Enteral Feeding at Varying Levels of Continuous Positive Airway Pressure in Critical Bronchiolitis

Introduction: Bronchiolitis is a leading cause of admission to pediatric intensive care units (PICUs). Utilization of continuous positive airway pressure (CPAP) to improve oxygenation and decrease respiratory effort is a mainstay of management. Concern for respiratory complications related to feeding on CPAP is a common cause of delayed enteral feeds and thus suboptimal nutrition. The goal of this study is to determine the association between the level of CPAP (cm H2O) at time of enteral feed initiation and incidence of adverse respiratory events in patients with bronchiolitis.


Methods: This was a retrospective study of patients aged 30 days - 24 months admitted to Cohen Children’s Medical Center PICU from 12/1/2018 to 6/30/2022 with bronchiolitis requiring CPAP for ≥ 24 hours. Patients who did not feed while on CPAP or who required positive pressure support at baseline were excluded. The primary outcome studied was the incidence of adverse respiratory events, defined as increased FiO2 requirement or CPAP level, apnea, endotracheal intubation, or cardiac arrest within 6 hours of feeding initiation. CPAP levels were categorized as low (5-6cm H2O), moderate (7-9cm H2O), or high (10cm H2O). Demographics, pre-existing conditions, concomitant infections, feed characteristics, and vital signs at the time of feeding—scored by Respiratory Rate-Oxygenation-Heart Rate (ROX-HR) index—were assessed.


Results: 179 patients were included in this interim analysis. Of these, 91, 54, and 34 patients received enteral feeds on low, moderate, and high support, respectively and 29 patients (16.2%) experienced an adverse respiratory event. No significant difference in proportion of adverse respiratory events between CPAP levels was found (p= 0.18). Patient and feed characteristics were also not significantly associated with incidence of adverse respiratory events. The ROX-HR scores were significantly lower among those with adverse respiratory events (p = 0.04).


Conclusions: In patients with bronchiolitis requiring CPAP, pressure level at the time of enteral feed initiation was not significantly associated with adverse respiratory events. These data suggest respiratory complications of enteral feeding on CPAP may be driven by factors independent of CPAP level, however further investigation with a larger sample is in progress.