Serious Air Leak Syndrome Complicating High-Flow Nasal Cannula Therapy: A Report of 3 Cases

Abstract

Despite the absence of clinical safety data, heated, humidified high-flow nasal cannula (HHFNC) therapy is increasingly being used as an alternative to positive-pressure ventilation in pediatrics. This use of HHFNC is "off label" because the US Food and Drug Administration's approval for these devices was only for air humidification and not as a modality to provide positive distending pressure. For the first time we describe 3 cases who developed serious air leaks related to HHFNC therapy. The first child was a previously healthy 2-month-old male infant with respiratory syncytial virus bronchiolitis who developed a right pneumothorax on day 5 of his illness at 8 liters per minute (lpm). He subsequently required intubation and ventilation for 14 days. The second case involved an otherwise healthy 16-year-old boy with cerebral palsy who developed pneumomediastinum and died of its complications. He was receiving 20 lpm HHFNC therapy when he developed pneumomediastinum. The third case involved a 22-month-old, previously healthy boy who developed subdural hematoma secondary to abuse. He developed a right pneumothorax while receiving HHFNC at a flow of 6 lpm, requiring chest tube placement. These cases emphasize the need for extreme caution while using HHFNC for the off-label indication of providing positive distending pressure in children, especially at flows higher than the patient's minute ventilation. A more detailed study to specifically look at the serious adverse events related to HHFNC is urgently needed.

Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis

“…126 There is evidence that high-flow nasal cannula improves physiologic measures of respiratory effort and can generate continuous positive airway pressure in bronchiolitis. [127][128][129][130] Clinical evidence suggests it reduces work of breathing 131,132 and may decrease need for intubation, [133][134][135][136] although studies are generally retrospective and small. The therapy has been studied in the ED 136,137 and the general inpatient setting, 134,138 as well as the ICU.…”

Heated humidified high-flow nasal cannula therapy in children

“…The authors cite the potential for an unpredictable rise in positive airways pressure as a possible contributory factor. 32 A further case report describes subcutaneous scalp emphysema, pneumo-orbitis and pneumocephalus, but no pneumothorax or pneumomediastinum, in a premature infant receiving HHHFNC therapy. 33 …”

Noninvasive Respiratory Support

“…102,103 Pressure-relief valves incorporated into some HFNC devices may not be sufficient to avoid excessive pressure. 83 Careful attention should be given to the size of the prongs to allow an adequate leak between the prongs and the infant's nares, as well as the use of the lowest effective flow rates.…”