Respiratory Medicine 131 (2017) 210e214

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Respiratory Medicine
journal homepage: www.elsevier.com/locate/rmed

The use of high-flow nasal cannula (HFNC) as respiratory support in

neonatal and pediatric intensive care units in Germany e A
nationwide survey
Florian Schmid a, *, Dirk Manfred Olbertz b, Manfred Ballmann a
a
Department of Pediatrics, University Hospital of Rostock, Germany
b
Department of Neonatology, Südstadt Hospital Rostock, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Background: High-flow nasal cannula (HFNC)1 is a technique of oxygen supply, initially being used as a
Received 29 May 2017 potentially less-invasive alternative to nasal continuous positive airway pressure (nCPAP)2 for premature
Received in revised form infants/neonates, which nowadays crosses the border of neonatal care. HFNC builds up a positive end-
31 July 2017
expiratory pressure (PEEP)3 but lacks the opportunity for continuous monitoring. Therefore, pressure-
Accepted 24 August 2017
Available online 1 September 2017
depending complications are a risk. Our goal was to evaluate the current use of HFNC in Germany
regarding indications, techniques of application and complications experienced.
Studydesign: We used a questionnaire sent to 226 pediatric clinics.
Keywords:
High-flow nasal cannula
Results: We received responses from 67 pediatric clinics (29.6%). HFNC was applied in the age group of 8
Indication to 14 years in 42% and between 14 and 18 years in 33% of the clinics. 54% of the clinics have been using
Complication HFNC for more than 3 years. Applied flow rates varied strongly among the clinics. 70% of the clinics use
Flow rate HFNC outside of the established indications (alternative to nCPAP for premature infants and neonates,
Pneumothorax bronchiolitis) for pneumonia, support after extubation and non-adherence to nCPAP. Severe complica-
Pediatric intensive care unit tions such as pneumothorax have been seen by 17,9% of the clinics.
Conclusion: We reported for the first time a nationwide overview about the expanded use of HFNC in
pediatric clinics. Our results emphasize the fact that, even though HFNC is widely accepted as a non-
invasive procedure there is still a potential of severe side effects. Therefore the use of HFNC should be
monitored continuously and closely within an intensive or intermediate care unit.
© 2017 Elsevier Ltd. All rights reserved.

1. Introduction HFNC delivers a mixture of air and oxygen, which is humidified

Oxygen supply via high-flow nasal cannula (HFNC) is a tech-
nique for non-invasive respiratory support, which can be placed,
regarding the level of support, between conventional oxygen
therapy and noninvasive ventilation. It has been primarily devel-
oped for premature infants as an alternative to noninvasive positive
pressure ventilation (nasal continuous positive airway pressure
(nCPAP)) [1e3]. Nowadays this technique is being used progres-
sively throughout all pediatric age groups, also with the consider-
ation of the use for adult patients [4,5].
* Corresponding author.
E-mail address: florian.schmid@med.uni-rostock.de (F. Schmid).
1
HFNC ¼ High-flow nasal cannula.
2
nCPAP ¼ nasal continuous positive airway pressure.
3 proves the mucociliary clearance [11].
PEEP ¼ positive end-expiratory pressure.
and heated up to 37
C [3]. This helps to prevent mucosal dryness
and increases the tolerance for the patient [6]. Currently there is no
generally admitted recommendation regarding the flow rates, but
some authors recommend adjusting it according to the weight of
the patient. In neonates and infants a flow rate of 2 L/kg/min has
been proposed, whereas in children flow rates should get closer to
1 L/kg/min [7,8]. The fraction of inspired oxygen can be adjusted via
a blender.
HFNC appears to provide an increased level of respiratory sup-
port with a reduced work of breathing than conventional oxygen
supply with nasal cannula or face masks, whilst not being consid-
ered as invasive as nCPAP [5,9]. Furthermore, due to the humidified
and heated gas-mixture, children tolerate HFNC better than con-
ventional oxygen supply, because of not having the sense of dry
nasal or oral mucosa [10]. The humidified and heated air also im-

