An Pediatr (Barc).



High flow nasal cannula oxygen therapy in the
treatment of acute bronchiolitis in neonates夽
Lorena Bermúdez Barrezueta ∗ , Nuria García Carbonell, Jorge López Montes,
Rafael Gómez Zafra, Purificación Marín Reina, Jana Herrmannova, Javier Casero Soriano

Departamento de Pediatría, Consorcio Hospital General Universitario de Valencia, Valencia, Spain

Received 29 December 2015; accepted 1 March 2016
Available online 30 November 2016

High flow nasal Objective: To determine whether the availability of heated humidified high-flow nasal cannula
cannula oxygen (HFNC) therapy was associated with a decrease in need for mechanical ventilation in neonates
therapy; hospitalised with acute bronchiolitis.
Neonates; Methods: A combined retrospective and prospective (ambispective) cohort study was per-
Bronchiolitis; formed in a type II-B Neonatal Unit, including hospitalised neonates with acute bronchiolitis
Invasive mechanical after the introduction of HFNC (HFNC-period; October 2011---April 2015). They were compared
ventilation; with a historical cohort prior to the availability of this technique (pre-HFNC; January 2008---May
Non-invasive 2011). The need for mechanical ventilation between the two study groups was analysed. Clini-
mechanical cal parameters and technique-related complications were evaluated in neonates treated with
ventilation HFNC.
Results: A total of 112 neonates were included, 56 after the introduction of HFNC and 56 from
the period before the introduction of HFNC. None of the patients in the HFNC-period required
intubation, compared with 3.6% of the patients in the pre-HFNC group. The availability of HFNC
resulted in a significant decrease in the need for non-invasive mechanical ventilation (30.4% vs
10.7%; P = .01), with a relative risk (RR) of .353 (95% CI: .150---.829), an absolute risk reduction
(ARR) of 19.6% (95% CI: 5.13---34.2), yielding a NNT of 5. In the HFNC-period, 22 patients received
high flow therapy, and 22.7% (95% CI: 7.8---45.4) required non-invasive ventilation. Treatment
with HFNC was associated with a significant decrease in heart rate (P = .03), respiratory rate
(P = .01), and an improvement in the Wood-Downes-Férres score (P = .00). No adverse effects
were observed.
Conclusions: The availability of HFNC reduces the need for non-invasive mechanical ventilation,
allowing a safe and effective medical management of neonates with acute bronchiolitis.
© 2015 Asociación Española de Pediatrı́a. Published by Elsevier España, S.L.U. All rights

夽 Please cite this article as: Bermúdez Barrezueta L, García Carbonell N, López Montes J, Gómez Zafra R, Marín Reina P, Herrmannova J,

et al. Oxigenoterapia de alto flujo con cánula nasal en el tratamiento de la bronquiolitis aguda en neonatos. An Pediatr (Barc). 2017;86:37---44.
∗ Corresponding author.

E-mail addresses:, (L. Bermúdez Barrezueta).

2341-2879/© 2015 Asociación Española de Pediatrı́a. Published by Elsevier España, S.L.U. All rights reserved.

