The use of HFNC therapy means the patient is unwell and requires more and not less nursing care and clinical monitoring. The child should be cared for in a close observation area with a competently trained clinician available at all times. The environment of care may vary according to facility, time of day, staffing and skill-mix. The patient should be cared for in the location most suitable for achieving both a quiet, child friendly environment as well as adequate monitoring and access to equipment and clinicians in terms of potential deterioration; this could be in the emergency department (ED) or ward. 

 Following commencement of HFNC therapy in the ED, children should not be transferred to a ward setting until clinically stable. A patient is deemed ‘clinically stable’ when they meet the indicators described below in “meet the clinical indicators outlined in clinical stabilisation’. Consultation with the relevant nursing clinical leadership (for example, Nurse Unit Manager, Clinical Nurse Consultant and/or shift Team Leader) and the treating medical team should also occur before transfer to ward. 

Children on HFNC outside of PICU, require a minimum of two (2) paediatric HFNC competent clinicians to be present on any given shift. (HFNC therapy competency is defined in Staff Education Below.)  This may be a combination of Registered Nurse’s (RN) or RN and Enrolled Nurse (EN).  At a minimum, one of these staff must be a Registered Nurse (RN).  If staffing is reduced, follow local practices to ensure patient safety.

When a patient is commenced on HFNC therapy, a SMO is required to remain within the facility, until the initial 2hr trial of therapy has been completed.  After this time, if the team has established that the patient has stabilised, the on-call SMO is required to arrive at the patient’s bedside within the local facilities specified guidelines regarding on-call times. 

Respiration rate, respiratory distress, oxygen (% delivered, ‘HF’ mode, actual FiO² and L/min on device screen), SpO², heart rate and conscious level must be documented at least 15 minutely for one (1) hr on commencement of HFNC therapy. Thereafter, observations are to be documented at least hourly. Continuous SpO² monitoring must stay in place. Undertake and document patient observations in accordance with the age appropriate CEWT. Undertake Paediatric Respiratory Observation Chart MR60A.7 with every set of observations.  

Airvo™2 Machine observations must be documented on the Airvo™2 Order and Machine Observations Form MR88atb, and are to be undertaken hourly, at shift change, and when therapy order is changed. These include: 

• Total air flow setting (L/min) 
• Temperature setting (°C) 
• Oxygen percentage delivered (FiO²) 
• Patient skin and Optiflow™ cannula check (for pressure areas and to ensure that a slight leak is present, as complete obstruction of the nares will inadvertently create high pressure and may lead to barotrauma. Also check for dislodgement of nasal cannula, as this may result in reduced respiratory support.) 
• Machine plugged in, turned on, condensation cleared  
• Humidifier water chamber and sterile water bag levels (document in ‘Other’ column) 

Clinical stabilisation

Clinical stabilisation is defined as: 

• The FiO² required to maintain SpO² in the target range (SpO² ≥90%) is ≤ 40%. 
• Heart rate reduced by 15 beats per minute (bpm) or to within normal range for that infant/child’s age group. 
• Respiratory rate reduced by 5-6 resps/min or to within normal range for that infant/child’s age group. 
• Signs of respiratory distress/effort have improved. 

Children who are unable to be stabilised with FiO² ≤ 40% should be discussed and reviewed by the level ≥4 CSCF facility and considered for transfer to the level ≥4 CSCF facility.

Nursing care 

• If the medical team deem an x-ray is indicated, it is to be completed as soon as possible. Aim for within the first two hours of HFNC therapy. An x-ray should not delay the initiation of the HFNC therapy. 
• Point of care pathology and/or formal pathology can be used to assess effectiveness of treatment if treating team deem it necessary. 

Weaning of HFNC therapy

Weaning of HFNC therapy must only be undertaken with guidance from a paediatrician. When weaning HFNC therapy, always maintain weight specific flows as per Table 1 and only reduce the FiO²  until room air (FiO² =21%) has been achieved.   

Weaning for children on HFNC room air only: 

For children who commence and remain on room air (FiO² =21%) only, maintain HFNC therapy for a minimum of two hours whilst maintaining targeted saturations (90-98%).  If patient remains stable, cease HFNC, remove nasal cannula and allow patient to breathe room air. If the patient desaturates, recommence HFNC at previous settings and titrate FiO² accordingly to maintain SpO²  90-98%. 

Weaning for children on HFNC with FiO²  >21%: 

Weaning of HFNC with FiO²  >21% can commence within four (4) hours, as instructed by the SMO, if the child’s clinical condition is improving: 

• First, decrease the FiO²  in 5% increments whilst maintaining saturations ≥ 90%. 
• Once the FiO²  reaches 21% and saturations have been stable ≥ 90% for one hour, flow can be ceased and nasal cannula removed. 
• If infant/child desaturates < 90% resume flow with FiO²  at 21%. 
• If not maintaining saturations ≥ 90% increase FiO²  until saturations are 90-98%. 
• Once stabilised with saturations ≥ 90% for at least two (2) hours weaning can recommence. 
• If the medical team deem an x-ray is indicated, it is to be completed as soon as possible. Aim for within the first two hours of HFNC therapy. An x-ray should not delay the initiation of the HFNC therapy. 
• Point of care pathology and/or formal pathology can be used to assess effectiveness of treatment if treating team deem it necessary. 

