A clinician’s how

Amin R. Clinical topics in pulmonary medicine. B83. Why yes, you can ski with your ventilator! Using technology to keep NIV/IMV ventilator dependent patients active and engaged in their communities. Presented at: American Thoracic Society International Conference; May 19-24, 2023; Washington, D.C.

Amin R. Clinical topics in pulmonary medicine. B83. Why yes, you can ski with your ventilator! Using technology to keep NIV/IMV ventilator dependent patients active and engaged in their communities. Presented at: American Thoracic Society International Conference; May 19-24, 2023; Washington, D.C.

WASHINGTON — From equipment to transportation to nursing orders, clinicians must consider various factors before a ventilated child can go to school, according to a presentation at the American Thoracic Society International Conference.

"It is absolutely possible to send your medically complex children on ventilators to school," Reshma Amin, MD, MSc, pediatric respirologist and director of sleep medicine and long-term ventilation at The Hospital for Sick Children in Toronto, said during her presentation. "You just need to plan early and assemble your team; ensure all the needed equipment is on site; plan for safe travel to and from school; complete thorough and detailed nursing orders; make sure the nurses are adequately trained; and on an iterative basis, update those nursing orders. [Additionally,] don't forget to think about accessibility, be prepared for emergencies, and even after you sent the child to school, keep in constant touch with the patients and the families to hear about how things are going and if things need to be updated or changed."

Sending a child who is ventilated to school requires preparedness in several areas, and there are steps that clinicians can follow to accomplish this so that they do not forget anything, according to Amin.

The first step that should be taken is assembling the team of individuals that will be involved in helping the child, which Amin said is the responsibility of the health care provider. This team includes patient and family caregivers, the community care coordinator, the homecare nursing agency, a front-line nurse, health care providers and those at the school, such as the teacher, principal and educational assistant.

"It's really important to start planning early," Amin said during the presentation. "This is not something that often happens quickly, and sometimes you need to have multiple meetings to be able to address all of the questions that will come up by the various stakeholders."

The next step for clinicians to consider is the equipment the child will need at school. Amin said it is important to figure out what the child needs to bring with them, how they are going to transport it and whether they will keep any equipment at the school.

According to Amin, there are several key pieces of equipment that are needed. These include:

The emergency trach kit is necessary for children with a tracheostomy, and Amin said this includes several items that must be kept with the child, such as a same-size and next size smaller tracheostomy, precut gauze, scissors, lubricant, and saline nebules.

For children who need oxygen, there are several additional things to consider when sending them to school.

"You need to think about having a portable oxygen source, and this might be a portable oxygen concentrator, but for some of your patients, you will need to have oxygen secured and available at school in the event of an emergency," Amin said. "If that is the case, you need to ensure that the tanks are safely stored and secure. They need to be well away from any furnace and open flame. You also need to ensure that the tanks are in a well-ventilated location; they can't just be shoved in a cabinet or a closet."

Amin went on to say that safe storage is also necessary for CoughAssist (Philips/Respironics) machines or other equipment that is going to stay at the child's school. Since this device is staying at school, she said it is crucial to remember maintenance and safety checks of the device.

Step three of the plan to get a ventilated child to school is to think about how they will be transported to and from school. Taking a school bus introduces several new concerns and possibilities for the clinician and parents to consider, according to Amin.

Clinicians must figure out whether a nurse needs to be on the bus with the child and develop a plan in case of an emergency on the bus. Parents, on the other hand, have several duties to carry out to ensure that their child is safe during transportation. Amin said they need to assess their child prior to leaving for school and riding the bus, suction before leaving the house if applicable, make sure the child is properly strapped in the bus and within view of the bus driver and make sure the child has all their equipment with them.

In addition to transportation, clinicians and parents must think about who will care for the child while they are attending school, especially children with tracheostomy tubes and children who use noninvasive ventilation, Amin said.

To ensure that proper care is given to the child, clinicians must remember to update their patients’ ventilation information after each clinic visit and send it to the school to be adjusted on the Nursing Orders. Some information provided on these orders include a patients’ diagnoses, ventilator settings, medications, allergies and directions on how to use the tools.

Amin again emphasized the importance of planning early since finding a nurse for the child may take some time.

"All across North America, we have a nursing shortage," Amin said. "Therefore, you need to work early with patients, families and the school to do your best to identify nurses to go to school with children. We've probably all had patients that have had to stay home from school because the care provider cannot be identified, so plan early."

To make sure the child is able to get around and participate with their class, clinicians must get information on the accessibility of the school, as well as set the conditions for when a child should not participate in recess.

"Make a plan ahead of time to keep children inside during recess when there's extremes of temperature," Amin said. "It's helpful also to give a particular range of temperatures when you want the child to be staying inside."

According to Amin, it is also crucial to make several preparations in case of an emergency at school. This includes providing phone numbers of care providers, having knowledge of the closest ED and knowing what to do if there is a power failure at the school.

In addition to a possible long wait time to find a nurse for the child, Amin said there are two other common challenges associated with sending a child on ventilation to school. The first challenge is that parents/guardians do not want to take the child's equipment to school and back home every day, to which Amin said clinicians can try and get them an additional piece of equipment. However, as outlined above, equipment stored at school must be checked regularly for safety and maintenance.

The second challenge is a lack of humidification in patients who are on 24/7 ventilation. Amin said there are several factors that clinicians can look into if their patients report frequent mucus plugs.

"[Clinicians should] ensure there's adequate humidification overnight; ensure they’re suctioning the tracheostomy tube regularly at least every 4 hours; ensure you have the largest HME that can be used [...] and make sure that they’re discarding it appropriately, so not reusing it, and throwing it away every 24 hours," Amin said during the presentation.

Amin further said clinicians should review the child's overall hydration status, especially in the spring and summer months. They need to ensure tracheostomy tubes are the appropriate size, in addition to asking about the age of this piece of equipment and how frequently it is changed. Lastly, Amin said, is to check that a patient does not have a concurrent infection.

"If you've done all of these things and you are still running into issues," Amin said, "you can consider providing them with a compressor to deliver nebulized saline at school."