Efficacy and Safety of Two Different Flow Rates of Nasal High-Flow Therapy in Preterm Neonates ≥28 Weeks of Gestation: A Randomized Controlled Trial

Abstract

Objective The study aimed to compare the efficacy and safety of two different nasal high-flow rates for primary respiratory support in preterm neonates

Study Design In this single-center, double-blinded randomized controlled trial, preterm neonates ≥28 weeks of gestation with respiratory distress from birth were randomized to treatment with either increased nasal flow therapy (8–10 L/min) or standard nasal flow therapy (5–7 L/min). The primary outcome of nasal high-flow therapy failure was a composite outcome defined as the need for higher respiratory support (continuous positive airway pressure [CPAP] or mechanical ventilation) or surfactant therapy.

Results A total of 212 neonates were enrolled. Nasal high-flow failure rate in the increased flow group was similar to the standard flow group (22 vs. 29%, relative risk = 0.81 [95% confidence interval: 0.57–1.15]). However, nasal flow rate escalation was significantly more common in the standard flow group (64 vs. 43%, p = 0.004). None of the infants in the increased flow group developed air leak syndromes.

Conclusion Higher nasal flow rate (8–10 L/min) when compared with lower nasal flow rate of 5 to 7 L/min did not reduce the need for higher respiratory support (CPAP/mechanical ventilation) or surfactant therapy in moderately and late preterm neonates. However, initial flow rates of 5 L/min were not optimal for most preterm infants receiving primary nasal flow therapy.

Key Points

• Use of high nasal flows (8–10 L/min) did not reduce the need for higher respiratory support in moderately and late preterm infants.

• Nasal flow rate of 5 L/min was not optimal for most preterms with respiratory distress from birth.

• Careful patient selection and optimized flow settings could enhance nasal flow success in neonates.

Keywords

nasal high flow - continuous positive airway pressure - respiratory distress - neonate

Authors' Contributions

H.B. conceptualized the study and drafted the initial manuscript. S.S. and S.M. collected the data and performed the initial analysis. L.S. and N.K. conducted literature search, supervised the study conduct, and critically reviewed the manuscript. B.G. and J.A. were involved in patient screening and enrollment and contributed to data analysis. Each author listed on the manuscript has seen and approved the submission of this version of the manuscript and takes full responsibility for the manuscript.

