NEWSLETTER: ISSUE 4

Go with the flow

Leading respiratory specialists share their stories to help you deliver
better patient outcomes. To learn more about one of the worlds
fastest-growing respiratory therapies, visit www.myoptiflow.com today.

Optiflow results in
improved clinical outcomes
compared to venturi mask
post-extubation.
MAGGIORE ET AL. 2014

A two-centre Italian randomised controlled trial (RCT)

has recently been published in the American Journal of
Respiratory and Critical Care Medicine. Led by Doctor
Maggiore, researchers compared the efficacy of Optiflow
to the venturi mask in 105 patients post-extubation.
The primary study outcome was to comparethe effects of the two
therapies on arterial oxygen tension (PaO2) to set inspired oxygen
fraction (FiO2SET) ratio post-extubation. Secondary endpoints assessed
patient discomfort, adverse events, and clinical outcomes.
The Optiflow group showed:
Improved oxygenation (PaO2/FiO2SET ratio)
Significant reduction in the requirement for reintubation from 21 to
4% and for any other form of ventilatory support from 35% to 8%
Fewer desaturations and interface displacement
Improved comfort and airway dryness
Study powered for primary outcome

Introduction
After the discontinuation of invasive ventilatory support, oxygen
therapy is often used to help restore respiratory homeostasis.
The venturi mask and a range of other traditional oxygen delivery
devices all provide dry gas at flow rates which are frequently lower
than the patients inspiratory demand; resulting in the entrainment
of room air and a subsequent loss of accuracy of the prescribed
fraction of inspired oxygen (FiO2).
CONTINUED ON NEXT PAGE

OPTIFLOW
INTRODUCTION
EXPERIENCE
AN INTERVIEW WITH

Dr Isabel Gonzalez, Consultant

Critical Care & Anaesthesia and
NoECCN Medical Lead, The James
Cook University Hospital,
Middlesbrough, England.
In October 2013 the critical care unit at
James Cook University Hospital began
an Optiflow evaluation, led by Dr Isabel
Gonzalez. It included 22 new AIRVO 2
systems. Although the one-year evaluation
is only part way through, this interview
provides valuable insights into the
hospitals experience of introducing
Optiflow for all patients not ventilated
who required oxygen therapy.

Q
A

What problems and challenges

led you to introduce Optiflow?

We felt our reintubation rate was a little

on the high side and we were finding it
difficult to humidify patients oxygen therapy,
particularly on the wards. Through a recently
introduced critical care outreach programme,
we could see ward patients coming to the
critical care unit who probably would have
benefited from a little better oxygen therapy
management on the ward.
Although we had owned two Optiflow with
AIRVO systems for a couple of years, we
werent using them very often. That was simply
CONTINUED ON PAGE THREE

GO WITH THE FLOW | PAGE 2

Optiflow results in improved clinical outcomes

compared to venturi mask post-extubation.
MAGGIORE ET AL. 2014
CONTINUED FROM FRONT PAGE

Optiflow is able to deliver heated

and humidified gas at flow rates of
up to 60 L/min and oxygen
concentrations ranging from 21% to
100%; both of which can be titrated
independently of each other.
In contrast to many other oxygen
delivery devices, Optiflow is able to
match or exceed the patients peak
inspiratory demand, eliminating the
need for room air entrainment1.
In addition, there is increasing
evidence to suggest that the higher
flow rates provide anatomical dead
space washout2,3. This effectively
decreases the relative dead space in
the conducting airways by washing
out a proportion of the resident CO2
gas and replenishing with oxygen
enriched gas2,3.
The humidified gas that Optiflow
provides affords additional
therapeutic benefits. Humidification
has been shown to aid the clearance
of secretions and improve patient
comfort and hence tolerance of
oxygen therapy4,5. Improving
tolerance should promote therapy
compliance. A less well tolerated
delivery device is more likely to be
displaced by the patient causing
interruption to the therapy and
gives rise to potential desaturation
in arterial oxygen levels.

mechanistic and physiological

benefits associated with Optiflow
use. Based on this evidence,
Maggiore et al. hypothesised that
oxygen therapy delivered by
Optiflow, in patients post-extubation,
would prove efficacious when
compared to oxygen therapy
delivered by venturi mask.

