Pediatric home mechanical ventilation: A Canadian Thoracic Society clinical practice guideline executive summary

Over the last 30 to 40 years, improvements in technology, as well as changing clinical practice regarding the appropriateness of long-term ventilation in patients with “non-curable” disorders, have resulted in increasing numbers of children surviving what were previously considered fatal conditions. This has come but at the expense of requiring ongoing, long-term prolonged mechanical ventilation (both invasive and noninvasive). Although there are many publications pertaining to specific aspects of home mechanical ventilation (HMV) in children, there are few comprehensive guidelines that bring together all of the current literature. In 2011 the Canadian Thoracic Society HMV Guideline Committee published a review of the available English literature on topics related to HMV in adults, and completed a detailed guideline that will help standardize and improve the assessment and management of individuals requiring noninvasive or invasive HMV. This current document is intended to be a companion to the 2011 guidelines, concentrating on the issues that are either unique to children on HMV (individuals under 18 years of age), or where common pediatric practice diverges significantly from that employed in adults on long-term home ventilation. As with the adult guidelines,1 this document provides a disease-specific review of illnesses associated with the necessity for long-term ventilation in children, including children with chronic lung disease, spinal muscle atrophy, muscular dystrophies, kyphoscoliosis, obesity hypoventilation syndrome, and central hypoventilation syndromes. It also covers important common themes such as airway clearance, the ethics of initiation of long-term ventilation in individuals unable to give consent, the process of transition to home and to adult centers, and the impact, both financial, as well as social, that this may have on the child\u27s families and caregivers. The guidelines have been extensively reviewed by international experts, allied health professionals and target audiences. They will be updated on a regular basis to incorporate any new information

Lung function in school-aged congenital diaphragmatic hernia patients; a longitudinal evaluation

Objective: Children with congenital diaphragmatic hernia (CDH) are at risk for pulmonary morbidity. Data on longitudinal evaluation of lung function in CDH are scarce. We hypothesized that CDH patients would have impaired lung function that worsens over time. We evaluated lung function and its determinants at ages 8 and 12 years. Methods: Dynamic and static lung volumes, and diffusion capacity were measured. Extracorporeal membrane oxygenation (ECMO) treatment, the standardized European neonatal treatment protocol, patch repair, duration of ventilation, type of initial mechanical ventilation, and nitric oxide treatment were entered as covariates in linear mixed models with standard deviation score (SDS) lung function parameters (FEV1, FEF 25-75, and K CO) as dependent variables. Results: Seventy-six children (27 ECMO-treated) born between 1999 and 2009 performed 113 reliable lung function tests. Severity of airflow obstruction deteriorated significantly from age 8 to 12 years: estimated mean difference (95% confidence interval [CI]) SDS FEV1 was −0.57 (−0.79 to −0.36) and SDS FEF25-75 was −0.63 (−0.89 to −0.37), both P <.001. Static lung volumes were within normal range and unchanged over time: estimated mean difference (95% CI) SDS TLC −0.27 (−0.58 to 0.04); P =.085. SDS KCO was below normal at 8 and 12 years and remained stable: −0.06 (−0.22 to 0.35); P =.648. These observations were irrespective of ECMO treatment. FEV1 and FEF25-75 were negatively associated with duration of ventilation (P <.001). Baseline data were not related with TLC or KCO. Conclusions: CDH patients should be followed into adulthood as they are at risk for worsening airflow obstruction and decreased diffusion capacity at school age, irrespective of ECMO treatment

Internet-based asthma education – A novel approach to compliance: A case report

Asthma costs Canadians over $1.2 billion per annum and, despite advances, many asthmatic patients still have poor control. An action plan, symptom diary and measurement of peak expiratory flow have been shown to improve clinical outcomes. Effective educational interventions are an important component of good care. However, many rural sites lack not only access to education but physician care as well. It is reasonable, therefore, that an Internet-based asthma management program may be used as an approach. In the present case report, a novel approach that may increase access in these poorly serviced areas is presented. In an Internet-based asthma management program, patients are reviewed by a physician, receive education and are given a unique password that provides program access. Patients record symptoms and peak expiratory flow rates. The present case report shows that a patient can be assisted through an exacerbation, thus averting emergency intervention and stabilizing control, even when travelling on another continent

Prevalence of Asthma and Risk Factors for Asthma-Like Symptoms in Aboriginal and Non-Aboriginal Children in the Northern Territories of Canada

BACKGROUND: Few studies have investigated the prevalence and risk factors of asthma in Canadian Aboriginal children

Workshop Report: Aerosol Delivery to Spontaneously Breathing Tracheostomized Patients.

The number of pediatric and adult patients requiring tracheostomy has increased. Many of them require aerosol therapy as part of their treatment. Practitioners have little guidance on how to optimize drug delivery in this population. The following is a report of a workshop dedicated to review the current status of aerosol delivery to spontaneously breathing tracheostomized patients and to provide practice recommendations

A children’s asthma education program: Roaring Adventures of Puff (RAP), improves quality of life

BACKGROUND: It is postulated that children with asthma who receive an interactive, comprehensive education program would improve their quality of life, asthma management and asthma control compared with children receiving usual care

Long-term outcome of children treated with neonatal extracorporeal membrane oxygenation: Increasing problems with increasing age

As more and more critically ill neonates survive, it becomes important to evaluate long-term morbidity. This review aims to provide an up-to-date overview of medical and neurodevelopmental outcomes in children who as neonates received treatment with extracorporeal membrane oxygenation (ECMO). Most patients-except those with congenital diaphragmatic hernia-have normal lung function and normal growth at older age. Maximal exercise capacity is below normal and seems to deteriorate over time in the CDH population. Gross motor function problems have been reported until school age. Although mental development is usually favorable within the first years and cognition is normal at school age, many children experience problems with working speed, spatial ability tasks, and memory. In conclusion, children who survived neonatal treatment with ECMO often encounter neurodevelopmental problems at school age. Long-term follow-up is needed to recognize problems early and to offer appropriate intervention