Home Mechanical Ventilators • LP - 6, LP 6+ • LP 10 (peds) • PLV-100, 102, 104 • Bear 33 • LVT-1000 • Achieva
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
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.
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
Most Important Alarms • Patient disconnect • Loss of electrical power • Low battery
Classification • Electrically powered • microprocessor controlled • Volume-control, time cycled • Rotary drive piston • Modes • Control • A/C • SIMV
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.
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
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.
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.
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.
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
Assist/Spontaneous LED Green indicator light indicates an assisted breath in A/C mode and indicates spontaneous breaths in SIMV mode. Assisted and Spontaneous breaths will register on the BPM Display.
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.
Tidal Volume Digital Display - displays tidal volume set. • Pressure Gauge - displays pressure at proximal airway.
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.
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.
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 Control
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.
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
Modes LP 6 • 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 10
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.
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.
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.
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.
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.
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.
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
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.
HOME CARE VENTILATION • Brief overview • Types of ventilators • What’s involved in sending a patient home on a ventilator.
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
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 ventilatorsbecause oftheskyrocketingcostsofhospitalcare.
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.
19% of these patients were under the age of 17 and • 51% were between 18 and 64 years of age.
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.
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.
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)
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)
Advantages of Negative Pressure Ventilators • Don't need artificial airway
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
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.
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
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