Tracheomegaly among Extremely Preterm Infants on Prolonged Mechanical Ventilation.

By using phantom radiographs, the accuracy of tracheal measurements was established. Preterm infants (≤29 weeks) were enrolled in short (<7 days) and prolonged ventilation (≥28 days) groups. Both groups had 3 weight categories, namely, <1000 g, 1000-1999 g, and >2000 g. Tracheal sizes were measured on serial chest radiographs (CXR). We noted tracheomegaly in association with prolonged ventilation at ≥1000 g.

Home mechanical ventilation: A retrospective review of safety incidents using the World Health Organization International Patient Safety Event classification.

BACKGROUND: There is a paucity of patient safety information from the community sector related to the medically fragile population requiring home mechanical ventilation (HMV). To improve safety, the risks HMV patients encounter must first be understood. OBJECTIVES: To describe patient safety incidents within the HMV population and discuss opportunities for preventing harm. METHODS: A retrospective observational review of on-call logs from the Ontario Ventilator Equipment Pool (VEP) was conducted. Classification of 248 on-call logs from April 1, 2011 to March 21, 2012 was completed using the standardized tool of the World Health Organization's (WHO) Patient Safety Taxonomy - International Classification System to quantitatively describe the types of incidents arising. Analysis of data classification was completed using descriptive and nonparametric statistics. RESULTS: Patient incidents were positive in 188 on-call logs; emerging from these were 227 incident types. Patient incident types included medical device issues (99 device failures, 41 user errors, 12 equipment availability), documentation (20 unavailable labels/prescriptions, four unclear information), clinical processes (16 inadequate treatment or general care) and clinical administration (10 inadequate handover or transfer of care). Patient incidents were associated with mild harm in 87 cases. CONCLUSIONS: The on-call logs were a good source of quality improvement data to understand harm and patient safety issues emerging in the HMV population. However, establishing a formal incident review and reporting system is required to provide a more comprehensive understanding.

La ventilation mécanique à domicile : une analyse rétrospective des incidents de sécurité au moyen de la Classification internationale pour la sécurité des patients de l'Organisation mondiale de la Santé. HISTORIQUE: Peu d'information sur la sécurité des patients provenant du secteur communautaire porte sur la population fragilisée sous ventilation mécanique à domicile (VMD). Pour améliorer la sécurité, il faut d'abord comprendre les risques que courent ces patients. OBJECTIFS: Décrire les incidents de sécurité des patients au sein de la population sous VMD et examiner des possibilités de prévenir les dommages. MÉTHODOLOGIE: Les chercheurs ont réalisé une étude d'observation rétrospective des registres d'appel de l'Ontario Ventilator Equipment Pool (VEP). Ils ont classé 248 registres d'appel prélevés du 1er avril 2011 au 21 mars 2012 au moyen de l'outil standardisé Taxonomie pour la sécurité des patients ­Système de classification internationale de l'Organisation mondiale de la Santé (OMS) afin d'effectuer une description quantitative du type d'incidents. L'analyse de la classification des données a été effectuée au moyen de statistiques descriptives et non paramétriques. RÉSULTATS: Les incidents des patients étaient positifs dans 188 des registres d'appel, et 227 types d'incidents en ont émergé. Les types d'incidents des patients incluaient des problèmes avec les dispositifs médicaux (99 défaillances de dispositifs, 41 erreurs des utilisateurs, 12 problèmes de disponibilité de l'équipement), la consignation (20 étiquettes ou prescriptions non disponibles, quatre renseignements nébuleux), les processus cliniques (16 traitements ou soins généraux inadéquats) et l'administration clinique (10 transferts de soins inadéquats). Dans 87 cas, les incidents se sont associés à de légers dommages. CONCLUSIONS: Les registres d'appel étaient une bonne source de données d'amélioration de la qualité pour comprendre les dommages et les problèmes liés à la sécurité des patients émergeant au sein de la population sous VMD. Cependant, il faut créer un système officiel d'analyse et de signalement des incidents pour mieux les comprendre.

