INTRODUCTION — This topic will focus on the use of noninvasive ventilation (NIV) for acute and impending respiratory failure, including benefits and risks, indications and contraindications, approach to initiation, predictors of NIV failure (need for tracheal intubation and invasive mechanical ventilation), and potential complications from the use of NIV.
The use of NIV for apnea and respiratory distress syndrome in premature and term neonates, chronic respiratory failure from neuromuscular disease, post-extubation respiratory distress, and obstructive sleep apnea are discussed separately as follows:
●(See "Respiratory distress syndrome (RDS) in preterm infants: Management" and "Respiratory support, oxygen delivery, and oxygen monitoring in the newborn", section on 'Nasal intermittent positive pressure ventilation' and "Respiratory distress syndrome (RDS) in preterm infants: Management", section on 'Nasal intermittent positive pressure ventilation'.)
DEFINITIONS — This topic uses the following definitions for acute respiratory failure and supportive respiratory care:
●Acute respiratory failure – In general, acute respiratory failure is defined as an infant or child who presents in acute respiratory distress with either acute hypoxia requiring supplemental fraction of inspired oxygen (FiO2) to maintain an oxygen saturation (SpO2) ≥92 percent and/or acute hypercarbia with a partial pressure of carbon dioxide (PaCO2) >50 mmHg (with an arterial pH usually <7.35). In practice, clinicians often intervene based upon oxygen saturation and degree of respiratory distress (eg, severe tachypnea, retractions), without obtaining blood gases.
●Noninvasive ventilation – NIV describes the delivery of mechanical respiratory support without the need for endotracheal intubation through an interface (eg, nasal prongs or mask, face mask, or helmet) that delivers continuous positive airway pressure (CPAP) or bilevel positive airway support (BPAP) . NIV offers the ability to reduce patient work of breathing and improve respiratory gas exchange while avoiding the risks and complications related to the placement of an endotracheal tube, administration of sedation and neuromuscular blockade, and delivery of invasive mechanical ventilation. NIV can be initiated during critical care transport, in the emergency department, in an intensive care unit (ICU), and in some "stepdown" (eg, intermediate or progressive care) units.
●High-flow nasal cannula oxygen therapy – The delivery of heated and humidified high-flow oxygen by nasal cannula has similar physiologic benefits compared with NIV. However, it is considered a different modality, and its use in children is discussed separately. (See "High-flow nasal cannula oxygen therapy in children".)
●Bubble continuous positive airway pressure – Bubble CPAP has been studied in preterm infants [2-4]. There are limited data available regarding use in children beyond the neonatal period . Further study is needed before bubble CPAP can be recommended in children, and therefore, it is not discussed in this topic.
PHYSIOLOGY — NIV offers three primary physiologic benefits as follows [6-9]:
●Decreasing the patient's work of breathing
●Maintaining patency throughout the respiratory tract, from the upper airways to the smaller lower airways, which can facilitate expiratory flow and reduce obstructed airflow
●Recruiting alveoli, resulting in increased functional residual capacity (FRC) and decreased ventilation-perfusion (V-Q) mismatch
Interface — A number of patient-ventilator interfaces are available for use during NIV in the pediatric population including:
●Nasal cannula (picture 1)
●Nasal mask (picture 2)
●Full-face mask (picture 3)
●Helmet (picture 4)
A full-face mask or helmet more reliably provides continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) but may cause agitation, especially in infants and younger children. A nasal cannula or nasal mask is often better tolerated but pressure leak due to a poor interface seal or through the mouth may limit effectiveness. (See 'Choosing an interface' below.)
Modes of ventilation — NIV refers to two types of ventilator support as follows [1,7,8]:
●Continuous positive airway pressure (CPAP) – CPAP provides a constant, programmed level of distending airway pressure throughout the entire respiratory cycle. Physiologically, it is the equivalent of positive end-expiratory pressure (PEEP). (See "Positive end-expiratory pressure (PEEP)", section on 'Definition'.)
