Using a high-flow nasal cannula provides superior results to OxyMask delivery in moderate to severe bronchiolitis: a randomized controlled study

Application of the TIDieR checklist to improve the HFNC use in bronchiolitis management

The use of High-Flow Nasal Cannula (HFNC) in children with bronchiolitis is globally increased in the last decade, despite the lack of evidence-based and universal guidelines to standardize their application in the clinical practice. In this systematic review, we aimed to analyse the completeness of previous studies on HFNC interventions in children with bronchiolitis using an adapted Template for Intervention Description and Replication (TIDieR) checklist. Randomized clinical trials (RCTs) and cohort studies on children younger than 2 years old with a diagnosis of bronchiolitis were included. We analysed manuscripts published between January 2010 and October 2023. An adapted TIDieR checklist based on 14 items about HFNC interventions was used to assess the completeness of the studies. A total sample of 67,324 patients was analysed in the 78 included manuscripts (21 RCTs and 57 cohort studies). Completeness of TIDieR checklist items ranged from 1% to 100%. The most reported items were related to the study rationale and the selection strategy (inclusion/exclusion criteria), identifying high quality of patients' selection in the included manuscripts. However, most of the studies did not provide separate indications for children with comorbidities. Only 23% of studies reported a complete definition and rates of treatment failure suggesting that this item needs more clarification in future studies. A minority of articles (40%) described the HFNC weaning procedures. Interestingly, most of the interventions took place in ICUs (61%), showing how, in the last decade, this location was the most cited for the use of HFNC in children with bronchiolitis.

CONCLUSIONS

 Our results suggest complete reporting of our TIDieR checklist in future studies may improve the quality of the research on HFNC use in children with bronchiolitis. Our findings encourage researchers to clarify the personalization of treatment administration and to better define the criteria for treatment failure. The adoption of universal definitions in this field is needed to increase the results' comparability and create standardized protocols. Researchers may use the proposed TIDieR checklist to develop, conduct and report clinical research into HFNC and bronchiolitis as this may help to create a consensus for establishing an evidence-based protocol for HFNC.

WHAT IS KNOWN

• High-flow nasal cannula (HFNC) is a common device used in children with bronchiolitis in the presence of respiratory distress, after the failure of standard oxygen therapy. However, no evidence-based and standardized protocol for the use of this device is globally available.

WHAT IS NEW

• By using an adapted Template for Intervention Description and Replication (TIDieR) checklist to review previous studies on HFNC in bronchiolitis, we found a global heterogeneity in the description of interventions with some items of the checklist poorly reported. Thus, we suggest using our TIDieR checklist for developing, conducting and reporting clinical research into HFNC and bronchiolitis as this may help to create a consensus for establishing an evidence-based protocol for HFNC.

Effectiveness of high flow nasal Cannula (HFNC) therapy compared to standard oxygen therapy (SOT) and continuous positive airway pressure (CPAP) in bronchiolitis

High Flow Nasal Cannula therapy (HFNC) is a form of respiratory support for bronchiolitis. Recent evidence confirms HFNC reduces the risk of treatment escalation by nearly half (45%) compared to standard oxygen therapy (SOT), although most patients (75%) with mild-moderate respiratory distress manage well on SOT. The majority of children (60%) failing SOT respond well to HFNC making rescue use of HFNC a more cost-effective approach compared to its first-line use. HFNC is compared toCPAP in the setting of moderate to severe bronchiolitis. Patients on HFNC have a slightly elevated risk of treatment failure especially in severe bronchiolitis, but this does not translate to a significant difference in patient or healthcare centred outcomes. HFNC has improved tolerance, a lower complication rate and is more easily available in peripheral hospitals. It is therefore the preferred first line option followed by rescue CPAP. HFNC is clinically effective and safe to use in bronchiolitis of all severities.

High flow, low results: The limits of high flow nasal cannula in the treatment of bronchiolitis

Bronchiolitis continues to be the most common cause of hospitalization in the first year of life. We continue to search for the remedy that will improve symptoms, shorten hospitalization and prevent worsening of disease. Although initially thought to be a promising therapy, large randomized controlled trials show us that high flow nasal cannula (HFNC) use is not that remedy. These trials show no major differences in duration of hospital stay, intensive care unit (ICU) admission rates, duration of stay in the ICU, duration of oxygen therapy, intubation rates, heart rate, respiratory rate or comfort scores. Additionally, practices regarding initiation, flow rates and weaning continue to vary from institution to institution and there are currently no agreed upon indications for its use. This reveals the need for evidence based guidelines on HFNC use in bronchiolitis.

High-flow nasal cannula therapy for infants with bronchiolitis

BACKGROUND

Bronchiolitis is a common lower respiratory tract illness, usually of viral aetiology, affecting infants younger than 24 months of age and is the most common cause of hospitalisation of infants. It causes airway inflammation, mucus production and mucous plugging, resulting in airway obstruction. Effective pharmacotherapy is lacking and bronchiolitis is a major cause of morbidity and mortality. Conventional treatment consists of supportive therapy in the form of fluids, supplemental oxygen, and respiratory support. Traditionally, oxygen delivery is as a dry gas at 100% concentration via low-flow nasal prongs. However, the use of heated, humidified, high-flow nasal cannula (HFNC) therapy enables delivery of higher inspired gas flows of an air/oxygen blend, at 2 to 3 L/kg per minute up to 60 L/min in children. It can provide some level of continuous positive airway pressure (CPAP) to improve ventilation in a minimally invasive manner. This may reduce the need for invasive respiratory support, thus potentially lowering costs, with clinical advantages and fewer adverse effects.

OBJECTIVES

To assess the effects of HFNC therapy compared with conventional respiratory support in the treatment of infants with bronchiolitis.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, and Web of Science (from June 2013 to December 2022). In addition, we consulted ongoing trial registers and experts in the field to identify ongoing studies, checked reference lists of relevant articles, and searched for conference abstracts. Date restrictions were imposed such that we only searched for studies published after the original version of this review.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) or quasi-RCTs that assessed the effects of HFNC (delivering oxygen or oxygen/room air blend at flow rates greater than 4 L/minute) compared to conventional treatment in infants (< 24 months) with a clinical diagnosis of bronchiolitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently used a standard template to assess trials for inclusion and extract data on study characteristics, risk of bias elements, and outcomes. We contacted trial authors to request missing data. Outcome measures included the need for invasive respiratory support and time until discharge, clinical severity measures, oxygen saturation, duration of oxygen therapy, and adverse events.

