The changing face of bronchopulmonary dysplasia: Part 2. Discharging an infant home on oxygen

Constructing a relevant decision aid for parents of children with bronchopulmonary dysplasia

BACKGROUND

To develop and test a decision aid for counseling parents of children with bronchopulmonary dysplasia (BPD).Local problem:Parental education about complex conditions is not standardized and communication and understanding may not be adequate.

METHODS

Semi-structured interviews were conducted with 33 neonatal clinicians and 12 parents of children with BPD using a qualitative research design. The interviews were used to identify education topics that were felt to be important in BPD education. These topics were then used to create a visual decision aid to be used in counseling sessions with parents. The decision aid was then used in mock counseling sessions with 15 'experienced' participants and 7 'naïve' participants to assess its efficacy. The participants completed a pre and post test to assess change in knowledge as well as an 11-question Likert style acceptability survey.

INTERVENTION

Implementation of a decision aid while educating parents about BPD.

RESULTS

Topics identified during the interviews were used to create eight educational cards which included pictures, pictographs and statistics. Overall, participants thought the decision aid contained an appropriate amount of information, were easy to understand and improved their knowledge about BPD. Testing demonstrated a significant increase in knowledge in both the 'experienced' (P<0.0001) and 'naïve' group (P=0.0064).

CONCLUSION

A decision aid for parents of children with BPD may improve understanding of the condition and help facilitate communication between parents and doctors.

Natural course following pediatric tracheostomy

OBJECTIVE

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

DESIGN

Retrospective, descriptive record review.

SETTINGS

Academic tertiary Pediatric Critical Care Unit.

METHODS AND RESULTS

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

CONCLUSION

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

The experience of mothers whose very low-birth-weight infant requires the delivery of supplemental oxygen in the neonatal intensive care unit

PURPOSE

This study examines the experience of mothers whose very low-birth-weight infants require the delivery of supplemental oxygen during their hospitalization in the neonatal intensive care unit (NICU).

SUBJECTS

Eleven mothers of very low-birth-weight infants who have received various supplemental oxygen delivery methods in the NICU for a minimum of 7 days were selected for interview.

DESIGN

Qualitative descriptive.

METHODS

One semistructured interview exploring mothers' experiences surrounding oxygen delivery methods was conducted. Qualitative content analysis was undertaken to describe mothers' experience.

PRINCIPLE RESULTS

Four themes emerged related to the oxygen therapy and the various methods of delivery: Oxygen therapy is a positive, worries about the adverse effects for my baby now and in the future, a learning experience, and the delivery of supplemental oxygen is a barrier to mothering.

CONCLUSION

Mothers balanced the positive aspects of oxygen therapy with their fears of the negative consequences. They were able to adapt to the equipment and trajectory of having their infant on supplemental oxygen delivery methods. Mothers were particularly distressed by the physical barriers created by oxygen delivery methods (ie, unable to hold, hear, or see their baby). Nurses in the NICU should support mothers' positive reframing as a way of coping, provide education about the consequences of this therapy, encourage mothers to touch and hold their infants, and provide opportunities for them to see their infants' faces.

Domiciliary oxygen for children

Domiciliary oxygen is used increasingly in pediatric practice, and the largest patient group to receive it is ex-premature babies with chronic neonatal lung disease. Because of a scarcity of good evidence to inform clinicians, there is a lack of consensus over many issues, even those as fundamental as the optimum target oxygen saturation. Nevertheless, many children benefit from receiving supplemental oxygen at home, particularly because it helps to keep them out of the hospital.

SAFE discharge for infants with high-risk home environments

Safe transitioning of high-risk infants from hospital to home requires these essential elements: (1) a thorough understanding and adherence to infant-identified discharge criteria; (2) the coordination and progression of educational activities that prepare families for care at home; (3) the appropriate identification and utilization of referral services, both during hospitalization and in the community; (4) the involvement of community healthcare providers well versed in the care and follow-up of infants born ill or prematurely; (5) the psychosocial adaptations parents make as they accept their role as independent caregiver. A family Social assessment, Advocacy by all healthcare team members for the safety and well-being of the infant, strong Family involvement, and accessible Environmental resources contribute to the success of a SAFE discharge.

