Safety of paediatric tracheal intubation after non-invasive ventilation failure

[Non-invasive Mechanical Ventilation in Acute Respiratory Failure. Clinical Practice Guidelines - on behalf of the German Society of Pneumology and Ventilatory Medicine]

The guideline update outlines the advantages as well as the limitations of NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications.Non-invasive ventilation (NIV) has a high value in therapy of hypercapnic acute respiratory failure, as it significantly reduces the length of ICU stay and hospitalization as well as mortality.Patients with cardiopulmonary edema and acute respiratory failure should be treated with continuous positive airway pressure (CPAP) and oxygen in addition to necessary cardiological interventions. This should be done already prehospital and in the emergency department.In case of other forms of acute hypoxaemic respiratory failure with only mild or moderately disturbed gas exchange (PaO2/FiO2 > 150 mmHg) there is no significant advantage or disadvantage compared to high flow nasal oxygen (HFNO). In severe forms of ARDS NIV is associated with high rates of treatment failure and mortality, especially in cases with NIV-failure and delayed intubation.NIV should be used for preoxygenation before intubation. In patients at risk, NIV is recommended to reduce extubation failure. In the weaning process from invasive ventilation NIV essentially reduces the risk of reintubation in hypercapnic patients. NIV is regarded useful within palliative care for reduction of dyspnea and improving quality of life, but here in concurrence to HFNO, which is regarded as more comfortable. Meanwhile NIV is also recommended in prehospital setting, especially in hypercapnic respiratory failure and pulmonary edema.With appropriate monitoring in an intensive care unit NIV can also be successfully applied in pediatric patients with acute respiratory insufficiency.

Mitigation and Outcomes of Difficult Bag-Mask Ventilation in Critically Ill Children

Difficult bag-mask ventilation (BMV) occurs in 10% of pediatric intensive care unit (PICU) tracheal intubations (TI). The reasons clinicians identify difficult BMV in the PICU and the interventions used to mitigate that difficulty have not been well-studied. This is a prospective, observational, single-center study. A patient-specific data form was sent to PICU physicians supervising TIs from November 2019 through December 2020 to identify the presence of difficult BMV, attempted interventions used, and perceptions about intervention success. The dataset was linked and merged with the local TI quality database to assess safety outcomes. Among 305 TIs with response (87% response rate), 267 (88%) clinicians performed BMV during TI. Difficult BMV was reported in 28 of 267 patients (10%). Commonly reported reasons for difficult BMV included: facial structure (50%), high inspiratory pressure (36%), and improper mask fit (21%). Common interventions were jaw thrust (96%) and an airway adjunct (oral airway 50%, nasal airway 7%, and supraglottic airway 11%), with ventilation improvement in 44% and 73%, respectively. Most difficult BMV was identified before neuromuscular blockade (NMB) administration (96%) and 67% (18/27) resolved after NMB administration. The overall success in improving ventilation was 27/28 (96%). TI adverse outcomes (hemodynamic events, emesis, and/or hypoxemia <80%) are associated with the presence of difficult BMV (10/28, 36%) versus non-difficult BMV (20/239, 8%, p< 0.001). Difficult BMV is common in critically ill children and is associated with increased TI adverse outcomes. Airway adjunct placement and NMB use are often effective in improving ventilation.

Development of a deep learning model that predicts Bi-level positive airway pressure failure

Delaying intubation for patients failing Bi-Level Positive Airway Pressure (BIPAP) may be associated with harm. The objective of this study was to develop a deep learning model capable of aiding clinical decision making by predicting Bi-Level Positive Airway Pressure (BIPAP) failure. This was a retrospective cohort study in a tertiary pediatric intensive care unit (PICU) between 2010 and 2020. Three machine learning models were developed to predict BIPAP failure: two logistic regression models and one deep learning model, a recurrent neural network with a Long Short-Term Memory (LSTM-RNN) architecture. Model performance was evaluated in a holdout test set. 175 (27.7%) of 630 total BIPAP sessions were BIPAP failures. Patients in the BIPAP failure group were on BIPAP for a median of 32.8 (9.2-91.3) hours prior to intubation. Late BIPAP failure (intubation after using BIPAP > 24 h) patients had fewer 28-day Ventilator Free Days (13.40 [0.68-20.96]), longer ICU length of stay and more post-extubation BIPAP days compared to those who were intubated ≤ 24 h from BIPAP initiation. An AUROC above 0.5 indicates that a model has extracted new information, potentially valuable to the clinical team, about BIPAP failure. Within 6 h of BIPAP initiation, the LSTM-RNN model predicted which patients were likely to fail BIPAP with an AUROC of 0.81 (0.80, 0.82), superior to all other models. Within 6 h of BIPAP initiation, the LSTM-RNN model would identify nearly 80% of BIPAP failures with a 50% false alarm rate, equal to an NNA of 2. In conclusion, a deep learning method using readily available data from the electronic health record can identify which patients on BIPAP are likely to fail with good discrimination, oftentimes days before they are intubated in usual practice.

