Heated Humidified High-flow Nasal Cannula Research Articles

Safety and Efficacy of Early Ambulation on an Alternative Oxygen Delivery Device for Patients Receiving Bedside Heated Humidified High-Flow Nasal Cannula Therapy

Purpose: Patients in the intensive care unit (ICU) receiving heated humidified high-flow nasal cannula (HHFNC) therapy for acute respiratory failure have limited ambulation distance due to restrictions in supplying HHFNC away from bedside. This study investigated the safety and efficacy of transitioning patients requiring HHFNC to a portable high-flow oxygen (HFO2) device for ambulation. Methods: Twenty-three patients with acute respiratory failure participated in this prospective longitudinal observational study. Three diagnostic groups were formed (cardiac n = 8; pulmonary n = 11; and other n = 4). Initial aerobic tolerance was established through bedside marching on HHFNC, then participants transitioned to HFO2 for ambulation. During each phase, vital signs were monitored. Results: No differences were found among diagnostic groups or sexes during ambulation for blood pressure, heart rate (HR), respiratory rate (RR), oxygen saturation (SpO2), or the Borg dyspnea scale (BDS) (all P > .05). Outcomes during marching and ambulation differed from outcomes at rest and during recovery for HR, RR, SpO2, and BDS (all P < .001). Transitory adverse events during ambulation included anxiety (n = 2), hypotension (n = 1), and arrhythmia (n = 2). Conclusions: Results indicate it is safe and efficacious for patients in the ICU with acute respiratory failure requiring HHFNC to ambulate on HFO2 under the supervision of a physical therapist.

Optiflow vs Vapotherm as extended weaning mode from nasal continuous positive airway pressure in preterm infants ≤ 28 weeks gestational age.

Current evidence supports nasal continuous positive airway pressure (NCPAP) weaning. Heated humidified high-flow nasal cannula (HHFNC) reduces NCPAP time in infants less than 28 weeks gestational age (GA) without increasing morbidity. The aim of the study was to compare the two most frequently used HHFNC devices in weaning from NCPAP. We performed a retrospective matched-pair case-control study of infants less than or equal to 28 GA born in a single tertiary neonatal center managed with Optiflow or Vapotherm after being weaned from NCPAP. Patients were matched for antenatal steroid doses, delivery mode, birth plurality, GA, birthweight, gender, surfactant doses, length of mechanical ventilation, and length of NCPAP. Outcome measures were duration of HHFNC, low-flow nasal cannula, nasal bridge lesions, pneumothorax, bronchopulmonary dysplasia, postnatal steroids, necrotizing enterocolitis, sepsis, intraventricular hemorrhage, retinopathy of prematurity, length of stay, discharge weight, and mortality. Results were displayed as median (interquartile range) or ratio (percentage). Statistical analysis was performed using Mann-Whitney U and χ2 tests. 70 patients were recruited retrospectively. Thirty-five infants were weaned from NCPAP to Optiflow and 35 infants to Vapotherm with gestational ages and birthweights of 27 GA (26-27) and 1010 g (835-1165) and 27 GA (26-28) and 960 g (788-1191), respectively. There was no statistically significant difference in any outcome measure. Infants managed with Vapotherm required a not statistically significant shorter length of time on HHFNC and low-flow nasal cannula. Optiflow and Vapotherm seem to be equally effective and safe for weaning from NCPAP. However, infants weaned to Vapotherm appear to spend less time on non-invasive respiratory support.

The Comparison of HHHFNC and NCPAP in Extremely Low-Birth-Weight Preterm Infants After Extubation: A Single-Center Randomized Controlled Trial.

