noninvasive ventilation in pediatrics (egypt) 3-09 (final version)

8/14/2019 Noninvasive Ventilation in Pediatrics (Egypt) 3-09 (Final Version)

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Noninvasive Ventilationin Pediatrics

Noninvasive Ventilationin Pediatrics

Ira M. Cheifetz, MD, FCCM, FAARCProfessor of Pediatrics

Chief, Pediatric Critical CareMedical Director, PICU and Peds Resp Care

Duke Childrens Hospital

Ira M. Cheifetz, MD, FCCM, FAARCIra M. Cheifetz, MD, FCCM, FAARC

Professor of PediatricsProfessor of Pediatrics

Chief, Pediatric Critical CareChief, Pediatric Critical CareMedical Director, PICU and Peds Resp CareMedical Director, PICU and Peds Resp Care

Duke ChildrenDuke Childrens Hospitals Hospital


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Do you use noninvasiveventilation for children in the

acute ICU setting?

Do you use noninvasiveventilation for children in the

acute ICU setting?

If yes, do you have convincing data tosupport your practice?

If no, is this because of a lack of

data?

appropriate delivery devices andinterfaces?

comfort with this ventilatory strategy?

If yes, do you have convincing data tosupport your practice?

If no, is this because of a lack of

data?

appropriate delivery devices andinterfaces?

comfort with this ventilatory strategy?


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Noninvasive Ventilation (NIV)Noninvasive Ventilation (NIV) Not a new concept

Many decades of experience neuromuscular weakness

obstructive sleep apnea

upper & lower airway obstruction acute hypoxic respiratory failure

post-extubation / facilitate extubation

So, why are some still unsure of usingNIV for pediatric patients?

Not a new conceptNot a new concept

Many decades of experienceMany decades of experience neuromuscular weakness

obstructive sleep apnea

upper & lower airway obstruction acute hypoxic respiratory failure

post-extubation / facilitate extubation

So, why are some still unsure of usingNIV for pediatric patients?


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Available Data?Available Data? Most data are from adults & neonates.

very different populations Most studies have involved patients with:

acute hypercapneic respiratory failure

co-morbidities premature infants

Very few studies have evaluated NIV forpure acute hypoxemic resp failure.

No conclusive pediatric data just one

study.

Most data are from adults & neonates.Most data are from adults & neonates.

very different populationsvery different populations

Most studies have involved patients with:Most studies have involved patients with:

acute hypercapneic respiratory failureacute hypercapneic respiratory failure

coco--morbiditiesmorbidities premature infantspremature infants

Very few studies have evaluated NIV forVery few studies have evaluated NIV for

purepure acute hypoxemic resp failure.acute hypoxemic resp failure.

No conclusive pediatric data just one

study.


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AARC 38th Journal Conference:

Respiratory Controversies in theCritical Care Setting

Should NIV be used for all forms of acuterespiratory failure?

Hess and Fessler, Respir Care, 2007

AARC 38th Journal Conference:

Respiratory Controversies in theCritical Care Setting

Should NIV be used for all forms of acuterespiratory failure?

Hess and Fessler, Respir Care, 2007


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NIV is indicated for all forms of ARFNIV is indicated for all forms of ARF Tremendous clinical experience

Utilization of NIV continues to dramatically

Significant recent technical advances

7 systematic reviews published to date with

consistent conclusions NIV intubation rate and mortality

Clear data for adult patients

COPD, card pulm edema, lung resection, solidorgan transplantation, immunosuppressed patients,prevent extubation failure, asthma

Tremendous clinical experienceTremendous clinical experience

Utilization of NIV continues toUtilization of NIV continues to dramaticallydramatically

Significant recent technical advancesSignificant recent technical advances

7 systematic reviews published to date with7 systematic reviews published to date with

consistent conclusionsconsistent conclusions NIVNIV intubation rate and mortalityintubation rate and mortality

