Abstract
Objective:
Nasal high-flow therapy (nHFT) is commonly used for noninvasive respiratory support in the neonatal intensive care unit. Our objective was to determine which aspects of neonatal nHFT have achieved adequate evidence base to support consensus among experienced clinical investigators, and to document areas lacking consensus to promote future investigations.
Study Design:
Prospective, modified Delphi collation of tabular queries related to specific aspects of neonatal nHFT. Seven international nHFT clinical researchers were queried regarding approaches to initiation, escalation, weaning and discontinuing nHFT. Completed tables were reviewed independently by each investigator, results clarified and discussed and areas of consensus determined.
Results:
Consensus agreement was reached for many aspects of nHFT including: need for adequate heating and humidification, need to prevent nares occlusion, maximum flow rate of 8 l min−1, assessment of fraction of inspired oxygen (FiO2) and work of breathing for either flow escalation or weaning, equivalence of nHFT to nasal continuous positive airway pressure (nCPAP) for noninvasive support of infants of ⩾28 weeks with resolving respiratory distress and use of nHFT for noninvasive support of stable infants on nCPAP. There was general agreement for initial gas flow rates in the range of 4 to 6 l min−1 and for nHFT as primary therapy for mild respiratory distress. There was no consensus on the approach to discontinuing nHFT.
Conclusions:
Among an experienced group of nHFT clinical researchers, there was general consensus in the approach to neonatal nHFT. Additional randomized studies are indicated to provide better evidence related to several aspects of nHFT, as well as to identify other clinical conditions where nHFT may provide safe, effective noninvasive support.
This is a preview of subscription content, access via your institution
Access options
Subscribe to this journal
Receive 12 print issues and online access
$259.00 per year
only $21.58 per issue
Rent or buy this article
Prices vary by article type
from$1.95
to$39.95
Prices may be subject to local taxes which are calculated during checkout
Similar content being viewed by others
References
Hough JL, Shearman AD, Jardine LA, Davies MW . Humidified high flow nasal cannulae: current practice in Australasian nurseries, a survey. J Paediatr Child Health 2012; 48: 106–113.
Ojha S, Gridley E, Dorling J . Use of heated humidified high-flow nasal cannula oxygen in neonates: a UK wide survey. Acta Paediatr 2013; 102: 249–253.
Roberts CT, Owen LS, Manley BJ, Davis PG for the Australian & New Zealand Neonatal Network. High-flow support in very preterm infants in Australia and New Zealand. Arch Dis Child Fetal Neonatal Ed 2016; 101: F1–F3.
Motojima Y, Ito M, Oka S, Uchiyama A, Tamura M, Namba F . Use of high-flow nasal cannula in neonates: nationwide survey in Japan. Pediatr Int 2016; 58: 308–310.
Shetty S, Sundaresan A, Hunt K, Desai P, Greenough A . Changes in the use of humidified high flow nasal cannula oxygen. Arch Dis Child Fetal Neonatal Ed 2016; 101: F371–F372.
Woodhead DD, Lambert DK, Clark JM, Christensen RK . Comparing two methods of delivering high-flow gas therapy by nasal cannula following endotracheal extubation: a prospective, randomized, masked, crossover trial. J Perinatol 2006; 26: 481–485.
Holleman-Duray D, Kaupie D, Weiss MG . Heated humidified high-flow nasal cannula: use and a neonatal early extubation protocol. J Perinatol 2007; 27: 776–781.
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: 85–91.
McQueen M, Rojas J, Sun SC, Tero R, Ives K, Bednarek F et al. Safety and long term outcomes with high flow nasal cannula therapy in neonatology: a large retrospective cohort study. J Pulm Respir Med 2014; 4: 216.
Collins CL, Holberton JR, Barfield C, Davis PG . A randomized controlled trial to compare heated humidified high-flow nasal cannulae with nasal continuous positive airway pressure postextubation in premature infants. J Pediatr 2013; 162: 949–954.
Yoder BA, Stoddard RA, Li M, King J, Dirnberger DR, Abbasi S . Heated, humidified high-flow nasal cannula versus nasal CPAP for respiratory support in neonates. Pediatrics 2013; 131: e1482–e1490.
Manley BJ, Owen LS, Doyle LW, Andersen CC, Cartwright DW, Pritchard MA et al. High-flow nasal cannulae in very preterm infants after extubation. N Engl J Med 2013; 369: 1425–1433.
Kugelman A, Riskin A, Said W, Shoris I, Mora F, Bader D . A randomized pilot study comparing heated humidified high-flow nasal cannulae with NIPPV for RDS. Pediatr Pulmonol 2015; 50: 576–583.
Lavizzari A, Colnaghi M, Ciuffini F, Veneroni C, Musumeci S, Mosca F . Heated, humidified high flow nasal cannula versus nasal CPAP for respiratory distress syndrome in preterm infants: a randomized clinical trial. JAMA Pediatr 2016; 131: e1482–e1490.
