Approaching to High Flow Oxygen Therapy Concepts: Venturi Mask Vshigh Flow Nasal Cannula-Juniper Publishers

 

Juniper Publishers- Open Access Journal of Case Studies

 

Approaching to High Flow Oxygen Therapy Concepts: Venturi Mask Vshigh Flow Nasal Cannula

Authored by Díaz Lobato S

Opinion

Oxygen therapy is the main supportive treatment in hypoxemic respiratory failure and has traditionally been delivered using low and high flow devices. However, the maximal flow rates that these devices can deliver are limited because of the insufficient heat and humidity provided to the gas administered. Low flow devices such as the nasal cannula, conventional face mask and reservoir bag deliver a flow rate of up to 15L/min by administering more variable oxygen fractions (FiO2), depending on the patient’s respiratory pattern, peak inspiratory flow and characteristics of the devices. Conventional high flow devices, such as venturi type masks, utilize a constant flow of oxygen through precisely sized ports, entraining the ambient air, using the Bernoulli principle, providing a more constant inspired oxygen fraction. However, they are less tolerated than nasal cannulas because they are less comfortable and the insufficient humidification and heating of the gas delivered [1].

In the last two decades, new devices have been developed to administer high humidified and heated flow through a nasal cannula (HFNC) that also allows the delivery of oxygen with a known FiO2 up to 100%. In the literature, this technique has also been called mini CPAP (continuous positive airway pressure), transnasal insufflations, high nasal flow ventilation, high flow oxygen therapy, and high flow nasal cannula oxygen therapy [2].

It is considered that high flow nasal cannula has certain benefits compared to those of oxygen therapy previously detailed. HFNC manages a flow of more than 30L/min, which is able to surpass the peak inspiratory flow of the patient, being able to reach values between 60-80L/min depending on the flow used. The gas source, which may be delivered by an air/oxygen blender, fans, or a flow generating turbine, is connected by an active humidifier to a nasal cannula and the FiO2 can be adjusted independently of the flow.

From a clinical point of view, there is some confusion between venturi and high flow nasal cannula devices. In the literature, both have been considered as high flow oxygen therapy devices. In our opinion this is not appropriate because the high nasal cannula flow is much more than a simple system for administering oxygen therapy [3]. Venturi-type masks provide the patient with a gas mixture with a controlled FiO2, but do not exert additional benefits on the ventilator mechanics of the patient. Nevertheless, HFNC allows the delivery of a high flow, which can also add oxygen therapy, providing a series of physiological effects that imply an active treatment to respiratory failure.

Effects related to HFNC include the following

1. Delivery of higher and more stable FiO2 values, because the flow delivered is greater than the patient’s inspiratory demand.
2. The anatomical dead space decreases by washing the nasopharynx, consequently increases alveolar ventilation. This improves the thoracoabdominal synchrony.
3. Respiratory work decreases because it acts as a mechanical stent in the airway and markedly attenuates inspiratory resistance.
4. The gas administered is warmed and humidified, improving mucociliar clearance, reducing the risk of atelectasis, improving ventilation perfusion and oxygenation ratio.
5. There is a CPAP-like effect. The dynamic positive respiratory airway pressure generated by HFNC reaches a value between 6-8cm H2o depending on the flow and the size of the cannula. This positive pressure distends the lungs and ensures their recruitment.
6. Pulmonary end-expiratory volume is higher with HFCN than with conventional high-flow oxygen therapy.
7. In addition, the technique is considered easy and simple for the medical staff and nurses, and can be used in different areas (emergency, hospitalization, critical care unit, weaning centers) and even at home [4].

Currently available evidence has demonstrated that HFNC therapy is an alternative for the treatment of acute hypoxemic respiratory failure, hypercapnic respiratory failure, acute heart failure, as rescue therapy preventive therapy in postextubation respiratory failure and in specific conditions such as bronchoscopy [5].

We believe that high-flow nasal cannula treatment should not be confused with high flow oxygen therapy of venturi masks. According to detailed mechanisms of action, HFNC is not limited to being only an oxygen therapy system but also behaves as a true treatment that can be used in different clinical scenarios, generating physiological benefits that result in the reduction of respiratory work. In addition, in venturi type masks, the air is not humidified and complications such as dryness and nasal pain are common, generating a poor tolerance to oxygen therapy. The benefits of proper humidification and heating of the gas delivered with HFNC therapy allows better comfort and tolerance of the patient with easy adherence to the treatment. All this contributes to making HFNC be considered a technique of choice in patients with hypoxemic respiratory failure. The growth in its use associated with easy acceptance for patients and the expansion in its application show us that HFNC is a promising therapy.

