Heated High-flow Nasal Cannula Research Articles

Heated humidified high flow nasal cannula therapy in children with obstructive sleep apnea: A randomized cross-over trial

Objective/backgroundModerate-to-severe obstructive sleep apnea (OSA) is highly prevalent in children with obesity and/or underlying medical complexity. The first line of therapy, adenotonsillectomy (AT), does not cure OSA in more than 50% of these children. Consequently, continuous positive airway pressure (CPAP) is the main therapeutic option but adherence is often poor. A potential alternative which may be associated with greater adherence is heated high-flow nasal cannula (HFNC) therapy; however, its efficacy in children with OSA has not been systematically investigated.The study aimed to compare the efficacy of HFNC with CPAP to treat moderate-to-severe OSA with the primary outcome measuring the change from baseline in the mean obstructive apnea/hypopnea index (OAHI). Participants/methodsThis was a single-blinded randomized, two period crossover trial conducted from March 2019 to December 2021 at a Canadian pediatric quaternary care hospital. Children aged 2–18 years with obesity and medical complexity diagnosed with moderate-to-severe OSA via overnight polysomnography and recommended CPAP therapy were included in the study. Following diagnostic polysomnography, each participant completed two further sleep studies; a HFNC titration study and a CPAP titration study (9 received HFNC first, and 9 received CPAP first) in a random 1:1 allocation order. ResultsEighteen participants with a mean ± SD age of 11.9 ± 3.8 years and OAHI 23.1 ± 21.7 events/hour completed the study. The mean [95% CI] reductions in OAHI (-19.8[-29.2, -10.5] vs. -18.8 [-28.2, -9.4] events/hour, p = 0.9), nadir oxygen saturation (7.1[2.2, 11.9] vs. 8.4[3.5, 13.2], p = 0.8), oxygen desaturation index (-11.6[-21.0, -2.3] vs. -16.0[-25.3, -6.6], p = 0.5) and sleep efficiency (3.5[-4.8, 11.8] vs. 9.2[0.9, 15.5], p = 0.2) with HFNC and CPAP therapy were comparable between conditions. ConclusionHFNC and CPAP therapy yield similar reductions in polysomnography quantified measures of OSA severity among children with obesity and medical complexities. Trial registrationNCT05354401 ClinicalTrials.gov.

DELAYED HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS (HLH) DIAGNOSIS IN A PATIENT WITH PULMONARY SARCOIDOSIS AND NEWLY DIAGNOSED T-CELL LYMPHOMA: A CASE REPORT

DELAYED HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS (HLH) DIAGNOSIS IN A PATIENT WITH PULMONARY SARCOIDOSIS AND NEWLY DIAGNOSED T-CELL LYMPHOMA: A CASE REPORT

Time-limited trials in the ICU: a mixed-methods sequential explanatory study of intensivists at two academic centres

ObjectiveTo understand intensivist perceptions of the appropriateness of time-limited trials (TLTs)—a strategy to align life-sustaining care with patient goals and values in the midst of clinical uncertainty.DesignWe conducted a mixed-methods...

Outcomes of Heated High Flow Nasal Cannula in Patients With Severe or Life-Threatening COVID-19 at a Military Treatment Facility-A Retrospective Cohort Study.

ABSTRACTIntroductionThe coronavirus-19 (COVID-19) pandemic has forced radical changes in management of healthcare in military treatment facilities (MTFs). Military treatment facilities serve unique patients that have a service connection; thus, research and data on this population are relatively sparse. The purpose of this study was to provide descriptive data on characteristics and outcomes of MTF patients with COVID-19 who are treated with heated high-flow nasal cannula (HHFNC).Materials and MethodsWe performed a single-center retrospective cohort study at the Wright-Patterson Medical Center, a 52-bed hospital in an urban setting. We received approval from our Institutional Review Board. The cohort included patients admitted from June 1, 2020, through May 15, 2021 with severe or life-threatening COVID-19 from a positive severe acute respiratory syndrome–related coronavirus 2 reverse transcription polymerase chain reaction test who were placed on HHFNC during their hospital stay. Severe disease was defined as dyspnea, respiratory rate ≥30/min, blood oxygen saturation ≤93% without supplemental oxygen, partial pressure of arterial oxygen to fraction of inspired oxygen ratio <300, or lung infiltrates involving >50% of lung fields within 24-48 hours. Life-threatening disease was defined as having septic shock or multiple organ dysfunction or requiring intubation. Patients meeting these criteria were retrieved from a quality improvement cohort that represents a consecutive group of patients with COVID-19 admitted to the Wright-Patterson Medical Center.ResultsOur MTF managed 70 cases of severe or life-threatening COVID-19 from June 1, 2020, to May 15, 2021. Of the 70 cases, 19 (27%) were placed on HHFNC. After initiation of HHFNC, median SpO2/FiO2 was 281.8 and at 24 hours 145.4. Median respiratory rate oxygenation at these times were 10.7 and 9.4, respectively. Fifty percent required mechanical ventilation during hospitalization. Median intensive care unit length of stay was 11 days, with a maximum stay of 39 days. Median hospital length of stay was 12 days, with a maximum of 39 days.ConclusionOur retrospective cohort study characterized and analyzed outcomes observed in a MTF population, with severe or life-threatening COVID-19, who were treated with HHFNC. While the study did not have the power to make concrete conclusions on the optimal form of respiratory support for COVID-19 patients, our data support HHFNC as a reasonable treatment modality despite some notable differences between our cohort and prior studied patient populations.

