Home Mechanical Ventilation Cori Daines, MD Pediatric Pulmonary Medicine.

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

• 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, deteriorationATS 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

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 breathCan trigger breaths, but needs support with each breath

SIMV Mode

Most patients, improved comfort, stable CO2sMost 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 RateMimic 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