Implementation of a High-Flow Nasal Cannula Management Protocol in the Pediatric ICU

Abstract

BACKGROUND: High-flow nasal cannula (HFNC) therapy is a respiratory modality that has been adopted to support pediatric patients with bronchiolitis. There is no standardized protocol for initiation, escalation, or weaning of HFNC in the pediatric ICU. The aim of this respiratory therapist (RT)-driven quality improvement management protocol was to decrease duration of HFNC. METHODS: An RTdriven HFNC management protocol based on an objective respiratory score was implemented in 2017 at a quaternary care children's hospital. Subjects included children less than 2 y old admitted to the pediatric ICU with bronchiolitis. All subjects needing HFNC were scored and placed within the protocol as appropriate for age, then weaned or escalated per the scoring tool. Comparison to a pre-intervention control group was performed. Average HFNC duration per subject was used as the primary outcome measure. Protocol compliance was used as a process measure. Noninvasive ventilation use, intubation rate, and 30-d pediatric ICU readmission rate were used as balancing measures. RT satisfaction with HFNC management before and after protocol implementation were measured. RESULTS: Protocol compliance was sustainable and above the goal of 80% after 4 months of protocol implementation. HFNC duration decreased from 2.5 d to 2 days for each subject during planning and then to 1.8 d after protocol implementation. Length of stay (LOS) in the pediatric ICU and hospital LOS decreased from 2.6 d to 2.1 d and from 5.7 d to 4.7 d after protocol implementation, respectively. The use of noninvasive ventilation and the rate of intubation did not change significantly. RTs reported increased involvement in HFNC management decisions and appropriateness on how quickly the team weaned HFNC. CONCLUSIONS: An RT-driven HFNC management protocol was safely implemented in a pediatric ICU and decreased HFNC duration, pediatric ICU LOS, and hospital LOS. It allows the RT to work independently to the highest extent of their scope of practice, leading to improvement in RT job satisfaction.

Is implementation of a hospital pathway for high‐flow nasal cannula initiation and weaning associated with reduced high‐flow duration in bronchiolitis?

“…In the unadjusted analysis, median total HFNC duration was 45 h [IQR: 23,69] Our data on HFNC initiation rates from the baseline period, which began before the widespread adoption of HFNC on the wards, demonstrate a steady increase. This finding aligns with those of prior studies that have observed substantial increases in HFNC use in bronchiolitis over the past several years without meaningful clinical benefits.…”

“… 22 Likewise, an RT‐driven PICU protocol for HFNC initiation and weaning was associated with decreased LOS and therapy duration. 23 On the wards, a multi‐center study found a weight‐based protocol was associated with decreased ICU utilization, noninvasive ventilation (NIV) use, and cost. 24 Existing literature underscores the importance of improving resource utilization by optimally targeting HFNC use without prolonging time on respiratory support or LOS.…”

“…22 Likewise, an RTdriven PICU protocol for HFNC initiation and weaning was associated with decreased LOS and therapy duration. 23 On the wards, a multi-center study found a weight-based protocol was associated with decreased ICU utilization, noninvasive ventilation (NIV) use, and cost. 24…”

Utilising pneuRIP device in determining the adequacy of respiratory support when weaning high‐flow nasal cannula in paediatric patients with acute respiratory distress: A pilot study

“…21,23,24 Presently, there is no standardised evidence-based protocol for weaning of HFNC in the PICU. 24,25 Development of protocols for weaning of HFNC would optimise utilisation, as often patients are maintained on higher degrees of respiratory support than they may require, given the challenge in determining right time and how quickly the respiratory support can be weaned. 4 Maintaining patients on higher degrees of respiratory support than necessary can prolong their PICU stay as well as their hospital course.…”

“…The feasibility of pneuRIP as a real‐time tool to identify thoracoabdominal asynchrony has been previously demonstrated 21,23,24 . Presently, there is no standardised evidence‐based protocol for weaning of HFNC in the PICU 24,25 . Development of protocols for weaning of HFNC would optimise utilisation, as often patients are maintained on higher degrees of respiratory support than they may require, given the challenge in determining right time and how quickly the respiratory support can be weaned 4 .…”