long term noninvasive ventilation in children: what’s new in 2015 - … · 2016-02-11 · long...
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Long term noninvasive ventilation in children: what’s new in 2015 ?
Brigitte Fauroux, MD PhDPediatric noninvasive ventilation and sleep unit
Necker university hospital, Inserm U 955Paris, France
InsermInstitut nationalde la santé et de la recherche médicale
Noninvasive ventilation in children: what’s new ?
• Epidemiology• Diseases that may require NIV• Interfaces• Compliance• CPAP monitoring• CPAP/NIV initiation
An italian experienceNumber of children treated with NIV since 1993 in a single centre
Pavone et al. Early Human Development 2013;89:S25
McDougall et al. Arch Dis Childh 2013;98:660
Incidence 1995-2009 Prevalence 1995-2009
15 year experience of a pediatric centre (Vancouver)
McDougall et al. Arch Dis Childh 2013;98:660
15 year experience of a pediatric centre (Vancouver)
McDougall et al. Arch Dis Childh 2013;98:66
McDougall et al. Arch Dis Childh 2013;98:660
Noninvasive ventilation in children: what’s new ?
• Epidemiology• Diseases that may require NIV• Interfaces• Compliance• CPAP monitoring• CPAP/NIV initiation
An italian experienceIndications for NIV in a single centre
Pavone et al. Early Human Development 2013;89:S25
Acute group
n=15
Subacute group
n=18
Chronic group
n=43
Age, years 1.2±3.4 6.4±7.2 5.9±7.1
Female/male 7/8 8/10 22/21
Diagnosis Pierre Robin syndromeLaryngomalaciaPolymalformative sdKabuki syndromeCystic fibrosisBPDNeuromuscular disorder
6321111
LaryngomalaciaPrader Willi syndromePierre Robin syndromeBDPCraniostenosisTreacher Collins s dVocal cord palsyDown syndromeMucopolysaccaridosisDuchenne MDLaryngeal massCraniofacial malform.Generalised dystonia AchondroplasiaTracheomalacia
411111111111111
Pierre Robin syndromeDown syndromeMucopolysaccaridosisCharge syndromeLaryngomalaciaNeuromuscular disordersPolymalformative syndromeTreacher Collins syndromeAchondroplasiaPrader Willi syndromeBPDMyhre syndromeSpinal muscular atrophyRett syndromeGoldenhar syndromeIdiopathic OSASHanhart syndromeBeckwith Wiedemann sdLoeys Dietz syndromeOssificant fibrodysplasia
55433332222111111111
76 children started on NIV during 2013-2014
88 patients3 mo – 44 yrs
NIV was started in 16 patients
Neonates hospitalizedn=37
No clinical UAOn=17
Clinical UAOn=20
Severe clinical UAOn=9
Immediate CPAP in the NICU
Moderate clinical UAOn=11
Sleep study with gas exchange
Tracheotomyn=4
CPAPn=5
Abnormal sleep studyCPAP, n=4
Normal sleep studyn=7
Moderate UAO group
Severe UAO group
Mild UAO group
No UAO group
Neonates seen as outpatientsn=7
Neonates with PRS evaluated over one yearn=44
No UAO group
Plastic and Reconstructive Surgery, in press
Pierre Robin syndrome:Necker airway management protocol
• CPAP was started – as a first line therapy in infants with severe UAO– after a (prone position) PG on the following criteria
• AHI >10/h and/or• oxygen desaturation index >15/h and/or • minimal SpO2<90% and/or • maximal PtcCO2>50 mmHg
• CPAP– avoided a tracheotomy in 5/9 patients with severe UAO– normalised sleep in the 4 patients with moderate OSA
Noninvasive ventilation in children: what’s new ?
• Epidemiology• Diseases that may require NIV• Interfaces• Compliance• CPAP monitoring• CPAP/NIV initiation
Interfaces used before 2014
Ramirez et al. Intensive Care Med 2012;38:655
• 14 patients, 2 – 7 yrs• Equivalence between the Pixi mask and the
patient’s previous mask– PSG– adherence (7.4 vs 7.2 h/night)
• Advantages of the Pixi mask– less leaks– improved comfort
J Clin Sleep Med 2014;10:979
Nasal interfaces for infants
Interfaces > 2014
Manufacturer Model
Air Liquide Healthcare
AG Industries
Philips Respironics
ResMed
Fisher and Paykel
Respireo nasal prongsRespireo Soft Baby nasal mask
Nonny pediatric nasal mask
Wisp nasal mask
Quattro air full face mask
Eson, Opus
Noninvasive ventilation in children: what’s new ?
