O2097: Analysis of High Flow Nasal Cannula Utilization During Pediatric Critical Care Transport

Background: This 15-month retrospective study describes high flow nasal cannula (HFNC) utilization during pediatric critical care transport (CCT) and evaluates the need for escalation in respiratory support within 24 hours of hospital admission.

Methods: Data was collected from January 1, 2019, to March 31, 2020. A total of 6,279 pediatric transports were completed during this time. Charts were reviewed and screened for inclusion criteria: >30 days and < 18 years old, required HFNC ≥4 L/min during transport, and admitted to Children's Mercy Hospital (CMH). SARS-COVID-19 patients were excluded from this study due to initial variability in non-invasive respiratory support recommendations. All patients used standard high flow equipment and no new equipment was trialed. HFNC data was collected and placed into three groups: initiated by CCT, initiated by the referral and continued by CCT, initiated by the referral but weaned by CCT. Patients were followed for 24 hours after admission to track escalations in respiratory support.

Results: A total of 382 charts were reviewed; 358 met inclusion criteria. HFNC patients had a median age of 0.7 years old with an interquartile range (IQR) of 0.3-1 year of age; median weight of 8.4 kilograms (kg) with an IQR of 6.2-11 kg. The median transport time was 80 minutes (min), with an IQR 69-115 min. Referrals initiated (78%) of our HFNC volume. Fifty-nine percent of the HFNC patients were transported to the pediatric intensive care unit (PICU), while (41%) were admitted to the general pediatric floor (Peds). Median HFNC 1.2 L/kg, 10 L/min, IQR 6-15 L/min appreciated at patient drop-off regardless of patient location (Peds vs PICU) or HFNC status (initiated by transport, continued referral settings, and weaned by transport) (p-value 0.122). A total of 118 patients (33%) had escalation of care; 90 (76%) required an increase in flow, 28 (24%) required non-invasive ventilation, and 0 (0%) required intubation within 24 hours. Escalations typically occurred within the first 6 hours after patient drop-off with a median HFNC 1.2 L/kg, 10.25 L/min, IQR 8-14 L/min.

Conclusion: Our data suggests HFNC utilization during pediatric CCT is a safe modality for non-invasive oxygen delivery with minimal risk of escalation to non-invasive ventilation and no need for intubation. The high number of escalations in flow after patient drop-off (~25% of CCT high flow volume) was due to CMH Peds HFNC protocol to initiate at 2 L/kg or max of 15 L/min regardless of patient condition. The large number of PICU admissions is likely due to our strict Peds HFNC criteria: < 2 years of age, without comorbidities, suspected respiratory viral illness, max 2 L/kg and/or 15 L/min, ≤40% FiO2. In the future, we plan to implement a HFNC protocol that aligns with inpatient policy while conducting further research and review.