Feeding during High-Flow Nasal Cannula for Bronchiolitis: Associations with Time to Discharge
BACKGROUND: High-flow nasal cannula (HFNC) is increasingly used to treat children hospitalized with bronchiolitis; however, the best practices for feeding during HFNC and the impact of feeding on time to discharge and adverse events are unknown. The study objective was to assess whether feeding exposure during HFNC was associated with time to discharge or feeding-related adverse events.
METHODS: This retrospective cohort study included inpatients aged 1-24 months receiving HFNC for bronchiolitis at an academic children’s hospital from January 1, 2015 to March 1, 2017. Feeding exposures during HFNC were categorized as fed or not fed. Among fed children, we further evaluated mixed (oral and tube) or exclusive oral feeding. The primary outcome was time to discharge after HFNC cessation. Secondary outcomes were aspiration, intubation after HFNC, and seven-day readmission.
RESULTS: Of 123 children treated with HFNC, 45 (37 %) were never fed. A total of 78 children (63%) were fed; 50 (41%) were exclusively orally fed and 28 (23 %) had mixed feeding. Median (interquartile range) time to discharge after HFNC was 29.5 hours (23.5-47.9) and 39.8 hours (26.4-61.5) hours in the fed and not fed groups, respectively. In adjusted models, time to discharge was shorter with any feeding (hazard ratio [HR] 2.17; 95% CI: 1.34-3.50) and with exclusive oral feeding (HR 2.13; 95% CI: 1.31-3.45) compared with no feeding. Time to discharge from HFNC initiation was shorter for exclusive oral feeding versus not feeding (propensity weighted HR 1.97 [95% CI: 1.13-3.43]). Adverse events (one intubation, one aspiration pneumonia, one readmission) occurred in both groups.
LIMITATIONS: Assessment of feeding exposure did not account for quantity and duration.
DISCUSSION: Children fed while receiving HFNC for bronchiolitis may have shorter time to discharge than those not fed. Feeding-related adverse events were rare regardless of the feeding method. Controlled prospective studies addressing residual confounding are needed to justify a change in the current practice.
© 2019 Society of Hospital Medicine
Bronchiolitis is the most common cause of nonbirth hospitalization in children in the United States less than one year of age.1 For children with severe bronchiolitis, high-flow nasal cannula (HFNC) is increasingly used2-4 to reduce work of breathing and prevent the need for further escalation of ventilatory support.5,6 Although previous studies suggest that enteral feeding is recommended in the management of patients hospitalized with bronchiolitis,7-9 limited evidence exists to guide feeding practices for patients receiving HFNC support.5,10,11
Respiratory support with HFNC has been associated with prolonged periods without enteral hydration/nutrition (ie, nil per os [NPO])12 primarily due to anticipation of further escalation of respiratory support or concern for increased risk of aspiration. The majority of patients with bronchiolitis managed with HFNC, however, do not require escalation of care.5,13 When feeding is attempted during HFNC support, it is frequently interrupted.5 Moreover, keeping all children NPO when receiving HFNC may be associated with weight loss and longer length of stay (LOS).12,14 Two small studies found that children admitted to the intensive care unit who received HFNC support for bronchiolitis did not have increased rates of emesis, worsening respiratory distress or aspiration pneumonia when enterally fed.10,11 However, no comparison of adverse events or LOS has been made between patients who were fed and those who were not fed during HFNC therapy, and previous studies have included only patients who have received HFNC in the intensive care setting.
Supporting safe feeding early in hospitalizations for bronchiolitis may facilitate expedited clinical improvement and discharge. As part of an ongoing bronchiolitis quality improvement initiative at our hospital, we sought to characterize feeding practices during HFNC therapy and assess whether feeding exposure was associated with (1) time to discharge after HFNC or (2) feeding-related adverse events. We hypothesized that feeding during HFNC therapy would be associated with a shorter time to discharge after HFNC cessation.
METHODS
Study Design, Setting, Participants
This was a retrospective cohort study of patients aged 1-24 months receiving HFNC support for respiratory failure due to bronchiolitis at an academic children’s hospital between January 1, 2015 and March 1, 2017. Our institution has had a clinical practice guideline, associated order set, and respiratory therapy protocol for general care patients with bronchiolitis since 2009. Patients with bronchiolitis who were weaning HFNC have been cared for in both the intensive and general care settings since 2013. A formal process for initiation of HFNC on general care units was instituted in January of 2017. During the study period, no patients with HFNC support for bronchiolitis had all their care entirely outside the intensive care unit at our institution. However, initiation and subsequent use of HFNC may have occurred in either the intensive care or general care setting. No specific guidance for feeding during HFNC existed during this period.
