Nasal continuous positive airway pressure decreases respiratory muscles overload in young infants with severe acute viral bronchiolitis

Noninvasive Neurally Adjusted Ventilatory Assist in Infants With Bronchiolitis: Respiratory Outcomes in a Single-Center, Retrospective Cohort, 2016-2018

OBJECTIVES

To describe our experience of using noninvasive neurally adjusted ventilatory assist (NIV-NAVA) in infants with bronchiolitis, its association with the evolution of respiratory effort, and PICU outcomes.

DESIGN

Retrospective analysis of a prospectively curated, high-frequency electronic database.

SETTING

A PICU in a university-affiliated maternal-child health center in Canada.

PATIENTS

Patients younger than 2 years old who were admitted with a diagnosis of acute bronchiolitis and treated with NIV-NAVA from October 2016 to June 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patient characteristics, as well as respiratory and physiologic parameters, including electrical diaphragmatic activity (Edi), were extracted from the electronic database. Respiratory effort was estimated using the modified Wood Clinical Asthma Score (mWCAS) and the inspiratory Edi. A comparison in the respiratory effort data was made between the 2 hours before and 2 hours after starting NIV-NAVA. In the two seasons, 64 of 205 bronchiolitis patients were supported with NIV-NAVA. These 64 patients had a median (interquartile range [IQR]) age of 52 days (32-92 d), and there were 36 of 64 males. Treatment with NIV-NAVA was used after failure of first-tier noninvasive respiratory support; 25 of 64 patients (39%) had at least one medical comorbidity. NIV-NAVA initiation was associated with a moderate decrease in mWCAS from 3.0 (IQR, 2.5-3.5) to 2.5 (IQR, 2.0-3.0; p < 0.001). NIV-NAVA initiation was also associated with a statistically significant decrease in Edi ( p < 0.01). However, this decrease was only clinically relevant in infants with a 2-hour baseline Edi greater than 20 μV; here, the before and after Edi was 44 μV (IQR, 33-54 μV) compared with 27 μV (IQR, 21-36 μV), respectively ( p < 0.001). Overall, six of 64 patients (9%) required endotracheal intubation.

CONCLUSIONS

In this single-center retrospective cohort, in infants with bronchiolitis who were considered to have failed first-tier noninvasive respiratory support, the use of NIV-NAVA was associated with a rapid decrease in respiratory effort and a 9% intubation rate.

Management of Acute Bronchiolitis in Spoke Hospitals in Northern Italy: Analysis and Outcome

Bronchiolitis is an acute viral infection of the lower respiratory tract that affects infants and young children. Respiratory syncytial virus (RSV) is the most common causative agent; however, other viruses can be involved in this disease. We retrospectively reviewed the clinical features of infants aged less than 12 months hospitalized for acute bronchiolitis in our Pediatric Units of Chivasso, Cirié, and Ivrea in Piedmont, Northern Italy, over two consecutive bronchiolitis seasons (September 2021-March 2022 and September 2022-March 2023). Patient-, disease-, and treatment-related variables were analyzed. The probability of therapeutic success (discharge home) was 96% for all patients (93% for RSV vs. 98% for non-RSV patients, p > 0.05). Among 192 patients, 42 infants (22%) underwent high-flow oxygen support (HFNC), and only 8 (4%) needed to be transferred to our hub referral hospital. Factors associated with hub hospital transfer were the age under 1 month and the failure of HFNC. The wide and increasing use of HFNC in pediatric inpatients improved the management of bronchiolitis in Spoke hospitals, reducing transfer to a hub hospital provided with Intensive Care Units.

ROX (Respiratory rate-OXygenation) index to predict early response to high-flow nasal cannula therapy in infants with viral bronchiolitis

INTRODUCTION

High-flow nasal cannula (HFNC) is commonly used as first step respiratory support in infants with moderate-to-severe acute viral bronchiolitis (AVB). This device, however, fails to effectively manage respiratory distress in about a third of patients, and data are limited on determinants of patient response. The respiratory rate-oxygenation (ROX) index is a relevant tool to predict the risk for HFNC failure in adult patients with lower respiratory tract infections. The primary objective of this study was to assess the relationship between ROX indexes collected before and 1 h after HFNC initiation, and HFNC failure occurring in the following 48 h in infants with AVB.

METHOD

This is an ancillary study to the multicenter randomized controlled trial TRAMONTANE 2, that included 286 infants of less than 6 months with moderate-to-severe AVB. Collection of physiological variables at baseline (H0), and 1 h after HFNC (H1), included heart rate (HR), respiratory rate (RR), fraction of inspired oxygen (FiO2 ), respiratory distress score (modified Wood's Clinical Asthma Score [mWCAS]), and pain and discomfort scale (EDIN). ROX and ROX-HR were calculated asSpO 2 FiO 2 RR $\frac{\left(\frac{{\mathrm{SpO}}_{2}}{{\mathrm{FiO}}_{2}}\right)}{\mathrm{RR}}$ and100 × ROX HR $100\times \frac{\mathrm{ROX}}{\mathrm{HR}}$ , respectively. Predefined HFNC failure criteria included increase in respiratory distress score or RR, increase in discomfort, and severe apnea episodes. The accuracies of ROX, ROX-HR indexes and clinical variable to predict HFNC failure were assessed using receiver operating curve analysis. We analyzed predictive factors of HFNC failure using multivariate logistic regressions.

RESULT

HFNC failure occurred in 111 of 286 (39%) infants, and for 56 (50% of the failure) of them within the first 6 h. The area under the curve of ROX indexes at H0 and H1 were, respectively, 0.56 (95% confidence interval [CI] 0.48-0.63, p = 0.14), 0.56 (95% CI 0.49-0.64, p = 0.09). ROX-HR performances were better but remained poorly discriminant. HFNC failure was associated with higher mWCAS score at H1 (p < 0.01) and lower decrease in EDIN scale during the first hour of HFNC delivery (p = 0.02). In the multivariate analyses, age and mWCAS score were were found to be independent factors associated with HFNC failure at H0. At H1, weight and mWCAS were associated factors.

CONCLUSION

In this study, neither ROX index, nor physiological variables usually collected in infants with AVB had early discriminatory capacity to predict HFNC failure.

Bubble Continuous Positive Airway Pressure Oxygen Therapy in Children Under Five Years of Age with Respiratory Distress in Pediatric Intensive Care Unit

Background

Continuous positive airway pressure (CPAP) has been used in children with bronchiolitis for a long time. Currently in the low-resource settings, the method of providing oxygen therapy via bubble CPAP (bCPAP) to children with respiratory distress is not standardized and the existing low-flow oxygen therapy has a high mortality rate.

Objectives

To study the effectiveness and safety of bCPAP as a respiratory support in children with respiratory distress.

Materials and methods

This prospective observational study was conducted in a tertiary care pediatric intensive care unit (PICU) over a period of 3 months. Children with respiratory distress were administered with bCPAP oxygen therapy. Baseline demographic data, such as age, sex, weight, severity of illness was collected. Changes in heart rate, respiratory rate, saturation, respiratory distress score and failure rate after bCPAP therapy were studied.

Results

During the study period, 30 children were recruited. Most common cause of respiratory distress requiring bCPAP was pneumonia (66.7%) followed by pleural effusion (20%) and bronchiolitis (13.3%). The median (IQR) CPAP duration and PICU stay in the study was 48 hours (27-48) and 4 days (4-8), respectively. Heart rate and respiratory rate, respiratory distress score improved significantly after CPAP therapy (p < 0.05). CPAP therapy failed in one child and required invasive ventilation. We did not observe any complications due to bCPAP therapy.

Conclusion

The use of bCPAP in the treatment of respiratory distress is safe and effective.

How to cite this article

Lalitha AV, Pujari CG, Raj JM. Bubble Continuous Positive Airway Pressure Oxygen Therapy in Children Under Five Years of Age with Respiratory Distress in Pediatric Intensive Care Unit. Indian J Crit Care Med 2023;27(11):847-854.

[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.

Respiratory effort during noninvasive positive pressure ventilation and continuous positive airway pressure in severe acute viral bronchiolitis

OBJECTIVES

To assess if noninvasive positive pressure ventilation (NIPPV) is associated with a greater reduction in respiratory effort as compared to continuous positive airway pressure (CPAP) during severe acute bronchiolitis, with both supports set either clinically or physiologically.

