Home Mechanical Ventilation

Cori Daines, MD Pediatric Pulmonary Medicine

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

Outline

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

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

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

Indications/Symptoms

• Shortness of breath – Especially on exertion or lying down • Morning headache and insomnia • Fatigue and lethargy • Increased respiratory rate • Restlessness and anxiety

Indications/Criteria

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

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

Interfaces

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

Noninvasive interfaces

• Nasal masks • Full facemasks • Nasal pillows • Sipper mouthpiece • Lipseal/mouthpiece device

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

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NIV: Full face mask

Decreased leak • Decreased – Cough – Talking – Eating • Increased risk of aspiration • Nocturnal use with daytime nasal mask

NIV: Sipper /Lipseal Mouthpiece

• Daytime use • Allows facial freedom • Flexed mouthpiece +/- custom orthodontics • Intermittently used to augment breathing • Continuously used

Complications of NIV

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

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

Tracheostomies

Ventilators

CPAP

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

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

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

Ventilator Choice

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

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

Assist Control Mode

Can trigger breaths, but needs support with each breath

SIMV Mode

Most patients, improved comfort, stable CO2s

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

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

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

Bilevel Mode

Mimic BiPAP / No Backup Rate

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

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

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

Continuing Assessment

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

Complications

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

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

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

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