{"id":11154,"date":"2022-09-06T17:29:34","date_gmt":"2022-09-06T17:29:34","guid":{"rendered":"https:\/\/todaysveterinarynurse.com\/?p=11154"},"modified":"2024-01-03T18:07:48","modified_gmt":"2024-01-03T18:07:48","slug":"emergency-medicine-critical-care-veterinary-high-flow-oxygen-therapy","status":"publish","type":"post","link":"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/emergency-medicine-critical-care\/veterinary-high-flow-oxygen-therapy\/","title":{"rendered":"Use of High-Flow Oxygen Therapy in Critical Canine Patients With Respiratory Distress"},"content":{"rendered":"<div class=\"su-spacer\" style=\"height:20px\"><\/div><div class=\"su-note\"  style=\"border-color:#d8d8d8;border-radius:3px;-moz-border-radius:3px;-webkit-border-radius:3px;\"><div class=\"su-note-inner su-u-clearfix su-u-trim\" style=\"background-color:#f2f2f2;border-color:#ffffff;color:#333333;border-radius:3px;-moz-border-radius:3px;-webkit-border-radius:3px;\"><b>Abstract<\/b><\/p>\n<p>For emergency patients presenting with respiratory distress who do not respond adequately to conventional oxygen therapy, high-flow oxygen therapy (HFOT) offers a middle-ground option before using mechanical ventilation. The purpose of this article is to review how HFOT compares with conventional oxygen therapy and mechanical ventilation, indications and contraindications, and guidelines for sedation protocols, nasal prong application techniques, and patient monitoring.<br \/>\n<b><\/b><\/p>\n<p><b>Take-Home Points <\/b><\/p>\n<ul>\n<li>High-flow oxygen therapy is not a replacement for mechanical ventilation.<\/li>\n<li>Oxygen toxicity can occur in patients maintained at 100% F\u0131o2 in as little as 24 hours.<\/li>\n<li>The nasal prong cannula diameter must be carefully measured to be sure it does not exceed approximately 50% of the diameter of the nares.<\/li>\n<li>The curvature of the nasal prongs should always point downward to prevent trauma to the mucous membranes and properly direct oxygen flow.<\/li>\n<li>When placing nasal prongs, nasoesophageal and nasogastric tubes may be left in place.<\/div><\/div><\/li>\n<\/ul>\n<p>Respiratory distress is one of the most common presenting emergencies in veterinary medicine. Until recently, therapies were limited to medical management, conventional oxygen therapy, and mechanical ventilation. Conventional oxygen therapies are relatively simple, involving oxygen cages, nasal oxygen cannulas, or flow-by oxygen. Mechanical ventilation is less commonly available because it is expensive and requires extensive training.<\/p>\n<p class=\"p2\"><span class=\"s2\">Approximately 6 years ago, high-flow oxygen therapy (HFOT) became available as a bridge between conventional oxygen therapies and mechanical ventilation in the veterinary setting.<sup>1<\/sup> HFOT has been used in human medicine for at least 20 years, primarily for neonates with respiratory compromise. Applications of this therapy in veterinary medicine have proven promising.<sup>2<\/sup><\/span><\/p>\n<h2 class=\"p3\">What is High-Flow Oxygen Therapy?<\/h2>\n<p class=\"p2\"><span class=\"s2\">HFOT is the administration of warm, humidified oxygen via nasal prongs, using a commercially available unit (<\/span><span class=\"s3\"><b>FIGURE 1<\/b><\/span><span class=\"s2\">). It allows the delivery of higher flow rates of oxygen (4 to 60 L\/min with some devices). The flow rate is set to meet or exceed the inspiratory flow demand of the patient (the speed at which the patient inhales). In normal mesocephalic dogs, the average flow demand is approximately 500 to 1000 mL\/sec.<sup>3<\/sup> Brachycephalic dogs may have lower flow demands due to naturally occurring airway obstructions. When a critically ill patient is experiencing respiratory distress, the flow demands are considerably higher owing to increased work of breathing, as well as the metabolic demands of illness.<\/span><\/p>\n<div id=\"attachment_11035\" style=\"width: 361px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig1.png\"><img fetchpriority=\"high\" decoding=\"async\" aria-describedby=\"caption-attachment-11035\" class=\" wp-image-11035\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig1.png\" alt=\"\" width=\"351\" height=\"468\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig1.png 720w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig1-225x300.png 225w\" sizes=\"(max-width: 351px) 100vw, 351px\" \/><\/a><p id=\"caption-attachment-11035\" class=\"wp-caption-text\">Figure 1. Patient receiving high-flow oxygen therapy.