Long-term Ventilatory Support Research Articles

Catastrophic Complications Following Spinal Deformity Surgery in a Patient with Myotonic Dystrophy

Myotonic dystrophy (MD) is a genetic disorder that causes progressive muscle weakness and atrophy, often leading to spinal deformities and decreased quality of life. While the surgical correction of spinal deformities is not absolutely contraindicated in MD patients, a comprehensive pre-anesthetic evaluation is crucial, particularly considering cardiovascular and respiratory health. We present a case of a 50-year-old woman with MD who underwent spinal deformity surgery to correct kyphosis and alleviate severe back pain. Despite the absence of significant events during surgery and preoperative risk factors, the patient experienced postoperative respiratory failure, hypotension, aggravated weakness, and mental deterioration in the intensive care unit. The patient received long-term ventilator support during hospitalization for respiratory muscle weakness. She demonstrated significant improvements in strength, mobility, and respiratory function with multidisciplinary support and rehabilitation, achieving functional independence within 6 months postoperatively. The authors discuss the possible etiological mechanisms underlying these complications and highlight the need for preoperative evaluations and multidisciplinary care for patients with MD.

Long-term sleep apnea CPAP via tracheostomy in children with tracheomalacia: 20-year experience.

Children with severe tracheobronchomalacia may need placements of tracheostomies and long-term mechanical ventilation. Due to financial constraints, continuous positive airway pressure (CPAP) machines commonly used to treat obstructive sleep apnea in adults have been utilized to deliver positive distending pressure to such children at our institution for more than 20 years with favorable outcomes. We, therefore, reported our experience with 15 children using this machine. This is a retrospective study during 2001-2021. Fifteen children, 9 boys, aged ranged 3 months-5.6 years, were discharged home with CPAP via tracheostomies. All had co-morbidities including gastroesophageal reflux (n = 9, 60%), neuromuscular disorders (n = 6, 40%), genetic abnormalities (n = 6, 40%), cardiac diseases (n = 4, 27%) and chronic lungs (n = 3, 20%). Eight (53%) children were aged less than 1 year old. The smallest child was aged 3 months old, weighing 4.9 kg. All caregivers were relatives and non-medical health professionals. The 1-month and 1-year readmission rates were 13% and 66% respectively. No factor-associated unfavorable outcomes were statistically identified. No complications related to CPAP malfunction were found. Five (33%) were weaned off CPAP, and 3 died (2 from sepsis and 1 from a sudden unknown cause). We first reported the use of sleep apnea CPAP via tracheostomy in children with severe tracheomalacia. In limited-resource countries, this simple device may be another option for long-term invasive ventilatory support. The CPAP use in children with tracheobronchomalacia requires adequately trained caregivers.

Prolonged Limb and Respiratory Muscle Weakness Associated with Japanese Encephalitis Virus Infection: A Case Report

Patients diagnosed with Japanese encephalitis (JE) may present with flaccid paralysis. JE has also been reported to be accompanied by anterior horn cell disease or motor axonal polyneuropathy. We report a case of a patient with JE with prolonged limb and respiratory muscle weakness who underwent electrodiagnostic studies, including a phrenic nerve conduction study, 10 months after the onset of paralysis. During that 10-month period, severe weakness of the upper and lower extremities showed no recovery, and the patient required long-term ventilator support through a tracheostomy. Nerve conduction studies and electromyography revealed chronic anterior horn cell disease with abundant denervation potentials involving the craniobulbar, cervical, thoracic, and lumbosacral segments. In addition to the nerves in the upper and lower extremities, the phrenic motor nerves showed abnormalities indicative of diaphragmatic weakness. Therefore, in patients with JE with chronic limb weakness and respiratory difficulty, thorough electrodiagnostic studies should be performed to diagnose the combination of anterior horn cell disease with encephalitis and to evaluate the condition’s severity and prognosis.

