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First-line treatment using high-flow nasal cannula for children with severe bronchiolitis: Applicability and risk
Insights
High-flow nasal cannula (HFNC) therapy is effective for treating severe bronchiolitis in children, potentially reducing the need for nasal continuous positive airway pressure (nCPAP). Higher carbon dioxide levels (pCO2) were identified as a key factor predicting HFNC therapy failure.
Area of Science:
- Pediatric critical care medicine
- Respiratory medicine
- Infectious diseases
Background:
- Viral bronchiolitis is a primary cause of pediatric hospitalization.
- Noninvasive ventilation strategies are crucial for managing bronchiolitis.
- High-flow nasal cannula (HFNC) therapy is an emerging respiratory support method.
Purpose of the Study:
- To assess HFNC as a first-line treatment for severe bronchiolitis.
- To identify predictors of HFNC therapy failure in pediatric patients.
Main Methods:
- Prospective observational study in a pediatric intensive care unit (PICU) over two seasons.
- Comparison of HFNC, nCPAP/BiPAP, and invasive ventilation utilization.
- Analysis of factors associated with HFNC failure using time-varying Cox regression models.
Main Results:
- HFNC use increased significantly in the second season (90% vs. 34%).
- Higher pCO2 levels were independently associated with HFNC therapy failure (HR 1.37 per 5mmHg).
- Heart rate and pH also showed associations with failure in bivariate analysis.
Conclusions:
- HFNC therapy may reduce nCPAP use in pediatric bronchiolitis.
- Elevated pCO2 is a significant predictor of HFNC failure.
- Further research on pCO2 thresholds for HFNC vs. nCPAP indication is warranted.
Background:
Viral bronchiolitis is the leading cause of hospitalization in children during the first 12 months of life. There is evidence to support the use of noninvasive ventilation in bronchiolitis. A recent respiratory management of bronchiolitis is the use of high-flow nasal cannula (HFNC) therapy. The primary objective of this study was to evaluate the use of HFNC as the first-line treatment for children with severe bronchiolitis and the secondary objective was to identify factors for HFNC therapy failure.
Methods:
Observational prospective study in a pediatric intensive care unit (PICU), during two consecutive seasons (2013-2014 without recommendation and 2014-2015 with a study design suggesting HFNC as first-line treatment). The percentages of children treated with HFNC, nasal continuous or biphasic positive airway pressure (nCPAP/BiPAP) and invasive ventilation were compared. Associations between parameters recorded and HFCN therapy failure were established.
Results:
The percentage of patients treated with HFNC at admission was higher during the second season (90%, n=55/61) than the first season (34%, n=14/41) (p<0.0001). In bivariate analysis, heart rate, pH, and pCO2 were significantly associated with the occurrence of HFNC therapy failure in time-varying Cox regression models using all available values (i.e., admission and repeated measures during the first 5 days of hospitalization). Only pCO2 remained independently associated as a factor of HFNC failure in the multivariate Cox model with a hazard ratio per 5mmHg of 1.37 (95%CI: 1.01-1.87; P=0.046).
Conclusion:
In our PICU, HFNC therapy for children with bronchiolitis can potentially decrease the use of nCPAP. In this study, the factor of failure was higher pCO2. Studies to evaluate PCO2 level to discriminate HFNC versus CPAP indication could be useful.
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