Noninvasive Ventilation and Outcomes in Bronchiolitis

OBJECTIVES

Evaluation of potential benefits of noninvasive ventilation for bronchiolitis has been precluded in part by the absence of large, adequately powered studies. The objectives of this study were to characterize temporal trends in and associations between the use of noninvasive ventilation in bronchiolitis and two clinical outcomes, invasive ventilation, and cardiac arrest.

DESIGN

Multicenter retrospective cross-sectional study.

SETTING

Forty-nine U.S. children's hospitals participating in the Pediatric Health Information System database.

PATIENTS

Infants under 12 months old who were admitted from the emergency department with bronchiolitis between January 1, 2010, and December 31, 2018.

MEASUREMENTS AND MAIN RESULTS

Primary outcomes were rates of noninvasive ventilation, invasive ventilation, and cardiac arrest. Trends over time were assessed with univariate logistic regression. In the main analysis, hospital-level multivariable logistic regression evaluated rates of outcomes including invasive ventilation and cardiac arrest among hospitals with high and low utilization of noninvasive ventilation. The study included 147,288 hospitalizations of infants with bronchiolitis. Across the entire study population, noninvasive and invasive ventilation increased between 2010 and 2018 (2.9-8.7%, 2.1-4.0%, respectively; p < 0·001). After adjustment for markers of severity of illness, hospital-level noninvasive ventilation (high vs low utilization) was not associated with differences in invasive ventilation (5.0%, 1.8%, respectively, adjusted odds ratio, 1.8; 95% CI, 0·7-4·6) but was associated with increased cardiac arrest (0.36%, 0.02%, respectively, adjusted odds ratio, 25.4; 95% CI, 4.9-131.0).

CONCLUSIONS

In a large cohort of infants at children's hospitals, noninvasive and invasive ventilation increased significantly from 2010 to 2018. Hospital-level noninvasive ventilation utilization was not associated with a reduction in invasive ventilation but was associated with higher rates of cardiac arrest even after controlling for severity. Noninvasive ventilation in bronchiolitis may incur an unintended higher risk of cardiac arrest, and this requires further investigation.

[Paediatric Life Support]

The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.

Difficult Bag-Mask Ventilation in Critically Ill Children Is Independently Associated With Adverse Events

OBJECTIVES

Bag-mask ventilation is commonly used prior to tracheal intubation; however, the epidemiology, risk factors, and clinical implications of difficult bag-mask ventilation among critically ill children are not well studied. This study aims to describe prevalence and risk factors for pediatric difficult bag-mask ventilation as well as its association with adverse tracheal intubation-associated events and oxygen desaturation in PICU patients.

DESIGN

A retrospective review of prospectively collected observational data from a multicenter tracheal intubation database (National Emergency Airway Registry for Children) from January 2013 to December 2018.

SETTING

Forty-six international PICUs.

PATIENTS

Children receiving bag-mask ventilation as a part of tracheal intubation in a PICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome is the occurrence of either specific tracheal intubation-associated events (hemodynamic tracheal intubation-associated events, emesis with/without aspiration) and/or oxygen desaturation (< 80%). Factors associated with perceived difficult bag-mask ventilation were found using univariate analyses, and multivariable logistic regression identified an independent association between bag-mask ventilation difficulty and the primary outcome. Difficult bag-mask ventilation is reported in 9.5% (n = 1,501) of 15,810 patients undergoing tracheal intubation with bag-mask ventilation during the study period. Difficult bag-mask ventilation is more commonly reported with increasing age, those with a primary respiratory diagnosis/indication for tracheal intubation, presence of difficult airway features, more experienced provider level, and tracheal intubations without use of neuromuscular blockade (p < 0.001). Specific tracheal intubation-associated events or oxygen desaturation events occurred in 40.2% of patients with reported difficult bag-mask ventilation versus 19.8% in patients without perceived difficult bag-mask ventilation (p < 0.001). The presence of difficult bag-mask ventilation is independently associated with an increased risk of the primary outcome: odds ratio, 2.28 (95% CI, 2.03-2.57; p < 0.001).

