1217 Non-invasive ventilation (NIV) for bronchiolitis

In an article from Australia it is stated that bronchiolitis is the commonest indication for (non-elective) admissions to paediatric ICU in Australia and New Zealand, representing 11.5% of such admissions in 2008. This admission rate is likely to be similar in equivalent populations in other developed countries. Outcomes are usually good, with a proportion of patients requiring assisted ventilation. Historically assistance involved intubation and positive pressure (continuous or intermittent), but NIV techniques have received attention and undergone development and refinement over the past two decades. In adult critical care patients NIV has been associated with lower morbidity, mortality and cost, and in paediatric practice it has improved outcomes for neonatal respiratory distress syndrome. However there is very little in the way of literature supporting the use of NIV in paediatric critical care apart from some small studies showing improved CO2 clearance, less ventilator-associated pneumonia, and/or reduced oxygen requirement post-ventilation. To address the paucity of data issue, a retrospective analysis was carried out on 10 years of NIV use in an academic paediatric ICU in Sydney. There were 8288 admissions between 2000 and 2009, of which 520 were admitted with a principle diagnosis of bronchiolitis. Mean age of the study subjects was 4.8 months and one patient died. Co-morbidities included prematurity, chronic lung disease, immune deficiency, neuromuscular disorders and congenital heart disease. Respiratory syncitial virus (RSV) status was noted from the records. 114 were intubated without a trial of NIV on the basis of an oxygen requirement of >60%, recurrent apnoea, clinical instability or poor perfusion after fluid resuscitation, 121 were not considered to be in need of ventilatory assistance at all (NIV or intubation), and 285 received a trial of NIV, 48 of whom failed and required intubation. Median length of stay was 1.08 days for those without a requirement for ventilatory assistance, 2.38 days for NIV successes, 5.19 days for those intubated directly, and 8.41 days for the NIV-failures. While the study appears to make a case for a trial of NIV in bronchiolitis, the major shortcoming is the absence of data around criteria for separating groups into those not requiring support at all vs those selected for a trial of NIV. Data are presented showing that presence of a co-morbid risk factor increased the likelihood of NIV-failure, but it is also possible that some of the infants going directly to intubation might have been candidates for a trial of NIV. Controlled trials will provide answers as will studies into different types of NIV (nasal CPAP vs high flow nasal oxygen vs nasopharyngeal CPAP.

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Intensive Care Med 2012; DOI 10.1007/s00134-012-2566-4
Br Med J (Clin Res Ed) 1981; 283: 1506-1508
Pediatr Crit Care Med 2008; 9: 484-9