High-Flow Nasal Cannula Use Outside of the ICU Setting

The applications of high-flow nasal cannulas in pediatric intensive care units in Taiwan

BACKGROUND/PURPOSE

The use of high-flow nasal cannulas (HFNC) in patients admitted to the pediatric intensive care unit (PICU) has gradually increased worldwide; however, details on clinical efficacy remain limited in Taiwan. Therefore, we explored the clinical characteristics and outcomes of pediatric patients using HFNC in the PICU.

METHODS

Medical records were retrospectively collected from pediatric patients (aged <18 years) who received HFNC support from December 2021 to January 2023 in the PICU of a medical center. Outcome parameters included treatment failure (defined as increased respiratory support to advanced non-invasive ventilators or intubations), duration of support from HFNC, and changes in clinical parameters after initiating HFNC.

RESULTS

A total of 261 episodes of HFNC use were included, with a failure rate of 24.5% and a median support length of 4 days. Multivariable analysis showed that infant age (adjusted odds ratio [aOR]: 2.1, p = 0.02) and accompanying complex chronic disease (aOR: 4.4, p = 0.014) were risk factors for treatment failure and a diagnosis of asthma or bronchiolitis had a lower hazard of treatment failure (aOR: 0.29, p = 0.025) than other diagnoses did. Improvements in clinical parameters, including pulse rate, respiratory rate, SpO2, and CO2 levels, were observed 24 h after the initiation of HFNC.

CONCLUSION

The application of HFNC in the PICU in Taiwan is effective but should be performed with care in infants with accompanying complex chronic diseases. In addition to low treatment failure, HFNC utilizations stabilized the clinical parameters of children with asthma/bronchiolitis within one day.

High-flow nasal cannula oxygen therapy for children with bronchiolitis: Implementation of a national guideline

AIM

High flow nasal cannula (HFNC) therapy is a form of respiratory support used in children with bronchiolitis. A national guideline for the use of HFNC was published in The Netherlands in 2020. We studied the implementation and use of this guideline.

METHODS

We performed a multicentre observational study amongst all hospitals in the North-West part of The Netherlands referring to the same paediatric intensive care unit (PICU). This study consisted of two parts: a comparison of local HFNC protocols to the national guideline and a survey about the use of HFNC amongst paediatricians in the participating centres.

RESULTS

We observed considerable variations between the local protocols and the national protocol, especially regarding criteria to initiate HFNC treatment and weaning practices. Survey results showed that expectations of HFNC widely varied, while the clinical use of HFNC deviated from both the national guideline as well as local protocols, especially for weaning practices and the use of pCO2 as a parameter for initiation and evaluation of the effect of HFNC.

CONCLUSION

Implementation of the national guideline for HFNC therapy in bronchiolitis was inefficacious, leading to non-uniform clinical practice.

Addressing high flow overuse in bronchiolitis - Successes and future directions

The use of high flow nasal cannula (HFNC) in the treatment of bronchiolitis has markedly increased in the last decade, yet randomized controlled trials have reported little clinical benefit with early, routine use. This article provides a concise overview of the current status of HFNC therapy, discusses successful de-implementation strategies to curtail HFNC overuse, and explores future bronchiolitis and HFNC quality improvement and research considerations.

High flow, low results: The limits of high flow nasal cannula in the treatment of bronchiolitis

Bronchiolitis continues to be the most common cause of hospitalization in the first year of life. We continue to search for the remedy that will improve symptoms, shorten hospitalization and prevent worsening of disease. Although initially thought to be a promising therapy, large randomized controlled trials show us that high flow nasal cannula (HFNC) use is not that remedy. These trials show no major differences in duration of hospital stay, intensive care unit (ICU) admission rates, duration of stay in the ICU, duration of oxygen therapy, intubation rates, heart rate, respiratory rate or comfort scores. Additionally, practices regarding initiation, flow rates and weaning continue to vary from institution to institution and there are currently no agreed upon indications for its use. This reveals the need for evidence based guidelines on HFNC use in bronchiolitis.

Bronchiolitis: Safely Doing Less Is the Next Big Thing

Bronchiolitis is a viral lower respiratory tract infection primarily affecting children younger than 2 years; a common cause of health care encounters, including hospitalization; and a considerable economic burden for health care systems in the United States and worldwide. The American Academy of Pediatrics (AAP) most recently updated its bronchiolitis guideline in 2014 and reaffirmed supportive care as the mainstay of treatment. Despite these recommendations, there is still significant variability in care provided for these children, especially in bronchodilator usage, radiography, and high-flow nasal cannula. Since the 2014 AAP guideline, many pediatric hospitalists have undertaken quality initiatives to improve the adherence to published guidelines, yet a large gap remains between what is recommended and what is practiced. This article presents research on the efficacy of common interventions as well as an introduction to diagnostics and treatments potentially on the horizon. [Pediatr Ann. 2024;53(6):e223-e228.].

Oral enteral nutrition in the emergency department for children with bronchiolitis hospitalized on high flow nasal cannula

OBJECTIVES

We assessed whether initiation of oral enteral nutrition in the emergency department (ED) for patients with bronchiolitis hospitalized on humidified high flow nasal cannula (HHFNC) was associated with a shorter hospital length of stay (LOS) without an increase in return ED visits or hospital readmissions.

PATIENTS AND METHODS

This retrospective cohort study included children ≤24 months of age with bronchiolitis hospitalized to the general pediatric floor on HHFNC in two time periods: October 1, 2018 - April 30, 2019, and following implementation of a revised institutional bronchiolitis pathway that encouraged enteral nutrition initiation in the ED, October 1, 2021 - April 30, 2022. The primary outcome of interest was hospital LOS where the exposure was enteral feeding in the ED.

