Home Mechanical
Ventilation
Cori Daines, MD
Pediatric Pulmonary Medicine
Outline
• Indications
• Patients
• Interfaces
• Ventilators
• Modes of ventilation
• Home considerations
• Complications
• Outcomes
Goals
• Extend the duration of life
• Enhance the quality of life
• Reduce morbidity
• Improve physiologic function
• Achieve normal growth and development
• Reduce overall health care costs
Indications
• Disorders of the respiratory pump
– Neuromuscular diseases, chest wall diseases, spinal cord
injury
• Obstructive diseases of the airway
– Craniofacial abnormalities, hypotonia, obesity
• Parenchymal lung disease
– BPD, cystic fibrosis
• Disorders of control of respiration
– Congenital central hypoventilation syndrome
Indications
• Inability to wean from mechanical ventilation
– After and acute illness
– After prolonged ventilation for a chronic disease
• Progressive chronic respiratory failure
• Sleep disturbance
– Central or obstructive, apnea or hypopnea
Indications/Symptoms
• Shortness of breath
– Especially on exertion or lying down
• Morning headache and insomnia
• Fatigue and lethargy
• Increased respiratory rate
• Restlessness and anxiety
Indications/Criteria
• Forced vital capacity < 50% predicted
• Maximal Inspiratory Pressure < 60
• ABG pCO2 > 45
• Moderate to severe sleep apnea
Patients
• Cardiopulmonary stability
• Positive trend in weight gain/maintenance
and growth
• Stamina for play or daily activities while
ventilated
• Freedom from active/recurrent infection,
fever, deterioration
ATS Position Paper 1990
Interfaces
• Noninvasive vs. Invasive
– Age
– Cognitive ability
– Body habitus
– Ventilatory needs
– Anticipated length of ventilation
– Family/patient preference
Noninvasive interfaces
• Nasal masks
• Full facemasks
• Nasal pillows
• Sipper mouthpiece
• Lipseal/mouthpiece device
NIV: Nasal mask / Prongs
• Many older patients prefer
compared to mouthpiece
• Problems:
– Leak, especially mouth
– Nasal bridge pressure with
mask
– Gum erosion or compression
with mask
– Nasal erosion with prongs
• Chin strap may be needed
NIV: Full face mask
• Decreased leak
• Decreased
– Cough
– Talking
– Eating
• Increased risk of
aspiration
• Nocturnal use with
daytime nasal mask
NIV: Sipper /Lipseal Mouthpiece
• Daytime use
• Allows facial freedom
• Flexed mouthpiece +/- custom
orthodontics
• Intermittently used to augment
breathing
• Continuously used
Complications of NIV
• Facial and orthodontic changes
• Aerophagia (PIP > 25 cmH2O)
• Nasal drying/congestion = humidify
• Volutrauma - air leak
• Inadequate ventilation
Tracheostomies
• Shiley, Bivona, Portex and others
• Pediatric sizes mimic ETT ID’s
• Neonatal, pediatric, adult and customized
lengths
• Cuffed and uncuffed
• Disposable inner cannula models
Tracheostomies
Ventilators
CPAP
• Continuous Positive Airway Pressure
• For simple sleep apnea
• Stents open the airway
• Decreases work of breathing
BiPAP
• Pressure Support Ventilation
• IPAP—the inspiratory positive airway pressure—extra
help when breathing in
• EPAP—the expiratory positive airway pressure--CPAP
• Cycles based on patient initiated breaths
• Available with timed back-up rates
• Used for severe sleep apnea, neuromuscular
weakness or insufficiency
Full Ventilation
• Noninvasive or invasive
• Pressure cycled or volume cycled
• SIMV vs. AC
• Allows pressure support, PEEP, inspiratory
time, flow to be added and manipulated
Ventilator Choice
• Noninvasive vs. invasive
• Portability
• Battery life
• Setting capabilities
• Reliability
• Community support
Control vs. SIMV
• CONTROL MODE
SIMV MODE
• Every breath fully
• Vent synchronizes to
supported
• Can’t wean by
decreasing rate
• Risk of hyperventilation
if agitated
support patient effort
• Patient takes own
breaths between vent
breaths
• Increased work of
breathing vs. control
Assist Control Mode
Can trigger breaths, but needs support with each breath
SIMV Mode
Most patients, improved comfort, stable CO2s
Pressure vs. Volume
Pressure
Volume
• Tidal volume changes as
• No limit on pressure
patient compliance
changes
• Potential hypoventilation
or overexpansion
• Obstructed trach
decreases delivered
volume
unless set
• Square wave pattern
results in higher pressure
delivered for same
volume delivered
Pressure vs. Volume
Pressure control
Volume control
• Set pressure, volume
• Set volume, pressure
variable
• Better control of
variable
• Better control of
oxygenation than
ventilation than
ventilation
oxygenation
• Better for younger,
noncompliant lungs
• Better for older more
compliant lungs
Pressure Support
• Trigger by patient
• Provides inspiratory flow during inspiration
• Given in addition to vent breaths in IMV
modes or alone without a set rate,
mimicking BiPAP
Bilevel Mode
Mimic BiPAP / No Backup Rate
Supporting Equipment
• External support—PEEP
• Alarms/Monitoring
– Pulse oximetry, Apnea monitor, Capnography
• Humidification
– External w/ heater, HME
• Airway clearance
– Suctioning, Vest, cough assist
• Talking devices
Discharge Criteria
• Presence of a stable airway
• FiO2 less than 40%
• PCO2 safely maintained
• Nutritional intake optimal
• Other medical conditions well controlled
• Above may vary if palliative care
Discharge Criteria
• Goals and plans clarified with family and caregivers
• Family and respite caregivers trained in the
ventilation, clearance, prevention, evaluation and all
equipment
• Nursing support arranged for nighttime
• Equipment lists developed and implemented with resupply and funding addressed
• Funding and insurance issues addressed
Continuing Assessment
• Titration sleep studies
• Blood gases
• Bronchoscopy
• Home monitoring
• Used more frequently when
weaning/decannulating
Complications
• Ventilator failure
• Tracheostomy issues
– Decannulation, blockage, infection
• Mask-related issues
– Pressure sores, facial growth issues
• Under- or over-ventilation
Outcomes
• Dependent on underlying disease
• Over 70% 10-year survival, most deaths
due to underlying disease
• In retrospective studies, 0-8% of deaths
were ventilator or technology-related
• Occasional hospitalization
Quality of Life
• Generally good
– Fewer hospitalizations
– Better sleep quality
– Better daytime functioning
• Some stress for patients, caregivers
– Related to amount of care and support needed
Home ventilation reality
• Every patient is unique
• These are guidelines not rules
• Vary settings, interfaces, strategies to
achieve goals of good health and
optimized quality of life
• Team approach necessary