Continuing Medical Education Article

Noninvasive positive-pressure ventilation avoids recannulation and

facilitates early weaning from tracheotomy in children*
Brigitte Fauroux, MD, PhD; Nicolas Leboulanger, MD; Gilles Roger, MD; Françoise Denoyelle, MD, PhD;
Arnaud Picard, MD, PhD; Erea-Noel Garabedian, MD; Guillaume Aubertin, MD; Annick Clément, MD, PhD

LEARNING OBJECTIVES
After participating in this educational activity, the participant should be better able to:
1. Understand the use of the technique of noninvasive positive pressure ventilation in children with tracheotomy.
2. Recognize factors favorably influenced by noninvasive positive pressure ventilation in children with tracheotomy.
3. Understand the factors associated with the successful transition to noninvasive positive pressure ventilation in children
with tracheotomy.
Unless otherwise noted below, each faculty or staff’s spouse/life partner (if any) has nothing to disclose.
The authors have disclosed that they have no financial relationships with or interests in any commercial companies
pertaining to this educational activity.
All faculty and staff in a position to control the content of this CME activity have disclosed that they have no financial
relationship with, or financial interests in, any commercial companies pertaining to this educational activity.
Visit the Pediatric Critical Care Medicine Web site (www.pccmjournal.org) for information on obtaining continuing medical
education credit.

Objective: To show that noninvasive positive-pressure ventilation
by means of a nasal mask may avoid recannulation after decannu-
lation and facilitate early decannulation.
Design: Retrospective cohort study.
Setting: Ear-nose-and-throat and pulmonary department of a pe-
diatric university hospital.
Patients: The data from 15 patients (age ⴝ 2–12 yrs) who needed
a tracheotomy for upper airway obstruction (n ⴝ 13), congenital
diaphragmatic hypoplasia (n ⴝ 1), or lung disease (n ⴝ 1) were
analyzed. Four patients received also nocturnal invasive ventilatory
support for associated lung disease (n ⴝ 3) or congenital diaphrag-
matic hypoplasia (n ⴝ 1). Decannulation was proposed in all patients
because endoscopic evaluation showed sufficient upper airway pa-
tency and normal nocturnal gas exchange with a small size closed
tracheal tube, but obstructive airway symptoms occurred either im-
mediately or with delay after decannulation without noninvasive
positive-pressure ventilation.
Interventions: In nine patients, noninvasive positive-pressure ven-
tilation was started after recurrence of obstructive symptoms after a
delay of 1 to 48 mos after a successful immediate decannulation.
Noninvasive positive-pressure ventilation was anticipated in six pa-
tients who failed repeated decannulation trials because of poor
clinical tolerance of tracheal tube removal or tube closure during
sleep.
Measurements and Main Results: After noninvasive positive-pres-
sure ventilation acclimatization, decannulation was performed with
success in all patients. Noninvasive positive-pressure ventilation was
associated with an improvement in nocturnal gas exchange and
marked clinical improvement in their obstructive sleep apnea symp-
toms. None of the 15 patients needed tracheal recannulation. Nonin-
vasive positive-pressure ventilation could be withdrawn in six pa-
tients after 2 yrs to 8.5 yrs. The other nine patients still receive
noninvasive positive-pressure ventilation after 1 yr to 6 yrs.
Conclusions: In selected patients with upper airway obstruction or
lung disease, noninvasive positive-pressure ventilation may repre-
sent a valuable tool to treat the recurrence of obstructive symptoms
after decannulation and may facilitate early weaning from tracheot-
omy in children who failed repeated decannulation trials. (Pediatr Crit
Care Med 2010; 11:31–37)
KEY WORDS: upper airway; decannulation; congenital airway abnor-
malities; noninvasive positive-pressure ventilation; child

