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NIPV for Peds
 

NIPV for Peds

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    NIPV for Peds NIPV for Peds Presentation Transcript

    • Noninvasive Ventilation in Pediatrics Ira M. Cheifetz, MD, FCCM, FAARC Professor of Pediatrics Chief, Pediatric Critical Care Medical Director, PICU and Peds Resp Care Duke Children’s Hospital Children’s
    • NIV: Is it worth the effort? ♦ Noninvasive ventilation (NIV) is not a new concept. ♦ Many decades of experience acute hypoxic respiratory failure – post-extubation / facilitate extubation – neuromuscular weakness – upper & lower airway obstruction – ♦ So, why are some still unsure of using NIV for pediatric patients?
    • Available Data? ♦ Most data are from adults & neonates. very different populations – ♦ Most studies have involved patients with: acute hypercapneic respiratory failure – co-morbidities co-morbidities – ‘‘preemies’ preemies’ – ♦ Very few studies have evaluated NIV for ‘‘pure’ acute hypoxic resp failure. pure’ ♦ No conclusive pediatric data – just one study.
    • 38th Journal Conference: ‘Respiratory Controversies in the Critical Care Setting’ Should NIV be used for all forms of acute respiratory failure? Hess and Fessler, Resp Care, 2007
    • NIV is for all forms of ARF ♦ Tremendous clinical experience Utilization of NIV has ↑ dramatically ♦ ♦ Significant recent technical advances ♦ 7 systematic reviews published to date with consistent conclusions NIV ↓ intubation rate & mortality – – ♦ Clear data for adult patients COPD, card pulm edema, lung resection, solid – – organ transplantation / immunosuppressed patients, prevent extubation failure, asthma. Hess and Fessler, Resp Care, 2007
    • NIV is for all forms of ARF ♦ Hypoxemic respiratory failure ↓ intubation rate & mortality – (meta-analysis; Keenan, CCM, 2004) (meta-analysis; ♦ Nosocomial pneumonia ↓ risk of VAP with NIV – (meta-analysis; Hess, Respir Care, 2005) (meta-analysis; ♦ Common exclusions airway protection, unable to fit mask, – severe illness, uncooperative patient Hess and Fessler, Resp Care, 2007
    • NIV is NOT for all forms of ARF No Δ in reintubation rates, mortality, or benefit in ♦ hypercarbic subset (Keenan, JAMA, 2002) ♦ NIV does not work to rescue patients with resp distress after extubation (Esteban, NEJM, 2004) ♦ Evidence of harm? resp failure after extubation → ↑ mortality – ♦ Should not be used in patients with a high likelihood of failure. ♦ NIV: ‘‘No clear advantage’ No advantage’ Hess and Fessler, Resp Care, 2007
    • Should NIV be used for all forms of acute resp failure? Excluding ICU bed availability and other administrative and technical issues, how many of the 13 experts routinely use NIV in patients with ARF? Everyone Hess and Fessler, Resp Care, 2007
    • Now, let’s take a closer look at the data!
    • Non-invasive Ventilation ↓ intubation rate, ICU LOS, & ICU mortality ♦ Keenan, CCM, 2004 (meta-analysis) (meta-analysis) – – ↓ nosocomial pneumonia risk ♦ Hess, Respir Care, 2005 (meta-analysis) (meta-analysis) – –
    • NIV to Avoid Intubation 90 NPPV Control 80 70 60 % intubated 50 40 30 20 10 0 Brochard Vitacca Brochard Kramer Wysocki Confalonieri 1990 1993 1995 1995 1995 1996 Marini, Crit Care Med, 2008
    • Antonelli, New Eng J Med, 1998.
    • Antonelli, New Eng J Med, 1998.
    • Hilbert, New Eng J Med, 2001.
    • Hilbert, New Eng J Med, 2001.
    • NIV ‘standard’ p (n=114) (n=107) reintubation 48% 48% n.s. rate time to 12 hrs 2.5 hrs 0.021 reintubation mortality 25% 14% 0.048 Esteban, New Eng J Med, 2004
    • Predictors? NIV failure NIV success (n = 38) (n = 16) p Age 64 60 0.86 APACHE III 81.5 55.5 <0.01 Sepsis 33 14 0.9 Shock 19 0 - PaO2/FiO2 112 147 0.02 PaCO2 36 42 0.1 pH 7.37 7.39 0.4 Base excess -4.0 0.5 0.01 Rana, Crit Care, 2006
    • NIV and Asthma Soroksky, Chest, 2003
    • Hill, Crit Care Med, 2007
    • Pediatric 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
    • Pediatric Data Yanez, Pediatr Crit Care Med, 2008
    • Pediatric Data Yanez, Pediatr Crit Care Med, 2008
    • Pediatric Data Yanez, Pediatr Crit Care Med, 2008
    • Peds NIV Is it worth the effort? ♦ NIV in peds is increasing at an exponential rate despite the lack of convincing data. ♦ Why? – same reasons as for adult pts & neonates – avoid intubation – facilitate extubation – ↓ length of ventilation
    • Real Life Situation ♦ 7 month old infant (5.9 kg) ♦ Problem list: large VSD s/p repair, pulmonary hypertension (on sildenafil), chronic lung disease, upper airway obstruction, severe GE reflux…. ♦ Mechanically ventilated for 8 weeks ♦ Now on minimal vent support & ‘stable’ ♦ Ready for extubation trial??
    • NIV: Available Technology ♦ 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
    • Pediatric NIV ♦ Challenges – substantial ♦ Current technology – real limitations ♦ Opportunities – huge
    • 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
    • Challenges: 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 –
    • Challenges: Interface ♦ Probably the biggest challenge ♦ Optimize patient comfort ♦ Must protect the skin and the eyes – an added challenge in the infant population (‘not much room to work’) (‘not work’) ♦ Nasal vs. full face masks
    • Pediatric NIV ♦ Challenges – substantial ♦ Current technology – real limitations ♦ Opportunities – huge
    • Current Technology ♦ Why not just use adult technology for peds patients? – some do! ♦ Is this ideal? – no!
    • What are the problems? ♦ High inspiratory flow rates dried secretions → potential for airway – obstruction patient discomfort due to high flow rates – ♦ Interfaces – generally not designed for infants and small children comfort – skin integrity –
    • Nasal Mask
    • FULL Face Mask
    • Securing Devices
    • What are we often left with?
    • So, why try NIV? ♦ To avoid invasive mechanical ventilation and all of its associated complications. – increased pharmacologic sedation – secondary lung injury – airway injury – nosocomial pneumonia – and, others….
    • Pediatric NIV ♦ Challenges – substantial ♦ Current technology – real limitations ♦ Opportunities – huge
    • Potential 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.
    • Potential 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
    • How many patients? ♦ International data are difficult to estimate. ♦ Duke data – NIV for acute etiologies – PICU – 87 pts over 12 mos representing 425 vent-days (average 4.9 days) – PBMT unit – 11 pts over 12 mos representing 141 vent-days (average 12.8 days) – And, this is without ideal technology or equipment.
    • Technology: How small? ♦ Age limits? ♦ Weight limits? – 5 years? – 20 kg? – 1 year? – 10 kg? – 1 month? – 5 kg? – 1 week? – 3 kg? ♦ The smaller, the better!
    • Pediatric 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 adult populations. ♦ Need consistent guidelines / protocols.
    • Pediatric 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