530 - Effect of a Respiratory-Therapist Driven Protocol on Post-Extubation High Flow Nasal Cannula Duration in A Pediatric Intensive Care Unit

Publication Number: 1509.530

Nayan Srivastava, Indiana University School of Medicine, Indianapolis, IN, United States; Aimee Ealy, Riley Hospital for Children at Indiana University Health, PLAINFIELD, IN, United States; Colin M. Rogerson, Indiana University School of Medicine, Indianapolis, IN, United States; Daniel T. Cater, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, United States; Samer Abu-Sultaneh, Riley Hospital for Children at Indiana University Health, Indianapolis, IN, United States

Background: High flow nasal cannula (HFNC) is increasingly used as a post-extubation respiratory support modality in pediatric intensive care units (PICUs). In October 2017, our center implemented a quality improvement initiative with a standardized respiratory therapist (RT) led HFNC management protocol. The protocol led to a decrease in HFNC duration, as well as both PICU and hospital length of stay (LOS) for patients admitted with bronchiolitis and status asthmaticus who did not require intubation.

Objective: This study aims to determine the effectiveness of the RT-driven HFNC protocol on HFNC duration, and PICU and hospital LOS in patients extubated to HFNC.

Design/Methods: This study was a retrospective analysis of patients at a single, quaternary PICU. Eligible patients were aged 0-18 years and were endotracheally intubated for at least 24 hours. The original RT HFNC management protocol allowed the RT to make decisions regarding the escalation and weaning of HFNC based on the Riley Hospital Respiratory Score, which is comprised of respiratory rate and severity of retractions (Plan-Do-Study-Act cycle [PDSA] 1) (Figure 1A). In July 2020, flow rate weaning was adjusted for patients < 12 months from 1 L/min to 1-2 L/min and for patients ≥13 years from 2 L/min to 5 L/min (PDSA 2). In October 2021, the HFNC holiday was implemented allowing RTs to halve HFNC rate or use simple nasal cannula based on the same score (PDSA 3) (Figure 1B).

All pediatric patients extubated to HFNC who were admitted to Riley Hospital between October 2015-December 2024 were identified. QI Macros was used to create control charts to study outcome measures over time. Changes in the center line were made when eight consecutive points were above or below the center line. Escalation to bilevel positive airway pressure (BiPAP) or re-intubation at any time after extubation were used as balancing measures and were compared using chi-squared or fisher's exact tests as appropriate.

Results: Of the 2335 intubated patients, 626 were extubated to HFNC without requiring escalation to BiPAP or re-intubation. HFNC duration decreased from 1.8 to 1.3 then to 1.1 days throughout the project (Figure 2A). PICU LOS decreased from 10.3 days to 8.3 days (Figure 2B). Moreover, hospital LOS decreased from 19.1 to 16.9 days (Figure 2C). Escalation to BiPAP and re-intubation rates did not significantly increase throughout the project (Table 1).

Conclusion(s): An RT-driven HFNC protocol has been effective in decreasing HFNC duration, PICU LOS, as well as hospital LOS.

Figures 1A and B.
The Respiratory Therapist Driven High Flow Nasal Cannula Management Protocol (A) and the High Flow Nasal Cannula Holiday Protocol (B).

Figures 2A-C.
Control charts for HFNC duration, PICU LOS, and Hospital LOS.

Table 1.
Balancing Measures for All Patients Extubated to HFNC Stratified by PDSA Cycle.