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The starting rate for high-flow nasal cannula oxygen therapy in infants with bronchiolitis: Is clinical judgment
Paola Papoff1, Elena Caresta1, Stefano Luciani1
1Department of Pediatrics, Pediatric Intensive Care Unit, Umberto I Policlinico, Sapienza University of Rome, Rome, Italy.
Insights
Physician-set high-flow nasal cannula (HFNC) rates meet infant peak inspiratory flow (PIF) demands in bronchiolitis. An initial HFNC flow of 2 L/kg/min improves respiratory mechanics and reduces breathing effort in infants.
Area of Science:
- Pediatric Intensive Care
- Respiratory Medicine
- Neonatology
Background:
- Bronchiolitis is a common respiratory infection in infants, often requiring intensive care.
- High-flow nasal cannula (HFNC) therapy is widely used, but optimal initial flow rates are debated.
- Peak inspiratory flow (PIF) demands vary significantly among infants with bronchiolitis.
Purpose of the Study:
- To evaluate if physician-determined HFNC starting rates meet infants' PIF demands.
- To assess the impact of HFNC on respiratory mechanics and breathing effort in infants with bronchiolitis.
- To identify potential differences in response based on PIF characteristics.
Main Methods:
- Simultaneous measurement of respiratory flow and esophageal pressure in 31 infants with moderate-to-severe bronchiolitis.
- Comparison of data across different HFNC flow rates: 1 L/kg/min, 2 L/kg/min, and physician-determined clinical judgment.
- Analysis of PIF, respiratory mechanics (airway resistance, intrinsic PEEP), and breathing effort (PTP/min).
Main Results:
- A significant proportion of infants (65%) had PIF < 1 L/kg/min, while others (45%) had PIF ≥ 1 L/kg/min.
- Physician-set HFNC rates (1.20-2.05 L/kg/min) successfully met all infants' PIF demands.
- Clinically judged HFNC flow improved PIF and tidal volume, reduced airway resistance and intrinsic PEEP in normal-PIF infants.
- HFNC therapy, particularly at 2 L/kg/min, decreased respiratory rate and breathing effort in all infants.
Conclusions:
- Infants with bronchiolitis exhibit diverse PIF demands, suggesting potential phenotypic differences.
- An initial HFNC flow rate of approximately 2 L/kg/min is effective in meeting patient flow demands.
- Optimizing HFNC flow rates improves respiratory mechanics and reduces breathing effort in infants with bronchiolitis.
Objectives:
To determine whether in infants with bronchiolitis admitted to a pediatric intensive care unit (PICU) the starting rate for high-flow nasal cannula (HFNC) therapy set by the attending physicians upon clinical judgment meets patients' peak inspiratory flow (PIF) demands and how it influences respiratory mechanics and breathing effort.
Methodology:
We simultaneously obtained respiratory flow and esophageal pressure data from 31 young infants with moderate-to-severe bronchiolitis before and after setting the HFNC rate at 1 L/kg/min (HFNC-1), 2 L/kg/min (HFNC-2) or upon clinical judgment and compared data for PIF, respiratory mechanics, and breathing effort.
Results:
Before HFNC oxygen therapy started, 16 (65%) infants had a PIF less than 1 L/kg/min (normal-PIF) and 15 (45%) had a PIF more than or equal to 1 L/kg/min (high-PIF). Normal-PIF-infants had higher airway resistance (p < .001) and breathing effort indexes (e.g., pressure rate product per min [PTP/min], p = .028) than high-PIF-infants. Starting the HFNC rate upon clinical judgment (1.20-2.05 L/kg/min) met all infants' PIFs. In normal-PIF-infants, the clinically judged flow rate increased PIF (p = .081) and tidal volume (p = .029), reduced airway resistance (p = .011), and intrinsic positive end-expiratory pressure (p = .041), whereas, in both high-PIF and normal-PIF infants, it decreased respiratory rate (p < .001) and indexes of breathing effort such as PTP/min (in normal-PIF infants, p = .004; in high-PIF infants, p = .001). The 2 L/kg/min but not 1 L/kg/min rate induced similar effects.
Conclusions:
The wide PIF distribution in our PICU population of infants with bronchiolitis suggests two disease phenotypes whose therapeutic options might differ. An initial flow rate of nearly 2 L/kg/min meets patients' flow demands and improves respiratory mechanics and breathing effort.
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