NEW NORMAL IN MANAGING

EARLY RESPIRATORY DISTRESS

USING HFNT
Hendri Pangestu
 Sabtu, 11 Juli 2020 | 23:20 WIB

Pemerintah Akui Salah Pakai Istilah New Normal Saat

Pandemi Covid-19, Malah Bikin Masyarakat Bingung
• Juru bicara pemerintah untuk penanganan Covid19, Achmad Yurianto,
menyatakan diksi New Normal atau normal baru yang didengungkan pemerintah
selama pandemi virus corona atau Covid19 ternyata salah.
• Yurianto menuturkan, masyarakat sempat kebingungan dengan pemakaian
istrilah New Normal saat pandemi memasuki bulan Mei dan Juni.
• Karena itu, pemerintah akhirnya memperbaiki pola komunikasi dengan
mengganti istilah New Normal dengan Adaptasi Kebiasaan Baru.
Not testing alone.
Not physical distancing alone.
Not contact tracing alone.
Not masks alone.
Do it all
Hypoxia is a condition in which the body or a region
of the body is deprived of adequate oxygen supply
at the tissue level.
Hypoxia may be classified as either generalized,
affecting the whole body, or local, affecting a region
of the body

Cyanosis refers to a bluish cast to the skin and mucous membranes.

Peripheral cyanosis is when there is a bluish discoloration to your
hands or feet. It's usually caused by low oxygen levels in the red
blood cells or problems getting oxygenated blood to your body

