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Child Health Guideline Identifier

Bronchiolitis - High Flow Nasal Cannula treatment

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This guideline is to support the use of High Flow Nasal Cannula (HFNC) for patients with bronchiolitis admitted to Starship Children's Hospital.

When to consider use of HFNC

  • Diagnosis of bronchiolitis
  • O2 saturations less than 92%
  • Patients not responding to use of traditional low flow nasal oxygen
  • Patients outside these criteria may be considered on a case-by-case basis on discussion with senior medical staff

Exclusion criteria (unless specifically discussed with and agreed by paediatric consultant)

  • Upper airway obstruction
  • Apnoeas
  • Craniofacial malformation
  • Basal skull fracture
  • Trauma
  • Critically ill with immediate need for intubation or non-invasive ventilation
  • Decreased level of consciousness
  • Cyanotic heart disease
  • Home O2 therapy

Commencing HFNC

HFNC High flow group

Titrating and weaning HFNC

titration flowchart

For patients on HFNC do not wean the flow rate, only wean the FiO2

Some clinical decisions are at the discretion of medical staff. The discussion below is to help guide these decisions.

When to determine a patient is a non-responder

No specific cut off time determines whether a patient is a non-responder. This is a clinical decision as the appropriate amount of time to wait will vary between patients. Some illustrative examples:

  • Patient 1 starts on HFNC at 60% FiO2. Effort of breathing clearly starts to improve within 30 minutes. FiO2 is able to be weaned quickly. It is appropriate to allow this patient time to see if the patient will manage with FiO2 <40% as there is observed clinical improvement.
  • Patient 2 starts on HFNC at 50% FiO2. Effort of breathing does not improve, and FiO2 requirement increases by 30 minutes. It is appropriate to call for PICU review at this point as there is clinical deterioration.

At any point, if there is concern about the clinical status of the patient, particularly if deteriorating, then call for PICU review

Feeding instructions for patient on HFNC

  • Feeding and fluid management follows standard practice for bronchiolitis.
  • For all patients on HFNC a nasogastric tube (NGT) is inserted.  Regular de-venting of the stomach through aspiration of the NGT needs to be performed every 4 hours at a minimum (including for patients on continuous feeding - therefore requiring a break from feeding every 4 hours to allow time for venting).
  • Feeding commences according to clinical team decision. All NGT feeding commenced should initially be continuous for the first 2 hours, then oral or bolus feeding as clinically determined and according to the treating clinical team.

Background information and Nursing care for a patient on HFNC

Starship has developed a guideline to support nursing care for use with HFNC. Click on the following link to view/download the pdf guideline Heated High Flow Humidification Delivery for a Child

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Document Control

  • Date last published: 27 June 2018
  • Document type: Clinical Guideline
  • Services responsible: General Paediatrics
  • Author(s): Greg Williams
  • Owner: Greg Williams
  • Editor: Greg Williams
  • Review frequency: 2 years

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