Fellow: Hannah Neubauer, Texas Children's Hospital, Baylor College of Medicine
Article: Kepreotes E, Whitehead B, Attia J, et al. High-flow warm humidified oxygen versus standard low-flow nasal cannula oxygen for moderate bronchiolitis (HFWHO RCT): an open, phase 4, randomised controlled trial. Lancet. 2017; 389(10072): 930-939.
Summary: This single-center randomized controlled trial in Australia compared the use of warm, humidified, high-flow nasal cannula (HFNC, at 1L/kg/min max) with standard nasal cannula (NC, at 2L/min) in a population of approximately 200 patients with moderate bronchiolitis < 24 months of age. This trial initiated oxygen therapy when oxygen saturations were < 95%, per Australian national guidelines, in contrast to AAP guidelines, which recommend oxygen therapy below 90%. There was no difference between the two groups in their primary outcome of time to weaning off of oxygen, but the NC group had significantly more treatment failures. HFNC was effective at preventing treatment failure and PICU transfer for the majority of patients in the NC group. Finally, in a cost analysis, the article concluded the most resource-efficient use of these therapies was to initiate NC in all eligible patients, and reserve HFNC for those patients needing escalation of care.
What are the key strengths of the article?
Randomization was performed and resulted in similar characteristics between the groups. The study was well-powered for the primary outcome and included important secondary outcomes, such as treatment failure, length of stay, cost, and adverse events. Detailed oxygen initiation, weaning, and escalation protocols were developed for the trial, which helps to counteract any performance bias that may have been present, as neither the families nor the medical providers were blinded. Though medications were administered to patients at providers' discretion, medications were well-matched across treatment groups.
Are there any limitations or flaws in the article?
In general, the biggest limitation of this study is that the generalizability of the findings may be limited given the single center design in Australia. The protocol for management of HFNC (1L/kg/min max) and the method of oxygen weaning (hourly) may differ in other institutions. Additionally, inclusion of patients with pulse ox < 95% may not represent the majority of patients in the United States (US) that would be started on oxygen therapy per AAP guidelines. Last, the population of moderate bronchiolitis patients, defined as per the Australian guidelines, may have a milder disease severity than the population in some US hospitals.
What is the major takeaway message?
This study reinforces the safety of HFNC use in bronchiolitis on the acute care floor (when using 1L/kg/min maximum flow) and demonstrates its effectiveness as a rescue therapy to prevent transfer to the PICU. Cost savings may result by initiating HFNC on the floor for patients with worsening distress as compared to transferring straight to the PICU.
Describe how this article should impact our practice.
This article supports the use of HFNC in moderate bronchiolitis on the acute care pediatric ward, as a safe therapy for reducing respiratory distress. In some patients, HFNC will prevent PICU transfer and possibly the initiation of CPAP or invasive ventilation. For those hospitals that do not have access to HFNC on the acute care ward, this article suggests that its use may help prevent some patients from needing PICU admission and will therefore potentially produce a cost savings to the healthcare system.
However, since HFNC is more expensive than standard nasal cannula, this article should also prompt providers nationwide to limit the inappropriate use of HFNC. One possibility is reserving HFNC only for patients who are more severely ill, those who fail nasal cannula therapy, or those who may need transfer to the PICU.
Article: Kepreotes E, Whitehead B, Attia J, et al. High-flow warm humidified oxygen versus standard low-flow nasal cannula oxygen for moderate bronchiolitis (HFWHO RCT): an open, phase 4, randomised controlled trial. Lancet. 2017; 389(10072): 930-939.
Summary: This single-center randomized controlled trial in Australia compared the use of warm, humidified, high-flow nasal cannula (HFNC, at 1L/kg/min max) with standard nasal cannula (NC, at 2L/min) in a population of approximately 200 patients with moderate bronchiolitis < 24 months of age. This trial initiated oxygen therapy when oxygen saturations were < 95%, per Australian national guidelines, in contrast to AAP guidelines, which recommend oxygen therapy below 90%. There was no difference between the two groups in their primary outcome of time to weaning off of oxygen, but the NC group had significantly more treatment failures. HFNC was effective at preventing treatment failure and PICU transfer for the majority of patients in the NC group. Finally, in a cost analysis, the article concluded the most resource-efficient use of these therapies was to initiate NC in all eligible patients, and reserve HFNC for those patients needing escalation of care.
What are the key strengths of the article?
Randomization was performed and resulted in similar characteristics between the groups. The study was well-powered for the primary outcome and included important secondary outcomes, such as treatment failure, length of stay, cost, and adverse events. Detailed oxygen initiation, weaning, and escalation protocols were developed for the trial, which helps to counteract any performance bias that may have been present, as neither the families nor the medical providers were blinded. Though medications were administered to patients at providers' discretion, medications were well-matched across treatment groups.
Are there any limitations or flaws in the article?
In general, the biggest limitation of this study is that the generalizability of the findings may be limited given the single center design in Australia. The protocol for management of HFNC (1L/kg/min max) and the method of oxygen weaning (hourly) may differ in other institutions. Additionally, inclusion of patients with pulse ox < 95% may not represent the majority of patients in the United States (US) that would be started on oxygen therapy per AAP guidelines. Last, the population of moderate bronchiolitis patients, defined as per the Australian guidelines, may have a milder disease severity than the population in some US hospitals.
What is the major takeaway message?
This study reinforces the safety of HFNC use in bronchiolitis on the acute care floor (when using 1L/kg/min maximum flow) and demonstrates its effectiveness as a rescue therapy to prevent transfer to the PICU. Cost savings may result by initiating HFNC on the floor for patients with worsening distress as compared to transferring straight to the PICU.
Describe how this article should impact our practice.
This article supports the use of HFNC in moderate bronchiolitis on the acute care pediatric ward, as a safe therapy for reducing respiratory distress. In some patients, HFNC will prevent PICU transfer and possibly the initiation of CPAP or invasive ventilation. For those hospitals that do not have access to HFNC on the acute care ward, this article suggests that its use may help prevent some patients from needing PICU admission and will therefore potentially produce a cost savings to the healthcare system.
However, since HFNC is more expensive than standard nasal cannula, this article should also prompt providers nationwide to limit the inappropriate use of HFNC. One possibility is reserving HFNC only for patients who are more severely ill, those who fail nasal cannula therapy, or those who may need transfer to the PICU.