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Galazzi A, Petrei M, Palese A. Tools used to assess comfort among patients undergoing high flow nasal cannula: A scoping review. Intensive Crit Care Nurs 2024; 83:103719. [PMID: 38718552 DOI: 10.1016/j.iccn.2024.103719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/11/2024] [Accepted: 04/30/2024] [Indexed: 06/12/2024]
Abstract
OBJECTIVE The aims were twofold: (a) to map tools documented in the literature to evaluate comfort among patients undergoing high flow nasal cannula (HFNC) treatment; and (b) to assess if the retrieved tools have been validated for this purpose. METHODS A scoping review, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR). In July 2023, PubMed, Scopus, CINAHL and Cochrane Library were consulted. Studies assessing comfort in adult, paediatric, and neonatal patients undergoing HFNC were included. RESULTS Seventy-four articles were included, among which nine (12.2 %) investigated comfort as the primary aim. Twenty-five different tools were found, classifiable into 14 types, mostly unidimensional and originating from those measuring pain. The most widely used was the Visual Analogic Scale (n = 27, 35.6 %) followed by the Numerical Rating Scale (n = 11, 14.5 %) and less defined generic tools (n = 10, 13.2 %) with different metrics (e.g. 0-5, 0-10, 0-100). Only the General Comfort Questionnaire and the Comfort Scale were specifically validated for the assessment of comfort among adults and children, respectively. CONCLUSION Although the comfort of patients undergoing HFNC is widely investigated in the literature, there is a scarcity of tools specifically validated in this field. Those used have been validated mainly to assess pain, suggesting the need to inform patients to prevent confusion while measuring comfort during HFNC and to develop more research in the field. IMPLICATIONS FOR CLINICAL PRACTICE Comfort assessment is an important aspect of nursing care. Given the lack of validation studies in the field, efforts in research are recommended.
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Affiliation(s)
| | - Matteo Petrei
- Department of Medicine, University of Udine, Udine, Italy
| | - Alvisa Palese
- Department of Medicine, University of Udine, Udine, Italy
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Armarego M, Forde H, Wills K, Beggs SA. High-flow nasal cannula therapy for infants with bronchiolitis. Cochrane Database Syst Rev 2024; 3:CD009609. [PMID: 38506440 PMCID: PMC10953464 DOI: 10.1002/14651858.cd009609.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
BACKGROUND Bronchiolitis is a common lower respiratory tract illness, usually of viral aetiology, affecting infants younger than 24 months of age and is the most common cause of hospitalisation of infants. It causes airway inflammation, mucus production and mucous plugging, resulting in airway obstruction. Effective pharmacotherapy is lacking and bronchiolitis is a major cause of morbidity and mortality. Conventional treatment consists of supportive therapy in the form of fluids, supplemental oxygen, and respiratory support. Traditionally, oxygen delivery is as a dry gas at 100% concentration via low-flow nasal prongs. However, the use of heated, humidified, high-flow nasal cannula (HFNC) therapy enables delivery of higher inspired gas flows of an air/oxygen blend, at 2 to 3 L/kg per minute up to 60 L/min in children. It can provide some level of continuous positive airway pressure (CPAP) to improve ventilation in a minimally invasive manner. This may reduce the need for invasive respiratory support, thus potentially lowering costs, with clinical advantages and fewer adverse effects. OBJECTIVES To assess the effects of HFNC therapy compared with conventional respiratory support in the treatment of infants with bronchiolitis. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, and Web of Science (from June 2013 to December 2022). In addition, we consulted ongoing trial registers and experts in the field to identify ongoing studies, checked reference lists of relevant articles, and searched for conference abstracts. Date restrictions were imposed such that we only searched for studies published after the original version of this review. SELECTION CRITERIA We included randomised controlled trials (RCTs) or quasi-RCTs that assessed the effects of HFNC (delivering oxygen or oxygen/room air blend at flow rates greater than 4 L/minute) compared to conventional treatment in infants (< 24 months) with a clinical diagnosis of bronchiolitis. DATA COLLECTION AND ANALYSIS Two review authors independently used a standard template to assess trials for inclusion and extract data on study characteristics, risk of bias elements, and outcomes. We contacted trial authors to request missing data. Outcome measures included the need for invasive respiratory support and time until discharge, clinical severity measures, oxygen saturation, duration of oxygen therapy, and adverse events. MAIN RESULTS In this update we included 15 new RCTs (2794 participants), bringing the total number of RCTs to 16 (2813 participants). Of the 16 studies, 11 compared high-flow to low-flow, and five compared high-flow to CPAP. These studies included infants less than 24 months of age as stated in our selection criteria. There were no significant differences in sex. We found that when comparing high-flow to low-flow oxygen therapy for infants with bronchiolitis there may be a reduction in the total length of hospital stay (mean difference (MD) -0.65 days, 95% confidence interval (CI) -1.23 to -0.06; P < 0.00001, I2 = 89%; 7 studies, 1951 participants; low-certainty evidence). There may also be a reduction in the duration of oxygen therapy (MD -0.59 days, 95% CI -1 to -0.18; P < 0.00001, I2 = 86%; 7 studies, 2132 participants; low-certainty evidence). We also found that there was probably an improvement in respiratory rate at one and 24 hours, and heart rate at one, four to six, and 24 hours in those receiving high-flow oxygen therapy when compared to pre-intervention baselines. There was also probably a reduced risk of treatment escalation in those receiving high-flow when compared to low-flow oxygen therapy (risk ratio (RR) 0.55, 95% CI 0.39 to 0.79; P = 0.001, I2 = 43%; 8 studies, 2215 participants; moderate-certainty evidence). We found no difference in the incidence of adverse events (RR 1.2, 95% CI 0.38 to 3.74; P = 0.76, I2 = 26%; 4 studies, 1789 participants; low-certainty evidence) between the two groups. The lack of comparable outcomes in studies comparing high-flow and CPAP, as well as the small numbers of participants, limited our ability to perform meta-analysis on this group. AUTHORS' CONCLUSIONS High-flow nasal cannula therapy may have some benefits over low-flow oxygen for infants with bronchiolitis in terms of a greater improvement in respiratory and heart rates, as well as a modest reduction in the length of hospital stay and duration of oxygen therapy, with a reduced incidence of treatment escalation. There does not appear to be a difference in the number of adverse events. Further studies comparing high-flow nasal cannula therapy and CPAP are required to demonstrate the efficacy of one modality over the other. A standardised clinical definition of bronchiolitis, as well as the use of a validated clinical severity score, would allow for greater and more accurate comparison between studies.
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Affiliation(s)
- Michael Armarego
- Department of Paediatrics, Royal Hobart Hospital, Hobart, Australia
- School of Medicine, University of Tasmania, Hobart, Australia
| | - Hannah Forde
- School of Medicine, University of Tasmania, Hobart, Australia
- Royal Hobart Hospital, Hobart, Australia
| | - Karen Wills
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Sean A Beggs
- Department of Paediatrics, Royal Hobart Hospital, Hobart, Australia
- School of Medicine, University of Tasmania, Hobart, Australia
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Dopper A, Steele M, Bogossian F, Hough J. High flow nasal cannula for respiratory support in term infants. Cochrane Database Syst Rev 2023; 8:CD011010. [PMID: 37542728 PMCID: PMC10401649 DOI: 10.1002/14651858.cd011010.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/07/2023]
Abstract
BACKGROUND Respiratory failure or respiratory distress in infants is the most common reason for non-elective admission to hospitals and neonatal intensive care units. Non-invasive methods of respiratory support have become the preferred mode of treating respiratory problems as they avoid some of the complications associated with intubation and mechanical ventilation. High flow nasal cannula (HFNC) therapy is increasingly being used as a method of non-invasive respiratory support. However, the evidence pertaining to its use in term infants (defined as infants ≥ 37 weeks gestational age to the end of the neonatal period (up to one month postnatal age)) is limited and there is no consensus of opinion regarding the safety and efficacy HFNC in this population. OBJECTIVES To assess the safety and efficacy of high flow nasal cannula oxygen therapy for respiratory support in term infants when compared with other forms of non-invasive respiratory support. SEARCH METHODS We searched the following databases in December 2022: Cochrane CENTRAL; PubMed; Embase; CINAHL; LILACS; Web of Science; Scopus. We also searched the reference lists of retrieved studies and performed a supplementary search of Google Scholar. SELECTION CRITERIA We included randomised controlled trials (RCTs) that investigated the use of high flow nasal cannula oxygen therapy in infants ≥ 37 weeks gestational age up to one month postnatal age (the end of the neonatal period). DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial eligibility, performed data extraction, and assessed risk of bias in the included studies. Where studies were sufficiently similar, we performed a meta-analysis using mean differences (MD) for continuous data and risk ratios (RR) for dichotomous data, with their respective 95% confidence intervals (CIs). For statistically significant RRs, we calculated the number needed to treat for an additional beneficial outcome (NNTB). We used the GRADE approach to evaluate the certainty of the evidence for clinically important outcomes. MAIN RESULTS We included eight studies (654 participants) in this review. Six of these studies (625 participants) contributed data to our primary analyses. Four studies contributed to our comparison of high flow nasal cannula (HFNC) oxygen therapy versus continuous positive airway pressure (CPAP) for respiratory support in term infants. The outcome of death was reported in two studies (439 infants) but there were no events in either group. HFNC may have little to no effect on treatment failure, but the evidence is very uncertain (RR 0.98, 95% CI 0.47 to 2.04; 3 trials, 452 infants; very low-certainty evidence). The outcome of chronic lung disease (need for supplemental oxygen at 28 days of life) was reported in one study (375 participants) but there were no events in either group. HFNC may have little to no effect on the duration of respiratory support (any form of non-invasive respiratory support with or without supplemental oxygen), but the evidence is very uncertain (MD 0.17 days, 95% CI -0.28 to 0.61; 4 trials, 530 infants; very low-certainty evidence). HFNC likely results in little to no difference in the length of stay at the intensive care unit (ICU) (MD 0.90 days, 95% CI -0.31 to 2.12; 3 trials, 452 infants; moderate-certainty evidence). HFNC may reduce the incidence of nasal trauma (RR 0.16, 95% CI 0.04 to 0.66; 1 trial, 78 infants; very low-certainty evidence) and abdominal overdistension (RR 0.22, 95% CI 0.07 to 0.71; 1 trial, 78 infants; very low-certainty evidence), but the evidence is very uncertain. Two studies contributed to our analysis of HFNC versus low flow nasal cannula oxygen therapy (LFNC) (supplemental oxygen up to a maximum flow rate of 2 L/min). The outcome of death was reported in both studies (95 infants) but there were no events in either group. The evidence suggests that HFNC may reduce treatment failure slightly (RR 0.44, 95% CI 0.21 to 0.92; 2 trials, 95 infants; low-certainty evidence). Neither study reported results for the outcome of chronic lung disease (need for supplemental oxygen at 28 days of life). HFNC may have little to no effect on the duration of respiratory support (MD -0.07 days, 95% CI -0.83 to 0.69; 1 trial, 74 infants; very low-certainty evidence), length of stay at the ICU (MD 0.49 days, 95% CI -0.83 to 1.81; 1 trial, 74 infants; very low-certainty evidence), or hospital length of stay (MD -0.60 days, 95% CI -2.07 to 0.86; 2 trials, 95 infants; very low-certainty evidence), but the evidence is very uncertain. Adverse events was an outcome reported in both studies (95 infants) but there were no events in either group. The risk of bias across outcomes was generally low, although there were some concerns of bias. The certainty of evidence across outcomes ranged from moderate to very low, downgraded due to risk of bias, imprecision, indirectness, and inconsistency. AUTHORS' CONCLUSIONS When compared with CPAP, HFNC may result in little to no difference in treatment failure. HFNC may have little to no effect on the duration of respiratory support, but the evidence is very uncertain. HFNC likely results in little to no difference in the length of stay at the intensive care unit. HFNC may reduce the incidence of nasal trauma and abdominal overdistension, but the evidence is very uncertain. When compared with LFNC, HFNC may reduce treatment failure slightly. HFNC may have little to no effect on the duration of respiratory support, length of stay at the ICU, or hospital length of stay, but the evidence is very uncertain. There is insufficient evidence to enable the formulation of evidence-based guidelines on the use of HFNC for respiratory support in term infants. Larger, methodologically robust trials are required to further evaluate the possible health benefits or harms of HFNC in this patient population.