*See also p. 146.
Professor (BF, GA, AC), Pediatric Pulmonary,
Hopital Armand Trousseau, Paris, France; Associate
Surgeon (NL, GR), Otolaryagology-Head & Neck Sur-
gery Department, Hopital Armand-Trousseau, Univer-
sitie Pierre et Marie Curie, Paris, France; Associate
Professor (FD), Otolaryagology-Head & Neck Surgery
Department, Hopital Armand Trousseau, Universitie
Pierre et Marie Curie, Paris, France; Professor (AP),
Plastic Surgery and Maxillo-Facial Department, Hopital
Armand-Trousseau, Paris, France; and Professor
(E-NG), Chief of Department (E-NG), Hopital Armand-
Trousseau, Universitie Pierre et Marie Curie, Paris,
France; and Professor (GA), Pediatric Pulmonary, Ho-
pital Armand Trousseau, Paris, France.
The research is supported, in part, by the Associ-
ation Française contre les Myopathies (AFM), Assis-
tance Publique-Hôpitaux de Paris, INSERM, Legs Poix,
ADEP Assistance, and Université Pierre et Marie Curie-
Paris 6 (BF).
For information regarding this article, E-mail:
brigitte.fauroux@trs.aphp.fr
Copyright © 2010 by the Society of Critical Care
Medicine and the World Federation of Pediatric Inten-
sive and Critical Care Societies
DOI: 10.1097/PCC.0b013e3181b80ab4

