Heated Humidified High Flow Nasal Cannula (HHHFNC) is not an effective method for initial treatment of Respiratory Distress Syndrome (RDS) versus nasal intermittent mandatory ventilation (NIMV) and nasal continuous positive airway pressure (NCPAP)

Abstract

Background:Noninvasive respiratory support techniques are widely used to treat respiratory distress syndrome (RDS) in preterm infants, and the effectiveness of these methods should be compared. In the current study, nasal continuous positive airway pressure (NCPAP), nasal intermittent mandatory ventilation (NIMV), and heated humidified high-flow nasal cannula (HHHFNC) were compared.Materials and Methods:In the current bicenter clinical trial, 109 preterm infants with RDS not treated with surfactant were randomly assigned to three groups: NCPAP, NIMV, and HHHFNC. The initial outcomes including the failure of treatment within the first initial 72 h, and the duration of RDS treatment, and the secondary outcomes including the need for intubation, the need for surfactants, the duration of oxygen dependency, the incidence of pneumothorax, the patent ductus arteriosus, intraventricular hemorrhage, length of stay, and mortality were compared among the groups.Results:The frequency of HHHFNC treatment failure (54.3%) was significantly higher compared with those of NIMV (21.6%) (P < 0.001, hazard ratio [HR] = 9.12, 95% confidence interval [CI] = 2.59 – 32.07) and NCPAP (35.1%) (P = 0.004, HR = 21.25, 95% CI = 2.51–180.08). The median duration of RDS treatment was longer (40 h) in the HHHFNC group, although it was not significantly different from those of NIMV (31.16 h) and NCPAP (38.91 h).Conclusion:Based on the high prevalence of failure of HHHFNC treatment than the other two methods (NCPAP and NIMV), HHHFNC is not recommended as the initial treatment of RDS.

Guidelines for high‐flow nasal cannula oxygen therapy in neonates (2022)

“…Evidence summary : A systematic review and meta‐analysis based on 22 RCTs ( n = 3807) was developed by the guidelines development working group. This analysis showed that there was no difference in the treatment failure rates (RR = 1.24, 95% CI 0.94−1.62, p = 0.12) between HFNC and NCPAP when used for the primary noninvasive respiratory support of neonates 48,49,51,53–70,72 . Additionally, a systematic review and meta‐analysis based on 22 RCTs ( n = 3832) developed by the guidelines development working group also showed no significant difference in the mechanical ventilation rate between the HFNC and NCPAP groups (RR = 1.02, 95% CI 0.87−1.20, p = 0.77) 48‐51,53‐56,58‐70,72 .…”

“…[119][120][121] This guidelines development working group performed a systematic evaluation and meta-analysis (29 RCTs, n = 4850) of primary noninvasive respiratory support after birth and postextubation respiratory support in neonates, which revealed that the incidence of air leakage was lower in the HFNC group (RR = 0.56, 95% CI 0.41−0.76, p = 0.001) than in the NCPAP group. 46,47,49,50,52,[54][55][56][58][59][60][61][62][63][64][65][66][67][68][69][70][71][72]77,[79][80][81][82][83] A network meta-analysis that compared different noninvasive modes for the primary treatment of preterm infants with NRDS (35 RCTs, n = 4078) showed no significant difference in the incidence of air leakage (RR = 0.85, 95% CI 0.39−1.94) between the HFNC and NIPPV groups (two RCTs, n = 165, gestational age < 35 weeks). 117 Recommendation notes: This recommendation was developed based on the available evidence indicating that HFNC reduces risk of air leakage in neonates than NCPAP, and that the incidence of air leakage caused by HFNC and NIPPV is similar in preterm infants.…”

Respiratory Management of the Preterm Infant: Supporting Evidence-Based Practice at the Bedside

“…The same result emerged for the application of MV after non-invasive respiratory support by evaluating twenty-one studies reporting this outcome. When four studies [ 6 , 7 , 47 , 48 ] were analyzed for the application of alternative noninvasive respiratory support when treatment failure occurred, no difference resulted in the application of MV between the HFNC group and CPAP group. This concludes that using nCPAP as a remedy for the treatment failure of HFNC does not avoid intubation, and the intubation rate difference is insignificant once failed cases on HFNC are rescued by nCPAP.…”

State of the art on neonatal noninvasive respiratory support: How physiological and technological principles explain the clinical outcomes

“…Neonatologists have applied nHFT after extubation, 72,73 as primary mode for treating respiratory distress, 56,72,74 preventing apnea of prematurity, 75 weaning from other support modes 76 and even as a tool for respiratory stabilization in the delivery room, 77 to support endotracheal intubation, 78 during transport 79 and in nontertiary centers 80 . However, only a few trials included a small number of infants <28 weeks' gestation 73,81,82 . Two meta‐analyses of large RCTs including infants of a broad GA range, showed comparable efficacy of nHFT to nCPAP postextubation 83,84 .…”

“…80 However, only a few trials included a small number of infants <28 weeks' gestation. 73,81,82 Two meta-analyses of large RCTs including infants of a broad GA range, showed comparable efficacy of nHFT to nCPAP postextubation. 83,84 Nevertheless, subgroup analysis of infants <28 weeks revealed a higher failure rate during nHFT.…”