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Bronchiolitis v.6.0: HFNC (ED)
For questions concerning this pathway,
contact: Bronchiolitis@seattlechildrens.org 2015 Seattle Childrens Hospital, all rights reserved, Medical Disclaimer
Prior to HFNC initiation:
Call respiratory therapist
Respiratory score, suction, score
MD to order:
Place PIV (consider normal saline bolus)
Obtain blood gas (may start HFNC prior to result)
NPO
Continuous CR and O2 sat monitoring
Admit to general medicine (Medical Hospitalist to be called for all
pathway eligible patients, participate in 90 minute huddle)
Consider PICU consult/admission if clinical concerns remain or RS
remains >8 (even if improving)
While awaiting transfer:
Score, Suction, Score and VS Q1 hour
RN/RT may adjust FiO2 to maintain saturations >90% awake, 88%
asleep
Note: For patients with initial PCO2 >55 who improve
with HFNC, a CBG may be rechecked after the huddle. If
PCO2 then falls to 55, patient may still be eligible for
general medicine admission.
Initiate HFNC, 50% FiO2:
4 lpm for 30-90 days
6 lpm for 91 days to 2 years
RS, RR, SpO2 and HR Q 30 minutes
Notify Medical Hospitalist (76058)
Huddle 90 minutes
post HFNC initiation
(RN, RT, ED providers, admitting
resident, Medical Hospitalist,+/- PICU provider)
Arrange for ICU transfer
May exceed maximum flow
rates / increase FiO2 while
waiting for transfer
Failing (Clinically unchanged or worsening) Clinically improving
Sign of clinical improvement:
Improving respiratory score
Lower RR (not inappropriately lower than normal for age)
Lower HR
Improved CBG (if repeated; not necessary for all patients)
Off
Pathway
Patients require ICU transfer for any of the
following:
Failure to improve on HFNC trial (or does notmeet inclusion criteria for inpatient part of HFNC
pathway after 90-minute huddle)
CO2 > 55 or pH < 7.30
Any apnea > 20 seconds requiring intervention
Desaturations below 90% despite 50% FiO2 Altered mental status (irritability, lethargy), poor
perfusion (cool extremities, capillary refill >3
seconds)
Go To HFNC Inpatient Phase
Last Updated: January 201
Valid Until: December 2016
HFNC Inclusion Criteria Previously healthy children with bronchiolitis
Age 44 weeks CGA to 2 years
ONE of the following:
1) Severe respiratory distress, or
2) Significant Hypoxia, (see chart) or
3) Respiratory score persistently 8-12 with
significantly increased WOB
HFNC Exclusion Criteria ANYpre-existing medical condition
Born prematurely at less than 34 weeks
History of intubation for respiratory failure
Concern for respiratory failure:
Apnea requiring intervention
PCO2 > 55, pH
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For questions concerning this pathway,
contact: Bronchiolitis@seattlechildrens.org 2011, Seattle Childrens Hospital, all rights reserved, Medical Disclaimer
Bronchiolitis v.6.0: HFNC (Inpatient)
For questions concerning this pathway,
contact: Bronchiolitis@seattlechildrens.org 2015, Seattle Childrens Hospital, all rights reserved, Medical Disclaimer
Prior to HFNC initiation: Score, suction, score
Consider albuterol trial ONCE if not already done
Call RRT; resident to notify attending MD
Notify Medical Hospitalist (76058, charge RN to notify)
MD to order (using HFNC orderset): Place PIV (consider normal saline bolus)
Obtain CBG (may start HFNC prior to result)
NPO
NG/OG if anticipated NPO > 2 days
Wean flow rates as tolerated
May orally feed only if patient has weaned at least 2 lpm from
maximum flow rate
Initiate HFNC, 50% FiO2:
4 lpm for 30-90 days
6 lpm for 91 days2 y
RS, RR, SpO2 and HR Q 30
minutes
Score, suction, score Q 1 h for 4
hours post initiation
Huddle 90 minutes
post HFNC initiation
(Bedside RN, RISK RN,
RT, senior, intern,
Medical Hospitalist)
Arrange for ICU transfer
May exceed maximum flow
rates / increase FiO2 while
waiting for transfer,
with ICU guidance
Weaning HFNC:
FiO2 may be weaned by RN/RT after 90 minute huddle to maintain
saturations >90% awake and >88% asleep.
