Format for Mini-CAT- Spring 2019

This should be an expanded version of a previous PICO question àPREVIOUS PICO DONE RT1WK3

Clinical Question: As in the past, please briefly outline the scenario and state your clinical question as concisely and specifically as possible

A 7-month-old infant is brought into the ED from clinic, tachypenic to 70 with an oxygen saturation of 81% on room air, suspected bronchiolitis who subsequently tested positive for RSV. Supportive care is administered with clearing of nasal secretions, nebulized saline, oxygen therapy via nasal cannula and preparations are made to transfer the patient to LIJ for continuation of care.

SEARCH QUESTION:In pediatric patients with bronchiolitis, can the early initiation of high flow oxygen therapy over standard oxygen therapy reduce the need for invasive interventions and length of hospital stay?

PICO Question:

Identify the PICO elements – this should be a revision of whichever PICO you have already begun in a previous week

P	I	C	O
Bronchiolitis	High flow oxygen therapy	Standard oxygen therapy	Fewer interventions
RSV	High flow nasal cannula	Standard flow nasal cannula	Intubation
Respiratory syncytial virus	HFNC	Standard care	Invasive mechanical ventilation
Pediatric	High flow oxygen	Low flow oxygen	Escalation of care
Children	Initial high flow therapy		Days in hospital
Infant	Early high flow therapy		ICU admission

Search Strategy:

Outline the terms used, databases or other tools used, how many articles returned, and how you selected the final articles to base your CAT on.  This will likewise be a revision and refinement of what you have already done.

Cochrane:

• Cochrane reviews àtopics àlung & airway à803 articles (+respiratory infections + type +intervention)à198 articles (+bronchiolitis) à15 articles
• High flow oxygen therapy pediatric bronchiolitis ICU admission à2 articles

NEJM:

• High flow oxygen therapy vs standard oxygen therapy bronchiolitis à8 articles
• Early high flow oxygen therapy vs standard oxygen therapy bronchiolitis pediatrics à2 articles

Science Direct:

• High flow oxygen therapy bronchiolitis à3,142 articles (+article type +review article +research articles) à1,821 articles (+publication title +The Journal of Pediatrics +Pediatric Respiratory Reviews +The Lancet) à167 articles
• High flow vs standard oxygen bronchiolitis à823 articles (+article type +review article +research articles) à423 articles (+publication title +The Journal of Pediatrics +Pediatric Respiratory Reviews +The Lancet) à38 articles
• High flow vs standard oxygen bronchiolitis invasive interventions à351 articles (+article type +review article +research articles) à99 articles (+publication title +The Journal of Pediatrics +Pediatric Respiratory Reviews +The Lancet) à17 articles
• High flow vs standard oxygen bronchiolitis intubation à829 articles (+article type +review article +research articles) 143 articles (+publication title +The Journal of Pediatrics +Pediatric Respiratory Reviews +Clinical Pediatric Emergency Medicine) à21 articles
• High flow vs standard oxygen RSV bronchiolitis escalation of care à55 articles (+article type +review article +research article) à11 articles

PubMed:

• High flow nasal cannula bronchiolitis invasive ventilation à8 articles
• High flow vs standard oxygen therapy RSV bronchiolitis pediatrics à108 (+article type +clinical trial +review +full text +publication date 5 years) à23 articles

In my search (as you can see) I generally got a high number of articles returned for my search phrases. However, I found that the larger the number returned, the less they were likely to answer my PICO question – the articles would not be restricted to a pediatric population or would simply discuss the use of high-flow nasal cannula (HFNC) or treatment of bronchiolitis but not both together, which is why I used the search parameters above to narrow the article selection. Even when I included bronchiolitis in my search terms I would get articles that were based on or included other respiratory pathologies which are some of those I excluded.

