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

Influence of caregiver-nurse communication on quality of life and clinical outcomes of children with long-term ventilator dependence

AIM

To determine the effects of communication behaviors observed during discussion of home management of hospitalized children with long-term ventilator dependence on post-discharge quality of life and clinical outcomes.

DESIGN

A descriptive, quantitative study of family caregiver and nurse communication.

METHODS

Conversations between 100 family caregivers and 48 nurses were recorded and transcribed. Transcripts were coded for key communication behaviors: ask, listen, explain, negotiate roles, verify understanding and advocate. Quality of life measures and clinical outcomes were collected one week and one month post-discharge. Analysis included descriptive statistics and linear mixed-effects models.

RESULTS

Each communication behavior was associated with quality of life outcomes. Family caregivers demonstrated more listening behaviors when there was poorer child quality of life (β = -1.52) and advocated more with increased child fatigue (β = 1.55). When family caregivers negotiated care roles with nurses, there was less child anxiety and more mobility (β = -2.15, β = -1.54). Less child fatigue and more mobility were evidenced when nurses advocated (β = -1.49, β = 0.92). Better child quality of life was predicted by nurses asking family caregivers more questions (β = 1.03), while poorer child quality of life was evident when nurses negotiated care roles (β = -2.22). Overall, when family caregivers demonstrated a need or willingness to negotiate care roles with nurses, more respiratory infections were found post-discharge at one week (β = 1.23) and one month (β = 1.59).

CONCLUSION

Family caregiver and nurse communication can impact outcomes for hospitalized children with long-term ventilator dependence. Family caregivers advocate and negotiate roles to ensure support and appropriate care for themselves and their child.

Arrangement of residence before hospital discharge for children on home-invasive mechanical ventilation

Children on long-term home mechanical ventilation are a growing population due to clinical and technological advances and the benefit for the child's quality of life. Invasive home ventilation is one of the most complex therapies offered in the home setting, requiring adequate home environment and appropriate equipment and supplies before discharge. The transition from hospital to home represents a vulnerable period that can be facilitated with an established transition plan with multidisciplinary team involvement. Readiness for home care is achieved when the patient is stable and has been transitioned from a critical care ventilator to a home mechanical ventilator. In parallel, comprehensive competency-based training regarding the knowledge and skills needed to help families use the equipment confidently and safely. Before discharge, families should be counseled on an adequate home environment to ensure a safe transition. The residence arrangement may include physical space modifications, verifying electrical installation, or moving to another home. Durable medical equipment and supplies must be ordered, and community healthcare support arranged. Parents should receive practical advice on setting up the equipment at home and on preventive measures to minimize complications related to tracheostomy and ventilator dependence, including regular maintenance and replacement of necessary equipment. Given the overall impact of invasive ventilation on home life, a structured home care action package is essential to alleviate the burdens involved.

Weaning strategies for children on home invasive mechanical ventilation

Children who require home mechanical ventilation (HMV) with an artificial airway or invasive mechanical ventilation (HMV) have a possibility of successful weaning due to the potential of compensatory lung growth. Internationally accepted guidelines on how to wean from HMV in children is not available, we summarize the weaning strategies from the literature reviews combined with our 27-year experience in the Pediatric Home Respiratory Care program at the tertiary care center in Thailand. The readiness to wean is considered in patients with hemodynamic stability, having effective cough measured by maximal inspiratory pressure, requiring a fraction of inspired oxygen (FiO2) < 40%, positive end expiratory pressure <5 cmH2O, and acceptable arterial blood gases. The strategies of weaning is start weaning during the daytime while the child is awake and close monitoring is feasible. Disconnect time is gradually increased through naps and sleeping hours. Weaning from the conventional mechanical ventilator to Bilevel PAP or CPAP are optional. Factors affected the successful weaning are mainly the underlying diseases, complications, growth and development, caregivers, and resources. Weaning should be stopped during acute illness or increased work of breathing. The readiness for decannulation could be determined by using the speaking devices, tracheostomy capping, and measurement of end-expiratory pressure. Polysomnography and airway evaluation by bronchoscopy are recommended before decannulation. Weaning when the child is ready is crucial because living with HMV can be challenging and stressful. Failure to remove a tracheostomy when indicated can result in delayed speech, social problems as well as risk for infection.

The follow-up of children on home invasive mechanical ventilation after hospital discharge

The number of children on home invasive mechanical ventilation (HIMV) has been increasing because it is a cost-effective strategy, the developments in technological tools, and its psychological and developmental advantages. Therefore, healthcare providers should be familiar with the follow-up of these patients after hospital discharge. This review will highlight the important points to be aware of during home care of children on HIMV, emphasizing the frequency of scheduled hospital visits after hospital discharge, recognizing adverse events related to HIMV, and ensuring the continued care of these children in areas such as vaccination, and performing appropriate tests in the follow-up.

Sleep Quality of Family Caregivers of Children With Tracheostomies or Home Ventilators: A Scoping Review

Family caregivers of children with tracheostomies or home ventilators are more likely to experience poor sleep quality when undertaking the full responsibility of caring for fragile children. This scoping review aimed to identify the sleep quality, related factors, and their impact on the health of family caregivers of children with tracheostomies or home ventilators. The included studies (N = 16) were retrieved through PubMed, CINAHL, Cochrane Library, Embase, PsycINFO, and Web of Science. Family caregivers' sleep were low in quality, frequently disturbed, and insufficient. Their sleep quality was related to fatigue, anxiety, depression, family functioning, and health-related quality of life. The sleep disturbing factors were classified as child, caregiver, or environment-related, which were mutually interrelated. This review emphasizes the need to develop nursing interventions to both improve the sleep quality of family caregivers and the health of children with tracheostomies or home ventilators based on an in-depth understanding of the family's context.

