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

Use of High-Flow Nasal Cannula Therapy in Pediatric Hematology/Oncology Patients Admitted to the Pediatric Intensive Care Unit with Acute Respiratory Failure

BACKGROUND

High-flow nasal cannula (HFNC) therapy is an essential tool for managing acute respiratory failure (ARF) in pediatric patients with hematological and oncological conditions. This study aimed to evaluate the HFNC failure rate and identify factors associated with HFNC failure in pediatric hematology/oncology patients admitted to the pediatric intensive care unit (PICU) with ARF.

METHODS

This is a retrospective cohort study that included 200 pediatric hematology/oncology patients aged 0-14 years with ARF who underwent HFNC. All patients were admitted to the PICU at the King Fahad National Center for Child Cancer in Saudi Arabia from January 2018 to December 2020.

RESULTS

The patient cohort had a median age of 3 years (interquartile range [IQR]: 1.3-7.0), and (61.5%) of patients were males. The key indications for HFNC were pneumonia (48.0%), sepsis (46.0%), and cardiac failure (18.0%). The median duration of HFNC was 36 h (IQR: 20-68), and the median PICU length of stay was 6 days (IQR: 4-16). HFNC failure rate was (27.0%). Air leaks were reported in (2.5%) of patients. The PICU mortality was 29.5% (59/200), including 40 patients (67.8%) with HFNC failure. Required intubation within 48 h was observed in 13.0% (26/200) of patients. Multivariable analysis revealed that the initial pH (p = 0.030), shorter HFNC duration (p < 0.001), cardiac failure (p = 0.009), and sepsis (p = 0.041) were predictors of HFNC failure.

CONCLUSION

The HFNC failure rate in this study was 27%, which is within the range of other studies. Thus, HFNC is an acceptable treatment option for pediatric hematology/oncology patients with ARF. However, further investigation is required.

"Comparative analysis of predictors of failure for high-flow nasal cannula in bronchiolitis"

OBJECTIVE

To assess a comparative analysis of the ROX index, Wood-Downes-Ferrés score (WDF), p-ROXI, and the SpO2/FiO2 ratio as predictors of high-flow nasal cannula (HFNC) failure in children hospitalized for bronchiolitis.

METHODS

Data were extracted from the clinical trial "Comparison between HFNC and NIV in children with acute respiratory failure caused by bronchiolitis" conducted at a tertiary Brazilian hospital (Emergency Department and PICU). The inclusion criteria were children under 2 years of age admitted for bronchiolitis who developed mild to moderate respiratory distress and were eligible for HFNC therapy. Performance was determined by ROC and AUC metrics to define the best sensitivity and specificity for each variable. Children were evaluated at 0 h, 2 h, 6 h, 12 h, 24 h, 48 h, 72 h and 96 h after HFNC therapy initiation.

RESULTS

A total of 126 patients were recruited for this analysis. The median age was 3 months. Ninety-one percent of the patients had an identified viral agent, with RSV being the most common (65%). Twenty-three percent (29/126) of patients experienced failed HFNC therapy and required mechanical ventilation. The best cutoff points at 12 hours were 4.5 for WDF (AUC = 0.83, 0.74-0.92), 8.8 for ROX (AUC = 0.7, 0.54-0.84), 1.45 for p-ROXI (AUC = 0.56, 0.38-0-74), and 269 for SpO2/FiO2 (AUC = 0.64, 0.48-0.74). The scores and indices were also correlated with the PICU and hospital LOS.

CONCLUSIONS

The ROX index and WDF were the most accurate scores for assessing HFNC failure considering 12-hour cutoff points.

TRIAL REGISTRATION NUMBER

U1111-1262-1740; RBR-104z966s. Date of registration: 03/01/2023.

Respiratory Rate Oxygenation (ROX) index as predictor of high flow nasal cannula in pediatric patients in pediatric intensive care unit

BACKGROUND

High-flow nasal cannula (HFNC) is often used in pediatric populations with respiratory distress. In adults, the respiratory-rate oxygenation (ROX) index is used as a predictor of HFNC therapy; however, children have age-associated differences in respiratory rate, thus may not be applicable to children. This study aims to find the reliability of ROX index and modified P-ROX index as predictors of HFNC therapy failure in pediatric patients.

METHODS

Subjects in this analytical cross-sectional study were taken from January 2023 until November 2023 in Cipto Mangunkusumo Hospital. Inclusion criteria are children aged 1 month to 18 years with respiratory distress and got HFNC therapy. Receiver operating characteristics (ROC) analysis was used to find mP-ROX index cutoff value as a predictor of HFNC failure. The area under curve (AUC) score of mP-ROX index was assessed at different time point.

RESULTS

A total of 102 patients, with 70% of the population with pneumonia, were included in this study. There are significant differences in the ROX index between the successful and failed HFNC group therapy (p < 0.05). This study suggests that mP-ROX index is not useful as predictor of HFNC therapy in pediatrics. While ROX index < 5.52 at 60 min and < 5.68 at 90 min after HFNC initiation have a sensitivity of 90% and specificity of 71%, sensitivity of 78% and specificity of 76%, respectively.