●Noninvasive positive pressure ventilation (NIPPV) – NIPPV provides an assisted ventilator pressure, either synchronized with each spontaneous respiratory effort (spontaneous) or at a defined backup rate (timed).
Bilevel positive airway support (BPAP), as the name implies, delivers two set levels of positive airway pressure, one during inspiration (IPAP) and one during expiration (EPAP). When the ventilator detects inspiratory flow, it delivers a higher inspiratory pressure until sensing a reduction in flow or when reaching a set inspiratory time limit. When inspiration terminates (based on flow or time), the device cycles to a lower expiratory pressure. BiPAP and BIPAP are terms related to the delivery of BPAP using proprietary ventilators. These are just two of several ventilators that can deliver BPAP.
NIPPV can also be used to deliver other modes of ventilation, such as assist control, pressure support, and proportional assist ventilation. However, these ventilation modes are used less frequently in children. (See "Noninvasive ventilation in adults with acute respiratory failure: Benefits and contraindications".)
With NIV, supplemental oxygen can be delivered via the ventilator tubing, mask, or oxygen blenders. In addition, adapters permit utilization of metered dose inhalers or nebulizers to deliver albuterol or racemic epinephrine without removing the patient interface or disrupting the delivery of CPAP or BPAP (picture 5) [10,11].
INDICATIONS — We suggest a trial of NIV for most hemodynamically stable infants and children with hypoxemic or hypercapnic respiratory failure, who do not require emergency endotracheal intubation once it is confirmed that they lack contraindications to NIV. (See 'Contraindications' below.)
For clinicians with limited experience initiating NIV in children, we encourage consultation with a pediatric critical care, pediatric pulmonologist, pediatric emergency medicine specialist or other clinician with expertise to determine the best method of respiratory support and to guide initiation of NIV, as needed.
High-flow nasal cannula (HFNC) oxygen therapy is being used more commonly than NIPPV to provide respiratory support in infants with bronchiolitis and hypoxemia. (See "Bronchiolitis in infants and children: Treatment, outcome, and prevention", section on 'HFNC and CPAP'.)
Limited evidence, primarily small case series, also suggests efficacy of NIV in patients with the following conditions :
●Acute chest syndrome
●Dynamic upper airway obstruction caused by tracheomalacia, laryngomalacia, and Pierre Robin syndrome
Evidence is lacking regarding the optimal use of NIV for children with coronavirus disease 2019 (COVID-19), and guidelines differ as to whether high-flow nasal cannula or NIV should be first-line for eligible patients . Nevertheless, NIV is an option for children with COVID-19 with persistent hypoxemia or labored work of breathing on supplemental oxygen or high-flow nasal cannula. In adult patients, helmet ventilation reduces aerosolization of SARS-CoV-2 during treatment, but there are no rigorous studies in children comparing aerosolization of helmet versus face mask .
Some experts use one or more clinical or laboratory parameters for initiating NIV including :
●Moderate to severe dyspnea not responsive to supplemental oxygen or other directed therapies (eg, bronchodilators for status asthmaticus)
●Persistent tachypnea caused by respiratory illness (respiratory rate >75th percentile for age (table 1))
●Hypoxemia (specifically, fraction of inspired oxygen [FiO2] >0.5 to maintain oxygen saturation in arterial blood [SaO2] >94 percent)
●Respiratory acidosis (arterial pH <7.35 or venous pH <7.30)
In addition, careful patient selection, the patient's ability to tolerate the selected interface, and proper support of the chosen modality by key members of the care team, such as nurses and respiratory therapists, are essential to the successful use of NIV. (See 'Patient selection' below.)
