The IX t h Makassed Medical Congress - American University of Beirut

(P=0.006, odds ratio=4.59), respectively.
IDA is common in Lebanese children and is associated with increased blood lead levels, lack of
iron supplementation, and cultural dietary habits. Remedial measures such as iron fortification of
commonly consumed food are needed on the national level. Lead exposure must be controlled
and awareness must be raised about the potentially devastating consequences of combined
iron deficiency and lead poisoning on young children.
NON-INVASIVE VENTILATION IN CHILDREN: INDICATIONS AND PREDICTIVE
FACTORS FOR THE OUTCOME
Francis Leclerc MD-PhD
Non-invasive ventilation (NIV) provides respiratory support without endotracheal tube or
tracheostomy. It usually refers to continuous positive airway (CPAP) or bilevel positive airway
pressure (BiPAP) delivered through nasal prongs, facemasks or head boxes. Many evidence is
accumulating that it may be beneficial for children with acute respiratory failure (ARF). In a 5-year
retrospective study, 83 of 114 children (77%) were treated successfully with NIV; the success rate
was 100% for acute chest syndrome, 92% for immuno-compromised children, 87% for community
acquired pneumonia, while only 22% for acute respiratory distress syndrome (ARDS) (1). In a
3-year prospective study, 32 episodes of ARF in 26 children (pneumonia: 46%) were treated with
NIV by a volumetric ventilator; there was a clinical (at 2-4 hours) and radiological (at 24 hours)
improvement and only 4 children required intubation (2). The mechanism by which NIV acts was
recently studied by Essouri et al. in 12 children with hypercapnic ARF by the mean of an esogastric
catheter: the authors observed that NIV was associated with a significant improvement
of breathing pattern, gas exchange and respiratory muscle output (3). Also, NIV limits alveolar
collapse (1). NIV includes simpler technology and equipment allowing use in settings other
than critical care units; this means that patients may benefit from additional respiratory support
earlier in the progression of their illness. Furthermore, NIV is associated with less need for sedation
and a decrease in nosocomial ventilator associated infections. This is, at least partly, due to
the diminished need for intubation, as reported by Yanez et al in their prospective randomised
controlled study (intubation rate: 60 % in controls, 28% in NIV group) (4).
When use NIV for acute respiratory failure?
Whilst for some problems, such as upper airway obstruction, stenting of the upper airway with
CPAP is often adequate to improve overall ventilation, there are other conditions where additional
BiPAP to enhance minute ventilation is used. For ARF, a combination of factors determines whether
assisted ventilation is needed, most commonly the degree of respiratory distress and whether the
child is tiring, exhausted, unable to vocalise, looking frightened, has altered conscious level or
deteriorating vital signs. The child’s clinical condition usually guides the need for intubation and
critical care, but continuous measurement of pulse oxygen saturation (SpO 2 ) and PtcCO 2 (5)
(as NIV is generally used for hypercapnic ARF) may help identify the progression of respiratory
failure and allow for earlier intervention with NIV. Several papers have summarized the published
evidence on NIV for ARF in adult patients: the results are presented in table 1 (6-8). The authors
of these meta-analyses concluded that NIV for ARF was supported by strong evidence from
patients with chronic obstructive pulmonary disease, acute cardiogenic pulmonary edema
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