High-Flow Nasal Cannula and August 2020

Volume 17, Number 8

Noninvasive Ventilation in Authors

Daniel Slubowski, MD

Pediatric Emergency Medicine

Assistant Professor of Clinical Emergency Medicine and Pediatrics,
Indiana University School of Medicine, Department of Emergency
Medicine, Riley Hospital for Children at Indiana University Health,
Indianapolis, IN
Abstract Timothy Ruttan, MD, FACEP
Assistant Professor of Pediatrics, University of Texas at Austin Dell
Medical School, Department of Pediatrics, Dell Children’s Medical
The use of high-flow nasal cannula and noninvasive ventilation has Center of Central Texas, Pediatric Emergency Medicine, Austin, TX

become increasingly common in emergency medicine as a first-line

Peer Reviewers
treatment of pediatric patients with respiratory distress secondary
to asthma and bronchiolitis. When implemented in clinical practice, Deborah A. Levine, MD
Assistant Professor of Clinical Emergency Medicine; Assistant
close monitoring of vital signs and ventilation parameters is warrant- Professor of Clinical Pediatrics, Weill Cornell Medicine, New York
ed to identify possible signs of respiratory failure. This issue provides Presbyterian Hospital, Komansky Children’s Hospital, New York, NY
evidence-based recommendations for the appropriate use of nonin- Joshua Nagler, MD, MHPEd
Associate Division Chief and Fellowship Director, Division of
vasive ventilation modalities in pediatric patients including high- Emergency Medicine, Boston Children’s Hospital; Associate
flow nasal cannula, continuous positive airway pressure, and bilevel Professor of Pediatrics and Emergency Medicine, Harvard Medical
School, Boston MA
positive airway pressure in the setting of acute respiratory distress.
Contraindications and complications associated with these modalities Prior to beginning this activity, see “CME Information”
on the back page.
are also discussed.

Editors-in-Chief Ari Cohen, MD, FAAP Alson S. Inaba, MD, FAAP Garth Meckler, MD, MSHS David M. Walker, MD, FACEP, FAAP
Chief of Pediatric Emergency Pediatric Emergency Medicine Associate Professor of Pediatrics, Chief, Pediatric Emergency
Ilene Claudius, MD Medicine, Massachusetts General Specialist, Kapiolani Medical Center University of British Columbia; Medicine, Department of Pediatrics,
Associate Professor; Director, Hospital; Instructor in Pediatrics, for Women & Children; Associate Division Head, Pediatric Emergency Joseph M. Sanzari Children's
Process & Quality Improvement Harvard Medical School, Boston, MA Professor of Pediatrics, University Medicine, BC Children's Hospital, Hospital, Hackensack University
Program, Harbor-UCLA Medical of Hawaii John A. Burns School of Vancouver, BC, Canada Medical Center, Hackensack, NJ
Center, Torrance, CA Jay D. Fisher, MD, FAAP, FACEP
Medicine, Honolulu, HI
Clinical Professor of Emergency Joshua Nagler, MD, MHPEd Vincent J. Wang, MD, MHA
Tim Horeczko, MD, MSCR, FACEP, Medicine and Pediatrics, University Madeline Matar Joseph, MD, FACEP, Associate Division Chief and Professor of Pediatrics and
FAAP of Nevada, Las Vegas School of FAAP Fellowship Director, Division of Emergency Medicine; Division
Associate Professor of Clinical Medicine, Las Vegas, NV Professor of Emergency Medicine Emergency Medicine, Boston Chief, Pediatric Emergency
Emergency Medicine, David Geffen and Pediatrics, Assistant Chair, Children's Hospital; Associate Medicine, UT Southwestern
School of Medicine, UCLA; Core Marianne Gausche-Hill, MD, FACEP,
Pediatric Emergency Medicine Professor of Pediatrics and Emergency Medical Center; Director of
Faculty and Senior Physician, Los FAAP, FAEMS
Quality Improvement, Pediatric Medicine, Harvard Medical School, Emergency Services, Children's
Angeles County-Harbor-UCLA Medical Director, Los Angeles
Emergency Medicine Division, Boston MA Health, Dallas, TX
Medical Center, Torrance, CA County EMS Agency; Professor of
University of Florida College of
Clinical Emergency Medicine and James Naprawa, MD International Editor
Editorial Board Medicine-Jacksonville,
Pediatrics, David Geffen School Attending Physician, Emergency
Jacksonville, FL Lara Zibners, MD, FAAP, FACEP,
Jeffrey R. Avner, MD, FAAP of Medicine at UCLA; Clinical Department USCF Benioff
Faculty, Harbor-UCLA Medical Stephanie Kennebeck, MD Children's Hospital, Oakland, CA MMEd
Chairman, Department of Honorary Consultant, Paediatric
Pediatrics, Professor of Clinical Center, Department of Emergency Associate Professor, University of Joshua Rocker, MD Emergency Medicine, St. Mary's
Pediatrics, Maimonides Children's Medicine, Los Angeles, CA Cincinnati Department of Pediatrics, Associate Chief and Medical Hospital Imperial College Trust,
Hospital of Brooklyn, Brooklyn, NY Cincinnati, OH
Michael J. Gerardi, MD, FAAP, Director, Assistant Professor of London, UK; Nonclinical Instructor
Steven Bin, MD FACEP, President Anupam Kharbanda, MD, MSc Pediatrics and Emergency Medicine, of Emergency Medicine, Icahn
Associate Clinical Professor, UCSF Associate Professor of Emergency Chief, Critical Care Services, Cohen Children's Medical Center of School of Medicine at Mount Sinai,
School of Medicine; Medical Director, Medicine, Icahn School of Medicine Children's Hospital Minnesota, New York, New Hyde Park, NY New York, NY
Pediatric Emergency Medicine, UCSF at Mount Sinai; Director, Pediatric Minneapolis, MN Steven Rogers, MD
Benioff Children's Hospital, San Emergency Medicine, Goryeb Tommy Y. Kim, MD Associate Professor, University of Pharmacology Editor
Francisco, CA Children's Hospital, Morristown Health Sciences Clinical Professor Connecticut School of Medicine, Aimee Mishler, PharmD, BCPS
Medical Center, Morristown, NJ
Richard M. Cantor, MD, FAAP, FACEP of Pediatric Emergency Medicine, Attending Emergency Medicine Emergency Medicine Pharmacist,
Professor of Emergency Medicine Sandip Godambe, MD, PhD University of California Riverside School Physician, Connecticut Children's Program Director – PGY2
and Pediatrics; Section Chief, Chief Quality and Patient Safety Officer, of Medicine, Riverside Community Medical Center, Hartford, CT Emergency Medicine Pharmacy
Pediatric Emergency Medicine; Professor of Pediatrics, Attending Hospital, Department of Emergency Residency, Valleywise Health
Christopher Strother, MD
Medical Director, Upstate Poison Physician of Emergency Medicine, Medicine, Riverside, CA Medical Center, Phoenix, AZ
Associate Professor, Emergency
Control Center, Golisano Children's Children's Hospital of The King's Melissa Langhan, MD, MHS Medicine, Pediatrics, and Medical APP Liaison
Hospital, Syracuse, NY Daughters Health System, Norfolk, VA Associate Professor of Pediatrics and Education; Director, Pediatric
Ran D. Goldman, MD Emergency Medicine; Fellowship Emergency Medicine; Director, Brittany M. Newberry, PhD, MSN,
Steven Choi, MD, FAAP MPH, APRN, ENP-BC, FNP-BC
Chief Quality Officer and Associate Professor, Department of Pediatrics, Director, Director of Education, Simulation; Icahn School of Medicine
Faculty, Emory University School
Dean for Clinical Quality, Yale University of British Columbia; Pediatric Emergency Medicine, Yale at Mount Sinai, New York, NY
Research Director, Pediatric University School of Medicine, New of Nursing, Emergency Nurse
Medicine/Yale School of Medicine; Adam E. Vella, MD, FAAP Practitioner Program, Atlanta, GA;
Vice President, Chief Quality Officer, Emergency Medicine, BC Children's Haven, CT Associate Professor of Emergency Nurse Practitioner, Fannin Regional
Yale New Haven Health System, Hospital, Vancouver, BC, Canada Robert Luten, MD Medicine and Pediatrics, Associate Hospital Emergency Department,
New Haven, CT Joseph Habboushe, MD, MBA Professor, Pediatrics and Chief Quality Officer, New York- Blue Ridge, GA
Assistant Professor of Emergency Emergency Medicine, University of Presbyterian/Weill Cornell Medicine,
Medicine, NYU/Langone and Florida, Jacksonville, FL New York, NY
Bellevue Medical Centers, New
York, NY; CEO, MD Aware LLC
Case Presentations Introduction
A 2-month-old girl, born full-term without complica- Respiratory disease is one of the most common
tions, presents to your ED in the middle of December. causes of morbidity in pediatric patients, and acute
According to her mother, she has had 3 days of cough and or impending respiratory failure remains the leading
congestion, as well as decreased feeding. The mother took diagnosis for admission to the pediatric intensive
her to the primary care physician’s office earlier in the day care unit (PICU).1 The mainstay of therapy for these
because she noticed that the girl's breathing had become patients has traditionally included mechanical
extremely fast. On examination, the primary care physi- ventilation. Inherent to endotracheal intubation and
cian noted wheezing and retractions, with an increased mechanical ventilation is the potential for iatrogenic
respiratory rate, and she recommended the mother take complications, including upper airway trauma,
the child to the ED. The infant's initial vital signs are: laryngeal swelling, postextubation vocal cord
temperature, 37.5°C (99.5°F); heart rate, 170 beats/min; dysfunction, prolonged sedation and hospitalization,
respiratory rate, 74 breaths/min; blood pressure, 82/60 and nosocomial infections.2 For more information
mm Hg; and oxygen saturation, 89% on room air. She on mechanical ventilation in pediatric patients, refer
weighs 5 kg. Her physical examination is notable for nasal to the July 2020 issue of Pediatric Emergency Medicine
congestion with grunting, tachypnea, and subcostal and Practice, “Mechanical Ventilation of Pediatric
supraclavicular retractions. She also has dry mucous Patients in the Emergency Department,” at:
membranes and a capillary refill of 3 seconds. Oxygen www.ebmedicine.net/PedMechVent
is provided by nonrebreather mask, and IV access is Noninvasive ventilation (NIV) has become an
obtained. Nasal suctioning is performed without much important tool in pediatric emergency medicine to
change in her respiratory status. You make the decision to delay or prevent endotracheal intubation. Initially
use high-flow nasal cannula as the initial form of respira- introduced in the adult and neonatal population,
tory support, with the following settings: FiO2, 40%; flow NIV has been used increasingly in the management
rate, 5 L/min. After about an hour on high-flow nasal of pediatric respiratory failure.3,4 High-flow nasal
cannula, the infant's vital signs are relatively unchanged. cannula (HFNC), continuous positive airway pres-
What are the signs of failure of high-flow nasal cannula? sure (CPAP), and bilevel positive airway pressure
Is there a maximum flow rate above which this modality is (BPAP) are the primary forms of NIV used in pedi-
not as effective, and how should it be titrated in pediatric atric patients. Several different device interfaces for
patients? Are higher rates more likely to cause harm? NIV exist, and emergency clinicians need to under-
On a mid-spring day, a 5-year-old boy with a past stand the options that are available in their particu-
medical history significant for asthma presents with au- lar clinical setting. While NIV has generally shown
dible wheezing and respiratory distress. His mother states good results when used in the management of acute
that he had been playing in the backyard with his sister respiratory failure secondary to bronchiolitis and
yesterday, and his symptoms have been persistent since asthma, its role in the management of pneumonia,
then. Despite using his albuterol nebulizer every 4 hours acute respiratory distress syndrome (ARDS), and
at home, he has still been coughing and wheezing. When other disease processes is less clear.
reviewing his history, you note that he has been admit- This issue of Pediatric Emergency Medicine
ted to the PICU for asthma exacerbations, with the most Practice reviews the different types of NIV, cites the
recent admission being 3 months ago. His vital signs are: indications for their use in the emergency depart-
temperature, 36.5°C (97.7°F); heart rate, 130 beats/min; ment (ED), and provides evidence-based recommen-
respiratory rate, 44 breaths/min; blood pressure, 100/76 dations for their use in patients with various disease
mm Hg; oxygen saturation, 93% on room air. He weighs processes.
20 kg. On initial examination, the patient is awake and
alert but in severe respiratory distress. He has diminished Critical Appraisal of the Literature
breath sounds throughout, with substernal and lower
intercostal retractions. He cannot speak in full sentences. A literature search was performed in PubMed,
You immediately order 3 consecutive nebulized albuterol Google Scholar, Ovid MEDLINE®, and the Cochrane
treatments with ipratropium, establish IV access, and Database of Systematic Reviews using the search
administer methylprednisolone. Given the severity of his terms: pediatric noninvasive ventilation, high-flow nasal
symptoms, you are considering bilevel positive airway cannula, HFNC, continuous positive airway pressure,
pressure (BPAP) to prevent intubation. What are the CPAP, bilevel positive airway pressure, and BiPAP. A
optimal settings when initiating BPAP therapy? Can total of 363 abstracts were evaluated, and 177 full-
nebulized medications be given through the mask interface text articles published between 1995 and 2019 were
with BPAP, and are they still effective? What complica- reviewed. Citations within articles were also cross-
tions may arise while using BPAP, and is it an effective referenced.
means of avoiding intubation?

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 The literature regarding NIV in pediatric pa- explain some of the observed clinical benefit.10-12 Un-
tients is limited in the number of prospective studies like CPAP and BPAP, however, this cannot be titrated
and randomized controlled trials. Most of the strong precisely, so the clinical response of the patient will
evidence for its use comes from neonatal and adult vary and must be monitored individually.
literature. All pediatric-specific Cochrane reviews Flow rates for HFNC can be titrated to as high as
regarding this topic did not have sufficient evidence 60 L/min to achieve the desired effect. However, the
to make recommendations. maximum benefit in the pediatric population appears
to be at flow rates between 1.5 to 2 L/kg/min.13
Physiology When compared with patients treated with HFNC
at 3 L/kg/min, there was no significant difference in
High-Flow Nasal Cannula failure rate, intubation rate, or duration of invasive
The introduction of HFNC into pediatric emergency ventilation or NIV. Additionally, patients with bron-
care has offered a less invasive means of improving chiolitis who were treated with 3 L/kg/min of flow
respiratory distress. In its most basic form, the equip- experienced greater discomfort and increased length
ment necessary for HFNC is a source of pressurized of stay in the PICU.14
oxygen or air, a sterile water reservoir, an insulated or
heated circuit, and a nonocclusive cannula interface. Noninvasive Ventilation
The equipment remains an open system, meaning NIV, which includes CPAP and BPAP, consists
that the cannula interface does not fully obstruct the of an external interface that delivers pressurized
nostrils. This characteristic distinguishes HFNC from gas supplied by a pressure-targeted ventilator.3
the closed systems used in other NIV modalities There are several different interfaces that can be
(CPAP and BPAP).5 In the existing literature, HFNC employed, which are shown in Table 1, page 4.15,16
is not routinely considered to be NIV and will thus be The most important aspect of the equipment is an
referred to as HFNC, while other modalities will be interface that fits the patient's face correctly. Gen-
referred to as NIV throughout this review. For infor- erally, one should be able to pass a finger between
mation on HFNC setup, watch the video at: the headgear and the face.17 Without an appropri-
www.youtube.com/watch?v=BD79VxUlsis ately sized mask, air leaks around the mask can
There are several mechanisms by which HFNC occur, which lead to patient-ventilator asynchrony
is believed to provide respiratory support to pedi- that results in insufficient inspiratory flow and
atric patients. The air or oxygen in HFNC is heated treatment failure.18,19 For information on how to
and humidified. Normally, the initial temperature set up a BPAP machine, watch the video at:
is 1°C to 2°C below body temperature and adjusted www.youtube.com/watch?v=hXtx0nEoL9E
for patient comfort. Theoretically, by providing There are various mechanisms by which positive
heated and humidified air, the HFNC system allows pressure ventilation provides support. It provides
for greater clearance of secretions, reduced airway extrinsic PEEP, which increases the functional re-
obstruction, and decreased energy expenditure. In sidual capacity to ultimately recruit more alveoli and
addition, HFNC can be titrated to higher flow rates decrease ventilation/perfusion mismatch.20 By re-
than simple nasal cannula. These flow rates can meet cruiting more alveoli, lung compliance is improved
and exceed the inspiratory demands of the patient, and work of breathing decreases. Additionally, posi-
thus decreasing the work of breathing. Because the tive pressure ventilation increases tidal volume and
patient is not inhaling as much room air through subsequently intrathoracic pressure. This increase
their own inspiratory forces, dilution of the oxygen in intrathoracic pressure decreases left ventricular
support provided by nasal cannula is prevented.6 Fi- afterload and improves cardiac output.17 Caution
nally, during rebreathing, HFNC can wash out CO2 must be used, however, as elevated intrathoracic
that collects in the relatively larger nasopharyngeal pressures will decrease venous return and preload,
dead space in children;7 this washout improves gas possibly resulting in cardiac strain.
exchange and breathing efficiency.5,6 Positive pressure ventilation also helps to sta-
Because HFNC is an open system, it was not bilize the chest wall, which is highly compliant in
regarded initially as a form of positive pressure ven- pediatric patients. During states of acute respiratory
tilation, as it was not believed to generate measurable failure, compliance decreases, and the dead space
airway pressures. It has now been shown that HFNC can nearly double. The added positive pressure can
can generate some degree of positive end-expiratory help the inspiratory muscles counteract any airflow
pressure (PEEP), thus recruiting alveoli and increas- limitation and chest wall overstretching, allowing
ing the functional residual capacity. Nonetheless, for an improvement in tidal volume. This improves
the measurement of pressure is highly variable and retractions and decreases energy expenditure, which
dependent on leakage around the nasal prongs.8,9 can be helpful in high metabolic states such as sepsis
Reports in the literature have shown that there is 3 or respiratory distress.21
to 6 cm H2O of PEEP generated, which may help to

August 2020 • www.ebmedicine.net 3 Copyright © 2020 EB Medicine. All rights reserved.

