Prolonged mechanical ventilation in children

Association of dead space ventilation and prolonged ventilation after repair of tetralogy of Fallot with pulmonary atresia

BACKGROUND

We set out to determine whether patients with tetralogy of Fallot with pulmonary atresia and major aortopulmonary collateral arteries (TOF/PA/MAPCA) are at risk for elevated dead space ventilation fraction (VD/VT), and whether this is associated with prolonged mechanical ventilation. We hypothesized that elevated VD/VT (>20%) in the first 24 hours after unifocalization surgery is associated with increased risk for prolonged mechanical ventilation (>7 days).

METHODS

All patients with TOF/PA/MAPCA undergoing unifocalization surgery between January 2003 and December 2015 were included in this study. Average VD/VT was calculated over the first 24 hours after surgery. Demographic and surgical data were collected. Outcome data included duration of mechanical ventilation. Patients were separated into 2 groups: elevated VD/VT and normal DVSF. Groups were compared using the Student t test, Wilcoxon rank-sum test, and χ² test. Univariable and multivariable regression analyses were performed with VD/VT as a continuous variable to test for association.

RESULTS

Of the 265 included patients, 127 (48%) had an elevated VD/VT. The 2 groups did not differ significantly in any demographic characteristic. Patients with an elevated VD/VT had longer cardiopulmonary bypass times (P = .03), were more likely to have delayed sternal closure, and more likely to have prolonged respiratory failure (odds ratio, 2.2; 95% confidence interval, 1.2-4.0; P = .007). The percent VD/VT was associated with duration of mechanical ventilation in univariable (P < .001) and multivariable (P < .001) regression analyses when controlled for age, weight and bypass time.

CONCLUSIONS

Elevated postoperative VD/VT is associated with prolonged mechanical ventilation in patients with TOF/PA/MAPCA following unifocalization. Elevated postoperative VD/VT may be an early indicator of patients who will require prolonged duration of mechanical ventilation, allowing optimization of medical management to promote better outcomes.

Outcomes of children treated with tracheostomy and positive-pressure ventilation at home

BACKGROUND

Long-term outcomes for children who survive on tracheostomy and positive-pressure ventilation (TPPV) at home are not well known.

METHODS

A retrospective review of 20 years of clinical data at a single institution was performed. Outcome measures included 5-year survival, decannulation rate, and neurocognition.

RESULTS

A total of 91 children were categorized under neuromotor dysfunction (52%), chronic lung disease (29%), and congenital anomalies (20%). The 5-year survival rates for these categories were 89% (95% confidence interval [CI] = 80%-99%), 76% (95% CI = 57%-100%), and 94% (95% CI = 83%-100%), respectively. Overall, the 5-year decannulation rate was 25% (95% CI = 14%-35%), with children with chronic lung disease having the highest rate (51%). It was found that 14% were extremely delayed in neurocognition.

CONCLUSION

Most children on TPPV at home survive beyond 5 years, and a significant number are decannulated. Primary care physicians and communities should be prepared to accommodate the increasing number of children on TPPV at home.

[Chronic dependence on mechanical pulmonary ventilation in pediatric care: a necessary debate for Brazil's Unified Health System]

People with prolonged dependence on mechanical ventilation require permanent care and the use of equipment that can result in longer term hospital internment. This can lead to difficulty of access for patients with acute injuries, as well as personal difficulties and stress with reduced quality of life for their families or caregivers due to such longer hospital internment. This critical review of publications dealing with dependence on mechanical ventilation among children and adolescents aimed at making information organized in a systematic manner available in order to support discussion on the subject. It should be borne in mind that changes in epidemiological profile and growing technological access determine needs such as intensive therapy hospital beds and complex home care for chronic patients, which still have limits of supply and regulatory restrictions in the Brazilian public health system.

Natural course following pediatric tracheostomy

OBJECTIVE

To describe the hospital course of pediatric posttracheostomy patients, their underlying diagnosis, and their demographic characteristics.

DESIGN

Retrospective, descriptive record review.

SETTINGS

Academic tertiary Pediatric Critical Care Unit.

