Canberra Hospital and Health Services Clinical



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Section 18 - High Flow Therapy



Purpose

The purpose of this Section is to describe the process for delivering High Flow Therapy to the infant. Listed is the equipment required and how to assemble it, as well as procedures to ensure appropriate and effective nursing care is delivered.


High flow is a humidified system that delivers air or oxygen via nasal cannula at flows of 2-8 L/min to baby’s who are spontaneously breathing and meet the inclusion criteria. It is an alternative to CPAP for infants with evolving or established chronic lung disease.
Advantages

  • Provides respiratory support (usually second line)

  • Alternative to CPAP in older neonate not tolerating CPAP

  • Less discomfort compared to CPAP

  • Ease of nursing care

  • Ease of Kangaroo care

  • Ease of non nutritive and nutritive sucking

  • Suitable for infants with chronic lung disease


Indications / Criteria

  • >1500 grams (maybe used on smaller babies on a case by case basis)

  • Evolving or established chronic lung disease and CPAP dependant

  • Consultant considers use of high flow as beneficial for the infant


Contraindications

  • Respiratory acidosis (pH <7.2)

  • Unstable infants with the following conditions:

  • Cardiovascular anomalies

  • Increasing oxygen requirements

  • Infants on inotropic support

  • Infants with suspected ileus


Equipment

  • Alcohol Based Hand rub (ABHR)

  • F&P Circuit RT329

  • Air/oxygen blender

  • Temperature probe

  • Heater wire adaptor

  • Water for irrigation (1 litre bag)

  • Humidifier base MR 730 set at 37 ‐2 for premature/neonate and MR 850 for Paediatric

  • Oxygen tubing

  • See chart below for correct cannula size


Cannula Size


Item Code

Description

Prong Outer Diameter (mm)

Septum width (mm)

Delivery tube outer diameter (mm)

Maximum patient flow (L/min)

BC2435

Neonatal

2.4

3.5

3.3

6

BC2745

Infant

2.7

4.5

3.3

7

BC3780

Paediatric

3.7

8

3.3

8


Approximate CPAP pressures for Flow Vs Weight


WT (KG)

flow=1

flow=2

flow=3

flow=4

flow=5

flow=6

flow=7

flow=8


1-1.5

1.3-2.0

2.1-2.8

2.9-3.6

3.7-4.4

4.5-5.2

5.3-6.0

6.1-6.8

6.9-7.6

1.6-2.0

0.6-1.2

1.4-1.9

2.2-2.8

3.0-3.6

3.8-4.4

4.6-5.2

5.4-6.0

6.2-6.8

2.1-2.5

0.5-0

0.7-1.2

1.5-2.1

2.3-2.9

3.1-3.7

3.9-4.5

4.7-5.3

5.5-6.1

2.6-3.0

0

0

0.8-1.4

1.6-2.2

2.4-3.0

3.2-3.8

4.0-4.6

4.8-5.4

3.1-3.5

0

0

0.1-0.7

0.9-1.5

1.7-2.3

2.5-3.1

3.3-3.9

4.1-4.7

3.6-4.0

0

0

0

0.2-0.8

1.0-1.6

1.8-2.4

2.6-3.2

3.4-4.0


Procedure

  1. Connect High Flow Nasal Prongs as follows


RT329 Infant Humidified Oxygen Therapy

Setup

  1. Slide the chamber onto the humidifier, remove the blue caps, unwind the waterfeed set and spike the waterbag

  2. Connect the pressure manifold to the chamber and attach flow source

  3. Set desired flow

  4. Connect the elbow of the blue inspiratory limb to the chamber

  5. Connect the blue temperature probe plug into the blue socket on the side of the humidifier

  6. Securely insert the blue twin probe into the breathing circuit elbow above the chamber

  7. Inset the airway probe into the port at the patient end of the circuit

  8. Connect the yellow heater wire adaptor plug into the yellow socket on the side of the humidifier

  9. Connect the clover leaf end into the socket on the breathing circuit elbow above the chamber

  10. Turn off the humidifier

  11. Start at flow 4-6 L/min (as ordered by Consultant/Registrar) with same FiO2 as being delivered by neopuff/Cot O2 or CPAP

  12. If there is an increase in FiO2 requirement

  13. Increase the flow maximum at 1 litre increments to a maximum 6 L/min for neonates

  14. Titrate the FiO2 to maintain oxygen saturations limits as per SOP observations

  15. If FiO2 exceed 60% or flow ≥6 L/min notify Medical Officer


Alert

Do Not use the unheated extension line included in the RT329 kit.



  1. Arterial/capillary blood gas as necessary

  2. Chest x-ray if required

  3. Minimal handling for sick babies

  1. Assessment should include: (see SOP Observation and Monitoring)

    1. Colour

    2. Respiratory rate, pattern, effort

    3. Temperature

    4. Breath sounds

    5. Heart rate and perfusion

    6. SaO2 preductal preferably

    7. GIT for abdominal distension and feeding tolerance

  2. Infants may be offered breast or bottle feeds whilst on high flow but continual respiratory assessment is essential


Weaning from High Flow

  1. Reduce oxygen first until there are no required changes in oxygen for 48 hours and saturations are maintained between 88‐95% or as directed by neonatologist

  2. Then reduce flow by 1L/min. Cease when flow is 2L/min or at the discretion of the Consultant

  3. If oxygen cannot be reduced transfer to low flow oxygen as per neonatologist order


Complications

  • Increasing apnoeas

  • Increased bradycardias

  • Tachypnoea

  • Intercostal retraction

  • Nasal flaring

  • Grunting

  • Over inflated lungs

  • GIT perforation

  • Intolerance of feed


Outcome

  • Successful transfer from CPAP to high flow system

  • The nasal prongs have been set up according to manufacturers specification


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