Weaning High-Flow Nasal Cannula in Pediatric Bronchiolitis: A PICU Quality Improvement Project

Tuesday, March 24, 2026

12:30 PM - 1:30 PM Central Time

Location: Connections Central - RST 13

AN

Anisha S. Nadkarni, MD, MHS

Johns Hopkins University

Disclosure(s): No relevant financial relationship(s) to disclose.
Emily Kemper, MD (she/her/hers)

Nationwide Children's Hospital At Ohio State University

Disclosure(s): No relevant financial relationship(s) to disclose.
Victoria Huang, MD (she/her/hers)

Johns Hopkins Hospital

Disclosure(s): No relevant financial relationship(s) to disclose.
Phillip D. Cohen, MD, MSc, MHS

Johns Hopkins Hospital, Maryland

Disclosure(s): No relevant financial relationship(s) to disclose.
Kristen S. Joseph, MD (she/her/hers)

Maryland

Disclosure(s): No relevant financial relationship(s) to disclose.
CS

Cheryl Salamone, MEHP, RRT-NPS

Neonatal/Pediatric Respiratory Clinical Manager
Johns Hopkins Hospital

Disclosure information not submitted.
AL

Amanda Levin, MD

Assistant Professor of Anesthesiology and Critical Care Medicine
Johns Hopkins University

Disclosure information not submitted.
LB

Lauren Booth, MSN, CRNP, PNP-AC

PICU Senior Nurse Practitioner
Johns Hopkins Hospital

Disclosure information not submitted.
SM

Stephanie Morgenstern, MSN, APRN, ACCNS-P

Clinical Nurse Specialist
Johns Hopkins Hospital

Disclosure information not submitted.
Jessica LaRosa, MD

Johns Hopkins School of Medicine

Disclosure(s): No relevant financial relationship(s) to disclose.

Introduction: High flow nasal cannula (HFNC) has been increasingly used in children with bronchiolitis requiring care in the pediatric intensive care unit (PICU). However, children may stay on HFNC longer than medically necessary when concerted efforts are not made to wean. We implemented a fellow-championed, respiratory therapist (RT)-driven weaning protocol for HFNC in the PICU for children with bronchiolitis using a quality improvement framework.

Methods: On September 1, 2024, we implemented a respiratory scoring system and an RT-driven decision support tool for children < 2 years of age with bronchiolitis in the PICU of a single academic children’s hospital. Patients with baseline respiratory support prior to admission, infants < 6 months born at < 34 weeks gestational age, and children with chronic lung disease or congenital heart disease were excluded. We retrospectively extracted data for 12 months pre- and 10 months post-intervention to compare outcomes and balancing metrics.

Results: A total of 242 bronchiolitis admissions in 236 unique children were included in the analysis: 120 (50%) admissions during the 12 months pre-intervention and 122 (50%) admissions during the 10 months post-intervention. Median age was 8.0 months (interquartile range 2.7-15.0). The median hospital length of stay (LOS) was significantly reduced post-intervention compared to pre-intervention (46.2h vs 70.7h, p < 0.001). The median HFNC length of therapy (LOT) was also significantly reduced after intervention (13.5h post-intervention vs 29.9h pre-intervention, p < 0.001). Prior to intervention, 19 bronchiolitis admissions (16%) required escalation to positive pressure ventilation (PPV), compared to 15 admissions (12%) post-intervention. Escalation to intubation occurred in 9 admissions (8%) pre-intervention and 3 admissions (2%) post-intervention. There were no deaths in either group. Further analyses of balancing measures are underway.

Conclusions: Implementation of a standardized HFNC weaning pathway was associated with decreases in hospital LOS and HFNC LOT, without worsening escalation to PPV, escalation to intubation, or death. An RT-driven pathway is a safe and feasible way to ensure continued weaning of HFNC when it becomes medically unnecessary, improving outcomes and optimizing healthcare resource utilization.