Nasobronchial interaction

High flow nasal cannula for respiratory support in term infants

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.

A Study to Assess the Effect of Non-asthmatic Allergic Rhinitis on Pulmonary Functions-A Prospective Case-control Study

Allergic rhinitis, beginning from childhood, is a global health problem. According to the literature, allergic rhinitis has been found association with asthma and other allergic manifestations. In this study we like to find out the significance and prognostic importance of spirometry in allergic rhinitis. The study was carried out over a period of 2 years, with 63 cases and controls each. Subjects in the age of 20-55 years with allergic rhinitis and SFAR score of > / = 7 were included as a case. Participants were interviewed and sent for spirometry. Controls were recruited from the retrospective data of healthy individuals with spirometry parameters done for health checkup. These controls had an SFAR score of < 7. All the data obtained were analyzed and compared between cases and controls. The mean age of the cases and controls were 33.17 ± 10.817 and 44.41 ± 7.4, respectively. Majority of cases and controls were males (60.3% and 57.1%). A statistically significant difference in FEF25-75% among cases and controls was noted (p = 0.00), thus proving probability of developing small airway obstruction in subjects with allergic rhinitis. Subjects with allergic rhinitis have a probability of developing small airway obstruction with subclinical changes, hence necessitating the need of regular follow-up.

Mechanism of Lower Airway Hyperresponsiveness Induced by Allergic Rhinitis

Allergic rhinitis is a global illness that puzzles many researchers. Most patients with allergic rhinitis also have lower airway hyperresponsiveness, and an allergic rhinitis attack can increase lower airway hyperresponsiveness. However, the mechanism of the effect of allergic rhinitis on the lower airways is still unclear. In this paper, the effects of allergic rhinitis on the lower airways are studied in terms of epidemiology, anatomy, pathophysiology, nasal function loss, inflammation drainage, nasobronchial reflex, and whole-body circulatory flow to determine the mechanism involved and provide ideas for future diagnosis, treatment, and experiments.

The Relationship Between Indicators of Nasal Respiratory Function and Spirometric Parameters in Children With Bronchial Asthma

Introduction: The relationship between objective indicators of nasal obstruction and airflow limitation in children with bronchial asthma (BA) and allergic rhinitis (AR) has not yet been studied. Objective: To study the relationship between objective parameters of nasal obstruction and airflow limitation, determined using the methods of anterior active rhinomanometry (AARM) and spirometry in children with BA and AR. Materials and Methods: Eighty eight children and adolescents with BA and AR, boys-65.9% (58/88), were examined. The median age was 11.09 [10.42; 11.76] years. To determine airflow limitation, the following spirometric parameters were evaluated: forced vital capacity of the lungs (FVC), forced expiratory volume in 1 s (FEV1), the ratio of FEV1/FVC, and maximum expiratory flow at the point 25% of the flow-volume loop (MEF25). Data were recorded both in absolute values and in relative units (% pred). Nasal respiratory function was determined by AARM based on the total nasal airflow (TNAF) in absolute (Pa/cm3/s) and relative units (RTNAF, % pred). Results: In the general cohort and in boys but not in girls, a statistically significant direct correlation was found between TNAF (Pa/cm3/s) and absolute spirometry parameters of bronchial patency-all had p < 0.01. Also, RTNAF and relative MEF25 values (% pred) in the general cohort were R = 0.22, p = 0.04, and in boys, R = 0.28, p = 0.03. In girls, there was no statistically significant correlation between nasal respiratory function and spirometric parameters, all p > 0.05. Additional analysis of literature was conducted to ascertain that the identified gender differences were not occasional. Conclusion: The significant positive correlation of absolute values of AARM and spirometric parameters in children with BA and AR was established, which apparently reflects the physical development of children. Of all the relative indicators of spirometry, only MEF25 (% pred), which indirectly reflects the patency of small bronchi, had a distinct direct correlation with RTNAF. These patterns are clearly expressed in boys with BA. In girls with this disease, however, the relationship between nasal respiratory function and spirometric indicators seems to be more complex and requires further study.