• Hypoxemia is defined as a decrease in the partial pressure of oxygen in

the blood whereas hypoxia is defined by reduced level of tissue
oxygenation. It can be due to either defective delivery or defective
utilization of oxygen by the tissues.
• Hypoxemia and hypoxia do not always coexist.
ARDS is an acute diffuse, inflammatory lung injury, leading to increased pulmonary vascular permeability, increased lung
weight, and loss of aerated lung tissue…[with] hypoxemia and bilateral radiographic opacities, associated with increased
venous admixture, increased physiological dead space and decreased lung compliance.
The P/F ratio is a quick calculation you can do that will give you some clues as to
whether your patient is A-OK pulmonary wise or heading toward ALI (acute lung
injury) or ARDS (acute respiratory distress syndrome).
Coronavirus disease 2019 (COVID-19) is a respiratory tract infection caused by a newly emergent coronavirus, SARS-
CoV-2, that was first recognized in Wuhan, China, in December 2019. Genetic sequencing of the virus suggests that
SARS-CoV-2 is a betacoronavirus closely linked to the SARS virus
While the majority of people with COVID-19
have uncomplicated or mild illness (81%), some will develop
severe illness requiring oxygen therapy (14%) and
approximately (5%) will require intensive care unit treatment.
Of those critically ill, most will require mechanical ventilation. The most
common diagnosis in severe COVID-19 patients is severe pneumonia.
Clinical syndromes associated with COVID-19
• Mild illness
• Patients with uncomplicated upper respiratory tract viral infection, may have non-
specific symptoms such as fever, fatigue, cough (with or without sputum
production), anorexia, malaise, muscle pain, sore throat, dyspnea, nasal congestion,
or headache. Rarely, patients may also present with diarrhea, nausea and vomiting .
• The elderly and immunosuppressed may present with atypical symptoms.
Symptoms due to physiologic adaptations of pregnancy or adverse pregnancy
events, such as e.g. dyspnea, fever, GI-symptoms or fatigue, may overlap with COVID-
19 symptoms.
• Pneumonia
• Adult with pneumonia but no signs of severe pneumonia and no need for
supplemental oxygen.
• Child with non-severe pneumonia who has cough or difficulty breathing + fast
breathing: fast breathing (in breaths/min): < 2 months: ≥ 60; 2–11 months: ≥ 50; 1–5
years: ≥ 40, and no signs of severe pneumonia.
Clinical syndromes associated with COVID-19
• Severe pneumonia
• Adolescent or adult: fever or suspected respiratory infection, plus one of:
respiratory rate > 30 breaths/min; severe respiratory distress; or SpO2 ≤ 93%
on room air.
• Child with cough or difficulty in breathing, plus at least one of the following:
• central cyanosis or SpO2 < 90%;
• severe respiratory distress (e.g. grunting, very severe chest indrawing); signs of
pneumonia with a general danger sign: inability to breastfeed or drink, lethargy or
unconsciousness, or convulsions .
• Other signs of pneumonia may be present: chest indrawing, fast breathing (in
breaths/min): < 2 months: ≥ 60; 2–11 months: ≥ 50; 1–5 years: ≥ 40 (16).
• While the diagnosis is made on clinical grounds; chest imaging may identify or exclude
some pulmonary complications.
 Clinical syndromes associated with COVID-19
Acute Respiratory Distress syndrome
• Onset: within 1 week of a known clinical insult or new or worsening respiratory
symptoms.
• Chest imaging (radiograph, CT scan, or lung ultrasound): bilateral opacities, not fully
explained by volume overload, lobar or lung collapse, or nodules.
• Origin of pulmonary infiltrates: respiratory failure not fully explained by cardiac failure
or fluid overload. Need objective assessment (e.g. echocardiography) to exclude
hydrostatic cause of infiltrates / edema if no risk factor present.
• Oxygenation impairment in adults:
• Mild ARDS: 200 mmHg < PaO2/FiO2a ≤ 300 mmHg (with PEEP or CPAP ≥ 5 cmH2O, or non-ventilated)
• Moderate ARDS: 100 mmHg < PaO2/FiO2 ≤ 200 mmHg (with PEEP ≥ 5 cmH2O, or non-ventilated)
• Severe ARDS: PaO2/FiO2 ≤ 100 mmHg (with PEEP ≥ 5 cmH2O, or non-ventilated)
• When PaO2 is not available, SpO2/FiO2 ≤ 315 suggests ARDS (including in non-ventilated patients).
 Clinical syndromes associated with COVID-19
• Sepsis
• Adults: life-threatening organ dysfunction caused by a dysregulated host response to
suspected or proven infection. Signs of organ dysfunction include:
• altered mental status,
• difficult or fast breathing,
• low oxygen saturation,
• reduced urine output,
• fast heart rate,
• weak pulse,
• cold extremities or
• low blood pressure,
• skin mottling, or
• laboratory evidence of coagulopathy, thrombocytopenia, acidosis, high lactate or hyperbilirubinemia.
• Children: suspected or proven infection and ≥ 2 aged based systemic inflammatory response
syndrome criteria, of which one must be abnormal temperature or white blood cell count.
 Clinical syndromes associated with COVID-19
• Septic shock
• Adults:
• persisting hypotension despite volume resuscitation, requiring vasopressors to maintain
MAP ≥ 65 mmHg and
• serum lactate level > 2 mmol/L.
• Children:
• any hypotension (SBP < 5th centile or > 2 SD below normal for age) or two or three of the
following: altered mental state; tachycardia or bradycardia (HR < 90 bpm or > 160 bpm in
infants and HR < 70 bpm or > 150 bpm in children); prolonged capillary refill (> 2 sec) or
feeble pulse; tachypnea; mottled or cool skin or petechial or purpuric rash; increased
lactate; oliguria; hyperthermia or hypothermia .
CONCLUSIONS
• In patients with nonhypercapnic acute hypoxemic respiratory failure,
treatment with high-flow oxygen, standard oxygen, or noninvasive
ventilation did not result in significantly different intubation rates.
• There was a significant difference in favor of high-flow oxygen in 90-
day m2ortality. (Funded by the Programme Hospitalier de Recherche
Clinique Interrégional 2010 of the French Ministry of Health; FLORALI
ClinicalTrials.gov number, NCT01320384.)3ww
• From February 2011 through April 2013, a total of 2506 patients with
acute hypoxemic respiratory failure were admitted to the 23
participating ICUs; 525 patients were eligible for inclusion in the
study, and 313 underwent randomization .
• After the secondary exclusion of 3 patients who withdrew consent,
310 patients were included in the analysis. A total of 94 patients were
assigned to standard oxygen therapy, 106 to high-flow oxygen
therapy, and 110 to noninvasive ventilation. The median interval
between randomization and the initiation of treatment was 60
minutes
Conclusions
Among extubated patients at low risk for reintubation, the use of high-flow nasal cannula oxygen compared with
conventional oxygen therapy reduced the risk of reintubation within 72 hours.
Heated and Humidified oxygen has a number of benefits compared to
standard oxygen therapy.
Standard oxygen therapy delivered through a nasal cannula or another
device such as a non-rebreather, is cold (not warmed) and dry (not
humidified). This can lead to airway inflammation, which can increase
airway resistance and impair mucociliary function possibly leading to
decrease secretion clearance .

