FIRST-line support for Assistance in Breathing in Children (FIRST-ABC): a multicentre pilot randomised controlled trial of high-flow nasal cannula therapy versus continuous positive airway pressure in paediatric critical care

High-Flow Nasal Cannula Versus Nasal Prong Bubble Continuous Positive Airway Pressure in Children With Moderate to Severe Acute Bronchiolitis: A Randomized Controlled Trial

OBJECTIVES

To compare high-flow nasal cannula (HFNC) versus nasal prong bubble continuous positive airway pressure (b-CPAP) in children with moderate to severe acute bronchiolitis.

DESIGN

A randomized controlled trial was carried out from August 2019 to February 2022. (Clinical Trials Registry of India number CTRI/2019/07/020402).

SETTING

Pediatric emergency ward and ICU within a tertiary care center in India.

PATIENTS

Children 1-23 months old with moderate to severe acute bronchiolitis.

INTERVENTION

Comparison of HFNC with b-CPAP, using a primary outcome of treatment failure within 24 hours of randomization, as defined by any of: 1) a 1-point increase in modified Wood's clinical asthma score (m-WCAS) above baseline, 2) a rise in respiratory rate (RR) greater than 10 per minute from baseline, and 3) escalation in respiratory support. The secondary outcomes were success rate after crossover, if any, need for mechanical ventilation (invasive/noninvasive), local skin lesions, length of hospital stay, and complications.

RESULTS

In 118 children analyzed by intention-to-treat, HFNC (n = 59) versus b-CPAP (n = 59) was associated with a lower failure rate (23.7% vs. 42.4%; relative risk [95% CI], RR 0.56 [95% CI, 0.32-0.97], p = 0.031). The Cox proportion model confirmed a lower hazard of treatment failure in the HFNC group (adjusted hazard ratio 0.48 [95% CI, 0.25-0.94], p = 0.032). No crossover was noted. A lower proportion escalated to noninvasive ventilation in the HFNC group (15.3%) versus the b-CPAP group (15.3% vs. 39% [RR 0.39 (95% CI, 0.20-0.77)], p = 0.004). The HFNC group had a longer median (interquartile range) duration of oxygen therapy (4 [3-6] vs. 3 [3-5] d; p = 0.012) and hospital stay (6 [5-8.5] vs. 5 [4-7] d, p = 0.021). No significant difference was noted in other secondary outcomes.

CONCLUSION

In children aged one to 23 months with moderate to severe acute bronchiolitis, the use of HFNC therapy as opposed to b-CPAP for early respiratory support is associated with a lower failure rate and, secondarily, a lower risk of escalation to mechanical ventilation.

High-flow nasal cannula use in pediatric patients for other indications than acute bronchiolitis-a scoping review of randomized controlled trials

The objective of the study is to summarize current literature on high-flow nasal cannula (HFNC) use for different indications in pediatric patient excluding acute bronchiolitis and neonatal care. The study design is a systematic scoping review. Pubmed, Scopus, and Web of Science databases were searched in February, 2023. All abstracts and full texts were screened by two independent reviewers. Randomized controlled trials focusing on HFNC use in pediatric patients (age < 18 years) were included. Studies focusing on acute bronchiolitis and neonatal respiratory conditions were excluded. Study quality was assessed by Cochrane risk of bias 2.0 tool. The main outcomes are patient groups and indications, key outcomes, and risk of bias. After screening 1276 abstracts, we included 22 full reports. Risk of bias was low in 11 and high in 5 studies. We identified three patient groups where HFNC has been studied: first, children requiring primary respiratory support for acute respiratory failure; second, perioperative use for either intraprocedural oxygenation or postoperative respiratory support; and third, post-extubation care in pediatric intensive care for other than postoperative patients. Clinical and laboratory parameters were assessed as key outcomes. None of the studies analyzed cost-effectiveness.Conclusion: This systematic scoping review provides an overview of current evidence for HFNC use in pediatric patients. Future studies should aim for better quality and include economic evaluation with cost-effectiveness analysis.Protocol registration: Protocol has been published https://osf.io/a3y46/ .

Is Provider Training Level Associated with First Pass Success of Endotracheal Intubation in the Pediatric Intensive Care Unit?

Endotracheal intubation is a life-saving procedure in critically ill pediatric patients and a foundational skill for critical care trainees. Multiple intubation attempts are associated with increased adverse events and increased morbidity and mortality. Thus, we aimed to determine patient and provider factors associated with first pass success of endotracheal intubation in the pediatric intensive care unit (PICU). This prospective, single-center quality improvement study evaluated patient and provider factors associated with multiple intubation attempts in a tertiary care, academic, PICU from May 2017 to May 2018. The primary outcome was the number of tracheal intubation attempts. Predictive factors for first pass success were analyzed by using univariate and multivariable logistic regression analysis. A total of 98 intubation encounters in 75 patients were analyzed. Overall first pass success rate was 67% (66/98), and 7% (7/98) of encounters required three or more attempts. A Pediatric critical care medicine (PCCM) fellow was the first laryngoscopist in 94% (92/98) of encounters with a first pass success rate of 67% (62/92). Age of patient, history of difficult airway, provider training level, previous intubation experience, urgency of intubation, and time of day were not predictive of first pass success. First pass success improved slightly with increasing fellow year (fellow year = 1, 66%; fellow year = 2, 68%; fellow year = 3, 69%) but was not statistically significant. We identified no intrinsic or extrinsic factors associated with first pass intubation success. At a time when PCCM fellow intubation experience is at risk of declining, PCCM fellows should continue to take the first attempt at most intubations in the PICU.

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.

Association of Extubation Failure Rates With High-Flow Nasal Cannula, Continuous Positive Airway Pressure, and Bilevel Positive Airway Pressure vs Conventional Oxygen Therapy in Infants and Young Children: A Systematic Review and Network Meta-Analysis

Importance

Extubation failure (EF) has been associated with worse outcomes in critically ill children. The relative efficacy of different modes of noninvasive respiratory support (NRS) to prevent EF is unknown.

Objective

To study the reported relative efficacy of different modes of NRS (high-flow nasal cannula [HFNC], continuous positive airway pressure [CPAP], and bilevel positive airway pressure [BiPAP]) compared to conventional oxygen therapy (COT).

Data Sources

MEDLINE, Embase, and CINAHL Complete through May 2022.

Study Selection

Randomized clinical trials that enrolled critically ill children receiving invasive mechanical ventilation for more than 24 hours and compared the efficacy of different modes of postextubation NRS.

Data Extraction and Synthesis

Random-effects models were fit using a bayesian network meta-analysis framework. Between-group comparisons were estimated using odds ratios (ORs) or mean differences with 95% credible intervals (CrIs). Treatment rankings were assessed by rank probabilities and the surface under the cumulative rank curve (SUCRA).

Main Outcomes and Measures

The primary outcome was EF (reintubation within 48 to 72 hours). Secondary outcomes were treatment failure (TF, reintubation plus NRS escalation or crossover to another NRS mode), pediatric intensive care unit (PICU) mortality, PICU and hospital length of stay, abdominal distension, and nasal injury.

