Implementation of High-Flow Nasal Cannula and Noninvasive Ventilation During Pediatric Interfacility Transport: Effect on Intubation Rates.

Admissions to the pediatric intensive care unit (PICU) due to bronchiolitis are increasing. Whether this increase is associated with changes in noninvasive respiratory support practices is unknown. To assess whether the number of PICU admissions for bronchiolitis between 2013 and 2022 was associated with changes in the use of high-flow nasal cannula (HFNC), noninvasive ventilation (NIV), and invasive mechanical ventilation (IMV) and to identify factors associated with HFNC and NIV success and failure. This cross-sectional study examined encounter data from the Virtual Pediatric Systems database on annual PICU admissions for bronchiolitis and ventilation practices among patients aged younger than 2 years admitted to 27 PICUs between January 1, 2013, and December 31, 2022. Use of HFNC and NIV was defined as successful if patients were weaned to less invasive support (room air or low-flow nasal cannula for HFNC; room air, low-flow nasal cannula, or HFNC for NIV). The main outcome was the number of PICU admissions for bronchiolitis requiring the use of HFNC, NIV, or IMV. Linear regression was used to analyze the association between admission year and absolute numbers of encounters stratified by the maximum level of respiratory support required. Multivariable logistic regression was used to analyze factors associated with HFNC and NIV success and failure (defined as not meeting the criteria for success). Included in the analysis were 33 816 encounters for patients with bronchiolitis (20 186 males [59.7%]; 1910 patients [5.6%] aged ≤28 days and 31 906 patients [94.4%] aged 29 days to <2 years) treated at 27 PICUs from 2013 to 2022. A total of 7615 of 15 518 patients (49.1%) had respiratory syncytial virus infection and 1522 of 33 816 (4.5%) had preexisting cardiac disease. Admissions to the PICU increased by 350 (95% CI, 170-531) encounters annually. When data were grouped by the maximum level of respiratory support required, HFNC use increased by 242 (95% CI, 139-345) encounters per year and NIV use increased by 126 (95% CI, 64-189) encounters per year. The use of IMV did not significantly change (10 [95% CI, -11 to 31] encounters per year). In all, 22 381 patients (81.8%) were successfully weaned from HFNC to low-flow oxygen therapy or room air, 431 (1.6%) were restarted on HFNC, 3057 (11.2%) were escalated to NIV, and 1476 (5.4%) were escalated to IMV or extracorporeal membrane oxygenation (ECMO). Successful use of HFNC increased from 820 of 1027 encounters (79.8%) in 2013 to 3693 of 4399 encounters (84.0%) in 2022 (P = .002). In all, 8476 patients (81.5%) were successfully weaned from NIV, 787 (7.6%) were restarted on NIV, and 1135 (10.9%) were escalated to IMV or ECMO. Success with NIV increased from 224 of 306 encounters (73.2%) in 2013 to 1335 of 1589 encounters (84.0%) in 2022 (P < .001). In multivariable logistic regression, lower weight, higher Pediatric Risk of Mortality III score, cardiac disease, and PICU admission from outside the emergency department were associated with greater odds of HFNC and NIV failure. Findings of this cross-sectional study of patients aged younger than 2 years admitted for bronchiolitis suggest there was a 3-fold increase in PICU admissions between 2013 and 2022 associated with a 4.8-fold increase in HFNC use and a 5.8-fold increase in NIV use. Further research is needed to standardize approaches to HFNC and NIV support in bronchiolitis to reduce resource strain.

High-flow nasal cannula oxygen therapy is superior to conventional oxygen therapy but not to non-invasive mechanical ventilation in reducing intubation rate in hypoxia and dyspnea due to acute heart failure: a systematic review and meta-analysis.

