High flow nasal cannula in asthmatic children with suspected COVID-19

Valéria Cabral Neves Joyce de Oliveira de Souza Adriana Koliski Bruno Silva Miranda Debora Carla Chong e Silva About the authors

Abstract

Introduction:

The use of a high-flow nasal cannula as an alternative treatment for acute respiratory failure can reduce the need for invasive mechanical ventilation and the duration of hospital stays.

Objective:

The present study aimed to describe the use of a high-flow nasal cannula in pediatric asthmatic patients with acute respiratory failure and suspected COVID-19.

Methods:

To carry out this research, data were collected from medical records, including three patients with asthma diagnoses. The variables studied were: personal data (name, age in months, sex, weight, and color), clinical data (physical examination, PRAM score, respiratory rate, heart rate, and peripheral oxygen saturation), diagnosis, history of the current disease, chest, and laboratory radiography (arterial blood gases and reverse-transcriptase polymerase chain reaction). Clinical data were compared before and after using a high-flow nasal cannula.

Results:

After the application of the therapy, a gradual improvement in heart, respiratory rate, PaO2/FiO2 ratio, and the Pediatric Respiratory Assessment Measure score was observed.

Conclusion:

The simple and quick use of a high-flow nasal cannula in pediatric patients with asthma can be safe and efficient in improving their respiratory condition and reducing the need for intubation.

Keywords:
Pediatrics; Oxygen therapy; Physiotherapy; Pediatric Intensive Care Units; Asthma

Resumo

Introdução:

A utilização da cânula nasal de alto fluxo como alternativa de tratamento para a insuficiência respiratória aguda pode diminuir a necessidade de utilização de ventilação mecânica invasiva e reduzir os dias de internamento.

Objetivo:

Descrever a utilização da cânula nasal de alto fluxo em pacientes pediátricos asmáticos com insuficiência respiratória aguda e suspeita de COVID-19.

Métodos:

Para a realização dessa pesquisa foram coletados dados de prontuários, sendo três pacientes com diagnóstico de asma incluídos. As variáveis estudadas foram: dados pessoais (nome, idade em meses, sexo, peso e cor) e clínicos (exame físico, PRAM Escore, frequência respiratória, frequência cardíaca, e saturação periférica de oxigênio), diagnóstico, história da moléstia atual, radiografia de tórax e exames laboratoriais (gasometria arterial e Reverse-Transcriptase Polymerase Chain Reaction). Foram comparados dados clínicos antes e após a utilização da cânula nasal de alto fluxo.

Resultados:

Após a aplicação da terapia foi possível observar melhora gradativa da frequência cardíaca e respiratória, relação PaO2/FiO2 e do escore Pediatric Respiratory Assessment Measure.

Conclusão:

A utilização simples e rápida da cânula nasal de alto fluxo em pacientes pediátricos com asma pode ser segura e eficiente para melhora do quadro respiratório, diminuindo a necessidade de intubação.

Palavras-chave:
Pediatria; Oxigenoterapia; Fisioterapia; Unidades de Terapia Intensiva Pediátrica; Asma

Introduction

Asthma affects all age groups, with a higher prevalence in pediatric patients. It has a high morbidity and mortality worldwide. Episodes of an exacerbation of this disease in children occur with respiratory manifestations, such as respiratory distress, dyspnea, and cough in different degrees of intensity.11 Venerabile ALG. Asma e COVID-19. Resid Pediatr. 2020; 10(2):1-9. DOI
DOI...

In children, a high-flow nasal cannula (HFNC) for the treatment of acute respiratory failure (ARF) can decrease the need for invasive mechanical ventilation. It can also reduce hospital stays.22 Tu GW, Liao YX, Li QY, Dong H, Yang LY, Zhang XY, et al. Prone positioning in high-flow nasal cannula for COVID-19 patients with severe hypoxemia: a pilot study. Ann Transl Med. 2020;8(9):598. DOI
DOI...
,33 Lyons C, Callagham M. The use of high-flow nasal oxygen in COVID-19. Anaesthesia. 2020;75(7):843-7. DOI
DOI...
The combination of heating and humidification of the inspired gas under higher flows, with control of the inspired fraction of oxygen (FiO2), increases the acceptance of the cannula in patients of all age groups.44 Yuste ME, Moreno O, Narbona S, Acosta F, Peñas L, Colmenero M, et al. Eficácia e segurança da oxigenoterapia com cânula nasal de alto fluxo na insuficiência respiratória hipercápnica moderada aguda. Rev Bras Ter Intensiva. 2019;31(2):156-63. DOI
DOI...
Its installation is simple, fast, and offers moist and heated oxygen, promoting better tolerability and comfort for children.22 Tu GW, Liao YX, Li QY, Dong H, Yang LY, Zhang XY, et al. Prone positioning in high-flow nasal cannula for COVID-19 patients with severe hypoxemia: a pilot study. Ann Transl Med. 2020;8(9):598. DOI
DOI...

