Abstract Objective To provide a systematic review of the existing pediatric decannulation protocols, including the role of polysomnography, and their clinical outcomes. Methods Five online databases were searched from database inception to May 29, 2020. Study inclusion was limited to publications that evaluated tracheostomy decannulation in children 18 years of age and younger. Data extracted included patient demographics and primary indication for tracheostomy. Methods used to assess readiness for decannulation were noted including the use of bronchoscopy, tracheostomy tube modifications, and gas exchange measurements. After decannulation, details regarding mode of ventilation, location, and length of observation period, and clinical outcomes were also collected. Descriptive statistical analyses were performed. Results A total of 24 studies including 1395 children were reviewed. Tracheostomy indications included upper airway obstruction at a well‐defined anatomic site (35%), upper airway obstruction not at a well‐defined site (12%) and need for long‐term ventilation and pulmonary care (53%). Bronchoscopy was routinely used in 23 of 24 (96%) protocols. Tracheostomy tube modifications in the protocols included capping ( n = 20, 83%), downsizing ( n = 14, 58%), and fenestrations ( n = 2, 8%). Measurements of gas exchange included polysomnography ( n = 13/18, 72%), oximetry ( n = 10/18, 56%), blood gases ( n = 3,17%), and capnography ( n = 3, 17%). After decannulation, children in 92% of protocols were transitioned to room air. Observation period of 48 h or less was used in 76% of children. Conclusions There exists large variability in pediatric decannulation protocols. Polysomnography plays an integral role in assessing most children for tracheostomy removal. Evidence‐based guidelines to standardize pediatric tracheostomy care remain an urgent priority.
We co-developed a multi-component virtual care solution (TtLIVE) for the home mechanical ventilation (HMV) population using the aTouchAway™ platform (Aetonix). The TtLIVE intervention includes (1) virtual home visits; (2) customizable care plans; (3) clinical workflows that incorporate reminders, completion of symptom profiles, and tele-monitoring; and (4) digitally secure communication via messaging, audio, and video calls; (5) Resource library including print and audiovisual material.Our primary objective is to evaluate the TtLIVE intervention compared to a usual care control group using an eight-center, pragmatic, parallel-group single-blind (outcome assessors) randomized controlled trial. Eligible patients are children and adults newly transitioning to HMV in Ontario, Canada. Our target sample size is 440 participants (220 each arm). Our co-primary outcomes are a number of emergency department (ED) visits in the 12 months after randomization and change in family caregiver (FC) reported Pearlin Mastery Scale score from baseline to 12 months. Secondary outcomes also measured in the 12 months post randomization include healthcare utilization measured using a hybrid Ambulatory Home Care Record (AHCR-hybrid), FC burden using the Zarit Burden Interview, and health-related quality of life using the EQ-5D. In addition, we will conduct a cost-utility analysis over a 1-year time horizon and measure process outcomes including healthcare provider time using the Care Coordination Measurement Tool. We will use qualitative interviews in a subset of study participants to understand acceptability, barriers, and facilitators to the TtLIVE intervention. We will administer the Family Experiences with Care Coordination (FECC) to interview participants. We will use Poisson regression for a number of ED visits at 12 months. We will use linear regression for the Pearlin Mastery scale score at 12 months. We will adjust for the baseline score to estimate the effect of the intervention on the primary outcomes. Analysis of secondary outcomes will employ regression, causal, and linear mixed modeling. Primary analysis will follow intention-to-treat principles. We have Research Ethics Board approval from SickKids, Children's Hospital Eastern Ontario, McMaster Children's Hospital, Children's Hospital-London Health Sciences, Sunnybrook Hospital, London Health Sciences, West Park Healthcare Centre, and Ottawa Hospital.This pragmatic randomized controlled single-blind trial will determine the effectiveness and cost-effectiveness of the TtLIVE virtual care solution compared to usual care while providing important data on patient and family experience, as well as process measures such as healthcare provider time to deliver the intervention.ClinicalTrials.gov NCT04180722 . Registered on November 27, 2019.
