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 Table of Contents  
Year : 2020  |  Volume : 7  |  Issue : 4  |  Page : 159-160

High-flow nasal cannula for acute viral bronchiolitis in children: Worth a high five

Department of Pediatrics and Voelcker Clinical, Research Center, Baylor College of Medicine, The Children's Hospital of San Antonio, San Antonio, Texas, USA

Date of Submission19-Apr-2020
Date of Acceptance25-May-2020
Date of Web Publication13-Jul-2020

Correspondence Address:
Dr. Utpal S Bhalala
315 N. San Saba St., Suite 1135, San Antonio, Texas 78207
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JPCC.JPCC_81_20

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How to cite this article:
Bhalala US. High-flow nasal cannula for acute viral bronchiolitis in children: Worth a high five. J Pediatr Crit Care 2020;7:159-60

How to cite this URL:
Bhalala US. High-flow nasal cannula for acute viral bronchiolitis in children: Worth a high five. J Pediatr Crit Care [serial online] 2020 [cited 2020 Aug 14];7:159-60. Available from: http://www.jpcc.org.in/text.asp?2020/7/4/159/289526

Acute respiratory failure is associated with approximately 30% of intensive care unit (ICU) admissions and 50% of ICU deaths. Approximately 60% of patients with acute respiratory failure require mechanical ventilation, which has been associated with various adverse events, including hospital mortality as high as 30%.[1],[2],[3] Noninvasive ventilation (NIV) has gained a growing interest as a respiratory support in patients with acute respiratory failure. It obviates complications of intubation and invasive mechanical ventilation in a selected patient population. However, NIV is associated with issues such as eye and/or skin damage, interface intolerance, agitation, and challenges with enteral nutrition.[4] These are the reasons, the medical community is exploring use of a high-flow nasal cannula (HFNC) in different patient populations with different types of hypoxic and/or hypercapnic respiratory failure.[5] In a recent review, HFNC was described to decrease the need for endotracheal intubation and was better tolerated in adults with acute respiratory failure.[1] HFNC is rapidly gaining recognition as an alternative to standard oxygen therapy and NIV in critically ill children with acute bronchiolitis and pneumonia and following extubation in children at risk for reintubation. This technology was introduced in preterm infants and then children with hypoxic respiratory failure and has recently been expanded to adults with respiratory failure.[6] HFNC has been shown to improve lung mechanics, change transpulmonary pressure, and therefore, reduce work of breathing.[6],[7] HFNC has been shown to deliver positive pressure and recruit alveoli based on the degree of flow.[8]

Despite growing popularity of HFNC as a noninvasive positive pressure support in children with hypoxic respiratory failure, the evidence supporting its use in children with acute bronchiolitis, especially in comparison to other noninvasive respiratory support, is contradictory.[9],[10],[11],[12],[13] More evidence is needed to understand the role of HFNC in acute viral bronchiolitis in children. In this particular edition of the Journal of Pediatric Critical Care, Sachdev et al. have described the results of a very well-conducted, randomized trial of HFNC versus noninvasive positive-pressure ventilation (NIPPV) to assess the failure of intervention and patient comfort during the management of acute viral bronchiolitis.[14] This is the first randomized trial comparing two noninvasive ventilator strategies for efficacy and patient comfort during the management of acute bronchiolitis in the Indian subcontinent. It was a prospective, randomized study conducted in a 12-bed, multispecialty pediatric ICU (PICU) at a tertiary care hospital in Northern India. The study included young children between 1 month and 2 years of age, admitted to the PICU for the first episode of acute viral bronchiolitis with moderate-to-severe respiratory distress based on modified Wood's score. Using a computer-generated randomization algorithm, patients were randomized to receive either HFNC (maximum flow 2 L/kg/min) or NIPPV (nasal interface with a maximum PEEP of 8 cmH2O). The study defined different criteria as failure of intervention, including need for endotracheal intubation and mechanical ventilation. The study also used comfort B-score in each group to assess patient comfort, which was one of the comparative outcome measures.