MAIN RESULTS

In this update we included 15 new RCTs (2794 participants), bringing the total number of RCTs to 16 (2813 participants). Of the 16 studies, 11 compared high-flow to low-flow, and five compared high-flow to CPAP. These studies included infants less than 24 months of age as stated in our selection criteria. There were no significant differences in sex. We found that when comparing high-flow to low-flow oxygen therapy for infants with bronchiolitis there may be a reduction in the total length of hospital stay (mean difference (MD) -0.65 days, 95% confidence interval (CI) -1.23 to -0.06; P < 0.00001, I2 = 89%; 7 studies, 1951 participants; low-certainty evidence). There may also be a reduction in the duration of oxygen therapy (MD -0.59 days, 95% CI -1 to -0.18; P < 0.00001, I2 = 86%; 7 studies, 2132 participants; low-certainty evidence). We also found that there was probably an improvement in respiratory rate at one and 24 hours, and heart rate at one, four to six, and 24 hours in those receiving high-flow oxygen therapy when compared to pre-intervention baselines. There was also probably a reduced risk of treatment escalation in those receiving high-flow when compared to low-flow oxygen therapy (risk ratio (RR) 0.55, 95% CI 0.39 to 0.79; P = 0.001, I2 = 43%; 8 studies, 2215 participants; moderate-certainty evidence). We found no difference in the incidence of adverse events (RR 1.2, 95% CI 0.38 to 3.74; P = 0.76, I2 = 26%; 4 studies, 1789 participants; low-certainty evidence) between the two groups. The lack of comparable outcomes in studies comparing high-flow and CPAP, as well as the small numbers of participants, limited our ability to perform meta-analysis on this group.

AUTHORS' CONCLUSIONS

High-flow nasal cannula therapy may have some benefits over low-flow oxygen for infants with bronchiolitis in terms of a greater improvement in respiratory and heart rates, as well as a modest reduction in the length of hospital stay and duration of oxygen therapy, with a reduced incidence of treatment escalation. There does not appear to be a difference in the number of adverse events. Further studies comparing high-flow nasal cannula therapy and CPAP are required to demonstrate the efficacy of one modality over the other. A standardised clinical definition of bronchiolitis, as well as the use of a validated clinical severity score, would allow for greater and more accurate comparison between studies.

Understanding the use and outcomes of high-flow nasal cannula among infants admitted to Canadian hospitals with bronchiolitis (CanFLO): a protocol for a multicentre, retrospective cohort study

INTRODUCTION

Bronchiolitis is the most common viral lower respiratory tract infection in children under 2 years of age. Respiratory support with high-flow nasal cannula (HFNC) is increasingly used in this patient population with limited understanding of the patients most likely to benefit and considerable practice variability of use. This study aims to understand the factors associated with failure of HFNC support among patients with bronchiolitis and to describe the current practice variations of HFNC use in patients with bronchiolitis in Canadian hospitals including fluid management and parameters to initiate, escalate and discontinue HFNC support.

METHODS AND ANALYSIS

This is a multicentre retrospective cohort study including hospitalised patients aged 0-24 months with bronchiolitis requiring support with HFNC between January 2017 and December 2021. Clinical data will be collected from patient medical records from Canadian hospitals (n=12), including academic and community centres. HFNC failure will be defined as the need for escalation to non-invasive or invasive mechanical ventilation. Factors associated with HFNC failure will be analysed using logistic regression. Descriptive statistics will be used to describe practice variations of HFNC utilisation and management.

ETHICS AND DISSEMINATION

Approval from the Research Ethics Boards (REBs) has been obtained for each participating study site prior to onset of data collection including Clinical Trials Ontario for all Ontario hospital sites and REBs from British Columbia Children's Hospital, Stollery Children's Hospital, Montreal Children's Hospital and CHU Sainte-Justine. Study results will be disseminated through presentation at national/international conferences and publication in high-impact, peer-reviewed journals.

High flow nasal cannula for respiratory support in term infants

BACKGROUND

Respiratory failure or respiratory distress in infants is the most common reason for non-elective admission to hospitals and neonatal intensive care units. Non-invasive methods of respiratory support have become the preferred mode of treating respiratory problems as they avoid some of the complications associated with intubation and mechanical ventilation. High flow nasal cannula (HFNC) therapy is increasingly being used as a method of non-invasive respiratory support. However, the evidence pertaining to its use in term infants (defined as infants ≥ 37 weeks gestational age to the end of the neonatal period (up to one month postnatal age)) is limited and there is no consensus of opinion regarding the safety and efficacy HFNC in this population.

OBJECTIVES

To assess the safety and efficacy of high flow nasal cannula oxygen therapy for respiratory support in term infants when compared with other forms of non-invasive respiratory support.

SEARCH METHODS

We searched the following databases in December 2022: Cochrane CENTRAL; PubMed; Embase; CINAHL; LILACS; Web of Science; Scopus. We also searched the reference lists of retrieved studies and performed a supplementary search of Google Scholar.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that investigated the use of high flow nasal cannula oxygen therapy in infants ≥ 37 weeks gestational age up to one month postnatal age (the end of the neonatal period).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility, performed data extraction, and assessed risk of bias in the included studies. Where studies were sufficiently similar, we performed a meta-analysis using mean differences (MD) for continuous data and risk ratios (RR) for dichotomous data, with their respective 95% confidence intervals (CIs). For statistically significant RRs, we calculated the number needed to treat for an additional beneficial outcome (NNTB). We used the GRADE approach to evaluate the certainty of the evidence for clinically important outcomes.

