High Flow Nasal Cannula Oxygen Use in Children with Bronchiolitis Admitted to the Inpatient Wards and Its Impact on Intensive Care Unit Utilization

Background: Bronchiolitis is the most common cause of hospitalization among infants. High flow nasal cannula oxygen (HFNC) is noninvasive respiratory support with heated and humidified air-oxygen mixtures via a nasal cannula interface, increasingly used for patients with bronchiolitis. Initial use was primarily in critical care settings; early studies of HFNC on pediatric wards showed no benefits in intensive care unit (ICU) or hospital length of stay (LOS). Subsequent studies suggest higher flow rates of 1.5-2.0 L/kg/min are efficacious and safe. Our institution implemented an “enhanced” HFNC protocol with flow rates of 1.5-2.0 mL/kg/min on the wards in 2019.

Methods: A quasi-experimental retrospective study was conducted in an urban, academic, free-standing pediatric hospital of children ages 0-24 months with a diagnosis of acute bronchiolitis managed with HFNC. Data from patients admitted between January 12 - April 30, 2017 (pre-protocol) and January 12 - April 30, 2019 (protocol) were assessed. The primary outcome was ICU LOS. Secondary outcomes included ICU transfers, number of rapid responses and codes, emergency department LOS, and overall hospital LOS.

Results: 703 electronic medical records of children ages 0-24 months diagnosed with bronchiolitis within the two timeframes were reviewed for eligibility. 64 patients were included in the final analysis. There was no statistical difference in the percentage of patients initiated on HFNC (13.8% vs 16.5%) and no significant demographic variation between the study groups. When compared to the pre-protocol group, the protocol group demonstrated shorter ICU LOS (28.7 hr vs 78.8 hr, respectively, p<0.001) and overall hospital LOS (74.2 hr vs 98.6 hr, p=0.009). There were also fewer patients managed in the ICU (60% vs 100%, p<0.001), with fewer patients requiring transfer to the ICU from the general pediatric wards (23.8% vs 100%, p<0.004) in the protocol group.

Conclusion: Implementation of an “enhanced” HFNC protocol on the inpatient wards reduces ICU LOS and ICU resource utilization without an increase in serious adverse events in children 0-24 months with bronchiolitis.