Pyramid of Care: Pediatric Edition

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Advisory Board Pyramid of Care: Pediatric Edition

Richard Branson, MS, RRT, FAARC Professor of Surgery, Emeritus By Matthew S. Pavlichko, MS, RRT, RRT-NPS University of Cincinnati College of Medicine Cincinnati, OH As our healthcare landscape changes, reimbursement difficulties, cost Kathleen Deakins, MS, RRT, NPS Manager, Women’s Children’s Respiratory Care containment, readmission penalties, and the role and scope of the future University Hospital, Rainbow Babies & Children respiratory therapist is up for debate. Identifying and providing value to Cleveland, OH

William Galvin, MSEd, RRT, CPFT, AE-C, FAARC the patient and the organization is imperative for any respiratory care de- Program Director, Respiratory Care Program Gwynedd Mercy College, Gwynedd Valley, PA. partment, large or small. Our value is never more evident than during

Carl Haas, MS, RRT, FAARC a respiratory emergency, most importantly, of a pediatric patient. This Educational & Research Coordinator University Hospitals and Health Centers Ann Arbor, MI article will review the historical need for winter pediatric preparations in

Richard Kallet, MSc, RRT, FAARC Director of Quality Assurance, respiratory care as well as the treatment theory called the “Respiratory Respiratory Care Services USCF General Hospital Pyramid of Care: Pediatric Edition.” San Francisco, CA

Neil MacIntyre, MD, FAARC Medical Director of Respiratory Services Duke University Medical Center Durham, NC Panel Discussion: NIV and HFNC for Neonates Tim Op’t Holt, EdD, RRT, AE-C, FAARC Professor, Department of Respiratory Care and Pediatric Patients and Cardiopulmonary Sciences University of Southern Alabama Mobile, AL Moderator: Kathleen Deakins, RRT-NPS FAARC

Helen Sorenson, MA, RRT, FAARC Assistant Professor, Dept. of Respiratory Care Panelists: Rob DiBlasi, RRT-NPS University of Texas Health Sciences Center San Antonio, TX Lee Williford, RRT-NPS, RCP W ebinars Keith Hirst, MS, RRT-ACCS, RRT-NPS, AE-C Clinical Foundations is dedicated to providing healthcare professionals Several methods are used in pediatric and infant populations to ensure with clinically relevant, evidence- adequate breathing and sufficient levels of blood oxygen. These meth- based topics. Clinical Foundations ods are placed along a continuum or pyramid of utility. Two of the most is pleased to announce a webinar series featuring leading healthcare popular methods are: High-Flow nasal cannula (HFNC) which adds heat professionals. To find out more and humidity to the air flow to create a level of comfort that other oxy- about the current webinar and to register, go to www.clinicalfounda- gen devices are lacking, and continuous positive pressure airway pres- tions.org. Each webinar is accred- sure (CPAP) devices, which is a noninvasive method of delivering air to ited for CRCEs and CEs. the lungs under mild pressure. In this panel discussion, three experts discuss the pros and cons of HFNC as well as CPAP, and when and how they Faculty Disclosures: should be used. Matthew S. Pavlichko, MS, RRT-NPS, Kathleen Deakins, RRT-NPS, FAARC, Rob DiBlasi, RRT-NPS, FAARC, Keith Hirst, MS, RRT-ACCS, RRT-NPS, AE-C, Lee Williford, RRT-NPS, RCP each disclosed no conflicts of interest associated with this publication

MC-005904 This program is sponsored by Teleflex Incorporated Clinical Foundations

Care” translates well to the pediatric patient population.(Figure 1) Pyramid of Care: The pyramid’s shape is the most important concept. The foundation of the pyramid serves the largest population and Pediatric Edition has the least complexity; i.e., patients on room air. As one moves up the pyramid, By Matthew S. Pavlichko, MS, RRT, RRT-NPS one shifts in treatments that are higher cost and complexity but are necessary for a smaller number of patients. When pa- s our healthcare landscape will describe the Respiratory Pyramid of tients’ conditions worsen, they advance changes, reimbursement diffi- Care within the scope of pediatrics. Its up the pyramid, but when they improve, culties, cost containment, read- purpose, is to provide comprehensive in- they are weaned down the pyramid. Each mission penalties, and the role sight into the respiratory treatment strat- treatment meets the patient’s needs, but Aand scope of the future respiratory thera- egy of the sick child and to better prepare each has nuances that can serve as a con- pist is up for debate. Identifying and pro- clinicians for the child who will inevitably duit or a barrier to care. Each is described viding value to the patient and the orga- arrive. in more in depth below. nization is imperative for any respiratory care department, large or small. Our value What is the Pyramid of Care? Treatments that Resolve Hypoxemia/ is never more evident than during a respi- The Council for Advances in Respi- Hypoxia ratory emergency, most importantly, of a ratory Therapy developed the theory of When the body’s partial pressure of

pediatric patient. This article will review “Navigating the Respiratory Pyramid of arterial oxygen (PaO2) falls below normal the historical need for winter pediatric Care” in 2010. Led by David Vines, PhD, levels, hypoxemia is present. Hypoxemia preparations in respiratory care as well as RRT, FAARC, the council (comprised of can be caused by hypoventilation, shunt- the treatment theory called the “Respira- expert respiratory care thought leaders ing, diffusion defects, abnormal hemoglo- tory Pyramid of Care: Pediatric Edition.” from across the country) developed an bin, anemia, and/or poor perfusion. Signs The Emergency Medicine Network extensive, peer-reviewed educational cur- and symptoms include increased work of has recorded that there are 5,273 EDs in riculum to create a comprehensive under- breathing (WOB), tachypnea, shortness the US.1 However, of those 5,273 emer- standing of oxygen therapy and ventila- of breath, tachycardia, poor perfusion, gency departments, only 220 reside in a tory support.5 This curriculum describes and potential neurological deficit.5 Hy- children’s hospital (CHA).2 These statis- the treatment selection strategy for adult poxemia can occur during severe trauma, tics lead to the assumption that most pedi- patients with respiratory compromise, shock, cyanide and carbon monoxide poi- atric ED visits are performed outside the as well as how to navigate the severity of soning, cardiac arrest, and perioperative walls of a children’s hospital. Chamberlain their illness, from worsening progression emergencies. and colleagues described the scope of this to weaning. Although, initially created to In 2016, The World Health Organiza- phenomenon in 2013,3 when they report- care for the adult patient, the “Pyramid of tion (WHO) created the Oxygen Therapy ed that up to 90% of all pediatric emergency cases did not receive care at a pediatric Respiratory Pyramid of Care specialty hospital. In addition, according to the Agency for Healthcare Research and Quality (AHRQ),4 only 5% of pediatric ED visits result in admission to the same hospital. The AHRQ also reported

that in 2015, the most common reason for Extreme A

Measures djunc pediatric patients to visit the ED was for C respiratory disorders, especially during Invasive omplexity 4 Ventilation winter months. tive The ED is not the only location that Noninvasive

ost Ventilation Therapies deals with respiratory emergencies. Many C inpatient pediatric units and neonatal in- Heated, Humidi ed Oxygen Therapy (HFNC) tensive care nurseries across the country reside outside the wall of a children’s hos- High Flow/High FIO2 Oxygen Therapy pital. This phenomenon places enormous pressure to deliver high quality care in a Low Flow/Low FIO2 OIxygen Therapy low-volume, high-risk patient population in settings where the least amount of ex- Room Air perience, knowledge, and resources are available. Is pediatric respiratory emergency truly “low-volume”? This module Figure 1.