MAIN RESULTS

We included eight studies (654 participants) in this review. Six of these studies (625 participants) contributed data to our primary analyses. Four studies contributed to our comparison of high flow nasal cannula (HFNC) oxygen therapy versus continuous positive airway pressure (CPAP) for respiratory support in term infants. The outcome of death was reported in two studies (439 infants) but there were no events in either group. HFNC may have little to no effect on treatment failure, but the evidence is very uncertain (RR 0.98, 95% CI 0.47 to 2.04; 3 trials, 452 infants; very low-certainty evidence). The outcome of chronic lung disease (need for supplemental oxygen at 28 days of life) was reported in one study (375 participants) but there were no events in either group. HFNC may have little to no effect on the duration of respiratory support (any form of non-invasive respiratory support with or without supplemental oxygen), but the evidence is very uncertain (MD 0.17 days, 95% CI -0.28 to 0.61; 4 trials, 530 infants; very low-certainty evidence). HFNC likely results in little to no difference in the length of stay at the intensive care unit (ICU) (MD 0.90 days, 95% CI -0.31 to 2.12; 3 trials, 452 infants; moderate-certainty evidence). HFNC may reduce the incidence of nasal trauma (RR 0.16, 95% CI 0.04 to 0.66; 1 trial, 78 infants; very low-certainty evidence) and abdominal overdistension (RR 0.22, 95% CI 0.07 to 0.71; 1 trial, 78 infants; very low-certainty evidence), but the evidence is very uncertain. Two studies contributed to our analysis of HFNC versus low flow nasal cannula oxygen therapy (LFNC) (supplemental oxygen up to a maximum flow rate of 2 L/min). The outcome of death was reported in both studies (95 infants) but there were no events in either group. The evidence suggests that HFNC may reduce treatment failure slightly (RR 0.44, 95% CI 0.21 to 0.92; 2 trials, 95 infants; low-certainty evidence). Neither study reported results for the outcome of chronic lung disease (need for supplemental oxygen at 28 days of life). HFNC may have little to no effect on the duration of respiratory support (MD -0.07 days, 95% CI -0.83 to 0.69; 1 trial, 74 infants; very low-certainty evidence), length of stay at the ICU (MD 0.49 days, 95% CI -0.83 to 1.81; 1 trial, 74 infants; very low-certainty evidence), or hospital length of stay (MD -0.60 days, 95% CI -2.07 to 0.86; 2 trials, 95 infants; very low-certainty evidence), but the evidence is very uncertain. Adverse events was an outcome reported in both studies (95 infants) but there were no events in either group. The risk of bias across outcomes was generally low, although there were some concerns of bias. The certainty of evidence across outcomes ranged from moderate to very low, downgraded due to risk of bias, imprecision, indirectness, and inconsistency.

AUTHORS' CONCLUSIONS

When compared with CPAP, HFNC may result in little to no difference in treatment failure. HFNC may have little to no effect on the duration of respiratory support, but the evidence is very uncertain. HFNC likely results in little to no difference in the length of stay at the intensive care unit. HFNC may reduce the incidence of nasal trauma and abdominal overdistension, but the evidence is very uncertain. When compared with LFNC, HFNC may reduce treatment failure slightly. HFNC may have little to no effect on the duration of respiratory support, length of stay at the ICU, or hospital length of stay, but the evidence is very uncertain. There is insufficient evidence to enable the formulation of evidence-based guidelines on the use of HFNC for respiratory support in term infants. Larger, methodologically robust trials are required to further evaluate the possible health benefits or harms of HFNC in this patient population.

High-Flow Oxygen and Other Noninvasive Respiratory Support Therapies in Bronchiolitis: Systematic Review and Network Meta-Analyses

OBJECTIVES

We present a systematic review on the effectiveness of noninvasive respiratory support techniques in bronchiolitis.

DATA SOURCES

Systematic review with pairwise meta-analyses of all studies and network meta-analyses of the clinical trials.

STUDY SELECTION

Patients below 24 months old with bronchiolitis who require noninvasive respiratory support were included in randomized controlled trials (RCTs), non-RCT, and cohort studies in which high-flow nasal cannula (HFNC) was compared with conventional low-flow oxygen therapy (LFOT) and/or noninvasive ventilation (NIV).

DATA EXTRACTION

Emergency wards and hospitalized patients with bronchiolitis.

DATA SYNTHESIS

A total of 3,367 patients were analyzed in 14 RCTs and 8,385 patients in 14 non-RCTs studies. Only in nonexperimental studies, HFNC is associated with a lower risk of invasive mechanical ventilation (MV) than NIV (odds ratio, 0.49; 95% CI, 0.42-0.58), with no differences in experimental studies. There were no differences between HFNC and NIV in other outcomes. HFNC is more effective than LFOT in reducing oxygen days and treatment failure. In the network meta-analyses of clinical trials, NIV was the most effective intervention to avoid invasive MV (surface under the cumulative ranking curve [SUCRA], 57.03%) and to reduce days under oxygen therapy (SUCRA, 79.42%), although crossover effect estimates between interventions showed no significant differences. The included studies show methodological heterogeneity, but it is only statistically significant for the reduction of days of oxygen therapy and length of hospital stay.

CONCLUSIONS

Experimental evidence does not suggest that high-flow oxygen therapy has advantages over LFOT as initial treatment nor over NIV as a rescue treatment.

Variation and Outcomes of Hospital-Level High-Flow Nasal Cannula Usage Outside of Intensive Care

OBJECTIVES

Bronchiolitis is a viral respiratory infection that can progress to acute respiratory failure. This study evaluated the variability of hospital-wide high-flow nasal cannula (HFNC) usage outside of the ICU and its association with length of stay (LOS) and cost among pediatric patients admitted with bronchiolitis.

METHODS

This study included patients <2 years old admitted with bronchiolitis between September 1, 2018 and March 31, 2019. Hospitals were divided into groups based on the proportion of patients among those who had never been in the ICU who received HFNC (non-ICU HFNC usage [NIHU]). We performed hierarchical mixed-model linear regression to estimate the association of NIHU with LOS and cost using multiplicative ratios (MR) and 95% confidence intervals (CI), both (1) unadjusted and (2) after adjusting for demographics, clinical characteristics, and individual utilization of HFNC and/or ICU.

RESULTS

Unadjusted LOS was longer for patients in moderate (MR 1.14; 95% CI 1.11-1.18) and high (MR 1.26; 95% CI 1.22-1.30) NIHU hospitals. Adjusted LOS was longer in moderate (MR 1.03; 95% CI 1.01-1.06), and high (MR 1.08; 95% CI 1.05-1.11) NIHU hospitals. Unadjusted total cost was higher for patients in moderate (MR 1.20; 95% CI 1.16-1.25) and high (MR 1.26; 95% CI 1.22-1.31) NIHU hospitals. Adjusted total cost was higher for patients in moderate (MR 1.05; 95% CI 1.03-1.08), and high (MR 1.05; 95% CI 1.02-1.08) NIHU hospitals.

CONCLUSIONS

In this study, increased NIHU is associated with increased LOS and total cost.

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

BACKGROUND

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.

PURPOSE

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.

METHODS

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.

RESULTS

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).

CONCLUSION

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.

High-flow nasal cannula oxygen in children with bronchiolitis: A randomized controlled trial

OBJECTIVE

To determine whether high-flow nasal cannula oxygen (HFNCO) provided enhanced respiratory support in bronchiolitis than low-flow oxygen (LFO).

