Pediatric Emergency Noninvasive Ventilation

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Key points

  • Noninvasive ventilation (NIV) is a powerful tool often initiated early in the management of pediatric acute respiratory failure (ARF).

  • NIV includes the following 2 positive pressure modalities: continuous positive airway pressure and bilevel positive airway pressure, which treat hypoxemic and hypercapnic respiratory failure, respectively.

  • Humidified high-flow nasal cannula, although not classically considered a mode of NIV, provides another mean of treating hypoxemic ARF in infants and children.

Introduction (background and definitions)

Respiratory illness is one of the most common reasons parents seek emergency medical care for their children. Although many of these children will have a benign and self-limited process, some will present with respiratory distress or frank respiratory failure. The ability to promptly recognize respiratory failure and appropriately, quickly, and safely initiate ventilatory support are vital skills for any professional providing care to sick or injured children. This article reviews the use of

General physiology

The primary objective of NIV used in the emergency management of pediatric acute respiratory distress and ARF is to improve oxygenation and ventilation while decreasing the work of breathing and the associated metabolic demands. There are 2 basic types of noninvasive positive pressure ventilation currently in use: continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP); although not historically considered a form of NIV, high-flow nasal cannula (HFNC) oxygen

Indications/relative and absolute contraindications

Practitioners of pediatric emergency care will encounter many patients with respiratory distress and some with respiratory failure. Being able to rapidly recognize the signs of both is a critically important skill (Table 1). NIV is typically initiated for children with impending or ARF as bridge therapy until the acute illness improves or as a treatment modality to prevent ETI, IMV, and the associated risks.8 It is recommended that in the absence of contraindications, NIV should be considered

Interfaces

The selection of a well-fitting, appropriately sized, comfortable interface is critical to achieving successful NIV while minimizing air leaks and maximizing patient comfort and synchrony with the ventilator. Despite the fact that interface tolerance is a major factor in NIV success, there are little comparative data on interfaces for infants and children.15 Typical interfaces are listed in Box 2. The smallest interface with the least air leak should be chosen to minimize dead space.9 For

Pediatric emergency department noninvasive positive pressure ventilation: the data and specific clinical scenarios

NIV has become increasingly prevalent in the pediatric emergency department (PED) and pediatric ICU (PICU) as supportive therapy for ARF. In 2008, the first pediatric RCT of NIV plus standard therapy versus standard therapy alone as support for undifferentiated ARF in children was published. The results showed a significantly improved heart rate (HR) and RR, improved Po2/Fio2 ratio, and a lower rate of ETI (28% vs 60%) in the NIV cohort.24 The trend toward improvement in vital signs (HR, RR, SpO

Summary

NIV has seen widespread use in the PED and PICU management of acute respiratory distress and seems to be claiming the position of the first-line therapy for pediatric ARF at many institutions.3, 5 Although there is a paucity of RCT high-quality evidence, the safety, tolerance, and efficacy of NIV in this application is supported by multiple observational studies. Early institution of NIV in carefully selected children may alleviate or preclude worsening of ARF, with reported rates of NIV

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  • Cited by (16)

    • Continuous Positive Airway Pressure vs. High Flow Nasal Cannula in children with acute severe or moderate bronchiolitis. A systematic review and Meta-analysis

      2022, Medicina Intensiva
      Citation Excerpt :

      In the last decade, the use of non-invasive respiratory therapies such as the Nasal Continuous Positive Air Pressure (CPAP), High-Flow Nasal Cannula (HFNC) and the Non-invasive Ventilation (NIV)5,6 have gained popularity in the pediatric intensive care field. All these therapies appear as therapeutic alternatives to the orotracheal intubation and conventional invasive ventilatory support, to minimize its associated risks such as barotrauma associated to the use of positive airway pressure, healthcare-associated infections, airway injury related to intubation, thoracic air leakage, longer length-of-stay, deconditioning associated to sedatives and neuromuscular blockers and subglottic stenosis, among others.7,8 A number of clinical trials have evaluated the efficacy of HFNC and CPAP.

    • Advances in Emergent Airway Management in Pediatrics

      2019, Emergency Medicine Clinics of North America
      Citation Excerpt :

      A brief review of high-flow nasal cannula (HFNC) and continuous positive airway pressure (CPAP) and bilevel positive airway support (BPAP) is included here. For more details on these topics, readers are referred to a separate recent review of this material.20 Traditional low-flow nasal cannula cannot match inspiratory flow rates in infants and children outside the neonatal period without causing nasal mucosal injury.

    • Oxygen therapy

      2023, Medico e Bambino
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    Disclosure Statement: The authors have no significant financial or other conflicts of interest to disclose.

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