<\/p><\/div>\n<h2 class=\"p3\">How Does HFOT Compare to Conventional Oxygen Therapy?<\/h2>\n<p class=\"p2\"><span class=\"s2\">Flow-by oxygen, oxygen cages, and nasal oxygen cannulas are often sufficient for initial support. One or more of these therapies is readily available in most clinical settings. <\/span><\/p>\n<h3 class=\"p4\">Flow-by Oxygen<\/h3>\n<p class=\"p2\"><span class=\"s2\">Flow-by oxygen therapy is a temporary solution. It requires 1-on-1 nursing care and can often feel like the room is receiving more oxygen support than the patient. While easily accessible and very inexpensive, it is not feasible for long-term support.<\/span><\/p>\n<h3 class=\"p4\">Oxygen Cage<\/h3>\n<p class=\"p2\"><span class=\"s2\">Oxygen cages take up a lot of space compared with other methods of support. They require frequent maintenance and routine soda lime changes, and the limited space can contribute to patient stress. While some oxygen cages come in larger sizes, patients often get overheated even with cooling support. Additionally, opening the cage door frequently to perform treatments may result in a decrease in oxygen levels inside the cage. Larger cages take longer to achieve adequate oxygen content, and flow-by is often needed to bridge the gap. <\/span><\/p>\n<h3 class=\"p4\">Nasal Cannulas<\/h3>\n<p class=\"p2\"><span class=\"s2\">Oxygen delivered via conventional nasal cannulas is not heated and not sufficiently humidified, and the flow rates are limited (1 to 5 L\/min). These flow rates are further diluted by room air (~21% oxygen) each time the patient inspires because mixing of gases leads to a less exact fraction of inspired oxygen (F\u0131o<sub>2<\/sub>).<sup>4<\/sup> Furthermore, the lack of temperature regulation and humidification may result in damage to the nasal mucosa, airway constriction, and inflammation.<sup>2<\/sup> <\/span><\/p>\n<h3 class=\"p4\">High-Flow Oxygen Therapy<\/h3>\n<p class=\"p2\"><span class=\"s2\">Compared with conventional oxygen therapies, HFOT has been shown to improve oxygenation in moderate to severe cases of hypoxemia.<sup>2,5<\/sup> A patient is considered hypoxemic when the arterial partial pressure of oxygen (Pao<sub>2<\/sub>) is less than 80 mm Hg or the oxygen saturation (Spo<sub>2<\/sub>) is less than 95%.<sup>6<\/sup> The heated and humidified oxygen is better tolerated by most patients and can be delivered at much higher flow rates. The patient also experiences less energy expenditure by not having to heat the oxygen gas on its own. The nasal prongs used in HFOT are usually well tolerated by most patients.<\/span><\/p>\n<p class=\"p2\"><span class=\"s2\">HFOT uses high rates of oxygen to flush out carbon dioxide from gas-conducting (versus gas-exchanging) areas of the upper airway and replacing it with oxygen-rich air.<sup>7<\/sup> This allows for a more optimized F\u0131o<sub>2<\/sub> to reach the alveoli and eliminates the mixing of gases. The resulting maintenance of increased pressure throughout the breathing cycle aids in the recruitment of alveoli, effectively acting similarly to PEEP (positive end-expiratory pressure) in ventilated patients.<sup>2,5<\/sup> HFOT provides approximately 3 to 5 cm H<sub>2<\/sub>O of simulated PEEP, which increases resistance to exhalation and promotes retention of oxygen.<\/span><\/p>\n<h2 class=\"p3\">How Does HFOT Compare to Mechanical Ventilation?<\/h2>\n<p class=\"p2\"><span class=\"s2\">It is important to remember that HFOT is not mechanical ventilation. There are no inspiratory pressure settings and no ability to set PEEP, respiratory rate, or volume, and it offers no additional monitoring (e.g., pressure-volume loops). Mechanical ventilation allows for full control of the airway and breathing cycle; however, it is very expensive, requires full-time care and monitoring by specially trained doctors and veterinary nurses, as well as the use of heavy sedation or anesthetics, and is not commonly available in most veterinary practices. <\/span><\/p>\n<p class=\"p2\"><span class=\"s2\">HFOT bridges the gap to mechanical ventilation, is less invasive than ventilation, and is generally more cost effective. For example, the unit used in the authors\u2019 institution (DRE Volumax; Avante Animal Health, <\/span><a href=\"http:\/\/dreveterinary.com\" target=\"_blank\" rel=\"noopener\"><span class=\"s3\">dreveterinary.com<\/span><\/a><span class=\"s2\">) employs a disposable cartridge that may be used for up to 30 days.<sup>8<\/sup> Disposable single-use nasal prongs are relatively inexpensive, and the sterile water bags necessary are often readily available.