Should We Intubate?

By: Erin Sventy, Ryan Cutro, Afnan S. Al-Raimi, Kelvin K. Opoku

The utilization of mechanical ventilation in the neonatal and pediatric populations have proven to be clinically challenging, due to the wide range of sizes, weights, ages, and disorders. Traditional invasive positive pressure ventilation (IPPV) has been a life saving device for many patients, but extended use can lead to the development of further and often times, severe complications, such as acute lung injury, retinopathy of prematurity (ROP), and bronchopulmonary dysplasia (BPD). Over the last several decades, there has been a growing interest in treating many neonatal and pediatric disorders with noninvasive positive airway pressure ventilation (NIPPV), as a safe alternative to IPPV. The advantages and disadvantages of IPPV and NIPPV in the treatment of premature infants as well as infants with acute bronchiolitis will be discussed in further detail.¹

Prematurity in infants is one of the leading causes of death during the neonatal phase of development. It is estimated that each year, 15 million infants are born prematurely, with about 10% of these infants being born between 28-32 weeks and 5% being born less than 28 weeks of gestational age. Many of these premature infants will require some form of respiratory support, but some infants will require more aggressive forms of ventilation in order to sustain breathing. When using mechanical ventilation, the goal is to improve lung function by improving pulmonary gas exchange, while decreasing the work of breathing and minimizing further lung injury. ²

Selecting the type of positive pressure ventilation should be determined by the infant’s current health status, availability of resources and the level of experience among the healthcare team. Some of the NIPPV modes that can be initiated include: continuous positive airway pressure (CPAP), neonatal nasal intermittent noninvasive positive pressure ventilation (NIPPV) and synchronized NIPPV. CPAP can be used if the infant is able to spontaneously breathe, yet still require additional support, in order to maintain adequate levels of oxygenation. Some of the potential complications from CPAP include pneumothorax if too much pressure is applied, nasal obstruction or necrosis from improper placement or fitting of the device, and abdominal distention from swallowing too much air. Nasal intermittent NIPPV is able to provide more support in comparison with CPAP. Unlike CPAP, nasal intermittent NIPPV can set the rate of breathing, which can be beneficial back up mode, in case the infant goes apneic. This mode can also help improve the respiratory drive while increasing functional residual capacity and tidal volume. Synchronized NIPPV allows the infant to have more control over breathing and can help prevent breath-stacking or air-trapping.²

When NIPPV modes of ventilation fail to improve the level of oxygenation or current symptoms, or the infant fails to breathe spontaneously, intubation is necessary. Some of the IPPV modes of ventilation that can be initiated include synchronized intermittent mandatory ventilation (SIMV) and volume-targeted ventilation. In SIMV, a delivered amount of pressure or volume can be set (along with a set rate). The patient can breathe spontaneously between the mandatory breaths set on the machine. Pressure support can be provided to the spontaneous breaths for additional support. In volume-targeted ventilation, there is a set targeted volume, which is maintained by automatic incremental increase or decrease in the pressure between breaths based on the ventilator’s calculation of airway resistance and lung compliance. Some of the complications that can occur from either of these modes include pneumothorax from excess positive pressure, accidental extubation, ROP, volutrauma, barotrauma, and increased risk of infection due to bypassing the upper airway.²

Recently, several small studies were conducted focusing on the early initiation of NIPPV in infants and pediatrics with acute bronchiolitis. One study monitored twenty-three children with acute bronchiolitis. The researchers found that NIPPV helped improve both the respiratory rate and carbon dioxide clearance. They were able to completely avoid IPPV. A retrospective study with eighty French infants with acute bronchiolitis compared the initiation of NIPPV versus IPPV. The infants that used NIPPV did not develop ventilator-associated pneumonia and required less supplemental oxygen after being weaned off the positive pressure ventilation. The length of hospital stay between NIPPV and IPPV were about the same. While these studies demonstrated some benefits of NIPPV in the care of neonates and pediatrics with bronchiolitis, they were limited by the small number of patients, thus making the results more difficult to generalize to the larger population.⁴

A larger retrospective study reviewed infants with acute bronchiolitis, under one year of age, who were admitted to the pediatric intensive care unit (PICU) during the winters of 2003-2004 and 2004-2005. The goal of this study was to compare how the initiation of NIPPV and IPPV impacted the duration of supplementary oxygen and ventilatory support required, as well as the rate of further complications. Infants that exhibited impending respiratory failure or rapid progression of disease were intubated. NIPPV was delivered via CPAP or bilevel positive airway pressure (BiPAP) through a nasal mask. CPAP was initially set at 5 cmH2O and increased up to 10 cmH2O and inspiratory pressure was initially set at 12 cmH2O and increased to 18 cmH2O. The study found that, infants on NIPPV overall required less supplementary oxygen, shorter duration of ventilatory support and reduced incidence of ventilator-associated pneumonia. The researchers felt that based on the data, NIPPV should be the primary method of treatment within this population.³

In conclusion, IPPV has been the traditional form of providing and maintaining ventilation in patients who become apneic, exhibit acute respiratory distress and/or impending respiratory failure. IPPV was also the primary mode of ventilation used in the treatment of premature infants and young children with acute bronchiolitis. With the growing interest in preventing ventilator associated complications and improved technology, the trend for ventilatory support of neonatal and pediatric patients is shifting towards early initiation of NIPPV modes. It is vital that treatment is selected on an individual basis, while utilizing evidence-based knowledge. The use of well-defined ventilator protocols and strategies may help improve ventilator management of infants and children.²

 

References:

 

1. Teague G, Batt-Thompson D, Walsh B, Crezee K. Noninvasive Mechanical Ventilation of the Infant and Child; Invasive Mechanical Ventilation of the Neonate and Pediatric Patient; Pediatric Airway Disorders and Parenchymal Lung Disease. In: Neonatal and Pediatric Respiratory Care, 4th edition Elsevier; 2015:287-342, 518-519.
2. Joseph RA. Neonatal Care. Prolonged Mechanical Ventilation: Challenges to Nurses and Outcome in Extremely Preterm Babies. Crit Care Nurse 2015;35(4):58-66.
3. Javouhey E, Barats A, Richard N, Stamm D, Floret D. Non-invasive ventilation as primary ventilatory support for infants with severe bronchiolitis. Intensive Care Med 2008;34(9):1608-1614.
4. Ganu SS, Gautam A, Wilkins B, Egan J. Increase in use of non-invasive ventilation for infants with severe bronchiolitis is associated with decline in intubation rates over a decade. Intensive Care Med 2012;38(7):1177-1183.