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Work of breathing indices in infants with respiratory insufficiency receiving high-flow nasal cannula and nasal continuous positive airway pressure

Journal of Perinatology volume 34, pages 27–32 (2014)Cite this article

Subjects

Abstract

Objective:

To compare work of breathing (WOB) indices between two nCPAP settings and two levels of HFNC in a crossover study.

Study Design:

Infants with a CGA 28–40 weeks, baseline of HFNC 3–5 lpm or nCPAP 5-6 cmH2O and fraction of inspired oxygen ⩽40% were eligible. WOB was analyzed using respiratory inductive plethysmography (RIP) for each of the four modalities: HFNC 3 and 5 lpm, nCPAP 5 and 6 cmH2O. N=20; Study weight 1516 g (±40 g).

Result:

Approximately 12 000 breaths were analyzed indicating a high degree of asynchronous breathing and elevated WOB indices at all four levels of support. Phase angle values (means) (P<0.01): HFNC 3 lpm (114.7°), HFNC 5 lpm (96.7°), nCPAP 5 cmH2O (87.2°), nCPAP 6 cmH2O (80.5°). The mean phase relation of total breath (PhRTB) (means) (P<0.01): HFNC 3 lpm (63.2%), HFNC 5 lpm (55.3%), nCPAP 5 cmH2O (49.3%), nCPAP 6 cmH2O (48.0%). The relative labored breathing index (LBI) (means) (P⩽0.001): HFNC 3 lpm (1.39), HFNC 5 lpm (1.31), nCPAP 5 cmH2O (1.29), nCPAP 6 cmH2O (1.26). Eighty-two percent of the study subjects—respiratory mode combinations displayed clustering, in which a proportion of breaths either occurred predominantly out-of-phase (relative asynchrony) or in-phase (relative synchrony).

Conclusion:

In this study, WOB indices were statistically different, yet clinically similar in that they were elevated with respect to normal values. These infants with mild-to-moderate respiratory insufficiency demonstrate a meaningful elevation in WOB indices and continue to require non-invasive respiratory support. Patient variability exists with regard to biphasic clustered breathing patterns and the level of supplemental fraction of inspired oxygen ⩽40% alone does not provide guidance to the optimal matching of WOB indices and non-invasive respiratory support.

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References

  1. Donn SM, Sinha SK . Minimising ventilator induced lung injury in preterm infants. Arch Dis Child Fetal Neonatal Ed 2006; 91 (3): F226–F230.

    Article  CAS  Google Scholar 

  2. Holleman-Duray D, Kaupie D, Weiss MG . Heated humidified high-flow nasal cannula: use and a neonatal early extubation protocol. J Perinatol 2007; 27 (12): 776–781.

    Article  CAS  Google Scholar 

  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.

    Article  CAS  Google Scholar 

  4. DeLemos RA, McLaughlin GW, Robison EJ, Schulz J, Kirby RR . Continuous positive airway pressure as an adjunct to mechanical ventilation in the newborn with respiratory distress syndrome. Anesth Analg 1973; 52 (3): 328–332.

    Article  CAS  Google Scholar 

  5. Chernick V . Hyaline-membrane disease: therapy with constant lung-distending pressure. N Engl J Med 1973; 289 (6): 302–304.

    Article  CAS  Google Scholar 

  6. Chatila WMD, Nugent TMD, Vance GRN, Gaughan JP, Criner GJMD . The effects of high-flow vs low-flow oxygen on exercise in advanced obstructive airways disease. Chest 2004; 126 (4): 1108–1115.

    Article  Google Scholar 

  7. Dysart K, Miller TL, Wolfson MR, Shaffer TH . Research in high flow therapy: mechanisms of action. Respir Med 2009; 103 (10): 1400–1405.

    Article  Google Scholar 

  8. Frizzola M, Miller TL, Rodriguez ME, Zhu Y, Rojas J, Hesek A et al. High-flow nasal cannula: impact on oxygenation and ventilation in an acute lung injury model. Pediatr Pulmonol 2011; 46 (1): 67–74.

