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

High-Flow Nasal Cannula Versus Nasal Prong Bubble Continuous Positive Airway Pressure in Children With Moderate to Severe Acute Bronchiolitis: A Randomized Controlled Trial

OBJECTIVES

To compare high-flow nasal cannula (HFNC) versus nasal prong bubble continuous positive airway pressure (b-CPAP) in children with moderate to severe acute bronchiolitis.

DESIGN

A randomized controlled trial was carried out from August 2019 to February 2022. (Clinical Trials Registry of India number CTRI/2019/07/020402).

SETTING

Pediatric emergency ward and ICU within a tertiary care center in India.

PATIENTS

Children 1-23 months old with moderate to severe acute bronchiolitis.

INTERVENTION

Comparison of HFNC with b-CPAP, using a primary outcome of treatment failure within 24 hours of randomization, as defined by any of: 1) a 1-point increase in modified Wood's clinical asthma score (m-WCAS) above baseline, 2) a rise in respiratory rate (RR) greater than 10 per minute from baseline, and 3) escalation in respiratory support. The secondary outcomes were success rate after crossover, if any, need for mechanical ventilation (invasive/noninvasive), local skin lesions, length of hospital stay, and complications.

RESULTS

In 118 children analyzed by intention-to-treat, HFNC (n = 59) versus b-CPAP (n = 59) was associated with a lower failure rate (23.7% vs. 42.4%; relative risk [95% CI], RR 0.56 [95% CI, 0.32-0.97], p = 0.031). The Cox proportion model confirmed a lower hazard of treatment failure in the HFNC group (adjusted hazard ratio 0.48 [95% CI, 0.25-0.94], p = 0.032). No crossover was noted. A lower proportion escalated to noninvasive ventilation in the HFNC group (15.3%) versus the b-CPAP group (15.3% vs. 39% [RR 0.39 (95% CI, 0.20-0.77)], p = 0.004). The HFNC group had a longer median (interquartile range) duration of oxygen therapy (4 [3-6] vs. 3 [3-5] d; p = 0.012) and hospital stay (6 [5-8.5] vs. 5 [4-7] d, p = 0.021). No significant difference was noted in other secondary outcomes.

CONCLUSION

In children aged one to 23 months with moderate to severe acute bronchiolitis, the use of HFNC therapy as opposed to b-CPAP for early respiratory support is associated with a lower failure rate and, secondarily, a lower risk of escalation to mechanical ventilation.

Extubation to High-Flow Nasal Cannula in Infants Following Cardiac Surgery: A Retrospective Cohort Study

High-flow nasal cannula (HFNC) therapy is commonly used in the pediatric intensive care unit (PICU) for postextubation respiratory support. This hypothesis-generating retrospective cohort study aimed to compare postextubation PICU length of stay in infants extubated to HFNC and low flow oxygen (LF) in PICU following cardiac surgery. Of 136 infants (newborn to 1 year) who were intubated and mechanically ventilated in PICU following cardiac surgery, 72 (53%) were extubated to HFNC and 64 (47%) to LF. Compared with patients extubated to LF, those extubated to HFNC had significantly longer durations of cardiopulmonary bypass (152 vs. 109 minutes; p  = 0.002), aortic cross-clamp (90 vs. 63 minutes; p  = 0.003), and invasive mechanical ventilation (3.2 vs. 1.6 days; p  < 0.001), although demographic and preoperative clinical variables were similar. No significant difference was observed in postextubation PICU length of stay between HFNC and LF groups in unadjusted analysis (3.3 vs. 2.6 days, respectively; p  = 0.19) and after controlling for potential confounding variables (F [1,125] = 0.17, p  = 0.68, R 2  = 0.16). Escalation of therapy was similar between HFNC and LF groups (8.3 vs. 14.1%; p  = 0.41). HFNC was effective as rescue therapy for six patients in the LF group requiring escalation of therapy. Need for reintubation was similar between HFNC and LF groups (8.3 vs. 4.7%; p  = 0.5). Although extubation to HFNC was associated with a trend toward longer postextubation PICU length of stay and was successfully used as rescue therapy for several infants extubated to LF, our results must be interpreted with caution given the limitations of our study.

Use of high‐flow cannula in pediatric patients with respiratory failure: A prospective cohort study in three high‐altitude hospitals

Background and Aims

Acute respiratory failure (ARF) is a common cause of morbimortality, and a frequent reason for admission to the pediatric intensive care unit (PICU). It requires a high‐flow oxygen device as treatment. Our aim is to determine the frequency and main indications for the use of high‐flow nasal cannula (HFNC), and the prevalence of HFNC failure and its main causes, in three hospitals

Methods

It is a multicenter prospective cohort study, developed in three hospitals in Bogota. Eligible patients were children older than 1 month and younger than 18 years who presented ARF and required management with an HFNC. The study was carried out between April 2020 and December 2021. The follow‐up was carried out at 1, 6, and 48 h after starting the management.

Results

Of 685 patients included in the study, 296 developed ARF. The prevalence of patients with ARF who required management with HFNC was 48%. The frequency of the pathologies that cause the ARF was: Bronchiolitis was the most frequent pathology (34.5%), followed by asthmatic crisis (15.5%) and pneumonia (12.7%). The average time of use of HFNC was 81.6 h. Regarding treatment failure with HFNC, 15 patients presented torpid evolution and required invasive mechanical ventilation, with a prevalence of therapeutic failure of the HFNC of 10.6%.

Conclusion

The use of HFNC is more frequent in patients with bronchiolitis, in children under 2 years of age and in males, which is in line with what has been reported in the literature. In addition, the failure rate of HFNC is low (10.6%), and it may be useful in other pathologies besides bronchiolitis, such as asthma, pneumonia, among others. It opens the possibility to continue evaluating the role of HFNC in pediatric pathology in new studies.

Feeding Pathway for Children on High Flow Nasal Cannula Decreases Time to Enteral Nutrition

High Flow Nasal Cannula (HFNC) is commonly used for children with respiratory failure, yet no standardized guidelines exist on how to initiate, escalate, and maintain enteral nutrition (EN) for these patients. EN in critically ill children is associated with decreased hospital length of stay, decreased ventilator days, and fewer acquired infections. We aimed to decrease the mean time to EN initiation by 50% after the start of HFNC in 6 months.

METHODS

This quality improvement project used the Model for Improvement to inform interventions. A multidisciplinary team created an EN pathway for critically ill patients on HFNC. We conducted Plan-Do-Study-Act cycles related to implementing a standardized pathway for EN on HFNC. The primary outcome was time to EN initiation once on HFNC. Secondary outcomes were time to goal caloric EN, duration of HFNC, and adverse events. Outcomes were plotted on statistical process control charts and analyzed for special cause variation between baseline and intervention periods.

RESULTS

We included 112 patients in the study. Special cause variation occurred for both primary and secondary outcomes. The mean time to EN initiation decreased from 24.6 hours to 11.7 hours (47.5%). Mean time to goal feeds decreased from 25.8 hours to 15.1 hours (58.5%). Mean HFNC duration did not show any special cause variation. There were no episodes of aspiration.

CONCLUSION

Implementation of a standardized pathway for EN on patients receiving HFNC resulted in decreased time to initiation of EN and time to goal caloric EN with no significant increase in adverse events.

