- Email: [email protected]
PSG for titration of home ventilation
Oral Presentations / Paediatric Respiratory Reviews 13S1 (2012) S1–S50
[3] [4]
[5]
[6]
[7]
Working Party on Paediatric Long Term Ventilation. Thorax. 1998 Sep;53(9):762–7. The World Bank Group. Thailand Economic Monitor – April 2011. [cited 2012 April 27]; Available from: http://go.worldbank.org/0QV5D81040. Pannarunothai S, Patmasiriwat D, Srithamrongsawat S. Universal health coverage in Thailand: ideas for reform and policy struggling. Health Policy. 2004 Apr;68(1):17–30. Preutthipan A, Suwanjutha S, Chantarojanasiri T. The state of affairs of pediatric respiratory home care in Thailand. American Academy of Pediatrics. The Section on Home Health Newsletter 2000; 4: 6–8. Preutthipan A, Suwanjutha S, Utrarachkij J. Present status and future trend of the pediatric respiratory home care program in Thailand. Bronchus. 1996; 11: 2–4. Preutthipan A. Sending the children home – Donated ventilators provide home care support. Chest Soundings. 2002; 16: 22–3.
PRL-03 PSG for titration of home ventilation N. Simakajornboon. Cincinnati Children’s Hospital Medical Center, Cincinnati, USA There are increasing numbers of technology dependent children who require tracheostomy and long term ventilator support. The most common indication for home mechanical ventilation is chronic respiratory failure associated with airway, parenchymal lung disease, neuromuscular disorders and respiratory control disorders. Respiratory support in these patients is changing due to alteration in respiratory mechanic associated with growth and improvement of underlying disease. Therefore, it is crucial to regularly assess the adequacy of ventilation and oxygenation in these children. The overnight sleep study is important tool in evaluation of home ventilation. The conventional way of setting ventilator settings is based on patient’s size and weight and then evaluating the adequacy of ventilation by monitoring oxygen saturation, and/or obtaining blood gas. Polysomnography provides many advantages compared to conventional method. First, sleep study allows assessment and making changes in real time. Second, sleep stage specific evaluation is an important part of ventilation titration study as sleep disordered breathing is usually worsen during REM sleep. Third, several additional problems besides inadequate ventilation can be identified from sleep study such as central sleep apnea, failure to trigger, excessive leak, auto-cycling. There are various protocols used for assessment of home ventilation such as ventilator titration, ventilator weaning. These protocols utilize various methods to optimizing ventilator settings including adjustment of ventilator parameters (tidal volume PIP, PS, PEEP, ventilator rate, sensitivity), oxygen flow, and leak assessment. In this lecture, we will review the role of polysomnography in diagnosis and management of children who are on home mechanical ventilation. Specific protocols related to pressure and volume control ventilator will be delineated. There is limited research study in this area. There is a need to conduct clinical research to examine the role of polysomnography in improved quality of life and decreased mobility in this population.
S37
excellent adaptability to varying TB diameter, stentplasty and the potential allowing for progressive expansion to accommodate the growing lumen without concomitant shortening in length. Therefore, BEMS are quite suitable for use in pediatric TB narrowing. In the past 14 years period (1998–2011), we have successfully implanted 100 BEMSs (25 Palmaz and 75 IntraStent) for TB lumen narrowing (65 malacia, 14 stenosis and 21 mixed) in 59 children by using short-length (30–35 cm) flexible endoscope (FE) with intravenous procedural sedation and a novel non-invasive ventilation (NIV, nasopharyngeal oxygen-nose closedabdomen compression) support. Three stent implantations were failure, 1 migration during balloon expansion and 2 premature departed, during procedure. Patient’s mean age was 23.4±32.0 months-old (10 days to 10 years) and body weight was 10.4±9.6 kg (2.3–33 kg). All these patients had already been using respiratory supports, 33 with nasal prongs NIV and 26 had tracheal intubation for prolonged periods and difficultly weaning. Stents were placed in the various locations of main TB lumens included 61 trachea, 7 carina, and 32 (right 15, left 17) bronchi. Multiple stents were placed in 28 patients due to complicated lesions. Duration of the main stent placement procedure was 6.3±1.6 min (4–12 min). All successfully stented patients showed immediate symptomatic improvement, got weaning of respiratory supports (NIV) and discharged home. Regularly bronchoscopic follow-ups (per 2–6 months) the TB lumens and stent conditions were recommended. The most common complication was stent-associated granulations which could be appropriately managed with inflated-balloon or laser debulking via FE. No any stent migration happens after its placement. Deformed stent could be repaired by using technique of stentplasty. Severe fractured, destructed or expected powerless stents (stayed >2 years) were considered to retrieved, by either rigid or flexible endoscopy. Following this policy, 30 stents (57.7%) were totally and safely retrieved, except one caused tracheal perforation and one needed tracheostomy (both were Palmaz). The total period of stented duration is 24.5±20.9 (median 19) months. There are no significant difficulties