1. Non-invasive positive pressure ventilation in the PICU

2. What is the daily practice of mechanical ventilation in ICU
In adults (in the years 1996 / 1997:
Esteban A et al. AJRCCM 2000; 161:1450–1458
In pediatrics (in the year 1999):
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

3. NIPPV in the Pediatric Intensive Care Unit
Geneva experience
Number of pediatric patients hospitalized
in the PICU over a 2-year period:
General pediatrics: (28%)
Cardiovascular surgery: (36%)
General surgery: (17%)
Neurosurgery: (9%)
Transplantation unit: (3%)
Onco-hematology: (2%)
Orthopedics: (5%)
Ventilated patients: (62%)
Intubated and ventilated patients: (87%)
Ventilatory support with NIPPV or CPAP 63 (13%)

4. NIPPV in acute pediatric respiratory failure Geneva experience 1998 - 1999
n = 63 CPAP: NPPV (BiPAP): 29
NPPV 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

5. High risk of respiratory distress in infants and small children
Small airways = high airway resistance
Compliant chest wall = low FRC
Relatively “inefficient” diaphragm
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

6. Objectives of Noninvasive Ventilation in
Pediatric Patients With Respiratory Disorders
Avoid intubation
Teague WG Pediatric Pulmonology 2003;35:418–426

7. Indications / Benefits of NIPPV in the PICU
Early case reports showed: Improvement of clinical manifestation of respiratory distress and respiratory gas exchange in children with AHRF
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)

8. NIPPV in acute hypoxic respiratory failure:
Benefit and treatment failures in 3 pediatric case series 4
Rimensberger PC Swiss Medical Weekly 2000;130:1880–6

9. NIPPV / CPAP in ARF: Treatment failures
Geneva experience
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

10. NIPPV in infants with AHRF
6 infants with AHRF of various etiology
Pressure support: IPAP 14 ± 0,5 cmH2O; EPAP 7,3 ± 1 cmH2O
Ti max: 0,6 ± 0,1 s ; insp. rise time: 100 ms.
pCO2 RR
F. Vermeulen et al. Annales Françaises d’Anesthésie et de Réanimation 2003; 22: 716–720

11. 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

12. PEEP: Tracheomalacia No PEEP PEEP 10cmH2O
Quen Mok, Great Ormond Street Hospital for Children, London

13. CPAP: Tracheomalacia No PEEP CPAP 10cmH2O
Quen Mok, Great Ormond Street Hospital for Children, London

14. Case serie in pediatric status asthmaticus with severe hypoxemia
Teague WG AJRCCM 1998; 157:542
prospective, non controlled case serie (n = 26)
NPPV: nasal mask; S/T mode
IPAP 13 ± 3 cmH2O; EPAP 7 ± 2 cmH2O; FiO ± 0.28
Results: 21 ± 27 hrs mean duration
169 ± 183 hrs O2 requirements
19/26 acutely improved
7/26 required intubation
11/26 did not well tolerate pH
paCO2
(mmHg)
paO2
pre-tx (n = 15)
7.36 ± 0.5
40 ± 10
87 ± 23
post-tx (n = 6)
7.42 ± 0.9
39 ± 14
94 ± 35
p > 0.05 for all comparisons

15. NPPV in pediatric status asthmaticus: Case serie* * *
* p < 0.05
* p < 0.05
not intubated (19)
intubated (7)
The oxygen response test?
Teague WG AJRCCM 1998; 157:542
was safe
allowed to shorten the length of ICU and hospital stay
did not prevent intubation in a subset of patients

16. NPPV in acute cardiogenic pulmonary edema (ACPE)
(patients who responded were hypercapnic,
those who failed were hypoxemic non-hypercapnic patients)
with the exception of patients with acute myocardial infarction, CPAP and/or NPPV is efficient in ACPE with hypercapnic ARF

17. 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

18. NIV for physiotherapy

19. NIV for physiotherapy

20. NIV for physiotherapy

21. NIV for physiotherapy

22. NIPPV in children with ARF: Complications
severe: air leaks
gastric perforation
aspiration
decrease in CO
minor: skin irritation / skin breakdown
nasal dryness
conjunctivitis

23. Physiological Factors Unique to Pediatric Patients Promoting Complications of NIPPV
Teague WG Pediatric Pulmonology 2003;35:418–426

24. NIPPV in children with ARF: Technical aspects
setting: restricted to acute care units
- pulsoxymeter
- tcpCO2 / TECO2
- cardiorespiratory monitoring

25. 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

26. 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

27. 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)

29. 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)

30. 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)

31. NIPPV in children with ARF: Technical aspects
ventilators: NIPPV ventilators (typ: BiPAP; mode: S/T)
ICU ventilators (PC / Pressure support)
sensitive flow trigger threshold
one way expiratory valve to prevent rebreathing
Not optimal for small children:
No back-up rate
- Very low (5%) fixed expiratory trigger / flow termination at very low flows

32. Patient-Ventilator Interaction -
Patient-ventilator asynchrony
by inspiratory trigger insensivity

33. RR 24 RR 60 Insp effort trigger vent Ineff trig abrupt COPD dec PSV
exp flow
COPD
PSV
(12)
RR 24
RR 60
Ineffective
effort
E. Kondili, G. Prinianakis and D. Georgopoulos

34. Pressure-Support and flow termination criteria
The non synchronized patient during Pressure-Support
(inappropriate end-inspiratory flow termination criteria)
Nilsestuen J Respir Care 2005;50:202–232.

35. Pressure-Support and flow termination criteria
Nilsestuen J
Respir Care 2005
Increase in RR, reduction in VT, increase in WOB

36. NPPV in acute or chronic pediatric respiratory failure:
Which mode, which device and which interface?
Infant ( months)
Small child ( 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
Chronic RF in neuromuscular disease
NIPPV
Congestive heart failure or acute pulmonary edema
Nasal CPAP
Nasal or full face CPAP or NIPPV

37. Helmet-delivered CPAP and/or non-invasive pressure support ventilation in children?
Need high flows to flush the system to avoid CO2-rebreathing

38. Helmet-delivered NIPSV in children with acute hypoxemic respiratory failure (P/F ratio < 200)
Piastra M et al. Intensive Care Med 2004; 30:

39. 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

40. Selection guidelines for NIPPV in pediatric ARF: Contra-indications
Ongoing emesis
Excessive bronchial secretions
Acute facial trauma
Upper airway protection not intact

41. 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

42. NIPPV in pediatric ARF current pediatric NIPPV questions:
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?