Indications
Contraindications
Atelectasis
Unconscious/noncooperative
Acute pulmonary edema
Hemodynamic instability
Pneumonia
Abundant and thick secretions
Diaphragmatic paralysis
Severe respiratory failure (P/F <150; S/F <200)
Airway edema: post-extubation laryngitis
Vomiting/gastrointestinal hemorrhage
Weaning in patient with polyneuromyopathy
Vocal cord paralysis
Alternative to reintubation if unplanned extubation
Facial trauma or cranial malformations
Support procedures with sedoanalgesia
Pneumothorax (not drained)
50.5.2 Devices
Any standard ventilator with an NIV option can be used. However, there could be limitations in the smallest children due to their inaccurate trigger systems and insufficient leak compensation. NIV-specific ventilators allow reaching programmed pressures despite high levels of leakage, resulting in a more accurate setting of activation and cycling-off trigger. Furthermore, newer generations of ventilators offer more sophisticated systems to overcome some of these limitations as well as alternative trigger systems, such as triggering based on diaphragmatic activity signal (neurally adjusted ventilation assist, NAVA) [13, 14]. Table 50.2 offers different options when selecting an NIV interface according to the patient’s age.
Table 50.2
Selection of adequate NIV interface
Age | First choice | Second choice |
|---|---|---|
Newborn | Bi-nasal prongs | Nasopharyngeal tube Nasal mask Full-face mask |
Infant | Full-face mask | Bi-nasal prongs Nasopharyngeal tube Nasal mask |
Child | Oronasal mask Full-face mask | Nasal mask |
50.5.3 Modes
CPAP: may improve oxygenation, increasing lung volume derived from alveoli recruitment and fluid redistribution. Myocardial function may be improved through a decrease in left ventricular afterload. Low CPAP levels (5–6 cm H2O) are recommended to start ventilation, increasing gradually 1–2 cm H2O up to 10 cm H2O according to respiratory requirements. Levels above 12 cm H2O are usually not well tolerated [8, 14].
Bi-level positive airway pressure (BPAP): additional PS and/or PC breaths. Its use is reserved for more distressed patients. These modes combine inspiratory positive airway pressure (IPAP, PPI) and expiratory positive airway pressure (EPAP, PEEP). A backup respiratory rate is added when the inspiratory effort generated by young children is often too small to be detected by the ventilator. To enhance comfort and compliance, ventilation settings start with PEEP (or EPAP) at 4–5 cm H2O and increase as necessary, up to a maximum of 10 cm H2O. Inspiratory positive airway pressure (PPI or IPAP) is started at 6–8 cm H20 and gradually increased to 18–20 cm H2O. The parameters are increased gradually to appropriate clinical setting within 30–120 min [8, 13].
50.5.4 Interfaces
The choice of the right interface may be challenging in young children. NIV can be delivered by way of nasal, oronasal, and full-face masks; nasal prongs and oropharyngeal tubes are commonly used in for infants. Full-face and oronasal masks are best suited for hypoxemic patients and advanced hypercapnic respiratory failure, in particular for more dyspneic patients. Nasal-type masks are usually indicated for hypercapnic patients, but only in those who are not very dyspneic and can keep their mouth closed. The main disadvantage of most of the interfaces is the difficulty of preserving a good seal and achieving adequate pressure [8, 14].
50.5.5 Ancillary Treatments
Heated humidifiers should be used to deliver adequate humidity close to body temperatureRelated posts:
Predictive Models of Prolonged Mechanical Ventilation and Difficult Weaning
Postoperative Continuous Positive Airway Pressure (CPAP)
Noninvasive Mechanical Ventilation in Postoperative Spinal Surgery
BiPAP for Preoxygenation During Reintubation in Acute Postoperative Respiratory Failure
Discharge Planning of Neuromuscular Patients with Noninvasive Mechanical Ventilation After Difficult Weaning from Invasive Mechanical Ventilation: From ICU to Home Care
Organization of a Weaning Unit
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