114 - Impact of High-Flow Nasal Cannula (HFNC) Weight-Based Guidelines on Initial Flow Rates, Escalation of Care, and Length of Stay in Infants with Bronchiolitis

Publication Number: 114.5415

Brooke E. Wilson, University of Texas Southwestern Medical School, Fort Worth, TX, United States; Amy Y. Cheng, University of Texas Southwestern Medical School, Dallas, TX, United States; Mohamed Badawy, University of Texas Southwestern Medical School, Dallas, TX, United States; Mia Maamari, University of Texas Southwestern Medical School, Dallas, TX, United States

Background: High-flow nasal cannula (HFNC) therapy is a standard supportive treatment for pediatric patients in respiratory distress from bronchiolitis; however, the initial flow rate has not been standardized. Recently, our hospital implemented weight-based flow guidelines for the hospital ward’s Acute Care Service (ACS), increasing the flow rate that can be managed outside of the Pediatric Intensive Care Unit (PICU).

Objective: To determine the impact of HFNC weight-based flow guidelines on initial flow rates in the Emergency Department (ED), escalation of care from ACS to PICU, and overall hospital length of stay (LOS) for infants hospitalized with bronchiolitis.

Design/Methods: A single-center observational cohort study was conducted via retrospective chart review, reviewing patients less than 12 months diagnosed with bronchiolitis and receiving HFNC therapy (n=435). Data were collected across 2 different bronchiolitis seasons, the pre- (n=145; 6/2021-8/2021) and post-(n=150; 10/2023-12/2023) implementation periods of the guidelines.

Results: The average initial flow rate was significantly higher in the post implementation cohort (0.70 L/kg/min pre, 0.87 L/kg/min post, p< 0.001). Similarly, the flow rate immediately prior to admission from the ED increased from 0.76 L/kg/min to 1.03 L/kg/min after guideline implementation (p < 0.001).

The guideline changes significantly reduced the need for escalation of care to the PICU after admission (from 9.7% pre to 2.7% post, p=0.016), and reduced the average hospital LOS from 3.47 days to 2.45 days (p=0.015). There was no significant difference in the number of patients who failed HFNC therapy (required BiPAP, CPAP, NIPPV, or intubation) in the pre- and post-implementation cohorts (6.9% pre and 2.0% post, p=0.790).

Conclusion(s): The introduction of new HFNC weight-based guidelines resulted in an increase in initial flow rate in the ED, reduced escalation of care to the PICU after admission, and decreased total LOS. This suggests the guidelines were appropriately adopted by clinical staff at our hospital and were both safe and effective. By starting HFNC therapy at a higher flow rate in the ED, escalation of care was minimized, and patients were discharged home in less time than before the guideline implementation. A larger patient sample size will be needed to show significance in the reduction of HFNC failure rates between cohorts. Overall, ACS floors can now manage higher flow rates using the weight-based guidelines, leading to more appropriate and timely interventions.

Impact of HFNC guideline implementation on flow rates, ICU admissions, failure rates, and LOS.
HFNC was initiated at higher flow rates in the post-guideline implementation cohort compared to the pre-guideline implementation cohort, suggesting successful adoption of the guidelines by clinical staff. There was a reduction in the percentage of patients directly admitted to the ICU, as well as the percentage of patients that failed HFNC therapy, but sample size limited the significance of these changes. Fewer patients were escalated to the ICU after initial admission to the floor, and overall LOS was significantly reduced.