Targeted Molecular Therapies in Allergy and Rhinology

Biologic agents, monoclonal antibodies that target highly-specific molecular pathways of inflammation, are becoming integrated into care pathways for multiple disorders that are relevant in otolaryngology and allergy. These conditions share common inflammatory mechanisms of so-called Type 2 inflammation with dysregulation of immunoglobulin E production and eosinophil and mast cell degranulation leading to tissue damage. Biologic agents are now available for the treatment of chronic rhinosinusitis with nasal polyps (CRSwNP), asthma, eosinophilic granulomatosis with polyangiitis (EGPA), atopic dermatitis (AD), and chronic spontaneous urticaria (CSU). This paper summarizes the diagnosis and management of these conditions and critically reviews the clinical trial data that has led to regulatory approval of biologic agents for these conditions.

Association Between Mouth Breathing and Asthma: a Systematic Review and Meta-analysis

PURPOSE OF REVIEW

This systematic review and meta-analysis evaluated the association between asthma and mouth breathing. We performed a systematic search in the PubMed, SCOPUS, Lilacs, Web of Science, Google Scholar and OpenThesis databases.

RECENT FINDINGS

Asthma is defined as a heterogeneous disease characterized by variable symptoms of wheezing, shortness of breath, chest oppression and/or cough, and limitation of expiratory airflow. Although several studies have examined the association between asthma and mouth breathing, there are no systematic reviews or meta-analyses that synthesize the available bodies of evidence. We used the odds ratio as a measure of the association between asthma and mouth breathing. Summary estimates were calculated using random-effects models, and the risk of bias was estimated using the Newcastle-Ottawa Scale for case-control studies and the National Institutes of Health tool for cross-sectional studies. Nine studies were included in the present systematic review. Data from 12,147 subjects were analyzed, of which 2083 were children and adolescents and 10,064 were adults. We found an association between mouth breathing and asthma in children and adolescents (OR 2.46, 95% CI 1.78-3.39) and in adults (OR 4.60, 95% CI 1.49-14.20). However, limitations were found in the methodological description of the included studies, as well as high heterogeneity among studies evaluating adult populations. This meta-analysis showed an association between mouth breathing and asthma in children, adolescents and adults, but the results should be interpreted with caution. Further studies with standardized criteria for the investigation of mouth breathing are needed.

Current opinions for the management of asthma associated with ear, nose and throat comorbidities

Ear, nose and throat (ENT) comorbidities are common in patients with asthma and are frequently associated with poorer asthma outcomes. All these comorbidities are "treatable traits" in asthma. Identification and management of these disorders may spare medication usage and contribute to improved asthma control and quality of life, and a decrease in exacerbation rates.This review summarises recent data about the prevalence, clinical impact and treatment effects of ENT comorbidities in asthma including allergic rhinitis, chronic rhinosinusitis with and without nasal polyposis, aspirin-exacerbated respiratory disease, obstructive sleep apnoea and vocal cord dysfunction.Many of these comorbidities are possible to be managed by the pulmonologist, but the collaboration with the ENT specialist is essential for patients with chronic rhinosinusitis or vocal cord dysfunction. Further rigorous research is needed to study the efficacy of comorbidity treatment to improve asthma outcomes, in particular with the development of biotherapies in severe asthma that can also be beneficial in some ENT diseases.

The impact of nasal aspiration with an automatic device on upper and lower respiratory symptoms in wheezing children: a pilot case-control study

Background

The impact of proper aspiration of nasal secretions during upper respiratory infection on the frequency and severity of symptoms of lower airways has never been investigated. The study was aimed at testing if cleaning the nasal cavities of children with recurrent wheezing using an automatic nasal aspirator improves the upper and lower respiratory symptoms during the cold season.

Methods

Parents of wheezing children (age 3-72 mo.) answered questionnaires and learned using a nebulizer equipped (cases) or not equipped (controls) with an automatic nasal aspirator (DuoBaby, OMRON, Japan). During a 90-days monitoring period parents filled an electronic diary (BreathMonitor, TPS, Rome, Italy) on their child’s symptoms of the upper and lower airways.

