Oxygen and ventilator weaning during inpatient pediatric pulmonary rehabilitation

Liberation and mortality outcomes in pediatric long-term ventilation: A qualitative systematic review

OBJECTIVE

To provide a systematic review of liberation from positive pressure ventilation and mortality of children with chronic respiratory failure who used long-term invasive and noninvasive ventilation (LTV).

METHODS

Papers published from 1980 to 2018 were identified using Pubmed MEDLINE, Ovid MEDLINE, Embase, and Cochrane databases. Search results were limited to English-language papers with (a) patients less than 22 years at initiation, (b) patients who used invasive ventilation (IV) via tracheostomy or noninvasive ventilation (NIV), and (c) data on mortality or liberation from LTV. Data were presented using descriptive statistics; changes in outcomes over time were explored using linear regression. Follow-up variability, cohort heterogeneity, and insufficient data precluded combining data to estimate incidences or rates.

RESULTS

One hundred and thirty papers with 12 704 patients were included. The median number of patients was 37 (interquartile range [IQR] 17-74, range 6-3802). Twenty-five percent of patients were initiated on IV; 75% on NIV. The maximum follow-up ranged from 0.5 to 31.8 years (median 8.8 years). The median proportion of patients liberated in these papers was 3% (IQR 0%-21%). The median proportion of mortality was 18% (IQR 8%-27%). Proportions of liberation and mortality did not significantly change over time. Progression of underlying disease (44%), respiratory illness (19%), and LTV accident (11%) were the most common causes of death.

CONCLUSIONS

These papers collectively show most patients survive for many years using LTV; in many subgroups, death is a more common outcome than liberation. However, the limitations of these papers preclude robust prognostication.

Children dependent on respiratory support: A 10-year review from one pediatric postacute care hospital

OBJECTIVE

Pediatric postacute care hospitals (PACH) provide long-term care for children with medical complexity including children dependent on respiratory support. Descriptions of PACH respiratory care populations and outcomes, however, remain under-reported. Our aim was to describe demographics, respiratory outcome, and longitudinal trend of children with respiratory support admitted to a single PACH in the United States.

METHODS

Using electronic records from 2009 to 2018, data were examined for all children dependent on respiratory support. Children were identified for inclusion using respiratory level of care classifications (type of support) as outlined in hospital policy. Outcome was defined as change in level from first admission to final discharge. Number of admissions by level and year during the study timeframe were analyzed.

RESULTS

There were 1423 admissions for 767 children requiring respiratory support during the study timeframe. Children with higher respiratory classification level (eg, mechanical ventilation) at initial admission had more admissions to PACH (P < .001) and longer length of stays (P < .001). From first admission to final discharge, there was a significant change (reduction) in respiratory level (z = -4.588, P < .001). An increase in the overall number of admissions for children with respiratory support during the study timeframe was noted, with the largest increase for children requiring the highest level of support.

CONCLUSION

There has been a consistent increase in the number of children requiring respiratory support at admission to PACH. Reduction in respiratory support with postacute care occurs but children admitted with a higher level of support stay longer and experience multiple admissions.

Outcomes and causes of death in children on home mechanical ventilation via tracheostomy: an institutional and literature review

OBJECTIVE

To describe outcomes and causes of death in children on chronic positive-pressure ventilation via tracheostomy.

STUDY DESIGN

We conducted a retrospective observational cohort analysis of 228 children enrolled in an university-affiliated home mechanical ventilation (HMV) program over 22 years (990 person-years). Cumulative incidences of survival and liberation from HMV are presented. Time-to-events were compared by reason for chronic respiratory failure (CRF) and age and date of HMV initiation with Kaplan-Meier and Cox regression analyses. Circumstances of death are described.

RESULTS

Of our cohort, 47 of 228 children died, and 41 children were liberated from HMV. The 5-year cumulative incidences of survival and liberation were 80% and 24%, respectively. Being placed on HMV for chronic pulmonary disease was independently associated with liberation from HMV (hazard ratio, 7.38; 95% CI, 3.0-18.2; P < .001). Neither age nor reasons for CRF were associated with shortened survival. Progression of underlying condition accounted for only 34% of deaths; 49% of deaths were unexpected.

CONCLUSION

Most children on HMV survive or were weaned off. However, a sizable number of children in our cohort died, and many deaths were unexpected and from causes not directly related to their primary reason for CRF.

Measuring physical function in children with airway support: a pilot study using computer adaptive testing

OBJECTIVE

To assess the responsiveness, examine the scoring range and determine the efficiency of a multidimensional computer adaptive testing version of the Pediatric Evaluation of Disability Inventory (PEDI-MCAT) for children admitted to inpatient pulmonary rehabilitation.

