Correspondence
Luis Vasconcello-Castillo, Departamento de KinesiologĂa, Universidad de
Chile, Independencia 1027, Santiago, Chile. Phone number: (562)
29786513. E-mail:
l.vasconcello.c@gmail.com
Key words: COVID-19; Home mechanical ventilation; children;
telemedicine
Abbreviated title: COVID-19 in home mechanical ventilation
To the editor,
COVID-19 has become a global public health problem. The virus mainly
affects the respiratory system, and its most common symptoms are cough,
dyspnea, fever, headache, and myalgia.1 It is also
characterized by a rapidly evolving severe respiratory condition, with
approximately 20% of those infected requiring hospitalization and 6%
in critical care and needing invasive ventilatory
assistance.1
Although this disease has been shown to be less severe and less
prevalent in children,1 a particular group of children
are considered a risk group for developing a severe COVID-19 infection,
namely, those who use home mechanical ventilation (HMV). This group is
composed of various groups of pathologies, mainly neuromuscular, sleep
disorders, and chronic lung diseases, which require the continuous use
of ventilatory support.2 Moreover, when faced with a
respiratory infection, many among this particular group need advanced
health care and special respiratory care to prevent hospitalization,
such as increased ventilatory support, manual or mechanical assistance
for cough, and/or respiratory physiotherapy at home.2
Many of these children receive various health care services through
different home hospitalization programs, which depend on the severity of
their diseases. In the current context, the visit to and monitoring of
these patients should be limited to the essential services with adequate
protection measures. In cases where professional visits are crucial, the
homes must already have the protection measures recommended by the World
Health Organization and the majority of health authorities around the
world.3
In this group of patients, health care should be maintained through
telemedicine systems to avoid any type of infection risk and not disrupt
the medical and educational care of the children. However, we recommend
providing the essential medical services and emergency professional
visits whenever possible to maintain the minimum standard of health
care.4
Despite these measures, these respiratory exacerbations usually have
extended durations and higher probabilities of coinfection with other
pathogens.5 For this reason, we need to prevent the
increased risk of contagion and adding to the burden of the
oversaturated health system; and if an infection occurs, we must act
quickly to avoid respiratory deterioration in the patients because the
prognosis of ICU-admitted patients is poor.1
In case a diagnosis of COVID-19 is confirmed in children with HMV, the
professionals who deliver health care at home must have the necessary
PPE (including N95/FFP2 mask or similar, goggles or face shield,
long-sleeved water-resistant gown, and gloves).3Caregivers must also have adequate protection measures for their care
and accompaniment for as long as they are staying at home. In addition,
home health care service must provide a contingency and protection plan
for the caregivers in the event that the child user of invasive or
non-invasive ventilation is COVID-19 positive. This plan must have the
implements commonly used by health personnel in hospitals, an
educational protocol for managing the patient, and telemedicine systems
to facilitate monitoring.
At the time of respiratory infection, a possible assistance strategy for
this group of patients is the modification of the ventilator
parameters.2 If the patient uses non-invasive
mechanical ventilation, then we must not forget that this intervention
has been classified as a high-risk procedure for SARS-Cov-2 transmission
because of the increased dispersion of droplets associated with the
increased flow produced by the device.3 These droplets
can even reach a distance of 92 cm from the expiratory
port.3 In the period of acute infection, the delivery
of inhaled drugs may be required. In this case, metered dose inhalers
should be preferred, and if nebulization is unavoidable, the necessary
measures must be taken to minimize the risk of droplet dispersion, such
as the use of surgical masks over the cloud expelled by the nebulizer or
the exit of caregivers from the patient’s room during the
procedure.3
Improving the effectiveness of respiratory care in children with HMV
will achieve lower respiratory morbidity with subsequent lower
utilization of health care resources, which is especially crucial in
this time of collapsed health systems.