Please call provider to wean patients flow rate Q4 hours as indicated
if patient meets all of below criteria:
Clinically improving
RS < 8 after suctioning
FiO2 < 30%
Flow rate may be weaned by provider in 1 lpm increments.
When HFNC is stable at 2 lpm for 4 hours, next step is to trial patientdirectly to room air or to low flow NC O2 (start at lpm and titrate to
keep sats >90% awake, 88% asleep).
If patient worsens after a wean, contact
provider to evaluate and increase flow
rate to previous levels. If patient
must increase beyond previous
level, or is at pathway maximum,
call RRT.
!
Do not exceed
flow rates of:
4 lpm for 30-90 days old
6 lpm for 91 days to 2
years on the floor.
Failing (Clinically unchanged or worsening) Clinically improving
ign of clinical improvement:
Improving RS
Lower RR (not inappropriately lower than normal for age)
Lower HR
Improved CBG (if repeated; not necessary for all
patients)
Off
Pathway
Criteria for transfer to the ICU:
Failure to improve on HFNC trial
CO2 > 55 or pH < 7.30
Any apnea > 20 seconds requiring intervention
Desaturations below 90% despite 50% FiO2
Altered mental status (irritability, lethargy), poorperfusion (cool extremities, capillary refill >3
seconds)
Criteria for transfer from the ICU to floor:
Stable on flow rate at or below the floor
maximum for >12 hours
Have a respiratory score
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Self-Assessment
Completion qualifies you for 1 hour of Category II CME credit. If you are taking this self-assessment as a
part of required departmental training at Seattle Childrens Hospital , you MUST logon to Learning Center.
http://learningcenter/TPOnline/TPOnline.dll/Homehttp://learningcenter/TPOnline/TPOnline.dll/Homehttp://learningcenter/TPOnline/TPOnline.dll/Homehttp://learningcenter/TPOnline/TPOnline.dll/Homehttp://learningcenter/TPOnline/TPOnline.dll/Homehttp://learningcenter/TPOnline/TPOnline.dll/Homehttp://learningcenter/TPOnline/TPOnline.dll/Home7/23/2019 High flow nasal cannula oxygen guideline
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HFNC Answer Key
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Executive Summary
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Executive Summary
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Bronchiolitis and HFNC Citation
Title: Bronchiolitis and HFNC Pathway
Authors:
Seattle Childrens Hospital
Lauren Wilson
Anne Slater
Elaine Beardsley
Dave Crotwell
Jason Debley
Jeff Foti
Michael Leu
Jennifer Magin
Coral Ringer
Joan Roberts
Date: December 10, 2013
Retrieval Website:http://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdf
http://www.seattlechildrens.org/pdf/HFNC-pathway.pdf
Example:
Seattle Childrens Hospital, Wilson L, Slater A, Beardsley E, Crotwell D, Debley J, Foti J, Michael
Leu, Magin J, Ringer C, Roberts J.2013 December. Bronchiolitis and HFNC Pathway. Available
from: http://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdf
http://www.seattlechildrens.org/pdf/HFNC-pathway.pdf
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http://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdfhttp://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdf7/23/2019 High flow nasal cannula oxygen guideline
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Evidence Ratings
To Bibliography
This pathway was developed through local consensus based on published evidence and expert
opinion as part of Clinical Standard Work at Seattle Childrens. Pathway teams include
representatives from Medical, Subspecialty, and/or Surgical Services, Nursing, Pharmacy, Clinical
Effectiveness, and other services as appropriate.
When possible, we used the GRADE method of rating evidence quality. Evidence is first assessedas to whether it is from randomized trial or cohort studies. The rating is then adjusted in the
following manner (from: Guyatt G et al. J Clin Epidemiol. 2011;4:383-94.):
Quality ratings are downgradedif studies:
Have serious limitations
Have inconsistent results
If evidence does not directly address clinical questions
If estimates are imprecise OR
If it is felt that there is substantial publication bias
Quality ratings are upgradedif it is felt that: The effect size is large
If studies are designed in a way that confounding would likely underreport the magnitude
of the effect OR
If a dose-response gradient is evident
GuidelineRecommendation is from a published guideline that used methodology deemed
acceptable by the team.
