High-flow nasal cannula (HFNC) support in interhospital transport of critically ill children

A Comprehensive Review on High-Flow Nasal Cannula Oxygen Therapy in Critical Care: Evidence-Based Insights and Future Directions

High-flow nasal cannula (HFNC) therapy has emerged as a significant advancement in respiratory support, offering a non-invasive alternative to traditional oxygen delivery methods in critical care settings. This review comprehensively evaluates HFNC therapy, focusing on its definition, historical evolution, and current clinical applications. HFNC therapy delivers humidified and heated oxygen at high flow rates through a nasal cannula, enhancing oxygenation and patient comfort. The review highlights the physiological mechanisms underlying HFNC and its efficacy in managing acute respiratory failure, chronic obstructive pulmonary disease exacerbations, and postoperative respiratory support. Key findings from clinical trials and meta-analyses are discussed, emphasizing HFNC's advantages over conventional methods, such as reduced intubation rates and shorter ICU stays. The review also addresses safety considerations, including potential risks and complications associated with HFNC therapy. Furthermore, it explores future directions for research and technological advancements aimed at optimizing HFNC use in diverse patient populations. This review aims to provide evidence-based insights to inform clinical practice and guide future investigations in respiratory therapy.

Expert consensus on the diagnosis, treatment, and prevention of respiratory syncytial virus infections in children

BACKGROUND

Respiratory syncytial virus (RSV) is the leading global cause of respiratory infections and is responsible for about 3 million hospitalizations and more than 100,000 deaths annually in children younger than 5 years, representing a major global healthcare burden. There is a great unmet need for new agents and universal strategies to prevent RSV infections in early life. A multidisciplinary consensus development group comprising experts in epidemiology, infectious diseases, respiratory medicine, and methodology aims to develop the current consensus to address clinical issues of RSV infections in children.

DATA SOURCES

The evidence searches and reviews were conducted using electronic databases, including PubMed, Embase, Web of Science, and the Cochrane Library, using variations in terms for "respiratory syncytial virus", "RSV", "lower respiratory tract infection", "bronchiolitis", "acute", "viral pneumonia", "neonatal", "infant" "children", and "pediatric".

RESULTS

Evidence-based recommendations regarding diagnosis, treatment, and prevention were proposed with a high degree of consensus. Although supportive care remains the cornerstone for the management of RSV infections, new monoclonal antibodies, vaccines, drug therapies, and viral surveillance techniques are being rolled out.

CONCLUSIONS

This consensus, based on international and national scientific evidence, reinforces the current recommendations and integrates the recent advances for optimal care and prevention of RSV infections. Further improvements in the management of RSV infections will require generating the highest quality of evidence through rigorously designed studies that possess little bias and sufficient capacity to identify clinically meaningful end points.

Analysis of High Flow Nasal Cannula Utilization During Pediatric Critical Care Transport

OBJECTIVE

There are limited studies on the safety and efficacy of high flow nasal cannula (HFNC) use in pediatrics during interfacility critical care transport. This 15-month retrospective study aims to describe our transport team's utilization of HFNC within the pediatric population and evaluates the need for patient escalation in respiratory support within 24 hours of hospital admission including increased liter flow, transition to noninvasive ventilation, or intubation.

METHODS

Retrospective charts were reviewed by study members from January 1, 2019, through March 31, 2020. Study dates were specifically chosen to reflect when HFNC was implemented in the transport department and before the beginning of the severe acute respiratory syndrome coronavirus disease 2019 (SARS-COVID-19) pandemic because of variability in respiratory support recommendations at the beginning of the pandemic. Patients were screened for inclusion criteria and were included if they were >30 days and <18 years of age, required HFNC at ≥4 L/min during transport, and were admitted to Children's Mercy Hospital.

RESULTS

During the study period, we completed 6,279 pediatric transports, of which 382 had documented HFNC use and 358 met the inclusion criteria. Our HFNC patients had a median age of 0.7 years with an interquartile range (IQR) of 0.3 to 1 year, a median weight of 8.4 kg with an IQR of 6.2 to 11 kg, a median liter flow of 10 L/min and 1.2 L/kg/min, and required a median transport time of 80 minutes with an IQR of 69 to 115 min. Patients were tracked for 24 hours post-admission for any escalations in care; 33% required an escalation, 76% of those had an increase in flow, 24% required noninvasive ventilation, and 0% required intubation.

CONCLUSION

Our study suggests HFNC is a safe and effective means for providing respiratory support to the pediatric population during interfacility critical care transport. Our data support utilization of 1 to 2 L/kg/min in the smaller pediatric population (<10 kg) during transport. There was minimal risk of escalation to noninvasive ventilation, and no patients required intubation within 24 hours post drop-off, likely because of the appropriate utilization of HFNC during transport. Additional studies, especially multicenter pediatric studies, are needed to analyze HFNC utilization with non-restricting circuits and vibrating mesh nebulizers.

Efficacy of prophylactic high-flow nasal cannula therapy for postoperative pulmonary complications after pediatric cardiac surgery: a prospective single-arm study

PURPOSE

This study investigated the incidence of postoperative pulmonary complications (PPC) when high-flow nasal cannula therapy (HFNC) is used prophylactically after pediatric cardiac surgery, and evaluated its efficacy.

METHODS

This was a single-arm prospective interventional study that was conducted in a tertiary teaching hospital with eight beds in the pediatric cardiac ICU after approval by the Ethics Committee. One-hundred children under the age of 48 months who were scheduled for cardiac surgery for congenital heart disease were recruited. HFNC was used for 24 h after extubation at a 2 L/kg/min flow rate. The primary outcome was the incidence of PPC within 48 h after extubation. PPC was defined as atelectasis and acute respiratory failure meeting certain criteria. We considered prophylactic HFNC as effective if the prevalence of PPC was < 10%, based on previous reports of reintubation rates of 6%-9% after pediatric cardiac surgery.

RESULTS

A total of 91 patients were finally included in the analysis. The incidence of PPC within 48 h after extubation was 18.7%, whereas atelectasis was observed in 13.2%, and acute respiratory failure in 8.8%. Reintubation rate within 48 h after extubation was 0%.

CONCLUSIONS

We found the incidence of PPC with prophylactic HFNC after planned extubation after pediatric cardiac surgery. However, the incidence was > 10%; therefore, we could not demonstrate its efficacy in this single-arm study. Further studies are needed to investigate whether the HFNC could be adapted as first-line oxygen therapy after pediatric cardiac surgery.

Clinical practice guidelines: management of severe bronchiolitis in infants under 12 months old admitted to a pediatric critical care unit

PURPOSE

We present guidelines for the management of infants under 12 months of age with severe bronchiolitis with the aim of creating a series of pragmatic recommendations for a patient subgroup that is poorly individualized in national and international guidelines.

