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HFNC Practice Patterns Reported by Neonatologists and Neonatal Nurse Practitioners in the US

Today I bring you the article “High-Flow Nasal Cannula Practice Patterns Reported by Neonatologists and Neonatal Nurse Practitioners in the United States” by Wakako Minamoto Eklund and Patricia A. Scott, published this year.

HFNC is widely used to treat neonatal respiratory conditions, including primary treatment of respiratory conditions and postextubation support, as well as weaning strategy for infants transitioning from noninvasive ventilation therapies. Despite significant evidence emerging in recent years to guide practice, current practice patterns and their alignment with the evidence remain unknown. Not all HFNC therapy practice variations have been explored in relation to safety and efficacy, as a primary mode for extremely preterm infants, best practices for weaning or the treatment of apnea of prematurity. There is also a lack of data describing current practices in the US, inhibiting the ability of neonatal providers from appraising and benchmarking their own practice against existing evidence.

The authors aimed to examine current HFNC practice patterns and availability of clinical practice guidelines used in neonatal intensive care units in the United States.

They designed a descriptive study using a web-based survey involving US neonatal providers.

A total of 947 responses were analyzed (626 neonatologists and 321 neonatal nurse practitioners). Analyses suggested wide variations in practice patterns. One-third of the respondents used clinical guidelines, lower than reported by the 2015 UK study (2/3) or the Canadian study (36%). The majority utilized HFNC devices in conjunction with nasal continuous positive airway pressure, more than two-thirds used HFNC as a primary respiratory support treatment, and among all respondents, significant differences related to HFNC device types were reported.

The current evidence supports the use of HFNC therapy postextubation in infants >=28weeks of gestational age. The most frequently “starting” flow rates were 2-4L/min, lower than 4-6L/min suggested by expert consensus (Yoder et al.) and the recommended 5-8L/min regardless of GA or weight (Manley). However, to date there has been no formal research related to “starting” flow rates.

This is also a reality for highest flow rates, as it is unknown whether variations in HFNC flow rates impacted outcomes.

As previously suspected and discussed, HFNC is widely used, being reported by clinicians across the US for a wide range of indications, flow rates, and gestational ages. This study allowed clinicians and researchers to analyze the current HFNC practice that are supported and not supported by the evidence.

The type of device used appears to impact practice patterns and approaches. It also provided the opportunity to evaluate the current practice guidelines and their alignment with the existing evidence.

Use of standardized guidelines was only reported by one-third of the respondents, and as such may be a contributing factor for wide practice variations.

This was the first HFNC practice study to include not only physicians, but also neonatal nurse practicioners as neonatal intensive care unit workforces who contribute to the management of respiratory conditions. 49 states were represented, and over one-third reported more than 10 years of experience utilizing HFNC therapy, allowing “highly experienced” descriptions.

Gathering what is known, HFNC is one of the most frequently used respiratory care modalities. It is used for mild-to-moderate respiratory distress. Despite having been studied extensively, not every aspect of its use is supported by evidence today. Current evidence supports that HFNC and CPAP provide similar postextubation support for infants born with >= 28 weeks. However, consensus has not been met regarding its use as a primary treatment for premature infants. Practice patterns vary widely.

Future research is needed to target aspects of practice where practice variations exist, or practice is not supported by evidence – use as primary treatment for extremely preterm infants, apnea of prematurity, comparison of the starting flow rates or the best practice for the weaning and withdrawing process of HFNC, feeding practice patterns when used for preterm infants, specific indications based on specific devices.

It is important to:

- Evaluate our own practices in comparison to reported practice patterns and existing evidence.

- Align current guidelines to ensure alignment with current evidence.

- Develop guidelines if no guidelines are available.

Best regards

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