High flow nasal cannula therapy versus continuous positive airway pressure and nasal positive pressure ventilation in infants with severe bronchiolitis: a randomized controlled trial

Abstract

Introduction non-invasive ventilation is widely used in the respiratory management of severe bronchiolitis. Methods a randomized controlled trial was carried out in a tertiary pediatric university hospital´s PICU over 3 years to compare between continuous positive airway pressure/nasal positive pressure ventilation (CPAP/NPPV) and high flow nasal cannula (HFNC) devices for severe bronchiolitis. The trial was recorded in the national library of medicine registry (NCT04650230). Patients aged from 7 days to 6 months, admitted for severe bronchiolitis were enrolled. Eligible patients were randomly chosen to receive either HFNC or CPAP/NPPV. If HFNC failed, the switch to CPAP/NPPV was allowed. Mechanical ventilation was the last resort in case of CPAP/NPPV device failure. The primary outcome was the success of the treatment defined by no need of care escalation. The secondary outcomes were failure predictors, intubation rate, stay length, serious adverse events, and mortality. Results a total of 268 patients were enrolled. The data of 255 participants were analyzed. The mean age was 51.13 ± 34.43 days. Participants were randomized into two groups; HFNC group (n=130) and CPAP/NPPV group (n=125). The success of the treatment was significantly higher in the CPAP/NPPV group (70.4% [61.6%- 78.2%) comparing to HFNC group (50.7% [41.9%- 59.6%])- (p=0.001). For secondary outcomes, lower baseline pH was the only significant failure predictor in the CPAP/NPPV group (p=0.035). There were no differences in intubation rate or serious adverse events between the groups. Conclusion high flow nasal cannula was safe and efficient, but CPAP/ NPPV was better in preventing treatment failure. The switch to CPAP/NPPV if HFNC failed, avoided intubation in 54% of the cases.

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

“…This study included 268 participants and is the largest sample size conducted to date, which explains its greater weight in the meta-analysis. In this study, the success of the treatment was signi cantly higher in the CPAP/NPPV group (70.4% [61.6%-78.2%) comparing to HFNC group (50.7% [41.9%-59.6%]) (17). However there are not statistically signi cant differences are reported in mechanical ventilation or adverse events.…”

“…Invasive mechanical ventilation: A total of 5 RCTs were included, including 541 children analysis (14)(15)(16)(17)(18). The risk of invasive mechanical ventilation was not signi cantly different in CPAP group and HFNC group [OR: 1.18 , 95% CI (0.74, 1.89), I² = 0%] (very low quality), gure 3a.…”

“…Adverse events: A total of 5 RCTs were included, including 541 children analysis (14)(15)(16)(17)(18). The risk of adverse events (skin lesions, poor system tolerance,abdominal distencion) was higher signi cantly in CPAP group than HFNC group [OR: 3.39, 95% CI (1.48, 7.77), I² = 7%] (low quality), gure 3e.…”

“…Length of stay : A total of 2 RCTs were included, including 318 children analysis (17,18). There are not differences signi cantly in the length of stay between CPAP group and HFNC group [MD =: -0.22, 95% CI (-0.91, 0.48), I² = 27%] (very low quality), gure 3c Mortality: A total of 1 RCTs were included, including 255 children analysis (17). There are not differences signi cantly in the mortality betweem CPAP group and HFNC group [OR: 3.14, 95% CI (0.13, 77.92), I² = NA] (very low quality), gure 3d.…”

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

“…A total of 2 RCTs were included, including 318 children analysis [ 17 , 18 ]. There are not differences significantly in the length of stay between CPAP group and HFNC group [MD =: -0.22, 95% CI (-0.91, 0.48), I² = 27%] (very low quality), Fig.…”