(Non)-invasive ventilation: transition from PICU to home. Christian Dohna-Schwake
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1 (Non)-invasive ventilation: transition from PICU to home Christian Dohna-Schwake
2 Increased use of NIV in PICUs over last 15 years First choice of respiratory support in many diseases Common temporary indications: postextubation failure, acute hypoxic and hypercapnic respiratory failure Bronchiolitis, status asthmaticus, immunocompromised patients with respiratory failure, after extended surgery (cardiac, liver tx)
3 Acute respiratory failure: NIV vs. intubation Borckink I, Acta Paediatrica 2014
4 Acute respiratory failure: NIV vs. standard care Faster reduction of RR Yanez et al.: PCCM 2008
5 Wolfler et al. PCCM 2016
6 150/197 patients initiated on PICU 2/3 neuromuscular disorders, 17% central nervous system disorders, 6% chronic pulmonary diseases, 11% miscellaneous Invasive ventilation decreased from 100 to 39% over decades
7
8 Patients on MV difficult to wean Neuromuscular disorders Impaired central drive Disorders of the lung Obesity hypoventilation Obstructive sleep apnea Severe thoracic deformities
9 Differences in circumstances (comparison of two pediatric hospitals with PICUs) Essen Bicetre 8 bed PICU 20 bed PICU (including surgical IMC) Pediatric pulmonology Pediatric neurology IMC with >100 cases of home MV/year Sleep studies available Respiratory therapist Large experience Initiation and control of HMV on IMC No pediatric pulmonology Pediatric neurology No (specialised) IMC No sleep studies available No specialised physiotherapy Little experience Initiation and control of HMV on ICU
10 Patient factors to consider Mode of ventilation (invasive, non-invasive) Length of ventilation (sleep 24 hours) Age of patient Mobility of patient Disease / oxygen dependency / cough insufficiency
11 Aims of discharge and transfer of child on MV Safe As fast as possible Kept privacy for child and family (no continuation of ICU at home) Interdisciplinary approach (ICU, pneumology, pediatric neurology, respiratory therapist, rehabilitation, family)
12 Can Respir J 2011
13 Medically stable Hemodynamics Nutrition Ventilation and oxygenation in normal ranges without changes of ventilator necessary
14 Motivated Family and patient willing to be part of the community
15 Adequate home setting Room for patient and equipment Time for patient care
16 Sufficient caregiver support Parents or caregivers willing to participate in medical support Additional need of medical support identified and provided (e. g. home nursing)
17 Adequate financial resources Health insurance coverage Other sources of financial resources and assistance identified
18 Appropriate equipment Ventilator (backup, battery in 24-hour-dependency) Oxygen supply Monitoring (saturation) Airway secretion management (assited coughing devices, suctioning device) Masks, tubes, suctioning catheters as substitutes Other medications
19 Initial training Caregivers/parents know how to handle devices, masks etc. Other medical caregivers (home nursing) experienced
20 Access to health care support Follow-up care in specialised ventilation unit Home care organized Help for medical emergencies provided
21 Neurology, mobilisation Referring staff, ventilation unit Home care, pediatrician Ventilation
22 tracheostomy mask procedures Devices: Suctioning, Cough assist, inhalation, oxygen, humidification
23 nutrition medication
24 Control before transfer HMV effective (meets treatment goals)? Home prepared? Caregivers identified and trained? Equipment complete and functioning? Access to health care support available in case of emergency and for regular control?
25 Optimal approach of patient on PICU with need of HMV to transfer at home Treatment and stabilisation of acute respiratory deterioration on PICU Transfer to specialised respiratory unit for HMV Optimization of respiratory support and organisation of caregiver support, equipment and health care access Rehabilitation unit? Short term care in specialized unit outside hospital? Transfer home
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