Home Care Ventilators

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Home Mechanical Ventilators

LP - 6, LP 6+ LP 10 (peds) PLV-100, 102, 104 Bear 33 LVT-1000 Achieva

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Circuits Like IPPB circuits without the nebulizer and

usually w addition of proximal airway pressure line

Usually nondisposable flex tube with adapter to connect to trach

Need exhalation valve If add PEEP with disposable PEEP valve to

exhalation valve outlet• Will increase WOB• Not recommended

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Differences with home care ventilators Patient may have uncuffed trach. Cuff will be down so patient can talk. Set volumes larger than expect to

account for leak around tube. Simple alarms, not easily adjusted - try

to make kid-proof. Reason why most vents incorporate a

mechanical pressure relief. Capable of running off external battery.

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Differences (cont.)

SIMV mode on most home care vents is not really SIMV

Pt must breathe through ventilator for spontaneous breaths • Increases CO2 since rebreathing air from insp limb

of circuit• No demand valve for spont breaths• Breathing through vent increases WOB unless

one-way valve added to insp limb close to pt wye

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Most Important Alarms

Patient disconnect Loss of electrical power Low battery

LIFECARE PLV-100

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Classification

Electrically powered• microprocessor controlled

Volume-control, time cycled Rotary drive piston Modes

• Control• A/C• SIMV

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Modes

Control Assist/Control SIMV - machine

"looks" for a patient inspiratory effort 6 seconds before the next scheduled mandatory breath.

Tidal Volume - LED display volume setting 50 - 3000 ml.

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Controls

Rate - LED display set rate 2 - 30 BPM.

I:E Ratio display• Flashes if inverse Ratio is

set. Flowrate - LED display of

flowrate 10 - 120 LPM. • Flashes when insufficient.

Sensitivity • Less or more

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Controls (cont.) Airway Pressure Limit (10-100

cm/H2O) • Vents excess pressure and

sounds audible alarm simultaneously. Inspiration ends.

Battery Test Switch• allows internal or external

battery voltage levels displayed in the Inspiratory Flow Rate LED window.

Power Switch (ON/OFF/RECHARGE)

• Internal and external battery will be charged as long as line cord is plugged into wall outlet, regardless of switch position.

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Alarms

Low Pressure (2 - 50 cm/H2O) • Delayed audible alarm activated when proximal airway

pressure falls below low pressure alarm setting. • Green LED lamp lights immediately when proximal airway

pressure falls below alarm setting (audible delayed 15 seconds in A/C and SIMV modes.

• In SIMV mode, if proximal airway pressure does not exceed Low Pressure setting during a machine breath, audible alarm activated immediately at the end of the machine breath. Serves as disconnect alarm).

Apnea Alarm• same as Low Pressure in SIMV during machine breath.

Power Failure• Audible alarm when "ON" and no power applied.

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Alarms (cont.) Microprocessor Failure

• Machine monitored internally and locks motor out if failure conditions sensed. Patient able to breathe through machine.

• During ventilator malfunctions (Pressure transducer failure and piston system failure), an audible "fast beep" alarm will sound.

Low Internal Battery• If voltage of internal battery falls below 9.5 volts, audible alarm

sounds and "Internal Battery" lamp will flash on and off. Low External Battery

• same as for internal battery. "External Battery" lamp will flash on and off.

Reverse External Battery Connection• If battery leads reversed on external battery connection, an

audible alarm will sound (even in OFF position) until the external battery is disconnected. No damage will occur to the unit or external battery.

Switch to Battery• When power source switches automatically to internal or

external battery, a 3 second audible alarm will sound to alert the operator that limited operation time remains.

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Front Panel Increase Inspiratory Flow

• Red indicator lamp flashes when set inspiratory flow is insufficient to meet other set parameters. Machine will increase flow over set value and flash red light.