Pediatr Crit Care Med 2010 Vol. 11, No. 1 31

C ongenital or acquired upper
airway abnormalities are com-
mon in children. Laryngeal
abnormalities (such as laryn-
gomalacia, subglottic stenosis, or vocal
cord paralysis), tracheal abnormalities
(such as tracheomalacia or tracheal ste-
nosis) as well as Pierre Robin syndrome
may be responsible for severe upper air-
way obstruction that may persist despite
medical and surgical treatment. In these
cases, tracheotomy is indicated to pre-
vent potentially serious complications,
such as airway obstruction and sudden
death (1, 2), pulmonary hypertension and
cor pulmonale (2, 3), failure to thrive (4,
5), and neurocognitive dysfunction with
the risk of intellectual impairment (6). In
case of severe lung disease, tracheotomy
may be indicated to allow invasive venti-
lation in order to improve alveolar venti-
lation (7).
However, tracheotomy is associated
with a significant morbidity and discom-
fort and may impair normal development
and, particularly, language development
(8, 9). Discomfort and social life and fam-
ily disruption are common in patients
with a tracheotomy (10). A recent study
has shown that parents caring for chil-
dren with tracheotomy tubes experience
significant caregiver burden and that the
mental health status for an adult caring
for a child with a tracheotomy tube is
significantly reduced (10). Although tra-
cheotomized children may be safely dis-
charged home after careful family educa-
tion and training, home treatment may
be difficult or even unfeasible for some
families (7, 11). Thus, whenever possible,
decannulation should be proposed as
soon as possible. But decannulation fail-
ure is not uncommon, and apart from the
medical consequences, the psychological
consequences on the child and the family
are important to consider. Nursing staff’s
observations of restlessness, anxiety, and
depression appeared more frequently in
children who failed decannulation (12).
Noninvasive positive-pressure ventila-
tion (NPPV), which consists of the deliv-
ery of positive airway pressure by means
of a nasal mask, has been shown to re-
duce the work of breathing in children
with upper airway obstruction associated
with alveolar hypoventilation (13–16).
NPPV, by maintaining the patency of the
upper airways during the breathing cycle,
allows an increase in tidal volume and
minute ventilation, which translates into
an improvement in gas exchange (15, 16).
NPPV has also demonstrated its benefit in
32
children with chronic lung disease, such
as cystic fibrosis (17–19). In recent years,
we have used NPPV in patients who have
had their tracheotomy removed and sub-
sequently developed recurrent airway ob-
struction. We then used NPPV to facili-
tate early decannulation in patients who
failed repeated decannulation trials. In
the present study, we relate our experi-
ence over the last 12 yrs.
MATERIALS AND METHODS
A tracheotomy was performed in 171 pa-
tients during the 12-yr study period (1996 –
2008) (Fig. 1). Seventy-one patients (42%)
have been decannulated successfully and re-
mained asymptomatic on systematic follow-up
examinations. Sixty patients are still tracheot-
omized and undergo regular evaluations.
Nineteen of these 60 patients could be future
candidates for decannulation because a suffi-
cient improvement in upper airway obstruc-
tion may be expected in the future. The
other patients have too severe upper airway
obstruction or associated morbid condi-
tions. Nineteen patients returned to their
primary hospital and have been lost to fol-
low-up. Six patients with severe underlying
conditions died.
Figure 1. Flow chart of diaphragm of patients.
NPPV, noninvasive positive-pressure ventilation.
Fifteen tracheotomized patients (8.8%)
have been treated with NPPV during the study
period and are analyzed in the present report.
Written approval for care was provided by all
parents and the analysis of the data was ap-
proved by the local ethical committee.
In a first approach, NPPV was used to treat
the recurrence of obstructive symptoms after
an immediate successful decannulation (de-
layed NPPV group). Patients with tracheoto-
mies undergo regular video-endoscopic evalu-
ation of the upper airways under general
anesthesia (spontaneous breathing and as-
sisted ventilation). Decannulation is proposed
when the following criteria are fulfilled:
1. Sufficient airway patency during spontane-
ous breathing in the operating room was
evaluated by endoscopy and reflected by
normal breathing and normal gas exchange
in room air.
2. Adequate airway patency during sleep was
assessed by the absence of obstructive
symptoms, such as stridor, agitation,
arousals, night sweats, and the absence of
nocturnal hypoxemia (⬍5 consecutive
mins with a pulse oximetry [SpO2] ⬍90%)
with hypercapnia (transcutaneous carbon
dioxide [PtcCO2] ⬎50 torr, ⬎6,7 kPa) while
sleeping in room air with a closed tracheal
tube. Before this test, the tracheal tube is
changed for a smaller model to favor easier
breathing during nocturnal sleep.
All patients who fulfilled these criteria
were decannulated without NPPV. A regular
3-mo follow-up was systematically performed
with clinical examination, endoscopic evalua-
tions when indicated, and nocturnal gas ex-
change recordings at least every 6 mos.
In a second approach, we used NPPV to
facilitate early weaning from tracheostomy
(immediate NPPV group). In these patients,
airway patency with a closed smaller tube was
not sufficient during nocturnal sleep as re-
flected by obstructive symptoms (described
above) and abnormal nocturnal gas exchange
in room air with at least 5 consecutive mins
with a SpO2 ⬍90% and/or a PtcCO2 ⬎50 torr
(⬎6,7 kPa). In this situation, or after previous
several failed decannulation attempts, NPPV
was proposed before decannulation.
In this immediate NPPV group, the decan-
nulation procedure was as follows. The first
step consisted of the acclimatization of the
patient to the nasal mask only, without the
ventilator. This step took between 2 to 15 days,
depending on the patient’s age, and his/her
medical and psychological history. Then,
when the patient accepted to wear the nasal
mask with the headgear, NPPV without seda-
tion was tried for short periods, lasting 2 to 5
mins, which were repeated during daytime.
When daytime tolerance exceeded 15 contin-
uous mins, NPPV was tried during the night as
Pediatr Crit Care Med 2010 Vol. 11, No. 1
the tracheal tube was closed. Because of the
partial airway obstruction due to the presence
of the tube, the inspiratory and expiratory
NPPV pressures were set 2 cm H2O above the
levels that would have been chosen without
the presence of the tube. Overnight SpO2,
PtcO2, and PtcCO2 recordings were systemati-
cally performed. At initiation, NPPV was per-
formed at night and during daytime with three
to four breaks of 2 to 3 hrs. But within 1 wk,
all the patients were able to use NPPV exclu-
sively during sleep, at night in all the patients
and during daytime naps in the youngest pa-
tients. The tracheal tube was then removed