associated with the techniques of stent placement, complication (granulations or infections) managements, stentplasty, and removal. During the follow-up period, 12 patients died and only 2 patients were stent-related (Palmaz), both happen in the early years. The longest period of stent is 10 years which still adopted well inside the left main bronchial lumen. Summary to our experience, BEMSs can be safely, successfully and effectively placed by using short-length FE with NIV support in pediatric patients, even those with severely cardiopulmonary compromised condition. Both short- and long-term prognosis of these stents and patients is promising. PRL-06 Removal of foreign body by flexible bronchoscopy P. Pohunek, T. Svobodova. ´ Pediatric Pulmonology, Pediatric Department, Charles University, 2nd Faculty of Medicine, University Hospital Motol, Prague, Czech Republic Keywords: flexible bronchoscopy; children; foreign body aspiration; foreign body extraction
Bronchoscopy PRL-04 Debate: Airway stent is an important and under-utilized intervention in pediatric tracheobronchial diseases – Pro W.-J. Soong. Chief, PICU, Department of Pediatrics, Taipei-Veterans General Hospital, Taipei, Taiwan, ROC Tracheobronchial (TB) stent placement, compared to surgical interventions such as aortopexy, slide tracheoplasty, and so on, is less invasive and can achieve dramatic and immediate responses. It has gradually being used to restore TB patency in selected patients. Balloon expandable metallic stents (BEMS) have the advantages of smaller pre-expanded diameters, thin wall, appropriate lengths,
Abstract: Aspiration of foreign body is one of rather frequent pediatric emergencies. Children aspirate various subjects, most frequently some foods, such as nuts, peanuts or vegetables. Often also some small parts of toys or various other subjects have been aspirated. Urgency of removal depends on the nature and size of the foreign body and on the degree of respiratory compromise that such an aspiration may cause. Traditionally, rigid bronchoscopy had been considered a method of choice; however, in recent years many published reports documented a possibility to remove airway foreign bodies in children by a flexible bronchoscope with appropriate accessories. Introduction: Aspiration of a foreign body (FB) has been documented to be one of frequent pediatric emergencies. Children
[3] [4]
[5]
[6]
[7]
Working Party on Paediatric Long Term Ventilation. Thorax. 1998 Sep;53(9):762–7. The World Bank Group. Thailand Economic Monitor – April 2011. [cited 2012 April 27]; Available from: http://go.worldbank.org/0QV5D81040. Pannarunothai S, Patmasiriwat D, Srithamrongsawat S. Universal health coverage in Thailand: ideas for reform and policy struggling. Health Policy. 2004 Apr;68(1):17–30. Preutthipan A, Suwanjutha S, Chantarojanasiri T. The state of affairs of pediatric respiratory home care in Thailand. American Academy of Pediatrics. The Section on Home Health Newsletter 2000; 4: 6–8. Preutthipan A, Suwanjutha S, Utrarachkij J. Present status and future trend of the pediatric respiratory home care program in Thailand. Bronchus. 1996; 11: 2–4. Preutthipan A. Sending the children home – Donated ventilators provide home care support. Chest Soundings. 2002; 16: 22–3.
PRL-03 PSG for titration of home ventilation N. Simakajornboon. Cincinnati Children’s Hospital Medical Center, Cincinnati, USA There are increasing numbers of technology dependent children who require tracheostomy and long term ventilator support. The most common indication for home mechanical ventilation is chronic respiratory failure associated with airway, parenchymal lung disease, neuromuscular disorders and respiratory control disorders. Respiratory support in these patients is changing due to alteration in respiratory mechanic associated with growth and improvement of underlying disease. Therefore, it is crucial to regularly assess the adequacy of ventilation and oxygenation in these children. The overnight sleep study is important tool in evaluation of home ventilation. The conventional way of setting ventilator settings is based on patient’s size and weight and then evaluating the adequacy of ventilation by monitoring oxygen saturation, and/or obtaining blood gas. Polysomnography provides many advantages compared to conventional method. First, sleep study allows assessment and making changes in real time. Second, sleep stage specific evaluation is an important part of ventilation titration study as sleep disordered breathing is usually worsen during REM sleep. Third, several additional problems besides inadequate ventilation can be identified from sleep study such as central sleep apnea, failure to trigger, excessive leak, auto-cycling. There are various protocols used for assessment of home ventilation such as ventilator titration, ventilator weaning. These protocols utilize various methods to optimizing ventilator settings including adjustment of ventilator parameters (tidal volume PIP, PS, PEEP, ventilator rate, sensitivity), oxygen flow, and leak assessment. In this lecture, we will review the role of polysomnography in diagnosis and management of children who are on home mechanical ventilation. Specific protocols related to pressure and volume control ventilator will be delineated. There is limited research study in this area. There is a need to conduct clinical research to examine the role of polysomnography in improved quality of life and decreased mobility in this population.
