Bronchiolitis v.6.

0: HFNC (ED)
Prior to HFNC initiation:
HFNC Inclusion Criteria

Call respiratory therapist

Respiratory score, suction, score
MD to order:

Place PIV (consider normal saline bolus)

Obtain blood gas (may start HFNC prior to result)

NPO

Continuous CR and O2 sat monitoring

Previously healthy children with bronchiolitis

Age 44 weeks CGA to 2 years
ONE of the following:
1) Severe respiratory distress, or
2) Significant
(see
chart)
or , or
SignificantHypoxia,
hypoxemia
(see
chart)
3) Respiratory score persistently 8-12 with
significantly increased WOB

HFNC Exclusion Criteria

Initiate HFNC, 50% FiO2:

4 lpm for 30-90 days

6 lpm for 91 days to 2 years

RS, RR, SpO2 and HR Q 30 minutes

Notify Medical Hospitalist (76058)

ANY pre-existing medical condition

Born prematurely at less than 34 weeks
History of intubation for respiratory failure
Concern for respiratory failure:
Apnea requiring intervention
PCO2 > 55, pH <7.3
Altered mental status
Poor perfusion

Huddle 90 minutes
post HFNC initiation
(RN, RT, ED providers, admitting
resident, Medical Hospitalist,
+/- PICU provider)

Failing (Clinically unchanged or worsening)

Arrange for ICU transfer

May exceed maximum flow
rates / increase FiO2 while
waiting for transfer

Off
Pathway

Patients require ICU transfer for any of the

following:

Failure to improve on HFNC trial (or does not

meet inclusion criteria for inpatient part of HFNC
pathway after 90-minute huddle)
CO2 > 55 or pH < 7.30
Any apnea > 20 seconds requiring intervention
Desaturations below 90% despite 50% FiO2
Altered mental status (irritability, lethargy), poor
perfusion (cool extremities, capillary refill >3

seconds)

!
Inclusion criteria
are more conservative
for HFNC than for the
Bronchiolitis Pathway.

Clinically improving

Admit to general medicine (Medical Hospitalist to be called for all

pathway eligible patients, participate in 90 minute huddle)
Consider PICU consult/admission if clinical concerns remain or RS
remains >8 (even if improving)
While awaiting transfer:
Score, Suction, Score and VS Q1 hour
RN/RT may adjust FiO2 to maintain saturations >90% awake, 88%
asleep

Note: For patients with initial PCO2 >55 who improve

with HFNC, a CBG may be rechecked after the huddle. If
PCO2 then falls to 55, patient may still be eligible for
general medicine admission.

Sign of clinical improvement:

Improving respiratory score

Lower RR (not inappropriately lower than normal for age)
Lower HR
Improved CBG (if repeated; not necessary for all patients)

Go To HFNC Inpatient Phase

For questions concerning this pathway,
contact: Bronchiolitis@seattlechildrens.org
2015 Seattle Childrens Hospital, all rights reserved, Medical Disclaimer

Last Updated: January 2015

Valid Until: December 2016

Bronchiolitis v.6.0: HFNC (Inpatient)

Prior to HFNC initiation:
Score, suction, score
Consider albuterol trial ONCE if not already done
Call RRT; resident to notify attending MD
Notify Medical Hospitalist (76058, charge RN to notify)
MD to order (using HFNC orderset):
Place PIV (consider normal saline bolus)
Obtain CBG (may start HFNC prior to result)
NPO

HFNC Inclusion Criteria

Previously healthy children with bronchiolitis
Age 44 weeks CGA to 2 years
ONE of the following:
1) Severe respiratory distress, or
2) Significant
(see
chart)
or , or
SignificantHypoxia,
hypoxemia
(see
chart)
3) Respiratory score persistently 8-12 with
significantly increased WOB

HFNC Exclusion Criteria

Initiate HFNC, 50% FiO2:

4 lpm for 30-90 days
6 lpm for 91 days 2 y
RS, RR, SpO2 and HR Q 30
minutes
Score, suction, score Q 1 h for 4
hours post initiation

Huddle 90 minutes
post HFNC initiation
(Bedside RN, RISK RN,
RT, senior, intern,
Medical Hospitalist)

ANY pre-existing medical condition

Born prematurely at less than 34 weeks
History of intubation for respiratory failure
Concern for respiratory failure:
Apnea requiring intervention
PCO2 > 55, pH <7.3
Altered mental status
Poor perfusion
!