Results
Patients in the Optiflow arm showed
significant improvement in patient
outcomes compared to venturi
mask group, all assessed up to
48 hours post-extubation, including:

The PaO2/FiO2SET ratio were

higher at all time points 24h
(p=0.03), 36h (p=0.0003),
and 48h (p=0.01)
Fewer patients required
re-intubation (p<0.01), or any
form of ventilatory support
(p<0.001)
Comfort related both to the
interface (p<0.05) and to
airways dryness (p0.01) was
significantly better
Fewer patients had interface
displacement (p=0.01), or
oxygen desaturation (p<0.001)

Why this trial?

How does this study help

clinicians and their patients?

To date, peer-reviewed evidence

has defined and described the

Supporting patients post-extubation

can be clinically challenging.

The primary aim is usually to provide

sufficient respiratory support until
respiratory stability is established,
negating the need for re-intubation.
Re-intubation is associated with an
increased risk of patient morbidity,
mortality and healthcare cost6.
The focus of this study was unique.
These results provide unprecedented
evidence regarding the efficacy of
Optiflow both in this setting and for
this patient group.

Next steps
This study has served as a pilot for
a larger multi-centre RCT led by
the same Principal Investigator
Dr. Maggiore. This multi-centre RCT
entitled Impact of nasal high-flow
vs venturi mask oxygen therapy on
weaning outcome: a multi-centre,
randomised, controlled trial,
is currently recruiting a target of
500 patients within four European
countries. See http://clinicaltrials.
gov/show/NCT02107183.

To view the abstract for the study, please visit: www.ncbi.nlm.nih.gov/pubmed/25003980

A webinar will be run to share a podcast on the study. For more details, please visit
https://attendee.gotowebinar.com/register/5378651814932364545 or education.fphcare.com.
REFERENCES:

1. Masclans J, Roca O. High-flow Oxygen Therapy in Acute Respiratory Failure. Clin Plum Med. 2012; 19 (3), 127-130.
2. Mndel T, Feng S, Tatkov S, Schneider H. Mechanisms of nasal high flow on ventilation during wakefulness and sleep. J Appl Physiol. 2013; 114: 1058-65.
3. Mller W, Feng S, Bartenstein P, Haussinger K, Eickelberg O, Schmid O, et al. Nasal High Flow Clears 81mKr-gas From Upper Airways In Healthy Volunteers. Am J Respir Crit Care Med. 187;
2013: A3098. [Abstract]
4. Hasani A, Chapman TH, McCool D, Smith RE, Dilworth JP, Agnew JE. Domiciliary humidification improves lung mucociliary clearance in patients with bronchiectasis. Chron Respir Dis.
2008; 5(2): 81-6.
5. Roca O, Riera J, Torres F, et al. High-flow oxygen therapy in acute respiratory failure. Respir Care. 2010; 55(4): 408-13.
6. Menon N, Joffe A, Deem S, Yanez D, Grabinsky A, Dagal A et al. Occurrence and Complications of Tracheal Reintubation in Critically Ill Adults. Respir Care. 2012; 57(10):155563.

GO WITH THE FLOW | PAGE 3

OPTIFLOW INTRODUCTION EXPERIENCE An interview with Dr Isabel Gonzalez

CONTINUED FROM FRONT PAGE

because there were only two units

so the nurses were unfamiliar with
them and therefore very reluctant
to use them.

Q
A

Where is Optiflow now

being used?

We started using it to give

patients who were on
noninvasive ventilation a break,
to allow them to eat or to get
physiotherapy.
The nurses saw that the patients
didnt need to go back onto
noninvasive therapy immediately
so the times off were prolonged
until they were basically weaned
off. That was quite a revelation for
the nurses.
We also started using Optiflow
more and more after extubation.
Initially it was reactive use but
became more elective as we saw
the benefits. Now, as the patient
extubates and they are coughing,
theres no de-oxygenation period.
Just recently a couple of my
colleagues and I began a small
observation trial using Optiflow to
minimise de-oxygenation during
intubation.
We have a spinal cord injury unit
here and on those patients we use
Optiflow electively from the moment
theyre admitted. These patients
need to lie flat in the bed and their
respiratory muscles do not work.
Were a major trauma centre so we
get plenty of trauma patients with
fractured ribs and so on. We use
Optiflow on those patients electively
as soon as we know they need
oxygen therapy. I think the comfort
and the advantage of using it this
way is obvious to the staff.
Our critical care outreach team have
extended the use of Optiflow onto
the wards. We designed a prescription
for ward nurses and very easy to
follow guidance. They only use
Optiflow with the back-up of the
critical care outreach team. Ward
nurses are always very reluctant to
use complicated equipment from
intensive care, but everybody has

