NIPPV in acute respiratory failure in children

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					Non-invasive positive pressure
   ventilation in the PICU
What is the daily practice of mechanical ventilation in ICU

In adults (in the years 1996 / 1997:




                              Esteban A et al. AJRCCM 2000; 161:1450–1458


In pediatrics (in the year 1999):
 ETT in 635 (96%; 95% CI: 94–97) of patients,
 tracheostomy in 11 (2%; 95% CI: 1–3),
 facial mask in 10 (1.5%; 95% CI: 1–3).
                         Farias A et al.   Intensive Care Med 2004; 30:918–925
NIPPV in the Pediatric Intensive Care Unit
Geneva experience 1998 - 1999


Number of pediatric patients hospitalized
in the PICU over a 2-year period:           771
         General pediatrics:                215   (28%)
         Cardiovascular surgery:            279   (36%)
         General surgery:                   133   (17%)
         Neurosurgery:                      69     (9%)
         Transplantation unit:              27     (3%)
         Onco-hematology:                   13     (2%)
         Orthopedics:                       35     (5%)


Ventilated patients:                        479   (62%)

Intubated and ventilated patients:          416   (87%)

Ventilatory support with NIPPV or CPAP      63    (13%)
NIPPV in acute pediatric respiratory failure
Geneva experience 1998 - 1999



n = 63        CPAP:                       30
              NPPV (BiPAP):               29
              NPPV and CPAP:               4

Etiology:     - infectieuse pneumopathy: n = 20

              - resp. insuffiency postoperatively: n = 10
                (orthopedic surgery: n = 3; diaphragmatic palsy: n = 5)
              - upper airway obstruction: n = 4
               (incl. postextubation stridor)

              - acute heart failure: n = 16
               (postoperative CHD, cardiomyopathy, myocarditis)

              - septicemia: n = 4
          High risk of respiratory distress
            in infants and small children

          Small airways = high airway resistance

              Compliant chest wall = low FRC

              Relatively “inefficient” diaphragm



The diaphragm should set off the inward motion of the rib cage to maintain tidal
volume constant, something which it can only do to a limited extent and will
result in paradoxic thoraco-abdominal movements.

Chest wall distortion represents a pressure-induced change in volume and
constitutes waste work which has an enormous energy cost
Objectives of Noninvasive Ventilation in
Pediatric Patients With Respiratory Disorders
 Avoid intubation




                Teague WG Pediatric Pulmonology 2003;35:418–426
Indications / Benefits of NIPPV in the PICU

 Early case reports showed: Improvement of clinical
 manifestation of respiratory distress and respiratory gas
 exchange in children with AHRF

Avoid or delay endotracheal intubation ?

Treatment of upper airway obstructions (stenting the
airways)
Treatment of atelectasis
Treatment of exacerbations of neuromuscular disease

Facilitation of weaning from invasive ventilation (e.g.
post-operative in patients with restrictive lung disease)
NIPPV in acute hypoxic respiratory failure:
Benefit and treatment failures in 3 pediatric case series



                              4




                   Rimensberger PC   Swiss Medical Weekly 2000;130:1880–6
NIPPV / CPAP in ARF: Treatment failures
Geneva experience 1998 - 1999


6 / 63 (9.5 %)

on CPAP
patient # 1 (4 months):    Bronchiolitis and BPD
patient # 2 (10 months):   DORV, Tetralogy of Fallot: postoperative
patient # 3 (6 months):    TGV, VSD postoperative BT-shunt

on NPPV (BiPAP)
patient # 4 (3 years):     ARDS, pneumonia
patient # 5 (15 years):    Fungal pneumonia and sepsis in immuncompromised
                           patient post lung transplantation
patient # 6 (15 years):    Orthopedic patient with postoperative paraplegia
NIPPV in infants with AHRF
6 infants with AHRF of various etiology
Pressure support: IPAP 14 ± 0,5 cmH2O; EPAP 7,3 ± 1 cmH2O
Ti max: 0,6 ± 0,1 s ; insp. rise time: 100 ms.



                 pCO2                                          RR




F. Vermeulen et al. Annales Françaises d’Anesthésie et de Réanimation 2003; 22: 716–720
NIPPV in children upper airway obstruction


chronic:   obstructive sleep apnea (OSA)
              a) anatomic obstruction of nasopharyngeal airways
              b) intermittent collapse of the nasopharyngeal airway
              - CPAP or NIPPV to prevent upper airway collapse

acute:     infectious conditions (epiglotitis, croup) or foreign body
               - CPAP or NIPPV works well in postextubation croup




No published experience with helium and NIPPV in these conditions
   PEEP: Tracheomalacia




   No PEEP                             PEEP 10cmH2O

Quen Mok, Great Ormond Street Hospital for Children, London
  CPAP: Tracheomalacia




