kind of give you some ideas on nomenclature, some things to be looking out for, some reasons why you would choose one device over the other, and just kind of get you a little bit more comfortable with the names of these things and how they work. Alright, I hope you all have a wonderful day and, whatever you have to do, a good afternoon.
