Association between parental education level & outcomes for children with long-term ventilator dependence: Communication behaviors as moderating variables.

PURPOSE: The purpose of this study was to examine the correlation between parental education level and outcomes for children with long-term ventilator dependence (LTVD) and their families and whether parent communication behaviors with hospital nurses moderated the relationship. Advances in medical technology and policy changes allow children with LTVD to be cared for at home. The child's diagnosis and disease severity affect their health outcomes, as do their family's social determinants of health (SDoH) such as parent education. DESIGN AND METHODS: This secondary data analysis used chi-square tests to evaluate the correlation between parental education level and outcomes. Generalized linear mixed effect models were used to examine the moderation effect of parent communication behaviors. RESULTS: Lower parental education level was associated with more child respiratory infections and more parental uncertainty within one month following hospital discharge. Lower parent education level was also associated with fewer unplanned contacts with providers within one week post-discharge. Additionally, parent use of Verifying Understanding communication behaviors moderated the relationship between parental education level and number of respiratory infections and amount of parental uncertainty. Finally, parent use of Negotiating Roles moderated the association between education level and number of unplanned visits. CONCLUSIONS: Contradicting previous research, lower parental education level does not consistently correspond to adverse outcomes and may be explained by parents' determination to ensure optimal outcomes for their children with LTVD. PRACTICE IMPLICATIONS: Overall, healthcare providers should not be concerned that children with LTVD will have different outcomes based on their parents' education level.

Factors associated with tracheostomy decannulation in infants with bronchopulmonary dysplasia.

OBJECTIVE: Premature infants represent a unique subset of patients who may require tracheostomy. Bronchopulmonary dysplasia (BPD) is among one of the most common sequelae of prematurity contributing to the need for prolonged ventilation requiring tracheostomy after other airway options have been exhausted. Our objective is to understand socioeconomic barriers to decannulation and identify factors that accelerate safe decannulation, focusing on patients with BPD. METHODS: An existing internal database from a tertiary pediatric hospital of patients undergoing tracheostomy prior to one year old was reviewed. Data from January 1, 2005 through December 31, 2020 was used to compare patients who were successfully decannulated to those who were not. A further subset of infants with BPD were identified and analyzed. Of those decannulated, survival analysis was used to identify factors associated with decreased time to decannulation. RESULTS: We identified 303 infants who underwent tracheostomy at less than one year old with 125 of those infants having a diagnosis of BPD. Of the 125 infants with BPD, 44 (35.2 %) were decannulated and 81 (64.8 %) were not. There was no significant difference in sex, race, ethnicity, insurance status, comorbidities, or presence of syndromes between those patients with BPD who were decannulated and those who were not. Those who were not decannulated had a significantly longer length of hospital stay, prolonged ventilator requirements after tracheostomy, and were more likely to be discharged home on the ventilator (p = 0.030; 0.020; 0.002, respectively). Of the 44 decannulated patients, mean and median time to decannulation were 37.9 and 27.8 months respectively (range 10.8-160.6 months). There was an inverse association with decannulation and both Black race (HR: 0.30) and neurological comorbidity (HR: 0.37) on multivariate analysis. Black race, presence of syndrome, and length of ventilator dependence were significantly associated with increased time to decannulation. Time to decannulation from time off the ventilator was not significantly influenced by sex, race, ethnicity, state of residence, or insurance status, but was significantly influenced by age (95 % CI: -6.9, -0.1; P = 0.044). While time from discharge to first follow up visit did not significantly impact time to decannulation, every additional follow up visit increased time to decannulation by 3.78 months when adjusting for confounding variables. CONCLUSION: In infants with BPD under one year requiring tracheostomy, socioeconomic factors were not found to influence likelihood of decannulation, however Black race, presence of underlying syndrome, and increased length of ventilator dependence were associated with prolonged timing. Children with more frequent follow up visits similarly had an increased time to decannulation, illustrating a vital point in the process. Ventilator weaning protocols and standardized decannulation protocols in patients with BPD, along with caregiver education, can safely expedite and facilitate decannulation.

Long-Term Outcomes of Tracheostomy-Dependent Children.

