NURSING PATIENT CARE POLICY & PROCEDURE
May 27, 2015
Nursing Manual (Red)
Policy #: 7.21P
Title: High Flow Nasal Cannula for
Pediatric Patients (Pediatric)
To safely and effectively administer high flow blended oxygen with heated,
humidified nasal cannula therapy.
High flow nasal cannulas deliver nasal high flow therapy using heated humidification
to supply a patient with higher and more concentrated volumes of oxygen than
standard cannulas. The rate prescribed for a particular patient will vary depending on
patient condition and size.
Indications for high flow nasal cannula (HFNC):
ξ Decrease the work of breathing through reduction of airway resistance
ξ Facilitate the hydration of thickened secretions
ξ Provide supplemental oxygen
Contraindications to HFNC:
ξ Inability to protect the airway
ξ Facial trauma
ξ Significant epistaxis
WARNING: Patients receiving HFNC are at high risk for hypoventilation even in the
setting of a normal pulse oximeter reading. Staff should be aware that hypoxemia
(SpO2 < 94%) in patients on HFNC may be due to hypoventilation as well as
A. No patient on HFNC will be admitted from the Emergency Department or outside
hospital to the General Care Units.
B. HFNC can be initiated on the General Care Unit for patients who are:
1. Receiving end of life care
2. Awaiting transfer to an ICU or IMC
C. The PICU Attending will be notified when HFNC is initiated. The PICU team
will work with general care team for transfer to the PICU.
D. A patient in the PICU on HFNC with an improving respiratory condition may be
transferred from the PICU service to the Hematology/Oncology, Hospitalist or
Pulmonology service on the General Care Unit.
1. The PICU Attending and the receiving Hematologist/Oncologist,
Hospitalist or Pulmonology Attending will determine transfer criteria
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collaboratively, and with the inclusion of unit-based nursing leadership
(i.e., Clinical Nurse Manager, Care Team Leader/Senior Team Member).
2. The PICU Attending or Fellow will discuss continued need for HFNC
daily as needed or as requested by the Hematologist/Oncologist,
Hospitalist or Pulmonary Attending until the patient is weaned off of
E. The patient will have continuous, centrally monitored (at the nursing station) vital
signs (heart rate, respiratory rate and pulse oximetry) until weaned off HFNC.
F. Respiratory Therapists (RT) will assess the patient at least every 4 hours.
G. HFNC will be titrated by the RT based upon a written order according to
H. HFNC will not be discontinued for any reason (such as radiology exams or
transfers) without the RT being present.
I. An RT will accompany all patients on HFNC who are transferring off the unit for
A. Nasal interface
B. Heated wire humidifier with circuit using the invasive mode
C. Air/oxygen blender
D. Oxygen analyzer
E. Sterile water
A. HFNC will be delivered through a heated humidification system to maintain a
temperature of 37 degrees C.
B. Condensation (a.k.a. “rain out”) in the humidification system is required to be
drained away from the patient every 2-4 hours. If condensation should reach the
patient, a nasal lavage may occur and cause apnea.
C. To avoid collection of condensation in the humidification system, the
humidification tubing should not lie on the floor or hang in dependent loops.
An air/oxygen blender connected to a flow meter will be used to ensure a
specified FiO2 is delivered through the nasal cannula.
The nasal prongs should fit the patient appropriately, as with a regular nasal
cannula. The external diameter of the prongs should be smaller than the internal
diameter of the nares in order to prevent an occlusive seal between the prongs and
nares that might predispose the patient to nasal necrosis and/or generation of
excessive airway pressure.
D. The RT will be responsible for titrating the HFNC based upon orders to keep the
oxygen saturation greater than or equal to 94% unless otherwise specified in the
physician orders. However, titration will occur in collaboration with both the
nursing and the medical team.
E. Documentation of HFNC will be the responsibility of the RT, although nursing
staff should be aware of the ordered parameters provided to the patient (FiO2 and
liter flow) found on the associated flowsheet in the clinical record.
F. The nurse will document vital signs and Pediatric Early Warning Signs (PEWS)
scores at least every 4 hours while on HFNC.
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G. The patient will be assessed for the need for nasal suctioning at least every 4
hours by both the RT and nurse.
H. Meticulous oral and nasal clearance or suctioning are required to maintain patent
nares and airway.
I. Presence of gastric distention will be assessed and documented at least every 4
hours by the nurse. There is a possibility for distention due to flow that enters the
stomach in addition to the airway. If gastric distention occurs, contact the
J. Infants may be offered breast or bottle while receiving HFNC if their readiness
score is a 5, but should have their respiratory status monitored while feeding.
K. The RT will be notified prior to anyone removing HFNC from a patient or prior to
transferring a patient off the unit on HFNC.
V. UWHC CROSS REFERENCES
A. AFCH/Pediatric Guidelines: Pediatric Early Warning Signs (PEWS)
B. Respiratory Care Services Policy 2.22, High Flow Nasal Cannula
C. Respiratory Care Services Policy 3.20, Pulse Oximetry Check & Continuous
Monitoring (Includes Ambulating SPO2)
A. Milési, C., Boubal, M., Jacquot, A., Baleirie, J., Durand, S., Odena, M.P., &
Cambonia, G. (2014). High-flow nasal cannula: recommendations for daily
practice in pediatrics. Ann Intensive Care. 4: 29. doi: 10.1186/s13613-014-0029-
B. Mayfield, S., Bogossian, F., O’Malley, L. & Schibler, A. (2014). High-flow nasal
cannula oxygen therapy for infants with bronchiolitis: Pilot study. Journal of
Paediatrics and Child Health, 50(5), 373-378.
C. Kallappa, C., Hufton, M., Millen, G. & Ninan, T.K. (2014). Use of high flow
nasal cannula oxygen (HFNCO) in infants with bronchiolitis on a paediatric ward:
a 3 year experience. Archives of disease in Childhood. doi: 10.1136/archdischild-
D. Sivieri, EM, Gerdes, JS, Abbasi, S. (2012). Effect of HFNC flow rate, cannula
size and nares diameter on generated airway pressures: An in vitro study. April
21. Wiley Periodicals, Inc. Published online; wileyonlinelibrary.com.
E. Thoyre, SM, Holditch-Davis, D., Schwartz, TA, Melendez, R., Carlos, R., & Nix,
W. (2012). Coregulated approach to feeding preterm infants with lung disease:
Effects during feeding. Nursing Research, 61(4), 242-251.
F. Thoyre SM, Shaker CS, Pridham KF. (2005). The early feeding skills assessment
for preterm infants. Neonatal Network, 24(3), 7-16.
VII. REVIEWED BY
AFCH Clinical Practice Council
Clinical Nurse Specialist, Universal Care Unit
Clinical Nurse Specialist, Pediatrics
Clinical Nurse Specialist, PICU
Oncology and Pulmonary Attending Physicians
PICU Attending Physician
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Supervisor, Respiratory Care
Nursing Patient Care Policy and Procedure Committee, May 2015
Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer