Nasal High Flow for Infants and Children

Guidance from literature suggests two key principles for implementing nasal high flow (NHF) in the care of infants and children: early use and integrated use.^1-6

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The decision for change, the lessons and the significant wins – learn about the implementation of NHF therapy at Queensland Children's Hospital (QCH), formerly known as Lady Cilento Children's Hospital.

The early use of NHF

The early use of NHF is associated with improved physiological and clinical outcomes compared to standard oxygen therapy, including^1-6:

improved breathing patterns and rapid unloading of the respiratory muscles
significant reduction in the work of breathing
rapid improvement to respiratory distress
reduced need for escalation of therapy in infants with bronchiolitis.

The integrated use of NHF

Integrating the use of NHF across the ward (floor), emergency department (ED), and pediatric intensive care units (PICU) may be associated with improved standardization of care.^4-6 When used cohesively across the hospital, NHF may also contribute to a change in respiratory support practice, moving towards less invasive strategies and leading to the potential for more patients to be managed in local hospitals and lower acuity settings.^4-6

Therefore, the goal should be to use NHF early and in an integrated manner to reduce the risk of escalation of care.^1-6

Setting flow rates for infants and children

Clinical evidence supports a dose-by-weight approach with suggested flow rates of approximately 2 liters per kilogram per minute (L/kg/min) for infants between 3.0 and 12.5 kilograms.^4,7-12

However, there is no evidence to support this practice for preterm neonates, older children or adults. Published clinical protocols may give guidance to setting flow rates in children.^7-12 The graphic below summarizes the findings from published literature.

^7-12Published clinical protocols may give guidance in setting flows for infants between 10-12.5kg (purple).
^4,7-12There is sufficient clinical evidence that supports flow rates of 2 L/kg/min (blue) for infants between 3-12.5kg.

Milesi, C. et al. Is treatment with a high flow nasal cannula effective in acute viral bronchiolitis? A physiologic study. Intensive Care Med. 39, 1088–1094 (2013).  View abstract here.
Rubin, S. et al. Effort of breathing in children receiving high-flow nasal cannula. Pediatr. Crit. Care Med. 15, 1–6 (2014).  View abstract here.
Pham, T., O’Malley, L., Mayfield, S., Martin, S., & Schibler, A. The effect of high-flow nasal cannula therapy on the work of breathing in infants with bronchiolitis. Pediatr. Pulmonol. 50, 713–720 (2015).  View abstract here.
Franklin, D. et al. A randomized trial of high-flow oxygen therapy in infants with bronchiolitis. N. Engl. J. Med. 378, 1121–1131 (2018). View abstract here. 
Schibler, A. et al. Reduced intubation rates for infants after introduction of high-flow nasal prong oxygen delivery. Intensive Care Med. 37, 847–852 (2011).  View abstract here.
Mayfield, S., Bogossian, F., O’Malley, L., & Schibler, A. High-flow nasal cannula oxygen therapy for infants with bronchiolitis: a pilot study. J. Paediatr. Child Health 50, 373–378 (2014).  View abstract here.
Ramnarayan P. et al. FIRST-line support for Assistance in Breathing in Children (FIRST-ABC): protocol for a multicentre randomised feasibility trial of non-invasive respiratory support in critically ill children. BMJ Open 7, e016181 (2017). View abstract here.
Franklin D., Shellshear D., Babl F.E. on behalf of PARIS and PREDICT, et al. Multicentre, randomised trial to investigate early nasal high—flow therapy in paediatric acute hypoxaemic respiratory failure: a protocol for a randomised controlled trial—a Paediatric Acute respiratory Intervention Study (PARIS 2) BMJ Open 9, e030516 (2019). View abstract here.
Nielsen K.R., Becerra R., Mallma G., Tantaleán da Fieno J. Successful Deployment of High Flow Nasal Cannula in a Peruvian Pediatric Intensive Care Unit Using Implementation Science-Lessons Learned. Front Pediatr. 6, 85 (2017). View abstract here.
Kepreotes, E. et al. High-flow warm humidified oxygen versus standard low-flow nasal cannula oxygen for moderate bronchiolitis (HFWHO RCT): an open, phase 4, randomised controlled trial. The Lancet 389, 930-939 (2017). View abstract here.
Schmidt, O. et al. Real-life effectiveness of asthma treatment with a fixed-dose fluticasone/formoterol pressurised metered-dose inhaler - Results from a non-interventional study. Respir. Med. 131, 166-174 (2017). View abstract here.
Miller, A.G., Gentle, M.A., Tyler, L.M., & Napolitano, N. High-Flow Nasal Cannula in Pediatric Patients: A Survey of Clinical Practice. Respir. Care. 63, 894-899 (2018). View abstract here.

View references

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