2 www.clinicalfoundations.org Clinical Foundations for Children Guide, which describes, in detail, assessment and identification, treatment strategies, and monitoring of children on oxygen therapy.6 PaO2 can be considered as a diagnosis of hypoxemia, but the measure of PaO2 requires an invasive arterial blood gas (ABG) test. The WHO identified a target oxygen satura- tion (SpO2), which is a non-invasive measure of tissue oxygenation, to adequately reflect hypoxemia and the response to therapy that is appropriate for children.

This target goal is defined as a SpO2 of 90-94%6 via pulse oximeter. Treatment should target that goal. High-flow Nasal Canuala Room Air Although not addressed by Vines and They come in many sizes, can be humidi- cludes the recommendation to resuscitate colleagues, room air is the best option for fied using a bubble humidifier, and now infants using < 100% FiO2 to meet tar- most pediatric patients, even those who- are made of very soft material to maxi- get saturations over time.9,10 Air-oxygen present with respiratory illness. Oxygen is mise comfort. Patients can talk and eat blenders, found routinely in the delivery a prescribed therapeutic intervention that while fitted with a nasal cannula. The ini- room, are becoming popular for deliver- has benefits but also side effects. If a pa- tial application may be difficult depending ing oxygen therapy to all children. The use tient is adequately oxygenating, oxygen is on the patient, but the standard nasal can- of blenders allows the clinician to deliver contraindicated. Hyperoxia leads to oxy- nula should be the first option for oxygen flow and FiO2 independent of one another. gen toxicity, alveolar damage, absorption therapy. FiO2 can be adjusted to meet SpO2 targets, atelectasis, etc.7 In addition, oxygen ther- and flow can be adjusted to meet work apy devices are difficult to manage with High-Flow – Fixed FiO2 Devices of breathing targets. What if an oxygen pediatric patients due to lack of patient When a higher level of FiO2 is re- delivery device could give precise/pre- understanding. Oxygen therapy is only ef- quired, the low-flow device may be inad- scribed FiO2 while using flow as a therapy fective when the application is consistent. equate and a high-flow fixed FiO2 may be and be comfortable for pediatric patients? Comfort can overcome reason, but when needed. In contrast to low-flow, a high- room air is adequate, it is always the best flow device is one that meets or exceeds Heated Humidified HFNC option. the patient’s inspiratory demand thus The next step of the pyramid is the

providing a stable or fixed FiO2. The FiO2 high-flow nasal cannula (HFNC). This Low-Flow – Variable FiO2 Devices at the blender flowmeter is what is deliv- very popular respiratory modality has When oxygen is needed, the first step ered to the patient with minimal air en- applications in both adults and pediat- of the Pyramid of Care is low-flow oxygen. trainment. These include non-rebreather rics,11,12 but its name is misleading. HFNC A low-flow oxygen device is described by masks, dual large-volume aerosol masks, only describes part of the therapy. The key

Egan as an oxygen device that delivers a and high-flow/high FiO2 air entrainment difference between this and a standard na- flow rate less than the inspiratory flow rate masks. Once again, masks are difficult op- sal cannula is not the flow rate, but rather of the patient, thus creating variable FiO2 tions for pediatric patients, which creates the addition of heat and humidity. The due to respiratory rate and tidal volume.8 a challenge to the delivery of high oxygen addition of heat and humidity, which cre- Examples of low-flow devices are a stan- volumes to children. ates a level of comfort that other oxygen dard nasal cannula, simple mask, air en- devices are lacking. Add a blender and trainment mask, and a large-volume aero- Air-Oxygen Blenders you have a heated, humidified high-flow sol mask. All these devices deliver FiO2 to The use of low-flow and high-flow ox- nasal cannula with customizable FiO2. It the patient less than that which is set on ygen devices creates a potential problem meets the major challenges in pediatric the flowmeter. Three of four use a mask as for respiratory therapists. Flow and FiO2 oxygen therapy, comfort, with consistent an interface. As pediatric patients come in that are dependent on each other does application of therapy, with FiO2 and flow all shapes and sizes, so do masks. As dis- not cause a major problem for adults but autonomously delivered. cussed in the previous section, effective- does present a barrier to the treatment of Heat and humidity at or near body ness requires consistency of therapy, so children. FiO2 is the treatment needed to temperature and pressure saturated comfort is very important. Have you ever meet the therapeutic SpO2 goal of 90-94%, (BTPS), delivering flow via nasal interface put a mask on a 2-year old? For reasons of but FiO2 is flow dependent. Or is it? provides comfort because it does not im- comfort and compliance, the nasal cannu- As described above, hyperoxia should pede the work of the nose. Heated humid- la is the standard low-flow delivery device always be avoided. In 2010, the AHA and ification prevents airway cooling, discom- for pediatrics. AAP changed the NRP algorithm to re- fort, and intolerance of high-flows. It also The nasal cannula is the most com- flect a strategy to reduce the detrimental prevents water loss, the cause of thickened fortable option, comparatively speaking. effects of hyperoxia. The algorithm in- nasal secretions, and inflammation, the

www.clinicalfoundations.org 3 Clinical Foundations cause of increased airway resistance. Heat optimal patient interfaces are available Non-Invasive Ventilation - BiPAP and humidity can make any nasal cannula which is especially challenging with Just as with CPAP, bilevel positive an HFNC, even those at low-flow rates. children. To create pressure, minimal or airway pressure, or BPAP, delivers Just as with a standard low-flow nasal can- no leak is required (in contrast to HFNC). pressure to the lungs to improve oxygen nula, the interface provides for consistent The mask or interface can be tight fitting, exchange at the alveolar level. BPAP also therapy due to its comfort and conve- feel “suffocating”, and potentially cause provides pressure on inspiration, called nience. skin breakdown17 (picture of patient IPAP. The difference in the two levels of

