Nasal High-Flow Therapy for Preterm Infants: Review of Neonatal Trial Data

doi:10.1016/j.clp.2016.07.005

Clinics in Perinatology

Volume 43, Issue 4, December 2016, Pages 673-691

https://doi.org/10.1016/j.clp.2016.07.005 Get rights and content

Section snippets

Key points

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There is insufficient evidence for nasal high-flow (HF) use as primary respiratory support for preterm infants.
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HF is equivalent to nasal continuous positive airway pressure (CPAP) as postextubation support for preterm infants, but there are limited data available in extremely preterm infants born less than 28 weeks’ gestation.
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There is insufficient evidence to recommend using HF to wean from CPAP in preterm infants with evolving or established bronchopulmonary dysplasia.
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HF may prolong the

Stabilization in the Delivery Room

There are no published randomized trials of HF use in the delivery room. However, Reynolds and colleagues¹⁶ recently published a case series of 28 preterm infants born less than 30 weeks’ gestation who were stabilized with HF. This was a single-center study in a center with extensive experience using HF as primary support. About 90% of infants were successfully stabilized and transferred to the neonatal intensive care unit on HF. Three of the four infants born at 23 or 24 weeks’ gestation

Nasal High-Flow Versus Continuous Positive Airway Pressure

Six randomized trials18, 23, 24, 25, 26, 27 (Table 2) comparing HF with CPAP as postextubation support have enrolled 936 preterm infants; these trials were mostly published in the last 2 years. Although gestational age subgroup data are not available from all trials, it seems less than 250 extremely preterm infants born less than 28 weeks’ gestation were included, most in the two Australian studies.24, 25 In these two studies infants in the HF group could receive rescue CPAP/NIPPV when

Nasal high-flow to wean preterm infants from continuous positive airway pressure

Although it has been shown that the simplest way to successfully wean a preterm infant from CPAP is to cease the therapy outright, and reinstate it only if predetermined clinical criteria are met,29, 30 HF is being used as an interim support to aid weaning. There are two randomized studies of using HF to wean preterm infants from CPAP31, 32 (Table 3) with conflicting results. In the study by Abdel-Hady and coworkers³¹ of 60 preterm infants greater than or equal to 28 weeks' gestation, the use

Nasal high-flow to aid establishment of suck feeding in preterm infants

There are no randomized studies of HF with the primary outcome of suck feeding establishment in preterm infants. Despite this, HF is perceived to be of benefit in this role, and this seems to be a common reason for switching preterm infants with evolving or established bronchopulmonary dysplasia (BPD) from CPAP to HF while they convalesce.

A recent retrospective, single-center cohort study³³ compared two clinical eras: the first when CPAP was the main noninvasive support used in preterm infants

Adverse events

Adverse events including death, BPD, and pneumothorax were included outcomes in the Cochrane Review.²⁰ No differences were found in the combined outcome of death or BPD, or either of these outcomes individually, when HF was used for any studied clinical indication. Despite earlier concerns that unmonitored distending pressure generation in the lung with HF may increase the risk of air leak from the lung, pneumothorax rates are low in all randomized trials; in fact there was a nonsignificant

Recommendations

The following recommendations for HF use in preterm infants are based on a mix of evidence from clinical trials, opinion, and current clinical practice. Consider HF use

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As an alternative to CPAP as postextubation support in preterm infants, with caution recommended in extremely preterm infants.
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As an alternative to CPAP in stable preterm infants
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  Who are at risk of, or have established, nasal trauma or other pressure injuries attributed to the CPAP interface (eg, head molding).
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  Where HF may be

Acknowledgments

Several figures used in this article were originally published in Wilkinson D, Andersen C, O'Donnell CPF, et al. High flow nasal cannula for respiratory support in preterm infants. Cochrane Database Syst Rev 2016;(2):CD006405. http://dx.doi.org/10.1002/14651858.CD006405.pub3 (http://dx.doi.org/10.1002/14651858.CD006405.pub3). Cochrane Reviews are regularly updated as new evidence emerges and in response to comments and criticisms, and the Cochrane Database of Systematic Reviews should be

