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Bronchiolitis Appendix (HFNC) Algorithm

Bronchiolitis Appendix (HFNC) Algorithm - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Respiratory, Related


Bronchiolitis High Flow Nasal Cannula (HFNC) Management on Emergency and General Care Units
Prior to HFNC Initiation:
MD to order (using bronchiolitis order set)
Resident to notify Attending
MD to consider:
ξ Place PIV (consider normal saline bolus)
ξ NPO
In ED:
ξ if unchanged: call PICU
ξ If improving: call pediatric hospitalist attending for
admission. Suction and VS q I hour while waiting to admit
On Floor:
ξ Suction at least q 2 hrs. until off HFNC, with VS q 2 hrs. x 6
hrs., then q 4 hrs unless clinical need for ↑ frequency
Weaning HFNC on general care unit:
FiO2 should be titrated by RT to maintain saturations>90% q1-
2 hr until 30%
HFNC flow rate should be weaned quickly in improving
patients, including at night. Wean flow by .5 q 1-2 hr until
≤3lpm as long as patient is:
ξ Clinically improving
ξ Requiring less than 30% FiO2
ξ WARM score is stable or improving
RT to assess using WARM Score prior to each wean and/or at
least q4 hour
RT to notify RN of any wean in flow
RN assess WOB and RR within 1 hour of wean in flow
When HFNC is stable at ≤ 3lpm for 2 hours, change to
humidified nasal cannula
ξ In ED: Call PICU if need > flow range
ξ On Floor: Call RRT if need > flow range
ξ Transfer patient to ICU if ≥ Max Flow of:
28 day-3 mo 12 Lpm
3 mo-12 mo 15 Lpm
13 mo-24 mo 20 Lpm
ξ Increase respiratory support with HFNC or other therapies
while awaiting transfer
Sign of clinical improvement (at least one):
ξ Improving WARM Score
ξ Lower respiratory rate (not inappropriately low for age)
ξ Lower heart rate
HFNC Inclusion Criteria
ξ On Pediatric Hospitalist Service
ξ Attending Hospitalist Notified
ξ On bronchiolitis protocol
ξ Age 28 days to < 24 months
HFNC Exclusion Criteria
One of the following:
ξ Patients excluded from bronchiolitis protocol
ξ Transported by CHETA on HFNC
ξ Exceeds Max general care unit flow/age
Meets Unstable Criteria
ξ FIO2 >50% to keep sats >90%
ξ Apnea
ξ Altered mental status (irritability, lethargy)
ξ Poor perfusion (cool extremities, capillary refill >
3 seconds)
ξ Bradycardia
ξ Concern for impending respiratory failure
Initiate HFNC in ED or general floor unit
FiO2 to maintain/titrate sats of > 90%
Age Flow
28 day-3 mo 4 Lpm
3 mo-12 mo 6 Lpm
13 mo-24 mo 8 Lpm
Huddle 60 minutes
post HFNC initiation/change.
In ED: RN, RT, EM resident/
attending and accepting floor
resident
On Floor: RN, CTL, RT,
senior resident
Clinically worsening despite support increase or other clinical
concerns
Clinically unchanged or improving
Criteria for transfer to the ICU:
ξ Clinical worsening on HFNC trial
ξ Meets unstable criteria
ξ Meets General Care Max Flow/age
Criteria for transfer from the ICU to floor:
ξ Meets inclusion criteria, stable on flow rate at or
below the floor maximum for 8-12 hours
ξ If does not meet bronchiolitis HFNC management
on general care units, see HFNC policy
↑WOB despite standard bronchiolitis care
Is patient
worsening?
Bronchiolitis HFNC algorithm; Dr. Shadman. Adapted from Seattle Children’s
Hospital, Wilson L, etal. Revised 10-17.
No
Yes
ξ ↑flow for ↑WOB
ξ ↑ O2 for ↓% saturations
ξ FYI Care team
In ED: Call PICU if needs ↑ flow rates
On Floor: Titrate flow to improve/
maintain WOB:
Age FlowRange
28 day-3 mo 4-8 Lpm
3 mo-12 mo 6-12 Lpm
13 mo-24 mo 8-15 Lpm
Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM @uwhealth.org Last Revised: 12/2017CCKM@uwhealth.org