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Affiliation(s)
- Alex Dopper
- School of Allied Health, Australian Catholic University, Brisbane, Australia
| | - Michael Steele
- School of Allied Health, Australian Catholic University, Brisbane, Australia
- Nursing Research and Practice Development Centre, The Prince Charles Hospital, Brisbane, Australia
| | - Fiona Bogossian
- School of Nursing, Midwifery and Social Work, The University of Queensland, St Lucia, Australia
- Sunshine Coast Health Institute, Birtinya, Australia
- School of Health, University of the Sunshine Coast, Petrie, Australia
| | - Judith Hough
- School of Allied Health, Australian Catholic University, Brisbane, Australia
- Department of Physiotherapy, Mater Health, South Brisbane, Australia
- Centre for Children's Health Research, The University of Queensland, South Brisbane, Australia
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Huijghebaert S, Parviz S, Rabago D, Baxter A, Chatterjee U, Khan FR, Fabbris C, Poulas K, Hsu S. Saline nasal irrigation and gargling in COVID-19: a multidisciplinary review of effects on viral load, mucosal dynamics, and patient outcomes. Front Public Health 2023; 11:1161881. [PMID: 37397736 PMCID: PMC10312243 DOI: 10.3389/fpubh.2023.1161881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 05/18/2023] [Indexed: 07/04/2023] Open
Abstract
With unrelenting SARS-CoV-2 variants, additional COVID-19 mitigation strategies are needed. Oral and nasal saline irrigation (SI) is a traditional approach for respiratory infections/diseases. As a multidisciplinary network with expertise/experience with saline, we conducted a narrative review to examine mechanisms of action and clinical outcomes associated with nasal SI, gargling, spray, or nebulization in COVID-19. SI was found to reduce SARS-CoV-2 nasopharyngeal loads and hasten viral clearance. Other mechanisms may involve inhibition of viral replication, bioaerosol reduction, improved mucociliary clearance, modulation of ENaC, and neutrophil responses. Prophylaxis was documented adjunctive to personal protective equipment. COVID-19 patients experienced significant symptom relief, while overall data suggest lower hospitalization risk. We found no harm and hence recommend SI use, as safe, inexpensive, and easy-to-use hygiene measure, complementary to hand washing or mask-wearing. In view of mainly small studies, large well-controlled or surveillance studies can help to further validate the outcomes and to implement its use.
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Affiliation(s)
| | - Shehzad Parviz
- Medstar Health, Brooke Grove Rehabilitation Village, Sandy Spring, MD, United States
- Infectious Disease, Adventist Healthcare, White Oak Medical Center, Silver Spring, MD, United States
| | - David Rabago
- Departments of Family and Community Medicine and Public Health Sciences, Penn State College of Medicine, Pennsylvania, PA, United States
| | - Amy Baxter
- Department of Emergency Medicine, Augusta University, Augusta, GA, United States
| | - Uday Chatterjee
- Department of Paediatric Surgery, Park Medical Research and Welfare Society, Kolkata, West Bengal, India
| | - Farhan R. Khan
- Department of Surgery, Aga Khan University, Karachi, Pakistan
| | | | | | - Stephen Hsu
- Department of Oral Biology, Augusta University, Augusta, GA, United States
- Department of Oral Health and Diagnostic Sciences, Augusta University, Augusta, GA, United States
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Zhang L, Mendoza-Sassi RA, Wainwright CE, Aregbesola A, Klassen TP. Nebulised hypertonic saline solution for acute bronchiolitis in infants. Cochrane Database Syst Rev 2023; 4:CD006458. [PMID: 37014057 PMCID: PMC10072872 DOI: 10.1002/14651858.cd006458.pub5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
BACKGROUND Airway oedema (swelling) and mucus plugging are the principal pathological features in infants with acute viral bronchiolitis. Nebulised hypertonic saline solution (≥ 3%) may reduce these pathological changes and decrease airway obstruction. This is an update of a review first published in 2008, and updated in 2010, 2013, and 2017. OBJECTIVES To assess the effects of nebulised hypertonic (≥ 3%) saline solution in infants with acute bronchiolitis. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily, Embase, CINAHL, LILACS, and Web of Science on 13 January 2022. We also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov on 13 January 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs using nebulised hypertonic saline alone or in conjunction with bronchodilators as an active intervention and nebulised 0.9% saline or standard treatment as a comparator in children under 24 months with acute bronchiolitis. The primary outcome for inpatient trials was length of hospital stay, and the primary outcome for outpatients or emergency department (ED) trials was rate of hospitalisation. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, data extraction, and assessment of risk of bias in included studies. We conducted random-effects model meta-analyses using Review Manager 5. We used mean difference (MD), risk ratio (RR), and their 95% confidence intervals (CI) as effect size metrics. MAIN RESULTS We included six new trials (N = 1010) in this update, bringing the total number of included trials to 34, involving 5205 infants with acute bronchiolitis, of whom 2727 infants received hypertonic saline. Eleven trials await classification due to insufficient data for eligibility assessment. All included trials were randomised, parallel-group, controlled trials, of which 30 were double-blinded. Twelve trials were conducted in Asia, five in North America, one in South America, seven in Europe, and nine in Mediterranean and Middle East regions. The concentration of hypertonic saline was defined as 3% in all but six trials, in which 5% to 7% saline was used. Nine trials had no funding, and five trials were funded by sources from government or academic agencies. The remaining 20 trials did not provide funding sources. Hospitalised infants treated with nebulised hypertonic saline may have a shorter mean length of hospital stay compared to those treated with nebulised normal (0.9%) saline or standard care (mean difference (MD) -0.40 days, 95% confidence interval (CI) -0.69 to -0.11; 21 trials, 2479 infants; low-certainty evidence). Infants who received hypertonic saline may also have lower postinhalation clinical scores than infants who received normal saline in the first three days of treatment (day 1: MD -0.64, 95% CI -1.08 to -0.21; 10 trials (1 outpatient, 1 ED, 8 inpatient trials), 893 infants; day 2: MD -1.07, 95% CI -1.60 to -0.53; 10 trials (1 outpatient, 1 ED, 8 inpatient trials), 907 infants; day 3: MD -0.89, 95% CI -1.44 to -0.34; 10 trials (1 outpatient, 9 inpatient trials), 785 infants; low-certainty evidence). Nebulised hypertonic saline may reduce the risk of hospitalisation by 13% compared with nebulised normal saline amongst infants who were outpatients and those treated in the ED (risk ratio (RR) 0.87, 95% CI 0.78 to 0.97; 8 trials, 1760 infants; low-certainty evidence). However, hypertonic saline may not reduce the risk of readmission to hospital up to 28 days after discharge (RR 0.83, 95% CI 0.55 to 1.25; 6 trials, 1084 infants; low-certainty evidence). We are uncertain whether infants who received hypertonic saline have a lower number of days to resolution of wheezing compared to those who received normal saline (MD -1.16 days, 95% CI -1.43 to -0.89; 2 trials, 205 infants; very low-certainty evidence), cough (MD -0.87 days, 95% CI -1.31 to -0.44; 3 trials, 363 infants; very low-certainty evidence), and pulmonary moist crackles (MD -1.30 days, 95% CI -2.28 to -0.32; 2 trials, 205 infants; very low-certainty evidence). Twenty-seven trials presented safety data: 14 trials (1624 infants; 767 treated with hypertonic saline, of which 735 (96%) co-administered with bronchodilators) did not report any adverse events, and 13 trials (2792 infants; 1479 treated with hypertonic saline, of which 416 (28%) co-administered with bronchodilators and 1063 (72%) hypertonic saline alone) reported at least one adverse event such as worsening cough, agitation, bronchospasm, bradycardia, desaturation, vomiting and diarrhoea, most of which were mild and resolved spontaneously (low-certainty evidence). AUTHORS' CONCLUSIONS Nebulised hypertonic saline may modestly reduce length of stay amongst infants hospitalised with acute bronchiolitis and may slightly improve clinical severity score. Treatment with nebulised hypertonic saline may also reduce the risk of hospitalisation amongst outpatients and ED patients. Nebulised hypertonic saline seems to be a safe treatment in infants with bronchiolitis with only minor and spontaneously resolved adverse events, especially when administered in conjunction with a bronchodilator. The certainty of the evidence was low to very low for all outcomes, mainly due to inconsistency and risk of bias.
