OPENPediatrics

High-Flow Nasal Cannula vs CPAP in Acutely Ill Children by P. Ramnarayan | OPENPediatrics

Aug 26, 2025
Guest
Padmanabhan "Ram" Ramnarayan
Dr. Padmanabhan "Ram" Ramnarayan, a leader in pediatric critical care from Imperial College London, shares insights from his groundbreaking clinical trial on high-flow nasal cannula (HFNC) versus CPAP for acutely ill children. He discusses the design and methodology of the study, emphasizing HFNC's non-inferiority and potential benefits. The conversation explores the implications of these findings for clinical practice, the importance of patient assessment, and future research directions in pediatric respiratory care.
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INSIGHT

HFNC Tested As A Pragmatic Noninferior Alternative

  • The trial tested whether HFNC is not unacceptably worse than CPAP for time to liberation from respiratory support.
  • The population was pragmatic and broad, including respiratory, cardiac, and other diagnoses.
ADVICE

Use Non-Inferiority When Practical Gains Matter

  • Choose non-inferiority when a new therapy offers practical benefits and you only need to rule out clinically important harm.
  • Predefine a non-inferiority margin with clinicians and patient representatives (they used HR 0.75 ≈ 16 hours).
ADVICE

Practical Starting And Failure Criteria

  • Start HFNC at weight-banded flows approximating 2 L/kg for <10 kg and scale toward ~1 L/kg at higher weights.
  • Start CPAP at 7–8 cmH2O and use clear failure criteria: oxygenation, respiratory distress, or intolerance.
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