Survey of Current Institutional Practices in the Use of High-Flow Nasal Cannula for Pediatric Patients

Abstract

High-flow nasal cannula (HFNC) is an oxygen delivery device that provides heated humidified air with higher flow rates. The purpose of this survey is to look at institutional practice patterns of HFNC initiation, weaning, and disposition for pediatric patients across the United States.Methods: Survey was sent via electronic listservs to pediatric physicians in emergency medicine, hospital medicine, critical care, and urgent care. The questionnaire was divided into demographics and HFNC practices (initiation, management, and weaning). One response per institution was included in the analysis.Results: Two hundred twenty-four responses were included in the analysis, composed of 40% pediatric emergency medicine physicians, 46% pediatric hospitalists, 13% pediatric intensive care unit (PICU) physicians, and 1% pediatric urgent care physicians. Ninety-eight percent of the participants have HFNC at their institution. Thirty-seven percent of the respondents had a formal guideline for HFNC initiation. Nearly all guideline and nonguideline institutions report HFNC use in bronchiolitis. Guideline cohort is more likely to have exclusion criteria for HFNC (42% in the guideline cohort vs 17% in the nonguideline cohort; P < 0.001) and less frequently mandates PICU admissions once on HFNC (11% in the guideline cohort vs 56% in the nonguideline cohort; P < 0.001). Forty-six percent of guideline cohort had an objective scoring system to help determine the need for HFNC, and 73% had a weaning guideline. Conclusions:Although there is general agreement to use HFNC in bronchiolitis, great practice variation remains in the initiation, management, and weaning of HFNC across the United States. There is also a discordance on PICU use when a patient is using HFNC.

Update on the Role of High-Flow Nasal Cannula in Infants with Bronchiolitis

“…However, details on HFNC use are not precisely defined [9][10][11] and, frequently, decisions on how to conduct O2 therapy and the type of method to be used in the individual case is left to the opinion and experience of the operator. A recent survey across the USA including pediatric wards and pediatric intensive care units showed that only 37% had formal guidelines for HFNC initiation and 73% had weaning guidelines [22]. Generally, HFNC is not recommended in infants presenting with history of apneas, documented hemodynamic instability, pneumothorax, or craniofacial abnormalities, and should be used with caution in patients with a decreased level of consciousness, congenital heart disease, and chronic respiratory disease [23].…”

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

“…While this weaning guidance remained identical in Interventions 1 and 2, it is possible that weaning guidance was a key factor in driving the outcomes that we saw as providers gained experience with the pathway. Significant heterogeneity in protocols across institutions makes it challenging to generalize about pathway utility 18 and some studies have not shown convincing benefits for HFNC pathway implementation. 35 , 36 These findings suggest that the impact of a hospital pathway largely depends on the specific guidance it provides as well as its accessibility and acceptance by staff.…”

“… 12 In a US survey of HFNC practices across institutions, only 37% of institutions with HFNC guidelines used a protocol to determine initial flow rates; weaning practices were highly variable. 18 …”

“…Of the studies included in a systematic review of HFNC in bronchiolitis, only one trial included a defined oxygen weaning protocol 12 . In a US survey of HFNC practices across institutions, only 37% of institutions with HFNC guidelines used a protocol to determine initial flow rates; weaning practices were highly variable 18 …”

“…12 In a US survey of HFNC practices across institutions, only 37% of institutions with HFNC guidelines used a protocol to determine initial flow rates; weaning practices were highly variable. 18 National experts recommend greater standardization in HFNC use, including providing a protocol for HFNC initiation, 19 with practice standardization projects being developed to reduce excessive use. 20,21 In a PICU quality improvement/pre-post intervention study, standardizing HFNC use with a protocol using higher initial flow rates was associated with faster weaning and decreased HFNC failure.…”