High flow nasal cannula oxygen therapy in the treatment of acute bronchiolitis in neonates

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Gráfico de medias (IC 95%) de flujo l/min administrado durante las primeras 48h de soporte respiratorio con OAF. B. 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(A) Heart rate (mean, 95% CI). (B) Respiratory rate (mean, 95% CI). (C) PCO2 obtained from capillary blood gas testing (mean, 95% CI). (D) Wood-Downes-Ferrés severity score (median, interquartile range)." ] ] ] "textoCompleto" => "IntroductionAcute bronchiolitis is the respiratory disease that is the most frequent cause of hospitalisation during the winter months.<a class="elsevierStyleCrossRefs" href="#bib0200">1,2</a> Although most cases are self-limiting and can be managed in the home, between 1 and 5% require hospital admission, and of the latter, 5–15% require respiratory support at the paediatric intensive care unit (PICU).<a class="elsevierStyleCrossRefs" href="#bib0205">2–6</a> Age less than 6 weeks is a risk factor for severity, and approximately 30–50% of patients admitted to the PICU are less than 1 month of age.<a class="elsevierStyleCrossRef" href="#bib0215">4</a>The treatment of bronchiolitis remains a controversial subject. There is no evidence of any treatment being capable of altering the natural course of the disease, but some treatments may prevent the development of complications and improve patient comfort. The approaches to the management of these patients backed by scientific evidence consist of supportive care and mechanical ventilation.<a class="elsevierStyleCrossRefs" href="#bib0205">2,6–10</a> In recent years, clinical practice has widely incorporated the use of nebulised hypertonic saline (HTS) in moderate bronchiolitis and of noninvasive ventilation (NIV) and high-flow nasal cannula (HFNC) oxygen therapy as supportive measures to prevent invasive mechanical ventilation (IMV) in patients with severe bronchiolitis.<a class="elsevierStyleCrossRefs" href="#bib0225">6,11–20</a> Although NIV has proven to be a useful tool in paediatric patients with respiratory failure, its use may be limited in low birth weight infants due to their poor tolerance of the technique.<a class="elsevierStyleCrossRef" href="#bib0300">21</a> High-flow nasal cannula therapy is a noninvasive respiratory support technique that delivers a heated and humidified blend of air and oxygen through nasal cannulae at rates exceeding the peak inspiratory flow, and has proven useful in the management of moderate to severe bronchiolitis.<a class="elsevierStyleCrossRefs" href="#bib0265">14,15,22–27</a> The effectiveness of this technique compared to CPAP has been assessed in newborns for the treatment of neonatal respiratory distress syndrome,<a class="elsevierStyleCrossRefs" href="#bib0335">28–32</a> but there is little published evidence on its use in newborns with bronchiolitis.<a class="elsevierStyleCrossRef" href="#bib0355">32</a>The aim of this study was to determine whether initiation of HFNC oxygen therapy with nasal cannulae in a neonatal unit succeeded in reducing the need for mechanical ventilation in newborns admitted with acute bronchiolitis. We also analysed the clinical outcomes of patients treated with HFOT, as well as the complications that developed.Patients and methodsWe conducted an ambispective cohort study in the level IIB neonatal unit of the Consorcio Hospital General Universitario de Valencia, Spain, which included: (1) a prospective cohort of newborns admitted with bronchiolitis from October 2011, when the use of HFNC oxygen therapy was introduced in the unit, to April 2015 (HFNC period); (2) comparison with a retrospective cohort of newborns admitted with bronchiolitis in the period preceding the introduction of HFNC, from January 2008 to May 2011 (pre-HFOT period).The diagnosis of bronchiolitis was made following the definition proposed by McConnochie: first episode of respiratory distress with wheezing, preceded by signs of viral respiratory illness.<a class="elsevierStyleCrossRef" href="#bib0360">33</a> The inclusion criteria were chronological age of 28 days or less in term newborns or corrected gestational age of 42 weeks or less in preterm newborns (<37 weeks’ gestation). We excluded patients with haemodynamic instability, sepsis, or that required intubation on admission.The primary outcome variable was the need for mechanical ventilation (NIV and IMV) in the two periods under study. We analysed other variables, such as sex, gestational age, birth weight, age and weight at the time of admission, aetiological agent, infant feeding method, prior history of palivizumab treatment, comorbidities, pharmacological treatment received during admission, length of stay and need for transfer to the PICU.The study was approved by the Research Commission of the Consorcio Hospital General Universitario de Valencia.High flow nasal cannula oxygen therapy periodHFNC oxygen therapy was introduced with a protocol based on the existing scientific evidence that set the criteria for its use as well as step-wise criteria to transition to other modalities of respiratory support when required (NIV or IMV). Continuous monitoring by pulse oximetry and supportive care were initiated in all patients, while the need for pharmacological treatment with nebulised adrenaline was assessed on a case-by-case basis, following the same protocol applied in preceding years. Respiratory support with HFNC oxygen therapy was initiated if patients met any of the criteria listed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>HFNC oxygen therapy was delivered using the Fisher & Paykel® MR850® system with nasal cannulae (Optiflow™). Therapy was initiated at a rate of 4–6L/min that was increased progressively to a maximum of 10L/min until clinical improvement was achieved. The initial fraction concentration of oxygen in inspired gas (FiO2) was set at the pressure required to achieve an oxygen (SaO2) of more than 92% and was adjusted based on how the patient responded to a maximum FiO2 of 0.40. If the patient became clinically stable with a Wood-Downes-Ferrés (WDF) score of 4 or higher, the flow rate was gradually reduced to 2L/min and the FiO2 to 0.25, and HFNC oxygen therapy was discontinued. At this point, the need for oxygen therapy with conventional nasal prongs at 2L/min or less was assessed.Failure of HFNC oxygen therapy was defined as lack of clinical improvement or worsening in the condition of the patient despite the optimisation of therapy with delivery of maximum FiO2 and flow rates, requiring transition to another modality of respiratory support. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> presents the criteria for initiation of NIV or IMV. The need for IMV was considered a criterion for admission to the PICU or the neonatal ICU.During treatment with HFNC oxygen therapy, we documented the following parameters at different time points: temperature, respiratory rate, heart rate (HR), SaO2, FiO2 and WDF score. The parameters were recorded at the time of initiation of HFNC oxygen therapy (baseline) and at 3, 6, 12, 18, 24, 36, 48, 72 and 96h. We recorded capillary blood gas parameters (pH, PCO2) at 6, 12, 18, 24, and 48h from initiation of HFNC oxygen therapy, and documented adverse effects (pneumothorax, intolerance to the technique, hypothermia, skin erosion at the area of contact with the cannula, or aspiration of food), duration of nothing by mouth (NPO), and method of feeding.Pre-high-flow oxygen therapy periodIn the second phase of the study, we collected data retrospectively by reviewing the medical records of newborns admitted with bronchiolitis over a period of four epidemic seasons preceding the introduction of HFNC oxygen therapy in the unit, applying the inclusion and exclusion criteria. During this period, the criteria for hospital admission and the management of patients were similar to those applied in the HFNC period, with the exception of the use of HFNC oxygen therapy.Statistical analysisWe performed the statistical analysis with the software package IBM SPSS 20.0 for Windows®. We have summarised categorical variables as percentages and 95% confidence intervals (CIs) and quantitative variables as mean±standard deviation in case they followed a normal distribution, or median and interquartile range otherwise.We compared the baseline characteristics of the two cohorts by means of the Mann–Whitney U test for continuous variables and Fisher's exact test or the chi-square test for categorical variables. We assessed the impact of the introduction of HFNC oxygen therapy on mechanical ventilation by means of the following measures: relative risk (RR), absolute risk reduction (ARR) and the number needed to treat (NNT) with HFNC oxygen therapy to prevent the use of mechanical ventilation. When we analysed the length of stay, we excluded patients that were transferred to the PICU.We analysed the changes in quantitative secondary outcome variables (WDF score, HR, respiratory rate, SaO2, pH, PCO2, flow rate in L/min) by means of the Mann–Whitney U test for paired samples. We defined statistical significance as a P-value of less than .05.ResultsWe included a total of 112 newborns, 56 in the cohort of the HFNC period (2011–2015) and 56 in the cohort of the period preceding the introduction of HFNC oxygen therapy (2008–2011). We did not find statistically significant differences between the cohorts in the baseline characteristics of the patients or the pharmacological treatment they received (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The respiratory support techniques used in each period were different, and we observed that the use of HFNC oxygen therapy was associated with a significant reduction in the need for NIV (30.4% vs 10.7%; P=.01), RR of 0.35 (95% CI: .15–.83), ARR of 19.6% (95% CI: 5.13–34.20) and NNT of 5. We did not find a significant difference in the use of IMV. The length of stay in days was similar in both groups (5.92 pre-HFOT vs 6.03 in the HFOT period; P=.688) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).We analysed the data for the patients that received respiratory support with HFNC oxygen therapy in the 2011–2015 period (n=22). <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows their baseline characteristics and the treatments they received.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>High-flow nasal cannula oxygen therapy was initiated with a mean flow rate of 6.8L/min (SD, 1.5). The flow rate was increased gradually until reaching the maximum value (mean, 8.1L/min; SD, 1.7) at 12h, as can be seen in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>. The maximum flow administered was 10L/min at a dose of 3L/kg/min, with a maximum FiO2 of 0.40.