1. Neonatal High Flow Nasal Cannula
Towards A Clinical Practice Guideline
Bradley A. Yoder, MD
Professor of Pediatrics
Division of Neonatology
University of Utah School of Medicine

2. Disclosure Statement
I have received research and/or travel compensation as a consultant to Drager Medical Fisher & Paykel Vapotherm & Ikaria

3. Objectives Recognize Detrimental Approaches
Suggest Clinical Guidelines
Identify Areas for Further Research

5. Contributing Consultants
Clare Collins, MBChB, PhD, FRACP. Department of Paediatrics, Mercy Hospital for Women, Melbourne, AU
Kevin Ives, MBBChir, , MD, FRCPCH. Dept of Neonatology, John Radcliffe Hospital, Oxford, UK
Brett Manley, MB BS (Hons.), PhD, FRACP. Consultant Neonatologist Neonatal Services and Newborn Research Centre, Royal Women's Hospital Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, AU
Michael McQueen, MD, MBA, FAAP. Neonatology, Banner Health System, Phoenix, AZ, USA
Bradley A. Yoder, MD, FAAP. Division of Neonatology, University of Utah School of Medicine, SLC, UT, USA

6. Why Do We Need Practice Guidelines?

7. Why Do We Need Practice Guidelines?
HHFNC universally available in US NICU’s
Expanding international use
Increasing pediatric & adult use
Only a few RCT’s have been completed
Guidelines generally improve outcomes
Assist in identifying areas to improve

8. HHHFNC - Mechanisms of Action
Process
References
Gas
condition
Reduced metabolic work
Maintain epithelial integrity
Improved lung mechanics
Greenspan, JPeds 1991
Williams, CCM 1996
Waugh, RespCare 2004
Schiffmann, RCCNA 2006
Chidekel, PulmMed 2012
Pressure
Minimal if:
small NC coupled w/ large
nasal interface
Increases EELV
Saslow, J Perinatol 2006
Kubicka, Peds 2008
Wilkinson, J Perinatol 2008
Frizzola, PedsPulm 2011
Sivieri, PedsPulm 2012
Collins, JPaedsChildH 2013
Hough, PedsCCM 2014
Flow
Dead space gas washout
Inspiratory resistance
Augment tidal volume
Off-loads diaphragm activity
Shepard, ARRD 1990
Dewan, Chest 1994
Rubin, PedsCCM 2014
Pham, PedsPulm 2014

9. HHHFNC Randomized Clinical Trials
Post-extubation HHHFNC v CPAP - preemies < 32 wks
C Collins (Melbourne, AU; n=132)
B Manley (Melbourne, AU; n= 300)
Post-extubation HHHFNC v CPAP
Liu C (China; n= 255)
Comparison of HHHFNC to Nasal CPAP in Neonates
B Yoder (University of Utah, n = 432; 150 < 32 wks)
Initial Rx for RDS HHHFNC v CPAP - preemies < 35 wks
A Kugelman (Haifa, Israel; n=76)

10. Summary of Current RCT’s
HHHFNC:
~ 1200 infants in 5 trials
Similar failure rates as nCPAP
As applied, no evidence for increased adverse events….particularly air leaks
Does not extend O2 use or hospital stay
Primarily relates to post-extubation use

11. Issues in Clinical Care
Cannula to nares ratio
Gas egress
Temp & humidity
Initial Flow Rate
Escalation/weaning flow
NG v OG tube
PO feeding on HFNC

12. Initial Set-up MUST maintain a leak at the nose
avoids excessive pressure generation
allows nasopharyngeal ‘washout’
more comfort & less nasal trauma
Keep temperature close to 37o C
Position tubing down & away from baby
minimize fluid into the nares/airway
reduces risk for pressure injuries

13. Occlusive NC
Non-occlusive NC

14. Critical Points Only use heated and humidified systems
Typical peak inspiratory flow ~ 1 lpm, thus
when flow > wt in kg, set FiO2 = delivered FiO2
HFNC is a non-invasive Rx: treat it like CPAP
titrate FiO2 first, then flow rate
if an infant needs > 50-60% oxygen  D modes
know when to bail (apnea, acidosis, hypoxia.…)

15. Indications for HHHFNC
Post-extubation support for preterm infants
Current evidence shows equivalence to CPAP
Data is limited for infants born < 26 weeks’ GA
Infants stable on CPAP, where HFNC therapy may be preferred
A variety of reasons may be offered including ease of care, neuro-developmental, nasal trauma, other

16. Unproven Benefit
As primary support for RDS or other acute neonatal respiratory disorder
Lack of evidence from RCT’s
But empirically used by many centers