Results

Eighty-nine/91 patients (43 cases, 46 controls) completed the study. Less days with upper (25.0% vs 46.4%, p = 0.004) or lower (21.8% vs 32.8%, p = 0.022) airways symptoms and less days with salbutamol inhalation (12.2% vs 16.9%, p < 0.001) were reported by cases than by controls. The episodes of upper respiratory symptoms were shorter [4.3 days (95%CI:3.8–4.9) vs 5.7 days (95%CI:5.0–6.4), p = 0.007] but not less frequent [2.3 (95%CI: 1.8–2.8) vs 2.6 (95%CI:2.2–3.0), p = 0.122] among cases than among controls. Similarly, the episodes of lower respiratory symptoms tended to be shorter [3.8 days, (95%CI: 3.4–4.2) vs 4.4 days, (95%CI: 4.4–6.0), p = 0.067] but not less frequent [1.9 (95%CI:1.5–2.3) vs 2.1 (95%CI:1.7–2.4), p = 0.240] among the group using the nasal aspirator.

Conclusions

In our pilot study, the use of an automatic nasal aspirator in children with a history of recurrent wheezing was associated with an improved respiratory health during the cold season.

Electronic supplementary material

The online version of this article (10.1186/s13052-018-0489-6) contains supplementary material, which is available to authorized users.

Effect of Nasal Obstructive Disorders on Sinonasal Symptoms in Children with Different Levels of Bronchial Asthma Control

Allergic rhinitis (AR) and allergic rhinosinusitis (ARS) are typical upper airway pathologies (UAP) in children with bronchial asthma (BA) frequently accompanied with nasal obstructive diseases (NOD). In order to establish the effect of NOD on correlations between nasal and synonasal symptoms with clinical assessments of asthma control, 82 children, 9.8 [8.9; 10.7] years old, with atopic BA were assessed using ACQ-5 for the BA control level, TNSS for nasal symptoms, and SNOT-20 for synonasal quality of life in combination with rhinovideoendoscopy for NOD. All patients had AR/ARS; in 76.3% (63/82) of children, UAP had a multimorbid character with the presence of NOD. Significant correlations were found between ACQ-5 and TNSS (R=0.40, p < 0.0001) and ACQ-5 and SNOT-20 (R=0.42, p < 0.0001). Correlations between TNSS/ACQ-5 and SNOT-20/ACQ-5 were higher in patients who do not have a combination of AR/ARS with NOD (R=0.67, p=0.0012; R=0.50, p=0.022, resp.) than in patients who have AR/ARS combined with NOD (R=0.30, p=0.015; R=0.26, p=0.04, resp.). Thus, the association of BA control level with the expression of nasal and synonasal symptoms is higher in children who do not have multimorbid UAP.

Strain Differences in a Murine Model of Air Pollutant-induced Nonatopic Asthma and Rhinitis

Ozone is an irritating gas found in photochemical smog. Epidemiological associations have been made between the onset of asthma and childhood exposures to increasing levels of ambient ozone (i.e., air pollutant-induced nonatopic asthma). Individuals, however, vary in their susceptibility to this outdoor air pollutant, which may be due, in part, to their genetic makeup. The present study was designed to test the hypothesis that there are murine strain-dependent differences in pulmonary and nasal pathologic responses to repeated ozone exposures. C57BL/6NTac and BALB/cNTac mice were exposed to 0 or 0.8 ppm ozone, 4 hr/day, for 9 consecutive weekdays. In both strains of mice, ozone induced eosinophilic inflammation and mucous cell metaplasia in the nasal and pulmonary airways. Lungs of ozone-exposed C57BL/6NTac mice, however, had greater eosinophilic inflammation, mucous cell metaplasia, and expression of genes related to type 2 immunity and airway mucus hypersecretion, as compared to similarly exposed BALB/cNTac mice. Ozone-exposed C57BL/6NTac mice also had greater eosinophilic rhinitis but a similar degree of mucous cell metaplasia in nasal epithelium, as ozone-exposed BALB/cNTac mice. These findings suggest that nonatopic individuals may differ in their inflammatory and epithelial responses to repeated ozone exposures that are due, in part, to genetic factors.

United airway disease: current perspectives

Upper and lower airways are considered a unified morphological and functional unit, and the connection existing between them has been observed for many years, both in health and in disease. There is strong epidemiologic, pathophysiologic, and clinical evidence supporting an integrated view of rhinitis and asthma: united airway disease in the present review. The term “united airway disease” is opportune, because rhinitis and asthma are chronic inflammatory diseases of the upper and lower airways, which can be induced by allergic or nonallergic reproducible mechanisms, and present several phenotypes. Management of rhinitis and asthma must be jointly carried out, leading to better control of both diseases, and the lessons of the Allergic Rhinitis and Its Impact on Asthma initiative cannot be forgotten.