1. Guideline for Metropolitan Paediatric Wards & Emergency Departments 1st edition Humidified High Flow Nasal Cannula Oxygen

2. Session Outline Background & aim of the guideline Definition & evidence Indications & contraindications Prescription for care Equipment Starting parameters & ongoing care Escalation & transfer Weaning Summary 1

3. Background & aim of the guideline MP4 Conference June 2014 – NETS presented data on use of HHFNC Oxygen in NSW NETS referrals Wide variability & challenges Decision to develop a guide for MP4 units & emergency departments to provide consistent, safe clinical practice when utilising Humidified High Flow Nasal Cannula Oxygen in infants 2

4. Definition & evidence Humidified High Flow Nasal Cannula (HHFNC) therapy is a simple to use system that delivers warm, moist gas at high flow rates that generate positive airway pressure. At flow rates of 1- 2 L/kg/min 1 it acts a bridge between low flow oxygen therapies and Continuous Positive Airways Pressure (CPAP), reducing the need for intubation. 1,2 3

5. The Evidence NICU evidence for HHFNC oxygen (flow rates >1L/min) Cochrane review: insufficient evidence for safety / efficacy (Wilkinson 2011) Evidence for safety/efficacy in PICU Retrospective reviews Variable indications for use Variable flow rates / delivery devices Emerging evidence for safety outside of PICU 4

6. Use of HHFNC in PICU McKiernan 2010 (et al) Reduced intubation rate following introduction of HHFNC for bronchiolitis (9%) compared to historic controls (23%) Decreased ICU Length of Stay for bronchiolitis No observed adverse events 5

7. Use of HHFNC in PICU Schibler 2011(et al.) Reduced intubation rates for bronchiolitis following introduction of HHFNC (7%) compared to historic controls (37%) 31% failure rate overall (19% Non Invasive Ventilation, 12% Invasive Ventilation) 4% of bronchiolitis escalated to Invasive Ventilation Predictors of success: ICM 2011 6

8. Indications & contraindications Inclusion criteria Moderate to severe respiratory distress in infants with bronchiolitis who have failed to respond to low flow oxygen May have a role in moderate to severe respiratory distress in children – limited evidence Use for indications other than bronchiolitis only after senior medical consultation Exclusion criteria Neonates in special care nurseries 7

9. Contraindications Nasal obstruction Ingestion/toxins Life threatening hypoxia/ apnoeas/ haemodynamic instability Trauma (maxillofacial/suspected base of skull fracture/chest) Pneumothorax Foreign body aspiration Proceed with caution in those with: Decreased level of consciousness (LOC) Congenital heart disease Asthma Chronic respiratory disease 8

10. Prescription for care Senior ED/Paediatric Medical Officer review prior to commencement On call paediatrician informed Prescription – FiO 2 and L/kg/min AFTER 15mins if no clinical improvement review by Senior Paediatric MO AFTER 60mins review by Senior Paediatric MO then 4hrly if stable Paediatric experienced RN Patient ratio 1:2 in high observation area 9

11. Equipment Oxygen and air source Oxygen blender or Oxygen analyser if blender not being used Flow meter 0-30 L/min Humidifier base & Humidifier circuit Nasal cannula – approp size Sterile 2Litre Water bag Nasogastric/ orogastric tube 10

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13. Starting parameters & ongoing care 12

14. Starting parameters In general, improvement is defined by a reduction in heart rate by 20%. A decrease in respiratory distress and rate should follow. In general the guide to titrating is: Increased work of breathing = increase flow Decreased oxygenation = increase FiO2 13

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16. Ongoing care Monitoring: Continuous cardio-respiratory & SpO 2 monitoring Continuous SpO 2 monitoring Check & documentation of FiO2, flow, circuit observations hourly Temperature 4th hourly Blood pressure once per shift unless abnormal Blood glucose level 6th hourly for fasting infants 15

17. Ongoing care Documentation: Initially every 15 mins then hourly once stable: Heart rate, respiratory rate, respiratory distress, SpO 2 Flow rate, FiO 2, & humidifier temperature Humidifier water level/bag check Nursing care: Check nasal prong position hourly (at a minimum) correct placement & pressure areas Saturation probe site change 2-4 hourly Gastric tube insitu Nasal hygiene 16

18. Ongoing care Feeding Dependent on respiratory status & clinical situation Breast feeding if able to without increased WOB Naso/oro gastric feeds Intravenous fluids 17

19. Escalation & transfer Escalate as per local CERS policy if: Any clinical deterioration or No signs of improvement within 60 minutes of therapy at 2L/kg/min and up to 60% FiO 2, Contact paediatrician and NETS 1300 362 500. Transfer from ED to ward: If clinically stable How will depend on system of delivery Fully monitored & accompanied by RN 18

20. Complications Pneumothorax Nasal trauma Condensation in tubing Ensure appropriate size Bag-Valve Mask +/- Neopuff at bedside which can be used with nasal prongs insitu to provide respiratory support if needed. 19

21. Weaning Indications for weaning: Mild or no increased work of breathing Normal parameters (HR & RR in white & blue zones of SPOC) SpO 2 > 92% Order of weaning: Wean FiO 2 by 10% increments, ideally aiming for 21% to maintain SpO 2 > 92% Once needing less than 40% FiO 2 with minimal increased work of breathing: Then decrease flow rate to 1L/kg/min. If child remains stable for 2-4 hours then reduce again to 0.5L/kg/min and then cease System can be ceased once child is in air on ≤ 4L/min 20

22. Weaning Generally there is no need for a prolonged weaning process - better to be on high flow oxygen therapy, standard low flow oxygen therapy or off oxygen therapy. If patient develops respiratory distress while weaning is in progress, return to the previous settings. If flow rate is under 2L/min and there is still an oxygen requirement, swap to low flow oxygen 21

23. Summary Senior ED/Paediatric Medical Officer review prior to commencement + On call paediatrician informed Commence at 1L/kg/min Flow and 40% FiO 2 AFTER 15mins if no clinical improvement review by Senior Paediatric Medical Officer - titrate up to 2L/kg/min to a maximum of 25 L/min Titrate FiO 2 up or down to maintain SpO 2 92-98% AFTER 60mins if no improvement or deteriorating escalate as per Local CERS & contact NETS 1300 36 2500 for transfer to Tertiary Facility If clinically stable wean 1. FiO 2 to maintain SpO 2 > 92% 2. Second decrease flow rate by half 22