METHODS

Twenty infants (median [IQR] age 1.2 [0.9; 3.2] months) treated <24 h with noninvasive respiratory support (CPAP Clin, set at 7 cmH₂ O, or NIPPV Clin) for bronchiolitis were included in a prospective single-center crossover study. Esogastric pressures were measured first with the baseline support, then with the other support. For each support, recordings were performed with the clinical setting and a physiological setting (CPAP Phys and NIPPV Phys), aiming at normalising respiratory effort. Patients were then treated with the optimal support. The primary outcome was the greatest reduction in esophageal pressure-time product (PTP_ES /min). Other outcomes included improvement of the other components of the respiratory effort.

RESULTS

NIPPV Clin and Phys were associated with a lower PTP_ES /min (164 [105; 202] and 106 [78; 161] cmH₂ O s/min, respectively) than CPAP Clin (178 [145; 236] cmH₂ O s/min; p = 0.01 and 2 × 10^-4 , respectively). NIPPV Clin and Phys were also associated with a significant reduction of all other markers of respiratory effort as compared to CPAP Clin. PTP_ES /min with NIPPV (Clin or Phys) was not different from PTP_ES /min with CPAP Phys. There was no significant difference between physiological and clinical settings.

CONCLUSION

NIPPV is associated with a significant reduction in respiratory effort as compared to CPAP set at +7 cmH₂ O in infants with severe acute bronchiolitis. CPAP Phys performs as well as NIPPV Clin.

Respiratory physiology during NAVA ventilation in neonates born with a congenital diaphragmatic hernia: The "NAVA-diaph" pilot study

BACKGROUND

Neurally adjusted ventilatory assist (NAVA) is a ventilatory mode that delivers synchronized ventilation, proportional to the electrical activity of the diaphragm (EAdi). Although it has been proposed in infants with a congenital diaphragmatic hernia (CDH), the diaphragmatic defect and the surgical repair could alter the physiology of the diaphragm.

AIM

To evaluate, in a pilot study, the relationship between the respiratory drive (EAdi) and the respiratory effort in neonates with CDH during the postsurgical period under either NAVA ventilation or conventional ventilation (CV).

METHODS

This prospective physiological study included eight neonates admitted to a neonatal intensive care unit with a diagnosis of CDH. EAdi, esophageal, gastric, and transdiaphragmatic pressure, as well as clinical parameters, were recorded during NAVA and CV (synchronized intermittent mandatory pressure ventilation) in the postsurgical period.

RESULTS

EAdi was detectable and there was a correlation between the ΔEAdi (maximal - minimal values) and the transdiaphragmatic pressure (r = 0.26, 95% confidence interval [CI] [0.222; 0.299]). There was no significant difference in terms of clinical or physiological parameters during NAVA compared to CV, including work of breathing.

CONCLUSION

Respiratory drive and effort were correlated in infants with CDH and therefore NAVA is a suitable proportional mode in this population. EAdi can also be used to monitor the diaphragm for individualized support.

Clinical practice guidelines: management of severe bronchiolitis in infants under 12 months old admitted to a pediatric critical care unit

PURPOSE

We present guidelines for the management of infants under 12 months of age with severe bronchiolitis with the aim of creating a series of pragmatic recommendations for a patient subgroup that is poorly individualized in national and international guidelines.

METHODS

Twenty-five French-speaking experts, all members of the Groupe Francophone de Réanimation et Urgence Pédiatriques (French-speaking group of paediatric intensive and emergency care; GFRUP) (Algeria, Belgium, Canada, France, Switzerland), collaborated from 2021 to 2022 through teleconferences and face-to-face meetings. The guidelines cover five areas: (1) criteria for admission to a pediatric critical care unit, (2) environment and monitoring, (3) feeding and hydration, (4) ventilatory support and (5) adjuvant therapies. The questions were written in the Patient-Intervention-Comparison-Outcome (PICO) format. An extensive Anglophone and Francophone literature search indexed in the MEDLINE database via PubMed, Web of Science, Cochrane and Embase was performed using pre-established keywords. The texts were analyzed and classified according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. When this method did not apply, an expert opinion was given. Each of these recommendations was voted on by all the experts according to the Delphi methodology.

RESULTS

This group proposes 40 recommendations. The GRADE methodology could be applied for 17 of them (3 strong, 14 conditional) and an expert opinion was given for the remaining 23. All received strong approval during the first round of voting.

CONCLUSION

These guidelines cover the different aspects in the management of severe bronchiolitis in infants admitted to pediatric critical care units. Compared to the different ways to manage patients with severe bronchiolitis described in the literature, our original work proposes an overall less invasive approach in terms of monitoring and treatment.

Continuous positive airway pressure (CPAP) for acute bronchiolitis in children

BACKGROUND

Acute bronchiolitis is one of the most frequent causes of emergency department visits and hospitalisation in children up to three years of age. There is no specific treatment for bronchiolitis except for supportive treatment, which includes ensuring adequate hydration and oxygen supplementation. Continuous positive airway pressure (CPAP) aims to widen the lungs' peripheral airways, enabling deflation of overdistended lungs in bronchiolitis. Increased airway pressure also prevents the collapse of poorly supported peripheral small airways during expiration. Observational studies report that CPAP is beneficial for children with acute bronchiolitis. This is an update of a review first published in 2015 and updated in 2019.

OBJECTIVES

To assess the efficacy and safety of CPAP compared to no CPAP or sham CPAP in infants and children up to three years of age with acute bronchiolitis.

SEARCH METHODS

We conducted searches of CENTRAL (2021, Issue 7), which includes the Cochrane Acute Respiratory Infections Group Specialised Register, MEDLINE (1946 to August 2021), Embase (1974 to August 2021), CINAHL (1981 to August 2021), and LILACS (1982 to August 2021) in August 2021. We also searched the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) for completed and ongoing trials on 26 October 2021.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs), quasi-RCTs, cross-over RCTs, and cluster-RCTs evaluating the effect of CPAP in children with acute bronchiolitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data using a structured pro forma, analysed data, and performed meta-analyses. We used the Cochrane risk of bias tool to assess risk of bias in the included studies. We created a summary of the findings table employing GRADEpro GDT software.  MAIN RESULTS: We included three studies with a total of 122 children (62/60 in intervention/control arms) aged up to 12 months investigating nasal CPAP compared with supportive (or 'standard') therapy. We included one new trial (72 children) in the 2019 update that contributed data to the assessment of respiratory rate and the need for mechanical ventilation for this update. We did not identify any new trials for inclusion in the current update. The included studies were single-centre trials conducted in France, the UK, and India. Two studies were parallel-group RCTs, and one study was a cross-over RCT. The evidence provided by the included studies was of low certainty; we made an assessment of high risk of bias for blinding, incomplete outcome data, and selective reporting, and confidence intervals were wide. The effect of CPAP on the need for mechanical ventilation in children with acute bronchiolitis was uncertain due to risk of bias and imprecision around the effect estimate (risk difference -0.01, 95% confidence interval (CI) -0.09 to 0.08; 3 RCTs, 122 children; low certainty evidence). None of the trials measured time to recovery. Limited, low certainty evidence indicated that CPAP decreased respiratory rate (decreased respiratory rate is better) (mean difference (MD) -3.81, 95% CI -5.78 to -1.84; 2 RCTs, 91 children; low certainty evidence). Only one trial measured change in arterial oxygen saturation (increased oxygen saturation is better), and the results were imprecise (MD -1.70%, 95% CI -3.76 to 0.36; 1 RCT, 19 children; low certainty evidence). The effect of CPAP on change in arterial partial carbon dioxide pressure (pCO₂) (decrease in pCO₂ is better) was imprecise (MD -2.62 mmHg, 95% CI -5.29 to 0.05; 2 RCTs, 50 children; low certainty evidence). Duration of hospital stay was similar in both the CPAP and supportive care groups (MD 0.07 days, 95% CI -0.36 to 0.50; 2 RCTs, 50 children; low certainty evidence). Two studies did not report pneumothorax, but pneumothorax did not occur in one study. No studies reported occurrences of deaths. Several outcomes (change in partial oxygen pressure, hospital admission rate (from the emergency department to hospital), duration of emergency department stay, and need for intensive care unit admission) were not reported in the included studies.

AUTHORS' CONCLUSIONS

The use of CPAP did not reduce the need for mechanical ventilation in children with bronchiolitis, although the evidence was of low certainty. Limited, low certainty evidence suggests that breathing improved (a decreased respiratory rate) in children with bronchiolitis who received CPAP; this finding is unchanged from the 2015 review and 2019 update. Due to the limited available evidence, the effect of CPAP in children with acute bronchiolitis is uncertain for our other outcomes. Larger, adequately powered trials are needed to evaluate the effect of CPAP for children with acute bronchiolitis.

