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Definition of Terms
Ceasing HFNP therapy
Humidified high flow nasal prong (HFNP) therapy is a form of non-invasive respiratory support. HFNP may act as a bridge between low flow oxygen therapies and CPAP, reducing the need for CPAP/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.Please Note: HFNP therapy is an aerosol generating procedure (AGP), a patient’s clinical requirement for HFNP should be balanced against the risk of aerosolization. When HFNP therapy is required for a SCOVID or COVID patient, this should be carried out in a negative pressure room using Airborne Precautions which include personal protective equipment (PPE): P2 respirator (N95 mask); Eye protection (e.g. Eyewear, face shield); Long-sleeved gown; Gloves (non-sterile). If a negative pressure room is unavailable, AGPs may be performed in a single room without negative pressure ventilation with the door closed. Airborne precautions should be maintained for 30minutes after an AGP has been performed. The patient should be transferred to a negative pressure room as soon as possible. PPE including P2/N95 masks should be discarded following an aerosol generating procedure or discarded and replaced if contaminated with blood or body fluids.
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
Patients requiring respiratory
Flow rate for HFNP Therapy is the same for all
patients regardless of medical condition
When HFNP therapy is commenced to provide respiratory support for children with non-respiratory issues, supplemental oxygen should be used cautiously with a FiO2 not greater than 0.3In children with cyanotic congenital heart disease and balanced circulation, HFNP therapy is generally used with an FiO2 of 0.21 (air) or a low increased fraction of oxygen (≤30%) The addition of supplemental oxygen requires approval from Cardiac or PICU ConsultantIn children with clinical signs of upper airway obstruction (noisy breathing, tracheal tug, subcostal retractions, absence of tachypnoea) or potential obstruction e.g., post-op Ts & As on HFNP therapy should only receive FiO2 0.21 (air). The addition of supplemental oxygen requires approval from ENT or PICU Consultant.Supplemental Oxygen therapy should be commenced for patients on HFNP who display hypoxaemia
Where supplemental oxygen is required, titrate FiO2 to the minimum amount required to maintain target SpO2.
Oxygen therapy should be reduced or ceased if:
Observation, 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.
The Airvo requires main power and is not portable. Patients receiving HFNP therapy who require transfer must be escorted by a nurse or doctor. Patients on HFNP with oxygen therapy, can be transferred on low flow oxygen therapy with HFNP re-established as soon as possible. If unstable off HFNP, patients require escalation of care prior to transport.
When the child's clinical condition is improving as indicated by:
Wean FiO2 to 21% then cease HFNP therapy. HFNP therapy should not be routinely weaned, just stopped.
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 Clinical 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 cease HFNP flow should be made at least once per shift.
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Please remember to read the disclaimer.
The development of this clinical guideline was coordinated by John Kemp, Clinical Support Nurse and Respiratory CNC, Sugar Glider and the coordination of making this guideline hospital wide was done by Sophie Linton, CNC, Nursing Innovation; and approved by the Nursing Clinical Effectiveness Committee. Updated November 2021.