Table 1. Interfaces for High-Flow Nasal Cannula and Noninvasive Ventilation15
Interface Example Comments
High-flow nasal cannula a Advantages:
• Decreases work of breathing
• Increases patient comfort (warmed, humidified)
• Dead space alveolar wash-out improves both oxygenation and ventilation

Disadvantages:
• Open system; does not actively enhance tidal volume
• May not be able to provide more than physiologic positive end-expiratory
pressure

Nasal mask b Advantages:

• Easy to fit
• No mouth coverage: allows talking, decreased risk of aspiration, less gastric
distension
• Low risk of asphyxia and claustrophobia

Disadvantages:
• Mouth leaks
• Contraindicated in mouth breathing or nasal obstruction
• Potential for pressure ulcers

Oronasal mask c Advantages:

• Improved gas exchange and minute ventilation
• No mouth leaks

Disadvantages:
• May cause aspiration, claustrophobia, gastric distension
• Unable to eat or talk

Full-face mask d Advantages:

• Fewer pressure ulcers
• Comfortable

Disadvantages:
• May cause aspiration, claustrophobia, gastric distension
• Allows more dead space

Helmet e Advantages:
• Allows eating and talking
• More comfortable and allows higher pressures
• No pressure ulcers

Disadvantages:
• Allows more dead space
• Noisy and may cause claustrophobia
• Difficult humidification and ventilator adaptation

a
Republished with permission of McGraw Hill LLC, from Emergency Medicine Procedures, Reichman E., 3rd edition, Copyright 2018, permission
conveyed through Copyright Clearance Center.
b
Source: https://commons.wikimedia.org/wiki/File:JOYCEone_Nasal.jpg Author: Pfrieda, User: Pfrieda. Used under the Creative Commons Attribution-
Share Alike 3.0 Unported License. https://creativecommons.org/licenses/by-sa/3.0/deed.en
c,d
These images were published in Turkish Journal of Emergency Medicine, Volume 18, Issue 2, Erkan Göksua, Deniz Kılıçb, Süleyman İbze, Non-
invasive ventilation in the ED: Whom, When, How?, Pages 52-56, Copyright Elsevier 2018.
e
Image used with permission of Harol. Image available at: https://harol.it/

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Continuous Positive Airway Pressure fails. However, due to its varying pressures between
CPAP delivers a continuous level of pressure to the cycles, BPAP is more prone to asynchrony when
airways, regardless of the cycle. Determination of compared with CPAP.19
initial settings depends on the size of the patient and
the work of breathing that the patient exhibits. A Contraindications and Complications
general guideline for CPAP is to start at a pressure of
3 cm H2O and titrate up to a maximum of 10 cm H2O. Critical to the success of HFNC and NIV is knowl-
Bubble CPAP is a form of CPAP that is used in edge of their indications, contraindications, and po-
older infants. The “bubble” refers to the fact that tential complications. Both HFNC and NIV require
the expiratory limb of this system is submerged in a intact airway reflexes and a normal mental status,
water-seal chamber, producing bubbles that some- since both means of ventilation require the patient to
times migrate back through the circuit. Nasal prongs initiate his or her own breath.
are the preferred interface. Bubble CPAP differs from
ventilator-driven CPAP in that it does not provide Contraindications
a consistent mean pressure but rather oscillates HFNC is relatively safe, and contraindications to its
around the mean pressure. This system provides the use are limited to certain patient characteristics. Spe-
most benefit when the compliance of the respira- cifically, it should not be used in patients with upper
tory system is low, allowing for alveolar recruitment airway abnormalities or those with trauma or recent
and maintenance of airway patency.22 When bubble surgery to the face or nose. NIV is contraindicated as
CPAP is used, it assists in stenting airways open and a primary therapy in patients with ARDS, cardiopul-
improving gas exchange. monary arrest, or severe hemodynamic instability,
as these patients require bag-valve mask ventilation
Bilevel Positive Airway Pressure or a more definitive airway.24 In addition, HFNC
In BPAP, two pressure settings must be controlled: and NIV should not be used in patients with severe
inspiratory positive airway pressure (IPAP) and neurologic compromise or those with moderate or
expiratory positive airway pressure (EPAP). BPAP severe bulbar weakness secondary to inability to
cycles between delivering IPAP and EPAP.3 The protect their airway.25,26 Patients who are unable to
IPAP should be set initially at 6 cm H2O and can be fit or tolerate an interface should not undergo NIV,
titrated up to a maximum of 25 cm H2O. The EPAP is as it will be ineffective in these cases.8
always lower than the IPAP and should be initiated Higher mean airway pressures are generated by
at 3 cm H2O and titrated up to a maximum of 10 cm CPAP and BPAP compared to HFNC and, as a result,
H2O. The difference between the IPAP and EPAP additional contraindications to their use exist. CPAP
settings limits barotrauma while allowing ventila- and BPAP can exert distending pressures in the gastro-
tion, which is especially important in patients with intestinal tract, and patients who are unable to manage
high lung compliance. Titrations of these pressures oral secretions, have had recent upper gastrointestinal
should be gradual and occur under close monitor- surgery, have an upper gastrointestinal bleed, or an un-
ing.8 Similar to invasive ventilation, BPAP settings repaired diaphragmatic hernia are at risk for vomiting,
should be adjusted to target specific patient goals. aspiration, and, rarely, gastrointestinal tract perfora-
For hypoxemic patients, EPAP, IPAP, and fraction tion.3 There is a relative contraindication to the use of
of inspired oxygen (FiO2) should be augmented to NIV in patients with untreated pneumothoraces.8
goal saturation. Conversely, in hypercapnic patients,
IPAP should be increased while EPAP remains Complications
stable, in order to improve ventilation by increasing
Many of the complications caused by these forms of
tidal volume while compliance remains stable.
respiratory support are infrequent and are usually

minor. A retrospective study of 177 PICU patients on
Comparison of CPAP and BPAP
HFNC reported complications in 0.9 per 100 HFNC
Although CPAP and BPAP both provide positive
treatment days. The complications reported were
pressure ventilation, they differ slightly in the sup-
nasal irritation, epistaxis, pneumomediastinum, and
port they provide. While both provide a level of
pneumothorax. However, the role of HFNC in the
external PEEP, BPAP theoretically provides better
development of these pneumothoraces is uncertain,
support by delivering a higher inspiratory pressure,
and patients with pre-existing pneumothoraces who
thus providing better muscle unloading, alveolar
were treated with HFNC did not worsen.27
recruitment, oxygenation, and CO2 washout. For
The list of complications from CPAP and BPAP
this reason, BPAP is generally preferred over CPAP
use is more extensive. The majority of complications
for hypercapnic respiratory failure.23 Also, given
are minor and are related to skin and eye irritation,
its higher inspiratory pressures, BPAP also creates
but gastric insufflation, gastroesophageal reflux
higher mean airway pressures, and is therefore also
exacerbation, and subsequent aspiration pneumo-
effective for hypoxemic respiratory failure if CPAP
nia can also occur, especially in a patient with a full

August 2020 • www.ebmedicine.net 5 Copyright © 2020 EB Medicine. All rights reserved.

stomach or with the risk factors and relative contra- respiratory support in out-of-hospital care. Careful
indications noted previously. Airway pressure can selection of patients is critical to success and should
also lead to barotrauma in the form of upper airway be outlined in protocols.40 Extensive training of
bleeding, pneumomediastinum, or pneumotho- transport teams is required, and the teams should
rax.3,17,21,24 Several prospective or randomized trials be comprised of paramedics, experienced nurses,
reported minimal or no complications of CPAP or respiratory therapists, or physicians. Out-of-hospital
BPAP, with facial, nasal, and eye irritation being the providers must be able to provide advanced airway
most common.28-30 Interfaces that have direct contact techniques such as airway suctioning, bag-valve
cause more facial sores than those that do not.31,32 mask ventilation, and endotracheal intubation in
In several studies, the rate of complications ranged the event of a failure of HFNC and NIV. Finally, the
from 0% to 20.2%.33-35 A prospective observational ability to transport the necessary equipment is es-
study of 42 PICU patients with acute respiratory sential.41 In addition, protocols should be in place to
failure of varying etiologies treated with CPAP or evaluate ongoing quality assurance and adjust train-
BPAP reported a complication rate of 64%, which ing and protocols as needed.
was the highest noted among studies reviewed. The
high rate of complications was attributed to the se- Recommendations for Specific Conditions
verity of disease in their patient population, and the
authors noted that these complications were signifi- Bronchiolitis
cantly greater and more severe in patients who did Bronchiolitis is the leading cause of hospital admis-
not respond to CPAP or BPAP.36 sion for infants in the United States, with 15% to
The most common complications can be pre- 25% of these infants being admitted to the PICU.
vented by proper device selection and use. When a Respiratory failure secondary to bronchiolitis occurs
nasal cannula is used, humidification, heating, and frequently, and 25% to 40% of these infants required
suctioning can decrease dryness and congestion as intubation prior to management with other forms
well as prevent mucus obstruction. When applying of respiratory support.42 However, the use of HFNC
a facial mask, pressure damage can be averted by and NIV has impacted the management of infants
applying a hydrocolloid patch between the skin and with bronchiolitis. In a 2018 cross-sectional survey
the interface.8 of pediatric intensivists, HFNC and CPAP were
the preferred modes for managing bronchiolitis.43
Prehospital Use Recognition of the clinical benefits as well as signs of
failed therapy are integral to their use in the treat-
The use of HFNC and NIV in the management of ment of bronchiolitis.
respiratory distress by out-of-hospital providers is
increasing, in many instances replacing invasive High-Flow Nasal Cannula
ventilation as the primary method of support. In a Benefits of High-Flow Nasal Cannula for Bronchiolitis
retrospective study of HFNC use in interhospital HFNC has several physiologic effects that, in theory,
transport of 793 critically ill children, HFNC reduced would benefit infants with bronchiolitis who require
the rate of intubations during transport from 49% to respiratory support, and positive clinical results
33%. Additionally, starting patients on HFNC prior have been demonstrated as well. A retrospective
to transport significantly reduced invasive ventila- review of 298 patients aged < 24 months recorded a
tion initiated by the transport team en route. Three significant decrease in respiratory rate and heart rate
percent of patients required escalation to CPAP or within 90 minutes of infants receiving HFNC.44 A
BPAP.37 Another retrospective review of 31 pediatric prospective study of 25 ED patients showed im-
patients receiving CPAP or BPAP in interhospital provement in a score of respiratory distress when
ground transport demonstrated similar results. infants with bronchiolitis were treated with HFNC.10
Oxygen saturation improved or remained > 93% Another prospective study of 14 PICU patients
throughout all transports, and no complications— demonstrated a reduction in work of breathing by
including intubations, cardiopulmonary resuscita- measuring decreased esophageal pressures and dia-
tion, or aspiration pneumonia—occurred during phragmatic activity, even when respiratory distress
transport. However, 26% of patients did require was not present.45 However, the effect of HFNC on
advanced airway skills, namely airway suctioning or length of stay in the hospital and in the PICU have
brief bag-valve mask ventilation to preserve oxygen- varied among studies. A retrospective cohort study
ation in between mask adjustments and suctioning comparing a total of 115 patients before and after the
attempts.38 Overall, it appears that HFNC and NIV introduction of HFNC demonstrated a decrease in
can decrease the need for invasive intubation during PICU length of stay,46 whereas another cohort study
transport of pediatric patients.39 of 166 PICU patients demonstrated a significant
Despite these positive results, caution is recom- decrease in hospital length of stay without any dif-
mended when planning to implement these forms of ference in PICU length of stay.47