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Affiliation(s)
- Linjie Zhang
- Faculty of Medicine, Federal University of Rio Grande, Rio Grande, Brazil
| | | | - Claire E Wainwright
- Department of Respiratory Medicine, Royal Children's Hospital, Brisbane, Australia
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Choi J, Park E, Park H, Kang D, Yang JH, Kim H, Cho J, Cho J. Effect of high-flow nasal cannula on mechanical ventilator duration in bronchiolitis patients. Respir Med 2022; 201:106946. [DOI: 10.1016/j.rmed.2022.106946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 07/18/2022] [Accepted: 07/29/2022] [Indexed: 10/16/2022]
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Pereira RA, Oliveira de Almeida V, Zambrano M, Zhang L, Amantéa SL. Effects of nebulized epinephrine in association with hypertonic saline for infants with acute bronchiolitis: A systematic review and meta‐analysis. Health Sci Rep 2022; 5:e598. [PMID: 35509393 PMCID: PMC9059211 DOI: 10.1002/hsr2.598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 02/06/2022] [Indexed: 12/03/2022] Open
Abstract
Background Nebulized epinephrine and hypertonic saline have been extensively studied in infants with acute bronchiolitis, with conflicting results. Aims To evaluate the efficacy on length of stay (LOS), clinical severity scores (CSS), oxygen saturation (SaO2), and safety profile of nebulized epinephrine plus hypertonic saline (HS) in infants with acute bronchiolitis. Materials & Methods This is a systematic review and meta‐analysis. Outcomes were represented by mean differences (MD) or standard mean differences (SMD) and 95% confidence intervals (CIs) were utilized. Results Eighteen trials were systematically selected and 16 of them contributed to the meta‐analysis (1756 patients). Overall, a modest but significant positive impact was observed of the combination therapy on LOS (MD of –0.35 days, 95% CI −0.62 to −0.08, p = 0.01, I2 = 91%). Stratification by time of CSS assessment unveiled positive results in favor of the combination therapy in CSS assessed 48 and 72 h after the admission (SMD of −0.35, 95% CI −0.62 to −0.09, p = 0.008, I2 = 41% and SMD of −0.27, 95% CI −0.50 to −0.04, p = 0.02, I2 = 0%, respectively). No difference in SaO2 was observed. Additional data showed a consistent safety profile, with a low rate of adverse events (1%), most of them mild and transient. Conclusion Low‐quality evidence from this systematic review suggests that nebulized epinephrine plus HS may be considered as a safe and efficient therapy for decreasing LOS and CSS in infants with acute bronchiolitis, especially in those who require hospitalization for more than 48 h.
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Affiliation(s)
- Renan A. Pereira
- Department of Pediatrics Federal University of Health Sciences of Porto Alegre Porto Alegre Brazil
| | | | - Mariana Zambrano
- Department of Pediatrics Federal University of Health Sciences of Porto Alegre Porto Alegre Brazil
| | - Linjie Zhang
- Maternal‐Infant Department, Faculty of Medicine Federal University of Rio Grande Rio Grande Brazil
| | - Sérgio L. Amantéa
- Department of Pediatrics Federal University of Health Sciences of Porto Alegre Porto Alegre Brazil
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Solana-Gracia R, Modesto i Alapont V, Bueso-Inchausti L, Luna-Arana M, Möller-Díez A, Medina A, Pérez-Moneo B. Changes in Ventilation Practices for Bronchiolitis in the Hospital Ward and Need for ICU Transfer over the Last Decade. J Clin Med 2022; 11:jcm11061622. [PMID: 35329951 PMCID: PMC8950048 DOI: 10.3390/jcm11061622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/02/2022] [Accepted: 03/14/2022] [Indexed: 11/16/2022] Open
Abstract
There is limited evidence of the potential benefits of the use of high-flow nasal cannula (HFNC) for the management of bronchiolitis in the ward. Our aim is to describe the ventilation trends for bronchiolitis in our hospital along with the introduction of an HFNC ward protocol and to determine the need for respiratory support escalation and transfer to an intensive care unit (ICU). A retrospective analytical observational study of children < 12 months old requiring admission for a first RSV bronchiolitis episode in a single centre from January 2009 to December 2018. The sample was divided into four groups according to the type of respiratory support that would ensure the clinical stability of the infants on admission. A total of 502 infants were recruited. The total number and percentage of patients admitted in the ward grew progressively over time. Simultaneously, there was an increase in HFNC and, paradoxically, an increase in ICU transfers. The risk of failure was higher for those who required HFNC or CPAP for clinical stabilisation in the first 12 h after admission. Moreover, the risk of failure was also higher in children with standard oxygen therapy promptly escalated to HFNC, especially if they had atelectasis/viral pneumonia, coinfections or a history of prematurity. Despite the limitations of a retrospective analysis, our study reflects usual clinical practice and no correlation was found between the usage of HFNC and a shorter length of hospital stay or less time spent on oxygen therapy.
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Affiliation(s)
- Ruth Solana-Gracia
- Department of Paediatrics, Hospital Universitario Infanta Leonor y Hospital Virgen de la Torre, 28031 Madrid, Spain;
- Correspondence: ; Tel.: +34-91-191-8000
| | | | - Leticia Bueso-Inchausti
- Faculty of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain; (L.B.-I.); (M.L.-A.); (A.M.-D.)
| | - María Luna-Arana
- Faculty of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain; (L.B.-I.); (M.L.-A.); (A.M.-D.)
| | - Ariadna Möller-Díez
- Faculty of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain; (L.B.-I.); (M.L.-A.); (A.M.-D.)
| | - Alberto Medina
- Paediatric Intensive Care Unit, Hospital Universitario Central de Asturias, 33011 Oviedo, Spain;
| | - Begoña Pérez-Moneo
- Department of Paediatrics, Hospital Universitario Infanta Leonor y Hospital Virgen de la Torre, 28031 Madrid, Spain;
- Faculty of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain; (L.B.-I.); (M.L.-A.); (A.M.-D.)
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Itdhiamornkulchai S, Preutthipan A, Vaewpanich J, Anantasit N. Modified high-flow nasal cannula for children with respiratory distress. Clin Exp Pediatr 2022; 65:136-141. [PMID: 34044481 PMCID: PMC8898618 DOI: 10.3345/cep.2020.01403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 05/13/2021] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
- Sarocha Itdhiamornkulchai
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Aroonwan Preutthipan
- Division of Pediatric Pulmonology, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Jarin Vaewpanich
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nattachai Anantasit
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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10
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Dafydd C, Saunders BJ, Kotecha SJ, Edwards MO. Efficacy and safety of high flow nasal oxygen for children with bronchiolitis: systematic review and meta-analysis. BMJ Open Respir Res 2021; 8:e000844. [PMID: 34326153 PMCID: PMC8323377 DOI: 10.1136/bmjresp-2020-000844] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 07/11/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND To assess the published evidence to establish the efficacy and safety of high flow oxygen cannula (HFNC) as respiratory support for children up to 24 months of age with bronchiolitis within acute hospital settings. METHODS We searched eight databases up to March 2021. Studies including children up to 24 months of age with a diagnosis of bronchiolitis recruited to an randomised controlled trial were considered in the full meta-analysis. At least one arm of the study must include HFNC as respiratory support and report at least one of the outcomes of interest. Studies were identified and extracted by two reviewers. Data were analysed using Review Manager V.5.4. RESULTS From 2943 article titles, 308 full articles were screened for inclusion. 23 studies met the inclusion criteria, 15 were included in the metanalyses. Four studies reported on treatment failure rates when comparing HFNC to standard oxygen therapy (SOT). Data suggests HFNC is superior to SOT (OR 0.45, 95% CI 0.36 to 0.57). Four studies reported on treatment failure rates when comparing HFNC to continuous positive airways pressure (CPAP). No significant difference was found between CPAP and HFNC (OR 1.64, 95% CI 0.96 to 2.79; p=0.07). Four studies report on adverse outcomes when comparing HFNC to SOT. No significant difference was found between HFNC & SOT (OR 1.47, 95% CI 0.54 to 3.99). CONCLUSION HFNC is superior to SOT in terms of treatment failure and there is no significant difference between HFNC and CPAP in terms of treatment failure. The results suggest HFNC is safe to use in acute hospital settings.
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Affiliation(s)
- Carwyn Dafydd
- Children's Hospital for Wales, University of Wales Hospital, Cardiff, Cardiff, UK
| | - Benjamin J Saunders
- Children's Hospital for Wales, University of Wales Hospital, Cardiff, Cardiff, UK
| | - Sarah J Kotecha
- Department of Child Health, Cardiff University, Cardiff, South Glamorgan, UK
| | - Martin O Edwards
- Children's Hospital for Wales, University of Wales Hospital, Cardiff, Cardiff, UK
- Department of Child Health, Cardiff University, Cardiff, South Glamorgan, UK
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11
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Tortosa F, Izcovich A, Carrasco G, Varone G, Haluska P, Sanguine V. High-flow oxygen nasal cannula for treating acute bronchiolitis in infants: A systematic review and meta-analysis. Medwave 2021; 21:e8190. [PMID: 34086669 DOI: 10.5867/medwave.2021.04.8190] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 03/29/2021] [Indexed: 11/27/2022] Open
Abstract
Introduction Oxygen therapy through a high-flow nasal cannula is thought to improve the work of breathing and the comfort of patients with acute bronchiolitis. It is widely used in hospital wards and critical care of pediatric patients. However, there is uncertainty on the magnitude of the effect on critical and important outcomes in these patients. Objectives The objective of this review is to evaluate the available evidence on the use of oxygen administered through high-flow cannula versus low-flow oxygen for the treatment of acute bronchiolitis in children under two years of age. Methodology We carried out a systematic review and a meta-analysis following the PRISMA standards for reporting. The search was carried out in electronic databases by two researchers independently. The evidence was summarized using the GRADE methodology. Results Six randomized and non-randomized clinical trials were included, including 1867 individuals younger than 24 months of age with acute bronchiolitis in pediatric emergency, hospitalization, and intensive care services. Mortality was not reported in the included studies. Treatment failure occurred in 108/933 in the high flow group and 233/934 in the low flow group (relative risk: 0.46; 95% confidence interval: 0.35 to 0.62), which shows 11.7% less treatment failure (95% confidence interval between 7.9% and 14.5% less) in the high flow group with a number needed to treat of 7.5 (95% confidence interval 6 to 10) with moderate certainty in the evidence. Conclusion The use of humidified and heated oxygen with high flow compared to oxygen at low flow is probably associated with decreased treatment failure in children younger than two years with acute bronchiolitis. There is uncertainty about the effect on hospitalization days and clinical progression.
