Humidified High Flow Nasal Cannula Research Articles

Heated humidified high-flow nasal cannula: a new conservative approach for neonatal nasal stenosis.

The aim of this study is to evaluate the efficacy of heated humidified high flow nasal cannula (HFNC) therapy as a conservative treatment option for newborns suffering from nasal stenosis, a condition that often leads to respiratory distress and feeding difficulties. Given the increasing utilization of HFNC in various upper and lower respiratory tract indications, characterized by its flow-based mechanism and minimal mucosal damage, we seek to investigate its potential benefits in this specific patient population. A retrospective chart review of newborns with congenital nasal stenosis treated with HFNC for respiratory distress or feeding difficulties in a pediatric tertiary center between 2014 and 2022. Data were collected for demographic characteristics, clinical presentation and ventilatory requirements, pre and post HFNC application. Six infants with nasal stenosis were included in the study cohort. Five were diagnosed with congenital pyriform aperture stenosis, three of whom had additional midnasal stenosis. One patient had nasal synechiae. Two patients had failed surgical treatment and all patients failed conservative treatment prior to HFNC treatment. Following HFNC use, improvement was noted in oxygen saturations, heart and respiratory rates, meal volumes and weight. None of the patients required any additional sinonasal surgical treatment. No complications were observed. In this case series, we present the first documented use of HFNC treatment for nasal stenosis, showing favorable results. Further studies with a larger cohort, wider range of conditions and extended follow-up periods are needed to establish the risks and benefits of HFNC for neonatal nasal stenosis.

Azithromycin therapy for prevention of chronic lung disease of prematurity (AZTEC): a multicentre, double-blind, randomised, placebo-controlled trial

Systematic reviews have reported conflicting evidence on whether macrolide antibiotics reduce rates of chronic lung disease of prematurity (CLD) in at-risk preterm infants born at less than 30 weeks' gestation, including in those colonised with pulmonary Ureaplasma spp. Since an adequately powered trial has been lacking, we aimed to assess if the macrolide azithromycin improved survival without the development of physiologically defined moderate or severe CLD in preterm infants. AZTEC was a multicentre, double-blind, randomised, placebo-controlled trial conducted in 28 tertiary neonatal intensive care units in the UK. Infants were eligible if they were born at less than 30 weeks' gestation and had received at least 2 h of either non-invasive (continuous positive airway pressure or humidified high flow nasal cannula therapy) or invasive respiratory support (via endotracheal tube) within 72 h of birth. Eligible infants were randomly allocated in a 1:1 ratio using random permuted blocks of four to receive either intravenous azithromycin at 20 mg/kg per day for 3 days followed by 10 mg/kg for 7 days, or to placebo. Allocation was stratified by centre and gestational age at birth (<28 weeks vs ≥28 weeks). Azithromycin and placebo vials were encased in tamper-evident custom cardboard cartons to ensure masking for clinicians, parents, and the research team. The primary outcome was survival without development of physiologically defined moderate or severe CLD at 36 weeks' postmenstrual age. Outcomes and safety were analysed on an intention-to-treat basis (all randomly allocated infants, regardless of any post-randomisation events). The study was registered with ISRCRN (11650227) and is closed. Infants were recruited between Oct 9, 2019, and March 22, 2022. 799 (53·1%) of 1505 eligible infants underwent random allocation; three infants were withdrawn, including consent to use their data, leaving 796 infants for analysis. Survival without moderate or severe CLD occurred in 166 (42%) of 394 infants in the intervention group and 179 (45%) of 402 in the placebo group (three-level adjusted OR [aOR] 0·84, 95% CI 0·55-1·29, p=0·43). Pulmonary Ureaplasma spp colonisation did not influence treatment effect. Overall, seven serious adverse events were reported for the azithromycin group (five graded as severe, two as moderate), and six serious adverse events were reported in the placebo group (two severe, two moderate, and two mild), as assessed by the local principal investigators. Since prophylactic use of azithromycin did not improve survival without development of physiologically-defined CLD, regardless of Ureaplasma spp colonisation, it cannot be recommended in clinical practice. UK National Institute for Health and Care Research.