Expert OpinionOur expert opinion is based on available evidence that does not meet GRADE
criteria (for example, case-control studies).
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Summary of Version Changes
Version 1 (10/10/2011):Go live
Version 1.1 and 1.2 (07/20/2012):Copyrighted photos and diagrams removed
Version 2.0 (10/22/2012):Updated to SpO2 monitoring recommendations
Version 3.0 (12/10/2013):Go live of Bronchiolitis HFNC Pathway
Version 3.1 (12/13/2013): Changes made to add contact hospitalist; correction to oral feeds to
match training slide; wording change in trial of albuterol to match the orders
Version 3.2 (01/15/2014): Changes to inclusion and exclusion criteria; changes to reflectmedical hospitalist at ED 90 minute huddle; admit to medical hospitalist
Version 4.0 (02/5/2014): Pathway document was divided into two documents and posted as
Bronchiolitis Pathway and HFNC Pathway
Version 5.0 (10/01/2014):Removal of daily CBG while on HFNC; highlighting of ability to
recheck PC02 after HFNC started for improved patients to meet floor admit criteria; PCO2
removed from inclusion criteria; composition of members of ED huddle; ability to admit to general
medicine service; abilityto trial patient on RA or low flow NC O2 after stable on HFNC at 2 lpm
for 4 hours
Version 6.0 (01/30/2015):Update to the pathway inclusion criteria to include severe respiratory
distress; added ICU to floor transfer criteria and link to education slide in transfer criteria box
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Medical Disclaimer
Medicine is an ever-changing science. As new research and clinical experience broaden our
knowledge, changes in treatment and drug therapy are required.
The authors have checked with sources believed to be reliable in their efforts to provide
information that is complete and generally in accord with the standards accepted at the time of
publication.
However, in view of the possibility of human error or changes in medical sciences, neither the
authors nor Seattle Childrens Healthcare System nor any other party who has been involved in
the preparation or publication of this work warrants that the information contained herein is in
every respect accurate or complete, and they are not responsible for any errors or omissions or
for the results obtained from the use of such information.
Readers should confirm the information contained herein with other sources and are
encouraged to consult with their health care provider before making any health care decision.
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Bibliography
Identification HFNC
Screening
Eligibility
Included
Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535
Studies were identified by searching electronic databases using search strategies developed and
executed by a medical librarian, Susan Klawansky. Searches were performed in May 2013. The
following databases were searchedon the Ovid platform: Medline (2002 to date), Cochrane
Database of Systematic Reviews (2005 to date), Cochrane Central Register of Controlled Trials
(2002 to date); elsewhereEmbase (2002 to date), CINAHL (2002 to date), National Guideline
Clearinghouse and TRIP (2002 to date). Retrieval was limited to humans 0-18 and English,French or German languages. As none of the searched databases provided index terminology
for the concept of high flow nasal cannula, all searching was conducted using textwords/
synonyms in various combinations. All retrieval was further limited to certain evidence
categories, such as relevant publication types, Clinical Queries, index terms for study types and
other similar limits. Additional articles were identified by team members and added to results.