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 When compared with standard oxygen therapy, Indicators of Failure of High-Flow Nasal Cannula for
HFNC has demonstrated positive results in the treat- Bronchiolitis
ment of bronchiolitis. In 2 randomized controlled tri- Overall, HFNC has numerous benefits and clinical
als, the most consistently reported benefit of HFNC effects when used as respiratory support for infants
was a reduction in treatment failure, which was with bronchiolitis; however, knowledge of the clinical
defined by persistent abnormal vital signs, physician predictors for its failure are crucial to its implementa-
discretion, and the need to escalate care. Addition- tion. Vital sign monitoring is critical in the first hours
ally, 61% of patients in these studies initially on stan- of therapy, which, in many clinical settings, may
dard therapy were rescued by HFNC.48,49 HFNC also be in the ED rather than the PICU. The inability to
plays a role in decreasing respiratory rate and work reduce respiratory rate, to decrease FiO2 to < 50%, or
of breathing.50 When compared to oxygen delivery to normalize heart rate in the first 2 hours suggests
by head box or face mask, HFNC has also demon- failure of HFNC and the need to consider additional
strated greater median oxygen saturation in arterial measures.53,61 Initial patient characteristics may also
blood51 and comfort level among patients.52 Howev- help predict failure. In a retrospective cohort review,
er, results have been inconsistent regarding the role triage respiratory rate more than the ninetieth percen-
of HFNC in reducing total time of oxygen therapy, tile for age, an initial pCO2 > 50 mm Hg, or an initial
PICU admission rate, and length of stay.48-51,53 Only pH < 7.3 were found to be predictors of intubation.55
1 randomized controlled trial has compared HFNC Subsequent increase in pCO2 or decrease in pH after
to inhaled hypertonic saline solution with standard the initiation of HFNC may also indicate failure.61
oxygen; it found no significant differences in respira- Despite these data, assessment of failure or success
tory assessment change score, PICU admission, or of therapy should remain primarily a clinical as-
length of stay.54 sessment, and blood gas monitoring should not be
The most important potential benefit of HFNC routine in the majority of patients with bronchiolitis
for patients is the avoidance of intubation; however, who are receiving HFNC.
the effect of HFNC on intubation rates in infants Certain patient characteristics may also pre-
with bronchiolitis has been documented in only dispose them to failure on HFNC. Age < 6 months,
retrospective studies.44,47,55,56 In a retrospective respiratory syncytial virus-positive status, and
review of 298 PICU patients, the increase in the use lower weight have been associated with therapy
of HFNC therapy over 5 years corresponded to a failure.47,61 Given the retrospective nature of these
reduction in the rate of intubation from 37% to 7%.44 studies, none of these have been validated as defini-
Intubation rates also decreased in 2 retrospective tive signs of failure, but it is recommended to closely
studies that compared the management of bronchi- monitor vital signs, venous blood gas parameters (if
olitis before and after the introduction of HFNC, indicated), and younger patients with bronchiolitis
ranging from 21% to 22.2% before and decreasing to on HFNC. In addition, if the patient requires transfer
7.8% to 10% after.47,56 A retrospective cohort study from a general ED to a pediatric center, close con-
that evaluated 650 patients aged < 24 months before sideration of these risks of failure and response to
and after the introduction of HFNC did not demon- therapy should be given prior to transport.
strate a difference in intubation rates but did note a
decrease in the number of days of mechanical venti- Summary: High-Flow Nasal Cannula for Bronchiolitis
lation after the introduction of HFNC.57 Overall, the Although positive benefits have been demonstrated
majority of the available data supports a decrease in in these studies as discussed, the evidence is not
intubation rates through the use of HFNC in bron- sufficient to make high-level recommendations or
chiolitis. In addition, none of the previously men- guidelines for the role of HFNC in acute bronchiolitis.
tioned studies showed any harm associated with A Cochrane review has evaluated the role of HFNC
the use of HFNC. Moreover, several studies did not in infants with bronchiolitis. At 8 and 12 hours into
demonstrate complications when HFNC was used therapy, HFNC demonstrated higher median oxygen
for patients with bronchiolitis.44,53,58 saturation in infants with bronchiolitis. This review
Another benefit of the use of HFNC for bronchi- also concluded that HFNC is safe and feasible in
olitis management is earlier feedings and improved infants with bronchiolitis. However, there is insuffi-
nutrition. Patients who were allowed to feed ear- cient evidence to definitively determine the effective-
lier had a shorter PICU length of stay compared to ness of HFNC therapy, and it cannot be concluded
those who were started later.59 Additionally, when to be equivalent or superior to other forms of NIV.
compared to standard therapy, using HFNC low- Also, an effect on total oxygen therapy or length of
ered expected treatment costs for bronchiolitis in a stay has not been demonstrated. Further randomized
decision-tree analysis of prior retrospective studies.60 controlled trials may help to definitively determine
the role of HFNC in bronchiolitis.62 Nonetheless,
HFNC does not appear to cause harm to patients with
bronchiolitis, and it may provide a reasonable benefit.

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Therefore, the balance of the available data—with its hospital compared nasal CPAP to standard care and
limitations—suggests that it is reasonable to consider demonstrated a positive effect on heart rate and
the use of HFNC in infants with bronchiolitis who do respiratory rate with CPAP.71 A retrospective cohort
not require immediate intubation, although its impact review of 135 PICU patients with severe bronchiolitis
on intubation rates and PICU length of stay is limited compared the management of bronchiolitis by nasal
to retrospective, observational studies. CPAP with invasive ventilation and showed that
the use of CPAP was independently associated with
Noninvasive Ventilation shorter duration of ventilation, shorter PICU length
Benefits of Noninvasive Ventilation for Bronchiolitis of stay, and reduced secondary pneumonia, even after
NIV, most commonly CPAP, has been shown to have adjusting for disease severity and comorbidities.72
clinical benefits in the management of bronchiolitis.
Retrospective and prospective studies evaluating Indicators of Failure of Noninvasive Ventilation for
the clinical impact of NIV demonstrate an overall Bronchiolitis
improvement in clinical parameters and a reduction The use of NIV in bronchiolitis requires recognition
in intubation rates. Improvements in vital signs, of when it is failing to improve the patient. The most
specifically respiratory rate and heart rate, have been commonly reported predictors of failure of NIV in
demonstrated in most studies, mainly seen early in infants with bronchiolitis are higher illness sever-
the course of treatment.63,64 A prospective observa- ity scores (eg, Pediatric Logistic Organ Dysfunction
tional study of 12 PICU patients aged < 3 months scores and Pediatric Risk of Mortality scores), which
also indicated improvement in respiratory distress are clinical scores used to predict mortality.28 These
score, blood pressure, and work of breathing as scores are typically used in the PICU setting, and
measured by esophageal pressures.63 Results on the variables include heart rate, temperature, blood pres-
effect on FiO2 have been mixed.63,64 When evaluat- sure, neurologic status, complete blood count, renal
ing the effects of NIV on blood gas parameters, it and hepatic function, and coagulation studies. Signs
positively improves hypercapnia in patients with that have been noted to be associated with unsuc-
bronchiolitis, with many studies also demonstrating cessful therapy are the clinical presence of apnea and
an improvement in pH.28,63-65 In several studies of an elevated PaCO2 at PICU admission time.65 Infants
infants with bronchiolitis, NIV has also decreased with certain comorbidities, such as prematurity,
rates of endotracheal intubation and its subsequent uncorrected congenital heart disease, and neuromus-
complications. In these studies, after the introduc- cular disease should be monitored closely for failure
tion of NIV therapy, intubation was avoided in 67% of NIV, as they seem to be at higher risk.68 Beyond
to 100% of patients with bronchiolitis.63-67 A retro- these clinical signs, interface adjustment and possible
spective review of 399 PICU patients demonstrated sedation in infants demonstrating intolerance can
a decrease in intubations by 1.4% each year since the help improve the likelihood of success of NIV.
introduction of NIV.68 Subsequently, many studies
have also demonstrated a decrease in bacterial infec- Heliox During Noninvasive Ventilation for Bronchiolitis
tions with the use of NIV, likely attributable to the The addition of helium-oxygen (heliox) to NIV in
avoidance of endotracheal intubation.64,66,67,69 There patients with bronchiolitis has demonstrated posi-
are mixed results regarding the effect of NIV on the tive results. Heliox is about 3 times less dense than
overall hospital length of stay in infants with bron- normal air and, as a result, is a method of reduc-
chiolitis.28,64,66-68 In a retrospective cohort review of ing airway resistance to gas flow. When added to
525 PICU patients before and after CPAP introduc- CPAP, heliox has been shown to reduce dyspnea and
tion, lower costs of care were demonstrated after improve the elimination of CO2. Additionally, it may
CPAP introduction,67 but no difference in mortality decrease the work of respiratory muscles, prevent
was demonstrated in patients with bronchiolitis airway collapse, and delay intubation.73 When com-
treated with NIV.69 The most common complication pared to oxygen alone in CPAP, patients treated with
reported was intolerance of the interface.28,63,64 heliox had improved clinical scores, oxygen satura-
When compared to standard care or conventional tions, pCO2, and respiratory rates.74 A Cochrane
oxygen therapy, NIV with CPAP appears to be ben- review evaluating the role of heliox in the manage-
eficial for patients with bronchiolitis. A randomized ment of bronchiolitis concluded that in the subgroup
controlled trial comparing nasal CPAP with standard of 21 infants placed on nasal CPAP, the length of
oxygen therapy in 19 PICU patients aged < 6 months treatment decreased significantly. No definitive con-
with bronchiolitis demonstrated a significant de- clusions could be made regarding intubation rates or
crease in respiratory severity scores, pCO2, FiO2, and treatment failure in this subgroup.75 The main side
inspiratory muscle work measured by esophageal effects noted with this therapy were hypoxemia and
pressures, without demonstrating a significant effect hypothermia. Heliox should be avoided in severely
on heart rate or respiratory rate.70 However, another hypoxemic patients, because increasing FiO2 will al-
randomized controlled trial of 72 infants aged < 1 ter the helium to oxygen ratio and may eliminate the
year with bronchiolitis who were admitted to the positive effects of helium. The risk of hypothermia is

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theoretical and can be managed with proper warm- ratory support over another in the management of
ing and humidification of the heliox.73 Although infants with bronchiolitis, and either HFNC or NIV
studies are limited, the addition of heliox to NIV may can be trialed as an initial management strategy in a
have beneficial effects in the management of infants patient with impending respiratory failure requiring
with bronchiolitis and should be considered as an therapy beyond simple oxygen. Management should
adjunct to NIV therapy prior to intubation. be individualized toward patient characteristics and
interface tolerance, with careful attention to patients
Mask Styles who are at risk for deterioration. Clinicians must
In studies of infants with bronchiolitis, the vari- be prepared to move to invasive strategies, such as
ous mask styles of NIV have been compared, with endotracheal intubation, when required.
some advantages to particular types noted. In a For more information on the management of
comparison of helmet versus nasal-prong CPAP bronchiolitis in the ED, see the October 2019 issue
used in 16 PICU patients with bronchiolitis who of Pediatric Emergency Medicine Practice, “Acute
were aged < 3 months, there were no differences in Bronchiolitis: Assessment and Management in
the outcomes, and both demonstrated significant the Emergency Department,” available at:
reduction in respiratory distress.76 When the helmet www.ebmedicine.net/bronchiolitis
interface was compared with facial mask, however,
CPAP by helmet had significantly reduced failure Asthma
rates and required less sedation, mainly as a result NIV can be used in patients with asthma to prevent
of facial mask tolerance. When these interfaces were respiratory failure. Management of patients with
tolerated by patients, both demonstrated improved acute asthma exacerbations includes therapies and
gas exchange and work of breathing.32 The limited medications directed at improving respiratory status
available evidence suggests that, when the device is and preventing intubation in severe cases. Given the
tolerated by the patient, efficacy is similar. role of HFNC and NIV in preventing invasive venti-
lation in other conditions, interest in their use as re-
Summary: Noninvasive Ventilation for Bronchiolitis spiratory support in patients with status asthmaticus
Despite some benefits demonstrated in the available has increased.81 BPAP has been evaluated most often
literature, the overall grade of evidence and qual- in this patient population, likely due to its success in
ity of studies remains low when evaluating the role adults with asthma and chronic obstructive pulmo-
of CPAP in management of acute bronchiolitis. A nary disease. The research in the pediatric popula-
Cochrane review77 and a systematic review78 both tion is more limited, but provides evidence for some
agreed that CPAP alone has a role in decreasing clinical benefits as well as guidance for its use in
respiratory rate. The systematic review also reported managing respiratory failure secondary to asthma.
that CPAP alone and CPAP with heliox reduced
pCO2 and clinical asthma scores in infants with Interfaces and Aerosol Delivery
bronchiolitis.78 Still, there is a need for higher quality Evaluation of the ability of the various interfaces to
evidence in this area. deliver aerosols has demonstrated positive results
overall. HFNC and its delivery of albuterol has been
Comparing HFNC and NIV for Treatment of evaluated in pediatric patients in a basic science
Bronchiolitis study in which albuterol was collected on an inspira-
Comparison of the clinical outcomes of infants with tory filter of an in vitro model and quantified with
bronchiolitis treated with HFNC versus NIV dem- ultraviolet spectrometry. The cannula size and flow
onstrated mixed results. A Cochrane review of a rate were evaluated for their effect on the quantity
study of 19 infants with bronchiolitis did not dem- of albuterol delivered. In infants and children, the
onstrate HFNC to be equivalent or superior to NIV, inspired dose increases significantly with increasing
and individual studies confirm a mixture of results cannula size but decreases significantly as the flow is
in low-quality studies.62 A retrospective cohort increased. Therefore, when increasing the flow rate,
study of HFNC and CPAP in the management of be cognizant that less medication may be delivered
34 infants with acute bronchiolitis concluded that to the distal airways.82 These parameters are im-
there was no difference in the length of stay, ventila- portant to keep in mind when considering HFNC
tion parameters, or vital sign changes between the therapy in asthma patients. In laboratory studies, it
modalities.79 Other retrospective studies have noted has been shown that NIV can improve bronchodila-
mixed results, with one showing less mortality and tor delivery to the lower airways.83-85
intubation with HFNC, while another showed CPAP
to be superior in decreasing vital sign parameters
and respiratory distress.42,80 In assessing the balance
of the available data, there are no definitive studies
demonstrating the superiority of one form of respi-

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 Clinical Pathway for the Use of HFNC and NIV in the Management
of Acute Respiratory Failure in Pediatric Patients

Patient presents with signs and symptoms

of acute respiratory failure

Does the patient require immediate intubation? YES

NO
Initiate invasive ventilation

Does the patient have absolute

YES
contraindications to HFNC or NIV?

NO

Obtain full set of vital signs, consider IV access

Etiology of respiratory failure

Acute respiratory
Acute bronchiolitis Asthma exacerbation Pneumonia, acute chest syndrome
distress syndrome

Hypoxemic Hypercapnic Mild Moderate/severe Mild

HFNC (Class II) CPAP (Class II)
Initial: 1 L/kg/min Initial: 3 cm H2O
Max: 2 L/kg/min Max: 10 cm H2O
Titrate FiO2 Titrate FiO2 CPAP BPAP (Class II) BPAP (Class III) BPAP (Class III)
Initiate
and flow to and PEEP to (Indeterminate) Initial (IPAP/ Initial (IPAP/ Initial (IPAP/
invasive
maintain O2 maintain O2 Initial: 3 cm H2O EPAP): 6/3 cm EPAP): 6/3 cm EPAP): 6/3 cm
ventilation
> 92% > 92% Max: 10 cm H2O H2O H2O H2O
Titrate FiO2 Max (IPAP/ Max (IPAP/ Max (IPAP/
and PEEP to EPAP): 25/10 EPAP): 25/10 EPAP): 25/10
maintain O2 cm H2O cm H2O cm H2O
> 92% Titrate FiO2 Titrate FiO2 Titrate FiO2
and PEEP to and PEEP to and PEEP to
maintain O2 maintain O2 maintain O2
• Monitor vital signs, patient tolerance, > 92%
> 92% > 92%
and mental status every 30 minutes Titrate IPAP
Titrate IPAP Titrate IPAP
• Consider adjunctive therapies while
while while
maintaining maintaining maintaining
EPAP to EPAP to EPAP to
improve improve improve
ventilation ventilation ventilation
Improvement Failure

Continue HFNC, NIV Initiate invasive

with close monitoring ventilation

Abbreviations: BPAP, bilevel positive airway pres­sure; CPAP, constant positive airway pressure; EPAP, expiratory positive airway pressure; FiO2, fraction
of inspired oxygen; HFNC, high-flow nasal cannula; IPAP, inspira­tory positive airway pressure; IV, intravenous; NIV, noninvasive ventilation; PEEP,
positive end-expiratory pressure.
For Class of Evidence definitions, see page 11.

