Non Invasive Ventilation in Pediatric Intensive Care Unit

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1 69 Congresso Nazionale SIP Bologna 8 10 Maggio 2013 «La ventilazione non invasiva in pediatria» Non Invasive Ventilation in Pediatric Intensive Care Unit Corrado Moretti U.O.C. di Pediatria d Urgenza e Terapia Intensiva Pediatrica Umberto I Policlinico di Roma

2 NIV advantages in PICU reduced intubation rates and risks associated with EET (VILI-VAP) increased survival preserve normal swallowing and cough mechanisms deep sedation not required decreased intensive care and hospital stay decreased costs

3 Tracheal injury from intubation

4 NIV disadvantages more difficult to start off slower correction of arterial blood gases airways are not protected difficulty in removing airway secretions gastric distension patient discomfort/claustrophobia

5 - observational retrospective cohort study: 3124 patients admitted, 1814 EET, 114 patients NPPV - 83/114 patients (77%) were successfully treated by NPPV without intubation - success rate of NPPV was significantly lower (22%) in the patients with ARDS than in the other patients number of patients admitted to PICU patients who required EET % patients treated with NIPPV/total % patients treated with NIPPV/total EET 0.2% 7% 0.45% 12%

6 NIV techniques Humidified high-flow nasal cannula (HFNC) Continuous positive airway pressure (CPAP) CPAP Bilevel positive airway pressure (BiPAP) Intermittent positive pressure ventilation

7 Why is NIV more effective if synchronized? because the positive pressure is delivered immediately after the start of a respiratory effort, when the glottis is opening

8 NIV: patient selection Well-established procedure in children with hypoventilation due to chronic respiratory dysfunction - neuromuscular disorders - restrictive rib cage and chest wall deformities - hypoventilation disorders due to obesity - chronic upper airway obstruction (OSAS) - chronic obstructive airway diseases (advanced cystic fibrosis) - disorders of respiratory control (?) Less well defined its role in children with acute hypoxemic respiratory failure - obstructive lung disease (ARF II): status asthmaticus, bronchiolitis - restrictive lung disease (ARF I): pneumonia, atelectasis, ARDS, pulmonary oedema

9 NIV: physiological effects FRC (PEEP) recruitment of collapsed or non-ventilated alveoli decreases airway/pulmonary resistances improves ventilation-perfusion ratio PaO 2 Vt (PIP) improves minute volume: PaCO 2 Work of breathing Cardiac output

10 HFNC: physiological effects - positive airway pressure generation (variable) - washout of nasopharyngeal anatomical dead space: alveolar gas fractions are moved toward fresh gas values

11 NIV: interface selection...the choice of the interface depends on the age of the patient

12 NIV: interface selection Binasal prongs Advantages - best for newborns and young infants - oral leaks are not a problem Disadvantages - possible nasal lesions - often not tolerated by infants

13 Nasal mask Advantages - low dead space - easier secretion clearance - oral leaks can be reduced using a pacifier - often best tolerated by older infants Disadvantages - higher resistance through the nose - nasal irritation and rhinorrhea - mouth leak - mouth dryness

14 Face mask Advantages - easier to fit - minimised leakage - more comfortable for some patients - less risk of skin lesions in recent models Disadvantages - gastric distension, worsening GER, risk of aspiration - increased dead space - patient cooperation may be difficult (claustophobia!) - potential drying of the eyes

15 Helmet Advantages - fits regardless of the shape of the face - more comfortable for some patients - no risk of facial skin lesions Disadvantages - increased dead space - risk of rebreathing - noisy with high flow (up to 100 db) - difficulty in the management of small patients - difficulty in removing airway secretions - poorer patient-ventilator synchrony -

16 NIV: when to start? moderate to severe dyspnoea respiratory rate > 75 percentile according to age gas-exchange derangement: - hypoxemia (ARF I) : FiO 2 > 0.5 to obtain peripheral SaO 2 > 94% and/or - acute hypercapnia (ARF II) with respiratory acidosis (ph < 7.30)

17 NIV: contraindications Significant respiratory distress (severe respiratory acidosis) Significant hemodynamic instability Low Pediatric Glasgow Coma Scale (eye, verbal and motor response) Severe air-leaks Vomiting/inability to protect the airway or to handle oral secretions Obstructed bowel/upper gastrointestinal tract bleeding Oro-facial abnormalities which interfere with fitting the mask

18 NIV: at the beginning the first min need a great attention an expert doctor or nurse must be present initiate NIV while holding the mask in place: no straps yet! FiO 2 SaO 2 > 90% avoid PIP > 20 cmh 2 O and PEEP 5 cm H 2 O optimize the position of the baby to keep the airways free and reduce leaks check for signs of poor tolerance and worsening of distress identify other factors that may interfere with the technique (heat/cold/pain /etc; consider mild sedation)

