Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2017 Jan 16;7(1):e011845.
doi: 10.1136/bmjopen-2016-011845.

Paediatric ED BiPAP continuous quality improvement programme with patient analysis: 2005-2013

Thomas Abramo  1   2 , Abby Williams  3   4 , Samaiya Mushtaq  3   5 , Mark Meredith  1   6 , Rawle Sepaule  7 , Kristen Crossman  1 , Cheryl Burney Jones  8 , Suzanne Godbold  9 , Zhuopei Hu  8 , Todd Nick  8
Affiliations

Paediatric ED BiPAP continuous quality improvement programme with patient analysis: 2005-2013

Thomas Abramo et al. BMJ Open. .

Abstract

Objective: In paediatric moderate-to-severe asthmatics, there is significant bronchospasm, airway obstruction, air trapping causing severe hyperinflation with more positive intraplural pressure preventing passive air movement. These effects cause an increased respiratory rate (RR), less airflow and shortened inspiratory breath time. In certain asthmatics, aerosols are ineffective due to their inadequate ventilation. Bilevel positive airway pressure (BiPAP) in acute paediatric asthmatics can be an effective treatment. BiPAP works by unloading fatigued inspiratory muscles, a direct bronchodilation effect, offsetting intrinsic PEEP and recruiting collapsed alveoli that reduces the patient's work of breathing and achieves their total lung capacity quicker. Unfortunately, paediatric emergency department (PED) BiPAP is underused and quality analysis is non-existent. A PED BiPAP Continuous Quality Improvement Program (CQIP) from 2005 to 2013 was evaluated using descriptive analytics for the primary outcomes of usage, safety, BiPAP settings, therapeutics and patient disposition.

Interventions: PED BiPAP CQIP descriptive analytics.

Setting: Academic PED.

Participants: 1157 patients.

Interventions: A PED BiPAP CQIP from 2005 to 2013 for the usage, safety, BiPAP settings, therapeutic response parameters and patient disposition was evaluated using descriptive analytics.

Primary and secondary outcomes: Safety, usage, compliance, therapeutic response parameters, BiPAP settings and patient disposition.

Results: 1157 patients had excellent compliance without complications. Only 6 (0.5%) BiPAP patients were intubated. BiPAP median settings: IPAP 18 (16,20) cm H2O range 12-28; EPAP 8 cmH2O (8,8) range 6-10; inspiratory-to-expiratory time (I:E) ratio 1.75 (1.5,1.75). Pediatric Asthma Severity score and RR decreased (p<0.001) while tidal volume increased (p<0.001). Patient disposition: 325 paediatric intensive care units (PICU), 832 wards, with 52 of these PED ward patients were discharged home with only 2 hours of PED BiPAP with no returning to the PED within 72 hours.

Conclusions: BiPAP is a safe and effective therapeutic option for paediatric patients with asthma presenting to a PED or emergency department. This BiPAP CQIP showed significant patient compliance, no complications, improved therapeutics times, very low intubations and decreased PICU admissions. CQIP analysis demonstrated that using a higher IPAP, low EPAP with longer I:E optimises the patient's BiPAP settings and showed a significant improvement in PAS, RR and tidal volume. BiPAP should be considered as an early treatment in the PED severe or non-responsive moderate asthmatics.

Keywords: BiPAP; BiPAP, Status Asthmaticus, Asthma, Pediatric Emergency Department, Continuous Quality Improvement Program (CQIP) Noninvasive Pos; Continuous Quality Improvement Program (CQIP); Noninvasive Positive Pressure Ventilation; Status Asthma.

PubMed Disclaimer

Conflict of interest statement

Conflicts of Interest: None declared.

Figures

Figure 1
Figure 1
Initial respiratory rate bpm (N=1157) Respiratory rate (bpm) fourth hour on BiPAP (N=1157) BiPAP, bilevel positive airway pressure; bpm, breaths per minute.
Figure 2
Figure 2
Initial IPAP cm H2O. Settings (N=1157); median: 14 (95% CI 12 to 16) cm. Final IPAP cm H2O (N=1157); median: 18 (95% CI 16 to 22) cm. Initial EPAP cm H2O settings (N=1157); median: 8 (95% CI 6 to 8) cm. Final EPAP cm H2O (N=1157); median: 8 (95% CI 8 to 8) cm.
Figure 3
Figure 3
Initial Tv mL (N=1157); median 235 mL (95% CI 190 to 345). Final Tv mL (N=1157); median 736 mL (95% CI 613 to 834). Tv, tidal volume.
Figure 4
Figure 4
All BiPAP patients PAS score (mild=PAS score 0–7, moderate=PAS score 8–11, severe=PAS score 12–15; N=1157). Patient's PAS measurement times. BiPAP, bilevel positive airway pressure; PAS, Pediatric Asthma Severity.
Figure 5
Figure 5
Patients with only 2–4 hours of PED BiPAP: PAS score (mild=PAS score 0–7, moderate=PAS score 8–11, severe=PAS score 12–15; N=832). Patient's PAS measurement times. BiPAP, bilevel positive airway pressure; PAS, Pediatric Asthma Severity; PED, paediatric emergency department.
See this image and copyright information in PMC

References

    1. Newth CJ, Meert KL, Clark AE et al. . Fatal and near-fatal asthma in children: the critical care perspective. J Pediatr 2012;161:214–21. 10.1016/j.jpeds.2012.02.041 - DOI - PMC - PubMed
    1. Nelson KA, Zorc JJ. Asthma update. Pediatr Clin North Am 2013;60:1035–48. 10.1016/j.pcl.2013.06.003 - DOI - PubMed
    1. Rogers L, Reibman J. Pharmacologic approaches to life-threatening asthma. Ther Adv Respir Dis 2011;5:397–408. 10.1177/1753465811398721 - DOI - PubMed
    1. Martin JG, Shore SA, Engel LA. Mechanical load and inspiratory muscle action during induced asthma. Am Rev Respir Dis 1983;128:455–60. 10.1164/arrd.1983.128.3.455 - DOI - PubMed
    1. Golden C, Xu M, Estrada C et al. . Clinical outcomes after bilevel positive airway pressure treatment for acute asthma exacerbations. JAMA Pediatr 2015;169:186–8. - PubMed