The effect of parenteral nutrition products on infection parameters in patients receiving long-term mechanical ventilation support

Aim: Malnutrition can increase the frequency of infections by reducing the immune system response. Parenteral nutrition (PN) is considered an important treatment for patients who cannot receive adequate oral or enteral nutrition. The contents of nutritional products may be different. In this study, we aimed to investigate the effects of soy-based and olive oil-based parenteral nutrition products on infection parameters.
 Material and Method: A total of 82 patients were included in the study, 50 of which were soy (Group 2) and 32 were olive-based (Group 1) parenteral nutrition. Patient files and laboratory results were reviewed. Age, gender, 1st, 7th, 14th and 21st days in intensive care, leukocyte and platelet counts, Neutrophil lymphocyte ratio (NLR), C-Reactive Protein (CRP) values, Acute Physiology and Chronic Health Evaluation (Apache II) score and first blood culture results after hospitalization were recorded.
 Results: The 7th and 21st day CRP values in Group 1 were statistically significantly lower than the 7th and 21st days CRP values in Group 2. In Group 1, growth in blood culture was statistically significantly lower and in Group 2 there was a statistically significant early growth.
 Conclusion: As a result, it was found that olive oil-based lipid-containing nutritional solutions were more advantageous in terms of infection on intensıve care than soy-based nutrition products. It was concluded that patients who received postoperative mechanical ventilator support fed with olive oil-based parenteral nutrition products had less infectious growth.

Diaphragm Neurostimulation Assisted Ventilation in Critically Ill Patients.

Diaphragm neurostimulation consists of placing electrodes directly on or in proximity to the phrenic nerve(s) to elicit diaphragmatic contractions. Since its initial description in the 18th century, indications have shifted from cardiopulmonary resuscitation to long-term ventilatory support. Recently, the technical development of devices for temporary diaphragm neurostimulation has opened up the possibility of a new era for the management of mechanically ventilated patients. Combining positive pressure ventilation with diaphragm neurostimulation offers a potentially promising new approach to the delivery of mechanical ventilation which may benefit multiple organ systems. Maintaining diaphragm contractions during ventilation may attenuate diaphragm atrophy and accelerate weaning from mechanical ventilation. Preventing atelectasis and preserving lung volume can reduce lung stress and strain and improve homogeneity of ventilation, potentially mitigating ventilator-induced lung injury. Furthermore, restoring the thoracoabdominal pressure gradient generated by diaphragm contractions may attenuate the drop in cardiac output induced by positive pressure ventilation. Experimental evidence suggests diaphragm neurostimulation may prevent neuroinflammation associated with mechanical ventilation. This review describes the historical development and evolving approaches to diaphragm neurostimulation during mechanical ventilation and surveys the potential mechanisms of benefit. The review proposes a research agenda and offers perspectives for the future of diaphragm neurostimulation assisted mechanical ventilation for critically ill patients.

Home Mechanical Ventilation in Children: Experience of Paediatric Pulmonology Divisions in Istanbul

Advances in technology in recent years increased the long-term survival rate of patients with chronic respiratory failure. As a result, the number of patients receiving long-term home mechanical ventilation (LTHV) support is increasing worldwide. The most important step in the management of patients with home mechanical ventilation (HMV) is to ensure adequate oxygenation and ventilation. Successful care at home requires the presence of trained caregivers and accessibility to medical devices and a care team. The aims of this study were, to describe the characteristics of children on LTHV in Istanbul, to compare the patients receiving non-invasive ventilation (NIV) and invasive ventilation, and to evaluate the frequency and risk factors of hospital admission in this population.

An unusual foreign body in the trachea: A broken PVC tracheostomy tube

In patients with upper airway obstruction and on long-term ventilatory support, tracheostomy is often needed. One rare complication of the same is fracture and aspiration of distal portion into the lower airway, mainly seen in metallic tubes. We report a very rare case, where aspiration of fractured PVC tracheostomy tube occurred, which was successfully removed by rigid bronchoscopy. The etiology and prevention measures are also being reviewed.

Aerosolized antibiotics – can they save us?

Introduction. In neonatal intensive care units, a serious complication for critical ill patients is represented by ventilator-associated pneumonia (VAP), most often caused by multiresistant Gram-negative bacteria. The treatment of this condition is very challenging, and neonatologists must take into consideration the side effects of broad-spectrum intravenous medications. According to different studies, aerosolized antibiotics could be efficient and safe for treating pulmonary infections in newborns. Case presentation. We report three cases of two extremely low birth weight (ELBW) premature babies and one late preterm with asphyxia who required long-term ventilatory support and who subsequently developed VAP, with the aggravation of their condition. Cultures from tracheal aspirates identified multiresistant Acinetobacter baumannii, rising issues regarding the therapeutic strategy. Colistin is a drug known to be active on most species of Acinetobacter in vitro, but for small premature babies there are concerns regarding its nephro- and neurotoxicity. Therefore, we chose to treat our patients with inhalatory colistimethate sodium for 14-21 days, given twice a day, as monotherapy in one case and as adjunctive therapy in the others, with clinical and bacteriological resolution. All babies could have been extubated and had a good respiratory outcome. Conclusions. In newborns with multiresistant VAP, aerosolized antibiotics can be beneficial and without systemic effects. The doses and regimens are yet to be standardized, but our experience confirms the studies that demonstrate this is a valid treatment which can be used alone or in association with intravenous antibiotics.

