INTENSIVE CARE AT HOME is the first fully accredited Australian provider of Intensive Home Care nursing services
In this document, we endeavour to answer all questions when it comes to mechanical ventilation with Tracheostomy in the home, as a genuine alternative to a long-term stay in Intensive Care. We furthermore endeavour to answer all questions regarding Non-invasive ventilation or mask ventilation in the home as well.
1.1 The reader of this section should, upon completion, be able to
- Understand the different methods of mechanical home ventilation(MHV) that are available for the individual with chronic respiratory failure
- Understand the similarities and differences between invasive or Tracheostomy ventilation and Non- invasive ventilation or mask ventilation
- Understand the appropriateness of individuals/families for mechanical home ventilation
- Understand the guidelines around mechanical ventilation at home, as a genuine alternative to a long term stay in Intensive Care
Methods Used for INTENSIVE CARE AT HOME’s services for Mechanical Home Ventilation
- Invasive Tracheostomy ventilation methods
- Non- invasive methods or mask ventilation methods
- Selection of Adults& Children for Mechanical Home Ventilation
- Support Team Requirements for Mechanical Home Ventilation
- Mechanical Home Ventilation as a treatment of choice and therefore best practice for chronic respiratory failure has been employed for many decades in countries such as Germany, Austria, the USA, Canada and now Australia as well. In the past two decades, there has been an increased interest in Mechanical home ventilation for several reasons, including improved survival following episodes of acute respiratory failure as a direct result of advanced treatment options in Intensive Care
- development of compact, portable ventilators, as well as non- invasive(mask ventilation) modes of ventilation; more comfortable commercial mask interfaces
- a lack of Quality of life and/or Quality of –end-of-life in Intensive Care for long-term Ventilator dependent Clients and their Families
- financial incentives for moving care for chronically ill individuals from Intensive Care to the home
- An increased demand on scarce and expensive Intensive Care beds
- an increased desire of Families to keep their loved one at home, due to the ability of services like INTENSIVE CARE AT HOME to provide advanced home Care
- a further shift from clinical care to home care
- the successful development of Intensive Home Care programs in countries like Australia, Germany, Austria or the US and Canada, where proof of concept has been established decades ago
- More educated, informed and demanding health consumers that look for solutions to their dilemmas
Patients with a wide variety of disorders that result in chronic respiratory failure have been treated at home with mechanical ventilation. These disease processes fall into four major categories and include
- impaired respiratory control
- restrictive neuromuscular diseases
- restrictive chest wall diseases
- primary pulmonary disease.
3.0 MAIN DISORDERS THAT CAN REQUIRE INTENSIV CARE AT HOME'S SERVICES FOR MECHANICAL HOME VENTILATION
- Chronic Respiratory failure
- Diseases of Impaired Respiratory Control
- Central alveolar hypoventilation
- Neuromuscular Diseases
- Spinal cord injury
- Nerve or muscular disease, eg, muscular dystrophy, amyotrophic lateral sclerosis
- Diaphragm paralysis
- Chest Wall Diseases
- Thoracoplasty (eg, TB )
- Pulmonary Diseases
- Guillan Barré Syndrome
- Cystic fibrosis
- Single or bilateral Lung transplant and ventilator dependency
4.0 METHODS OF MECHANICAL HOME VENTILATION
The methods of delivering Mechanical Home Ventilation can be divided into two major categories:
- invasive positive-pressure ventilation via Tracheostomy (TPPV)
- non-invasive ventilation (NIV) or mask ventilation, of which there are several varieties
Full-time or part-time ventilation can be accomplished with either method of ventilation. Although equipment varies somewhat between the two methods, characteristics of Client, family, and the quality of the nursing service that lead to successful home ventilation are similar
5.0 TECHNIQUES FOR MECHANICAL HOME VENTILATION
- Invasive Ventilation such as Tracheostomy positive-pressure ventilation (TPPV)
- Non-invasive Ventilation (NIV) or mask ventilation
- Non-invasive positive-pressure ventilation (NPPV)
- Nasal mask ventilation
- Oro-nasal mask ventilation
- Mouthpiece ventilation (MPV)
5.1 Invasive Ventilation or Tracheostomy ventilation
Invasive Tracheostomy ventilation at home has been used successfully for decades and published series of cases in a several large series in Adults& Children. Benefits of this type of ventilator support include complete control of the machine-delivered tidal gas volume and ease of access to the central airways for suctioning of secretions. In addition, treatment during episodes of acute respiratory failure requires no change in the method of ventilation.
In order to have the abilities and capabilities to safely look after ventilated Adults& Children in the home, a number of prerequisites and minimum skills, which are generally Critical Care nursing skills must be available before a mechanically ventilated Adult or Child can be safely transitioned into the home.
