The Cause of Acute Respiratory Failure Predicts the Outcome of Noninvasive Ventilation in Immunocompromised Children

Abstract

Background: Noninvasive ventilation (NIV) may be superior to conventional therapy in immunocompromised children with respiratory failure.

Methods: Mortality, success rate, prognostic factors and side effects of NIV for acute respiratory failure (ARF) were investigated retrospectively in 41 in children with primary immunodeficiency, after stem cell transplantation or chemotherapy for oncologic disease.

Results: In 11/41 (27%) children invasive ventilation was avoided and patients were discharged from ICU. In children with NIV failure ICU-mortality was 19/30 (63%). 8/11 (72%) children with NIV success had recurrence of ARF after 27 days. Only 4/11 (36%) children with first episode NIV success and 8/30 (27%) with NIV failure survived to hospital discharge. Lower FiO2, SpO2/FiO2 and blood culture positive bacterial sepsis were predictive for NIV success, while fungal sepsis or culture negative ARF were predictive for NIV failure. We observed catecholamine treatment in 14/41 (34%), pneumothorax in 2/41 (5%), mediastinal emphysema in 3/41 (7%), a life threatening nasopharyngeal hemorrhage and need for resuscitation during intubation in 5/41 (12%) NIV-episodes.

Conclusions: The prognosis of ARF in immunocompromised children remains guarded independent of initial success or failure of NIV due to a high rate of recurrent ARF. Reversible causes like bacterial sepsis had a higher NIV response rate. Relevant side effects of NIV were observed.

Zusammenfassung

Hintergrund: Nichtinvasive Beatmung könnte gegenüber konventioneller Therapie eine Vorteil bei der Behandlung des Atemversagens bei immunsupprimierten Kindern haben.

Methoden: Mortalität, Erfolgsrate, prognostische Faktoren und Nebenwirkungen von nichtinvasiver Beatmung (NIV) beim akuten Atemversagen (ARF) wurden retrospektiv in einer Kohorte von 41 Kindern mit primärem Immundefekt, nach onkologischer Therapie oder nach Stammzelltransplantation untersucht.

Ergebnisse: Bei 11/41 (27%) konnte die Intubation vermieden werden und die Kinder wurden von der Intensivstation entlassen. Die Intensivmortalität der Kinder mit NIV-Versagen betrug 19/30 (63%). 8/11 (72%) Kinder mit NIV-Erfolg wurden nach im Median 27 Tagen mit erneutem Atemversagen auf die Intensivstation wiederaufgenommen und benötigten erneut NIV. Nur 4/11 (36%) Kinder mit NIV-Erfolg in der ersten Episode und 8/30 (27%) Kinder mit NIV-Versagen überlebten bis zur Krankenhausentlassung. Niedrigerer FiO2, SpO2/FiO2 und blutkultur-positive bakterielle Sepsis waren mit NIV-Erfolg, während Pilzinfektionen oder kultur-negatives Atemversagen mit NIV-Versagen assoziiert waren. Als Nebenwirkungen wurden Katecholaminbedarf in 14/41 (34%), Pneumothorax in 2/41 (5%), Mediastinalemphysem in 3/41 (7%), und Notwendigkeit zur Reanimation im Rahmen der Intubation bei 5/41 (12%) der NIV-Episoden beobachtet.

Schlussfolgerung: Die Prognose des ARF bei immunsupprimierten Kindern ist eingeschränkt, unabhängig vom initialen Erfolg oder Versagen der NIV aufgrund der hohen Rate an Rezidiven des Atemversagens. Behandelbare Ursachen des Atemversagens wie bakterielle Sepsis hatten eine höhere Rate an NIV-Erfolg. Relevante Nebenwirkungen der NIV müssen beachtet werden.

Key words

acute respiratory distress syndrome - noninvasive ventilation - non-invasive ventilation - immunosuppression - stem cell transplantation - cancer

Schlüsselwörter

akutes Atemversagen - nichtinvasive Beatmung - nicht-invasive Beatmung - Immunsuppression - Stammzelltransplantation - Krebserkrankung