19 NIV: monitoring SaO 2 EGA within 1h, if needed at 2-6 h PaO 2 /FiO 2 RR HR BP Gastric distension Asynchrony Dyspnoea Comfort Consciousness (pco 2 )

20 NIV: indicators of success Early use, ph > 7.25 Improvement of HR, RR, BP, ph and PaCO 2 within 30 min-2 h of starting Improvement of oxygenation and decreased retractions and accessory muscle use Comfort of the patient and synchronization Team effort

21 Bronchiolitis - is the leading cause of lower respiratory tract infection in infants: 64 million cases and 160 thousand deaths in the world every year (WHO 2009) - admission to a PICU is required in ~ 8-10% of the cases for: evolving respiratory distress apnoea spells and/or bradicardia hyponatriemia and seizures myocarditis - with coexisting co-morbidities this percentage increases to more than 30% e.g. CLD, CHD, immunodeficiency, prematurity

22 Significant increase in the use of NIV: 2.8 %/year NIV ETT LOS: 5.19 ± 6.34 days LOS: 2.38 ± 2.43 days

23 years retrospective analysis of all infants < 24 months admitted to the PICU within their first 24 h and treated with HFNP between 2005 and criteria for admission: O 2 requirement of more than 2 l/min and need for respiratory support additional to supplemental O 2 HF+N: HFNP followed by other non-invasive ventilation

24 2011

25 Bronchiolite complicata da grave broncospasmo Bambina di 6 mesi ricoverata per bronchiolite VRS + Iniziato trattamento con aerosol e cortisone Dopo alcune ore presenta: SaO 2 90% in aria espirazione prolungata TC 39,2 C; FR 88; FC 180 ph 7.38 con pco 2 38 Inizia NIV con maschera facciale: PIP 25; PEEP 7; FiO 2 0,8 SaO 2 98% Salbutamolo ev 0,2 gamma/kg/min midazolam 2 g/kg/min NIV per 4 giorni

26 SNIPPV as rescue therapy in 21 infants with severe bronchiolitis A/C n. 16 MV n. 5 Age on admission (days) 50 (13-147) 34 (10-61) ph (T0) ph (T1) pco 2 (T0) pco 2 (T1) FiO 2 (T0) FiO 2 (T1) 7.30 ± ± ± ± ± ± ± ± ± ± ± ± 0.31 Time spent on ventilation (h) 32 ± ± 37 Time spent on oxygen (h) 38 ± ± 29 RSV positive (n.) 7/16 5/5 T0= at the time of ventilation T1= within 3 hours of ventilation [mean(sd)]

27 - 8 patients < 3m with bronchiolitis (apneas, paco 2 > 55 mmhg, SaO 2 < 92%) - Treatment: CPAP cm H 2 O & Heliox 70% - Results: 2 patients needed PS, 1 patient MV

28 - pressure support NIV - salbutamol nebulized continuously - ipratropium bromide every 2 hr - methyl-prednisolone at a dose of 1 2 mg/kg/6 hr

29 Paziente con bronchite asmatica bambino di 1 aa, tosse da 3 gg in trattamento con aerosol e metilprednisolone trasferito direttamente in TIP per bronchite asmatica farmaco-resistente TC 38,2 C FR 70/min FC 200 bpm o critical pressure

30 inizia NIV con maschera con PIP e PEEP +8 cm H 2 O salbutamolo in ev a 2γ/kg/min sospende per scarso adattamento dopo 4 ore peggioramento clinico con FiO (EGA: ph 7,09 pco 2 90) inizia clonidina ev e riprende NIV con sevorane 2,5% dopo 48 ore sospende NIV, mantiene O 2 40% con maschera venturi, continua salbutamolo ev. per 6 gg

31 NIV parameters: PIP cm H 2 O; PEEP cmh 2 O

32

33 Paziente con linfoma di Hodgkin ragazza di 14 anni con linfoma di Hodgkin stadio IV polmonite da Pneumocystis Carinii dispnea e necessità di O 2 FC 140, FR 70, vigile, non febbrile, O 2 con maschera e reservoir ph 7.35, pco 2 36, PO 2 73, BE 2.3 NIV: A/C Ti 1.15, PIP +23, PEEP +15, FiO h dopo la NIV: SaO 2 98%, FiO 2 0.7, FC 121, FR 37 trasferita dopo 4 gg con FiO in maschera

34 Paziente trapiantato di midollo per β-talassemia major 7anni, GVHD cronica, CMV positivo FC 150 bpm; FR 50/min; SaO 2 96% con FiO 2 1

35 NIV con maschera con PIP +13 cm H 2 O e PEEP +7 cm H 2 O FiO 2 0,75 e SaO 2 100% NIV per 4 giorni

36 Obstructive Sleep Apnea Syndrome

37 NIV: open issues Need for better data and RCTs Development of age-appropriate interfaces Improvement of synchronization (Nava?) Combination with other treatments (Heliox?)

38

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