nasal cpap vs high flow for endoscopy?

[stephenpatrickd]

Hi all,
Does anyone have thoughts on which machine would be better to buy for a gi suite that would have occasional large patients for endo/colon: nasal cpap vs high flow nasal oxygen?

For example, which of these two:

V60 ventilator - Respironics Hospital Ventilator | Philips

The Philips Respironics V60 ventilator is our gold standard hospital-dedicated ventilator which adapts to your patients’ ventilation needs.

www.usa.philips.com

Airvo™ 2 Nasal High Flow/HFNC System [2 - 60 L/min]

The Airvo 2 is a compact Nasal High Flow system (with an inbuilt flow generator) that delivers Optiflow™ NHF therapy across the hospital, from 2 - 60 L/min.

www.fphcare.com

Thanks!

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[GassYous]

I've never needed these. I use either nasal cannula or the pom mask.

 

[TheLoneWolf]

PoM NRB and blast the oxygen to 15 LPM for the BMI 50+ crew

 

[Bertelman]

We trialed Optiflow, should be coming to our hospital soon. I was pretty impressed. 2-3 minute pre-ox, basically maintained 100% sats through a standard induction with literally no bagging. Great for RSI or other aspiration risks.

Definitely helpful for our obese population with a scope down their esophagus.

 

[chessknt]

V60 is a fantastic and versatile vent for what it's worth. It can double as a high flow/avaps or even as a basic vent if you end up intubating all on the same machine.

 

[PpfSuxTube]

If someone is paying for this great but unless you are regularly doing orcas this is massive overkill... we have a high volume endoscopy cente at our hospital. never needed it. 6 rooms run every day with probably 15 to 18 cases per room. Nasal prongs is fine

 

[Bertelman]

There are proceduralists- either Cardiology or GI- that can make these cases difficult. Requiring too much sedation to pass the probe, taking 15 min to do the full exam, etc.

It’s not always about the patient.

 

[amyl]

We use nasal cpaps for lots of cases in gi but especially our pre gastric bypass egds. They’re a game changer. Get it on and breathing w positive pressure, bmi 65, big slug of propofol…. No problem

 

[Dynamis]

Oh interesting! Hadn't thought of nasal CPAP -- need to find out if my hospital has them and report back to you Impressed to see that it's not that hard to use, compared to the usual CPAP. It actually... looks pretty comfortable? Except could be annoying in the patient has a lot of hair.

I'm assuming you're in a small setting, but if you're part of a bigger hospital, you should see if there is one you can borrow on occasion. My current hospital always has some available.

As these other physicians with more experience hint, I think the positioning and technique matter more than anything in the ambulatory setting. Just look at the "no difference" outcome in this nasal cannula vs HFNC RCT.

High-flow versus standard nasal cannula in morbidly obese patients during colonoscopy: A prospective, randomized clinical trial - PubMed

At similar FiO₂, HFNC was not significantly different from SNC for prevention of arterial oxygen desaturation in morbidly obese patients undergoing propofol sedation for colonoscopy.

pubmed.ncbi.nlm.nih.gov

However, also +1 for POM masks, which I loved at my previous hospital. Never needed anything else beyond it.

The main scenario I find myself reaching for these tools nowadays would be for the sick inpatient in which I would like to avoid intubation. However, these are mainly the TEE patients that we also cover in our "GI suite" area.

 

[narcusprince]

Here we use the supernova. A nasal highflow mask that you can do cpap. Great for morbidly obese egds and colonoscopies and Tee.

 

[sakata8242]

We're a tertiary care center where we see a lot of orcas, and many of our proceduralists simply suck and regularly take forever to do a simple EGD.

We have both POM masks and HHFNC. When we first got HHFNC availability in the endoscopy suites it was love at first sight for a lot of the CRNAs. I just told them to try not think about what the patient's pCO2 likely was...

 

[Bertelman]

….but that number doesn’t appear in the record….

 

[BobLoblaw78]

We trialed Optiflow, should be coming to our hospital soon. I was pretty impressed. 2-3 minute pre-ox, basically maintained 100% sats through a standard induction with literally no bagging. Great for RSI or other aspiration risks.

Definitely helpful for our obese population with a scope down their esophagus.

So with Optiflow have you been happy? Do you just not monitor EtCO2? Have you found it to be worth the cost? What is the cost? I am trying to determine whether I want to take the leap. I am also considering SuperNova but I assume the cost is even more than optiflow.

 

[IDGARA]

I tried HFNC once, but didn't feel comfortable not having an ETCO2, so then went with the nasal CPAP. Nasal CPAP works great. But then I ran it by a partner who said, "Why the duck don't you just intubate them?" I stopped using nasal CPAP after that.

 

[kb1900]

I tried HFNC once, but didn't feel comfortable not having an ETCO2, so then went with the nasal CPAP. Nasal CPAP works great. But then I ran it by a partner who said, "Why the duck don't you just intubate them?" I stopped using nasal CPAP after that.

Why would that make any sense

Supernova you get end tidal, relieve obstruction and can be comfortable head away for bmi 50+ patients. Or can do the upper and “maybe a lower” case without instrumenting the airway. And you can do the entire case barely lifting a finger.


I intubate all the time in endo because we only do high risk advanced endo in our hospital but with good patient selection I think nasal cpap saves both time and risk. Avoiding intubating doses of meds for 15-20 minute procedures in obese and/or frail people is a major win

 

[woopedazz]

I don't get how nasal CPAP works if their mouth is held open by a bite block and scope...

Surely it's just (low-flow) nasal oxygen at that point...

Am I dumb?