In my NEJM and Cochrane searches, the number of articles returned were fairly small and of those articles I have included here the one from NEJM as it is an RCT with a good sample size and was published last year. I decided to omit the one relevant article that I retrieved from my Cochrane search because while it was a review article it only included results from one RCT with a sample size of 19. While searching in Science Direct, I used various search terms and then applied the same or similar filters to all of my searches. Of the two articles I selected, one was chosen because it was a systematic review and the other because it was an RCT published in The Lancet which is a very reputable source. Both were recent publications.

I performed one additional database search for the miniCAT in PubMed. In that search I came across two of the articles already highlighted below and one additional article that I chose to include here, because although it is a retrospective cohort which is a lower quality of evidence than the other articles I chose it specifically looks at the use of HFNC in children under 24 months of age and subsequent need for ICU admission and/or invasive mechanical ventilation. The retrospective cohort followed patients before the use of HFNC, when HFNC was used solely in an intensive care setting, and once HFNC became more widely used throughout the hospital – i.e. in the early intervention setting of the ED. I thought this article offered a unique perspective on my PICO question and made valid conclusions applicable to the broader population.

Of the studies I chose to include in my miniCAT, 3 were done in Australia. During my search I endeavored to find studies done in the US as the results would be more generalizable to the population I will be treating. However, as of yet the most recent studies published with the largest sample sizes, and parameters most consistent with my PICO question were done in Australia. As I mentioned above I did find one Cochrane review in my search, but both the level of evidence and sample size were very low. Being that HFNC use for infants with bronchiolitis is fairly new practice there weren’t many systematic reviews available in the literature which is why I included multiple RCTs here as that would be the next highest level of evidence for my PICO question.

Articles Chosen(3-5) for Inclusion (please copy and paste the abstract with link):

Please pay attention to whether the articles actually address your question and whether they are the highest level of evidence available.  If you cannot find high quality articles, be prepared to explain the extensiveness of your search and why there aren’t any better sources available. 

 A Randomized Trial of High-Flow Oxygen Therapy in Infants with Bronchiolitis.Franklin D., Babl F.E., Schlapbach L.J., et al. N Engld J Med. 2018; 378: 1121-1131

ABSTRACT

BACKGROUND

High-flow oxygen therapy through a nasal cannula has been increasingly used in infants with bronchiolitis, despite limited high-quality evidence of its efficacy. The efficacy of high-flow oxygen therapy through a nasal cannula in settings other than intensive care units (ICUs) is unclear.

METHODS

In this multicenter, randomized, controlled trial, we assigned infants younger than 12 months of age who had bronchiolitis and a need for supplemental oxygen therapy to receive either high-flow oxygen therapy (high-flow group) or standard oxygen therapy (standard-therapy group). Infants in the standard-therapy group could receive rescue high-flow oxygen therapy if their condition met criteria for treatment failure. The primary outcome was escalation of care due to treatment failure (defined as meeting ≥3 of 4 clinical criteria: persistent tachycardia, tachypnea, hypoxemia, and medical review triggered by a hospital early-warning tool). Secondary outcomes included duration of hospital stay, duration of oxygen therapy, and rates of transfer to a tertiary hospital, ICU admission, intubation, and adverse events.

RESULTS

The analyses included 1472 patients. The percentage of infants receiving escalation of care was 12% (87 of 739 infants) in the high-flow group, as compared with 23% (167 of 733) in the standard-therapy group (risk difference, −11 percentage points; 95% confidence interval, −15 to −7; P<0.001). No significant differences were observed in the duration of hospital stay or the duration of oxygen therapy. In each group, one case of pneumothorax (<1% of infants) occurred. Among the 167 infants in the standard-therapy group who had treatment failure, 102 (61%) had a response to high-flow rescue therapy.

CONCLUSIONS

Among infants with bronchiolitis who were treated outside an ICU, those who received high-flow oxygen therapy had significantly lower rates of escalation of care due to treatment failure than those in the group that received standard oxygen therapy. (Funded by the National Health and Medical Research Council and others; Australian and New Zealand Clinical Trials Registry number, ACTRN12613000388718.)

