The optimization of home oxygen weaning in premature infants trial: Design, rationale, methods, and lessons learned

Improved survival among preterm infants has led to an increase in diagnosis of chronic lung disease and infants discharged home from the NICU on supplemental oxygen. Despite this increased prevalence, no clearly defined guidelines for the management of home oxygen therapy (HOT) exist. This lack of consensus leads to significant variability in the duration of home oxygen therapy and a general paucity of evidence-based practice. Our team has identified recorded home oxygen therapy (RHO) as a potential new resource to guide clinical decision making in the outpatient pulmonology clinic. By recording extended O2 saturation data during the weaning process, RHO has the potential to save cost and improve the processes of HOT management. Our team is currently supporting a prospective, multi-center, randomized, controlled trial of RHO guided HOT weaning with the aims of determining effect upon duration of HOT, perceived parent quality of life and effect upon growth and respiratory outcomes. We plan to randomize 196 infants into one of two study arms evaluating standard HOT management versus RHO guided oxygen weaning. Our primary outcomes are total HOT duration and parental quality of life. This trial represents an unprecedented opportunity to test a novel home monitoring intervention for weaning within a vulnerable yet quickly growing population. If effective, the use of RHO may provide clinicians a tool for safe weaning.

Interdisciplinary approach to the rehabilitation of an 18-year-old patient with bronchopulmonary dysplasia, using telerehabilitation technology

We describe the use of telehealth technology in the rehabilitation of a college student with bronchopulmonary dysplasia. The present telerehabilitation application was necessitated by the absence of a formal university-based pulmonary rehabilitation program at Texas State University-San Marcos. Patient referral, evaluation, and rehabilitation were accomplished via interdisciplinary efforts of 3 separate university entities. Initial referral was obtained from the student health center, with pulmonary evaluation provided by the respiratory care department. Commercially available telerehabilitation equipment was then utilized to resolve exercise supervision and physiologic data-acquisition concerns. Forty-five individualized exercise sessions were administered by physical therapists via telerehabilitation distance voice and vision technology. Results reveal no substantive changes in pulmonary function test results, but there was improvement in functional aerobic capacity. Given the reduced life expectancy associated with bronchopulmonary dysplasia, investigators were afforded a unique opportunity to study an adult patient with this condition. Further, it appears the combined application of telerehabilitation technology and interdisciplinary cooperation among university departments is efficacious in the identification, evaluation, and rehabilitation of students with selected pulmonary disorders.

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

Transitioning an infant with bronchopulmonary dysplasia (BPD) home on oxygen is a complex process. It requires an interdisciplinary team, with clear but flexible discharge criteria, and a coordinated process to manage the complexity. In "The Changing Face of Bronchopulmonary Dysplasia: Part I" (Advances in Neonatal Care, December 2002, pp 327-338), the evolving nature of BPD was presented, along with new diagnostic criteria, a description of the risk factors and clinical profile of this condition, and a discussion of preventative strategies as well as the medical and neurodevelopmental outcomes. "The Changing Face of Bronchopulmonary Dysplasia: Part 2. Discharging an Infant Home on Oxygen" provides strategies to support families during the pivotal transition home on oxygen and other related technologies. The use of a systematic interdisciplinary discharge planning process, guided by clear criteria for discharge, is presented. An outline of the comprehensive discharge teaching, home care, and multispecialty follow-up that are necessary to ensure a safe and smooth transition into the community to avoid repeat or unnecessary rehospitalizations and to enhance outcomes is provided. Medical fragility persists in infants with BPD, placing additional stress on families. Pragmatic strategies to provide intensive parent support throughout the process are offered.

Feeding interactions in infants with very low birth weight and bronchopulmonary dysplasia

Infants with very low birth weight (VLBW) are at increased risk for feeding disorders that can affect growth and development. One hundred and forty one mother-infant pairs were compared [55 with infants with high medical risk due to infant VLBW and bronchopulmonary dysplasia (BPD), 34 VLBW without BPD, and 52 term infants] on operationally defined measures of feeding behaviors and maternal self-report of depression and anxiety. Mothers of VLBW infants with and without BPD spent more time prompting their infants to feed when their infants engaged in nonfeeding behavior. Despite increased maternal efforts, infants with BPD took in less formula, spent less time sucking, and spent a greater proportion of time nonfeeding. VLBW infants without BPD were equivalent to term infants in percentage of time sucking and in volume of formula ingested and were more likely to take in higher calories than infants with BPD. Mothers of VLBW infants with and without BPD were also more likely to report clinically significant symptoms of depression and anxiety than mothers of term infants. Because mothers of VLBW infants who were more depressed or anxious were less likely to verbally prompt their infants to eat, maternal psychological symptoms should be considered in assessing interactions of VLBW mother-infant dyads.

