Assessment of dispersion of airborne particles of oral/nasal fluid by high flow nasal cannula therapy

Background Nasal High Flow (NHF) therapy delivers flows of heated humidified gases up to 60 LPM (litres per minute) via a nasal cannula. Particles of oral/nasal fluid released by patients undergoing NHF therapy may pose a cross-infection risk, which is a potential concern for treating COVID-19 patients. Methods Liquid particles within the exhaled breath of healthy participants were measured with two protocols: (1) high speed camera imaging and counting exhaled particles under high magnification (6 participants) and (2) measuring the deposition of a chemical marker (riboflavin-5-monophosphate) at a distance of 100 and 500 mm on filter papers through which air was drawn (10 participants). The filter papers were assayed with HPLC. Breathing conditions tested included quiet (resting) breathing and vigorous breathing (which here means nasal snorting, voluntary coughing and voluntary sneezing). Unsupported (natural) breathing and NHF at 30 and 60 LPM were compared. Results Imaging: During quiet breathing, no particles were recorded with unsupported breathing or 30 LPM NHF (detection limit for single particles 33 μm). Particles were detected from 2 of 6 participants at 60 LPM quiet breathing at approximately 10% of the rate caused by unsupported vigorous breathing. Unsupported vigorous breathing released the greatest numbers of particles. Vigorous breathing with NHF at 60 LPM, released half the number of particles compared to vigorous breathing without NHF. Chemical marker tests: No oral/nasal fluid was detected in quiet breathing without NHF (detection limit 0.28 μL/m3). In quiet breathing with NHF at 60 LPM, small quantities were detected in 4 out of 29 quiet breathing tests, not exceeding 17 μL/m3. Vigorous breathing released 200–1000 times more fluid than the quiet breathing with NHF. The quantities detected in vigorous breathing were similar whether using NHF or not. Conclusion During quiet breathing, 60 LPM NHF therapy may cause oral/nasal fluid to be released as particles, at levels of tens of μL per cubic metre of air. Vigorous breathing (snort, cough or sneeze) releases 200 to 1000 times more oral/nasal fluid than quiet breathing (p < 0.001 with both imaging and chemical marker methods). During vigorous breathing, 60 LPM NHF therapy caused no statistically significant difference in the quantity of oral/nasal fluid released compared to unsupported breathing. NHF use does not increase the risk of dispersing infectious aerosols above the risk of unsupported vigorous breathing. Standard infection prevention and control measures should apply when dealing with a patient who has an acute respiratory infection, independent of which, if any, respiratory support is being used. Clinical trial registration ACTRN12614000924651

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Assessment of dispersion of airborne particles of oral/nasal fluid by high flow nasal cannula therapy

10.1101/2020.05.14.20102517 ◽

2020 ◽

Author(s):

Mark C Jermy ◽

Callum JT Spence ◽

Robert Kirton ◽

Jane F O'Donnell ◽

Natalia Kabaliuk ◽

...

Keyword(s):