Continuous Positive Airway Pressure vs. High Flow Nasal Cannula in children with acute severe or moderate bronchiolitis. A systematic review and Meta-analysis

OBJECTIVE

To compare the safety and effectiveness of Continuous Positive Airway Pressure (CPAP) vs. High Flow Nasal Cannula (HFNC) to prevent therapeutic failure and the need of invasive ventilation in children with acute moderate-severe bronchiolitis.

DESIGN

A systematic review and meta-analysis.

SETTING

Medline, Embase, Lilacs, Cochrane and gray literature (May 2020) was performed.

PARTICIPANTS

Randomized clinical trials patients with moderate to severe bronchiolitis.

MAIN VARIABLES

Therapeutic failure, need for invasive ventilation, adverse events, length of PCCU and of hospital stay.

INTERVENTION

The quality of the studies was assessed with the Cochrane risk and bias tool. We conducted meta-analysis using fixed effect model and random effects model.

RESULTS

Three RCTs were included. Showed less risk of therapeutic failure with CPAP compared with HFNC (RR=0.7; 95%CI 0.5-0.99) developed hours later in patients with CPAP (MD=3.16; 95%CI 1.55-4.77). We did not find differences in other outcomes, such as need of invasive ventilation (RR=0.60; 95%CI 0.25-1.43), apnea (RR=0.40; 95%CI 0.08-1.99), or number of days in the intensive care unit (MD=0.02; 95%CI -0.38 to 0.42), and length of hospitalization (MD=-1.00; 95%IC -2.66 to 0.66). Adverse events (skin lesions) were more common with CPAP (RR 2.47; 95%CI 1.17-5.22).

CONCLUSIONS

In moderate/severe bronchiolitis CPAP demonstrated a lower risk of therapeutic failure and a longer time to failure. But more adverse events like nasal injury. There were no differences in other variables.

Safety and effectiveness of bubble continuous positive airway pressure as respiratory support for bronchiolitis in a pediatric ward

The results of several clinical trials suggest that continuous positive airway pressure (CPAP) for acute bronchiolitis can be more effective than high-flow nasal cannula (HFNC). The use of HFNC involved a minimum reduction (5%) in admissions to the pediatric intensive care unit (PICU) in our hospital. Our main aim was to evaluate its safety and effectiveness as respiratory support for patients with bronchiolitis in a pediatric general ward. A secondary goal was to compare the admissions to PICU and the invasive mechanical ventilation (IMV) rate of patients treated with HFNC and those treated with HFNC/b-CPAP during the 2018-2019 and 2019-2020 epidemic seasons, respectively. Two prospective single-centre observational studies were performed. For the main aim, a cohort study (CS1) was carried out from 1st of November 2019 to 15th of January 2020. Inclusion criteria were children aged up to 3 months with bronchiolitis treated with b-CPAP support when HFNC failed. Epidemiological and clinical parameters were collected before and 60 min after the onset of CPAP and compared between the responder (R) and non-responders (NR) groups. NR was the group that required PICU admission. One hundred fifty-eight patients were admitted to the ward with bronchiolitis and HFNC. Fifty-seven out of one hundred fifty-eight required b-CPAP. No adverse events were observed. Thirty-two out of fifty-seven remained in the general ward (R-group), and 25/57 were admitted to PICU (NR-group). There were statistically significant differences in respiratory rate (RR) and heart rate (HR) between both groups before and after the initiation of b-CPAP, but the multivariable models showed that the main differences were observed after 60 min of therapy (lower HR, RR, BROSJOD score and FiO2 in the R-group). For the secondary aim, another cohort study (CS2) was performed comparing data from a pre-b-CPAP bronchiolitis season (1st of November 2018 to 15th January 2019) and the b-CPAP season (2019-2020). Inclusion criteria in pre-b-CPAP season were children aged up to 3 months admitted to the same general ward with moderate-severe bronchiolitis and with HFNC support. Admissions to PICU during the CPAP season were significantly reduced, without entailing an increase in the rate of IMV.

CONCLUSION

The implementation of b-CPAP for patients with bronchiolitis in a pediatric ward, in whom HFNC fails, is safe and effective and results in a reduction in PICU admissions.

WHAT IS KNOWN

• Bronchiolitis is one of the most frequent respiratory infections in children and one of the leading causes of hospitalization in infants. • Several studies suggest that the use of continuous positive airway pressure (CPAP) for acute bronchiolitis can be more effective than the high flow nasal cannula (HFNC). CPAP is a non-invasive ventilation (NIV) therapy used in patients admitted to pediatric intensive care unit (PICU) with progressive moderate-severe bronchiolitis. There is little experience in the literature on the use of continuous positive airway pressure (CPAP) for acute bronchiolitis in a general ward.

WHAT IS NEW

• CPAP could be safely and effectively used as respiratory support in young infants with moderate-severe bronchiolitis in a general ward and it reduced the rate of patients who required PICU admission. • Patients' heart and respiratory rate and their FiO2 needs in the first 60 minutes may help to decide whether or not to continue the CPAP therapy in a general ward.

The Effects and Safety of Continuous Positive Airway Pressure in Children with Bronchiolitis: A Systematic Review and Meta-Analysis

OBJECTIVES

To evaluate the effects and safety of continuous positive airway pressure (CPAP) for initial respiratory management of bronchiolitis.

METHODS

PubMed, EMBASE, Cochrane Library, CNKI, Wanfang data and CQ VIP were searched until 17 June 2020. Randomized controlled trials (RCTs) which investigated the effect of CPAP for bronchiolitis were included.

RESULTS

Twenty-seven RCTs met the eligibility criteria. In the comparison of CPAP versus standard oxygen therapy, CPAP can reduce the length of stay (LOS) in hospital, respiratory rate (RR), PaCO2, heart rate, mechanical ventilation and increase PaO2, but the SpO2 and PH were not improved. In the comparison of CPAP versus high-flow nasal cannula, CPAP can reduce treatment failure, but the PICU LOS, Incidence of intubation, RR, Modified Woods Clinical Asthma Score were not decreased. Treatment failure may be less in helmet comparing with the mask though there was no quantitative analysis.

CONCLUSION

CPAP for the initial respiratory management significantly benefit children with bronchiolitis, the delivery of CPAP by helmet may be a better choice. More high-quality research is needed to confirm the conclusion.

Assessment of Peak Inspiratory Flow in Young Infants with Acute Viral Bronchiolitis: Physiological Basis for Initial Flow Setting in Patients Supported with High-Flow Nasal Cannula

OBJECTIVE

To assess the inspiratory demand in young infants with acute viral bronchiolitis to provide a physiological basis for initial flow setting for patients supported with high flow nasal cannula.

STUDY DESIGN

Prospective study in 44 infants up to 6 months old with acute viral bronchiolitis, admitted to a pediatric intensive care unit from November 2017 to March 2019. Airflow measurements were performed using spirometry. The primary endpoint was the inspiratory demand as measured by peak tidal inspiratory flow (PTIF). The secondary endpoints were the relationships determined between PTIF, patient weight, and disease severity.

RESULTS

Median (Q₂₅-Q₇₅) age and weight of the patients were 37 (20-67) days and 4.3 (3.5-5.0) kg, respectively. Mean PTIF was 7.45 (95% CI 6.51-8.39, min-max: 2.40-16.00) L/minute. PTIF indexed to weight was 1.68 (95% CI 1.51-1.85, min-max: 0.67-3.00) L/kg/minute. PTIF was <2.5 L/kg/minute in 89% (95% CI 75-96) of infants. PTIF was correlated with weight (ρ= 0 .55, P < .001) but not with markers of disease severity, including modified Woods clinical asthma score, Silverman-Andersen score, respiratory rate, fraction of inspired oxygen, and PCO₂.

CONCLUSIONS

High flow nasal cannula therapy is used commonly to support infants with acute viral bronchiolitis. The efficiency of the device is optimal if the flow setting matches the patient's inspiratory demand. According to our results, a flow rate of <2.5 L/kg/minute would be appropriate in most situations.

Preemptive high-flow nasal cannula treatment in severe bronchiolitis: Results from a high-volume, resource-limited pediatric emergency department

BACKGROUND

The aims of this study were to evaluate the outcomes of patients with severe bronchiolitis who received preemptive high-flow nasal cannula (HFNC) treatment according to the authors' protocol, and to identify potential baseline characteristics that might predict patients who will not benefit from HFNC.

