High Flow Nasal Cannula Therapy Title of Guideline (must include the word Guideline (not protocol, policy, procedure etc) Guide line for the use of HFNCT (High Flow Nasal Cannula Therapy) Contact Name and Job Title (author) Directorate & Speciality Date of submission November 2017 Date when guideline reviewed November 2020 Guideline Number 2684 Version 2 Explicit definition of patient group to which it applies (e.g. inclusion and exclusion criteria, diagnosis) Abstract Key Words Colin Gilhooley (registrar) Catarina Silvestre (PICU consultant) Laura Ashmore (Consultant Paediatrician) Directorate: Family Health Children Speciality: PICU Children with respiratory distress needing HFNCT The guideline describes the current indication for the use of HFNCT, contra-indications, weaning and escalation of treatment. Paediatrics. Children. Respiratory Failure. High Flow Statement of the evidence base of the guideline has the guideline been peer reviewed by colleagues? 1a meta analysis of randomised controlled Put a cross (X) in the highest level of evidence. trials 2a at least one well-designed controlled study without randomisation 2b at least one other type of well-designed quasi-experimental study 3 well designed non-experimental descriptive studies (ie comparative / correlation and case studies) 4 expert committee reports or opinions and / X or clinical experiences of respected authorities 5 recommended best practise based on the clinical experience of the guideline developer Consultation Process Staff at Nottingham Children s Hospital via the Guidelines E-mail process. Target audience Staff at the Nottingham Children s Hospital This guideline has been registered with the trust. However, clinical guidelines are guidelines only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.
Document Control Document Amendment Record Version Issue Date Author V1 December 2016 Colin Gilhooley (ST6) Catarina Silvestre (PICU Consultant) V2 November 2017 Colin Gilhooley, ST8 Catarina Silvestre, PICU Consultant Laura Ashmore, Consultant Paediatrician Summary of changes for new version: Can start HFNCT without a prior chest xray, but chest xray to be done if not improving after 1 hour or clinical concern of infection Blood gases not needed routinely after initiation Changes to recommended flow rates for under 2 year olds Change to weaning guidance Statement of Compliance with Child Health Guidelines SOP This guideline has followed Child Health Guideline SOP. It has been circulated to all Paediatric Senior staff and comments incorporated before uploading to the Trust Guideline site. Maria Moran Clinical Guideline Lead 10 th November 2017
Introduction High-flow nasal cannula therapy (HFNCT) is a relatively new form of respiratory support. In pediatrics, HFNCT use continues to increase as the system is easily set up and is well tolerated by patients. The use of nasal cannula adapted to the infant s nares size to deliver heated and humidified gas at high flow rates has been associated with improvements in washout of nasopharyngeal dead space, lung mucociliary clearance, and oxygen delivery compared with other oxygen delivery systems. HFNCT also creates positive pharyngeal pressure to reduce the work of breathing, which positions the device midway between classical oxygen delivery systems like the high-concentration face mask, and continuous positive airway pressure (CPAP) generators. Indications In the paediatric literature the benefits of HFNCT have been reported only for moderately severe acute viral bronchiolitis. But, the experience with this device in neonatology and adult intensive care may broaden the paediatric indications to include weaning from invasive ventilation and acute asthma. As for any form of respiratory support, HFNC initiation in patients requires close monitoring. HFNCT is used for the same indications as the traditional method of CPAP: o Bronchiolitis. o Viral induce wheeze o Pneumonia Patients with complex needs are not a contraindication for the therapy; needs to be discuss with consultant. Clinical parameters suggesting the need for HFNCT Respiratory rate > 60 breaths/min Apnoeas, bradypnoea or cyanotic episodes (with or without bradycardia) despite supplemental O2 Severe intercostal recession and indrawing Need for > 2 L/min O2 via nasal prongs or 60% headbox O2 PaCO2 6.5 kpa or more (in children without pre-existing chronic lung disease) Rising PaCO2 (> 2 kpa from baseline) Respiratory acidosis if ph < 7.20 consider ventilation Contraindications to the use of HFNCT Upper airway abnormalities that may make HFNCT, NCPAP, or Nasal Mask (NM) CPAP ineffective or potentially dangerous (e.g. choanal atresia, cleft palate or tracheoesophageal fistula) Severe cardiovascular instability and impending arrest Air leak: Pneumomediastinum or Pneumothorax (if not drained) Multi-organ compromise Respiratory acidosis (ph< 7.2)