and NPPV settings were adjusted to obtain a
normal breathing pattern without stridor and
adequate gas exchange, as defined by the ab-
sence of nocturnal hypoxemia (⬍5 consecu-
tive mins with an SpO2 ⬍90%) and hypercap-
nia (no periods with a PtcCO2 ⬎50 torr [⬎6,7
kPa]). The acceptance and optimal setting of
NPPV lasted 3 to 15 more days, depending on
the age of patient, his/her medical history,
anxiety, and psychological stress.
NPPV was always performed by pressure-
controlled ventilators (Harmony or Synchrony
(Respironics, Craquefou, France), VPAP 3ST
or STA (Resmed, Saint Priest, France), Vivo 40
(Breas Medical, Saint Priest, France), or
Knightstar (Tyco Healthcare, Elancourt,
France), delivering bilevel positive airway
pressure by means of a commercially available
(Respironics, Resmed or Fisher Paykel nasal
masks), or custom-made nasal mask. These
custom-made masks were composed of a ther-
moformable plastic frame (VT Plastics, Gen-
nevilliers, France) with an interior coverage of
either self-sticking foam (Adhesia Laboratoire,
Mulhouse, France) or a protection and com-
fort gel (Adhesia Laboratoire, Mulhouse,
France). The nasal mask was connected to an
expiratory valve and a nonrebreathing circuit
by a plastic tube of an inner diameter of 22
mm, which was fixed on the mask by an au-
topolymerizable resin (Orthoresin, Dentsply,
Weybridge, United Kingdom). The masks were
modeled on plaster phantoms corresponding
to the age and the physiognomy of the patient.
Bedside adjustments were then realized, if
necessary, by thermoforming the plastic frame
to obtain the best comfort with minimal leaks
(20). Custom-made masks were used in case of
age ⬍2 yrs, facial deformity, and/or intoler-
ance of an industrial mask (20). Inspiratory
pressures of 6 to 10 cm H2O and expiratory
pressures of 4 to 6 cm H2O were used, with a
ramp when available and a back-up rate of 2 to
5 breaths below the patient’s spontaneous
breathing rate.
Nocturnal gas exchange was routinely eval-
uated by oxygen and CO2 recording, either by
the Tina monitor (Tina, Radiometer, Copen-
hague, Denmark), or by the SenTec Digital
Monitor (SenTec, Therwil, Switzerland) dur-
Pediatr Crit Care Med 2010 Vol. 11, No. 1
ing the acclimatization to NPPV. Sleep studies
looked for obstructive apnea, which was de-
fined as the absence of air flow with continued
chest-wall and abdominal movement for at
least two breaths (21, 22). Hypopnea was de-
fined as a decrease in nasal flow of ⱖ50% with
a corresponding decrease in SpO2 ⱖ4% and/or
with associated arousal. The apnea index and
the hypopnea index were defined as the num-
bers of apnea and hypopneas per hour of total
sleep time. A desaturation was defined as a
decrease of SpO2 ⱖ4% below baseline and the
desaturation index was calculated as the num-
ber of desaturations per hour of total sleep
time (21, 22). Evaluation of diurnal gas ex-
change was assessed by arterialized capillary
blood gases in the morning, after a night of
NPPV (23). Initially, the tracheal stoma was
occluded by a sticking plaster. The number of
patients who needed a surgical closure of the
tracheal stoma was recorded.
Discharge to home with NPPV was allowed
when the following criteria were fulfilled:
● Ability to sleep at least 5 hrs with NPPV;
● Absence of nocturnal hypoxemia or hyper-
capnia while on NPPV without supplemen-
tal oxygen;
● Parents and family educated to NPPV.
RESULTS
Delayed NPPV Group
The delayed NPPV group comprised
nine patients (Table 1). In seven patients
(patients 1 to 7), tracheotomy was per-
formed before 6 mos of age, because of
vocal cord paralysis (which was always
associated with another cause of airway
obstruction) in four patients (patients 2,
3, 6, and 7), Treacher-Collins syndrome
in one patient (patient 1), congenital pa-
ralysis of the diaphragm in one patient
(patient 4), and cystic lymphangioma in
one patient (patient 5). Patients 4 and 6
received nocturnal NPPV on the tracheal
tube before decannulation because of di-
aphragmatic paralysis and associated
bronchopulmonary dysplasia, respec-
tively. Immediate decannulation was well
tolerated by all patients, without clinical
symptoms of upper airway obstruction,
nocturnal desaturations, or hypercapnia
as previously defined. However, after a
delay of 1 to 48 mos, all patients devel-
oped symptoms of obstructive sleep ap-
nea with stridor, night sweats and arous-
als, daytime fatigue, and change in mood
and attention. Nocturnal SpO2, PtCO2, and
PtcCO2 recordings in room air showed the
presence of apneas and hypopneas, asso-
ciated with periods of desaturation and
hypercapnia (Table 2). These obstructive
symptoms were explained by an increase
of pharyngolaryngeal hypotonia or the re-
currence of the primary disorder for
which no satisfactory surgical interven-
tion could be proposed. NPPV was initi-
ated to avoid recannulation. Nocturnal
bilevel positive-pressure ventilation was
performed with inspiratory pressures of 6
to 10 cm H2O and expiratory pressures of
4 to 6 cm H2O. The five youngest patients
were equipped with a custom-made
mask, whereas the four older patients
used a commercially available mask. The
daytime and nocturnal gas exchange in-
dices and sleep parameters exhibited a
trend toward improvement but because
of the small number of patients, the dif-
ferences did not reach statistical signifi-
cance (Table 2). All the patients were dis-
charged home. A surgical closure of the
tracheal stoma was required in four pa-
tients (patients 1, 2, 8, and 9). NPPV
could be definitely withdrawn in three
patients, after 2 yrs in patients 2 and 5,
and after 8.5 yrs in patient 8. At follow-
up, none of the patients needed a recan-
nulation and none of the patients died.
Immediate NPPV Group
The immediate NPPV group com-
prised six patients (Table 1). In four of
these patients, tracheotomy was per-
formed before 3 mos of age because of
severe upper airway obstruction in the
neonatal period. The two other patients
were tracheotomized at ages 1.5 yrs and
2.7 yrs because of mandibular hypoplasia
(patient 14) and chronic respiratory in-
sufficiency related to an acute respiratory
distress syndrome of unknown origin (pa-
tient 15). This latter patient received noc-
turnal pressure-controlled ventilation be-
cause of his associated lung disease as
well as patient 10 because of associated
bronchopulmonary dysplasia. In these
two patients, NPPV was started before
decannulation because of the need to
continue nocturnal ventilatory support.
Once the decision had been made to at-
tempt tracheotomy removal, a smaller
tube was placed to facilitate spontaneous
breathing. In the four patients who were
not on long-term invasive ventilation, de-
cannulation without NPPV was not pos-
sible because of nocturnal hypoventila-
tion due to upper airway obstruction. All
patients developed clinical symptoms of
upper airway obstruction with stridor,
chest retractions, and night sweats, asso-
ciated with periods exceeding 5 continu-
33
Table 1. Description of the patients