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Treatment with HFNC oxygen therapy was associated with significant decreases in HR from 160±15.4 to 150.2±11.6 (P=.03), in respiratory rate from 59±14.6 to 48.7±8.6 (P=.01) and in the WDF score from 7 (6.8–8.3) to 6 (5–7) (P=.001), starting at 3h from initiation of HFNC oxygen therapy. We also observed a significant decrease in capillary blood PCO2 from 55.7±7.2 to 51.1±6.8 (P=.012) at 6h. We observed a decreasing trend in the different parameters under study throughout the treatment with HFNC oxygen therapy with a peak in clinical stabilisation at 18 to 24h (HR, 141±14; respiratory rate, 44±8; PCO2, 48.7±6; WDF severity score, 4 [4–5]) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>We did not observe adverse effects such as pneumothorax, intolerance of HFNC oxygen therapy, hypothermia, skin erosion at the area of contact with the cannula or aspiration of food.Enteral feeding by nipple feeding or orogastric tube was used in 86.3% of patients during treatment following a period of initial stabilisation with a median duration of NPO of 12.3h (7.8–25).High-flow oxygen therapy failed in five patients (22.7%; 95% CI: 7.8–45.4), who required sequential treatment with NIV. The causes of failure were respiratory acidosis (60%), requirement of a FiO2 greater than 0.40 (20%) and increased breathing effort (20%). None of the patients required intubation or transfer to the PICU or neonatal ICU. During this period, one patient was treated with NIV without prior HFNC oxygen therapy due to meeting the severity criteria for NIV at the time of admission.The median duration of HFNC oxygen therapy was 57h (34.5–80.1) and the median length of stay was 8.1 days (6.6–9.7).DiscussionThe main finding of our study was a significant decrease in the use of NIV after the introduction of HFNC oxygen therapy in our neonatal unit. Furthermore, two patients required IMV during the pre-HFNC period, while none required intubation or transfer to the ICU after the introduction of HFNC oxygen therapy.Several studies have demonstrated that NIV is a useful tool in the management of severe bronchiolitis, its main advantage being that it reduces the incidence of complications associated with IMV.<a class="elsevierStyleCrossRefs" href="#bib0255">12,17</a> However, its use may pose challenges in infants due to limitations related to the interface or to poor tolerance, with some of the patients requiring sedation.<a class="elsevierStyleCrossRefs" href="#bib0300">21,34</a> Furthermore, it requires a ventilator and in many instances, transfer to the ICU, which results in increased costs of treatment. For these reasons, we believe that a reduction in the use of NIV offers significant advantages in the management of patients with bronchiolitis in addition to a reduction of health care costs, although we did not analyse these variables in our study.When it came to the characteristics of our sample, the newborns included in the study did not have relevant perinatal risk factors, such as bronchopulmonary dysplasia, severe prematurity or cyanotic heart disease, which could be accounted for by the level of care of the unit. Our sample was not representative of the neonatal population with risk factors for severe disease, so our findings should be interpreted with caution and may only be applicable to populations with similar characteristics.Previous studies have demonstrated that HFNC oxygen therapy reduces the need for intubation from 23% to 9% in patients with bronchiolitis admitted to the PICU.<a class="elsevierStyleCrossRef" href="#bib0300">21</a> A retrospective study that included children aged less than 24 months admitted to the PICU with different respiratory diseases found that in the subset of patients with bronchiolitis, 25% required NIV after HFNC oxygen therapy and 4% required IMV.<a class="elsevierStyleCrossRef" href="#bib0310">23</a> Another prospective study assessed the use of HFNC therapy in patients with bronchiolitis in a paediatric ward and found a significant reduction in the percentage of admissions to the PICU compared to previous periods; 20% of the patients in the study required admission to the PICU following HFNC oxygen therapy (16% NIV and 4% IMV).<a class="elsevierStyleCrossRef" href="#bib0320">25</a>Consistent with the existing literature, 22.7% of the patients in our study required NIV following HFNC oxygen therapy. However, the population and setting of our study are different. Some studies that have analysed the use of HFNC oxygen therapy in infants with bronchiolitis included newborns in their samples, but did not report specific findings for this group of patients.<a class="elsevierStyleCrossRefs" href="#bib0265">14,35</a> The vulnerability of newborns, which results from the immaturity of their immune system and entails a higher risk of severe bronchiolitis, makes this population markedly different from other populations studied in the past. Our study is one of the first to assess the use of HFNC oxygen therapy in the treatment of bronchiolitis exclusively in newborns, and while our data did not suffice to evince a reduction in the rate of intubation, they demonstrated that HFNC oxygen therapy is effective in newborns with bronchiolitis, as its use was associated with a reduced need for NIV (from 30.4% to 10.7%).Studies conducted in PICUs have shown a reduction in length of stay with the use of HFNC therapy.<a class="elsevierStyleCrossRef" href="#bib0305">22</a> Our study did not find a significant difference in length of stay between the two periods. One possible explanation is that we analysed length of stay excluding patients that needed transferring, as they were not followed up in our institution by our research team. This probably led to an underestimation of the length of stay in the pre-HFNC period, as several previous studies have found a positive correlation between length of stay and the need for intubation.<a class="elsevierStyleCrossRef" href="#bib0305">22</a>The prospective phase of the study allowed us to analyse the outcomes of newborns treated with HFNC oxygen therapy. We observed a quick and gradual improvement in the HR, respiratory rate and severity score during treatment, with a period of increased clinical stability at 18–24h from its initiation. This improvement made it possible to give enteral feeds to 86.3% of the newborns after an initial stabilisation period.On the other hand, there was a significant reduction in the PCO2 starting at 6h of treatment, a variable for which there is little data in the use of this technique. Previous studies have demonstrated that HFNC oxygen therapy achieves a PEEP of 4±1.99cmH2O, increasing the mean airway pressure.<a class="elsevierStyleCrossRefs" href="#bib0375">36,37</a> The improvement in clinical condition resulting from a reduction of respiratory muscle fatigue and lung volume recruitment could contribute to improving gas exchange, with the corresponding reduction in the PCO2.In this cohort, HFNC oxygen therapy was initiated on patients with a median WDF score of 7, which is indicative of moderate severity. Early initiation of HFNC could be the key to achieve optimal results, as easing respiratory effort prevents progression to respiratory muscle fatigue and the development of atelectases.<a class="elsevierStyleCrossRef" href="#bib0385">38</a>Although one study reported the cases of one infant and two children who experienced adverse effects from HFNC therapy,<a class="elsevierStyleCrossRef" href="#bib0390">39</a> the patients in our study did not experience any complications at the delivered flow rates. Previous studies have shown that the administration of flows equal or greater than 2L/kg/min produces a mean laryngeal pressure of 4 or more cmH2O that is correlated with clinically relevant results, such as an improved breathing pattern.<a class="elsevierStyleCrossRef" href="#bib0265">14</a> The flow administered in our cohort was the amount needed to achieve clinical improvement without the development of side effects.The findings of this study must be interpreted taking into account its strengths and weaknesses. One of its limitations lies in its nonrandomised design, which could be a source of bias. In order to minimise the possibility of selection bias, we included all patients with bronchiolitis and developed a protocol that established the criteria for the use of HFNC oxygen therapy with the purpose of avoiding overtreatment with this technique. The supportive care measures and the indications for NIV used during the HFCN period were the same as those used in the preceding period, as we attempted to minimise the time-period bias. The analysis of the data showed that the cohorts were similar in their baseline characteristics and other treatments received, which allowed us to obtain results of acceptable validity. While we are aware that the design of the study implies a poor control of potential biases, our findings could serve as the starting point for future studies.The main strength of the study is that it is one of the first in the literature that assesses the impact of the use of HFNC oxygen therapy in newborns with bronchiolitis. Considering that the neonatal period is clearly different from all other paediatric age groups, and that newborns are a high-risk group with a high rate of admissions to intensive care units during epidemic seasons, providing evidence on this group of patients is highly relevant.We concluded that HFNC oxygen therapy oxygen delivery is an efficacious, easy to use, well-tolerated therapy that succeeds in reducing the frequency of NIV in newborns with bronchiolitis, in addition to facilitating enteral nutrition. Its easy implementation makes it an ideal technique for level I and II neonatal units, which could contribute to improving the management of resources by trying to reserve neonatal and paediatric intensive care units for patients that require intensive respiratory support.Conflict of interestsThe authors have no conflict of interests to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres782724" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec781684" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres782725" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec781685" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Patients and methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "High flow nasal cannula oxygen therapy period" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Pre-high-flow oxygen therapy period" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Statistical analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0030" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-12-29" "fechaAceptado" => "2016-03-01" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec781684" "palabras" => array:5 [ 0 => "High flow nasal cannula oxygen therapy" 1 => "Neonates" 2 => "Bronchiolitis" 3 => "Invasive mechanical ventilation" 4 => "Non-invasive mechanical ventilation" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec781685" "palabras" => array:5 [ 0 => "Oxigenoterapia de alto flujo" 1 => "Neonatos" 2 => "Bronquiolitis aguda" 3 => "Ventilación mecánica invasiva" 4 => "Ventilación mecánica no invasiva" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveTo determine whether the availability of heated humidified high-flow nasal cannula (HFNC) therapy was associated with a decrease in need for mechanical ventilation in neonates hospitalised with acute bronchiolitis. MethodsA combined retrospective and prospective (ambispective) cohort study was performed in a type II-B Neonatal Unit, including hospitalised neonates with acute bronchiolitis after the introduction of HFNC (HFNC-period; October 2011–April 2015). They were compared with a historical cohort prior to the availability of this technique (pre-HFNC; January 2008–May 2011). The need for mechanical ventilation between the two study groups was analysed. Clinical parameters and technique-related complications were evaluated in neonates treated with HFNC. ResultsA total of 112 neonates were included, 56 after the introduction of HFNC and 56 from the period before the introduction of HFNC. None of the patients in the HFNC-period required intubation, compared with 3.6% of the patients in the pre-HFNC group. The availability of HFNC resulted in a significant decrease in the need for non-invasive mechanical ventilation (30.4% vs 10.7%; P=.01), with a relative risk (RR) of .353 (95% CI: .150–.829), an absolute risk reduction (ARR) of 19.6% (95% CI: 5.13–34.2), yielding a NNT of 5. In the HFNC-period, 22 patients received high flow therapy, and 22.7% (95% CI: 7.8–45.4) required non-invasive ventilation. Treatment with HFNC was associated with a significant decrease in heart rate (P=.03), respiratory rate (P=.01), and an improvement in the Wood-Downes-Férres score (P=.00). No adverse effects were observed. ConclusionsThe availability of HFNC reduces the need for non-invasive mechanical ventilation, allowing a safe and effective medical management of neonates with acute bronchiolitis." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoDeterminar si el uso de oxigenoterapia de alto flujo (OAF) en cánulas nasales disminuye la necesidad de ventilación mecánica en neonatos hospitalizados con bronquiolitis aguda. MétodosEstudio de cohortes ambispectivo, realizado en una unidad neonatal IIB, que incluyó neonatos ingresados con bronquiolitis desde la instauración de la técnica de OAF (período-OAF: octubre de 2011-abril de 2015), comparándolo con una cohorte histórica de la temporada previa a su uso (período pre-OAF: enero de 2008-mayo de 2011). Se analizó la proporción de ventilación mecánica antes y después del inicio del tratamiento con OAF y se evaluaron parámetros clínicos y complicaciones de los pacientes tratados con esta técnica. ResultadosSe incluyeron 112 neonatos, 56 del período-OAF y 56 de la temporada pre-OAF. En el período-OAF ningún paciente requirió intubación en comparación con la temporada previa, donde el 3,6% precisó ventilación mecánica invasiva. El uso de OAF se asoció con una disminución significativa de ventilación mecánica no invasiva (30,4% vs 10,7%; p=0,01), con un RR de 0,353 (IC 95%: 0,150-0,829), RAR de 19,6% (IC 95%: 5,13-34,2) y NNT de 5. En el período-OAF 22 pacientes recibieron terapia de alto flujo y 22,7% de ellos (IC 95%: 7,8-45,4) requirieron ventilación no invasiva. Tras el inicio de OAF se observó una mejoría rápida y progresiva de la frecuencia cardiaca (p=0,03), frecuencia respiratoria (p=0,01) y escala clínica (p=0,00) a partir de 3h. No se registraron efectos adversos. ConclusionesEl uso de OAF disminuye la necesidad de ventilación no invasiva y es un tratamiento seguro que consigue mejoría clínica de neonatos con bronquiolitis." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Bermúdez Barrezueta L, García Carbonell N, López Montes J, Gómez Zafra R, Marín Reina P, Herrmannova J, et al. Oxigenoterapia de alto flujo con cánula nasal en el tratamiento de la bronquiolitis aguda en neonatos. An Pediatr (Barc). 2017;86:37–44." ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1153 "Ancho" => 2844 "Tamanyo" => 438042 ] ] "descripcion" => array:1 [ "en" => "(A) Mean (95% CI) flow in L/min administered during the first 48h of respiratory support with HFNC oxygen therapy. (B) Mean and standard deviation (SD) of flow (L/min) at different time intervals." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2097 "Ancho" => 2720 "Tamanyo" => 539694 ] ] "descripcion" => array:1 [ "en" => "Changes in cardiorespiratory parameters and in the Wood-Downes-Ferrés severity score in the first 48h of treatment with HFNC oxygen therapy. (A) Heart rate (mean, 95% CI). (B) Respiratory rate (mean, 95% CI). (C) PCO2 obtained from capillary blood gas testing (mean, 95% CI). (D) Wood-Downes-Ferrés severity score (median, interquartile range)." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Criteria for use of high-flow nasal cannula oxygen therapy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Wood-Downes-Ferrés score>6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Requires oxygen therapy with conventional nasal prongs at >2L/min to maintain an oxygen saturation>92% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Respiratory acidosis with hypercapnia>50mmHg in capillary blood gas \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Apnoeas \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Criteria for initiation of noninvasive mechanical ventilation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Persistent apnoeas \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypercapnia with pH of 7.20–7.25 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Requires FiO2>0.40 to achieve SaO2>92% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Criteria for initiation of invasive mechanical ventilation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Symptoms of severe respiratory distress with signs of imminent respiratory failure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Persistent apnoeas despite NIV \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Requires FiO2>0.6 to achieve SaO2>90% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Altered level of consciousness \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1300509.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Criteria for initiation of different respiratory support modalities." ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Categorical variables are expressed as percentage (95% CI) and quantitative variables as median [interquartile range]." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pre-HFNC group (n=56) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">HFNC group (n=56) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">P \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age (days) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Median \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20 [15.2–26.9] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21.6 [17.1–26.3] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.59 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Birth weight (g) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Median \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3200 [2900–3650] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3265 [2965–3627.5] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.76 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Weight at admission (g) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Median \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3490 [3013.8–3803.8] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3597.5 [3276.3–3993.8] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gestational age (weeks) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Median \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">39.3 [1.38–40] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">39.2 [3.38–40] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.78 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Preterm birth (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17.9 (6.928.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16.1 (5.626.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.80 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sex (male) (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">53.6 (39.6–67.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50.9 (36–64) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.78 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Respiratory syncytial virus (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">78.6 (66.9–90.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">78.6 (66.9–90.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Palivizumab (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.4 (1.1–14.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.4 (1.1–14.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Breastfeeding (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50 (36–64) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60.7 (47–74.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.25 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bronchopulmonary dysplasia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acyanotic heart disease (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.8 (0.1–9.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.4 (1.1–14.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.62 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Neuropathy (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.8 (0.1–9.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Antibiotic treatment (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">32.1 (19.2–45.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26.8 (14.3–39.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.53 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nebulised adrenaline (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">67.9 (54.7–81) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">78.6 (66.9–90.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.20 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nebulised salbutamol (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16.1 (5.6–26.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.5 (3–22.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.59 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nebulised 3% hypertonic saline (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17.9 (6.9–28.