Severe apnoea Complications of HFNCT Potential complications of HFNCT therapy to consider: Potential barotrauma leading to surgical emphysema / pneumothoraxes, especially if cannulae occupy more than 50% of the diameter of the nares. Gastric distention and diaphragmatic splinting Obstruction or irritation due to improper sizing of nasal cannulas Blocked HFNC due to secretions Management 1. Equipment Airvo 2 system Humidifier Circuit tubing to attach to humidifier o Children <12.5kg: small volume circuit tubing (RT 329) o Children 12.5kg: adult oxygen therapy circuit tubing (RT203) Nasal cannula (prongs) to attach to humidifier circuit tubing (size to fit nares comfortably) o o Infants and children up to 10kg: OPT316 Infant (max flow 20L/min) or up to 12.5kg: OPT318 Paediatric cannula (max flow 25L/min) Children >10kg: Adult cannula size S OPT542, size M OPT544, size L OPT546 When using OPT316 and OPT318 the junior mode needs to be activated on the Airvo 2. The junior mode has different limits settings with a maximal temperature of 34 0 C and a flow of 25 l/m. 2. Monitoring All patients requiring respiratory support should have: Continuous HR and SpO2 monitoring Hourly recording of observations (RR,HR,SpO2) for the first 2 hours Within 2 hours it should be possible to reduce the FiO2 and clinical stabilisation should be seen: FiO2 required to maintain SpO2 in the target range should decrease to 0.4 The heart rate and respiratory rate should reduce by 20% Chest in drawing and other signs of respiratory distress should improve If clinical improvement occurs in the first 4 hours, patient can be on 4 hourly observation. If no improvement in the first hour of therapy: Blood gases Chest X ray
3. HFNCT initial settings FiO2: Set target SpO2 for child (normally 92-95%) may need to be lower in children with chronic lung disease or congenital heart disease. ( see bronc guidelines) Start with 0.6- and wean hourly as tolerated. Flow: 10Kg 2 L per kg per minute >10Kg 2 L per kg per minute for the first 10kg + 0.5L/kg/min for each kg above that (max flow 50 L/min) i.e. 16kg= 20L (2 x first 10kg) + 3L (0.5 x 6kg) = 23L/min; 40kg = 20L (2 x first 10kg) + 15L (0.5 x 30kg) = 35L/min The maximal flow should be applied. 4. Assessment SpO2 > 95% Reduce FiO2 in 10% increments until SpO2 92 95% (or target) If the patient is stable, with FiO2 < 30% for at least 12 hours, the therapy can be discontinued SpO2 < 92% Increase FiO2 to 60% If SpO2 is still < 92%,check if the flow is in the maximum for weight Exclude causes for failure: nasal obstruction, pneumothorax, gastric distension leading to diaphragmatic splinting Once SpO2 rises to more than 95% maintain high flow and reduce FiO2 until SpO2 92-95% If not improving, consider need for CPAP or intubation- CALL PICU Success of treatment: Reduction in frequency/ severity of apnoea Reduction in oxygen requirement Reduction in heart rate and respiratory rate (evidence suggests possible within first 90 minutes) Improvement in respiratory acidosis Reduction in work of breathing Failure of treatment: Persistent apnoeas Increasing oxygen requirement Unchanged/ rising heart rate and respiratory rate
Failure to improve respiratory acidosis An unchanged or increased work of breathing SpO2< 92% at FiO2 > 60% and maximal age-appropriate flow rate If HFNCT is failing: Check circuit and nasal cannulae position Consultant Paediatrician review PICU review Weaning Therapy is weaned if the infant s condition improves and there are no clinically significant apnoeas for 12 hrs: Once a child is on HFNCT FiO2 should be reduced before flow Reduce FiO2 to keep SpO2 92-95% Only when FiO2 is less than 0.4 (40%), and the child is stable, flow rate discontinued after at least 12 hours of stability If the child shows signs of respiratory distress, the therapy should be re-started Patient nursing care All infants on high flow should have a nasogastric tube Nasogastric tube on free drainage while starting: once stable on high flow, the infant should be assessed as to whether they can feed. Some infants can continue to breast feed, but most require feeding via a nasogastric tube Regularly aspirate the NG 4 hourly for air Oral and nasal care must be performed 4 hourly Note nasal prongs are in correct position and no pressure areas to nares Check humidifier water level hourly.