 

High-flow warm humidified oxygen versus standard low-flow nasal cannula oxygen for moderate bronchiolitis (HFWHO RCT): an open, phase 4, randomized controlled trial. Kepreotes E., Whitehead B., Attia J., Oldmeadow C., Mattes J. The Lancet. 2018; 389; 10072, 4-10: 930-939.

ABSTRACT

BACKGROUND

Bronchiolitisis the most common lung infectionin infants and treatment focuses on management of respiratory distressand hypoxia. High-flow warm humidified oxygen (HFWHO) is increasingly used, but has not been rigorously studied in randomised trials. We aimed to examine whether HFWHO provided enhanced respiratory support, thereby shortening time to weaningoff oxygen.

METHODS

In this open, phase 4, randomised controlled trial, we recruited children aged less than 24 months with moderate bronchiolitis attending the emergency department of the John Hunter Hospital or the medical unit of the John Hunter Children’s Hospital in New South Wales, Australia. Patients were randomly allocated (1:1) via opaque sealed envelopes to HFWHO (maximum flow of 1 L/kg per min to a limit of 20 L/min using 1:1 air–oxygen ratio, resulting in a maximum FiO₂of 0·6) or standard therapy (coldwall oxygen 100% via infant nasal cannulaeat low flow to a maximum of 2 L/min) using a block size of four and stratifying for gestational ageat birth. The primary outcome was time from randomisation to last use of oxygen therapy. All randomised children were included in the primary and secondary safety analyses. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12612000685819.

FINDINGS

From July 16, 2012, to May 1, 2015, we randomly assigned 202 children to either HFWHO (101 children) or standard therapy (101 children). Median time to weaning was 24 h (95% CI 18–28) for standard therapy and 20 h (95% CI 17–34) for HFWHO (hazard ratio [HR] for difference in survival distributions 0·9 [95% CI 0·7–1·2]; log rank p=0·61). Fewer children experienced treatment failure on HFWHO (14 [14%]) compared with standard therapy (33 [33%]; p=0·0016); of these children, those on HFWHO were supported for longer than were those on standard therapy before treatment failure (HR 0·3; 95% CI 0·2–0·6; p<0·0001). 20 (61%) of 33 children who experienced treatment failure on standard therapy were rescued with HFWHO. 12 (12%) of children on standard therapy required transfer to the intensive care unit compared with 14 (14%) of those on HFWHO (difference −1%; 95% CI −7 to 16; p=0·41). Four adverse events occurred (oxygen desaturation and condensation inhalation in the HFWHO group, and two incidences of oxygen tubing disconnection in the standard therapy group); none resulted in withdrawal from the trial. No oxygen-related serious adverse events occurred. Secondary effectiveness outcomes are reported in the Results section.

INTERPRETATION

HFWHO did not significantly reduce time on oxygen compared with standard therapy, suggesting that early use of HFWHO does not modify the underlying disease process in moderately severe bronchiolitis. HFWHO might have a role as a rescue therapyto reduce the proportion of children requiring high-cost intensive care.

Respiratory Support for Infants with Bronchioloitis, a Narrative Review of the Literature.Fraser J.F., Franklin D., Schibler A. In press, accepted manuscript. Available online October 2018.

ABSTRACT

Bronchiolitis is a common viral disease that significantly affects infants less than 12 months of age. The purpose of this review is to present a review of the current knowledge of the uses of respiratory support in the management of infants with bronchiolitis presenting to hospital. We electronically searched MEDLINE, Cochrane, CINAHL and EMBASE (inception to 25th March 2018), to manually search for clinical trials that address the management strategies for respiratory support of infants with bronchiolitis.