RESULTS

We included 391 'fed', 114 'not fed' and 304 'unknown' patients. HHFNC treatment time (25 h for 'fed' vs. 43 h for 'not fed' vs. 35 h for'unknown', p = 0.0001) and hospital LOS (39 h for 'fed' vs. 56 h for 'not fed' vs. 48 h for 'unknown', p = 0.0001) was shorter in the 'fed' group. There were no significant differences in return ED visits or hospital readmissions. Using our median LOS (45.1 h, inter-quartile range 30.2, 64.4 h) while controlling for age, sex, initial HHFNC flow rate, the respiratory oxygenation (ROX) index, viral etiology, and time period, an adjusted logistic regression analysis demonstrated that patients fed in the ED were 1.8 times more likely to have a hospital LOS of <45 h (aOR 1.88, 95% CI 1.11-3.18, p = 0.019).

CONCLUSIONS

Initiation of oral enteral nutrition in the ED for patients with bronchiolitis on HHFNC is associated with a shorter hospital LOS without an increase in return ED visits or hospital readmissions. Future prospective studies are needed to develop feeding recommendations for children with bronchiolitis receiving HHFNC support.

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

Background

Despite limited evidence, a high-flow nasal cannula (HFNC) is often used to treat mild to moderate (m/m) bronchiolitis. We aimed to decrease the rate of HFNC use in the pediatric emergency department (PED) for m/m bronchiolitis from a baseline of 37% to less than 18.5%.

Methods

A multidisciplinary team created a bronchiolitis pathway and implemented it in December 2019. A respiratory score (RS) in the electronic medical record objectively classified bronchiolitis severity as mild, moderate, or severe. We tracked HFNC utilization in the PED among patients with m/m bronchiolitis as our primary outcome measure between December 2019 and December 2021. We monitored the percentage of patients with an RS as a process measure. Interventions through four plan-do-study-act cycles included updating the hospital oxygen therapy policy, applying the RS to all patients in respiratory distress, modifying the bronchiolitis order set, and developing a bronchiolitis-specific HFNC order.

Results

Three hundred twenty-five patients were admitted from the PED with m/m bronchiolitis during the 11-month baseline period and 600 patients during the 25-month intervention period. The mean rate of HFNC utilization decreased from 37% to 17%. Despite a decrease in bronchiolitis encounters after the pandemic, in the spring of 2021, when volumes returned, we had a sustained HFNC utilization rate of 17%. RS entry increased from 60% to 73% in the intervention period.

Conclusions

A clinical pathway for bronchiolitis can lead to decreased use of HFNC for m/m bronchiolitis. Consistent RS, order set development with decision support, and education led to sustained improvement despite pandemic-related volumes.

Respiratory Support Practices for Bronchiolitis in the Pediatric Intensive Care Unit

Importance

Admissions to the pediatric intensive care unit (PICU) due to bronchiolitis are increasing. Whether this increase is associated with changes in noninvasive respiratory support practices is unknown.

Objective

To assess whether the number of PICU admissions for bronchiolitis between 2013 and 2022 was associated with changes in the use of high-flow nasal cannula (HFNC), noninvasive ventilation (NIV), and invasive mechanical ventilation (IMV) and to identify factors associated with HFNC and NIV success and failure.

Design, Setting, and Participants

This cross-sectional study examined encounter data from the Virtual Pediatric Systems database on annual PICU admissions for bronchiolitis and ventilation practices among patients aged younger than 2 years admitted to 27 PICUs between January 1, 2013, and December 31, 2022. Use of HFNC and NIV was defined as successful if patients were weaned to less invasive support (room air or low-flow nasal cannula for HFNC; room air, low-flow nasal cannula, or HFNC for NIV).

Main Outcomes and Measures

The main outcome was the number of PICU admissions for bronchiolitis requiring the use of HFNC, NIV, or IMV. Linear regression was used to analyze the association between admission year and absolute numbers of encounters stratified by the maximum level of respiratory support required. Multivariable logistic regression was used to analyze factors associated with HFNC and NIV success and failure (defined as not meeting the criteria for success).

Results

Included in the analysis were 33 816 encounters for patients with bronchiolitis (20 186 males [59.7%]; 1910 patients [5.6%] aged ≤28 days and 31 906 patients [94.4%] aged 29 days to <2 years) treated at 27 PICUs from 2013 to 2022. A total of 7615 of 15 518 patients (49.1%) had respiratory syncytial virus infection and 1522 of 33 816 (4.5%) had preexisting cardiac disease. Admissions to the PICU increased by 350 (95% CI, 170-531) encounters annually. When data were grouped by the maximum level of respiratory support required, HFNC use increased by 242 (95% CI, 139-345) encounters per year and NIV use increased by 126 (95% CI, 64-189) encounters per year. The use of IMV did not significantly change (10 [95% CI, -11 to 31] encounters per year). In all, 22 381 patients (81.8%) were successfully weaned from HFNC to low-flow oxygen therapy or room air, 431 (1.6%) were restarted on HFNC, 3057 (11.2%) were escalated to NIV, and 1476 (5.4%) were escalated to IMV or extracorporeal membrane oxygenation (ECMO). Successful use of HFNC increased from 820 of 1027 encounters (79.8%) in 2013 to 3693 of 4399 encounters (84.0%) in 2022 (P = .002). In all, 8476 patients (81.5%) were successfully weaned from NIV, 787 (7.6%) were restarted on NIV, and 1135 (10.9%) were escalated to IMV or ECMO. Success with NIV increased from 224 of 306 encounters (73.2%) in 2013 to 1335 of 1589 encounters (84.0%) in 2022 (P < .001). In multivariable logistic regression, lower weight, higher Pediatric Risk of Mortality III score, cardiac disease, and PICU admission from outside the emergency department were associated with greater odds of HFNC and NIV failure.

Conclusions and Relevance

Findings of this cross-sectional study of patients aged younger than 2 years admitted for bronchiolitis suggest there was a 3-fold increase in PICU admissions between 2013 and 2022 associated with a 4.8-fold increase in HFNC use and a 5.8-fold increase in NIV use. Further research is needed to standardize approaches to HFNC and NIV support in bronchiolitis to reduce resource strain.

