Life with pediatric home ventilation: Expectations versus experience

Opportunities to Improve Care Processes for Ventilator-Dependent Children: A Single-Center Study

OBJECTIVE

Children with chronic ventilator dependence are a complex and heterogeneous population with unique needs. We sought input from parents, clinicians, and hospital staff to identify opportunities for process improvement during hospitalization and discharge preparation.

METHODS

We conducted a qualitative study at a large referral center for children with chronic ventilator dependence. Participants included parents of children with chronic ventilator dependence, physicians, nurses, respiratory therapists, and support staff. Two group-level assessment (GLA) sessions occurred, followed by one-on-one semistructured interviews. Thematic analysis identified areas for process improvements in the care of children with chronic ventilator dependence.

RESULTS

A total of 27 individuals participated in 2 GLA sessions followed by 9 interviews. Potential areas for process improvements included (1) acknowledging and addressing limited resources for children with long-term mechanical ventilation dependence; (2) advancing beyond a "one-size-fits-most" care model; (3) placing the patient and family at the center of care; and (4) improving support for families and staff. Families persistently noted a traumatic component of their experiences through hospitalizations and learning to care for a child with chronic ventilator dependence.

CONCLUSIONS

There are multiple opportunities for process improvement during the hospitalization of children with chronic ventilator dependence. Protocols and practices that support efficient and safe care, such as education before discharge, may require modifications to better meet family needs, address system shortcomings, and mitigate trauma.

Mapping Surgical Intervention Trajectories in Seriously Ill Children Receiving Palliative Care

BACKGROUND/PURPOSE

Despite the prevalence of surgical intervention in seriously ill children, data is scarce regarding interventions performed based on type of serious illness. We therefore sought to evaluate the surgical interventions performed from the time of serious illness diagnosis to the present in a cohort of children receiving palliative care, including identification of the surgical specialists involved in these procedures.

METHODS

We conducted a retrospective cohort analysis of surgical interventions in 197 children enrolled in a multicenter prospective cohort study (Pediatric Palliative Care Research Network SHARE Study). All surgical interventions were abstracted via clinical record review.

RESULTS

189 (of 197, 96%) patients (45% female) with an average of 5.3 complex, chronic conditions (CCC) underwent 3331 surgical interventions (median = 13) by 21 specialist teams (most commonly general surgeons). Those with hematologic malignancies underwent intervention most frequently, followed by children with respiratory, genetic/metabolic, and gastrointestinal/genitourinary (GI/GU) diagnoses. Children with cardiovascular disease, malignancies, and prematurity had the shortest time between diagnosis and first intervention and between diagnosis and pediatric palliative care (PPC) services. By contrast, those with genetic, neurologic, and respiratory diagnoses had significantly longer intervals between diagnosis and intervention.

CONCLUSIONS

Nearly all seriously ill children receiving PPC undergo surgical intervention, and many undergo tens of interventions by a variety of subspecialist teams. Surgical intervention differs by serious illness type, with children with more acutely life-limiting illnesses undergoing high-volume, high-risk interventions in the immediate post-diagnosis period. Those with chronic, life-limiting illnesses undergo a higher lifetime volume of interventions that are relatively lower risk and more evenly distributed over time.

LEVEL OF EVIDENCE

N/A.

Pediatric Perspectives on Palliative Care in the Neurocritical Care Unit

Pediatric neurocritical care teams care for patients and families facing the potential for significant neurologic impairment and high mortality. Such admissions are often marked by significant prognostic uncertainty, high levels of parental emotional overload, and multiple potentially life-altering decision points. In addition to clinical acumen, families desire clear and consistent communication, supported decision-making, a multidisciplinary approach to psychosocial supports throughout an admission, and comprehensive bereavement support after a death. Distinct from their adult counterparts, pediatric providers care for a broader set of rare diagnoses with limited prognostic information. Decision-making requires its own ethical framework, with substitutive judgment giving way to the best interest standard as well as "good parent" narratives. When a child dies, bereavement support is often needed for the broader community. There will always be a role for specialist palliative care consultation in the pediatric neurocritical care unit, but the care of every patient and family will be well served by improving these primary palliative care skills.