Just like high-flow, fixed FiO2 devices, on CPAP). The American Academy of pressure is pressure support (PS), or the an HFNC can meet or exceed the patient’s Respiratory Medicine Clinical Practice pressure created to inflate the lungs to inspiratory flow rate, thus delivering exact Guidelines suggest active humidification remove CO2. BPAP provides oxygenation FiO2 to help prevent hyperoxia. Using a is an option to improve adherence and and ventilation where as CPAP only high-flow/blender system, the clinician provide some relief during use of this provides oxygenation. Ventilation is 18 may deliver precise flows and FiO2 to therapy, but this also has its challenges. delivered non-invasively, thus not meet the patient’s needs.5 For example, a Patients must also be able to protect their incurring the complications of invasive nasal cannula delivering heated humidity own airway due to risk of aspiration. conventional mechanical ventilation 16 at a flow rate of 20 L/min at 30% FiO2 is Limited comfort with this therapy (CMV). The therapy goals of SpO2 possible using this system. FiO2 indepen- also may require sedation, which may remain the same, with the added goal dent of flow is key to delivering specific challenge efforts to avoid aspiration. This of improving ventilation, normalizeing 5 oxygen therapy to children. modality is considered advanced; proper PaCO2 and increasing pH to > 7.35. One cannot discuss HFNC without resources and experienced personnel Initial settings are debated, but as in all discussing airway pressure created by flow should be available. therapies, aim to meet patient needs or PEEP. There is an enormous amount of without excess. Initial IPAP settings of Treatments for Hypoxemia/ literature on this subject; does it provide 8-10 cm H2O and PEEP of 3-5 cm H2O benefit or detriment because the pressure Hypoventilation appear to be safe. To meet the patient’s created is not fixed? HFNC does create The next steps of the Respiratory oxygenation needs, FiO2 and PEEP may PEEP, but it varies based on nares size, Pyramid of Care represent a higher be adjusted (PEEP of 1-2 cm H2O). To 13 cannula size, and respiratory pattern. In complexity of care that requires wean or adjust to meet PaCO2 and pH 2004, Bamford & Lain stated that high- overcoming a new challenge: hypercarbia. goals, the level of PS should be adjusted. flow delivered through a non-occluding Patients whose disease state leads to This is completed by increasing or nasal cannula does create a small, but con- hypoventilation require reestablishment decreasing the IPAP by 1-2 cm H2O. sistent, increase in oropharyngeal pres- of ventilation to ensure survival. CPAP and BPAP share the same chal- sure.14 In their model, 36 L/min created 3 Hypoventilation is an abnormally high lenges. Non-invasive ventilation is not in- cm H2O pressure to the oropharynx. The partial pressure of arterial carbon dioxide dicated for every child, even if the therapy most important part of their statement is (PaCO2) or hypercarbia. Hypercarbia is required. Comfort and application is- “through a non-occluding” cannula14. The that leads to acidosis or pH < 7.30 is sues remain barriers, and some pediatric purpose of HFNC therapy is to provide respiratory failure. These patients require patients are unable to generate enough flow; PEEP is inadvertent. HFNC therapy oxygen therapy and assistance with flow to trigger the IPAP. This may cause an is not (CPAP) therapy; thus its own cat- ventilation.5 increase in WOB as the patient is “locked egory on the pyramid below CPAP. o u t ”. 17 BPAP therapy is also considered an Initial settings for HFNC are debated advanced practice. as well. Recent studies have stated that 1.5 to 2 L/min/kg is safe and effective for pe- Conventional Mechanical Ventilation diatric patients.15,16 Safe is a relative term, based on the resources available (i.e. prox- imity and pediatric intensive care). Signs of clinical improvement, oxygenation, • Negler, J. and Cheifetz, I., September 2018, Initiating and WOB should guide your care. Close mechanical ventilation in children. UpToDate. • Initial Settings: Extreme and careful monitoring is required. Measures • Vt 5-8 ml/kg IBW or PIP to achieve it(<28 cm H2O) • PEEP 5-8 cm H O Invasive 2 Ventilation Non-Invasive Ventilation - CPAP • PS 5-10 cm H O (when mode applicable) 2 Noninvasive With some pediatric patients, flow • RR to maintain adaquate Ve Ventilation does not provide enough therapeutic • Ti to acheive 1:2-1:3 (or > if needed) Heated, Humidi ed • FIO to keep Sats 88-92% Oxygen Therapy (HFNC) value; pressure is required to improve 2 • Mode selection similar to adult ventilation High Flow/High FIO2 hypoxia. The next escalation of the Oxygen Therapy • Spontaneous vs. SIMV vs. AC Low Flow/Low FIO2 pyramid is CPAP therapy. The patient • VC vs. PC vs. Dual controlled OIxygen Therapy care goals remain the same: improve Room Air oxygenation and WOB. The challenge with CPAP therapy is its application: few Figure 2.

4 www.clinicalfoundations.org Clinical Foundations

Conventional Mechanical ventilation modes, high frequency ven- 2. About Children’s Hospitals. CHA. 2018. Re- trieved from https://www.Childrenshospitals. Ventilation tilators, and extra corporeal membrane org/About-Us/About-Childrens-Hospitals The last step of the pyramid that will oxygenation. The availability and prox- 3. Chamberlain JM, Krug S, Shaw K. Health Af- be reviewed is conventional mechani- imity of these options should be consid- fairs: The Future of Emergency Medicine: Chal- lenges & Opportunities. Emerg Care Child US. cal ventilation, or CMV. Although, in- ered when creating a pediatric emergen- 2013;32(12). tubation and ventilation are life-saving cy plan. 4. McDermott K, Stocks C, Freeman W. Overview of Pediatric Emergency Department Visits, 2015. measures, this step incurs many inherent AHRQ: Healthcare Cost and Utilization Project. risks. The main characteristic of invasive Pediatric Emergency Plan: 2018; Statistical Brief 242. ventilation compared with non-invasive Stabilization and Transfer 5. Vines D, et. al. Advances in respiratory therapy: ventilation (NIV), is the endo-tracheal Stabilization and transport is a key Navigating the respiratory pyramid of care, 2010. 6. Oxygen therapy for children: a manual for tube (ETT). ETT intubation of a child is step to any pediatric emergency plan. healthcare workers. WHO. 2016. Retrieved a high-risk, low-volume procedure that Transporting a critically ill child has its from http://apps.who.int/iris/bitstream/han- dle/10665/204584/9789241549554_eng.pdf;jsess should be performed by the most capable risks, so careful and calculated actions ionid=86801EAB4C461599157591450A1F4CD9 and available clinician.9 Risks are pres- are required prior to the physical trans- ?sequence=1 ent during the act of intubation such as port. Communication with all clinicians 7. Bitterman H. Bench-to-bedside review: Oxygen as a drug. Crit Care. 2009;13(1):205. bleeding, aspiration, trauma, and cardiac involved is vital. Key elements of patient 8. Heuer AJ, Scanlan CL. Medical Gas Therapy. compromise. Lee, J. stated that “Number transport include decision to transfer, Egan’s Fundamentals of Respiratory. 2009. of intubation attempts was associated stabilization and preparation, mode of 9. Textbook of Neonatal Resuscitation 7th ed. with desaturations and increased occur- transport, personnel needed, equipment, American Academy of Pediatrics. 2016. 10. Walsh B, Smallwood C. Pediatric oxygen rence of intubation associated events in drugs, monitoring, documentation, and therapy: A review and update. Respir Care. critically ill children with acute respira- handoff.21 2017;62(6):645-661. tory failure. Thoughtful attention to ini- Proactive preparations are crucial 11. Shoemaker MT, Pierce MR, Yoder BA, DiGeron- imo RJ. High-flow nasal cannula versus nCPAP tial provider as well as optimal setting/ to successfully caring for the pediatric for neonatal respiratory disease: a retrospective preparation is important to maximize patient. Often, communication between study. J Perinatol. 2007;27(2):85-91. 12. Miller A, Gentile M, Tyler L, Napolitano the chance for first attempt success and facilities and key opinion leaders are for- N. High-Flow nasal cannula in pediatric pa- to avoid desaturation.”19 Risk is also pres- gotten, which jeopardizes the quality of tients: A survey of clinical practice. Respir Care. ent when attaching the patient to the continuing care. Whether a rural com- 2018;63(7):894-899. 13. Ejiofor B, Carroll R, Bortcosh W, Kacmarek R. ventilator such as asynchrony, pneumo- munity hospital or a large referring chil- PEEP generated by high-flow nasal cannula in thorax, and ventilator-associated pneu- dren’s hospital, the communication and a pediatric model. Respir Care. 2018;63(Suppl monia. All risks should be considered preparation between the care networks 10):3015906. 14. Bamford O, Lain D. Effects of high nasal gas prior to intubation, and ventilation to is essential. Children’s hospitals should flow on upper airway pressure. Respir Care. ensure optimal safety and benefit. be discussing plans with community 2004;49:1443. The goals of CMV are similar to NIV hospitals; providing support, education, 15. Stubblefield S. Optimal rate of flow for high-flow nasal cannula in young children. The Hospitalist. and the rest of the pyramid of care: main- and resources. Community hospitals 2018. Retrieved from https://www.the- hospi- tain adequate oxygenation, ventilation, should not hesitate to ask for this assis- talist.org/hospitalist/article/155936/ pediatrics/ optimal-rate-flow-high-flow-nasal-cannula- and airway protection. Initial settings for tance. Potential topics include resource young-children CMV should consider disease process management, standards of care, referral 16. Weiler T, Kamerkar A, Hotz J, Ross P, Newth C, Khemani R. The relationship between high-flow (healthy vs unhealthy lungs) and should communication, and potential extenu- nasal cannula flow rate and effort of breathing in always keep lung protection in mind. ating circumstances (distance, weather, children. Jour of Pediatr. 2017;189(3):66-71. Comfort considerations include seda- emergency management, etc.). 17. Lillie B. Pediatric Noninvasive Ventilation. RT for Dec Makers in RC. 2011. Retrieved from tion, paralytics, and active or passive hu- http://www.rtmagazine.com/2011/01/pediatric- midification. Consulting with an expert Conclusion noninvasive-ventilation/ is also recommended.20 Although initial Sick children will arrive, the question 18. Restrepo R, Walsh B. Humidification during invasive and noninvasive mechanical ventilation: settings are not standardized, Neglar and is when? Start preparing by conducting 2012. Respir Care. 2012; 57(5):782-788. Cheifetz (2018) published an UpToDate a labor and non-labor needs assessment 19. Lee JH, Turner DA, Kamat P, et al. The number article on safe starting settings (Figure 2). and address the gaps found during that of tracheal intubation attempts matters! A pro- spective multi-institutional pediatric observa- The authors also offered insight on assessment. Use resources that are avail- tional study. BMC Pediatr. 2016;16(58). monitoring, stabilization, and wean- able, including training programs, clini- 20. Naglar J, Cheiftez I. Initiating mechanical ventilation in children. UpToDate. 2018. Retrieved ing of the ventilated pediatric patient cal practice guidelines, and treatment from https://www.uptodate.com/contents/initi- that includes serial blood gases, cardiac methodologies like the Pyramid of Care. ating-mechanical-ventilation-in-children monitoring, pulse oximetry, and capnog- Most of all, collaborate and communi- 21. Kulshrestha A, Singh J. Inter-hospital and intra- 20 hospital patient transfer: Recent concepts. Indian raphy. Keeping respiratory therapists cate with your health-care team mem- J Anaesth. 2016;60(7):451-457. competent and current with evidence- bers to ensure the best possible outcomes based practice will ensure the best pos- for this vulnerable patient population. sible outcomes. Extreme measures are the top of References 1. National Emergency Department Inventory. the respiratory pyramid of care and are Emergency Medicine Network. 2015. Retrieved exclusive to tertiary children’s hospitals. from http://www.emnet-usa.org/nedi/nedi_usa. These measures may include advanced htm