17. Management of Flow Rate
Initiating flow:
Dependent on size &/or gestation
Dependent on 1o v 2o Rx
Dependent on current Paw/FiO2
Criteria for escalation:
FiO2
Respiratory rate
RDS score/WOB
Radiograph
Approach to weaning:
Time on HF
FiO2
Respiratory exam

18. Management of HHHFNC Therapy
Weight
EGA
Current
Rx Mode
PAW
FiO2
Resp Rate
Time On
Exam RDS-S
Initial flow rate
N = 4
Y = 1
N = 5
N = 3
Y = 2
N = 1
Y = 4
Y = 5
Flow Escalation
N = 2
Y = 3
Weaning
Flow
The majority of consultants use the infants underlying clinical
condition, rather than weight or gestation, to manage HHHFNC

19. What criteria do you use in initiating HHHFNC therapy in neonates?
Flow Rate
“A” “B” “C” “D” “E”
Current weight
< 1000 g g
> 2000 g
5-7 lpm lpm lpm lpm lpm
all wts lpm all wts all wts all wts
4-8 lpm
Postnatal age
< 24 hrs
< 7 days
other
5-7 lpm all Same lpm all lpm all lpm all
as above
Prior Rx mode
HFV
SIMV
CPAP
Other
NO Same lpm lpm Same as
6-7 lpm as above; lpm for all above;
5-7 lpm includes Rarely Occ <28 wk Don’t use CPAP
HFV may go NIMV/CPAP
FiO2
< 40%
< 30% RA
7-8 lpm by 1 lpm lpm lpm lpm if
5-7 lpm Same lpm for all FiO2 > 40%
5-7 lpm as above otherwise 4-6 lpm
PAW
< 8 cm H2O
< 6 cm H2O
6-8 lpm Same Same lpm lpm all
5-7 lpm as above for all for all typically not
CPAP < Same successful if > 9-10
7-8 lpm if Flow need based
WOB on all of above

20. Initiation of HHHFNC Therapy
Weight
FiO2
PAW
Initial
flow
rate
“A” 5-7 any weight
“B” Varies by wt 3-8 lpm
“C” 5-8 any weight
“D” 8 any weight
“E” 4-6 any weight
Increase for > 30%
Always start at 8 lpm
Increase for > 6-7 cm H2O
Same as for weight
Same; poor success rate
if > 9-10 at extubation
Gestation & postnatal age not a factor

21. Consensus Recommendations Initiating High Flow
Use only heated/humidified systems
Use NC sized to allow ready egress of gas
Start at 5-8 lpm
no evidence comparing starting flow rates
consider increased flow based on FiO2/Paw/WOB

22. What criteria do you use in escalating HHHFNC therapy in neonates?
Increase in Flow Rate
“A” “B” “C” “D” “E”
Current weight
< 1000 g g
> 2000 g
Don’t use Don’t use Don’t use Don’t use Don’t use
Postnatal age
< 24 hrs
< 7 days
other
Don’t use Don’t use Don’t use Don’t u se Don’t use
FiO2
< 40%
< 30%
> 21%
> 30% use by 1-2 lpm by 1 lpm If FiO by 1-2 lpm
7-8 lpm if > 30% as FiO flow back if > 40%
by 1 lpm to 8 lpm
Resp rate
< 60
60-80
> 80
As above only if > 60
by 1 lpm by 1 lpm by 1 lpm for FiO only if signs
by 1 lpm by 1-2 lpm by 1 lpm WOB/distress
RDS score or WOB
Specify
by 1 lpm by 1-2 lpm by 1 lpm As above As above
Time on HHFNC
< 6 hrs
< 12 hrs
> 12 hrs
> 24 hrs
No time Same as Same As above Do not use
limit “A” Don’t wait more time epochs
D to CPAP than 1-2 hrs to Consider Depends on baby
if HFNC = 8 lpm escalate to D to CPAP Do not use CPAP
& concerns CPAP/NIMV or NIMV Occ use BiPAP

23. Consensus Recommendations Escalating High Flow
Don’t exceed 8 lpm flow in neonates
Increase flow for:
WOB
Respiratory rate
FiO2
Don’t delay in escalating flow
Change to CPAP/NIMV if not improving