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14.3 (4.2–24.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.61 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top">Respiratory support (%)</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19.6 (8.3–30.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">33.9 (20.6–47.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.09 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">O2 nasal cannulae \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">50 (36–64) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">25 (12.8–37.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.01 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">HFNC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">39.3 (25.6–53) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.00 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">NIV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30.4 (17.4–43.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.7 (1.7–19.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.01 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">IMV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.6 (0.4–12.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.50 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="5" align="left" valign="top"></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Length of stay in days \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Median \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.92 [4.46–7.51] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.03 [4.68–7.94] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.69 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1300510.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Characteristics of the newborns in the two periods under study: pre-HFNC (2008–2011) and HFNC (2011–2015)." ] ] 4 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Values expressed as percentage (95% CI) and median (interquartile range [IQR])." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N=22 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">95% CI [IQR] \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age (days) [median] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">[16.9–25.6] \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gestational age (weeks) [median] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">39.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">[38.1–40.3] \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Preterm birth (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (18.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.2–40.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Birth weight (g) [median] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.235 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">[2.800–3.500] \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Weight at admission (g) [median] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.525 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">[3.280–3.870] \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sex (male) (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13 (59.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">36.3–81.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Respiratory syncytial virus (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21 (95.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">77.2–99.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Family history of atopy (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 (22.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.8–45.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Previous admission (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9 (40.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18.1–63.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acyanotic heart disease (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (4.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.1–22.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Breastfeeding (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 (50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26.8–73.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Palivizumab (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fever (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">14 (63.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">41.3–86 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Atelectasis/consolidation (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 (50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26.8–73.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Antibioterapia (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11 (50) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26.8–73.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nebulised adrenaline (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">22 (100) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">84.5–100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nebulised salbutamol (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 (4.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.1–22.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nebulised 3% hypertonic saline (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 (18.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.2–40.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Clinical parameters prior to initiation of HFNC [median]</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Clinical score \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">[7–8] \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Heart rate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">160 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">[150–170] \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Respiratory rate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">[48–70] \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Oxygen saturation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">94 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">[91–97] \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">FiO2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">[21–27] \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">pH (capillary blood gas) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.34 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">[7.32–7.38] \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PCO2 (capillary blood gas) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">57 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">[52–60.5] \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1300511.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Characteristics of patients that received respiratory support with HFOT in the 2011–2015 period." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:39 [ 0 => array:3 [ "identificador" => "bib0200" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "221.e1–221.e33" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Conferencia de consenso sobre bronquiolitis aguda (I): Metodología y recomendaciones" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J. 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Original Article

High flow nasal cannula oxygen therapy in the treatment of acute bronchiolitis in neonates

Oxigenoterapia de alto flujo con cánula nasal en el tratamiento de la bronquiolitis aguda en neonatos

Lorena Bermúdez Barrezueta

Corresponding author

bermudezlorena@hotmail.com
bermudezlorena2@gmail.com

Corresponding author.

, Nuria García Carbonell, Jorge López Montes, Rafael Gómez Zafra, Purificación Marín Reina, Jana Herrmannova, Javier Casero Soriano

Departamento de Pediatría, Consorcio Hospital General Universitario de Valencia, Valencia, Spain

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There is no evidence of any treatment being capable of altering the natural course of the disease&#44; but some treatments may prevent the development of complications and improve patient comfort&#46; The approaches to the management of these patients backed by scientific evidence consist of supportive care and mechanical ventilation&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">2&#44;6&#8211;10</span></a> In recent years&#44; clinical practice has widely incorporated the use of nebulised hypertonic saline &#40;HTS&#41; in moderate bronchiolitis and of noninvasive ventilation &#40;NIV&#41; and high-flow nasal cannula &#40;HFNC&#41; oxygen therapy as supportive measures to prevent invasive mechanical ventilation &#40;IMV&#41; in patients with severe bronchiolitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">6&#44;11&#8211;20</span></a> Although NIV has proven to be a useful tool in paediatric patients with respiratory failure&#44; its use may be limited in low birth weight infants due to their poor tolerance of the technique&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">21</span></a> High-flow nasal cannula therapy is a noninvasive respiratory support technique that delivers a heated and humidified blend of air and oxygen through nasal cannulae at rates exceeding the peak inspiratory flow&#44; and has proven useful in the management of moderate to severe bronchiolitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">14&#44;15&#44;22&#8211;27</span></a> The effectiveness of this technique compared to CPAP has been assessed in newborns for the treatment of neonatal respiratory distress syndrome&#44;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">28&#8211;32</span></a> but there is little published evidence on its use in newborns with bronchiolitis&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">32</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The aim of this study was to determine whether initiation of HFNC oxygen therapy with nasal cannulae in a neonatal unit succeeded in reducing the need for mechanical ventilation in newborns admitted with acute bronchiolitis&#46; We also analysed the clinical outcomes of patients treated with HFOT&#44; as well as the complications that developed&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">We conducted an ambispective cohort study in the level IIB neonatal unit of the Consorcio Hospital General Universitario de Valencia&#44; Spain&#44; which included&#58; &#40;1&#41; a prospective cohort of newborns admitted with bronchiolitis from October 2011&#44; when the use of HFNC oxygen therapy was introduced in the unit&#44; to April 2015 &#40;HFNC period&#41;&#59; &#40;2&#41; comparison with a retrospective cohort of newborns admitted with bronchiolitis in the period preceding the introduction