Non Invasive Ventilation

1. Non Invasive Ventilation in
Children
Prof Ashwani K Sood
Medical Superintendent,
MMI MSR Mullana (HR)

2. NIV in Children
• Endotracheal intubation carries potential risks , including
ventilator- associated pneumonia and laryngeal-tracheal
damage.
• NIV assists in distending the airways , improves
oxygenation at the alveolar level --→ unloading of
respiratory muscles /decreasing breathing effort ,without the
need for an invasive tracheal device.
• NIV in acute setting has been found to improve outcome ,
reduce the need for intubation .

3. NIV DEFINITION
• Use of positive pressure ventilation without invasive airway
(Et tube)
• Respiratory assistance is provided by using pressure greater
than atmospheric pressure to drive air into the lungs.
• Avoid risks and complications associated with Et intubation
and mechanical ventilation – trauma to airway with
laryngoscopy , sedation and analgesia and neuromuscular
blockade, V
AP , patient discomfort , and loss of verbal
communication.
• Patient selection and proper mask/interface is crucial

4. Non Invasive Ventilation in
Children (NIV-C)
BIPAP CPAP

5. Learning Goals
• Respiratory failure ( RF)
• How to recognize RF
• Strategy to treat ( NIV )
• CPAP
• BIPAP
• INTERFACE
• Initial settings
• Monitoring (The Golden Two Hours)
• Predictors of success/failures
• Complications

6. NIV BENEFITS IN PEDIATRIC PATIENTS
✓ By improving respiratory mechanics and assisting in work of breathing
,allows respiratory muscles to rest .
✓ By decreasing work of breathing , decreases total oxygen consumption.
✓ Decreases hypercapnea and increases the tidal volume through the IPAP
.
✓ Improves patient’s comfort(subjective sensation of respiratory
insufficiency)
✓ The patient can stay awake and sedation is not necessary
✓ Avoids the complications associated with endotracheal intubation and
endotracheal tubes
✓ Increases FRC through both EPAP and CPAP(Alveolar recruitment and
improved oxygenation),
✓ Stent the airway open through the respiratory system
✓ (Fernandez et al , Spain )

7. NIV BENEFITS IN PEDIATRIC
PATIENTS
✓ Intact natural airway clearance mechanisms(no plugging of ETT)
✓ No mechanical trauma related to ETT placement
✓ Lower rates of nosocomial infections
✓ No sedation or paralysis needed

8. When NOT to use NIV
❑ Cardiac / and or respiratory arrest.
❑ If patient is dependent on airway management due to coma / significant
altered mental status / unstable patient.
❑ Hemodynamic instability(shock), multi-organ failure
❑ Upper GI bleed – need to secure and protect airway.
❑ Impaired airway protective reflexes – pts who are unable to protect the
airway , inability to cough, risk of pulmonary aspiration
❑ Facial injuries OR craniofacial malformation – precludes interface use
❑ Unco-operative patient.
❑ Pneumothorax without chest tube in place
(Non invasive ventilation in pediatric critical care, Hamilton Medical)

9. Respiratory failure ( RF)
Tachypnea
↑ 𝑅𝑅
Respiratory Distress
(↑
𝑅𝑅 𝑝𝑙𝑢𝑠 𝑜𝑡ℎ𝑒𝑟 𝑠𝑖𝑔𝑛𝑠)
Respiratory
Failure
Type I , Hypoxic,
gas exchange
failure,
Respiratory
Failure
Type II,
Hypercapnia,
Ventilatory
Failure

10. How to recognize ?
Respiratory Distress
• Tachypnea
• Retractions ( Intercostal, subcostal
, suprasternal )
• Grunting ( Attempt to create
PEEP )
• Nasal Flaring
• Head Bobbing
• Accessory muscle use
Respiratory Failure
• Severe dyspnea/distress/apnea
• Hypoxia : FiO2 >50% for SpO2
>92%
• Hypercarbia: PCO2 >50 mm Hg
• Respiratory acidosis with pH
<7.35
• Accessory muscle exhaustion
• Decreased level of consciousness

11. Strategy to treat ?
• NIV ( Non-invasive V
entilation ) : Delivery
of ventilatory support without the use of an
invasive artificial airway
• Does not require Endotracheal intubation
• Settings : home & hospital
• Role in
Chronic Respiratory Failure ( Obstructive sleep
apnea )
Hypoxic Respiratory Failure
Hypercarbic Respiratory Failure

12. NIV ( Mechanism of Action )
Extrinsically applied PEEP -→ alveolar recruitment--→
increase
area available for gas exchange—> improves lung
compliance---decreases WOB and patient effort– allows
respiratory muscle rest .

