A. Ioana Cristea

Outcomes of Children With Severe Bronchopulmonary Dysplasia Who Were Ventilator Dependent at Home

OBJECTIVE: To describe the incidence and outcomes of children with chronic respiratory failure secondary to severe bronchopulmonary dysplasia (BPD) on chronic positive pressure ventilation (PPV) via tracheostomy at home. METHODS: We retrospectively reviewed medical charts of patients with severe BPD who were PPV dependent at home and who were enrolled in a university-affiliated home ventilator program between 1984 and 2010. We excluded patients with other comorbidities that could contribute to the development of chronic respiratory failure. We reported the incidence of these children in Indiana and cumulative incidences of survival, liberation from PPV, and decannulation. RESULTS: Over 27 years, 628 children were cared for in our home ventilator program. Of these, 102 patients met inclusion criteria: 83 (81.4%) were alive and 19 (18.6%) were deceased. Sixty-nine patients (67.6%) were liberated from PPV, and 97.1% of them were weaned before their fifth birthday, with a median age at liberation of 24 months (interquartile range, 19–33). Similarly, 60 patients (58.8%) were decannulated, of which 96.7% completed this process before their sixth birthday, with a median age at decannulation of 37.5 months (interquartile range, 31.5–45). The incidence of children with chronic respiratory failure secondary to BPD who were PPV-dependent at home in Indiana was 1.23 per 100 000 live births in 1984 and increased to 4.77 per 100 000 live births in 2010. CONCLUSIONS: Although extreme prematurity associated with severe BPD necessitating PPV at home carries significant risks of morbidity and mortality, successful liberation from mechanical ventilation and decannulation are likely to occur.

Use of polysomnography to assess safe decannulation in children

Tracheostomy is a lifesaving procedure to secure the airway and provide respiratory support. The decision to decannulate has classically been an individual physician decision without consensus among experts. The objective of this retrospective study was to assess the safety and efficacy of a standard institutional protocol that utilizes the sleep laboratory to assist in the decannulation process.

Physiologic findings in children previously ventilator dependent at home due to bronchopulmonary dysplasia.

Bronchopulmonary dysplasia (BPD) is the primary respiratory complication of premature birth. Some preterm newborns develop chronic respiratory failure, requiring home ventilator support. While physiologic measures have been described for prematurely born children, little is known about spirometric indices in patients with severe BPD who were previously ventilator dependent at home.

Multifaceted quality improvement initiative to decrease pediatric asthma readmissions

ABSTRACT Background: Asthma is the most common chronic disease of childhood and a leading cause of hospitalization in children. A primary goal of asthma control is prevention of hospitalizations. A hospital admission is the single strongest predictor of future hospital admissions for asthma. The 30-day asthma readmission rate at our institution was significantly higher than that of other hospitals in the Childrens Hospital Association. As a result, a multifaceted quality improvement project was undertaken with the goal of reducing the 30-day inpatient asthma readmission rate by 50% within two years. Methods: Analysis of our institutions readmission patterns, value stream mapping of asthma admission, discharge, and follow-up processes, literature review, and examination of comparable successful programs around the United States were all utilized to identify potential targets for intervention. Interventions were implemented in a stepwise manner, and included increasing inhaler availability after discharge, modifying asthma education strategies, and providing in-home post-discharge follow-up. The primary outcome was a running 12-month average 30-day inpatient readmission rate. Secondary outcomes included process measures for individual interventions. Results: From a peak of 7.98% in January 2013, a steady decline to 1.65% was observed by July 2014, which represented a 79.3% reduction in 30-day readmissions. Conclusion: A significant decrease in hospital readmissions for pediatric asthma is possible, through comprehensive, multidisciplinary quality improvement that spans the continuum of care.

