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

Detecting Ventilator-Induced Diaphragmatic Dysfunction Using Point-of-Care Ultrasound in Children With Long-term Mechanical Ventilation

Long-term mechanical ventilation (MV) is defined as the use of MV for more than 6 hours per day for at least 3 weeks. Children requiring long-term MV include those with neuromuscular disease, central dysregulation, or lung dysfunction. Such children with medical complexity may be at risk for ventilator-induced diaphragmatic dysfunction. Ventilator-induced diaphragmatic dysfunction has been described in adult patients requiring acute MV with ultrasound (US). At this time, diaphragmatic US has not been evaluated in the pediatric post-acute care setting or incorporated into weaning strategies. We present 24 cases of children requiring long-term MV who underwent diaphragmatic US examinations to evaluate for ventilator-induced diaphragmatic dysfunction.

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.

Long-term ventilation for children with chronic lung disease of infancy

PURPOSE OF REVIEW

Modern medical advances have resulted in an increased survival after extremely preterm birth. However, some infants will develop severe bronchopulmonary dysplasia (BPD) and fail to wean from invasive or noninvasive positive pressure support. It remains unclear which infants will benefit from tracheostomy placement for chronic ventilation. Once the decision to pursue chronic ventilation has been made, questions remain with respect to the timing of tracheotomy surgery, optimal strategies for mechanical ventilation, and multidisciplinary care in both the inpatient and outpatient settings. The appropriate time for weaning mechanical ventilation and tracheostomy decannulation has similarly not been determined.

RECENT FINDINGS

Although there remains a paucity of randomized controlled trials involving infants with severe BPD, a growing body of evidence suggests that chronic ventilation via tracheostomy is beneficial to support the growth and development of severely affected preterm children. However, delivering such care is not without risk. Chronic ventilation via tracheostomy requires complex care coordination and significant resource utilization.

SUMMARY

When chronic respiratory insufficiency limits a preterm infant's ability to grow and develop, chronic invasive ventilation may facilitate neurodevelopmental progress and may lead to an improved long-term outcome.

Weaning nocturnal ventilation and decannulation in a pediatric ventilator care program

INTRODUCTION

Children with chronic respiratory failure and upper airway disorders may require tracheostomy placement and long-term mechanical ventilation, yet many improve to permit ventilator weaning and decannulation.

METHODS

As a quality improvement project, we conducted a chart review of patients followed by our Ventilator Care Program who underwent evaluation for weaning nocturnal ventilation (NV) and/or decannulation from 2007-2014. We collected patient demographics and characterized location, monitoring techniques, and outcomes for patients undergoing weaning NV or decannulation. We attempted to implement end tidal carbon dioxide (ETCO2 ) monitoring and used linear regression to compare ETCO2 with morning pCO2 .

RESULTS

Weaning NV was successful in 20/21 patients. Decannulation was successful in 18/21 attempts. Once implemented, ETCO2 was piloted and successfully performed in 12 attempts (29%). Blood testing was performed in 24/42 trials (57%). When measured, the final ETCO2 result partially correlated with morning pCO2 (R(2)  = 0.53, P < 0.02). Neither blood testing nor ETCO2 was performed for the four patients with unsuccessful attempts.

CONCLUSIONS

Inpatient observation for weaning NV and decannulation is safe and, in most cases, successful. With close observation, weaning NV at home may also be safe. Blood testing and ETCO2 monitoring were frequently utilized, but rarely affected decision-making since signs of respiratory distress were observed clinically prior to testing. ETCO2 monitoring may provide reassurance without venipuncture. With our experience, we propose an algorithm for weaning NV and decannulation. Pediatr Pulmonol. 2016;51:825-829. © 2016 Wiley Periodicals, Inc.

Respiratory failure

On the basis of research evidence, (1)(2) numerous diseases and conditions can impair gas exchange, resulting in failure to meet the body's metabolic demands and leading to respiratory failure. On the basis of consensus, (1)(2)(7)(8)(9)(10) the clinical presentations of respiratory failure depend on the underlying cause and the level of hypoxemia and hypercapnia. Early diagnosis, close monitoring, and timely intervention are of utmost importance. On the basis of research evidence, (5)(14)(25) interventions range from noninvasive methods, such as close monitoring and supplemental oxygen, to full respiratory support with mechanical ventilation and in extreme cases even the use of extracorporeal membrane oxygenation.

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.

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.