Liu Jie, Li Deyuan, Luo Lili, Liu Zhongqiang, Li Xiaoqing, Qiao Lina
Department of Pediatric Intensive Care Unit, West China Second Universal Hospital, Sichuan University, Chengdu, China.
NHC Key Laboratory of Chronobiology (Sichuan University), Ministry of Education, Chengdu, China.
Front Pediatr. 2022 Aug 23;10:979944. doi: 10.3389/fped.2022.979944. eCollection 2022.
Evidence-based clinical practice guidelines regarding high-flow nasal cannula (HFNC) use for respiratory support in critically ill children are lacking. Therefore, we aimed to determine the risk factors for early HFNC failure to reduce the failure rate and prevent adverse consequences of HFNC failure in children with acute respiratory dysfunction.
Demographic and laboratory data were compared among patients, admitted to the pediatric intensive care unit between January 2017 and December 2018, who were included in a retrospective cohort study. Univariate and multivariate analyses were performed to determine risk factors for eventual entry into the predictive model for early HFNC failure and to perform an external validation study in a prospective observational cohort study from January to February 2019. Further, the association of clinical indices and trends pre- and post-treatment with HFNC treatment success or failure in these patients was dynamically observed.
In total, 348 pediatric patients were included, of these 282 (81.0%) were included in the retrospective cohort study; HFNC success was observed in 182 patients (64.5%), HFNC 0-24 h failure in 74 patients (26.2%), and HFNC 24-48 h failure in 26 patients (9.2%). HFNC 24 h failure was significantly associated with the pediatric risk of mortality (PRISM) III score [odds ratio, 1.391; 95% confidence interval (CI): 1.249-1.550], arterial partial pressure of carbon dioxide-to-arterial partial pressure of oxygen (PaCO/PaO) ratio (odds ratio, 38.397; 95% CI: 6.410-230.013), and respiratory rate-oxygenation (ROX) index (odds ratio, 0.751; 95% CI: 0.616-0.915). The discriminating cutoff point for the new scoring system based on the three risk factors for HFNC 24 h failure was ≥ 2.0 points, with an area under the receiver operating characteristic curve of 0.794 (95% CI, 0.729-0.859, < 0.001), sensitivity of 68%, and specificity of 79%; similar values were noted on applying the model to the prospective observational cohort comprising 66 patients (AUC = 0.717, 95% CI, 0.675-0.758, sensitivity 83%, specificity 44%, = 0.009). In this prospective cohort, 11 patients with HFNC failure had an upward trend in PaCO/PaO ratio and downward trends in respiratory failure index (P/F ratio) and ROX index; however, opposite directions of change were observed in 55 patients with HFNC success. Furthermore, the fractional changes (FCs) in PaCO/PaO ratio, P/F ratio, percutaneous oxygen saturation-to-fraction of inspired oxygen (S/F) ratio, and ROX index at 2 h post-HFNC therapy onset were statistically significant between the two groups (all, < 0.05).
In the pediatric patients with acute respiratory insufficiency, pre-treatment PRISM III score, PaCO/PaO ratio, and ROX index were risk factors for HFNC 24 h failure, and the direction and magnitude of changes in the PaCO/PaO ratio, P/F ratio, and ROX index before and 2 h after HFNC treatment were warning indicators for HFNC 24 h failure. Further close monitoring should be considered for patients with these conditions.
目前缺乏关于在危重症儿童中使用高流量鼻导管（HFNC）进行呼吸支持的循证临床实践指南。因此，我们旨在确定早期HFNC失败的危险因素，以降低失败率，并预防急性呼吸功能障碍儿童HFNC失败的不良后果。
对2017年1月至2018年12月期间入住儿科重症监护病房的患者的人口统计学和实验室数据进行比较，这些患者纳入了一项回顾性队列研究。进行单因素和多因素分析，以确定最终纳入早期HFNC失败预测模型的危险因素，并在2019年1月至2月的一项前瞻性观察性队列研究中进行外部验证研究。此外，动态观察这些患者治疗前后临床指标及变化趋势与HFNC治疗成功或失败的相关性。
总共纳入348例儿科患者，其中282例（81.0%）纳入回顾性队列研究；182例患者（64.5%）HFNC治疗成功，74例患者（26.2%）HFNC在0 - 24小时内失败，26例患者（9.2%）HFNC在24 - 48小时内失败。HFNC在24小时内失败与儿科死亡风险（PRISM）III评分显著相关[比值比，1.391；95%置信区间（CI）：1.249 - 1.550]、动脉血二氧化碳分压与动脉血氧分压（PaCO₂/PaO₂）比值（比值比，38.397；95%CI：6.410 - 230.013）以及呼吸频率 - 氧合（ROX）指数（比值比，0.751；95%CI：0.616 - 0.915）。基于HFNC 24小时失败的三个危险因素的新评分系统的鉴别临界点为≥2.0分，受试者操作特征曲线下面积为0.794（95%CI，0.729 - 0.859，P < 0.001），灵敏度为68%，特异度为79%；将该模型应用于包含66例患者的前瞻性观察性队列时也得到了类似的值（AUC = 0.717，95%CI，0.675 - 0.758，灵敏度83%，特异度44%，P = 0.009）。在这个前瞻性队列中，11例HFNC失败的患者PaCO₂/PaO₂比值呈上升趋势，呼吸衰竭指数（P/F比值）和ROX指数呈下降趋势；然而，55例HFNC治疗成功的患者则观察到相反的变化方向。此外，两组之间HFNC治疗开始后2小时时PaCO₂/PaO₂比值、P/F比值、经皮血氧饱和度与吸入氧分数（S/F）比值以及ROX指数的分数变化（FCs）具有统计学意义（均P < 0.05）。
在急性呼吸功能不全的儿科患者中，治疗前PRISM III评分、PaCO₂/PaO₂比值和ROX指数是HFNC 24小时失败的危险因素，HFNC治疗前后2小时内PaCO₂/PaO₂比值、P/F比值和ROX指数的变化方向和幅度是HFNC 24小时失败的警示指标。对于有这些情况的患者应考虑进一步密切监测。