http://dx.doi.org/10.1016/j.rmed.2017.08.027
0954-6111/© 2017 Elsevier Ltd. All rights reserved.
 F. Schmid et al. / Respiratory Medicine 131 (2017) 210e214
An important mechanism of action consists of the continuous
wash-out of the nasopharyngeal dead space. A consistent high flow
rate leads to a reduced alveolar carbon dioxide concentration and
thus reduced hypercapnia [12].
As respiratory support with nCPAP, the HFNC-system provides a
positive airway pressure and thus builds up a positive end-
expiratory pressure (PEEP), which can be similar, greater or less
than those produced by the nCPAP-systems [13e15].
But in comparison to nCPAP, there is no monitoring available for
the level of extending pressure in HFNC. Furthermore the pressure
can vary dangerously because of a fluctuating leak through the
mouth and nasal passages [16e19]. The unpredictable nature of
such complications has raised concerns about the unconsidered use
of HFNC [20].
In light of the growing use of HFNC among pediatric intensive
care units and the insufficient evidence demonstrating the safety of
this technique, the aim of this study was to give an overview about
the use of HFNC throughout Germany regarding techniques of
application, indications and complications [6,21].
2. Methods
2.1. Study design
The survey was based on a questionnaire sent to 226 clinics in
Germany, which provide the facilities for a neonatal intensive care
units (NICU)4 and/or a pediatric intensive care unit (PICU)5.
The questionnaire aimed to get information regarding the
application method of HFNC, indications and complications expe-
rienced. The questionnaire has been designed mainly with closed
questions only regarding indications and complications open
questions have been set (Appendix). Duplicate responses from one
clinic were excluded.
2.2. Data analysis
The statistical analysis has been performed using IBM SPSS
version 22 (SPSS Inc., Chicago, USA) and graphic representation of the
results was made with Microsoft Excel 2016 (Microsoft Corporation,
USA) and Prism Version 6.0 (GraphPad Software, Lo Jolla, USA).
A p-value less than 0.05 was considered to be statistically
significant.
3. Results
We received responses from 67 clinics (67/226; 29.6%). 63% of
the participating clinics have the intensive care facilities including
NICU and a PICU (n ¼ 42), whereas in 28% (n ¼ 19) pediatricians
only work on NICUs and in 9% (n ¼ 6) only on PICUs.
3.1. Application method of HFNC
Regarding the number of applications of oxygen supply via HFNC
per year, 43.3% have a total number between 20 and 50 applications
per year. 17.9% are using this technique more than 100 times a year.
Unsurprisingly the number of applications per year depends signif-
icantly on the number of beds in the intensive care unit (p ¼ 0.01).
More than half of the clinics have experiences with HFNC for
already more than three years (53.7%), whereas only 4.5% noted that
they just started with this technique in the last year before the survey.
We could not find any significant correlation between the size of the
4
NICU ¼ neonatal intensive care units.
5 6
PICU ¼ pediatric intensive care unit.
211
clinic and the time, since when HFNC has been applied (p ¼ 0.54).
As shown in Fig. A1, the maximal flow rates administered in the
certain age groups vary strongly between the clinics. In the age
group of eight to 14 years a number of clinics stated to use under
20 L/min, whereas other clinics are applying up to 60 L/min, obvi-
ously depending on the patient's weight.
3.2. Patient population and indications
Because the technique of HFNC has been initially developed for
premature infants and neonates, it is not surprising, that a high
number of the clinics are using it in this age group (92.5% and
97.0%). Between the age of 8 till 14 years and between 15 and 18
years 41.8% and respectively 32.8% are supplying oxygen via HFNC.
Regarding the established indications for the use of HFNC on
NICUs and PICUs, 82.1% of the clinics apply this method of oxygen
supply in children with bronchiolitis due to an infection of respi-
ratory syncytial virus (RSV)6. The number of clinics with a PICU
using the HFNC for RSV-positive bronchiolitis is higher than clinics,
which only have the facilities of a NICU (83.3% vs. 57.9%). 95.2% and
66.7% respectively of the clinics which have a NICU and a PICU are
applying HFNC in children with respiratory distress due to pneu-
monia or severe obstructive bronchitis (table. A1).
