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High Flow Nasal Cannula use for Bronchiolitis – Maternal/child Health unit PURPOSE: The purpose of this policy is to establish guidelines for initiation, maintenance, and weaning of high flow nasal cannula for use in infants and children with bronchiolitis. SCOPE: This policy applies to physicians, nurses, respiratory therapists and other staff responsible for assessing and treating children with bronchiolitis in the Maternal/Child Health unit. DEFINITIONS: For the purposes of this policy, the following definitions apply: High-flow Nasal Cannula (HFNC): A device that delivers humidified air and/or oxygen via nasal cannula at flow rates of up to 8 liters per minute. FiO2: Fractional concentration of inhaled oxygenSpO2: Pulse oximetry readingRespiratory assessment scoring sheet: Respiratory scoring tool for evaluating severity of bronchiolitis PROCESS: DETERMINATION OF NEED FOR HFNCAll pediatric patients arriving in the ED and on the pediatric unit are to be interviewed and examined by a physician. If bronchiolitis is the likely diagnosis, the need for HFNC will be considered. A respiratory assessment score (see attachment) is useful in identifying patients with bronchiolitis in need of increased intervention. A score greater than 8 suggests inadequate response to management. If the score remains greater than 8 despite conservative measures described below, HFNC should be considered.HFNC should be considered for patients aged greater than 8 weeks of age who are diagnosed with bronchiolitis, and who have a score greater than 8 despite a trial of more conservative measures which may include nasal suctioning, saline nebulization, albuterol nebulization, humidified air or oxygen provided via blow-by, low flow nasal cannula (up to 2 liters per minute flow), or simple oxygen mask. INITIATION OF HIGH-FLOW NASAL CANNULAThe decision to initiate HFNC should be made by a physician based on clinical discretion after an interview, physical examination, diagnostic studies, and conservative interventions as deemed appropriate.The initiation of HFNC is described in the HFNC Algorithm. A tertiary hospital PICU will be notified of the plan to initiate HFNC in a patient in case this intervention is not effective and ultimate transfer is required. In patients less than 8 weeks of age, HFNC can be started in anticipation of transfer to a tertiary care centerThe pediatric hospitalist will meet with the unit charge nurse, bedside nurse and RT to discuss the patient and staffing availability; if it is felt by any party that there is not appropriate staffing to appropriately care for the patient, arrangements will be made for transfer to a tertiary hospital. HFNC will be started as outlined below pending transfer. Prior to initiation, the equipment setup in the patient’s room should be evaluated to ensure that appropriate oxygen, suctioning and resuscitative equipment are present and functioning in the room.HFNC will be started with the assistance of respiratory therapy; flow rate will be 6 liters per minute for infants <5kg, and 8 liters per minute for infants >5kg. FiO2 will be started at the level the patient had previously been requiring, up to 100%. A cannula at least ? the diameter of the nares will be used to minimize air leak. If applicable, pacifier use will also be encouraged to minimize oral air leak. Additional testing including a blood gas and CXR will be considered if not already performed.Vital signs every 30 minutes for one hour, then hourly until the respiratory assessment score is less than 8. The patient will be on continuous pulse oximetry monitoring; cardiac monitoring may also be requested per provider preference.The patient will be made NPO for the first 4 hours of treatment and placed on appropriate IV fluids. After 4 hours, the patient’s ability to take PO may be re-evaluated as described in Section III.Reflux precautions (elevation of head of bed/crib) will be observed. ONGOING EVALUATION FOR PATIENTS UTILIZING HIGH-FLOW NASAL CANNULAIf a patient’s score is less than 8 and HFNC settings are stable or weaning, vital signs (including respiratory assessment scoring) may be done every 2-4 hours at the discretion of the physician.After 4 hours of