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Cited by (15)

Invasive and non-invasive ventilatory strategies for early and evolving bronchopulmonary dysplasia
2023, Seminars in Perinatology
In the age of surfactant and antenatal steroids, neonatal care has improved outcomes of preterm infants dramatically. Since the early 2000’s neonatologists have strived to decrease bronchopulmonary dysplasia (BPD) by decreasing ventilator-associated lung injury and utilizing many novel modes of non-invasive respiratory support. After the initial success with nasal continuous positive airway pressure, it was established that discontinuing invasive ventilation early in favor of non-invasive respiratory support is the most effective way to reduce the incidence of BPD.
In this review, we discuss the management of the preterm lung from the time of delivery, through the phases of respiratory distress syndrome (early BPD) and then evolving BPD. The goal remains to optimize respiratory support of the preterm lung while minimizing ventilator-associated lung injury and oxygen toxicity. A multidisciplinary approach involving the medical team and family is quintessential in reaching this goal and involves adequate respiratory support, optimizing nutrition and fluid balance as well as preventing infections.
Use of high flow nasal cannula in Spanish neonatal units
2022, Anales de Pediatria
El uso de la terapia con cánulas de alto flujo (CNAF) en las unidades neonatales ha experimentado un incremento en los últimos años, pero no existen guías de consenso sobre sus indicaciones y estrategias de aplicación. Nuestro objetivo fue conocer la tasa de empleo de CNAF, sus indicaciones y la variabilidad de uso entre las unidades neonatales españolas.
Encuesta de 25 preguntas dirigida a personal médico y de enfermería. Se contactó telefónicamente con unidades de nivel II y III y se envió en formato Google Forms entre septiembre 2016 y diciembre 2018.
Se recibieron 97 respuestas (63,9% medicina, 36,1% enfermería), de 69 unidades neonatales que representan a 15 comunidades autónomas (87% nivel asistencial III; 13% nivel II). Todas las unidades, salvo una, disponen de CNAF con sistema humidificado y caliente. Sus indicaciones más frecuentes son: destete de ventilación no invasiva (VNI) (79,4%), bronquiolitis (69,1%), distrés respiratorio del recién nacido a término (RNT) (58,8%), tras extubación (50,5%). El flujo mínimo varía entre 1-5 lpm y el flujo máximo entre 5-15 lpm. El 22,7% ha experimentado algún efecto indeseado por su uso (9 fuga aérea, 12 traumatismo nasal).
Menos de la mitad tiene protocolo de empleo, pero todas las respuestas coinciden en la utilidad de unas recomendaciones nacionales.
La terapia con CNAF está ampliamente extendida en las unidades españolas, pero existe gran variabilidad en sus indicaciones y estrategias de utilización. Unas recomendaciones a nivel nacional serían aplicables en la mayoría de las unidades y permitirían unificar su empleo.
The use of high-flow cannula therapy (HFNC) in neonatal units has increased in recent years, but there are no consensus guidelines on its indications and application strategies. Our aim was to know the rate of use of HFNC, their indications and the management variability among Spanish neonatal units.
Twenty-five-question survey for medical and nursing staff. Level II and III units were contacted by phone and sent in Google forms between September 2016 and December 2018.
Ninety-seven responses (63.9% medical, 36.1% nursing), from 69 neonatal units representing 15 autonomous communities (87% level of care III; 13% level II). All units except one have HFNC with a humidified and heated system. Their most frequent indications are: non-invasive ventilation weaning (79.4%), bronchiolitis (69.1%), respiratory distress of the term newborn (58.8%), after extubation (50.5%). Minimum flow (1–5 L/min) and maximum flow (5–15 L/min) are variable between units. 22.7% have experienced some adverse effect from its use (9 air leak, 12 nasal trauma).
Less than half have an employment protocol, but all the answers agree on the usefulness of national recommendations.
HFNC therapy is widely used in Spanish units, but there is great variability in its indications and strategies of use. National recommendations would be applicable in most units and would allow unifying its use.
Investigation and management of the long-term ventilated premature infant
2018, Early Human Development
Citation Excerpt :
The typical flow rate required in neonates and young infants is 6–8 L/min. Its main perceived advantages over NIV are that the interface is simpler to apply, less likely to cause skin trauma, and better tolerated [15]. A 2016 Cochrane review found HFNC to be comparable to other forms of non-invasive support for initial management of preterm infants with RDS, with no differences in rates of treatment failure, reintubation or BPD, and reduced rates of nasal trauma and pneumothorax.
Bronchopulmonary dysplasia (BPD) is a common complication of prematurity, and despite significant advances in neonatal care over recent decades its incidence has not diminished. Although most affected infants have mild disease requiring a short period of oxygen supplementation or respiratory support, severely affected infants can become dependent on positive pressure support for a prolonged duration. In such cases, investigations should be carried out to ascertain whether there are secondary disease processes exacerbating the child’s respiratory status. In case of established severe BPD, respiratory support with non-invasive or invasive positive pressure ventilation is required. In this paper we discuss the indications for, and practicalities of, the various modalities available. Potential cardiorespiratory sequelae of BPD include recurrent respiratory infections, childhood wheezing illnesses, abnormalities of lung structure and function, and pulmonary hypertension.
Guidelines for high-flow nasal cannula oxygen therapy in neonates (2023)
2024, Chinese Journal of Evidence-Based Medicine
Guidelines for high-flow nasal cannula oxygen therapy in neonates (2022)
2023, Journal of Evidence-Based Medicine
High-flow nasal cannula versus continuous positive airway pressure in primary respiratory support for preterm infants: A systematic review and meta-analysis
2022, Frontiers in Pediatrics