Our data showed that the indications mentioned in table. A1
have been treated with HFNC throughout all age groups. Other in-
dications mentioned were as a tool for bridging to intubation and for
post-extubation respiratory support. The percentage distribution in
the different types of intensive care units showed, that especially in
pediatric patients, physicians rely on HFNC as respiratory support
during the change to or from a more invasive type of oxygen supply.
Furthermore, there are a number of clinics applying HFNC as an
alternative to nCPAP when there is a need for continuous PEEP but
nCPAP is not well tolerated by the patient. Regarding this point, in
opposite to the above-mentioned indication during intubation or
extubation, HFNC is more frequently being used in neonates.
We also asked in open questions for further indications not
quoted in the questionnaire. Acute respiratory failure due to cystic
fibrosis has been mentioned, along with respiratory support for
cardiac patients, obstruction of the upper airway system and res-
piratory support for patients with neuromuscular diseases.
3.3. Complications
In addition, we asked for complications seen with the use of
HFNC. Severe complications, like pressure depended pneumo-
thoracis have been reported by 17.9% of the clinics, whereas only
three clinics have experienced barotrauma more than three times
since starting HFNC in their unit (4.5%). Two of these three clinics
apply HFNC more than 100 times a year. But we could not find a
statistically significant correlation between the size of the clinic
and the number of patients with pneumothoracis.
Despite the inhaled air is heated up and humidified, damage to
nasal mucosa has been seen as a problem by the participating
clinics (table. A2). Another frequent problem was non-adherence,
experienced by more than 40% of the clinics (table. A2). Again
there was no correlation between the size of the clinic and the
number of reported cases of non-adherence to HFNC.
In an open question we asked for further complications expe-
rienced. Following complications were listed: Failure of therapy
(4x), problems with alimentation (2x), conjunctivitis (1x), mete-
orism and vomiting (1x).
RSV ¼ respiratory syncytial virus.
212 F. Schmid et al. / Respiratory Medicine 131 (2017) 210e214
4. Discussion
Oxygen supply via HFNC is increasing in popularity in the pe-
diatric field, also beyond the neonatal intensive care units, never-
theless because of the easier and more comfortable handling in
comparison to nCPAP-systems [7,22].
But till now there is no randomized, controlled trial, which
confirms the effectiveness and safety of HFNC [21e23]. Further-
more a Cochrane review in 2014 could not find clear indications
and guidelines with a high level of evidence [21].
Our survey displayed the increasing use of HFNC on intensive
care units, crossing the border of primary neonatal care and
widening the indications. We showed that HFNC is considered for
more and more diseases from the pediatric spectrum, like pneu-
monia, obstructive bronchitis or respiratory support in patients
with cystic fibrosis or neuromuscular diseases. This observation
matches with the growing number of publications regarding the
use of HFNC as oxygen supply for diseases of the pediatric and
adolescent spectrum and nowadays even in adults [3,6,24,25]. The
high number of hospitals, which responded to apply HFNC for pa-
tients with obstructive bronchitis on NICU facilities, suggest that in
these clinics not only preterm infants and severely ill neonates, but
also young infants must have been treated. This reflects, that a
rigorous separation between neonatal und pediatric intensive care
medicine cannot be made in all pediatric hospitals in Germany.
Although approved by the US Food and Drug Administration due
to the positive side effects of the humidification of the applied air-
oxygen mixture, a lot of physicians nowadays see the HFNC-
systems as a potentially less invasive alternative to nCPAP, because
of the distending pressure produced by the high flow rates [26e28].
But this pressure is, in comparison to nCPAP, subject to fluctuations
and lacks a continuous monitoring [7]. The findings, that the deliv-
ered pressure by nCPAP does not exceed the set pressure cannot be
easily transferred to HFNC [20]. Previous studies regarding HFNC
observed that the proximal airway pressure varied strongly
