What are examples of noninvasive ventilation (NIV) in the pediatric intensive care unit (ICU) setting?

Examples of Noninvasive Ventilation (NIV) in the Pediatric ICU Setting

Noninvasive ventilation in the pediatric ICU includes several modalities that deliver respiratory support without an artificial airway, including bi-level positive airway pressure, CPAP, high-flow nasal cannula, and negative pressure ventilation. 1

Types of Noninvasive Respiratory Support (NRS)

1. Noninvasive Ventilation (NIV)

• Defined as positive pressure with variable levels of pressure delivered without an artificial airway via an occlusive interface 1
• Examples include:
  • Bi-level positive airway pressure (BiPAP) 1
  • Nasal high-frequency oscillation ventilation 1
• Interfaces used:
  • Nasal mask 1
  • Nasal pillows/prongs 1
  • Full face mask 1
  • Helmet 1

2. Continuous Positive Airway Pressure (CPAP)

• Delivers a single continuous distending pressure via an occlusive interface 1
• Uses the same interfaces as NIV (nasal mask, face mask, helmet) 1
• Distinguished from NIV by providing only constant pressure rather than variable pressure levels 1

3. High-Flow Nasal Cannula (HFNC)

• Heated humidified flow delivered through nasal cannula at specific flow rates:
  • ≥1 L/kg/min for patients up to 10 kg 1
  • ≥10 L/min for patients above 10 kg 1
• Considered distinct from conventional oxygen therapy 1
• Increasingly used in PICUs for various indications 1

4. Negative Pressure Ventilation (NPV)

• Respiratory support where the thorax and/or abdomen is exposed to sub-atmospheric (negative) pressure 1
• Less commonly used than positive pressure modalities 1, 2

Clinical Applications in PICU

Post-Extubation Support

• NIV can be used in two contexts after extubation:
  • Planned: initiated immediately after liberation from invasive mechanical ventilation 1
  • Rescue: applied within 48 hours after extubation when not initially planned 1

Primary Support for Respiratory Failure

NIV can be considered before intubation in:

• Obstructive airway disease 1
• Restrictive lung disease 1
• Mild-to-moderate pediatric acute respiratory distress syndrome (PARDS) 1
• Mild-to-moderate cardiorespiratory failure 1

Specific Clinical Scenarios

• Status asthmaticus 1
• After cardiac surgery for congenital heart disease 1
• Neuromuscular disorders with acute respiratory failure 1
• Prevention of extubation failure 1, 3

Practical Considerations

Monitoring for Success

• Success of NIV should be assessed within 1 hour of initiation by monitoring:
  • Heart rate and respiratory rate 1
  • SpO2/FiO2 ratio 1
  • pH (low pH after 1-2 hours is associated with NIV failure) 3
  • Level of consciousness 1
  • Presence of organ failure 1

Cautions and Limitations

• NIV should not delay endotracheal intubation when needed 1
• Failure rates vary by condition, with post-extubation patients generally showing better outcomes than those with acute respiratory insufficiency 3
• The interface should be selected to minimize leakage 1

Extubation Readiness Testing

• When transitioning from invasive to noninvasive support, a bundle approach should assess:
  • Sedation level 1
  • Neurologic control of airway (cough and gag reflexes) 1
  • Risk of post-extubation upper airway obstruction 1
  • Respiratory muscle strength 1
  • Airway secretions 1
  • Hemodynamic status 1
  • Plan for post-extubation respiratory support 1

Emerging Trends

• Machine learning approaches are being developed to predict NIV failure, with base excess, weight, age, systolic blood pressure, and fraction of inspired oxygen identified as important predictive factors 4
• Early identification of NIV failure is crucial to prevent adverse outcomes 4