clinical practice has widely incorporated We conducted an ambispective cohort study in the level IIB the use of nebulised hypertonic saline (HTS) in moderate neonatal unit of the Consorcio Hospital General Universitario bronchiolitis and of noninvasive ventilation (NIV) and high. but some HFOT.U. 5---15% require respiratory sup.15. 56 del período-OAF y 56 de la temporada pre-OAF. minuye la necesidad de ventilación mecánica en neonatos hospitalizados con bronquiolitis Ventilación mecánica aguda.8-45. retrospective cohort of newborns admitted with bronchioli- tory failure.6% precisó ventilación mecánica invasiva. from due to their poor tolerance of the technique.00) a partir de 3 h.829). its use may be limited in low birth weight infants tis in the period preceding the introduction of HFNC.7%. Spain. which included: (1) a prospective cohort flow nasal cannula (HFNC) oxygen therapy as supportive of newborns admitted with bronchiolitis from October 2011. treatments may prevent the development of complications and improve patient comfort. invasiva. We subject. © 2015 Asociación Española de Pediatrı́a. Oxigenoterapia de alto flujo con cánula nasal en el tratamiento de la bronquiolitis PALABRAS CLAVE aguda en neonatos Oxigenoterapia de alto flujo. de Valencia.13-34. Métodos: Estudio de cohortes ambispectivo.01) y escala clínica (p = 0.L. Objetivo: Determinar si el uso de oxigenoterapia de alto flujo (OAF) en cánulas nasales dis- Bronquiolitis aguda. nasal cannula therapy is a noninvasive respiratory support The diagnosis of bronchiolitis was made following the def- technique that delivers a heated and humidified blend of inition proposed by McConnochie: first episode of respiratory .2 Although most cases are self-limiting and can be has been assessed in newborns for the treatment of managed in the home.01). En el período-OAF ningún paciente requirió intubación en comparación con la temporada previa. En el período-OAF 22 pacientes recibieron terapia de alto flujo y 22. Resultados: Se incluyeron 112 neonatos. There is no evidence of any treatment being capa. and approximately The aim of this study was to determine whether initiation 30---50% of patients admitted to the PICU are less than 1 of HFNC oxygen therapy with nasal cannulae in a neonatal month of age. RAR de 19.2---6 Age less bronchiolitis.28---32 but there is admission.2) y NNT de 5. Bermúdez Barrezueta et al. as well as the complications that developed. S. Conclusiones: El uso de OAF disminuye la necesidad de ventilación no invasiva y es un tratamiento seguro que consigue mejoría clínica de neonatos con bronquiolitis.353 (IC 95%: 0.11---20 Although NIV has unit. to April 2015 (HFNC period). measures to prevent invasive mechanical ventilation (IMV) when the use of HFNC oxygen therapy was introduced in the in patients with severe bronchiolitis. frecuencia respiratoria (p = 0. The approaches to the man- agement of these patients backed by scientific evidence Patients and methods consist of supportive care and mechanical ventilation.14. con un RR de 0.2.6. and of the latter.32 than 6 weeks is a risk factor for severity. Tras el inicio de OAF se observó una mejoría rápida y progresiva de la frecuencia cardiaca (p = 0. little published evidence on its use in newborns with port at the paediatric intensive care unit (PICU).21 High-flow January 2008 to May 2011 (pre-HFOT period). between 1 and 5% require hospital neonatal respiratory distress syndrome.1. donde el 3. Publicado por Elsevier España. (2) comparison with a proven to be a useful tool in paediatric patients with respira.6% (IC 95%: 5.150-0.4) requirieron ventilación no invasiva. realizado en una unidad neonatal IIB. Resumen Neonatos.6---10 In recent years. que incluyó Ventilación mecánica neonatos ingresados con bronquiolitis desde la instauración de la técnica de OAF (período-OAF: no invasiva octubre de 2011-abril de 2015).4 unit succeeded in reducing the need for mechanical ven- The treatment of bronchiolitis remains a controversial tilation in newborns admitted with acute bronchiolitis. p = 0. and has proven useful in the Acute bronchiolitis is the respiratory disease that is the management of moderate to severe bronchiolitis. Introduction air and oxygen through nasal cannulae at rates exceed- ing the peak inspiratory flow.03). comparándolo con una cohorte histórica de la temporada previa a su uso (período pre-OAF: enero de 2008-mayo de 2011).22---27 most frequent cause of hospitalisation during the winter The effectiveness of this technique compared to CPAP months. El uso de OAF se asoció con una disminu- ción significativa de ventilación mecánica no invasiva (30.38 L. No se registraron efectos adversos.7% de ellos (IC 95%: 7.4% vs 10. also analysed the clinical outcomes of patients treated with ble of altering the natural course of the disease. Todos los dere- chos reservados. Se analizó la proporción de ventilación mecánica antes y después del inicio del tratamiento con OAF y se evaluaron parámetros clínicos y complicaciones de los pacientes tratados con esta técnica.