Age at Age at NPPV Delay

Patient Gender Diagnosis Tracheotomy Detubation (yrs) (mos) Outcome

Delayed NPPV
group
1 female Treacher-Collins 1 mo 2.5 6 on NPPV since 1 mo
syndrome
2 female Vocal cord paralysis ⫹ 1 mo 2.5 4 successful NPPV withdrawal at
tracheomalacia age 5, now 7.5 yrs old
3 male Vocal cord paralysis ⫹ 3 mos 11 48 still on NPPV at age 18
polymalformation
4 male Congenital 3 mos 5.7 12 still on NPPV at age 12
diaphragmatic
hypoplasia #
5 female Cystic lymphangioma 6 mos 2 1 successful NPPV withdrawal at
age 4, now 11 yrs old
6 male Vocal cord paralysis ⫹ 6 mos 2 1 still on NPPV at age 4
BPD #
7 male Vocal cord paralysis ⫹ 6 mos 10 6 still on NPPV at age 11
multiple congenital
anomalies
8 male Laryngeal cleft 1 yr 3 6 successful NPPV withdrawal at
age 12, now 13 yrs old
9 female Vocal cord paralysis ⫹ 6.5 yrs 10.5 9 still on NPPV at age 12
cerebral tumor
Immediate NPPV
group
10 male Pierre Robin sequence 1 mo 3.5 0 successful NPPV withdrawal at
⫹ BPD # age 7, now 8 yrs old
11 female Cystic lymphangioma 1 mo 12 0 still on NPPV at age 17
⫹ mandibular
hypoplasia
12 male Laryngeal cleft grade 2 mos 2.5 0 successful NPPV withdrawal at
IV age 5, now 8 yrs old
13 male Vocal cord paralysis ⫹ 3 mos 6 0 successful NPPV withdrawal at
tracheomalacia age 8, now 8.5 yrs old
14 female Mandibular hypoplasia 1.5 yrs 9 0 still on NPPV at age 14
15 male ARDS sequelae # 2.7 yrs 7 0 still on NPPV at age 9