View all citing articles on Scopus

: Disclosure Statement: B.J. Manley is an investigator on several clinical trials of nasal high-flow in newborn infants, both published and ongoing, and is a recipient of a research fellowship from the National Health and Medical Research Council (Australia). He is a coauthor of the recently published, updated Cochrane Review of nasal high-flow use in preterm infants (Wilkinson and colleagues 2016). He has no other conflicts of interest to declare.

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Nasal High-Flow Therapy for Preterm Infants: Review of Neonatal Trial Data

Section snippets

Key points

Stabilization in the Delivery Room

Nasal High-Flow Versus Continuous Positive Airway Pressure

Nasal high-flow to wean preterm infants from continuous positive airway pressure

Nasal high-flow to aid establishment of suck feeding in preterm infants

Adverse events

Recommendations

Acknowledgments

First page preview

J Pediatr

J Pediatr

J Pediatr

Early Hum Dev

Nasal CPAP or intubation at birth for very preterm infants

N Engl J Med

Benign gaseous distension of the bowel in premature infants treated with nasal continuous airway pressure: a study of contributing factors

Am J Roentgenol

Nasal deformities resulting from flow driver continuous positive airway pressure

Arch Dis Child Fetal Neonatal Ed

Nasal trauma due to nasal continuous positive airway pressure in newborns

Arch Dis Child Fetal Neonatal Ed

Children with respiratory distress treated with high-flow nasal cannula

J Intensive Care Med

Reduced intubation rates for infants after introduction of high-flow nasal prong oxygen delivery

Intensive Care Med

Humidified high flow nasal cannulae: current practice in Australasian nurseries, a survey

J Paediatr Child Health

The use of high flow nasal cannulae in neonatal intensive care units: is clinical practice consistent with the evidence?

J Neonatal Perinatal Med

Current practices of high and low flow oxygen therapy and humidification in UK neonatal units

Pediatr Int

Use of heated humidified high-flow nasal cannula oxygen in neonates: a UK wide survey

Acta Paediatr

Report of the Australian and New Zealand Neonatal Network 2013

Assessment of pain during application of nasal-continuous positive airway pressure and heated, humidified high-flow nasal cannulae in preterm infants

J Perinatol

Patient comfort during treatment with heated humidified high flow nasal cannulae versus nasal continuous positive airway pressure: a randomised cross-over trial

Arch Dis Child Fetal Neonatal Ed