Detection Limit ◽

High Flow ◽

Nasal Cannula ◽

Control Measures ◽

Infection Prevention And Control ◽

Chemical Marker ◽

Quiet Breathing ◽

Significant Difference ◽

Filter Papers ◽

Nasal Fluid

Background Nasal High Flow (NHF) therapy delivers flows of heated humidified gases up to 60 LPM (litres per minute) via a nasal cannula. Particles of oral/nasal fluid released by patients undergoing NHF therapy may pose a cross-infection risk, which is a potential concern for treating COVID-19 patients. Methods Liquid particles within the exhaled breath of healthy participants were measured with two protocols: (1) high speed camera imaging and counting exhaled particles under high magnification (6 participants) and (2) measuring the deposition of a chemical marker (riboflavin-5-monophosphate) at a distance of 100 and 500 mm on filter papers through which air was drawn (10 participants). The filter papers were assayed with HPLC. Breathing conditions tested included quiet (resting) breathing and vigorous breathing (which here means nasal snorting, voluntary coughing and voluntary sneezing). Unsupported (natural) breathing and NHF at 30 and 60 LPM were compared. Results (1) Imaging: During quiet breathing, no particles were recorded with unsupported breathing or 30 LPM NHF (detection limit for single particles 33 microns). Particles were detected in 2 of 6 participants at 60 LPM quiet breathing at approximately 10% of the rate caused by unsupported vigorous breathing. Unsupported vigorous breathing released the greatest numbers of particles. Vigorous breathing with NHF at 60 LPM, released half the number of particles compared to vigorous breathing without NHF. (2) Chemical marker tests: No oral/nasal fluid was detected in quiet breathing without NHF (detection limit 0.28 microlitres/m3). In quiet breathing with NHF at 60 LPM, small quantities were detected in 4 out of 29 quiet breathing tests, not exceeding 17 microlitres/m3. Vigorous breathing released 200-1000 times more fluid than the quiet breathing with NHF. The quantities detected in vigorous breathing were similar whether using NHF or not. Conclusion During quiet breathing, 60 LPM NHF therapy may cause oral/nasal fluid to be released as particles, at levels of tens of microlitres per cubic metre of air. Vigorous breathing (snort, cough or sneeze) releases 200 to 1000 times more oral/nasal fluid than quiet breathing. During vigorous breathing, 60 LPM NHF therapy caused no statistically significant difference in the quantity of oral/nasal fluid released compares to unsupported breathing. NHF use does not increase the risk of dispersing infectious aerosols above the risk of unsupported vigorous breathing. Standard infection prevention and control measures should apply when dealing with a patient who has an acute respiratory infection, independent of which, if any, respiratory support is being used.

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High-Flow Nasal Cannula: A Promising Oxygen Therapy for Patients with Severe Bronchial Asthma Complicated with Respiratory Failure

Canadian Respiratory Journal ◽

10.1155/2020/2301712 ◽

2020 ◽

Vol 2020 ◽

pp. 1-7 ◽

Cited By ~ 2

Author(s):

Wanru Geng ◽

Wuliji Batu ◽

Shuhong You ◽

Zhaohui Tong ◽

Hangyong He

Keyword(s):

Respiratory Failure ◽

Bronchial Asthma ◽

Oxygen Therapy ◽

Response Rate ◽

High Flow ◽

Nasal Cannula ◽

High Flow Nasal Cannula ◽

Therapy Technique ◽

Significant Difference ◽

Life Threatening

Severe bronchial asthma complicated with respiratory failure, a common critical illness in respiratory medicine, may be life-threatening. High-flow nasal cannula (HFNC) is a novel oxygen therapy technique developed in recent years. HFNC was applied in this study for treating adult patients with severe bronchial asthma complicated with respiratory failure. Its efficacy was analyzed comparatively to conventional oxygen therapy (COT). HFNC and COT were randomly performed based on conventional treatment. The HFNC group was similar to COT-treated patients in terms of response rate, with no significant difference in efficacy between the two groups. In patients with bronchial asthma, effectively increased PO2 and reduced PCO2 were observed after treatment in both groups. However, HFNC was more efficient than COT in elevating PO2 in patients with severe bronchial asthma complicated with respiratory failure, while no statistically significant difference in PCO2 reduction was found between the two groups. Heart rate (HR) and respiratory rate (RR) between the two groups on admission (0 h) and at 2, 8, 24, and 48 h after admission were compared. Both indicators significantly decreased with time. No significant differences in HR and RR were found between the groups at 0, 2, and 8 h after admission. However, these indicators were significantly lower in the HFNC group compared with the COT group at 24 and 48 h after admission. HFNC could significantly elevate PO2 and reduce HR and RR. Thus, it is a promising option for patients with severe bronchial asthma complicated with respiratory failure.

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Efficacy of High-flow Nasal Cannula Oxygen Therapy in Patients with Mild Hypercapnia

10.21203/rs.3.rs-616727/v1 ◽

2021 ◽

Author(s):

Lingling Su ◽

Qinyu Zhao ◽

Taotao Liu ◽

Yujun Xu ◽

Weichun Li ◽

...

Keyword(s):

