Improving high-flow weaning in district general hospitals

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It's a retrospective audit of children aged 0 to 16 in two district general hospitals, and we were looking at the adherence to the high flow weaning guideline that we use, which is the STPM guideline. The background to this is that we have found that high flow is being used increasingly for children with respiratory distress, but we don't have enough evidence in relation to the optimal weaning. So we potentially could be putting children on therapy for longer than they really need to. I've also noted that a lot of children remain on high flow until their FiO2 reaches 21%, which is basically air. So the aim of this project was to assess the adherence to the STPM weaning aspect of the high flow guideline.

The study was an audit. So it was a retrospective audit of 42 children aged 0 to 16 across two district general hospitals. The data was pulled out from our paediatric critical care dashboard and it was pulled into an Excel spreadsheet and that's how it was analysed.

In terms of the results, mainly as expected, the median age was about 7 months of age with the most common diagnosis being bronchiolitis. In terms of the adherence to the protocol, there was a large proportion of children who did not follow the weaning strategy that was outlined in the guideline. A few reasons for that is that we found that the most common indication for the high flow to be initiated was respiratory distress and not particularly hypoxia, and the guideline weaning protocol really is focused around FiO2 banding. So those children might have near normal oxygenation but they have a respiratory distress. So hence it was really difficult to follow that guideline from that aspect. Also the majority of patients reached a maximum of high flow that is less than FiO2 is less than 40%. So again the FiO2 banding was not really applicable to them. And finally a large proportion, about two-thirds of the patients, remained on FiO2 of 21% before high flow was stopped.

So the conclusion is that we didn't have good adherence to the guideline, but also it was a retrospective small study and we did not take into account the work of breathing, which could have informed the clinician's decision-making and could have explained why the guideline was not adhered to.

So in terms of action plans, we've moved actually by increasing the clinicians' awareness of the guideline. We've also incorporated work of breathing along with the FiO2 banding and oxygenation to the guideline, and I've also shared the findings with STPM, which is the writers of the guideline, and I hope that they will incorporate in future updates. Thank you.