High-flow nasal cannula failure: can clinical outcomes determine early interruption?

OBJECTIVE: To evaluate the evolution of clinical outcomes in children with bronchiolitis who used a high-flow nasal cannula, and to determine after long of non-clinical improvement the therapy should be discontinued, and treatment should be escalated to other forms of ventilatory support. METHODS: An observational retrospective study of infants with bronchiolitis who used a high-flow nasal cannula. Patients were divided into two study groups according to success or failure of high-flow nasal cannula therapy, namely the Success Group and the Failure Group. The main demographics and clinical variables were assessed 30 minutes and 6 hours after initiating therapy until removal of the high-flow nasal cannula. RESULTS: A total of 83 children were studied and 18 children (21.7%) failed therapy. Among subjects with successful therapy, a significant decrease in respiratory rate (p<0.001), and a significant increase in peripheral oxygen saturation (p<0.001) were observed within 30 minutes. The Success Group was significantly different from the Failure Group after 6 hours, for both respiratory rate (p<0.01) and peripheral oxygen saturation (p<0.01). CONCLUSION: The absence of clinical sign improvement within 30 minutes and for up to a maximum of 6 hours can be considered as failure of the high-flow nasal cannula therapy. If this time elapses with no improvements, escalating to another type of ventilatory support should be considered.

High-flow nasal cannula failure: can clinical outcomes determine early interruption? / Falha da cânula nasal de alto fluxo: os desfechos clínicos podem determinar a interrupção precoce?

ABSTRACT Objective: To evaluate the evolution of clinical outcomes in children with bronchiolitis who used a high-flow nasal cannula, and to determine after long of non-clinical improvement the therapy should be discontinued, and treatment should be escalated to other forms of ventilatory support. Methods: An observational retrospective study of infants with bronchiolitis who used a high-flow nasal cannula. Patients were divided into two study groups according to success or failure of high-flow nasal cannula therapy, namely the Success Group and the Failure Group. The main demographics and clinical variables were assessed 30 minutes and 6 hours after initiating therapy until removal of the high-flow nasal cannula. Results: A total of 83 children were studied and 18 children (21.7%) failed therapy. Among subjects with successful therapy, a significant decrease in respiratory rate (p<0.001), and a significant increase in peripheral oxygen saturation (p<0.001) were observed within 30 minutes. The Success Group was significantly different from the Failure Group after 6 hours, for both respiratory rate (p<0.01) and peripheral oxygen saturation (p<0.01). Conclusion: The absence of clinical sign improvement within 30 minutes and for up to a maximum of 6 hours can be considered as failure of the high-flow nasal cannula therapy. If this time elapses with no improvements, escalating to another type of ventilatory support should be considered.

RESUMO Objetivo: Avaliar a evolução de desfechos clínicos em crianças com bronquiolite que utilizaram cânula nasal de alto fluxo, e determinar com quanto tempo de não melhora clínica a terapia deve ser interrompida para escalonamento do tratamento para outras formas de suporte ventilatório. Métodos: Estudo observacional retrospectivo, de lactentes com bronquiolite que utilizaram cânula nasal de alto fluxo. Os pacientes foram divididos em dois grupos de estudo, de acordo com o sucesso ou não da terapêutica com cânula nasal de alto fluxo, nomeados Grupo Sucesso e Grupo Falha. Foram analisadas as principais características demográficas e variáveis clínicas, tendo sido avaliadas 30 minutos e 6 horas após o início do tratamento até a retirada da cânula nasal de alto fluxo. Resultados: Foram estudados 83 crianças; destas, 18 crianças (21,7%) falharam. Entre os pacientes que tiveram sucesso na terapia, observou-se diminuição significativa da frequência respiratória (p<0,001), e também aumento significativo da saturação de oxigênio (p<0,001) já nos primeiros 30 minutos. O Grupo Sucesso foi significativamente diferente do Grupo Falha a partir de 6 horas, tanto para frequência respiratória (p<0,01), quanto para saturação de oxigênio (p<0,01). Conclusão: Na ausência de melhora dos sinais clínicos, a falha da terapia com cânula nasal de alto fluxo já pode ser considerada a partir de 30 minutos e, no máximo, em até 6 horas após o início da terapia. Após esse período sem melhora, o escalonamento para outro tipo de suporte ventilatório deve ser avaliado.

