Weaning strategies for children on home invasive mechanical ventilation

Abstract

Children who require home mechanical ventilation (HMV) with an artificial airway or invasive mechanical ventilation (HMV) have a possibility of successful weaning due to the potential of compensatory lung growth. Internationally accepted guidelines on how to wean from HMV in children is not available, we summarize the weaning strategies from the literature reviews combined with our 27‐year experience in the Pediatric Home Respiratory Care program at the tertiary care center in Thailand. The readiness to wean is considered in patients with hemodynamic stability, having effective cough measured by maximal inspiratory pressure, requiring a fraction of inspired oxygen (FiO2) < 40%, positive end expiratory pressure <5 cmH2O, and acceptable arterial blood gases. The strategies of weaning is start weaning during the daytime while the child is awake and close monitoring is feasible. Disconnect time is gradually increased through naps and sleeping hours. Weaning from the conventional mechanical ventilator to Bilevel PAP or CPAP are optional. Factors affected the successful weaning are mainly the underlying diseases, complications, growth and development, caregivers, and resources. Weaning should be stopped during acute illness or increased work of breathing. The readiness for decannulation could be determined by using the speaking devices, tracheostomy capping, and measurement of end‐expiratory pressure. Polysomnography and airway evaluation by bronchoscopy are recommended before decannulation. Weaning when the child is ready is crucial because living with HMV can be challenging and stressful. Failure to remove a tracheostomy when indicated can result in delayed speech, social problems as well as risk for infection.

Multidisciplinary management of pediatric patients on home invasive mechanical ventilation

“…17 Although many children require HIMV for life, some underlying conditions may improve with time, which will require evaluation and planning for gradual withdrawal of HIMV. The importance of timing of weaning, creating a weaning program and recognizing weaikning failure and success for children dependent on HIMV are reviewed by Kamaloporn et al 18 A core principle guiding clinical practice and modern medicine is 'first do no harm'. The decision making process of initiating HIMV in children, many whom have incurable life-limiting conditions, must often navigate complex ethical considerations to find a balance between parental or patient wishes (autonomy), improving QOL (beneficence) and avoiding doing more harm (nonmaleficence).…”