Clear data for adult patientsClear data for adult patients

COPD, card pulm edema, lung resection, solidCOPD, card pulm edema, lung resection, solidorgan transplantation, immunosuppressed patients,organ transplantation, immunosuppressed patients,

prevent extubation failure, asthmaprevent extubation failure, asthma

Hess and Fessler, Resp Care, 2007Hess and Fessler, Resp Care, 2007


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NIV is indicated for all forms of ARFNIV is indicated for all forms of ARF Hypoxemic respiratory failure

intubation rate & mortality(meta-analysis; Keenan, CCM, 2004)

Nosocomial pneumonia

risk of VAP with NIV(meta-analysis; Hess, Respir Care, 2005)

Common exclusions

airway protection, unable to fit mask,severe illness, uncooperative patient

Hypoxemic respiratory failureHypoxemic respiratory failure

intubation rate & mortalityintubation rate & mortality(meta(meta--analysis; Keenan, CCM, 2004)analysis; Keenan, CCM, 2004)

Nosocomial pneumoniaNosocomial pneumonia

risk of VAP with NIVrisk of VAP with NIV((metameta--analysis; Hess, Respir Care, 2005)analysis; Hess, Respir Care, 2005)

Common exclusionsCommon exclusions

airway protection, unable to fit mask,airway protection, unable to fit mask,severe illness, uncooperative patientsevere illness, uncooperative patient



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NIV is NOT for all forms of ARFNIV is NOT for all forms of ARF No change in reintubation rates, mortality, or

benefit in hypercarbic pts (Keenan, JAMA, 2002)

NIV does not work to rescue patients with respdistress after extubation

evidence of harm (Esteban, NEJM, 2004) resp failure after extubation mortality

Should not be used in patients with a highlikelihood of failure

NIV: No clear advantage

NoNo changechange in reintubation rates, mortality, orin reintubation rates, mortality, or

benefit in hypercarbic ptsbenefit in hypercarbic pts (Keenan, JAMA, 2002)(Keenan, JAMA, 2002)

NIV does not work to rescue patients with respNIV does not work to rescue patients with resp

distress after extubationdistress after extubation

evidence of harmevidence of harm (Esteban, NEJM, 2004)(Esteban, NEJM, 2004) resp failure after extubationresp failure after extubation mortalitymortality

Should not be used in patients with a highShould not be used in patients with a high

likelihood of failurelikelihood of failure

NIV: No clear advantage



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Should NIV be used for all forms ofacute resp failure?Should NIV be used for all forms ofacute resp failure?

Excluding ICU bed availability and otheradministrative and technical issues, howmany of the 13 experts routinely use NIV in

patients with acute resp failure?

Excluding ICU bed availability and otherExcluding ICU bed availability and otheradministrative and technical issues, howadministrative and technical issues, how

many of the 13 experts routinely use NIV inmany of the 13 experts routinely use NIV in

patients with acute resp failure?patients with acute resp failure?

EveryoneEveryone



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Now, lets take a closer lookat the data!Now, lets take a closer lookat the data!


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Non-invasive VentilationNon-invasive Ventilation intubation rate, ICU LOS, & ICU mortality Keenan, CCM, 2004 (meta-analysis)

nosocomial pneumonia risk Hess, Respir Care, 2005 (meta-analysis)

intubation rate, ICU LOS, & ICUintubation rate, ICU LOS, & ICU mortalitymortality

Keenan, CCM, 2004 (metaKeenan, CCM, 2004 (meta--analysis)analysis)

nosocomial pneumonia risknosocomial pneumonia risk Hess, Respir Care, 2005 (metaHess, Respir Care, 2005 (meta--analysis)analysis)


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NIV to Avoid IntubationNIV to Avoid Intubation

0

10

20

30

40

50

60

70

80

90

Brochard

1990

Vitacca

1993

Brochard

1995

Kramer

1995

Wysocki

1995

Confalonieri

1996

%in

tubated

NPPV Control

Marini, Crit Care Med, 2008Marini, Crit Care Med, 2008


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Antonelli, New Eng J Med, 1998Antonelli, New Eng J Med, 1998


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Antonelli, New Eng J Med, 1998Antonelli, New Eng J Med, 1998


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Hilbert, New Eng J Med, 2001Hilbert, New Eng J Med, 2001


