AnPediatr(Barc).2019;90(2):69---71
www.analesdepediatria.org
EDITORIAL
High-flow oxygen therapy: Non-invasive respiratory support goes out of the PICU. Is it an efficient
alternative? 夽
Oxigenoterapia de alto flujo: el soporte respiratorio no invasivo sale de la UCIP. ¿Es una alternativa eficiente?
Javier Pilar Orive
a, Vicent Modesto i Alapont
b,∗aUnidaddeCuidadosIntensivosPediátricos,HospitalUniversitariodeCruces,Barakaldo,Vizcaya,Spain
bUnidaddeCuidadosIntensivosPediátricos„HospitalUniversitariiPolitècnicLaFe,València,Spain
‘‘Moremedicineisnotbettermedicine’’
ElliotSFisher,NewYorkTimes,December1,2003.
Afewyearshavepassedsince,inthemidstofthedebate forhealth carereformintheUnitedStates,thisNewYork Timesopinionpiecebroughtawarenesstothefactthateffi- ciency was a necessary condition to attain sustainability (financialsolvency)inpublichealthcaresystems.Efficiency not through the implementation of budget cuts, assome understood it, but by investingsolely ontherapeutic and diagnostic methods of proven cost-effectiveness. This, in turn, requires better information (rigorous scientific evi- dence) and better incentives. The bioethical principle of justice concerns us all,health care managers and practi- tionersalike.
夽 Pleasecitethisarticleas:PilarOriveJ,Modestoi AlapontV.
High-flowoxygen therapy: Non-invasiverespiratory support goes outofthePICU.Is itanefficientalternative? AnPediatr (Barc).
2019;90:69---71.
∗Correspondingauthor.
E-mailaddress:[email protected] (V.ModestoiAlapont).
Inrecentyears,highflow nasalcannula(HFNC)oxygen therapy hasbeen emerging asa well-tolerated and feasi- bletechnique to help our patients, especially those with hypoxaemic respiratoryfailure,cope withrespiratorydis- tress.However,itsindications in paediatric practicehave yet to be clearly established. Before generalising its use inPICUs,paediatricwardsandemergencydepartments,it isessentialthatweestablishitsefficacy, actualeffective- nessin clinical practiceand its efficiency, witha critical evaluationofthemostrecentscientificevidence.
In science,efficacy is a relativeconcept: it is defined basedonthecontroltreatmentthatisusedforcomparison.
Comparedtoconventional oxygen therapy,in pneumonia1 andbronchiolitis2aswellastheearlystagesofacuterespi- ratory distress syndrome, in the event of acute severe hypoxaemic respiratory failure, the type of non-invasive respiratory support that has been proven efficacious and effective (and is therefore indicated) is continuous posi- tiveairwaypressure(CPAP)withorwithoutpressuresupport ventilation.Today,wealsoknowthatinthisregard,HFNC is not more efficacious than CPAP in the management of pneumonia3orbronchiolitis.4
The use of HFNC has only been proven to be more efficacious than low-flow nasal cannula in patients with 2341-2879/©2019PublishedbyElsevierEspa˜na,S.L.U.onbehalfofAsociaci´onEspa˜noladePediatr´ıa.Thisisanopenaccessarticleunder theCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).
70 J.PilarOrive,V.ModestoiAlapont bronchiolitiswithmildtomoderatehypoxaemicrespiratory
failure.5,6Comparedtoconventionaloxygentherapy,italle- viatesrespiratorydistressanddecreases thefrequency of treatmentfailure,butitdoesnotreducethefrequencyof admissiontothe PICU,the length of stay or theduration ofsupplementaloxygen.Prospectivestudiesarerequiredto analysetheclinicaleffectivenessofHFNC inpatientswith bronchiolitismanagedintheinpatientward.
Incasesofhypercapnicrespiratoryfailuresecondaryto severe status asthmaticus, non-invasive ventilation (NIV) potentiatestheeffectsofpharmacotherapy.Itsuseinthe emergency department can prevent hospital admissions,7 while in the PICU it alleviates respiratory distress and reduces the need for inhaled bronchodilators and rescue therapies.8Forsomeyearsnow,NIVhasbeenthefirst-line modeofrespiratorysupportinpaediatricasthma.Theuse ofHFNCinchildrenwithstatusasthmaticusadmittedtothe PICUmaydelayinitiationofNIVandthereforeprolongthe durationofrespiratorysupportandthelengthofstayinthe PICU.9
A recent randomised clinical trial10 showed that com- paredtostandard bronchodilatortherapy (excludingNIV), HFNC delivered on an emergency basis in children with moderatetosevereasthmawasnotassociatedwithanysta- tisticallysignificant changesin theoutcomes understudy.
Theonly outcomethat wasbetterinthe HFNCgroup was the improvementof symptoms,which was assessed with- outmasking. In the current issue of Anales de Pediatría, González Martínez et al.11 present a prospective cohort studywithmultivariateanalysisonthereal-lifeeffective- nessofHFNC inthemanagementofasthmaexacerbations atthepaediatricwardlevel.Paediatriciansweremorelikely tousethisapproachinmoreseverelyillpatientsorpatients witha highernumber of previous admissions. Its use was associatedwithimprovementat3---6hoftreatment. Com- paredtotheuseof lowerflowrates, theuseof highflow rates(15L/min)independentlyandsignificantlyreducedthe probabilityofadmissiontothePICU.Thisaspectseemsrel- evantwhenitcomestodeterminingtheinitialflowratein clinicalpractice.
Thesecondstep,afterestablishingtheeffectivenessof HFNC, is to analyse its cost-efficiency, as has been done in the field of neonatoloty.12 But the efficacy of a treat- ment is a necessary condition for its efficiency. So the only way that HFNC may be efficientis in comparison to conventional supplemental oxygen delivery through nasal prongs. And the most dependable estimate, taking into accountcurrentprices,showsthatitisnotacost-effective therapy.13 Treatment with HFNC only seems to improve patientcomfort,whereasitincreasescostsbytwoordersof magnitude.Wemaybesquanderingthetaxpayers’money.
Under these circumstances, rationality dictates that the use of this approach be suspended until evidence of its cost-effectivenessbecomesavailableandaclinicalpractice guidelinedevelopedtoguideitsappropriateuse.
Unsubstantiatedfads,beliefs andfantasiesthreatenall sciences,includingmedicine. They undermine the quality ofcareandresultinexorbitantcostsandahugevariability inclinical practices,the outcomesofwhich arenotactu- allyknown.Thebestapproachtofightingthesethreatsin pursuitofthesustainabilityofourhealthcaresystemisto baseexpenditureonrobustscientificevidenceand onthe
economicconceptofopportunitycost.Therationalsolution is nottocutcosts, whichis certaintohurtthe qualityof thesystem.Therightapproachistowithdrawinvestment:
toeliminateresourcesallocatedtomedicalpracticesthat areoflittlebenefittohealthandreallocatethemtoother practicesthathavebeenproventobeefficacious,effective andefficient.
Economic theory teaches us that an option that can bringrealsolutionsisinnovation: toresearchtheapplica- tionofefficacioustherapiesoutsidethePICU.Non-invasive ventilationisusedinadultinpatientwards,andtheeffec- tivenessofbubbleCPAPinpaediatricwardshasalreadybeen demonstratedindevelopingcountries.Thus,averypromis- ingstrategywhoseeffectivenessisworthinvestigatingisthe early use of CPAP in patients withbronchiolitis in paedi- atricwardsorduringinterhospitaltransport.Theresultsof theexperiencepublishedinthecurrent issueofAnalesde Pediatríaonthisapproachareencouraging.14
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