Development of High-Flow Nasal Cannula Initiation Criteria for Hospitalized Patients with Bronchiolitis to Quantify Overuse

From the 2021 HVPAA National Conference

Jennifer Treasure (Children’s Hospital Medical Center, Cincinnati), Matthew Lipshaw, Preston Dean, Zach Paff, Katherine Innis, Anita Arnsperger, Matthew Gillen, Natalie Segev, Laura Woeste, Mindy Caito, Leann Blanchet, Randi Mullaney, Patrick Brady, Angela Statile


High-flow nasal cannula (HFNC) has been increasingly used to treat bronchiolitis, with a 12-fold increase at our institution over the past decade. However, HFNC use on the general pediatric unit has not improved patient outcomes (e.g., time on oxygen therapy, length of stay, or rate of intensive care unit transfers). A lack of standardization regarding which patients would benefit from HFNC initiation is likely an important driver of overuse.


To develop and pilot test evidence-informed and consensus-driven initiation criteria for HFNC therapy in patients hospitalized with bronchiolitis and to retrospectively quantify HFNC overuse over a 1.5 year period.


We assembled a multi-disciplinary team of clinicians representing emergency medicine, hospital medicine, and intensive care including physicians, respiratory therapists, and nurses at our tertiary care children’s hospital. We conducted an extensive literature review and identified evidence-based objective criteria supporting HFNC therapy. Our team refined the criteria through feedback from frontline providers and discussions with family representatives. Plan-Do-Study-Act cycles were used to pilot and iteratively improve the criteria, with additional changes made based on qualitative feedback from providers prior to widespread distribution. We then retrospectively applied the criteria in a structured chart review of patients hospitalized with bronchiolitis from September 2018 to March 2020 to quantify HFNC overuse.


The final HFNC initiation criteria in infants and young children diagnosed with bronchiolitis are listed in Table 1. Qualitative feedback indicated that providers and families found the criteria clear and usable. Applying these initiation criteria to bronchiolitis hospitalizations over the past two years, 35% of patients who were placed on HFNC failed to meet any evidence-based criteria. With bronchiolitis admissions down 93% (56 eligible infants from 4/20-12/20 vs. 789 in the same period in 2019), PDSA testing been limited. We have identified strategies to present the criteria to clinicians and audit and feedback performance data. No safety concerns have been identified.


We created and implemented criteria for initiating HFNC therapy in patients hospitalized with bronchiolitis at our center where >1/3 of infants received HFNC without an evidence-based indication. Future work following the expected return of bronchiolitis admissions post-COVID pandemic will study the impact of this approach on HFNC deimplementation and clinical outcomes.

Clinical Implications

Establishing objective criteria to support HFNC therapy in patients with severe bronchiolitis will allow fewer infants with mild to moderate bronchiolitis to be placed on a therapy that is unlikely to help them, may increase their risk of transfer to the intensive care unit, and increase the cost of care unnecessarily.

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