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51]

Review Article

How to choose between high‑flow nasal cannula, continuous

positive airway pressure, and bilevel positive airway
pressure in children with acute respiratory illness
Karthik Narayanan R, Ashwath Ram R N1, Manu Sundaram2
Department of Pediatric Critical Care, Rainbow Children's Hospital, Chennai, Tamil Nadu, 1Department of Pediatric Intensive Care,
Manipal Hospital, Banglore, Karnataka, India, 2Paediatric Critical Care Unit, Sidra Medicine, Doha, Qatar

Abstract In pediatric patients with acute respiratory illnesses, the widespread availability of heated humidified
high‑flow nasal cannula (HHHFNC) devices, ease of use, and increased compliance have increased their use
in conditions such as pneumonia, acute respiratory failure, asthma, and acute respiratory distress syndrome.
Due to the patient comfort and ease of use of HHHFNC, there are widely used. Similarly, the use of NIV is
increasing due to the availability of better interfaces and non-invasive ventilators (NIV) for use in infants The
conundrum has been regarding the generation of positive end‑expiratory pressure in these open circuits
of the HHHFNC devices versus the pressures delivered by the closed circuits in the NIV devices. This article
reviewed the latest literature based on the clinical conditions and the rationale for selecting respiratory
support in common acute respiratory illnesses.

Keywords: Bilevel positive airway pressure, continuous positive airway pressure, high‑flow nasal cannula

Address for correspondence: Dr. Manu Sundaram, Paediatric Critical Care Unit, Sidra Medicine, Doha, Qatar.
E‑mail: [email protected]

INTRODUCTION and bilevel positive airway pressure (BiPAP) among children

with acute respiratory failure in several pediatric intensive care
Although many patients have been managed on these units (PICU) in India.[6,7] HHHFNC, NIV‑CPAP, and BiPAP
devices, there is an increase in the incidence of delayed have been interchangeably used in various clinical conditions,
intubation from prolonged trials of HHHFNC.[1] Most including acute bronchiolitis, pneumonia, bronchial asthma,
of the high quality evidence was from the randomized and pulmonary edema. Recently, HHHFNC has been used
controlled trials of HHHFNC in bronchiolitis. With better more among children with acute respiratory distress in
interfaces, noninvasive ventilation (NIV) has increased, but Indian settings than NIV due to its convenience and ease of
large randomized controlled trials are currently lacking.[2-5] nursing care. In a multicenter observational study, Morris
There is increasing usage of heated humidified high‑flow et al. observed that initiating NIV as unplanned respiratory
nasal cannula (HHHFNC) and noninvasive ventilation (NIV) support before invasive ventilation significantly reduced
modalities such as continuous positive airway pressure (CPAP) mortality, ventilation‑free days, and length of PICU stay.[8]
However, increased mortality was observed when the impact
Received: 19‑04‑2023 Revised: 03-05-2023
Accepted: 07-05-2023 Published: 19-05-2023
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How to cite this article: Narayanan RK, Ashwath Ram RN, Sundaram M.
DOI: How to choose between high-flow nasal cannula, continuous positive airway
10.4103/jpcc.jpcc_33_23 pressure, and bilevel positive airway pressure in children with acute
respiratory illness. J Pediatr Crit Care 2023;10:101-6.

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Narayanan, et al.: HFNC, CPAP or BiPAP: In acute respiratory illness