Parent perspectives on education to support hospital discharge for children with invasive mechanical ventilation

BACKGROUND

Children with invasive mechanical ventilation (IMV) often live at home, but for safety, parents must be prepared to assume primary responsibility for all aspects of their child's medically complex care. Prior studies have described discharge education programs, however often without perspectives of parents with lived experience transitioning home.

PURPOSE

To describe parent perspectives on hospital-based education for discharging home a child with IMV.

DESIGN AND METHODS

A secondary qualitative analysis of 23 parent interviews between February 2019 to January 2022 on topics related to caring for a child with IMV. Each interview was coded independently and discussed to consensus. Data from codes related to parent education and training were analyzed to identify themes and sub-themes.

RESULTS

Parents of 23 children with IMV participated in the primary interviews a month after hospital discharge. Four main themes in the secondary dataset were identified: (1) Training context: The hospital can be a stressful and difficult learning environment; (2) Training characteristics: Parents receive thorough training from interdisciplinary providers; (3) Learner characteristics: Parents are motivated learners who independently seek out knowledge; (4) Post-discharge education: Parents gain confidence in their expertise after navigating an emergency.

CONCLUSIONS

Parents who have transitioned from hospital-to-home describe sufficiently detailed hospital-based education; many felt trained as capably as nurses. However, parents experienced in-hospital training as inflexible and stressful.

PRACTICE IMPLICATIONS

Parents of children with IMV are eager learners but parent education is not always family-centered. Reforming the hospital learning environment to match parent needs will improve family experiences and training.

Characteristics and Outcomes of Home-Ventilated Children Undergoing Noncardiac Surgery

OBJECTIVES

To determine the frequency of children with chronic respiratory failure (CRF) and home ventilator dependence undergoing surgery at a tertiary children's hospital, and to describe periprocedural characteristics and outcomes.

METHODS

We conducted a retrospective cohort study of patients with CRF and home ventilator dependence who underwent noncardiac surgery from January 1, 2013, to December 31, 2019. Descriptive statistics were used to report patient and procedural characteristics. Univariable and multivariable analyses were used to assess for factors associated with 30-day readmission.

RESULTS

We identified 416 patients who underwent 1623 procedures. Fifty-one percent of patients used transtracheal mechanical ventilation (trach/vent) support at the time of surgery; this cohort was younger (median age 5.5 vs 10.8 years) and more complex according to American Society of Anesthesiologists status compared with bilevel positive airway pressure-dependent patients. Postoperatively, compared with bilevel positive airway pressure-dependent patients, trach/vent patients were more likely to be admitted to the ICU with longer ICU length of stay (median 5 vs 2 days). Overall 30-day readmission rate was 12% (n = 193). Presence of chronic lung disease (adjusted odds ratio 1.65, 95% confidence interval 1.01-1.69) and trach/vent dependence (adjusted odds ratio 1.65, 95% confidence interval 1.02-2.67) were independently associated with increased odds for readmission.

CONCLUSIONS

Children with CRF use anesthetic and surgical services frequently and repeatedly. Those with trach/vent dependence have higher hospital and ICU resource utilization. Although overall mortality for these patients is quite low, underlying diagnoses, nuances of technology dependence, and other factors for frequent readmission require further study to optimize resource utilization and outcomes.

Transitioning children using home invasive mechanical ventilation from hospital to home: Discharge criteria, disparities, and ethical considerations

Children using home invasive mechanical ventilation (HIMV), a valuable therapeutic option for chronic respiratory failure, constitute a growing population. Transitioning children using HIMV from hospital to home care is a complex process that requires a multidisciplinary approach involving healthcare professionals, caregivers, and community resources. Medical stability, caregiver competence, and home environment suitability are essential factors in determining discharge readiness. Caregiver education and training play a pivotal role in ensuring safe and effective home care. Simulation training and staged education progression are effective strategies for equipping caregivers with necessary skills. Resource limitations, inadequate home nursing support, and disparities in available community resources are common obstacles to successful HIMV discharge. International perspectives shed light on diverse healthcare systems and challenges faced by caregivers worldwide. While standardizing guidelines for HIMV discharge may be complex, collaboration among healthcare providers and the development of evidence-based regional guidelines can improve outcomes for children using HIMV and their caregivers. This review seeks to synthesize literature, provide expert guidance based on experience, and highlight components to safely discharge children using HIMV. It further assesses disparities and divergences within regional and international healthcare systems while addressing relevant ethical considerations.