METHODS

We conducted a prospective, randomized controlled trial in children between 1 and 24 months diagnosed with moderate-to-severe bronchiolitis requiring oxygen therapy. Participants received LFO via face mask (6-10 L/min) or HFNCO (2 L/kg/min). Primary outcomes were the time that heart rate (HR) and respiratory rate (RR) return to their normal range for age and the time that baseline clinical respiratory score (CRS) regress to a lower severity score. Secondary outcomes were changes in HR, RR, and CRS over time, length of stay (LOS), duration of oxygen requirement, treatment failure, and adverse event (AE).

RESULTS

Eighty-seven children were enrolled (48 in LFO; 39 in HFNCO). The time that HR and RR baseline values reached their normal range for age was shorter in HFNCO therapy (2.0 h [1.0-4.0] vs. 12.0 h [2.0-24.0], and 4.0 h [2.0-12.0] vs. 24.0 h [4.0-48.0], respectively; p < 0.001); additionally, the improvement in CRS emerged more quickly in children treated with HFNCO (2.0 h [1.0-4.0] vs. 4.0 h [2.0-24.0]; p = 0.003). While the duration of oxygen requirement (19.0 h [4.0-30.0] vs. 29.5 h [14.0-45.7]; p = 0.009) and treatment failure (3% vs. 21%) was statistically lower in children who received HFNCO, there were no differences in LOS and AE between groups.

CONCLUSION

HFNCO may provide enhanced respiratory support with a notable improvement in HR, RR, and CRS than LFO. Comprehensive studies are needed to assess the clinical efficacy of HFNCO therapy.

High Flow Nasal Cannula in the Pediatric Intensive Care Unit

INTRODUCTION

The use of high flow nasal cannula (HFNC) has become widely used in pediatric intensive care units (PICUs) throughout the world. The rapid adoption has outpaced the number of studies evaluating the safety and efficacy in a variety of pediatric diseases/conditions.

AREAS COVERED

This scoping review begins with the definition and mechanisms of action of HFNC and then follows with a review of the literature focused on studies performed on critically ill children cared for in the PICU. The Pubmed database was searched with a pediatric filter from the time period 2000 to 2021.

EXPERT OPINION

The rapid adoption of HFNC in PICUs has largely been driven by changes in institutional practices and small observational studies. There is a lack of adequately powered studies evaluating patient-centered outcomes, such as intubation rates, mortality, PICU and hospital length of stay. Given the wide variability in flow rates and clinical indications, more research is needed to better define effective flow rates for different disease states as well as markers of treatment success and failure. One particular entity that is poorly studied is the use of HFNC in those at risk for developing pediatric acute respiratory distress syndrome (PARDS).

High Flow Nasal Cannula Therapy in the Emergency Department: Main Benefits in Adults, Pediatric Population and against COVID-19: A Narrative Review

This review aims to summarize the literature’s main results about high flow nasal cannula therapy (HFNC) HFNC benefits in the Emergency Department (ED) in adults and pediatrics, including new Coronavirus Disease (COVID-19). HFNC has recently been established as the usual treatment in the ED to provide oxygen support. Its use has been generalized due to its advantages over traditional oxygen therapy devices, including decreased nasopharyngeal resistance, washing out of the nasopharyngeal dead space, generation of positive pressure, increasing alveolar recruitment, easy adaptation due to the humidification of the airways, increased fraction of inspired oxygen and improved mucociliary clearance. A wide range of pathologies has been studied to evaluate the potential benefits of HFNC; some examples are heart failure, pneumonia, chronic pulmonary obstructive disease, asthma, and bronchiolitis. The regular use of this oxygen treatment is not established yet due to the literature’s controversial results. However, several authors suggest that it could be useful in several pathologies that generate acute respiratory failure. Consequently, the COVID-19 irruption has generated the question of HFNC as a safety and effective treatment. Our results suggested that HFNC seems to be a useful tool in the ED, especially in patients affected by acute hypoxemic respiratory failure, acute heart failure, pneumonia, bronchiolitis, asthma and acute respiratory distress syndrome in patients affected by COVID-19. Its benefits in hypercapnic respiratory failure are more discussed, being only observed benefits in patients with mild-moderate disease. These results are based in clinical as well as cost-effectiveness outcomes. Future studies with largest populations are required to confirm these results as well as establish a practical guideline to use this device.

Impact of High Flow Nasal Cannula on Resource Utilization in Bronchiolitis

OBJECTIVES

High flow nasal cannula (HFNC) is increasingly used for children hospitalized with bronchiolitis. We aimed to validate identification of HFNC use in a national database, then compare resource utilization among children treated with and without HFNC.

METHODS

In this cross-sectional, multicenter study, we obtained clinical and resource utilization data from the Pediatric Health Information System (PHIS) database for healthy children aged 1 to 24 months admitted for bronchiolitis. We assessed HFNC use based on a combination of billing codes and reviewed charts at 2 hospitals to determine their accuracy. We compared costs, length of stay, and readmissions between the HFNC and no HFNC groups at hospitals utilizing the HFNC codes.

RESULTS

The PHIS codes demonstrated 90.4% sensitivity and 99.3% specificity to detect HFNC use as verified by chart review at 2 hospitals. However, only 24 of 51 PHIS hospitals used these codes for ≥1% of patients with bronchiolitis. Within those hospitals, children treated with HFNC had greater total costs ($7054 vs $4544; P < .001), greater daily costs ($2922 vs $2613; P < .001), and longer length of stay (57.6 vs 41.6 hours; P < .001). Those treated with HFNC were less likely to be readmitted at 3 and 7 days (P < .001), but by 14 days, readmissions were similar in the 2 groups.

CONCLUSIONS

Billing codes for HFNC are inconsistently applied across PHIS hospitals; however, among those hospitals that routinely apply these codes, HFNC was associated with more intense resource utilization. Standardization of billing practices for HFNC would allow future study to more broadly describe the value of HFNC.

