Outcomes of Children With Bronchiolitis Treated With High-Flow Nasal Cannula or Noninvasive Positive Pressure Ventilation*

Abstract

Objectives: Initial respiratory support with noninvasive positive pressure ventilation or high-flow nasal cannula may prevent the need for invasive mechanical ventilation in PICU patients with bronchiolitis. However, it is not clear whether the initial choice of respiratory support modality influences the need for subsequent invasive mechanical ventilation. The purpose of this study is to compare the rate of subsequent invasive mechanical ventilation after initial support with noninvasive positive pressure ventilation or high-flow nasal cannula in children with bronchiolitis. Design: Analysis of the Virtual Pediatric Systems database. Setting: Ninety-two participating PICUs. Patients: Children less than 2 years old admitted to a participating PICU between 2009 and 2015 with a diagnosis of bronchiolitis who were prescribed high-flow nasal cannula or noninvasive positive pressure ventilation as the initial respiratory treatment modality. Interventions: None. Subsequent receipt of invasive mechanical ventilation was the primary outcome. Measurements and Main Results: We identified 6,496 subjects with a median age 3.9 months (1.7–9.5 mo). Most (59.7%) were male, and 23.4% had an identified comorbidity. After initial support with noninvasive positive pressure ventilation or high-flow nasal cannula, 12.3% of patients subsequently received invasive mechanical ventilation. Invasive mechanical ventilation was more common in patients initially supported with noninvasive positive pressure ventilation compared with high-flow nasal cannula (20.1% vs 11.0%: p < 0.001). In a multivariate logistic regression model that adjusted for age, weight, race, viral etiology, presence of a comorbid diagnosis, and Pediatric Index of Mortality score, initial support with noninvasive positive pressure ventilation was associated with a higher odds of subsequent invasive mechanical ventilation compared with high-flow nasal cannula (odds ratio, 1.53; 95% CI, 1.24–1.88). Conclusions: In this large, multicenter database study of infants with acute bronchiolitis that received initial respiratory support with high-flow nasal cannula or noninvasive positive pressure ventilation, noninvasive positive pressure ventilation use was associated with higher rates of invasive mechanical ventilation, even after adjusting for demographics, comorbid condition, and severity of illness. A large, prospective, multicenter trial is needed to confirm these findings.

A comparison between high‐flow nasal cannula and noninvasive ventilation in the management of infants and young children with acute bronchiolitis in the PICU

“…In a recent multicenter observational study, Clayton et al found that the initial treatment of acute bronchiolitis with CPAP or BiPAP was associated with an increased need for mechanical ventilation, although CPAP or BiPAP patients group were more severely ill compared with HFNC group.…”

Emergency room endotracheal intubation in children with bronchiolitis: A cohort study using a multicenter database

“…VPS data, however, are entered by trained personnel and undergo several quality control procedures before inclusion in the database, enabling it to support several prior PICU studies. 14,15,25 Second, the database does not contain data that the clinician may have considered when deciding to perform endotracheal intubation, such as vital signs, physical exam findings, hypercarbia, presence of apnea, and others, making it prone to confounding by indication. Third, endotracheal intubation and weaning from MV were not protocolized, and prior studies show there is tremendous practice variation in severe bronchiolitis.…”

“…VPS is an international database that prospectively collects and manages standardized clinical data from over 135 PICUs for the purpose of quality improvement and research. 25 With the exception of three centers in Saudi Arabia, all contributing centers are located in the United States or Canada. Participation in VPS is voluntary and, therefore, may not be fully representative of all PICUs, but approximately one-third of all US PICUs participate in VPS and it has supported several prior research studies.…”

“…(as recorded at each VPS center), and PIM-2 score. 25,28,29 Secondarily, variables loosely associated (P < .10) with the outcome were included in separate multivariable linear regression models. Data are shown as n (%) and median (interquartile range).…”

Prospective real‐life studies are needed on bronchiolitis treatment protocols

“…On the other hand, active use of HFNC therapy has decreased the need of intensive care and nCPAP or BiPAP therapies. 4 An advantage of HFNC treatment is that it can be carried out in the emergency departments and on the pediatric wards. 5 Instead, there is an urgent need for prospective controlled reallife studies on treatment protocols for infant bronchiolitis.…”