Objectives: To compare the clinical efficacy of heated, humidified high-flow nasal cannula (HHHFNC) and nasal continuous positive airway pressure (NCPAP) in extremely low-birth-weight preterm infants (ELBWI) after extubation.Methods: This trial included 94 extremely low-birth-weight infants (ELBWI), within 7 days after birth, and prepared for tracheal extubation and a change to non-invasive ventilation in the neonatal intensive care unit (NICU) admitted to our hospital from January 2015 to December 2018, with 48 infants in the HHHFNC group and 46 infants in the NCPAP group. Reintubation rate within 72 h after initial extubation, total ventilation time, non-invasive ventilation time, total oxygen inhalation time, and the time to reach full enteral feeding were the primary outcome measures. Total intestinal feeding time, average weight gain rate, days of hospitalization, costs of hospitalization, and complication rates, including nasal injury, IVH, BPD, NEC, ROP, and PDA, were used as secondary outcomes. Data were analyzed using Student's t-test or the Mann-Whitney U-test with a Chi-square test or Fisher's exact test, as appropriate, in SPSS (25.0).Results: HHHFNC not only shortened the oxygen exposure time but also effectively reduced the incidence of nasal injury (6.25 vs. 36.96%) and NEC (10.42 vs. 28.26%) (P < 0.05). Additionally, HHHFNC achieved a significant advance in the time to reach full enteral feeding (31.24 ± 11.35 vs. 34.21 ± 14.09 days); increased the average weight gain rate (16.07 ± 3.10 vs. 13.74 ± 4.21) and reduced the days of hospitalization (73.45 ± 18.84 vs. 79.24 ± 19.75), with a lower cost of hospitalization (16.04 ± 3.64 vs.18.79 ± 4.13) thousand dollars (all P < 0.05).Conclusions: Compared with NCPAP, HHHFNC was effective in preventing extubation failure in mechanically ventilated preterm ELBWI. HHHFNC shortens oxygen consumption time and significantly reduces the incidence of nasal injury and necrotizing enterocolitis; moreover, it can also reduce the length of stay and the hospitalization costs.

Effect of high flow nasal cannula treatment in children with respiratory distress at the general ward

Purpose: This study evaluated the clinical effects of heated humidified high flow nasal cannula (HHHFNC) treatment in pediatric pa tients with respiratory disease and respiratory insufficiency. Methods: We reviewed the medical records for clinical features and tests performed in patients admitted to Chungnam University Hospital pediatric ward and treated with HHHFNC between July 2014 and December 2018. We evaluated the effects of HHHFNC treatment in patients with bronchiolitis treated with oxygen using a nasal prong. Results: The 136 children were treated with HHHFNC during the study period, and their median age was 8 months. Among the 136 patients, 39 (28.7%) were diagnosed with bronchiolitis and pneumonia, 42 (30.9%) with pneumonia, 28 (20.6%) with bronchiolitis, and 3 (2.2%) with epilepsy. Thirty-five patients (25.7%) had underlying neurological disorders. Fifty-one (37.5%) received invasive ventilator treatment. After HHHFNC treatment, venous blood gas analysis showed a pH increase from 7.32 to 7.37 (P<0.05) and a decrease in partial pressure of carbon dioxide (pCO2) from 53.1 to 46.2 mmHg (P<0.05). The respiratory rate had decreased from 46.3 to 43.3/min (P<0.05). There were no statistically significant differences in hospital stay duration or intensive care unit admission rates between bronchiolitis patients receiving HHHFNC treatment and those not receiving. Conclusion: In this study, in various diseases leading to pediatric respiratory insufficiency, HHHFNC treatment may improve physio logic parameters at the pediatric ward. HHHFNC may also be effective in patients with underlying neurological disorders and those with respiratory insufficiency from nonrespiratory infectious disease. (Allergy Asthma Respir Dis 2020;8:73-79)

Short-Term High-Flow Nasal Cannula for Moderate to Severe Bronchiolitis Is Effective in a General Pediatric Ward.