Comparative analysis of the effects of two chest physical therapy interventions in patients with bronchiolitis during hospitalization period / Análise comparativa dos efeitos de duas intervenções de fisioterapia respiratória em pacientes com bronquiolite durante o período de internação hospitalar

Objective To evaluate and compare the effects of two chest physiotherapy interventions in patients hospitalized due to acute bronchiolitis. Methods Prospective randomized study with a sample of 83 calls for 29 patients aged between 3 months and 1 year hospitalized for acute bronchiolitis. Patients were distributed randomly into two groups: Group 1, submitted to postural drainage, tapping and tracheal aspiration; and Group 2, submitted to postural drainage, expiratory acceleration flow and tracheal aspiration. Assessments were made before and 10 and 60 minutes after the end of therapy. Patients also underwent drug treatment. The endpoint was to compare two physical therapy interventions as to clinical improvement in infants with acute bronchiolitis by means of oxygen saturation and the Respiratory Distress Assessment Instrument score. The parents/guardians was requested to answer a questionnaire about the treatment applied before the last evaluation in order to measure their satisfaction related to the interventions made. Results The groups were similar regarding the use of antibiotics and bronchodilators. A greater number of patients used corticosteroids in Group 2. A relevant improvement was observed on Respiratory Distress Assessment Instrument score with physical therapy, with reduction of the score 10 minutes after interventions, and the same score 60 minutes later, with no differences between techniques applied. There was no significant variation of pulse oximetry after chest physiotherapy. Most items assessed by the questionnaire had satisfactory answers. Conclusion No differences were observed between groups regarding the items assessed (time required to discharge from study, pulse oximetry in room air and disease severity according ...

Objetivo Avaliar e comparar os efeitos de duas intervenções fisioterapêuticas em pacientes com bronquiolite aguda durante internação hospitalar. Métodos Estudo prospectivo e randomizado, com amostra de 83 atendimentos de 29 pacientes com idade entre 3 meses e 1 ano internados por bronquiolite aguda. Os pacientes foram randomizados em dois grupos: Grupo 1, submetido à drenagem postural, tapotagem e aspiração nasotraqueal; e Grupo 2, submetido à drenagem postural, aceleração do fluxo expiratório e aspiração nasotraqueal. Foram realizadas avaliações antes e 10 e 60 minutos após o término da fisioterapia. Os pacientes também foram submetidos a tratamento medicamentoso. O objetivo foi comparar duas intervenções fisioterapêuticas quanto à melhora clínica de lactentes com bronquiolite aguda por meio da saturação periférica de oxigênio e do escore Respiratory Distress Assessment Instrument. Um questionário sobre o tratamento ministrado foi aplicado ao responsável, antes da última avaliação, para mensurar a satisfação dos mesmos em relação às intervenções. Resultados Os grupos foram similares em relação ao uso de antibiótico e broncodilatador. Observamos um número maior de pacientes que utilizaram corticoide no Grupo 2. Observou-se melhora significante no escore Respiratory Distress Assessment Instrument com o tratamento fisioterapêutico, com redução do mesmo, 10 minutos após as intervenções e manutenção dos valores 60 minutos após, sem diferenças entre as técnicas empregadas. Não houve var...

Comparative analysis of the effects of two chest physical therapy interventions in patients with bronchiolitis during hospitalization period.

OBJECTIVE: To evaluate and compare the effects of two chest physiotherapy interventions in patients hospitalized due to acute bronchiolitis. METHODS: Prospective randomized study with a sample of 83 calls for 29 patients aged between 3 months and 1 year hospitalized for acute bronchiolitis. Patients were distributed randomly into two groups: Group 1, submitted to postural drainage, tapping and tracheal aspiration; and Group 2, submitted to postural drainage, expiratory acceleration flow and tracheal aspiration. Assessments were made before and 10 and 60 minutes after the end of therapy. Patients also underwent drug treatment. The endpoint was to compare two physical therapy interventions as to clinical improvement in infants with acute bronchiolitis by means of oxygen saturation and the Respiratory Distress Assessment Instrument score. The parents/guardians was requested to answer a questionnaire about the treatment applied before the last evaluation in order to measure their satisfaction related to the interventions made. RESULTS: The groups were similar regarding the use of antibiotics and bronchodilators. A greater number of patients used corticosteroids in Group 2. A relevant improvement was observed on Respiratory Distress Assessment Instrument score with physical therapy, with reduction of the score 10 minutes after interventions, and the same score 60 minutes later, with no differences between techniques applied. There was no significant variation of pulse oximetry after chest physiotherapy. Most items assessed by the questionnaire had satisfactory answers. CONCLUSION: No differences were observed between groups regarding the items assessed (time required to discharge from study, pulse oximetry in room air and disease severity according to the Respiratory Distress Assessment Instrument score). Parents answered positively about the effects of therapy in the majority of items in the questionnaire, both for the expiratory acceleration flow technique and for tapping.

