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Contemporary Reviews in Critical Care Medicine |

CPAP and High-Flow Nasal Cannula Oxygen in BronchiolitisNoninvasive Respiratory Support in Bronchiolitis

Ian P. Sinha, PhD; Antonia K. S. McBride, MBChB; Rachel Smith, MBChB; Ricardo M. Fernandes, MD
Author and Funding Information

From the Respiratory Unit (Drs Sinha, McBride, and Smith), Alder Hey Children’s Hospital, Liverpool, England; Department of Pediatrics (Dr Fernandes), Santa Maria Hospital, Lisbon Academic Medical Centre, Lisbon, Portugal; and Clinical Pharmacology Unit (Dr Fernandes), Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal.

CORRESPONDENCE TO: Ian P. Sinha, PhD, Respiratory Unit, Alder Hey Children’s Hospital, Alder Rd, Liverpool, L12 2AP, England; e-mail: iansinha@liv.ac.uk


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(3):810-823. doi:10.1378/chest.14-1589
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Severe respiratory failure develops in some infants with bronchiolitis because of a complex pathophysiologic process involving increased airways resistance, alveolar atelectasis, muscle fatigue, and hypoxemia due to mismatch between ventilation and perfusion. Nasal CPAP and high-flow nasal cannula (HFNC) oxygen may improve the work of breathing and oxygenation. Although the mechanisms behind these noninvasive modalities of respiratory support are not well understood, they may help infants by way of distending pressure and delivery of high concentrations of warmed and humidified oxygen. Observational studies of varying quality have suggested that CPAP and HFNC may confer direct physiologic benefits to infants with bronchiolitis and that their use has reduced the need for intubation. No trials to our knowledge, however, have compared CPAP with HFNC in bronchiolitis. Two randomized trials compared CPAP with oxygen delivered by low-flow nasal cannula or face mask and found some improvements in blood gas results and some physiologic parameters, but these trials were unable to demonstrate a reduction in the need for intubation. Two trials evaluated HFNC in bronchiolitis (one comparing it with headbox oxygen, the other with nebulized hypertonic saline), with the results not seeming to suggest important clinical or physiologic benefits. In this article, we review the pathophysiology of respiratory failure in bronchiolitis, discuss these trials in detail, and consider how future research studies may be designed to best evaluate CPAP and HFNC in bronchiolitis.

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