Oxygen Therapy ◽

Medical Information ◽

Characteristic Curve ◽

Predictive Performance ◽

High Flow ◽

Nasal Cannula ◽

Intubation Rate ◽

High Flow Nasal Cannula ◽

Inpatient Hospitalization ◽

Significant Difference

Abstract Objectives: To investigate the indications of high-flow nasal cannula (HFNC) oxygen therapy among patients with mild hypercapnia and to explore the predictors of intubation when HFNC fails.Methods: This retrospective study was conducted based on the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Adult patients with mild hypercapnia (45<PaCO2≤60 mmHg) received either HFNC or noninvasive ventilation (NIV) oxygen therapy. Propensity score matching (PSM) was implemented to increase between-group comparability. The Kaplan-Meier method was used to estimate overall survival and cumulative intubation rates, while 28-day mortality, 48-hour and 28-day intubation rates were compared using the Chi-square test. The predictive performances of HR/SpO2 and the ROX index (the ratio of SpO2/FiO2 to respiratory rate) at 4 hours were assessed regarding HFNC failure, which was determined if intubation was given within 48 hours after the initiation of oxygen therapy. The area under the receiver operating characteristic curve (AUC) for HR/SpO2 and the ROX index were calculated and compared.Results: A total of 524,520 inpatient hospitalization records were screened, 106 patients in HFNC group and 106 patients in NIV group were successfully matched. No significant difference in 48-hour intubation rate between the HFNC group and the NIV group (14.2% vs. 8.5%, P=0.278); patients receiving HFNC had higher 28-day intubation rate (26.4% vs. 14.2%, P=0.029), higher 28-day mortality (17.9% vs. 8.5%, P=0.043), longer ICU length of stay (4.4 vs. 3.3 days, P=0.019), compared to those of NIV group. The AUC of HR/SpO2 at 4 hours after the initiation of HFNC yielded around 0.660 for predicting 48-hour intubation, greater than that of the ROX index with an AUC of 0.589 (P<0.01).Conclusions: HFNC therapy cannot completely replace NIV for patients with mild hypercapnia. As opposed to the ROX index, a modest, yet improved predictive performance is demonstrated using HR/SpO2 in predicting the failure of HFNC among these patients.

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First Attempt at Using Electrical Impedance Tomography to Predict High Flow Nasal Cannula Therapy Outcomes at an Early Phase

Frontiers in Medicine ◽

10.3389/fmed.2021.737810 ◽

2021 ◽

Vol 8 ◽

Author(s):

Zhe Li ◽

Zhiyun Zhang ◽

Qian Xia ◽

Danling Xu ◽

Shaojie Qin ◽

...

Keyword(s):

Electrical Impedance Tomography ◽

Electrical Impedance ◽

Final Analysis ◽

High Flow ◽

Nasal Cannula ◽

Time To Failure ◽

High Flow Nasal Cannula ◽

Impedance Tomography ◽

Rapid Shallow Breathing Index ◽

Significant Difference

Objective: Spatial and temporal ventilation distributions in patients with acute respiratory failure during high flow nasal cannula (HFNC) therapy were previously studied with electrical impedance tomography (EIT). The aim of the study was to explore the possibility of predicting HFNC failure based on various EIT-derived parameters.Methods: High flow nasal cannula failure was defined reintubation within 48 h after HFNC. EIT was performed with the patients spontaneously breathing in the supine position at the start of HFNC. EIT-based indices (comprising the global inhomogeneity index, center of ventilation, ventilation delay, rapid shallow breathing index, minute volume, and inspiration to expiration time) were explored and evaluated at three time points (prior to HFNC, T1; 30 min after HFNC started, T2; and 1 h after, T3).Results: A total of 46 subjects were included in the final analysis. Eleven subjects had failed HFNC. The time to failure was 27.8 ± 12.4 h. The ROX index (defined as SpO2/FiO2/respiratory rate) for HFNC success patients was 8.3 ± 2.7 and for HFNC failure patients, 6.2 ± 1.8 (p = 0.23). None of the investigated EIT-based parameters showed significant differences between subjects with HFNC failure and success. Further subgroup analysis indicated that a significant difference in ventilation inhomogeneity was found between ARDS and non-ARDS [0.54 (0.37) vs. 0.46 (0.28) as evaluated with GI, p < 0.01]. Ventilation homogeneity significantly improved in ARDS after 60-min HFNC treatment [0.59 (0.20) vs 0.57 (0.19), T1 vs. T3, p < 0.05].Conclusion: Spatial and temporal ventilation distributions were slightly but insignificantly different between the HFNC success and failure groups. HFNC failure could not be predicted by changes in EIT temporal and spatial indexes of ventilation distribution within the first hour. Further studies are required to predict the outcomes of HFNC.

