Use of continuous positive airway pressure during stabilisation and retrieval of infants with suspected bronchiolitis

Noninvasive Respiratory Support during Pediatric Critical Care Transport: A Retrospective Cohort Study

Noninvasive respiratory support (NRS) including high flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), and bilevel positive airway pressure (BiPAP) is increasingly used for children with respiratory failure requiring interhospital transport by pediatric critical care transport (PCCT) teams. In this retrospective observational study of children receiving NRS on transport between January 1 st , 2017 and December 31 st , 2019 by a single PCCT service in England, we describe a cohort of children, looking at patient characteristics, journey logistics, adverse events, and failure of NRS (as defined by emergency intubation on transport or within 24 hours of arriving on the pediatric intensive care unit), and to attempt to identify risk factors that were associated with NRS failure. A total of 3,504 patients were transported during the study period. Three hundred and seventeen (9%) received NRS. Median age was 4.9 months (IQR: 1.0-18.2); median weight was 5.1 kg (IQR: 3.1-13). The primary diagnostic category was cardiorespiratory in 244/317 (77%) patients. Comorbidities were recorded in 189/317 (59.6%) patients. Median Pediatric Index of Mortality-3 (PIM3) score was 0.024 (IQR: 0.012-0.045). Median stabilization time was 80 minutes while median patient journey time was 40 minutes. Nineteen adverse events were described (clinical deterioration, equipment failure/interface issues) affecting 6% of transports. The incidence of NRS failure was 6.6%. No risk factors associated with NRS failure were identified. We concluded that NRS can be considered safe during pediatric transport for children with a wide range of diagnoses and varying clinical severity, with a low rate of adverse events and need for intubation on transport or on the PICU.

Clinical practice guidelines: management of severe bronchiolitis in infants under 12 months old admitted to a pediatric critical care unit

PURPOSE

We present guidelines for the management of infants under 12 months of age with severe bronchiolitis with the aim of creating a series of pragmatic recommendations for a patient subgroup that is poorly individualized in national and international guidelines.

METHODS

Twenty-five French-speaking experts, all members of the Groupe Francophone de Réanimation et Urgence Pédiatriques (French-speaking group of paediatric intensive and emergency care; GFRUP) (Algeria, Belgium, Canada, France, Switzerland), collaborated from 2021 to 2022 through teleconferences and face-to-face meetings. The guidelines cover five areas: (1) criteria for admission to a pediatric critical care unit, (2) environment and monitoring, (3) feeding and hydration, (4) ventilatory support and (5) adjuvant therapies. The questions were written in the Patient-Intervention-Comparison-Outcome (PICO) format. An extensive Anglophone and Francophone literature search indexed in the MEDLINE database via PubMed, Web of Science, Cochrane and Embase was performed using pre-established keywords. The texts were analyzed and classified according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. When this method did not apply, an expert opinion was given. Each of these recommendations was voted on by all the experts according to the Delphi methodology.

RESULTS

This group proposes 40 recommendations. The GRADE methodology could be applied for 17 of them (3 strong, 14 conditional) and an expert opinion was given for the remaining 23. All received strong approval during the first round of voting.

CONCLUSION

These guidelines cover the different aspects in the management of severe bronchiolitis in infants admitted to pediatric critical care units. Compared to the different ways to manage patients with severe bronchiolitis described in the literature, our original work proposes an overall less invasive approach in terms of monitoring and treatment.

Noninvasive ventilation of air transported infants with respiratory distress in the Canadian Arctic

Objectives

Since 2016, use of nasal continuous positive airway pressure (nCPAP) in Nunavut for air transport in select patients has become common practice. This study examines the outcomes of patients transferred by air from the Qikiqtaaluk Region during air transport. We examined intubation rates, adverse events during transfer, and respiratory parameters at departure and upon arrival.

Methods

This was a retrospective review from September 2016 to December 2019 including patients under 2 years of age transferred by air on nCPAP from the Qikiqtaaluk Region of Nunavut.

Results

Data were collected for 40 transfers involving 34 unique patients. Six transfers were from remote communities in Nunavut to Iqaluit, and 33 transfers were from Iqaluit to CHEO. The primary outcome measure was whether the patient required intubation during transport, or urgent intubation upon arrival to CHEO. The median nCPAP setting during transport was 6 cm H2O (5–7 cm H2O) and at arrival to CHEO was 6 cm H2O (6–7 cm H2O). Six of the 33 (18.2%) patients required intubation during their hospital stay and five (15.2%) in a controlled ICU setting. There were no discernible adverse events that occurred during transport for 28 patients (84.5%). Four patients (12.1%) required a brief period of bag-mask ventilation and one patient had an episode of bradycardia.

