Clinical factors associated with intubation in the high flow nasal cannula era

Am J Emerg Med. 2020 Dec;38(12):2500-2505. doi: 10.1016/j.ajem.2019.12.017. Epub 2019 Dec 26.


Background: Bronchiolitis is the most common cause for hospitalization in infants. While the use of high flow nasal cannula (HFNC) has increased, it has not uniformly reduced intubation rates.

Objective: We identified factors associated with respiratory failure in children with bronchiolitis on HFNC.

Methods: We conducted a retrospective study of previously healthy children <24 months of age with bronchiolitis, who were treated with HFNC in two pediatric emergency departments from 1/2014-1/2018. The primary outcome was the identification of demographic and clinical factors that are associated with intubation after an antecedent trial of HFNC. A multivariable logistic regression model was constructed to identify predictors of respiratory failure.

Results: Of 2657 children on HFNC, the median age was 7 months, while the median age of the intubated cohort was 3 months. Ten percent (271) progressed to mechanical ventilation within 48 h of PED presentation. Of the 301 patients that needed escalation to CPAP and/or BiPAP, 91 required intubation. Factors associated with intubation were young age and a high respiratory tool score; factors associated with no progression to intubation were a reduction in tachycardia after initiation of HFNC and presentation after day 5 of illness. A secondary analysis also revealed decreased rate of intubation with the use of bronchodilators. We identified demographic, clinical, and therapeutic factors that are associated with requiring intubation.

Conclusion: Given the high burden of bronchiolitis in pediatric emergency departments, these factors can be considered upon presentation of children with bronchiolitis to selectively identify children at higher risk for respiratory failure.

Keywords: Bronchiolitis; Emergency department; High flow nasal cannula; Intubation; Respiratory failure.

MeSH terms

  • Adrenal Cortex Hormones / therapeutic use
  • Bronchiolitis / physiopathology
  • Bronchiolitis / therapy
  • Bronchiolitis, Viral / physiopathology
  • Bronchiolitis, Viral / therapy*
  • Bronchodilator Agents / therapeutic use
  • Cannula
  • Continuous Positive Airway Pressure / statistics & numerical data*
  • Disease Progression
  • Female
  • Humans
  • Infant
  • Intubation, Intratracheal / statistics & numerical data*
  • Length of Stay
  • Logistic Models
  • Male
  • Multivariate Analysis
  • Noninvasive Ventilation / methods*
  • Oxygen Inhalation Therapy / methods*
  • Pediatric Emergency Medicine
  • Respiration, Artificial / statistics & numerical data
  • Respiratory Insufficiency / physiopathology
  • Respiratory Insufficiency / therapy*
  • Respiratory Syncytial Virus Infections / physiopathology
  • Respiratory Syncytial Virus Infections / therapy
  • Retrospective Studies
  • Risk Factors
  • Tachycardia / physiopathology


  • Adrenal Cortex Hormones
  • Bronchodilator Agents