Inclusion criteria
are more conservative
for HFNC than for the
Bronchiolitis Pathway.

Failing (Clinically unchanged or worsening)

Arrange for ICU transfer

May exceed maximum flow
rates / increase FiO2 while
waiting for transfer,
with ICU guidance

Off
Pathway

Sign of clinical improvement:

Clinically improving
NG/OG if anticipated NPO > 2 days
Wean flow rates as tolerated
May orally feed only if patient has weaned at least 2 lpm from
maximum flow rate

Weaning HFNC:

Improving RS
Lower RR (not inappropriately lower than normal for age)
Lower HR

FiO2 may be weaned by RN/RT after 90 minute huddle to maintain

saturations >90% awake and >88% asleep.

Improved CBG (if repeated; not necessary for all

patients)

Please call provider to wean patients flow rate Q4 hours as indicated

if patient meets all of below criteria:

Criteria for transfer to the ICU:

Failure to improve on HFNC trial

CO2 > 55 or pH < 7.30
Any apnea > 20 seconds requiring intervention

Flow rate may be weaned by provider in 1 lpm increments.

Desaturations below 90% despite 50% FiO2

Altered mental status (irritability, lethargy), poor
perfusion (cool extremities, capillary refill >3
seconds)

When HFNC is stable at 2 lpm for 4 hours, next step is to trial patient
directly to room air or to low flow NC O2 (start at lpm and titrate to
keep sats >90% awake, 88% asleep).

Criteria for transfer from the ICU to floor:

Clinically improving
RS < 8 after suctioning
FiO2 < 30%

Stable on flow rate at or below the floor

maximum for >12 hours
Have a respiratory score <8 prior to transfer
CBG with PCO2 <55

If patient worsens after a wean, contact

provider to evaluate and increase flow
rate to previous levels. If patient
must increase beyond previous
level, or is at pathway maximum,
call RRT.

Have no pathway EXCLUSION criteria

For questions concerning this pathway,
contact: Bronchiolitis@seattlechildrens.org
2015,
2011, Seattle Childrens Hospital, all rights reserved, Medical Disclaimer

!
Do not exceed
flow rates of:
4 lpm for 30-90 days old
6 lpm for 91 days to 2
years on the floor.

Last Updated: January 2015

Valid Until: December 2016

Return to Home

Return to Home

Return to Home

Return to Home

Return to Home

Return to Home

Return to Home

Return to Home

Return to Home

Self-Assessment
Completion qualifies you for 1 hour of Category II CME credit. If you are taking this self-assessment as a
part of required departmental training at Seattle Childrens Hospital, you MUST logon to Learning Center.

Return to Home

View Answers

HFNC Answer Key

Return to Home

Executive Summary

Return to Home

Executive Summary

Return to Home

Executive Summary

Return to Home

Executive Summary

Return to Home

Bronchiolitis and HFNC Citation

Title: Bronchiolitis and HFNC Pathway
Authors:
Seattle Childrens Hospital
Lauren Wilson
Anne Slater
Elaine Beardsley
Dave Crotwell
Jason Debley
Jeff Foti
Michael Leu
Jennifer Magin
Coral Ringer
Joan Roberts
Date: December 10, 2013
Retrieval Website: http://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdf
http://www.seattlechildrens.org/pdf/HFNC-pathway.pdf
Example:
Seattle Childrens Hospital, Wilson L, Slater A, Beardsley E, Crotwell D, Debley J, Foti J, Michael
Leu, Magin J, Ringer C, Roberts J.2013 December. Bronchiolitis and HFNC Pathway. Available
from: http://www.seattlechildrens.org/pdf/bronchiolitis-pathway.pdf
http://www.seattlechildrens.org/pdf/HFNC-pathway.pdf

Return to Home

Evidence Ratings
This pathway was developed through local consensus based on published evidence and expert
opinion as part of Clinical Standard Work at Seattle Childrens. Pathway teams include
representatives from Medical, Subspecialty, and/or Surgical Services, Nursing, Pharmacy, Clinical
Effectiveness, and other services as appropriate.
When possible, we used the GRADE method of rating evidence quality. Evidence is first assessed
as to whether it is from randomized trial or cohort studies. The rating is then adjusted in the
following manner (from: Guyatt G et al. J Clin Epidemiol. 2011;4:383-94.):
Quality ratings are downgraded if studies:
Have serious limitations
Have inconsistent results
If evidence does not directly address clinical questions
If estimates are imprecise OR
If it is felt that there is substantial publication bias
Quality ratings are upgraded if it is felt that:
The effect size is large
If studies are designed in a way that confounding would likely underreport the magnitude
of the effect OR
If a dose-response gradient is evident
Guideline Recommendation is from a published guideline that used methodology deemed
acceptable by the team.
Expert Opinion Our expert opinion is based on available evidence that does not meet GRADE
criteria (for example, case-control studies).