Oxygen Economics: The Use of Heated High-Flow Nasal Oxygen in Air Medical Transport of the Adult Patient

The use of oxygen via a heated high-flow nasal cannula (HHFNC) in transport of the adult patient experiencing hypoxemic respiratory failure is an emerging and successful adjunct. Although early intubation was thought to be the safest intervention early in the coronavirus disease 2019 pandemic, what we have learned over the past year was that it would serve the patient best to avoid intubation. We discuss an individual case study of a coronavirus disease 2019–infected patient who required subsequent interfacility air transport to our quaternary care facility. This patient presented to the receiving air medical team on HHFNC. Before January 2021, the capability of this program to transport these patients on HHFNC was not possible because our current ventilation platforms had to be upgraded to include the high-flow option and because of the relative infancy of the HHFNC platforms available for adult air transport. The previously noted approach to not intubate these patients, or to certainly use caution when making the decision to intubate, was not the common theme until late in 2020. Presented in this case discussion will be pertinent positive and negatives as they relate to transporting the patient on HHFNC to include the all-important issue of oxygen supply and demand. The authors would emphasize that the named products in this case are simply products used by the receiving air medical program and do not in any way support an endorsement of these products over any other platforms used to provide positive patient interventions and outcomes.

Reducing High-flow Nasal Cannula Overutilization in Viral Bronchiolitis.

Heated high-flow nasal cannula (HHFNC) therapy for bronchiolitis has become increasingly prevalent without evidence that this therapy impacts patient outcomes. Lack of criteria for appropriate use may lead to overutilization, resulting in increased costs without patient benefit. Our primary aim was to decrease use of HHFNC in patients with bronchiolitis over one season. Patients with Bronchiolitis younger than 2 years of age admitted to the Hospital Medicine Service were included in this study. Using the model for improvement framework, we identified key drivers for HHFNC overuse and revised our bronchiolitis protocol to include low-flow nasal cannula trials before HHFNC initiation. We compared preintervention HHFNC utilization (December 2018-April 2019) with postintervention HFNC utilization (December 2019-March 2020). One hundred ninety patients met inclusion criteria, 98 of them in the preintervention cohort and 92 in the postintervention cohort. Overall, the median age was 9 months and 65% of patients were male. Our HHFNC utilization rate decreased from 62% (61/98) to 43% (40/92) in the postintervention period. Our SPC analysis suggested special cause variation based on 7 points below the preintervention mean. This QI intervention implementing a specified low-flow nasal cannula trial before the initiation of HHFNC shows promise in reducing overall HHFNC use. Future studies should focus on clear initiation and discontinuation criteria for HHFNC use in bronchiolitis.

200: Successful Use of Convalescent Plasma for Severe COVID-19 Infection in Two Adolescent Patients

Crosley, Caitlin1; Frayre, Philip1; Fenton, Kimberly1; Echeverri, Carolina1; Gaitan, Juliana2; Oliveira, Eduardo2; Ensor, Christopher2; Levent, Fatma1 Author Information

Accuracy of Administrative Codes for Distinguishing Positive Pressure Ventilation From High-Flow Nasal Cannula.

