SERIES: VENTILATOR STRATEGIES
Non-invasive positive pressure ventilation: current status in paediatric patients

https://doi.org/10.1016/j.prrv.2004.11.014Get rights and content

Summary

Non-invasive positive pressure ventilation (NPPV) is a treatment for patients with respiratory dysfunction accomplished by an external interface and a positive pressure ventilator. The goals of NPPV therapy are to decrease the work of breathing and to improve respiratory gas exchange. Children with respiratory dysfunction are increasingly being treated with NPPV with the belief that it is a safe and effective alternative to invasive mechanical ventilation. Reports in support of NPPV are most promising in older children with chronic respiratory failure associated with restrictive pulmonary disorders and neuromuscular weakness. In children with advanced cystic fibrosis and nocturnal hypoxaemia, NPPV appears to be superior to treatment with supplemental oxygen alone in preventing hypoventilation. The role of NPPV in children with acute hypoxaemic respiratory failure is less well defined. Although early reports are encouraging, the question remains unanswered whether early application of NPPV as opposed to standard treatment reduces the likelihood or only delays the need for invasive mechanical ventilation. As young infants may not trigger the inspiratory pressure support feature of bi-level ventilators, application of NPPV with current devices is problematic in patients of this age. The horizon is promising for NPPV in the paediatric population and will likely include novel interfaces and responsive positive pressure devices better suited to the unique mechanical properties of the developing respiratory system.

Section snippets

INTRODUCTION

The term ‘non-invasive positive pressure ventilation’ (NPPV) refers to a method to increase tidal volume and thereby augment alveolar ventilation in patients with respiratory insufficiency. NPPV utilises an external interface, typically a nasal or nasal–oral mask and a pressure-targeted ventilator. This review in paediatric patients is limited to NPPV and does not address respiratory assistance with negative (sub-atmospheric) pressure devices. The primary advantage of NPPV over invasive forms

Restrictive and ‘overlap’ respiratory disorders

Probably the best-documented application of NPPV in paediatric patients is in the treatment of hypoventilation associated with chronic restrictive chest disorders (Table 1). Early detection of sleep-associated abnormalities including obstructive apnoea with polysomnography is now possible in children with chronic restrictive disorders, thus increasing trials with NPPV and other therapeutic adjuncts in this population.5 Furthermore, advances in critical care medicine in the treatment of severe

NPPV IN CHILDREN WITH UPPER AIRWAY OBSTRUCTION

Upper airway obstruction is an important cause of both hypoxaemic and hypercarbic respiratory failure in children. Hypoventilation results from soft tissue collapse such as with significant obesity and adenotonsillar hypertrophy, or a fixed and often severe pattern of obstruction associated with craniofacial syndromes and mid-facial hypoplasia. The obstruction places a significant mechanical load on the diaphragm, thus diaphragmatic fatigue is an important factor leading to hypoventilation.

NPPV IN CHILDREN WITH DISORDERS OF RESPIRATORY CONTROL

There is growing interest in the application of NPPV in the treatment of the most important long-term disorder of respiratory control in paediatrics – congenital central hypoventilation syndrome (CCHS). CCHS is a genetic disorder that presents with hypoventilation during quiet sleep and is due to an impaired ventilatory response to hypercarbia. CCHS presents early in life with intermittent cyanosis during sleep, hypoventilation and ‘atypical apnoea’. Untreated or poorly treated CCHS ultimately

Promising outcomes with NPPV treatment in adults with acute hypoxaemic respiratory failure

In sharp contrast to the growing experience with NPPV in children with chronic respiratory dysfunction, there are relatively few published data in support of NPPV in paediatric patients with acute respiratory distress. Based on successful clinical trials, NPPV is considered to be the preferred initial treatment for adults with hypercarbic exacerbations of COPD.3, 4, 21 In such patients, NPPV has been shown to significantly decrease the likelihood of endotracheal intubation, improve survival

