ABSTRACT
Background and Aims:
The pediatric cardiac intensive care unit (PCICU) frequently uses noninvasive ventilation (NIV). There are several reasons for its use, including prophylactic use right after the patient has been extubated. It is also used when patients are experiencing acute respiratory failure due to either cardiac or noncardiac reasons but are still able to maintain their airways. The objective of this study was to understand the spectrum of use of NIV following congenital cardiac surgery and analyze the outcome.
Methods and Results:
A retrospective observational study was conducted in a 14-bed PCICU, reviewing data from August 2019 to August 2022. Among 1750 congenital cardiac surgeries, 523 patients (29.9%) received NIV. The median age of the population was 2.5 months. Factors such as higher Risk-Adjusted Classification for Congenital Heart Surgery-1 category, longer intraoperative cardiopulmonary bypass time, and aortic cross-clamp time were associated with increased NIV use. Preoperative ventilator needs, infections, genetic syndromes, diaphragmatic paralysis, high vasoactive inotrope score (VIS) in the first 24 h, neonatal age, and weight <5 kg were independently associated with increased NIV need. The NIV group had a longer intensive care unit (ICU) stay compared to non-NIV patients. The success rate of NIV was 84%, with 440 successful cases and 83 failures. The mortality rate in the success and failure groups was not significantly different (5.27% vs. 6.0%).
Conclusions:
NIV is widely used in PCICU, but it is associated with longer ICU stays. It proves beneficial after congenital cardiac surgery, especially for patients with specific risk factors. However, NIV may not directly impact mortality rates, suggesting that other factors contribute to patient survival.
Keywords: Children, congenital heart disease surgery, extubation, noninvasive ventilation, pediatric cardiac intensive care unit, Risk-Adjusted Classification for Congenital Heart Surgery-1 score
INTRODUCTION
Noninvasive ventilation (NIV) is a crucial tool for managing respiratory distress and failure in the postoperative pediatric cardiac intensive care unit (PCICU) setting. Offering a less invasive and more comfortable alternative to invasive mechanical ventilation, NIV helps reduce complications and promote quicker patient recovery. NIV is used prophylactically and nonprophylactically in patients with respiratory failure who can maintain their airway.
Many studies suggest NIV as a better approach than mechanical ventilation for treating acute respiratory failure in the postoperative periods.[1,2] By reducing the need for intubation and invasive ventilation in pediatric patients, NIV leads to fewer complications and improved outcomes.[3,4,5] NIV also avoids complications associated with invasive mechanical ventilation, like ventilator-induced lung injury and infections, by maintaining spontaneous breathing and minimizing airway manipulation. Moreover, NIV shows potential in reducing the pediatric intensive care unit (PICU) length of stay (LOS) and overall mortality risk. Fast-tracking patients with acceptable hemodynamic parameters in the PCICU and avoiding re-intubation postoperatively is becoming increasingly common.[6]
However, NIV has limitations in these settings. Proper selection of the patient population and the right timing for NIV initiation is essential. Failure to do so could lead to delayed intubation, and increased morbidity and mortality.[7] NIV might not be effective in patients with severe respiratory failure or those with upper airway obstruction. Ensuring a proper seal to avoid air leaks and maintaining close patient monitoring is crucial, requiring adequate monitoring and well-trained staff.[8] Despite the widespread use of NIV, questions remain about its indications, patient characteristics, and outcomes. More literature from this part of the world could help fill these knowledge gaps, guiding future research and quality improvement initiatives to optimize pediatric respiratory support in the PCICU.
The objective of the study is to estimate the frequency of use of NIV and describe the clinical characteristics of children who required NIV for respiratory failure or prophylactic reasons after undergoing corrective or palliative cardiac surgery for congenital heart diseases. We also wished to determine the success and mortality rate of NIV and identify factors predictive of increased use of NIV success in resource-limited settings.
MATERIALS AND METHODS
The study was approved by the Institutional Ethics Committee. Since this was a retrospective study involving anonymous patient data, the Institutional Ethics Committee granted a waiver of individual patient consent (EC Reference Number: NSHEC/INV/Non-Reg/2023/001). This was conducted in a cardiac surgical center in Eastern India. This was a retrospective descriptive observational study conducted in a 14-bed PCICU between August 2019 and August 2022. We perform between 550 and 600 congenital cardiac surgeries of all complexities annually.
