FreeO2

Automatisation de l’administration d’Oxygène aux Urgences

Prescription, surveillance et triagePr Erwan L’HER, LATIM INSERM UMR 1101, Brest

Automatisation de l’administration d’Oxygène aux Urgences Prescription, surveillance et triage

LIENS D’INTERET

Co-fondateur et consultant pour la société Oxynov Inc. ,

spin-off de l’Université Laval, Qc, Canada (FreeO2)

Consultant pour GE Healthcare, Sedana, Smiths Medical

Eviter l’hypoxémie !

Oxygen is the metabolic fuel ! For all patients, adults, childs, pregnancy, …etc…

• SCA: Vasoconstriction coronaire • TC: Réduction du débit sanguin cérébral • Nouveaux Nés: Lésions rétiniennes • BPCO: Aggravation de l’hypercapnie

Eviter l’Hyperoxie

SpO2 target 94-98%

SpO2 target 97-100%

ICU Mortality = 11.6%

ICU Mortality = 20.2%

Girardis JAMA 2016

PaO2 mediane = 87 mmHg

PaO2 mediane = 102 mmHg

RCT 434 patients ventilés

Hyperoxia

ROS

Decrease in [NO]

Vasoconstriction

OXYDATIVE STRESS & VASOCONSTRICTION

Membran lesions DNA Fragmentation Apoptosis Inflammation Lipid oxydation...

Ganz Circulation 1972, Frobert CU 2004, Bak AP 2007, McNulthy Am J Physiol Heart Circ Physiol 2005, Farquhar AHJ 2009, Cabello Cochrane 2013, Stub Circulation 2015, Fonnes Int J Cardiol 2016

Johnson BJA 2003, Floyd JAP 2003, Floyd, Journal of Cardiothoracic Anesthesia 2007, Ronning Stroke 1999, Rincon Crit Care Med 2014, Rincon J Neurol Neurosurg Psy 2014, Brenner Arch Surgery 2012

Kilgannon JAMA 2010, Bellomo Crit Care 2011, Janz Crit Care Med 2012, Ihle Crit Care Rescus 2013, Nelskyla Scan J Trauma Resusc Emerg Med 2013, Lee Am J Emerg Med 2014

Hyperoxia ↘ cardiac output (10-15%) ↘ coronary flow (20-30%) ↗ coronary resistances, vasoconstriction ↗ cardiac enzymes ↗ infarctus size (+35%) ↗ peri-operative infarctus (2.2 vs.0.9%) ↘ cerebral blood flow (20-30%) ↗ mortality (stroke, TBI) ↗ mortality (post cardiac arrest)

18 patients (stable coronary disease)

Room Air 15’

100% 15’

Coronary Blood Flow (cm3/min)

45 32

Coronary vascular resistances (mmHg/(min/cm3))

2.2 3.1PaO2

(mmHg) 73 273SaO2

(%)93 100

Hyperoxia in patients with stroke

Minimal SpO2 ! 92 % (ICU) or 88% (ARDS) Jubran Crit Care 2015

! 94 % (all patients except COPD) O’Driscoll Thorax 2017 ! 88% (COPD) O’Driscoll Thorax 2017

Maximal SpO2 (under additional oxygen) ! 96-98 % (ICU) or 92% (ARDS)

! 98 % (all patients except COPD) O’Driscoll Thorax 2017 ! 92% (COPD) O’Driscoll Thorax 2017

Résumé des recommandations

www.ncepod.org.uk

Initial management Oxygen therapy is the #1 treatment in the acute care

88-92 in 28.6% Below 88 in 24.4%

Above 92 in 47%

www.ncepod.org.uk

Initial managementOxygen

Audit #1 June-August 2009

102 patients

Audit #2 October 2009-February 2010

102 patients

Audit #3 February-May 2014

72 patients

INTERVENTION September 2009

Présentations Working groups

Protocols Stickers….

Pas ou peu d’innovation dans le

domaine de l’oxygénothérapie…..

