High Flow Nasal Cannula Because of a Gurner
But let's talk about Gurning first. I met my first Gurner and likely be the champion of the world if she could consent to it and show up at Egremont Crab Fair in England.
The Crab Fair was first held in 1267. It is believed that the traditional fair has been held continuously since this time, except for unavoidable interruptions during the War years. The Lord of Egremont started a tradition of giving away crab apples, from where the fair gets its name. The tradition continues to this day with the Parade of the Apple Cart, where apples are thrown to the crowds which throng the Main Street. The modern day fair commences with a number of sporting events. Cumberland wrestling, an ancient and traditional lakeland sport, features prominently. The rest of the day's amusements include the celebrated World Gurning Championship where contestants pull ugly faces through a horse collar or 'braffin', a pipe smoking event and the singing of hunting songs.
See link below:
I wouldnt have thought of Gurning until I saw my patient
Desating to low 80% and brought into the resuscitatiaton room. Pt was edentulous and aphasic but fully awake. Pt noted to a have a lax jaw with mobility demonstrated with the lower lip riding high and covering the nares of her nose. Hx of severe CVA that left her bedbound and aphasic. Daughter at ed bedside says this dyspnea has happened before. She noted we had considered NIV with a facemask apparatus but she definitely based on her small face would be small, but No part of facial orifices were open to open air. She coughed a little and then would on her own lower her jaw and uncover her nose. CXR noted new right upper lobe infiltrate. pt with elevated wbc. and fever. I sure heck didnt want to intubate this lady who can't speak to me or make her wishes known. Her daughter loves her a lot and wants her Full Code of course. Daughter mentioned at the other hospital, they used High Flow... I had only heard of this with use in the pediatric population whose faces are too small for standard NIV facemasks. I had some memory of podcasts by Dr. Weingart
So we called our respiratory therapist and she brought this machine by Fisher & Paykal, and the daughter smiled so hard, and said, "High flow." She was happy. Saying that machine saved her mother's life before. It was placed on her mother's face. Sats shot up to 97%. Pt couldn't smile, but couldn't cover the nose with her lower lip. She could still DAB her lower lip on the nasal cannula apparatus. I didnt care. The daughter was happy. I had one less patient to intubate and she didn't tire out which was my other fear.
I figure to read more about the great things and limitations of this HIGH FLOW NASAL CANNULA APPARATUS. Possible use in promoting apneic oxygenation before intubation. Possibly using it as part of my Delayed Sequence Intubation arsenal. Or just patients who can't tolerate the discomfort of CPAP or Bipap NIV. This device is not perfect.
I learned from Lead Respiratory Therapist at New York Presbyterian Queens, Joseph Mathew. Thank you Sir for spending time with me and my Greek Fellow Effie Polyzogopoulou and educating me on this apparatus.
ADVANTAGE: Air entrained from the atmosphere is Warmed and Humidified. One can talk and eat with it on. And it does provide some Positive End Expiratory Pressure (PEEP) to recruit more alveoli to open and stay open.
The cannulas come in Small, Medium, Large with respect to the size of the cannulas to the nares they will be placed in. The patient needs to be allowed some leak, some way to breathing in and out from their own noses still. Some nares are humongous like KRS-One of Boogie Down Productions. Would have needed a large of course.
DISADVANTAGE: Required a lot of oxygen. Great for hospitals with a seemingly endless supply of oxygen via the wall or canisters, but not great for pre-hospital EMS who only have 1 or 2 oxygen tanks with them. The oxygen at 50 to 60 liters per minute will use up the tanks so fast.
Not all patients will tolerate this device.