Safety and clinical findings of BiPAP utilization in children 20 kg or less for asthma exacerbations

Non-invasive positive pressure ventilation for acute asthma in children

BACKGROUND

Asthma is one of the most common reasons for hospital admission among children, with significant economic burden and impact on quality of life. Non-invasive positive pressure ventilation (NPPV) is increasingly used in the care of children with acute asthma, although the evidence supporting it is weak, and clinical guidelines do not offer any recommendations on its routine use. However, NPPV might be an effective way to improve outcomes for some children with asthma. A previous review did not demonstrate a clear benefit, but was limited by few studies with small sample sizes. This is an update of the previous review.

OBJECTIVES

To assess the benefits and harms of NPPV as an add-on therapy to usual care (e.g. bronchodilators and corticosteroids) in children (< 18 years) with acute asthma.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register, CENTRAL, MEDLINE, and Embase. We also conducted a search of ClinicalTrials.gov and the WHO ICTRP. We searched all databases from their inception to March 2023, with no restrictions on language of publication.

SELECTION CRITERIA

We included randomised clinical trials (RCTs) assessing NPPV as add-on therapy to usual care versus usual care for children hospitalised for acute asthma exacerbations.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods.

MAIN RESULTS

We included three RCTs randomising 60 children with acute asthma to NPPV and 60 children to control. All included trials assessed the effects of bilevel positive airway pressure (BiPAP) for acute asthma in a paediatric intensive care unit (PICU) setting. None of the trials used continuous positive airway pressure (CPAP). The controls received standard care. The median age of children ranged from three to six years, and asthma severity ranged from moderate to severe. Our primary outcome measures were all-cause mortality, serious adverse events, and asthma symptom score. Secondary outcomes were non-serious adverse events, health-related quality of life, arterial blood gases and pH, pneumonia, cost, and PICU length of stay. None of the trials reported any deaths or serious adverse events (except one trial that reported intubation rate). Two trials reported asthma symptom score, each demonstrating reductions in asthma symptoms in the BiPAP group. In one trial, the asthma symptom score was (mean difference (MD) -2.50, 95% confidence interval (CI) -4.70 to -0.30, P = 0.03; 19 children) lower in the BiPAP group. In the other trial, a cross-over trial, BiPAP was associated with a lower mean asthma symptom score (MD -3.7; 16 children; very low certainty evidence) before cross-over, but investigators did not report a standard deviation, and it could not be estimated from the first phase of the trial before cross-over. The reduction in both trials was above our predefined minimal important difference. Overall, NPPV with standard care may reduce asthma symptom score compared to standard care alone, but the evidence is very uncertain. The only reported serious adverse event was intubation rate in one trial. The trial had an intubation rate of 40% and showed that BiPAP may result in a large reduction in intubation rate (risk ratio 0.47, 95% CI 0.23 to 0.95; 78 children), but the evidence is very uncertain. Post hoc analysis showed that BiPAP may result in a slight decrease in length of PICU stay (MD -0.87 day, 95% CI -1.52 to -0.22; 100 children), but the evidence is very uncertain. Meta-analysis or Trial Sequential Analysis was not possible because of insufficient reporting and different scoring systems. All three trials had high risk of bias with serious imprecision of results, leading to very low certainty of evidence.

AUTHORS' CONCLUSIONS

The currently available evidence for NNPV is uncertain. NPPV may lead to an improvement in asthma symptom score, decreased intubation rate, and slightly shorter PICU stay; however, the evidence is of very low certainty. Larger RCTs with low risk of bias are warranted.

[Non-invasive Mechanical Ventilation in Acute Respiratory Failure. Clinical Practice Guidelines - on behalf of the German Society of Pneumology and Ventilatory Medicine]

