A total of 218 respondents participated in the survey, representing 81 hospitals (total registered hospitals with acute paediatric services in Great Britain and Northern Ireland as per the RCPCH Medical Force Census 2015 were 171), a median of 2.7 (range: 1-11) responses per hospital (Figure 1). Majority of the participants were paediatric consultants (213/218, 97.7%) with a wide range of clinical experience in their field (table 1).
Forty-seven out of 81 responding hospitals (58%) had dedicated HDUs compared to 34 hospitals with no HDU (42%). Of these (19/47 HDUs, 40%, 98/218 responses, 45%) were located in hospitals that have a Paediatric Intensive Care support (PICU) with 12 HDUs (63%) were solely managed by the intensive care team and only seven HDUs (7/47»15%) had a dedicated paediatrician. The majority of HDUs provided all types of non-invasive ventilation (including Bilevel Positive pressure ventilation, BLPAP) and long-term invasive ventilation (LTV) (43/47, 91.5%). A variety of patient categories were generally managed on hospital wards (table 2).
Use of HHFNC:
Respondents reported using HHFNC in a variety of illnesses on their wards particularly where HDU and intensive care facilities are not readily available (such as respiratory, cardiac, and neuromuscular diseases). Respiratory diseases collectively accounted for more than 75% of the reasons to start HHFNC (figure 2).
The most common clinical indication for HHFNC initiation was hypoxia (oxygen saturation <92%) not responding to low flow oxygen (defined as administration of low-flow oxygen of ≤ 4L/min via nasal cannula) (figure 3).
Paediatric wards were the primary location to start HHFNC according to the majority of respondents (167/218, 76.6%). Other locations such as the emergency department were also considered an option when a ward bed was not immediately available. Six respondents representing 5 cardiology wards from 4 different regions reported using HHFNC for cardiac patients with different pathologies (pre- and post-heart surgery). Some respondents with respiratory background (26/218, 11.9%) considered their respiratory wards as HDU-acuity level therefore HHFNC became a standard therapy on these wards. HDU and PICU were the primary locations to start HHFNC therapy in 8/218 responses (3.6%).
Starting HHFNC therapy on the ward was overall a paediatric team-led decision, and similarly modification and weaning off HHFNC (paediatric consultant, respiratory consultant, registrar, senior nurse, or nurse practitioner) particularly in hospitals with no HDU compared to hospitals with dedicated HDUs {24/34 (70.3%) VS 17/47 (36.6%), 95%CI: 22.6%-50.4%, P: .002}.
Relevant guidance on HHFNC was more available in hospitals with HDUs compared to hospitals with no HDU {36/47, (77%) VS 17/34 (50%), 95%CI: 5.9-45.6, P: .012} (Table 3):
For better understanding of how a decision around starting and modifying HHFNC on the ward is made, we presented 2 clinical vignettes in our survey in terms of application of HHFNC on the wards based on age and weight: findings to these scenarios are summarized in figure 4:
Clinical parameters by which the respondents assessed failure of HHFNC included significant work of breathing, worsening respiratory acidosis, apnoea needing stimulation, significant tachypnoea and tachycardia, deterioration on the local assessment scores (i.e. PEWS).
Weaning off HHFNC was managed variably by respondents with the majority opting to wean the FiO2 to a certain value (most commonly 0.40, indicated by 62.2% of respondents) and then gradually weaning the flow rate afterwards (75.7% of respondents).
Respondents were asked to compare between nCPAP and HHFNC on the wards. More than two thirds of them said HHFNC is either the same or superior to nCPAP with fewer complications (table 4).
Research priorities on the use of HHFNC was an important focus that we tried to explore in this survey. Clinicians were asked to rank the three most important outcome measures in any future research looking at the effect of HHFNC therapy in paediatric patients (figure 5).
Failure rate of HHFNC was the first most important concern amongst the respondents followed by the length of need for HHFNC support as second most important and cost effectiveness as third (37.1%, 28%, and 28.8% respectively).
Overall, 187 clinicians (85.8%) supported the idea of developing national guidance on the use of HHFNC in general paediatric practice. A small number of clinicians thought that such a guidance is not necessary (12/218, 5.7%) and the remaining respondents were not sure if such guidelines might change current practice.