METHODS

Twenty-five French-speaking experts, all members of the Groupe Francophone de Réanimation et Urgence Pédiatriques (French-speaking group of paediatric intensive and emergency care; GFRUP) (Algeria, Belgium, Canada, France, Switzerland), collaborated from 2021 to 2022 through teleconferences and face-to-face meetings. The guidelines cover five areas: (1) criteria for admission to a pediatric critical care unit, (2) environment and monitoring, (3) feeding and hydration, (4) ventilatory support and (5) adjuvant therapies. The questions were written in the Patient-Intervention-Comparison-Outcome (PICO) format. An extensive Anglophone and Francophone literature search indexed in the MEDLINE database via PubMed, Web of Science, Cochrane and Embase was performed using pre-established keywords. The texts were analyzed and classified according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. When this method did not apply, an expert opinion was given. Each of these recommendations was voted on by all the experts according to the Delphi methodology.

RESULTS

This group proposes 40 recommendations. The GRADE methodology could be applied for 17 of them (3 strong, 14 conditional) and an expert opinion was given for the remaining 23. All received strong approval during the first round of voting.

CONCLUSION

These guidelines cover the different aspects in the management of severe bronchiolitis in infants admitted to pediatric critical care units. Compared to the different ways to manage patients with severe bronchiolitis described in the literature, our original work proposes an overall less invasive approach in terms of monitoring and treatment.

Interfacility Transport of Critically Ill Patients

OBJECTIVES

To assess recent advances in interfacility critical care transport.

DATA SOURCES

PubMed English language publications plus chapters and professional organization publications.

STUDY SELECTION

Manuscripts including practice manuals and standard (1990-2021) focused on interfacility transport of critically ill patients.

DATA EXTRACTION

Review of society guidelines, legislative requirements, objective measures of outcomes, and transport practice standards occurred in work groups assessing definitions and foundations of interfacility transport, transport team composition, and transport specific considerations. Qualitative analysis was performed to characterize current science regarding interfacility transport.

DATA SYNTHESIS

The Task Force conducted an integrative review of 496 manuscripts combined with 120 from the authors' collections including nonpeer reviewed publications. After title and abstract screening, 40 underwent full-text review, of which 21 remained for qualitative synthesis.

CONCLUSIONS

Since 2004, there have been numerous advances in critical care interfacility transport. Clinical deterioration may be mitigated by appropriate patient selection, pretransport optimization, and transport by a well-resourced team and vehicle. There remains a dearth of high-quality controlled studies, but notable advances in monitoring, en route management, transport modality (air vs ground), as well as team composition and training serve as foundations for future inquiry. Guidance from professional organizations remains uncoupled from enforceable regulations, impeding standardization of transport program quality assessment and verification.

Noninvasive ventilation of air transported infants with respiratory distress in the Canadian Arctic

Objectives

Since 2016, use of nasal continuous positive airway pressure (nCPAP) in Nunavut for air transport in select patients has become common practice. This study examines the outcomes of patients transferred by air from the Qikiqtaaluk Region during air transport. We examined intubation rates, adverse events during transfer, and respiratory parameters at departure and upon arrival.

Methods

This was a retrospective review from September 2016 to December 2019 including patients under 2 years of age transferred by air on nCPAP from the Qikiqtaaluk Region of Nunavut.

Results

Data were collected for 40 transfers involving 34 unique patients. Six transfers were from remote communities in Nunavut to Iqaluit, and 33 transfers were from Iqaluit to CHEO. The primary outcome measure was whether the patient required intubation during transport, or urgent intubation upon arrival to CHEO. The median nCPAP setting during transport was 6 cm H2O (5–7 cm H2O) and at arrival to CHEO was 6 cm H2O (6–7 cm H2O). Six of the 33 (18.2%) patients required intubation during their hospital stay and five (15.2%) in a controlled ICU setting. There were no discernible adverse events that occurred during transport for 28 patients (84.5%). Four patients (12.1%) required a brief period of bag-mask ventilation and one patient had an episode of bradycardia.

Conclusions

nCPAP on air transport is a safe and useful method for providing ventilatory support to infants and young children with respiratory distress.

High Flow Nasal Cannula in the Pediatric Intensive Care Unit

INTRODUCTION

The use of high flow nasal cannula (HFNC) has become widely used in pediatric intensive care units (PICUs) throughout the world. The rapid adoption has outpaced the number of studies evaluating the safety and efficacy in a variety of pediatric diseases/conditions.

AREAS COVERED

This scoping review begins with the definition and mechanisms of action of HFNC and then follows with a review of the literature focused on studies performed on critically ill children cared for in the PICU. The Pubmed database was searched with a pediatric filter from the time period 2000 to 2021.

EXPERT OPINION

The rapid adoption of HFNC in PICUs has largely been driven by changes in institutional practices and small observational studies. There is a lack of adequately powered studies evaluating patient-centered outcomes, such as intubation rates, mortality, PICU and hospital length of stay. Given the wide variability in flow rates and clinical indications, more research is needed to better define effective flow rates for different disease states as well as markers of treatment success and failure. One particular entity that is poorly studied is the use of HFNC in those at risk for developing pediatric acute respiratory distress syndrome (PARDS).

Prehospital Pediatric Respiratory Distress and Airway Management Interventions: An NAEMSP Position Statement and Resource Document

Devices and techniques such as bag-valve-mask ventilation, endotracheal intubation, supraglottic airway devices, and noninvasive ventilation offer important tools for airway management in critically ill EMS patients. Over the past decade the tools, technology, and strategies used to assess and manage pediatric respiratory and airway emergencies have evolved, and evidence regarding their use continues to grow.NAEMSP recommends:Methods and tools used to properly size pediatric equipment for ages ranging from newborns to adolescents should be available to all EMS clinicians. All pediatric equipment should be routinely checked and clearly identifiable in EMS equipment supply bags and vehicles.EMS agencies should train and equip their clinicians with age-appropriate pulse oximetry and capnography equipment to aid in the assessment and management of pediatric respiratory distress and airway emergencies.EMS agencies should emphasize noninvasive positive pressure ventilation and effective bag-valve-mask ventilation strategies in children.Supraglottic airways can be used as primary or secondary airway management interventions for pediatric respiratory failure and cardiac arrest in the EMS setting.Pediatric endotracheal intubation has unclear benefit in the EMS setting. Advanced approaches to pediatric ETI including drug-assisted airway management, apneic oxygenation, and use of direct and video laryngoscopy require further research to more clearly define their risks and benefits prior to widespread implementation.If considering the use of pediatric endotracheal intubation, the EMS medical director must ensure the program provides pediatric-specific initial training and ongoing competency and quality management activities to ensure that EMS clinicians attain and maintain mastery of the intervention.Paramedic use of direct laryngoscopy paired with Magill forceps to facilitate foreign body removal in the pediatric patient should be maintained even when pediatric endotracheal intubation is not approved as a local clinical intervention.

Prehospital Noninvasive Ventilation: An NAEMSP Position Statement and Resource Document

Noninvasive ventilation (NIV), including bilevel positive airway pressure and continuous positive airway pressure, is a safe and important therapeutic option in the management of prehospital respiratory distress. NAEMSP recommends:NIV should be used in the management of prehospital patients with respiratory failure, such as those with chronic obstructive pulmonary disease, asthma, and pulmonary edema.NIV is a safe intervention for use by Emergency Medical Technicians.Medical directors must assure adequate training in NIV, including appropriate patient selection, NIV system operation, administration of adjunctive medications, and assessment of clinical response.Medical directors must implement quality assessment and improvement programs to assure optimal application of and outcomes from NIV.Novel NIV methods such as high-flow nasal cannula and helmet ventilation may have a role in prehospital care.

