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Outcomes of Children With Bronchiolitis Treated With High-Flow Nasal Cannula or Noninvasive Positive Pressure Ventilation*

Clayton, Jason A., MD, PhD; McKee, Bryan, MD; Slain, Katherine N., DO; Rotta, Alexandre T., MD; Shein, Steven L., MD

Pediatric Critical Care Medicine: February 2019 - Volume 20 - Issue 2 - p 128–135
doi: 10.1097/PCC.0000000000001798
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Objectives: Initial respiratory support with noninvasive positive pressure ventilation or high-flow nasal cannula may prevent the need for invasive mechanical ventilation in PICU patients with bronchiolitis. However, it is not clear whether the initial choice of respiratory support modality influences the need for subsequent invasive mechanical ventilation. The purpose of this study is to compare the rate of subsequent invasive mechanical ventilation after initial support with noninvasive positive pressure ventilation or high-flow nasal cannula in children with bronchiolitis.

Design: Analysis of the Virtual Pediatric Systems database.

Setting: Ninety-two participating PICUs.

Patients: Children less than 2 years old admitted to a participating PICU between 2009 and 2015 with a diagnosis of bronchiolitis who were prescribed high-flow nasal cannula or noninvasive positive pressure ventilation as the initial respiratory treatment modality.

Interventions: None. Subsequent receipt of invasive mechanical ventilation was the primary outcome.

Measurements and Main Results: We identified 6,496 subjects with a median age 3.9 months (1.7–9.5 mo). Most (59.7%) were male, and 23.4% had an identified comorbidity. After initial support with noninvasive positive pressure ventilation or high-flow nasal cannula, 12.3% of patients subsequently received invasive mechanical ventilation. Invasive mechanical ventilation was more common in patients initially supported with noninvasive positive pressure ventilation compared with high-flow nasal cannula (20.1% vs 11.0%: p < 0.001). In a multivariate logistic regression model that adjusted for age, weight, race, viral etiology, presence of a comorbid diagnosis, and Pediatric Index of Mortality score, initial support with noninvasive positive pressure ventilation was associated with a higher odds of subsequent invasive mechanical ventilation compared with high-flow nasal cannula (odds ratio, 1.53; 95% CI, 1.24–1.88).

Conclusions: In this large, multicenter database study of infants with acute bronchiolitis that received initial respiratory support with high-flow nasal cannula or noninvasive positive pressure ventilation, noninvasive positive pressure ventilation use was associated with higher rates of invasive mechanical ventilation, even after adjusting for demographics, comorbid condition, and severity of illness. A large, prospective, multicenter trial is needed to confirm these findings.

All authors: Division of Pediatric Critical Care Medicine, Department of Pediatrics, UH Rainbow Babies & Children’s Hospital, Cleveland, OH.

*See also p. 192.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/pccmjournal).

Dr. Rotta received funding from Elsevier (royalties) and Vapotherm (received honoraria relative to lecturing and development of educational materials). The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: Jason.Clayton@uhhospitals.org

©2019The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies