title: High-flow nasal prong oxygen therapy or nasopharyngeal continuous positive airway pressure for children with moderate-to-severe respiratory distress?*.
abstract: OBJECTIVE
  The aim of this study was to compare the use of high-flow nasal prong oxygen therapy to nasopharyngeal continuous positive airway pressure in a PICU at a tertiary hospital; to understand the safety and effectiveness of high-flow nasal prong therapy; in particular, what proportion of children require escalation of therapy, whether any bedside monitoring data predict stability or need for escalation, and complications of the therapies.
  
  
  METHODS
  This was a prospective observational study of the first 6 months after the introduction of high-flow nasal prong oxygen therapy at the Royal Children's Hospital in Melbourne. Data were collected on all children who were managed with either high-flow nasal prong oxygen therapy or nasopharyngeal continuous positive airway pressure. The mode of respiratory support was determined by the treating medical staff. Data were collected on each patient before the use of high-flow nasal prong or nasopharyngeal continuous positive airway pressure, at 2 hours after starting the therapy, and the children were monitored and data collected until discharge from the ICU. Therapy was considered to be escalated if children on high-flow nasal prong required a more invasive form or higher level of respiratory support, including nasopharyngeal continuous positive airway pressure or mask bilevel positive airway pressure or endotracheal intubation and mechanical ventilation. Therapy was considered to be escalated if children on nasopharyngeal continuous positive airway pressure required bilevel positive airway pressure or intubation and mechanical ventilation.
  
  
  RESULTS
  As the first mode of respiratory support, 72 children received high-flow nasal prong therapy and 37 received nasopharyngeal continuous positive airway pressure. Forty-four patients (61%) who received high-flow nasal prong first were weaned to low-flow oxygen or to room air and 21 (29%) required escalation of respiratory support, compared with children on nasopharyngeal continuous positive airway pressure: 21 (57%) weaned successfully and 9 (24%) required escalation. Repeated treatment and crossover were common in this cohort. Throughout the study duration, escalation to a higher level of respiratory support was needed in 26 of 100 high-flow nasal prong treatment episodes (26%) and in 10 of 55 continuous positive airway pressure episodes (18%; p = 0.27). The need for escalation could be predicted by two of failure of normalization of heart rate and respiratory rate, and if the FIO2 did not fall to lower than 0.5, 2 hours after starting high-flow nasal prong therapy. Nasopharyngeal continuous positive airway pressure was required for significantly longer periods than high-flow nasal prong (median 48 and 18 hours, respectively; p ≤ 0.001).
  
  
  CONCLUSIONS
  High-flow nasal prong therapy is a safe form of respiratory support for children with moderate-to-severe respiratory distress, across a large range of diagnoses, whose increased work of breathing or hypoxemia is not relieved by standard oxygen therapy. About one quarter of all children will require escalation to another form of respiratory support. This can be predicted by simple bedside observations.
authors.affiliation: 1Erasmus University Medical Centre, Rotterdam, The Netherlands. 2Intensive Care Unit, Royal Children's Hospital, Melbourne, Australia.
authors.forename: Fia
authors.initials: F
authors.lastname: ten Brink
authors.forename: Trevor
authors.initials: T
authors.lastname: Duke
authors.forename: Janine
authors.initials: J
authors.lastname: Evans
mesh_terms: D001784:Blood Gas Analysis; D002675:Child, Preschool; D045422:Continuous Positive Airway Pressure / Q000379:methods*; D005260:Female; D006339:Heart Rate; D006801:Humans; D007223:Infant; D015278:Intensive Care Units, Pediatric; D007442:Intubation, Intratracheal; D008297:Male; D062072:Patient Acuity; D011446:Prospective Studies; D012131:Respiratory Insufficiency / Q000628:therapy*; D012135:Respiratory Sounds; D062606:Tertiary Care Centers