What are the guidelines for initiating pediatric high flow nasal cannula (HFNC) therapy?

From the Guidelines

High flow nasal cannula (HFNC) therapy in pediatric patients should typically be initiated at flow rates of ≥ 1 L/kg/min for patients up to 10 kg and ≥ 10 L/min for patients above 10 kg, as defined by recent operational definitions related to pediatric ventilator liberation 1. When starting HFNC, it is crucial to consider the patient's weight and adjust the flow rate accordingly. For patients up to 10 kg, the flow rate should be at least 1 L/kg/min, while for those above 10 kg, the flow rate should be at least 10 L/min. Some key points to consider when initiating HFNC include:

• Starting with an FiO2 (oxygen concentration) of 40-60% and titrating based on oxygen saturation goals, typically aiming for SpO2 >92-94%
• Setting the temperature at 34-37°C for optimal humidification and comfort
• Ensuring proper equipment sizing by selecting an appropriate cannula size that occupies no more than 50% of the nares to allow adequate pressure release
• Monitoring the patient closely after initiation, including continuous pulse oximetry, respiratory rate, work of breathing, and heart rate HFNC is particularly useful for children with moderate respiratory distress, including conditions like bronchiolitis, pneumonia, or asthma, who require more support than conventional oxygen therapy but do not yet need non-invasive or invasive ventilation 1. It is essential to note that HFNC works by providing heated, humidified oxygen at flows that exceed the patient's inspiratory flow rate, which washes out anatomical dead space, provides some positive pressure, reduces work of breathing, and improves oxygenation and ventilation. By following these guidelines and considering the latest evidence, healthcare providers can effectively initiate HFNC therapy in pediatric patients and improve their outcomes.

From the Research

Initiating Pediatric High Flow Nasal Cannula

To initiate pediatric high flow nasal cannula (HFNC), several factors should be considered, including the patient's age, weight, and underlying condition.

• The initial flow rate for HFNC in pediatric patients can vary, but a study by 2 found that post-protocol patients had a significantly higher initial flow rate (median 14.5 L/min) compared to pre-protocol patients (median 10 L/min).
• Another study by 3 suggests that HFNC may be beneficial for moderately severe acute viral bronchiolitis, and its use may be considered for weaning from invasive ventilation and acute asthma.
• When initiating HFNC, it is essential to monitor the patient closely, whether in the emergency department, pediatric intensive care unit, or during transport 3.
• The definition of HFNC, how to set initial flow, and aerosolized medication delivery are areas where more research is needed, as there is currently no consensus on these topics 4.

Setting Initial Flow Rate

The initial flow rate for HFNC in pediatric patients can be set based on various factors, including:

• Provider orders 4
• Respiratory therapist-driven protocol 4
• Patient weight 4
• Patient age 4
• A study by 2 found that a higher initial flow rate was associated with a higher weaning rate and a lower HFNC failure rate.

Considerations for Oral Feeding

When considering oral feeding for pediatric patients on HFNC, it is essential to note that:

• There is a lack of data on optimal flow rates and its impact on morbidity, mortality, and desired outcomes 5
• The practice of withholding oral feeding solely because of HFNC is not supported in the literature, but clinicians should proceed with caution and consider patient-specific factors 5