Conclusions

nCPAP on air transport is a safe and useful method for providing ventilatory support to infants and young children with respiratory distress.

Continuous Positive Airway Pressure vs. High Flow Nasal Cannula in children with acute severe or moderate bronchiolitis. A systematic review and Meta-analysis

OBJECTIVE

To compare the safety and effectiveness of Continuous Positive Airway Pressure (CPAP) vs. High Flow Nasal Cannula (HFNC) to prevent therapeutic failure and the need of invasive ventilation in children with acute moderate-severe bronchiolitis.

DESIGN

A systematic review and meta-analysis.

SETTING

Medline, Embase, Lilacs, Cochrane and gray literature (May 2020) was performed.

PARTICIPANTS

Randomized clinical trials patients with moderate to severe bronchiolitis.

MAIN VARIABLES

Therapeutic failure, need for invasive ventilation, adverse events, length of PCCU and of hospital stay.

INTERVENTION

The quality of the studies was assessed with the Cochrane risk and bias tool. We conducted meta-analysis using fixed effect model and random effects model.

RESULTS

Three RCTs were included. Showed less risk of therapeutic failure with CPAP compared with HFNC (RR=0.7; 95%CI 0.5-0.99) developed hours later in patients with CPAP (MD=3.16; 95%CI 1.55-4.77). We did not find differences in other outcomes, such as need of invasive ventilation (RR=0.60; 95%CI 0.25-1.43), apnea (RR=0.40; 95%CI 0.08-1.99), or number of days in the intensive care unit (MD=0.02; 95%CI -0.38 to 0.42), and length of hospitalization (MD=-1.00; 95%IC -2.66 to 0.66). Adverse events (skin lesions) were more common with CPAP (RR 2.47; 95%CI 1.17-5.22).

CONCLUSIONS

In moderate/severe bronchiolitis CPAP demonstrated a lower risk of therapeutic failure and a longer time to failure. But more adverse events like nasal injury. There were no differences in other variables.

Neonatal emergency transport teams and general emergency departments: Who will intubate the neonate?

OBJECTIVE

Confidence treating critically ill infants presenting to general ED may be limited by inexperience, with procedures deferred until specialised transport teams arrive.

METHODS

This retrospective cohort study analysed critical procedures performed by referring ED physicians, compared with a neonatal emergency transport service, on infants transferred over a 12-month period.

RESULTS

All 150 eligible infants were included, with median (interquartile range) age 28 (16-43) days. Forty critical procedures were performed in this cohort. Of 26 intubations, 17 (65%) were performed by local ED physicians.

CONCLUSION

Referring ED physicians perform the majority of critical procedures where infants require inter-hospital transfer by neonatal emergency transport service.

Critical Breaths in Transit: A Review of Non-invasive Ventilation (NIV) for Neonatal and Pediatric Patients During Transportation

Respiratory illnesses are a leading cause of death for children worldwide, with the majority of these cases occurring from preterm birth complications or acute respiratory infections. Appropriate respiratory intervention must be provided quickly to lower the chances of death or permanent harm. As a result, respiratory support given in prehospital and interfacility transport can substantially improve health outcomes for these patients, particularly in areas where transportation time to appropriate facilities is lengthy. Existing literature supports the use of non-invasive ventilation (NIV), such as nasal or bilevel continuous positive airway pressure, as a safe form of respiratory support for children under 18 years old in certain transportation settings. This mini review summarizes the literature on pediatric NIV in transport and highlights significant gaps that future researchers should address. In particular, we identify the need to: solidify clinical guidelines for the selection of eligible pediatric patients for transport on NIV; explore the range of factors influencing successful NIV implementation during transportation; and apply appropriate best practices in low and middle income countries.

Continuous Positive Airway Pressure vs. High Flow Nasal Cannula in children with acute severe or moderate bronchiolitis. A systematic review and Meta-analysis

OBJECTIVE

To compare the safety and effectiveness of Continuous Positive Airway Pressure (CPAP) vs. High Flow Nasal Cannula (HFNC) to prevent therapeutic failure and the need of invasive ventilation in children with acute moderate-severe bronchiolitis.

