1
|
Ford T, Lane J, Noelck M, Byrd C. Addressing high flow overuse in bronchiolitis - Successes and future directions. Paediatr Respir Rev 2024:S1526-0542(24)00051-4. [PMID: 38937209 DOI: 10.1016/j.prrv.2024.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 06/03/2024] [Indexed: 06/29/2024]
Abstract
The use of high flow nasal cannula (HFNC) in the treatment of bronchiolitis has markedly increased in the last decade, yet randomized controlled trials have reported little clinical benefit with early, routine use. This article provides a concise overview of the current status of HFNC therapy, discusses successful de-implementation strategies to curtail HFNC overuse, and explores future bronchiolitis and HFNC quality improvement and research considerations.
Collapse
Affiliation(s)
- Taylor Ford
- Emory University School of Medicine, Pediatric Hospital Medicine, Department of Pediatrics, Children's Healthcare of Atlanta, 1405 Clifton Road, Atlanta, GA 30322, United States
| | - Jennifer Lane
- Oregon Health and Science University, Pediatric Hospital Medicine, Department of Pediatrics, Oregon Health & Science University, 707 SW Gaines Street, mail code CDRCP, Portland, OR 97239, United States
| | - Michelle Noelck
- Oregon Health and Science University, Pediatric Hospital Medicine, Department of Pediatrics, Oregon Health & Science University, 707 SW Gaines Street, mail code CDRCP, Portland, OR 97239, United States
| | - Courtney Byrd
- Emory University School of Medicine, Pediatric Hospital Medicine, Department of Pediatrics, Children's Healthcare of Atlanta, 1405 Clifton Road, Atlanta, GA 30322, United States.
| |
Collapse
|
2
|
Lane JE, Ford T, Noelck M, Byrd C. High flow, low results: The limits of high flow nasal cannula in the treatment of bronchiolitis. Paediatr Respir Rev 2024:S1526-0542(24)00052-6. [PMID: 38964936 DOI: 10.1016/j.prrv.2024.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Accepted: 06/03/2024] [Indexed: 07/06/2024]
Abstract
Bronchiolitis continues to be the most common cause of hospitalization in the first year of life. We continue to search for the remedy that will improve symptoms, shorten hospitalization and prevent worsening of disease. Although initially thought to be a promising therapy, large randomized controlled trials show us that high flow nasal cannula (HFNC) use is not that remedy. These trials show no major differences in duration of hospital stay, intensive care unit (ICU) admission rates, duration of stay in the ICU, duration of oxygen therapy, intubation rates, heart rate, respiratory rate or comfort scores. Additionally, practices regarding initiation, flow rates and weaning continue to vary from institution to institution and there are currently no agreed upon indications for its use. This reveals the need for evidence based guidelines on HFNC use in bronchiolitis.
Collapse
Affiliation(s)
- Jennifer E Lane
- Division of Hospital Medicine, Department of Pediatrics, Oregon Health and Science University, Portland, OR, United States.
| | - Taylor Ford
- Division of Hospital Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.
| | - Michelle Noelck
- Division of Hospital Medicine, Department of Pediatrics, Oregon Health and Science University, Portland, OR, United States.
| | - Courtney Byrd
- Division of Hospital Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.
| |
Collapse
|
3
|
Kannikeswaran N, Ehrman RR, Spencer P, Pitman-Hunt C, Leja J, Lelak K, Arora R, Delaroche A. Impact of initial high flow nasal cannula flow rates on clinical outcomes in children with bronchiolitis. Pediatr Pulmonol 2024; 59:1281-1287. [PMID: 38353397 DOI: 10.1002/ppul.26900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 01/14/2024] [Accepted: 01/27/2024] [Indexed: 04/30/2024]
Abstract
PURPOSE Our aim was to evaluate the impact of the initial high flow nasal cannula (HFNC) flow rate on clinical outcomes in children with bronchiolitis. METHODS This secondary analysis of retrospective data included children <2 years who required HFNC for bronchiolitis between 10/01/2018-04/20/2019, and following implementation of a revised institutional bronchiolitis pathway between 10/01/2021-04/30/2022. The new pathway recommended weight-based initiation of HFNC at 1.5-2 L/kg/min. We evaluated the effect of low (<1.0 L/kg/min), medium (1-1.5 L/kg/min) and high (>1.5 L/kg/min) HFNC flow rates on need for positive pressure ventilation (PPV), intensive care unit (ICU) transfer, HFNC treatment time, and hospital length of stay (LOS). RESULTS The majority of the 885 included children had low initial flow rates (low [n = 450, 50.8%], medium [n = 332, 37.5%] and high [n = 103, 11.7%]). There were no significant differences in PPV (high: 7.8% vs. medium: 9.3% vs. low: 8.2%, p = 0.8) or ICU transfers (high: 4.9% vs. medium: 6.0% vs. low: 3.8%, p = 0.3). The low flow group had a significantly longer median HFNC treatment time (High: 29 [18, 45] vs. medium: 29 [16, 50] vs. low: 39 [25, 63], p < .001) and hospital LOS (High: 41 [27, 59] vs. medium: 42 [29, 66] vs. low: 50 (39, 75), p < .001). Logistic and linear regression models did not demonstrate any associations between HFNC flow rates and PPV or hospital LOS. CONCLUSIONS Initial HFNC flow rates were not associated with significant changes in clinical outcomes in children in children with bronchiolitis.