Efficacy for NIV in selected conditions is discussed in more detail separately:
CONTRAINDICATIONS — The need for immediate endotracheal intubation based upon clinical assessment is an absolute contraindication to initiating NIV. Specific examples of situations where NIV should not be used include [6,7,14-17]:
●Acutely impaired mental status, (eg, Glasgow coma score <8 or rapidly declining or patients with status epilepticus)
●High aspiration risk (eg, absence of airway protective reflexes or inability to clear secretions)
●Need for airway protection (eg, epiglottitis, progressive upper airway edema, or burns)
NIV is also typically avoided in patients with the following conditions [6,7,14-17]:
●Hemodynamic instability requiring high or escalating levels of vasopressor support
●Upper gastrointestinal bleed
●Facial injuries (eg, large lacerations, or facial bone fractures) for which maintenance of a good mask seal will not be possible or morbidity may be increased
●Untreated pneumothorax, although NIV is acceptable once a chest tube is in place
In addition, if a face mask is required for NIV, obtaining a proper mask seal may also be difficult in patients with facial or airway anomalies (eg, micrognathia, Apert syndrome, Crouzon syndrome).
Although NIV may be attempted, it is frequently unsuccessful for providing the necessary respiratory support in patients with acute respiratory distress syndrome. (See 'Predictors of failure' below.)
The decision to proceed with NIV in a patient with these conditions needs to consider the likelihood of success while weighing the potential risks of further respiratory or circulatory decompensation, which may make other management strategies, especially subsequent endotracheal intubation, more difficult.
PATIENT SELECTION — Appropriate patient selection is essential to success. The following conditions should be assessed prior to the initiation of NIV:
●Presence of contraindications to NIV (see 'Contraindications' above)
●Likelihood a patient will tolerate the planned mode of support
●Potential risk of complications secondary to failing to secure the airway with endotracheal intubation in patients with need for airway protection (eg, at high aspiration risk or with altered mental status)
The decision to trial NIV in children is ultimately based on a combination of disease processes likely to respond well to noninvasive support, provider comfort, and experience with NIV; and the presence of health care professionals (eg, respiratory therapists, nurses, or physicians) who can guide the child through initiation and ensure tolerance of the chosen modality.
The effective use of NIV is described in all ages across the pediatric spectrum, including neonates [15,18]. A survey of pediatric intensivists and a multicenter, prospective observational study suggest that providers may be more likely to use NIV in older patients and those with lower airway disease and less likely to use NIV rather than invasive respiratory support in neonates and trauma patients [19,20]. (See "Respiratory support, oxygen delivery, and oxygen monitoring in the newborn", section on 'Nasal intermittent positive pressure ventilation'.)
Monitoring — Patients receiving NIV warrant the same level of monitoring as children undergoing invasive support with endotracheal intubation and mechanical ventilation including continuous cardiorespiratory and pulse oximetry, frequent blood pressure measurement, and ongoing monitoring of ventilation (eg, frequent blood gas measurements or transcutaneous CO2).
COVID-19 precautions — Noninvasive ventilation is considered an aerosol-generating procedure. Thus, appropriate infection control precautions are required when it is being administered to patients with unknown or positive COVID-19 status, as discussed separately. (See "COVID-19: Infection prevention for persons with SARS-CoV-2 infection", section on 'Aerosol-generating procedures/treatments' and "COVID-19: Respiratory care of the nonintubated hypoxemic adult (supplemental oxygen, noninvasive ventilation, and intubation)", section on 'Infection control precautions for noninvasive modalities'.)
Choosing an interface — Once the decision to initiate NIV has been made, the first step is to choose an appropriate patient-ventilator interface. The selection of an interface should be made with the following goals:
●Maximal comfort to promote compliance
●Appropriate fit with minimal leak to maximize efficacy
●Interface least likely to result in adverse events (eg, skin breakdown or ocular injury)
The child's age and size, availability of different interfaces, severity of respiratory distress, and established local practice patterns may all influence individual approaches.
