Non-plaque-induced gingivitis and oral complications in a pediatric patient on long-term mechanical ventilation – A case report

Gender differences in patients starting long-term home mechanical ventilation due to obesity hypoventilation syndrome

Canadian longitudinal data from a pediatric domiciliary long-term mechanical ventilation (LTMV) program is lacking. Our aim was to report on the clinical characteristics and trends of children followed in one of Canada's pediatric home ventilation programs over the past 20 years. A retrospective chart review was conducted on patients receiving long-term domociliary mechanical ventilation between January 1, 1991 and December 31, 2011 in a single center. Domiciliary long-term mechanical ventilation was defined as the daily use of invasive mechanical ventilation (IMV) or noninvasive positive pressure ventilation (NiPPV) for at least 3 months, in the users' home or in a long-term residential facility. Between 1991 and 2011, a total of 379 children were identified (313 [83%] with noninvasive ventilation). The median age at initiation was 9.6 years (interquartile range [IQR] 2.9-13.9), the median duration of ventilation was 2.2 years (IQR 0.8-4.9) and 53% were male. Ninety-nine percent of children were cared for at home. The reason for ventilation was "musculoskeletal" in origin for the majority of children. The number of children receiving long-term mechanical ventilation at home increased from 2 in 1991 to 156 children as of December 2011. There was a twofold increase in the number of invasive ventilation initiations in the second 10 years, n = 45 (2001-2011) as compared to the first 10 years, n = 21 (1991-2000). However, there was more than a fivefold increase in the number of noninvasive initiations in the first 10 years, n = 50 (1991-2000) as compared to the second 10 years, n = 263 (2001-2011). The largest growth was in the 13-18 years age group. There were 55 (15%) mortalities over the study period. In summary, our 20-year retrospective study has shown that there has been an exponential growth in the number of children receiving domiciliary LTMV with the majority of children having favorable outcomes. Our study represents a step towards developing a Canadian registry to design and implement programmatic change for this medically complex population to ensure best practice for these children as well as their families.

The purpose of this prospective, quantitative, comparative study, conducted at the 55 bed cardiothoracic intensive care unit of the Heart Institute (InCor), University of Sao Paulo Medical School, was to identify factors involved in the weaning of patients who require long-term (> 10 days) mechanical ventilation after cardiac surgery. The subjects included all patients who underwent open-heart surgery with cardiopulmonary bypass during a 10 month period from April 2000 to January 2001 (n = 946). From this group, 52 (5.7%) patients who required a tracheotomy for the management of long-term mechanical ventilation after cardiac surgery with cardiopulmonary bypass were selected. Pre-, intra- and postoperative data from patients who were not successfully weaned after reintubation and who underwent an elective tracheotomy were compared. Parameters of respiratory mechanics such as respiratory complications, oxygenation, and cardiac, renal, and neurological function were evaluated. Weaning success was defined as the ability of a patient to tolerate 48 hours without pressure or flow support from a mechanical ventilator. A patient was considered to have failed weaning if they died or remained under ventilation for more than 8 weeks. Of the 52 patients studied, 25 were successfully weaned, 21 died, and 6 remained ventilated for more than 8 weeks. We found significant statistical differences (P < 0.05) between the groups with respect to success or failure in LVEF (P = 0.0035), the need for vasoactive agents (P = 0.0018), and renal failure (P = 0.002). Parameters of respiratory mechanics and oxygenation (eg, static airway compliance, airway resistance) did not influence the success or failure of weaning. There was a significant difference in relation to the presence of pneumonia (P = 0.0086) between the two groups. Although neurological complications were more frequent in patients in the weaning success group, the failure group had lower GCS scores, which is indicative of worse prognoses. It is concluded that cardiac dysfunction, the need for dialysis, and pneumonia are determinants for weaning failure in patients undergoing long-term mechanical ventilation after cardiac surgery.

