Non invasive respiratory support in pediatric patients

1. Pediatric
Non Invasive
Respiratory
Support
Noha El-Anwar
Lecturer of pediatrics and pediatric critical care
Cairo University

3. Definition
 Non-Invasive Ventilation (NIV) is the provision
of ventilatory assistance without the need for
airway invasion.
 Increasing use in critical care units to avoid
endotracheal intubation and its attendant
complications.

4. Historical review

10. Paul Alexander (polio survivor)
 Paul Richard Alexander (born 1946) is an
American lawyer and paralytic polio survivor.
He is popularly known as the Last person
living inside of an iron lung after he contracted
polio in 1952 at the age of six.
 He almost died in the Parkland hospital before
a doctor noticed he was not breathing and
rushed him into an iron lung.

11.  Alexander taught himself glossopharyngeal
breathing which allowed him to leave the iron
lung for gradually increasing periods of time.
 Alexander has been recognized by Guinness
World Records as the person who has spent the
longest amount of time living in an iron lung.

12. The Man Who’s Lived In An Iron
Lung For 70 Years

13. Invasive MV
 Ventilator-associated lung injury.
 Nosocomial infections.
 Airway complications.
 Need for potentially harmful neuro-sedatives
and muscle relaxants.

14. NIV
 Decreases incidence of nosocomial infections
 Patient comfort
 Minimal sedation requirement
 Less painful
 Accelerates weaning
 Decreases PICU length of stay, mortality
 Decreased costs

15. Patient selection
 Respiratory arrest
 Airway obstruction
 Facial trauma, burn.
 Severe acidosis pH<7.2
 Hypotension.
 Uncooperative patients (severe agitation, impaired
mental status)
 Excessive airway secretions, vomiting .
 Recent upper airway or GI surgery.
 Pneumothorax.

16. Patient selection
 Appropriate diagnosis with potential reversibility
 Establish need for ventilatory assistance:
 Moderate to severe respiratory distress
 Tachypnea
 Accessory muscle use or abdominal paradox
 Blood gas derangement
1. pH < 7.35, PaCO2 >45, or
2. PaO2/FiO2 <200

17. Patient interface

18. Patient interface
 Nasal masks/ cannula
 Well tolerated
 Better with lower severity illness
 Allows speaking, drinking, coughing and
secretion clearance
 More leak possibilities

19.  Oro-facial masks
 Better with higher severity illness
 More effective ventilation
 Claustrophobic
 Hinder speaking and coughing
 Risk of aspiration with emesis

20.  Helmet

21. Modes of NIPPV
 High flow nasal cannula (HFNC)
 High velocity nasal insufflation (HVNI)
 Continuous positive airway pressure (CPAP)
 Bi-level positive airway pressure (Bi-PAP)
 ???

22. 1- High flow nasal cannula

23. High flow nasal cannula
 Technique for O2 delivery using heated and
humidified gas
 O2 flow rate up to 40-60 L/min can be
delivered through wide nasal prongs without
discomfort or mucosal injury
 Creates positive pressure in the nasopharynx
, maintains a constant stream of fresh gas,
washing out upper airway dead space.

25. 2- High velocity nasal insufflation

26. High velocity nasal insufflation
 Insufflation: “ to blow” is the act of blowing
something into a body cavity.
 HVNI is a form of HFNC that utilizes a small-bore
nasal cannula to generate higher velocities of
gas delivery.
 Efficiently flushes the upper airway dead space
between breaths to improve alveolar ventilation
efficiency.
 Technique for O2 delivery using heated and
humidified gas.

28. 3- CPAP

29. CPAP
 Improves oxygenation by increasing FRC
and recruiting collapsed alveoli.
 It provides certain positive airway pressure
throughout all phases of spontaneous
ventilation
 CPAP* ≈ PEEP

30. CPAP
 It reduces the preload and afterload. Hence it
is very efficient for management of pulmonary
edema.
 Pressures are usually limited to 5-12 cm
H2O, since higher pressure tends to result in
gastric distention.

33. 4- Bi-PAP

34. Bi-PAP
 IPAP + EPAP (CPAP)
 The higher pressure augments alveolar
ventilation and CO2 clearance.
 The lower pressure maintains alveolar
recruitment .
 Differential in pressure between inspiration
and expiration allows for better patient
ventilator synchrony, comfort.

35. Bi-PAP
 EPAP ≈ CPAP ≈ PEEP
 IPAP≈ PS
 Augments TV
 Reduces atelectasis
 Reduce WOB

37. 5- ???

38. 5- Biphasic Cuirass Ventilation (BCV)

39. 5- Biphasic Cuirass Ventilation
(BCV)
 A modern development of the iron lung, consisting of a
wearable rigid upper body shell which functions as a
negative pressure ventilator.
 Biphasic ventilation controls both inspiration and
expiration
 Modern improvement of NPV which controls inspiration
only, with passive expiration by elastic recoil
 Can provide rapid alternating +ve and –ve pressures to
the chest as physiotherapy to aid in secretion
clearance.

40. Monitoring
 Select patient
 Bed at 45°, mask size, select mode, adjust
settings.
 Backup rate.
 Set alarms.
 Monitor: ABGs, SPO2, respiratory distress,
tolerance and comfort,, (improvement should be within 1l2 hour)
 First hour: titrate settings, minimal sedation if
needed.

41. Discontinuation of NIV
Indications of NIV failure:
 Patient intolerance
 Deterioration of vital signs
 Failure to improve after 1-2 hours
 Inability to handle secretions
 apnea

42.  NIV is promising as a beneficial adjunct to
conventional mechanical ventilation.
 NIV mode is tailored to each patient and his type
of illness
 NIV shortness the PICU length of stay, decreases
mortality, and aids in patient comfort
 Physicians should be aware by NIV failure
 Negative pressure ventilation is a re-emerging
promising NIV modality