Oral enteral nutrition in the emergency department for children with bronchiolitis hospitalized on high flow nasal cannula

ObjectivesWe assessed whether initiation of oral enteral nutrition in the emergency department (ED) for patients with bronchiolitis hospitalized on humidified high flow nasal cannula (HHFNC) was associated with a shorter hospital length of stay (LOS) without an increase in return ED visits or hospital readmissions. Patients and methodsThis retrospective cohort study included children ≤24 months of age with bronchiolitis hospitalized to the general pediatric floor on HHFNC in two time periods: October 1, 2018 – April 30, 2019, and following implementation of a revised institutional bronchiolitis pathway that encouraged enteral nutrition initiation in the ED, October 1, 2021 – April 30, 2022. The primary outcome of interest was hospital LOS where the exposure was enteral feeding in the ED. ResultsWe included 391 ‘fed’, 114 ‘not fed’ and 304 ‘unknown’ patients. HHFNC treatment time (25 h for ‘fed’ vs. 43 h for ‘not fed’ vs. 35 h for‘unknown’, p = 0.0001) and hospital LOS (39 h for ‘fed’ vs. 56 h for ‘not fed’ vs. 48 h for ‘unknown’, p = 0.0001) was shorter in the ‘fed’ group. There were no significant differences in return ED visits or hospital readmissions. Using our median LOS (45.1 h, inter-quartile range 30.2, 64.4 h) while controlling for age, sex, initial HHFNC flow rate, the respiratory oxygenation (ROX) index, viral etiology, and time period, an adjusted logistic regression analysis demonstrated that patients fed in the ED were 1.8 times more likely to have a hospital LOS of <45 h (aOR 1.88, 95% CI 1.11–3.18, p = 0.019). ConclusionsInitiation of oral enteral nutrition in the ED for patients with bronchiolitis on HHFNC is associated with a shorter hospital LOS without an increase in return ED visits or hospital readmissions. Future prospective studies are needed to develop feeding recommendations for children with bronchiolitis receiving HHFNC support.

To study the efficiency of high-flow nasal cannula in improving the arterial blood gas parameters in children admitted to pediatric intensive care unit with respiratory distress

Abstract Background: In recent times, heated humidified high-flow nasal cannula has become increasingly popular and is now recognized as a standard respiratory support method for pediatric patients experiencing acute respiratory distress. Aims and Objectives: To study the correlation of high-flow nasal cannula (HFNC) with arterial blood gas (ABG) and clinical parameters. Materials and Methods: This prospective observational study included children aged 1 month to 14 years experiencing acute respiratory distress receiving HFNC support. Demographic information, vital signs, and ABG parameters were collected at four-time points: the first ABG at “0” h, indicating admission; the second ABG at “1” h, approximately 1 h after HFNC initiation; the third ABG at “12” h, as a follow-up after the initiation of respiratory support; and the fourth ABG at “24” h, representing daily monitoring for assessing the child’s condition and outcomes. The collected data was subjected to analysis. Results: The study included 133 children, of which 64.66% were male and 35.34% were female, with a mean age of 0.9 years (ranging from 0.3 to 3 years) and a mean weight of 7.8 kg (ranging from 4.7 to 11.8 kg). Over time, there was a statistically significant decrease in heart rate, respiratory rate, and the need for FiO2. Significant reductions in these parameters were observed within the first hour of initiating HFNC therapy, and improvements continued at 12 and 24 h compared to the baseline values (P value &lt; 0.05). The study also revealed a decreasing trend in pCO2 and lactate levels over time. Statistically significant reductions in these parameters were noted at the first hour of HFNC initiation, and improvements persisted at 12 and 24 h compared to the baseline (P value &lt; 0.05). On the other hand, there was an increasing trend in SpO2, pO2, base excess, and HCO3 over time. Significant increases in these parameters were observed at the first hour of HFNC initiation, and the positive trend continued at 12 and 24 h compared to the baseline (P value &lt; 0.05). Conclusion: HFNC can serve as the primary noninvasive respiratory support for children facing respiratory distress. The majority of patients in our study demonstrated good tolerance to the HFNC. Notably, the utilization of HFNC resulted in a significant enhancement of the comfort scale among the participants. Positive changes were observed in vital parameters, comfort scale, and ABG parameters within just 1 h of initiating HFNC.

