ReviewInterfaces for noninvasive ventilation in the acute setting in children
Introduction
Respiratory failure is the leading cause of hospital admissions in the pediatric intensive care unit (PICU) and nowadays noninvasive ventilation (NIV) represents the first-line treatment for acute respiratory failure [1], [2]. NIV is increasingly used in acute or chronic respiratory failure with various etiologies [3]. NIV in acute settings has been shown to be useful in critically ill children with bronchiolitis [2], [4], post extubation respiratory failure [5], pneumonia [6], acute chest syndrome [7], and status asthmaticus [8]. Moreover, findings regarding the benefits of NIV from clinical studies were confirmed by several physiological studies [9], [10].
The use of NIV is very specific in the acute setting as compared to its use in a chronic setting [11]. Indeed, in the PICU, NIV may be required around the clock and initiation has to be fast and easy. Different types of interfaces should be immediately available and the medical team should be experienced with the choice and the use of the different interfaces. Several types of interfaces are currently available: nasal mask, nasal prongs, oronasal mask, full face mask, and the helmet. Interfaces are characterized by different shapes, sizes, and materials. However, despite the increasing use of NIV and the larger choice of interfaces, data comparing the tolerance or efficacy of different interfaces for pediatric patients are scarce and recommendations for the most appropriate choice of interface are lacking [12], [13], [14], [15].
The aim of the present paper is to describe the different types of interfaces available for children in the acute setting, their advantages and limitations, to highlight how to choose the optimal interface, and how to monitor the tolerance of the interface.
Section snippets
Vented or non-vented ventilation?
Interfaces can be vented or non-vented, i.e with or without intentional leaks. In PICU, due to the performance and availability of ICU ventilators, most patients are supported by non-vented NIV with closed double-limb respiratory circuits [3]. On the other hand, most home ventilators and CPAP devices use a single limb circuit with vented interfaces. The appropriate selection of equipment, including an appropriate mask, circuit, device and device settings is essential for the success of NIV. The
Nasal interface
Nasal masks cover solely the nose and differ with regard to the presence or not of a forehead support, internal flap and type of fixation. Nasals masks are available for all ages, from the newborn to the adolescent. They are usually chosen as a first choice and are preferred to nasobuccal or full face masks due to the small static dead space, especially in the younger patients [16], [17]. Nasal masks are easy to apply and have the advantage of causing less anxiety, which may be a major issue in
The interface
The choice of the optimal interface for NIV in acute settings is challenging and of paramount importance for the success of NIV [47] (Table 2). In critically ill children, the ideal interface should be: (i) small, with minimal dead-space; (ii) causing minimal leaks; (iii) light-weight; (iv) easy to fit and remove; (v) nontraumatic; (vi) manufactured with nonallergenic material; (vii) cheap and (viii) having an appropriate and well-adapted headgear that confers stability preventing movement or
Conclusion
The choice of interface for NIV in the acute setting is crucial and a major contributor of the success of NIV. The availability of interfaces and headgears could certainly be improved and future pediatric studies are required to identify the best strategy to choose the interface, depending on the patient characteristics and condition.
Financial support
No financial support was required to perform this work.
Educational aims
The reader will come to appreciate that in critically ill children:
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The ideal interface should be: small, inexpensive, comfortable, light-weight, easy to fit and remove.
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The interface should manufactured with non-allergenic material and have appropriate and well-adapted headgear.
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The choice of interface for NIV depends on patient's age, weight and clinical situation, facial anatomy the mode of ventilation and the type of circuit (vented or non-vented) and the risk of skin injury.
Directions for future research
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The availability of interfaces and headgears could certainly be improved and future pediatric studies are required to identify the best strategy to choose the interface, depending on the patient characteristics and condition.
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