Use of home oxygen for children in England and Wales

Use of pulse oximetry as an investigative test for paediatric respiratory sleep disorders

The article covers the following elements: practical and technological considerations for optimising data collection and output; reference ranges for oximetry parameters across the ages; things to consider when interpreting a pulse oximetry study (eg, sleep/wake times); the ability of pulse oximetry to predict obstructive sleep apnoea; using oximetry as a screening tool for sleep disordered breathing in children with Down syndrome; things to consider when setting up a home oximetry service; and a case of an infant being weaned from oxygen using pulse oximetry studies.

Characteristics and outcome of infants with bronchopulmonary dysplasia established on long-term ventilation from neonatal intensive care

INTRODUCTION

Ex-preterm infants with severe bronchopulmonary dysplasia (BPD) sometimes require long-term ventilation (LTV) to facilitate weaning from respiratory support. There are however limited data characterizing this cohort. We aim to describe the background characteristics, neonatal comorbidities, characteristics at the initiation of ventilation, and outcomes of neonatal unit graduates with BPD established on LTV.

METHODS

A retrospective cohort study of infants born <32 weeks gestation with BPD referred to a regional LTV service between January 2015 and December 2020.

RESULTS

Twenty-five infants were referred during the study period. Median birth gestation was 26 + 1 weeks (24 + 0-30 + 4) and birth weight 645 g (430-1485). At 36 weeks postmenstrual age (PMA), median FiO₂ was 0.45 (0.24-0.80) and one-quarter of infants remained on invasive ventilation. Twenty (80%) infants were established on noninvasive ventilation (NIV), with the smallest weighing 2085 g, and five (20%) required tracheostomy invasive ventilation (TIV). At initiation of NIV/TIV, median PMA was 41 + 1 weeks and median FiO₂ 0.40 (0.29-0.80). Infants established on TIV spent almost five times longer in hospital before discharge compared to those on NIV (p = 0.003). By March 2022, 18 (72%) infants had discontinued ventilation, spending a median total time of 113 days (18-1792) on ventilation.

CONCLUSION

Due to advances in interfaces, headgear, and ventilator technology, NIV is an attractive and practically achievable option for infants with severe BPD as small as 2 kg. Initiation and weaning should take place in a facility with the required multidisciplinary expertize.

Personality metatraits predict resilience among family caregivers responsible for a dependent youth's chronic respiratory management

Background

Family caregivers of children and youth with severe neurodisabilities that require chronic respiratory management often report a compromised quality of life. In this cross-sectional study, we used DeYoung’s (Psychol Inq 21(1): 26–33, 2010. 10.1080/10478401003648674) conceptualization of two personality metatraits, Alpha and Beta, to test their theorized role in facilitating resilience among these family caregivers. We expected higher Alpha and Beta would exhibit direct, beneficial effects on caregiver mental and physical health quality of life (QoL), and they would operate through self-reported resilience and coping to exert positive, indirect effects on caregiver QoL.

Methods

Family caregivers of children and youth at an outpatient chronic respiratory management clinic were informed of the study. Of the 68 who consented, 61 provided complete data on measures of personality traits, coping styles, and physical and mental health-related QoL. Factor analytic techniques verified the two personality metatraits, consistent with the DeYoung model. The metatraits were then used as predictor variables in a path model to predict physical and mental health-related QoL. Self-reported resilience and a coping variable were examined as possible mediators of the personality-QoL relationship.

Results

Correlational analyses isolated a coping variable that met criteria as a possible mediator. The path model exhibited good fit to the data. The Alpha metatrait—characterized by emotional stability, self-regulation, perseverance, and intrinsic motivation—was directly predictive of caregiver mental health. The Beta metatrait, reflecting a disposition for adaptive flexibility, responsiveness, and interpersonal initiative, demonstrated significant indirect effects to physical and mental health through its positive association with coping efforts to maintain social support and a sense of self.