<\/span><\/p>\n<h2 class=\"p3\">Indications and Contraindications For the Use of HFOT<\/h2>\n<p class=\"p2\"><span class=\"s2\">HFOT is indicated for any patient in which conventional oxygen therapy has failed or where mechanical ventilation is unavailable, too costly, or detrimental to patient safety. It is also a great alternative when owners are unwilling to consider mechanical ventilation. HFOT has also been utilized in brachycephalic dogs immediately after extubation to aid in recovery from anesthesia.<sup>9<\/sup><\/span><\/p>\n<p class=\"p2\"><span class=\"s2\">Early indicators of a poor response to HFOT may include persistently increased respiratory rate and effort, increased heart rate, ventricular premature contractions, orthopneic posturing, head bobbing, restlessness, \u201cguppy\u201d breathing, true dyspnea or signs of respiratory fatigue, and cyanosis.<sup>10<\/sup> HFOT is not a replacement for mechanical ventilation.<b> <\/b>If Spo<sub>2<\/sub> cannot be maintained above 93%, carbon dioxide cannot be maintained below 60\u00a0mm\u00a0Hg, or the patient has clinical signs of respiratory fatigue, then intubation and mechanical ventilation are indicated.<sup>11<\/sup> <\/span><\/p>\n<p class=\"p2\"><span class=\"s2\">Exclusion criteria for HFOT may include chronic lung disease or severe hypercapnic respiratory failure. Patients requiring a chest tube should have one placed prior to using HFOT or mechanical ventilation. Contraindications for HFOT may also include epistaxis, nasal masses or facial trauma, increased intracranial pressures and traumatic brain injury, esophageal foreign bodies or obstructions, or patients with increased sensitivity to facial manipulation. <\/span><\/p>\n<p class=\"p2\"><span class=\"s2\">Due to the potential for esophageal or gastric <\/span>distention from aerophagia, patients with gastrointestinal<span class=\"s2\"> bleeding may not be candidates for HFOT. Hemodynamically unstable patients or those unable to maintain a functional airway are also not always eligible. <\/span><\/p>\n<p class=\"p2\"><span class=\"s2\">Patients with chronic airway or pulmonary disease may have adapted to higher carbon dioxide levels; therefore, lowering carbon dioxide levels with the use of supplemental oxygen may result in severe hypoventilation. Lowering carbon dioxide levels even a small amount will decrease the respiratory drive and ultimately lead to respiratory failure.<sup>11<\/sup> <\/span><\/p>\n<p class=\"p2\"><span class=\"s2\">Nasal prongs are not currently available for use with cats, neonates, micropets, or exotic pets. In these patients, the size of the prongs would completely occlude the nares and prevent proper gas exchange, resulting in hypercapnia or barotrauma. Cats cannot tolerate HFOT due to their inability to pant for prolonged periods of time. They are also obligate nasal breathers. Additionally, the increased pressures associated with HFOT may not be safe for patients with smaller tidal volumes (patients &lt;4 kg). <\/span><\/p>\n<h2 class=\"p3\">The High-Flow Oxygen Unit<\/h2>\n<p class=\"p2\"><span class=\"s2\">Most HFOT units consist of the high-flow unit itself, a roll stand for easy transport, the air compressor, detachable\/disposable patient circuits, disposable nasal prongs, gas inlet filters, medical air\/oxygen hoses, and a power cord. Most units have a backup battery system that allows for up to 15 minutes of power during an emergency outage. Systems are relatively quiet while in use, which is ideal in a critical care setting. See <b>Using the DRE Volumax<\/b> for an overview of unit setup in the authors\u2019 institution as an example; however, details of setup and use vary by model, and the user manual should always be consulted for each specific unit.<\/span><\/p>\n<div class=\"su-box su-box-style-default\" id=\"\" style=\"border-color:#606060;border-radius:3px;\"><div class=\"su-box-title\" style=\"background-color:#939393;color:#FFFFFF;border-top-left-radius:1px;border-top-right-radius:1px\">Using the DRE Volumax<\/div><div class=\"su-box-content su-u-clearfix su-u-trim\" style=\"border-bottom-left-radius:1px;border-bottom-right-radius:1px\"><strong>Supplies needed <\/strong><\/p>\n<ul>\n<li>1 patient circuit cartridge, chosen based on patient size<\/li>\n<li>1 nasal prong oxygen cannula<\/li>\n<li>1-L bags of sterile water<\/li>\n<li>Access to oxygen and medical air<\/li>\n<\/ul>\n<p><strong>Note:<\/strong> Each circuit cartridge can be used for multiple patients for up to 30 days after the initial setup. It is important to use the date sticker on the side of the cartridge to prevent the circuit from being overused (<strong>FIGURE A<\/strong>).