of HFNC&#44; from January 2008 to May 2011 &#40;pre-HFOT period&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The diagnosis of bronchiolitis was made following the definition proposed by McConnochie&#58; first episode of respiratory distress with wheezing&#44; preceded by signs of viral respiratory illness&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">33</span></a> The inclusion criteria were chronological age of 28 days or less in term newborns or corrected gestational age of 42 weeks or less in preterm newborns &#40;&#60;37 weeks&#8217; gestation&#41;&#46; We excluded patients with haemodynamic instability&#44; sepsis&#44; or that required intubation on admission&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The primary outcome variable was the need for mechanical ventilation &#40;NIV and IMV&#41; in the two periods under study&#46; We analysed other variables&#44; such as sex&#44; gestational age&#44; birth weight&#44; age and weight at the time of admission&#44; aetiological agent&#44; infant feeding method&#44; prior history of palivizumab treatment&#44; comorbidities&#44; pharmacological treatment received during admission&#44; length of stay and need for transfer to the PICU&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The study was approved by the Research Commission of the Consorcio Hospital General Universitario de Valencia&#46;</p><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">High flow nasal cannula oxygen therapy period</span><p id="par0040" class="elsevierStylePara elsevierViewall">HFNC oxygen therapy was introduced with a protocol based on the existing scientific evidence that set the criteria for its use as well as step-wise criteria to transition to other modalities of respiratory support when required &#40;NIV or IMV&#41;&#46; Continuous monitoring by pulse oximetry and supportive care were initiated in all patients&#44; while the need for pharmacological treatment with nebulised adrenaline was assessed on a case-by-case basis&#44; following the same protocol applied in preceding years&#46; Respiratory support with HFNC oxygen therapy was initiated if patients met any of the criteria listed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">HFNC oxygen therapy was delivered using the Fisher &#38; Paykel<span class="elsevierStyleSup">&#174;</span> MR850<span class="elsevierStyleSup">&#174;</span> system with nasal cannulae &#40;Optiflow&#8482;&#41;&#46; Therapy was initiated at a rate of 4&#8211;6<span class="elsevierStyleHsp" style=""></span>L&#47;min that was increased progressively to a maximum of 10<span class="elsevierStyleHsp" style=""></span>L&#47;min until clinical improvement was achieved&#46; The initial fraction concentration of oxygen in inspired gas &#40;FiO<span class="elsevierStyleInf">2</span>&#41; was set at the pressure required to achieve an oxygen &#40;SaO<span class="elsevierStyleInf">2</span>&#41; of more than 92&#37; and was adjusted based on how the patient responded to a maximum FiO<span class="elsevierStyleInf">2</span> of 0&#46;40&#46; If the patient became clinically stable with a Wood-Downes-Ferr&#233;s &#40;WDF&#41; score of 4 or higher&#44; the flow rate was gradually reduced to 2<span class="elsevierStyleHsp" style=""></span>L&#47;min and the FiO<span class="elsevierStyleInf">2</span> to 0&#46;25&#44; and HFNC oxygen therapy was discontinued&#46; At this point&#44; the need for oxygen therapy with conventional nasal prongs at 2<span class="elsevierStyleHsp" style=""></span>L&#47;min or less was assessed&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Failure of HFNC oxygen therapy was defined as lack of clinical improvement or worsening in the condition of the patient despite the optimisation of therapy with delivery of maximum FiO<span class="elsevierStyleInf">2</span> and flow rates&#44; requiring transition to another modality of respiratory support&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> presents the criteria for initiation of NIV or IMV&#46; The need for IMV was considered a criterion for admission to the PICU or the neonatal ICU&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">During treatment with HFNC oxygen therapy&#44; we documented the following parameters at different time points&#58; temperature&#44; respiratory rate&#44; heart rate &#40;HR&#41;&#44; SaO<span class="elsevierStyleInf">2</span>&#44; FiO<span class="elsevierStyleInf">2</span> and WDF score&#46; The parameters were recorded at the time of initiation of HFNC oxygen therapy &#40;baseline&#41; and at 3&#44; 6&#44; 12&#44; 18&#44; 24&#44; 36&#44; 48&#44; 72 and 96<span class="elsevierStyleHsp" style=""></span>h&#46; We recorded capillary blood gas parameters &#40;pH&#44; PCO<span class="elsevierStyleInf">2</span>&#41; at 6&#44; 12&#44; 18&#44; 24&#44; and 48<span class="elsevierStyleHsp" style=""></span>h from initiation of HFNC oxygen therapy&#44; and documented adverse effects &#40;pneumothorax&#44; intolerance to the technique&#44; hypothermia&#44; skin erosion at the area of contact with the cannula&#44; or aspiration of food&#41;&#44; duration of nothing by mouth &#40;NPO&#41;&#44; and method of feeding&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Pre-high-flow oxygen therapy period</span><p id="par0060" class="elsevierStylePara elsevierViewall">In the second phase of the study&#44; we collected data retrospectively by reviewing the medical records of newborns admitted with bronchiolitis over a period of four epidemic seasons preceding the introduction of HFNC oxygen therapy in the unit&#44; applying the inclusion and exclusion criteria&#46; During this period&#44; the criteria for hospital admission and the management of patients were similar to those applied in the HFNC period&#44; with the exception of the use of HFNC oxygen therapy&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Statistical analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">We performed the statistical analysis with the software package IBM SPSS 20&#46;0 for Windows<span class="elsevierStyleSup">&#174;</span>&#46; We have summarised categorical variables as percentages and 95&#37; confidence intervals &#40;CIs&#41; and quantitative variables as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation in case they followed a normal distribution&#44; or median and interquartile range otherwise&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">We compared the baseline characteristics of the two cohorts by means of the Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test for continuous variables and Fisher&#39;s exact test or the chi-square test for categorical variables&#46; We assessed the impact of the introduction of HFNC oxygen therapy on mechanical ventilation by means of the following measures&#58; relative risk &#40;RR&#41;&#44; absolute risk reduction &#40;ARR&#41; and the number needed to treat &#40;NNT&#41; with HFNC oxygen therapy to prevent the use of mechanical ventilation&#46; When we analysed the length of stay&#44; we excluded patients that were transferred to the PICU&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">We analysed the changes in quantitative secondary outcome variables &#40;WDF score&#44; HR&#44; respiratory rate&#44; SaO<span class="elsevierStyleInf">2</span>&#44; pH&#44; PCO<span class="elsevierStyleInf">2</span>&#44; flow rate in L&#47;min&#41; by means of the Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test for paired samples&#46; We defined statistical significance as a <span class="elsevierStyleItalic">P</span>-value of less than &#46;05&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0080" class="elsevierStylePara elsevierViewall">We included a total of 112 newborns&#44; 56 in the cohort of the HFNC period &#40;2011&#8211;2015&#41; and 56 in the cohort of the period preceding the introduction of HFNC oxygen therapy &#40;2008&#8211;2011&#41;&#46; We did not find statistically significant differences between the cohorts in the baseline characteristics of the patients or the pharmacological treatment they received &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The respiratory support techniques used in each period were different&#44; and we observed that the use of HFNC oxygen therapy was associated with a significant reduction in the need for NIV &#40;30&#46;4&#37; vs 10&#46;7&#37;&#59; <span class="elsevierStyleItalic">P<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;</span>01&#41;&#44; RR of 0&#46;35 &#40;95&#37; CI&#58; &#46;15&#8211;&#46;83&#41;&#44; ARR of 19&#46;6&#37; &#40;95&#37; CI&#58; 5&#46;13&#8211;34&#46;20&#41; and NNT of 5&#46; We did not find a significant difference in the use of IMV&#46; The length of stay in days was similar in both groups &#40;5&#46;92 pre-HFOT vs 6&#46;03 in the HFOT period&#59; <span class="elsevierStyleItalic">P<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;</span>688&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">We analysed the data for the patients that received respiratory support with HFNC oxygen therapy in the 2011&#8211;2015 period &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows their baseline characteristics and the treatments they received&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">High-flow nasal cannula oxygen therapy was initiated with a mean flow rate of 6&#46;8<span class="elsevierStyleHsp" style=""></span>L&#47;min &#40;SD&#44; 1&#46;5&#41;&#46; The flow rate was increased gradually until reaching the maximum value &#40;mean&#44; 8&#46;1<span class="elsevierStyleHsp" style=""></span>L&#47;min&#59; SD&#44; 1&#46;7&#41; at 12<span class="elsevierStyleHsp" style=""></span>h&#44; as can be seen in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; The maximum flow administered was 10<span class="elsevierStyleHsp" style=""></span>L&#47;min at a dose of 3<span class="elsevierStyleHsp" style=""></span>L&#47;kg&#47;min&#44; with a maximum FiO<span class="elsevierStyleInf">2</span> of 0&#46;40&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Treatment with HFNC oxygen therapy was associated with significant decreases in HR from 160<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>15&#46;4 to 150&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>11&#46;6 &#40;<span class="elsevierStyleItalic">P<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;</span>03&#41;&#44; in respiratory rate from 59<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#46;6 to 48&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;6 &#40;<span class="elsevierStyleItalic">P<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;</span>01&#41; and in the WDF score from 7 &#40;6&#46;8&#8211;8&#46;3&#41; to 6 &#40;5&#8211;7&#41; &#40;<span class="elsevierStyleItalic">P<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;</span>001&#41;&#44; starting