Non-invasive positive pressure
ventilation in the PICU
What is the daily practice of mechanical ventilation in ICU
In adults (in the years 1996 / 1997:
Esteban A et al. AJRCCM 2000; 161:1450–1458
In pediatrics (in the year 1999):
ETT in 635 (96%; 95% CI: 94–97) of patients,
tracheostomy in 11 (2%; 95% CI: 1–3),
facial mask in 10 (1.5%; 95% CI: 1–3).
Farias A et al.
Intensive Care Med 2004; 30:918–925
NIPPV in the Pediatric Intensive Care Unit
Geneva experience 1998 - 1999
Number of pediatric patients hospitalized
in the PICU over a 2-year period:
General pediatrics:
Cardiovascular surgery:
General surgery:
Neurosurgery:
Transplantation unit:
Onco-hematology:
Orthopedics:
771
215
279
133
69
27
13
35
(28%)
(36%)
(17%)
(9%)
(3%)
(2%)
(5%)
Ventilated patients:
479
(62%)
Intubated and ventilated patients:
416
(87%)
Ventilatory support with NIPPV or CPAP
63
(13%)
NIPPV in acute pediatric respiratory failure
Geneva experience 1998 - 1999
n = 63
CPAP:
NPPV (BiPAP):
NPPV and CPAP:
30
29
4
Etiology:
- infectieuse pneumopathy: n = 20
- resp. insuffiency postoperatively: n = 10
(orthopedic surgery: n = 3; diaphragmatic palsy: n = 5)
- upper airway obstruction: n = 4
(incl. postextubation stridor)
- acute heart failure: n = 16
(postoperative CHD, cardiomyopathy, myocarditis)
- septicemia: n = 4
High risk of respiratory distress
in infants and small children
Small airways = high airway resistance
Compliant chest wall = low FRC
Relatively “inefficient” diaphragm
The diaphragm should set off the inward motion of the rib cage to maintain tidal
volume constant, something which it can only do to a limited extent and will
result in paradoxic thoraco-abdominal movements.
Chest wall distortion represents a pressure-induced change in volume and
constitutes waste work which has an enormous energy cost
Objectives of Noninvasive Ventilation in
Pediatric Patients With Respiratory Disorders
Avoid intubation
Teague WG Pediatric Pulmonology 2003;35:418–426
Indications / Benefits of NIPPV in the PICU
Early case reports showed: Improvement of clinical
manifestation of respiratory distress and respiratory gas
exchange in children with AHRF
Avoid or delay endotracheal intubation ?
Treatment of upper airway obstructions (stenting the
airways)
Treatment of atelectasis
Treatment of exacerbations of neuromuscular disease
Facilitation of weaning from invasive ventilation (e.g.
post-operative in patients with restrictive lung disease)
NIPPV in acute hypoxic respiratory failure:
Benefit and treatment failures in 3 pediatric case series
4
Rimensberger PC
Swiss Medical Weekly 2000;130:1880–6
NIPPV / CPAP in ARF: Treatment failures
Geneva experience 1998 - 1999
6 / 63 (9.5 %)
on CPAP
patient # 1 (4 months):
patient # 2 (10 months):
patient # 3 (6 months):
on NPPV (BiPAP)
patient # 4 (3 years):
patient # 5 (15 years):
patient # 6 (15 years):
Bronchiolitis and BPD
DORV, Tetralogy of Fallot: postoperative
TGV, VSD postoperative BT-shunt
ARDS, pneumonia
Fungal pneumonia and sepsis in immuncompromised
patient post lung transplantation
Orthopedic patient with postoperative paraplegia
NIPPV in infants with AHRF
6 infants with AHRF of various etiology
Pressure support: IPAP 14 ± 0,5 cmH2O; EPAP 7,3 ± 1 cmH2O
Ti max: 0,6 ± 0,1 s ; insp. rise time: 100 ms.
