High-flow nasal cannula therapy not inferior to CPAP for acutely ill children in pediatric ICU: JAMA

UK: An article on the care of pediatric patients in PICU published in the Journal of the American Medical Association (JAMA) illustrated that first-line use of high-flow nasal cannula therapy (HFNC) is not inferior to continuous positive airway pressure (CPAP). The non-inferiority was seen in terms of time to liberation from respiratory support in acutely ill children admitted to pediatric critical care units (PICU).

The primary goal of critical care is to resuscitate and salvage critically ill children with rapid therapeutic interventions of which respiratory support is the most common intervention. The risks associated with invasive mechanical ventilation have led to greater use of noninvasive modes of respiratory support in acutely ill children. HFNC(noninvasive) therapy has become popular as it has been associated with better tolerance, lower complications, and lower cost.

Recently surveys have indicated that HFNC is frequently used as the first-line mode for respiratory support in a range of diseases but there is very little evidence to support the clinical effectiveness of HFNC in acutely ill children.

Dr Padmanabhan, Imperial College, London, UK and his team organized a study to evaluate the noninferiority of HFNC as the first-line noninvasive respiratory support for acute illness, compared with CPAP, for time to liberation from all forms of respiratory support.

The study was a randomized noninferiority clinical trial conducted in 24 pediatric critical care units in the UK among 600 acutely ill children (aged 0 - 15 years), who were clinically assessed to require noninvasive respiratory support. Patients were randomized 1:1 to commence either HFNC at a flow rate based on patient weight (n = 301) or CPAP of 7 to 8 cm H2O (n = 299).

Trial data showed,

• The median time to liberation was 52.9 hours for HFNC vs 47.9 hours for CPAP. This met the criterion for noninferiority (adjusted hazard ratio, 1.03).

• Of the 7 prespecified secondary outcomes, 3 were significantly lower in the HFNC group: use of sedation, mean duration of critical care stay and mean duration of acute hospital stay.

• The most common adverse event was nasal trauma (HFNC: 6/295; CPAP: 18/278).

The authors concluded that HFNC met the criterion for noninferiority for time to liberation from respiratory support when compared with CPAP among acutely ill children assessed to require noninvasive respiratory support and admitted to a pediatric critical care unit. HFNC is beneficial for children admitted to pediatric ICU.

Reference:

Ramnarayan P, Richards-Belle A, Drikite L, et al. Effect of High-Flow Nasal Cannula Therapy vs Continuous Positive Airway Pressure Therapy on Liberation From Respiratory Support in Acutely Ill Children Admitted to Pediatric Critical Care Units: A Randomized Clinical Trial. JAMA. Published online June 16, 2022. doi:10.1001/jama.2022.9615