Conclusions

Consistent with DeYoung’s conceptualization, higher Alpha and Beta predicted caregiver resilience, albeit through different pathways. The emotional stability, perseverance and emotional regulation associated with Alpha likely accounted for its positive association with caregiver mental health. Beta, in contrast, may operate through their adaptive flexibility, personal resourcefulness and social engagement to augment coping efforts that involve others and support family activities, which, in turn, promote their own physical and mental health. Limitations of the cross-sectional design, and potential theoretical and clinical implications of the personality metatraits and their relation to resilience are discussed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-022-00791-y.

The high-risk factors of different severities of bronchopulmonary dysplasia (BPD) based on the national institute of child health and human development (NICHD) diagnosis criteria in 2018

Objective

To investigate the clinical characteristics of preterm infants with different severities of bronchopulmonary dysplasia (BPD) and disclose the high-risk factors of exacerbating BPD.

Methods

Collection of clinical data of 91 preterm infants admitted to the NICU and diagnosed with BPD, categorized in groups according to the disease severity: 41 mild cases,, 24 moderate cases, and 26 severe cases. Comparison and analysis of perinatal risk factors, treatment, complications and prognosis of the infants with different severity degrees.

Results

The severe group had a higher proportion of infants with congenital heart disease (CHD) higher than the moderate group (P < 0.05), and a higher ratio of pneumonia and mechanical ventilation (MV) ≥ seven days than the mild group (P < 0.05). The severe group also presented higher reintubation incidence than both the mild and moderate groups (P < 0.05). The groups presented different (P < 0.05) incidence rates of hemodynamically significant patent ductus arteriosus (hsPDA) . Ridit analysis suggested that the premature infants (PIs) with hsPDA, multiple microbial pulmonary infections, or Klebsiella pneumoniae pneumonia had more severe illness.

Conclusion

CHD, hsPDA, MV ≥ seven days, reintubation, pneumonia, especially multiple microbial pulmonary infections, and Klebsiella pneumoniae pneumonia are correlated with the severity of BPD and can be used as BPD progression predictor.

Weaning oxygen in infants with bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD) is a form of chronic lung disease commonly seen in preterm infants as the sequelae following respiratory distress syndrome. The management of evolving BPD aims to minimise lung injury and prevent the impact of hypoxia and hyperoxia. Proposed morbidities include respiratory instability, pulmonary hypertension, suboptimal growth, altered cerebral oxygenation and long-term neurodevelopmental impairment. The ongoing management and associated morbidity present a significant burden for carers and healthcare systems. Long-term oxygen therapy may be required for variable duration, though there is a lack of consensus and wide variation in practise when weaning supplemental oxygen. Furthermore, a shift in care towards earlier discharge and community care underlines the importance of a structured discharge and weaning process that eliminates the potential risks associated with hypoxia and hyperoxia. This review article describes recent evidence outlining oxygen saturation reference ranges in young infants, on which structured guidance can be based.

Impact of a protocol-driven unified service for neonates with bronchopulmonary dysplasia

Aim

A new specialised service for preterm infants with bronchopulmonary dysplasia requiring long-term oxygen therapy (LTOT) was established in 2007, led by the paediatric respiratory team, transitioning from neonatal-led follow-up. The new service included the utilisation of a clear protocol. Our objective was to review whether this service initiation led to a reduction of time in LTOT and hospital readmissions.

Methods

We performed a retrospective cohort study of infants born at <32 weeks’ gestation requiring LTOT in a single tertiary neonatal service. Cases were identified from hospital records, BadgerNet and a local database for two cohorts, 2004–2006 and 2008–2010. Data collected for infants requiring LTOT included demographic details, length of neonatal stay, time in oxygen and hospital attendance rates.

Results

The initiation of the service led to an increase in the number of discharges in LTOT: 13.1% of infants born alive before 32 weeks’ gestation in comparison to 3.5% (p<0.001). However, the length of time in LTOT reduced from 15 to 5 months (p=0.01). There was no difference in hospital readmission rates (p=0.365).

