Published online July 1, 2008
PEDIATRICS Vol. 122 No. 1 July 2008, pp. 218-219 (doi:10.1542/peds.2008-0882)

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LETTER TO THE EDITOR

Heated, Humidified High-Flow Nasal Cannula Therapy: Yet Another Way to Deliver Continuous Positive Airway Pressure?

Boura'a A. BouAram, MD
Caraciolo J. Fernandes, MD
Department of Pediatrics
Baylor College of Medicine
Houston, TX 77030

To the Editor.—

We read with interest the recent article by Kubicka et al,¹ who evaluated the efficacy of heated, humidified high-flow nasal cannula (HHHFNC) therapy in generating clinically significant continuous positive airway pressure (CPAP), and we wish to discuss the following issues raised by the authors' data and conclusions.

First, the authors concluded that oral cavity pressure can estimate the level of CPAP. However, data were not provided, and their conclusions were based on a sample of 5 infants. Because it is possible that oral cavity pressure measurements may vary with the infant's size, weight, and level of CPAP administered, and these results would influence interpretation of their data, the authors should consider their validation across a range of infants that resembles the study population with a larger sample size.

Second, the authors did not discuss the reason for the apparent popularity of the use of HHHFNC despite the conflicting literature on the subject.^2–5 Others have found significant increases in the use of HHFNC (14%–64% over a 2-year period) with fewer infants who received HHFNC failing a trial of extubation than those who received nasal CPAP (NCPAP) (18% vs 40%; P < .03).³ The authors did not provide data on the frequency of use of HHHFNC in comparison with their use of conventional CPAP or whether this has changed over time. However, because less than half (13 of 27) of their study cohort were very low birth weight (VLBW) (<1500 g) infants, the authors should consider investigating the reasons for the popularity of HHHFNC at their institution.

Finally, to best study the utility and safety of HHHFNC in neonatal respiratory care, we propose that future studies be randomized among interventions: in VLBW infants, between HHHFNC and NCPAP, and in non-VLBW infants, between HHHFNC, conventional NCPAP, and either "room air" or Oxyhood therapy (oxygen but no pressure). Randomly assigning infants to a "no-CPAP" group would help clarify whether infants placed on either conventional NCPAP or HHHFNC require any positive pressure support. From the authors' data, one could conclude that levels of CPAP generated in non-VLBW infants are minimal and ill-sustained at best. Also, 8 infants were prescribed 21% fraction of inspired oxygen by nasal cannula, 4 of whom were >1500 g, which might raise doubt about their need for the nasal cannula therapy. However, Walsh et al⁶ found that 7 of the 22 infants prescribed 21% oxygen by nasal cannula intentionally (with flow rates up to 2 L/minute) were unable to maintain their oxygen saturations when their "room-air" nasal cannula was discontinued (ie, they failed their room-air "challenge"). These apparently conflicting results can only be resolved with appropriate randomized, controlled trials.

REFERENCES

1. Kubicka ZJ, Limauro J, Darnall RA. Heated, humidified high-flow nasal cannula therapy: yet another way to deliver continuous positive airway pressure? Pediatrics.2008; 121 (1):82 –88[Abstract/Free Full Text]
2. Sreenan C, Lemke RP, Hudson-Mason A, Osiovich H. High-flow nasal cannulae in the management of apnea of prematurity: a comparison with conventional nasal continuous positive airway pressure. Pediatrics.2001; 107 (5):1081 –1083[Abstract/Free Full Text]
3. Shoemaker MT, Pierce MR, Yoder BA, DiGeronimo RJ. High flow nasal cannula versus nasal CPAP for neonatal respiratory disease: a retrospective study. J Perinatol.2007; 27 (2):85 –91[CrossRef][Web of Science][Medline]
4. Campbell DM, Shah PS, Shah V, Kelly EN. Nasal continuous positive airway pressure from high flow cannula versus infant flow for preterm infants. J Perinatol.2006; 26 (9):546 –549[CrossRef][Web of Science][Medline]
5. Finer NN. Nasal cannula use in the preterm infant: oxygen or pressure? Pediatrics.2005; 116 (5):1216 –1217[Free Full Text]
6. Walsh M, Engle W, Laptook A, et al. Oxygen delivery through nasal cannulae to preterm infants: can practice be improved? Pediatrics.2005; 116 (4):857 –861[Abstract/Free Full Text]

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PEDIATRICS (ISSN 1098-4275). ©2008 by the American Academy of Pediatrics

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This Article Extract Full Text (PDF) Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by BouAram, B. A. Articles by Fernandes, C. J. Search for Related Content PubMed PubMed Citation Articles by BouAram, B. A. Articles by Fernandes, C. J. Related Collections Premature & Newborn Social Bookmarking                         What's this?