Home Ventilation Research Articles

Monitoring Systems in Home Ventilation.

Non-invasive ventilation (NIV) is commonly used at home for patient with nocturnal hypoventilation caused by a chronic respiratory failure. Monitoring NIV is required to optimize the ventilator settings when the lung condition changes over time, and to detect common problems such as unintentional leaks, upper airway obstructions, and patient-ventilator asynchronies. This review describes the accuracy and limitations of the data recorded by the ventilator. To efficiently interpret this huge amount of data, clinician assess the daily use and regularity of NIV utilization, the unintentional leaks and their repartition along the NIV session, the apnea-hypopnea index and the flow waveform, and the patient-ventilator synchrony. Nocturnal recordings of gas exchanges are also required to detect nocturnal alveolar hypoventilation. This review describes the indication, validity criteria, and interpretation of nocturnal oximetry and transcutaneous capnography. Polygraphy and polysomnography are indicated in specific cases to characterize upper airway obstruction. Telemonitoring of the ventilator is a useful tool that should be integrated in the monitoring strategy. The technical solution, information, and limitations are discussed. In conclusion, a basic monitoring package is recommended for all patients complemented by advanced monitoring for specific cases.

Characteristics and Outcomes of Patients Discharged Directly Home From the Pediatric Intensive Care Unit.

Introduction: Patients admitted to the pediatric intensive care unit (PICU) typically transfer to an acute care floor prior to discharge (ACD). Various circumstances, including rapid clinical improvement, technology dependence, or capacity constraints, may lead to discharge directly to home from a PICU (DDH). This practice has been studied in adult intensive care units, but research is lacking for PICU patients. Methods: We aimed to describe characteristics and outcomes of patients requiring PICU admission who experienced DDH versus ACD. We conducted a retrospective cohort study of patients ≤18 years old admitted to our academic, tertiary care PICU between 1/1/15 and 12/31/20. Patients who died or were transferred to another facility were excluded. Baseline characteristics (including home ventilator dependence) and markers of illness severity, specifically the need for vasoactive infusion or new mechanical ventilation, were compared between groups. Admission diagnoses were categorized using the Pediatric Clinical Classification System (PECCS). Our primary outcome was hospital readmission within 30 days. Results: Of 4042 PICU admissions during the study period, 768 (19%) were DDH. Baseline demographic characteristics were similar, although DDH patients were more likely to have a tracheostomy (30% vs 5%, P < .01) and require a home ventilator at discharge (24% vs 1%, P < .01). DDH was associated with being less likely to have required a vasoactive infusion (7% vs 11%, P < .01), shorter median length of stay (LOS) (2.1 days vs 5.9 days, P < .01) and increased rate of readmission within 30 days of discharge (17% vs 14%, P < .05). However, repeat analysis after removing ventilator-dependent patients at discharge (n = 202) showed no difference in rates of readmission (14% vs 14%, P = .88). Conclusions: Direct discharge home from the PICU is a common practice. DDH and ACD groups had similar 30-day readmission rate when patient admissions with home ventilator dependence were excluded.

Is hypoalbuminemia a predictor for mortality in Tracheostomized patients transferred from intensive care unit to palliative service?

Objective: Tracheostomy is a bedside surgical procedure that is frequently performed in intensive care units. It allows patients who need a long-term mechanical ventilator to be transferred from intensive care through a home-type mechanical ventilator. In this study, we aimed to evaluate the relationship between serum albumin levels before hospitalization and discharge or before exitus and mortality in patients who were transferred to the palliative care service with a home type mechanical ventilator by opening a tracheostomy in the intensive care unit. Material-Method: 110 patients with tracheostomy and home ventilator who were transferred from the intensive care unit to the palliative care service between 01/05/2018-11/05/2021 were analyzed retrospectively. Patients' age, gender, diagnosis of hospitalization (chronic obstructive pulmonary disease (COPD) / malignancy), presence of comorbidity, number of days of tracheostomy (on which day the tracheostomy was opened in the intensive care unit admission), Glasgow Coma Scale (GCS) and intensive care severity scores (Acute Physiology and Chronic Health Evaluation Score (APACHE II), Sequential Organ Failure Assessment (SOFA), hospitalization serum albumin (g/dl) values, and recent serum albumin values of those who had exitus or discharge before discharge or exitus were examined retrospectively. Results: The study's results showed that the 28-day mortality relation with old age is statistically significant. There is a statistically significant relationship between the high SOFA score at admission to the intensive care unit and 28-day mortality. There is no statistically significant difference between gender, presence of comorbidity in patients with COPD and malignancy hospitalization, GCS, APACHE II showing intensive care severity score, number of days of tracheostomy and 28-day mortality. There is a statistically significant difference between the intensive care hospitalization serum albumin value and the low serum albumin values before discharge/decease and the mortality rate of 28 days. Conclusion: In the analysis of this study, it was observed that old age and high SOFA score increased 28-day mortality in tracheostomized patients transferred to the palliative service in the intensive care unit. In addition, the low level of albumin values in intensive care hospitalization and before discharge/death also increases mortality.