Subglottic dilatation in extremely preterm infants on prolonged mechanical ventilation.

BACKGROUND: Airway injuries are reported among preterm infants with bronchopulmonary dysplasia. We hypothesized that prolonged ventilation in preterm infants is associated with subglottic dilatation that can be reliably evaluated by point of care ultrasonography (POCUS). METHODS: All preterm infants (<29-weeks) admitted to the neonatal ICU at the Advent-Health from January-2020 to June-2022 were eligible if they required invasive ventilation for ≤7 days in the first 28 days of life (control) or remained intubated for ≥28 days (prolonged ventilation). Sonography was performed by one technician and all images were reviewed by the pediatric radiologist. The trachea size was measured 3 times by randomly selecting three images. The first 20 scans were also independently reported by a different pediatric radiologist. Intra and inter-observer variability was estimated. Mean trachea size and weight at the time of imaging were compared. RESULTS: Out of 417 eligible infants; 11 died before 28 days and 163 required ventilation for 8-27 days. Consent missed for 80 infants during COVID-19 pandemic. We enrolled 23 and 28 infants in the control & prolonged ventilation groups, respectively. Inter and intra-observer correlations were 0.83 and 0.97 respectively. Infants in the control group had higher gestation and birth weight. Infants on prolonged ventilation were at higher risk for infections, BPD, longer hospital stay and significant subglottic dilation (4.51 ± 0.04 vs 4.17 ± 0.02 mm, p < 0.01) despite smaller body weight at the time of imaging (884 ± 102 vs 1059 ± 123g, p < 0.01). CONCLUSION: Extremely preterm infants on prolonged ventilation are at risk for sub-glottic dilatation that can be reliably measured by POCUS.

Chronic tracheostomy care of ventilator-dependent and -independent children: Clinical practice patterns of pediatric respirologists in a publicly funded (Canadian) healthcare system.

OBJECTIVES: To describe the current clinical practice patterns of Canadian pediatric respirologists at pediatric tertiary care institutions regarding chronic tracheostomy tube care and management of home invasive ventilation. METHODS: A pediatric respirologist/pediatrician with expertise in tracheostomy tube care and home ventilation was identified at each Canadian pediatric tertiary care center to complete a 59-item survey of multiple choice and short answer questions. Domains assessed included tracheostomy tube care, caregiver competency and home monitoring, speaking valves, medical management of tracheostomy complications, decannulation, and long-term follow-up. RESULTS: The response rate was 100% (17/17) with all Canadian tertiary care pediatric centers represented and heterogeneity of practice was observed in all domains assessed. For example, though most centers employ Bivona™ (17/17) and Shiley™ (15/17) tracheostomy tubes, variability was observed around tube change, re-use, and cleaning practices. Most centers require two trained caregivers (14/17) and recommend 24/7 eyes on care and oxygen saturation monitoring. Discharge with an emergency tracheostomy kit was universal (17/17). Considerable heterogeneity was observed in the timing and use of speaking valves and speech-language assessment. Inhaled anti-pseudomonal antibiotics are employed by most centers (16/17) though the indication, agent, and protocol varied by center. Though decannulation practices varied considerably, the requirement of upper airway patency was universally required to proceed with decannulation (17/17) independent of ongoing ventilatory support requirements. CONCLUSION: Considerable variability in pediatric tracheostomy tube care practice exists across Canada. These results will serve as a starting point to standardize and evaluate tracheostomy tube care nationally.

Mechanical Ventilation During Chronic Lung Disease.

For infants with the most severe forms of chronic lung disease, regardless of etiology, chronic mechanical ventilation can provide stability, reduce acute respiratory events, and alleviate increased work of breathing. This approach prioritizes the baby's growth and development during early life. Once breathing comfortably, these infants can tolerate developmental therapies with the goal of achieving the best neurocognitive outcomes possible.

Absence of COVID-19 Disease Among Chronically Ventilated Nursing Home Patients.