METHODS

This was a retrospective chart review of patients with severe bronchiolitis, who received preemptive HFNC treatment according to the authors' protocol and who were admitted to the pediatric emergency department between January 1, 2015, and December 31, 2016.

RESULTS

Eighty-four patients in total were enrolled over the 2 year period. Twenty-three patients (27.3%) failed HFNC. Of these, four responded to non-invasive mechanical ventilation and 19 required subsequent invasive ventilation. According to logistic regression analysis, existence of a chronic condition, significant tachycardia, existence of dehydration, and a venous pH <7.30 at admission were found to be predictors of HFNC failure. There were no cases of pneumothorax or any other reported adverse effects related to HFNC therapy.

CONCLUSIONS

Preemptive HFNC treatment, complying with a preestablished protocol, might be a safe way to support patients with severe bronchiolitis in high-volume, resource-limited pediatric emergency departments. The existence of a chronic condition, significant tachycardia, dehydration, and a venous pH <7.30 at admission could be risk factors for preemptive HFNC treatment failure in severe bronchiolitis.

Electromagnetic inductance plethysmography to study airflow after nebulized saline in bronchiolitis

BACKGROUND

Spirometric effects from therapeutic interventions in infants with severe respiratory distress cannot readily be measured, hampering development of better treatment for acute bronchiolitis. Inhaled normal saline is regularly used in these infants, with little knowledge of how this influences lung physiology.

OBJECTIVES

Assess feasibility of infant lung function testing using electromagnetic inductance plethysmography (EIP) in a clinical setting in a busy pediatric department, and explore effects from inhaled normal saline on tidal flow-volume loops in infants with acute bronchiolitis.

METHODS

Observational study conducted at the Children's Clinic, Haukeland University Hospital, Bergen, Norway during the winters 2016 and 2017, enrolling children with bronchiolitis below six months of age. EIP was performed immediately before and 5 and 20 min after saline inhalation. EIP is a noninvasive method to measure tidal breathing parameters by quantifying volume changes in the chest and abdomen during respiration. The method consists of an electromagnet/antenna and a patient vest.

RESULTS

EIP was successfully applied in 36/45 (80%) enrolled infants at mean (standard deviation) age 2.9 (2.5) months, after a hospital stay of 2.2 (1.9) days. After saline inhalation, tidal expiratory to inspiratory time ratio (Te/Ti) had increased significantly, whereas the other relevant flow/volume parameters had changed numerically in a direction compatible with a more obstructive pattern.

CONCLUSIONS

EIP could successfully be used to obtain tidal breathing parameters in infants with respiratory distress and appears a promising tool for assessment of therapeutic interventions in bronchiolitis. Saline inhalations should be used with caution as placebo in intervention studies.

Continuous Positive Airway Pressure vs. High Flow Nasal Cannula in children with acute severe or moderate bronchiolitis. A systematic review and Meta-analysis

OBJECTIVE

To compare the safety and effectiveness of Continuous Positive Airway Pressure (CPAP) vs. High Flow Nasal Cannula (HFNC) to prevent therapeutic failure and the need of invasive ventilation in children with acute moderate-severe bronchiolitis.

DESIGN

A systematic review and meta-analysis.

SETTING

Medline, Embase, Lilacs, Cochrane and gray literature (May 2020) was performed.

PARTICIPANTS

Randomized clinical trials patients with moderate to severe bronchiolitis.

MAIN VARIABLES

Therapeutic failure, need for invasive ventilation, adverse events, length of PCCU and of hospital stay.

INTERVENTION

The quality of the studies was assessed with the Cochrane risk and bias tool. We conducted meta-analysis using fixed effect model and random effects model.

RESULTS

Three RCTs were included. Showed less risk of therapeutic failure with CPAP compared with HFNC (RR=0.7; 95%CI 0.5-0.99) developed hours later in patients with CPAP (MD=3.16; 95%CI 1.55-4.77). We did not find differences in other outcomes, such as need of invasive ventilation (RR=0.60; 95%CI 0.25-1.43), apnea (RR=0.40; 95%CI 0.08-1.99), or number of days in the intensive care unit (MD=0.02; 95%CI -0.38 to 0.42), and length of hospitalization (MD=-1.00; 95%IC -2.66 to 0.66). Adverse events (skin lesions) were more common with CPAP (RR 2.47; 95%CI 1.17-5.22).

CONCLUSIONS

In moderate/severe bronchiolitis CPAP demonstrated a lower risk of therapeutic failure and a longer time to failure. But more adverse events like nasal injury. There were no differences in other variables.

Pediatric respiratory distress: California out-of-hospital protocols and evidence-based recommendations

OBJECTIVES

Prehospital protocols vary across local emergency medical service (EMS) agencies in California. We sought to develop evidence-based recommendations for the out-of-hospital evaluation and treatment of pediatric respiratory distress, and we evaluated the protocols for pediatric respiratory distress used by the 33 California local EMS agencies.

METHODS

Evidence-based recommendations were developed through an extensive literature review of the current evidence regarding out-of-hospital treatment of pediatric patients with respiratory distress. The authors compared the pediatric respiratory distress protocols of each of the 33 California local EMS agencies with the evidence-based recommendations. Our focus was on the treatment of 3 main pediatric respiratory complaints by presentation: stridor (croup), wheezing < 24 months (bronchiolitis), and wheezing > 24 months (asthma).

RESULTS

Protocols across the 33 California local EMS agencies varied widely. Stridor (croup) had the highest protocol variability of the 3 presentations we evaluated, with no treatment having uniform use among all agencies. Only 3 (9.1%) of the local EMS agencies differentiated wheezing in children < 24 months of age, referencing this as possible bronchiolitis. All local EMS agencies included albuterol and epinephrine (intravenous/intramuscular) in their pediatric wheezing (asthma) treatment protocols. The least common treatments for wheezing (asthma) included nebulized epinephrine (3/33) and magnesium (2/33). No agencies included steroids in their treatment protocols (0/33).

CONCLUSION

Protocols for pediatric respiratory distress vary widely across the state of California, especially among those for stridor (croup) and wheezing in < 24 months (bronchiolitis). The evidence-based recommendations that we present for the prehospital treatment of these conditions may be useful for EMS medical directors tasked with creating and revising these protocols.

[Predictive factors for failure of continuous positive airway pressure treatment in infants with bronchiolitis]

OBJECTIVE

To study the predictive factors for the failure of continuous positive airway pressure (CPAP) treatment in infants with bronchiolitis.

METHODS

A retrospective analysis was performed on the clinical data of 310 hospitalized children (aged 1-12 months) with bronchiolitis treated with CPAP. Their clinical features were compared between the successful treatment group (270 cases) and the failed treatment group (40 cases). A multivariate logistic regression analysis was used to explore the predictive factors for failure of CPAP treatment.

RESULTS

The multivariate logistic regression analysis showed that the score of the Pediatric Risk of Mortality III (PRISM III) ≥10 (OR=13.905), development of atelectasis (OR=12.080), comorbidity of cardiac insufficiency (OR=7.741), and no improvement in oxygenation index (arterial partial pressure of oxygen/fraction of inhaled oxygen, P/F) after 2 hours of CPAP treatment (OR=34.084) were predictive factors for failure of CPAP treatment for bronchiolitis (P<0.05). In predicting CPAP treatment failure, no improvement in P/F after 2 hours of CPAP treatment had an area under the receiver operating characteristic curve of 0.793, with a sensitivity of 70.3% and a specificity of 82.4% at a cut-off value of 203.

CONCLUSIONS

No improvement in P/F after 2 hours of CPAP treatment, PRISM III score ≥10, development of atelectasis, and comorbidity of cardiac insufficiency can be used as predictive factors for CPAP treatment failure in infants with bronchiolitis.

High-Flow Nasal Cannula versus Continuous Positive Airway Pressure in Critical Bronchiolitis: A Randomized Controlled Pilot

We conducted a randomized controlled pilot study in infants with critical bronchiolitis ( n  = 63) comparing high-flow nasal cannula (HFNC, n  = 35) to continuous positive airway pressure (CPAP, n  = 28). The primary outcome was treatment failure, defined as the need for bilevel positive pressure ventilation or endotracheal intubation. Treatment failure occurred in 10 patients (35.7%) in the CPAP group and 13 patients (37.1%) in the HFNC group ( p  = 0.88). Pediatric intensive care unit length of stay was similar between the CPAP and HFNC groups (5 [4-7] days and 5 [4-8] days, p  = 0.46, respectively). In this pilot study, treatment with HFNC resulted in a rate of treatment failure similar to CPAP.

