Outcomes of a respiratory therapist driven high flow nasal cannula management protocol for pediatric critical asthma patients

Abstract

IntroductionThis study aimed to determine if a respiratory therapist (RT)‐driven high flow nasal cannula (HFNC) protocol could decrease duration of HFNC use, pediatric intensive care unit (PICU) and hospital length of stay (LOS), and duration of continuous albuterol use in pediatric patients with critical asthma.MethodsThis was a quality improvement project performed at a quaternary academic PICU. Patients admitted to the PICU between 2 and 18 years of age with a diagnosis of asthma requiring continuous albuterol and HFNC were included. Implementation of an RT‐driven HFNC protocol [Plan‐Do‐Study‐Act (PDSA) 1] occurred in October 2017. Additional interventions included weaning continuous albuterol and HFNC simultaneously (PDSA 2; March 2019), adjusting HFNC wean rate (PDSA 3; July 2020), and a HFNC holiday (PDSA 4; October 2021). HFNC duration was the primary outcome. Secondary outcomes included LOS data and continuous albuterol duration. Noninvasive ventilation (NIV), invasive mechanical ventilation (IMV), and 7‐day PICU and hospital readmission rates were used as balancing measures.ResultsA total of 410 patients were included. Patient demographics and adjunct therapy use did not differ among the groups. After PDSA 2, mean HFNC duration decreased (26.8–18.1 h). Mean PICU LOS decreased (41–31.8 h). Mean hospital LOS also decreased (86.5–68 h). These outcomes remained stable during PDSA 3 and 4. Continuous albuterol duration and NIV use were unchanged, while IMV use decreased.ConclusionsAn RT‐driven HFNC protocol led to decreased length of HFNC and PICU and hospital LOS for pediatric patients with critical asthma without an increase in adverse events.

High‐flow nasal cannula in critical asthma: Time for the respiratory therapists to drive care!

“…The lack of a meaningful improvement observed by Maue et al 18 on duration of HFNC therapy, PICU and hospital LOS, and duration of continuous albuterol treatment after PDSA cycle 2 was likely multifactorial. First, the team may have already fully realized the potential benefit from their protocol and HFNC weaning was not a significant driver of LOS.…”

“…Additional challenges in comparing various studies on HFNC in pediatric critical asthma arise from variations in the entry criteria used to define the study cohorts. For instance, Gates et al 12 evaluated HFNC in a critical asthma cohort with an Modified Pulmonary Index Score (MPIS) ≥8 and demonstrated a longer duration of continuous albuterol by 6 h and longer PICU LOS by 14 h compared to the study conducted by Maue et al 18 However, interestingly, the overall hospital LOS was shorter in the Gates study 12 . Furthermore, other studies have also reported shorter durations of continuous albuterol, PICU LOS, and hospital LOS in comparison to the current report 20,21 .…”

“…16 Despite the lack of high-quality evidence, HFNC is now ubiquitous to PICUs and its frequency of use in children with critical asthma is increasing. 5,17 In this issue of Pediatric Pulmonology, Maue et al 18 used standard quality improvement (QI) methodology combined with multivariable linear regression to evaluate the effect of adding a respiratory therapist (RT)-driven HFNC weaning protocol to their existing continuous albuterol weaning pathway for children with critical asthma. 19 The primary outcome was duration of HFNC therapy.…”

“…Consequently, reductions in treatment duration or PICU LOS, without concurrent improvements in hospital LOS, may hold lesser importance than those that effectively reduce total hospitalization time. In this study, Maue et al 18 chose duration of HFNC use as the primary outcome, whereas Gates et al 12 used hospital LOS, Brennan et al 20 used PICU LOS, and others used time on continuous albuterol. 19,21 These differing primary outcomes make it challenging to directly compare findings across studies.…”

“…No clinical study is perfect, so the fact that the one by Maue et al 18 has a few notable limitations is unsurprising. First, the study did not report when HFNC treatment was used in relation to the clinical trajectory.…”