Critical care-related factors impact morbidity after pediatric respiratory failure
In children who experienced acute respiratory failure, factors related to critical care, such as mechanical ventilation and inadequate pain management, were associated with worse functional status and health-related quality of life after hospital discharge, according to data published in the American Journal of Respiratory and Critical Care Medicine.
From 2009 to 2011, the cluster randomized RESTORE trial enrolled 2,449 children aged 2 weeks to 17 years who were mechanically ventilated for acute respiratory failure at 31 U.S. sites. The researchers conducted assessments 6 months after children’s discharge from the pediatric ICU and interviewed parents or guardians to assess children’s functional status and complete health-related quality of life questionnaires.
Functional decline after discharge
Twenty percent of 949 children with baseline and post-discharge interview data experienced decline in functional status from baseline to follow-up.
In univariate analyses, functional decline occurred more often in children with a history of prematurity or cancer, greater illness severity or a diagnosis of sepsis-related acute respiratory failure at hospital admission. In contrast, functional decline occurred less often in children with normal baseline function, a history of asthma or a diagnosis of bronchiolitis or asthma at hospital admission.
Univariate analyses demonstrated associations between decline in functional status and moderate or severe pediatric acute respiratory distress syndrome, 7 days or more of mechanical ventilation, and a stay of 14 days or more in the pediatric ICU and hospital.
Additionally, results linked functional decline to aspects of pain management and sedation, including receipt of specific types and amounts of medication and inadequate pain or sedation management. Decline in functional status was also more common with multiple organ dysfunction syndrome and increasing number of dysfunctional organs.
In multivariable analyses, the likelihood of decline was lower with normal baseline function and hospital admission for bronchiolitis or asthma, whereas functional decline was more likely with prematurity, cancer, hospital admission for exacerbation of chronic disease causing respiratory failure, longer duration of mechanical ventilation and receipt of clonidine (OR = 2.14; 95% CI, 1.22-3.76).
Of 960 children whose parents or guardians were interviewed, 91% had been discharged to home and 6% had been discharged to a rehabilitation or assisted living or immediate care facility. Thirty-four percent were readmitted to the hospital and 28% received paid home health care. Children with declines in functional status were less likely to be discharged home (80% vs. 94%; P < .0001) and more likely to be readmitted to the hospital (54% s. 39%; P < .0001) or receive paid medical help at home (43% vs. 24%; P < .0001).
Worse health-related quality of life
The researchers assessed health-related quality of life using the Infant and Toddler Quality of Life Questionnaire-97 (ITQOL) in children aged younger than 2 years and the Pediatric Quality of Life Inventory, Version 4.0 Generic Core Scales (PedsQL) in children older than 2. The ITQOL was used instead of the PedsQL in children aged 2 to 6 years with substantial developmental impairment.
ITQOL scores were significantly lower than U.S. norms for physical abilities, growth and development, pain and discomfort, getting along with others and general health perceptions in 273 children with normal baseline function. Among 63 children with impaired baseline function, ITQOL scores were worse than U.S. norms in all domains except for general behavior.
Among children with normal baseline function, 20% had impaired growth and development scores, of which receipt of methadone (OR = 2.27; 95% CI, 1.18-4.36) and inadequate pain management (OR = 2.94; 95% CI, 1.39-6.19) were shown to be independent predictors in multivariable analysis.
In the 343 children older than 2 years with normal baseline function, PedsQL scores were lower for emotional and school functioning than physical and social functioning. When compared with the reference group, these children had comparable total scores, but lower scores for the emotional functioning subscale and higher scores for the social functioning subscale. Children with impaired baseline function, however, had lower total scores and lower scores for all subscales than the reference group.
Overall, 19% of children with normal baseline function had scores indicating lower health-related quality of life. In univariate analyses, higher PRISM III-12 scores, inadequate pain or sedation management, longer durations of mechanical ventilation, pediatric ICU stay and hospital stay and receipt of opioid and/or benzodiazepines at hospital discharge were associated with impaired health-related quality of life.
In the final multivariable model, older age, non-white or Hispanic race or ethnicity and cancer diagnosis and inadequate sedation management were independently associated with impaired health-related quality of life (OR = 3.15; 95% CI, 1.74-5.72).
Potential role of critical care factors
The researchers noted that the study had several limitations, including incomplete data on socioeconomic status, the fact that baseline function was dependent on parental recall and medical history, and the assignment of functional status to broad categories due to the use of the Pediatric Cerebral Performance Category and Pediatric Overall Performance Category assessments.
Nevertheless, they noted that post-discharge morbidity was common in children with acute respiratory illness.
“Even when controlling for sociodemographic factors and pre-existing health status and features of the presenting acute illness, modifiable factors related to critical care were important, notably duration of mechanical ventilation, receipt of medications used to facilitate weaning from prolonged use of sedatives and analgesics, inadequate pain management among younger patients with normal baseline function, and sedation management among older patients with normal baseline function. The extent to which these factors led to adverse outcomes and, if modified, would have led to better outcomes is unclear but mandates further study,” the researchers wrote. “These factors identify populations at high risk of long-term adverse sequelae requiring careful evaluation and treatment after hospital discharge.” – by Melissa Foster
Disclosure: Healio Pulmonology could not confirm the authors’ relevant financial disclosures at the time of publication.