heart rate (HR). pharmacological another modality of respiratory support. pH. Table 1 Criteria for initiation of different respiratory sup- port modalities. skin erosion at the area of contact with ive care were initiated in all patients. concentration of oxygen in inspired gas (FiO2 ) was set at the During this period. infant feeding method. the flow rate was gradually reduced to 2 L/min and the FiO2 tion). Respiratory support with HFNC oxygen therapy was initiated if patients met any of Pre-high-flow oxygen therapy period the criteria listed in Table 1. gestational clinical improvement or worsening in the condition of the age. The initial fraction in the unit. such as sex. SaO2 . We recorded capillary on the existing scientific evidence that set the criteria for blood gas parameters (pH. the Consorcio Hospital General Universitario de Valencia. nique. comorbidities. 24. Altered level of consciousness We analysed the changes in quantitative secondary out- come variables (WDF score. and 48 h its use as well as step-wise criteria to transition to other from initiation of HFNC oxygen therapy. We assessed the impact of the Hypercapnia with pH of 7. 36. duration of nothing by pharmacological treatment with nebulised adrenaline was mouth (NPO). We analysed other variables. to 0. of 42 weeks or less in preterm newborns (<37 weeks’ gesta. . 72 and 96 h. patient despite the optimisation of therapy with delivery sion. and documented modalities of respiratory support when required (NIV or adverse effects (pneumothorax. Statistical analysis Criteria for use of high-flow nasal cannula oxygen therapy Wood-Downes-Ferrés score > 6 We performed the statistical analysis with the software ® Requires oxygen therapy with conventional nasal prongs package IBM SPSS 20.40 to achieve SaO2 > 92% tilation by means of the following measures: relative risk Criteria for initiation of invasive mechanical ventilation (RR). The need for IMV need for transfer to the PICU. When we analysed the length Persistent apnoeas despite NIV of stay. PCO2 ) at 6. the need for oxygen therapy with conventional nasal The primary outcome variable was the need for mechan. 18.25 introduction of HFNC oxygen therapy on mechanical ven- Requires FiO2 > 0. 12.33 The inclusion criteria were chronological age of 28 a maximum FiO2 of 0. absolute risk reduction (ARR) and the number needed Symptoms of severe respiratory distress with signs of to treat (NNT) with HFNC oxygen therapy to prevent the imminent respiratory failure use of mechanical ventilation. At this sepsis. following the same pro- tocol applied in preceding years. SaO2 . 48. intolerance to the tech- IMV). length of stay and the criteria for initiation of NIV or IMV. point.6 to achieve SaO2 > 90% PICU. with the exception of the use of HFNC oxygen therapy. We excluded patients with haemodynamic instability. FiO2 High flow nasal cannula oxygen therapy period and WDF score. respiratory rate. During treatment with HFNC oxygen therapy. HFNC oxygen therapy was delivered using the Fisher & In the second phase of the study. ical ventilation (NIV and IMV) in the two periods under Failure of HFNC oxygen therapy was defined as lack of study. hypothermia. applying the inclusion and exclusion criteria. Continuous monitoring by pulse oximetry and support. or that required intubation on admission. 18. birth weight. We have summarised at >2 L/min to maintain an oxygen saturation> 92% categorical variables as percentages and 95% confidence Respiratory acidosis with hypercapnia > 50 mmHg in intervals (CIs) and quantitative variables as mean ± standard capillary blood gas deviation in case they followed a normal distribution. Table 1 presents treatment received during admission. the criteria for hospital admission and pressure required to achieve an oxygen (SaO2 ) of more than the management of patients were similar to those applied in the HFNC period. rospectively by reviewing the medical records of newborns Therapy was initiated at a rate of 4---6 L/min that was admitted with bronchiolitis over a period of four epidemic increased progressively to a maximum of 10 L/min until seasons preceding the introduction of HFNC oxygen therapy clinical improvement was achieved.40. we collected data ret- ® ® Paykel MR850 system with nasal cannulae (OptiflowTM ). aetiological agent.20---7. 12. preceded by signs of viral respiratory 92% and was adjusted based on how the patient responded to illness. prongs at 2 L/min or less was assessed.0 for Windows . and HFNC oxygen therapy was discontinued. and method of feeding. or Apnoeas median and interquartile range otherwise. assessed on a case-by-case basis. was considered a criterion for admission to the PICU or the The study was approved by the Research Commission of neonatal ICU. HFNC oxygen therapy was introduced with a protocol based 6.High flow therapy in neonates with bronchiolitis 39 distress with wheezing.25. while the need for the cannula. we excluded patients that were transferred to the Requires FiO2 > 0. The parameters were recorded at the time of initiation of HFNC oxygen therapy (baseline) and at 3. We compared the baseline characteristics of the two Criteria for initiation of noninvasive mechanical cohorts by means of the Mann---Whitney U test for contin- ventilation uous variables and Fisher’s exact test or the chi-square test Persistent apnoeas for categorical variables. or aspiration of food). If the patient became clinically sta- days or less in term newborns or corrected gestational age ble with a Wood-Downes-Ferrés (WDF) score of 4 or higher. prior history of maximum FiO2 and flow rates. respiratory rate. 24. HR. age and weight at the time of admis. requiring transition to of palivizumab treatment. we docu- mented the following parameters at different time points: temperature.

