Risk Factors for Noninvasive Ventilation Failure in Children Post-Hematopoietic Cell Transplant

Courtney M Rowan; Julie C Fitzgerald; Asya Agulnik; Matt S Zinter; Matthew P Sharron; James E Slaven; Erin M Kreml; Rajinder P S Bajwa; Kris M Mahadeo; Jerelyn Moffet; Keiko M Tarquinio; Marie E Steiner

doi:10.3389/fonc.2021.653607

Risk Factors for Noninvasive Ventilation Failure in Children Post-Hematopoietic Cell Transplant

Front Oncol. 2021 May 27:11:653607. doi: 10.3389/fonc.2021.653607. eCollection 2021.

Authors

Affiliations

¹ Department of Pediatrics, Division of Critical Care, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, United States.
² Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States.
³ Department of Global Pediatric Medicine, Division of Critical Care, St. Jude's Children's Research Hospital, Memphis, TN, United States.
⁴ Department of Pediatrics, Division of Critical Care, University of California San Francisco, San Francisco, CA, United States.
⁵ Department of Pediatrics, Division of Critical Care, George Washington University School of Medicine and Health Sciences, Children's National, Washington, DC, United States.
⁶ Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, United States.
⁷ Critical Care Medicine, Phoenix Children's Hospital, Phoenix, AZ, United States.
⁸ Division of Heme/Onc/Bone Marrow Transplant, Nationwide Children's Hospital, Columbus, OH, United States.
⁹ Department of Pediatrics, Division of Pediatric Stem Cell Transplant and Cellular Therapy, University of Texas at MD Anderson Cancer Center, Houston, TX, United States.
¹⁰ Department of Pediatrics, Division of Blood and Marrow Transplant, Duke Children's Hospital, Duke University, Durham, NC, United States.
¹¹ Department of Pediatrics, Division of Pediatric Critical Care Medicine, Emory University, Children's Healthcare of Atlanta, Atlanta, GA, United States.
¹² Department of Pediatrics, Division of Critical Care and Division of Hematology, Masonic Children's Hospital, University of Minnesota, Minneapolis, MN, United States.

Abstract

Rationale: Little is known on the use of noninvasive ventilation (NIPPV) in pediatric hematopoietic cell transplant (HCT) patients.

Objective: We sought to describe the landscape of NIPPV use and to identify risk factors for failure to inform future investigation or quality improvement.

Methods: This is a multicenter, retrospective observational cohort of 153 consecutive children post-HCT requiring NIPPV from 2010-2016.

Results: 97 (63%) failed NIPPV. Factors associated with failure on univariate analysis included: longer oxygen use prior to NIPPV (p=0.04), vasoactive agent use (p<0.001), and higher respiratory rate at multiple hours of NIPPV use (1hr p=0.02, 2hr p=0.04, 4hr p=0.008, 8hr p=0.002). Using respiratory rate at 4 hours a multivariable model was constructed. This model demonstrated high ability to discriminate NIPPV failure (AUC=0.794) with the following results: respiratory rate >40 at 4 hours [aOR=6.3 9(95% CI: 2.4, 16.4), p<0.001] and vasoactive use [aOR=4.9 (95% CI: 1.9, 13.1), p=0.001]. Of note, 11 patients had a cardiac arrest during intubation (11%) and 3 others arrested prior to intubation. These 14 patients were closer to HCT [14 days (IQR:4, 73) vs 54 (IQR:21,117), p<0.01] and there was a trend toward beginning NIPPV outside of the PICU and arrest during/prior to intubation (p=0.056).

Conclusions: In this cohort respiratory rate at 4 hours and vasoactive use are independent risk factors of NIPPV failure. An objective model to predict which children may benefit from a trial of NIPPV, may also inform the timing of both NIPPV initiation and uncomplicated intubation.

Keywords: cardiopulmonary resuscitation; hematopoietic (stem) cell transplantation (HCT); intubation; noninvasive (positive pressure) ventilation; respiratory insufficiency.

Abstract

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