www.clinicalfoundations.org 5 Clinical Foundations

Clinical Foundations Panel Discussion

NIV/HFNC for modate. Different manufacturers have HFNC is capable different size cannulas and different flow limitations. The cannula should not oc- Neonates and clude any more than 50% of the nares. of providing Most of the single limb circuits can ac- Pediatric commodate the flows needed. There is an additional advantage that most patients Patients humidification at will tolerate a high-flow nasal cannula when compared to a nasal interface for CPAP. Moderator: Kathleen Deakins, RRT NPS higher flows than FAARC DiBlasi: HFNC provides humidification Panelists: Rob DiBlasi, RRT NPS standard oxygen and oxygen to spontaneously breathing Lee Williford ,RRT-NPS RCP patients. The level of support provided by HFNC is based on the patient size, respi- Keith Hirst, MS, RRT-ACCS, therapy… ratory pattern, flow setting, cannula size, RRT-NPS, AE-C oral and/or nasal leak, and the HFNC - DiBlasi - system being used. Oxygen therapy, using anhydrous gas, is usually titrated to Can you clarify the terminology used for a maximum value of 2 and 6 L/min for heated high-flow nasal cannula (HFNC)? 2.5 kg infant should have their flows set to neonates and adults, respectively. HFNC Are there limitations or advantages when ≥ 3 L/min if the team wants the patient to is capable of providing humidification at using these systems in the pediatric vs the be in true high-flow. Otherwise, it is just higher flows than standard oxygen ther- neonatal population? considered a high humidity nasal cannula. apy, so there is less risk associated with Hirst: A high-flow device is anything that In pediatrics, flows > 6 L/min that administering dry gas. meets or exceeds the patient’s inspiratory are typically considered high-flow.2 HFNC Technical definitions for HFNC are demands. Because of this, clinicians can use continues to increase as the system is lacking, especially when the range of patient diseases and sizes that are support- deliver a more precise level of FiO2 to easily set up and is well tolerated by pa- the patient. Proper implementation of a tients. The use of a nasal cannula adapted ed by this therapy are considered. Some high-flow system is meant to minimize to the infant’s nares size to deliver heated sources define HFNC as flows that exceed the amount of air that is entrained, which and humidified gas at high-flow rates has peak inspiratory flow or minute ventilation.3 Unlike CPAP, the HFNC prongs would lower the FiO2. The general rule of been associated with improvements in thumb in neonates is that the flow has to washout of nasopharyngeal dead space, are intended to occlude 50% of the nasal be equal to or greater than the patient’s lung mucociliary clearance, and oxygen airway opening. Increasing flows will pro- 1 vide increased FiO and pressure delivery. current weight to deliver precise FiO2. delivery, compared with other oxygen 2 Studies in vitro4 and in vivo5,6 have shown However, FiO2 also varies with changes in delivery systems. HFNC may also create the patient’s breathing, which are factors positive pharyngeal pressure to reduce that increasing flow will provide pres- beyond our control. While a stable oxygen the work of breathing (WOB) which posi- sure in the lungs that is similar to CPAP delivery is desirable, combinations of flow tions the device midway between classical in infants. The feature that sets HFNC and concentration that maximize stability oxygen delivery systems, like the high- apart from CPAP is the unique ability to over time need to be studied. In the neo- concentration face mask, and continuous improve effective minute ventilation by nates, if that flow is below their current positive airway pressure (CPAP). The eliminating re-breathing of exhaled car- weight, then you are only delivering high basic limitation is the cannula size, the bon dioxide from the nasopharyngeal humidity to the patient. For example, a patient, and the flow that it can accom- deadspace. 4,7 This effect is notable even at

