Children With Bronchiolitis on High-Flow Nasal Cannula: To Feed or Not Feed, That IsNotthe Only Question

Abstract

Bronchiolitis remains the single most common cause of hospitalization during the first year of life.1 Although supportive treatment is the cornerstone of bronchiolitis therapy, with excellent recovery in the majority of children,2 clinicians continue to search for new and better treatment strategies. As reflected in the most recent American Academy of Pediatrics clinical practice guidelines for bronchiolitis,1 previously embraced treatment strategies such as ribavirin, chest physiotherapy, systemic glucocorticoids, epinephrine, and β-agonist therapy are not recommended for children with bronchiolitis. Even the stance emphasizing continuous pulse oximetry has been prudently revisited (clinicians may choose not to use it for patients who do not require supplemental oxygen or if oxygen saturation is >90%). However, treatment guidelines have not yet confronted the putative benefits of high-flow nasal cannula (HFNC) in the more severely ill component of the population. There is also no consensus surrounding the propriety of enteral nutrition in infants with bronchiolitis being treated with HFNC. Despite the absence of data showing the efficacy of HFNC in the context of bronchiolitis, the strategy is increasingly being used. For children with accelerating illness, and who display respiratory distress and hypoxemia despite nasal cannula support, HFNC is generally more well tolerated than nasal continuous positive airway pressure devices. In a small trial ( N = 14), HFNC had a demonstrably favorable effect on diaphragmatic contraction in children with bronchiolitis, thereby decreasing the work of breathing.3 Although it is tempting to ascribe a lower rate of intubation4,5 with the use of HFNC, these studies involved historical control subjects, which confounds data interpretation. The first randomized controlled trial to …