Non-invasive ventilation: transition from PICU to · PDF file(Non)-invasive ventilation:...
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(Non)-invasive ventilation: transition from PICU to home
Christian Dohna-Schwake
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)
Acute respiratory failure: NIV vs. intubation
Borckink I, Acta Paediatrica 2014
Acute respiratory failure: NIV vs. standard care
Yanez et al.: PCCM 2008
Faster reduction of RR
Wolfler et al. PCCM 2016
150/197 patients initiated on PICU
2/3 neuromuscular disorders, 17% central nervous system disorders, 6% chronicpulmonary diseases, 11% miscellaneous
Invasive ventilation decreasedfrom 100 to 39% over decades
Patients on MV difficult to wean
Neuromuscular disorders Impaired central drive Disorders of the lung Obesity hypoventilation Obstructive sleep apnea Severe thoracic deformities
Differences in circumstances (comparison of twopediatric hospitals with PICUs)
Essen Bicetre
8 bed PICU 20 bed PICU (including surgical IMC)
Pediatric pulmonology No pediatric pulmonology
Pediatric neurology Pediatric neurology
IMC with >100 cases of home MV/year No (specialised) IMC
Sleep studies available No sleep studies available
Respiratory therapist No specialised physiotherapy
Large experience Little experience
Initiation and control of HMV on IMC Initiation and control of HMV on ICU
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
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)
Can Respir J 2011
Medically stable
Hemodynamics Nutrition Ventilation and oxygenation in normal ranges without
changes of ventilator necessary
Motivated
Family and patient willing to be part of the community
Adequate home setting
Room for patient and equipment Time for patient care
Sufficient caregiver support
Parents or caregivers willing to participate in medicalsupport
Additional need of medical support identified and provided(e. g. home nursing)
Adequate financial resources
Health insurance coverage Other sources of financial resources and assistance identified
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
Initial training
Caregivers/parents know how to handle devices, masks etc. Other medical caregivers (home nursing) experienced
Access to health care support
Follow-up care in specialised ventilation unit Home care organized Help for medical emergencies provided
Referring staff, ventilation unit
Home care, pediatrician
Neurology, mobilisation
Ventilation
tracheostomy
mask
Devices: Suctioning, Coughassist, inhalation, oxygen, humidification
procedures
nutrition
medication
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?
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