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Did Primary Health Care Doctors Lose the Battle with the Specialist and Consultants?-Juniper Publishers

Juniper Publishers- Open Access Journal of Case Studies

Did Primary Health Care Doctors Lose the Battle with the Specialist and Consultants?

Authored by Manal Ali Ghandour

Opinion

Many organizations claim to be “Primary Healthcare (PHC) focused” and working on preventive measures and strategies. However, when you look to the number of initiatives or projects planned for preventive medicine (PM) and (PHC) in comparison to secondary and Tertiary care initiatives & projects, you will notice that Secondary and Tertiary care are getting up to 70% of the budget or more; thus in some places, one hospital will be a located a budget equal to 100 facilities working in preventive medicine and primary health care. Therefore, unless we see a strategic shift in the budget allocation and that (PM) and (PHC) sectors are allocated 60% or more of the budget, then I cannot believe that the Healthcare System is “Primary Healthcare &Preventive Medicine focused” [1].

On the grounds, Primary Healthcare Doctors (PHDs) had lost the battle with specialists and consultants due to different set ups and regulations that results in giving more support and gratitude to the specialist and the consultant while the PHDs get only struggles and I will explain why. There are four perspectives that support the specialists and consultants and make them well equipped with knowledge and environmental factors while making GPs and alike doctors struggle.

The first perspective is, the scope of practice: GP is required to know everything. While the specialist or Consultants (Spec & Cons) are more in depth prepared to deal with a system or two or one organ. So if Spec & Cons Can reaches mastery after having 10,000 hours practice in one subject, GPs reach nowhere for the same number of hours, e.g. they will not become specialist or consultant in certain field [2].

Also, from the Environmental perspective: Spec. & Cons. are given more equipment, can do sophisticated procedures and allowed to request all types of investigations. Also they are provided with specialized intelligent EMR and reasonable appointment time and referrals. In short, Spec. & Cons. are prepared to succeed, while GPs are provided with basic equipment, basic health record system that is broad and has no sense of intelligence. Also they are booked with many patients for very short time of consultation ranging between 7 to 20 minutes. When GP refers a patient, the patient is treated with least priority and thus booked the last on the Specialist or Consultant’s list. Thus GPs are prone for failure and poor outcomes.

Moreover, to be Licensed to Practicee.g in Dubai Healthcare City; GPs should have two years’ experience, and one year internship, while Specialist should have 2-5 years’ experience and 3years of residency or more. So on minimal level GP with 3 years of proper practice will be competing with Specialist who has 5 years of experience.

Looking into continuing education perspective, the GP needs to keep abreast with very huge knowledge, as one new disease will be discovered in every year (at least) and many drugs are added on yearly bases that he should know. For example, 22 new drugs were approved in 2016 by USA FDA alone and there are many countries who are introducing new medications every year. Lastly GPs are rarely involved in any researches or get any sort of feedback on their services. On the other hand, Specialists rarely encounter discovering a new disease or get 1-2 new drugs released per year. They get different feedbacks from incident reports, pharmacists, researches and audits. So they are helped for internal and external continuous improvements [3].

Hence, as a Patient, if you had the choice where will you go for treatment? Definitely patients prefer to go to consultants and specialists due to all reasons mentioned before. The consultants and specialists are equipped with many success factors, specially speed of appointment, investigations, diagnosis and treatment.

So what solutions we can adapt to improve GP practice? There are many solutions that can be used individually or consequently or all together:

1. Provide EMR systems that classify cases rather than taking them as general cases (chest case, heart case, asthma sheet, pediatric sheet etc.
2. Impede dictionaries and guidelines in HIS systems, use intelligent differential diagnosis, free lab and radiology access, and add quality checks and auditing to the work processes.
3. Consultant and Specialist are required to have 80CME hours to keep on top of their profession and get renewal of license. GPs should be offered at least, 160CME from their practice hours to keep up to date with medical and technology advances [4].
4. Segregate GPs into specialties, meaning each doctor gets more cases on certain problems as if he is going to specialize; so we need to have Asthma GP, Heart Problems GP and Diabetes GP. In addition to the general cases they see, they will be able to focus and follow up on certain cases with higher degree of effectiveness and will work closely with one type of specialty and make referral easy and get proper feedback [5].
5. Involve them into more research and case studies building.

