High-flow nasal cannula safe outside of pediatric ICU, but may up length of stay
NASHVILLE, TENN. – Young children with acute bronchiolitis do not need to be admitted to the pediatric ICU for high-flow nasal cannula treatment of up to 6 L/min and 50% oxygen; it is safe to administer it on the floor, according to a review of 6,804 acute bronchiolitis cases in children younger than 2 years treated at the University of Texas Southwestern Medical Center, Dallas.
Use of high-flow nasal cannulas (HFNC) has increased dramatically in recent years at UT Southwestern and elsewhere. It soothes children and can rapidly improve breathing without the nasal edema and nose bleeds common with cooler, drier, 100% oxygen. At Southwestern, HFNC use on the pediatric wards increased from 5% of acute bronchiolitis cases in the September 2010 to April 2011 season to 60% in the 2015-2016 season. Use for bronchiolitis in the PICU increased from 82% to 98% over the same period.
Dr. Vineeta Mittal
The increase correlated with a drop in intubation for acute bronchiolitis from 14% of children in 2010-2011 to just 2% in 2015-2016. The only HFNC adverse events were minor air leaks in two children.
As HFNC became more common, however, the Dallas team found that length of stay for acute bronchiolitis increased from 1.8 days in 2011-2012 to 2.4 days in 2015-2016, perhaps because the use of HFNC gives providers the impression that children are sicker than they actually are.
To counter the problem, lead investigator Vineeta Mittal, MD, associate professor of pediatrics, and her colleagues created an HFNC weaning protocol that gradually steps down treatment based on blood oxygen saturation levels and breathing effort, leading ultimately to a room-air challenge. It helped; the mean length of stay as of November 2016 was 1.7 days.
There’s been pushback in some places about giving HFNC on the floor: Intensivists sometimes consider it a form of ventilation that should be administered in the PICU. At levels up to 6 L/min and 50% oxygen, though, HFNC is “safe to give on the floor, because there’s no pneumothorax risk,” Dr. Mittal explained. HFNC “is not a ventilator; it’s an effective form of noninvasive respiratory support in children with moderate to severe respiratory distress from bronchiolitis.”
At Southwestern, “we are managing 80% of cases on the floor” with the help of HFNC, Dr. Mittal said at Pediatric Hospital Medicine.
At least for now, children at Southwestern go to the PICU if they need higher flow rates, but Dr. Mittal said it’s not clear if that’s necessary. “We said [6 L/min] is safe,” but maybe “we could even use 8 L/min or even 12 L/min” – the maximum delivered in the PICU over the study period – “because we know it’s safe,” she said. In addition, keeping kids on the floor also saves money, she noted at the meeting, which was sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.
Dr. Mittal is concerned HFNC might be overused. “We have gotten so used to this machine that the moment we see distress, we put the kid on high flow,” rather than observing them for a bit to see if they recover on their own. More data are needed to determine when HFNC should be initiated, and when to pull the plug on HFNC and intubate, she said.
Dr. Mittal had no disclosures.
