High Flow Interventions to Facilitate Less Overuse (HIFLO) Project Background

The use of high flow nasal cannula (HFNC) therapy for the treatment of bronchiolitis has increased dramatically in the past 10 years. The increased utilization of HFNC has been driven primarily by observational studies that reported reduced rates of intubation in the critical care setting. More recently however, three separate randomized controlled trials found no differences in clinically meaningful outcomes between early vs late (aka rescue) use of HFNC therapy in patients with moderately severe bronchiolitis.  No significant difference was found in hospital length of stay (LOS), oxygen duration, pediatric ICU utilization, adverse events, or intubation rates between patients with early initiation of HFNC versus those where HFNC was utilized as a rescue therapy. Furthermore, when aggregating two RCTs that permitted crossover from low flow nasal cannula (LFNC) to HFNC, ~70% of patients randomized to the conventional LFNC arm did not require escalation in respiratory support, and most of the ~30% of patients who did require escalation were safely “rescued” with HFNC. 

Despite the above evidence that early HFNC does not improve bronchiolitis patient outcomes, there are currently no standardized national protocols or consensus statements to guide appropriate use of HFNC for patients with bronchiolitis. This project aims to standardize HFNC use for patients with mild-to-moderate bronchiolitis in the Emergency Department (ED) and inpatient pediatric settings across North America and evaluate the impact of initiation and weaning interventions on HFNC utilization.  

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Project Structure

This QI project sought to standardize the use of HFNC in the management of bronchiolitis via implementation of a standardized protocol. The protocol may be used as a supplement to current bronchiolitis guidelines and HFNC practices. In addition to a standardized protocol, this project will provide QI education, in-time review of data with a QI coach, and robust clinical education for an interprofessional and interdisciplinary audience.  

Participating hospitals selected which protocol group they’d like to be placed in – Group 1 focused on a HFNC initiation pause protocol and Group 2 focused on a HFNC weaning protocol.