Roberts CT, Owen LS, Manley BJ, Frøisland DH, Donath SM, Dalziel KM et al. Nasal high-flow therapy for primary respiratory support in preterm infants. N Eng J Med 2016; 375: 1142–1151.
Kotecha SJ, Adappa R, Gupta N, Watkins WJ, Kotecha S, Chakraborty M . Safety and efficacy of high-flow nasal cannula therapy in preterm infants: a meta-analysis. Pediatrics 2015; 136: 542–553.
Wilkinson D, Andersen C, O’Donnell CPF, De Paoli AG, Manley BJ . High flow nasal cannula for respiratory support in preterm infants. Cochrane Database Syst Rev 2016; 2: CD006405.
Lee JH, Rehder KJ, Williford L, Cheifetz IM, Turner DA . Use of high flow nasal cannula in critically ill infants, children, and adults: a critical review of the literature. Intensive Care Med 2013; 39: 247–257.
Isayama T, Chai-Adisaksopha C, McDonald SD . Noninvasive ventilation with vs without early surfactant to prevent chronic lung disease in preterm infants: a systematic review and meta-analysis. JAMA Pediatr 2015; 169: 731–739.
Akins RB, Homer Tolson H, Cole BR . Stability of response characteristics of a Delphi panel: application of bootstrap data expansion. BMC Med Res Methodol 2005; 5: 37.
Stevens TP, Blennow M, Soll RF . Early surfactant administration with brief ventilation vs selective surfactant and continued mechanical ventilation for preterm infants with or at risk for respiratory distress syndrome. Cochrane Database Syst Rev 2004; 3: CD003063.
Manley BJ, Owen LS . High-flow nasal cannula: mechanisms, evidence and recommendations. Semin Fetal Neonatal Med 2016; 21: 146–153.
Collins CL, Barfield C, Horne RS, Davis PG . A comparison of nasal trauma in preterm infants extubated to either heated humidified high-flow nasal cannulae or nasal continuous positive airway pressure. Eur J Pediatr 2014; 173: 181–186.
Klingenberg C, Pettersen M, Hansen EA, Gustavson LJ, Dahl IA, Leknessund A et al. 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 2014; 99: F134–F137.
Osman M, Elsharkawy A, Abdel-Hady H . Assessment of pain during application of nasal-continuous positive airway pressure and heated, humidified high-flow nasal cannulae in preterm infants. J Perinatol 2015; 35: 263–267.
Collins CL, Holberton JR, König K . Comparison of the pharyngeal pressure provided by two heated, humidified high-flow nasal cannulae devices in premature infants. J Paediatr Child Health 2013; 49: 554–556.
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: 67–74.
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 2013; 48: 506–514.
Hough JL, Pham TM, Schibler A . Physiologic effect of high-flow nasal cannula in infants with bronchiolitis. Pediatr Crit Care Med 2014; 15: e214–e219.
Lavizzari A, Veneroni C, Colnaghi M, Ciuffini F, Zannin E, Fumagalli M et al. Respiratory mechanics during NCPAP and HHHFNC at equal distending pressures. Arch Dis Child Fetal Neonatal Ed 2014; 99: F315–F320.
Möller W, Celik G, Feng S, Bartenstein P, Meyer G, Eickelberg O et al. Nasal high flow clears anatomical dead space in upper airway models. J Appl Physiol 2015; 118: 1525–1532.
Boyle M, Chaudhary R, Kent S, O’Hare S, Broster S, Dassios T . High-flow nasal cannula on transport: moving with the times. Acta Paediatr 2014; 103: e181.
Schlapbach LJ, Schaefer J, Brady A, Mayfield S, Schibler A . High-flow nasal cannula (HFNC) support in interhospital transport of critically ill children. Intensive Care Med 2014; 40: 592–599.
Reynolds P, Leontiadi S, Lawson T, Otunla T, Ejiwumi O, Holland N . Stabilisation of premature infants in the delivery room with nasal high flow. Arch Dis Child Fetal Neonatal Ed 2016; 101: 284–287.
Acknowledgements
Author contributions
BA Yoder initiated the study design and implementation, participated in data collection and analysis and wrote the initial manuscript; B Manley contributed to study design, data collection, initial manuscript writing and revisions; C Collins, K Ives, A Kugelman, A Lavizarri and M McQueen contributed to study design, data collection and manuscript revisions; all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Competing interests
The authors declare no conflict of interest.
Rights and permissions
About this article
Cite this article
Yoder, B., Manley, B., Collins, C. et al. Consensus approach to nasal high-flow therapy in neonates. J Perinatol 37, 809–813 (2017). https://doi.org/10.1038/jp.2017.24
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1038/jp.2017.24