Pediatric emergency medicine trisk 0167 0167
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pediatrics. Interfaces should be chosen balancing the desire to maximize comfort
and compliance while ensuring minimal leak. In addition to pressure, NIV can
also deliver supplemental oxygen and inhaled therapies such as albuterol or
racemic epinephrine.
Similar to HFNC, NIV can be used for either acute hypoxic or hypercarbic
respiratory failure. CPAP may be appropriate when hypoxemia is the primary
indication. Because it delivers higher mean airway pressures while offloading
inspiratory effort, BPAP can be used for more severe hypoxemia and to address
hypercapnia. Multiple parameters can be titrated with NIV, including CPAP
(typically 5- to 10-cm H2 O), EPAP and IPAP (typically 5 to 10 cm H2 0 and 8 to
22 cm H2 O, respectively), FiO2 , and backup ventilation rate for patients
experiencing intermittent apnea or hypopnea. If successful, NIV eliminates some
complications related to intubation, such as laryngeal or tracheal injury or
ventilator-associated pneumonia, as well the risks associated with sedation and
neuromuscular blockade. NIV should not be used in patients requiring immediate
endotracheal intubation, or those with impaired mental status or requiring airway
protection. Relative contraindications include facial injury, upper gastrointestinal
bleeding, untreated pneumothorax, and significant or escalating vasopressor
support. Most children, with appropriate coaching and provider patience during
initiation, will tolerate NIV though some require anxiolysis or sedation. Beyond
the potential for failure of NIV, the significant complications include barotrauma,
aspiration, and hemodynamic instability due to decreased venous return. Minor
complications include skin breakdown, eye irritation, nasal mucosal trauma, and
gastric distention.
APPROACH TO ENDOTRACHEAL INTUBATION
Rapid sequence intubation (RSI) is the favored approach when advanced airway
management is required in pediatrics. RSI can optimize intubating conditions and
results in higher intubation success rates than sedation alone approaches. In brief,
RSI involves the near simultaneous administration of a sedative and
neuromuscular-blocking agent (NMBA) to render a patient unconscious and
immobile, with blunted natural airway reflexes. In pure RSI, bag mask ventilation
is not performed to avoid gastric insufflation and increased risk of aspiration in
patients presumed not to be fasted. Modified or controlled RSI differs in that it
includes the delivery of gentle positive pressure breaths following medication
administration to prevent hypoxia or hypercarbia during apnea. Sedation-only
intubation may be preferred in cases of upper airway obstruction or in cases