Does acute flaccid myelitis cause respiratory failure in children?

Acute flaccid myelitis (AFM) is a rare disease that affects spinal cord gray matter, results in acute flaccid weakness of one or more limbs and predominantly involves the cervical spinal cord, which places patients at higher risk for respiratory failure. Our study aims to describe respiratory failure in pediatric AFM patients with emphasis on the need for assisted ventilation and respiratory nerve involvement from an acute and long-term perspective. We reviewed the medical records of patients diagnosed with AFM seen in a multidisciplinary clinic for persistent limb weakness between 2016 and 2020. We studied 54 patients, 35% were female. The median age of patients at illness onset was 5 years (range 7 months-19 years). The median age of patients at the time of study was 8.5 years (range 2-20 years). Eleven patients (20%) required assisted ventilation for acute respiratory failure. Of those that experienced acute respiratory failure, 81% developed chronic respiratory failure. Fifty-six percent of patients with chronic respiratory failure were able to wean off assisted ventilation by 1year. All patients that experienced unilateral diaphragm impairment with AFM onset experienced acute and chronic respiratory failure. Many patients with AFM may experience respiratory compromise and develop chronic respiratory failure. However, most of these patients can be weaned off ventilatory support by 1 year from illness onset. Most children with unilateral diaphragm impairment can sustain adequate ventilation without the need for long-term ventilatory support.

Using Telemedicine to Monitor the Patient with Chronic Respiratory Failure.

Background: Advances in management have improved mortality of individuals with chronic respiratory failure (CRF), leading to an increase in need for long-term oxygen therapy and/or ventilatory support. These individuals require frequent visits and monitoring of their physiological parameters as well as of the functioning of their devices, such as ventilators or oxygen concentrators. Telemedicine is a clinical application of Information Communication Technology connecting patients to specialised care consultants. This narrative review aims to explore the current available telemonitoring options for individuals with CRF and reported or potential results. Methods: The research focused on EMBASE, CINALH, PubMed, and Scopus databases. Papers published between 2003 and 2021 in English were considered. Results: Different sensors, transmission devices and systems, and interventions are used with promising but not conclusive clinical results. However, legal problems are still unsolved, and economic advantages for health care systems, although potentially high, are still under debate. Conclusions: Telemonitoring systems for individuals with CRF are increasingly used; with promising results still to be clarified, legal, economical and organisational issues must be defined.

Tracheostomy in COVID-19 Pandemic Era

The outbreak of new coronavirus (COVID-19) has emerged as the cause of a severe acute respiratory. The COVID-19 pandemic led to an unexpected increase in the number of patients who are critically ill and required mechanical ventilation for active respiratory support. Tracheostomy is a common surgical procedure performed on patient to provide long-term ventilator support or to manage upper airway obstruction. It could be a critical role in the management of COVID-19 patients. Insertion of a tracheal cannula has become a viable alternative to prolonged endotracheal intubation, with the benefits of decreased airway resistance, improved patient comfort, reduced need for sedation, easier sputum removal. While these interventions could be necessary to provide adequate care, they require special precautions to minimize occupational risk. Because the spread of COVID-19 happened by aerosol and fine droplets, medical staffs are in direct danger of occupational exposure while caring for these patients. The purpose of this article is to review the preoperative preparation and tracheostomy guidelines related to COVID-19 pandemic spread.

Comparison of Two Noninvasive Ventilation Strategies (NHFOV Versus NIPPV) as Initial Postextubation Respiratory Support in High-Risk Infants After Congenital Heart Surgery

This study aimed to compare the effects of nasal high-frequency oscillatory ventilation (NHFOV) and noninvasive positive-pressure ventilation (NIPPV) as the initial postextubation therapies on preventing extubation failure (EF) in high-risk infants younger than three months after congenital heart surgery (CHS). This was a single-center, randomized, unblinded clinical trial. The study was performed in a teaching hospital. Between January 2020 and January 2021, a total of 150 infants underwent CHS in the authors' hospital. Infants younger than three months with a high risk for extubation failure who were ready for extubation were randomized to either an NHFOV therapy group or an NIPPV therapy group, and received the corresponding noninvasive mechanical ventilation to prevent EF. Primary outcomes were reintubation, long-term noninvasive ventilation (NIV) support (more than 72 hours), and the time in NIV therapy. The secondary outcomes were adverse events, including mild-moderate hypercapnia, severe hypercapnia, severe hypoxemia, treatment intolerance, signs of discomfort, unbearable dyspnea, inability to clear secretions, emesis, and aspiration. Of 92 infants, 45 received NHFOV therapy, and 47 received NIPPV therapy after extubation. There were no significant differences between the NHFOV and the NIPPV therapy groups in the incidences of reintubation, long-term NIV support, and total time under NIV therapy. No significant difference was found of the severe hypercapnia between the two groups, but NHFOV treatment significantly decreased the rate of mild-moderate hypercapnia (p < 0.05). Other outcomes were similar in the two groups. Among infants younger than three months after CHS who had undergone extubation, NIPPV therapy and NHFOV therapy were the equivalent NIV strategies for preventing extubation failure, and NHFOV therapy was more effective in avoiding mild-moderate hypercapnia.

Scoliosis in Pediatric Patients With Acute Flaccid Myelitis.

Acute flaccid myelitis (AFM) is an anterior horn disorder that manifests as rapid onset muscle weakness or paralysis. Development of scoliosis in pediatric AFM patients has been anecdotally reported, but associated risk factors or incidence have yet to be determined. Pediatric AFM patients treated over a 10-year period at a tertiary care center were identified. Patients were considered to have scoliosis if there was radiographic evidence of coronal curvature ≥15 degrees. Number of limbs affected, independent ambulation and head control, ventilator requirement at initial admission, and long-term ventilatory support (≥1 year) were recorded. Muscle strength and functional status were assessed by manual muscle testing (MMT) and Physical Abilities and Mobility Scale (PAMS), respectively. Areas of spinal cord lesion on initial MRI were recorded. Bivariate analyses were performed, with alpha set to 0.05. Fifty-six AFM patients (27 scoliosis, 29 no scoliosis) were identified. Mean time from AFM presentation to scoliosis diagnosis was 0.93 years. Mean major Cobb angle at first radiograph was 31.7 ± 14.3 degrees. Lack of independent ambulation, ventilator dependence at time of admission or long term, number of limbs affected, and decreased MMT and PAMS scores were more common in patients who developed scoliosis (all, p < .05). Patients who developed scoliosis had more extensive thoracic spinal cord involvement on initial MRI (p = .03). AFM patients who develop scoliosis are more likely to be ventilator dependent, lack independent ambulation, and have more extensive thoracic SCI.

Feasibility of Pediatric Non-Invasive Respiratory Support in Low- and Middle-Income Countries

Non-Invasive respiratory support can be viewed as mechanical respiratory support without endotracheal intubation and it includes continuous positive airway pressure, bi-level positive airway pressure, high flow nasal cannula, and non-invasive positive pressure ventilation. Over past few years, non-invasive respiratory support is getting more popular across pediatric intensive care units for acute respiratory failure as well as for long-term ventilation support at home. It reduces the need for invasive mechanical ventilation, decreases the risk of nosocomial pneumonia as well as mortality in selected pediatric and adult population. Unfortunately, majority of available studies on non-invasive respiratory support have been conducted in high-income countries, which are different from low-and middle-income countries (LMICs) in terms of resources, manpower, and the disease profile. Hence, we need to consider disease profile, severity at hospital presentation, availability of age-appropriate equipment, ability of healthcare professionals to manage patients on non-invasive respiratory support, and cost-benefit ratio. In view of the relatively high cost of equipment, there is a need to innovate to develop indigenous kits/devices with available resources in LMICs to reduce the cost and potentially benefit health system. In this review, we highlight the role of non-invasive respiratory support in different clinical conditions, practical problems encountered in LMICs setting, and few indigenous techniques to provide non-invasive respiratory support.

