Comparing the Efficacy of Negative-Pressure Ventilation to Noninvasive, Positive-Pressure Ventilation in Children With Acute Respiratory Failure

Background: Negative-pressure ventilation (NPV) avoids a positive-pressure facial interface, but contemporary multi-center pediatric data comparing NPV with noninvasive positive-pressure ventilation (NIV) are limited. We describe modern NPV epidemiology and compare outcomes with NIV in children younger than 3 years with acute respiratory failure. Methods: We conducted a multi-center retrospective cohort study using the Virtual Pediatric Systems (VPS) database. Children younger than 3 years who received NPV or NIV during a pediatric ICU (PICU) admission for acute or acute-on-chronic respiratory failure were included; outpatient use of either modality was excluded. Subjects were categorized according to initial respiratory support modality. The primary outcome was endotracheal intubation after initiation of noninvasive respiratory support. The primary analysis used multivariable mixed-effects logistic regression with center included as a random intercept. Propensity-score matching using Pediatric Risk of Mortality III score, age, sex, weight, diagnostic variables, and center was performed as a sensitivity analysis. Results: Crude intubation rates were higher in the NPV group than in the NIV group (27.3% vs 10.4%, P < .001). After adjustment for measured subject-level factors and center-level clustering, ventilation modality was not independently associated with intubation (NIV vs NPV adjusted OR 0.675, 95% CI 0.393–1.158, P = .154). In the propensity-score-matched cohort, intubation remained numerically higher in the NPV group but was not statistically significant (NPV vs NIV OR 1.64, 95% CI 0.92–2.93, P = .12). Conclusions: In this multi-center retrospective cohort, NPV was used in a small minority of children younger than 3 years with acute respiratory failure. After adjustment for measured confounders and center-level clustering, ventilation modality was not independently associated with intubation. Prospective studies are needed to define optimal patient selection and the role of NPV in pediatric acute respiratory failure.