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Affiliation(s)
- Fernando Tortosa
- Comité de Evaluación de Biotecnologías, Ministerio de Salud, Río Negro, Argentina; Red Argentina Pública de Evaluación de Tecnologías Sanitarias, Neuquén, Argentina; Departamento de Docencia e Investigación, Hospital Zonal Ramón Carrillo de Bariloche, Río Negro, Argentina. Dirección: Moreno 601, San Carlos de Bariloche, Río Negro, Argentina. . ORCID: 0000-0002-0303-6055
| | - Ariel Izcovich
- Servicio de Clínica Médica, Hospital Alemán, Buenos Aires, Argentina. ORCID: 0000-0001-9053-4396
| | - Gabriela Carrasco
- Red Argentina Pública de Evaluación de Tecnologías Sanitarias, Neuquén, Argentina. ORCID: 0000-0002-8039-6345
| | - Gabriela Varone
- Departamento de Docencia e Investigación, Hospital Zonal Ramón Carrillo de Bariloche, Río Negro, Argentina; División Pediatría, Hospital Zonal Ramón Carrillo de Bariloche, Río Negro, Argentina. ORCID: 0000-0002-6460-5645
| | - Pedro Haluska
- Departamento de Docencia e Investigación, Hospital Zonal Ramón Carrillo de Bariloche, Río Negro, Argentina. ORCID: 0000-0002-5086-0880
| | - Verónica Sanguine
- Dirección Nacional de Calidad en Servicios de Salud y Regulación Sanitaria, Ministerio de Salud de la Nación, Buenos Aires, Argentina. ORCID: 0000-0002-4842-0528
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12
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Update on the Role of High-Flow Nasal Cannula in Infants with Bronchiolitis. CHILDREN-BASEL 2021; 8:children8020066. [PMID: 33498527 PMCID: PMC7909574 DOI: 10.3390/children8020066] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/13/2021] [Accepted: 01/15/2021] [Indexed: 11/17/2022]
Abstract
Bronchiolitis (BR), a lower respiratory tract infection mainly caused by respiratory syncytial virus (RSV), can be very severe. Presently, adequate nutritional support and oxygen therapy remain the only interventions recommended to treat patients with BR. For years, mild BR cases were treated with noninvasive standard oxygen therapy (SOT), i.e., with cold and poorly or totally non-humidified oxygen delivered by an ambient headbox or low-flow nasal cannula. Children with severe disease were intubated and treated with invasive mechanical ventilation (IMV). To improve SOT and overcome the disadvantages of IMV, new measures of noninvasive and more efficient oxygen administration have been studied. Bi-level positive air way pressure (BiPAP), continuous positive airway pressure (CPAP), and high-flow nasal cannula (HFNC) are among them. For its simplicity, good tolerability and safety, and the good results reported in clinical studies, HFNC has become increasingly popular and is now widely used. However, consistent guidelines for initiation and discontinuation of HFNC are lacking. In this narrative review, the role of HFNC to treat infants with BR is discussed. An analysis of the literature showed that, despite its widespread use, the role of HFNC in preventing respiratory failure in children with BR is not precisely defined. It is not established whether it can offer greater benefits compared to SOT and when and in which infants it can replace CPAP or BiPAP. The analysis of the results clearly indicates the need for multicenter studies and official guidelines. In the meantime, HFNC can be considered a safe and effective method to treat children with mild to moderate BR who do not respond to SOT.
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13
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O'Brien S, Craig S, Babl FE, Borland ML, Oakley E, Dalziel SR. 'Rational use of high-flow therapy in infants with bronchiolitis. What do the latest trials tell us?' A Paediatric Research in Emergency Departments International Collaborative perspective. J Paediatr Child Health 2019; 55:746-752. [PMID: 31270867 DOI: 10.1111/jpc.14496] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 01/29/2019] [Accepted: 04/30/2019] [Indexed: 11/26/2022]
Abstract
Bronchiolitis is the most common reason for infants to be hospitalised. Over the past decade, the use of high-flow nasal cannulae (HFNC) therapy has increased markedly and it is now utilised not only in the intensive care unit setting but in general paediatric wards and emergency departments. The aim of this systematic review was to summarise and critique the current evidence-base for the use of HFNC in infants with bronchiolitis. We searched Ovid Medline, OvidEmbase, PubMed, Cinahl, Cochrane Library, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials for systematic reviews and randomised controlled trials of HFNC therapy in infants with bronchiolitis from 1 January 2000 to 27 June 2018. We identified four randomised controlled trials (n = 1891) of HFNC in infants with bronchiolitis: three of these studies involved infants treated in emergency departments and inpatient paediatric wards in Spain, Australia and New Zealand, and one study involved infants treated in paediatric intensive care units in France. The findings of this review suggest that HFNC should be used as a rescue treatment for hypoxaemic infants who have not responded to standard sub nasal oxygen therapy. The use of HFNC for work of breathing in the absence of hypoxaemia, and severe disease, is not currently supported by the evidence, and should only be considered in the context of an appropriate research trial.
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Affiliation(s)
- Sharon O'Brien
- Emergency Department, Perth Children's Hospital, Perth, Western Australia, Australia.,School of Nursing, Midwifery and Paramedicine, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | - Simon Craig
- Emergency Department, Monash Medical Centre, Melbourne, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Franz E Babl
- Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Emergency Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Meredith L Borland
- Emergency Department, Perth Children's Hospital, Perth, Western Australia, Australia.,Division of Paediatric and Emergency Medicine, School of Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Ed Oakley
- Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Emergency Research, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Paediatric Emergency Medicine Centre of Research Excellence, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Stuart R Dalziel
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand.,Department of Surgery, Child and Youth Health, The University of Auckland, Auckland, New Zealand.,Department of Paediatrics, Child and Youth Health, The University of Auckland, Auckland, New Zealand
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14
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Lin J, Zhang Y, Xiong L, Liu S, Gong C, Dai J. High-flow nasal cannula therapy for children with bronchiolitis: a systematic review and meta-analysis. Arch Dis Child 2019; 104:564-576. [PMID: 30655267 DOI: 10.1136/archdischild-2018-315846] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 11/24/2018] [Accepted: 12/07/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To review the effects and safety of high-flow nasal cannula (HFNC) for bronchiolitis. METHODS Six electronic databases including PubMed, EMBASE, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, CQ VIP Database and Wanfang Data were searched from their inception to 1 June 2018. Randomised controlled trials (RCTs) which investigated the effects of HFNC versus other forms of oxygen therapies for bronchiolitis were included. RESULTS Nine RCTs with 2121 children met the eligibility criteria. There was no significant difference in length of stay in hospital (LOS), length of oxygen supplementation (LOO), transfer to intensive care unit, incidence of intubation, respiratory rate, SpO2 and adverse events in HFNC group compared with standard oxygen therapy (SOT) and nasal continuous positive airway pressure (nCPAP) groups. A significant reduction of the incidence of treatment failure (risk ratio (RR) 0.50, 95% CI 0.40 to 0.62, p<0.01) was observed in HFNC group compared with SOT group, but there was a significant increase of the incidence of treatment failure (RR 1.61, 95% CI 1.06 to 2.42, p0.02) in HFNC group compared with nCPAP group. In subgroup analysis, LOS was significantly decreased in HFNC group compared with SOT group in low-income and middle-income countries. CONCLUSION The systematic review suggests HFNC is safe as an initial respiratory management, but the evidence is still lacking to show benefits for children with bronchiolitis compared with SOT or nCPAP.
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Affiliation(s)
- Jilei Lin
- Respiratory Department, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Yin Zhang
- Respiratory Department, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Limei Xiong
- Respiratory Department, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Sha Liu
- Respiratory Department, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Caihui Gong
- Respiratory Department, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Jihong Dai
- Respiratory Department, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
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15
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Chen DY, Zee ED, Gildengorin G, Fong EW. A pilot study of heated and humidified low flow oxygen therapy: An assessment in infants with mild and moderate bronchiolitis (HHOT AIR study). Pediatr Pulmonol 2019; 54:620-627. [PMID: 30887708 DOI: 10.1002/ppul.24267] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 12/19/2018] [Indexed: 11/07/2022]
Abstract
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.
