PulmonaryPredictive factors for the outcome of high flow nasal cannula therapy in a pediatric intensive care unit: Is the SpO2/FiO2 ratio useful?☆,☆☆,★
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
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The English in this document has been checked by at least two professional editors, both native speakers of English. For a certificate, please see: http://www.textcheck.com/certificate/LxgBJC.
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The study was performed in Tepecik Teaching and Research Hospital, Pediatric Intensive Care Unit, Izmir, Turkey.
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There is no conflict of interest.