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Evidence of Outcomes of High-Flow Nasal Cannula reducing the alveolar pressure required to initiate a
for Asthma breath. Overall, this improves ventilation-perfusion
The use of HFNC in the management of acute respi- mismatch in asthma patients.90,91 Hesitation by clini-
ratory failure in pediatric asthma is limited in the cians to use BPAP for asthma is driven by the belief
available literature. When evaluated retrospectively that it will worsen auto-PEEP, but in fact, it helps to
in 73 children with status asthmaticus, pH improved relieve it by the previously described mechanisms.
significantly in the first 2 hours of HFNC use. An BPAP alone directly bronchodilates and decreases
improvement in heart rate, respiratory rate, and hyperresponsiveness.8 By opening up the airways,
pCO2 was also demonstrated; 2.6% of patients failed patients expend less effort to stent open alveoli. EPAP
HFNC therapy and were switched to NIV, without assists in this as well.92 Optimal settings for BPAP in
any intubations.86 When compared to standard oxy- asthma are a higher IPAP, a lower EPAP, and a longer
gen therapy, significantly more patients treated with inspiratory:expiratory ratio.81 Several studies have
HFNC had a decrease of > 2 in their asthma pulmo- shown that these physiologic effects of BPAP on asth-
nary score (score range 0-9, determined by respirato- matic lungs have translated to clinical effects.
ry rate, wheezing, and accessory muscle use). How-
ever, no significant differences were demonstrated Benefits of Noninvasive Ventilation for Asthma
in disposition, length of stay, or need for additional The greatest benefits of NIV in the management of
therapies.87 Overall, its use appears to be safe.24 asthma include improvement in gas exchange, cor-
HFNC was less efficacious when compared with rection of vital signs, and a reduction in intubation
NIV in patients with severe asthma exacerbations. rates. BPAP appears to improve ventilation, as dem-
In a retrospective cohort study of 42 patients com- onstrated by improvements in PaCO2 and pH.93 NIV
paring these modalities, 40% of patients on HFNC has also decreased intubation rates in children with
required escalation to BPAP, whereas 0% of those on status asthmaticus. When NIV is used in patients
BPAP required intubation, including those initially with status asthmaticus, rates of mechanical ventila-
started on HFNC. Patients who failed HFNC thera- tion ranged from 0% to 27%.3,81,94-97 When added
py had a significantly longer length of stay as well as to standard care for asthma, NIV improves respira-
duration of respiratory support. Predictors of failure tory rate, heart rate, FiO2 requirements, and clinical
included persistently elevated heart rate and respi- asthma scores.81,93-98 A physiologic study of 18 pa-
ratory rate.88 As a result of these limited studies, tients with status asthmaticus refractory to standard
HFNC appears to be safe and to have some clinical treatment also demonstrated increased tidal volume,
benefit, but its use as primary respiratory support in inspiratory time (the time over which tidal volume
severe asthma exacerbations cannot be recommend- is delivered), and thoracoabdominal synchrony
ed, based on the currently available evidence. measured by plethysmography.99 Additionally,
BPAP may help asthma patients sleep more comfort-
Noninvasive Ventilation for Asthma ably and be more active when awake.98 Studies of
There is a role for NIV in moderate to severe pediatric the effectiveness of NIV on hospital admissions and
asthma to prevent intubation. BPAP is estimated to be length of stay have had mixed results.19,81,98
used in 3% to 5% of children critically ill with asthma,
and its use may be increasing overall.89 During an Complications of Noninvasive Ventilation for Asthma
acute asthma exacerbation, closure of the small air- The frequency of complications from NIV use in pa-
ways leads to an increase in positive pressure at end tients with asthma is low overall, but they do occur.
expiration. BPAP functions by reducing distal airway Most studies that have employed BPAP in the man-
hyperinflation, reducing airflow limitation, and agement of status asthmaticus did not result in any

Class of Evidence Definitions

Each action in the clinical pathways section of Pediatric Emergency Medicine Practice receives a score based on the following definitions.
Class I Class II Class III Indeterminate
• Always acceptable, safe • Safe, acceptable • May be acceptable • Continuing area of research
• Definitely useful • Probably useful • Possibly useful • No recommendations until further
• Proven in both efficacy and effectiveness • Considered optional or alternative treat- research
Level of Evidence: ments
Level of Evidence: • Generally higher levels of evidence Level of Evidence:
• One or more large prospective studies • Nonrandomized or retrospective studies: Level of Evidence: • Evidence not available
are present (with rare exceptions) historic, cohort, or case control studies • Generally lower or intermediate levels of • Higher studies in progress
• High-quality meta-analyses • Less robust randomized controlled trials evidence • Results inconsistent, contradictory
• Study results consistently positive and • Results consistently positive • Case series, animal studies, • Results not compelling
compelling consensus panels
• Occasionally positive results

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright © 2020 EB Medicine. www.ebmedicine.net. No part of this publication may be reproduced in any format without written consent of EB Medicine.

August 2020 • www.ebmedicine.net 11 Copyright © 2020 EB Medicine. All rights reserved.

critical complications.81,95,96 As in the management monia have reduced lung compliance, as bacteria,
of other conditions, intolerance of the interface is the leukocytes, and debris obstruct the smaller airways,
most common complication of NIV therapy. Asyn- leading to air trapping and ventilation-perfusion
chrony and subsequent respiratory failure can occur mismatch. HFNC and NIV have been evaluated
in asthma patients with severe cough, for example.98 as possible sources of respiratory support in adult
The more severe complications of NIV are the result patients with pneumonia, but the literature in the
of barotrauma and include pneumothorax, pneumo- pediatric population remains more limited.
mediastinum, and subcutaneous emphysema.24 In a
retrospective review of 45 children with asthma ex- High-Flow Nasal Cannula for Pneumonia
acerbations, occurrence of barotrauma did not differ HFNC has been used in the treatment of a variety of
significantly between patients who received invasive disease processes, but no studies have directly evalu-
ventilation compared to those who received NIV.100 ated its role in pneumonia. A retrospective cohort
review of 650 patients analyzed before and after the
Predictors of Failure of Noninvasive Ventilation for introduction of HFNC noted that physicians tend
Asthma to use HFNC less often in pneumonia compared to
No direct studies on predictors of failure of NIV in bronchiolitis.57 Additionally, in a retrospective cohort
asthma have been conducted, but certain clinical review of 498 patients aged < 2 years, pediatric pa-
parameters have been identified that require esca- tients with pneumonia who were treated with HFNC
lation of care. As in other conditions, intolerance were more likely to be intubated when compared
of the interface can be predictive of failure; see the to their counterparts with bronchiolitis or asthma.55
“Sedation” section on page 14 for more information In a randomized controlled trial of children aged <
on management with sedation medications. In a ret- 5 years with pneumonia, patients were randomized
rospective chart review of 83 pediatric patients with to receive low-flow nasal cannula, HFNC, or bubble
asthma that was refractory to standard treatment CPAP. When compared to low-flow nasal cannula,
and who were then placed on NIV, this intolerance patients treated with HFNC demonstrated signifi-
was usually noted early in its initiation; this was cantly fewer failure rates and lower rates of mortal-
particularly true in the younger patient population.95 ity.102 HFNC can be a helpful tool in the support of
An increase in FiO2 requirement and an increasing respiratory disease, but it cannot be recommended
pCO2 have been seen in asthma patients requiring definitively at this time as a reliable source of support
intubation, despite the use of BPAP.94 Nonetheless, for patients with pneumonia, especially for patients
these signs and symptoms have not been validated with moderate or severe disease.
as predictors of failure in sufficient studies.
Noninvasive Ventilation for Pneumonia
Summary: Noninvasive Ventilation in Asthma NIV has been shown to benefit patients with pneu-
NIV appears to have a key contemporary clinical monia by improving vital signs and preventing
role in the management of pediatric patients with intubation, but research in this field remains limited
status asthmaticus, but its overall benefit is unclear. as well. When compared to low-flow nasal can-
A Cochrane review that included 2 randomized nula, bubble CPAP has significantly fewer treatment
controlled trials evaluated the role of noninvasive failures and lower rates of death in the management
positive pressure ventilation in acute asthma and of children with pneumonia and hypoxemia. When
found few high-quality studies comparing BPAP to bubble CPAP is used, it assists in stenting airways
standard care. The asthma symptom score decreased open and improving gas exchange, especially in
significantly when BPAP was used; however, the infants with low compliance in their lungs. In a ran-
authors were unable to confirm or reject benefit, domized controlled trial, mortality rates were similar
based on the small sample sizes.101 Future random- between bubble CPAP and HFNC.102
ized controlled trials could provide more evidence of A retrospective chart review of 28 PICU patients
the benefits of NIV in the management of pediatric with acute hypoxemic respiratory failure evaluated
asthmatic patients. That being said, given the overall BPAP for management of pneumonia. The study
safety and potential efficacy, the best currently demonstrated improved respiratory rate, PaCO2,
available data and clinical experience suggest that PaO2, A-a gradient, pH, and PaO2/FiO2 at 1 hour.103
NIV should be considered in pediatric patients with NIV has also demonstrated an 85% to 100% success
status asthmaticus who are judged to be at risk for rate in preventing intubation.30,103-105 A retrospective
requiring intubation. review evaluated the use of BPAP by facial mask in
45 patients with pneumonia and ARDS. When NIV
Pneumonia was implemented as respiratory support for pediat-
Pneumonia is another cause of respiratory failure ric patients with pneumonia, the following param-
in pediatric patients that can lead to PICU admis- eters were predictive of failure: patient age < 6 years,
sion and potential intubation. Children with pneu- FiO2 > 60%, and pCO2 > 55 mm Hg.106

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Acute Respiratory Distress Syndrome inflammation and decreased oxygen saturation
Pediatric ARDS is the physiologic process in which lead to further red blood cell sickling, exacerbating
diffuse alveolar damage and inflammation stem hypoxemia and vaso-occlusion. BPAP by facial or
from damage to capillary endothelia and subsequent nasal mask has been the only form of NIV evaluated
increased permeability. Shunt physiology develops in studies of acute chest syndrome. In a retrospec-
with resultant hypoxemia. Premature airway col- tive chart review of 9 patients, patients treated with
lapse leads to hypoventilation and air trapping. This BPAP demonstrated improved respiratory rate,
process is worsened further by the lower compliance heart rate, PaO2, and FiO2 requirement; 44% of these
of the chest wall in pediatric patients. Theoretically, patients avoided admission to the PICU after initial
positive airway pressure should support alveolar admission to the wards.114 Other studies involving a
recruitment and provide PEEP. However, evidence- total of 14 patients with acute chest syndrome dem-
based support for the use of noninvasive positive onstrated avoidance of intubation in 80% to 100%
pressure ventilation in ARDS—especially moderate of patients when BPAP by nasal or facial mask was
to severe ARDS—is minimal. used.104,105 Again, data are limited, but clinical ex-
A summary of the proceedings of the Pediatric perience suggests a trial of NIV may be reasonable,
Acute Lung Injury Consensus Conference Group with close monitoring for clinical improvement and
noted a “weak” recommendation for the early use of the need for more invasive modalities in the event of
noninvasive positive pressure ventilation in patients deterioration or lack of improvement.
with mild ARDS but strongly recommended against
its use in patients with severe ARDS.107,108 Success Immunodeficiency
rates for NIV in ARDS have been reported to range Immunocompromised patients are high-risk patients
from 0% to 40%.30,104,109 Even when other disease in the setting of pulmonary disease and respiratory
processes are present, patients who meet ARDS distress, and the decision to intubate these patients
criteria are more likely to require intubation.110 There must take into consideration the potentially severe
is a weak recommendation for its use in immuno- infectious complications of mechanical ventilation.
compromised children, for whom the benefits of Therefore, NIV has been used as a means of respira-
NIV may outweigh the risks and complications of tory support to prevent iatrogenic complications
endotracheal intubation.111 When immunocompro- in this patient population. BPAP has demonstrated
mised patients responded to NIV, they demonstrated improved respiratory rate, PaCO2, and PaO2 after the
a lower mortality rate and a shorter PICU length of first few hours of initiation.104,111 When patients im-
stay.112 BPAP provides a higher level of support and prove clinically with BPAP, they have a significantly
is recommended as a first-line modality. A well- lower mortality rate and PICU length of stay.112
fitting facial or oronasal mask with humidified air Success rates in preventing intubation are variable
should be used.107 in studies, ranging from 54% to 92%.104,111,112,115
Close monitoring of ARDS patients receiving NIV appears to be tolerated better by patients with
NIV is required, due to the high failure rate. Sev- pneumonia compared to those with ARDS;2 as
eral factors have been noted in patients who fail to mentioned previously, patients with ARDS do worse
respond to CPAP or BPAP therapy; these are similar with NIV compared to those with other respira-
to other disease processes. In a prospective observa- tory conditions.104,111,112,115 In a retrospective cohort
tional study of 390 patients with acute respiratory study of 239 patients, immunocompromised patients
failure managed with NIV, severe hypoxemia or a on BPAP had a significantly lower mortality rate,
decreasing PaO2/FiO2 ratio were shown to be pre- a higher PICU survival rate, and a higher 30-day
dictive of failure.113 An increasing FiO2 requirement, survival rate when compared with patients treated
specifically > 60%, and an elevated PaCO2 level, es- with invasive ventilation; however, the more severe
pecially > 55 mm Hg, also portend deterioration.106 clinical status requiring intubation was a confound-
Increasing respiratory rate and an altered level of ing factor in this evaluation.115
consciousness are preceding signs of failure of NIV. Certain patient characteristics (derived by mul-
Experience with HFNC in patients with ARDS tivariate analysis of those patients requiring intuba-
is not well evaluated in the pediatric population and tion) predicted failure for immunocompromised
is not equivalent to CPAP or BPAP therapy. Despite patients. These risk factors included solid tumors,
its value in numerous other respiratory disease cardiovascular dysfunction, and elevated therapeu-
processes, HFNC cannot be recommended for use in tic intervention scoring system scores.115 Therefore,
patients with ARDS.107 BPAP can be recommended as an initial means of
respiratory support for immunocompromised pa-
Other Respiratory Conditions tients with respiratory failure but must be monitored
Acute Chest Syndrome closely for early signs of failure. Even if the rates of
Acute chest syndrome occurs in patients with sickle failure are as high as noted, the potential to avoid
cell disease with a new infiltrate on imaging. The invasive ventilation and its complications in these

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 Risk Management Pitfalls for High-Flow Nasal Cannula
and Noninvasive Ventilation in Pediatric Patients
1. “The patient was not improving on BPAP. I 6. “I titrated the flow of HFNC to 30 L/min on my
wanted to avoid endotracheal intubation and its 10-kg patient and monitored for improvement.”
associated complications, so I continued man- While titrating respiratory support to the patient’s
agement with BPAP.” needs, it is important to notice when switching ther-
Since its introduction in pediatric emergency apies may be necessary. Most studies have demon-
care, NIV has helped avoid intubation in several strated the greatest benefit of HFNC to be between
patient populations. Despite this, ignoring the 1.5 and 2 L/kg/min. Particularly when titration is
signs that indicate when escalation of therapy is occurring rapidly, the patient needs to be reassessed
necessary can be fatal. When a patient’s respira- for complications or escalation of therapy.
tory rate is worsening, the PaCO2 is climbing, or
intolerance of the interface is preventing adequate 7. “I didn’t want to use BPAP in my patient with
ventilation, it may be necessary to perform endo- asthma, because I was afraid it would cause a
tracheal intubation. pneumothorax.”
While pneumothoraces are possible complications
2. “The infant with bronchiolitis appeared to be of NIV, they are uncommon in the present stud-
stable after 15 minutes of HFNC, so I switched ies28-30 and should not prevent its use, especially
vital signs checks to every 6 hours.” when the patient requires respiratory support
Close monitoring in the first few hours after initia- and intubation may alter physiologic respiratory
tion of HFNC or NIV is critical. Monitoring the dynamics. Medical management should be maxi-
patient’s respiratory rate, heart rate, and work of mized, but use of BPAP has shown improved gas
breathing is integral to recognizing when therapy exchange and clinical scores.
is failing.
8. “I didn’t think medications could be delivered
3. “The patient had bronchiolitis and increased through NIV interfaces.”
work of breathing. I placed him on HFNC at Physiological studies have evaluated deposition
4 L/min and admitted him to the floor.” of albuterol when using CPAP or BPAP and have
Monitoring the patient closely, especially in the demonstrated good results. Similarly, using heliox
first few hours, is important. Monitoring in the as additive therapy to HFNC or CPAP has been
ED for improvement or worsening status prior to beneficial in patients with bronchiolitis.
early disposition is recommended.
9. “My trauma patient with a Glasgow Coma Scale
4. “This patient did not tolerate any respiratory score of 6 and several pulmonary contusions
support near her nose, so I decided she needed needed respiratory support. I initiated CPAP
to be intubated.” since his oxygen saturation was 100%.”
There are several interfaces that can be used for Alteration in mental status (eg, a low Glasgow
NIV. Full-face masks and helmets may distrib- Coma Scale score) when the patient is not protect-
ute the pressure over a broader surface and may ing his airway requires intubation. This is a con-
not be as irritating to the patient. Additionally, traindication for NIV. Other contraindications to
introducing distracting techniques or providing its use include severe craniofacial abnormalities,
sedation with dexmedetomidine may be helpful. severe ARDS, untreated pneumothorax, or severe
hemodynamic instability.
5. “The patient was still breathing fast after 5 min-
utes of BPAP therapy, so I decided it was time to 10. “My patient appeared calm, but she kept trying
intubate him.” to lift up the orofacial mask from her nose.”
Troubleshooting for reasons for deterioration after Complications secondary to the equipment used
placement of NIV should be systematic. Evalua- should be anticipated, and early resolution may
tion of the mask and how well it fits is important. help improve the success of NIV. Skin and eye
Observe the patient for asynchrony with the irritation are some of the most common complica-
machine and the possible etiologies. Examine tions, and choosing an appropriate mask as well as
the patient for complications secondary to initia- evaluating the skin often are important. Other com-
tion. Finally, evaluate the equipment for possible plications to monitor include gastric insufflation
failure. After troubleshooting and evaluating for and irritation, nasal dryness or epistaxis, aspira-
complications, if NIV still appears to be failing, tion, and pneumothorax. Sedation may be needed
then intubation may be necessary. to increase compliance in pediatric patients.

