Clinical update

28September 2014 Volume 22, No. 3

anmf.org.au

Clinical update
High flow nasal cannula oxygen therapy for infants and
young children with bronchiolitis
Danielle Hanlon
Bronchiolitis is the most
common cause of lower
respiratory tract infection
and the leading reason for
hospitalisation among infants
in developed countries
(Cambonie et al 2008: 1865). The
majority of bronchiolitis illness
is attributed to respiratory
syncytial virus (RSV) and is
characterised by bronchiole
obstruction with oedema,
cellular debris and mucous,
resulting in symptoms of
increased work of breathing,
tachypnoea, tachycardia, cough,
rhinorrhoea, wheeze, fever and
often hypoxaemia (Teshome,
Gattu & Brown 2013: 1020).
Since there is no therapeutic option
available for the treatment of bronchiolitis,
management is based on supportive
care for the symptoms, which can lead
to dehydration and respiratory distress
leading to exhaustion and respiratory
arrest (Cambonie et al 2008). An emerging
method to support breathing is using
blended, heated, humidified air and oxygen,
through nasal cannulae at flow rates higher
than two litres per minute. This is known
as high-flow nasal cannula therapy and it
allows the comfortable delivery of these high
flow rates, which may improve ventilation,
and may lead to a reduced need for invasive
respiratory support (Beggs, Wong, Kaul,
Ogden & Walters 2014: 2).
High flow nasal cannula (HFNC) therapy
enables the delivery of an oxygen-air mixture
that is heated and humidified at higher
inspired gas flows of up 30 litres/minute
(although usually flow rates much less than
this is required). The goal of HFNC is to meet
anmf.org.au

or exceed a patients spontaneous inspiratory

effort, and therefore create a reservoir of
oxygen within the nasopharynx by washing
out the nasopharyngeal dead space and
providing a form of positive airway pressure
(Beggs et al 2014; Walter 2013).
A review of the literature was conducted,
using five peer reviewed articles to ascertain
if it is advantageous to use high flow nasal
cannula oxygen therapy in the treatment of
infants and children younger than two years
old admitted to hospital with bronchiolitis.
The use of high flow, humidified oxygen
therapy was compared to the use of
standard nasal cannula dry oxygen at levels
of two litres and less.
A search of the literature was conducted
using CIAP, The Cochrane Review Register,
Informit, CINAHL, Clinicaltrials.gov and
Australian New Zealand Clinical Trials
Registry. A PICO format was used to develop
the research question, population included
infants and young children, newborn to
two years old, diagnosed with bronchiolitis.
The intervention was the use of high flow
nasal cannula oxygen therapy (heated and
humidified) compared to supplemental
oxygen therapy given by conventional nasal
prongs, or low flow nasal cannula oxygen
therapy. The outcome being the use of
high flow nasal cannula oxygen therapy
is more effective in the management/
treatment of infants and young children
with bronchiolitis, when compared to low
flow supplemental oxygen therapy.
A word list was formulated to search the
available data, keywords included infants,
children, paediatric, bronchiolitis, respiratory
syncytial virus, lower respiratory tract
infection, high flow nasal cannula/nasal
prong, low flow nasal cannula/nasal prong,
oxygen therapy. The search results were
limited to only peer reviewed articles, with
restrictions to include articles from between
2005 and 2014, to ensure only current
literature was collected.

The five studies included in the literature

review consisted of three retrospective
chart reviews, with 113 to 298 children
aged less than 24 months (Abboud et al
2012; Schibler et al 2011; McKiernan,
Chua, Visintainer & Allen 2010) and two
prospective observational studies, with 25
and 21 (respectively) infants aged less than 6
months (Milesi et al 2013; Arora, Mahajan,
Zidan & Sethuraman 2012). The umbrella
objective of the retrospective chart reviews
was to determine if the introduction of
heated humidified high flow nasal cannula
therapy was associated with decreased
rates of intubation in infants and young
children with bronchiolitis (McKiernan et al
2010). Identification of any laboratory and
clinical variables that may have predicted
the failure of high flow nasal cannula
therapy among the study participants with
bronchiolitis was also examined (Abboud
et al 2012), along with looking at the
change in ventilatory practice in the five
years after the introduction of high flow
nasal prong therapy in infants (Schibler et
al 2011). In the two physiological studies,
the main objective was to determine if high
flow nasal cannula therapy in bronchiolitis
generated nasopharyngeal pressures or
positive airway pressures at different flow
rates and the clinical significance of these
pressures (Milesi et al 2013; Arora et al
2012). Respiratory support in infants and
children with moderate to severe symptoms
of bronchiolitis has in the past included
the use of supplemental low flow oxygen,
continuous positive airway pressure (CPAP)
and intubation with mechanical ventilation
(McKiernan et al 2010). It is a commonly
acknowledged point among the literature
that the flow rates of standard or low
flow nasal cannula oxygen are well below
patients spontaneous inspiratory flow rates
and do not provide an adequate amount
of airway pressure or wash out the carbon
dioxide rich gas within the anatomical
dead space (Milesi et al 2013; Abboud et al
2012; Arora et al 2012; Schibler et al 2011;
McKiernan et al 2010).
September 2014 Volume 22, No.329