[CPAP vs oxygen therapy in infants being transported due to acute respiratory failure]

OBJECTIVE

The aims of our study are to evaluate the effectiveness and security of CPAP (continuous positive airway pressure) in infants transferred with acute respiratory failure (ARF) and to compare their evolution in PICU between CPAP vs oxygen therapy.

MATERIALS AND METHODS

We conducted a retrospective observational and analytical study by reviewing the health records of infants with ARF aged 0 to 12months that required interhospital transfer to the PICU.

RESULTS

We included 110 patients: 71 transported with CPAP and 39 with oxygen therapy. The main cause of ARF was acute bronchiolitis (81.8%). The median level of CPAP was 7cmH₂O (interquartile range, 6-7). Controlling by the previous values in specific multivariable models, CPAP produced a significant decrease in the Wood-Downes score (beta = -1.08; 95% CI = -1.76 to -0.40; P = .002) and the heart rate (beta = -19.64, 95% CI = -28.46 to -10.81; P < .001). No patients required endotracheal intubation during transport. During the PICU stay, the intubation rate was similar in the CPAP group (7%) and the oxygen therapy group (5.1%) (P=.689). The proportion of patients that required bilevel positive airway pressure within 6hours of admission to the PICU was higher in the oxygen therapy group: 100% (11/11) vs 69.2% (18/26), P=.04.

CONCLUSIONS

Early administration of CPAP to infants with ARF was a safe respiratory support intervention during interhospital transport. During patient transport, the use of CPAP achieved greater decreases in the Wood-Downes score and heart rate compared to oxygen therapy.

Relationship Between Diaphragmatic Electrical Activity and Esophageal Pressure Monitoring in Children

OBJECTIVES

Mechanical ventilation is an essential life support technology, but it is associated with side effects in case of over or under-assistance. The monitoring of respiratory effort may facilitate titration of the support. The gold standard for respiratory effort measurement is based on esophageal pressure monitoring, a technology not commonly available at bedside. Diaphragmatic electrical activity can be routinely monitored in clinical practice and reflects the output of the respiratory centers. We hypothesized that diaphragmatic electrical activity changes accurately reflect changes in mechanical efforts. The objectives of this study were to characterize the relationship between diaphragmatic electrical activity and esophageal pressure.

DESIGN

Prospective crossover study.

SETTING

Esophageal pressure and diaphragmatic electrical activity were simultaneously recorded using a specific nasogastric tube in three conditions: in pressure support ventilation and in neurally adjusted ventilatory support in a random order, and then after extubation.

PATIENTS

Children in the weaning phase of mechanical ventilation.

INTERVENTIONS

The maximal swing in esophageal pressure and esophageal pressure-time product, maximum diaphragmatic electrical activity, and inspiratory diaphragmatic electrical activity integral were calculated from 100 consecutive breaths. Neuroventilatory efficiency was estimated using the ratio of tidal volume/maximum diaphragmatic electrical activity.

MEASUREMENTS AND MAIN RESULTS

Sixteen patients, with a median age of 4 months (interquartile range, 0.5-13 mo), and weight 5.8 kg (interquartile range, 4.1-8 kg) were included. A strong linear correlation between maximum diaphragmatic electrical activity and maximal swing in esophageal pressure (r > 0.95), and inspiratory diaphragmatic electrical activity integral and esophageal pressure-time product (r > 0.71) was observed in all ventilatory conditions. This correlation was not modified by the type of ventilatory support.

CONCLUSIONS

On a short-term basis, diaphragmatic electrical activity changes are strongly correlated with esophageal pressure changes. In clinical practice, diaphragmatic electrical activity monitoring may help to inform on changes in respiratory efforts.

Respiratory support for infants with bronchiolitis, a narrative review of the literature

Bronchiolitis is a common viral disease that significantly affects infants less than 12 months of age. The purpose of this review is to present a review of the current knowledge of the uses of respiratory support in the management of infants with bronchiolitis presenting to hospital. We electronically searched MEDLINE, Cochrane, CINAHL and EMBASE (inception to 25th March 2018), to manually search for clinical trials that address the management strategies for respiratory support of infants with bronchiolitis. We identified 120 papers who met the inclusion criteria, of which 33 papers were relevant for this review with only nine randomized controlled trials. This review demonstrated that non-invasive respiratory support reduced the need for escalation of therapy, particularly the proportion of intubations required for infants with bronchiolitis. Additionally, clear economic benefits have been demonstrated when non-invasive ventilation has been used. The potential early use of non-invasive respiratory supports such as nasal high flow therapy and non-invasive ventilation may have an impact on health care costs and reduction in ICU admissions and intubation rates. High-grade evidence demonstrates safety and quality of high flow therapy in general ward settings.

Physiological Effect of Prone Position in Children with Severe Bronchiolitis: A Randomized Cross-Over Study (BRONCHIO-DV)

OBJECTIVE

To assess the effect of the prone position on physiological measures, including inspiratory effort, metabolic cost of breathing, and neural drive to the diaphragm as compared with the supine position in infants with severe bronchiolitis requiring noninvasive ventilation.

STUDY DESIGN

Fourteen infants, median age 33 days (IQR [first and third quartiles], 25-58) were randomized to receive 7 cmH₂O continuous positive airway pressure for 1 hour in the prone position or in the supine position, which was followed by cross-over to the supine position and the prone position for 1 hour, respectively. Flow, esophageal, airway, gastric, and transdiaphragmatic pressures, as well as electrical activity of the diaphragm were simultaneously recorded. The modified Wood clinical asthma score was also assessed.

RESULTS

Median esophageal pressure-time product per minute was significantly lower in the prone position than in the supine position (227 cmH₂O*s/minute [IQR, 156-282] cmH₂O*s/minute vs 353 cmH₂O*s/minute [IQR, 249-386 cmH₂O*s/minute]; P = .048), as were the modified Wood clinical asthma score (P = .033) and electrical activity of the diaphragm (P = .006). The neuromechanical efficiency of the diaphragm, as assessed by transdiaphramagtic pressure to electrical activity of the diaphragm swing ratio, was significantly higher in the prone position than in the supine position (1.1 cmH₂O/µV [IQR, 0.9-1.3 cmH₂O/µV] vs 0.7 cmH₂O/µV [IQR, 0.6-1.2 cmH₂O/µV], respectively; P = .022).

CONCLUSIONS

This study suggests a benefit of the prone position for infants with severe bronchiolitis requiring noninvasive ventilation by significantly decreasing the inspiratory effort and the metabolic cost of breathing. Further studies are needed to evaluate the potential impact of these physiological findings in a larger population.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT02602678.

Continuous positive airway pressure (CPAP) for acute bronchiolitis in children

BACKGROUND

Acute bronchiolitis is one of the most frequent causes of emergency department visits and hospitalisation in children. There is no specific treatment for bronchiolitis except for supportive treatment, which includes ensuring adequate hydration and oxygen supplementation. Continuous positive airway pressure (CPAP) aims to widen the lungs' peripheral airways, enabling deflation of overdistended lungs in bronchiolitis. Increased airway pressure also prevents the collapse of poorly supported peripheral small airways during expiration. Observational studies report that CPAP is beneficial for children with acute bronchiolitis. This is an update of a review first published in 2015.

OBJECTIVES

To assess the efficacy and safety of CPAP compared to no CPAP or sham CPAP in infants and children up to three years of age with acute bronchiolitis.

SEARCH METHODS

We conducted searches of CENTRAL (2017, Issue 12), which includes the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1946 to December, 2017), Embase (1974 to December 2017), CINAHL (1981 to December 2017), and LILACS (1982 to December 2017) in January 2018.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs), quasi-RCTs, cross-over RCTs, and cluster-RCTs evaluating the effect of CPAP in children with acute bronchiolitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data using a structured pro forma, analysed data, and performed meta-analyses.