We retrospectively reviewed the medical records of all children between the ages of 1 day and 19 years who underwent corrective or palliative cardiac surgery (either with or without cardiopulmonary bypass [CPB]). All of these patients underwent either transesophageal echocardiography or epicardial echocardiography postsurgery after coming off from CPB, to define adequacy of repair and rule out major residual defects. We used pressure assist control (PAC) ventilation and heated high-flow nasal cannula (HHFNC) oxygen as modes of delivery of NIV. Full face masks were used to deliver PAC ventilation and appropriate sized nasal cannulae were used to deliver high flow. There are some controversies if HHFNC could be considered a form of NIV. Some believe that it is a form of NIV, whereas another school of thought does not consider it. We chose to designate it as a form of noninvasive respiratory support, but the conglomerate data were included in the study.
The full-face mask interface was used to deliver the PAC mode of NIV. This interface covered the entire face from forehead to chin. Positive end-expiratory pressure was set at 5 cm H2O for all the patients and was titrated up to a maximum of 8 cm H2O if no improvement in oxygen saturation or arterial PaO2 was achieved. Peak inspiratory pressure was initiated at 12–14 cm H2O and was gradually titrated to a maximum of 18–20 cm H2O depending on the clinical status and gas exchange. We began with 0.5 FiO2, titrating as appropriate depending on the patient’s physiology and clinical status. We started NIV with an age-appropriate respiratory rate.
An appropriate-size nasal cannula was used to deliver HHFNC. We started with 1 L/kg/min of flow with 0.5 FiO2 and titrated up to a maximum of 2 L/kg/min depending on the patient’s needs.
Both these forms of noninvasive respiratory support were delivered through Mindray Synovent E5 and Mindray SV300 ventilators.
When NIV was begun right after extubation, we either designated the patients into prophylactic groups or when it was started after signs and symptoms of acute respiratory failure, we designated them into nonprophylactic groups. Patients were labeled as responders if they received NIV and did not need tracheal reintubation throughout their time in the PCICU, and nonresponders if they did not, necessitating tracheal reintubation.
The decision to start prophylactic NIV was taken by the intensive care unit (ICU) team led by the consultant cardiac intensivist. At times, the decision would be subjective based on the understanding of the patient’s physiology and assumptions on the patient’s reserve, who were considered at high risk for difficulty in breathing after endotracheal tube removal. Typically we strongly considered the following subset of patients for putting on NIV: neonates and infants <5 kg, malnourished infants, children on prolonged invasive ventilation, low left ventricular ejection fraction during the time of extubation, those who showed signs of low cardiac output, cardiac surgery with a Risk-Adjusted Classification for Congenital Heart Surgery (RACHS-1) score[9] of 3 and above, those with high Vasoactive Inotropic Score (VIS) in the first 24 h of ICU stay, those with evidence of acute lung injury, those with a neuromuscular disorder, and those with suspected or confirmed diaphragm dysfunction. RACHS-1 score was created to determine each patient’s (children < 18 years) risk of hospital mortality after undergoing CHD surgery.
The definition of VIS was adapted from the publication of Gaies et al.[10] Inotrope score (IS) = Dopamine dose (μg/kg/min) + Dobutamine dose (μg/kg/min) +100 × Epinephrine dose (μg/kg/min).
Vasoactive-inotropic score (VIS) = IS + 10 × Milrinone dose (μg/kg/min) +10,000 × Vasopressin dose (units/kg/min) +100 × Norepinephrine dose (μg/kg/min). A score of ≥20 was considered to be high.[11]
Acute respiratory failure was defined as an oxygen requirement of 50% or more for normal oxygen saturations (≥94% for acyanotic cardiac lesions or 75%–87% for cyanotic cardiac lesions), arterial partial pressure of carbon dioxide (PaCO2) of 50 mmHg or higher (or a venous PaCO2 of C55 mmHg), or evidence of moderate-to-severe respiratory distress demonstrated by dyspnea worsening from baseline, tachypnea (respiratory rate greater than two standard deviations over the typical range for the child’s age), and use of accessory muscles of respiration.
Reintubation criteria would typically depend on the individual patient’s clinical status, underlying condition, and reason for NIV use. The PCICU team strongly considered reintubation under the following circumstances:
If the child’s respiratory distress or failure worsened despite optimal NIV support; decreased level of consciousness, making it difficult to maintain airway patency; if the child became hemodynamically unstable, requiring high levels of vasopressor support; if the child developed excessive secretions that could not be cleared with suctioning or other interventions. Wherever clinically appropriate, transthoracic echocardiography was done in the PCICU by pediatric cardiologists to rule out hemodynamically significant residual lesions.
