What is the most effective post-extubation noninvasive respiratory support modality in children?
Myron Yaster MD, Shawn Jackson MD, and Ethan Sanford MD
Both in the OR and in the PICU/NICU, we are often faced with the dilemma “I’d like to extubate but am unsure if the patient’s respiratory function and diaphragmatic muscle strength will allow it” which is often accompanied by “what is the best post-extubation noninvasive respiratory support to assist the patient and prevent extubation failure?” These dilemmas have become more common as the baseline complexity and morbidities of our patient population has increased. Today’s pediatric anesthesiologist have a variety of respiratory supports at their disposal to aid in providing post-extubation noninvasive respiratory support, including high-flow nasal cannula (HFNC), continuous positive airway pressure (CPAP), and bilevel positive airway pressure (BiPAP). Furthermore, these devices have also demonstrated their usefulness prior to intubation (apneic oxygenation) in the OR to prevent desaturation and hypoxemia during laryngoscopy and intubation (PAAD reference).
Although there are many studies looking at these questions a definitive answer to the question “What is the most effective post-extubation noninvasive respiratory support modality in children?” does not exist. Unfortunately, today’s PAAD by Iyer et al.1 may not provide the answer either.
I’ve asked Drs. Shawn Jackson and Ethan Sanford, both trained in Pediatrics, Anesthesiology, Pediatric Critical Care Medicine and Pediatric Anesthesiology to assist. Both have been very involved in resurrecting the Pediatric Critical Care Medicine Special Interest Group at SPA. If you are interested in joining this SIG, contact them or Dr. Welch and come to their meeting at the Annual SPA meeting in San Francisco. Myron Yaster MD
Original article
Iyer NP, Rotta AT, Essouri S, et al. Association of Extubation Failure Rates With High-Flow Nasal Cannula, Continuous Positive Airway Pressure, and Bilevel Positive Airway Pressure vs Conventional Oxygen Therapy in Infants and Young Children: A Systematic Review and Network Meta-Analysis. JAMA Pediatr. 2023;177(8):774–781. doi:10.1001/jamapediatrics.2023.1478
In today’s PAAD, a well-published group lead by Drs. Khemani and Iyer at the Children’s Hospital of Los Angeles offers a review and meta-analysis of RCTs assessing different modes of noninvasive respiratory support (NRS) in preventing post-extubation failure for children who received invasive mechanical ventilation for longer than a day.
As context, over the past 2 decades all forms of NRS (HFCN, CPAP, BiPAP) have proliferated in use among children with both acute and chronic forms of respiratory failure. This practice adoption by PICU and pediatric anesthesia providers speaks to the successful anecdotal/experiential use of these modalities. Unfortunately, peer reviewed evidence basis for which modality to use, when to use them and population or disease processes which are more or less amenable to NRS is lacking, particularly among children. Today’s PAAD, therefore, is important as it summarizes the accumulated pediatric evidence to guide if and how NRS may be implemented for children post-extubation.
Does the study population correlate with children cared for by pediatric anesthesiologists? Increasingly, the answer is yes. Anesthesiologists may be asked to participate in the extubation of children in the PICU or OR who have real or perceived possibility of difficult re-intubation. Even more commonly, we must anesthetize children in various stages of respiratory distress/failure for diagnostic or therapeutic intervention with the goal of extubation and return to pre-anesthetic respiratory status. As highlighted in prior PAAD discussions, extubation and “landing the plane” is frequently the highest risk time period for the children we care for and about.
Before jumping into the data, it is worth highlighting the methodological approach the authors used. A network meta-analysis, also called a mixed treatments comparison, goes beyond the typical scope of a meta-analysis (grouping of multiple pair-wise comparisons) by analyzing both direct and indirect comparators across trials. In this case, the NRS modalities (HFNC, CPAP, BiPAP) are primarily compared to conventional oxygen therapy, but additional estimation of the effect of each modality on the outcome are made in order to rank the NRS modalities for probability of which modality is best among all options. As a result, this methodology presents unique advantages (and disadvantages) that readers must be aware of when assessing the data.
OK, what did they find? Their “study results suggest that HFNC, CPAP, and BiPAP appeared to be better than conventional oxygen therapy in preventing extubation failure (EF) and therapy failure (TF) in the 9 included trials. CPAP was likely the best modality for preventing EF and TF. HFNC was likely the second best modality for preventing EF and TF, with an effectiveness only modestly lower than that of CPAP”. Children receiving HFNC or CPAP were roughly half as likely to require re-intubation (12% vs 6%). Because of the importance respiratory muscle strength4 and the need to maintain FRC5 the importance of CPAP following extubation makes perfect sense. Indeed, many (most?) of you do this routinely in the OR following extubation when you apply a tight-fitting mask and CPAP during the transition to the PACU. However, implementation of CPAP or HFNC in the PACU is not trivial in many centers. The standard barriers include cost, experience/knowledge in setup, and cultural acceptance (aka annoying people to do something different/new). In many centers these modalities are reserved for the PICU. However, perhaps we should be implementing NRS strategies more commonly in at-risk children in order to prevent adverse outcomes and costly PICU admission in an era where PICU beds are more limited. One can imagine several PACU rooms stocked with necessary equipment and trained nurses where NRS is implemented in an anticipatory fashion rather than reflexively when a child is failing. This may already be commonly done for children with baseline NRS need, but seems less common for children with acute need. Careful consideration of this practice is advised to prevent delayed re-intubation of children where a time-limited trial of NRS fails.
Interestingly, many of us would empirically identify BiPAP as being the most useful in preventing extubation failure amongst our most tenuous patients. Is the conclusion that traditional CPAP being the best modality simply a result of the methodology used in this study or does the nuances of synchrony with BiPAP play a role in extubation failure and therapy failure?
What type of noninvasive respiratory support do you use in the OR prior to intubation and after extubation? Does your PACU staff support noninvasive respiratory ventilation in the peri-operative period or are respiratory therapists from the floor or ICU involved? Send your responses to Myron who will post in a Friday Reader Response.
References
1. Iyer NP, Rotta AT, Essouri S, et al. Association of Extubation Failure Rates With High-Flow Nasal Cannula, Continuous Positive Airway Pressure, and Bilevel Positive Airway Pressure vs Conventional Oxygen Therapy in Infants and Young Children: A Systematic Review and Network Meta-Analysis. JAMA pediatrics. 2023;177(8):774-781. doi:10.1001/jamapediatrics.2023.1478
2. Jiang J, Pan J. Preventive use of non-invasive ventilation is associated with reduced risk of extubation failure in patients on mechanical ventilation for more than 7 days: a propensity-matched cohort study. Intern Med J. Nov 2020;50(11):1390-1396. doi:10.1111/imj.14740
3. Murad MH, Asi N, Alsawas M, Alahdab F. New evidence pyramid. Evid Based Med. Aug 2016;21(4):125-7. doi:10.1136/ebmed-2016-110401
4. Khemani RG, Sekayan T, Hotz J, Flink RC, Rafferty GF, Iyer N, Newth CJL. Risk Factors for Pediatric Extubation Failure: The Importance of Respiratory Muscle Strength. Critical care medicine. Aug 2017;45(8):e798-e805. doi:10.1097/ccm.0000000000002433
5. Chen HC, Ruan SY, Huang CT, et al. Pre-extubation functional residual capacity and risk of extubation failure among patients with hypoxemic respiratory failure. Sci Rep. Jan 22 2020;10(1):937. doi:10.1038/s41598-020-58008-4