DARUL SEHAT HOSPITAL

DR.SYEDA MALEEHA SHAKEEL

Senior Medical Officer
Darul Sehat Hospital
Darul Sehat Hospital

What is Journal
Club???
• A journal club is a form of
meeting regularly held among
health practitioners to discuss
recently published related
literature.
 UNDERSTAND THE KEEPING UP-TO-DATE TEACHING CRITICAL
ARTICLE WITH THE LITERATURE APPRAISAL SKILLS

OBJECTIVES

DARUL SEHAT HOSPITAL

PROMOTING PROVIDING PROMOTING SOCIAL
EVIDENCE BASED CONTINUING INTERACTION
MEDICINE (EBM) EDUCATION
 Sir William Osler of Montreal, Canada, is credited
with starting the first formal journal club in 1875
However Sir James Paget wrote of a similar group
of students at St. Bartholomew's Hospital in
History Of Journal London who read journals together from 1835 to
Club 1854. 
Osler founded the first journal club in the United
States at the Johns Hopkins Hospital around ten
years later (in 1889).

DARUL SEHAT HOSPITAL

 Sections Of Article

Introduction
Evidence-
(Title, Author, Abstract Study Design Methodology
Based
Aim)

Results Discussion Limitation Applicability Conclusion

DARUL SEHAT HOSPITAL

Author: M.L.Catano-Jaramillo , J.C.Jaramillo-Bustamante , I.D.Florez
MEDICINA INTENSIVA: (JOURNAL)
• Journal of the Spanish Society of Intensive and Critical Care medicines
and Coronary units and of Pan American and Iberian Federation of
Societies of Intensive and Critical Care Medicine.

Systemic review: (STUDY DESIGN)

• Critical assessment and evaluation of all research studies that address a
particular clinical issue.
• A summary of the clinical literature

Meta-analysis:(STUDY DESIGN)
• a statistical process that combines the findings from individual studies.
• It is a way of combining data from many different research studies.
 DARUL SEHAT HOSPITAL
Objective • To compare the safety & effectiveness of
Continuous Positive Airway Pressure

of the (CPAP) vs. High Flow Nasal Canula

(HFNC) to prevent therapeutic failure &
the need of invasive ventilation in children
study: with acute moderate-severe bronchiolitis
 • Acute bronchiolitis is still one of the most
prevalent illnesses in children under two years.
Introduction • frequent reason for hospitalization.
• Despite the availability of several treatments,
only supplementary oxygen and hydration has
demonstrated a positive effect on the condition
of patients.
• Respiratory Syncytial Virus(RSV), most common
pathogen involved

DARUL SEHAT HOSPITAL

 • From a mild disease with a spontaneous
resolution to a severe disease that could lead to
Introduction respiratory failure & need for ventilatory support
• Recently, use of non invasive respiratory
therapies have gained popularity i.e.
nasal continuous positive air pressure (nCPAP)
high-flow nasal canula (HFNC)
non-invasive ventilation(NIV)
• All these therapies appear as therapeutic
alternatives to intubation & invasive ventilatory
support to minimize the associated risks.

DARUL SEHAT HOSPITAL

Why there is need of study???

• Two recent systemic reviews were done that have evaluated the effect of
CPAP vs HFNC
1. Conducted by Moorel et al
Concluded that treatment failure higher in children from HFNC group as
compared to CPAP group but there were no differences in need for
intubation, invasive ventilation, length of stay in PCCU & length of oxygen
therapy during the intervention.

In this study, META ANALYSIS were not conducted.

DARUL SEHAT HOSPITAL

 Why there is need of study???
2. Conducted by Lin et al
Conducted meta analysis of available evidence of HFNC & CPAP in children with bronchiolitis.
• Both intervention compared against control group & against each other.
• HFNC & CPAP were superiors to Control Group.
• However, found a significant increase in treatment failure events in HFNC group compared
with the CPAP group w/o differences in other variables.

Drawbacks:
• Included patients with any type of bronchiolitis regardless of their severity
• Didn’t perform subgroup analysis to determine the differences in the effect of these
interventions in children with moderate to severe bronchiolitis.
• There is no appropriate evidence synthesis & have to face the uncertainty that which
intervention might work better in children with moderate to severe disease.
DARUL SEHAT HOSPITAL
Knowledge Gap

• Lack of structured evidence synthesis about the relative differences

between these two alternatives.
• we hypothesized that CPAP leads to fewer therapeutic failures & fewer
mechanical ventilation rates than HFNC
• We aimed to determine the comparative effectiveness between HFNC &
CPAP in children with moderate to severe bronchiolitis in decreasing the
need for invasive ventilation & therapeutic failure through a systemic
review of the literature & meta analysis

DARUL SEHAT HOSPITAL

 • Study Design: A Systemic Review and
Meta-analysis.
• Search Strategy: MEDLINE, EMBASE,
METHODOL LILACS & COCHRANE Central & gray
literature in clinical trials databases (
OGY www.clinicaltrials.gov ) till May 2020
• Keywords: Therapeutic failure , need for
invasive ventilation, adverse
events,length of PCCU and of hospital
stay.

