Optimizing High-Flow Nasal Cannula Weaning in Patients With Bronchiolitis

There is significant variation in published weaning strategies for patients with bronchiolitis on high-flow nasal cannula (HFNC). We studied how modifying the weaning arm of an HFNC pathway impacted HFNC duration and hospital length of stay (LOS), with a goal of a 20% reduction in both.

Patients were younger than 24 months with a primary diagnosis of bronchiolitis. They were admitted to an intermediate care unit and intensive care unit at a children's hospital and placed on HFNC during the baseline and intervention phases (December 2018 to November 2019 and January 2020 to April 2023, respectively). We iteratively modified an HFNC pathway's weaning arm in intervention phases 1 to 3 to accelerate weaning, ultimately recommending a 1 L/kg/min flow wean attempt every 4 hours.

A total of 642 children were included. The average HFNC duration decreased from 35.9 hours (Baseline phase) to 22.6 hours (Plan-Do-Study-Act [PDSA] 3 phase), meeting criteria for special cause variation following both PDSA cycle 1 and PDSA cycle 3 launches. We also met criteria for special cause variation with hospital LOS, which decreased from 101.7 hours to 76.5 hours from baseline to the intervention phases. There was no increase in the percentage of children who required noninvasive ventilation (NIV).

Optimizing an HFNC weaning strategy resulted in a shorter HFNC duration and hospital LOS in children with bronchiolitis on HFNC. At our institution, an aggressive HFNC weaning strategy of attempting to decrease flow by 1 L/kg/min every 4 hours effectively reduced HFNC duration without an increase in the percentage of children who required NIV.