All authors: Division of Pediatric Critical Care Medicine, Department of Pediatrics, UH Rainbow Babies & Children's Hospital, Cleveland, OH.
Pediatr Crit Care Med. 2019 Feb;20(2):128-135. doi: 10.1097/PCC.0000000000001798.
Initial respiratory support with noninvasive positive pressure ventilation or high-flow nasal cannula may prevent the need for invasive mechanical ventilation in PICU patients with bronchiolitis. However, it is not clear whether the initial choice of respiratory support modality influences the need for subsequent invasive mechanical ventilation. The purpose of this study is to compare the rate of subsequent invasive mechanical ventilation after initial support with noninvasive positive pressure ventilation or high-flow nasal cannula in children with bronchiolitis.
Analysis of the Virtual Pediatric Systems database.
Ninety-two participating PICUs.
Children less than 2 years old admitted to a participating PICU between 2009 and 2015 with a diagnosis of bronchiolitis who were prescribed high-flow nasal cannula or noninvasive positive pressure ventilation as the initial respiratory treatment modality.
None. Subsequent receipt of invasive mechanical ventilation was the primary outcome.
We identified 6,496 subjects with a median age 3.9 months (1.7-9.5 mo). Most (59.7%) were male, and 23.4% had an identified comorbidity. After initial support with noninvasive positive pressure ventilation or high-flow nasal cannula, 12.3% of patients subsequently received invasive mechanical ventilation. Invasive mechanical ventilation was more common in patients initially supported with noninvasive positive pressure ventilation compared with high-flow nasal cannula (20.1% vs 11.0%: p < 0.001). In a multivariate logistic regression model that adjusted for age, weight, race, viral etiology, presence of a comorbid diagnosis, and Pediatric Index of Mortality score, initial support with noninvasive positive pressure ventilation was associated with a higher odds of subsequent invasive mechanical ventilation compared with high-flow nasal cannula (odds ratio, 1.53; 95% CI, 1.24-1.88).
In this large, multicenter database study of infants with acute bronchiolitis that received initial respiratory support with high-flow nasal cannula or noninvasive positive pressure ventilation, noninvasive positive pressure ventilation use was associated with higher rates of invasive mechanical ventilation, even after adjusting for demographics, comorbid condition, and severity of illness. A large, prospective, multicenter trial is needed to confirm these findings.
在患有毛细支气管炎的 PICU 患者中，最初使用无创正压通气或高流量鼻导管进行呼吸支持可能会避免需要进行有创机械通气。然而，目前尚不清楚初始呼吸支持方式的选择是否会影响后续有创机械通气的需求。本研究的目的是比较毛细支气管炎患儿最初使用无创正压通气或高流量鼻导管支持后，后续进行有创机械通气的发生率。
对 Virtual Pediatric Systems 数据库进行分析。
92 个参与的 PICU。
2009 年至 2015 年间，年龄小于 2 岁、被诊断为毛细支气管炎并被开具高流量鼻导管或无创正压通气作为初始呼吸治疗方式的患儿，入住参与的 PICU。
无。后续接受有创机械通气为主要结局。
我们共纳入 6496 名患儿，中位年龄为 3.9 个月（1.7-9.5 个月）。大多数（59.7%）为男性，23.4%有合并症。在最初接受无创正压通气或高流量鼻导管支持后，12.3%的患儿随后接受了有创机械通气。与高流量鼻导管相比，最初接受无创正压通气支持的患儿更常接受有创机械通气（20.1% vs 11.0%：p<0.001）。在调整年龄、体重、种族、病毒病因、合并症诊断和小儿死亡指数评分后，多变量逻辑回归模型显示，与高流量鼻导管相比，初始接受无创正压通气与后续有创机械通气的可能性更高（比值比，1.53；95%可信区间，1.24-1.88）。
在这项针对急性毛细支气管炎婴儿的大型、多中心数据库研究中，与高流量鼻导管相比，使用无创正压通气初始呼吸支持与更高的有创机械通气率相关，即使在调整了人口统计学、合并症和疾病严重程度后也是如此。需要进行一项大型、前瞻性、多中心试验来证实这些发现。
