Home mechanical ventilation of children

Caring for Children Who Are Technology-Dependent and Their Families: The Application of Watson's Caring Science to Guide Nursing Practice

Advancements in the medical field have resulted in an increased number of children with complex chronic conditions that may depend on technology to sustain or optimize life. Given that nurses provide substantial physical and emotional care for these children and families during their frequent hospitalizations, the development of an authentic caring relationship is imperative. A critical review of the literature examining the experiences and unmet care needs of this population was carried out and analyzed using Watson's Caring Science to explore how nurses can create an authentic caring relationship and environment for children who are technology-dependent and their families.

Hospital readmissions for newly discharged pediatric home mechanical ventilation patients

BACKGROUND

Ventilator-dependent children have complex chronic conditions that put them at risk for acute illness and repeated hospitalizations.

OBJECTIVES

To determine the 12-month incidence of and risk factors for non-elective readmission in children with chronic respiratory failure (CRF) after initiation on home mechanical ventilation (HMV) via tracheostomy.

METHODS

A retrospective cohort study of 109 HMV patients initiated and followed at an university-affiliated children's hospital between 2003 and 2009. Patient characteristics are presented using descriptive statistics; generalized estimated equations are used to estimate adjusted odds ratios of select predictor variables for readmission.

RESULTS

The 12-month incidence of non-elective readmission was 40%. Close to half of these readmissions occurred within the first 3 months post-index discharge. Pneumonia and tracheitis were the most common reasons for readmission; 64% were pulmonary- or tracheostomy-related. Most demographic and clinical patient characteristics were not statistically associated with non-elective readmissions. Although, a change in the child's management within 7 days before discharge was associated readmissions shortly after index discharge.

CONCLUSION

Non-elective readmissions of newly initiated pediatric HMV patients were common and likely multifactorial. Many of these readmissions were airway-related, and some may have been potentially preventable.

Inpatient health care utilization for children dependent on long-term mechanical ventilation

OBJECTIVE

The objective was to describe the characteristics of pediatric discharges associated with long-term mechanical ventilation (LTMV) compared with those with complex chronic conditions (CCCs), and evaluate trends over time in health care utilization for the discharges associated with LTMV.

METHODS

The Kids' Inpatient Database, compiled by the Agency for Healthcare Research and Quality, was used. Routine newborn care was excluded. Discharges associated with LTMV were identified by using the International Classification of Diseases, Ninth Revision, code v46.1x and compared with discharges associated with CCCs in 2006 using simple regression and χ(2) analyses. Trends in LTMV-associated discharges from 2000 to 2006 were assessed using variance-weighted least squares regression.

RESULTS

In 2006, there were an estimated 7812 discharges associated with LTMV. Compared with discharges for children with CCCs, LTMV discharges had significantly higher mortality, longer lengths of stay, higher mean charges, more emergency department admissions, and more discharges to long-term care. From 2000 to 2006, there was a 55% increase in the number of LTMV discharges and a concurrent 70% increase in aggregate hospital charges. The majority of LTMV discharges occurred in children 4 years old and younger, and ∼50% of the aggregate charges were for children younger than 1 year.

CONCLUSIONS

Discharges for children associated with LTMV require substantively greater inpatient resource use than other children with CCCs. As the number of discharges and associated aggregate charges increase over time, additional research must examine patterns of care for specific clinical subgroups of LTMV, especially children aged 4 years and younger.

A home respiratory support programme for children by parents and layperson carers

AIM

To describe a respiratory support programme for children at home by parents and layperson carers.

METHODS

Analysis of records of children with long-term mechanical respiratory support at home.

RESULTS

From 1979 to 2008 the programme managed 168 children (median age 7 years, range 3 weeks-19 years) with obstructive sleep apnoea (55, 32%), neuromuscular conditions (42, 25%), tracheo-bronchomalacia (23, 14%), kyphoscoliosis-cerebral palsy (20, 12%), acquired central hypoventilation (8, 5%), congenital central hypoventilation (7, 4%), chronic lung disease or pulmonary hypoplasia (8, 5%), traumatic quadriplegia (3, 2%) and tumour-related quadriplegia (2, 1%). One hundred and sixty-one (96%) were discharged: 73 (46%) remain in the programme; 27 (16%) transferred to adult services, 25 (15%) recovered and 36 (23%) died. Principal modes of therapy were mask continuous positive airway pressure (CPAP) 35%, mask bilevel positive airway pressure 30%, tracheostomy CPAP 20%, tracheostomy mechanical ventilation 8%, phrenic nerve pacing 3%, negative pressure chamber ventilation 2% and nasal tube CPAP 2%. Two unexpected deaths occurred at home: one from accidental tracheostomy decannulation and another unrelated to respiratory support. Average time in the programme was 3.3 years. Parents of 69 children were provided with trained carers. Successful discharge resulted from early recognition of potential to discharge, parental training, recruitment and training of carers, purchase of equipment and secure funding. Seven children were not discharged, two of whom died in the hospital and five are subject to discharge planning.