Clinical update

All research is in agreeance that using CPAP

to avoid the need for intubation has been
common practice, and CPAP has been
shown to improve clinical scores, decrease
respiratory rate and improve ventilation
(McKiernan et al 2010: 634). The theories of
the mechanisms of action of CPAP include
the reduction of airway resistance, improved
functional residual capacity and prevention
of gas trapping in hyperinflated lungs (Arora
et al 2013: 1179). However this agreeance
is also evident across the literature in the
limitations and disadvantages of the use of
CPAP, including difficulty keeping the device
insitu, difficulty maintaining an adequate
seal, noise issues with the device, it is often
poorly tolerated by infants and children and
has the potential for septal erosion and nasal
damage (Milesi et al 2013; Arora et al 2012;
McKiernan et al 2010).

RESPIRATORY SUPPORT IN
INFANTS AND CHILDREN
WITH MODERATE TO
SEVERE SYMPTOMS OF
BRONCHIOLITIS HAS IN THE
PAST INCLUDED THE USE OF
SUPPLEMENTAL LOW FLOW
OXYGEN, CONTINUOUS
POSITIVE AIRWAY PRESSURE
(CPAP) AND INTUBATION
WITH MECHANICAL
VENTILATION (MCKIERNAN
ET AL 2010)
High flow nasal cannula therapy has
many advantages over other forms of
oxygen therapy including the heating and
humidification of inspired gas mixture to
reduce the risk of damage to the upper
airway mucosa, the oxygen concentration
can be titrated to the patients needs, it is
better tolerated by the patient, decreased
nasal trauma, ease of use by nursing staff. It
is less invasive so infants and children can still
feed/drink and move around their cot/bed, it
decreases the patient risk of potential airway
damage or ventilatory-associated infection,
and has the potential to decrease the
patients requirements for sedation, as well
as allowing children to be nursed outside of
the intensive care environment, thus reducing
costs associated with care (Milesi et al 2013;
30September 2014 Volume 22, No. 3

Abboud et al 2012; Arora et al 2012; Schibler

et al 2011: McKiernan et al 2010).
The three retrospective chart reviews
(Abboud et al 2012; Schibler et al 2011;
McKiernan et al 2010) were conducted
within childrens hospitals, two in the
United States and one in Australia. All
three were conducted within the paediatric
intensive care unit, infants and children
were admitted from either the emergency
department or the general paediatric
wards. All infants and children meeting the
inclusion criteria were included and data
was collected on patient characteristics and
clinical variability. All three studies used the
Fisher Paykel heated humidified high flow
nasal cannula system to provide the HFNC
therapy. McKiernan et al and Schibler et
al both started infants and children on the
maximum flow rates for the system used
and that was 8 litres/minute and weaned
flows down depending on clinical condition,
whereas Abboud et al adjusted flow rates
to minimise the patients work of breathing
and to maintain an oxygen saturation level
of equal to and above 92%, these flow
rates ranged from 4 to 8 litres/minute.
Laboratory data including white blood cell
count, capillary blood gas (both before and
after initiation of HFNC) and respiratory
cultures were sent (Abboud et al 2012).
More importantly ventilatory parameters
and physiological variables such as heart
rate, respiratory rate, SpO2, inspired oxygen
fraction (FiO2) when HFNC initially started
and SpO2/FiO2 ratio after commencement
of therapy, any complications and PICU
length of stay were documented (Schibler
et al 2011; McKiernan et al 2010). Patients
were categorised as having failed high
flow nasal cannula therapy if they required
more intensive respiratory support which
in all three studies was intubation and
mechanical ventilation (Abboud et al
2012; Schibler et al 2011; McKiernan et al
2010). Intubation criteria were based on
overall clinical status including respiratory
rate and work of breathing (retractions,
flaring, grunting) and ability to maintain
that respiratory effort. In addition, poor
neurological status (lethargy), cyanosis,
mottling, poor perfusion, apnoea or inability
to maintain adequate oxygen saturations
were indications for intubation, as was the
clinical decision of the treating medical
officer (Abboud et al 2012; McKiernan et al
2010: 635).