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Hilbert, New Eng J Med, 2001Hilbert, New Eng J Med, 2001


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0.0480.04814%14%25%25%mortalitymortality

0.0210.0212.5 hrs2.5 hrs12 hrs12 hrstime totime to

reintubationreintubation

n.s.n.s.48%48%48%48%reintubationreintubation

raterate

pstandard(n=107)

NIV(n=114)

Esteban, New Eng J Med, 2004Esteban, New Eng J Med, 2004


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PredictorsPredictors

0.010.5-4.0Base excess0.47.397.37pH

0.14236PaCO2

0.02147112PaO2/FiO

2

-019Shock

0.91433Sepsis


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Soroksky, Chest, 2003Soroksky, Chest, 2003

NIV and AsthmaNIV and Asthma


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Hill, Crit Care Med, 2007Hill, Crit Care Med, 2007


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Pediatric DataPediatric Data Randomized, controlled trial

Yanez, Pediatr Crit Care Med, 2008

What else has been published?

case series

case reports

poorly controlled studies

not even a well-performed survey study

Randomized, controlled trial

Yanez, Pediatr Crit Care Med, 2008

What else has been published?

case series

case reports

poorly controlled studies

not even a well-performed survey study


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Pediatric DataPediatric Data

Yanez, Pediatr Crit Care Med, 2008Yanez, Pediatr Crit Care Med, 2008


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Pediatric DataPediatric Data

Yanez, Pediatr Crit Care Med, 2008Yanez, Pediatr Crit Care Med, 2008


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Pediatric NIVIs it worth the effort?

Pediatric NIVIs it worth the effort?

Pediatric NIV is increasing at an exponentialrate despite the lack of convincing data.

Why?same reasons as for adult pts & neonates

avoid intubation

facilitate extubation

length of ventilation

Pediatric NIV is increasing at an exponentialrate despite the lack of convincing data.

Why?

same reasons as for adult pts & neonates

avoid intubation

facilitate extubation



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Real Life SituationReal Life Situation 7 month old infant (5.9 kg)

Problem list: VSD s/p repair, pulmonaryhypertension (on sildenafil), chronic lungdisease, upper airway obstruction, severe

GE reflux. Mechanically ventilated for 8 weeks

Now on minimal vent support & stable Ready for extubation trial??

7 month old infant (5.9 kg)

Problem list: VSD s/p repair, pulmonaryhypertension (on sildenafil), chronic lungdisease, upper airway obstruction, severe

GE reflux. Mechanically ventilated for 8 weeks

Now on minimal vent support & stable Ready for extubation trial??


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NIV: Available TechnologyNIV: Available Technology

Neonatal CPAP

stand alone systems

full-service ventilators

Bi-level ventilation (i.e., BiPAP)

limited availability of FDA approvedequipment (ventilator and interface)

Reintubation not an ideal option

A real dilemma for the clinician

Neonatal CPAP

stand alone systems

full-service ventilators

Bi-level ventilation (i.e., BiPAP)

limited availability of FDA approved

equipment (ventilator and interface)

Reintubation not an ideal option A real dilemma for the clinician


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Challenges:

Patient Population

Challenges:

Patient Population Variability in patient size and age

neonates to 18 years

3 kg to > 100 kg

Variety of diagnosis (medial and surgical)acute hypoxemic respiratory failure

neuromuscular weakness

cardiac

airway obstruction

Variability in patient size and ageVariability in patient size and age

neonates to 18 yearsneonates to 18 years

3 kg to > 100 kg3 kg to > 100 kg

Variety of diagnosis (medial and surgical)Variety of diagnosis (medial and surgical)acute hypoxemic respiratory failureacute hypoxemic respiratory failure

neuromuscular weaknessneuromuscular weakness

cardiaccardiac

airway obstructionairway obstruction


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Challenges: TechnicalChallenges: Technical Inspiratory flow

ideally flow should be adjustable

Response time

needs to be fast and able to reliably

synchronize with the infant / child

Monitoring (currently minimal)

tidal volume

graphics

capnography

Inspiratory flowInspiratory flow

ideally flow should be adjustable

Response time

needs to be fast and able to reliably

synchronize with the infant / child Monitoring (currently minimal)

tidal volume

graphics

capnography


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Challenges: InterfaceChallenges: Interface Probably the biggest challenge

