High Flow Oxygen Therapy and the Pressure to Feed Infants With Acute Respiratory Illness

Abstract

Purpose Infants hospitalized for an acute respiratory illness often require the use of noninvasive respiratory support during the initial stage to improve their breathing. High flow oxygen therapy (HFOT) is becoming a more popular means of noninvasive respiratory support, often used to treat respiratory syncytial virus/bronchiolitis. These infants present with tachypnea and coughing, resulting in difficulties in coordinating sucking and swallowing. However, they are often allowed to feed orally despite having high respiratory rate, increased work of breathing and on HFOT, placing them at risk for aspiration. Feeding therapists who work with these infants have raised concerns that HFOT creates an additional risk factor for swallowing dysfunction, especially with infants who have compromised airways or other comorbidities. There is emerging literature concluding changes in pharyngeal pressures with HFOT, as well as aspiration in preterm neonates who are on nasal continuous positive airway pressure. However, there is no existing research exploring the effect of HFOT on swallowing in infants with acute respiratory illness. This discussion will present findings from literature on HFOT, oral feeding in the acutely ill infant population, and present clinical practice guidelines for safe feeding during critical care admission for acute respiratory illness. Conclusion Guidelines for safety of oral feeds for infants with acute respiratory illness on HFOT do not exist. However, providers and parents continue to want to provide oral feeds despite clinical signs of respiratory distress and coughing. To address this challenge, we initiated a process change to use clinical bedside evaluation and a “cross-systems approach” to provide recommendations for safer oral feeds while on HFOT as the infant is recovering from illness. Use of standardized feeding evaluation and protocol have improved consistency of practice within our department. However, further research is still necessary to develop clinical practice guidelines for safe oral feeding for infants on HFOT.

Prevalence and Risk Factors for Tube-Feeding at Discharge in Infants following Early Congenital Heart Disease Surgery: A Single-Center Cohort Study

“…13,34 The need for respiratory support impedes the opportunities for natural oral stimulation, physiological instability with suck-swallow-breathing coordination and affect the feeding endurance to consume sufficient volumes to meet caloric needs. [35][36][37] Severity and complexity of CHD (RACHS 3 or STAT 38 -Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery) has been found to be a factor associated with TF at discharge especially in infants requiring multiple corrective CHD surgeries or infants requiring CHD surgery in the newborn period. 14 However, some studies did not observe a correlation between the categories on RACHS/STAT and the oral feeding outcomes in newborns and infants.…”

“…13 34 The need for respiratory support impedes the opportunities for natural oral stimulation, physiological instability with suck–swallow–breathing coordination and affect the feeding endurance to consume sufficient volumes to meet caloric needs. 35 36 37…”

Assessment and management of feeding difficulties for infants with complex CHD

“…10 Institution specific protocols should take into consideration respiratory status, oral feeding readiness cues, oral motor and swallowing coordination, and endurance to determine safe level for small volume of therapeutic feeding trials for infants with acute respiratory illness on high-flow nasal cannula. 11…”