We examined the clinical and physiological benefits of heated humidified high-flow nasal cannula (HHHFNC) in treating pediatric bronchiolitis in a general pediatric ward. Children aged 0 to 2 years, hospitalized with moderate to severe bronchiolitis, were connected to HHHFNC. Each child was evaluated at 4- to 10-hour intervals, both on and off the device, using the Wang et al Bronchiolitis Severity score and transcutaneous CO2 monitor. Sixteen children were included in the final analysis. The Bronchiolitis Severity score improved by 3 points during the first and second intervals (P = .001). Transcutaneous CO2 values were reduced by an average 8.7 mm Hg (P = .001). No adverse effects were noted in children connected to the device. The HHHFNC device used in a general pediatric ward setting served as a safe and efficacious tool in treating moderate to severe bronchiolitis. Immediate clinical and physiological improvement was observed and maintained 1 to 4 hours after disconnection from the device.

Comparison of the Heated Humidified High-flow Nasal Cannula with Nasal Continuous Positive Airway Pressure as Primary Respiratory Support for Preterm Neonates: A Prospective Observational Study

Background: Heated humidified high-flow nasal cannula (HHHFNC) is gaining popularity in the management of respiratory distress in preterm neonates. However, it is not known whether it takes precedence over the gold standard nasal continuous positive airway pressure (NCPAP) in this age group as a primary mode of non-invasive ventilation (NIV). There is limited evidence addressing this issue in the literature. Therefore, this study aimed to focus on the effect of HHHFNC on preterm neonates with respiratory distress, compared to NCPAP as a primary mode of respiratory support. Methods: A prospective observational study conducted in tertiary level III NICU. The preterm neonates 28-36 weeks with respiratory distress syndrome (onset of distress within ≤4 hours of life with FiO2 ≥0.25 with compatible chest radiograph) were managed with either HHHFNC or nCPAP The need for invasive ventilation within 72 hours of initiation of non-invasive respiratory support was studied. FiO2 and Downe’s scores were recorded every 4th hour for the first 48 hours. Results: In total, 84 neonates were enrolled in this study. Treatment failure for HHHFNC group was 34.4%, whereas it was 32.2% (P=0.34) for NCPAP group which indicated no significant differences. In the late preterm strata, NCPAP group obtained longer duration for NIV (Median: 64 vs 43 hours, respectively; P<0.001); however, there were no differences between the study groups regarding the use of supplemental oxygen. The estimation of the survival time was plotted using the Kaplan-Meier curve (P<0.001). In addition, the two groups were compared through Gehan–Breslow–Wilcoxon test. Moreover, the results revealed differences between the two groups in terms of the hazards ratio for time to success regarding such items as the intervention group, gestational age, birth weight, surfactant therapy, and Downe’s score (1.17; CI: 95% [0.7, 1.8]). Conclusion: Early HHHFNC obtained similar results, compared to NCPAP as a primary mode of NIV for a preterm population with respiratory distress, and it may not be superior to NCPAP.

How to use humidified high-flow nasal cannula in breathless adults in the emergency department.

Undifferentiated breathlessness is a common presenting symptom in the ED.1 Until recently, supplemental oxygen via a facemask has been the ‘one‐size fits all’ initial treatment; however, research shows us that hyperoxaemia may be detrimental in some clinical contexts.2 Attention has turned to oxygen‐sparing alternatives, and heated humidified high‐flow nasal cannula (HHFNC) with its attractive theoretical basis, has achieved acceptance and widespread use somewhat ahead of the supporting evidence. In the present paper, we combine currently available evidence with our own experience from adult HHFNC implementation, to provide simple instructions for intelligent use of HHFNC in the ED.

Diaphragm electromyography results at different high flow nasal cannula flow rates

