Daniel Cater
Indiana University School of Medicine, Riley Hospital for Children
Indianapolis, Indiana
Disclosure information not submitted.
Julie Fitzgerald, MD, PhD, FCCM
Children's Hospital of Philadelphia
Philadelphia, Pennsylvania
Disclosure information not submitted.
Shira Gertz, MD
Faculty
Saint Barnabas Medical Center, United States
Disclosure information not submitted.
Jennifer McArthur, DO
Associate Member
St. Jude Chidren's Research Hospital
Memphis, Tennessee, United States
Disclosure information not submitted.
Megan Daniel, MD
Faculty
Nationwide Children's Hospital, United States
Disclosure information not submitted.
Kris Mahadeo, MD, MPH
Associate Professor
MD Anderson, United States
Disclosure information not submitted.
Deyin Hsing, MD, FAAP
Assistant Professor
Weill Cornell Medical Center
New York, New York, United States
Disclosure information not submitted.
Lincoln Smith, MD
Assistant professor
Saettle Children's Hospital, United States
Disclosure information not submitted.
Francis Pike, BS, MS, PhD
PhD
Indiana University School of Medicine, United States
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.
Title: Noninvasive Ventilation Use Prior to Intubation in Pediatric Hematopoietic Cell Transplant Patients
Introduction: Non-invasive ventilation (NIV) has not been well-studied in certain high-risk patient populations, such as the allogeneic hematopoietic cell transplantation (HCT) recipient, who may be prone to more negative effects from this treatment modality. The aim of this study is to determine whether NIV use is associated with worse outcomes in this highly vulnerable patient population after controlling for other important risk factors.
Methods: A secondary analysis of a retrospective multicenter cohort study of children and young adults that experienced respiratory failure post allogeneic HCT was performed. Patients were categorized into those who received NIV and those who did not prior to intubation. The primary outcome was PICU mortality, secondary outcomes included ventilator free days at 28 days and development of pediatric acute respiratory distress syndrome (PARDS). Multivariable logistic and linear regression models were constructed using variables significant on univariable analysis and clinically important factors.
Results: Two-hundred twenty-two patients were included. Of these, 91 (41%) received NIV prior to intubation. Those that received NIV prior to intubation were older (13 vs 6 years, p< 0.001), and more commonly had respiratory distress on PICU admission (89% versus 75%, p=0.004). Adjusting for age, respiratory distress at PICU admission, and the use of vasoactive agents, NIV use prior to intubation was associated with a higher PICU mortality (HR: 1.51 (95%CI: 1.04, 2.19), p =0.029), and fewer ventilator free days (VFD) at 28 days (β -3.02 (95%CI: -5.66, -0.38), p=0.025). Those with NIV exposure prior to intubation also had higher rates of development of PARDS within 72 hours of intubation (93% versus 78%, p=0.002). Those with NIV exposure prior to intubation had increased odds of developing PARDS within the first 24 hours of mechanical ventilation (OR=5.01 (95% CI: 1.89, 13.27)).
Conclusions: In this cohort of children post-HCT, NIV use prior to intubation was associated with worse outcomes. The benefits and risks of NIV in this unique patient population should be considered prior to its use and careful patient selection is crucial to its safe utilization.