Bronchiolitis is a leading cause of pediatric hospital admissions. While high-flow nasal
cannula (HFNC) is effective as a rescue therapy for patients with severe respiratory
distress when standard oxygen therapy fails, studies suggest that early use of HFNC in
moderate cases does not significantly improve outcomes such as hospital stay duration or
intubation rates. Despite its limited clinical benefits, the use of HFNC in children with
bronchiolitis is increasing, raising concerns about unnecessary treatment and extended
hospital stays due to a lack of standardized weaning protocols.
Evidence suggests that HFNC should be used effectively as a rescue treatment after
standard oxygen therapy fails, serving as an intermediate step before invasive support.
However, the high costs and self-limiting nature of bronchiolitis necessitate reducing
the overuse of HFNC in hospitalized children. Previous studies using quality improvement
(QI) methodologies have successfully reduced HFNC usage through weaning protocols and
trials of standard oxygen therapy.
This study involves implementing an HFNC initiation and weaning protocol at Aydın
Maternity and Children's Hospital, involving infants aged 1-24 months admitted with
bronchiolitis. A multidisciplinary team will evaluate patients using the Respiratory
Assessment Scale (RAS), with mild, moderate, and severe classifications. The study
compares HFNC duration, hospital stay, oxygen support duration, and associated costs
before and after the protocol implementation.
Exclusion Criteria:
Premature infants born at less than 32 weeks Patients with cardiopulmonary, genetic,
congenital, or neuromuscular abnormalities were excluded.
A prospective, randomized controlled trial will be conducted to evaluate the
effectiveness of a newly developed HFNC (High-Flow Nasal Cannula) weaning protocol in
infants aged 1-24 months with bronchiolitis, compared to the standard weaning protocol.
The new HFNC weaning protocol was developed using Quality Improvement (QI) methodology,
involving input from pediatricians, nurses, and hospital staff through training sessions.
The training lasted one month before the implementation, focusing on classifying patients
using the Respiratory Assessment Scale (RAS), which includes respiratory rate, the
workload of breathing, and consciousness level. A multidisciplinary team will apply the
protocol.
Protocol for Bronchiolitis in Children Under 2 Years:
Aspiration, postural drainage, hydration, antipyretics if necessary, nasal cannula for
SpO₂ drop (3-4 L/min)
Despite nasal cannula >3 LPM (FiO₂: 32), hypoxemia (≤92% FiO₂) or moderate-to-severe RAS:
Yes: Start HFNC (High-Flow Nasal Cannula) therapy. No: Continue with HFNC or nasal
cannula/mask.
HFNC Therapy Initiation:
Initial FiO₂: 50%, Flow rate: 1-2 L/kg Target SpO₂ between 92-96% by titrating FiO₂.
Calculate the baseline ROX index.
Reassess in 30-60 minutes:
Is there clinical deterioration? (Moderate-to-severe RAS)
If clinical deterioration is present:
FiO₂ ≥ 50% SpO₂ < 90% pCO₂ ≥ 60 Positive pressure ventilation should be considered if
there is apnea or bradycardia.
If there is no clinical deterioration:
After 4 hours of stable condition, reassess. Is there improvement in RAS and ROX index,
and is the patient clinically stable?
Yes:
If FiO₂ < 30%, start weaning the flow rate and FiO₂ simultaneously. Reduce the flow rate
by 2 L/min every 2-4 hours, and evaluate the RAS-ROX trend every 2-4 hours.
If there is respiratory deterioration:
Continue or increase HFNC flow rate and FiO₂ as needed.
If there is no respiratory deterioration:
Weaning continues. Discontinue HFNC when the flow rate reaches 4 L/min and FiO₂ < 30%.
Is there respiratory deterioration?
Yes:
Return to the previous flow rate, and reassess within 30 minutes.
Randomization and Groups:
Participants will be randomly assigned to one of two groups:
Control Group: Will follow the existing HFNC weaning protocol. Intervention Group: The
intervention group will follow the newly developed multidisciplinary HFNC weaning
protocol.
Outcomes:
The 2 groups will be compared regarding HFNC duration, hospital stay, oxygen support
duration, intensive care readmission, noninvasive ventilation (NIV) needs, intubation
rates, and costs.