Critical bronchiolitis is a common reason for pediatric intensive care unit (PICU) admission, and management varies widely, with limited data from South American PICUs. This study aimed to characterize critical bronchiolitis trajectories in a Brazilian PICU and to measure adherence to a clinical protocol deemphasizing ancillary pharmacologic treatments while using the modified Wood-Downes score (mWDS) to guide respiratory support. It also aimed to assess whether admission mWDS would be associated with the need for subsequent invasive mechanical ventilation. We conducted a retrospective cohort study of infants <24 months admitted with critical bronchiolitis to a Brazilian PICU between March 2021 and April 2023. The protocol was implemented in January 2021 and discouraged the use of inhaled β-agonists, systemic corticosteroids, and inhaled hypertonic saline. It also recommended respiratory support based on the mWDS conventional oxygen for scores ≤3, high-flow nasal cannula (HFNC) or noninvasive ventilation (NIV) for scores 4-7, and consideration of mechanical ventilation for scores >7. We assessed patient characteristics, protocol adherence, and predictive value of admission mWDS for intubation. Among 299 infants (median age 4.9 mo), 69% had respiratory syncytial virus infection. Maximum respiratory support was conventional oxygen in 61%, HFNC in 22%, NIV in 14%, and mechanical ventilation in 3%. Complete protocol adherence was 43%. Individual component adherence varied:hypertonic saline 100%, corticosteroids 83%, β-agonists 77%, and appropriate respiratory support 54%. Most protocol violations (66%) involved undertreatment with conventional oxygen for mWDS 4-7. The mWDS score at PICU admission was associated with intubation with an area under the curve of 0.77 (95% CI: 0.63-0.91); no subjectwith mWDS at PICU admission <4 required intubation. This Brazilian cohort demonstrated low intubation rates despite suboptimal protocol adherence. The mWDS score at PICU admission showed acceptable discrimination for the need for mechanical ventilation, with scores <4 identifying low-risk patients.

Introduction: High flow nasal cannula (HFNC) oxygen therapy is a non-invasive form of respiratory support that is rapidly being taken up in paediatric intensive care units (PICU). For infants with bronchiolitis – who are the largest non-elective source of admissions to a PICU – there is some evidence that using HFNC therapy reduces the need for intubation and mechanical ventilation. The aim of this thesis is to explore, describe, critique and add to the evidence surrounding the use of HFNC therapy in the paediatric population for the management of respiratory distress. Methodology: A case series analysis was undertaken to describe common pathophysiology presentations to a PICU that used HFNC therapy as a method of respiratory treatment. Consent was sought from individual patients who represented common presentations of patients requiring respiratory support in a PICU (asthma, bronchiolitis and cardiomyopathy). A Cochrane systematic review was undertaken to determine the evidence for the clinical application of HFNC in the paediatric population. However, there remains a paucity of literature on HFNC application in lower acuity settings. To address this, a pilot study was undertaken in the Paediatric Emergency Department (PED) of the Mater Children's Hospital (MCH), Brisbane, Australia, with infants with bronchiolitis who met the inclusion criteria and for whom parental consent was obtained. Once enrolled, HFNC therapy was commenced, and observations recorded at least hourly until treatment cessation. A comparison group was identified and included during the course of the study, consisting of all infants who were eligible but not enrolled during the study period. The study protocol detailed the clinical treatment of those infants in the trial group, and no other changes were made to the usual management of infants with bronchiolitis during the study period. The primary outcome of interest was PICU admission. Secondary outcomes included: physiological response to HFNC; adverse outcomes; intubation rates; and hospital and PICU length of stay. Results: The case series analysis conducted indicated that HFNC therapy was successful in managing three patients with differing underlying pathophysiologies that caused respiratory distress. The Cochrane systematic review did not identify any studies that matched its inclusion criteria. Sixty-one infants were enrolled in the pilot study and 33 who met the inclusion criteria were later identified and formed the comparison group. Infants managed with HFNC therapy were four times less likely to require admission to PICU compared to those infants managed with standard low flow nasal oxygen therapy (OR 4.086, p=0.043). No infant, in either group, required intubation or mechanical ventilation. However, not all infants responded to HFNC therapy. Heart rate, respiratory rate and HiFOD score (a composite of physiological scores) indicated response to treatment over time (Generalised Linear Model p<0.001). The HFNC group successfully managed on the ward (Responders) had a mean reduction in heart rate of 13 bpm within 60 minutes of HFNC commencing. Whereas the heart rate of the HFNC group who were admitted to PICU (Non-Responders) increased (p=0.02). Likewise HiFOD scores also significantly reduced in the HFNC Responders with Non Responders maintaining or slightly decreasing their HiFOD score (p=0.006) at 60 minutes. A similar trend was observed with respiratory rate; however this did not become significant until 180 minutes (p=0.001). Discussion: Clinical uptake of HFNC in the intensive care setting is increasing Intensive care settings are increasingly using HFNC therapy with reported clinical effect. However, the literature contains a paucity of evidence about its appropriate use and effectiveness, with only one small paediatric RCT conducted to date. The case series analysis revealed that using HFNC therapy may be safe and effective in the clinical management of infants with respiratory impairment. Further, the results of the pilot study indicate that HFNC therapy in low acuity settings, implemented as per the developed protocol, may reduce PICU admissions for infants with bronchiolitis. Additionally, the clinical reduction in heart rate and HiFOD scores at 60 minutes suggests that individual infants who receive HFNC therapy in a low acuity environment, but who do not respond within this time, may need to have their treatment reviewed and intervention escalated. These findings have implications for the effective management of bronchiolitis globally. Conclusion: Bronchiolitis is the largest cause of PICU admissions. This thesis examines the evidence and builds on the extant literature by reporting a case series, a systematic review and a pilot study. Based on the results of this thesis, a trial of HFNC therapy in a low acuity setting may be considered, with anticipated clinical improvement evident in 60 minutes. This may indicate that the patient can be managed outside of an intensive care setting. Preventing PICU admissions will likely reduce both financial and social impact on hospitals and families.