Commentary on the First-Line Support for Assistance in Breathing in Children Trials on Noninvasive Respiratory Support: Taking a Closer Look

Noninvasive respiratory support modalities such as high-flow nasal cannula (HFNC) therapy and continuous positive airway pressure (CPAP) are used frequently in pediatric critical care to support acutely ill children with respiratory failure (step-up management) and children following extubation (step-down management). Although there are several observational studies and database analyses comparing the efficacy of HFNC and CPAP, and a few small randomized clinical trials (RCTs), until recently, there were no large RCTs comparing the two modalities in a mixed group of critically ill children. In the first half of 2022, results from the First-Line Support for Assistance in Breathing in Children (FIRST-ABC) trials were published; these comprised a master protocol of two trials: one in acutely ill children (step-up RCT) and one in extubated children (step-down RCT). Each of these pragmatic trials randomized 600 children to either HFNC or CPAP when the treating clinician decided that noninvasive respiratory support beyond standard oxygen therapy was required. The primary outcome was time to liberation from all forms of respiratory support (invasive and noninvasive), excluding supplemental oxygen. The FIRST-ABC trials represent a significant advance in the field of noninvasive respiratory support, which has traditionally been evidence-poor and associated with considerable variability in clinical practice. In this article, we provide an overview of how the FIRST-ABC trials were conceived and conducted, our view on the results, and how the trial findings have changed our clinical practice.

Commentary on High-Flow Nasal Cannula and Continuous Positive Airway Pressure Practices After the First-Line Support for Assistance in Breathing in Children Trials

Continuous positive airway pressure (CPAP) and heated humidified high-flow nasal cannula (HFNC) are commonly used to treat children admitted to the PICU who require more respiratory support than simple oxygen therapy. Much has been published on these two treatment modalities over the past decade, both in Pediatric Critical Care Medicine (PCCM ) and elsewhere. The majority of these studies are observational analyses of clinical, administrative, or quality improvement datasets and, therefore, are only able to establish associations between exposure to treatment and outcomes, not causation. None of the initial randomized clinical trials comparing HFNC and CPAP were definitive due to their relatively small sample sizes with insufficient power for meaningful clinical outcomes (e.g., escalation to bilevel noninvasive ventilation or intubation, duration of PICU-level respiratory support, mortality) and often yielded ambiguous findings or conflicting results. The recent publication of the First-Line Support for Assistance in Breathing in Children (FIRST-ABC) trials represented a major step toward understanding the role of CPAP and HFNC use in critically ill children. These large, pragmatic, randomized clinical trials examined the efficacy of CPAP and HFNC either for "step up" (i.e., escalation in respiratory support) during acute respiratory deterioration or for "step down" (i.e., postextubation need for respiratory support) management. This narrative review examines the body of evidence on HFNC published in PCCM , contextualizes the findings of randomized clinical trials of CPAP and HFNC up to and including the FIRST-ABC trials, provides guidance to PICU clinicians on how to implement the literature in current practice, and discusses remaining knowledge gaps and future research priorities.

Comparison of high flow oxygen therapy versus noninvasive mechanical ventilation for successful weaning from invasive ventilation in children: An observational study

Post-extubation respiratory failure is associated with a poor prognosis due to increased ventilator-associated pneumonia, and longer length of stay in the ICU and hospital. In this study, we aimed to evaluate the efficacy of high-flow nasal cannula (HFNC) and noninvasive mechanical ventilation (NIMV) on extubation success in children. A total of 48 patients, aged between 1 month and 18 years, who were weaned to either NIMV or HFNC were included. Patients who had tracheostomy or were not weaned and underwent unplanned extubation were excluded. Age, gender, anthropometric parameters, Pediatric Risk of Mortality and Pediatric Logistic Organ Dysfunction scores, oxygenation index, mechanical ventilation length of stay (LOS), HFNC/NIMV LOS, Modified Downes-Silverman score (MDS), and venous blood gas parameters, pediatric intensive care unit (PICU) LOS were recorded. 24 patients were extubated to NIMV, and 24 patients to HFNC. HFNC LOS and NIMV LOS were similar (P = .621). The failure rates at the 48th hour of HFNC and NIMV were 33% (n = 8), and 33% respectively (n = 8) (P = 1.0). PICU LOS and mortality rate was also similar (P = .06, P = .312 respectively). MDS decreased significantly in both groups (P < .001, P = .02 respectively). Changes in blood gas parameters and MDS within the first 48-hour of device application were similar between the 2 groups. HFNC is not inferior to NIMV in patients with extubation difficulty or those expected to have such difficulty in terms of treatment success, PICU LOS, and mortality. Therefore, HFNC appears to be a weaning technique alternative to NIMV after extubation.

Comparison of Two Weaning Methods from Heated Humidified High-Flow Nasal Cannula Therapy in Pediatric Intensive Care Unit

Background and Objective: Although high-flow nasal cannula (HFNC) is widely used in children, there is no consensus on the methods for starting, maintenance, and weaning. The aim of this study was to compare weaning methods in children. Methods: The study included all patients in pediatric intensive care unit (PICU) who were started on HFNC treatment. The respiratory assessment score was used in the decisions for starting, continuing, and weaning from HFNC. The patients who responded and for whom weaning was planned were randomized by month into 2 groups as directly weaned from HFNC and weaned by reducing the flow. Success rates, treatment, and length of stay (LOS) in weaning methods were compared. Results: Of the 145 patients initially included in the study, 32 (22%) were excluded, and analysis was made of 113 patients. Successful weaning from HFNC was obtained in 76.9% of the patients, in 82.1% of flow weaning, and 73.6% of direct weaning, with no statistically significant difference determined between the groups (P = 0.286). The median duration of HFNC and the median LOS in PICU were determined to be statistically significantly shorter in direct weaning than in flow weaning [36 h interquartile range (IQR) 24-48 h] versus 60 h (IQR 60-72 h), P < 0.001 and 6 days (4-14 days) versus 9.5 days (5.25-20.75 days, P = 0.043, respectively). Conclusion: In patients who responded to HFNC in PICU, the responses to direct weaning and flow reduction were seen to be similar. In patients directly weaned off, both the HFNC duration and LOS in PICU were significantly shorter.

Bronchiolitis Management and Unnecessary Antibiotic Use Across 3 Canadian PICUs

OBJECTIVES

To describe the patient characteristics, clinical management, and infectious etiology in critically ill children with bronchiolitis. The secondary objective was to determine the association between antibiotic use and hospital length of stay among patients without concomitant bacterial infections.

METHODS

Retrospective cohort study including patients ≤2 years old with bronchiolitis admitted to 3 Canadian pediatric intensive care units between 2016 and 2018.

RESULTS

We included 372 patients with a median age of 2.1 months (interquartile range 1.2-6.6) and Pediatric Risk of Mortality III score 3.0 (interquartile range 0-3.0). Initial ventilatory management included high flow nasal cannula (28.2%) and noninvasive positive pressure ventilation (53.7%), of which 41.9% and 87.5%, respectively, did not require escalation of ventilatory support. Chest radiographs (81.7%) and respiratory virus testing (95.4%) were performed in most patients; 14.0% received systemic steroids. Respiratory syncytial virus was detected in 61.3% patients, and 7.5% had a culture-positive concomitant bacterial infection. Of 258 (69.4%) patients with a viral infection, only 45.3% received antibiotics. In this group, antibiotic use beyond 72 hours was not associated with hospital length of stay (ratio 1.14, 95% confidence interval 0.97-1.34).

CONCLUSIONS

High flow nasal canulae and noninvasive ventilation are commonly used in severe bronchiolitis. Despite contrary evidence, steroids and antibiotics were also frequently used. Evidence-based guidelines specific to children with severe bronchiolitis are needed to improve the care delivered to this patient population.

