What are the initial settings for fiO2 (fraction of inspired oxygen) and LPM (liters per minute) for a patient starting Vapotherm (high flow nasal oxygen therapy)?

Initial Vapotherm Settings for High-Flow Nasal Oxygen Therapy

Start with a flow rate of 30-40 L/min and FiO2 of 50-60%, then titrate based on the patient's oxygenation status and clinical response. 1

Starting Parameters

Flow Rate

• Begin at 30-40 L/min as this range is well-tolerated and provides adequate support for most patients initiating high-flow nasal oxygen (HFNO) 1
• Flow can be increased up to 60 L/min if needed for patients with severe hypoxemia or high respiratory rates 1
• The system is capable of delivering flows up to 60 L/min with FiO2 up to 1.0 (100%) 1

FiO2 (Oxygen Concentration)

• Start with FiO2 of 50-60% (0.5-0.6) as the initial setting 1
• This provides adequate oxygenation for most patients while avoiding unnecessarily high oxygen concentrations 1

Target Oxygen Saturation Based on Patient Risk Profile

For Patients WITHOUT Risk of Hypercapnic Respiratory Failure

• Target SpO2: 94-98% 2, 3
• This includes most patients with pneumonia, acute respiratory distress, or standard hypoxemic respiratory failure 2

For Patients WITH Risk of Hypercapnic Respiratory Failure

• Target SpO2: 88-92% 1, 3
• Risk factors include: COPD, cystic fibrosis, neuromuscular disease, chest wall deformities, and morbid obesity 3
• These patients require lower target saturations to avoid worsening hypercapnia 1

Titration Algorithm After Initiation

Upward Titration (If Target SpO2 Not Achieved)

1. First, increase flow rate before increasing FiO2, as improved alveolar ventilation from higher flow may improve gas exchange 1
2. If SpO2 remains below target after optimizing flow (up to 50-60 L/min), then increase FiO2 in increments 1
3. Critical threshold: If requiring FiO2 >70% and flow >50 L/min for more than 1 hour without improvement, consider escalating to non-invasive ventilation or intubation 1

Downward Titration (If Target SpO2 Exceeded)

• Reduce FiO2 first if SpO2 is consistently above target range 2
• Allow at least 5 minutes at each setting before making further adjustments 2

Monitoring Requirements

Immediate Assessment (Within First Hour)

• Continuous pulse oximetry monitoring 1
• Respiratory rate and work of breathing 1
• Obtain arterial blood gas within 1 hour of initiation to assess for hypercapnia, especially in at-risk patients 3

Ongoing Monitoring

• Respiratory rate >30 breaths/min despite adequate SpO2 indicates respiratory distress requiring intervention 2
• Monitor for signs of treatment failure: worsening respiratory distress, inability to maintain target SpO2, or development of altered mental status 1

Common Pitfalls and Contraindications

Absolute Contraindications to HFNO

• Hemodynamic instability 1
• Multi-organ failure 1
• Abnormal mental status or inability to protect airway 1

Relative Contraindications

• Hypercapnia with respiratory acidosis: These patients may require non-invasive ventilation instead, though HFNO may be safe in mild-moderate non-worsening hypercapnia 1
• Cardiogenic pulmonary edema (consider NIV as first-line) 1

Key Warning Signs

• Do not delay intubation if patient shows signs of deterioration on maximal HFNO settings (FiO2 >70%, flow >50 L/min for 1 hour) 1
• Recognize that HFNO provides less ventilatory support than non-invasive ventilation and may not be appropriate for patients with significant hypercapnia 1

Special Considerations

For Preoxygenation Before Intubation

• HFNO at 100% oxygen can be used for preoxygenation when laryngoscopy is expected to be challenging 1
• Provides continuous oxygen flow during apneic periods, though concerns exist about potential gastric insufflation 1

Patient Comfort

• HFNO via Vapotherm provides heated and humidified oxygen, which improves patient tolerance compared to standard high-flow systems 4, 5
• Better nasal mucosal preservation and lower respiratory effort scores compared to standard high-flow nasal cannula 5