Pediatric noninvasive positive pressure ventilation

OBJECTIVE: To review the clinical use of noninvasive positive pressure ventilation (NPPV) in both acute hypoxic and hypercarbic forms of pediatric respiratory failure, including its mechanism of action and implementation. DATA SOURCES: Studies were identified through a MEDLINE search using respiratory failure, pediatrics, noninvasive ventilation, and mechanical ventilation as key words. STUDY SELECTION: All original studies, including case reports, relating to the use of noninvasive positive pressure in pediatric respiratory failure were included. Because of the paucity of published literature on pediatric NPPV, no study was excluded. DATA EXTRACTION: Study design, numbers and diagnoses of patients, types of noninvasive ventilator, ventilator modes, outcome measures, and complications were extracted and compiled. DATA SYNTHESIS: For acute hypoxic respiratory failure, all the studies reported improvement in oxygenation indices and avoidance of endotracheal intubation. The average duration of NPPV therapy before noticeable clinical improvement was 3 hrs in most studies, and NPPV was applied continuously for 72 hrs before resolution of acute respiratory distress. In patients with acute hypercarbic respiratory failure, application of NPPV resulted in reduction of work of breathing, reduction in CO(2) tension, and increased serum bicarbonate and pH. These patients are older than patients in the acute hypoxic respiratory failure group and, in addition to improved blood gas indices, they reported improvement in subjective symptoms of dyspnea. Improvement in gas exchange abnormalities and subjective symptoms occurred within the same time span (the first 3 hrs) as in the acute hypoxic respiratory failure group. However, use of noninvasive techniques in patients with acute hypercarbic respiratory failure continued after resolution of acute symptoms. Complications related to protracted use of NPPV were common in this group. CONCLUSIONS: NPPV has limited benefits in a group of carefully selected pediatric patients with acute hypoxic and hypercarbic forms of respiratory failure. The routine use of this technique in pediatric respiratory failure needs to be studied in randomized controlled trials and better-defined patient subsets.