Transition to Weight-Based High-Flow Nasal Cannula Use Outside of the ICU for Bronchiolitis

Importance

Most children's hospitals have adopted weight-based high-flow nasal cannula (HFNC) bronchiolitis protocols for use outside of the intensive care unit (ICU) setting. Whether these protocols are achieving their goal of reducing bronchiolitis-related ICU admissions remains unknown.

Objective

To measure the association between hospital transition to weight-based non-ICU HFNC use and subsequent ICU admission.

Design, Setting, and Participants

This multicenter retrospective cohort study was conducted with a controlled interrupted time series approach and involved 18 children's hospitals that contribute data to the Pediatric Health Information Systems database. The cohort included patients aged 0 to 24 months who were hospitalized with a diagnosis of bronchiolitis between January 1, 2010, and December 31, 2021. Data were analyzed from July 2023 to January 2024.

Exposure

Hospital-level transition from ICU-only to weight-based non-ICU protocol for HFNC use. Data for the ICU-only group were obtained from a previously published survey.

Main Outcomes and Measures

Proportion of patients with bronchiolitis admitted to the ICU.

Results

A total of 86 046 patients with bronchiolitis received care from 10 hospitals in the ICU-only group (n = 47 336; 27 850 males [58.8%]; mean [SD] age, 7.6 [6.2] years) and 8 hospitals in the weight-based protocol group (n = 38 710; 22 845 males [59.0%]; mean [SD] age, 7.7 [6.3] years). Mean age and sex were similar for patients between the 2 groups. Hospitals in the ICU-only group vs the weight-based protocol group had higher proportions of Black (26.2% vs 19.8%) and non-Hispanic (81.6% vs 63.8%) patients and patients with governmental insurance (68.1% vs 65.9%). Hospital transition to a weight-based HFNC protocol was associated with a 6.1% (95% CI, 8.7%-3.4%) decrease per year in ICU admission and a 1.5% (95% CI, 2.8%-0.1%) reduction per year in noninvasive positive pressure ventilation use compared with the ICU-only group. No differences in mean length of stay or the proportion of patients who received invasive mechanical ventilation were found between groups.

Conclusions and Relevance

Results of this cohort study of hospitalized patients with bronchiolitis suggest that transition from ICU-only to weight-based non-ICU HFNC protocols is associated with reduced ICU admission rates.

Increased bronchiolitis burden and severity after the pandemic: a national multicentric study

BACKGROUND

The coronavirus 2019 (COVID-19) related containment measures led to the disruption of all virus distribution. Bronchiolitis-related hospitalizations shrank during 2020-2021, rebounding to pre-pandemic numbers the following year. This study aims to describe the trend in bronchiolitis-related hospitalization this year, focusing on severity and viral epidemiology.

METHODS

We conducted a retrospective investigation collecting clinical records data from all infants hospitalized for bronchiolitis during winter (1st September-31th March) from September 2018 to March 2023 in six Italian hospitals. No trial registration was necessary according to authorization no.9/2014 of the Italian law.

RESULTS

Nine hundred fifty-three infants were hospitalized for bronchiolitis this last winter, 563 in 2021-2022, 34 in 2020-2021, 395 in 2019-2020 and 483 in 2018-2019. The mean length of stay was significantly longer this year compared to all previous years (mean 7.2 ± 6 days in 2022-2023), compared to 5.7 ± 4 in 2021-2022, 5.3 ± 4 in 2020-2021, 6.4 ± 5 in 2019-2020 and 5.5 ± 4 in 2018-2019 (p < 0.001), respectively. More patients required mechanical ventilation this winter 38 (4%), compared to 6 (1%) in 2021-2022, 0 in 2020-2021, 11 (2%) in 2019-2020 and 6 (1%) in 2018-2019 (p < 0.05), respectively. High-flow nasal cannula and non-invasive respiratory supports were statistically more common last winter (p = 0.001 or less). RSV prevalence and distribution did not differ this winter, but coinfections were more prevalent 307 (42%), 138 (31%) in 2021-2022, 1 (33%) in 2020-2021, 68 (23%) in 2019-2020, 61 (28%) in 2018-2019 (p = 0.001).

CONCLUSIONS

This study shows a growth of nearly 70% in hospitalisations for bronchiolitis, and an increase in invasive respiratory support and coinfections, suggesting a more severe disease course this winter compared to the last five years.

When to Transfer: Predictors of Pediatric High Flow Nasal Cannula Failure at a Community Hospital

OBJECTIVES

To identify risk factors of high flow nasal cannula (HFNC) failure at a US pediatric hospital without a co-located ICU.

METHODS

Retrospective cohort study of patients aged 0 to 18 years who were started on HFNC in the emergency department or inpatient unit at a community hospital over a 16-month period. Children with chronic medical conditions were excluded. Outcome was HFNC failure, defined as HFNC need greater than floor limit, noninvasive positive pressure, or mechanical ventilation. In bivariate analysis, we compared demographic and clinical factors between those with and without failure. We included variables in a multivariable model on the basis of statistical significance. We used Poisson regression with robust error variance to calculate the adjusted relative risk (aRR) of failure for each variable.

RESULTS

Of 195 children, 51% had HFNC failure. In adjusted analysis, failure was higher in all age groups <12 months as compared with older children. For example, children aged 3 to 5 months had a higher risk of failure compared with patients 12 months or older (aRR 1.85, confidence interval [CI] 1.34-2.54). Patients with an asthma exacerbation had a higher risk of failure (aRR 1.39, CI 1.03-1.88). Patients whose respiratory rate or heart rate did not improve also had a higher risk of failure (aRR 1.73, CI 1.24-2.41; aRR 1.47, CI 1.14-1.90).

CONCLUSIONS

Patients who were younger, had asthma, and did not have improved respiratory rate or heart rate after HFNC were more likely to experience HFNC failure.

Acute paediatric asthma treatment in the prehospital setting: a retrospective observational study

OBJECTIVES

To describe the incidence of and patterns of 'escalated care' (care in addition to standard treatment with systemic corticosteroids and inhaled bronchodilators) for children receiving prehospital treatment for asthma.