Psychosocial factors affecting the quality of life of parents who have children with home mechanical ventilation

INTRODUCTION

Most children with medical complexity have to live with home mechanical ventilation (HMV). Undertaking the care of a child with HMV creates a psychosocial burden on parents. This study investigated the impact of selected potential determinants on the quality of life of parents who have children with HMV.

METHODS

A cross-sectional survey study was conducted using a structured questionnaire to determine the sociodemographic characteristics of the parents. The World Health Organization Quality of Life Assessment-Brief version, the Beck Depression Inventory (BDI), and the Multidimensional Scale of Perceived Social Support were applied.

RESULTS

A total of 35 participants responded to the questionnaires. Paired data from mothers and fathers were obtained from 12 families. A moderately significant positive correlation was found between the perceived social support levels of the parents and all domains of the quality of life scale (for the physical domain: r = .455, p = .006; for the psychological domain: r = .549, p = .001; for the social domain: r = .726, p = .000; and for the environment domain: r = .442, p = .008). A moderate negative relationship was found between parents' perceived social support levels and BDI scores (r = -.557, p = .001). The multivariate regression analysis determined that being a mother, quitting a job to become a caregiver, being the only caregiver at home, and having a neurological/neuromuscular disease as the primary disease of the child were associated with lower scores in more than one quality of life domain.

CONCLUSION

Our results emphasize that appropriate social support is important for improving the quality of life scores of parents of children with HMV.

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.

Tracheostomy and long-term invasive ventilation decision-making in children: A scoping review

An increasing number of children are surviving critical illnesses requiring tracheostomy/long-term ventilation (LTV). This scoping review seeks to collate the available evidence on decision-making for tracheostomy/LTV in children. Systematic searches of electronic databases and websites were conducted for articles and reports. Inclusion criteria included: (1) children 0-18 years old; (2) described use of tracheostomy or tracheostomy/LTV; and (3) information on recommendations for tracheostomy decision-making or decision-making experiences of family-caregivers or health care providers. Articles not written in English were excluded. Of the 4463 records identified through database search and other methods, a total of 84 articles, 2 dissertations, 1 book chapter, 3 consensus statement/society guidelines, and 8 pieces of grey literature were included. Main thematic domains identified were: (1) legal and moral standards for decision-making; (2) decision-making models, roles of decision-makers, and decisional aids towards a shared decision-making model; (3) experiences and perspectives of decision-makers; (4) health system and society considerations; and (5) conflict resolution and legal considerations. A high degree of uncertainty and complexity is involved in tracheostomy/LTV decision-making. There is a need for a standardized decision-support process that is consistent with a child's best interests and shared decision-making. Strategies for optimizing communication and mechanism for managing disputes are needed.

Building clinician-parent partnerships to improve care for chronically critically Ill children: A pilot project

OBJECTIVE

Multicenter pilot to assess feasibility, acceptability, and educational value of videos for families and clinicians regarding unique inpatient challenges of pediatric chronic critical illness.

METHODS

Videos were developed for 3 hospitalization timepoints: 1) chronic critical illness diagnosis, 2) transfers, 3) discharge. Parents of hospitalized children, and interdisciplinary clinicians, were recruited to watch videos and complete surveys.

RESULTS

33 parents (16 English-speaking, 17 Spanish-speaking) and 34 clinicians participated. Enrollment was better for families than clinicians (78% vs. 43%). Video acceptability was high: families and clinicians endorsed verisimilitude of depicted hospitalization challenges for chronic critical illness. All families felt the videos would help other families, all clinicians felt they would help other clinicians. Families gained expectations for the hospital course, discovered resources for hospitalization challenges, and learned there are other families in similar situations. Clinicians learned to recognize chronic critical illness, and how families experience hospitalizations, transfers, and discharges.

CONCLUSION

Educational videos about pediatric chronic critical illness were overall feasible, acceptable, and educational for hospitalized families and clinicians.

PRACTICE IMPLICATIONS

Just-in-time hospital education about pediatric chronic critical illness is valuable to families and clinicians; next steps are to assess potential to reduce gaps in care of children with chronic critical illness.