OBJECTIVE: To describe the experience of COVID-19 disease among chronically ventilated and nonventilated nursing home patients living in 3 separate nursing homes. DESIGN: Observational study of death, respiratory illness and COVID-19 polymerase chain reaction (PCR) results among residents and staff during nursing home outbreaks in 2020. SETTING AND PARTICIPANTS: 93 chronically ventilated nursing home patients and 1151 nonventilated patients living among 3 separate nursing homes on Long Island, New York, as of March 15, 2020. Illness, PCR results, and antibody studies among staff are also reported. MEASUREMENTS: Data were collected on death rate among chronically ventilated and nonventilated patients between March 15 and May 15, 2020, compared to the same time in 2019; prevalence of PCR positivity among ventilated and nonventilated patients in 2020; reported illness, PCR positivity, and antibody among staff. RESULTS: Total numbers of deaths among chronically ventilated nursing home patients during this time frame were similar to the analogous period 1 year earlier (9 of 93 in 2020 vs 8 of 100 in 2019, P = .8), whereas deaths among nonventilated patients were greatly increased (214 of 1151 in 2020 vs 55 of 1189 in 2019, P < .001). No ventilated patient deaths were clinically judged to be COVID-19 related. No clusters of COVID-19 illness could be demonstrated among ventilated patients. Surveillance PCR testing of ventilator patients failed to reveal COVID-19 positivity (none of 84 ventilator patients vs 81 of 971 nonventilator patients, P < .002). Illness and evidence of COVID-19 infection was demonstrated among staff working both in nonventilator and in ventilator units. CONCLUSIONS AND IMPLICATIONS: COVID-19 infection resulted in illness and death among nonventilated nursing home residents as well as among staff. This was not observed among chronically ventilated patients. The mechanics of chronic ventilation appears to protect chronically ventilated patients from COVID-19 disease.

Chronic respiratory failure in bronchopulmonary dysplasia.

Although survival has improved dramatically for extremely preterm infants, those with the most severe forms of bronchopulmonary dysplasia (BPD) fail to improve in the neonatal period and go on to develop chronic respiratory failure. When careful weaning of respiratory support is not tolerated, the difficult decision of whether or not to pursue chronic ventilation via tracheostomy must be made. This requires shared decision-making with an interdisciplinary medical team and the child's family. Although they suffer from increased morbidity and mortality, the majority of these children will survive to tolerate ventilator liberation and tracheostomy decannulation. Care coordination for the technology-dependent preterm infant is complex, but there is a growing consensus that chronic ventilation can best support neurodevelopmental progress and improve long-term outcomes.

Prolonged Mechanical Ventilation: A Comparison of Patients Treated at Home Compared With Hospital Long-Term Care.

OBJECTIVE: To compare the characteristics of patients treated with invasive prolonged mechanical ventilation (PMV) at home or in hospital long-term care (HLTC), specifically focusing on medical and functional status, caregiver strain, 6-month outcomes, and health maintenance organization (HMO) costs. DESIGN: Observational study. SETTING: A single HLTC and home hospital, serving a defined catchment area in the greater Jerusalem area, Israel. PARTICIPANTS: A total of 120 PMV patients aged ≥18 years, all insurees of the same HMO. All PMV patients in the local HMO were approached, of whom 46 of 47 home PMV and 74/76 HLTC patients were enrolled. MEASUREMENTS: Medical and sociodemographic factors, Barthel Index, Short Geriatric Depression Score, modified Caregiver Strain Index; 6-month follow-up for hospitalization, infections, pressure sores, and mortality; HMO costs. RESULTS: Home PMV was associated with younger age, improved functional status, financial difficulty, less comorbidity, and longer duration of PMV. Primary reasons for home PMV were degenerative neuromuscular disease and chronic lung disease, compared with acute illnesses with or without resuscitation among HLTC patients. Most home patients were alert and able to communicate (n = 40/46) versus HLTC (n = 22/74), and reported less depression. Caregiver strain was similar for home and HLTC. Among HLTC versus home patients, 6-month mortality (27% vs 7%, P = .012) and frequency of pressure sores (45% vs. 29%, P = .042) were higher in HLTC, with no differences for infection rates or hospitalization. In multivariate analyses, being treated at home with PMV was significantly associated with being able to communicate, lower age, financial difficulties, and improved functional status. HMO costs were one-third for home PMV versus HLTC. CONCLUSIONS AND IMPLICATIONS: Differing profiles were described for home and HLTC PMV patients, with lower rates of depression, pressure sores, mortality, and one-third the cost to HMO at home. Caregiver strain was similar irrespective of site of care. With appropriate targeting for eligible patients, home PMV is a viable and financially beneficial option.