<\/p>\n<div id=\"attachment_11043\" style=\"width: 310px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_FigA.png\"><img decoding=\"async\" aria-describedby=\"caption-attachment-11043\" class=\" wp-image-11043\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_FigA.png\" alt=\"\" width=\"300\" height=\"252\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_FigA.png 864w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_FigA-300x252.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_FigA-768x646.png 768w\" sizes=\"(max-width: 300px) 100vw, 300px\" \/><\/a><p id=\"caption-attachment-11043\" class=\"wp-caption-text\">Figure A. Date sticker on circuit cartridge.<\/p><\/div>\n<p><strong>Unit setup<\/strong><\/p>\n<ul>\n<li>After proper handwashing, open the new cartridge bag while wearing examination gloves and aseptically attach the new circuit to a 1-L bag of sterile water. Be certain a secondary liter bag of sterile water is available; do not let the bag attached to the unit run dry.<\/li>\n<li>Hang the sterile water bag from the pole and allow the cartridge to fill with approximately 200 mL of sterile water (<strong>FIGURE B<\/strong>).<\/li>\n<\/ul>\n<div id=\"attachment_11044\" style=\"width: 260px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_FigB.png\"><img decoding=\"async\" aria-describedby=\"caption-attachment-11044\" class=\" wp-image-11044\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_FigB.png\" alt=\"\" width=\"250\" height=\"333\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_FigB.png 720w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_FigB-225x300.png 225w\" sizes=\"(max-width: 250px) 100vw, 250px\" \/><\/a><p id=\"caption-attachment-11044\" class=\"wp-caption-text\">Figure B. Setting up the DRE Volumax.<\/p><\/div>\n<ul>\n<li>Insert the cartridge.<\/li>\n<li>Attach the oxygen lines and the medical air lines to the outlets.<\/li>\n<\/ul>\n<p><strong>Note:<\/strong> Medical air is only necessary when providing an F\u0131o<span class=\"s2\"><sub>2<\/sub><\/span> (fraction of inspired oxygen) less than 100% to the patient.<\/p>\n<p><strong>Unit operation<\/strong><\/p>\n<ul>\n<li>Plug in and turn on the unit. If the air compressor will be used, it must be turned on before the Volumax machine. Medical air must flow through the unit before humidifying so that moisture does not build up inside the machine.<\/li>\n<li>Set parameters (gas, flow rate, F\u0131o<span class=\"s2\"><sub>2<\/sub><\/span>, temperature) (<strong>FIGURE C<\/strong>). Flow rates are chosen based on the severity of disease and size of the animal (<strong>TABLE 1<\/strong>).<\/li>\n<li>Activate the machine.<\/li>\n<\/ul>\n<div id=\"attachment_11045\" style=\"width: 260px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_FigC.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-11045\" class=\" wp-image-11045\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_FigC.png\" alt=\"\" width=\"250\" height=\"333\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_FigC.png 720w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_FigC-225x300.png 225w\" sizes=\"(max-width: 250px) 100vw, 250px\" \/><\/a><p id=\"caption-attachment-11045\" class=\"wp-caption-text\">Figure C. Setting parameters on the DRE Volumax.<\/p><\/div>\n<p><strong>Begin therapy<\/strong><br \/>\nAttach the circuit to the nasal cannula. Make sure you do not connect the unit to the patient until the system has had a chance to warm up and purge the excess moisture. Connection immediately after setup can cause the patient discomfort due to improperly heated air or excess moisture in the line. Proper warmup takes about 5 minutes. <\/div><\/div>\n<h3 class=\"p4\">Controls<\/h3>\n<p class=\"p2\"><span class=\"s2\">Parameters that can be set and adjusted include temperature, F\u0131o<sub>2<\/sub>, and flow rate. Air delivered to the patient may be heated and humidified.<\/span><\/p>\n<h3 class=\"p4\">Compressor<\/h3>\n<p class=\"p2\"><span class=\"s2\">The purpose of the compressor is to blend medical air with 100% oxygen to reach F\u0131o<sub>2<\/sub> levels lower than full concentration.<b> <\/b><\/span><\/p>\n<p class=\"p2\"><span class=\"s2\">Oxygen toxicity (hyperoxia) can occur in patients maintained at 100% F\u0131o<sub>2<\/sub> in as little as 24 hours.