Modified high-flow nasal cannula for children with respiratory distress

BACKGROUND

High-flow nasal cannula (HFNC) is a noninvasive respiratory support that provides the optimum flow of an air-oxygen mixture. Several studies demonstrated its usefulness and good safety profile for treating pediatric respiratory distress patients. However, the cost of the commercial HFNC is high; therefore, the modified high-flow nasal cannula was developed.

PURPOSE

This study aimed to compare the effectiveness, safety, and nurses' satisfaction of the modified system versus the standard commercial HFNC.

METHODS

This prospective comparative study was performed in a tertiary care hospital. We recruited children aged 1 month to 5 years who developed acute respiratory distress and were admitted to the pediatric intensive care unit. Patients were assigned to 2 groups (modified vs. commercial). The effectiveness and safety assessments included vital signs, respiratory scores, intubation rate, adverse events, and nurses' satisfaction.

RESULTS

A total of 74 patients were treated with HFNC. Thirty- nine patients were assigned to the modified group, while the remaining 35 patients were in the commercial group. Intubation rate and adverse events did not differ significantly between the 2 groups. However, the commercial group had higher nurses' satisfaction scores than the modified group.

CONCLUSION

Our findings suggest that our low-cost modified HFNC could be a useful respiratory support option for younger children with acute respiratory distress, especially in hospital settings with financial constraints.

Predicting Flow Rate Escalation for Pediatric Patients on High Flow Nasal Cannula Using Machine Learning

Background: High flow nasal cannula (HFNC) is commonly used as non-invasive respiratory support in critically ill children. There are limited data to inform consensus on optimal device parameters, determinants of successful patient response, and indications for escalation of support. Clinical scores, such as the respiratory rate-oxygenation (ROX) index, have been described as a means to predict HFNC non-response, but are limited to evaluating for escalations to invasive mechanical ventilation (MV). In the presence of apparent HFNC non-response, a clinician may choose to increase the HFNC flow rate to hypothetically prevent further respiratory deterioration, transition to an alternative non-invasive interface, or intubation for MV. To date, no models have been assessed to predict subsequent escalations of HFNC flow rates after HFNC initiation. Objective: To evaluate the abilities of tree-based machine learning algorithms to predict HFNC flow rate escalations. Methods: We performed a retrospective, cohort study assessing children admitted for acute respiratory failure under 24 months of age placed on HFNC in the Johns Hopkins Children's Center pediatric intensive care unit from January 2019 through January 2020. We excluded encounters with gaps in recorded clinical data, encounters in which MV treatment occurred prior to HFNC, and cases electively intubated in the operating room. The primary study outcome was discriminatory capacity of generated machine learning algorithms to predict HFNC flow rate escalations as compared to each other and ROX indices using area under the receiver operating characteristic (AUROC) analyses. In an exploratory fashion, model feature importance rankings were assessed by comparing Shapley values. Results: Our gradient boosting model with a time window of 8 h and lead time of 1 h before HFNC flow rate escalation achieved an AUROC with a 95% confidence interval of 0.810 ± 0.003. In comparison, the ROX index achieved an AUROC of 0.525 ± 0.000. Conclusion: In this single-center, retrospective cohort study assessing children under 24 months of age receiving HFNC for acute respiratory failure, tree-based machine learning models outperformed the ROX index in predicting subsequent flow rate escalations. Further validation studies are needed to ensure generalizability for bedside application.

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.

Enteral Nutrition Improves Vital Signs in Children With Bronchiolitis on Noninvasive Ventilation

OBJECTIVES

In children hospitalized for bronchiolitis, enteral nutrition (EN) practices during noninvasive ventilation (NIV) vary widely. We sought to assess the potential impact of EN by observing changes in physiometric indices (heart rate [HR] and respiratory rate [RR]) before and after EN initiation.

METHODS

We performed a retrospective cohort study in children <2 years of age hospitalized for bronchiolitis receiving NIV from 2017 to 2019 in a quaternary ICU. The primary outcome was patient HR and RR before and after EN initiation. Descriptive data included demographics, anthropometrics, comorbidities, NIV parameters, EN characteristics, and general hospital outcomes. Analyses included paired comparative and descriptive statistics.

RESULTS

Of the 124 children studied, 85 (69%) were permitted EN at a median of 12 (interquartile range [IQR]: 7 to 29) hours. The route was oral (76.5%), nasogastric (15.3%), or postpyloric (8.2%) and was predominantly started during high-flow nasal cannula (71%) at flow rates of 1 (IQR: 0.7 to 1.4) L/kg per minute. After EN initiation, reductions in the median RR (percentage change: -11 [IQR: -23 to 3]; P < .01) and HR (percentage change: -5 [IQR: -12 to 1]; P < .01) were noted. Those permitted EN were younger (5 [IQR: 2 to 11] vs 11 [IQR: 3 to 17] months; P < .01) and more likely to have bronchopulmonary dysplasia (19% vs 5%; P = .04). Malnutrition rates, comorbidities, admission timing, flow rates, length of stay, and NIV duration did not differ for those provided or not provided EN. No aspiration events were observed.

CONCLUSIONS

Reductions between pre- and postprandial RR after EN initiation among children hospitalized for bronchiolitis on NIV were observed without clinically significant aspiration. These findings support existing data that suggest that EN is safe during NIV and may lessen distress in some patients.

Predicting Failure of Non-Invasive Ventilation With RAM Cannula in Bronchiolitis

INTRODUCTION

In infants hospitalized for bronchiolitis on non-invasive ventilation (NIV) via the RAM cannula nasal interface, variables predicting subsequent intubation, or NIV non-response, are understudied. We sought to identify predictors of NIV non-response.

METHODS

We performed a retrospective cohort study in infants admitted for respiratory failure from bronchiolitis placed on NIV in a quaternary children's hospital. We excluded children with concurrent sepsis, critical congenital heart disease, or with preexisting tracheostomy. The primary outcome was NIV non-response defined as intubation after a trial of NIV. Secondary outcomes were vital sign values before and after NIV initiation, duration of NIV and intubation, and mortality. Primary analyses included Chi-square, Wilcoxon rank-sum, student's t test, paired analyses, and adjusted and unadjusted logistic regression assessing heart rate (HR) and respiratory rate (RR) before and after NIV initiation.

RESULTS

Of 138 infants studied, 34% were non-responders. There were no differences in baseline characteristics of responders and non-responders. HR decreased after NIV initiation in responders (156 [143-156] to149 [141-158], p < 0.01) compared to non-responders (158 [149-166] to 158 [145-171], p = 0.73). RR decreased in responders (50 [43-58] vs 47 [41-54]) and non-responders (52 [48-58] vs 51 [40-55], both p < 0.01). Concurrent bacterial pneumonia (OR 6.06, 95% CI: 2.54-14.51) and persistently elevated HR (OR: 1.04, 95% CI: 1.01-1.07) were associated with NIV non-response.

CONCLUSION

In children with acute bronchiolitis who fail to respond to NIV and require subsequent intubation, we noted associations with persistently elevated HR after NIV initiation and concurrent bacterial pneumonia.