OBJECTIVE: To estimate the 1-, 5-, and 10-year survival and decannulation rates of children with a tracheostomy. STUDY DESIGN: Ambidirectional cohort. SETTING: Tertiary children's hospital. METHODS: All patients (<18 years) that had a tracheostomy placed between 2009 and 2020 were included and followed until 21 years of age, decannulation, or death. The Kaplan-Meier method estimated cumulative probabilities of death and decannulation. RESULTS: A total of 551 children underwent tracheostomy at a median age of 7.2 months (interquartile range [IQR]: 3.8-49.2). Children were followed for a median of 2.1 years (IQR: 0.7-4.2, range 0-11.5). The cumulative probability of mortality at 1 year was 11.9% (95% confidence interval [CI]: 9.4-15.1), at 5 years was 26.1% (95% CI: 21.6-31.3), and at 10 years was 41.6% (95% CI: 32.7-51.8). Ventilator dependence at index discharge (hazard ratio [HR]: 2.04, 95% CI: 1.10-3.81, p = .03), severe neurologic disability (HR: 2.79, 95% CI: 1.61-4.84, p < .001), and cardiac disease (HR: 1.69, 95% CI: 1.08-2.65, p = .02) were associated with time to death. The cumulative probability of decannulation was 10.4% (95% CI: 8.0-13.5), 44.9% (95% CI: 39.4-50.9), and 54.1% (95% CI: 47.4-61.1) at 1 year, 5 years, and 10 years, respectively. Ventilator dependence (HR: 0.43, 95% CI: 0.31-0.60, p < .001), severe neurologic disability (HR: 0.20, 95% CI: 0.14-0.30, p < .001), and tracheostomy indicated for respiratory failure (HR: 0.68, 95% CI: 0.48-0.96, p = .03) correlated with longer decannulation times. CONCLUSION: After tracheostomy, estimated mortality approaches 42% by 10 years and decannulation approaches 54%. Children with ventilator support at discharge and severe neurological disability had poorer long-term survival and longer times to decannulation.

Rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation (ROHHAD): a collaborative review of the current understanding.

PURPOSE: To provide an overview of the discovery, presentation, and management of Rapid-onset Obesity with Hypothalamic dysfunction, Hypoventilation, and Autonomic Dysregulation (ROHHAD). To discuss a search for causative etiology spanning multiple disciplines and continents. METHODS: The literature (1965-2022) on the diagnosis, management, pathophysiology, and potential etiology of ROHHAD was methodically reviewed. The experience of several academic centers with expertise in ROHHAD is presented, along with a detailed discussion of scientific discovery in the search for a cause. RESULTS: ROHHAD is an ultra-rare syndrome with fewer than 200 known cases. Although variations occur, the acronym ROHHAD is intended to alert physicians to the usual sequence or unfolding of the phenotypic presentation, including the full phenotype. Nearly 60 years after its first description, more is known about the pathophysiology of ROHHAD, but the etiology remains enigmatic. The search for a genetic mutation common to patients with ROHHAD has not, to date, demonstrated a disease-defining gene. Similarly, a search for the autoimmune basis of ROHHAD has not resulted in a definitive answer. This review summarizes current knowledge and potential future directions. CONCLUSION: ROHHAD is a poorly understood, complex, and potentially devastating disorder. The search for its cause intertwines with the search for causes of obesity and autonomic dysregulation. The care for the patient with ROHHAD necessitates collaborative international efforts to advance our knowledge and, thereby, treatment, to decrease the disease burden and eventually to stop, and/or reverse the unfolding of the phenotype.

Mortality and ventilator dependence in critically ill patients with ventilator-associated pneumonia caused by carbapenem-resistant Acinetobacter baumannii.