determining the structure of leading microbial colonizers of the respiratory tract as potential causative agents of ventilator-associated pneumonia and their sensitivity to antibacterial drugs plays an important role in choosing effective tactics for etiotropic therapy of newborns. According to the data of scientific publications, the etiological structure of infectious complications associated with long-term respiratory support in newborns is known to have certain features. The spectrum of nosocomial microbial pathogens and their sensitivity to antimicrobial drugs are among them. The patients of early age are characterized by a number of peculiarities of anatomical and physiological characteristics and the qualitative and quantitative composition of the microbiota of the respiratory tract. In order to form ideas about the determining causative agents of VAP in newborns, it was advisable to conduct a microbiological study of the species composition of microorganisms associated with this infectious complication, as well as to determine their sensitivity to antibiotics recommended by the management protocols of the corresponding pathology. To study and solve this problem, it is necessary to study the spectrum and antibiotic sensitivity of the causative agents of VAP. A prospective study was conducted in 69 newborns with VAP (2020 - 2023), who were treated in the Neonatal Intensive Care Unit (NICU) of the Vinnytsia Regional Children's Clinical Hospital (VRCCH) and consisted in studying the composition of the microbiota and antibiotic sensitivity. We took into account opportunistic microorganisms that are not characteristic of this biotope of the respiratory tract of newborns who were diagnosed with VAP during long-term mechanical ventilation. As a result of the prospective analysis of the microbiological study of the microbiota of 69 newborns, 82 microorganisms - etiologically significant pathogens of VAP - were isolated and identified. Thus, according to the data of our bacteriological studies, 17 Gram-positive and 65 Gram-negative pathogens of VAP were isolated and identified in NICU VRCCH for 2020-2023. As a result of the study of antibiotic sensitivity of VAP pathogens in newborns, the following trends were observed. Low sensitivity of Acinetobacter baumannii to ceftazidime, aztreonam, imipinem, meropenem, amoxicillin, piperacillin, levofloxacin, ciprofloxacin was established. And sensitive to amikacin, gentamicin and cefoperazone-sulbactam. High rates of resistance of Pseudomonas aeruginosa to ceftazidime, doxycycline, imipinem, meropenem, gentamicin, piperacillin, levofloxacin, ciprofloxacin, ofloxacin were established. The best indicators of sensitivity of P. aeruginosa to amikacin, cefoperazone-sulbactam and tobramycin were found. According to the results of the sensitivity of K. pneumoniae to antibiotics, resistance to all antibiotics was established. The development of resistance of Staphylococcus aureus to azithromycin, norfloxacin, cefotaxime, benzylpenicillin has been established. The indicators of S. aureus sensitivity to amikacin, tetracycline and vancomycin turned out to be the best. We took into account opportunistic microorganisms that are not typical for this biotype of the airways of newborns who were diagnosed with VAP during long-term mechanical ventilation. The results of the study indicate the need to take into account the data of a microbiological study with the mandatory identification of isolated pathogens, their microbial load at the site of infection, determining their antibiotic sensitivity is of crucial importance in the selection of etiotropic treatment tactics for newborns with VAP.

Despite the extensive investigations in the area of weaning, clinicians are still struggling with the question of when to begin the process of weaning. Clinical weaning indices designed to predict the weaning potential are most frequently based on pulmonary factors. However, many physiological, respiratory, and mechanical factors also have impact on weaning, but are often overlooked. We suggest a new "nonpulmonary weaning index" (NPWI), which assesses the influence of factors such as blood albumin and total blood protein on the weaning success. We assess the information value of 17 clinical and paraclinical indices in a retrospective study covering 151 patients on a long-term (at least 7 days) mechanical ventilation. The most informative of those 17 indices are used in the formulation of NPWI. Its threshold differentiates the successful from the unsuccessful weaning trials. From all 17 indices the most significant are: total blood protein, blood albumin, PaO2, hematocrit, lactate, the ratio PaO2/FiO2, hemoglobine, and RUE. The proposed index uses only two of them: blood albumin and total blood protein. It is easily calculated and can easily be tracked in time. It has high sensitivity and specificity. The results of this study suggest that in the decision whether to attempt weaning from long-term mechanical ventilation, more attention should be paid to the nonpulmonary factors.