For each patient, we collected the following data: demographic details, indication, duration and mode of NIV, interface (nasal cannula or full-face mask), NIV failure, mortality, presence of pre- and postoperative infections, preoperative ventilator needs, diaphragmatic paralysis, and PCICU LOS. Operative details including total intraoperative CPB time, aortic cross-clamp time, and RACHS-1 score were collected.
Continuous variables were expressed as median (interquartile range [IQR]) and frequency (percentage) for categorical variables. Comparison between the two groups was done using the Wilcoxon rank sum for continuous variables and the Chi-square or Fisher’s exact test for categorical data. P <0.05 was considered statistically significant.
Every assessment was conducted using a significance threshold of 5%. We used MedCalc Version 20.014 for statistical analysis. The computation of the sample was based on a 5% single-tailed alpha error and a 20% beta error. An assumed NIV usage rate of 45% was considered.[12] Thus, the minimum calculated sample size was 30 in the NIV group. However, as stated earlier, we retrospectively reviewed charts of all patients who underwent congenital cardiac surgery during the study period. All records were complete and were included in the study.
RESULTS
During the study period, a total of 1750 cardiac surgeries were performed at our center, out of whom 523 (29.9%) were treated with NIV. Of the NIV group, 53.9% were boys and 46.1% were girls, and the median age was 2.5 months (IQR: 0.5–8.5). Overall, 205 children (39.2%) in the NIV group were neonates. PAC mode of ventilation was used in 33.4% of patients, followed by HHFNC in 25.2% of children and a combination of both in 41.3% of patients. Genetic syndromes were identified among 12% of the patients in the NIV group. The median duration of invasive ventilation was 5.5 days (IQR: 0–9.7) and the median duration of NIV was 62.5 h (IQR: 36.2–142) [Table 1].
Table 1.
Demographic and miscellaneous variable data of children on noninvasive ventilation
| Variables | Number of observations (Percentage) and Median (IQR) |
|---|---|
| NIV (n) | 523 |
| Total surgeries | 1750 (29.9) |
| Sex | |
| Male | 282 (53.9) |
| Female | 241 (46.1) |
| Age (months), median (IQR) | 2.5 (0.5–8.5) |
| Newborn/infants <5 kg | 321 (61.4) |
| Newborn | 205 (39.2) |
| Interface | |
| Face mask (PAC ventilation) | 175 (33.4) |
| HFNC only | 132 (25.2) |
| Face mask and HFNC | 216 (41.3) |
| Syndromes | |
| Genetic syndromes | 63 (12) |
| Down syndrome | 42 (66.7) |
| 22q11 deletion | 12 (19) |
| Turner syndrome | 5 (8) |
| CHARGE syndrome | 4 (6.3) |
| Duration of invasive ventilation (days), median (IQR) | 5.5 (0–9.7) |
| Duration of NIV (h), median (IQR) | 62.5 (36.2–142) |
NIV: Noninvasive ventilation, IQR: Interquartile range, PAC: Pressure assist control, HFNC: High-flow nasal cannula
Factors associated with increased use of noninvasive ventilation
Surgical factors
It was found that a higher RACHS category was significantly associated with increased use of NIV (P < 0.05). Moreover, the NIV group had a significantly longer total intraoperative CPB time (P = 0.036) and aortic cross-clamp time (P = 0.014) than the non-NIV group.
Nonsurgical factors
Preoperative ventilator needs, preoperative infections, the existence of genetic syndromes, diaphragmatic paralysis, high VIS in the first 24 h, younger age group (neonates), and weight <5 kg were all independently associated with an increased need for NIV [Tables 2 and 3]. Out of the 59 patients with diaphragmatic paralysis, 58 needed NIV. Fourteen out of 58 patients (24%) could not be managed by conservative methods and needed plication.
Table 2.
