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Dolinay T, Hsu L, Maller A, Walsh BC, Szűcs A, Jerng JS, Jun D. Ventilator Weaning in Prolonged Mechanical Ventilation-A Narrative Review. J Clin Med 2024; 13:1909. [PMID: 38610674 PMCID: PMC11012923 DOI: 10.3390/jcm13071909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/11/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
Patients requiring mechanical ventilation (MV) beyond 21 days, usually referred to as prolonged MV, represent a unique group with significant medical needs and a generally poor prognosis. Research suggests that approximately 10% of all MV patients will need prolonged ventilatory care, and that number will continue to rise. Although we have extensive knowledge of MV in the acute care setting, less is known about care in the post-ICU setting. More than 50% of patients who were deemed unweanable in the ICU will be liberated from MV in the post-acute setting. Prolonged MV also presents a challenge in care for medically complex, elderly, socioeconomically disadvantaged and marginalized individuals, usually at the end of their life. Patients and their families often rely on ventilator weaning facilities and skilled nursing homes for the continuation of care, but home ventilation is becoming more common. The focus of this review is to discuss recent advances in the weaning strategies in prolonged MV, present their outcomes and provide insight into the complexity of care.
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Affiliation(s)
- Tamás Dolinay
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
| | - Lillian Hsu
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
| | - Abigail Maller
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
| | - Brandon Corbett Walsh
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
- Department of Medicine, Division of Palliative Care Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA
| | - Attila Szűcs
- Department of Anesthesiology, András Jósa County Hospital, 4400 Nyíregyháza, Hungary;
| | - Jih-Shuin Jerng
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, National Taiwan University Hospital, Taipei 100, Taiwan;
| | - Dale Jun
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA; (L.H.); (A.M.); (B.C.W.); (D.J.)
- Barlow Respiratory Hospital, Los Angeles, CA 90026, USA
- Pulmonary, Critical Care and Sleep Section, West Los Angeles VA Medical Center, Los Angeles, CA 90073, USA
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Kwiatosz-Muc M, Kopacz B, Fijałkowska-Nestorowicz A. Quality of Life and Stress Levels in Patients under Home Mechanical Ventilation: What Can We Do to Improve Functioning Patients at Home? A Survey Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:874. [PMID: 36613195 PMCID: PMC9820158 DOI: 10.3390/ijerph20010874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/19/2022] [Accepted: 12/23/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Home mechanical ventilation (HMV) is becoming more widely available in many countries. OBJECTIVES The aim of this study was to measure the health-related quality of life and stress levels of patients ventilated mechanically at home. The relation between quality of life and stress levels was investigated including multiple regression analysis. METHODS 100 patients treated with HMV in Poland were surveyed with the WHOQOL-BREF questionnaire and Perceived Stress Scale (PSS-10). RESULTS 26% of patients assessed their quality of life as bad or very bad and 34% as good or very good. Stress levels measured with PSS-10 Scale were high level. For the group of patients with neurological disorders, stress levels were significantly higher than for the group of patients with pulmonological disorders. CONCLUSIONS The higher the stress levels of patients, the lower the quality of life in particular domains. Improving the living conditions of HMV patients can influence improving their quality of life.
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Affiliation(s)
- Magdalena Kwiatosz-Muc
- 1st Clinic of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Jaczewskiego Street 8, 20-093 Lublin, Poland
| | - Bożena Kopacz
- Department of Anaesthesiological and Intensive Care Nursing, Medical University of Lublin, Chodźki Street 7, 20-093 Lublin, Poland
| | - Anna Fijałkowska-Nestorowicz
- Department of Anaesthesiological and Intensive Care Nursing, Medical University of Lublin, Chodźki Street 7, 20-093 Lublin, Poland
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Serafim MCA, Orlandini MF, Datrino LN, Tavares G, Tristão LS, dos Santos CL, Pinheiro Filho JEL, Bernardo WM, Tustumi F. Is early extubation after esophagectomy safe? A systematic review and meta‐analysis. J Surg Oncol 2022; 126:68-75. [DOI: 10.1002/jso.26821] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 02/07/2022] [Indexed: 01/27/2023]
Affiliation(s)
| | | | | | - Guilherme Tavares
- Department of Evidence‐Based Medicine Centro Universitário Lusíada Santos Brazil
| | | | | | | | - Wanderley Marques Bernardo
- Department of Evidence‐Based Medicine Centro Universitário Lusíada Santos Brazil
- Department of Evidence‐Based Medicine Universidade de São Paulo São Paulo Brazil
| | - Francisco Tustumi
- Department of Evidence‐Based Medicine Centro Universitário Lusíada Santos Brazil
- Department of Evidence‐Based Medicine Universidade de São Paulo São Paulo Brazil
- Department of Surgery Hospital Israelita Albert Einstein São Paulo Brazil
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Wasilewski MB, Kokorelias KM, Nonoyama M, Dale C, McKim DA, Road J, Leasa D, Tandon A, Goldstein R, Rose L. The experience of family caregivers of ventilator-assisted individuals who participated in a pilot web-based peer support program: A qualitative study. Digit Health 2022; 8:20552076221134964. [DOI: 10.1177/20552076221134964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 10/05/2022] [Indexed: 11/27/2022] Open
Abstract
Introduction Family caregivers play an important role supporting the day-to-day needs of ventilator-assisted individuals (VAIs) living at home. Peer-to-peer communication can help support these caregivers and help them sustain caregiving in the community. Online peer-support has been suggested as a way to help meet caregivers’ support needs. Methods A qualitative descriptive approach was used to elicit the perspectives of support received from caregivers who participated in a pilot web-based peer support program from October to December 2018. Data were collected through the transcripts of weekly online peer-to-peer group chats. Data were analyzed using an integration of thematic and framework analysis. Results In total, eight caregivers and five peer mentors participated in the pilot. All five mentors and four of the caregivers participated in the weekly chats. We identified three themes, a) The experience of caregivers is characterized by unique challenges related to the complexity of VAI care including technology; b) Mentors and caregiver participants reciprocally share support; c) Despite hardships, there are things that make caregiving easier and joyful. Discussion Our results add to the growing body of evidence pointing to the importance of online communities for supporting vulnerable caregivers. The reciprocal element of peer support, where trained mentors and untrained participants both benefit from support, can help sustain peer-support interventions. Despite the challenges of providing care to a VAI, there are facilitators that may help ease the caregiving experience and caregivers can benefit from ongoing support that is tailored to their needs along the caregiving trajectory.
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Affiliation(s)
- Marina B. Wasilewski
- St. John's Rehab Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kristina M. Kokorelias
- St. John's Rehab Research Program, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Mika Nonoyama
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
| | - Craig Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Douglas A McKim
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Jeremy Road
- Division of Respiratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - David Leasa
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Anu Tandon
- Division of Respiratory, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Roger Goldstein
- Respiratory Medicine, West Park Healthcare Centre, Toronto, Ontario, Canada
| | - Louise Rose
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
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Allen J, Panitch H. Bronchopulmonary dysplasia-A historical perspective. Pediatr Pulmonol 2021; 56:3478-3489. [PMID: 33638603 DOI: 10.1002/ppul.25341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 02/22/2021] [Accepted: 02/24/2021] [Indexed: 11/08/2022]
Abstract
Bronchopulmonary dysplasia (BPD) was first described by Northway et al in 1967. This article describes the evolution of our understanding of the pathophysiology of BPD and the approaches to treatments of this illness developed over the past fifty years. These interventions had their roots in the understanding of the principles of the surface tension present at air-liquid interfaces, which were developed over 150 years before BPD's initial description. Improving outcomes in neonatal care have led to greater survival of preterm and very preterm infants, and to an evolution of the pathogenesis and pathology of BPD, from an illness caused primarily by barotrauma and oxygen toxicity to one of interruption of lung development. While the incidence of BPD has remained about the same in recent decades, this is because survival of infants born at lower gestational ages is increasing. Understanding of molecular, genetic and physiologic mechanisms has led to newer treatments that have mitigated some of the harmful effects of prolonged mechanical ventilation. Recognition of BPD as a chronic multi-system disease has resulted in further improvements in care after discharge from neonatal intensive care. Since many of the origins of chronic obstructive lung disease in adults are based in childhood respiratory illnesses, improving outcomes of BPD in infancy and childhood will undoubtedly lead to improved respiratory outcomes in the adults that these children will become.
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Affiliation(s)
- Julian Allen
- Division of Pulmonary and Sleep Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Howard Panitch
- Division of Pulmonary and Sleep Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Continuous noninvasive ventilatory support outcomes for patients with neuromuscular disease: a multicenter data collaboration. Pulmonology 2021; 27:509-517. [PMID: 34656524 DOI: 10.1016/j.pulmoe.2021.06.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 06/18/2021] [Accepted: 06/18/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Typically, patients with progressive neuromuscular disorders (NMDs) develop acute respiratory failure (ARF), are intubated, and when failing spontaneous breathing trials (SBTs) undergo a tracheotomy and receive tracheostomy mechanical ventilation (TMV). However, increasing numbers of patients use nasal noninvasive ventilation (NIV), initially for sleep and this is extended to continuous dependence (CNVS). This can be used as a strategy to assist in successful extubation . We retrospectively reviewed 19 centers offering CNVS and mechanical insufflation-exsufflation (MI-E) as an alternative to TMV. METHODS Centers with publications or presentations concerning CNVS outcomes data were pooled for amyotrophic lateral sclerosis (ALS), Duchenne muscular dystrophy (DMD), and spinal muscular atrophy type 1 (SMA1). Progression to CNVS dependence without hospitalization, duration of dependence, and extubations and decannulations to CNVS were recorded. Prolongation of life was defined by duration of CNVS dependence without ventilator free breathing ability (VFBA). RESULTS There were 1623 part time (<23 h/day) NVS users with ALS, DMD, and SMA1 from 19 centers in 16 countries of whom 761 (47%) were CNVS dependent for 2218 patient-years. This included: 335 ALS patients for a mean 1.2 ± 1.0 (range to 8) years each; 385 DMD patients for 5.4 ± 1.6 (range to 29) years; and 41 SMA1 patients for 5.9 ± 1.8 (range to 20) years. Thirty-five DMD and ALS TMV users were decannulated to CNVS and MI-E. At data collection 494 (65%) patients were CNVS dependent but 110 (74 of whom with bulbar ALS), had undergone tracheotomies. CONCLUSIONS ALS, DMD, and SMA1 patients can become CNVS dependent without requiring hospitalization but CNVS cannot be used indefinitely for many patients with advanced upper motor neuron diseases.