3 Lyons C, Callagham M. The use of high-flow nasal oxygen in COVID-19. Anaesthesia. 2020;75(7):843-7. DOI
DOI...
-44 Yuste ME, Moreno O, Narbona S, Acosta F, Peñas L, Colmenero M, et al. Eficácia e segurança da oxigenoterapia com cânula nasal de alto fluxo na insuficiência respiratória hipercápnica moderada aguda. Rev Bras Ter Intensiva. 2019;31(2):156-63. DOI
DOI...

Due to the COVID-19 pandemic, the use of CNAF has been widely discussed. It was initially believed that its high potential for aerosolization in the hospital environment could lead to a decrease in safety for health professionals engaged in patient care. Recently, however, its use has proven to be safe. It has a low risk of aerosolization when used with the guidance of teams that care for pediatric patients.22 Tu GW, Liao YX, Li QY, Dong H, Yang LY, Zhang XY, et al. Prone positioning in high-flow nasal cannula for COVID-19 patients with severe hypoxemia: a pilot study. Ann Transl Med. 2020;8(9):598. DOI
DOI...
For the biosafety of the multiprofessional team, it is recommended that patients wear a surgical mask while using CNAF to avoid aerosol dispersion.22 Tu GW, Liao YX, Li QY, Dong H, Yang LY, Zhang XY, et al. Prone positioning in high-flow nasal cannula for COVID-19 patients with severe hypoxemia: a pilot study. Ann Transl Med. 2020;8(9):598. DOI
DOI...
,55 Gómez CC, Rodríguez OP, Torné ML, Santaolalla CE, Jiménez JFM, Fernández JG, et al. Recomendaciones de consenso respecto al soporte respiratorio no invasivo en el paciente adulto con insuficiencia respiratoria aguda secundaria a infección por SARS-CoV-2. Arch Bronconeumol. 2020;56(Suppl 2):11-18. DOI
DOI...

The present case report describes the use of CNAF in three pediatric asthmatic patients with ARF and suspected COVID-19.

Methods

Data were collected from the medical records. The three patients studied were admitted to the pediatric intensive care unit (PICU) of the Hospital de Clínicas Complex of Curitiba, PR, between July and August 2020.

The variables studied were: personal data (name, age in months, sex, weight, and color) and clinical (physical examination, PRAM score, respiratory rate, heart rate, and peripheral oxygen saturation), diagnosis, history of the current disease, chest radiography, and laboratory tests (arterial blood gas analysis and reverse-transcriptase polymerase chain reaction [PCR-RT]). The nutritional status of the patients was assessed at the time of admission using the Z-score (normal values for nutritional status between -2 and +2). In addition, ventilatory care parameters and medications used throughout the hospital stay were recorded.

The collected data were stored in an Excel Microsoft® spreadsheet for comparison and documentation of the results. The data were stored under the guardianship of the researchers for comparison at a later stage.

All patients had a confirmed asthma diagnosis and underwent a PCR-RT exam for COVID-19. A sample was collected from the nasopharynx at hospital admission and between the second and seventh day of the onset of respiratory symptoms.

Respiratory distress was assessed using the Pediatric Respiratory Assessment Measure (PRAM) score. This is a validated clinical tool that assesses the severity of respiratory effort in pediatric patients diagnosed with asthma. This score has a minimum level of 0 and a maximum level of 12 points. Scores from 1 to 3 indicate mild discomfort, 4 to 7 indicate moderate discomfort, and 8 to 12 indicate severe discomfort. A change of ≥ three points is indicative of a clinically significant change, either as an improvement or a worsening of the clinical picture. The score includes evaluation of signs of respiratory effort, air intake, and peripheral oxygen saturation (SpO2).66 Chalut DS, Ducharme FM, Davis GM. The Preschool Respiratory Assessment Measure (PRAM): a responsive index of acute asthma severity. J Pediatr. 2000;137(6):762-8. DOI
DOI...

Bronchodilator therapy prescribed by the medical team and physiotherapeutic evaluation and care were performed twice a day. The objective was to clear the upper airways. The clinical decision of the medical and physiotherapeutic team to place a HFNC was based on the physical, laboratory results, and the PaO2/FiO2 ratio of the three patients.