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Affiliation(s)
- Diana Y Chen
- Department of Pediatrics, Division of Pediatric Pulmonology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Eric D Zee
- Department of Pediatrics, Division of Pulmonology, Stanford University School of Medicine, Palo Alto, California
| | - Ginny Gildengorin
- Department of Statistics, UCSF Benioff Children's Hospital, Oakland, California
| | - Edward W Fong
- Department of Pediatrics, Section of Pediatric Pulmonology, Kapiolani Medical Center for Women and Children, Honolulu, Hawaii
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16
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Freire G, Kuppermann N, Zemek R, Plint AC, Babl FE, Dalziel SR, Freedman SB, Atenafu EG, Stephens D, Steele DW, Fernandes RM, Florin TA, Kharbanda A, Lyttle MD, Johnson DW, Schnadower D, Macias CG, Benito J, Schuh S. Predicting Escalated Care in Infants With Bronchiolitis. Pediatrics 2018; 142:peds.2017-4253. [PMID: 30126934 DOI: 10.1542/peds.2017-4253] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/21/2018] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, School of Medicine, University of California, Davis, Sacramento, California
| | - Roger Zemek
- Division of Pediatric Emergency Medicine, University of Ottawa and Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Amy C Plint
- Division of Pediatric Emergency Medicine, University of Ottawa and Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Franz E Babl
- Emergency Department, Royal Children's Hospital, Murdoch Children's Research Institute, Parkville, Australia.,University of Melbourne, Melbourne, Australia
| | - Stuart R Dalziel
- Emergency Department, Starship Children's Hospital and the University of Auckland, Auckland, New Zealand
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital, Departments of Pediatrics, Alberta Children's Hospital Research Institute, Cumming School of Medicine, Calgary University, Calgary, Canada
| | - Eshetu G Atenafu
- Department of Biostatistics, Princess Margaret Cancer Centre, University of Toronto, Toronto, Canada
| | - Derek Stephens
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Dale W Steele
- Department of Pediatric Emergency Medicine, Hasbro Children's Hospital and Departments of Emergency Medicine, Pediatrics, and Health Services, Policy, and Practice, Brown University, Providence, Rhode Island
| | - Ricardo M Fernandes
- Department of Pediatrics, Hospital de Santa Maria and Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal
| | - Todd A Florin
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Anupam Kharbanda
- Department of Pediatric Emergency Medicine, Children's Hospital of Minnesota, Minneapolis, Minnesota
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children and Faculty of Health and Applied Life Sciences, University of the West of England, Bristol, United Kingdom
| | - David W Johnson
- Sections of Pediatric Emergency Medicine, and Physiology and Pharmacology, Alberta Children's Hospital and Alberta Children's Hospital Research Institute, Cumming School of Medicine, Calgary University, Calgary, Canada
| | - David Schnadower
- Department of Pediatric Emergency Medicine, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Charles G Macias
- Department of Pediatric Emergency Medicine, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas; and
| | - Javier Benito
- Pediatric Emergency Department, Cruces University Hospital, Barakaldo, Spain
| | - Suzanne Schuh
- Division of Pediatric Emergency Medicine, and .,Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Canada
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17
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Sarkar M, Sinha R, Roychowdhoury S, Mukhopadhyay S, Ghosh P, Dutta K, Ghosh S. Comparative Study between Noninvasive Continuous Positive Airway Pressure and Hot Humidified High-flow Nasal Cannulae as a Mode of Respiratory Support in Infants with Acute Bronchiolitis in Pediatric Intensive Care Unit of a Tertiary Care Hospital. Indian J Crit Care Med 2018. [PMID: 29531447 PMCID: PMC5842462 DOI: 10.4103/ijccm.ijccm_274_17] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background Early initiation of appropriate noninvasive respiratory support is utmost important intervention to avoid mechanical ventilation in severe bronchiolitis. Aim This study aims to compare noninvasive continuous positive airway pressure (nCPAP) and hot humidified high-flow nasal cannulae (HHHFNC) as modes of respiratory support in infants with severe bronchiolitis. Methods Prospective, randomized, open-label pilot study done in a tertiary-care hospital Pediatric Intensive Care Unit (PICU). Participants: 31 infants (excluding neonates) clinically diagnosed with acute bronchiolitis having peripheral capillary oxygen saturation (SpO2) <92% (with room air oxygen); Respiratory Distress Assessment Index (RDAI) ≥11. Intervention: nCPAP (n = 16) or HHHFNC (n = 15), initiated at enrollment. Primary outcome: Reduction of need of mechanical ventilation assessed by improvements in (i) SpO2% (ii) heart rate (HR); respiratory rate; (iii) partial pressure of carbon dioxide; (iv) partial pressure of oxygen; (v) COMFORT Score; (vi) RDAI from preintervention value. Secondary outcome: (i) total duration of noninvasive ventilation support; (ii) PICU length of stay; and (iii) incidence of nasal injury (NI). Results Mean age was 3.41 ± 1.11 months (95% confidence interval 2.58-4.23). Compared to nCPAP, HHHFNC was better tolerated as indicated by better normalization of HR (P < 0.001); better COMFORT Score (P < 0.003) and lower incidence of NI (46.66% vs. 75%; P = 0.21). Improvements in other outcome measures were comparable for both groups. For both methods, no major patient complications occurred. Conclusion HHHFNC is an emerging alternative to nCPAP in the management of infants with acute bronchiolitis.
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Affiliation(s)
- Mihir Sarkar
- Department of Pediatrics, Medical College and Hospital, Kolkata, West Bengal, India
| | - Rajasree Sinha
- Department of Pediatrics, Medical College and Hospital, Kolkata, West Bengal, India
| | | | | | - Pramit Ghosh
- Department of Community Medicine, Medical College and Hospital, Kolkata, West Bengal, India
| | - Kalpana Dutta
- Department of Pediatrics, Medical College and Hospital, Kolkata, West Bengal, India
| | - Shibarjun Ghosh
- Department of Pediatrics, Medical College and Hospital, Kolkata, West Bengal, India
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18
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Zhang L, Mendoza‐Sassi RA, Wainwright C, Klassen TP. Nebulised hypertonic saline solution for acute bronchiolitis in infants. Cochrane Database Syst Rev 2017; 12:CD006458. [PMID: 29265171 PMCID: PMC6485976 DOI: 10.1002/14651858.cd006458.pub4] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Airway oedema (swelling) and mucus plugging are the principal pathological features in infants with acute viral bronchiolitis. Nebulised hypertonic saline solution (≥ 3%) may reduce these pathological changes and decrease airway obstruction. This is an update of a review first published in 2008, and previously updated in 2010 and 2013. OBJECTIVES To assess the effects of nebulised hypertonic (≥ 3%) saline solution in infants with acute bronchiolitis. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily, Embase, CINAHL, LILACS, and Web of Science on 11 August 2017. We also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov on 8 April 2017. SELECTION CRITERIA We included randomised controlled trials and quasi-randomised controlled trials using nebulised hypertonic saline alone or in conjunction with bronchodilators as an active intervention and nebulised 0.9% saline, or standard treatment as a comparator in children under 24 months with acute bronchiolitis. The primary outcome for inpatient trials was length of hospital stay, and the primary outcome for outpatients or emergency department trials was rate of hospitalisation. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, data extraction, and assessment of risk of bias in included studies. We conducted random-effects model meta-analyses using Review Manager 5. We used mean difference (MD), risk ratio (RR), and their 95% confidence intervals (CI) as effect size metrics. MAIN RESULTS We identified 26 new trials in this update, of which 9 await classification due to insufficient data for eligibility assessment, and 17 trials (N = 3105) met the inclusion criteria. We included a total of 28 trials involving 4195 infants with acute bronchiolitis, of whom 2222 infants received hypertonic saline.Hospitalised infants treated with nebulised hypertonic saline had a statistically significant shorter mean length of hospital stay compared to those treated with nebulised 0.9% saline (MD -0.41 days, 95% CI -0.75 to -0.07; P = 0.02, I² = 79%; 17 trials; 1867 infants) (GRADE quality of evidence: low). Infants who received hypertonic saline also had statistically significant lower post-inhalation clinical scores than infants who received 0.9% saline in the first three days of treatment (day 1: MD -0.77, 95% CI -1.18 to -0.36, P < 0.001; day 2: MD -1.28, 95% CI -1.91 to -0.65, P < 0.001; day 3: MD -1.43, 95% CI -1.82 to -1.04, P < 0.001) (GRADE quality of evidence: low).Nebulised hypertonic saline reduced the risk of hospitalisation by 14% compared with nebulised 0.9% saline among infants who were outpatients and those treated in the emergency department (RR 0.86, 95% CI 0.76 to 0.98; P = 0.02, I² = 7%; 8 trials; 1723 infants) (GRADE quality of evidence: moderate).Twenty-four trials presented safety data: 13 trials (1363 infants, 703 treated with hypertonic saline) did not report any adverse events, and 11 trials (2360 infants, 1265 treated with hypertonic saline) reported at least one adverse event, most of which were mild and resolved spontaneously. AUTHORS' CONCLUSIONS Nebulised hypertonic saline may modestly reduce length of stay among infants hospitalised with acute bronchiolitis and improve clinical severity score. Treatment with nebulised hypertonic saline may also reduce the risk of hospitalisation among outpatients and emergency department patients. However, we assessed the quality of the evidence as low to moderate.
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Affiliation(s)
- Linjie Zhang
- Federal University of Rio GrandeFaculty of MedicineRua Visconde Paranaguá 102CentroRio GrandeRSBrazil96201‐900
| | - Raúl A Mendoza‐Sassi
- Federal University of Rio GrandeFaculty of MedicineRua Visconde Paranaguá 102CentroRio GrandeRSBrazil96201‐900
| | - Claire Wainwright
- Royal Children's HospitalDepartment of Respiratory MedicineHerston RoadHerstonBrisbaneQueenslandAustralia4029
| | - Terry P Klassen
- Manitoba Institute of Child Health513‐715 McDermot AvenueWinnipegMBCanadaR3E 3P4
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Davison M, Watson M, Wockner L, Kinnear F. Paediatric high-flow nasal cannula therapy in children with bronchiolitis: A retrospective safety and efficacy study in a non-tertiary environment. Emerg Med Australas 2017; 29:198-203. [PMID: 28332328 DOI: 10.1111/1742-6723.12741] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 11/25/2016] [Accepted: 12/13/2016] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Michelle Davison
- Department of Emergency Medicine and Children's Service, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Mike Watson
- Department of Emergency Medicine and Children's Service, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Leesa Wockner
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Frances Kinnear
- Department of Emergency Medicine and Children's Service, The Prince Charles Hospital, Brisbane, Queensland, Australia
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20
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Can FK, Anil AB, Anil M, Zengin N, Bal A, Bicilioglu Y, Gokalp G, Durak F, Ince G. Impact of high-flow nasal cannula therapy in quality improvement and clinical outcomes in a non-invasive ventilation device-free pediatric intensive care unit. Indian Pediatr 2017; 54:835-840. [DOI: 10.1007/s13312-017-1145-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Cambonie G, Pons-Odena M, Baleine J, Milési C. High flow nasal cannulae for acute viral bronchiolitis in young infants: evidence-based medicine is underway to define target populations and optimal flows. J Thorac Dis 2017; 9:1763-1766. [PMID: 28839957 DOI: 10.21037/jtd.2017.06.42] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Gilles Cambonie
- Pediatric Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, Montpellier, France
| | - Marti Pons-Odena
- Pediatric Intensive Care Unit, Sant Joan de Deu University Hospital Centre, University of Barcelona, Esplugues de Llobregat, Barcelona, Spain
| | - Julien Baleine
- Pediatric Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, Montpellier, France
| | - Christophe Milési
- Pediatric Intensive Care Unit, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, Montpellier, France
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Abstract
PURPOSE OF REVIEW High-flow nasal cannula (HFNC) is emerging as a means of oxygen delivery and respiratory support for a range of conditions outside the perinatal period. We aim to review the mechanisms of action and advantages of HFNC and to summarize current findings regarding clinical benefit in specific pediatric disease processes and in patients with significant respiratory distress. RECENT FINDINGS Currently published studies outside the neonatal population demonstrate both safety and efficacy of this mode of respiratory support. Retrospective and prospective observational trials have shown improvements in oxygenation and respiratory distress, as well as reductions in the need for intubation in select patient populations. Randomized controlled trials are ongoing. SUMMARY HFNC is emerging as a means of oxygen delivery and respiratory support across a wide range of pediatric conditions. Available data suggest that it is well tolerated by children and can have a favorable effect on clinical outcomes. Future research will better define optimal patient populations and best practices for use.