Results

A total of 11 615 citations were screened, and 9 randomized clinical trials with a total of 1421 participants were included. Both CPAP and HFNC were found to be more effective than COT in reducing EF and TF (CPAP: OR for EF, 0.43; 95% CrI, 0.17-1.0 and OR for TF 0.27, 95% CrI 0.11-0.57 and HFNC: OR for EF, 0.64; 95% CrI, 0.24-1.0 and OR for TF, 0.34; 95% CrI, 0.16- 0.65). CPAP had the highest likelihood of being the best intervention for both EF (SUCRA, 0.83) and TF (SUCRA, 0.91). Although not statistically significant, BiPAP was likely to be better than COT for preventing both EF and TF. Compared to COT, CPAP and BiPAP were reported as showing a modest increase (approximately 3%) in nasal injury and abdominal distension.

Conclusions and Relevance

The studies included in this systematic review and network meta-analysis found that compared with COT, EF and TF rates were lower with modest increases in abdominal distension and nasal injury. Of the modes evaluated, CPAP was associated with the lowest rates of EF and TF.

High flow nasal cannula therapy in the pediatric home setting

BACKGROUND

High-flow nasal cannula (HFNC) therapy may be better tolerated than traditional noninvasive ventilation (NIV) and is rapidly gaining acceptance in pediatric acute care. In Israel, HFNC is approved for domestic use. We aim to describe its indications, efficacy, parental satisfaction, and safety.

METHODS

Retrospective study of children treated with home HFNC therapy in three pediatric centers. Data included demographic parameters, indication of use, weight and days of hospitalization before and after initiation. Safety, tolerability, and parental satisfaction were assessed via standardized telephone questionnaire.

RESULTS

Median (interquartile range [IQR]) age of initiating home HFNC in 75 children was 8.3 (2.2, 29.6) months. Indications were obstructive sleep apnea (33; 44%), airway malacia (19; 25%), chronic lung disease (15; 20%), neuromuscular disease (4; 5%), and postextubation support (4; 5%). Weight standard deviation score rose from -2.3 pre-HFNC to -1.7 at 6.7 months post-HFNC initiation, p < 0.001. Hospital admission days during the 2 months pre- versus post-HFNC initiation were 22 (5.5, 60) and 5 (0, 14.7) respectively, p < 0.008. Median (IQR) parental satisfaction score was 5/5 (4, 5). Fifty of 60 (83%) respondents would recommend home HFNC to other families in a similar situation. There were no serious adverse events.

CONCLUSION

In our population, domestic HFNC appeared safe and well tolerated for a variety of indications. Its introduction was associated with improved weight gain, fewer hospitalization days and high parental satisfaction. Further work is required to characterize groups of children most likely to benefit from HFNC, as opposed to traditional modes of NIV.

Noninvasive Ventilation for Acute Respiratory Failure in Pediatric Patients: A Systematic Review and Meta-Analysis

OBJECTIVE

To perform a systematic review and meta-analysis of randomized controlled trials (RCTs) on the use of noninvasive ventilation (NIV) for acute respiratory failure (ARF) in pediatric patients.

DATA SOURCES

We searched PubMed, EMBASE, the Cochrane Central Register of Clinical Trials, and Clinicaltrials.gov with a last update on July 31, 2022.

STUDY SELECTION

We included RCTs comparing NIV with any comparator (standard oxygen therapy and high-flow nasal cannula [HFNC]) in pediatric patients with ARF. We excluded studies performed on neonates and on chronic respiratory failure patients.

DATA EXTRACTION

Baseline characteristics, intubation rate, mortality, and hospital and ICU length of stays were extracted by trained investigators.

DATA SYNTHESIS

We identified 15 RCTs (2,679 patients) for the final analyses. The intubation rate was 109 of 945 (11.5%) in the NIV group, and 158 of 1,086 (14.5%) in the control group (risk ratio, 0.791; 95% CI, 0.629-0.996; p = 0.046; I2 = 0%; number needed to treat = 31). Findings were strengthened after removing studies with intervention duration shorter than an hour and after excluding studies with cross-over as rescue treatment. There was no difference in mortality, and ICU and hospital length of stays.

CONCLUSIONS

In pediatric patients, NIV applied for ARF might reduce the intubation rate compared with standard oxygen therapy or HFNC. No difference in mortality was observed.

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.

Evaluation of tracheal intubations in a paediatric intensive care unit

INTRODUCTION

Tracheal intubation is a frequent procedure in paediatric intensive care units (PICUs) that carries a risk of complications that can increase morbidity and mortality.

PATIENTS AND METHODS

Prospective, longitudinal, observational study in patients intubated in a level III PICU between January and December 2020. We analysed the risk factors associated with failed intubation and adverse events.

RESULTS

The analysis included 48 intubations. The most frequent indication for intubation was hypoxaemic respiratory failure (25%). The first attempt was successful in 60.4% of intubations, without differences between procedures performed by staff physicians and resident physicians (62.5% vs 56.3%; P = .759). Difficulty in bag-mask ventilation was associated with failed intubation in the first attempt (P = .028). Adverse events occurred in 12.5% of intubations, and severe events in 8.3%, including 1 case of cardiac arrest, 2 cases of severe hypotension and 1 of oesophageal intubation with delayed recognition. None of the patients died. Making multiple attempts was significantly associated with adverse events (P < .002). Systematic preparation of the procedure with cognitive aids and role allocation was independently associated with a lower incidence of adverse events.

CONCLUSIONS

In critically ill children, first-attempt intubation failure is common and associated with difficulty in bag-mask ventilation. A significant percentage of intubations may result in serious adverse events. The implementation of intubation protocols could decrease the incidence of adverse events.

Executive Summary: International Clinical Practice Guidelines for Pediatric Ventilator Liberation, A Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network Document

Rationale: Pediatric-specific ventilator liberation guidelines are lacking despite the many studies exploring elements of extubation readiness testing. The lack of clinical practice guidelines has led to significant and unnecessary variation in methods used to assess pediatric patients' readiness for extubation. Methods: Twenty-six international experts comprised a multiprofessional panel to establish pediatrics-specific ventilator liberation clinical practice guidelines, focusing on acutely hospitalized children receiving invasive mechanical ventilation for more than 24 hours. Eleven key questions were identified and first prioritized using the Modified Convergence of Opinion on Recommendations and Evidence. A systematic review was conducted for questions that did not meet an a priori threshold of ⩾80% agreement, with Grading of Recommendations, Assessment, Development, and Evaluation methodologies applied to develop the guidelines. The panel evaluated the evidence and drafted and voted on the recommendations. Measurements and Main Results: Three questions related to systematic screening using an extubation readiness testing bundle and a spontaneous breathing trial as part of the bundle met Modified Convergence of Opinion on Recommendations criteria of ⩾80% agreement. For the remaining eight questions, five systematic reviews yielded 12 recommendations related to the methods and duration of spontaneous breathing trials, measures of respiratory muscle strength, assessment of risk of postextubation upper airway obstruction and its prevention, use of postextubation noninvasive respiratory support, and sedation. Most recommendations were conditional and based on low to very low certainty of evidence. Conclusions: This clinical practice guideline provides a conceptual framework with evidence-based recommendations for best practices related to pediatric ventilator liberation.

