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

High-flow nasal cannula oxygen therapy for children with bronchiolitis: Implementation of a national guideline

AIM

High flow nasal cannula (HFNC) therapy is a form of respiratory support used in children with bronchiolitis. A national guideline for the use of HFNC was published in The Netherlands in 2020. We studied the implementation and use of this guideline.

METHODS

We performed a multicentre observational study amongst all hospitals in the North-West part of The Netherlands referring to the same paediatric intensive care unit (PICU). This study consisted of two parts: a comparison of local HFNC protocols to the national guideline and a survey about the use of HFNC amongst paediatricians in the participating centres.

RESULTS

We observed considerable variations between the local protocols and the national protocol, especially regarding criteria to initiate HFNC treatment and weaning practices. Survey results showed that expectations of HFNC widely varied, while the clinical use of HFNC deviated from both the national guideline as well as local protocols, especially for weaning practices and the use of pCO2 as a parameter for initiation and evaluation of the effect of HFNC.

CONCLUSION

Implementation of the national guideline for HFNC therapy in bronchiolitis was inefficacious, leading to non-uniform clinical practice.

Effectiveness of Manual Bronchial Clearance Techniques in the Treatment of Bronchiolitis

BACKGROUND

Bronchiolitis is a seasonal viral infection of the respiratory tract that causes numerous childhood hospitalizations annually. Treatments vary based on severity, with mild cases requiring fluids and moderate to severe cases involving hospitalization with oxygen therapy, bronchodilators, and chest physiotherapy. Manual bronchial clearance techniques differ between Anglo-Saxon and European schools, and their effectiveness remains a subject of debate.

OBJECTIVE

The aim of this systematic review is to evaluate the effectiveness of manual bronchial clearance techniques in bronchiolitis by assessing clinical outcomes, including improved ventilation, increased oxygen saturation, and enhanced hemodynamic and respiratory stability.

MATERIALS AND METHODS

A systematic review was conducted between 2013 and 2024 using PRISMA guidelines. Databases searched included PubMed, Science Direct, Scopus, Springer, and Google Scholar; the inclusion criteria focused on randomized clinical trials and cohort studies in English, Spanish, and Portuguese. The selection bias was evaluated. The study was registered in Prospero (CRD42023486450).

RESULTS

Five articles involving 291 participants diagnosed with mild to moderate bronchiolitis were analyzed. The assessed techniques included Anglo-Saxon school and European School. Heart rate was evaluated in four studies, showing significant reductions in one (p < 0.01), while the significance in the other studies was not specified. Respiratory rate was assessed in three studies, with significant results being seen in two (p < 0.05). SpO2 was examined in all six studies, demonstrating significant improvements in two (p = 0.02 and p < 0.05). The Kristjansson respiratory score showed significant changes in one study (p = 0.005), and the Wang respiratory score indicated significant results in another (p = 0.03). These findings support the efficacy of chest physiotherapy techniques in managing bronchiolitis.

CONCLUSIONS

While Anglo-Saxon techniques are widely used, their effectiveness remains a subject of debate. In contrast, European techniques indicate promising clinical outcomes, including improved ventilation, increased oxygen saturation, and enhanced respiratory stability; however, additional studies could further validate these findings.

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.

Systematic review and network meta-analysis of non-invasive respiratory support in paediatric patients with acute hypoxaemic respiratory failure: a protocol

INTRODUCTION

Acute hypoxic respiratory failure (AHRF) is one of the most common causes of admission to paediatric intensive care units (PICUs) around the world, posing a serious health concern for the global community. Non-invasive respiratory support (NRS) is considered effective in reducing mortality and intubation rates in adults. However, it is not yet clear whether NRS is beneficial for children and which NRS modalities are most effective. This network meta-analysis aims to summarise existing evidence and compare the efficacy and safety of different NRS modalities in paediatric patients with acute hypoxaemic respiratory failure.