depending on flow rates, mouth opening and nasal cannula size in
comparison to the size of the nares diameter [16,17,19]. Sivieri et al.
showed with an in vitro study that with flow rates of 1e6 L/min and
an open mouth, the distending pressure does not exceed 2 cm H2O. In
contrast in the same model with the mouth closed, the pressure rises
up to 10 cm H2O [19]. With these pressure peaks the patient could be
at risk of severe pressure dependent complications. Therefore, con-
cerns about the wide spread use of HFNC as a potentially less invasive
form of oxygen supply have been raised [20]. Previous publications
reported only individual cases of air-leak syndromes (i.e. pneumo-
thorax, pneumocephalus) linked to the use of HFNC [3,28,29].
Our data showed, that 17.9% of all participating clinics have
experienced at least one time pressure dependent complications,
like pneumothoracis. Interestingly the size of the clinic didn't
matter, so even small clinics could experience those complications
due to the increased number of application per year. This empha-
sizes the great importance of a continuous monitoring of pediatric
patients during the application of HFNC in an intensive care or an
intermediate care setting, especially in the first hours of use. In
particular an inappropriate size of the prongs in comparison to the
nasal diameter seems to higher the risk for barotrauma [7].
Other complications mentioned by the clinics were irritated nasal
mucosa and skin reactions. But the relatively small number of pa-
tients, developing these side effect seems not limit the use of HFNC in
the participating clinics. Previous studies have shown, that the rate of
these complications are similar or even less in comparison to nCPAP
[30,31]. So particularly regarding nursing, the combination of less
damage to skin and mucosa, and the more comfortable handling
compared to nCPAP, makes HFNC an interesting alternative for res-
piratory support in children [7]. This is supported by our data.
The number of clinics should not be underestimated, who
answered that they experienced non-adherence to HFNC, so the
physicians had to escalate the therapy towards nCPAP or intuba-
tion. In severe conditions it always remains the danger of delay to
more invasive ventilations techniques. So especially in the first
hours of use, a close monitoring of the patient is crucial [7,32].
However the data of our study regarding non-adherence, should be
considered carefully, as different definitions of non-adherence may
have influence the answers by the clinics.
But our survey was able to give a descriptive overview about the
use of HFNC on intensive care units in Germany, although due to the
retrospective study design the data has to be considered carefully,
because certain questions regarding complication rate in compar-
ison to flow rates couldn't be answered. Further prospective studies
are needed to discuss this point.
5. Conclusion
Our survey gave the first nation-wide overview about the pro-
gressively widespread use of HFNC as oxygen supply for children.
We noticed a great variety of different indications apart from those
established in neonatal care. We also demonstrated, that unless the
opinion prevails, that HFNC is a safer and less invasive technique
than nCPAP in children with respiratory distress, it can still lead to
severe complications. Therefore its use should be monitored care-
fully i.e. in an intensive or intermediate care setting.
Our data showed that HFNC is nowadays widely used although
for most indications controlled randomized clinical studies which
compare HFNC to other methods are missing.
Appendices
1. Figures
Fig. A.1. (One column fitting image) Maximal flow rates (L/min) in different age
groups. Each dot represents one clinic. Red line indicates the median.
2. Tables
Table A.1
Indications of HNFC among NICUs and PICUs in Germany.
Indication Total NICU PICU NICU & PICU
n ¼ 67 n ¼ 19 n¼6 n ¼ 42
Bronchiolitis 55 (82.1%) 11 (57.9%) 5 (83.3%) 39 (92.9%)
Respiratory support for preterm 54 (80.6%) 15 (78.9%) 1 (16.7%) 38 (90.5%)
infants
Pneumonia 57 (85.1%) 12 (63.2%) 5 (83.3%) 40 (95.2%)
Severe obstructive 39 (58.2%) 8 (42.1%) 3 (50%) 28 (66.7%)
bronchitis/Asthma bronchiale
Bridging to intubation 23 (34.3%) 1 (5.3%) 3 (50%) 19 (45.2%)
Post-extubation support 50 (74.6%) 8 (42.1%) 4 (66.7%) 38 (90.5%)
Non-adherence to nCPAP 56 (83.6%) 17 (89.5%) 4 (66.7%) 35 (83.3%)
 F. Schmid et al. / Respiratory Medicine 131 (2017) 210e214 213

