Heated Humidified High-flow Nasal Cannula Research Articles

The clinical effectiveness and cost-effectiveness of heated humidified high-flow nasal cannula compared with usual care for preterm infants: systematic review and economic evaluation.

Respiratory problems are one of the most common causes of morbidity in preterm infants and may be treated with several modalities for respiratory support such as nasal continuous positive airway pressure (NCPAP) or nasal intermittent positive-pressure ventilation. The heated humidified high-flow nasal cannula (HHHFNC) is gaining popularity in clinical practice. To address the clinical effectiveness of HHHFNC compared with usual care for preterm infants we systematically reviewed the evidence of HHHFNC with usual care following ventilation (the primary analysis) and with no prior ventilation (the secondary analysis). The primary outcome was treatment failure defined as the need for reintubation (primary analysis) or intubation (secondary analysis). We also aimed to assess the cost-effectiveness of HHHFNC compared with usual care if evidence permitted. The following databases were searched: MEDLINE (2000 to 12 January 2015), EMBASE (2000 to 12 January 2015), The Cochrane Library (issue 1, 2015), ISI Web of Science (2000 to 12 January 2015), PubMed (1 March 2014 to 12 January 2015) and seven trial and research registers. Bibliographies of retrieved citations were also examined. Two reviewers independently screened all titles and abstracts to identify potentially relevant studies for inclusion in the review. Full-text copies were assessed independently. Data were extracted and assessed for risk of bias. Summary statistics were extracted for each outcome and, when possible, data were pooled. A meta-analysis was only conducted for the primary analysis, using fixed-effects models. An economic evaluation was planned. Clinical evidence was derived from seven randomised controlled trials (RCTs): four RCTs for the primary analysis and three RCTs for the secondary analysis. Meta-analysis found that only for nasal trauma leading to a change of treatment was there a statistically significant difference, favouring HHHFNC over NCPAP [risk ratio (RR) 0.21, 95% confidence interval (CI) 0.10 to 0.42]. For the following outcomes, there were no statistically significant differences between arms: treatment failure (reintubation < 7 days; RR 0.76, 95% CI 0.54 to 1.09), bronchopulmonary dysplasia (RR 0.92, 95% CI 0.72 to 1.17), death (RR 0.56, 95% CI 0.22 to 1.44), pneumothorax (RR 0.33, 95% CI 0.03 to 3.12), intraventricular haemorrhage (grade ≥ 3; RR 0.41, 95% CI 0.15 to 1.15), necrotising enterocolitis (RR 0.41, 95% CI 0.15 to 1.14), apnoea (RR 1.08, 95% CI 0.74 to 1.57) and acidosis (RR 1.16, 95% CI 0.38 to 3.58). With no evidence to support the superiority of HHHFNC over NCPAP, a cost-minimisation analysis was undertaken, the results suggesting HHHFNC to be less costly than NCPAP. However, this finding is sensitive to the lifespan of equipment and the cost differential of consumables. There is a lack of published RCTs of relatively large-sized populations comparing HHHFNC with usual care; this is particularly true for preterm infants who had received no prior ventilation. There is a lack of convincing evidence suggesting that HHHFNC is superior or inferior to usual care, in particular NCPAP. There is also uncertainty regarding whether or not HHHFNC can be considered cost-effective. Further evidence comparing HHHFNC with usual care is required. This review is registered as PROSPERO CRD42015015978. The National Institute for Health Research Health Technology Assessment programme.

Work of breathing during CPAP and heated humidified high-flow nasal cannula

ObjectiveTo determine whether continuous positive airway pressure (CPAP) compared with heated humidified, high-flow nasal cannula (HHFNC) in infants with evolving or established bronchopulmonary dysplasia (BPD) reduced the work of breathing...

Randomized controlled trial to compare sleep and wake in preterm infants less than 32 weeks of gestation receiving two different modes of non-invasive respiratory support

AimTo determine whether respiratory support via heated humidified high flow nasal cannulae (HHHFNC) results in infants <32weeks gestation spending a greater proportion of time in sleep compared to those receiving nasal continuous positive airway pressure (NCPAP). MethodsA subgroup of infants enrolled in a randomized controlled trial to compare HHHFNC or NCPAP post-extubation had sleep and wake activity measured by actigraphy for 72hours post-extubation. Activity diaries were completed contemporaneously to record episodes of infant handling. Actigraphy data were downloaded with known periods of handling excluded from the analysis. Results28 infants with mean gestation of 28.3weeks (SD 2) and birth weight 1074g (SD 371) were studied. Infants receiving HHHFNC spent a lesser proportion of time in sleep 59.8% (SD 18.5) than those on NCPAP 82.2% (SD 23.8) p=0.004. Infants receiving HHHFNC had a lower sleep efficiency and higher mean activity score than those on NCPAP (p=0.003, p=0.002, respectively). ConclusionInfants receiving HHHFNC had a higher mean activity score and spent less time in sleep than those allocated NCPAP. Further study of sleep wake activity in preterm infants receiving respiratory support is required as this may impact on neurodevelopmental outcomes.

