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\begin{document}

\title{Tough Transitions: Family Caregiver Experiences with a Pediatric Long
Term Ventilation Discharge Pathway}



\author[1]{Jackie Chiang}%
\author[1]{Allia Karim}%
\author[2]{Andrea Hoffman}%
\author[3]{Karen Dryden Palmer}%
\author[4]{Krista Keilty}%
\author[5]{Faiza Syed}%
\author[1]{Joanna Janevski}%
\author[6]{Tilak Dutta}%
\author[2]{Maryanne Fellin}%
\author[2]{Sally Lindsay}%
\author[2]{Laura Beaune}%
\author[5]{Reshma Amin}%
\affil[1]{The Hospital for Sick Children Department of Paediatrics}%
\affil[2]{Holland Bloorview Kids Rehabilitation Hospital}%
\affil[3]{Hospital for Sick Children Research Institute}%
\affil[4]{Hospital for Sick Children}%
\affil[5]{The Hospital for Sick Children}%
\affil[6]{Toronto Rehab}%


\vspace{-1em}



  
  \date{June 10, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
Objectives: Discharging a child home on long term ventilation (LTV) via
tracheostomy is complex and involves multiple healthcare providers
across healthcare sectors. To date, patient and family feedback of a
newly developed LTV discharge pathway has been anecdotal. Our objective
was to explore the perceptions of family caregivers (FCs) that have
completed the LTV pathway to home with respect to their: (1) experience
with transitions across the pathway (2) perceptions of competency
attainment and, (3) viewed opportunities for improvement. Methods: We
conducted 11 semi structured interviews with FCs. Interviews focused on
FCs experience with the training process, perception of competency from
a knowledge and skill perspective and opportunities for improvement.
Interviews were audiotaped, transcribed verbatim, coded and analyzed
using an inductive thematic analysis approach. Results: Eight mothers
and 3 fathers of 10 children participated. Six primary themes were
identified: 1) making an informed decision, 2) transitioning to
rehabilitation, 3) building capacity for self-care, 4) coordinating case
management, 5) readying for discharge home and, 6) experiencing home
care. Conclusion: Overall, FCs felt that the preparation and transition
support obtained through the application of a standardized LTV discharge
pathway allowed successful attainment of new knowledge and skills
necessary to care for their child with LTV at home.%
\end{abstract}%



\sloppy


\textbf{INTRODUCTION}

Long term ventilation (LTV) at home via tracheostomy represents one of
the most advanced, highly specialized and complex therapies offered to
individuals outside of a hospital setting. \textsuperscript{1,2} These
children are medically fragile with significant associated morbidity and
mortality.\textsuperscript{3,4}

Notably, the caregiver burden for these families is high. Family
caregivers (FC) of children using LTV at home are tasked with providing
'intensive care' in their homes. As such, robust FC competency-based
knowledge and skills training must take place in hospital prior to the
child's initial discharge home. The published reported median length of
stay in hospitals for families to accomplish this preparation is broad
ranging from 46 days to 9.6 months. \textsuperscript{3,5,6-10} A handful
of studies to date have reported barriers to achieving discharge for
this population.\textsuperscript{3,5,7,8,11-13} These have included
delays in organizational decision-making and lack of coordinated
approach to care associated with preparation to transition to home.

In partnership with key clinical stakeholders, a LTV discharge pathway
was developed in late 2016 to restructure and standardize discharge
preparation placing emphasis on ensuring quality FC learning and
minimizing system borne delay. The pathway was developed to promote safe
and timely transitions across three publicly funded but distinct health
care organizations that voluntarily collaborate to coordinate care for
children on LTV. The pathway starts with a child in an intensive care
unit at a tertiary care pediatric hospital followed by transfer to a
pediatric rehabilitation hospital and then transition to home. Using a
process mapping approach, guided by content experts, the LTV discharge
pathway was developed to outline the steps to transition a child newly
initiated on LTV from the acute care setting to home. The pathway
includes role-based tasks and graduated milestones (see Appendix 1 and
2).

To date, patient and family input into the LTV discharge pathway has
been largely anecdotal and never systematically analysed. With the goal
of informing a robust family centered LTV pathway, we deigned this study
to explore the perceptions of FCs that have completed the LTV discharge
pathway with respect to their: (1) experience with transitions across
the pathway (2) perceptions of competency attainment (knowledge and
skills acquisition) and, (3) opportunities for improvement.