Background: There is little data on the 3 year prognosis and quality of life of patients on long-term (>72 hour) mechanical ventilation in a medical intensive care unit (MICU). Methods: Patients with long-term mechanical ventilation from May 2003 through July 2003 in MICU of Asan Medical Center, Seoul were enrolled in this studay. The survival rates were observed prospectively at 1, 3, 6, 12, 24, 36 months, and the quality of life of survivor was measured at 12 months by using Short Form 36 (SF-36). Results: The survival rate at 1, 3, 6, 12, 24 and 36 months was 54.8% (40/73), 39.7% (29/73), 30.1% (22/73), 20.5% (15/73), 18.3% (13/71) and 16.9% (12/71), respectively. There was a similar survival rate regardless of the diseases that required mechanical ventilation. A neoplasm or chronic liver disease had a worse survival rate than chronic lung or kidney disease (p

Weaning and liberation from mechanical ventilation in pediatric patients with tracheostomy and long-term mechanical ventilation constitute a challenging process due to diagnosis heterogeneity and significant variability in the clinical condition. We aimed to evaluate the physiological response during the first attempt of a spontaneous breathing trial (SBT) and to compare variables in subjects who failed or passed the SBT. This was a prospective observational study in tracheostomized children with long-term mechanical ventilation admitted to the Hospital Josefina Martinez, Santiago, Chile, between 2014-2020. Cardiorespiratory variables such as breathing pattern, use of accessory respiratory muscles, heart rate, breathing frequency, and oxygen saturation were registered at baseline and throughout a 2-h SBT with or without positive pressure depending on an SBT protocol. Comparison of demographic and ventilatory variables between groups (SBT failure and success) was performed. A total of 48 subjects were analyzed (median [IQR] age of 20.5 [17.0-35.0] months, 60% male). Chronic lung disease was the primary diagnosis in 60% of subjects. Eleven (23%) total subjects failed the SBT (< 2 h), with an average failure time of 69 ± 29 min. Subjects who failed the SBT had a significantly higher breathing frequency, heart rate, and end-tidal CO2 than subjects who succeeded (P < .001). In addition, subjects who failed the SBT had significantly shorter duration of mechanical ventilation before the SBT, higher proportion unassisted SBT, and higher rate of deviation SBT protocol in comparison with subjects who succeeded. Conducting an SBT to evaluate the tolerance and cardiorespiratory response in tracheostomized children with long-term mechanical ventilation is feasible. Time on mechanical ventilation before the first attempt and type of SBT (with or without positive pressure) could be associated with SBT failure.

Children who use invasive long-term mechanical ventilation (LTMV) are a rare, clinically heterogenous population with relatively high hospitalization rates, most commonly for acute respiratory infection (ARI). We sought to describe patterns of ARI-related utilization and mortality in pediatric patients with LTMV, evaluating the association of a pre-existing neurologic diagnoses with outcomes. We studied a longitudinal retrospective cohort across 40 U.S. children's hospital emergency department (ED) and hospital encounters for patients (< 21 years) with LTMV and an ARI diagnosis code (10/1/2016-6/30/2023). We examined mortality and ED/hospital utilization outcomes, defining short-stay hospitalizations as ≤ 2 calendar days. We stratified analyses by high intensity neurologic impairment (HINI) using a validated coding algorithm. We included 4866 patients (median age 4.5 years; 58.6% male) with LTMV and ≥ 1 ARI encounter. Most (95.1%) were hospitalized on their index encounter, and among those most received intensive care (71.7%). 4.1% died during the index hospitalization (5.3% with HINI vs. 1.3% without HINI, p < 0.001). Median hospital length of stay was 6 days (interquartile range 3-12). Short stay hospitalizations occurred in 16.9% overall but were as high as 26.6% in children without HINI. ED return visits within 1 year occurred in 60.7%; ARI was the most common reason (40.1%). Pediatric patients using LTMV presenting for ED care with ARI are almost always hospitalized, usually in an intensive care setting. Overall, outcomes were poorer for those with HINI than those without HINI. More precision is needed to align resources with illness severity and comorbidities to improve ARI outcomes.