Operational Definitions Related to Pediatric Ventilator Liberation

BACKGROUND

Common, operational definitions are crucial to assess interventions and outcomes related to pediatric mechanical ventilation. These definitions can reduce unnecessary variability among research and quality improvement efforts, to ensure findings are generalizable, and can be pooled to establish best practices.

RESEARCH QUESTION

Can we establish operational definitions for key elements related to pediatric ventilator liberation using a combination of detailed literature review and consensus-based approaches?

STUDY DESIGN AND METHODS

A panel of 26 international experts in pediatric ventilator liberation, two methodologists, and two librarians conducted systematic reviews on eight topic areas related to pediatric ventilator liberation. Through a series of virtual meetings, we established draft definitions that were voted upon using an anonymous web-based process. Definitions were revised by incorporating extracted data gathered during the systematic review and discussed in another consensus meeting. A second round of voting was conducted to confirm the final definitions.

RESULTS

In eight topic areas identified by the experts, 16 preliminary definitions were established. Based on initial discussion and the first round of voting, modifications were suggested for 11 of the 16 definitions. There was significant variability in how these items were defined in the literature reviewed. The final round of voting achieved ≥ 80% agreement for all 16 definitions in the following areas: what constitutes respiratory support (invasive mechanical ventilation and noninvasive respiratory support), liberation and failed attempts to liberate from invasive mechanical ventilation, liberation from respiratory support, duration of noninvasive respiratory support, total duration of invasive mechanical ventilation, spontaneous breathing trials, extubation readiness testing, 28 ventilator-free days, and planned vs rescue use of post-extubation noninvasive respiratory support.

INTERPRETATION

We propose that these consensus-based definitions for elements of pediatric ventilator liberation, informed by evidence, be used for future quality improvement initiatives and research studies to improve generalizability and facilitate comparison.

Commentary on the First-Line Support for Assistance in Breathing in Children Trials on Noninvasive Respiratory Support: Taking a Closer Look

Noninvasive respiratory support modalities such as high-flow nasal cannula (HFNC) therapy and continuous positive airway pressure (CPAP) are used frequently in pediatric critical care to support acutely ill children with respiratory failure (step-up management) and children following extubation (step-down management). Although there are several observational studies and database analyses comparing the efficacy of HFNC and CPAP, and a few small randomized clinical trials (RCTs), until recently, there were no large RCTs comparing the two modalities in a mixed group of critically ill children. In the first half of 2022, results from the First-Line Support for Assistance in Breathing in Children (FIRST-ABC) trials were published; these comprised a master protocol of two trials: one in acutely ill children (step-up RCT) and one in extubated children (step-down RCT). Each of these pragmatic trials randomized 600 children to either HFNC or CPAP when the treating clinician decided that noninvasive respiratory support beyond standard oxygen therapy was required. The primary outcome was time to liberation from all forms of respiratory support (invasive and noninvasive), excluding supplemental oxygen. The FIRST-ABC trials represent a significant advance in the field of noninvasive respiratory support, which has traditionally been evidence-poor and associated with considerable variability in clinical practice. In this article, we provide an overview of how the FIRST-ABC trials were conceived and conducted, our view on the results, and how the trial findings have changed our clinical practice.

Commentary on High-Flow Nasal Cannula and Continuous Positive Airway Pressure Practices After the First-Line Support for Assistance in Breathing in Children Trials

Continuous positive airway pressure (CPAP) and heated humidified high-flow nasal cannula (HFNC) are commonly used to treat children admitted to the PICU who require more respiratory support than simple oxygen therapy. Much has been published on these two treatment modalities over the past decade, both in Pediatric Critical Care Medicine (PCCM ) and elsewhere. The majority of these studies are observational analyses of clinical, administrative, or quality improvement datasets and, therefore, are only able to establish associations between exposure to treatment and outcomes, not causation. None of the initial randomized clinical trials comparing HFNC and CPAP were definitive due to their relatively small sample sizes with insufficient power for meaningful clinical outcomes (e.g., escalation to bilevel noninvasive ventilation or intubation, duration of PICU-level respiratory support, mortality) and often yielded ambiguous findings or conflicting results. The recent publication of the First-Line Support for Assistance in Breathing in Children (FIRST-ABC) trials represented a major step toward understanding the role of CPAP and HFNC use in critically ill children. These large, pragmatic, randomized clinical trials examined the efficacy of CPAP and HFNC either for "step up" (i.e., escalation in respiratory support) during acute respiratory deterioration or for "step down" (i.e., postextubation need for respiratory support) management. This narrative review examines the body of evidence on HFNC published in PCCM , contextualizes the findings of randomized clinical trials of CPAP and HFNC up to and including the FIRST-ABC trials, provides guidance to PICU clinicians on how to implement the literature in current practice, and discusses remaining knowledge gaps and future research priorities.

The United Kingdom Paediatric Critical Care Society Study Group: The 20-Year Journey Toward Pragmatic, Randomized Clinical Trials

Over the past two decades, pediatric intensive care research networks have been formed across North America, Europe, Asia, and Australia/New Zealand. The U.K. Paediatric Critical Care Society Study Group (PCCS-SG) has over a 20-year tradition of fostering collaborative research, leading to the design and successful conduct of randomized clinical trials (RCTs). To date, the PCCS-SG network has delivered 13 different multicenter RCTs, covering a spectrum of study designs, methodologies, and scale. Lessons from the early years have led PCCS-SG to now focus on the entire process needed for developing an RCT, starting from robust preparatory steps such as surveys, data analysis, and feasibility work through to a definitive RCT. Pilot RCTs have been an important part of this process as well. Facilitators of successful research have included the presence of a national registry to facilitate efficient data collection; close partnerships with established Clinical Trials Units to bring together clinicians, methodologists, statisticians, and trial managers; greater involvement of transport teams to recruit patients early in trials of time-sensitive interventions; and the funded infrastructure of clinical research staff within the National Health Service to integrate research within the clinical service. The informal nature of PCCS-SG has encouraged buy-in from clinicians. Greater international collaboration and development of embedded trial platforms to speed up the generation and dissemination of trial findings are two key future strategic goals for the PCCS-SG research network.

Effect of High-Flow Nasal Cannula Therapy vs Continuous Positive Airway Pressure Therapy on Liberation From Respiratory Support in Acutely Ill Children Admitted to Pediatric Critical Care Units: A Randomized Clinical Trial

IMPORTANCE

The optimal first-line mode of noninvasive respiratory support for acutely ill children is not known.

OBJECTIVE

To evaluate the noninferiority of high-flow nasal cannula therapy (HFNC) as the first-line mode of noninvasive respiratory support for acute illness, compared with continuous positive airway pressure (CPAP), for time to liberation from all forms of respiratory support.

DESIGN, SETTING, AND PARTICIPANTS

Pragmatic, multicenter, randomized noninferiority clinical trial conducted in 24 pediatric critical care units in the United Kingdom among 600 acutely ill children aged 0 to 15 years who were clinically assessed to require noninvasive respiratory support, recruited between August 2019 and November 2021, with last follow-up completed in March 2022.