DESIGN

Retrospective observational study.

SETTING

State-wide ambulance service data (Ambulance Victoria in Victoria, Australia, population 6.5 million) PARTICIPANTS: Children aged 1-17 years and given a final diagnosis of asthma by the treating paramedics and/or treated with inhaled bronchodilators from 1 July 2019 to 30 June 2020.

PRIMARY AND SECONDARY OUTCOME MEASURES

We classified 'escalation of care' as parenteral administration of epinephrine, or provision of respiratory support. We compared clinical, demographic and treatments administered between those receiving and not receiving escalation of care.

RESULTS

Paramedics attended 1572 children with acute exacerbations of asthma during the 1 year study period. Of these, 22 (1.4%) had escalated care, all receiving parenteral epinephrine. Patients with escalated care were more likely to be older, had previously required hospital admission for asthma and had severe respiratory distress at initial assessment.Of 1307 children with respiratory status data available, at arrival to hospital, the respiratory status of children had improved overall (normal/mild respiratory distress at initial assessment 847 (64.8%), normal/mild respiratory distress at hospital arrival 1142 (87.4%), p<0.0001).

CONCLUSIONS

Most children with acute exacerbations of asthma did not receive escalated therapy during their pre-hospital treatment from ambulance paramedics. Most patients were treated with inhaled bronchodilators only and clinically improved by the time they arrived in hospital.

High-flow oxygen therapy in moderate to severe bronchiolitis: a randomised controlled trial

BACKGROUND AND OBJECTIVE

High-flow (HF) oxygen therapy is being used increasingly in infants with bronchiolitis, despite lack of convincing evidence of its superiority over low flow (LF). We aimed to compare the effect of HF to LF in moderate to severe bronchiolitis.

METHODS

Multicentre randomised controlled trial during four winter seasons (2016-2020) including 107 children under 2 years of age admitted with moderate to severe bronchiolitis, oxygen saturation of <92% and severely impaired vital signs. Crossovers were not allowed. HF was administered at flow rates of 2 L/kg for the first 10 kg, plus 0.5 L/kg for every kg >10 kg, LF with a maximum flow rate of 3 L/min. Primary outcome was improvement of vital signs and dyspnoea severity within 24 hours assessed by a composite score. Secondary outcomes were comfort, duration of oxygen therapy, supplemental feedings, hospitalisation duration and intensive care admission for invasive ventilation.

RESULTS

Significant improvement within 24 hours occurred in 73% of 55 patients randomised to HF and in 78% of 52 patients with LF (difference 6%, 95% CI -13% to 23%). Intention-to-treat analysis revealed no significant differences in any secondary outcome: duration of oxygen therapy, supplemental feedings, hospitalisation and need for invasive ventilation or intensive care admission, except for comfort (face, legs, activity, cry, consolability), which was one point (out of a scale of 0-10) higher in the LF group. No adverse effects occurred.

CONCLUSION

We found no measurable clinically relevant benefit in the use of HF compared with LF in hypoxic children with moderate to severe bronchiolitis.

TRIAL REGISTRATION NUMBER

NCT02913040.

Randomized Trial of Weight-Based Versus Fixed Limit High-Flow Nasal Cannula in Bronchiolitis

BACKGROUND

High flow nasal cannula (HFNC) is increasingly used to treat bronchiolitis. Although lower HFNC rates (≤8 L per minute) are commonly employed, higher weight-based flows more effectively alleviate dyspnea. The impact of higher flows on the need for care escalation is unclear.

METHODS

A randomized clinical trial was performed in a community hospital inpatient pediatric unit. Patients with bronchiolitis on HFNC were randomized to an existing "standard" HFNC protocol (max flow of 8 L per minute), or to a novel weight-based protocol (max flow of 2 L/kg per minute). Weaning of HFNC for the patients in the standard arm was left to provider discretion but was prescribed in the weight-based arm. The primary outcome was interhospital transfer to a PICU. The study was powered to detect a 35% difference in transfer rate.

RESULTS

51 patients were randomized to the weight-based or standard HFNC arms. The interhospital PICU transfer rate did not differ significantly between the standard (41.7%) and weight-based arms (51.9%) P = .47. Hospital length of stay was significantly shorter in the weight-based arm with protocolized weaning (45 h [interquartile range 42.1-63.3] versus 77.6 h [interquartile range 47.3-113.4]); P = .01. There were no significant adverse events in either group.

CONCLUSIONS

Weight-based provision of HFNC did not significantly impact the number of patients with bronchiolitis requiring interhospital transfer from a community hospital to a PICU, though we were underpowered for this outcome. Patients who received weight-based flow with protocolized weaning had a shorter length of stay, which may reflect a clinical impact of weight-based flow or the efficacy of the aggressive weaning pathway.

The Current State of High-Flow Nasal Cannula Protocols at Children's Hospitals

OBJECTIVES

To describe the current state of non-ICU high flow nasal cannula (HFNC) protocols at children's hospitals and explore associations between HFNC protocol type and utilization outcomes.

METHODS

We performed a cross-sectional study of the Pediatric Health Information Systems (PHIS) database. First, we designed a survey with the purpose of classifying HFNC protocols used at hospitals currently contributing data to PHIS. Next, we categorized hospitals based on their current HFNC protocol (ICU only, age-based non-ICU, or weight-based non-ICU). Finally, using the PHIS database, we compared hospital characteristics and patient-level bronchiolitis outcomes by HFNC protocol group.

RESULTS

We received survey responses from 36 of 44 (82%) hospitals contributing data to PHIS in 2021. During the time period studied, there was a steady increase in adoption of non-ICU HFNC protocols, with 71% of responding children's hospitals reporting non-ICU HFNC protocols in 2021 compared with 11% before 2010. No differences in hospital characteristics were observed between ICU-only hospitals, age-based hospitals, or weight-based hospitals. Age-based hospitals had the highest proportion of bronchiolitis patients treated in the ICU (36.1%), whereas weight-based hospitals had the lowest proportion of patients treated in the ICU (21.0%, P < .001). Length of stay was longer at age-based hospitals (2.9 days) as compared with weight-based and ICU-only hospitals (1.9 days, P < .001).