Table A.2
Number and percentage of clinics reporting different complications of HFNC among
NICUs and PICUs in Germany (data from n ¼ 67 clinics).

Complication No events 1 event 1e3 events >3 events

Pneumothorax 55 (82.1%) 8 (11.9%) 1 (1.5%) 3 (4.5%)

Non-adherence to HFNC 38 (56.7%) 6 (8.9%) 7 (10.5%) 16 (23.9%)
Skin reaction 56 (83.6%) 1 (1.5%) 3 (4.5%) 7 (10.4%)
Irritated nasal mucosa 52 (77.6%) 3 (4.5%) 4 (6.0%) 8 (11.9%)

Questionnaire (translated into English)

214 F. Schmid et al. / Respiratory Medicine 131 (2017) 210e214

References measurement of upper airway pressures, Anaesth. Intensive Care 39 (2011)

1103e1110. http://www.ncbi.nlm.nih.gov/pubmed/22165366.
[17] R.A. Hasan, R.H. Habib, Effects of flow rate and airleak at the nares and mouth
[1] C. Sreenan, R.P. Lemke, A. Hudson-Mason, H. Osiovich, High-flow nasal
opening on positive distending pressure delivery using commercially avail-
cannulae in the management of apnea of prematurity: a comparison with
able high-flow nasal cannula systems: a lung model study, Pediatr. Crit. Care
conventional nasal continuous positive airway pressure, Pediatrics 107 (2001)
Med. A J. Soc. Crit. Care Med. World Fed. Pediatr. Intensive Crit. Care Soc. 12
1081e1083. http://www.ncbi.nlm.nih.gov/pubmed/11331690.
(2011) e29e33, http://dx.doi.org/10.1097/PCC.0b013e3181d9076d.
[2] C. Dani, S. Pratesi, C. Migliori, G. Bertini, High flow nasal cannula therapy as  Carrillo,
[18] pez-Herce, J.A. Gallardo, M.J. Solana, A.
J. Urbano, J. del Castillo, J. Lo
respiratory support in the preterm infant, Pediatr. Pulmonol. 44 (2009)
High-flow oxygen therapy: pressure analysis in a pediatric airway model,
629e634, http://dx.doi.org/10.1002/ppul.21051.
Respir. Care 57 (2012) 721e726, http://dx.doi.org/10.4187/respcare.01386.
[3] F. Baudin, S. Gagnon, B. Crulli, F. Proulx, P. Jouvet, G. Emeriaud, Modalities and
[19] E.M. Sivieri, J.S. Gerdes, S. Abbasi, Effect of HFNC flow rate, cannula size, and
complications associated with the use of high-flow nasal cannula: experience
nares diameter on generated airway pressures: an in vitro study, Pediatr.
in a pediatric ICU, Respir. Care 61 (2016) 1305e1310, http://dx.doi.org/
Pulmonol. 48 (2013) 506e514, http://dx.doi.org/10.1002/ppul.22636.
10.4187/respcare.04452.
[20] N.N. Finer, F.L. Mannino, High-flow nasal cannula: a kinder, gentler CPAP?
[4] B. Sztrymf, J. Messika, T. Mayot, H. Lenglet, D. Dreyfuss, J.-D. Ricard, Impact of
J. Pediatr. 154 (2009) 160e162, http://dx.doi.org/10.1016/j.jpeds.2008.08.021.
high-flow nasal cannula oxygen therapy on intensive care unit patients with
[21] S. Mayfield, J. Jauncey-Cooke, J.L. Hough, A. Schibler, K. Gibbons, F. Bogossian,
acute respiratory failure: a prospective observational study, J. Crit. Care 27