Weaning from the Ventilator in Bronchopulmonary Dysplasia.

For the newborns needing respiratory support at 36 weeks postmenstrual age, regardless of the type of ventilation used, it is critical to take into account the mechanics properties of both airways and lungs affected by severe bronchopulmonary dysplasia (sBPD). Ventilator strategies, settings, and weaning must change dramatically after sBPD is established, but to date there is almost no high-quality evidence base supporting a specific approach to guide the optimal ventilator management and weaning in patients with sBPD. Weaning from invasive mechanical ventilation, management of the immediately postextubation period, and weaning from noninvasive ventilation in patients with sBPD are the topics covered in this chapter.

Health Care Resource Utilization for Children Requiring Prolonged Mechanical Ventilation via Tracheostomy.

BACKGROUND: More children are discharged from ICUs on prolonged mechanical ventilation (PMV) via tracheostomy than ever before. These patients have long hospitalizations with high resource expenditure. Our objective was to describe the characteristics of these resource-intensive patients and to evaluate their costs of care. We hypothesized that subjects requiring PMV for neurologic diagnoses would have higher costs, longer hospital length of stay (LOS), and worse outcomes than those with primarily respiratory diagnoses. METHODS: We identified 50 pediatric subjects between January 2015 and December 2017 at our institution who had a new tracheostomy placement and were enrolled in a home mechanical ventilation program. Collected data included demographics, indication for tracheostomy, LOS, hospital costs, readmissions, and outcomes. We also compared subjects who required PMV for respiratory diagnoses versus neurologic diagnoses. RESULTS: Of 50 subjects, 41 were < 12 months old at the time of tracheostomy. Thirty-four subjects had a respiratory diagnosis requiring PMV, 14 had a neurologic diagnosis, and 2 had a cardiac diagnosis. The total initial hospitalization cost was $31,133,582, which averages to $622,671 per subject. The average initial hospitalization LOS was 155 d. Respiratory subjects had longer LOS and higher average costs than neurologic subjects. The average readmission rate was 2.16 per subject in the first year after discharge, and the average readmission cost per subject was $73,144. Eight subjects died in the first year after discharge, and 4 suffered a serious morbidity. CONCLUSIONS: This descriptive study evaluated the social and medical characteristics of subjects being discharged from the pediatric ICU with PMV via tracheostomy, as well as quantified the financial impact of their care. Those requiring PMV for neurologic diagnoses had shorter hospital LOS and lower hospital costs than those with respiratory diagnoses. No definitive differences in outcomes were found.

Tracheostomy care: Clinical practice patterns of pediatric otolaryngologists-head and neck surgeons in a publicly funded (Canadian) health care system.

