Implementation of a High-Flow Nasal Cannula Protocol for Viral Lower Respiratory Infections

Background: Bronchiolitis is the leading cause of hospital admission for infants in the US. Evidence supports the use of HFNC for bronchiolitis. The use of HFNC was not standardized in our children’s hospital. We identified the need of an evidence based protocol for the treatment of bronchiolitis and initiated a children’s hospital quality improvement (QI) effort. Methods: In our single center QI project we created a HFNC protocol guiding physicians, RTs and RNs on the introduction and titration of HFNC in children 0-36 months with bronchiolitis. The pilot went live 12/18- 1/19 with HFNC Bronchiolitis Protocol 1.0 which included a previously published respiratory assessment tool to guide HFNC titration. Staff was surveyed through face to face conversation and e-mail seeking feedback. The protocol was changed and re-implemented 2/19 with HFNC Bronchiolitis Protocol 2.0. This 2nd version the initiated flows changed and a new Respiratory Assessment Classification (RAC) was created based on qualitative feedback from staff. Results: Qualitative analyses of our Protocol have been overall positive. Version 1.0 included a published respiratory assessment tool. However, staff reported the tool too complicated and we found staff titrated HFNC per clinical judgment versus protocol. We queried staff for clinical indicators used for titration of HFNC and identified 3 top criteria: breathing frequency, WOB, and mental status. Staff reported the first tool was complicated and time consuming. We adapted a 2nd tool to create the Respiratory Assessment Classification (RAC) that classifies a patient’s status as mild, moderate, or severe. Qualitative data from the 2nd version show staff find the RAC easy to use and that HFNC is titrated most often per protocol versus clinical judgment. Initial flows were increased with 2.0. RTs reported desire to “dial in” the initiation flow for a patient during version 1.0. Version 2.0 allowed for titration 1-2 L/kg for patients with Moderate RAC, and then 2 L/kg up to max of 20 L for those with Severe RAC. Following the second implementation, staff reported increased confidence with higher flows. Conclusions: A simplified respiratory assessment tool that includes common clinical categories used by staff for HFNC titration is better received than more complex published assessment tools and leads to HFNC titration in a protocolized manner. Our protocol has provided RTs and RNs with more autonomy and confidence in the use of higher flows.