BACKGROUND: Carbapenem-resistant Acinetobacter baumannii (CRAB) is a key pathogen associated with ventilator-associated pneumonia (VAP). Research on treatment outcomes, especially ventilator dependence, in patients with VAP caused by CRAB remains limited. METHODS: This retrospective multicenter study included ICU-admitted patients with VAP caused by CRAB. The original cohort was included as the mortality evaluation cohort. The ventilator dependence evaluation cohort included cases that survived more than 21 days after VAP and without prolonged ventilation before VAP onset. The mortality rate, ventilator dependence rate, clinical factors associated with treatment outcomes, and treatment outcome differences with various VAP onset times were investigated. RESULTS: In total, 401 patients with VAP caused by CRAB were analyzed. The 21-day all-cause mortality rate was 25.2%, and the 21-day ventilator dependence rate was 48.8%. Clinical factors associated with 21-day mortality included lower body mass index, higher sequential organ failure assessment score, vasopressors usage, CRAB persistence, and VAP onset time > seven days. Clinical factors associated with 21-day ventilator dependence included older age, vasopressors usage, and VAP onset time > seven days. CONCLUSIONS: ICU-admitted patients with CRAB-related VAP had high mortality and ventilator dependence rates. Older age, vasopressor usage, and longer VAP onset time were independent factors associated with ventilator dependence.

Developmental disorders affecting the respiratory system: CCHS and ROHHAD.

Rapid-onset Obesity with Hypothalamic dysfunction, Hypoventilation, and Autonomic Dysregulation (ROHHAD) and Congenital Central Hypoventilation Syndrome (CCHS) are ultra-rare distinct clinical disorders with overlapping symptoms including altered respiratory control and autonomic regulation. Although both disorders have been considered for decades to be on the same spectrum with necessity of artificial ventilation as life-support, recent acquisition of specific knowledge concerning the genetic basis of CCHS coupled with an elusive etiology for ROHHAD have definitely established that the two disorders are different. CCHS is an autosomal dominant neurocristopathy characterized by alveolar hypoventilation resulting in hypoxemia/hypercarbia and features of autonomic nervous system dysregulation (ANSD), with presentation typically in the newborn period. It is caused by paired-like homeobox 2B (PHOX2B) variants, with known genotype-phenotype correlation but pathogenic mechanism(s) are yet unknown. ROHHAD is characterized by rapid weight gain, followed by hypothalamic dysfunction, then hypoventilation followed by ANSD, in seemingly normal children ages 1.5-7 years. Postmortem neuroanatomical studies, thorough clinical characterization, pathophysiological assessment, and extensive genetic inquiry have failed to identify a cause attributable to a traditional genetic basis, somatic mosaicism, epigenetic mechanism, environmental trigger, or other. To find the key to the ROHHAD pathogenesis and to improve its clinical management, in the present chapter, we have carefully compared CCHS and ROHHAD.

Machine Learning Approaches for Predicting Acute Respiratory Failure, Ventilator Dependence, and Mortality in Chronic Obstructive Pulmonary Disease.

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of mortality and contributes to high morbidity worldwide. Patients with COPD have a higher risk for acute respiratory failure, ventilator dependence, and mortality after hospitalization compared with the general population. Accurate and early risk detection will provide more information for early management and better decision making. This study aimed to build prediction models using patients' characteristics, laboratory data, and comorbidities for early detection of acute respiratory failure, ventilator dependence, and mortality in patients with COPD after hospitalization. We retrospectively collected the electronic medical records of 5061 patients with COPD in three hospitals of the Chi Mei Medical Group, Taiwan. After data cleaning, we built three prediction models for acute respiratory failure, ventilator dependence, and mortality using seven machine learning algorithms. Based on the AUC value, the best model for mortality was built by the XGBoost algorithm (AUC = 0.817), the best model for acute respiratory failure was built by random forest algorithm (AUC = 0.804), while the best model for ventilator dependence was built by LightGBM algorithm (AUC = 0.809). A web service application was implemented with the best models and integrated into the existing hospital information system for physician's trials and evaluations. Our machine learning models exhibit excellent predictive quality and can therefore provide physicians with a useful decision-making reference for the adverse prognosis of COPD patients.

End-Expiratory Lung Volumes During Spontaneous Breathing Trials in Tracheostomized Subjects on Prolonged Mechanical Ventilation.

