Noninvasive Ventilation in Pediatric
Respiratory Failure: Does It Work?
James D. Fortenberry MD FCCM, FAAP
Director, Critical Care Medicine
Children’s Healthcare of Atlanta at Egleston
Clinical Associate Professor
Emory University School of Medicine
Atlanta, Georgia USA
History of Ventilation
 Noninvasive ventilation: foundation of concept of
mechanical ventilation
• 1876: First iron lung
• 1889: Alexander Graham Bell-first iron lung for
newborn infant
• 1920’s: Drinker iron lung
• 1940’s: Polio epidemics
• 1960’s: Rise of positive pressure ventilation
• 1990’s: Resurgence of interest in NIV
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First Reported Use of Noninvasive
Ventilation
And the Lord God formed man of the
dust of the ground and breathed into
his nostrils the breath of life, and man
became a living soul.
-- Genesis 2:7
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What is Noninvasive Ventilation?
 Delivery of ventilatory support without the use of an
invasive artificial airway
 Role in:
• Chronic respiratory insufficiency:obstructive
sleep apnea
• Acute respiratory failure
 Hypoxemic
 Hypercarbic
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What is Noninvasive Ventilation?
 Modalities
• Negative pressure: inspiration  lowers
pressures surrounding chest wall, augments tidal
volume, more physiologic
 Iron lung
 Cuirass
• Positive pressure (NIPPV): generates positive
pressure flow to meet need in spontaneously
breathing patient
 Current standard
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Noninvasive Positive Pressure
Ventilation
 Modes of Delivery
• Volume ventilator
• Pressure-controlled
 Continuous (CPAP)
 Bilevel (BiPAP® is trade name): cycles
between inspiratory (IPAP) and expiratory
(EPAP) pressures
• Intermittent
• Continuous
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Modes of BiPAP
 Spontaneous: response to threshold level of patient
inspiratory flow to provide IPAP with extra flow,
EPAP after peak
 Spontaneous/Timed: cycle added in event of apnea
 Timed: intermittent pulses at set rate only
 Continuous PAP (CPAP)
 Problems:
• infant may have difficulty achieving sufficient
inspiratory flow to trigger
• Mask leak prolongs inflation time
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NIPPV: Mechanisms of Action
• Stabilize chest wall
• “Unload” diaphragm and accessory muscles of
breathing
• Increase tidal volume/minute ventilation
• Increase FRC
• Prevent atelectasis
• Decrease auto-PEEP/stent airways
• Maintain upper airway patency/ decrease apnea
and hypopnea
How well NIPPV provides these is undocumented
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NIPPV: Potential Benefits
• Avoidance of risks of intubation
• Improved bedside caregiver time
• Decreased nosocomial pneumonia
• Potential decreased ICU length of stay, mortality
• Decreased costs
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NIPPV: Initiation in Children
• Varied approaches
• General BiPAP settings: IPAP 12, EPAP 6
cmH2O
• Blended oxygen flow to titrate
• Bedside caregiver presence high initially
• Sedation often needed in children to tolerate
 Ketamine bolus/infusion our choice
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NIPPV: Delivery Systems
• Conventional ventilators
• CPAP device
 Aladdin
• Bilevel device:
 BiPAP (Respironics)
 Knightstar (Puritan-Bennett)
• High flow nasal cannula devices:
 Vapotherm
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NIPPV: Interface modes and systems
• Mask
• Nasal
• Full face
• Type of mask
• Mask vs. pillows/cannula
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Nasal Mask
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Full Face Mask
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Nasal Prong Devices
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Nasal Pillow Devices
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Interfaces for NIPPV
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Nasal
Oronasal
 Advantages
• Less aspiration risk
• Easier secretion
clearance
• Less dead space
• Easier fit in adults
 Disadvantages
• Mouth leak
• Higher resistance
through nasal passages
• Nasal irritation
• Potential nasal
obstruction
• Fit in infants?
 Advantages
• Better control of mouth
leak
• Better for mouth
breathers
 Disadvantages
• More dead space
• Claustrophobia
• Higher aspiration risk
• More difficulty in
speaking
• Risk if vent malfunction
• Greater sedation need in
kids?
NIPPV: Potential Indications
 Cardiogenic pulmonary edema
 Hypercarbic respiratory failure/COPD
 Hypoxemic respiratory failure
 Peri-extubation
 Immunocompromised patients
 Asthma
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NIPPV: Contraindications
• Significant altered mental status/inability to
protect airway
• Hemoptysis
• Facial injuries
• NP obstruction
• Airway foreign bodies
• Significant cardiovascular instability
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NIPPV: Potential Complications
• Acute unrecognized deterioration
• Nasal/facial erosions
• Aspiration
• Abdominal distention (GE sphincter pressure up
to 25 cmH2O)
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