We sought to characterize ALS patients who opt for tracheostomy and long-term mechanical ventilation (LTMV) and compare them with respect to medical, psychiatric, and psychosocial measures to patients who declined tracheostomy and died. We studied 72 ALS patients who were identified as hospice-eligible. They were assessed monthly until the endpoint of death or tracheostomy. LTMV patients continued to be followed for up to 55 months. The spouse or other caregiver was similarly interviewed and followed. Medical and psychiatric evaluations were conducted, in addition to self-reported depressive symptoms, future orientation, attitudes about hastened death, religious beliefs, and quality of life. Global cognitive capacity was assessed by caregivers. Fourteen patients chose LTMV; 58 died without LTMV. At study entry, those who later chose LTMV were younger, more had young children, had more education, and higher household incomes on average. Although their physical conditions were similar, they reported higher levels of optimism including belief in imminent cure, and more positive appraisals of their ability to function in daily life, their physical health and overall life satisfaction. At study entry, none who later chose LTMV were clinically depressed, compared to 26% of those who later refused LTMV, and their mean scores on the Beck Depression Inventory were in the "not depressed" range while the mean for patients who later died was in the "probable depression" range. Fourteen percent of patients who later chose LTMV were reported by caregivers to have had at least mild cognitive problems, compared to 49% of those who later died. After an average of 33 months on LTMV, only about half retained high levels of optimism and enjoyment of daily life, independent of residence (home vs. facility). Two patients expressed interest in hastening death but none had asked to terminate ventilation despite disease progression. However, half identified future circumstances that would render life intolerable. At last contact with caregivers, only one LTMV patient was reported to have major cognitive impairment. While reporting substantial emotional burden after LTMV, most but not all spousal caregivers continued to express satisfaction with care-giving. Our findings suggest that the choice of LTMV was not about desperation (although it may involve unrealistic expectations of cure by some), ignorance, or inability to make wishes clear during a chaotic dying period. Rather, LTMV choice was consistent with a sustained sense that life was worth living in any way possible, at least for some time and within certain boundaries. ALS clinicians will need to recognize this motivation and provide appropriate clinical education to both patient and family.

BackgroundChildren with chronic respiratory failure and/or sleep disordered breathing due to a broad range of diseases may require long-term ventilation to be managed at home. Advances in the use of long-term non-invasive ventilation has progressively leaded to a reduction of the need for invasive mechanical ventilation through tracheostomy. In this study, we sought to characterize a cohort of children using long-term NIV and IMV and to perform an analysis of those children who showed significant changes in ventilatory support management.MethodsWe performed a retrospective cohort study of pediatric (within 18 years old) patients using long-term, NIV and IMV, hospitalized in our center between January 1, 2000 and December 31, 2017. A total of 432 children were included in the study. Long Term Ventilation (LTV) was defined as IMV or NIV, performed on a daily basis, at least 6 h/day, for a period of at least 3 months.Results315 (72.9%) received non-invasive ventilation (NIV); 117 (27.1%) received invasive mechanical ventilation (IMV). Children suffered mainly from neuromuscular (30.6%), upper airway (24.8%) and central nervous system diseases (22.7%). Children on IMV were significantly younger when they start LTV [NIV: 6.4 (1.2–12.8) years vs IMV 2.1 (0.8–7.8) years] (p < 0.001)]. IMV was likely associated with younger age at starting ventilatory support (aOR 0.9428; p = 0.0220), and being a child with home health care (aOR 11.4; p < 0.0001). Overtime 39 children improved (9%), 11 children on NIV (3.5%) received tracheostomy; 62 children died (14.3%); and 74 children (17.1%) were lost to follow-up (17.8% on NIV, 15.4% on IMV).ConclusionsChildren on LTV suffered mainly from neuromuscular, upper airways, and central nervous system diseases. Children invasively ventilated usually started support younger and were more severely ills.