Surgical factors associated with increased use of noninvasive ventilation
| Type of surgery | Total | NIV group (n=523), n (%) | Non-NIV group (only on invasive ventilation) (n=1227), n (%) | P |
|---|---|---|---|---|
| RACHS-1 | 267 | 4 (0.76) | 263 (21.4) | 0.85 |
| RACHS-2 | 647 | 113 (21.6) | 534 (42.5) | 0.41 |
| RACHS-3 | 547 | 240 (45.9) | 307 (25) | 0.023 |
| RACHS-4 | 289 | 166 (31.7) | 123 (10) | 0.016 |
|
| ||||
| Surgical details | Median (IQR) | P | ||
|
| ||||
| NIV group | Non-NIV group (only on invasive ventilation) | |||
|
| ||||
| Total intraoperative CPB time (min) | 188 (108.5–343) | 89 (72.5–214) | 0.036 | |
| Aortic cross-clamp time (min) | 117 (60.5–203.5) | 65 (51–163.5) | 0.014 | |
NIV: Noninvasive ventilation, IQR: Interquartile range, RACHS: Risk-Adjusted Classification for Congenital Heart Surgery, CPB: Cardiopulmonary bypass
Table 3.
Nonsurgical factors associated with increased use of noninvasive ventilation
| n/total (%) | NIV group, n (%) | Non-NIV group, n (%) | P | |
|---|---|---|---|---|
| Preoperative ventilator needs | 181/1750 (10.3) | 112 (62) | 69 (38) | 0.012 |
| Genetic syndromes | 106/1750 (6.1) | 63 (12) | 4 (3.5) | 0.029 |
| Preoperative infections | 114/1750 (6.5) | 98 (86) | 16 (14) | 0.046 |
| Diaphragmatic paralysis | 59/1750 (3.4) | 58 (98.3) | 1 (1.7) | 0.011 |
| High VIS in the first 24 h (≥20) | 487/1750 (27.8) | 352 (72.3) | 135 (27.7) | 0.039 |
| Neonates and infants<5 kg | 621/1750 (35.5) | 321 (62) | 300 (38) | 0.027 |
| Prolonged postoperative invasive ventilation (>72 h) | 485/1750 (27.7) | 409 (84.3) | 78 (15.7) | 0.027 |
VIS: Vasoactive Inotropic Score, NIV: Noninvasive ventilation
The outcome of noninvasive ventilation
The overall success rate of NIV was 84%, with 440 successful cases and 83 failed cases. The mortality rate was 5.27% (23 patients) and 6.0% (5 patients) in the success and failure groups, respectively, with no significant difference between the two groups. The median length of ICU stay and the duration of invasive ventilation were significantly longer in the success group than in the failure group (P < 0.05). However, the duration of NIV did not differ significantly between the successful and failed cases (P = 0.16). The interface used for NIV did not affect the outcome significantly [Table 4].
Table 4.
Outcome of noninvasive ventilation
| Success (n=440), n (%) | Failure (n=83), n (%) | P | |
|---|---|---|---|
| Mortality | 23 (5.27) | 5 (6.0) | 0.24 |
| ICU stay (days), median (IQR) | 8.4 (5.3–12.5) | 11.7 (7.2–18.6) | 0.032 |
| Duration of invasive ventilation (days), median (IQR) | 5.8 (3.4–7.1) | 7.9 (5.1–12.2) | 0.017 |
| Duration of NIV (h), median (IQR) | 59.1 (32.3–135) | 65.7 (38.8–147.5) | 0.16 |
| Interface | |||
| Face mask | 135 (30.7) | 32 (36.8) | 0.32 |
| HFNC | 111 (25.2) | 18 (20.7) | |
| Face mask and high flow | 194 (44.1) | 37 (42.5) |
ICU: Intensive care unit, IQR: Interquartile range, NIV: Noninvasive ventilation, HFNC: High-flow nasal cannula
Intensive care unit course of noninvasive ventilation versus non-noninvasive ventilation group
The median length of ICU stay was 8.5 (IQR: 4.2–12.3) days in the NIV group and 3.1 (IQR: 2.5–5.2) days in the non-NIV group, which was statistically significant (P = 0.011). The duration of invasive ventilation was 151 (IQR: 81.6–326.4) h in the NIV group and 9.6 (IQR: 4.8–55.2) h in the non-NIV group, which was statistically significant (P = 0.016). The initiation of feeds was delayed in the NIV group. However, there was no statistically significant difference in mortality difference between the two groups [Table 5].
Table 5.