AC Power Source• Green indicator light

Internal DC Power Source• Amber indicator light

External DC Power Source• White indicator light

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•Assist/Spontaneous LEDAssist/Spontaneous LEDGreen indicator light indicates an assisted breath in Green indicator light indicates an assisted breath in A/C mode and indicates spontaneous breaths in A/C mode and indicates spontaneous breaths in SIMV mode. Assisted and Spontaneous breaths SIMV mode. Assisted and Spontaneous breaths will register on the BPM Displaywill register on the BPM Display..

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Front Panel (cont.) Patient BPM Digital Display –

• In Control mode, indicates BPM set.

• In Assist/Control mode displays total number of breaths.

• In SIMV mode displays total number of machine and spontaneous breaths.

• Updated every 4 breaths or whenever rate knob changed.

I:E Ratio Digital Display - blinks during inverse ratio or readings over 1: 9.99 (Off during SIMV).

Inspiratory Flow Rate Digital Display - displays peak flows.

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•Tidal Volume Digital Tidal Volume Digital Display - displays tidal Display - displays tidal volume set.volume set.

•Pressure Gauge - Pressure Gauge - displays pressure at displays pressure at proximal airway.proximal airway.

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On Start-Up

Diagnostic Check On Start-Up• When PLV turned on, performs 5 second

self check. • During check• Digital read 88's• Vt displays 0.0 (in case of pressure

transducer failure, Vt displays 1.0). • If test detects error, 2.0 will be displayed in

Vt display and audible alarm sounds - Do Not Use.

Life Products LP-6, LP 6 Plus and LP 10

Home Ventilator

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Classification• Electrically powered• Microprocessor

controlled • Single circuit • Rotary drive piston• Modes LP 6

• OFF, Battery Charge, A/C, SIMV, and Pressure Limited modes

• Sine flow wave in all modes.

• PEEP possible by adding PEEP valve to exhalation valve.

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LP 10

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Modes on LP 6 Plus and LP 10• Standby• A/C: pressure limited or not (LP 10)• SIMV: machine breaths press limited

or not (LP 10)• Pressure Cycle

• Set VT

• I.T. controls flowrate• Hi pressure alarm setting

ends inspiration but without audible alarm. Airway pressure is independent of HP alarm setting during inspiration.

• Pressure Limit Control (LP 10 only) does not end inspiration. Pressure Limit ControlPressure Limit Control

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Classification• In SIMV, patient must

breathe through the circuit, humidifier and then through the piston intake valve unless one-way valve teed in near patient wye.

• Internal resistance is 1.0 cm H2O /L/sec.

• Oxygen is added between the ventilator and the humidifier or via reservoir bag added to piston intake valve for 40% or more oxygen concentrations.

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Controls Vt = 100 - 2200 ml Rate = 1 - 38 BPM Inspiratory Time = .5 - 5.5 sec Sensitivity -10 to +10 cm H2O

High Pressure Alarm Limit 25 to 100 cm H2O

Internal pressure relief at 100 cm H2O.

LP 10 has Pressure Limit Control

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Modes A/C Mode

• Set • Tidal volume • Inspiratory time

• If the inspiratory time is set too long, a system error alarm will be activated.

• Otherwise, inspiratory time essentially determines the flow rate of the set tidal volume.

• Rate• LP 10 breaths can be

Pressure Limited – This pressure limit does not end inspiration.

LP 6

LP 10

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Modes cont. Pressure Limited Mode (LP 6)

• The High Pressure Alarm/Limit control limits pressure without an alarm and does not end inspiration.

• The set tidal volume may not be delivered if inadequate inspiratory time is set.

• If inspiratory time too long will get System Error Alarm.

• Airway pressure developed during inspiration is independent of alarm/limit setting.

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Modes cont. SIMV Mode• Mandatory breaths given

according to the Rate control and patient allowed to breathe through ventilator or one-way valve, if added, for spontaneous breaths.

• If the SIMV rate is set < 6 BPM and the patient fails to initiate an assisted SIMV breath within 20 seconds, the apnea alarm activates and the ventilator switches to Backup ventilation at a rate of 10 BPM.

