Medical complications in a telemedicine home care programme for paediatric ventilated patients.

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.

Usefulness of telemedicine for home ventilator-dependent children.

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.

Noninvasive ventilation in pediatric acute respiratory failure by means of a conventional volumetric ventilator.

BACKGROUND: Acute respiratory failure (ARF) is one of the main causes for admission to pediatric intensive care unit (PICU). This study aimed to evaluate the feasibility and outcome of noninvasive ventilation (NIV) by a volumetric ventilator with a specific mode in pediatric acute respiratory failure. METHODS: A three-year prospective non-controlled study was undertaken in children with ARF who had received NIV delivered by Evita 2 Dura with NIV mode through a nonvented oronasal mask. RESULTS: Thirty-two episodes of ARF were observed in 26 patients. Pneumonia was observed in most of the children (46.8%). Pediatric logistic organ dysfunction (PELOD) score was 12.4% ± 24% (range 0-84%). Peak inspiratory pressure was 18.5 ± 2.7 cmH2O, positive end-expiratory pressure 5.7 ± 1.1 cmH2O, pressure support 10.5 ± 2.7 cmH2O, and mean pressure 9.2 ± 2 cmH2O. The clinical score was improved progressively within the first 6 hours. Before the initiation of NIV, respiratory rate was 41.7 ± 16.3, heart rate 131.6 ± 25.8, systolic arterial pressure 108 ± 19.5, diastolic arterial pressure 58.2 ± 13.9, pH 7.33 ± 0.12, pCO2 55.1 ± 20.2, SatO2 87.8 ± 9.9 and FiO2 0.55 ± 0.25. There was a significant improvement in the respiratory rate, heart rate, pH, pCO2 and SatO2 at 2-4 hours. This improvement was kept throughout the first 24 hours. The level of FiO2 was significantly lower at 24 hours. Radiological improvement was observed after 24 hours in 17 out of 26 patients. The duration of NIV was 85.4 ± 62.8 hours. Complications were defined as minor. Only 4 patients required intubation. All patients survived. CONCLUSIONS: NIV can be successfully applied to infants and children with ARF using this volumetric ventilator with specific NIV mode. It should be considered particularly in children whose underlying condition warrants avoidance of intubation.