The infant with severe bronchiolitis: from high flow nasal cannula to continuous positive airway pressure and mechanical ventilation.

Bronchiolitis is one of the most frequent reasons for Pediatric Intensive Care Unit (PICU) admission in children less than 1 year of age. It causes a wide spectrum of clinical scenarios from mild to severe respiratory failure and supportive therapy range from high flow nasal cannula (HFNC) to nonconventional ventilation and extra corporeal membrane oxygenation (ECMO) in the most severe forms. Aim of this article is to review the available ventilation mode in children with bronchiolitis and the scientific evidence. The main medical databases were explored to search for clinical trials that address management strategies for respiratory support of infants with respiratory syncytial virus (RSV) infection. HFNC use is increasing and it seems to be useful as first line therapy in the emergency room and in the pediatric ward to prevent PICU admission but it is not clear yet if it is equivalent to noninvasive ventilation (NIV). NIV use in bronchiolitis is well established, mainly in continuous positive airway pressure mode in moderate and severe bronchiolitis. A mild evidence towards use of NIV to prevent endotracheal intubation is raising from few studies. Finally, for patients who failed a NIV trial, endotracheal intubation should be considered as the best option to support ventilation with conventional, nonconventional mode and ECMO in the most severe acute respiratory distress syndromes. There is a lack of quality studies for the use of any of the proposed ventilatory support in infants with bronchiolitis, especially in the severe forms. Nevertheless, in the last two decades daily use of noninvasive positive pressure supports have reached a large consensus based on clinical judgement and weak published evidence. We need specific and clear guidelines on which is the optimal management of these patients, and more robust randomized clinical trials to best evaluate timing and efficacy of HFNC and NIV use.