Systematic review and meta-analysis of efficacy and safety of continuous positive airways pressure versus high flow oxygen cannula in acute bronchiolitis

Abstract

Introduction There are a trend towards increasing use of High-Flow Nasal Cannula (HFNC), outside of paediatric intensive care unit. Give this trend is necessary to update the actual evidence and to assess available published literature to determinate the efficacy of HFNC over Continuous Positive Air Pressure (CPAP) as treatment for children with severe bronchiolitis. Methods We searched MEDLINE, EMBASE, LILACS, and COCHRANE Central, and gray literature in clinical trials databases (www.clinicaltrials.gov), from inception to June 2022. The inclusion criteria for the literature were randomized clinical trials (RCTs) that included children < 2 years old, with acute moderate or severe bronchiolitis. All study selection and data extractions are performed independently by two reviewers. Results The initial searches including 106 records. Only five randomized controlled trial that met the inclusion criteria were included in meta-analysis. The risk of invasive mechanical ventilation was not significantly different in CPAP group and HFNC group [OR: 1.18, 95% CI (0.74, 1.89), I² = 0%] (very low quality). The risk of treatment failure was less significantly in CPAP group than HFNC group [OR: 0.51, 95% CI (0.36, 0.75), I² = 0%] (very low quality). Conclusion In conclusion, there was no significant difference between HFNC and CPAP in terms of risk of invasive mechanical ventilation. CPAP reduces de risk of therapeutic failure with a highest risk of non severe adverse events. More trials are needed to confirm theses results.

Randomized Trials to Reduce Clinical Uncertainty: Gold Standard or Fool’s Gold?*

“…The justification for this proposed effect size is unclear. It is very ambitious at best given that the existing literature suggests a failure rate with CPAP that is half of that of HFNC in high-resource comparisons with HFNC (13) and in that in the larger trials that do not focus solely on bronchiolitis, suggest only noninferiority or indeed a signal in favor of CPAP (7,8) The results then almost exactly replicate the power calculation. There was a lower proportion of treatment failure in the HFNC vs. b-CPAP group (14/59 vs. 25/59; RR, 0.56; 95% CI, 0.32-0.97; p = 0.031).…”

The changing virology and trends in resource utilization for bronchiolitis since COVID‐19

“…Increased use of high flow, albuterol, chest radiographs and ICU admissions for bronchiolitis were seen during the lower volume period when rhinovirus was the dominant pathogen detected. While high flow nasal cannula showed initial promise to reduce intubation rates, more recent studies have not proven this, and quality improvement initiatives have tried to reduce its use in mild to moderate bronchiolitis 6–9,23 . Other studies have shown that providers are more likely to utilize diagnostic tests and medications once high flow is initiated, and increased use of low value care for bronchiolitis during lower census periods has been described 24,25 .…”

“…While high flow nasal cannula showed initial promise to reduce intubation rates, more recent studies have not proven this, and quality improvement initiatives have tried to reduce its use in mild to moderate bronchiolitis. [6][7][8][9]23 Other studies have shown that providers are more likely to utilize diagnostic tests and medications once high flow is initiated, and increased use of low value care for bronchiolitis during lower census periods has been described. 24,25 Prior studies have not shown an increase in bronchiolitis severity during this time.…”

Trattare la bronchiolite con nCPAP nelle Pediatrie per “proteggere” le Terapie Intensive pediatriche?

“…Non abbiamo osservato il verificarsi di complicanze respiratorie acute e i tre trasferimenti sono avvenuti sempre con assistenza rianimatoria in condizioni di stabilità dei pazienti. Va comunque ricordato che possibili eventi avversi della ventilazione non invasiva sono le lesioni cutanee nella sede di applicazione del sistema, l'intolleranza alla ventilazione e la distensione addominale [42][43][44] . L'esperienza di un singolo centro segnala il verificarsi di un caso di pneumotorace su 17 bambini trattati con CPAP 45 .…”