To Bibliography

Return to Home

Summary of Version Changes

Version 1 (10/10/2011): Go live

Version 1.1 and 1.2 (07/20/2012): Copyrighted photos and diagrams removed
Version 2.0 (10/22/2012): Updated to SpO2 monitoring recommendations
Version 3.0 (12/10/2013): Go live of Bronchiolitis HFNC Pathway
Version 3.1 (12/13/2013): Changes made to add contact hospitalist; correction to oral feeds to
match training slide; wording change in trial of albuterol to match the orders
Version 3.2 (01/15/2014): Changes to inclusion and exclusion criteria; changes to reflect
medical hospitalist at ED 90 minute huddle; admit to medical hospitalist
Version 4.0 (02/5/2014): Pathway document was divided into two documents and posted as
Bronchiolitis Pathway and HFNC Pathway
Version 5.0 (10/01/2014): Removal of daily CBG while on HFNC; highlighting of ability to
recheck PC02 after HFNC started for improved patients to meet floor admit criteria; PCO2
removed from inclusion criteria; composition of members of ED huddle; ability to admit to general
medicine service; ability to trial patient on RA or low flow NC O2 after stable on HFNC at 2 lpm
for 4 hours
Version 6.0 (01/30/2015): Update to the pathway inclusion criteria to include severe respiratory
distress; added ICU to floor transfer criteria and link to education slide in transfer criteria box

Return to Home

Medical Disclaimer
Medicine is an ever-changing science. As new research and clinical experience broaden our
knowledge, changes in treatment and drug therapy are required.
The authors have checked with sources believed to be reliable in their efforts to provide
information that is complete and generally in accord with the standards accepted at the time of
publication.
However, in view of the possibility of human error or changes in medical sciences, neither the
authors nor Seattle Childrens Healthcare System nor any other party who has been involved in
the preparation or publication of this work warrants that the information contained herein is in
every respect accurate or complete, and they are not responsible for any errors or omissions or
for the results obtained from the use of such information.
Readers should confirm the information contained herein with other sources and are
encouraged to consult with their health care provider before making any health care decision.

Return to Home

Bibliography
Studies were identified by searching electronic databases using search strategies developed and
executed by a medical librarian, Susan Klawansky. Searches were performed in May 2013. The
following databases were searched on the Ovid platform: Medline (2002 to date), Cochrane
Database of Systematic Reviews (2005 to date), Cochrane Central Register of Controlled Trials
(2002 to date); elsewhere Embase (2002 to date), CINAHL (2002 to date), National Guideline
Clearinghouse and TRIP (2002 to date). Retrieval was limited to humans 0-18 and English,
French or German languages. As none of the searched databases provided index terminology
for the concept of high flow nasal cannula, all searching was conducted using textwords/
synonyms in various combinations. All retrieval was further limited to certain evidence
categories, such as relevant publication types, Clinical Queries, index terms for study types and
other similar limits. Additional articles were identified by team members and added to results.
Susan Klawansky, MLS, AHIP
December 3, 2013
Identification HFNC
70 records identified through
database searching

1 additional records identified

through other sources

Screening
71 records after duplicates removed

71 records screened

45 records excluded

Eligibility
Identification
26 full-text articles assessed for eligibility

10 full-text articles excluded

Included
16 studies included in pathway
Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535

