Guidelines for High-Flow Nasal Cannula Oxygen Therapy in Infants and Children
High-flow nasal cannula (HFNC) oxygen therapy is recommended as an initial respiratory support option for infants and children with respiratory distress, particularly in cases of moderate to severe bronchiolitis or sepsis-induced respiratory compromise. 1, 2
Indications for HFNC Use
Primary Indications
- Respiratory distress with hypoxemia despite conventional oxygen therapy
- Initial respiratory support in septic shock 1
- Post-extubation respiratory support, especially in high-risk patients 1
- Moderate to severe bronchiolitis 2
- Acute respiratory failure not requiring immediate intubation 3
Patient Selection Criteria
- SpO₂ < 92% despite conventional oxygen therapy
- Compensatory tachypnea
- Increased work of breathing (retractions, nasal flaring, grunting)
- No contraindications such as severe nasal obstruction
Age-Specific Recommendations
Infants (<1 year)
- CPAP is preferred over HFNC for infants under 1 year of age requiring non-invasive respiratory support 1
- For infants with CPAP contraindications, HFNC may be used as an alternative
- Initial flow rates: 1-2 L/kg/min (maximum 8-10 L/min)
- FiO₂ titrated to maintain SpO₂ ≥ 92%
Children (>1 year)
- HFNC, CPAP, or NIV are all appropriate first-line therapies 1
- Initial flow rates: 0.5-1 L/kg/min (maximum 20-30 L/min for older children)
- Choice depends on clinical setting and patient circumstances
Implementation Protocol
Initial Settings
Flow Rate:
- Infants: 1-2 L/kg/min (maximum 8-10 L/min)
- Children: 0.5-1 L/kg/min (maximum 20-30 L/min)
FiO₂:
- Start at 0.4-0.6
- Titrate to maintain SpO₂ ≥ 92%
Temperature:
- 37°C for adequate humidification
Monitoring Parameters
- Continuous monitoring of:
- Respiratory rate
- Heart rate
- Oxygen saturation
- Work of breathing (retractions, accessory muscle use)
- Level of consciousness
- Signs of respiratory muscle fatigue
Response Assessment
- Evaluate response within 1-2 hours of initiation
- Positive response indicators:
- Decreased respiratory rate
- Decreased heart rate
- Improved oxygen saturation
- Reduced work of breathing
- Improved level of consciousness
Escalation of Care
Indicators for Treatment Failure
- Persistent or worsening tachypnea
- Increased work of breathing despite HFNC
- Inability to maintain SpO₂ > 92% despite increasing FiO₂
- Deteriorating level of consciousness
- Development of apnea
Next Steps for Treatment Failure
- For infants < 1 year: Consider switching to CPAP 1
- For children > 1 year: Consider NIV if HFNC fails 1
- Prepare for intubation if non-invasive support fails
Clinical Benefits and Evidence
- HFNC reduces the risk of treatment failure by 85% compared to conventional oxygen therapy 4
- Significant improvement in clinical respiratory scores, heart rate, and respiratory rate at 120-360 minutes compared to conventional oxygen therapy 4
- May prevent endotracheal intubation in children with moderate-to-severe respiratory distress 2, 4
- Provides better patient comfort than NIV 5
- Offers physiological benefits including:
- Improved oxygenation
- Reduced work of breathing
- Low-level positive end-expiratory pressure
- Enhanced secretion clearance through heated humidification 5
Potential Complications and Cautions
- Nasal irritation or soreness
- Reduced effectiveness with severe nasal congestion
- Delayed recognition of clinical deterioration (monitor closely)
- Not recommended as first-line therapy for severe ARDS or severe hypercapnic respiratory failure
Key Practice Points
- HFNC should be initiated early in the course of respiratory distress
- For infants < 1 year, CPAP is preferred over HFNC when available 1
- Close monitoring is essential to identify treatment failure early
- HFNC can be used in emergency departments, hospital wards with appropriate monitoring, and intensive care settings 3
- HFNC may be particularly beneficial in bronchiolitis, post-extubation support, and sepsis-induced respiratory distress 1, 2
By following these guidelines, clinicians can effectively implement HFNC therapy in pediatric patients with respiratory distress, potentially avoiding the need for more invasive respiratory support while improving patient outcomes and comfort.