BACKGROUND: The role of end-expiratory lung volume (EELV) during a spontaneous breathing trial (SBT) in patients who were tracheostomized and on prolonged mechanical ventilation is unclear. This study aimed to assess EELV during a 60-min SBT and its correlation with weaning success. METHODS: Enrolled subjects admitted to a weaning unit were measured for EELV and relevant parameters before and after the SBT. RESULTS: Of the 44 enrolled subjects, 29 (66%) were successfully liberated, defined as not needing mechanical ventilation for 5 d. The success group had fewer subjects with chronic kidney disease (41% vs 73%, P = .044), stronger mean ± SD maximum inspiratory pressure (41.6 ± 10.4 vs 34.1 ± 7.1 cm H2O; P = .02) and mean ± SD maximum expiratory pressure (46.9 ± 11.7 vs 35.3 ± 16.9 cm H2O; P = .01) versus the failure group. Toward the end of the SBT, the success group had a significant increase in the mean ± SD EELV (before vs after: 1,278 ± 744 vs 1,493 ± 867 mL; P = .040) and a decrease in the mean ± SD rapid shallow breathing index (83.8 ± 39.4 vs 66.3 ± 29.4; P = .02), whereas there were no significant changes in these 2 parameters in the failure group. The Cox regression analysis showed that, at the beginning of SBT, a greater difference between EELV with a PEEP of 0 cm H2O and with a PEEP of 5 cm H2O was significantly correlated to a higher likelihood of weaning success. Toward the end of the SBT, a greater EELV level at a PEEP of 0 cm H2O was also correlated with weaning success. Also, the greater difference of EELV at a PEEP of 0 cm H2O between the beginning and the end of the SBT was also correlated with a shorter duration to weaning success. CONCLUSIONS: The change in EELV during a 60-min SBT may be of prognostic value for liberation from prolonged mechanical ventilation in patients who had a tracheostomy. Our findings suggest a model to understand the underlying mechanism of failure of liberation from mechanical ventilation in these patients.

The Combination of SOFA Score and Urinary NGAL May Be an Effective Predictor for Ventilator Dependence among Critically Ill Surgical Patients: A Pilot Study.

BACKGROUND: Ventilator dependence (VD) has been considered as a serious complication in critically ill patients in the intensive care unit (ICU). Acute kidney injury (AKI) is associated with VD as a result of lung-kidney interaction. The aim of our study was to investigate novel biomarkers in predicting ventilator dependence in critically ill surgical patients. METHODS: Patients who were admitted to surgical ICU were enrolled and their serum and urine samples were collected. Novel biomarkers including gelatinase-associated lipocalin (NGAL), calprotectin, kidney injury molecule-1 (KIM-1), cystatin C, and growth differentiation factor 15 (GDF-15) were analyzed and correlated with clinical outcome. RESULTS: A total of 33 patients were enrolled and analyzed. The majority of them received abdominal surgery prior to ICU admission. Thirteen patients were classified into the VD group, while the remaining 20 were in a non-ventilator dependence group (nVD). Statistical analysis demonstrated that the following were significantly higher in the VD group than in the nVD group: serum NGAL (420.25 ± 45.18 ng/mL vs. 314.68 ± 38.12 ng/mL, p-value 0.036), urinary NGAL (420.87 ± 41.08 ng/mL vs. 250.84 ± 39.45 ng/mL, p-value 0.002), SOFA score (11.3 ± 1.5 vs. 5.6 ± 0.7, p-value 0.001), and APACHE II score (23.2 ± 2.6 vs. 13.6 ± 0.8, p-value 0.001). The area under the ROC curve (AUROC) of urinary NGAL for VD was 0.808. The combination of urinary NGAL and SOFA score could further increase AUROC for VD to 0.835. CONCLUSIONS: The current study demonstrated the predictive capability of urinary NGAL for ventilator dependence among critically ill surgical patients. When combined with SOFA score, the predictive ability was further augmented. Further large-scale studies are warranted to validate our findings.

Body Mass Index and Ventilator Dependence in Critically Ill Subjects in Japan: A Cohort Study Using a Nationwide Database.