CONCLUSION

Respiratory support of children at home by trained parents and layperson carers is safe and efficient. All modes of respiratory support may be used.

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

As medical and technological advances have made it possible to prolong the life of children with chronic respiratory failure, children are being referred to post-acute inpatient rehabilitation programmes. In these settings, children can be weaned from their ventilators and receive medical and rehabilitative care in a developmentally supportive environment at a lower financial cost than in an intensive care unit. There is strong evidence that weaning children from mechanical ventilation has beneficial effects on their functionality, ease of care and quality of life. There is, however, little scientific evidence describing how often successful weaning is achieved or the most effective methods. The purpose of this article is to present a consensus report detailing a structured approach to weaning children from mechanical ventilation in a post-acute care setting. This study proposes a Weaning Severity Index and a Weaning Algorithm for use in the assessment and implementation of the weaning process in post-acute rehabilitation. Future clinical studies are needed to validate the suggested approach to ventilator weaning and to determine whether or not the weaning algorithm results in beneficial patient outcomes.

'It's okay, it helps me to breathe': the experience of home ventilation from a child's perspective

There are few studies that focus on children's subjective responses to home ventilation and how this in turn affects their daily lives. This multiple case study explored the experience of home ventilation from the children's perspective. Data were collected from five children through observation and audiotaped interviews. Children expressed their physical and emotional relationship with the ventilator, stating: 'It's okay. It helps me to breathe' - a theme that had a number of distinct dimensions. Other themes included the medicalization of childhood, being a child and hopes for the future. Unlike other study findings to date, the children in this study concluded that the technology was only one small part of their lives. Nurses must ensure that these children have an opportunity to communicate their perspectives, in order to provide care that is clinically effective and child-centered.

Mental health of mothers caring for ventilator-assisted children at home

The complex management of ventilator-assisted children cared for in the home can place emotional and mental strain on parents, in particular, mothers. The purpose of this study was to explore the relationships among functional status of the child, impact of ventilator-assistance on the family, coping, social support, and depression in mothers caring for ventilator-assisted children at home. Thirty-eight mothers participated in the study. Almost half of the mothers experienced depressive mood symptoms. Impact on family was positively related to depression and social support was inversely related to depression. In addition, social support was a significant predictor of depression. The findings show that the high demands related to the care of ventilator-assisted children can be a significant risk factor for poor mental health outcomes of those mothers providing care at home. Interventions by mental health and pediatric nurses should focus on enhancing mothers' coping skills and assisting mothers in accessing a positive social network to help mediate the stress related to caring for their child.

Long-term outcome of children with high tetraplegia and ventilator dependence

BACKGROUND/OBJECTIVES

Since 1978, 350 children with ventilator dependence, including 49 with spinal cord injuries (SCIs), have been followed at the University of Michigan C.S. Mott Children's Hospital. Some data were kept on these children prospectively and included in various studies relating to their outcomes and quality of life. This study was designed to determine physical outcomes of children with SCI and long-term mechanical ventilation (LTMV) and to determine predictors of quality of life for children with SCI and LTMV.

METHODS

Prospective data collection and retrospective chart reviews were conducted for all 49 children with SCI and LTMV followed at the University of Michigan C.S. Mott Children's Hospital from 1978 to 2003.

RESULTS

Of the 49 children with SCI and LTMV, 25 are alive, 16 have died following initial hospital discharge, and 8 have been lost to follow-up. Age at injury was under 5 years for 15, 5 to 9 years for 12, 10 to 14 years for 9, and over 14 years for 13. Forty had high tetraplegia, 7 had low tetraplegia, and 2 had paraplegia. Forty-two had ASIA A injuries, and 7 had ASIA D. All were discharged to their own homes or foster care.

CONCLUSION

Our research studies of children with ventilator dependence with and without history of SCI have examined daily activities, perceptions of their quality of life, and their health and medical complications. This study compares individuals 16 years of age and older with matched control groups of those with tetraplegic SCI who do not use ventilators and those with other diagnoses who use home ventilation. Overall, these children have done remarkably well medically and psychologically.

Technology-dependent children and their families: a review

BACKGROUND

Advances in medical technology and nursing care have enabled children who rely on long-term medical and technical support to reunite with their families and community. The impact of discharging these children into the community involves a number of unprecedented social implications that warrant policy consideration. To begin with, an effort must be made to understand the phenomenon of caring for technology-dependent children living at home.

