HFNC/High Flow Nasal Cannual vs. Conventional Oxygen Therapy vs. Non-Invasive Positive Pressure Ventilation

Can High-flow Nasal Cannula Reduce the Rate of Endotracheal Intubation in Adult Patients With Acute Respiratory Failure Compared With Conventional Oxygen Therapy and Noninvasive Positive Pressure Ventilation? A Systematic Review and Meta-analysis

I need help with this. Is it me or is this an apples to oranges study? I ask that because the authors compared high flow nasal cannula to conventional oxygen therapy and then they compared HFNC to NIPPV. Okay, the COT versus HFNC is an easy one to settle. Fewer people are going to be intubated if they’re on HFNC, all comers. But the caveats kick in when the authors compare HFNC to NIPPV which many of you know as BiPAP. My issue is because they included patients who were having acute exacerbations of COPD, acute cardiogenic pulmonary edema, asthma exacerbations, and ARDS in the HFNC vs NIV arm of the study. It is my opinion that that’s a bit ridiculous bc we know (and knew in 2017 when this study was published) that those patient populations more often than not need more support than what HFNC can provide. I will say there is data for HFNC in all those settings, but not enough to prove a benefit to NIV. Can you chime in below with your thoughts? I don’t think they should have looked at all comers for HFNC. Taking it by disease processes which other authors have done would yield actual real world results. These devices need to be carefully tailored to the patients you are treating. I’m more than willing to change my mind but I need help. Thanks.  

-EJ

Link to abstract

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

How much volume is in an adult resuscitator? 1600ml

The quick and easy answer to how much volume is in the ventilation bag (the part you squeeze) in an adult resuscitator is 1600ml.

You hear the alarm go through the hospital "CODE BLUE in room XYZ". You, like me, are an ambulance chaser and want to get there as soon as possible to either run the code or handle the airway or all of the above. A patient needs to be saved! Your team sorts itself out with everyone assuming their roles (or being delegated to their roles). Someone in at the head of the bed with the resuscitator, also known in many places as the "Ambu". I sometimes call it the BVM for bag-valve mask. We need to get better at our language in this game. That's besides the point. So someone is at the head of the bed with a huge adrenaline rush pounding away at the resuscitator squishing the bag ferociously trying to get all the O2's that exist into the patients lungs RIGHT NOW. More squeeze equals more air and then that's "more better", right?  This is too common and this post is to hopefully slow us down when we "bag" the patient. I'm not going to go into proper technique to apply the mask because that's a topic for another day. The purpose of this post. The problem is that whether you are utilizing this tool to "bag" someone through a mask or once the endotracheal tube is placed, people bag too much volume and too fast. I've seen several cases now where patients have developed pneumothoraces secondary to this issue. People just don't know the volume of the bag and the fact that you don't have to squeeze it entirely like you're trying to get the last of the lemon into your vodka tonic. 1/3 of the way will do.

The reason for this is because our total lung capacity is approximately 6 liters. From those 6L you need to subtract about 1200ml of residual volume and 1200ml expiratory reserve volume. You have 3600cc left to go. Then you bag, bag, bag without allowing time for exhalation and the lungs end up popping like balloons. Then your patient who just coded ended up on a ventilator, whatever the etiology of the arrest was to begin with, and a couple of chest tubes to seal the deal. Be careful with this tool, team.

Credit to Laerdal for publishing the pretty picture and the volume of their resuscitator.
Resuscitator Link

-EJ

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Is there a doctor on the plane?

I will start off by stating that this is not a call that should only be responded to by someone with an MD or a DO behind their name. I know of many seriously good critical care nurses who push away physicians who freeze in a tough situation and just handle it. I know nurses who can do much better patient assessments, bag patients, perform better chest compressions than many MD's. ARNP's and PA's, I haven't forgotten about you all. You can respond to this call as well. It all of our duties.
This is going to be you or me who rises up from our seat when duty calls and we need to tend to a sick person on an airplane. I always think that this may happen on my particular flight because, well, I'm insane. As I walk through the aisle and pass through all the rows to the back to the plane because, face it, I am not First Class level, I survey the individuals in the seats to prepare for who may crash and burn. Not talking about the plane, of course. That being said, I can't believe that until this moment I had never thought about what medical equipment is actually available on the flights. This made me do a little deeper dig rather than just "figure it out" when the situation presented itself. Hopefully never, of course. But hey, poop happens and this is what we are trained to do. So let's do it!

