High-Flow Nasal Cannula and Noninvasive Ventilation in Pediatric Emergency Medicine

Points & Pearls Excerpt

• Respiratory failure is the leading cause for admission to the pediatric intensive care unit. Noninvasive ventilation (NIV) can be used for pediatric respiratory failure to delay or prevent endotracheal intubation and its subsequent complications.
• High-flow nasal cannula (HFNC) improves gas exchange and breathing efficiency in pediatric patients with respiratory distress. HFNC is an open system that provides humidified air at higher flow rates than nasal cannula, with some degree of positive end-expiratory pressure (PEEP) (3-6 cm H₂O). Flow rates between 1.5 to 2 L/kg/min are recommended and can be titrated to the desired clinical effect.
• NIV with continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BPAP) provides positive pressure ventilation and increases lung compliance. Patient intolerance and inappro-priate mask fit may lead to treatment failure.
• CPAP delivers a continuous level of pressure to the airways. It is recommended to start at a pressure of 3 cm H₂O and titrate up to a maximum of 10 cm H₂O. Bubble CPAP with nasal prongs is used in older infants to stent airways open and improve gas exchange.
• BPAP provides higher inspiratory pressures and therefore is generally preferred over CPAP for hypercapnic respiratory failure. BPAP also creates higher mean airway pressures, and it is therefore also effective for hypoxemic respiratory failure if CPAP fails.

Most Important References

• Viscusi CD, Pacheco GS. Pediatric emergency noninvasive ventilation. Emerg Med Clin North Am. 2018;36(2):387-400. (Review) 
• Weiler T, Kamerkar A, Hotz J, et al. The relationship between high flow nasal cannula flow rate and effort of breathing in children. J Pediatr. 2017;189:66-71.E3. (Prospective cohort trial; 21 patients) 
• Mayfield S, Bogossian F, O’Malley L, et al. High-flow nasal cannula oxygen therapy for infants with bronchiolitis: pilot study. J Paediatr Child Health. 2014;50(5):373-378. (Prospective pilot study; 94 patients) 
• Martinon-Torres F. Noninvasive ventilation with helium-oxygen in children. J Crit Care. 2012;27(2):220.e1-9. (Review) 
• Perry SA, Kesser KC, Geller DE, et al. Influences of cannula size and flow rate on aerosol drug delivery through the vapotherm humidified high-flow nasal cannula system. Pediatr Crit Care Med. 2013;14(5):e250-e256. (Bench study)