Predictors of Failure of Noninvasive Ventilation in Critically Ill Children

Abstract

Noninvasive ventilation (NIV) is a common modality employed to treat acute respiratory failure. Most data guiding its use is extrapolated from adult studies. We sought to identify clinical predictors associated with failure of NIV, defined as requiring intubation. This single-center retrospective observational study included children admitted to pediatric intensive care unit (PICU) between July 2014 and June 2016 treated with NIV, excluding postextubation. A total of 148 patients was included. Twenty-seven (18%) failed NIV. There was no difference between the two groups with regard to age, gender, comorbidities, or etiology of acute respiratory failure. Those that failed had higher admission pediatric risk of mortality (p = 0.01) and pediatric logistic organ dysfunction (p = 0.002) scores and higher fraction of inspired oxygen (FiO2; p = 0.009) at NIV initiation. Failure was associated with lack of improvement in tachypnea. At 6 hours of NIV, the failure group had worsening tachypnea with a median increase in respiratory rate of 8%, while the success group had a median reduction of 18% (p = 0.06). Multivariable Cox's proportional hazard models revealed FiO2 at initiation and worsening respiratory rate at 1- and 6-hour significant risks for failure of NIV. Failure was associated with a significantly longer PICU length of stay (success [2.8 days interquartile range (IQR): 1.7, 5.5] vs. failure [10.6 days IQR: 5.6, 13.2], p < 0.001). NIV can be successfully employed to treat acute respiratory failure in pediatric patients. There should be heightened concern for NIV failure in hypoxemic patients whose tachypnea is unresponsive to NIV. A trend toward improvement should be closely monitored.

Noninvasive Respiratory Support for Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference

“…The literature search identified 6,336 studies, 187 were selected for full-text review, and 14 underwent data extraction (36–50) ( Supplemental Fig. S1 , http://links.lww.com/PCC/C300).…”

“…Evidence for the use of NIV in PARDS is based mostly on observational studies and two randomized controlled trials (RCTs) ( Table 1 ) (3–8, 10, 18, 28, 29, 36, 37, 43, 46, 48–50). Many of these studies include a heterogeneous pediatric population from at risk to severe PARDS.…”

“…However, delayed intubation and NIV failure may be harmful in children with PARDS. In two observational studies, children with NIV failure had longer duration of PICU LOS compared with those who were successfully treated with NIV (46, 50) and compared with historical controls (51). Timely prediction of NIV failure is therefore critical in children with PARDS.…”

Respiratory Support Practices for Bronchiolitis in the Pediatric Intensive Care Unit

“…While previous trials have compared HFNC and NIV use, the present study is the first multicenter analysis to evaluate risk factors for NIV failure in bronchiolitis . Similar to prior single-center work, we found higher severity of illness was associated with higher odds of HFNC and NIV failure. Characterizing which patients are likely to be successfully treated with NIV remains an important goal of PICU precision medicine.…”

SNAP: Supportive non‐invasive ventilation for acute chest syndrome prevention for hospitalized children with sickle cell disease: Perspectives of patients, parents, and the healthcare team

“…Most studies of BiPAP use in pediatrics focus on the treatment of acute respiratory failure in ICU settings, 21,22 chronic use for the treatment of chronic respiratory insufficiency for patients with neuromuscular disease, 23 or adherence to positive airway pressure among patients with obstructive sleep apnea (OSA). 24,25 There are very limited data about feasibility and tolerability of BiPAP, specifically among patients with SCD.…”