Patients in New Pilot Study of Vapotherm High Velocity Therapy Showed Similar Outcomes to CPAP for Infants with Moderate to Severe Bronchiolitis

Vapotherm high velocity therapy has been clinically proven as a mask-free and seal-free alternative to CPAP for both, primary respiratory support for RDS and post-extubation support. [1,2] A recent pilot study now also may suggest that high velocity therapy could be an alternative to CPAP for the treatment of infants with critical bronchiolitis.[3]

Cesar and colleagues randomized 63 infants (median age 2.7 months) to either a high flow arm (n=35, supported exclusively on Vapotherm high velocity therapy) or a CPAP arm (n=28) and compared the two groups for treatment failure.3 Treatment failure was defined as escalation to either intubation or bilevel positive pressure support (NiPPV). The authors explained that their goal was to enroll critically ill, younger children (no older than 9 months) who would be more likely to meet the treatment failure criteria. In these patients studied, the two arms showed similar outcomes for both, treatment failure and PICU length of stay, as shown in Table 1. 

Table 1: Vapotherm high velocity therapy vs CPAP Outcomes 

CPAPHigh velocity therapy p
Treatment failure 35.7% 37.1% 0.88 
PICU Length of Stay  (median IQR) 5 [4–7] days 5 [4–8] 0.46 

The authors note several limitations to the study, including that definitive conclusions cannot be drawn from the small sample size. Additionally, there was no crossover component. Patients that were perceived as failing on one therapy could not be switched to the other. In this way, it’s unclear whether high velocity therapy could have rescued patients who failed on CPAP and vice versa. The authors also note that the hospital where the study was conducted had greater familiarity with CPAP than high velocity therapy and write that “it is impossible to estimate whether the timing of failure in the HFNC group could have been influenced by clinician experience or comfort with this treatment modality.” 

Clarification of Terminology  

It should be pointed out that authors at this institution call Vapotherm high velocity therapy high-flow nasal cannula (HFNC). The two therapies are often conflated in studies, but importantly don’t show the same outcomes in trials and don’t carry the same FDA indications. The FDA classifies commodity high flow oxygen products as respiratory humidifiers. Vapotherm high velocity therapy is a form of Mask-Free NIV intended to provide oxygen and ventilatory support to spontaneously breathing patients in respiratory distress.  

Given the quick adoption of high velocity nasal insufflation as well as conventional high flow and the confusion between devices in existing studies, clinicians need to be aware of precisely what technology they are using and what outcomes they can expect with it.  

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[1] Lavizarri A, Colnaghi M, Ciuffini F, Veneroni C, Musumeci S, Cortinovis I, Mosca F. “Heated, humidified high-flow nasal cannula vs nasal continuous positive airway pressure for respiratory distress syndrome of prematurity – a randomized clinical noninferiority trial.” JAMA Pediatr. 2016 Aug 8. 
[2] Collins C, Holberton J, Barfield C, Davis P. “A randomized controlled trial to compare heated humidified high-flow nasal cannulae with nasal continuous positive airway pressure postextubation in premature infants.” J Pediatrics. 2013 May; 162: 949-54. 
[3] Cesar, Regina Grigolli, Bibiane Ramos Pinheiro Bispo, Priscilla Helena Costa Alves Felix, Maria Carolina Caparica Modolo, Andreia Aparecida Freitas Souza, Nelson K. Horigoshi, Alexandre T. Rotta.High-Flow Nasal Cannula versus Continuous Positive Airway Pressure in Critical Bronchiolitis: A Randomized Controlled Pilot. J Pediatr Intensive Care. April 2020. DOI: 10.1055/s-0040-1709656