High-Flow Nasal Cannula in Transport: Process, Results, and Considerations

Objective

The current coronavirus disease 2019 pandemic has increased interest in the use of high-flow nasal cannula (HFNC) in the transport setting. The purpose of this report was to outline the clinical workflow of using HFNC in transport and the results of a retrospective chart review of patients undergoing interhospital transfer on HFNC.

Methods

We conducted a retrospective chart review of all patient transfers using HFNC between January 2018 and June 2019. The primary data abstracted from patient charts included patient demographics, transport distance, HFNC settings including flow rate in liters per minute and fraction of inspired oxygen (Fio₂), and vital signs.

Results

There was a total of 220 patients, 148 pediatric and 72 adult patients. Both pediatric groups experienced statistically significant reductions in heart rate, systolic blood pressure, and diastolic blood pressure. The most common flow rate for both pediatric groups was 10 L/min and 50 L/min for adults. For pediatrics, the most common settings ranged between 30% and 50% Fio₂, with the most common setting being 30% Fio₂. The adult Fio₂ settings ranged from 30% to 100% Fio₂, with the 2 most common settings being 50% Fio₂ and 80% Fio₂. No patients were intubated during the transport encounter.

Conclusion

Our study provides evidence that HFNC is feasible and tolerated by patients and is an additional option for noninvasive ventilation in transport across the age continuum. Future studies are needed to compare HFNC with other noninvasive modalities that include assessing patient tolerance and comfort as contributing factors and to identify indications and contraindications for use in the transport setting.

Queensland Pediatric Sepsis Breakthrough Collaborative: Multicenter Observational Study to Evaluate the Implementation of a Pediatric Sepsis Pathway Within the Emergency Department

Supplemental Digital Content is available in the text.

To evaluate the implementation of a pediatric sepsis pathway in the emergency department as part of a statewide quality improvement initiative in Queensland, Australia.

Indications and Safety of High Flow Nasal Cannula in Pediatric Intensive Care Unit: Retrospective Single Center Experience in Saudi Arabia

Background

High flow nasal cannula (HFNC) is a new device for respiratory support. Its use continues to increase in pediatrics as its system is easily set up and well tolerated by patients. We aimed in this study to explore indications and safety of HFNC use and predictors of HFNC failure.

Methods

Hospital records of 92 children with acute respiratory distress admitted to the pediatric intensive care unit (PICU) in Abha Maternity and Children Hospital from January 2018 until March 2020 and received HFNC therapy were studied. A data collection sheet was used that included patients’ age, gender, the indication of HFNC, associated chronic diseases, previous admission to PICU, vital signs (initially, 8 hours and 48 hours after using HFNC), outcome after using HFNC, and reasons for HFNC failure.

Results

After receiving HFNC, children’s respiratory rate, heart rate, systolic blood pressure, and oxygen saturation improved significantly (p < 0.001, p < 0.001, p < 0.001, p = 0.005, and p < 0.001, respectively). Regarding laboratory findings, pH and serum bicarbonate improved significantly (p < 0.001 for both), while PaCO2 improved but not significantly. The failure rate of HFNC was 23.0%. HFNC failure rates were significantly higher among children with chronic diseases than those with no chronic disease (33.3% and 14.9%, respectively, p = 0.038) and among children with the air-leak syndrome (p < 0.001). After 48 hours of HFNC use, children who experienced HFNC failure had significantly higher respiratory and heart rates (p < 0.001 and p = 0.018, respectively), lower diastolic blood pressure (p = 0.011), and higher PaCO2 (p < 0.001).

Conclusion

After HFNC use, significant improvements occur in all clinical parameters and laboratory values of children with respiratory distress, but about one-fourth of cases may experience HFNC failure. Predictors for HFNC failure include underlying chronic disease, low diastolic blood pressure, high respiratory rate, high heart rate, high initial PaCO2.

Interhospital transport of children with bronchiolitis by a statewide emergency transport service

Objective: To investigate the rate of interhospital emergency transport for bronchiolitis and intensive care admission following the introduction of high flow nasal cannula and standardised paediatric observation and response charts. Design: Retrospective cohort study. Setting: A statewide paediatric intensive care transport service and its two referral paediatric intensive care units (PICUs) in Victoria, Australia. Participants: Children less than 2 years old emergently transported with bronchiolitis during two time periods: 2008-2012 and 2015-2019. Main outcome measures: Incidence rates of bronchiolitis transport episodes, PICU admissions and respiratory support. Results: 802 children with bronchiolitis were transported during the study period, 233 in the first period (2008-2012) and 569 in the second period (2015-2019). The rate of interhospital transport for bronchiolitis increased from 32.9 to 71.8 per 100 000 children aged 0-2 years. The population-adjusted rate of PICU admission increased from 16.2 to 36.6 per 100 000 children aged 0-2 years. Metropolitan hospitals were the predominant referral source and this increased from 60.1% of transports to 78.6% (P < 0.001). In children admitted to a PICU, the administration of high flow nasal cannula during transport increased significantly from 1.7% to 75.9% (P < 0.001) and a concomitant reduction in continuous positive airway pressure and mechanical ventilation occurred (40-12.4% and 27-6.9% respectively; P < 0.001). The proportion of mechanical ventilation as well as PICU and hospital length of stay decreased over time. Conclusions: The population-adjusted rate of interhospital transport and admission to the PICU for bronchiolitis increased over time. This occurred despite a lower rate of non-invasive and invasive mechanical ventilation during transport and in the PICU.

Clinical impact of implementing humidified high-flow nasal cannula on interhospital transport among children admitted to a PICU with respiratory distress: a cohort study

Background

There is a limited evidence for humidified high-flow nasal cannula (HHFNC) use on inter-hospital transport. Despite this, its use during transport is increasing in children with respiratory distress worldwide. In 2015 HHFNC was implemented on a specialized pediatric retrieval team serving for Victoria. The aim of this study is to investigate the effect of the HHFNC implementation on the retrieval team on the paediatric intensive care unit (PICU) length of stay and respiratory support use.

Methods

We performed a cohort study using a comparative interrupted time-series approach controlling for patient and temporal covariates, and population-adjusted analysis. We studied 3022 children admitted to a PICU in Victoria with respiratory distress January 2010–December 2019. Patients were divided in pre-intervention era (2010–2014) and post-intervention era (2015–2019).

