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High Flow Nasal Cannula in Bronchiolitis | Part 1

Lisa Patel, MD and Andrea Marmor, MD

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High flow nasal cannula is being used with increasing frequency on pediatric ward floors for children with bronchiolitis.  Lisa and Andi discuss the evidence on its use to reduce escalation of care and decrease length of stay. They also discuss how to start, titrate and wean settings on HFNC.

  • High flow nasal cannula (HFNC) is a well tolerated noninvasive method of ventilatory support. The advantage of HFNC over standard nasal cannula include the fact that it permits high flow rates of humidified and heated oxygen.

    • The warmth and humidity inhibit the bronchoconstriction reflexes triggered by cold and dry air.

    • The heat itself helps preserve some of the metabolic energy use of the patient. 

    • HFNC is though to deliver a higher FiO2 into the lower airways and it provides some degree of positive end expiratory pressure, which prevents alveolar collapse at the end of expiration. 

    • HFNC provides CO2 wash out of the anatomic dead space in the upper and intrathoracic airways  thereby improving the efficiency of ventilation and enhancing oxygen delivery. 

  • A 2014 Cochrane review assessed the effects of HFNC therapy compared with conventional respiratory support in the treatment of infants with bronchiolitis. There was no clear evidence of a difference in total duration of oxygen therapy, time to discharge or total length of stay between the two groups. 

Beggs et al. High-flow nasal cannula therapy for infants with bronchiolitis. Cochrane Database Syst Rev. 2014 Jan 20;(1):CD009609. PMID: 24442856.

  • More recently, there have been two high quality randomized controlled trials that have shown that the initiation of HFNC reduces the need for escalation of care (such as needing transfer to the ICU) and is well tolerated without adverse events. However, the studies did not find a significant difference in the duration of hospital stay or the duration of oxygen therapy. 

Franklin et al. A Randomized Trial of High-Flow Oxygen Therapy in Infants with Bronchiolitis. N Engl J Med. 2018 Mar 22;378(12):1121-1131. PMID: 29562151. 

Kepreotes et al. High-flow warm humidified oxygen versus standard low-flow nasal cannula oxygen for moderate bronchiolitis (HFWHO RCT): an open, phase 4, randomised controlled trial.  Lancet. 2017 Mar 4;389(10072):930-939. PMID: 28161016. 

  • The use of HFNC therapy should be considered in infants and children who are worsening or who have failed standard oxygen therapy; it can be a means to avoid  endotracheal intubation. (Standard oxygen therapy is most typically defined as supplemental oxygen through a nasal cannula, up to a maximum of 2 liter per minute). 

    • Respiratory scores, which vary by institution, can be used to help assess how a patient’s respiratory status is responding to a particular therapy and can help the clinician determine if the patient requires escalation of care. The majority of respiratory scores look at the following variables: hypoxemia, respiratory distress (i.e. respiratory rate), work of breathing (i.e. retractions), auscultatory findings, and dyspnea (e.g. ability to feed). 

  • Relative contraindications to starting HFNC on the floor include abnormalities of the face or airway that preclude an appropriate-fitting nasal cannula, airway abnormalities, infants with cyanotic heart disease, infants who were receiving oxygen therapy at home or those that have chronic lung disease. 

  • When weaning HFNC, it is generally recommended that FiO2 be weaned first and then the flow rate. Flow should be weaned stepwise, from floor max to min to off. In some instances, flow can be weaned from max flow to off. 

  • Indications that a patient might require transfer to the ICU include a patient that is clinically worsening despite maximum floor HFNC flow and/or a patient that has desaturations despite maximum floor FiO2. 

  • Because there is limited data on the treatment of critically-ill children with bronchiolitis, albuterol may be trialed as an adjunct therapy in patients with severe distress or risk factors for asthma.

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Hippo Peds RAP - October 2019 Written Summary 347 KB - PDF

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