High Flow Nasal Cannula

(HFNC)
in Bronchiolitis:
Managing Care Outside
the ICU

Wednesday, November 2, 2022

11 a.m.
Faculty

• Estevan Garcia, MD, DPH, MPA, FAAP, Chief Medical

Officer, Massachusetts Department of Public Health
• Alla Smith, MD, Attending Physician, Division of Medical
Critical Care, Boston Children's Hospital
Key Objectives

The webinar is tailored to clinicians who are managing patients with bronchiolitis
on HFNC outside the ICU – in both community hospitals and sites where there may
be a pediatric ICU that is currently at capacity.

Participants should expect to achieve the following learning objectives through

this webinar:
• Summarize the physiologic mechanism for HFNC in bronchiolitis;
• Identify patients with bronchiolitis who may benefit from HFNC;
• Discuss a weight-based approach for initiation, escalation, and weaning of
HFNC; and
• Assess how a pathway for management of HFNC in bronchiolitis might be
implemented in your health system
HFNC in Bronchiolitis:
Managing Care Outside the ICU
Alla Smith, 11/2/2022
High Flow Nasal Cannula Pathway

HFNC in Bronchiolitis Pathway guides management of

patients with bronchiolitis on HFNC using optimal flows
and incorporates aggressive weaning.

Goal:
 Bring this pathway back to your facility- adapt it to that
environment
 Improve staff comfort with this patient population
 Shorten duration of critical illness/time on HFNC
HFNC: What is it?
 Heated, humidified air with titratable FiO2 (0.21 to 1),
typically delivered at flows >4L/minute
 HFNC: How does it help?

 Allows for effective dead space wash-out1

 Humidifies airways, which assists with secretion clearance1
 Provides (small) PEEP in patients with bronchiolitis1
 Improves tachypnea and dyspnea in patients with bronchiolitis2

1. Milési, C., Baleine, J., Matecki, S., Durand, S., Combes, C., Novais, A. R. B., & Combonie, G. (2013). Is treatment with a high flow
nasal cannula effective in acute viral bronchiolitis? A physiologic study. Intensive Care Medicine, 39(6), 1088–1094.

2. Rubin, S., Ghuman, A., Deakers, T., Khemani, R., Ross, P., & Newth, C. J. (2014). Effort of Breathing in Children Receiving High-
Flow Nasal Cannula. Pediatric Critical Care Medicine, 15(1), 1–6.
HFNC: Who should get it?

 Hospitalized patients with moderate to severe

bronchiolitis who have failed standard therapies3

 Patients with bronchiolitis (<2yo) who have

 Hypoxia requiring >2L/minute LFNC
OR
 Persistent moderate to severe dyspnea or tachypnea

3. O’Brien, S. et al. ‘Rational use of high‐flow therapy in infants with bronchiolitis. What do the latest trials tell us?’ A
Paediatric Research in Emergency Departments International Collaborative perspective. J Paediatr Child H 55, 746–752
(2019)
 HFNC: What flows are best?

 Most pediatric inpatient units in US use fixed liter limit

flows that are low (<8LPM)4
 Weight-Based Flows
 2L/kg/minute are optimal5

4. Kalburgi, S. & Halley, T. High-Flow Nasal Cannula Use Outside of the ICU Setting. Pediatrics 146, e20194083 (2020)

5. Milési C, Pierre AF, Deho A, et al. A multicenter randomized controlled trial of a 3-L/kg/min versus 2-L/kg/min high-flow
nasal cannula flow rate in young infants with severe viral bronchiolitis (TRAMONTANE 2). Intens Care Med.
2018;44(11):1870-1878
HFNC: Weaning is Important

 Higher flows are associated with longer LOS5

 Aggressive weaning protocols can shorten LOS6
 Regularly turn down flows and assess how patients respond

5. Milési C, Pierre AF, Deho A, et al. A multicenter randomized controlled trial of a 3-L/kg/min versus 2-L/kg/min high-flow nasal
cannula flow rate in young infants with severe viral bronchiolitis (TRAMONTANE 2). Intens Care Med. 2018;44(11):1870-1878.
doi:10.1007/s00134-018-5343-1

6. Sokuri P, Heikkilä P, Korppi M. National high‐flow nasal cannula and bronchiolitis survey highlights need for further research and
evidence‐based guidelines. Acta Paediatr. 2017;106(12):1998-2003. doi:10.1111/apa.13964
HFNC: What to do when it fails
 Some studies suggest reduction in ICU need- but a
proportion of children on HFNC (15-50%) will require ICU
transfer7-11
 Building in institution-specific transfer criteria is key to
pathway success
 NIV with CPAP or BIPAP is a reasonable next step for most
patients

7. Franklin, D., Babl, F. E., Schlapbach, L. J., Oakley, E., Craig, S., Neutze, J., et al. (2018). A Randomized Trial of High-
Flow Oxygen Therapy in Infants with Bronchiolitis. The New England Journal of Medicine, 378(12), 1121–1131

8. Willer, R. J. et al. Implementation of a Weight-Based High-Flow Nasal Cannula Protocol for Children With
Bronchiolitis. Hosp Pediatrics 11, 891–895 (2021)

9. Kepreotes, E., Whitehead, B., Attia, J., Oldmeadow, C., Collison, A., Searles, A., et al. (2017). High-flow warm
humidified oxygen versus standard low-flow nasal cannula oxygen for moderate bronchiolitis (HFWHO RCT): an open, phase
4, randomised controlled trial. The Lancet, 389(10072), 930–939