Long-Term Mechanical Ventilation in Neonates: A 10-Year Overview and Predictive Model

Objectives: Significant resources are devoted to neonatal prolonged mechanical ventilation (NPMV), but little is known about the outcomes in those children. Our primary objective was to describe the NPMV respiratory, digestive, and neurological outcomes at 18 months corrected age. Our second objective was on the early identification of which patients, among the NPMV cohort, will need to be ventilated for ≥125 days, which corresponded to the 75th percentile in the preliminary data, and to describe that subgroup. Methods: In this retrospective cohort study, we included all children born between 2004 and 2013 who had a NPMV (≥21 days of invasive or noninvasive respiratory support reached between 40 and 44 weeks of postconceptional age). We used random forests, logistic regression with penalization, naive Bayes, and XGBoost to predict which patients will need ≥125 days of ventilation. We used a Monte Carlo cross validation. Results: We included 164 patients. Of which, 40% (n = 66) were female, and the median gestational age was 29 weeks [interquartile range (IQR): 26-36 weeks] with a bimodal distribution. Median ventilation days were 104 (IQR: 66-139 days). The most frequently associated diagnoses were pulmonary hypertension (43%), early pulmonary dysplasia (41%), and lobar emphysema (37%). At 18 months corrected age, 29% (n = 47) had died, 59% (n = 97) were free of any respiratory support, and 45% (n = 74) were exclusively orally fed. A moderate area under the ROC curve of 0.65 (95% CI: 0.54-0.72) for identifying patients in need of ≥125 days of ventilation at inclusion was achieved by random forests classifiers. Among the 26 measured at inclusion, the most contributive ones were PCO₂, inspired O₂ concentration, and gestational age. At 18 months corrected age, patients ventilated for ≥125 days had a lower respiratory weaning success (76 vs. 87%, P = 0.05), lower exclusive oral feeding proportion (51 vs. 84%, P < 0.001), and a higher neurological impairment (median Pediatric Cerebral Performance Category score 3 vs. 2, P = 0.008) than patients ventilated for < 125 days. Conclusion: NPMV is a severe condition with a high risk of mortality, neurological impairment, and oral feed delay at 18 months. Most survivors are weaned of any respiratory support. We identified the risk factors that allow for the early identification of the most at-risk children of long-term ventilation with a moderate discrimination.

High-Flow Nasal Cannula Therapy in Children With Acute Respiratory Distress With Hypoxia in A Pediatric Intensive Care UnitA Single Center Experience

Aim: High-flow nasal cannulas (HFNCs) show potential in the application of positive pressure, improving gas exchange, and decreasing work of breathing in patients with acute respiratory distress. The aims of this study were to elucidate the indications for HFNC therapy in children of all ages and diagnoses, and to evaluate the efficacy and risk factors for failure of HFNC therapy in children with acute respiratory distress with hypoxia in a pediatric intensive care unit. Methods: We conducted this retrospective cohort study at a tertiary pediatric intensive care unit between January 1, 2018 and December 31, 2020. All children, from 1 month to 18 years of age, with acute respiratory distress with hypoxia and HFNC therapy were eligible. The clinical data were reviewed. Results: One hundred and two children met the eligibility criteria for the study, of whom 57 (55.9%) were male, and the mean age was 7.00 6.79 years. Seventy-eight (76.5%) of the children had underlying disorders. The most common indications for the use of HFNC therapy were pneumonia (40, 39.2%), sepsis-related respiratory distress (17, 16.7%), and bronchiolitis (16, 15.7%). The failure rate was 15.7% (16 of 102 children). Higher initial and maximum fraction of inspiration O2 levels and lower initial and lowest SpO2/FiO2 (S/F) ratio were early and possible signs of failure requiring escalation of respiratory support. Conclusion: In our population, we found that HFNC therapy could be initiated as the first-line therapy for various etiologies of acute respiratory distress with hypoxia in a pediatric intensive care unit and for all age groups.

Physiometric Response to High-Flow Nasal Cannula Support in Acute Bronchiolitis

OBJECTIVES

To describe the rate of high-flow nasal cannula (HFNC) nonresponse and paired physiometric responses (changes [∆] in heart rate [HR] and respiratory rate [RR]) before and after HFNC initiation in hospitalized children with bronchiolitis.

METHODS

We performed a single-center, prospective descriptive study in a PICU within a quaternary referral center, assessing children aged ≤2 years admitted for bronchiolitis on HFNC from November 2017 to March 2020. We excluded for cystic fibrosis, airway anomalies, pulmonary hypertension, tracheostomy, neuromuscular disease, congenital heart disease, or preadmission intubation. Primary outcomes were paired ∆ and %∆ in HR and RR before and after HFNC initiation. Secondary outcomes were HFNC nonresponse rate (ie, intubation or transition to noninvasive positive pressure ventilation). Analyses included χ², Student's t, Wilcoxon rank, and paired testing.

RESULTS

Of the 172 children studied, 56 (32.6%) experienced HFNC nonresponse at a median of 14.4 (interquartile range: 4.8-36) hours and 11 (6.4%) were intubated. Nonresponders had a greater frequency of bacterial pneumonia, but otherwise no major differences in demographics, comorbidities, or viral pathogens were noted. Responders experienced reductions in both %ΔRR (-17.1% ± 15.8% vs +5.3% ± 22.3%) and %ΔHR (-6.5% ± 10.5% vs 0% ± 10.9%) compared with nonresponders.

CONCLUSIONS

In this prospective, observational cohort study, we provide baseline data describing expected physiologic changes after initiation of HFNC for children admitted to the PICU for bronchiolitis. In our descriptive analysis, patients with comorbid bacterial pneumonia appear to be at additional risk for subsequent HFNC nonresponse.

Nasal high flow therapy introduction lowers reintubation risk in a Peruvian paediatric intensive care unit

AIM

We examined the impact of introducing high-flow nasal oxygen therapy (HFNT) on children under five with post-extubation respiratory failure in a paediatric intensive care unit (PICU) in Peru.

METHODS

This quasi-experimental study compared clinical outcomes before and after initial HFNT deployment in the PICU at Instituto Nacional de Salud del Niño in Lima in June 2016. We compared three groups: 29 received post-extubation HFNT and 17 received continuous positive airway pressure (CPAP) from 2016-17 and 12 historical controls received CPAP from 2012-16. The primary outcome was the need for mechanical ventilation. Adjusted hazard ratios (aHR) and 95% confidence intervals (95% CI) were calculated via survival analysis.

RESULTS

High-flow nasal oxygen therapy and CPAP did not alter the need for mechanical ventilation after extubation (aHR 0.47, 95% CI 0.15-1.48 and 0.96, 95% CI 0.35-2.62, respectively) but did reduce the risk of reintubation (aHR 0.18, 95% CI 0.06-0.57 and 0.14, 95% CI 0.03-0.72, respectively). PICU length of stay was 11, 18 and 37 days for CPAP, HFNT and historical CPAP and mortality was 12%, 7% and 27%, respectively. There was no effect on the duration of sedative infusions.

CONCLUSION

High-flow nasal oxygen therapy provided effective support for some children, but larger studies in resource-constrained settings are needed.

Progression of Respiratory Support Following Pediatric Extubation

OBJECTIVES

High-flow nasal cannula and noninvasive positive pressure ventilation have become ubiquitous in contemporary PICUs. Practice patterns associated with the use of these modalities have not been well described. In this study, we aimed to describe the use of high-flow nasal cannula and noninvasive positive pressure ventilation in children after extubation and analyze the progression of usage in association with patient factors. Our secondary aim was to describe interventions used for postextubation stridor.

DESIGN

Single-center retrospective cohort study.

SETTING

A 36-bed quaternary medical-surgical PICU.