DESIGN

A systematic review and meta-analysis.

SETTING

Medline, Embase, Lilacs, Cochrane and gray literature (May 2020) was performed.

PARTICIPANTS

Randomized clinical trials patients with moderate to severe bronchiolitis.

MAIN VARIABLES

Therapeutic failure, need for invasive ventilation, adverse events, length of PCCU and of hospital stay.

INTERVENTION

The quality of the studies was assessed with the Cochrane risk and bias tool. We conducted meta-analysis using fixed effect model and random effects model.

RESULTS

Three RCTs were included. Showed less risk of therapeutic failure with CPAP compared with HFNC (RR=0.7; 95%CI 0.5-0.99) developed hours later in patients with CPAP (MD=3.16; 95%CI 1.55-4.77). We did not find differences in other outcomes, such as need of invasive ventilation (RR=0.60; 95%CI 0.25-1.43), apnea (RR=0.40; 95%CI 0.08-1.99), or number of days in the intensive care unit (MD=0.02; 95%CI -0.38 to 0.42), and length of hospitalization (MD=-1.00; 95%IC -2.66 to 0.66). Adverse events (skin lesions) were more common with CPAP (RR 2.47; 95%CI 1.17-5.22).

CONCLUSIONS

In moderate/severe bronchiolitis CPAP demonstrated a lower risk of therapeutic failure and a longer time to failure. But more adverse events like nasal injury. There were no differences in other variables.

Use of Noninvasive Ventilation and High-Flow Nasal Therapy for Infants and Children with Acute Respiratory Distress Outside of Paediatric Intensive Care: A review article

Noninvasive ventilation (NIV) and high-flow nasal cannulae therapy (HFNCT) are first-line methods of treatment for children presenting with acute respiratory distress, with paediatric intensive care units (PICUs) providing an ideal environment for subsequent treatment monitoring. However, the availability of step-down units, where NIV and HFNCT can be safely utilised, has reduced the need for such patients to be admitted to PICUs, thereby leading to the better overall utilisation of critical care resources. In addition, NIV and HFNCT can also be used during transport instead of invasive ventilation, thus avoiding the complications associated with the latter approach. This review article examines the safety and applicability of these respiratory support approaches outside of paediatric intensive care as well as various factors associated with treatment success or failure.

[Predictive factors for failure of continuous positive airway pressure treatment in infants with bronchiolitis]

OBJECTIVE

To study the predictive factors for the failure of continuous positive airway pressure (CPAP) treatment in infants with bronchiolitis.

METHODS

A retrospective analysis was performed on the clinical data of 310 hospitalized children (aged 1-12 months) with bronchiolitis treated with CPAP. Their clinical features were compared between the successful treatment group (270 cases) and the failed treatment group (40 cases). A multivariate logistic regression analysis was used to explore the predictive factors for failure of CPAP treatment.

RESULTS

The multivariate logistic regression analysis showed that the score of the Pediatric Risk of Mortality III (PRISM III) ≥10 (OR=13.905), development of atelectasis (OR=12.080), comorbidity of cardiac insufficiency (OR=7.741), and no improvement in oxygenation index (arterial partial pressure of oxygen/fraction of inhaled oxygen, P/F) after 2 hours of CPAP treatment (OR=34.084) were predictive factors for failure of CPAP treatment for bronchiolitis (P<0.05). In predicting CPAP treatment failure, no improvement in P/F after 2 hours of CPAP treatment had an area under the receiver operating characteristic curve of 0.793, with a sensitivity of 70.3% and a specificity of 82.4% at a cut-off value of 203.

CONCLUSIONS

No improvement in P/F after 2 hours of CPAP treatment, PRISM III score ≥10, development of atelectasis, and comorbidity of cardiac insufficiency can be used as predictive factors for CPAP treatment failure in infants with bronchiolitis.

[CPAP vs oxygen therapy in infants being transported due to acute respiratory failure]

OBJECTIVE

The aims of our study are to evaluate the effectiveness and security of CPAP (continuous positive airway pressure) in infants transferred with acute respiratory failure (ARF) and to compare their evolution in PICU between CPAP vs oxygen therapy.

