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Heated humidified high-flow nasal cannula versus low-flow nasal cannula as weaning mode from nasal CPAP in infants ≤28 weeks of gestation

Abstract

Despite the paucity of evidence, the practice of weaning nasal continuous positive airway pressure (NCPAP) is widespread. However, the most clinically effective non-invasive ventilatory support strategy remains to be determined. We compared the outcome of very premature infants with respiratory distress syndrome treated with a combination of NCPAP and heated humidified high-flow nasal cannula (HHFNC) versus NCPAP and low-flow nasal cannula (LFNC). Between 2004 and 2008, patients ≤28 weeks of gestation and <1,250 g of birth weight were treated with NCPAP + HHFNC or NCPAP + LFNC. Their respiratory and non-respiratory outcome including cost-effectiveness was compared after matching for antenatal steroid doses, mode of delivery, birth plurality, gestational age, birth weight, gender, surfactant doses, length of mechanical ventilation and clinical risk index for babies-II (CRIB-II) score. Thirty-nine infants received HHFNC + NCPAP, and 40 received NCPAP + LFNC. Median gestational age and birth weight were 27 weeks and 930 g and 27 weeks and 980 g, respectively. The total number of NCPAP days was significantly reduced by 50 % in the HHFNC group. Thirteen percent of the patients on NCPAP suffered from nasal bridge lesions compared to none on HHFNC. Respiratory and non-respiratory outcome was not significantly different otherwise. Combination of NCPAP and HHFNC reduced costs by 33 %. Conclusions: HHFNC shortens NCPAP time without increasing overall length of non-invasive respiratory support in very preterm infants. Unlike NCPAP, HHFNC does not seem to increase the risk of nasal trauma and appears to improve cost-effectiveness whilst producing otherwise equal respiratory and non-respiratory outcomes.

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Abbreviations

RDS:

Respiratory distress syndrome

NCPAP:

Nasal continuous positive airway pressure

HHFNC:

Heated humidified high-flow nasal cannula

References

  1. Abdel-Hady H, Shouman B, Aly H (2011) Early weaning from CPAP to high flow nasal cannula in preterm infants is associated with prolonged oxygen requirement: a randomized controlled trial. Early Hum Dev 87(3):205–208

    PubMed  Article  Google Scholar 

  2. Alsop EA, Cooke J, Gupta SK, Sinha SK (2008) Nasal trauma in preterm infants receiving nasal continuous positive airway pressure. Arch Dis Child 93(S2):n23

    Google Scholar 

  3. Carlo WA (2012) Gentle ventilation: the new evidence from the SUPPORT, COIN, VON, CURPAP, Colombian Network, and Neocosur Network trials. Early Hum Dev 88(S2):S81–S83

    PubMed  Article  Google Scholar 

  4. Centers for Disease Control and Prevention (CDC) (2005) Update: Ralstonia species associated with Vapotherm oxygen delivery devices—United States. MMWR Morb Mortal Wkly Rep 54(43):1286–1287

    Google Scholar 

  5. Cockburn F, Cooke RWI, Gamsu HR, Greenough A, Hopkins A, McIntosh N, Ogston SA, Parry GJ, Silverman M, Shaw JCL, Tarnow-Mordi WO, Wilkinson AR (1993) The CRIB (clinical risk index for babies) score: a tool for assessing initial neonatal risk and comparing performance of neonatal intensive care units. Lancet 342:193–198

    Article  Google Scholar 

  6. Courtney SE, Pyon KH, Saslow JG, Arnold GK, Pandit PB, Habib RH (2001) Lung recruitment and breathing pattern during variable versus continuous flow nasal continuous positive airway pressure in premature infants: an evaluation of three devices. Pediatrics 107:304–308

    CAS  PubMed  Article  Google Scholar 

  7. De Klerk A (2008) Humidified high-flow nasal cannula: is it the new and improved CPAP? Adv Neonatal Care 8(2):98–106

    PubMed  Article  Google Scholar 

  8. De Paoli AG, Lau R, Davis PG, Morley CJ (2005) Pharyngeal pressure in preterm infants receiving nasal continuous positive airway pressure. Arch Dis Child Fetal Neonatal Ed 90:79–81

    Article  Google Scholar 

  9. Fischer C, Bertelle V, Hohlfeld J, Forcada-Guex M, Stadelmann-Diaw C, Tolsa JF (2010) Nasal trauma due to continuous positive airway pressure in neonates. Arch Dis Child Fetal Neonatal Ed 95(6):F447–F451

    PubMed  Article  Google Scholar 

  10. Fisher & Paykel Healthcare Ltd. (2010) Optiflow™. Auckland, www.fphcare.com/userfiles/file/RH/BrochureDownloads/Nurturing%20Life.pdf, accessed 15 Aug 2011

  11. Holleman-Duray D, Kaupie D, Weiss MG (2007) Heated humidified high-flow nasal cannula: use and a neonatal early extubation protocol. J Perinatol 27:776–781

    CAS  PubMed  Article  Google Scholar 

  12. Jardine LA, Inglis GD, Davies MW (2011) Strategies for the withdrawal of nasal continuous positive airway pressure (NCPAP) in preterm infants. Cochrane Database Syst Rev 16(2), CD006979

    Google Scholar 

  13. Kernick J, Magarey J (2010) What is the evidence for the use of high flow nasal cannula oxygen in adult patients admitted to critical care units? A systematic review. Aust Crit Care 23(2):53–70

