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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