A retrospective study was performed in children (aged one month - 16 years) receiving HFNC to determine the frequency, efficacy and adverse effects of high flow nasal cannula (HFNC) therapy in the pediatric intensive care unit (PICU), from January to December 2017. Treatment failure was defined as clinical deterioration on HFNC therapy such that mechanical ventilation (MV) was required. Clinical parameters before and after HFNC were assessed using repeated measures analysis of variance. A total of 120 patients received HFNC therapy (21% of total admissions). Primary diagnosis were respiratory disease (50%), central nervous system diseases (14.2%), sepsis (10.8%), and postoperative care (10%). Mean duration of HFNC was 27.5 ±19.7 hours and mean PICU length of stay was 6 ± 6 days. Pneumothorax developed in four patients. MV was required in 28 patients, and subsequently, 15 deaths occurred in that group. HFNC is a frequently used, safe and effective therapy for children requiring respiratory support in PICU. Key Words: Respiratory insufficiency, Non-invasive ventilation, Paediatric intensive care unit

Abbas, Qalab

Azim, Asim

Haque, Anwar Ul

Saeed, Bushra

English

eCommons@AKU

eCommons@AKU Department of Paediatrics and Child Health Division of Woman and Child Health 1-1-2021 High flow nasal cannula therapy in children with acute respiratory insufficiency in the pediatric intensive care unit of a resource-limited country: A preliminary experience Bushra Saeed Asim Azim Anwar Ul Haque Qalab Abbas Follow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_women_childhealth_paediatr  Part of the Maternal and Child Health Commons, Pediatrics Commons, and the Respiratory Tract Diseases Commons SHORT COMMUNICATIONJournal  of  the College of  Physicians and Surgeons Pakistan 2021,  Vol.  31(01):  110-112110High Flow Nasal Cannula Therapy in Children with AcuteRespiratory Insufficiency in the Pediatric Intensive CareUnit of a Resource-limited Country: A PreliminaryExperienceBushra Saeed1, Asim Azim2, Anwar Ul Haque3 and Qalab Abbas41Pediatric ICU, Children's Hospital, Lahore, Pakistan2Pediatric ICU, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia3Pediatric ICU, The Indus Hospital, Karachi, Pakistan4Department of Pediatrics and Child Health, The Aga Khan University Hospital, Karachi, PakistanABSTRACTA retrospective study was performed in children (aged one month – 16 years) receiving HFNC to determine the frequency,efficacy and adverse effects of high flow nasal cannula (HFNC) therapy in the pediatric intensive care unit (PICU), from Januaryto December 2017.  Treatment failure was defined as clinical  deterioration on HFNC therapy such that mechanical  ventilation(MV) was required. Clinical parameters before and after HFNC were assessed using repeated measures analysis of variance. Atotal of 120 patients received HFNC therapy (21% of total admissions). Primary diagnosis were respiratory disease (50%),central nervous system diseases (14.2%), sepsis (10.8%), and postoperative care (10%). Mean duration of HFNC was 27.5±19.7 hours and mean PICU length of stay was 6 ± 6 days. Pneumothorax developed in four patients. MV was required in 28patients, and subsequently, 15 deaths occurred in that group. HFNC is a frequently used, safe and effective therapy for childrenrequiring respiratory support in PICU.Key Words: Respiratory insufficiency, Non-invasive ventilation, Paediatric intensive care unit.How to cite this article: Saeed B, Azim A, Haque AU, Abbas Q. High Flow Nasal Cannula Therapy in Children with Acute RespiratoryInsufficiency  in  the  Pediatric  Intensive  Care  Unit  of  a  Resource-limited  Country:  A  Preliminary  Experience.  J  Coll  Physicians  Surg  Pak2021; 31(01):110-112.Respiratory illnesses are one of the leading causes for pediatricintensive  care  unit  (PICU)  admission  (26.3%).1  Respiratorysupport  in  PICU has evolved from predominantly  mechanicalventilation (MV) to non-invasive ventilation. This has markedlyreduced complications related to invasive mechanical ventila-tion.2,3 Heated, humidified, high-flow nasal cannula (HFNC) is arelatively new method of respiratory support.4 HFNC washes outthe carbon dioxide-rich gas in a portion of the anatomical deadspace  and  potentially  provides  positive  airway  pressure.Humidification saves energy spent warming and enables bettertolerance by decreasing the risk of nasal trauma.5 Previous clin-ical studies using HFNC therapy have shown a reduction in intuba-tion  rates  in  critically  ill  infants  in  PICU  with  a  better  safetyprofile.3,4,6Correspondence  to:  Dr.  