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Ishimori S, Nagase S, Kanagawa A, Nakajiri T, Okita S, Oyazato Y, Nishiyama A, Yonetani M. Modified setting of negative pressure in children with mild respiratory disease. Pediatr Int 2021; 63:838-844. [PMID: 33251674 DOI: 10.1111/ped.14560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 09/16/2020] [Accepted: 10/20/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Continuous negative extra-thoracic pressure (CNEP) can prevent children with apnea developing severe respiratory infection with endotracheal intubation. Little is known about children with mild acute respiratory disease, especially with a focus on clinical respiratory symptoms. METHODS We conducted a prospective, observational study between July 2014 and July 2017 to evaluate the safety of a modified setting of CNEP in hospitalized children with symptoms of chest-wall retraction or nasal alar breathing without the requirement for immediate intubation therapy in a single center. A modified setting of CNEP was defined as 4 h of treatment comprising 3 consecutive hours of CNEP followed by 1 h of rest. RESULTS We studied 19 hospitalized children with retraction or nasal breathing but no possible state of endotracheal intubation. The median age at admission was 0.9 years and the duration of CNEP was 6 days. No sedative drugs were used. The percentage of children with retraction or nasal breathing after 24 h from initiation of CNEP was significantly decreased compared with that just before CNEP (68% vs 100%, P = 0.02). Logistic regression showed no statistical evidence of contributing factors for pulmonary symptoms. No patients were transferred to receive intubation, but one boy reinitiated respiratory support within 6 months after discharge. No children had adverse events of upper airway obstruction, skin injury, interfering with access, hypothermia, discomfort from fitting a cuirass, and neck excoriation. CONCLUSIONS Our results suggest that a modified setting of CNEP management can be tolerated and continued without concern of adverse events.
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Affiliation(s)
- Shingo Ishimori
- Department of Pediatrics, Kakogawa Central City Hospital, Kakogawa, Japan.,Department of Pediatrics, Takatsuki General Hospital, Takatsuki, Japan
| | - Shizuka Nagase
- Department of Pediatrics, Kakogawa Central City Hospital, Kakogawa, Japan
| | - Atsuko Kanagawa
- Department of Pediatrics, Kakogawa Central City Hospital, Kakogawa, Japan
| | - Tomoshi Nakajiri
- Department of Pediatrics, Kakogawa Central City Hospital, Kakogawa, Japan
| | - Sora Okita
- Department of Pediatrics, Kakogawa Central City Hospital, Kakogawa, Japan
| | - Yoshinobu Oyazato
- Department of Pediatrics, Kakogawa Central City Hospital, Kakogawa, Japan
| | - Atsushi Nishiyama
- Department of Pediatrics, Kakogawa Central City Hospital, Kakogawa, Japan
| | - Masahiko Yonetani
- Department of Pediatrics, Kakogawa Central City Hospital, Kakogawa, Japan
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Ishimori S, Okizuka Y, Onishi S, Shinomoto T, Minami H. Predictive factors of continuous negative extrathoracic pressure management failure in children with moderate to severe respiratory syncytial virus infection. Sci Rep 2021; 11:8063. [PMID: 33850205 PMCID: PMC8044183 DOI: 10.1038/s41598-021-87582-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 03/26/2021] [Indexed: 11/17/2022] Open
Abstract
Continuous negative extrathoracic pressure (CNEP) might be beneficial for children with severe respiratory tract infections. However, there are no available data on the predictors of its failure among individuals with respiratory syncytial virus (RSV) infections. Here, we conducted a retrospective cohort study between October 1, 2015 and October 31, 2018 in hospitalized children with moderate to severe symptoms of respiratory syncytial virus (RSV) infections. We divided 45 children requiring CNEP ventilation with a non-fluctuating negative pressure of - 12 cm H2O into two groups. They were classified based on improvement or deterioration of their respiratory disorder under CNEP ventilation (responder group: n = 27, failure group: n = 18). Based on the univariate analysis, the responder and failure groups significantly differed in terms of median age, days elapsed from RSV onset to the initiation of CNEP, white blood cell count (WBC), titer of venous pCO2, body temperature at admission, and modified Wood-Downes Score (mWDS) 6 h after initiating CNEP. Based on a logistic regression analysis adjusted for age < 1 year upon admission, less than 5 days elapsed from RSV onset to the initiation of CNEP, not high value of WBC and body temperature at admission, and high values of mWDS 6 h after initiating CNEP were found to be significant independent risk factors for CNEP ventilation failure. The former two variables were associated with less failure (odds ratio was approximately 5), and the latter two variables are associated with more failure (odds ratio was approximately 8-9). Thus, CNEP could be a valid option for children with moderate to severe RSV infections, especially in those who were aged > 1 year, and specific clinical and laboratory findings.
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Affiliation(s)
- Shingo Ishimori
- Department of Pediatrics, Takatsuki General Hospital, 1-3-13 Kosobe-cho, Takatsuki City, Osaka, 5691192, Japan.
| | - Yo Okizuka
- Department of Pediatrics, Intensive Care of Medicine, Takatsuki General Hospital, Osaka, Japan
| | - Satoshi Onishi
- Department of Pediatrics, Intensive Care of Medicine, Takatsuki General Hospital, Osaka, Japan
| | - Tadashi Shinomoto
- Department of Pediatrics, Intensive Care of Medicine, Takatsuki General Hospital, Osaka, Japan
| | - Hirotaka Minami
- Department of Pediatrics, Takatsuki General Hospital, 1-3-13 Kosobe-cho, Takatsuki City, Osaka, 5691192, Japan
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Kwiatosz-Muc M, Kopacz B. Home Mechanical Ventilation: A Patient's Perspective Survey Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18084048. [PMID: 33921363 PMCID: PMC8069923 DOI: 10.3390/ijerph18084048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 02/23/2021] [Accepted: 03/10/2021] [Indexed: 11/16/2022]
Abstract
Background: An increasing number of patients included in home mechanical ventilation (HMV) care has been under observation for many years. The study aimed to assess the patients opinion concerning the expected and perceived quality of care in an HMV system and a patient’s satisfaction with care. Methods: In 2017, patients treated with HMV were surveyed in Poland with the modified SERVQUAL questionnaire. Results: One hundred correctly completed surveys were analyzed. Patient Satisfaction Index was high. In every examined area, the expectations were statistically significant larger than the perception of the services. The biggest gap was in the tangibility dimension and the smallest gap was in the empathy dimension. Perceived respect and understanding for a patient’s needs are close to the expectations. Conclusions: The level of satisfaction with health care among patients treated with HMV in majority of investigated components is high. Moreover, the difference between perceived and expected quality of health care in the HMV system was relatively small in the opinion of the patients themselves. Further investigations with alternative methods are needed.
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Sison SM, Sivakumar GK, Caufield-Noll C, Greenough WB, Oh ES, Galiatsatos P. Mortality outcomes of patients on chronic mechanical ventilation in different care settings: A systematic review. Heliyon 2021; 7:e06230. [PMID: 33615014 PMCID: PMC7880845 DOI: 10.1016/j.heliyon.2021.e06230] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/24/2021] [Accepted: 02/04/2021] [Indexed: 01/08/2023] Open
Abstract
Objectives To determine the outcomes of chronically ventilated patients outside the setting of intensive care units. Design Systematic review. Setting and participants Studies evaluating patients on chronic invasive mechanical ventilation in different care settings. Methods A systematic literature search of the PubMed, Embase, Cochrane Library, CINAHL (EBSCOhost), LILACS and Scopus databases from inception to March 27, 2020. Studies reporting mortality outcomes of patients ≥18 years of age on chronic invasive mechanical ventilation in intensive care units and other care settings were eligible for inclusion. Results Sixty studies were included in the systematic review. Mortality rates ranged from 13.7% to 77.8% in ICUs (n = 17 studies), 7.8%-51.0% in non-ICUs including step-down units and inpatient wards (n = 26 studies), and 12.0%-91.8% in home or nursing home settings (n = 19 studies). Age was associated with mortality in all care settings. Weaning rates ranged from 10.0% to 78.2% across non-ICU studies. Studies reporting weaning as their primary outcome demonstrated higher success rates in weaning. Home care studies reported low incidences of ventilator failure. None of the studies reported ventilator malfunction as the primary cause of death. Conclusions and implications Mortality outcomes across various settings were disparate due to methodological and clinical heterogeneity among studies. However, there is evidence to suggest non-ICU venues of care as a comparable alternative to ICUs for stable, chronically ventilated patients, with the additional benefit of providing specialized weaning programs. By synthesizing the global data on managing chronically ventilated patients in various care settings, this study provides health care systems and providers alternative venue options for the delivery of prolonged ventilatory care in the context of limited ICU resources.