Going home: Clinician perspectives on decision-making in paediatric home mechanical ventilation.

Despite a recent increase in the use of ventilators in the home setting for children with chronic respiratory failure, there is currently no unified approach for clinical decision-making for children requiring long-term mechanical ventilation. The purpose of this study is to understand the clinician's perspective on decision-making around home ventilation for children, and how home-based care contributes to successful outcomes in this population. We recruited physicians and home ventilation nurses with at least 2 years' experience working in an Australian paediatric tertiary home ventilation service using professional networks and snowball sampling. Semi-structured interviews were conducted by two researchers between February 2019 and June 2020. Interviews were audio-recorded, transcribed, and analysed using inductive content analysis. Twenty-five individuals participated (17 physicians and 8 home ventilation nurses). Participants viewed themselves as impartial medical advocates in the decision-making process, believing the decision to initiate or cease ventilation belonged to the child's family. While participants held the child's quality of life as the cornerstone of decision-making, quality of life was subjective and family specific. These findings provide insight into how clinicians working with children with chronic respiratory insufficiency approach the decision to introduce home-based ventilation. By understanding their role, strategies can be developed to assist them, leading to better outcomes for patients and families. Further research is needed to compare the perspectives of clinicians with the experience of ventilator-assisted children and families in Australia.

"What Would Give Her the Best Life?": Understanding Why Families Decline Pediatric Home Ventilation.

Background: Families who must decide about pediatric home ventilation rely on the clinicians who counsel them for guidance. Most studies about pediatric home ventilation decisions focus on families who opt for this intervention, leaving much unknown about the families who decline. Objective: To describe the rationales of families who decline home ventilation. Design: Semi-structured interview study. Setting/Subjects: We interviewed 16 families in hospitals across 3 U.S. states, identified by their clinicians as previously deciding to not pursue home ventilation via tracheostomy within the past five years. Measurements: Targeted content and narrative analyses were used to understand family intentions and reasons for declining. Results: The clinical and social context varied among the 16 families in this study. Families' intentions in saying "no" fell into two categories: (1) definitive "No": Families who stood firm on in their decision and (2) contingent "No": Families who may consider this in the future. Families described four reasons why their child did not receive home ventilation: (1) concern about medical impacts, (2) concern about physical and/or communication restrictions, (3) concern that there would be no clear health benefit, and (4) concern about no clear meaningful life. Most families mentioned all four reasons, but concern about no clear meaningful life predominated. Conclusions: Though these families did not see home ventilation as an appropriate option, each reported a complex interplay of intentions behind and reasons for declining. Clinicians who counsel families about home ventilation could share the reasons that families commonly decline this intervention to facilitate a balanced discussion.

Pulmonary care for ALS: Progress, gaps, and paths forward.

Adults with amyotrophic lateral sclerosis (ALS) have been using home mechanical ventilation for over 50 years. More recently, home respiratory care has evolved to include portable home ventilators, airway clearance devices, and physiological assessments with telemonitoring capability. National organizations currently offer incentives for providing a pulmonary care specialist within a multidisciplinary ALS clinic; however, several critical gaps exist between the available technology and employing a clinician with the necessary expertise. Lack of formal training and poor financial incentives have led to a paucity of both clinicians and active clinical research engaging in the home respiratory care of ALS. Criteria for noninvasive ventilation (NIV) initiation are controversial, and few guidelines exist on the ideal subsequent adjustments of NIV with evolving disease. Consequently, many patients with ALS tolerate NIV poorly and must face the harrowing decision of hospice vs tracheostomy. Advancement of respiratory care in ALS has been hindered by critical gaps in pulmonologist availability, training in chronic respiratory failure, financial support, clinical research, and clarity on ventilation management beyond initiation. Only a multifaceted approach will suffice for addressing the voids in ALS respiratory care, including various education initiatives, financial incentives, clinical research programs, and elevating the standard of respiratory care.

Analysis of individual differences in tidal volume in different home ventilators

Analysis of individual differences in tidal volume in different home ventilators

Retraction of: P093 Chronic Obstructive Pulmonary Disease - Obstructive Sleep Apnoea Overlap Syndrome - Prevalence in a Home ventilation service.

[This retracts the article DOI: 10.1093/sleepadvances/zpac029.163.].

Testing the Properties of Radon Barrier Materials and Home Ventilation to Mitigate Indoor Radon

Indoor radon is the second cause of lung cancer. Mitigation strategies are based on (i) building protection with radon barrier materials, (ii) increasing home ventilation or (iii) room pressurization. A scale model room created with a porous ignimbrite rich in radon precursors was used as an analogue to test the indoor radon reduction ability of various radon barrier materials in a real room. The properties of these materials were tested with and without room pressurization by introducing outdoor air at different flow rates. The best materials reduced indoor radon up to 80% and, when the highest pressurization was applied, to 93%.

Transition from intensive care unit to a portable ventilatorin children with severe bronchopulmonary dysplasia.

As the population of ventilator-dependent children (VDC) with tracheostomies due to underlying severe bronchopulmonary dysplasia grows, there is an increasing need to shift the care of these children from hospital to home. Transitioning the ventilator-dependent child from the hospital to home is a complex process that requires coordination between the medical team and the family. One crucial step in the process is transitioning from an Intensive care unit (ICU) ventilator to a portable home ventilator (PHV). The Clinical team needs to understand the nuances in transitioning to PHV, including assessing readiness to transition and choosing the optimum settings on an available home ventilator. In recent years, various ventilator modes have been available in PHV that can help achieve synchronous breathing to allow for adequate gas exchange for the infant. This review details some approaches to asses readiness to transition and the process of Transition along with commonly used modes of support available in PHV, as well as the primary and secondary settings in which we should be mindful in supporting a child with chronic respiratory failure in the home setting.

Determinant of ARI Incident in Toddlers in The Working Area of Tomia Health Center Wakatobi Regency

Infections in the upper respiratory tract are the cause of under-five mortality and are also a crucial health problem in Indonesia, the main cause in the Tomia Health Center area which every year has increased, namely in 2018 the prevalence of toddler ARI cases by 9,4%, in 2019 by 12,8% while in 2020 increased to 17,0%. The motivation behind the review is to discover the determinant of ARI events in toddlers in the Working Area of Tomia Health Center Wakatobi Regency. This kind of examination is an insightful study with a Cross-Sectional Study plan. The review populace was all moms who had toddlers in the Tomia Health Center Work Area as numerous as 705 people with a sample number of 88 toddlers taken proportionally random sampling. The analysis method uses the Chi-Square test. The results of the study with Chi-Square test showed that the ventilation variables of the house obtained values (X2calculated= 27.381 and = 0.581), occupancy density (X2count= 27.929 and = 0.586) air pollution in the house (X2count= 22,863 and = 0.533) and floor type (X2count= 19.939 and = 0.499). The conclusion pf this study that there is a relationship between home ventilation, occupancy density, air contamination in the house and the kind of floor with the rate of ARI in toddlers in the Tomia Health Center Work Area. It is recommended to the Tomia Health Center to further improve counselling related to the importance of a health-qualified home environment.