CONCLUSIONS

Most children's hospitals have adopted non-ICU HFNC protocols for patients with bronchiolitis, the majority of which are now utilizing weight-based maximum flow rates. Weight-based HFNC protocols were associated with decreased ICU utilization compared with age-based HFNC protocols.

High flow nasal cannula therapy in the pediatric home setting

BACKGROUND

High-flow nasal cannula (HFNC) therapy may be better tolerated than traditional noninvasive ventilation (NIV) and is rapidly gaining acceptance in pediatric acute care. In Israel, HFNC is approved for domestic use. We aim to describe its indications, efficacy, parental satisfaction, and safety.

METHODS

Retrospective study of children treated with home HFNC therapy in three pediatric centers. Data included demographic parameters, indication of use, weight and days of hospitalization before and after initiation. Safety, tolerability, and parental satisfaction were assessed via standardized telephone questionnaire.

RESULTS

Median (interquartile range [IQR]) age of initiating home HFNC in 75 children was 8.3 (2.2, 29.6) months. Indications were obstructive sleep apnea (33; 44%), airway malacia (19; 25%), chronic lung disease (15; 20%), neuromuscular disease (4; 5%), and postextubation support (4; 5%). Weight standard deviation score rose from -2.3 pre-HFNC to -1.7 at 6.7 months post-HFNC initiation, p < 0.001. Hospital admission days during the 2 months pre- versus post-HFNC initiation were 22 (5.5, 60) and 5 (0, 14.7) respectively, p < 0.008. Median (IQR) parental satisfaction score was 5/5 (4, 5). Fifty of 60 (83%) respondents would recommend home HFNC to other families in a similar situation. There were no serious adverse events.

CONCLUSION

In our population, domestic HFNC appeared safe and well tolerated for a variety of indications. Its introduction was associated with improved weight gain, fewer hospitalization days and high parental satisfaction. Further work is required to characterize groups of children most likely to benefit from HFNC, as opposed to traditional modes of NIV.

Protocol-Driven Initiation and Weaning of High-Flow Nasal Cannula for Patients With Bronchiolitis: A Quality Improvement Initiative

OBJECTIVES

Bronchiolitis is the most common cause for nonelective infant hospitalization in the United States with increasing utilization of high-flow nasal cannula (HFNC). We standardized initiation and weaning of HFNC for bronchiolitis and quantified the impact on outcomes. Our specific aim was to reduce hospital and ICU length of stay (LOS) by 10% between two bronchiolitis seasons after implementation.

DESIGN

A quality improvement (QI) project using statistical process control methodology.

SETTING

Tertiary-care children's hospital with 24 PICU and 48 acute care pediatric beds.

PATIENTS

Children less than 24 months old with bronchiolitis without other respiratory diagnoses or underlying cardiac, respiratory, or neuromuscular disorders between December 2017 and November 2018 (baseline), and December 2018 and February 2020 (postintervention).

INTERVENTIONS

Interventions included development of an HFNC protocol with initiation and weaning guidelines, modification of protocol and respiratory assessment classification, education, and QI rounds with a focus on efficient HFNC weaning, transfer, and/or discharge.

MEASUREMENTS AND MAIN RESULTS

A total of 223 children were included (96 baseline and 127 postintervention). The primary outcome metric, average LOS per patient, decreased from 4.0 to 2.8 days, and the average ICU LOS per patient decreased from 2.8 to 1.9 days. The secondary outcome metric, average HFNC treatment hours per patient, decreased from 44.0 to 36.3 hours. The primary and secondary outcomes met criteria for special cause variation. Balancing measures included ICU readmission rates, 30-day readmission rates, and adverse events, which were not different between the two periods.

CONCLUSIONS

A standardized protocol for HFNC management for patients with bronchiolitis was associated with decreased hospital and ICU LOS, less time on HFNC, and no difference in readmissions or adverse events.

Oral Feeding on High-Flow Nasal Cannula in Children Hospitalized With Bronchiolitis

OBJECTIVE

Oral feeding by children with bronchiolitis on high-flow nasal cannula (HFNC) is questioned, resulting in high practice variability. Our objective was to determine the incidence of aspiration pneumonia and adverse feeding events in otherwise healthy children with bronchiolitis on HFNC who fed orally from admission.

METHODS

We conducted a single-center, retrospective chart review, in a tertiary children's hospital, of 876 children who were <24 months old, admitted for bronchiolitis, and treated with HFNC in the pediatric ward from March 2017 to May 2020. Primary outcomes included the incidence of aspiration pneumonia and adverse feeding events. Secondary outcomes included escalation of care, frequency and duration of nil per os status, length of stay, and 7-day readmission.

RESULTS

Most patients (77.2%) met inclusion criteria and were fed orally within 2 hours of admission. The average maximum HFNC flow rate was 8 L/min (1 L/kg/min); the average maximum respiratory rate was 62 ± 10. Adverse feeding events occurred in 11 patients (1.6%), of which 3 had a concern for possible microaspiration. None were diagnosed with or treated for aspiration pneumonia. Few patients (8.1%) were made nil per os while on HFNC but returned to oral feeding by discharge.

CONCLUSION

Among those with bronchiolitis on HFNC who received oral nutrition on admission, there were few incidences of adverse feeding events and no diagnoses of aspiration pneumonia, suggesting that oral feeding while on HFNC can be well-tolerated in similar populations. However, this study was limited by its single-center retrospective design, and future prospective studies are needed.

High-Flow Oxygen and Other Noninvasive Respiratory Support Therapies in Bronchiolitis: Systematic Review and Network Meta-Analyses

OBJECTIVES

We present a systematic review on the effectiveness of noninvasive respiratory support techniques in bronchiolitis.