Results

1006 children following interhospital transport and 2016 non-transport children were included. Median (IQR) age was 1.4 (0.7–4.5) years. Pneumonia (39.1%) and bronchiolitis (34.3%) were common. On retrieval, HHFNC was used in 5.0% (21/420) and 45.9% (269/586) in pre- and post-intervention era. In an unadjusted model, median (IQR) PICU length of stay was 2.2 (1.1–4.2) and 1.7 (0.9–3.2) days in the pre- and post-intervention era in transported children while the figures were 2.4 (1.3–4.9) and 2.1 (1.2–4.5) days in non-transport children. In the multivariable regression model, the intervention was associated with the reduced PICU length of stay (ratio 0.64, 95% confidential interval 0.49–0.83, p = 0.001) with the predicted reduction of PICU length of stay being − 10.6 h (95% confidential interval − 16.9 to − 4.3 h), and decreased respiratory support use (− 25.1 h, 95% confidential interval − 47.9 to − 2.3 h, p = 0.03). Sensitivity analyses including a model excluding less severe children showed similar results. In population-adjusted analyses, respiratory support use decreased from 4837 to 3477 person-hour per year in transported children over the study era, while the reduction was 594 (from 9553 to 8959) person-hour per year in non-transport children. With regard to the safety, there were no escalations of respiratory support mode during interhospital transport.

Conclusions

The implementation of HHFNC on interhospital transport was associated with the reduced PICU length of stay and respiratory support use among PICU admissions with respiratory distress.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03620-7.

Critical Breaths in Transit: A Review of Non-invasive Ventilation (NIV) for Neonatal and Pediatric Patients During Transportation

Respiratory illnesses are a leading cause of death for children worldwide, with the majority of these cases occurring from preterm birth complications or acute respiratory infections. Appropriate respiratory intervention must be provided quickly to lower the chances of death or permanent harm. As a result, respiratory support given in prehospital and interfacility transport can substantially improve health outcomes for these patients, particularly in areas where transportation time to appropriate facilities is lengthy. Existing literature supports the use of non-invasive ventilation (NIV), such as nasal or bilevel continuous positive airway pressure, as a safe form of respiratory support for children under 18 years old in certain transportation settings. This mini review summarizes the literature on pediatric NIV in transport and highlights significant gaps that future researchers should address. In particular, we identify the need to: solidify clinical guidelines for the selection of eligible pediatric patients for transport on NIV; explore the range of factors influencing successful NIV implementation during transportation; and apply appropriate best practices in low and middle income countries.

Use of Noninvasive Ventilation and High-Flow Nasal Therapy for Infants and Children with Acute Respiratory Distress Outside of Paediatric Intensive Care: A review article

Noninvasive ventilation (NIV) and high-flow nasal cannulae therapy (HFNCT) are first-line methods of treatment for children presenting with acute respiratory distress, with paediatric intensive care units (PICUs) providing an ideal environment for subsequent treatment monitoring. However, the availability of step-down units, where NIV and HFNCT can be safely utilised, has reduced the need for such patients to be admitted to PICUs, thereby leading to the better overall utilisation of critical care resources. In addition, NIV and HFNCT can also be used during transport instead of invasive ventilation, thus avoiding the complications associated with the latter approach. This review article examines the safety and applicability of these respiratory support approaches outside of paediatric intensive care as well as various factors associated with treatment success or failure.

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.

A randomised trial of high-flow nasal cannula in infants with moderate bronchiolitis

BACKGROUND

The objective was to determine whether high-flow nasal cannula (HFNC), a promising respiratory support in infant bronchiolitis, could reduce the proportion of treatment failure requiring escalation of care.

METHODS

In this randomised controlled trial, we assigned infants aged <6 months who had moderate bronchiolitis to receive either HFNC at 3 L·kg^-1·min^-1 or standard oxygen therapy. Crossover was not allowed. The primary outcome was the proportion of patients in treatment failure requiring escalation of care (mostly noninvasive ventilation) within 7 days following randomisation. Secondary outcomes included rates of transfer to the paediatric intensive care unit (PICU), oxygen, number of artificial nutritional support-free days and adverse events.

RESULTS

The analyses included 268 patients among the 2621 infants assessed for inclusion during two consecutive seasons in 17 French paediatric emergency departments. The percentage of infants in treatment failure was 14% (19 out of 133) in the study group, compared to 20% (27 out of 135) in the control group (OR 0.66, 95% CI 0.35-1.26; p=0.21). HFNC did not reduce the risk of admission to PICU (21 (15%) out of 133 in the study group versus 26 (19%) out of 135 in the control group) (OR 0.78, 95% CI 0.41-1.41; p=0.45). The main reason for treatment failure was the worsening of modified Wood clinical asthma score (m-WCAS). Short-term assessment of respiratory status showed a significant difference for m-WCAS and respiratory rate in favour of HFNC. Three pneumothoraces were reported in the study group.

CONCLUSIONS

In patients with moderate bronchiolitis, there was no evidence of lower rate of escalating respiratory support among those receiving HFNC therapy.

Noninvasive ventilation for pediatric interfacility transports: a retrospective study

BACKGROUND

To characterize pediatric patients supported with continuous positive airway pressure and bilevel positive airway pressure (CPAP/BiPAP) or high-flow nasal cannula (HFNC) during interfacility transport (IFT).

METHODS

A retrospective study with a provincial pediatric transport team from a tertiary hospital pediatric intensive care unit. Pediatric patients aged 28 days to < 17 years, who required IFT between January 2017 and December 2018, were identified through a transport registry and were included in the study.

RESULTS

A total of 118 (26.7%) patients received CPAP/BIPAP or HFNC support for IFT. The most common respiratory diagnosis was bronchiolitis (46%). These patients were placed on respiratory support, 31.4 minutes after the transport team's arrival. None required intubation during their IFT, despite mean transport times of 163 minutes.

CONCLUSIONS

This study may provide important information for programs with large catchment areas, in which large distances and transport times should not be barriers to NIV implementation.

Endotracheal intubation by a specialised paediatric retrieval team

OBJECTIVES

Intubation of critically ill children is an infrequent procedure, and is associated with significant risk. We set out to describe intubations carried out by the Children's Health Queensland Retrieval Service (CHQRS), with the intention to identify areas for improvement in the performance of intubation in the retrieval setting.

METHODS

Paediatric patients undergoing transport while intubated were identified, and cases where intubation occurred after the arrival of the CHQRS team were examined.

RESULTS

Over the study period of January 2015 to September 2018, 498 intubated retrievals were undertaken; 85 patients were intubated after the arrival of CHQRS; the age range was 1 day to 16.5 years (median 0.5, interquartile range [IQR] 0.11-3 years). The median weight was 6.2 kg (IQR 3.7-16.5 kg). The pathology requiring intubation included respiratory 36 (42.3%), sepsis 21 (24.7%), neurological 11 (12.9%) and trauma 7 (8.2%). A total of 470 of 498 (94.4%) of intubated patients were from regional referral or tertiary hospitals, 28 of 498 (5.6%) were from rural and remote facilities. Of 85 patients, 57 (67.1%) were intubated by CHQRS and 28 (32.9%) were intubated by a doctor from the referring facility. The CHQRS team was more likely to perform the intubation in smaller children (median weight 5.0 vs 9.9 kg, P = 0.03). The mean scene time was 2.8 h. The scene time was shorter if the intubation was performed by CHQRS (mean 2.6 h, median 2.5, IQR 1.8-3.3; median 3, IQR 2.2-3.9; P = 0.048). The scene time was shorter when the intubation was predicted from tasking information (2.6 vs 3.1 h; P = 0.03).