Any service delivery without Critical Care trained nurses puts the ventilated Adult or Child at risk and increases the burden on the Client and their Family. Service delivery that doesn’t meet the minimum standards and doesn’t meet the minimum qualifications of staff is outside of the guidelines.
The basic requirements for ventilators were determined according to ISO-Standards, distinguishing between „Home care ventilators for ventilator-dependent patients“ (ISO 10651-2: 2004) and „Home-care ventilation support devices“ (ISO 10651-6:2004). In life-supporting ventilation, or for Clients unable to remove their own face masks, a ventilation machine with an internal battery is required (ISO 10651-2: 2004). If the Client’s ability to breathe spontaneously is greatly reduced (daytime ventilation time > 16 hours), an external battery pack with a capacity of at least 8–10 hours is required. If the duration of mechanical home ventilation exceeds 16 hours/day, an additional identical ventilator must be provided. The replacement of the existing ventilator with a different type of machine or the adjustment of the ventilation mode must each take place under hospital conditions.
Invasively/ Tracheostomy ventilated Adults or Children require high-performance, battery- supplied suction devices (flow rate > 25 litres/min), as well as a replacement machine and ventilation bag.
5.3 Tubing and Exhalation Systems
Single tube systems with exhalation systems positioned within Client proximity are commonly used. In an open so-called ’leakage’ system, a series of openings in the tubing system or face masks that are close to the Client are present to aid in the elimination of expired CO2. The prerequisite for this is the presence of continuous positive pressure during expiration (EPAP: expiratory positive airway pressure), since a significant amount of CO2 can otherwise be re-breathed from the tubing system. Pneumatically-driven exhalation vents can alternatively perform this task. A changeover of the exhalation system must take place under clinically-controlled conditions
5.4 Ventilation Interfaces
Nasal masks, oro- nasal masks, full-face masks, mouth masks or mouth pieces are all available for home non-invasive ventilation (NIV) purposes. The choice depends on the Client’s tolerance of the ventilation as well as on ventilation efficacy. Every Client should possess at least one reserve mask; for long periods of ventilation, a number of different masks may be necessary to relieve contact pressure zones.
For home invasive Tracheostomy ventilation, the Tracheostoma must be stable, which generally corresponds to being epithelialized. In ventilation via a tracheal cannula, either a blocked or an unblocked cannula can be used; the use of a blocked cannula requires a cuff pressure gauge. In addition to the required reserve cannula of the same size, one smaller reserve cannula must also be at hand to aid emergency cannulation in difficult cases of cannula exchange
Invasive ventilation(Tracheostomy ventilation) always requires a humidifying system, in non-invasive ventilated Adults& Children a humidifier should be prescribed according to the Client’s symptoms.
As part of being fully ventilator dependent with tracheostomy all ventilated Patients require a fully functional and medically appropriate humidifier at 37 C for when they are ventilated on wet circuits.
Humidification at 37 C is what is medically recommended for ventilated Patients with tracheostomy as per guidelines and research.
Humidification at 37 C for invasively ventilated Patients has shown to be more effective compared to HME filter ventilation or lower temperature ventilation.
Research and evidence have shown that ventilator associated Pneumonia(VAP) is reduced when humidified air or humidified oxygen is being delivered at 37C.
The same is applicable when it comes to non-invasive ventilation(BIPAP/CPAP).
Medical recommendations are to deliver humidification at
Active humidification is suggested for NIV, as it may improve adherence and comfort.
When providing active humidification to patients who are invasively ventilated, it is suggested that the device provide a humidity level between 33 mg H2O/L and 44 mg H2O/L and gas temperature between 34°C and 41°C at the circuit Y-piece, with an RH of 100%.
5.6 Additional Accessories
Unit-side particle filters fitted at the point of air inlet are necessary.
There is insufficient evidence to suggest that filters at the point of air outlet are necessary for home use. It is recommended that filters are changed at 1–7 day intervals.
The oxygen flow rate is clinically titrated. Home monitoring via pulse oximetry is not mandatory but it is recommended. However, Clients with Neuromuscular Diseases and cough insufficiency, as well as children, present as exceptions: in these Client groups, a drop in oxygen saturation can prematurely indicate imminent, significant secretion retention. Selective measurements during invasive ventilation are also worthwhile.
- Alterations to the ventilator or ventilator settings must occur exclusively upon doctor’s orders and be carried out by Critical Care trained registered Nurses
- A second ventilator and an external battery pack are necessary if ventilation periods exceed 16 hours/day
- Every non-invasively-ventilated Client requires at least one reserve mask; every invasively-ventilated Client requires at least one reserve cannula
- A humidifier is a mandatory requirement for invasive ventilation and is also useful for non-invasive ventilation if typical symptoms are present
- In Neuromuscular Disease Clients with cough insufficiency and in children, selective use of a pulse oxymeter is necessary
6.0 ESTABLISHING HOME MECHANICAL VENTILATION
High-quality, individually-customized, tailor made and holistic care is paramount in the management of mechanically ventilated Adults& Children. The aim is to adapt at any time the extent of care to the necessity of ventilation duration and type of ventilation interface; the inclusion of relatives in the care of ventilated Clients is also paramount. This is only accomplished through close consultation and good organization between all participating professionals.
