Association of high-flow nasal cannula (HFNC) therapy with intensive care unit admission and mechanical ventilation use in respiratory syncytial virus–positive bronchiolitis in pediatric patients: a retrospective single-center cohort study

High-flow nasal cannula (HFNC) therapy is increasingly used in pediatric patients with respiratory syncytial virus (RSV)–positive bronchiolitis to manage respiratory distress. Despite widespread adoption in both intensive care unit (ICU) and non-ICU settings, evidence regarding its impact on critical clinical outcomes remains inconsistent. This study aimed to evaluate the association between HFNC use and ICU admission and mechanical ventilation (MV) use in children with RSV-positive bronchiolitis. We conducted a retrospective cohort study of pediatric patients under two years of age admitted with polymerase chain reaction–confirmed RSV bronchiolitis at a tertiary care hospital in Palestine between January 2021 and December 2023. Patients receiving HFNC were compared with those managed using standard low-flow oxygen therapy. Primary outcomes were ICU admission and MV use. Secondary outcomes included co-infection rates, antibiotic use, laboratory and radiological findings, and markers of disease severity. Multivariable logistic regression models were used to identify independent predictors of ICU admission and MV, adjusting for age, HFNC use, chronic illness, co-infection, and C-reactive protein (CRP). A total of 712 patients were included. HFNC recipients were younger (mean age 4.07 vs. 7.48 months) and had a higher prevalence of chronic medical conditions compared with non-HFNC patients. In unadjusted analyses, HFNC use was associated with higher rates of ICU admission (16.1% vs. 6.5%; p = 0.006) and MV (14.5% vs. 5.7%; p = 0.007). Co-infection was strongly associated with ICU admission and MV (p < 0.001). In multivariable analysis, HFNC use was independently associated with lower odds of ICU admission (OR 0.393, 95% CI 0.174–0.885; p = 0.024) but was not significantly associated with MV (OR 0.445, 95% CI 0.187–1.055; p = 0.066). Increasing age was associated with higher odds of MV (OR 1.161, 95% CI 1.041–1.294; p = 0.007). CRP levels were not associated with either outcome. HFNC therapy was more frequently used in younger and higher-risk pediatric patients with RSV bronchiolitis. After adjustment for confounders, HFNC use was associated with lower odds of ICU admission but was not independently associated with MV.