Chidekel, A et al. The Effects of Gas Humidification with

High-Flow Nasal Cannula on Cultured Human Airway
Epithelial Cells. Pulmonary Medicine 2012.
PMID: 22988501
• One obvious benefit, but worth mentioning is that high flow can give
you a very high flow of gas.
• This is important as patients in acute respiratory failure can be
extremely tachypneic, and therefore their peak inspiratory flows,
which may normally be 30L/min – 60L/min, can reach up to 120
L/min.
• So if you place your tachypneic patient with PIF rate of 120L/min and
minute volume >20L/min on a 15L/min NRB mask, you may not be
helping them as much as you think. I am going to get into this point a
bit later on in this review when we discuss the concept of oxygen
dilution.
70 kg male breathing 30-40 bpm with normal tidal volumes (~500 mL’s) and develops some
hypoxemia.

This patient’s minute ventilation would be between 15-20 liters/minute. You decide to place
this patient on 6 liters/min NC which should theoretically deliver an fiO2 ~ 45% (6L x 4% = 24
+ Room Air (21%) = 45%) if the “1:4 rule” holds true.

If this patient is breathing 15-20L through his mouth and through the nares (around the nasal
cannula) at 21% then
do you believe that this patient will actually get 45% fiO2 delivered to the trachea?
Every increase by 1 LPM equates to a 4%
increase in FiO2, starting from 24%. This easy
rule of thumb gives you a safe estimate when
approximating your “effective FiO2” at home
based on your liter flow.
To deliver higher amounts of fiO2 effectively to your patient you have to not only match,
but exceed your patient minute ventilation and inspiratory demands to minimize oxygen
dilution.
Washout of Dead-space
• We normally rebreathe a third of our previously expired tidal volume and instead
of breathing 21% (room air) and negligible amounts of carbon dioxide; we may
rebreathe more like 15-16% oxygen and 5-6% carbon dioxide.
• This is because of previously exhaled breath (low in oxygen and with some carbon
dioxide) is not fully exhaled and remains in the upper airway.
• When you patient takes their next breath from atmospheric gas not all of that gas
enters the alveoli. In fact it’s a mix of the new atmospheric gas (21% 02, negligible
CO2) and their previously exhaled gas (<21% oxygen and some CO2).
• In patients with acute respiratory failure, the percentage of gas we rebreathe gets
larger, and as a result, we can rebreathe larger amounts of carbon dioxide as we
draw our breaths from a mixed reservoir from our upper airway. Another way to
say this is our dead-space increases with acute respiratory failure.
• One of the major benefits of HFNC (some argue it’s actually the main
benefit) is that it gives you a continuous flow of fresh gas at high flow
rates replacing or washing out the patient’s pharyngeal dead-space
(the old gas low in oxygen and high in CO2). Each breath that the
patient now re-breathes will be washed out of carbon dioxide and
replaced with oxygen rich gas improving breathing efficiency

Möller W et al. Nasal High Flow Clears Anatomical Dead

Space in Upper Airway Models. Journal of Applied
Physiology 2015). PMID: 25882385
A: upper airway tube model (TM) made from a sapphire tube and a sodium chloride (NaCl) nozzle
with a cannula inserted into the nozzle in front of the IR-heat radiation source (blackbody). Also
shown are the pressure ports and the pneumotachographs to monitor pressure and flow within
the tube and the cannula. The cannula flow rates [nasal high flow (NHF)] were delivered into the
nozzle at 15, 30, and 45 l/min.
B: an infrared absorption image (left) and a gamma camera image (right) show the filling stage of
the model with CO2 and 81mKr gas before air was flushed into the cannula. Anterior (TM1) and
posterior (TM2) ROIs were defined for data analysis.
 A: control demonstrates filling of the TM during the
expiration phase without NHF from a cannula. At the
beginning of inspiration all gas from the TM will be
rebreathed into the lungs.
B: NHF from the cannula purges the expired CO2-rich gas
from the model and replaces it with fresh air. This
results in a reduction of CO2 rebreathing. Breathing
through the model demonstrates that the replacement
of expired gas with air starts before the end of expiration
and that the static conditions used in the experiments
led to an underestimation of the speed of dead-space
clearance during respiration.