Our typical approach is to start with a nasal interface (prongs or masks) in infants, toddlers, and younger children, who may not tolerate a full-face mask, provided they are adequately supported via the nasal interface. Published studies in infants and younger children favor this approach as well [21,22]. However, it can be difficult to achieve sufficient ventilator support using nasal delivery in some children secondary to poor seal, or as a result of air leak through an open mouth.
We commonly use face masks as the initial interface in school-age children and adolescents with less severe disease. They should be prepared for what to expect and coached through the NIV initiation process. We also use a full-face mask as the initial interface for any infant or child with more severe hypoxia or hypercarbia to ensure adequate seal and delivery of PEEP, recognizing that cooperation may be less likely. Sedation with dexmedetomidine or midazolam may facilitate initiation of NIV in anxious or agitated patients. (See 'Sedation' below.)
In infants and children who are too agitated to tolerate NIV or in whom mask seal is not achievable, invasive ventilation should not be delayed if the patient needs additional support.
Use of helmets as the initial interface of choice in infants and young children has been described in small case series [23,24], but they are not as widely available as other pediatric NIV interfaces.
Interface sizing — Nasal and full face masks are typically available in three sizes: infant and small child (picture 2), youth (picture 3 and picture 6), and standard (adult). Specific sizes may vary by manufacturer. The clinician should choose the mask that covers the nose, or nose and mouth without contacting the eyes. The smallest mask that properly fits should also be used to limit dead space (volume of inhaled gas not reaching the alveoli for gas exchange). Masks that appear to be the best anatomic match should then be tested for adequacy of seal during initiation of NIV. If the patient complains of discomfort or a large leak is noted, alternative sizes or types of interfaces can be trialed.
Skin protection — The following measures help to reduce skin irritation and breakdown:
●Hydrocolloid dressing can be placed on the skin of the nasal bridge or face beneath the interface to provide barrier protection (picture 7).
●Selection of the most appropriately fitting mask will distribute pressure more equally, minimizing pressure points and breakdown.
●Using a mask that is constructed with air or gel cushions reduces contact pressure (picture 6).
●For longer-term use, rotating the type of interface can help to reduce the risk of skin compromise, although the limited choice of interfaces makes this approach less feasible in infants and younger children as compared with older children and adults.
●During initiation, the interface device can be gently applied and manually held in place by a healthcare professional; the patient, when they are old enough to cooperate; or a family member. This approach may mitigate feelings of claustrophobia or suffocation that can occur when the interface is initially secured using head straps.
●After the patient adapts to the device, the straps can be gently secured either directly or, especially in infants and younger children, by use of a form-fitting cap attached to straps (picture 9).
●Providers should avoid excessive tightening of interface straps in an attempt to overcome a poor seal when an appropriately fitted mask is not available for a given pediatric patient. In such a situation, NIV is likely not a suitable option.
Selecting the mode of ventilation — Several factors influence the mode of ventilation as follows:
●Continuous positive airway pressure (CPAP) – CPAP can reduce dynamic upper airway obstruction (eg, tracheomalacia, laryngomalacia, and oropharyngeal hypotonia), apnea, and work of breathing related to acute respiratory failure in infants and children, particularly when hypoxemia is the primary concern. CPAP is also commonly utilized as a therapy for obstructive sleep apnea. (See 'Modes of ventilation' above and "Continuous positive airway pressure (CPAP) for pediatric obstructive sleep apnea".)
Examples of patients who we typically start on CPAP include infants with bronchiolitis and intermittent apnea who benefit from the stimulation provided by NIV, or those with increased work of breathing who appear at risk of tiring. Children with reversible obstructive processes, such as status asthmaticus or croup may benefit in conjunction with medical therapies in more severe cases. Patients with pneumonia may also benefit from CPAP if the patient’s primary problem is hypoxemia and not hypercarbia.
●Bilevel PAP (BPAP) – BPAP is often selected for patients in need of a greater level of respiratory support, including those who do not show timely improvement with CPAP. With higher mean airway pressures, bilevel support is likely to better address hypoxemia. In addition, the increased support during inspiration can further offload work of breathing, increase tidal volume ventilation, and more rapidly assist with managing hypercapnia.
