indications for noninvasive ventilation: when and for whom?a/panitch_ventil… · indications for...
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Indications for Noninvasive Ventilation: When and For Whom?
Howard B. Panitch, M.D.Division of Pulmonary Medicine
Children’s Hospital of Philadelpia
Philadelphia, PA
Indications for Noninvasive Ventilation (NIV)
• Acute respiratory failure– Avoid intubation– Avoid extubation failure
• Chronic respiratory failure– Progression of chronic disease– Acute exacerbation of chronic disease
• Palliation
Goals of Noninvasive Ventilation in Acute Respiratory Failure
• Improve alveolar ventilation• Improve oxygenation• Unload respiratory muscles• Maintain upper airway patency
Noninvasive vs. Invasive Ventilation
Advantages• Avoid tracheal/laryngeal
injury• sedation• risk of ventilator-
associated pneumonia• tolerance of enteral
feedings• Preserve airway
clearance mechanisms
Disadvantages• Skin injury• Abdominal distension• Inadequate for more
severe disease• Delay in controlling a
failing/unstable patient
Some Indications for NIV in Acute Respiratory Failure
• Neonatal RDS• Bronchiolitis• Asthma• Pneumonia• Pediatric ARDS
– (mild to moderate)
Rationale for NIV in Acute Respiratory Failure
CPAP• Recruitment of
collapsed areas• Stabilize upper airway• Central airway patency• Improve P-V
relationships
NPPV• Unload respiratory
muscles• Enhance ventilation• Alveolar recruitment
Mechanisms of NIV in Pediatric ARDS
Essouri S et al. Pediatr Crit Care Med 16:S102; 2015
PSV
CPAP
CPAP
Contraindications for NIV in Acute Respiratory Failure
• Exhaustion– Abdominal muscle use with thoraco-
abdominal paradox• SpO2/FiO2 <150• PaCO2 >55• pH < 7.30
Calderini E et al. Curr Opin Anaesthes 23:368; 2010
Use of NIV for Acute Respiratory Failure (2006-
2012)
Indication and Failure Rate Mode of Support by Age
Wolfler A et al. Pediatr Crit Care Med 16:418; 2015
N = 585 (15%)
NIV for Status Asthmaticus
Basnet S et al. Pediatr Crit Care Med 13: 393; 2012
HRFiO2
RRAsthmaScore
Long-Term NIV for Chronic Respiratory Failure
Castro-Codesal ML et al. PLoS ONE 13:e0192111; 2018
Respiratory Failure
Lung Failure “Pump” Failure
Gas exchange FailureHypoxemia
Ventilatory FailureHypercapnea
Central Depression
MechanicalDefect
FatigueFrom Roussos C and Macklem PT. N Engl J Med 307:786; 1982
Advantages of NIV for Chronic Respiratory Failure
• Decreased risk of nosocomial pneumonia
• Management outside of an ICU• Less sedation• Improved tolerance of enteral
feedings• Ambulation/improved mobility
Chronic Respiratory Failure
Lung Failure “Pump” Failure
Obstructive Diseases• COPD• Bronchiectasis
• Cystic fibrosis• BPD
Restrictive Diseases• Neuromuscular Disease• Chest wall deformities• Spinal cord injuries• Diaphragm paralysis• Hypertonic cerebral palsy
Control of breathing disorders• CCHS
Pulmonary Home Ventilation Program
0
20
40
60
80
100
120
140
160
180
Airway CHD CLD COB Neuro NMD OSA RLD
NIVTrach
Goals of Noninvasive Ventilation
• Prolong survival• Normalize gas exchange• Reverse/correct sleep-disordered
breathing and architecture• Prevent / reverse cor pulmonale• Improve daytime function• Sustain/promote growth and
development
Goals of Mechanical Ventilation in Progressive
Diseases• Palliate dyspnea• Support during acute illnesses• Reverse hypoventilation• Improve sleep quality• Facilitate home care/reduce
hospitalizations• Remodel thorax, ?promote lung growth
Chest Wall Compliance in Children with NMD
Cw ml/cm H2O /kg
Papastamelos C et al. Am J Respir Crit Care Med 154:1045; 1996
Age, mos
10
00 24 48
8
2
6
4
4 yrs after NIPPV
Simonds AK. In Non-Invasive Respiratory
Support, Simonds AK, ed. pp 181-2;
2001
Lung Insufflation and Chest Wall Shape
7 mo 3 yr, 6 mo
Bach Jr and Bianchi C. Am J Phys Med Rehabil 82:815; 2003
Types of Sleep Problems
Hull J et al. Thorax 67:i1; 2012
Mechanical Ventilatory SupportWhen to Begin?
• Evaluate when daytime PaCO2 > 45 torr1,2
• Acute respiratory illness and failure to wean
• Abnormal polysomnography
• ?Preventative treatment?• Preservation / promotion of lung growth?
1Rutgers M et al. Neuromuscul Disord 6:431; 19962Finder J et al. Am J Respir Crit Care Med 170:456; 2004
Sritippapayawan S et al. J Pediatr 142:481; 2003
Before 1987 1987-1989 1990-1992 1993-1995 1996-1998 1999-20010
2
4
6
8
10
12
14
PSG
Elective HMV Non-elective HMV
# of Patients
Introduction of Chronic Ventilation
Predictors of SDBIVC, PaCO2
Mellies U et al. Neuromuscul Disord 13:123; 2003
Sens 97%Spec 87%
Sens 96%Spec 88% Sens 92%
Spec 72%
RCT for Those with Nocturnal Hypoventilation
• daytime PaCO2(n = 5)
• Symptomatic relief (n = 2)
• FTT, acute pneumonia (n = 1)
• TcCO2, in PFTs (n = 1)
1
2
3
4
5
6
7
8
9
10
PatientNo Months from entry into study (0 – 24)
Baseline0%
6 months50%
12 months70%
24 months90%
18 months70%
no NIV on NIV
Reason for Initiation of NIV
Ward S et al. Thorax 60:1019; 2005
How Should We Target Ventilator Support?
Clinical Assessment• Increase Vt• Decrease trigger
effort• Optimize synchrony
– Patient - ventilator– Chest - abdomen
• Normoxemia• Normocapnia
Polysomnography• Improve sleep
architecture• Reverse thoraco-
abdominal paradox• Normocapnia• Normoxemia• Resolution of SDB
Summary
• NIV can be used for both acute and chronic respiratory failure– Goals for each are different
• The use of NIV is growing for both Acute and Chronic Respiratory Failure
• Pediatric indications require more data