DATA SOURCES

Systematic review with pairwise meta-analyses of all studies and network meta-analyses of the clinical trials.

STUDY SELECTION

Patients below 24 months old with bronchiolitis who require noninvasive respiratory support were included in randomized controlled trials (RCTs), non-RCT, and cohort studies in which high-flow nasal cannula (HFNC) was compared with conventional low-flow oxygen therapy (LFOT) and/or noninvasive ventilation (NIV).

DATA EXTRACTION

Emergency wards and hospitalized patients with bronchiolitis.

DATA SYNTHESIS

A total of 3,367 patients were analyzed in 14 RCTs and 8,385 patients in 14 non-RCTs studies. Only in nonexperimental studies, HFNC is associated with a lower risk of invasive mechanical ventilation (MV) than NIV (odds ratio, 0.49; 95% CI, 0.42-0.58), with no differences in experimental studies. There were no differences between HFNC and NIV in other outcomes. HFNC is more effective than LFOT in reducing oxygen days and treatment failure. In the network meta-analyses of clinical trials, NIV was the most effective intervention to avoid invasive MV (surface under the cumulative ranking curve [SUCRA], 57.03%) and to reduce days under oxygen therapy (SUCRA, 79.42%), although crossover effect estimates between interventions showed no significant differences. The included studies show methodological heterogeneity, but it is only statistically significant for the reduction of days of oxygen therapy and length of hospital stay.

CONCLUSIONS

Experimental evidence does not suggest that high-flow oxygen therapy has advantages over LFOT as initial treatment nor over NIV as a rescue treatment.

Financial outcomes of high-flow nasal cannula use for bronchiolitis on the general pediatric floor

High-flow nasal cannula (HFNC) is an increasingly common treatment utilized for bronchiolitis on general pediatric hospital floors. This could present a financial burden for hospitals if reimbursement has not accounted for the increased costs associated with increased HFNC use. Pediatric Health Information System and Revenue Management Program data set discharges from 2018 to 2019 were utilized to calculate the ratio of reimbursements to costs as a cost coverage ratio (CCR). The CCR was compared by HFNC use, the severity of illness, and payor type. The CCR was highest at 1.68 for children with high severity and HFNC use but varied greatly by payor. The lowest CCR at 0.77 was seen for children with low severity and public insurance and indicated potential financial losses for these patients. This was lower than low-severity patients on HFNC with private payors (1.68) and high-severity patients on HFNC with public payors (1.18).

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

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.

Acceptability of Deimplementing High-Flow Nasal Cannula in Pediatric Bronchiolitis

BACKGROUND AND OBJECTIVES

High-flow nasal cannula (HFNC) in children hospitalized with bronchiolitis does not significantly improve clinical outcomes but can increase costs and intensive care unit use. Given widespread HFNC use, it is imperative to reduce use. However, there is limited information on key factors that affect deimplementation. To explore acceptability of HFNC deimplementation, perceptions of HFNC benefits, and identify barriers and facilitators to deimplementation.

METHODS

We conducted a study of health care providers that included quantitative survey data supplemented by semistructured interviews. Data were analyzed using univariate tests and thematic content analysis.

RESULTS

A total of 152 (39%) providers completed the survey; 9 participated in interviews. Eighty-three (55%) providers reported feeling positively about deimplementing HFNC. Reports of feeling positively increased as perceived familiarity with evidence increased (P = .04). Physicians were more likely than nurses and respiratory therapists to report feeling positively (P = .003). Hospital setting and years of clinical experience were not associated with feeling positively (P = .98 and .55, respectively). One hundred (66%) providers attributed nonevidence-based clinical benefits to HFNC. Barriers to deimplementation included discomfort with not intervening, perception that HFNC helps, and variation in risk tolerance and clinical experience. Facilitators promoting deimplementation include staff education, a culture of safely doing less, and enhanced multidisciplinary communication.

CONCLUSIONS

Deimplementation of HFNC in children with bronchiolitis is acceptable among providers. Hospital leaders should educate staff, create a culture for safely doing less, and enhance multidisciplinary communication to facilitate deimplementation.

Treatment of Pediatric Patients With High-Flow Nasal Cannula and Considerations for Oral Feeding: A Review of the Literature

PURPOSE

High-Flow Nasal Cannula (HFNC) has become an increasingly common means of noninvasive respiratory support in pediatrics and is being used in infants and children with respiratory distress both inside and outside of the intensive care units. Despite the widespread use of HFNC, there remains a paucity of data on optimal flow rates and its impact on morbidity, mortality, and desired outcomes. Given the scarcity of information in these critical areas, it is not surprising that guidelines for initiation of oral feeding do not exist. This review article will review HFNC mechanisms of action, its use in specific populations and settings, and finally what is known about initiation of feeding during this therapy.

CONCLUSIONS

The practice of withholding oral feeding solely, because of HFNC, is not supported in the literature at the time of this writing, but in the absence of safety data from clinical trials, clinicians should proceed with caution and consider patient-specific factors while making decisions about oral feeding. Well-controlled prospective clinical trials are needed for development of best practice clinical guidelines and attainment of optimal outcomes.

Hospital Charges Associated With Critical Bronchiolitis From 2009 to 2019

OBJECTIVES

To evaluate the contribution of PICU care to increasing hospital charges for patients with bronchiolitis over a 10-year study period.

DESIGN

In this retrospective multicenter study, changes in annual hospital charges (adjusted for inflation) were analyzed using linear regression for subjects admitted to the PICU with invasive mechanical ventilation (PICU + IMV) and without IMV (PICU - IMV), and for children not requiring PICU care.

SETTING

Free-standing children's hospitals contributing to the Pediatric Health Information System (PHIS) database.

