SCCM Resource Library-28-Noninvasive Ventilation in Severe Bronchiolitis: Effects on Intubation Rates and Outcomes

Video Transcription

Hello, my name is Michael Salt. I'm a third-year Pediatric Critical Care Fellow at Mass General  Hospital for Children in Boston, Massachusetts. And today I'll be talking to you about noninvasive  ventilation in severe bronchiolitis and the effects on intubation rates and outcomes in the Pediatric Intensive Care Unit. Before we start, I'd like to disclose that I have  no financial relationships to discuss. Bronchiolitis is the most common diagnosis in children less  than two years of age in the United States. Approximately 3% of all infants are hospitalized with this illness each year. Of those that are hospitalized, between 6% and 20% require  pediatric ICU admissions. Cost of these admissions exceeds $1 billion annually. To date, despite  extensive research, supportive care, including various modalities of respiratory support, continues to be the mainstay of treatment. While invasive modalities have historically  been utilized for management, data suggests that noninvasive ventilation, including high-flow  nasal cannula, CPAP, and BiPAP, can be effective and safe. One such modality, ram cannula, which is more typically used in the NICU, can be used off-label to deliver noninvasive  CPAP and biphasic ventilatory support. The purported benefits of using noninvasive ventilation  are decreased rates of intubation, decreased usage of sedating medications, shorter ICU stays, and overall shorter hospitalizations. In addition, the use of noninvasive ventilation  minimizes the intrinsic risk of complications with mechanical ventilation, including laryngeal trauma and granuloma formation, unplanned extubation, ventilator-associated pneumonia,  subglottic pathology, atelectasis, and pneumothorax. Despite these benefits, there continues to  be wide practice variability in the use of noninvasive ventilation and mechanical ventilation  in this population. The objective of this study is to characterize how changes in practice  patterns have affected intubation rates and outcomes among patients with severe bronchiolitis.  A retrospective analysis was performed using data from the Virtual Pediatric Systems, VPS,  an international database of PICU unit admissions. VPS was queried for patients at our center  with a listed diagnosis of bronchiolitis from September of 2008 to March of 2020. All patients  over two years of age or who had prior tracheostomy were excluded from our cohort. An additional  query was performed to assess the number of patients who were treated on the inpatient wards using high-flow nasal cannula from internal respiratory therapy billing database.  Patient characteristics, hospitalization details, and outcomes were obtained. Descriptive analyses  were performed to assess trends in ventilator and noninvasive ventilation utilization in context of their illness severity using PIM-2 scores. From there, a factorial ANOVA analysis  was used to compare means across respiratory support groups and across the study period.  We found that 627 patients fit our criteria and were treated in the pediatric ICU. Additionally,  starting in 2016, 231 patients were treated with high-flow nasal cannula on the pediatric wards. You can see that with each winter, the number of patients treated on the wards  increased. Our results showed that the mean severity of illness in patients rose over time from 2009 to 2020. We identified this based on  mean PIM-2 scores, the average in 2020 being negative 5.18 in comparison to negative 6.09 in 2009. The trend in intubations and use of mechanical ventilation decreased over this  period of time despite the increase in illness severity. Looking at this graph from the onset of its use in 2016, we see that BiPAP via RAM cannula  was used in only 2% of patients that first year. Since that time, we have seen a steady increase in its utilization, and in 2020, escalation to BiPAP via RAM cannula occurred  in 75% of patients in the pediatric ICU. During that same time period, 13% of patients required  mechanical ventilation in 2016, whereas only 4.4% required mechanical ventilation in 2020. This graph visually represents the usage of each respiratory modality over time in context  of each patient's illness severity. Red representing mechanical ventilation, yellow for BiPAP,  blue for CPAP, and green for high-flow nasal cannula. Trend lines show that the severity of illness for all patients, with the exception of those receiving high-flow nasal cannula,  rose over this time period. The average PIM-2 score, as previously mentioned, rose from negative 6.09 in 2009 to negative 5.18 in 2020.  Again, the yellow markers denote patients who received BiPAP. You will notice the increase in appearance as time goes on in the clustering during the 2019 and 2020 years, making up  the majority of patients. There are also fewer red markers as time progresses, showing  the decreased utilization of mechanical ventilation, despite the increase in severity of illness.  Additionally, you will see noted with a star the fall of 2016, when patients were allowed to receive high-flow nasal cannula on the wards. This further allowed the pediatric  ICU to offload less severely ill patients. Here we aim to compare means across different respiratory modalities, in particular BiPAP  and mechanical ventilation. We chose to look at BiPAP versus mechanical ventilation specifically  because BiPAP is viewed as the highest level of non-invasive support we will offer prior to intubation and mechanical ventilation.  Breaking these down by groups, we will first see that there is a mean difference in PICU  length of stay between our BiPAP and mechanical ventilation groups that is statistically significant  in all years. We see differences in length of stay between the two groups of up to 6.7 days during this time period.  Not surprisingly, we see similar patterns in the difference of mean hospital length of stay. These differences are statistically significant with the exception of the year  of 2018. The greatest difference in hospital length of stay being in 2020, where patients receiving BiPAP had a mean 6.8 day shorter stay.  Lastly, we see that we don't have the same statistical significance in the difference between PIM-2 scores in our BiPAP and mechanical ventilation groups. Only 2019 and 2017 show  statistical significance in the difference between groups. Putting that all together, we see that in general, we have shorter PICU and hospital  length of stay in our patients who receive non-invasive ventilation as opposed to those  that receive mechanical ventilation. Classically, we would say that, of course, this makes sense  because our sicker patients are requiring intubation in mechanical ventilation. However,  we also found that we cannot detect statistically significant difference between PIM-2 scores in most years.  The limitations of this study include the fact that it is a retrospective single institution study. It relies not only on human input into VPS, but using diagnosis codes to pull  the data. Also, we note that PIM-2 scoring is not specific for bronchiolitis. With such  low levels of mortality in this disease process, it is not the most ideal predictor of illness severity.  In conclusion, the use of non-invasive ventilation, and particularly biphasic ventilatory support  via ram cannula, continues to be a safe and effective treatment modality for patients with severe bronchiolitis. The aggressive use of this has allowed patients to be treated  with non-invasive ventilation, who historically may have required mechanical ventilation based on illness severity scores. Additionally, these patients may avoid complications and  sedation that are associated with mechanical ventilation. Further benefits were observed  with shorter hospital and PICU length of stay for patients treated with BIPAP via ram cannula despite similar illness severity scores. I very much appreciate it.

