Elsevier

Journal of Critical Care

Volume 44, April 2018, Pages 436-444
Journal of Critical Care

Pulmonary
Predictive factors for the outcome of high flow nasal cannula therapy in a pediatric intensive care unit: Is the SpO2/FiO2 ratio useful?,☆☆,

https://doi.org/10.1016/j.jcrc.2017.09.003Get rights and content

Highlights

  • HFNC seems to be a successful treatment method in children with respiratory distress in PICU.

  • S/F ratio may be used as a predictor for HFNC success just before or on follow up at 60 min of therapy.

  • Monitoring of S/F might be useful and practical in order not to delay escalation to another ventilation support.

Abstract

Objectives

To determine the predictive factors for the outcome of high-flow nasal cannula (HFNC) therapy in a pediatric intensive care unit (PICU).

Materials and methods

We prospectively included all patients with acute respiratory distress/failure aged 1 month to 18 years who were admitted to the PICU between January 2015 and May 2016 and treated with HFNC as a primary support and for postextubation according to our pre-established protocol. HFNC failure was defined as the need for escalation to non-invasive ventilation (NIV) or invasive mechanical ventilation (MV). HFNC responders and nonresponders were compared based on clinical data obtained just before HFNC and at 30, 60, and 120 min, 12, 24, and 48 h, and at the end of therapy.

Results

A total of 204 patients (median age: 16.5 months) participated in the study. Twenty-six (12.7%) patients required escalation (4 to NIV and 22 to MV). Age > 120 months, higher PRISM-III and respiratory scores, and a lower SpO2/FiO2 (S/F) ratio at admission were predictors of HFNC failure. Achievement of the S/F > 200 goal at 60 min significantly predicted successful HFNC.

Conclusion

Monitoring the S/F ratio might be useful and practical to avoid delaying escalation to another ventilation support. Failure to achieve S/F > 200 at 60 min should be a warning for the escalation of respiratory support.

Introduction

Acute respiratory distress/failure is one of the most common causes of pediatric intensive care unit (PICU) admission. Respiratory support often plays a central role in the management of critically ill children, and invasive mechanical ventilation (MV) has been a mainstay intervention in many cases. Recently, there has been a tendency to use non-invasive mechanical ventilation (NIV) on critically ill children with a variety of respiratory distress etiologies in the PICU. NIV has many advantages over intubation: decreased risk of ventilator-acquired pneumonia, decreased sedation requirement, lower hospital costs, decreased laryngeal/tracheal injury, decreased length of PICU stay, and increased mobility [1]. Despite these advantages, it requires an experienced staff and specific NIV devices. Moreover, the clinician has to compete with low patient tolerance [2], [3].

High-flow nasal cannula (HFNC) oxygen therapy is a relatively new system that provides noninvasive respiratory support, and it is often well tolerated by patients. HFNC therapy stands between conventional oxygen delivery devices and NIV; thus, it is not equivalent to NIV. The HFNC apparatus comprises an air/oxygen blender, an active humidifier, a single heated circuit, and a nasal cannula. HFNC is considered to have a number of physiological effects: reduction of anatomical dead space, positive end-expiratory pressure effect, constant fraction of inspired oxygen, and good humidification [4], [5], [6]. Its application is very easy, which often motivates staff to use it as a noninvasive respiratory support. Recently, studies have suggested that HFNC therapy decreases the work of breathing, improves oxygenation, and provides a continuous positive airway pressure (CPAP) effect for a range of respiratory distress diagnoses in PICU and emergency care settings [6], [7], [8]. Moreover, a reduction in the intubation rate, which is similar to the effect of nasal CPAP, has been shown in a limited number of studies [9], [10]. HFNC can be used as a next-step respiratory support after nasal prongs or an oxygen mask. The beneficial effects of HFNC should be monitored through pulse oxygen saturation (SpO2), oxygen need, respiratory rate (RR), heart rate (HR), and symptoms of difficulty breathing. If there is no improvement on follow-up, more aggressive ventilation techniques, such as NIV or invasive MV, should be considered [11]. In the literature, there is limited information regarding the best predictors of the HFNC outcome in a heterogeneous pediatric population in a PICU [8], [12]. Although it is suggested that continuous vital parameters be monitored for the outcome of children treated with HFNC [11], we wished to determine the best predictors of positive outcomes, which should be reliable, useful, and practical tools.