METHODS AND ANALYSIS

To identify randomised controlled trials, we will perform a systematic search of key databases (Embase, PubMed, CENTRAL, CINAHL Complete and Web of Science) and registered clinical trials (ClinicalTrials.gov, WHO ICTRP and ISRCTN). To ensure the inclusion of the latest literature, an initial pilot search was conducted on 8 July 2024, and an updated search will be conducted after the main research work of this study. AHRF in children treated with NRS will be included. Hospital mortality, intubation rate, treatment failure rate and serious adverse events are critical outcomes closely related to patient-centredness and importance. Two authors will independently select the studies and extract the data. The risk of bias will be assessed using the Cochrane risk of bias tool V.2.0. In order to compare the effects of different NRS modalities, pairwise meta-analysis and network meta-analysis will be conducted using R software. Several subgroup analyses will be conducted, including analyses of different causes of AHRF. We will conduct sensitivity analyses by excluding studies with a high risk of bias and those involving neonates. Using the Grading of Recommendations Assessment, Development and Evaluation methodology, we will assess the certainty of the evidence for the effect estimates of all the outcomes.

ETHICS AND DISSEMINATION

Since this research is a network meta-analysis based on published literature, no formal ethics approval is required. The results will be disseminated through a peer-reviewed journal for publication.

PROSPERO REGISTRATION NUMBER

CRD42024529804.

Pediatric pulmonology year in review-Pediatric pulmonary critical care

Pediatric pulmonary critical care literature has continued to grow in recent years. Our aim in this review is to narrowly focus on publications providing clinically-relevant advances in pediatric pulmonary critical care in 2023.

High-flow nasal cannula in Spanish Pediatric Intensive Care Services: A national web survey about its use and indications

OBJECTIVE

To describe the high-flow nasal cannula (HFNC) indications in the Spanish pediatric critical care units (PICUs).

DESIGN

Descriptive cross-sectional observational study.

SETTING

Electronic survey among members of the Spanish Society of Pediatric Intensive Care (SECIP). It was sent weekly from April 10, 2023, to May 21, 2023.

PARTICIPANTS

All SECIP members.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

The questions focused on workplace, years of experience, use or non-use of HFNC, justification and expectations regarding its application, starting point within each center, clinical criteria for indication, existence of clinical guidelines, evaluation during its use, and criteria and mode of withdrawal.

RESULTS

Two hundred and two participants, 176 were from Spain. Of these, 87/176 had over ten years of experience. One hundred sixty two use HFNC and 66/162 have HFNC clinical guidelines. Acute bronchiolitis (138/162) and respiratory assistance after extubation (106/56) are the two main indications. For 62/162 HFNC may reduce therapeutic escalation. Neuromuscular diseases (105/162) and anatomical airway diseases (135/162) are the two main contraindications. The reasons to do not use HFNC were the absence of evidence about it effectiveness (8/14) and its inadequate cost/effectiveness balance (8/14).

CONCLUSIONS

A majority of Spanish pediatric intensivists use HFNC. Its application and withdrawal appears to be primarily based on clinical experience. Besides, those who use HFNC are aware of its limitations and the lack of evidence in some cases. It is necessary to develop single-center and multicenter studies to elucidate the effectiveness of this therapy in the context of critically ill children.

Nasal CPAP in the Pediatric Ward to Reduce PICU Admissions for Severe Bronchiolitis?

In treating acute bronchiolitis in infants, the decision to use continuous positive airway pressure (CPAP) often involves infant referral from the pediatric ward to the pediatric intensive care unit (PICU). We present our experience of CPAP use in a general pediatric ward, aiming to reduce the pressure on the PICU in recent outbreaks of bronchiolitis. Clinical data of patients less than 12 months of age and admitted for bronchiolitis from 1 October 2021 to 31 March 2023 were retrospectively collected. Of 82 infants admitted for bronchiolitis, 16 (19%) were treated with nasal CPAP (nCPAP group); of the remaining 66, 21 (26%) were treated with a low-flow nasal cannula (LFNC) only, 1 (1%) was also treated a with high-flow nasal cannula (HFNC), 12 (15%) were treated with an HFNC only, and 41 (50%) were treated without oxygen support (no-nCPAP group). Overall, coinfection with RSV and SARS-CoV-2 was observed in three patients and SARS-CoV-2 infection was observed in two patients. None of them required any type of oxygen support. Only 3/16 (19%) infants in the nCPAP group were referred to the PICU due to worsening clinical conditions despite nCPAP support. In our experience of treating epidemic bronchiolitis, nCPAP can be safely managed in a general pediatric ward, thus reducing the burden of admissions to the PICU. Training and regular updating of the pediatric staff, careful monitoring of the patient, and close cooperation with the PICU were instrumental for our team.