<sup>12<\/sup><b> <\/b>Oxygen toxicity is an iatrogenic condition in which supplemental oxygen becomes toxic to the lungs over a prolonged period. Signs range from coughing, nausea, and muscle twitching to disorientation, seizures, and even death.<sup>10,12<\/sup><\/span><\/p>\n<h2 class=\"p3\">Choosing and Using Nasal Prongs<\/h2>\n<p class=\"p2\"><span class=\"s2\">Once the HFOT machine is set up, the nasal prongs should be chosen and fitted to the patient. A new set of nasal prongs should be used with every patient. <\/span><\/p>\n<h3 class=\"p4\">Measuring the Prong Diameter<\/h3>\n<p class=\"p2\"><span class=\"s2\">The cannula diameter should be carefully measured to be sure it does not exceed approximately 50% of the diameter of the nares (<span class=\"s3\"><b>FIGURE<\/b><\/span><\/span><span class=\"s3\"><b>\u00a02<\/b><\/span><span class=\"s2\">). Too large a diameter can obstruct the patient\u2019s ability to ventilate, while too small a diameter will provide inadequate flow and offer poor respiratory support. Prong size can be assessed by placing a hand or cotton ball in front of the animal\u2019s nose. If air flow can be felt, or if the cotton ball moves, the prongs are likely not occluding more than 50% of the nares. Additionally, if the prongs are the right size, <\/span>there should be an audible \u201cbreak\u201d in the flow each time<span class=\"s2\"> the patient exhales. The HFOT unit manufacturer may also provide recommendations for cannula diameter related to patient size and compatible flow rate.<\/span><\/p>\n<div id=\"attachment_11036\" style=\"width: 360px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig2.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-11036\" class=\" wp-image-11036\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig2.png\" alt=\"\" width=\"350\" height=\"467\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig2.png 720w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig2-225x300.png 225w\" sizes=\"(max-width: 350px) 100vw, 350px\" \/><\/a><p id=\"caption-attachment-11036\" class=\"wp-caption-text\">Figure 2. Patient measured for proper nasal prong diameter. Courtesy Yu Ueda, DVM, PhD, DACVECC, North Carolina State University College of Veterinary Medicine<\/p><\/div>\n<h3 class=\"p4\">Securing the Cannula<\/h3>\n<p class=\"p2\"><span class=\"s2\">The nasal prong cannula should be secured to the patient in a way to prevent inadvertent disconnection. A variety of techniques can be used; however, the authors have found suturing the nasal prongs to each side of the patient\u2019s muzzle using a finger-trap method to be the most successful (<span class=\"s3\"><b>FIGURE<\/b><\/span><\/span><span class=\"s3\"><b>\u00a03<\/b><\/span><span class=\"s2\">).<\/span><\/p>\n<div id=\"attachment_11037\" style=\"width: 360px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig3.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-11037\" class=\" wp-image-11037\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig3.png\" alt=\"\" width=\"350\" height=\"466\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig3.png 720w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig3-225x300.png 225w\" sizes=\"(max-width: 350px) 100vw, 350px\" \/><\/a><p id=\"caption-attachment-11037\" class=\"wp-caption-text\">Figure 3. Nasal prongs being secured to the patient with sutures. Courtesy Michael Kato, DVM, DACVECC, North Carolina State University College of Veterinary Medicine<\/p><\/div>\n<p class=\"p2\"><span class=\"s2\">Some nasal prongs may be better secured by creating a small tape \u201cbridge\u201d over the muzzle to help the prong tubing hold the proper shape as well as decrease suture tension on the patient\u2019s face (<span class=\"s3\"><b>FIGURES<\/b><\/span><\/span><span class=\"s3\"><b> 4 AND 5<\/b><\/span><span class=\"s2\">).<\/span><\/p>\n<div id=\"attachment_11038\" style=\"width: 360px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig4.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-11038\" class=\" wp-image-11038\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig4.png\" alt=\"\" width=\"350\" height=\"467\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig4.png 720w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig4-225x300.png 225w\" sizes=\"(max-width: 350px) 100vw, 350px\" \/><\/a><p id=\"caption-attachment-11038\" class=\"wp-caption-text\">Figure 4. Proper tape bridge in use on a patient receiving high-flow oxygen therapy.<\/p><\/div>\n<div id=\"attachment_11039\" style=\"width: 360px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig5-e1662144276191.