Noninvasive Ventilation in Pediatric Respiratory Failure: Does It Work?

1
Noninvasive Ventilation in Pediatric Respiratory
Failure Does It Work?

• James D. Fortenberry MD FCCM, FAAP
• Director, Critical Care Medicine
• Childrens Healthcare of Atlanta at Egleston
• Clinical Associate Professor
• Emory University School of Medicine
• Atlanta, Georgia USA

2
History of Ventilation

• Noninvasive ventilation foundation of concept of
  mechanical ventilation
• 1876 First iron lung
• 1889 Alexander Graham Bell-first iron lung for
  newborn infant
• 1920s Drinker iron lung
• 1940s Polio epidemics
• 1960s Rise of positive pressure ventilation
• 1990s Resurgence of interest in NIV

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First Reported Use of Noninvasive Ventilation

• And the Lord God formed man of the dust of the
  ground and breathed into his nostrils the breath
  of life, and man became a living soul.

-- Genesis 27
4
What is Noninvasive Ventilation?

• Delivery of ventilatory support without the use
  of an invasive artificial airway
• Role in
• Chronic respiratory insufficiencyobstructive
  sleep apnea
• Acute respiratory failure
• Hypoxemic
• Hypercarbic

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What is Noninvasive Ventilation?

• Modalities
• Negative pressure inspiration ? lowers pressures
  surrounding chest wall, augments tidal volume,
  more physiologic
• Iron lung
• Cuirass
• Positive pressure (NIPPV) generates positive
  pressure flow to meet need in spontaneously
  breathing patient
• Current standard

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Noninvasive Positive Pressure Ventilation

• Modes of Delivery
• Volume ventilator
• Pressure-controlled
• Continuous (CPAP)
• Bilevel (BiPAP is trade name) cycles between
  inspiratory (IPAP) and expiratory (EPAP)
  pressures
• Intermittent
• Continuous

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Modes of BiPAP

• Spontaneous response to threshold level of
  patient inspiratory flow to provide IPAP with
  extra flow, EPAP after peak
• Spontaneous/Timed cycle added in event of apnea
• Timed intermittent pulses at set rate only
• Continuous PAP (CPAP)
• Problems
• infant may have difficulty achieving sufficient
  inspiratory flow to trigger
• Mask leak prolongs inflation time

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NIPPV Mechanisms of Action

• Stabilize chest wall
• Unload diaphragm and accessory muscles of
  breathing
• Increase tidal volume/minute ventilation
• Increase FRC
• Prevent atelectasis
• Decrease auto-PEEP/stent airways
• Maintain upper airway patency/ decrease apnea and
  hypopnea
• How well NIPPV provides these is undocumented

9
NIPPV Potential Benefits

• Avoidance of risks of intubation
• Improved bedside caregiver time
• Decreased nosocomial pneumonia
• Potential decreased ICU length of stay, mortality
• Decreased costs

10
NIPPV Initiation in Children

• Varied approaches
• General BiPAP settings IPAP 12, EPAP 6 cmH2O
• Blended oxygen flow to titrate
• Bedside caregiver presence high initially
• Sedation often needed in children to tolerate
• Ketamine bolus/infusion our choice

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NIPPV Delivery Systems

• Conventional ventilators
• CPAP device
• Aladdin
• Bilevel device
• BiPAP (Respironics)
• Knightstar (Puritan-Bennett)
• High flow nasal cannula devices
• Vapotherm

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NIPPV Interface modes and systems

• Mask
• Nasal
• Full face
• Type of mask
• Mask vs. pillows/cannula

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Nasal Mask
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Full Face Mask
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Nasal Prong Devices
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Nasal Pillow Devices
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Interfaces for NIPPV

• Nasal
• Advantages
• Less aspiration risk
• Easier secretion clearance
• Less dead space
• Easier fit in adults
• Disadvantages
• Mouth leak
• Higher resistance through nasal passages
• Nasal irritation
• Potential nasal obstruction
• Fit in infants?