Non-invasive ventilation in neonates: a review of current literature

Moving from an era of invasive ventilation to that of non-invasive respiratory support, various modalities have emerged resulting in improved neonatal outcomes. Respiratory distress is the commonest problem seen both in preterm and term neonates, and the use of appropriate respiratory support could be lifesaving. This article reviews the currently available non-invasive ventilation (NIV) strategies in neonates including nasal continuous positive airway pressure, nasal intermittent positive pressure ventilation (NIPPV), bi-level CPAP, heated humidified high flow nasal cannula, nasal high-frequency ventilation (NHFV) and non-invasive neutrally adjusted ventilatory assist (NIV-NAVA). Though multiple systematic reviews and meta-analyses have indicated the superiority of synchronized NIPPV over the other forms of non-invasive respiratory support in neonates, there is no single NIV modality that universally suits all. Hence, the choice of NIV for a neonate should be individualized based on its efficacy, the disease pathology, resource settings, the clinician's familiarity and parental values. Future studies should evaluate emerging modalities such as NIV-NAVA and NHFV in the respiratory management of neonates as the evidence pertaining to these is insufficient.

Use of Inhaled Epoprostenol in Patients With COVID-19 Receiving Humidified, High-Flow Nasal Oxygen Is Associated With Progressive Respiratory Failure

The clinical benefit of using inhaled epoprostenol (iEpo) through a humidified high-flow nasal cannula (HHFNC) remains unknown for patients with COVID-19. Can iEpo prevent respiratory deterioration for patients with positive SARS-CoV-2 findings receiving HHFNC? This multicenter retrospective cohort analysis included patients aged 18 years or older with COVID-19 pneumonia who required HHFNC treatment. Patients who received iEpo were propensity score matched to patients who did not receive iEpo. The primary outcome was time to mechanical ventilation or death without mechanical ventilation and was assessed using Kaplan-Meier curves and Cox proportional hazard ratios. The effects of residual confounding were assessed using a multilevel analysis, and a secondary analysis adjusted for outcome propensity also was performed in a multivariable model that included the entire (unmatched) patient cohort. Among 954 patients with positive SARS-CoV-2 findings receiving HHFNC therapy, 133 patients (13.9%) received iEpo. After propensity score matching, the median number of days until the composite outcome was similar between treatment groups (iEpo: 5.0 days [interquartile range, 2.0-10.0 days] vs no-iEpo: 6.5 days [interquartile range, 2.0-11.0 days]; P = .26), but patients who received iEpo were more likely to meet the composite outcome in the propensity score-matched, multilevel, and multivariable unmatched analyses (hazard ratio, 2.08 [95% CI, 1.73-2.50]; OR, 4.72 [95% CI, 3.01-7.41]; and OR, 1.35 [95% CI, 1.23-1.49]; respectively). In patients with COVID-19 receiving HHFNC therapy, use of iEpo was associated with the need for invasive mechanical ventilation.