DARUL SEHAT HOSPITAL

 INCLUSION CRITERIA EXCLUSION CRITERIA

 Randomised control trial  Non Randomised studies

 Children < 2yrs  > 2years of age

 Acute moderate – severe bronchiolitis  Were not performed exclusively in patients with
moderate-severe bronchiolitis

 Compared HFNC & CPAP  Had different comparator

•STUDY SELEC TION :
Two reviewers ( MLC,JCJ) screened the titles and abstract independently and in
duplicate.
Also reviewed full text independently and in duplicate to determine their inclusion.
Disagreement were resolved by consensus or by a third researcher(IDF).

•D ATA E X T R A C T I O N :
General information ( name of the author, year of publication, study design, title)
Population Characteristics (Bronchiolitis classification, age, RSV identification, history
of prematurity or broncho pulmonary dysplasia).
Intervention & its comparator characteristics ( type of HFNC, CPAP positive pressure
used, fraction of inspiratory oxygen, length of the intervention)
Outcomes Data ( number events, number of patients per group or mean & standard
deviation).
RISK OF BIAS
ASSESSMENT
• Two reviewers
(MLC,JCJ) assessed
the RoB of the
included studies with
the Cockrane RoB
Tool.
 Conducted meta-analysis with the random-effect & fixed-
effect model.
 Calculated relative risk for dichotomous outcome and for
continuous outcomes the mean difference, with their 95%
confidence interval.
DATA Heterogeneity calculated through I squared test.
SYNTHESI  Low heterogeneity = < 25%
S&  Moderate heterogeneity = 25% - 50%
STATISTIC  High heterogeneity = > 50%
S Sub group analysis based on the severity of the disease
(moderate vs severe)and on the etiology of the
disease(RSV vs no RSV).
Statistical analysis performed with review manager 5.3
(RevMan)

DARUL SEHAT HOSPITAL

RESULTS
CHARACTERISTICS OF INCLUDED STUDIES
• FOREST PLOT :
Graphical representation of estimated results from no of
scientific studies addressing the same question along with
the overall results. Forest plot is for meta-analysis.
• Confidence interval:
 A confidence interval is the mean of your estimate
plus and minus the variation in that estimate. This is
the range of values you expect your estimate to fall
between if you redo your test, within a certain level of
confidence.
 Narrow CI will indicate more precise estimate
 Wider CI will indicate less precise estimate
 The situation of no difference between the two
groups will be indicated by a value of 1.
 If CI 95% = 1 means two groups are equal
 If CI 95% of the ratio contains value 1, p-value > 0.05
(statistically insignificant)
 If CI 95% of the ratio doesn’t contain the value 1,p-
value <0.05 (statistically significant)
• RELATIVE RISK (RISK RATIO):

RR = INCIDENCE OF OUTCOME WITH EXPOSURE

INCIDENCE OF OUTCOME WITHOUT EXPOSURE
 Expresses how many times more or less likely an exposed person
develops an outcome relative to an unexposed person.
INTERPRETATION:
RR = 1 no risk of outcome
RR > 1 increased risk of outcome
RR < 1 decreased risk of outcome
PRIMARY OUTCOME

 Showed a lower risk of therapeutic

failure in the patients with CPAP in
comparison to HFNC.

 The pooled estimate for invasive

ventilation showed no differences
between CPCP & HFNC.
• SECONDARY OUTCOME
 Two studies examined the
presence of Apnea and found no
differences between both
intervention.

 Two studies examined the

differences in the length of time
until the development of
therapeutic failure showed that
the time to failure (hours) was
slightly higher in patients with
HFNC compared to CPAP
 Didn’t find differences in the

• length of therapy between both

intervention

• total length of time of non-

invasive ventilatory support

• length of stay in PCCU

• total length of stay in hospital.

 ADVERSE EVENTS

• Found a higher risk of having skin

lesions in the CPAP group
compared to the HFNC group.

