Decreasing Inappropriate Supplemental Oxygen With High-Flow Nasal Cannula for Bronchiolitis

Bronchiolitis is a leading cause of pediatric hospitalization. Treatment focuses on supportive care including supplemental oxygen for hypoxemia. High-flow nasal cannula (HFNC) has emerged as a modality to provide respiratory support with or without supplemental oxygen. At a freestanding children's hospital, inappropriate supplemental oxygen was frequently used. This study aimed to decrease the proportion of patients started on supplemental oxygen without documented hypoxemia from ∼90% to <70% and the proportion of patients weaned from HFNC without supplemental oxygen to nasal cannula with supplemental oxygen from ∼23% to <10%.

A multidisciplinary taskforce was convened to develop an evidence-based protocol for HFNC usage. Data collection was obtained among patients aged <2 years admitted with bronchiolitis from September 2018 to September 2021. Institution-wide protocol changes occurred in November 2019 and October 2020, with ongoing education and evaluation. Data were summarized using statistical process control charts.

Following implementation of a revised protocol in October 2020, the percentage of patients without documented hypoxemia (defined as an oxygen saturation <90% on pulse oximetry) who were inappropriately started on supplemental oxygen decreased from a baseline of 90.2% to 57.2%. At the same time, the percentage of patients weaned from HFNC without nasal cannula oxygen decreased from a baseline of 23.1% to 4.7%.

Using supplemental oxygen in the absence of hypoxemia in bronchiolitis is an example of low-value care. Implementation of focused, standardized protocols with concurrent education can feasibly decrease inappropriate and unnecessary use of supplemental oxygen in children with bronchiolitis.