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Milési C, Essouri S, Pouyau R, Liet JM, Afanetti M, Portefaix A, Baleine J, Durand S, Combes C, Douillard A, Cambonie G. 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). Intensive Care Med 2017; 43:209-216. [PMID: 28124736 DOI: 10.1007/s00134-016-4617-8] [Citation(s) in RCA: 170] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 10/31/2016] [Indexed: 12/26/2022]
Abstract
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).
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Affiliation(s)
- Christophe Milési
- Pediatric Intensive Care Unit, Département de Pédiatrie Néonatale et Réanimations, CHU de Montpellier, Arnaud de Villeneuve University Hospital, 371 Avenue du Doyen G. Giraud, 34295, Montpellier Cedex 5, France
| | - Sandrine Essouri
- Pediatric Intensive Care Unit, Kremlin Bicêtre University Hospital, Paris, France
| | - Robin Pouyau
- Pediatric Intensive Care Unit, Women-Mothers and Children's University Hospital, Lyon, France
| | - Jean-Michel Liet
- Pediatric Intensive Care Unit, Women and Children's University Hospital, Nantes, France
| | - Mickael Afanetti
- Pediatric Intensive Care Unit, Lenval University Hospital, Nice, France
| | - Aurélie Portefaix
- Pediatric Intensive Care Unit, Women-Mothers and Children's University Hospital, Lyon, France.,INSERM, CIC1407, 69500, Bron, France
| | - Julien Baleine
- Pediatric Intensive Care Unit, Département de Pédiatrie Néonatale et Réanimations, CHU de Montpellier, Arnaud de Villeneuve University Hospital, 371 Avenue du Doyen G. Giraud, 34295, Montpellier Cedex 5, France
| | - Sabine Durand
- Pediatric Intensive Care Unit, Département de Pédiatrie Néonatale et Réanimations, CHU de Montpellier, Arnaud de Villeneuve University Hospital, 371 Avenue du Doyen G. Giraud, 34295, Montpellier Cedex 5, France
| | - Clémentine Combes
- Pediatric Intensive Care Unit, Département de Pédiatrie Néonatale et Réanimations, CHU de Montpellier, Arnaud de Villeneuve University Hospital, 371 Avenue du Doyen G. Giraud, 34295, Montpellier Cedex 5, France
| | - Aymeric Douillard
- Department of Medical Information, Arnaud de Villeneuve University Hospital, Montpellier, France
| | - Gilles Cambonie
- Pediatric Intensive Care Unit, Département de Pédiatrie Néonatale et Réanimations, CHU de Montpellier, Arnaud de Villeneuve University Hospital, 371 Avenue du Doyen G. Giraud, 34295, Montpellier Cedex 5, France.
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Abstract
Viral bronchiolitis is a common clinical syndrome affecting infants and young children. Concern about its associated morbidity and cost has led to a large body of research that has been summarised in systematic reviews and integrated into clinical practice guidelines in several countries. The evidence and guideline recommendations consistently support a clinical diagnosis with the limited role for diagnostic testing for children presenting with the typical clinical syndrome of viral upper respiratory infection progressing to the lower respiratory tract. Management is largely supportive, focusing on maintaining oxygenation and hydration of the patient. Evidence suggests no benefit from bronchodilator or corticosteroid use in infants with a first episode of bronchiolitis. Evidence for other treatments such as hypertonic saline is evolving but not clearly defined yet. For infants with severe disease, the insufficient available data suggest a role for high-flow nasal cannula and continuous positive airway pressure use in a monitored setting to prevent respiratory failure.
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Affiliation(s)
- Todd A Florin
- Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Amy C Plint
- Division of Emergency Medicine, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada; Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | - Joseph J Zorc
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Bermúdez Barrezueta L, García Carbonell N, López Montes J, Gómez Zafra R, Marín Reina P, Herrmannova J, Casero Soriano J. High flow nasal cannula oxygen therapy in the treatment of acute bronchiolitis in neonates. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.anpede.2016.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Heikkilä P, Forma L, Korppi M. High-flow oxygen therapy is more cost-effective for bronchiolitis than standard treatment-A decision-tree analysis. Pediatr Pulmonol 2016; 51:1393-1402. [PMID: 27148885 DOI: 10.1002/ppul.23467] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 04/15/2016] [Accepted: 04/24/2016] [Indexed: 11/10/2022]
Abstract
We evaluated the cost-effectiveness of high-flow nasal cannula (HFNC) to provide additional oxygen for infants with bronchiolitis, compared to standard low-flow therapy. The cost-effectiveness was evaluated by decision analyses, using decision tree modeling, and was based on real costs from our recently published retrospective case-control study. The data on the effectiveness of HFNC treatment were collected from earlier published retrospective studies, using admission rates to pediatric intensive care units (PICU). The analyses in the study showed that the expected treatment costs of each episode of infant bronchiolitis varied between €1,312-2,644 ($1,786-3,600) in the HFNC group and €1,598-3,764 ($2,175-5,125) in the standard treatment group. The PICU admission rates and consequential costs were lower for HFNC than for standard treatment. HFNC treatment proved more cost-effective than standard treatment in all the baseline analyses and was also more cost-effective in the sensitivity analyses, except for in the worst-case scenario analysis. In conclusion, our modeling demonstrated that HFNC was strongly cost-effective for infant bronchiolitis, compared to standard treatment because it was both more effective and less expensive. Thus, if children hospitalized for bronchiolitis need oxygen, it should be delivered as HFNC treatment. Pediatr Pulmonol. 2016;51:1393-1402. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Paula Heikkilä
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland
| | - Leena Forma
- School of Health Sciences, University of Tampere, Tampere, Finland
| | - Matti Korppi
- Tampere Center for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland
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Mikalsen IB, Davis P, Øymar K. High flow nasal cannula in children: a literature review. Scand J Trauma Resusc Emerg Med 2016; 24:93. [PMID: 27405336 PMCID: PMC4942966 DOI: 10.1186/s13049-016-0278-4] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 06/17/2016] [Indexed: 01/22/2023] Open
Abstract
High flow nasal cannula (HFNC) is a relatively new non-invasive ventilation therapy that seems to be well tolerated in children. Recently a marked increase in the use of HFNC has been seen both in paediatric and adult care settings. The aim of this study was to review the current knowledge of HFNC regarding mechanisms of action, safety, clinical effects and tolerance in children beyond the newborn period.We performed a systematic search of the databases PubMed, Medline, EMBASE and Cochrane up to 12th of May 2016. Twenty-six clinical studies including children on HFNC beyond the newborn period with various respiratory diseases hospitalised in an emergency department, paediatric intensive care unit or general ward were included. Five of these studies were interventional studies and 21 were observational studies. Thirteen studies included only children with bronchiolitis, while the other studies included children with various respiratory conditions. Studies including infants hospitalised in a neonatal ward, or adults over 18 years of age, as well as expert reviews, were not systematically evaluated, but discussed if appropriate.The available studies suggest that HFNC is a relatively safe, well-tolerated and feasible method for delivering oxygen to children with few adverse events having been reported. Different mechanisms including washout of nasopharyngeal dead space, increased pulmonary compliance and some degree of distending airway pressure may be responsible for the effect. A positive clinical effect on various respiratory parameters has been observed and studies suggest that HFNC may reduce the work of breathing. Studies including children beyond the newborn period have found that HFNC may reduce the need of continuous positive airway pressure (CPAP) and invasive ventilation, but these studies are observational and have a low level of evidence. There are no international guidelines regarding flow rates and the optimal maximal flow for HFNC is not known, but few studies have used a flow rate higher than 10 L/min for infants.Until more evidence from randomized studies is available, HFNC may be used as a supplementary form of respiratory support in children, but with a critical approach regarding effect and safety, particularly when operated outside of a paediatric intensive care unit.