In comparison the two prospective,

observational studies (Milesi et al 2013; Arora
et al 2012), used a more hands on approach
inserting a transducer/pressure probe into
the nasopharynx to record continuous clinical
and manometric data. Both studies also
used the Fisher Paykel system to provide the
humidified, high flow oxygen therapy. The
flow rates in both studies were increased
in increments, starting at the lowest flow
rate of 0.5 litres/minute to a maximum of
8 litres/minute, the child was allowed a
period of time for stabilisation and recording
before the flow rate was further increased.
Clinical documentation included heart rate,
respiratory rate, SpO2 and blood pressure, a
pacifier/dummy was used to provide a closed
mouth system, to limit the amount of air leak
from the mouth (Milesi et al 2013: 1089).
Informed consent was obtained from the
patients parents in both studies.
Common themes among the three chart
review studies, show promising results
for the introduction of high flow nasal
cannula oxygen therapy. All three have
shown a clinically significant reduction
in the intubation rates when a child with
bronchiolitis is treated with HFNC therapy,
as McKiernan et al (2010) compared two
seasons, one without HFNC and one with
HFNC, in the season before the introduction
23% of the infants who presented with
bronchiolitis required intubation as compared
with 9% of the infants who presented the
following season when HFNC was available
as a treatment option. Thus the availability
of HFNC resulted in a 14% absolute
risk reduction in the need for intubation
(McKiernan et al 2010: 636). Similarly,
Abboud et al (2012) had a failure rate to
HFNC of only 18.6%, meaning 81.4%
responded to HFNC, it was noted that of
those who did not respond to HFNC therapy
and required intubation, most were clinically
more unwell prior to commencing HFNC
therapy and 11 out of the 17 patients tested
for co-infections, were positive for various
bacterial sources of infection. Those who did
respond had improved oxygen saturations
and decreased respiratory rates (Abboud
et al 2012: 346). In keeping with reduced
intubation rates, Schibler et al (2013) state
the overall intubation rate within the unit
dropped from 37% prior to HFNC therapy, to
just 7% after its introduction four years later.
The median length of stay within the PICU for
bronchiolitic infants dropped from 2.42 days
anmf.org.au

Clinical update

THE REVIEW OF THE

LITERATURE HAS SHOWN
THAT THE USE OF HFNC
OXYGEN THERAPY IS OF
SIGNIFICANT BENEFIT
TO THOSE INFANTS AND
YOUNG CHILDREN WITH
BRONCHIOLITIS REQUIRING
OXYGEN SUPPORT.
to 2.33 days in this study. In all infants there
was a significant reduction in respiratory rate
and heart rate after the initiation of HFNC
therapy, in this study there was no significant
interaction between HFNC therapy and SpO2
or SpO2/FiO2 ratio (Schibler et al 2013: 850).
Milesi et al (2013), compliments the results
in reduction of intubation rates seen in the
case reviews with scientific data. Pharyngeal
pressure increased from 0.2cmH2O at 1litre/
minute to 4cmH2O at maximal flow of 8 litres/
minute. However only flows equal to and
greater than 6L/min generated an increase
in pharyngeal pressure resulting in positive
pressure values during both inspiration and
expiration. A flow equal to 2L/kg/min was
associated with the generation of a mean
pharyngeal pressure greater than 4cmH2O
(Milesi et al 2013: 1091). Arora et al (2012)
recorded similar results, nasopharyngeal
pressures increased linearly with increasing
flow rate up to 6L/min both in open and
closed mouth positions. On average,
nasopharyngeal pressure increased by
0.45cmH2O for each 1L/min increase in flow
rate, the maximum recording achieved was
5cmH2O, however mean nasopharyngeal
pressure for clinical improvement was
3.4cmH2O (Arora et al 2012: 1181).
The review of the literature has shown
that the use of HFNC oxygen therapy is
of significant benefit to those infants and
young children with bronchiolitis requiring
oxygen support. The chart reviews have
shown an overwhelming appreciation in
order to reduce the intubation rates, HFNC
does in the majority of cases reduce a
childs work of breathing and provides an
increase in oxygen saturations, not only
does it improve physiological scores but it
also allows the child more freedom. The
physiological studies have also provided
anmf.org.au