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-11039\" class=\" wp-image-11039\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig5-e1662144276191.png\" alt=\"\" width=\"350\" height=\"350\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig5-e1662144276191.png 570w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig5-e1662144276191-300x300.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig5-e1662144276191-150x150.png 150w\" sizes=\"(max-width: 350px) 100vw, 350px\" \/><\/a><p id=\"caption-attachment-11039\" class=\"wp-caption-text\">Figure 5. Top view of a patient illustrating a tape bridge over the nose.<\/p><\/div>\n<p class=\"p2\"><span class=\"s2\">The prongs can also be secured using a tape butterfly method. When using the taped butterfly method or when using a tape bridge, waterproof surgical tape is usually more effective than porous tape. The tubing should be completely dried with a piece of gauze prior to applying the tape to the prongs, as waterproof tape may slip if the tube is wet.<\/span><\/p>\n<h3 class=\"p4\">Placing the Nasal Prongs<\/h3>\n<p class=\"p2\"><span class=\"s2\">The direction of the prongs is very important. The curvature of the nasal prongs should always point downward to prevent trauma to the mucous membranes and properly direct the flow without obstruction (<\/span><span class=\"s3\"><b>FIGURE 6<\/b><\/span><span class=\"s2\">).<\/span><\/p>\n<div id=\"attachment_11040\" style=\"width: 360px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig6.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-11040\" class=\" wp-image-11040\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig6.png\" alt=\"\" width=\"350\" height=\"467\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig6.png 720w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig6-225x300.png 225w\" sizes=\"(max-width: 350px) 100vw, 350px\" \/><\/a><p id=\"caption-attachment-11040\" class=\"wp-caption-text\">Figure 6. Nasal prongs held in the proper direction for placement.<\/p><\/div>\n<p class=\"p2\"><span class=\"s2\">When placing nasal prongs, nasoesophageal and nasogastric tubes may be left in place; however, it is recommended to remove all red rubber nasal cannulas prior to initiating HFOT.<b> <\/b>Red rubber nasal cannulas often become occluded with nasal secretions and are<b> <\/b>ideally replaced every 2 days. A new red rubber cannula may be placed after HFOT is discontinued. <\/span><\/p>\n<h2 class=\"p3\">Initiating HFOT<\/h2>\n<p class=\"p2\"><span class=\"s2\">HFOT is a fairly new treatment in veterinary medicine. Hospital staff should be properly educated on the use and equipment management prior to launching the use of HFOT in any hospital. <\/span><\/p>\n<p class=\"p2\"><span class=\"s2\">At the authors\u2019 institution, an F\u0131o<sub>2<\/sub> of 100% is chosen initially unless the clinician requests otherwise (compressor use is required to reduce F\u0131o<sub>2<\/sub>). The temperature can be set between 34 \u00b0C and 38 \u00b0C; however, the authors suggest starting at 37 \u00b0C for nearly all patients.<\/span><\/p>\n<p class=\"p2\"><span class=\"s2\">The flow rate may be calculated at 0.5 to 2 L\/kg.<sup>2<\/sup> The initial flow rate should be set lower and titrated up as needed based on patient response. The authors suggest taping a printout of flow rate settings to the HFOT machine for quick reference (<span class=\"s3\"><b>FIGURE<\/b><\/span><\/span><span class=\"s3\"><b>\u00a07<\/b><\/span><span class=\"s2\">).\u00a0<\/span><\/p>\n<div id=\"attachment_11041\" style=\"width: 360px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig7.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-11041\" class=\" wp-image-11041\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig7.png\" alt=\"\" width=\"350\" height=\"467\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig7.png 720w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig7-225x300.png 225w\" sizes=\"(max-width: 350px) 100vw, 350px\" \/><\/a><p id=\"caption-attachment-11041\" class=\"wp-caption-text\">Figure 7. At-a-glance flow rates.<\/p><\/div>\n<p><span class=\"s3\"><b>TABLE 1<\/b><\/span><span class=\"s2\"> lists suggested initial HFOT flow rates; however, it is important to remember that each patient\u2019s need and response are individual, and flow rates and F\u0131o<sub>2<\/sub> should be titrated based on need, comfort, and tolerance.