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Monitoring on LTV

Monitoring on LTV. Martin Samuels. Bristol Course on Long Term Ventilation in Children. Objectives. understand monitoring of the child on LTV know the methods available and when to apply them develop a framework for assessment & monitoring of children and young people on established LTV.

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Monitoring on LTV

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  1. Monitoring on LTV Martin Samuels Bristol Course on Long Term Ventilation in Children

  2. Objectives • understand monitoring of the child on LTV • know the methods available and when to apply them • develop a framework for assessment & monitoring of children and young people on established LTV

  3. Workshop Content • devise a proforma for assessing the child on LTV • discuss components of assessment, including physiological monitoring • discuss follow-up • discuss home monitoring

  4. Devise a Proforma for Assessment You’re away when the following child attends your unit. A junior member of your team needs help on what needs review... • 3 year old RTC trach ventilated • 9 year old SMA pillows • 15 year old DMD mask ventilated • 10 year old SLD & SDB mask Now decide on follow-up arrangements ...

  5. Assessment • Clinical progress • Equipment • Care package • Examination • Investigations • Communications & follow-up

  6. 1. Clinical Progress • Appetite & nutrition • Feeding & swallowing • Mobility • Sleep • RTI’s • Use of antibiotics • Hospital admissions • School attendance / progress • Ventilator use • Disturbances: • alarms • leaks • disconnections • Secretions / suction • Parental coping • Carers’ charts

  7. 2. Equipment Ventilator: • Settings • Servicing • Hour meter • Dowload • Tidal volume • Minute ventilation • Leaks • Usage • Interfaces • Check fit • Cleanliness • Complications • Monitors • Suction • Tubing • Humidity • Oxygen

  8. 3. Care Package • Carers • Nocturnal disturbances • Supplies • Respite • Community team • Social care & support • Finance

  9. 4. Examination • Growth • Nutrition • Skin / stoma care • Nose • Chest • Cardiac, incl PHT • Spine • Posture

  10. 5. Investigations • SaO2 • Spirometry: • FVC / VC • FEV1 / MEF • Sleep study: • SaO2 • tcPCO2 / ET-CO2 • Pmask • synchrony

  11. 5. Investigations • SaO2 • Spirometry: • FVC / VC • FEV1 / MEF • Sleep study: • SaO2 • tcPCO2 / ET-CO2 • Pmask • synchrony + consider: • sputum MC&S • CXR • ECG • peak cough flow • nasal sniff pressure • max Pi & Pe • mouth occlusion P • P0.1 / Pi-max

  12. 6. Communications Check reviews: • Physiotherapy • SALT • Dietician • OT • Psychology • Neuromuscular • Cardiology • Spinal • Community paed • Immunisation • Flu • Pneumovax • Emergency care plan • Prescription check • Ventilator • Medicines • Follow-up • Transition

  13. Adequacy of Gas Exchange • O/P v I/P • home • invasive v non-invasive • duration Measure • SaO2 • tcPCO2 • end-tidal CO2 • ? bicarbonate

  14. Short period of low baseline Normal SaO2 Frequency Curves Whole night low baseline

  15. mask pressure at patient 10 minute page

  16. mask pressure synchrony 30 second page

  17. mask pressure asynchrony

  18. SaO2 heart rate tcPCO2 whole night trend

  19. ATS Guidelines for DMD • visit 4-6 years old & before loss of ambulation • 6 monthly resp OP: • non-ambulant • FVC <80% • >11y old • 3 monthly resp OP: • NIV • Cough Assist • Review before surgery

  20. ATS Guidelines for DMD At each visit: • SaO2 • awake CO2 • FVC, FEV1, MEF • Max Pi & Pe • Peak cough flow • FBC • Bicarbonate • CXR

  21. Follow-up: Personal Practice • referrals to respiratory OP • Annual sleep study (DMD 12y) • 6 monthly SS if SDB present • Initiate LTV when symptomatic • SS 3-6 months later • Annual review

  22. Reasons for Home Monitoring Recognition of: • airway obstruction • failure of respiratory support • interruption of O2 • prevention of sudden death • cyanotic-apnoeic episodes • worsening respiratory failure

  23. Tracheostomy Related Death Author Year n SUDs % Wetmore 82 420 8 2 Gerson 82 123 1 0.8 MacRae 84 93 2 2 Freezer 90 142 2 1.4 Puhakka 92 33 1 3 Simma 94 108 0 0 Donnelly 96 29 0 0 Shinkwin 96 56 1 1.8 Dubey 99 40 1 2.5 Midwinter 02 143 4 2.8 Total 1187 20 (1 in 60) 1.7

  24. Reasons for Home Monitoring Recognition of: • airway obstruction • failure of respiratory support • interruption of O2 • prevention of sudden death • cyanotic-apnoeic episodes • worsening respiratory failure

  25. Oximetry – Motion Artefact • Pulsatile component is 1 – 5% of absorbances • Movement seriously affects measurement • Results in frequent false alarms

  26. Motion Resistant SaO2 – Masimo SET • small, portable • battery operable • few false alarms Radical Pulse Oximeter Rad5 Oximeter

  27. Suggested Home Monitoring • Respiratory support: • none • Life support: • SaO2 • CCHS: • SaO2 & CO2 SenTec SaO2 & tcPCO2 Capnocheck SaO2 & ET-CO2

  28. Investigations & Monitoring Varies between • individual condition • Individuals • centres Limit in palliative care to • symptom relief

  29. Summary • understand monitoring of child on LTV • know the monitoring methods available and when to apply them • develop a framework for assessment of children and young people on established LTV

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