Nurses' experiences by using heated humidified high flow cannula to premature infants versus nasal continuous positive airway pressure

BackgroundSome premature infants are now being treated with heated humidified high flow nasal cannula (HHHFNC) instead of nasal continuous positive airway pressure (nCPAP). PurposeTo explore nurses' experiences of using HHHFNC compared with nCPAP for premature infants. MethodSix qualitative in-depth interviews were completed with nurses at two different newborn intensive care units. ResultsPreterm infants showed greater satisfaction with HHHFNC than nasal continuous positive airway pressure. HHHFNC was also associated with fewer pressure injuries and less facial discomfort, and an increased bonding between baby and parent. However, HHHFNC gave less ventilation support than nCPAP. ConclusionWhenever clinically possible, premature infants should be placed on HHHFNC because, compared to nCPAP, it results in less pressure related injuries, provides the most comfort and allows increased interaction between the parents and infant.

G391(P) Use of non-invasive respiratory support in bronchiolitis: a national survey

Aims Bronchiolitis accounts for a significant proportion of hospital and intensive care admissions in children aged 1,2 Nasal continuous positive airway pressure (nCPAP) has been used traditionally as first-line respiratory support modality. Heated-humidified High Flow Nasal Cannula (HFNC) therapy is rapidly gaining popularity as an alternate mode of non-invasive respiratory support due to its ease of use. This is despite lack of clinical trial evidence to support its use in bronchiolitis. 3 We aimed to establish current practice relating to HFNC and CPAP use in the United Kingdom (UK). Methods We devised an on-line survey (Survey Monkey, USA) and disseminated the link through regional retrieval services to hospitals with paediatric inpatient facilities. Responses were requested from one senior nurse and doctor from each hospital. The questionnaire covered: hospital characteristics, clinical indications for use of CPAP and/or HFNC in bronchiolitis, and willingness to participate in future research. Denominator data (number of UK hospitals with inpatient services) was obtained from the RCPCH 2013 census. Results Five regional retrieval services distributed the survey to their local hospitals, covering 109 of 191 hospitals in the UK with inpatient paediatric services. 156 respondents from 102 individual hospitals provided information (response rate: 94%). Of the 102 hospitals, 23 had a dedicated paediatric intensive care unit, 38 a dedicated paediatric high dependency unit (PHDU), 50 had dedicated PHDU beds on general paediatric wards. 30% have no PHDU provision. 95 (93%) units can deliver nCPAP to children with bronchiolitis and 73 (71%) can deliver HFNC. The main indications for HFNC use: as an alternative to nCPAP (69%), escalation of therapy from low flow oxygen (74%), and weaning from nCPAP (57%). The majority (71%) would choose HFNC over nCPAP in a deteriorating child with bronchiolitis; despite this, 76% were prepared to randomise infants between nCPAP and HFNC in a clinical trial. Conclusions Use of HFNC is common across UK hospitals. Despite this, survey responses support clinical equipoise amongst the majority of clinicians, indicating the feasibility of a trial of nCPAP and HFNC at this time. References Nagakumar P, Doull I. Current therapy for bronchiolitis. Arch Dis Child. 2012;97(9):827–830 Paediatric Intensive Care Audit Network, 2013 Annual Report. Accessed June 2012 Beggs S, Wong ZH, Kaul S, Ogden KJ, Walters JA. High flow nasal canula therapy for infants with bronchiolitis. Cochrane Database Syst Rev 2014:CD009609

Hydrocolloid to prevent breakdown of nares in preterm infants.