Development and validation of a Japanese version of The Quality of Discharge Teaching Scale-Parent Form (JQDTS-PF): A cross-sectional observational study

BACKGROUND

Advances in medical care have enabled home treatment and advanced medical care for children with chronic illnesses. Nurses are not only required to teach their caregivers skills but also understand the families' needs and identify their anxieties in discharge teaching. However, no measure is currently available in Japan to evaluate the quality of discharge teaching provided by nurses. Therefore, this study aimed to develop a Japanese version of the Quality of Discharge Teaching Scale Parent-Form (JQDTS-PF) developed by Weiss et al. METHODS: A Japanese version of the scale was created after obtaining permission from the original author. The questionnaire was then distributed to caregivers of children discharged from hospitals in Japan who required some form of medical care after discharge.

FINDINGS

The study population comprised 113 respondents (response rate: 93.3%). The reliability of the scale was 0.88 for "need," 0.86 for "receive," and 0.93 for "delivery." Significant positive correlations were found between the JQDTS-PF subscale and the Japanese version of Readiness for Hospital Discharge Scale (JRHDS-PF). Significant correlations were also found between child and family characteristics and subscales of the JQDTS-PF.

DISCUSSION

The developed Japanese version of the scale was found to be sufficiently reliable. Validity of the scale was also sufficiently confirmed by correlation analysis, which yielded results similar to those of previous studies.

APPLICATION TO PRACTICE

This scale would be useful in improving and evaluating the quality of discharge teaching by nurses in Japan in the future.

Parents' experiences of their children's medical journeys with tracheostomies: A Focus Group Study

Objectives

Children living with a tracheostomy have among the most complex medical care needs in Canada. The focus of this study was to gain a contemporary understanding of key aspects of these children's medical journeys.

Methods

We conducted a qualitative constructivist grounded theory study using semi-structured focus groups with parents whose children are living in the community with a tracheostomy. Parents were recruited from the Stollery Children's Hospital Tracheostomy Clinic, which serves a geographically wide and diverse population.

Results

Three focus groups were completed, including a total of 12 participants. Key themes leading up to tracheostomy related to contextual understanding, experiences of inclusion, and perceptions of proportionality. Parents discussed the preparedness for how a tracheostomy would affect their child, their own involvement in recovery, and the education needed for their child's medical care. Navigating hospital units related to inconsistencies in care, accommodations of families' needs, and confidence in care received. Finally, living in the community was the focus of much of the participants' discussions including coping with system-related issues, limited homecare and medical support, cost of care, and connections with the broader community of parents of children with complex medical needs. All themes encircled the family's deeply felt responsibility to care for their child.

Conclusions

From both patient- and family-centered care perspectives, there exist individual and systemic issues related to the care delivery for children with a tracheostomy. It is in particular in the community where there is a severe deficiency of support afforded to these children and their families.

Establishing Goals of Care in Serious and Complex Pediatric Illness

An increasing number of children are living for months and years with serious/complex illness characterized by long-term prognostic uncertainty, intensive interactions with medical systems, functional limitations, and often home medical technologies that shape the child's and family's quality of life. These families face many medical decision points that require intentional and iterative discussions about goals of care. Threats to cohesive goals of care include prognostic uncertainty, diffusion of medical responsibility, individual family context, and blended goals of care. This article offers strategies for addressing each of these challenges.

Home values and experiences navigation track (HomeVENT): Supporting decisions about pediatric home ventilation

Objective

To pilot feasibility and acceptability of HomeVENT, a systematic approach to family-clinician decision-making about pediatric home ventilation.

Methods

Parents and clinicians of children facing home ventilation decisions were enrolled at 3 centers using a pre/post cohort design. Family interventions included: 1) a website describing the experiences of families who previously chose for and against home ventilation 2) a Question Prompt List (QPL); 3) in-depth interviews exploring home life and values. Clinician HomeVENT intervention included a structured team meeting reviewing treatment options in light of the family's home life and values. All participants were interviewed one month after the decision.

Results

We enrolled 30 families and 34 clinicians. Most Usual Care (14/15) but fewer Intervention (10/15) families elected for home ventilation. Families reported the website helped them consider different treatment options, the QPL promoted discussion within the family and with the team, and the interview helped them realize how home ventilation might change their daily life. Clinicians reported the team meeting helped clarify prognosis and prioritize treatment options.

Conclusions

The HomeVENT pilot was feasible and acceptable.

Innovation

This systematic approach to pediatric home ventilation decisions prioritizes family values and is a novel method to increase the rigor of shared decision-making in a rushed clinical environment.