HUBUNGAN KONDISI RUMAH DENGAN KEJADIAN TUBERKULOSIS PARU

Dense housing conditions make it possible to spread germs from one human to another. Pulmonary tuberculosis is an infectious disease caused by Mycobacterium tuberculosis. Mycobacterial is transmitted through droplets in the air a person with pulmonary tuberculosis is the cause of pulmonary tuberculosis infection in the population. This study aims to determine the relationship between occupant density and ventilation conditions of the house with the incidence of pulmonary tuberculosis in Maros South Sulawesi. The type of research used is quantitative research with a descriptive survey design. The total sample of 33 home patients with positive pulmonary tuberculosis was determined by purposive sampling. The results showed a correlation between the occupant density of residents and home ventilation conditions with the incidence of pulmonary tuberculosis. Advice for family and community housing should have enough space especially for people with pulmonary tuberculosis that room made specifically to reduce the risk of transmission to residents sharing. House window to be created and placed in a way that ensures the sunlight can get into the main house in the morning because the sun can be deadly Mycobacterium tuberculosis.

Improved indoor air quality during desert dust storms: The impact of the MEDEA exposure-reduction strategies

Desert dust storms (DDS) are natural events that impact not only populations close to the emission sources but also populations many kilometers away. Countries located across the main dust sources, including countries in the Eastern Mediterranean, are highly affected by DDS. In addition, climate change is expanding arid areas exacerbating DDS events. Currently, there are no intervention measures with proven, quantified exposure reduction to desert dust particles. As part of the wider “MEDEA” project, co-funded by LIFE 2016 Programme, we examined the effectiveness of an indoor exposure-reduction intervention (i.e., decrease home ventilation during DDS events and continuous use of air purifier during DDS and non-DDS days) across homes and/or classrooms of schoolchildren with asthma and adults with atrial fibrillation in Cyprus and Crete-Greece. Participants were randomized to a control or intervention groups, including an indoor intervention group with exposure reduction measures and the use of air purifiers. Particle sampling, PM10 and PM2.5, was conducted in participants' homes and/or classrooms, between 2019 and 2022, during DDS-free weeks and during DDS days for as long as the event lasted. In indoor and outdoor PM10 and PM2.5 samples, mass and content in main and trace elements was determined. Indoor PM2.5 and PM10 mass concentrations, adjusting for premise type and dust conditions, were significantly lower in the indoor intervention group compared to the control group (PM2.5-intervention/PM2.5-control = 0.57, 95% CI: 0.47, 0.70; PM10-intervention/PM10-control = 0.59, 95% CI: 0.49, 0.71). In addition, the PM2.5 and PM10 particles of outdoor origin were significantly lower in the intervention vs. the control group (PM2.5 infiltration intervention-to-control ratio: 0.49, 95% CI: 0.42, 0.58; PM10 infiltration intervention-to-control ratio: 0.68, 95% CI: 0.52, 0.89). Our findings suggest that the use of air purifiers alongside decreased ventilation measures is an effective protective measure that reduces significantly indoor exposure to particles during DDS and non-DDS in high-risk population groups.

699: PERIOPERATIVE MANAGEMENT AND OUTCOMES FOR HOME-VENTILATED CHILDREN UNDERGOING SURGERY

Introduction: Advances in medicine and technology have led to increased survival of children with home ventilation-dependence and chronic respiratory failure (CRF). These patients often have underlying conditions or cumulative morbidities that require surgery. There are currently no studies on the perioperative care of these patients. Methods: We conducted a retrospective cohort study of patients who underwent non-cardiac surgery at Boston Children’s Hospital from January 1, 2013 to December 31, 2019. Inclusion criteria were: (1) Diagnosis of CRF based on ICD-9/ICD-10 codes, (2) Use of home ventilation at the time of procedure. Fisher exact and Wilcoxon rank sum tests were used to examine associations between the type of respiratory support and perioperative outcomes. Results: We identified 416 patients who underwent 1623 surgeries. 56% (n = 235) were male, 59% (n = 245) had an underlying neuromuscular/neurologic condition, 20% (n = 84) had chronic lung disease, and 18% (n = 74) had congenital anomalies. At the time of surgery, 51% (n = 820) required trach-vent and 49% (n = 803) were on BiPAP. BiPAP-dependent patients were more likely to be only nocturnally vented (95% vs 45%, p < 0.001), older (median age 10.8 vs 5.5 years, p < 0.001), and less complex according to ASA status. General anesthesia was used in 93% (n = 1509) cases. Post-operatively, trach-vented patients were more likely to be admitted to the ICU (n = 627, 76%) compared to those BPAP-dependent (n = 405, 50% **stats?) and had longer ICU length of stay (median 5 vs 2 days, p < 0.001). 30-day mortality was < 1% (n = 6). 30-day readmission rate was 12%, higher in trach-vented patients (n = 122 vs n = 71, p = < 0.001). Conclusions: Home-ventilated patients presenting to surgery who are trach-vented represent a different population from those who are BPAP-dependent. Patients who require trans-tracheal ventilation appear to be more complex and it is unsurprising that they are more likely to be admitted to the ICU following surgery with a longer ICU stay. While overall mortality for these patients is quite low, reasons for frequent readmission require further study to align actual needs and services to optimize resource utilization and outcomes.