Utilisation en médecine depuis plus de 100 ans ! Maximillien Neu: 1ère publication sur l’utilisation du rotamètre = 1910

Le débitmètre à bille est une technologie de la fin du XIXème siècle

Currently:Oxygen flowrate

setting

+Oxygen flowmeter

Constant Oxygen flowrate

Manual adjustements

Oxymeter

Variable SpO2

Variable oxygen Automated titration and weaning

Every second to maintain the target SpO2

Constant SpO2

Monitoring: SpO2 O2 flowrate

RR HR Trends

Future: with FreeO2

The clinician set the SpO2 target +

East TD, Respiratory Care 1992Computers in ICU: panacea or plague ?

Les craintes de l’automatisation …

COMPUTER-ASSISTED

COMPUTER-ASSISTED

COMPUTER-ASSISTED

COMPUTER-ASSISTED

COMPUTERS MAY BE HELPFUL !

Inclusion criteria: ED admission for acute respiratory distress requiring O2≥3L/min Exclusion criteria : O2≥15 L/min, urgent mechanical ventilation support(invasive or NIV) Randomisation: FreeO2 or manual adjustment of O2 during 3 hours In both groups, SpO2 was continuously recorded by the same oximeter (Nonin technology)

Primary outcome: % of time in the SpO2 target:

88-92% (hypercapnic patients) 92-96% (hypoxemic patients)

L’Her et al. ERJ 2017Grants: PHRC National FreeO2 Hypox (France), MDEIE (Québec)

RESULTS Oxygenation

L’Her et al. European Respiratory Journal 2017

> 96% du temps dans cible si exclusion temps sans O2

RESULTS Oxygenation

L’Her et al. European Respiratory Journal 2017

L’Her et al. European Respiratory Journal 2017

% o

f pao

ents

0

10

20

30

40

Paroal O2 weaning O2 weaning

FreeO2TotalManual O2Total

Partial or complete oxygen weaning during the 3 hours

P<0.001

P<0.001

Num

ber

of D

ays

0

5

10

15

20

Duraoon of oxygen administraoon Hospital LOS

FreeO2TotalManual O2Total

P=0.002

P=0.001

Impact on outcomes after study

( > 50% reduction of oxygen flowrate)

Number of oxygen flow modifications: 1.2 ± 1.3 vs. 6715 ± 2312; p<0.001

L’Her et al. European Respiratory Journal 2017

Effet « Triage »

0%

5%

10%

15%

20%

25%

Manual FreeO2 (92%)

FreeO2(97%)

% o

f ti

me

wit

h H

R >

80/

min

HR 80-99 HR 100-119

0

10

20

30

40

50

60

Time (min) withSpO2 < 90%

% of patients with PrematureVentricular Contraction

Manual O2 TitrationFreeO2/92%FreeO2/97%

Figure 2: Mean total duration (minutes) with SpO2 <90% and % of patients with premature ventricular contractions in the 3 study groups (*P < 0.01).

Figure 3: % of time with Heart Rate (HR) above 80/min (*P < 0.01, **P = 0.05).

* * * **

Mean inclusion duration = 11.5 ± 2.8 hours

FreeO2 during acute coronary syndrome

Oxygenation following myocardial infarction in the CICU Sous presse

Early postoperative monitoring

Continuous adjustment and rapid weaning, less hyperoxia

Late postoperative monitoring

Rapid response to adverse events and less hypoxemia

Utilisation FreeO2 pour gestion OHD

Sur 8h, stabilisation SpO2 et FR, diminution FIO2 et relai par O2 débit conventionnel

- 3000 $ CAD par hospitalisation de patient après exacerbation aiguë BPCO

2018

Le débit d’O2 doit être titré afin d’obtenir la normoxie (traitement “personnalisé”)

L’automatisation du processus permet d’atteindre efficacement l’objectif fixé

Les caractéristiques intrinsèques de FreeO2 permettent une surveillance et un triage des patients