Heated humidified high-flow nasal cannula: use and a neonatal early extubation protocol

Objective: Respiratory distress syndrome ( RDS) and bronchopulmonary dysplasia ( BPD) are frequent complications of prematurity. To decrease ventilator-induced lung injury, we evaluated the safety, efficacy and neonatal outcomes of a heated humidified high-flow nasal cannula ( HFNC) system and an early extubation protocol ( EEP) designed for preterm infants 25 to 29 weeks' gestational age ( GA). Study Design: The Vapotherm ( VT) high-flow humidification system was introduced to our unit in March 2004. After 10 months of VT use, an EEP was developed to begin January 2005. Infants 25 to 29 weeks of GA, intubated for RDS, were enrolled in January-December 2005 to extubate to VT following the EEP. Exclusion criteria were: major congenital anomalies, asphyxia and a 5 min Apgar score < 5. Variables examined included BPD, growth and infection. Subjects were compared to historical controls, admitted January to December 2003, prior to the use of VT. Result: Inclusion criteria were met by 49/57 infants in the control group and 65/75 infants in the HFNC group. The groups had similar demographics, perinatal conditions, birthweight, GA, timing and total doses of surfactant. There were no differences in rates of extubation failure, patent ductus arteriosus, intraventricular hemorrhage, periventricular leukomalacia, necrotizing enterocolitis, laser eye surgery, sepsis, BPD at 28 days and 36 weeks and death. The groups did not differ in oxygen use, i.v. steroid days, or parenteral nutrition days. Days to reach full feeds were similar. Infants in the HFNC group were extubated from a higher ventilator rate ( 32.6 +/- 8.5 vs 28 +/- 7.5, P 0.003) and spent fewer days on the ventilator ( 11.4 +/- 12.8 vs 18.5 +/- 21, P 0.028). Rates of ventilator-associated pneumonia were higher in the control group ( P = 0.018). Discharge weights were greater in the HFNC group ( P = 0.016) despite similar length of stay and GA at discharge. Conclusion: High-flow nasal cannula use appears safe and well-tolerated. Infants extubated to HFNC spent fewer days on the ventilator. Additional benefits may include a decreased rate of ventilator associated with pneumonia and improved growth.