Advertisement

Pilot Clinical Trial of High-Flow Oxygen Therapy in Children with Asthma in the Emergency Service

Published:January 11, 2018DOI:https://doi.org/10.1016/j.jpeds.2017.10.075

      Objectives

      To assess the efficacy of high-flow nasal cannula (HFNC) oxygen therapy and safety in children with asthma and moderate respiratory failure in the emergency department (ED).

      Study design

      This was a prospective randomized pilot trial of children (aged 1-14 years) presenting to a tertiary academic pediatric ED with moderate-to-severe asthma exacerbations between September 2012 and December 2015. Patients with a pulmonary score (PS) ≥6 or oxygen saturation <94% with a face mask despite initial treatment (salbutamol/ipratropium bromide and corticosteroids) were randomized to HFNC or to conventional oxygen therapy. Pharmacologic treatment was at the discretion of attending physicians. The primary outcome was a decrease in PS ≥2 in the first 2 hours. Secondary outcomes included disposition, length of stay, and need for additional therapies.

      Results

      We randomly allocated 62 children to receive either HFNC (n = 30) or standard oxygen therapy (n = 32). Baseline patient characteristics were similar in the 2 groups. At 2 hours after the start of therapy, PS had decreased by ≥2 points in 16 patients in the HFNC group (53%) compared with 9 controls (28%) (P = .01). Between-group differences in disposition, length of stay, and need for additional therapies were not significant. No side effects were reported.

      Conclusion

      HFNC appears to be superior to conventional oxygen therapy for reducing respiratory distress within the first 2 hours of treatment in children with moderate-to-severe asthma exacerbation refractory to first-line treatment. Further studies are needed to demonstrate its overall efficacy in the management of asthma and respiratory failure in the ED.

      Trial registration

      EudraCT: 2012-001771-36.

      Keywords

      Abbreviations:

