High-flow oxygen therapy is more cost-effective for bronchiolitis than standard treatment-A decision-tree analysis

Effect Modifiers of the Association of High-Flow Nasal Cannula and Bronchiolitis Length of Stay

BACKGROUND AND OBJECTIVES

High-flow nasal cannula (HFNC) therapy for hospitalized children with bronchiolitis is associated with a longer length of stay (LOS) when used outside of the ICU. We sought to explore the association between HFNC and LOS to identify if demographic and clinical factors may modify the effect of HFNC usage on LOS.

METHODS

In this multicenter retrospective cohort study, we used a combination of hospital records and the Pediatric Health Information System. We included encounters from September 1, 2018 to March 31, 2020 for patients <2 years old diagnosed with bronchiolitis. Multivariable Poisson regression was performed for the association of LOS with measured covariates, including fixed main effects and interaction terms between HFNC and other factors.

RESULTS

Of 8060 included patients, 2179 (27.0%) received HFNC during admission. Age group, weight, complex chronic condition, initial tachypnea, initial desaturation, and ICU services were significantly associated with LOS. The effect of HFNC on LOS differed among hospitals (P < .001), with the estimated increase in LOS ranging from 32% to 139%. The effect of HFNC on LOS was modified by age group, initial desaturation, and ICU services, with 1- to 6-month-old infants, patients without initial desaturation, and patients without ICU services having the highest association between HFNC and LOS, respectively.

CONCLUSIONS

We identified multiple potential effect modifiers for the relationship between HFNC and LOS. The authors of future prospective studies should investigate the effect of HFNC usage on LOS in non-ICU patients without documented desaturation.

Variation and Outcomes of Hospital-Level High-Flow Nasal Cannula Usage Outside of Intensive Care

OBJECTIVES

Bronchiolitis is a viral respiratory infection that can progress to acute respiratory failure. This study evaluated the variability of hospital-wide high-flow nasal cannula (HFNC) usage outside of the ICU and its association with length of stay (LOS) and cost among pediatric patients admitted with bronchiolitis.

METHODS

This study included patients <2 years old admitted with bronchiolitis between September 1, 2018 and March 31, 2019. Hospitals were divided into groups based on the proportion of patients among those who had never been in the ICU who received HFNC (non-ICU HFNC usage [NIHU]). We performed hierarchical mixed-model linear regression to estimate the association of NIHU with LOS and cost using multiplicative ratios (MR) and 95% confidence intervals (CI), both (1) unadjusted and (2) after adjusting for demographics, clinical characteristics, and individual utilization of HFNC and/or ICU.

RESULTS

Unadjusted LOS was longer for patients in moderate (MR 1.14; 95% CI 1.11-1.18) and high (MR 1.26; 95% CI 1.22-1.30) NIHU hospitals. Adjusted LOS was longer in moderate (MR 1.03; 95% CI 1.01-1.06), and high (MR 1.08; 95% CI 1.05-1.11) NIHU hospitals. Unadjusted total cost was higher for patients in moderate (MR 1.20; 95% CI 1.16-1.25) and high (MR 1.26; 95% CI 1.22-1.31) NIHU hospitals. Adjusted total cost was higher for patients in moderate (MR 1.05; 95% CI 1.03-1.08), and high (MR 1.05; 95% CI 1.02-1.08) NIHU hospitals.

CONCLUSIONS

In this study, increased NIHU is associated with increased LOS and total cost.

High Flow Nasal Cannula Therapy in the Emergency Department: Main Benefits in Adults, Pediatric Population and against COVID-19: A Narrative Review

This review aims to summarize the literature’s main results about high flow nasal cannula therapy (HFNC) HFNC benefits in the Emergency Department (ED) in adults and pediatrics, including new Coronavirus Disease (COVID-19). HFNC has recently been established as the usual treatment in the ED to provide oxygen support. Its use has been generalized due to its advantages over traditional oxygen therapy devices, including decreased nasopharyngeal resistance, washing out of the nasopharyngeal dead space, generation of positive pressure, increasing alveolar recruitment, easy adaptation due to the humidification of the airways, increased fraction of inspired oxygen and improved mucociliary clearance. A wide range of pathologies has been studied to evaluate the potential benefits of HFNC; some examples are heart failure, pneumonia, chronic pulmonary obstructive disease, asthma, and bronchiolitis. The regular use of this oxygen treatment is not established yet due to the literature’s controversial results. However, several authors suggest that it could be useful in several pathologies that generate acute respiratory failure. Consequently, the COVID-19 irruption has generated the question of HFNC as a safety and effective treatment. Our results suggested that HFNC seems to be a useful tool in the ED, especially in patients affected by acute hypoxemic respiratory failure, acute heart failure, pneumonia, bronchiolitis, asthma and acute respiratory distress syndrome in patients affected by COVID-19. Its benefits in hypercapnic respiratory failure are more discussed, being only observed benefits in patients with mild-moderate disease. These results are based in clinical as well as cost-effectiveness outcomes. Future studies with largest populations are required to confirm these results as well as establish a practical guideline to use this device.

