High-flow Nasal Cannula In Children Research Articles

Reducing Overutilization of High-flow Nasal Cannula in Children with Bronchiolitis.

Bronchiolitis is a leading cause of pediatric hospitalizations. A high-flow nasal cannula (HFNC) does not significantly improve clinical outcomes and is associated with increased costs and intensive care unit (ICU) utilization. Despite this, hospitals continue to overuse HFNC in children with bronchiolitis. We aimed to reduce HFNC initiation in children hospitalized with bronchiolitis by 20 percentage points within 6 months. This study included patients aged 1 month to 2 years diagnosed with bronchiolitis, excluding patients with prematurity less than 32 weeks or preexisting cardiopulmonary, genetic, congenital, or neuromuscular abnormalities. Measures included HFNC utilization, length of stay, length of oxygen supplementation (LOOS), ICU transfers, and emergency department (ED) revisits and readmissions. For our primary intervention, we implemented a HFNC initiation protocol incorporating a respiratory scoring system, a multidisciplinary care-team huddle, and an emphasis on supportive care. Staff education, electronic health record integration, and audit and feedback were used to support implementation. Statistical process control charts were used to track metrics. We analyzed 325 hospitalizations (126 baseline and 199 postintervention). The proportion of children hospitalized with bronchiolitis who received HFNC decreased from a mean of 82% to 60% within 1 month of implementation. Length of stay decreased from a median of 54 to 42 hours, and length of oxygen supplementation decreased from 50 to 38 hours. There were no significant changes in ICU transfers, 7-day ED revisits, or readmissions. Implementing a HFNC initiation protocol can safely reduce the overutilization of HFNC in children hospitalized with bronchiolitis.

Noninvasive Respiratory Support for Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference.

To develop evidence-based recommendations for the Second Pediatric Acute Lung Injury Consensus Conference (PALICC) regarding the effectiveness of noninvasive respiratory support for pediatric acute respiratory distress syndrome (PARDS). These include consideration of the timing and duration of noninvasive ventilation (NIV) and high-flow nasal cannula (HFNC), whether effectiveness varies by disease severity or by characteristics of treatment delivery, and best practices for the use of NIV. MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). Searches included all studies involving the use of NIV or HFNC in children with PARDS or hypoxemic respiratory failure. Title/abstract review, full-text review, and data extraction using a standardized data extraction form. The Grading of Recommendations Assessment, Development, and Evaluation approach was used to identify and summarize evidence and develop recommendations. Out of 6,336 studies, we identified 187 for full-text review. Four clinical recommendations were generated, related to indications, timing and duration of NIV in patients with PARDS, predictors of NIV failure and need for intubation (signs and symptoms of worsening disease including pulse oximetry saturation/Fio2 ratio), and use of NIV in resource-limited settings. Six good practice statements were generated related to how and where to deliver NIV, the importance of trained experienced staff and monitoring, types of NIV interfaces, the use of sedation, and the potential complications of this therapy. One research statement was generated related to indications of HFNC in patients with PARDS. NIV is a widely used modality for the treatment of respiratory failure in children and may be beneficial in a subset of patients with PARDS. However, there needs to be close monitoring for worsening disease and NIV failure.

Oral Feeding on High-Flow Nasal Cannula in Children Hospitalized With Bronchiolitis.

Oral feeding by children with bronchiolitis on high-flow nasal cannula (HFNC) is questioned, resulting in high practice variability. Our objective was to determine the incidence of aspiration pneumonia and adverse feeding events in otherwise healthy children with bronchiolitis on HFNC who fed orally from admission. We conducted a single-center, retrospective chart review, in a tertiary children's hospital, of 876 children who were <24 months old, admitted for bronchiolitis, and treated with HFNC in the pediatric ward from March 2017 to May 2020. Primary outcomes included the incidence of aspiration pneumonia and adverse feeding events. Secondary outcomes included escalation of care, frequency and duration of nil per os status, length of stay, and 7-day readmission. Most patients (77.2%) met inclusion criteria and were fed orally within 2 hours of admission. The average maximum HFNC flow rate was 8 L/min (1 L/kg/min); the average maximum respiratory rate was 62 ± 10. Adverse feeding events occurred in 11 patients (1.6%), of which 3 had a concern for possible microaspiration. None were diagnosed with or treated for aspiration pneumonia. Few patients (8.1%) were made nil per os while on HFNC but returned to oral feeding by discharge. Among those with bronchiolitis on HFNC who received oral nutrition on admission, there were few incidences of adverse feeding events and no diagnoses of aspiration pneumonia, suggesting that oral feeding while on HFNC can be well-tolerated in similar populations. However, this study was limited by its single-center retrospective design, and future prospective studies are needed.