To determine if a double-barrier hydrocolloid dressing prevents trauma to the nares and columella in very low birthweight (VLBW) infants (<1,500 grams) receiving heated humidified high-flow nasal cannula (HHHFNC) oxygen. Retrospective two-group comparative study design. Medical records (N = 53) of VLBW infants receiving HHHFNC were reviewed. Control infants (n = 27) did not have a double-barrier hydrocolloid dressing. Intervention infants (n = 26) had a double-barrier hydrocolloid dressing. Groups were similar on sex, race, birthweight, and gestational age. Control infants were significantly older than intervention infants at study entry (4.3 weeks and 1.5 weeks, respectively, p = .001). Skin condition of nares was scored daily ranging from 3 (no breakdown) to 9 (extensive breakdown). Skin scores were abstracted from medical records at baseline then weekly for comparison over time. There were no significant differences in skin scores between groups or over time. Week 1 mean skin score was 3.4 (±0.1) in both groups. Mean skin score at week 4 was 3.4 (±0.1) in Control infants and 3.1 (±0.08) in Intervention infants. HHHFNC is more frequently being used in infants of extreme prematurity. The dressing may have protected the more immature skin of the intervention infants; however, vigilant nursing observation of the infants' nares during HHHFNC cannot be ruled out. Nurses need adequate education on the consistent application of the hydrocolloid barrier and on documenting skin assessment scores each shift to promote skin protection in this vulnerable population.

Respiratory mechanics during NCPAP and HHHFNC at equal distending pressures

ObjectiveTo compare the effect of heated, humidified, high-flow nasal cannula (HHHFNC) and nasal continuous positive airways pressure (NCPAP) on lung function and mechanics in preterm infants with respiratory distress syndrome...

A randomized pilot study comparing heated humidified high‐flow nasal cannulae with NIPPV for RDS

To compare the requirement for endotracheal ventilation in preterm infants treated with heated, humidified high-flow nasal cannula (HHHFNC) with those treated with nasal intermittent positive pressure ventilation (NIPPV) for the primary treatment of respiratory distress syndrome (RDS). Randomized, controlled, prospective, single-center pilot study. Infants (gestational age [GA] <35 weeks, birth weight [BW] >1,000 g) with RDS were randomly assigned to receive HHHFNC (38 infants) delivered by Vapotherm® device (Precision Flow™ or 2000 i, Vapotherm Inc., Stevensville, MD), at flows between 1.0 and 5.0 L/min, or NIPPV (38 infants) delivered by the SLE 2000 or 5000. Surfactant was administered as rescue therapy. Analysis was done by intention-to-treat. Infant's characteristics ([mean ± SD] GA 31.8 ± 2.3 vs. 32.0 ± 2.3 weeks) and cardio-respiratory status at study entry (FiO2 0.25 ± 0.05 vs. 0.26 ± 0.07; SpO2 90 ± 6% vs. 87 ± 12; PCO2 54.4 ± 10.4 vs. 52.6 ± 8.0 mmHg) were comparable for the HHHFNC and NIPPV groups. There was no significant difference in the need for endotracheal ventilation (28.9% vs. 34.2%) between HHHFNC and NIPPV groups. One infant failed HHHFNC and succeeded on NIPPV. The rate of neonatal morbidities (pneumothorax, bronchopulmonary dysplasia, intra-ventricular hemorrhage, necrotizing enterocolitis, patent ductus arteriosus, and nasal trauma) was comparable in both groups. Duration of nasal support was longer with HHHFNC compared with NIPPV (5.4 ± 4.0 vs. 2.6 ± 1.9 days, P = 0.006) but the duration of endotracheal ventilation, time to full feeds, and length of stay were comparable. Our pilot study suggests that HHHFNC maybe as effective as NIPPV in preventing endotracheal ventilation in the primary treatment of RDS in premature infants (<35 weeks GA and BW >1,000 g).

High flow therapy versus hypertonic saline in bronchiolitis: randomised controlled trial

ObjectiveTo demonstrate that heated humidified high-flow nasal cannula (HHHFNC) is superior to inhaled hypertonic saline solution (HSS) in improving respiratory distress in moderate bronchiolitis. In addition, it could improve comfort...

A comparison of two interventions for HHHFNC in preterm infants weighing 1,000 to 1,500 g in the recovery period of newborn RDS.