pCO2
RR
F. Vermeulen et al. Annales Françaises d’Anesthésie et de Réanimation 2003; 22: 716–720
NIPPV in children upper airway obstruction
chronic:
obstructive sleep apnea (OSA)
a) anatomic obstruction of nasopharyngeal airways
b) intermittent collapse of the nasopharyngeal airway
- CPAP or NIPPV to prevent upper airway collapse
acute:
infectious conditions (epiglotitis, croup) or foreign body
- CPAP or NIPPV works well in postextubation croup
No published experience with helium and NIPPV in these conditions
PEEP: Tracheomalacia
No PEEP
PEEP 10cmH2O
Quen Mok, Great Ormond Street Hospital for Children, London
CPAP: Tracheomalacia
No PEEP
CPAP 10cmH2O
Quen Mok, Great Ormond Street Hospital for Children, London
Case serie in pediatric status asthmaticus with severe
hypoxemia
Teague WG AJRCCM 1998; 157:542
prospective, non controlled case serie (n = 26)
NPPV:
nasal mask; S/T mode
IPAP 13 ± 3 cmH2O; EPAP 7 ± 2 cmH2O; FiO2 0.68 ± 0.28
Results: 21 ± 27 hrs mean duration
169 ± 183 hrs O2 requirements
19/26 acutely improved
7/26 required intubation
11/26 did not well tolerate
pH
paCO2
(mmHg)
paO2
(mmHg)
pre-tx (n = 15)
7.36 ± 0.5
40 ± 10
87 ± 23
post-tx (n = 6)
7.42 ± 0.9
39 ± 14
94 ± 35
p > 0.05 for all
comparisons
NPPV in pediatric status asthmaticus: Case serie
120
25
100
20
*
80
pre NPPV
60
intubated
15
*
post NPPV
10
40
20
* p < 0.05
*
5
* p < 0.05
0
FiO2
SO2
not intubated (19)
FiO2
SO2
intubated (7)
The oxygen response test?
not
intubated
0
Hospital Days
PICU days
Teague WG AJRCCM 1998; 157:542
• was safe
• allowed to shorten the length of ICU and hospital stay
• did not prevent intubation in a subset of patients
NIPPV / CPAP in Bronchiolitis
with Acute Hypoxic-Hypercapnic Respiratory Failure
Geneva experience 1998 - 1999
retrospective chart review (1998 - 1999)
n = 14 (age 5.2 ± 3.9 months; range: 1.5 - 12)
2 patients with BPD
- surfactant B deficiency
- Wilson-Mikity-syndrome
pre-treatment:
pH
7.26 ± 0.05 (range: 7.17 - 7.33)
pCO2 76 ± 9 mmHg (range: 61 - 88)
tSO2
60 ± 11 (range: 40 - 80) at room-air
NIPPV / CPAP in Bronchiolitis
with Acute Hypoxic-Hypercapnic Respiratory Failure
Geneva experience 1998 - 1999
initial
treatment
number of treatment duration of
Com m ents
patients
failure
ventilatory
support (days)
CPAP
12
1
2.8 ± 1.1
(range: 2 - 5)
tx-failure in
patient # 1
with BPD
NPPV
(BiPAP)
1
0
3
patient # 2
with BPD
endotracheal
intubation
1
3 (+ 2 d CPAP) intubated prior
to transfer
NPPV in acute cardiogenic pulmonary edema (ACPE)
n o. of p a tie n ts
stu d y d e sign
ve n tila tion
m od e
tre a tm e n t Re su lts
fa ilu re
CPAP
0 vs 35%
n o d iffe re n ce in
le n gth of ICU sta y
H offm a n n B 29
BiPAP
CCM 1999;25
op e n p rosp e ctive
in 1
p a tie n t
im p rove d SO 2 a n d
d e cre a se d p CO 2 in
a ll p a tie n ts
Ru ste rh olz T 26
BiPAP
CCM 1999;25
op e n p rosp e ctive
21%
im p rove d SO 2 a n d
d e cre a se d p CO 2 in
re p on d e rs
Be rste n AD
NEJM 1991;325 CPAP vs O 2
(patients who responded were hypercapnic,
those who failed were hypoxemic non-hypercapnic patients)
with the exception of patients with acute myocardial infarction,
CPAP and/or NPPV is efficient in ACPE with hypercapnic ARF
NPPV in acute heart failure and/or pulmonary
edema
Geneva experience 1998 - 1999
indication
postextubation
after CHD-repair
number of days of
patients
ventilation
before NPPV
days on
NPPV
treatment
failure
12
3.8 ± 1.8
2.5 ± 1.4
1 /12
AHF in
myocarditis
1
-
7
0
non cardiogenic
pulm onary
edem a
2
-
4 / 2
0/ 2
Perioperative use of noninvasive ventilation
Non-invasive mask ventilation in 25 patients with respiratory failure preand/or postoperative
Success rate of 68%, but different in respect to the varying causes of
respiratory failure.
CONCLUSION:
With noninvasive mask ventilation it is possible to avoid in some
patients with acute postoperative respiratory failure complications who
are referred to intubation.
In patients with postoperative decompensation of chronic respiratory
failure postoperative treatment becomes easier, in extraordinary cases
the method makes surgery possible.
Karg O et al.