Copyright © 2020 EB Medicine. All rights reserved. 14 Reprints: www.ebmedicine.net/pempissues

patients makes it a promising option to consider, is initiated prior to apneic oxygenation and starts
although data do suggest caution with use. There are the process of nitrogen washout. Other goals dur-
limited data and clinical experience regarding the ing this period are to maintain the patient’s oxygen
use of HFNC in this population. saturation as close as possible to 100% while maxi-
mally oxygenating the bloodstream.120 HFNC can
Controversies and Cutting Edge play an important role prior to intubation and can
assist with alveolar recruitment,121 but studies in the
Sedation pediatric population are limited.
A common reason for failure of NIV is intolerance A randomized controlled trial of 48 healthy
of the patient to the mask or nasal prongs. This can children in the operating room with normal airways
lead to air leaks and asynchrony between the patient and cardiorespiratory function compared transnasal
and the ventilator. Some studies have implemented humidified rapid-insufflation ventilatory exchange
protocols to prevent failure by using medications (a form of HFNC) to standard therapy. When com-
for minimal sedation, including midazolam, ket- pared in 4 different groups with various age ranges,
amine, and even chloral hydrate (in older studies). A safe apnea time was significantly longer in groups
retrospective study of the use of CPAP or BPAP in 22 receiving HFNC. However, no difference was noted
infants with acute respiratory failure identified need in the transcutaneous CO2 measurements.122 Reluc-
for sedation as a predictor of failure; it is not clear tance to implement HFNC into standard practice
to what extent this can be ameliorated through the may be due to the required setup involved, especial-
use of appropriate medications.116 However, caution ly during emergent intubations.120 Further studies
should be exercised when respiratory depressants into the use of HFNC in preoxygenation and apneic
are used, as hypoventilation can also lead to wors- oxygenation are required in the pediatric population
ening of respiratory failure. For this reason, dexme- before definitive recommendations can be made.
detomidine has been gaining popularity for use in
patients using NIV who require sedation. Dexme- Considerations for Noninvasive Ventilation
detomidine is an alpha-2 agonist that provides seda- With Aerosolizing Diseases
tion and anxiolysis to attenuate the stress response Given the current coronavirus disease (COVID-19)
without the side effect of respiratory depression, pandemic, a brief commentary on the use of HFNC
and it has a lower risk for delirium or neurotoxicity. and NIV in patients with COVID-19 and other simi-
Important side effects of dexmedetomidine include lar aerosolizing diseases is warranted. Of note, there
hypotension, bradycardia, oversedation, and with- are limited data and evidence available, and most of
drawal. Dexmedetomidine has been trialed with all this discussion is based on expert opinions, open-
forms of noninvasive support (HFNC, CPAP, and forum discussions, and hypotheses based on current
BPAP), with varying interfaces, and for a variety of knowledge. Both HFNC and NIV are considered
disease processes causing acute respiratory failure. aerosol-generating procedures, and thus, airborne
Overall, retrospective studies show promise for its precautions should be used if concern for an aerosol-
use. In an observational study of 202 PICU patients, izing disease exists. Airborne precautions consist
targeted sedation level was reached in 83% of pa- of standard precautions, which include use of hand
tients.117 When given with positive pressure ventila- hygiene, gloves, gowns, caps, and eye protection,
tion in a cohort study of 40 patients, those receiving and an N95 respirator or a powered air-purifying
dexmedetomidine demonstrated lower Richmond respirator (PAPR). Additionally, the patient should be
Agitation-Sedation Scale scores and a significant placed in an airborne isolation room, which provides
increase in PaO2/FiO2, without noted side effects.118 negative pressure and has direct exhaust of air to the
In a retrospective chart review of 382 children with outside or through a high-efficiency particulate air
bronchiolitis or asthma treated with BPAP, when (HEPA) filter. Transport of these patients should be
side effects of dexmedetomidine occurred, they were limited to medically necessary purposes. If a pa-
managed with fluid boluses, a decrease in dose, tient must be transported, the patient should wear a
or titration of NIV.119 Further prospective trials are surgical mask over the involved interface, if possible.
needed to support the use of dexmedetomidine as a Interactions with immunocompromised healthcare
sedating medication to improve the success of NIV personnel should be avoided when possible. These
as well as HFNC, but early studies demonstrate precautions should be instituted until further re-
safety and efficacy. search defines the risk of aerosolization inherent to
HFNC and NIV. That being said, different countries
High-Flow Nasal Cannula in Apneic and institutions take different approaches regarding
Oxygenation the risk of HFNC and NIV, and local protocols and
Apneic oxygenation is the passive flow of oxygen guidelines should be consulted to minimize risk to
into the alveoli while the patient is not spontane- the medical team and other patients.
ously breathing prior to intubation. Preoxygenation

August 2020 • www.ebmedicine.net 15 Copyright © 2020 EB Medicine. All rights reserved.

 Although no studies exist that define the exact discharged on hospital day 3 without respiratory support.
risk of dissemination of particles from pediatric The decision was made to continue adjunctive
patients, general management precautions should therapies and withhold NIV for the 5-year-old boy with
be employed with HFNC and NIV when used in asthma. The patient was given a normal saline bolus and
patients with aerosolizing diseases. HFNC should be 1 g of magnesium sulfate over 30 minutes. His pediatric
instituted at the lowest effective flow rate required asthma score was unchanged, and another hour-long alb-
to provide support to the patient, with the inten- uterol treatment was given. Frequent evaluations showed
tion of decreasing dissemination of particles. When his clinical status continuing to worsen. Terbutaline
available, an interface such as a full-face mask or therapy was initiated, and BPAP therapy was initiated by
helmet should be used to help decrease the risk of orofacial mask, with continuous albuterol. The boy was
aerosolization when using NIV. If these interfaces admitted to the PICU, but after 2 hours of therapy, his
are unavailable, the most appropriate mask is one clinical asthma score remained unchanged. His IPAP was
that creates a good seal. increased, and a low-dose epinephrine drip was started for
There is currently limited experience with using hypotension. He remained mentally alert, and in an effort
HFNC and NIV as respiratory support in the pediat- to avoid intubation, he was monitored on BPAP through
ric population with respiratory distress secondary to the night. A central line was placed on hospital day 3,
COVID-19. When the decision to use these modali- and total parenteral nutrition was initiated. His epineph-
ties is made, these patients should be monitored rine drip was weaned, and by hospital day 4, his BPAP
carefully for deterioration. Early intubation should settings were weaned. NIV was stopped on hospital day
be employed if patients are deteriorating rapidly on 6, and the patient was started on a regular diet. He was
either of these modalities. discharged on hospital day 9 with a corticosteroid taper
and pulmonology follow-up the next day.
Summary
Time- and Cost-Effective Strategies
Respiratory failure is a leading diagnosis in PICU
admissions, and management of these patients with • Always consider HFNC and NIV as possible op-
endotracheal intubation and mechanical ventilation tions for respiratory support prior to intubation.
may lead to further complications. HFNC, CPAP, • Minor complications after initiation of NIV oc-
and BPAP are emerging as important modalities cur frequently. Implementation of preventative
of respiratory support in the management of pe- strategies to reduce these complications may
diatric respiratory failure. Physiologically, these improve success.
methods can stabilize the chest wall, wash out dead • When caring for patients with asthma or bron-
space, and improve gas exchange. Complications chiolitis, use of medications combined with
are typically minor and include skin irritation and respiratory support is encouraged and can have
mask intolerance, but patients should be monitored additive benefits.
closely for signs of respiratory failure and possible • HFNC and NIV strategies require close moni-
barotrauma. While the impact of HFNC and CPAP toring. Escalation of therapy in a timely man-
on bronchiolitis and BPAP on asthma demonstrate ner, when it is required, can prevent prolonged
initially positive results, there is still little evidence hospitalizations and complications.
on their role in other disease processes. Quality stud-
ies evaluating the potential and role of HFNC and References
NIV in pediatric populations remains scarce.
Evidence-based medicine requires a critical ap-
Case Conclusions praisal of the literature based upon study methodol-
ogy and number of subjects. Not all references are
Given the lack of improvement in the vital signs of the equally robust. The findings of a large, prospective,
2-month-old girl with cough and congestion, adjustments randomized, and blinded trial should carry more
were made to the HFNC settings. Her FiO2 was increased weight than a case report.
to 60%, and her flow rate was increased to 10 L/min. To help the reader judge the strength of each
After observing the patient on these settings for a half reference, pertinent information about the study, such
hour, her vital signs were recorded: temperature 37.7°C as the type of study and the number of patients in the
(99.9°F); heart rate, 144 beats/min; respiratory rate, 50 study is included in bold type following the references,
breaths/min; blood pressure, 86/64 mm Hg; oxygen satu- where available. The most informative references cited
ration, 96% on HFNC. She was admitted to the PICU for in this paper, as determined by the authors, are noted
further therapy and monitoring. Her work of breathing by an asterisk (*) next to the number of the reference.
continued to improve over the next 24 hours, and the sup-
port she required by HFNC decreased. She was trans- 1. Conti G, Piastra M. Mechanical ventilation for children. Curr
Opin Crit Care. 2016;22(1):60-66. (Review)
ferred to the floor and started on her home feeds. She was

Copyright © 2020 EB Medicine. All rights reserved. 16 Reprints: www.ebmedicine.net/pempissues

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 tion in acute respiratory failure from respiratory syncytial 86. Baudin F, Buisson A, Vanel B, et al. Nasal high flow in man-
virus bronchiolitis. Rev Bras Ter Intensiva. 2012;24(4):375-380. agement of children with status asthmaticus: a retrospective
(Retrospective cohort study; 162 patients) observational study. Ann Intensive Care. 2017;7(1):55. (Retro-
70.* Milesi C, Matecki S, Jaber S, et al. 6 cmH2O continuous posi- spective observational study; 73 patients)
tive airway pressure versus conventional oxygen therapy in 87. Ballestero Y, De Pedro J, Portillo N, et al. Pilot clinical trial
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2013;48(1):45-51. (Randomized controlled trial; 19 patients) emergency service. J Pediatr. 2018;194:204-210.e3. (Prospec-
71. Lal SN, Kaur J, Anthwal P, et al. Nasal continuous positive tive randomized pilot trial; 62 patients)
airway pressure in bronchiolitis: a randomized controlled 88. Pilar J, Modesto IAV, Lopez-Fernandez YM, et al. High-
trial. Indian Pediatr. 2018;55(1):27-30. (Randomized con- flow nasal cannula therapy versus non-invasive ventila-
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72. Borckink I, Essouri S, Laurent M, et al. Infants with severe observational cohort study. Med Intensiva. 2017;41(7):418-424.
respiratory syncytial virus needed less ventilator time with (Retrospective observational cohort study; 42 patients)
nasal continuous airways pressure then invasive mechanical 89. Kline-Krammes S, Patel NH, Robinson S. Childhood asthma:
ventilation. Acta Paediatr. 2014;103(1):81-85. (Retrospective a guide for pediatric emergency medicine providers. Emerg
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73. Martinon-Torres F. Noninvasive ventilation with helium- 90. Levine DA. Novel therapies for children with severe asthma.
oxygen in children. J Crit Care. 2012;27(2):220.e1-9. (Review) Curr Opin Pediatr. 2008;20(3):261-265. (Review)
74. Martinon-Torres F, Rodriguez-Nunez A, Martinon-Sanchez 91. de Souza Silva P, Barreto SS. Noninvasive ventilation in
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for bronchiolitis in infants. Cochrane Database Syst Rev. Noninvasive positive-pressure ventilation in pediatric status
2015(9):CD006915. (Cochrane review; 7 trials, 447 total asthmaticus. Pediatr Crit Care Med. 2002;3(2):181-184. (Brief
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76. Mayordomo-Colunga J, Rey C, Medina A, et al. Helmet 94. Mayordomo-Colunga J, Medina A, Rey C, et al. Non-inva-
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Respir Care. 2018;63(4):455-463. (Prospective randomized observational study. Pediatr Pulmonol. 2011;46(10):949-955.
crossover study; 16 patients) (Prospective observational study; 72 patients)
77. Jat KR, Mathew JL. Continuous positive airway pressure 95. Beers SL, Abramo TJ, Bracken A, et al. Bilevel positive
(CPAP) for acute bronchiolitis in children. Cochrane Database airway pressure in the treatment of status asthmaticus in
Syst Rev. 2019;1:CD010473. (Cochrane review; 3 studies, 122 pediatrics. Am J Emerg Med. 2007;25(1):6-9. (Retrospective
patients) chart review; 83 patients)
78. Donlan M, Fontela PS, Puligandla PS. Use of continuous 96. Williams AM, Abramo TJ, Shah MV, et al. Safety and clinical
positive airway pressure (CPAP) in acute viral bronchiolitis: findings of BiPAP utilization in children 20 kg or less for
a systematic review. Pediatr Pulmonol. 2011;46(8):736-746. asthma exacerbations. Intensive Care Med. 2011;37(8):1338-
(Systematic review; 8 studies) 1343. (Descriptive prospective and retrospective trial; 165
79. Metge P, Grimaldi C, Hassid S, et al. Comparison of a high- patients)
flow humidified nasal cannula to nasal continuous posi- 97. Carroll CL, Schramm CM. Noninvasive positive pres-
tive airway pressure in children with acute bronchiolitis: sure ventilation for the treatment of status asthmaticus in
experience in a pediatric intensive care unit. Eur J Pediatr. children. Ann Allergy Asthma Immunol. 2006;96(3):454-459.
2014;173(7):953-958. (Retrospective cohort study; 34 patients) (Retrospective review; 5 patients)
80. Pedersen MB, Vahlkvist S. Comparison of CPAP and HFNC 98. Basnet S, Mander G, Andoh J, et al. Safety, efficacy, and toler-
in management of bronchiolitis in infants and young children. ability of early initiation of noninvasive positive pressure
Children (Basel). 2017;4(4):28. (Retrospective review; 49 pa- ventilation in pediatric patients admitted with status asth-
tients) maticus: a pilot study. Pediatr Crit Care Med. 2012;13(4):393-
81. Abramo T, Williams A, Mushtaq S, et al. Paediatric ED BiPAP 398. (Prospective randomized controlled trial; 20 patients)
continuous quality improvement programme with patient 99. Needleman JP, Sykes JA, Schroeder SA, et al. Noninvasive
analysis: 2005-2013. BMJ Open. 2017;7(1):e011845. (Continu- positive pressure ventilation in the treatment of pediatric
ous Quality Improvement Program descriptive analytics; status asthmaticus. Pediatr Asthma, Allergy & Immunol.
1157 patients) 2004;17(4):272-277. (Prospective trial; 18 patients)
82. Perry SA, Kesser KC, Geller DE, et al. Influences of cannula 100. Carroll CL, Zucker AR. Barotrauma not related to type of
size and flow rate on aerosol drug delivery through the va- positive pressure ventilation during severe asthma exacerba-
potherm humidified high-flow nasal cannula system. Pediatr tions in children. J Asthma. 2008;45(5):421-424. (Retrospective
Crit Care Med. 2013;14(5):e250-e256. (Bench study) review; 45 patients)
83. Thill PJ, McGuire JK, Baden HP, et al. Noninvasive positive- 101.* Korang SK, Feinberg J, Wetterslev J, et al. Non-invasive
pressure ventilation in children with lower airway obstruc- positive pressure ventilation for acute asthma in children.
tion. Pediatr Crit Care Med. 2004;5(4):337-342. (Prospective Cochrane Database Syst Rev. 2016;9:CD012067. (Cochrane
randomized crossover study; 20 patients) review; 2 studies, 80 patients)
84. White CC, Crotwell DN, Shen S, et al. Bronchodilator de- 102.* Chisti MJ, Salam MA, Smith JH, et al. Bubble continuous
livery during simulated pediatric noninvasive ventilation. positive airway pressure for children with severe pneumonia
Respir Care. 2013;58(9):1459-1466. (Bench study) and hypoxaemia in Bangladesh: an open, randomised con-
85. Velasco J, Berlinski A. Albuterol delivery efficiency in a pediat- trolled trial. Lancet. 2015;386(9998):1057-1065. (Randomized
ric model of noninvasive ventilation with double-limb circuit. controlled trial; 225 patients)
Respir Care. 2018;63(2):141-146. (In vitro simulator study) 103. Fortenberry JD, Del Toro J, Jefferson LS, et al. Management