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Affiliation(s)
- Stephanie M Sison
- Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - Gayathri K Sivakumar
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | | | - William B Greenough
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Esther S Oh
- Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Panagis Galiatsatos
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Cost-Utility Analysis of Home Mechanical Ventilation in Patients with Amyotrophic Lateral Sclerosis. Healthcare (Basel) 2021; 9:healthcare9020142. [PMID: 33535635 PMCID: PMC7912812 DOI: 10.3390/healthcare9020142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/26/2021] [Accepted: 01/28/2021] [Indexed: 11/16/2022] Open
Abstract
Amyotrophic lateral sclerosis is a disease with rapid progression. The use of mechanical ventilation helps to manage symptoms and delays death. Use in a home environment could reduce costs and increase quality of life. The aim of this study is a cost–utility analysis of home mechanical ventilation in adult patients with amyotrophic lateral sclerosis from the perspective of healthcare payers in the Czech Republic. The study evaluates home mechanical ventilation (HMV) and mechanical ventilation (MV) in a healthcare facility. A Markov model was compiled for evaluation in a timeframe of 10 years. Model parameters were obtained from the literature and opinions of experts from companies dealing with home care and home mechanical ventilation. The cost–utility analysis was carried out at the end of the study and results are presented in incremental cost–utility ratio (ICUR) using quality-adjusted life-years. Uncertainty was assessed by one-way sensitivity analysis and scenario analysis. The cumulative costs of HMV are CZK 1,877,076 and the cumulative costs of the MV are CZK 7,386,629. The cumulative utilities of HMV are 12.57 quality-adjusted life year (QALY) and the cumulative utilities of MV are 11.32 QALY. The ICUR value is CZK-4,403,259. The results of this study suggest that HMV is cost effective.
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12
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Schönhofer B, Geiseler J, Dellweg D, Fuchs H, Moerer O, Weber-Carstens S, Westhoff M, Windisch W. Prolonged Weaning: S2k Guideline Published by the German Respiratory Society. Respiration 2020; 99:1-102. [PMID: 33302267 DOI: 10.1159/000510085] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 01/28/2023] Open
Abstract
Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by respiratory muscle insufficiency and/or lung parenchymal disease; that is, when other treatments such as medication, oxygen administration, secretion management, continuous positive airway pressure (CPAP), or nasal high-flow therapy have failed. MV is required for maintaining gas exchange and allows more time to curatively treat the underlying cause of respiratory failure. In the majority of ventilated patients, liberation or "weaning" from MV is routine, without the occurrence of any major problems. However, approximately 20% of patients require ongoing MV, despite amelioration of the conditions that precipitated the need for it in the first place. Approximately 40-50% of the time spent on MV is required to liberate the patient from the ventilator, a process called "weaning". In addition to acute respiratory failure, numerous factors can influence the duration and success rate of the weaning process; these include age, comorbidities, and conditions and complications acquired during the ICU stay. According to international consensus, "prolonged weaning" is defined as the weaning process in patients who have failed at least 3 weaning attempts, or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Given that prolonged weaning is a complex process, an interdisciplinary approach is essential for it to be successful. In specialised weaning centres, approximately 50% of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, the heterogeneity of patients undergoing prolonged weaning precludes the direct comparison of individual centres. Patients with persistent weaning failure either die during the weaning process, or are discharged back to their home or to a long-term care facility with ongoing MV. Urged by the growing importance of prolonged weaning, this Sk2 Guideline was first published in 2014 as an initiative of the German Respiratory Society (DGP), in conjunction with other scientific societies involved in prolonged weaning. The emergence of new research, clinical study findings and registry data, as well as the accumulation of experience in daily practice, have made the revision of this guideline necessary. The following topics are dealt with in the present guideline: Definitions, epidemiology, weaning categories, underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV, and recommendations for end-of-life decisions. Special emphasis was placed on the following themes: (1) A new classification of patient sub-groups in prolonged weaning. (2) Important aspects of pulmonary rehabilitation and neurorehabilitation in prolonged weaning. (3) Infrastructure and process organisation in the care of patients in prolonged weaning based on a continuous treatment concept. (4) Changes in therapeutic goals and communication with relatives. Aspects of paediatric weaning are addressed separately within individual chapters. The main aim of the revised guideline was to summarize both current evidence and expert-based knowledge on the topic of "prolonged weaning", and to use this information as a foundation for formulating recommendations related to "prolonged weaning", not only in acute medicine but also in the field of chronic intensive care medicine. The following professionals served as important addressees for this guideline: intensivists, pulmonary medicine specialists, anaesthesiologists, internists, cardiologists, surgeons, neurologists, paediatricians, geriatricians, palliative care clinicians, rehabilitation physicians, intensive/chronic care nurses, physiotherapists, respiratory therapists, speech therapists, medical service of health insurance, and associated ventilator manufacturers.
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Affiliation(s)
- Bernd Schönhofer
- Klinikum Agnes Karll Krankenhaus, Klinikum Region Hannover, Laatzen, Germany,
| | - Jens Geiseler
- Klinikum Vest, Medizinische Klinik IV: Pneumologie, Beatmungs- und Schlafmedizin, Marl, Germany
| | - Dominic Dellweg
- Fachkrankenhaus Kloster Grafschaft GmbH, Abteilung Pneumologie II, Schmallenberg, Germany
| | - Hans Fuchs
- Universitätsklinikum Freiburg, Zentrum für Kinder- und Jugendmedizin, Neonatologie und Pädiatrische Intensivmedizin, Freiburg, Germany
| | - Onnen Moerer
- Universitätsmedizin Göttingen, Klinik für Anästhesiologie, Göttingen, Germany
| | - Steffen Weber-Carstens
- Charité, Universitätsmedizin Berlin, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Virchow-Klinikum und Campus Mitte, Berlin, Germany
| | - Michael Westhoff
- Lungenklinik Hemer, Hemer, Germany
- Universität Witten/Herdecke, Herdecke, Germany
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Universität Witten/Herdecke, Herdecke, Germany
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13
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Abstract
An increasing number of patients require prolonged weaning from mechanical ventilation as a result of advanced age, patient comorbidities, technical progress in surgery and intensive care medicine. The data of the WeanNet register show that more than half (64%) of patients transferred from the intensive care unit (ICU) to a specialized weaning center could definitely be weaned from the respirator. Weaning failure was associated with prolonged ventilation prior to transfer to a weaning center, low body mass index, pre-existing neuromuscular diseases and advanced age. The number of patients with out of hospital ventilation who had to be re-hospitalized because of ventilation control or as part of emergency management quadrupled in Germany between 2006 and 2016. Invasive out-of-hospital ventilation and long-term noninvasive ventilation are associated with a significant loss of autonomy and with low quality of life. Therefore, the initiation must be carefully reviewed and regularly re-evaluated in the context of patient comorbidities and, if necessary, decisions should be made with respect to changing treatment targets. Specialized weaning centers have been established for patients in whom weaning on the ICU was unsuccessful. In cases of persisting weaning failure the adequate transition to out-of-hospital ventilation should be managed by a weaning unit. Weaning centers are responsible for outpatient invasive or noninvasive ventilation strategies and control of treatment quality. Depending on the infrastructure and networking of the respective weaning center, it is basically also possible to provide outpatient care for clinically stable patients in a cooperation model together with pulmonologists in private practice experienced in respiratory medicine.
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Affiliation(s)
- K. Fricke
- Lungenklinik Merheim, Kliniken der Stadt Köln gGmbH, Universität Witten/Herdecke, Ostmerheimer Str. 200, 51109 Köln, Deutschland
| | - B. Schönhofer
- Pneumologische Praxis und pneumologischer Konsildienst im Klinikum Agnes KarllLaatzen, Klinikum Region Hannover, Hannover, Deutschland
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14
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Park S, Suh ES. Home mechanical ventilation: back to basics. Acute Crit Care 2020; 35:131-141. [PMID: 32907307 PMCID: PMC7483009 DOI: 10.4266/acc.2020.00514] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 08/27/2020] [Indexed: 11/30/2022] Open
Abstract
Over recent decades, the use of home mechanical ventilation (HMV) has steadily increased worldwide, with varying prevalence in different countries. The key indication for HMV is chronic respiratory failure with alveolar hypoventilation (e.g., neuromuscular and chest wall disease, obstructive airway diseases, and obesity-related respiratory failure). Most modern home ventilators are pressure-targeted and have sophisticated modes, alarms, and graphics, thereby facilitating optimization of the ventilator settings. However, different ventilators have different algorithms for tidal volume estimation and leak compensation, and there are also several different circuit configurations. Hence, a basic understanding of the fundamentals of HMV is of paramount importance to healthcare workers taking care of patients with HMV. When choosing a home ventilator, they should take into account many factors, including the current condition and prognosis of the primary disease, the patient’s daily performance status, time (hr/day) needed for ventilator support, family support, and financial costs. In this review, to help readers understand the basic concepts of HMV use, we describe the indications for HMV and the factors that influence successful delivery, including interface, circuits, ventilator accessories, and the ventilator itself.
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Affiliation(s)
- Sunghoon Park
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Eui-Sik Suh
- Lane Fox Respiratory Service, Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London, UK
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15
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Gulla KM, Sahoo T, Sachdev A. Technology-dependent children. Int J Pediatr Adolesc Med 2020; 7:64-69. [PMID: 32642538 PMCID: PMC7335821 DOI: 10.1016/j.ijpam.2019.07.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 07/09/2019] [Indexed: 11/29/2022]
Abstract
In recent past, revolution in medical technology resulted in improved survival rates and outcomes of critically ill children. Unfortunately, its impact relating to morbidity is not well documented. Although survival rates of these critically ill children who are medically fragile and technology-dependent have improved, we as health professionals are still in the learning curve to improve the quality of life of these children at home. Factors such as support from society, infrastructure, and funding play an important role in technology-dependent child care at home. In this review, commonly prescribed home-based medical technologies such as home ventilation, enteral nutrition, renal replacement therapy, and peripherally inserted central catheter, which are useful for quick revision, are described.