6 (P = .03 in the HFOT period. Pre-HFNC group (n = 56) HFNC group (n = 56) P Age (days) Median 20 [15.5 (3---22. WDF the patients or the pharmacological treatment they received severity score.2) . in respiratory rate from 59 ± 14.92 12. breathing effort (20%).1 (19.012) at 6 h.6---53) .3---3993. 1. High-flow oxygen therapy failed in five patients (22.9 (36---64) . pre-HFOT vs 6.61 Respiratory support (%) No 19.9---90.2---24.8) 14.7---81) 78. 141 ± 14.2) .2) 78. Treatment with HFNC oxygen therapy was associated with significant decreases in HR from 160 ± 15.6 (8. P = . 2).8) 16.01 HFNC 0 39.3) 0 .8 (0.35 (95% Enteral feeding by nipple feeding or orogastric tube was CI: . During this with a mean flow rate of 6.8 (P = .7 ± 8.38---40] 39. skin were different.4) .6 (39.8---37.8 (0.00 NIV 30.9 (54.8---3803.01) and in the WDF score from 7 (6. 4 [4---5]) (Fig.6 (0.4 to 150. SD.20) and NNT of used in 86.5) 0 1 Antibiotic treatment (%) 32.4---43.9) 5. ARR of 19.3] .5) 5.68---7. PCO2 .53 Nebulised adrenaline (%) 67. of initial stabilisation with a median duration of NPO of The length of stay in days was similar in both groups (5.928.2 to 51.40 (20%) and increased and the treatments they received. We did not observe adverse effects such as pneumotho- The respiratory support techniques used in each period rax.6% (95% CI: 5.2---26.4 (1.3---30.9 (20.1) .2---45.69 Categorical variables are expressed as percentage (95% CI) and quantitative variables as median [interquartile range].8---8.6) . The flow rate period.4).8---45. PCO2 . Bermúdez Barrezueta et al.4---12.3 h (7.8 L/min (SD.3% of patients during treatment following a period 5.9---28.2 [3. as a P-value of less than . the HFNC period (2011---2015) and 56 in the cohort of the We observed a decreasing trend in the different parameters period preceding the introduction of HFNC oxygen therapy under study throughout the treatment with HFNC oxygen (2008---2011).59 Nebulised 3% hypertonic saline (%) 17. 48. starting at 3 h from initiation of HFNC oxygen ther- apy.83).78 Preterm birth (%) 17.6 (66.8] . who required sequential treatment with ratory support with HFNC oxygen therapy in the 2011---2015 NIV.7 ± 6.12 Gestational age (weeks) Median 39.15---.6 (P = . as can be seen in Fig.6) 12. at the time of admission.1 (5. 95% CI: 7. The causes of failure were respiratory acidosis (60%).1---9.09 O2 nasal cannulae 50 (36---64) 25 (12.25 Bronchopulmonary dysplasia 0 0 Acyanotic heart disease (%) 1.92 [4. and we observed that the use of HFNC oxy.5) 50.6 (66. 1.46---7. Table 2 Characteristics of the newborns in the two periods under study: pre-HFNC (2008---2011) and HFNC (2011---2015).9 (6.4 (17.3 (25.9] 21.40.6 to 48.01).3) . We analysed the data for the patients that received respi.05.7) at 12 h.38---40] .4% vs 10.1 L/min.3) to 6 (5---7) Results (P = . intolerance of HFNC oxygen therapy. one patient was treated with NIV without prior HFNC was increased gradually until reaching the maximum value oxygen therapy due to meeting the severity criteria for NIV (mean.8 (14.6 (66. We did not find statistically significant differ.1---26.1---9.7 ± 7.3---39.3) . respiratory rate.7%.80 Sex (male) (%) 53.9---90.3) 26.8---25). .6---67. therapy with a peak in clinical stabilisation at 18 to 24 h ences between the cohorts in the baseline characteristics of (HR.78 Respiratory syncytial virus (%) 78. We did not find a significant difference in the use of IMV.6---47.1---14.9) 1 Breastfeeding (%) 50 (36---64) 60.7 (47---74.9) .94] .688) (Table 2).13---34. with a maximum FiO2 of 0.3) 10.4 (1.3 [1.6 [17. Table 3 shows their baseline characteristics requirement of a FiO2 greater than 0. RR of 0.03 [4. erosion at the area of contact with the cannula or aspiration gen therapy was associated with a significant reduction in of food.1---14.5] . We also observed a significant decrease in capillary We included a total of 112 newborns.40 L.5 [3276.20 Nebulised salbutamol (%) 16. 56 in the cohort of blood PCO2 from 55. the need for NIV (30.7---19. P = . (Table 2).1 (5.76 Weight at admission (g) Median 3490 [3013.001).3 (4.1 ± 6.9---90. We defined statistical significance 3 L/kg/min.7) . None of the patients required intu- High-flow nasal cannula oxygen therapy was initiated bation or transfer to the PICU or neonatal ICU.9) 33.1---14.2 ± 11.2) .51] 6.9 (6.8] 3597. flow rate in L/min) by means of the Mann---Whitney U The maximum flow administered was 10 L/min at a dose of test for paired samples.626.7%.62 Neuropathy (%) 1.5).03).4 (1.2) 1 Palivizumab (%) 5. 8.59 Birth weight (g) Median 3200 [2900---3650] 3265 [2965---3627. hypothermia.6---26.7 (1. 44 ± 8. period (n = 22).01 IMV 3. 1.50 Length of stay in days Median 5.

