NIV: Transition from ICU to home

Uros Krivec

Unit for pulmonary diseases

University children’s hospital Ljubljana, Slovenia

Introduction

AIMS

• Patients at risk for unsuccessful weaning from the mechanical

ventilation in the ICU

• The interplay of ICU and HDU / specialised ward for successful

transfer from the hospital to the home

• Real-life case scenario

Question 1

Where do you work?

1. Pediatric ICU

2. Pediatric HDU / Ward

3. Adult ICU

4. Adult HDU / Ward

5. Other

Question 2

Does your hospital have ICU /

HDU / Ward interdisciplinary

meetings (other than direct

patient care)?

1. Yes

2. No, but I would wish to

3. No, not realistic

Morbidity of pediatric ICU survivors

Pinto NP et al. Pediatr Crit Care Med. 2017;18(3):e122-e130

The ICU path of ventilatory support

Kneyber MCJ et al.

Intensive Care Med. 2017;43(12):

1764-1780 .

Risk of weaning failure

Kurachek SC et al.

Crit Care Med. 2003;31(11):2657-64

NIV after extubation

Mayordomo-Colunga J et al. BMC Pediatr. 2015;10:29

• There are insufficient data to recommend the routine use of non-invasive respiratory

support after extubation for any patient category.

• However, early application of NIV combined with cough-assist techniques should be

considered in neuromuscular diseases to prevent extubation failure (strong

agreement).

Kneyber MCJ et al. Intensive Care Med. 2017;43(12):1764-1780 .

Fine-Goulden MR et al. Lancet Respir Med. 2015;3(10):745-6

„Children with neuromuscular and

neurological disorders are least likely to

wean off “ [mechanical ventilation].

„Children with severe physical and

cognitive disabilities are also

increasingly offered long-term

ventilation to prolong life, with no

expectation of weaning.“

Who is at risk?

Windisch W et al. Respiration. 2018;96(2):171-203.

Leaving ICU possible, but NIV still required

Amaddeo A et al.

Pediatr Pulmonol. 2016;

51(9):968-74

From ICU to home

HDU / Specialised ward

Parents / Home team

ICU

Multidisciplinary Team Care ProtocolsChild needing

home ventilation

Effective communication

The interplay for success

ICU HDU / Ward / Home care

Effective communicationICU HDU / Ward / Home care

Difficult weaning foreseen HV patient admitted

↔ Gather informationDeliver information

Arrange parent/medical team meeting

↔ Get actively involved

Get the right equipment / advice on management

↔ Support

Plan for optimal timing ↔ Get ready

Initiate NIVStep down to home device

↔ Actively assist

Monitor and adapt accordingly ↔ Actively assistGet ready for admission

Pre transfer parent/medical team meeting

↔ Deliver information Make a clear plan

Ready for transfer ↔ AdmissionDischarge planning

In the ICU

Mortamet G et al.

Paediatr Respir Rev.

2017;23:84-88

ICU Foreseeing transfer

The medical teamAdequate training, effective communication

→ Be available, get actively involved

NIV requirements 24/7, fast & easy initiation → Periods of respiratory autonomy

DeviceICU ventilator → Home ventilator

Interface / headgearLarge choice, immediately availableNon-vented / ventedNasal mask 1st choiceOther if unsuccessful (oro-nasal, total face, helmet)

→ VentedShift to nasal / “minimal-contact”

SedationWean off, nonpharmacologicalPacifier

→ Anxiety reduction approach,pacifier

In the ICUICU Foreseeing transfer

ComplicationsIntoleranceAir leaksSkin damageDeterioration / atelectasis

→ Get ready, provide support

Respiratory physiotherapyTeam member, cough assist → Availability, adequate care

NutritionIV to enteral (NGT, GS, PO) → Tolerability of feeding, NG tube

issues?

ParentsClear explanations, realistic plans

→ Be presentActive involvement / teaching

Mortamet G et al. Paediatr Respir Rev. 2017;23:84-88

In the HDU / on the ward

Main goal: Going home / chronic care facility

Escarrabill J. ERS Practical Handbook of Noninvasive Ventilation, 2015

Getting ready → discharge planning:

• Assessment of the patient

• Planned interventions by the multidisciplinary

team

• Structured therapeutic education for the patient

and their carers

• A follow-up programme

Assessment - NIV optimisationInterface adaptation

• Change for nasal, minimal contact mask

Ventilatory settings optimisation

• General condition changes after ICU discharge

Overnight oximetry / PG

• Verification of efficient ventilation

Secretions management

• Cough assist, efficient cough support

Is the patient ready?

Stable condition - no ventilatory settings/oxygen changes for several days on home device.

Sterni LM et al. Am J Respir Crit Care Med. 2016;193(8):e16-35

Structured education for the parents /carer

Parent / carer must:

• Get basic clinical knowledge

• Be familiar with equipment use and maintenance

• Be proficient in basic technical skills

• Efficiently solve basic emergency events

• Be trained in secretion clearance techniques

Systematic knowledge examination must be made.

If available, teaching in a simulation centre can be perused.

Rose L et al. Respir Care. 2015;60(5):695-704

Boroughs DS. Children (Basel). 2017;4(5). pii: E33

Contacts• NIV Centre team access (phone / e-mail)

• Out office hours phone contact

• Technical support 24/7 phone contact

• Emergency phone contact

Home /community • Specific advice on how to adapt the home

• Solve transfers and mobility in the home issues

• Contact home team/nurse/doctor service

• Social worker‘s advice on available support

Follow-up

Courtesy of Prof Fauroux

„C'est arrivé près de chez vous“

15-yr-old boy with DMD – What went wrong?

