Fellows journal Club
Fellow: Brandon Palmer, MD, Children’s Hospital Los Angeles, Los Angeles, CA
Article: Durand P, Guiddir T, Kyheng C, et al. A Randomised Trial of High-Flow Nasal Cannula in Infants with Moderate Bronchiolitis [published online ahead of print, 2020 May 7]. Eur Respir J. 2020;1901926. doi:10.1183/13993003.01926-2019
Summary: Routine High-Flow nasal cannula (HFNC) use in bronchiolitis has gained popularity in the US and internationally. However, there have not been randomized controlled trials that test if early or pre-emptive support with HFNC is superior to low-flow oxygen to reduce the rate of treatment failure leading to escalation of care. This multicenter randomized controlled trial of infants aged 7 days to 6 months with a first episode of hospitalization for bronchiolitis sought to determine whether HFNC use compared to low-flow oxygen therapy would reduce the rate of treatment failure requiring escalating care with noninvasive or invasive ventilation within 7 days following randomization. Data was gathered on 268 block randomized patients during two successive bronchiolitis seasons from 2016 to 2017. The study spanned 17 tertiary and non-tertiary hospitals throughout Paris, France. Patients were randomized within 48 hours of admission. The patients received either standard low-flow oxygen therapy up to 2L/min to maintain SpO2 at 94% or higher (control group) or HFNC therapy at 3L/kg/min with FiO2 adjusted to maintain a similar SpO2 target. Bronchiolitis severity was determined using the modified Wood clinical asthma score (m-WCAS), with patients included with a m-WCAS of 2 to 5 (indicating moderate bronchiolitis). Treatment failure was described as FiO2 requirement on HFNC >40% or nasal cannula >2L/min, elevated m-WCAS by 1 point or more at hour 6 or any score >5, refractory apnea episodes or increasing PaCO2 or above 60mmHg at hour 6. The study found that HFNC use did NOT result in statistically significant improvement in rate of treatment failure, as failure occurred in 14% of patients in the HFNC group, compared to 20% in the control group (OR 0.66, p=0.21). HFNC use also did not result in statistically significant reduced risk of admission to the ICU (OR 0.78, p=0.45). There were three cases of pneumothoraces in the HFNC group, with no complications in the control group.
Key Strengths: This is one of the first randomized controlled trials to assess the utility of HFNC in reducing the rate of treatment failure and escalation of care in infants with moderate bronchiolitis. Two previous RCTs have shown no benefit of HFNC over standard oxygen therapy to reduce duration of oxygen therapy or length of stay. This study was unique in that HFNC was used as routine therapy rather than rescue therapy, and the primary outcome assessed rate of treatment failure, which is clinically relevant. The study highlights the lack of evidence for routine HFNC use in bronchiolitis, and along with the findings of the two previous RCTs highlights a potential need for de-implementation.
Limitations: The study was performed across 17 institutions, many of which were non-tertiary institutions and most of which did not utilize HFNC prior to the study. This may have led to a lack of comfort with HFNC and respiratory insufficiency, leading to an increased rate of treatment failure in those patients. Also, the SpO2 limit chosen (94%) was higher than the threshold established by the AAP, and the majority of treatment failure in the HFNC group was due to an elevated m-WCAS score, which is of unknown clinical significance, limiting the generalizability of the study. Lastly, there was an absence of a PICU in all but one recruiting center, potentially leading to inclusion and evaluation bias.
Main Takeaway: Routine High Flow Nasal Cannula use in moderate bronchiolitis to prevent respiratory failure is not evidence-based. This study, as well as two other RCTs, have not shown a significant benefit of HFNC compared to standard oxygen therapy to reduce rates of treatment failure, duration of oxygen therapy or length of stay. This study highlights the need for further RCTs on HFNC use in bronchiolitis.
Impact on Practice: Routine use of HFNC in moderate bronchiolitis to prevent treatment failure is not evidence-based and may lead to increased costs and adverse events. Similar to previous interventions utilized in bronchiolitis, such as steroids, ribavirin and hypertonic saline, it may be time to discuss de-implementation of the routine use of HFNC in bronchiolitis.