Conclusions

In our experience the increase in neonates requiring LTOT is likely to be due to enhanced provision of overnight oximetry studies prior to discharge. Structured monitoring and weaning led to a shorter duration of home oxygen therapy.

The implementation of a clear protocol for assessment and management of neonates with bronchopulmonary dysplasia may lead to more infants being discharged in home oxygen, but has potential to reduce overall healthcare costs and improve long-term outcomeshttp://ow.ly/fYcv30nIc2c

Home oxygen therapy criteria, guidelines and protocols for hypoxia management in pediatric patients with acute bronchiolitis: a scoping review protocol

REVIEW OBJECTIVE/QUESTION

The objectives of this scoping review are: to explore existing literature related to discharge criteria, guidelines and protocols from hospitals or clinics that are being implemented for home oxygen therapy (HOT) in the management of hypoxia in pediatric patients with acute bronchiolitis, examine and conceptually map the evidence, and identify any gaps in the literature.The question of this review is: what discharge criteria, guidelines, and protocols are used for HOT in the management of hypoxia in pediatric patients with acute bronchiolitis?

Bronchopulmonary Dysplasia Within and Beyond the Neonatal Unit

BACKGROUND

Bronchopulmonary dysplasia (BPD), also known as chronic lung disease of prematurity or chronic neonatal lung disease, is a major cause of respiratory illness in premature babies. Newborn babies survive at gestational ages of 23 to 26 weeks, earlier than when BPD was first described. New mechanisms of lung injury have therefore emerged and the clinical and pathological characteristics of pulmonary involvement have changed.

PURPOSE

Improved neonatal intensive care unit modalities have increased survival rates; the overall prevalence of the condition, however, has not changed. Management of evolving BPD aims at minimizing lung injury. Management of established, especially severe BPD, still poses significant clinical challenge as these babies need long-term oxygen therapy (LTOT) for variable length of time. We aim to give an overview of management of established BPD with particular focus on weaning home oxygen therapy at our local center in the United Kingdom.

SEARCH AND RESULTS

On the basis of most recent evidence, we concluded that an integrated pathway for managing babies on LTOT is very important after discharge from neonatal unit.

IMPLICATIONS FOR PRACTICE

A structured weaning pathway for premature babies on home oxygen improves outcome.

IMPLICATIONS FOR RESEARCH

The management of severe BPD and related complications, particularly during the first 2 years of life, remains a continuing challenge for parents and healthcare providers. The most beneficial respiratory support strategy to minimize lung injury and/or promote lung healing remains unclear and requires further investigation.

An observational study examining the relationship between respiratory symptoms, airway inflammation and bacteriology in children with severe neurodisability

Background

Children with severe neurodisability (ND) commonly suffer from chronic respiratory symptoms that impact greatly on quality of life, and lead to recurrent hospital admissions. This morbidity (and its causes) is poorly described, despite being well recognised by paediatricians. In this study, we characterised respiratory symptoms in children with ND at times of stability and deterioration. We also assessed the relationship between respiratory symptoms, lower airway inflammatory markers and levels of infection/colonisation.

Methods

ND children were recruited upon admission for elective surgery (Elective-ND [n = 16]), or acutely upon admission to Intensive Care (PICU-ND [n = 19]), and compared to healthy control children [n = 12]. Parents completed a validated respiratory symptom questionnaire in which symptoms associated with activity were removed (total maximal score of 108). Bronchoalveolar lavage (BAL) was collected, and BAL neutrophil counts, IL-8 and TGFβ-1 levels measured. BAL microbial analysis was performed using a 16S/18S rRNA gene based assay and Pseudomonas aeruginosa PCR.

Results

All ND children had high levels of respiratory symptoms (median [IQR] symptom score PICU-ND, 55[38-64]; Elective-ND, 26[7-45]; Control, 4[0-7]: p<0.01), which affected their families, particularly at nighttime. Elective-ND patients with a total respiratory symptom score >20 invariably had BAL neutrophilia. Elective patients with 16S/18S microbial rDNA positive BAL had higher neutrophil counts (positive, 33[18-70]%; negative, 8[4-38]%: p<0.05) and generally higher symptom scores (positive, 17[5-32]; negative, 5[0-9]: p = 0.097). Streptococcus mitis was commonly identified in BAL from ND children; Pseudomonas aeruginosa was not identified in any sample.