CONCLUSIONS

Difficult bag-mask ventilation is reported in approximately one in 10 PICU patients undergoing tracheal intubation. Given its association with adverse procedure-related events and oxygen desaturation, future study is warranted to improve preprocedural planning and real-time management strategies.

Impact of Failure of Noninvasive Ventilation on the Safety of Pediatric Tracheal Intubation

OBJECTIVES

Noninvasive ventilation is widely used to avoid tracheal intubation in critically ill children. The objective of this study was to assess whether noninvasive ventilation failure was associated with severe tracheal intubation-associated events and severe oxygen desaturation during tracheal intubation.

DESIGN

Prospective multicenter cohort study of consecutive intubated patients using the National Emergency Airway Registry for Children registry.

SETTING

Thirteen PICUs (in 12 institutions) in the United States and Canada.

PATIENTS

All patients undergoing tracheal intubation in participating sites were included. Noninvasive ventilation failure group included children with any use of high-flow nasal cannula, continuous positive airway pressure, or bilevel noninvasive ventilation in the 6 hours prior to tracheal intubation. Primary tracheal intubation group included children without exposure to noninvasive ventilation within 6 hours before tracheal intubation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Severe tracheal intubation-associated events (cardiac arrest, esophageal intubation with delayed recognition, emesis with aspiration, hypotension requiring intervention, laryngospasm, pneumothorax, pneumomediastinum) and severe oxygen desaturation (< 70%) were recorded prospectively. The study included 956 tracheal intubation encounters; 424 tracheal intubations (44%) occurred after noninvasive ventilation failure, with a median of 13 hours (interquartile range, 4-38 hr) of noninvasive ventilation. Noninvasive ventilation failure group included more infants (47% vs 33%; p < 0.001) and patients with a respiratory diagnosis (56% vs 30%; p < 0.001). Noninvasive ventilation failure was not associated with severe tracheal intubation-associated events (5% vs 5% without noninvasive ventilation; p = 0.96) but was associated with severe desaturation (15% vs 9% without noninvasive ventilation; p = 0.005). After controlling for baseline differences, noninvasive ventilation failure was not independently associated with severe tracheal intubation-associated events (p = 0.35) or severe desaturation (p = 0.08). In the noninvasive ventilation failure group, higher FIO2 before tracheal intubation (≥ 70%) was associated with severe tracheal intubation-associated events.

CONCLUSIONS

Critically ill children are frequently exposed to noninvasive ventilation before intubation. Noninvasive ventilation failure was not independently associated with severe tracheal intubation-associated events or severe oxygen desaturation compared to primary tracheal intubation.

The Impact of Preintubation Noninvasive Ventilation on Outcomes in Pediatric Acute Respiratory Distress Syndrome

OBJECTIVES

There is evidence that noninvasive ventilation decreases the need for invasive mechanical ventilation. However, children with pediatric acute respiratory distress syndrome who fail noninvasive ventilation may have worse outcomes than those who are intubated without exposure to noninvasive ventilation. Our objective was to evaluate the impact of preintubation noninvasive ventilation on children with pediatric acute respiratory distress syndrome.

DESIGN

Secondary analysis of data from the Randomized Evaluation of Sedation Titration for Respiratory Failure trial.

SETTING

Thirty-one PICUs in the United States.

PATIENTS

Children 2 weeks to 17 years old with pediatric acute respiratory distress syndrome receiving invasive mechanical ventilation, excluding those admitted with tracheostomies.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 2,427 subjects receiving invasive mechanical ventilation, preintubation noninvasive ventilation was used in 995 (41%). Compared with subjects without preintubation noninvasive ventilation use, subjects with preintubation noninvasive ventilation use were more likely to have a history of seizures (10% vs 8%; p = 0.04) or cancer (11% vs 6%; p < 0.001) and have moderate or severe pediatric acute respiratory distress syndrome by the end of their first full day of invasive mechanical ventilation (68% vs 60%; p < 0.001). Adjusting for age, severity of illness on PICU admission, and baseline functional status, preintubation noninvasive ventilation use resulted in longer invasive mechanical ventilation duration (median 7.0 vs 6.0 d), longer PICU (10.8 vs 8.9 d), and hospital (17 vs 14 d) lengths of stay, and higher 28-day (5% vs 4%) and 90-day (8% vs 5%) inhospital mortalities (all comparisons p < 0.001). Longer duration of noninvasive ventilation before intubation was associated with worse outcomes.