CONCLUSION

Paediatric endotracheal intubation is an infrequent procedure in our service. An airway registry could improve documentation and gather information to identify specific training requirements and areas for practice improvement.

Efficacy and Safety of Nasal High-Flow Therapy for Neonatal Transport

OBJECTIVE

Noninvasive ventilation, including nasal high-flow therapy (nHFT), provides effective neonatal respiratory support. There are limited data on nHFT use during neonatal transport. Our objective was to assess the efficacy and safety of nHFT during neonatal transport.

METHODS

One hundred ninety-five neonates transported on nHFT via a Neo-Pod "T" system (Westmed Inc, Tucson, AZ) were identified from Life Flight transport data. Data included demographics, transport location, distance, indication, and mode as well as pretransport and intratransport respiratory support data. We compared neonates who successfully tolerated nHFT transport with those who required support escalation (defined as increase in flow ≥2 L/min or fraction of inspired oxygen [FiO₂] ≥20%).

RESULTS

Eighty-seven percent of neonates (170/195) were effectively transported on nHFT. Infants requiring escalation of nHFT support had a significantly higher pretransport FiO₂ (median = 0.60 [interquartile range, 0.36-1.00] vs. 0.36 [0.23-0.56]; P < .05) and a longer ground time for stabilization (56 ± 25 vs. 39 ± 18 minutes, P < .05) and were more frequently transported by air.

CONCLUSION

Nasal HFT can be an effective mode of respiratory support in the transport of selected neonates. FiO₂ at the time of transport may be a key parameter to aid in determining neonates who can be safely transported on nHFT.

Respiratory support for infants with bronchiolitis, a narrative review of the literature

Bronchiolitis is a common viral disease that significantly affects infants less than 12 months of age. The purpose of this review is to present a review of the current knowledge of the uses of respiratory support in the management of infants with bronchiolitis presenting to hospital. We electronically searched MEDLINE, Cochrane, CINAHL and EMBASE (inception to 25th March 2018), to manually search for clinical trials that address the management strategies for respiratory support of infants with bronchiolitis. We identified 120 papers who met the inclusion criteria, of which 33 papers were relevant for this review with only nine randomized controlled trials. This review demonstrated that non-invasive respiratory support reduced the need for escalation of therapy, particularly the proportion of intubations required for infants with bronchiolitis. Additionally, clear economic benefits have been demonstrated when non-invasive ventilation has been used. The potential early use of non-invasive respiratory supports such as nasal high flow therapy and non-invasive ventilation may have an impact on health care costs and reduction in ICU admissions and intubation rates. High-grade evidence demonstrates safety and quality of high flow therapy in general ward settings.

Nasal High Flow in Room Air for Hypoxemic Bronchiolitis Infants

Background: Bronchiolitis is the most common reason for hospital admission in infants, with one third requiring oxygen therapy due to hypoxemia. It is unknown what proportion of hypoxemic infants with bronchiolitis can be managed with nasal high-flow in room air and their resulting outcomes. Objectives and Settings: To assess the effect of nasal high-flow in room air in a subgroup of infants with bronchiolitis allocated to high-flow therapy in a recent multicenter randomized controlled trial. Patients and Interventions: Infants allocated to the high-flow arm of the trial were initially treated with room air high-flow if saturations were ≥85%. Subsequently, if oxygen saturations did not increase to ≥92%, oxygen was added and FiO₂ was titrated to increase the oxygen saturations. In this planned sub-study, infants treated during their entire hospital stay with high-flow room air only were compared to infants receiving either standard-oxygen or high-flow with oxygen. Baseline characteristics, hospital length of stay and length of oxygen therapy were compared. Findings: In the per protocol analysis 64 (10%) of 630 infants commenced on high-flow room air remained in room air only during the entire stay in hospital. These infants on high-flow room air were on average older and presented with moderate hypoxemia at presentation to hospital. Their length of respiratory support and length of stay was also significantly shorter. No pre-enrolment factors could be identified in a multivariable analysis. Conclusions: In a small sub-group of hypoxemic infants with bronchiolitis hypoxemia can be reversed with the application of high-flow in room air only. Trial registration: ACTRN12615001305516.

High-flow Nasal Cannula: Mechanisms of Action and Adult and Pediatric Indications

The use of the heated and humidified high-flow nasal cannula has become increasingly popular in the treatment of patients with respiratory failure through all age groups. This article will examine the main mechanisms of actions attributed to the use of the high-flow nasal cannula and review the indications in adult and pediatric populations (outside of the neonatal period). It is unclear which of the mechanisms of action is the most important, but it may depend on the cause of the patient’s respiratory failure. This article describes the mechanism of action in an easy to remember mnemonic (HIFLOW); Heated and humidified, meets Inspiratory demands, increases Functional residual capacity (FRC), Lighter, minimizes Oxygen dilution, and Washout of pharyngeal dead space. We will also examine some of the main indications for its use in both the adult and pediatric age groups. The data for the use of high-flow nasal cannula is growing, and currently, some of the main adult indications include hypoxemic respiratory failure due to pneumonia, post-extubation, pre-oxygenation prior to intubation, acute pulmonary edema, and use in patients who are "do not resuscitate or intubate". The main pediatric indication is in infants with bronchiolitis, but other indications are being studied, such as its use in asthma, croup, pneumonia, transport of a critically ill child, and post-extubation.

Predicting Escalated Care in Infants With Bronchiolitis

BACKGROUND AND OBJECTIVES

Early risk stratification of infants with bronchiolitis receiving airway support is critical for focusing appropriate therapies, yet the tools to risk categorize this subpopulation do not exist. Our objective was to identify predictors of "escalated care" in bronchiolitis. We hypothesized there would be a significant association between escalated care and predictors in the emergency department. We subsequently developed a risk score for escalated care.

METHODS

We conducted a retrospective cohort study of previously healthy infants aged <12 months with bronchiolitis. Our primary outcome was escalated care (ie, hospitalization with high-flow nasal cannula, noninvasive or invasive ventilation, or intensive care admission). The predictors evaluated were age, prematurity, day of illness, poor feeding, dehydration, apnea, nasal flaring and/or grunting, respiratory rate, oxygen saturation, and retractions.

RESULTS

Of 2722 patients, 261 (9.6%) received escalated care. Multivariable predictors of escalated care were oxygen saturation <90% (odds ratio [OR]: 8.9 [95% confidence interval (CI) 5.1-15.7]), nasal flaring and/or grunting (OR: 3.8 [95% CI 2.6-5.4]), apnea (OR: 3.0 [95% CI 1.9-4.8]), retractions (OR: 3.0 [95% CI 1.6-5.7]), age ≤2 months (OR: 2.1 [95% CI 1.5-3.0]), dehydration (OR 2.1 [95% CI 1.4-3.3]), and poor feeding (OR: 1.9 [95% CI 1.3-2.7]). One of 217 (0.5%) infants without predictors received escalated care. The risk score ranged from 0 to 14 points, with the estimated risk of escalated care from 0.46% (0 points) to 96.9% (14 points). The area under the curve was 85%.