of preintubation noninvasive respiratory support (HHHFNC mask –95%). The chest X‑ray (CXR) showed bilateral
and NIV) was studied in children with pediatric respiratory consolidation [Figure 1]. He was hemodynamically stable.
distress syndrome. Hence, choosing the right patient and The infant was shifted to PICU for respiratory support.
appropriate noninvasive respiratory support is essential What respiratory support would you offer?
to improve outcomes. This article discusses how to select
the proper respiratory support in children with various Answer: NIV (BiPAP/S/T mode).
pathological lung conditions with case‑based discussions.
Rationale
CONTRAINDICATIONS FOR NONINVASIVE The infant has a parenchymal lung disease leading to
RESPIRATORY SUPPORT type 1 respiratory failure. The probable pathological
mechanism causing hypoxia is reduced compliance and
One should avoid considering noninvasive respiratory functional residual capacity, increased dead space, shunt
support in children without contraindications. The fraction, and extravascular lung water. This results in low
neurology, airway, breathing, circulation (NABC) acronym PaO2 with usually typical PaCO2. In a patient with severe
provides a structured approach to check the different respiratory distress, recurrent alveoli collapse can result in
contraindications[9] [Table 1]. atelectotrauma and subsequent pediatric self‑inflicted lung
CASE 1: ACUTE PNEUMONIA/RESPIRATORY
injury (p‑SILI).[10] Early initiation of bilevel ventilation
FAILURE/ACUTE RESPIRATORY DISTRESS and optimal positive end‑expiratory pressure (PEEP) to
SYNDROME[9] achieve tidal volumes of 6–8 ml/kg reduced the risk of
p‑SILI. Chisti et al., in their landmark paper, have shown
A 6‑month‑old child presented with fever, cough for 3 days, an increase in the mortality of patients on low‑flow oxygen
and rapid breathing for 1 day. On examination, respiratory therapy compared to bubble CPAP.[11] In this patient with
rate was 78/min, intercostal and subcostal retractions pneumonia, the success rate for NIV was 80%.[12]
were present, bilateral crepitations on auscultation,
and room air saturation 78% (on a nonrebreathing In these same patients, if the FiO2 keeps increasing, this
patient would be on the spectrum for pediatric acute
Table 1: Noninvasive ventilation contraindications respiratory distress syndrome (pARDS).[9] The success rates
Absolute Relative for NIV in pARDS are lower than 50%. Early intubation
Neuro Unconscious: Patient unable to protect Noncompliant without an NIV trial should be considered in children with
airways patients
Airways Compromised airways Orofacial severe pARDS (P/F ratio <100; S/F ratio <150). NIV
Severe upper gastrointestinal bleeding anomalies trial can be offered in moderate acute respiratory distress
or vomiting
Breathing Moderate‑to‑severe ARDS Nondrained
syndrome (ARDS) (P/F ratio <200, S/F ratio 150–235),
(P/F ratio <200 or S/F ratio <150) pneumothorax where the response is judged as the reduction in heart rate,
Risk of aspiration respiratory rate, work of breathing, and FiO2 after a trial of
Circulation Imminent cardiac or respiratory arrest
Hemodynamic instability NIV for 2–6 h. Consider intubation and invasive ventilation
ARDS: Acute respiratory distress syndrome in these patients with moderate to severe ARDS [Figure 2].
One should be very cautious to avoid overdistention of the
lung, which may lead to p‑SILI while using NIV.[13]

HHHFNC has little effect on lung recruitment. Although

some benefits can be obtained by its impact on decreasing
extra thoracic dead space and modest positive pharyngeal
pressure of about 4 cm H2O during expiration, it does not
recruit the lung and improve functional residual capacity.[14]
It can be used to preoxygenate the child before invasive
mechanical ventilation (as it can reliable deliver fixed FiO2).
Nonetheless, the quality of oxygenation, higher comfort,
and the results of the FLORALI trial in adults with acute
hypoxic respiratory failure have raised the role of HHHFNC
or the harmful effects of overdistention of the lungs due
to NIV.[15] In the FIRST‑ABC Step‑Up randomized trial by
Figure 1: The CXR showing bilateral consolidation. CXR: Chest X‑ray Ramnarayan et al., which compared HHFNC and NIV as
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Narayanan, et al.: HFNC, CPAP or BiPAP: In acute respiratory illness

Figure 2: Choosing respiratory support in acute hypoxic respiratory failure[9]

Table 2: Preferred modes for noninvasive respiratory support rate is 85%. This is typical for patients with various muscular
Pathology Preferred mode dystrophies and myopathy to have respiratory failure and
Cardiac failure with RDS with high CO2 NIPPV (or NIV‑BiPAP) then require NIV for acute on chronic respiratory failure.
and Low O2
Cardiac failure with RDS with CPAP (or more EPAP in BIPAP)
hypoxemia only
CASE 2: ACUTE BRONCHIOLITIS
Bronchiolitis with RDS HHFNC >CPAP
GBS on tracheostomy with trigger issue NIPPV (or NIV‑BiPAP) A 3‑month‑old infant with no significant perinatal history
and no hypoxemia but rise in CO2 and
increased WOB
presented with fever, cold for 3 days, and breathing
Postextubation – Increased WOB, but HHFNC >NIV‑CPAP>NIV‑BiPAP difficulty for 1 day. Examination revealed intercostal and
no hypoxemia or other issues subcostal retractions and bilateral wheeze with crepitation.
Postextubation – Normal sensorium but NIV‑BiPAP>NIV‑CPAP
increased work of breathing and low O2 Room air saturation was 88%. On nasal oxygen therapy,
RDS: Respiratory distress syndrome, GBS: Guillain–Barré syndrome, saturation improved to 95%; the infant was nebulized with
NIPPV: Noninvasive positive pressure ventilation, NIV: Noninvasive 3% saline and adrenaline. Wheeze reduced, but distress
ventilation, BiPAP: Bilevel positive airway pressure, CPAP: Continuous
positive airway pressure, EPAP: Expiratory positive airway pressure,
persisted. The CXR showed bilateral hyperinflation with
HHFNC: Humidified high‑flow nasal cannula, WOB: Work of breathing streaky opacities with segmental atelectasis [Figure 3]. What
is the ideal respiratory support for this child?
first‑line respiratory support in acute hypoxic respiratory
failure, HHHFNC was found noninferior to NIV when Answer: Heated, humidified high‑flow nasal cannula is
the time to liberation from respiratory support as outcome appropriate respiratory support for this child.
parameter was considered. However, 50% of the cohort
consisted of acute bronchiolitis, and fewer (<10%) had Rationale
pneumonia.[16] Hence, the utility of HHHFNC as an The high‑flow nasal cannula (HFNC) has most often been
alternative to NIV‑CPAP requires further studies. Till then, evaluated in populations with acute viral bronchiolitis,
it is better to limit its use to mild ARDS with low work of with several studies comparing the efficacy and tolerance
breathing or low risk of p‑SILI. of HHHFNC with various CPAP systems. A recent
meta‑analysis (15 studies, 1127 patients) showed that
Studies have shown that the success rate for NIV is higher the prophylactic use of HHHFNC did not reduce PICU
in patients with a neuromuscular condition who have admission in the study done by Milési et al. HFNC has a
respiratory failure. In type 2 respiratory failure, the success higher failure rate compared to nasal CPAP (nCPAP).[3] This
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Narayanan, et al.: HFNC, CPAP or BiPAP: In acute respiratory illness