Heated Humidified High-Flow Nasal Cannula in Children: State of the Art.

High-flow nasal cannula (HFNC) therapy is a non-invasive ventilatory support that has gained interest over the last ten years as a valid alternative to nasal continuous positive airway pressure (nCPAP) in children with respiratory failure. Its safety, availability, tolerability, and easy management have resulted its increasing usage, even outside intensive care units. Despite its wide use in daily clinical practice, there is still a lack of guidelines to standardize the use of HFNC. The aim of this review is to summarize current knowledge about the mechanisms of action, safety, clinical effects, and tolerance of HFNC in children, and to propose a clinical practices algorithm for children with respiratory failure.

Efficacy and safety analysis of high-flow nasal cannula in children with bronchiolitis: a systematic review and meta-analysis.

Oxygen therapy is one of the most common treatments for bronchiolitis, But traditional standard oxygen therapy is poorly tolerated by patients. Nasal continuous positive airway pressure (nCPAP) also has many contraindications. High-flow nasal cannula (HFNC), as a new method of adjunctive respiratory support, has received extensive attention in oxygen therapy in pediatric. In this meta-analysis, we evaluated the efficacy and safety of HFNC in the treatment of infant bronchiolitis. We searched PubMed, Web of Science, CNKI, GeenMedical, Wanfang, and Weipu using the following keywords: children with respiratory diseases, infant bronchiolitis, bronchiolitis treatment, HFNCs, warming and humidifying high-flow, nasal catheter oxygen inhalation, and conventional oxygen therapy. The publication time was set from the establishment of the database to October 2021. Selected articles were randomized controlled trial (RCT) studies in which the patients were less than 16 years old and the experimental group was treated with HFNCs, and the control group was treated with nCPAP or conventional oxygen. After extracting the data, the study subjects were divided into HFNC treatment and control groups. The Cochrane risk of bias tool was used to assess the quality of the included literature, and RevMan 5.30 was used for meta-analysis. Seven articles met the inclusion criteria. All articles described random sequence generation, four articles reported on allocation concealment, only two articles reported on the double-blind method. All articles described the complete blinding of outcome evaluation bias, outcome data bias, selective reporting bias, and other risk biases. The HFNC treatment group included 436 children, 405 children treated with nCPAP or standard oxygen therapy were included in the control. The results showed that the failure rate [relative risk (RR) is 0.57, 95% CI: 0.43-0.76], respiratory rate [mean difference (MD) is -7.43, 95% CI: -8.42 to -6.43], and social function (MD is 0.76, 95% CI: -0.32 to 1.83) of HFNC-treated children with bronchiolitis were significantly different to that of the control group patients. HFNC treatment provides the same improvement in arterial oxygen partial pressure as standard oxygen therapy or transnasal positive airway pressure treatment, but it is significantly better at improving the respiratory rate of children with bronchiolitis.

High-Flow Nasal Cannula Reduces Effort of Breathing But Not Consistently via Positive End-Expiratory Pressure

High-flow nasal cannula (HFNC) therapy reduces the effort of breathing in patients with bronchiolitis, but the mechanisms are not understood. Theorized mechanisms include dead space washout and positive end-expiratory pressure (PEEP) application. What are the mechanisms of action of HFNC therapy in patients with bronchiolitis? Prospective, single-center study of children 3 years of age or younger with bronchiolitis from January 2020 through March 2021. Flow was titrated between 0.5 and 2 L/kg/min. Electrical impedance tomography measured end-expiratory lung impedance (EELZ) change as an end-expiratory lung volume (EELV) change surrogate and change in tidal impedance difference (ΔZ) as a tidal volume (VT) surrogate. A subset showed manometry measuring esophageal pressure change (ΔPes; transpulmonary pressure surrogate) and pressure rate product (PRP; effort of breathing metric). We hypothesized that EELV and VT would not change and that effort would reduce via respiratory rate (not ΔPes). Measurements were reported as the difference from 0.5 L/kg/min. We studied 22 patients in total, 10 with esophageal manometry. Median EELZ increased by 0.36 arbitrary unit (AU), 2.42 AU, and 4.8 AU at 1 L/kg/min, 1.5 L/kg/min, and 2 L/kg/min (P= .01, 2 L/kg/min vs0.5 L/kg/min), which corresponded to a median increase in EELV of 1.8mL/kg between 0.5 and 2 L/kg/min. Seven patients showed an increase in EELZ of > 5 AU, 12 showed no change in EELZ (± 5 AU), and three showed a decrease in EELZ of > 5 AU. ΔZ (ie, VT) did not change from 0.5 L/kg/min to 2 L/kg/min (median change, 0.29 AU; P= .48). Median PRP decreased by 78cm H2O/min from 0.5 L/kg/min to 2 L/kg/min (P= .02), with all patients demonstrating a reduction in PRP, with a nonsignificant change in ΔPes (P= .68). Increasing HFNC in children with bronchiolitis reduces the effort of breathing, but no consistent increase occurs in end-expiratory lung volume and no significant change occurs in VT or transpulmonary pressure. This suggests that PEEP application is not the primary mechanism of action of HFNC in children with bronchiolitis.

