Physiologic Basis for Nasal Continuous Positive Airway Pressure, Heated and Humidified High-Flow Nasal Cannula, and Nasal Ventilation

Dysart, Kevin

doi:10.1016/j.clp.2016.07.001

Cited by 13 publications

(14 citation statements)

References 34 publications

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“…Single-centre studies from the United States and Canada and audit data from the United Kingdom indicate that 16–35% of PICU admissions currently receive HFNC at some point during their stay [ 15 – 17 ]. Through diverse mechanisms such as reduction of airway resistance, reduction of dead space by nasopharyngeal washout with fresh gas and delivery of positive airway pressure (“CPAP effect”), HFNC has been shown to reduce the work of breathing and improve oxygenation and ventilation in children [ 18 – 23 ]. In single-centre observational studies, the use of HFNC has also been shown to be associated with a dramatic reduction in the need for intubation and invasive ventilation compared with historical controls [ 24 – 26 ].…”

Section: Introductionmentioning

confidence: 99%

FIRST-line support for Assistance in Breathing in Children (FIRST-ABC): a multicentre pilot randomised controlled trial of high-flow nasal cannula therapy versus continuous positive airway pressure in paediatric critical care

et al. 2018

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BackgroundAlthough high-flow nasal cannula therapy (HFNC) has become a popular mode of non-invasive respiratory support (NRS) in critically ill children, there are no randomised controlled trials (RCTs) comparing it with continuous positive airway pressure (CPAP). We performed a pilot RCT to explore the feasibility, and inform the design and conduct, of a future large pragmatic RCT comparing HFNC and CPAP in paediatric critical care.MethodsIn this multi-centre pilot RCT, eligible patients were recruited to either Group A (step-up NRS) or Group B (step-down NRS). Participants were randomised (1:1) using sealed opaque envelopes to either CPAP or HFNC as their first-line mode of NRS. Consent was sought after randomisation in emergency situations. The primary study outcomes were related to feasibility (number of eligible patients in each group, proportion of eligible patients randomised, consent rate, and measures of adherence to study algorithms). Data were collected on safety and a range of patient outcomes in order to inform the choice of a primary outcome measure for the future RCT.ResultsOverall, 121/254 eligible patients (47.6%) were randomised (Group A 60%, Group B 44.2%) over a 10-month period (recruitment rate for Group A, 1 patient/site/month; Group B, 2.8 patients/site/month). In Group A, consent was obtained in 29/33 parents/guardians approached (87.9%), while in Group B 84/118 consented (71.2%). Intention-to-treat analysis included 113 patients (HFNC 59, CPAP 54). Most reported adverse events were mild/moderate (HFNC 8/59, CPAP 9/54). More patients switched treatment from HFNC to CPAP (Group A: 7/16, 44%; Group B: 9/43, 21%) than from CPAP to HFNC (Group A: 3/13, 23%; Group B: 5/41, 12%). Intubation occurred within 72 h in 15/59 (25.4%) of HFNC patients and 10/54 (18.5%) of CPAP patients (p = 0.38). HFNC patients experienced fewer ventilator-free days at day 28 (Group A: 19.6 vs. 23.5; Group B: 21.8 vs. 22.2).ConclusionsOur pilot trial confirms that, following minor changes to consent procedures and treatment algorithms, it is feasible to conduct a large national RCT of non-invasive respiratory support in the paediatric critical care setting in both step-up and step-down NRS patients.Trial registrationclinicaltrials.gov, NCT02612415. Registered on 23 November 2015.Electronic supplementary materialThe online version of this article (10.1186/s13054-018-2080-3) contains supplementary material, which is available to authorized users.

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Section: Introductionmentioning

confidence: 99%

FIRST-line support for Assistance in Breathing in Children (FIRST-ABC): a multicentre pilot randomised controlled trial of high-flow nasal cannula therapy versus continuous positive airway pressure in paediatric critical care

et al. 2018

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“…There is strong evidence from physiological and observational studies to support the use of HFNC in PICU—HFNC allows the delivery of heated and humidified medical gases to the patient at high-gas flow rates (matching or exceeding the patient’s own peak inspiratory flow rate), which has been shown to confer a diverse range of beneficial effects such as reduction of airway resistance, reduction of dead space by nasopharyngeal washout with fresh gas, as well as delivery of positive airway pressure (similar to CPAP). 16 17 Studies in infants and children confirm that HFNC reduces the work of breathing and improves oxygenation and ventilation. 18 19 In single-centre observational studies, the use of HFNC has been shown to be associated with a dramatic reduction in the rate of intubation and invasive ventilation.…”