6 www.clinicalfoundations.org Clinical Foundations lower flows (~2 L/min) in premature and fixation. This requires highly skilled indi- term newborn models. Based on over a These high-flows viduals to ensure patient comfort, mini- decade of research with HFNC, there is mize leaks, and avoid pressure injuries. an improved understanding about the HFNC may overcome many of these complex physiologic effects in what ap- provide flushing of limitations and may be preferable after a pears to be a relatively simple noninva- delivery or post-extubation. The added sive system. However, based on recent benefit of carbon dioxide from the dead- findings, it is unclear whether HFNC extrathoracic dead space, coupled with similar pressures is more like CPAP or noninvasive ven- as CPAP, make HFNC an attractive op- tilation (NIV), such as noninvasive in- tion. However, there is a lack of research, termittent positive pressure ventilation space with fresh gas standardized clinical protocols, and (NIPPV). disease-specific guidelines for HFNC in newborns, which make it difficult to Williford: As noted by my colleagues, which results in a determine timing for therapy, maximum HFNC is the use of flows greater than a settings, and weaning approaches in pa- supplemental nasal cannula can provide more efficient oxygen tients. A review of clinical data related to (1, 3, and 6 L/min in neonate, pediatric, outcomes in newborn infants is reviewed and adult patients, respectively). The later in this interview. term, “high-flow” also implies that the delivery and clearance flow meets or exceeds the patient’s in- Williford: Noninvasive modes of respira- spiratory demand. These high-flows pro- tory support, such as HFNC, CPAP, and vide flushing of extrathoracic dead space of carbon dioxide. (NIPPV), are common methods to obtain with fresh gas which results in a more respiratory stability in the patients with efficient oxygen delivery and clearance - Williford- increasing respiratory distress. High- of carbon dioxide.3,8,9 In addition, there flow nasal cannula provides heated hu- is evidence that positive pressure equiva- midified gas that provides positive end- lent to CPAP is generated by HFNC, al- delivery? expiratory pressure (PEEP) levels similar lowing for airway stenting and alveolar Hirst: There have been several recent to CPAP.17,18 CPAP has been established recruitment.4 These benefits associated clinical trials that have looked at this as the support mechanism in preterm with HFNC provide offloading of respi- question. The first one was the HIPSTER infants that can prevent intubation.15 ratory work at flows up to 6 – 8 L/min trial.14 HIPSTER showed that HFNC HFNC and CPAP have been shown to in neonates10 and between 1.5 and 2 L/ was inferior for newborns with respira- reduce extubation failure.16 Nasal trauma min/kg in pediatric patients < 8 kg.11 The tory distress syndrome (RDS) and had a is the most common complication asso- effect is less dramatic in patients > 8 kg. higher failure rate when compared with ciated with CPAP. In a recent Cochrane The flow rate/kg needed to achieve op- nCPAP. Since then, some additional tri- review in which CPAP was compared to timal support in larger patients appears als have come out which, depending on NIPPV, NIPPV was superior to CPAP in to decrease based on a L/min/kg dosing. which one you read, may support the use reducing respiratory failure and need for One possible cause for this reduction in of HFNC or nCPAP in the newborn. Re- intubation.21 There are no data that sug- flow/kg in larger patients is the amount cently a meta-analysis looked at all the gest chronic lung disease is lower with of extrathoracic dead space: in infants, 3 trials published and reviewed the qual- NIPPV, CPAP or HFNC. mL/kg of anatomic dead space is appre- ity of the evidence, which they graded When providing support to new- ciated, which reduces with age to approx- as moderate quality.15 They concluded borns, the mechanism of action specific imately 0.8 mL/kg at age 6. The fact that that HFNC is inferior to nCPAP when it to HFNC and CPAP are similar. Each HFNC provides comparative support to comes to newborns with RDS.13 A recent improves respiratory efficiency due to a nCPAP (nCPAP) and has a simple, skin- analysis showed that using CPAP was flushing of anatomic dead space, reduc- friendly application makes this mode of more cost-effective than using HFNC tion of inspiratory resistance, and stent- respiratory support desirable. The limita- with CPAP as rescue.16 Based on this and ing of the airway through distending tion of one level of support that is based other reviews, I would suggest continu- pressure.11,18 The choice between CPAP on set flow can limit its application when ing nCPAP when it comes to providing and HFNC may be associated with avail- respiratory distress progresses. respiratory support for newborns right ability, personal practice preference, and after delivery. comfort with a given device. Along with Respiratory therapists are on a quest to preference, nasal deformities are associ- do the right thing. Can you provide evi- DiBlasi: A major limitation with CPAP ated with CPAP. This may provide su- dence supporting noninvasive respira- and NIV in pediatric patients is that periority to HFNC when compared to tory support devices to be used after a most interfaces require a complicated CPAP.

www.clinicalfoundations.org 7 Clinical Foundations

NIPPV provides inspiratory sup- tory support modes should be done in a port above a baseline pressure. This in- Many will use HFNC stepwise manner. Failure associated with spiratory support decreases thoracoab- these devices must be recognized. During dominal asynchrony, decreases the need initiation of HFNC an expected reduction for intubation, and has been shown to for use in recently in oxygen requirement and overall WOB decrease extubation failure.24 When ini- should be noted within one hour.33 If ei- tiating this type of unsynchronized respi- ther of these requirements are not met, an ratory support, the rate should be set to extubated infants or increase in support or change in mode provide support for > 50% of the patients’ may be indicated. intrinsic respiratory rate. When at least In pediatric respiratory distress pa- 60% synchrony is seen, patients’ WOB for patients who may tients, flow should be initiated at 1.5 L/ is reduced when compared to HFNC.25 min/kg in patients <8 kg.11 The flow/kg Given that data suggest that NIPPV is of body weight appears to decrease with superior to nCPAP, an initial therapy of have failed trials off age, which suggests, in patients > 8 kg, a NIPPV can be recommended to prevent flow of 1 L/min/kg may be a good starting respiratory failure post-delivery. CPAP. point. Flow via HFNC can be increased to a maximum of 2 L/min/kg based on pa- Do protocols and guidelines support clini- - Hirst - tient respiratory assessment. If 2 L/min/ cal practice? What flow rates are recom- kg is utilized and a decrease in WOB and mended and how are they determined for oxygen need is not seen, positive pressure neonates and pediatric patients? DiBlasi: There are very few available ev- via noninvasive or invasive support may Hirst: Hospital-based protocols and idence-based guidelines and protocols to be indicated. guidelines should be supported by cur- support clinical practice in pediatric pa- In neonatal patients, flow setting rent evidence. The use of HFNC in both tients. Many HFNC strategies have been should be set based on patient weight as the neonatal and pediatric population is derived from study protocols or are based well. Flows of 4-6 L/min in preterm in- an evolving area. Guidelines and protocol on expert opinion or both.24 In the neona- fants <1599 grams and 6-8 L/min for pa- need to include indications as well as con- tal intensive care unit (NICU), many cen- tients >1599 g.21 These flows are based on traindication, flow ranges, failure criteria, ters use HFNC at 2-8 L/min, since these the potential CPAP achieved. etc. It is important to look at not only the settings have been shown to result in ~2-8 5,6 body but the level of evidence. For neo- cm H2O CPAP in the lungs of infants. Compare and contrast HFNC and CPAP nates, a consensus conference was held It is not uncommon for some institutions for pediatric patients. Can similar out- in 2015, and based on the literature and to report using 1.5-3.0 L/min/kg outside comes be achieved from using either de- evidence then, they recommended flows of the neonatal setting. This would equate vice? from 2 -8 L/min.26 Many will use HFNC in to HFNC settings ~ 20-60 L/min in a 20 Hirst: With HFNC, there is clearly a better recently extubated infants or for patients kg child. In a 3D-printed closed-mouth, comfort level that can be achieved, com- who may have failed trials off CPAP. There anatomic nasopharyngeal and lung mod- pared with CPAP in the pediatric popula- is a growing body of literature that is sug- el, reported end-expiratory pressures tion. There is less risk of skin breakdown gesting that use of HFNC in infants may of 15-22 cm H2O at 30 L/min have been with HFNC as well. There does seem to be prolong oxygen requirements and delay reported using two different HFNC sys- some clinical evidence that use of HFNC discharge. Many also feel that switching to tems.4 Owing to the lack of definitive data, may reduce the risk or incident of intu- HFNC may be a way to safely orally feed determining appropriate HFNC settings bation in the pediatric ICU (PICU).26,27 infants. However, current literature and in children represents a major challenge While there does not appear to be any di- research does not support this.22 and area for new research. As such, many rect head-to-head study looking at HFNC For pediatrics, there are a multitude clinicians choose to take an individual- and CPAP in the pediatric population, of studies, but none really support any ized strategy or transition to CPAP or NIV based on the current studies, I do believe level of flow. Most flow is titrated to meet once HFNC reaches a predefined maxi- that you could get similar outcomes if you the patients demands/needs. This is sup- mum setting. HFNC protocols and guide- used either device. ported by a recent survey, which showed lines are needed using the highest level of a lack of consensus regarding where to evidence. In toddlers and small children, DiBlasi: A growing body of evidence sup- set flow and how to titrate.23 This is still there is a lack of appropriately sized CPAP ports HFNC as an alternative to other a work in progress as how you treat the and NIV masks. HFNC therapy has been noninvasive support techniques for term pediatric population. It is going to vary a wonderful option over traditional CPAP and preterm infants following extubation. because of the different disease states that and NIV for this niche patient population. A meta-analysis from six randomized one sees in the pediatric population. Williford: Utilization of these respira- control trials (n = 934 subjects) comparing outcomes between HFNC and CPAP