Parent Perspectives on the Child Experience of Pediatric Home Ventilation via Tracheostomy

BACKGROUND AND OBJECTIVE

Parents facing the decision of whether to initiate pediatric mechanical ventilation via tracheostomy ("home ventilation") report wanting information about what to expect for life at home for their child. The study objective is to explore parent descriptions of the child experience of home ventilation to increase awareness for clinicians in the inpatient setting caring for these children.

METHODS

Semistructured interviews were conducted using purposive sampling of parents with children who initiated home ventilation within the previous 5 years from 3 geographically diverse academic medical centers.

RESULTS

We interviewed 21 families from 3 geographic regions in the United States. About 75% of children had respiratory failure in the first year of life, 80% had medical complexity, and half had severe neurologic impairment. Five domains emerged regarding parent perceptions of their child's experience of home ventilation: (1) health and well-being; (2) development; (3) adaptation; (4) mobility and travel; and (5) relationships. Within each domain, several themes were identified. For each theme, there was a positive and negative subtheme to illustrate how the child's experience was modified by home ventilation. Parent descriptions were generally positive, however, in all domains and to varying degrees, parents expressed negative aspects of home ventilation.

CONCLUSIONS

By providing information about the realistic experiences of children using home ventilation, clinicians can support families in the inpatient setting as they face this complex decision. Balanced information about home ventilation is critical to enhancing clinician counseling so that families may benefit from the perspectives of experienced parents.

Codesign of remote data collection for chronic management of pediatric home mechanical ventilation

INTRODUCTION

Outpatient monitoring of children using invasive home mechanical ventilation (IHMV) is recommended, but access to care can be difficult. This study tested if remote (home-based) data collection was feasible and acceptable in chronic IHMV management.

METHODS

A codesign study was conducted with an IHMV program, home nurses, and English- and Spanish-speaking parent-guardians of children using IHMV (0-17 years; n = 19). After prototyping, parents used a remote patient monitoring (RPM) bundle to collect patient heart rate, respiratory rate (RR), oxygen saturation, end-tidal carbon dioxide (EtCO2 ), and ventilator pressure/volume over 8 weeks. User feedback was analyzed using qualitative methods and the System Usability Scale (SUS). Expected marginal mean differences within patient measures when awake, asleep, or after a break were calculated using mixed effects models.

RESULTS

Patients were a median 2.9 years old and 11 (58%) took breaks off the ventilator. RPM data were entered on a mean of 83.7% (SD ± 29.1%) weeks. SUS scores were 84.8 (SD ± 10.5) for nurses and 91.8 (SD ± 10.1) for parents. Over 90% of parents agreed/strongly agreed that RPM data collection was feasible and relevant to their child's care. Within-patient comparisons revealed that EtCO2 (break-vs-asleep 2.55 mmHg, d = 0.79 [0.42-1.15], p < .001; awake-vs-break 1.48, d = -0.49 [0.13-0.84], p = .02) and RR (break-vs-asleep 16.14, d = 2.12 [1.71-2.53], p < .001; awake-vs-break 3.44, d = 0.45 [0.10-0.04], p = .03) were significantly higher during ventilator breaks.

CONCLUSIONS

RPM data collection in children with IHMV was feasible, acceptable, and captured clinically meaningful vital sign changes during ventilator breaks, supporting the clinical utility of RPM in IHMV management.

Shared decision-making experiences in child long-term ventilation: a systematic review

INTRODUCTION

Recent decades have seen an increase in children receiving long-term ventilation. To ensure that long-term ventilation decisions incorporate the perspectives of stakeholders, it is vital that empirical evidence is gathered to substantiate frameworks and guidance on shared decision-making for long-term ventilation. This systematic review and qualitative evidence synthesis aimed to clarify what shared decision-making constitutes in relation to long-term ventilation initiation for children and young people (<21 years).

METHODS

A systematic review of qualitative research was undertaken. Searches were conducted in MEDLINE, Embase, CINAHL, PsycINFO and Web of Science.

RESULTS

Findings from 13 studies were included representative of 363 caregivers and 143 healthcare professional experiences. Components that support shared decision-making included acknowledging the unique positionality of caregivers and ensuring caregivers were informed about the implications of long-term ventilation. Beneficial qualities of engagement between stakeholders included honest, clear and timely dialogue using lay, tactful and sensitive language.

