Transnasal Humidified Rapid Insufflation Ventilatory Exchange in children requiring emergent intubation (Kids THRIVE): a protocol for a randomised controlled trial.

INTRODUCTION: Emergency intubation of children with abnormal respiratory or cardiac physiology is a high-risk procedure and associated with a high incidence of adverse events including hypoxemia. Successful emergency intubation is dependent on inter-related patient and operator factors. Preoxygenation has been used to maximise oxygen reserves in the patient and to prolong the safe apnoeic time during the intubation phase. Transnasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) prolongs the safe apnoeic window for a safe intubation during elective intubation. We designed a clinical trial to test the hypothesis that THRIVE reduces the frequency of adverse and hypoxemic events during emergency intubation in children and to test the hypothesis that this treatment is cost-effective compared with standard care. METHODS AND ANALYSIS: The Kids THRIVE trial is a multicentre randomised controlled trial performed in participating emergency departments and paediatric intensive care units. 960 infants and children aged 0-16 years requiring emergency intubation for all reasons will be enrolled and allocated to THRIVE or control in a 1:1 allocation with stratification by site, age (<1, 1-7 and >7 years) and operator (junior and senior). Children allocated to THRIVE will receive weight appropriate transnasal flow rates with 100% oxygen, whereas children in the control arm will not receive any transnasal oxygen insufflation. The primary outcomes are defined as follows: (1) hypoxemic event during the intubation phase defined as SpO2 <90% (patient-dependent variable) and (2) first intubation attempt success without hypoxemia (operator-dependent variable). Analyses will be conducted on an intention-to-treat basis. ETHICS AND DISSEMINATION: Ethics approval for the protocol and consent process has been obtained (HREC/16/QRCH/81). The trial has been actively recruiting since May 2017. The study findings will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: ACTRN12617000147381.

Increase in use of non-invasive ventilation for infants with severe bronchiolitis is associated with decline in intubation rates over a decade.

PURPOSE: To redress the paucity of studies evaluating non-invasive respiratory support in bronchiolitis patients. METHODS: Following ethics committee approval, the clinical database of a tertiary 23-bed paediatric intensive care unit (PICU) was reviewed for bronchiolitis admissions from January 2000 to December 2009. Length of stay (LOS), ventilatory requirements and risk factors, including prematurity, respiratory syncytial virus (RSV) status, chronic lung, neuromuscular, immune and congenital heart disease, were analysed. RESULTS: Of 8,288 admissions, 520 (6.27 %) had bronchiolitis with 343 (65.9 %) having RSV. Median (±SD) age and LOS were 2.78 months and 2.68 (±4.32) days. One (0.2 %) patient died. Assisted ventilation was required for 399 (76.7 %) patients. A total of 114 (28.6 %) patients were intubated directly and 285 (71.4 %) had a trial of non-invasive ventilation (NIV). Significant increase in the use of NIV was seen (2.8 %/year) with decline in intubation rates (1.9 %/ year) (p = 0.002). Of NIV patients, 237 (83.2 %) needed only NIV and 48 (16.8 %) failed and therefore needed intubation. The median LOS was shorter in those who succeeded NIV (2.38 ± 2.43 days) compared to those with invasive ventilation (5.19 ± 6.34 days) and those who failed NIV (8.41 ± 3.44 days). Presence of a risk factor increased the chances of failing NIV from 6 to 10 %. CONCLUSION: NIV was successful in the vast majority of patients, particularly in those without risk factors and halved the LOS in intensive care. Failure of NIV was associated with increased duration of invasive ventilation and PICU LOS. A prospective study comparing different techniques of NIV will be helpful in defining the risks of failure of NIV.