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Use of High Flow Nasal Cannula to Prevent Oro Tracheal Intubations in Children and Infants with Severe Acute Respiratory Failure in the Emergency Department
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A5100 - Use of High Flow Nasal Cannula to Prevent Oro Tracheal Intubations in Children and Infants with Severe Acute Respiratory Failure in the Emergency Department
Author Block: D. Perusso, P. V. Andrade, F. A. Ferrante, K. F. Mediotti, J. K. Mizutani, P. S. Oliveira, P. C. Silva; Emergency, Hospital Israelita Albert Einstein, Sao Paulo, Brazil.
RATIONALE: High flow nasal cannula (HFNC) systems utilize higher gas flow rates than standard nasal cannula. The use of HFNC as a respiratory support modality is increasing in the infant and pediatric populations as an alternative to non-invasive positive pressure ventilation. The purpose of this study was to verify whether HFNC could be an alternative noninvasive ventilation strategy to nasal CPAP in reversing the symptoms of severe acute respiratory failure (ARF) in children and infants in order to avoid tracheal oro intubation (TOT); METHODS: A care protocol was created containing inclusion criteria, such as ARF signs (accessory musculature, paradoxical breathing, drawing, firing retraction and nose wing beat), accompanied by respiratory rate increase (proportional to age) and SpO2 drop less than or equal to 94%, originating from pathologies such as Bronchiolitis, Pneumonia and Asthmatic Crisis; being the exclusion criteria the lowering of the level of consciousness, face trauma and the need for previous TOT. Patients with a time of use greater than 1 hour without signs of ARF improvement were considered to be failure of the HFNC; RESULTS: The implementation of the HFNC, associated to the multiprofessional care protocol, the training of the physiotherapy team, had a positive impact on the number of TOT, representing a reduction of 100% in the period of high demand, when compared to the previous year and reversion of severe ARF in 100% of the pediatric patients in whom the protocol could be applied. Of these, 90% of the cases had a significant reduction of the clinical signs of severe ARF in the first 10 minutes and total reversal in 1 hour. We verified a reduction in the rate of hospitalization of pediatric ICU (severe ARF) from 19.5% from 2016 to 9.5% in 2017. CONCLUSION: The use of HFNC likely continue to increase given the increasing awareness of this support modality and ease of application. Although there are theoretical advantages over the other devices, the HFNC demonstrates potential lack of consistency of the positive pressure generated, making NIV with positive airway pressure at two levels still to be considered in all cases where oxygen supplementation is insufficient and when a consistent positive pressure is indicated. We believe that HFNC is likely to benefit certain subsets of patients who require respiratory support and can certainly reverse ARF symptoms, minimize TOT and length of stay.
Author Block: D. Perusso, P. V. Andrade, F. A. Ferrante, K. F. Mediotti, J. K. Mizutani, P. S. Oliveira, P. C. Silva; Emergency, Hospital Israelita Albert Einstein, Sao Paulo, Brazil.
RATIONALE: High flow nasal cannula (HFNC) systems utilize higher gas flow rates than standard nasal cannula. The use of HFNC as a respiratory support modality is increasing in the infant and pediatric populations as an alternative to non-invasive positive pressure ventilation. The purpose of this study was to verify whether HFNC could be an alternative noninvasive ventilation strategy to nasal CPAP in reversing the symptoms of severe acute respiratory failure (ARF) in children and infants in order to avoid tracheal oro intubation (TOT); METHODS: A care protocol was created containing inclusion criteria, such as ARF signs (accessory musculature, paradoxical breathing, drawing, firing retraction and nose wing beat), accompanied by respiratory rate increase (proportional to age) and SpO2 drop less than or equal to 94%, originating from pathologies such as Bronchiolitis, Pneumonia and Asthmatic Crisis; being the exclusion criteria the lowering of the level of consciousness, face trauma and the need for previous TOT. Patients with a time of use greater than 1 hour without signs of ARF improvement were considered to be failure of the HFNC; RESULTS: The implementation of the HFNC, associated to the multiprofessional care protocol, the training of the physiotherapy team, had a positive impact on the number of TOT, representing a reduction of 100% in the period of high demand, when compared to the previous year and reversion of severe ARF in 100% of the pediatric patients in whom the protocol could be applied. Of these, 90% of the cases had a significant reduction of the clinical signs of severe ARF in the first 10 minutes and total reversal in 1 hour. We verified a reduction in the rate of hospitalization of pediatric ICU (severe ARF) from 19.5% from 2016 to 9.5% in 2017. CONCLUSION: The use of HFNC likely continue to increase given the increasing awareness of this support modality and ease of application. Although there are theoretical advantages over the other devices, the HFNC demonstrates potential lack of consistency of the positive pressure generated, making NIV with positive airway pressure at two levels still to be considered in all cases where oxygen supplementation is insufficient and when a consistent positive pressure is indicated. We believe that HFNC is likely to benefit certain subsets of patients who require respiratory support and can certainly reverse ARF symptoms, minimize TOT and length of stay.
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