-EJ

This table was taken from HERE.

Sphygmonanometer	1
Stethoscope	1
Airways, oropharyngeal (3 sizes): 1 pediatric, 1 small adult, 1 large adult or equivalent	3
Self-inflating manual resuscitation device with 3 masks (1 pediatric, 1 small adult, 1 large adult or equivalent)	1:3 masks
CPR mask (3 sizes), 1 pediatric, 1 small adult, 1 large adult, or equivalent	3
IV Admin Set: Tubing w/ 2 Y connectors	1
Alcohol sponges	2
Adhesive tape, 1-inch standard roll adhesive	1
Tape scissors	1 pair
Tourniquet	1
Saline solution, 500 cc	1
Protective nonpermeable gloves or equivalent	1 pair
Needles (2-18 ga., 2-20 ga., 2-22 ga., or sizes necessary to administer required medications)	6
Syringes (1-5 cc, 2-10 cc, or sizes necessary to administer required medications)	4
Analgesic, non-narcotic, tablets, 325 mg	4
Antihistamine tablets, 25 mg	4
Antihistamine injectable, 50 mg, (single dose ampule or equivalent)	2
Atropine, 0.5 mg, 5 cc (single dose ampule or equivalent)	2
Aspirin tablets, 325 mg	4
Bronchodilator, inhaled (metered dose inhaler or equivalent)	1
Dextrose, 50%/50 cc injectable, (single dose ampule or equivalent)	1
Epinephrine 1:1000, 1 cc, injectable, (single dose ampule or equivalent)	2
Epinephrine 1:10,000, 2 cc, injectable, (single dose ampule or equivalent)	2
Lidocaine, 5 cc, 20 mg/ml, injectable (single dose ampule or equivalent)	2
Nitroglycerin tablets, 0.4 mg	10
Basic instructions for use of the drugs in the kit	1

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

High Flow Nasal Cannula: Does my patient with pneumonia need to be intubated?

The article I'm referencing in this post is titled: An Index Combining Respiratory Rate and Oxygenation to Predict Outcome of Nasal High-Flow Therapy. It was published in the American Journal of Respiratory and Critical Care Medicine in June of 2019. 

We see this every day in the intensive care unit. A patient with pneumonia sucking wind. Tachypenic. Slightly altered. Requiring a bunch of oxygen. Should we intubate them and place them on mechanical ventilation, or should we give them a shot and see if they fly on high flow nasal cannula? The data for pneumonia and using BiPAP isn't there so that's not an option. Side note, check the FLORALI trial which I posted on my site as it has some of the same researchers on the matter. I really really don't want to have to intubate the patient with all the risks and complications known to go with that unless it's really really needed. In a joking manner, we all think we're big shots and can call it just by seeing it. You know the type, I am the same way. I can tell a patient needs to be intubated as soon as I lay eyes on them. Big shot. Yep. This is true, or is it? We also know that delaying intubation is far worse for patient populations that just intubating them early on. What ends up happening is that once you finally go ahead and proceed with intubation after the patient has been developing more and more fatigue, you notice that you're in deep poop when the induction agents destroy your patients hemodynamics. Start bolusing fluids. Place a central line and start vasopressors. Death spiral ensues. If this hasn't happened to you in your career, you haven't been working long enough. 