Respiratory support strategies in the prevention and treatment of bronchopulmonary dysplasia

Neonates who are born preterm frequently have inadequate lung development to support independent breathing and will need respiratory support. The underdeveloped lung is also particularly susceptible to lung injury, especially during the first weeks of life. Consequently, respiratory support strategies in the early stages of premature lung disease focus on minimizing alveolar damage. As infants grow and lung disease progresses, it becomes necessary to shift respiratory support to a strategy targeting the often severe pulmonary heterogeneity and obstructive respiratory physiology. With appropriate management, time, and growth, even those children with the most extreme prematurity and severe lung disease can be expected to wean from respiratory support.

Home mechanical ventilation for children with severe neurological impairment: Parents' perspectives on clinician counselling

AIM

To retrospectively explore the perspectives of parents of children with severe neurological impairment (SNI), such as those with severe cerebral palsy, epilepsy syndromes, and structural brain differences, on clinician counseling regarding home mechanical ventilation (HMV).

METHOD

Inductive thematic analysis was performed on data from telephone interviews with parents who chose for and against HMV for their child with SNI at three academic children's hospitals across the USA.

RESULTS

Twenty-six parents/legal guardians of 24 children were interviewed. Fourteen children had static encephalopathy, 11 received HMV, and 20 were alive at the time of parent interviews. Themes included how HMV related to the child's prognosis, risk of death, and integration with goals of care. Although clinicians voiced uncertainty about how HMV would impact their child, parents felt this was coupled with prescriptive/intimidating examples about the child's end of life and judgments about the child's quality of life.

INTERPRETATION

While prognositc uncertainty exists, this study suggests that parents of children with SNI seek clinician counseling about HMV that considers their goals of care and views on their child's quality of life.

Allocation of Pediatric Home Care Nursing Hours: The Minnesota Experience

Despite an increasing demand for pediatric home care nursing, there is no comprehensive or universal standard of care for prescribing pediatric home care nursing hours based on a child's medical complexity. Adoption of a qualification tool (QT) to allocate home care nursing hours based on the medical complexity of a child may mitigate inequality in access to care and improve the patient and family experience. A QT, developed in Minnesota, recommends home care nursing hours based on the level of medical complexity and need for skilled nursing interventions. Four hypothetical case studies demonstrate the use of the QT to calculate recommended nursing hours. To validate the tool, a survey of discharge planners found a percentage difference in calculated hours of 4.1, 5.7, 11.2, and 24.9 in the four case studies. Discharge planners rated the usability of the QT as favorable with a score of 3.6 on a Likert scale of 5. The recommended nursing hours prescribed for families, based on the QT, was perceived as meeting the needs of the child by 56% and 42% of surveyed parents and home care nurses (HCNs), respectively. The need for additional nursing hours was expressed by 33% and 50% of parents and nurses, respectively. In general, HCNs' assessment of allocated nursing hours paralleled that of parents. Further refinement and adoption of a standardized QT to allocate home care nursing hours may improve access and outcomes for children requiring home care nursing.

Chronic respiratory failure in bronchopulmonary dysplasia

Although survival has improved dramatically for extremely preterm infants, those with the most severe forms of bronchopulmonary dysplasia (BPD) fail to improve in the neonatal period and go on to develop chronic respiratory failure. When careful weaning of respiratory support is not tolerated, the difficult decision of whether or not to pursue chronic ventilation via tracheostomy must be made. This requires shared decision-making with an interdisciplinary medical team and the child's family. Although they suffer from increased morbidity and mortality, the majority of these children will survive to tolerate ventilator liberation and tracheostomy decannulation. Care coordination for the technology-dependent preterm infant is complex, but there is a growing consensus that chronic ventilation can best support neurodevelopmental progress and improve long-term outcomes.

Development and validation of a novel informational booklet for pediatric long-term ventilation decision support

OBJECTIVES

To provide accessible, uniform, comprehensive, and balanced information to families deciding whether to initiate long-term ventilation (LTV) for their child, we sought to develop and validate a novel informational resource.

METHODS

The Ottawa Decision Support Framework was followed. Previous interviews with 44 lay and 15 professional stakeholders and published literature provided content for a booklet. Iterative versions were cognitive tested with six parents facing decisions and five pediatric intensivists. Ten parents facing decisions evaluated the booklet using the Preparation for Decision Making Scale and reported their decisional conflict, which was juxtaposed to the conflict of 21 parents who did not read it, using the Decisional Conflict Scale. Twelve home ventilation program directors evaluated the booklet's clinical sensibility and sensitivity, using a self-designed six-item questionnaire. Data presented using summary statistics.

RESULTS

The illustrated booklet (6th-grade reading level) has nine topical sections on chronic respiratory failure and invasive and noninvasive LTV, including the option to forgo LTV. Ten parents who read the booklet rated it as helping "Quite a bit" or more on all items of the Preparation for Decision Making Scale and had seemingly less decisional conflict than 21 parents who did not. Twelve directors rated it highly for clinical sensibility and sensitivity.

CONCLUSIONS

The LTV booklet was rigorously developed and favorably evaluated. It offers a resource to improve patient/family knowledge, supplement shared decision-making, and reduce decisional conflict around LTV decisions. Future studies should validate it in other settings and further study its effectiveness.