Managing Pediatric Patients on Non-Invasive Ventilation...Asthma Most common medical emergency in pediatric patients 1Ømar, K. et al, Emergency presentation and management of acute

Managing Pediatric Patients on

Non-Invasive Ventilation

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FDA guidelines

Adolescent

greater than 12 to 21 years of age

Child

greater than 2 to 12 years of age

Infant

greater than 1 month to 2 years of age

Newborn (neonate)

from birth to 1 month of age

http://www.fda.gov/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/ucm089740.htm

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Ventilation

• Pediatrics

• NIV

Disorders• Pediatric disorders

Masks• Masks

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What is NIV?

The application of positive pressure ventilation without

airway intubation for the purpose of augmenting alveolar

ventilation 1

Ventilation

1Wilkins, et al. Egan's Fundamentals of Respiratory Care, 9th Ed., 2009.

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Goals of NIV

• Avoid intubation1

• Improve mortality1

• Decrease VAP1

• Maximize patient comfort1

Ventilation


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Goals of NIV

• Alleviate respiratory

distress1

• Decrease WOB1

• Decrease LOS2

1Perkin, R. et al, Noninvasive Ventilation in Pediatric Patients: Roles as Supportive Technique in the ED, The Gale Group, A Thompson Healthcare

Company; 2009.

Ventilation


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Initial NIV settings1

• IPAP: 8-10 cmH2O

• EPAP: 4-6 cmH2O

• FIO2: per hospital protocol

1Perkin, R. et al, Noninvasive Ventilation in Pediatric Patients: Roles as Supportive Technique in the ED, The Gale Group, A Thompson

Healthcare Company; 2009. www.accessmylibrary.com

Ventilation

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Contraindications

• Excessive secretions1

• Uncooperative1

• Unconscious1

• Unable to protect the

airway1

• Hemodynamically

unstable1

1Perkin, R. et al, Noninvasive Ventilation in Pediatric Patients: Roles as Supportive Technique in the ED, The Gale Group, A Thompson Healthcare Company; 2009. www.accessmylibrary.com

Ventilation

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Pediatric Disorders

RSV

Croup

Epiglottitis

Cystic fibrosis

Asthma

Pneumonia

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RSV

• Respiratory tract infection1

• 1 out of every 10 children

under the age of 211

• May require ventilation and

oxygenation1

Disorders


An x ray of a child with RSV showing the typical bilateral perihilar fullness*

*Obtained from Wikipedia-used with permissions

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Croup

• Viral disorder1

• Subglottic swelling and

obstruction1

• Barking cough and stridor1

• May require supplemental

oxygen1

Disorders


AP x-ray of the neck in a child with croup demonstrating the

steeple sign; narrowing of the trachea*


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Epiglottitis

• Life-threatening1

• Upper airway obstruction1

• May require intubation1

Disorders


Visible epiglottis at the back of the throat on a two year old*


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Cystic fibrosis

• Genetic disorder1

• Produces copious

secretions1

• May require supplemental

oxygen1


Disorders

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Asthma

• Airway obstruction1

• Airway inflammation1

• Management is

prevention1

Disorders

Normal airway Constricted airway

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Asthma

Most common medical emergency in pediatric patients

1Ømar, K. et al, Emergency presentation and management of acute severe asthma in children, Scandinavia Journal of Trauma, Resuscitation and

Emergency Medicine 2009; 17:40

Disorders


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Asthma

• BiPAP therapy

• Intubation

1Ømar, K. et al, Emergency presentation and management of acute severe asthma in children, Scandinavia Journal of Trauma, Resuscitation and

Emergency Medicine 2009; 17:40

Disorders

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1Perkin, R. et al, Noninvasive Ventilation in Pediatric Patients: Roles as Supportive Technique in the ED, The Gale Group, A

Thompson Healthcare Company; 2009.

Disorders

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Conclusion

Patients treated safely with BiPAP and it was well tolerated

No adverse effects noted

Clinical status after initiation of BiPAP

77%-decreased RR 88% - improved O2 saturation

83 pediatric patients with status asthmaticus

73 (88%) BiPAP 57 of 73-PICU

Beers, S., et al, Bilevel positive airway pressure in the treatment of status asthmaticus in pediatrics, The American Journal of Emergency Medicine 2007;

25:6-9

Disorders

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Conclusion

BiPAP safely and effectively improved respiratory status

BiPAP may decrease the need for intubation

Patient population

20 primary pulmonary parenchymal process

16 postoperative atelectasis with respiratory insufficiency

PICU study

5 yr study-BiPAP in PICU Respiratory insufficiency

1Joshi, G., Five-Year Experience with the Use of BiPAP in Pediatric Intensive Care Unit Population; Journal of Intensive Care Medicine

2007, Vol. 22;No.1:38-43

Disorders

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Results

Decreased WOB

Decreased accessory muscle use

Decreased RR

Decreased dyspnea

2 hrs NIV followed by 2 hrs standard therapy OR

2 hrs standard therapy followed by 2 hrs of NIV

Prospective, randomized study in US

20 children – lower airway obstruction

1Thill, P. et al., Noninvasive positive-pressure ventilation in children with lower airway obstruction; Pediatr Crit Care Med 2004; Vol5, No.4:337-342

Disorders

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Conclusion:

NIV success = 57%NIV can be successfully applied to infants in ARF

Median age = 2.45 yrs

21 patients received NIV

42 hypoxemic or hypercarbic RF

RF patients at risk for intubation

1Bernet, V., et al.; Predictive factors for success of noninvasive mask ventilation in infants and children with acute respiratory

failure; Pediatr Crit Care Med 2005; Vol.6; No. 6: 660-664

Disorders

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Pneumonia

• Major cause of morbidity

and mortality

• Community-acquired

• Hospital-acquired

Disorders

A very prominent pneumonia of the middle lobe of the right lung*


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Mask considerations

• Well-fitting

• Comfortable

• Minimal leaks

1Perkin, R. et al, Noninvasive Ventilation in Pediatric Patients: Roles as Supportive Technique in the ED, The Gale Group, A Thompson Healthcare

Company; 2009. www.accessmylibrary.com

Masks

Sizing is tricky business

Masks

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Sizing analysis

60.0

76.0

92.0

108.0

124.0

140.0

156.0

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Ch

in t

o F

ore

head

(m

m)

Age (years)

Chin to Forehead Height (averaged)

Male - High

Male - Mean

Male - Low

Female - High

Female - Mean

Female - Low

Eye width Temple to temple

Chin to forehead

Masks

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PerforMax small

• 7 years or old (> 20 kg)

• SE or EE Leak 2 elbows

• Rapid application

Masks

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PerforMax x small

• 1 year or older (> 7 kg)

• SE or EE Leak 2 elbows

• Bonnet headgear

Masks

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PerforMax xx small


• SE or EE Leak 2

elbows

• Bonnet headgear

Masks

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PN831


• Nasal gel mask

• Leak 4 setting on V60

Masks

Philips ventilators intended for pediatric masks:

Ventilator Location Patient

Trilogy 202 Institutional > 7kg

Trilogy 100 Institutional > 7kg

V60 Institutional > 20kg

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Ventilator compatibility

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Take aways

• Kids are NOT little adults

• NIV-first choice therapy

• Small faces need small

masks