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Abstract

We would like to thank Bromiker et al and Roberts et al1 for their comments on our report. We agree that the use of high flow nasal cannula (HFNC) has increased significantly in recent years.1Roberts C.T. Owen L.S. Manley B.J. Davis P.G. Australian and New Zealand Neonatal Network (ANZNN)High-flow support in very preterm infants in Australia and New Zealand.Arch Dis Child Fetal Neonatal Ed. 2015; https://doi.org/10.1136/archdischild-2015-309328Crossref Scopus (21) Google Scholar We should be concerned with this dramatic increase in the use of HFNC specifically in the most immature infants. There is no evidence that HFNC is beneficial or safe in extremely low birth weight (ELBW) infants. We did not report the time at which HFNC treatment was commenced, and it is possible that some of the outcomes may have occurred before these infants received HFNC. However, the primary outcome of bronchopulmonary dysplasia (BPD) or death and several other important secondary outcomes (days to room air, time to oral feeding, and length of hospitalization) are unlikely to occur before the commencement of therapy with the HFNC. The rate of home oxygen use at discharge was not different between the groups likely because of prolonged hospitalization. The median days to room air was significantly higher in infants in the HFNC and HFNC ± continuous positive airway pressure (CPAP) groups. The infants in the group receiving HFNC ± CPAP had lower birth weights and gestational ages (GA), but this was adjusted in the regression analysis. Moreover, there were no significant differences in birth weight and GA in the CPAP and HFNC groups. Death was not analyzed and reported in our study. In response to the comments, we evaluated data on mortality and found it to be 9.6%, 6.0%, and 4.3%, respectively, in the 3 groups (CPAP, HFNC, HFNC ± CPAP). The difference in death was not significant between the CPAP and HFNC group. Bromiker et al calculated mortality in the CPAP and HFNC groups by subtracting the BPD from the composite outcome of BPD or death. This calculation is not correct. Several infants in all 3 groups had BPD at 36 weeks postmenstrual age and died later. The actual mortality was CPAP group of 90 infants (9.6%) and HFNC group of 20 infants (6.0%), P = .061. The mortality was higher in infants in the group receiving CPAP compared with the group receiving HFNC ± CPAP. It is unlikely that the use of HFNC will reduce death in ELBW infants. On the other hand, increased BPD, days to room air, delayed oral feeding, and an increased length of hospitalization with the use of HFNC is biologically plausible as discussed in the article. As with all retrospective studies, our data can only suggest relationships and a randomized clinical trial would be superior evidence. We agree that the conclusion should be drawn from the highest quality data. Unfortunately, data do not exist on the use of HFNC in ELBW infants. In the Cochrane review quoted by Roberts et al,1 only 233 out of 934 infants had the GA of <28 weeks. There was a potential for bias as the interventions were not blinded to the caregivers, and the studies were designed to investigate the short-term outcomes of treatment failure or extubation failure.1Roberts C.T. Owen L.S. Manley B.J. Davis P.G. Australian and New Zealand Neonatal Network (ANZNN)High-flow support in very preterm infants in Australia and New Zealand.Arch Dis Child Fetal Neonatal Ed. 2015; https://doi.org/10.1136/archdischild-2015-309328Crossref Scopus (21) Google Scholar, 2Wilkinson D. Andersen C. O'Donnell C.P. De Paoli A.G. Manley B.J. High flow nasal cannula for respiratory support in preterm infants.Cochrane Database Syst Rev. 2016; (CD006405)Google Scholar, 3Manley B.J. Owen L.S. Doyle L.W. Andersen C.C. Cartwright D.W. Pritchard M.A. et al.High-flow nasal cannulae in very preterm infants after extubation.N Engl J Med. 2013; 369: 1425-1433Crossref PubMed Scopus (241) Google Scholar, 4Collins C.L. Holberton J.R. Barfield C. Davis P.G. A randomized controlled trial to compare heated humidified high-flow nasal cannulae with nasal continuous positive airway pressure postextubation in premature infants.J Pediatr. 2013; 162 (e1): 949-954Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar The review concluded that further evidence is required for evaluating the safety and efficacy of HFNC in extremely preterm infants.3Manley B.J. Owen L.S. Doyle L.W. Andersen C.C. Cartwright D.W. Pritchard M.A. et al.High-flow nasal cannulae in very preterm infants after extubation.N Engl J Med. 2013; 369: 1425-1433Crossref PubMed Scopus (241) Google Scholar We all are in agreement that there is an urgent need of prospective randomized controlled trial for the use of HFNC in ELBW infants. High flow nasal cannula and poor outcomes?The Journal of PediatricsVol. 178PreviewWe read with interest the study by Taha et al.1 There is a gap of knowledge as to the safety and efficacy of high flow nasal cannula (HFNC) in extremely low birth weight (ELBW) infants as suggested in the recent Cochrane review.2 Although Manley et al3 showed that HFNC was noninferior to nasal continuous positive airway pressure (NCPAP) for postextubation treatment in infants <32 weeks postmenstrual age, this study suggested a trend for benefit for NCPAP. The information on initial use of HFNC vs NCPAP4 or nasal intermittent positive ventilation5 is limited especially in ELBW infants. Full-Text PDF Chicken or egg? Dangers in the interpretation of retrospective studiesThe Journal of PediatricsVol. 178PreviewHigh flow nasal cannulae (HFNC) use has increased significantly in recent years.1 It would be of great concern to neonatologists if, as suggested by Taha et al,2 higher rates of adverse outcomes “are due to the use of HFNC.” We should be cautious about drawing such a conclusion. The infants were not randomized to receive HFNC or continuous positive airway pressure (CPAP), and there may be substantial differences in the baseline condition of the infants receiving HFNC. The authors report that infants treated with HFNC, in addition to weighing less and being more immature at birth, were more likely to receive endotracheal ventilation, multiple courses of ventilation, and postnatal steroids. Full-Text PDF