Use of bilevel positive pressure ventilation in patients with bronchiolitis

Abstract

Rational: This study aims at describing the use of bilevel positive airway pressure (BiPAP) in infants with severe bronchiolitis. Working Hypothesis: The use of BiPAP in infants with bronchiolitis may be associated with a worst outcome. Study Design: A single-center retrospective study performed from October 2013 to April 2016. Methodology: All infants from 1 day to 6 months of age admitted in the pediatric intensive care unit (PICU) were included if they had a clinical diagnosis of bronchiolitis and if they required any type of noninvasive ventilation (NIV), including high flow nasal cannula, continuous positive airway pressure and BiPAP at admission in PICU. There was no local written protocol regarding the ventilator management during the study. Results: Overall, 252 infants (median age 45 (26-72) days) were included in the study and 110 infants (44%) were supported by BiPAP at admission. More infants were born preterm in the group of patients supported by BiPAP at admission. No complication related to NIV occurred. Patients in the BiPAP group had a longer duration of noninvasive support as well as a longer PICU length of stay. However, hospital length of stay did not differ according to the type of respiratory support at admission. Conclusion: The use of BiPAP was not associated with endotracheal intubation, however it was associated with increased PICU length of stay and increased duration of NIV.

Improving synchrony in young infants supported by noninvasive ventilation for severe bronchiolitis: Yes, we can… so we should!

“…In an elegant physiological study performed in infants with AVB, Baudin et al 30 characterized the main inspiratory asynchronies with noninvasive pressure assist control ventilation from diaphragmatic electrical activity recordings. Autotriggering, double triggering, and above all nontriggered breaths were observed for nearly 40% of the respiratory cycles, highlighting difficulties in detecting inspiratory effort in patients younger than 6 months, the targeted population in the study by Delacroix et al 14 These triggering asynchronies are associated with leaks, notably when BiPAP is performed with a nasal interface 31 . This issue is explained by the insufficient sensitivity of the triggers with regard to the modest volumes and flows generated during inspiration at this young age 32 .…”

“…The inherent limitation of these retrospective studies, whether monocentric 14,16 or database‐driven, 15 is the presence of confounders, which influence both the choice of the initial respiratory support and the outcome. It was particularly interesting to note in Delacroix et al's 14 study that the clinicians' preferred choice was BiPAP, although no local written protocol required it in this situation. However, the BiPAP‐treated group also included a higher rate of premature infants, a condition associated with the immaturity of immune defenses and airway development and ventilation‐induced airway injury that predisposes to more severe bronchiolitis 17 …”

“…In practice, CPAP and HFNC are introduced early in the course of the disease—even as a preemptive measure in some cases—in infants generally not exhausted. While NIV is widely used to treat bronchiolitis, 25 most clinicians, unlike in Delacroix et al's 14 study, consider BiPAP the next step for patients failing with HFNC or CPAP 19 . Failure rates vary widely, from 10% to 50% in the major randomized controlled studies, 1,2,22–24 and depend on multiple factors, the most important probably related to the criteria and delays in defining failure.…”

“…The need for synchronization appears with the use of NIV, which interferes with the patient's spontaneous ventilation by facilitating the entry of gas into the lungs via the cyclical application of active ventilator assistance programmed for pressure or volume or a mix of the two. Delacroix et al 14 point out that the unfavorable results in their BiPAP group may have resulted from a suboptimal patient‐ventilator interaction 14 . Indeed, use of pressure support in spontaneous/timed modes requires inspiratory synchrony, expiratory synchrony, and rapid compensation for leaks to reach pre‐established pressure values during inspiration 26 .…”

“…7 Indeed, most of the studies carried out in this field have been observational, with comparisons with historical cohorts, 5,6,[8][9][10] or physiological, assessing differences with and without noninvasive respiratory support. 4,[11][12][13] In this issue of Pediatric Pulmonology, Delacroix et al 14 reevaluate the use of BiPAP as the first-line respiratory support in less than 6-month patients with bronchiolitis. 14 In their single-center retrospective study, they report longer durations of noninvasive support and longer PICU stays in the patients supported with BiPAP compared with CPAP and HFNC.…”