CONCLUSIONS

In children with pediatric acute respiratory distress syndrome, preintubation noninvasive ventilation use is associated with worse outcomes when compared with no preintubation noninvasive ventilation use. These data can be used to inform the design of clinical studies to evaluate best noninvasive ventilation practices in children with pediatric acute respiratory distress syndrome.

Early factors related to mortality in children treated with bi-level noninvasive ventilation and CPAP

OBJECTIVE

To describe and analyze the characteristics and the early risk factors for mortality of noninvasive ventilation (NIV) in critically ill children.

STUDY DESIGN

A multicenter, prospective, observational 2-year study carried out with critically ill patients (1 month - 18 years of age) who needed NIV. Clinical data and NIV parameters during the first 12 h of admission were collected. A multilevel mixed-effects logistic regression was performed to identify mortality risk factors.

RESULTS

A total of 781 patients (44.2 ± 57.7 months) were studied (57.8% male). Of them, 53.7% had an underlying condition, and 47.1% needed NIV for lower airway respiratory pathologies. Bi-level NIV was the initial support in 78.2% of the patients. Continuous positive airway pressure (CPAP) was used more in younger patients (33.7%) than in older ones (9.7%; p < .001). About 16.7% had to be intubated and 6.2% died. The risk factors for mortality were immunodeficiency (odds ratio [OR] = 11.79; 95% confidence interval [CI] = 2.95-47.13); cerebral palsy (OR = 5.86; 95% CI = 1.94-17.65); presence of apneas on admission (OR = 5.57; 95% CI = 2.13-14.58); tachypnea 6 h after NIV onset (OR = 2.59; 95% CI = 1.30-6.94); and NIV failure (OR = 6.54; 95% CI = 2.79-15.34).

CONCLUSION

NIV is used with great variability in types of support. Younger children receive CPAP more frequently than older children. Immunodeficiency, cerebral palsy, apneas on admission, tachypnea 6 h after NIV onset, and NIV failure are the early factors associated with mortality.

European Resuscitation Council Guidelines 2021: Paediatric Life Support

These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.

Analysis of Pneumothorax in Noninvasive Ventilator Users With Duchenne Muscular Dystrophy

BACKGROUND

With the advancement of cardiorespiratory interventions, the survival rate among patients with Duchenne muscular dystrophy (DMD) has increased. Subsequently, pneumothorax has become a significant problem in patients with prolonged ventilatory support.

RESEARCH QUESTION

What are the frequency, recurrence rate, risk factors, and prognosis of pneumothorax in patients with DMD requiring noninvasive ventilation (NIV)? Also, are there known risk factors of pneumothorax on chest CT scans?

STUDY DESIGN AND METHODS

This retrospective longitudinal cohort study included 176 patients treated between 2006 and 2019. We collected information regarding location, severity, treatment methods, recurrence frequency, abnormal findings on CT scanning, and date of death. We compared the pneumothorax and nonpneumothorax groups. We calculated the estimated survival probabilities from the age at NIV application according to pneumothorax occurrence.

RESULTS

Sixteen of the 176 patients (9.0%) experienced pneumothorax (median age at diagnosis, 24.6 years; range, 20.7-33.7 years). Among the 16 patients, 15 demonstrated pneumothorax after NIV application (median time between diagnosis and initial NIV application, 5.6 years; range, 3 days-9.6 years). Sixteen patients experienced 31 episodes of pneumothoraces (range, one-five episodes); among them, seven episodes (22.6%) were asymptomatic. Known risk factors not clearly visible by radiography scans were found in chest CT scan in 11 patients (68.8%). Seven of 16 patients (43.8%) eventually sustained severe lung damage with pulmonary fibrosis. No significant between-group differences were found in body weight, BMI, and age at NIV application; however, the pneumothorax group showed a significantly higher mortality rate after NIV application.

INTERPRETATION

On pneumothorax occurrence in patients with DMD, recurrences and severe lung damage are common; moreover, these patients show higher mortality rates than patients without pneumothorax. Chest CT scans should be performed to identify risk factors, and treatment should be initiated accordingly. In addition, physicians should consider chest CT scanning in the case of suspected pneumothorax, even if no radiographic abnormality is found.

Noninvasive Ventilation Is Interrupted Frequently and Mostly Used at Night in the Pediatric Intensive Care Unit

BACKGROUND

Noninvasive ventilation (NIV) is commonly used to support children with respiratory failure, but detailed patterns of real-world use are lacking. The aim of our study was to describe use patterns of NIV via electronic medical record (EMR) data.

