Source:

Franklin
D
,
Babl
FE
,
Schlapbach
LJ
, et al
.
A randomized trial of high-flow oxygen therapy in infants with bronchiolitis
.
N Engl J Med.
2018
;
378
(
12
):
1121
1131
; doi:
https://doi.org/10.1056/NEJMoa1714855

Investigators from multiple institutions conducted a randomized controlled trial to test the effect on treatment failure of high-flow therapy in infants with bronchiolitis and hypoxemia. Infants <12 months of age with clinical signs of bronchiolitis and a need for supplemental oxygen therapy were eligible. Bronchiolitis was defined according to accepted guidelines as symptoms of respiratory distress associated with symptoms of a viral respiratory tract infection. Clinical and demographic characteristics were collected at baseline.

Participants were randomized to receive either high-flow oxygen at a rate of 2 L/kg per body weight/min or standard therapy (supplemental oxygen through a nasal cannula, up to a maximum of 2 L/min). In both groups, the goal was to maintain an oxygen saturation level in the range of 92%–98%. Weaning of oxygen in both groups was permitted at any time to provide the lowest possible oxygen percentage to maintain an oxygen saturation level of ≥92%.

The primary outcome was treatment failure resulting in an escalation of care during the hospital admission. Criteria for treatment failure included at least 3 of the following: (a) heart or (b) respiratory rate that remained unchanged or increased by any amount since admission; (c) oxygen requirement increase that exceeded a fraction of inspired oxygen of 0.4 in the high-flow group or 2 L/min in the standard therapy group; and (d) an internal, early warning tool used by the hospital that triggered a review of the participant’s clinical condition. Clinicians also escalated therapy if they were concerned for other clinical reasons outside of these criteria. Secondary outcomes included the duration of hospital stay and the duration of oxygen therapy.

There were 1,638 children randomized and 1,472 included in the analysis (166 were excluded because of the inability to obtain parental consent). There were no differences in baseline demographic and physiological characteristics between the 2 treatment groups. There were significantly fewer participants with treatment failure in the high-flow group than in the standard therapy group (12% vs 23%; P<.001). Among those in the standard therapy group with treatment failure, all received high-flow oxygen as a rescue treatment, and 61% did not require transfer to an ICU. There were no differences between groups in the duration of hospital stay, transfer to ICU, or the duration of oxygen therapy.

The investigators conclude that high-flow oxygen therapy in bronchiolitis is associated with reduced treatment failure leading to escalation of care.

Dr Lesser has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

Supportive care remains the mainstay of treatment for infants with bronchiolitis. Positive airway pressure by using high-flow blended oxygen can improve respiratory mechanics and decrease work of...

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