CONCLUSIONS

We identified variables measured in the emergency department predictive of escalated care in bronchiolitis and derived a risk score to stratify risk of this outcome. This score may be used to aid management and disposition decisions.

High-Flow Nasal Cannula versus Conventional Oxygen Therapy in Children with Respiratory Distress

Purpose:

The aim of this study is to determine the clinical efficacy of high-flow nasal cannula (HFNC) therapy compared with conventional oxygen therapy in children presented with respiratory distress.

Study Design:

This was a randomized controlled study.

Materials and Methods:

Infants and children aged between 1 month to 5 years who were admitted to our tertiary referral center for respiratory distress (July 1, 2014 to March 31, 2015) and met the inclusion criteria were recruited.

Interventions:

Infants and children hospitalized with respiratory distress were randomized into two groups of interventions. All clinical data, for example, respiratory score, pulse rate, and respiratory rate were recorded. The results were subsequently analyzed.

Results:

A total of 98 respiratory distress children were enrolled during the study period. Only 4 children (8.2%) failed in HFNC therapy, compared with 10 children (20.4%) in conventional oxygen therapy group (P = 0.09). After adjusted for body weight, underlying diseases, and respiratory distress score, there was an 85% reduction in the odds of treatment failure in HFNC therapy group (adjusted odds ratio 0.15, 95% confidence interval 0.03–0.66, P = 0.01). Most children in HFNC therapy group had significant improvement in clinical respiratory score, heart rate, and respiratory rate at 240, 360, and 120 min compared with conventional oxygen therapy (P = 0.03, 0.04, and 0.03).

Conclusion:

HFNC therapy revealed a potential clinical advantage in management children hospitalized with respiratory distress compared with conventional respiratory therapy. The early use of HFNC in children with moderate-to-severe respiratory distress may prevent endotracheal tube intubation.

Trial Register:

TCTR 20170222007.

Paediatric high-flow nasal cannula therapy in children with bronchiolitis: A retrospective safety and efficacy study in a non-tertiary environment

OBJECTIVE

The objective was to examine the safety and efficacy of high-flow nasal cannula (HFNC) therapy for children with bronchiolitis in a non-tertiary paediatric setting.

METHODS

This was a single-centre retrospective study conducted over 26 months (March 2013-April 2015) on children aged 1-23 months with suspected bronchiolitis, who commenced on HFNC therapy in either the ED or the ward. Changes with respect to baseline data were analysed for effect on work of breathing (WOB), heart rate (HR) and respiratory rate (RR). Data was analysed using a linear mixed effects model and adjusted for age (≤12 months and >12 months) and location (ED vs ward). Transfer to a tertiary environment, escalation of care and adverse event rates were also recorded.

RESULTS

A total of 61 children commenced on HFNC therapy, with flow rates ranging from 0.6 to 3.3L/kg/min. The proportion of patients with higher WOB scores appeared to reduce within 60 min of initiation of therapy. There was also a progressive reduction in surrogate markers of respiratory distress (HR and RR), with significant reductions evident by 60 min (P < 0.05). There were no adverse events related to HFNC therapy. The transfer rate was 13%. It was predominantly due to lack of improvement of physiological parameters post initiation of HFNC therapy. None of the transferred patients required escalation of care.

CONCLUSION

Within the limitations of this study it appears HFNC therapy may be safely commenced in both age groups in a non-tertiary ED or ward, with an appropriate level of observation and robust transfer criteria.

Aerosol therapy through high flow nasal cannula in pediatric patients

INTRODUCTION

High flow nasal cannula (HFNC) is increasingly used in pediatric patients suffering from respiratory failure. In some disease processes, patients may also benefit from aerosol therapy. Therefore, the use of HFNC to deliver aerosolized medications is a convenient and attractive option. Areas covered: This review aims to appraise available evidence concerning the efficiency of aerosol nebulized therapy delivery using HFNC in pediatric patients. Expert commentary: Delivery of aerosol particles is a very complex process and depends on the use of oxygen vs. heliox, nebulizer type and position within the HFNC circuit, patient's breathing effort and pattern, and more importantly cannula size and flow rates. Current in vitro evidence suggests the amount of aerosol delivery is likely to be very low at high flows. Clinical studies are limited in pediatric patients and given the limited clinical data, it is not possible to make recommendations for or against aerosol delivery through HFNC for pediatric patients.

Variability of Care in Infants with Severe Bronchiolitis: Less-Invasive Respiratory Management Leads to Similar Outcomes

OBJECTIVE

To compare the management of children with severe bronchiolitis requiring intensive care (based on duration of ventilatory support and duration of pediatric intensive care unit [PICU] stay) in 2 countries with differing pediatric transport and PICU organizations.

STUDY DESIGN

This was a prospective observational care study in 2 PICUs of tertiary care university hospitals, 1 in France and 1 in Canada. All children with bronchiolitis who required admission to the PICU between November 1, 2013, and March 31, 2014, were included.

RESULTS

A total of 194 children were included. Baseline characteristics and illness severity were similar at the 2 sites. There was a significant difference between centers in the use of invasive ventilation (3% in France vs 26% in Canada; P < .0001). The number of investigations performed from admission to emergency department presentation and during the PICU stay was significantly higher in Canada for both chest radiographs and blood tests (P < .001). The use of antibiotics was significantly higher in Canada both before (60% vs 28%; P < .001) and during (72% vs 33%; P < .0001) the PICU stay. The duration of ventilatory support, median length of stay, and rate of PICU readmission were similar in the 2 centers.

CONCLUSION

Important differences in the management of children with severe bronchiolitis were observed during both prehospital transport and PICU treatment. Less invasive management resulted in similar outcomes with in fewer complications.

Consensus approach to nasal high-flow therapy in neonates

OBJECTIVE

Nasal high-flow therapy (nHFT) is commonly used for noninvasive respiratory support in the neonatal intensive care unit. Our objective was to determine which aspects of neonatal nHFT have achieved adequate evidence base to support consensus among experienced clinical investigators, and to document areas lacking consensus to promote future investigations.

STUDY DESIGN

Prospective, modified Delphi collation of tabular queries related to specific aspects of neonatal nHFT. Seven international nHFT clinical researchers were queried regarding approaches to initiation, escalation, weaning and discontinuing nHFT. Completed tables were reviewed independently by each investigator, results clarified and discussed and areas of consensus determined.

RESULTS

Consensus agreement was reached for many aspects of nHFT including: need for adequate heating and humidification, need to prevent nares occlusion, maximum flow rate of 8 l min^-1, assessment of fraction of inspired oxygen (FiO₂) and work of breathing for either flow escalation or weaning, equivalence of nHFT to nasal continuous positive airway pressure (nCPAP) for noninvasive support of infants of ⩾28 weeks with resolving respiratory distress and use of nHFT for noninvasive support of stable infants on nCPAP. There was general agreement for initial gas flow rates in the range of 4 to 6 l min^-1 and for nHFT as primary therapy for mild respiratory distress. There was no consensus on the approach to discontinuing nHFT.

