Non-invasive positive pressure ventilation in the PICU

1
Non-invasive positive pressure ventilation in the
PICU
2
What is the daily practice of mechanical
ventilation in ICU
In adults (in the years 1996 / 1997
Esteban A et al. AJRCCM 2000 16114501458
In pediatrics (in the year 1999)
ETT in 635 (96 95 CI 9497) of
patients, tracheostomy in 11 (2 95 CI 13),
facial mask in 10 (1.5 95 CI 13).
Farias A et al. Intensive Care Med 2004
30918925
3
NIPPV in the Pediatric Intensive Care Unit Geneva
experience 1998 - 1999
Number of pediatric patients hospitalized in the
PICU over a 2-year period 771 General
pediatrics 215 (28) Cardiovascular
surgery 279 (36) General surgery 133
(17) Neurosurgery 69 (9) Transplantatio
n 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)
4
NIPPV in acute pediatric respiratory failure
Geneva experience 1998 - 1999
n 63 CPAP 30 NPPV (BiPAP) 29 NPPV
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
5
High risk of respiratory distress in infants and
small children
Small airways high airway resistance
Compliant chest wall low FRC
Relatively inefficient diaphragm
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
6
Objectives of Noninvasive Ventilation
in Pediatric Patients With Respiratory Disorders
Avoid intubation
Teague WG Pediatric Pulmonology 200335418426
7
Indications / Benefits of NIPPV in the PICU
Early case reports showed Improvement of
clinical manifestation of respiratory distress
and respiratory gas exchange in children with AHRF
8
NIPPV in acute hypoxic respiratory
failure Benefit and treatment failures in 3
pediatric case series
Rimensberger PC Swiss Medical Weekly
200013018806
9
NIPPV / CPAP in ARF Treatment failures Geneva
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
10
NIPPV in infants with AHRF
6 infants with AHRF of various etiology Pressure
support IPAP 14 0,5 cmH2O EPAP 7,3 1
cmH2O Ti max 0,6 0,1 s insp. rise time 100
ms.
pCO2
RR
F. Vermeulen et al. Annales Françaises
dAnesthésie et de Réanimation 2003 22 716720
11
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
12
PEEP Tracheomalacia
No PEEP
PEEP 10cmH2O
Quen Mok, Great Ormond Street Hospital for
Children, London
13
CPAP Tracheomalacia
No PEEP
CPAP 10cmH2O
Quen Mok, Great Ormond Street Hospital for
Children, London
14
Case serie in pediatric status asthmaticus with
severe hypoxemia

Teague WG AJRCCM 1998 157542
prospective, non controlled case serie (n
26) NPPV nasal mask S/T mode IPAP 13 3
cmH2O EPAP 7 2 cmH2O FiO2 0.68 0.28
Results 21 27 hrs mean duration 169 183
hrs O2 requirements 19/26 acutely
improved 7/26 required intubation 11/26 did
not well tolerate
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
p gt 0.05 for all comparisons
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NPPV in pediatric status asthmaticus Case serie



p lt 0.05
p lt 0.05
not intubated (19)
intubated (7)
The oxygen response test?
Teague WG AJRCCM 1998 157542

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

16
NPPV in acute cardiogenic pulmonary edema (ACPE)
(patients who responded were hypercapnic, those
who failed were hypoxemic non-hypercapnic
patients)
with the exception of patients with acute
myocardial infarction, CPAP and/or NPPV is
efficient in ACPE with hypercapnic ARF
17
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 238-40
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NIV for physiotherapy
19
NIV for physiotherapy
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NIV for physiotherapy
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NIV for physiotherapy
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NIPPV in children with ARF Complications
severe air leaks gastric perforation aspiration
decrease in CO minor skin irritation / skin
breakdown nasal dryness conjunctivitis
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Physiological Factors Unique to Pediatric
Patients Promoting Complications of NIPPV
Teague WG Pediatric Pulmonology 200335418426
24
NIPPV in children with ARF Technical aspects
setting restricted to acute care units -
pulsoxymeter - tcpCO2 / TECO2 -
cardiorespiratory monitoring
25
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
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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
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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)
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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)

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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)
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NIPPV in children with ARF Technical aspects
ventilators NIPPV ventilators (typ BiPAP mode
S/T) ICU ventilators (PC / Pressure support)

• Not optimal for small children
• No back-up rate
• - Very low (5) fixed expiratory trigger / flow
  termination at very low flows

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Patient-Ventilator Interaction -
Patient-ventilator asynchrony by inspiratory
trigger insensivity
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Insp effort trigger vent
Ineff trig abrupt dec exp flow
COPD PSV
(12)
Ineffective effort
E. Kondili, G. Prinianakis and D. Georgopoulos
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Pressure-Support and flow termination criteria
The non synchronized patient during
Pressure-Support (inappropriate end-inspiratory
flow termination criteria)
Nilsestuen J Respir Care 200550202232.
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Pressure-Support and flow termination criteria
Nilsestuen J Respir Care 2005
Increase in RR, reduction in VT, increase in WOB
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NPPV in acute or chronic pediatric respiratory
failure Which mode, which device and which
interface?
Infant (0 - 12 months) Small child (12 - 24 months) gt 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
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Helmet-delivered CPAP and/or non-invasive
pressure support ventilation in children?
Need high flows to flush the system to avoid
CO2-rebreathing
38
Helmet-delivered NIPSV in children with acute
hypoxemic respiratory failure (P/F ratio lt 200)
Piastra M et al. Intensive Care Med 2004
30472-476
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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

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Selection guidelines for NIPPV in pediatric
ARFContra-indications

• Ongoing emesis
• Excessive bronchial secretions
• Acute facial trauma
• Upper airway protection not intact

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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
42
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?
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