What if there was a tool to help us with this decision? Wouldn't that be great? How about a tool so simple that all you need is a pulse oximeter, a HFNC setup telling you the FiO2 being delivered to the patient, and a set of eyeballs to count a patients respiratory rate (because we all know that whatever device measures RR on the monitor is inaccurate and showing "apneic" more often than it should). Well, we're all in luck! These authors came up with the ROX index which is (SpO2/FiO2)/RR. SpO2 is the number you get from the pulse oximeter and it's on the monitor. It should be entered as a whole number. FiO2 is entered as a decimal. For example room air is 21% so 0.21. RR is, well, respiratory rate. Based on the data provided in this article, it should be a statistically significant prediction of whether your patient is going to be intubated or not. Hopefully the delay of mechanical ventilation we all are dreading should be avoided. This should also help you make the decision to just intubate the person before you leave your partner who is working the opposite shift with an airway dump, one of the worst kinds of dumps. 

I am not going to go deep into the data of this study because this team knows what they are doing far better than I ever will and the truth is that the abstract here is a pretty darn good representation of what is within the bulk of the text. I am curious, however, of why the article was published in its "in press" format in December of 2018 and was not fully released until June 2019. So many people could have benefitted from it. 

Also, a little tidbit that you may or may not have known. The journal where this was published, the American Journal of Respiratory and Critical Care Medicine is the high ranked journal for Critical Care Medicine based on Impact Factor. Don't know what Impact Factor is? You should definitely check it out because it evaluates the quality of the journal. That will keep you from making a mistake that I made where I showed my Program Director in residency an article from this small European journal something about atrial fibrillation and then he proceeded to make fun of me and showed me where to look up the actual data on afib, the American Heart Association Guidelines. Anyway, that's enough of a rant. Enjoy the article and until next time! 

ADDENDUM: Someone who follows my on instagram named Jessie just opened my eyes to a use case for this ROX index that I hadn't thought of before. It could potentially be used to help either alert or calm nurses and respiratory therapists regarding the potential decline of a patient who is on HFNC either in a step-down/PCU/intermediate unit. It could be an objective piece of data that they could provide to physicians to provide evidence that the patient needs to be transferred to the intensive care unit for intubation or that the patient is deteriorating. Wow! I feel silly that I had not thought of that myself but I'm glad she reached out and pointed it out to me. Thanks Jessie! 

-EJ




Link to the Abstract

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Docusate in the Hospital: Cut the Crap

Everybody poops. There’s a book about it. Read it. It’s worth your while. You know what’s not worth your while? Something that I’ve been guilty of doing my whole career. Providing docusate just because. I’m a bit embarrassed but I was sent this article by bedsideroundz and doctorwarsgame yesterday evening so I could take this apart. Well, no need for me to take it apart. The authors did a great job at reviewing the data and concluding that we should just stop prescribing docusate. Hope no one holds shares in the companies who manufacture this medication as it is earning them $100,000,000 a year for a product with crappy results. Was that a pun? Perhaps the most important part of the article is towards the end where they provide recommendations regarding alternatives. I know what the nurses in the crowd are saying... “oh I’m not going to request lactulose for my patient”. Everything in moderation, team. Bowel movements are importante. 💩

-EJ

Link to Article

Link to PDF

Robert J Fakheri, MD, Frank M Volpicelli, MD, Things We Do for No Reason: Prescribing Docusate for Constipation in Hospitalized Adults. J. Hosp. Med 2019;2;110-113. doi:10.12788/jhm.3124

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Why we should NOT be checking for residual tube feeds

Do you as a nurse spend any part of your day checking for residuals on your patients who are on mechanical ventilation and receiving tube feeds/enteral feeding? Did you know that since 2016, the ASPEN guidelines have recommended against this? Now may be your opportunity to present this data to the powers that be and let you have your time back so you can "play cards" (obvious joke) and do more important things in patient care. It's 2019, think of all the time you've spent partaking in this practice. Sigh. Okay don't think about it. We NEED you at the bedside. In the McClave study there was no support for using residual volumes as a marker for the risk of aspiration. the frequency was 21.6% vs 22.6%. The Poulard study from 2010 was calling checking residual gastric volume "standard practice". I guess that's why some institutions are still doing it. They wanted to do the study because there was no data to find a correlation between residuals and adverse events. Know what they found? That not checking residuals allowed for a greater daily volume of enteric feeds. No difference in vomiting between the two groups nor was there a difference in ventilator associated pneumonia. Worth it to check residuals? Still not convinced? Lets look at more data then. Last but definitely not least, the Reignier study in 2013, 3 years after the 2010 study showed that there wasn't a benefit to checking residuals (in all fairness the study took place in 2010) looked at ventilator associate pneumonia as the primary endpoint. Did they find a difference? They found a whole bunch of NOPE. Does that settle the argument in your mind? Yes, I know that we all had that ONE patient who aspirated and got sick. It's not perfect. But the data is there, actually, right here. Three articles that you can obtain on my website. A little literature review from me, if you will. Hope you got something out of it and your time will now be saved. Share this with your nurse managers, dietitian teams, and fellow nurses so everyone can benefit.

