Hansen Gregory, Hochman Joshua, Garner Meghan, Dmytrowich Jeffrey, Holt Tanya
Division of Pediatric Critical Care, Department of Pediatrics, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
Division of General Pediatrics, Department of Pediatrics, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.
Pediatr Int. 2019 Mar;61(3):278-283. doi: 10.1111/ped.13787. Epub 2019 Mar 18.
Delivery of non-invasive ventilation commonly occurs in the pediatric intensive care unit (PICU). With the advent of high-flow nasal cannula (HFNC), patients with respiratory distress may be rescued on the ward without a PICU admission. We evaluated our ward HFNC algorithm to determine its safety profile and independent predictors for non-responders, defined as requiring subsequent PICU admission.
A retrospective chart review of patients <17 years of age admitted with respiratory distress between 2016 and 2017 was carried out. Pediatric Early Warning System (PEWS) respiratory score was used to assess the clinical response of patients requiring HFNC. Variables associated with non-responders were evaluated, and their PICU admission was studied for escalation of care and criticality.
Patients with comorbidities (P = 0.02) were more likely to require HFNC. Of the 18 patients initiated on HFNC, 44% (n = 8) remained on the ward. Non-responders (n = 10; 56%) had higher (2.7 vs 1.8; P = 0.03) and worsening (-0.1 vs 0.3; P = 0.05) PEWS respiratory scores 90 min after HFNC initiation. Eighty percent (n = 8) of non-responders required escalation to continuous positive airway pressure or bilevel positive airway pressure in the PICU. For both HFNC responders and non-responders, there were no requirements for intubation, evidence of air leak or difference in days of respiratory support.
High and worsening PEWS scores 90 min after HFNC initiation may indicate non-response when coupled with a standardized ward HFNC algorithm for respiratory distress. Further improvements may be seen with an earlier initiation of HFNC in the emergency department and more aggressive flow escalation on the ward.
无创通气通常在儿科重症监护病房（PICU）进行。随着高流量鼻导管（HFNC）的出现，呼吸窘迫患者可在病房得到救治，无需入住PICU。我们评估了病房HFNC算法，以确定其安全性以及无反应者（定义为随后需要入住PICU）的独立预测因素。
对2016年至2017年间因呼吸窘迫入院的17岁以下患者进行回顾性病历审查。使用儿科早期预警系统（PEWS）呼吸评分来评估需要HFNC的患者的临床反应。评估与无反应者相关的变量，并研究他们入住PICU以进行护理升级和危急情况处理的情况。
合并症患者（P = 0.02）更有可能需要HFNC。在开始使用HFNC的18例患者中，44%（n = 8）留在了病房。无反应者（n = 10；56%）在开始使用HFNC 90分钟后的PEWS呼吸评分更高（2.7对1.8；P = 0.03）且呈恶化趋势（-0.1对0.3；P = 0.05）。80%（n = 8）的无反应者需要在PICU升级为持续气道正压通气或双水平气道正压通气。对于HFNC反应者和无反应者，均无需插管，无漏气证据，呼吸支持天数也无差异。
在针对呼吸窘迫的标准化病房HFNC算法下，开始使用HFNC 90分钟后PEWS评分高且呈恶化趋势可能表明无反应。在急诊科更早开始使用HFNC以及在病房更积极地提高流量可能会带来进一步改善。
