Children & Young People s Directorate Paediatric-Neonatal Guidelines Checklist & Version Control Sheet

Transcription

1 Children & Young People s Directorate Paediatric-Neonatal Guidelines Checklist & Version Control Sheet 1. Name of Guideline / Policy/ Procedure 2. Purpose of Procedure/ Guidelines/ Protocol Guideline for the Commencement, Management and Weaning of Oxygen delivered via High flow Nasal Cannula (HFNC) for Paediatric Bronchiolitis Patients To assist acute paediatric team in the delivery of HFNC 3. Replaces: Guideline for the heated humidified high flow oxygen for the management of Bronchiolitis on the paediatric ward- SHSCT 4. Applicable to which staff: Acute paediatric staff 5. Name & Title of Author: Adapted from the Bristol clinical guidelines (2015) OPTIFLOW - HIGH FLOW NASAL CANNULA OXYGEN THERAPY (AIRVO 2 / NEONATAL OPTIFLOW). Version 2. Mike Smith, Paediatrician SHSCT Bassam Aljarad, Paediatrician SHSCT 6. Equality Screened by: Note any issues 7. Proposals for dissemination: Via team leads 8. Proposals for implementation: 9. Training Implications: 10. Date Procedure/Guideline/ Protocol submitted to Procedures Committee: 11. Outcome: Laura Spiers, Lead Nurse Acute DHH, SHSCT N/A Submitted for approval at CYP Clinical Governance Oversight Committee Meeting Approved Dr S Thompson, CD approved Approved/Minor amendments Not approved Deferred 12. Date of CYP SMT approval Comments: 13. Date of approval by Trust SMT (if required): 14. Date for further review (3 year April 2021 default) 15. Date added to repository: 16. Clinical Guidelines ID: CG0562

2 Guideline for the Commencement, Management and Weaning of Oxygen delivered via High flow Nasal Cannula (HFNC) for Paediatric Bronchiolitis Patients Introduction HFNC is designed to administer a heated and humidified mixture of air and oxygen at a flow higher than the patient s inspiratory flow. HFNC reduces the sensation of respiratory distress and mouth dryness for the patient. Alongside this, the heated and humidified gases reduce the resistance in the nasal mucosa as opposed to using dry and cold gases, and therefore reduce the effort of breathing. The greater oxygen flow washes out the end expiratory oxygen depilated gas, meaning with the next breath, the patient inhales more oxygen. This dead space wash out also reduces CO2 rebreathing. Reductions in rates of intubation in infants with bronchiolitis have also been reported following introduction of HFNC therapy; however research remains limited within paediatrics. Aim The aim of this guideline is to assist the practitioner with the indications for use and management in children receiving HFNC for Bronchiolitis on the acute paediatric ward. This guideline presents methods and techniques of clinical practice, based on the available published evidence. Healthcare staff will use clinical judgement in applying the general principles and recommendations contained within the guideline.

3 Assessment of Need to Commence HFNC for Bronchiolitis Patients The need for HFNC can be measured objectively using the respiratory component of the Paediatric Early Warning (PEW) score (excluding oxygen delivery). A child with an increased respiratory rate, signs of respiratory distress and/or increasing oxygen requirements may benefit from HFNC. Parameter Description Score Respiratory Rate Scoring Either 0, 1, 2, 3 Dependant on age specific rates on PEWS chart Oxygen Scoring either 0,1,2,3 on PEWS chart Saturations (without oxygen) >92%= %= %=2 <85%=3 None=0 Mild=1 Moderate= 2 Severe= 3 Nasal Head Sternal Respiratory distress Flaring, Intercostal recession bobbing Subcostal recession Inspiratory or expiratory noises Tracheal Tug recession Exhaustion Impending respiratory arrest TOTAL Any patient with a respiratory PEWS score of three or more should be managed according to the flowchart below. A senior doctor (ST3+ Registrar or a Consultant) should review the patient prior to initiating HFNC therapy. A clear plan should be documented in the notes.