The guideline update outlines the advantages as well as the limitations of NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications.Non-invasive ventilation (NIV) has a high value in therapy of hypercapnic acute respiratory failure, as it significantly reduces the length of ICU stay and hospitalization as well as mortality.Patients with cardiopulmonary edema and acute respiratory failure should be treated with continuous positive airway pressure (CPAP) and oxygen in addition to necessary cardiological interventions. This should be done already prehospital and in the emergency department.In case of other forms of acute hypoxaemic respiratory failure with only mild or moderately disturbed gas exchange (PaO2/FiO2 > 150 mmHg) there is no significant advantage or disadvantage compared to high flow nasal oxygen (HFNO). In severe forms of ARDS NIV is associated with high rates of treatment failure and mortality, especially in cases with NIV-failure and delayed intubation.NIV should be used for preoxygenation before intubation. In patients at risk, NIV is recommended to reduce extubation failure. In the weaning process from invasive ventilation NIV essentially reduces the risk of reintubation in hypercapnic patients. NIV is regarded useful within palliative care for reduction of dyspnea and improving quality of life, but here in concurrence to HFNO, which is regarded as more comfortable. Meanwhile NIV is also recommended in prehospital setting, especially in hypercapnic respiratory failure and pulmonary edema.With appropriate monitoring in an intensive care unit NIV can also be successfully applied in pediatric patients with acute respiratory insufficiency.

Changes in the Use of Invasive and Noninvasive Mechanical Ventilation in Pediatric Asthma: 2009-2019

Rationale: Despite lower overall hospitalization rates for asthma in recent years, there has been an increase in the number of pediatric patients receiving intensive care management in the United States. Objectives: To investigate how the use of invasive and noninvasive mechanical ventilation for asthma has changed in the context of an evolving cohort of critically ill pediatric patients with asthma. Methods: We analyzed children admitted to intensive care units for asthma from 2009 through 2019 in the Virtual Pediatric Systems database. Regression analyses were used to evaluate how respiratory support interventions, mortality, and patient characteristics have changed over time. Odds ratios were calculated to determine how patient characteristics were associated with respiratory support needs. Stratified analyses were performed to determine how changing practice patterns may have differed between patient subgroups. Results: There were 67,614 admissions for 56,727 patients analyzed. Intubation occurred in 4.6% of admissions and decreased from 6.9% to 3.4% over time (P < 0.001), whereas noninvasive ventilation as the maximal respiratory support increased from 8.9% to 20.0% (P < 0.001). Over time, the cohort shifted to include more 2- to 6-year-olds and patients of Asian/Pacific Islander or Hispanic race/ethnicity. Although intubation decreased and noninvasive ventilation increased in all subgroups, the changes were most pronounced in the youngest patients and slightly less pronounced for obese patients. Conclusions: In pediatric asthma, use of intubation has halved, whereas use of noninvasive ventilation has more than doubled. This change in practice appears partially related to a younger patient cohort, although other factors merit exploration.

High-flow nasal cannula in children with asthma exacerbation: A review of current evidence

Asthma is the commonest obstructive airway disease and the leading cause of morbidity in children. In the pediatric population, acute exacerbations of asthma are a frequent cause of presentations and hospital admissions. An acute asthma exacerbation is potentially life-threatening; it is predominantly treated using conventional oxygen therapy with bronchodilators and systemic corticosteroids. The treatment of those who do not respond to conventional therapy is escalated to noninvasive positive pressure ventilation (NIPPV) before invasive ventilation. Although NIPPV has demonstrated benefits and safety, it still has limitations such as treatment intolerance caused mainly by discomfort and complications. High-flow oxygen therapy administered through a nasal cannula (HFNC) provides respiratory support with adequate airway humidity and has demonstrated safety and benefits in clinical practice. In the present review, we discuss HFNC and variations in HFNC use, focusing on its feasibility and current evidence of using it on children with asthma exacerbations.

[Paediatric Life Support]

The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.

European Resuscitation Council Guidelines 2021: Paediatric Life Support

These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.

Trends in the Use of Noninvasive and Invasive Ventilation for Severe Asthma

OBJECTIVES

To explore and define contemporary trends in the use of invasive mechanical ventilation (IMV) and noninvasive ventilation (NIV) in the treatment of children with asthma.

METHODS

We performed a serial cross-sectional analysis using data from the Pediatric Health Information System. We examined 2014-2018 admission abstracts from patients aged 2 to 17 years who were admitted to member hospitals with a primary diagnosis of asthma. We report temporal trends in IMV use, NIV use, ICU admission, length of stay, and mortality.

RESULTS

Over the study period, 48 hospitals reported 95 204 admissions with a primary diagnosis of asthma. Overall, IMV use remained stable at 0.6% between 2014 and 2018 (interquartile range [IQR]: 0.3%-1.1% and 0.2%-1.3%, respectively), whereas NIV use increased from 1.5% (IQR: 0.3%-3.2%) to 2.1% (IQR: 0.3%-5.6%). There was considerable practice variation among centers, with NIV rates more than doubling within the highest quartile of users (from 4.8% [IQR: 2.8%-7.5%] to 13.2% [IQR: 7.4%-15.2%]; P < .02). ICU admission was more common among centers with high NIV use, but centers with high NIV use did not differ from lower-use centers in mortality, IMV use, or overall average length of stay.