Video Summary

Michael Salt, a Pediatric Critical Care Fellow, discusses the use of noninvasive ventilation in severe bronchiolitis in pediatric intensive care units (PICUs). Bronchiolitis is a common illness in children under two years old, with a significant number requiring PICU admissions. Traditional invasive methods have been used, but noninvasive ventilation, such as high-flow nasal cannula, CPAP, and BiPAP, has proven effective and safe. The use of noninvasive ventilation has shown benefits including decreased intubation rates, less sedating medications, shorter ICU stays, and overall shorter hospitalizations. The study analyzed data from the Virtual Pediatric Systems database and found that the use of noninvasive ventilation has led to decreased intubations and mechanical ventilation despite the increased severity of illness. There were also shorter PICU and hospital stays for patients receiving noninvasive ventilation. Overall, noninvasive ventilation, particularly biphasic ventilatory support via ram cannula, is a safe and effective treatment option for severe bronchiolitis, helping to avoid intubation and complications associated with mechanical ventilation.

Asset Subtitle

Pediatrics, Pulmonary, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Michael Salt

Introduction/Hypothesis: Bronchiolitis is the most common diagnosis in children <2 years old. Of those hospitalized, 6-16% require pediatric ICU (PICU) admission. While invasive modalities have historically been utilized for management, data suggest that non-invasive ventilation (NIV) can be effective and safe. One such modality, RAM cannula, can be used off-label to deliver noninvasive CPAP and BiPAP. However, there continues to be wide practice variability in the use of NIV for these patients. At Massachusetts General Hospital for Children, we are increasingly using BiPAP via RAM cannula as the maximum level of NIV prior to intubation. This study aims to characterize how changes in practice patterns have affected intubation rates and outcomes among patients with severe bronchiolitis.

Methods: A retrospective analysis was performed using Virtual Pediatric Systems (VPS). VPS was queried for patients at MGHfC with a diagnosis of bronchiolitis. All patients over 2 years old, or who had a prior tracheostomy were excluded. Patient characteristics and outcomes were obtained. Descriptive analyses were performed to assess trends in ventilator and RAM cannula utilization in context of their illness severity using PIM2 scores.

Results: 627 patients fitting criteria were treated in the PICU over 11 years. The severity of illness for all patients increased over this period with an average PIM2 score of -5.18 in 2020 vs. -6.09 in 2009. The trend in intubations decreased over this time, despite increasing severity of illness scores. Adopted in 2016, BiPAP via RAM cannula was initially used in 2% of patients as opposed to 75% of patients in 2020. In 2016, 13.6% required mechanical ventilation (MV), whereas only 4.4% required MV in 2020. Patients treated with BiPAP via RAM cannula had an average PIM2 score of -5.14, a hospital length of stay (LOS) of 6.84 days and an ICU stay of 4.98 days, compared to patients requiring MV who had PIM2 scores of -5.15, a hospital LOS of 13.36 days, and an ICU stay of 10.02 days.

Conclusions: RAM cannula is an effective treatment modality for patients with severe bronchiolitis. Increased utilization of this modality allowed patients to be treated with NIV, who historically may have required MV based on illness scores. Use of RAM cannula has decreased hospital and PICU length of stay.

Meta Tag

Content Type Presentation

Knowledge Area Pediatrics

Knowledge Area Pulmonary

Knowledge Level Advanced

Membership Level Select

Tag Ventilation

Tag Airway Management

Tag Pediatrics

Year 2021

Keywords

noninvasive ventilation

severe bronchiolitis

pediatric intensive care units

decreased intubation rates

biphasic ventilatory support

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