Heated, humidified, high-flow nasal cannula (HHHFNC) is increasingly being used, but there is a paucity of evidence as to the optimum flow rates in prematurely born infants. We have determined the impact of three flow rates on the work of breathing (WOB) assessed by transcutaneous diaphragm electromyography (EMG) amplitude in infants with respiratory distress or bronchopulmonary dysplasia (BPD). Flow rates of 4, 6 and 8 L/min were delivered in random order. The mean amplitude of the EMG trace and mean area under the EMG curve (AEMGC) were calculated and the occurrence of bradycardias and desaturations recorded. Eighteen infants were studied with a median gestational age of 27.8 (range 23.9–33.5) weeks and postnatal age of 54 (range 3–122) days. The median flow rate prior to the study was 5 (range 3–8) L/min and the fraction of inspired oxygen (FiO2) was 0.29 (range 0.21–0.50). There were no significant differences between the mean amplitude of the diaphragm EMG and the AEGMC and the number of bradycardias or desaturations between the three flow rates.Conclusions: In infants with respiratory distress or BPD, there was no advantage of using high (8 L/min) compared with lower flow rates (4 or 6 L/min) during support by HHHFNC.What is known:• Humidified high flow nasal cannulae (HHHFNC) is increasingly being used as a non-invasive form of respiratory support for prematurely born infants.• There is a paucity of evidence regarding the optimum flow rate with 1 to 8 L/min being used.What is new:• We have assessed the work of breathing using the amplitude of the electromyogram of the diaphragm at three HHHFNC flow rates in infants with respiratory distress or BPD.• No significant differences were found in the EMG amplitude results or the numbers of bradycardias or desaturations at 4, 6 and 8 L/min.

Enteral Nutrition Tolerance And REspiratory Support (ENTARES) Study in preterm infants: study protocol for a randomized controlled trial

BackgroundRespiratory distress syndrome (RDS) and feeding intolerance are common conditions in preterm infants and among the major causes of neonatal mortality and morbidity.For many years, preterm infants with RDS have been treated with mechanical ventilation, increasing risks of acute lung injury and bronchopulmonary dysplasia.In recent years non-invasive ventilation techniques have been developed. Showing similar efficacy and risk of bronchopulmonary dysplasia, nasal continuous positive airway pressure (NCPAP) and heated humidified high-flow nasal cannula (HHHFNC) have become the most widespread techniques in neonatal intensive care units. However, their impact on nutrition, particularly on feeding tolerance and risk of complications, is still unknown in preterm infants.The aim of the study is to evaluate the impact of NCPAP vs HHHFNC on enteral feeding and to identify the most suitable technique for preterm infants with RDS.MethodsA multicenter randomized single-blind controlled trial was designed. All preterm infants with a gestational age of 25–29 weeks treated with NCPAP or HHHFNC for RDS and demonstrating stability for at least 48 h along with the compliance with inclusion criteria (age less than 7 days, need for non-invasive respiratory support, suitability to start enteral feeding) will be enrolled in the study and randomized to the NCPAP or HHHFNC arm. All patients will be monitored until discharge, and data will be analyzed according to an intention-to-treat model.The primary outcome is the time to reach full enteral feeding, while parameters of respiratory support, feeding tolerance, and overall health status will be evaluated as secondary outcomes. The sample size was calculated at 141 patients per arm.DiscussionThe identification of the most suitable technique (NCPAP vs HHHFNC) for preterm infants with feeding intolerance could reduce gastrointestinal complications, improve growth, and reduce hospital length of stay, thus improving clinical outcomes and reducing health costs. The evaluation of the timing of oral feeding could be useful in understanding the influence that these techniques could have on the development of sucking-swallow coordination. Moreover, the evaluation of the response to NCPAP and HHHFNC could clarify their efficacy as a treatment for RDS in extremely preterm infants.Trial registrationClinicalTrials.gov, NCT03548324. Registered on 7 June 2018.

Heated Humidified High Flow Nasal Cannula (HHHFNC) is not an effective method for initial treatment of Respiratory Distress Syndrome (RDS) versus nasal intermittent mandatory ventilation (NIMV) and nasal continuous positive airway pressure (NCPAP).