CONCLUSIONS

The use of IMV is at historic lows, and NIV has replaced it as the primary mechanical support mode for asthma. However, there is considerable variability in NIV use. Increased NIV use was not associated with a change in IMV rates, which remained stable. Higher NIV use was associated with increased ICU admissions. NIV's precise contribution to the cost and quality of care remains to be determined.

Extracorporeal and advanced therapies for progressive refractory near-fatal acute severe asthma in children

Asthma is the most common chronic illness and is one of the most common medical emergencies in children. Progressive refractory near-fatal asthma requiring intubation and mechanical ventilation can lead to death. Extracorporeal membrane oxygenation (ECMO) can provide adequate gas exchange during acute respiratory failure although data on outcomes in children requiring ECMO support for status asthmaticus is sparse with one study reporting survival rates of nearly 85% with asthma being one of the best outcome subsets for patients with refractory respiratory failure requiring ECMO support. We describe the current literature on the use of ECMO and other advanced extracorporeal therapies available for children with acute severe asthma. We also review other advanced invasive and noninvasive therapies in acute severe asthma both before and while on ECMO support.

A Respiratory Therapist-Driven Asthma Pathway Reduced Hospital Length of Stay in the Pediatric Intensive Care Unit

BACKGROUND

Asthma is a common reason for admissions to the pediatric intensive care unit (PICU). Since June 2014, our institution has used a pediatric asthma clinical pathway for all patients, including those in PICU. The pathway promotes respiratory therapist-driven bronchodilator weaning based on the Modified Pulmonary Index Score (MPIS). This pathway was associated with decreased hospital length of stay (LOS) for all pediatric asthma patients; however, the effect on PICU patients was unclear. We hypothesized that the implementation of a pediatric asthma pathway would reduce hospital LOS for asthmatic patients admitted to the PICU.

METHODS

We retrospectively reviewed the medical records of all pediatric asthma subjects 2-17 y old admitted to our PICU before and after pathway initiation. Primary outcome was hospital LOS. Secondary outcomes were PICU LOS and time on continuous albuterol. Data were analyzed using the chi-square test for categorical data, the t test for normally distributed data, and the Mann-Whitney test for nonparametric data.

RESULTS

A total of 203 eligible subjects (49 in the pre-pathway group, 154 in the post group) were enrolled. There were no differences between groups for age, weight, gender, home medications, cause of exacerbation, medical history, or route of admission. There were significant decreases in median (interquartile range) hospital LOS (4.4 [2.9-6.6] d vs 2.7 [1.6-4.0] d, P < .001), median PICU LOS (2.1 [1.3-4.0] d vs 1.6 [0.8-2.4] d, P = .003), and median time on continuous albuterol (39 [25-85] h vs 27 [13-42] h, P = .001). Significantly more subjects in the post-pathway group were placed on high-flow nasal cannula (32% vs 6%, P = .001) or noninvasive ventilation (10% vs 4%, P = .02).

CONCLUSION

The implementation of an asthma pathway was associated with decreased hospital LOS, PICU LOS, and time on continuous albuterol. There was also an increase in the use of high-flow nasal cannula and noninvasive ventilation after the implementation of this clinical pathway.

Paediatric ED BiPAP continuous quality improvement programme with patient analysis: 2005-2013

OBJECTIVE

In paediatric moderate-to-severe asthmatics, there is significant bronchospasm, airway obstruction, air trapping causing severe hyperinflation with more positive intraplural pressure preventing passive air movement. These effects cause an increased respiratory rate (RR), less airflow and shortened inspiratory breath time. In certain asthmatics, aerosols are ineffective due to their inadequate ventilation. Bilevel positive airway pressure (BiPAP) in acute paediatric asthmatics can be an effective treatment. BiPAP works by unloading fatigued inspiratory muscles, a direct bronchodilation effect, offsetting intrinsic PEEP and recruiting collapsed alveoli that reduces the patient's work of breathing and achieves their total lung capacity quicker. Unfortunately, paediatric emergency department (PED) BiPAP is underused and quality analysis is non-existent. A PED BiPAP Continuous Quality Improvement Program (CQIP) from 2005 to 2013 was evaluated using descriptive analytics for the primary outcomes of usage, safety, BiPAP settings, therapeutics and patient disposition.