Results

On admission the physical examination showed all three patients were tachypneic and had moderate to severe respiratory distress and significant psychomotor agitation, irritability, and upper airway obstruction due to a large amount of secretions. All patients used a low-flow oxygen nasal catheter. However, within 24 hours after hospitalization, clinical worsening was observed.

The three patients were transferred from the emergency care unit to the PICU with ARF and suspected COVID-19. Despite the clinical symptoms of COVID-19, the patients tested negative for COVID-19 on the PCR-RT exam. Patients 1 and 2 had a positive rhinovirus result on a virology test. The general characteristics of the patients are shown in Table 1.

Table 1
Characteristics of patients

On the day of admission, two of the patients (patients 1 and 3) had a score of 8. This indicated moderate respiratory effort. One of the patients had a score of 9 which indicated severe effort. During hospitalization, with the application of HFNC, the scores of all three patients gradually decreased. This indicated an improvement in their respiratory condition. At hospital discharge, patients 1 and 2 had a score of 3, indicating mild discomfort, and patient 3 showed no signs of discomfort. This assessment was according to their Z-scores (Figure 1).

Figure 1
Evaluation by the Pediatric Respiratory Assessment Measure (PRAM SCORE) from the day of admission until D4.

On admission, the three patients presented with tachypnea when using low-flow oxygen therapy. From the time of the placement of the HFNC (D1), a decrease in respiratory rate was observed in patients 1 and 2. On the second day of hospitalization the gas flow was reduced, as an improvement in respiratory distress was observed (Figure 2).

Figure 2
Respiratory rate and gas flow.

Patients 1 and 2 had tachycardia on D0. However, all three patients showed a decrease in HR with the application of HFNC. All patients had HR values within the normal range at hospital discharge (Figure 3).

Figure 3
Heart rate of the three patients evaluated.

The supply of FiO2 was higher on D1 due to the patient’s requirements. FiO2 was gradually reduced with the improvement in hypoxemia. Patient 1 required HFNC for four days, while patients 2 and 3 used HFNC for three days. This therapy proved to be effective in improving oxygenation and the clinical conditions of all three patients (Figure 4A). The PaO2/FiO2 ratio demonstrated hypoxemia between 172 and 250 at the initiation of therapy. From D2 on, the relationship gradually improved until all three patients were discharged from the hospital (Figure 4B).

Figure 4
Fraction of inspired oxygen (A) and PaO2/FiO2 ratio (B).

The HFNC weaning was conducted using a gradual decrease in the flow of gas as the patient presented a decrease in HR, RR, and an improvement in blood oxygenation. The termination of the HFNC therapy was performed when the FiO2 was less than 40% and the flow of gas was less than 50% of the initial flow.77 Ramnarayan P, Lister P, Dominguez T, Habibi P, Edmonds N, Canter RR, et al. FIRST-line support for Assistance in Breathing in Children (FIRST-ABC): a multicentre pilot randomised controlled trial of high-flow nasal cannula therapy versus continuous positive airway pressure in paediatric critical care. Critical Care. 2018;22(1):144. DOI
DOI...

Discussion

Three patients were admitted with suspected symptoms of COVID-19 (fever, moderate respiratory effort, and hypoxemia). This was in addition to asthma exacerbation, assessed using the PRAM score. The use of HFNC in patients diagnosed with COVID-19 at the beginning of the pandemic was contraindicated. It was believed that there would be a high risk of aerosol generation during its use. Thus, this would reduce the safety of the healthcare professionals who would provide direct patient care. However, HFNC has been used to treat and improve the clinical conditions of patients with COVID-19. The risk of contamination was similar to that of other oxygen therapy devices. In addition, the use of a surgical mask under the interface can add another layer of protection for the healthcare team.88 World Health Organization. Clinical management of severe acute respiratory infection when novel coronavirus (2019-nCoV) infection is suspected: Interim Guidance, 28 January 2020. Full text link
Full text link...

The choice and administration of HFNC must be made with constant observation of the patient's vital signs and assessment of the patient’s clinical condition. Studies have recommended constant monitoring of the patient's respiratory status. If their condition worsens, tracheal intubation should be performed in a controlled environment.99 Zayed Y, Banifadel M, Barbarawi M, Kheiri B, Chahine A, Rashdan L, et al. Noninvasive oxygenation strategies in immunocompromised patients with acute hypoxemic respira-tory failure: a pairwise and network meta-analysis of randomized controlled trials. J Intensive Care Med. 2020;35(11):1216-25. DOI
DOI...