MAIN RESULTS

We included three studies with a total of 122 children (62/60 in intervention/control arms) aged up to 12 months that investigated nasal CPAP compared with supportive (or "standard") therapy. We included one new trial (72 children) that contributed data to the assessment of respiratory rate and need for mechanical ventilation for this update. The included studies were single-centre trials conducted in France, the UK, and India. Two studies were parallel-group RCTs and one was a cross-over RCT. The evidence provided by the included studies was low quality; we assessed high risk of bias for blinding, incomplete outcome data, and selective reporting, and confidence intervals were wide.The effect of CPAP on the need for mechanical ventilation in children with acute bronchiolitis was uncertain due to imprecision around the effect estimate (3 RCTs, 122 children; risk ratio (RR) 0.69, 95% confidence interval (CI) 0.14 to 3.36; low-quality evidence). None of the trials measured time to recovery. Limited, low-quality evidence indicated that CPAP decreased respiratory rate (2 RCTs, 91 children; mean difference (MD) -3.81, 95% CI -5.78 to -1.84). Only one trial measured change in arterial oxygen saturation, and the results were imprecise (19 children; MD -1.70%, 95% CI -3.76 to 0.36). The effect of CPAP on change in arterial partial carbon dioxide pressure (pCO₂) was imprecise (2 RCTs, 50 children; MD -2.62 mmHg, 95% CI -5.29 to 0.05; low-quality evidence). Duration of hospital stay was similar in both CPAP and supportive care groups (2 RCTs, 50 children; MD 0.07 days, 95% CI -0.36 to 0.50; low-quality evidence). Two studies did not report about pneumothorax, but pneumothorax did not occur in one study. No studies reported occurrences of deaths. Several outcomes (change in partial oxygen pressure, hospital admission rate (from emergency department to hospital), duration of emergency department stay, and need for intensive care unit admission) were not reported in the included studies.

AUTHORS' CONCLUSIONS

Limited, low-quality evidence suggests that breathing improved (a decreased respiratory rate) in children with bronchiolitis who received CPAP; this finding is unchanged from the 2015 review. Further evidence for this outcome was provided by the inclusion of a low-quality study for the 2018 update. Due to the limited available evidence, the effect of CPAP in children with acute bronchiolitis is uncertain for other outcomes. Larger, adequately powered trials are needed to evaluate the effect of CPAP for children with acute bronchiolitis.

[Anemia, a new severity factor in young infants with acute viral bronchiolitis?]

INTRODUCTION

The role of anemia is raised as a risk of low respiratory infection of the child, but there are no data on anemia as a severity factor in acute viral bronchiolitis (AVB) in infants.

METHODS

All infants less than 16 weeks old admitted to Montpellier University Hospital from 2015/10/01 to 2016/04/01 for AVB were included in a retrospective observational study. The primary objective was to determine whether the hemoglobin (Hb) concentration on admission was an independent factor of clinical severity, judged by the modified Wood's clinical asthma score (m-WCAS). The secondary objective was to assess the impact of Hb level on the characteristics of hospitalization, including the type and duration of respiratory support.

RESULTS

The m-WCAS was used at least once during hospitalization in 180 out of 220 patients (82%), making it possible to distinguish patients with mild AVB (maximum m-WCAS<2, n=81) from patients with severe AVB (maximum m-WCAS>2, n=99). A logistic regression model indicated that the Hb concentration, for every 1g/dL decrement, was an independent factor of AVB severity (OR 1.16 [1.03-1.29], P=0.026). A level under 10g/dL on admission was associated with a higher use of continuous positive airway pressure (P<0.001), as well as a longer duration of respiratory support (P=0.01).

CONCLUSION

This study suggested that anemia may influence the clinical expression of AVB in young infants.

[Noninvasive ventilation in pediatric acute respiratory failure]

Noninvasive ventilation (NIV) may be used to treat pediatric acute respiratory failure. Recent improvements in ventilator technology and availability of nasal and full face masks for infants and children have simplified the use of NIV even in the smallest children. Mainly patients with hypercapnic respiratory failure may benefit from noninvasive ventilation. There is some evidence available that supports the use of NIV in viral bronchiolitis, asthma and acute on chronic respiratory failure in patients with neuromuscular or chronic pulmonary disease. Furthermore, noninvasive ventilation is beneficial during prolonged weaning from invasive ventilation and to treat upper airway obstructions. Children suffering from hypoxic respiratory failure, such as community-acquired pneumonia and acute respiratory distress syndrome do not benefit from NIV. Due to possibly relevant side effects and the possibility of rapid deterioration in gas exchange in failure of NIV, invasive ventilation should be readily available; therefore, treatment with noninvasive ventilation for acute respiratory failure in children should be initiated on the pediatric intensive care ward.

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.

Esogastric pressure measurement to assist noninvasive ventilation indication and settings in infants with hypercapnic respiratory failure: A pilot study

OBJECTIVE

Noninvasive ventilation (NIV) in usually set on clinical parameters. The aim of the study was to assess the value of esophageal (P_ES ) and gastric pressure (P_GAS ) measurements for the indication and optimal settings of NIV in infants with hypercapnic respiratory failure in whom the efficacy of NIV was uncertain on clinical noninvasive parameters.

DESIGN

A retrospective study.

PATIENT-SUBJECT SELECTION

P_ES and P_GAS measurements were performed in seven infants <2 years old admitted in the Pediatric Intensive Care Unit for an acute or acute-on-chronic hypercapnic respiratory failure.

METHODOLOGY

P_ES swing and esophageal pressure time product (PTP_ES ) during spontaneous breathing, NIV set on clinical parameters (NIVclin) and on P_ES (NIVphys) were compared. According to the P_ES measurements, NIV was continued if NIV was associated with an at least 20% reduction of the P_ES swing and PTP_ES and not initiated or withdrawn in the other case.

RESULTS

In all seven patients, the P_ES and P_GAS measurements were informative and led to the decision to initiate NIV in one patient or continue NIV with different settings in three patients. In the three other patients, NIV was not initiated in one patient and withdrawn in the two last patients because of a lack of improvement in P_ES swing and PTP_ES .

CONCLUSIONS

P_ES and P_GAS measurements may be useful for the indication and optimal setting of NIV in a selected group of infants with hypercapnic respiratory failure.

Comparison of Effort of Breathing for Infants on Nasal Modes of Respiratory Support

OBJECTIVE

To directly compare effort of breathing between high flow nasal cannula (HFNC), nasal intermittent mechanical ventilation (NIMV), and nasal continuous positive airway pressure (NCPAP).

STUDY DESIGN

This was a single center prospective cross-over study for patients <6 months in the cardiothoracic or pediatric intensive care unit receiving nasal noninvasive respiratory support after extubation. We measured effort of breathing using esophageal manometry with pressure-rate product (PRP) on all 3 modes. NIMV synchrony was determined by comparing patient efforts (esophageal manometry) with mechanically delivered breaths (spirometry in ventilator circuit). On NIMV, PRP and synchrony was also measured after adding a nasal clip on 26 patients.

RESULTS

Forty-two children were included. Median (IQR) age was 2 (0.5, 4) months. There was no difference in median PRP between HFNC 6 liters per minute, 355 (270,550), NIMV 12/5 cm H₂O, 341 (235, 472), and NCPAP 5 cm H₂O, 340 (245,506) (P?=?.33). Results were similar regardless of HFNC flow rate or NIMV inspiratory pressure. Median PRP on CPAP of 5 cm H₂O prior to extubation 255 (176, 375) was significantly lower than all postextubation values (P?<?.002). On NIMV, less than 50% of patient efforts resulted in a ventilator breath, which was not improved with a nasal clip (P?>?.07)). However, as NIMV synchrony improved (>60%), PRP on NIMV was lower than on HFNC.

CONCLUSIONS

For infants, effort of breathing is similar on HFNC, NIMV, and NCPAP after extubation, regardless of flow rate or inspiratory pressure. We speculate that bi-level NIMV may be superior if high levels of synchrony can be achieved.

Effectiveness of airway clearance techniques in children hospitalized with acute bronchiolitis

OBJECTIVE

To evaluate the effectiveness of two airway clearance techniques (ACT's) in children <24 months hospitalized with mild to moderate bronchiolitis.

DESIGN

One hundred and three children were randomly allocated to receive one 20-min session daily, either assisted autogenic drainage (AAD), intrapulmonary percussive ventilation (IPV), or bouncing (B) (control group), ninety-three finished the study.

OUTCOME MEASURES

Mean time to recovery in days was our primary outcome measure. The impact of the treatment and the daily improvement was also assessed by a validated clinical and respiratory severity score (WANG score), heart rate (HR), and oxygen saturation (SaO₂ ).

RESULTS

Mean time to recovery was 4.5 ± 1.9 days for the control group, 3.6 ± 1.4 days, P < 0.05 for the AAD group and 3.5 ± 1.3 days, P = 0.03 for the IPV group. Wang scores improved significantly for both physiotherapy techniques compared to the control group.

CONCLUSION

Both ACT's reduced significantly the length of hospital stay compared to no physiotherapy. Pediatr Pulmonol. 2017;52:225-231. © 2016 Wiley Periodicals, Inc.