Noninvasive positive pressure ventilation (NIPPV) is increasingly used in critically ill pediatric patients, despite limited data on safety and efficacy. Administrative data may be a good resource for observational studies. Therefore, we sought to assess the performance of the International Classification of Diseases, Ninth Revision procedure code for NIPPV. Patients admitted to the PICU requiring NIPPV or heated high-flow nasal cannula (HHFNC) over the 11-month study period were identified from the Virtual PICU System database. The gold standard was manual review of the electronic health record to verify the use of NIPPV or HHFNC among the cohort. The presence or absence of a NIPPV procedure code was determined by using administrative data. Test characteristics with 95% confidence intervals (CIs) were generated, comparing administrative data with the gold standard. Among the cohort (n = 562), the majority were younger than 5 years, and the most common primary diagnosis was bronchiolitis. Most (82%) required NIPPV, whereas 18% required only HHFNC. The NIPPV code had a sensitivity of 91.1% (95% CI: 88.2%-93.6%) and a specificity of 57.6% (95% CI: 47.2%-67.5%), with a positive likelihood ratio of 2.15 (95% CI: 1.70-2.71) and negative likelihood ratio of 0.15 (95% CI: 0.11-0.22). Among our critically ill pediatric cohort, NIPPV procedure codes had high sensitivity but only moderate specificity. On the basis of our study results, there is a risk of misclassification, specifically failure to identify children who require NIPPV, when using administrative data to study the use of NIPPV in this population.

A Review of Heated High-Flow Nasal Cannula in Pediatrics—From Critical Care to Ward Use

Heated high-flow nasal cannula (HFNC) is used in management of acute respiratory distress and is increasingly used in the emergency department (ED) and ward setting. This review aimed to highlight existing literature on ward use of HFNC. HFNC reduces work of breathing, increases mucociliary clearance, and improves oxygenation. Within limits, HFNC can be safely used on pediatric wards for management of moderate to severe respiratory distress. Weight-based and non-weight-based flow rates have been successfully used on pediatric wards, and maximum acceptable flow rates on wards are site and resource specific. Frequent monitoring can identify responders and non-responders requiring escalation. Early observation suggests that oral feeding is safe. Ward HFNC weaning protocols are lacking. Evidence suggests that in selected populations of children with moderate to severe respiratory distress due to acute bronchiolitis, HFNC with close monitoring is safe for use on the pediatric wards.

Heated High Flow Nasal Cannula Use at the Hospital for Sick Children: A Retrospective Chart Review

SESSION TITLE: Pediatrics SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: Introduction: Heated high flow nasal cannula (HFNC) therapy is a method of providing oxygen using flow rates higher than that used with traditional oxygen therapy. There is a dearth of evidence regarding the efficacy, effectiveness and safety of HFNC in the paediatric population. Objectives: to describe HFNC therapy at SickKids, including predictors of treatment failure. METHODS: Retrospective chart review of patients treated with HFNC in the Critical Care Unit (CCU), wards and Emergency Department between September 1st 2013 and January 31st 2016. Patients were categorized as non-responders (NR) (intolerance/agitation, transition to non-invasive (NIV) or invasive mechanical ventilation (IV), transfer to the CCU, cardiac arrest or death) or responders (R) (all other scenarios). Analysis: descriptive statistics; R vs. NR using chi-square (categorical), two-sample t-test (continuous) and Wilcoxon rank sums tests (skewed variables). Significant predictors in past literature and deemed important by the clinical respiratory therapists (RTs) were included in a multiple logistic regression model for predicting NR. RESULTS: 357 patients used HFNC: n=158(44%) females; n=208(58%) after extubation; n=139 (39%) for respiratory distress or work of breathing; mean(SD) age=2.1(2.9) years; duration of therapy=57.6(84.3) days. N=117(33%) were NRs, the majority requiring NIV or IV (98(84%)). Significant associations of NR: change in flowrate/kg in the first 4 hours (NR vs. R: 0.05(0.1) vs. -0.08(0.05) lpm/kg), p=0.05; change in respiratory rate (RR) in the first 4 hours (-5.8(3.3) vs. 0.2(2.4) bpm), p=0.04; hospital LOS (111.4(17.9) vs. 65.6(9.9) days), p=0.02. CONCLUSIONS: The majority of children at SickKids were placed on HFNC after extubation or due to respiratory distress. An increased flowrate and decreased RR in the first 4 hours, and longer hospital LOS was associated with failure of HFNC. CLINICAL IMPLICATIONS: Monitoring these parameters may help RTs anticipate HFNC failure and avoid higher forms of respiratory support. This may help inform HFNC protocols for initiation, weaning and discontinuation. DISCLOSURE: The following authors have nothing to disclose: Mika Nonoyama, Katherine Reise, Jason Macartney, Cameron Wright No Product/Research Disclosure Information

Is there a role for humidified heated high-flow nasal cannula therapy in paediatric emergency departments?

BackgroundHumidified heated high-flow nasal cannula (HFNC) therapy is a potentially useful form of non-invasive respiratory support for children with moderate respiratory distress and/or hypoxaemia. No prospective data support its use...