High flow nasal cannula oxygen guideline

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Bronchiolitis v.6.0: HFNC (ED)

For questions concerning this pathway,

contact: [email protected] 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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contact: [email protected] 2011, Seattle Childrens Hospital, all rights reserved, Medical Disclaimer

Bronchiolitis v.6.0: HFNC (Inpatient)


contact: [email protected] 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.
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HFNC Answer Key


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Executive Summary


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Executive Summary

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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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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

To Bibliography, Pg 2Return to Home


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BibliographyBronchiolitis HFNC

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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-

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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.

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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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High flow nasal cannula oxygen guideline

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