SHA24/078004

Mohamed Salim Kabbani Head Pediatric Cardiac ICU

King AbduAziz Medical City Riyadh- Saudi Arabia 1

Introduction Definition of NIV Types of NIV When, where and how Pros & Cons Few supporting literatures  Conclusions      

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The average PICU has about 30% (range 20 – 64%) of its patients mechanically ventilated, for a mean of 5–6 days.

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50% of ventilated PICU patients will have been extubated by 48 hours after admission

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Failed planned extubations in the latter group average 8% TO 20%

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50% of unplanned extubations end in success, implying

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 Infection  tracheal injury  sedation

 Sub-glottic stenosis  Tracheostomy  Emotional and Psychological  Valuotraumas/ Barotraumas  BPD

( Bronchopulmonary Dysplesia) 4

X ď‚Ą

Noninvasive ventilation is the delivery of ventilatory support without the need for an invasive artificial airway

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Intubation % : 60% in control group vs. 28% in NIV group (p =0.045)

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NIV improves hypoxemia

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NIV improves signs and symptoms of acute respiratory failure.

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NIV seems to afford these patients protection from endotracheal intubation.

Negative pressure  Non invasive positive pressure ventilation 

 CPAP (Continuous Positive Airway Pressure)  IPPV (Intermittent Positive Pressure

Ventilation)

 Humidified High flow support (HHFS) 9

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Iron Lung

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Cuirass Ventilation

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Continuous positive airway pressure (CPAP)

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Bi-level positive airway pressure (BiPAP)

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Bi-level nasal CPAP

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Intermittent positive pressure breathing (IPPB)

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Humidified high-flow nasal cannula (HHFNC) 11

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Reduction in inspiratory muscle work and avoidance of respiratory muscle fatigue

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Decrease O2 consumption

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Tidal volume is increased

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Increase FRC ( improve oxygenation, lung compliance )

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Maintain and splint collapsed airways.

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NIV improves respiratory system compliance by reversing microatelectasis of the lung

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Preserved defense mechanisms.

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Improve diaphragmatic activity. Less sedation

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Noninvasiveness  Application (compared with endotracheal

intubation)  Easy to implement  Easy to remove  Allows intermittent application 

Comfort and convenient  Improves patient comfort  Reduces the need for sedation  Oral patency (preserves speech, swallowing, and

cough, reduces the need for NG/OG tubes)

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 Avoid the resistive work imposed by the

endotracheal tube

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Avoid complications

 Avoids the complications of endotracheal

intubation

 Early (local trauma, aspiration)  Late (injury to the the hypopharynx, larynx, and trachea, nosocomial infections)

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System

 Slower correction of gas exchange

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abnormalities  Increased initial time commitment  Gastric distension (occurs in <2% patients)  Inadequate, variable pressure

Mask

 Air leakage  Transient hypoxemia from accidental removal  Eye irritation

 Facial skin necrosis –most common complication.

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Access to patient  Lack of airway access and protection  Suctioning of secretions  Aspiration

General concern  It can increase morbidity and mortality if patient is not ready and needs intubation due to severity of illness, inability to protect airway or unrecognized airway obstruction.

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Contraindication  Apneas  Hemodynamic instability  Refractory hypoxemia  Impaired mental status  Moderate to severe bulbar weakness  Inability to handle oral secretions  Inability to tolerate nasal or face masks  Upper gastrointestinal bleed  Acute facial trauma  Upper airway abnormalities…choanal atresia.. Cleft palate

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ď&#x201A;Ą

NIV can be administered in the emergency department, intermediate care unit.

NIV ER

ICU

Intermediate care

Ward 20

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By physicians, nurses, or respiratory care therapists

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Depends on staff experience and availability of resources for monitoring, and managing complications

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For the first few hours, one-to-one monitoring by a skilled and experienced nurse, respiratory therapist, or physician is mandatory

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Immediate access to staff skilled in invasive

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Constant level of pressure support to the airways during inspiration and expiration (5 -12 cm of water)  CPAP can be delivered through several different external interfaces including: 

 Facial Mask and helmet (adult)  Oronasal masks ( children)  Nose masks  Nasopharyngeal prongs,  Single-nasal prongs ( example: ETT)  Bi-nasal prongs (Infants and Neonates).

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Nasal masks, Prongs,  less dead space  less claustrophobia  allow for expectoration vomiting and oral intake  vocalize

facial mask dyspneic patients are usually mouth breathers 

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More dead space

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Continuous flow CPAP: • bubble CPAP • ventilator generator

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Variable flow CPAP.

