Respiratory and Oxygen Guidelines

Children’s Hospital of Illinois

Contents:

Oxygen and HHFNC Monitoring and Weaning

Initiation and Management of HHFNC on General Pediatrics

Feeding Guidelines for Patients on HHFNC

Bronchiolitis Pathway

References

Updated March 2022

Oxygen and HHFNC Monitoring and Weaning

Oxygen Saturation Monitoring

• Oxygen saturation will be assessed on admission and with vital signs as per protocol
• Continuous pulse oximetry should ONLY be used when:

• The first hour after initiation of oxygen therapy
• Patient is on >2 LPM oxygen
• Patient has severe respiratory distress or severe bronchiolitis (score >6)
• Patient is less than 1 month of age

• For patients weaning oxygen, continuous monitoring may be discontinued when they have weaned to 2 LPM

Oxygen Therapy Initiation

• Patient will be placed on oxygen to maintain SpO2 greater than 90%, for persistently increased work of breathing, or persistent tachypnea for age
• Patients >2 years should be started on 1 LPM; patients <2 years should be started on 0.5 LPM

Oxygen Weaning for Nasal Cannula

• Patient may be weaned when SpO2 greater than 94%
• Patients should be weaned approximately every 1-2 hours as tolerated
• Patients >2 years should be weaned in 1 LPM or greater increments; patients <2 years should be weaned in 0.5 LPM or greater increments, as tolerated
• Regulators that allow weaning in <0.5 LPM increments should be reserved for those infants <1 month with a history of prematurity or comorbidities

Oxygen Weaning for HHFNC

• Wean FiO2 by 5-10 % every hour toward FiO2 less than 40% before beginning to wean flow, then wean FiO2 and flow in an alternating manner or per clinician discretion
• Flow should be weaned approximately every 1-2 hours as tolerated
• The nurse will be notified of any changes to the oxygen flow rate or FiO2
• The respiratory therapist or nurse will reassess the patient 5-10 minutes after the oxygen flow rate is changed

Reasons to notify the physician/provider

• Increasing oxygen flow rate or FiO2
• Increase in bronchiolitis score to > 6 or PEWS score > 6
• Signs of worsening respiratory distress
• Patient has met discharge criteria

Discharge to Home Criteria

**Must meet all 4 discharge criteria**

• SpO2 greater than 90%
• Off of supplemental oxygen for at least 6 hours (must include at least one period of sleep; pulse ox should be checked at least once but continuous monitoring is not required)
• Normal respiratory rate or mild tachypnea
• Minimal to no retractions

Initiation and Management of Heated High Flow Nasal Cannula (HHFNC) on General Pediatrics

Purpose

The goal of these guidelines is to standardize the use of HHFNC on general pediatrics. They are not intended to replace clinical judgement.

Prior to initiation of HHFNC, other measures should be tried first such as suctioning, anti-pyretics, and hydration. HHFNC should be limited to moderate-severe bronchiolitis.

Patient disposition should take into consideration other patient factors and not flow rates alone.

Inclusion Criteria

• Infants and children admitted for bronchiolitis

Exclusion Criteria (may use HHFNC however will need higher level of care)

• Age <2 months
• Prematurity with corrected GA <50 weeks
• Airway abnormalities
• Chronic conditions (neuromuscular, chronic lung, or significant cardiac disease)
• Respiratory conditions other than bronchiolitis (asthma, pneumonia)

Instructions when initiating HHFNC on General Pediatrics

• Initiate at 1 L/kg/min
• Reassess 30 minutes after initiation
• Vital signs and focused respiratory assessment Q1hr x2, then per pathway

• Transfer to higher level of care criteria:  

• Patients with failure to improve or severe symptoms after ~1-2 hours on HHFNC, sooner if worsening (based on bronchiolitis scores, PEWS, and multidisciplinary assessment)
• Patients in the SFMC ED newly started on ≥1 L/kg/min HHFNC without sufficient time to observe prior to disposition
• Flow rates ~1.5 L/kg/min (max 10-15 L), consider PIC transfer
• Flow rates ~2 L/kg/min (max 15-20 L), consider PICU transfer/consult
• FiO2 >60% for greater than 2-3 hours, consider PICU transfer/consult

Criteria for Early Transfer from PIC to General Pediatrics while on HHFNC

• Stable respiratory status or decreasing flow for 12 hours; no specific flow rate criteria
• Exclusion criteria same as above        
• Patients with respiratory failure requiring intubation or positive pressure ventilation should be closely monitored in PIC for at least 24 hours

Feeding Guidelines for Patients on HHFNC

Oral feedings

• Keep NPO status for at least 4 hours after initiation of HHFNC
• Start reflux precautions in all patients on HHFNC
• Oral feeds may be restarted if patient stable and the following criteria are met:

• Stable or decreasing flow rates for at least 4 hours
• RR ≤ 65 BPM in patients < 1 year of age
• RR ≤ 45 BPM in patients > 1 year of age

• First feeding MUST be closely monitored by bedside nurse or feeding therapist
• Consider delaying oral feeds until off HHFNC if:

• Prior history of aspiration
• Exclusion criteria listed above for HHFNC on general pediatrics

Nasogastric tube feedings

• Should be kept NPO for 4 hours after initiation of HHFNC
• May be used in patients who do not meet criteria to start oral feeds or oral intake is inadequate
• May be started when patient is stable or improving

G or J tube feedings

• Should be kept NPO for 4 hours after initiation of HHFNC
• Feeds may be restarted if patient is stable and tolerates feedings

For ALL Feedings

• Feedings should be discontinued at any time if there are signs of aspiration or intolerance to feedings
• Parents and/or caregivers MUST be educated on feedings and signs of aspiration

Bronchiolitis Pathway

References

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2. Beggs S, Wong ZH, Kaul S, Ogden KJ, Walters JA. High-flow nasal cannula therapy for infants with bronchiolitis. Cochrane Database Syst Rev. 2014 Jan 20;1:CD009609.