High-flow nasal cannula therapy for respiratory support in children, Cochrane
(2012) 324, http://dx.doi.org/10.1016/j.jcrc.2011.07.075 e9-13.
Database Syst. Rev. (2014), http://dx.doi.org/10.1002/14651858.CD009850.pub2.
[5] J.H. Lee, K.J. Rehder, L. Williford, I.M. Cheifetz, D.A. Turner, Use of high flow
CD009850.
nasal cannula in critically ill infants, children, and adults: a critical review of
[22] E. Kepreotes, B. Whitehead, J. Attia, C. Oldmeadow, A. Collison, A. Searles,
the literature, Intensive Care Med. 39 (2013) 247e257, http://dx.doi.org/
B. Goddard, J. Hilton, M. Lee, J. Mattes, High-flow warm humidified oxygen
10.1007/s00134-012-2743-5.
versus standard low-flow nasal cannula oxygen for moderate bronchiolitis
[6] F.A. Hutchings, T.N. Hilliard, P.J. Davis, Heated humidified high-flow nasal
(HFWHO RCT): an open, phase 4, randomised controlled trial, Lancet (2017),
cannula therapy in children, Arch. Dis. Child. 100 (2015) 571e575, http://
http://dx.doi.org/10.1016/S0140-6736(17)30061-2 (London, England).
dx.doi.org/10.1136/archdischild-2014-306590.
si, M. Boubal, A. Jacquot, J. Baleine, S. Durand, M.P. Odena, G. Cambonie, [23] J.J. Cummings, R.A. Polin, Noninvasive respiratory support, Pediatrics 137
[7] C. Mile
(2016), http://dx.doi.org/10.1542/peds.2015-3758.
High-flow nasal cannula: recommendations for daily practice in pediatrics,
[24] P. Ramnarayan, A. Schibler, Glass half empty or half full? The story of high-
Ann. Intensive Care 4 (2014) 29, http://dx.doi.org/10.1186/s13613-014-0029-5.
flow nasal cannula therapy in critically ill children, Intensive Care Med. 43
[8] S. Mayfield, F. Bogossian, L. O'Malley, A. Schibler, High-flow nasal cannula
(2017) 246e249, http://dx.doi.org/10.1007/s00134-016-4663-2.
oxygen therapy for infants with bronchiolitis: pilot study, J. Paediatr. Child.
[25] J. Porhomayon, A.A. El-Solh, L. Pourafkari, P. Jaoude, N.D. Nader, Applications
Health 50 (2014) 373e378, http://dx.doi.org/10.1111/jpc.12509.
of nasal high-flow oxygen therapy in critically ill adult patients, Lung 194
[9] T.M.T. Pham, L. O'Malley, S. Mayfield, S. Martin, A. Schibler, The effect of high
(2016) 705e714, http://dx.doi.org/10.1007/s00408-016-9885-0.
flow nasal cannula therapy on the work of breathing in infants with bron-
[26] US Food and Drug Administration, FDA 510(k) Approval of HHFNC from
chiolitis, Pediatr. Pulmonol. 50 (2015) 713e720, http://dx.doi.org/10.1002/
Vapotherm, (n.d.). https://www.accessdata.fda.gov/cdrh_docs/pdf11/K111640.
ppul.23060.
pdf (accessed March 3, 2017).
[10] O. Roca, J. Riera, F. Torres, J.R. Masclans, High-flow oxygen therapy in acute
[27] B.J. Manley, L.S. Owen, High-flow nasal cannula: mechanisms, evidence and
respiratory failure, Respir. Care 55 (2010) 408e413. http://www.ncbi.nlm.nih.
