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High-flow oxygen effective treatment for bronchiolitis in infants
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Infants with bronchiolitis who are treated with high-flow oxygen therapy are less likely to require increased care when compared with infants who receive standard oxygen therapy, according to a study published in The New England Journal of Medicine.
“The hallmark of severe bronchiolitis is small airway inflammation resulting in hypoxemia, hypercarbia and increased work of breathing, all of which respond to the provision of positive pressure,” Donna Franklin, BN, MBA, from the Pediatric Critical Care Research Group in the Center for Children’s Health Research at Lady Cilento Children’s Hospital, Australia, and colleagues wrote. “However, respiratory support involving continuous positive airway pressure, intubation and mechanical ventilation has traditionally been restricted to the intensive care setting.”
To determine whether high-flow oxygen therapy delivered through a nasal cannula was effective in treating infants with bronchiolitis in environments other than ICUs, the researchers conducted a multicenter, randomized, controlled trial that included children aged younger than 12 months. All were diagnosed with bronchiolitis and required supplemental oxygen therapy. Infants were administered either high-flow oxygen therapy or standard oxygen therapy. Those who met criteria for treatment failure in the standard therapy group could be administered high-flow oxygen.
Franklin and colleagues assessed the number of infants who needed increased care because of treatment failure, which was defined by the researchers as meeting at least three of four criteria, including persistent tachycardia, tachypnea, hypoxemia and medical review triggered by a hospital early-warning tool. Additionally, the researchers examined the length of hospitalization; duration of oxygen therapy; and the rates of transfer to tertiary hospitals, ICU admission, intubation and adverse events.
Of the 1,472 infants included in the analysis, 12% in the high-flow group received escalated care and 23% received escalated care in the standard therapy group (risk difference, –11 percentage points, 95% CI, –15 to –7; P < .001). The researchers observed no significant difference in length of hospital stay or how long oxygen therapy was required.
When the Franklin and colleagues assessed adverse events, they observed that both groups included one case of pneumothorax (<1%). Additionally, when treatment failure occurred in infants who were randomly selected to receive standard therapy, 61% responded to high-flow therapy.
“Escalation of care was allowed if clinically warranted in the judgement of the treating clinician; this was necessary as a safeguard, given that our trial tested an intervention that had been previously performed only in ICUs,” Franklin and colleagues wrote. “Clinicians escalated care in 34% of the infants who did not meet at least three of the four prespecified clinical criteria, according to the independent chart review we conducted. This relatively high percentage indicates that the selected clinical criteria may not comprehensively cover the clinical decision process and suggests that other elements in clinical judgement were not captured in this trial when escalation of care occurred.”
“… Considering that the trial was not blinded and that a similar proportion of infants in each group met the clinical criteria, we conclude that there was unlikely to be a major bias due to variation in judgement among the attending physicians,” the researchers added. – by Katherine Bortz
Disclosures: Franklin reports no relevant financial disclosures. Please see the study for a full list of other authors’ relevant financial disclosures.
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