INTERVENTIONS

Patients were randomized 1:1 to commence either HFNC at a flow rate based on patient weight (n = 301) or CPAP of 7 to 8 cm H2O (n = 299).

MAIN OUTCOMES AND MEASURES

The primary outcome was time from randomization to liberation from respiratory support, defined as the start of a 48-hour period during which a participant was free from all forms of respiratory support (invasive or noninvasive), assessed against a noninferiority margin of an adjusted hazard ratio of 0.75. Seven secondary outcomes were assessed, including mortality at critical care unit discharge, intubation within 48 hours, and use of sedation.

RESULTS

Of the 600 randomized children, consent was not obtained for 5 (HFNC: 1; CPAP: 4) and respiratory support was not started in 22 (HFNC: 5; CPAP: 17); 573 children (HFNC: 295; CPAP: 278) were included in the primary analysis (median age, 9 months; 226 girls [39%]). The median time to liberation in the HFNC group was 52.9 hours (95% CI, 46.0-60.9 hours) vs 47.9 hours (95% CI, 40.5-55.7 hours) in the CPAP group (absolute difference, 5.0 hours [95% CI -10.1 to 17.4 hours]; adjusted hazard ratio 1.03 [1-sided 97.5% CI, 0.86-∞]). This met the criterion for noninferiority. Of the 7 prespecified secondary outcomes, 3 were significantly lower in the HFNC group: use of sedation (27.7% vs 37%; adjusted odds ratio, 0.59 [95% CI, 0.39-0.88]); mean duration of critical care stay (5 days vs 7.4 days; adjusted mean difference, -3 days [95% CI, -5.1 to -1 days]); and mean duration of acute hospital stay (13.8 days vs 19.5 days; adjusted mean difference, -7.6 days [95% CI, -13.2 to -1.9 days]). The most common adverse event was nasal trauma (HFNC: 6/295 [2.0%]; CPAP: 18/278 [6.5%]).

CONCLUSIONS AND RELEVANCE

Among acutely ill children clinically assessed to require noninvasive respiratory support in a pediatric critical care unit, HFNC compared with CPAP met the criterion for noninferiority for time to liberation from respiratory support.

TRIAL REGISTRATION

ISRCTN.org Identifier: ISRCTN60048867.

Noninvasive ventilation of air transported infants with respiratory distress in the Canadian Arctic

Objectives

Since 2016, use of nasal continuous positive airway pressure (nCPAP) in Nunavut for air transport in select patients has become common practice. This study examines the outcomes of patients transferred by air from the Qikiqtaaluk Region during air transport. We examined intubation rates, adverse events during transfer, and respiratory parameters at departure and upon arrival.

Methods

This was a retrospective review from September 2016 to December 2019 including patients under 2 years of age transferred by air on nCPAP from the Qikiqtaaluk Region of Nunavut.

Results

Data were collected for 40 transfers involving 34 unique patients. Six transfers were from remote communities in Nunavut to Iqaluit, and 33 transfers were from Iqaluit to CHEO. The primary outcome measure was whether the patient required intubation during transport, or urgent intubation upon arrival to CHEO. The median nCPAP setting during transport was 6 cm H2O (5–7 cm H2O) and at arrival to CHEO was 6 cm H2O (6–7 cm H2O). Six of the 33 (18.2%) patients required intubation during their hospital stay and five (15.2%) in a controlled ICU setting. There were no discernible adverse events that occurred during transport for 28 patients (84.5%). Four patients (12.1%) required a brief period of bag-mask ventilation and one patient had an episode of bradycardia.

Conclusions

nCPAP on air transport is a safe and useful method for providing ventilatory support to infants and young children with respiratory distress.

A systematic review, meta-analysis and economic evaluation on Neonatal cpap

The review mainly focuses on the goals to evaluate the clinical and cost effectiveness of neonatal CPAP in a decrease of Mortality, Length of Stay, Respiratory support, Extubation and Intubation. Introduction: Inclusion criteria: This review is conducted in neonates with respiratory failure, Pneumonia sepsis, necrotizing infections, Pneumothorax, Broncho pulmonary distress, respiratory distress syndrome (RDS), COVID-19, and other comorbidities also included.

Methods: The databases like PubMed, Google Scholar, and Cochrane were used in this review. Depending on inclusion criteria the full-text articles were assessed and chosen studies were recovered by methodological quality.

Results: one twenty-six studies are retrieved which met the inclusion criteria and the extracted studies were pooled statistically and their outcomes were measured. All the studies explain the efficacy of CPAP by reducing Mortality, Length of Stay, Respiratory support, Extubation and Intubation.

Conclusion: Currently the evidence states that CPAP reduces Mortality, Length of Stay, Respiratory support, Extubation and Intubation

Effect of High-Flow Nasal Cannula Therapy vs Continuous Positive Airway Pressure Following Extubation on Liberation From Respiratory Support in Critically Ill Children: A Randomized Clinical Trial

IMPORTANCE

The optimal first-line mode of noninvasive respiratory support following extubation of critically ill children is not known.

OBJECTIVE

To evaluate the noninferiority of high-flow nasal cannula (HFNC) therapy as the first-line mode of noninvasive respiratory support following extubation, compared with continuous positive airway pressure (CPAP), on time to liberation from respiratory support.

DESIGN, SETTING, AND PARTICIPANTS

This was a pragmatic, multicenter, randomized, noninferiority trial conducted at 22 pediatric intensive care units in the United Kingdom. Six hundred children aged 0 to 15 years clinically assessed to require noninvasive respiratory support within 72 hours of extubation were recruited between August 8, 2019, and May 18, 2020, with last follow-up completed on November 22, 2020.

INTERVENTIONS

Patients were randomized 1:1 to start either HFNC at a flow rate based on patient weight (n = 299) or CPAP of 7 to 8 cm H2O (n = 301).

MAIN OUTCOMES AND MEASURES

The primary outcome was time from randomization to liberation from respiratory support, defined as the start of a 48-hour period during which the child was free from all forms of respiratory support (invasive or noninvasive), assessed against a noninferiority margin of an adjusted hazard ratio (HR) of 0.75. There were 6 secondary outcomes, including mortality at day 180 and reintubation within 48 hours.

RESULTS

Of the 600 children who were randomized, 553 children (HFNC, 281; CPAP, 272) were included in the primary analysis (median age, 3 months; 241 girls [44%]). HFNC failed to meet noninferiority, with a median time to liberation of 50.5 hours (95% CI, 43.0-67.9) vs 42.9 hours (95% CI, 30.5-48.2) for CPAP (adjusted HR, 0.83; 1-sided 97.5% CI, 0.70-∞). Similar results were seen across prespecified subgroups. Of the 6 prespecified secondary outcomes, 5 showed no significant difference, including the rate of reintubation within 48 hours (13.3% for HFNC vs 11.5 % for CPAP). Mortality at day 180 was significantly higher for HFNC (5.6% vs 2.4% for CPAP; adjusted odds ratio, 3.07 [95% CI, 1.1-8.8]). The most common adverse events were abdominal distension (HFNC: 8/281 [2.8%] vs CPAP: 7/272 [2.6%]) and nasal/facial trauma (HFNC: 14/281 [5.0%] vs CPAP: 15/272 [5.5%]).

