Continue monitoring on pediatric ward. Proceed to Weaning Pathway
Original version 10/31/17
Last updated 5/2019
Within 30-60min after escalation, reevaluate and discuss patient status with pediatric intensivist to determine if patient can continue to be managed on the pediatric ward versus PICU admission.
Important Notes:
- If a patient admitted on a non-hospitalist service qualifies for HHFNC initiation on the ward, they must be transferred to the in-house hospitalist service if HHFNC is to be initiated.
- For patients on HHFNC, the RT, RN, and MD will gather for a brief bedside huddle twice daily to discuss patient's course and condition at 0900 and 2100.
- Patients placed on HHFNC should not be started on enteral feeds (PO or NG) until 12-24hr of improvement
Monitor on pediatric ward
PICU patients on HHFNC may be transferred to the pediatric ward after ~12hr if:
- Flow 6LPM or less
- FiO2 = 40% or less
- No need for suctioning more frequently than q2hr
- Not on continuous nebulized medication (i.e. albuterol, racemic epinephrine)
Transfer to pediatric center with PICU support
Decision making post-bedside huddle.
Transfer to pediatric center with PICU support
Weaning Pathway
- If RS<5, wean by 1L/min every 4 hours until on minimum flow rate of 2LPM
- Wean FiO2 to goal of 21% as tolerated if blender is available
- Once stable on 2L/min at FiO2 <40% for 12hr, switch to conventional NC 1L/min at FiO2=100%
- When on weaning pathway, MD to assess patient and perform respiratory score at least every 12 hours with RT (ideally at 0900 and 2100)
Continue weaning conventional NC per RN/MD staff
Bedside huddle within 30-60min of initiating HHFNC to reevaluate and determine disposition. Consider repeating capillary blood gas to trend PaCO2.
- Bedside RN
- Primary RT
- Pediatric hospitalist
- ED physician (if initiated in ED)
- Consider involvement of pediatric intensivist
Initiate HHHFNC at 6 L/min, FiO2 100%
References:
John Muir Medical Center Heated High Flow Nasal Cannula Policy (intranet link)
Kallappa C, Hufton M, Millen G, Ninan TK. 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(8):790–791
Mikalsen IB, Davis P, Øymar K. High flow nasal cannula in children: a literature review. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2016;24:93. doi:10.1186/s13049-016-0278-4
Admit to PICU
Respiratory Score
Variable | 0 | 1 | 2 | 3 | Total |
RR (3-12mo) RR (1-2yo) RR (2-3yo) | n/a | <50 <40 <30 | 51-59 41-49 31-35 | >60 >50 >36 | ________ |
Retractions | None | Mild (abdominal only) | Moderate (intercostal, subcostal) | Severe (deep throughout) | ________ |
Dyspnea | Normal feeding, vocalizations, activity | 1 of the following: Difficulty feeding, decreased vocalization, agitation | 2 of the following: Difficulty feeding, decreased vocalization, agitation | Stops feeding, no vocalization, grunting (infant) OR confused/drowsy | ________ |
Auscultation | Normal breathing, no wheezing | End-expiratory wheezing only | Expiratory wheeze only | Inspiratory and expiratory wheezing AND/OR decreased breath sounds | ________ |
Total Respiratory Score: | ________ |
- Increased work of breathing (Respiratory Score >/= 5) despite repositioning and nasopharyngeal suctioning
- SpO2 consistently <90% despite administration of 2-4L supplemental oxygen via conventional nasal cannula (FiO2 100%)
- Age <12 weeks OR history of ex-35wk prematurity
- Concern for impending respiratory failure requiring intubation (lethargy, apnea)
- History of respiratory failure requiring intubation, positive pressure ventilation, and/or PICU admission
- Known cardiac disease
- Known neuromuscular disease
- Chronic lung disease
- Abnormal airway anatomy
- Immunodeficiency
- Concomitant use of any continuously nebulized medication (albuterol, racemic epinephrine)
Before initiation of HHFNC
- Optimize nasopharyngeal suctioning
- Consider capillary blood gas to evaluate level of hypercarbia
- Consider placing PIV, giving NS bolus, and making patient NPO
Escalation Pathway
- Continue routine suctioning and repositioning
- If patient's SpO2 remains <90% and/or no improvement in WOB score despite 6L/min flow at FiO2 100%, increase flow to 8L/min
- While on escalation pathway, MD should assess every 30min-1hr until patient either stable or is transferred to higher level of care (PICU)