Return to Home

To Bibliography, Pg 2

Bibliography Bronchiolitis HFNC

Abboud, P. A., Roth, P. J., Skiles, C. L., Stolfi, A., & Rowin, M. E. (2012). Predictors of failure in infants
with viral bronchiolitis treated with high-flow, high-humidity nasal cannula therapy*. Pediatric Critical
Care Medicine, 13(6), e343-9. doi:http://dx.doi.org/10.1097/PCC.0b013e31825b546f
Arora, B., Mahajan, P., Zidan, M. A., & Sethuraman, U. (2012). Nasopharyngeal airway pressures in
bronchiolitis patients treated with high-flow nasal cannula oxygen therapy. Pediatric Emergency
Care, 28(11), 1179-1184. doi:http://dx.doi.org/10.1097/
de Klerk, A. (2008). Beyond the basics. humidified high-flow nasal cannula: Is it the new and improved
CPAP? Advances in Neonatal Care (Elsevier Science), 8(2), 98-106. Retrieved from http://
search.ebscohost.com/login.aspx?direct=true&db=cin20&AN=2009897598&site=ehost-live
Hasan, R. A., & Habib, R. H. (2011). Effects of flow rate and airleak at the nares and mouth opening on
positive distending pressure delivery using commercially available high-flow nasal cannula systems:
A lung model study. Pediatric Critical Care Medicine, 12(1), e29-33. doi:http://dx.doi.org/10.1097/
PCC.0b013e3181d9076d
Hegde, S., & Prodhan, P. (2013). Serious air leak syndrome complicating high-flow nasal cannula
therapy: A report of 3 cases. Pediatrics, 131(3), e939-44. doi:http://dx.doi.org/10.1542/peds.20113767
Kelly GS, Simon HK, Sturm JJ. (2013) High Flow Nasal Cannula Use in Children With Respiratory
Distress in the Emergency Department: Predicting the Need for Subsequent Intubation. Pediatr
Emer Care.;29: 888-92
Lee, J. H., Rehder, K. J., Williford, L., Cheifetz, I. M., & Turner, D. A. (2013). Use of high flow nasal
cannula in critically ill infants, children, and adults: A critical review of the literature. Intensive Care
Medicine, 39(2), 247-257.
Matecki, S., Milesie, C., Baleine, J., Jacquot, A., & Cambonie, G. (2013). Effect of high-flow nasal
cannula nasal on nasopharyngeal airway pressure and respiratory muscles loading in young infants
with severe acute viral bronchiolitis. Fundamental and Clinical Pharmacology, 27, 89.
Mayfield, S., Hough, J., Pham, T., & Schibler, A. (2011). High flow nasal prong oxygen reduces the
need for mechanical ventilation in bronchiolitic infants. Pediatric Critical Care Medicine, 12(3),
A118.
McKiernan, C., Chua, L. C., Visintainer, P. F., & Allen, H. (2010). High flow nasal cannulae therapy in
infants with bronchiolitis. Journal of Pediatrics, 156(4), 634-638. doi:http://dx.doi.org/10.1016/
j.jpeds.2009.10.039
Milesi, C., Baleine, J., Matecki, S., Durand, S., Combes, C., Rideau Batista Novais, A., & Combonie,
G. (2013). Is treatment with a high flow nasal cannula effective in acute viral bronchiolitis? A
physiologic study. Intensive Care Medicine, 39(6), 1088-1094. doi:http://dx.doi.org/10.1007/
s00134-013-2879-y
Schibler, A., Pham, T. M., Dunster, K. R., Foster, K., Barlow, A., Gibbons, K., & Hough, J. L. (2011).
Reduced intubation rates for infants after introduction of high-flow nasal prong oxygen delivery.
Intensive Care Medicine, 37(5), 847-852. doi:http://dx.doi.org/10.1007/s00134-011-2177-5

To Bibliography, Pg 1

Return to Home

To Bibliography, Pg 3

Bibliography Bronchiolitis HFNC

Sood, R., Stolfi, A., & Rowin, M. (2012). Use of high flow high humidity nasal cannula therapy for
infants with bronchiolitis. Journal of Investigative Medicine, 60(1), 453.
Spentzas, T., Minarik, M., Patters, A. B., Vinson, B., & Stidham, G. (2009). Children with respiratory
distress treated with high-flow nasal cannula. Journal of Intensive Care Medicine, 24(5), 323-328.
doi:http://dx.doi.org/10.1177/0885066609340622
Thorburn, K., & Ritson, P. (2012). Heated, humidified high-flow nasal cannula therapy in viral
bronchiolitis--panacea, passing phase, or progress?*. Pediatric Critical Care Medicine, 13(6),
700-701. doi:http://dx.doi.org/10.1097/PCC.0b013e3182677456
Wing, R., James, C., Maranda, L. S., & Armsby, C. C. (2012). Use of high-flow nasal cannula support
in the emergency department reduces the need for intubation in pediatric acute respiratory
insufficiency. Pediatric Emergency Care, 28(11), 1117-1123. doi:http://dx.doi.org/10.1097/
PEC.0b013e31827122a9

To Bibliography, Pg 2

Return to Home