Figure 3: Bilateral hyperinflation with multiple segmental atelectasis Figure 4: Bilateral hyperinflation in the CXR. CXR: Chest X‑ray

crossover study demonstrated that patients who failed on gas revealed hypercapnic metabolic acidosis (pH – 7.23,
HHHFNC responded to rescue therapy with CPAP and pO2‑62, pCO2‑78, HCO3‑26). What is the optimal initial
vice versa. respiratory support?

Assess the severity of distress and oxygenation in the child Answer: Noninvasive BiPAP.
with acute bronchiolitis; if the infant has SpO2 <90% on
nasal oxygen, S/F ratio <200 on HHHFNC, decreased Rationale
air entry bilaterally, depressed sensorium, and severe The child has Type 2‑hypercapnic respiratory failure
retractions, then consider starting nCPAP/BiPAP. If the caused due to hypoventilation resulting from lower airway
above findings are not observed, HHHFNC is the preferred obstruction. Asthma causes dynamic airway obstruction
respiratory support in moderate bronchiolitis (SpO2 >90% leading to air trapping and auto‑PEEP. HHHFNC and
on nasal oxygen, mild‑to‑moderate respiratory distress, NIV‑CPAP can deliver fixed FiO2; however, it might not
agitated and alert sensorium, and regular air entry). be helpful to overcome the auto‑PEEP effectively and
HHHFNC of up to 2 ml/kg/min and FiO2 of 50% can increase minute ventilation, thereby causing carbon dioxide
be initiated in pediatric wards, and it is safe in various washout. NIV‑BiPAP helps overcome dynamic airway
studies. Apnea is the only contraindication to noninvasive inflation to decrease respiratory muscle overload, increase
respiratory support in bronchiolitis, which requires minute ventilation, and improve gas exchange. The NIV
intubation and mechanical ventilation [Table 2]. acts as a bridge to support the work of breathing while
the bronchodilator therapy is working, with continuous
If the patient has deterioration on the HHHFNC therapy inhaled bronchodilators and steroids. The success rate for
and a collapse consolidation is noted on the CXR, then NIV in severe asthma has been quoted as about 80%.[12,17,18]
the patient would benefit from a CPAP as it delivers a de Miguel‑Díez et al. observed that NIV decreased
measurable PEEP. Therefore, reserving HHHFNC use the length of PICU stay in children with acute asthma
for moderate bronchiolitis and NIV/CPAP for severe
exacerbation.[19] Contraindications include an unconscious
bronchiolitis seems reasonable.
child with compromised airways and hemodynamic
CASE 3: BRONCHIAL ASTHMA instability with imminent cardiorespiratory arrest (gasping
respiration, cyanosis, and bradycardia).
A 5‑year‑old child presented to the emergency room
with acute onset breathing difficulty. He was drowsy HHHFNC has also been attempted in bronchial asthma
with decreased bilateral air entry, wheeze on expiration, and observed to be well tolerated. Heated and humidified
prolonged expiration, and room air SpO2‑85% and 93% gas flow reduces the burden on inspiratory muscle related
on venturi face mask oxygen (FiO2‑60%). He was given to auto‑PEEP and limits bronchoconstriction induced by
nebulization with beta‑agonists, intravenous steroids, and cold, dry gas. In an observational study, the failure rate
intravenous magnesium sulfate. The CXR had bilateral was higher with HHHFNC than with NIV.[20] The role
hyperinflation [Figure 4]. There was no response, and of HHHFNC is limited to moderate asthma, and NIV
his SpO2 on 60% FiO2 decreased to 88%. Arterial blood is preferable in severe asthma.[20] Another caution that
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Narayanan, et al.: HFNC, CPAP or BiPAP: In acute respiratory illness

