Humidified high-flow nasal cannula oxygen for bronchiolitis: should we go with the flow?

Mace, Ariel O; Gibbons, James T. D.; Schultz, André; Knight, Geoff; Martin, Andrew C.

doi:10.1136/archdischild-2017-313950

Cited by 13 publications

(11 citation statements)

References 4 publications

(6 reference statements)

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“…Although ward-based HFNC protocols are often implemented to reduce ICU use, recent observational studies have revealed either no improvement or a paradoxical increase in ICU use following implementation of such protocols. 4,12,13 However, data from these studies were obtained when most institutions used agebased and modest (8-10 L/minute) flow rates. 3,4 Our findings suggest that weightbased HFNC flow rates may be an important component of ward-based HFNC bronchiolitis protocols that seek to reduce ICU use.…”

Section: Discussionmentioning

confidence: 99%

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

Willer

Johnson

Cipriano

et al. 2021

Hospital Pediatrics

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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, weightbased approaches may lead to improved resource use.

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Section: Discussionmentioning

confidence: 99%

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

Willer

Johnson

Cipriano

et al. 2021

Hospital Pediatrics

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“…Despite these beneficial effects of HHHFNC, it has not been recommended by international guidelines. Nevertheless, the data are still limited on using this modality in ED setting …”

Section: Introductionmentioning

confidence: 99%

Comparison of heated humidiﬁed high‐flow nasal cannula flow rates (1‐L·kg·min⁻¹ vs 2‐L·kg·min⁻¹) in the management of acute bronchiolitis

Yurtseven

Turan

Erseven

et al. 2019

Pediatric Pulmonology

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Objective We aimed to compare the heated humidiﬁed high‐ﬂow nasal cannula (HHHFNC) flow rate of 1‐L·kg·min−1 (1 L) with 2‐L·kg·min −1 (2 L) in patients with severe bronchiolitis presenting to the pediatric emergency department. Study design We performed a study in which all patients were allocated to receive these two flow rates. The primary outcome was admitted as treatment failure, which was defined as a clinical escalation in respiratory status. Secondary outcomes covered a decrease of respiratory rate (RR), heart rate (HR), the clinical respiratory score (CRS), rise of peripheral capillary oxygen saturation (SpO2), and rates of weaning, intubation, and intensive care unit (ICU) admission. Results One hundred and sixty‐eight cases (88 received the 1‐L flow rate and 80, the 2‐L flow rate) were included in the analyses. Treatment failure was 11.4% (10 of 88) in the 1‐L group, and 10% (8 of 80) in the 2‐L group (P = .775). Significant variation in the intubation rate or the ICU admission rate was not determined. At the 2nd hour, the rate of weaning (53.4% vs 35%; P = .017), the falling down of the CRS (−2.1 vs −1.5; P < .001), RR (−15.2 vs −11.8; P < .001), and HR (− 24.8 vs − 21.2; P < .001), and the increase of SpO 2 (4.8 vs 3.6; P < .001) were significantly more evident in the 1‐L group. Conclusion HHHFNC with the 1‐L·kg·min−1 flow rate, which provides a more frequent earlier effect, reached therapy success as high as the 2‐L·kg·min −1 flow rate in patients with severe acute bronchiolitis.

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“…Since then, single center observational studies examining the association between ward-based HFNC protocols and subsequent ICU utilization have come to discordant conclusions. [11][12][13][14] Studying the effect of employing HFNC outside of the ICU is challenging in the context of a randomized, controlled trial (RCT) because it is difficult to blind healthcare providers to the intervention and because crossover from the control group to HFNC is frequent. Two unblinded RCTs published in 2017 and 2018 found that children randomized to conventional nasal cannula were frequently escalated to HFNC (flow rates of 1-2 L/kg per minute), but neither trial found a difference in ICU admission.…”

mentioning

confidence: 99%

Intensive Care Unit Utilization After Adoption of a Ward‐Based High‐Flow Nasal Cannula Protocol

Coon

Stoddard

Brady

2020

Journal of Hospital Medicine

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BACKGROUND: Hospitals are increasingly adopting ward-based high-flow nasal cannula (HFNC) protocols that allow HFNC treatment of bronchiolitis outside of the intensive care unit (ICU). Our objective was to determine whether adoption of a ward-based HFNC protocol reduces ICU utilization. METHODS: We examined a retrospective cohort of infants aged 3 to 24 months hospitalized with bronchiolitis at hospitals in the Pediatric Health Information System database. The study exposure was adoption of a ward-based HFNC protocol, measured by direct contact with pediatric hospital medicine leaders at each hospital. All analyses utilized an interrupted time series approach. The primary analysis compared outcomes three respiratory seasons before and three respiratory seasons after HFNC adoption, among adopting hospitals. Supplementary analysis 1 mirrored the primary analysis with the exception that the first season after adoption was censored. In supplementary analysis 2, effects among nonadopting hospitals were subtracted from effects measured among adopting hospitals. RESULTS: Of 44 contacted hospitals, 41 replied (93% response rate), of which 18 were categorized as non-adopting hospitals and 12 were categorized as adopting hospitals. Included ward-based HFNC protocols were adopted between the 2010-2011 and 2015-2016 respiratory seasons. The primary analysis included 26,253 bronchiolitis encounters and measured immediate increases in the proportion of patients admitted to the ICU (absolute difference, 3.1%; 95% CI, 2.8%-3.4%) and ICU length of stay (absolute difference, 9.1 days per 100 patients; 95% CI, 5.1-13.2). Both supplementary analyses yielded similar findings. CONCLUSION: Early protocols for ward-based HFNC were paradoxically associated with increased ICU utilization.

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Humidified high-flow nasal cannula oxygen for bronchiolitis: should we go with the flow?

Cited by 13 publications

References 4 publications

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

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

Comparison of heated humidiﬁed high‐flow nasal cannula flow rates (1‐L·kg·min⁻¹ vs 2‐L·kg·min⁻¹) in the management of acute bronchiolitis

Intensive Care Unit Utilization After Adoption of a Ward‐Based High‐Flow Nasal Cannula Protocol

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Humidified high-flow nasal cannula oxygen for bronchiolitis: should we go with the flow?

Cited by 13 publications

References 4 publications

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

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

Comparison of heated humidiﬁed high‐flow nasal cannula flow rates (1‐L·kg·min−1 vs 2‐L·kg·min−1) in the management of acute bronchiolitis

Intensive Care Unit Utilization After Adoption of a Ward‐Based High‐Flow Nasal Cannula Protocol

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Comparison of heated humidiﬁed high‐flow nasal cannula flow rates (1‐L·kg·min⁻¹ vs 2‐L·kg·min⁻¹) in the management of acute bronchiolitis