SGEM #401: Hey Ho! High Flow vs Standard Oxygen Therapy for Hospitalized Children with Respiratory Failure

Date: April 20, 2023 Reference:  Franklin D, et al. Effect of early high-flow nasal oxygen vs standard oxygen therapy on length of hospital stay in hospitalized children with acute hypoxemic respiratory failure: the PARIS-2 randomized clinical trial. JAMA 2023 Guest Skeptic: Dr. Michael Falk is a Pediatric Emergency Medicine attending at Mount Sinai Medical Center and Associate Professor of Emergency Medicine at the Icahn School of Medicine in New York. He is interested in simulation and medical education. Dr. Michael Falk Case: A 14-month-old boy presents to the emergency department (ED) with two days of upper respiratory symptoms and respiratory distress.  He has a cough, fever of 38.5°C, runny nose and increased work of breathing that started today.  He is breathing at rate of 48 breaths per minutes with intercostal retractions and oxygen saturation of 88%.  His lung exam reveals bilateral wheezing, rhonchi but no focal findings. He is drinking well, and parents report normal urine output.  He is suctioned and given trial of Beta agonist because has a history of eczema and a sibling with asthma with no change.  Despite your interventions, he continues to breathe rapidly with an oxygen saturation of 89% on room air.   You are working with an eager medical student, and she asks, “Should we start high flow nasal cannula (HFNC) at 2L/kg/min and admit the patient?” Background: Respiratory illnesses remain one of the most frequent causes of admission for children less than 5 years.  Some of these illnesses result in acute hypoxemic respiratory failure. Historically, there were not many treatments for these children, and they were admitted for observation or intubated and started on mechanical ventilation. High flow nasal cannula (HFNC) started gaining popularity in the early 2000s as an option of noninvasive ventilation.   We have covered the use of HFNC in pediatrics a few times on the SGEM including SGEM #228 and SGEM #379. Previous research has shown that HFNC can lower the rate of escalation of care but showed no impact on admission to the intensive care unit (ICU) or length of stay [1].  Clinical Question:  Does the early use of HFNC reduce the length of hospital stay in pediatric patients with acute hypoxemic respiratory failure compared with standard oxygen therapy? Reference:  Franklin D, et al. Effect of early high-flow nasal oxygen vs standard oxygen therapy on length of hospital stay in hospitalized children with acute hypoxemic respiratory failure: the PARIS-2 randomized clinical trial. JAMA 2023 Population: Children aged 1 to 4 years of age who presented across 14 emergency departments in Australia and New Zealand requiring hospital admission for acute hypoxemic respiratory failure Exclusion: There was a long list of exclusion criteria that you can find in the supplemental material, but these included craniofacial abnormalities, upper airway obstruction, cyanotic heart disease, tracheostomies, apneas, immediate high-level care in the ICU or required noninvasive or invasive mechanical ventilation. Intervention: HFNC at differing rates depending on weight Comparison: Oxygen via nasal cannula at 2L/min or by face mask up to 8L/min  Outcome:  Primary Outcome: Length of hospital stay defined as time from randomization to time of hospital discharge/death. Secondary Outcomes: Length of oxygen therapy from the time of randomization Length of hospital stay starting from arrival in the ED Proportion of children requiring a change in therapy on the general ward Proportion of children that required ICU admission or transfer to hospital with a pediatric ICU Proportion of children that required escalation of care to noninvasive or invasive ventilation Adverse events Tolerance of intervention Clinical triggers that warranted a change in that child’s care Type of Study: Multicenter, randomized clinical trial