Section: Introductionmentioning

confidence: 95%

FIRST-line support for Assistance in Breathing in Children (FIRST-ABC): protocol for a multicentre randomised feasibility trial of non-invasive respiratory support in critically ill children

et al. 2017

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IntroductionOver 18 000 children are admitted annually to UK paediatric intensive care units (PICUs), of whom nearly 75% receive respiratory support (invasive and/or non-invasive). Continuous positive airway pressure (CPAP) has traditionally been used to provide first-line non-invasive respiratory support (NRS) in PICUs; however, high-flow nasal cannula therapy (HFNC), a novel mode of NRS, has recently gained popularity despite the lack of high-quality trial evidence to support its effectiveness. This feasibility study aims to inform the design and conduct of a future definitive randomised clinical trial (RCT) comparing the two modes of respiratory support.Methods and analysisWe will conduct a three-centre randomised feasibility study over 12 months. Patients admitted to participating PICUs who satisfy eligibility criteria will be recruited to either group A (primary respiratory failure) or group B (postextubation). Consent will be obtained from parents/guardians prior to randomisation in ‘planned’ group B, and deferred in emergency situations (group A and ‘rescue’ group B). Participants will be randomised (1:1) to either CPAP or HFNC using sealed, opaque envelopes, from a computer-generated randomisation sequence with variable block sizes. The study protocol specifies algorithms for the initiation, maintenance and weaning of HFNC and CPAP. The primary outcomes are related to feasibility, including the number of eligible patients in each group, feasibility of randomising >50% of eligible patients and measures of adherence to the treatment protocols. Data will also be collected on patient outcomes (eg, mortality and length of PICU stay) to inform the selection of an appropriate outcome measure in a future RCT. We aim to recruit 120 patients to the study.Ethics and disseminationEthical approval was granted by the National Research Ethics Service Committee North East—Tyne&Wear South (15/NE/0296). Study findings will be disseminated through peer-reviewed journals, national and international conferences.Trials registration numberNCT02612415; pre-results.

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“…[1][2][3] The primary mechanism of action of CPAP is the delivery of distending airway pressure, which assists with lung aeration, maintains functional residual capacity, improves oxygenation, and reduces work of breathing. 4,5 CPAP is produced by the flow of heated, humidified gas against a resistance at the distal end of the circuit. This pressure is partly transferred to the infant"s airways through tightly fitting short binasal prongs or a nasal mask.…”

Section: Introductionmentioning

confidence: 99%

Gas flow in preterm infants treated with bubble CPAP: an observational study

Payne

Owen

Hodgson

et al. 2020

Arch Dis Child Fetal Neonatal Ed

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ObjectiveTo measure the nasal gas flow in infants treated with bubble continuous positive airway pressure (CPAP) and compare it with commonly used flows during nasal high flow (nHF) treatment.DesignThis is a prospective, single-centre study. Bubble CPAP pressure was measured at the nasal prongs. Set gas flow was reduced until bubbling in the water chamber just ceased. Set gas flow without bubbling then approximated flow entering the infant’s nose (‘delivered flow’).SettingNeonatal intensive care at The Royal Women’s Hospital, Melbourne, Australia.PatientsClinically stable preterm infants receiving bubble CPAP therapy.Main outcome measureDelivered flow (L/min) when bubbling stopped at a range of clinically set CPAP pressures (cm H2O).ResultsForty-four infants were studied, with a mean (SD) gestational age at birth of 28.4 (2.2) weeks and birth weight of 1154 (419) g. At the time of the study, infants had a median (IQR) age of 4.5 (2–12) days and a mean (SD) weight of 1205 (407) g. Delivered flow ranged from 0.5 to 9.0 L/min, and increased with higher set CPAP pressures (median 3.5 L/min at CPAP 5 cm H2O vs 6.3 L/min at CPAP 8 cm H2O) and heavier weights (median 3.5 L/min in infants <1000 g vs 6.5 L/min for infants >1500 g).ConclusionsNasal gas flows during bubble CPAP in preterm infants are similar to flows used during nHF and increase with higher set bubble CPAP pressures and in larger infants.Trial registration number ACTRN12619000197134.

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Physiologic Basis for Nasal Continuous Positive Airway Pressure, Heated and Humidified High-Flow Nasal Cannula, and Nasal Ventilation

Cited by 13 publications

References 34 publications

FIRST-line support for Assistance in Breathing in Children (FIRST-ABC): a multicentre pilot randomised controlled trial of high-flow nasal cannula therapy versus continuous positive airway pressure in paediatric critical care

FIRST-line support for Assistance in Breathing in Children (FIRST-ABC): a multicentre pilot randomised controlled trial of high-flow nasal cannula therapy versus continuous positive airway pressure in paediatric critical care

FIRST-line support for Assistance in Breathing in Children (FIRST-ABC): protocol for a multicentre randomised feasibility trial of non-invasive respiratory support in critically ill children

Gas flow in preterm infants treated with bubble CPAP: an observational study

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