Pediatric early warning score and deteriorating ward patients on high‐flow therapy

Abstract

Background 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. Methods 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. Results 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. Conclusions 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.

A multicentered study on efficiency of noninvasive ventilation procedures (SAFE-NIV)

“…Similarly, Mayordomo-Colunga et al stated the absence of RR decline at 1st and 6th hours in NIPPV failure [26]. Several models also predict HFNC failure such as RR above the 90th percentile for age at triage [1,27], no RR or HR change within sixty minutes [28] and worsening pediatric early warning scores [29]. The failure rate (13.4%) in this study was within the reported ranges of 3% and 30% [3,8,30].…”

The Effectiveness of Heated Humidified High-flow Nasal Cannula in Children with Severe Bacterial Pneumonia in the Emergency Department

“…It is very important to predict the determining factors of HHHFNC therapy failure in children with RD (13,14). That will enable us to identify patients who will not respond, and thus other treatment options will not be delayed.…”

“…Although it probably has some helpful effects, there is limited evidence on using this treatment option in patients with pneumonia (8,9). There are already a few studies which evaluate the treatment success of HHHFNC for children with SBP with almost all of them being conducted in the intensive care unit (ICU) (13,14). The goal of this prospective clinical study was to determine whether the use of HHHFNC therapy is associated with a reduction in severity among children with SBP presenting to the ED.…”

Sustainability of high flow in a Peruvian PICU: A qualitative analysis

“…Resource-rich settings have established that high flow is a safe, well-tolerated and feasible method for managing respiratory failure on the general paediatric ward (Mikalsen et al 2016;Sachs et al 2019). However, a cohort study from Canada reported that approximately half of children initiated on high flow in the emergency department required escalation to CPAP or BiPAP in the PICU (Hansen et al 2019). The risk of clinical deterioration after high flow initiation, the drastic difference in resource availability between resourcerich and resource-limited settings and the wide regional variability in paediatric resource availability in RLS raise the question whether high flow should be used outside the PICU in these settings.…”