13. Types of NIV
CPAP
• Continuous Positive Airway
Pressure
• Through out entire cycle of
respiration
• Type 1 ( hypoxic ) Respiratory
Failure
• Useful for infants and children
with tachypnea
• Obstructive apnea ( stenting
airways )
• Central apnea ( respiratory
stimulation )
• Improves oxygenation and
decreases the work of breathing
BiPAP
• Bilevel positiveAirway Pressure
• Delivers preset IPAP> than EPAP
( PEEP )
• Patient triggered with back up
Mandatory breaths
• Tidal volume α ( IPAP-EPAP)
• Type 2 >>> type 1 RF
• Higher level of support than
CPAP

14. CPAP & BiPAP
➢ CPAP and BiPAP both deliver positive pressure through a noninvasive
interface .
➢ CPAP delivers a constant distending airway pressure throughout the
entire respiratory cycle(inspiration and expiration) while the patient is
spontaneously breathing.
▪ Increases oxygenation and CO2 washout by expanding collapsed alveoli
and recruiting lung volume.
▪ Reducing the work of breathing.
▪ Preventing apnea by stenting the upper airways.
➢ BiPAP uses two pressure settings, IPAP and EPAP
. IPAP is delivered to
the patient when the device senses that the patient is initiating a breath.
( Adapted from Pediatric Noninvasive ventilation, Maryland, United States)

15. CPAP & BiPAP
• Use of double-circuit (inspiratory and expiratory limbs ) NIV
devices
• Use of full face, oronasal , or helmet interfaces
• Use of heat and moisture exchanger filter of the circuit near
the patient interface or HEPA filter in the exhalation limb
• The patient is in isolation room with negative pressure or
well-ventilated room

16. Parts of CPAP -1

17. Parts of CPAP -1

18. BiPAP
BiPAPof our ward Starting BiPAP
• Get used to your BiPAP
• Set Inspiratory P – 6-8 cm
of H20
• Set Expiratory P – 3-5 cm of
water
• Set Fio2 : 100 % ( Titrate )
• I/E ratio : 1:2
• Back up RR : as per child
age breaths/min

19. BiPAP
• It has been suggested to start with [IPAP ] 10-12 cm H20 ;[EPAP]
5-6 cmH2O with a gradual increase in pressure( IPAP by 2cm
H2O; EPAP by 1cm H2O) to maintain spo2 >=92% and
continuously evaluating patient’s respiratory function and oxygen
saturation.
Ref : 1) Covid 19 diagnosis and management update Carlotti APCP et al, CLINICS 2020; 75e 2353
2) Pediatric noninvasive ventilation. Cathy Haut; J Pediatr Intensive care 2015; United States

21. HFNC
• Deliver the patient’s entire ventilatory demand , meeting or exceeding the patient’s
flow rate, thereby providing an accurate FiO2 ( 21 to 100 %).
1) Heated and humidified
Standard oxygen therapy delivered through a nasal cannula or NRBM,delivers cold (not
warm)and dry(not humidifed ) gas. This cold , dry gas can lead to airway inflammation,
drying of mucosa, impair mucociliary function and secretion clearance.
Heated and humidified oxygen improves FRC and mucociliary clearance of
secretions , thereby reducing work of breathing in acute respiratory failure.
2) Inspiratory demands
HFNC can deliver very high flow rates of gas to match a patient’s inspiratory flow
demands. Patients in acute respiratory failure can become extremely tachypneic with
increasing ventilatory demand.
3) PEEP effect
HFNC provides PEEP due to high gas flow. A positive distending pressure of 4-6cm of H2O
may be achieved with closed mouth breathing.

23. HFNC
4) Patient tolerance
Pts often prefer use of HFNC to that of CPAP or BiPAP as tight fiting mask
can be uncomfortable for some pts , many pts. Experience claustrophobia
while using CPAP masks,--- HFNC avoids this by using nasal prongs ,HFNC
works well for patients in respiratory distress who cannot tolerate
CPAP/BiPAP , [ awake, proning , feeding]
Patient must have intact respiratory drive to benefit from HFNC.
Recommended for patients with mild acute respiratory failure.
(Adapted from HFNC: Mechanisms of action and adult and pediatric indications,
Lodeserto et al, San Antonio, USA)

24. STARTING CPAP
• Connect O2 Outlet tube
• Connect air outlet tube
• Set Fio2 to 30 %
• Set Humidifier temp 36.8 ͦ C- 37.2 ͦ C
• Set PEEP to 5 cm of H2O and titrate as per
need
• Connect circuit > interface > patient
• Monitor : HR, RR, CFT, Pulse

25. PITFALLS IN NIV IN PEDIA
TRIC PA
TIENTS
1) PEDIATRIC INTERFACE
• Dead space in the adult interface is too big for children, use of pediatric
interface.
2) Patient’s Cooperation and level of consciousness
• This is important in children who are less cooperative than adults. It is
important to maintain a good level of consciousness to obtain good
cooperation from the child
• The best way to achieve cooperation is to adapt the interface carefully ,
perhaps even with the patients assistance , so that pt. can experience
how the NIV relieves his muscular fatigue and sensation of dyspnea. If
this happens he will tolerate and accept the interface.
If the patient is agitated and still does not tolerate after 1 hour, NIV is
probably failing and sedation will not resolve the situation.

