Does your unit often utilize HFNC?

[boomerang12]

Hi everyone,

i was hoping to hear how often/in what circumstances everyone's unit utilizes high flow nasal prongs. I'm especially interested in hearing about anyone whose unit utilizes it when getting babies off of CPAP.

My unit has fairly strict guidelines regarding taking a baby off of CPAP (must be +4, 21% all the time and >33 weeks) and is quick to jump on putting babies back on CPAP (failure is any increase in A/Bs, any oxygen requirement - even just a 1% increase, decreased interest in oral feeding, any change in WOB). We will keep babies on CPAP up to 38 weeks if they continually fail to come off. However we rarely utilize HFNC (just use regular nasal prongs instead) expect for babies who are still failing regular nasal prongs at 38 weeks.

I've had trouble finding any studies comparing HFNC to nasal prongs for the purposes of weaning babies off of CPAP. Most of the literature I have read on HFNC compares it to CPAP as a primary mode of support or post extubation and the outcomes appear to be fairly comparable. I would love to hear if anyone else has any experience with this. I don't necessarily think we need to change our approach at my unit, however it is so hard for parents to watch their babies fail to come off of CPAP over and over again, so I'm wondering if this is something we should be utilizing more.

Thanks for for any input you might have!

[NICUmiiki, DNP, NP]

Our HFNC setup uses regular nasal prongs (same equipment as "regular") delivering 1L/min and uses an O2 blender. We don't use "regular" nasal cannula (100% O2, 0.1L/min) at all unless they are going home on it. We like to be able to carefully control the amount of O2 the babies get. Once they stay at 21% on the HFNC, we wean them to room air. We won't go back to CPAP unless there are >10 apnea/brady that aren't self resolved or they have a dramatic increase (>20%) in O2 requirements. Occasionally, we may wean directly to room air from CPAP+4, but not usually; big TTN babies come to mind. We use RAM nasal cannulas for NIPPV and CPAP.

Interesting that you guys have an age requirement. We have plenty of babies less than 33 weeks on room air. We wean them as soon as they stop needing the oxygen (25 weeks and up go straight to NIPPV at birth and work up as needed). I love seeing a little bitty 28 weeker on room air.

[boomerang12]

Thanks for the response. Just to clarify when I say "regular nasal prongs" I mean prongs at a flow of 1/4 - 1 LPM and blended O2. Our high flow systems are heated/humidified, able to be blended and generally use flow rates > 2 LPM.

It sounds like you guys are much less quick to go back to CPAP than us. How much do you find you're upping the Os on these kids when you wean? (We aren't allowed to go up at all, if we have to it's back to CPAP). I can't believe you have 28 weekers on room air! We will keep babies who were brought to us from L&D on room air (generally those 30-33 week kids) on room air until they prove they need more support, but as soon as they go on CPAP it is staying until 33 weeks.

Thanks again for the response, it's so interesting hearing about what other units do.

[NicuGal, MSN, RN]

We extubate babies as young as 24-25 weeks to either NIMV using a RAM cannula or to vapotherm as soon as possible. We also extubate from oscillators to vapotherm. Of course we have those that have to stay intubated, but we will trial them if we think there is a chance. We wean to RA as quickly as possible to decrease the risk for ROP. We use CPAP more often for bigger kids with TTN. I am curious as to your neos reasoning for leaving on CPAP and O's until 33 weeks. Many of our kids by that age are on Vapotherm or just a nasal cannula with flow. We have guidelines that allow us to adjust the oxygen as needed to keep sats 89-93% for our preemies and greater than 93% for our term kids.

I always find it interesting to see how different units are.

[boomerang12]

Thanks for your response. That is definitely interesting. Are you finding the kids need much for Os while on the vapotherm?

The rationale for leaving the CPAP on for so long is actually to avoid using any oxygen to keep their sats within range (88-93). The idea is that the use of pressure from the CPAP rather than oxygen for support optimizes FRC while reducing oxidative injury and might improve pulmonary outcomes. So when they are on CPAP the goal is to wean them down to +4, 21% with sats in range ~90% of the time. Then when they meet those criteria and are 33 weeks we try to wean them to nasal cannula, usually 1L 21%, but these kids often fail (and often fail more than once), so this is where I'm wondering if using high flow more often might help us.

[NicuGal, MSN, RN]

I don't find that they use any more oxygen. Many of our kids wean pretty rapidly once we get them on Vapo. Once we hit 2L on our Vapo we change over to a standard nasal cannula at 2L. We found that high flow cannula/Vapo work as well as CPAP.

[NICUmiiki, DNP, NP]

We don't use Vapotherms very often. I think I've seen one on the unit twice in almost 2 years. Our "high-flow" is humidified O2 on a blender at 1L. It's expected that some kids might need increased Os when first making the jump from CPAP +4, but they usually wean down to 21% fairly quickly and can move to room air.