at 3<span class="elsevierStyleHsp" style=""></span>h from initiation of HFNC oxygen therapy&#46; We also observed a significant decrease in capillary blood PCO<span class="elsevierStyleInf">2</span> from 55&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;2 to 51&#46;1<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#46;8 &#40;<span class="elsevierStyleItalic">P<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;</span>012&#41; at 6<span class="elsevierStyleHsp" style=""></span>h&#46; We observed a decreasing trend in the different parameters under study throughout the treatment with HFNC oxygen therapy with a peak in clinical stabilisation at 18 to 24<span class="elsevierStyleHsp" style=""></span>h &#40;HR&#44; 141<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14&#59; respiratory rate&#44; 44<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#59; PCO<span class="elsevierStyleInf">2</span>&#44; 48&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6&#59; WDF severity score&#44; 4 &#91;4&#8211;5&#93;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">We did not observe adverse effects such as pneumothorax&#44; intolerance of HFNC oxygen therapy&#44; hypothermia&#44; skin erosion at the area of contact with the cannula or aspiration of food&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Enteral feeding by nipple feeding or orogastric tube was used in 86&#46;3&#37; of patients during treatment following a period of initial stabilisation with a median duration of NPO of 12&#46;3<span class="elsevierStyleHsp" style=""></span>h &#40;7&#46;8&#8211;25&#41;&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">High-flow oxygen therapy failed in five patients &#40;22&#46;7&#37;&#59; 95&#37; CI&#58; 7&#46;8&#8211;45&#46;4&#41;&#44; who required sequential treatment with NIV&#46; The causes of failure were respiratory acidosis &#40;60&#37;&#41;&#44; requirement of a FiO<span class="elsevierStyleInf">2</span> greater than 0&#46;40 &#40;20&#37;&#41; and increased breathing effort &#40;20&#37;&#41;&#46; None of the patients required intubation or transfer to the PICU or neonatal ICU&#46; During this period&#44; one patient was treated with NIV without prior HFNC oxygen therapy due to meeting the severity criteria for NIV at the time of admission&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The median duration of HFNC oxygen therapy was 57<span class="elsevierStyleHsp" style=""></span>h &#40;34&#46;5&#8211;80&#46;1&#41; and the median length of stay was 8&#46;1 days &#40;6&#46;6&#8211;9&#46;7&#41;&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0125" class="elsevierStylePara elsevierViewall">The main finding of our study was a significant decrease in the use of NIV after the introduction of HFNC oxygen therapy in our neonatal unit&#46; Furthermore&#44; two patients required IMV during the pre-HFNC period&#44; while none required intubation or transfer to the ICU after the introduction of HFNC oxygen therapy&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Several studies have demonstrated that NIV is a useful tool in the management of severe bronchiolitis&#44; its main advantage being that it reduces the incidence of complications associated with IMV&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">12&#44;17</span></a> However&#44; its use may pose challenges in infants due to limitations related to the interface or to poor tolerance&#44; with some of the patients requiring sedation&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">21&#44;34</span></a> Furthermore&#44; it requires a ventilator and in many instances&#44; transfer to the ICU&#44; which results in increased costs of treatment&#46; For these reasons&#44; we believe that a reduction in the use of NIV offers significant advantages in the management of patients with bronchiolitis in addition to a reduction of health care costs&#44; although we did not analyse these variables in our study&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">When it came to the characteristics of our sample&#44; the newborns included in the study did not have relevant perinatal risk factors&#44; such as bronchopulmonary dysplasia&#44; severe prematurity or cyanotic heart disease&#44; which could be accounted for by the level of care of the unit&#46; Our sample was not representative of the neonatal population with risk factors for severe disease&#44; so our findings should be interpreted with caution and may only be applicable to populations with similar characteristics&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Previous studies have demonstrated that HFNC oxygen therapy reduces the need for intubation from 23&#37; to 9&#37; in patients with bronchiolitis admitted to the PICU&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">21</span></a> A retrospective study that included children aged less than 24 months admitted to the PICU with different respiratory diseases found that in the subset of patients with bronchiolitis&#44; 25&#37; required NIV after HFNC oxygen therapy and 4&#37; required IMV&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">23</span></a> Another prospective study assessed the use of HFNC therapy in patients with bronchiolitis in a paediatric ward and found a significant reduction in the percentage of admissions to the PICU compared to previous periods&#59; 20&#37; of the patients in the study required admission to the PICU following HFNC oxygen therapy &#40;16&#37; NIV and 4&#37; IMV&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">25</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Consistent with the existing literature&#44; 22&#46;7&#37; of the patients in our study required NIV following HFNC oxygen therapy&#46; However&#44; the population and setting of our study are different&#46; Some studies that have analysed the use of HFNC oxygen therapy in infants with bronchiolitis included newborns in their samples&#44; but did not report specific findings for this group of patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">14&#44;35</span></a> The vulnerability of newborns&#44; which results from the immaturity of their immune system and entails a higher risk of severe bronchiolitis&#44; makes this population markedly different from other populations studied in the past&#46; Our study is one of the first to assess the use of HFNC oxygen therapy in the treatment of bronchiolitis exclusively in newborns&#44; and while our data did not suffice to evince a reduction in the rate of intubation&#44; they demonstrated that HFNC oxygen therapy is effective in newborns with bronchiolitis&#44; as its use was associated with a reduced need for NIV &#40;from 30&#46;4&#37; to 10&#46;7&#37;&#41;&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Studies conducted in PICUs have shown a reduction in length of stay with the use of HFNC therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">22</span></a> Our study did not find a significant difference in length of stay between the two periods&#46; One possible explanation is that we analysed length of stay excluding patients that needed transferring&#44; as they were not followed up in our institution by our research team&#46; This probably led to an underestimation of the length of stay in the pre-HFNC period&#44; as several previous studies have found a positive correlation between length of stay and the need for intubation&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">22</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">The prospective phase of the study allowed us to analyse the outcomes of newborns treated with HFNC oxygen therapy&#46; We observed a quick and gradual improvement in the HR&#44; respiratory rate and severity score during treatment&#44; with a period of increased clinical stability at 18&#8211;24<span class="elsevierStyleHsp" style=""></span>h from its initiation&#46; This improvement made it possible to give enteral feeds to 86&#46;3&#37; of the newborns after an initial stabilisation period&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">On the other hand&#44; there was a significant reduction in the PCO<span class="elsevierStyleInf">2</span> starting at 6<span class="elsevierStyleHsp" style=""></span>h of treatment&#44; a variable for which there is little data in the use of this technique&#46; Previous studies have demonstrated that HFNC oxygen therapy achieves a PEEP of 4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;99<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O&#44; increasing the mean airway pressure&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">36&#44;37</span></a> The improvement in clinical condition resulting from a reduction of respiratory muscle fatigue and lung volume recruitment could contribute to improving gas exchange&#44; with the corresponding reduction in the PCO<span class="elsevierStyleInf">2</span>&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">In this cohort&#44; HFNC oxygen therapy was initiated on patients with a median WDF score of 7&#44; which is indicative of moderate severity&#46; Early initiation of HFNC could be the key to achieve optimal results&#44; as easing respiratory effort prevents progression to respiratory muscle fatigue and the development of atelectases&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">38</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Although one study reported the cases of one infant and two children who experienced adverse effects from HFNC therapy&#44;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">39</span></a> the patients in our study did not experience any complications at the delivered flow rates&#46; Previous studies have shown that the administration of flows equal or greater than 2<span class="elsevierStyleHsp" style=""></span>L&#47;kg&#47;min produces a mean laryngeal pressure of 4 or more cmH<span class="elsevierStyleInf">2</span>O that is correlated with clinically relevant results&#44; such as an improved breathing pattern&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">14</span></a> The flow administered in our cohort was the amount needed to achieve clinical improvement without the development of side effects&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">The findings of this study must be interpreted taking into account its strengths and weaknesses&#46; One of its limitations lies in its nonrandomised design&#44; which could be a source of bias&#46; In order to minimise the possibility of selection bias&#44; we included all patients with bronchiolitis and developed a protocol that established the criteria for the use of HFNC oxygen therapy with the purpose of avoiding overtreatment with this technique&#46; The supportive care measures and the indications for NIV used during the HFCN period