Med Klin 1996; 91 Suppl 2:38-40
NIV for physiotherapy
NIV for physiotherapy
NIV for physiotherapy
NIV for physiotherapy
NIPPV in children with ARF: Complications
severe:
air leaks
gastric perforation
aspiration
decrease in CO
minor:
skin irritation / skin breakdown
nasal dryness
conjunctivitis
Physiological Factors Unique to Pediatric
Patients Promoting Complications of NIPPV
Teague WG Pediatric Pulmonology 2003;35:418–426
Indications et contre-indications de la ventilation non invasive en
réanimation pédiatrique
Indications
Contre-indications
Obstruction des voies aériennes supérieures
Absolues
Maladies pulmonaires primaires
Œdème aigu cardiogénique
Œdème aigu lésionnel
Infection
Arrêt cardiaque ou respiratoire
Instabilité hémodynamique
Patients à risque d'inhalation : encéphalopathie sévère,
encombrement pharyngé quelle que soit l'origine ,
vomissements incoercibles,
hémoptysies
massives.
Obstruction des voies aériennes inférieures
Syndrome occlusif abdominal
Syndrome thoracique aigu (drépanocytose)
Allergie aux interfaces nasales et faciales
Affections chroniques en décompensation aiguë
(mucovicidose)
Décompensation respiratoire aiguë de maladies
neuromusculaires (amyotrophie spinale, dystrophie
neuromusculaire)
Affections congénitales et acquises avec altération aiguë
du contrôle de la respiration
Déformations thoraciques congénitales ou acquises (en
péri-opératoire le plus souvent) Autres : anesthésie
de courte durée, extubation précoce, échec
d'extubation
Relatives
Évolutivité rapide de la défaillance respiratoire ou
neurologique
Patient non coopératif
Lésions faciales
Disponibilité insuffisante du personnel
NIPPV in children with ARF: Technical aspects
setting:
restricted to acute care units
- pulsoxymeter
- tcpCO2 / TECO2
- cardiorespiratory monitoring
NIPPV in children with ARF: Technical aspects
interface:
soft preformed nasal mask appropriately sized
usually work and are much better tolerated
- chin strips can reduce the air leak
NIPPV in children with ARF: Technical aspects
interface:
soft preformed nasal mask appropriately sized
usually work and are much better tolerated
- chin strips can reduce the air leak
NIPPV in children with ARF: Technical aspects
interface:
soft preformed nasal mask appropriately sized
usually work and are much better tolerated
- chin strips can reduce the air leak
alternatives: 1) nasal prongs (typically used in newborns and
small infants)
2) full face (nasal-oral) masks
- but increased risk of aspiration in small children
(immature airway protective response)
NIPPV in children with ARF: Technical aspects
DELIVERY SYSTEMS
- CPAP devices
need bias flow:
- to compensate for mask leaks
- to maintain constant airway pressure
during in- and expiration
- Volume-cycled devices
need variable flow (pressure controlled / pressure targeted)
should be able to deliver high inflation flows:
- to allow to match inspiratory flow demands of the patient to reduce WOB,
- to compensate for leaks
need automated cycle feature (apnea)
NIPPV in children with ARF: Technical aspects
DELIVERY SYSTEMS
- flow-triggered devices
with independent adjustements
of IPAP and EPAP
one way expiratory valve to
prevent rebreathing
(EPAP regulates CO2 elimination:
minimum 3 cmH2O)
NIPPV in children with ARF: Technical aspects
ventilators: NIPPV ventilators (typ: BiPAP; mode: S/T)
ICU ventilators (PC / Pressure support)
sensitive flow trigger threshold
one way
expiratory
valve to
prevent
rebreathing
Not optimal for
small children:
- No back-up rate
- Very low (5%) fixed
expiratory trigger /
flow termination at
very low flows
Decision making
•Mode and Settings
•Level of support
•Level of sedation
Patient-ventilator asynchrony
Patient
•Hering-Breuer reflexes
•Respiratory Muscle Weakness
•Respiratory system mechanics
•Pathology
•Leaks
Ventilator
•Ventilator algorithms and control
•Trigger signal
•Cycling off
•Rate and character of inspiratory flow
•Intrinsic PEEP
•Leaks
Patient-Ventilator Interaction Patient-ventilator asynchrony
by inspiratory trigger insensivity
Insp effort trigger vent
COPD
PSV
Ineffective
effort
(12)
Ineff
trig
abrupt
dec
exp flow
RR 24
RR 60
E. Kondili, G. Prinianakis and D. Georgopoulos
Pressure-Support and flow termination criteria
The non synchronized patient during Pressure-Support
(inappropriate end-inspiratory flow termination criteria)
Nilsestuen J
Respir Care 2005;50:202–232.
Pressure-Support and flow termination criteria
Increase in RR, reduction in VT, increase in WOB
Nilsestuen J
Respir Care 2005
NPPV in acute or chronic pediatric respiratory failure:
Which mode, which device and which interface?