8 www.clinicalfoundations.org Clinical Foundations post-extubation in term and preterm might be better as a rescue therapy. newborns showed no differences in In larger infants and death or chronic lung disease or rate of Williford: In pediatric patients, < 6 treatment failure or reintubation.10 While months of age, the reduction in WOB these findings were not consistent across children (<18 years), when comparing HFNC and CPAP, is all trials, subgroup analysis of infants 28- negligible. When comparing HFNC, 32 weeks of age shows less treatment fail- CPAP, and NIPPV with respect to per- ure with HFNC than CPAP. Also, infants HFNC at 8 L/min cent of assisted breaths to total respirato- randomized to HFNC had lower nasal ry rate, NIPPV plays a role in the reduc- trauma, and pneumothorax and trend tion of work. When patients have a high toward lower necrotizing enterocolitis was shown to result level of synchrony, NIPPV is superior compared with other forms of noninva- to CPAP and HFNC.20 In a randomized sive therapy. It is important to note that control trial, Milesi et al reviewed CPAP very few extremely low birth weight in- in similar effort of vs HFNC in bronchiolitis and suggested fants were included in these studies. An- that CPAP may be more efficient in treat- other study comparing HFNC to CPAP breathing as CPAP in a ing moderate-to-severe bronchiolitis, but in subjects from a cardiac ICU showed they note that both CPAP and HFNC are that subjects initially extubated to CPAP safe.33 CPAP data are limited with respect experienced greater resource utilization: PICU setting. to use in pediatric patients with acute ill- longer time to low-flow nasal cannula, ness except for bronchiolitis. CPAP and longer time to room air, and longer post- NIPPV provides challenges associated surgical hospital length of stay.28 - DiBlasi - with appropriately sized mask and prongs, While research supports HFNC especially in small pediatric patients. Us- as an effective alternative to CPAP post- age of HFNC for asthma, bronchiolitis, extubation, clinicians are increasingly al ventilation in the primary treatment pneumonia, and congenital heart disease considering HFNC as an initial form of of RDS in premature infants.40, 41 More have all been described in the literature support in premature infants. In a recent studies are needed in preterm infants to with success.34 The patient population meta-analysis (4 studies, 439 premature determine whether HFNC is as effective with the highest rate of failure was pneu- infants), when used as primary respira- as an initial form of noninvasive support. monia. Indications of failure are: wors- tory support after birth, there were no Outside of the NICU setting, most ening respiratory rate, PCO2, or need for differences in death or chronic lung dis- research has focused on short-term out- increased oxygen after initiation.2 Due ease between HFNC and CPAP.10 HFNC comes in patients with bronchiolitis, and to the aforementioned challenges with resulted in longer duration of respiratory very few include subjects outside of in- appropriate masks and prongs, the level support, but there were no differences fancy. In infants, WOB has been shown of support provided, and ease of applica- in other secondary outcomes. The HIP- to be similar on HFNC, NIMV, and nC- tion, HFNC is a superior in the setting of STER study is one of the only random- PAP after extubation.42 In larger infants acute onset respiratory distress. ized controlled trials that has compared and children (>18 years), HFNC at 8 L/ outcomes in premature infants prior min was shown to result in similar WOB How do you determine when to use to surfactant administration between as CPAP in a PICU setting.8 which non-invasive modality? (CPAP or HFNC (6-8 L/min) and CPAP (6-8 cm Few data exist to support safety and HFNC) 12 Hirst: H2O). There was greater combined effectiveness for HFNC in large pediat- All of our patients who require ini- treatment failure in the HFNC group. ric patients.31 As mentioned previously, tial respiratory support for RDS will get a

Failure criteria were based on FiO2 > 0.4, the most widely-studied HFNC group trial of CPAP unless there is a direct con- hypercarbia, and/or severe apnea. No dif- outside of NICU includes infants with traindication for CPAP, at which point the ferences were noted for individual failure bronchiolitis, but data remain inconclu- patient will get intubated. Our preferred outcomes between the two groups. There sive as to whether HFNC improves out- mode of support for post-extubation were no differences in in intubation rates comes when compared with other forms is CPAP, usually Bubble. To minimize within 72 hr but, infants randomized to of noninvasive support. HFNC has been nares and skin breakdown we alternate CPAP had more nasal pressure injuries, shown to result in less need for care esca- between a nasal mask and prongs. There a higher frequency of pneumothorax or lation than a ‘low-flow’ oxygen cannula are some instances where we will extu- other air leak, and were more likely to in bronchiolitis patients. Also, fewer in- bate to either a low-flow nasal cannula require emergent intubation than infants fants with bronchiolitis experience treat- or room air. In our NICU, HFNC is used supported with HFNC. Two clinical tri- ment failure on HFNC than with stan- primarily when a patient has failed room als have shown that HFNC may be as ef- dard oxygen cannula but length of O2 air or low-flow nasal cannula trial off nC- fective as NIV in preventing endotrache- therapy is not different.32 As such, HFNC PAP at least twice. Our clinicians believe