Non-Invasive Ventilation Strategies in Children With Acute Lower Respiratory Infection: A Systematic Review and Bayesian Network Meta-Analysis

Background: Multiple non-invasive ventilation (NIV) modalities have been identified that may improve the prognosis of pediatric patients with acute lower respiratory infection (ALRI). However, the effect of NIV in children with ALRI remains inconclusive. Hence, this study aimed to evaluate the efficacy of various NIV strategies including continuous positive airway pressure (CPAP), high flow nasal cannula (HFNC), bilevel positive airway pressure (BIPAP), and standard oxygen therapy in children with ALRI and the need for supplemental oxygen. Methods: Embase, PubMed, Cochrane Library, and Web of Science databases were searched from inception to July 2021. Randomized controlled trials (RCTs) that compared different NIV modalities for children with ALRI and the need for supplemental oxygen were included. Data were independently extracted by two reviewers. Primary outcomes were intubation and treatment failure rates. Secondary outcome was in-hospital mortality. Pairwise and Bayesian network meta-analyses within the random-effects model were used to synthesize data. The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation framework. Results: A total of 21 RCTs involving 5,342 children were included. Compared with standard oxygen therapy, CPAP (OR: 0.40, 95% CrI: 0.16-0.90, moderate quality) was associated with a lower risk of intubation. Furthermore, both CPAP (OR: 0.42, 95% CrI: 0.19-0.81, low quality) and HFNC (OR: 0.51, 95% CrI: 0.29-0.81, low quality) reduced treatment failure compared with standard oxygen therapy. There were no significant differences among all interventions for in-hospital mortality. Network meta-regression showed that there were no statistically significant subgroup effects. Conclusion: Among children with ALRI and the need for supplemental oxygen, CPAP reduced the risk of intubation when compared to standard oxygen therapy. Both CPAP and HFNC were associated with a lower risk of treatment failure than standard oxygen therapy. However, evidence is still lacking to show benefits concerning mortality between different interventions. Further large-scale, multicenter studies are needed to confirm our results. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=172156, identifier: CRD42020172156.

Superiority of OxyMaskTM with less carbon dioxide rebreathing in children

Despite the growing importance of oxygen-delivery devices worldwide, there are only a few reports of physiological data on various oxygen masks in children. The possibility of carbon dioxide (CO₂) rebreathing has been a prevalent concern with the use of oxygen-delivery devices. OxyMask Kid^TM (Southmedic Inc. Canada; hereafter OxyMask) is expected to reduce CO₂ rebreathing even at low oxygen flow rates because of its structural features. Biological data using OxyMask in children have not been well investigated. Measured respiratory parameters of OxyMask with those of a simple oxygen mask in healthy children were compared. Ten subjects were enrolled, with a median age of 5.4 years. All subjects used both OxyMask and a simple oxygen mask. The fraction of inspiratory oxygen (F_IO₂), partial pressure of inspiratory CO₂ (P_ICO₂), and partial pressure of end-tidal CO₂ were measured using a sidestream gas-sampling monitor in all subjects. The oxygen flow rate was set at 1, 3, 5, and 10 L/min. F_IO₂ levels were higher with OxyMask than those with the simple oxygen mask at 3 L/min of oxygen. P_ICO₂ levels were significantly lower with OxyMask than those with the simple oxygen mask (1.5 mmHg vs. 3.7 mmHg at 1 L/min, P = 0.005; 1.0 mmHg vs. 2.7 mmHg at 3 L/min, P = 0.005, respectively), whereas P_ICO₂ levels were higher at low oxygen flow rates with both masks.Conclusion: Our results showed that higher F_IO₂ and less CO₂ rebreathing were achieved with OxyMask than those with a simple oxygen mask at low flow rates of oxygen in healthy children. What is Known: • OxyMask is expected to reduce carbon dioxide rebreathing even at low oxygen flow rates because of its structural features. • Efficacy has been demonstrated in experimental models and adult data, but clinical data on the use of the OxyMask in children are limited. What is New: • Higher fraction of inspiratory oxygen and lesser carbon dioxide rebreathing were achieved with OxyMask than with a simple oxygen mask at low flow rates of oxygen in healthy children.

The cost-utility of early use of high-flow nasal cannula in bronchiolitis

BACKGROUND

High-flow nasal cannula (HFNC) oxygen is a non-invasive ventilation system that was introduced as an alternative to CPAP (continuous positive airway pressure), with a marked increase in its use in pediatric care settings. This study aimed to evaluate the cost-effectiveness of early use of HFNC compared to oxygen by nasal cannula in an infant with bronchiolitis in the emergency setting.

METHODS

A decision tree model was used to estimate the cost-effectiveness of HFNC compared with oxygen by nasal cannula (control strategy) in an infant with bronchiolitis in the emergency setting. Cost data were obtained from a retrospective study on bronchiolitis from tertiary centers in Rionegro, Colombia, while utilities were collected from the literature.

RESULTS

The QALYs per patient calculated in the base-case model were 0.9141 (95% CI 0.913-0.915) in the HFNC and 0.9105 (95% CI 0.910-0.911) in control group. The cost per patient was US$368 (95% CI US$ 323-411) in HFNC and US$441 (95% CI US$ 384-498) per patient in the control group.

CONCLUSIONS

HFNC was cost-effective HFNC compared to oxygen by nasal cannula in an infant with bronchiolitis in the emergency setting. The use of this technology in emergency settings will allow a more efficient use of resources, especially in low-resource countries with high prevalence of bronchiolitis .

Efficacy and safety of high flow nasal oxygen for children with bronchiolitis: systematic review and meta-analysis

BACKGROUND

To assess the published evidence to establish the efficacy and safety of high flow oxygen cannula (HFNC) as respiratory support for children up to 24 months of age with bronchiolitis within acute hospital settings.

METHODS

We searched eight databases up to March 2021. Studies including children up to 24 months of age with a diagnosis of bronchiolitis recruited to an randomised controlled trial were considered in the full meta-analysis. At least one arm of the study must include HFNC as respiratory support and report at least one of the outcomes of interest. Studies were identified and extracted by two reviewers. Data were analysed using Review Manager V.5.4.

RESULTS

From 2943 article titles, 308 full articles were screened for inclusion. 23 studies met the inclusion criteria, 15 were included in the metanalyses. Four studies reported on treatment failure rates when comparing HFNC to standard oxygen therapy (SOT). Data suggests HFNC is superior to SOT (OR 0.45, 95% CI 0.36 to 0.57). Four studies reported on treatment failure rates when comparing HFNC to continuous positive airways pressure (CPAP). No significant difference was found between CPAP and HFNC (OR 1.64, 95% CI 0.96 to 2.79; p=0.07). Four studies report on adverse outcomes when comparing HFNC to SOT. No significant difference was found between HFNC & SOT (OR 1.47, 95% CI 0.54 to 3.99).

CONCLUSION

HFNC is superior to SOT in terms of treatment failure and there is no significant difference between HFNC and CPAP in terms of treatment failure. The results suggest HFNC is safe to use in acute hospital settings.

High-flow oxygen nasal cannula for treating acute bronchiolitis in infants: A systematic review and meta-analysis

Introduction

Oxygen therapy through a high-flow nasal cannula is thought to improve the work of breathing and the comfort of patients with acute bronchiolitis. It is widely used in hospital wards and critical care of pediatric patients. However, there is uncertainty on the magnitude of the effect on critical and important outcomes in these patients.

Objectives

The objective of this review is to evaluate the available evidence on the use of oxygen administered through high-flow cannula versus low-flow oxygen for the treatment of acute bronchiolitis in children under two years of age.