Qalab  Abbas,  Department  of  Pedi-atrics  and  Child  Health,  The  Aga  Khan  UniversityHospital,  National  Stadium  Road,  Karachi,  PakistanE-mail:  qalababbas@gmail.com.....................................................Received: December 03, 2019;  Revised: February 29, 2020;Accepted:  May  11,  2020DOI:  https://doi.org/10.29271/jcpsp.2021.01.110We describe use of HFNC in our PICU. This study will pave thepath for larger studies on use of HFNC in children with acuterespiratory distress.Retrospective review of medical records of children (aged onemonth – 16 years) admitted in PICU of the Aga Khan UniversityHospital  and  received  HFNC,  was  done  from  January  toDecember 2017 after ethical approval (2019-1036-2634). Thedecision to start HFNC was based on patients’ clinical condition[respiratory  distress  defined  as  increased  respiratory  rate,increased work of breathing, oxygen saturation as per standardpediatric advanced life support (PALS) guidelines],  hemody-namic stability (age-appropriate normal heart rate, perfusionand blood pressure as per PALS criteria), normal Glasgow comascale (GCS) and oxygen saturation (SaO2) and attending physi-cian discretion. Patients with SaO2 <88% on pulse oximetry,GCS  <12,  and  hemodynamic  instability  were  not  providedHFNC. HFNC was provided at the maximum rate of 2 litres/kilo-gramme body weight/minute, through Optiflow® system withage appropriate nasal cannulas (Fisher and Paykel Healthcare).HFNC was switched to O2 by nasal prongs, if patient was at <40%FiO2 for more than 6 hours with stable vital signs and work ofbreathing, and was labelled HFNC success.Bushra Saeed,  Asim Azim, Anwar Ul  Haque and Qalab AbbasJournal  of  the College of  Physicians and Surgeons Pakistan 2021,  Vol.  31(01):  110-112 111Table I: Comparison of variables between high flow nasal cannula success and failure.  High flow nasal cannula failure(intubated)n=28High flow nasal cannula success(non-intubated)n=92Independent  t-test /Chi-square testp-value (95% CI)Heart rate Mean ± SD* Mean ± SD  0 hours (before start of HFNC) 154 ± 21 145.6 ± 21 0.11At 2 hours of HFNC 135 ± 13 125.38 ± 21 0.034At end of HFNC 127.18 ± 26 115.11 ± 19 0.01Respiratory rate    0 hours (before start) 46.7 ± 13 49.30 ± 12 0.352 hours 39.6 ± 14 35.37 ± 8 0.066End of HFNC 35.82 ± 18 28.67 ± 8 0.003SaO2 / FiO2 ratio 210 ± 63.28 217.56 ± 51.70 0.59Gender:MaleFemale 217 53390.09, (0.85 – 5.71)Admission source:EmergencyInpatientOperating roomCardiac ICU 20701 5330810.23Reason for admission:Acute respiratory distressacute respiratory failurepost-op careOthers (for monitoring) 32203 383212100.001Comorbids:YesNo 1612 49430.72 (0.49 – 2.75)Diagnosis:Central nervous system diseasesCardiovascular diseasesRespiratory diseasesGastrointestinal diseasesInfectionsMalignancySurgicalMiscellaneous 351413011 146460101114    Survival:YesNo 199 8660.001 (0.047 – 0.46)*SD = standard deviation.If  a  patient had SaO2  <88% on HFNC, FiO2  requirements>70%,  respiratory  distress  or  hemodynamic  instability,HFNC treatment was regarded as failure and MV was insti-tuted.  Patients  were  also  observed  for  development  ofcomplication (pneumothorax) detected on chest X-ray.Data  collection  included demographic,  clinical,  and  HFNCdetails. Chi-square / T-test were applied to compare HFNCsuccess versus  failure.  A p-value of  <0.05 was taken assignificant.A total of 120 patients met the inclusion criteria, making21% of total PICU admissions. The primary diagnosis wasrespiratory  system  diseases  (60,  50%),  central  nervoussystem diseases (17, 14.2%), sepsis (13, 10.8%), postopera-tive care (12, 10%) and miscellaneous (two patients withacute kidney injury and severe diabetic ketoacidosis eachand one patient with severe malnutrition).Mean HFNC duration was 27.5 ±19.7 hours, while mean PICUlength  of  stay  was  6  ±  6  days.  Twenty-eight  patients(23.3%) failed HFNC and required MV. Complication (pneu-mothorax) developed in four (3.3%) and all survived. Meanheart rate and respiratory rate decreased significantly in allpatients after two hours of HFNC therapy (p < 0.05, Table I).This  difference  was  more  pronounced  in  patients  in  whomHFNC was successful  as compared to patients who failedHFNC therapy (Table I). The SaO2 / FiO2 ratio was same inboth groups (p=0.59). Fifteen (12.5%) patients died, under-lying cause was acute respiratory distress syndrome (ARDS)in seven, acute heart failure in four, sepsis in two, and acuteleukemia with relapse in one.HFNC is being increasingly used in children for a variety ofconditions.2 Recent studies have shown HFNC to be effectivein  infants  with  bronchiolitis,  requiring  less  escalation  oftherapy compared to standard therapy.6High flow nasal  cannula therapy in  children with acute respiratory insufficiencyJournal  of  the College of  Physicians and Surgeons Pakistan 2021,  Vol.  31(01):  110-112112Escalation to MV (23%) in this study was higher than inprevious studies of 8-18%.3,6  Amongst patients who failedHFNC, there were 15 deaths and failure of HFNC could bedue  to  the  severity  of  presenting  disease.  