We identified 120 papers who met the inclusion criteria, of which 33 papers were relevant for this review with only nine randomised controlled trials. This review demonstrated that non-invasive respiratory support reduced the need for escalation of therapy, particularly the proportion of intubations required for infants with bronchiolitis. Additionally, clear economic benefits have been demonstrated when non-invasive ventilation has been used. The potential early use of non-invasive respiratory supports such as nasal high flow therapy and non-invasive ventilation may have an impact on health care costs and reduction in ICU admissions and intubation rates. High-grade evidence demonstrates safety and quality of high flow therapy in general ward settings.

Humidified high-flow nasal cannula oxygen in bronchiolitis reduces need for invasive ventilation but not intensive care admission. Goh C.T., Kirby L.J., Schell D.N., Egan J.R. J Paediatr Child Health. 2017; 53(9): 897-902. PMID: 28544665.

ABSTRACT

AIM

To describe the changes to paediatric intensive care unit (PICU) admission patterns and ventilation requirements for children with bronchiolitisfollowing the introduction of humidified high-flownasal cannulaoxygen outside the PICU.

METHODS

Retrospective study comparing patients <24 months of age with a discharge diagnosis of bronchiolitisadmitted to the PICU. A comparison was made between those before humidified high-flownasal cannulaoxygen use (year 2008) to those immediately following the introduction of humidified high-flownasal cannulaoxygen use (year 2011) and those following further consolidation of humidified high-flownasal cannulaoxygen use outside the PICU (year 2013).

RESULTS

Humidified high-flownasal cannulaoxygen use up to 1 L/kg/min in the hospital did not reduce PICU admission. Intubation rates were reduced from 22.2% in 2008 to 7.8% in 2013. There was a non-significant trend towards decreased length of stay in the PICU while hospital length of stay showed a significant decrease following the introduction of humidified high-flownasal cannulaoxygen. Age <6 months and respiratory syncytial virus bronchiolitiswere associated with an increased chance of failing humidified high-flownasal cannulaoxygen therapy.

CONCLUSION

Humidified high-flownasal cannulaoxygen utilised outside of the PICU in our institution for children with bronchiolitisdid not reduce admission rates or length of stay to the PICU but was associated with a decreasing need for invasive ventilation and reduced hospital length of stay.

© 2017 Paediatrics and Child Health Division (The Royal Australasian College of Physicians).

Summary of the Evidence:

Author (Date)	Level of Evidence	Sample/Setting (# of subjects/ studies, cohort definition etc. )	Outcome(s) studied	Key Findings	Limitations and Biases
Franklin et al., 2018	Multicenter, randomized controlled trial	1472 infants ≤12 months with bronchiolitis randomly assigned to receive either standard oxygen therapy (control, n=733) or high-flow oxygen therapy (treatment, n=739) at emergency departments or pediatric inpatient units of 17 tertiary hospitals in Australia and New Zealand   Mean age: control – 5.76 months treatment – 6.10 months	Primary outcome: treatment failure that resulted in escalation of care during the hospital admission determined by meeting 3 of the 4 criteria seen below -HR remains unchanged or increased any amount since admission -RR remains unchanged or increased any amount since admission -the oxygen requirement in the high-flow group exceeded FIO2 of 0.4 to maintain an oxygen saturation level of at least 92% -requirement for supplemental oxygen in the standard-therapy group exceeded 2L/min to maintain an oxygen saturation of at least 92%   Secondary outcome: -proportion of infants transferred to an ICU -duration of ICU stay -duration of oxygen therapy -intubation rates -adverse events	Treatment failure with escalation of care occurred in 87 of 739 infants (12%) in the high-flow group and 167 of 733 infants (23%) in the standard-therapy group. NNT to prevent one escalation of care was 9.   There were no significant differences between length of hospital stay, duration of stay in the ICU, or duration of oxygen therapy between the two groups. Of the 167 infants in the standard-therapy group who received escalation of care, clinicians opted to offer high-flow therapy as a rescue treatment. 102 infants had a response to high-flow rescue therapy while in 65 infants high-flow therapy was ineffective and the infants were transferred to the ICU. In total, 12 infants, including 8 infants in the high-flow group and 4 in the standard-therapy group underwent intubation. Adverse events were low with one pneumothorax occurring in each group.	Not possible to mask the oxygen delivery method. In order to minimize bias, specific clinical criteria were used to determine whether or not escalation of care was warranted. Escalation of care occurred in more infants when the hospital had an on-site ICU. High-flow oxygen therapy is considered to be the standard practice in Australia and New Zealand and was therefore used as a rescue therapy for infants that had failed standard-therapy.   As I mentioned above, this study did not take place in the US which may lead to limitations in the generalization of the results to my future treatment population.
Kepreotes et al., 2018	Open, phase 4 randomized controlled trial	202 infants ≤ 24 months who were determined to have a clinical diagnosis of moderate bronchiolitis requiring oxygen supplementation were randomly assigned to receive either high-flow warm humidified oxygen (HFWHO, treatment, n=101) or standard oxygen therapy (control, n=101) at either the emergency department or inpatient pediatric department of a large tertiary hospital that serves approximately 900,000 people in the Hunter New England Local Health District of New South Wales, Australia	Primary outcome: time to weaning off of oxygen   Secondary outcome: -time from randomization to treatment failure -proportion of serious adverse events -transfer to ICU -length of hospital stay -baseline-adjusted HR and RR at 4 and 24hrs	Time to weaning off oxygen therapy did not differ significantly between the standard therapy group and the HFWHO group (24 hrs vs 20 hrs respectively).   Treatment failure was set at 24hrs at which time 90% of the HFWHO had not experienced treatment failure as compared with 60% in the standard therapy group. 33 infants were not supported by standard therapy and were trialed on HFWHO as a rescue therapy, 12 required transfer to the ICU while the remaining infants improved with HFWHO. Of the 14 infants who had treatment failure with HFWHO all were admitted to the ICU, one at a different hospital where bubble-CPAP was administered.   No serious oxygen-related adverse events such as pneumothorax, pressure injuries, or bleeding occurred, and no child died.	Patients were randomly assigned but masking was not possible due to the obvious difference between the two modes of oxygen delivery. The study was also only a single-center study.   The study itself had only 202 participants and was done at a single tertiary hospital. Although the hospital was large with a high volume of patients, a multi-center study would have been preferred. As mentioned above the study itself was conducted in Australia.
Fraser et al., 2018	Systematic review of current knowledge of the uses of respiratory support in the management of infants with bronchiolitis presenting to the hospital	Infants ≤ 24 months with bronchiolitis admitted to the hospital requiring respiratory support or oxygen therapy.   An electronic search of MEDLINE, Cochrane, CINAHL, and EMBASE was conducted a total of 2765 articles were returned of which 120 met inclusion criteria and 33 were discussed in the review. 9 of the 33 are RCTs	This paper was meant to be a review of the different therapies available in the management of bronchiolitis in infants ≤ 24 months who were admitted to the hospital and required respiratory support or oxygen therapy.   There were 9 RCTs included that compared two to three respiratory support modes	The review of existing literature for respiratory support modalities in infants with bronchiolitis showed there is increasing high-grade evidence to recommend the use of non-invasive respiratory support in the form on nasal high-flow (NHF) therapy or CPAP to prevent invasive mechanical ventilation. There is also high-grade evidence that NHF therapy can be used safely in general wards and does not require constant monitoring. It was also found that NHF reduces the requirement to escalate therapy. All studies uniformly suggest that on the more severe end of the disease spectrum, any form of non-invasive respiratory support (NHF or CPAP) has the potential to reduce intubation rate.   The option to start early respiratory support in the form of NHF therapy, when the infant presents to the ED or when transferred to a general pediatric ward has widened the scope of non-invasive ventilation for infants with bronchiolitis.	This article is currently in accepted manuscript format. It has a date for publication in Paediatric Respiratory Reviews an Elsevier publication and according to the Elsevier website the article has been fully peer-reviewed, but is not in its completed format.   Two of the studies included in the review were over ten years old.
Goh et al., 2017	Retrospective cohort study	Infants ≤ 24 months with a discharge diagnosis of bronchiolitis admitted to the PICU were separated into 3 cohorts: -pre high-flow nasal cannula (HFNC) introduction (2008) -initial HFNC introduction (2011) -consolidation of HFNC use (2013)   A total of 166 infants with bronchiolitis were admitted to the PICU during the three epochs	Primary outcome: whether or not introduction of HFNC therapy in the wards and ED led to any changes in PICU admission patterns and outcomes for infants with bronchiolitis	The use of HFNC was significantly higher in 2013 as compared with 2011 and 2008. A total of 98.7% of patients admitted to the PICU in 2013 had HFNC as a form of ventilator support at some point during their stay.   The increased use of HFNC was associated with a fall in non-invasive ventilator (NIV) usage of 32.5% in 2013 compared to 83.3% in 2008. The proportion of patients requiring intubation were significantly lower in the 2 years when HFNC was employed with 7.8, 9.4, and 22.2% of admitted patients requiring intubation in 2013, 2011 and 2008 respectively.   PICU length of stay did not significantly change after the introduction of HFNC. However, total hospital length of stay was shorter in the years (i.e. 2011, 2013) post-HFNC use.   Rates of failure of HFNC as defined by need for escalation of therapy to NIV or invasive ventilation were similar between to 2 years in which HFNC was in use (24% in 2011 and 29.1% in 2013). Patients failing HFNC therapy were more likely to be less than 6 months or were RSV positive. Presence of comorbidities did not predict HFNC failure.	This was a retrospective cohort study and while it does make some useful comparisons to the need for escalation of care and invasive ventilation pre and post HFNC use there are some draw-backs. For one, PICU admission was not determined by any set criteria and was left to the discretion of the attending intensivist for further monitoring and/or escalation of care as required.   The main focus of this study was HFNC vs NIV, however standard oxygen therapy was used in the earliest cohort (2008).   Finally, this study also took place in Australia, which may make generalizability more difficult to the US population.