CONCLUSION

Our findings clarify components and approaches supportive of shared decision-making in discussions about long-term ventilation. This review therefore provides a valuable resource to implement shared decision-making practices in the context of long-term ventilation decisions for children and young people.

Family-Reflections.com: Creating a parent-to-parent web-based tool regarding pediatric home ventilation

BACKGROUND

The decision to initiate pediatric mechanical ventilation via tracheostomy ("home ventilation") is complex and parents often desire information from other parents who have faced this decision. However, parent-to-parent communication is challenging as it is difficult to connect new families to experienced families in ways that optimize informed, balanced decision-making.

OBJECTIVE

Create a parent-to-parent web-based tool to support decision-making about pediatric home ventilation.

PATIENT INVOLVEMENT

The tool was created based on interviews and feedback from parents.

METHODS

We interviewed parents who previously chose for, or against, home ventilation for their child. Interview themes and family comments guided website development. Viewer feedback was solicited via an embedded survey in the tool.

RESULTS

We created 6 composite character families to communicate 6 themes about home ventilation: 1) Considering treatment options, 2) Talking with medical team, 3) Impact on life at home, 4) Impact on relationships, 5) Experience for the child, and 6) If the child's life is short. Nine families who reviewed the draft tool felt it would have helped with their decision about home ventilation. Specifically, it supported families in thinking through what was "most important about their child's breathing problems" (7 of 9 parents) and feeling "more at peace with the decision" (8 of 9 parents). Between 6/1/20-12/31/22, nearly 5500 viewers have accessed the tool and 56 viewers completed the survey (including 13 families and 39 clinicians). Feedback from experienced families and clinicians reported the tool taught them something new.

DISCUSSION

This novel parent-to-parent tool shows promise for expanding access to balanced, family-centered information about pediatric home ventilation.

PRACTICAL VALUE

The diverse stories and decisions let parents access multiple family perspectives. The tool's focus is on family-centric information that parents reported was usually missing from clinician counseling.

FUNDING

This work was supported by the National Palliative Care Research Center.

Predictors for invasive home mechanical ventilation duration in bronchopulmonary dysplasia

BACKGROUND

Children with bronchopulmonary dysplasia (BPD) who require invasive home mechanical ventilation (IHMV) are medically vulnerable and experience high caregiving and healthcare costs. Predictors for duration of IHMV in children with BPD remain unclear, which can make prognostication and decision-making challenging.

METHODS

A retrospective cohort study of children with BPD requiring IHMV was conducted from independent children's hospital records (2005-2021). The primary outcome was IHMV duration, defined as time from initial discharge home on IHMV until cessation of positive pressure ventilation (day and night). Two new variables were included: discharge age corrected for tracheostomy (DACT) (chronological age at discharge minus age at tracheostomy) and level of ventilator support at discharge (minute ventilation per kg per day). Univariable Cox regression was performed with variables of interest compared to IHMV duration. Significant nonlinear factors (p < 0.05) were included in the multivariable analysis.

RESULTS

One-hundred-and-nineteen patients used IHMV primarily for BPD. Patient median index hospitalization lasted 12 months (interquartile range [IQR] 8.0,14.4). Once home, half of the patients were weaned off IHMV by 36.0 months and 90% by 52.2 months. Being Hispanic/Latinx ethnicity (hazard ratio [HR] 0.14 (95% confidence interval [CI] 0.04, 0.53), p < 0.01) and having a higher DACT were associated with increased IHMV duration (HR 0.66 (CI 0.43, 0.98), p < 0.05).

CONCLUSIONS

Disparity in IHMV duration exists among patients using IHMV after prematurity. Prospective multisite studies that further investigate new analytic variables, such as DACT and level of ventilator support, and address standardization of IHMV care are needed to create more equitable IHMV management strategies.