10. Mayfield, S., Bogossian, F., O'Malley, L., & Schibler, A. (2014). High-flow nasal cannula oxygen therapy for infants with
bronchiolitis: Pilot study. Journal of Paediatrics and Child Health, 50(5), 373–378

11. Clayton, J. A., McKee, B., Slain, K. N., Rotta, A. T., & Shein, S. L. (2019). Outcomes of Children With Bronchiolitis
Treated With High-Flow Nasal Cannula or Noninvasive Positive Pressure Ventilation. Pediatric Critical Care Medicine, 20(2),
128–135.
HFNC Pathway at a Community Hospital
Average Hours on HFNC and LOS by Arm Group
90
Standard HFNC Arm 77.4
80
Weight-Based HFNC Arm
70

60
50.6

50
Hours

40.1

40

30
24.0

20

10

0
HFNC (hours) LOS (hours)
p <0.001 p <0.001
HFNC Pathway at BCH
Compared with Standard Practice at BCH:
 Reduction in Time on HFNC
 Reduction in Hospital and Critical Care LOS
 Decrease in the percentage of patients who require
escalation to NIV or IMV*
*preliminary data
HFNC: What are the risks?

 Minimal.
 Risk of air leak is very low, even when using higher flows
 Recent large (~1500) patient RCT did not demonstrate any air
leak7

7. Franklin,
D., Babl, F. E., Schlapbach, L. J., Oakley, E., Craig, S., Neutze, J., et al. (2018). A Randomized Trial of
High-Flow Oxygen Therapy in Infants with Bronchiolitis. The New England Journal of Medicine, 378(12), 1121–1131
HFNC Pathway: RN/RT Staffing
 HFNC does not obviate or reduce the need for RN and
RT support
 Patients generally staffed at 1:2 to 1:3 for nursing
 RT supports vary- but they are often involved in
assessments/flow changes
PIMCU Network
 Interested in high-acuity care outside the ICU?
 Join the PIMCU Network! Email me or the network
administrator* for an invitation to the group’s website.
Post questions/share pathways etc. Over 150 members
nationally
 Join the new AAP Sub-committee on Pediatric
Intermediate Care (under SOHM and SOCC)

* alla.smith@childrens.harvard.edu or peter.hopkins@childrens.Harvard.edu
 Acknowledgements

 Network Team  BCH Team

 Debra Banville  Michael Agus
 Mark Waltzman  Christiana Russ
 Karen Gruskin  Elyse Jones
 Jesslyn Lenox  Daria Donelly

And many others!

High Flow Nasal Cannula- trends

 Fujiogi, M. et al. Trends in Bronchiolitis Hospitalizations in the United States:

2000–2016. Pediatrics 144, e20192614 (2019).
 Updated: 4/27 v12

HFNC Study: Weight Based Protocol

Initiate HFNC @ Initial 1 lpm/kg and 21% Oxygen

TRANSFER CRITERIA:
HR: unchanged or
Does the patient have a BASS increased, compared with
score of mild bronchiolitis after HR at HFNC initiation.
2 hours?* RR: unchanged or
increased, compared with
RR at HFNC initiation.
YES NO WOB: unchanged or
increased, compared with
MAINTAIN: WOB at HFNC initiation.
Initiate 4 hours of observation Oxygen requirement >40%
to maintain SpO2 >90%
* Consider earlier transfer in the
setting of sustained clinical
Consider wean
Already on max YES worsening on maximum flow.
after 4 hours.
settings?

NO

Escalation to
ESCALATE:
Moderate or Severe
YES Increase to max flow rate.
Bronchiolitis @ any
Maintain SpO2 >90%
time?

NO
NO
Wean FiO2:
Wean FiO2 to 21% over 2 hours. At 4 hours,
YES CONSIDER
(If already on 21% go directly to 3 of the 4 Transfer
TRANSFER
wean flow.) Criteria* are met?

Return to previous
21%
FiO2 to maintain
With SpO2 NO
SpO2 >90%.
>90%
Monitor x2 hours
YES

Wean Flow:
Cut flow in half
Monitor x2 hours.

Patient
breathing Return to
comfortably with NO previous flow
SpO2 Monitor x2 hours
>90%

Yes
Remove
* consider escalating sooner if patient is decompensating
 3/5 v4

Standard Pediatric HFNC

Initiate HFNC @ Initial 4 lpm and FiO2 to maintain SpO2 >92%

Patient exhibits
decreased WOB and stable
SpO2>92%?

YES NO

After a period of stability, begin wean. Increase flow to a max of 8 lpm

Decrease FiO2 by 10% down to 30% as and FiO2 to max 60% as
tolerated to maintain SpO2 >92% needed to reduce WOB and
maintain SpO2 >92%

Return to previous
Patient stable
NO settings and
on 30%?
monitor. YES Patient Improved??

YES

Decrease flow rate NO

as tolerated down to 1 lpm.

Transfer

SpO2 >92% and Return to previous

stable WOB on NO settings and
1 lpm ? monitor .

YES

Remove
Follow Up & Next Steps

• Patricia Noga, PhD, RN, MBA, NEA-BC, FAAN, Vice

President, Clinical Affairs, MHA
– pnoga@mhalink.org

• Adam Delmolino, Director, Virtual Care & Clinical Affairs,

MHA
– adelmolino@mhalink.org

• Steve Defossez, MD, EMHL, CPE, Vice President, Clinical

Integration, MHA
– sdefossez@mhalink.org