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Abstract

Introduction: Non-invasive ventilation (NIV) is increasingly used in pediatric intensive care unit (PICU) to limit the complications associated with mechanical ventilation. However, NIV may fail, and the delay in initiation of invasive ventilation may be associated with a complicated evolution. Hypothesis: NIV failure may be associated with a higher incidence of severe tracheal intubation associated events (TIAEs) and longer pediatric intensive care unit (PICU) stay compared to children undergoing intubation without prior NIV. Methods: Consecutive tracheal intubation procedures were prospectively evaluated in our PICU from 01/2011 to 02/2012, as part of the multicenter National Emergency Airway Registry for Children (NEAR-4-KIDS) collaborative. Additional chart review was conducted to assess the presence of NIV in the 24 hours prior intubation. Severe TIAEs (cardiac arrest, esophageal intubation with delayed recognition, emesis with aspiration, hypotension requiring intervention, laryngospasm, malignant hyperthermia, pneumothorax and pneumomediastinum) and bradycardia <50 bpm were recorded prospectively. Statistical analysis was done in SPSS using Fisher’s exact test for categorical data and Mann–Whitney U test for continuous, non-parametric data. Results: 75 intubation events were analyzed, among which 35 (47%) followed NIV failure. Compared to patients intubated primarily, patients intubated after NIV failure were younger although not significant (median (interquartile range) 60 (30-485) days vs 363 (60-805) days, p=0.08). Their PIM2 score at admission was lower (1.0 (0.6- 3.3) vs 2.2 (1.0-5.4), p=0.01), but their severity had reached a similar level prior intubation (PELOD score 1 (0-11) vs 1 (1-11); p=0.35). The incidence of severe TIAEs or bradycardia was 40% after NIV failure, and 23% in primarily intubated patients (p=0.13). The PICU stay was longer after NIV failure (10 (8-18) days vs 7 (5-14) days, p=0.03). Conclusions: Children who failed an NIV trial were less sick at admission. However they spent a significantly longer time in PICU, and seemed to have a high incidence of TIAEs. Evidence for an optimal use of NIV is lacking. Further research is warranted to identify conditions in which intubation should not be delayed.