6.1 Prerequisites for Discharge from Hospital
The transition phase from the clinical to the non-clinical environment is highly vulnerable. For quality of life reasons, it is preferable to accommodate the Client at home. The correct time point for discharge is reached only when the underlying and secondary illness(es) are deemed stable, and when the meeting of costs as well as the provision of the necessary equipment, resources and materials have been secured. If the ventilated adult or child is still not at an optimal level of function and performance, (early) rehabilitative measures should be considered.
Also find more about the discharge process in our discharge management section https://intensivecareathome.com/discharge-management
6.2 Out-of-hospital Care Team
The care of a home-ventilated adult or child entails:
- Ongoing clinical supervision (usually provided by Intensivists, Respiratory physicians, anaesthetists, paediatricians or neurologists) in cooperation with INTENSIVE CARE AT HOME
- At-home care team, with highly skilled critical care trained nursing staff who have a minimum of 18 months Intensive Care nursing experience and who have completed a postgraduate Critical Care certificate or equivalent, including family members of the ventilated adult or child
- Technical support from equipment providers for machines and accessories.
- A team of therapists (speech-, occupational-, physio- and social therapists, teachers).
- A qualified care team as well as a representative from the equipment provider should always be contactable 24/7
6.3 Specialized Professional Care and critical care trained nursing staff
Specialized professional care must only be provided by legitimate health care professionals carrying a high level of qualification. The necessary quality of care is determined by the degree of ventilation dependence, as well as the autonomy of the ventilated Adult or Child; this decision should be made in cooperation with INTENSIVE CARE AT HOME, the discharging facility and with the Client and their Family.
Mechanical Home ventilation must only be provided by Critical Care trained nursing staff in order to provide the highest level of Care and keep the stress at a minimum of for the ventilated Client and their Family and also in order to maximize the Client’s and their Family’s Quality of Life. These minimum skills and minimum qualifications of staff enable ventilated Adults or Children to live at home as a genuine alternative to a long-term stay in Intensive Care. It also minimizes the risk of readmission back to Intensive Care.
INTENSIVE CARE AT HOME exclusively works with Critical Care trained nursing staff and therefore provides a high level Intensive Home Care nursing service, enabling ventilator dependent adults or children to live at home, as a genuine alternative to a long term stay in Intensive Care and keeps readmissions back to Intensive Care at a minimum.
6.4 Minimum Qualifications of the nursing team
- Physiology and Anatomy of the Respiratory system and mechanical ventilation
- Understanding and knowledge about mechanical ventilation and mechanical ventilators
- Oxygen therapy
- Knowledge and understanding about Tracheostomy and mask ventilation
- Tracheostomy management
- Management of secretions
- Management of inhalation and nebuliser management
- Humidification management of the respiratory system
6.5 Specialised nursing care for ventilated Clients in the Home
The provision of specialized nursing care for ventilated Adults& Children in the home can only be provided by specialized and accredited Nursing services. A specialized and accredited nursing service must be able to provide up to 24/7 specialized nursing care and be contactable 24/7.
In order to provide nursing care for ventilated Adults& Children in the home, a designated specialist nurse must be assigned in order to organize and manage the care of a particular Client.
