Survey of Current Institutional Practices in the Use of High-Flow Nasal Cannula for Pediatric Patients.

OBJECTIVES: High-flow nasal cannula (HFNC) is an oxygen delivery device that provides heated humidified air with higher flow rates. The purpose of this survey is to look at institutional practice patterns of HFNC initiation, weaning, and disposition for pediatric patients across the United States. METHODS: Survey was sent via electronic listservs to pediatric physicians in emergency medicine, hospital medicine, critical care, and urgent care. The questionnaire was divided into demographics and HFNC practices (initiation, management, and weaning). One response per institution was included in the analysis. RESULTS: Two hundred twenty-four responses were included in the analysis, composed of 40% pediatric emergency medicine physicians, 46% pediatric hospitalists, 13% pediatric intensive care unit (PICU) physicians, and 1% pediatric urgent care physicians. Ninety-eight percent of the participants have HFNC at their institution. Thirty-seven percent of the respondents had a formal guideline for HFNC initiation. Nearly all guideline and nonguideline institutions report HFNC use in bronchiolitis. Guideline cohort is more likely to have exclusion criteria for HFNC (42% in the guideline cohort vs 17% in the nonguideline cohort; P < 0.001) and less frequently mandates PICU admissions once on HFNC (11% in the guideline cohort vs 56% in the nonguideline cohort; P < 0.001). Forty-six percent of guideline cohort had an objective scoring system to help determine the need for HFNC, and 73% had a weaning guideline. CONCLUSIONS: Although there is general agreement to use HFNC in bronchiolitis, great practice variation remains in the initiation, management, and weaning of HFNC across the United States. There is also a discordance on PICU use when a patient is using HFNC.

High flow nasal cannula use outside of the ICU; factors associated with failure.

OBJECTIVES: High flow nasal cannula (HFNC) use is increasing in pediatrics. Few studies exist examining the safety of HFNC use outside the intensive care unit (ICU). This study aimed to characterize patient qualities associated with failure of HFNC use outside the ICU. STUDY DESIGN: A retrospective chart review of patients placed on HFNC outside the ICU from September 2011 to July 2013 was completed. Failure was defined as intubation or cardiopulmonary arrest. Two-sample tests and binary logistic regression determined significant factors associated with failed HFNC administration, both unadjusted and adjusted for hospital. RESULTS: Two hundred thirty-one patients met inclusion criteria, with 192 receiving treatment for a primary respiratory diagnosis (83%). Fourteen (6%) progressed to HFNC failure; 12 transferred to the ICU and were intubated, two with congenital heart disease suffered cardiopulmonary arrest on the floor. Two-sample tests revealed failure patients were more likely to have a cardiac history (P = 0.026), history of intubation (P = 0.040), and require higher fraction of inspired oxygen (FiO2 ) (median 100%; 25th-75th 60-100%; P = <0.001). Hospital adjusted logistic regression further demonstrated failure patients were more likely to be treated with higher FiO2 (OR: 38.3; 95% CI: 4.0-366.3; P = 0.002), and less likely to have a diagnosis of bronchiolitis (OR: 0.3; 95% CI: 0.1-0.9; P = 0.048). CONCLUSIONS: High FiO2 requirements, history of intubation, and cardiac co-morbidity are associative predictors of HFNC failure. Bronchiolitis patients may be treated with HFNC outside of the ICU with lower odds of failure. Pediatr Pulmonol. 2017;52:806-812. © 2017 Wiley Periodicals, Inc.