Comparison of Heated Humidified High-flow Nasal Cannula and Noninvasive Ventilation in Children with Acute Hypoxemic Respiratory Failure Using Clinical Respiratory Score: A Prospective Observational Study.

Abstract

Aims and background: Comparative data on the efficacy of high-flow nasal cannula (HFNC) vs noninvasive ventilation (NIV) in children are limited. This study aims to address this gap by comparing the modalities using the clinical respiratory score (CRS) and factors that predict failure.

Patients and methods: This prospective observational study was conducted in the pediatric intensive care unit (PICU) of a tertiary care hospital over a period of 20 months. Children (2-18 years) admitted to PICU with acute hypoxemic respiratory failure requiring HFNC or NIV were eligible. Multiorgan dysfunction, hemodynamic instability, intubation within 2 hours, cyanotic congenital heart disease, craniofacial malformations, chronic lung diseases, neuromuscular diseases, and upper airway obstruction were exclusions. Children were allocated to either HFNC or NIV therapy at the clinician's discretion. The severity of respiratory distress was assessed using CRS at baseline, 2, 6, 12, 24, and 48 hours. Escalation of therapy was considered a treatment failure.

Results: A total of 59 children were enrolled in the study and categorized into HFNC (n = 38) and NIV (n = 21) groups. Baseline CRS was slightly higher in the NIV group [9 (8-10) vs 10 (9-10); p = 0.072]. Diagnosis distribution differed significantly, with pneumonia being higher in the HFNC group (63.1%), and acute respiratory distress syndrome (ARDS) and capillary leak syndrome (33.3-28.6%, respectively) were more common in the NIV group. Treatment success rates were similar (76.3 vs 71.4%; p = 0.680). Escalation to NIV occurred in 10.5% of the HFNC group and to invasive mechanical ventilation in 13.2% of HFNC and 28.6% of NIV patients. Clinical respiratory score at initiation and at 2 hours was comparable. At 6 hours, CRS showed significantly better improvement in the NIV group [7 (6-8) vs 5 (4-7); p = 0.023]. Clinical respiratory score at initiation and at 2 hours was significantly higher in the failures in both groups compared to the successes.

Conclusion: There was no significant difference in treatment failures between the two groups. Noninvasive ventilation demonstrated early respiratory improvement, while HFNC was not inferior in the long term. Lower CRS at initiation and improvement at 2 hours were predictive of treatment success.

Clinical significance: Stringent bedside monitoring during the initial hours of noninvasive respiratory support is critical, along with an individualized approach for choice of modality to improve the chances of success of HFNC and NIV.

How to cite this article: Kadappanavar TR, Ravikumar N, Ramu SA. Comparison of Heated Humidified High-flow Nasal Cannula and Noninvasive Ventilation in Children with Acute Hypoxemic Respiratory Failure Using Clinical Respiratory Score: A Prospective Observational Study. Indian J Crit Care Med 2026;30(5):414-419.