The study findings confirmed that HFNC and NIPPV are equally efficient in the management of moderate-to-severe bronchiolitis and that HFNC was more comfortable to patients as compared to NIPPV. Since minimizing agitation is important in children with acute bronchiolitis for minimizing turbulent airflow and work of breathing, HFNC is a potentially promising NIV strategy. The small sample size in this trial limits the study in generating strong evidence but certainly directs future, multicenter trials in the Indian subcontinent. With an exponential growth in pediatric critical care subspecialty and pediatric critical care training and research in India,[15],[16] it is about time to leverage the collaborative efforts initiated by the IAP Intensive Care Chapter in India to conduct a multicenter trial to generate a robust evidence in relation to efficacy and comfort of HFNC as compared to NIPPV in children with acute bronchiolitis.

  References Top

Ni YN, Luo J, Yu H, Liu D, Ni Z, Cheng J, et al. Can high-flow nasal cannula reduce the rate of endotracheal intubation in adult patients with acute respiratory failure compared with conventional oxygen therapy and noninvasive positive pressure ventilation?: A Systematic review and meta-analysis. Chest 2017;151:764-75.  Back to cited text no. 1
Esteban A, Anzueto A, Frutos F, Alía I, Brochard L, Stewart TE, et al. Characteristics and outcomes in adult patients receiving mechanical ventilation: A 28-day international study. JAMA 2002;287:345-55.  Back to cited text no. 2
Kollef MH. What is ventilator-associated pneumonia and why is it important? Respir Care 2005;50:714-21.  Back to cited text no. 3
Hill NS. Complications of noninvasive ventilation. Respir Care 2000;45:480-1.  Back to cited text no. 4
Dries DJ. High-flow nasal cannula: Where does it fit? Respir Care 2018;63:367-70.  Back to cited text no. 5
Mauri T, Turrini C, Eronia N, Grasselli G, Volta CA, Bellani G, et al. Physiologic effects of high-flow nasal cannula in acute hypoxemic respiratory failure. Am J Respir Crit Care Med 2017;195:1207-15.  Back to cited text no. 6
Delorme M, Bouchard PA, Simon M, Simard S, Lellouche F. Effects of high-flow nasal cannula on the work of breathing in patients recovering from acute respiratory failure. Crit Care Med 2017;45:1981-8.  Back to cited text no. 7
Nedel WL, Deutschendorf C, Moraes Rodrigues Filho E. High-flow nasal cannula in critically ill subjects with or at risk for respiratory failure: A systematic review and meta-analysis. Respir Care 2017;62:123-32.  Back to cited text no. 8
Habra B, Janahi IA, Dauleh H, Chandra P, Veten A. A comparison between high-flow nasal cannula and noninvasive ventilation in the management of infants and young children with acute bronchiolitis in the PICU. Pediatr Pulmonol 2020;55:455-61.  Back to cited text no. 9
Metge P, Grimaldi C, Hassid S, Thomachot L, Loundou A, Martin C, et al. Comparison of a high-flow humidified nasal cannula to nasal continuous positive airway pressure in children with acute bronchiolitis: Experience in a pediatric intensive care unit. Eur J Pediatr 2014;173:953-8.  Back to cited text no. 10
Milési C, Essouri S, Pouyau R, Liet JM, Afanetti M, Portefaix A, et al. High flow nasal cannula (HFNC) versus nasal continuous positive airway pressure (nCPAP) for the initial respiratory management of acute viral bronchiolitis in young infants: A multicenter randomized controlled trial (TRAMONTANE study). Intensive Care Med 2017;43:209-16.  Back to cited text no. 11
Wolfler A, Raimondi G, Pagan de Paganis C, Zoia E. The infant with severe bronchiolitis: From high flow nasal cannula to continuous positive airway pressure and mechanical ventilation. Minerva Pediatr 2018;70:612-22.  Back to cited text no. 12
Beggs S, Wong ZH, Kaul S, Ogden KJ, Walters JA. High-flow nasal cannula therapy for infants with bronchiolitis. Cochrane Database Syst Rev 2014;(1):CD009609. doi: 10.1002/14651858.CD009609.pub2.  Back to cited text no. 13
Sachdev A, Vohra R, Gupta N, Gupta D, Gupta S. Comparison of high-flow nasal cannula and noninvasive positive pressure ventilation in children with acute bronchiolitis. J Pediatr Crit Care 2020;7:159-60.  Back to cited text no. 14
Bhalala U, Khilnani P. Pediatric critical care medicine training in India: Past, present, and future. Front Pediatr 2018;6:34.  Back to cited text no. 15
Bhalala U, Bansal A, Chugh K. Advances in pediatric critical care research in India. Front Pediatr 2018;6:150.  Back to cited text no. 16


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