Use of Fenestrated Tracheostomy Tubes: A Comparative Study

ABSTRACT Introduction Tracheostomy is commonly performed in patients requiring long-term ventilator support. There are many types of tracheostomy tubes like fenestrated and non-fenestrated tubes. This study is to compare the types of fenestrated tubes. Type I is a fenestrated tube with multiple small fenestrae and type II is a fenestrated tracheostomy tube with a single large fenestra. Materials and methods A total of 87 patients who underwent tracheostomy due to prolonged ventilation from January 2015 to January 2016 were included in the study. Type I tube was used in 40 patients and type II tube was used in 47 patients. Tube change was done on the 10th day, at the end of 1 month, and at the end of 3 months. Flexible laryngoscopy is done during every tube change to assess the airway. Results Two groups were compared in terms of granulation through fenestra, stomal granulation, frequency of suctioning, and inner tube block. Statistical analysis was done and the values were compared. A p value &lt;0.05 was considered to be statistically significant. There was a statistically significant difference between both groups in terms of less incidence of granulation through the fenestra and stomal granulation in type II tube. Conclusion Type II tubes are more patient compliant. The incidence of inner tube block is comparatively less which makes it safe to use and avoid life-threatening situations. Decannulation can be done earlier and without complications in patients with type II tubes due to the less incidence of stomal granulation. Thus, type II tube is safer to use and has minimal complications. How to cite this article Lakshmanan S, Jeyabalakrishnan SP, Saravanam PK. Use of Fenestrated Tracheostomy Tubes: A Comparative Study. Int J Head Neck Surg 2021;12(1):15–18.

Stroke in long-term intensive care unit

Aim: Long-term acute care hospitals (LTACH) provide specialized care for patients recovering from severe acute diseases and for patients with chronic and critical illnesses; who need long-term ventilatory support. This study aimed to investigate the factors affecting the length of stay in our long-term intensive care unit (LTICU) in patients with stroke.&#x0D; Material and Method: This retrospective study included 200 stroke patients; who were followed up in the LTICU. The demographic characteristics, comorbid diseases, and culture results of the study patients were examined as variables and the effects of these variables on the length of intensive care unit stay were investigated.&#x0D; Result: Of the patients; the mean age was 79(41-99) years, 99 (49.5%) were males and the mean length of stay was 46 (7-463) days. The length of stay in LTICU was significantly long in stroke patients with a tracheostomy and positive growth in urine cultures (p = 0.013, p = 0.018). The length of stay was significantly short in patients; who received TPN (p = 0.006).&#x0D; Conclusion: Our study has demonstrated that growth in tracheostomy and urine cultures increased but TPN significantly decreased the length of stay of stroke patients in LTICU. To optimize LTACH facilities for stroke patients; we suggest that the overall pattern of the use of such centers should be better known, further integration with acute care units should be established, and further studies should be conducted.

Quality of life and long-term outcomes after hospitalization for COVID-19: Protocol for a prospective cohort study (Coalition VII).

IntroductionThe long-term effects caused by COVID-19 are unknown. The present study aims to assess factors associated with health-related quality of life and long-term outcomes among survivors of hospitalization for COVID-19 in Brazil.MethodsThis is a multicenter prospective cohort study nested in five randomized clinical trials designed to assess the effects of specific COVID-19 treatments in over 50 centers in Brazil. Adult survivors of hospitalization due to proven or suspected SARS-CoV-2 infection will be followed-up for a period of 1 year by means of structured telephone interviews. The primary outcome is the 1-year utility score of health-related quality of life assessed by the EuroQol-5D3L. Secondary outcomes include all-cause mortality, major cardiovascular events, rehospitalizations, return to work or study, physical functional status assessed by the Lawton-Brody Instrumental Activities of Daily Living, dyspnea assessed by the modified Medical Research Council dyspnea scale, need for long-term ventilatory support, symptoms of anxiety and depression assessed by the Hospital Anxiety and Depression Scale, symptoms of posttraumatic stress disorder assessed by the Impact of Event Scale-Revised, and self-rated health assessed by the EuroQol-5D3L Visual Analog Scale. Generalized estimated equations will be performed to test the association between five sets of variables (1- demographic characteristics, 2- premorbid state of health, 3- characteristics of acute illness, 4- specific COVID-19 treatments received, and 5- time-updated postdischarge variables) and outcomes.Ethics and disseminationThe study protocol was approved by the Research Ethics Committee of all participant institutions. The results will be disseminated through conferences and peer-reviewed journals.