\textbf{METHODS}

\textbf{Study Design}

We conducted a qualitative thematic-analysis study comprised of
semi-structured interviews with FCs of children requiring LTV support at
home. Data was collected between April 2019 and January 2020.
Institutional ethics review board approval was received from The
Hospital for Sick Children (REB \#1000061042) and Holland Bloorview Kids
Rehabilitation Hospital (REB \#18-831). Parents were eligible for study
inclusion if they: (1) had a child who was initiated on the LTV
discharge pathway between December 2016 and September 2018 and (2) could
read and write English. We used purposeful sampling to ensure we
captured perspectives of FCs who provide care at home for children with
a range of ages and medical conditions that represent varied experiences
across the pathway.

\textbf{Recruitment of Study Participants}

Family caregivers were recruited from the hospital's LTV program
clinical database and were introduced to the study via an informational
email sent out by a member of the LTV team within the circle of care. A
follow up telephone call was conducted by the study's research
coordinator where FCs were provided further information about the study,
the opportunity to indicate their interest in participating and complete
the consenting process if they chose to participate.

\textbf{Data Collection}

Data collection included individual semi-structured interviews,
gathering demographic data and patient medical record review. Interview
guides were informed iteratively by the research team after a review of
relevant literature. Using concepts of
Kirkpatrick's\textsuperscript{14}model of evaluation as a conceptual
framework (with a focus on level 1: reactions of learners), a
semi-structured interview guide was developed. The 31 question,
semi-structured guide explored FC experience in all phases and domains
of the LTV discharge pathway and perspectives on where they identified
opportunities for improvement (see Appendix 3). Pilot testing of the
interview guide was completed with two FCs. The interviews were
conducted via telephone by an experienced qualitative researcher.
Interviews lasted between 45-60 minutes and occurred at a time that was
convenient for the family.

Demographic data was collected during the interview. Data about the
child and the medical context of LTV support was retrospectively
collected via the hospital's electronic medical database.

\textbf{Data Analysis}

Interviews were audio recorded, transcribed verbatim and de-identified
by a professional transcriptionist. Qualitative data analysis
software\textsuperscript{15} was used for data and coding management. An
inductive, thematic analysis process to familiarize, code, and identify
important themes from the text was used to analyze the data via multiple
readings of the transcripts.\textsuperscript{16} The coding authors (JC,
RA, LB, AK) engaged in an immersive reading of the transcripts. Initial
patterns and recurring categories were identified via consensus. Next,
similarities and differences between participant accounts in the data
were exposed and final thematic codes developed. A codebook was created
and iteratively modified. This approach created relationships between
concepts or variables that were determined to influence the experiences
of FCs with care grounded in the LTV discharge
pathway.\textsuperscript{17,18} Methodological rigor was established
through prolonged engagement and peer debriefing.\textsuperscript{19} We
followed the Consolidated Criteria for Reporting Qualitative
studies.\textsuperscript{20} After 11 interviews, thematic saturation
had been achieved.\textsuperscript{17}

\textbf{RESULTS}

Thirteen eligible FCs were contacted by the research coordinator. Eleven
FCs agreed to be interviewed and two FCs of the same child were
interviewed together. See Tables 1 and 2 for demographic characteristics
of study participants and their children using LTV. {[}Table 1, Table
2{]}

\textbf{FC Experience Themes}

Six themes emerged from this data that described FC experiences within
the LTV discharge pathway (Figure 1). Each theme was associated with a
pathway phase from time of choosing to proceed with invasive ventilation
up to the point of caring independently for their child at home. These
themes were: 1) making an informed decision, 2) transitioning to
rehabilitation, 3) building capacity for self-care, 4) coordinating case
management, 5) readying for discharge home and, 6) experiencing home
care.