HFNC, if the flow rate is less than 8 liters per minute and respiratory rate is not in the “severe” category as described in the respiratory assessment scoring, oral or nasogastric tube feedings may be considered.Patient will be monitored with continuous pulse oximetry.WEANING OF HIGH-FLOW NASAL CANNULAWean FiO2 as tolerated with every vital signs assessment to a goal FiO2 of 40%. Continue to wean as long as patient’s SpO2 is greater than 90% while awake and 88% while asleep. Once FiO2 is weaned to 40%, and if the score is 5 or less, decrease flow rate of air/oxygen by 1-2 L/min with every vital signs assessment to a goal of 2 L/min.When a patient is stable on HFNC at FiO2 of 40% or less, with a respiratory assessment score of 5 or less, and a flow rate of 2 L/min, consider transition to regular (low-flow) nasal cannula with a flow rate of 2 L/min or less. TRANSFER TO INCREASED LEVEL OF CAREFor patients requiring HFNC, criteria for transfer to a higher level of care include:No improvement in clinical appearance and/bronchiolitis score after 90 minutes of HFNC useUnable to wean FiO2 below 60% after 90 minutesPneumothoraxChronic lung diseaseNeuromuscular diseaseUnstable cardiac conditionsApnea greater than 20 secondsAge less than 8 weeksPrimary diagnosis does not include bronchiolitisUnable to wean any HFNC settings after 6 hoursInadequate staffing to provide appropriate care of the patientREFERENCES:Mayfield S, Jauncey-Cooke J, Hough JL, et al. High-flow nasal cannula therapy for respiratory support in children. Cochrane Database Syst Rev. 2014 Mar 7;(3):CD009850.Sinha I, McBride AKS, Smith R, et al. CPAP and High-Flow Nasal Cannula Oxygen in Bronchiolitis. Chest 2015;148(3): 810-823.McCallum, G, Morris, P, Wilson, C, et al. Severity Scoring Systems: Are They Internally Valid, Reliable and Predictive of Oxygen Use in Children With Acute Bronchiolitis? Pediatric Pulmonology 2013; 48: 797-803.Mikalsen I, Davis P and Oymar K. High flow nasal cannula in children: a literature review. Scand J Trauma Resusc Emerg Med 2016; 24: 93.Milesi C, Baleine J, Matecki S, et al. Is treatment with a high flow nala cannula effective in viral bronchiolitis? A physiologic study. Intensive Care Med 2013 Jun; 39(6):1170. Milesi C, Boubal M, Jacquot A, et al. High-flow nasal cannula: recommendations for daily practice in pediatrics. Annals of Intensive Care 2014; 4:29Kallappa C, Hufton M, Millen G, et al. Use of high flow nasal cannula oxygen (HFNCO) in infants with bronchiolitis on a paediatric ward: a 3-year experience. Arch Dis Child 2014; 99: 790-791.Newton-Wellesley Hospital – High-Flow Nasal Cannula Use for BronchiolitisKaiser Hospital System, Northern California – Pediatric High Flow Nasal Cannula Bronchiolitis PathwayRiverton Hospital – High-Flow Nasal Cannula for Bronchiolitis AlgorithmSeattle Children’s – HFNC Inpatient GuidelinesRespiratory Assessment Scoring Sheet0123ScoreRespiratory RateNormal≤ 2 mo <602-12 mo <5012-24 mo <40Mild tachypnea≤ 2mo 60-692-12 mo 50-5912-24 mo 40-49Moderate tachypnea≤ 2 mo 70-792-12 mo 60-6912-24 mo 50-59Severe tachypnea≤ 2 mo ≥802-12 mo ≥7012-24 mo ≥60General AppearanceAsleep, calm, content. Happy and/or interactive.Mildly irritable when touched with occasional crying, but can be consoled.Moderately irritable, difficult to console, less interactive.Extremely irritable, cannot be comforted, crying inconsolable. Or not interactive.Accessory Muscle UseNo retractionsMild retractions (Abdominal)Moderate retractions (Intercostal, Subcostal, some increased work of breathing)Severe retractions (Obvious intercostal, subcostal, tracheal retractions. Seesaw breathing and nasal flaring.)WheezingNo wheezing or cracklesScattered wheezing with end expiratory wheezes and cracklesModerate wheezing (diffuse expiratory wheezing, with or without scattered early inspiratory wheezing)Severe wheezing (diffuse inspiratory and expiratory wheezing). Tight/absent breath sounds.Total:Adapted from Wang et al. Observer agreement for respiratory signs and oximetry in infants hospitalized with lower respiratory tract infections. Am Rev Respir Dis 1992; 145(1): 106-109.Moderate bronchiolitis = score >5Severe bronchiolitis = score >8, consider HFNC ................
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