August 2020 • www.ebmedicine.net 19 Copyright © 2020 EB Medicine. All rights reserved.

 of pediatric acute hypoxemic respiratory insufficiency with 119. Shutes BL, Gee SW, Sargel CL, et al. Dexmedetomidine as
bilevel positive pressure (BiPAP) nasal mask ventilation. single continuous sedative during noninvasive ventilation:
CHEST. 1995;108(4):1059-1064. (Retrospective study; 28 typical usage, hemodynamic effects, and withdrawal. Pediatr
patients) Crit Care Med. 2018;19(4):287-297. (Retrospective chart
104. Essouri S, Chevret L, Durand P, et al. Noninvasive positive review; 382 patients)
pressure ventilation: five years of experience in a pediatric 120. Weingart SD, Levitan RM. Preoxygenation and prevention
intensive care unit. Pediatr Crit Care Med. 2006;7(4):329-334. of desaturation during emergency airway management. Ann
(Retrospective cohort study; 114 patients) Emerg Med. 2012;59(3):165-175. (Review article)
105. Padman R, Lawless ST, Kettrick RG. Noninvasive ventila- 121. Mosier JM, Hypes CD, Sakles JC. Understanding preoxy-
tion via bilevel positive airway pressure support in pediatric genation and apneic oxygenation during intubation in the
practice. Crit Care Med. 1998;26(1):169-173. (Prospective critically ill. Intensive Care Med. 2017;43(2):226-228. (Review)
noncontrolled study; 34 patients) 122. Humphreys S, Lee-Archer P, Reyne G, et al. Transnasal
106. Joshi G, Tobias JD. A five-year experience with the use of humidified rapid-insufflation ventilatory exchange (THRIVE)
BiPAP in a pediatric intensive care unit population. J Intensive in children: a randomized controlled trial. Br J Anaesth.
Care Med. 2007;22(1):38-43. (Retrospective review; 45 patients) 2017;118(2):232-238. (Randomized controlled trial; 48 patients)
107. Essouri S, Carroll C. Noninvasive support and ventilation for
pediatric acute respiratory distress syndrome: proceedings
from the Pediatric Acute Lung Injury Consensus Conference. CME Questions
Pediatr Crit Care Med. 2015;16(5 Suppl 1):S102-S110. (Litera-
ture review)
Take This Test Online!
108. Morris JV, Ramnarayan P, Parslow RC, et al. Outcomes for
children receiving noninvasive ventilation as the first-line
mode of mechanical ventilation at intensive care admis- Current subscribers receive CME credit absolutely
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109. Abadesso C, Nunes P, Silvestre C, et al. Non-invasive ven-
Category I credits, 4Take
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This credits, or
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110.* Yañez LJ, Yunge M, Emilfork M, et al. A prospective, receive your free CME credits for this issue, scan
randomized, controlled trial of noninvasive ventilation in
the QR code below with your smartphone or visit
pediatric acute respiratory failure. Pediatr Crit Care Med.
2008;9(5):484-489. (Randomized controlled trial; 50 patients) www.ebmedicine.net/P0820.
111. 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(6):383-
388. (Retrospective cohort study; 16 patients)
112. 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(8):1420-1427. (Prospective noncontrolled observa-
tional cohort study; 23 patients)
1. A 3-month-old boy is transferred to the ED
113. Mayordomo-Colunga J, Pons M, Lopez Y, et al. Predicting
with a diagnosis of acute bronchiolitis. His ini-
non-invasive ventilation failure in children from the SpO(2)/
FiO(2) (SF) ratio. Intensive Care Med. 2013;39(6):1095-1103. tial vital signs are: temperature, 37.5°C (99.5°F);
(Prospective observational study; 390 patients) heart rate, 180 beats/min; respiratory rate, 68
114. Padman R, Henry M. The use of bilevel positive airway pres- breaths/min; blood pressure, 78/60 mm Hg;
sure for the treatment of acute chest syndrome of sickle cell oxygen saturation, 91% on room air; he weighs
disease. Del Med J. 2004;76(5):199-203. (Retrospective chart 6 kg. The decision is made to initiate high-flow
review; 9 patients)
nasal cannula (HFNC). When titrating therapy,
115. Pancera CF, Hayashi M, Fregnani JH, et al. Noninvasive maximum benefit is likely reached at what
ventilation in immunocompromised pediatric patients: eight
years of experience in a pediatric oncology intensive care
flow rate?
unit. J Pediatr Hematol Oncol. 2008;30(7):533-538. (Retrospec- a. 4 L/min
tive cohort study; 239 patients) b. 6 L/min
116. Cavari Y, Sofer S, Rozovski U, et al. Non invasive positive c. 12 L/min
pressure ventilation in infants with respiratory failure. Pe- d. 24 L/min
diatr Pulmonol. 2012;47(10):1019-1025. (Retrospective cohort
study; 22 patients)
117. Venkatraman R, Hungerford JL, Hall MW, et al. Dexme-
detomidine for sedation during noninvasive ventilation in
pediatric patients. Pediatr Crit Care Med. 2017;18(9):831-837.
(Retrospective observational cohort study; 202 patients)
118. Piastra M, Pizza A, Gaddi S, et al. Dexmedetomidine is ef-
fective and safe during NIV in infants and young children
with acute respiratory failure. BMC Pediatr. 2018;18(1):282.
(Retrospective cohort study; 40 patients)

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2. A 12-year-old boy presents to the ED after 7. The decision is made to initiate BPAP in a
being involved in a motor vehicle crash. He is patient with cough-variant asthma. The patient
minimally responsive, with an oxygen satura- is coughing excessively and becomes agitated
tion of 90% on room air. He has equal breath during therapy. Agitation is a possible compli-
sounds bilaterally, weak pulses, and a Glasgow cation of NIV that can lead to failure of thera-
Coma Scale score of 5. The initial form of re- py, most commonly for which of the following
spiratory support should be: reasons?
a. Mechanical ventilation a. Self-induced pneumomediastinum
b. HFNC b. Excessive lowering of CO2
c. Bilevel positive airway pressure (BPAP) c. Mask interface obstruction
d. No respiratory support is needed d. Patient-ventilator asynchrony

3. In retrospective evaluations of noninvasive 8. Although the studies are limited, in which of

ventilation (NIV) use, what has been the most the following disease processes has NIV been
common complication? the least successful in preventing intubation?
a. Skin irritation b. Epistaxis a. Acute chest syndrome
c. Gastrointestinal bleed d. Pneumothorax b. Pneumonia
c. Asthma
4. HFNC and NIV are being used increasingly d. Acute respiratory distress syndrome
by prehospital providers. Which of the follow-
ing statements best characterizes the evidence 9. Dexmedetomidine has emerged as a possible
behind their use? medication to reduce patient intolerance of
a. There is support for their use in the out-of- NIV. Which of the following is the mechanism
hospital setting with well-trained personnel. of action of dexmedetomidine and a possible
b. There is no evidence for their use, due to the side effect?
high rate of complications. a. Alpha-2 agonist; bradycardia
c. There is support for their use, but intubation b. Alpha-1 antagonist; hypertension
rates prior to interhospital transport remain c. N-methyl-d-aspartate (NMDA) receptor
unchanged. antagonist; hypotension
d. HFNC use is acceptable, but NIV requires d. Gamma-aminobutyric acid (GABA)-A
physician presence. agonist; respiratory depression

5. Which of the following can be used as a clini- 10. Experiments have been initiated evaluating
cal predictor of failure of HFNC when treating the role of HFNC in apneic oxygenation. One
a patient with bronchiolitis? randomized controlled trial compared it to
a. Older age standard oxygen therapy in pediatrics. Which
b. FiO2 of 70% after 1 hour of therapy of the following results were demonstrated in
c. Initial pCO2 of 45 mm Hg the group treated with HFNC?
d. Low Pediatric Risk of Mortality score a. Lower average oxygen saturation
b. Longer safe apnea time
6. A 7-year-old boy with a history of asthma is c. Lower average transcutaneous CO2
placed on continuous albuterol therapy due measurements
to a continued elevated clinical asthma score. d. Increased first-pass success rates
Continuous positive airway pressure (CPAP)
therapy is also initiated. Which of the follow-
ing statements regarding concomitant use of
NIV and nebulized medications is CORRECT?
a. Nebulized medications and NIV cannot be
used together.
b. Nebulized medications and NIV can be used
together, but this decreases bronchodilator
therapy delivery to the lower airway.
c. Nebulized medications and NIV can be used
together, but only at extremely elevated
pressures.
d. Nebulized medications and NIV can be used
together, and this increases bronchodilator
therapy delivery to the lower airways.

August 2020 • www.ebmedicine.net 21 Copyright © 2020 EB Medicine. All rights reserved.

 NEED TO MOVE TO
MECHANICAL VENTILATION?
Read Points & Pearls for July 2020
or read the full issue at:
www.ebmedicine.net/PedMechVent

July 2020
A Quick-Read Review of Key Points & Clinical Pearls, June 2020

Mechanical Ventilation of Pediatric Patients

in the Emergency Department
A Quick-Read Review of Key Points & Clinical Pearls, June 2020

Points Pearls
• EB MEDICINE
Pediatric patients have higher resistance due
Blood gas analysis using venous samples is
A Quick-Read
to narrower airways, Review
as well as high of Key Points & Clinical
chest-wall Pearls, June 2020
an acceptable alternative to arterial blood gas
compliance. A more pliable chest wall results in
analysis, as both detect hypercapnia with a
lower functional residual capacity.
high degree of sensitivity, and both have been
• Use a cuffed endotracheal tube in all children.
A Quick-Read Review of Key Points & Clinical
shown Pearls,
to correlate June pH.2020
EB MEDICINE
• Clinicians should use the mode of ventilation
that is most familiar to them; the choice should Tidal volumes measured by the ventilator are
be based on clinician experience, patient patho- not especially accurate in infants and small chil-
physiology, and ventilator availability. dren. Thus, it is preferable to use pressure-con-
• Use synchronized intermittent mandatory ventila- trolled modes of ventilation and avoid volume-
tion (SIMV) for patients without spontaneous respi- controlled ventilation in this population.
EB MEDICINE
ratory effort, and use SIMV with pressure support
for patients with spontaneous respiratory effort. For patients with severely depressed lung
• Use assist-control ventilation in patients with little compliance or PARDS, tidal volumes of 3 to 6
to no spontaneous respiratory effort or in those mL/kg are preferable.
EB MEDICINE
who require complete respiratory support, as the
Consider initiation of extracorporeal mem-
ventilator will assume full work of breathing.
• Use spontaneous supported ventilation as a way brane oxygenation in patients with persistent
to ease work of breathing in children who are hypoxemia or inability to meet the goals of
breathing spontaneously. However, do not use it ventilation despite optimal medical care and
in paralyzed patients or those with no spontane- ventilator settings.
ous respiratory effort.
• Upon initiation of mechanical ventilation, order a
• Should complete neuromuscular blockade be
chest x-ray, blood gas analysis, and guided diag-
employed, optimize the patient’s analgesia and
nostic testing for the underlying pathology.
sedation prior to administering a paralytic. Use
• When employing lung-protective ventilation,
the State Behavioral Score to assess sedation in
elevated PaCO2 or permissive hypercapnia may
pediatric patients.
be tolerated as a strategy to limit plateau pres-
sures. Target a pH of > 7.2. However, permissive
hypercapnia and increasing PaCO2 may be harm-
Issue Authors
ful in patients with sickle cell disease, pulmonary
hypertension, or elevated intracranial pressure. Casey Carr, MD
Critical Care Fellow, University of Florida Shands, Gainesville, FL
• Immediate feedback can be provided via end-tidal
Courtney W. Mangus, MD, FAAP
CO2 (EtCO2) monitoring; however, in patients Clinical Lecturer, Departments of Emergency Medicine & Pediatrics,
with rapidly changing lung mechanics, EtCO2 The University of Michigan, Ann Arbor, MI
may not accurately reflect changes in arterial CO2. J. Kate Deanehan, MD, RDMS
Assistant Professor, Pediatric Emergency Medicine, Johns Hopkins
• For patients with generally healthy lungs, target Children’s Center, Baltimore, MD
an oxygen saturation of 92% to 97%. For patients Points & Pearls Contributor
with pulmonary pathology, such as pediatric
Kathryn H. Pade, MD
acute respiratory distress syndrome (PARDS), Assistant Professor of Pediatrics, Department of Emergency Medicine, Rady
lower saturations of 88% to 92% are acceptable. Children’s Hospital, University of California San Diego, San Diego, CA

Copyright © 2020 EB Medicine. All rights reserved. 1 22 CopyrightReprints: www.ebmedicine.net/pempissues