Changes in the patterns of respiratory support and incidence of bronchopulmonary dysplasia; a single center experience

BackgroundWith the advances in neonatal intensive care, the survival rate of extremely preterm infants is increasing. However, bronchopulmonary dysplasia (BPD) remains a major cause of morbidity among infants in this group. This study examined the changes in respiratory support modalities, specifically heated humidified high-flow nasal cannula (HHHFNC), and their association with BPD incidence among preterm infants born at < 29 weeks of gestation.MethodThis population-based retrospective cohort study included infants born at < 29 weeks of gestation between 2016 and 2020. Data regarding the use and duration of respiratory support modalities were obtained, including mechanical ventilation, continuous positive airway pressure, HHHFNC, and low-flow oxygen therapy. Additionally, the incidence of BPD was determined in the included infants. Trend analysis for each respiratory support modality and BPD incidence rate was performed to define the temporal changes associated with changes in BPD rates. In addition, a logistic regression model was developed to identify the association between BPD and severity grade using HHHFNC.ResultsThree Hundred and sixteen infants were included in this study. The use and duration of HHHFNC therapy increased during the study period. Throughout the study period, the overall incidence of BPD was 49%, with no significant trends. The BPD rate was significantly higher in the infants who received HHHFNC than in those who did not (52% vs. 39%, P = 0.03). Analysis of BPD severity grades showed that both grade 1 BPD (34% vs. 21%, P = 0.03) and grade 2 BPD (12% vs. 1%, P < 0.01) were significantly more common among infants who received HHHFNC than among those who did not. In contrast, the incidence of grade 3 BPD was lower in infants who received HHFNC (6% vs. 17%, P < 0.01). The duration in days of HHHFNC was found to significantly predict BPD incidence (OR 1.04 [95%CI: 1.01–1.06], P < 0.01) after adjusting for confounding variables.ConclusionThe use of HHHFNC in extremely preterm infants born at < 29 weeks of gestation is increasing. There was a significant association between the duration of HHHFNC therapy and the development of BPD in extremely preterm infants born at < 29 weeks of gestation.

Effect of Nasal Continuous Positive Airway Pressure vs Heated Humidified High-Flow Nasal Cannula on Feeding Intolerance in Preterm Infants With Respiratory Distress Syndrome

Respiratory distress syndrome and feeding intolerance are common conditions that are often associated with preterm infants. Showing similar efficacy, nasal continuous positive airway pressure (NCPAP) and heated humidified high-flow nasal cannula (HHHFNC) are the most widespread noninvasive respiratory support (NRS) in neonatal intensive care units, but their effect on feeding intolerance is unknown. To evaluate the effect of NCPAP vs HHHFNC on high-risk preterm infants with respiratory distress syndrome. This multicenter randomized clinical trial involved infants who were born in 1 of 13 neonatal intensive care units in Italy between November 1, 2018, and June 30, 2021. Preterm infants with a gestational age of 25 to 29 weeks, who were suitable for enteral feeding and who proved to be medically stable on NRS for at least 48 hours were enrolled in the study within the first week of life and randomized to receive either NCPAP or HHHFNC. Statistical analysis was performed according to the intention-to-treat approach. NCPAP or HHHFNC. The primary outcome was the time to full enteral feeding (FEF), defined as an enteral intake of 150 mL/kg per day. Secondary outcomes were the median daily increment of enteral feeding, signs of feeding intolerance, effectiveness of the assigned NRS, peripheral oxygen saturation (SpO2)-fraction of inspired oxygen (FIO2) ratio at changes of NRS, and growth. Two-hundred forty-seven infants (median [IQR] gestational age, 28 [27-29] weeks; 130 girls [52.6%]) were randomized to the NCPAP group (n = 122) or the HHHFNC group (n = 125). There were no differences in the primary and secondary nutritional outcomes between the 2 groups. The median time to reach FEF was 14 days (95% CI, 11-15 days) in the NCPAP group and 14 days (95% CI, 12-18 days) in the HHHFNC group, and similar results were observed in the subgroup of infants with less than 28 weeks' gestation. On the first NRS change, higher SpO2-FIO2 ratio (median [IQR], 4.6 [4.1-4.7] vs 3.7 [3.2-4.0]; P < .001) and lower rate of ineffectiveness (1 [4.8%] vs 17 [73.9%]; P < .001) were observed in the NCPAP vs HHHFNC group. This randomized clinical trial found that NCPAP and HHHFNC had similar effects on feeding intolerance, despite different working mechanisms. Clinicians may tailor respiratory care by selecting and switching between the 2 NRS techniques on the basis of respiratory effectiveness and patient compliance, without affecting feeding intolerance. ClinicalTrials.gov Identifier: NCT03548324.

