Ward Weight-based High Flow Nasal Cannula Treatment

Source: Willer RJ , Brady PW , Tyler AN , et al . Transition to weight-based high-flow nasal cannula use outside of the ICU for bronchiolitis. JAMA Netw Open. 2024;7(3):e242722.Investigators from multiple institutions conducted an interrupted time series study to assess the association between hospital policy shift from ICU-only administration of high flow nasal cannula (HFNC) treatment for children with bronchiolitis to non-ICU ward, weight-based HFNC on rate of ICU admission. Study data were abstracted from the Pediatric Health Information Systems (PHIS) database that includes demographics, diagnostic and procedural codes, and pharmacy data from children’s hospitals in North America. Information regarding hospital policy regarding use of HFNC for patients with bronchiolitis and transition from ICU-only to ward weight-based HFNC treatment was obtained from a 2021 survey on this topic. Based on the survey results, hospitals were classified as continuing ICU-only HFNC treatment or transitioning to ward weight-based HFNC. For those hospitals that had a change in policy, the data of transition was noted.Study participants were children <24 months old with an ICD-9 or ICD-10 code for bronchiolitis admitted to 1 of 18 hospitals between 2010 and 2021 that contributed data to the PHIS database and whose policy on HFNC use had been collected in the 2021 survey. In 8 participating hospitals, a policy of transition to ward weight-based HFNC treatment had been implemented, and at 10 sites, HFNC treatment for bronchiolitis remained ICU-only. The transition point, ie, date, to ward weight-based HFNC treatment was recorded for hospitals with a change in policy. In those sites, the change in proportion of patients with bronchiolitis admitted to the ICU in the 3 years before and 3 years after the transition point was determined. For hospitals retaining an ICU-only HFNC policy, a “transition point” date was established by matching to a hospital on location and size that changed policy and using that hospital’s transition point. Outcomes before and after this “transition point” in the hospitals with an ICU-only policy also were calculated. Mixed effects regression was used to compare changes in outcomes for patients treated in hospitals that retained an ICU-only HFNC policy and those transitioning to ward weight-based HFNC, after controlling for confounders.Data were analyzed on 86,046 children with bronchiolitis, including 47,336 at ICU-only and 38,710 at ward weight-based HFNC hospitals. For patients treated at ward weight-based ICU hospitals, there was a 4.2% reduction per year in ICU admission after the transition point, compared to a 1.8% increase per year for those treated at an ICU-only site. In the multivariate analysis, there was a 6.1% (95% confidence interval [CI], 3.4, 8.7) decrease in ICU admissions per year at ward weight-based HFNC sites compared to ICU-only hospitals.The authors conclude that the transition to a hospital policy for treating patients with bronchiolitis from ICU-only HFNC to ward weight-based HFNC treatment was associated with reduced ICU admission rates.Dr Loyal has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Most hospitalized children with bronchiolitis are safely managed on inpatient units with supportive care. Historically, children with worsening respiratory status that is non-responsive to conventional low-flow oxygen delivery have been admitted to the ICU for increasing respiratory support in the form of HFNC or CPAP.1 Oxygen delivery via HFNC is humidified, heated, and blended, allowing for higher flow rates and more comfortable delivery of oxygen to improve ventilation.1 As reported in the current study, over the past decade an increasing number of children’s hospitals have expanded the usage of HFNC to pediatric inpatient units. More hospitals are utilizing weight-based HFNC protocols, and as a result, ICU admission rates have decreased.An exceptional surge of RSV bronchiolitis in 2022 resulted in markedly increased hospital volumes and stress on bed capacity.2 Expanding the use of HFNC to the inpatient units was practical to relieve bed capacity issues and cost; although, of 18 children’s hospitals included in the current study, 10 still restricted the use to the ICU setting only. There were no significant changes in LOS or invasive mechanical ventilation (IMV), but notably, an increase in overall non-invasive positive pressure ventilation (NIPPV) use, which speaks to the potential unintended consequences of this shift. Are children with bronchiolitis sicker than before, or are we initiating HFNC too soon on the inpatient units and the next natural step in escalation once in the ICU is NIPPV? Although the use of HFNC outside of the ICU setting results in reduced admissions to the ICU, the dial may have shifted too far on the inpatient units without clear evidence of benefit.3 (See AAP Grand Rounds. 2023;49[1]:6.)4The current study cohort includes patients admitted to children’s hospitals who participate in the PHIS administrative database, and the authors acknowledge the limitations of an administrative data set. Outside of increasingly regionalized inpatient pediatric care in the US, some community hospitals without an ICU can initiate HFNC. It would be interesting to know if these capabilities result in fewer hospital transfers and safely keep children and families more local.Weight-based non-ICU HFNC use is associated with decreased ICU admissions among hospitalized patients with bronchiolitis in children’s hospitals.