Infant (0 - 12
months)
Small child (12 - 24
months)
> 24 months
AHRF
Nasal CPAP (nasal
prongs or mask) or
NIPPV with a
modified circuit
Nasal CPAP or
NIPPV with nasal or
NIPPV with nasal or full face mask
full face mask
Upper airway
obstruction
Nasal or
nasopharyngeal
CPAP
CPAP or NIPPV by
nasal mask
CPAP or NIPPV
Tracheobronchomalacia
CPAP with
relatively high
pressure levels
CPAP with
relatively high
pressure levels
CPAP with
relatively high
pressure levels
Chronic RF in
neuromuscular
disease
NIPPV
NIPPV
NIPPV
Congestive heart
failure or acute
pulmonary edema
Nasal CPAP
Nasal or full face
CPAP or NIPPV
Nasal or full face
CPAP or NIPPV
Helmet-delivered CPAP and/or non-invasive
pressure support ventilation in children?
Need high flows to
flush the system to
avoid CO2-rebreathing
Helmet-delivered NIPSV in children with acute
hypoxemic respiratory failure (P/F ratio < 200)
Piastra M et al. Intensive Care Med 2004; 30:472-476
Selection guidelines for NIPPV in pediatric ARF
•
Progressive respiratory failure or insufficiency in the
absence of apnea or impeding cardiorespiratory
collapse
•
Failure of NIPPV would not produce immediate
morbidity or mortality
•
Relative cooperation (of a lethargic or sedated patient)
•
Adequate mask fit achieved
Selection guidelines for NIPPV in pediatric ARF:
Contra-indications
•
Ongoing emesis
• Excessive bronchial secretions
•
Acute facial trauma
•
Upper airway protection not intact
NIPPV in acute respiratory failure in children
widespread use in PICU
• commonly applied to

avoid intubation / reintubation

improve atelectasis (type I failure / AHRF)

Improve alveolar hypoventilation (type II failure)

facilitate early extubation (postoperative / restrictive
lung disease - neuromuscular disease - scoliosis
repair)
despite popularity,
therapeutic efficacy has never been evaluated
NIPPV in pediatric ARF
1)
NPPV is safe in pediatric patients with ARF
2)
NPPV can improve oxygenation in mild to moderate hypoxemic
respiratory insufficiency
3)
May be particularly useful in patients in whom intubation
should be avoided
current pediatric NIPPV questions:
- does NPPV in ARF prevent or delay intubation?
- in which type of respiratory failure should it be used?
- does NIPPV reduce mortality in ARF in children?
- are ventilators appropriate for small children?
( mortality rate = 15%)
Pressure
Pressure
CMV
Bivent
Pressure
SIMV
Mechanical
Ventilation
Time
Time
CPAP
Pressure
APRV
Pressure
Time
Time
Spontaneous
Breathing
Time
Modification of the tubing for the use in infants
F. Vermeulen et al. Annales Françaises d’Anesthésie et de Réanimation 2003; 22: 716–720
Indications for tracheostomy:
1) Upper airway obstruction
2) Long-term ventilation/pulmonary toilet
1) Upper airway obstruction
Subglottic stenosis
Congenital/acquired
Tracheomalacia
Congenital/acquired
Tracheal stenosis
Congenital/acquired
Craniofacial syndromes
Pierre-Robin sequence
CHARGE syndrome
Treacher–Collins syndrome
Beckwith–Wiedemann syndrome
Craniofacial and laryngeal tumours
Cystic hygroma, haemangioma
Bilateral vocal cord paralysis
Hydrocephalus internus
Moebius syndrome
Obstructive sleep apnoea
Laryngeal trauma
Burn, fracture
Indications for tracheostomy:
1) Upper airway obstruction
2) Long-term ventilation/pulmonary toilet
2) Long-term ventilation/pulmonary toilet
Pulmonary disease
Bronchopulmonary dysplasia
Scoliosis with restrictive pneumopathy
Congenital heart disease
Postoperative diaphragmatic paresis
Neurological/neuromuscular disease
Duchenne muscular dystrophy
Spinal muscle atrophy type I
Congenital central hypoventilation syndrome
Cerebral palsy
Traumatic brain and spinal injury
Spina bifida
Criteria favouring tracheostomy in children
The child with upper airway obstruction
Low chance of definitive, spontaneous resolution within a reasonable time (weeks)
Low probability that surgery can definitely correct the cause
High risk of critical upper airway obstruction with simple respiratory tract infections or minor
bleeding (epistaxis)
High risk of or previous history of difficulties in airway management in case of an emergency
Difficult-to-control gastro-oesophageal reflux
The child requiring long-term ventilation/ pulmonary toilet
Young age with a high risk of mid-facial deformation from mask pressure
Ventilator dependency for most of the day (more than 12 hours per day)
Inability to cope with a mask (full face or nasal mask)
Recurrent aspirations (gastro-oesophageal reflux, laryngeal incompetence) with significant
benefit from pulmonary toilet
Safety-measures and local experience highly in favour of invasive ventilation