Making an informed decision

The way in which health care providers (HCPs) share and discuss a
child's diagnosis and decision for LTV is a critical touchpoint in
building FC trust in the LTV discharge plan. FCs expressed that this was
a time of both emotional and informational overload for them. They
identified that characteristics of information they perceived as helpful
were hopeful, family centred and consistent. FCs explained that it was
difficult to hear acute care HCPs share information about their child's
prognosis that they experienced as fatalistic. They expressed a desire
for their child's prognosis to be viewed from a holistic perspective.
Access and interactions with LTV and clinical disease experts instilled
parental confidence and reassured FCs that they made the correct
decision to pursue LTV for their child. Factors that inhibited this
process were a perceived lack of communication amongst various clinical
teams, informational gaps, and misinformation. They also expressed the
need to connect with families in similar situations, for enhanced
emotional support (see Appendix 4).

Transitioning to rehabilitation

FCs expressed that moving from an acute intensive care setting to a
rehabilitative setting raised fear and anxiety because of potentially
different organizational structure and teaching approaches. They
explained that their concerns were eased by effective team communication
as well as transitioning into a more active parenting role which they
linked to increasing their confidence and capacity to care for their
child. Challenges occurred when teaching practices differed between
organizations. FCs recommended family involvement in transition
meetings, a key HCP contact in acute care to accompany the family to the
rehabilitation setting to support continuity of care both from a process
and physical lens (see Appendix 5).

Building capacity for self-care

FCs provided valuable insights into effective strategies that supported
their capacity in preparing to care for their child at home.
Comprehensive training was instrumental to their perceived readiness to
care for their child upon discharge home. The identified key components
included: 1) training by consistent content experts (nurses and
respiratory therapists), 2) experiential or ``hands-on'' learning
approach, 3) parent led pace, 4) knowledge demonstration and 5) adaptive
and flexible sessions. In the acute care setting, there was a lack of
opportunity for ``hands-on'' teaching. However, they also
self-identified that immediately after tracheostomy insertion, their
emotional state hindered readiness to learn while in acute care (see
Appendix 6).

Coordinating case management

FCs described that they were unprepared and overwhelmed by financial
costs. These related to the cost of equipment and supplies. Although
efforts were made to connect and organize respiratory vendors with FCs
prior to discharge, FCs felt that they did not have enough information
or expertise with managing this aspect of care. They reported the need
for experiential advice from other FCs who could help guide them in
determining how to get things set up at home (see Appendix 7).

Readying for Discharge Home

FCs expressed their feelings of competence in caring for their child at
home along with its many challenges. Common across all FCs were the
experiences of constant worry about the ``what if's'' such as an
emergency event with their child. FCs described feeling that HCPs had
encouraged them to maintain a 24/7 vigilance over their child's care
which FCs experienced as unsustainable. Loss of hospital expertise and
after hours support for guidance and problem solving were described as
extremely concerning for FCs. The stress of having to turn their home
into a safe and ongoing medical space for their child surfaced
throughout the interviews (see Appendix 8).

Experiencing home care

FCs shared their experiences with respect to helpful and unhelpful
in-home support. Many FCs cited challenging experiences with nursing
support at home including unavailability of nurses and their lack of
experience with children, tracheostomy tubes or emergency situations.
FCs found tremendous benefit in connecting with other families through
on-line support groups where they often learned care tips. Some FCs
flagged opportunities for re-education and training post discharge as
their child's development and care needs changed (see Appendix 9).

\textbf{DISCUSSION}

To our knowledge, we are reporting on the first Canadian data exploring
the experiences of FCs of children requiring LTV via tracheostomy
transitioned from hospital to home within a newly developed pediatric
LTV discharge pathway framework. An emerging model of factors that are
reported to impact FC experience with the LTV pathway was developed as
an outcome of our study (Figure 2).

Our study provides new insight into the experiences of FCs with their
HCPs and information sharing. Several FCs in our study perceived that
information sharing by HCPs about their child's life with LTV was ``doom
and gloom''. These findings are similar to a recent study of children
with medical complexity in which FCs stated that they preferred that
broad Advance Care Planning conversations to be holistic and
hopeful.\textsuperscript{21} Additionally, in a study that explored the
perspectives of North American directors of pediatric home ventilation
programs, the authors found that negative bias about the quality of life
and abilities of children with severe disabilities posed a barrier to FC
decision making in pursuing LTV and recommended HCP education to reduce
this inherent bias.\textsuperscript{22} FCs in our study reported that
they preferred to have conversations with HCPs who were more familiar
with the experience of children with LTV at home and who were aware of
the range of possibilities for their child's quality of life, happiness
and life at home.