METHODS AND RESULTS

One hundred and forty-one patients 1 month to 20 years old identified and included in the study. The length of in-hospital stay ranged from 14 to 280 days. The most common indications for tracheostomy were ventilation of chronic lung disease (CLD), subglottic stenosis, or combination at 44.7% of the cases followed by neurological cases 26.2%. Patients requiring prolonged stay were more likely to have pulmonary hypertension (odds ratio [OR] = 5.43), gastrointestinal reflux (OR = 2.09), prior episodes of failure to thrive (OR = 4.17), feeding failure requiring feeding tube (OR = 3.32), and tracheitis (OR = 4.17). The chances for home ventilation requirement increased with long preoperative in-hospital ventilation time and high ventilator respiratory rate on the day of tracheostomy as 0.98 days for each preoperative day and 0.94 days for each set ventilator breath (set respiratory rate per minute). The survival rate was 98.9% for the first 30 days and 78% afterward.

CONCLUSION

Chronic lung disease, subglottic stenosis, and combinations are the most common causes for tracheostomy at present followed for tracheostomy due to neurological problems. Children requiring tracheostomy have lengthy hospital stay. Establishing an accurate diagnosis helps predict the length of hospitalization and the need for home ventilation; however, in less clear cases, the length of stay can be predicted from the presence of pulmonary hypertension, reflux, and failure to thrive. The mortality rate is low at the postoperative period and increases depending upon the underline reason for tracheostomy referral.

The population prevalence of children receiving invasive home ventilation in Utah

Children requiring home mechanical ventilation (HMV) represent a select group of technology-dependent patients. We evaluated the prevalence of children using invasive HMV in Utah from 1996 to 2004. Residents of Utah, 16 years old and less ventilated via a tracheostomy between 1996 and 2004 were identified. Children ventilated in 1996 and 2004 were compared. Data including demographic information, diagnosis leading to HMV, and age at initiation were compared between the two groups. The prevalence of HMV in 1996 was 5.0/100,000 (95% CI: 4.4-8.1) and 6.3/100,000 (95% CI: 4.7-8.4) in 2004. Median age at initiation was 6.5 months (IQR: 1.3, 24.0). Sixty-one percent (n = 47) were male, 84% (n = 65) lived in an urban county, and 86% (n = 66) had public insurance. The most frequent diagnostic category was abnormal ventilatory control (n = 36, 47%), followed by chronic lung disease (n = 19, 25%), airway abnormalities (n = 12, 16%), and neuromuscular weakness (n = 10, 13%). Thirteen patients died (17%). The median length of HMV was 39 months (IQR: 15, 102). Diagnostic categories, age at initiation of HMV, and sex did not differ significantly over the 8 years. The prevalence of children requiring HMV differed very little between 1996 and 2004. Moreover, the diagnoses for which children received this therapy remained constant.

Health and quality of life of ventilator-dependent children

AIM

This paper reports a qualitative study with ventilator-dependent children and their parents, describing their experiences and meanings concerning the children's health and quality of life.

BACKGROUND

Recent medical advances have enabled children to survive premature birth, congenital anomalies, critical illness and accidents with long-term use of mechanical ventilation to support breathing. In economically developed countries, the number of ventilator-dependent children is increasing and many require nurse-led home healthcare services. Debate has been polarized as to whether life on a ventilator is in the best interests of all children. The perspectives of ventilator-dependent children are largely absent in the literature.

METHODS

Principles derived from Heideggerian phenomenology were used to describe how children and their parents interpreted and rationalized the quality of the child's 'ventilator-dependent' life and their health. The study had two phases with data collection commencing in 1998 and completed in 2004.

RESULTS

The participants were 35 ventilator-dependent children, and 50 mothers and 17 fathers of 53 children. Emergent themes revealed some common features across this heterogeneous group. Ventilation made the children feel better and if they had sufficient breath, they experienced better quality of life. It was not possible to delineate the magnitude of health gain or benefit, especially amongst preverbal children and those with profound sensory impairments. Quality of life equated to quality of life experiences, but some children experienced negative social impacts and low self-esteem. Home healthcare services were not designed to bring about the desired social outcomes that children identified. Parent's accounts showed subtle more negative differences.

CONCLUSION

The acceptance of children's dependence on machines to live has brought about the need for nursing, medical, social and biological boundaries to be redefined, especially around children's meanings of their health, what they understand to be good quality of life, and what they need to achieve it. Flexible, high quality child-focused homecare is likely to improve children's outcomes.

Long-term mechanical ventilation and nutrition

Mechanical ventilation (MV) in chronic situations is commonly used, either delivered invasively or by means of non-invasive interfaces, to control hypoventilation in patients with chest wall, neuromuscular or obstructive lung diseases (either in adulthood or childhood). The global prevalence of ventilator-assisted individuals (VAI) in Europe ranges from 2 to 30 per 100000 population according to different countries. Nutrition is a common problem to face with in patients with chronic respiratory diseases: nonetheless, it is a key component in the long-term management of underweight COPD patients whose muscular disfunction may rapidly turn to peripheral muscle waste. Since long-term mechanical ventilation (LTMV) is usually prescribed in end-stage respiratory diseases with poor nutritional status, nutrition and dietary intake related problems need to be carefully assessed and corrected in these patients. This paper aims to review the most recent innovations in the field of nutritional status and food intake-related problems of VAI (both in adulthood and in childhood).