AIM

The aim of this paper is to provide a comprehensive literature review on caring for technology-dependent children living at home.

METHODS

The review was conducted via keyword searches using various electronic databases. These included CINAHL, MEDLINE, Social Science Index, Sociological Abstracts, Australian Family and Society Abstracts, and the Australian Bureau of Statistics. The articles and books found were examined for commonality and difference, significant themes were extracted, and the strength of the research methods and subsequent evidence were critiqued.

FINDINGS

In this paper, themes relating to home care for technology-dependent children and their families are elucidated and summarized. These are: chronic illness and children; the impact of paediatric home care on children; the uniqueness of technology-dependent children and their families; and parents' experience of paediatric home care.

DISCUSSION

Contentious issues, relevant to the social life of these children and their families, are raised and are discussed with the intention of extending awareness and provoking further debate among key stakeholders. These issues include: the changed meaning of home; family dynamics; social isolation; saving costs for whom?; shifts in responsibility; and parent-professional relationships.

CONCLUSION

More research is needed in the arena of paediatric home care, to facilitate relevant policy formation and implementation.

Clinical findings and resource use of infants and toddlers dependent on oxygen and ventilators

Medical records were reviewed to describe characteristics, report clinical and resource measures, and determine if differences exist between the diagnostic groups of prematurity and multiple congenital anomalies/neurologic conditions for initial admissions of 37 infants and toddlers to an inpatient pulmonary rehabilitation program. More than 75% of the children had a tracheostomy at admission and discharge. Forty-six percent of the sample was admitted requiring only oxygen, whereas 51% were discharged requiring only oxygen and not mechanical ventilation. Thirty percent of the children weaned to a less invasive mode of ventilation while just under half of the children were discharged home. Between-group comparisons indicated statistically significant differences for nutritional support at discharge (p < or = 0.05) and discharge disposition (p = 0.04). Complete weaning of oxygen or ventilator support during an initial inpatient pulmonary rehabilitation admission occurred less frequently than weaning to a less invasive mode of ventilation. This is an important consideration for referring children to rehabilitation programs, for clinical program improvement activities, and for setting realistic expectations for referral sources, patients and families, clinical staff, and payers. Further study is recommended using clinical data in program planning, in program improvements, and for setting outcome expectations for infants and toddlers dependent on pulmonary technology.

Barriers that delay children and young people who are dependent on mechanical ventilators from being discharged from hospital

A qualitative study of user perspectives published previously by the author found that children and young people who are dependent on ventilators spend many months and in some cases years in hospital when they no longer had a medical need or wanted to be there. This second paper is drawn from the same qualitative study and reports on the barriers that the children and young people who are dependent on ventilators, and their parents, described as important factors in preventing their discharge from hospital. Six issues were identified as significant barriers that prevented the children and young people from being discharged. These were: the attitudes of professionals; the lack of joint commissioning and accounting responsibility; general poor management both within the health service and in collaborating with other services; complex social issues; housing problems; and a general lack of auditing and outcome measures. The generalizability of the findings is unknown. However, recommendations are made in relation to the need to establish joint commissioning and accounting responsibility for care and services, and to establish outcome measures to monitor the effectiveness and appropriateness of the care and services provided.

Mechanical ventilation care in severe childhood neurological disorders

Forty-five patients underwent long-term life-sustaining mechanical ventilation care in the Child Neurology Ward, National Center Hospital for Mental, Nervous and Muscular Disorders from 1990 to 2000. Twenty patients had chronic respiratory insufficiency due to neuromuscular disorders, nine of whom underwent home mechanical ventilation care. Nineteen of the 45 patients had chronic respiratory insufficiency due to progressive central nervous system disorders, three of whom underwent home mechanical ventilation care. Six patients with chronic respiratory insufficiency due to the sequelae of transient events were on ventilation, two of whom underwent home mechanical ventilation care. In some patients, especially ones with neuromuscular disorders, mechanical ventilation care is very useful for improving their daily activity and quality of life. In other patients, however, mechanical ventilation care is merely a means of prolonging life without visible improvement of their quality of life. As medical resources are limited, home mechanical ventilation care is a recommended method for patients who need life-sustaining mechanical ventilation care. Considering an individual or social consensus, the indication of long-term life-sustaining mechanical ventilation care for chronic respiratory insufficiency due to severe childhood neurological disorders should be further discussed.

The experiences and views of parents who care for ventilator-dependent children

Discussion in this paper is drawn from the literature examining the management of children with long-term assisted ventilation, and a study of parents' experiences and views of caring for their ventilator-dependent child at home. Difficulties in undertaking research into this group of children are highlighted. Recommendations are proposed regarding future multidisciplinary, multiagency service development in order to meet the needs of ventilator-dependent children and their families.