BACKGROUND: Body mass index (BMI) can be an important indicator for health outcomes among critically ill patients. However, the association between BMI and ventilator dependence at ICU discharge among these patients remains unknown. We aimed to evaluate the association between BMI at ICU admission and ventilator dependence at the time of ICU discharge. As secondary outcomes, we used ICU mortality, hospital mortality, and implementation of tracheostomy during ICU stay. METHODS: This is a retrospective cohort study. The data were derived from The Japanese Intensive Care Patient Database, a nationwide ICU database in Japan. We included all patients in the registry who were ≥ 16 y old, received mechanical ventilation, and were admitted to an ICU between April 2018 and March 2019. On the basis of their BMI at ICU admission, subjects were classified as underweight (< 18.5 kg/m2); normal weight (≥ 18.5 kg/m2 to < 23 kg/m2); overweight (≥ 23 kg/m2 to < 27.5 kg/m2); or obese (≥ 27.5 kg/m2). RESULTS: Among 11,801 analyzed subjects, 388 (3.3%) subjects were ventilator-dependent at ICU discharge. Compared with normal-weight subjects, the risk for ventilator dependence at ICU discharge increased among underweight subjects even after adjusting for potential confounders and inter-ICU variance in 2-level multivariable logistic regression analysis (odds ratio 1.46 [95% CI 1.18-1.79]). Although obesity was also associated with a higher risk of ventilator dependence, the association was less clear (odds ratio 1.10 [95% CI 0.99-1.22]). The risk of ICU mortality, hospital mortality, and implementation of tracheostomy also increased in underweight subjects. CONCLUSIONS: Critically ill underweight subjects had a higher risk of ventilator dependence at ICU discharge compared to normal-weight subjects, even after adjusting for potential confounders and inter-ICU variance. The association between BMI and ventilator dependence should be examined using information on subjects' nutritional status and frailty in further studies.

Thirty-Six-Month Follow-up of Diaphragm Pacing with Phrenic Nerve Stimulation for Ventilator Dependence in Traumatic Tetraplegia: The Way Forward for Spinal Cord Injury Rehabilitation in a Developing Country.

Respiratory failure and chronic ventilator dependence in tetraplegics following cervical injuries located high on the spine (C1-C3) constitute significant challenges in the rehabilitation of patients given the occurrence of repeated hospitalizations and an ever-increasing financial burden. A 30-year-old man presented with posttraumatic tetraplegia following an unstable injury at the C1-C2 level with cord compression; he was managed by posterior stabilization and decompression followed by ventilator dependence and no rehabilitation until 6 months postinjury. We implanted phrenic nerve stimulator electrodes bilaterally for indirect diaphragm pacing by an implantable pulse generator that allowed for weaning from mechanical ventilation and spontaneous ventilator-free breathing at 20 weeks post-implantation and which facilitated post-tetraplegia rehabilitation. At 36 months after implantation, the patient is ventilator-free without any procedure-related complications or respiratory infections. Diaphragm pacing with phrenic nerve stimulation may be a way forward for ventilator-dependent tetraplegics in developing countries to pursue effective rehabilitation and improved quality of life.

Clinical Factors Influencing Time to Decannulation in Children with Tracheostomy and Ventilator Dependence Secondary to Bronchopulmonary Dysplasia.

OBJECTIVE: To determine whether demographic or clinical factors affected the time to tracheostomy decannulation for patients with severe bronchopulmonary dysplasia (BPD). STUDY DESIGN: We retrospectively abstracted information from the electronic medical record for 93 patients with BPD or chronic lung disease of prematurity with tracheostomy and ventilator dependence cared for in our Pulmonary Clinic between January 1, 2006, and December 31, 2015. Univariable and multivariable models controlling for sex, race, ethnicity, and gestational age assessed the impact of cohort demographics, comorbid medical conditions, and physician factors on time to decannulation. RESULTS: The mean age of the 66 patients who were decannulated was 3.3 ± 1.12 years. Having a chronic neurologic condition was associated with a prolonged time to tracheostomy decannulation (hazard ratio, 0.3; 95% CI, 0.1-0.9), particularly if the patient was not decannulated by 3 years of age. Individuals who had only pulmonary hypertension, required airway reconstruction, or had none of the identified risk factors had similar rates of tracheostomy decannulation. Race, ethnicity, and provider clinical volume were not significantly associated with time to decannulation. CONCLUSIONS: A chronic neurologic condition was the sole factor significantly associated with time to tracheostomy decannulation in our patients with severe BPD. Further work to understand the driving factors for this association will allow clinicians to provide families with more informed guidance as they navigate the complex process of long-term mechanical ventilation.