were the same as those used in the preceding period&#44; as we attempted to minimise the time-period bias&#46; The analysis of the data showed that the cohorts were similar in their baseline characteristics and other treatments received&#44; which allowed us to obtain results of acceptable validity&#46; While we are aware that the design of the study implies a poor control of potential biases&#44; our findings could serve as the starting point for future studies&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The main strength of the study is that it is one of the first in the literature that assesses the impact of the use of HFNC oxygen therapy in newborns with bronchiolitis&#46; Considering that the neonatal period is clearly different from all other paediatric age groups&#44; and that newborns are a high-risk group with a high rate of admissions to intensive care units during epidemic seasons&#44; providing evidence on this group of patients is highly relevant&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">We concluded that HFNC oxygen therapy oxygen delivery is an efficacious&#44; easy to use&#44; well-tolerated therapy that succeeds in reducing the frequency of NIV in newborns with bronchiolitis&#44; in addition to facilitating enteral nutrition&#46; Its easy implementation makes it an ideal technique for level I and II neonatal units&#44; which could contribute to improving the management of resources by trying to reserve neonatal and paediatric intensive care units for patients that require intensive respiratory support&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interests</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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          "identificador" => "sec0010"
          "titulo" => "Patients and methods"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "High flow nasal cannula oxygen therapy period"
            ]
            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Pre-high-flow oxygen therapy period"
            ]
            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Statistical analysis"
            ]
          ]
        ]
        6 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Results"
        ]
        7 => array:2 [
          "identificador" => "sec0035"
          "titulo" => "Discussion"
        ]
        8 => array:2 [
          "identificador" => "sec0040"
          "titulo" => "Conflict of interests"
        ]
        9 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2015-12-29"
    "fechaAceptado" => "2016-03-01"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec781684"
          "palabras" => array:5 [
            0 => "High flow nasal cannula oxygen therapy"
            1 => "Neonates"
            2 => "Bronchiolitis"
            3 => "Invasive mechanical ventilation"
            4 => "Non-invasive mechanical ventilation"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec781685"
          "palabras" => array:5 [
            0 => "Oxigenoterapia de alto flujo"
            1 => "Neonatos"
            2 => "Bronquiolitis aguda"
            3 => "Ventilaci&#243;n mec&#225;nica invasiva"
            4 => "Ventilaci&#243;n mec&#225;nica no invasiva"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To determine whether the availability of heated humidified high-flow nasal cannula &#40;HFNC&#41; therapy was associated with a decrease in need for mechanical ventilation in neonates hospitalised with acute bronchiolitis&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A combined retrospective and prospective &#40;ambispective&#41; cohort study was performed in a type II-B Neonatal Unit&#44; including hospitalised neonates with acute bronchiolitis after the introduction of HFNC &#40;HFNC-period&#59; October 2011&#8211;April 2015&#41;&#46; They were compared with a historical cohort prior to the availability of this technique &#40;pre-HFNC&#59; January 2008&#8211;May 2011&#41;&#46; The need for mechanical ventilation between the two study groups was analysed&#46; Clinical parameters and technique-related complications were evaluated in neonates treated with HFNC&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 112 neonates were included&#44; 56 after the introduction of HFNC and 56 from the period before the introduction of HFNC&#46; None of the patients in the HFNC-period required intubation&#44; compared with 3&#46;6&#37; of the patients in the pre-HFNC group&#46; The availability of HFNC resulted in a significant decrease in the need for non-invasive mechanical ventilation &#40;30&#46;4&#37; vs 10&#46;7&#37;&#59; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#44; with a relative risk &#40;RR&#41; of &#46;353 &#40;95&#37; CI&#58; &#46;150&#8211;&#46;829&#41;&#44; an absolute risk reduction &#40;ARR&#41; of 19&#46;6&#37; &#40;95&#37; CI&#58; 5&#46;13&#8211;34&#46;2&#41;&#44; yielding a NNT of 5&#46; In the HFNC-period&#44; 22 patients received high flow therapy&#44; and 22&#46;7&#37; &#40;95&#37; CI&#58; 7&#46;8&#8211;45&#46;4&#41; required non-invasive ventilation&#46; Treatment with HFNC was associated with a significant decrease in heart rate &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;03&#41;&#44; respiratory rate &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;01&#41;&#44; and an improvement in the Wood-Downes-F&#233;rres score &#40;<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;00&#41;&#46; No adverse effects were observed&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The availability of HFNC reduces the need for non-invasive mechanical ventilation&#44; allowing a safe and effective medical management of neonates with acute bronchiolitis&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Determinar si el uso de oxigenoterapia de alto flujo &#40;OAF&#41; en c&#225;nulas nasales disminuye la necesidad de ventilaci&#243;n mec&#225;nica en neonatos hospitalizados con bronquiolitis aguda&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio de cohortes ambispectivo&#44; realizado en una unidad neonatal IIB&#44; que incluy&#243; neonatos ingresados con bronquiolitis desde la instauraci&#243;n de la t&#233;cnica de OAF &#40;per&#237;odo-OAF&#58; octubre de 2011-abril de 2015&#41;&#44; compar&#225;ndolo con una cohorte hist&#243;rica de la temporada previa a su uso &#40;per&#237;odo pre-OAF&#58; enero de 2008-mayo de 2011&#41;&#46; Se analiz&#243; la proporci&#243;n de ventilaci&#243;n mec&#225;nica antes y despu&#233;s del inicio del tratamiento con OAF y se evaluaron par&#225;metros cl&#237;nicos y complicaciones de los pacientes tratados con esta t&#233;cnica&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se incluyeron 112 neonatos&#44; 56 del per&#237;odo-OAF y 56 de la temporada pre-OAF&#46; En el per&#237;odo-OAF ning&#250;n paciente requiri&#243; intubaci&#243;n en comparaci&#243;n con la temporada previa&#44; donde el 3&#44;6&#37; precis&#243; ventilaci&#243;n mec&#225;nica invasiva&#46; El uso de OAF se asoci&#243; con una disminuci&#243;n significativa de ventilaci&#243;n mec&#225;nica no invasiva &#40;30&#44;4&#37; vs 10&#44;7&#37;&#59; p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41;&#44; con un RR de 0&#44;353 &#40;IC 95&#37;&#58; 0&#44;150-0&#44;829&#41;&#44; RAR de 19&#44;6&#37; &#40;IC 95&#37;&#58; 5&#44;13-34&#44;2&#41; y NNT de 5&#46; En el per&#237;odo-OAF 22 pacientes recibieron terapia de alto flujo y 22&#44;7&#37; de ellos &#40;IC 95&#37;&#58; 7&#44;8-45&#44;4&#41; requirieron ventilaci&#243;n no invasiva&#46; Tras el inicio de OAF se observ&#243; una mejor&#237;a r&#225;pida y progresiva de la frecuencia cardiaca &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;03&#41;&#44; frecuencia respiratoria &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;01&#41; y escala cl&#237;nica &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;00&#41; a partir de 3<span class="elsevierStyleHsp" style=""></span>h&#46; No se registraron efectos adversos&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El uso de OAF disminuye la necesidad de ventilaci&#243;n no invasiva y es un tratamiento seguro que consigue mejor&#237;a cl&#237;nica de neonatos con bronquiolitis&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Objetivo"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "M&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
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          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
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    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Berm&#250;dez Barrezueta L&#44; Garc&#237;a Carbonell N&#44; L&#243;pez Montes J&#44; G&#243;mez Zafra R&#44; Mar&#237;n Reina P&#44; Herrmannova J&#44; et al&#46; Oxigenoterapia de alto flujo con c&#225;nula nasal en el tratamiento de la bronquiolitis aguda en neonatos&#46; An Pediatr &#40;Barc&#41;&#46; 2017&#59;86&#58;37&#8211;44&#46;</p>"
      ]
    ]
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        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
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        "figura" => array:1 [
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            "imagen" => "gr1.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Mean &#40;95&#37; CI&#41; flow in L&#47;min administered during the first 48<span class="elsevierStyleHsp" style=""></span>h of respiratory support with HFNC oxygen therapy&#46; &#40;B&#41; Mean and standard deviation &#40;SD&#41; of flow &#40;L&#47;min&#41; at different time intervals&#46;</p>"
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      1 => array:7 [
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Changes in cardiorespiratory parameters and in the Wood-Downes-Ferr&#233;s severity score in the first 48<span class="elsevierStyleHsp" style=""></span>h of treatment with HFNC oxygen therapy&#46; &#40;A&#41; Heart rate &#40;mean&#44; 95&#37; CI&#41;&#46; &#40;B&#41; Respiratory rate &#40;mean&#44; 95&#37; CI&#41;&#46; &#40;C&#41; PCO<span class="elsevierStyleInf">2</span> obtained from capillary blood gas testing &#40;mean&#44; 95&#37; CI&#41;&#46; &#40;D&#41; Wood-Downes-Ferr&#233;s severity score &#40;median&#44; interquartile range&#41;&#46;</p>"
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        "etiqueta" => "Table 1"
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                0 => """
