Brett Russi, MD (he/him/his)
Pediatric Critical Care Fellow
Johns Hopkins All Children's Hospital
St. Petersburg, Florida
Disclosure information not submitted.
Anthony Sochet, MD, MS
Assistant Professor, Anesthesiology and Critical Care Medicine
Johns Hopkins All Childrens Hospital
St Petersburg, Florida
Disclosure information not submitted.
Title: Critical Asthma and Noninvasive Ventilation: Trends for HFNC and BiPAP Among 49 Children's Hospitals
INTRODUCTION: Noninvasive ventilation (NIV) for critical asthma (CA) is used to improve pulmonary physiology, deliver nebulized therapies, and ward off invasive mechanical ventilation (MV). We sought to describe NIV prescribing patterns for CA including heated humidified high-flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), and bilevel positive airway pressure (BiPAP).
Methods: We performed a retrospective cohort study querying the Pediatric Health Information System (PHIS) registry among subjects aged 3-17 years admitted to a pediatric intensive care unit for CA from Jan 2010 through Dec 2019. Encounters with malignancy, transplant status, tracheostomy dependence, neuromuscular disease, or critical congenital heart disease were excluded. Primary outcomes were descriptive including NIV prescribing trends by year, center, and patient age. Exploratory analyses assessed frequency of MV and length of stay (LOS) by NIV modality. Analyses were performed in Stata v15.1.
Results: 28,191 unique encounters met all study criteria. NIV modalities included were HFNC (n=1,034, 3.7%), CPAP (n=5,089, 18.1%), and BiPAP (n=2,185, 7.8%). All NIV types exhibited increasing annual prescribing rates with HFNC use increasing the most by 2.9% annually from 2.3% in 2014 to 14.7% in 2019. Also, HFNC prescribing by participating center varied greatly with a mean rate of 3.7 ± 11.8% (range: 0 to 32.8%). Of the 7,804 subjects prescribed ≥1 NIV modality, children on HFNC were younger (median age: 6.7 [IQR: 4.6,10.4] vs 8.4 [IQR: 5.5,11.8]), had a greater proportion classified as moderate to severe persistent asthma (73% vs 61%), had shorter hospitalization (median LOS 3 [IQR:2,5] vs 4 [IQR:3,5]), and lower MV rates (5.5% versus 19.6%, all p-values < 0.001) than those on CPAP and/or BiPAP.
Conclusions: Over the last decade, HFNC prescribing rates for CA appears increasing among 49 children’s hospitals participating in the PHIS registry. We speculate this trend may be the result of perceived patient comfort for HFNC as compared to the mask interfaces of CPAP or BiPAP in younger children. At this time, prospective, controlled trials are needed to establish comparative effectiveness for HFNC versus traditional NIV for CA and identify specific populations that may guide management.