Optimize patient comfort Must protect the skin and the eyes

an added challenge in the infantpopulation (not much room to work)

Nasal vs. full face masks

Probably the biggest challengeProbably the biggest challenge

Optimize patient comfortOptimize patient comfort Must protect the skin and the eyesMust protect the skin and the eyes

an added challenge in the infantan added challenge in the infantpopulation (population (not much room to worknot much room to work))

Nasal vs. full face masksNasal vs. full face masks


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What are the problems?What are the problems? High inspiratory flow rates

dried secretions

potential for airwayobstruction

patient discomfort due to high flow rates

Interfaces generally not designed forinfants and small children

comfort

skin integrity

High inspiratory flow rates

dried secretions

potential for airwayobstruction

patient discomfort due to high flow rates

Interfaces generally not designed forinfants and small children

comfort

skin integrity


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Nasal MaskNasal Mask


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FULL Face MaskFULL Face Mask


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Securing DevicesSecuring Devices


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What are we often left with?What are we often left with?


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So, why try NIV for pediatrics?So, why try NIV for pediatrics? To avoid invasive mechanical ventilation

and all of its associated complications.

increased pharmacologic sedation

secondary lung injury

airway injury

nosocomial pneumonia

To avoid invasive mechanical ventilationTo avoid invasive mechanical ventilation

and all of its associated complications.and all of its associated complications.

increased pharmacologic sedation

secondary lung injury

airway injury

nosocomial pneumonia


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Potential ApplicationsPotential Applications Hypoxemic respiratory failure / ALI

pneumonia, aspiration, any etiology

Upper and lower airway obstruction

subglottic stenosis; tracheolaryngomalacia

asthma; bronchiolitis Neuromuscular weakness

critical illness myopathy

spinal muscular atrophy

Application should be based on patho-physiology; not necessarily on diagnosis

Hypoxemic respiratory failure / ALIHypoxemic respiratory failure / ALI

pneumonia, aspiration, any etiology

Upper and lower airway obstruction

subglottic stenosis; tracheolaryngomalacia

asthma; bronchiolitis Neuromuscular weakness

critical illness myopathy

spinal muscular atrophy Application should be based on patho-

physiology; not necessarily on diagnosis


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Potential ApplicationsPotential Applications Special populations

immunosuppressed patients;

s/p bone marrow transplantation

chronic lung disease;

bronchopulmonary dysplasia Overall goals

avoid intubation

encourage prompt extubation


Special populationsSpecial populations

immunosuppressed patients;s/p bone marrow transplantation

chronic lung disease;chronic lung disease;

bronchopulmonary dysplasiabronchopulmonary dysplasia Overall goals

avoid intubation

encourage prompt extubation



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Pediatric NIV: SummaryPediatric NIV: Summary Technology (which is as good as the adult

products) does not currently exist for infants

and small children.

Interfaces are probably the biggest challenge.

Clinical need for technology does exist. Need more pediatric data, but the use of NIV

in pediatrics seems reasonable based on

extrapolation from the neonatal and adultpopulations.

Need consistent guidelines / protocols.

Technology (which is as good as the adult

products) does not currently exist for infants

and small children.

Interfaces are probably the biggest challenge.

Clinical need for technology does exist. Need more pediatric data, but the use of NIV

in pediatrics seems reasonable based on

extrapolation from the neonatal and adultpopulations.

Need consistent guidelines / protocols.


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Pediatric NIV: SummaryPediatric NIV: Summary Use of NIV in the pediatric population is

growing at an increasing rate.

Is it worth the effort?

yes

Do the benefits outweigh the risks?

probably

Use of NIV in the pediatric population isgrowing at an increasing rate.

Is it worth the effort?

yes

Do the benefits outweigh the risks?

probably

noninvasive ventilation in pediatrics (egypt) 3-09 (final version)

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