Facilitating ventilator weaning through rib fixation combined with video-assisted thoracoscopic surgery in severe blunt chest injury with acute respiratory failure.

BACKGROUND: Severe blunt chest injury sometimes induces acute respiratory failure (ARF), requiring ventilator use. We aimed to evaluate the effect of performing rib fixation with the addition of video-assisted thoracoscopic surgery (VATS) on patients with ARF caused by blunt thoracic injury with ventilator dependence. METHODS: This observational study prospectively enrolled patients with multiple bicortical rib fractures with hemothorax caused by severe blunt chest trauma. All patients received positive pressure mechanical ventilation within 24 h after trauma because of ARF. Some patients who received rib fixation with VATS were enrolled as group 1, and the others who received only VATS were designated as group 2. The length of ventilator use was the primary clinical outcome. Rates of pneumonia and length of hospital stay constituted secondary outcomes. RESULTS: A total of 61 patients were included in this study. The basic demographic characteristics between the two groups exhibited no statistical differences. All patients received operations within 6 days after trauma. The length of ventilator use was shorter in group 1 (3.19 ± 3.37 days vs. 8.05 ± 8.23, P = 0.002). The rate of pneumonia was higher in group 2 (38.1% vs. 75.0%, P = 0.005). The length of hospital stay was much shorter in group 1 (17.76 ± 8.38 days vs. 24.13 ± 9.80, P = 0.011). CONCLUSION: Rib fixation combined with VATS could shorten the length of ventilator use and reduce the pneumonia rate in patients with severe chest blunt injury with ARF. Therefore, this operation could shorten the overall length of hospital stay.

Survival analysis and decannulation outcomes of infants with tracheotomies.

OBJECTIVE: To evaluate for differences in time to decannulation and survival rates for pediatric tracheotomy patients based on ventilator status upon discharge. STUDY DESIGN: Retrospective longitudinal cohort study. METHODS: A single-institution longitudinal study of pediatric tracheostomy patients was conducted. Patients were categorized based on mechanical ventilation status on discharge and principal reason for tracheostomy. Survival rates were determined using the Kaplan-Meier method. The Wilcoxon's Rank Sum test and Cox regression analysis evaluated differences in survival times and time to decannulation based on primary indication for tracheotomy and ventilation status. RESULTS: Chart review identified 305 patients who required a tracheostomy under the age of 3. The median age at the time of tracheotomy was 5.2 months. The indications for tracheotomy in these patients were airway obstruction in 145 (48%), respiratory failure in 214 (70%), and pulmonary toilet in 10 (3.3%). Seventy-nine percent of patients were ventilator dependent at discharge. At the conclusion of the study period, 55% of patients were alive with tracheostomy in place, 30% patients were decannulated, and 15% patients were deceased. Patients with ventilator dependence at initial discharge, bronchopulmonary dysplasia, or airway obstruction were more likely to be decannulated. Hispanic patients were less likely to be decannulated. Patients had an equal probability of death regardless of ventilator status at discharge. CONCLUSIONS: This study demonstrated that the time to decannulation and likelihood of decannulation varies based on the indication for the tracheostomy. The majority of patients with a tracheostomy were not decannulated at the conclusion of this study. Median time to decannulation was 2.5 years for patients with a median death time of 6 months. LEVEL OF EVIDENCE: 2b Laryngoscope, 130:2319-2324, 2020.

Prediction of prolonged ventilator dependence in preterm infants.

