Outcomes and Protocol Overview: High Flow Nasal Cannula Use in Bronchiolitis in Acute Care and ED

In March 2018, Kline and colleagues published a literature review in Clinical Pediatric Emergency Medicine titled “High Flow Nasal Cannula Therapy in Bronchiolitis Across the Emergency Department and Acute Care Floor.” Given the increased prevalence of High Flow Nasal Cannula (HFNC) use on bronchiolitis patients, the authors set out to review existing studies on the efficacy of this modality as well as its use in acute care settings.[1]

HFNC May Reduce Intubations of Bronchiolitis Patients

A prospective pilot study and a few retrospective studies included in the literature review all suggest that HFNC use may decrease risk of intubation for bronchiolitis patients. These results were most prevalent in children with acute bronchiolitis without comorbidities, and without high initial pCO2.

Markers to Identify Efficacy in of HFNC Therapy

The authors note that HFNC has been demonstrated to be safe, but that the question of how to best measure its clinical efficacy is still unanswered. Based on two studies reviewed, they suggest that decreased respiratory scores are indicative of efficacy, while increasing respiratory scores appear to be predictive of HFNC failure in patients with bronchiolitis.Regarding markers for effective HFNC weaning, the authors note that it is a very sparsely studied subject, but they do highlight a “holiday” weaning protocol published by a group at Emory University. The protocol calls for assessing patient symptoms, such as nasal flaring, chest movement, etc. to create a score to determine weaning initiation.

Flow Rate Protocols from Seven Different Hospitals

There is no clear consensus for flow rates when using HFNC on pediatric patients. The authors looked at protocols from seven different hospitals that provided their maximum flow rates in relation to patient age. Those maximum rate ranges are as follows:

Summary of Age-Based Maximum Flow Ranges from Seven Pediatric Inpatient Floor Protocols

Patient AgeMaximum Flow Range
Less than 6 months4-8 LPM
6-12 months8-12 LPM
12-18 months10-12 LPM
18-24 months10-15 LPM

Most of the hospitals that provided protocols cut off their age indicator at 24 months, except for Intermountain Healthcare in Salt Lake City, UT, which listed a maximum of 10 LPM for patients >12-36 months.Two more hospitals indicated weight as the determining factor for HFNC flow selection. Dell Children’s in Austin, TX stated 6 LPM for patients under 7kg, 8 LPM for 7-9 kg, and 10 LPM for patients over 9kg. Children’s Hospital of Omaha, on the other hand, stated 2 LPM per kilogram of the patient’s weight. So, by comparison, they would administer 18 LPM to a 9kg patient, whereas Dell Children’s would administer 10 LPM.These protocols illustrate that there is a very wide range of practice when it comes to flow rate selection in pediatrics.

Learn more about pediatric HFNC best practices

[1] Kline, Jaclyn, Sonal Kalburgi, Tina Halley. High Flow Nasal Cannula Therapy for Bronchiolitis Across the Emergency Department and Acute Care Floor. Clinical Pediatric Emergency Medicine Volume 19, Issue 1, March 2018, Pages 40-45. https://doi.org/10.1016/j.cpem.2018.02.001

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