A randomized trial of home oxygen therapy from the emergency department for acute bronchiolitis

OBJECTIVE

Hypoxia is a common reason for hospital admission in infants and children with acute bronchiolitis. No study has evaluated discharge from the emergency department (ED) on home oxygen. This study evaluated the feasibility and safety of ED discharge on home oxygen in the treatment of acute bronchiolitis.

METHODS

This was a prospective, randomized trial of infants and children with acute bronchiolitis and hypoxia (room-air saturations of < or =87%) aged 2 to 24 months presenting to an urban, academic, tertiary care children's hospital ED from December 1998 to April 2001. Subjects received inpatient admission or home oxygen after an 8-hour observation period in the ED. We measured the failure to meet discharge criteria during the observation period, return for hospital admission, and incidence of serious complications.

RESULTS

Ninety-two patients were enrolled. Fifty three (58%) were randomly assigned to home and 39 (42%) to inpatient admission. There were no differences between the groups in age, initial room-air saturation, and respiratory distress severity score. Of 53 patients, 37 (70%) randomly assigned to home oxygen completed the observation period and were discharged from the hospital. The remaining 16 patients were excluded from the study (6), resolved their oxygen requirement (5), or failed to meet the discharge criteria and were admitted (5). One discharged patient (2.7%) returned to the hospital and was admitted for a cyanotic spell at home after the 24-hour follow-up appointment. The patient had an uncomplicated hospital course with a length of stay of 45 hours. The remaining 36 patients (97%) were treated successfully as outpatients with home oxygen. Satisfaction with home oxygen was high from the caregiver and the primary care provider.

CONCLUSIONS

Discharge from the ED on home oxygen after a period of observation is an option for patients with acute bronchiolitis. Secondary to the low incidence of complications, the safety of this practice will require a larger study.

Home oxygen for children: who, how and when?

A review of the specific requirements of home oxygen therapy in children which attempts to offer guidance to clinicians and service providers.

Home care of the high-risk infant

Increasingly, infants are discharged from the neonatal intensive care unit (NICU) with unresolved healthcare issues and ongoing technology needs. A well-planned discharge of a medically stable infant is important to assure safe and effective care in the home and to minimize avoidable hospital readmissions. This article addresses the discharge of and home care options for 3 groups of infants who have traditionally been cared for in the hospital. These include infants requiring palliative care, infants who are technology dependent, and those stable premature infants requiring intensive home support. Intermittent and continuous home nursing care options are defined, and the goals of home care nursing are outlined. The importance of objective discharge criteria and medical stability is discussed along with practical tips and strategies to assure success. A teaching tool to assist parents in choosing a home care provider is included.

Effective strategies to prepare infants and families for home tracheostomy care

In neonates tracheostomies are most often indicated to provide a stable airway for infants with congenital or acquired airway obstructions and to provide long-term mechanical ventilation. Learning to care for an infant with a tracheostomy can be challenging for both professionals and families. This article provides an overview of tracheostomy care and the essential elements of family teaching. The surgical procedure and basic anatomical changes are reviewed. Complications such as accidental decannulation, mucus plugging, infection, bleeding, and granulation tissue formation are discussed. Humidification is critical for the infant with a tracheostomy and humidification delivery methods are discussed. Further, an overview of the impact of the tracheostomy on normal development, such as swallowing and language development, is provided. Teaching parents to safely care for the infant with a tracheostomy at home requires careful planning and systematic education. The parents must acquire a unique set of technical skills demonstrating competence and comfort in providing stoma care, suctioning, and tube changes. Parents must be prepared to initiate cardiopulmonary resuscitation (CPR) and need to understand alterations in CPR techniques in infants with a tracheostomy. They also need to develop critical thinking skills to handle emergency situations. A safe transition to the home can be accomplished by using a multidisciplinary approach to coordinate all facets of care.