NPPV, noninvasive positive-pressure ventilation; BPD, bronchopulmonary dysplasia; ARDS, acute respiratory distress syndrome; #, patients receiving
nocturnal positive-pressure ventilation on the tracheal tube before decannulation.

ous mins with a SpO2 ⬍90% and a PtcCO2
⬎50 torr (⬎6,7 kPa) during tracheal tube
closure and/or removal trials. In these
patients, no surgical option was available
to facilitate decannulation without seri-
ous drawbacks, such as an increase in the
risk of false passages. Previous attempts
of decannulation without NPPV had been
undertaken at least two times in all six
patients over long periods (mean pe-
riod ⫽ 14.3 mos; range ⫽ 6 –32 mos)
without success. Mean age at decannula-
tion in these patients was 6.7 yrs
(range ⫽ 2.5–12 yrs). The daytime and
nocturnal gas exchange indices and sleep
parameters with nocturnal NPPV were
within the normal range (Table 2).
The three youngest patients were
equipped with custom-made masks and
the three older patients with commer-
cially available nasal masks. All the pa-
tients were discharged home and the
three patients who were in a transitional
care facility were able to return to their
families. After decannulation, all the pa-
tients experienced improvements in lan-
guage and development. Initially, the tra-
cheal stoma was occluded by a plastic
sticker, but a secondary surgical closure
of the tracheal stoma was necessary in all
patients. Three patients could be weaned
from NPPV after 2 yrs to 3 yrs and three
others were still on NPPV at ages 9, 14,
and 17 yrs. None of the patients died.
DISCUSSION
This study shows that NPPV is able to
treat successfully the recurrence of ob-
structive airway disorders after tracheot-
omy weaning in children. But, most im-
portantly, we show for the first time that
NPPV may facilitate decannulation in
children who failed repeated decannula-
tion trials. Tracheotomy weaning could
only be achieved with immediate NPPV
support. The use of bilevel positive end-
expiratory pressure by means of a nasal
mask was associated with an improve-
ment of nocturnal gas exchange in all
patients and during follow-up, none of
the patients needed recannulation.
NPPV has been shown to be an alter-
native to invasive ventilation in selected
patients with neuromuscular disease,
managed by highly skilled teams. In ad-
olescents and young adults with Duch-
enne muscular dystrophy, NPPV by
means of a nasal mask during the night
and a mouthpiece during the day, associ-
ated with cough-assisted techniques, may
allow extubation or decannulation and
prolong survival in well-trained and
highly qualified teams (24, 25). Even in
young infants with spinal muscular atro-
phy Type I, a noninvasive respiratory
management approach may be successful
in selected cases, with an improvement in