24. What criteria do you use in escalating HHHFNC therapy in neonates?
Increase in Flow Rate
“A” “B” “C” “D” “E”
Current weight
< 1000 g g
> 2000 g
Don’t use Don’t use Don’t use Don’t use Don’t use
Postnatal age
< 24 hrs
< 7 days
other
Don’t use Don’t use Don’t use Don’t u se Don’t use
FiO2
< 40%
< 30%
> 21%
> 30% use by 1-2 lpm by 1 lpm If FiO by 1-2 lpm
7-8 lpm if > 30% as FiO flow back if > 40%
by 1 lpm to 8 lpm
Resp rate
< 60
60-80
> 80
As above only if > 60
by 1 lpm by 1 lpm by 1 lpm for FiO only if signs
by 1 lpm by 1-2 lpm by 1 lpm WOB/distress
RDS score or WOB
Specify
by 1 lpm by 1-2 lpm by 1 lpm As above As above
Time on HHFNC
< 6 hrs
< 12 hrs
> 12 hrs
> 24 hrs
No time Same as Same As above Do not use
limit “A” Don’t wait more time epochs
D to CPAP than 1-2 hrs to Consider Depends on baby
if HFNC = 8 lpm escalate to D to CPAP Do not use CPAP
& concerns CPAP/NIMV or NIMV Occ use BiPAP

25. What criteria do you use in weaning HHHFNC therapy in neonates?
Decrease in Flow Rate
“A” “B” “C” “D” “E”
Current weight
< 1000 g g
> 2000 g
Wean qod q hrs qod if Keep 8 lpm lpm q D
q hrs < 1500 g til > 1 kg lpm q D
Wean q q hrs kg by 1 lpm q lpm prn
> 2 kg as tolerated
Postnatal age
< 24 hrs
< 7 days
other
Don’t use Wean as NO As above Don’t use
above unless
“bigger” baby
FiO2
< 40%
< 30% RA
No wean Same Same As above if lpm if CLD
if > 30-35% FiO2 stable otherwise as
& < 40% above for WT
Resp rate
< 60
60-80
> 80
No wean Same Same No wean No wean
if RR> if > if > 80
RDS score or WOB
Specify
No wean Same Same Same Same
Decreased WOB & FiO2 drive weaning more rapidly among larger infants
Stick to slower wean for smaller/younger infants
Time on HHFNC
< 6-12 hrs
> 12 hrs
> 24 hrs
If “quick” recover Same Same Not a Not a
from RDS WOB more a factor factor factor
For ELBW p-ext than time except for ELBW
wean qod if FiO2 > 25%

26. Consensus Recommendations Weaning High Flow
Wean the FiO2 first, then the gas flow
Similar to CPAP; to at least < 35%, probably < 30%
Review at least every hrs to determine if flow rate can be weaned or discontinued
May be able to wean infants > 2 kg more quickly
Wean by lpm decrements

27. Stopping HHHFNC Therapy
Weight
EGA
Postnatal Age
“A” 4 lpm *
“B” 1-2 < 1000g; lpm at higher weights
“C” 3 lpm - “smaller” babies
“D” 4 lpm *
“E” lpm for VLBWI, prefer to “dry” low-flow NC
“A” Rarely < 4 lpm w/ BPD
“B” Same as weight
“C” 3-4 lpm if larger/older
“D” Same as weight
“E” Same as weight
“A” Same as weight
“C” Expect “smaller” on 3-5 lpm for 2-3 wks
Preferably stable > 24 hrs, FiO2 < 30% and normal WOB/RR
* 1o related to funding issues

28. Consensus Recommendations Discontinuing High Flow
There is no consensus on when to D/C HF
No studies comparing effect or outcomes related to D/C HFNC at different support levels
Recommendations vary from 1 – 4 lpm
Centers vary by weight of infant
Also variation related to support for BPD

29. CONSENSUS !
THIS WOULD WORK A LOT BETTER IF YOU’D JUST AGREE WITH ME

30. Consensus on HHHFNC: A Tale of Two NICU’s Preferred Non-Invasive Approach by NICU RN’s
Au data from Roberts CT, J Paeds Child Health 2014; UK data from K Ives, unpublished

31. The Future Challenges are what make life interesting ……
…… overcoming them is what makes life meaningful
Joshua J. Marine

32. Future Studies Additional large RCTs are needed:
to evaluate HHHFNC use in ELBWIs
to compare different HHHFNC devices
to evaluate various approaches to HHHFNC
to assess economic impact of HHHFNC
to address specific respiratory conditions
other

33. .
V I G I L A N C E
You can’t see it if you don’t stay awake

34. SUMMARY HHHFNC is in wide clinical use
RCT’s support HHHFNC as safe, effective alternative to nCPAP at the time of extubation
Additional RCT’s are needed to study HHHFNC as 1o therapy & related to flow management
Except for stopping, there is moderate consensus in the management of HHHFNC

35. Contributing Consultants
Clare Collins, MBChB, PhD, FRACP.
Mercy Hospital for Women, Melbourne, AU
Kevin Ives, MBBChir, , MD, FRCPCH.
John Radcliffe Hospital, Oxford, UK
Brett Manley, MB BS (Hons.), PhD, FRACP.
The University of Melbourne, Melbourne, AU
Michael McQueen, MD, MBA, FAAP.
Banner Health System, Phoenix, AZ, USA

36. ??