Article: Durand P, Guiddir T, Kyheng C, et al. A Randomised Trial of High-Flow Nasal Cannula in Infants with Moderate Bronchiolitis [published online ahead of print, 2020 May 7]. Eur Respir J. 2020;1901926. doi:10.1183/13993003.01926-2019
Summary: Routine High-Flow nasal cannula (HFNC) use in bronchiolitis has gained popularity in the US and internationally. However, there have not been randomized controlled trials that test if early or pre-emptive support with HFNC is superior to low-flow oxygen to reduce the rate of treatment failure leading to escalation of care. This multicenter randomized controlled trial of infants aged 7 days to 6 months with a first episode of hospitalization for bronchiolitis sought to determine whether HFNC use compared to low-flow oxygen therapy would reduce the rate of treatment failure requiring escalating care with noninvasive or invasive ventilation within 7 days following randomization. Data was gathered on 268 block randomized patients during two successive bronchiolitis seasons from 2016 to 2017. The study spanned 17 tertiary and non-tertiary hospitals throughout Paris, France. Patients were randomized within 48 hours of admission. The patients received either standard low-flow oxygen therapy up to 2L/min to maintain SpO2 at 94% or higher (control group) or HFNC therapy at 3L/kg/min with FiO2 adjusted to maintain a similar SpO2 target. Bronchiolitis severity was determined using the modified Wood clinical asthma score (m-WCAS), with patients included with a m-WCAS of 2 to 5 (indicating moderate bronchiolitis). Treatment failure was described as FiO2 requirement on HFNC >40% or nasal cannula >2L/min, elevated m-WCAS by 1 point or more at hour 6 or any score >5, refractory apnea episodes or increasing PaCO2 or above 60mmHg at hour 6. The study found that HFNC use did NOT result in statistically significant improvement in rate of treatment failure, as failure occurred in 14% of patients in the HFNC group, compared to 20% in the control group (OR 0.66, p=0.21). HFNC use also did not result in statistically significant reduced risk of admission to the ICU (OR 0.78, p=0.45). There were three cases of pneumothoraces in the HFNC group, with no complications in the control group.
Key Strengths: This is one of the first randomized controlled trials to assess the utility of HFNC in reducing the rate of treatment failure and escalation of care in infants with moderate bronchiolitis. Two previous RCTs have shown no benefit of HFNC over standard oxygen therapy to reduce duration of oxygen therapy or length of stay. This study was unique in that HFNC was used as routine therapy rather than rescue therapy, and the primary outcome assessed rate of treatment failure, which is clinically relevant. The study highlights the lack of evidence for routine HFNC use in bronchiolitis, and along with the findings of the two previous RCTs highlights a potential need for de-implementation.
Limitations: The study was performed across 17 institutions, many of which were non-tertiary institutions and most of which did not utilize HFNC prior to the study. This may have led to a lack of comfort with HFNC and respiratory insufficiency, leading to an increased rate of treatment failure in those patients. Also, the SpO2 limit chosen (94%) was higher than the threshold established by the AAP, and the majority of treatment failure in the HFNC group was due to an elevated m-WCAS score, which is of unknown clinical significance, limiting the generalizability of the study. Lastly, there was an absence of a PICU in all but one recruiting center, potentially leading to inclusion and evaluation bias.
Main Takeaway: Routine High Flow Nasal Cannula use in moderate bronchiolitis to prevent respiratory failure is not evidence-based. This study, as well as two other RCTs, have not shown a significant benefit of HFNC compared to standard oxygen therapy to reduce rates of treatment failure, duration of oxygen therapy or length of stay. This study highlights the need for further RCTs on HFNC use in bronchiolitis.
Impact on Practice: Routine use of HFNC in moderate bronchiolitis to prevent treatment failure is not evidence-based and may lead to increased costs and adverse events. Similar to previous interventions utilized in bronchiolitis, such as steroids, ribavirin and hypertonic saline, it may be time to discuss de-implementation of the routine use of HFNC in bronchiolitis.