Acute Bronchiolitis in Term Newborns Following Relaxation in COVID-19 Appropriate Behavior

Abstract Objective Neonatal bronchiolitis is not well characterized. We studied the profile of acute bronchiolitis in term newborns during a respiratory syncytial virus (RSV) surge following relaxation in coronavirus disease 2019 (COVID-19) appropriate behavior. Methods This was a retrospective descriptive study performed in the neonatology division of a tertiary care pediatric hospital at Srinagar, Jammu and Kashmir, India. Term neonates (born at ≥37 completed gestational weeks) from 7 up to 28 days of life admitted with bronchiolitis over a 1-month period (November 2021) were included. Results Out of total 480 neonatal admissions over a month, 35 (7%) had acute bronchiolitis. Eight neonates were excluded. Out of 27 included neonates, 13 were males. Mean age at presentation was 20 days. All neonates were born at term (≥37 completed gestational weeks). Cough (26), rapid breathing (20), and lower chest indrawing (20) were the predominant presenting features. Median SPO2 was 87% (interquartile range 85–92%). Fourteen (52%) neonates needed admission to neonatal intensive care unit. Respiratory support was needed in the form of oxygen through nasal prongs in 24 (89%) newborns. Heated humidified high-flow nasal cannula (HHHFNC) and bubble continuous positive airway pressure were used in five neonates each. Two neonates were mechanically ventilated. The mean duration of the hospital stay was 6.2 days. All neonates survived. Conclusion A series of 27 term neonates with bronchiolitis during an RSV surge is reported in the aftermath of lifting of COVID-19 restrictions. Many of these neonates were sick enough to require significant respiratory support. The outcome was good in all neonates.

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.

Advances in Management of Respiratory Failure in Children.

Providing the right respiratory support is an essential skill, vital for anyone treating sick children. Recent advances in respiratory support include developments in both non-invasive and invasive ventilatory strategies. In non-invasive ventilation, newer modalities are being developed, in an attempt to decrease the need for invasive ventilation. This include newer techniques like Heated humidified high-flow nasal cannula (HHHFNC) and improvements in existing modes. The success of Continuous positive airway pressure (CPAP) and other non-invasive modes depend to a large extent on choosing and maintaining a suitable interface. When it comes to invasive ventilation, recent advances are focussing on increasing automation, improving patient comfort and minimising lung injury. Concepts like mechanical power are attempts at understanding the mechanisms of unintended injuries resulting from respiratory support and newer monitoring methods like transpulmonary pressure, thoracic impedance tomography are attempts at measuring potential markers of lung injury. Using the vast arrays of available ventilatory options judiciously, considering their advantages and drawbacks in every individual case will be the prime responsibility of clinicians in the future. Simultaneously, efforts have been made to identify potential drugs that can favourably modify the pathophysiology of acute respiratory distress syndrome (ARDS). Unfortunately, though eagerly awaited, most pharmaceutical agents tried in pediatric ARDS have not shown definite benefit. Pulmonary local drug and gene therapy using liquid ventilation strategies may revolutionize our future understanding and management of lung diseases.