      ED (Emergency department), FiO2 (Fraction of inspired oxygen), HFNC (High-flow nasal cannula), HR (Heart rate), n.s (Not significant), PICU (Pediatric intensive care unit), PS (Pulmonary score), RR (Respiratory rate), SpO2 (Oxygen saturation)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The Journal of Pediatrics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Akinbami L.J.
        • Moorman J.E.
        • Garbe P.L.
        • Sondik E.J.
        Status of childhood asthma in the United States, 1980-2007.
        Pediatrics. 2009; 123: S131-S145
        • Akinbami L.J.
        • Schoendorf K.C.
        Trends in childhood asthma: prevalence, health care utilization, and mortality.
        Pediatrics. 2002; 110(2 Pt 1): 315-322
        • Benito J.
        • Bayon J.L.
        • Montiano J.
        • Sanchez J.
        • Mintegui S.
        • Vazquez C.
        Time trends in acute childhood asthma in Basque Country, Spain.
        Pediatr Pulmonol. 1995; 20: 184-188
        • Global Initiative for Asthma (GINA)
        Global strategy for asthma management and prevention.
        (Available at:)
        http://ginasthma.org/archived-reports/
        Date: 2015
        Date accessed: June , 2016
        • Mintegui Raso S.
        • Benito Fernández J.
        • González-Balenciaga M.
        • Fernández Landaluce A.
        Consequences of strength treatment of children with asthma in a pediatric emergency department on to in-hospital admission.
        Emergencias. 2003; 15 (in Spanish): 345-350
        • Benito Fernández J.
        • Mintegui Raso S.
        • Sánchez Echániz J.
        • Vázquez Ronco M.A.
        • Pijoán Zubizarreta J.I.
        Recent changes in emergency room visits and hospitalization for asthma in children.
        An Esp Pediatr. 1998; 49 (in Spanish): 577-581
        • Benito-Fernández J.
        Short-term clinical outcomes of acute treatment of childhood asthma.
        Curr Opin Allergy Clin Immunol. 2005; 5: 241-246
        • Benito-Fernández J.
        • Onis-González E.
        • Alvarez-Pitti J.
        • Capapé-Zache S.
        • Vázquez-Ronco M.A.
        • Mintegi-Raso S.
        Factors associated with short-term clinical outcomes after acute treatment of asthma in a pediatric emergency department.
        Pediatr Pulmonol. 2004; 38: 123-128
        • Schibler A.
        • Pham T.M.
        • Dunster K.R.
        • Foster K.
        • Barlow A.
        • Gibbons K.
        • et al.
        Reduced intubation rates for infants after introduction of high-flow nasal prong oxygen delivery.
        Intensive Care Med. 2011; 37: 847-852
        • Wing R.
        • James C.
        • Maranda L.S.
        • Armsby C.C.
        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; 28: 1117-1123
        • McKiernan C.
        • Chua L.C.
        • Visintainer P.F.
        • Allen H.
        High flow nasal cannulae therapy in infants with bronchiolitis.
        J Pediatr. 2010; 156: 634-638
        • Waugh J.B.
        • Granger W.M.
        An evaluation of 2 new devices for nasal high-flow gas therapy.
        Respir Care. 2004; 49: 902-906
        • Spence K.L.
        • Murphy D.
        • Kilian C.
        • McGonigle R.
        • Kilani R.A.
        High-flow nasal cannula as a device to provide continuous positive airway pressure in infants.
        J Perinatol. 2007; 27: 772-775
        • Lee J.H.
        • Rehder K.J.
        • Williford L.
        • Cheifetz I.M.
        • Turner D.A.
        Use of high-flow nasal cannula in critically ill infants, children and adults: a critical review of the literature.
        Intensive Care Med. 2013; 39: 247-257
        • Milési C.
        • Baleine J.
        • Matecki S.
        • Durand S.
        • Combes C.
        • Novais A.R.
        • et al.
        Is treatment with a high flow nasal cannula effective in acute viral bronchiolitis? A physiologic study.
        Intensive Care Med. 2013; 39: 1088-1094
        • Spentzas T.
        • Minarik M.
        • Patters A.B.
        • Vinson B.
        • Stidham G.
        Children with respiratory distress treated with high-flow nasal cannula.
        J Intensive Care Med. 2009; 24: 323-328
        • Kubicka Z.J.
        • Limauro J.
        • Darnall R.A.
        Heated, humidified high-flow nasal cannula therapy: yet another way to deliver continuous positive airway pressure?.
        Pediatrics. 2008; 121: 82-88
        • Lampland A.L.
        • Plumm B.
        • Meyers P.A.
        • Worwa C.T.
        • Mammel M.C.
        Observational study of humidified high-flow nasal cannula compared with nasal continuous positive airway pressure.
        J Pediatr. 2009; 154: 177-182
        • Dewan N.A.
        • Bell C.W.
        Effect of low-flow and high-flow oxygen delivery on exercise tolerance and sensation of dyspnea: a study comparing the transtracheal catheter and nasal prongs.
