Noninvasive positive pressure ventilation in infants with respiratory failure

Introduction

Respiratory failure is a common indication for admission to a pediatric intensive care unit (PICU). Tracheal intubation and invasive ventilation carries some risk and can contribute to morbidity and possible mortality. Noninvasive positive pressure ventilation (NIPPV) is a mode in which ventilation is applied without tracheal intubation but via nasal prongs or a face mask. We hypothesized that using NIPPV in infants with pending respiratory failure may improve their outcome.

Methods

In this prospective study, we enrolled infants admitted with pending respiratory failure to the PICU. NIPPV was delivered using silicone INCA nasal prongs (Ackrad Labs, Trumbull, CT, USA) connected to an INFANT STAR 950 standard ventilator. The NIPPV mode of support (continuous positive airway pressure vs. synchronized nasal intermittent positive pressure ventilation) was set to meet patient needs. Vital signs, ventilator settings and laboratory results were recorded electronically. The primary outcome was prevention of invasive ventilation. Secondary outcomes were seeking a physiological marker for NIPPV failure and complications from NIPPV.

Results

Between December 2007 and November 2008, 18 patients (15 infants, three enrolled twice) were eligible to receive NIPPV based on the attending physician's decision. Median age was 3 months (15 days to 17 months). Eleven patients had apnea and seven patients had respiratory distress. Among them, five patients had bronchiolitis, two had central hypotonia, two had Pertussis and six patients had other miscellaneous respiratory conditions needing support. Fourteen infants (78%) were improved and weaned off NIPPV while four (22%) infants had to be intubated. The mean length of NIPPV was 47 hours. No complication secondary to the NIPPV was recorded. No single vital sign or laboratory test predicted whether a patient would improve or fail NIPPV, although the improvement (when happened) was noticed within hours of NIPPV. All four failures were due to continuum of apnea.

Conclusion

Our study shows that NIPPV is a safe and successful method to support infants suffering from pending respiratory failure. Lacking a physiological or biological marker that could distinguish between so-called responders and nonresponders to NIPPV, and the high rate of success in preventing the need for invasive ventilation, supports our recommendation to trial any infant in pending respiratory failure with NIPPV.