managing pediatric patients on non-invasive ventilation...asthma most common medical emergency in...
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Managing Pediatric Patients on
Non-Invasive Ventilation
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3
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
1Wilkins, et al. Egan's Fundamentals of Respiratory Care, 9th Ed., 2009.
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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
2Wilkins, et al. Egan's Fundamentals of Respiratory Care, 9th Ed., 2009.
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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
1Wilkins, et al. Egan's Fundamentals of Respiratory Care, 9th Ed., 2009.
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
1Wilkins, et al. Egan's Fundamentals of Respiratory Care, 9th Ed., 2009.
AP x-ray of the neck in a child with croup demonstrating the
steeple sign; narrowing of the trachea*
*Obtained from Wikipedia-used with permissions
13
Epiglottitis
• Life-threatening1
• Upper airway obstruction1
• May require intubation1
Disorders
1Wilkins, et al. Egan's Fundamentals of Respiratory Care, 9th Ed., 2009.
Visible epiglottis at the back of the throat on a two year old*
*Obtained from Wikipedia-used with permissions
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Cystic fibrosis
• Genetic disorder1
• Produces copious
secretions1
• May require supplemental
oxygen1
1Wilkins, et al. Egan's Fundamentals of Respiratory Care, 9th Ed., 2009.
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
2Wilkins, et al. Egan's Fundamentals of Respiratory Care, 9th Ed., 2009.
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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*
*Obtained from Wikipedia-used with permissions
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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
• 1 year or older (> 7 kg)
• SE or EE Leak 2
elbows
• Bonnet headgear
Masks
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PN831
• 1 year or older (> 7 kg)
• 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
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