Breathing (part 4 of 4)

29 July, 2010 by: colinparker

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What is the role for Non-Invasive Ventilation in the Paediatric Emergency Department?
Does NIV present the same rescue options as in adult respiratory emergencies, where blowing air through the window of opportunity can prevent endotracheal intubation?

B is for Breathing

In this PEMcast, we explore Bi-level Positive Airways Pressure and a few of its lesser-known cousins, using the limited literature as our map, and Dan as our tour-guide.

Random Useful Fact: 1mmHg = 13.6mmH2O = 1.36cmH2O

Outline of Audio Proceedings

CP: Role of NIV (“BiPAP”) in kids – reference to PEMP review

Noninvasive Ventilation Techniques in the Emergency Department: Applications in Pediatric Patients – by Jamie Deis & colleagues, Nashville TN, June 2009 (EBmedicine.net)

Theoretical advantages of NIV (WOB, metabolic demand of breathing, recruitment, FRC, gas exchange, V/Q mismatch, airway patency, hypoventilation)
Compared to ETT: less trauma, less sedation, more communication

Disadvantages (alertness/airway protection, shock/unstable, secretions/vomit/bleeding, co-operation, airway /upper GI surgery, staffing for coaching & monitoring)

Multiple modes of delivery, interfaces (masks facial/nasal, nasal prongs)

CPAP (5-10[15])

BiPAP (10-16[20]/5-10, start at 8-10/2-4; IPAP minus EPAP = PS)

HHFNC (humidified high-flow nasal cannula) 8L/min infants, 40L/min

Nasal IPPV (hi & lo CPAP cycles, not triggerable by patient) (start at 8&5)

KB: Thill 2004: Noninvasive positive-pressure ventilation in children with lower airway obstruction [Paediatric Critical Care Medicine 2004; 5: 337-342]
(crossover RCT, n=20)

CP: Beers 2007:  Bilevel positive airway pressure in the treatment of status asthmaticus in pediatrics [American J Emergency Medicine 2007; 25: 6-9]
(retrospective chart review, n=83)

We tried it. We liked it. Retrospective Chart review (methods some description, 1 reviewer, not blinded) No stats
BiPAP on billing → asthma

83 patients, median age 8 yrs, 2-17, IQR 5-11yrs
10 did not tolerate BiPAP (12%)

Of those who tolerated BiPAP (73):
77% improved RR (avg 24%drop), 88% improved SpO2 (avg 6.6 point rise)
22% escaped PICU admission (?effect of other treatments vs effect of BiPAP)

Only 2 patients subsequently intubated

Limitations:
“Failed routine treatment” – no clear indication for starting BiPAP
Additional interventions not controlled for (Mg, epinephrine, IV terbutaline)
No control group
No idea how many went straight to intubation & ventilation

“Safe & well-tolerated”, prospective studies needed

DA: Yanez 2008: A prospective, randomized, controlled trial of noninvasive ventilation in pediatric acute respiratory failure  [Paediatric Critical Care Medicine 2008; 9: 484-489]
(RCT, n=50)

All: SUMMARY / consensus

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One Response to “Breathing (part 4 of 4)”
  1. Artur says:

    Hey Colin,
    here is a paper where they used a sham Bipap:

    http://www.ncbi.nlm.nih.gov/pubmed/12684289?dopt=Abstract

    Cheers

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