Introduction: Severe bronchiolitis is the most common cause of admission to the pediatric ICU in infants (PICU). Non-invasive respiratory support (NRS) has become the standard of care for infants with severe disease. Currently, the choice of NRS mode and escalation strategy lacks evidence and guidelines. NAVA (Neurally adjusted ventilatory assist) is a mode of NRS that improves patient-ventilator synchrony and effort of breathing. Despite this, its impact on clinical outcomes in patients with severe bronchiolitis has not been reported. The main objectives of this study are to 1) describe the NRS strategies (initial support and escalation) across three Canadian PICUs and 2) evaluate if NIV-NAVA is associated with a lower intubation rate than traditional NRS strategies.
Methods: This is a retrospective cohort of infants < 2years with a first episode of severe bronchiolitis admitted to Sainte-Justine Hospital (HSJ), Montreal Children’s Hospital (MCH) and CHEO between November 2017-April 2022. The primary outcome was rate of endotracheal intubation. Secondary outcomes include duration of ventilatory support and outcome of primary NRS mode (success, escalation, intubation). Propensity-matched analysis was used to compare NIV-NAVA to traditional NIV.
Results: 859 patients were included, with a median age 1.9 months (1.1-4.3) and 245 (28.5%) had comorbidities. 104 (12.1%) patients were primarily intubated while 755 (87.9%) received primary NRS. CPAP was the most common primary NRS mode at all three PICU sites. Primary NRS mode was successful in 422 (88%) at HSJ, 270 (78%) at MCH, and 28 (67%) at CHEO. NAVA was successful in 114 ventilation episodes (95%). 35 patients (4%) failed NRS and required intubation: 13 (3%) at HSJ (NAVA site), 21 (6%) at MCH, 1 (2%) CHEO (p=0.04). The total duration of ventilatory support was significantly longer at MCH 70.5h (34.7-133.5). Propensity matched analysis in process.
Conclusions: NRS support strategies were similar among participating PICUs. NAVA was used successfully in patients with severe bronchiolitis and sites that had NAVA available, had a significantly lower intubation rate. These results support the advent of a prospective study to further compare NIV-NAVA to traditional NRS modes.