CONCLUSION

mP-ROX index is not useful as a predictor of HFNC therapy in pediatrics. Meanwhile, ROX index at 60 min and 90 min after initiation of HFNC is useful as a predictor of HFNC failure.

Development and Validation of a Model for Endotracheal Intubation and Mechanical Ventilation Prediction in PICU Patients

OBJECTIVES

To develop and externally validate an intubation prediction model for children admitted to a PICU using objective and routinely available data from the electronic medical records (EMRs).

DESIGN

Retrospective observational cohort study.

SETTING

Two PICUs within the same healthcare system: an academic, quaternary care center (36 beds) and a community, tertiary care center (56 beds).

PATIENTS

Children younger than 18 years old admitted to a PICU between 2010 and 2022.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Clinical data was extracted from the EMR. PICU stays with at least one mechanical ventilation event (≥ 24 hr) occurring within a window of 1-7 days after hospital admission were included in the study. Of 13,208 PICU stays in the derivation PICU cohort, 1,175 (8.90%) had an intubation event. In the validation cohort, there were 1,165 of 17,841 stays (6.53%) with an intubation event. We trained a Categorical Boosting (CatBoost) model using vital signs, laboratory tests, demographic data, medications, organ dysfunction scores, and other patient characteristics to predict the need of intubation and mechanical ventilation using a 24-hour window of data within their hospital stay. We compared the CatBoost model to an extreme gradient boost, random forest, and a logistic regression model. The area under the receiving operating characteristic curve for the derivation cohort and the validation cohort was 0.88 (95% CI, 0.88-0.89) and 0.92 (95% CI, 0.91-0.92), respectively.

CONCLUSIONS

We developed and externally validated an interpretable machine learning prediction model that improves on conventional clinical criteria to predict the need for intubation in children hospitalized in a PICU using information readily available in the EMR. Implementation of our model may help clinicians optimize the timing of endotracheal intubation and better allocate respiratory and nursing staff to care for mechanically ventilated children.

ROX index as a predictor of failure of high-flow nasal cannula in infants with bronchiolitis

High-flow nasal cannula (HFNC) is a relatively recent therapy that has been used to treat respiratory failure. Until now, the criterion for failure requiring escalation to other forms of ventilatory support has remained unclear. This study evaluated how the ROX index predicts the success or failure of HFNC in infants with bronchiolitis. A prospective, observational, multicenter study was conducted in 2 pediatric ICUs. The data were collected at 7 moments. Patients were categorized into failure and success groups according to HFNC. A total of 102 infants were included, 18(17.6%) of whom failed HFNC therapy. For the ROX index, significant differences were observed between the failure 5.8(95%CI 4.7-7.1) and success 7.7(95%CI 7.2-8.2) groups (p = 0.005) at the 12 h evaluation. According to the analysis of the performance of the ROX index, the AUC at 12 h was 0.716(95%CI 0.591-0.842; p = 0.016). The best cutoff range for the ROX index at 12 h was 6.50-7.18, with a sensitivity of 42% and a specificity of 66% at the cutoff of 6.50, and a sensitivity of 92% and a specificity of 54% at the cutoff of 7.18. We concluded that the ROX index could be effective at predicting the failure of HFNC therapy in infants with bronchiolitis beginning at 12 h after installation.

[Analysis of ROX Index, ROX-HR Index, and SpO2/FIO2 Ratio in Patients Who Received High-Flow Nasal Cannula Oxygen Therapy in Pediatric Intensive Care Unit]

PURPOSE

This study aimed to evaluate the use of the respiratory rate oxygenation (ROX) index, ROX-heart rate (ROX-HR) index, and saturation of percutaneous oxygen/fraction of inspired oxygen ratio (SF ratio) to predict weaning from high-flow nasal cannula (HFNC) in patients with respiratory distress in a pediatric intensive care unit.

METHODS

A total of 107 children admitted to the pediatric intensive care unit were enrolled in the study between January 1, 2017, and December 31, 2021. Data on clinical and personal information, ROX index, ROX-HR index, and SF ratio were collected from nursing records. The data were analyzed using an independent t-test, χ² test, Mann-Whitney U test, and area under the curve (AUC).

RESULTS

Seventy-five (70.1%) patients were successfully weaned from HFNC, while 32 (29.9%) failed. Considering specificity and sensitivity, the optimal cut off points for predicting treatment success and failure of HFNC oxygen therapy were 6.88 and 10.16 (ROX index), 5.23 and 8.61 (ROX-HR index), and 198.75 and 353.15 (SF ratio), respectively. The measurement of time showed that the most significant AUC was 1 hour before HFNC interruption.

CONCLUSION

The ROX index, ROX-HR index, and SF ratio appear to be promising tools for the early prediction of treatment success or failure in patients initiated on HFNC for acute hypoxemic respiratory failure. Nurses caring for critically ill pediatric patients should closely observe and periodically check their breathing patterns. It is important to continuously monitor three indexes to ensure that ventilation assistance therapy is started at the right time.