Liberation From Technology: Weaning From the Ventilator and Decannulation in Children Requiring Long-term Ventilator Support

Abstract

PURPOSE: Increasing numbers of children require long-term ventilator support. For many, the goal is liberation from this technology. Home ventilation weaning and tracheostomy decannulation strategies vary due to multiple clinical indications and lack of clinical practice standards. We evaluated how children were successfully weaned from the ventilator and decannulated. We hypothesized there are differences in the timing based on underlying diagnoses [e.g., chronic lung disease of prematurity (CLD) versus congenital heart disease (CHD)]. METHODS: This was a retrospective review of 30 children followed in Children's Hospital of Wisconsin's Tracheostomy/Ventilator program successfully decannulated between July 1999 and December 2011. Ages at important steps in weaning were calculated for all subjects and in the CHD and CLD populations. Statistical analysis was performed in SPSS 16. RESULTS: Thirty children were decannulated (15 boys, 14 Caucasian, 11 CLD, 13 CHD). Overall, median age at tracheostomy placement was 4.1 months. Ninety percent of children (n=27) started home ventilation during their initial hospitalization (median age 7.4 months). Median age of trach collar (TC) initiation was 13.4 months; 37% (n=11) started TC during initial hospitalization. Median age at home ventilator discontinuation and decannulation were 27.2 and 44.8 months, respectively. Eighty percent of children decannulated between April and October (n=24). CLD children weaned from the ventilator more quickly compared to CHD children (21.1 versus 28.3 months; p=0.04); yet, there was no statistically significant difference in age at decannulation (p= 0.26). We identified 7 major weaning steps towards decannulation that combined into 12 pathways without consensus on a single, best pathway. Forty-six percent (n=14) of children completed all 7 steps with trach capping most frequently skipped (n=14). CONCLUSIONS: Children with complex medical histories can be liberated from technology at relatively young ages. Younger age at ventilator discontinuation in CLD may reflect its natural history compared to the surgical interventions required in CHD.