CONCLUSIONS

Among an experienced group of nHFT clinical researchers, there was general consensus in the approach to neonatal nHFT. Additional randomized studies are indicated to provide better evidence related to several aspects of nHFT, as well as to identify other clinical conditions where nHFT may provide safe, effective noninvasive support.

A Novel Weaning Protocol for High-Flow Nasal Cannula in the PICU

OBJECTIVE

High-flow nasal cannula use in the PICU continues to increase; however, a protocol for weaning patients has yet to be published. This study aimed to create an efficient and safe protocol for weaning high-flow nasal cannula.

DESIGN

A Respiratory Assessment Score was created using two validated scoring systems. A protocol was established for set "holidays" off high-flow nasal cannula, where nasal cannula flow was reduced to age-based low-flow nasal cannula rates if Respiratory Assessment Scores met certain criteria.

SETTING

The PICU at Children's Healthcare of Atlanta at Egleston, a quaternary level hospital affiliated with Emory University.

PATIENTS

Patients treated in the PICU with high-flow nasal cannula from August 2013 to March 2014. Exclusions included apnea, heliox therapy, oxygen saturations less than 92% with a FIO2 greater than 50%, admitted to PICU less than 6 hours, progression to intubation prior to scoring, or those ordered by physician to not receive holidays based on clinical status.

INTERVENTIONS

Patients who qualified for a "holiday" based on Respiratory Assessment Score were trialed off high-flow nasal cannula and rescored afterwards to assess tolerance.

MEASUREMENTS AND MAIN RESULTS

One hundred thirty-three patients were treated with high-flow nasal cannula, with the most common diagnosis being bronchiolitis (43%). Of these 133 patients, 119 (89.5%) successfully weaned to low-flow nasal cannula within four holiday attempts. Eighty-three patients (70%) weaned with only one attempt. Fourteen patients (10.5%) failed to wean. Reasons for failure were reintubation, increasing flow on high-flow nasal cannula, too high of Respiratory Assessment Score to meet weaning criteria, or slow weaning after failed attempts. Holidays did not precipitate clinical deterioration or lead to immediate intubation.

CONCLUSIONS

Our study suggests that a high-flow nasal cannula "holiday" protocol is a safe and effective way to successfully wean PICU patients off high-flow nasal cannula. Additional investigation including validation of the scoring system used is warranted.

Burden of disease and change in practice in critically ill infants with bronchiolitis

Bronchiolitis represents the most common cause of non-elective admission to paediatric intensive care units (ICUs).

We assessed changes in admission rate, respiratory support, and outcomes of infants <24 months with bronchiolitis admitted to ICU between 2002 and 2014 in Australia and New Zealand.

During the study period, bronchiolitis was responsible for 9628 (27.6%) of 34 829 non-elective ICU admissions. The estimated population-based ICU admission rate due to bronchiolitis increased by 11.76 per 100 000 each year (95% CI 8.11–15.41). The proportion of bronchiolitis patients requiring intubation decreased from 36.8% in 2002, to 10.8% in 2014 (adjusted OR 0.35, 95% CI 0.27–0.46), whilst a dramatic increase in high-flow nasal cannula therapy use to 72.6% was observed (p<0.001). We observed considerable variability in practice between units, with six-fold differences in risk-adjusted intubation rates that were not explained by ICU type, size, or major patient factors. Annual direct hospitalisation costs due to severe bronchiolitis increased to over USD30 million in 2014.

We observed an increasing healthcare burden due to severe bronchiolitis, with a major change in practice in the management from invasive to non-invasive support that suggests thresholds to admittance of bronchiolitis patients to ICU have changed. Future studies should assess strategies for management of bronchiolitis outside ICUs.

High-flow nasal cannula therapies for respiratory management in pediatric patients

High-flow nasal cannula (HFNC) oxygen therapy is a non-invasive form of respiratory support that is rapidly being taken up in pediatric intensive care units (PICU). For infants with bronchiolitis, who are the largest non-elective source of admissions to a PICU, there is some evidence that using HFNC therapy reduces the need for intubation and mechanical ventilation. The aim of this review article is to explore, describe, critique and add to the evidence surrounding the use of HFNC therapy in the pediatric population for the management of respiratory distress.

High-flow nasal cannula support therapy: new insights and improving performance

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2017. Other selected articles can be found online at http://ccforum.com/series/annualupdate2017 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901 .

High-flow nasal cannula therapy versus non-invasive ventilation in children with severe acute asthma exacerbation: An observational cohort study

INTRODUCTION

The present study describes our experience with the high-flow humidified nasal cannula (HFNC) versus non-invasive ventilation (NIV) in children with severe acute asthma exacerbation (SA).

METHODS

An observational study of a retrospective cohort of 42 children with SA admitted to a Pediatric Intensive Care Unit (PICU) for non-invasive respiratory support was made. The primary outcome measure was failure of initial respiratory support (need to escalate from HFNC to NIV or from NIV to invasive ventilation). Secondary outcome measures were the duration of respiratory support and PICU length of stay (LOS).

RESULTS

Forty-two children met the inclusion criteria. Twenty (47.6%) received HFNC and 22 (52.3%) NIV as initial respiratory support. There were no treatment failures in the NIV group. However, 8 children (40%) in the HFNC group required escalation to NIV. The PICU LOS was similar in both the NIV and HFNC groups. However, on considering the HFNC failure subgroup, the median length of respiratory support was 3-fold longer (63h) and the PICU LOS was also longer compared with the rest of subjects exhibiting treatment success.

CONCLUSIONS

Despite its obvious limitations, this observational study could suggest that HFNC in some subjects with SA may delay NIV support and potentially cause longer respiratory support, and longer PICU LOS.

The Clinical Impact of Heated Humidified High-Flow Nasal Cannula on Pediatric Respiratory Distress

OBJECTIVES

To assess the impact on a single PICU of introducing high-flow nasal cannula as a management tool for respiratory distress.

DESIGN

Retrospective cohort study, including an interrupted time series analysis with a propensity score adjustment and a matched-pair analysis.

SETTING

A single university-affiliated children's hospital PICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Differences in clinical outcomes when comparing the pre-high-flow nasal cannula era (2004-2008) and the high-flow nasal cannula era (2010-2014), excluding 2009 as a washout period, and clinical impacts of high-flow nasal cannula as an exposure of interest. A total of 1,766 children met the inclusion criteria (pre-high-flow nasal cannula era: 699 patients; high-flow nasal cannula era: 1,067 patients). High-flow nasal cannula was used in 455 patients (42.6%) in the high-flow nasal cannula era. The interrupted time series analysis failed to show a statistically significant difference in PICU length of stay, but the duration of invasive ventilation was shortened by an average of 2.3 days in the high-flow nasal cannula era group (95% CI, 0.2-4.4; p = 0.030). The PICU intubation rate in the high-flow nasal cannula era was 0.72 times that of the pre-high-flow nasal cannula era (95% CI, 0.63-0.84; p < 0.001). A total of 373 pairs were formed for the matched-pair analysis. The odds for being intubated in the PICU for those patients using high-flow nasal cannula was 0.06 (95% CI, 0.02-0.16; p < 0.001) when compared with those who did not use high-flow nasal cannula. The PICU length of stay increased by 2.9 days in those patients in which high-flow nasal cannula was used (95% CI, 1.3-4.4; p < 0.001).