Publikationsverlauf

Eingereicht: 01. November 2020

Angenommen: 01. Februar 2021

Artikel online veröffentlicht:
23. März 2021

• References

• 1 Shetty S, Sundaresan A, Hunt K, Desai P, Greenough A. Changes in the use of humidified high flow nasal cannula oxygen. Arch Dis Child Fetal Neonatal Ed 2016; 101 (04) F371-F372
• 2 Mukerji A, Shah PS, Shivananda S. et al; Canadian Neonatal Network Investigators. Survey of noninvasive respiratory support practices in Canadian neonatal intensive care units. Acta Paediatr 2017; 106 (03) 387-393
• 3 Hough JL, Shearman AD, Jardine LA, Davies MW. Humidified high flow nasal cannulae: current practice in Australasian nurseries, a survey. J Paediatr Child Health 2012; 48 (02) 106-113
• 4 Ojha S, Gridley E, Dorling J. Use of heated humidified high-flow nasal cannula oxygen in neonates: a UK wide survey. Acta Paediatr 2013; 102 (03) 249-253
• 5 Kotecha SJ, Adappa R, Gupta N, Watkins WJ, Kotecha S, Chakraborty M. Safety and efficacy of high-flow nasal cannula therapy in preterm infants: a meta-analysis. Pediatrics 2015; 136 (03) 542-553
• 6 Klingenberg C, Pettersen M, Hansen EA. et al. Patient comfort during treatment with heated humidified high flow nasal cannulae versus nasal continuous positive airway pressure: a randomised cross-over trial. Arch Dis Child Fetal Neonatal Ed 2014; 99 (02) F134-F137
• 7 Roberts CT, Manley BJ, Dawson JA, Davis PG. Nursing perceptions of high-flow nasal cannulae treatment for very preterm infants. J Paediatr Child Health 2014; 50 (10) 806-810
• 8 Roberts CT, Owen LS, Manley BJ. et al; HIPSTER Trial Investigators. Nasal high-flow therapy for primary respiratory support in preterm infants. N Engl J Med 2016; 375 (12) 1142-1151
• 9 Manley BJ, Arnolda GRB, Wright IMR. et al; HUNTER Trial Investigators. Nasal high-flow therapy for newborn infants in special care nurseries. N Engl J Med 2019; 380 (21) 2031-2040
• 10 Hodgson KA, Manley BJ, Davis PG. Is nasal high flow inferior to continuous positive airway pressure for neonates?. Clin Perinatol 2019; 46 (03) 537-551
• 11 Sivieri EM, Foglia EE, Abbasi S. Carbon dioxide washout during high flow nasal cannula versus nasal CPAP support: an in vitro study. Pediatr Pulmonol 2017; 52 (06) 792-798
• 12 Nielsen KR, Ellington LE, Gray AJ, Stanberry LI, Smith LS, DiBlasi RM. Effect of high-flow nasal cannula on expiratory pressure and ventilation in infant, pediatric, and adult models. Respir Care 2018; 63 (02) 147-157
• 13 Al-Alaiyan S, Dawoud M, Al-Hazzani F. Positive distending pressure produced by heated, humidified high flow nasal cannula as compared to nasal continuous positive airway pressure in premature infants. J Neonatal Perinatal Med 2014; 7 (02) 119-124
• 14 Liew Z, Fenton AC, Harigopal S, Gopalakaje S, Brodlie M, O'Brien CJ. Physiological effects of high-flow nasal cannula therapy in preterm infants. Arch Dis Child Fetal Neonatal Ed 2020; 105 (01) 87-93
• 15 Mazmanyan P, Darakchyan M, Pinkham MI, Tatkov S. Mechanisms of nasal high flow therapy in newborns. J Appl Physiol (1985) 2020; 128 (04) 822-829
• 16 Yoder BA, Manley B, Collins C. et al. Consensus approach to nasal high-flow therapy in neonates. J Perinatol 2017; 37 (07) 809-813
• 17 Murki S, Singh J, Khant C. et al. High-flow nasal cannula versus nasal continuous positive airway pressure for primary respiratory support in preterm infants with respiratory distress: a randomized controlled trial. Neonatology 2018; 113 (03) 235-241
• 18 Iyer NP, Mhanna MJ. Association between high-flow nasal cannula and end-expiratory esophageal pressures in premature infants. Respir Care 2016; 61 (03) 285-290
• 19 Lavizzari A, Colnaghi M, Ciuffini F. et al. Heated, humidified high-flow nasal cannula vs nasal continuous positive airway pressure for respiratory distress syndrome of prematurity: a randomized clinical noninferiority trial. JAMA Pediatr 2016;
• 20 Zivanovic S, Scrivens A, Panza R. et al. Nasal high-flow therapy as primary respiratory support for preterm infants without the need for rescue with nasal continuous positive airway pressure. Neonatology 2019; 115 (02) 175-181
• 21 Yoder BA, Stoddard RA, Li M, King J, Dirnberger DR, Abbasi S. Heated, humidified high-flow nasal cannula versus nasal CPAP for respiratory support in neonates. Pediatrics 2013; 131 (05) e1482-e1490
• 22 Lee WY, Choi EK, Shin J, Lee EH, Choi BM, Hong YS. Risk factors for treatment failure of heated humidified high-flow nasal cannula as an initial respiratory support in newborn infants with respiratory distress. Pediatr Neonatol 2020; 61 (02) 174-179
• 23 Manley BJ, Roberts CT, Frøisland DH, Doyle LW, Davis PG, Owen LS. Refining the use of nasal high-flow therapy as primary respiratory support for preterm infants. J Pediatr 2018; 196: 65-70.e1
• 24 Milési C, Pierre AF, Deho A. et al; GFRUP Respiratory Study Group. A multicenter randomized controlled trial of a 3-L/kg/min versus 2-L/kg/min high-flow nasal cannula flow rate in young infants with severe viral bronchiolitis (TRAMONTANE 2). Intensive Care Med 2018; 44 (11) 1870-1878