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Analysis of High Flow Nasal Cannula Utilization During Pediatric Critical Care Transport

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      Objective

      There are limited studies on the safety and efficacy of high flow nasal cannula (HFNC) utilization in pediatric critical care transport (CCT). This 15-month retrospective study was designed to describe HFNC utilization by our transport team and to track escalations in respiratory support within 24 hours of hospital admission including increased liter flow, non-invasive ventilation (NIV), or intubation.

      Methods

      This study was conducted at a large quaternary free standing children's hospital with a dedicated pediatric transport team that completes an average of 5,500 transports per year. Data was collected from January 1, 2019, to March 31, 2020. A total of 6,279 pediatric transports were completed during the study period. Inclusion criteria: >30 days and <18 years old, required HFNC ≥4 L/min during transport, and admitted to our pediatric facility. Our institutions HFNC pediatric floor (Peds) criteria: <2 years of age, no comorbidities, suspected respiratory viral illness, max 2 L/kg and/or 15 L/min, ≤40% FiO2. All patients used the standard HFNC equipment in our department. No new equipment was trialed during this study. We did not include SARS-COVID-19 patients given the initial variability in non-invasive respiratory support.

      Results

      A total of 382 charts reviewed; 358 patients met inclusion criteria. Median age 0.7 years old, with an interquartile range (IQR) of 0.3-1 year of age. Median weight 8.4 kilograms (kg), IQR 6.2-11 kg. Median transport time 80 minutes (min), IQR 69-115 min. Most of our HFNC volume was initiated by the referral (279, 78%) and we initiated the remainder (79, 22%). The majority of our HFNC patients were transported from the (ER) (184, 51%) and Peds (119, 33%) with the remainder being from urgent care (UC) (42, 12%), and Pediatric Intensive Care Unit (PICU) (13, 4%). We transported (210, 41%) back to the PICU versus (148, 41%) to Peds. Of the 279 patients that were on HFNC started by the referral, 42 (15%) had their flow weaned by the transport team. Median HFNC 10 L/min with an IQR of 6-15 L/min appreciated at drop-off regardless of HFNC status (initiated by transport, weaned by transport, or continued referral settings) (p-value 0.122).
      Escalations of care were tracked up to 24 hours after patient drop-off. A total of 118 patients (33%) had an escalation of care; 90 (76%) required an increase in flow, 28 (24%) required NIV, and 0 (0%) required intubation within 24 hours. Escalations of care typically occurred within the first 6 hours after patient drop-off, 96 (27%), with a median HFNC 10.25 L/min, IQR 8-14 L/min (p-value range ≤0.310).

      Conclusion

      Our data suggests HFNC utilization in pediatric patients during CCT is a safe modality for non-invasive oxygen delivery with minimal risk of escalation requirement and no need for intubation. The number of escalations in liter flow after patient drop-off (∼25% of high flow volume) was likely due to inpatient protocol to place all HFNC patients on 2 L/kg or max of 15 L/min. In the future, we plan to implement a HFNC protocol for management guidelines during CCT while conducting further research and review.
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