INTERVENTIONS

PED BiPAP CQIP descriptive analytics.

SETTING

Academic PED.

PARTICIPANTS

1157 patients.

INTERVENTIONS

A PED BiPAP CQIP from 2005 to 2013 for the usage, safety, BiPAP settings, therapeutic response parameters and patient disposition was evaluated using descriptive analytics.

PRIMARY AND SECONDARY OUTCOMES

Safety, usage, compliance, therapeutic response parameters, BiPAP settings and patient disposition.

RESULTS

1157 patients had excellent compliance without complications. Only 6 (0.5%) BiPAP patients were intubated. BiPAP median settings: IPAP 18 (16,20) cm H₂O range 12-28; EPAP 8 cmH₂O (8,8) range 6-10; inspiratory-to-expiratory time (I:E) ratio 1.75 (1.5,1.75). Pediatric Asthma Severity score and RR decreased (p<0.001) while tidal volume increased (p<0.001). Patient disposition: 325 paediatric intensive care units (PICU), 832 wards, with 52 of these PED ward patients were discharged home with only 2 hours of PED BiPAP with no returning to the PED within 72 hours.

CONCLUSIONS

BiPAP is a safe and effective therapeutic option for paediatric patients with asthma presenting to a PED or emergency department. This BiPAP CQIP showed significant patient compliance, no complications, improved therapeutics times, very low intubations and decreased PICU admissions. CQIP analysis demonstrated that using a higher IPAP, low EPAP with longer I:E optimises the patient's BiPAP settings and showed a significant improvement in PAS, RR and tidal volume. BiPAP should be considered as an early treatment in the PED severe or non-responsive moderate asthmatics.

Non-invasive positive pressure ventilation for acute asthma in children

BACKGROUND

Asthma is one of the most common reasons for hospital admission among children and constitutes a significant economic burden. Use of non-invasive positive pressure ventilation (NPPV) in the care of children with acute asthma has increased even though evidence supporting the intervention has been considered weak and clinical guidelines do not recommend the intervention. NPPV might be an effective intervention for acute asthma, but no systematic review has been conducted to assess the effects of NPPV as an add-on therapy to usual care in children with acute asthma.

OBJECTIVES

To assess the benefits and harms of NPPV as an add-on therapy to usual care (e.g. bronchodilators and corticosteroids) in children with acute asthma.

SEARCH METHODS

We identified trials from the Cochrane Airways Group Specialised Register (CAGR). The Register contains trial reports identified through systematic searches of bibliographic databases, including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, AMED and PsycINFO, and by handsearching of respiratory journals and meeting abstracts. We also conducted a search of ClinicalTrials.gov (www.ClinicalTrials.gov) and the WHO trials portal (www.who.int/ictrp/en/). We searched all databases from their inception to February 2016, with no restriction on language of publication.

SELECTION CRITERIA

We included randomised clinical trials (RCTs) assessing NPPV as add-on therapy to usual care versus usual care for children (age < 18 years) hospitalised for an acute asthma attack.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts. We retrieved all relevant full-text study reports, independently screened the full text, identified trials for inclusion and identified and recorded reasons for exclusion of ineligible trials. We resolved disagreements through discussion or, if required, consulted a third review author. We recorded the selection process in sufficient detail to complete a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) flow diagram and 'Characteristics of excluded studies' table. We identified the risk of bias of included studies to reduce the risk of systematic error. We contacted relevant study authors when data were missing.