CONCLUSIONS AND RELEVANCE

Among critically ill children requiring noninvasive respiratory support following extubation, HFNC compared with CPAP following extubation failed to meet the criterion for noninferiority for time to liberation from respiratory support.

TRIAL REGISTRATION

isrctn.org Identifier: ISRCTN60048867.

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

BACKGROUND

Oxygen therapy is one of the most common treatments for bronchiolitis, But traditional standard oxygen therapy is poorly tolerated by patients. Nasal continuous positive airway pressure (nCPAP) also has many contraindications. High-flow nasal cannula (HFNC), as a new method of adjunctive respiratory support, has received extensive attention in oxygen therapy in pediatric. In this meta-analysis, we evaluated the efficacy and safety of HFNC in the treatment of infant bronchiolitis.

METHODS

We searched PubMed, Web of Science, CNKI, GeenMedical, Wanfang, and Weipu using the following keywords: children with respiratory diseases, infant bronchiolitis, bronchiolitis treatment, HFNCs, warming and humidifying high-flow, nasal catheter oxygen inhalation, and conventional oxygen therapy. The publication time was set from the establishment of the database to October 2021. Selected articles were randomized controlled trial (RCT) studies in which the patients were less than 16 years old and the experimental group was treated with HFNCs, and the control group was treated with nCPAP or conventional oxygen. After extracting the data, the study subjects were divided into HFNC treatment and control groups. The Cochrane risk of bias tool was used to assess the quality of the included literature, and RevMan 5.30 was used for meta-analysis.

RESULTS

Seven articles met the inclusion criteria. All articles described random sequence generation, four articles reported on allocation concealment, only two articles reported on the double-blind method. All articles described the complete blinding of outcome evaluation bias, outcome data bias, selective reporting bias, and other risk biases. The HFNC treatment group included 436 children, 405 children treated with nCPAP or standard oxygen therapy were included in the control. The results showed that the failure rate [relative risk (RR) is 0.57, 95% CI: 0.43-0.76], respiratory rate [mean difference (MD) is -7.43, 95% CI: -8.42 to -6.43], and social function (MD is 0.76, 95% CI: -0.32 to 1.83) of HFNC-treated children with bronchiolitis were significantly different to that of the control group patients.

DISCUSSION

HFNC treatment provides the same improvement in arterial oxygen partial pressure as standard oxygen therapy or transnasal positive airway pressure treatment, but it is significantly better at improving the respiratory rate of children with bronchiolitis.

Non-Invasive Respiratory Support During Pediatric Critical Care Transport: A Retrospective Cohort Study

Non-invasive respiratory support (NRS) including high flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), and bilevel positive airway pressure (BiPAP) is increasingly used for children with respiratory failure requiring interhospital transport by pediatric critical care transport (PCCT) teams. In this retrospective observational study of children receiving NRS on transport between January 1st, 2017 and December 31st, 2019 by a single PCCT service in England, we describe a cohort of children, looking at patient characteristics, journey logistics, adverse events, and failure of NRS (as defined by emergency intubation on transport or within 24 hours of arriving on the pediatric intensive care unit), and to attempt to identify risk factors that were associated with NRS failure. A total of 3,504 patients were transported during the study period. Three hundred and seventeen (9%) received NRS. Median age was 4.9 months (IQR 1.0–18.2); median weight was 5.1 kg (IQR 3.1–13). The primary diagnostic category was cardiorespiratory in 244/317 (77%) patients. Comorbidities were recorded in 189/317 (59.6%) patients. Median Pediatric Index of Mortality-3 (PIM3) score was 0.024 (IQR 0.012–0.045). Median stabilization time was 80 minutes while median patient journey time was 40 minutes. Nineteen adverse events were described (clinical deterioration, equipment failure/interface issues) affecting 6% of transports. The incidence of NRS failure was 6.6%. No risk factors associated with NRS failure were identified. We concluded that NRS can be considered safe during pediatric transport for children with a wide range of diagnoses and varying clinical severity, with a low rate of adverse events and need for intubation on transport or on the PICU.

Clinical review of High Flow Nasal Cannula and Continuous Positive Airway Pressure in pediatric acute respiratory distress

Acute Respiratory Distress Syndrome (ARDS) causes much morbidity and mortality in children. In mild to moderate ARDS, non-invasive ventilation (NIV) is the treatment of choice. Recently, there are 2 kinds of NIV used Continuous Positive Airway Pressure (CPAP) or High Flow Nasal Cannula (HFNC). Both of them can be used in various respiratory distress and have different physiological mechanisms. The effectiveness to improve the clinical parameter, morbidity, and mortality are similar between CPAP and HFNC. However, HFNC application is more tolerated in acute respiratory distress in children, with less nasal injury, lower heart rate inflicted, and better comfort index score.

•

CPAP & HFNC widely used in pediatric acute respiratory distress.

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Both modalities have a different characteristics, beneficial in certain condition.

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The usage of each modalities depends on the causes of the respiratory distress.

High flow nasal cannula therapy versus continuous positive airway pressure and nasal positive pressure ventilation in infants with severe bronchiolitis: a randomized controlled trial

Introduction

non-invasive ventilation is widely used in the respiratory management of severe bronchiolitis.

Methods

a randomized controlled trial was carried out in a tertiary pediatric university hospital´s PICU over 3 years to compare between continuous positive airway pressure/nasal positive pressure ventilation (CPAP/NPPV) and high flow nasal cannula (HFNC) devices for severe bronchiolitis. The trial was recorded in the national library of medicine registry (NCT04650230). Patients aged from 7 days to 6 months, admitted for severe bronchiolitis were enrolled. Eligible patients were randomly chosen to receive either HFNC or CPAP/NPPV. If HFNC failed, the switch to CPAP/NPPV was allowed. Mechanical ventilation was the last resort in case of CPAP/NPPV device failure. The primary outcome was the success of the treatment defined by no need of care escalation. The secondary outcomes were failure predictors, intubation rate, stay length, serious adverse events, and mortality.

Results

a total of 268 patients were enrolled. The data of 255 participants were analyzed. The mean age was 51.13 ± 34.43 days. Participants were randomized into two groups; HFNC group (n=130) and CPAP/NPPV group (n=125). The success of the treatment was significantly higher in the CPAP/NPPV group (70.4% [61.6%- 78.2%) comparing to HFNC group (50.7% [41.9%- 59.6%])- (p=0.001). For secondary outcomes, lower baseline pH was the only significant failure predictor in the CPAP/NPPV group (p=0.035). There were no differences in intubation rate or serious adverse events between the groups.

Conclusion

high flow nasal cannula was safe and efficient, but CPAP/ NPPV was better in preventing treatment failure. The switch to CPAP/NPPV if HFNC failed, avoided intubation in 54% of the cases.

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.

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.

