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

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T h e I X t h M a k a s e d M e d i c a l C o n g r e s s and weaning off invasive ventilation, but there was only weak support for NIV in others, such as immunocompromised patients. For other groups, such as patients with asthma, pneumonia, or acute lung injury, RCT-level evidence was lacking or did not suggest benefit (6-8). More recently, 53 adult patients with severe acute asthma (FEV1 < 30% of predicted) were randomized to NIV (n=28) or standard medical therapy (n=25). ICU and hospital stay was significantly shorter and the mean dose of inhaled bronchodilator was significantly less in the NIV group. The four patients with standard-medical-therapy failure improved with NIV. Two patients in the NIV arm required invasive ventilation. There was no mortality in either of the arms. The authors concluded that a larger study is required (9). For children, there is little evidence from randomised controlled trials that early intervention with NIV reduces mortality; however, a number of reports suggest that NIV is useful in ARF by avoiding the need for intubation (10). In the prospective series by Yanez et al, comparing 25 children NIV plus standard therapy (n=25) with standard therapy (n=25), diagnoses were moderate asthma (n=5), viral bronchiolitis-pneumonia (n=42), bacterial peumonia (n=3). Tracheal intubation was lower in the NIV group (28%/60%; p=0.045) (4). In another series, 20 children (mean age 48 months) with lower airway obstruction were randomized to receive alternatively 2 hours of nasal NIV, followed by crossover to 2 hours of standard medical treatment. Compared to the baseline values, NIV was associated with lower respiratory rate, total Clinical Asthma Score, and delivered oxygen concentration needed to maintain oxygen saturation ≥ 90% (all p < .01) (11). Viral bronchiolitispneumonia, mainly due to RSV, represents the largest cohort of children treated with NIV (2, 4, 12-16). In all reported series (none of them was randomized and prospective), a decrease in respiratory rate and pCO 2 level was usually observed within 1 or 2 hours, and 75-80% of infants did not need intubation (15). Clinical conditions with ARF where NIV is used are summarized in table 2 (10). Finally, NIV may also be palliative. Do we have predictive factors of NIV failure in children with acute respiratory failure? In children with severe exhaustion from respiratory failure or reduced conscious level, there are risks from treatment with NIV without an adequately secured airway, including gastric distension and aspiration. NIV does not protect the airway or allow as effective clearance of lower airway secretions as does intubation, particularly in the child with a reduced conscious level. However, effective airway clearance is helped by any ventilation that allows maintenance of good lung volumes from which a more effective cough may be generated. The best predictive factors for the success of NIV in acute respiratory failure appear to be the respiratory rate and the level of inspired oxygen 1 or 2 hours after starting NIV. Lack of effectiveness arises mainly from agitation, poor airway protection or abdominal distension. Several authors have identified different predictive factors of NIV failure in the PICU: the results of studies, which regard children with ARF of different causes, are given in table 3. Other studies have focused on only one disease such as bronchiolitis in infants (12-15). In conclusion, NIV is a treatment option available for children experiencing acute respiratory failure. NIV needs an experienced staff and is not appropriate for children who are unable to protect their own airway, severely exhausted or have a reduced level of consciousness. The selection of the NIV interface is essential in order to achieve the most successful outcome (17). Clinical assessment with continuous monitoring of SpO 2 and if possible PtcCO 2 must be rigorous in order to identify patients not responding to NIV and needing intubation. 60
Table 1: Randomized controlled trials of noninvasive ventilation for acute respiratory failure in adults. Condition RCTs (n) Benefit Hypoxemic Acute Respiratory Failure Cardiopulmonary edema 4 NIV RCT = randomized controlled trial; ALI = acute lung injury; ARDS = acute respiratory distress syndrome; NIV = noninvasive ventilation; CPAP = continuous positive airway pressure 61 6 CPAP Yes ALI/ARDS 3 NIV Unclear Severe community-acquired or hospital- acquired pneumonia 1 CPAP No 2 NIV Unclear Chest trauma 1 NIV Unclear Atelectasis 0 Acute on chronic respiratory disease (eg. Interstitial lung disease) Hypercapnic Acute Respiratory Failure 1 CPAP Unclear Chronic obstructive pulmonary disease 17 NIV Yes Asthma 2 NIV Unclear Neuromuscular 0 Primary central nervous system 0 Weaning from invasive ventilation 12 NIV Yes 0
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The IX th Makassed Medical Congress
Page 3 and 4:
CONGRESS PRESIDENT Said Sayegh, MD,
Page 5 and 6:
GENERAL INFORMATION
Page 7 and 8:
• Target Audience: Physicians, Pr
Page 9 and 10: Durriya Sinno, MD Pediatrics Americ
Page 11 and 12: Moderators
Page 13 and 14: PEDIATRICS Bassem Abou Merhi, MD Pe
Page 15 and 16: Maroun Sokhn, MD Pediatrics Saint G
Page 17 and 18: Scientific Program
Page 19 and 20: Session 3: Intensive Care Neonatolo
Page 21 and 22: Session 1: Pediatric Intensive Care
Page 23 and 24: 8:00 - 8:05 08:05 - 08:10 Welcome r
Page 25 and 26: Cardiology Session III: Interventio
Page 27 and 28: Cardiology Session VI: Intervention
Page 29: Cardiology Symposia (NON-CME) Frida
Page 32 and 33: T h e I X t h M a k a s e d M e d i
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The IX t h Makassed Medical Congress - American University of Beirut

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