Examples of patients who we typically start on BPAP include patients with lower airway disease, such as pneumonia or cystic fibrosis, with increased work of breathing and resultant hypercarbia. We also integrate BPAP into our approach to the management of patients with status asthmaticus who have not responded to standard medical therapy, or those in whom hypercarbia is the most significant pathophysiologic derangement. For patients who have been successfully treated with BPAP previously, either during acute illness or intermittently at home, we will generally initiate BPAP early in their course of respiratory compromise.
Initial settings — A variety of approaches to initial NIV settings have been described [7,11,15,25,26]. Initial pressures will vary by mode of ventilation, etiology, severity of underlying disease, and patient tolerance. Initial settings should be viewed as a starting point that requires careful monitoring and adjustment to maximize the effectiveness of NIV.
The following represent typical initial settings that we employ in our practice:
●Continuous positive airway pressure (CPAP) – CPAP is often started at a pressure of approximately 5 cm H2O and titrated up relatively quickly, as needed, depending upon clinical and physiologic response and patient tolerance [11,15,25]. Reported practices patterns describe safe use of initial pressures of 8 to 10 cm H2O with no associated hemodynamic compromise [7,26] and then titrating up or down as needed to maintain oxyhemoglobin saturation in an acceptable range (eg, 92 to 95 percent). Ventilator devices permit delivery of pressure as high as 20 cm H2O .
●Bilevel positive airway pressure (BPAP) – BPAP is often initiated with an expiratory PAP (EPAP) of approximately 5 cm H2O and an inspiratory PAP (IPAP) of 8 to 10 cm H2O. These pressures can be titrated up depending upon clinical and physiologic response and patient comfort [6,11,15]. Final IPAP pressures of 15 to 22 cm H2O are common [6,25-28].
●Fraction of inspired oxygen (FiO2) – FiO2 can be adjusted to reach the target oxygen saturation, often with a goal of >92 to 95 percent [6,26,27]. The target for a specific patient should be determined based upon the patient's respiratory disease, perceived toxicity of support, and trajectory of illness. Most commonly, the goal is to increase the PEEP (EPAP or CPAP) so that the FiO2 can be weaned to 50 percent or less.
Sedation — NIV can generally be initiated in children using verbal reassurance and "coaching", particularly in older children. However, anxiety or agitation can lead to patient-ventilator asynchrony, which limits effectiveness, increases the risk for barotrauma, and may necessitate pharmacologic anxiolysis or sedation. Prior to sedation, the clinician should ensure that hypoxia and/or hypercarbia are not the cause of agitation.
The ideal sedative agent for patients undergoing NIV should provide anxiolysis without adverse impact on respiratory drive, airway protection and hemodynamic stability. In general, dexmedetomidine best meets these criteria and is being used with increased frequency for this purpose in intensive care settings although evidence is limited [29,30]. A reasonable alternative may be to titrate intermittent small doses of benzodiazepines (eg, midazolam) [11,18,24]. It should be emphasized that most pediatric patients tolerate NIV with minimal to no anxiolytic or sedative agents. Patients developing a decreased level of consciousness due to worsening hypercarbia, exhaustion or effects of sedatives likely need invasive mechanical ventilation to protect from aspiration.
Preliminary data from small case series suggest the careful use of sedating agents does not decrease the efficacy of NIV in terms of an increased risk of need for endotracheal intubation [24,31].
Assessment of effectiveness — Any patient being initiated on NIV requires close monitoring and careful reassessment, especially over the first one to two hours after initiation. Clinical findings and blood gas analysis may be used to evaluate physiologic response and inform adjustments to NIV settings and continuation of NIV as follows [8,9,32]:
●Respiratory rate and heart rate – Reduction in respiratory rate is a reliable sign of effective response to NIV . Several studies have reported improvement in both respiratory and heart rate in patients, typically within the first hour after initiation of NIV, and with continued use [11,25,26,28,32,33].