Background:Nasal cannula, beside administering low-flow therapy, showed the capability for the administration of continuous positive airway pressure (CPAP) through high-flow nasal cannula (HFNC). Meeting specific physical criteria of 100% relative humidity (RH) and temperature of 37°C are the basic interventional requirements to administer oxygen for the newborns through a nasal cannula. Recently, two systems, MR850 and PMH7000, received the Food and Drug Administration (FDA) approval to administer heated, humidified HFNC (HHHFNC). These systems are evaluated in this study based on their humidifying and heating capabilities.Materials and Methods:This study was done as an RCT on newborns weighing 1,000 to 1,500 g recovering from respiratory distress syndrome (RDS) while nCPAP was administered at CDP = 4 cmH2O, Fio2 <30%. Patients were randomized to two groups of 35 receiving HHHFNC after treatment with nCPAP, with one group using MR850 humidifier and the other PMH7000. The patients were compared according to the duration of HHHFNC administration, repeated need for nCPAP respiratory support, the need for invasive ventilation, apnea, chronic lung disease (CLD), nasal trauma, RH, and temperature of the gases.Results:The average time of support with HHHNFC did not show any significant difference in the two groups. There was no significant difference between the groups in the need for nCPAP, invasive ventilation, apnea, nasal trauma, and CLD. The difference in the levels of average temperature and humidity was significant (P value <0.001).Conclusion:Although the records of temperature and RH in the PMH7000 system was lower than the records from the MR850 system, no clinical priority was observed for respiratory support with HHHNFC in the two systems.

Patient comfort during treatment with heated humidified high flow nasal cannulae versus nasal continuous positive airway pressure: a randomised cross-over trial

ObjectiveTo compare patient comfort in preterm infants treated with heated humidified high flow nasal cannulae (HHHFNC) versus nasal continuous positive airway pressure (NCPAP).DesignRandomised cross-over trial (2×24 h).SettingSingle tertiary neonatal unit.Patients20...

A comparison of nasal trauma in preterm infants extubated to either heated humidified high-flow nasal cannulae or nasal continuous positive airway pressure

The objectives of this study were (1) to devise a nasal trauma score for preterm infants receiving non-invasive respiratory support, (2) to compare the incidence of nasal trauma in preterm infants <32 weeks gestation randomised to either nasal continuous positive airway pressure (NCPAP) or heated humidified high-Flow nasal cannulae (HHHFNC), in the first 7 days post-extubation and (3) to assess the effect of two different nasal dressings in those assigned to NCPAP. We randomly assigned preterm ventilated infants to receive Vapotherm® HHHFNC or NCPAP post-extubation. Infants receiving HHHFNC were treated with Sticky Whiskers® and infants receiving NCPAP received either Sticky Whiskers® or Cannualaide® nasal dressings. Bedside nursing staff scored six sites on each infant's nose for erythema, bleeding or ulceration. Scores were recorded three times daily for the first 7 days post-extubation. The sum of these 21 scores was used as the summary measure of nasal trauma. The mean nasal trauma score for infants assigned HHHFNC was 2.8 (SD 5.7) compared to 11.7 for NCPAP (SD 10.4), p < 0.001. There was no difference in mean trauma score between infants on NCPAP assigned Sticky Whiskers® 14.4 (SD 12.5) or Cannualaide® 9.5 (SD 7.3), p = 0.06. HHHFNC resulted in significantly less nasal trauma in the first 7 days post-extubation than NCPAP and was most significant in infants <28 weeks of gestation. The use of protective dressings was not associated with decreased nasal trauma for infants on NCPAP.

Heated humidified high-flow nasal cannula versus low-flow nasal cannula as weaning mode from nasal CPAP in infants ≤28 weeks of gestation

Despite the paucity of evidence, the practice of weaning nasal continuous positive airway pressure (NCPAP) is widespread. However, the most clinically effective non-invasive ventilatory support strategy remains to be determined. We compared the outcome of very premature infants with respiratory distress syndrome treated with a combination of NCPAP and heated humidified high-flow nasal cannula (HHFNC) versus NCPAP and low-flow nasal cannula (LFNC). Between 2004 and 2008, patients ≤28 weeks of gestation and <1,250 g of birth weight were treated with NCPAP + HHFNC or NCPAP + LFNC. Their respiratory and non-respiratory outcome including cost-effectiveness was compared after matching for antenatal steroid doses, mode of delivery, birth plurality, gestational age, birth weight, gender, surfactant doses, length of mechanical ventilation and clinical risk index for babies-II (CRIB-II) score. Thirty-nine infants received HHFNC + NCPAP, and 40 received NCPAP + LFNC. Median gestational age and birth weight were 27 weeks and 930 g and 27 weeks and 980 g, respectively. The total number of NCPAP days was significantly reduced by 50 % in the HHFNC group. Thirteen percent of the patients on NCPAP suffered from nasal bridge lesions compared to none on HHFNC. Respiratory and non-respiratory outcome was not significantly different otherwise. Combination of NCPAP and HHFNC reduced costs by 33 %. HHFNC shortens NCPAP time without increasing overall length of non-invasive respiratory support in very preterm infants. Unlike NCPAP, HHFNC does not seem to increase the risk of nasal trauma and appears to improve cost-effectiveness whilst producing otherwise equal respiratory and non-respiratory outcomes.