In addition to being a fully qualified Registered Nurse, the designated specialist nurse assigned to organise and manage the care of a ventilated Client in the home must only consist of Registered Nurses who
- have a minimum of three years clinical Intensive Care or Critical care nursing experience within the last 5 years
- completed a postgraduate degree/certificate in Intensive Care/ Critical Care Nursing
The nursing team being involved in the day to day care of a ventilated Client at home must have the following minimum qualifications:
- fully qualified Registered Nurse
- minimum of 18 months Intensive Care/ Critical Care nursing experience
6.6 Further knowledge and skills required
- an understanding of the disease processes leading to ventilator dependency
- an understanding of the gas exchange process and the differentiation between hypocapnic and hypoxic respiratory insufficiency and the therapy of such
- knowledge and understanding about ventilation modes, including ventilation parameters and alarm limits of such ventilators
- Maintenance and care of ventilators, humidification systems and Cannulas
- Oxygen application in combination with ventilation
6.7 Management of the Transition Phase
The transition-management team should consist of the following professionals:
- Team manager- should be an experienced Critical Care Nurse who organizes and structures the care of a Client in the home
- Medical Doctor (in the clinic and at home)
- Care team (in the clinic and at home)- the care team should again, only comprise of critical care trained nursing staff, who have a minimum of 18 months clinical Intensive Care
- Nursing experience
- Equipment provider
- Social worker, social therapist
- Specialized therapists (if necessary)
- Health insurance provider (if applicable) or health funding agency
- Allocation of team members should be done in consultation with the Client’s Family. The team should begin planning as early as possible the discharge of the Client from the Intensive Care Unit
A check list of the minimal requirements for Client discharge and subsequent set-up of the home ventilation station comprises the following:
- Full technical installation of the ventilation machinery and surveillance systems
- Surveillance standards in terms of personnel (nurse attendance Time, which will be mainly 24/7)
- Time schedule and content of nursing procedures(documented in INTENSIVE CARE AT HOME’s Quality manual)
- Type of ventilation interface and the corresponding cleaning and exchange intervals
- Detailed description of ventilator mode and associated parameters
- Duration of assisted ventilation and, if applicable, phases of spontaneous ventilation
- Oxygen flow rates during assisted and spontaneous ventilation
- Procedures for managing secretions(Documented in INTENSIVE CARE AT HOME’s Quality Manual)
- Application of inhaled medication
- Planning for nutritional needs
- Psychosocial care of the Client and, if applicable, the Client’s Family
- Additional therapeutic and educative measures
- Additional resources (e. g. wheel chair, therapeutic bed, communication aids)
6.8 Surveillance and Documentation of Home
In cases of permanent ventilation, the ventilation parameters and measured values should be continuously monitored and documented accordingly; this should be performed at least once per shift and/or as required. Clinical changes (e. g. increasing spontaneous breathing times, deteriorations) require medical consultation and treatment. Conduct during emergency situations should be based on the medically-necessary aspects as well as on those declared in the Client’s living will.
6.9 Equipment Provider
The machine provider is responsible for briefing all personnel and Family members involved in the care of the ventilated Client. An additional briefing on the day of hospital discharge and a functional check-up of the machinery at the final ventilation location are generally desirable; for specialized nursing care, this is obligatory.
If technical problems with the ventilator and/or interface arise, a technician must be available within 24 hours to resolve the issue.
Mechanical Home ventilation and Intensive Home Care nursing prior to discharge from Intensive Care to a home care setting.
- The meeting of costs and supply of equipment, resources and materials must be secured before the ventilated Client is discharged from Intensive Care
- Professional care is more extensive than assistive care and therefore requires highly-qualified care personnel.
- The minimum standards are to exclusively work with Critical Care trained nursing staff
- The equipment provider must guarantee round-the-clock availability and ensure a prompt and customized service. An introduction to the ventilation machinery is compulsory
6.10 Indications for Invasive Ventilation via Tracheostoma
There is an indication for Tracheotomy in the following situations (in accordance with the thoroughly-informed Client’s wishes and consent)
- When fitting of an appropriate Non- Invasive device(mask) is impossible
- Intolerance of Non-Invasive Ventilation(mask ventilation)
- Ineffectiveness of Non-Invasive Ventilation(mask ventilation)
- Severe bulbar symptoms with recurrent aspiration
- Ineffective non-invasive management of secretions
- Failure to transfer to Non-Invasive Ventilation(mask ventilation) after invasive ventilation
Specific aspects in the ventilation of Client’s with Neuromuscular Disease and chronic respiratory failure comprise:
- Muscle weakness in the oro-pharyngeal area, carrying the risk of reduced ability or complete inability to close the mouth
- Bulbar symptoms with the risk of recurrent aspiration
- Hypersalivation; therapy with anti-cholinergics (e. g. Scopolamine patch, amitryptiline or botulinum toxin injections into the salivary glands
- Coughing weakness, with the development of acute de-compensation
- Reduced gas exchange in the lungs(increased shunt)
7.0 COUGH IMPAIRMENT AND SECRETION MANAGEMENT
A reduced cough impulse (peak cough flow; PCF < 270 l/min) can lead to acute de-compensations and increased incidence of aspiration Pneumonia. Measures to eliminate secretions should therefore be taken when SaO2< 95%, or a 2–3% drop in the Client’s individual best value occurs.
Step-based secretion management consists of measures to increase intrapulmonary volume via air stacking, frog breathing or manual hyperinflation, as well as assisted coughing techniques or mechanical cough assistants (CoughAssist ®, Pegaso Cough®).
