Decreasing mechanical ventilator support in medically fragile children with bronchopulmonary dysplasia: A step-by-step weaning protocol at a pediatric long term extended care facility

Issue title: Complex Care in Pediatrics: Great Progress, Greater Challenges

Subtitle:

Guest editors: Rishi Agrawal

Article type: Research Article

Authors: Suresh, Swetha^{a; b; c} | Huxol, Heather G.^{a; d; *} | Morton, Ronald L.^a

Affiliations: [a] Department of Pediatrics, University of Louisville School of Medicine, Louisville, KY, USA | [b] Department of General Internal Medicine, University of Louisville School of Medicine, Louisville, KY, USA | [c] Department of Palliative Medicine, University of Louisville School of Medicine, Louisville, KY, USA | [d] The Home of the Innocents, Louisville, KY, USA

Correspondence: [*] Corresponding author: Heather Huxol, University of Louisville School of Medicine, 323 East Chestnut Street, Louisville, KY 40202-3866, USA. Tel.: +1 502 852 2706; E-mail:heather.huxol@louisville.edu

Abstract: PURPOSE: Prolonged mechanical ventilation (PMV) in medically fragile children is commonly used in pediatric long term extended care facilities (P-LTEC). Currently, PMV weaning is performed in an unstandardized fashion. Without an official protocol, patients are subjected to delayed weaning, infection, increased mortality, and difficulty obtaining placement at adult group homes. A step-wise approach may help these children wean from PMV effectively. METHODS: A retrospective chart review of five tracheostomized children with bronchopulmonary dysplasia was conducted. RESULTS: A 5-step weaning protocol was created using data collected retrospectively. First, pressure control ventilator settings were decreased until rate = 10, fraction of inspired oxygen = 30% and pressure support = 6-10. Second, continuous positive airway pressure (CPAP) was trialed while awake with ventilator at night. Third, CPAP was continued for 24 hours. Fourth, tracheostomy collar (TC) was trialed while awake, with CPAP at night. Lastly, TC was continued for 24 hours. Advancing to Step 2 required the most time, likely secondary to episodic illnesses, with a mean of 31.2 months. The process required 3.2 months to advance to Step 3, 1.6 months to achieve Step 4, and 2.6 months to attain Step 5. CONCLUSION: Using the data obtained in this case series an official protocol could be created to wean P-LTEC residents from PMV, with reasonable expectations of the process.

Keywords: Mechanical ventilation, weaning, pediatric long term extended care facilities, medically fragile children, bronchopulmonary dysplasia

DOI: 10.3233/PRM-150328

Journal: Journal of Pediatric Rehabilitation Medicine, vol. 8, no. 2, pp. 147-156, 2015