• Infrared absorption images of expiratory flow through a tube model (TM) of upper airways demonstrate rebreathing from dead space.
• The images show four stages of filling of the model with exhaled CO2 at
• (i) peak expiratory flow,
• (ii) expiratory flow 30 l/min,
• (iii) expiratory flow 15 l/min, and
• (iv) end of expiration.
High Flow Nasal Cannula Putative beneficial
mechanisms of high flow nasal cannula (HFNC) oxygen
therapy. EELV, end-expiratory lung volume; FiO2,
inspiratory oxygen fraction; Temp., temperature.

• Nasopharyngeal CO2 washout

• Decreased anatomical dead space
• Maintenance of mucociliary function
• Positive airway pressure
• Increased airway calibres
• Decreased hydrostatic capillary-alveolar gradient
Review 1: we synthesized results from randomized-controlled trials (RCTs) comparing HFNC to conventional oxygen therapy
(COT) in critically ill patients with acute hypoxemic respiratory failure.

Review 2: we narratively summarized findings from studies evaluating droplet dispersion, aerosol generation, or infection
transmission associated with HFNC. For both reviews
• Kotoda et al. conducted three simulations using fresh yeast (Sacchromyces
cerevisiae), evaluating dispersion with and without HFNC at 60 Lmin-1 in an
experimental mannequin model.
• Yeast dispersion was evaluated using 18 Petri dishes placed at 30-cm intervals
from the mannequin and four dishes placed 5 m away.
• Colonies were only detected in the closest dish with a mean (SD) of 2.3 (0.5)
colony forming units, and there was increased dispersion extending to two dishes
in front of and lateral to the mannequin with manual repositioning of the cannula
(P = 0.039). The investigators did not observe colony formation on the dishes 5 m
away from the mannequin.
• Leung et al. conducted a prospective study of 19 critically ill adults receiving COT
because of gram- negative bacterial pneumonia. They evaluated the degree of
environmental bacterial contamination with HFNC vs simple face mask oxygen.
The results show that high-flow nasal cannula use was not associated with increased air or contact surface
contamination by either Gram-negative bacteria or total bacteria, suggesting that additional infection
control measures are not required.
 shows no difference in GNB count
between the HFNC and OM use for air
samples, settle plates at 0.4 or 1.5 m,
and at six or at 12 ACH (P ¼
0.119e0.500).

Placement of settle plates around patients. At each sampling condition, Petri

dishes are placed 0.4 m and 1.5 m from the patient’s nose at the right,
centre, and left positions to evaluate the environmental surface bacterial
load.
 Modes of transmission

This section briefly describes possible modes of transmission for SARS-CoV-2, including
contact,
droplet,
airborne,
fomite,
fecal-oral,
bloodborne,
mother-to-child, and
animal-to-human transmission.
Infection with SARS-CoV-2 primarily causes respiratory illness ranging from mild disease to severe disease and death, and
some people infected with the virus never develop symptoms.
• Airborne transmission is defined as the spread of an infectious agent
caused by the dissemination of droplet nuclei (aerosols) that remain
infectious when suspended in air over long distances and time.
• Airborne transmission of SARS-CoV-2 can occur during medical
procedures that generate aerosols (“aerosol generating procedures”).
• WHO, together with the scientific community, has been actively
discussing and evaluating whether SARS-CoV-2 may also spread
through aerosols in the absence of aerosol generating procedures,
particularly in indoor settings with poor ventilation.
 Conclusions
• We found that HFNC applied to patients with respiratory failure may
substantially reduce the need for invasive ventilation and escalation of
therapy to NIV or intubation (low certainty), with no apparent effect on
mortality or patient-reported symptoms. Complications of therapy were
comparable to COT modalities.
• Very low certainty evidence showed uncertain findings with regards to
droplet dispersion and aerosol generation with HFNC. No direct evidence
applicable to COVID-19 was available for either efficacy or infection-related
risk.
• Taken together, the benefits of HFNC in the face of the COVID-19 pandemic
must be carefully balanced against the unknown risk of airborne
transmission of infection to healthcare workers and other patients.
Terima kasih semoga bermanfaat
Semoga badai CEPAT berlalu