Impact of High Flow Nasal Cannula on Resource Utilization in Bronchiolitis

OBJECTIVES

High flow nasal cannula (HFNC) is increasingly used for children hospitalized with bronchiolitis. We aimed to validate identification of HFNC use in a national database, then compare resource utilization among children treated with and without HFNC.

METHODS

In this cross-sectional, multicenter study, we obtained clinical and resource utilization data from the Pediatric Health Information System (PHIS) database for healthy children aged 1 to 24 months admitted for bronchiolitis. We assessed HFNC use based on a combination of billing codes and reviewed charts at 2 hospitals to determine their accuracy. We compared costs, length of stay, and readmissions between the HFNC and no HFNC groups at hospitals utilizing the HFNC codes.

RESULTS

The PHIS codes demonstrated 90.4% sensitivity and 99.3% specificity to detect HFNC use as verified by chart review at 2 hospitals. However, only 24 of 51 PHIS hospitals used these codes for ≥1% of patients with bronchiolitis. Within those hospitals, children treated with HFNC had greater total costs ($7054 vs $4544; P < .001), greater daily costs ($2922 vs $2613; P < .001), and longer length of stay (57.6 vs 41.6 hours; P < .001). Those treated with HFNC were less likely to be readmitted at 3 and 7 days (P < .001), but by 14 days, readmissions were similar in the 2 groups.

CONCLUSIONS

Billing codes for HFNC are inconsistently applied across PHIS hospitals; however, among those hospitals that routinely apply these codes, HFNC was associated with more intense resource utilization. Standardization of billing practices for HFNC would allow future study to more broadly describe the value of HFNC.

Use of high-flow nasal cannula and intravenous propofol sedation while performing flexible video bronchoscopy in the intensive care unit: Case reports

Flexible video bronchoscopy is a procedure that plays an important role in diagnosing various types of pulmonary lesions and abnormalities. Case 1 is a 68-year-old male patient with a lesion in the right lung apex of approximately 4 mm × 28 mm with atelectasis bands due to a crash injury. High-flow system with 35 L/min and fraction of inspired oxygen (FiO₂) 0.45 and temperature of 34 °C was installed prior to the video bronchoscopy. SpO₂ was maintained at 98%-100%. The total dose of sedative was 50 mg of propofol. In Case 2, a 64-year-old male patient with bronchiectasis, cystic lesions and pulmonary fibrosis of the left lung field was placed on a high-flow system with 45 L/min and 0.35 FiO₂ at a temperature of 34 °C. SpO₂ was maintained at 100%. The total duration of the procedure was 25 min; SpO₂ of 100% was sustained with oxygenation during maintenance time with the flexible bronchoscope within the airway. The total dose of propofol to reach the degree of desired sedation was 0.5-1 mg/kg. Both patients presented hypotension. For the patient of case 1, a vasopressor (norepinephrine at doses of 0.04 µg/kg/min) was given, and for the patient of case 2, only saline volume expansion was used. The video bronchoscopy with propofol sedation and high-flow nasal cannula allows adequate oxygenation during procedure in the intensive care unit.

Clinical practices related to high-flow nasal cannulas in pediatric critical care in Brazil compared to other countries: a Brazilian survey

Objetivo

Descrever as práticas clínicas atuais relacionadas à utilização de cânula nasal de alto fluxo por intensivistas pediátricos brasileiros e compará-las com as de outros países.

Métodos

Para o estudo principal, foi administrado um questionário a intensivistas pediátricos em países das Américas do Norte e do Sul, Ásia, Europa e Austrália/Nova Zelândia. Comparou-se a coorte brasileira com coortes dos Estados Unidos, Canadá, Reino Unido e Índia.