- Ventilator dependent Adults& Children with Chronic Respiratory failure(CRF) should undergo clinical assessment and assessment of Vital Capacity(VC) at 3–12 month-intervals. Polygraphy and CO2-measurement are indicated when VC is < 70%
- Failure or rejection of Non-Invasive Ventilation(mask ventilation), invasive or Tracheostomy. Ventilation should only be established in accordance with the explicit wishes of the Client and Family or NOK, respectively
- The most important criteria for the initiation of Non- Invasive Ventilation(mask ventilation) are hypercapnia in combination with the characteristic symptoms of respiratory failure, and a reduction in quality of life
- The measurement of coughing capacity in Neuromuscular Disease Client’s is obligatory. Coughing weakness (PCF < 270 l/min) indicates the need for the initiation of secretion management
8.0 SPECIAL CONSIDERATIONS FOR PEDIATRIC VENTILATION
Most of the underlying diseases that lead to ventilator dependency in childhood are complex and often associated with multiple disabilities that must be treated in a spezialized clinic. A therapeutic master plan must anticipate both the progressive course of the underlying disease and all corresponding respiratory complications, and also include infection prevention, ventilation, treatment of cough insufficiency, sufficient nutrition and adequate management of complications and emergencies.
Burdens such as fever, airway infections or operations may necessitate earlier implementation of ventilation.
8.1 Paediatric diseases that are accompanied by respiratory failure and may require ventilation therapy
a) Lung Diseases
- Cystic Fibrosis
- Bronchopulmonary Dysplasia
b) Neuromuscular Disorders
- Duchenne’s muscular dystrophy
- Spinal muscular atrophy
- Congenital muscular dystrophy
- Myotonic dystrophy
- Myopathy (congenital, mitochondrial, storage diseases)
c) Diseases und Syndromes with Primary and Secondary Thoracic Deformities
- Asphyxiating thoracic dystrophy
- McCune-Albright Syndrome
- Cerebral palsy
d) Disorders of Central Respiratory Regulation
- Congenital central hypoventilation (Undine Syndrome)
- Acquired central hypoventilation after trauma, encephalitis or CNS degeneration
- Hydrocephalus with increased cranial pressure
- Arnold Chiari malformation
e) Obesity Hypoventilation Syndrome
- Morbid alimentary obesity
- Prader-Willi Syndrome
f) Diseases with primary, non- curable obstruction of the upper airway (when CPAP-therapy is inadequate)
- Down Syndrome
- Mid-facial hypoplasias (Pierre-Robin Syndrome and others)
- Morbid alimentary obesity
- Prader-Willi Syndrome
8.2 Special Aspects in Home Mechanical Ventilation of Paediatric Clients
- Not all ventilators are licensed and appropriate for small children
- Most children with muscle weakness are unable to independently trigger the ventilator
- Small children have very low tidal volumes
- Children have irregular breathing frequencies and depths
- The ventilation needs of children change constantly(depending on state of consciousness, stage of sleep, fever, airway infection)
- Customised masks have a relatively high amount of dead space and often don’t fit children, especially infants. The risk of developing mid-facial hypoplasia is increased when using masks with high contact pressure
- Infants, as well as children with muscular disease and immobility, are unable to independently remove the ventilation mask in emergency situations (e. g. ventilator malfunction, power failure)
Hence, the following specific demands must be met:
- A sensitive trigger and low tidal volumes must be possible for optimal ventilation control
- Particularly in infants, successful ventilation is usually only possible with pressure-driven equipment
- There is better adaptation to the breathing pattern and leakage with pressure-driven ventilation compared to ventilation with preset volumes
- Inefficacy of a conventional mask indicates replacement with an individually-customized mask. The manufacture of new masks is frequently required due to childhood growth
8.3 Special Considerations for Paediatric Home Invasive Ventilation/ Tracheostomy ventilation
In principle, there is no difference between children and adults in the indication for invasive Tracheostomy ventilation and it should be determined in close consultation with the children, parents and the treatment team.
- The danger for airway blockage with secretions increases with a decreasing inner diameter of the cannula of the Tracheostomy
- Even a slight contamination of small cannula can lead to an exponential increase in airway resistance
- The significant fluid loss that accompanies childhood tachypnoea requires sufficient conditioning of the inspired air
- Sufficient leakage for sound production in babies and infants is necessary for speech development
- Cannula-associated emergencies occur more often in childhood than in adulthood (accidental removal of cannula, aspiration)
- Airway infections, fever, augmented secretions, cough, dyspnoe and strenuous breathing indicate the application of a pulse oxymeter during spontaneous inhalation of ambient air
8.4 Ethical considerations
Since the prognosis for Clients with Chronic Respiratory Failure is often quite poor, quality of life becomes paramount. In this light, INTENSIVE CARE AT HOME’s service for mechanical home ventilation affords on the one hand the chance to relieve the extent of Chronic Respiratory Failure and markedly improve the Quality of life and/or Quality of end of life. It also gives ventilated Adults& Children the opportunity to leave Intensive Care and it furthermore gives them the opportunity to live a life with dignity and privacy in the safety of their own home, away from the stressful and busy Intensive Care environment.
