Implementation of a Weight-Based High-Flow Nasal Cannula Protocol for Children With Bronchiolitis

Abstract

Objectives: To determine if the implementation of a weight-based high-flow nasal cannula (HFNC) protocol for infants with bronchiolitis was associated with improved outcomes, including decreased ICU use.

Methods: We implemented a weight-based HFNC protocol across a tertiary care children's hospital and 2 community hospitals that admit pediatric patients on HFNC. We included all patients who were <2 years old and had a discharge diagnosis of bronchiolitis or viral pneumonia during the preimplementation (November 2013 to April 2018) and postimplementation (November 2018 to April 2020) respiratory seasons. Data were analyzed by using an interrupted time series approach. The primary outcome measure was the proportion of patients treated in the ICU. Patients with a complex chronic condition were excluded.

Results: Implementation of the weight-based HFNC protocol was associated with an immediate absolute decrease in ICU use of 4.0%. We also observed a 6.2% per year decrease in the slope of ICU admissions pre- versus postintervention. This was associated with an immediate reduction in median cost per bronchiolitis encounter of $661, a 2.3% immediate absolute reduction in the proportion of patients who received noninvasive ventilation, and a 3.4% immediate absolute reduction in the proportion of patients who received HFNC.

Conclusions: A multicenter, weight-based HFNC protocol was associated with decreased ICU use and noninvasive ventilation use. In hospitals where HFNC is used in non-ICU units, weight-based approaches may lead to improved resource use.

Trial registration: ClinicalTrials.gov NCT03354325.

Conflict of interest statement

POTENTIAL CONFLICTS OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Copyright © 2021 by the American Academy of Pediatrics.

Figures

Figure 1.

The proportion of patients who received appropriately targeted flow rates before and after adoption of a weight-based high-flow nasal cannula protocol. Interrupted time series analysis, displaying trends in the pre- and post-implementation respiratory seasons. Error bars represent the 95% confidence interval. Month −1 to −6 represent the pre-implementation season while months +1 to +6 and months +7 to +12 represent the first and second post-implementation seasons, respectively. Due to a change in electronic medical record systems, HFNC flow rates were not available prior to the first pre-implementation respiratory season.

Figure 2.

Outcomes before and after adoption of a weight-based high-flow nasal cannula protocol. Interrupted time series analysis, displaying trends in the pre- and post-implementation respiratory seasons. The adoption season is denoted by the vertical dotted line. There are six sub-figures displaying the following outcomes among hospitalized children with bronchiolitis: (A) the proportion of patients admitted to the ICU; (B) total mean hospital length of stay in hours; (C) median hospital cost per encounter in inflation-adjusted dollars; (D) the proportion of patients treated with high-flow nasal cannula; (E) the proportion of patients treated with non-invasive ventilation; (F) the proportion of patients treated with invasive mechanical ventilation. Error bars represent the 95% confidence interval.