• LP 10 machine breaths can be Pressure Limited.

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Alarms

Low Pressure/Apnea – • Low pressure is the primary

disconnect alarm except when rate set < 6 BPM.

• Apnea alarm activates if no patient effort sensed within 20 seconds and the rate is < 6 BPM.

• Automatically switches to 10 BPM at the same tidal volume and inspiratory time. Alarm must be manually reset.

• Functional in all modes.

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Alarms Low Power –

• alarms when battery power drops to 10 volts.

• There is no alarm when power source switches from internal battery to AC.

• There is an alarm when power switches from AC to internal and must be reset.

High Pressure – • Ends inspiration in A/C and

SIMV modes. • Sets the pressure limit which

does not end inspiration in Pressure Limited Mode for LP 6.

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Alarms Setting error –

• activates if inspiratory time setting incompatible with set tidal volume and respiratory rate. Ends inspiration.

Power switch over – • indicates whether

AC, internal, or external battery in use.

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Indicators

Battery Test - shows charge level underneath airway pressure.

Breathing effort - indicates assisted breaths.

Power - indicates whether AC power or battery charge, external battery, or internal battery in use. Battery requires 2 hours of charge for every 1 hour of use.

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O2 Bleed in

Can bleed in oxygen between ventilator and humidifier up to 40%. 40% and over must add reservoir bag and oxygen to the back at the piston intake filter.

VT set = VT desired (1 - FIO2)

.79 LPM = (VT desired - VT set) BPM

1000

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Circuit

Circuit Requires exhalation valve and

proximal airway pressure line. Clean circuit with soapy water, rinse, and then soak in 1/3 cup vinegar per cup of water for 30 minutes every 24 hr.

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HOME CARE VENTILATION

Brief overview Types of ventilators What’s involved in sending a patient

home on a ventilator.

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Historically

Ventilatory support in home dates back to polio epidemics of 1940s

Since the mid 1980’s the Home Care Industry has steadily grown.

Prior to 1970, ventilatory support in the home provided by

negative pressure ventilators

rocking beds

pneumobelts

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Over the last several years there’s been greater interest in

positive pressure ventilators oxygen delivery systems use of other durable medical equipment

(DME) in the home infant apnea monitors, oximeters, etc.

More and more patients are going home on ventilators because of the

sky rocketing costs of hospital care.

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In 1983 the AARC conducted 21-state survey to determine

the number of ventilator-assisted patients at home

and the home care costs for them. Over 2,000 hospitalized, chronically

ventilator-dependent patients were medically able to go home.

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19% of these patients were under the age of 17 and

51% were between 18 and 64 years of age.

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The ARRC estimated the cost to Medicare/Medicaid per year for a

ventilator- assisted person

$270,000 in the hospital but only $21,000 per year at home.

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Although the reimbursement issue for services

provided by RRTs and equipment costs is continuing to evolve, more and more people will be sent

home requiring some type of ventilatory support.

There's always Medicare/Medicaid

reimbursement updates at every state and national meeting.

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Types of patients requiring ventilatory support

Chronic respiratory failure with noctural hypercapnia and hypoxemia

Neuromuscular weakness, restrictive lung disease, or chest-wall disease.

Obstructive Sleep Apnea (Mask CPAP)

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Methods of Ventilatory Support in Home Care

Non-invasive mechanical ventilation• Negative Pressure Ventilators (NPV)

• Chest cuirass• Poncho Wrap• Iron Lung

• Non-invasive positive press ventilation (NPPV)

Invasive mechanical ventilation• Positive Pressure Ventilators (PPV)

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Advantages of Negative Pressure Ventilators

Don't need artificial airway

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Disadvantages of NPV

Difficult to synchronize machine with the patient's respirations

Negative pressure ventilation doesn't prevent upper airway obstruction and may actually contribute to it.

