The Effect of a High-Flow Nasal Cannula Titration Protocol on Patient Length of Stay in the Pediatric Population

Abstract

Background:

There is a current need for a protocol for high-flow nasal cannula (HFNC) therapy in the pediatric population. HFNC is fairly new to the pediatric population, and tolerated well. Although there has been an increase in its use, a protocol and a uniform process with practice has yet to be made readily available. The purpose of the study was to determine the effect of a HFNC protocol on patient length of stay and readmissions in children.

Methods:

Development of a HFNC protocol for children with bronchiolitis began with a multidisciplinary team of respiratory therapists, hospitalists, nurses, and quality control personnel. The protocol was designed to set the initial flow based on patient weight. If the patient was <7 kg, the initial flow was set at 4 L/min, and FIO₂ adjusted via blender for SPO₂ >90%. After the patient was assessed with a scoring tool, the RN or RT would increase the flow by 2 L/min and reassess after each titration. The HFNC protocol was solely implemented in the pediatric ward at Dell Children’s Hospital. After obtaining IRB approval, the data collected included the length of stay for each patient with the HFNC protocol ordered. Inclusion criteria were infants age 0-12 months of age with moderate to severe respiratory distress diagnosed with bronchiolitis who failed to respond to low flow oxygen. Exclusion criteria included neonates in NICU, those with nasal obstruction, ingestion, life threatening hypoxia, hemodynamic instability, facial trauma, pneumothorax, or foreign body aspiration. The independent t-test and Pearson correlations tests were used to compare the HFNC protocol to the old standard of care and the P-value <0.05 was considered statistically significant.

Results:

The Table shows the means and standard deviations of patient age and length of stay. No significant difference was found between the old standard of care and the new HFNC protocol on age (P=0.98). Using the new HFNC protocol reduced patients’ length of stay from 63.97 h to 53.25 h (P=0.14). While 3 patients (4.5%) who received the old standard of care were readmitted to the hospital, only 1 patient (1.8%) in the new protocol group was readmitted. Age was negatively correlated with patient length of stay (r=-0.313, P=0.001) and was responsible for 9.79% of the variance in length of stay.

Conclusions:

Although non-statistically significant, the HFNC protocol reduces patient length of stay compared to the old standard of care in pediatrics. The older the child the shorter the length of stay in the ward.

Flow Rate	Treatment Groups	n	Age(0-12 mo)	Length of Stay(hrs)
4 L/min	Old Standard of Care	66	143.9 ± 90.8	63.97 ± 46.8
4 L/min	New HFNC Titration Protocol	53	144.3 ± 95.1	53.25 ± 26.5
4 L/min	p-value	 	0.98	0.14