Noninvasive Ventilation or CPAP in the Initial Treatment Phase of Small Infants With Respiratory Failure

Andrew G Miller; Karan R Kumar; Bhargav S Adagarla; Kaitlyn E Haynes; Rachel M Gates; Jeanette L Muddiman; Travis S Heath; Veerajalandhar Allareddy; Alexandre T Rotta

doi:10.4187/respcare.11935

Noninvasive Ventilation or CPAP in the Initial Treatment Phase of Small Infants With Respiratory Failure

Respir Care. 2024 Jul 16:respcare.11935. doi: 10.4187/respcare.11935. Online ahead of print.

Authors

Andrew G Miller¹, Karan R Kumar², Bhargav S Adagarla³, Kaitlyn E Haynes⁴, Rachel M Gates⁴, Jeanette L Muddiman⁴, Travis S Heath⁵, Veerajalandhar Allareddy⁶, Alexandre T Rotta⁶

Affiliations

¹ Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina; and Respiratory Care Services, Duke University Medical Center, Durham, North Carolina. Andrew.g.miller@duke.edu.
² Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina; and Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
³ Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
⁴ Respiratory Care Services, Duke University Medical Center, Durham, North Carolina.
⁵ Department of Pharmacy, Duke University Medical Center, Durham, North Carolina.
⁶ Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, North Carolina.

PMID: 39013572
DOI: 10.4187/respcare.11935

Abstract

Background: Respiratory failure in infants is a common reason for admission to the pediatric ICU (PICU). Although high-flow nasal cannula (HFNC) is the preferred first-line treatment at our institution, some infants require CPAP or noninvasive ventilation (NIV). Here we report our experience using CPAP/NIV in infants < 10 kg.

Methods: We conducted a retrospective review of infants < 10 kg treated with CPAP/NIV in our PICUs between July 2017-May 2021 in the initial phase of treatment. Demographic, support type and settings, vital signs, pulse oximetry, and intubation data were extracted from the electronic health record. We compared subjects successfully treated with CPAP/NIV with those who required intubation.

Results: We studied 62 subjects with median (interquartile range) age 96 [6.5-308] d and weight 4.5 (3.4-6.6) kg. Of these, 22 (35%) required intubation. There were no significant differences in demographics, medical history, primary interface, pre-CPAP/NIV support, and device used to deliver CPAP/NIV. HFNC was used in 57 (92%) subjects before escalation to CPAP/NIV. Subjects who failed CPAP/NIV were less likely to have bronchiolitis (27% vs 60%, P = .040), less likely to be discharged from the hospital to home (68% vs 93%, P = .02), had a longer median hospital length of stay (LOS) (26.9 [21-50.5] d vs 10.4 [5.6-28.4] d, P = .002), and longer median ICU LOS (14.6 [7.9-25.2] d vs 5.8 [3.8-12.4] d, P = .004). Initial vital signs and F_IO₂ were similar, but S_pO₂ was lower and F_IO₂ higher at 6 h and 12 h after support initiation for subjects who failed CPAP/NIV. Initial CPAP/NIV settings were similar, but subjects who failed CPAP/NIV had higher maximum and final inspiratory/expiratory pressure.

Conclusions: Most infants who failed initial HFNC support were successfully managed without intubation using NIV or CPAP. Bronchiolitis was associated with a lower rate of CPAP/NIV failure, whereas lower S_pO₂ and higher F_IO₂ levels were associated with higher rates of intubation.

Keywords: CPAP; children; infants; noninvasive ventilation; pediatrics; respiratory distress; respiratory failure.