PATIENTS

Mechanically ventilated pediatric patients admitted between April 2017 and March 2018. Exclusions were patients in the cardiac ICU, patients requiring a tracheostomy or chronic ventilatory support, and patients with limited resuscitation status.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data regarding respiratory modality use was collected for the first 72 hours after extubation. There were 427 patients included in the analysis; 51 patients (11.9%) were extubated to room air, 221 (51.8%) to nasal cannula, 132 (30.9%) to high-flow nasal cannula, and 23 (5.4%) to noninvasive positive pressure ventilation. By 72 hours, 314 patients (73.5%) were on room air, 52 (12.2%) on nasal cannula, 29 (6.8%) on high-flow nasal cannula, eight (1.9%) on noninvasive positive pressure ventilation, and 24 (5.6%) were reintubated. High-flow nasal cannula was the most used respiratory modality for postextubation stridor. Multivariate analysis demonstrated that longer duration of invasive mechanical ventilation increased the odds of initial high-flow nasal cannula and noninvasive positive pressure ventilation use, and a diagnosis of cerebral palsy increased the odds of escalating from high-flow nasal cannula to noninvasive positive pressure ventilation in the first 24 hours post extubation.

CONCLUSIONS

High-flow nasal cannula is commonly used immediately after pediatric extubation and the development of postextubation stridor; however, its usage sharply declines over the following 72 hours. Larger multicenter trials are needed to identify high-risk patients for extubation failure that might benefit the most from prophylactic use of high-flow nasal cannula and noninvasive positive pressure ventilation after extubation.

Timing of tracheal intubation on mortality and duration of mechanical ventilation in critically ill children: A propensity score analysis

OBJECTIVE

We aimed to investigate whether early tracheal intubation (TI) is associated with a reduced risk of mortality and increased ventilator-free days (VFD).

METHODS

We performed a retrospective cohort study of children 0 to 18 years old in a pediatric intensive care unit (PICU), between 2008 and 2017. Patient demographics, vital signs, and laboratory findings were extracted. Using a time-dependent propensity score-matched algorithm, each patient was matched with another equally likely to be intubated within the same hour but was actually intubated with ≤2 hours, 2 to 4 hours, and 4 to 6 hours delays. Outcomes were mortality and VFD.

RESULTS

Among 333 patients, the median age was 1.72 years (interquartile range [IQR] 0.17-7.75). Thirty children died (9.0%) and the median PICU length of stay was 6.7 days (IQR 3.9-13.2). Early TI did not decrease mortality significantly when compared to a ≤2 hour delay (odds ratios [OR] 0.86; 95% CI, 0.40-1.85), a 2 to 4 hour delay (OR, 0.81; 95% CI, 0.39-1.69), or a 4 to 6 hour delay (OR, 0.87; 95% CI, 0.43-1.79). Similarly, early TI did not significantly increase VFD. Patients with early TI had 0.09 more VFD (95% CI -1.83 to 2.01) when compared to a delay within 2 hours, 0.23 more VFD (95% CI -1.66 to 2.13) when compared to a 2 to 4-hour delay and 0.56 more VFD (95% CI -1.49-2.61) when compared to a 4 to 6-hour delay.

CONCLUSIONS

We did not find a significant association between the timing of TI and mortality or VFD in critically ill children.

Diagnosis and management of community-acquired pneumonia in children: South African Thoracic Society guidelines

BACKGROUND

Pneumonia remains a major cause of morbidity and mortality amongst South African children. More comprehensive immunisation regimens, strengthening of HIV programmes, improvement in socioeconomic conditions and new preventive strategies have impacted on the epidemiology of pneumonia. Furthermore, sensitive diagnostic tests and better sampling methods in young children improve aetiological diagnosis.

OBJECTIVES

To produce revised guidelines for pneumonia in South African children under 5 years of age.

METHODS

The Paediatric Assembly of the South African Thoracic Society and the National Institute for Communicable Diseases established seven expert subgroups to revise existing South African guidelines focusing on: (i) epidemiology; (ii) aetiology; (iii) diagnosis; (iv) antibiotic management and supportive therapy; (v) management in intensive care; (vi) prevention; and (vii) considerations in HIV-infected or HIVexposed, uninfected (HEU) children. Each subgroup reviewed the published evidence in their area; in the absence of evidence, expert opinion was accepted. Evidence was graded using the British Thoracic Society (BTS) grading system. Sections were synthesized into an overall guideline which underwent peer review and revision.

RECOMMENDATIONS

Recommendations include a diagnostic approach, investigations, management and preventive strategies. Specific recommendations for HIV infected and HEU children are provided.

VALIDATION

The guideline is based on available published evidence supplemented by the consensus opinion of SA paediatric experts. Recommendations are consistent with those in published international guidelines.

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.

Use of heated humidified high flow nasal cannula for obstructive sleep apnea in infants

OBJECTIVE

Heated humidified high flow nasal cannula (HHHFNC) has gained popularity in the treatment of children with respiratory distress and bronchiolitis in the past decade. Its efficacy as a mode of non-invasive respiratory support has been demonstrated in both adults and children. However, reports on its use in the treatment of obstructive sleep apnea (OSA) in infants are limited. We aimed to evaluate the efficacy of HHHFNC therapy as treatment in infants with OSA.

METHODS

A retrospective analysis of OSA infants who had undergone polysomnographic titration between 2015 and 2017 was undertaken. Data about the age, gender, AHI, co-morbid conditions and flow used for each patient were retrieved.

RESULTS

Ten infants were included in this study (median age 34 weeks; IQR 27-38 weeks). The median optimal HHHFNC flow rate was 8.0 L/min (IQR 6.7-8.0 L/min). HHHFNC significantly reduced median obstructive apnea-hypopnea index (OAHI) from 9.1 (IQR 5.1-19.3) to 0.9 (IQR 0-1.6; P = 0.005) events/h; median obstructive apnea index (OAI) from 5.8 (IQR 1.1-13.4) to 0 (IQR 0-0.9; P = 0.021) events/h; median obstructive hypopnea index (OHI) from 4.1 (IQR 0.9-6.8) to 0.1 (0-0.9; P = 0.017) events/h; and median oxygen saturation (SpO2) nadir increased from 88% (IQR 83-94%) to 94% (IQR 93-96%; P = 0.040).

CONCLUSION

HHHFNC significantly reduced respiratory events and improved oxygenation in infants with OSA.

Intensive Care Unit Utilization After Adoption of a Ward-Based High-Flow Nasal Cannula Protocol

BACKGROUND

Hospitals are increasingly adopting ward-based high-flow nasal cannula (HFNC) protocols that allow HFNC treatment of bronchiolitis outside of the intensive care unit (ICU). Our objective was to determine whether adoption of a ward-based HFNC protocol reduces ICU utilization.

METHODS

We examined a retrospective cohort of infants aged 3 to 24 months hospitalized with bronchiolitis at hospitals in the Pediatric Health Information System database. The study exposure was adoption of a ward-based HFNC protocol, measured by direct contact with pediatric hospital medicine leaders at each hospital. All analyses utilized an interrupted time series approach. The primary analysis compared outcomes three respiratory seasons before and three respiratory seasons after HFNC adoption, among adopting hospitals. Supplementary analysis 1 mirrored the primary analysis with the exception that the first season after adoption was censored. In supplementary analysis 2, effects among nonadopting hospitals were subtracted from effects measured among adopting hospitals.

RESULTS

Of 44 contacted hospitals, 41 replied (93% response rate), of which 18 were categorized as non-adopting hospitals and 12 were categorized as adopting hospitals. Included ward-based HFNC protocols were adopted between the 2010-2011 and 2015-2016 respiratory seasons. The primary analysis included 26,253 bronchiolitis encounters and measured immediate increases in the proportion of patients admitted to the ICU (absolute difference, 3.1%; 95% CI, 2.8%-3.4%) and ICU length of stay (absolute difference, 9.1 days per 100 patients; 95% CI, 5.1-13.2). Both supplementary analyses yielded similar findings.