●Dyspnea – Both subjective assessments of dyspnea and various scoring systems can be used to assess response to NIV. As an example, in a series of 34 patients receiving NIV for impending respiratory failure of which three ultimately required endotracheal intubation, improvement on a subjective 9-point dyspnea scale of at least two standard deviations occurred in all patients, and up to five standard deviations in two-thirds of patients. These improvements in subjective scales were also associated with improvements in other physiologic indicators, such as pH, pCO2, and respiratory rate .
●O2 requirement – Pulse oximetry or PaO2 by blood gas analysis can be used to determine the required FiO2 for a given patient. Effective NIV has been shown to decrease the required FiO2 within one hour . Our goal is to provide NIV such that FiO2 can be weaned to <50 percent while maintaining oxyhemoglobin saturation at >92 to 95 percent. In general, the persistent requirement for an elevated FiO2 delivery indicates NIV failure.
●Hypercarbia – Blood gas analysis can provide objective data regarding changes in ventilation. Numerous studies have shown significant improvements after initiating NIV [26,28,32,33]. An absence of improvement or worsening of hypercarbia may be used as a parameter to adjust noninvasive positive pressure ventilation (NIPPV) settings when clinically feasible, change from continuous positive airway pressure (CPAP) to bilevel positive airway pressure (BPAP), or prompt a decision to move to endotracheal intubation and invasive ventilation . Transcutaneous CO2 monitoring, when correlated with an initial blood gas, may also be useful for ongoing monitoring of effectiveness [34-36].
Clinical and laboratory improvement as described above can be expected within one to two hours after initiation of NIV [8,26,31,33]. Failure to see improvement in this timeframe, despite efforts to address interface problems and patient cooperation, suggests a need to move to invasive mechanical ventilation, assuming NIV settings have been optimized.
PREDICTORS OF FAILURE — Understanding which patients are at greatest risk for failing NIV is important in patient selection. Underlying diagnosis, severity of disease, and inadequate response within one to two hours after initiation have been identified as independent predictors of NIV failure as follows:
●Underlying diagnosis – In two observational pediatric studies, one prospective and one retrospective, the diagnoses of pneumonia  and acute respiratory distress syndrome (ARDS)  were identified as risk factors for NIV failure. Only 22 percent of ARDS patients treated with NIV avoided endotracheal intubation. Although a trial of NIV may be acceptable for select patients with ARDS, use of NIV in these high-risk patients requires frequent reassessments and simultaneous preparation for intubation if NIV were to provide insufficient support. In addition, children with primary respiratory illness may be more likely to avoid intubation than those with conditions where prolonged ventilation will be necessary such as sepsis, malignancy, or immunosuppression .
●Markers of illness severity – Patients with high severity of overall illness as measured by Pediatric Risk of Mortality (PRISM)  and Pediatric Logistic Organ Dysfunction (PLOD) scoring  were noted to be more likely to fail NIV.
●Response to treatment – Finally, an inadequate response to NIV, as evidenced by a lack of significant decrease in respiratory rate [26,37]; persistently elevated fraction of inspired oxygen (FiO2) requirement [22,38]; or pH <7.25 on blood gas analysis  have also been identified as variables associated with failure of NIV. Generally, significant improvement should be seen within one to two hours of initiation of NIV. A patient who is worsening despite escalation of NIV most likely requires urgent intubation.
BENEFITS AND RISKS — The benefits of noninvasive ventilation include reduced complications related to invasive airway management, including avoidance of [6,39]:
●Laryngeal or tracheal injury, which may result from the intubation procedure or longstanding mucosal pressure from an endotracheal tube/cuff
●Interruption of the natural airway clearance mechanisms, potentially resulting in ventilator-associated pneumonia
●Potential adverse effects or complications related to sedation with or without neuromuscular blockade
Observational studies and two small trials indicate that invasive mechanical ventilation may be avoided in 60 to 100 percent of patients receiving NIV; most studies report a success rate of 75 to 95 percent [11,14,18,25,26,31,33,38,40-43]. Efficacy of NIV for reducing escalation of therapy is best established for infants with bronchiolitis and hypoxemia. (See "Bronchiolitis in infants and children: Treatment, outcome, and prevention", section on 'HFNC and CPAP'.)
