Robert Lindell, MD
Childrens Hospital of Philadelphia
Philadelphia, Pennsylvania
Disclosure information not submitted.
Julie Fitzgerald, MD, PhD, FCCM
Children's Hospital of Philadelphia
Philadelphia, Pennsylvania
Disclosure information not submitted.
Courtney Rowan, MD
Division of Critical Care, Department of Pediatrics
Riley Hospital For Children at Indiana University Health, Indiana, United States
Disclosure information not submitted.
Heidi Flori, MD
Associate Professor
University of Michigan C.S. Mott Children's Hospital
Ann Arbor, MI
Disclosure information not submitted.
Matteo Di Nardo, MD
Consultant Neonatal and Pediatric Intensivist
Children’s Hospital Bambino Gesù, IRCCS, United States
Disclosure information not submitted.
Natalie Napolitano, MPH, MPH, RRT-NPS (she/her/hers)
Research Clinical Specialist
The Children's Hospital of Philadelphia
Philadelphia, Pennsylvania, United States
Disclosure information not submitted.
Danielle Traynor, MSN, RN, CCRN
Department of Anesthesiology and Critical Care Medicine
Children's Hospital of Philadelphia, United States
Disclosure information not submitted.
Kyle Lenz, MD
Children's Hospital of Philadelphia
Philadelphia, Pennsylvania
Disclosure information not submitted.
Guillaume Emeriaud, MD, PhD
Department of Pediatrics, Pediatric Intensive Care Unit
CHU Sainte Justine. Université de Montréal, United States
Disclosure information not submitted.
Asumthia Jeyapalan, DO, MHA
Division of Pediatric Critical Care Medicine
University of Miami Miller School of Medicine, United States
Disclosure information not submitted.
Akira Nishisaki, MD, MSCE
Associate Professor of Anesthesia and Critical Care Medicine
The Children's Hospital of Philadelphia, United States
Disclosure information not submitted.
Title: Duration of Pre-intubation NIPPV is Associated with PICU Mortality in Immunocompromised Children
Introduction/Hypothesis: High-flow nasal cannula (HFNC) and non-invasive positive pressure ventilation (NIPPV) are common first-line therapies for pediatric acute respiratory failure. It is unclear if children who fail HFNC/NIPPV experience worse outcomes than patients who receive invasive mechanical ventilation (IMV) primarily. We hypothesized that, among patients who require IMV, a) duration of pre-intubation respiratory support would be associated with PICU mortality, b) PICU mortality would vary by immune status, and c) patient outcomes would vary by center.
Methods: Using the VPS database, we completed a retrospective cohort study of patients 1 month to 17 years of age who required intubation and IMV for >24 hours. The primary outcome was PICU mortality; exposures were pre-intubation HFNC/NIPPV and immune status [immunocompetent vs immunocompromised (IC) vs hematopoietic cell transplant (HCT)] defined through VPS diagnosis and procedure codes. We constructed mixed effects logistic regression models to test the association between pre-intubation respiratory support and PICU mortality.
Results: HFNC and/or NIPPV was used prior to intubation in 1,825 (34%) of 5,348 PICU intubations across 82 centers. IC diagnoses were identified in 41% of patients; 9% of patients had prior HCT. Compared to patients intubated without prior support, pre-intubation exposure to HFNC (aOR 1.33, 95%CI 1.10-1.62) or NIPPV (aOR 1.44, 95%CI 1.20-1.74) was associated with an increased odds of PICU mortality. Compared to non-IC patients, pre-intubation respiratory support was associated with increased odds of PICU mortality in IC patients (HFNC: aOR 1.41, 95%CI 1.04-1.92; NIPPV: aOR 1.65, 95%CI 1.22-2.23) and HCT patients (HFNC: aOR 4.80, 95%CI 3.08-7.49; NIPPV: aOR 5.06, 95%CI 3.24-7.90). Duration of NIPPV >6hr was associated with increased mortality in IC (aOR 1.81, 95%CI 1.08-3.02) and HCT (aOR 8.58, 95%CI 4.34-16.96) patients compared to NIPPV < 6hr. After adjustment for patient and center characteristics, both pre-intubation HFNC/NIPPV use (median 15%, range 0-63%) and PICU mortality varied by center.
Conclusions: Pre-intubation exposure to HFNC/NIPPV was associated with increased odds of PICU mortality among IC and HCT patients. Mortality risk was highest in IC and HCT patients with prolonged ( >6h) exposure to pre-intubation NIPPV.