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

Abstract

Background High‐flow nasal cannula (HFNC) therapy is widely used for children with bronchiolitis, but its optimal role remains uncertain. Our institution created and later revised a clinical pathway guiding HFNC initiation and weaning. Methods A retrospective review of 1690 bronchiolitis encounters was conducted. Trends in the duration of HFNC and hours spent weaning HFNC as proportions of the monthly hospital length of stay (LOS) for bronchiolitis, hospital LOS, and escalation of care were compared using interrupted time series (ITS) models across three study periods: Baseline (HFNC managed at provider discretion), Intervention 1 (pathway with initiation at 0.5 L/kg/min and escalation up to 2 L/kg/min), and Intervention 2 (revised pathway, initiation at the maximum rate of 2 L/kg/min). Both pathway iterations provided titration and weaning guidance. Maximum respiratory scores were used to adjust for case severity. Results After adjustment for severity and time, both HFNC duration and HFNC weaning time (as a proportion of monthly LOS) decreased at the start of Intervention 1, but subsequently increased. During Intervention 2, both these measures trended downward, returning to baseline. Total LOS did not change in the baseline or intervention periods. Escalation of care did not differ from baseline to the end of Intervention 2. Conclusion Initiating HFNC at higher flow rates with weaning guidance for children hospitalized with bronchiolitis was associated with a reduction in HFNC duration without differences in LOS or escalation of care. These findings suggest that standardization through clinical pathways can limit HFNC duration in bronchiolitis.

Emergency Department Initiative to Decrease High-flow Nasal Cannula Use for Admitted Patients with Bronchiolitis

“… 26 , 27 Tarantino et al found that after implementing a bronchiolitis pathway with HFNC initiation and weaning guidelines, HFNC duration decreased without changing hospital LOS or escalation of care. 28 This finding conflicts with other studies that show that a decrease in HFNC treatment leads to a decrease in hospital LOS. 29 One explanation could be that HFNC has no impact on the course of bronchiolitis for m/m disease and, therefore, has no impact on LOS.…”

Reducing Overutilization of High-flow Nasal Cannula in Children with Bronchiolitis

“…The next steps include efforts to further reduce the overutilization of HFNC, given our still high postintervention rates based on the literature. 12 , 22 We intend to incorporate a trial off of HFNC for incoming transported patients arriving with a mild to moderate respiratory score while on HFNC.…”