    Article  Google Scholar 

  9. Miller SM, Dowd SA . High-flow nasal cannula and extubation success in the premature infant: a comparison of two modalities. J Perinatol 2010; 30 (12): 805–808.

    Article  CAS  Google Scholar 

  10. TMDM Spentzas, Minarik MMD, Patters AB, BCRTL Vinson, GMD Stidham . Children with respiratory distress treated with high-flow nasal cannula. J Intens Care Med 2009; 24 (5): 323–328.

    Article  Google Scholar 

  11. Saslow JG, Aghai ZH, Nakhla TA, Hart JJ, Lawrysh R, Stahl GE et al. Work of breathing using high-flow nasal cannula in preterm infants. J Perinatol 2006; 26 (8): 476–480.

    Article  CAS  Google Scholar 

  12. Locke RG, Wolfson MR, Shaffer TH, Rubenstein SD, Greenspan JS . Inadvertent administration of positive end-distending pressure during nasal cannula flow. Pediatrics 1993; 91 (1): 135–138.

    CAS  Google Scholar 

  13. Sivieri EM, Gerdes JS, Abbasi S . Effect of HFNC flow rate, cannula size, and nares diameter on generated airway pressures: an in vitro study. Pediatr Pulmonol 2012; 48 (5): 506–514.

    Article  Google Scholar 

  14. Spence KL, Murphy D, Kilian C, McGonigle R, Kilani RA . High-flow nasal cannula as a device to provide continuous positive airway pressure in infants. J Perinatol 2007; 27 (12): 772–775.

    Article  CAS  Google Scholar 

  15. 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.

    Article  Google Scholar 

  16. de Klerk A . Humidified high-flow nasal cannula: is it the new and improved CPAP? Adv Neonat Care 2008; 8 (2): 98–106.

    Article  Google Scholar 

  17. Hammer J . NC. Assessment of thoraco-abdominal asynchrony. Paediatr Resp Rev 2009; 10 (2): 75–80.

    Article  CAS  Google Scholar 

  18. Gappa M, Pillow JJ, Allen J, Mayer O, Stocks J . Lung function tests in neonates and infants with chronic lung disease: lung and chest-wall mechanics. Pediatr Pulmonol 2006; 41 (4): 291–317.

    Article  Google Scholar 

  19. Wolfson MR, Greenspan JS, Deoras KS, Allen JL, Shaffer TH . Effect of position on the mechanical interaction between the rib cage and abdomen in preterm infants. J Appl Physiol 1992; 72 (3): 1032–1038.

    Article  CAS  Google Scholar 

  20. Allen JL, Greenspan JS, Deoras KS, Keklikian E, Wolfson MR, Shaffer TH . Interaction between chest wall motion and lung mechanics in normal infants and infants with bronchopulmonary dysplasia. Pediatr Pulmonol 1991; 11 (1): 37–43.

    Article  CAS  Google Scholar 

  21. Allen JL, Wolfson MR, McDowell K, Shaffer TH . Thoracoabdominal asynchrony in infants with airflow obstruction. Am Rev Respir Dis 1990; 141 (2): 337–342.

    Article  CAS  Google Scholar 

  22. Locke R, Greenspan JS, Shaffer TH, Rubenstein SD, Wolfson MR . Effect of nasal CPAP on thoracoabdominal motion in neonates with respiratory insufficiency. Pediatr Pulmonol 1991; 11 (3): 259–264.

    Article  CAS  Google Scholar 

  23. Deoras KS, Greenspan JS, Wolfson MR, Keklikian EN, Shaffer TH, Allen JL . Effects of inspiratory resistive loading on chest wall motion and ventilation: differences between preterm and full-term infants. Pediatr Res 1992; 32 (5): 589–594.