METHODS

The PEDI-MCAT was completed by clinician report for 30 infants and children. Mean self-care and mobility admission scores were compared with discharge scores for the total group and two diagnostic sub-groups (prematurity and congenital/neurological conditions). The scoring range of the mobility and self-care scales was examined to determine placement of the scores along the overall PEDI-MCAT scale. Efficiency was determined using an internal clock and average number of items required for score generation.

RESULTS

Mean changes for the total group and both sub-groups were significant for both self-care and mobility, except for the prematurity group's mobility scores. Effect sizes were small-to-moderate. Scores for both groups were at the low end of the scoring ranges. Average time to complete the PEDI-MCAT was 1.57 minutes. Average number of items administered was nine for self-care and 11 for mobility.

CONCLUSION

The PEDI-MCAT was responsive to change in physical function, although only low-ability items were needed. The PEDI-MCAT can potentially minimize clinician burden in inpatient settings.

Weaning children from mechanical ventilation in a post-acute care setting

As medical and technological advances have made it possible to prolong the life of children with chronic respiratory failure, children are being referred to post-acute inpatient rehabilitation programmes. In these settings, children can be weaned from their ventilators and receive medical and rehabilitative care in a developmentally supportive environment at a lower financial cost than in an intensive care unit. There is strong evidence that weaning children from mechanical ventilation has beneficial effects on their functionality, ease of care and quality of life. There is, however, little scientific evidence describing how often successful weaning is achieved or the most effective methods. The purpose of this article is to present a consensus report detailing a structured approach to weaning children from mechanical ventilation in a post-acute care setting. This study proposes a Weaning Severity Index and a Weaning Algorithm for use in the assessment and implementation of the weaning process in post-acute rehabilitation. Future clinical studies are needed to validate the suggested approach to ventilator weaning and to determine whether or not the weaning algorithm results in beneficial patient outcomes.

Development and evaluation of a minimum data set for children with airway support for transfers between acute and post-acute care

OBJECTIVE

To generate consensus on the reasons why children with airway support transfer between acute and post-acute care; develop a minimum data set to transmit between care settings; and examine transfer reports to determine the frequency of data set content.

STUDY DESIGN

Two consensus development meetings were conducted of acute and post-acute care professionals to identify reasons for transfer and develop the minimum data set. A content analysis was used to generate the frequency of inclusion of minimum data set elements in the narrative reports of 15 acute to post-acute and 15 post-acute to acute transfer summaries. The observed frequencies were compared with the expected frequencies (95%), as were frequencies between the two groups.

RESULTS

Advanced diagnostic assessment and unexpected changes in medical, surgical and mental health conditions were the primary reasons for transfer from post-acute to acute care. For transfers in both directions, 20 of the 34 data elements were present in <75% of the cases and were statistically different than the pre-set 95% standard. No statistical difference in the occurrence of data elements between transfer directions existed.

CONCLUSION

A minimum data set has the potential to reduce redundancy, improve safety and optimize care co-ordination between facilities for children with airway support.

Outcomes of post-acute hospital episodes for young children requiring airway support

In this descriptive study, we examined changes in invasive and non-invasive airway support; studied the rates of home discharge vs. long-term care or acute hospitalization; and examined the relationship between the level of airway support and discharge to home for 92 children (<3 years of age) with 104 admission-discharge episodes to a consortium of pediatric rehabilitation hospitals over a one-year period. We found a significant reduction (p < 0.001) in the level of airway support between admission and discharge. In 21 of 47 (45%) episodes, children weaned from mechanical ventilation to a less restrictive type of support. Sixty percent of the children had final discharges to home. There was a significant, though fair correlation (Spearman Rho = -0.344, p = 0.001) between home discharge and level of airway support. These outcomes data provide a multi-site baseline for understanding expected changes in airway support and home discharge rates of young children who are admitted to a post-acute inpatient program.

Ventilator weaning outcomes in chronic respiratory failure in children

The purpose of this study was to describe mechanical ventilation weaning outcomes for children with chronic respiratory failure discharged from one of six post-acute rehabilitation facilities. Demographic, clinical and outcome data were collected from the medical record. Forty-four children were included in this prospective series; 20 (45%) were weaned off the ventilator at discharge. Children required significantly lower levels of ventilatory support at discharge than admission. Hourly use on the ventilator decreased from admission to discharge for the full cohort and for the subgroup who required a ventilator at discharge. Seventy-five percent of the children discharged with a ventilator had a portable unit. We conclude that nearly half of the children using mechanical ventilation achieve weaning during a postacute rehabilitation admission, whereas others have positive outcomes in severity, hours off the ventilator or portability of equipment.