We have experienced the use of HFNC as a primary respiratory support and for postextubation in children with acute respiratory distress/failure since November 2013; since that time, a pre-established protocol has been in use. Because delayed intubation is associated with poor outcomes, we aimed to identify early predictors of the outcome just before treatment and during follow-up in patients receiving HFNC treatment due to respiratory distress in a PICU.

Section snippets

Setting

This study was conducted in the PICU of the Tepecik Teaching and Research Hospital in İzmir, Turkey. This PICU is a 10-bed tertiary mixed surgical/cardiac/medical unit with an age range of 1 month to 18 years and approximately 350 admissions annually. Although NIV is used with high frequency, over 60% of PICU admissions require intubation.

Design and patients

This study was conducted from January 2015 through May 2016. In this prospective observational study, we included all consecutive patients aged 1 month to 18 

Results

A total of 204 patients participated in this study between January 2015 and May 2016. Their median age was 16.5 months (IQR: 5–48 months; minimum: 1.5 months; maximum: 204 months); 102 of the patients (50%) were male. Initially, the median flow (l/kg/min) was 2.2 (1.4–2.8). Twenty-six patients required escalation (four patients to NIV and 22 patients to invasive MV) between 30 min and 24 h after the beginning of treatment. HFNC was successful in 178 patients (87.2%). In the nonresponder group, 20

Discussion

HFNC was used as a primary respiratory support and for postextubation in 204 patients aged 1 month to 18 years with various etiologies of respiratory distress/failure in the PICU. The overall success rate was 87.2%. In our study, an age > 120 months, a higher PRISM III-24 score, a higher RS at admission, and a lower S/F at admission were associated with a higher HFNC failure rate. In contrast, the presence of bronchiolitis was associated with a higher HFNC success rate. A significant number of

Conclusion

The HFNC system is a noninvasive, simple, effective, easy-to-use, and safe respiratory support method for children respiratory distress/failure of various etiologies. However, the likelihood of HFNC success is low in the older age group, in those with more severe disease, or in those with more severe respiratory distress. Initial improvement in RR, HR, and RS may not indicate final HFNC success. The most important issue regarding HFNC use is the early prediction of HFNC failure so as to avoid

References (38)

  • T.M. Pham et al.

    The effect of high flow nasal cannula therapy on the work of breathing in infants with bronchiolitis

    Pediatr Pulmonol

    (2015)
  • J.H. Lee et al.

    Use of high flow nasal cannula in critically ill infants, children, and adults: a critical review of the literature

    Intensive Care Med

    (2013)
  • T. Spentzas et al.

    Children with respiratory distress treated with high-flow nasal cannula

    J Intensive Care Med

    (2009)
  • A. Schibler et al.

    Reduced intubation rates for infants after introduction of high-flow nasal prong oxygen delivery

    Intensive Care Med

    (2011)
  • R. Wing et al.

    Use of high-flow nasal cannula support in the emergency department reduces the need for intubation in pediatric acute respiratory insufficiency

    Pediatr Emerg Care

    (2012)
  • J. Pilar et al.

    High flow oxygen therapy and continuous positive airway pressure

  • F. ten Brink et al.

    High-flow nasal prong oxygen therapy or nasopharyngeal continuous positive airway pressure for children with moderate-to severe respiratory distress?*

    Pediatr Crit Care Med

    (2013)
  • B. Goldstein et al.

    International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics

    Pediatr Crit Care Med

    (2005)
  • P. Sharma et al.

    Oxygen therapy in pediatrics

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    ☆☆

    The study was performed in Tepecik Teaching and Research Hospital, Pediatric Intensive Care Unit, Izmir, Turkey.

    There is no conflict of interest.

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