"What Would Give Her the Best Life?": Understanding Why Families Decline Pediatric Home Ventilation

Background: Families who must decide about pediatric home ventilation rely on the clinicians who counsel them for guidance. Most studies about pediatric home ventilation decisions focus on families who opt for this intervention, leaving much unknown about the families who decline. Objective: To describe the rationales of families who decline home ventilation. Design: Semi-structured interview study. Setting/Subjects: We interviewed 16 families in hospitals across 3 U.S. states, identified by their clinicians as previously deciding to not pursue home ventilation via tracheostomy within the past five years. Measurements: Targeted content and narrative analyses were used to understand family intentions and reasons for declining. Results: The clinical and social context varied among the 16 families in this study. Families' intentions in saying "no" fell into two categories: (1) definitive "No": Families who stood firm on in their decision and (2) contingent "No": Families who may consider this in the future. Families described four reasons why their child did not receive home ventilation: (1) concern about medical impacts, (2) concern about physical and/or communication restrictions, (3) concern that there would be no clear health benefit, and (4) concern about no clear meaningful life. Most families mentioned all four reasons, but concern about no clear meaningful life predominated. Conclusions: Though these families did not see home ventilation as an appropriate option, each reported a complex interplay of intentions behind and reasons for declining. Clinicians who counsel families about home ventilation could share the reasons that families commonly decline this intervention to facilitate a balanced discussion.

Year in review 2021: Neuromuscular diseases

In this years' review of neuromuscular respiratory medicine, there were a series of articles on home mechanical ventilation, real-world studies assessing the impact of nusinersen, and studies describing upper airway dysfunction. Beyond this, we highlight two excellent reviews regarding cardiac dysfunction in neuromuscular diseases.

Collaborative decision-making: A framework for decision-making about life-sustaining treatments in children with medical complexity

OBJECTIVE

Caregivers of children with medical complexity (CMC) face decisions about life-sustaining treatments (LST) like tracheostomy. We sought to develop a clinically relevant and realistic model for decision-making about tracheostomy placement that might apply to other LST in CMC.

DESIGN

This qualitative study, conducted between 2013 and 2015, consisted of 41 interviews with 56 caregivers of CMC who had received tracheostomies and 5 focus groups of 33 healthcare providers (HCPs) at a tertiary-care children's hospital in North Carolina. Participants were asked about their perspectives on the tracheostomy decision-making process. Data were transcribed, and coded. Using thematic content analysis, we inductively developed a tracheostomy decision-making framework and process.

RESULTS

Many factors influenced caregivers' decisions, including children's well-being and caregivers' values, faith, knowledge, experience, emotional state, and social factors; preserving the child's life was the most important. HCPs consider many clinical and nonclinical factors; recommending tracheostomy for children with limited survival, perceived poor functioning and quality of life, and progressive conditions is ethically difficult. The framework of tracheostomy decision-making has inter-related caregiver- and HCP-level factors that influence the process. The framework contains elements not captured in a shared decision-making model, but better fits a collaborative decision-making (CDM) model. The tracheostomy CDM process that emerged from the data has two nonsequential components that HCPs could use: (1) gaining understanding and (2) holding decision-making conversations.

CONCLUSIONS

CDM could be a useful model for clinicians guiding families about tracheostomy for CMC. The applicability of CDM for decision-making about other LSTs needs further exploration.

Parent education programs for children assisted by invasive mechanical ventilation: A scoping review

PROBLEM

The population of children assisted by invasive mechanical ventilation (IMV) and living at home is growing. Although parent education is essential for safe transitions from hospital-to-home, little is known about how this education is delivered. The aim of this review is to identify existing literature about parent education programs, synthesize the evidence, and identify gaps in the literature for future inquiry.

ELIGIBILITY CRITERIA

This scoping review was conducted in accordance with the Joanna Briggs Institute methodology. Full-text publications in the English language focused on describing parent education programs for children assisted by IMV, indexed in CINAHL, PubMed, OVID, and PsycINFO and published from 2010 to 2021 were included. Reference lists of relevant articles were reviewed, and a hand search was completed to locate any additional literature outside the original search.

SAMPLE

A total of 2472 citations were identified. After screening titles and abstracts, 37 full-text articles were retrieved and assessed for eligibility. Two independent reviewers completed the screening process. A hand search located one additional article. A final sample of 18 articles were included in the review.

RESULTS

The parent education programs described in the final sample included standardized discharge education programs, simulation training, resourcefulness training, patient-specific action plans, disaster preparedness, and symptom and technology management.

CONCLUSION

Although most parent education programs identified in this review focused on teaching caregiver skills, program characteristics and outcome measures varied widely.

IMPLICATIONS

This review recommends directions for future research to optimize parent education for children assisted by IMV.