Hyperinflation and its association with successful transition to home ventilator devices in infants with chronic respiratory failure and severe bronchopulmonary dysplasia.

To estimate the association between lung hyperinflation and the time to successful transition to home ventilators in infants with sBPD and chronic respiratory failure. Infants with sBPD <32 weeks' gestation who received tracheostomies were identified. Hyperinflation was the main exposure. Time from tracheostomy to successful transition to the home ventilator was the main outcome. Kaplan-Meier and multivariable Cox proportional hazards were used to estimate the relationships between hyperinflation and the main outcome. Sixty-two infants were included; 26 (42%) were hyperinflated. Eleven died before transition, and 51 successfully transitioned. Hyperinflation was associated with both mortality (31% vs 8.3%, p = 0.02) and an increased duration (72 vs. 56 days) to successful transition (hazard ratio (HR) = 0.38, 95% CI: 0.19, 0.76, p = 0.006). Growth velocity was similar after tracheostomy placement. In infants with chronic respiratory failure and sBPD <32 weeks' gestation, hyperinflation is related to mortality and inpatient morbidities.

Mechanical insufflation-exsufflation for invasively ventilated critically ill patients-A focus group study.

Mechanical Insufflation-Exsufflation (MI-E) is used as an airway clearance intervention in primary care (home ventilation), long-term care (prolonged rehabilitation after intensive care, neuromuscular diseases, and spinal cord injury), and increasingly in acute care in intensive care units (ICU). We sought to develop in-depth understanding of factors influencing decision-making processes of health care professionals regarding initiation, escalation, de-escalation, and discontinuation of MI-E for invasively ventilated patients including perceived barriers and facilitators to use. We conducted focus groups (3 in the Netherlands; 1 with participants from four European countries) with clinicians representing the ICU interprofessional team and with variable experience of MI-E. The semi-structured interview guide was informed by the Theoretical Domains Framework (TDF). Two researchers independently coded data for directed content analysis using codes developed from the TDF. A purposive sample of 35 health care professionals participated. Experience varied from infrequent to several years of frequent MI-E use in different patient populations. We identified four main themes: (1) knowledge; (2) beliefs; (3) clinical decision-making; and (4) future adoption. Interprofessional knowledge and expertise of MI-E in invasively ventilated patients is limited due to minimal available evidence and adoption. Participants believed MI-E a potentially useful intervention for airway clearance and inclusion in weaning protocols when more evidence is available. This focus group study provides an overview of current practice, knowledge and expertise, and barriers and facilitators to using MI-E in mechanically ventilated patients. From these data, it is evident there is a need to develop further clinical expertise and evidence of efficacy to further understand the role of MI-E as an airway clearance technique for ventilated patients.

Outcomes of infants with severe bronchopulmonary dysplasia who received tracheostomy and home ventilation.

