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Liberalizing Maximum High-Flow Nasal Cannula Flow Rates in the General Inpatient Ward Is Associated With Decreased
Chris Miller1, Michelle Dunn2, Jeremy Jones1,2
1Division of Pediatric Emergency Medicine.
Insights
Increasing high-flow nasal cannula (HFNC) oxygen rates in inpatient wards reduced intensive care admissions for infants with bronchiolitis. This policy change appears safe, without increasing care escalation or length of stay.
Area of Science:
- Pediatrics
- Respiratory Medicine
- Critical Care Medicine
Background:
- Bronchiolitis is a common pediatric respiratory infection.
- High-flow nasal cannula (HFNC) oxygen therapy is increasingly used for infants with bronchiolitis.
- Previous guidelines limited HFNC flow rates in inpatient (IP) wards.
Purpose of the Study:
- To evaluate the impact of increased HFNC flow rate maximums on intensive care utilization in infants with bronchiolitis.
- To assess the safety of higher HFNC flow rates in the IP setting.
Main Methods:
- Retrospective pre-post cohort study at a tertiary care children's hospital.
- Included infants without complex chronic conditions presenting with bronchiolitis (2018-2020).
- Analyzed patient disposition, IP to pediatric intensive care unit (PICU) transfer, care escalation, and hospital length of stay before and after a policy change increasing allowable HFNC flow rates to 2 L/min/kg on IP wards.
Main Results:
- No significant increase in overall hospital admission rates after adjusting for confounders.
- A significant reduction in PICU admissions was observed.
- No increase in the risk of IP-to-PICU transfer, care escalation, or hospital length of stay.
Conclusions:
- Increasing HFNC flow rates to 2 L/min/kg on IP wards is associated with decreased intensive care admissions for infants with bronchiolitis.
- The policy change appears safe, as evidenced by stable rates of care escalation and length of stay.
Objective:
To compare the use of intensive care for infants with bronchiolitis following a policy change increasing the rate maximums for high-flow oxygen given by nasal cannula [high-flow nasal cannula (HFNC)] allowable in the inpatient (IP) ward setting.
Methods:
This was a retrospective pre-post cohort study at an urban, tertiary care children's hospital. Infants without complex chronic conditions presenting to the emergency department with bronchiolitis from December 2018 to March 2019 and December 2019 to March 2020 were included in the study. In December 2019, our institution increased the allowable HFNC flow rate on IP to 2 liters per minute/kilogram. The primary outcome was patient disposition from the emergency department. Secondary outcomes were the need for IP to pediatric intensive care unit (PICU) transfer, the need for care escalation to positive airway pressure or invasive mechanical ventilation, and hospital length of stay.
Results:
In total, 1043 and 1104 patients were included in the 2018 to 2019 and 2019 to 2020 cohorts, respectively. Infants in the second cohort were more likely to be admitted, though this association was not significant after adjusting for patient age and triage acuity. Infants in the second cohort had a lower risk of admission to the PICU, before and after adjusting for age and triage acuity. The risk of IP-to-PICU transfer, risk of care escalation, and length of stay did not increase.
Conclusions:
Increasing HFNC flow rates up to 2 liters per minute/kilogram on IP wards was associated with a reduction in intensive care admission and appears safe by balancing measures of care escalation.
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