High Flow Nasal Cannula (HFNC) in bronchiolitis

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High Flow Nasal Cannula (HFNC) in bronchiolitis

If you have questions about any of the clinical pathways or about the process of creating a clinical pathway please contact the Clinical Pathway Oversight Committee at CPOC@montefiore.org.

Disclaimer: Clinical pathways are intended as a resource to guide diagnosis, treatment and management in order to improve quality of care and promote better patient outcomes. They are based on available medical evidence at the time of development; the date on the pathway indicates the most recent update. Pathways are not intended to provide medical advice or consultation regarding the care of any individual patient, and should not replace or supersede a practitioner’s professional opinion or clinical judgment. Because medical knowledge is constantly evolving, and accepting the possibility of error, The Children’s Hospital at Montefiore does not warrant or represent that pathways are complete or accurate. Neither the Hospital nor the individuals involved in the development or publication of the pathways is responsible for results or outcomes related to their use.

Prior to Initiation:

  • Nasal suction then score
  • Notify bedside RN, RT, and MD
  • Make NPO; offer breast pump if breastfeeding
  • Consider PIV or NGT

In 15 minutes:

  • Obtain and document Respiratory Score, RR, pulse oximetry, HR, and BP


  • Continuous pulse oximetry
  • Suction then score q2h
  • Document HR, RR, pulse oximetry q2h

  • Wean FiO2 to maintain O2 sat > 90%
  • Wean flow by 1 lpm q2h
  • Document HR, RR, pulse oximetry q2h
  • Suction then score q2h

Respiratory Score 1-4

  • Continue weaning as above
  • When stable at 2 lpm and <30% FiO2 for 4h, trial on room air or low flow NC O2



Inclusion Criteria
  • One of the following: (1) Severe respiratory distress; (2) Significant hypoxemia (requiring ≥2 lpm O2); (3) Respiratory Score persistently 9-12
  • HFNC from PICU: stable ≥4 hrs, 4L flow, FiO2 ≤50%
  • HFNC from ER: stable ≥1 hr, Respiratory Score ≤8; max flow 6L <6 mo, 8L ≥6 mo; FiO2 ≤50%
  • Previously healthy children with bronchiolitis
  • Age 40 weeks CGA to 24 months
Exclusion Criteria
  • Any pre-existing medical condition, including BPD
  • cGA <40 weeks
  • Any apnea
  • Altered mental status
  • Poor perfusion

Weaning pathway

Activate PMET to arrange PCCU transfer if:

  • Unchanged or worsening: RS remains ≥9 despite maximum flow (8 lpm <6 mos, 10 lpm ≥6 mos)
  • Any apnea
  • FiO2 requirement ≥50% to maintain O2 sat ≥90%
  • Altered mental status
  • Poor perfusion

Place PIV if not done already

May increase maximum flow rates/increase FiO2 while awaiting transfer, with ICU guidance

Increase flow rate q15min to a maximum of:

  • 8 lpm for <6 mos of age
  • 10 lpm for ≥ 6 mos of age

Respiratory Score improves to ≤8?


  • May resume PO feeding if RR<60, with 1st feeding observed by staff
  • If RR remains >60, consider continuous NG feeds

Consider proceeding to Weaning Pathway after 4 hours of Respiratory Score <5

Respiratory Score improves to ≤8?

Respiratory Score 5-8

  • Return to Maintenance phase and continue current flow rate

Initiate HFNC at following flow rates:

  • 4 lpm for <6 mos of age
  • 6 lpm for ≥6 mos of age

Titrate FiO2 to maintain O2 sat ≥90%

  • Continuous q15 min assessments as above for 1 hour
  • HUDDLE 60 min post-initiation: Bedside RN, RT, MD

Clinically improving?

  • RS<5, RR/HR improved
  • No apnea
  • FiO2 ≤50%
  • Normal mental status
  • Adequate perfusion

Respiratory Score 9-12

  • Return to Initiation phase and increase flow rate q15min until RS≤ 8, to maximum rates

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