High Flow Nasal Cannula Clinical Pathway: Bronchiolitis

Prior to Initiation:
-Nasal suction then score Inclusion criteria:
-Notify bedside RN, RT and MD Previously healthy children with
-Make NPO; offer breast pump if breastfeeding bronchiolitis
-Consider PIV or NGT -Age 40 weeks CGA to 24 months
-One of the following:
1) Severe respiratory distress
-Intiate HFNC at following flow rates: 2) Significant hypoxemia (Requiring
4 lpm for <6 mos of age >2 lpm NCO2)
6 lpm for > 6 mos of age 3) RS persistently 9-12
-Titrate FiO2 to maintain O2 sat > 90% -HFNC from ER: stable ≥1 hr RS≤8; max
flow 6L<6mos, 8L≥6mos;
Initiation Pathway

FiO2 ≤50%
In 15 minutes: -HFNC from PICU: stable ≥4hrs, 4Lflow,
- obtain and document Respiratory Score, RR, pulse oximetry, HR and BP FiO2 ≤50%

Exclusion criteria:
-ANY pre-existing medical condition,
No Increase flow rate q15min to a
including BPD
Respiratory Score maximum of:
-CGA <40 weeks
improves to ≤8? 8 lpm for < 6 mos of age
-Any apnea
10 lpm for > 6 mos of age
-Altered mental status
Yes -Poor perfusion

-Activate PMET to arrange PCCU transfer

-Continue q15 min assessments as Yes Respiratory No -Place PIV if not done already
above for 1 hour Score improves -May increase maximum flow rates/increase
-HUDDLE 60 min post-initiation: to ≤8? FiO2 while awaiting transfer, with ICU
Bedside RN, RT, MD guidance

MONITORING:
-Continuous pulse oximetry,
-Suction then score q2h Escalation: Activate PMET to arrange
-Document HR, RR, pulse oximetry q2h PCCU transfer if:
Maintenance

- Unchanged or worsening: RS remains ≥9

despite maximum flow (8 lpm <6 mos, 10 lpm
FEEDING: ≥6 mos)
-May resume PO feeding if RR<60, with 1st feeding observed by staff -Any apnea
-If RR remains >60, consider continuous NG feeds - FiO2 requirement ≥50% to maintain O2 sat
≥90%
-Altered mental status
-Poor perfusion

Consider proceeding to Weaning Pathway after 4 hours of Respiratory Score <5

Clinically improving?
-RS<5, RR/HR improved
-No apnea
-FiO2 ≤50%
-Normal mental status
-Adequate perfusion
Weaning Pathway

-Wean FiO2 to maintain O2 sat > 90%

-Wean flow by 1 lpm q2h
-Document HR, RR, pulse oximetry q2h
-Suction then score q2h

Respiratory Score 1-4 Respiratory Score 5-8 Respiratory Score 9-12

-Continue weaning as above

-When stable at 2 lpm and <30% Return to Maintenance phase and Return to Initiation phase and
FiO2 for 4h, trial on room air or continue current flow rate increase flow rate q15min until
low flow NC O2 RS≤ 8, to maximum rates

Follow Inpatient Bronchiolitis

Pathway

Authors: Alyssa Silver MD, Joanne Nazif MD, Gabriella Azzarone MD 9/15