Technology-dependent children and their families: a review

BACKGROUND

Advances in medical technology and nursing care have enabled children who rely on long-term medical and technical support to reunite with their families and community. The impact of discharging these children into the community involves a number of unprecedented social implications that warrant policy consideration. To begin with, an effort must be made to understand the phenomenon of caring for technology-dependent children living at home.

AIM

The aim of this paper is to provide a comprehensive literature review on caring for technology-dependent children living at home.

METHODS

The review was conducted via keyword searches using various electronic databases. These included CINAHL, MEDLINE, Social Science Index, Sociological Abstracts, Australian Family and Society Abstracts, and the Australian Bureau of Statistics. The articles and books found were examined for commonality and difference, significant themes were extracted, and the strength of the research methods and subsequent evidence were critiqued.

FINDINGS

In this paper, themes relating to home care for technology-dependent children and their families are elucidated and summarized. These are: chronic illness and children; the impact of paediatric home care on children; the uniqueness of technology-dependent children and their families; and parents' experience of paediatric home care.

DISCUSSION

Contentious issues, relevant to the social life of these children and their families, are raised and are discussed with the intention of extending awareness and provoking further debate among key stakeholders. These issues include: the changed meaning of home; family dynamics; social isolation; saving costs for whom?; shifts in responsibility; and parent-professional relationships.

CONCLUSION

More research is needed in the arena of paediatric home care, to facilitate relevant policy formation and implementation.

Oxygen and ventilator weaning during inpatient pediatric pulmonary rehabilitation

Rates of oxygen and ventilator weaning, and factors related to successful weaning in inpatient pediatric pulmonary programs for infants and young children, have not been frequently reported in the literature. A retrospective review was conducted of 34 infants and toddlers with either a diagnostic condition of prematurity (PM) or congenital anomalies/neuromuscular disease (CA/NM) discharged from an inpatient pulmonary program. These cases represent 67 hospital admission-discharge episodes over a 6-year period. The rate of successful oxygen weaning (decrease to 0 hr per day) and ventilator weaning (decrease to <12 hr per day) and predictive factors related to successful ventilator weaning per admission-discharge episode were examined. Successful oxygen weaning was achieved during 24% and successful ventilator weaning was achieved during 30% of the admission-discharge episodes. No significant relationships were found between the selected demographic and clinical factors and oxygen weaning. Using a logistic regression model, the major variable associated with successful ventilator weaning per admission-discharge episode was diagnostic condition. Age at admission and the presence of comorbidities added slightly to the prediction model. The overall model yielded 86% accuracy for predicting a decrease in ventilator hours. However, projecting in which episodes children will not be weaned (negative predictive value = 88.9%) was more accurate than projecting in which episodes children will be weaned (positive predictive value = 73.3%). Although the program achieved a relatively low rate of successful ventilator weaning, children with a diagnostic condition of prematurity were more likely to be successfully weaned during inpatient pulmonary rehabilitation.

The epidemiology and costs of chronic critical illness

CCI patients are patients who have suffered acute illness or injury and require life support or care in an ICU setting for periods of weeks or months. These patients account for between 5% and 10% of ICU admissions, and they appear to be increasing in number. Over half of the patients are over age 65. Patients with underlying premorbid conditions who suffer complications of acute illness are at highest risk for becoming CCI. These patients have poor short-term and long-term survival, although survival may be improving for some types of CCI patients as the medical system adapts to their specific needs. Long-term survival is associated with age and premorbid condition or functional status. Survivors have significant functional limitations, but their reported quality of life is generally good. CCI patients consume a disproportionate share of ICU and hospital resources, and significant additional resources are required for continued recovery or care after discharge. Specialized units have been evolving to manage these patients at lower costs than in acute ICUs, and with similar outcomes. Further refinement of the definition of CCI is an important objective, and should pave the way to better design of outcomes studies. Efforts should continue to learn how to identify patients at high risk for CCI and poor outcome so that expensive resources can be managed effectively, and patient-provider decision making can be better informed.