Conclusion(s):
– Briefly summarize the conclusions of each article, then provide an overarching conclusion.

Franklin et al. conclude that the use of high-flow oxygen therapy early in the admission of an infant with bronchiolitis significantly reduced the need for escalation of care when compared with standard oxygen therapy.

Kepreotes et al. determined that there was no difference in time on oxygen when high-flow warm humidified oxygen (HFWHO) was compared with standard therapy, which suggests that early use of HFWHO does not modify the disease process in moderate bronchiolitis. However, its use did seem to be safe at the conservative flows used in the trial (1L/min max) and prevented intensive care admission for patients who failed standard therapy.

Fraser et al. conclude that the use of non-invasive ventilation (CPAP) or NHF therapy has historically reduced the need for invasive mechanical ventilation in infants with bronchiolitis. The future trend is to offer respiratory support such as NHF therapy outside intensive care, reducing health care costs and potentially further reducing the need for invasive ventilation.

Goh et al. found high-flow nasal cannula (HFNC) to be a safe and effective treatment for infants with bronchiolitis and associated with a reduction of length of total hospital stay for patients admitted to the PICU. However, use of HFNC at low flow rates (<1L/min) outside of the PICU did not reduce admission rates of bronchiolitis patients to the PICU.

Overall, the articles highlighted here generally found high-flow oxygen therapy to be safe in a non-monitored setting such as the ED or pediatric ward. There was minimal support for decreased length of stay, but use of early high-flow therapy was shown to reduce the need for more invasive interventions such as CPAP or intubation. High-flow therapy was also shown to be an effective rescue therapy for patients who failed standard oxygen therapy.