Role of Helmet-Delivered Noninvasive Pressure Support Ventilation in COVID-19 Patients

Analysis of High Flow Nasal Cannula Utilization During Pediatric Critical Care Transport

Respiratory failure (RF) is a main cause of pediatric intensive care unit (PICU) admission in children with hemato-oncological diseases. We present a retrospective chart review of children admitted to our PICU because of RF (January 2006 to December 2010). The aims of this study are the following: (1) to describe the demographical and clinical characteristics and respiratory management of these children; and (2) to identify the factors associated with mechanical ventilation (MV) and mortality. A total of 69 patients, encompassing 88 episodes, were included (55/88 cases were hypoxemic RF). The first respiratory support at PICU admission was, in decreasing order of frequency, high-flow oxygen nasal cannula (HFNC; 50/88), noninvasive ventilation (NIV; 13/88), and oxygen nasal cannula (16/88). MV was necessary in 47/88 episodes, 38/47 after another respiratory support. In 18/28 children with initial NIV, MV was required later. MV was associated with O-PRISM score, NIV requirement, suspected respiratory infection, and days of PICU treatment. Patients without MV showed an increased survival rate (P=0.001). In summary, the hypoxemic RF was the main cause of PICU admission, and HFNC or NIV was almost always the first respiratory support. The use of MV was associated with a higher mortality rate. The utility of precocious HFNC or NIV should be investigated in larger clinical studies.

Background: Extubation failure is associated with increased morbidity and mortality. Respiratory support may be needed to prevent extubation failure which can be in the form of conventional oxygen therapy (COT) by nasal prong, face mask, or high-flow nasal cannula (HFNC) or noninvasive ventilation. In our study, we compared the effect of HFNC with COT in preventing extubation failure in children admitted to the pediatric intensive care unit (PICU). Subjects and Methods: The study was a single-center open-label randomized control trial done in children after extubation in a tertiary care PICU. All the demographic and clinical details, investigations, and outcomes were recorded in the study proforma. Children included in the study were randomized equally to either receive COT or HFNC. Modified Respiratory Distress Assessment Instrument (mRDAI) was used to gauge the failure or success of the respiratory support. Results: A total of 102 children were included in the study with 51 children receiving either COT or HFNC. Reintubation rates did not differ significantly in both groups [HFNC (n = 12, 23.5%) vs. COT (n = 15, 29.4%)]. There was an improvement in mRDAI scores over the treatment period in both study groups. There was no difference in mortality between the two groups. Conclusions: There was no difference in extubation failure when HFNC or COT was applied in children after postextubation.