However,mechanical ventilation was not warranted at the start oftreatment in any of the patients and so there was clinicalequipoise as to the use of HFNC at this stage of diseaseevolution, allowing us to determine our own criteria for itsuse.  This  study  did  not  consider  the  diagnosis-specificfailure  rate.Pneumothorax was the main complication observed in thisstudy. Previous report show frequency of <1% of develop-ment of pneumothorax with HFNC.3,6 Pneumothorax on HFNCdevelops  with  severe  underlying  lung disease  or  due toformation of  seal  around the nasal  cannula due to thicksecretions or inappropriate nasal cannula size.Pneumothorax was small in all these patients with no hemo-dynamic instability and spontaneous resolution in three, onerequired chest drain insertion. It could be related to under-lying disease process but further exploration into the causeof pneumothorax was not possible because of type of studydesign.Heart  rate  and  respiratory  rate  improved  significantlywithin two hours of start of HFNC therapy in all the patients,and  this  difference  was  significant  in  patients  with  HFNCsuccess compared to those who failed the intervention. Thismeans that clinical status assessment after two hours ofstarting HFNC therapy is important and can be a predictorof  HFNC  therapy  success.  Further  studies  must  beperformed to explore this. SaO2 and FiO2 ratio (a marker ofseverity of hypoxia and disease) were similar in the boththe groups.The study has limitations of being a single centre, retrospec-tive and small sample size. Further studies may identify reli-able cardiorespiratory and diagnostic predictors of therapyfailure. Despite that, HFNC is frequently used, safe and effec-tive  therapy for  children requiring  respiratory  support  inPICU.ETHICAL APPROVAL:This study was exempted from full ethical approval because ofobservational  nature  of  this  study  by  the  Ethical  ReviewCommittee of the Aga Khan University (Ref #2019-1036-2634).PATIENTS' CONSENT:Because of  the  observational  nature  of  the  study whichdidn’t  involve  any  patients’  interaction/intervention,  theneed  for  consent  was  waived  by  the  Ethical  ReviewCommittee.CONFLICT OF INTEREST:The authors declared no conflict of interest.AUTHORS' CONTRIBUTION:BS, AA: Wrote protocol  along with QA and AH guidance,collected data, and contributed in manuscript writing. QA, AH: Conceived the idea and contributed in manuscriptwriting.QA: Analysed data.All approved final form of the manuscript.REFERENCESNamachivayam P, Shann F, Shekerdemian L, Taylor A, van1.Sloten I, Delzoppo C, et al. Three decades of pediatric inten-sive care: Who was admitted, what happened in intensivecare, and what happened afterward. Pediatr Crit Care Med2010; 11(5):549-55. doi: 10.1097/PCC.0b013 e3181ce7427Xu XP, Zhang XC, Hu SL, Xu JY, Xie JF, Liu SQ, et al. Non-inva-2.sive ventilation in acute hypoxemic nonhypercapnic respira-tory  failure:  A  systematic  review and meta-analysis.  CritCare  Med  2017;  45(7):e727-e33.  do.'i:  10.1097/CCM.0000000000002361.Clayton  JA,  McKee  B,  Slain  KN,  Rotta  AT,  Shein  SL.3.Outcomes of children with bronchiolitis treated with high--flow nasal cannula or noninvasive positive pressure ventila-tion.  Pediatr  Crit  Care  Med  2019;  20(2):128-35.  doi:10.1097/PCC.0000000000001798.Morris  JV,  Kapetanstrataki  M,  Parslow  RC,  Davis  PJ,4.Ramnarayan  P.  Patterns  of  use  of  heated  humidified  high--flow nasal cannula therapy in PICUs in the United Kingdomand  republic  of  ireland.  Pediatr  Crit  Care  Me  2019;20(3):223-32. doi: 10.1097/PCC.0000000000001805.Liew Z, Fenton AC, Harigopal S, Gopalakaje S, Brodlie M,5.O'Brien  CJ.  Physiological  effects  of  high-flow  nasal  cannulatherapy in preterm infants. Arch Dis Child Fetal Neonatal Ed2020;  105(1):87-93.  doi:  10.1136/archdischild-2018-316773.  Franklin  D,  Babl  FE,  Schlapbach  LJ,  Oakley  E,  Craig  S,6.Neutze  J,  et  al.  A  randomised  trial  of  high-flow  oxygentherapy in infants with bronchiolitis.  N Engl J  Med  2018;378(12):1121-31. doi: 10.1056/NEJMoa1714855.••••••••••

High flow nasal cannula therapy in children with acute respiratory insufficiency in the pediatric intensive care unit of a resource-limited country: A preliminary experience

https://ecommons.aku.edu/cgi/viewcontent.cgi?article=1991&amp;context=pakistan_fhs_mc_women_childhealth_paediatr

High flow nasal cannula therapy in children with acute respiratory insufficiency in the pediatric intensive care unit of a resource-limited country: A preliminary experience

Abstract

Similar works

Full text

Available Versions

eCommons@AKU