Clinical Bottom Line:

Please include an assessment of the following:

– Weight of the evidence – summarize the weaknesses/strengths of the articles and explain how they factored into your clinical bottom line (this may recap what you discussed in the criteria for choosing the articles)

– Magnitude of any effects

– Clinical significance (not just statistical significance)

– Any other considerations important in weighing this evidence to guide practice  – If the evidence you retrieved was not enough to conclude an answer to the question, discuss what aspects still need to be explored and what the next studies will have to answer/provide (e.g. larger number, higher level of evidence, answer which sub-group benefits, etc)

As mentioned above, the use of high-flow oxygen therapy for infants with bronchiolitis is still a fairly new practice. As such, there weren’t many systematic reviews or meta-analyses available to answer my PICO question. The next highest level of evidence being RCT, I selected two to include here. The majority of the studies highlighted here were done in Australia and New Zealand, this is because HFNC has become standard of care for infants that present to the hospital with bronchiolitis in need of respiratory support and have failed standard therapy. Both of the RCTs included here and the retrospective cohort were conducted in Australia and while that may affect my ability to generalize the findings of those studies to my patient population it is a good start to encourage similar research in the US.

I was able to find a systematic review that included 33 papers, 9 of which were RCTs that discussed management guidelines for infants with bronchiolitis. The review did not specifically focus on the use of HFNC vs standard oxygen therapy. Other non-invasive forms of ventilation were included like CPAP. That being said recommendations regarding HFNC were made to the extent that is can be safely used in a non-monitored setting and its use has reduced the need for invasive mechanical intubation. Another weakness of this study is that it is in accepted manuscript form. There is a date for publication in an Elsevier publication and according to the Elsevier website the article has been peer-reviewed, but it is not in its completed format.

The article that was weighted most heavily in my own clinical bottom line was Franklin et al. This is because it is a multicenter RCT with a large sample size that was published just last year in the New England Journal of Medicine. The study design was well thought-out and the primary outcome as well as intervention and comparison were completely aligned with my PICO question – Treatment failure with escalation of care occurred in 87 of 739 infants (12%) in the high-flow group, as compared with 167 of 733 (23%) in the standard-therapy group (risk difference, -11 percentage points; 95% CI, -15 to -7; P<0.001).I then considered the recommendations from the Fraser et al. review. Although the level of evidence is technically higher, the fact that the review is not yet in its completed format and that it offers general guidelines for respiratory support in infants with bronchiolitis makes it less relevant to my own clinical bottom line. The information presented in this article that was most useful to my own clinical decision-making is the safety data and lack of reported adverse events with the use of HFNC.

The last two articles I considered in terms of weight of evidence were the Kepreotes et al. and Goh et al. articles. The Kepreotes et al. article was a well-designed RCT published in The Lancet, but the sample size was small (n=202) and the primary outcome was not aligned with my PICO question, but the secondary outcomes were useful for my recommendation which is why I included it here. Finally, the Goh et al. study while the lowest level of evidence included here, provided a useful comparison for the need for escalation of care and invasive intubation techniques before and after the initiation of high-flow oxygen therapy for infants with bronchiolitis.

Bronchiolitis is a serious respiratory illness that primarily affects children under the age of 24 months and is the most common reason for non-elective hospital admission in infants. Currently, treatment is supportive in nature. The clinical significance of the evidence included here is that high-flow oxygen therapy may become a safe and useful tool to treat infants with bronchiolitis in need of respiratory support. The ease of use allows for immediate interventions in non-monitored setting such as the emergency room or general pediatric inpatient population and may prevent escalation of care leading to more invasive forms of ventilation and greater cost to the health care system overall. Before concrete recommendations are made, more studies need to be conducted – preferably a multicenter, multi-country RCT with a large sample size and specific clinical parameters for failure of therapy. If the findings of such a study are in line with those I have highlighted here I would feel comfortable initiating HFNC therapy for infants with bronchiolitis in need of respiratory support.