In North American studies, asthma is listed as a risk factor for severe COVID-19. In studies conducted in China among patients with the new coronavirus, asthma and respiratory allergies were not identified as risk factors for severe COVID-19.1010 Halpin DMG, Singh D, Hadfield RM. Inhaled corticosteroids and COVID-19: a systematic review and clinical perspective. Eur Respir J. 2020;55(5):2001009. DOI
DOI...
,1111 Jackson DJ, Busse WW, Bacharier LB, Kattan M, O'Connor GT, Wood RA, et al. Association of respiratory allergy, asthma, and expression of the SARS-CoV-2 receptor ACE2. J Allergy Clin Immunol. 2020;146(1):203-206. DOI
DOI...

The three patients in the present study showed RR and HR reduction during the use of HFNC. Geng et al.1212 Geng W, Batu W, You S, Tong Z, He H. High-Flow nasal cannula: a promising oxygen therapy for patients with severe bronchial asthma complicated with respiratory failure. Can Respir J. 2020;2020: 2301712. DOI
DOI...
evaluated the improvement of physiological variables (RR and HR) in patients with acute asthma using HFNC. Their research showed that during the use of this therapy, the evaluated variables gradually decreased until hospital discharge. Teng et al.1313 Teng XB, Shen Y, Han MF, Yang G, Zha L, Shi JF. The value of high-flow nasal cannula oxygen therapy in treating novel coronavirus pneumonia. Eur J Clin Invest. 2021;51(3):e13435. DOI
DOI...
compared the efficacy of HFNC with orotracheal intubation in children with COVID-19. The authors observed that the HR, RR, and PaO2/FiO2 ratio significantly improved 6, 24, and 72 h after the installation of HFNC when compared to orotracheal intubation.

In the present study, it was observed that the administration of a higher gas flow and FiO2 during acute hypoxemic respiratory failure can lead to SpO2, RR, and HR improvement. These findings are similar to those found by Pilar et al.1414 Pilar J, Alapont VMI, Lopez-Fernandez YM, Lopez-Macias O, Garcia-Urabayen D, Amores-Hernandez I. High-flow nasal cannula therapy versus non-invasive ventilation in children with severe acute asthma exacerbation: an observational cohort study. Med Intensiva. 2017;41(7):418-24. DOI
DOI...

The role of physiotherapy in these patients was not only in the management of ventilatory assistance, but also in the maintenance of airway permeability. In patients with acute hypoxemic respiratory failure, the presence of respiratory secretions may limit the application of certain techniques, such as noninvasive ventilation.1515 Wood KE, Flaten AL, Backes WJ. Inspissated secretions: a life-threatening complication of prolonged noninvasive ventilation. Respir Care. 2000;45(5):491-3. PubMed
PubMed...
The use of HFNC ensures greater comfort for these patients. In addition, this allows not only the ability to expel secretions without the need for interruption of the application, but also to assist in the excretion of secretions due to its humidification and heating system.44 Yuste ME, Moreno O, Narbona S, Acosta F, Peñas L, Colmenero M, et al. Eficácia e segurança da oxigenoterapia com cânula nasal de alto fluxo na insuficiência respiratória hipercápnica moderada aguda. Rev Bras Ter Intensiva. 2019;31(2):156-63. DOI
DOI...
,1616 Franklin D, Babl FE, Schlapbach LJ, Oakley E, Craig S, Neutze J, et al. A randomized trial of high-flow oxygen therapy in infants with bronchiolitis. N Engl J Med. 2018;378(12):1121-31. DOI
DOI...
Despite HFNC benefits, it must be administered carefully to avoid injury due to the excessive and prolonged use of oxygen therapy. In this study the use of HFNC resulted in a positive effect on the patients’ treatment. Consequently, there was an improvement in the respiratory condition of the three pediatric patients.1616 Franklin D, Babl FE, Schlapbach LJ, Oakley E, Craig S, Neutze J, et al. A randomized trial of high-flow oxygen therapy in infants with bronchiolitis. N Engl J Med. 2018;378(12):1121-31. DOI
DOI...

Conclusion

This study showed the safe use of HFNC in patients with acute hypoxemic respiratory failure with a potential risk for intubation. Considering the literature, this study contributes to the rationale for physical therapy treatment in pediatric patients. It also provided benefits to the studied patients. To contribute to these results, it is suggested that further studies be conducted with a larger number of participants and additional methodologies.

