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Home Mechanical Ventilation

Home Mechanical Ventilation. Cori Daines, MD Pediatric Pulmonary Medicine. Outline. Indications Patients Interfaces Ventilators Modes of ventilation Home considerations Complications Outcomes. Goals. Extend the duration of life Enhance the quality of life Reduce morbidity

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Home Mechanical Ventilation

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  1. Home Mechanical Ventilation Cori Daines, MD Pediatric Pulmonary Medicine

  2. Outline • Indications • Patients • Interfaces • Ventilators • Modes of ventilation • Home considerations • Complications • Outcomes

  3. Goals • Extend the duration of life • Enhance the quality of life • Reduce morbidity • Improve physiologic function • Achieve normal growth and development • Reduce overall health care costs

  4. Indications • Disorders of the respiratory pump • Neuromuscular diseases, chest wall diseases, spinal cord injury • Obstructive diseases of the airway • Craniofacial abnormalities, hypotonia, obesity • Parenchymal lung disease • BPD, cystic fibrosis • Disorders of control of respiration • Congenital central hypoventilation syndrome

  5. Indications • Inability to wean from mechanical ventilation • After and acute illness • After prolonged ventilation for a chronic disease • Progressive chronic respiratory failure • Sleep disturbance • Central or obstructive, apnea or hypopnea

  6. Indications/Symptoms • Shortness of breath • Especially on exertion or lying down • Morning headache and insomnia • Fatigue and lethargy • Increased respiratory rate • Restlessness and anxiety

  7. Indications/Criteria • Forced vital capacity < 50% predicted • Maximal Inspiratory Pressure < 60 • ABG pCO2 > 45 • Moderate to severe sleep apnea

  8. Patients • Cardiopulmonary stability • Positive trend in weight gain/maintenance and growth • Stamina for play or daily activities while ventilated • Freedom from active/recurrent infection, fever, deterioration ATS Position Paper 1990

  9. Interfaces • Noninvasive vs. Invasive • Age • Cognitive ability • Body habitus • Ventilatory needs • Anticipated length of ventilation • Family/patient preference

  10. Noninvasive interfaces • Nasal masks • Full facemasks • Nasal pillows • Sipper mouthpiece • Lipseal/mouthpiece device

  11. NIV: Nasal mask / Prongs • Many older patients prefer compared to mouthpiece • Problems: • Leak, especially mouth • Nasal bridge pressure with mask • Gum erosion or compression with mask • Nasal erosion with prongs • Chin strap may be needed

  12. NIV: Full face mask • Decreased leak • Decreased • Cough • Talking • Eating • Increased risk of aspiration • Nocturnal use with daytime nasal mask

  13. NIV: Sipper /LipsealMouthpiece • Daytime use • Allows facial freedom • Flexed mouthpiece +/- custom orthodontics • Intermittently used to augment breathing • Continuously used

  14. Complications of NIV • Facial and orthodontic changes • Aerophagia (PIP > 25 cmH2O) • Nasal drying/congestion = humidify • Volutrauma - air leak • Inadequate ventilation

  15. Tracheostomies • Shiley, Bivona, Portex and others • Pediatric sizes mimic ETT ID’s • Neonatal, pediatric, adult and customized lengths • Cuffed and uncuffed • Disposable inner cannula models

  16. Tracheostomies

  17. Ventilators

  18. CPAP • Continuous Positive Airway Pressure • For simple sleep apnea • Stents open the airway • Decreases work of breathing

  19. BiPAP • Pressure Support Ventilation • IPAP—the inspiratory positive airway pressure—extra help when breathing in • EPAP—the expiratory positive airway pressure--CPAP • Cycles based on patient initiated breaths • Available with timed back-up rates • Used for severe sleep apnea, neuromuscular weakness or insufficiency

  20. Full Ventilation • Noninvasive or invasive • Pressure cycled or volume cycled • SIMV vs. AC • Allows pressure support, PEEP, inspiratory time, flow to be added and manipulated

  21. Ventilator Choice • Noninvasive vs. invasive • Portability • Battery life • Setting capabilities • Reliability • Community support

  22. Control vs. SIMV • CONTROL MODE • Every breath fully supported • Can’t wean by decreasing rate • Risk of hyperventilation if agitated SIMV MODE • Vent synchronizes to support patient effort • Patient takes own breaths between vent breaths • Increased work of breathing vs. control

  23. Assist Control Mode Can trigger breaths, but needs support with each breath

  24. SIMV Mode Most patients, improved comfort, stable CO2s

  25. Pressure vs. Volume Pressure • Tidal volume changes as patient compliance changes • Potential hypoventilation or overexpansion • Obstructed trach decreases delivered volume Volume • No limit on pressure unless set • Square wave pattern results in higher pressure delivered for same volume delivered

  26. Pressure vs. Volume Pressure control • Set pressure, volume variable • Better control of oxygenation than ventilation • Better for younger, noncompliant lungs Volume control • Set volume, pressure variable • Better control of ventilation than oxygenation • Better for older more compliant lungs

  27. Pressure Support • Trigger by patient • Provides inspiratory flow during inspiration • Given in addition to vent breaths in IMV modes or alone without a set rate, mimicking BiPAP

  28. Bilevel Mode Mimic BiPAP / No Backup Rate

  29. Supporting Equipment • External support—PEEP • Alarms/Monitoring • Pulse oximetry, Apnea monitor, Capnography • Humidification • External w/ heater, HME • Airway clearance • Suctioning, Vest, cough assist • Talking devices

  30. Discharge Criteria • Presence of a stable airway • FiO2 less than 40% • PCO2 safely maintained • Nutritional intake optimal • Other medical conditions well controlled • Above may vary if palliative care

  31. Discharge Criteria • Goals and plans clarified with family and caregivers • Family and respite caregivers trained in the ventilation, clearance, prevention, evaluation and all equipment • Nursing support arranged for nighttime • Equipment lists developed and implemented with re-supply and funding addressed • Funding and insurance issues addressed

  32. Continuing Assessment • Titration sleep studies • Blood gases • Bronchoscopy • Home monitoring • Used more frequently when weaning/decannulating

  33. Complications • Ventilator failure • Tracheostomy issues • Decannulation, blockage, infection • Mask-related issues • Pressure sores, facial growth issues • Under- or over-ventilation

  34. Outcomes • Dependent on underlying disease • Over 70% 10-year survival, most deaths due to underlying disease • In retrospective studies, 0-8% of deaths were ventilator or technology-related • Occasional hospitalization

  35. Quality of Life • Generally good • Fewer hospitalizations • Better sleep quality • Better daytime functioning • Some stress for patients, caregivers • Related to amount of care and support needed

  36. Home ventilation reality • Every patient is unique • These are guidelines not rules • Vary settings, interfaces, strategies to achieve goals of good health and optimized quality of life • Team approach necessary

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