Resultados

Responderam ao questionário 501 médicos, dos quais 127 eram do Brasil. Apenas 63,8% dos participantes brasileiros tinham disponibilidade de cânula nasal de alto fluxo, em contraste com 100% dos participantes no Reino Unido, no Canadá e nos Estados Unidos. Coube ao médico responsável a decisão de iniciar a utilização de uma cânula nasal de alto fluxo segundo responderam 61,2% dos brasileiros, 95,5% dos localizados no Reino Unido, 96,6% dos participantes dos Estados Unidos, 96,8% dos médicos canadenses e 84,7% dos participantes da Índia; 62% dos participantes do Brasil, 96,3% do Reino Unido, 96,6% dos Estados Unidos, 96,8% do Canadá e 84,7% da Índia relataram que o médico responsável era quem definia o desmame ou modificava as regulagens da cânula nasal de alto fluxo. Quando ocorreu falha da cânula nasal de alto fluxo por desconforto respiratório ou insuficiência respiratória, 82% dos participantes do Brasil considerariam uma tentativa com ventilação não invasiva antes da intubação endotraqueal, em comparação com 93% do Reino Unido, 88% dos Estados Unidos, 91,5% do Canadá e 76,8% da Índia. Mais intensivistas brasileiros (6,5%) do que do Reino Unido, Estados Unidos e Índia (1,6% para todos) afirmaram utilizar sedativos com frequência concomitantemente à cânula nasal de alto fluxo.

Conclusão

A disponibilidade de cânulas nasais de alto fluxo no Brasil ainda não é difundida. Há algumas divergências nas práticas clínicas entre intensivistas brasileiros e seus colegas estrangeiros, principalmente nos processos e nas tomadas de decisão relacionados a iniciar e desmamar o tratamento com cânula nasal de alto fluxo.

Real-life study of the role of high-flow nasal cannula for bronchiolitis in children younger than 3 months hospitalised in general pediatric departments

We aimed to describe the real-life role of high-flow nasal cannula (HFNC) for bronchiolitis in infants under 3 months of age admitted to three general pediatric departments during the 2017-2018 epidemic period. We retrospectively assessed the clinical severity (Wang score) for every 24-h period of treatment (H0-H24 and H24-H48) according to the initiated medical care (HFNC, oxygen via nasal cannula, or supportive treatments only), the child's discomfort (EDIN score), and transfer to the pediatric intensive care unit (PICU). A total of 138 infants were included: 47±53 days old, 4661±851.9 g, 70 boys (50.7%), 58 with hypoxemia (42%), Wang score of 6.67±2.58, 110 (79.7%) staying for 48 consecutive hours in the same ward. During the H0-H24 period, only patients treated with HFNC had a statistically significant decrease in the severity score (n=21/110; -2 points, P=0.002) and an improvement in the discomfort score (n=15/63; -3.8 points, P<0.0001). There was no difference between groups during the H24-H48 period. The rate of admission to the PICU was 2.9% for patients treated for at least 24 h with HFNC (n=34/138, 44% with oxygen) versus 16.3% for the others (P=0.033). Early use of HFNC improves both clinical status and discomfort in infants younger than 3 months admitted for moderately severe bronchiolitis, whatever their oxygen status.

First-line oxygen therapy with high-flow in bronchiolitis is not cost saving for the health service

BACKGROUND

Bronchiolitis is the most common reason for hospital admission in infants. High-flow oxygen therapy has emerged as a new treatment; however, the cost-effectiveness of using it as first-line therapy is unknown.

OBJECTIVE

To compare the cost of providing high-flow therapy as a first-line therapy compared with rescue therapy after failure of standard oxygen in the management of bronchiolitis.

METHODS

A within-trial economic evaluation from the health service perspective using data from a multicentre randomised controlled trial for hypoxic infants (≤12 months) admitted to hospital with bronchiolitis in Australia and New Zealand. Intervention costs, length of hospital and intensive care stay and associated costs were compared for infants who received first-line treatment with high-flow therapy (early high-flow, n=739) or for infants who received standard oxygen and optional rescue high-flow (rescue high-flow, n=733). Costs were applied using Australian costing sources and are reported in 2016-2017 AU$.

RESULTS

The incremental cost to avoid one treatment failure was AU$1778 (95% credible interval (CrI) 207 to 7096). Mean cost of bronchiolitis treatment including intervention costs and costs associated with length of stay was AU$420 (95% CrI -176 to 1002) higher per infant in the early high-flow group compared with the rescue high-flow group. There was an 8% (95% CrI 7.5 to 8.6) likelihood of the early high-flow oxygen therapy being cost saving.

CONCLUSIONS

The use of high-flow oxygen as initial therapy for respiratory failure in infants with bronchiolitis is unlikely to be cost saving to the health system, compared with standard oxygen therapy with rescue high-flow.