Conclusions

Children with severe ND often have high levels of chronic respiratory symptoms, which may relate to lower airway inflammation. Bacterial airway colonisation, particularly with oral commensals, may play a role in both symptom generation and inflammation.

Oxygen therapy in preterm infants

Despite being the most widely used and vital therapy in neonatology, optimal strategies for the use of oxygen in preterm infants remain controversial. Achieving the balance between attaining adequate tissue oxygenation and avoiding oxygen toxicity is challenging. There remains a paucity of clear evidence based guidance for clinicians on safe oxygen saturation targets. What does seem apparent is that these targets vary over time in the life of a preterm infant. This article summarises the evidence behind current practice of oxygen monitoring and administration from the first few minutes after birth, through to the acute neonatal and later convalescent periods. Finally, we review the use of home oxygen for preterm infants with bronchopulmonary dysplasia including administration and weaning from domically home oxygen.

Recommendations for long-term home oxygen therapy in children and adolescents

OBJECTIVE

To advise pediatricians, neonatologists, pulmonologists, pediatric pulmonologists, and other professionals in the area on the main indications and characteristics of long-term home oxygen therapy in children and adolescents.

DATA SOURCE

A literature search was carried out in the MEDLINE/PubMed database (1990 to 2011). Additionally, references from selected studies were included. As consistent scientific evidence does not exist for many aspects, some of the recommendations were based on clinical experience.

DATA SYNTHESIS

Long-term home oxygen therapy has been a growing practice in pediatric patients and is indicated in bronchopulmonary dysplasia, cystic fibrosis, bronchiolitis obliterans, interstitial lung diseases, and pulmonary hypertension, among others. The benefits are: decrease in hospitalizations, optimization of physical growth and neurological development, improvement of exercise tolerance and quality of sleep, and prevention of pulmonary hypertension/cor pulmonale. The levels of oxygen saturation indicative for oxygen therapy differ from those established for adults with chronic obstructive pulmonary disease, and vary according to age and disease. Pulse oximetry is used to evaluate oxygen saturation; arterial blood gas is unnecessary. There are three available sources of oxygen: gas cylinders, liquid oxygen, and oxygen concentrators. The flows used are usually smaller, as are the number of hours/day needed when compared to the use in adults. Some diseases show improvement and oxygen therapy discontinuation is possible.

CONCLUSIONS

Long-term home oxygen therapy is increasingly common in pediatrics and has many indications. There are relevant particularities when compared to its use in adults, regarding indications, directions for use, and monitoring.

The importance of understanding epidemiology in order to inform financial decisions: a lesson from the Scottish Home Oxygen Service

OBJECTIVES

To ensure that decisions on the future planning of the Scottish Home Oxygen Service reflect population needs by examining the epidemiology of the main conditions that require home oxygen therapy and trends in their management.

STUDY DESIGN

Analysis of routinely available vital event and health service data supplemented by published literature. Use of linked data to provide person-based analyses.

METHODS

Consideration of trends in key risk factors, disease incidence, prevalence and mortality for chronic neonatal lung disease, cystic fibrosis, chronic interstitial lung disease in adults and chronic obstructive pulmonary disease. Examination of trends in management of these conditions including hospital admissions, length of stay and re-admissions.

RESULTS

The prevalence of all the conditions studied has increased in Scotland over recent years due to a combination of increased incidence, increased survival, more active case finding and demographic changes. There have been changes in management with trends towards shorter hospital stays.

CONCLUSIONS

The clinical need for home oxygen therapy is likely to continue to increase over the next 10-20 years. It will encompass all age groups and a complex range of conditions. Public health needs to be proactive in providing relevant needs assessment information to ensure that planning within financial constraints is appropriately informed on population needs.