METHODS

We performed a retrospective electronic chart review in a tertiary care pediatric ICU in the United States. Subjects admitted to the pediatric ICU from 2014 to 2017 who were mechanically ventilated were included in the study.

RESULTS

The median number of discrete device episodes, defined as a time on support without interruption, was 20 (interquartile range [IQR] 8-49) per subject. The median duration of bi-level positive airway pressure (BPAP) support prior to interruption was 6.3 h (IQR 2.4-10.4); the median duration of CPAP was 6 h (IQR 2.1-10.4). Interruptions to BPAP had a median duration of 6.3 h (IQR 2-15.5); interruptions to CPAP had a median duration of 8.6 h (IQR 2.2-16.8). Use of NIV followed a diurnal pattern, with 44% of BPAP and 42% of CPAP subjects initiating support between 7:00 pm and midnight, and 49% of BPAP and 46% of CPAP subjects stopping support between 5:00 am and 10:00 am.

CONCLUSIONS

NIV was frequently interrupted, and initiation and discontinuation of NIV follows a diurnal pattern. Use of EMR data collected for routine clinical care allowed the analysis of granular details of typical use patterns. Understanding NIV use patterns may be particularly important to understanding the burden of pediatric ICU bed utilization for nocturnal NIV. To our knowledge, this is the first study to examine in detail the use of pediatric NIV and to define diurnal use and frequent interruptions to support.

[Systematic analysis of airway registries in emergency medicine]

BACKGROUND

A myriad of publications have contributed to an evidence-based approach to airway management in emergency services and admissions in recent years; however, it remains unclear which international registries on airway management in emergency medicine currently exist and how they are characterized concerning inclusion criteria, patient characteristics and definition of complications.

METHODS

A systematic literature research was carried out in PubMed with respect to publications from 2007-2017. All publications from airway registries collecting data on prehospital or emergency department (ED) airway management were included. Publications from pediatric intensive care units (PICU) were also included as long as they were the primary place of pediatric emergency care.

RESULTS

A total of eleven emergency airway registries (EAR) were identified that were primarily concerned with airway management. Furthermore, reported data on emergency airway management were extracted from different, national resuscitation registries. There was only one multinational EAR which exclusively collects data on pediatric emergency airway management (NEAR4KIDS, National Emergency Airway Registry for Kids). Additionally, all emergency department airway registries identified include data on pediatric emergency airway management to varying degrees (0.2-10.5%). Published observation periods were also highly variable with a minimum of 18 months and a maximum of 156 months. The ANZEDAR (Australia and New Zealand Emergency Airway Registry) is currently the largest EAR with data from 43 participating institutions in 2 different countries, while the NEAR III (National Emergency Airway Registry) includes data on 21,374 emergency intubations over a 10-year period and thus has the largest number of emergency interventions. Reported rapid sequence induction (RSI) rates in the registries are between 27.5% and 100%. First-pass success rates vary between 69% and 89%, while the reported use of video laryngoscopy is 0-73%.

CONCLUSION

This study identified eleven EARs that sometimes widely differed concerning inclusion periods, inclusion criteria, definition of complications and application of newer methods of emergency airway management. Thus, comparability of the reported results and first-pass success rates is only possible to a limited extent. The authors therefore advocate the initiation of an airway registry in emergency medicine in German-speaking countries.

Non-invasive ventilation practices in children across Europe

OBJECTIVES

To describe the diversity in practice in non-invasive ventilation (NIV) in European pediatric intensive care units (PICUs).

WORKING HYPOTHESIS

No information about the use of NIV in Pediatrics across Europe is currently available, and there might be a wide variability regarding the approach.

STUDY DESIGN

Cross-sectional electronic survey.

METHODOLOGY

The survey was distributed to the ESPNIC mailing list and to researchers in different European centers.

