The Appropriate Use of High-Flow Nasal Cannula in Bronchiolitis: A Delphi Approach

OBJECTIVES There is considerable practice variation nationally for using high-flow nasal cannula (HFNC) to treat hospitalized children with bronchiolitis, despite an abundance of literature supporting specific practices. We developed recommendations for using HFNC based on available evidence and expert opinion. METHODS Following the Research and Development (RAND)/University of California, Los Angeles Appropriateness Method, we conducted an exhaustive literature search for studies regarding the use of HFNC in bronchiolitis and drafted proposed use recommendations based on these findings. We convened an expert panel composed of nominees from national professional organizations with a range of professions (nursing, respiratory therapy, medicine) and clinical expertise (intensive care, emergency medicine, hospital-based care). Panelists rated recommendations for appropriateness and necessity in 3 sequential rating sessions and a moderated meeting. RESULTS The 15-member panel evaluated 60 recommendations for the initiation, reassessment, escalation, and de-escalation of HFNC in bronchiolitis. The panel reached agreement on the appropriateness of HFNC for 52 of 60 recommendations and on necessity for 46 of 52. The panel agreed with practices that may curtail HFNC use, including initiating HFNC only for refractory hypoxemia or impending respiratory failure, initiating HFNC at flow rates of 1.5 to 2 L/kg/min, and discontinuing HFNC once a patient is stable on fraction of inspired oxygen of 0.21 for 1-4 hours. CONCLUSIONS A national expert panel agreed on the appropriateness and necessity of parameters for HFNC use in bronchiolitis. These recommendations allow for standardization of practice that may optimize outcomes and curb indiscriminate use of this respiratory support modality.