<b>Introduction:</b> Amyotrophic lateral sclerosis (ALS) is a degenerative disease of motor neurons resulting in progressive weakness of striated muscles. Respiratory failure is the most common cause of death. <b>Aims and objectives:</b> To present outcomes and perspectives of long term mechanical ventilation (LTMV) in ALS patients. <b>Methods:</b> Data are based on a national register for the period 2002-2014. All units starting treatment were included. Prevalence and survival of ALS with LTMV was assessed using log rank test and cox regression analysis. Steady-state of patient population was estimated based on current incidence and survival rates. <b>Results:</b> A total of 316 ALS patients were treated with LTMV, 75% with non-invasive ventilation (NIV) and 25% with tracheostomy, representing a 5 fold increase since 2002. More men (70%) than women (30%) with ALS used LTMV (p&lt;0.05). Median (25/75 percentiles) survival was 15.4 months (5.9/30.2) months with NIV and 74.8 months (44.1/112.8) months with tracheostomy or NIV/tracheostomy. Survival time decreased with age, whereas gender had no significant impact on survival. Based on measured incidence and survival rates, the number of ALS cases with LTMV in Norway is expected to remain at current levels. <b>Conclusions:</b> Median life expectancy of ALS patients on LTMV, in particular with tracheostomy, was higher than shown in previous studies and without significant gender differences. The number of ALS patients with LTMV will probably stabilize close to the 2014 level.

To examine changes and explanatory variables for changes in health-related quality of life in patients treated with long-term mechanical ventilation over a 6-year period. Long-term mechanical ventilation is a treatment for individuals with chronic hypercapnic respiratory failure, primarily caused by neuromuscular diseases, obesity hypoventilation syndrome, chronic obstructive pulmonary and restrictive thoracic diseases. Studies on long-term outcome on health-related quality of life and factors influencing it are lacking. Prospective cohort study. Data were collected from the Norwegian Long-Term-Mechanical-Ventilation Registry and from patient-reported questionnaire in 2008 and 2014. Health-related quality of life was measured by the Severe Respiratory Insufficiency questionnaire, containing 49 items and seven subdomains. Linear mixed effects models were used to measure changes and identify factors for changes. After 6years, 60 patients were still participating, out of 127 at baseline. Health-related quality of life improved significantly in the total score and in four subdomains of the questionnaire. Satisfaction with training in long-term mechanical ventilation was an explanatory variable for improved 'psychological well-being' and follow-up for improvement of 'anxiety'. Side effects of the treatment like facial soreness were associated with the total score. High age and high forced vital capacity were related to lower 'physical function' and improved 'social functioning', respectively. Long-term mechanical ventilation over 6years improved health-related quality of life in most patients. Patient training, follow-up and reduction of side effects, largely delivered by trained nurses, contribute to achieve the main goal of the treatment-improved health-related quality of life.