Shared decision making in paediatric health is grounded in a family
centred framework. It centres on the FC and HCP partnership and respect
for FC goals and guides a collaborative effort to come to an agreement
on the child's plan of care.\textsuperscript{23-25} Barriers to shared
decision making from the FC perspective occur when information is not
shared early enough in the child's illness trajectory, conversations are
not conducted with HCPs who have sufficient knowledge of the family,
HCPs provide inconsistent information and/or lack capacity to address
cultural differences. \textsuperscript{21,22,26} Many FCs in our study
experienced barriers to shared decision making such as inadequate
information about the meaning of LTV for their child and lack of access
to LTV or disease-specific experts to address their questions. FCs in
this study recommended having access to peer support from families with
children who had similar care needs.

There is a small but growing body of research exploring the experiences
of transitions from hospital to home of FCs supporting individuals with
LTV needs. \textsuperscript{27-30} A literature review of 14 studies
found that overall FCs demonstrated competence in caring for their child
with LTV needs at home but that resounding themes included feelings of
isolation when transitioning to home from
hospital.\textsuperscript{28}FCs in our study reported that through the
LTV discharge pathway, they had acquired competency and skills regarding
the routine medical needs required by their child at home. FC reports of
knowledge and capacity attainment have been previously linked to
teaching by ventilator experts, opportunities to demonstrate
self-efficacy prior to discharge home\textsuperscript{1} and a learning
process cycle\textsuperscript{30} all of which were substantiated in
this study.

The initial discharge home was noted to be particularly stressful for
FCs. Expectations with respect to being fully responsible for the
child's medical needs at home along with providing continuous 24/7 care
created stress and fear. The negative impact on the health and
well-being of FCs caring for technologically dependent children at home
has been well documented to include higher risks of sleep deprivation,
depression and lowered health related quality of life and family
functioning.\textsuperscript{31} Although the experiences of FCs in our
study over time were not examined, emotional distress and concerns
regarding sleep quality were identified.

FC anxiety were exacerbated by being disconnected from familiar hospital
HCPs post discharge. Direct access to hospital experts within the first
several weeks after transitioning home was reported as positively
impacting problem solving, consolidating learned knowledge and enhanced
self-efficacy for ventilator assisted adults transitioning to home
.\textsuperscript{1} We recommend a formal extension of the LTV
discharge pathway activities into the first month that includes a
telephone follow-up prior to the first LTV clinic visit. In addition,
connecting FCs to families of children with LTV who have successfully
transitioned home early in the pathway process may be beneficial in
terms of helping families understand and prepare for the challenges of
being home and navigating coordination of care.\textsuperscript{30}

One of the biggest challenges reported by FCs in our study and
previously documented by others\textsuperscript{3,29,30,32} are issues
related to gaps in services in the home setting. In our study, FCs
discussed the additional burden of care related to supervising home care
nurses as well as the lack of consistent overnight
nursing.\textsuperscript{33} FCs also discussed the incredible amount of
time spent on case management including dealing with equipment and
supplies. We recommend innovative partnerships with home care nursing
agencies to support the training of community nurses which may include
matching community nurses to FCs who are learning LTV care in the
hospital to support dual learning and relationship building that is
continued into the child's home. Mobile training such as joint medical
simulation may be useful for training in the home for home care nurses
and continued learning for FCs.\textsuperscript{30} Given the uptake of
new electronic health technologies, opportunities to virtually access
the inside of a family's home, may help HCPs and peer families guide FCs
in setting up medical equipment, organizing their home and addressing
safety procedures, thus providing an additional layer of support for
families.\textsuperscript{30} {[}Table 3{]}

Our study did have some notable limitations. The research was conducted
at one point in time and subject to participant recall bias. All FC
participants were English-speaking, predominantly mothers, and from
well-educated, middle- to high-income families. Although in the sampling
strategy, participants were purposefully selected to reflect the
diversity of families who live in Toronto, Ontario, Canada, our study
results may not reflect the experiences of other socio-economically or
linguistically diverse families. It may also not be generalizable to
other LTV programs given the different infrastructure and operations
that exist nationally and internationally. As such, the caregiver
training procedures, community resources and supports for caregivers
will vary although the guiding principles would all be the same.

