Non-invasive positive pressure ventilation in the PICU
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Transcript of Non-invasive positive pressure ventilation in the PICU
Non-invasive positive pressure ventilation in the PICU
Esteban A et al. AJRCCM 2000; 161:1450–1458
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
What is the daily practice of mechanical ventilation in ICU
In adults (in the years 1996 / 1997:
In pediatrics (in the year 1999):
NIPPV in the Pediatric Intensive Care UnitGeneva experience 1998 - 1999
Number of pediatric patients hospitalizedin the PICU over a 2-year period: 771
General pediatrics: 215 (28%)Cardiovascular surgery: 279 (36%)General surgery: 133 (17%)Neurosurgery: 69 (9%)Transplantation unit: 27 (3%)Onco-hematology: 13 (2%)Orthopedics: 35 (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: 30 NPPV (BiPAP): 29NPPV and CPAP: 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
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
Small airways = high airway resistance
Compliant chest wall = low FRC
Relatively “inefficient” diaphragm
Objectives of Noninvasive Ventilation inPediatric Patients With Respiratory Disorders
Teague WG Pediatric Pulmonology 2003;35:418–426
Avoid intubation
Indications / Benefits of NIPPV in the PICU
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)
Early case reports showed: Improvement of clinical manifestation of respiratory distress and respiratory gas exchange in children with AHRF
Rimensberger PC Swiss Medical Weekly 2000;130:1880–6
NIPPV in acute hypoxic respiratory failure:Benefit and treatment failures in 3 pediatric case series
4
NIPPV / CPAP in ARF: Treatment failuresGeneva experience 1998 - 1999
6 / 63 (9.5 %)
on CPAP
patient # 1 (4 months): Bronchiolitis and BPD
patient # 2 (10 months): DORV, Tetralogy of Fallot: postoperative
patient # 3 (6 months): TGV, VSD postoperative BT-shunt
on NPPV (BiPAP)
patient # 4 (3 years): ARDS, pneumonia
patient # 5 (15 years): Fungal pneumonia and sepsis in immuncompromised
patient post lung transplantation
patient # 6 (15 years): Orthopedic patient with postoperative paraplegia
pCO2 RR
F. Vermeulen et al. Annales Françaises d’Anesthésie et de Réanimation 2003; 22: 716–720
6 infants with AHRF of various etiologyPressure support: IPAP 14 ± 0,5 cmH2O; EPAP 7,3 ± 1 cmH2OTi max: 0,6 ± 0,1 s ; insp. rise time: 100 ms.
NIPPV in infants with AHRF
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
Quen Mok, Great Ormond Street Hospital for Children, London
No PEEP PEEP 10cmH2O
No PEEP CPAP 10cmH2O
CPAP: Tracheomalacia
Quen Mok, Great Ormond Street Hospital for Children, London
Case serie in pediatric status asthmaticus with severe hypoxemia
prospective, non controlled case serie (n = 26)
NPPV: nasal mask; S/T modeIPAP 13 ± 3 cmH2O; EPAP 7 ± 2 cmH2O; FiO2 0.68 ±
0.28
Results: 21 ± 27 hrs mean duration169 ± 183 hrs O2 requirements19/26 acutely improved7/26 required intubation11/26 did not well tolerate
Teague WG AJRCCM 1998; 157:542
p > 0.05 for all comparisons
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
• was safe• allowed to shorten the length of ICU and hospital stay• did not prevent intubation in a subset of patients
0
5
10
15
20
25
Hospital Days PICU days
intubated
notintubated
NPPV in pediatric status asthmaticus: Case serie
0
20
40
60
80
100
120
FiO2 SO2 FiO2 SO2
pre NPPV
post NPPV
not intubated (19) intubated (7)
* p < 0.05
*
* p < 0.05
*
*
Teague WG AJRCCM 1998; 157:542The oxygen response test?
