Abstract

Respiratory distress is a common symptom in children and a common reason for visits to the emergency department.¹ Even for experienced emergency care providers, the management of respiratory distress in children can be challenging and frightening. While the great majority of children with respiratory distress will respond to standard therapies, including aerosols, suctioning, and supplemental oxygen, some patients will require a higher level of respiratory support. Endotracheal intubation and mechanical ventilation are critical interventions in many cases of respiratory failure, but there are definite risks associated with intubation. Children with asthma, in particular, are at high risk for complications, including pneumothoraces and pneumomediastinum.^2,3 In appropriately selected patients, noninvasive ventilation (NIV) may be an extremely valuable alternative to intubation. NIV refers to the application of ventilatory support using techniques that do not require an invasive endotracheal airway. Multiple forms of NIV are available for use in children, including continuous positive airway pressure (CPAP), bi-level positive airway pressure (BiPAP), intermittent positive pressure breathing (IPPB), humidified high-flow nasal cannula (HHFNC), and bi-level nasal CPAP. Use of NIV in pediatric patients is increasing in the emergency department, critical care unit, and prehospital environment, but what is the evidence supporting its use? This issue of Pediatric Emergency Medicine Practice reviews the history of noninvasive ventilation, the rationale for its use, and the evidence supporting its use in children with acute and chronic respiratory failure. We will describe four modes in NIV currently available for use in children as well as techniques for initiation of each NIV device in the emergency department.