Noninvasive Ventilation

in Pediatrics
Ira M. Cheifetz, MD, FCCM, FAARC
Professor of Pediatrics
Chief, Pediatric Critical Care
Medical Director, PICU and Peds Resp Care
Duke Children ’s Hospital
Children’s
 Do you use noninvasive
ventilation for children in the
acute ICU setting?
♦ If yes, do you have convincing data to
support your practice?

♦ If no, is this because of a lack of

– data?
– appropriate delivery devices and
interfaces?
– comfort with this ventilatory strategy?
 Noninvasive Ventilation (NIV)
♦ Not a new concept
♦ Many decades of experience
– neuromuscular weakness
– obstructive sleep apnea
– upper & lower airway obstruction
– acute hypoxic respiratory failure
– post-extubation / facilitate extubation

♦ So, why are some still unsure of using

NIV for pediatric patients?
 Available Data?
♦ Most data are from adults & neonates.
– very different populations
♦ Most studies have involved patients with:
– acute hypercapneic respiratory failure
– co -morbidities
co-morbidities
– premature infants
♦ Very few studies have evaluated NIV for
‘‘pure’
pure’ acute hypoxemic resp failure.
♦ No conclusive pediatric data – just one
study.
 AARC 38th Journal Conference:
‘Respiratory Controversies in the
Critical Care Setting’
Should NIV be used for all forms of acute
respiratory failure?
Hess and Fessler, Respir Care, 2007
NIV is indicated for all forms of ARF
♦ Tremendous clinical experience
♦ Utilization of NIV continues to ↑ dramatically
♦ Significant recent technical advances
♦ 7 systematic reviews published to date with
consistent conclusions
–– NIV ↓ intubation rate and mortality
♦ Clear data for adult patients
–– COPD, card pulm edema, lung resection, solid
organ transplantation, immunosuppressed patients,
prevent extubation failure, asthma
Hess and Fessler, Resp Care, 2007
NIV is indicated for all forms of ARF
♦ Hypoxemic respiratory failure
– ↓ intubation rate & mortality
(meta -analysis; Keenan, CCM, 2004)
(meta-analysis;
♦ Nosocomial pneumonia
– ↓ risk of VAP with NIV
(meta -analysis; Hess, Respir Care, 2005)
meta-analysis;
♦ Common exclusions
– airway protection, unable to fit mask,
severe illness, uncooperative patient

Hess and Fessler, Resp Care, 2007

 NIV is NOT for all forms of ARF
♦ No change in reintubation rates, mortality, or
benefit in hypercarbic pts (Keenan, JAMA, 2002)
♦ NIV does not work to rescue patients with resp
distress after extubation
– evidence of harm (Esteban, NEJM, 2004)
– resp failure after extubation → ↑ mortality
♦ Should not be used in patients with a high
likelihood of failure
♦ NIV: ‘No clear advantage’
Hess and Fessler, Resp Care, 2007
Should NIV be used for all forms of
acute resp failure?
Excluding ICU bed availability and other
administrative and technical issues, how
many of the 13 experts routinely use NIV in
patients with acute resp failure?

Everyone

Hess and Fessler, Resp Care, 2007

Now, let’s take a closer look
at the data!
 Non-invasive Ventilation
♦ ↓ intubation rate, ICU LOS, & ICU mortality
–– Keenan, CCM, 2004 (meta-analysis)
(meta-analysis)
♦ ↓ nosocomial pneumonia risk
–– Hess, Respir Care, 2005 (meta -analysis)
(meta-analysis)
 NIV to Avoid Intubation
90
NPPV Control
80

70

60
% intubated

50

40

30

20

10

0
Brochard Vitacca Brochard Kramer Wysocki Confalonieri
1990 1993 1995 1995 1995 1996

Marini, Crit Care Med, 2008

Antonelli, New Eng J Med, 1998
Antonelli, New Eng J Med, 1998
Hilbert, New Eng J Med, 2001
Hilbert, New Eng J Med, 2001
 NIV ‘standard’ p
(n=114) (n=107)
reintubation 48% 48% n.s.
rate
time to 12 hrs 2.5 hrs 0.021
reintubation
mortality 25% 14% 0.048

Esteban, New Eng J Med, 2004

 Predictors
NIV failure NIV success
(n = 38) (n = 16) p
Age 64 60 0.86
APACHE III 81.5 55.5 <0.01
Sepsis 33 14 0.9
Shock 19 0 -
PaO2/FiO2 112 147 0.02
PaCO2 36 42 0.1
pH 7.37 7.39 0.4
Base excess -4.0 0.5 0.01

Rana, Crit Care, 2006

NIV and Asthma

Soroksky, Chest, 2003

Hill, Crit Care Med, 2007
 Pediatric Data
♦ Randomized, controlled trial
– Yanez, Pediatr Crit Care Med, 2008

♦ What else has been published?