Preface. Foreword. Chronic Respiratory Failure. Principles of Positive Pressure Mechanical Ventilatory Support. Chronic Respiratory Failure As A Global Issue. The difficult to wean patient in the ICU setting. Causes of difficult weaning: Which mechanisms are associated with long-term ventilator dependence? Size of the Problem, What Constitutes Prolonged Mechanical Ventilation, Natural History, Epidemiology. Weaning protocols - including NIV. Weaning Units - The U.S. Perspective. Weaning in a Specialized Facility. Rehabilitation in the intensive care unit. Organization Of Rehabilitaiton In The ICU. Indications and Physiological Basis of Rehabilitation in the ICU. Peripheral and respiratory muscle training. Innovative Approaches in Muscle Training: Transcutaneous Electrical Muscle Stimulation. Psychological Aspects and Interventions in Patients with Chronic Respiratory Failure. Chronic Ventilatory Assistance In the hospital (non ICU). Definition and indications. Clinical Settings For Ventilator-Assisted Individuals - When And Why - LTAC-SNF-CAVC. The Multidisciplinary Team-Training and Experience. Clinical Experience in CAVC Unit. Long term mechanical ventilation in the community. Indications, Definitions, Guidelines and Outcomes in Restriction and Obstruction. Choice of Devices, Ventilators, Interfaces and Monitors. Training the Home Health Team. Sending the Ventilated Patient Home. Health-related Quality of Life. Mechanical Ventilation-Legal and Ethical Issues. Special Considerations. Pharmacological Treatment for Patients with Chronic Respiratory Failure. Patient-Ventilator Interfaces for Invasive and Noninvasive Ventilation. Tracheostomy Weaning from Longer Term Ventilation. Communication Alternatives. Diaphragmatic Pacing in Chronic Respiratory Failure. Secretion Management. The Importance of Overnight Monitoring in the Management of Chronic Respiratory Failure. Management of Respiratory Infections. Nutrition in the ICU. Skin Integrity, Bowel and Bladder Care. Palliative Care For The Ventilator Patient End Of Life Issues And Approaches. Chronic Respiratory Failure in Different Patient Groups (Elective or Post ICU). Management of Chronic Respiratory Failure and obesity. Progressive Neuromuscular and Degenerative Diseases. Chronic Ventilatory Support in Obstructive Lung Disease. Ventilation Among the Pediatric Population. Perspectives on Long Term Ventilation. The Perspective of Patients. The Perspective of Family Caregivers. The Perspective of Physicians (Intensive Care Specialist - Respiratory Specialist - Family Physician). Perspective of the Allied Health Professionals. Worlwide Approaches to Long Term Ventilation. The North American Perspective on Long-Term Mechanical Ventilation. The European Perspective. The South American Perspective. Long-Term Ventilation in Japan.

BackgroundThe Severe Respiratory Insufficiency (SRI) questionnaire is a specific measure of health-related quality of life (HRQoL) in patients treated with long-term mechanical ventilation (LTMV). The aim of the present study was to examine whether SRI sum scores and related subscales are associated with mortality in LTMV patients.MethodsThe study included 112 LTMV patients (non-invasive and invasive) from the Norwegian LTMV registry in Western Norway from 2008 with follow-up in August 2014. SRI data were obtained through a postal questionnaire, whereas mortality data were obtained from the Norwegian Cause of Death Registry. The SRI questionnaire contains 49 items and seven subscales added into a summary score (range 0–100) with higher scores indicating a better HRQoL. The association between the SRI score and mortality was estimated as hazard ratios (HRs) with 95% confidence intervals (95% CI) using Cox regression models and HRs were estimated per one unit change in the SRI score.ResultsOf the 112 participating patients in 2008, 52 (46%) had died by August 2014. The mortality rate was the highest in patients with chronic obstructive pulmonary disease (75%), followed by patients with neuromuscular disease (46%), obesity hypoventilation syndrome (31%) and chest wall disease (25%) (p < 0.001). Higher SRI sum scores in 2008 were associated with a lower mortality risk after adjustment for age, education, hours a day on LTMV, time since initiation of LTMV, disease category and comorbidity (HR 0.98, 95% CI: 0.96–0.99). In addition, SRI-Physical Functioning (HR 0.98, 95% CI: 0.96–0.99), SRI-Psychological Well-Being (HR 0.98, 95% CI: 0.97–0.99), and SRI-Social Functioning (HR 0.98, 95% CI: 0.97–0.99) remained significant risk factors for mortality after covariate adjustment. In the subgroup analyses of patient with neuromuscular diseases we found significant inverse associations between some of the SRI subscales and mortality.ConclusionsSRI score is associated with mortality in LTMV-treated patients. We propose the use of SRI in the daily clinic with repeated measurements as part of individual follow-up. Randomized clinical trials with interventions aimed to improve HRQoL in LTMV patients should consider the SRI questionnaire as the standard HRQoL measurement.

Long-Term Mechanical Ventilation: Recommendations of the Swiss Society of Pulmonology