17 However.6) 41.3---86 Atelectasis/consolidation (%) 11 (50) 26.4 ± 1.7 7.8 ± 1.2 − 7.5) 0.525 [3.8 Breastfeeding (%) 11 (50) 26.235 [2.9---25.5) 0. two patients required IMV (34.1) and the median length of stay was 8. Furthermore.2---40.6 6.8---45.5) 77.7 Acyanotic heart disease (%) 1 (4.9 Respiratory syncytial virus (%) 21 (95.2 Antibioterapia (%) 11 (50) 26.2---99. its use may A 9.2 [38.6 6.38] PCO2 (capillary blood gas) 57 [52---60.2) 5.12.2---40.3 ± 1.280---3.5---80.1) 36.9 ± 1.5 12 hours 8.800---3.0 48 hours 7.6] Gestational age (weeks) [median] 39.2 6.6---9.3---81.500] Weight at admission (g) [median] 3.5] Values expressed as percentage (95% CI) and median (interquartile range [IQR]).870] Sex (male) (%) 13 (59.5 6.7). Discussion Several studies have demonstrated that NIV is a use- ful tool in the management of severe bronchiolitis.4 7.1---22.2 − 8.3 Birth weight (g) [median] 3.1 days during the pre-HFNC period.5 7.9 Family history of atopy (%) 5 (22.8---73.3 − 8. .0 Flow L/min 6 hours 7.1---63.4 Previous admission (%) 9 (40. or transfer to the ICU after the introduction of HFNC oxygen therapy. (B) Mean and standard deviation (SD) of flow (L/min) at different time intervals.32---7.6 ± 1.0 24 hours 7.9 ± 1.2 Palivizumab (%) --.9) 18. --- Fever (%) 14 (63.5---100 Nebulised salbutamol (%) 1 (4.1---40.2) 5.High flow therapy in neonates with bronchiolitis 41 Table 3 Characteristics of patients that received respiratory support with HFOT in the 2011---2015 period.4 7.8---73.7) 7. The median duration of HFNC oxygen therapy was 57 h in our neonatal unit.5 36 hours 7.1 ± 1.3 Clinical parameters prior to initiation of HFNC [median] Clinical score 7 [7---8] Heart rate 160 [150---170] Respiratory rate 60 [48---70] Oxygen saturation 94 [91---97] FiO2 24 [21---27] pH (capillary blood gas) 7. N = 22 95% CI [IQR] Age (days) [median] 20.5 3 hours 7. its The main finding of our study was a significant decrease in main advantage being that it reduces the incidence of the use of NIV after the introduction of HFNC oxygen therapy complications associated with IMV.2 − 8. while none required intubation (6.2 Start 3 6 12 24 36 48 Hours of HFOT Figure 1 (A) Mean (95% CI) flow in L/min administered during the first 48 h of respiratory support with HFNC oxygen therapy.1---22.7 6.34 [7.0 B Flow L/min 95% CI (mean ± SD) 8.8---73.8 [16.9 7.2 7−8 8.3 − 8.8 Nebulised 3% hypertonic saline (%) 4 (18.5 Start 6.2 Nebulised adrenaline (%) 22 (100) 84.3] Preterm birth (%) 4 (18.5 − 8.

22 Our study did diseases found that in the subset of patients with bronchi. so our findings should ment of bronchiolitis exclusively in newborns. (A) Heart rate (mean. severe prematurity or cyanotic heart disease. they demonstrated that HFNC oxygen ther- Previous studies have demonstrated that HFNC oxygen apy is effective in newborns with bronchiolitis. interquartile range). (B) Respiratory rate (mean. Some studies that have analysed the addition to a reduction of health care costs. such as bronchopulmonary dyspla. 25% required NIV after HFNC oxygen therapy and 4% two periods. 