Therapy Considerations for Your Patient
Going Home with Non-Invasive Ventilation, by Lauren Perlman.
Hi.
My name is Lauren Perlman.
I'm a respiratory care practitioner here
at Boston Children's Hospital.
I will be discussing non-invasive ventilation,
including BiPAP and CPAP, more specifically considerations
for your patient using these therapies in the hospital
and transitioning to home.
I have no financial disclosures.
There are several considerations when
choosing the appropriate device for use in the home,
including the patient's age and weight,
the patient's developmental age.
Can your patient remove their interface?
Can your patient sustain normal breathing
without support in the event of a power failure at home?
Does your patient's device require a power failure alarm
and backup battery power?
Does the backup battery power need
to be integrated into the device?
Does your patient require their support during the day?
How significant is their level of support
and more importantly, their oxygen requirement?
Does your patient require more than one level of support?
Do you anticipate the placement of a tracheostomy tube
in the near future?
What is the designated caregiver's ability
to learn this new care?
Will your child and family benefit
from time at a rehabilitation facility prior to going home?
There are FDA regulations on the use of ventilators, BiPAP,
and CPAP devices.
The lowest FDA approval is currently five kilograms.
The approvals vary by device.
The equipment companies do offer a waiver
that can be signed by the guardian, such
that the equipment can be used off-label or out of weight
range.
The equipment companies may consider patients for discharge
under five kilograms if there are specific considerations,
such as hospice care.
Can your patient remove their interface
if the power fails in the home?
This may be due to age, developmental age, or disease
process, such as those with neuromuscular disease.
If it has been determined that they require
both their nose and mouth to be covered for therapy,
they are considered to be at higher risk
both in the event of power failure,
but also due to the risk of aspiration
of oral or gastric fluids.
Please do periodically consider the use
of a nasal interface and perhaps a chinstrap
to minimize air leaks out of their mouth.
The options are to choose a device with a power failure
alarm, a power failure alarm and battery
that can then be attached to the device,
or a device with integrated backup battery
power and alarms.
Although it seems like a simple choice,
there are further considerations,
as the devices with integrated power and alarms
are now considered ventilators with additional cost.
And more importantly, they require significantly more
caregiver education.
These more expensive devices will require more documentation
as to why your patient needs this type of device
to obtain approval from the insurance agencies.
Obtaining this approval may delay discharge
from the hospital, as compared to the use
of the more simple devices.
If your patient can be without support overnight
in the event of a power failure in the home
and they have a nasal interface, you
may choose a simple device without specific alarms
or battery backup for ease of use.
When a patient cannot be without support,
either overnight or for those that use support during
the day, use two levels of support such as an overnight
mask ventilation and daytime mouthpiece ventilation,
or you believe that a tracheostomy will be considered
in the near future, the decision is clear.
They will require a ventilator type of device
for their support.
In our area, the Philips Respironics Trilogy
and the ResMed Astral are available for use.
These ventilators offer the choice of a passive circuit,
such as utilized with BiPAP technology, in which one hose
is attached to the patient interface,
and exhalation takes place in the mask
through specific venting holes, and they also
offer an active or a dual-limb ventilator configuration,
as we are familiar with on our ICU ventilators, the CareFusion
LTV and the Newport series of ventilators.
The most important consideration when
deciding about these options is your patient's oxygen
requirement.
It's difficult to provide more than about 40%
oxygen when using the high-flow BiPAP passive circuitry
in the home setting.
The passive circuitry flow of air
significantly dilutes the liters of oxygen
that are added to the circuit to meet your patient's needs.
The passive circuit with high flow rate
is specifically designed to compensate for air leaks,
as it was created and designed for patients
with facial interfaces and not tracheostomy tubes.
The ventilators with active circuits,
such as we use in the hospital setting,
can provide non-invasive ventilation by facial interface
with high oxygen levels.
But the patient may require the use of a mask over nose
and mouth due to the air leak around the mask,
in particular when they are asleep.
Of note, our Trilogy ventilators here
at Boston Children's require oxygen
to be bled in such as it is in the home setting.
Patients requiring more than approximately 40%
oxygen will be on the Philips Respironics V60 device
not designed for home use.
Additional considerations when dealing
with infants and children are the patient's ability
to trigger on a breath when using BiPAP support.
If the infant or child is unable to initiate the support,
it is recommended that you set the backup breath rate just
below the patient's spontaneous breath rate.
The ventilator type of devices such as the Trilogy or Astral
do seem to respond to our littlest and weakest patients
with regard to being able to initiate and trigger
their support.
It's important to pay special attention to skincare.
If possible, having two different interfaces
that may have different contact points on the face
can reduce skin irritation.
Our recommended skin barrier product
is Mepilex Light, which has a mild adhesive property
and can be cut to fit under the interface at skin contact
points.
Education for your patient's family
will be provided by our Children's staff and their home
care company.
The patient may qualify for block nursing care in the home.
Please do consult with their case manager
to discuss this as an evaluation from the payer
and then determination of hours of help come first,
and then the nursing agencies will be contacted
to find help for your patient.
Non-invasive support on our patient population
is no easy task for our families.
Spending time at a local rehabilitation facility
may be warranted to establish all of the supports needed
for home.
It's important to be very clear when ordering BiPAP or CPAP.
We routinely provide a backup rate here at Children's.
This requires the mode be referred to
as ST, or Spontaneous Timed.
The devices that provide ST mode versus S mode
are more expensive.
Thus, your order must specify that you
are ordering a backup rate, thus the ST mode.
You will order a mode such as CPAP or BiPAP
without a rate or BiPAP ST. You will
need to specify with BiPAP the backup rate
and the inspiratory and expiratory pressures.
When ordering CPAP or BiPAP on a ventilator type of device,
there are more specific parameters to order,
such as rise time, flow termination, et cetera.
Please do speak with your respiratory therapists
to determine what must be ordered when using a ventilator
type of device.
For oxygen orders, please do provide
a range of liter flow with oxygen saturation parameters,
such as 0 to 5 liters per minute to maintain oxygen saturations
of 92% to 96%.
Please consider the use of oximetry
as an adjunct alarm for your patient
going home with CPAP or BiPAP.
If your patient is very active during the use of support,
there may be several false alarms, and thus
alarm fatigue in the home.
Remember that if the child moves the interface from their nose
or nose and mouth to their cheek,
the device may not alarm, as this is not
seen as a disconnect situation.
The apnea alarm use requires more consideration.
As we discussed, some of our patients
will be assisted by the device, as they may not
be able to consistently activate a supported breath.
You do not want the device to sound an alarm every time
the patient is unable to activate a breath,
unless you did not order a backup breath rate.
Ventilators offer a multitude of alarms,
as they are used in various situations.
Please order only what is necessary for the safety
of your patient.
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