Volutrauma is an important factor in the pathogenesis of bronchopulmonary dysplasia (BPD). Our aims were to identify risk factors in the first 24 h for prolonged ventilator dependence and assess volume delivery and carbon dioxide levels in infants with evolving BPD. A retrospective study was undertaken of 41 infants born at less than 32 weeks of gestational age (GA). A higher tidal volume, minute volume and resistance and a lower GA, birth weight and compliance were associated with a significantly higher risk of ventilator dependence at 28 days. The strongest relationships were with birth weight (area under the receiver operating characteristic curve, AUROC = 0.771) and GA (AUROC = 0.813). Tidal volume remained significantly higher after adjusting for GA in those who remained ventilator dependent at 28 days. The 18 who remained ventilator dependent at 28 days had increased mean carbon dioxide (PCO2) levels with increasing age from a mean of 41 mmHg in the first 24 h to 65 mmHg at 28 days PMA (p < 0.001). The increase in PCO2 occurred despite increases in peak inflation pressures (p < 0.001), tidal volumes (p = 0.002) and minute volumes (p < 0.001).Conclusion: These results suggest that initial volutrauma may contribute to the development of chronic ventilator dependence. What is Known: • In prematurely born infants, excessive tidal volumes are important in the pathogenesis of bronchopulmonary dysplasia (BPD), but a tidal volume that is too low will increase the risk of atelectasis, work of breathing and energy expenditure. What is New: • A high tidal volume in the first 24 h was associated with an increased risk of ventilator dependence at 28 days, which remained significant after adjusting for gestational age. Carbon dioxide levels significantly increased over the first month despite increased pressures and volumes in those who remained ventilator dependent.

Is quicker better? A NSQIP analysis of anesthesia time and complications following tracheostomy placement.

BACKGROUND: Increased anesthesia time may lead to respiratory complications in patients receiving tracheostomy, which contributes to patient morbidity. METHODS: The American College of Surgeon's National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for cases of planned tracheostomy (CPT 31600) from 2005 to 2012. Patients were stratified into quintiles based on anesthesia duration. Pearson's chi square, Fischer's exact test, one-way ANOVA, and multivariate regression were used to determine the association between patient characteristics with pneumonia and ventilator dependence. RESULTS: Out of 752 patients, 83 patients experienced post-operative pneumonia, and 166 experienced ventilator dependence. Following multivariate regression analysis, anesthesia quintiles were not significantly associated with pneumonia or ventilator dependence. Age (OR 1.03, 95% CI 1.00-1.05, P = .032), dyspnea (OR 2.21, 95% CI 1.18-4.13; P = .013), pre-operative ventilator dependence (OR 3.08, 95% CI 1.19-7.98; P = .020), and sepsis (OR 6.68, 95% CI 3.19-14.0; P < .001) remained as significant predictors of post-operative ventilator dependence. CONCLUSIONS: Faster may not be better-- prolonged anesthesia time does not increase the risk of post-operative pneumonia or ventilator dependence in patients receiving a planned tracheostomy in the operating room.

Avoiding Respiratory and Peripheral Muscle Injury During Mechanical Ventilation: Diaphragm-Protective Ventilation and Early Mobilization.

Both limb muscle weakness and respiratory muscle weakness are exceedingly common in critically ill patients. Respiratory muscle weakness prolongs ventilator dependence, predisposing to nosocomial complications and death. Limb muscle weakness persists for months after discharge from intensive care and results in poor long-term functional status and quality of life. Major mechanisms of muscle injury include critical illness polymyoneuropathy, sepsis, pharmacologic exposures, metabolic derangements, and excessive muscle loading and unloading. The diaphragm may become weak because of excessive unloading (leading to atrophy) or because of excessive loading (either concentric or eccentric) owing to insufficient ventilator assistance.

Surgery for Cerebellar Hemorrhage: A National Surgical Quality Improvement Program Database Analysis of Patient Outcomes and Factors Associated with 30-Day Mortality and Prolonged Ventilation.

