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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 may be achieved. The high flows and humidification improve 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.HFNP is an aerosol generating procedure (AGP), a patient’s clinical requirement for HFNP should be balanced against the risk of aerosolization.
The aim of this guideline is to describe the
indications and procedure for the use of High Flow Nasal Prong (HFNP) therapy
within The Royal Children’s Hospital Melbourne
This guideline does not refer to the management of HFNP in the neonatal
patient. Please refer to the Newborn Intensive
There is provision for use of HFNP therapy on patients in mild respiratory distress or who exhibit signs of increasing oxygen requirements in order to prevent further deterioration.
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.
Oxygen therapy should be reduced or ceased if:
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.
Where an infant clinically improves, oral
feeds can commence:
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.
Continuous monitoring of SpO2 and HR until clinically stable
Within 2 hours it should be possible to reduce the FiO2 (where required) and signs of clinical stabilization should be seen
Seek medical review if any of the following occurs:
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 PICU Outreach if unsure.
When the child's clinical condition is improving as indicated by:
Consider transfer to low flow nasal prong oxygen therapy where HFNP is no longer required but clinical requirement for oxygen persists. Consult section on weaning oxygen on the Oxygen Nursing Guideline.
Continue pulse oximetry monitoring for 30 minutes post cessation of HFNP therapy, perform vital sign observation, intermittent SpO2 monitoring 30 minutes later, then hourly for 2 hours.
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.
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Please remember to read the disclaimer.
development of this nursing guideline was coordinated byThe development of this clinical guideline was coordinated by John Kemp, Clinical Support Nurse and Respiratory CNC, with the help of Lauren Davis, RN, Danielle Smith, NUM, and Rebecca McGrath, Clinical Nurse Specialist, all from Sugar Glider Medical Care, along with Dr Ed Oakley, Dr Micheal Cheung, Dr. Trevor Duke, and approved by the Nursing Clinical Effectiveness Committee. Updated June 2021.
Special thanks to Annabelle Santos and Bernie Attard, Clinical Support Nurses, Koala Ward