I'm sorry that I can't get you these articles as they are hidden behind the dreaded paywall but the ASPEN guidelines are free.


-EJ














Link to Article

Reignier, J. (2013). Effect of Not Monitoring Residual Gastric Volume on Risk of Ventilator-Associated Pneumonia in Adults Receiving Mechanical Ventilation and Early Enteral Feeding. JAMA, 309(3), 249.



Link to Article

McClave, S. A., Lukan, J. K., Stefater, J. A., Lowen, C. C., Looney, S. W., Matheson, P. J., … Spain, D. A. (2005). Poor validity of residual volumes as a marker for risk of aspiration in critically ill patients*. Critical Care Medicine, 33(2), 324–330.



Link to Abstract

Poulard, F., Dimet, J., Martin-Lefevre, L., Bontemps, F., Fiancette, M., Clementi, E., … Reignier, J. (2009). Impact of Not Measuring Residual Gastric Volume in Mechanically Ventilated Patients Receiving Early Enteral Feeding. Journal of Parenteral and Enteral Nutrition, 34(2), 125–130.

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.

Can early enteral nutrition decrease mortality?

Early enteral nutrition, provided within 24 h of injury or intensive care unit admission, significantly reduces mortality in critically ill patients: a metaanalysis of randomised controlled trials.


Link to Abstract

Early enteral nutrition, provided within 24 h of injury or intensive care unit admission, significantly reduces mortality in critically ill patients: a metaanalysis of randomised controlled trials.

In my quest for sort out the answer of when to initiate enteral nutrition in my critically ill ICU patients, the data leans toward starting early. In this meta-analysis that was published in 2009, despite the sample sizes being very small, they were able to find a benefit regarding mortality and pneumonias when you start feeding patients within 24 hours. How small you ask? Well, 234 in the group that determined a benefit in mortality and just 80 in the group that determined a benefit towards pneumonia of early feeding. We need larger studies. All these authors admit this. We need some super ambitious RD's out there to take this bull by the horns and definitely answer these questions for us! A 🎩 tip to the authors!

-EJ

Doig GS, Heighes PT, Simpson F, Sweetman EA, Davies AR. Early enteral nutrition, provided within 24 h of injury or intensive care unit admission, significantly reduces mortality in critically ill patients: a metaanalysis of randomised controlled trials. Intensive Care Med. 2009;35(12): 2018-2027.

Enteral Nutrition: When should we start in our mechanically ventilated patients? Day 1 or 4?

Link to Abstract

Delayed enteral feeding impairs intestinal carbohydrate absorption in critically ill patient.

When trying to decide when to initiate enteral nutrition in our critically ill patients who are on mechanical ventilation, there is not a great amount of data. Should we start on day 1, 2, 3, 4, 5... on and on. This study shows us that we should definitely NOT wait until day 4 to get started. Although these was no difference in mortality, the authors were able to see an increase in days of mechanical ventilation as well as a prolonged ICU length of stay in the patients who received enteral nutrition on day 4 as opposed to day 1. The authors hypothesized that not feeding the patients when they were ill creates intestinal atrophy and ulceration, therefore leading to disruptions of the intestinal tract that proved harmful to patients. The patient population of this study, 28 patients, was small but it provides some insight as to what we should be doing. The next questions should be "start at day 1 vs day 2" or "start at day 1 vs day 3"? We do not know those answers yet. 

