Should the Pendulum Swing Back? More Transfers to the ICU After Implementing Ward-Based High-Flow Nasal Cannula Initiation Protocols for Bronchiolitis

Abstract

As an appealing, physiologically plausible treatment, humidified oxygen delivery via high-flow nasal cannula (HFNC) has been rapidly adopted for the treatment of bronchiolitis despite weak evidence supporting its routine and early use in hypoxemic infants.1 Although HFNC use has been associated with decreased work of breathing and lower rates of progression to invasive ventilation in some studies, the one large trial published on the topic found no difference between early HFNC and standard oxygen therapy on length of stay in hospital, duration of oxygen therapy, or rates of intubation.2,3 No adequately powered studies have examined the effect of ward-based HFNC initiation on ICU transfer, an outcome that it is designed to prevent.

De-escalation of High-flow Respiratory Support for Children Admitted with Bronchiolitis: A Quality Improvement Initiative

“…Several studies have demonstrated reduced LOS, 11 decreased rate of ICU admission, 12 and reduced intubation rate. 8–10,13 Other studies have demonstrated no improvement in intubation rate or LOS 14,15 and instead showed an increased ICU admission rate 14,15 and higher resource utilization. 16 These data suggest that HFNC has become over-utilized in some patients who will not benefit from it, likely due to a lack of clear criteria for initiation of HFNC.…”