Asthma is one of the most pervasive chronic pediatric diseases, accounting for about 1.6 million emergency department (ED) visits annually and showing an upward trend.[1,2]
Emergency clinicians have been suspecting that High Flow Nasal Cannula (HFNC) could be a safe and effective tool in the treatment of children with asthma, but research on the subject has been sparse. The findings of two recent studies add evidence to suggest that HFNC is a viable alternative to standard oxygen therapy for asthma treatment in the emergency department.
A retrospective observational study published by Baudin and colleagues in May of 2017 in the Annals of Intensive Care, titled “Nasal high flow in management of children with status asthmaticus: a retrospective observational study” looked at 73 children who were admitted to the PICU from 2009 to 2014. 39 children were treated with HFNC (53%) and 30 (41%) with standard oxygen therapy. The study found that the mean standard deviation heartrate decreased over time in children treated with HFNC: at hour 6 (161 ±22 per min, p< 0.01), at hour 12 (155 ±22 per min, p< 0.01) and at 24 hours after beginning of treatment (141 ± 25/min, p < 0.01). As for respiratory rate, the results show a decrease from hour 0 (40 ± 13 per min, p < 0.01) to hour 24 (31 ± 8/min, p < 0.01) in the children treated with HFNC. The writers concluded that HFNC is a safe and feasible treatment for children presenting in the ED with severe asthma.
More recently, a prospective, single-center, randomized controlled trial published by Ballestero and colleagues in March 2018 in The Journal of Pediatrics titled “Pilot Clinical Trial of High-Flow Oxygen Therapy in Children with Asthma in the Emergency Service” found that 16 out of 30 (53%) children with moderate-to-severe asthma in the HFNC modality experienced a ≥ 2 point decrease in the Pulmonary score (PS) within 2 hours of start of treatment while only 9 out of 32 (28%) of children in the standard oxygen therapy modality did (P = .01). There were no significant baseline differences in the two groups and multivariable analysis found that HFNC treatment was strongly associated with the decreased PS outcome (OR, 4.70; 95% CI, 1.23-17.89; P = .02).
There were no significant between-group differences in secondary outcomes of disposition, length of stay—for neither the PICU nor the ward—, or need for additional therapies, such as salbutamol, corticosteroids, and intravenous magnesium. However, the authors note that HFNC was not available in the pediatric ward where the study was being conducted and that children were admitted to the PICU in order to continue HFNC treatment beyond 36 hours. Had HFNC been available on the ward, there would have been a PICU admission reduction of 50%.
The question of HFNC use for children with asthma presenting in the ED still requires more study. With the results of Baudin’s retrospective study and Ballestero’s randomized controlled pilot study both suggesting that HFNC is safe and feasible, there is a strong case to be made for a multi-center randomized controlled trial with a larger sample size.
Learn more about pediatric HFNC best practices
 Centers for Disease Control and Prevention. “Most Recent Asthma Data.” Retrieved May 15, 2018: https://www.cdc.gov/asthma/most_recent_data.htm
 Johnson, Laurie H et al. “Asthma-related emergency department use: current perspectives.” Open Access Emerg Med. 2016; 8: 47–55. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4950546/#b8-oaem-8-047
 Milési, Christophe, Mathilde Boubal, Aurélien Jacquot, Julien Baleine, Sabine Durand, Marti Pons Odena, and Gilles Cambonie. “High-flow nasal cannula: recommendations for daily practice in pediatrics.” Ann Intensive Care. 2014; 4: 29. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4273693/
 Baudin, Florent et al. “Nasal high flow in management of children with status asthmaticus: a retrospective observational study.” Ann Intensive Care. Ann Intensive Care. 2017; 7: 55. Published online 2017 May 22. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5440424/
 Ballestero, Yolanda et al. “Pilot Clinical Trial of High-Flow Oxygen Therapy in Children with Asthma in the Emergency Service.” Journal of Pediatrics. 2018 Mar;194:204-210. https://www.ncbi.nlm.nih.gov/pubmed/29331328
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