Collapse
Affiliation(s)
| | - Robert R Ehrman
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Priya Spencer
- Children's Hospital of Michigan, Detroit, Michigan, USA
| | - Chaya Pitman-Hunt
- Children's Hospital of Michigan, Central Michigan University, Detroit, Michigan, USA
| | - Jacqueline Leja
- Children's Hospital of Michigan, Central Michigan University, Detroit, Michigan, USA
| | - Karima Lelak
- Pediatric Emergency Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Rajan Arora
- Children's Hospital of Michigan, Central Michigan University, Detroit, Michigan, USA
| | - Amy Delaroche
- Children's Hospital of Michigan, Central Michigan University, Detroit, Michigan, USA
| |
Collapse
|
4
|
Li J, Deng N, He WJA, Yang C, Liu P, Albuainain FA, Ring BJ, Miller AG, Rotta AT, Guglielmo RD, Milési C. The effects of flow settings during high-flow nasal cannula oxygen therapy for neonates and young children. Eur Respir Rev 2024; 33:230223. [PMID: 38537946 PMCID: PMC10966474 DOI: 10.1183/16000617.0223-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 01/18/2024] [Indexed: 07/23/2024] Open
Abstract
BACKGROUND During neonatal and paediatric high-flow nasal cannula therapy, optimising the flow setting is crucial for favourable physiological and clinical outcomes. However, considerable variability exists in clinical practice regarding initial flows and subsequent adjustments for these patients. Our review aimed to summarise the impact of various flows during high-flow nasal cannula treatment in neonates and children. METHODS Two investigators independently searched PubMed, Embase, Web of Science, Scopus and Cochrane for in vitro and in vivo studies published in English before 30 April 2023. Studies enrolling adults (≥18 years) or those using a single flow setting were excluded. Data extraction and risk of bias assessments were performed independently by two investigators. The study protocol was prospectively registered with PROSPERO (CRD42022345419). RESULTS 38 406 studies were identified, with 44 included. In vitro studies explored flow settings' effects on airway pressures, humidity and carbon dioxide clearance; all were flow-dependent. Observational clinical studies consistently reported that higher flows led to increased pharyngeal pressure and potentially increased intrathoracic airway pressure (especially among neonates), improved oxygenation, and reduced respiratory rate and work of breathing up to a certain threshold. Three randomised controlled trials found no significant differences in treatment failure among different flow settings. Flow impacts exhibited significant heterogeneity among different patients. CONCLUSION Individualising flow settings in neonates and young children requires consideration of the patient's peak inspiratory flow, respiratory rate, heart rate, tolerance, work of breathing and lung aeration for optimal care.