MATERIALS AND METHODS

We conducted a retrospective observational and analytical study by reviewing the health records of infants with ARF aged 0 to 12months that required interhospital transfer to the PICU.

RESULTS

We included 110 patients: 71 transported with CPAP and 39 with oxygen therapy. The main cause of ARF was acute bronchiolitis (81.8%). The median level of CPAP was 7cmH₂O (interquartile range, 6-7). Controlling by the previous values in specific multivariable models, CPAP produced a significant decrease in the Wood-Downes score (beta = -1.08; 95% CI = -1.76 to -0.40; P = .002) and the heart rate (beta = -19.64, 95% CI = -28.46 to -10.81; P < .001). No patients required endotracheal intubation during transport. During the PICU stay, the intubation rate was similar in the CPAP group (7%) and the oxygen therapy group (5.1%) (P=.689). The proportion of patients that required bilevel positive airway pressure within 6hours of admission to the PICU was higher in the oxygen therapy group: 100% (11/11) vs 69.2% (18/26), P=.04.

CONCLUSIONS

Early administration of CPAP to infants with ARF was a safe respiratory support intervention during interhospital transport. During patient transport, the use of CPAP achieved greater decreases in the Wood-Downes score and heart rate compared to oxygen therapy.

Nasal CPAP on paediatric air transport in the Canadian Arctic: A case series

Aims

Paediatric transport in remote regions of Canada represents a huge challenge given the acuity of the patients, immense distances, weather and lack of road infrastructure. Transport of patients in the Baffin region of Nunavut is completed entirely by air transport. Two very common paediatric transports are in regards to lower respiratory tract infections and premature deliveries in small rural communities north of Iqaluit. Recently, the advent of noninvasive ventilation has been introduced to the region.

Method

We report five cases of long-distance air transport of paediatric patients in respiratory distress using nasal continuous positive airway pressure (nCPAP). Two cases involve lower respiratory tract infections, and three cases involve neonates (two premature infants and one term infant).

Results

Overall, these cases highlight effective and safe use of noninvasive ventilation in air transport of patients in respiratory distress and demonstrate how this modality can improve patient transport in rural and remote regions.

Variability of Care in Infants with Severe Bronchiolitis: Less-Invasive Respiratory Management Leads to Similar Outcomes

OBJECTIVE

To compare the management of children with severe bronchiolitis requiring intensive care (based on duration of ventilatory support and duration of pediatric intensive care unit [PICU] stay) in 2 countries with differing pediatric transport and PICU organizations.

STUDY DESIGN

This was a prospective observational care study in 2 PICUs of tertiary care university hospitals, 1 in France and 1 in Canada. All children with bronchiolitis who required admission to the PICU between November 1, 2013, and March 31, 2014, were included.

RESULTS

A total of 194 children were included. Baseline characteristics and illness severity were similar at the 2 sites. There was a significant difference between centers in the use of invasive ventilation (3% in France vs 26% in Canada; P < .0001). The number of investigations performed from admission to emergency department presentation and during the PICU stay was significantly higher in Canada for both chest radiographs and blood tests (P < .001). The use of antibiotics was significantly higher in Canada both before (60% vs 28%; P < .001) and during (72% vs 33%; P < .0001) the PICU stay. The duration of ventilatory support, median length of stay, and rate of PICU readmission were similar in the 2 centers.

CONCLUSION

Important differences in the management of children with severe bronchiolitis were observed during both prehospital transport and PICU treatment. Less invasive management resulted in similar outcomes with in fewer complications.

CPAP and High-Flow Nasal Cannula Oxygen in Bronchiolitis

Severe respiratory failure develops in some infants with bronchiolitis because of a complex pathophysiologic process involving increased airways resistance, alveolar atelectasis, muscle fatigue, and hypoxemia due to mismatch between ventilation and perfusion. Nasal CPAP and high-flow nasal cannula (HFNC) oxygen may improve the work of breathing and oxygenation. Although the mechanisms behind these noninvasive modalities of respiratory support are not well understood, they may help infants by way of distending pressure and delivery of high concentrations of warmed and humidified oxygen. Observational studies of varying quality have suggested that CPAP and HFNC may confer direct physiologic benefits to infants with bronchiolitis and that their use has reduced the need for intubation. No trials to our knowledge, however, have compared CPAP with HFNC in bronchiolitis. Two randomized trials compared CPAP with oxygen delivered by low-flow nasal cannula or face mask and found some improvements in blood gas results and some physiologic parameters, but these trials were unable to demonstrate a reduction in the need for intubation. Two trials evaluated HFNC in bronchiolitis (one comparing it with headbox oxygen, the other with nebulized hypertonic saline), with the results not seeming to suggest important clinical or physiologic benefits. In this article, we review the pathophysiology of respiratory failure in bronchiolitis, discuss these trials in detail, and consider how future research studies may be designed to best evaluate CPAP and HFNC in bronchiolitis.

