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 CO
2 of circuit since rebreathing air from insp limb
•
• 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
• Flashes if inverse Ratio is set.
 Flowrate - LED display of flowrate 10 - 120 LPM.
• Flashes when insufficient.
 Sensitivity
• Less or more
10

Controls (cont.)



Airway Pressure Limit (10-100 cm/H
2
O)
• 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.
11

Alarms



Low Pressure (2 - 50 cm/H
2
O)
• 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 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 V
T
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.

•
•
•
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 H
2
O /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 H
2
O
High Pressure Alarm Limit 25 to 100 cm H
2
O
Internal pressure relief at 100 cm H
2
O.
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

O
2
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.
 V
T set = V
T desired (1 - FIO
2
)
.79
 LPM = (V
T desired - V
T 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 in the hospital but
 only $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 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)
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 PaO
2 within several weeks and PaCO
2
's
 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:
1.
2.
3.
PaCO
2
> 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.
If pt has both COPD and OSAS, must qualify under OSAS criteria
52

OSAS criteria to qualify for NPPV
1.
2.
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
Still has apneas, hypopneas, or desaturation on
CPAP
CPAP pressure so high that pt cannot exhale against it
53

Criteria for restrictive thoracic disorders:
 PaCO
2
> 45 torr or nocturnal SpO
2
< 88% for
5 continuous minutes on pt’s usual oxygen setting
 Pts w/ progressive neuromuscular disease qualify if NIF < 60 cm H
2 predicted
O or FVC is < 50% of
• 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