Non-invasive positive pressure ventilation in the PICU

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

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

What is the daily practice of mechanical ventilation in ICU

In adults (in the years 1996 / 1997:

In pediatrics (in the year 1999):

NIPPV in the Pediatric Intensive Care UnitGeneva experience 1998 - 1999

Number of pediatric patients hospitalizedin 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): 29NPPV 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

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

Small airways = high airway resistance

Compliant chest wall = low FRC

Relatively “inefficient” diaphragm

Objectives of Noninvasive Ventilation inPediatric Patients With Respiratory Disorders

Teague WG Pediatric Pulmonology 2003;35:418–426

Avoid intubation

Indications / Benefits of NIPPV in the PICU

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)

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

Rimensberger PC Swiss Medical Weekly 2000;130:1880–6

NIPPV in acute hypoxic respiratory failure:Benefit and treatment failures in 3 pediatric case series

4

NIPPV / CPAP in ARF: Treatment failuresGeneva 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

pCO2 RR

F. Vermeulen et al. Annales Françaises d’Anesthésie et de Réanimation 2003; 22: 716–720

6 infants with AHRF of various etiologyPressure support: IPAP 14 ± 0,5 cmH2O; EPAP 7,3 ± 1 cmH2OTi max: 0,6 ± 0,1 s ; insp. rise time: 100 ms.

NIPPV in infants with AHRF

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

Quen Mok, Great Ormond Street Hospital for Children, London

No PEEP PEEP 10cmH2O

No PEEP CPAP 10cmH2O

CPAP: Tracheomalacia

Quen Mok, Great Ormond Street Hospital for Children, London

Case serie in pediatric status asthmaticus with severe hypoxemia

prospective, non controlled case serie (n = 26)

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

0.28

Results: 21 ± 27 hrs mean duration169 ± 183 hrs O2 requirements19/26 acutely improved7/26 required intubation11/26 did not well tolerate

Teague WG AJRCCM 1998; 157:542

p > 0.05 for all comparisons

pH paCO2

(mmHg)

paO2

(mmHg)

pre-tx (n = 15) 7.36 ± 0.5 40 ± 10 87 ± 23

post-tx (n = 6) 7.42 ± 0.9 39 ± 14 94 ± 35

• was safe• allowed to shorten the length of ICU and hospital stay• did not prevent intubation in a subset of patients

0

5

10

15

20

25

Hospital Days PICU days

intubated

notintubated

NPPV in pediatric status asthmaticus: Case serie

0

20

40

60

80

100

120

FiO2 SO2 FiO2 SO2

pre NPPV

post NPPV

not intubated (19) intubated (7)

* p < 0.05

*

* p < 0.05

*

*

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

retrospective chart review (1998 - 1999)

n = 14 (age 5.2 ± 3.9 months; range: 1.5 - 12)

2 patients with BPD - surfactant B deficiency

- Wilson-Mikity-syndrome

pre-treatment: pH 7.26 ± 0.05 (range: 7.17 - 7.33)

pCO2 76 ± 9 mmHg (range: 61 - 88)

tSO2 60 ± 11 (range: 40 - 80) at room-air

NIPPV / CPAP in Bronchiolitis

with Acute Hypoxic-Hypercapnic Respiratory Failure

Geneva experience 1998 - 1999

NIPPV / CPAP in Bronchiolitis

with Acute Hypoxic-Hypercapnic Respiratory Failure

Geneva experience 1998 - 1999initialtreatment

number ofpatients

treatmentfailure

duration ofventilatorysupport (days)

Comments

CPAP 12 1 2.8 ± 1.1(range: 2 - 5)

tx-failure inpatient # 1with BPD

NPPV(BiPAP)

1 0 3 patient # 2with BPD

endotrachealintubation

1 3 (+ 2 d CPAP) intubated priorto transfer

NPPV in acute cardiogenic pulmonary edema (ACPE)

no. of patientsstudy design

ventilationmode

treatmentfailure

Results

Bersten ADNEJM 1991;325 CPAP vs O2

CPAP 0 vs 35% no difference inlength of ICU stay

Hoffmann BCCM 1999;25

29open prospective

BiPAP in 1patient

improved SO2 anddecreased pCO2 inall patients

Rusterholz TCCM 1999;25

26open prospective

BiPAP 21% improved SO2 anddecreased pCO2 inreponders

with the exception of patients with acute myocardial infarction,

CPAP and/or NPPV is efficient in ACPE with hypercapnic ARF

(patients who responded were hypercapnic,

those who failed were hypoxemic non-hypercapnic patients)

NPPV in acute heart failure and/or pulmonary

edemaGeneva experience 1998 - 1999

indication number ofpatients

days ofventilationbefore NPPV

days onNPPV

treatmentfailure

postextubationafter CHD-repair

12 3.8 ± 1.8 2.5 ± 1.4 1 /12

AHF inmyocarditis

1 - 7 0

non cardiogenicpulmonaryedema

2 - 4 / 2 0/ 2

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

Indications et contre-indications de la ventilation non invasive en réanimation pédiatrique

Indications

Obstruction des voies aériennes supérieures

Maladies pulmonaires primaires

Œdème aigu cardiogénique

Œdème aigu lésionnel

Infection

Obstruction des voies aériennes inférieures

Syndrome thoracique aigu (drépanocytose)

Affections chroniques en décompensation aiguë (mucovicidose)

Décompensation respiratoire aiguë de maladies neuromusculaires (amyotrophie spinale, dystrophie neuromusculaire)

Affections congénitales et acquises avec altération aiguë du contrôle de la respiration

Déformations thoraciques congénitales ou acquises (en péri-opératoire le plus souvent) Autres : anesthésie de courte durée, extubation précoce, échec d'extubation

Contre-indications

Absolues

Arrêt cardiaque ou respiratoire

Instabilité hémodynamique

Patients à risque d'inhalation : encéphalopathie sévère, encombrement pharyngé quelle que soit l'origine , vomissements incoercibles, hémoptysies massives.