<\/span><\/p>\n<p><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Table1.png\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter size-full wp-image-11155\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Table1.png\" alt=\"\" width=\"1990\" height=\"494\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Table1.png 1990w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Table1-300x74.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Table1-1024x254.png 1024w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Table1-768x191.png 768w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Table1-1536x381.png 1536w\" sizes=\"(max-width: 1990px) 100vw, 1990px\" \/><\/a><\/p>\n<h2 class=\"p3\">Patient Monitoring and Nursing Care Requirements<\/h2>\n<p class=\"p2\"><span class=\"s2\">Once HFOT is initiated, patients must be carefully monitored for response to therapy or worsening of clinical signs. A patient on HFOT will generally exhibit a positive response within 30 to 60 minutes after initiation of therapy. <\/span><\/p>\n<p class=\"p2\"><span class=\"s2\">Serial venous blood gas or arterial blood gas measurements should be assessed frequently to gauge response to HFOT. Blood gas results, in conjunction with continuous pulse oximetry (i.e., Spo<sub>2<\/sub>) evaluation, will help determine if HFOT is effective for the patient. Nasal prongs should be checked frequently for proper fit\/location and connection to the unit, as patients may inadvertently become disconnected.<\/span><\/p>\n<p class=\"p2\"><span class=\"s2\">Most patients seem to tolerate HFOT and the nasal prongs fairly well. Elizabethan collars are occasionally used to deter a patient from pawing or rubbing at the nasal cannula and accidentally becoming disconnected (<span class=\"s3\"><b>FIGURE<\/b><\/span><\/span><span class=\"s3\"><b>\u00a08<\/b><\/span><span class=\"s2\">). Once the nasal prongs are secured, if the patient seems irritated or uncomfortable, unit settings should be adjusted and inspected to ensure that the irritation is not a sign of continued hypoxia.<\/span><\/p>\n<div id=\"attachment_11042\" style=\"width: 360px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig8.png\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-11042\" class=\" wp-image-11042\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig8.png\" alt=\"\" width=\"350\" height=\"319\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig8.png 864w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig8-300x273.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/09\/LaJuettBabineau_TVNFall22_HFOT_Fig8-768x700.png 768w\" sizes=\"(max-width: 350px) 100vw, 350px\" \/><\/a><p id=\"caption-attachment-11042\" class=\"wp-caption-text\">Figure 8. Patient receiving high-flow oxygen therapy with Elizabethan collar.<\/p><\/div>\n<p class=\"p2\"><span class=\"s2\">Respiratory rate and effort, temperature, and heart rate monitoring are invaluable. Setting the temperature on the HFOT unit too high may result in iatrogenic hyperthermia. Temperature probes are available to limit patient handling and stress. Electrocardiography (<a href=\"https:\/\/todaysveterinarynurse.com\/cardiology\/veterinary-electrocardiogram-interpretation\/\" target=\"_blank\" rel=\"noopener\">ECG<\/a>) monitors allow continuous evaluation of heart rate and rhythm and provide early indications of distress and hypoxemia. Eye lubrication is important to prevent corneal ulceration and irritation of ocular mucosa.<\/span><\/p>\n<p class=\"p2\"><span class=\"s2\">Patients on HFOT are occasionally sick enough to be recumbent. Turn orders to prevent atelectasis and aid in potential alveolar recruitment are necessary for these patients. Additionally, passive range of motion exercises may assist in venous return and increased circulation of oxygenated blood.<\/span><\/p>\n<p class=\"p2\"><span class=\"s2\">Patients should also be monitored for stomach distention, prong-related side effects such as nose sores or skin lesions over the bridge of the nose, and difficulty synchronizing breathing. If the patient is not responding adequately to HFOT, mechanical ventilation should be considered.