www.clinicalfoundations.org 9 Clinical Foundations that patients should be removed from a CPAP and not supported by HFNC. This References Based on the available 1. Benaron DA, Benitz WE. Maximizing the stabil- method, called the CICADA (CeasIng ity of oxygen delivered via nasal cannula. Arch Cpap At standarD criteriA) method was Pediatr Adolesc Med. 1994;148(3):294-300. 2. Milési C, Boubal M, Jacquot A, et al. High-flow trialed and validated in Australia through evidence in the nasal cannula: Recommendations for daily prac- a series of studies and RCT.37 We will also tice in pediatrics. Ann Intensive Care. 2014;4(1). 3. Dysart K, Miller TL, Wolfson MR, Shaffer TH. use HFNC for patients with apnea of pre- Research in high-flow therapy: mechanisms of maturity when a low-flow nasal cannula is neonatal setting, action. Respir Med. 2009;103(10):1400-1405. 4. Nielsen KR, Ellington LE, Gray AJ, Stanberry LI, not stimulating them enough. Smith LS, DiBlasi RM. Effect of high-flow nasal For pediatric patients, the issue cannula on expiratory pressure and ventilation in infant, pediatric, and adult models. Respir arises regarding the amount of support CPAP and HFNC are Care. 2018;63(2):147-157. and how much lung is collapsed as well 5. Iyer NP, Mhanna MJ. Association between high- flow nasal cannula and end-expiratory esopha- as the level of respiratory acidosis. For pa- geal pressures in premature infants. Respir Care. tients who have minimal lung collapse or interchangeable. 2016;61(3):285-90. the lung appears over-distended, I would 6. Al-Alaiyan S, Dawoud M, Al-Hazzani F. Positive - Williford - distending pressure produced by heated, hu- recommend HFNC, titrating to the ef- midified high-flow nasal cannula as compared to nasal continuous positive airway pressure fect that the team wants. This includes in premature infants. J Neonatal Perinatal Med. patients with bronchiolitis, asthma, and are interchangeable. Consideration may 20141;7(2):119-24. 7. Frizzola M, Miller TL, Rodriguez ME, Zhu pneumonia. However, if there is collapse be given to CPAP in patients with up- Y, Rojas J, Hesek A, et al. High-flow nasal can- or the team’s main goal is to recruit the per airway obstruction. If HFNC failure nula: impact on oxygenation and ventilation in an acute lung injury model. Pediatr Pulmonol. lung, then I would recommend the use of is noted, transition to NIPPV is the next 2011;46(1):67-74. CPAP for the main reason that the level clinical step for respiratory support. NIP- 8. Rubin S, Ghuman A, Deakers T, Khemani R, Ross P, Newth CJ. Effort of breathing in children of end expiratory pressure on HFNC can PV usage with an initial rate of ≥ 50% of receiving high-flow nasal cannula. Pediatr Crit be variable, and if the patient needs lung the patient’s intrinsic rate and an initial Care Med. 2014;15(1):1-6. 9. Rivieri EM, Foglia EE, Abbasi S. Carbon di- recruitment, it is better to deliver the pres- peak inspiratory pressure (PIP) of 2 above oxide washout during high-flow nasal cannula versus nCPAP support: An in vitro study. sure that is needed. For patients who are the settings at extubation, or 16 cm H2O 19 2017;52(6):792-798. Pediatric Pulmonol. in the early stages of respiratory failure, and a PEEP of 5 is commonly described. 10. Wilkinson D, Andersen C, O’Donnell CP, De HFNC may be suitable to prevent intuba- Once the patient is weaned to a minimum Paoli AG, Manley BJ. High-flow nasal cannula for respiratory support in preterm infants. Co- tion. However, for those patients who are fraction of inspired oxygen and a mean chrane Database Syst Rev. 2016;2:Cd006405. starting to fail, CPAP would be a more ap- airway, pressure that can be duplicated via 11. Weiler T, Kamerkar A, Hotz J, Ross PA, Newth CJL, Khemani RG. The Relationship between propriate. HFNC, the patient can be transitioned to High-flow Nasal Cannula Flow Rate and Effort a high-flow nasal cannula setup. Failure of of Breathing in Children. J Pediatr. 2017;189:66- 71.e63. DiBlasi: In the NICU setting, patients both modes is associated with tachypnea 12. Roberts CT, Owen LS, Manley BJ, et al. Na- who do not tolerate ≤ 8 L/min may re- and increasing oxygen requirement. sal high-flow therapy for primary respiratory support in preterm infants. New Engl J Med. quire a different form of NIV as an alter- Within the pediatric population, 2016;375(12):1142-1151. native to intubation. In some infants with HFNC is the first-line treatment for mild- 13. Conte F, Orfeo L, Gizzi C, Massenzi L, Fasola S. Rapid systematic review shows that using floppy airways, flows of ~10 L/min may to-moderate distress. Evidence suggest a high-flow nasal cannula is inferior to nasal be necessary to stent the airways open. that HFNC flows of 1.5–2 L/min/kg pro- continuous positive airway pressure as first- line support in preterm neonates. Acta Paediatr. In larger infants and small children, it is vides a similar reduction in WOB when 2018;107(10):1684-1696. common to use flows 10-20 L/min. It is compared with CPAP and NIPPV when 14. Huang L, Roberts CT, Manley BJ, Owen LS, Da- 13 vis PG, Dalziel KM. Cost-effectiveness analysis unclear whether this can be tolerated, so used in smaller pediatric patients. CPAP of nasal continuous positive airway pressure ver- clinicians need to use caution in this age and NIPPV can be used interchangeably sus nasal high flow therapy as primary support for infants born preterm. J Pediatr. 2018;196:58- group, as pressures have not been mea- for patients < 6 months of age for increas- 64.e2. sured at those flows, so air-leak could be a ing respiratory distress as an alternative to 15. Dunn MS, Kaempf J, de Klerk A, de Klerk R, Reilly M, Howard D, et al. Randomized trial risk; whereas CPAP or NIV may not pose HFNC. In larger pediatric patients, there comparing 3 approaches to the initial respiratory management of preterm neonates. Pediatrics a similar risk. Institutions that use HFNC are limited data associated with HFNC. A 2011;128(5):e1069-1076. must develop protocols using specific reasonable approach in the pediatric pop- 16. Manley BJ, Owen LS, Doyle LW, Andersen CC, HFNC systems in order to determine the ulation > 10 kg may be the use of a lower Cartwright DW, Pritchard MA, et al. High-flow nasal cannulae in very preterm infants after extu- appropriate timing and location to initi- prescribed dose, starting at a flow setting bation. New Engl J Med. 2013;369(15):1425-1433. ate HFNC or switch to a different form of of 1 L/min/kg. This approach may be pru- 17. Lemyre B, Laughon M, Bose C, Davis PG. Early nasal intermittent positive pressure ventilation noninvasive support. dent given the reduced overall extratho- (NIPPV) versus early nasal continuous positive airway pressure (NCPAP) for preterm infants. racic dead space and the lack of data in Cochrane Database Syst Rev. 2016;12:Cd005384. Williford: Based on the available evidence this patient population. In these patients 18. Sivieri EM, Foglia EE, Abbasi S. Carbon dioxide in the neonatal setting, CPAP and HFNC who require increasing support, a bilevel washout during high-flow nasal cannula versus support mode of NIV may be indicated.

10 www.clinicalfoundations.org Clinical Foundations

nCPAP support: An in vitro study. Pediatr Pul- continuous positive airway pressure for respi- monol. 2017;52(6):792-798. ratory distress syndrome of prematurity: A 19. Bhandari V. Nasal intermittent positive pres- randomized clinical noninferiority trial. JAMA sure ventilation in the newborn: review of liter- Pediatr. 2016 Aug 8. doi:10.1001/jamapediat- ature and evidence-based guidelines. J Perinatol. rics.2016.1243 [Epub ahead of print]. 2010;30(8):505-512. 31. Mayfield S, Jauncey-Cooke J, Hough JL, 20. Kamerkar A, Hotz J, Morzov R, Newth CJL, Schibler A, Gibbons K, Bogossian F. High-flow Ross PA, Khemani RG. Comparison of effort of nasal cannula therapy for respiratory support breathing for infants on nasal modes of respira- in children. Cochrane Database Syst Rev. 2014; tory support. J Pediatr. 2017;185:26-32.e23. 7;(3):CD009850. 21. Roehr CC, Yoder BA, Davis PG, Ives K. Evi- 32. Kepreotes E, Whitehead B, Attia J, Oldmeadow dence support and guidelines for using heated, C, Collison A, Searles A, Goddard B, Hilton J, humidified, high-flow nasal cannulae in neona- Lee M, Mattes J. High-flow warm humidified tology: Oxford Nasal High-Flow Therapy Meet- oxygen versus standard low-flow nasal cannula ing, 2015. Clin Perinatol. 2016;43(4):693-705. oxygen for moderate bronchiolitis (HFWHO RCT): an open, phase 4, randomised controlled 22. Hirst K, Dodrill P, Gosa M. noninvasive respi- trial. Lancet. 2017 Mar 4;389(10072):930-939. ratory support and feeding in the neonate. Per- spect ASHA Spec Interest Groups. 2017;2(13):82- 33. Milesi C, Essouri S, Pouyau R, Liet JM, Afanetti 92. M, Portefaix A, et al. High-flow nasal cannula (HFNC) versus nasal continuous positive air- 23. Miller AG, Gentle MA, Tyler LM, Napolitano N. way pressure (nCPAP) for the initial respira- High-flow nasal cannula in pediatric patients: a tory management of acute viral bronchiolitis in survey of clinical practice. Resp Care. 2018:re- young infants: a multicenter randomized con- spcare.05961. trolled trial (TRAMONTANE study). Intensive 24. Yoder BA, Manley B, Collins C, Ives K, Kugel- Care Med. 2017;43(2):209-216. man A, Lavizzari A, McQueen M. Consensus 34. Kelly GS, Simon HK, Sturm JJ. High-flow nasal approach to nasal high-flow therapy in neo- cannula use in children with respiratory dis- nates. J Perinatol. 2017;37(7):809-813. tress in the emergency department: predicting 25. Mikalsen IB, Davis P, Oymar K. High-flow the need for subsequent intubation. Pediatr nasal cannula in children: a literature review. Emerg Care. 2013;29(8):888-892. Scand J Trauma Resusc Emerg Med. 2016;24:93. 35. König K, Stock EL, Jarvis M. Noise levels of 26. Can FK, Anil AB, Anil M, et al. Impact of high- neonatal high-flow nasal cannula devices-an flow nasal cannula therapy in quality improve- in-vitro study. Neonatology. 2013;103(4):264- ment and clinical outcomes in a non-invasive 267. ventilation device-free pediatric intensive care 36. Waitz M, Mense L, Kirpalani H, Lemyre B. Na- unit. Indian Pediatrics. 2017;54(10):835-840. sal Intermittent Positive Pressure Ventilation 27. Kawaguchi A, Yasui Y, Decaen A, Garros D. The for Preterm Neonates: Synchronized or Not? clinical impact of heated humidified high-flow Clin Perinatol. 2016;43(4):799-816. nasal cannula on pediatric respiratory distress. 37. Heath Jeffery RC, Broom M, Shadbolt B, Todd Pediatr Crit Care Med. 2017;18(2):112-119. DA. CeasIng Cpap At standarD criteriA (CI- 28. Richter RP, Alten JA, King RW, Gans AD, Akm CADA): Implementation improves neonatal FR, Kalra Y, Borasino S. Positive airway pres- outcomes. Paediatr Child Health (Oxford). sure versus high-flow nasal cannula for pre- 2016;52(3):321-326. vention of extubation failure in infants after congenital heart surgery. Pediatr Crit Care Med. 2018. 29. Kugelman A, Riskin A, Said W, Shoris I, Mor F, Bader D. A randomized pilot study comparing heated humidified high-flow nasal cannulae with NIPPV for RDS. Pediatr Pulmonol. 2015;50(6):576-83. 30. Lavizzari A, Colnaghi M, Ciuffini F, Veneroni C, Musumeci S, Cortinovis I, Mosca F. Heated, humidified high-flow nasal cannula vs nasal