Background:Noninvasive respiratory support techniques are widely used to treat respiratory distress syndrome (RDS) in preterm infants, and the effectiveness of these methods should be compared. In the current study, nasal continuous positive airway pressure (NCPAP), nasal intermittent mandatory ventilation (NIMV), and heated humidified high-flow nasal cannula (HHHFNC) were compared.Materials and Methods:In the current bicenter clinical trial, 109 preterm infants with RDS not treated with surfactant were randomly assigned to three groups: NCPAP, NIMV, and HHHFNC. The initial outcomes including the failure of treatment within the first initial 72 h, and the duration of RDS treatment, and the secondary outcomes including the need for intubation, the need for surfactants, the duration of oxygen dependency, the incidence of pneumothorax, the patent ductus arteriosus, intraventricular hemorrhage, length of stay, and mortality were compared among the groups.Results:The frequency of HHHFNC treatment failure (54.3%) was significantly higher compared with those of NIMV (21.6%) (P < 0.001, hazard ratio [HR] = 9.12, 95% confidence interval [CI] = 2.59 – 32.07) and NCPAP (35.1%) (P = 0.004, HR = 21.25, 95% CI = 2.51–180.08). The median duration of RDS treatment was longer (40 h) in the HHHFNC group, although it was not significantly different from those of NIMV (31.16 h) and NCPAP (38.91 h).Conclusion:Based on the high prevalence of failure of HHHFNC treatment than the other two methods (NCPAP and NIMV), HHHFNC is not recommended as the initial treatment of RDS.

Comparison of efficacy of nasal continuous positive airway pressure and heated humidified high-flow nasal cannula as a primary mode of respiratory support in preterm infants

Background: Nasal continuous positive airway pressure (NCPAP) is a well-recognized mode of noninvasive respiratory support (NIV) for newborns with respiratory distress. Evidence for the heated humidified high-flow nasal cannula (HHHFNC) as an alternative mode of respiratory support is scarce. The aim of this work was to evaluate whether HHHFNC is equally efficacious to NCPAP as providing primary respiratory support in the first 6 h of life for preterm neonates with respiratory distress. Methods: Preterm infants (gestation 26–34 weeks) with respiratory distress were randomized to either HHHFNC or NCPAP. The primary outcomes of the study were inferred in terms of total duration of NIV support (in hours) and total duration of oxygen supplementation (NIV + oxyhood/oxygen by nasal prongs) required. The secondary outcomes measured and compared between the two study groups were total time taken to reach full feeds; incidence and severity of nasal trauma; incidence of air leaks, bronchopulmonary dysplasia, patent ductus arteriosus, and retinopathy of prematurity. Results: The mean duration of NIV support in NCPAP and HHHFNC group was 69.1 ± 37.75 and 67.57 ± 45.48 h, respectively (P = 0.867). The mean durations of total oxygen supplementation in NCPAP and HHHFNC groups were 96.88 ± 100 and 83.73 ± 107 h, respectively (P = 0.062). The failure rate was similar in both the study groups (P = 1.000). Conclusions: We conclude from the present study that HHHFNC is equally efficacious to NCPAP as a primary mode of respiratory support for respiratory distress in preterm infants.

Use of high-flow nasal cannula oxygen therapy in infants and children.

Heated, humidified high-flow nasal cannula (HHHFNC) therapy provides warmed, humidified oxygen to infants and children in respiratory distress at flow rates that deliver higher oxygen concentrations and some positive airway pressure compared with standard low-flow therapy. Increased use and experience is informing practice and establishing the benefits of HHHFNC use in a variety of clinical conditions. The focus of this practice point is to describe best practices for HHHFNC in (non- neonatal) paediatric patients with moderate-to-severe respiratory distress and to offer a safe, practical approach to oxygen delivery, and support.

Work of breathing during HHHFNC and synchronised NIPPV following extubation.