A randomized controlled trial to compare the success rates and efficacy of high flow nasal cannulae versus nasal continuous positive airway pressure in post extubation period in neonates

Background: Nasal continuous positive airway pressure (nCPAP) is the mainstay for non-invasive respiratory support for all respiratory distress neonates. Recent advances in Heated humidified high flow nasal cannula (HHHFNC) usage with enhanced humidity, and improved comfort factors have led to its widespread use, at times replacing nCPAP in many neonatal settings. The present study was to assess the efficacy and safety of HHHFNC compared with nCPAP for non-invasive respiratory support in post-extubation period. Methods: A hospital based randomized controlled trial was conducted in neonatal intensive care unit (NICU) of S. Nijalingappa Medical College and HSK Hospital, Bagalkot from January 2019 to June 2020. 140 post-extubated neonates were enrolled for the study after obtaining informed consent from parents, and those who were directly extubated to no support and with major congenital anomalies were excluded from the study. Randomization was done by computer generated random number allocation method. Results: Of the140 babies, 60% were males and 40% were females. Out of 84 male neonates, 47 (67.1%) were on nCPAP and 37 (32.9%) on HHHFNC and out of 56 female neonates 23 (32.9%) were on nCPAP and 33 (47.1%) on HFNC. In this study, 4 babies on nCPAP required re-intubation within 72 hours. 5 babies on HHHFNC, 3 babies required re-intubation within 72 hours and 2 babies within 5 days. The incidence of nasal trauma, hospital stay and duration of NIV support were less in HHHFNC group as compared to nCPAP group. Conclusions: HHHFNC therapy is as effective as nCPAP therapy for the facilitation of extubation in neonates.

Incidence of nasal trauma in nasal continuous positive airway pressure versus heated humidified high flow nasal cannula in neonates, our experience in Government Medical College Srinagar

Background: The nCPAP (nasal continuous positive airway pressure) is noninvasive mode of ventilation that decreases the need for mechanical ventilation in neonates. The newer device heated humidified high flow nasal cannula (HHHFNC) delivers heated (to body temperature, 37 °C) and humidified (near 100% relative humidity) gas at flow rates of more than 1 liter/min through small bi-nasal prongs, that is more physiological. Methods: This was a retrospective study conducted in neonatal intensive care unit. The eligible neonates who were put on HHHFNC or nCPAP depending upon the availability of any of these devices at the time of admission. The details regarding complications were recorded from the admission files of these patients from medical record section of the hospital. Results: There was no statistically significant difference in complications like shock, NEC, pulmonary air leak, apnea, PDA, ROP, IVH or PVL for nCPAP or HHHFNC. However, nasal trauma was present in 18 (18%) patients in nCPAP group but in no patient in HHHFNC. Conclusions: There is no significant differences in complication in nCPAP vs HHHFNC except nasal trauma which is more common in nCPAP.

Noise Levels of Invasive and Non Invasive Respiratory Support used in Neonatal Intensive Care Unit of Northern India: A Cross-sectional Study

Introduction: The average noise level exposure inside Neonatal Intensive Care Unit (NICU) is more than the recommended guidelines. The source of noise exposure inside NICU is multifactorial. There is need of studies to assess the noise levels of respiratory equipment used inside the NICU. Aim: To assess the noise levels of invasive versus non invasive and respiratory support in preterm neonates admitted to NICU. Materials and Methods: This cross-sectional descriptive study was done in NICU of a tertiary health care center of Sanjay Gandhi Postgraduate Institute, Lucknow, Uttar Pradesh, India over one year duration from December 2019 to December 2020. A sample of 85 eligible neonates without major congenital anomalies (26- 36+6 weeks gestation) was enroled in this study after obtaining informed consent from parents. The noise levels of Heated Humidified High Flow Nasal Cannula (HHHFNC), Continuous Positive Airway Pressure (CPAP), conventional ventilation and High-Frequency Ventilation (HFV) were measured using a sound level meter for a period of first 24 hours of life. The median sound level from non invasive ventilation is compared with invasive ventilation. The continuous variables were expressed as median with range, while categorical data were expressed as frequencies and percentages. Results: A total of 85 neonates were enroled majority of them were born in 32-34 weeks of gestation and were with birth weight of 1501-2500 grams. The sound level exposure of HHHFNC support was 56.1 dB (52.6-60 dB) from warmer and 47.3 dB (44.6-50.8 dB) from the incubator. The median sound level exposure per hour of bubble CPAP was 59 dB (55.2-61.9 dB) with warmer and 51.4 dB (47-55 dB) with incubator. The median sound level exposure per hour of the conventional ventilator was 60 dB (57.4-63.9 dB) with warmer and 53 dB (50.2-56.1 dB) with incubator. The median sound level exposure per hour of high-frequency ventilator was 69.1 dB (66.3-71.8 dB) with warmer and 67.3 dB (66.2-68.9 dB) with incubator. Conclusion: Non invasive ventilation (HHHFNC and bubble CPAP) was less noisy than invasive ventilation. The lowest measured noise exposure was higher than the American Academy of Paediatrics (AAP) recommendation of 45 dB, even after isolation with physical barrier.

