Objectives To share the feasibility and experience of HFNC on a paediatric ward.

Design Observational retrospective cohort study.

Setting Paediatric ward in a tertiary children’s hospital

Patients: Children with bronchiolitis admitted to paediatric ward (September 2014 – October 2016).

Results 1630 children with bronchiolitis were admitted to paediatric ward during the study period. In the first year, HFNC was limited to children with no additional co-morbidities. In the second year, with increasing staff confidence and winter capacity constraints in PIC, HFNC was extended to children with co-morbidities such as congenital heart disease, chronic lung disease and neuromuscular problems. A standard operational procedure document guided management. 155 children were treated with HFNC (350 HFNC days)and <10% required escalation to CPAP/invasive ventilation. Data analysis shows that success rate of HFNC was significantly higher in children with no co-morbidities and better in children with stable co-morbidities. However, a significant number of children with co-morbidities were also successfully managed just with HFNC. The limited experience on the use of HFNC in the paediatric population is demonstrated by a lack of consensus in the flow rates used. In PIC settings, there is evidence for the use of flow rates upto and beyond 4 litres per kilogram, with no adverse effects, but in ward settings, flow rates beyond 2 litres per kilogram do not tend to be used. Our guideline used flow rates based on the nasal cannula size (infant and paediatric) rather than on flow/kg. Thus, we have gone up to flow rates of 20L in babies on the infant nasal cannula and 25 litre for babies on the paediatric nasal cannula i.e, flow rates of up to 3 litres per kg, which has been well tolerated and with no adverse effects such as air leaks.

Conclusions Our experience demonstrates the feasibility, safety and efficacy of HFNC therapy for children with bronchiolitis including children with stable co-morbidities, in a busy paediatric ward. Our use of higher flow rates has not resulted in adverse effects and this adds to the body of evidence on HFNC flow rates in paediatric population. Use of HFNC for non-bronchiolitis respiratory failure outside PICU needs further study.