Our aim was to compare the work of breathing (WOB) during synchronised nasal intermittent positive pressure ventilation (SNIPPV) and heated humidified high flow nasal cannula (HHHFNC) when used as post-extubation support in preterm infants. A randomised crossover study was undertaken of nine infants with a median gestational age of 27 (range 24-31)weeks and post-natal age of 7 (range 2-50)days. Infants were randomised to either SNIPPV or HHHFNC immediately following extubation. They were studied for 2h on one mode and then switched to the other modality and studied for a further 2-h period. The work of breathing, assessed by measuring the pressure time product of the diaphragm (PTPdi), and thoracoabdominal asynchrony (TAA) were determined at the end of each 2-h period. The infants' inspired oxygen requirement, oxygen saturation, heart rate and respiratory rate were also recorded. The median PTPdi was lower on SNIPPV than on HHHFNC (232 (range 130-352) versus 365 (range 136-449) cmH2Os/min, p = 0.0077), and there was less thoracoabdominal asynchrony (13.4 (range 8.5-41.6) versus 36.1 (range 4.3-50.4) degrees, p = 0.038).Conclusion: In prematurely born infants, SNIPPV compared to HHHFNC post-extubation reduced the work of breathing and thoracoabdominal asynchrony. What is Known: • The work of breathing and extubation failure are not significantly different in prematurely-born infants supported by HHHFNC or nCPAP. • SNIPPV reduces inspiratory effort and increases tidal volume and carbon dioxide exchange compared to nCPAP in prematurely born infants. What is New: • SNIPPV, as compared to HHHFNC, reduced the work of breathing in prematurely-born infants studied post-extubation. • SNIPPV, as compared to HHHFNC, reduced thoracoabdominal asynchrony in prematurely born infants studied post-extubation.

Chronic lung disease in preterm infants receiving various modes of noninvasive ventilation at ≤30 weeks’ postmenstrual age

Objective: To determine the incidence of chronic lung disease (CLD) in mechanically ventilated infants who were born at <29 weeks’ gestational age (GA), extubated to continuous positive airway pressure (CPAP) or nasal intermittent positive pressure ventilation (NIPPV), and treated with CPAP/NIPPV alone, changed to heated humidified high flow nasal cannula (HHHFNC), or exposed to a combination of CPAP/NIPPV and HHHFNC at ≤30 weeks’ postmenstrual age (PMA).Study design: Retrospective cohort study of infants born at <29 weeks’ GA admitted to tertiary Canadian neonatal intensive care units between 2011 and 2015. Infants were grouped according to the type of noninvasive ventilation they received at ≤30 weeks’ PMA: CPAP/NIPPV alone, HHHFNC alone, or a combination of both.Results: Of the 2378 eligible infants, 1091 (46%) were on CPAP/NIPPV alone, 173 (7.3%) were on HHHFNC alone, and 1114 (47%) were on a combination of CPAP/NIPPV and HHHFNC at ≤30 weeks’ PMA until weaned to room air or low flow nasal cannula. After adjustment for confounders, infants in both the CPAP/NIPPV (odds ratio [95% confidence interval]; 2.37 [1.18, 4.79]) and Combination (3.47 [2.06, 5.86]) groups had higher odds of developing CLD than infants in the HHHFNC group.Conclusions: Our results demonstrate that infants transitioned to HHHFNC ≤30 weeks’ PMA after extubation to CPAP/NIPPV were associated with a lower odds of CLD than infants maintained on CPAP/NIPPV or a combination of CPAP/NIPPV and HHHFNC.

Heated Humidified High-Flow Nasal Cannula Versus Nasal Continuous Positive Airway Pressure for the Facilitation of Extubation in Preterm Neonates with Respiratory Distress

Background: Heated humidified high-flow nasal cannula (HHHFNC) is gaining popularity as an alternative to nasal continuous positive airway pressure (nCPAP) therapy in the management of preterm neonates with respiratory distress due to ease of administration and patient comfort. However, limited evidence is available addressing its risks and benefits. To study the efficacy and safety of HHHFNC in comparison to nCPAP for the facilitation of extubation in preterm neonates (born at 27-34 weeks of gestation) with respiratory distress.Methods: A prospective observational study was conducted, where 64 neonates were assigned either to nCPAP (n=34) or HHHFNC (n=30) groups post-extubation. The primary outcome was treatment failure (defined by pre-specified criteria) requiring a higher modality of respiratory support within 72 hours after extubation.Results: Treatment failure was seen in 36.7% of neonates assigned to the HHHFNC group compared to 14.7% in the nCPAP group (P=0.043). The incidence and severity of nasal trauma were higher in the nCPAP group compared to the HHHFNC group (nCPAP: 58.6% vs. HHHFNC: 15.7%; P=0.001). No significant difference was observed between the two groups in terms of other outcomes such as days on primary non-invasive ventilation (NIV), days of total NIV, duration of hospitalization, days to reach full enteral feeding, weight gain at discharge, incidence and severity of nasal trauma, incidence of pneumothorax, necrotizing enterocolitis, intraventricular hemorrhage, retinopathy of prematurity, sepsis, and death.Conclusion: Though a gentler modality with less incidence of nasal trauma, HHHFNC does not appear to be as effective as nCPAP in the management of preterms with respiratory distress.

