The document discusses noninvasive ventilation (NIV) in pediatrics. It notes that while NIV use has increased, pediatric data is limited compared to adults and neonates. There are significant challenges to pediatric NIV including a wide range of patient sizes, limited technology designed for small children, and interface issues. However, NIV may help avoid intubation and mechanical ventilation in situations like respiratory failure, airway obstruction, and neuromuscular weakness. Further research and improved pediatric-specific technology are still needed.

1. 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

2. NIV: Is it worth the effort?
♦ Noninvasive ventilation (NIV) is not a
new concept.
♦ Many decades of experience
acute hypoxic respiratory failure
–
post-extubation / facilitate extubation
–
neuromuscular weakness
–
upper & lower airway obstruction
–
♦ So, why are some still unsure of using
NIV for pediatric patients?

3. 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
–
‘‘preemies’
preemies’
–
♦ Very few studies have evaluated NIV for
‘‘pure’ acute hypoxic resp failure.
pure’
♦ No conclusive pediatric data – just one
study.

4. 38th Journal Conference:
‘Respiratory Controversies in the
Critical Care Setting’
Should NIV be used for all forms of acute
respiratory failure?
Hess and Fessler, Resp Care, 2007

5. NIV is for all forms of ARF
♦ Tremendous clinical experience
Utilization of NIV has ↑ dramatically
♦
♦ Significant recent technical advances
♦ 7 systematic reviews published to date with
consistent conclusions
NIV ↓ intubation rate & 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

6. NIV is 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

7. NIV is NOT for all forms of ARF
No Δ in reintubation rates, mortality, or benefit in
♦
hypercarbic subset (Keenan, JAMA, 2002)
♦ NIV does not work to rescue patients with resp
distress after extubation (Esteban, NEJM, 2004)
♦ Evidence of harm?
resp failure after extubation → ↑ mortality
–
♦ Should not be used in patients with a high
likelihood of failure.
♦ NIV: ‘‘No clear advantage’
No advantage’
Hess and Fessler, Resp Care, 2007

8. 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 ARF?
Everyone
Hess and Fessler, Resp Care, 2007

9. Now, let’s take a closer look
at the data!

10. 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)
–
–

11. 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

13. Antonelli, New Eng J Med, 1998.

14. Antonelli, New Eng J Med, 1998.

16. Hilbert, New Eng J Med, 2001.

17. Hilbert, New Eng J Med, 2001.

19. 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

20. 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

21. NIV and Asthma
Soroksky, Chest, 2003

23. Hill, Crit Care Med, 2007

24. 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

25. Pediatric Data
Yanez, Pediatr Crit Care Med, 2008

26. Pediatric Data
Yanez, Pediatr Crit Care Med, 2008

27. Pediatric Data
Yanez, Pediatr Crit Care Med, 2008

28. Peds NIV
Is it worth the effort?
♦ NIV in peds 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

29. Real Life Situation
♦ 7 month old infant (5.9 kg)
♦ Problem list: large 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??

32. 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

35. Pediatric NIV
♦ Challenges – substantial
♦ Current technology – real limitations
♦ Opportunities – huge

36. 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

37. 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
–

38. Challenges: Interface
♦ Probably the biggest challenge
♦ Optimize patient comfort
♦ Must protect the skin and the eyes
– an added challenge in the infant
population (‘not much room to work’)
(‘not work’)
♦ Nasal vs. full face masks

39. Pediatric NIV
♦ Challenges – substantial
♦ Current technology – real limitations
♦ Opportunities – huge

40. Current Technology
♦ Why not just use adult technology for peds
patients?
– some do!
♦ Is this ideal?
– no!

41. 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
–

42. Nasal Mask

43. FULL Face Mask

44. Securing Devices

45. What are we often left with?

46. So, why try NIV?
♦ To avoid invasive mechanical ventilation
and all of its associated complications.
– increased pharmacologic sedation
– secondary lung injury
– airway injury
– nosocomial pneumonia
– and, others….

47. Pediatric NIV
♦ Challenges – substantial
♦ Current technology – real limitations
♦ Opportunities – huge

48. 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.

49. 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

50. How many patients?
♦ International data are difficult to estimate.
♦ Duke data – NIV for acute etiologies
– PICU – 87 pts over 12 mos representing
425 vent-days (average 4.9 days)
– PBMT unit – 11 pts over 12 mos
representing 141 vent-days (average
12.8 days)
– And, this is without ideal technology or
equipment.

51. Technology: How small?
♦ Age limits? ♦ Weight limits?
– 5 years? – 20 kg?
– 1 year? – 10 kg?
– 1 month? – 5 kg?
– 1 week? – 3 kg?
♦ The smaller, the better!

52. 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.

53. 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