RESULTS

One hundred one units from 23 countries participated. All respondent units used NIV. Almost all PICUs considered NIV as initial respiratory support (99.1%), after extubation (95.5% prophylactically, 99.1% therapeutically), and 77.5% as part of palliative care. Overall NIV use outside the PICUs was 15.5% on the ward, 20% in the emergency department, and 36.4% during transport. Regarding respiratory failure cause, NIV was delivered in pneumonia (97.3%), bronchiolitis (94.6%), bronchospasm (75.2%), acute pulmonary edema (84.1%), upper airway obstruction (76.1%), and in acute respiratory distress syndrome (91% if mild, 53.1% if moderate, and 5.3% if severe). NIV use in asthma was less frequent in Northern European units in comparison to Central and Southern European PICUs (P = 0.007). Only 47.7% of the participants had a written protocol about NIV use. Bilevel NIV was applied mostly through an oronasal mask (44.4%), and continuous positive airway pressure through nasal cannulae (39.8%). If bilevel NIV was required, 62.3% reported choosing pressure support (vs assisted pressure-controlled ventilation) in infants; and 74.5% in older children.

CONCLUSIONS

The present study shows that NIV is a widespread technique in European PICUs. Practice across Europe is variable.

Recommendations for mechanical ventilation of critically ill children from the Paediatric Mechanical Ventilation Consensus Conference (PEMVECC)

Purpose

Much of the common practice in paediatric mechanical ventilation is based on personal experiences and what paediatric critical care practitioners have adopted from adult and neonatal experience. This presents a barrier to planning and interpretation of clinical trials on the use of specific and targeted interventions. We aim to establish a European consensus guideline on mechanical ventilation of critically children.

Methods

The European Society for Paediatric and Neonatal Intensive Care initiated a consensus conference of international European experts in paediatric mechanical ventilation to provide recommendations using the Research and Development/University of California, Los Angeles, appropriateness method. An electronic literature search in PubMed and EMBASE was performed using a combination of medical subject heading terms and text words related to mechanical ventilation and disease-specific terms.

Results

The Paediatric Mechanical Ventilation Consensus Conference (PEMVECC) consisted of a panel of 15 experts who developed and voted on 152 recommendations related to the following topics: (1) general recommendations, (2) monitoring, (3) targets of oxygenation and ventilation, (4) supportive measures, (5) weaning and extubation readiness, (6) normal lungs, (7) obstructive diseases, (8) restrictive diseases, (9) mixed diseases, (10) chronically ventilated patients, (11) cardiac patients and (12) lung hypoplasia syndromes. There were 142 (93.4%) recommendations with “strong agreement”. The final iteration of the recommendations had none with equipoise or disagreement.

Conclusions

These recommendations should help to harmonise the approach to paediatric mechanical ventilation and can be proposed as a standard-of-care applicable in daily clinical practice and clinical research.

Electronic supplementary material

The online version of this article (doi:10.1007/s00134-017-4920-z) contains supplementary material, which is available to authorized users.

Non-invasive respiratory support for infants with bronchiolitis: a national survey of practice

Background

Bronchiolitis is a common respiratory illness of early childhood. For most children it is a mild self-limiting disease but a small number of children develop respiratory failure. Nasal continuous positive airway pressure (nCPAP) has traditionally been used to provide non-invasive respiratory support in these children, but there is little clinical trial evidence to support its use. More recently, high-flow nasal cannula therapy (HFNC) has emerged as a novel respiratory support modality. Our study aims to describe current national practice and clinician preferences relating to use of non-invasive respiratory support (nCPAP and HFNC) in the management of infants (<12 months old) with acute bronchiolitis.

Methods

We performed a cross-sectional web-based survey of hospitals with inpatient paediatric facilities in England and Wales. Responses were elicited from one senior doctor and one senior nurse at each hospital. We analysed the proportion of hospitals using HFNC and nCPAP; clinical thresholds for their initiation; and clinician preferences regarding first-line support modality and future research.

Results

The survey was distributed to 117 of 171 eligible hospitals; 97 hospitals provided responses (response rate: 83%). The majority of hospitals were able to provide nCPAP (89/97, 91.7%) or HFNC (71/97, 73.2%); both were available at 65 hospitals (67%). nCPAP was more likely to be delivered in a ward setting in a general hospital, and in a high dependency setting in a tertiary centre. There were differences in the oxygenation and acidosis thresholds, and clinical triggers such as recurrent apnoeas or work of breathing that influenced clinical decisions, regarding when to start nCPAP or HFNC. More individual respondents with access to both modalities (74/106, 69.8%) would choose HFNC over nCPAP as their first-line treatment option in a deteriorating child with bronchiolitis.

Conclusions

Despite lack of randomised trial evidence, nCPAP and HFNC are commonly used in British hospitals to support infants with acute bronchiolitis. HFNC appears to be currently the preferred first-line modality for non-invasive respiratory support due to perceived ease of use.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-017-0785-0) contains supplementary material, which is available to authorized users.