To Compare the Efficacy of Heated Humidified High-Flow Nasal Cannula and Continuous Positive Airway Pressure in Post-Extubation Period in VLBW Infants

The objective of this study was to compare efficacy of continuous positive airway pressure (CPAP) and heated humidified high-flow nasal cannula (HHHFNC) as noninvasive respiratory support in post-extubation period in very low birth weight (VLBW) infants. This retrospective study enrolled 136 neonates, ≤32 weeks gestation and ≤1500 grams birth weight, requiring noninvasive respiratory support during post-extubation period. There was no significant difference in post-extubation failure in HHHFNC group when compared with CPAP group (p > 0.05) but post-extubation complication was significantly higher in CPAP group (p < 0.05) including nasal septal trauma and pneumothorax. In neonates ≤32 weeks of gestational age, HHHFNC showed similar efficacy, and better safety profile than nasal-CPAP when used during post-extubation period for respiratory support.

Heated humidified high-flow nasal cannula therapy in children

Heated humidified high-flow nasal cannula(HHFNC) is a relatively new noinvasive method for respiratory support, initially used in premature infant apnea.In recent years, the development of HHFNC applications is rapid, and HHFNC is gradually used in older infants and children.Compared to other noninvasive oxygen supply devices, HHFNC can be used effectively in clinic because of its high comfort, good tolerance, easy care, and reducing the rate of endotracheal intubation. Key words: Heated humidified high-flow nasal cannula; Children,

High-flow ventilation in newborn infants – what is the evidence?

Abstract Heated Humidified High Flow Nasal Cannula (HHHFNC) devices deliver an adjustable mixture of heated and humidified oxygen and air at a variable flow rate. Over recent years HHHFNC devices have become a popular method of non-invasive respiratory support in infants and preterm neonates due to ease of use and being well tolerated by infants. Recent evidence suggests that HHHFNC therapy may reduce work of breathing and improve the efficiency of ventilation in newborn infants, possibly with clinically significant outcomes such as avoidance of the need for nasal continuous positive airways pressure (nCPAP) and a reduced requirement for invasive ventilation. Despite its rapid adoption, there is relatively limited data about the exact mechanisms of action of HHHFNC. There is growing evidence of the feasibility of HHHFNC as an alternative to other forms of non-invasive ventilation in preterm infants. We review the mechanisms of action, and the supporting evidence in favour of using heated humidified high-flow nasal cannula therapy in newborn infants.

Heated, Humidified High-Flow Nasal Cannula vs Nasal Continuous Positive Airway Pressure for Respiratory Distress Syndrome of Prematurity: A Randomized Clinical Noninferiority Trial.