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Types of prongs • Argyle • Hudson • Inca • Fisher & Paykel • EME • Others

Meta-analysis of randomized trials showed that: 1-Short Bi-nasal devices are more effective at preventing re-intubation in the week post-extubation 2-ShortBi-nasal device have better oxygenation, respiratory rate, and weaning success when compared with single prong nasopharyngeal CPAP. WHY: Probably due to lower resistance, allowing greater transmission of the applied pressure to the airway.

Cochrane Neonatal review: Devices and pressure sources for administration of nasal continuous positive airway pressure (NCPAP) in preterm neonates De Paoli AG, Davis PG, Faber B, Morley CJ 26

•Mouth closure, with a pacifier or by direct closure, will raise pharyngeal pressure. The pharyngeal pressure may fall significantly if the mouth is open even slightly.

•Chin straps have been used to avoid the fluctuations in the delivered pressure seen with intermittent mouth opening.

•The success of CPAP has been shown in most studies without actively closing babies 'mouths.

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Nasal Pillows or Nasal Cushions (continued) for • Suitable patients with • Claustrophobia • Skin sensitivities for • Need visibility

Respironics Comfort Lite Nasal Mask

Bi-level positive airway pressure devices provide two levels of positive airway pressure during the respiratory cycle. â&#x20AC;˘A higher level of pressure is provided during inspiration (IPAP) â&#x20AC;˘A lower level of pressure is provided during expiration (EPAP).

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Traditional nasal cannula gas flow in young infants is limited to 2 to 3 L/min due to mucosal irritation and dryness from the cool, dry air.

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High-flow nasal cannula devices deliver warmed humidified gas to the airways  nasal mucosal irritation is greatly reduced.  Improved tolerance of high gas flow up to 8 L/min in

infants and up to 40 L/min in adults 32

1) Washout of nasopharyngeal dead space 2) Reduction of inspiratory resistance (work of breathing) by providing adequate flow 3) Improved mechanics by supplying adequately warmed and humidified gas 4) Reduction in the metabolic cost of gas conditioning 5) Provision of distending pressure 33

A retrospective chart review of infants with bronchiolitis admitted before introduction of HFNC and in the season after the introduction of HFNC. Children in the treatment group received 7 to 8 LPM of high flow 02  9% of infants admitted to the PICU with bronchiolitis and

managed with HFNC required intubation

 23% in the prior season managed without HFNC and required

intubation (P= .043).  68% decrease in need for intubation with HFNC  Median PICU length of stay decreased from 6 to 4 days.

Outcome measure

Bronchioloitis season before introduction of HFNC (n=57)

Bronchiolitis season after introduction of HFNC (n=58)

P value

Requirement of intubation in PICU

23%

9%

0.043

Median length of stay in PICU

6 days

4 days

0.0058

High Flow Nasal Cannula:  Decreases rates of intubation in infants with bronchiolitis  Decreases the respiratory rate and work of breathing  Provides comfortable and well-tolerated means of noninvasive ventilatory support  Decrease the length of PICU stay

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Decreased respiratory rate

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Decreased retractions and accessory muscle use

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Reduced airway occlusion events

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Improved oxygenation on pulse oximetry and blood gases

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Improved lung volumes on chest radiographs

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Physiological

a) Continuous oximetry b) Exhaled tidal volume c) ABG should be obtained with 1 hour and, as necessary, at 2 to 6 hour intervals.

Objective

a) Respiratory rate b) blood pressure c) pulse rate

Subjective

a) dyspnea b) Comfort c) mental alertness 38

Mask Fit, Comfort, Air leak, Secretions, Skin necrosis Respiratory muscle unloading Accessory muscle activity, paradoxical abdominal motion Abdomen Gastric distension 39

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Air leaks Gastric perforation Aspiration Gastric distension if PIP >20 cm H2O Skin irritation / skin breakdown Nasal dryness Conjunctivitis 40

oFirst 30 min. of NPPV is labor intensive oBedside presence of a respiratory therapist or nurse familiar with this mode is essential. oProviding reassurance and adequate explanation oBe ready to intubate and start invasive ventilation.

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Inability to tolerate the mask because of discomfort or pain Inability to improve gas exchange or dyspnea Need for endotracheal intubation to manage secretions or protect airway Hemodynamic instability ECG – ischemia/arrhythmia Failure to improve mental status in those with CO2 narcosis.

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Non invasive positive pressure ventilation is corner stone in management of critical care pediatric patients It minimizes the need for invasive ventilation with all complications associated with it It helps preventing intubation & re-intubation It is not for every body and there is contraindication for non-invasive ventilation Careful monitoring and close follow up is necessary for those cases 43

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Thanks

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