promising results, showing that HFNC

provides positive pressure within the
nasopharyngeal space, as well as providing
a washout of carbon dioxide rich gas, this
has been shown to be most effective in flow
rates of 4L/min and more.
The literature chosen for this review paints
a promising picture for the future use of
high flow nasal cannula oxygen therapy in
the treatment of infants and young children
with bronchiolitis. It has the potential to
significantly decrease the intubation rates,
by decreasing the infants work of breathing
and respiratory distress whilst providing a
comfortable and well tolerated means of
non-invasive ventilatory support (McKiernan
et al 2010: 637). Some of the studies did
have a small sample size, so a multi-centre
randomised controlled trial comparing
HFNC therapy with standard care is needed
to assess and prove the efficacy of HFNC
therapy (Schibler et al 2011). Objective
measures of work of breathing could test the
hypothesis that HFNC decreases the rates
of intubation in infants and young children
with bronchiolitis (McKiernan et al 2010:
637). At this time there is one randomised
controlled trial of high flow nasal cannula
oxygen therapy compared to standard
oxygen therapy in the management of
moderate bronchiolitis in infants less than 24
months in progress in Australia (registered
with Australia New Zealand Clinical Trials
Registry), however no results are available
as yet. The safety of HFNC oxygen remains
an issue due to the concern for barotrauma.
When infants receive conventional nasal
CPAP, it is possible to measure and regulate
the pressure applied to the pharynx
from the circuit, however, in HFNC the
pressure delivered to the airway cannot be
determined, so this does raise concerns
about the possibility of airway and lung
trauma, therefore, larger prospective studies
are needed to assess the safety and efficacy
of HFNC therapy (Arora et al 2012: 1183).
The most common reason for non-elective
admissions to a PICU in Australia is viral
bronchiolitis which imposes a significant
financial burden on the hospital (Schibler et
al 2011:850). Not only is there a financial
burden for the hospital, but also to the
family, but more importantly there is also
the emotional and physical needs of the sick
child and their family to consider. On average
the general paediatric ward of Albury
Wodonga Health admits 85 infants and

young children with bronchiolitis each year,

many of these children require supportive
care which often includes oxygen therapy.
The use of high flow nasal cannula oxygen
therapy has increased in this unit, however at
this time children can receive a maximum of
4 litres/min of oxygen/air therapy, if there is
no improvement in their condition, they are
required to be transferred to the intensive
care unit or a tertiary centre. Further research
on the efficacy and safety of this treatment
will lend itself to improved and evidenced
based practice on the care of a child with
bronchiolitis receiving high flow nasal
cannula oxygen therapy.

References
Abboud, P.A., Roth, P.J., Skiles, C.L., Stolfi, A. & Rowin,
M.E. 2012. Predictors of failure in infants with viral
bronchiolitis treated with high-flow, high-humidity nasal
cannula therapy. Pediatric Critical Care Medicine. 13
(6):343-349.
Arora, B., Mahajan, P., Zidan, M.A. & Sethuraman, U.
2012. Nasopharyngeal airway pressures in bronchiolitis
patients treated with high-flow nasal cannula oxygen
therapy. Pediatric Emergency Care. 28 (11): 1179-1184.
Beggs, S., Wong, Z.H., Kaul, S., Ogden, K.J. & Walters,
J.A. 2014. High-flow nasal cannula therapy for infants
with bronchiolitis (Review). The Cochrane Database of
Systematic Reviews. 1: 1-24.
Cambonie, G., Milesi, C., Jaber, S., Amsallem, F.,
Barbotte, E., Picaud, J.C. & Matecki, S. 2008. Nasal
continuous positive airway pressure decreases respiratory
muscles overload in young infants with severe acute viral
bronchiolitis. Intensive Care Medicine. 34: 1865-1872.
McKiernan, C., Chua, L.C., Visintainer, P.F. & Allen, H.
2010. High flow nasal cannulae therapy in infants with
bronchiolitis. The Journal of Pediatrics. 156 (4): 634-638.
Milesi, C., Baleine, J., Matecki, S., Durand, S., Combes,
C., Novais, A.R. & Cambonie, G. 2013. Is treatment
with a high flow nasal cannula effective in acute
viral bronchiolitis? A physiologic study. Intensive Care
Medicine. 39: 1088-1094.
Schibler, A., Pham, T.M., Dunster, K.R., Foster, K.,
Barlow, A., Gibbons, K. & Hough, J.L. 2011. Reduced
intubation rates for infants after introduction of
high-flow nasal prong oxygen delivery. Intensive Care
Medicine. 37: 847-852.
Teshome, G., Gattu, R. & Brown, R. 2013. Acute
bronchiolitis. Pediatric Clinic. 60: 1019-1034.
Walter, E.C. 2013. High-flow nasal cannula- What is it,
how does it work, and do we know if it works? Critical
Care Alert. 21 (1): 1-5.

Danielle Hanlon is a Registered Nurse

(currently completing her post graduate
certificate in Paediatrics) at Albury
Wodonga Health- Paediatric Ward in
New South Wales.
September 2014 Volume 22, No.331

Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.