• Non of the studies reported air

leakage events.
DISCUSSI
ON
• Authors extract the evidence from 3 studies
that analyze 236 patients
• CPAP was superior to HFNC in terms of less
therapeutic failures (absolute reduction of
124 fewer failures per 1000 patients) and at
a later moment in time (3.16hr).
• There were no differences in the need of
invasive ventilation between two groups.
• Quality of evidence for these outcomes was
considered as low according to GRADE
quality assessment.
What is CPAP?
The delivery of constant positive pressure to
Continuous positive airway pressure (CPAP)
is a type of positive airway pressure, where
the air flow is introduced into the airways to
maintain a continuous pressure to constantly
stent the airways open. CPAP is a way of
delivering PEEP but also maintains the set
pressure throughout the respiratory cycle,
during both inspiration and expiration
the airway maintains
1. adequate functional residual capacity
within the alveoli to prevent atelectasis,
2. increases lung volume (avoiding alveolar
collapse )
3. diameter of the airways (decreasing the
resistance of lower airways & avoiding
obstructive apnea).
• Observational studies evaluated that after beginning of CPAP in
patients with bronchiolitis showing improvement after few hours in
some physiological variables (R/R,H/R , Partial pressure of CO2).
• Fleming et al also described that introduction of CPAP was associated
with reduced intubation and invasive ventilation rates with no
adverse events.
• Prospective studies comparing CPAP to conventional oxygen therapy
in acute severe bronchiolitis showed decreased in inspiratory work
with CPAP.
• RCT showed significant reduction in PCO2 ,severity score and
respiratory rate with the use of CPAP compared to standard care.
 High-flow nasal cannula (HFNC) therapy is an oxygen
supply system capable of delivering up to 100%
humidified and heated oxygen at a flow rate of up to 60
liters per minute.

What is It improves minute volume of ventilation, decreases

HFNC?
dead space in the nasopharynx (decreasing the
ventilatory work),improves mobilization of secretions
and avoiding bronchial obstruction and inflammation
due to dry and cold air.

It provides an unquantifiable degree of PEEP,which is

lower in comparison to CPAP.
• Prospective observational study of the use of HFNC described that
mean respiratory rate, esophageal and diaphragmatic activity of
infants with bronchiolitis decreased.
• Two large RCTs showed that the use of HFNC as initial therapy in
patients with acute bronchiolitis who require oxygen has proven
superior to conventional therapy.
• Relevant outcome was the therapeutic failure with HFNC and there is
no difference in need of orotracheal intubation, time length of oxygen
therapy, length of stay in PCCU and hospitalization.
CPAP or HFNC?
• Evidence have supported that both CPAP and HFNC work better than
conventional care in bronchiolitis.
• Both alternatives had reduced the risk for intubation and therefore
the number of cases that will require it is much fewer than when only
oxygen therapy is used.
• Therapeutic failure with CPAP is much lower as compared to HFNC.
 • Although superior to HFNC,CPAP produced more
adverse events such as nasal and skin lesions.
• Reported incidence of nasal injury has been as high
as 100% out of which 80% were mild injuries like
skin hyperemia and none of them causing
permenant sequels.
• Factors related to higher risk of injury

ADVERSE  More than 48hr of use

 Inappropriate prong sizes
EVENTS  Inappropriate fixation techniques
 Lack of use of nasal barrier dressings
• None of the included studies analyzed the
previously described factors and also failed to
report the severity of the injuries.
• These adverse events potential occurrence might
not be significant enough to prevent the use of an
intervention that produce relative reduction of the
risk of failure. Moreover, controlling the mentioned
risk factors for CPAP may reduce their incidence.
STRENGTHS OF
STUDY
• Performed a comprehensive and systemic
search of the literature in the main databases.
• Didn’t limit language or publication status.
• Included gray literature searches including
clinical trials, registries and conference
preceedings.
• Followed the highest methodological
standards for the development of a systemic
review of the literature according to
Cochrane.
• Evaluated the quality of evidence with grade
approach which allow the readers to interpret
the evidence in light of the certainty of the
results.
 LIMITATION
• Low number of studies
• Does not perform publication bias
evaluation
• Subgroup & sensitivity analysis
• Low quality of evidence in primary
outcomes & in some others outcome
(related to risk of bias, lack of precision,
low number of patients & events of
interest)
CONCLUSION
With low certainty
 CPAP is superior to HFNC in
decreasing the probability of
therapeutic failure and when
this event occurs,it appears
later in patient with CPAP
compared to HFNC
(more than 3hr).
With moderate certainty
• CPAP produces more adverse
events than HFNC but these
were local and non severe.
This Photo by Unknown author is licensed under CC BY-SA.