Nutritional management and practices in patients with bronchiolitis on non-invasive ventilation using a total face mask: an international survey in French network

doi:10.21203/rs.3.rs-4957100/v1

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Research Article

Nutritional management and practices in patients with bronchiolitis on non-invasive ventilation using a total face mask: an international survey in French network

https://doi.org/10.21203/rs.3.rs-4957100/v1

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Purpose

Bronchiolitis is a major cause of respiratory failure in infants, necessitating non-invasive ventilation (NIV). While total face masks (TFM) are an alternative to nasal interfaces for NIV, they pose unique challenges for enteral feeding due to their design, which can limit airway access and increase the risk of complications. This study aimed to investigate the feeding practices of pediatric intensivists managing bronchiolitis patients using TFM for NIV.

Methods

A cross-sectional survey (Survey-Monkey® software (San Matteo, California, USA)) was conducted among pediatric intensivists in the Groupe Francophone de Réanimation et d'Urgences Pédiatrique (GFRUP) across four French-speaking countries. The survey, consisting of 11 multiple-choice questions, assessed clinical practices related to TFM use and enteral feeding, including initiation timing, feeding methods, and associated complications.

Results

From January 2024 to April 2024, 33 intensivists from 10 units and 4 countries (France, Switzerland, Belgium, Canada) answered the survey. All physicians used routinely TFM with 40% of them using it as a first-line NIV interface. Enteral feeding was commonly initiated within 6 hours of TFM initiation, with 72% of clinicians waiting for a stabilization period of 3 to 6 hours. The majority (85%) employed gastric feeding, with a low incidence of severe complications reported. Vomiting was the most frequent issue, while aspiration pneumonia was rare.

Conclusions

Despite the challenges associated with TFM, enteral feeding is widely practiced among pediatric intensivists, with a cautious approach to initiation and a low complication rate. These findings highlight the need for individualized feeding strategies and further research to optimize feeding practices in this population.

Bronchiolitis

clinical practice

nutrition

total face mask

Bronchiolitis is one of the leading causes of respiratory failure in children younger than two years¹. Patients with specific risk factors such as age under 3 months old, preterm infants, and those with underlying cardiopulmonary disease or immunodeficiency, have an elevated risk of complications such as PICU admission and mechanical ventilation^1,2. According to current guidelines, non-invasive ventilation (NIV) is considered the primary treatment option for the management of patients with bronchiolitis³. For infants receiving NIV, nasal prongs or nasal masks are the most common interfaces employed. However, alternative options like total face masks (TFM) can offer increased comfort and providing NIV support to some patients^2,4. Enteral feeding should be preferred over intravenous hydration regardless of the type of ventilatory support³. While TFM can provide effective NIV, their use in conjunction with enteral feeding remains a topic of debate due to their design, which limits airway access and can result in increased gastric distention and vomiting caused by reduced air leaks. There is a paucity of scientific literature and guidelines available to guide feeding practices for patients with bronchiolitis using to TFM for NIV. In response, a survey was launched to compile insights and clinical practices from healthcare professionals regarding the enteral feeding management of infants with bronchiolitis requiring NIV support via TFM.

The survey was initially developed by one of the authors (T.C.) and subsequently reviewed and approved by the other authors of the article through an iterative consensus process based on the CHERRIES statement⁵. The questions were in French and formatted as multiple choice. The objective was to assess the feeding practices of clinicians using TFM in their routine care of patients with bronchiolitis. The survey was distributed to members of the GFRUP (Groupe Francophone de Réanimation et d'Urgences Pédiatrique), an international group of French-speaking pediatric intensivists (https://gfrup.sfpediatrie.com).

The survey comprised 11 items and was cross-sectional in design, consisting of multiple-choice questions. The survey included two questions about the characteristics of the respondents' healthcare centers, three questions focusing on the management strategies for bronchiolitis, four questions addressing the use of full-face masks, and two questions concerning complications associated with the interface. Following its final approval, the survey was disseminated electronically via SurveyMonkey® (San Matteo, California, USA) along with an informational letter detailing the study's purpose and questions from January 1st to April 30th, 2024. Two reminder emails were sent during the study period to encourage participation. Descriptive analyses were performed using Microsoft Excel (Microsoft Corporation, Redmond, WA, USA). As our study is solely descriptive, no statistical comparisons were performed. As a survey that not involve sensitive health data, and in agreement with institutional policy, this study was exempt from ethics committee review.

During the study period from January 2024 to April 2024, 33 physicians from 10 different intensive care units across four French-speaking countries (France, Switzerland, Canada, and Belgium) completed the online survey. The survey had less than 1% missing data. Detailed results are presented in supplemental digital content. Approximately 48% of respondents work in centers that treat between 50 and 100 bronchiolitis cases annually, and 50% have more than 10 years of experience in the field. All participating physicians routinely use TFM for noninvasive ventilation in bronchiolitis, with 40% using it as the primary NIV interface.

