Improving Outcomes for Bronchiolitis Patients After Implementing a High-Flow Nasal Cannula Holiday and Standardizing Discharge Criteria in a PICU

Application of the TIDieR checklist to improve the HFNC use in bronchiolitis management

The use of High-Flow Nasal Cannula (HFNC) in children with bronchiolitis is globally increased in the last decade, despite the lack of evidence-based and universal guidelines to standardize their application in the clinical practice. In this systematic review, we aimed to analyse the completeness of previous studies on HFNC interventions in children with bronchiolitis using an adapted Template for Intervention Description and Replication (TIDieR) checklist. Randomized clinical trials (RCTs) and cohort studies on children younger than 2 years old with a diagnosis of bronchiolitis were included. We analysed manuscripts published between January 2010 and October 2023. An adapted TIDieR checklist based on 14 items about HFNC interventions was used to assess the completeness of the studies. A total sample of 67,324 patients was analysed in the 78 included manuscripts (21 RCTs and 57 cohort studies). Completeness of TIDieR checklist items ranged from 1% to 100%. The most reported items were related to the study rationale and the selection strategy (inclusion/exclusion criteria), identifying high quality of patients' selection in the included manuscripts. However, most of the studies did not provide separate indications for children with comorbidities. Only 23% of studies reported a complete definition and rates of treatment failure suggesting that this item needs more clarification in future studies. A minority of articles (40%) described the HFNC weaning procedures. Interestingly, most of the interventions took place in ICUs (61%), showing how, in the last decade, this location was the most cited for the use of HFNC in children with bronchiolitis.

CONCLUSIONS

 Our results suggest complete reporting of our TIDieR checklist in future studies may improve the quality of the research on HFNC use in children with bronchiolitis. Our findings encourage researchers to clarify the personalization of treatment administration and to better define the criteria for treatment failure. The adoption of universal definitions in this field is needed to increase the results' comparability and create standardized protocols. Researchers may use the proposed TIDieR checklist to develop, conduct and report clinical research into HFNC and bronchiolitis as this may help to create a consensus for establishing an evidence-based protocol for HFNC.

WHAT IS KNOWN

• High-flow nasal cannula (HFNC) is a common device used in children with bronchiolitis in the presence of respiratory distress, after the failure of standard oxygen therapy. However, no evidence-based and standardized protocol for the use of this device is globally available.

WHAT IS NEW

• By using an adapted Template for Intervention Description and Replication (TIDieR) checklist to review previous studies on HFNC in bronchiolitis, we found a global heterogeneity in the description of interventions with some items of the checklist poorly reported. Thus, we suggest using our TIDieR checklist for developing, conducting and reporting clinical research into HFNC and bronchiolitis as this may help to create a consensus for establishing an evidence-based protocol for HFNC.

Pediatric pulmonology year in review-Pediatric pulmonary critical care

Pediatric pulmonary critical care literature has continued to grow in recent years. Our aim in this review is to narrowly focus on publications providing clinically-relevant advances in pediatric pulmonary critical care in 2023.

Outcomes of a respiratory therapist driven high flow nasal cannula management protocol for pediatric critical asthma patients

INTRODUCTION

This study aimed to determine if a respiratory therapist (RT)-driven high flow nasal cannula (HFNC) protocol could decrease duration of HFNC use, pediatric intensive care unit (PICU) and hospital length of stay (LOS), and duration of continuous albuterol use in pediatric patients with critical asthma.

METHODS

This was a quality improvement project performed at a quaternary academic PICU. Patients admitted to the PICU between 2 and 18 years of age with a diagnosis of asthma requiring continuous albuterol and HFNC were included. Implementation of an RT-driven HFNC protocol [Plan-Do-Study-Act (PDSA) 1] occurred in October 2017. Additional interventions included weaning continuous albuterol and HFNC simultaneously (PDSA 2; March 2019), adjusting HFNC wean rate (PDSA 3; July 2020), and a HFNC holiday (PDSA 4; October 2021). HFNC duration was the primary outcome. Secondary outcomes included LOS data and continuous albuterol duration. Noninvasive ventilation (NIV), invasive mechanical ventilation (IMV), and 7-day PICU and hospital readmission rates were used as balancing measures.

RESULTS

A total of 410 patients were included. Patient demographics and adjunct therapy use did not differ among the groups. After PDSA 2, mean HFNC duration decreased (26.8-18.1 h). Mean PICU LOS decreased (41-31.8 h). Mean hospital LOS also decreased (86.5-68 h). These outcomes remained stable during PDSA 3 and 4. Continuous albuterol duration and NIV use were unchanged, while IMV use decreased.

CONCLUSIONS

An RT-driven HFNC protocol led to decreased length of HFNC and PICU and hospital LOS for pediatric patients with critical asthma without an increase in adverse events.