Noninvasive Ventilation to Facilitate Extubation in a Pediatric Intensive Care Unit

Pope JF, Birnkrant DJ. Noninvasive ventilation to facilitate extuWeaning from mechanical ventilation and endotrabation in a pediatric intensive care unit. J Intensive Care Med cheal extubation is generally accomplished un2000;15:99–103. eventfully in children. Extubation failure, defined Noninvasive ventilation has been used extensively to treat as the need for reintubation, was reported to occur chronic respiratory failure associated with neuromuscular in 16% of patients in a recent study of 208 children. and other restrictive thoracic diseases, and is also effective Sixty-four percent of patients who failed extubation in the treatment of acute respiratory failure, allowing some exhibited signs and symptoms of excessive respirapatients to avoid intubation. Noninvasive positive pressure ventilation is a potentially effective way to transition selected tory muscle load or inadequate respiratory effort patients off endotracheal mechanical ventilation. The au[1]. Failure to extubate is most commonly the result thors present a retrospective chart review of pediatric paof inadequate respiratory pump function resulting tients extubated with the use of noninvasive ventilation. from neuromuscular weakness, increased respiraExtubation with noninvasive positive pressure ventilation tory muscle load, or a combination of both [2]. was attempted in 25 patients. The patients had a variety of diagnoses, including neuromuscular diseases, cerebral palsy Pediatric patients with various chronic and acute with chronic respiratory insufficiency, asthma, and acute illnesses may have particular difficulty being liberrespiratory distress syndrome (ARDS), reflecting the diverated from mechanical ventilation. For example, sity of patients with respiratory failure seen in our pediatric when children with neuromuscular disease or intensive care unit (ICU). Indications for noninvasive ventilamental retardation/cerebral palsy complicated by tion-assisted extubation were chronic respiratory insufficiency, clinical evidence the patient was failing extubation, chronic respiratory insufficiency requiremechanical or failure of a previous attempt to extubate. Extubation was ventilation, weaning is problematic and tracheossuccessfully facilitated in 20 of 25 patients. Of the five patomy may be required to accomplish endotracheal tients failing an initial attempt at noninvasive ventilationtube removal.Weaning may also be difficult in pediassisted extubation, two required tracheostomy, two were atric patients with acquired neuromuscular weaksubsequently extubated with the aid of noninvasive ventilation, and one was subsequently extubated without the use ness due to prolonged mechanical ventilation, of noninvasive ventilation. Risk factors for failure to successpharmacologic neuromuscular blockade, or high fully extubate with the assistance of noninvasive positive spinal cord injuries. pressure ventilation included the patient’s inability to manNoninvasive positive pressure ventilation is a age respiratory tract secretions, severe upper airway obstrucpractical and effective method of chronic respiration, impaired mental status, and ineffective cough with mucus plugging of the large airways. All patients had mild tory support for patients with various causes of to moderate skin irritation due to the mask interface. No respiratory insufficiency, including neuromuscular patient had any serious or long-term adverse effect of noninand other restrictive thoracic diseases [3]. Noninvavasive positive pressure ventilation. All patients left the hospisive ventilation can be used to treat acute respiratal alive. Noninvasive positive pressure ventilation can tory failure, avoiding the need for intubation [4–6]. facilitate endotracheal extubation in pediatric patients with diverse diagnoses who have failed or who are at risk of failing In contrast to these well-described clinical applicaextubation, including those with neuromuscular weakness. tions of noninvasive ventilation, there are few published reports of the use of noninvasive ventilation to facilitate endotracheal extubation in patients From the *Department of Pediatrics, Children’s Hospital Medical who require mechanical ventilation [7–9]. However, Center of Akron, Northeastern Ohio Universities College of Mednoninvasive positive pressure ventilation is a potenicine, Akron, OH, and †Department of Pediatrics, MetroHealth Medical Center, Case Western Reserve University School of Meditially effective way to transition selected patients off cine, Cleveland, OH. endotracheal mechanical ventilation by providing Received Jun 7, 1999, and in revised form Sep 13, 1999. Accepted respiratory muscle support and decreasing the for publication Sep 15, 1999. work of breathing. In this article we review our Address correspondence to Dr Pope, Department of Pediatrics, experience using noninvasive ventilation to faciliDivision of Critical Care, Children’s Hospital Medical Center of tate endotracheal extubation in our pediatric intenAkron, One Perkins Square, Akron, OH 44308–1062, or e-mail: [email protected] sive care unit (PICU).