Early Identification of Respiratory Failure During High-Flow Nasal Cannula Therapy in Pediatric Patients: A Scoping Review
Keywords:
High-Flow Nasal Cannula, HFNC Treatment Failure, Early Warning Signs, Pediatric Patients, Scoping ReviewAbstract
High-flow nasal cannula failure occurs in approximately 10–30% of pediatric patients, and delayed escalation of respiratory support is associated with increased morbidity and mortality. However, evidence on early warning signs and standardized nursing assessment criteria remains fragmented. Objectives: To (1) map and categorize early signs predictive of HFNC failure in pediatric patients, and (2) identify clinical tools, scoring systems, and physiological indices used to assess those signs. A scoping review was conducted following the Joanna Briggs Institute (JBI) framework (Peters et al., 2020) and reported according to PRISMA extension for Scoping Reviews (PRISMA-ScR; Tricco et al., 2018). Three electronic databases — PubMed (MEDLINE), CINAHL, and SCOPUS — were searched in December 2025, covering publications from 2015 to 2025, using a Population–Concept–Context (PCC) search strategy. Two independent reviewers screened articles with inter-rater reliability assessed by Cohen's Kappa.
Of 156 records identified, 16 studies met inclusion criteria, involving pediatric patients aged 0–18 years across PICU, general pediatric ward, and emergency department settings. HFNC failure rates ranged from 11% to 23%, with most failures occurring within the first 24 hours. Four categories of early warning signs were identified: gas exchange indices (SpO₂/FiO₂ ratio and ROX index failing to improve within 1–4 hours); vital sign response (HR and RR reduction of less than 20% within 1–2 hours); clinical severity scores (CRS, Wood–Downes–Ferrés, and p-HACOR demonstrating high accuracy at 1 and 12 hours); and baseline risk factors (age under 3 months, prematurity, congenital heart disease, non-respiratory pathology, and FiO₂ requirement exceeding 0.6).
High-flow nasal cannula failure in pediatric patients can be predicted early through integrated assessment of physiological indices, clinical severity scores, and baseline risk factors. The first 1–2 hours post-initiation represent a critical "early warning window" requiring intensive monitoring. These findings provide an evidence base for developing standardized nursing assessment protocols to reduce delayed intubation and improve patient safety.
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