www.clinicalfoundations.org 11 Bios

Matthew S. Pavlichko, MS, RRT-NPS projects and initiatives related to Respiratory and is a Certified Asthma Educator. Keith has Matt has been in the field of respiratory care for Care. She is also a fellow of the AARC presented lectures and research on neonatal over 20 years. In 2014, Matt became the Direc- and pediatric topics at the regional, national and tor of Cardiopulmonary Services at Levine Chil- Rob DiBlasi, RRT-NPS, FAARC international level. His clinical and research in- dren’s Hospital. Here he had the opportunity to Rob is a Respiratory Therapist and Manager of terests include mechanical ventilation and non- lead a complex organization while dedicating Research in the Respiratory Care Department invasive ventilation, their effect on lung develop- his work to the health of children. In 2018, he at the Seattle Children’s Hospital. Rob manages ment, and non-invasive monitoring. returned home to Pennsylvania and is currently clinical, aerosol and animal research as Program the Director of Respiratory Care and Pulmonary Manager for Translational Respiratory Research Lee Williford, RRT-NPS, RCP Diagnostics for Penn Medicine Lancaster General at the Seattle Children’s Hospital Research In- Lee Williford, is the Directory of Respiratory Care Health. Matt has multiple publications and the stitute. His research interests include: neonatal and ECMO at the Children’s Hospital of the King’s honor ofspeaking across the country on leader- pulmonary mechanics monitoring, patient/ven- Daughters In Norfolk, VA. Lee has been working ship and management topics. He is an active tilator interaction, ventilator induced lung injury, as a healthcare practitioner for nearly 30 years in member of the North Carolina Society for Respi- neonatal lung protective strategies, mechanical progressively more senior positions. He is highly ratory Care, Pennsylvania Society for Respiratory ventilator performance, and aerosolization of re- skilled clinician with extensive experience in me- Care, and American Association for Respiratory spiratory medications. He has published 40 pa- chanical ventilation, ECMO, Pediatric Advanced Care (AARC). pers in peer review journals and written over 10 Life Support (PALS), and patient education. He textbook chapters related to Respiratory Care. has been awarded the Neonatal Pediatric Spe- Kathleen Deakins, RRT-NPS, FAARC He is also a fellow of the AARC. cialty Practitioner of the Year, and has published Kathleen is a Respiratory Therapist and Manager numerous articles in peer reviewed journals on of Women’s and Children’s Respiratory Care for Keith Hirst, MS, RRT-ACCS, RRT-NPS, AE-C number of topics including the use of ECMO. University Hospitals Rainbow Babies and Chil- Keith is the Manager of Newborn Respiratory dren’s Hospital where she manages the Pediatric Therapy at Brigham and Women’s Hospital and Respiratory Care Department, Pediatric Pulmo- oversees a staff of 18 neonatal respiratory ther- nary Function and Infant Monitoring Depart- apistswho work exclusively in the NICU. Keith ments. Her interests include research related to has specialized in working with neonates and Airway Clearance and Devices, Resuscitation de- pediatrics for over 16 years and is credentialed vices and Monitoring. She has been involved in as a Respiratory Therapist as well as a Neona- many research abstracts, quality improvement tal Pediatric Specialist, Critical Care Specialist,

Clinical Foundations This education activity is approved for 2.0 contact is a serial educa- hours. Provider approved by California Board of Learning Objectives tion program distributed free of charge Nursing, Provider #14477 Provider approved by the Upon completion of this activity, the participant Florida Board of Nursing. Provider # CE 50-17032 to health professionals. Clinical Founda- will be able to: tions is published by Saxe Healthcare This program has been approved for 2.0 contact hours of continuing education (CRCE) by the Ameri- 1. Identify the signs and symptoms of impending Communications and is sponsored by can Association for Respiratory Care (AARC). AARC is Teleflex Incorporated. The goal of Clinical accredited as an approver of continuing education in respiratory failure in children. respiratory care. Foundations: A Patient-Focused Education 2. Describe “Pyramid of Care” theory and its rela- Program for Healthcare Professionals is to To earn credit, do the following: tion to neonatal/pediatric respiratory care. present clinically- and evidence-based prac- 1. Read all the articles. 3. Discuss safe and effective initial settings for this tices to assist the clinician in making an in- 2. Complete the entire post-test and partici- population based on evidence-based guidelines formed decision on what is best for his/her pant evaluation online at www.saxetesting. patient. The opinions expressed in Clini- com/cf. cal Foundations are those of the authors 4. Identify the clinical practice applications of 3. To earn 2.0 CRCEs or CEs, you must HFNC and NIV in pediatric and neonatal only. Neither Saxe Healthcare Commu- achieve a score of 75% or more. If you do not patients. nications nor Teleflex Incorporated make pass the test you may take it over one more any warranty or representations about the time. This test is available only online at. accuracy or reliability of those opinions or 4. This test must be taken online. Go to www.saxetesting.com/cf You must their applicability to a particular clinical www.saxetesting.com/cf and log in. Upon register to take your test. Enter your successful completion, your certificate can situation. Review of these materials is not be printed out immediately. AARC mem- answers in the appropriate box. Once a substitute for a practitioner’s independent bers’ results are automatically forwarded to successfully completed, your certificate research and medical opinion. Saxe Health- the AARC for accreditation. of completion can be printed out care Communications and Teleflex disclaim 5. Faculty Disclosures. Matthew S. Pavlichko, immediately. any responsibility or liability for such mate- MS, RRT-NPS, Kathleen Deakins, RRT-NPS, rial. They shall not be liable for any direct, FAARC, Rob DiBlasi, RRT-NPS, FAARC, special, indirect, incidental, or consequen- Keith Hirst , MS, RRT-ACCS, RRT-NPS, AE- tial damages of any kind arising from the C, Lee Williford, RRT-NPS, RCP each disclosed no conflicts of interest associated with use of this publication or the materials con- this publication. tained therein. Please direct your correspondence to:

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