Bulky, chest shells don't fit that well,• custom made shells expensive,

uncomfortable

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Non-Invasive Positive Pressure Ventilation (NPPV)

The improved design of nasal masks for nasal CPAP to treat patients with obstructive sleep apnea led to increased success in applying PPV via mask.

Has advantages over NPV.

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Advantages NPPV (Mask PPV) are similar to adv nasal CPAP

Stablizes upper airway and prevents upper airway obstruction during sleep (both NREM and REM sleep)

Improves daytime PaO2 and PaCO2's within several weeks

Reduced daytime sleepiness (hypersomnolence)

Reduced morning headaches (hypercapnia)

Don't need tracheostomy

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Patient reported problems with NPPV

Difficulty obtaining appropriate interface• nasal mask, full face mask, or nasal pillows • Must be easy to put on

skin abrasions from tight fitting masks nasal dryness or congestion eye irritation (from leaks around mask) gastric distention

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3 routes that pts can qualify for NPPV in the home according to

Medicare guidelines.

COPD OSAS Restrictive thoracic diseases

(neuromuscular)

Different criteria for each diagnosis

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Medicare Conditions for COPD- Pt must have:

1. PaCO2 > 52 torr while on at least 2 LPM oxygen.

2. A minimum of 5 minutes of continuous desaturation during sleep study (polysomnography) while on at least 2 LPM oxygen.

3. OSAS ruled out as a diagnosis during polysomnography study.

• If pt has both COPD and OSAS, must qualify under OSAS criteria

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OSAS criteria to qualify for NPPV

1. Must qualify for CPAP first, i.e. have OSAS: [apnea/hypopnea index (AHI) ≥ 15/hr or btw 5 – 15/hr w/ symptoms]

2. Pt fails to tolerate CPAP or CPAP is ineffective

• Still has apneas, hypopneas, or desaturation on CPAP

• CPAP pressure so high that pt cannot exhale against it

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Criteria for restrictive thoracic disorders:

PaCO2 > 45 torr or nocturnal SpO2 < 88% for 5 continuous minutes on pt’s usual oxygen setting

Pts w/ progressive neuromuscular disease qualify if NIF < 60 cm H2O or FVC is < 50% of predicted• Only pt group to qualify for device with backup

rate.• Other two groups must start with device w/o

backup rate (respiratory assist device) and demonstrate that it is ineffective.

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After pt qualifies for NPPV

Forms must be submitted to Medicare after 60 and 90 days• Pt has used device > 4 hrs per 24 hrs• Physician documents pt’s compliance w

treatment Most CPAP devices have built-in time-

on counters and some record time-at-pressure to verify use.

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Invasive Positive Pressure Ventilation - Home

Means that pt has a tracheostomy.• Mask ventilation no longer effective

Added problems of artificial airway.

It takes 2 - 5 days instructing the patient and home care givers about the ventilator - all this is only part of what it takes to set a patient up

on home ventilation.

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There are many other considerations after deciding what

type of ventilatory support is needed.

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Getting a Patient Home on a Ventilator

When its determined that a patient will need a ventilator at home - it takes at least 2 weeks

to prepare the patient, the patient's family, and the patient's home.

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Discharge committee or team of health care workers needed

consists of :

Home visiting nurse Social Worker Home care company to supply the

ventilator & other equipment needs Someone to arrange the financial end of

it - social security.

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Someone assesses the home situation to see:

If it needs ramps for wheelchair If electrical systems adequate for

medical equipment If living arrangements accommodate

patient’s situation

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What training of the patient and the patient's family will be needed on • Ventilator care and maintenance• Suctioning• Assessment - when to suction,

when to call for assistance.

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Most institutions have a CHECKLIST on how to get a patient home with a ventilator.

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Remember

No nursing home will take a patient on ventilator.

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There are many things involved in home care of a ventilator

patient

For ex. always need to have two machines in the home

and a bag - in case a machine went out and they couldn't reach anyone.

There are a lot of things you have to think about

More details will be provided in your Pulmonary Rehab course.

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