Viral bronchiolitis is a leading cause of hospitalization in the first year of life. While supportive care is the mainstay of treatment, the use of heated and humidified high flow nasal cannula (HFNC) in the treatment of bronchiolitis has increased dramatically over the last 10 years, without any associated improvement in patient outcomes.1 There is currently wide variability in HFNC initiation and weaning practices, and no national guideline to inform the appropriate use of HFNC in the treatment of bronchiolitis.2

Recently, randomized controlled trials found no difference in clinically meaningful outcomes between early versus late (aka rescue) use of HFNC therapy- including length of stay, ICU utilization or intubation rates.3,4 Furthermore, these studies demonstrated a large proportion of infants successfully treated with low flow nasal cannula only, without escalation of care to HFNC. This suggests that indiscriminate early initiation of HFNC may increase health care costs without associated clinical benefit to the patient. Additionally, there is increasing evidence that rapid HFNC discontinuation protocols for healthy infants with bronchiolitis is safe and may reduce both hours of HFNC treatment and hospital length of stay.5,6,7

Project Leadership

Courtney (Charvat) Byrd, MD FAAP – Project Co-Leader
Michelle Noelck, MD FAAP – Project Co-Leader
Shawn Ralston, MD, MS FAAP
Valerie Riss, MD
Kristin Shadman, MD, FAAP
Mersine Bryan, MD MPH FAAP
Robert Willer, DO FAAP
Michelle Hamline, MD, PhD, MAS FAAP
Steven Shein, MD
Olivia Ostrow, MD FAAP
Brittany Jennings – AAP Staff

Project Time Period

Summer 2021 through Spring 2022

Project Aims & Measurement

Global Aim: By March 2022, reduce overutilization of HFNC in the treatment of infants with bronchiolitis utilizing quality improvement methodologies targeting both HFNC initiation and weaning practices.

Primary Aims:

  • Reduce the proportion of infants with bronchiolitis treated with HFNC by 30%
  • Reduce the total hours of treatment with HFNC in infants with bronchiolitis by 30%

Process Measures:

  • 80% of patients started on HFNC will undergo HFNC initiation pause
  • 80% of patients treated with HFNC will undergo rapid HFNC discontinuation trial

Balancing Measures

  • There will be no change in ED length of stay at sites implementing HFNC initiation pause
  • There will be no significant rate of rapid deterioration following rapid HFNC discontinuation attempt
  • There will be no increase in the inpatient length of stay after interventions

Project Resources

Measures Grid
HFNC Initiation Pause (HIP) Toolkit
HFNC Weaning (HOLIDAY) Toolkit
Feeding Protocol