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Affiliation(s)
- Krishna Mohan Gulla
- Division of Pediatrics, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - Tanushree Sahoo
- Division of Neonatology, All India Institute of Medical Sciences, New Delhi, India
| | - Anil Sachdev
- Division of Pediatrics, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
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16
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Park M, Jang H, Sol IS, Kim SY, Kim YS, Kim YH, Sohn MH, Kim KW. Pediatric Home Mechanical Ventilation in Korea: the Present Situation and Future Strategy. J Korean Med Sci 2019; 34:e268. [PMID: 31674158 PMCID: PMC6823518 DOI: 10.3346/jkms.2019.34.e268] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 09/08/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The number of children using home mechanical ventilation (HMV) has increased markedly in Europe and North America, but little is known about the situation in Korea. We described the clinical characteristics of children using HMV and investigated the current situation of HMV utilization in children. METHODS Data on HMV prescriptions in year 2016 for children under the age of 19 was retrieved from the National Health Insurance Service for nationwide information. For more detailed information, data from year 2016 to 2018 was also retrieved from a tertiary center, Severance Children's Hospital. RESULTS Nationwide, 416 children were prescribed with HMV in 2016, with an estimated prevalence of 4.4 per 100,000 children, of which 64.2% were male and mean age was 6-year-old. The estimated number of patients using invasive ventilators via tracheostomy was 202 (49%). Neuromuscular diseases were the most frequent cause (217; 52%), followed by central nervous system diseases (142; 34%), and cardiopulmonary diseases (57; 14%). In the tertiary center, a total of 62 children were prescribed with HMV (19 [31%] with non-invasive ventilation; 43 [69%] with invasive ventilation]. The number of children with HMV increased from 11 in 2016 to 29 in 2018. The mean age for initiation of HMV was 3.1 years and male patients comprised 65%. The most frequent diagnostic reason for HMV was central nervous system diseases (68%), followed by cardiopulmonary diseases (19%) and neuromuscular diseases (13%). Five patients died during the study period and five patients weaned from HMV. CONCLUSION This study provides insights on the present situation of HMV utilization in Korean children.
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Affiliation(s)
- Mireu Park
- Department of Pediatrics, Severance Hospital, Institute of Allergy, Institute for Immunology and Immunological Diseases, Severance Biomedical Science Institute, Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Haerin Jang
- Department of Pediatrics, Severance Hospital, Institute of Allergy, Institute for Immunology and Immunological Diseases, Severance Biomedical Science Institute, Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - In Suk Sol
- Department of Pediatrics, Severance Hospital, Institute of Allergy, Institute for Immunology and Immunological Diseases, Severance Biomedical Science Institute, Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Soo Yeon Kim
- Department of Pediatrics, Severance Hospital, Institute of Allergy, Institute for Immunology and Immunological Diseases, Severance Biomedical Science Institute, Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Young Suh Kim
- Department of Pediatrics, Severance Hospital, Institute of Allergy, Institute for Immunology and Immunological Diseases, Severance Biomedical Science Institute, Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Yoon Hee Kim
- Department of Pediatrics, Severance Hospital, Institute of Allergy, Institute for Immunology and Immunological Diseases, Severance Biomedical Science Institute, Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Myung Hyun Sohn
- Department of Pediatrics, Severance Hospital, Institute of Allergy, Institute for Immunology and Immunological Diseases, Severance Biomedical Science Institute, Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Won Kim
- Department of Pediatrics, Severance Hospital, Institute of Allergy, Institute for Immunology and Immunological Diseases, Severance Biomedical Science Institute, Brain Korea 21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Korea.
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17
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Muñoz-Bonet JI, López-Prats JL, Flor-Macián EM, Cantavella T, Domínguez A, Vidal Y, Brines J. Medical complications in a telemedicine home care programme for paediatric ventilated patients. J Telemed Telecare 2019; 26:462-473. [PMID: 31023136 DOI: 10.1177/1357633x19843761] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Advances in paediatric medicine have increased survival rates for patients with severe chronic illnesses, of which the most complex are ventilator-dependent children (VDCs). Although home care improves their quality of life, morbidity and mortality rates are high. Our aim was to study the medical complications (events) that occur at home and assess the usefulness of telemedicine in their detection and treatment. METHODS A prospective clinical study (2007-2017) was performed for tracheotomised VDCs. We used a high-density data telemedicine monitoring system from our Paediatric Intensive Care Unit and analysed events during the first two years of home care to study how different variables inter-correlated with the four most common ones: hospital admissions, admissions avoided, event durations and life-threatening events (LTEs); the significance level was set at an alpha of 0.05 in all cases. RESULTS All our VDCs were included (n = 12); there were 141 events, and these were homogeneously distributed over the study period. The incidence was higher in children who were ventilator dependent for more than 12 h a day (70.9%, p < 0.001) and the main cause was respiratory (69.5%, p < 0.001). Telemedicine was the main initial care and monitoring approach (86.5% and 90.1%, respectively, p < 0.001); 13 events were LTEs, nine were resolved telemedically, four required medicalised transfer to hospital and three resulted in a hospital admission. DISCUSSION Clinical complications are frequent in VDCs receiving home care, and respiratory decompensation is the most frequent cause. Telemedicine facilitated diagnosis and early treatment, and was useful in managing LTEs.
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Affiliation(s)
- Juan I Muñoz-Bonet
- Paediatric Intensive Care Unit, Hospital Clínico Universitario de Valencia, Spain.,Department of Paediatrics, Obstetrics, and Ginecology, Universidad de Valencia, Spain
| | - José L López-Prats
- Paediatric Intensive Care Unit, Hospital Clínico Universitario de Valencia, Spain
| | - Eva M Flor-Macián
- Paediatric Intensive Care Unit, Hospital Clínico Universitario de Valencia, Spain
| | - Teresa Cantavella
- Paediatric Home Hospitalisation Unit, Hospital Clínico Universitario de Valencia, Spain
| | - Amparo Domínguez
- Paediatric Home Hospitalisation Unit, Hospital Clínico Universitario de Valencia, Spain
| | - Yvan Vidal
- Paediatric Home Hospitalisation Unit, Hospital Clínico Universitario de Valencia, Spain
| | - Juan Brines
- Department of Paediatrics, Obstetrics, and Ginecology, Universidad de Valencia, Spain
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18
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Edwards JD, Kun SS, Graham RJ, Keens TG. End-Of-Life Discussions and Advance Care Planning for Children on Long-Term Assisted Ventilation with Life-Limiting Conditions. J Palliat Care 2018. [DOI: 10.1177/082585971202800104] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Families of children with life-limiting conditions who are on long-term assisted ventilation need to undertake end-of-life advance care planning (ACP) in order to align their goals and values with the inevitability of their child's condition and the risks it entails. To discuss how best to conduct ACP in this population, we performed a retrospective analysis of end-of-life discussions involving our deceased ventilator-assisted patients between 1987 and 2009. A total of 34 (72 percent) of 47 study patients were the subject of these discussions; many discussions occurred after acute deterioration. They resulted in directives to forgo or limit interventions for 21 children (45 percent). We surmise that many families were hesitant to discuss end-of-life issues during periods of relative stability. By offering anticipatory guidance and encouraging contemplation of patients’ goals both in times of stability and during worsening illness, health care providers can better engage patients’ families in ACP. As the child's condition progresses, the emphasis can be recalibrated. How families respond to such encouragement can also serve as a gauge of their willingness to pursue ACP.
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Affiliation(s)
- Jeffrey D. Edwards
- JD Edwards (corresponding author): Division of Pediatric Critical Care, University of California, San Francisco, and Moffitt Hospital, Box 0106, 505 Parnassus Avenue, San Francisco, California, USA 94143–0106
| | - Sheila S. Kun
- SS Kun: Division of Pediatric Pulmonology, Children's Hospital Los Angeles, and Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Robert J. Graham
- RJ Graham: Critical Care, Anesthesia, Perioperative Extension (CAPE) and Home Ventilation Program, and Division of Critical Care Medicine, Children's Hospital Boston, and Harvard Medical School, Boston, Massachusetts, USA
| | - Thomas G. Keens
- TG Keens: Division of Pediatric Pulmonology, Children's Hospital Los Angeles, and Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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19
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Muñoz-Bonet JI, López-Prats JL, Flor-Macián EM, Cantavella T, Bonet L, Domínguez A, Brines J. Usefulness of telemedicine for home ventilator-dependent children. J Telemed Telecare 2018; 26:207-215. [PMID: 30537895 DOI: 10.1177/1357633x18811751] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Medical care for ventilator-dependent children must avoid hospital confinement, which is detrimental to the patient, their family and Paediatric Intensive Care Unit. Our objective was to assess the role of telemedicine in facilitating early and permanent discharge of such patients to home care. METHODS This was a prospective clinical study (2007-2017) in tracheotomised ventilator-dependent children. We used a Big Data Telemedicine home system (Medlinecare 2.1) from the Paediatric Intensive Care Unit. Specialised home-nursing services were available. Clinical events were analysed using the Chi-square test (significance p < 0.05). Families subsequently completed a satisfaction survey. The Paediatric Intensive Care Unit management indicators were analysed. RESULTS All of our ventilator-dependent children were included (n=12). At time of discharge from the Paediatric Intensive Care Unit, they all required continuous mechanical ventilation and met the criteria of groups I-III of the OTA classification. In the first two years there were 141 events; the main cause was respiratory (69.5%, p < 0.001) and telemedicine was the main care approach (86.5%, p < 0.001). Eleven events required hospitalisation (7.8%) but 38 (27.0%) hospitalisations were avoided. The emergency readmission time accounted for 0.99% of the total time. Six patients were decannulated, and one patient died due to primary cardiac arrest. All the families considered that the telemedicine had helped to avoid hospital visits, was not an intrusion into their privacy, and improved the child's safety and quality of life. An improvement in Paediatric Intensive Care Unit indicators was achieved. DISCUSSION Telemedicine facilitated early and permanent discharge of our ventilator-dependent children to home care without affecting their quality of care.