However, the heterogeneity of these study populations based upon age, underlying diagnoses, and illness severity as well as the absence of control groups in most studies makes generalization of these findings difficult. Nevertheless, this evidence suggests that NIV permits the management of acute respiratory compromise in infants and children while avoiding endotracheal intubation in a large proportion of selected patients.
Unfortunately, use of NIV is not without risk. Most importantly, it may delay endotracheal intubation and mechanical ventilation for patients who require this therapy. It may also provide insufficient positive end-expiratory pressure if there is a large air leak. (See 'Complications' below.)
COMPLICATIONS — Evidence from observational studies and our experience suggest that NIV is safe for use in pediatrics when used in carefully selected patients with continuous monitoring by attentive clinicians [1,7,8].
Potential complications include the following:
●Major – Although major complications are uncommon during NIV, they can be severe including:
•Barotrauma – As with any positive pressure ventilation strategy, there is a risk of barotrauma or air leak syndrome in patients receiving NIV. Tension pneumothorax, pneumomediastinum, or massive subcutaneous emphysema have all occurred [11,18,44,45]. Based upon small observational studies, rates of barotrauma range from 1.4 to 9.0 percent [11,18,45]. Thus, patients receiving NIV warrant close monitoring for signs of barotrauma and should have settings adjusted to achieve physiologic improvement with the lowest possible amount of positive airway pressure.
•Aspiration – Aspiration is a concern when using NIV, particularly in any child who vomits while wearing a full-face mask. Risk of vomiting increases in patients on higher ventilatory settings. For children with gastrostomy tubes, venting the tubes can be helpful without interfering with the lower esophageal sphincter. Furthermore, treatment of nausea with antiemetics (eg, ondansetron) may be warranted in selected patients. No cases of aspiration have been reported in published studies, likely reflecting the infrequency of this complication as well as careful adherence to exclusion criteria in NIV protocols, especially the avoidance of NIV in patients with impaired airway protective reflexes, difficulty clearing their secretions, or acutely altered mental status. (See 'Contraindications' above.)
Prophylactic attempts to decompress the stomach using an oro- or naso-gastric tube may also increase the risk of vomiting and should be avoided in most patients.
•Hemodynamic instability – Hemodynamic instability is a potential concern with decreasing venous return following initiation of any form of positive pressure ventilation. Depressed cardiac output has been reported ; however, careful selection of suitable candidates for NIV, specifically, avoiding NIV in patients with shock that does not rapidly respond to fluid administration, can mitigate this risk. (See 'Contraindications' above.)
●Minor – Minor complications generally do not interfere with the efficacy of NIV and are easily addressed, if they arise as follows:
•Skin breakdown – Facial skin irritation, breakdown, and ulceration are the most commonly reported complications when using nasal or oronasal masks as the patient ventilator interface . Skin breakdown over the nasal bridge was reported in approximately 12 percent of patients in one study . Measures to avoid this complication consist of proper mask selection, skin protection, and rotation of interface for patients undergoing prolonged NIV. (See 'Interface sizing' above and 'Skin protection' above.)
•Nasal mucosal trauma – Nasal mucosal trauma has also been noted with the use of nasal masks or nasal prongs. Resultant mucus hypersecretion can obstruct nasal prongs. Alternatively, absence of humidification can lead to dry nasal mucosa or epistaxis. Thus, patency of nasal prongs should be monitored during NIV, and patients receiving NIV via nasal masks or prongs should always have humidified and warmed gas delivery.