An interactive case

Distressed call in May…

Situation

• Tertiary PICU admission for left

side pneumonia 10 days ago

• Acute respiratory failure, ET

intubation

• Low fever and low

inflammation markers

• Received intensive respiratory

physiotherapy (Cough Assist)

• Extubation 2x unsuccessful

• NIV not provided

Why?

?

Question 3

What is in your opinion the main reason for extubation failure?

1. Disease progression

2. Upper airway instability

3. ICU-acquired weakness

4. Suboptimal physiotherapy

5. No NIV after extubation

Regular follow-up…

Situation

• Seen 6 mo before

• No chest infections in past year

• VC 360 ml, PCF 100 l/min

• CBG: pH 7.382, PCO2 45 mm Hg,

HCO3 29 mmol/L

• Overnight polygraphy: M SpO2

97%, Time <90% - 2% TST, Peaks

PtcCO2 52 mmHg

• Has Cough Assist at home

• Control scheduled in 6 mo

Why?

?

Question 4

What would you do at this point:

1. Recheck - repeat PG in 1 mo

2. Consider night-time NIV in near future

3. Start nigh-time NIV

4. Optimise respiratory physiotherapy

5. Get expert advice

Transfer to our PICU…

Situation

• Extubation planned for Friday

10:00

• Cough assist prior to

extubation

• Full face mask, CPAP

• Acute deterioration, presumed

L lung atelectasis

• Bronchoscopy

• SIMV (BackUpRate 10/min)

• At 02:36 - reintubated

Why?

?

Question 5

What is in your opinion the main reason for extubation failure?

1. Suboptimal extubation planning

2. Bronchoscopy aggravated patent‘s condition

3. Patient can not be weaned, tracheostomy should be performed

4. No adequate communication

5. Lack of NIV expertise

2nd atempt…

Situation

• Extubation planned for Monday

10:00

• Cough assist prior to

extubation

• Oro-nasal mask, NIV PC

AVAPS (BackUp Rate 20/min)

• Regular physiotherapy

• Success – stable on NIV

• 2nd day - transferred to HDU on

NIV

Why?

?

Discharged home on NIV…

Situation

• Change to nasal minimal

contact mask

• S/T AVAPS, IPAP 18/14, EPAP

6, TV 300 ml, FD 20 /min, Ti

1.0 s, Triger: auto-trak

• Regular Cough Assist + parent

education

• Re-feeding (-10 kg)

• Discharged on D13

• Scheduled for control in 2 w

Why?

?

Question 6

What was in your opinion the key to successful weaning?

1. Spontaneous recovery

2. Refeeding

3. High back-up rate

4. Adequate sedation

5. Getting advice and support from outside the ICU

6. Adequate timing

WHAT WENT WRONG?

Distressed call in May…

Situation

• Tertiary PICU admission for left

side pneumonia

• Acute respiratory failure, ET

intubation

• Low fever and low

inflammation markers

• Regular respiratory

physiotherapy (Cough Assist)

• Extubation 2x unsuccessful

Why?

NIV not attempted

Atelectasis most probable

Low pressures (+/- 20 cm H2O)

No protocol

Regular follow-up…

Situation

• Seen 6 mo before

• No chest infections in past yr

• VC 360 ml, PCF 100 l/min

• CBG: pH 7.382, PCO2 45 mm

Hg, HCO3 29 mmol/L

• Overnight polygraphy: M SpO2

97%, Time SpO2<90% - 2%

TST, Peaks PtcCO2 52 mm Hg

• Has Cough Assist at home

• Control scheduled in 6 mo

Why?

Very compromised LF

Borderline day-time

hypercarbia

Overnight high PCO2 peaks

CA not correctly checked (!)

Transfer to our PICU…

Situation

• Extubation planned for Friday

10:00

• Cough Assist prior to

extubation

• Full face mask, CPAP

• Acute deterioration, presumed

L atelectasis

• Bronchoscopy

• SIMV (BackUp Rate 10/min)

• 02:36 - reintubated

Why?

Pressures +/- 26 cm H2O (!)

Severe anxiety, no resp. pump support (CPAP!)

Really necessary?

Inadequate respiratory support

Bad result

2nd atempt…

Situation

• Extubation planned for Monday

10:00

• Cough Assist prior to

extubation

• Oronasal mask, NIV S/T

AVAPS (BackUp Rate 20/min)

• Regular physiotherapy

• 2nd day transferred to HD Unit

on NIV

Why?

Pressures +/- 65 cm H2O

+ oscillations

Appropriate setting, lower

anxiety

First time sleeps > 3 hours

Discharged home on NIV…

Situation

• Change to nasal minimal

contact mask

• S/T AVAPS, IPAP 18/14, EPAP

6, TV 300 ml, FD 20/min, Ti

1.0 s, Triger: Auto-trak

• Regular Cough Assist + parent

education

• Re-feeding (-10 kg)

• Discharged on D13

• Scheduled for control in 2 w

Why?

Can talk and carefully drink

Respiratory support step down

Appropriate re-education (!)

Muscle mass regain

Further corrections needed

What made the difference?

• Right approach and anxiety relief

• CHECK / RE-CHECK the basics (CA pressures)

• Deliver support and guidance

• Optimal equipment (device / interfaces)

• Experience

Conclusions

• An increase in complexity and morbidity has been seen

in children leaving the ICUs.

• Children with different chronic conditions are at risk for

difficult weaning (specially neuromuscular diseases ).

• The number of children on long term (non-invasive and

invasive) ventilation is rising.

Conclusions

• Effective communication and the continuum of care

between ICU and HDU/specialised ward is the key to

success in ventilatory management.

• Structured discharge planning enables safe transfer of

ventilator-dependent children from the hospital to the

home.

• Adequate education and empowerment of parents/carers

allows for successful home care of complex, technology

dependent children.

Thank you for your attention!

Questions?