2 nd Joint International Meeting JIVD and ERCA March 2015, Lyon, France NIV as an alternative to tracheotomy Jacques Cotting MD PICU CHUV, Lausanne, Switzerland March 2015
NIV as an alternative to tracheostomy? To answer the question First to review Ø Epidemiology of tracheostomy in children Ø Indications Ø Outcomes Secondly to review Laryngotracheal lesions NIV and tracheostomy
There is few review on tracheostomy in children Pitzburg experience 1991 to 1995 (Tantinikorn W. 2003) 185 tracheostomy, age 3.8±5.3 years, 55% 1year Indications: upper airway obstruction (60%) ventilatory support (30%) Late complications minor 60%, major 5% Mortality: 13.3% Operative procedure in 43% with 64% of decannulation Tantinikorn W and al: Outcome in Pediatric Tracheotomy. Am J Otolaryngol 2003;24:131-137.
There is few review on tracheostomy in children Aukland experience, 1987-2003, (Mahadevan M. 2007) 122 tracheostomy, age 7.8 months, 66% 1year Indications: craniofacial and subglottic (70%), ventilatory support (30%) Late complications 52% Mortality: 14%, 2 patients from tracheostomy complication Decannulation in 75% Mahadevan M and al: Pediatric Tracheotomy: 17 year review. International Journal of Pediatric Otorhinolaryngology (2007) 71, 1829 1835
There is few review on tracheostomy in children Aukland experience, 1987-2003, (Mahadevan M. 2007) Mahadevan M and al: Pediatric Tracheotomy: 17 year review. International Journal of Pediatric Otorhinolaryngology (2007) 71, 1829 1835
There is few review on tracheostomy in children Turkey 37-years experience, 1968-2005, (Oezmen S. 2009) 282 tracheostomy, age 27 months, 23% 1year Indications: upper airway obstruction (72%) of those infections (50%) (Haemophilus) ventilatory support (28%) Late complications 19% Mortality: 19%, 3 patients from tracheostomy complication Decannulation in 35% Oezmen S. and all: Pediatric tracheotomies: A 37-year experience in 282 children. International Journal of Pediatric Otorhinolaryngology (2009) 73, 959 961
There is few review on tracheostomy in children Lyon-France experience, 1996-2001, (Butnaru C.S. 2005) 46 tracheostomy, age 3.8 years, 35% 1year Indications: ventilatory support (57%) upper airway obstruction (43%) Late complications 50% Mortality: 13%, 3 patients from tracheostomy complication Decannulation in 52% Butnaru C.S. and all:tracheotomy in children: Evolution in indications. International Journal of Pediatric Otorhinolaryngology (2006) 70, 115 119
Tracheostomy in children There is few national analysis Maxwell and McMilland 2014 Using the US Kids Inpatient Database From 1997 to 2009, all data of US children hospitals (0-18 y) Focused on tracheostomy in children with congenital heart disease Maxwell and McMillan (2014), Tracheostomy in children with congenital heart disease: a national analysis of the Kids Inpatient Database. PeerJ 2:e568; DOI 10.7717/peerj.568
Tracheostomy in children Maxwell and McMilland 12 years analysis All Tracheostomy performed: 25 928 In Congenital Heart Disease 2 495 = 9.6% Note: Much higher than in Europa CHD admissions 355 460 Tracheostomy in CHD =3.5% Note that CHD patients could have many admissions Maxwell and McMillan (2014), Tracheostomy in children with congenital heart disease: a national analysis of the Kids Inpatient Database. PeerJ 2:e568; DOI 10.7717/peerj.568
Maxwell and McMilland a 12 years analysis Maxwell and McMillan (2014), Tracheostomy in children with congenital heart disease: a national analysis of the Kids Inpatient Database. PeerJ 2:e568; DOI 10.7717/peerj.568
Maxwell and McMilland a 12 years analysis They observed Ø Ø increased number of tracheostomy performed over the time in both paediatric and congenital heart disease (CHD) patients CHD No CHD Ø Days from admission to tracheo 35 d 30 d Ø LOS (days) 98 47 Ø Hospital charges ($) 603 651 368 956 Ø Discharge at home 41% 35% Ø With home health 28% 16% Ø Long term Care 31% 48% Ø Mortality 16% 7% Maxwell and McMillan (2014), Tracheostomy in children with congenital heart disease: a national analysis of the Kids Inpatient Database. PeerJ 2:e568; DOI 10.7717/peerj.568
Children at Risk for in-hospital mortality following tracheotomy (Berry J.G. 2010) Kids Inpatients Database (1997, 2000, 2003 and 2006) Admissions 25 746 876 Tracheotomy performed 18 806 Annual mortality ranged from 7.7% to 8.5% Observed higher mortality rate in < 1 year compared to 1-4 y : 10-13% vs 1-4% CHD vs no CHD 13-19% vs 6-7% Prematurity vs without 13-19% vs 6-7% Lower mortality observed in children with upper airway obstruction Berry J and all (2010). Patient characteristics associated with in-hospital mortality in children following tracheotomy. Arch Dis Child 95(9):703-710
Laryngotracheal lesions Except neurological or muscular disease, most tracheostomy are due to Endotracheal intubations Larynx malformations Grade of stenosis (Myer-Cotton airway grading system) Grade I 50% of the lumen Grade II 51% 70% Grade III 71% 99% Grade IV Total obstruction