95% CI). transfer to the ICU.7% of the increased costs of treatment.35 The vulnerability the newborns included in the study did not have relevant of newborns.7%). it requires a ventilator following HFNC oxygen therapy (16% NIV and 4% IMV). 95% CI). makes this population markedly different from other could be accounted for by the level of care of the unit. This probably led to an underestimation . retrospective study that included children aged less than Studies conducted in PICUs have shown a reduction in 24 months admitted to the PICU with different respiratory length of stay with the use of HFNC therapy. as its use therapy reduces the need for intubation from 23% to 9% was associated with a reduced need for NIV (from 30. but did not report spe- When it came to the characteristics of our sample. gen therapy. which olitis. of intubation. (D) Wood-Downes-Ferrés severity score (median. Our populations studied in the past.34 Furthermore. 95% CI). For these reasons. not find a significant difference in length of stay between the olitis. although we use of HFNC oxygen therapy in infants with bronchiolitis did not analyse these variables in our study. pose challenges in infants due to limitations related to the admissions to the PICU compared to previous periods.23 Another prospective study assessed the use length of stay excluding patients that needed transferring.42 L. which results from the immaturity of their perinatal risk factors. with some of the patients of the patients in the study required admission to the PICU requiring sedation. One possible explanation is that we analysed required IMV. However. the population and setting of our tages in the management of patients with bronchiolitis in study are different. we believe patients in our study required NIV following HFNC oxy- that a reduction in the use of NIV offers significant advan.25 and in many instances.21 A 10. of HFNC therapy in patients with bronchiolitis in a paediatric as they were not followed up in our institution by our ward and found a significant reduction in the percentage of research team. cific findings for this group of patients. 20% interface or to poor tolerance. A 170 B 70 165 65 60 Respiratory rate (bpm) 160 Heart rate (bpm) 155 55 150 50 145 45 140 40 135 35 130 30 Start 3 6 12 18 24 36 48 Start 3 6 12 18 24 36 48 Hours Hours C 60 D 9 8 Wood-Downes-Ferrés 55 7 severity score PCO2 mmHg 6 50 5 4 45 3 40 2 Start 6 12 18 24 48 Start 3 6 12 18 24 36 48 Hours Hours Figure 2 Changes in cardiorespiratory parameters and in the Wood-Downes-Ferrés severity score in the first 48 h of treatment with HFNC oxygen therapy. and while be interpreted with caution and may only be applicable to our data did not suffice to evince a reduction in the rate populations with similar characteristics.14. Our study is one of the sample was not representative of the neonatal population first to assess the use of HFNC oxygen therapy in the treat- with risk factors for severe disease. which results in Consistent with the existing literature. (C) PCO2 obtained from capillary blood gas testing (mean. 22. immune system and entails a higher risk of severe bronchi- sia.4% to in patients with bronchiolitis admitted to the PICU. included newborns in their samples. Bermúdez Barrezueta et al.21.

