Published in Springer Link
July 31, 2015
To initiate home mechanical ventilation in children is much more difficult than in adults. Children have smaller airway diameters. Collateral ventilation such as Pore of Khon or Canal of Lambert has not been fully developed in young children. Therefore, airway clearance procedures are essential. The danger of airway blockage with secretions increases with a decreasing inner diameter of the tracheostomy cannula [11]. Children are at increased risks of accidental removal of cannula and aspirations. Fewer choices of mechanical ventilators are available for children. Small children with poor effort may not be able to trigger the ventilator. So, home ventilators designed for children must be able to provide more sensitive trigger, lower tidal volume and lower flow rate. Commercial masks have a relatively high amount of dead space and often do not fit children well, especially infants [11]. The risk of developing mid-facial hypoplasia is increased in children when using masks with high contact pressure [12]. Some children are too young to help themselves in emergency situations such as ventilator malfunction, electrical power failure etc. [11]. So they require well trained care givers who can observe them closely and help them immediately.
Even though there are a lot of difficulties as described above, many studies have shown that properly selected infants and children could be safely ventilated at home [1–3, 5, 6]. As compared to adults with chronic obstructive pulmonary disease (COPD), better outcomes have been reported in children especially those with reversible underlying diseases such as bronchopulmonary dysplasia and tracheobronchomalacia [2, 13]. More than half of the children suffering from severe bronchopulmonary dysplasia were liberated from positive pressure ventilation and decannulated before their sixth birthday [13]. A good quality of life has been also demonstrated in ventilator-dependent children with congenital central hypoventilation syndrome (CCHS), who were able to attend school and function normally in society [14, 15]. Figure 1 shows one of the author’s patients with CCHS who has normal growth and development. She can go to primary school like other normal children in the day and has been on mechanical ventilator at night for 6 y. Some patients with spinal cord injury and neuromuscular conditions, who became ventilator-dependent before 6 y of age, could graduate from universities, earned degree and run their own business [16]. Similarly, Fig. 2 shows author’s patient with spinal muscular atrophy who has been on non-invasive ventilator for 17 y. At present she supports herself and raises the family by writing novel
Ventilators Designed for Home Use
The goal of home mechanical ventilation is to correct respiratory failure and maximize oxygenation and ventilation in order to allow children to reach their developmental potential [27]. Long-term ventilators designed for home use must be small, lightweight, portable and durable. It must have an internal air compressor, which can be run on electricity. It should also be powered by the internal battery in case of inaccessible electricity. Home ventilators must offer adequate audible alarms to alert caregivers in time to check the child and the ventilator.
Home mechanical ventilators are classified into invasive and non-invasive mechanical ventilators. Advantages of non-invasive ventilation relate to the fact that no tracheostomy is required, which reduces complications and discomfort related to tracheostomy. Caregivers do not need to take care of tracheostomy, which is a heavy burden. In general, a requirement for only nocturnal support warrants non-invasive ventilation, while a requirement for 24 h support often warrants invasive ventilation [18]. The decision to choose whether invasive or non-invasive ventilation for children needing more than nocturnal but less than 24 h support must be individualized [18]. Due to a lot of advantages, non-invasive ventilation should be considered first for children with chronic respiratory insufficiencies [28]. Invasive ventilation is used only when the children show evidence of either failure to adequately ventilate with non-invasive ventilation, failure to tolerate masks, bulbar dysfunction with a high risk of ongoing aspiration and ineffective non-invasive management of secretions or high level of dependence on assisted ventilation (>16 h/d) [27–29].
Obstacles to Establish Home Mechanical Ventilation
The levels of financial support for at-home care for children on long-term ventilator support are highly different across the world. In high income countries, home health care service are covered by either the government or medical health insurance, while in lower income countries, patients and families are responsible for all expenses that may occur [2]. The cost of equipment, supplies, and caregivers must be met by the family themselves. A number of patients whose conditions are suitable for home care still have to undergo long-term hospitalization unnecessarily because of the lack of family resources. The feasibility of home care depends very much on the family’s resources and their ability to cope with ensuing problems [2]. BPAP and CPAP via tracheostomy have been using instead of standard home ventilator to cut down the expense [2]. Fortunately some children received ventilators from donations. In case of mechanical ventilator failure or electrical power failure or outage, patients need to go to nearby hospitals as soon as possible since they are provided only one set of each device.
In order to effectively run home care program in this difficult situation, the team has to face a lot of barriers including designating family members as caregivers, seeking for funding for home care equipment, teaching and training family members who mostly are lay persons for all aspects of sophisticated home care, emotional and social support to the family, preparing safe home environment, coordinating with other specialties involved in the care of the child such as nutritionists, neurologists, speech therapists, occupational therapists, social workers, physical therapists and schools. A checklist of caregiver’s evaluation form should be completely filled-in before discharge (Appendix). All tasks require a good team work; dedicated members of the team are the key factor.
Source: https://link.springer.com/article/10.1007/s12098-015-1842-z
Summary: This article talks about the specific obstacles pertaining to children with mechanical ventilation. It touches on what is out there currently and common issues families have as well as how being at home really improves the quality of life for these kids. I think this paints a realistic image of the ventilator’s place in the home of a child.