Clinical Factors of High-Flow Nasal Cannula Oxygen Success in Children

This study was aimed to evaluate the success rate of high-flow nasal cannula (HFNC) oxygen therapy and factors causing therapy failure. This prospective observational study included 131 children who received HFNC oxygen and followed-up in the pediatric emergency department, pediatric clinics, and pediatric intensive care unit between March 2018 and December 2019. The median age was 23.0 months (interquartile range [IQR]: 9.0-92.0) and 65 patients were male (49.6%). The most common reason for requiring HFNC oxygen therapy was pneumonia ( n  = 75, 57.3%). A complex chronic condition was present in 112 (85.5%) patients. Therapy success was achieved in 116 patients (88.5%). The reason for requiring treatment and the patients' complex chronic condition did not affect the success of the therapy ( p  = 0.294 and 0.091, respectively). In the first 24 hours of treatment, a significant improvement in pulse rate, respiratory rate, pH, and lactate level were observed in successful HFNC oxygen patients ( p  < 0.05). In addition, these patients showed a significant improvement in SpO ₂ and SpO ₂ /FiO ₂ ratio, and a significant decrease in FiO ₂ and flow rate ( p  < 0.05). HFNC oxygen success rate was 95.6% in patients with SpO ₂ /FiO ₂ ≥ 150 at the 24th hour; it was 58.0% in those with SpO ₂ /FiO ₂  < 150 ( p  < 0.001). Caution should be exercised in terms of HFNC oxygen failure in patients with no significant improvement in vital signs and with SpO ₂ /FiO ₂  < 150 during treatment.

[Paediatric Life Support]

The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.

Research Priorities for U.K. Pediatric Critical Care in 2019: Healthcare Professionals' and Parents' Perspectives

OBJECTIVES

The Paediatric Intensive Care Society Study Group conducted a research prioritization exercise with the aim to identify and agree research priorities in Pediatric Critical Care in the United Kingdom both from a healthcare professional and parent/caregiver perspective.

DESIGN

A modified three-round e-Delphi survey, followed by a survey of parents of the top 20 healthcare professional priorities.

SETTING

U.K. PICUs.

PATIENTS

U.K. PICU healthcare professionals who are members of the professional society and parents and family members of children, with experience of a U.K. PICU admission.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Forty-nine healthcare professional submitted topics in round 1, 98 participated in round 2, and 102 in round 3. These topics were categorized into eight broad domain areas, and within these, there were 73 specific topics in round 2. At round 3, 18 topics had a mean score less than 5.5 and were removed, leaving 55 topics for ranking in round 3. Ninety-five parents and family members completed the surveys from at least 17 U.K. PICUs. Both parents and healthcare professional prioritized research topics associated with the PICU workforce. Healthcare professional research priorities reflected issues that impacted on day-to-day management and practice. Parents' prioritized research addressing acute situations such as infection identification of and sepsis management or research addressing long-term outcomes for children and parents after critical illness. Parents prioritized research into longer term outcomes more than healthcare professional. Parental responses showed clear support for the concept of research in PICU, but few novel research questions were proposed.

CONCLUSIONS

This is the first research prioritization exercise within U.K. PICU setting to include parents' and families' perspectives and compare these with healthcare professional. Results will guide both funders and future researchers.

European Resuscitation Council Guidelines 2021: Paediatric Life Support

These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.

High flow nasal cannula in asthmatic children with suspected COVID-19

Abstract Introduction: The use of a high-flow nasal cannula as an alternative treatment for acute respiratory failure can reduce the need for invasive mechanical ventilation and the duration of hospital stays. Objective: The present study aimed to describe the use of a high-flow nasal cannula in pediatric asthmatic patients with acute respiratory failure and suspected COVID-19. Methods: To carry out this research, data were collected from medical records, including three patients with asthma diagnoses. The variables studied were: personal data (name, age in months, sex, weight, and color), clinical data (physical examination, PRAM score, respiratory rate, heart rate, and peripheral oxygen saturation), diagnosis, history of the current disease, chest, and laboratory radiography (arterial blood gases and reverse-transcriptase polymerase chain reaction). Clinical data were compared before and after using a high-flow nasal cannula. Results: After the application of the therapy, a gradual improvement in heart, respiratory rate, PaO2/FiO2 ratio, and the Pediatric Respiratory Assessment Measure score was observed. Conclusion: The simple and quick use of a high-flow nasal cannula in pediatric patients with asthma can be safe and efficient in improving their respiratory condition and reducing the need for intubation.

Progression of Respiratory Support Following Pediatric Extubation

OBJECTIVES

High-flow nasal cannula and noninvasive positive pressure ventilation have become ubiquitous in contemporary PICUs. Practice patterns associated with the use of these modalities have not been well described. In this study, we aimed to describe the use of high-flow nasal cannula and noninvasive positive pressure ventilation in children after extubation and analyze the progression of usage in association with patient factors. Our secondary aim was to describe interventions used for postextubation stridor.

DESIGN

Single-center retrospective cohort study.

SETTING

A 36-bed quaternary medical-surgical PICU.

PATIENTS

Mechanically ventilated pediatric patients admitted between April 2017 and March 2018. Exclusions were patients in the cardiac ICU, patients requiring a tracheostomy or chronic ventilatory support, and patients with limited resuscitation status.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data regarding respiratory modality use was collected for the first 72 hours after extubation. There were 427 patients included in the analysis; 51 patients (11.9%) were extubated to room air, 221 (51.8%) to nasal cannula, 132 (30.9%) to high-flow nasal cannula, and 23 (5.4%) to noninvasive positive pressure ventilation. By 72 hours, 314 patients (73.5%) were on room air, 52 (12.2%) on nasal cannula, 29 (6.8%) on high-flow nasal cannula, eight (1.9%) on noninvasive positive pressure ventilation, and 24 (5.6%) were reintubated. High-flow nasal cannula was the most used respiratory modality for postextubation stridor. Multivariate analysis demonstrated that longer duration of invasive mechanical ventilation increased the odds of initial high-flow nasal cannula and noninvasive positive pressure ventilation use, and a diagnosis of cerebral palsy increased the odds of escalating from high-flow nasal cannula to noninvasive positive pressure ventilation in the first 24 hours post extubation.

CONCLUSIONS

High-flow nasal cannula is commonly used immediately after pediatric extubation and the development of postextubation stridor; however, its usage sharply declines over the following 72 hours. Larger multicenter trials are needed to identify high-risk patients for extubation failure that might benefit the most from prophylactic use of high-flow nasal cannula and noninvasive positive pressure ventilation after extubation.

First-line support for assistance in breathing in children: statistical and health economic analysis plan for the FIRST-ABC trial

Background

The FIRST-ABC trial comprises of two pragmatic, multicentre, parallel groups, non-inferiority randomised clinical trials designed to evaluate the clinical non-inferiority of first-line use of high flow nasal cannula (HFNC) to continuous positive airway pressure (CPAP) in critically ill children who require non-invasive respiratory support (NRS).

Objectives

To describe the pre-specified statistical and health economic analysis for the FIRST-ABC trial before completion of patient recruitment and data collection.