4 Response to a child with a Respiratory PEWS 3 Respiratory component (i.e. RR, SpO2 and respiratory distress but not oxygen delivery) of PEW score 3 Increased respiratory support needed? YES NO Optimise current management e.g. effectiveness of oxygen delivery, commence nasogastric feeds or intravenous fluids, adjust child s position. Obtain blood gas and consider need for CXR Note: likelihood of HFNC failure if: Contraindication to HFNC therapy? 1. Respiratory acidosis with ph< Recurrent apnoea 3. Air leak (pneumothorax, pneumomediastinum) ph < 7.3 and pco 2 >8 or need > 1.7 L/kg O 2 (but not a contraindication to a trial) Tend to fail in first 1-2 hours or improve with RR < 50 and HR <150 NO 4. Multi-organ compromise 1. Commence HFNC according to guidance below. YES 2. Optimise the management of the cause of respiratory insufficiency. Urgent contact with Paediatric Intensive Care Unit (PICU) for advice. Child may need intubated ventilated and transferred to PICU

5 Management of Child receiving HFNC therapy Initiation and Escalation Initial settings First escalation of therapy Second escalation of therapy Neonate (Up to 1 month) (If under 3 kg, consider Neonatal Optiflow) Infant (1 12 month) 6L/min and FiO2 40%. Wean FiO2 to maintain SpO %. High- Dependency care 8L/min and FiO2 40%. Wean FiO2 to maintain SpO %. High- Dependency care Increase flow rate to 8L/min. Increase FiO2 to 50% if oxygen saturations are less than 92%. This is maximal therapy outside of the PICU. Increase flow rate to 10L/min. Increase FiO2 to 50% if oxygen saturations are less than 92%. This is maximal therapy outside of the PICU. Increase the FiO2 to maintain oxygen saturations at least 92% and contact PICU urgently for advice as child may need to be intubated, ventilated and transferred to PICU Increase the FiO2 to maintain oxygen saturations at least 92% and contact PICU team urgently for advice as child may need to be intubated, ventilated and transferred to PICU A child whom has reached maximum interventions as outlined above in the first escalation of therapy, but continues to have saturations <92% should be considered as having failed HFNC therapy and urgent contact with PICU team established. Patients who fail HFNC usually tend to fail quickly i.e. within first 1-2 hours

6 Medical Management: Reassessment within one hour of commencement of HFNC therapy should be undertaken by a senior doctor. Further clinical assessment should be documented using the HFNC clinical assessment record at the end of this guideline Keep Nil by mouth in the immediate period after commencement of HFNC and administer Intravenous fluids in accordance with local policies. Reassess daily in accordance with compliance with treatment with the potential to introduce nasogastric feeding Continuous ECG and saturation monitoring for the duration of treatment Treat in accordance with NICE (2015) Bronchiolitis: Diagnosis and Management Passage of a nasogastric tube to reduce gastric distension should be considered Nursing Management: High dependency patient with a maximum Nurse: patient ratio of 1:2 Record hourly PEWS and complete high flow observation sheet Deliver care in accordance with High flow nursing care plan Escalation to medical team if there is rapid deterioration of oxygen saturation or marked increased work of breathing Nasal prongs should be used for no longer than 7 days and sets no longer than 14 days Humidifier temperature set to 34 for paediatrics Damage to nasal mucosa caused by cannula Gastric distension Potential Complications: Air leak. If increasing respiratory support, arrange urgent medical review to include CXR. Care must be taken when using HHFNC in infants with small nostrils as there is a risk of creating a closed circuit which can deliver unpredictable levels of positive pressure. Nasal cannula should not cover more than 50% of nares. A spare oxygen cylinder with non re-breathable mask and bagging set must be available at the bedside in case of sudden deterioration / emergency Be aware that nasal secretions can block cannula so check patency with nursing checks