    PubMed  Article  Google Scholar 

  14. Kliegman RM, Fanaroff AA (1984) Necrotizing enterocolitis. N Engl J Med 310:1093

    CAS  PubMed  Article  Google Scholar 

  15. Kopelman AE (2003) Airway obstruction in two extremely low birthweight infants treated with oxygen cannulas. J Perinatol 23(2):164–165

    PubMed  Article  Google Scholar 

  16. Kubicka ZJ, Limauro J, Darnall RA (2008) Heated, humidified high-flow nasal cannula therapy: yet another way to deliver continuous positive airway pressure? Pediatrics 121(1):82–88

    PubMed  Article  Google Scholar 

  17. Lampland AL, Plumm B, Mayers PA, Worwa CT, Mammel MC (2009) Observational study of humidified high-flow nasal cannula compared with nasal continuous positive airway pressure. J Pediatr 154:177–182

    PubMed  Article  Google Scholar 

  18. Locke RG, Wolfson MR, Shaffer TH, Rubenstein SD, Greenspan JS (1993) Inadvertent administration of positive end-distending pressure during nasal cannula flow. Pediatrics 91(1):135–138

    CAS  PubMed  Google Scholar 

  19. Myers TR (2002) AARC Clinical Practice Guideline: selection of an oxygen delivery for neonatal and pediatric patients—2002 revision and update. Respir Care 47(6):707–716

    PubMed  Google Scholar 

  20. Parry G, Tucker J, Tarnow-Mordi WO for the UK Neonatal Staffing Study Collaborative Group (2003) CRIB II: an update of the clinical risk index for babies score. Lancet 361:1789–1791

    Article  Google Scholar 

  21. Saslow JG, Aghai ZH, Nakhla TA, Hart JJ, Lawrysh R, Stahl GE, Pyon KH (2006) Work of breathing using high-flow nasal cannula in preterm infants. J Perinatol 26:476–480

    CAS  PubMed  Article  Google Scholar 

  22. Shoemaker M, Pierce MR, Yoder BA, DiGeronimo RJ (2007) High flow nasal cannula versus nasal CPAP for neonatal respiratory disease: a retrospective study. J Perinatol 27:85–91

    CAS  PubMed  Article  Google Scholar 

  23. Sreenan C, Lemke RP, Hudson-Mason A, Osiovich H (2001) High-flow nasal cannulae in the management of apnea of prematurity: a comparison with conventional nasal continuous positive airway pressure. Pediatrics 107:1081–1083

    CAS  PubMed  Article  Google Scholar 

  24. Todd DA, Wright A, Broom M, Chauhan M, Meskell S, Cameron C, Perdomi AM, Rochefort M, Jardine L, Stewart A, Shadbolt B (2010) Methods of weaning preterm babies <30 weeks gestation off CPAP: a multicentre randomized controlled trial. Arch Dis Child Fetal Neonatal Ed 97(4):F236–F240

    Article  Google Scholar 

  25. Vapotherm, Inc (2008) Vapotherm® 2000. Stevensville, www.vtherm.com/_pdfs/Operating%20Manual_2000i_RevE%2006.pdf, accessed 15 Aug 2011

  26. Volpe JJ (2001) Intracranial hemorrhage: germinal matrix-intraventricular hemorrhage or the premature infant. In: Volpe JJ (ed) Neurology of the newborn, 4th edn. Saunders, Philadelphia, pp 428–493

    Google Scholar 

  27. Waugh JB, Granger WM (2004) An evaluation of two new devices for nasal high-flow gas therapy. Respir Care 94(8):902–906

    Google Scholar 

  28. Wilkinson D, Andersen C, O'Donnell CP, De Paoli AG (2011) High flow nasal cannula for respiratory support in preterm infants. Cochrane Database Syst Rev 11(5), CD006405

    Google Scholar 

  29. Wilkinson AR, Haines L, Head K, Fielder AR (2008) UK retinopathy of prematurity guideline. Early Hum Dev 84(2):71–74

    CAS  PubMed  Article  Google Scholar 

  30. Woodhead DD, Lambert DK, Clark JM, Christensen RD (2006) Comparing two methods of delivering high-flow gas therapy by nasal cannula following endotracheal extubation: a prospective randomised, masked, crossover trial. J Perinatol 26:481–485

    CAS  PubMed  Article  Google Scholar 

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Acknowledgements

The authors would like to thank Prof. Anne Greenough, Department of Neonatology, King's College Hospital, London, UK; and Tracy Coelho (Paediatric Registrar), Patricia Walker (Neonatal Secretary), and Sue Clayton (Clinical Librarian), Department of Neonatology, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.

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Correspondence to Jose Ramon Fernandez-Alvarez.

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Fernandez-Alvarez, J.R., Gandhi, R.S., Amess, P. et al. Heated humidified high-flow nasal cannula versus low-flow nasal cannula as weaning mode from nasal CPAP in infants ≤28 weeks of gestation. Eur J Pediatr 173, 93–98 (2014). https://doi.org/10.1007/s00431-013-2116-2

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Keywords

  • Heated humidified high-flow nasal cannula
  • Low-flow nasal cannula
  • Nasal continuous positive airway pressure
  • Weaning
  • Outcome
  • Premature infant