Outcomes and problems in pediatric pulmonary rehabilitation

OBJECTIVE

To provide baseline information on the state of pediatric pulmonary rehabilitation, including data regarding diagnosis, age, gender, race, gestational age, disposition, medications, complications, procedures, consultations, pulmonary status, and outcomes.

DESIGN

Retrospective review.

SETTING

Pediatric pulmonary rehabilitation unit of a pediatric rehabilitation hospital that is free-standing, but that receives most of its referrals from a tertiary care pediatric hospital.

PATIENTS

All patients (70 subjects) who had completed a course of inpatient rehabilitation over the 5-yr life of the hospital.

MAIN OUTCOME MEASURES

Descriptive data were collected in regard to the objectives. In addition, outcome measures were developed for this study. They include measurements of developmental equivalence at admission and discharge and the changes in these scores, both actual and expected.

RESULTS

Descriptive characteristics are listed in the text. Forty-six patients had bronchopulmonary dysplasia (BPD). The success rate of weaning those with BPD who were admitted with a goal of ventilator weaning was 81% (24% for those without BPD). On admission, 36 of those with BPD required three pulmonary aids (O2, continuous positive airway pressure, ventilator, and tracheostomy); at discharge, 28 required three aids. Of those without BPD, 16 required three aids at admission and 14 did so at discharge.

CONCLUSIONS

Basic descriptive data are provided. The characteristics are similar to those in previous studies, although with a larger sample size and more detail. The outcome measures described cannot be compared with a criterion standard, but do offer a starting point in this underdeveloped field and will assist in future research directions.

Early transfer to a rehabilitation hospital for infants with chronic bronchopulmonary dysplasia

Shortly after being weaned off the respirator, 43 infants with severe chronic bronchopulmonary dysplasia (BPD) were transferred from an intensive-care nursery at a teaching hospital to an affiliated children's rehabilitation hospital in a program that included special staff instruction. Morbidity, measured by rate of transfer back to the acute-care hospital, was lower than in a comparison group of 15 infants treated for severe BPD during the previous two years. Average length of stay was significantly shortened and an average of $60,000 per patient was saved. Using a rehabilitation hospital as a step-down unit shifts the emphasis from acute needs to chronic and developmental needs and from intensive monitoring and nursing care to care given at home by parents with nursing assistance.

[Speech cannula for children with tracheotomy and oxygen inhalation therapy]

Because of various possible problems tracheotomy in children should be performed only in urgent cases and should be sewed up as soon as possible. Early language therapy and the use of cannulas with speaking device promote language development. We propose a special silver cannula with speaking device for children with oxygen dependence due to bronchopulmonary dysplasia.

Neonatal intensive care and pediatric rehabilitation: a joint program for care of chronically ill infants

A joint program involving a traditional neonatal intensive care unit and a pediatric rehabilitation unit was developed to care for the increasing number of infants with chronic illnesses requiring long-term specialized care. The program emphasizes provision of a more normal, age-appropriate environment, parent education, and opportunities for extended parent-child interaction.

[New transportable CPAP respiratory aid]

A mobile respiratory aid has been developed for a 7-year-old child in cooperation with the Institute for Electromechanical Construction of Darmstadt Technical University. Born prematurely in week 27 with bronchopulmonary dysplasia, she has thus been enabled to leave the ward without any major technical difficulties, opening up numerous opportunities for development to the child notwithstanding her continuing dependence on the breathing aid. The robust, handy device weights less than 10 kg, and is housed in an aluminum case the size of a briefcase. It is battery-driven, a charging lasting for some 7 to 8 hours of operation. All parts subject to wear, such as filter, tubings, and bellows, are commercially available through the medical equipment market. Reported is a period of use of more than 2000 hours, and it is hoped that other pediatric centres looking after children with similar problems will cooperate in further developing this mobile CPAP respiratory aid.