In this section
Definition of Terms
Humidified high flow nasal prong (cannula) therapy is a form of non-invasive respiratory support which has been compared to continuous positive airway pressure (CPAP). HFNP may act as a bridge between low flow oxygen therapies and Nasal CPAP (NCPAP), reducing the need for NCPAP/intubation. At high flows of 2 litres per kilogram per minute, using appropriate nasal prongs, a positive distending pressure of 4-8 cmH2O may be achieved. The high flows and humidification improves functional residual capacity and mucocililary clearance of secretions thereby reducing work of breathing. The high flows may also affect pulmonary and systemic circulation which is an important consideration when applying HFNP therapy to children with cardiac disease.
The aim of this guideline is to describe the indications and procedure for the use of High Flow Nasal Prong (HFNP) therapy in approved areas within The Royal Children’s Hospital MelbourneThis guideline does not refer to the management of HFNP in the neonatal patient. Please refer to the Newborn Intensive Care Unit.
Note: A randomized controlled trial is currently being undertaken at RCH investigating the early use of HFNP in children with acute hypoxemic respiratory failure – see link to PARIS II
NB. See also Paris II trial
Secure nasal cannula on patients using supplied “Wiggle pads,” ensuring the prongs sit well into the nares. Nasal prongs should not completely occupy the nares. Start the high flow nasal cannula system in room air ie. 21% oxygenOnce prescribed flow rate is reached assess requirement for supplemental oxygen.
NB. See also Paris II
trial (for children 1-5 years of age)
Flow rate for HFNP Therapy is the same for all
patients regardless of medical condition
There is a difference in oxygen requirements of
children with cyanotic congenital heart disease and balanced circulation
compared to general medical patients. In such patients HFNP therapy is
generally used with an FiO2
of 0.21 (i.e. room air), or a low increased fraction of oxygen (≤30%).
Approval should be sought with the Cardiac
Consultant or PICU consultant before oxygen therapy is commenced for a patient
with cyanotic congenital heart disease.
Because flows used are high, heated water humidification is necessary to avoid drying of respiratory secretions and for maintaining nasal cilia function. Airvo humidifier setting at 34° C non-invasive setting.
If an infant clinically improves as described below, it is allowed to feed orally on the condition that HFNP therapy is turned down to LOW FLOW, and 95% oxygen where they have an oxygen requirement, using the AIRVO2, for the duration of the feeds. After a maximum of 20 minutes, oral feeds/breast feed should be stopped and HFNP therapy recommenced at previous settings.Oral feed should be ceased and HFNP therapy recommenced if child clinically deteriorates during feeding.
Observation and patient clinical assessment and documentation should occur hourly at a minimum. Adjustment of frequency of patient observation and assessment should occur in response to clinical condition.
Sometimes an infant commenced on HFNP will be more distressed because of the discomfort of the therapy. This is sometimes interpreted as indicating a deterioration requiring escalation of therapy. However sometimes such infants will be just as stable, or even more settled, simply on standard low flow 100% oxygen. Deciding which children require escalation and which children would be better changed to standard flow 100% oxygen therapy requires judgement and sometimes a trial of standard oxygen. This decision is best made by a doctor and nurse who have observed the child consistently since commencement of HFNP therapy. Contact the Consultant Paediatrician or ICU Outreach / ICU Consultant if unsure.
When the child's clinical condition is improving as indicated by:
Where cessation of HFNP therapy is successful – usually known within 2 hours of stopping - continuous pulse oximetry monitoring may be discontinued.Unless contraindicated, an attempt to wean oxygen or stop HFNP flow should be made at least once per shift.Generally there is no need for a weaning process from HFNP better to be on high flow, standard low flow, or off oxygen therapy.
Click here to view the evidence table.
Please remember to read the disclaimer.
development of this nursing guideline was coordinated by John Kemp, Clinical Support Nurse, SugarGlider,
and approved by the Nursing Clinical Effectiveness Committee. Updated October 2018.