- In cases of highly-advanced or rapidly-progressive Chronic Respiratory Failure, Clients and their Families should be informed well ahead of time of imminent respiratory emergencies and the therapeutic options for the end-stage of the disease
- A strong partnership between the Client and their Family, INTENSIVE CARE AT HOME and the treating medical doctor is also necessary in the final stage of a Client’s life, where not only medical competence and care of duty, but also frank statements about the prognosis, particularly those concerning questions about the end of life, all remain indispensable
- The rejection of treatment as expressed in the living will is binding for the treating medical doctor, as long as the real, ensuing situation corresponds to the one described in the Client’s will, and there is no recognizable evidence for retrospective changes of will
- When “withholding” or “withdrawing” the ventilation therapy, the principles of palliative medicine must be applied in the form of combined, pre-emptive pharmacological and non-pharmacological treatment of dyspnea, agitation and pain
- A separate room should be provided in which the Client is afforded a dignified death in the presence of their Family and loved ones
9.0 EQUIPMENT REQUIREMENTS
9.1 The equipment required for invasive Tracheostomy ventilation will include at a minimum
1. Tracheostomy tube and replacements, including inner cannulas
2. Dressings for Tracheostomy site
3. Volume-cycled ventilator with appropriate alarms and humidifier
4. Backup ventilator for primary ventilator failure
5. Handheld resuscitation bag with Tracheostomy adapter
6. Suction device with catheters for secretion removal
7. Backup power supply for ventilator (battery or generator)
9.2 Ventilation-specific tasks for those caring for Clients using invasive Tracheostomy ventilation will include the following
1. Regular suctioning of the Tracheostomy as needed (one time to multiple times per day)
2. Daily cleaning of Tracheostomy site and stoma site dressing changes
3. Changing of Tracheostomy tube every 30 to 90 days
4. At least twice daily changes of the inner cannula of the Tracheostomy
9.3 Non-invasive Ventilation
In the last several decades, there has been great interest in Non-Invasive Ventilation(mask ventilation) for providing home ventilation. Non-Invasive Ventilation(mask ventilation) is the most common method for non-invasive home ventilation.
There are currently three main methods of delivery: (1) via nasal mask,( 2) via full face mask, or ( 3) via mouthpiece with or without a lip-seal. Mask-type Non-Invasive Ventilation is most often used at night, where the mask will not interfere with activities such as speaking and eating. Many conditions will require Non-invasive ventilation(mask ventilation) at night only or, sometimes, initially at night only. However, when ventilation is required during the daytime when speech and eating are needed and where wearing a bulky mask would be socially uncomfortable, Mouthpiece ventilation is most often used with a volume-cycled ventilator.
Other forms of Non-Invasive Ventilation called “body ventilators” are available but rarely used today.
Secretion management for Clients using Non-Invasive Ventilation(mask ventilation) is important and will need to be approached in a different manner than for Invasive Tracheostomy ventilation, where immediate access to the airway is available for suctioning secretions. Secretions will need to be mobilized into the mouth for expectoration or suctioning. Techniques for mobilizing secretions into the mouth include manually assisted cough, breath-stacking, and the mechanical insufflators or exsufflator.
The equipment required for Non- Invasive ventilation at a minimum includes the following:
1. Pressure- or volume-type ventilator
2. Appropriate interface mask or mouthpiece
3. Secretion management program or device
4. Backup power supply for ventilator (battery or generator)
Ventilation-specific tasks for those caring for individuals using Non- Invasive ventilation(mask ventilation) include the following:
1. Placement of mask interface at nighttime and removal in morning or whenever clinically indicated
2. Adjustment of MPV device set-up for Client at the beginning of the day
3. Assistance with secretion management, as clinically indicated
4. Replacement of interface every 6 to 12 months
9.4 OTHER FACTORS TO CONSIDER FOR SUCCESS
Although selection of technique and equipment is important in success of home ventilation, some of the important factors to consider in ensuring success in providing mechanical ventilation in the home that will be covered in this document include
- appropriate Client selection
- ensuring a safe and appropriate home setting
- adequate family support
- adequate home health-care team support
9.5 Client Selection
The selection of candidates for Mechanical Home Ventilation involves careful analysis, not only for the type of disease from which the Client suffers and equipment and support service requirements, but also a number of other factors that will have a significant impact on the successful outcome of the endeavour.
Obviously, Clients who require either invasive or non-invasive ventilation suffer from respiratory failure. This may require either full-time or part-time ventilator support, the latter most often occurring at night. Although mild hypoxemia may be a part of the presentation of respiratory failure, the major problem for Clients receiving Mechanical Home ventilation is hypercapnic respiratory failure. Clients will be unable to maintain ventilation and gas exchange without, at least, part-time ventilation.