High flow nasal cannula (HFNC) versus nasal continuous positive airway pressure (nCPAP) for the initial respiratory management of acute viral bronchiolitis in young infants: a multicenter randomized controlled trial (TRAMONTANE study)

PURPOSE

Nasal continuous positive airway pressure (nCPAP) is currently the gold standard for respiratory support for moderate to severe acute viral bronchiolitis (AVB). Although oxygen delivery via high flow nasal cannula (HFNC) is increasingly used, evidence of its efficacy and safety is lacking in infants.

METHODS

A randomized controlled trial was performed in five pediatric intensive care units (PICUs) to compare 7 cmH₂O nCPAP with 2 L/kg/min oxygen therapy administered with HFNC in infants up to 6 months old with moderate to severe AVB. The primary endpoint was the percentage of failure within 24 h of randomization using prespecified criteria. To satisfy noninferiority, the failure rate of HFNC had to lie within 15% of the failure rate of nCPAP. Secondary outcomes included success rate after crossover, intubation rate, length of stay, and serious adverse events.

RESULTS

From November 2014 to March 2015, 142 infants were included and equally distributed into groups. The risk difference of -19% (95% CI -35 to -3%) did not allow the conclusion of HFNC noninferiority (p = 0.707). Superiority analysis suggested a relative risk of success 1.63 (95% CI 1.02-2.63) higher with nCPAP. The success rate with the alternative respiratory support, intubation rate, durations of noninvasive and invasive ventilation, skin lesions, and length of PICU stay were comparable between groups. No patient had air leak syndrome or died.

CONCLUSION

In young infants with moderate to severe AVB, initial management with HFNC did not have a failure rate similar to that of nCPAP. This clinical trial was recorded in the National Library of Medicine registry (NCT 02457013).

Non-invasive ventilation in paediatric critical care

Non-invasive ventilation (NIV) is a well recognised and increasingly prevalent intervention in the paediatric critical care setting. In the acute setting NIV is used to provide respiratory support in a flexible manner that avoids a requirement for endotracheal intubation or tracheostomy, with the aim of avoiding the complications of invasive ventilation. This article will explore the physiological benefits, complications and epidemiology of the different modes of NIV including continuous positive airway pressure (CPAP), non-invasive positive pressure ventilation (NIPPV) and high-flow nasal cannula oxygen (HFNC). The currently available equipment and patient interfaces will be described, and the practical aspects of using NIV clinically will be explored. The current evidence for use of NIV in different clinical settings will be discussed, drawing on adult and neonatal as well as paediatric literature.

Safety of paediatric tracheal intubation after non-invasive ventilation failure

CONTEXT

Non-invasive ventilation (NIV) is increasingly used in pediatric intensive care units to limit the complications associated with intubation. However, NIV may fail, and the delay in initiating invasive ventilation may be associated with adverse outcomes. The objective of this retrospective study was to evaluate the safety of tracheal intubation after NIV failure.

METHODS

Consecutive tracheal intubation procedures were prospectively evaluated in our PICU from 01/2011 to 02/2012, as part of the National Emergency Airway Registry for Children (NEAR4KIDS) collaborative. The incidence of severe tracheal intubation associated events (TIAEs, including cardiac arrest, esophageal intubation with delayed recognition, emesis with aspiration, hypotension requiring intervention, laryngospasm, malignant hyperthermia, pneumothorax, and pneumomediastinum) and severe desaturation (below 80% when pre-intubation saturation was greater than 94%) were recorded prospectively. NIV use before intubation was retrospectively assessed.

RESULTS

100 consecutive intubation events were analyzed, 46 of which followed NIV failure. NIV exposed and non-exposed groups had different baseline characteristics, with lower weight, more frequent lower airway and lung disorder, and lower PIM2 score at admission in NIV failure patients (all P < 0.05). The nasal route for intubation was more frequent in NIV patients (P < 0.01). The incidence of severe TIAE or desaturation was 41% in the NIV failure group and 24% in primarily intubated patients (P = 0.09).

CONCLUSION

Complications occurred in 41% of intubations after NIV failure in this series. Further research is warranted to evaluate strategies to prevent these complications and to identify conditions in which intubation should not be delayed for a trial of NIV.

Neurally adjusted ventilator assist (NAVA) reduces asynchrony during non-invasive ventilation for severe bronchiolitis

BACKGROUND

To determine the prevalence of main inspiratory asynchrony events during non-invasive intermittent positive-pressure ventilation (NIV) for severe bronchiolitis. Ventilator response time and asynchrony were compared in neurally adjusted ventilator assist (NAVA) and in pressure assist/control (PAC) modes.

METHODS

This prospective physiological study was performed in a university hospital's paediatric intensive care unit and included 11 children (aged 35.2 ± 23 days) with respiratory syncytial virus bronchiolitis with failure of nCPAP. Patients received NIV for 2 hr in PAC mode followed by 2 hr in NAVA mode. Electrical activity of the diaphragm and pressure curves were recorded for 10 min. Trigger delay, main asynchronies (auto-triggering, double triggering, or non-triggered breaths) were analyzed, and the asynchrony index was calculated for each period.

RESULTS

The asynchrony index was lower during NAVA than during PAC (3 ± 3% vs. 38 ± 21%, P < 0.0001), and the trigger delay was shorter (43.9 ± 7.2 vs. 116.0 ± 38.9 ms, P < 0.0001). Ineffective efforts were significantly less frequent in NAVA mode (0.54 ± 1.5 vs. 21.8 ± 16.5 events/min, P = 0.01). Patient respiratory rates were similar, but the ventilator rate was higher in NAVA than in PAC mode (59.5 ± 17.9 vs. 49.8 ± 8.5/min, P = 0.03). The TcPCO2 baselines values (64 ± 12 mmHg vs. 62 ± 9 mmHg during NAVA, P = 0.30) were the same and their evolution over the 2 hr study period (-6 ± 10 mmHg vs. -12 ± 17 mmHg during NAVA, P = 0.36) did not differ.

CONCLUSION

Patient-ventilator inspiratory asynchronies and trigger delay were dramatically lower in NAVA mode than in PAC mode during NIV in infants with severe bronchiolitis.

CPAP and High-Flow Nasal Cannula Oxygen in Bronchiolitis

Severe respiratory failure develops in some infants with bronchiolitis because of a complex pathophysiologic process involving increased airways resistance, alveolar atelectasis, muscle fatigue, and hypoxemia due to mismatch between ventilation and perfusion. Nasal CPAP and high-flow nasal cannula (HFNC) oxygen may improve the work of breathing and oxygenation. Although the mechanisms behind these noninvasive modalities of respiratory support are not well understood, they may help infants by way of distending pressure and delivery of high concentrations of warmed and humidified oxygen. Observational studies of varying quality have suggested that CPAP and HFNC may confer direct physiologic benefits to infants with bronchiolitis and that their use has reduced the need for intubation. No trials to our knowledge, however, have compared CPAP with HFNC in bronchiolitis. Two randomized trials compared CPAP with oxygen delivered by low-flow nasal cannula or face mask and found some improvements in blood gas results and some physiologic parameters, but these trials were unable to demonstrate a reduction in the need for intubation. Two trials evaluated HFNC in bronchiolitis (one comparing it with headbox oxygen, the other with nebulized hypertonic saline), with the results not seeming to suggest important clinical or physiologic benefits. In this article, we review the pathophysiology of respiratory failure in bronchiolitis, discuss these trials in detail, and consider how future research studies may be designed to best evaluate CPAP and HFNC in bronchiolitis.

Bubble continuous positive airway pressure for children with severe pneumonia and hypoxaemia in Bangladesh: an open, randomised controlled trial

BACKGROUND

In developing countries, mortality in children with very severe pneumonia is high, even with the provision of appropriate antibiotics, standard oxygen therapy, and other supportive care. We assessed whether oxygen therapy delivered by bubble continuous positive airway pressure (CPAP) improved outcomes compared with standard low-flow and high-flow oxygen therapies.

METHODS

This open, randomised, controlled trial took place in Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh. We randomly assigned children younger than 5 years with severe pneumonia and hypoxaemia to receive oxygen therapy by either bubble CPAP (5 L/min starting at a CPAP level of 5 cm H2O), standard low-flow nasal cannula (2 L/min), or high-flow nasal cannula (2 L/kg per min up to the maximum of 12 L/min). Randomisation was done with use of the permuted block methods (block size of 15 patients) and Fisher and Yates tables of random permutations. The primary outcome was treatment failure (ie, clinical failure, intubation and mechanical ventilation, death, or termination of hospital stay against medical advice) after more than 1 h of treatment. Primary and safety analyses were by intention to treat. We did two interim analyses and stopped the trial after the second interim analysis on Aug 3, 2013, as directed by the data safety and monitoring board. This trial is registered at ClinicalTrials.gov, number NCT01396759.