Assessment of respiratory component of PEWS (respiratory rate, sato2, respiratory distress) triggers a Review ST4 or consultant and senior nurse review Increase respiratory support need? (See table 1) Yes There is contraindications for HFNCT? Yes No Optimize current management Urgent referral to PICU Start HFNC (table 2) Improvement after 1 hour? Reduce FiO2 < 0.4 Reduce HR and RR Improvement of the respiratory distress Yes Start weaning after 12 hours of stabilization No Check nasal cannula position Check flow Blood gases and CXR Call PICU 10 kg >10 kg Initial setting 2 L/kg/minute 2 L/kg/ minute for the first 10kg + 0.5L/kg/min for each kg (max flow 50 L/min) Escalation if sato2 < 92% Increase O2 to 60% Increase the flow until max flow achieved Weaning if SatO2 > 95% Reduce FiO2 in 10% increments until sat 92-95% or target Consider weaning and stop the therapy
References: Reference (include title, author, journal title, year of publication, volume and issue, pages) 1 Dysart K, Miller TL, Wolfson MR, Shaffer TH. (2009) Research in high flow therapy: mechanisms of action. Respiratory Medicine.;103:1400-5. 2 Groves N & Tobin A. (2007). High flow nasal oxygen generates positive airway pressure in adult volunteers. Australian Critical Care. 20, 126 131 3 Spentzas T, Minarik M, Patters AB, Vinson B, Stidham G. Children with respiratory distress treated with highflow nasal cannula. J Intensive Care Med 2009;24:323-8. 4 Schibler, A., Pham, T.,Dunster, K., Foster, K., Barlow, A., Gibbons, K., and Hough, J. (2011) Reduced intubation rates for infants after introduction of high-flow nasal prong oxygen delivery. Intensive Care Medicine. May;37(5):847-52 5 McKieman, C., Chua, L.C., Visintainer, P. and Allen, P. (2010) High Flow Nasal Cannulae Therapy in Infants with Bronchiolitis. Journal of Pediatrics 156:634-38 6 Ingvild B M, Peter D, Knut O (2016): High flow nasal cannula in children: a literature review. Journal of Trauma, Resuscitation and Emergency Medicine: 29-93 7 Wraight T, Ganu S (2015). High-flow nasal cannula use in a paediatric intensive care unit over 3 years. Critical Care and Resuscitation: 17(3):197-201. Evidence level (I-VII) VII VI Key findings, outcomes or recommendations Proposed physiological mechanisms for the efficacy for HFNC including pulmonary compliance, reduction in energy expenditure and work of breath and a mild distending pressure Suggests that HFNC therapy has been shown to have similar effect to nasal CPAP A degree of CPAP is generated however flow is dependent on mouth being open or closed Suggests HFNC therapy improves respiratory scale score, O2 saturations and patient comfort Suggests HFNP therapy provided efficient oxygen delivery and respiratory support in infants with a viral bronchiolitis Appeared to reduce the need for intubation in infants (<24 months) with viral bronchiolitis Suggests HFNC therapy reduces the rates of intubation in infants with bronchiolitis compared to other forms of respiratory support Provides a well-tolerated and comfortable method of noninvasive ventilatory support Mata analysis that suggests that HFNC is safe outside intensive care, with a critical approach regarding effect and safety, specially when use outside intensive care areas. HFNC therapy was successful in most patients, and success was associated with a shorter PICU LOS
8 Mayfield S Bogossian F, O Malley L, Schibler A. High-flow nasal cannula oxygen therapy for infants with bronchiolitis: Pilot study (2014). Journal of Paediatrics and Child Health. 373 378 9 Kallappa C, Hufton M, Millen G, Ninan T. Use of high flow nasal cannula oxygen (HFNCO) in infants with bronchiolitis on a paediatric ward: a 3- year experience (2014). Arch Dis Child. 99 (8) 10 FLORALI Study Group, REVA Network. High-Flow Oxygen through Nasal Cannula in Acute Hypoxemic Respiratory Failure (2015). NEJM. DOI: 10.1056/NEJMoa1503326 11 Hutchings FA, Hilliard TN, Davies P. Heaqted humidified-flow nasal cannula therapy in children (2014). Arch Dis Child.100: 571-575 HFNC treatment in the paediatric ward is safe. Nonresponders requiring PICU admission can be identified within the first hour of HFNC treatment by monitoring HR and RR. It is feasible to undertake a randomised controlled trial based on this pilot with the aim of decreasing PICU admissions. We conclude that in our experience this simple technique has decreased the number of unstable infants that were previously transferred to a PHDU for ncpap. VI In patients with nonhypercapnic acute hypoxemic respiratory failure, treatment with high-flow oxygen, standard oxygen, or noninvasive ventilation did not result in significantly different intubation rates. There was a significant difference in favor of high-flow oxygen in 90-day mortality. VI Review paper about indications, mechanism of action and complications of HFNCT in children.