• Epidemiology• Diseases that may require NIV• Interfaces• Compliance• CPAP monitoring• NIV/CPAP initiation
NIV and CPAP adherence according to the interface
Ramirez et al. Sleep Med 2013;14:1290
NIV and CPAP duration� < 3 months� 3-12 months� > 12 months
• 5/8 patients with SDB did not tolerated CPAP
• These patients were deficient in tests of • adaptive behavior• visual-motor integration• achievement
Noninvasive ventilation in children: what’s new ?
• Epidemiology• Diseases that may require NIV• Interfaces• Compliance• CPAP monitoring• NIV/CPAP initiation
PSG during CPAP/NIVNo description of eventsNo explanation on recommended CPAP/NIV changes
Number ofrespiratory events/polygraphy
Consequences of the respiratory events
Nocturnal gas exchange didnot predict PG results
Noninvasive ventilation in children: what’s new ?
• Epidemiology• Diseases that may require NIV• Interfaces• Compliance• CPAP monitoring• NIV/CPAP initiation
CPAP/NIV initiation
• No validated criteria to start CPAP/NIV due to the lack of markers of SDB end-organ morbidity
3 clinical scenario
AcuteImpossibility to
wean from NIV in the ICUN=15
SubacuteAbnormal
nocturnal gas exchange
N=18
ChronicAbnormal P(S)G
N=43
• Minimal SpO2 < 90%• Maximal PtcCO2 > 50 mmHg• % of time with a SpO2 < 90% ≥ 2%• % of time with a PtcCO2 > 50mmHg ≥ 2%• Oxygen desaturation index > 1.4/h
• AHI > 10/h
Number of criteria in the subacute and chronic group
Subacute groupChronic group
Acute group
n=15
Subacute group
n=18
Chronic group
n=43
Age, years 1.2±3.4 6.4±7.2 5.9±7.1
Female/male 7/8 8/10 22/21
Diagnosis Pierre Robin syndromeLaryngomalaciaPolymalformative sdKabuki syndromeCystic fibrosisBPDNeuromuscular disorder
6321111
LaryngomalaciaPrader Willi syndromePierre Robin syndromeBDPCraniostenosisTreacher Collins s dVocal cord palsyDown syndromeMucopolysaccaridosisDuchenne MDLaryngeal massCraniofacial malform.Generalised dystonia AchondroplasiaTracheomalacia
411111111111111
Pierre Robin syndromeDown syndromeMucopolysaccaridosisCharge syndromeLaryngomalaciaNeuromuscular disordersPolymalformative syndromeTreacher Collins syndromeAchondroplasiaPrader Willi syndromeBPDMyhre syndromeSpinal muscular atrophyRett syndromeGoldenhar syndromeIdiopathic OSASHanhart syndromeBeckwith Wiedemann sdLoeys Dietz syndromeOssificant fibrodysplasia
55433332222111111111
76 children started on NIV during 2013-2014
Comparison of nocturnal gas exchange between the
subacute and chronic groupSubacute group
n=18
Chronic group
n=43
Nocturnal gas exchange
Mean SpO2 (%)
Minimal SpO 2 (%)
Time spent with SpO 2 < 90% (%)
Oxygen Desaturation index (number/hr)
Mean PtcCO 2 (mmHg)
Maximal PtcCO 2 (mmHg)
Time spent with PtcCO 2 > 50 mmHg (%)
94.2 ± 2.8
76.8 ± 9.8
7.9 ± 16.6
26.3 ± 24.4
45.8 ± 5.4
53.6 ± 9.4
21.5 ± 34
94.2 ± 2.7
77.3 ± 9.5
8.2 ± 16.0
27.6 ± 25.3
45.7 ± 5.5
53.3 ± 9.4
20.9 ± 32.9
AHI NA 27.2 ± 30
Conclusion
• Epidemiology: � use of NIV• Diseases that may require NIV: expanding• Interfaces: interfaces for infants• Compliance: value of specialised centers• CPAP monitoring: few events• NIV/CPAP initiation: future studies should
look for benefit of CPAP/NIV on end-organ morbidity