– case series
– case reports
– poorly controlled studies
– not even a well-performed survey study
 Pediatric Data

Yanez, Pediatr Crit Care Med, 2008

 Pediatric Data

Yanez, Pediatr Crit Care Med, 2008

 Pediatric Data

Yanez, Pediatr Crit Care Med, 2008

 Pediatric NIV
Is it worth the effort?
♦ Pediatric NIV is increasing at an exponential
rate despite the lack of convincing data.

♦ Why?

– same reasons as for adult pts & neonates

– avoid intubation

– facilitate extubation

– ↓ length of ventilation
 Real Life Situation
♦ 7 month old infant (5.9 kg)

♦ Problem list:VSD s/p repair, pulmonary

hypertension (on sildenafil), chronic lung
disease, upper airway obstruction, severe
GE reflux….
♦ Mechanically ventilated for 8 weeks

♦ Now on minimal vent support & ‘stable’

♦ Ready for extubation trial??

 NIV: Available Technology
♦ Neonatal CPAP
– stand alone systems
– full-service ventilators
♦ Bi-level ventilation (i.e., BiPAP)
– limited availability of FDA approved
equipment (ventilator and interface)
♦ Reintubation – not an ideal option
♦ A real dilemma for the clinician
 Challenges:
Patient Population
♦ Variability in patient size and age
– neonates to 18 years
– 3 kg to > 100 kg
♦ Variety of diagnosis (medial and surgical)
– acute hypoxemic respiratory failure
– neuromuscular weakness
– cardiac
– airway obstruction
 Challenges: Technical
♦ Inspiratory flow
– ideally flow should be adjustable
♦ Response time
– needs to be ‘fast’ and able to reliably
synchronize with the infant / child
♦ Monitoring (currently minimal)
– tidal volume
– graphics
– capnography
 Challenges: Interface
♦ Probably the biggest challenge

♦ Optimize patient comfort

♦ Must protect the skin and the eyes

– an added challenge in the infant

population ((‘not
‘not much room to work ’)
work’)
♦ Nasal vs. full face masks
 What are the problems?
♦ High inspiratory flow rates
– dried secretions → potential for airway
obstruction
– patient discomfort due to high flow rates
♦ Interfaces – generally not designed for
infants and small children
– comfort
– skin integrity
Nasal Mask
FULL Face Mask
Securing Devices
What are we often left with?
So, why try NIV for pediatrics?
♦ To avoid invasive mechanical ventilation
and all of its associated complications.
– increased pharmacologic sedation

– secondary lung injury

– airway injury

– nosocomial pneumonia
 Potential Applications
♦ Hypoxemic respiratory failure / ALI
– pneumonia, aspiration, any etiology
♦ Upper and lower airway obstruction
– subglottic stenosis; tracheolaryngomalacia
– asthma; bronchiolitis
♦ Neuromuscular weakness
– critical illness myopathy
– spinal muscular atrophy
♦ Application should be based on patho-
physiology; not necessarily on diagnosis
 Potential Applications
♦ Special populations
– immunosuppressed patients;
s/p bone marrow transplantation
– chronic lung disease;
bronchopulmonary dysplasia
♦ Overall goals
– avoid intubation
– encourage prompt extubation
– ↓ length of ventilation
 Pediatric NIV: Summary
♦ Technology (which is as good as the ‘adult’
products) does not currently exist for infants
and small children.
♦ Interfaces are probably the biggest challenge.
♦ Clinical need for technology does exist.
♦ Need more pediatric data, but the use of NIV
in pediatrics seems reasonable based on
extrapolation from the neonatal and adult
populations.
♦ Need consistent guidelines / protocols.
 Pediatric NIV: Summary
♦ Use of NIV in the pediatric population is
growing at an increasing rate.
♦ Is it worth the effort?

– yes

♦ Do the benefits outweigh the risks?

– probably