Introduction: Recent trends demonstrate increased E-cigarette/vaping usage amongst adolescents, despite known adverse health effects. The existing literature is limited regarding the prevalence of E-cigarette use in adolescents with chronic lung conditions who may be at highest risk, such as cystic fibrosis (CF) and primary ciliary dyskinesia (PCD). The aim of this study was to assess the prevalence of E-cigarette use among adolescents with CF and PCD. Method: This was a quality improvement project conducted between October 2022 and February 2023 for adolescents aged 12-18 years with CF or PCD at SickKids Hospital, Toronto Canada. Adolescents were screened during regularly scheduled visits to the CF and PCD clinics. Existing clinic templates that probed for cigarette smoking were modified to specifically inquire about E-cigarette use. Results: 36 patients were included in the analysis (21 CF and 15 PCD). There was no significant difference between groups for female gender (48% vs 67%, p=0.26) or age at screening; 14.1 years (1.9) vs 14.2 (1.6), for CF versus PCD, respectively. Rates of E-cigarette use were higher in adolescents with PCD compared to CF (4/15 (27%) vs 1/21 (5%), p=0.06). Vaping use was mostly daily or several times per week and mostly with friends or at school. All patients who screened positive for e-cigarette usage had not previously screened positive when assessed for traditional cigarette smoking. Conclusion: E-cigarette use is more common among adolescents with PCD compared to CF. Clinicians must specifically inquire about E-cigarette usage to provide necessary supports. Further studies assessing the clinical impact of E-cigarettes in CF and PCD are needed.
Abstract Primary Subject area Respirology Background Despite the large morbidity and potential mortality associated with tracheostomy tube decannulation failure, there are currently no consensus guidelines on pediatric tracheostomy decannulation. This has led to wide practice variation that is largely based on expert option. This is the largest review of pediatric decannulation protocols. Objectives To systematically review the literature on existing pediatric decannulation protocols, including the role of polysomnography, and their clinical outcomes. Design/Methods Five online databases were searched for relevant studies from database inception to May 29, 2020. Study inclusion was limited to publications that evaluated tracheostomy decannulation in children 18 years of age and younger. Independent reviewers extracted data, including patient demographics and primary indication for tracheostomy. Methods used to assess readiness for decannulation were noted, including the use of bronchoscopy, tracheostomy tube modifications, and gas exchange measurements. After decannulation, details regarding mode of ventilation, location and length of observation period, and clinical outcomes were also collected. Quality assessment of included studies was performed using the Newcastle-Ottawa Scale (NOS) tool. Descriptive statistical analyses were performed. Results Twenty-three studies with 1328 children were included (Figure 1). Tracheostomy indications included upper airway obstruction at a well-defined anatomic site (37%), upper airway obstruction not at a well-defined site (13%), and need for long-term ventilation (50%). Bronchoscopy was routinely used in 96% of protocols. Tracheostomy tube modifications in the protocols included capping (83%), downsizing (57%), and fenestrations (9%). Measurements of gas exchange in the protocols included polysomnography (72%), oximetry (61%), blood gases (17%), and capnography with end-tidal CO2 (17%). After tracheostomy decannulation, children in 92% of protocols were transitioned to room air, and 38% of protocols used non-invasive ventilation. Most children (76%) were observed in hospital for 48 hours or less. Of all decannulation attempts, 79% were successful. Overall risk of bias in included studies was low. Conclusion The absence of clear evidence-based guidelines in pediatric tracheostomy decannulation has led to large variability in clinical practice. Most protocols include bronchoscopy, tube modifications, gas exchange measurements, and brief hospital admission. Polysomnography plays an integral role in assessing the majority of children for tracheostomy removal. Evidence-based guidelines to standardize pediatric tracheostomy care remain an urgent priority.
This report describes the first known case of Mucopolysaccharidosis type IIIA presenting with respiratory symptoms and characteristic lung pathology. This case highlights under-recognized areas of systemic involvement and earlier modes of presentation in lysosomal storage disorders as well as the importance of investigating infants who have persistent tachypnea.
Children with neuromuscular disease (NMD) are at risk of acquiring respiratory complications. Both clinical assessments and respiratory diagnostic tests are important to optimize the respiratory health and care of such children. The following respiratory diagnostic tools and their utility for evaluating children with NMD are discussed in this article: lung function testing (spirometry and lung volumes), peak cough flow (PCF), respiratory muscle strength testing, oximetry, capnography, and polysomnography.
Several cases of parkinsonism were found in a ferromanganese smelter after the ventilation system had broken down and had not been repaired for eight months in 1985. To determine the aetiology and prevalence of parkinsonism, 132 workers were submitted to thorough medical examination and estimated air concentrations of carbon monoxide and manganese at different worksites. Only six of eight workers performing electrode fixation or welding during 1985 developed parkinsonism. They were exposed for 30 minutes each day, seven days a week, to high concentrations of air manganese (greater than 28.8 mg/m3). There was a consistent trend between the index of exposure to manganese and signs and symptoms exhibited by extrapyramidal systems. After repair of the ventilation system, the air concentration of manganese during electrode fixation and welding decreased to less than 4.4 mg/m3; furthermore, no new cases of parkinsonism have been observed. Workers with parkinsonism recovered partially after removal from original worksites and treatment with levodopa. It is concluded that the outbreak resulted from exposure to high concentrations of manganese fumes through the breakdown of the ventilation system.
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