High-Flow Nasal Oxygen vs Standard Oxygen Therapy and Length of Hospital Stay in Children With Acute Hypoxemic Respiratory Failure
Journal
JAMA
Journal Volume
329
Journal Issue
18
Pages
1610
Date Issued
2023-05-09
Author(s)
Abstract
To the Editor A recent randomized clinical trial1 reported that children who received early high-flow nasal oxygen therapy for mild to moderate acute hypoxemic respiratory failure had a significantly longer length of stay in the hospital than those who initially received standard oxygen therapy. Although we appreciate the authors’ list of hypotheses for why children allocated to high-flow oxygen therapy had a prolonged length of stay, we believe there may be some other important explanations for this trial’s finding.
First, similar to all methods of advanced ventilatory support, weaning of high-flow oxygen therapy requires additional observational time after discontinuation of the high-flow system. A longer length of stay in the intensive care unit (ICU) than the duration of high-flow oxygen therapy also was observed in a previous trial that compared high-flow oxygen vs conventional oxygen therapy.2
Second, a higher proportion of patients were transferred to the ICU in the high-flow oxygen therapy group vs the standard oxygen group (12.5% vs 6.9%).1 However, the percentages of children who required noninvasive ventilation and invasive ventilation were similar, approximately 11% to 12%, in both groups. There may have been some confounding factors for escalation to care in the ICU in the high-flow oxygen therapy group. In addition, admission to the ICU may result in a longer hospital length of stay due to intrahospital transfer pathways (ward to ICU to ward) and handoffs.3
Third, a recent study of children with bronchiolitis in Canada reported an annual 7.2% increase in ICU admissions despite a stable hospitalization rate for bronchiolitis and a stable median length of stay of 3 days.4 This study,4 along with the study by Dr Franklin and colleagues,1 delineates the potential overuse of ICU resources for children and reemphasizes the confounding of clinical decision-making on primary outcomes in interventional trials.
First, similar to all methods of advanced ventilatory support, weaning of high-flow oxygen therapy requires additional observational time after discontinuation of the high-flow system. A longer length of stay in the intensive care unit (ICU) than the duration of high-flow oxygen therapy also was observed in a previous trial that compared high-flow oxygen vs conventional oxygen therapy.2
Second, a higher proportion of patients were transferred to the ICU in the high-flow oxygen therapy group vs the standard oxygen group (12.5% vs 6.9%).1 However, the percentages of children who required noninvasive ventilation and invasive ventilation were similar, approximately 11% to 12%, in both groups. There may have been some confounding factors for escalation to care in the ICU in the high-flow oxygen therapy group. In addition, admission to the ICU may result in a longer hospital length of stay due to intrahospital transfer pathways (ward to ICU to ward) and handoffs.3
Third, a recent study of children with bronchiolitis in Canada reported an annual 7.2% increase in ICU admissions despite a stable hospitalization rate for bronchiolitis and a stable median length of stay of 3 days.4 This study,4 along with the study by Dr Franklin and colleagues,1 delineates the potential overuse of ICU resources for children and reemphasizes the confounding of clinical decision-making on primary outcomes in interventional trials.
SDGs
Type
letter