Adult 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. PERSON’S INFORMATION
Name
Last Name
Address
First Name
Title
Mr
Ms
Other
Suburb & Post Code
Mrs
Phone
Miss
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
2.
Evidence of Hypoventilation
a. Diagnostic sleep study or nocturnal respiratory monitoring demonstrating sleep hypoventilation
(mean SpO2 ≤ 88% or TcCO2 ≥ 8 mmHg from baseline) OR
b. Copy of paired evening-morning Arterial Blood Gases (ABG’s) demonstrating a PaCO2 rise ≥
8mmHg OR
c. Copy of an ABG demonstrating awake PaCO2 ≥ 45 mmHg
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
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 – Neurodegenerative and Neuromuscular disorders
6. Diagnosis
7.
Evidence of Hypoventilation
a. Documentation of an acute event with respiratory de-compensation requiring hospitalisation
where complete weaning has not been possible OR
b. VC ≤ 50% and Pimax ≤ 40% predicted OR
c. Diagnostic sleep study or nocturnal respiratory monitoring demonstrating a fall in SpO2 below 90%
for more than 2% of total sleep time OR
d. Diagnostic sleep study or nocturnal respiratory monitoring demonstrating sleep hypoventilation
(mean SpO2 ≤ 88% or TcCO2 ≥ 8 mmHg from baseline) OR
e. Copy of paired evening-morning ABG’s demonstrating a PaCO2 rise ≥ 8mmHg OR
f. Copy of an ABG demonstrating awake PaCO2 ≥ 45 mmHg OR
8. Treatment
a. Recent nocturnal ventilation titration sleep study OR
b. Recent Polygraphic download (including parameters such as tidal volume, flow etc.) performed
with oximetry whilst stable
9. 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
10. Follow up
Follow up report from respiratory/sleep physician which includes the longer term plan (e.g. advanced
medical plan, nutrition, secretion management)
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Adult Nocturnal Ventilation
Equipment Request Form
Disease Specific Criteria – COPD with awake respiratory failure/nocturnal hypoventilation
whilst stable
11. Diagnosis
Copy of an ABG demonstrating awake PaCO2 ≥ 52 mmHg during a period of clinical stability
12. Treatment
Recent nocturnal ventilation titration sleep study demonstrating improved control of sleep disordered
breathing and gas exchange
13. 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
14. Follow up
Follow up report from respiratory/sleep physician
- Disease Specific Criteria – Non-hypercapnic Central Sleep Apnea
15. Diagnosis
a. Recent diagnostic sleep study or nocturnal respiratory monitoring demonstrating CSA/CSR with
AHI ≥ 20/hr in which at least 50% of events are central OR
b. Recent CPAP titration sleep study or nocturnal respiratory monitoring demonstrating CSA/CSR
with ongoing AHI ≥ 20/hr
16. A downloaded compliance report on fixed pressure CPAP following the CPAP titration sleep study
demonstrating that CSA/CSR is not resolved or not tolerated after a ≥ 2 week trial.
17. Treatment
Recent servo ventilation titration sleep study demonstrating improved control of sleep disordered
breathing and gas exchange
18. 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
19. Follow up
Follow up report from respiratory/sleep physician outlining reasons that CPAP therapy was ineffective or
was not tolerated and the need for long-term nocturnal ventilation therapy.
3. INTERFACE
Full face/Nasal mask
Tracheostomy
Mouth piece
4. EQUIPMENT SPECIFICATIONS
Mode
Max Pressure
AVAPS rate
-
IPAP
Max Pressure Support
Tidal Volume
EPAP
Min Pressure Support
(if prescribed volume assured
Rate
Max EPAP
pressure support)
Min EPAP
Alarms
Inspiratory Time
OR
Max Ti
Rise Time
Min Ti
The person uses other respiratory equipment.
Please specify:
5. DELIVERY INFORMATION
Person’s Home address
Other: Name of contact
Address
Postcode
Phone
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Adult Nocturnal Ventilation
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6. PRESCRIBER DECLARATION
I declare that I have assessed the person and recommend this equipment for the safe management of this
person’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.
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