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Identifying predictive patients’ characteristics in case of High Flow Nasal Cannula failure when used for post-extubation failure

10.21203/rs.2.17791/v2 ◽

2020 ◽

Author(s):

Afra L.E. Terstappen ◽

Lenneke E.M. Haas ◽

Esther S.E. van Seumeren ◽

Anja Balzereit ◽

Henrik Endeman

Keyword(s):

Kidney Injury ◽

Extubation Failure ◽

Primary Diagnosis ◽

High Flow ◽

Nasal Cannula ◽

Secondary Outcome ◽

Breathing Frequency ◽

High Flow Nasal Cannula ◽

Failure Group ◽

Significant Difference

Abstract Background: High Flow Nasal Cannula (HFNC) is a relatively new but broadly used type of oxygen therapy. Hence, not much is known about HFNC in the setting of post-extubation failure. Aim of this study is to identify patients’ characteristics that predict failure of HFNC when used for post-extubation failure. Methods: This retrospective, observational study was conducted in a Dutch ICU. Between 2008 and 2014 all subjects aged 18 and older who started with HFNC due to respiratory failure within 2 to 72 hours after extubation were included. Primary outcome was patient characteristics predicting failure of HFNC. Failure was defined as reintubation or death following HFNC. Success was defined as the opportunity to stop HFNC after a non-specified time. Secondary outcome was the difference in length of stay (LOS) and mortality between the success and failure group. Results: A total of 246 subjects were included; in 135 (55%) cases HFNC failed. The success and failure group were comparable in terms of age, primary diagnosis and duration of mechanical ventilation prior to extubation. HFNC was started median 14 (min-max: 2-71) after extubation. Significant differences were found for breathing frequency (success: 21 (9-45)/min vs failure: 24(7-45)/min, p=0.009) and the presence of acute kidney injury (51% vs. 79%, p=0.003). There was a non-significant difference in pH pH (7.42(7.27-7.56) vs. 7.41 (7.13-7.58), p=0.08) After logistic breathing frequency (p=0.02) and pH (p=0.01) remained independent predictors of HFNC failure. LOS at the ICU after starting HFNC differed (success: median 131, min-max: 12-1432 hours vs. failure: 250 (23-4726) hours p<0.001. ICU and hospital mortality were not significantly different between groups. Conclusion: In more than half of the patients HFNC failed when used for post-extubation failure. Breathing frequency and pH were predictors of HFNC failure.

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A randomised trial of high-flow nasal cannula in infants with moderate bronchiolitis

European Respiratory Journal ◽

10.1183/13993003.01926-2019 ◽

2020 ◽

Vol 56 (1) ◽

pp. 1901926 ◽

Cited By ~ 2

Author(s):

Philippe Durand ◽

Tamma Guiddir ◽

Christèle Kyheng ◽

Florence Blanc ◽

Olivier Vignaud ◽

...

Keyword(s):

Treatment Failure ◽

Controlled Trial ◽

Randomised Trial ◽

High Flow ◽

Nasal Cannula ◽

Respiratory Support ◽

Control Group ◽

Study Group ◽

High Flow Nasal Cannula ◽

Significant Difference

BackgroundThe objective was to determine whether high-flow nasal cannula (HFNC), a promising respiratory support in infant bronchiolitis, could reduce the proportion of treatment failure requiring escalation of care.MethodsIn this randomised controlled trial, we assigned infants aged <6 months who had moderate bronchiolitis to receive either HFNC at 3 L·kg−1·min−1 or standard oxygen therapy. Crossover was not allowed. The primary outcome was the proportion of patients in treatment failure requiring escalation of care (mostly noninvasive ventilation) within 7 days following randomisation. Secondary outcomes included rates of transfer to the paediatric intensive care unit (PICU), oxygen, number of artificial nutritional support-free days and adverse events.ResultsThe analyses included 268 patients among the 2621 infants assessed for inclusion during two consecutive seasons in 17 French paediatric emergency departments. The percentage of infants in treatment failure was 14% (19 out of 133) in the study group, compared to 20% (27 out of 135) in the control group (OR 0.66, 95% CI 0.35–1.26; p=0.21). HFNC did not reduce the risk of admission to PICU (21 (15%) out of 133 in the study group versus 26 (19%) out of 135 in the control group) (OR 0.78, 95% CI 0.41–1.41; p=0.45). The main reason for treatment failure was the worsening of modified Wood clinical asthma score (m-WCAS). Short-term assessment of respiratory status showed a significant difference for m-WCAS and respiratory rate in favour of HFNC. Three pneumothoraces were reported in the study group.ConclusionsIn patients with moderate bronchiolitis, there was no evidence of lower rate of escalating respiratory support among those receiving HFNC therapy.