• Oronasal
• Advantages
• Better control of mouth leak
• Better for mouth breathers
• Disadvantages
• More dead space
• Claustrophobia
• Higher aspiration risk
• More difficulty in speaking
• Risk if vent malfunction
• Greater sedation need in kids?

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NIPPV Potential Indications

• Cardiogenic pulmonary edema
• Hypercarbic respiratory failure/COPD
• Hypoxemic respiratory failure
• Peri-extubation
• Immunocompromised patients
• Asthma

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NIPPV Contraindications

• Significant altered mental status/inability to
  protect airway
• Hemoptysis
• Facial injuries
• NP obstruction
• Airway foreign bodies
• Significant cardiovascular instability

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NIPPV Potential Complications

• Acute unrecognized deterioration
• Nasal/facial erosions
• Aspiration
• Abdominal distention (GE sphincter pressure up to
  25 cmH2O)

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NIPPV What is the evidence for its benefit?

• Fifteen suitable randomized controlled trials for
  COPD
• Eight suitable RCTs in AHRF
• 2 major meta-analyses
• No pediatric RCTs

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NIPPV Meta-Analysis Effect on ICU Mortality in
COPD
-- Significant mortality benefit with NIPPV for
COPD (Lightowler JV, et al., BMJ 2003326185)
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NIPPV For COPD/Obstructive Airways Diseases

• Conclusions strongest support for a NIPPV
  indication
• COPD-NIPPV now considered a standard of care
• Asthma-potential benefit, less evidence

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NIPPV Meta-Analysis Effect on Intubation in AHRF
-- Significant benefit on need for intubation
(Keenan et al., Crit Care Med 2004322520)
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NIPPV Meta-Analysis Effect on ICU Length of Stay
in AHRF
-- Significant NIPPV benefit on ICU length of
stay (Keenan et al., Crit Care Med 2004322520)
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NIPPV Meta-Analysis Effect on ICU Mortality in
AHRF

• Significant mortality benefit demonstrated
• (Keenan et al., Crit Care Med 2004322520)

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NIPPV Meta-Analysis NIPPV Benefit As A Function
of Unit Mortality
-- Outcome benefit increases with increased
overall ICU mortality (Keenan et al., Crit Care
Med 2004)
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NIPPV for Hypoxemic Respiratory Failure

• Conclusions
• Limited evidence supports its use
• In the setting of single organ respiratory
  failure, a trial of NIPPV is warranted
• Intubation should not be delayed if rapid
  improvement does not occur

- Caples SM, Gay. Crit Care Med 2005332651
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NIPPV For Postoperative and Post-Extubation
Respiratory Failure

• Trials
• Use of NIPPV for respiratory distress after
  extubation
• Use to facilitate extubation
• Results
• Conclusions

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NIPPV for Respiratory Failure After Extubation

• 37 centers
• 221 adults extubated with respiratory failure
  within 48 hours
• Randomized to face mask NIPPV or standard therapy

- Esteban et al., N Engl J Med 20043502452
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NIPPV for Respiratory Failure After Extubation
- Esteban et al., N Engl J Med 20043502452
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Impact of NIPPV vs. Intubation on Nosocomial
Pneumonia
- NPPV associated with decreased nosocomial
pneumonia/infections
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NIPPV For Immunocompromised Patients

• Avoidance of infectious complications beneficial
• 2 RCTs of NPPV vs. standard therapy
• 40 solid organ transplants (Antonelli, JAMA 2000)
• NPPV decreased intubation and ICU mortality
• 52 neutropenic patients (Hilbert, NEMJ 2001)
• NPPV Fewer intubations, decreased mortality

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Effect of NIPPV on Caregiver Time
Respiratory Therapist
Nurse
Minutes
Minutes
- Kramer et al., AJRCCM 19951511799
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Why NIPPV Might Work Better in Children

• Immature chest wall more highly compliant
• Predicted FRC closer to total lung capacity
• Increased pharyngeal tone needed at expiration to
  maintain FRC
• Fewer fatigue-resistant muscle fiber types in
  infant diaphragm
• Prone to asynchrony of thorax and abdomen
  retractions
• Marginal increase in positive pressure support
  may be more helpful in child

