Comparison of Effort of Breathing for Infants on Nasal Modes of Respiratory Support

Abstract

Objective To directly compare effort of breathing between high flow nasal cannula (HFNC), nasal intermittent mechanical ventilation (NIMV), and nasal continuous positive airway pressure (NCPAP). Study design This was a single center prospective cross-over study for patients <6 months in the cardiothoracic or pediatric intensive care unit receiving nasal noninvasive respiratory support after extubation. We measured effort of breathing using esophageal manometry with pressure-rate product (PRP) on all 3 modes. NIMV synchrony was determined by comparing patient efforts (esophageal manometry) with mechanically delivered breaths (spirometry in ventilator circuit). On NIMV, PRP and synchrony was also measured after adding a nasal clip on 26 patients. Results Forty-two children were included. Median (IQR) age was 2 (0.5, 4) months. There was no difference in median PRP between HFNC 6 liters per minute, 355 (270,550), NIMV 12/5 cm H2O, 341 (235, 472), and NCPAP 5 cm H2O, 340 (245,506) (P = .33). Results were similar regardless of HFNC flow rate or NIMV inspiratory pressure. Median PRP on CPAP of 5 cm H2O prior to extubation 255 (176, 375) was significantly lower than all postextubation values (P < .002). On NIMV, less than 50% of patient efforts resulted in a ventilator breath, which was not improved with a nasal clip (P > .07)). However, as NIMV synchrony improved (>60%), PRP on NIMV was lower than on HFNC. Conclusions For infants, effort of breathing is similar on HFNC, NIMV, and NCPAP after extubation, regardless of flow rate or inspiratory pressure. We speculate that bi-level NIMV may be superior if high levels of synchrony can be achieved.

Clinical characteristics and outcomes associated with nasal intermittent mandatory ventilation in acute pediatric respiratory failure

“…The strongest evidence for NIMV in the pediatric population to date are limited to pathologies encountered in the NICU; for example, it shows significant clinical benefit over other modes of NIV in neonatal respiratory distress syndrome, apnea of prematurity, and the prevention of post-extubation failure[ 4 , 12 , 13 ]. In discordance with the NICU literature, a recent prospective study of NIV for post-extubation support in the PICU showed no difference in respiratory effort when compared between NIMV, HFNC, and CPAP, though NIMV in this study was synchronized to approximately 50%[ 14 ].…”

Predicting Failure of Non-Invasive Ventilation With RAM Cannula in Bronchiolitis

“…Finally, given our study inclusion and exclusion criteria, we cannot generalize our findings to other clinical scenarios where NIV is used, such as the cardiac ICU population or for prevention of extubation failure. 4,17 The study setting was a quaternary pediatric referral center our findings may not be generalizable to community hospitals with varying degrees of respiratory services.…”

“…1 A spectrum of respiratory support modalities has emerged, ranging from oxygen delivery devices such as heated humidified high-flow nasal cannula (HFNC) to NIV modalities such as continuous positive airway pressure (CPAP) and bilevel pressure positive pressure ventilation (BiPAP). 2 These modalities reduce work of breathing by inspired gas conditioning and reduced airway resistance, [2][3][4][5][6][7][8][9][10][11] with BiPAP enhancing carbon dioxide clearance. 12 Since the introduction and wide application of these modalities, a reduction in intubation rates has been observed.…”

“…1,3,13,14 While HFNC and CPAP are commonly used, 6 some children still require escalated support with BiPAP through a variety of interfaces. 4,8,15,16 The Ramanathan (RAM) nasal cannula is an interface used to deliver either CPAP or BiPAP. 2,[17][18][19][20] Use of the RAM cannula originated in the neonatal intensive care unit where it is associated with reduced extubation failure and intubation rates in children with neonatal respiratory distress syndrome.…”

A Phase II randomized controlled trial for lung and diaphragm protective ventilation (Real-time Effort Driven VENTilator management)

“…This range of PRP corresponds to a pressure-time product range between 75 and 200. In addition, we have also found this range is significantly lower than the typical PRP range for infants with bronchiolitis who are maintained on high flow nasal cannula (> 75% have PRP over 400), and slightly lower than the typical PRP range for infants on nasal Continuous Positive Airway Pressure (CPAP) [46,47]. Therefore, this range appears to result in effort of breathing even lower than what most critical care clinicians would deem acceptable for critically ill children who are not on MV.…”