MAIN RESULTS

We included two RCTs that randomised 20 participants to NPPV and 20 participants to control. We assessed both studies as having high risk of bias; both trials assessed effects of bilateral positive airway pressure (BiPAP). Neither trial used continuous positive airway pressure (CPAP). Controls received standard care. Investigators reported no deaths and no serious adverse events (Grades of Recommendation, Assessment, Development and Evaluation (GRADE): very low quality of evidence due to serious risk of bias and serious imprecision of results). Both trials showed a statistically significant reduction in symptom score. One trial did not report a standard deviation (SD), but by using an estimated SD, we found a statistically significantly reduced asthma symptom score (mean difference (MD) -2.50, 95% confidence interval (CI) -4.70 to -0.30, P = 0.03, 19 participants, GRADE: very low quality of evidence). In the other trial, NPPV was associated with a lower total symptom score (5.6 vs 1.9, 16 participants, very low quality of evidence) before cross-over, but investigators did not report an SD, nor could it be estimated from the first phase of the trial, before the cross-over. These gains could be clinically relevant, as a reduction of three or more points in symptom score is considered a clinically meaningful change. Researchers documented five dropouts (12.5%), four of which were due to intolerance to NPPV, and one to respiratory failure requiring intubation. Owing to insufficient reporting in the latter trial and use of different scoring systems, it was not possible to conduct a meta-analysis nor a Trial Sequential Analysis.

AUTHORS' CONCLUSIONS

Current evidence does not permit confirmation or rejection of the effects of NPPV for acute asthma in children. Large RCTs with low risk of bias are warranted.

Pediatric acute asthma exacerbations: Evaluation and management from emergency department to intensive care unit

OBJECTIVE

The goal of this report is to review available modalities for assessing and managing acute asthma exacerbations in pediatric patients, including some that are not included in current expert panel guidelines. While it is not our purpose to provide a comprehensive review of the National Asthma Education and Prevention Program (NAEPP) guidelines, we review NAEPP-recommended treatments to provide the full range of treatments available for managing exacerbations with an emphasis on the continuum of care between the ER and ICU.

DATA SOURCES

We searched PubMed using the following search terms in different combinations: asthma, children, pediatric, exacerbation, epidemiology, pathophysiology, guidelines, treatment, management, oxygen, albuterol, β2-agonist, anticholinergic, theophylline, corticosteroid, magnesium, heliox, BiPAP, ventilation, mechanical ventilation, non-invasive mechanical ventilation and respiratory failure. We attempted to weigh the evidence using the hierarchy in which meta-analyses of randomized controlled trials (RCTs) provide the strongest evidence, followed by individual RCTs, followed by observational studies. We also reviewed the NAEPP and Global Initiative for Asthma expert panel guidelines.

RESULTS AND CONCLUSIONS

Asthma is the most common chronic disease of childhood, and acute exacerbations are a significant burden to patients and to public health. Optimal assessment and management of exacerbations, including appropriate escalation of interventions, are essential to minimize morbidity and prevent mortality. While inhaled albuterol and systemic corticosteroids are the mainstay of exacerbation management, escalation may include interventions discussed in this review.

Noninvasive ventilation in status asthmaticus in children: levels of evidence

OBJECTIVE

To evaluate the quality of available evidence to establish guidelines for the use of noninvasive ventilation for the management of status asthmaticus in children unresponsive to standard treatment.

METHODS

Search, selection and analysis of all original articles on asthma and noninvasive ventilation in children, published until September 1, 2014 in all languages in the electronic databases PubMed, Web of Science, Cochrane Library, Scopus and SciELO, located using the search terms: "asthma", "status asthmaticus", "noninvasive ventilation", "Bronchospasm", "continuous positive airway pressure", "child", "infant", "pediatrics", "hypercapnia", "respiratory failure" and the keywords "BIPAP", "CPAP", "Bilevel", "acute asthma" and "near fatal asthma". The articles were assessed based on the levels of evidence of the GRADE system.

RESULTS

Only nine original articles were located; two (22%) articles had level of evidence A, one (11%) had level of evidence B and six (67%) had level of evidence C.

CONCLUSION

The results suggest that noninvasive ventilation is applicable for the treatment of status asthmaticus in most pediatric patients unresponsive to standard treatment. However, the available evidence cannot be considered as conclusive, as further high-quality research is likely to have an impact on and change the estimate of the effect.

Childhood asthma: a guide for pediatric emergency medicine providers

Pediatric asthma is a disease that is managed across outpatient physicians, hospitalists, critical care physicians, and emergency department (ED) physicians. Scoring systems may facilitate a rapid assessment of the child with asthma in the ED. Short-acting beta agonists are still the mainstay of therapy for acute exacerbations along with corticosteroids and ipratropium bromide. ED providers must also know the indications for noninvasive ventilation and intubation. Most patients can be treated and discharged from the ED after acute exacerbation, and should be given a plan for going home that provides educational material and emergency scenarios to help prevent future acute incidents.