High Flow, Higher Standards: We Can Do Better

High-flow nasal cannula (HFNC) remains one of a pediatric hospitalist's most bewildering tools in managing respiratory distress in small children. Despite limited evidence supporting its role as a primary therapy, HFNC use has become ubiquitous, particularly in bronchiolitis, for which it is used in >50% of pediatric hospital admissions in the United States.1,2 HFNC is correlated with longer lengths of stay, more intensive care unit (ICU) transfers, and higher hospital costs, without consistent benefits.3–10 In recent years, study teams have used a variety of quality improvement (QI) tools to curb the use of HFNC. A study by Hunter et al11 contributes nicely to the growing arsenal of techniques to reduce HFNC use at the institutional level.In this well-designed QI study, Hunter et al successfully improved key outcomes for children receiving HFNC for common respiratory illnesses. To accomplish this task, the authors adapted established approaches in HFNC reduction, using a QI framework. Generally healthy patients aged 1 month to 5 years receiving HFNC for bronchiolitis, asthma, or pneumonia in the emergency department, inpatient floor, or pediatric ICU (PICU) were included. In all, 430 patients were included (281 in the baseline phase and 149 in the improvement phase). The primary intervention was an algorithm for HFNC use bundled with a clinical decision support tool; it promoted a rapid wean and an abrupt discontinuation of high flow when meeting set parameters (ie, a "holiday"12). Additional interventions included staff education, as well as feedback regarding patient outcomes given to treating clinicians. At the study conclusion, holiday occurrences increased from 10.9% to 82.8%, length of stay (LOS) decreased from 94.3 to 70.6 hours, and length of HFNC treatment (LOT) decreased from 55.7 to 39.7 hours.The authors build on an existing body of literature demonstrating that QI initiatives to decrease HFNC correlate with shorter LOS and LOT. However, gaps arise when comparing the magnitude of LOS and LOT improvements in these QI studies with data from randomized controlled trials, which inconsistently demonstrate LOS differences.10,13,14 Prolongations in LOS and LOT seen in experimental studies about HFNC are on the magnitude of hours; in contrast, Hunter et al and several other QI teams have consistently achieved LOS and/or LOT reductions of approximately 24 hours when they reduce the use of HFNC.12,15–18 Given the discrepancy between experimentally derived effects of HFNC vs the marked reductions in LOS and LOT demonstrated in QI initiatives, there is likely an unmeasured, real-world harm associated with the ways that HFNC is typically used in the inpatient setting.A 24-hour reduction in LOS is significant for hospital metrics, as well as for families. To that end, it is poignant to note the relative paucity of published family perspectives on HFNC discontinuation practices. Caregivers are typically highly attuned to their child's well appearance, and they are often readily available. To that end, the authors might have considered soliciting family experiences with rapid HFNC discontinuation. This information would allow additional framing for the study findings, similarly to the evolving practice of shared decision-making in other clinical situations.It is impressive the authors included patients across multiple units in their institution, including the ICU setting—a patient demographic that is often excluded from similar studies. However, the authors did not provide information about patient volumes by unit or stratify performance metrics by unit. This makes it difficult to interpret the robust increase in holiday occurrences that coincided with the expansion of the primary intervention to the PICU. It might truly represent a broadly accepted, well-designed clinical decision support tool. It might also be a function of an overrepresented PICU population, a setting where it might be more feasible to try a high-flow holiday.Although this study did include a fairly large number of patients with a strong baseline sample size, it did not capture information from a discrete respiratory season following the primary study intervention. Instead, it included the latter portion of the 2022–2023 season (during the "Tripledemic") and the first half of the 2023–2024 season.19 The Tripledemic was a historically atypical, high-volume respiratory season that is quite challenging to compare with other respiratory seasons. These outcomes are further confounded by a concurrent institutional initiative to decrease LOS that likely independently interacted with study interventions, even in the absence of record-high patient volumes.The authors do not discuss sustainability of their interventions, which is notable given the association between frequent provider feedback and improvement in their study measures. Providing feedback to clinicians is labor-intensive, and we speculate it may be difficult to sustain this level of engagement long-term, particularly across multiple years. Although the authors did not present data demonstrating long-term sustainability, their study incorporates a high-impact intervention to support culture change—an order set embedded in the electronic medical record.20 By integrating this clinical decision support tool, it is promising the team may see sustainability over years.This study demonstrates incremental progress in a growing field of single-center initiatives to optimize HFNC discontinuation approaches. It emphasizes the urgency of creating national guidelines for the appropriate use of HFNC throughout all phases of care and prioritizing multicenter, context-informed work in deimplementation efforts.