SUBJECTS

Children less than 2 years with bronchiolitis discharged from a PHIS hospital between July 2009 and June 2019. Subjects were categorized as high risk if they were born prematurely or had a chronic complex condition.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

PICU patients were 26.5% of the 283,006 included subjects but accrued 66% of the total $14.83 billion in charges. Annual charges increased from $1.01 billion in 2009-2010 to $2.07 billion in 2018-2019, and PICU patients accounted for 83% of this increase. PICU + IMV patients were 22% of all PICU patients and accrued 64% of all PICU charges, but PICU - IMV patients without a high-risk condition had the highest relative increase in annual charges, increasing from $76.7 million in 2009-2010 to $377.9 million in 2018-2019 (374% increase, ptrend < 0.001).

CONCLUSIONS

In a multicenter cohort study of children hospitalized with bronchiolitis, PICU patients, especially low-risk children without the need for IMV, were the highest driver of increased hospital charges over a 10-year study period.

Current practices and policies regarding the use of high-flow nasal cannula on general pediatric inpatient wards in Canada

OBJECTIVES

High-flow nasal cannula (HFNC) oxygen therapy has become a common treatment for respiratory conditions in children. To our knowledge, no study has described practice patterns for HFNC on pediatric inpatient wards in Canada. The aim of this study was to survey current practices and policies regarding the use of HFNC on the ward in children's hospitals in Canada.

METHODS

We conducted a web-based survey of Pediatric Hospital Medicine section chiefs in major tertiary care hospitals in Canada. The primary outcome was the proportion of hospitals that use HFNC on the general pediatric ward. Secondary outcomes included indications for HFNC, initial and maximum flow rates, maximum FiO2, method of nutrition delivery while on HFNC, level of nursing and respiratory therapist care required, criteria for pediatric intensive care unit transfer, and subjective successes and challenges of implementing a ward-based HFNC policy.

RESULTS

The section chief survey response rate was 100% (15/15). Eight centres (53%) allowed the use of HFNC outside of an intensive care setting. Six centres initiated HFNC on the ward, while two centres only accepted patients after HFNC had been initiated in an intensive care setting. Other practices and policies varied considerably from centre to centre.

CONCLUSION

Our study reveals that approximately half of tertiary children's hospitals in Canada currently use HFNC on the ward and utilize a range of practices and policies. Other centres are considering implementation. Further research is needed to inform best practices for HFNC therapy, support stewardship of health care resources, and promote safe patient care.

Trends in Hospital Costs and Levels of Services Provided for Children With Bronchiolitis Treated in Children's Hospitals

IMPORTANCE

Increasing hospital costs for bronchiolitis have been associated with increasing patient complexity and mechanical ventilation. However, the associations of illness severity and diagnostic coding practices with bronchiolitis hospitalization costs have not been examined.

OBJECTIVE

To investigate the association of patient complexity, illness severity, and diagnostic coding practices with bronchiolitis hospitalization costs.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cross-sectional study included 385 883 infants aged 24 months or younger who were hospitalized with bronchiolitis at 39 hospitals in the Pediatric Health Information System database from January 1, 2010, to December 31, 2019.

EXPOSURE

Hospitalization for bronchiolitis.

MAIN OUTCOMES AND MEASURES

Inflation-adjusted standardized unit cost (expressed in dollar units) per hospitalization over time. A nested subgroup analysis was performed to further examine factors associated with changes in cost.

RESULTS

A total of 385 883 bronchiolitis hospitalizations were studied; the patients had a mean (SD) age of 7.5 (6.4) months and included 227 309 of 385 883 boys (58.9%) and 253 870 of 385 883 publicly insured patients (65.8%). Among patients hospitalized with bronchiolitis, the median standardized unit cost per hospitalization increased significantly during the study period (from $5636 [95% CI, $5558-$5714] in 2010 to $6973 [95% CI, $6915-$7030] in 2019; P < .001 for trend). Similar increases in cost were observed among subgroups of patients without a complex chronic condition and without the need for mechanical ventilation. However, costs for patients without a complex chronic condition or mechanical ventilation, who received care outside the intensive care unit did not change in an economically significant manner (from $4803 [95% CI, $4752-$4853] in 2010 to $4853 [95% CI, $4811-$4895] in 2019; P < .001 for trend), suggesting that intensive care unit use was a primary factor associated with cost increases. Substantial changes in coding practices were observed. Among patients hospitalized with bronchiolitis, 1.2% (95% CI, 1.1%-1.3%) were assigned an APR-DRG (All Patient Refined Diagnosis Related Group) for respiratory failure in 2010, which increased to 21.6% (95% CI, 21.2%-21.9%) in 2019 (P < .001 for trend). Increased costs and coding intensity were not accompanied by objective evidence of worsening illness severity.

CONCLUSIONS AND RELEVANCE

This cross-sectional study suggests that hospitalized children with bronchiolitis are receiving costlier and more intensive care without objective evidence of increasing severity of illness. Changes in coding practices may complicate efforts to study trends in the use of health care resources using administrative data.

Interhospital transport of children with bronchiolitis by a statewide emergency transport service

Objective: To investigate the rate of interhospital emergency transport for bronchiolitis and intensive care admission following the introduction of high flow nasal cannula and standardised paediatric observation and response charts. Design: Retrospective cohort study. Setting: A statewide paediatric intensive care transport service and its two referral paediatric intensive care units (PICUs) in Victoria, Australia. Participants: Children less than 2 years old emergently transported with bronchiolitis during two time periods: 2008-2012 and 2015-2019. Main outcome measures: Incidence rates of bronchiolitis transport episodes, PICU admissions and respiratory support. Results: 802 children with bronchiolitis were transported during the study period, 233 in the first period (2008-2012) and 569 in the second period (2015-2019). The rate of interhospital transport for bronchiolitis increased from 32.9 to 71.8 per 100 000 children aged 0-2 years. The population-adjusted rate of PICU admission increased from 16.2 to 36.6 per 100 000 children aged 0-2 years. Metropolitan hospitals were the predominant referral source and this increased from 60.1% of transports to 78.6% (P < 0.001). In children admitted to a PICU, the administration of high flow nasal cannula during transport increased significantly from 1.7% to 75.9% (P < 0.001) and a concomitant reduction in continuous positive airway pressure and mechanical ventilation occurred (40-12.4% and 27-6.9% respectively; P < 0.001). The proportion of mechanical ventilation as well as PICU and hospital length of stay decreased over time. Conclusions: The population-adjusted rate of interhospital transport and admission to the PICU for bronchiolitis increased over time. This occurred despite a lower rate of non-invasive and invasive mechanical ventilation during transport and in the PICU.