A 🎩 tip to the authors! 

- EJ

Nguyen, N. Q., Besanko, L. K., Burgstad, C., Bellon, M., Holloway, R. H., Chapman, M., … Fraser, R. J. L. (2012). Delayed enteral feeding impairs intestinal carbohydrate absorption in critically ill patients*. Critical Care Medicine, 40(1), 50–54. 

Pharmacists save lives!

Link to Abstract

To those who say that only doctors and nurses save lives. There's a new teammate to share the glory with. Now, to any of us who have spent just 15 seconds in the ICU, this is NOT news. But it is always nice to be recognized, right? It is a little shady that all the authors are pharmacists, but we will excuse that because we all know the findings are true.
What have we learned from this article?
1. No matter how they juggled the data, pharmacists decrease mortality
2. Patients stay in the ICU for a shorter period of time because of pharmacists
3. This one is a no-brainer because it basically reflects that pharmacists are doing their job but they decreased both preventable and non-preventable adverse drug events.
So how about a little hip-hip-horray for our pharmacy colleagues? Tag your favorite ICU pharmacist. Much love to all.
A hat tip to the authors!

-EJ

Blood Pressure Measurements in the ICU: Trust ONLY the MAP in Oscillometric Devices!

Link to Abstract

Link to Article

Full disclosure. I did not learn this until I was a fellow in Critical Care Medicine. It is not widely taught. Do not feel bad that you did not know this. All I ask is for your help to share this with others so we all speak the same language and do the best for our patients.

What are the normal sounds you hear with the "old fashioned"/auscultatory method of taking a patients blood pressure?
Those sounds define the systolic blood pressure and diastolic blood pressure respectively.
Then you do math and could calculate the mean arterial pressure (MAP) by using the formula of (2xDBP)+SBP/3 but there are a number of different ways to derive the MAP.
Does the BP cuff you have in the ICU, hospital or throughout the majority of doctor offices have ears? We if that's the case, you CANNOT assume that the SBP and DBP provided by these devices are exact.

How do oscillometric devices work?
The device measures the oscillations from the blood vessel wall during cuff deflation. The maximal oscillation point is the MAP. The device uses an algorithm that is proprietary to define the SBP and DBP. Those algorithms are closely kept secrets to the manufacturers.

Why is this important, well, BP is GOLD in the ICU world. My nurses titrate pressors based on MAP number, as the guidelines suggest, but I have too often seen nurses whipping out their phone calculating the MAP by hand as they feel that the numbers generated on the screen are inaccurate. Now, this occurred when I trained in community academic hospital, then ivory tower fancy pants hospital, and now in a community hospital which is why I feel writing this post is so important. We need to understand how our technology works!
It is known, however, that the MAP is the most important value generated by the device.

The study listed above noted that there was a significant difference between calculated MAP, i.e. the nurses/staff doing the calculation themselves, and the observed MAP (generated by the machine). They found that the generated MAP could either be lower or higher that the observed MAP. These differences were amplified even further when analyzed on individual patients rather than the cohorts. Would you feel comfortable treating your patients like this? I sure don't.

The authors discuss a trial where patients had their BP taken via oscillometric device in the OR vs. intraarterial and there was no statistically significant difference in the MAP. There was a difference in the SBP by 19mmHg, though. Could you imagine treating these patients based on an algorithm generated SBP? You'd be treating them (or not treating them) inappropriately!

Now, this post may seem like it's being directed at nurses, after all, you all are the main ones at the bedside, but we all need to get better. The docs needs to stop presenting patients to each other by referencing the SBP. Docs need to stop telling nurses to hit SBP goals for their pressors instead of MAPs.

Well, now you know how this all works and you won't make silly comments anymore. I hope I taught you something.

- EJ

Although great care has been taken to ensure that the information in this post is accurate, eddyjoemd, LLC shall not be held responsible or in any way liable for the continued accuracy of the information, or for any errors, omissions or inaccuracies, or for any consequences arising therefrom.