Clinical assessments 

• If the medical team deem an x-ray is indicated, it is to be completed as soon as possible. Aim for within the first two hours of HFNC therapy. An x-ray should not delay the initiation of the HFNC therapy.
• Point of care pathology and/or formal pathology can be used to assess effectiveness of treatment if treating team deem it necessary.

In keeping with the age appropriate CEWT, seek medical review if any of the following occurs: 

• Respiratory rate increases 
• Degree of respiratory distress worsens 
• Requirement for FiO²>40%  
• Hypoxaemia persists despite high gas flow 
• Child shows signs of tiring (e.g. decreased respiratory rate and effort despite SpO² <90%) 

Remember: Children have the ability to sustain physiological parameters in the face of significant illness before rapidly decompensating. Many traditionally measured observations which are relied upon in adult medicine may underestimate the severity of a child’s state. 

In the case of clinical deterioration: 

• Call for help/assistance as per local CEWT escalation process 
• If bag and mask breaths are required always remove the nasal cannula first, to ensure adequate mask seal. 
• Consider increasing flow according to the flow rate table in consultation with treating medical officer.  
• Consider that if a high FiO² is used, oxygen saturation may be maintained in an infant despite the development of hypercarbic respiratory failure.  
• Consider pneumothorax as a complication of HFNC therapy if there is a rapid deterioration of oxygen saturation and/or marked increased work of breathing. Exclude this by performing a chest x-ray. 
• Consider blood gas analysis where clinically indicated. 

Once stable on HFNC therapy, the child should be assessed as to whether they can feed.  

• Some infants can continue to breast/bottle feed, but many require feeding via a NGT 
• Feeds given via the NGT can be either bolus or continuous 
• For infants who wish to orally feed (bottle/breastfeed/drink or eat), it is preferential (particularly in ≤12 months) to reduce the HFNC therapy to low flow humidified oxygen for a short period (up to 20 minutes) as per below table
• After a maximum of 20 minutes, oral feeding should be stopped, and HFNC therapy recommenced at the previous settings. 

• Older children have demonstrated that they can synchronise their swallow with eating and drinking whilst high flow is in place, with no adverse effects. However, if the child is very tachypnoeic and working very hard or has difficulty synchronising feeding/drinking with the HFNC therapy, then reduce to low flow humidified oxygen as outlined above.  Reduce for a short timeframe only (up to 20 minutes) and recommence at the previous settings. 
• Infants/children who do not clinically stabilise within 2 hours or who do not tolerate NGT feeds should have an I.V. inserted to receive hydration. Aim for patient to be managed with 2/3 fluids maintenance.  

Inhalation therapy with HFNC

Children on HFNC, requiring inhalation therapy via a nebuliser or multidose inhaler (MDI) are to perform the following: 

• MDI’s:
  • Remove nasal cannula to ensure a good seal for MDI and administer inhalation medication
  • Following inhalation completion replace nasal cannula and continue HFNC at previous settings.

• Nebulisers: 
  • Stop HFNC and remove nasal cannula for greater seal to skin and administer nebuliser OR
  • keep cannula in place and reduce flows to low flow humidified settings for duration of nebuliser. These settings are in accordance to the AIRVO2 and 3 mode differences:
  • Following nebuliser completion replace nasal cannula and continue HFNC at previous settings.

Note: 

• When setting up HFNC therapy, ensure that the Airvo device is placed below patient head height to prevent water from entering nasal cannula.
• Manage excess condensation in tubing by disconnecting from patient and lifting the patient end of the tube to allow the condensation to run into the water chamber.
• When removing nasal cannula, then replacing (e.g., for MDI use), ensure tubing is free from water before re-applying to child

Transfer of Airvo systems

Intrahospital transfers, such as movement from ED to ward/radiology can occur with the use of the Airvo™3 battery built-in system that will last up to 40 minutes. If the patient requires oxygen, ensure the change over from wall oxygen outlet to cylinder oxygen occurs using the dual high pressure oxygen setup.  

Inter-hospital transfers and mode of respiratory support will be as per the decision of the retrieval team to ensure respiratory support mode will be functional for entire transport.

NB: The Airvo™2 device does not allow HFNC therapy delivery during transport unless it is connected to power or an external battery.  

In the event of transfer to a higher care facility (e.g., Level 4), clinical handover must occur between two HFNC competent nurses. I.e. HFNC competent nurse at Remote HHS facility, and HFNC competent nurse at level ≥4 CSCF facility. 

Cleaning of the Airvo 2 or Airvo 3

The Airvo Humidifier requires cleaning and disinfection between patients. Follow the instructions in the Fisher and Paykel Airvo2 Disinfection Kit Manual or Fisher and Paykel Airvo3 Manual – section 8. Keep the orange disinfection tubing connected post disinfection cycle, to ensure the Airvo does not collect dust inside the equipment. 

Humidifier chamber, circuits and nasal cannula are single patient use. They are to be disposed of in general waste. If a patient is receiving HFNC therapy for an extended period, the consumables are to be changed every seven (7) days.