Early Use of Bronchodilators and Outcomes in Bronchiolitis

BACKGROUND AND OBJECTIVES

There are no effective interventions to prevent hospital admissions in infants with bronchiolitis. The American Academy of Pediatrics recommends against routine bronchodilator use for bronchiolitis. The objective of this study was to characterize trends in and outcomes associated with the use of bronchodilators for bronchiolitis.

METHODS

This is a multicenter retrospective study of infants <12 months of age with bronchiolitis from 49 children's hospitals from 2010 to 2018. The primary outcomes were rates of hospital admissions, ICU admissions, emergency department (ED) return visits after initial ED discharge, noninvasive ventilation, and invasive ventilation. Multivariable logistic regression was used to evaluate the rates of outcomes among hospitals with high and low early use of bronchodilators (on day of presentation).

RESULTS

A total of 446 696 ED visits of infants with bronchiolitis were included. Bronchodilator use, hospital admissions, and ED return visits decreased between 2010 and 2018 (all P < .001). ICU admissions and invasive and noninvasive ventilation increased over the study period (all P < .001). Hospital-level early bronchodilator use (hospitals with high versus low use) was not associated with differences in patient-level hospital admissions, ICU admissions, ED return visits, noninvasive ventilation, or invasive ventilation (all P > .05).

CONCLUSIONS

In a large study of infants at children's hospitals, bronchodilator therapy decreased significantly from 2010 to 2018. Hospital-level early bronchodilator use was not associated with a reduction in any outcomes. This study supports the current American Academy of Pediatrics recommendation to limit routine use of bronchodilators in infants with bronchiolitis.

Increasing burden of viral bronchiolitis in the pediatric intensive care unit; an observational study

PURPOSE

Viral bronchiolitis is a major cause of pediatric intensive care unit (PICU) admission. Insight in the trends of bronchiolitis-associated PICU admissions is limited, but imperative for future PICU resource and capacity planning.

MATERIALS AND METHODS

We retrospectively studied trends in PICU admissions for bronchiolitis in six European sites, including three full national registries, between 2000 and 2019 and calculated population-based estimates per 100,000 children where appropriate. Information concerning risk factors for severe disease and use of invasive mechanical ventilation was also collected when available.

RESULTS

In total, there were 15,606 PICU admissions for bronchiolitis. We observed an increase in the annual number, rate and estimates per 100,000 children of PICU admissions for bronchiolitis at all sites over the last two decades, while the proportion of patients at high risk for severe disease remained relatively stable.

CONCLUSIONS

The international increased burden of bronchiolitis for the PICU is concerning, and warrants further international attention and investigation.

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

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.

Capillary blood gas in infants with bronchiolitis: Can end-tidal capnography replace it?

OBJECTIVES

To explore the predictive ability of capillary blood gas (CBG) pCO₂ for respiratory decompensation in infants aged ≤6 months with bronchiolitis admitted from the emergency department; to determine whether end-tidal CO₂ (etCO₂) capnography can serve as a less invasive substitute for CBG pCO₂.

STUDY DESIGN

This was a prospective cohort study of previously healthy infants aged ≤6 months admitted for bronchiolitis from the emergency department (ED). Initial CBG pCO₂ and etCO₂ capnography were obtained in the ED prior to inpatient admission. Simple logistic regression modeling was used to examine the associations of CBG pCO₂ and etCO₂ capnography with respiratory decompensation. Pearson's correlation measured the relationship between CBG pCO₂ and etCO₂ capnography.

RESULTS

Of 134 patients, 61 had respiratory decompensation. There was a significant association between CBG pCO₂ and respiratory decompensation (OR = 1.07, p = 0.003), even after outlying values were excluded (OR = 1.06, p = 0.005). End tidal CO₂ capnography was not significantly associated with decompensation (OR = 1.02, p = 0.17), even after outlying values were excluded (OR = 1.02, p = 0.24). There was a moderate correlation between etCO₂ capnography and CBG pCO₂ (r = 0.39, p < 0.001).

CONCLUSION

In infants with bronchiolitis, CBG pCO₂ provides an objective measure for predicting respiratory decompensation, and a single etCO₂ measurement should not replace its use.

Quality Initiative to Reduce High-Flow Nasal Cannula Duration and Length of Stay in Bronchiolitis

OBJECTIVES

High-flow nasal cannula (HFNC) use in bronchiolitis may prolong length of stay (LOS) if weaned more slowly than medically indicated. We aimed to reduce HFNC length of treatment (LOT) and inpatient LOS by 12 hours in 0- to 18-month-old patients with bronchiolitis on the pediatric hospital medicine service.

METHODS

After identifying key drivers of slow weaning, we recruited a multidisciplinary "Wean Team" to provide education and influence provider weaning practices. We then implemented a respiratory therapist-driven weaning protocol with supportive sociotechnical interventions (huddles, standardized orders, simplification of protocol) to reduce LOT and LOS and promote sustainability.

RESULTS

In total, 283 patients were included: 105 during the baseline period and 178 during the intervention period. LOT and LOS control charts revealed special cause variation at the start of the intervention period; mean LOT decreased from 48.2 to 31.2 hours and mean LOS decreased from 84.3 to 60.9 hours. LOT and LOS were less variable in the intervention period compared with the baseline period. There was no increase in PICU transfers or 72-hour return or readmission rates.

CONCLUSIONS

We reduced HFNC LOT by 17 hours and LOS by 23 hours for patients with bronchiolitis via multidisciplinary collaboration, education, and a respiratory therapist-driven weaning protocol with supportive interventions. Future steps will focus on more judicious application of HFNC in bronchiolitis.