High Velocity Therapy as an Alternative to NIPPV to Support a Patient in CHF Crisis
Sheldon Spivey, RRT • Terrell Ashe, RRT-NPS • Rose Dennis, RRT • Angela Spivey, RRT
Athens Regional Medical Center (Athens, Georgia)
Vapotherm does not practice medicine or provide medical services or advice. Vapotherm’s high velocity therapy is a tool for treating respiratory distress. Although individual results may vary, Vapotherm believes this case study is an example of the clinical benefit Vapotherm’s high velocity therapy can have in an emergency department setting.
Patient History and Presentation
A 66 year old male presented at the Emergency Department via emergency medical service in severe hypoxemia secondary to CHF exacerbation. The patient had gone to his PCP with a two day history of congestion and cough associated with angina where he was found to be in profound type I respiratory failure with a SpO2 measurement of 60% on room air. He received an aerosolized treatment with albuterol sulfate 2.5mg and ipratropium bromide 0.5mg and was sent to the ED on a 4 L/min nasal cannula. Upon arrival to the emergency department, he was found to have a markedly labored work of breathing and +2 pitting edema.
Treatment and Response
The patient was placed on a Salter nasal cannula attached to an unheated bubble humidifier, which was run off a 15 L/min Thorpe tube from the wall oxygen supply. It was observed through an arterial blood gas and clinical observation that this therapy did not alleviate his dyspnea or hypoxemia. The patient was switched from the Salter cannula to high velocity therapy (Vapotherm Precision Flow) running at 25 L/min and 100% oxygen. The patient’s SpO2 improved within seven minutes and remained above 92%, in addition to a drop in systolic blood pressure of 19 mmHg, for the remainder of his ED stay. In conjunction with the high velocity therapy, the patient was given furosemide 40 mg and was placed onto a nitroglycerin intravenous drip when access was obtained. From the patient’s perspective, he indicated that he felt “better and [was] having an easier time breathing” as reported in the nursing notes. Eventually, in the ED, the patient was titrated to 30 L/min and 80% oxygen per saturation and comfort. The patient remained on high velocity therapy through the completion of his time in the ED and was eventually disposed to the ICU for continued diuresis and to address a complaint of chest pain.
This patient’s dyspnea was not mitigated by use of the initial simple high flow nasal cannula. The simple high flow nasal cannula does not appear to have a patient interface that allows the full amount of flow set on the Thorpe tube flow meter to pass through the prongs into the nares. Moreover, the humidification of this gas is limited and is therefore poorly tolerated at higher flows. The design of the Salter prongs appear to occlude greater than 50% of the nare opening which impedes expulsion of expiratory gas and replenishment with fresh gas at the desired FiO2. Immediately following application of high velocity therapy, this patient improved rapidly with an increase in SpO2 and a decrease in blood pressure that corresponded with a 15% decrease in respiratory rate.
Vapotherm high velocity therapy provided a decrease in work of breathing over conventional oxygen therapy that turned this patient who was otherwise a candidate for more invasive therapies. Therefore, the complexities and the associated hazards of non-invasive positive pressure ventilation were avoided in the emergency setting. Moreover, high velocity therapy afforded the patient the ability to breathe synchronously and spontaneously with a remarkable short time for the patient to adapt to the therapy.