References

  • 1
    Venerabile ALG. Asma e COVID-19. Resid Pediatr. 2020; 10(2):1-9. DOI
    » DOI
  • 2
    Tu GW, Liao YX, Li QY, Dong H, Yang LY, Zhang XY, et al. Prone positioning in high-flow nasal cannula for COVID-19 patients with severe hypoxemia: a pilot study. Ann Transl Med. 2020;8(9):598. DOI
    » DOI
  • 3
    Lyons C, Callagham M. The use of high-flow nasal oxygen in COVID-19. Anaesthesia. 2020;75(7):843-7. DOI
    » DOI
  • 4
    Yuste ME, Moreno O, Narbona S, Acosta F, Peñas L, Colmenero M, et al. Eficácia e segurança da oxigenoterapia com cânula nasal de alto fluxo na insuficiência respiratória hipercápnica moderada aguda. Rev Bras Ter Intensiva. 2019;31(2):156-63. DOI
    » DOI
  • 5
    Gómez CC, Rodríguez OP, Torné ML, Santaolalla CE, Jiménez JFM, Fernández JG, et al. Recomendaciones de consenso respecto al soporte respiratorio no invasivo en el paciente adulto con insuficiencia respiratoria aguda secundaria a infección por SARS-CoV-2. Arch Bronconeumol. 2020;56(Suppl 2):11-18. DOI
    » DOI
  • 6
    Chalut DS, Ducharme FM, Davis GM. The Preschool Respiratory Assessment Measure (PRAM): a responsive index of acute asthma severity. J Pediatr. 2000;137(6):762-8. DOI
    » DOI
  • 7
    Ramnarayan P, Lister P, Dominguez T, Habibi P, Edmonds N, Canter RR, et al. FIRST-line support for Assistance in Breathing in Children (FIRST-ABC): a multicentre pilot randomised controlled trial of high-flow nasal cannula therapy versus continuous positive airway pressure in paediatric critical care. Critical Care. 2018;22(1):144. DOI
    » DOI
  • 8
    World Health Organization. Clinical management of severe acute respiratory infection when novel coronavirus (2019-nCoV) infection is suspected: Interim Guidance, 28 January 2020. Full text link
    » Full text link
  • 9
    Zayed Y, Banifadel M, Barbarawi M, Kheiri B, Chahine A, Rashdan L, et al. Noninvasive oxygenation strategies in immunocompromised patients with acute hypoxemic respira-tory failure: a pairwise and network meta-analysis of randomized controlled trials. J Intensive Care Med. 2020;35(11):1216-25. DOI
    » DOI
  • 10
    Halpin DMG, Singh D, Hadfield RM. Inhaled corticosteroids and COVID-19: a systematic review and clinical perspective. Eur Respir J. 2020;55(5):2001009. DOI
    » DOI
  • 11
    Jackson DJ, Busse WW, Bacharier LB, Kattan M, O'Connor GT, Wood RA, et al. Association of respiratory allergy, asthma, and expression of the SARS-CoV-2 receptor ACE2. J Allergy Clin Immunol. 2020;146(1):203-206. DOI
    » DOI
  • 12
    Geng W, Batu W, You S, Tong Z, He H. High-Flow nasal cannula: a promising oxygen therapy for patients with severe bronchial asthma complicated with respiratory failure. Can Respir J. 2020;2020: 2301712. DOI
    » DOI
  • 13
    Teng XB, Shen Y, Han MF, Yang G, Zha L, Shi JF. The value of high-flow nasal cannula oxygen therapy in treating novel coronavirus pneumonia. Eur J Clin Invest. 2021;51(3):e13435. DOI
    » DOI
  • 14
    Pilar J, Alapont VMI, Lopez-Fernandez YM, Lopez-Macias O, Garcia-Urabayen D, Amores-Hernandez I. High-flow nasal cannula therapy versus non-invasive ventilation in children with severe acute asthma exacerbation: an observational cohort study. Med Intensiva. 2017;41(7):418-24. DOI
    » DOI
  • 15
    Wood KE, Flaten AL, Backes WJ. Inspissated secretions: a life-threatening complication of prolonged noninvasive ventilation. Respir Care. 2000;45(5):491-3. PubMed
    » PubMed
  • 16
    Franklin D, Babl FE, Schlapbach LJ, Oakley E, Craig S, Neutze J, et al. A randomized trial of high-flow oxygen therapy in infants with bronchiolitis. N Engl J Med. 2018;378(12):1121-31. DOI
    » DOI

Publication Dates

  • Publication in this collection
    28 June 2021
  • Date of issue
    2021

History

  • Received
    24 Nov 2020
  • Reviewed
    03 May 2021
  • Accepted
    11 May 2021
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