Use of high-flow nasal cannula in infants with viral bronchiolitis outside pediatric intensive care units

High-flow nasal cannula (HFNC) is frequently used in infants with acute viral bronchiolitis outside pediatric intensive care units (PICU). A structured questionnaire was sent out to pediatricians of all public French hospitals with pediatric emergency and/or general pediatric departments on their use of HFNC outside PICU (department using HFNC, number of available devices, monitoring, criteria for initiating or stopping HFNC, and personal comments on HFNC). Of the 166 eligible hospitals, 135 answered (96 general and 39 university hospitals; 81.3%), for a total of 217 answering pediatricians. Seventy-two hospitals (53.3%) used HFNC in acute bronchiolitis outside PICU, particularly, general hospitals (59.4% vs 38.5%), and mostly in pediatric general departments (75%). Continuous patient monitoring with a cardiorespiratory monitor was usual (n = 58, 80%). Nursing staff was responsible for 2.7 children on HFNC and checked vital signs 8.6 times per day. Criteria for HFNC initiation and withdrawal were not standardized. Pediatricians had a positive opinion of HFNC and were willing to extend its use to other diseases.Conclusion: Use of HFNC outside PICU in infants with acute bronchiolitis is now usual, but urgently requires guidelines. What is Known: • Acute viral bronchiolitis treatment is only supportive • High-flow nasal cannula (HFNC) is a respiratory support accumulating convincing clinical evidence in bronchiolitis • This latter treatment is usually proposed in pediatric intensive care unit (PICU) What is New: • HFNC are increasingly used outside PICU in bronchiolitis, particularly, in general hospitals and in pediatric general departments • Pediatricians are enthusiastic about this device, but validated criteria for initiation and withdrawal are lacking • Guidelines for the use of HFNC outside PICU are urgently required.

Uses of high-flow nasal cannula on the community paediatric ward and risk factors for deterioration

Background

High-flow nasal cannula (HFNC) is a form of noninvasive respiratory support used for paediatric acute respiratory illnesses. Past HFNC research has focused on its use in bronchiolitis and in intensive care units, but little is reported on its use in the community hospital setting. We aimed to investigate the paediatric population using HFNC, any adverse events, and risk factors for deterioration.

Methods

A retrospective chart review was performed on patients admitted to a community paediatric ward. Inclusion criteria were patients between 1 day and 17 years of age, admitted between September 2013 and April 2016, and treated with HFNC for at least 4 hours.

Results

A total of 85 children met inclusion criteria. The average age of patients in our study was 3.41 years with 39% of patients >2 years of age. 46% of patients had an admitting diagnosis of bronchiolitis, 33% pneumonia, and 16% with asthma. Transfer rate to tertiary care centre paediatric intensive care unit was 18%. Patients transferred required greater FIO2 (odds ratio [OR] 1.04, P=0.018, confidence interval [CI] 1.007 to 1.082), and were 3.2 times more likely to be positive for respiratory syncytial virus (RSV) (P=0.081, CI 0.868-11.739). There were no adverse events attributed to HFNC in the population.

Conclusion

HFNC is being utilized in the community hospital setting for children of varied age and types of respiratory illnesses. Children requiring higher FIO2 are at risk of respiratory deterioration which may identify them earlier for transfer to tertiary care. Further research into the safety and efficacy of HFNC for different paediatric illnesses in the community is needed.

High flow nasal cannula in the emergency department: indications, safety and effectiveness

INTRODUCTION

Heated humidified high flow nasal cannula therapy (HHHFNCT) is emerging as a popular non-invasive mode of respiratory support in adults and children. In recent years, its use has extended beyond the intensive care unit to other clinical areas. This review aims to explore the mechanism of action, indications, safety, and effectiveness of HHHFNCT use in the Emergency Department (ED).

AREAS COVERED

The mechanism of action of HHHFNCT, as well as its use in adult and pediatric ED will be discussed in this review.

EXPERT COMMENTARY

While there exists increasing enthusiasm in the use of HHHFNCT in the ED, constant monitoring of the patients and an experienced assessment of their response to treatment are critical and may require additional manpower deployment, which may be challenging, in the busy ED environment. Our experience with the use of HHHFNCT in children is still growing. Continual research in this area remains crucial in helping us better understand the patient types and conditions managed in ED that would most benefit from this device.

Using high-flow nasal cannulas for infants with bronchiolitis admitted to paediatric wards is safe and feasible

AIM

Using a high-flow nasal cannula (HFNC) for infant bronchiolitis is increasingly common, but insufficiently studied. In this retrospective study, we examined the outcomes of HFNC and compared infants who did and did not respond to this oxygen delivery method.