Laryngotracheal stenosis Congenital stenosis 15% Laryngomalacia Vocal cord paresis (uni-bilateral) Subglottic stenosis Web, kystes, hemangioma Acquired stenosis 85% Prevalence 1970 : 12-20% of intubations 1990 : 1 8% >2000 : 0.9-3%
Laryngomalacia Before After Co2 laser surgical it is often a stressful procedure for the c and also for the examiner. Moveover, in a situation where the steno compensated or it is an unexpected high it can quickly turn into an emergency. Th enced staff and age-appropriate tools for mechanical ventilation must be absolute Other disadvantages are a defensive po matisation of the child, a significantly GMS Current Topics in Otorhin Frequently, post op NIV is needed (oedema) for 24 to 72h Important surgical expertise is required at this age Sittel C:Pathology of the larynx and trachea in chilhood. GMS Current Topics in Otorhinolaryngology - Head and Neck Surgery 2014, Vol. 13
Complex laryngotracheal reconstruction tenoid fixation are not suitab treatment. 10,11 We used a la ancillary treatment for remova ytenoidectomy for CAA (n ¼ distance after the open operat 414 The Journal of Th lation. Combined laryngotra tenoid fixation are not suita treatment. 10,11 We used a l ancillary treatment for remov ytenoidectomy for CAA (n ¼ distance after the open opera 414 The Journal of T lation. Combined laryngotra tenoid fixation are not suita treatment. 10,11 We used a l ancillary treatment for remov ytenoidectomy for CAA (n ¼ distance after the open opera 414 The Journal of T Cure of combined subglottic and posterior glottic stenosis After operation, tracheostomy could stay in place for months Decannulation could success after several attemps Monnier and all: Management of severe pediatric subglottic stenosis with of glottic involvement. J Thorac Cardiovasc Surg (2010);139:411-417
Complex laryngotracheal reconstruction Pre OP ¼ dren in the isolated SGS group. seling of the parents regarding postoperative course is importa G-SGS. Voice Outcome Preoperative evaluation of vo the majority of these children w patients) or aphonic on present 416 The Journal of Tho at 6 months ¼ dren in the isolated SGS gr seling of the parents regard postoperative course is imp G-SGS. Voice Outcome Preoperative evaluation the majority of these child patients) or aphonic on pre 416 The Journal of 1-year-old boy with mixed stenosis (acquired on congenital) glotto-subglottic stenosis Monnier and all: Management of severe pediatric subglottic stenosis with of glottic involvement. J Thorac Cardiovasc Surg (2010);139:411-417
Paediatric non-invasive ventilation (NIV) NIV use has increased markedly over the last 10 years (Hull 2014) Commonly used in most PICU In some high dependency unit NIV at home followed by tertiary respiratory units Published evidence for use of VNI in acute or chronic respiratory failure remain relatively weak in children It is now very unlikely that there will be any more randomised controlled trials for this intervention Hull J. The value of non-invasive ventilation. Arch Dis Child (2014):99; 1050-1054
Turbine generators: triggers time delay 400.0 300.0 Générateurs de flux Response time delay (* : p < 0.001 VPAPIIISTa (high) vs other devices for 5 and 8 l/min. # : p < 0.001 VPAPIIISTa (high), VPAPIIST VSync, RPM Bilevel vs other devices for 12 l/min) ms 5 l/min 8 l/min 12 l/min 200.0 100.0 # * # # 0.0 VPAP IIST Vsync VPAP IIST VPAP IIISTa (low) VPAP IIISTa (middle) VPAP IIISTa (high) Harmony PV101 (low) PV101 (middle) PV101 (high) RPM Bilevel Moritz IIST VS Ultra Somnovent
Turbine generators: volume response Response volume (* : p < 0.001 VPAPIIISTa (high) vs other devices) 140.0 5 l/min 8 l/min 12 l/min 120.0 * 100.0 80.0 ml 60.0 40.0 20.0 0.0 VPAP IIST Vsync VPAP IIST VPAP IIISTa (low) VPAP IIISTa (middle) * VPAP IIISTa (high) Harmony PV101 (low) PV101 (middle) PV101 (high) * RPM Bilevel Moritz IIST VS Ultra Somnovent
VNI Bi-Level Compared to spontaneous ventilation, Bi-level VNI Decreased respiratory rate Decreased work of breathing 0 Ventilation spontanée VNI mbar -10-20 sec sec
VNI after laryngotracheal reconstruction Special needs: Perfect pre-operative evaluation Good surgeon! High skilled nursing and physiotherapist team High sensitive VNI machine The best interface In < 1 year children Humidification could be a concern Analgesia and sedation could be very complex
Our first attempts Gagarine 1999
Today A prototype Comfortable market mask
Finally, to respond to the question With the important progress of NIV in children Tracheostomy versus VNI is no more a choice VNI use is mandatory for the majority of children Tracheostomy must be view as temporarily option for Some stage of laryngotracheal reconstruction Rare severe cranio-facial trauma
Thank you for your attention