Heated, humidified high-flow nasal cannula (HHHFNC) has gained increasing popularity as respiratory support for newborn infants thanks to ease of use and improved patient comfort. However, its role as primary therapy for respiratory distress syndrome (RDS) of prematurity needs to be further elucidated by large, randomized clinical trials. To determine whether HHHFNC provides respiratory support noninferior to nasal continuous positive airway pressure (nCPAP) or bilevel nCPAP (BiPAP) as a primary approach to RDS in infants older than 28 weeks' gestational age (GA). An unblinded, monocentric, randomized clinical noninferiority trial at a tertiary neonatal intensive care unit. Inborn infants at 29 weeks 0 days to 36 weeks 6 days of GA were eligible if presenting with mild to moderate RDS requiring noninvasive respiratory support. Criteria for starting noninvasive respiratory support were a Silverman score of 5 or higher or a fraction of inspired oxygen higher than 0.3 for a target saturation of peripheral oxygen of 88% to 93%. Infants were ineligible if they had major congenital anomalies or severe RDS requiring early intubation. Infants were enrolled between January 5, 2012, and June 28, 2014. Randomization to either HHHFNC at 4 to 6 L/min or nCPAP/BiPAP at 4 to 6 cm H2O. Need for mechanical ventilation within 72 hours from the beginning of respiratory support. The absolute risk difference in the primary outcome and its 95% confidence interval were calculated to determine noninferiority (noninferiority margin, 10%). An intention-to-treat analysis was performed. A total of 316 infants were enrolled in the study: 158 in the HHHFNC group (mean [SD] GA, 33.1 [1.9] weeks; 52.5% female) and 158 in the nCPAP/BiPAP group (mean [SD] GA, 33.0 [2.1] weeks; 47.5% female). The use of HHHFNC was noninferior to nCPAP with regard to the primary outcome: failure occurred in 10.8% vs 9.5% of infants, respectively (95% CI of risk difference, -6.0% to 8.6% [within the noninferiority margin]; P = .71). Significant between-group differences in secondary outcomes were not found between the HHHFNC and nCPAP/BiPAP groups, including duration of respiratory support (median [interquartile range], 4.0 [2.0 to 6.0] vs 4.0 [2.0 to 7.0] days; 95% CI of difference in medians, -1.0 to 0.5; P = .45), need for surfactant (44.3% vs 46.2%; 95% CI of risk difference, -9.8 to 13.5; P = .73), air leaks (1.9% vs 2.5%; 95% CI of risk difference, -3.3 to 4.5; P = .70), and bronchopulmonary dysplasia (4.4% vs 5.1%; 95% CI of risk difference, -3.9 to 7.2; P = .79). In this study, HHHFNC showed efficacy and safety similar to those of nCPAP/BiPAP when applied as a primary approach to mild to moderate RDS in preterm infants older than 28 weeks' GA. clinicaltrials.gov Identifier: NCT02570217.

Heated Humidified High-Flow Nasal Cannula for Weaning from Continuous Positive Airway Pressure in Preterm Infants: A Randomized Controlled Trial

Background: Heated humidified high-flow nasal cannula (HHHFNC) therapy has been widely used in preterm infants. However, evidence to support its use as a continuous positive airway pressure (CPAP) weaning method is still controversial. Objectives: We aimed to compare time to wean directly off CPAP vs. weaning by using HHHFNC. Methods: Infants with a gestational age (GA) of <32 weeks who met the predefined criteria for weaning off CPAP, i.e. with a CPAP of ≤6 cm H₂O and a fraction of inspired oxygen (FiO₂) of ≤0.3 for at least 24 h, were randomly assigned to wean by using HHHFNC or wean directly from CPAP. In the HHHFNC group, flow rate was reduced by 1 liter/min every 24 h to 2-3 liters/min depending on body weight (i.e. < or ≥1,000 g), and then HHHFNC was discontinued. In the CPAP group, pressure was reduced by 1 cm H₂O every 24 h until stable on CPAP 4 cm H₂O and then discontinued. The primary outcome was the time it took to wean off the use of the CPAP or HHHFNC devices. Results: One-hundred and one infants were enrolled, 51 in the HHHFNC and 50 in the CPAP group. Both groups had similar demographics and respiratory conditions before enrollment. There was no difference in time to successfully wean between the 2 groups [median (IQR): 11 (4-21) days in the HHHFNC group vs. 11 (4-29) days in the CPAP group; p = 0.12]. There were no differences in morbidities or related complications. Infants in the HHHFNC group had significantly less nasal trauma (20 vs. 42%; p = 0.01). Conclusions: In our study, the time to wean off CPAP using HHHFNC was not different from when weaning directly from CPAP.