34 Pediatr Crit Care Med 2010 Vol. 11, No. 1

Table 2. Daytime and nocturnal gas exchange indices press their will, refused the eventuality of
a recannulation.
Delayed NPPV Group n ⫽ 9
We present here a series of 14 patients
Immediate NPPV
Normal Valuesa Before NPPV With NPPV Group n ⫽ 6 with upper airway disease and one patient
with lung disease in whom NPPV was able
Daytime to facilitate decannulation or treat ob-
parameters struction recurrence. Several requisites
PaO2, torr 80 ⫾ 10 78 ⫾ 8 73 ⫾ 2 82 ⫾ 7 must be fulfilled for NPPV to be success-
PaCO2, torr 35 ⫾ 10 37 ⫾ 3 39 ⫾ 3 40 ⫾ 4 ful. First, endoscopic evaluation should
Nocturnal
parameters
show a sufficient airway patency, allow-
Apnea index ⬍1 3⫾3 0.0 ⫾ 0.0 0.2 ⫾ 0.4 ing acceptable tolerance of spontaneous
Hypopnea ⬍1 37 ⫾ 39 0.6 ⫾ 1.3 0.4 ⫾ 0.5 breathing without a tracheal tube. Be-
index cause of lack of objective measurable cri-
% of time with ⱖ99% 54 ⫾ 33 69 ⫾ 29 36 ⫾ 29 teria to estimate airway caliber in young
SpO2 ⱖ95% children, this decision relies on the sub-
% of time with ⱕ1% 29 ⫾ 21 29 ⫾ 13 63 ⫾ 16
SpO2 91%–
jective estimation of the airway patency
94% by an experienced pediatric ear-nose-
% of time with 0% 16 ⫾ 34 2⫾6 1⫾1 throat surgeon.
SpO2 ⱕ90% Second, NPPV in this age group re-
Desaturation ⬍1 38 ⫾ 35 25 ⫾ 22 22 ⫾ 14 quires some technical requisites. The
index choice of the interface is problematic in
PtcO2 min, torr ⱖ70 62 ⫾ 27 69 ⫾ 11 63 ⫾ 11
PtcCO2 max, ⱕ50 51 ⫾ 8 49 ⫾ 3 48 ⫾ 4
young children (20). To our knowledge,
torr no adequate commercial nasal masks are
Delta PtcCO2 ⱕ10 15 ⫾ 8 11 ⫾ 3 9⫾3 available for children weighing ⬍10 kg.
max, torr These young children need thus custom-
made masks, which require an experi-
NPPV, noninvasive positive-pressure ventilation; PaO2, partial arterial oxygen pressure; PaCO2, enced and motivated pediatric maxillofa-
partial arterial carbon dioxide pressure; SpO2, pulse oximetry; PtcO2 min, minimum transcutaneous cial team. Because of facial growth and
oxygen pressure; PtcCO2 max, maximum transcutaneous carbon dioxide pressure; delta PtcCO2 max,
potential side effects, such as skin injury
maximum awake/night change of transcutaneous carbon dioxide pressure.
a
American Thoracic Society (21) and Montgomery-Downs et al (22).
and facial deformity, a close follow-up of
these masks is absolutely necessary (20).
With this maxillofacial monitoring, no
medical condition and quality of life for randomized, controlled trial but the fea- significant skin or facial side effects were
the child and his/her family (26, 27). sibility of such a study may be extremely observed in the patients included in the
To our knowledge, information re- difficult because of practical and ethical present study.
garding the use of NPPV to facilitate ex- issues. Even if large series have reported Finally, the psychological aspect is of
tubation or tracheotomy weaning in a low occurrence rate of tracheotomy- paramount importance. A tracheotomy is
other pediatric diseases is lacking. Indi- related mortality and morbidity, severe an invasive procedure, associated with re-
cations for tracheotomies in children in- complications may occur during the can- current invasive maneuvers, such as as-
clude airway obstruction, inadequate air- nulation period, such as tube obstruction piration, tube removal, and change, and,
way protection, chronic lung disease, or dislocation, accidental decannulation, as a consequence, hospital visits and hos-
neuromuscular weakness, and central hy- or pneumothorax (7, 31–34). Long-term pitalizations. All these children have se-
poventilation (7). All these conditions complications include tracheal stenosis, vere, and often multiple medical disor-
may be managed by NPPV, if the patient stomal narrowing, and recurrent lung in- ders, which contribute to anxiety, pain,
has an adequate respiratory autonomy, and psychological stress, both for the
fections occurring in 10% to 40% of pa-
allowing NPPV to be used preferentially child and his/her family. This may explain
tients (7, 33, 34). There is also evidence
at night. Interestingly, regular use of why some children resist any procedure
that children with tracheotomies are at
NPPV at night was associated with an involving the face or the upper airway. In
risk for delays in receptive and expressive
improvement in daytime spontaneous more than half of the children in the
breathing and gas exchange, as observed language development as well in deficits present study, acclimatization to the na-
in children with other conditions, such as in oral/vocal speech and voice production sal mask took ⬎1 wk, which is twice as
neuromuscular disease (28 –30). As such, (35–37). NPPV, as a noninvasive tech- long as our experience with children who
NPPV could be proposed to a selected nique, is not associated with these nu- did not have a prior tracheotomy. The
group of tracheotomized patients to facil- merous side effects. Importantly, unex- active role of the parents, but also the
itate decannulation. pected readmission rate may reach 63% nurses, psychologists, and school teach-
Our protocol is based on the assump- in some series of children with tracheot- ers are of great help in such situations.
tion that long-term use of NPPV is asso- omy (7), whereas none of the 15 patients Encouragements and positive rewards
ciated with a better quality of life for the reported in the present study required were used by the medical team and family
patient and his/her family and fewer side readmission to the hospital for an acute to help the child to accept NPPV. One
effects than a prolonged tracheotomy. To upper or lower respiratory tract problem child, who underwent tracheotomy in the
our knowledge, NPPV has not been com- during the follow-up. Importantly, all the neonatal period for congenital myasthe-
pared with tracheotomy in a prospective, families and patients, when able to ex- nia which was diagnosed only at the age