Methods

The statistical analysis plan was designed by the chief investigators and statisticians. We define the primary and secondary outcomes, summarise methods for data collection and safety monitoring, and present a detailed description of the planned statistical and health economic analysis.

Results

The primary clinical outcome is time to liberation from respiratory support. The primary effect estimate will be the adjusted hazard ratio, reported with a 95% confidence interval. As a sensitivity analysis, the primary analysis will be repeated using time to start weaning of NRS. Subgroup analyses will be performed to test for interactions between the effect of allocated treatment group and pre-specified baseline covariates. The health economic analysis will follow the intention-to-treat principle and report the mean (95% confidence interval) incremental costs, quality-adjusted life years (QALYs) and cost-effectiveness up to 6 months. All analyses will be performed separately for each of the two trials, and any results will not be combined.

Conclusion

The FIRST-ABC trial will assess the non-inferiority of HFNC compared to CPAP in two parallel trials with shared infrastructure (step-up RCT and step-down RCT). We have developed a pre-specified statistical and health economics analysis plan for the FIRST-ABC study before trial completion to minimise analytical bias.

Trial registration

ISRCTN ISRCTN60048867. Registered on 19 June 2019.

FIRST-line support for assistance in breathing in children (FIRST-ABC): a master protocol of two randomised trials to evaluate the non-inferiority of high-flow nasal cannula (HFNC) versus continuous positive airway pressure (CPAP) for non-invasive respiratory support in paediatric critical care

INTRODUCTION

Even though respiratory support is a common intervention in paediatric critical care, there is no randomised controlled trial (RCT) evidence regarding the effectiveness of two commonly used modes of non-invasive respiratory support (NRS), continuous positive airway pressure (CPAP) and high-flow nasal cannula therapy (HFNC). FIRST-line support for assistance in breathing in children is a master protocol of two pragmatic non-inferiority RCTs to evaluate the clinical and cost-effectiveness of HFNC (compared with CPAP) as the first-line mode of support in critically ill children.

METHODS AND ANALYSIS

We will recruit participants over a 30-month period at 25 UK paediatric critical care units (paediatric intensive care units/high-dependency units). Patients are eligible if admitted/accepted for admission, aged >36 weeks corrected gestational age and <16 years, and assessed by the treating clinician to require NRS for an acute illness (step-up RCT) or within 72 hours of extubation following a period of invasive ventilation (step-down RCT). Due to the emergency nature of the treatment, written informed consent will be deferred to after randomisation. Randomisation will occur 1:1 to CPAP or HFNC, stratified by site and age (<12 vs ≥12 months). The primary outcome is time to liberation from respiratory support for a continuous period of 48 hours. A total sample size of 600 patients in each RCT will provide 90% power with a type I error rate of 2.5% (one sided) to exclude the prespecified non-inferiority margin of HR of 0.75. Primary analyses will be undertaken separately in each RCT in both the intention-to-treat and per-protocol populations.

ETHICS AND DISSEMINATION

This master protocol received favourable ethical opinion from National Health Service East of England-Cambridge South Research Ethics Committee (reference: 19/EE/0185) and approval from the Health Research Authority (reference: 260536). Results will be disseminated via publications in peer-reviewed medical journals and presentations at national and international conferences.

TRIAL REGISTRATION NUMBER

ISRCTN60048867.

A nationwide survey on the use of heated humidified high flow oxygen therapy on the paediatric wards in the UK: current practice and research priorities

Background

Heated Humidified High Flow Nasal Cannula Oxygen Therapy (HHFNC) is increasingly used on the paediatric wards and High Dependency Units (HDU) for different types of pathologies and different age groups. We aimed to describe current practice related to the use of HHFNC on the paediatric wards and HDUs, weaning practices and preferred outcome measures for future research.

Methods

We carried out a cross-sectional online survey of UK paediatric consultants or their delegates working on the paediatric wards. Descriptive analysis of their geographical, and organizational characteristics, their specialties, and their level of experience was investigated. Reasons for HHFNC initiation, weaning criteria, patients’ characteristics and their primary pathologies were also analysed.

Results

Participation of 218 paediatricians from 81 hospitals (Median: 2.7, Range: 1–11) was registered. HHFNC was provided in most of the surveyed hospitals (93%, 75/81). A High Dependency Unit (HDU) was available in 47 hospitals (58%); less than a third of those have a dedicated paediatrician. Decisions around HHFNC were made solely by paediatricians in (75%) of the cases, mostly at hospitals with no HDU compared to those with dedicated HDUs (70.3% VS 36.6, 95%CI:22.6–50.4%, P < .001). HHFNC was reported by nearly two-thirds (68%) of the practitioners who used it on the wards to be as effective or superior to CPAP (Continuous Positive Airway Pressure) with fewer complications. Failure rate while on HHFNC was identified as the most important outcome measure in any future research followed by the length of need for HHFNC support (37.1, and 28% respectively).

Conclusion

This survey showed support for developing paediatric-specific national guidance on the use of HHFNC on the wards. Our list of defined research priorities may help guide further collaborative research efforts in this field.

In vitro comparison of unit dose vs infusion pump administration of albuterol via high-flow nasal cannula in toddlers

OBJECTIVES

Transnasal pulmonary aerosol delivery using high-flow nasal cannula (HFNC) devices has become a popular route of aerosol administration in toddlers. Clinically, albuterol is administered using an infusion pump or unit doses. However, little evidence is available to compare the two administration strategies.

METHODS

A toddler manikin (15 kg) with appropriate anatomic airway was connected with collecting filter to a simulator of distressed breathing. HFNC device with mesh nebulizer placed at the inlet of a humidifier at 37°C, with the gas flow set at 25 and 3.75 L/min. Five milligrams of albuterol was delivered in all experiments. With infusion pump administration, albuterol concentrations of 5 and 1 mg/mL were delivered at 4 and 20 mL/hr for 15 minutes. With unit dose administration, 1 mL (5 mg/mL) and 2 mL (2.5 mg/mL) of albuterol were nebulized. Additional tests with mouth open and nebulizers via mask were using 5 mg/1 mL for mesh nebulizer and 5 mg/3 mL for jet nebulizer (n = 3). The drug was eluted from the filter and assayed with UV spectrophotometry (276 nm).

RESULTS

The inhaled dose was higher with unit dose than infusion pump administration with gas flows of 25 L/min (2.66 ± 0.38 vs 1.16 ± 0.28%; P = .004) and 3.75 L/min (10.51 ± 1.29 vs 8.58 ± 0.68%; P = .025). During unit dose administration, compared with closed-mouth breathing, open-mouth breathing generated a higher inhaled dose at 3.75 L/min and lower inhaled dose at 25 L/min. Compared to the nebulizers via mask with both open and closed-mouth breathing, nebulization via HFNC at 3.75 L/min generated greater inhaled dose, while HFNC at 25 L/min generated lower inhaled dose.

CONCLUSIONS

During transnasal aerosol delivery, the inhaled dose was higher with medication administrated using unit dose than using an infusion pump.