CONCLUSIONS

The introduction of high-flow nasal cannula as a therapy for respiratory distress in the PICU was associated with a significant decrease in the PICU intubation rate with no associated change in mortality.

High flow nasal cannula (HFNC) versus nasal continuous positive airway pressure (nCPAP) for the initial respiratory management of acute viral bronchiolitis in young infants: a multicenter randomized controlled trial (TRAMONTANE study)

PURPOSE

Nasal continuous positive airway pressure (nCPAP) is currently the gold standard for respiratory support for moderate to severe acute viral bronchiolitis (AVB). Although oxygen delivery via high flow nasal cannula (HFNC) is increasingly used, evidence of its efficacy and safety is lacking in infants.

METHODS

A randomized controlled trial was performed in five pediatric intensive care units (PICUs) to compare 7 cmH₂O nCPAP with 2 L/kg/min oxygen therapy administered with HFNC in infants up to 6 months old with moderate to severe AVB. The primary endpoint was the percentage of failure within 24 h of randomization using prespecified criteria. To satisfy noninferiority, the failure rate of HFNC had to lie within 15% of the failure rate of nCPAP. Secondary outcomes included success rate after crossover, intubation rate, length of stay, and serious adverse events.

RESULTS

From November 2014 to March 2015, 142 infants were included and equally distributed into groups. The risk difference of -19% (95% CI -35 to -3%) did not allow the conclusion of HFNC noninferiority (p = 0.707). Superiority analysis suggested a relative risk of success 1.63 (95% CI 1.02-2.63) higher with nCPAP. The success rate with the alternative respiratory support, intubation rate, durations of noninvasive and invasive ventilation, skin lesions, and length of PICU stay were comparable between groups. No patient had air leak syndrome or died.

CONCLUSION

In young infants with moderate to severe AVB, initial management with HFNC did not have a failure rate similar to that of nCPAP. This clinical trial was recorded in the National Library of Medicine registry (NCT 02457013).

Noninvasive Respiratory Support During Transportation

To minimize ventilator-associated lung injury in neonates, use of noninvasive (NIV) respiratory support has markedly increased over the past decade, especially in neonates younger than 28-weeks gestational age and 1250 g. Previously, neonates with respiratory failure who required anything greater than an oxyhood or low-flow nasal cannula were intubated for transport. This increased use has required transport teams to develop or incorporate a new set of support tools to minimize lung injury. This article reviews the various modes of NIV used during neonatal transport, important patient selection criteria, appropriate assessment, and the associated risks and benefits.

[Neonatal transport characteristics]

Neonatal transport is necessary where a neonate is transferred between two care units. It provides all the skills of a dedicated team, representing a real mobile neonatal intensive care unit. Informing and involving the families is essential during this transport, which can be a source of stress for the child and its family.

Current evidence for the effectiveness of heated and humidified high flow nasal cannula supportive therapy in adult patients with respiratory failure

High flow nasal cannula (HFNC) supportive therapy has emerged as a safe, useful therapy in patients with respiratory failure, improving oxygenation and comfort. Recently several clinical trials have analyzed the effectiveness of HFNC therapy in different clinical situations and have reported promising results. Here we review the current knowledge about HFNC therapy, from its mechanisms of action to its effects on outcomes in different clinical situations.

Heated humidified high-flow nasal cannula therapy in children

Heated humidified high-flow nasal cannula therapy (HHHFNC) was originally described as a mode of respiratory support in premature neonates and is now increasingly used in the management of acute respiratory failure in older infants and children. Heating and humidification of gas mixtures allow comfortable delivery of flow rates that match or exceed the patient's inspiratory flow rate. Emerging evidence from observational studies suggests that the use of HHHFNC therapy may be associated with reduced work of breathing, improved ventilation efficiency and a decreased need for intubation in children with respiratory insufficiency. There are several proposed mechanisms of action, and the potential for provision of unpredictable positive distending pressure has caused concern. Randomised controlled trial evidence comparing clinical outcomes with those achieved using other forms of respiratory support is, however, awaited. We review the proposed mechanisms of actions, indications, advantages and complications of HHHFNC therapy in children and describe our approach to its use in the paediatric ward environment.

Feasibility of high-flow nasal cannula oxygen therapy for acute respiratory failure in patients with hematologic malignancies: A retrospective single-center study

PURPOSE

This study investigated the feasibility of high-flow nasal cannula (HFNC) oxygen therapy for acute respiratory failure in adult patients with hematologic malignancies.

MATERIALS AND METHODS

We identified 45 acute respiratory failure patients with hematologic malignancies who received HFNC therapy between March 2012 and June 2014 at Seoul St Mary's Hospital. Their medical records were reviewed retrospectively to identify useful prognostic factors for successful treatment.

RESULTS

Of the 45 patients, 15 (33.3%) successfully recovered, and 30 were changed to invasive ventilation due to failed HFNC treatment. The etiologies of acute respiratory failure were bacterial pneumonia (57.8%), Pneumocystis jirovecii pneumonia (17.8%), pulmonary edema (8.9%), and bronchiolitis obliterans organizing pneumonia (8.9%). The overall mortality rate was 62.2%. The HFNC treatment success rate was significantly different between the survivors and nonsurvivors. To evaluate risk factors for HFNC treatment failure, differences between the HFNC treatment success and failure groups were compared. There were no significant differences in the severity of underlying medical conditions. The percentage of bacterial pneumonia was significantly higher in the HFNC treatment failure group compared with the success group (73.3% vs 26.7%; P = .004).

CONCLUSIONS

High-flow nasal cannula offers an interesting alternative to invasive ventilation in acute respiratory failure patients with hematologic malignancies. However, attention must be paid to the appropriate choice of HFNC settings such as oxygen flow.

High-flow nasal cannula: recommendations for daily practice in pediatrics

High-flow nasal cannula (HFNC) is a relatively new device for respiratory support. In pediatrics, HFNC use continues to increase as the system is easily set up and is well tolerated by patients. The use of nasal cannula adapted to the infant’s nares size to deliver heated and humidified gas at high flow rates has been associated with improvements in washout of nasopharyngeal dead space, lung mucociliary clearance, and oxygen delivery compared with other oxygen delivery systems. HFNC may also create positive pharyngeal pressure to reduce the work of breathing, which positions the device midway between classical oxygen delivery systems, like the high-concentration face mask and continuous positive airway pressure (CPAP) generators. Currently, most of the studies in the pediatric literature suggest the benefits of HFNC therapy only for moderately severe acute viral bronchiolitis. But, the experience with this device in neonatology and adult intensive care may broaden the pediatric indications to include weaning from invasive ventilation and acute asthma. As for any form of respiratory support, HFNC initiation in patients requires close monitoring, whether it be for pre- or inter-hospital transport or in the emergency department or the pediatric intensive care unit.