Methodology

We carried out a systematic review and a meta-analysis following the PRISMA standards for reporting. The search was carried out in electronic databases by two researchers independently. The evidence was summarized using the GRADE methodology.

Results

Six randomized and non-randomized clinical trials were included, including 1867 individuals younger than 24 months of age with acute bronchiolitis in pediatric emergency, hospitalization, and intensive care services. Mortality was not reported in the included studies. Treatment failure occurred in 108/933 in the high flow group and 233/934 in the low flow group (relative risk: 0.46; 95% confidence interval: 0.35 to 0.62), which shows 11.7% less treatment failure (95% confidence interval between 7.9% and 14.5% less) in the high flow group with a number needed to treat of 7.5 (95% confidence interval 6 to 10) with moderate certainty in the evidence.

Conclusion

The use of humidified and heated oxygen with high flow compared to oxygen at low flow is probably associated with decreased treatment failure in children younger than two years with acute bronchiolitis. There is uncertainty about the effect on hospitalization days and clinical progression.

LOCATE: a prospective evaluation of the value of Leveraging Ongoing Citation Acquisition Techniques for living Evidence syntheses

BACKGROUND

Living systematic reviews (LSRs) can expedite evidence synthesis by incorporating new evidence in real time. However, the methods needed to identify new studies in a timely manner are not well established.

OBJECTIVES

To explore the value of complementary search approaches in terms of search performance, impact on results and conclusions, screening workload, and feasibility compared to the reference standard.

METHODS

We developed three complementary search approaches for a systematic review on treatments for bronchiolitis: Automated Full Search, PubMed Similar Articles, and Scopus Citing References. These were automated to retrieve results monthly; pairs of reviewers screened the records and commented on feasibility. After 1 year, we conducted a full update search (reference standard). For each complementary approach, we compared search performance (proportion missed, number needed to read [NNR]) and reviewer workload (number of records screened, time required) to the reference standard. We investigated the impact of the new trials on the effect estimate and certainty of evidence for the primary outcomes. We summarized comments about feasibility.

RESULTS

Via the reference standard, reviewers screened 505 titles/abstracts, 24 full texts, and identified four new trials (NNR 127; 12.4 h). Of the complementary approaches, only the Automated Full Search located all four trials; these were located 6 to 12 months sooner than via the reference standard but did not alter the results nor certainty in the evidence. The Automated Full Search was the most resource-intensive approach (816 records screened; NNR 204; 17.1 h). The PubMed Similar Articles and Scopus Citing References approaches located far fewer records (452 and 244, respectively), thereby requiring less screening time (9.4 and 5.2 h); however, each approach located only one of the four new trials. Reviewers found it feasible and convenient to conduct monthly screening for searches of this yield (median 15-65 records/month).

CONCLUSIONS

The Automated Full Search was the most resource-intensive approach, but also the only to locate all of the newly published trials. Although the monthly screening time for the PubMed Similar Articles and Scopus Citing Articles was far less, most relevant records were missed. These approaches were feasible to integrate into reviewer work processes.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework. https://doi.org/10.17605/OSF.IO/6M28H .

Update on the Role of High-Flow Nasal Cannula in Infants with Bronchiolitis

Bronchiolitis (BR), a lower respiratory tract infection mainly caused by respiratory syncytial virus (RSV), can be very severe. Presently, adequate nutritional support and oxygen therapy remain the only interventions recommended to treat patients with BR. For years, mild BR cases were treated with noninvasive standard oxygen therapy (SOT), i.e., with cold and poorly or totally non-humidified oxygen delivered by an ambient headbox or low-flow nasal cannula. Children with severe disease were intubated and treated with invasive mechanical ventilation (IMV). To improve SOT and overcome the disadvantages of IMV, new measures of noninvasive and more efficient oxygen administration have been studied. Bi-level positive air way pressure (BiPAP), continuous positive airway pressure (CPAP), and high-flow nasal cannula (HFNC) are among them. For its simplicity, good tolerability and safety, and the good results reported in clinical studies, HFNC has become increasingly popular and is now widely used. However, consistent guidelines for initiation and discontinuation of HFNC are lacking. In this narrative review, the role of HFNC to treat infants with BR is discussed. An analysis of the literature showed that, despite its widespread use, the role of HFNC in preventing respiratory failure in children with BR is not precisely defined. It is not established whether it can offer greater benefits compared to SOT and when and in which infants it can replace CPAP or BiPAP. The analysis of the results clearly indicates the need for multicenter studies and official guidelines. In the meantime, HFNC can be considered a safe and effective method to treat children with mild to moderate BR who do not respond to SOT.

Real-life study of the role of high-flow nasal cannula for bronchiolitis in children younger than 3 months hospitalised in general pediatric departments

We aimed to describe the real-life role of high-flow nasal cannula (HFNC) for bronchiolitis in infants under 3 months of age admitted to three general pediatric departments during the 2017-2018 epidemic period. We retrospectively assessed the clinical severity (Wang score) for every 24-h period of treatment (H0-H24 and H24-H48) according to the initiated medical care (HFNC, oxygen via nasal cannula, or supportive treatments only), the child's discomfort (EDIN score), and transfer to the pediatric intensive care unit (PICU). A total of 138 infants were included: 47±53 days old, 4661±851.9 g, 70 boys (50.7%), 58 with hypoxemia (42%), Wang score of 6.67±2.58, 110 (79.7%) staying for 48 consecutive hours in the same ward. During the H0-H24 period, only patients treated with HFNC had a statistically significant decrease in the severity score (n=21/110; -2 points, P=0.002) and an improvement in the discomfort score (n=15/63; -3.8 points, P<0.0001). There was no difference between groups during the H24-H48 period. The rate of admission to the PICU was 2.9% for patients treated for at least 24 h with HFNC (n=34/138, 44% with oxygen) versus 16.3% for the others (P=0.033). Early use of HFNC improves both clinical status and discomfort in infants younger than 3 months admitted for moderately severe bronchiolitis, whatever their oxygen status.

Has the introduction of high-flow nasal cannula modified the clinical characteristics and outcomes of infants with bronchiolitis admitted to pediatric intensive care units? A retrospective study

BACKGROUND

This study aimed to assess how the emergence of high-flow nasal cannula (HFNC) has modified the demographic and clinical characteristics as well as outcomes of infants with bronchiolitis admitted to a pediatric intensive care unit (PICU).

METHODS

This was a single-center retrospective study including infants aged 1 day to 6 months with bronchiolitis requiring HFNC, noninvasive ventilation (NIV), or invasive ventilation on admission.