Initiation de la ventilation non invasive aux urgences pédiatriques dans les bronchiolites sévères du nourrisson

Introduction

La ventilation non invasive (VNI) dans les bronchiolites sévères du nourrisson s’est développée rapidement en réanimation et au service mobile d’urgence et réanimation pédiatrique (Smur) depuis 2003. Les objectifs de cette étude sont de vérifier les indications de mise sous VNI utilisées aux urgences pédiatriques d’Ambroise-Paré en les comparant à celles utilisées en réanimation et de confirmer l’efficacité de cette technique aux urgences pédiatriques.

Méthodes et population

Étude rétrospective sur 31 nourrissons ventilés par VNI pour bronchiolite sévère aux urgences pédiatriques de l’hôpital Ambroise-Paré (92) des hivers 2009 à 2011.

Résultats

La population étudiée était composée de 16 % d’anciens prématurés sans hypotrophie ni antécédent notable et âgés d’en moyenne deux mois au moment de la bronchiolite. Le pourcentage de bronchiolites apnéisantes (seule indication de VNI selon la conférence de consensus de 2006) était de 17 %. Au moins deux indications de recours à la VNI ont été retrouvées pour chaque patient. Cinquante-huit pour cent des nourrissons étaient transférés plus de deux heures après la mise sous VNI, avec une amélioration constatée sur la fréquence respiratoire (FR), la saturation, la PCO₂ et le pH (p < 0,001) et sans complications aux urgences. La VNI a été poursuivie en réanimation dans 84 % des cas. La durée moyenne de VNI était de 2,7 jours, celle d’hospitalisation en réanimation de 4,2 jours.

Conclusion

L’utilisation de la VNI aux urgences pédiatriques est une procédure simple, permettant une prise en charge précoce, avant transfert en réanimation, des bronchiolites sévères du nourrisson et permettant une amélioration clinique et gazométrique de leur insuffisance respiratoire.

Continuous positive airway pressure for bronchiolitis in a general paediatric ward; a feasibility study

Background

Continuous positive airway pressure (CPAP) is commonly used to relieve respiratory distress in infants with bronchiolitis, but has mostly been studied in an intensive care setting. Our prime aim was to evaluate the feasibility of CPAP for infants with bronchiolitis in a general paediatric ward, and secondary to assess capillary PCO₂ (cPCO₂) levels before and during treatment.

Methods

From May 1^st 2008 to April 30^th 2012, infants with bronchiolitis at Stavanger University Hospital were treated with CPAP in a general paediatric ward, but could be referred to an intensive care unit (ICU) when needed, according to in-house guidelines. Levels of cPCO₂ were prospectively registered before the start of CPAP and at approximately 4, 12, 24 and 48 hours of treatment as long as CPAP was given. We had a continuous updating program for the nurses and physicians caring for the infants with CPAP. The study was population based.

Results

672 infants (3.4%) were hospitalized with bronchiolitis. CPAP was initiated in 53 infants (0.3%; 7.9% of infants with bronchiolitis), and was well tolerated in all but three infants. 46 infants were included in the study, the majority of these (n = 33) were treated in the general ward only. These infants had lower cPCO₂ before treatment (8.0; 7.7, 8.6)(median; quartiles) than those treated at the ICU (n = 13) (9.3;8.5, 9.9) (p < 0.001). The level of cPCO₂ was significantly reduced after 4 h in both groups; 1.1 kPa (paediatric ward) (p < 0.001) and 1.3 kPa (ICU) (p = 0.002). Two infants on the ICU did not respond to CPAP (increasing cPCO₂ and severe apnoe) and were given mechanical ventilation, otherwise no side effects were observed in either group treated with CPAP.

Conclusion

Treatment with CPAP for infants with bronchiolitis may be feasible in a general paediatric ward, providing sufficient staffing and training, and the possibility of referral to an ICU when needed.