Title: Noninvasive Ventilation in Pediatric Respiratory Failure: Does It Work?
1Noninvasive 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
2History 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
3First 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
4What 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
5What 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
6Noninvasive 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
7Modes 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
8NIPPV 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
9NIPPV Potential Benefits
- Avoidance of risks of intubation
- Improved bedside caregiver time
- Decreased nosocomial pneumonia
- Potential decreased ICU length of stay, mortality
- Decreased costs
10NIPPV 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
11NIPPV Delivery Systems
- Conventional ventilators
- CPAP device
- Aladdin
- Bilevel device
- BiPAP (Respironics)
- Knightstar (Puritan-Bennett)
- High flow nasal cannula devices
- Vapotherm
12NIPPV Interface modes and systems
- Mask
- Nasal
- Full face
- Type of mask
- Mask vs. pillows/cannula
13Nasal Mask
14Full Face Mask
15Nasal Prong Devices
16Nasal Pillow Devices
17Interfaces 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?
18NIPPV Potential Indications
- Cardiogenic pulmonary edema
- Hypercarbic respiratory failure/COPD
- Hypoxemic respiratory failure
- Peri-extubation
- Immunocompromised patients
- Asthma
19NIPPV Contraindications
- Significant altered mental status/inability to
protect airway - Hemoptysis
- Facial injuries
- NP obstruction
- Airway foreign bodies
- Significant cardiovascular instability
20NIPPV Potential Complications
- Acute unrecognized deterioration
- Nasal/facial erosions
- Aspiration
- Abdominal distention (GE sphincter pressure up to
25 cmH2O)
21NIPPV 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
22NIPPV Meta-Analysis Effect on ICU Mortality in
COPD
-- Significant mortality benefit with NIPPV for
COPD (Lightowler JV, et al., BMJ 2003326185)
23NIPPV 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
24NIPPV Meta-Analysis Effect on Intubation in AHRF
-- Significant benefit on need for intubation
(Keenan et al., Crit Care Med 2004322520)
25NIPPV 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)
26NIPPV Meta-Analysis Effect on ICU Mortality in
AHRF
- Significant mortality benefit demonstrated
- (Keenan et al., Crit Care Med 2004322520)
27NIPPV 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)
28NIPPV 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
29NIPPV For Postoperative and Post-Extubation
Respiratory Failure
- Trials
- Use of NIPPV for respiratory distress after
extubation - Use to facilitate extubation
- Results
- Conclusions
30NIPPV 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
31NIPPV for Respiratory Failure After Extubation
NIPPV Standard Therapy
Need for re-intubation 48 48
Death 25 (RR 1.78, 95 CI 1.03-3.20) 14
Time from respiratory failure to re-intubation 12 hours (p 0.02) 2. 5 hours
- Esteban et al., N Engl J Med 20043502452
32Impact of NIPPV vs. Intubation on Nosocomial
Pneumonia
- NPPV associated with decreased nosocomial
pneumonia/infections
33NIPPV 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
34Effect of NIPPV on Caregiver Time
Respiratory Therapist
Nurse
Minutes
Minutes
- Kramer et al., AJRCCM 19951511799
35Why 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
36NIPPV 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
37Early 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
38Early Experience With NIPPV (BiPAP) in Children
- Fortenberry et al., Chest 1995 1081059
39NIPPV 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
40NIPPV 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
41NIPPV 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
42NIPPV in Children With Lower Airway Obstruction
Effect on Asthma Score
- Thill et al., Pediatr Crit Care Med 20045337
43New 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
44Vapotherm 2000i
45Vapotherm Mechanism of Action
46Vapotherm 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
47Vapotherm 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
48NIPPV 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!