Home Care Ventilators
Home Mechanical Ventilators
 LP
- 6, LP 6+
 LP 10 (peds)
 PLV-100, 102, 104
 Bear 33
 LVT-1000
 Achieva
2
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
3
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.
4
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
5
Most Important Alarms
 Patient
disconnect
 Loss of electrical power
 Low battery
6
LIFECARE PLV-100
Classification
 Electrically
•
powered
microprocessor controlled
 Volume-control,
time cycled
 Rotary drive piston
 Modes
•
Control
• A/C
• SIMV
8
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.
9
Controls

Rate - LED display set
rate 2 - 30 BPM.
 I:E Ratio display
•

Flowrate - LED display of
flowrate 10 - 120 LPM.
•

Flashes if inverse Ratio is
set.
Flashes when insufficient.
Sensitivity
•
Less or more
10
Controls (cont.)

Airway Pressure Limit (10-100
cm/H2O)
•

Battery Test Switch
•

Vents excess pressure and
sounds audible alarm
simultaneously. Inspiration
ends.
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.
11
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.
12
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 alert13
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
14
•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.
15
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.
16
•Tidal Volume Digital
Display - displays tidal
volume set.
•Pressure Gauge displays pressure at
proximal airway.
17
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.
18
Life Products LP-6, LP 6 Plus and
LP 10
Home Ventilator
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.
20
LP 10
21
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.
22
Pressure Limit Control
Classification
•
•
•
In SIMV, patient must
breathe through the
circuit, humidifier and
then through the piston
intake valve unless oneway 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.
23







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
24
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
25
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.
26

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.
27
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.
28
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.
29
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.
30
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.
31
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
32
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.
33
HOME CARE VENTILATION
 Brief
overview
 Types of ventilators
 What’s involved in sending a patient
home on a ventilator.
34
Historically
 Ventilatory
support in home dates back
to polio epidemics of 1940s
 Since
the mid 1980’s the Home Care
Industry has steadily grown.
35
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.
37
More and more patients are going
home on ventilators because of the
sky rocketing costs of hospital care.
In 1983 the AARC conducted 21state 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.
39
 19%
of these patients were under the
age of 17 and
 51% were between 18 and 64 years of
age.
40
The ARRC estimated the cost to
Medicare/Medicaid per year for a
ventilator- assisted person
 $270,000
 only
in the hospital but
$21,000 per year at home.
41
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.
42
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)
44
Methods of Ventilatory Support in
Home Care
 Non-invasive
•
Negative Pressure Ventilators (NPV)
•
•
•
•
Chest cuirass
Poncho Wrap
Iron Lung
Non-invasive positive press ventilation
(NPPV)
 Invasive
•
mechanical ventilation
mechanical ventilation
Positive Pressure Ventilators (PPV)
45
Advantages of Negative Pressure
Ventilators
 Don't
need artificial airway
46
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
47
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.
48
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
49
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
50
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
51
Medicare Conditions for COPD
- Pt must have:
PaCO2 > 52 torr while on at least 2
LPM oxygen.
A minimum of 5 minutes of continuous
desaturation during sleep study
(polysomnography) while on at least 2
LPM oxygen.
OSAS ruled out as a diagnosis during
polysomnography study.
1.
2.
3.
•
If pt has both COPD and OSAS, must
qualify under OSAS criteria
52
OSAS criteria to qualify for NPPV
Must qualify for CPAP first, i.e. have OSAS:
[apnea/hypopnea index (AHI) ≥ 15/hr or btw 5
– 15/hr w/ symptoms]
Pt fails to tolerate CPAP or CPAP is
ineffective
1.
2.
•
•
Still has apneas, hypopneas, or desaturation on
CPAP
CPAP pressure so high that pt cannot exhale
against it
53
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.
54
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-atpressure to verify use.
55
Invasive Positive Pressure Ventilation Home
 Means
•
that pt has a tracheostomy.
Mask ventilation no longer effective
 Added
problems of artificial airway.
56
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.
35
There are many other
considerations after deciding what
type of ventilatory support is
needed.
36
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.
59
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.
60
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
61
 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.
62
Most institutions have a
CHECKLIST on how to get a
patient home with a ventilator.
63
Remember
 No
nursing home will take a patient
on ventilator.
64
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.
65
There are a lot of things you have
to think about
More details will be provided in
your Pulmonary Rehab course.
44