Syndrome occlusif abdominal

Allergie aux interfaces nasales et faciales

Relatives

Évolutivité rapide de la défaillance respiratoire ou neurologique

Patient non coopératif

Lésions faciales

Disponibilité insuffisante du personnel

NIPPV in children with ARF: Technical aspects

setting: restricted to acute care units

- pulsoxymeter

- tcpCO2 / TECO2

- cardiorespiratory monitoring

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

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

Not optimal for small children:

- No back-up rate

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

one way expiratory valve to prevent rebreathing

•Hering-Breuer reflexes•Respiratory Muscle Weakness•Respiratory system mechanics•Pathology•Leaks

Patient

•Ventilator algorithms and control •Trigger signal•Cycling off•Rate and character of inspiratory flow•Intrinsic PEEP•Leaks

Ventilator

•Mode and Settings•Level of support•Level of sedation

Decision making

Patient-ventilator asynchrony

Patient-Ventilator Interaction -

Patient-ventilator asynchrony by inspiratory trigger insensivity

E. Kondili, G. Prinianakis and D. Georgopoulos

COPDPSV

Insp effort trigger vent Inefftrigabruptdecexp flow

Ineffective effort

(12) RR 24

RR 60

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

Pressure-Support and flow termination criteria

Increase in RR, reduction in VT, increase in WOB Nilsestuen J Respir Care 2005

NPPV in acute or chronic pediatric respiratory failure:

Which mode, which device and which interface?

Infant (0 - 12 months)

Small child (12 - 24 months)

> 24 months

AHRF Nasal CPAP (nasal prongs or mask) or NIPPV with a modified circuit

Nasal CPAP or NIPPV with nasal or full face mask

NIPPV with nasal or full face mask

Upper airway obstruction

Nasal or nasopharyngeal CPAP

CPAP or NIPPV by nasal mask

CPAP or NIPPV

Tracheo-bronchomalacia

CPAP with relatively high pressure levels

CPAP with relatively high pressure levels

CPAP with relatively high pressure levels

Chronic RF in neuromuscular disease

NIPPV NIPPV NIPPV

Congestive heart failure or acute pulmonary edema

Nasal CPAP Nasal or full face CPAP or NIPPV

Nasal or full face CPAP or NIPPV

Helmet-delivered CPAP and/or non-invasive pressure support ventilation in children?

Need high flows to flush the system to avoid CO2-rebreathing

Piastra M et al. Intensive Care Med 2004; 30:472-476

Helmet-delivered NIPSV in children with acute hypoxemic respiratory failure (P/F ratio < 200)

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

• Ongoing emesis

• Excessive bronchial secretions

• Acute facial trauma

• Upper airway protection not intact

Selection guidelines for NIPPV in pediatric ARF:Contra-indications

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?

SpontaneousBreathing

Mechanical Ventilation

Pre

ssur

eP

ress

ure

Pre

ssur

eP

ress

ure

Pre

ssur

e

Time

Time

Time

Time

Time

CMV

SIMV

Bivent

APRV

CPAP

F. Vermeulen et al. Annales Françaises d’Anesthésie et de Réanimation 2003; 22: 716–720

Modification of the tubing for the use in infants

1) Upper airway obstruction 

Subglottic stenosis Congenital/acquired 

Tracheomalacia Congenital/acquired 

Tracheal stenosis Congenital/acquired 

Craniofacial syndromes Pierre-Robin sequenceCHARGE syndromeTreacher–Collins syndromeBeckwith–Wiedemann syndrome 

Craniofacial and laryngeal tumours Cystic hygroma, haemangioma 

Bilateral vocal cord paralysis Hydrocephalus internusMoebius syndrome 

Obstructive sleep apnoea 

Laryngeal trauma

Burn, fracture

Indications for tracheostomy: 1) Upper airway obstruction2) Long-term ventilation/pulmonary toilet 

2) Long-term ventilation/pulmonary toilet 

Pulmonary disease Bronchopulmonary dysplasiaScoliosis with restrictive pneumopathy 

Congenital heart disease

Postoperative diaphragmatic paresis 

Neurological/neuromuscular disease Duchenne muscular dystrophySpinal muscle atrophy type ICongenital central hypoventilation syndromeCerebral palsyTraumatic brain and spinal injurySpina bifida

Indications for tracheostomy: 1) Upper airway obstruction2) Long-term ventilation/pulmonary toilet 

Criteria favouring tracheostomy in children

The child with upper airway obstruction

Low chance of definitive, spontaneous resolution within a reasonable time (weeks) Low probability that surgery can definitely correct the cause High risk of critical upper airway obstruction with simple respiratory tract infections or minor bleeding (epistaxis) High risk of or previous history of difficulties in airway management in case of an emergency Difficult-to-control gastro-oesophageal reflux

The child requiring long-term ventilation/ pulmonary toilet

Young age with a high risk of mid-facial deformation from mask pressure Ventilator dependency for most of the day (more than 12 hours per day) Inability to cope with a mask (full face or nasal mask) Recurrent aspirations (gastro-oesophageal reflux, laryngeal incompetence) with significant benefit from pulmonary toilet Safety-measures and local experience highly in favour of invasive ventilation