recommendations, Semin. Fetal Neonatal Med. 21 (2016) 139e145, http://
gov/pubmed/20406507.
dx.doi.org/10.1016/j.siny.2016.01.002.
[11] K. Dysart, T.L. Miller, M.R. Wolfson, T.H. Shaffer, Research in high flow ther-
[28] S. Hegde, P. Prodhan, Serious air leak syndrome complicating high-flow nasal
apy: mechanisms of action, Respir. Med. 103 (2009) 1400e1405, http://
cannula therapy: a report of 3 cases, Pediatrics 131 (2013) e939e944, http://
dx.doi.org/10.1016/j.rmed.2009.04.007.
dx.doi.org/10.1542/peds.2011-3767.
[12] M. Frizzola, T.L. Miller, M.E. Rodriguez, Y. Zhu, J. Rojas, A. Hesek, A. Stump,
[29] L.R. Jasin, S. Kern, S. Thompson, C. Walter, J.M. Rone, M.D. Yohannan, Subcu-
T.H. Shaffer, K. Dysart, High-flow nasal cannula: impact on oxygenation and
taneous scalp emphysema, pneumo-orbitis and pneumocephalus in a neonate
ventilation in an acute lung injury model, Pediatr. Pulmonol. 46 (2011) 67e74,
on high humidity high flow nasal cannula, J. Perinatol. Off. J. Calif. Perinat.
http://dx.doi.org/10.1002/ppul.21326.
Assoc. 28 (2008) 779e781, http://dx.doi.org/10.1038/jp.2008.99.
[13] A.L. Lampland, B. Plumm, P.A. Meyers, C.T. Worwa, M.C. Mammel, Observa-
[30] B.A. Yoder, R.A. Stoddard, M. Li, J. King, D.R. Dirnberger, S. Abbasi, Heated,
tional study of humidified high-flow nasal cannula compared with nasal
humidified high-flow nasal cannula versus nasal CPAP for respiratory support
continuous positive airway pressure, J. Pediatr. 154 (2009) 177e182, http://
in neonates, Pediatrics 131 (2013) e1482e1490, http://dx.doi.org/10.1542/
dx.doi.org/10.1016/j.jpeds.2008.07.021.
peds.2012-2742.
[14] T.A. Volsko, K. Fedor, J. Amadei, R.L. Chatburn, High flow through a nasal
[31] A. Kugelman, A. Riskin, W. Said, I. Shoris, F. Mor, D. Bader, A randomized pilot
cannula and CPAP effect in a simulated infant model, Respir. Care 56 (2011)
study comparing heated humidified high-flow nasal cannulae with NIPPV for
1893e1900, http://dx.doi.org/10.4187/respcare.01204.
RDS, Pediatr. Pulmonol 50 (2015) 576e583, http://dx.doi.org/10.1002/
[15] G.Y. Chang, C.A. Cox, T.H. Shaffer, Nasal cannula, CPAP, and high-flow nasal
ppul.23022.
cannula: effect of flow on temperature, humidity, pressure, and resistance,
[32] G.S. Kelly, H.K. Simon, J.J. Sturm, High-flow nasal cannula use in children with
Biomed. Instrum. Technol. 45 (2011) 69e74, http://dx.doi.org/10.2345/0899-
respiratory distress in the emergency department: predicting the need for
8205-45.1.69.
subsequent intubation, Pediatr. Emerg. Care 29 (2013) 888e892, http://
[16] J.E. Ritchie, A.B. Williams, C. Gerard, H. Hockey, Evaluation of a humidified
dx.doi.org/10.1097/PEC.0b013e31829e7f2f.
nasal high-flow oxygen system, using oxygraphy, capnography and