Pediatr Crit Care Med 2010 Vol. 11, No. 1 35

of 4 yrs, never accepted the nasal mask
and NPPV. His spontaneous sleep without
a tracheotomy and ventilatory support
was acceptable after decannulation but
after 1 yr, he required 5 days of invasive
ventilation for an acute viral lower airway
infection. It is highly possible that, in this
neuromuscular patient, the long-term
use of NPPV would have been able to
prevent acute invasive ventilatory sup-
port (38, 39). These medical, technical,
and psychological requirements may ex-
plain why NPPV is not considered as a
routine procedure to facilitate decannu-
lation in young children.
We acknowledge that the patients of
the present study had particularly severe
upper airway obstruction that required
maintenance of the tracheal tube to a very
advanced age (⬎6 yrs of age) whereas de-
cannulation for usual upper airway ob-
struction is generally achieved before the
age of 4 yrs. At that advanced age, our
patients did not tolerate decannulation
without NPPV even after several trials, re-
flecting the severity of the residual obstruc-
tion that NPPV was able to improve.
An important observation from the de-
layed NPPV group is that patients with
severe upper airway obstruction need a
close and prolonged medical follow-up
after decannulation. Alveolar hypoventi-
lation could recur as long as 48 mos after
decannulation (patient 3). Apart from
medical and endoscopic examination,
careful attention must be paid to sleep-
disordered breathing and sleep-related
problems. Ideally, all those patients
should have a complete polysomnogra-
phy, which is the gold standard for the
diagnosis of sleep-disordered breathing.
Such a complete evaluation was not pos-
sible in the immediate NPPV group be-
cause of the unstable clinical condition of
the patients. In the delayed NPPV group,
some patients had a polysomnography
but others, because of time and practical
constraints, had only an overnight re-
cording of gas exchange. However, these
recordings were always sufficiently ab-
normal to institute NPPV without delay.
Finally, the use of NPPV as an alter-
native to recannulation and as a weaning
tool for tracheotomized patients raises
the question of the optimal indications
for tracheotomy in children. The useful-
ness of NPPV as a first-line treatment in
selected patients with severe upper air-
way obstruction, who have sufficient air-
way patency when awake during daytime
and who need positive pressure only dur-
ing sleep, is worthy of evaluation.
36
CONCLUSIONS
To our knowledge, we report here a
first experience of successful use of NPPV
to treat recurrent respiratory obstruction
after decannulation and facilitate decan-
nulation in young children with severe
upper airway obstruction or lung disease.
The increasing use of NPPV in children,
both in the acute (40) and chronic setting
(41, 42), should be extended also to a
selected group of tracheotomized pa-
tients, to improve the quality of life for
the child and his/her family.
ACKNOWLEDGMENT
We thank Emmanuelle Cohen for her
excellent technical assistance.
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