Paediatric Nocturnal Ventilation
Equipment Request Form
This form should be used to request Nocturnal Ventilation equipment. Refer to the Clinical Criteria for
information regarding eligible people, eligible prescribers and equipment provided.
1. CHILD’S INFORMATION
Name
Last Name
Address
First Name
Title
Phone
Master
Other
Suburb & Post Code
Miss
Mr
Date of Birth
Mobile
N.B. The full technical and physician reports of all relevant tests must be submitted
with this request
2. EQUIPMENT ELIGIBILITY
- General Criteria
1. Diagnosis
ABG demonstrating PaCO2 ≥ 45 mmHg OR VBG demonstrating CO2 ≥ 50mmHg
2. Evidence of Hypoventilation
Diagnostic sleep study or nocturnal respiratory monitoring demonstrating sleep hypoventilation (mean
SpO2 ≤ 93%) and
a. TcCO2 ≥ 8 mmHg from baseline OR
b. Copy of paired evening-morning ABG’s demonstrating a PaCO2 rise ≥ 8mmHg
3. Treatment
Recent nocturnal ventilation titration sleep study demonstrating improved control of sleep disordered
breathing and gas exchange
a. Where significant upper airway obstruction is seen on a diagnostic study, the full technical and
physician report of a CPAP titration sleep study demonstrating insufficiency of CPAP
b. Cause of hypoventilation (if diagnosis is not OSA/OHS):
4. Compliance
Download of a recept nocturnal ventilation compliance report performed over 4 consecutive weeks,
within 12 weeks of application lodgement date, demonstrating consistent usage of nocturnal ventilation
≥ 4 hours per night for ≥ 70% of nights
5. Follow up
Follow up report from respiratory/sleep physician
- Disease Specific Criteria – Neuromuscular disorders
6. Diagnosis
a. Documentation of more than 3 hospitalisations for chest infections per year OR
b. Documentation of an acute event with respiratory decompensation requiring hospitalisation where
complete weaning off ventilatory support has not been possible
7. Treatment
Recent nocturnal ventilation titration sleep study demonstrating improved control of sleep disordered
breathing and gas exchange
8. Compliance
Download of a recept nocturnal ventilation compliance report performed over 4 consecutive weeks,
within 12 weeks of application lodgement date, demonstrating consistent usage of nocturnal ventilation
≥ 4 hours per night for ≥ 70% of nights
9. Follow up
Follow up report from respiratory/sleep physician
- Follow up
Follow up report from respiratory/sleep physician
3. INTERFACE
Full face/Nasal mask
Tracheostomy
Mouth piece
EnableNSW Paediatric Nocturnal Ventilation Equipment Request Form
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Paediatric Nocturnal Ventilation
Equipment Request Form
4. EQUIPMENT SPECIFICATIONS
Mode
Max Pressure
AVAPS rate
IPAP
Max Pressure Support
Tidal Volume
(if prescribed volume assured
EPAP
Min Pressure Support
pressure support)
Rate
Max EPAP
Inspiratory Time
OR
Min EPAP
Alarms
Max Ti
Rise Time
Min Ti
The child uses other respiratory equipment.
Please specify:
5. DELIVERY INFORMATION
Child’s Home address
Other: Name of contact
Address
Postcode
Phone
6. PRESCRIBER DECLARATION
I declare that I have assessed the child and recommend this equipment for the safe management of this
child’s long term respiratory condition in the community.
Prescriber name
Provider number
Name of service
Qualification/Role
Address
Date
Phone
Signature
Email:
Fax:
7. OTHER CONTACTS
Name
Name
Address
Address
Phone
Phone
Email
Email
Fax
Fax
Qualification/Role
Qualification/Role
ENABLENSW CONTACT DETAILS
Email
enable@health.nsw.gov.au
Post
EnableNSW
Locked Bag 5270
Parramatta NSW 2124
Phone
Fax
1800 362 253
(02) 8797 6543
NB: Please ensure all contact details and a completed consumer application form is provided.
EnableNSW Paediatric Nocturnal Ventilation Equipment Request Form
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