RESULTS

A total of 252 infants (mean age 53±36 days) were included in the study. The use of HFNC increased from 18 (21.4%) during 2013-2014 to 53 infants (55.2%) during 2015-2016. The length of stay in the PICU decreased over time from 4.7±2.9 to 3.5±2.7 days (P<0.01) but the hospital length of stay remained similar (P=0.17). On admission, patients supported by HFNC as the first-line therapy were older. The PICU length of stay was similar according to the type of respiratory support (P=0.16), but the hospital length of stay was longer for patients supported by HFNC (P=0.01).

CONCLUSION

The distribution of respiratory support has significantly changed over time for patients with bronchiolitis and HFNC is increasingly used. The demographic and clinical characteristics of the have not changed over time. However, the PICU length of stay decreased significantly.

Nasal high flow higher than 60 L/min in patients with acute hypoxemic respiratory failure: a physiological study

Background

Nasal high flow delivered at flow rates higher than 60 L/min in patients with acute hypoxemic respiratory failure might be associated with improved physiological effects. However, poor comfort might limit feasibility of its clinical use.

Methods

We performed a prospective randomized cross-over physiological study on 12 ICU patients with acute hypoxemic respiratory failure. Patients underwent three steps at the following gas flow: 0.5 L/kg PBW/min, 1 L/kg PBW/min, and 1.5 L/kg PBW/min in random order for 20 min. Temperature and FiO₂ remained unchanged. Toward the end of each phase, we collected arterial blood gases, lung volumes, and regional distribution of ventilation assessed by electrical impedance tomography (EIT), and comfort.

Results

In five patients, the etiology was pulmonary; infective disease characterized seven patients; median PaO₂/FiO₂ at enrollment was 213 [IQR 136–232]. The range of flow rate during NHF 1.5 was 75–120 L/min. PaO₂/FiO₂ increased with flow, albeit non significantly (p = 0.064), PaCO₂ and arterial pH remained stable (p = 0.108 and p = 0.105). Respiratory rate decreased at higher flow rates (p = 0.014). Inhomogeneity of ventilation decreased significantly at higher flows (p = 0.004) and lung volume at end-expiration significantly increased (p = 0.007), but mostly in the non-dependent regions. Comfort was significantly poorer during the step performed at the highest flow (p < 0.001).

Conclusions

NHF delivered at rates higher than 60 L/min in critically ill patients with acute hypoxemic respiratory failure is associated with reduced respiratory rate, increased lung homogeneity, and additional positive pressure effect, but also with worse comfort.

Decision-making in acute viral bronchiolitis: A universal guideline and a publication gap

Background

Acute viral bronchiolitis is very common in infants and children up to 2 years. Some patients develop serious respiratory symptoms and need to be hospitalized. In 2014, the American Academy of Pediatrics (AAP) published a guideline on acute bronchiolitis which has gained global acceptance. We hypothesized that a publication gap, which is increasingly perceived in clinical medicine, might have also affected these universal recommendations.

Methods

We determined the proportion of published and unpublished studies registered at ClinicalTrials.gov that were marked as completed by October 1^st 2018. The major trial and literature databases were used to search for publications. In addition, the study investigators were contacted directly.

Results

Of the 69 registered studies on the treatment of acute viral bronchiolitis, only 50 (72%) have been published by November 2019. Published trials contained data from n = 9403 patients, whereas n = 4687 patients were enrolled in unpublished trials. Median time to publication was 20 months, and only 8 of 50 trials were published within 12 months after completion. Only 40% of the clinical trials that were completed after the release of the AAP guideline were subsequently published as compared to 80% before 2014.

Conclusion

There is a significant publication gap regarding therapy of acute viral bronchiolitis that may have influenced certain recommendations of the AAP guideline. In turn, recommendations of the guideline might have discouraged investigators to publish their results after its release.

High flow nasal cannula as respiratory support in treating infant bronchiolitis: a systematic review

Bronchiolitis is a common respiratory illness in early childhood, often leading to hospitalization and associated healthcare costs. Low flow 100% oxygen through nasal prongs is the standard therapy for infants with bronchiolitis and hypoxemia. Nasal continuous positive airway pressure (nCPAP) or invasive ventilation is used in case of progressive respiratory failure. High flow heated and humidified oxygen therapy with delivery of an air-oxygen mixture up to 2 L/min/kg body weight via nasal prongs (referred to as high flow nasal cannula or HFNC) is a newer method for respiratory support. Initial data from retrospective studies were promising but should be interpreted with caution. A limited number of prospective randomized controlled trials (RCT) have now compared HFNC with either standard oxygen therapy (SOT) or nCPAP. In this review, we critically summarize the data from these RCTs with the aim to provide advice on how to position HFNC in clinical practice.Conclusion: HFNC is a safe mode of respiratory support that can be positioned between SOT and nCPAP as rescue therapy for children not adequately supported by SOT. It does not seem to shorten the duration of oxygen need nor the duration of hospital admission.What is Known:• HFNC is being used increasingly in the context of infant bronchiolitis. However, evidence on efficacy and safety are limited. Different published studies involve different disease severities and different pediatric settings.What is New:• In this review, we summarize data only from prospective RCTs with the aim to provide guidance on how to use HFNC.

Efficacy of High-Flow Nasal Cannula vs Standard Oxygen Therapy or Nasal Continuous Positive Airway Pressure in Children with Respiratory Distress: A Meta-Analysis

OBJECTIVES

To evaluate the efficacy of high-flow nasal cannula (HFNC) oxygen therapy in providing respiratory support of children with acute lower respiratory infection (ALRI), hypoxemia, and respiratory distress.

STUDY DESIGN

We performed a meta-analysis of randomized controlled trials that compared HFNC and standard flow oxygen therapy or nasal continuous positive airway pressure (nCPAP) and reported treatment failure as an outcome. Data were synthesized using Mann-Whitney U test.

RESULTS

Compared with standard oxygen therapy, HFNC significantly reduced treatment failure (risk ratio [RR] 0.49, 95% CI 0.40-0.60, P < .001) in children with mild hypoxemia (arterial pulse oximetry [SpO2] >90% on room air). HFNC had an increased risk of treatment failure compared with nCPAP in infants age 1-6 months with severe hypoxemia (SpO2 <90% on room air or SpO2 >90% on supplemental oxygen) (RR 1.77, 95% CI 1.17-2.67, P = .007). No significant differences were found in intubation rates and mortality between HFNC and standard oxygen therapy or nCPAP. HFNC had a lower risk of nasal trauma compared with nCPAP (RR 0.35, 95% CI 0.16-0.77, P = .009).