OBJECTIVES: To investigate variability in pediatric tracheostomy tube care practice patterns and access to resources across Canada. METHODS: Canadian pediatric otolaryngologists-head & neck surgeons reported their own practice patterns for children with chronic tracheostomy tubes using a web-based, 29-item multiple choice and short answer questionnaire. Domains investigated included tracheostomy team membership, inpatient care practices, caregiver education, homecare resources, speech and communication, and completeness of emergency tracheostomy kits. RESULTS: The response rate was 86.4% (38/44). Most respondents care for children with tracheostomy tubes as part of an inter-professional team (25/36; 69.4%) and arrange routine follow-up with a speech and language pathologist (22/36; 61.1%). However, the majority (23/34; 67.6%) of respondents do not formally reassess caregiver competencies (i.e. cardiopulmonary resuscitation, emergency tracheostomy care). Notably, respondents were also unsure 36.1% (13/36) of how frequently Shiley tracheostomy tubes should be washed and reused with the majority (15/36; 41.7%) reporting never. Most (15/36; 41.7%) respondents were also unsure of reuse recommendations for Bivona tracheostomy tubes. One third (12/36; 33.3%) of respondents were unsure about government-funded homecare services being provided in their community to children with tracheostomy tubes. CONCLUSION: There is much variability in pediatric tracheostomy tube care practice patterns across Canada. Results suggest that an evidence-based Canadian clinical practice guideline may help to streamline care provided to Canadian children with tracheostomy tubes.

1-Year Survival of Subjects Discharged From a Long-Term Chronic Ventilator Unit.

INTRODUCTION: Among survivors of intensive care, many remain dependent on mechanical ventilation and are discharged to long-term chronic ventilator units or to skilled nursing facilities. Few long-term outcome data are available on patients transferred from long-term chronic ventilator units. METHODS: We retrospectively followed subjects discharged from a long-term chronic ventilator unit from 2010-2012. We determined where these subjects went, evaluating whether location of discharge had an effect on mortality. RESULTS: We followed 79 subjects who were 64.9 ± 15.9 y old. Average stay in the long-term chronic ventilator unit was 38.5 ± 20.1 d. Within the first year after discharge, 24 (30.3%) subjects died: 17 in a skilled nursing facility, 7 at home. Of those who survived the first year, 28 had been discharged to a skilled nursing facility and 27 to home. Survivors were younger (62.6 ± 12.4 vs 70.4 ± 13.1 y, P = .03), had shorter intensive care unit lengths of stay (10.4 ± 5.0 vs 16.4 ± 11.5 d, P = .03), and were more likely discharged home from long-term chronic ventilator unit (49.0% vs 29.1%, P = .040). CONCLUSIONS: Subjects discharged from an long-term chronic ventilator unit and were alive at 1 y had shorter stays in the ICU and were more likely to be discharged home. Further attention is warranted to assure the survival of critical care patients once they are discharged from intensive care units.

Caloric Requirements of Patients With Brain Impairment and Cerebral Palsy Who Are Dependent on Chronic Ventilation.

BACKGROUND AND OBJECTIVE: Israeli law mandates chronic ventilator support for children and adolescents who are severely brain impaired and show minimal responses. Feeding protocols in these cases have been based on the caloric requirements of healthy children, deducting calories for lack of activity as well as an individual adjustment according to the cerebral palsy growth curves. However, patients are still inclined to gain excessive weight. Our objective was to determine the caloric requirements of these patients. DESIGN AND METHOD: Sixteen patients hospitalized in a dedicated unit who were ventilated through tracheostomies and fed via gastrostomies were included. Patients were aged 3-24 years; duration of ventilation was 1-7.5 years; and diagnoses included congenital genetic or brain malformations (n = 9), hypoxic accidents (n = 4), and postbacterial or postviral encephalitis (n = 3). Resting energy expenditure (REE) was determined by indirect calorimetry. REE values were compared with the caloric requirements of age-comparable healthy children and the calories actually delivered. Data were analyzed with paired t tests, Pearson correlations, and linear regression. RESULTS: The REE of our patients was 46% lower than the estimated caloric requirements of healthy children. In practice, patients received 32% more calories than that measured by REE. These findings were not affected by age, weight, diagnosis, or length of hospitalization. CONCLUSIONS: The caloric expenditure of these patients is very low. A diet guided by indirect calorimetry is proposed to aid in providing optimal nutrition support for this unique population to avoid overfeeding and obesity.