Abstract
Background:
High velocity nasal insufflation (HiVNI) is used commonly in pediatric bronchiolitis patients in respiratory distress. The use of oxygen, of any kind, in this population can impact hospital length of stay (LOS). Our existing bronchiolitis pathway (BP), which promotes standardized care for these patients, was revised with the goal of more rapidly decreasing and discontinuing HiVNI while maintaining patient safety.
Methods:
A multi-disciplinary work group was formed and focused on reducing length of stay (LOS) and readmission rates for BP patients. Changes were made to our HiVNI weaning guidelines to aid in more rapid decrease and succinct removal of therapy (Table 1 and Image 1) . For BP patients on HiVNI after a 4-hour period of stability on HiVNI, the flow was dropped to the initial flow for two hours. If the patient remained without severe distress for the two-hour trial period they were placed on room air. A retrospective chart analysis was completed comparing BP patients from 01/2019-03/2019 to 01/2020-03/2020, periods from before and after implementation of the revised BP. Variables for analysis included LOS, HiVNI use, and readmission rate (RA).
Results:
In the 2019 period, 233 patients were admitted on the BP. 52% (121/233) of these patients received HiVNI therapy. In the 2020 period, 190 patients were admitted on the BP and 32% (59/190) received HiVNI therapy. Hospital LOS decreased from 2.23 days in 2019 to 1.84 days in 2020 (P=0.027) for HiVNI BP patients. RA were unchanged from 21% in 2019 to 19% in 2020 (P=0.34). The use of HiVNI for patients on the BP decreased by 47.61% from 2019 to 2020.
Conclusions:
Revising our BP with a focus on a more rapid decrease and succinct removal of HiVNI reduced hospital LOS by 39% without adverse effect in RA in our hospital’s pediatric bronchiolitis population. Further research must be done to evaluate the most effective weaning method from HiVNI in pediatric and other applicable populations.
Note: If patient does not have increased work of breathing or hypoxemic respiratory failure (decrease in oxygen level in blood due to respiratory failure), consider other low flow modalities prior to the initiation of HiVNI. Flow may be limited by cannula or cartridge based on manufacture recommendations.
HFNC Weaning Recommendations for BP Patients at Nemours Alfred I. duPont Hospital for Children View all access options for this article.HiVNI Initiation and Weaning Guidelines
Age
Initiate Flow
Increase Flow By
Upper Limit of Flow (for Acute Care Floors)
Hypoxic </= 90% Saturation
0-30 days
4 LPM
2 LPM for severe distress
Flow >8LPM and/or Fi02 >/= 60%
Start Fi02 at 40% and increase as needed to keep oxygen saturation >90%
>1 month- 2 years
6 LPM
2 LPM for severe distress
Flow >12LPM and/or Fi02 >/= 60%
Start Fi02 at 40% and increase as needed to keep oxygen saturation >90%
> 2 years- 6 years
8 LPM
2 LPM for severe distress
Flow >14LPM and/or Fi02 >/= 60%
Start Fi02 at 40% and increase as needed to keep oxygen saturation >90%
Get full access to this article