Near-Fatal Asthma: An Ounce of Prevention May be Worth More than a Pound of Cure

High-flow nasal cannulae (HFNC) deliver high flows of blended humidified air and oxygen via wide-bore nasal cannulae and may be useful in providing respiratory support for adults experiencing acute respiratory failure, or at risk of acute respiratory failure, in the intensive care unit (ICU). This is an update of an earlier version of the review. To assess the effectiveness of HFNC compared to standard oxygen therapy, or non-invasive ventilation (NIV) or non-invasive positive pressure ventilation (NIPPV), for respiratory support in adults in the ICU. We searched CENTRAL, MEDLINE, Embase, CINAHL, Web of Science, and the Cochrane COVID-19 Register (17 April 2020), clinical trial registers (6 April 2020) and conducted forward and backward citation searches. We included randomized controlled studies (RCTs) with a parallel-group or cross-over design comparing HFNC use versus other types of non-invasive respiratory support (standard oxygen therapy via nasal cannulae or mask; or NIV or NIPPV which included continuous positive airway pressure and bilevel positive airway pressure) in adults admitted to the ICU. We used standard methodological procedures as expected by Cochrane. We included 31 studies (22 parallel-group and nine cross-over designs) with 5136 participants; this update included 20 new studies. Twenty-one studies compared HFNC with standard oxygen therapy, and 13 compared HFNC with NIV or NIPPV; three studies included both comparisons. We found 51 ongoing studies (estimated 12,807 participants), and 19 studies awaiting classification for which we could not ascertain study eligibility information. In 18 studies, treatment was initiated after extubation. In the remaining studies, participants were not previously mechanically ventilated. HFNC versus standard oxygen therapy HFNC may lead to less treatment failure as indicated by escalation to alternative types of oxygen therapy (risk ratio (RR) 0.62, 95% confidence interval (CI) 0.45 to 0.86; 15 studies, 3044 participants; low-certainty evidence). HFNC probably makes little or no difference in mortality when compared with standard oxygen therapy (RR 0.96, 95% CI 0.82 to 1.11; 11 studies, 2673 participants; moderate-certainty evidence). HFNC probably results in little or no difference to cases of pneumonia (RR 0.72, 95% CI 0.48 to 1.09; 4 studies, 1057 participants; moderate-certainty evidence), and we were uncertain of its effect on nasal mucosa or skin trauma (RR 3.66, 95% CI 0.43 to 31.48; 2 studies, 617 participants; very low-certainty evidence). We found low-certainty evidence that HFNC may make little or no difference to the length of ICU stay according to the type of respiratory support used (MD 0.12 days, 95% CI -0.03 to 0.27; 7 studies, 1014 participants). We are uncertain whether HFNC made any difference to the ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO2/FiO2) within 24 hours of treatment (MD 10.34 mmHg, 95% CI -17.31 to 38; 5 studies, 600 participants; very low-certainty evidence). We are uncertain whether HFNC made any difference to short-term comfort (MD 0.31, 95% CI -0.60 to 1.22; 4 studies, 662 participants, very low-certainty evidence), or to long-term comfort (MD 0.59, 95% CI -2.29 to 3.47; 2 studies, 445 participants, very low-certainty evidence). HFNC versus NIV or NIPPV We found no evidence of a difference between groups in treatment failure when HFNC were used post-extubation or without prior use of mechanical ventilation (RR 0.98, 95% CI 0.78 to 1.22; 5 studies, 1758 participants; low-certainty evidence), or in-hospital mortality (RR 0.92, 95% CI 0.64 to 1.31; 5 studies, 1758 participants; low-certainty evidence). We are very uncertain about the effect of using HFNC on incidence of pneumonia (RR 0.51, 95% CI 0.17 to 1.52; 3 studies, 1750 participants; very low-certainty evidence), and HFNC may result in little or no difference to barotrauma (RR 1.15, 95% CI 0.42 to 3.14; 1 study, 830 participants; low-certainty evidence). HFNC may make little or no difference to the length of ICU stay (MD -0.72 days, 95% CI -2.85 to 1.42; 2 studies, 246 participants; low-certainty evidence). The ratio of PaO2/FiO2 may be lower up to 24 hours with HFNC use (MD -58.10 mmHg, 95% CI -71.68 to -44.51; 3 studies, 1086 participants; low-certainty evidence). We are uncertain whether HFNC improved short-term comfort when measured using comfort scores (MD 1.33, 95% CI 0.74 to 1.92; 2 studies, 258 participants) and responses to questionnaires (RR 1.30, 95% CI 1.10 to 1.53; 1 study, 168 participants); evidence for short-term comfort was very low certainty. No studies reported on nasal mucosa or skin trauma. HFNC may lead to less treatment failure when compared to standard oxygen therapy, but probably makes little or no difference to treatment failure when compared to NIV or NIPPV. For most other review outcomes, we found no evidence of a difference in effect. However, the evidence was often of low or very low certainty. We found a large number of ongoing studies; including these in future updates could increase the certainty or may alter the direction of these effects.