Fellow: Brandon Palmer, MD, Children’s Hospital Los Angeles
Fellowship Accomplishments/Current Research: In my first year of fellowship I have created a prospective survey-based study to characterize the current landscape and needs of hospitalist mentorship in PHM. I will use the data from the survey to help create a mentorship curriculum in the division of hospital medicine at Children’s Hospital Los Angeles. I have also been leading a quality improvement project to improve the medication reconciliation process, especially for limited-English-proficiency patients.
Goals/Plans for the Future: My long-term goal is to be a hospitalist-educator in academic medicine, with a leadership role in program directorship. I am currently pursuing a Masters in Academic Medicine at the Keck School of Medicine at University of Southern California, with a focus on curriculum development and educational scholarship production. I plan to continue studying the role of mentorship in career development, while creating innovative curriculum for all levels of learners.
Fun Fact: I am a huge Chicago Cubs fan and spent a summer as a vendor at Wrigley Field selling peanuts.
Fellowship Accomplishments/Current Research: In my first year of fellowship I have created a prospective survey-based study to characterize the current landscape and needs of hospitalist mentorship in PHM. I will use the data from the survey to help create a mentorship curriculum in the division of hospital medicine at Children’s Hospital Los Angeles. I have also been leading a quality improvement project to improve the medication reconciliation process, especially for limited-English-proficiency patients.
Goals/Plans for the Future: My long-term goal is to be a hospitalist-educator in academic medicine, with a leadership role in program directorship. I am currently pursuing a Masters in Academic Medicine at the Keck School of Medicine at University of Southern California, with a focus on curriculum development and educational scholarship production. I plan to continue studying the role of mentorship in career development, while creating innovative curriculum for all levels of learners.
Fun Fact: I am a huge Chicago Cubs fan and spent a summer as a vendor at Wrigley Field selling peanuts.
Previous Articles:
- Hannah Neubauer - HHFNC vs. low flow
- Amanda Messer - UTIs and renal scarring
- Christiane Lenzen - procalcitonin and CAP
- Melanie Rudnick - dexamethasone and parapneumonic effusions
- Jane Im - empiric antibiotic therapy in infants
- Ashley Jenkins - AKI with vancomycin and piperacillin/tazobactam therapy
- Fatuma Barqadle - US for LPs
- Marni Shear - Hypotonic IV fluids and bronchiolitis
- Ivy Tam - Ipratropium and IV magnesium in asthmatics
- Daniela Burger - HSV in Infants
- Lindsay Weiss - macrolides in pneumonia
- Tiranun Rungvivatjarus - High Flow Nasal Cannula
- Karisa Grizzle - Empiric Antibiotics in Osteomyelitis
- Mike Fenster - Bacterial meningitis in positive UA
- Courtney Charvat - CSF bioplex assay
- Audrey Uong - Complex Care Discharges
- Adam Cohen - Early Master Clinician Traits
- Alice Lee - Variation in Orbital Cellulitis Care
- Joy Solano - Family centered interventions to improve education
- Sunita Hemani - Discharging after q3 albuterol in asthma
- Jennifer Chen - Discharge Instruction Literacy
- John Morrison - Readmission Models for Complex Care
- Hanna Siddiqui - Fever, PEWS, and deterioration
- Kate Kyler - Reducing Safety Events in Suicidal Patients via QI
- Sonya Tang Girwood - Antibiotics in RSV Related Respiratory Failure
- Maria Santos - Positive UA and Meningitis
- Chionye Ossai - Parent Perception of Patient Portal
- Sarah Bram - Predictors of bacteremia in CAP
- Kris Chang - Note Bloat
- Risa Bochner - SBI with fever alone <60 days
- Alexandra Kilinsky - Promoting Fellow Autonomy
- Sasha Wee - Somatic Symptom Pathway
- Kate Donowitz - Predicting High Risk BRUE
- Caleb Hancock - Imaging Cervical Lymphadenitis
- Nathan Money - Duration of Antibiotics in Pyelonephritis
- Alison Carroll - Criteria for Invasive Bacterial Infections
- Scarlett Johnson - Deimplementation of Interventions in Bronchiolitis