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Updated Epidemiology COVID-19 in Gansu Province, China-Juniper Publishers

Juniper Publishers- Open Access Journal of Case Studies

Updated Epidemiology COVID-19 in Gansu Province, China

Authored by Shisan Bao

Abstract

The outbreak of COVID-19 became a pandemic around the world with huge morbidity and high mortality. Gansu Province is in a remote region in northwest China with a population of 26.4 million within its area of 425,900km2, but the population density in the CBD of the capital city, Lanzhou, is even bigger than Beijing. The geographic importance of Gansu is due to being a key transportation hub connecting to five provinces in northwest China. Fortunately, only a total of 92 indigenous COVID-19 cases are confirmed in Gansu till now, including both primary and secondary patients, which is considered to be a consequence of the strict screening approach applied in Gansu during the period of outbreak. Consequently, the emergency response measures to COVID-19 were able to be decreased from level 1 (top) to level III (low). Furthermore, there are some reverse transmission cases from other countries during March 2019. There were 37 confirmed COVID-19 infections among 311 evacuated Chinese from Iran. Gansu authorities undertook full preparation in advance, involving high level, streamlined cooperation between the transportation department, quarantine department and medical resource department. In addition to these organized returnees from Iran, 10 COVID-19 patients were confirmed amongst independent travellers from abroad, who unfortunately were able to scatter within the community, causing a significant potential risk to spread COVID-19. These data highlight the need for an exceptionally high level of vigilance and for a pre-emptive response, to prevent reverse infection occurring within a community where the pandemic had been successfully controlled.

Keywords: COVID-19 outbreak; SARS-CoV-2; Asymptomatic cases; Imported cases

Abbreviations: COVID-19: Coronavirus Disease 2019; SARS-CoV-2: Severe Acute Respiratory Syndrome Coronavirus 2; QR code: Quick Response Code

Introduction

SARS-CoV-2 is a new virus responsible for the outbreak of COVID-19, which has been transmitted to almost every country around the world within two months since it was first identified in Wuhan, Hubei Province, China in December of 2019 [1]. Globally, 210 countries and territories have reported a total of 2,259,001 confirmed cases of COVID-19, and a death toll of 154,390 deaths up till 18 April 2020 [2]. Additional confirmed cases are being identified internationally at a rapidly growing rate.

Although Gansu Province is located in a rather remote region in China, geographically Gansu is a key transportation hub connecting to five provinces in northwest China. Furthermore, Gansu has complex terrain with mountains, plateaus, plains, and the Gobi desert [3]. The population of Gansu is 26.4 million, residing within its area of 425,900km2 [4]. Interestingly, the population density is relatively low in Gansu, however, the population density in the Central Business District of Lanzhou (Capital of Gansu) is ～50,000/km2, which is more than many of the highly dense cities in China, such as Beijing and Shanghai [5], due to its location within a narrow river valley. Gansu is about 1400km from Wuhan, the pandemic epicentre within China, consequently it has been relatively less affected by COVID-19. However, the complex geographical factors mentioned above have the potential to increase the risk of COVID-19 spread and the difficulty of prevention and control.

Discussion

Since the first case of COVID-19 diagnosed on 23 January 2020 in Gansu Province, there have been in total 92 indigenous confirmed cases in Gansu till now (18 April 2020) [6]. During the early phase of the epidemic the patients were mainly primary patients, who had travelled from COVID-19 epidemic areas, but in the second phase the patients were mainly secondary patients who had never left Gansu Province but were infected by the primary patients [7]. The relatively small number of COVID-19 cases in Gansu is probably due to the strict screening approach during the period of the outbreak, which has largely come under controlled [8], mainly as a consequence of the implementation of a series of measures, including mandatory wearing of facemasks, and extremely strict limitations on outdoor and group activities, particularly mandating almost no public and/or private social gatherings [9]. As a consequence of this largely successful containment strategy, the emergency response measures to COVID-19 were decreased from level 1 (top) to level III (low) on 2nd March 2020, because there had been no new confirmed COVID-19 case for 16 consecutive days [10]. These data provide a clear example of the critical impact of incoming travelers, mostly asymptomatic at the time of travel, initiating the local epidemic within a discrete and geographically defined population, and the effectiveness of a robust containment strategy when rigorously applied within that population.