26. PITFALLS IN NIV IN PEDIATRIC
PATIENTS
3) Choosing the right time to introduce NIV
If NIV is delayed and hypercapnia provokes decreased consciousness,
The child will require intubation and then is not a good NIV candidate.
“The sooner the better”
4) Adequate seal of interface to minimize air leak
(Adapted from NIV in pediatric patients, Fernandez et al, Spain)

27. Youtube links
• https://www.youtube.com/watch?v=WZRuOsJ
uYTY

28. INTERFACE
• Device that fits on patient face to deliver
required pressure ( CPAP or BiPAP )
• Ideal : minimize air leaks, maximise patient
comport, synchrony with ventilator
Interfaces Age group
Nasal cannula or Prongs Infants
Nasal mask Infants
Oronasal face mask Older children and young
Adults
Total face mask Older children
Helmet Adolescents

29. Interfaces
Nasal Cannula
Nasal Mask

30. Interfaces

32. Initial settings

33. Monitoring (The Golden Two Hours)
• Requires more careful observation in Initial 2
hours
• Child should be nil orally and Intravenous fluids
• Monitor: HR, RR, Pulse, spo2, chest findings,
work of breathing, patient tolerance/ synchrony,
interface leak , periodic blood gas
• This helps in picking early : patient needing IMV
• Good response to NIV : typically manifests in 2
hours.

34. CRITERIA FOR NIV FAILURE- DECISION TO INTUBATE
▪ Clinical worsening or no improvement of dyspnea.
▪ Higher respiratory rate and greater work of breathing with the threat
of exhaustion.
▪ Increasing Fio2>0.6
▪ Asynchrony between ventilator and patient.
▪ Need for higher ventilation pressures (PIP>20 cmH2O; PEEP>12)
▪ Worsening of the blood gases(pH <7.2 ;pco2>60mmHg)
▪ Refusal by patient or relatives.
▪ Disorders of consciousness / confusion, coma.
(Adapted from Hamilton Medical)

35. CRITERIA FOR NIV FAILURE-
DECISION TO INTUBATE
• DO NOT DELAY ENDOTRACHEAL INTUBATION IF PATIENT IS NOT
IMPROVING QUICKLY ON NIV AS THIS CAN LEAD TO WORSENED PATIENT
CONDITION AND UNFAVORABLE CONDITIONS FOR INTUBATION
• FREQUENT ASSESSMENT OF WHETHER THE PATIENT IS IMPROVING IS
CRITICAL.

36. Failures/ Complications
Predictors of Failures
• Medical condition ( mild,
moderate , severe)
• Type of respiratory failure
• Timing of starting treatment
• Experience of health care team
• Younger age
• More severe Respiratory distress
and apnea.
• Higher INITIAL oxygen
requirement
• Underlying co- morbid condition
Complications
• Inadequate oxygenation/
ventilation
• Pressure damage
• Nasal cannula/ prong
mucous obstruction
• Nasal dryness/ congestion
• Gastric distension
• Barotrauma/ volutrauma
• Airleaks

37. References
• Roussos C, Koutsoukou A. Respiratory failure. Eur Respir J Suppl. 2003
Nov;47:3s-14s. doi: 10.1183/09031936.03.00038503. PMID: 14621112.
• Viscusi CD, Pacheco GS. Pediatric Emergency Noninvasive Ventilation.
Emerg Med Clin North Am. 2018 May;36(2):387-400. doi:
10.1016/j.emc.2017.12.007. Epub 2018 Feb 10. PMID: 29622329.
• Mas A, Masip J. Noninvasive ventilation in acute respiratory failure. Int J
Chron Obstruct Pulmon Dis. 2014 Aug 11;9:837-52. doi:
10.2147/COPD.S42664. PMID: 25143721; PMCID: PMC4136955.
• Fedor KL. Noninvasive Respiratory Support in Infants and Children. Respir
Care. 2017 Jun;62(6):699-717. doi: 10.4187/respcare.05244. PMID:
28546373.
• Blumenthal JA, Duvall MG. Invasive and noninvasive ventilation strategies
for acute respiratory failure in children with coronavirus disease 2019.
Curr Opin Pediatr
. 2021 Jun 1;33(3):311-318. doi:
10.1097/MOP
.0000000000001021. PMID: 33851935; PMCID:
PMC8117173.

38. Skills to be enhanced
• Ability to recognize Respiratory Distress v/s
Respiratory Failure
• Familiarizing with basic terms of ventilation ( PIP
,
PEEP
, TV
, FIO2, SPO2, MV
, RR)
• Familiarizing with Devices ( CPAP
, BIPAP )
• Familiarizing with Interfaces (Adv & Disadv )
• Ability to initiate ventilation
• Ability to detect Failures and complications
• Self learning :
https://www.youtube.com/watch?v=uKMkrJeChCg.