      No PEEP                     CPAP 10cmH2O

Quen Mok, Great Ormond Street Hospital for Children, London
Case serie in pediatric status asthmaticus with severe
hypoxemia                      Teague WG AJRCCM 1998; 157:542


prospective, non controlled case serie (n = 26)

NPPV:      nasal mask; S/T mode
           IPAP 13 ± 3 cmH2O; EPAP 7 ± 2 cmH2O; FiO2 0.68 ± 0.28

Results: 21 ± 27 hrs mean duration
         169 ± 183 hrs O2 requirements
         19/26 acutely improved
         7/26 required intubation
         11/26 did not well tolerate


                  pH           paCO2      paO2
                               (mmHg)     (mmHg)
pre-tx (n = 15)   7.36 ± 0.5   40 ± 10    87 ± 23   p > 0.05 for all
post-tx (n = 6)   7.42 ± 0.9   39 ± 14    94 ± 35   comparisons
NPPV in pediatric status asthmaticus: Case serie


120                                                       25
100
             *                                            20
 80
                                              pre NPPV
                                                          15
                                                                                               intubated
 60
                                              post NPPV                 *                      not
 40                                                       10                                   intubated
                                                                                    *
 20                                        * p < 0.05     5
                                                                                           * p < 0.05
  0
      FiO2       SO2       FiO2      SO2                  0
      not intubated (19)   intubated (7)                       Hospital Days   PICU days


The oxygen response test?                                      Teague WG AJRCCM 1998; 157:542


 • was safe
 • allowed to shorten the length of ICU and hospital stay
 • did not prevent intubation in a subset of patients
NPPV in acute cardiogenic pulmonary edema (ACPE)

               n o. of p a tie n ts   ve n tila tion   tre a tm e n t Re su lts
               stu d y d e sign       m od e           fa ilu re
Be rste n AD                          CPAP             0 vs 35%      n o d iffe re n ce in
NEJM 1991;325 CPAP vs O 2                                            le n gth of ICU sta y
H offm a n n B 29                    BiPAP             in 1          im p rove d SO 2 a n d
CCM 1999;25    op e n p rosp e ctive                   p a tie n t   d e cre a se d p CO 2 in
                                                                     a ll p a tie n ts

Ru ste rh olz T 26                    BiPAP            21%           im p rove d SO 2 a n d
CCM 1999;25     op e n p rosp e ctive                                d e cre a se d p CO 2 in
                                                                     re p on d e rs

(patients who responded were hypercapnic,
those who failed were hypoxemic non-hypercapnic patients)

with the exception of patients with acute myocardial infarction,
CPAP and/or NPPV is efficient in ACPE with hypercapnic ARF
Perioperative use of noninvasive ventilation

Non-invasive mask ventilation in 25 patients with respiratory failure pre-
and/or postoperative

Success rate of 68%, but different in respect to the varying causes of
respiratory failure.

CONCLUSION:
With noninvasive mask ventilation it is possible to avoid in some
patients with acute postoperative respiratory failure complications who
are referred to intubation.

In patients with postoperative decompensation of chronic respiratory
failure postoperative treatment becomes easier, in extraordinary cases
the method makes surgery possible.


                           Karg O et al.   Med Klin 1996; 91 Suppl 2:38-40
NIV for physiotherapy
NIV for physiotherapy
NIV for physiotherapy
NIV for physiotherapy
NIPPV in children with ARF: Complications

severe:      air leaks
             gastric perforation
             aspiration
             decrease in CO


minor:       skin irritation / skin breakdown
             nasal dryness
             conjunctivitis
Physiological Factors Unique to Pediatric
Patients Promoting Complications of NIPPV




              Teague WG Pediatric Pulmonology 2003;35:418–426
NIPPV in children with ARF: Technical aspects

setting:   restricted to acute care units


           - pulsoxymeter
           - tcpCO2 / TECO2
           - cardiorespiratory monitoring
NIPPV in children with ARF: Technical aspects

interface:   soft preformed nasal mask appropriately sized
             usually work and are much better tolerated
               - chin strips can reduce the air leak
NIPPV in children with ARF: Technical aspects

interface:   soft preformed nasal mask appropriately sized
             usually work and are much better tolerated
               - chin strips can reduce the air leak
NIPPV in children with ARF: Technical aspects

interface:   soft preformed nasal mask appropriately sized
             usually work and are much better tolerated
                - chin strips can reduce the air leak


alternatives: 1) nasal prongs (typically used in newborns and
             small infants)
             2) full face (nasal-oral) masks
                - but increased risk of aspiration in small children
                              (immature airway protective response)
NIPPV in children with ARF: Technical aspects