population in Spain. 2004.High flow therapy in neonates with bronchiolitis 43 of the length of stay in the pre-HFNC period. as easing respiratory effort pronósticos de evolución complicada en la bronquiolitis que requiere ingreso en cuidados intensivos pediátricos. The main strength of the study is that it is one of the first Pediatrics. Inter-society consensus document on treatment and pre- to obtain results of acceptable validity. easy to use. Conferencia de exchange. our findings could serve as the starting point for 11. Randolph AG. and that newborns are a high-risk 13. An Pediatr (Barc).65:325---30. Santiago Lozano MJ.47:909---16. Klonin H. give enteral feeds to 86.37 The improvement in clinical condition References resulting from a reduction of respiratory muscle fatigue and lung volume recruitment could contribute to improving gas 1. Mar- to achieve clinical improvement without the development of tinez de Azagra A. An Pediatr The findings of this study must be interpreted taking into (Barc).e1---221. Straliotto SM.40:65. HFNC oxygen therapy was initiated on daciones. Ventre KM. future studies. Sanchez Galindo A. Estudio de variabilidad lies in its nonrandomised design. Bronquiolitis grave. side effects. Bellon Cano JM. increasing the mean airway pressure. paediatric age groups. An Pediatr (Barc). Considering severe bronchiolitis: analysis and evidence.131:867---72. 2009. Milesi C. Matecki S. Lanari M. with a period of increased clinical stability at 18---24 h and paediatric intensive care units for patients that require from its initiation. 2013. acteristics and other treatments received. Non-invasive ventilation for oxygen therapy in newborns with bronchiolitis. Respiratory relevant results. with the corresponding reduction in the PCO2 . as several We concluded that HFNC oxygen therapy oxygen delivery previous studies have found a positive correlation between is an efficacious. Perez-Yarza EG. Its lyse the outcomes of newborns treated with HFNC oxygen easy implementation makes it an ideal technique for level therapy. Diez Domingo J. Maia TMR. In order to minimise the possibility of selection bias. et al. 2003. This improvement made it possible to intensive respiratory support.48:45---51. Perez Suarez E.22 succeeds in reducing the frequency of NIV in newborns with The prospective phase of the study allowed us to ana.121:e1190---5.e33.99 cmH2 O. which is indicative 2. the management of resources by trying to reserve neonatal ment. Pediatr Pulmonol. Previ. Mejias A.38 3. tial biases. Gonzalez de Dios J. Rodriguez-Nunez A. Siqueira MM.72. indications for NIV used during the HFCN period were the 9. On the other hand. Previous stud. Mura T. that the neonatal period is clearly different from all other 2012. Early initiation of HFNC could be the laescusa JU. . respiratory rate and severity score during treat. 4.72:4---18. Vil- of moderate severity. Vicente D. Cambios epidemiológicos y de soporte respiratorio. to minimise the time-period bias.70:27---33. Serrano A. The authors have no conflict of interests to declare. ies have shown that the administration of flows equal or Hospitalization for respiratory syncytial virus in the paediatric greater than 2 L/kg/min produces a mean laryngeal pres. providing evidence on this group tional oxygen therapy in severe viral bronchiolitis: a randomized of patients is highly relevant. et al. Rossi GA. showed that the cohorts were similar in their baseline char. Ital J Pediatr. Basu AP.74:371---6. Manzoni P. sure of 4 or more cmH2 O that is correlated with clinically 5. Ramilo O. in addition to facilitating enteral nutrition. Luchetti M.39 the patients in our study did not experience any Valenciana (2001 y 2002). Martinon-Sanchez JM.78:205---7. which allowed us et al. complications at the delivered flow rates. Hernando Puente M. development of atelectases. Garcia-Teresa MA. An Pediatr we included all patients with bronchiolitis and developed a (Barc). there was a significant reduction Conflict of interests in the PCO2 starting at 6 h of treatment. Ochoa Sangrador C. well-tolerated therapy that length of stay and the need for intubation. bronchiolitis. as we attempted bronquiolitis: perspectivas en el 2013. Gonzalez de Dios J. account its strengths and weaknesses.14 viruses in the pediatric intensive care unit: prevalence and clin- ical aspects. Iglesias Bouzas MI. 221. The analysis of the data 2013. 2014. Davison C. Machado V. Lopez-Herce Cid J. Jaber S. 2011. Incidencia y costes de la hospitalización por bronquiolitis y de two children who experienced adverse effects from HFNC las infecciones por virus respiratorio sincitial en la Comunidad therapy. Vandini S. Baraldi E. Martinon-Torres F. We observed a quick and gradual improvement in I and II neonatal units. Lazner MR. Onoro G. with this technique.3% of the newborns after an initial stabilisation period. Rimini A. which could be a source of en el abordaje de la bronquiolitis aguda en España en relación bias. Pidoux O. Factores key to achieve optimal results. The flow administered in our cohort was the amount needed 6. protocol that established the criteria for the use of HFNC 8.99:883---7. 2010. Novedades en el tratamiento de la same as those used in the preceding period. 2008. Ridao Lopez M. An Pediatr prevents progression to respiratory muscle fatigue and the (Barc). Mem Inst Oswaldo Cruz. 2006. Pediatr Crit Care Med. such as an improved breathing pattern. patients with a median WDF score of 7. Ubeda Sansano I. a variable for which there is little data in the use of this technique. 2010.5:482---9. The supportive care measures and the 2004. 10. Nasal continuous positive airway pressure with heliox versus air oxygen in infants with acute bronchiolitis: a crossover study. that the design of the study implies a poor control of poten. group with a high rate of admissions to intensive care units 6 cm H2 O continuous positive airway pressure versus conven- during epidemic seasons. While we are aware vention of bronchiolitis in newborns and infants. Cilla G. Jacquot A. Ballester Sanz Although one study reported the cases of one infant and A. ous studies have demonstrated that HFNC oxygen therapy achieves a PEEP of 4 ± 1.36. Ochoa Sangrador C. consenso sobre bronquiolitis aguda (I): Metodología y recomen- In this cohort. Montes M. Pediatr Pulmonol. which could contribute to improving the HR. trial. con la edad de los pacientes (Proyecto aBREVIADo). Efficacy of oxygen therapy with the purpose of avoiding overtreatment interventions for bronchiolitis in critically ill infants: a sys- tematic review and meta-analysis. Perez-Trallero E. in the literature that assesses the impact of the use of HFNC 12. An Pediatr (Barc). Epidemiol Infect. One of its limitations 7.