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
NIPPV / CPAP in Bronchiolitis
with Acute Hypoxic-Hypercapnic Respiratory Failure
Geneva experience 1998 - 1999initialtreatment
number ofpatients
treatmentfailure
duration ofventilatorysupport (days)
Comments
CPAP 12 1 2.8 ± 1.1(range: 2 - 5)
tx-failure inpatient # 1with BPD
NPPV(BiPAP)
1 0 3 patient # 2with BPD
endotrachealintubation
1 3 (+ 2 d CPAP) intubated priorto transfer
NPPV in acute cardiogenic pulmonary edema (ACPE)
no. of patientsstudy design
ventilationmode
treatmentfailure
Results
Bersten ADNEJM 1991;325 CPAP vs O2
CPAP 0 vs 35% no difference inlength of ICU stay
Hoffmann BCCM 1999;25
29open prospective
BiPAP in 1patient
improved SO2 anddecreased pCO2 inall patients
Rusterholz TCCM 1999;25
26open prospective
BiPAP 21% improved SO2 anddecreased pCO2 inreponders
with the exception of patients with acute myocardial infarction,
CPAP and/or NPPV is efficient in ACPE with hypercapnic ARF
(patients who responded were hypercapnic,
those who failed were hypoxemic non-hypercapnic patients)
NPPV in acute heart failure and/or pulmonary
edemaGeneva experience 1998 - 1999
indication number ofpatients
days ofventilationbefore NPPV
days onNPPV
treatmentfailure
postextubationafter CHD-repair
12 3.8 ± 1.8 2.5 ± 1.4 1 /12
AHF inmyocarditis
1 - 7 0
non cardiogenicpulmonaryedema
2 - 4 / 2 0/ 2
Perioperative use of noninvasive ventilation
Non-invasive mask ventilation in 25 patients with respiratory failure pre- and/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
Obstruction des voies aériennes supérieures
Maladies pulmonaires primaires
Œdème aigu cardiogénique
Œdème aigu lésionnel
Infection
Obstruction des voies aériennes inférieures
Syndrome thoracique aigu (drépanocytose)
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
Contre-indications
Absolues
Arrêt cardiaque ou respiratoire
Instabilité hémodynamique
Patients à risque d'inhalation : encéphalopathie sévère, encombrement pharyngé quelle que soit l'origine , vomissements incoercibles, hémoptysies massives.
Syndrome occlusif abdominal
Allergie aux interfaces nasales et faciales
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
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
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
Not optimal for small children:
- No back-up rate
- Very low (5%) fixed expiratory trigger / flow termination at very low flows
one way expiratory valve to prevent rebreathing
•Hering-Breuer reflexes•Respiratory Muscle Weakness•Respiratory system mechanics•Pathology•Leaks
Patient
•Ventilator algorithms and control •Trigger signal•Cycling off•Rate and character of inspiratory flow•Intrinsic PEEP•Leaks
Ventilator
•Mode and Settings•Level of support•Level of sedation
Decision making
Patient-ventilator asynchrony
Patient-Ventilator Interaction -
Patient-ventilator asynchrony by inspiratory trigger insensivity
E. Kondili, G. Prinianakis and D. Georgopoulos
COPDPSV
Insp effort trigger vent Inefftrigabruptdecexp flow
Ineffective effort
(12) RR 24
RR 60
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
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 full face mask
NIPPV with nasal or full face mask
Upper airway obstruction
Nasal or nasopharyngeal CPAP
CPAP or NIPPV by nasal mask
CPAP or NIPPV
Tracheo-bronchomalacia
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
Piastra M et al. Intensive Care Med 2004; 30:472-476
Helmet-delivered NIPSV in children with acute hypoxemic respiratory failure (P/F ratio < 200)
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
• Ongoing emesis
• Excessive bronchial secretions
• Acute facial trauma
• Upper airway protection not intact
Selection guidelines for NIPPV in pediatric ARF:Contra-indications
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? ( mortality rate = 15%)
- are ventilators appropriate for small children?
SpontaneousBreathing
Mechanical Ventilation
Pre
ssur
eP
ress
ure
Pre
ssur
eP
ress
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Pre
ssur
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Time
Time
Time
Time
Time
CMV
SIMV
Bivent
APRV
CPAP
F. Vermeulen et al. Annales Françaises d’Anesthésie et de Réanimation 2003; 22: 716–720
Modification of the tubing for the use in infants
1) Upper airway obstruction
Subglottic stenosis Congenital/acquired
Tracheomalacia Congenital/acquired
Tracheal stenosis Congenital/acquired
Craniofacial syndromes Pierre-Robin sequenceCHARGE syndromeTreacher–Collins syndromeBeckwith–Wiedemann syndrome
Craniofacial and laryngeal tumours Cystic hygroma, haemangioma
Bilateral vocal cord paralysis Hydrocephalus internusMoebius syndrome
Obstructive sleep apnoea
Laryngeal trauma
Burn, fracture
Indications for tracheostomy: 1) Upper airway obstruction2) Long-term ventilation/pulmonary toilet
2) Long-term ventilation/pulmonary toilet
Pulmonary disease Bronchopulmonary dysplasiaScoliosis with restrictive pneumopathy
Congenital heart disease
Postoperative diaphragmatic paresis
Neurological/neuromuscular disease Duchenne muscular dystrophySpinal muscle atrophy type ICongenital central hypoventilation syndromeCerebral palsyTraumatic brain and spinal injurySpina bifida
Indications for tracheostomy: 1) Upper airway obstruction2) Long-term ventilation/pulmonary toilet
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