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

High-Flow Nasal Cannula and Noninvasive Ventilation in Pediatric Emergency Medicine
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Publication Date: August 2020 (Volume 17, Number 8)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-A or 2-B CME credits. CME expires 8/01/2023.


Daniel Slubowski, MD
Assistant Professor of Clinical Emergency Medicine and Pediatrics, Indiana University School of Medicine, Department of Emergency Medicine, Riley Hospital for Children at Indiana University Health, Indianapolis, IN
Timothy Ruttan, MD, FACEP
Assistant Professor of Pediatrics, University of Texas at Austin Dell Medical School, Department of Pediatrics, Dell Children’s Medical Center of Central Texas, Pediatric Emergency Medicine, Austin, TX

Peer Reviewers

Deborah A. Levine, MD
Assistant Professor of Clinical Emergency Medicine; Assistant Professor of Clinical Pediatrics, Weill Cornell Medicine, New York Presbyterian Hospital, Komansky Children’s Hospital, New York, NY
Joshua Nagler, MD, MHPEd
Associate Division Chief and Fellowship Director, Division of Emergency Medicine, Boston Children’s Hospital; Associate Professor of Pediatrics and Emergency Medicine, Harvard Medical School, Boston MA


The use of high-flow nasal cannula and noninvasive ventilation has become increasingly common in emergency medicine as a first-line treatment of pediatric patients with respiratory distress secondary to asthma and bronchiolitis. When implemented in clinical practice, close monitoring of vital signs and ventilation parameters is warranted to identify possible signs of respiratory failure. This issue provides evidence-based recommendations for the appropriate use of noninvasive ventilation modalities in pediatric patients including high-flow nasal cannula, continuous positive airway pressure, and bilevel positive airway pressure in the setting of acute respiratory distress. Contraindications and complications associated with these modalities are also discussed.

Excerpt From This Issue

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 respiratory 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?

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