CONCLUSIONS

Among children <5 years of age with ALRI, respiratory distress, and mild hypoxemia, HFNC reduced the risk of treatment failure when compared with standard oxygen therapy. However, nCPAP was associated with a lower risk of treatment failure than HFNC in infants age 1-6 months with ALRI, moderate-to-severe respiratory distress, and severe hypoxemia. No differences were found in intubation and mortality between HFNC and standard oxygen therapy or nCPAP.

Use of high-flow nasal cannula in infants with viral bronchiolitis outside pediatric intensive care units

High-flow nasal cannula (HFNC) is frequently used in infants with acute viral bronchiolitis outside pediatric intensive care units (PICU). A structured questionnaire was sent out to pediatricians of all public French hospitals with pediatric emergency and/or general pediatric departments on their use of HFNC outside PICU (department using HFNC, number of available devices, monitoring, criteria for initiating or stopping HFNC, and personal comments on HFNC). Of the 166 eligible hospitals, 135 answered (96 general and 39 university hospitals; 81.3%), for a total of 217 answering pediatricians. Seventy-two hospitals (53.3%) used HFNC in acute bronchiolitis outside PICU, particularly, general hospitals (59.4% vs 38.5%), and mostly in pediatric general departments (75%). Continuous patient monitoring with a cardiorespiratory monitor was usual (n = 58, 80%). Nursing staff was responsible for 2.7 children on HFNC and checked vital signs 8.6 times per day. Criteria for HFNC initiation and withdrawal were not standardized. Pediatricians had a positive opinion of HFNC and were willing to extend its use to other diseases.Conclusion: Use of HFNC outside PICU in infants with acute bronchiolitis is now usual, but urgently requires guidelines. What is Known: • Acute viral bronchiolitis treatment is only supportive • High-flow nasal cannula (HFNC) is a respiratory support accumulating convincing clinical evidence in bronchiolitis • This latter treatment is usually proposed in pediatric intensive care unit (PICU) What is New: • HFNC are increasingly used outside PICU in bronchiolitis, particularly, in general hospitals and in pediatric general departments • Pediatricians are enthusiastic about this device, but validated criteria for initiation and withdrawal are lacking • Guidelines for the use of HFNC outside PICU are urgently required.

The Problematic 2014 American Academy of Pediatrics Bronchiolitis Guidelines

The 2014 American Academy of Pediatrics bronchiolitis guidelines do not adequately serve the needs and clinical realities of front-line clinicians caring for undifferentiated wheezing infants and children. This article describes the clinical challenges of evaluating and managing a heterogeneous disease syndrome presenting as undifferentiated patients to the emergency department. Although the 2014 American Academy of Pediatrics bronchiolitis guidelines and the multiple international guidelines that they closely mirror have made a good faith attempt to provide clinicians with the best evidence-based recommendations possible, they have all failed to address practical, front-line clinical challenges. The therapeutic nihilism of the guidelines and the dissonance between many of the recommendations and frontline realities have had wide-ranging consequences. Nevertheless, newer evidence of therapeutic options is emerging and forecasts hope for more therapeutically optimistic recommendations with the next revision of the guidelines.

Does high-flow oxygen reduce escalation of care in infants with hypoxaemic bronchiolitis?

Bronchiolitis is an acute, lower respiratory tract disease of viral aetiology that affects infants below 2 years of age [1]. Bronchiolitis is common. One in five children have at least one healthcare visit related to bronchiolitis during infancy and it is a major cause of hospitalisation, accounting for 18% of all hospitalisations in the USA in children younger than 1 year [2]. The diagnosis is clinical and based on viral respiratory infection symptoms and signs such as tachypnoea, wheeze, crackles, rhonchi and respiratory distress [3]. There are no effective medical therapies for bronchiolitis so treatment is based on hydration and respiratory supportive care when necessary [3]. The use of high-flow oxygen through nasal cannula as respiratory support in infants with bronchiolitis has increased in recent years [4]. It provides a high flow of humidified air warmed to body temperature with an adjustable fraction of oxygen, and is usually well tolerated by infants. It may improve oxygenation and breathing effort by producing a positive pressure at the end of the expiration [5]. Franklinet al. [6] examined treatment failure resulting in escalation of care in infants with bronchiolitis and hypoxaemia who were treated in emergency departments or general paediatric wards with either high-flow oxygen or standard therapy with supplemental oxygen through a nasal cannula.

Treatment failure leading to escalation of care occurred less often in infants with hypoxaemic bronchiolitis treated with high-flow oxygen than with standard oxygen therapy, but there were no differences in the proportion needing ICU transfer or intubationhttp://bit.ly/2F3rSi1

Nutritional management of young infants presenting with acute bronchiolitis in Belgium, France and Switzerland: survey of current practices and documentary search of national guidelines worldwide

Feeding difficulties are common in young infants presenting with acute bronchiolitis, but limited data is available to guide clinicians adapting nutritional management. We aimed to assess paediatricians' nutritional practices among Western Europe French speaking countries. A survey was disseminated to describe advice given to parents for at home nutritional support, in hospital nutritional management, and preferred methods for enteral nutrition and for intravenous fluid management. A documentary search of international guidelines was concomitantly conducted. Ninety-three (66%) contacted physicians responded. Feeding difficulties were a common indication for infants' admission. Written protocols were rarely available. Enteral nutrition was favoured most of the time when oral nutrition was insufficient and might be withheld in case of severe dyspnoea to decrease respiratory workload. Half of physicians were aware of hyponatremia risk and pathophysiology, and isotonic intravenous solutions were used in less than 15% of centres. International guideline search (23 countries) showed a lack of detailed nutritional management recommendations in most of them.Conclusion: practices were inconsistent among physicians. Guidelines detailed nutritional management poorly. Awareness of hyponatremia risk in relation to intravenous hypotonic fluids and of the safety of enteral hydration and nutrition is insufficient. New guidelines including detailed nutritional management recommendations are urgently needed. What is Known? • Infants presenting with acute bronchiolitis face feeding difficulties. • Underfeeding may promote undernutrition, and intravenous hydration with hypotonic fluids may induce hyponatremia. What is New? • Physicians' nutritional practices are inconsistent and awareness of hyponatremia risk and pathophysiology is insufficient among physicians. • Awareness of hyponatremia risk and pathophysiology is insufficient among physicians. • The reasons for enteral nutrition withholding in bronchiolitis infants are not evidence based, and national guidelines of acute bronchiolitis across the world are elusive regarding nutritional management. • National guidelines of acute bronchiolitis across the world are elusive regarding nutritional management.