FINDINGS

Between Aug 4, 2011, and July 17, 2013, 225 eligible children were recruited. We randomly allocated 79 (35%) children to receive oxygen therapy by bubble CPAP, 67 (30%) to low-flow oxygen therapy, and 79 (35%) to high-flow oxygen therapy. Treatment failed for 31 (14%) children, of whom five (6%) had received bubble CPAP, 16 (24%) had received low-flow oxygen therapy, and ten (13%) had received high-flow oxygen therapy. Significantly fewer children in the bubble CPAP group had treatment failure than in the low-flow oxygen therapy group (relative risk [RR] 0·27, 99·7% CI 0·07-0·99; p=0·0026). No difference in treatment failure was noted between patients in the bubble CPAP and those in the high-flow oxygen therapy group (RR 0·50, 99·7% 0·11-2·29; p=0·175). 23 (10%) children died. Three (4%) children died in the bubble CPAP group, ten (15%) children died in the low-flow oxygen therapy group, and ten (13%) children died in the high-flow oxygen therapy group. Children who received oxygen by bubble CPAP had significantly lower rates of death than the children who received oxygen by low-flow oxygen therapy (RR 0·25, 95% CI 0·07-0·89; p=0·022).

INTERPRETATION

Oxygen therapy delivered by bubble CPAP improved outcomes in Bangladeshi children with very severe pneumonia and hypoxaemia compared with standard low-flow oxygen therapy. Use of bubble CPAP oxygen therapy could have a large effect in hospitals in developing countries where the only respiratory support for severe childhood pneumonia and hypoxaemia is low-flow oxygen therapy. The trial was stopped early because of higher mortality in the low-flow oxygen group than in the bubble CPAP group, and we acknowledge that the early cessation of the trial reduces the certainty of the findings. Further research is needed to test the feasibility of scaling up bubble CPAP in district hospitals and to improve bubble CPAP delivery technology.

FUNDING

International Centre for Diarrhoeal Disease Research, Bangladesh, and Centre for International Child Health, University of Melbourne.

Continuous positive airway pressure with helmet versus mask in infants with bronchiolitis: an RCT

BACKGROUND

Noninvasive continuous positive airway pressure (CPAP) is usually applied with a nasal or facial mask to treat mild acute respiratory failure (ARF) in infants. A pediatric helmet has now been introduced in clinical practice to deliver CPAP. This study compared treatment failure rates during CPAP delivered by helmet or facial mask in infants with respiratory syncytial virus-induced ARF.

METHODS

In this multicenter randomized controlled trial, 30 infants with respiratory syncytial virus-induced ARF were randomized to receive CPAP by helmet (n = 17) or facial mask (n = 13). The primary endpoint was treatment failure rate (defined as due to intolerance or need for intubation). Secondary outcomes were CPAP application time, number of patients requiring sedation, and complications with each interface.

RESULTS

Compared with the facial mask, CPAP by helmet had a lower treatment failure rate due to intolerance (3/17 [17%] vs 7/13 [54%], P = .009), and fewer infants required sedation (6/17 [35%] vs 13/13 [100%], P = .023); the intubation rates were similar. In successfully treated patients, CPAP resulted in better gas exchange and breathing pattern with both interfaces. No major complications due to the interfaces occurred, but CPAP by mask had higher rates of cutaneous sores and leaks.

CONCLUSIONS

These findings confirm that CPAP delivered by helmet is better tolerated than CPAP delivered by facial mask and requires less sedation. In addition, it is safe to use and free from adverse events, even in a prolonged clinical setting.

Variability of intensive care management for children with bronchiolitis

OBJECTIVE

To determine the extent of variability in testing and treatment of children with bronchiolitis requiring intensive care.

METHODS

This prospective, multicenter observational study included 16 academic children's hospitals across the United States during the 2007 to 2010 fall and winter seasons. The study included children<2 years old hospitalized with bronchiolitis who required admission to the ICU and/or continuous positive airway pressure (CPAP) within 24 hours of admission. Among the 2207 enrolled patients with bronchiolitis, 342 children met inclusion criteria. Clinical data and nasopharyngeal aspirates were collected.

RESULTS

Respiratory distress severity scores and intraclass correlation coefficients were calculated. The study patients' median age was 2.6 months, and 59% were male. Across the 16 sites, the median respiratory distress severity score was 5.1 (interquartile range: 4.5-5.4; P<.001). The median value of the percentages for all sites using CPAP was 15% (range: 3%-100%), intubation was 26% (range: 0%-100%), and high-flow nasal cannula (HFNC) was 24% (range: 0%-94%). Adjusting for site-specific random effects (as well as children's demographic characteristics and severity of bronchiolitis), the intraclass correlation coefficient for CPAP and/or intubation was 21% (95% confidence interval: 8-44); for HFNC, it was 44.7% (95% confidence interval: 24-67).

CONCLUSIONS

In this multicenter study of children requiring intensive care for bronchiolitis, we identified substantial institutional variability in testing and treatment, including use of CPAP, intubation, and HFNC. These differences were not explained by between-site differences in patient characteristics, including severity of illness. Further research is needed to identify best practices for intensive care interventions for this major cause of pediatric hospitalization.

Continuous positive airway pressure (CPAP) for acute bronchiolitis in children

BACKGROUND

Acute bronchiolitis is one of the most frequent causes of emergency department visits and hospitalisation in infants. There is no specific treatment for bronchiolitis except for supportive therapy. Continuous positive airway pressure (CPAP) is supposed to widen the peripheral airways of the lung, allowing deflation of over-distended lungs in bronchiolitis. The increase in airway pressure also prevents the collapse of poorly supported peripheral small airways during expiration. In observational studies, CPAP is found to be beneficial in acute bronchiolitis.

OBJECTIVES

To assess the efficacy and safety of CPAP compared to no CPAP or sham CPAP in infants and children up to three years of age with acute bronchiolitis.

SEARCH METHODS

We searched CENTRAL (2014, Issue 3), MEDLINE (1946 to April week 2, 2014), EMBASE (1974 to April 2014), CINAHL (1981 to April 2014) and LILACS (1982 to April 2014).

SELECTION CRITERIA

We considered randomised controlled trials (RCTs), quasi-RCTS, cross-over RCTs and cluster-RCTs evaluating the effect of CPAP in children with acute bronchiolitis.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, extracted data using a structured proforma, analysed the data and performed meta-analyses.

MAIN RESULTS

We included two studies with a total of 50 participants under 12 months of age. In one study there was a high risk of bias for incomplete outcome data and selective reporting, and both studies had an unclear risk of bias for several domains including random sequence generation. The effect of CPAP on the need for mechanical ventilation in children with acute bronchiolitis was uncertain due to imprecision around the effect estimate (two RCTs, 50 participants; risk ratio (RR) 0.19, 95% CI 0.01 to 3.63; low quality evidence). Neither trial measured our other primary outcome of time to recovery. One trial found that CPAP significantly improved respiratory rate compared with no CPAP (one RCT, 19 participants; mean difference (MD) -5.70 breaths per minute, 95% CI -9.30 to -2.10), although the other study reported no difference between groups with no numerical data to pool. Change in arterial oxygen saturation was measured in only one trial and the results were imprecise (one RCT, 19 participants; MD -1.70%, 95% CI -3.76 to 0.36). The effect of CPAP on the change in partial pressure of carbon dioxide (pCO2) was also imprecise (two RCTs, 50 participants; MD -2.62 mmHg, 95% CI -5.29 to 0.05; low quality evidence). Duration of hospital stay was similar in both of the groups (two RCTs, 50 participants; MD 0.07 days, 95% CI -0.36 to 0.50; low quality evidence). Both trials reported no cases of pneumothorax and there were no deaths in either study. Change in partial pressure of oxygen (pO2), hospital admission rate (from emergency department to hospital), duration of emergency department stay, need for intensive care unit admission, local nasal effects and shock were not measured in either study.

AUTHORS' CONCLUSIONS

The effect of CPAP in children with acute bronchiolitis is uncertain due to the limited evidence available. Larger trials with adequate power are needed to evaluate the effect of CPAP in children with acute bronchiolitis.