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Affiliation(s)
- Ingvild Bruun Mikalsen
- Department of Paediatrics, Stavanger University Hospital, P.O. Box 8100, N-4068, Stavanger, Norway. .,Department of Clinical Science, University of Bergen, Bergen, Norway.
| | - Peter Davis
- Department of Paediatric Intensive Care, Bristol Royal Hospital for Children, Bristol, UK
| | - Knut Øymar
- Department of Paediatrics, Stavanger University Hospital, P.O. Box 8100, N-4068, Stavanger, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
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28
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Bermúdez Barrezueta L, García Carbonell N, López Montes J, Gómez Zafra R, Marín Reina P, Herrmannova J, Casero Soriano J. [High flow nasal cannula oxygen therapy in the treatment of acute bronchiolitis in neonates]. An Pediatr (Barc) 2016; 86:37-44. [PMID: 27068070 DOI: 10.1016/j.anpedi.2016.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 02/22/2016] [Accepted: 03/01/2016] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To determine whether the availability of heated humidified high-flow nasal cannula (HFNC) therapy was associated with a decrease in need for mechanical ventilation in neonates hospitalised with acute bronchiolitis. METHODS A combined retrospective and prospective (ambispective) cohort study was performed in a type II-B Neonatal Unit, including hospitalised neonates with acute bronchiolitis after the introduction of HFNC (HFNC-period; October 2011-April 2015). They were compared with a historical cohort prior to the availability of this technique (pre-HFNC; January 2008-May 2011). The need for mechanical ventilation between the two study groups was analysed. Clinical parameters and technique-related complications were evaluated in neonates treated with HFNC. RESULTS A total of 112 neonates were included, 56 after the introduction of HFNC and 56 from the period before the introduction of HFNC. None of patients in the HFNC-period required intubation, compared with 3.6% of the patients in the pre-HFNC group. The availability of HFNC resulted in a significant decrease in the need for non-invasive mechanical ventilation (30.4% vs 10.7%; P=.01), with a relative risk (RR) of .353 (95% CI; .150-.829), an absolute risk reduction (ARR) of 19.6% (95% CI; 5.13 - 34.2), yielding a NNT of 5. In the HFNC-period, 22 patients received high flow therapy, and 22.7% (95% CI; 7.8 to 45.4) required non-invasive ventilation. Treatment with HFNC was associated with a significant decrease in heart rate (P=.03), respiratory rate (P=.01), and an improvement in the Wood-Downes Férres score (P=.00). No adverse effects were observed. CONCLUSIONS The availability of HFNC reduces the need for non-invasive mechanical ventilation, allowing a safe and effective medical management of neonates with acute bronchiolitis.
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Affiliation(s)
| | - Nuria García Carbonell
- Departamento de Pediatría, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - Jorge López Montes
- Departamento de Pediatría, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - Rafael Gómez Zafra
- Departamento de Pediatría, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - Purificación Marín Reina
- Departamento de Pediatría, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - Jana Herrmannova
- Departamento de Pediatría, Consorcio Hospital General Universitario de Valencia, Valencia, España
| | - Javier Casero Soriano
- Departamento de Pediatría, Consorcio Hospital General Universitario de Valencia, Valencia, España
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Baron J, El-Chaar G. Hypertonic Saline for the Treatment of Bronchiolitis in Infants and Young Children: A Critical Review of the Literature. J Pediatr Pharmacol Ther 2016; 21:7-26. [PMID: 26997926 DOI: 10.5863/1551-6776-21.1.7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Bronchiolitis, an infection of the lower respiratory tract, is the leading cause of infant and child hospitalization in the United States. Therapeutic options for management of bronchiolitis are limited. Hypertonic saline inhalation therapy has been studied in numerous clinical trials with mixed results. In 2014, the American Academy of Pediatrics (AAP) published updated guidelines on the diagnosis and management of bronchiolitis, which include new recommendations on the use of hypertonic saline. We reviewed all published clinical trials mentioned in the 2014 AAP guidelines, as well as additional trials published since the guidelines, and critically evaluated each trial to determine efficacy, safety, and expectations of hypertonic saline inhalation therapy. A total of 2682 infants were studied over the course of 22 clinical trials. Nine trials were carried out in the outpatient/clinic/emergency department and 13 in the inpatient setting. We agree with the AAP guidelines regarding the recommendation to use nebulized hypertonic saline for infants hospitalized with bronchiolitis, with the expectation of reducing bronchiolitis scores and length of stay when it is expected to last more than 72 hours. However, we also believe there might be an advantage for hypertonic saline in reducing admission rates from the emergency department, based on close examination of the results of recent trials. This review also highlights important gaps in the available literature that need to be addressed in order to define the role of inhaled hypertonic saline therapy.
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Affiliation(s)
- Jeffrey Baron
- Pharmacy Department, Roswell Park Cancer Institute, Buffalo, New York
| | - Gladys El-Chaar
- Pharmacy Department, Roswell Park Cancer Institute, Buffalo, New York ; Department of Pharmacy, Winthrop-University Hospital, Mineola, New York ; Department of Clinical Pharmacy Practice, St John's University College of Pharmacy and Health Sciences, Jamaica, New York
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Sinha IP, McBride AKS, Smith R, Fernandes RM. CPAP and High-Flow Nasal Cannula Oxygen in Bronchiolitis. Chest 2015; 148:810-823. [PMID: 25836649 DOI: 10.1378/chest.14-1589] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Severe respiratory failure develops in some infants with bronchiolitis because of a complex pathophysiologic process involving increased airways resistance, alveolar atelectasis, muscle fatigue, and hypoxemia due to mismatch between ventilation and perfusion. Nasal CPAP and high-flow nasal cannula (HFNC) oxygen may improve the work of breathing and oxygenation. Although the mechanisms behind these noninvasive modalities of respiratory support are not well understood, they may help infants by way of distending pressure and delivery of high concentrations of warmed and humidified oxygen. Observational studies of varying quality have suggested that CPAP and HFNC may confer direct physiologic benefits to infants with bronchiolitis and that their use has reduced the need for intubation. No trials to our knowledge, however, have compared CPAP with HFNC in bronchiolitis. Two randomized trials compared CPAP with oxygen delivered by low-flow nasal cannula or face mask and found some improvements in blood gas results and some physiologic parameters, but these trials were unable to demonstrate a reduction in the need for intubation. Two trials evaluated HFNC in bronchiolitis (one comparing it with headbox oxygen, the other with nebulized hypertonic saline), with the results not seeming to suggest important clinical or physiologic benefits. In this article, we review the pathophysiology of respiratory failure in bronchiolitis, discuss these trials in detail, and consider how future research studies may be designed to best evaluate CPAP and HFNC in bronchiolitis.
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Affiliation(s)
- Ian P Sinha
- From the Respiratory Unit, Alder Hey Children's Hospital, Liverpool, England.
| | - Antonia K S McBride
- From the Respiratory Unit, Alder Hey Children's Hospital, Liverpool, England
| | - Rachel Smith
- From the Respiratory Unit, Alder Hey Children's Hospital, Liverpool, England
| | - Ricardo M Fernandes
- Department of Pediatrics, Santa Maria Hospital, Lisbon Academic Medical Centre, Lisbon, Portugal; Clinical Pharmacology Unit, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal
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31
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Maguire C, Cantrill H, Hind D, Bradburn M, Everard ML. Hypertonic saline (HS) for acute bronchiolitis: Systematic review and meta-analysis. BMC Pulm Med 2015; 15:148. [PMID: 26597174 PMCID: PMC4657365 DOI: 10.1186/s12890-015-0140-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 11/10/2015] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Acute bronchiolitis is the commonest cause of hospitalisation in infancy. Currently management consists of supportive care and oxygen. A Cochrane review concluded that, "nebulised 3 % saline may significantly reduce the length of hospital stay". We conducted a systematic review of controlled trials of nebulised hypertonic saline (HS) for infants hospitalised with primary acute bronchiolitis. METHODS Searches to January 2015 involved: Cochrane Central Register of Controlled Trials; Ovid MEDLINE; Embase; Google Scholar; Web of Science; and, a variety of trials registers. We hand searched Chest, Paediatrics and Journal of Paediatrics on 14 January 2015. Reference lists of eligible trial publications were checked. Randomised or quasi-randomised trials which compared HS versus either normal saline (+/- adjunct treatment) or no treatment were included. Eligible studies involved children less than 2 years old hospitalised due to the first episode of acute bronchiolitis. Two reviewers extracted data to calculate mean differences (MD) and 95 % Confidence Intervals (CIs) for length of hospital stay (LoS-primary outcome), Clinical Severity Score (CSS) and Serious Adverse Events (SAEs). Meta-analysis was undertaken using a fixed effect model, supplemented with additional sensitivity analyses. We investigated statistical heterogeneity using I(2). Risk of bias, within and between studies, was assessed using the Cochrane tool, an outcome reporting bias checklist and a funnel plot. RESULTS Fifteen trials were included in the systematic review (n = 1922), HS reduced mean LoS by 0.36, (95 % CI 0.50 to 0.22) days, but with considerable heterogeneity (I(2) = 78 %) and sensitivity to alternative analysis methods. A reduction in CSS was observed where assessed [n = 516; MD -1.36, CI -1.52, -1.20]. One trial reported one possible intervention related SAE, no other studies described intervention related SAEs. CONCLUSIONS There is disparity between the overall combined effect on LoS as compared with the negative results from the largest and most precise trials. Together with high levels of heterogeneity, this means that neither individual trials nor pooled estimates provide a firm evidence-base for routine use of HS in inpatient acute bronchiolitis.
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Affiliation(s)
- Chin Maguire
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK.
| | - Hannah Cantrill
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK.
| | - Daniel Hind
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK.
| | - Mike Bradburn
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK.
| | - Mark L Everard
- School of Paediatrics and Child Health (SPACH), The University of Western Australia, Perth, Australia.
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Nayak S. Bronchiolitis – Rationale for current recommendations for diagnosis and management. PEDIATRIC INFECTIOUS DISEASE 2015. [PMCID: PMC7153727 DOI: 10.1016/j.pid.2015.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Bronchiolitis is a lower respiratory infection caused commonly by RSV in the initial 2 years of life. It is responsible for a large number of hospitalizations. Pulse oximetry plays an important role in monitoring the progression of disease. Supplemental oxygen administration is not recommended at saturation levels above 90%.
