Does the use of a vibrating mesh nebuliser through a high flow nasal cannula compared to the jet nebuliser improve nebuliser tolerance among toddlers with respiratory distress?

Aim: To determine if using a high-flow nasal cannula circuit for nebuliser administration improves nebuliser tolerance in infants, which hastens clinical improvement in respiratory distress. Design: An integrative literature review. Background: Tolerance during nebuliser administration is poor in the infant population when administered through the traditional device of a jet nebuliser, which is distressing for all participants required when administering the nebuliser correctly. High-flow nasal cannula therapy has recently been introduced for respiratory support in paediatrics. With this, the vibrating mesh nebuliser has been introduced within the high-flow circuit, which remains controversial as minimal research has been conducted. Method: Four electronic databases were searched, which included reviewing reference lists of studies relevant to the research question. The author approached sales representatives for high-flow nasal circuit equipment, and the Aerogen device was approached about relevant research they conducted. Results: Four studies were identified that met the requirements of the inclusion criteria, and two were randomised cross-over studies with a low risk of bias. The remaining two were a case study and a retrospective chart review with a high risk of bias. All of the studies described improved nebuliser tolerance in infants to be more with the high flow nasal cannula and vibrating mesh nebuliser group compared to the high flow nasal cannula and jet nebuliser group, with improved distress and increased heart rate confirming bronchodilator effect from the nebuliser treatment. Parents also noted improved nebuliser tolerance and favoured the vibrating mesh nebuliser in the two RCT studies conducted, as they were not required to restrain or distract during the nebuliser therapy, and the infant was calm and relaxed. All four studies lacked evidence of clinical improvement when nebuliser tolerance was present. Conclusion: Improved nebuliser tolerance displayed by less distraction and agitation as well as an increased heart rate was present when the vibrating mesh nebuliser was delivered within the high flow nasal cannula circuit, whilst there was decreased nebuliser tolerance when using the jet nebuliser, which was displayed by agitation, causing difficulty of assessing physiological parameters due to distress. More research should be conducted to evaluate nebuliser tolerance when an infant requires nebuliser therapy, such as including the jet nebuliser within the high-flow nasal cannula circuit, like the vibrating mesh nebuliser device. Further research should include older infants and toddlers, as they can be more combative, and more asthmatic patients less than four years of age, to assess tolerance and the physiological response.