Furthermore, a large proportion of patients (>70%) randomized to LFNC were successfully managed without need for escalation to HFNC. Patients who did require escalation from LFNC to HFNC were safely rescued without an increase in ICU transfers or adverse events. These findings suggest that indiscriminate early – or routine – use of HFNC for moderate bronchiolitis does not provide clinical benefit.

In an effort to provide evidenced based and high value care, the Scottish Rite Emergency Department and Pediatric Hospital Medicine service are participating in an American Academy of Pediatrics national quality improvement collaborative to reduce the overutilization of HFNC in the treatment of mild-to-moderate bronchiolitis. Importantly, all bronchiolitis care will continue to be dictated by the treatment team, and patients who arrive in extremis or with a severe clinical respiratory score will continue to be managed with HFNC, noninvasive, or invasive mechanical ventilation as indicated. 

Some bronchiolitis patients admitted to the hospital, regardless of whether they received HFNC, will require nasogastric tube feedings at discharge due to inadequate oral intake and/or aspiration risk. This is particularly true for patients who required intubation and/or those with underlying comorbidities such as prematurity, hypotonia, developmental delay, hemodynamically significant cardiac disease, and chronic lung disease. Patients discharged with tube feedings due to inadequate intake often improve rapidly at home and are counseled to have the tube removed at home or by their primary care physician. Those with concerns for aspiration typically have an outpatient Speech Language Pathology visit about two weeks after discharge to determine whether tube feeding is still indicated.

Additional discharge instructions often include smaller but more frequent feeds while still congested and taking less by mouth, suctioning prior to feeds (e.g., saline drops and nasal aspirator), avoiding aggressive suctioning to prevent nasal trauma and edema, reassurance that coughing may continue for up to two weeks and cough medicines are not indicated, and emphasizing attentive hand washing to reduce viral transmission.

Dr. Courtney Charvat is a Pediatric Hospitalist at CHOA Egleston and co-leader of the national quality improvement collaborative, entitled “HI-FLO: High flow Interventions to Facilitate Less Overuse”. The project is run by the Value in Inpatient Pediatrics (VIP) Network within the American Academy of Pediatrics and includes 85 participating hospitals from the United States and Canada. 

Dr. Abby Williams is a Pediatric Emergency Medicine physician at CHOA Scottish Rite and is the local site leader for the HI-FLO quality improvement project.

References

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2. Coon ER, Stoddard G, Brady PW. Intensive Care Unit Utilization After Adoption of a Ward-Based High-Flow Nasal Cannula Protocol. J Hosp Med. 2020;15(6):325-330. doi:10.12788/jhm.3417
3. Garland H, Gunz AC, Miller MR, Lim RK. High-flow nasal cannula implementation has not reduced intubation rates for bronchiolitis in Canada. Pediatrics & Child Health. 2020;1-5. doi:10.1093/pch/pxaa023 
4. Fujiogi, M., Goto, T., Yasunaga, H., Fujishiro, J., Mansbach, J. M., Camargo, C. A., Jr, & Hasegawa, K. (2019). Trends in Bronchiolitis Hospitalizations in the United States: 2000-2016. Pediatrics. 2019;144(6), e20192614.
5. Kalburgi S, Halley T. High-Flow Nasal Cannula Use Outside of the ICU Setting. Pediatrics. 2020;146(5):e20194083. doi:10.1542/peds.2019-4083
6. Pelletier JH, Au AK, Fuhrman D, et al. Trends in Bronchiolitis ICU Admissions and Ventilation Practices: 2010-2019. Pediatrics. 2021;147(6):e2020039115
7. Durand P, Guiddir T, Kyheng C, et al. A randomized trial of high-flow nasal cannula in infants with moderate bronchiolitis. Eur Respir J. 2020 Jul 16;56(1):1901926
8. Franklin D, Babl FE, Schlapbach LJ, Oakley E, Craig S, Neutze J, Furyk J, Fraser JF, Jones M, Whitty JA, Dalziel SR, Schibler A. A Randomized Trial of High-Flow Oxygen Therapy in Infants with Bronchiolitis. N Engl J Med. 2018 Mar 22;378(12):1121-1131. doi: 10.1056/NEJMoa1714855. PMID: 29562151.
9. Kepreotes E, Whitehead B, Attia J, Oldmeadow C, Collison A, Searles A, Goddard B, Hilton J, Lee M, Mattes J. High-flow warm humidified oxygen versus standard low-flow nasal cannula oxygen for moderate bronchiolitis (HFWHO RCT): an open, phase 4, randomised controlled trial. Lancet. 2017 Mar 4;389(10072):930-939.
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Planning Committee

Kiesha Fraser Doh, MD

Thuy Bui, MD

Anthony Cooley, MD

Ashley Izydore Euler, CMP

Stacy Anderson

Faculty

Courtney Charvat, MD

Abby Williams, MD

Angela Costa, MD

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