Predictors of high-flow nasal cannula failure in pediatric patients with acute respiratory distress.

Heated humidified high-flow nasal cannula (HFNC) has gained popularity recently and is considered a standard respiratory support tool for pediatric patients with acute respiratory distress. However, data are limited on the bedside parameters that can predict HFNC failure in pediatric patients. To evaluate the performance of SpO2/FiO2 (SF) ratio, pediatric respiratory rate-oxygenation (pROX) index, and clinical respiratory score (CRS), for predicting the HFNC outcomes. This prospective observational study included 1- month to 15-year-old patients with acute respiratory distress who required HFNC support. The HFNC setting, vital signs, CRS, and treatment outcomes were recorded. Data were analyzed to determine the predictors of HFNC failure. Eighty-two children participated in the study, 16 of whom (19.5%) did not respond to HFNC treatment (failure group). Pneumonia was the main reason for intubation (62.5%). Predictors of HFNC failure at 12 hours were: SF index ≤166 (sensitivity, 62.5%; specificity, 87.8%; area under the curve [AUC], 0.75), pROX index <132 (sensitivity, 68.7%; specificity, 84.8%; AUC, 0.77), and CRS ≥6 (sensitivity, 87.5%; specificity, 96.9%; AUC, 0.92). The CRS was the most accurate predictor of HFNC failure in pediatric patients. A CRS ≥ 6 at 12 hours after HFNC initiation and pROX, a newly modified parameter, are helpful indicators of HFNC failure.

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.

A randomised trial comparing weaning from CPAP alone with weaning using heated humidified high flow nasal cannula in very preterm infants: the CHiPS study

ObjectiveTo determine whether weaning from nasal continuous positive airway pressure (nCPAP) using heated humidified high flow nasal cannula (nHF) was non-inferior to weaning using nCPAP alone in relation to time...

High-flow nasal cannula therapy for pediatric obstructive sleep apnea: a systematic review and meta-analysis.

Heated and humidified high-flow nasal cannula (HFNC) therapy has been used to manage different respiratory conditions in pediatric patients. However, no review has summarized its efficacy for the management of pediatric obstructive sleep apnea (OSA). PubMed, Embase, CENTRAL, and Google Scholar were searched for all types of studies assessing the efficacy of HFNC for pediatric OSA. We compared pre-treatment and post-treatment obstructive apnea-hypopnea index (OAHI), obstructive hypopnea index (OHI), obstructive apnea index (OAI), SPO2 nadir and SPO2 mean values in a random-effect meta-analysis model. Six studies reporting data of 67 pediatric patients treated with HFNC were included. Most of the data were from one-time titration. Meta-analysis revealed a statistically significant reduction in OAHI with HFNC therapy (MD: 15.58 95% CI: 8.30, 22.86 I2=77% p=0.001). Similarly, pooled analysis revealed that both OHI (MD: 12.35 95% CI: 0.78, 23.92 I2=98% p=0.04) and OAI (MD: 7.54 95% CI: 2.10, 12.98 I2=79% p=0.007) were significantly reduced with HFNC treatment. Also, HFNC led to statistically significant improvement in SPO2 nadir values (MD: -8.17 95% CI: -10.40, -5.94 I2=21% p<0.00001) but it did not change the mean SPO2 values before and after treatment (MD: -0.85 95% CI: -1.94, 0.25 I2=52% p=0.13). Evidence from a limited number of heterogeneous and uncontrolled titration studies indicates that HFNC improves OAHI and minimum oxygen saturation in pediatric patients with OSA. However, further research is required on the long-term efficacy and compliance of HFNC therapy with a focus on different pediatric age groups.