Intensive care unit course of noninvasive ventilation versus non-noninvasive ventilation group
| NIV group | Non-NIV group | P | |
|---|---|---|---|
| Length of ICU stay (days), median (IQR) | 8.5 (4.2–12.3) | 3.1 (2.5–5.2) | 0.011 |
| Initiation of feeds (days), median (IQR) | 2.1 (1.3–3.5) | 1.2 (0.5–1.8) | 0.025 |
| Mortality | 28 (5.3) | 79 (4.5) | 0.13 |
| Duration of invasive ventilation (h), median (IQR) | 151 (81.6–326.4) | 9.6 (4.8–55.2) | 0.016 |
ICU: Intensive care unit, IQR: Interquartile range, NIV: Noninvasive ventilation
The age-wise difference in characteristics within the noninvasive ventilation group
Finally, we went on to evaluate the use and outcome of NIV in neonates and infants <5 kg. Of the total population of 523 patients, 61.4% were children weighing more than 5 kg, and 38.6% were neonates and infants. The use of NIV was prophylactic in 77.2% of cases in the neonatal and infant group, and in 49.5% of cases in the children weighing more than 5 kg group. The remaining cases were nonprophylactic. The median duration of NIV and the length of ICU stay were significantly longer in the neonatal and infant group than in the children weighing more than 5 kg group. The mortality rate was not significantly different between the two groups, with 5% mortality in the neonatal and infant group and 5.9% mortality in the children weighing more than 5 kg group [Table 6]. The surgeries were of varied complexities distributed across different RACHS categories [Table 7].
Table 6.
Age-wise difference in characteristics within the noninvasive ventilation group
| Neonates and infants <5 kg, n (%) | Children with >5 kg, n (%) | P | |
|---|---|---|---|
| Total (n=523) | 321 (61.4) | 202 (38.6) | 0.027 |
| Prophylactic indications | 248 (77.2) | 100 (49.5) | 0.043 |
| Nonprophylactic indications | 73 (22.7) | 102 (50.5) | 0.048 |
| Duration of NIV (h), median (IQR) | 78.5 (42.3–147) | 47.2 (18.7–114) | 0.016 |
| Length of ICU stay (days), median (IQR) | 11.7 (7.2–14.5) | 6.1 (4.3–8.4) | 0.015 |
| Mortality | 16 (5) | 12 (5.9) | 0.23 |
ICU: Intensive care unit, IQR: Interquartile range, NIV: Noninvasive ventilation
Table 7.
Case distribution as per Risk-Adjusted Classification for Congenital Heart Surgery category
| Categorical distribution of different surgeries | Number of Observations |
|---|---|
| RACHS-1 case distribution | n=267 |
| Patent ductus arteriosus surgery at age >30 days | 24 |
| Coarctation repair at age >30 days | 48 |
| Atrial septal defect surgery | 131 |
| Partially anomalous pulmonary venous connection surgery | 64 |
| RACHS-2 case distribution | n=647 |
| Subaortic stenosis resection | 6 |
| Right ventricular infundibulectomy pulmonary outflow tract augmentation | 17 |
| Ventricular septal defect repair | 171 |
| Total repair of tetralogy of Fallot | 247 |
| Repair of total anomalous pulmonary veins at age >30 days | 79 |
| Glenn shunt | 88 |
| Coarctation repair at age ≤30 days | 21 |
| Atrial septal defect primum repair | 12 |
| Repair of aortopulmonary window | 6 |
| RACHS-3 case distribution | n=547 |
| Tricuspid valve repositioning for Ebstein anomaly at age >30 days | 12 |
| Repair of anomalous coronary artery without intrapulmonary tunnel | 10 |
| Right ventricular to pulmonary artery conduit | 22 |
| Repair of double-outlet right ventricle with or without repair of right ventricular obstruction | 69 |
| Fontan procedure | 54 |
| Repair of transitional or complete atrioventricular canal | 71 |
| Pulmonary artery banding | 47 |
| Repair of tetralogy of Fallot with pulmonary atresia | 92 |
| Repair of cor triatriatum | 6 |
| Systemic to pulmonary artery shunt | 35 |
| Atrial switch operation | 18 |
| Arterial switch operation | 72 |
| Reimplantation of anomalous pulmonary artery | 8 |
| Repair of coarctation and ventricular septal defect | 28 |
| Excision of intracardiac tumor | 3 |
| RACHS-4 case distribution | n=289 |
| Repair of total anomalous pulmonary veins at age ≤30 days | 66 |
| Repair of transposition, ventricular septal defect, and subpulmonary stenosis (Rastelli) | 34 |
| Atrial switch operation with ventricular septal defect closure | 9 |
| Arterial switch operation with ventricular septal defect closure | 73 |
| Arterial switch operation with repair of subpulmonary stenosis | 5 |
| Repair of truncus arteriosus | 28 |
| Repair of hypoplastic or interrupted arch without ventricular septal defect closure | 22 |
| Repair of hypoplastic or interrupted aortic arch with ventricular septal defect closure | 35 |
| Unifocalization for tetralogy of Fallot and pulmonary atresia | 12 |
| Repair of complex anomaly (single ventricle) by ventricular septal defect enlargement | 5 |
RACHS: Risk-Adjusted Classification for Congenital Heart Surgery
DISCUSSION
In summary, our data showed that NIV could be successfully used for children who underwent cardiac surgeries to prevent extubation failure. A longer period of intubation and mechanical ventilatory support before and after extubation, preoperative infections, diaphragmatic paralysis, and elevated VIS score were associated with increased use of NIV.