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NIPPV in Pediatrics Clinical Experience

• Limited in children
• 9 published case series (no RCTs)
• AHRF combined 73 reported cases - only 8
  required intubation
• Acute hypercarbic respiratory failure combined
  34 reported cases- 16 required intubation

- Akingbola et al., Ped Crit Care Med 20012164
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Early Experience With NIPPV (BiPAP) in Children

• 28 children
• Median age 8 years (4-204 months)
• AHRF Mean P/F 141, A-a 271
• Most common diagnosis pneumonia
• BiPAP median IPAP 12 (8-16), EPAP 6 (5-8)
• Median duration of BiPAP 72 hours
• Improvement in all parameters
• Only 3/28 required intubation/reintubation

- Fortenberry et al., Chest 1995 1081059
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Early Experience With NIPPV (BiPAP) in Children
- Fortenberry et al., Chest 1995 1081059
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NIPPV Pediatric Experience in Varied Settings

• Use in 34 hypercapnic or hypoxemic children with
  impending respiratory failure in PICU decreased
  dyspnea, only 3 intubated (Padman CCM, 1998)
• Pediatric OSA decreased apnea (Padman Clin
  Pediatr 2002)
• Acute chest syndrome in HbSS 24/25 improved
  respiratory distress (Padman Del Med J 2004)
• Liver transplant/ respiratory insufficiency (Chin
  Liver Transpl 2005)
• 15 children (2.5 months-15 years previously
  reintubated)
• Hypercarbia improved
• 13 of 15 remained extubated

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NIPPV in Pediatric Status Asthmaticus

• Theoretical benefits
• Offset of auto-PEEP with airway obstruction
• Reduce inspiratory WOB without hyperinflation
• Unload diaphragm
• Improve delivery of bronchodilators
• Avoid PPV high risk in asthma

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NIPPV in Pediatric Status Asthmaticus

• Limited case reports
• Prospective crossover trial
• BiPAP (10/5) vs. standard therapy
• 20 asthmatic children
• Median 4 yrs, 2 mo-14 yrs

Thill et al., Pediatr Crit Care Med 20045337
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NIPPV in Children With Lower Airway Obstruction
Effect on Asthma Score

• Thill et al., Pediatr Crit Care Med 20045337

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New Aspects of NIPPV Vapotherm

• A high flow nasal cannula up to xx LPM
• Warms and humidifies high flows of gas for
  patient delivery
• Water and gas circuit separate Gas warmed and
  humidified through vapor transfer cartridge
  pressurizes water into molecular vapor
• Potential benefits positive pressure support in
  a more comfortable interface
• Infants, neonates
• Vapor transfer cartridge requires disinfection

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Vapotherm 2000i
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Vapotherm Mechanism of Action
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Vapotherm Infection Problems

• CDC Public Health Notification (12/2005)
• Contamination 29 institutions in 16 states
• Ralstonia spp. (GNR similar to Pseudomonas,
  Burkholderia) from instruments and 40 pediatric
  patients
• Majority probably colonization one active
  infection ? one death
• Disinfecting protocol ineffective
• encouraged to weigh the risk of bacterial
  contamination against the benefits Vapotherm
  might provide

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Vapotherm Voluntary Recall

• Vapotherm, Inc. issues voluntary recall (1/2006)
• Childrens of Atlanta removed all devices
• Replacement other high-flow nasal cannulas
  (Fisher-Paykel 10-12 LPM flow Aladdin) limited
  by flow

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NIPPV Conclusions

• NIPPV offers potential benefits for
• Acute/chronic hypercarbic respiratory failure
• Acute hypoxemic respiratory failure-less certain
• Immuno-compromised host to avoid intubation
• Post-extubation failure high risk for
  deterioration
• Benefit of NIPPV in children
• Anecdotal-hypercarbia/AHRF
• Likely helps in selected cases to avoid
  intubation or re-intubation
• We need a randomized study!