There are Client personality characteristics that lend themselves to successful implementation of Mechanical Home Ventilation. The most successful Clients using home mechanical ventilation programs are highly motivated or have family members with a high level of motivation to care for the Client at home. A less supportive Family does not exclude ventilated Clients to go home, as with the development of specialized Intensive Home Care nursing services, Client’s are less dependent on Families.
Considerable stress and frustration can be involved in the preparation for movement to the home environment so that flexibility and patience are also important characteristics.
Clients who may be considered successful candidates for long-term Mechanical Home Ventilation may have other associated medical illnesses. These illnesses do not necessarily disqualify them from receiving Mechanical Home Ventilation if the problems can be dealt with in the home and do not necessitate frequent admission to a medical facility for evaluation or treatment.
The home itself must be safe and accessible for the ventilator-dependent Client.
Electric supply to the house must be adequate to support the ventilator and associated equipment, and it is advisable to have home circuitry inspected to ensure that this is the case. If the Client uses ventilation during the daytime, wheelchairs may need to be fitted with ventilator equipment and may have larger space requirements that need to be taken into account (hallways and room entrances, in particular).
Mechanical Home Ventilation can be expensive but is still more cost effective compared to a prolonged stay in Intensive Care, so careful discussion with the Clients, family, and insurers or governmental agencies responsible for funding will be important for the eventual success of the venture.
1 Windisch W, Brambring J, Budweiser S et al. Nichtinvasive und invasive Beatmung als Therapie der chronischen respiratorischen Insuffizienz. S2-Leitlinie herausgegeben von der Deutschen Gesellschaft fur Pneumologie und Beatmungsmedizin e.V. Pneumologie 2010; 64: 207–240
2 Roussos C. The failing ventilatory pump. Lung 1982; 160: 59–84
3 Criée C, Laier-Groeneveld G. Die Atempumpe: Atemmuskulatur und intermittierende Selbstbeatmung. 1. Aufl. New York: Thieme, 1995
4 Kabitz H, Windisch W. Respiratory muscle testing: state of the art. Pneumologie 2007; 61: 582–587
5 Tobin MJ, Laghi F, Brochard LJ. Role of the respiratory muscles in acute respiratory failure of COPD: lessons from weaning failure. J Appl Physiol 2009; 107: 962–970
6 Mehta S, Hill NS. Noninvasive ventilation. Am J Respir Crit Care Med 2001; 163: 540–577
7 AAHCP/AARC/AACP/AAP/ASDA/ATS/NAMDRC. Clinical indications for noninvasive positive pressure ventilation in chronic respiratory failure due to restrictive lung disease, COPD, and nocturnal hypoventilation – a consensus conference report. Chest 1999; 116: 521–534
8 Simonds AK, Elliott MW. Outcome of domiciliary nasal intermittent positive pressure ventilation in restrictive and obstructive disorders. Thorax 1995; 50: 604–609
9 Simonds AK. Home ventilation. Eur Respir J Suppl 2003; 47: 38s–46s
10 Schönhofer B. Choice of ventilator types, modes, and settings for longterm ventilation. Respir Care Clin N Am 2002; 8: 419–445
11 Windisch W, Dreher M, Storre JH, Sorichter S. Nocturnal non-invasive positive pressure ventilation: physiological effects on spontaneous breathing. Respir Physiol Neurobiol 2006; 150: 251–260
12 AARC clinical practice guideline. Long-term invasive mechanical ventilation in the home-2007 revision update. Respir Care 2007; 52:1056–1062
13 Schettino GPP, Chatmongkolchart S, Hess DR, Kacmarek RM. Position of exhalation port and mask design affect CO2 rebreathing during noninvasive positive pressure ventilation. Crit Care Med 2003; 31: 2178– 2182
14 Younes M, Kun J, Webster K, Roberts D. Response of ventilator-dependent patients to delayed opening of exhalation valve. Am J Respir Crit Care Med 2002; 166: 21–30
15 Storre JH, Schönhofer B. Noninvasive mechanical ventilation in chronic respiratory failure: ventilators and interfaces. In: Muir J, Ambrosino N, Simonds AK, eds. European RespiratoryMonograph. Sheffield: ERS Journals, 2008: 319–337
16 Navalesi P, Frigerio P, Gregoretti C. Interfaces und humidification in the home setting. In: Muir J, Ambrosino N, Simonds AK, eds. European Respiratory Monograph. Sheffield: ERS Journals, 2008: 338–349
