Impact of Weight-Based High-Flow Nasal Cannula Flow Limits on Intensive Care Unit Utilization in Bronchiolitis

Background: High-flow nasal cannula (HFNC) is a common respiratory support device utilized in the management of children hospitalized with bronchiolitis. Early adoption in many pediatric wards was developed using age-based flow limits. However, age-based limits do not align with current evidence and potentially contribute to ICU admissions. To align with current evidence and improve ICU bed allocation, we implemented weight-based flow limits within our wards. The primary objective of this study was to evaluate the impact of these changes on ICU utilization. Methods: This retrospective study was conducted at Children's Medical Center in Plano, Texas, a free-standing, community-based hospital affiliated with an academic quaternary center. Subjects were patients < 2 years of age admitted for bronchiolitis and supported via HFNC in the 12 months before and after implementation of weight-based flow limits. Primary outcomes were ED disposition and ICU transfer rates. Secondary outcomes were evaluation of adverse respiratory events and stay. Results: A total of 1,207 subjects met inclusion criteria; 558 pre- and 649 post-implementation. There were no differences between groups in age, weight, or gender. Compared with the pre-implementation group, we observed an 8.6% absolute decrease in ICU admissions [92 (16.5%) vs 51 (7.9%), P < .001], a 3% absolute decrease in ward to ICU transfers [28 (6%) vs 19 (3%), P = .034], and no difference in escalation of respiratory support [6 (1.1%) vs 4 (0.6%), P = .38] or escalation within one hour of transfer [0 (0%) vs 2 (50%), P > .99]. Overall median stay decreased by 15.9 h in the post-implementation group, [59.4 (IQR 39.1- 85.9) vs 43.5 (IQR 26.9-67.2), P < .001]. Conclusions: These findings suggest that for hospital systems utilizing similar age-based HFNC flow limits, transitioning to weight-based flows, with safeguards in place, may improve ICU bed utilization while maintaining comparable patient outcomes.