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Nasal CPAP Beat HFNC for Bronchiolitis

April 4, 2017

Short Attention Span Summary

Tramontane – “a person who lives over the mountains”
This RCT from France found that high flow nasal cannula (HFNC) had higher failure rate than nasal CPAP for acute viral bronchiolitis in the first 24 hours.  Failure was determined by worsening of either a validated score of bronchiolitis severity, increased respiratory rate, worsening of a validated infant discomfort score, or more than two severe apnea episodes per hour.  Secondary outcomes, including intubation rate and skin breakdown, were no different.  HFNC is increasingly used for infants with bronchiolitis, but this study showed that nCPAP may be a better mode of non-invasive respiratory support.

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Nasal CPAP beats HFNC for non-invasive respiratory support in infants with bronchiolitis.


Intensive Care Med. 2017 Feb;43(2):209-216. doi: 10.1007/s00134-016-4617-8. Epub 2017 Jan 26.

High flow nasal cannula (HFNC) versus nasal continuous positive airway pressure (nCPAP) for the initial respiratory management of acute viral bronchiolitis in young infants: a multicenter randomized controlled trial (TRAMONTANE study).

Milési C1, Essouri S2, Pouyau R3, Liet JM4, Afanetti M5, Portefaix A3,6, Baleine J1, Durand S1, Combes C1, Douillard A7, Cambonie G8; Groupe Francophone de Réanimation et d’Urgences Pédiatriques (GFRUP).

Author information:

1Pediatric Intensive Care Unit, Département de Pédiatrie Néonatale et Réanimations, CHU de Montpellier, Arnaud de Villeneuve University Hospital, 371 Avenue du Doyen G. Giraud, 34295, Montpellier Cedex 5, France.

2Pediatric Intensive Care Unit, Kremlin Bicêtre University Hospital, Paris, France.

3Pediatric Intensive Care Unit, Women-Mothers and Children’s University Hospital, Lyon, France.

4Pediatric Intensive Care Unit, Women and Children’s University Hospital, Nantes, France.

5Pediatric Intensive Care Unit, Lenval University Hospital, Nice, France.

6INSERM, CIC1407, 69500, Bron, France.

7Department of Medical Information, Arnaud de Villeneuve University Hospital, Montpellier, France.

8Pediatric Intensive Care Unit, Département de Pédiatrie Néonatale et Réanimations, CHU de Montpellier, Arnaud de Villeneuve University Hospital, 371 Avenue du Doyen G. Giraud, 34295, Montpellier Cedex 5, France. g-cambonie@chu-montpellier.fr.



Nasal continuous positive airway pressure (nCPAP) is currently the gold standard for respiratory support for moderate to severe acute viral bronchiolitis (AVB). Although oxygen delivery via high flow nasal cannula (HFNC) is increasingly used, evidence of its efficacy and safety is lacking in infants.


A randomized controlled trial was performed in five pediatric intensive care units (PICUs) to compare 7 cmH2O nCPAP with 2 L/kg/min oxygen therapy administered with HFNC in infants up to 6 months old with moderate to severe AVB. The primary endpoint was the percentage of failure within 24 h of randomization using prespecified criteria. To satisfy noninferiority, the failure rate of HFNC had to lie within 15% of the failure rate of nCPAP. Secondary outcomes included success rate after crossover, intubation rate, length of stay, and serious adverse events.


From November 2014 to March 2015, 142 infants were included and equally distributed into groups. The risk difference of -19% (95% CI -35 to -3%) did not allow the conclusion of HFNC noninferiority (p = 0.707). Superiority analysis suggested a relative risk of success 1.63 (95% CI 1.02-2.63) higher with nCPAP. The success rate with the alternative respiratory support, intubation rate, durations of noninvasive and invasive ventilation, skin lesions, and length of PICU stay were comparable between groups. No patient had air leak syndrome or died.


In young infants with moderate to severe AVB, initial management with HFNC did not have a failure rate similar to that of nCPAP. This clinical trial was recorded in the National Library of Medicine registry (NCT 02457013).

PMID: 28124736 [PubMed – in process]

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