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A study of heated, humidified high flow nasal cannula as an initial respiratory support in preterm neonates

QJM ◽

10.1093/qjmed/hcab113.010 ◽

2021 ◽

Vol 114 (Supplement_1) ◽

Author(s):

Hesham A Awad ◽

Rania A El-Farrash ◽

Dina M Shinkar ◽

Yasmin A. F Aly ◽

Nanies Soliman ◽

...

Keyword(s):

Respiratory Distress ◽

Treatment Failure ◽

Preterm Infants ◽

High Flow ◽

Nasal Cannula ◽

Respiratory Support ◽

Invasive Ventilation ◽

High Flow Nasal Cannula ◽

Non Invasive ◽

Significant Difference

Abstract Background There is an increased use of heated, humidified, high-flow nasal cannula (HHFNC) as a non-invasive respiratory support. Yet, there are limited data that compares it with nasal continuous positive airway pressure (nCPAP) as regard the efficacy & outcome when used for initial treatment in preterm infants with respiratory distress syndrome (RDS) shortly postnatal. Method A prospective study conducted aiming to evaluate the effectiveness & outcome of HHFNC compared to nCPAP for the treatment of preterm infants with RDS. Preterms < 35 weeks of gestational age with symptoms and signs of RDS early after birth were randomized to HHFNC or nCPAP. Primary outcome was the incidence of treatment failure (defined as need for upgrading to noninvasive positive pressure ventilation or invasive ventilation). Results Analysis of the randomly allocated infants to HHFNC and nCPAP showed no significant difference in treatment failure (P > 0.05). There was also no significant difference (P > 0.05) among groups as regard mortality, sepsis, necrotizing enterocolitis, incidence of interventricular hemorrhage and bronchopulmonary dysplasia. Conclusion This indicates that HHFNC may be used as an equally effective and safe method of non-invasive ventilation when compared to nCPAP for initial respiratory support in preterm infants with respiratory distress.

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Identifying predictive patients’ characteristics in case of High Flow Nasal Cannula failure when used for post-extubation failure

10.21203/rs.2.17791/v1 ◽

2019 ◽

Author(s):

Afra L.E. Terstappen ◽

Lenneke E.M. Haas ◽

Esther S.E. van Seumeren ◽

Anja Balzereit ◽

Henrik Endeman

Keyword(s):

Kidney Injury ◽

Extubation Failure ◽

Primary Diagnosis ◽

High Flow ◽

Nasal Cannula ◽

Secondary Outcome ◽

Breathing Frequency ◽

High Flow Nasal Cannula ◽

Failure Group ◽

Significant Difference

Abstract Background: High Flow Nasal Cannula (HFNC) is a relatively new but broadly used type of oxygen therapy. Hence, not much is known about HFNC in the setting of post-extubation failure. Aim of this study is to identify patients’ characteristics that predict failure of HFNC when used for post-extubation failure. Methods: This retrospective, observational study was conducted in a Dutch ICU. Between 2008 and 2014 all subjects aged 18 and older who started with HFNC due to respiratory failure within 2 to 72 hours after extubation were included. Primary outcome was patient characteristics predicting failure of HFNC. Failure was defined as reintubation or death following HFNC. Success was defined as the opportunity to stop HFNC after a non-specified time. Secondary outcome was the difference in length of stay (LOS) and mortality between the success and failure group. Results: A total of 246 subjects were included; in 135 (55%) cases HFNC failed. The success and failure group were comparable in terms of age, primary diagnosis and duration of mechanical ventilation prior to extubation. HFNC was started 19 ± 15 hours (mean ± SD) after extubation. Significant differences were found for breathing frequency (success: 22 ± 7/min vs. failure: 24 ± 7/min, p=0.009) and the presence of acute kidney injury (51% vs. 79%, p=0.003). There was a non-significant difference in pH (7.43 ± 0.07 vs. 7.40 ± 0.08, p=0.08). After logistic breathing frequency (p=0.02) and pH (p=0.01) remained independent predictors of HFNC failure. LOS at the ICU after starting HFNC differed (success: 181 ± 177 hours vs. failure: 405 ± 519 hours, p<0.001). ICU and hospital mortality were not significantly different between groups. Conclusion: In more than half of the patients HFNC failed when used for post-extubation failure. Breathing frequency and pH were predictors of HFNC failure.