Essentially mechanical ventilation alters lung pressures and volumes which in turn affects preload, afterload, contractility, and heart rate. Positive airway pressure, on the one hand, reduces pulmonary vasculature resistance and left ventricle afterload but also increases the risk of airway damage, lung injury, and ventilator-associated pneumonia which is associated with a longer PICU LOS. NIV decreases the risk of these complications while maintaining the desirable effects of positive airway pressure, enabling an earlier extubation.[5,13,14] Nevertheless, only a few studies have been performed to understand the spectrum of NIV use in the postoperative period of heart surgery in children.[14,15,16]
Our study shows that the use of NIV has reduced the dependence on invasive mechanical ventilation for the treatment of acute respiratory failure in these patients. Around 40% of the patients required both face masks and high-flow nasal cannula. The success of the user interface for NIV also depends on the acceptance and tolerance by the children as well as its availability and the competence of the PCICU team to handle it. While neonates and infants <5 kg require longer mechanical ventilation and their need for NIV was greater than that of older children, similar results were also seen with children belonging to higher RACHS category, increased disease severity in the preoperative period, or diaphragmatic paralysis. Similar observations have been reported in previous studies as well.[6,16,17,18] This can be attributed to the greater complexity of cardiac surgery being performed, higher total intraoperative CPB time, greater metabolic demands, or due to damage to the diaphragmatic muscles in the postoperative period.
Our study found a 30% frequency of the use of NIV following congenital cardiac surgery. This is very similar to the observation in a recent study.[19] Another study from an Italian PCICU shows a 70% postoperative need for NIV with bilevel use in 40% of the patients and HHFNC in 60% of patients.[20] However, the study population only included postoperative pediatric heart transplant patients, hence markedly different from our study population.
The findings of our study have been corroborated with other similar studies of the pediatric population including both cardiac (postsurgery) and noncardiac patients, showing a success rate of around 70%.[2,3,14,15,21,22,23,24]
The presence of a control group would allow us to understand whether reintubation was avoidable in the same group without the use of NIV. However, this remains a limitation of the study since NIV was offered to all patients be it for prophylactic or nonprophylactic indications. We found a significant occurrence of prophylactic NIV usage in postoperative cardiac patients, but the justification for its use in high-risk patients remains unclear. A study by Richter et al.[25] highlights the potential negative impact on patients who do not benefit from NIV. This brings us to the important question as to whether NIV is necessary for all children of the above-described setting or is the judgment made after weighing the pros and cons of the same. This presents an exciting opportunity to conduct further research in this area.
There are other limitations of this study. Being a single-center study, the findings may not apply to all centers.
Patients requiring reintubation within 20 min of the NIV trial were not included in the study and were considered a case of extubation failure. Due to the limited availability of data, the impact of increased ventilatory pressures and FiO2 on the success or failure of NIV could not be studied. Various other parameters such as the etiology of extubation failure in a particular population, central venous pressure, and left atrial pressure before and after the use of NIV could not be studied for the same reason. Some children may not have required NIV, especially for prophylactic indications, and the shortcomings of the same have not been studied. This may have affected the result as well. Despite these limitations, this study has demonstrated the effectiveness of NIV in enhancing patient outcomes and has laid the cornerstone for further research into the use of NIV as an important adjunctive strategy to safely wean patients off of mechanical ventilation.