<\/span><\/p>\n<h2 class=\"p3\">Sedation Protocols<\/h2>\n<p class=\"p2\"><span class=\"s2\">Anxiolytics such as <a href=\"https:\/\/todaysveterinarypractice.com\/pain_management\/gabapentin-and-amantadine-for-chronic-pain\/\" target=\"_blank\" rel=\"noopener\">gabapentin<\/a> and trazodone can be given as needed to keep the patient calm. On rare occasions a patient may require sedation to tolerate either the high-flow nasal prongs or their current respiratory distress. Boluses of butorphanol at 0.2 mg\/kg IV are preferred for these circumstances. Butorphanol boluses can be escalated to a continuous rate infusion or dexmedetomidine can be added (when not contraindicated due to comorbidities) only when absolutely necessary. <\/span><\/p>\n<p class=\"p2\"><span class=\"s2\">If continued anxiety and activity centered on removing the nasal prongs persist, this may be an indication the patient is feeling well enough to discontinue HFOT. <\/span><\/p>\n<h2 class=\"p3\">De-escalation of HFOT<\/h2>\n<p class=\"p2\"><span class=\"s2\">Much like weaning a patient from conventional oxygen therapies, discontinuing the use of HFOT is initiated by the gradual decrease of oxygen concentration and flow rate. Continued patient monitoring is crucial, and other sources of oxygen should be available should a need arise. If the patient is not responding well to weaning, therapy should be reinstituted and maintained for an additional 12 to 24\u00a0hours. In the authors\u2019 experience, patients routinely require conventional oxygen therapy for some time following the use of HFOT. Similar de-escalation techniques are used to transition the patient to room air oxygen concentrations.<\/span><\/p>\n<p class=\"p2\"><span class=\"s2\">Once the patient no longer requires high-flow support, the unit should be properly shut down and cleaned to prevent delays in treating the next patient. <\/span><\/p>\n<h2 class=\"p3\">Conclusion<\/h2>\n<p class=\"p2\"><span class=\"s2\">For patients that do not respond adequately to conventional oxygen therapy, HFOT is an effective alternative method of delivering high volumes and pressures of oxygen without the use of mechanical ventilation. Cost-effective equipment, easily obtained supplies, and patient tolerance are advantages of HFOT in any practice. If the patient is not responding to traditional therapy or HFOT, referral to a specialty practice for mechanical ventilation is indicated.<\/span><\/p>\n<div class=\"su-box su-box-style-default\" id=\"\" style=\"border-color:#606060;border-radius:3px;\"><div class=\"su-box-title\" style=\"background-color:#939393;color:#FFFFFF;border-top-left-radius:1px;border-top-right-radius:1px\">GLOSSARY<\/div><div class=\"su-box-content su-u-clearfix su-u-trim\" style=\"border-bottom-left-radius:1px;border-bottom-right-radius:1px\"><strong>Aerophagia<\/strong> Swallowing air<\/p>\n<p><strong>Atelectasis<\/strong> Collapse of the lung<\/p>\n<p><strong>Barotrauma<\/strong> Trauma caused by rapid changes in air pressure<\/p>\n<p><strong>F\u0131o<span class=\"s2\"><sub>2<\/sub><\/span> (fraction of inspired oxygen)<\/strong> Concentration of oxygen in a gas mixture<\/p>\n<p><strong>Flow rate<\/strong> Volume of oxygen per unit of time (L\/min)<\/p>\n<p><strong>Hypoxemia<\/strong> Low blood oxygen level<\/p>\n<p><strong>Mesocephalic<\/strong> Having a head of medium proportions, not brachycephalic or dolichocephalic<\/p>\n<p><strong>Orthopneic<\/strong> Body position indicating respiratory distress and dyspnea in which the patient elevates its head and stretches its neck out to maximize its ability to breathe<\/p>\n<p><strong>PEEP (positive end-expiratory pressure)<\/strong> Alveolar pressure that exists at the end of expiration<\/p>\n<p><strong>Tidal volume<\/strong> Amount of air that moves in and out of the lungs during each breath<\/div><\/div>\n<hr \/>\n<p><strong>Editor&#8217;s Note:<\/strong> A previous version of this article incorrectly stated that a patient is considered hypoxemic when the the oxygen saturation (Spo2) is <em>greater<\/em> than 95%. This has been corrected in the text.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>For patients that do not respond adequately to conventional oxygen therapy, HFOT is an effective alternative method of delivering high volumes and pressures of oxygen.<\/p>\n","protected":false},"author":236,"featured_media":11046,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"iawp_total_views":0,"footnotes":""},"categories":[232],"tags":[192,145],"class_list":["post-11154","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-fall-2022","tag-continuing-education","tag-peer-reviewed","column-continuing-education","clinical_topics-emergency-medicine-critical-care","clinical_topics-respiratory-medicine"],"acf":{"hide_sidebar":false,"hide_sidebar_ad":false,"hide_all_ads":false},"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v24.7 (Yoast SEO v27.4) - 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