• References

• 1 Adda M, Coquet I, Darmon M et al. Predictors of noninvasive ventilation failure in patients with hematologic malignancy and acute respiratory failure. Crit Care Med 2008; 36: 2766-2772
• 2 Antonelli M, Conti G, Bufi M et al. Noninvasive ventilation for treatment of acute respiratory failure in patients undergoing solid organ transplantation: a randomized trial. JAMA 2000; 283: 235-241
• 3 Bernet V, Hug MI, Frey B. Predictive factors for the success of noninvasive mask ventilation in infants and children with acute respiratory failure. Pediatr Crit Care Med 2005; 6: 660-664
• 4 Bratton SL, Van Duker H, Statler KD et al. Lower hospital mortality and complications after pediatric hematopoietic stem cell transplantation. Crit Care Med 2008; 36: 923-927
• 5 British Thoracic Society Standards of Care Committee . Non-invasive ventilation in acute respiratory failure. Thorax 2002; 57: 192-211
• 6 Chima RS, Daniels RC, Kim MO et al. Improved outcomes for stem cell transplant recipients requiring pediatric intensive care. Pediatr Crit Care Med 2012; 13: e336-e342
• 7 Depuydt PO, Benoit DD, Roosens CD et al. The impact of the initial ventilatory strategy on survival in hematological patients with acute hypoxemic respiratory failure. J Crit Care 2010; 25: 30-36
• 8 Dohna-Schwake C, Stehling F, Tschiedel E et al. Non-invasive ventilation on a pediatric intensive care unit: feasibility, efficacy, and predictors of success. Pediatr Pulmonol 2011; 46: 1114-1120
• 9 Duncan CN, Lehmann LE, Cheifetz IM et al. Clinical Outcomes of Children Receiving Intensive Cardiopulmonary Support During Hematopoietic Stem Cell Transplant. Pediatr Crit Care Med 2013; 14: 261-267
• 10 Goldstein B, Giroir B, Randolph A. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med 2005; 6: 2-8
• 11 Gristina GR, Antonelli M, Conti G et al. Noninvasive versus invasive ventilation for acute respiratory failure in patients with hematologic malignancies: a 5-year multicenter observational survey. Crit Care Med 2011; 39: 2232-2239
• 12 Hilbert G, Gruson D, Vargas F et al. Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure. N Engl J Med 2001; 344: 481-487
• 13 Kache S, Weiss IK, Moore TB. Changing outcomes for children requiring intensive care following hematopoietic stem cell transplantation. Pediatr Transplant 2006; 10: 299-303
• 14 Khemani RG, Thomas NJ, Venkatachalam V et al. Comparison of SpO2 to PaO2 based markers of lung disease severity for children with acute lung injury. Crit Care Med 2012; 40: 1309-1316
• 15 Leteurtre S, Martinot A, Duhamel A et al. Validation of the paediatric logistic organ dysfunction (PELOD) score: prospective, observational, multicentre study. Lancet 2003; 362: 192-197
• 16 Mayordomo-Colunga J, Medina A, Rey C et al. Predictive factors of non invasive ventilation failure in critically ill children: a prospective epidemiological study. Intensive Care Med 2009; 35: 527-536
• 17 Munoz-Bonet JI, Flor-Macian EM, Brines J et al. Predictive factors for the outcome of noninvasive ventilation in pediatric acute respiratory failure. Pediatr Crit Care Med 2010; 11: 675-680
• 18 Pancera CF, Hayashi M, Fregnani JH et al. Noninvasive ventilation in immunocompromised pediatric patients: eight years of experience in a pediatric oncology intensive care unit. J Pediatr Hematol Oncol 2008; 30: 533-538
• 19 Pandharipande PP, Shintani AK, Hagerman HE et al. Derivation and validation of Spo2/Fio2 ratio to impute for Pao2/Fio2 ratio in the respiratory component of the Sequential Organ Failure Assessment score. Crit Care Med 2009; 37: 1317-1321
• 20 Piastra M, De Luca D, Marzano L et al. The number of failing organs predicts non-invasive ventilation failure in children with ALI/ARDS. Intensive Care Med 2011; 37: 1510-1516
• 21 Piastra M, De Luca D, Pietrini D et al. Noninvasive pressure-support ventilation in immunocompromised children with ARDS: a feasibility study. Intensive Care Med 2009; 35: 1420-1427
• 22 Pollack MM, Patel KM, Ruttimann UE et al. PRISM III: an updated Pediatric Risk of Mortality score. Crit Care Med 1996; 24: 743-752
• 23 Ranieri VM, Rubenfeld GD, Thompson BT et al. Acute respiratory distress syndrome: the Berlin Definition. JAMA 2012; 307: 2526-2533
• 24 Schiller O, Schonfeld T, Yaniv I et al. Bi-level positive airway pressure ventilation in pediatric oncology patients with acute respiratory failure. J Intensive Care Med 2009; 24: 383-388
• 25 Schonhofer B, Kuhlen R, Neumann P et al. Clinical practice guideline: non-invasive mechanical ventilation as treatment of acute respiratory failure. Dtsch Arztebl Int 2008; 105: 424-433
• 26 Squadrone V, Massaia M, Bruno B et al. Early CPAP prevents evolution of acute lung injury in patients with hematologic malignancy. Intensive Care Med 2010; 36: 1666-1674
• 27 Steinbach D, Wilhelm B, Kiermaier HR et al. Long term survival in children with acute leukaemia and complications requiring mechanical ventilation. Arch Dis Child 2011; 96: 1026-1032
• 28 Tamburro RF, Barfield RC, Shaffer ML et al. Changes in outcomes (1996–2004) for pediatric oncology and hematopoietic stem cell transplant patients requiring invasive mechanical ventilation. Pediatr Crit Care Med 2008; 9: 270-277
• 29 van Gestel JP, Bollen CW, van der Tweel I et al. Intensive care unit mortality trends in children after hematopoietic stem cell transplantation: a meta-regression analysis. Crit Care Med 2008; 36: 2898-2904
• 30 Wermke M, Schiemanck S, Hoffken G et al. Respiratory failure in patients undergoing allogeneic hematopoietic SCT – a randomized trial on early non-invasive ventilation based on standard care hematology wards. Bone Marrow Transplant 2012; 47: 574-580