High-Flow Nasal Cannula vs. Continuous Positive Airway Pressure Therapy for the Treatment of Children <2 Years With Mild to Moderate Respiratory Failure Due to Pneumonia

Background: The aim of this prospective randomized controlled study was to further compare the clinical benefits and adverse reactions of HFNC with CPAP in the treatment of mild to moderate respiratory failure due to pneumonia in children below 2 years old. Methods: Using a prospective randomized controlled study method, 84 patients with pneumonia and mild to moderate respiratory failure admitted to the Children's Hospital Affiliated to Chongqing Medical University from January 2018 to December 2019 were randomly divided into the HFNC group and the CPAP group. It was registered as a clinical trial at clinical trials.gov, registration number: ChiCTR2000030463. Results: The analyses included 84 patients. No differences were observed between the two groups in baseline demographic or physiological characteristics. Treatment failure necessitating intubation and transfer to the PICU was noted in six of 43 infants (14%) in the HFNC group, as compared with four of 41 infants (10%) in the CPAP group (P > 0.05). There were no significant differences between the two groups in the duration of hospital stay, the duration of non-invasive respiratory support, and mortality. The 10 infants who experienced treatment failure had more severe hypoxemia with lower PaO2/FiO2 (HFNC 182 ± 11.5 and CPAP 172 ± 8.6). We found that both the HFNC group and the CPAP group showed significantly improved oxygenation and relief of respiratory distress after treatment. No differences were observed between the two groups in the development improvement of RR, PaO2, PaCO2, SpO2, and PH. Assessment of the occurrence of adverse events showed that the HFNC group had a lower level of nasal injury, a lower risk of abdominal distension, a lower intensity and frequency of sedation, and better tolerance. Conclusion: HFNC is an effective and safe initial respiratory support treatment in children <2 years with mild to moderate respiratory failure due to pneumonia, and the incidence of intubation and death is very low; concurrently, the comfort and tolerance of HFNC are better. To some extent, HFNC is a well-tolerated alternative to CPAP.

High-flow nasal cannula oxygen therapy in children: a clinical review

High-flow nasal cannula (HFNC) is a relatively safe and effective noninvasive ventilation method that was recently accepted as a treatment option for acute respiratory support before endotracheal intubation or invasive ventilation. The action mechanism of HFNC includes a decrease in nasopharyngeal resistance, washout of dead space, reduction in inflow of ambient air, and an increase in airway pressure. In preterm infants, HFNC can be used to prevent reintubation and initial noninvasive respiratory support after birth. In children, flow level adjustments are crucial considering their maximal efficacy and complications. Randomized controlled studies suggest that HFNC can be used in cases of moderate to severe bronchiolitis upon initial low-flow oxygen failure. HFNC can also reduce intubation and mechanical ventilation in children with respiratory failure. Several observational studies have shown that HFNC can be beneficial in acute asthma and other respiratory distress. Multicenter randomized studies are warranted to determine the feasibility and adherence of HFNC and continuous positive airway pressure in pediatric intensive care units. The development of clinical guidelines for HFNC, including flow settings, indications, and contraindications, device management, efficacy identification, and safety issues are needed, particularly in children.

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.

Decrease the flow setting to improve trans-nasal pulmonary aerosol delivery via "high-flow nasal cannula" to infants and toddlers

OBJECTIVES

Trans-nasal pulmonary aerosol delivery for infants and toddlers has recently gained popularity, however, the reported lung deposition is low. We aimed to investigate the influential factors to improve the delivery.

METHODS

Anatomic airway manikins simulating infant (5 kg) and toddler (15 kg) with collecting filter connected the trachea and breath simulator, were set to represent quiet and distressed breathing. Nasal cannula flow was set at 0.125, 0.25, 0.5, 1, and 2 L/kg/min. A mesh nebulizer (Aerogen) was placed at the inlet of humidifier (Fisher & Paykel) and proximal to patient. Albuterol (5 mg in 1 mL) was nebulized for each condition (n = 3). Drug was eluted from the filter and assayed with UV spectrophotometry (276 nm).

RESULTS

Inhaled dose was higher with nebulizer placed at the inlet of humidifier than proximal to patient in all settings, except the infant model at low gas flow settings (0.125 and 0.25 L/kg/min). When nebulizer was placed at the inlet of humidifier, inhaled dose was higher when gas flow was below patient's inspiratory flow than when gas flow exceeded patient's inspiratory flow (8.77 ± 3.84 vs 2.16 ± 1.29%, P < 0.001); aerosol deposition increased as gas flow decreased, with greatest deposition at gas flow of 0.25 L/kg/min (11.29 ± 2.15%). A multiple linear regression identified gas flow as the primary predictor of aerosol delivery.

CONCLUSIONS

Trans-nasal pulmonary aerosol delivery was significantly improved when gas flow was below patient's inspiratory flow, aerosol deposition increased with decreased nasal cannula flow, with greatest deposition at 0.25 L/kg/min.

Permissive versus restrictive temperature thresholds in critically ill children with fever and infection: a multicentre randomized clinical pilot trial

Background

Fever improves pathogen control at a significant metabolic cost. No randomized clinical trials (RCT) have compared fever treatment thresholds in critically ill children. We performed a pilot RCT to determine whether a definitive trial of a permissive approach to fever in comparison to current restrictive practice is feasible in critically ill children with suspected infection.

Methods

An open, parallel-group pilot RCT with embedded mixed methods perspectives study in four UK paediatric intensive care units (PICUs) and associated retrieval services.

Participants were emergency PICU admissions aged > 28 days to < 16 years receiving respiratory support and supplemental oxygen.

Subjects were randomly assigned to permissive (antipyretic interventions only at ≥ 39.5 °C) or restrictive groups (antipyretic interventions at ≥ 37.5 °C) whilst on respiratory support. Parents were invited to complete a questionnaire or take part in an interview. Focus groups were conducted with staff at each unit. Outcomes were measures of feasibility: recruitment rate, protocol adherence and acceptability, between group separation of temperature and safety.

Results

One hundred thirty-eight children met eligibility criteria of whom 100 (72%) were randomized (11.1 patients per month per site) without prior consent (RWPC). Consent to continue in the trial was obtained in 87 cases (87%). The mean maximum temperature (95% confidence interval) over the first 48 h was 38.4 °C (38.2–38.6) in the restrictive group and 38.8 °C (38.6–39.1) in the permissive group, a mean difference of 0.5 °C (0.2–0.8). Protocol deviations were observed in 6.8% (99/1438) of 6-h time periods and largely related to patient comfort in the recovery phase. Length of stay, duration of organ support and mortality were similar between groups. No pre-specified serious adverse events occurred. Staff (n = 48) and parents (n = 60) were supportive of the trial, including RWPC. Suggestions were made to only include invasively ventilated children for the duration of intubation.

Conclusion

Uncertainty around the optimal fever threshold for antipyretic intervention is relevant to many emergency PICU admissions. A more permissive approach was associated with a modest increase in mean maximum temperature. A definitive trial should focus on the most seriously ill cases in whom antipyretics are rarely used for their analgesic effects alone.

Trial registration

ISRCTN16022198. Registered on 14 August 2017.

Electronic supplementary material

The online version of this article (10.1186/s13054-019-2354-4) contains supplementary material, which is available to authorized users.