SAFETY OF NPPV IN THE PAEDIATRIC POPULATION

NPPV is an attractive mode of treatment because it is generally considered to be safer than invasive forms of mechanical ventilation. This statement has some validity based on studies in adults but needs further testing in children. Minor complications are common in children treated with NPPV and include dermal abrasion at the interface margin, eye irritation and gastric distension with air. Reports of major complications are unusual but tension pneumothorax, depressed cardiac output and, most

Contra-indications and setting

Key variables to consider before implementation of NPPV in paediatric patients are the age of the child, the pattern of respiratory system dysfunction, the level of cardio-respiratory stability and the clinical setting. As a general principle, NPPV has no clear benefit in young infants with significant respiratory distress and thus is not recommended with currently available devices. NPPV is also contra-indicated in children with significant cardiovascular instability. Furthermore, NPPV

LONG-TERM TREATMENT WITH NPPV IN THE OUTPATIENT SETTING

NPPV can provide an important clinical benefit to children with chronic respiratory failure who either do not require or electively want to avoid a tracheostomy. In this setting, the primary advantage of NPPV is to improve sleep quality, improve nocturnal respiratory gas exchange and reduce the mechanical load on the respiratory muscles. Most children treated on a long-term basis with NPPV prefer a nasal mask interface, thus meticulous skin care and careful fit are essential. There are concerns

UNRESOLVED CHALLENGES FOR FUTURE NPPV TREATMENT IN CHILDREN

Probably the most important unresolved issue limiting applicability of NPPV in the paediatric population is the lack of well-organised clinical data in support of its safety, effectiveness and limitations. It is tempting to blame the device manufacturers and Food and Drug Administration for this shortcoming but, in fact, clinicians must share responsibility since we have used and, in some cases, advocated NPPV therapy in children well in advance of objective data. Several unanswered questions

REFERENCES (31)

  • J. Bott et al.

    Randomized controlled trial of nasal ventilation in acute ventilatory failure due to chronic obstructive airways disease

    Lancet

    (1993)
  • J.D. Fortenberry et al.

    Management of pediatric acute hypoxemic respiratory insufficiency with bilevel positive pressure (BiPAP) nasal mask ventilation

    Chest

    (1995)
  • N. Bencault et al.

    Mortality rate attributed to ventilator-associated nosocomial pneumonia in an adult intensive care unit: a prospective case-control study

    Crit Care Med

    (2001)
  • E. Girou et al.

    Secular trends in nosocomial infections and mortality associated with noninvasive ventilation in patients with exacerbation of COPD and pulmonary edema

    JAMA

    (2003)
  • L. Brochard et al.

    Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease

    N Engl J Med

    (1995)
  • L. Brochard et al.

    Reversal of acute exacerbations of chronic obstructive lung disease by inspiratory pressure assistance with a face mask

    N Engl J Med

    (1990)
  • Y. Khan et al.

    Obstructive apnoeas in Duchenne muscular dystrophy

    Thorax

    (1994)
  • D.J. Birnkrant et al.

    Pediatric noninvasive nasal ventilation

    J Child Neurol

    (1997)
  • D. Gozal

    Nocturnal ventilatory support in patients with cystic fibrosis: comparison with supplemental oxygen

    Eur Respir J

    (1997)
  • N.S. Hill

    Noninvasive ventilation: does it work, for whom, and how?

    Am Rev Respir Dis

    (1993)
  • E. Gomez-Merino et al.

    Duchenne muscular dystrophy: prolongation of life by noninvasive ventilation and mechanically assisted coughing

    Am J Physical Med Rehab

    (2002)
  • J.R. Bach et al.

    Spinal muscular atrophy type 1: management and outcomes

    Pediatr Pulmonol

    (2002)
  • Y. Khan

    Effect of nasal ventilation on nocturnal hypoxaemia in neuromuscular patients

    Am Rev Respir Dis

    (1992)
  • R. Padman et al.

    Non-invasive ventilation via bi-level positive airway pressure support in pediatric practice

    Crit Care Med

    (1998)
  • W.G. Teague et al.

    Noninvasive ventilatory support in pediatric respiratory failure

    Respir Care

    (1995)

    • Cited by (0)

    View full text
    Copyright © 2005 Elsevier Ltd. All rights reserved.