As the epidemic progressively came under controlled in China, alarmingly rapid spread of the virus occurred within Italy and Iran [11]. In order to seek shelter from the risk of exposure to the SARSCoV2 virus and to ensure access to adequate medical resources, overseas Chinese sought to return to China from these and similar high-risk regions. As the designated province for receiving evacuees by the Chinese authority, 311 evacuated Chinese citizens from Iran were sent to Lanzhou, using two charter planes [12], and shortly after arrival 37 evacuees were confirmed to have a COVID-19 infection [13]. Local Gansu authorities undertook full preparation in advance for the evacuation, involving high level, streamlined cooperation between the transportation department, quarantine department and medical resource department, to make sure these people would not contact any others and would be effectively quarantined within designated hotels, to isolate for 14 days. However, in addition to these organized returnees from Iran, 10 COVID-19 patients were confirmed amongst independent travelers from abroad, including oversea students, general travelers, and business workers [14]. Unfortunately, many of these infected returnees were able to scatter within the community without being quarantined, which caused a significant potential risk to spread COVID-19. The failure to quarantine many of these returnees was largely due to their early return, when the epidemic was not considered to be serious outside of China, or in some cases, they were exhibited an asymptomatic infection [15]. These data highlight the need for an exceptionally high level of vigilance and the need for a pre-emptive response, to prevent reverse infection occurring within a community where the pandemic had been successfully controlled, from returnees from other international locations, where the extent of infection at those distant sites had not yet been fully realized.

After many weeks of the lockdown all over China, especially in Hubei Province, the Chinese government has launched a health QR code system on the smartphone to keep the virus from further spreading, as China eases the lockdown allowing residents to restart normal activities, e.g. working and studying [16]. The green code means individuals are ok to participate these activities without risk of infection. However, it has been noticed that one asymptomatic person with a green code from Hubei Province was subsequently confirmed as a COVID-19-infected patient in a hospital in Lanzhou on 28 March 2020 [17]. Furthermore, other asymptomatic cases in other regions are constantly being reported. A recent report has shown that there is no difference in the secondary infection rate within the population following exposure to confirmed cases exhibiting symptoms compared to asymptomatic cases [18]. Consequently, the Chinese government has urged responsible authorities to focus on detection of asymptomatic cases and authorities have begun to report asymptomatic cases from 1st April 2020 [19]. In an attempt to address the issue of asymptomatic carriers, Australia has proposed a system of sentinel testing of people, where random, but potentially risky, individuals will be tested irrespective of having any symptoms. The aims of this measure will be, firstly, to attempt to gauge the extent of asymptomatic carriers, and secondly, to attempt to detect infection clusters before any symptomatic individuals develop symptoms, to then guide targeted testing amongst the contacts of that sentinel individual [20]. A good example of this approach from Australia would be to test several sentinel staff members from every aged care facility, irrespective of symptoms. Clearly, if a sentinel staff member is determined to be an asymptomatic carrier, authorities would then target testing and robust quarantine within the affected aged care facility.

The most important task for the Chinese authorities is to identify these potential COVID-19 risk populations, including local residents and/or overseas returnees, using a more sensitive diagnostic approach and probably also to offer some more flexible quarantine locations to deal with people who have been determined to be within an infection cluster. These data highlight the substantial difficulties associated with the detection of, and the disastrous potential for spread from, asymptomatic carriers.

Conclusion

In conclusion, COVID-19 is has been well controlled within the defined population of Gansu Province of China, which represents an interesting case study of epidemic spread and the effectiveness of a range of responses to that spread. However, continuing robust vigilance, combined with aggressive control measures remains essential, particularly in relation to documented cases of reverse transmission from returning overseas Chinese citizens and other travelers, and/or asymptomatic SARS-CoV-2 virus carriers, who should be taken care of rigorously to ensure the final complete success of pandemic containment to preventing second outbreak of COVID-19.

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