131:e939---44. Bressan S. Lopez Sanguos C. Visintainer PF.15:e214---9. high flow nasal cannula in critically ill infants. Evolución de la ventilación mecánica no invasiva en la bron. Olivares Ortiz J. Sasi A.121:82---8. Turner DA. Stamm D. Chen S-J. Kaul S. Urbano Villaescusa J. Arch Dis Child. children.93:45---7. Thia LP. Gibbons nasal cannula therapy: yet another way to deliver continuous K. Incidence of nasal trauma asso. 2014.37:847---52. Arch Dis Child Fetal Neona. et al. Matecki S. Shoemaker MT. O’Donnell CP. Novais ARB. Floret D. 2008. 36. 2014.369:1425---33. Lopez-Herce Cid J.51: 19. Hegde S. Reduced intubation rates for infants after introduction positive airway pressure? Pediatrics. Lopez-Herce Cid J. An Pediatr (Barc). Bueno Campana M. A prospective. An Pediatr (Barc). An Pediatr (Barc). 30. 2013.90:F480---3. Ruperez 2013. Lee JH. Durand S. Cochrane 25.68:4---8. Predictors of tal Ed. Darnall RA. . 26. 14.34:1608---14. flow nasal cannula for respiratory support in preterm infants. Allen H. Rey C. Kozlowska WJ. Mayordomo-Colunga J. Fernandez Rincon A. Emilfork M. Limauro J. Baleine J. with respiratory distress treated with high-flow nasal cannula. et al. 31. McKiernan C. 2008. Ogden KJ. Wilkinson D. 24. Cidoncha Escobar E. J Paediatr Child Health. Vinson B. Menendez S. J Perinatol. nasal cannula therapy for infants with bronchiolitis. Patino Hernandez O. Blyth TP.39:247---57. Use of for infants with severe bronchiolitis. Yong S-C. Eur J Pediatr. Gonzalez Sanchez MI. Children 2011. domised controlled trial. Lapadula M. Hough JL. Mencia Bartolome S. 16. Database Syst Rev. Spentzas T. dez R. 18. Non-invasive ventilation as primary ventilatory support 32.39:1088---94.172:1649---56. Rowin ME. et al. Krauss B. Cochrane Database Syst Rev. Schibler A. 29. High quiolitis. nandez C. Foster K. Cartwright DW. Rehder KJ. Concha 21. Pham TMT. Skiles CL. Baleine J. Owen LS. Odena J Intensive Care Med. Fernandez Lafever SN. nasal cannula versus nasal CPAP for neonatal respiratory dis- Diaz-Chiron Sanchez L. Yunge M. infants: a randomised control study. 2010. High-flow nasal cannula: recommendations for daily 38. 2014. Expe- Baraldi E. Pham TMT. Zanconato S. Stidham G. Abboud PA. Arch Dis Child. Milési C. 2009.44 L. Sanchez da Silva M. Dunster KR. Prodhan P. Walters JA. 20. Yoder BA.4:29. High 33. randomized. positive airway pressure treatment in very low birthweight 2009. Pediatr Crit Care in acute viral bronchiolitis? A physiologic study. Pierce MR. 2013. Pediatr Crit Care Med. High flow 17. Pediatrics. Gonzalez Martinez F. McConnochie KM. 2007. 2005. Bermúdez Barrezueta et al. a single-centre experience. Lucas M. N Engl J Med. 2008. Yanez LJ. Andersen C. Predictores de éxito y fracaso en la venti- ciated with nasal prong versus nasal mask during continuous lación no invasiva en la bronquiolitis aguda. Randomised controlled trial of nasal continuous pos. 2013. Los Arcos M. Combes C. ous positive airway pressure weaning in preterm neonates: 2008. Med. failure in infants with viral bronchiolitis treated with high-flow. et al. humidified high-flow 23.27:85---91. Intensive Care Med. 2013. Notario Munoz C.78:210---5. Balzani M. 28. Manley BJ. Intensive Care Med. Durand S. Serious air leak syndrome complicating por alto flujo de oxígeno en el tratamiento de la bronquiolitis high-flow nasal cannula therapy: a report of 3 cases. Carrillo Alvarez A. Impacto clínico de la implantación de la ventilación 39.99:511---5. Minarik M. High-flow nasal cannula oxygen for bronchiolitis in a riencia con la oxigenoterapia de alto flujo en cánulas nasales en pediatric ward: a pilot study. 2015. Fer. Richard N.137:11---3. An Pediatr (Barc). et al. Patters AB. Carr SB. 27. nasal cannulae therapy in infants with bronchiolitis. and 2008.156:634---8. 199---203. infants after extubation. Wong ZH. Intensive Care Med. 22. High-flow practice in pediatrics. Intensive Care Med. Jacquot A. Medina A.9:484---9. Boubal M. Chua LC. Stolfi A.13:e343---9. Kubicka ZJ. Roth PJ. Alcantara A. MP. 2013. McKenzie SA. Schibler A. Child. Bronchiolitis.24:323---8. 34. Javouhey E. Barlow A. de Paoli AG. 2011:CD006405. Minasian CC. Pettenazzo A. Is treatment with a high flow nasal cannula effective nasal cannula in infants with bronchiolitis. Milesi C.1:CD009609. Williford L. 35. DiGeronimo RJ. Ann Intensive Care. 15. ease: a retrospective study. 2015. adults: a critical review of the literature. Boo N-Y. J Pediatr. Barats A. 37. High flow high-humidity nasal cannula therapy. Santiago Lozano MJ. Cheifetz IM. en una planta de hospitalización pediátrica. Heated. Doyle LW. Beggs S. Malhotra A. A.70:34---9. of high-flow nasal prong oxygen delivery. controlled trial of Pritchard MA. Rodriguez Fernan. niños. What’s in the name? Am J Dis flow therapy versus hypertonic saline in bronchiolitis: ran. High flow nasal cannula for continu- itive airways pressure (CPAP) in bronchiolitis. 2014. Toledo del Castillo B. Physiologic effect of high-flow et al. 2012. Andersen CC. High-flow nasal cannulae in very preterm noninvasive ventilation in pediatric acute respiratory failure. Pediatr Crit Care Med.83:117---22. 1983.