METHODS

This 2012-2015 study of six Finnish hospitals focused on 88 infants under 12 months who received HFNC: 53 on paediatric wards and 35 in paediatric intensive care units (PICUs). We reviewed patient files for underlying factors, clinical parameters and HFNC treatment. The treatment failed if the patient was transferred to another respiratory support.

RESULTS

We found HFNC treatment was successful in 76 (86%) infants, including all 53 on the paediatric wards and 23/35 PICU patients. The responders' heart rates were significantly lower, and their oxygen saturation was significantly higher at 60 minutes after HFNC treatment started and then stayed relatively constant. Their respiratory rate was only significantly lower after 360 minutes. In non-responders, the respiratory rate initially decreased but was higher at 180 and 360 minutes after the start of HFNC.

CONCLUSION

We found preliminary evidence that oxygen support needs and heart rate were useful early predictors of HFNC therapy success in infants hospitalised with bronchiolitis, but respiratory rate was not.

National high-flow nasal cannula and bronchiolitis survey highlights need for further research and evidence-based guidelines

AIM

High-flow nasal cannula (HFNC) therapy provides noninvasive respiratory support for infant bronchiolitis and its use has increased following good clinical experiences. This national study describes HFNC use in Finland during a severe respiratory syncytial virus (RSV) epidemic.

METHODS

A questionnaire on using HFNC for infant bronchiolitis during the 2015-2016 RSV epidemic was sent to the head physicians of 18 Finnish children's hospitals providing inpatient care for infants: 17 hospitals answered, covering 77.5% of the infants born in Finland in 2015.

RESULTS

Most (85%) HFNC was given on paediatric wards. The mean incidence for bronchiolitis treated with HFNC in infants under the age of one in 15 of 17 hospitals was 3.8 per 1000 per year (range: 1.4-8.1): one hospital did not supply the relevant data and one supplied a figure of 34.1 due to a different treatment policy. Instructions on how to start and wean HFNC therapy were present in 71% and 61% of the hospitals, respectively, weighted to the population. Providing weaning instructions was associated with shorter weaning times.

CONCLUSION

High-flow nasal cannula was actively used for infants with bronchiolitis, with no substantial overuse. Randomised controlled studies are needed before any evidence-based guidelines can be constructed for using HFNC in infant bronchiolitis.

The treatment of acute bronchiolitis: past, present and future

Lower respiratory tract infections are a common cause of hospitalisation in infants. It is estimated that infants younger than 12 months with bronchiolitis account for 18% of all paediatric admission [1], representing a great burden to industrialised healthcare systems each winter.

Acute bronchiolitis treatment: little has changed from late 19th century to nowadays, promising strategies incominghttp://ow.ly/BmH230aWoXr

Pediatric pulmonology year in review 2016: Part 2

Pediatric Pulmonology continues to publish research and clinical topics related to the entire range of children's respiratory disorders. As we have done annually in recent years, we here summarize some of the past year's publications in our major topic areas, as well as selected literature in these areas from other core journals relevant to our discipline. This review (Part 2) covers selected articles on neonatology, asthma, physiology and lung function testing, and infectious diseases.

High-Flow Nasal Cannula in Bronchiolitis: Modeling the Economic Effects of a Ward-Based Protocol

OBJECTIVES

High-flow nasal cannula (HFNC) use has increased in patients with bronchiolitis, with the majority of use restricted to the ICU. Broadening HFNC to the wards may have substantial economic implications. This study compares the cost of a standardized clinical pathway that permits HFNC use in the wards for patients with bronchiolitis with an ICU-only HFNC care model.

METHODS

We constructed a decision analytic model to simulate 2 options for treating bronchiolitic patients: one in which HFNC is used in the wards (ward HFNC) and one in which HFNC is restricted to the ICU (ICU HFNC). The model inputs were based on patients admitted with bronchiolitis without major comorbidities between 2010 and 2015. 1432 patients were included for analysis. We simulated 10 000 patients for 5000 trials to assess parameter variability and sampling uncertainty, respectively. The primary outcome was average admission cost per patient. The secondary outcome was average length of stay (LOS) per patient.

RESULTS

In the model, the average admission cost per patient for the ward HFNC group was $7020 (95% confidence interval [CI] $6840-$7194) compared with $7626 (95% CI $7427-$7839) in the ICU HFNC group, with a net difference of $606 (95% CI $408-$795). The average LOS for the ward HFNC group was 2.29 days (95% CI 2.24-2.33) compared with 2.61 days (95% CI 2.56-2.66) in the ICU HFNC group, with a net difference of 0.32 days (95% CI 0.27-0.37).

CONCLUSIONS

Using HFNC in the ward for bronchiolitis may be cost-effective and may decrease LOS compared with ICU-only HFNC.