© 2020 EB Medicine. All rights reserved.
July 2020 • Emergency Medicine Practice
 • Patients with obstructive physiology are prone
Table 4. Suggested Initial Ventilator
to dynamic hyperinflation, also known as auto–
Settings for Pressure Control
positive end-expiratory pressure, which occurs
Setting Neonate Infant/Child Adolescent when a reduction in expiratory flow results in
Respiratory rate 24-30 18-25 12-20 incomplete exhalation before the subsequent
(breaths/min) breath.
Inspiratory time (sec) 0.3-0.5 0.6-0.9 0.9-1.2 • Avoid intubation and mechanical ventilation in
Peak inspiratory 15-25 15-25 15-25 patients with obstructive lung disease. If intuba-
pressure (cm H2O) tion is necessary, use permissive hypercapnia
Positive end-expira- 5 5 5
and increase the inspiratory-to-expiratory ratio
tory pressure (cm to 1:4 to allow for additional time required to
H2O) fully exhale.
Pressure support 6-10 6-10 6-10
(cm H2O)
Most Important References
www.ebmedicine.net
4.* Pacheco GS, Mendelson J, Gaspers M. Pediatric ventilator
management in the emergency department. Emerg Med Clin
Table 5. Suggested Initial Ventilator North Am. 2018;36(2):401-413. (Review)
Settings for Volume Control DOI: https://doi.org/10.1016/j.emc.2017.12.008
9.* Duyndam A, Ista E, Houmes RJ, et al. Invasive ventilation
Setting Neonate Infant/Child Adolescent modes in children: a systematic review and meta-analysis.
Respiratory rate 24-30 18-25 12-20 Crit Care. 2011;15(1):R24. (Systematic review and meta-anal-
(breaths/min) ysis; 5 trials, 421 patients)
DOI: https://doi.org/10.1186/cc9969
Inspiratory time (sec) 0.3-0.5 0.6-0.9 0.9-1.2
10.* Kneyber MCJ, de Luca D, Calderini E, et al. Recommenda-
Tidal volume (mL/kg) 6-8 6-8 6-8 tions for mechanical ventilation of critically ill children from
Positive end-expira- 5 5 5 the Paediatric Mechanical Ventilation Consensus Confer-
tory pressure (cm ence (PEMVECC). Intensive Care Med. 2017;43(12):1764-1780.
H2O) (Guideline recommendations)
DOI: https://doi.org/10.1007/s00134-017-4920-z
Pressure support 6-10 6-10 6-10 11.* Rimensberger PC, Cheifetz IM, Pediatric Acute Lung Injury
(cm H2O) Consensus Conference Group. Ventilatory support in
children with pediatric acute respiratory distress syndrome:
www.ebmedicine.net proceedings from the Pediatric Acute Lung Injury Consensus
Conference. Pediatr Crit Care Med. 2015;16(5 Suppl 1):S51-S60.
(Guideline recommendations)
DOI: https://doi.org/10.1097/pcc.0000000000000433
22.* Pediatric Acute Lung Injury Consensus Conference Group.
Pediatric acute respiratory distress syndrome: consensus
recommendations from the Pediatric Acute Lung Injury Con-
sensus Conference. Pediatr Crit Care Med. 2015;16(5):428-439.
(Consensus recommendations)
DOI: https://doi.org/10.1097/PCC.0000000000000350
A Quick-Read Review of Key Points & Clinical Pearls, June 2020
Access your issue by scanning the QR code
with your smartphone or tablet Also treating adult patients?
July 2020
Read the Emergency Medicine
Practice issue, "Ventilator
Number 7

nagement
Volume 22,

Ventilator Ma ts in the
Author Center;
MD LA Medical
, Harbor-UC Geffen School
Ryan Pedigo, Student Education David

ien
Medical y Medicine,

of Adult Pat
Director, of Emergenc CA
Assistant Professor Angeles,
at UCLA, Los

Department
Management of Adult Patients
of Medicine

Questions, comments, suggestions? Emergency

Peer Reviewers FNCS ery,
MD, FACEP,
Knight, IV, and Neurosurg
William A. of Emergenc
y Medicine Program;
Associate
Professor Practice Provider of
EM Advanced nce ICU, University
Medical Director, Director, Neuroscie
Medical
Associate OH
Cincinnati,
Abstract le to the emer-
Cincinnati, MPH

in the Emergency Department,"

MD, EMDM, Professor,
European
options availab l settings

To write a letter to the editor,

Charles Stewart, Tulsa, OK; Visiting
ventilator y Physician;
variety of g optima
ns on choosin Understanding the
Emergenc Medicine Program
There are a Master Disaster n”
n, and decisio tances. e patient “CME Informatio
gency clinicia the clinical circums
see
this activity,
on ment can improv ion Prior to beginningon the back page.
will depend or manage and ventilat
re in ventilat oxygenation ced lung injury.
latest literatu g optimal

available at:
by ensurin or-indu
outcomes al for ventilat or settings

email: [email protected] or
g the potenti riate ventilat -
and reducin the most approp adult patients present
This article
reviews in intubated recommenda-
of conditions ent, and gives venti-
for a variety ncy departm ed patient and making
ing to the
emerge -19-associ-
ring the ventilat ng COVID
tions on monito An update on managi is also included.

www.ebmedicine.net/MechVent
ents. me Editors
lator adjustm distress syndro International

[email protected].
respiratory MD
ated acute
MD
Robert Schiller, of Family Medicine, Peter Cameron, Alfred
Director, The Centre,
MD Chair, Department Center; Senior Academic
and Trauma
Eric Legome, Mount Medical Emergency
Medicine, Beth Israel Medicine and
Melbourne,
MD, MS, FACEP, Chair, Emergency Sinai St. Luke's; Faculty, Family School of Monash University,
Deborah Diercks, Sinai West
& Mount
Affairs for Community
Health, Icahn
New York,
NY Australia
of Academic Mount Sinai,
FACC Department Vice Chair, Mount Sinai Medicine at
Editor-In-Chief and Chair, MD
Professor University
of
Emergency
Medicine, of FACEP Andrea Duca, Physician,
MD, FACEP Medicine, Center, Icahn School York, NY Scott Silvers, MD, of Emergency Attending
Emergency XXIII,
Andy Jagoda, Chair Emeritus, Emergency rn Medical Health System, New Professor Papa Giovanni
and Texas Southweste Mount Sinai, and
Professor Medicine; Medicine at Associate of Facilities FL
Ospedale
Italy
Department
of Emergency
Dallas, TX MD, MS Medicine, Chair Clinic, Jacksonville, Bergamo,
for Emergency Keith A. Marill, Peeters, MD
Director, Center Department Planning, Mayo
and Research, MD Professor, FACP, FACEP Suzanne Y.G. Physician,
Daniel J. Egan,
of Harvard
Medicine Education at Mount Vice Chair Associate Medicine, Slovis, MD, Emergency
of Medicine Associate
Professor, of Emergency of Emergency Massachusetts Corey M. Chair, Department
Attending Hospital, Almere,
Icahn School Flevo Teaching
York, NY Education,
Department Medical School, Boston, MA Professor and Medicine, Vanderbilt
Sinai, New Columbia
University
Nashville, TN The Netherlands
and General Hospital, of Emergency MD, FIFEM
Editor-In-Chief
Medicine, of Physicians Medical Center,
e FACEP Menendez,
Vagelos College York, NY Mills, MD, University Edgardo and Emergency
Associat MD, FACEP New Angela M. Department MD in Medicine
Surgeons, and Chair, Ron M. Walls, COO, Departmen
t of Professor EM, Churruca
Kaushal Shah, Vice Chair Professor Medicine,
Columbia Director of
Associate
Professor, of elle Elie, MD of Emergency of Professor
and
Brigham and Medicine;
Buenos Aires
University,
Department Marie-Carm Department Vagelos College Medicine, Hospital of
for Education, Weill Cornell Associate
Professor, & Critical University Surgeons,
New York, Emergency Harvard Medical Aires, Argentina
Medicine, NY Medicine & Hospital, Buenos
Emergency New York, of Emergency University of Florida Physicians Women's MA tikul, MD
School of
Medicine, FL NY School, Boston, Dhanadol
Rojanasarn
Emergency
Care Medicine, Gainesville, MA, MD, Physician,
College of
Medicine, Pollack Jr., Editors Attending rn
Charles V. Critical Care
Editorial Board FAHA, FESC King Chulalongkoof
PhD Medicine,
MD, FACEP Genes, MD, of FACEP, FAAEM, Advisor for MD, FACEP, Hospital; FacultyUniversity,
Saadia Akhtar,
of Nicholas Department & Senior Knight IV, Memorial rn
Department Professor, Professor
ary Research
and William A. Chulalongko
Associate
Professor,
Associate
Dean Associate Icahn School Interdisciplin Department of FNCS Medicine,
Medicine, Medicine, New of Emergency
Emergency Professor Thailand
Emergency
Medical Education, at Mount Sinai, Clinical Trials, Sidney Kimmel Associate ry, Medical MPH
for Graduate of Medicine Medicine, Jefferson Medicine and
Neurosurge Thomas, MD,
Emergency
York, NY
Emergency of Thomas Advanced
Practice Stephen H. Chair, Emergency
Program Director, Mount Sinai FACEP Medical College , PA Director, EM Associate
Medical
Professor
& Corp.,
Medicine Residency, Gibbs, MD, Philadelphia
Provider Program; e ICU, University Hamad Medical
New York,
NY Michael A. Department University, Medicine, Qatar;
Beth Israel, and Chair, MD, MBA,
MPH
Director, Neuroscienc OH Medical College,
Professor Medicine,
Carolinas
Ali S. Raja, Emergency Cincinnati, Weill Cornell -Chief,
Brady, MD of Emergency of North Vice Chair, of Cincinnati, Physician-in
William J. Medicine University Executive tts General MD, FCCM Emergency Hospital,
Professor
of EmergencyDirector, Medical Center, of Medicine, Chapel Medicine,
Massachuse of Scott D. Weingart, Medicine; Hamad General
Professor
and Medicine;
Medical
t, UVA Carolina School Hospital; Associate and Radiology, Professor of
Emergency
Stony Brook Doha, Qatar
Managemen Hill, NC Medicine Boston, MA Critical Care,
Emergency Operational
Medical
MD, FACEP Emergency School, Chief, EM Brook, NY Zelihic, MD
Medical Stony Edin of Emergency
Medical Center; County Fire Steven A.
Godwin,
Department Harvard
FACEP,
Medicine,
Head, Department Hospital,
Director, Albemarle ille, VA and Chair, Assistant Rogers, MD, Leopoldina
Professor Robert L. Editors
Research
Medicine, Medicine,
Rescue, Charlottesv of Emergency , Germany
FAAEM, FACP

EB MEDICINE
Education, of Emergency BCPS Schweinfurt
MD Dean, Simulation PharmD,
Brown III, , COM- Professor of Aimee Mishler,
Calvin A. Compliance University
of Florida , FL
Assistant
The University Medicine Pharmacist,
Physician
Director of Care , Jacksonville Medicine,
School of
Medicine, Emergency PGY2 EM
g and Urgent Jacksonville Maryland Program Director, Valleywise
Credentialin of Emergency , MD MBA MD Residency,
Services, Department Women's Joseph Habboushe of Emergency Baltimore, Pharmacy
Phoenix, AZ
Brigham and Assistant Professor
ne and MD, FACEP Health,
Medicine, MA Sacchetti, MD
NYU/Lango York, Alfred Professor,
Hospital, Boston, Medicine, Centers, New Assistant Clinical Medicine, Joseph D. Toscano,of Emergency
MD Bellevue Medical LLC Department
of Emergency
Chief, Department Regional
Peter DeBlieux, MD Aware University, San Ramon
of Clinical
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 CME Information
Date of Original Release: August 1, 2020. Date of most recent review: July 15, 2020.
Termination date: August 1, 2023.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical
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Num
Volume 17,

Neonates: Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA
Seizures in
Authors

ent
FAAP gency

d Managem
Langhan,
MD, MHS, trics and Emer University

PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the
Melissa L. ts of Pedia ine, Yale
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Section of n, CT
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tality,
er, MD
Nicole Gerb ssor of Clinical Pedia
Assistant Profe on of Pediatric Emer
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Center, New
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high morbidi n present with
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Neonatal seiz difficult to diagnose
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s. Initi al management  ure  cess ation, Clinical Assis School of Medicine,
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subtle sign ude patient
ACEP Accreditation: Pediatric Emergency Medicine Practice is approved by the American
CA Information”
n Los Angeles,
artment incl etiology; identificatio ed. Further 
man- ty, see “CME
ning this activi page.
gency dep e Prior to begin
ation of th ld be prioritiz ination findings, on the back
and determin of the seizures shou credits.
es physical exam
treatable caus s on the history and studies. This issue
dep end ging
reviews
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is eligible
for 2 Pharm
acology CME
College of Emergency Physicians for 48 hours of ACEP Category I credit per annual
agem ent  lts, and ima l seizures, con ence
labo rato ry testing resu
entations and
common pres rgency department
caus es of neonata
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AAP Accreditation: This continuing medical education activity has been reviewed by the
, FAAP
antiepilepti r, MD, FACEP
regarding er, MD, MSHS
David M. Walkeric Emergency
Chief, Pediat of Pediatrics,
Garth Meckl of Pediatrics, Department
Professor Medicine, n's
Sanzari Childre sity

American Academy of Pediatrics and is acceptable for a maximum of 48 AAP credits per
MD, FAAP Associate bia; Joseph M.
Alson S. Inaba, ency Medicine of British Colum ency nsack Univer
University Pediatric Emerg Hospital, Hacke, Hackensack, NJ
Pediatric Emerg ani Medical Center Division Head,Children's Hospital,
Ari Cohen
, MD, FAAP ency list, Kapiol iate BC Medical Center
ic Emerg Specia n; Assoc Medic ine, a , MD, MHA
Chief of Pediatr chusetts General & Childre BC, Canad Wang
-Chief for Women University Vincent J. of Pediatrics and

year. These credits can be applied toward the AAP CME/CPD Award available to Fellows
of Pediatrics, School of Vancouver,
Editors-in Medicine, Massator in Pediatrics, Professor A. Burns r, MD, MHPE ics
d Professor
Medicine;
Division
ius, MD Hospital; Instruc l School, Boston, MA of Hawaii John lu, HI Joshua Nagle or of Pediatr Emergency ric Emergency
Ilene Claud Director,
Professor; Harvard Medica Medicine,
Honolu Assistant ProfessMedicine, Harvard Chief, Pediat Southwestern
Associate ement FACEP h, MD, FACEP
, ency
Quality Improv , MD, FAAP, and Emerg Division UT

and Candidate Fellows of the American Academy of Pediatrics.

Process & al
Jay D. Fisher ency Matar Josep l; Associate Medicine, r; Director
of
r-UCLA Medic sor of Emerg Madeline Medical Schoo ship Director, Divisio
n
Program, Harbo Clinical Profes Pediatrics, University Medical Cente Children's
ce, CA FAAP Medicine Chief and Fellow Services,
Center, Torran Medicine and Vegas School of Emergency Medicine, Boston Emergency , TX
, FACEP, Professor of Assistant Chair, of Emergency
zko, MD, MSCR of Nevada,
Las
NV Pediatrics, ne Hospita l, Boston, MA Health, Dallas
nal Editor
Tim Horec Vegas , and Medici Childre n’s
Las ency
Medicine, FACEP, Pediatric Emerg
FAAP of Clinical he-Hill, MD, ement, Pediat n,
ric wa, MD Internatio FACEP,

AOA Accreditation: Pediatric Emergency Medicine Practice is eligible for up to 48 American

Professor Quality Improv James Napra Emergency
Associate David Geffen Marianne Gausc Medicine Divisioe of Physician, s, MD, FAAP,
Medicine, S Emergency Attending f Lara Zibner
Emergency UCLA; Core FAAP, FAEM r, Los Angeles of Florida Colleg USCF Beniof d, CA tric
Medicine, sor of University Depar tment MMed ltant, Paedia
School of Physic ian, Los Medic al Directo y; Profes ksonvi lle, n's Hospit al, Oaklan ary Consu
Senior Agenc Medicine-Jac Childre Honor St. Mary's
Faculty and y-Harbor-UCL
A County EMS ency Medicine and Medicine,
Emergency

Osteopathic Association Category 2-A or 2-B credit hours per year.

