title: Comparison of Effort of Breathing for Infants on Nasal Modes of Respiratory Support.
abstract: To directly compare effort of breathing between high flow nasal cannula (HFNC), nasal intermittent mechanical ventilation (NIMV), and nasal continuous positive airway pressure (NCPAP).
  
  
  
  This was a single center prospective cross-over study for patients <6 months in the cardiothoracic or pediatric intensive care unit receiving nasal noninvasive respiratory support after extubation. We measured effort of breathing using esophageal manometry with pressure-rate product (PRP) on all 3 modes. NIMV synchrony was determined by comparing patient efforts (esophageal manometry) with mechanically delivered breaths (spirometry in ventilator circuit). On NIMV, PRP and synchrony was also measured after adding a nasal clip on 26 patients.
  
  
  
  Forty-two children were included. Median (IQR) age was 2 (0.5, 4) months. There was no difference in median PRP between HFNC 6 liters per minute, 355 (270,550), NIMV 12/5 cm H2O, 341 (235, 472), and NCPAP 5 cm H2O, 340 (245,506) (P?=?.33). Results were similar regardless of HFNC flow rate or NIMV inspiratory pressure. Median PRP on CPAP of 5 cm H2O prior to extubation 255 (176, 375) was significantly lower than all postextubation values (P?<?.002). On NIMV, less than 50% of patient efforts resulted in a ventilator breath, which was not improved with a nasal clip (P?>?.07)). However, as NIMV synchrony improved (>60%), PRP on NIMV was lower than on HFNC.
  
  
  
  For infants, effort of breathing is similar on HFNC, NIMV, and NCPAP after extubation, regardless of flow rate or inspiratory pressure. We speculate that bi-level NIMV may be superior if high levels of synchrony can be achieved.
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA.
authors.forename: Asavari
authors.initials: A
authors.lastname: Kamerkar
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA.
authors.forename: Justin
authors.initials: J
authors.lastname: Hotz
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA.
authors.forename: Rica
authors.initials: R
authors.lastname: Morzov
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA; Department of Pediatrics, University of Southern California, Keck School of Medicine, Los Angeles, CA.
authors.forename: Christopher J L
authors.initials: CJL
authors.lastname: Newth
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA; Department of Pediatrics, University of Southern California, Keck School of Medicine, Los Angeles, CA.
authors.forename: Patrick A
authors.initials: PA
authors.lastname: Ross
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA; Department of Pediatrics, University of Southern California, Keck School of Medicine, Los Angeles, CA.
authors.forename: Robinder G
authors.initials: RG
authors.lastname: Khemani
mesh_terms: D060666:Airway Extubation; D000072601:Cannula; D045422:Continuous Positive Airway Pressure; D018592:Cross-Over Studies; D004947:Esophagus; D005260:Female; D006330:Heart Defects, Congenital / Q000601:surgery; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D015278:Intensive Care Units, Pediatric; D007385:Intermittent Positive-Pressure Ventilation; D008297:Male; D008365:Manometry; D010102:Oxygen Inhalation Therapy / Q000379:methods*; D011182:Postoperative Care; D011446:Prospective Studies; D012131:Respiratory Insufficiency / Q000628:therapy; D013147:Spirometry; D014939:Work of Breathing
keywords: humidified high flow nasal cannula; nasal continuous positive airway pressure; nasal intermittent mechanical ventilation