7 Weaning HFNC Therapy Weaning should be initiated by a senior member of the medical team (ST4+ or Consultant) and the plan should be documented in the medical notes. Weaning should begin when the FiO2 is less than 40% and the respiratory component of the PEW score (i.e. RR, SpO2 and respiratory distress but not oxygen delivery) is less than three Oxygen saturation 92% in FiO2<40% and respiratory component (i.e. RR, SpO2 and respiratory distress but not oxygen delivery) of PEW score < 3 Wean flow rate by: Up to 1L/min every 2 hours in children over 1 month of age Up to 1L/min every 4 hours in children under 1 month of age Oxygen saturation 92% in FiO2<40% and respiratory component of PEW score < 3have been maintained after each reduction in flow rate For babies with bronchiolitis, it is anticipated that weaning of HFNC therapy will occur over approximately a 24 hour period. No YES Continue to wean flow as above until rate is 4L/min in children under 1 month or 5L/min in children over 1 month. From these settings, switch to the most appropriate method of oxygen delivery appropriate for the child s age. Increase flow rate to previous setting where oxygen saturation 92% and respiratory component of PEW score < 3

8 Reference List 1. Abboud PA, Roth PJ, Skiles CL, et al. Predictors of failure in infants with viral bronchiolitis treated with highflow, high-humidity nasal cannula therapy. Paediatric Critical Care Medicine 2012;13:e B RHC HDU Working Group. Clinical Guideline. OPTIFLOW - HIGH FLOW NASAL CANNULA OXYGEN THERAPY (AIRVO 2 / NEONATAL OPTIFLOW) Version 2 University Hospital Bristol 3. Bradley BA, Stoddart RA, Li M, King J, Dirnberger DR, Abassi S. Heated, humidified high-flow nasal cannula versus nasal CPAP for respiratory support in neonates. Pediatrics. 2013; e Bressan S, Balzani M, Krauss B, et al. High-flow nasal cannula oxygen for bronchiolitis in a pediatric ward: A pilot study. European Journal of Pediatrics. 2013;172(12): Christophe Milési, Mathilde Boubal, Aurélien Jacquot, Julien Baleine, Sabine Durand, Marti Pons Odena and Gilles Cambonie. High-flow nasal cannula: recommendations for daily practice in paediatrics. Annals of Intensive Care 2014, 4:29 6. Dysart K, Miller TL, Wolfson MR, Shaffer TH. Research in high flow therapy: Mechanisms of action. Respiratory Medicine. 2009; 103: Hedge S, Prodhan P. Serious air leak syndrome complicating high-flow nasal cannula therapy: A report of 3 cases. Pediatrics. 2013; 131: e Hutchings FA, Hilliard TN, Davis PJ. Heated humidified high-flow nasal cannula therapy in children. Archives of Disease in Childhood Jun;100(6): Mayfield S, Bogossian F, O'Malley L, et al. High-flow nasal cannula oxygen therapy for infants with bronchiolitis: pilot study. Journal of Paediatric Child Health 2014;50: Schibler A, Phan TMT, Dunster KR, Foster K, Barlow A, Gibbons K, Hough JL. Reduced intubation rates for infants after introduction of high-flow nasal prong oxygen delivery. Intensive Care Medicine. 2011; 3: Ten Brink F, Duke T, Evans J. High-flow nasal prong oxygen therapy or nasopharyngeal continuous positive airway pressure for children with moderate-to-severe respiratory distress? Pediatric Critical Care Medicine 2013;14:e Wing R, James C, Maranda LS, Armsby CC. Use of high-flow nasal cannula support in the emergency department reduces the need for intubation in pediatric acute respiratory insufficiency. Pediatric Emergency Care. 2012: 28:

9 High Flow Nasal Cannula (HFNC) Oxygen Clinical Assessment Sheet Respiratory rate Patient Details: Name: D.O.B: H+C/Hosp No: Score: Monitoring: Initial settings Decision to commence HFNC Oxygen: Date/Time: Medical Professional: Date/ time Flow Rate FiO2 SPO2 Respiratory rate Respiratory distress SPO2 without oxygen Respiratory Distress FiO2 requirement prior to HFNC Initial gas (ven, art, cap) Record Blood Gas prior to commencing therapy Ph: pco2: po2: BE: HCO3: PEWS Action taken Doctor First 1hr Second 2hrs & blood gas

10 Date/ time Flow Rate FiO2 SPO2 Respiratory rate Respiratory distress PEWS Action taken Doctor