•Gastric distension – Gastric insufflation and distension can occur when inspiratory pressures exceed lower esophageal sphincter pressure (normally 10 mmHg) or when the patient swallows air (eg, during crying). Gastric distension may promote vomiting, which can increase the risk for aspiration in patients receiving NIV by face mask. Keeping patients calm, with appropriate sedation as needed, and adjusting settings as low as possible to achieve physiologic improvement with the least amount of positive airway pressure helps to prevent gastric distention. For a child with a gastrostomy tube, venting the tube can be helpful without interfering with closure of the lower esophageal sphincter. Conversely, placement of a naso- or orogastric tube may cause vomiting and should be avoided. We avoid prophylactic attempts to decompress the stomach in patients on NIV using an oro- or naso-gastric tube as this may increase the risk of vomiting.
•Eye irritation or injury – Ocular trauma, primarily corneal abrasion or ulceration, can occur if the edge of the mask is in contact with the eye surface. In addition, eye irritation or conjunctivitis can occur if a poorly fitting mask permits air leak at the nasal bridge across the eyes. Both of these complications can be avoided by the use of a properly fitted mask. (See 'Interface sizing' above.)
SUMMARY AND RECOMMENDATIONS
●Noninvasive ventilation (NIV) describes the delivery of mechanical respiratory support without the need for endotracheal intubation through an interface (eg, nasal prongs or mask, face mask, or helmet (picture 1 and picture 2 and picture 3 and picture 4)) that delivers continuous positive airway pressure (CPAP) or bilevel positive airway support (BPAP). (See 'Definitions' above.)
●We suggest a trial of NIV for most hemodynamically stable infants and children with hypoxemic or hypercapnic respiratory failure, who do not require emergency endotracheal intubation and lack other contraindications (Grade 2C). Careful patient selection, the patient's ability to tolerate the selected interface, and frequent monitoring by key members of the care team, such as nurses and respiratory therapists are essential to the successful use of NIV. For clinicians with limited experience with NIV in children, consultation with a pediatric critical care, pediatric pulmonologist, pediatric emergency medicine specialist or other clinician with expertise to determine the best method of respiratory support and to guide initiation of NIV is encouraged. (See 'Indications' above and 'Patient selection' above and 'Benefits and risks' above.)
●NIV should not be used in patients with cardiopulmonary arrest, acutely impaired mental status, difficulty handling secretions, or need for airway protection (eg, epiglottitis and upper airway edema or burns) and is typically avoided in patients with hemodynamic instability requiring high levels of vasopressor support, upper gastrointestinal bleeding, untreated pneumothorax, and facial anomalies or significant facial injuries. (See 'Contraindications' above.)
●The approach to initiation of NIV in children including selection and securing of the interface (picture 8), selecting the mode of ventilation, and initial settings are provided. (See 'Initiation' above.)
●Proper interface sizing, skin protection measures, and use of warmed and humidified gas delivery help avoid the complications of skin breakdown, nasal mucosal trauma, and eye irritation. (See 'Interface sizing' above and 'Skin protection' above and 'Complications' above.)
●Potential major complications of NIV include barotrauma resulting in air leak syndrome, aspiration, and hemodynamic instability. Keeping patients calm, with appropriate sedation as needed, and adjusting settings as low as possible to achieve physiologic improvement with the lowest possible amount of positive airway pressure helps to reduce the risk of these adverse events. (See 'Initial settings' above and 'Sedation' above and 'Complications' above.)
●Close monitoring is needed in all patients receiving NIV with frequent titration to optimize support. Clinical response should occur within the first one to two hours after initiation. Failure to see improvement in respiratory rate, heart rate, work of breathing, pulse oximetry, and/or blood gas indices should prompt escalation in the current level of support or a change in the ventilator support strategy (eg, progression from continuous positive airway pressure to bilevel positive airway pressure or endotracheal intubation and mechanical ventilation). (See 'Assessment of effectiveness' above.)
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