AARC Clinical Practice Guideline: Management of Pediatric Patients With Tracheostomy in the Acute Care Setting.

Children requiring a tracheostomy to maintain airway patency or to facilitate long-term mechanical ventilatory support require comprehensive care and committed, trained, direct caregivers to manage their complex needs safely. These guidelines were developed from a comprehensive review of the literature to provide guidance for the selection of the type of tracheostomy tube (cuffed vs uncuffed), use of communication devices, implementation of daily care bundles, timing of first tracheostomy change, type of humidification used (active vs passive), timing of oral feedings, care coordination, and routine cleaning. Cuffed tracheostomy tubes should only be used for positive-pressure ventilation or to prevent aspiration. Manufacturer guidelines should be followed for cuff management and tracheostomy tube hygiene. Daily care bundles, skin care, and the use of moisture-wicking materials reduce device-associated complications. Tracheostomy tubes may be safely changed at postoperative day 3, and they should be changed with some regularity (at a minimum of every 1-2 weeks) as well as on an as-needed basis, such as when an obstruction within the lumen occurs. Care coordination can reduce length of hospital and ICU stay. Published evidence is insufficient to support recommendations for a specific device to humidify the inspired gas, the use of a communication device, or timing for the initiation of feedings.

Tracheostomy in the pediatric trisomy 21 population

IntroductionTracheostomy in children is often performed to alleviate airway obstruction (AO) or to facilitate long-term ventilator support due to respiratory failure of various etiologies, such as heart failure, and postoperative respiratory failure. Although many of these pathologies are common among trisomy 21 patients, tracheostomy rates among this population have not previously been reported. The aim of our study was to determine the incidence of trisomy 21 patients undergoing tracheostomy. Secondary objectives include decannulation rates and mortality associated with tracheostomy. Materials and methodsA retrospective cohort study was conducted on pediatric trisomy 21 patients undergoing tracheostomy between 2004 and 2013. ResultsTwenty patients underwent tracheostomy at a median age of 7.1 months (interquartile range [IQR] = 3.5,21.3). The estimated incidence of tracheostomy in trisomy 21 patients among our tracheostomy population was 1.7% (20/1173) over 10 years. The most common indications were airway obstruction (AO) (55%), cardiac/pulmonary respiratory failure (CRF) (25%), or both (20%). Overall mortality was 30%, much lower among AO patients (9%) than CRF (40%) or both (60%), (P = 0.029). Nine patients (45%) were successfully decannulated, with median duration of cannulation of 2.2 years (IQR = 1.7,3). ConclusionsThis study suggests a rate of tracheostomy in the pediatric trisomy 21 population approximately 3 times that of the general pediatric population. Over half in this cohort underwent tracheostomy for isolated AO, while the general pediatric tracheostomy population demonstrates a much higher prevalence of prematurity-related CRF. Overall mortality rate and decannulation rate approximated that of the general pediatric tracheostomy population, although outcomes were significantly poorer among patients trisomy 21 patients undergoing tracheostomy for CRF.

Transition From an ICU Ventilator to a Portable Home Ventilator in Children.

The transition from an ICU ventilator to a portable home ventilator (PHV) for children requiring long-term mechanical ventilation is a crucial step in preparing for discharge home and may not be successful on the first attempt. A review of this process at our institution revealed that some children required multiple trials before they were able to tolerate a PHV. A protocol was developed to standardize the transition process and reduce the number of failed attempts. Key features of the protocol included a transition readiness assessment and criteria for changing to the PHV. A retrospective chart review was completed to evaluate the process of changing to a PHV before and after the protocol was in place during the time period of 2011-2018. Primary outcome measures included the number of transition attempts and the length of time to achieve successful transition. A successful transition attempt was defined as the ability to tolerate a PHV for 14 d. The study included 56 children ≤ 3 y old with a tracheostomy who required long-term ventilator support. The majority of subjects were from the neonatal ICU and had a diagnosis of bronchopulmonary dysplasia. There was a significant decrease in the number of attempts (P = .005) and in the length of time (P = .01) to successfully transition to a PHV for those who underwent the protocol. The process of changing from an ICU ventilator to a PHV in children requiring long-term mechanical ventilation was improved through the use of a standardized protocol. Both the number of failed attempts and the length of time to achieve successful transition were reduced when the protocol was applied. Further study is needed to evaluate other medical and nonmedical factors that may affect successful transition to a PHV.