CONCLUSION
Our research highlights the common indications and factors associated with the use of NIV in PCICU. NIV has revolutionized patient management by reducing the need for invasive ventilation and its associated complications. However, our study reveals that NIV usage may lengthen ICU stays and does not reduce the mortality rates. NIV has a crucial role in cardiac critical care, but its use requires an unbiased approach. Our study’s findings can guide future research, aiding a better understanding of NIV use in PCICU and its optimal application.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
- 1.Rolim DS, Galas FR, Faria LS, Amorim EF, Regenga MM, Troster EJ. Use of noninvasive ventilation in respiratory failure after extubation during postoperative care in pediatrics. Pediatr Cardiol. 2020;41:729–35. doi: 10.1007/s00246-020-02290-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Fernández Lafever S, Toledo B, Leiva M, Padrón M, Balseiro M, Carrillo A, et al. Non-invasive mechanical ventilation after heart surgery in children. BMC Pulm Med. 2016;16:167. doi: 10.1186/s12890-016-0334-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Yañez LJ, Yunge M, Emilfork M, Lapadula M, Alcántara A, Fernández C, et al. A prospective, randomized, controlled trial of noninvasive ventilation in pediatric acute respiratory failure. Pediatr Crit Care Med. 2008;9:484–9. doi: 10.1097/PCC.0b013e318184989f. [DOI] [PubMed] [Google Scholar]
- 4.Pavone M, Verrillo E, Caldarelli V, Ullmann N, Cutrera R. Non-invasive positive pressure ventilation in children. Early Hum Dev. 2013;89(Suppl 3):S25–31. doi: 10.1016/j.earlhumdev.2013.07.019. [DOI] [PubMed] [Google Scholar]
- 5.Mayordomo-Colunga J, Medina A, Rey C, Díaz JJ, Concha A, Los Arcos M, et al. Predictive factors of non invasive ventilation failure in critically ill children:A prospective epidemiological study. Intensive Care Med. 2009;35:527–36. doi: 10.1007/s00134-008-1346-7. [DOI] [PubMed] [Google Scholar]
- 6.Mittnacht AJ, Hollinger I. Fast-tracking in pediatric cardiac surgery –The current standing. Ann Card Anaesth. 2010;13:92–101. doi: 10.4103/0971-9784.62930. [DOI] [PubMed] [Google Scholar]
- 7.Essouri S, Chevret L, Durand P, Haas V, Fauroux B, Devictor D. Noninvasive positive pressure ventilation:Five years of experience in a pediatric intensive care unit. Pediatr Crit Care Med. 2006;7:329–34. doi: 10.1097/01.PCC.0000225089.21176.0B. [DOI] [PubMed] [Google Scholar]
- 8.Fauroux B, Khirani S, Griffon L, Teng T, Lanzeray A, Amaddeo A. Non-invasive ventilation in children with neuromuscular disease. Front Pediatr. 2020;8:482. doi: 10.3389/fped.2020.00482. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Jenkins KJ. Risk adjustment for congenital heart surgery:The RACHS-1 method. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2004;7:180–4. doi: 10.1053/j.pcsu.2004.02.009. [DOI] [PubMed] [Google Scholar]
- 10.Gaies MG, Gurney JG, Yen AH, Napoli ML, Gajarski RJ, Ohye RG, et al. Vasoactive-inotropic score as a predictor of morbidity and mortality in infants after cardiopulmonary bypass. Pediatr Crit Care Med. 2010;11:234–8. doi: 10.1097/PCC.0b013e3181b806fc. [DOI] [PubMed] [Google Scholar]