3. Bressan S, Balzani M, Krauss B, Pettenazzo A, Zanconato S, Baraldi E. High-flow nasal cannula oxygen for bronchiolitis in a pediatric ward: a pilot study. Eur J Pediatr. 2013 Dec;172(12):1649-56.

4. 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 Aug;99(8):790-1.

5. Mayfield S, Bogossian F, O'Malley L, Schibler A. High-flow nasal cannula oxygen therapy for infants with bronchiolitis: pilot study. J Paediatr Child Health. 2014 May;50(5):373-8.

6. McKiernan C, Chua LC, Visintainer PF, Allen H. High flow nasal cannulae therapy in infants with bronchiolitis. J Pediatr. 2010 Apr;156(4):634-8.

7. Milesi C, Baleine J, Matecki S, Durand S, Combes C, Novais AR, et al. Is treatment with a high flow nasal cannula effective in acute viral bronchiolitis? A physiologic study. Intensive Care Med. 2013 Jun;39(6):1088-94.

8. Milesi C, Boubal M, Jacquot A, Baleine J, Durand S, Odena MP, et al. High-flow nasal cannula: recommendations for daily practice in pediatrics. Ann Intensive Care. 2014 Sep 30;4:29,014-0029-5. eCollection 2014.

9. Schibler A, Pham TM, Dunster KR, Foster K, Barlow A, Gibbons K, et al. Reduced intubation rates for infants after introduction of high-flow nasal prong oxygen delivery. Intensive Care Med. 2011 May;37(5):847-52.

10. Wing R, James C, Maranda LS, Armsby CC. Use of high-flow nasal cannula support in the emergency department reduces the need for intubation in pediatric acute respiratory insufficiency. Pediatr Emerg Care. 2012 Nov;28(11):1117-23.

11. Bressan S, Balzani M, Krauss B, Pettenazzo A, Zanconato S, Baraldi E. High-flow nasal cannula oxygen for bronchiolitis in a pediatric ward: a pilot study. Eur J Pediatr. 2013 Dec;172(12):1649-56.

12. Mayfield S1, Bogossian F, O'Malley L, Schibler A. High-flow nasal cannula oxygen therapy for infants with bronchiolitis: pilot study. J Paediatr Child Health. 2014 May;50(5):373-8.

13. Riese J, Fierce J, Riese A, Alverson BK. Effect of a Hospital-wide High-Flow Nasal Cannula Protocol on Clinical Outcomes and Resource Utilization of Bronchiolitis Patients Admitted to the PICU. Hosp Pediatr. 2015 Dec;5(12):613-8.

14. Riese J, Porter T, Fierce J, Riese A, Richardson T, Alverson BK. Clinical Outcomes of Bronchiolitis After Implementation of a General Ward High Flow Nasal Cannula Guideline. Hosp Pediatr. 2017 Apr;7(4):197-203.

15. Kepreotes E, Whitehead B, Attia J, Oldmeadow C, Collison A, Searles A, Goddard B, Hilton J, Lee M, Mattes J. High-flow warm humidified oxygen versus standard low-flow nasal cannula oxygen for moderate bronchiolitis (HFWHO RCT): an open, phase 4, randomised controlled trial. Lancet. 2017 Mar 4;389(10072):930-939.

16. Goh CT, Kirby LJ, Schell DN, Egan JR. Humidified high-flow nasal cannula oxygen in bronchiolitis reduces need for invasive ventilation but not intensive care admission. J Paediatr Child Health. 2017 Sep;53(9):897-902.

17. Davison M, Watson M, Wockner L, Kinnear F. Paediatric high-flow nasal cannula therapy in children with bronchiolitis: A retrospective safety and efficacy study in a non-tertiary environment. Emerg Med Australas. 2017 Apr;29(2):198-203.
18. Betters KA, Gillespie SE, Miller J, Kotzbauer D, Hebbar KB. High flow nasal cannula use outside of the ICU; factors associated with failure. Pediatr Pulmonol. 2017 Jun;52(6):806-812.

19. Sochet AA, McGee JA, Waeerah T. Oral Nutrition in Children With Bronchiolitis on High-Flow Nasal Cannula Is Well Tolerated. Hospital Pediatrics May 2017, 7 (5) 249-255.

20. Slain KN, Martinez-Schlurmann N, Shein SL, Stormorken A. Nutrition and High-Flow Nasal Cannula Respiratory Support in Children With Bronchiolitis. Hospital Pediatrics May 2017, 7 (5) 256-262.