Collapse
Affiliation(s)
- Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, IL, USA
- These authors contributed equally
| | - Ni Deng
- Department of Respiratory Care, West China Hospital of Sichuan University, Chengdu, China
- These authors contributed equally
| | - Wan Jia Aaron He
- School of Nursing, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China
- These authors contributed equally
| | - Cui Yang
- Department of Pediatric Intensive Care Unit, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, China
- These authors contributed equally
| | - Pan Liu
- Department of Pediatric Intensive Care Unit, Children's Hospital of Fudan University, National Center for Children's Health, Shanghai, China
- These authors contributed equally
| | - Fai A Albuainain
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, IL, USA
- Department of Respiratory Care, College of Applied Medical Sciences, Imam Abdulrahman bin Faisal University, Jubail, Saudi Arabia
| | - Brian J Ring
- Department of Surgery, Division of Trauma and Critical Care, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Andrew G Miller
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
- Respiratory Care Services, Duke University Medical Center, Durham, NC, USA
| | - Alexandre T Rotta
- Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Robert D Guglielmo
- Division of Pediatric Critical Care, Department of Pediatrics, Loma Linda University Children's Hospital, Loma Linda, CA, USA
- Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Christophe Milési
- Pediatric Intensive Care Unit, University of Montpellier I, Montpellier, France
| |
Collapse
|
5
|
High-Flow Oxygen and Other Noninvasive Respiratory Support Therapies in Bronchiolitis: Systematic Review and Network Meta-Analyses. Pediatr Crit Care Med 2023; 24:133-142. [PMID: 36661419 DOI: 10.1097/pcc.0000000000003139] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES We present a systematic review on the effectiveness of noninvasive respiratory support techniques in bronchiolitis. DATA SOURCES Systematic review with pairwise meta-analyses of all studies and network meta-analyses of the clinical trials. STUDY SELECTION Patients below 24 months old with bronchiolitis who require noninvasive respiratory support were included in randomized controlled trials (RCTs), non-RCT, and cohort studies in which high-flow nasal cannula (HFNC) was compared with conventional low-flow oxygen therapy (LFOT) and/or noninvasive ventilation (NIV). DATA EXTRACTION Emergency wards and hospitalized patients with bronchiolitis. DATA SYNTHESIS A total of 3,367 patients were analyzed in 14 RCTs and 8,385 patients in 14 non-RCTs studies. Only in nonexperimental studies, HFNC is associated with a lower risk of invasive mechanical ventilation (MV) than NIV (odds ratio, 0.49; 95% CI, 0.42-0.58), with no differences in experimental studies. There were no differences between HFNC and NIV in other outcomes. HFNC is more effective than LFOT in reducing oxygen days and treatment failure. In the network meta-analyses of clinical trials, NIV was the most effective intervention to avoid invasive MV (surface under the cumulative ranking curve [SUCRA], 57.03%) and to reduce days under oxygen therapy (SUCRA, 79.42%), although crossover effect estimates between interventions showed no significant differences. The included studies show methodological heterogeneity, but it is only statistically significant for the reduction of days of oxygen therapy and length of hospital stay. CONCLUSIONS Experimental evidence does not suggest that high-flow oxygen therapy has advantages over LFOT as initial treatment nor over NIV as a rescue treatment.
Collapse
|
6
|
Steindor M, Wagner CE, Kavvalou A, Bock C, Olivier M, Stehling F. Indications and outcome of home high-flow nasal therapy in children, a single-center experience. Pediatr Pulmonol 2022; 57:2048-2052. [PMID: 35574827 DOI: 10.1002/ppul.25974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/03/2022] [Accepted: 05/13/2022] [Indexed: 11/09/2022]
Abstract
High-flow nasal therapy (HFNT) is a safe and simple way to deliver humidified air and oxygen for respiratory support in infants and children. HFNT is well established in an inpatient setting, but home HFNT lacks evidence. In the current study, we studied characteristics and outcomes of pediatric patients with home HFNT. In a monocentric retrospective analysis of data for 10 years (April 2010-April 2020), patient characteristics from the time point of the first discharge from hospital with home HFNT-treatment and the subsequent course were analyzed. Patients were divided into three HFNT indication groups: (1) bronchopulmonary dysplasia (BPD), (2) upper airway obstruction (UAO), and (3) other indications. Forty patients received home HFNT in the study period. Seventeen patients were treated for BPD, 15 for UAO, and 8 had other indications. Twenty-two patients (55%) were successfully weaned from HFNT (12 [70.6%] BPD, 7 [46.7%] UAO, 3 [37.5%] other), while seven patients (17.5%) died during follow-up (4 BPD, 2 UAO, 1 other). Twenty-three patients (57.5%) required (intermittent) additional oxygen application (14 [82.4%] BPD, 6 [40%] UAO, 4 [50%] other). Weaning success and need for additional oxygen were significantly more probable in BPD patients compared to the UOA group. In conclusion, HFNT plays an increasing role in home treatment of respiratory insufficiency of various etiologies in childhood. It often represents a temporary intervention, especially for children with BPD but might also serve as long-term treatment for children in whom other forms of ventilatory support are not feasible or desired.
Collapse
Affiliation(s)
- Mathis Steindor
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics III, Children's Hospital, University of Duisburg-Essen, Essen, Germany
| | - Carolin Ellen Wagner
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics III, Children's Hospital, University of Duisburg-Essen, Essen, Germany
| | - Alexandra Kavvalou
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics III, Children's Hospital, University of Duisburg-Essen, Essen, Germany
| | - Claudia Bock
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics III, Children's Hospital, University of Duisburg-Essen, Essen, Germany
| | - Margarete Olivier
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics III, Children's Hospital, University of Duisburg-Essen, Essen, Germany
| | - Florian Stehling
- Division of Pediatric Pulmonology and Sleep Medicine, Department of Pediatrics III, Children's Hospital, University of Duisburg-Essen, Essen, Germany
| |
Collapse
|