What’s Your Diagnosis? High-Flow Nasal Cannula and Noninvasive Ventilation in Pediatric Emergency Medicine

Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check to see if you got last month’s case on Mechanical Ventilation of Pediatric Patients in the Emergency Department right.

Case Presentation: High-Flow Nasal Cannula and Noninvasive Ventilation in Pediatric Emergency Medicine

A 2-month-old girl, born full-term without complications, presents to your ED in the middle of December. According to her mother, she has had 3 days of cough and congestion, as well as decreased feeding. The mother took her to the primary care physician?s office earlier in the day because she noticed that the girl’s breathing had become extremely fast. On examination, the primary care physician noted wheezing and retractions, with an increased respiratory rate, and she recommended the mother take the child to the ED.

The infant’s initial vital signs are: temperature, 37.5?C (99.5?F); heart rate, 170 beats/min; respiratory rate, 74 breaths/min; blood pressure, 82/60 mm Hg; and oxygen saturation, 89% on room air. She weighs 5 kg. Her physical examination is notable for nasal congestion with grunting, tachypnea, and subcostal and supraclavicular retractions. She also has dry mucous membranes and a capillary refill of 3 seconds.

Oxygen is provided by nonrebreather mask, and IV access is obtained. Nasal suctioning is performed without much change in her respiratory status. You make the decision to use high-flow nasal cannula as the initial form of respira- tory support, with the following settings: FiO2, 40%; flow rate, 5 L/min. After about an hour on high-flow nasal cannula, the infant’s vital signs are relatively unchanged.

What are the signs of failure of high-flow nasal cannula? Is there a maximum flow rate above which this modality is not as effective, and how should it be titrated in pediatric patients? Are higher rates more likely to cause harm?

Case Conclusion

Given the lack of improvement in the vital signs of the 2-month-old girl with cough and congestion, adjustments were made to the HFNC settings. Her FiO2 was increased to 60%, and her flow rate was increased to 10 L/min. After observing the patient on these settings for a half hour, her vital signs were recorded: temperature 37.7?C (99.9?F); heart rate, 144 beats/min; respiratory rate, 50 breaths/min; blood pressure, 86/64 mm Hg; oxygen saturation, 96% on HFNC. She was admitted to the PICU for further therapy and monitoring. Her work of breathing continued to improve over the next 24 hours, and the support she required by HFNC decreased. She was transferred to the floor and started on her home feeds. She was discharged on hospital day 3 without respiratory support.

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Last Updated on August 21, 2020

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