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Extubation to High-Flow Nasal Cannula in Infants Following Cardiac Surgery: A Retrospective Cohort Study

Journal of Pediatric Intensive Care ◽

10.1055/s-0041-1730933 ◽

2021 ◽

Author(s):

Hannah Stevens ◽

Julien Gallant ◽

Jennifer Foster ◽

David Horne ◽

Kristina Krmpotic

Keyword(s):

Cardiac Surgery ◽

Cohort Study ◽

Length Of Stay ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Rescue Therapy ◽

High Flow ◽

Nasal Cannula ◽

High Flow Nasal Cannula ◽

Significant Difference

AbstractHigh-flow nasal cannula (HFNC) therapy is commonly used in the pediatric intensive care unit (PICU) for postextubation respiratory support. This hypothesis-generating retrospective cohort study aimed to compare postextubation PICU length of stay in infants extubated to HFNC and low flow oxygen (LF) in PICU following cardiac surgery. Of 136 infants (newborn to 1 year) who were intubated and mechanically ventilated in PICU following cardiac surgery, 72 (53%) were extubated to HFNC and 64 (47%) to LF. Compared with patients extubated to LF, those extubated to HFNC had significantly longer durations of cardiopulmonary bypass (152 vs. 109 minutes; p = 0.002), aortic cross-clamp (90 vs. 63 minutes; p = 0.003), and invasive mechanical ventilation (3.2 vs. 1.6 days; p < 0.001), though demographic and preoperative clinical variables were similar. No significant difference was observed in postextubation PICU length of stay between HFNC and LF groups in unadjusted analysis (3.3 vs. 2.6 days, respectively; p = 0.19) and after controlling for potential confounding variables (F [1,125] = 0.17, p = 0.68, R2 = 0.16). Escalation of therapy was similar between HFNC and LF groups (8.3 vs. 14.1%; p = 0.41). HFNC was effective as rescue therapy for six patients in the LF group requiring escalation of therapy. Need for reintubation was similar between HFNC and LF groups (8.3 vs. 4.7%; p = 0.5). Although extubation to HFNC was associated with a trend toward longer postextubation PICU length of stay and was successfully used as rescue therapy for several infants extubated to LF, our results must be interpreted with caution given the limitations of our study.

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High-flow nasal cannula therapy for children with bronchiolitis: a systematic review and meta-analysis

Archives of Disease in Childhood ◽

10.1136/archdischild-2018-315846 ◽

2019 ◽

Vol 104 (6) ◽

pp. 564-576 ◽

Cited By ~ 17

Author(s):

Jilei Lin ◽

Yin Zhang ◽

Limei Xiong ◽

Sha Liu ◽

Caihui Gong ◽

...

Keyword(s):

Systematic Review ◽

Treatment Failure ◽

Low Income ◽

High Flow ◽

Nasal Cannula ◽

Controlled Trials ◽

Cochrane Central Register ◽

High Flow Nasal Cannula ◽

Respiratory Management ◽

Significant Difference

ObjectivesTo review the effects and safety of high-flow nasal cannula (HFNC) for bronchiolitis.MethodsSix electronic databases including PubMed, EMBASE, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, CQ VIP Database and Wanfang Data were searched from their inception to 1 June 2018. Randomised controlled trials (RCTs) which investigated the effects of HFNC versus other forms of oxygen therapies for bronchiolitis were included.ResultsNine RCTs with 2121 children met the eligibility criteria. There was no significant difference in length of stay in hospital (LOS), length of oxygen supplementation (LOO), transfer to intensive care unit, incidence of intubation, respiratory rate, SpO2 and adverse events in HFNC group compared with standard oxygen therapy (SOT) and nasal continuous positive airway pressure (nCPAP) groups. A significant reduction of the incidence of treatment failure (risk ratio (RR) 0.50, 95% CI 0.40 to 0.62, p<0.01) was observed in HFNC group compared with SOT group, but there was a significant increase of the incidence of treatment failure (RR 1.61, 95% CI 1.06 to 2.42, p0.02) in HFNC group compared with nCPAP group. In subgroup analysis, LOS was significantly decreased in HFNC group compared with SOT group in low-income and middle-income countries.ConclusionThe systematic review suggests HFNC is safe as an initial respiratory management, but the evidence is still lacking to show benefits for children with bronchiolitis compared with SOT or nCPAP.

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