17 Bach JR, Alba AS. Tracheostomy ventilation. A study of efficacy with deflated cuffs and cuffless tubes. Chest 1990; 97: 679–683
18 Wenzel M,Wenzel G, KlaukeMet al. Charakteristik mehrerer Befeuchter für die CPAP- sowie invasive und nicht invasive Beatmungstherapie und Sauerstofflangzeittherapie unter standardisierten Bedingungen in einer Klimakammer. Pneumologie 2008; 62: 324–329
19 Nava S, Cirio S, Fanfulla F et al. Comparison of two humidification systems for long-term noninvasive mechanical ventilation. Eur Respir J 2008; 32: 460–464
20 Nakagawa NK, Macchione M, Petrolino HM et al. Effects of a heat and moisture exchanger and a heated humidifier on respiratory mucus in patients undergoing mechanical ventilation. Crit Care Med 2000; 28:312–317
21 Ricard JD, Le Miere E, Markowicz P et al. Efficiency and safety of mechanical ventilation with a heat and moisture exchanger changed only once a week. Am J Respir Crit Care Med 2000; 161: 104–109
22 Tzeng AC, Bach JR. Prevention of pulmonary morbidity for patients with neuromuscular disease. Chest 2000; 118: 1390–1396
23 Vargo JJ, Zuccaro GJ, Dumot JA et al. Automated graphic assessment of respiratory activity is superior to pulse oximetry and visual assessment for the detection of early respiratory depression during therapeutic upper endoscopy. Gastrointest Endosc 2002; 55: 826–831
24 Dreher M, Storre J, Schmoor C, Windisch W. High-intensity versus low intensity non-invasive ventilation in stable hypercapnic COPD patients: a randomized cross-over trial. Thorax 2010; 65: 303–308
25 Windisch W, Haenel M, Storre JH, Dreher M. High-intensity non-invasive positive pressure ventilation for stable hypercapnic COPD. Int J Med Sci 2009; 6: 72–76
26 Windisch W, Kostic S, Dreher M et al. Outcome of patients with stable COPD receiving controlled noninvasive positive pressure ventilation aimed at a maximal reduction of Pa(CO2). Chest 2005; 128: 657–662
27 Magnussen H, Kirsten A, Köhler D et al. Leitlinien zur Langzeit-Sauerstofftherapie. Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin e. V. Pneumologie 2008; 62: 748–756
28 Schönhofer B, Geibel M, Sonneborn M et al. Daytime mechanical ventilation in chronic respiratory insufficiency. Eur Respir J 1997; 10: 2840–2846
29 Toussaint M, Soudon P, Kinnear W. Effect of non-invasive ventilation on respiratory muscle loading and endurance in patients with Duchenne muscular dystrophy. Thorax 2008; 63: 430–434
30 Storre JH, Steurer B, Kabitz H et al. Transcutaneous PCO2 monitoring during initiation of noninvasive ventilation. Chest 2007; 132: 1810–1816
31 Schönhofer B, Euteneuer S, Nava S et al. Survival of mechanically ventilated patients admitted to a specialised weaning centre. Intensive Care Med 2002; 28: 908–916
32 Farre R, Lloyd-Owen SJ, Ambrosino N et al. Quality control of equipment in home mechanical ventilation: a European survey. Eur Respir J 2005; 26: 86–94
33 Farre R, Navajas D, Prats E et al. Performance of mechanical ventilators at the patient’s home: a multicentre quality control study. Thorax 2006; 61: 400–404
34 Farre R, Giro E, Casolive V et al. Quality control of mechanical ventilation at the patient’s home. Intensive Care Med 2003; 29: 484–486
35 Fuchs M, Bickhardt J, Morgenstern U. Variabilität von Beatmungsparametern bei Heimbeatmungsgeräten. Biomed Tech (Berl) 2002; 47 Suppl 1 Pt 2: 845–848
36 Lofaso F, Fodil R, Lorino H et al. Inaccuracy of tidal volume delivered by home mechanical ventilators. Eur Respir J 2000; 15: 338–341
37 Vitacca M, Barbano L, D’Anna S et al. Comparison of five bilevel pressure ventilators in patients with chronic ventilatory failure: a physiologic study. Chest 2002; 122: 2105–2114
38 Goldberg AI, Frownfelter D. The Ventilator-assisted Individuals Study. Chest 1990; 98: 428–433
39 Ambrosino N, Vianello A.Where to performlong-term ventilation. Respir Care Clin N Am 2002; 8: 463–478
40 Lindsay ME, Bijwadia JS, Schauer WW, Rozich JD. Shifting care of chronic ventilator-dependent patients from the intensive care unit
to the nursing home. Jt Comm J Qual Saf 2004; 30: 257–265
41 Dettenmeier PA. Planning for successful homemechanical ventilation. AACN Clin Issues Crit Care Nurs 1990; 1: 267–279
42 Leger P, Laier-Groeneveld G. Infrastructure, funding and follow-up in a programme of noninvasive ventilation. Eur Respir J 2002; 20: 1573– 1578
Windisch Wet al. Guidelines for Non-Invasive and Invasive Mechanical Ventilation for Treatment