CONCLUSION

Early protocols for ward-based HFNC were paradoxically associated with increased ICU utilization.

Variation in Practice Related to the Use of High Flow Nasal Cannula in Critically Ill Children

OBJECTIVES

To determine current management of critically ill children and gather views regarding high flow nasal cannula therapy and to evaluate research priorities for a large prospective randomized controlled trial of noninvasive respiratory support in children.

DESIGN

Multinational cross-sectional questionnaire survey conducted in 2018.

SETTING

The sample included pediatric intensive care physicians in North and South America, Asia, Europe, and Australia/New Zealand.

MEASUREMENT

Questions consisted of: 1) characteristics of intensivists and hospital, 2) practice of high flow nasal cannula, 3) supportive treatment, and 4) research of high flow nasal cannula.

INTERVENTIONS

None.

MAIN RESULTS

We collected data from 1,031 respondents; 919 (North America, 215; Australia/New Zealand, 34; Asia, 203; South America, 186; Europe, 281) were analyzed. Sixty-nine percent of the respondents used high flow nasal cannula in non-PICU settings in their institutions. For a case of bronchiolitis/pneumonia infant, 2 L/kg/min of initial flow rate was the most commonly used. For a scenario of pneumonia with 30 kg weight, more than 60% of the respondents initiated flow based on patient body weight; while, 18% applied a fixed flow rate. Noninvasive ventilation was considered as a next step in more than 85% of respondents when the patient is failing with high flow nasal cannula. Significant practice variations were observed in clinical practice markers used, flow weaning strategy, and supportive practices. Views comparing high flow nasal cannula to continuous positive airway pressure also noticeably varied across the respondents.

CONCLUSIONS

Significant practice variations including views of high flow nasal cannula compared to continuous positive airway pressure was found among pediatric intensive care physicians. To expedite establishment and standardization of high flow nasal cannula practice, research aimed at understanding the heterogeneity found in this study should be undertaken.

High-flow nasal cannula oxygen therapy in children: a clinical review

High-flow nasal cannula (HFNC) is a relatively safe and effective noninvasive ventilation method that was recently accepted as a treatment option for acute respiratory support before endotracheal intubation or invasive ventilation. The action mechanism of HFNC includes a decrease in nasopharyngeal resistance, washout of dead space, reduction in inflow of ambient air, and an increase in airway pressure. In preterm infants, HFNC can be used to prevent reintubation and initial noninvasive respiratory support after birth. In children, flow level adjustments are crucial considering their maximal efficacy and complications. Randomized controlled studies suggest that HFNC can be used in cases of moderate to severe bronchiolitis upon initial low-flow oxygen failure. HFNC can also reduce intubation and mechanical ventilation in children with respiratory failure. Several observational studies have shown that HFNC can be beneficial in acute asthma and other respiratory distress. Multicenter randomized studies are warranted to determine the feasibility and adherence of HFNC and continuous positive airway pressure in pediatric intensive care units. The development of clinical guidelines for HFNC, including flow settings, indications, and contraindications, device management, efficacy identification, and safety issues are needed, particularly in children.

[Factors associated to high-flow nasal cannula treatment failure in pediatric patients with respiratory failure in two pediatric intensive care units at high altitude]

INTRODUCTION

Acute respiratory failure is the leading cause of hospitalization in pediatrics. High-flow nasal cannulas (HFNCs) offer a new alternative, but the evidence and indications are still debated. The performance of HFNCs at high altitude has not been described to date.

OBJECTIVE

To describe the use of HFNCs in pediatric patients admitted with respiratory failure and explore the factors associated with treatment failure.

METHODOLOGY

A prospective cohort study was carried out in patients between 1 month and 18 years of age managed with HFNCs. The demographic and treatment response data were recorded at baseline and after 1, 6 and 24hours. The number of failures was determined, as well as the length of stay, complications and mortality. Patients with treatment failure were compared with the rest.

RESULTS

A total of 539 patients were enrolled. Infants (70.9%) of male sex (58.4%) and airway diseases such as asthma and bronchiolitis (61.2%) were more frequent. There were 53 failures (9.8%), with 21 occurring in the first 24hours. The median length of stay was 4 days (IQR 4); there were 5 deaths (0.9%) and 13 adverse events (epistaxis) (2.2%). Improvement was observed in vital signs and severity over time, with differences in the group that failed, but without interactions. The final logistic model established an independent relationship of failure between the hospital (OR 2.78, 95%CI 1.48-5.21) and the initial respiratory rate (OR 1.56, 95%CI 1.21-2.01).

CONCLUSIONS

HFNCs afford good clinical response, with few complications and a low failure rate. The differences found between institutions suggest a subjective relationship in the decision of therapy failure.

The Problematic 2014 American Academy of Pediatrics Bronchiolitis Guidelines

The 2014 American Academy of Pediatrics bronchiolitis guidelines do not adequately serve the needs and clinical realities of front-line clinicians caring for undifferentiated wheezing infants and children. This article describes the clinical challenges of evaluating and managing a heterogeneous disease syndrome presenting as undifferentiated patients to the emergency department. Although the 2014 American Academy of Pediatrics bronchiolitis guidelines and the multiple international guidelines that they closely mirror have made a good faith attempt to provide clinicians with the best evidence-based recommendations possible, they have all failed to address practical, front-line clinical challenges. The therapeutic nihilism of the guidelines and the dissonance between many of the recommendations and frontline realities have had wide-ranging consequences. Nevertheless, newer evidence of therapeutic options is emerging and forecasts hope for more therapeutically optimistic recommendations with the next revision of the guidelines.

Increased Use of Noninvasive Ventilation Associated With Decreased Use of Invasive Devices in Children With Bronchiolitis

To assess how a change in practice to more frequent use of high-flow nasal cannula for the treatment of bronchiolitis would affect the use of invasive devices in children.

A pilot study of heated and humidified low flow oxygen therapy: An assessment in infants with mild and moderate bronchiolitis (HHOT AIR study)

BACKGROUND

Heated and humidified high flow nasal cannula oxygen therapy has been used in children with severe bronchiolitis. No data exists in children with mild to moderate bronchiolitis requiring lower flows of heated and humidified oxygen therapy.

METHODS

We conducted a prospective, randomized pilot study of standard dry oxygen (control) versus heated and humidified low flow nasal cannula (HHLFNC), <4 liters per minute (LPM) oxygen, (treatment) in healthy children ≤24 months old with bronchiolitis. Clinical assessments were made using Respiratory Distress Assessment Instrument (RDAI), respiratory rate (RR), and oxygen saturation.

RESULTS

Thirty-two children were enrolled (16 participants in each group). There was no significant difference in mean RDAI over time between groups. There was a significant difference in mean RDAI over time within control group, at hour 12, and treatment group, at hour 1, compared to baseline. RDAI in the treatment group was overall lower over time compared to control group. There was no significant difference in mean RR over time between or within groups, between mean length of stay and duration of oxygen requirement. Subgroup analyses showed lower RDAI in subjects that had RSV infection, male gender, and non-black race.

CONCLUSIONS

The use of HHLFNC oxygen therapy may provide more comfort and may result in more rapid improvements in RDAI compared to standard dry oxygen therapy over time. HHFLNC is safe and well tolerated compared to standard dry oxygen. Larger studies are needed to assess the clinical efficacy of HHLFNC oxygen therapy.