must be considered while using HHHFNC is the delivery FiO2. Consider NIPPV or NIV BiPAP if there is associated
of inhalational bronchodilator medications. The dose hypercarbia (pCO2 >50 cm H2O).
of bronchodilator delivered varies from 0.5% to 25%
of the administered dose.[20] The highest dose delivery HHHFNC, compared to conventional oxygen therapy
is observed when the flow is reduced, and the aerosol is devices, is associated with better oxygenation (PaO2/FiO2
delivered upstream of the humidifier with an ultrasonic ratio), reducing the need for NIPPV but not intubation in
nebulizer.[21,22] postoperative cardiac children. For clinical practice, HFNC
is better tolerated and seems feasible in most populations
CASE 4: CARDIOGENIC PULMONARY EDEMA currently managed with NIV and CPAP. HHHFNC must
be used early, in mild‑to‑moderate respiratory distress and
An 8‑month‑old infant presented with a low‑grade fever minimal pulmonary opacity, normal perfusion, and P/F
and cold for 3 days, irritability, and breathing difficulty ratio >200. Since our index child has low cardiac output
for the past 6 h. On examination, there was tachycardia, with impaired perfusion, HHHFNC is not ideal in the
tachypnea with retractions, bilateral crepitations on above setting.
lung auscultation, gallop on cardiac auscultation and
hepatomegaly, and room air saturation 88% (98% on a In CPE, in conditions of fluid overload like nephrotic
nonrebreathing mask), and the CXR showed cardiomegaly syndrome and oncology patients on hyperhydration regime,
with pulmonary edema. His peripheries were cold, his the success rate for NIV with diuretic therapy is around
blood pressure was at the 5th centile for age and height, 95%.
and he had feeble peripheral pulses. He was started on
epinephrine infusion at 0.05 µg/kg/min. How to choose CONCLUSION
the ideal respiratory support?
The Indications, contraindications, equipment,
Answer: Noninvasive positive pressure ventilation (NIPPV). modes, analysis of failure/ success, and next steps
(ICEMAN) acronym provides a structured approach to
Rationale the initiation of NIV. The components are indications,
The index child has cardiogenic pulmonary edema (CPE) contraindications, equipment, modes, analysis of failure/
due to myocarditis. This is a low cardiac output state with success, and next steps.
increased extravascular lung water and alveolar flooding.
Respiratory distress in a baby with cardiac failure can Choosing the proper respiratory support depends
worsen organ perfusion (as 50% of the cardiac output is on the pathology behind the respiratory difficulty.
used to fulfill the metabolic demands of the respiratory Contraindications to noninvasive respiratory support
muscles). Increased negative pleural pressures generated should be identified before initiation. HHHFNC is
due to respiratory distress can increase the afterload of better than low‑flow oxygen therapy and noninferior to
the left ventricle, thereby leading to a further decrease in NIV‑CPAP in children with mild‑moderate respiratory
cardiac output.[23] disease. In severe respiratory distress, NIV‑BiPAP/NIPPV
should be initiated. Monitoring for the failure of NIV and
NIV (CPAP/BiPAP or NIPPV) is most helpful in lung
early intubation is the key to the optimal outcome.
parenchymal disease. It is useful in obstructive airway
diseases (bronchiolitis) as it reduces the transmural Declaration of patient consent
pressure swing and maintains airway patency. Reducing The authors certify that they have obtained all appropriate
transthoracic pressure swinging reduces left ventricular patient consent forms. In the form the patient (s) has/have
afterload and improves stroke volume. With decreasing given his/her/their consent for his/her/their images and
work of breathing, the cardiac output is better distributed other clinical information to be reported in the journal.
and reduces lactic acidosis. It can prevent intubation and The patients understand that their names and initials will
mechanical ventilation complications, decrease the need not be published and due efforts will be made to conceal
for these interventions, and prevent extubation failure. their identity, but anonymity cannot be guaranteed.
For all children having heart disease with increased
work breathing and lung parenchymal problems, we Financial support and sponsorship
can start NIPPV considering altered lung mechanics as Nil.
described above. The minimum recommended expiratory
positive airway pressure (EPAP)/PEEP is 4–5 cm H2O. Conflicts of interest
EPAP ≥5 cm is associated with an added benefit above There are no conflicts of interest.
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Narayanan, et al.: HFNC, CPAP or BiPAP: In acute respiratory illness

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