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Variation in Practice Related to the Use of High Flow Nasal Cannula in Critically Ill Children
Atsushi Kawaguchi1,2, Daniel Garros3, Ari Joffe3
1Department of Pediatrics, University of Montreal, CHU Sainte-Justine, Montreal, QC, Canada.
Insights
Pediatric intensive care physicians show significant variations in high flow nasal cannula (HFNC) use and comparisons to continuous positive airway pressure (CPAP). Further research is needed to standardize HFNC practices in critically ill children.
Area of Science:
- Pediatric Critical Care Medicine
- Respiratory Support
- Medical Device Technology
Background:
- High flow nasal cannula (HFNC) therapy is increasingly used for respiratory support in critically ill children.
- Current management practices and physician perspectives on HFNC are not well-defined globally.
- Variations in clinical practice may impact patient outcomes and necessitate standardization.
Purpose of the Study:
- To assess the current management of critically ill children receiving respiratory support.
- To gather pediatric intensive care physicians' views on high flow nasal cannula (HFNC) therapy.
- To identify research priorities for a large prospective randomized controlled trial on noninvasive respiratory support in children.
Main Methods:
- A multinational, cross-sectional questionnaire survey was conducted in 2018.
- Data were collected from 1,031 pediatric intensive care physicians across North America, South America, Asia, Europe, and Australia/New Zealand.
- The survey addressed physician/hospital characteristics, HFNC practice, supportive treatment, and research perspectives.
Main Results:
- 69% of respondents utilized HFNC in non-pediatric intensive care unit settings.
- Common initial flow rates for infants with bronchiolitis/pneumonia were 2 L/kg/min.
- Over 85% considered noninvasive ventilation as the next step for patients failing HFNC, with significant practice variations observed in weaning strategies and supportive care.
Conclusions:
- Substantial heterogeneity exists in pediatric intensive care physicians' practices and views regarding HFNC and its comparison to CPAP.
- Significant practice variations were noted in clinical markers, flow weaning, and supportive measures.
- Research is crucial to understand and address the observed heterogeneity to facilitate the establishment and standardization of HFNC practice.
Objectives:
To determine current management of critically ill children and gather views regarding high flow nasal cannula therapy and to evaluate research priorities for a large prospective randomized controlled trial of noninvasive respiratory support in children.
Design:
Multinational cross-sectional questionnaire survey conducted in 2018.
Setting:
The sample included pediatric intensive care physicians in North and South America, Asia, Europe, and Australia/New Zealand.
Measurement:
Questions consisted of: 1) characteristics of intensivists and hospital, 2) practice of high flow nasal cannula, 3) supportive treatment, and 4) research of high flow nasal cannula.
Interventions:
None.
Main Results:
We collected data from 1,031 respondents; 919 (North America, 215; Australia/New Zealand, 34; Asia, 203; South America, 186; Europe, 281) were analyzed. Sixty-nine percent of the respondents used high flow nasal cannula in non-PICU settings in their institutions. For a case of bronchiolitis/pneumonia infant, 2 L/kg/min of initial flow rate was the most commonly used. For a scenario of pneumonia with 30 kg weight, more than 60% of the respondents initiated flow based on patient body weight; while, 18% applied a fixed flow rate. Noninvasive ventilation was considered as a next step in more than 85% of respondents when the patient is failing with high flow nasal cannula. Significant practice variations were observed in clinical practice markers used, flow weaning strategy, and supportive practices. Views comparing high flow nasal cannula to continuous positive airway pressure also noticeably varied across the respondents.
Conclusions:
Significant practice variations including views of high flow nasal cannula compared to continuous positive airway pressure was found among pediatric intensive care physicians. To expedite establishment and standardization of high flow nasal cannula practice, research aimed at understanding the heterogeneity found in this study should be undertaken.
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