Clinical findings and resource use of infants and toddlers dependent on oxygen and ventilators

Medical records were reviewed to describe characteristics, report clinical and resource measures, and determine if differences exist between the diagnostic groups of prematurity and multiple congenital anomalies/neurologic conditions for initial admissions of 37 infants and toddlers to an inpatient pulmonary rehabilitation program. More than 75% of the children had a tracheostomy at admission and discharge. Forty-six percent of the sample was admitted requiring only oxygen, whereas 51% were discharged requiring only oxygen and not mechanical ventilation. Thirty percent of the children weaned to a less invasive mode of ventilation while just under half of the children were discharged home. Between-group comparisons indicated statistically significant differences for nutritional support at discharge (p < or = 0.05) and discharge disposition (p = 0.04). Complete weaning of oxygen or ventilator support during an initial inpatient pulmonary rehabilitation admission occurred less frequently than weaning to a less invasive mode of ventilation. This is an important consideration for referring children to rehabilitation programs, for clinical program improvement activities, and for setting realistic expectations for referral sources, patients and families, clinical staff, and payers. Further study is recommended using clinical data in program planning, in program improvements, and for setting outcome expectations for infants and toddlers dependent on pulmonary technology.

[Decompensation in chronic respiratory insufficiency in children]

In patients with acute exacerbations of chronic obstructive or restrictive pulmonary disease, noninvasive ventilation can be used in an attempt to avoid endotracheal intubation and complications associated with mechanical ventilation. The main obstructive pathology concerned is bronchopulmonary dysplasia: bronchial hyperreactivity is a main feature of the situation, leading eventually to acute or prolonged assisted ventilation. Usually performed by tracheostomy, ventilation can possibly be managed through a nasal mask. The use of noninvasive ventilation is also indicated when symptoms of hypoventilation and daytime hypercarbia develop in a variety of neuromuscular disorders.

Pulmonary risk factors compromising postoperative recovery after surgical repair for congenital heart disease

STUDY OBJECTIVES

To identify pulmonary risk factors associated with prolonged ICU stay in young children (< or = 2 years) undergoing surgical repair for congenital heart disease (CHD).

DESIGN

Retrospective case series analysis.

SETTING

Tertiary-care facility.

PATIENTS

Clinical records of 134 consecutive patients aged < or = 2 years undergoing cardiac surgery for CHD were reviewed, and 37 were excluded according to inclusion criteria. Thus, 97 patients were allocated to two groups based on the duration of ICU stay: < or = 7 days (group 1, n = 57), and > 7 days (group 2, n = 40).

RESULTS

Mean ICU duration for groups 1 and 2 was 3.0 +/- 0.4 days and 28.1 +/- 4.4 days, respectively (p < 0.001). In group 1, there were three extubation failures, whereas 41 extubation failures occurred in group 2 (p < 0.0001). A total of 22 patients (4 in group 1 and 18 in group 2) developed noninfectious pulmonary complications, such as airway problems, including extrinsic airway compression and tracheobronchomalacia (n = 6); pulmonary hypertension (n = 5); phrenic nerve palsy (n = 7); and pleural effusion (n = 8). These 22 patients (23%) contributed to the majority of total ventilator days (67%) as well as ICU stay (61%).

CONCLUSIONS

Pulmonary complications in general, and central airway problems in particular, are a frequent cause for delayed recovery following cardiac surgery in young children.

The experiences and views of parents who care for ventilator-dependent children

Discussion in this paper is drawn from the literature examining the management of children with long-term assisted ventilation, and a study of parents' experiences and views of caring for their ventilator-dependent child at home. Difficulties in undertaking research into this group of children are highlighted. Recommendations are proposed regarding future multidisciplinary, multiagency service development in order to meet the needs of ventilator-dependent children and their families.

Home mechanical ventilation in mitochondrial encephalomyopathy syndrome

Long-term home mechanical ventilation of children has only recently become more practically feasible and ethically acceptable by the medical community. It has been particularly controversial in cases of degenerative myopathies in which quality of life has been questioned. There are no reports in the literature of long-term home mechanical ventilation of a child with mitochondrial encephalomyopathy (MELAS) syndrome despite the many descriptions of possible etiologies of the concomitant respiratory failure. The patient reported here has used home mechanical ventilation for 6 years with few medical complications, no hospitalizations in the past 3 years, and increased function in activities of daily living. Despite the ill-defined nature of the disease and uncertain prognosis, we believe that long-term home mechanical ventilation of children with early onset MELAS syndrome is a viable option for both patients and their families and results in overall improvement in quality of life for the patient.