As highlighted in Fig. 1-A, all intensivists initiated feeding within 6 hours of TFM initiation, with 72% waiting for a stabilization period of 3 to 6 hours before starting feeds in patients ventilated with TFM. Prone position had a minimal impact on practice, with only 2 out of 33 (6%) stopping feeds while the patient was prone (Fig. 1-B). The majority of clinicians (28 out of 33, or 85%) used a gastric probe for nutrition (Fig. 1-C). Nearly half reported using either continuous or intermittent gastric nutrition based on the patient’s tolerance.

Severe complications in fed patients with TFM were reported to be rare, with 29 out of 33 (87%) intensivists indicating they occurred "Never" or "Very rarely" (Fig. 1D). Although complications are reported as rare, the most reported complication is vomiting, and only two respondents reporting aspiration pneumonia. Two participants detailed severe complications: one case of cardiorespiratory arrest and death due to pulmonary aspiration in a child with neuromuscular disease, and one case of poor airway opening due to incorrect mask positioning.

In this international survey, we showed that the use of TFM interface for NIV does not deter clinicians from feeding patients with bronchiolitis, even when they are in the prone position. Gastric feeding was widely practiced in patients with TFM support. While complications were reported to be rare, the majority of respondents seem to introduce feeding cautiously and tailor strategies to individual patients to mitigate the risk of aspiration pneumonia. Current guidelines recommend use of enteral feeding in patients with bronchiolitis, but there is limited literature on this topic^3,6. Feeding practices in bronchiolitis were reported in an international survey, showing inconsistent practices among physicians ⁶.The TFM interface which covers the mouth, the nose and the eyes to limit air leaks while improving the delivery of intended FiO2, can pose additional challenges to feeding ². It can limit access to the airways for suctioning and may increase gastric distension due to suppressed air leaks. Despite these limitations, a significant number of clinicians continued to feed patients enterally while using TFM, including in the prone position. Gastric feeding emerged as the primary method for feeding these patients, consistent with recommendations for PICU patients⁷. Many intensivists reported waiting several hours to assess the patient's response and respiratory tolerance to TFM before initiating feeds, whether the patient was supine or prone. This cautious approach may be prudent, as these patients often require invasive ventilation and tracheal intubation within the first hours after admission. Feeding while supported by NIV with a TFM was generally well- tolerated, with a low rate of complications. The most common issue was vomiting with some rare cases of aspiration pneumonia reported. Although these events were rare, the potential for catastrophic outcomes, such as the reported cases of death due to aspiration highlights the need for individualized feeding practices. An observation period under TFM support may help the clinicians to tailor feeding strategies to meet the specific needs of each patient.

Several limitations to the present study must be mentioned, including the small sample size and the subjective nature of responses. Additionally, we lack detailed information on feedings protocols, such as daily volume, type of milk used or the number of feeds per day and it may limit the interpretation of clinicians’ practices.

This study also has several strengths. It is one of the few investigations providing insights into the feeding practices of clinicians using TFM for patients with bronchiolitis across multiple international centers. The high survey completion rate with minimal missing data enhances the reliability of the findings. Additionally, the diverse representation of countries (France, Switzerland, Canada, and Belgium) adds to the study's generalizability. The data gathered offers valuable information on real-world practices and clinician experiences, contributing to the limited literature on this topic. Despite the challenges associated with TFM use, the study highlights that enteral feeding is still commonly and successfully practiced, which is an important finding for improving patient care protocols in pediatric intensive care units.

In conclusion, this study highlights the varied clinical practices regarding feeding patients with NIV and TFM. A high proportion of clinicians reported enterally feeding these patients with reasonable tolerance and a low complication rate. An initial observation period under TFM before initiating feeds appears to be a prudent approach. Further research is needed to define the safest feeding strategies and to develop stronger recommendations.

Consent To Participate Declaration

This article does not contain any studies with human participants performed by any of the authors. Informed consent was implicit for surveyed physicians upon response to the survey.

Funding Declaration

No external funding was received for this study.

Ethics Accordance

The research was conducted in accordance with the Declaration of Helsinki.

Ethics Approval

As a retrospective study on a quality improvement project, and in agreement with institutional policy, this study was exempt from ethics committee review.

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Milési, C. et al. Clinical practice guidelines: management of severe bronchiolitis in infants under 12 months old admitted to a pediatric critical care unit. Intensive Care Med 49, 5–25 (2023)
Cousin, V. L., Corbisier, T., Rimensberger, P. C., Polito, A. & Bordessoule, A. Total face mask with neurally adjusted ventilatory assist as a rescue therapy in infants with severe bronchiolitis. Eur J Pediatr (2024) doi:10.1007/s00431-024-05543-1.
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No competing interests reported.

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Reviewers agreed at journal
24 Sep, 2024
Reviewers invited by journal
20 Sep, 2024
Editor assigned by journal
28 Aug, 2024
Submission checks completed at journal
28 Aug, 2024
First submitted to journal
22 Aug, 2024

You are reading this latest preprint version

Nutritional management and practices in patients with bronchiolitis on non-invasive ventilation using a total face mask: an international survey in French network

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