Susan Klawansky, MLS, AHIP
December 3, 2013
Identification
70 records identified through
database searching
1 additional records identified
through other sources
71 records after duplicates removed
71 records screened 45 records excluded
10 full-text articles excluded26 full-text articles assessed for eligibility
16 studies included in pathway
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BibliographyBronchiolitis HFNC
Return to Home
Abboud, P. A., Roth, P. J., Skiles, C. L., Stolfi, A., & Rowin, M. E. (2012). Predictors of failure in infant
with viral bronchiolitis treated with high-flow, high-humidity nasal cannula therapy*.Pediatric Critic
Care Medicine, 13(6), e343-9. doi:http://dx.doi.org/10.1097/PCC.0b013e31825b546f
Arora, B., Mahajan, P., Zidan, M. A., & Sethuraman, U. (2012). Nasopharyngeal airway pressures in
bronchiolitis patients treated with high-flow nasal cannula oxygen therapy.Pediatric EmergencyCare, 28(11), 1179-1184. doi:http://dx.doi.org/10.1097/
de Klerk, A. (2008). Beyond the basics. humidified high-flow nasal cannula: Is it the new and improved
CPAP?Advances in Neonatal Care (Elsevier Science), 8(2), 98-106. Retrieved from http://
search.ebscohost.com/login.aspx?direct=true&db=cin20&AN=2009897598&site=ehost-live
Hasan, R. A., & Habib, R. H. (2011). Effects of flow rate and airleak at the nares and mouth opening o
positive distending pressure delivery using commercially available high-flow nasal cannula system
A lung model study.Pediatric Critical Care Medicine, 12(1), e29-33. doi:http://dx.doi.org/10.1097/
PCC.0b013e3181d9076d
Hegde, S., & Prodhan, P. (2013). Serious air leak syndrome complicating high-flow nasal cannulatherapy: A report of 3 cases.Pediatrics, 131(3), e939-44. doi:http://dx.doi.org/10.1542/peds.2011-
3767
Kelly GS, Simon HK, Sturm JJ. (2013) High Flow Nasal Cannula Use in Children With Respiratory
Distress in the Emergency Department: Predicting the Need for Subsequent Intubation. Pediatr
Emer Care.;29: 888-92
Lee, J. H., Rehder, K. J., Williford, L., Cheifetz, I. M., & Turner, D. A. (2013). Use of high flow nasal
cannula in critically ill infants, children, and adults: A critical review of the literature.Intensive Care
Medicine, 39(2), 247-257.
Matecki, S., Milesie, C., Baleine, J., Jacquot, A., & Cambonie, G. (2013). Effect of high-flow nasal
cannula nasal on nasopharyngeal airway pressure and respiratory muscles loading in young infanwith severe acute viral bronchiolitis.Fundamental and Clinical Pharmacology, 27, 89.
Mayfield, S., Hough, J., Pham, T., & Schibler, A. (2011). High flow nasal prong oxygen reduces the
need for mechanical ventilation in bronchiolitic infants.Pediatric Critical Care Medicine, 12(3),
A118.
To Bibliography, Pg 3To Bibliography, Pg 1
McKiernan, C., Chua, L. C., Visintainer, P. F., & Allen, H. (2010). High flow nasal cannulae therapy in
infants with bronchiolitis.Journal of Pediatrics, 156(4), 634-638. doi:http://dx.doi.org/10.1016/
j.jpeds.2009.10.039
Milesi, C., Baleine, J., Matecki, S., Durand, S., Combes, C., Rideau Batista Novais, A., & Combonie,
G. (2013). Is treatment with a high flow nasal cannula effective in acute viral bronchiolitis? A
physiologic study.Intensive Care Medicine, 39(6), 1088-1094. doi:http://dx.doi.org/10.1007/
s00134-013-2879-y
Schibler, A., Pham, T. M., Dunster, K. R., Foster, K., Barlow, A., Gibbons, K., & Hough, J. L. (2011).
Reduced intubation rates for infants after introduction of high-flow nasal prong oxygen delivery.
Intensive Care Medicine, 37(5), 847-852. doi:http://dx.doi.org/10.1007/s00134-011-2177-5
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Sood, R., Stolfi, A., & Rowin, M. (2012). Use of high flow high humidity nasal cannula therapy for
infants with bronchiolitis.Journal of Investigative Medicine, 60(1), 453.
Spentzas, T., Minarik, M., Patters, A. B., Vinson, B., & Stidham, G. (2009). Children with respiratory
distress treated with high-flow nasal cannula.Journal of Intensive Care Medicine, 24(5), 323-328.
doi:http://dx.doi.org/10.1177/0885066609340622
Thorburn, K., & Ritson, P. (2012). Heated, humidified high-flow nasal cannula therapy in viral
bronchiolitis--panacea, passing phase, or progress?*.Pediatric Critical Care Medicine, 13(6),
700-701. doi:http://dx.doi.org/10.1097/PCC.0b013e3182677456
Wing, R., James, C., Maranda, L. S., & Armsby, C. C. (2012). Use of high-flow nasal cannula support
in the emergency department reduces the need for intubation in pediatric acute respiratory
insufficiency.Pediatric Emergency Care, 28(11), 1117-1123. doi:http://dx.doi.org/10.1097/
PEC.0b013e31827122a9
BibliographyBronchiolitis HFNC
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