Ventilator weaning and tracheostomy decannulation in children: More than one way

Tracheostomy was first described more than 2000 years ago, but was performed infrequently for centuries. In children, its application became acceptable during the diphtheria and poliomyelitis epidemics of the early 20 century. Tracheostomy was later routinely used to relieve upper airway obstruction (e.g., epiglottitis), provide chronicmechanical ventilation, facilitatemucus clearance, and stabilize the airway prior to reconstructive surgery for major craniofacial abnormalities. In more recent years, improved survival rates in preterm infants with severe bronchopulmonary dysplasia, children with congenital malformations, and critically-ill children have broadened the indications for tracheostomy. Removal of a tracheostomy may be indicated once the underlying condition has resolved. However, determining readiness for tracheostomy decannulation is challenging in the pediatric population. In addition to resolution of the initial indication, factors supporting clinical readiness include the health of the patient, stability of underlying medical comorbidities, and the child’s functional status. Premature removal of a tracheostomy tube can result in poor growth, more frequent illnesses, hospitalizations and possibly death. On the other hand, failure to remove a tracheostomy when indicated can result in speech delay, increased infection risk, increased costs for care, limitation of participation in school, and sudden death due to mucous plugging. American Thoracic Society and American Academy of Otolaryngology Head and Neck Surgery guidelines recommend endoscopic evaluation of airway anatomyprior to decannulation to confirmadequate airway patency at all levels and to exclude or treat peristomal complications such as granulation tissue. Although various protocols have been reported, there is no standardized approach to weaning chronic mechanical ventilation or decannulation in children. In this issue of the Pediatric Pulmonology, Cristea et al., Henningfeld et al., and Liptzin et al. describe the experiences of three institutionswith respect toweaning mechanical ventilation and tracheostomy decannulation. Cristea et al. describes 201 decannulation attempts performed on 189 patients (sixteen patients had multiple attempts). 167 (79.5%) decannulation attempts were successful. Of those successfully decannulated, four (2.4%) were recannulated within six months. After endoscopic evaluation of the airway, this institution’s decannulation protocol recommends for all patients to be evaluated via polysomnogram (PSG) in the sleep laboratory with the stoma decannulated and covered by an occlusive dressing. Henningfeld et al. performed a retrospective chart review of 46 children who were once ventilatordependent, but have since underwent successful decannulation. All patients underwent both bronchoscopy and at least one PSG before decannulation was attempted. Interestingly, 30 of these children (65%) required some form of airway surgery (most commonly adenotonsillectomy, granuloma removal, and laryngotracheal reconstruction). The authors conclude that liberation from chronic mechanical ventilation is a complex multi-step process that can be done safely once a child’s respiratory condition has improved.

Tracheostomy Following Surgery for Congenital Heart Disease A 14-year Institutional Experience

Background: Tracheostomy following congenital heart disease (CHD) surgery is a rare event and associated with significant mortality. Hospital survival has been reported from 20% to 40%. Late mortality for these patients is not well characterized. Methods: We performed a retrospective observational study of patients who had a tracheostomy following CHD surgery (excluding isolated patent ductus arteriosus ligation) between January 2000 and December 2013. Patients were categorized into single-ventricle or biventricular physiology groups. Demographics, genetic syndromes, pulmonary disease, and comorbidities were collected. Outcomes including hospital survival, long-term survival, and weaning from positive pressure ventilation are reported. Bivariate and time-to-event models were used. Results: Over a 14-year period, 61 children (0.9% incidence) had a tracheostomy placed following CHD surgery. There were 12 single-ventricle patients and 49 biventricular patients. Prematurity, genetic syndromes, lung/airway disease, and other comorbidities were common in both CHD groups. Gastrostomy tubes were used more frequently in biventricular physiology patients (91.8%) versus single-ventricle patients (66.7%, P = .04). Survival to hospital discharge was 50% in the single-ventricle group compared to 86% in biventricular patients (P = .01). Long-term survival continued to be poor in the single-ventricle group comparatively (three years, 27.8% vs 64.8%, P = .01). Gastrostomy tube placement was independently associated with survival in both groups (P = .002). Conclusion: Tracheostomy is performed following many types of surgery for CHD and is commonly associated with other comorbidities. Both hospital and long-term survival are substantially lower in children with single-ventricle physiology as compared to patients with biventricular physiology.

Diagnostic Modalities: Pulmonary Function Testing and Imaging

Premature birth is associated with adverse late pulmonary outcomes, most commonly manifested as reduced pulmonary function, recurrent wheeze, exercise limitation, and chronic cough [1–3]. The realization that insults to the developing lung may have lifelong effects, with respiratory disease burden noted later in life, has led to the need to develop sensitive methods of assessing respiratory function and structural disease during infancy as well as the preschool and school-age years.

Nurse practitioner coverage is associated with a decrease in length of stay in a pediatric chronic ventilator dependent unit.

AIM To hypothesize a dedicated critical care nurse practitioner (NP) is associated with a decreased length of stay (LOS) from a pediatric chronic ventilator dependent unit (PCVDU). METHODS We retrospectively reviewed patients requiring care in the PCVDU from May 2001 through May 2011 comparing the 5 years prior to the 5 years post implementation of the critical care NP in 2005. LOS and room charges were obtained. RESULTS The average LOS decreased from a median of 55 d [interquartile range (IQR): 9.8-108.3] to a median of 12 (IQR: 4.0-41.0) with the implementation of a dedicated critical care NP (P < 1.0001). Post implementation of a dedicated NP, a savings of 25738049 in room charges was noted over 5 years. CONCLUSION Our data demonstrates a critical care NP coverage model in a PCVDU is associated with a significantly reduced LOS demonstrating that the NP is an efficient and likely cost-effective addition to a medically comprehensive service.