To obtain data on the safety and clinical impact of managing infants with bronchiolitis on the ward with high-flow nasal cannula (HFNC) treatment. A prospective pilot study was conducted of 61 infants aged <12 months with bronchiolitis and oxygen requirement presenting to the emergency department. HFNC was commenced at 2 L/kg/min, and fraction of inspired oxygen was titrated to oxygen saturation > 94%. A standard-treatment group (n = 33) managed with standard low-flow subnasal oxygen during the same time period was retrospectively identified. Admission demographics, heart rate (HR) and respiratory rate (RR) were similar in test and standard-treatment groups. Responders and non-responders to HFNC were identified within 60 min of treatment. Non-responders to HFNC requiring paediatric intensive care unit (PICU) admission showed no change in HR and RR, whereas responders showed decreases in HR and RR (P < 0.02). Patients receiving HFNC were four times less likely to need PICU admission than the standard treatment group (OR 4.086, 95%CI 1.0-8.2; P = 0.043). No adverse events such as pneumothorax, bradycardia, bradypnoea, emergency intubation or cardiopulmonary resuscitation were observed. No patients admitted to the PICU required intubation. HFNC treatment in the paediatric ward is safe. Non-responders requiring PICU admission can be identified within the first hour of HFNC treatment by monitoring HR and RR. It is feasible to undertake a randomised controlled trial based on this pilot with the aim of decreasing PICU admissions.

Controversies in airway management of COVID-19 patients: updated information and international expert consensus recommendations

Fluid overload has been associated with increased oxygen requirement, prolonged duration of mechanical ventilation, and longer length of hospital stay in children hospitalized with pulmonary diseases. Critically ill infants with bronchiolitis admitted to the pediatric intensive care unit (PICU) also tend to develop fluid overload and there is limited information of its role on noninvasive respiratory support. Thus, our primary objective was to study the association of fluid overload in patients with bronchiolitis admitted to the PICU with respiratory support escalation (RSE) and need for endotracheal intubation (ETI). Infants ≤24 months of age with bronchiolitis and admitted to the PICU between 9/2009 and 6/2015 were retrospectively studied. Demographic variables, clinical characteristics including type of respiratory support and need for ETI were evaluated. Fluid overload as assessed by net fluid intake and output (net fluid balance), cumulative fluid balance (CFB) (mL/kg), and percentage fluid overload (FO%), was compared between patients requiring and not requiring RSE and among patients requiring ETI and not requiring ETI at 0 (PICU admission), 12, 24, 36, 48, 72, 96, and 120 hours. One-hundred sixty four of 283 patients with bronchiolitis admitted to the PICU qualified for our study. Thirty-four of 164 (21%) patients required escalation of respiratory support within 5 days of PICU admission and of these 34 patients, 11 patients required ETI. Univariate analysis by Kruskal-Wallis test of fluid overload as assessed by net fluid balance, CFB, and FO% between 34 patients requiring and 130 patients not requiring RSE and among 11 patients requiring ETI and 153 patients not requiring ETI, at 0, 12, 24, 36, 48, 72, 96 and 120 hours did not reveal any significant difference ( p >0.05) at any time interval. Multivariable logistic regression analysis revealed higher PRISM score (odds ratio [OR]: 4.95, 95% confidence interval [95% CI]: 1.79-13.66; p = 0.002), longer hours on high flow nasal cannula (OR: 4.86, 95% CI: 1.68-14.03; p = 0.003) and longer hours on noninvasive ventilation (OR: 11.16, 95% CI: 3.36-36.98; p < 0.001) were associated with RSE. Fluid overload as assessed by net fluid balance, CFB, and FO% was not associated with RSE or need for ETI in critically ill bronchiolitis patients admitted to the PICU. Further prospective studies involving larger number of patients with bronchiolitis are needed to corroborate our findings.