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Affiliation(s)
- Juan I Muñoz-Bonet
- Paediatric Intensive Care Unit, Hospital Clínico Universitario de Valencia, Spain.,Department of Paediatrics, Obstetrics and Ginecology, Universidad de Valencia, Spain
| | - José L López-Prats
- Paediatric Intensive Care Unit, Hospital Clínico Universitario de Valencia, Spain
| | - Eva M Flor-Macián
- Paediatric Intensive Care Unit, Hospital Clínico Universitario de Valencia, Spain
| | - Teresa Cantavella
- Paediatric Home Hospitalization Unit, Hospital Clínico Universitario de Valencia, Spain
| | - Laura Bonet
- Paediatric Home Hospitalization Unit, Hospital Clínico Universitario de Valencia, Spain
| | - Amparo Domínguez
- Paediatric Home Hospitalization Unit, Hospital Clínico Universitario de Valencia, Spain
| | - Juan Brines
- Department of Paediatrics, Obstetrics and Ginecology, Universidad de Valencia, Spain
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20
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Aarrestad S, Qvarfort M, Kleiven AL, Tollefsen E, Skjønsberg OH, Janssens JP. Diagnostic accuracy of simple tools in monitoring patients with chronic hypoventilation treated with non-invasive ventilation; a prospective cross-sectional study. Respir Med 2018; 144:30-35. [DOI: 10.1016/j.rmed.2018.09.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 09/24/2018] [Accepted: 09/25/2018] [Indexed: 12/14/2022]
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21
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22
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McFarlane DC, Doig AK, Agutter JA, Brewer LM, Syroid ND, Mittu R. Faster clinical response to the onset of adverse events: A wearable metacognitive attention aid for nurse triage of clinical alarms. PLoS One 2018; 13:e0197157. [PMID: 29768477 PMCID: PMC5955574 DOI: 10.1371/journal.pone.0197157] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 04/27/2018] [Indexed: 11/18/2022] Open
Abstract
Objective This study evaluates the potential for improving patient safety by introducing a metacognitive attention aid that enables clinicians to more easily access and use existing alarm/alert information. It is hypothesized that this introduction will enable clinicians to easily triage alarm/alert events and quickly recognize emergent opportunities to adapt care delivery. The resulting faster response to clinically important alarms/alerts has the potential to prevent adverse events and reduce healthcare costs. Materials and methods A randomized within-subjects single-factor clinical experiment was conducted in a high-fidelity 20-bed simulated acute care hospital unit. Sixteen registered nurses, four at a time, cared for five simulated patients each. A two-part highly realistic clinical scenario was used that included representative: tasking; information; and alarms/alerts. The treatment condition introduced an integrated wearable attention aid that leveraged metacognition methods from proven military systems. The primary metric was time for nurses to respond to important alarms/alerts. Results Use of the wearable attention aid resulted in a median relative within-subject improvement for individual nurses of 118% (W = 183, p = 0.006). The top quarter of relative improvement was 3,303% faster (mean; 17.76 minutes reduced to 1.33). For all unit sessions, there was an overall 148% median faster response time to important alarms (8.12 minutes reduced to 3.27; U = 2.401, p = 0.016), with 153% median improvement in consistency across nurses (F = 11.670, p = 0.001). Discussion and conclusion Existing device-centric alarm/alert notification solutions can require too much time and effort for nurses to access and understand. As a result, nurses may ignore alarms/alerts as they focus on other important work. There has been extensive research on reducing alarm frequency in healthcare. However, alarm safety remains a top problem. Empirical observations reported here highlight the potential of improving patient safety by supporting the meta-work of checking alarms.
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Affiliation(s)
- Daniel C. McFarlane
- Patient Care & Monitoring Solutions, Innovation Office, Royal Philips, Andover, Massachusetts, United States of America
- * E-mail:
| | - Alexa K. Doig
- College of Nursing, University of Utah, Salt Lake City, Utah, United States of America
| | - James A. Agutter
- College of Architecture & Planning, University of Utah, Salt Lake City, Utah, United States of America
- Applied Medical Visualizations (Medvis), Salt Lake City, Utah, United States of America
| | - Lara M. Brewer
- Department of Anesthesiology, University of Utah Health Sciences Center, Salt Lake City, Utah, United States of America
| | - Noah D. Syroid
- Applied Medical Visualizations (Medvis), Salt Lake City, Utah, United States of America
- Anesthesiology Center for Patient Simulation, University of Utah, Salt Lake City, Utah, United States of America
| | - Ranjeev Mittu
- Information Technology Division, Information Management and Decision Architectures Branch, United States Naval Research Laboratory, Washington, District of Columbia, United States of America
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23
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Stieglitz S, Matthes S, Kietzmann I, Priegnitz C, Hagmeyer L, Randerath W. Emergencies and outcome in invasive out-of-hospital ventilation: An observational study over a 1-year period. CLINICAL RESPIRATORY JOURNAL 2017; 12:1447-1453. [PMID: 28776915 DOI: 10.1111/crj.12681] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 05/19/2017] [Accepted: 07/30/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The number of ventilated patients is further increasing which leads to an increasing number of patients with weaning failure. In Germany, the treatment of patients with invasive out-of-hospital becomes more and more common. The aim of the study was to observe the outcome, the frequency and character of emergencies of patients with invasive out-of-hospital ventilation. METHODS We conducted a prospective study over 1 year. Fifty-nine invasively ventilated patients living either at home or at nursing homes specialized in ventilator medicine were included. RESULTS Forty-one (71%) of the patients were living in a nursing home. Chronic obstructive pulmonary disease (COPD) was the most common underlying disease (52.5%). Duration of daily ventilation did not change over the 1-year period. 52.8% of the months went without a documented emergency. The most common emergencies were oxygen desaturation (29.6%), increase of secretion (12.2%) and dyspnea (8.7%). We found no difference in the frequency of emergencies between patients cared for in their own home compared with residential care. Ten patients died during the observation period. Fewer emergencies (P = .02, CI 0.03-0.85) was the only parameter associated with a reduced mortality. Frequency of emergencies as well as survival showed no difference regarding the way patients were cared for. CONCLUSIONS In patients with invasive home mechanical ventilation survival for more than 1 year seems to be common. Only the rate of emergencies affected survival.
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Affiliation(s)
- Sven Stieglitz
- Medical Department I, Petrus Hospital Wuppertal, Academic Teaching Hospital of the University of Duesseldorf, Wuppertal, Germany
| | - Sandhya Matthes
- Medical Department V, LMU Hospital of the University of Munich, Munich, Germany
| | - Ilona Kietzmann
- Clinic for Pneumology and Allergology, Centre for Sleep and Ventilation Medicine, Bethanien Hospital, Institute of Pneumology, University Witten/Herdecke, Solingen, Germany
| | - Christina Priegnitz
- Clinic for Pneumology and Allergology, Centre for Sleep and Ventilation Medicine, Bethanien Hospital, Institute of Pneumology, University Witten/Herdecke, Solingen, Germany
| | - Lars Hagmeyer
- Clinic for Pneumology and Allergology, Centre for Sleep and Ventilation Medicine, Bethanien Hospital, Institute of Pneumology, University Witten/Herdecke, Solingen, Germany
| | - Winfried Randerath
- Clinic for Pneumology and Allergology, Centre for Sleep and Ventilation Medicine, Bethanien Hospital, Institute of Pneumology, University Witten/Herdecke, Solingen, Germany
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24
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Levy J, Bensmail D, Prigent H. Response to comments on: 'Respiratory impairment in multiple sclerosis: a study of respiratory function in wheelchair-bound patients'. Eur J Neurol 2017; 24:e49-e50. [PMID: 28707813 DOI: 10.1111/ene.13343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 05/15/2017] [Indexed: 11/30/2022]
Affiliation(s)
- J Levy
- Department of Physical and Rehabilitation Medicine, Raymond Poincaré Hospital, APHP, Garches, France.,UMR 1179 - INSERM, University of Versailles Saint-Quentin-en-Yvelines, Montigny le Bretonneux, France
| | - D Bensmail
- Department of Physical and Rehabilitation Medicine, Raymond Poincaré Hospital, APHP, Garches, France.,UMR 1179 - INSERM, University of Versailles Saint-Quentin-en-Yvelines, Montigny le Bretonneux, France
| | - H Prigent
- UMR 1179 - INSERM, University of Versailles Saint-Quentin-en-Yvelines, Montigny le Bretonneux, France.,Department of Physiology and Functional Testing - Raymond Poincaré Hospital, Garches, France
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25
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Levy J, Bensmail D, Brotier-Chomienne A, Butel S, Joussain C, Hugeron C, Prigent H. Respiratory impairment in multiple sclerosis: a study of respiratory function in wheelchair-bound patients. Eur J Neurol 2017; 24:497-502. [DOI: 10.1111/ene.13231] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 11/23/2016] [Indexed: 12/12/2022]
Affiliation(s)
- J. Levy
- Department of Physical Medicine and Rehabilitation; Raymond Poincaré University Hospital - APHP; Garches France
- UMR1179 - INSERM, Versailles Saint-Quentin-en-Yvelines University; Montigny-le-Bretonneux France
| | - D. Bensmail
- Department of Physical Medicine and Rehabilitation; Raymond Poincaré University Hospital - APHP; Garches France
- UMR1179 - INSERM, Versailles Saint-Quentin-en-Yvelines University; Montigny-le-Bretonneux France
| | - A. Brotier-Chomienne
- Department of Physical Medicine and Rehabilitation; Raymond Poincaré University Hospital - APHP; Garches France
| | - S. Butel
- Department of Physiology; Raymond Poincaré University Hospital - APHP; Garches France
| | - C. Joussain
- Department of Physical Medicine and Rehabilitation; Raymond Poincaré University Hospital - APHP; Garches France
- UMR1179 - INSERM, Versailles Saint-Quentin-en-Yvelines University; Montigny-le-Bretonneux France
| | - C. Hugeron
- Department of Physical Medicine and Rehabilitation; Raymond Poincaré University Hospital - APHP; Garches France
| | - H. Prigent
- UMR1179 - INSERM, Versailles Saint-Quentin-en-Yvelines University; Montigny-le-Bretonneux France
- Department of Physiology; Raymond Poincaré University Hospital - APHP; Garches France
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26
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Abstract
Although precise numbers are difficult to obtain, the population of patients receiving long-term ventilation has increased over the last 20 years, and includes patients with chronic lung diseases, neuromuscular diseases, spinal cord injury, and children with complex disorders. This article reviews the equipment and logistics involved with ventilation outside of the hospital. Discussed are common locations for long-term ventilation, airway and secretion management, and many of the potential challenges faced by individuals on long-term ventilation.