Análise dos sintomas, sinais clínicos e suporte de oxigênio em pacientes com bronquiolite antes e após fisioterapia respiratória durante a internação hospitalar / Analysis of symptoms, clinical signs and oxygen support in patients with bronchiolitis before and after chest physiotherapy during hospitalization

OBJETIVO:Avaliar os efeitos da fisioterapia em pacientes pediátricos, internados com bronquiolite. MÉTODOS:O estudo incluiu 29 pacientes menores de um ano, com diagnóstico médico de bronquiolite aguda, sem cardiopatia congênita não corrigida, neuropatia, doença pulmonar de base ou que necessitassem de suporte ventilatório, no período de março a julho de 2009. Foi avaliada, por meio de questionário, a opinião dos pais ou responsáveis acerca das condições clínicas do paciente antes e após a primeira sessão de fisioterapia. Foram realizadas manobras de desobstrução brônquica, como drenagem postural, tapotagem, vibração, aceleração de fluxo expiratório e aspiração nasotraqueal. A avaliação foi realizada diariamente por meio de exame físico antes do atendimento fisioterapêutico e 15 a 45 minutos após, seguindo uma ficha específica. Os desfechos analisados foram: modificações do suporte de oxigênio, sinais clínicos (ausculta pulmonar, presença de tiragens, oxigenação e classificação da gravidade pelo escore de Downes) e sintomas (inapetência, hipoatividade, dificuldade para dormir, obstrução nasal e tosse constante). RESULTADOS:Dos 29 pacientes avaliados, houve melhora significativa nos seguintes sinais e sintomas: ausculta pulmonar com ruídos adventícios (p<0,001), estertores subcrepitantes (p=0,017) e sibilos (p=0,010), tiragens de modo geral (p<0,001), tiragem intercostal (p<0,001) e classificação da gravidade pelo escore de Downes (p<0,001). Também foi observada melhora significativa em todos os aspectos avaliados no questionário (p<0,001). CONCLUSÕES: A fisioterapia respiratória promoveu uma melhora significante em curto prazo das condições clínicas dos pacientes com bronquiolite aguda.

OBJECTIVE:To evaluate the effects of chest physiotherapy in hospitalized patients with bronchiolitis. METHODS: The study included 29 patients younger than one year, diagnosed with acute bronchiolitis, without uncorrected congenital heart disease, neuropathy, lung pathology or need of mechanical ventilation, from March to July 2009. The opinion of the parents or guardians was evaluated using a questionnaire about the clinical condition of the patient before and after the first session of chest physiotherapy. Airway clearance techniques, such as postural drainage, manual percussion, vibration, acceleration of expiratory flow and tracheal suction were applied. The evaluation was performed daily by physical examination prior to physiotherapy and 15 to 45 minutes later, following a specific form. The outcomes observed were: changes of oxygen support, clinical signs (pulmonary auscultation, presence of retractions, oxygenation and severity classification by Downes score) and symptoms (difficulty in sleeping and in feeding, decreased activities, nasal obstruction and constant cough). RESULTS: Among the 29 patients evaluated, a significant improvement was noticed in the following signs and symptoms: pulmonary auscultation with adventitious sounds - general (p<0.001), rales (p=0.017) and wheezes (p=0.010); retractions - general (p<0.001) and intercostal retraction (p<0.001); severity of Downes Score (p<0.001). A significant improvement was also noted in all aspects evaluated in the questionnaire (p<0.001). CONCLUSIONS: Chest physiotherapy lead to a significant short term improvement in infants with bronchiolitis.