Clinical characteristics and outcomes associated with nasal intermittent mandatory ventilation in acute pediatric respiratory failure

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.

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.

A multicentered study on efficiency of noninvasive ventilation procedures (SAFE-NIV)

Background/aim

To characterize the clinical course of noninvasive positive pressure ventilation (NIPPV) and high flow humidified nasal cannula ventilation (HFNC) procedures; perform risk analysis for ventilation failure.

Material and methods

This prospective, multi-centered, observational study was conducted in 352 PICU admissions (1 month-18 years) between 2016 and 2017. SPSS-22 was used to assess clinical data, define thresholds for ventilation parameters and perform risk analysis.

Results

Patient age, onset of disease, previous intubation and hypoxia influenced the choice of therapy mode: NIPPV was preferred in older children (p = 0.002) with longer intubation (p < 0.001), ARDS (p = 0.001), lower respiratory tract infections (p < 0.001), chronic respiratory disease, (p = 0.005), malignancy (p = 0.048) and immune deficiency (p = 0.026). The failure rate was 13.4%. sepsis, ARDS, prolonged intubation, and use of nasal masks were associated with NIV failure (p = 0.001, p < 0.001, p < 0.001, p = 0.025). The call of intubation or re-intubation was given due to respiratory failure in twenty-seven (57.5%), hemodynamic instability in eight (17%), bulbar dysfunction or aspiration in 5 (10.6%), neurological deterioration in 4 (8.5%) and developing ARDS in 3 (6.4%) children. A reduction of less than 10% in the respiration within an hour increased the odds of failure by 9.841 times (OR: 9.841, 95% CI: 2.0021–48.3742). FiO2 > 55% at 6th hours and PRISM-3 >8 were other failure predictors. Of the 9.9% complication rate, the most common complication was pressure ulcerations (4.8%) and mainly observed when using full-face masks (p = 0.047). Fifteen (4.3%) patients died of miscellaneous causes. Tracheostomy cannulation was performed on 16 children due to prolonged mechanical ventilation (8% in NIPPV, 2.6% in HFNC)

Conclusion

Absence of reduction in the respiration rate within an hour, FiO2 requirement >55% at 6th hours and PRISM-3 score >8 predict NIV failure.

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.

A pediatric high-flow nasal cannula protocol standardizes initial flow and expedites weaning

OBJECTIVE

Respiratory illnesses compose the most common diagnoses of patients admitted to pediatric intensive care units. In pediatrics, high-flow nasal cannula (HFNC) therapy is an intermediate level of respiratory support with variability in practice. We conducted a pre-post intervention study of patients placed on HFNC therapy before and after the implementation of an HFNC protocol.

METHODS

This was a quality improvement/pre-post intervention study of pediatric patients who received HFNC therapy in our teaching, tertiary care children's hospital between January 2015 and April 2019. Patients were evaluated before and after the implementation of a protocol that promoted initiation of higher flow and rapid weaning. Our primary outcomes were initial flow and rate of weaning pre- and post-protocol; our secondary outcomes were HFNC failure rate (defined as escalation to noninvasive ventilation or mechanical ventilation) and length of hospital stay. Propensity matching was used to account for differences in age and weight pre- and post-protocol.

RESULTS

In total, 584 patients were included, 292 pre-protocol, and 292 post-protocol. The median age was 20 months, and the indication for HFNC therapy was bronchiolitis in 29% of patients. Post-protocol patients compared to pre-protocol patients had significantly a higher initial flow (median 14.5 L/min vs. 10 L/min, p < .001) and a higher weaning rate of flow (median 4.1 L/min/h vs. 2.4 L/min/h, p < .001). Post-protocol patients also had a lower HFNC failure rate (10% vs. 17%, p = .015) and a shorter length of stay (5.97 days vs. 6.80 days, p = .006).

CONCLUSION

Among pediatric patients, the implementation of an HFNC protocol increases initial flow, allows for more rapid weaning, and may decrease the incidence of escalation to noninvasive ventilation or mechanical ventilation.

Use of bilevel positive pressure ventilation in patients with bronchiolitis

RATIONAL

This study aims at describing the use of bilevel positive airway pressure (BiPAP) in infants with severe bronchiolitis.

WORKING HYPOTHESIS

The use of BiPAP in infants with bronchiolitis may be associated with a worst outcome.

STUDY DESIGN

A single-center retrospective study performed from October 2013 to April 2016.

METHODOLOGY

All infants from 1 day to 6 months of age admitted in the pediatric intensive care unit (PICU) were included if they had a clinical diagnosis of bronchiolitis and if they required any type of noninvasive ventilation (NIV), including high flow nasal cannula, continuous positive airway pressure and BiPAP at admission in PICU. There was no local written protocol regarding the ventilator management during the study.

RESULTS

Overall, 252 infants (median age 45 (26-72) days) were included in the study and 110 infants (44%) were supported by BiPAP at admission. More infants were born preterm in the group of patients supported by BiPAP at admission. No complication related to NIV occurred. Patients in the BiPAP group had a longer duration of noninvasive support as well as a longer PICU length of stay. However, hospital length of stay did not differ according to the type of respiratory support at admission.

CONCLUSION

The use of BiPAP was not associated with endotracheal intubation, however it was associated with increased PICU length of stay and increased duration of NIV.