Clinical effect analysis on 66 cases of neonatal hyaline membrane disease treated by heated humidified high-flow nasal cannula

Objective To explore the clinical effects of heated humidified high-flow nasal cannula (HHFNC) in treating neonatal hyaline membrane disease (NHMD).Methods 66 infants were diagnosed as mild NHMD according clinical findings and chest X-ray.HHFNC was used after building diagnosis.We adjusted HHFNC parameter according patients' arterial blood gas.Results 59 of 66 patients were fully recovered using HHFNC treatment.7 patients were incubated and used mechanical ventilation.Conclusion HHFNC is an available and effective treatment method for mild NHMD and provide respiratory support,and can improve hyoxemia symptoms. Key words: Heated humidified high-flow nasal cannula (HHFNC); Neonatal hyaline membrane disease (NHMD); Noninvasive ventilation

Comparison of the pharyngeal pressure provided by two heated, humidified high‐flow nasal cannulae devices in premature infants

This study aims to determine if there is a difference in the pharyngeal pressure, measured as a surrogate for continuous positive distending airway pressure, delivered to premature infants between two commonly used heated, humidified high-flow nasal cannulae (HHHFNC) devices: Fisher & Paykel Healthcare HHHFNC and Vapotherm 2000i. Pharyngeal pressure measurements were taken from stable premature infants receiving HHHFNC for respiratory support. Flow rates of 2-8 L/min were studied. Nine infants had pharyngeal pressure measurements recorded with both HHHFNC devices at flow rates of 2-8 L/min. There was no difference in pharyngeal pressures recorded between devices at flow rates of 2-6 L/min; measured pressure was linearly associated with flow (R(2) = 0.9). At flow rates of 7 L/min, Vapotherm delivered a mean (standard deviation) pharyngeal pressure of 4.7 (2.2) cmH2 O compared with 4.23 (2.2) cmH2 O by the Fisher & Paykel device (P = 0.04). At a flow of 8 L/min, the mean pharyngeal pressure via Vapotherm was 4.9 (2.2) cmH2 O compared with 4.1 (2.3) cmH2 O with the Fisher & Paykel device (P = 0.05). Both HHHFNC delivered similar pharyngeal pressures at flow rates of 2-6 L/min. The pressure limiter valve of the Fisher & Paykel device attenuated the pharyngeal pressures at flows of 7 and 8 L/min. Vapotherm trended towards higher delivered pharyngeal pressure at flow rates 7 and 8 L/min, but the clinical significance of the difference remains unclear.

Heated, Humidified High-Flow Nasal Cannula Versus Nasal CPAP for Respiratory Support in Neonates

Heated, humidified high-flow nasal cannula (HHHFNC) is commonly used as a noninvasive mode of respiratory support in the NICU. The safety and efficacy of HHHFNC have not been compared with other modes of noninvasive support in large randomized trials. The objective was to assess the efficacy and safety of HHHFNC compared with nasal continuous positive airway pressure (nCPAP) for noninvasive respiratory support in the NICU. Randomized, controlled, unblinded noncrossover trial in 432 infants ranging from 28 to 42 weeks' gestational age with planned nCPAP support, as either primary therapy or postextubation. The primary outcome was defined as a need for intubation within 72 hours of applied noninvasive therapy. There was no difference in early failure for HHHFNC (23/212 [10.8%]) versus nCPAP (18/220 [8.2%]; P = .344), subsequent need for any intubation (32/212 [15.1%] vs 25/220 [11.4%]; P = .252), or in any of several adverse outcomes analyzed, including air leak. HHHFNC infants remained on the study mode significantly longer than nCPAP infants (median: 4 vs 2 days, respectively; P < .01), but there were no differences between study groups for days on supplemental oxygen (median: 10 vs 8 days), bronchopulmonary dysplasia (20% vs 16%), or discharge from the hospital on oxygen (19% vs 18%). Among infants ≥28 weeks' gestational age, HHHFNC appears to have similar efficacy and safety to nCPAP when applied immediately postextubation or early as initial noninvasive support for respiratory dysfunction.