S37
excellent adaptability to varying TB diameter, stentplasty and the potential allowing for progressive expansion to accommodate the growing lumen without concomitant shortening in length. Therefore, BEMS are quite suitable for use in pediatric TB narrowing. In the past 14 years period (1998–2011), we have successfully implanted 100 BEMSs (25 Palmaz and 75 IntraStent) for TB lumen narrowing (65 malacia, 14 stenosis and 21 mixed) in 59 children by using short-length (30–35 cm) flexible endoscope (FE) with intravenous procedural sedation and a novel non-invasive ventilation (NIV, nasopharyngeal oxygen-nose closedabdomen compression) support. Three stent implantations were failure, 1 migration during balloon expansion and 2 premature departed, during procedure. Patient’s mean age was 23.4±32.0 months-old (10 days to 10 years) and body weight was 10.4±9.6 kg (2.3–33 kg). All these patients had already been using respiratory supports, 33 with nasal prongs NIV and 26 had tracheal intubation for prolonged periods and difficultly weaning. Stents were placed in the various locations of main TB lumens included 61 trachea, 7 carina, and 32 (right 15, left 17) bronchi. Multiple stents were placed in 28 patients due to complicated lesions. Duration of the main stent placement procedure was 6.3±1.6 min (4–12 min). All successfully stented patients showed immediate symptomatic improvement, got weaning of respiratory supports (NIV) and discharged home. Regularly bronchoscopic follow-ups (per 2–6 months) the TB lumens and stent conditions were recommended. The most common complication was stent-associated granulations which could be appropriately managed with inflated-balloon or laser debulking via FE. No any stent migration happens after its placement. Deformed stent could be repaired by using technique of stentplasty. Severe fractured, destructed or expected powerless stents (stayed >2 years) were considered to retrieved, by either rigid or flexible endoscopy. Following this policy, 30 stents (57.7%) were totally and safely retrieved, except one caused tracheal perforation and one needed tracheostomy (both were Palmaz). The total period of stented duration is 24.5±20.9 (median 19) months. There are no significant difficulties associated with the techniques of stent placement, complication (granulations or infections) managements, stentplasty, and removal. During the follow-up period, 12 patients died and only 2 patients were stent-related (Palmaz), both happen in the early years. The longest period of stent is 10 years which still adopted well inside the left main bronchial lumen. Summary to our experience, BEMSs can be safely, successfully and effectively placed by using short-length FE with NIV support in pediatric patients, even those with severely cardiopulmonary compromised condition. Both short- and long-term prognosis of these stents and patients is promising. PRL-06 Removal of foreign body by flexible bronchoscopy P. Pohunek, T. Svobodova. ´ Pediatric Pulmonology, Pediatric Department, Charles University, 2nd Faculty of Medicine, University Hospital Motol, Prague, Czech Republic Keywords: flexible bronchoscopy; children; foreign body aspiration; foreign body extraction
Bronchoscopy PRL-04 Debate: Airway stent is an important and under-utilized intervention in pediatric tracheobronchial diseases – Pro W.-J. Soong. Chief, PICU, Department of Pediatrics, Taipei-Veterans General Hospital, Taipei, Taiwan, ROC Tracheobronchial (TB) stent placement, compared to surgical interventions such as aortopexy, slide tracheoplasty, and so on, is less invasive and can achieve dramatic and immediate responses. It has gradually being used to restore TB patency in selected patients. Balloon expandable metallic stents (BEMS) have the advantages of smaller pre-expanded diameters, thin wall, appropriate lengths,
Abstract: Aspiration of foreign body is one of rather frequent pediatric emergencies. Children aspirate various subjects, most frequently some foods, such as nuts, peanuts or vegetables. Often also some small parts of toys or various other subjects have been aspirated. Urgency of removal depends on the nature and size of the foreign body and on the degree of respiratory compromise that such an aspiration may cause. Traditionally, rigid bronchoscopy had been considered a method of choice; however, in recent years many published reports documented a possibility to remove airway foreign bodies in children by a flexible bronchoscope with appropriate accessories. Introduction: Aspiration of a foreign body (FB) has been documented to be one of frequent pediatric emergencies. Children