Frequency and Correlates of Pediatric High-Flow Nasal Cannula Use for Bronchiolitis, Asthma, and Pneumonia.

Heated humidified high-flow nasal cannula (HFNC) is a respiratory support device historically used in pediatrics for infants with bronchiolitis. No large-scale analysis has determined the current frequency or demographic distribution of HFNC use in children. The objective of this study was to determine the frequency and correlates of HFNC use in children presenting to the hospital for asthma, bronchiolitis, or pneumonia. This longitudinal observational study was based on electronic health record data from a large regional health information exchange, the Indiana Network for Patient Care (INPC). Subjects were age 0-18 y with recorded hospital encounters at an INPC hospital between 2010-2019 with International Classification of Diseases codes for bronchiolitis, asthma, or pneumonia. Annual proportions of HFNC use among all hospital encounters were assessed using generalized additive models. Log-binomial regression models were used to identify correlates of incident HFNC use and determine risk ratios of specific subjects receiving HFNC. The study sample included 242,381 unique subjects with 412,712 hospital encounters between 2010-2019. The 10-y period prevalence of HFNC use was 2.54% (6,155/242,381) involving 7,974 encounters. Hospital encounters utilizing HFNC increased by 400%, from 326 in 2010 to 1,310 in 2019. This increase was evenly distributed across all 3 diagnostic categories (bronchiolitis, asthma, and pneumonia). Sex, race, age, and ethnicity all significantly influenced the risk of HFNC use. Over the 10-y period, the percentage of all hospital encounters using HFNC increased from 1.11% in 2010 to 3.15% in 2018. Subjects with multiple diagnoses had significantly higher risk of receiving HFNC. The use of HFNC in children presenting to the hospital with common respiratory diseases has increased substantially over the past decade and is no longer confined to treating infants with bronchiolitis. Demographic and diagnostic factors significantly influenced the frequency of HFNC use.

Comparison of Two Weaning Methods from Heated Humidified High-Flow Nasal Cannula Therapy in Pediatric Intensive Care Unit.

Background and Objective: Although high-flow nasal cannula (HFNC) is widely used in children, there is no consensus on the methods for starting, maintenance, and weaning. The aim of this study was to compare weaning methods in children. Methods: The study included all patients in pediatric intensive care unit (PICU) who were started on HFNC treatment. The respiratory assessment score was used in the decisions for starting, continuing, and weaning from HFNC. The patients who responded and for whom weaning was planned were randomized by month into 2 groups as directly weaned from HFNC and weaned by reducing the flow. Success rates, treatment, and length of stay (LOS) in weaning methods were compared. Results: Of the 145 patients initially included in the study, 32 (22%) were excluded, and analysis was made of 113 patients. Successful weaning from HFNC was obtained in 76.9% of the patients, in 82.1% of flow weaning, and 73.6% of direct weaning, with no statistically significant difference determined between the groups (P = 0.286). The median duration of HFNC and the median LOS in PICU were determined to be statistically significantly shorter in direct weaning than in flow weaning [36 h interquartile range (IQR) 24-48 h] versus 60 h (IQR 60-72 h), P < 0.001 and 6 days (4-14 days) versus 9.5 days (5.25-20.75 days, P = 0.043, respectively). Conclusion: In patients who responded to HFNC in PICU, the responses to direct weaning and flow reduction were seen to be similar. In patients directly weaned off, both the HFNC duration and LOS in PICU were significantly shorter.