The results of several clinical trials suggest that continuous positive airway pressure (CPAP) for acute bronchiolitis can be more effective than high-flow nasal cannula (HFNC). The use of HFNC involved a minimum reduction (5%) in admissions to the pediatric intensive care unit (PICU) in our hospital. Our main aim was to evaluate its safety and effectiveness as respiratory support for patients with bronchiolitis in a pediatric general ward. A secondary goal was to compare the admissions to PICU and the invasive mechanical ventilation (IMV) rate of patients treated with HFNC and those treated with HFNC/b-CPAP during the 2018–2019 and 2019–2020 epidemic seasons, respectively. Two prospective single-centre observational studies were performed. For the main aim, a cohort study (CS1) was carried out from 1st of November 2019 to 15th of January 2020. Inclusion criteria were children aged up to 3 months with bronchiolitis treated with b-CPAP support when HFNC failed. Epidemiological and clinical parameters were collected before and 60 min after the onset of CPAP and compared between the responder (R) and non-responders (NR) groups. NR was the group that required PICU admission. One hundred fifty-eight patients were admitted to the ward with bronchiolitis and HFNC. Fifty-seven out of one hundred fifty-eight required b-CPAP. No adverse events were observed. Thirty-two out of fifty-seven remained in the general ward (R-group), and 25/57 were admitted to PICU (NR-group). There were statistically significant differences in respiratory rate (RR) and heart rate (HR) between both groups before and after the initiation of b-CPAP, but the multivariable models showed that the main differences were observed after 60 min of therapy (lower HR, RR, BROSJOD score and FiO2 in the R-group). For the secondary aim, another cohort study (CS2) was performed comparing data from a pre-b-CPAP bronchiolitis season (1st of November 2018 to 15th January 2019) and the b-CPAP season (2019–2020). Inclusion criteria in pre-b-CPAP season were children aged up to 3 months admitted to the same general ward with moderate-severe bronchiolitis and with HFNC support. Admissions to PICU during the CPAP season were significantly reduced, without entailing an increase in the rate of IMV.Conclusion: The implementation of b-CPAP for patients with bronchiolitis in a pediatric ward, in whom HFNC fails, is safe and effective and results in a reduction in PICU admissions.What is Known:• Bronchiolitis is one of the most frequent respiratory infections in children and one of the leading causes of hospitalization in infants.• Several studies suggest that the use of continuous positive airway pressure (CPAP) for acute bronchiolitis can be more effective than the high flow nasal cannula (HFNC). CPAP is a non-invasive ventilation (NIV) therapy used in patients admitted to pediatric intensive care unit (PICU) with progressive moderate-severe bronchiolitis.There is little experience in the literature on the use of continuous positive airway pressure (CPAP) for acute bronchiolitis in a general ward.What is New:• CPAP could be safely and effectively used as respiratory support in young infants with moderate-severe bronchiolitis in a general ward and it reduced the rate of patients who required PICU admission.• Patients' heart and respiratory rate and their FiO2 needs in the first 60 minutes may help to decide whether or not to continue the CPAP therapy in a general ward.

Objectives High-flow nasal cannula (HFNC) oxygen therapy is a recent technique delivering a high flow of heated and humidified gas. HFNC is simpler to use and apply than non-invasive ventilation (NIV). We conducted this study to assess the effect of high flow nasal cannula versus the conventional non-invasive positive pressure ventilation regarding escalation of respiratory support and mortality in acute hypoxemic patients. Methods A total of 100 patients with acute hypoxemic respiratory failure (50 for each modality HFNC and NIPPV) were closely monitored for intubation rate, ICU length of stay, and 28 days mortality. Results Regarding the intubation rate, there was no statistically significant difference between HFNC and NIPPV. In the HFNC group, 25 patients (50%) received invasive mechanical ventilation while 25 (50%) of others improved. In the NIPPV group, 23 patients (46%) were invasively ventilated, and 27 patients (54%) improved with P value 0.68. This also applies for ICU length of stay, as the mean value in the HFNC group was 8.76 while in NIPPV group it was 8.6, with P value of 0.7. Regarding 28-day mortality in the HFNC group, 21 (42%) patients died, and 29 (58%) patients survived. While in the NIPPV group, 19 patients (38%) died while 31 patients (62%) survived with P value of 0.68. Conclusion High flow nasal cannula can be a comparable alternative to non-invasive positive pressure ventilation in acute hypoxemic respiratory failure with no significant differences in intubation rate and mortality.