High flow oxygen therapy

• Published in: Archives of disease in childhood Vol. 108; no. 3; p. 177
• Format: Journal Article
• Language: English
• Published: England BMJ Publishing Group Ltd and Royal College of Paediatrics and Child Health 01.03.2023; BMJ Publishing Group LTD
• Subjects: Hospitals; Humans; Intensive care; Intensive care units; Length of stay; Miscellanea; Oxygen; Oxygen - therapeutic use; Oxygen Inhalation Therapy; Oxygen therapy; Pediatrics; Respiratory Insufficiency - therapy; Singing
• ISSN: 0003-9888; 1468-2044; 1468-2044
• DOI: 10.1136/archdischild-2023-325437

High flow oxygen therapy (HFOT) appears to associated with a significantly longer length-of-stay and an increased admission rate to intensive care units compared with standard oxygen therapy in children (aged 1 year to 4 years) requiring oxygen therapy support for their respiratory failure. Maria de Benedictus F warned us of the most important learning from the Odyssey; that is returning safely to Ithaca by resisting the sweet song of the Sirens (JAMA Pediatr 2019;173:125–126. doi:10.1001/jamapediatrics.2018.3831) after publication of the PARIS one study examining the role of HFOT in bronchiolitis (Franklin D et al. N Engl J Med 2018;378:1121–1131. doi:10.1056/NEJMoa1714855). The PARIS two study has now been published and will probably be one of the most important papers of 2023 and resisting the sweet song of Sirens may also be the message. Franklin D et al (JAMA. 2023;329:224–234. doi:10.1001/jama.2022.21805) have shown, in a randomised controlled study, that the early use of nasal high-flow oxygen therapy in children aged 1 to 4 years with acute hypoxemic respiratory failure, increases the length of hospital stay compared with standard oxygen therapy. This magnificent multicentere clinical trial was conducted by the PREDICT network from Australia and New Zealand. There were 1567 children aged 1 to 4 years with acute hypoxemic respiratory failure caused by asthma, pneumonia older children with bronchiolitis and lower respiratory tract infections. This was an open study where high-flow oxygen therapy (n = 753) or standard oxygen therapy (n = 764) was compared. The length of hospital stay was significantly longer in the high-flow oxygen group with a median of 1.77 days (IQR, 1.03–2.80 days) vs 1.50 days (IQR, 0.85–2.44 days) in the standard oxygen group (adjusted HR, 0.83 [95% CI, 0.75 to 0.92]; p < 0.001). The median length of oxygen therapy was higher for the high flow group compared with the standard oxygen therapy group (adjusted HR, 0.78 [95% CI, 0.70 to 0.86]) and those in the high flow group were nearly two times more likely to be admitted to an intensive care unit (adjusted OR, 1.93 [95% CI, 1.35 to 2.75]). This significant difference was consistent for children presenting with wheezing and those who were not wheezing. This is an unblinded open study, so the primary outcome should be as robust as possible. Length of stay can be subject to many influences (rather than ‘clinically ready for discharge’ which is a little more robust.) so there is a potential bias influencing clinical decision making. There were 323 children (42.9%) in the high-flow oxygen group who crossed over and received standard oxygen therapy compared with 141 children (18.5%) in the standard oxygen group who crossed over and received high-flow oxygen therapy (adjusted OR, 3.42 [95% CI, 2.70 to 4.34] so this change to a second form of oxygen therapy may have prolonged time receiving oxygen therapy and thus a longer stay in the hospital. HFOT has taken over oxygen supplementation throughout the world. We just need to be aware that the risks may, out-weigh the potential benefits. Beware the sweet song of Sirens.