    Article  CAS  Google Scholar 

  24. Miller TL, Palmer C, Shaffer TH, Wolfson MR . Neonatal chest wall suspension splint: a novel and noninvasive method for support of lung volume. Pediatr Pulmonol 2005; 39 (6): 512–520.

    Article  Google Scholar 

  25. Miller TL, Cox T, Blackson T, Paul D, Weiss K, Shaffer TH . Pulmonary function assessment in an infant with Barnes syndrome: proactive evaluation for surgical intervention. Pediatrics 2006; 118 (4): e1264–e1267.

    Article  Google Scholar 

  26. Rodriguez ME, Mackenzie WG, Ditro C, Miller TL, Chidekel A, Shaffer TH . Skeletal dysplasias: evaluation with impulse oscillometry and thoracoabdominal motion analysis. Pediatr Pulmonol 2010; 45 (7): 679–686.

    Article  CAS  Google Scholar 

  27. Warren RH, Horan SM, Robertson PK . Chest wall motion in preterm infants using respiratory inductive plethysmography. Eur Respir J. 1997; 10 (10): 2295–2300.

    Article  CAS  Google Scholar 

  28. Newth CJL, Hammer J . Measurements of Thoraco-Abdominal Asynchrony and Work of Breathing in Children. Paediatric Pulmonary Function Testing: Basel, Karger; 2005. 9 p.

  29. Rusconi F, Gagliardi L, Aston H, Silverman M . Respiratory inductive plethysmography in the evaluation of lower airway obstruction during methacholine challenge in infants. Pediatr Pulmonol 1995; 20 (6): 396–402.

    Article  CAS  Google Scholar 

  30. Hellwig B, Hengstler JG, Schmidt M, Gehrmann MC, Schormann W, Rahnenfuhrer J . Comparison of scores for bimodality of gene expression distributions and genome-wide evaluation of the prognostic relevance of high-scoring genes. BMC bioinformatics. 2010; 11: 276.

  31. Technology NIoSa. Guide to the Statistical Tests. csrc.nist.gov/groups/ST/toolkit/rng/stats_tests.html2000 [updated June 19, 2012; cited 2013 January].

  32. 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.

    Article  CAS  Google Scholar 

  33. TL Miller . High flow nasal cannula therapy in neonatology. Resp Ther 8 (2): 30–35.

  34. Chang GY, Cox CA, Shaffer TH . Nasal cannula, CPAP, and high-flow nasal cannula: effect of flow on temperature, humidity, pressure, and resistance. Biomed Instr Technol 2011; 45 (1): 69–74.

    Article  Google Scholar 

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Acknowledgements

We would like to thank the parents and families in the Neonatal Intensive Care Unit. This study was supported by Nemours Biomedical Research (THS), NIH COBRE P20 GM 103464-8 (THS), Christiana Neonatal Research (RL, BDJ) and NIGMS T32-GM08562 (ER) pediatric clinical pharmacology fellow funded by NICHD.

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Authors and Affiliations

  1. Department of Neonatology, St Christopher’s Hospital for Children, Philadelphia, PA, USA

    B E de Jongh

  2. Department of Pediatrics, Drexel University College of Medicine, Philadelphia, PA, USA

    B E de Jongh

  3. Department of Neonatology, Christiana Care Health System, Newark, DE, USA

    R Locke, A Mackley, J Emberger, D Bostick & J Stefano

  4. Department of Pediatrics/Neonatology, Thomas Jefferson University, Philadelphia, PA, USA

    R Locke, J Stefano & T H Shaffer

  5. Nemours Research Lung Center, Alfred I duPont Children's Hospital, Wilmington, DE, USA

    E Rodriguez & T H Shaffer

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Correspondence to B E de Jongh.

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de Jongh, B., Locke, R., Mackley, A. et al. Work of breathing indices in infants with respiratory insufficiency receiving high-flow nasal cannula and nasal continuous positive airway pressure. J Perinatol 34, 27–32 (2014). https://doi.org/10.1038/jp.2013.120

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