- 11.Gaies MG, Jeffries HE, Niebler RA, Pasquali SK, Donohue JE, Yu S, et al. Vasoactive-inotropic score is associated with outcome after infant cardiac surgery:An analysis from the pediatric cardiac critical care consortium and virtual PICU system registries. Pediatr Crit Care Med. 2014;15:529–37. doi: 10.1097/PCC.0000000000000153. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Romans RA, Schwartz SM, Costello JM, Chanani NK, Prodhan P, Gazit AZ, et al. Epidemiology of noninvasive ventilation in pediatric cardiac ICUs. Pediatr Crit Care Med. 2017;18:949–57. doi: 10.1097/PCC.0000000000001282. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Abadesso C, Nunes P, Silvestre C, Matias E, Loureiro H, Almeida H. Non-invasive ventilation in acute respiratory failure in children. Pediatr Rep. 2012;4:e16. doi: 10.4081/pr.2012.e16. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Zhang CY, Tan LH, Shi SS, He XJ, Hu L, Zhu LX, et al. Noninvasive ventilation via bilevel positive airway pressure support in pediatric patients after cardiac surgery. World J Pediatr. 2006;2:297–302. [Google Scholar]
- 15.Pons Odena M, Piqueras Marimbaldo I, Segura Matute S, Balaguer Argallo M, Palomeque Rico A. Non-invasive ventilation after cardiac surgery. A prospective study. An Pediatr (Barc) 2009;71:13–9. doi: 10.1016/j.anpedi.2009.03.014. [DOI] [PubMed] [Google Scholar]
- 16.Gupta P, Kuperstock JE, Hashmi S, Arnolde V, Gossett JM, Prodhan P, et al. Efficacy and predictors of success of noninvasive ventilation for prevention of extubation failure in critically ill children with heart disease. Pediatr Cardiol. 2013;34:964–77. doi: 10.1007/s00246-012-0590-3. [DOI] [PubMed] [Google Scholar]
- 17.López-Herce Cid J, Leyton Avilés P, Urbano Villaescusa J, Cidoncha Escobar E, Del Castillo Peral J, Carrillo Alvarez A, et al. Risk factors for prolonged mechanical ventilation after cardiac surgery in children. Med Intensiva. 2008;32:369–77. doi: 10.1016/s0210-5691(08)75707-3. [DOI] [PubMed] [Google Scholar]
- 18.Kovacikova L, Skrak P, Dobos D, Zahorec M. Noninvasive positive pressure ventilation in critically ill children with cardiac disease. Pediatr Cardiol. 2014;35:676–83. doi: 10.1007/s00246-013-0837-7. [DOI] [PubMed] [Google Scholar]
- 19.Negro D, Canepari A, Orqueda D, Carolina C, Lucrecia W, Lucia P. PP316 [Heart »Heart]:Use of non-invasive ventilation post extubation in post operative period of pediatric cardiovascular surgery patients. Pediatric Critical Care Medicine 23. 2022 November;((Supplement 1 11S)) DOI:10.1097/01.pcc.0000901064.39081.5d. [Google Scholar]
- 20.Canepari AP, Wamba ML, Cereigido C, Barberis S, Orqueda DR, Massara MM, et al. PP305 [Heart »Heart]:Use of non-invasive ventilation support in the postoperative period of pediatric heart transplantation. Pediatric Critical Care Medicine 23. 2022 November;((Supplement 1 11S)) DOI:10.1097/01.pcc.0000901024.98180.23. [Google Scholar]
- 21.Lum LC, Abdel-Latif ME, de Bruyne JA, Nathan AM, Gan CS. Noninvasive ventilation in a tertiary pediatric intensive care unit in a middle-income country. Pediatr Crit Care Med. 2011;12:e7–13. doi: 10.1097/PCC.0b013e3181d505f4. [DOI] [PubMed] [Google Scholar]
- 22.Pancera CF, Hayashi M, Fregnani JH, Negri EM, Deheinzelin D, de Camargo B. Noninvasive ventilation in immunocompromised pediatric patients:Eight years of experience in a pediatric oncology intensive care unit. J Pediatr Hematol Oncol. 2008;30:533–8. doi: 10.1097/MPH.0b013e3181754198. [DOI] [PubMed] [Google Scholar]
- 23.Morley SL. Non-invasive ventilation in paediatric critical care. Paediatr Respir Rev. 2016;20:24–31. doi: 10.1016/j.prrv.2016.03.001. [DOI] [PubMed] [Google Scholar]
- 24.Mayordomo-Colunga J, Medina A, Rey C, Concha A, Menéndez S, Los Arcos M, et al. Non invasive ventilation after extubation in paediatric patients:A preliminary study. BMC Pediatr. 2010;10:29. doi: 10.1186/1471-2431-10-29. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Richter RP, Alten JA, King RW, Gans AD, Rahman AF, Kalra Y, et al. Positive airway pressure versus high-flow nasal cannula for prevention of extubation failure in infants after congenital heart surgery. Pediatr Crit Care Med. 2019;20:149–57. doi: 10.1097/PCC.0000000000001783. [DOI] [PubMed] [Google Scholar]