A Randomized Controlled Trial to Compare Heated Humidified High-Flow Nasal Cannulae with Nasal Continuous Positive Airway Pressure Postextubation in Premature Infants

To determine whether postextubation respiratory support via heated, humidified, high-flow nasal cannulae (HHHFNC) results in a greater proportion of infants younger than 32 weeks' gestation being successfully extubated after a period of endotracheal positive pressure ventilation compared with conventional nasal continuous positive airway pressure (NCPAP). We randomly assigned preterm ventilated infants to Vapotherm HHHFNC or NCPAP after extubation. The primary outcome, extubation failure, was defined by prespecified failure criteria in the 7 days after extubation. A total of 132 ventilated infants younger than 32 weeks' gestation were randomized to receive either HHHFNC (n = 67) or NCPAP (n = 65). Extubation failure occurred in 15 (22%) of the HHHFNC group compared with 22 (34%) of the NCPAP group. There was no difference in the number of infants reintubated in the first week. Treatment with HHHFNC reduced the nasal trauma score 3.1 (SD 7.2) versus NCPAP 11.8 (SD 10.7), P < .001. HHHFNC and NCPAP produced similar rates of extubation failure.

Use of heated humidified high‐flow nasal cannula oxygen in neonates: a UK wide survey

Heated humidified high-flow nasal cannula (HHHFNC) oxygen is a relatively new form of respiratory support and is increasing in popularity despite lack of supportive evidence and amid safety concerns. We investigated the prevalence of its use in tertiary neonatal units in the UK. Electronic survey. A total of 57 units were contacted and replies received from 44 (77%). HHHFNC was used in 34/44 (77%) units. Vapotherm 2000i and Fisher and Paykel RT329 were the most popular devices. 39% units used HHHFNC without policies. Most reported use in infants of any gestation (24/34, 71%) and weight (26/34, 77%) and for a variety of indications including as an alternative to CPAP (26/34, 77%), weaning off CPAP (24/34, 71%) and postextubation (18/34, 53%). The flow rates, cannula size and mouth position varied widely. The popularity of HHHFNC appeared to be its perceived ease of use and improved access to the baby. This survey demonstrates that HHHFNC is a widely used modality in UK neonatal units. Its current use appears to be without clear criteria and mostly based on individual preference. In view of doubts about its efficacy and concerns regarding safety, this study highlights the urgent need for research to evaluate its use in newborns.

The use of high flow nasal cannulae in neonatal intensive care units: Is clinical practice consistent with the evidence?

Background: In the recent years, a new treatment modality, high-flow nasa l cannulae (HFNC) has become widely used despite limited systematic evaluation. Objective: To survey the attitudes and practices in academic neonatal units in the United States regarding the use of HFNC and to review the current literature on HFNC. Methods: A questionnaire regarding HFNC use was distributed to all (n = 97) Neonatal-Perinatal Medicine Fellowship Training Program Directors in the United States. Results: Fifty eight (60%) program directors responded to the questionnaire. Of these 40 (69%) reported using heated humidified HFNC (HHHFNC) and 18 (31%) not using this modality. Reported starting flows ranged from 1 to 6 L/min and maximal flows from 2 to 8 L/min. The indication for use of HHHFNC varied between units. Conclusions: The findings of our survey and our review of the literature sug gest that the use of HHHFNC is widespread despite lack of evidence of efficacy from large clinical trials. The i ndications for HHHFNC and the initial, minimal and maximal fl ows varied widely among the centers. This report supports the need for well designed randomized controlled clinical trials to evaluate the efficacy and safety of HHHFNC for a variety of clinical ind ications.

High flow nasal cannula therapy as respiratory support in the preterm infant

We reviewed the literature on the effects of high flow nasal cannula (HFNC) and heated, humidified, high-flow, nasal cannula (HHHFNC) treatment in preterm infants. We found nine studies, but only two were randomized controlled trials. These studies show that: HFNC application is associated to the delivery of continuous distending pressure (CDP) in patients with closed mouth, whose value is proportional to the delivered flow only in smaller infants; the CDP delivered by HFNC is unpredictable and present large inter-patient and intra-patient variability; the use of recently available HHHFNC devices is effective in minimizing nasal mucosa injuries compared to traditional HFNC; the effectiveness of HHHFNC versus NCPAP for the treatment of apnoea of prematurity, respiratory distress syndrome, and the prevention of extubation failure, has been poor investigated and firm conclusions cannot be drawn on this matter. In conclusion, on the basis of published data, the routinary application of HFNC should be limited to patients requiring oxygen-therapy, HHHFNC devices should be preferred to HFNC, but their employment as an alternative to NCPAP should wait for the conclusion of randomized controlled trials.