FL r, MD Trust,
Angeles Count , Torrance, CA Clinical Emerg Geffen School Jacksonville, Joshua Rocke Medical al College
David MD Chief and Hospital Imperi Instructor
Medical Center Pediatrics, l Kennebeck, of Associate nt Professor
of Nonclinical
at UCLA; Clinica Stephanie University London, UK; Medicine, Icahn
d of Medicine r-UCLA Medical Professor,
of Pediatrics, Director, AssistaEmergency Medicine,
Editorial Boar FAAP Faculty, Harbotment of Emergency
Associate
Cincinnati
Depar tment Pediatrics
and l Center of
of Emergency ine at Mount Sinai,
Medic
Avner, MD,
n's Medica School of
Jeffrey R. tment of Center, Depar Angeles, CA Cincin nati, OH Cohen Childre Hyde Park, NY York, NY

Needs Assessment: The need for this educational activity was determined by a survey
Depar Los MSc New New
Chairman,
Professor
of Clinical Medicine, anda, MD,
Anupam Kharbl Care Services,
New York,
y Editor
Pharmacolog
FAAP,
Pediatrics, Children's Gerardi, MD, Steven Roger
s, MD of
Maimonides Michael J. Chief, Critica sota, University BCPS
Pediatrics, yn, NY ent
FACEP, Presid sor of Emergency Hospital Minne Associate
Professor,
Medicine, r, PharmD,
Brooklyn, Brookl Children's School of Aimee Mishle Medicine Pharmacist,
Hospital of Associate
Profes
l of Medicine MN Connecticut Medicine Emergency

of medical staff, including the editorial board of this publication; review of morbidity and
MD Icahn Schoo Pediatric Minneapolis, Emergency Children's or – PGY2 acy
Steven Bin, UCSF Medicine, Director, Attending Program Direct
l Professor, Tommy Y.
Kim, MD or Connecticut CT Medicine
Pharm
Associate Clinicane; Medical Directo
r, at Mount Sinai; ine, Goryeb es Clinical Profess Physician, Emergency

Mechanical Ventilation of
Medic Health Scienc , Hartford, Valleywise
Health
School of Mediciency Medicine, UCSF Emergency town Medicine, Medical Center Residency,
Hospital, Morris NJ Emergency ix, AZ
of Pediatric Riverside School er, MD Center, Phoen

mortality data from the CDC, AHA, NCHS, an ACEP; and evaluation of prior activities for
Pediatric Emergn's Hospital, San Children's town, Californ ia opher Stroth ency Medic al
, Morris University of unity Christ Emerg
Benioff Childre Medical Center
be, MD, PhD of Medicine,
Riverside Comm ency Associate July 2020
Professor,
and Medica
l
Liaison

Pediatric Patients in the

CA of Emerg Pediatrics, APP
Francisco, FACEP p Godam Officer, Depart ment Medici ne, ric PhD, MSN,
FAAP, Sandi Safety Hospital, Director, Pediat r, Newberry,
Richard M.
Cantor, MD, Medicine Chief Quality
and Patient ng
Pediatrics, Attendi ne, Medicine, Riversi
de, CA Education; Volume 17, Number 7
Medicine; DirectoMedicine
Brittany M. , ENP-BC,
FNP-BC

emergency physicians.
sor of EmergencyChief, or of MHS Emerg ency l of MPH, APRN sity School
Profes n Profess
Emergency
Medici an, MD, Authors and Icahn Schoo NY Univer
and Pediat
rics; Sectio ine; Physician of Melissa Langh of Pediatrics Simulation; Faculty, Emory Nurse

Emergency Department
ency Medic The King's ate Professor Fellowship York, g, Emergency
ric Emerg Poison Childre n's Hospital of , Norfolk, VA Associ ne; at Mount Sinai, New of Nursin Atlanta , GA;
Pediat r, Upstate Health System Emergency
Medici Casey Carr, MD Practitioner
Program, Regional
Medical Directo, Golisano Children's Daughters r of Education, Yale E. Vella, MD,
FAAP
ioner, Fannin
Director, Directo ency Medici Critical
ne, CareAdam of Emergency Nurse Practit ency Department,
Control Center se, NY an, MD Fellow, iate Professor
Ran D. Goldm of Pediatrics, Pediatric Emerg l of Medici Assoc University of rics,
FloridaAssoc iate
Shands,

Target Audience: This enduring material is designed for emergency medicine physicians,
ne, New Gainesville,
Hospital Emerg FL
Hospital, Syracu Professor,
Depar tment Schoo Courtney W. Mangus,
MedicineMD, and Pediat
FAAP, New York-
FAAP of British Columbia; University Officer ine, Blue Ridge, GA
MD, iate sity Clinical Lecturer,Chief Quality
Cornell Medic
Abstract
Steven Choi, Officer and Assoc
Chief Quality l Quality, Yale
Univer
Research
Medic ine, BC
ric
Director, Pediat Children's
a
Haven, CT
t Luten , MD The University ofPresby
Departments
terian/Weillof Emergency Medicine & Pediatrics,
Michigan, NY Ann Arbor, MI
Clinica ine; ency Rober and York,

physician assistants, nurse practitioners, and residents.

Dean for Medic Emerg uver, BC, Canad Pediatrics J. Kate New
le School of ,
Hospital, Vanco Professor, University
of
Deanehan, MD, RDMS
Medicine/Ya Quality Officer MBA Medicine, Assistant
ent, Chief
When pediatric patients require
Vice Presid , ushe, MD, Emergency nville, FL Professor, Pediatric Emergency
Health System Joseph Habbo sor of Emerg
ency
Florida, Jackso
Medicine, Johns Hopkins
Yale New Haven mechanical ventilation in the Assistant Profes angone and
Children’s Center, Baltimore,
MD
gency department, the emergenc
New Haven
, CT emer- NYU/L Peer Reviewers
y clinician should be prepared Medicine, al Centers,
New
select initial ventilator settings to
Goals: Upon completion of this activity, you should be able to: (1) demonstrate medical
Bellevue Medic MD Aware LLC
and respond to an intubated York, NY; CEO, Nicole Gerber, MD
tient’s dynamic physiolog pa-
ic needs to ensure ongoing Assistant Professor of Clinical
Pediatrics, Department of
ventilation, and hemodyna oxygenation, Medicine, Division of Pediatric Emergency

decision-making based on the strongest clinical evidence; (2) cost-effectively diagnose and
mic stability. Pressure-targeted Presbyterian/Weill Cornell
Emergency Medicine, New
York-
tion is generally recommen ventila- Medical Center, New York,
ded in pediatric patients, with Garrett S. Pacheco, MD NY
ventilator settings varying initial
depending on age and the Assistant Professor, Residency

treat the most critical ED presentations; and (3) describe the most common medicolegal
etiology of Associate Program Director,
respiratory failure. This issue Combined EM & Pediatrics, EM and
reviews indications for mechanica and Pediatrics, University
Departments of Emergency
Medicine
ventilation and offers recommen l of Arizona, Tucson, AZ
dations for ventilator settings
pitfalls for each topic covered.
dosing of analgesics, sedatives, and Prior to beginning this activity,
and neuromuscular blockers, see “CME Information”
focus on patient populatio with a on the back page.
ns in whom the approach
ventilation may be different. to mechanical

Editors-in-Chief Ari Cohen, MD, FAAP

CME Objectives: Upon completion of this activity, you should be able to: (1) discuss the
indications and contraindications for initiation of high-flow nasal cannula (HFNC) and
Ilene Claudius, MD Chief of Pediatric Emergency Alson S. Inaba, MD, FAAP
Pediatric Emergency Medicine Garth Meckler, MD, MSHS
Associate Professor; Director, Medicine, Massachusetts General Associate Professor of Pediatrics, David M. Walker, MD, FACEP,
Specialist, Kapiolani Medical FAAP
Process & Quality Improvement Hospital; Instructor in Pediatrics, Center University of British Columbia; Chief, Pediatric Emergency
Program, Harbor-UCLA Medical Harvard Medical School, Boston, for Women & Children; Associate Medicine, Department of Pediatrics,

noninvasive ventilation (NIV); (2) discuss the complications associated with HFNC and NIV;
MA Professor of Pediatrics, University Division Head, Pediatric Emergency
Center, Torrance, CA Joseph M. Sanzari Children's
Jay D. Fisher, MD, FAAP, of Hawaii John A. Burns School Medicine, BC Children's Hospital,
FACEP of Hospital, Hackensack University
Tim Horeczko, MD, MSCR, Clinical Professor of Emergency Medicine, Honolulu, HI Vancouver, BC, Canada
FACEP, Medical Center, Hackensack,
FAAP Medicine and Pediatrics, University Joshua Nagler, MD, MHPEd NJ
Madeline Matar Joseph,

(3) identify clinical parameters that indicate success or failure of therapy; and (4) discuss the
Associate Professor of Clinical of Nevada, Las Vegas School MD, FACEP, Assistant Professor of Pediatrics Vincent J. Wang, MD, MHA
of FAAP
Emergency Medicine, David Medicine, Las Vegas, NV and Emergency Medicine, Harvard Professor of Pediatrics
Geffen Professor of Emergency Medicine and
School of Medicine, UCLA; Emergency Medicine; Division
Core Marianne Gausche-Hill, MD, and Pediatrics, Assistant Chair, Medical School; Associate Division
Faculty and Senior Physician, FACEP, Chief, Pediatric Emergency
Los FAAP, FAEMS Chief and Fellowship Director,

evidence behind the use of HFNC and NIV in certain disease processes such as asthma
Angeles County-Harbor-UCLA Pediatric Emergency Medicine Division Medicine, UT Southwestern
Medical Director, Los Angeles Quality Improvement, Pediatric of Emergency Medicine, Boston
Medical Center, Torrance, Children’s Medical Center; Director of
CA County EMS Agency; Professor Emergency Medicine Division, Hospital, Boston, MA
of Emergency Services, Children's
Editorial Board Clinical Emergency Medicine
and University of Florida College
of James Naprawa, MD Health, Dallas, TX
Pediatrics, David Geffen School

and bronchiolitis.
Jeffrey R. Avner, MD, FAAP Medicine-Jacksonville, Attending Physician, Emergency
Chairman, Department of
of Medicine at UCLA; Clinical Jacksonville, FL Department USCF Benioff International Editor
Faculty, Harbor-UCLA Medical Children's Hospital, Oakland,
Pediatrics, Professor of Clinical Center, Department of Emergency Stephanie Kennebeck, MD CA Lara Zibners, MD, FAAP, FACEP,
Pediatrics, Maimonides Children's Medicine, Los Angeles, CA Associate Professor, University Joshua Rocker, MD MMEd
of
Hospital of Brooklyn, Brooklyn, Cincinnati Department of Pediatrics, Associate Chief and Medical Honorary Consultant, Paediatric
NY Michael J. Gerardi, MD, FAAP,

Discussion of Investigational Information: As part of the journal, faculty may be presenting

Steven Bin, MD Cincinnati, OH Director, Assistant Professor Emergency Medicine, St. Mary's
FACEP, President of
Associate Clinical Professor, Anupam Kharbanda, MD, Pediatrics and Emergency Hospital Imperial College Trust,
UCSF Associate Professor of Emergency MSc Medicine,
School of Medicine; Medical Chief, Critical Care Services, Cohen Children's Medical Center London, UK; Nonclinical Instructor
Director, Medicine, Icahn School of of of Emergency Medicine, Icahn
Pediatric Emergency Medicine, Medicine Children's Hospital Minnesota, New York, New Hyde Park,
at Mount Sinai; Director, Pediatric NY

investigational information about pharmaceutical products that is outside Food and Drug
UCSF School of Medicine at Mount
Benioff Children's Hospital, San Emergency Medicine, Goryeb Minneapolis, MN Steven Rogers, MD Sinai,
Francisco, CA New York, NY
Children's Hospital, Morristown Tommy Y. Kim, MD Associate Professor, University
of
Richard M. Cantor, MD, FAAP, Medical Center, Morristown,
NJ Health Sciences Clinical Professor Connecticut School of Medicine, Pharmacology Editor
FACEP Attending Emergency Medicine

Administration approved labeling. Information presented as part of this activity is intended

Professor of Emergency Medicine Sandip Godambe, MD, PhD of Pediatric Emergency Medicine, Aimee Mishler, PharmD,
and Pediatrics; Section Chief, University of California Riverside Physician, Connecticut Children's BCPS
Chief Quality and Patient Safety School Medical Center, Hartford, CT Emergency Medicine Pharmacist,
Pediatric Emergency Medicine; Officer, of Medicine, Riverside Community
Professor of Pediatrics, Attending Program Director – PGY2
Medical Director, Upstate Poison Physician of Emergency Medicine, Hospital, Department of Emergency Christopher Strother, MD Emergency Medicine Pharmacy

solely as continuing medical education and is not intended to promote off-label use of any
Control Center, Golisano Children's Children's Hospital of The King's Medicine, Riverside, CA Associate Professor, Emergency Residency, Valleywise Health
Hospital, Syracuse, NY Daughters Health System, Norfolk, Melissa Langhan, MD, MHS Medicine, Pediatrics, and Medical Medical Center, Phoenix,
VA Education; Director, Pediatric AZ
Steven Choi, MD, FAAP Ran D. Goldman, MD Associate Professor of Pediatrics
Chief Quality Officer and Associate Emergency Medicine; Fellowship
and Emergency Medicine; Director, APP Liaison
Professor, Department of Pediatrics,

pharmaceutical product.
Simulation; Icahn School of
Dean for Clinical Quality, Yale University of British Columbia; Director, Director of Education, Medicine Brittany M. Newberry, PhD, MSN,
Medicine/Yale School of Medicine; Pediatric Emergency Medicine, at Mount Sinai, New York, NY MPH, APRN, ENP-BC, FNP-BC
Research Director, Pediatric Yale
Vice President, Chief Quality Emergency Medicine, BC University School of Medicine, Adam E. Vella, MD, FAAP Faculty, Emory University School
Officer, Children's New
Yale New Haven Health System, Hospital, Vancouver, BC, Canada Haven, CT Associate Professor of Emergency of Nursing, Emergency Nurse
New Haven, CT Robert Luten, MD Medicine and Pediatrics, Associate Practitioner Program, Atlanta,
Joseph Habboushe, MD, GA;

Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity, balance, independence,

MBA Professor, Pediatrics and Chief Quality Officer, New Nurse Practitioner, Fannin Regional
Assistant Professor of Emergency York-
Emergency Medicine, University Presbyterian/Weill Cornell Hospital Emergency Department,
Medicine, NYU/Langone and of Medicine,
Florida, Jacksonville, FL New York, NY Blue Ridge, GA
Bellevue Medical Centers,
New
York, NY; CEO, MD Aware

transparency, and scientific rigor in all CME-sponsored educational activities. All faculty
LLC

participating in the planning or implementation of a sponsored activity are expected to disclose

to the audience any relevant financial relationships and to assist in resolving any conflict of
interest that may arise from the relationship. Presenters must also make a meaningful disclosure
In upcoming issues of to the audience of their discussions of unlabeled or unapproved drugs or devices. In compliance
with all ACCME Essentials, Standards, and Guidelines, all faculty for this CME activity were
asked to complete a full disclosure statement. The information received is as follows: Dr.
Pediatric Emergency Medicine Slubowski, Dr. Ruttan, Dr. Levine, Dr. Nagler, Dr. Mishler, Dr. Claudius, Dr. Horeczko, and
their related parties report no significant financial interest or other relationship with the
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Pediatric Emergency Medicine Practice (ISSN Print: 1549-9650, ISSN Online: 1549-9669, ACID-FREE) is published monthly (12 times per year) by EB Medicine (3475 Holcomb Bridge Rd, Suite 100, Peachtree
Corners, GA 30092). Opinions expressed are not necessarily those of this publication. Mention of products or services does not constitute endorsement. This publication is intended as a general guide and is
intended to supplement, rather than substitute, professional judgment. It covers a highly technical and complex subject and should not be used for making specific medical decisions. The materials contained
herein are not intended to establish policy, procedure, or standard of care. Pediatric Emergency Medicine Practice is a trademark of EB Medicine. Copyright © 2020 EB Medicine All rights reserved. No part of
this publication may be reproduced in any format without written consent of EB Medicine. This publication is intended for the use of the individual subscriber only, and may not be copied in whole or in part or
redistributed in any way without the publisher’s prior written permission – including reproduction for educational purposes or for internal distribution within a hospital, library, group practice, or other entity.

Copyright © 2020 EB Medicine. All rights reserved. 24 Reprints: www.ebmedicine.net/pempissues