                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Criteria for use of high-flow nasal cannula oxygen therapy</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Wood-Downes-Ferr&#233;s score<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Requires oxygen therapy with conventional nasal prongs at &#62;2<span class="elsevierStyleHsp" style=""></span>L&#47;min to maintain an oxygen saturation&#62;<span class="elsevierStyleHsp" style=""></span>92&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Respiratory acidosis with hypercapnia<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>50<span class="elsevierStyleHsp" style=""></span>mmHg in capillary blood gas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Apnoeas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Criteria for initiation of noninvasive mechanical ventilation</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Persistent apnoeas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hypercapnia with pH of 7&#46;20&#8211;7&#46;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Requires FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;40 to achieve SaO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>92&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Criteria for initiation of invasive mechanical ventilation</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Symptoms of severe respiratory distress with signs of imminent respiratory failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Persistent apnoeas despite NIV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Requires FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;6 to achieve SaO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>90&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Altered level of consciousness&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Criteria for initiation of different respiratory support modalities&#46;</p>"
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      ]
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        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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        "detalles" => array:1 [
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            "identificador" => "at2"
            "detalle" => "Table "
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Categorical variables are expressed as percentage &#40;95&#37; CI&#41; and quantitative variables as median &#91;interquartile range&#93;&#46;</p>"
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            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pre-HFNC group &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>56&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age &#40;days&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Median</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20 &#91;15&#46;2&#8211;26&#46;9&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">21&#46;6 &#91;17&#46;1&#8211;26&#46;3&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Birth weight &#40;g&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Median</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3200 &#91;2900&#8211;3650&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3265 &#91;2965&#8211;3627&#46;5&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Weight at admission &#40;g&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Median</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3490 &#91;3013&#46;8&#8211;3803&#46;8&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3597&#46;5 &#91;3276&#46;3&#8211;3993&#46;8&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Gestational age &#40;weeks&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Median</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">39&#46;3 &#91;1&#46;38&#8211;40&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">39&#46;2 &#91;3&#46;38&#8211;40&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;78&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Preterm birth &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17&#46;9 &#40;6&#46;928&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&#46;1 &#40;5&#46;626&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;80&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Sex &#40;male&#41; &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">53&#46;6 &#40;39&#46;6&#8211;67&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50&#46;9 &#40;36&#8211;64&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;78&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Respiratory syncytial virus &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">78&#46;6 &#40;66&#46;9&#8211;90&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">78&#46;6 &#40;66&#46;9&#8211;90&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Palivizumab &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;4 &#40;1&#46;1&#8211;14&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;4 &#40;1&#46;1&#8211;14&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Breastfeeding &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50 &#40;36&#8211;64&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&#46;7 &#40;47&#8211;74&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Bronchopulmonary dysplasia</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Acyanotic heart disease &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;8 &#40;0&#46;1&#8211;9&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;4 &#40;1&#46;1&#8211;14&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Neuropathy &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&#46;8 &#40;0&#46;1&#8211;9&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Antibiotic treatment &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">32&#46;1 &#40;19&#46;2&#8211;45&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&#46;8 &#40;14&#46;3&#8211;39&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Nebulised adrenaline &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">67&#46;9 &#40;54&#46;7&#8211;81&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">78&#46;6 &#40;66&#46;9&#8211;90&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Nebulised salbutamol &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16&#46;1 &#40;5&#46;6&#8211;26&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12&#46;5 &#40;3&#8211;22&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;59&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Nebulised 3&#37; hypertonic saline &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">17&#46;9 &#40;6&#46;9&#8211;28&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&#46;3 &#40;4&#46;2&#8211;24&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;61&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleItalic">Respiratory support &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19&#46;6 &#40;8&#46;3&#8211;30&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">33&#46;9 &#40;20&#46;6&#8211;47&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;09&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>O<span class="elsevierStyleInf">2</span> nasal cannulae&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">50 &#40;36&#8211;64&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">25 &#40;12&#46;8&#8211;37&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>HFNC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">39&#46;3 &#40;25&#46;6&#8211;53&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>NIV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">30&#46;4 &#40;17&#46;4&#8211;43&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10&#46;7 &#40;1&#46;7&#8211;19&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>IMV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;6 &#40;0&#46;4&#8211;12&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="5" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Length of stay in days</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleItalic">Median</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;92 &#91;4&#46;46&#8211;7&#46;51&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6&#46;03 &#91;4&#46;68&#8211;7&#46;94&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">N</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">95&#37; CI &#91;IQR&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age &#40;days&#41; &#91;median&#93;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#91;16&#46;9&#8211;25&#46;6&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Gestational age &#40;weeks&#41; &#91;median&#93;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">39&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#91;38&#46;1&#8211;40&#46;3&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Preterm birth &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;18&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#46;2&#8211;40&#46;3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">26&#46;8&#8211;73&#46;2&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 23412879
Original language: English

DOI:10.1016/j.anpede.2016.03.006

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2024 November	10	8	18
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2024 March	99	32	131
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2023 October	69	64	133
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2023 July	47	35	82
2023 June	51	30	81
2023 May	71	26	97
2023 April	58	27	85
2023 March	72	33	105
2023 February	52	25	77
2023 January	46	43	89
2022 December	74	51	125
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2022 October	73	63	136
2022 September	41	40	81
2022 August	58	53	111
2022 July	51	49	100
2022 June	54	42	96
2022 May	76	53	129
2022 April	64	57	121
2022 March	95	63	158
2022 February	71	33	104
2022 January	79	41	120
2021 December	65	57	122
2021 November	77	76	153
2021 October	108	88	196
2021 September	70	58	128
2021 August	69	48	117
2021 July	58	52	110
2021 June	108	57	165
2021 May	107	70	177
2021 April	231	99	330
2021 March	124	45	169
2021 February	97	39	136
2021 January	83	36	119
2020 December	73	35	108
2020 November	73	37	110
2020 October	77	20	97
2020 September	82	33	115
2020 August	86	13	99
2020 July	73	27	100
2020 June	207	28	235
2020 May	134	44	178
2020 April	65	31	96
2020 March	53	36	89
2020 February	49	32	81
2020 January	69	22	91
2019 December	62	27	89
2019 November	54	21	75
2019 October	59	20	79
2019 September	96	34	130
2019 August	60	20	80
2019 July	81	31	112
2019 June	92	34	126
2019 May	176	29	205
2019 April	173	68	241
2019 March	99	60	159
2019 February	88	33	121
2019 January	85	36	121
2018 December	99	46	145
2018 November	150	49	199
2018 October	200	65	265
2018 September	103	31	134
2018 August	4	0	4
2018 July	2	0	2
2018 June	2	0	2
2018 May	14	0	14
2018 April	52	0	52
2018 March	36	0	36
2018 February	37	0	37
2018 January	33	0	33
2017 December	25	0	25
2017 November	19	0	19
2017 October	36	0	36
2017 September	26	0	26
2017 August	16	0	16
2017 July	33	3	36
2017 June	30	25	55
2017 May	51	16	67
2017 April	102	83	185
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