\textbf{CONCLUSION}

FCs of children using LTV willingly take on the intensive medical care
that their child requires to live at home. To quote one of the FC's
interviewed in the study ``it's a massive undertaking when you sit back
and reflect on what you do\ldots{}You're actually a full-blown {[}health
care{]} professional yourself, but it is full time care''.

FCs reported that they need to be prepared in all aspects of `what life
will be like' living with a child with LTV care needs at home. They
reported a positive impact of knowledge and skills learned but also
recommended that decisions to implement the LTV pathway should be framed
as hopeful and holistic. FCs favored a teaching approach that was
comprehensive, flexible and family centred. FCs in this study
highlighted the need for enhanced support with respect to the child's
care coordination and access to skilled and consistent in-home nursing
support. They also shared the need for continued support of hospital
experts beyond the child's discharge from hospital to ensure continuity
of care, family well-being, and continued opportunities to build on
self-efficacy.

\textbf{ACKNOWLEDGEMENTS:}

The authors thank all participants including patients, parents, health
care providers, administrators and community partners who participated
in or contributed to the study.

\textbf{REFERENCES}

1. Dale CM, King J, Nonoyama M, Carbone S, McKim D, Road J, Rose L.
Transitions to Home Mechanical Ventilation. The Experiences of Canadian
Ventilator-assisted Adults and Their Family Caregivers. Ann Am Thorac
Soc. 2018 Mar;15(3):357-64.

2. Wallis C, Paton JY, Beaton S, Jardine E. Children on long-term
ventilatory support: 10 years of progress. Arch Dis Child.
2011;96:998-1002.

3. Edwards EA, Hsiao K, Nixon GM. Paediatric home ventilatory support:
the Auckland experience. J Paediatr Child Health. 2005;41:652-658.

4. Edwards JD, Kun SS, Keens TG. Outcomes and causes of death in
children on home mechanical ventilation via tracheostomy: an
institutional and literature review. J Pediatr. 2010;157:955-959.

5. Oktem S, Ersu R, Uyan ZS, et al. Home ventilation for children with
chronic respiratory failure in Istanbul. Respiration; international
review of thoracic diseases. 2008;76:76-81.

6. Appierto L, Cori M, Bianchi R, et al. Home care for chronic
respiratory failure in children: 15 years experience. Paediatr Anaesth.
2002; 124: 345-350.

7. Graf JM, Montagnino BA, Hueckel R, McPherson ML. Children with new
tracheostomies: Planning for family education and common impediments to
discharge. Pediatr Pulmonol. 2008; 438: 788-794.

8. DeWitt PK, Jansen MT, Ward SL, Keens TG. Obstacles to discharge of
ventilator-assisted children from the hospital to home. Chest. 1993;
1035: 1560-1565.

9. Tearl DK, Cox TJ, Hertzog JH. Hospital discharge of respiratory
technology-dependent children: Role of a dedicated respiratory care
discharge coordinator. Respir Care. 2006; 517: 744-749.

10. Fraser J, Henrichsen T, Mok Q, Tasker RC. Prolonged mechanical
ventilation as a consequence of acute illness. Arch Dis Child. 1998;
783: 253-256.

11. Amin R, Sayal A, Syed F, et al. How Long Does It Take to Initiate a
Child on Long-term Invasive Ventilation: Results from a Canadian
Paediatric Home Ventilation Program. Can Respir J. 2015; 22: 103-108.

12. Goldberg AI, Frownfelter D. The Ventilator-assisted Individuals
Study. Chest. 1990; 982: 428-433.

13. Noyes J. Barriers that delay children and young people who are
dependent on mechanical ventilators from being discharged from hospital.
J Clin Nurs. 2002; 111: 2-11.

14. Kirkpatrick DL. Evaluation of training. In R. L. Craig (Ed.),
Training and development handbook: A guide to human resource
development. New York (NY): McGraw Hill; 1976.

15. NVivo qualitative data analysis software. Version 9 {[}Computer
Software{]}. Doncaster (AU): QSR International Pty Ltd; 2007.

16. Braun V \& Clarke V. Using thematic analysis in psychology. Qual Res
in Psychol. 2006;3(2):77-101.

17. Padgett DK. Strategies for Rigor. In: Qualitative Methods in Social
Work Research, 2nd ed. Thousand Oaks (CA): Sage Publications Inc; 2008.
p 179--198.

