Original Investigation
Caring for the Critically Ill Patient
June 16, 2022
Effect of High-Flow Nasal Cannula Therapy vs Continuous Positive Airway Pressure Therapy on Liberation From Respiratory Support in Acutely Ill Children Admitted to Pediatric Critical Care Units: A Randomized Clinical Trial
Padmanabhan Ramnarayan, Alvin Richards-Belle, Laura Drikite, et al
JAMA. Published online June 16, 2022. doi:10.1001/jama.2022.9615
Key Points
Question In acutely ill children clinically assessed to require noninvasive respiratory support in a pediatric critical care unit, is first-line use of high-flow nasal cannula therapy (HFNC) noninferior to continuous positive airway pressure (CPAP) in terms of time to liberation from all forms of respiratory support?
Findings In this randomized noninferiority trial of 600 acutely ill children clinically assessed to require noninvasive respiratory support, median time to liberation was 52.9 hours for HFNC vs 47.9 hours for CPAP. The 1-sided 97.5% confidence limit for the hazard ratio was 0.86, falling within the noninferiority margin of 0.75.
Meaning Among acutely ill children clinically assessed to require noninvasive respiratory support in a pediatric critical care unit, HFNC met the criterion for noninferiority compared with CPAP for time to liberation from respiratory support.
Abstract
Importance The optimal first-line mode of noninvasive respiratory support for acutely ill children is not known.
Objective To evaluate the noninferiority of high-flow nasal cannula therapy (HFNC) as the first-line mode of noninvasive respiratory support for acute illness, compared with continuous positive airway pressure (CPAP), for time to liberation from all forms of respiratory support.
Design, Setting, and Participants Pragmatic, multicenter, randomized noninferiority clinical trial conducted in 24 pediatric critical care units in the United Kingdom among 600 acutely ill children aged 0 to 15 years who were clinically assessed to require noninvasive respiratory support, recruited between August 2019 and November 2021, with last follow-up completed in March 2022.
Interventions Patients were randomized 1:1 to commence either HFNC at a flow rate based on patient weight (n = 301) or CPAP of 7 to 8 cm H2O (n = 299).
Main Outcomes and Measures The primary outcome was time from randomization to liberation from respiratory support, defined as the start of a 48-hour period during which a participant was free from all forms of respiratory support (invasive or noninvasive), assessed against a noninferiority margin of an adjusted hazard ratio of 0.75. Seven secondary outcomes were assessed, including mortality at critical care unit discharge, intubation within 48 hours, and use of sedation.
Results Of the 600 randomized children, consent was not obtained for 5 (HFNC: 1; CPAP: 4) and respiratory support was not started in 22 (HFNC: 5; CPAP: 17); 573 children (HFNC: 295; CPAP: 278) were included in the primary analysis (median age, 9 months; 226 girls [39%]). The median time to liberation in the HFNC group was 52.9 hours (95% CI, 46.0-60.9 hours) vs 47.9 hours (95% CI, 40.5-55.7 hours) in the CPAP group (absolute difference, 5.0 hours [95% CI –10.1 to 17.4 hours]; adjusted hazard ratio 1.03 [1-sided 97.5% CI, 0.86-∞]). This met the criterion for noninferiority. Of the 7 prespecified secondary outcomes, 3 were significantly lower in the HFNC group: use of sedation (27.7% vs 37%; adjusted odds ratio, 0.59 [95% CI, 0.39-0.88]); mean duration of critical care stay (5 days vs 7.4 days; adjusted mean difference, −3 days [95% CI, −5.1 to −1 days]); and mean duration of acute hospital stay (13.8 days vs 19.5 days; adjusted mean difference, −7.6 days [95% CI, −13.2 to −1.9 days]). The most common adverse event was nasal trauma (HFNC: 6/295 [2.0%]; CPAP: 18/278 [6.5%]).
Conclusions and Relevance Among acutely ill children clinically assessed to require noninvasive respiratory support in a pediatric critical care unit, HFNC compared with CPAP met the criterion for noninferiority for time to liberation from respiratory support.
Trial Registration ISRCTN.org Identifier: ISRCTN60048867
