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Updated: Dec 9, 2025
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Published on: January 17, 2011
Implementation of a High-Flow Nasal Cannula Management Protocol in the Pediatric ICU
Rachel J Peterson1, Daniel O Hassumani2, Acrista J Hole3
1Department of Pediatrics, Division of Hospital Medicine, Indiana University School of Medicine and Riley Hospital for Children at IU Health, Indianapolis, Indiana. rjdodge@iu.edu.
Insights
A respiratory therapist-driven protocol for high-flow nasal cannula (HFNC) therapy in pediatric intensive care units (PICUs) reduced HFNC duration and length of stay. This quality improvement initiative enhanced respiratory therapist job satisfaction.
Area of Science:
- Pediatric critical care medicine
- Respiratory therapy
- Quality improvement in healthcare
Background:
- High-flow nasal cannula (HFNC) therapy is widely used for pediatric bronchiolitis.
- Lack of standardized protocols for HFNC initiation, escalation, and weaning exists in pediatric ICUs.
- A quality improvement project aimed to reduce HFNC duration using a respiratory therapist-driven protocol.
Purpose of the Study:
- To implement and evaluate an RT-driven HFNC management protocol.
- To decrease the duration of HFNC therapy in pediatric patients.
- To assess the impact on length of stay and other clinical outcomes.
Main Methods:
- An objective respiratory score-based HFNC protocol was implemented in a pediatric ICU.
- Pediatric patients under 2 years with bronchiolitis receiving HFNC were included.
- HFNC duration was the primary outcome; noninvasive ventilation use, intubation rates, and RT satisfaction were secondary measures.
Main Results:
- Protocol compliance exceeded 80% after 4 months.
- Average HFNC duration decreased from 2.5 to 1.8 days.
- Pediatric ICU and hospital length of stay significantly decreased.
- Noninvasive ventilation use and intubation rates remained unchanged.
- Respiratory therapists reported increased involvement and satisfaction.
Conclusions:
- An RT-driven HFNC protocol can be safely implemented in a pediatric ICU.
- The protocol effectively reduces HFNC duration and length of stay.
- Empowering RTs improves their job satisfaction and optimizes patient care.
Background:
High-flow nasal cannula (HFNC) therapy is a respiratory modality that has been adopted to support pediatric patients with bronchiolitis. There is no standardized protocol for initiation, escalation, or weaning of HFNC in the pediatric ICU. The aim of this respiratory therapist (RT)-driven quality improvement management protocol was to decrease duration of HFNC.
Methods:
An RT-driven HFNC management protocol based on an objective respiratory score was implemented in 2017 at a quaternary care children's hospital. Subjects included children less than 2 y old admitted to the pediatric ICU with bronchiolitis. All subjects needing HFNC were scored and placed within the protocol as appropriate for age, then weaned or escalated per the scoring tool. Comparison to a pre-intervention control group was performed. Average HFNC duration per subject was used as the primary outcome measure. Protocol compliance was used as a process measure. Noninvasive ventilation use, intubation rate, and 30-d pediatric ICU readmission rate were used as balancing measures. RT satisfaction with HFNC management before and after protocol implementation were measured.
Results:
Protocol compliance was sustainable and above the goal of 80% after 4 months of protocol implementation. HFNC duration decreased from 2.5 d to 2 days for each subject during planning and then to 1.8 d after protocol implementation. Length of stay (LOS) in the pediatric ICU and hospital LOS decreased from 2.6 d to 2.1 d and from 5.7 d to 4.7 d after protocol implementation, respectively. The use of noninvasive ventilation and the rate of intubation did not change significantly. RTs reported increased involvement in HFNC management decisions and appropriateness on how quickly the team weaned HFNC.
Conclusions:
An RT-driven HFNC management protocol was safely implemented in a pediatric ICU and decreased HFNC duration, pediatric ICU LOS, and hospital LOS. It allows the RT to work independently to the highest extent of their scope of practice, leading to improvement in RT job satisfaction.
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