A Respiratory Therapist–Driven High-Flow Nasal Cannula Liberation Protocol at High Altitude

Résumé fourni par la source

Background: High-flow nasal cannula (HFNC) liberation strategies in pediatric intensive care often transition patients directly from HFNC to room air. At high altitude, oxygen requirements may persist after flow-dependent respiratory support is no longer needed. We evaluated the association between a protocolized, respiratory therapist–driven HFNC liberation strategy and time to successful liberation from high-flow support in children with acute respiratory failure. Methods: We conducted a retrospective cohort study using prospectively collected LARed Network registry data from a tertiary PICU in Bogotá, Colombia (2,600 m altitude). In September 2022, the unit implemented an HFNC liberation strategy designed to separate persistent oxygen requirement from ongoing need for high-flow support. The primary analysis included the first HFNC episode per PICU admission from March 2018 to March 2025. The primary outcome was time to successful HFNC liberation. Kaplan–Meier curves and multivariable Cox regression were used; gamma log-link models were used for sensitivity analyses, including a prespecified bronchiolitis subgroup. Results: We included 1,086 PICU admissions, 627 before and 459 after implementation. Median HFNC duration decreased from 59.8 h (interquartile ranges [IQR] 34.7–91.4) to 53.1 h (IQR 32.3–80.5, P = .01). Kaplan–Meier analysis showed earlier HFNC liberation after implementation (log-rank P < .01). Implementation was associated with earlier liberation in adjusted Cox regression (hazard ratio 1.17, 95% CI 1.03–1.34, P = .02). PICU stay decreased from 4.7 days (IQR 3.2–6.9) to 4.0 days (IQR 2.9–5.8, P < .01). In bronchiolitis, implementation was associated with an 18.2% relative reduction in HFNC duration (95% CI 7.7–27.5%, P < .01). Conclusions: In a high-altitude PICU, a respiratory therapist–driven HFNC liberation strategy was associated with earlier liberation from high-flow support. A strategy that preserves oxygen delivery while testing tolerance of minimal flow may be useful in high-altitude settings.

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