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Child Health Guideline Identifier

Respiratory support on Starship wards

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Placement of an infant, child or young person receiving respiratory support on Starship Child Health wards

This guideline covers the placement of an infant, child or young person who requires respiratory support on Starship Child Health wards. The respiratory support includes: high flow, non-invasive and invasive continuous positive airway pressure (CPAP), non-invasive and invasive bi-level pressure support (BPAP).

Transfer of a child receiving respiratory support from a high acuity setting (NICU, PICU, HDU) to a Starship Child Health ward is an in-hours, planned process recognising that such a transfer constitutes a considerable "step-down" in the intensity of monitoring, nursing surveillance and complexity of technology.

Individual plans should include:

  • Clinical decision on appropriate mode of respiratory support, considering necessity for ventilation guarantee and safety of alarms.
  • Availability of appropriate respiratory support equipment.
  • Contingency planning for equipment failure, including outside of ordinary hours. Please be aware that medical wards do not routinely have spare respiratory support equipment nor the technical expertise to set them up outside of ordinary working hours.
  • An opportunity for the parents to visit the ward and meet with the Charge Nurse and SMO who will be in charge of the child's ongoing care prior to transfer.

Where a child has an end of life care plan with no advanced intervention for acute deterioration (e.g. CPR, intubation or admission to PICU), they should be managed in the most appropriate clinical environment, considering where good working relationships exist.

The following criteria should be met prior to transfer of a child from a high acuity setting:

Patients must meet ALL the following criteria to be safely managed on a ward. Patients who do not meet these criteria require HDU or ICU level care.

  • The patient is physiologically stable.
  • For highly dependent patients on long term support, optimal settings have been established with no changes in the week prior to transfer (except where indicated for fine tuning or weaning).
  • The patient requires an FiO2 of 0.40 or below.
  • The patient does not require frequent emergency interventions (eg bag mask ventilation) or more than hourly airway suctioning.
  • The patient is able to tolerate being placed on and off support without developing severe cyanosis (SaO2 < 80%) or apnoea requiring manual (bag) ventilation or other extraordinary intervention.
  • The patient is able to consistently tolerate periods off support on standard or low flow oxygen therapy without acute clinical deterioration. As a guide patients requiring pressure support (ie other than high flow) should be able to tolerate at least 6-8 hours within a 24 hour period (e.g. 2x4hrs or 3x2hrs) off support without requiring acute attention. In the case of highly dependent long term ventilated patients, this criterion should be met for at least one week prior to transfer.
  • In the case of highly dependent long term ventilated patients there should be no general anaesthesia planned for the next 2 weeks - all anticipated or planned procedures should be completed prior to transfer to allow post anaesthetic ICU monitoring or support if needed.

Ward physiological monitoring / nursing of patient:

  • Refer to Observation and Monitoring of an Infant, Child and Young person Guideline (ADHB Policies).
  • The patient will be monitored with oxygen saturation monitoring (continuous or spot check) as clinically indicated. If the patient requires continuous monitoring the alarms must be audible in staff areas.

Quick guide for after hours for placement of children on respiratory support. Placement may be reviewed using above criteria during usual working hours.

Initiating support High flow Mask CPAP Mask BPAP Trache CPAP Trache BPAP
Medically stable child initiating long term support    All NICU
PICU
HDU
NICU
PICU
HDU
Medically unstable child or young infant initiating long term respiratory support  All   NICU / PICU / HDU  
Child initiating support for acute respiratory illness  All NICU / PICU / HDU
Already established on support** High flow Mask CPAP Mask BPAP Trache CPAP Trache BPAP
Admission on their usual prescription for non-respiratory reason    Any ward 26B*
PICU
HDU
 
PICU
HDU
Admission on support with new / increased respiratory indication (eg acute respiratory illness)  PICU / HDU
Consider 26B*
PICU
HDU
Elective admission for assessment of respiratory support  26B 26B*
PICU
HDU

CPAP - continuous positive airway pressure, BPAP - bilevel positive pressure support
* After consideration of level of dependency, nursing & monitoring needs as elsewhere in this document. Also consider overall ward 26b caseload.
**Check Emergency Respiratory Management Plan on concerto which may offer individualised advice that differs from this chart.

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Document Control

  • Date last published: 16 June 2017
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Respiratory
  • Owner: Jacob Twiss
  • Editor: Greg Williams
  • Review frequency: 2 years

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