Patterns of Use of Heated Humidified High-Flow Nasal Cannula Therapy in PICUs in the United Kingdom and Republic of Ireland

OBJECTIVES

To 1) describe patterns of use of high-flow nasal cannula therapy, 2) examine differences between patients started on high-flow nasal cannula and those started on noninvasive ventilation, and 3) explore whether patients who failed high-flow nasal cannula therapy were different from those who did not.

DESIGN

Retrospective analysis of data collected prospectively by the Paediatric Intensive Care Audit Network.

SETTING

All PICUs in the United Kingdom and Republic of Ireland (n = 34).

PATIENTS

Admissions to study PICUs (2015-2016) receiving any form of respiratory support at any time during PICU stay.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Eligible admissions were classified into nine groups based on the combination of the first-line and second-line respiratory support modes. Uni- and multivariate analyses were performed to test the association between PICU and patient characteristics and two outcomes: 1) use of high-flow nasal cannula versus noninvasive ventilation as first-line mode and 2) high-flow nasal cannula failure, requiring escalation to noninvasive ventilation and/or invasive ventilation. We analyzed data from 26,423 admissions; high-flow nasal cannula was used in 5,951 (22.5%) at some point during the PICU stay. High-flow nasal cannula was used for first-line support in 2,080 (7.9%) and postextubation support in 978 admissions (4.5% of patients extubated after first-line invasive ventilation). High-flow nasal cannula failure occurred in 559 of 2,080 admissions (26.9%) when used for first-line support. Uni- and multivariate analyses showed that PICU characteristics as well as patient age, primary diagnostic group, and admission type had a significant influence on the choice of first-line mode (high-flow nasal cannula or noninvasive ventilation). Younger age, unplanned admission, and higher admission severity of illness were independent predictors of high-flow nasal cannula failure.

CONCLUSIONS

The use of high-flow nasal cannula is common in PICUs in the United Kingdom and Republic of Ireland. Variation in the choice of first-line respiratory support mode (high-flow nasal cannula or noninvasive ventilation) between PICUs reflects the need for clinical trial evidence to guide future practice.

HIGH-FLOW NASAL CANNULA POST-TRACHEAL EXTUBATION IN A CHILD WITH UPPER AIRWAY OBSTRUCTION: CASE REPORT

OBJECTIVE

To report a case of a patient who required tracheal intubation in a pediatric emergency department due to acute laryngitis and that, after the planned extubation, has successfully used the high-flow nasal cannula, which possibly prevented extubation failure.

CASE DESCRIPTION

A male 8-month-old child was admitted to the pediatric emergency room with acute respiratory distress due to a high airway obstruction secondary to severe acute laryngitis. He was immediately intubated and referred to the pediatric intensive care unit. He presented extubation failure due to a significant laryngeal edema evidenced by bronchoscopy. In the second attempt to extubate, he presented respiratory distress, but, after the use of the high-flow nasal cannula, he became stable, reducing the heart and respiratory frequencies, and the extubation was successful.

COMMENTS

The use of the high-flow nasal cannula was effective and presented good response in this patient with acute laryngitis, suggesting that it is a possible adjuvant for the treatment, avoiding worsening respiratory conditions and the need for reintubation.

FIRST-line support for Assistance in Breathing in Children (FIRST-ABC): a multicentre pilot randomised controlled trial of high-flow nasal cannula therapy versus continuous positive airway pressure in paediatric critical care

BACKGROUND

Although high-flow nasal cannula therapy (HFNC) has become a popular mode of non-invasive respiratory support (NRS) in critically ill children, there are no randomised controlled trials (RCTs) comparing it with continuous positive airway pressure (CPAP). We performed a pilot RCT to explore the feasibility, and inform the design and conduct, of a future large pragmatic RCT comparing HFNC and CPAP in paediatric critical care.

METHODS

In this multi-centre pilot RCT, eligible patients were recruited to either Group A (step-up NRS) or Group B (step-down NRS). Participants were randomised (1:1) using sealed opaque envelopes to either CPAP or HFNC as their first-line mode of NRS. Consent was sought after randomisation in emergency situations. The primary study outcomes were related to feasibility (number of eligible patients in each group, proportion of eligible patients randomised, consent rate, and measures of adherence to study algorithms). Data were collected on safety and a range of patient outcomes in order to inform the choice of a primary outcome measure for the future RCT.

RESULTS

Overall, 121/254 eligible patients (47.6%) were randomised (Group A 60%, Group B 44.2%) over a 10-month period (recruitment rate for Group A, 1 patient/site/month; Group B, 2.8 patients/site/month). In Group A, consent was obtained in 29/33 parents/guardians approached (87.9%), while in Group B 84/118 consented (71.2%). Intention-to-treat analysis included 113 patients (HFNC 59, CPAP 54). Most reported adverse events were mild/moderate (HFNC 8/59, CPAP 9/54). More patients switched treatment from HFNC to CPAP (Group A: 7/16, 44%; Group B: 9/43, 21%) than from CPAP to HFNC (Group A: 3/13, 23%; Group B: 5/41, 12%). Intubation occurred within 72 h in 15/59 (25.4%) of HFNC patients and 10/54 (18.5%) of CPAP patients (p = 0.38). HFNC patients experienced fewer ventilator-free days at day 28 (Group A: 19.6 vs. 23.5; Group B: 21.8 vs. 22.2).

CONCLUSIONS

Our pilot trial confirms that, following minor changes to consent procedures and treatment algorithms, it is feasible to conduct a large national RCT of non-invasive respiratory support in the paediatric critical care setting in both step-up and step-down NRS patients.

TRIAL REGISTRATION

clinicaltrials.gov, NCT02612415 . Registered on 23 November 2015.

Early predictors of unresponsiveness to high-flow nasal cannula therapy in a pediatric emergency department

AIM

High-flow nasal cannula (HFNC) is a new treatment option for pediatric respiratory distress and we aimed to assess early predictive factors of unresponsiveness to HFNC therapy in a pediatric emergency department (ED).

METHOD

Patients who presented with respiratory distress and were treated by HFNC, were included. The age, gender, weight, medical history, diagnosis, vital signs, oxygen saturation/fraction of inspired oxygen (SpO₂ /FiO₂ ) ratio, modified Respiratory Distress Assessment Instrument (mRDAI) scores, medical interventions, duration of HFNC therapy, time to escalation, adverse effects, and laboratory test results were obtained from medical and nursing records. The requirement of a higher level of respiratory support due to unchanged or increased RR compared to initial RR, incipient, or progressive respiratory acidosis, incipient hemodynamic instability was defined as unresponsiveness to HFNC.

RESULTS

The study enrolled 154 children with a median age of 10 months (interquartile range [IQR], 5.7-22.5 months). The diagnosis was acute bronchiolitis in 59 patients (38.3%), bacterial pneumonia in 64 patients (41.6%), and atypical or viral pneumonia in 31 patients (20.1%). Twenty-five patients (16.2%) were in the unresponsive group, and the median time for escalating respiratory support was 7 h (IQR: 4-20 h). The unresponsive group had lower SpO₂ and SpO₂ /FiO₂ (SF) ratio on admission, lower venous pH, and higher partial pressure of carbon dioxide (pCO₂ ) (P = 0.002, P = 0.012, and P = 0.001, respectively). Also the alteration of RR, mRDAI score, and SF ratio at the first hour was greater in the responsive group. The cut-off value of SF ratio at the first hour of HFNC was 195 for unresponsiveness.

