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Trial finds most effective breathing support for children in intensive care

A widely-used breathing support method for children in intensive care is not as effective as clinicians assume, according to new research funded by the National Institute for Health and Care Research (NIHR).

The FIRST-ABC trial was the first to compare types of breathing support given when children come off mechanical ventilation to help them transition to unaided breathing.

The study compared High-Flow Nasal Cannula therapy (HFNC), where oxygen is delivered through tubes into the nostrils, with Continuous Positive Airwave Pressure (CPAP), which delivers air pressure through an oxygen mask to keep airway passages open.

HFNC has become increasingly popular in children's intensive care units as it is more comfortable to tolerate. However, researchers found children on HFNC needed breathing support for up to 18 hours longer than those using CPAP.

Over 1,000 children aged up to 15 were recruited, including 59 from the John Radcliffe Hospital, Oxford. Half were randomly selected to move to HFNC following ventilation and half to CPAP.

Only 10 percent of children on CPAP couldn’t tolerate it and were moved to HFNC as a result. Findings were consistent irrespective of age and condition.

Dr Padmanabhan Ramnarayan, the trial’s lead researcher, said: “We know that HFNC can’t deliver the same levels of breathing support as CPAP, but it’s been assumed the reduced effectiveness is a price worth paying for the additional comfort it provides. Our results show that may not be the case.

“Most paediatricians have tended to prefer HFNC, but these results are likely to make them more cautious. While the choice of breathing support is specific to each patient, my own preference now is to start with CPAP and if children struggle to tolerate it, only then to use HFNC as the next option.”

The study was led by Imperial College London and sponsored by Great Ormond Street Hospital for Children and NIHR’s Health Technology Assessment (HTA) Programme.

The team is currently analysing data from a second trial, following the same format, which compares CPAP and HFNC when used as the first breathing support provided in children not yet on a ventilator. Findings will be published later this year.

Read more on the NIHR website.