18: EPIDEMIOLOGY OF NONINVASIVE AND INVASIVE MECHANICAL VENTILATION USE FOR CHILDREN AT THE END OF LIFE

Abstract

Introduction: Invasive mechanical ventilation (IMV) is an intensive intervention commonly experienced by children at the end of life. Non-invasive mechanical ventilation (NIV) is a potential alternative to IMV, and studies have shown increasing use of NIV without decreasing IMV for adults. The objective was to describe the trends, predictors, and hospital variability in use of NIV and IMV for children at the end of life. Methods: Multi-center retrospective cohort study of children 0 to 21 years who died in 1 of 37 hospitals in Pediatrics Health Information Systems (PHIS) Database between 2010 and 2019. ICD-9, ICD-10, and CTC codes were used to identify mode of ventilation (IMV, NIV, both or none). Descriptive statistics summarized socio-demographic and clinical characteristics by mode of ventilation, and hospital NIV use quartiles were calculated. The Cochran-Armitage test assessed for trends over time and multivariable random-effect logistic regression assessed for independent predictors of ventilatory support. Results: 41,091 patients (median age 0.4, IQR [0,6.7] y, 45% female, 42% white) died in the hospital. Increasing age predicted lower odds of IMV (aOR .95 per year, 95% CI .95-.96, p<.001) or both (aOR .98 per year, 95% CI .97-.99, p=.005) compared to none. Number of complex chronic conditions (CCC) (median [IQR]) was 2 [1,3] overall and for IMV, 3 [2,3] for NIV, and 3 [2,4] for both. Self-pay patients were less likely than commercially or government insured to receive IMV (aOR .69, 95% CI .56-.84, p<.001) or both (aOR .37, 95% CI .27-.5, p<.001). From 2010 to 2019, exposure to NIV increased (771 [18.8%] vs. 1075 [25.9%], p<.001) with no change in IMV (3636 [88.6%] vs. 3669 [88.5%], p=.86); increase in NIV was more often experienced as both (688 [16.8%] vs. 944 [22.8%]) than NIV (83 [2%] vs. 131 [3.2%]). For hospitals in the highest NIV use quartile, the aOR for any NIV was 6.16 (95% CI 3.98-9.52, p<.001) and any IMV was .8 (95% CI .55-1.17, p=.249) compared to the lowest NIV use quartile. Conclusions: Use of NIV has increased over time for children nearing the end of life, without a reciprocal decrease in use of IMV. Differences exist based on age, insurance status, and chronic medical complexity. Significant interhospital variability in NIV use exists, which does not correlate with use of IMV.