found Optiflow so easy to use, easy to

set up and easy to clean and maintain.

from local hospitals interested in

hearing more about our experience.

The ward areas are asking for

Optiflow to be used more and
more. Nurses are keen to keep
their patients on it. There are
times when we all feel like
saying the patient is OK now,
so actually Im going to go
home! You know?

Weve only just started to collect data

so we can evaluate the use of the
Optiflow on the ward. But at this stage
I can tell you that patients who are
given Optiflow on the ward tend to
stay on the ward.

How did you ensure a

successful transition to
Optiflow?

When we started, we wrote a

first draft of guidance on how
to use it. This was based on the
literature and the experiences of
colleagues around the world.
We kept it localised to our intensive
care unit and started a very intense
two weeks of training for our 200
nurses, 16 consultants and around
20 trainees. With fantastic support
from Fisher & Paykel Healthcare,
particularly our local rep, we
successfully trained about 75%
of our nurses and doctors. Most of
the training was delivered bedside,
day and night, so our busy nurses
were not taken off the job.
The challenge was to get from nurses
who have never seen the equipment
to nurses using it as a standard of
care. This was only achieved because
the equipment was readily available,
they were familiar with it and they
were seeing the benefits.
After two weeks of education and
a four week initial evaluation,
we updated the guidance using
feedback from a group of willing
and enthusiastic people, including
nurses and patients.
As I mentioned earlier, our critical
care outreach nurses then took
Optiflow out onto the wards and
I think it has been very successful.
After that, the use of Optiflow
spread naturally through the
hospital. Weve also had enquiries

Are there plans to extend

the use of Optiflow further
at your hospital?

Our separate cardiothoracic

intensive care has borrowed
some of our Optiflow equipment.
Theyre doing their own trial now and
starting to use it more, especially
with their thoracic patients.
Our neuro high dependency
colleagues received quite a few of
our patients on Optiflow, so theyre
starting to use it more themselves.
The critical care outreach team is
using it more and more for immunosuppressed patients on the ward.
They dont want to transfer these
patients to the intensive care just for
humidification. Theyre better off being
managed in the ward side rooms,
rather than moved around the hospital.
The respiratory ward has also been
using Optiflow. And as I mentioned
earlier, the spinal cord injury unit and
trauma ward were very keen to use
it from early on and that is continuing.

What advice would you give

to other hospitals who are
considering introducing Optiflow?

I would say the main secret is to

keep the equipment, training
and education concentrated inside
one small area. Then once the staff
are trained, they know how to use it
and they can see the benefits, it just
expands and explodes from there.
We really valued the support of
Fisher & Paykel Healthcare. Without
that bedside training and collaboration
with our own nurse educators, it
wouldnt have been possible to train
75% of our nurses and doctors in just
two weeks.

Q
A

What are your

next steps?

After the evaluation has run for

a full year, well have sufficient
data to determine the extent of
Optiflows effect on things like
decreased length of stay, decreased
re-intubation rate and subsequent
cost savings. Were certainly looking
forward to seeing that.

About the hospital

James Cook University Hospital provides a wide range of district general hospital services and specialist services including neurosciences,
renal medicine, spinal injuries, major trauma, cardiothoracic, vascular surgery and cancer services. All specialties are delivered from one site.
The hospital includes a 32-bed critical care unit, with 16 beds for ventilated patients and 16 for high-dependency patients.