CONCLUSION

The low initial SpO₂ and SF ratio, respiratory acidosis, and SF ratio less than 195 at the first hours of treatment were related to unresponsiveness to HFNC therapy in our pediatric emergency department.

Treatment of severe bronchiolitis: A survey of Canadian pediatric intensivists

OBJECTIVE

To describe management practices and the factors guiding admission and treatment decisions for viral bronchiolitis across Canadian pediatric intensive care units (PICUs).

DESIGN

Cross-sectional survey.

SETTING

Canadian PICUs.

SUBJECTS

Pediatric intensivists.

MEASUREMENTS AND MAIN RESULTS

A survey using two case scenarios (non-intubated vs intubated patients) was developed using focus groups and a literature review. We analyzed our results using descriptive statistics and multivariate logistic regression. Our response rate was 55% (57/103). Regarding bronchiolitis management, 75% (42/56) of respondents would use inhaled therapies, with nebulized epinephrine (33/56, 59%) and salbutamol (20/56, 36%) being the most common. Antibiotic use within the first hour of admission to PICU almost doubled in frequency (36% vs 71%) in patients who required mechanical ventilation (p 0.0004). High flow nasal cannula (HFNC; 32/56, 57%) and continuous positive airway pressure (CPAP; 16/56, 29%) were the preferred modes of non-invasive ventilation (NIV).

CONCLUSION

The management of severe viral bronchiolitis is similar across Canadian PICUs. The use of NIV, inhaled treatments, and antibiotics is frequent, which differs from the recommendations made by published guidelines. Canadian pediatric intensivists use homogeneous PICU admission criteria based on patients' characteristics and severity of the clinical picture. Clinical practice guidelines for children with viral bronchiolitis should address the management of patients with severe clinical disease.

Temporal Changes in Prescription of Neuropharmacologic Drugs and Utilization of Resources Related to Neurologic Morbidity in Mechanically Ventilated Children With Bronchiolitis

OBJECTIVES

Critically ill children with bronchiolitis may require neuropharmacologic medications and support for neuro-functional sequelae, but current practices are not well described. We aimed to describe recent trends in neuropharmacology and utilization of neuro-rehabilitation resources in mechanically ventilated children with bronchiolitis.

DESIGN

Analysis of the multicenter Pediatric Health Information System database.

SETTING

Forty-seven U.S. children's hospitals.

PATIENTS

PICU patients less than 2 years old with bronchiolitis undergoing mechanical ventilation between 2006 and 2015.

INTERVENTIONS

None. Annual rates of utilization of neuropharmacologic medications (sedatives, analgesics, etc) and of neuro-rehabilitation services (physical therapy, neurologic consultation, etc) over the 10-year study period were compared.

MEASUREMENTS AND MAIN RESULTS

Neuropharmacologic medications prescribed on greater than or equal to 2 days were extracted. Utilization of MRI of the brain, neurologic consultation, swallow evaluation, occupational therapy, and physical therapy was also extracted. Among 12,508 subjects, the median age was 2.8 months, ~50% had comorbid conditions, and the median duration of mechanical ventilation was 7 days. The percentage of children prescribed greater than or equal to five drugs/drug classes increased over the study period from 36.5% to 55.8% (p < 0.001). There were significant increases over time in utilization of 10 of the 15 individual drugs/drug classes analyzed. More than half of subjects (6,294 [50.3%]) received at least one service that evaluates/treats neurologic morbidity. There were significant increases in the use of greater than or equal to one service (36.3% in 2006 to 59.6% in 2015; p < 0.001) and in the use of greater than or equal to two services (20.8% to 34.8%; p < 0.001). Utilization of each of the five individual resources increased significantly during the study period, but use of vasoactive medications and mortality did not.

CONCLUSIONS

Prescription of neuropharmacologic agents increased over time using metrics of both overall drug burden and specific drug usage. Concurrently, the utilization of services that evaluate and/or treat neurologic morbidity was common and also increased over time.

The use of high-flow nasal cannula in the pediatric emergency department

OBJECTIVES

To summarize the current literature describing high-flow nasal cannula use in children, the components and mechanisms of action of a high-flow nasal cannula system, the appropriate clinical applications, and its role in the pediatric emergency department.

SOURCES

A computer-based search of PubMed/MEDLINE and Google Scholar for literature on high-flow nasal cannula use in children was performed.

DATA SUMMARY

High-flow nasal cannula, a non-invasive respiratory support modality, provides heated and fully humidified gas mixtures to patients via a nasal cannula interface. High-flow nasal cannula likely supports respiration though reduced inspiratory resistance, washout of the nasopharyngeal dead space, reduced metabolic work related to gas conditioning, improved airway conductance and mucociliary clearance, and provision of low levels of positive airway pressure. Most data describing high-flow nasal cannula use in children focuses on those with bronchiolitis, although high-flow nasal cannula has been used in children with other respiratory diseases. Introduction of high-flow nasal cannula into clinical practice, including in the emergency department, has been associated with decreased rates of endotracheal intubation. Limited prospective interventional data suggest that high-flow nasal cannula may be similarly efficacious as continuous positive airway pressure and more efficacious than standard oxygen therapy for some patients. Patient characteristics, such as improved tachycardia and tachypnea, have been associated with a lack of progression to endotracheal intubation. Reported adverse effects are rare.

CONCLUSIONS

High-flow nasal cannula should be considered for pediatric emergency department patients with respiratory distress not requiring immediate endotracheal intubation; prospective, pediatric emergency department-specific trials are needed to better determine responsive patient populations, ideal high-flow nasal cannula settings, and comparative efficacy vs. other respiratory support modalities.

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.

FIRST-line support for Assistance in Breathing in Children (FIRST-ABC): protocol for a multicentre randomised feasibility trial of non-invasive respiratory support in critically ill children

INTRODUCTION

Over 18 000 children are admitted annually to UK paediatric intensive care units (PICUs), of whom nearly 75% receive respiratory support (invasive and/or non-invasive). Continuous positive airway pressure (CPAP) has traditionally been used to provide first-line non-invasive respiratory support (NRS) in PICUs; however, high-flow nasal cannula therapy (HFNC), a novel mode of NRS, has recently gained popularity despite the lack of high-quality trial evidence to support its effectiveness. This feasibility study aims to inform the design and conduct of a future definitive randomised clinical trial (RCT) comparing the two modes of respiratory support.

METHODS AND ANALYSIS

We will conduct a three-centre randomised feasibility study over 12 months. Patients admitted to participating PICUs who satisfy eligibility criteria will be recruited to either group A (primary respiratory failure) or group B (postextubation). Consent will be obtained from parents/guardians prior to randomisation in 'planned' group B, and deferred in emergency situations (group A and 'rescue' group B). Participants will be randomised (1:1) to either CPAP or HFNC using sealed, opaque envelopes, from a computer-generated randomisation sequence with variable block sizes. The study protocol specifies algorithms for the initiation, maintenance and weaning of HFNC and CPAP. The primary outcomes are related to feasibility, including the number of eligible patients in each group, feasibility of randomising >50% of eligible patients and measures of adherence to the treatment protocols. Data will also be collected on patient outcomes (eg, mortality and length of PICU stay) to inform the selection of an appropriate outcome measure in a future RCT. We aim to recruit 120 patients to the study.

ETHICS AND DISSEMINATION

Ethical approval was granted by the National Research Ethics Service Committee North East-Tyne&Wear South (15/NE/0296). Study findings will be disseminated through peer-reviewed journals, national and international conferences.

TRIALS REGISTRATION NUMBER

NCT02612415; pre-results.