Effect of Early High-Flow Nasal Oxygen vs Standard Oxygen Therapy on Length of Hospital Stay in Hospitalized Children With Acute Hypoxemic Respiratory Failure

Author:

Franklin Donna12345,Babl Franz E.5678,George Shane12345,Oakley Ed5678,Borland Meredith L.5910,Neutze Jocelyn51112,Acworth Jason513,Craig Simon51415,Jones Mark16,Gannon Brenda17,Shellshear Deborah513,McCay Hamish18,Wallace Alexandra1118,Hoeppner Tobias9,Wildman Mark19,Mattes Joerg2021,Pham Trang M. T.3,Miller Letitia3,Williams Amanda567,O’Brien Sharon59,Lawrence Shirley512,Bonisch Megan522,Gibbons Kristen3,Moloney Susan23,Waugh John2425,Hobbins Sue26,Grew Simon27,Fahy Rose26,Dalziel Stuart R.5112228,Schibler Andreas5293031

Affiliation:

1. Children’s Emergency and Critical Care Research, Gold Coast University Hospital, Southport, Australia

2. Emergency Department, Gold Coast University Hospital, Southport, Australia

3. Faculty of Medicine, University of Queensland, Brisbane, Australia

4. Menzies Health Institute Queensland, Griffith University, Southport, Australia

5. Paediatric Research in Emergency Departments International Collaborative, Melbourne, Australia

6. Emergency Department, Royal Children’s Hospital, Melbourne, Australia

7. Murdoch Children’s Research Institute, Melbourne, Australia

8. Department of Paediatrics, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, Australia

9. Emergency Medicine, Perth Children’s Hospital, Nedlands, Australia

10. Divisions of Emergency Medicine and Paediatrics, School of Medicine, University of Western Australia, Crawley

11. Departments of Surgery and Paediatrics: Child and Youth Health, University of Auckland, Auckland, New Zealand

12. KidzFirst Middlemore Hospital, Auckland, New Zealand

13. Emergency Department, Queensland Children’s Hospital, South Brisbane, Australia

14. Department of Paediatrics, School of Clinical Sciences, Monash University, Clayton, Australia

15. Emergency Department, Monash Medical Centre, Melbourne, Australia

16. Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia

17. Centre for the Business and Economics of Health, University of Queensland, Brisbane, Australia

18. Department of Paediatrics, Waikato Hospital, Hamilton, New Zealand

19. Emergency Department, Townsville University Hospital, Douglas, Australia

20. Paediatric Respiratory and Sleep Medicine, John Hunter Children’s Hospital, New Lambton Heights, Australia

21. Priority Research Centre GrowUpWell, University of Newcastle, Callaghan, Australia

22. Children’s Emergency Department, Starship Children’s Hospital, Auckland, New Zealand

23. Paediatric Department, Gold Coast University Hospital, Griffith University School of Medicine, Southport, Australia

24. Paediatric Department, Ipswich General Hospital, Ipswich, Australia

25. Paediatric Department, Caboolture Hospital, Caboolture, Australia

26. Paediatric and Emergency Departments, Prince Charles Hospital, Chermside, Australia

27. Paediatric Department, Redcliffe Hospital, Redcliffe, Australia

28. University of Auckland, Auckland, New Zealand

29. St Andrew’s War Memorial Hospital, Brisbane, Australia

30. Critical Care Research Group, St Andrew’s War Memorial Hospital, Brisbane, Australia

31. Wesley Medical Research, Wesley Hospital, Auchenflower, Australia

Abstract

ImportanceNasal high-flow oxygen therapy in infants with bronchiolitis and hypoxia has been shown to reduce the requirement to escalate care. The efficacy of high-flow oxygen therapy in children aged 1 to 4 years with acute hypoxemic respiratory failure without bronchiolitis is unknown.ObjectiveTo determine the effect of early high-flow oxygen therapy vs standard oxygen therapy in children with acute hypoxemic respiratory failure.Design, Setting, and ParticipantsA multicenter, randomized clinical trial was conducted at 14 metropolitan and tertiary hospitals in Australia and New Zealand, including 1567 children aged 1 to 4 years (randomized between December 18, 2017, and March 18, 2020) requiring hospital admission for acute hypoxemic respiratory failure. The last participant follow-up was completed on March 22, 2020.InterventionsEnrolled children were randomly allocated 1:1 to high-flow oxygen therapy (n = 753) or standard oxygen therapy (n = 764). The type of oxygen therapy could not be masked, but the investigators remained blinded until the outcome data were locked.Main Outcomes and MeasuresThe primary outcome was length of hospital stay with the hypothesis that high-flow oxygen therapy reduces length of stay. There were 9 secondary outcomes, including length of oxygen therapy and admission to the intensive care unit. Children were analyzed according to their randomization group.ResultsOf the 1567 children who were randomized, 1517 (97%) were included in the primary analysis (median age, 1.9 years [IQR, 1.4-3.0 years]; 732 [46.7%] were female) and all children completed the trial. 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 hazard ratio, 0.83 [95% CI, 0.75-0.92]; P < .001). Of the 9 prespecified secondary outcomes, 4 showed no significant difference. The median length of oxygen therapy was 1.07 days (IQR, 0.50-2.06 days) in the high-flow oxygen group vs 0.75 days (IQR, 0.35-1.61 days) in the standard oxygen therapy group (adjusted hazard ratio, 0.78 [95% CI, 0.70-0.86]). In the high-flow oxygen group, there were 94 admissions (12.5%) to the intensive care unit compared with 53 admissions (6.9%) in the standard oxygen group (adjusted odds ratio, 1.93 [95% CI, 1.35-2.75]). There was only 1 death and it occurred in the high-flow oxygen group.Conclusions and RelevanceNasal high-flow oxygen used as the initial primary therapy in children aged 1 to 4 years with acute hypoxemic respiratory failure did not significantly reduce the length of hospital stay compared with standard oxygen therapy.Trial Registrationanzctr.org.au Identifier: ACTRN12618000210279

Publisher

American Medical Association (AMA)

Subject

General Medicine

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