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Affiliation(s)
- Sarina Sahetya
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sarah Allgood
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Peter C Gay
- Pulmonary and Critical Care, The Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
| | - Noah Lechtzin
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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27
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Affiliation(s)
- Robin L. Kingston
- Pediatric Critical Care Medicine, Pediatric Home Ventilator Program at the Penn State Children's Hospital in Hershey, Pennsylvania
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Rowan CM, Cristea AI, Hamilton JC, Taylor NM, Nitu ME, Ackerman VL. Nurse practitioner coverage is associated with a decrease in length of stay in a pediatric chronic ventilator dependent unit. World J Clin Pediatr 2016; 5:191-197. [PMID: 27170929 PMCID: PMC4857232 DOI: 10.5409/wjcp.v5.i2.191] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 03/22/2016] [Accepted: 04/11/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To hypothesize a dedicated critical care nurse practitioner (NP) is associated with a decreased length of stay (LOS) from a pediatric chronic ventilator dependent unit (PCVDU).
METHODS: We retrospectively reviewed patients requiring care in the PCVDU from May 2001 through May 2011 comparing the 5 years prior to the 5 years post implementation of the critical care NP in 2005. LOS and room charges were obtained.
RESULTS: The average LOS decreased from a median of 55 d [interquartile range (IQR): 9.8-108.3] to a median of 12 (IQR: 4.0-41.0) with the implementation of a dedicated critical care NP (P < 1.0001). Post implementation of a dedicated NP, a savings of 25738049 in room charges was noted over 5 years.
CONCLUSION: Our data demonstrates a critical care NP coverage model in a PCVDU is associated with a significantly reduced LOS demonstrating that the NP is an efficient and likely cost-effective addition to a medically comprehensive service.
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Validity of transcutaneous PCO 2 in monitoring chronic hypoventilation treated with non-invasive ventilation. Respir Med 2016; 112:112-8. [DOI: 10.1016/j.rmed.2016.01.017] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 01/21/2016] [Accepted: 01/23/2016] [Indexed: 11/18/2022]
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Kucuk C, Arda K, Ata N, Turkkani MH, Yildiz ÖÖ. Tracheomegaly and tracheosephagial fistula following mechanical ventilation: A case report and review of the literature. Respir Med Case Rep 2016; 17:86-9. [PMID: 27222792 PMCID: PMC4821361 DOI: 10.1016/j.rmcr.2016.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 01/25/2016] [Accepted: 02/01/2016] [Indexed: 11/24/2022] Open
Abstract
Postintubation Tracheoesophageal fistula (TEF) is a rare complication. Acquired TEF most commonly occurred following prolonged mechanical ventilation with an endotracheal or tracheostomy tube, cuff-related tracheal injury, post-intubation injury. We present a case of both tracheomegaly and tracheosephagial fistula following mechanical ventilation for 15 days, in the light of the literature.
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Affiliation(s)
- Canan Kucuk
- Ankara 29 Mayıs Hosp., Dept of Anesthesiology and Reanimation, Turkey
- Corresponding author. Mustafa Kemal Mahallesi Barış Sitesi 2091, Sokak No: 14 Çankaya, Ankara, Turkey.Mustafa Kemal Mahallesi Barış Sitesi 2091Sokak No: 14 ÇankayaAnkaraTurkey
| | - Kemal Arda
- Ankara Atatürk Research and Education Hosp., Dept of Radiology, Turkey
| | - Naim Ata
- Ankara 29 Mayıs Hosp., Dept of Internal Medicine, Turkey
| | | | - Özgür Ömer Yildiz
- Dıskapi Yildirim Beyazit Research and Education Hosp., Dept of Chest Surgery, Turkey
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Chronic Ventilatory Support for Children Following Trauma or Severe Neurologic Injury. Respir Med 2016. [DOI: 10.1007/978-1-4939-3749-3_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Panitch HB. Chronic Invasive Mechanical Ventilation. Respir Med 2016. [DOI: 10.1007/978-1-4939-3749-3_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Sansone VA, Racca F, Ottonello G, Vianello A, Berardinelli A, Crescimanno G, Casiraghi JL. 1st Italian SMA Family Association Consensus Meeting: Management and recommendations for respiratory involvement in spinal muscular atrophy (SMA) types I-III, Rome, Italy, 30-31 January 2015. Neuromuscul Disord 2015; 25:979-89. [PMID: 26453142 DOI: 10.1016/j.nmd.2015.09.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Revised: 08/24/2015] [Accepted: 09/09/2015] [Indexed: 12/24/2022]
Affiliation(s)
- V A Sansone
- Centro Clinico NEMO, Neurorehabilitation Unit, University of Milano, Milano, Italy.
| | - F Racca
- Pediatric Anesthesiology and Intensive Care Unit, SS Antonio Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - G Ottonello
- Famiglie SMA Scientific Committee, Milan, Italy
| | - A Vianello
- Respiratory Pathophysiology Division, University - City Hospital of Padova, Padova, Italy
| | - A Berardinelli
- I.R.C.C.S Istituto Neurologico Nazionale Casimiro Mondino, Pavia, Italy
| | - G Crescimanno
- A.O. Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
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Abstract
The number of children dependent on home mechanical ventilation has been reported to be increasing in many countries around the world. Home mechanical ventilation has been well accepted as a standard treatment of children with chronic respiratory failure. Some children may need mechanical ventilation as a lifelong therapy. To send mechanically ventilated children back home may be more difficult than adults. However, relatively better outcomes have been demonstrated in children. Children could be safely ventilated at home if they are selected and managed properly. Conditions requiring home ventilation include increased respiratory load from airway or lung pathologies, ventilatory muscle weakness and failure of neurologic control of ventilation. Home mechanical ventilation should be considered when the patient develops progressive respiratory failure or intractable failure to wean mechanical ventilation. Polysomnography or overnight pulse oximetry plus capnometry are used to detect nocturnal hypoventilation in early stage of respiratory failure. Ventilator strategy including non-invasive and invasive approach should be individualized for each patient. The author strongly believes that parents and family members are able to take care of their child at home if they are trained and educated effectively. A good team work with dedicated members is the key factor of success.
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Affiliation(s)
- Aroonwan Preutthipan
- Division of Pediatric Pulmonology, Department of Pediatrics, Ramathibodi Hospital Sleep Disorder Center, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand, 10400,
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Gregoretti C, Pisani L, Cortegiani A, Ranieri VM. Noninvasive Ventilation in Critically Ill Patients. Crit Care Clin 2015; 31:435-57. [DOI: 10.1016/j.ccc.2015.03.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Kun SS, Beas VN, Keens TG, Ward SSL, Gold JI. Examining pediatric emergency home ventilation practices in home health nurses: Opportunities for improved care. Pediatr Pulmonol 2015; 50:691-7. [PMID: 24706404 DOI: 10.1002/ppul.23040] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 01/20/2014] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To assess the pediatric home health nurses' knowledge in tracheostomy and ventilator emergency care on home mechanical ventilation (HMV). BACKGROUND Emergencies are frightening experiences for solo home health nurses and require advanced skills in emergency response and care, especially in pediatric patients who pose unique challenges. WORKING HYPOTHESIS Nurses with greater years of nursing experience would perform better on emergency HMV case-based scenarios than nurses with less years of experience. STUDY DESIGN An exploratory online survey was used to evaluate emergency case-based pediatric scenarios. Demographic and professional experiences were profiled. PATIENT-SUBJECT SELECTION Seventy-nine nurses had an average of 6.73 (SD = 1.41) years in pediatric nursing. Over 70% received their HMV training in their agency, 41% had less than 4 years of experience, and 30.4% had encountered at least one emergency situation at home. METHODOLOGY The online survey was distributed by managers of 22 home health agencies to nurses providing pediatric HMV care. RESULTS Nurses scored an average of 4.87 out of 10 possible points. There were no significant differences between nurses with <4 years of experience versus those with more experience on ventilator alarms knowledge or total knowledge. Ninety-seven percent of the nurses favored more training in HMV from a variety of settings (e.g., agency, on-line training). CONCLUSIONS Nurses did not perform well in case-based ventilator alarm scenarios. Length of nursing experience did not differentiate greater knowledge. It is clear that nurses require and want more training in emergency-based HMV. Recommendations for an enhanced curriculum are suggested.
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Affiliation(s)
- Sheila S Kun
- Division of Pediatric Pulmonary, Children's Hospital Los Angeles, Los Angeles, California
| | - Virginia N Beas
- Anesthesia Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Thomas G Keens
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Sally S L Ward
- Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jeffrey I Gold
- Anesthesia Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California
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Antommaria AHM, Collura CA, Antiel RM, Lantos JD. Two infants, same prognosis, different parental preferences. Pediatrics 2015; 135:918-23. [PMID: 25847802 DOI: 10.1542/peds.2013-4044] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/12/2014] [Indexed: 11/24/2022] Open
Abstract
A central principle of justice is that similar cases should be decided in similar ways. In pediatrics, however, there are cases in which 2 infants have similar diagnoses and prognoses, but their parents request different treatments. In this Ethics Rounds, we present such a situation that occurred in a single NICU. Three physician-ethicists analyze the issues.