GO WITH THE FLOW | PAGE 4

Introducing Ben Carlson-Oakes

BSc, BA, Territory Manager, Northeast England
From Great Britain triathlon
representative to advanced
respiratory care
Bens role is to provide exceptional
customer service. In addition to
ongoing product support, this
frequently includes conference
seminars, product demonstrations
and in-service training for the wide
range of medical professionals
involved in respiratory care. He also
provides full setup support and
training to ensure continuity of care
for patients and caregivers at
hospitals undertaking Optiflow
evaluations.
Armed with a degree in 3D design,
Ben established a career in the
furniture industry before his love of
triathlon led him to respiratory
physiotherapy. After completing
professional training and qualifications,
Ben worked as a senior respiratory
physiotherapist in critical care at
James Cook University Hospital in
Middlesbrough. He joined the UK
Fisher & Paykel Healthcare team at
the beginning of 2013 as the territory
manager for Northeast England.

185048334 REV A 2014 Fisher & Paykel Healthcare Limited

Ben grew up in Darlington, Northeast

England which is a particularly scenic
part of the world. Driven by a love of
fitness, and in particular cycling, Ben
went on to represent Great Britain in
triathlon at two world championships;
one in France and the other in Spain.

Communication and flexibility

the key to helping clinicians
Ben was raised on the importance of
being respectful and remembering
that manners cost nothing. Its a
simple set of values that has given
him a natural empathy for others.
Having worked in a medical role
within the NHS, Ben knows the
importance of understanding the
unique challenges a hospital is facing

before succinctly explaining how

Optiflow or other Fisher & Paykel
Healthcare products could help. Hes
also well aware of the pressures
clinicians face and the unpredictable
nature of their work.
Whether Im talking with doctors,
nurses or hospital administrators I try
to look at things from their perspective
to understand what is important to
them and their patients, explains Ben.
And while I might plan my diary
weeks and months in advance, for
my customers a staffing or patient
crisis can completely change their
day within seconds. I understand the
strains theyre under and I do my best
to be as accommodating as possible
with their training and support.

Helping people deliver better

outcomes for countless patients
For Ben, the successful completion
of an extensive Optiflow trial at
James Cook University Hospital was
a personal highlight.

It was the culmination of

about four months careful
preparation at a big hospital
thats now buzzing with
the use of Optiflow.
Within a short time several hospital
trusts across the UK had already
heard about the trial. They were
asking about what took place and
wanting to install Optiflow in their
own critical care areas.
Its great to see the use of Optiflow
steadily increasing as more and more
medical professionals discover its
ability to deliver better patient
outcomes, explains Ben.
Ben has noticed that many clinicians
dont realise how simple the therapy
is and how easy Optiflow is to use.
He says nurses, with their busy
workloads, are naturally concerned

a new device will require a lot of

training and work on their part.
Once you complete the training with
them, they soon realise its easy to
set up, easy for the patients to use
and the patients compliance is much
better, which ultimately makes the
nurses job easier. They just love it
after that and they totally embrace
the therapy, explains Ben.

The support of a trusted company

For Ben, the transition from a medical
role as a senior respiratory physiotherapist in the ICU to a sales role
seemed a little daunting at first.
But hes quick to point out he hadnt
realised the level of support and
collaboration Fisher & Paykel
Healthcare would provide.
I was met with staff who were
immediately in tune, even though
they worked in different areas of the
company. Their willingness to put
themselves out and provide support
really helped me relax and become
part of the team. Its an all-in
approach that exists throughout the
company and extends to the way we
support customers, explains Ben.

Back home in Darlington and

still pulling on the Lycra
After living in various places around
the UK, including a stint in London,
Ben has returned to where he grew up.
Its mainly about the scenic cycling,
although these days he says the
surrounding hills are getting steeper
with every ride. More recently, Ben has
taken to writing articles, several of
which have already been published.

Fisher & Paykel Healthcare

employs reps just like Ben all
over the world. To speak to
your local Fisher & Paykel
Healthcare representative,
please visit www.fphcare.com.

To request further information, please contact your local

F&P Healthcare provider. See our website for more details.
Alternatively you can contact us by email at info@myoptiflow.com

www.myoptiflow.com

Disclaimer: Any clinical opinions in this newsletter are the opinions of the contributing authors and are given for
information purposes only. The clinical opinions are not intended as and do not substitute medical advice.