DELIVERY SYSTEMS
 - CPAP devices
   need bias flow:      - to compensate for mask leaks
                        - to maintain constant airway pressure
                          during in- and expiration



 - Volume-cycled devices
   need variable flow (pressure controlled / pressure targeted)
   should be able to deliver high inflation flows:
   - to allow to match inspiratory flow demands of the patient to reduce WOB,
   - to compensate for leaks

   need automated cycle feature (apnea)
NIPPV in children with ARF: Technical aspects

DELIVERY SYSTEMS

- flow-triggered devices

   with independent adjustements
   of IPAP and EPAP

   one way expiratory valve to
   prevent rebreathing
   (EPAP regulates CO2 elimination:
   minimum 3 cmH2O)
NIPPV in children with ARF: Technical aspects

ventilators: NIPPV ventilators (typ: BiPAP; mode: S/T)
               ICU ventilators (PC / Pressure support)
                    sensitive flow trigger threshold

 one way
 expiratory                           Not optimal for
 valve to
 prevent                               small children:
 rebreathing
                                      - No back-up rate

                                      - Very low (5%) fixed
                                        expiratory trigger /
                                        flow termination at
                                        very low flows
Patient-Ventilator Interaction -


Patient-ventilator asynchrony
              by inspiratory trigger insensivity
                                  Insp effort trigger vent   Ineff
                                                             trig
COPD
                                                             abrupt
PSV
                                                             dec
                                                             exp flow



                    (12)                                      RR 24
Ineffective
effort



                                                              RR 60




    E. Kondili, G. Prinianakis and D. Georgopoulos
Pressure-Support and flow termination criteria


The non synchronized patient during Pressure-Support
(inappropriate end-inspiratory flow termination criteria)




 Nilsestuen J   Respir Care 2005;50:202–232.
Pressure-Support and flow termination criteria




                                                   Nilsestuen J
Increase in RR, reduction in VT, increase in WOB   Respir Care 2005
NPPV in acute or chronic pediatric respiratory failure:
Which mode, which device and which interface?
                   Infant (0 - 12       Small child (12 - 24   > 24 months
                   months)              months)

AHRF               Nasal CPAP (nasal    Nasal CPAP or       NIPPV with nasal or
                   prongs or mask) or   NIPPV with nasal or full face mask
                   NIPPV with a         full face mask
                   modified circuit
Upper airway       Nasal or             CPAP or NIPPV by       CPAP or NIPPV
obstruction        nasopharyngeal       nasal mask
                   CPAP
Tracheo-           CPAP with            CPAP with              CPAP with
bronchomalacia     relatively high      relatively high        relatively high
                   pressure levels      pressure levels        pressure levels
Chronic RF in      NIPPV                NIPPV                  NIPPV
neuromuscular
disease
Congestive heart   Nasal CPAP           Nasal or full face     Nasal or full face
failure or acute                        CPAP or NIPPV          CPAP or NIPPV
pulmonary edema
Helmet-delivered CPAP and/or non-invasive
pressure support ventilation in children?




                       Need high flows to
                       flush the system to
                       avoid CO2-rebreathing
Helmet-delivered NIPSV in children with acute
hypoxemic respiratory failure (P/F ratio < 200)




              Piastra M et al. Intensive Care Med 2004; 30:472-476
Selection guidelines for NIPPV in pediatric ARF

•   Progressive respiratory failure or insufficiency in the
    absence of apnea or impeding cardiorespiratory
    collapse


•   Failure of NIPPV would not produce immediate
    morbidity or mortality


•   Relative cooperation (of a lethargic or sedated patient)


•   Adequate mask fit achieved
Selection guidelines for NIPPV in pediatric ARF:
              Contra-indications


•   Ongoing emesis


•   Excessive bronchial secretions


•   Acute facial trauma


• Upper airway protection not intact
NIPPV in acute respiratory failure in children

widespread use in PICU
   • commonly applied to
         avoid intubation / reintubation
         improve atelectasis (type I failure / AHRF)
         Improve alveolar hypoventilation (type II failure)
         facilitate early extubation (postoperative / restrictive
          lung disease - neuromuscular disease - scoliosis
          repair)


despite popularity,
   therapeutic efficacy has never been evaluated
NIPPV in pediatric ARF
1)    NPPV is safe in pediatric patients with ARF

2)    NPPV can improve oxygenation in mild to moderate hypoxemic
      respiratory insufficiency

3)    May be particularly useful in patients in whom intubation
      should be avoided




current pediatric NIPPV questions:

     - does NPPV in ARF prevent or delay intubation?
     - in which type of respiratory failure should it be used?
     - does NIPPV reduce mortality in ARF in children?     ( mortality rate = 15%)
     - are ventilators appropriate for small children?

				
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