Modified high-flow nasal cannula for children with respiratory distress.

Background High-flow nasal cannula (HFNC) is a noninvasive respiratory support that provides the optimum flow of an air-oxygen mixture. Several studies demonstrated its usefulness and good safety profile for treating pediatric respiratory distress patients. However, the cost of the commercial HFNC is high; therefore, the modified high-flow nasal cannula was developed.Purpose This study aimed to compare the effectiveness, safety, and nurses’ satisfaction of the modified system versus the standard commercial HFNC.Methods This prospective comparative study was performed in a tertiary care hospital. We recruited children aged 1 month to 5 years who developed acute respiratory distress and were admitted to the pediatric intensive care unit. Patients were assigned to 2 groups (modified vs. commercial). The effectiveness and safety assessments included vital signs, respiratory scores, intubation rate, adverse events, and nurses’ satisfaction.Results A total of 74 patients were treated with HFNC. Thirty-nine patients were assigned to the modified group, while the remaining 35 patients were in the commercial group. Intubation rate and adverse events did not differ significantly between the 2 groups. However, the commercial group had higher nurses’ satisfaction scores than the modified group.Conclusion Our findings suggest that our low-cost modified HFNC could be a useful respiratory support option for younger children with acute respiratory distress, especially in hospital settings with financial constraints.

The Effectiveness of Heated Humidified High-flow Nasal Cannula in Children with Severe Bacterial Pneumonia in the Emergency Department

The Effectiveness of Heated Humidified High-flow Nasal Cannula in Children with Severe Bacterial Pneumonia in the Emergency Department

High-flow nasal cannula for children not compliant with continuous positive airway pressure

ObjectivesContinuous positive airway pressure (CPAP) is an effective treatment of severe obstructive sleep apnea (OSA) but poor compliance is a major limitation. High-flow nasal cannula (HFNC) has been used as an alternative but data about efficacy and objective long-term compliance are scarce; this study aims to address this lack of data. Patients/methodsAll consecutive patients, aged 0–18 years, treated with CPAP for a severe OSA defined as an apnea–hypopnea index (AHI) > 10 events/h, and not compliant with home CPAP therapy, defined by a CPAP use of <2 h/night, after at least four weeks from CPAP initiation were considered eligible for the study. HFNC was started during an outpatient visit. Study outcomes were the objective compliance (number of hours use/night) after one month and the improvement of OSA on a respiratory polygraphy (RP) with HFNC. ResultsEight patients (two boys, mean age 8.9 ± 6.2 years, mean AHI 33 ± 22 events/h) were included in the study: Down syndrome (N = 6), Pierre Robin syndrome (N = 1), Pfeiffer syndrome (N = 1). After one month, five (62%) patients slept with HFNC more than 4 h/night (mean compliance 7 h 10 min ± 0 h 36 min/night). HFNC corrected OSA in the five compliant patients (mean AHI 2 ± 2 events/h with HFNC). HFNC was not accepted by the three oldest patients with Down syndrome. ConclusionA good compliance as well as a correction of OSA may be obtained with HFNC in selected children with OSA not compliant to CPAP. HFNC may be used as a rescue therapy for children not compliant with CPAP.

Outcomes of Children With Bronchiolitis Treated With High-Flow Nasal Cannula or Noninvasive Positive Pressure Ventilation.

