The impact of an autonomous nurse‐led high‐flow nasal cannula oxygen protocol on clinical outcomes of infants with bronchiolitis

High-flow nasal cannula oxygen is a relatively novel method of respiratory support and has rapidly become the standard of care for patients with acute capillary bronchitis. Although it has more significant advantages in terms of patient comfort and gas exchange, it is more costly than standard oxygen therapy. Elks and colleagues recently compared the clinical outcomes of high-flow nasal cannula oxygen therapy with standard care in children with capillary bronchiolitis and demonstrated that the implementation of a nurse-led high-flow nasal cannula protocol was associated with a shorter hospital stay (Elks et al., 2023). Although the nature of the study lacked randomization and limited the ability to determine causality, it still has some practical significance. Similar to previous studies (Borgi et al., 2021; Eşki et al., 2022), this excellent study by Elks et al. further confirms the superiority of high-flow nasal cannula oxygen administration over low-flow standard oxygen administration therapy in infants with capillary bronchiolitis requiring supplemental oxygen. However, this finding also raises several questions for me. First, previous studies have shown that most patients with capillary bronchiolitis requiring oxygen therapy can be treated with low-flow oxygen and that, in exceptional cases, children receiving standard therapy continue to do well after resuscitation with high-flow oxygen therapy (Kepreotes et al., 2017). Therefore, should high-flow oxygen therapy be used routinely in all infants with capillary bronchiolitis? Second, is it the delivery of higher oxygen concentrations that provides the potential benefit of high-flow oxygen therapy, or do other components such as warmth, higher humidity and sustained positive pressure also play a role? Third, perhaps limited by sample size, the authors did not mention in the article whether there were differences between the two groups in reducing ICU transfers. Fourth, the results in this study indicated that the treatment group had a shorter length of hospital stay, time on high flow and weaning time; does this imply that early introduction of high flow oxygen therapy improves the course of capillary bronchiolitis? However, previous randomised controlled trials of higher quality and with larger sample sizes have shown that high-flow oxygen therapy does not improve the course of capillary bronchiolitis (Franklin et al., 2018; Kepreotes et al., 2017). Finally, whether patients with different phenotypes of capillary bronchiolitis have different benefits. For example, the effectiveness of high-flow oxygen therapy may differ in children with combined respiratory syncytial virus and rhinovirus-induced capillary bronchiolitis. None. No conflicts of interest for this study. This article does not contain any studies with human participants or animals performed by any of the authors.