Ventilator-Assisted Living©

Fall 2001, Vol. 15, No. 3

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Pediatric Noninvasive Ventilation

Several pediatric respiratory physicians, nurses, and therapists summarize the use of noninvasive positive pressure ventilation (NIPPV) in their pediatric programs.

Lisa Bylander, RRT
Arkansas Children's Hospital, Little Rock, Arkansas

Finding a comfortable interface is one of our biggest problems. There are so few made for children. We use only commercial masks, especially Respironics' Simplicity™ and Gold Seal™ masks.

Another problem is cost. It is difficult to justify several types of expensive interfaces when we do not know whether the infant or child can even tolerate CPAP or bilevel ventilation. One mask may cost more than $100, and then we discover that no matter how comfortable the mask appears, the child does not want it (or anything) on his/her face.

We have tried some infants on NIPPV, but with little success. Again, the interface is our biggest obstacle. The youngest patient whom we have been able to keep on NIPPV for chronic use is 3 years old.

The machines with which we have had success are Respironics' BiPAP® Synchrony™ and BiPAP® Vision™, the Sullivan® VPAP (ResMed), and Puritan Bennett's LP10.

Sue Porth, MSN, CRNP
Alfred I. DuPont Hospital, Wilmington, Delaware

Our children use commercial masks – the petite sizes in the Sullivan® nasal mask (ResMed) and Monarch™ (Respironics, Inc.). Some of the parents especially like the gel masks. One mother, whose 5-year-old has CCHS and was recently decannulated, tried a larger mask to cover both his nose and mouth. Almost all of our ventilator-assisted children use the LTV950™ (Pulmonetic Systems). Some still use bi-level units, either Quantum® PSV or BiPAP® Vision™ (Respironics, Inc.). I prefer the LTV series – their size, ease in programming, and use in pressure support and CPAP modes. However, they are expensive, and if the children just use them at night, some insurance companies will not cover them. One little boy switched from tracheostomy to noninvasive ventilation very comfortably using the LTV.

Another little guy, born with bilateral diaphragmatic eventration (no functional diaphragm) uses the NEV-100 and Porta-Lung (Respironics, Inc.). He used to need it up to 16 hours a day, but now, at the age of 2, uses it only at night. It works well, but it is not very portable. There are a few children with SMA who also use the Porta-Lung at night. One uses a combination of Porta-Lung and bi-level unit.

I think that noninvasive ventilation definitely has a place in pediatrics, but it is sometimes more labor-intensive than a stable tracheostomy and less comfortable for the younger children at least. Children who need more ventilatory support than naptime and sleep are more transportable, active, and comfortable with a tracheostomy. When you deal with medically fragile children, management is everything. I view these children as normal and the technology as supportive, and make the machines work for the child, not the other way around.

One more caveat about bi-level units – some of our children have enough muscle weakness so that their vocal chords do not work well and they are at high risk for aspiration. When you begin pushing high pressures through their upper airway, you can make the aspiration much worse. The downside of negative pressure ventilators such as the Porta-Lung is that some children, especially those with neuromuscular disease, may have positional upper airway obstruction. They may need to wear a soft collar while they are in the Porta-Lung or need a hi-flow nasal cannula to keep their upper airways stented open.

Elspeth Jardine
Respiratory Nurse Specialist, Royal Hospital for Sick Children, Glasgow, Scotland

Twenty-five paediatric patients use noninvasive ventilation. The most commonly used mask is Respironics' gel mask; however, some children use Puritan Bennett nasal pillows. We use CPAP units and a wide range of ventilators: Breas PV 401, PV 102, and PV 101, BiPAP® S/T 30 (Respironics, Inc.), Pulmonetic Systems' LTV1000™, and Nippaed (B&D Electromedical).

We select the equipment to suit our patients, and therefore are unable to standardize to one supplier.

Georgiana M. Sanders, MD
University of Michigan, Ann Arbor, Michigan

Most of our children use commercial masks. We would like very much to obtain infant masks. However, we do make some custom masks, particularly for children with degenerative muscle disorders and molding problems secondary to this. Our children with noninvasive ventilation almost all use BiPAP®. We are using the LTV950™ often (the LTV1000™ in-hospital only) because it enables us to send home children (particularly babies) who have significant pressure requirements. Also, since BiPAP® via trach is not approved by many insurances or the FDA, we are using the LTV to provide bi-level treatment for many trach patients. The LTV950™ is very flexible, but there is concern that it is not as reliable as the LP10.

Jim Ripka, RRT
Children's Hospital Los Angeles, Los Angeles, California

We use only commercial masks, primarily Respironics, alternating between the gel seal masks and nasal pillows to avoid skin breakdown. We plan to try the small nasal mask from Hans Rudolph.

For ventilators, we use BiPAP® and LP10s. We are starting to use the LTV™ ventilators, but the increased cost of the LTV over the LP10 and the justification required for insurance re-imbursement make them harder to acquire. So far both we and the parents like them. They are generally ordered for ventilator-assisted children at home who require PEEP. One thing we will be watching is the durability of the LTVs. The LP10 has been a very reliable ventilator over the years.

Aroonwan Preutthipan, MD
Ramathibodi Hospital, Bangkok, Thailand

We generally use the masks from Respironics and ResMed as well as their CPAP and BiPAP® machines. There are difficulties in finding the mask that can be best fitted to an individual patient, especially the young ones. We cannot make custom masks by ourselves. In Thailand, not all sizes and shapes of masks are available. If noninvasive ventilators become more popular, we hope there will be more masks to choose from.

Judith Green-Latner, RN, MSN, FNP
Loma Linda University Children's Hospital, Loma Linda, California

There are currently 59 children in the Home Mechanical Ventilation program at Loma Linda University Children's Hospital. Twenty-three have tracheostomies with 22 using ventilators for varying periods during the day; 36 use noninvasive ventilation, either bi-level or CPAP via mask, predominantly during sleep.

The most common mask is the Simplicity® mask (Respironics, Inc.), but on some of the bigger children we use the Mirage® full face mask (ResMed). There is a definite need for smaller masks and for appropriate sized headgear for children. The home care res-piratory therapists alter the straps to make them work for the children. Although the staff alters the headgear to fit the smaller heads, we do not currently make any kind of custom mask.

The most common ventilator, and definitely the workhorse, is the LP10 (Puritan Bennett), and the PLV®-100 (Respironics, Inc.). We may soon use the LTV900™ or LTV950™ (Pulmonetic Systems).

Catherine Lockwood, RN
New Children's Hospital, Parramatta, New South Wales, Australia

We have 22 children using NPPV with a variety of masks, mostly from Respironics and ResMed. The only custom masks we make are for infants needing CPAP. The ventilators we use are the PLV®-100 and BiPAP® (Respironics, Inc.), and Sullivan VPAP® (ResMed).

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