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Affiliation(s)
- Armand H Matheny Antommaria
- Ethics Center and Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Christopher A Collura
- Departments of Pediatric and Adolescent Medicine, and Palliative Care Fellow, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts; Department of Medicine, Boston Children's Hospital, Boston, Massachusetts; Center for Bioethics, University of Minnesota, Minneapolis, Minnesota
| | | | - John D Lantos
- Department of Pediatrics, University of Missouri, Kansas City, Missouri; and Children's Mercy Hospital Bioethics Center, Kansas City, Missouri
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Wang M, Gorasiya S, Antoine DJ, Sitapara RA, Wu W, Sharma L, Yang H, Ashby CR, Vasudevan D, Zur M, Thomas DD, Mantell LL. The compromise of macrophage functions by hyperoxia is attenuated by ethacrynic acid via inhibition of NF-κB-mediated release of high-mobility group box-1. Am J Respir Cell Mol Biol 2015; 52:171-82. [PMID: 24992505 DOI: 10.1165/rcmb.2013-0544oc] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The prolonged exposure to hyperoxia can compromise macrophage functions and contribute to the development of ventilator-associated pneumonia. High levels of extracellular high-mobility group box-1 (HMGB1) in the airways of mice exposed to hyperoxia can directly cause macrophage dysfunction. Hence, inhibition of the release of nuclear HMGB1 into the extracellular milieu may help to maintain macrophage functions under hyperoxic conditions. The present study investigates whether ethacrynic acid (EA) affects hyperoxia-induced HMGB1 release from macrophages and improves their functions. Macrophage-like RAW 264.7 cells and bone marrow-derived macrophages were exposed to different concentrations of EA for 24 hours in the presence of 95% O2. EA significantly decreased the accumulation of extracellular HMGB1 in cultured media. Importantly, the phagocytic activity and migration capability of macrophages were significantly enhanced in EA-treated cells. Interestingly, hyperoxia-induced NF-κB activation was also inhibited in these cells. To determine whether NF-κB plays a role in hyperoxia-induced HMGB1 release, BAY 11-7082, an inhibitor of NF-κB activation, was used. Similar to EA, BAY 11-7082 significantly inhibited the accumulation of extracellular HMGB1 and improved hyperoxia-compromised macrophage migration and phagocytic activity. Furthermore, 24-hour hyperoxic exposure of macrophages caused hyperacetylation of HMGB1 and its subsequent cytoplasmic translocation and release, which were inhibited by EA and BAY 11-7082. Together, these results suggest that EA enhances hyperoxia-compromised macrophage functions by inhibiting HMGB1 hyperacetylation and its release from macrophages, possibly through attenuation of the NF-κB activation. Therefore, the activation of NF-κB could be one of the underlying mechanisms that mediate hyperoxia-compromised macrophage functions.
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Affiliation(s)
- Mao Wang
- 1 Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences, St. John's University, Queens, New York
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Annane D, Orlikowski D, Chevret S. Nocturnal mechanical ventilation for chronic hypoventilation in patients with neuromuscular and chest wall disorders. Cochrane Database Syst Rev 2014; 2014:CD001941. [PMID: 25503955 PMCID: PMC7068159 DOI: 10.1002/14651858.cd001941.pub3] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Chronic alveolar hypoventilation is a common complication of many neuromuscular and chest wall disorders. Long-term nocturnal mechanical ventilation is commonly used to treat it. This is a 2014 update of a review first published in 2000 and previously updated in 2007. OBJECTIVES To examine the effects on mortality of nocturnal mechanical ventilation in people with neuromuscular or chest wall disorders. Subsidiary endpoints were to examine the effects of respiratory assistance on improvement of chronic hypoventilation, sleep quality, hospital admissions and quality of life. SEARCH METHODS We searched the Cochrane Neuromuscular Disease Group Specialized Register, CENTRAL, MEDLINE and EMBASE on 10 June 2014. We contacted authors of identified trials and other experts in the field. SELECTION CRITERIA We searched for quasi-randomised or randomised controlled trials of participants of all ages with neuromuscular or chest wall disorder-related stable chronic hypoventilation of all degrees of severity, receiving any type and any mode of long-term nocturnal mechanical ventilation. The primary outcome measure was one-year mortality and secondary outcomes were unplanned hospital admission, short-term and long-term reversal of hypoventilation-related clinical symptoms and daytime hypercapnia, improvement of lung function and sleep breathing disorders. DATA COLLECTION AND ANALYSIS We used standard Cochrane methodology to select studies, extract data and assess the risk of bias in included studies. MAIN RESULTS The 10 eligible trials included a total of 173 participants. Roughly half of the trials were at low risk of selection, attrition or reporting bias, and almost all were at high risk of performance and detection bias. Four trials reported mortality data in the long term. The pooled risk ratio (RR) of dying was 0.62 (95% confidence interval (CI) 0.42 to 0.91, P value = 0.01) in favour of nocturnal mechanical ventilation compared to spontaneous breathing. There was considerable and significant heterogeneity between the trials, possibly related to differences between the study populations. Information on unplanned hospitalisation was available from two studies. The corresponding pooled RR was 0.25 (95% CI 0.08 to 0.82, P value = 0.02) in favour of nocturnal mechanical ventilation. For most of the outcome measures there was no significant long-term difference between nocturnal mechanical ventilation and no ventilation. Most of the secondary outcomes were not assessed in the eligible trials. Three out of the 10 trials, accounting for 39 participants, two with a cross-over design and one with two parallel groups, compared volume- and pressure-cycled non-invasive mechanical ventilation in the short term. From the only trial (16 participants) on parallel groups, there was no difference in mortality (one death in each arm) between volume- and pressure-cycled mechanical ventilation. Data from the two cross-over trials suggested that compared with pressure-cycled ventilation, volume-cycled ventilation was associated with less sleep time spent with an arterial oxygen saturation below 90% (mean difference (MD) 6.83 minutes, 95% CI 4.68 to 8.98, P value = 0.00001) and a lower apnoea-hypopnoea (per sleep hour) index (MD -0.65, 95% CI -0.84 to -0.46, P value = 0.00001). We found no study that compared invasive and non-invasive mechanical ventilation or intermittent positive pressure versus negative pressure ventilation. AUTHORS' CONCLUSIONS Current evidence about the therapeutic benefit of mechanical ventilation is of very low quality, but is consistent, suggesting alleviation of the symptoms of chronic hypoventilation in the short term. In four small studies, survival was prolonged and unplanned hospitalisation was reduced, mainly in participants with motor neuron diseases. With the exception of motor neuron disease and Duchenne muscular dystrophy, for which the natural history supports the survival benefit of mechanical ventilation against no ventilation, further larger randomised trials should assess the long-term benefit of different types and modes of nocturnal mechanical ventilation on quality of life, morbidity and mortality, and its cost-benefit ratio in neuromuscular and chest wall diseases.
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Affiliation(s)
- Djillali Annane
- Critical Care Department, Hôpital Raymond Poincaré, Assistance Publique - Hôpitaux de Paris, 104. Boulevard Raymond Poincaré, Garches, Ile de France, 92380, France.
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40
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Institutional care for long-term mechanical ventilation in Canada: A national survey. Can Respir J 2014; 21:357-362. [PMID: 25184510 DOI: 10.1155/2014/538687] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION No national Canadian data define resource requirements and care delivery for ventilator-assisted individuals (VAIs) requiring long-term institutional care. Such data will assist in planning health care services to this population. OBJECTIVE To describe institutional and patient characteristics, prevalence, equipment used, care elements and admission barriers for VAIs requiring long-term institutional care. METHODS Centres were identified from a national inventory and snowball referrals. The survey weblink was provided from December 2012 to April 2013. Weekly reminders were sent for six weeks. RESULTS The response rate was 84% (54 of 64), with 44 adult and 10 pediatric centres providing data for 428 VAIs (301 invasive ventilation; 127 noninvasive ventilation [NIV]), equivalent to 1.3 VAIs per 100,000 population. An additional 106 VAIs were on wait lists in 18 centres. More VAIs with progressive neuromuscular disease received invasive ventilation than NIV (P<0.001); more VAIs with chronic obstructive pulmonary disease (P<0.001), obesity hypoventilation syndrome (P<0.001) and central hypoventilation syndrome (P=0.02) required NIV. All centres used positive pressure ventilators, 21% diaphragmatic pacing, 15% negative pressure and 13% phrenic nerve stimulation. Most centres used lung volume recruitment (55%), manually (71%) and mechanically assisted cough (55%). Lack of beds and provincial funding were common admission barriers.CONCLUSIONS: Variable models and care practices exist for institutionalized care of Canadian VAIs. Patient prevalence was 1.3 per 100,000 Canadians.
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Chiner E, Sancho-Chust JN, Landete P, Senent C, Gómez-Merino E. Complementary home mechanical ventilation techniques. SEPAR Year 2014. Arch Bronconeumol 2014; 50:546-53. [PMID: 25138799 DOI: 10.1016/j.arbres.2014.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Revised: 06/13/2014] [Accepted: 06/16/2014] [Indexed: 12/16/2022]
Abstract
This is a review of the different complementary techniques that are useful for optimizing home mechanical ventilation (HMV). Airway clearance is very important in patients with HMV and many patients, particularly those with reduced peak cough flow, require airway clearance (manual or assisted) or assisted cough techniques (manual or mechanical) and suctioning procedures, in addition to ventilation. In the case of invasive HMV, good tracheostomy cannula management is essential for success. HMV patients may have sleep disturbances that must be taken into account. Sleep studies including complete polysomnography or respiratory polygraphy are helpful for identifying patient-ventilator asynchrony. Other techniques, such as bronchoscopy or nutritional support, may be required in patients on HMV, particularly if percutaneous gastrostomy is required. Information on treatment efficacy can be obtained from HMV monitoring, using methods such as pulse oximetry, capnography or the internal programs of the ventilators themselves. Finally, the importance of the patient's subjective perception is reviewed, as this may potentially affect the success of the HMV.