To describe the survival rate, timing of liberation from the ventilator, and factors favorable for decannulation among infants with severe bronchopulmonary dysplasia (sBPD) who received tracheostomy. Demographics and clinical outcomes were obtained through retrospective chart review of 98 infants with sBPD who were born between 2004 and 2017, received tracheostomy at <1 year of age, and were followed in the Infant Tracheostomy and Home Ventilator clinic up to 4 years of age. The number of infants with sBPD who received tracheostomy increased significantly over the study period. The median age at tracheostomy was 4 months (IQR 3, 5) or 43 weeks corrected gestational age; the median age at NICU discharge was 7 months (IQR 6, 9). At 48 months of age, all subjects had been liberated from the ventilator, at a median age of 24 months (IQR 18, 29); 52% had been decannulated with a median age at decannulation of 32 months (IQR 26, 39). Only 1 (1%) infant died. Multivariate logistic regression showed infants who were White, liberated from the ventilator by 24 months of age and have public insurance had significantly greater odds of being decannulated by 48 months of age. Tracheobronchomalacia was associated with decreased odds of decannulation. Infants with sBPD who received tracheostomy had an excellent survival rate. Liberation from home ventilation and decannulation are likely to occur by 4 years of age.

Disaster Evacuation for Home-Based Patients with Special Healthcare Needs: A Cross-Sectional Study.

Recent super-typhoons and torrential rains triggered by global warming have had disproportionately large effects on medically vulnerable people in Japan. This study aimed to identify factors associated with intention to evacuate to the nearest public shelter among family caregivers of pediatric patients receiving home medical care. The study included family caregivers of these patients from the Department of Pediatrics, Fukuoka University Hospital, Japan, including family caregivers of young adults with special healthcare needs. An original questionnaire was prepared drawing on previous studies and used for an interview survey. Overall, 57 individuals provided valid data and were included in the analysis. Factors associated with evacuation intention were non-use of a home ventilator (odds ratio [OR] 3.99, 95% confidence interval [CI]: 1.13-14.03) and not having made arrangements to use a non-public shelter (OR 7.29 95% CI: 1.62-32.88). This means that those who use mechanical ventilation or have secured alternative places to go if they need to evacuate their homes may not use the nearest public shelter in a disaster. We recommend that policy makers consider the use of mechanical ventilation and the availability of non-public shelters as predictors of evacuation behavior when considering disaster preparedness for these patients.

Retracted: P093 Chronic Obstructive Pulmonary Disease – Obstructive Sleep Apnoea Overlap Syndrome – Prevalence in a Home ventilation service

Abstract This article has been retracted. Please see: https://doi.org/10.1093/sleepadvances/zpad008

Impact of the MEDEA exposure-reduction strategies on indoor air quality during desert dust storms

Abstract Background Desert dust storms (DDS) impact the Mediterranean basin heavily, particularly in the context of climate change, reduced precipitation and increasing desertification. There is a pressing need to develop policies protecting EU citizens’ health from DDS. While Public Health authorities in affected regions commonly issue warnings, the effectiveness of recommendations to reduce exposure has not been documented. Methods This work is part of the wider “MEDEA” intervention studies, co-funded by LIFE 2016 Programme. Among other outcomes, the studies examined the effectiveness of an indoor exposure-reduction intervention (i.e., decrease home ventilation and use of air cleaners) across homes of asthmatic schoolchildren and individuals with atrial fibrillation in Cyprus. Participants were randomized to either a control or indoor intervention group. The assessment took place in a sample of participants’ homes, during 2019 and 2021, with the collection of indoor and outdoor PM10 and PM2.5 samples, which were analyzed for mass and elemental concentrations. Results Indoor PM2.5 and PM10 mass and elements concentrations were significantly lower in the indoor intervention group compared to the control group, both during days with no dust (e.g., 55% and 48% reduction for PM2.5 and PM10, respectively) and days with desert dust (PM2.5: 47% and PM10: 40% reduction). In addition, the infiltration of PM2.5 and PM10 particles from the outdoor to the indoor air was significantly lower in the intervention vs. the control group (PM2.5: -55%, 95% CI: -42%, -65%; PM10: -41%, 95% CI: -61%, -12%). Conclusions The study assessed a realistic exposure-reduction strategy and provided first-time evidence that closing doors and windows along with air cleaners can reduce indoor exposure to DDS particles. This evidence can further inform decision-making and strategic planning for population-level mitigation of DDS health effects in Mediterranean Europe. Key messages