OBJECTIVE: Primary cerebellar hemorrhage accounts for 10% of all intracranial hemorrhages. Given the confined space of the posterior fossa, cerebellar hemorrhage management sometimes necessitates suboccipital decompression and hematoma evacuation. In this study, we examine outcomes after surgery for primary cerebellar hemorrhage and identify risk factors associated with adverse outcomes. METHODS: A retrospective review of the 2005-2014 American College of Surgeons-National Surgical Quality Improvement Program database was performed, with Current Procedural Terminology Code 61315 (suboccipital craniectomy or craniotomy for evacuation of cerebellar hemorrhage) queried between 2005 and 2014. Patient demographics, preoperative comorbidities, and 30-day outcomes were analyzed. Univariate and multivariate regression analyses were performed to identify predictors of mortality and adverse events. RESULTS: A total of 158 craniotomies were studied, with a 30-day mortality rate of 26.6%. The most common adverse events included ventilator dependence after 48 hours (48.7%) and pneumonia (24.1%). Almost one quarter (24.7%) of patients required additional operations, with 8.5% of patients undergoing repeat craniotomy. Death was associated with premorbid dependent functional status (P = 0.005), American Society of Anesthesiologists class (P = 0.010), and history of congestive heart failure (P = 0.031). Prolonged ventilation was associated with premorbid functional status (P = 0.043) and ventilator dependence (P = 0.007) before surgery. CONCLUSIONS: Cerebellar hemorrhage is associated with significant risk of mortality and ventilator dependence. In patients who require surgery, 30-day mortality risk remains high (26.6%), with functional status and American Society of Anesthesiologists class predictive of death.

An Evaluation of a Continuing Education Program for Family Caregivers of Ventilator-Dependent Children with Spinal Muscular Atrophy (SMA).

Until 25 years ago, there were limited options for long-term mechanical ventilation of children, and the majority of children were cared for in hospitals. However, with improving technology, the pediatric intensive care unit has moved from the hospital to a home setting, as children with increasingly complex healthcare needs are now often cared for by family members. One of the most complex care conditions involves ventilator and tracheostomy support. Advanced respiratory technologies that augment natural respiratory function prolong the lives of children with respiratory compromise; however, this care often comes with serious risks, including respiratory muscle impairment, respiratory failure, and chronic pulmonary disease. Both non-invasive assisted ventilation and assisted ventilation via tracheostomy can prolong survival into adulthood in many cases; however, mechanical ventilation in the home is a high-stakes, high risk intervention. Increasing complexity of care over time requires perpetual skill training of family caregivers that is delivered and supported by professional caregivers; yet, opportunities for additional training outside of the hospital rarely exist. Recent data has confirmed that repetitive caregiver education is essential for retention of memory and skills in adult learners. This study analyzes the use of continued education and training in the community for family caregivers of ventilator-dependent children diagnosed with spinal muscular atrophy (SMA).

Routine airway surveillance in pediatric tracheostomy patients.

OBJECTIVES: The aim of this study is to review airway findings in children with tracheostomies who underwent surveillance direct laryngoscopy and bronchoscopy (DLB) to determine the yield of routine airway evaluation in these patients. STUDY DESIGN: Retrospective chart review at tertiary referral children's hospital. METHODS: A retrospective chart review was conducted of all of the children with tracheostomies who underwent DLB after tracheostomy between 1984 and 2015. RESULTS: A total of 303 patients met inclusion criteria. The median time interval between tracheostomy and first follow-up DLB was 12.0 months (IQR 4.8-28.9 months). There was no significant difference in the incidence of airway lesions between patients who underwent endoscopy <6 months post tracheostomy versus those who had a longer time interval between tracheostomy and DLB (p = 0.16). One hundred sixty seven patients (55.1%) were diagnosed with lesions, with suprastomal granulation (39.9%) being the most common. Symptomatic patients were significantly more likely to have an airway lesion identified (69.9% versus 42.0%; p < 0.001). Ventilator dependent patients and those with either cardiopulmonary disease or traumatic injury as indications for tracheostomy were significantly more likely to have an airway lesion (p = 0.01). CONCLUSIONS: The high incidence of airway lesions noted during surveillance DLB support the utility of routine airway endoscopy in pediatric tracheostomy patients. Symptomatic patients, those with ventilator dependence, or cardiopulmonary or trauma indications for tracheostomy are more likely to have airway lesions and should be monitored closely. The ideal time interval between surveillance endoscopies needs to be examined further.