18. Tuckett A. Rigour in qualitative research: Complexities and
solutions. Researcher 2005;13:29-42.

19. Patton M. Purposeful Sampling. In: Qulitative evaluation and
research methods. Beverly Hills (CA): Sage; 1990. p 169-186.

20. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting
qualitative research (COREQ): a 32-item checklist for interviews and
focus groups. Int J Qual Health Care. 2007;19(6):349--357.

21. Orkin J, Beaune L, Moore C, Weiser N, Arje D, Rapoport A, Netten K,
Adams S, Cohen E, Amin R. Toward an Understanding of Advance Care
Planning in Children with Medical Complexity. Pediatrics. 2020 Mar
1;145(3).

22. Edwards JD, Morris MC, Nelson JE, Panitch HB, Miller RL. Decisions
around long-term ventilation for children. Perspectives of directors of
pediatric home ventilation programs. Ann Am Thorac Soc. 2017
Oct;14(10):1539-1547.

23. Adams RC, Levy SE. Shared decision-making and children with
disabilities: pathways to consensus. Pediatrics. 2017 Jun 1;139(6):
e20170956.

24. Dunst CJ, Trivette CM, Hamby DW. Metaanalysis of family-centered
helpgiving practices research. Ment Retard Dev Disabil Res Rev.
2007;13(4):370--378.

25. Kuo DZ, Houtrow AJ, Arango P, Kuhlthau KA, Simmons JM, Neff JM.
Familycentered care: current applications and future directions in
pediatric health care. Matern Child Health J. 2012;16(2):297--305.

26. Edwards JD, Panitch HB, Nelson JE, Miller RL, Morris MC. Decisions
for long-term ventilation for children: perspectives of family members.
Ann Am Thorac Soc. 2020 Jan;17(1):72-80.

27. Edwards EA, O'Toole M, Wallis C. Sending children home on
tracheostomy dependent ventilation: pitfalls and outcomes. Arch Dis
Child. 2004;89:251-255.

28. Condon A. Parents' perceptions of the transition of their child who
is ventilator dependent from hospital to home. Nurs Child Young People.
2020 Jan 9;32(1).

29. Park M, Jang H, Sol IS, Kim SY, Kim YS, Kim YH, Sohn MH, Kim KW.
Pediatric home mechanical ventilation in Korea: the present situation
and future strategy. J Korean Med Sci. 2019 Oct 1;34(42).

30. Amar-Dolan LG, Horn MH, O'Connell B, Parsons SK, Roussin CJ,
Weinstock PH, Graham RJ. ``This Is How Hard It Is'': Family Experience
of Hospital-to-Home Transition with a Tracheostomy. Ann Am Thorac Soc.
2020 Jul;17(7):860-868.

31. Chan YH, Lim CZ, Bautista D, Malhotra R, \selectlanguage{ngerman}Østbye T. The health and
well-being of caregivers of technologically dependent children. Glob
Pediatr Health. 2019 Jan; 6: 2333794X18823000.

32. Whiting, M. Caring for children -- `24-7': The experience of
WellChild Nurses and the families for whom they are providing care and
support. J Child Health Care. 2018 May 17;23(1):35-44.

33. Amin R, Sayal P, Syed F, Chaves A, Moraes TJ, MacLusky I. Pediatric
long-term home mechanical ventilation: Twenty years of follow-up from
one Canadian center. Pediatr Pulmonol. 2014 Aug;49(8):816-24.

\par\null

\textbf{TABLES}

\textbf{Table 1.} FC Demographic Characteristics

\emph{Insert Table 1}

\textbf{Table 2.} Child with LTV Demographic Characteristics

\emph{Insert Table 2}

\textbf{Table 3.} Recommendations for Hospital to Home LTV discharge
pathway

\emph{Insert Table 3}

\textbf{FIGURES}

\textbf{Figure 1.} Overall Thematic Framework

\emph{Insert Figure 1}

\textbf{Figure 2.} Facilitators of Hospital to Home LTV Discharge
Pathway

\emph{Insert Figure 2}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/LTV-Figure-1-final/LTV-Figure-1-final}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/LTV-Figure-2-final/LTV-Figure-2-final}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