Initial respiratory support with noninvasive positive pressure ventilation or high-flow nasal cannula may prevent the need for invasive mechanical ventilation in PICU patients with bronchiolitis. However, it is not clear whether the initial choice of respiratory support modality influences the need for subsequent invasive mechanical ventilation. The purpose of this study is to compare the rate of subsequent invasive mechanical ventilation after initial support with noninvasive positive pressure ventilation or high-flow nasal cannula in children with bronchiolitis. Analysis of the Virtual Pediatric Systems database. Ninety-two participating PICUs. Children less than 2 years old admitted to a participating PICU between 2009 and 2015 with a diagnosis of bronchiolitis who were prescribed high-flow nasal cannula or noninvasive positive pressure ventilation as the initial respiratory treatment modality. None. Subsequent receipt of invasive mechanical ventilation was the primary outcome. We identified 6,496 subjects with a median age 3.9 months (1.7-9.5 mo). Most (59.7%) were male, and 23.4% had an identified comorbidity. After initial support with noninvasive positive pressure ventilation or high-flow nasal cannula, 12.3% of patients subsequently received invasive mechanical ventilation. Invasive mechanical ventilation was more common in patients initially supported with noninvasive positive pressure ventilation compared with high-flow nasal cannula (20.1% vs 11.0%: p < 0.001). In a multivariate logistic regression model that adjusted for age, weight, race, viral etiology, presence of a comorbid diagnosis, and Pediatric Index of Mortality score, initial support with noninvasive positive pressure ventilation was associated with a higher odds of subsequent invasive mechanical ventilation compared with high-flow nasal cannula (odds ratio, 1.53; 95% CI, 1.24-1.88). In this large, multicenter database study of infants with acute bronchiolitis that received initial respiratory support with high-flow nasal cannula or noninvasive positive pressure ventilation, noninvasive positive pressure ventilation use was associated with higher rates of invasive mechanical ventilation, even after adjusting for demographics, comorbid condition, and severity of illness. A large, prospective, multicenter trial is needed to confirm these findings.

First-line treatment using high-flow nasal cannula for children with severe bronchiolitis: Applicability and risk factors for failure

BackgroundViral bronchiolitis is the leading cause of hospitalization in children during the first 12 months of life. There is evidence to support the use of noninvasive ventilation in bronchiolitis. A recent respiratory management of bronchiolitis is the use of high-flow nasal cannula (HFNC) therapy. The primary objective of this study was to evaluate the use of HFNC as the first-line treatment for children with severe bronchiolitis and the secondary objective was to identify factors for HFNC therapy failure. MethodsObservational prospective study in a pediatric intensive care unit (PICU), during two consecutive seasons (2013–2014 without recommendation and 2014–2015 with a study design suggesting HFNC as first-line treatment). The percentages of children treated with HFNC, nasal continuous or biphasic positive airway pressure (nCPAP/BiPAP) and invasive ventilation were compared. Associations between parameters recorded and HFCN therapy failure were established. ResultsThe percentage of patients treated with HFNC at admission was higher during the second season (90%, n=55/61) than the first season (34%, n=14/41) (p<0.0001). In bivariate analysis, heart rate, pH, and pCO2 were significantly associated with the occurrence of HFNC therapy failure in time-varying Cox regression models using all available values (i.e., admission and repeated measures during the first 5 days of hospitalization). Only pCO2 remained independently associated as a factor of HFNC failure in the multivariate Cox model with a hazard ratio per 5mmHg of 1.37 (95%CI: 1.01–1.87; P=0.046). ConclusionIn our PICU, HFNC therapy for children with bronchiolitis can potentially decrease the use of nCPAP. In this study, the factor of failure was higher pCO2. Studies to evaluate PCO2 level to discriminate HFNC versus CPAP indication could be useful.

High-flow nasal cannula versus conventional oxygen therapy in children with respiratory distress

Purpose:The aim of this study is to determine the clinical efficacy of high-flow nasal cannula (HFNC) therapy compared with conventional oxygen therapy in children presented with respiratory distress.Study Design:This was a randomized controlled study.Materials and Methods:Infants and children aged between 1 month to 5 years who were admitted to our tertiary referral center for respiratory distress (July 1, 2014 to March 31, 2015) and met the inclusion criteria were recruited.Interventions:Infants and children hospitalized with respiratory distress were randomized into two groups of interventions. All clinical data, for example, respiratory score, pulse rate, and respiratory rate were recorded. The results were subsequently analyzed.Results:A total of 98 respiratory distress children were enrolled during the study period. Only 4 children (8.2%) failed in HFNC therapy, compared with 10 children (20.4%) in conventional oxygen therapy group (P = 0.09). After adjusted for body weight, underlying diseases, and respiratory distress score, there was an 85% reduction in the odds of treatment failure in HFNC therapy group (adjusted odds ratio 0.15, 95% confidence interval 0.03–0.66, P = 0.01). Most children in HFNC therapy group had significant improvement in clinical respiratory score, heart rate, and respiratory rate at 240, 360, and 120 min compared with conventional oxygen therapy (P = 0.03, 0.04, and 0.03).Conclusion:HFNC therapy revealed a potential clinical advantage in management children hospitalized with respiratory distress compared with conventional respiratory therapy. The early use of HFNC in children with moderate-to-severe respiratory distress may prevent endotracheal tube intubation.Trial Register:TCTR 20170222007.