 

[Arch Guillotti]

Why would that make any sense

Supernova you get end tidal, relieve obstruction and can be comfortable head away for bmi 50+ patients. Or can do the upper and “maybe a lower” case without instrumenting the airway. And you can do the entire case barely lifting a finger.


I intubate all the time in endo because we only do high risk advanced endo in our hospital but with good patient selection I think nasal cpap saves both time and risk. Avoiding intubating doses of meds for 15-20 minute procedures in obese and/or frail people is a major win

wtf is advanced endo?

 

[ProwlerturnGas]

wtf is advanced endo?

Colonoscopy through the oral route

 

[woopedazz]

wtf is advanced endo?

I laugh because it's true. It's just ERCPs, EUS, enteroscopies, stents and stuff.

 

[DocMcCoy]

I don't get how nasal CPAP works if their mouth is held open by a bite block and scope...

Surely it's just (low-flow) nasal oxygen at that point...

Am I dumb?

I wear a cpap at night tried a nasal appliance once and as a mouth breather it was almost useless. So it’s a valid question. I don’t understand the physiology either.

 

[kb1900]

wtf is advanced endo?

As far as I can tell just normal endo for people on deaths door or have already died at least once lol

 

[Bertelman]

So with Optiflow have you been happy? Do you just not monitor EtCO2? Have you found it to be worth the cost? What is the cost? I am trying to determine whether I want to take the leap. I am also considering SuperNova but I assume the cost is even more than optiflow.

Admittedly I don’t spend much time in those suites during the procedure. But we have one primary nurse who runs the CV/TEE area. She loves it. Uses it 1-2 a week, which for that room means about once every 15 patients.

I’d have to ask Endo about their usage.

Cost? Have no idea. I think the units are negligible, around 5k. Disposables aren’t terribly complicated. There is a humidifier that must be replaced, or maybe just refilled, q24. Fortunately, I work for a system that isn’t very concerned with that.

 

[Bertelman]

wtf is advanced endo?

Here’s a taste. We have fellows coming out talking about this.

They’ve come a long way from a scope with a camera that takes pictures. Which means we aren’t just seeing the 55 y/o with polyps. The patients come with the comorbidities associated with the indications.

Complex Interventional Endoscopy Procedures | Sutter Health

Sutter Health offers a variety of complex endoscopic procedures where interventional endoscopy specialists apply innovative techniques to perform intricate incisionless operations.

www.sutterhealth.org

 

[anaesthetic]

So with Optiflow have you been happy? Do you just not monitor EtCO2? Have you found it to be worth the cost? What is the cost? I am trying to determine whether I want to take the leap. I am also considering SuperNova but I assume the cost is even more than optiflow.

The ones we have have a connection for the EtCO2, although it works maybe 80% of the time and the waveform clearly loses some of the CO2 to the environment/mouth. That being said, we use it for the sick TEEs/EGDs that take forever due to fellows. We also have the SuperNova which works okay as well.

I tried HFNC once, but didn't feel comfortable not having an ETCO2, so then went with the nasal CPAP. Nasal CPAP works great. But then I ran it by a partner who said, "Why the duck don't you just intubate them?" I stopped using nasal CPAP after that.

Nasal CPAP works great when it works. Most difficult part is making a proper seal. Still can’t seem to get it down consistently. ETCO2 capture is inconsistent as well even though it has a port for it.

I don't get how nasal CPAP works if their mouth is held open by a bite block and scope...

Surely it's just (low-flow) nasal oxygen at that point...

Am I dumb?

You can see it working if you attach a Jackson-Rees circuit to the unit and watch the bag fill/provide CPAP. The seal and lack of consistent EtCO2 is a big flaw though, especially if you’re losing some through the mouth which is inevitable. I used to use it for the BMI 50+ EGDs. It works well if you can get a seal.

Admittedly I don’t spend much time in those suites during the procedure. But we have one primary nurse who runs the CV/TEE area. She loves it. Uses it 1-2 a week, which for that room means about once every 15 patients.

I’d have to ask Endo about their usage.

Cost? Have no idea. I think the units are negligible, around 5k. Disposables aren’t terribly complicated. There is a humidifier that must be replaced, or maybe just refilled, q24. Fortunately, I work for a system that isn’t very concerned with that.

We use the Optiflow for sick TEEs/EGDs who can’t tolerate prolonged hypoxia. It has a slot for the EtCO2 which works okay. I like it. There’s good data on apneic/passive oxygenation, and HFNC/Optiflow supposedly provides some CPAP as well although I don’t know how clinically relevant it is. Anecdotally, it works better than simple NC but usually unnecessary unless they’re sick. We’re a big tertiary center so do a lot of sick referrals and pre-/post- heart/lung transplants. Not sure about exact cost but have heard from the techs that it’s not too bad comparatively.

 

[operaman]

ENT here. - do a lot of tubeless endoscopic airway work for various kinds of laryngotracheal stenosis and find the high flow nasal cannula invaluable. In healthy non obese patients I can often get 30-45 minutes of apnea with having sats drop and having to use jet to bring them back up. The obese ones can be tougher, but even then they often go a long time before needing rescue. I rarely even have to mask anymore either at the beginning waiting for the roc to circulate or the end waiting for the wakeup - high flow wide open and a jaw thrust works almost all the time.

We never monitor ETCO2 because it just isn’t feasible or necessary for these airway cases. I use the clock knowing the number goes up about 1mmhg per minute with complete apnea. With such short cases it’s rarely an issue.

 

[Bertelman]

To be fair, our NORA glorified bedside monitors have an 80% success rate of monitoring CO2 on any case, regardless of O2 delivery device.