(668) Complex Failure of NIV in Children: Looking Beyond Intubation to Clinically Meaningful Outcomes

Introduction: Non-invasive ventilation (NIV) is a standard of care to support children with acute respiratory failure. NIV failure is often reported as the need for tracheal intubation (TI). Indication for TI is subject to provider preference and may not link to outcomes. We developed a new patient-centered NIV failure definition: complex NIV failure. Aim to describe the incidence and characteristics of complex NIV failure using an electronic health record data over 5 years from a large academic PICU in the US.

Methods: Single center, retrospective study of an index PICU admission with initial primary NIV exposure from 2015-2019. Exclusions by the following criteria: >18y, existing tracheostomy, chronic home NIV use, active DNR/DNI, post-extubation NIV, and NIV exposure duration < 60min. Complex NIV failure was defined as: 1) ICU mortality, 2) new tracheostomy, 3) invasive ventilation post NIV for > 10 days, 4) Relevant adverse events during TI (cardiac arrest, hypotension requiring intervention, dysrhythmia, emesis with aspiration, or pneumothorax/ pneumomediastinum), or 5) severe desaturation during TI (SpO2>90% after preoxygenation and lowest SpO2 during intubation of < 70%). Median with interquartile range (IQR). Chi-square for categorical analysis, Wilcoxon rank-sum for non-normally distributed variables.

Results: 9,857 (49%) out of 20,059 ICU admissions had an exposure to NIV. 3,997 index PICU admissions with NIV exposure met inclusion criteria. 106 (2.7%) of these NIV patients led to TI. Complex NIV failure occurred in 203 (5.5%). Median age 2.0y [0.84-6.18] for success and 4.22y [0.87-11.49] for complex failures (p < 0.001). NIV duration was 22 [7-68] hrs in complex failure vs 26 [13-48] in NIV success (p=0.10). TI rate (success 1.3% vs failure 27%, p< 0.001), total ventilation support time (success median 30 [15-59] hrs and failure 412 [241-756] hrs, p< 0.001) and length of ICU stay (success median 2.5 [1.5-4.7] days and failure 27.6 [15.9-43.1] days, p< 0.001) were significantly different.

Conclusions: Complex NIV failure occurred in 5% patients receiving primary NIV for acute support in the PICU and represent a different population than the usual definition based on TI. This new patient-oriented definition may be utilized to identify high risk populations and trajectory of care.