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Everard ML, Hind D, Ugonna K, Freeman J, Bradburn M, Dixon S, Maguire C, Cantrill H, Alexander J, Lenney W, McNamara P, Elphick H, Chetcuti PA, Moya EF, Powell C, Garside JP, Chadha LK, Kurian M, Lehal RS, MacFarlane PI, Cooper CL, Cross E. Saline in acute bronchiolitis RCT and economic evaluation: hypertonic saline in acute bronchiolitis - randomised controlled trial and systematic review. Health Technol Assess 2015; 19:1-130. [PMID: 26295732 PMCID: PMC4781529 DOI: 10.3310/hta19660] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Acute bronchiolitis is the most common cause of hospitalisation in infancy. Supportive care and oxygen are the cornerstones of management. A Cochrane review concluded that the use of nebulised 3% hypertonic saline (HS) may significantly reduce the duration of hospitalisation. OBJECTIVE To test the hypothesis that HS reduces the time to when infants were assessed as being fit for discharge, defined as in air with saturations of > 92% for 6 hours, by 25%. DESIGN Parallel-group, pragmatic randomised controlled trial, cost-utility analysis and systematic review. SETTING Ten UK hospitals. PARTICIPANTS Infants with acute bronchiolitis requiring oxygen therapy were allocated within 4 hours of admission. INTERVENTIONS Supportive care with oxygen as required, minimal handling and fluid administration as appropriate to the severity of the disease, 3% nebulised HS every ± 6 hours. MAIN OUTCOME MEASURES The trial primary outcome was time until the infant met objective discharge criteria. Secondary end points included time to discharge and adverse events. The costs analysed related to length of stay (LoS), readmissions, nebulised saline and other NHS resource use. Quality-adjusted life-years (QALYs) were estimated using an existing utility decrement derived for hospitalisation in children, together with the time spent in hospital in the trial. DATA SOURCES We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and other databases from inception or from 2010 onwards, searched ClinicalTrials.gov and other registries and hand-searched Chest, Paediatrics and Journal of Paediatrics to January 2015. REVIEW METHODS We included randomised/quasi-randomised trials which compared HS versus saline (± adjunct treatment) or no treatment. We used a fixed-effects model to combine mean differences for LoS and assessed statistical heterogeneity using the I (2) statistic. RESULTS The trial randomised 158 infants to HS (n = 141 analysed) and 159 to standard care (n = 149 analysed). There was no difference between the two arms in the time to being declared fit for discharge [median 76.6 vs. 75.9 hours, hazard ratio (HR) 0.95, 95% confidence interval (CI) 0.75 to 1.20] or to actual discharge (median 88.5 vs. 88.7 hours, HR 0.97, 95% CI 0.76 to 1.23). There was no difference in adverse events. One infant developed bradycardia with desaturation associated with HS. Mean hospital costs were £2595 and £2727 for the control and intervention groups, respectively (p = 0.657). Incremental QALYs were 0.0000175 (p = 0.757). An incremental cost-effectiveness ratio of £7.6M per QALY gained was not appreciably altered by sensitivity analyses. The systematic review comprised 15 trials (n = 1922) including our own. HS reduced the mean LoS by -0.36 days (95% CI -0.50 to -0.22 days). High levels of heterogeneity (I (2) = 78%) indicate that the result should be treated cautiously. CONCLUSIONS In this trial, HS had no clinical benefit on LoS or readiness for discharge and was not a cost-effective treatment for acute bronchiolitis. Claims that HS achieves small reductions in LoS must be treated with scepticism. FUTURE WORK Well-powered randomised controlled trials of high-flow oxygen are needed. STUDY REGISTRATION This study is registered as NCT01469845 and CRD42014007569. FUNDING DETAILS This project was funded by the NIHR Health Technology Assessment (HTA) programme and will be published in full in Health Technology Assessment; Vol. 19, No. 66. See the HTA programme website for further project information.
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Affiliation(s)
- Mark L Everard
- School of Paediatrics and Child Health (SPACH), University of Western Australia, Perth, WA, Australia
| | - Daniel Hind
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Kelechi Ugonna
- Department of Respiratory Medicine, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Jennifer Freeman
- Division of Epidemiology & Biostatistics, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Mike Bradburn
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Simon Dixon
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Chin Maguire
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Hannah Cantrill
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - John Alexander
- Children's Centre, Hospital of North Staffordshire NHS Trust, Stoke-on-Trent, UK
| | - Warren Lenney
- Institute for Science & Technology in Medicine, Keele University, Stoke-on-Trent, UK
| | - Paul McNamara
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | - Heather Elphick
- Department of Respiratory Medicine, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Philip Aj Chetcuti
- Children's Respiratory Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Eduardo F Moya
- Department of Paediatrics, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Colin Powell
- Department of Child Health, University Hospital of Wales, Cardiff, UK
| | - Jonathan P Garside
- Children's Outpatients, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, UK
| | - Lavleen Kumar Chadha
- Paediatrics, Doncaster and Bassetlaw Hospitals NHS Foundation Trust, Doncaster, UK
| | - Matthew Kurian
- Paediatrics, Doncaster and Bassetlaw Hospitals NHS Foundation Trust, Doncaster, UK
| | | | | | - Cindy L Cooper
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Elizabeth Cross
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Essouri S, Durand P. Place de l'oxygénothérapie à haut débit dans la prise en charge des bronchiolites. Arch Pediatr 2015; 22:155-6. [DOI: 10.1016/s0929-693x(15)30077-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Pryhuber GS, Maitre NL, Ballard RA, Cifelli D, Davis SD, Ellenberg JH, Greenberg JM, Kemp J, Mariani TJ, Panitch H, Ren C, Shaw P, Taussig LM, Hamvas A. Prematurity and respiratory outcomes program (PROP): study protocol of a prospective multicenter study of respiratory outcomes of preterm infants in the United States. BMC Pediatr 2015; 15:37. [PMID: 25886363 PMCID: PMC4407843 DOI: 10.1186/s12887-015-0346-3] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 03/11/2015] [Indexed: 12/17/2022] Open
Abstract
Background With improved survival rates, short- and long-term respiratory complications of premature birth are increasing, adding significantly to financial and health burdens in the United States. In response, in May 2010, the National Institutes of Health (NIH) and the National Heart, Lung, and Blood Institute (NHLBI) funded a 5-year $18.5 million research initiative to ultimately improve strategies for managing the respiratory complications of preterm and low birth weight infants. Using a collaborative, multi-disciplinary structure, the resulting Prematurity and Respiratory Outcomes Program (PROP) seeks to understand factors that correlate with future risk for respiratory morbidity. Methods/Design The PROP is an observational prospective cohort study performed by a consortium of six clinical centers (incorporating tertiary neonatal intensive care units [NICU] at 13 sites) and a data-coordinating center working in collaboration with the NHLBI. Each clinical center contributes subjects to the study, enrolling infants with gestational ages 23 0/7 to 28 6/7 weeks with an anticipated target of 750 survivors at 36 weeks post-menstrual age. In addition, each center brings specific areas of scientific focus to the Program. The primary study hypothesis is that in survivors of extreme prematurity specific biologic, physiologic and clinical data predicts respiratory morbidity between discharge and 1 year corrected age. Analytic statistical methodology includes model-based and non-model-based analyses, descriptive analyses and generalized linear mixed models. Discussion PROP incorporates aspects of NICU care to develop objective biomarkers and outcome measures of respiratory morbidity in the <29 week gestation population beyond just the NICU hospitalization, thereby leading to novel understanding of the nature and natural history of neonatal lung disease and of potential mechanistic and therapeutic targets in at-risk subjects. Trial registration Clinical Trials.gov NCT01435187. Electronic supplementary material The online version of this article (doi:10.1186/s12887-015-0346-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gloria S Pryhuber
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Nathalie L Maitre
- Monroe Carrell Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA.
| | - Roberta A Ballard
- Department of Pediatrics, University of California, San Francisco School of Medicine, San Francisco, CA, USA.
| | - Denise Cifelli
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Stephanie D Davis
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Jonas H Ellenberg
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - James M Greenberg
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - James Kemp
- Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA.
| | - Thomas J Mariani
- Department of Pediatrics and Pediatric Molecular and Personalized Medicine Program, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Howard Panitch
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
| | - Clement Ren
- Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | - Pamela Shaw
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Lynn M Taussig
- Department of Pediatrics, University of Colorado, Provost's Office, University of Denver, Denver, CO, USA.
| | - Aaron Hamvas
- Edward Mallinckrodt Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA. .,Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Montiano Jorge J, Salado Marin C. Oxigenoterapia de alto flujo en planta de hospitalización. An Pediatr (Barc) 2015; 82:210-2. [DOI: 10.1016/j.anpedi.2014.05.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 05/22/2014] [Accepted: 05/23/2014] [Indexed: 11/24/2022] Open
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Milési C, Boubal M, Jacquot A, Baleine J, Durand S, Odena MP, Cambonie G. High-flow nasal cannula: recommendations for daily practice in pediatrics. Ann Intensive Care 2014; 4:29. [PMID: 25593745 PMCID: PMC4273693 DOI: 10.1186/s13613-014-0029-5] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 08/20/2014] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Christophe Milési
- Département de Pédiatrie Néonatale et Réanimations, Pôle Universitaire Enfant, CHRU de Montpellier, Montpellier 34000, France ; Réanimation Pédiatrique, Hôpital Arnaud de Villeneuve, 371 avenue du doyen G. Giraud, Montpellier CEDEX 5, 34295, France
| | - Mathilde Boubal
- Département de Pédiatrie Néonatale et Réanimations, Pôle Universitaire Enfant, CHRU de Montpellier, Montpellier 34000, France
| | - Aurélien Jacquot
- Département de Pédiatrie Néonatale et Réanimations, Pôle Universitaire Enfant, CHRU de Montpellier, Montpellier 34000, France
| | - Julien Baleine
- Département de Pédiatrie Néonatale et Réanimations, Pôle Universitaire Enfant, CHRU de Montpellier, Montpellier 34000, France
| | - Sabine Durand
- Département de Pédiatrie Néonatale et Réanimations, Pôle Universitaire Enfant, CHRU de Montpellier, Montpellier 34000, France
| | - Marti Pons Odena
- Unidad de Cuidados Intensivos Pediatricos, Hospital Universitario Sant Joan de Deu, Universitat de Barcelona, Esplugues de Llobregat, Barcelona 08950, Spain
| | - Gilles Cambonie
- Département de Pédiatrie Néonatale et Réanimations, Pôle Universitaire Enfant, CHRU de Montpellier, Montpellier 34000, France
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