1. High Flow Nasal Cannula for Patient Care Units- ACH
ACH Hospital Pediatrics Fall Retreat
September 16/

2. Oxygen Delivery Systems
Blow by
Nasal cannula
Low-flow- 1-4 LPM delivers 25-40% FiO2 (limit flow to 2 LPM in infants)
High-flow- delivers heated and humidified O2 - up to 8LPM (infants); up to 40 LPM (children/adults); may be better tolerated than O2 by face mask
Masks
Simple – flow rates: 5-10 LPM delivers 35-50% FiO2 (unreliably)
Partial rebreathing- flow rates LPM delivers 50-60% FiO2
Nonrebreathing- flow rates of LPM delivers FiO2 up to 95%
Enclosure systems
Hoods – flow rates LPM delivers FiO2 of %
Tents – using high flow rates can deliver up to 50% FiO2
Ventilation bags
Self-inflating
Flow-inflating

3. High Flow Nasal Cannula (HFNC)
Key benefits over nasal prongs:
Delivery of up to 100% oxygen more accurately
Anatomical dead space flushed
Providing warmed + humidified gas reduces metabolic work (in adults estimated at 156 cal/min)
Providing warmed + humidified gas improves conductance and pulmonary compliance
Positive airway pressure throughout the respiratory cycle
Overcomes inspiratory resistance
May be able to provide positive distending pressure for lung recruitment (up to 5-6 cm H2O- depending on mouth open and leak in very small infants) – unreliably!!!
Potentially aids in mucociliary clearance
Mechanism of Action
Washout of nasopharyngeal dead space, which contributes to improved alveolar gas exchange
Distensibility of the nasopharynx increases resistance on inspiration normally; HF provides flow rates that can match this inspiratory resistance and thus attenuate this resistance, improving WOB
Warmed and humidified gas improves conductance and pulmonary compliance
Warmed and humidified gas reduces the metabolic work associated with gas conditioning
High flow can be titrated to provided positive distending pressure for lung recruitment

4. Uses in Pediatrics • RDS of prematurity • Bronchiolitis
• Apnea of prematurity
• Chronic Lung Disease
• Infants susceptible to nasal trauma/maintaining mucosal integrity
• Infants weaning from invasive ventilation and CPAP
*Indications for use are non-specific; no formal recommendations are available for specific clinical indications
Key patient populations where HFNC has been shown to be a potentially effective treatment option:

5. “Criteria” for use Effective spontaneous respiratory effort
Requirement for moderate to high amounts of oxygen when NP or facial mask not amenable
CO2 elimination maintained

6. CPAP vs HFNC 3 key problems with CPAP making HFNC attractive:
Mechanical difficulties of maintaining CPAP apparatus in nose
CPAP commonly causes nasal septum trauma
CPAP is tightly affixed to nose and face- causes intolerance with patient movement, trauma, need for sedation, etc.
Mechanism of Action
Washout of nasopharyngeal dead space, which contributes to improved alveolar gas exchange
Distensibility of the nasopharynx increases resistance on inspiration normally; HF provides flow rates that can match this inspiratory resistance and thus attenuate this resistance, improving WOB
Warmed and humidified gas improves conductance and pulmonary compliance
Warmed and humidified gas reduces the metabolic work associated with gas conditioning
High flow can be titrated to provided positive distending pressure for lung recruitment

7. Consider HFNC a bridge between Low Flow NP and CPAP
While HFNC may provide some positive pressure, it is not regulated and highly variable
(but give HFNC the “respect” given to non-invasive modes of ventilation)

8. Basic Set-up

17. Potential Complications
Respiratory Failure
Excessive condensation in the tubing
Aspiration (above/below)
Potential for infection
Barotrauma with unmeasured CPAP
Pneumothorax
Subcutaneous scalp emphysema, pnemo-orbitis, pneumocephalus has been described in one neonate on HFNC
Pulmonary hemorrhage
Nasal septal damage

18. Other considerations Need for NG to decompress stomach
Ability to orally feed
Nare occlusion

19. Guidelines for HFNC Use At ACH
Will be initiated and stabilized in PICU/NICU prior to transfer to Unit 2
Currently only being used for patients with chronic oxygen needs and/or craniofacial anomalies
Patients on HFNC MUST be on CRM
Patients will go to Unit 2, Yellow Hallway and preferably Purple Team
Respirology consult is mandatory

20. Guidelines cont’d RT to assess the patient AT MINIMUM of q4h
RN to assess the patient AT MINIMUM of q4h (alternating q2h with RT assessment)
Orders for HFNC must include: Flow rate and FiO2
Signage will be placed at the bedside of these patients by RT
Weaning can only be ordered by Respirology and Hospital Pediatrics

21. Weaning of HFNC Indications:
Once patient FiO2 is <40%
Disease process is improving
Order can be specific or written “as tolerated”
must be in discussion with Hospital Pediatrician and Respirology
Drop flow in increments of 1-2 LPM
<6 mos of age: once flow is 2 LPM consider changing to regular nasal prongs
> 6 mos of age: once clow is 3 LPM consider changing to regular nasal prongs

22. QUESTIONS??