        Chest. 1994; 105: 1061-1065
        • Spoletini G.
        • Alotaibi M.
        • Blasi F.
        • Hill N.S.
        Heated humidified high-flow nasal oxygen in adults: mechanisms of action and clinical implications.
        Chest. 2015; 148: 253-261
        • Dysart K.
        • Miller T.L.
        • Wolfson M.R.
        • Shaffer T.H.
        Research in high-flow therapy: mechanisms of action.
        Respir Med. 2009; 103: 1400-1405
        • Hutchings F.A.
        • Hilliard T.N.
        • Davis P.J.
        Heated humidified high-flow nasal cannula therapy in children.
        Arch Dis Child. 2015; 100: 571-575
        • Milési C.
        • Boubal M.
        • Jacquot A.
        • Baleine J.
        • Durand S.
        • Odena M.P.
        • et al.
        High- flow nasal cannula: recommendations for daily practice in pediatrics.
        Ann Intensive Care. 2014; 4: 29
        • Shepard Jr, J.W.
        • Burger C.D.
        Nasal and oral flow-volume loops in normal subjects and patients with obstructive sleep apnea.
        Am Rev Respir Dis. 1990; 142(6 Pt 1): 1288-1293
        • Kelly G.S.
        • Simon H.K.
        • Sturm J.J.
        High-flow nasal cannula use in children with respiratory distress in the emergency department: predicting the need for subsequent intubation.
        Pediatr Emerg Care. 2013; 29: 888-892
        • Abboud P.A.
        • Roth P.J.
        • Skiles C.L.
        • Stolfi A.
        • Rowin M.E.
        Predictors of failure in infants with viral bronchiolitis treated with high-flow, high-humidity nasal cannula therapy.
        Pediatr Crit Care Med. 2012; 13: e343-e349
        • ten Brink F.
        • Duke T.
        • Evans J.
        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; 14: e326-e331
        • Hilliard T.N.
        • Archer N.
        • Laura H.
        • Heraghty J.
        • Cottis H.
        • Mills K.
        • et al.
        Pilot study of vapotherm oxygen delivery in moderately severe bronchiolitis.
        Arch Dis Child. 2012; 97: 182-183
        • Bressan S.
        • Balzani M.
        • Krauss B.
        • Pettenazzo A.
        • Zanconato S.
        • Baraldi E.
        High- flow nasal cannula oxygen for bronchiolitis in a pediatric ward: a pilot study.
        Eur J Pediatr. 2013; 172: 1649-1656
        • González Martínez F.
        • González Sánchez M.I.
        • Rodríguez Fernández R.
        Clinical impact of introducing ventilation with high-flow oxygen in the treatment of bronchiolitis in a paediatric ward.
        An Pediatr (Barc). 2013; 78 (in Spanish): 210-215
        • Montiano Jorge J.I.
        • Salado Marin C.
        High-flow oxygen therapy in a hospital ward.
        An Pediatr (Barc). 2015; 82 (in Spanish): 210-212
        • Mayfield S.
        • Bogossian F.
        • O'Malley L.
        • Schibler A.
        High-flow nasal cannula oxygen therapy for infants with bronchiolitis: pilot study.
        J Paediatr Child Health. 2014; 50: 373-378
        • Mayfield S.
        • Jauncey-Cooke J.
        • Bogossian F.
        A case series of paediatric high-flow nasal cannula therapy.
        Aust Crit Care. 2013; 26: 189-192
        • Smith S.R.
        • Baty J.D.
        • Hodge 3rd, D.
        Validation of the pulmonary score: an asthma severity score for children.
        Acad Emerg Med. 2002; 9: 99-104
        • Greenberg R.A.
        • Kerby G.
        • Roosevelt G.E.
        A comparison of oral dexamethasone with oral prednisone in pediatric asthma exacerbations treated in the emergency department.
        Clin Pediatr (Phila). 2008; 47: 817-823
        • Qureshi F.
        • Zaritsky A.
        • Poirier M.P.
        Comparative efficacy of oral dexamethasone versus oral prednisone in acute pediatric asthma.
        J Pediatr. 2001; 139: 20-26
        • Benito-Fernández J.
        • Mojica-Muñoz E.
        • Andrés-Olaizola A.
        • González-Balenciaga M.
        • Urrutia-Adan M.
        • Martinez-Indart L.
        • et al.
        Impact on quality of life by improving asthma control medication in patients with persistent asthma in a paediatric emergency department.
        Eur J Emerg Med. 2013; 20: 350-355
        • Mayfield S.
        • Jauncey-Cooke J.
        • Hough J.L.
        • Schibler A.
        • Gibbons K.
        • Bogossian F.
        High-flow nasal cannula therapy for respiratory support in children.
        Cochrane Database Syst Rev. 2014; (CD009850)
        • Hegde S.
        • Prodhan P.
        Serious air leak syndrome complicating high-flow nasal cannula therapy: a report of 3 cases.
        Pediatrics. 2013; 131: e939-e944
        • Dani C.
        • Pratesi S.
        • Migliori C.
        • Bertini G.
        High-flow nasal cannula therapy as respiratory support in the preterm infant.
        Pediatr Pulmonol. 2009; 44: 629-634