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Affiliation(s)
- Eusebi Chiner
- Servicio de Neumología, Hospital Universitari Sant Joan d'Alacant, Sant Joan d'Alacant, Alicante, España.
| | - José N Sancho-Chust
- Servicio de Neumología, Hospital Universitari Sant Joan d'Alacant, Sant Joan d'Alacant, Alicante, España
| | - Pedro Landete
- Servicio de Neumología, Hospital Universitari Sant Joan d'Alacant, Sant Joan d'Alacant, Alicante, España
| | - Cristina Senent
- Servicio de Neumología, Hospital Universitari Sant Joan d'Alacant, Sant Joan d'Alacant, Alicante, España
| | - Elia Gómez-Merino
- Servicio de Neumología, Hospital Universitari Sant Joan d'Alacant, Sant Joan d'Alacant, Alicante, España
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Patient transitions relevant to individuals requiring ongoing ventilatory assistance: a Delphi study. Can Respir J 2014; 21:287-92. [PMID: 24791254 DOI: 10.1155/2014/484835] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Various terms, including 'prolonged mechanical ventilation' (PMV) and 'long-term mechanical ventilation' (LTMV), are used interchangeably to distinguish patient cohorts requiring ventilation, making comparisons and timing of clinical decision making problematic. OBJECTIVE To develop expert, consensus-based criteria associated with care transitions to distinguish cohorts of ventilated patients. METHODS A four-round (R), web-based Delphi study with consensus defined as >70% was performed. In R1, participants listed, using free text, criteria perceived to should and should not define seven transitions. Transitions comprised: T1 - acute ventilation to PMV; T2 - PMV to LTMV; T3 - PMV or LTMV to acute ventilation (reverse transition); T4 - institutional to community care; T5 - no ventilation to requiring LTMV; T6 - pediatric to adult LTMV; and T7 - active treatment to end-of-life care. Subsequent Rs sought consensus. RESULTS Experts from intensive care (n=14), long-term care (n=14) and home ventilation (n=10), representing a variety of professional groups and geographical areas, completed all Rs. Consensus was reached on 14 of 20 statements defining T1 and 21 of 25 for T2. 'Physiological stability' had the highest consensus (97% and 100%, respectively). 'Duration of ventilation' did not achieve consensus. Consensus was achieved on 13 of 18 statements for T3 and 23 of 25 statements for T4. T4 statements reaching 100% consensus included: 'informed choice', 'patient stability', 'informal caregiver support', 'caregiver knowledge', 'environment modification', 'supportive network' and 'access to interprofessional care'. Consensus was achieved for 15 of 17 T5, 16 of 20 T6 and 21 of 24 T7 items. CONCLUSION Criteria to consider during key care transitions for ventilator-assisted individuals were identified. Such information will assist in furthering the consistency of clinical care plans, research trials and health care resource allocation.
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Mayaud L, Lejaille M, Prigent H, Louis B, Fauroux B, Lofaso F. An open-source software for automatic calculation of respiratory parameters based on esophageal pressure. Respir Physiol Neurobiol 2014; 192:1-6. [DOI: 10.1016/j.resp.2013.11.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Revised: 11/07/2013] [Accepted: 11/12/2013] [Indexed: 01/02/2023]
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Birkenfeld F, Lucius R, Ewald K. Leakage of fluid around endotracheal tube cuffs: a cadaver study. Korean J Anesthesiol 2013; 65:438-41. [PMID: 24363847 PMCID: PMC3866340 DOI: 10.4097/kjae.2013.65.5.438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 07/05/2013] [Accepted: 07/09/2013] [Indexed: 11/10/2022] Open
Abstract
Background The aim of the study was to evaluate the leakage of liquid past the cuffs of tracheal tubes in fresh frozen human heads. Methods Six truncated fresh frozen heads were used and intubated with 8.0 mm endotracheal tubes. The intracuff pressures tested were 30 and 100 cmH2O. Subsequently, 20 ml of each of two oral antiseptic rinses (0.2% chlorhexidine and octenidine [octenidol®, Schülke & Mayr GmbH, Norderstedt, Germany]) was applied for thirty seconds in the mouth. During the trial, leakage of the cuffs was examined. Results The sealing between the tracheal cuff and tracheal wall was leakage-proof for all tested intracuff pressures and all tested antiseptic rinses. However, approximately 5.6 ml and 1.8 ml leaked into the esophagus and remained as a cuff-puddle, respectively. Conclusions The sealing between an endotracheal tube cuff with an intracuff pressure of 30 cmH2O and the tracheal wall is leakage-proof during oral care with antiseptic rinsing. An increase of intracuff pressure to 100 cmH2O does not appear to be required.
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Affiliation(s)
- Falk Birkenfeld
- Institute of Anatomy, Christian-Albrechts University, Kiel, Germany
| | - Ralph Lucius
- Institute of Anatomy, Christian-Albrechts University, Kiel, Germany
| | - Kristian Ewald
- Department of Research and Development, Schülke & Mayr GmbH, Norderstedt, Germany
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Vianello A, Semplicini C, Paladini L, Concas A, Ravaglia S, Servidei S, Toscano A, Mongini T, Angelini C, Pegoraro E. Enzyme replacement therapy improves respiratory outcomes in patients with late-onset type II glycogenosis and high ventilator dependency. Lung 2013; 191:537-44. [PMID: 23839583 DOI: 10.1007/s00408-013-9489-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 06/17/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Type II glycogenosis (GSDII) is a rare and often fatal neuromuscular disorder caused by acid alpha-glucosidase deficiency. Although alglucosidase alfa enzyme replacement therapy (ERT) significantly improves outcomes in subjects with the infantile form, its efficacy in patients with the late-onset one is not entirely clear. The long-term efficacy of ERT in late-onset GSGII complicated by severe pulmonary impairment causing high mechanical ventilation dependency was investigated in this study. METHODS The long-term clinical efficacy of ERT was assessed in eight late-onset GSDII patients using home mechanical ventilation (HMV) by comparing their outcomes with those of six historical control patients (GSDII patients) who had received HMV alone. The number of hospitalizations due to pulmonary exacerbations and of hours of daily use of HMV were considered the study's primary efficacy endpoints. RESULTS The treatment group showed an increased tendency toward shorter follow-up compared to the control group (35.8 ± 29.2 vs. 52.6 ± 8.55 months; p = 0.04). At the end of the study period, the daily use of HMV (12.5 ± 7.6 vs. 19 ± 14.3 h; p = 0.004) and the hospitalization rate [incidence rate ratio = 0.43 (95 % confidence interval 0.18-0.93); p = 0.03] were significantly lower in the patients receiving ERT. The differences in the forced vital capacity absolute value and percentage change from baseline were not significantly different in the two groups. CONCLUSIONS ERT reduces ventilator dependency in late-onset GSDII patients and the need for hospitalization due to respiratory exacerbations.
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Affiliation(s)
- Andrea Vianello
- Respiratory Pathophysiology Division, University-City Hospital of Padova, Padua, Italy,
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Guidelines for the Management of Respiratory Complications in Patients With Neuromuscular Disease. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.arbr.2013.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Family caregiver perspectives on caring for ventilator-assisted individuals at home. Can Respir J 2013; 19:373-9. [PMID: 23248801 DOI: 10.1155/2012/452898] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The trend of patients who are invasively ventilated to prefer home care is one that benefits both the patient and the health care system. However, this assumes a role for patients' family members to become informal caregivers. OBJECTIVE To explore the impact of caring for a ventilator-assisted individual on informal caregivers. METHODS A descriptive design with semistructured caregiver interviews and the Caregiver Burden Inventory were used. Participants were informal caregivers of a family member with a progressive neuromuscular disease on invasive ventilation for at least six months. Transcript coding was performed and regularly reviewed, and recruitment continued until data saturation. Qualitative analysis was based on 'thematic analysis'. RESULTS A total of 21 caregivers were interviewed. Five themes developed: a sense of duty; restriction of day-to-day life; physical and emotional burden; training and education; and the need for more paid support. Caregivers described a sense of duty to take care of loved ones, but suffered a significant restriction of their own time with a negative impact on their physical and mental health. The initial transfer home was highlighted as the most stressful part of the process. The Caregiver Burden Inventory scores supported a high level of burden: median 49 (interquartile range 39.5 to 53.0) of a maximum 96. CONCLUSION Homecare for ventilator-assisted individuals with progressive neuromuscular disease causes significant burden to informal caregivers. Approaches to lessen this burden, such as increased paid care, improved professional support and respite care, may enable home ventilation to be a more sustainable modality of care.
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Farrero E, Antón A, Egea CJ, Almaraz MJ, Masa JF, Utrabo I, Calle M, Verea H, Servera E, Jara L, Barrot E, Casolivé V. Guidelines for the management of respiratory complications in patients with neuromuscular disease. Sociedad Española de Neumología y Cirugía Torácica (SEPAR). Arch Bronconeumol 2013; 49:306-13. [PMID: 23410743 DOI: 10.1016/j.arbres.2012.12.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Revised: 12/05/2012] [Accepted: 12/11/2012] [Indexed: 12/13/2022]
Affiliation(s)
- Eva Farrero
- Unidad Funcional Interdisciplinaria Sociosanitaria (UFISS) Respiratoria, Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, España
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Kim MS, Koh EJ, Choi HY. Occurrence of Acquired Tracheoesophageal Fistula Due to Excess Endotracheal Tube Cuff Volumes - A Case Report -. Korean J Crit Care Med 2013. [DOI: 10.4266/kjccm.2013.28.2.146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Myeong Soo Kim
- Department of Neurosurgery, Dong Kang Medical Center, Ulsan, Korea
| | - Eun Jeong Koh
- Department of Neurosurgery, Research Institute of Clinical Medicine, Chonbuk National University Medical School/Hospital, Jeonju, Korea
| | - Ha Young Choi
- Department of Neurosurgery, Research Institute of Clinical Medicine, Chonbuk National University Medical School/Hospital, Jeonju, Korea
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