Variation in Practice Related to the Use of High Flow Nasal Cannula in Critically Ill Children

Abstract

Objectives: To determine current management of critically ill children and gather views regarding high flow nasal cannula therapy and to evaluate research priorities for a large prospective randomized controlled trial of noninvasive respiratory support in children. Design: Multinational cross-sectional questionnaire survey conducted in 2018. Setting: The sample included pediatric intensive care physicians in North and South America, Asia, Europe, and Australia/New Zealand. Measurement: Questions consisted of: 1) characteristics of intensivists and hospital, 2) practice of high flow nasal cannula, 3) supportive treatment, and 4) research of high flow nasal cannula. Interventions: None. Main Results: We collected data from 1,031 respondents; 919 (North America, 215; Australia/New Zealand, 34; Asia, 203; South America, 186; Europe, 281) were analyzed. Sixty-nine percent of the respondents used high flow nasal cannula in non-PICU settings in their institutions. For a case of bronchiolitis/pneumonia infant, 2 L/kg/min of initial flow rate was the most commonly used. For a scenario of pneumonia with 30 kg weight, more than 60% of the respondents initiated flow based on patient body weight; while, 18% applied a fixed flow rate. Noninvasive ventilation was considered as a next step in more than 85% of respondents when the patient is failing with high flow nasal cannula. Significant practice variations were observed in clinical practice markers used, flow weaning strategy, and supportive practices. Views comparing high flow nasal cannula to continuous positive airway pressure also noticeably varied across the respondents. Conclusions: Significant practice variations including views of high flow nasal cannula compared to continuous positive airway pressure was found among pediatric intensive care physicians. To expedite establishment and standardization of high flow nasal cannula practice, research aimed at understanding the heterogeneity found in this study should be undertaken.

Weaning from noninvasive ventilation and high flow nasal cannula in bronchiolitis: A survey of practice

“…In addition, this may have a greater impact on PICU bed‐availability during the winter season. To our knowledge, this is one of the first studies assessing the weaning practices from any type of NIV support in the pediatric population, 15 and the first about CPAP and BiPAP.…”

Improving synchrony in young infants supported by noninvasive ventilation for severe bronchiolitis: Yes, we can… so we should!

“…Several national and multinational surveys have demonstrated that pediatric intensivists currently select HFNC for initial respiratory care in cases of severe bronchiolitis 18,19 . This popularity among caregivers appears to be associated with the perception of a technique that is easy to implement, with comparable effectiveness and fewer complications than CPAP 20 .…”

“…In practice, CPAP and HFNC are introduced early in the course of the disease—even as a preemptive measure in some cases—in infants generally not exhausted. While NIV is widely used to treat bronchiolitis, 25 most clinicians, unlike in Delacroix et al's 14 study, consider BiPAP the next step for patients failing with HFNC or CPAP 19 . Failure rates vary widely, from 10% to 50% in the major randomized controlled studies, 1,2,22–24 and depend on multiple factors, the most important probably related to the criteria and delays in defining failure.…”

“…17 Several national and multinational surveys have demonstrated that pediatric intensivists currently select HFNC for initial respiratory care in cases of severe bronchiolitis. 18,19 This popularity among caregivers appears to be associated with the perception of a technique that is easy to implement, with comparable effectiveness and fewer complications than CPAP. 20 The physiological background for using CPAP in this instance is that the application of nearly constant pressure support is associated with rapid unloading of respiratory muscles, increased expiratory time, and concomitantly improved respiratory distress.…”

“…While NIV is widely used to treat bronchiolitis, 25 most clinicians, unlike in Delacroix et al's 14 study, consider BiPAP the next step for patients failing with HFNC or CPAP. 19 Failure rates vary widely, from 10% to 50% in the major randomized controlled studies, 1,2,[22][23][24] and depend on multiple factors, the most important probably related to the criteria and delays in defining failure. According to the TRAMONTANE study, the main causes of failure are worsening respiratory distress, especially in patients supported by HFNC; patient discomfort, the leading cause in patients treated with CPAP; and the occurrence of apnea in a minority of cases in both groups.…”