Noninvasive Ventilation in Pediatrics (Egypt) 3-09 (Final Version)
Transcript of 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
Hess and Fessler, Resp Care, 2007Hess and Fessler, Resp Care, 2007
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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
Hess and Fessler, Resp Care, 2007Hess and Fessler, Resp Care, 2007
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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
Hess and Fessler, Resp Care, 2007Hess and Fessler, Resp Care, 2007
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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
length of ventilation
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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
length of ventilation
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
length of ventilation
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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