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Primary Care of Home Ventilator Patients

Adam Turigliatto RT Amy Light MD

Susan Bray-Hall MD

15 ventilator dependent at Portland VAMC

◦12 have ALS◦1 spinal cord injury◦2 severe respiratory insufficiency

with nocturnal ventilation Cared for either in homes (5/12) or

Adult Foster Homes (7/12)

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Pt is placed on the ventilator and monitored in the ICU for complications (first night)

RT bedside education starts immediately; family present

Transitioned to the ward Continue with education both day and

night shift Education period can last up to 14 days or

longer if needed

Tracheostomy Placed

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Educate, Educate, Educate!

Introduction to the mechanical ventilator Daily education and hands on training How to order proper equipment and

supplies Preparation for discharge to home

Setting Families Up for Success

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The family/caregiver is supplied with introduction to mechanical ventilation packet including:

Basic functions and features of the ventilator

Definitions of the controls/alarms Patient values/baseline Troubleshooting the ventilator

Ventilator Education

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RT provides daily education that includes: Daily trach care How to change an inner cannula Proper suctioning, both inline and sterile How to manually ventilate the patient How to handle an emergency decannulation Trouble shooting and assess for complications Standard mandatory bedside items: spare trach,

obturator, manual resuscitation device How to operate other RT equipment: suction,

humidification, assistive devices

Caregiver Daily Tasks

Family members/caregivers responsible for providing care must complete

an overnight competency stay in the hospital.

Caregiver Daily Tasks

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Home ventilator, both primary and back-up External batteries incase of power failure Caregiver should contact the power company If oxygen not necessary at baseline, is safe

practice to have an 02 tanks for emergencies DME equipment: suction machine, O2 sat

monitor, humidification, assisting device Sufficient quantity daily disposables: trach

supplies, inner cannulas, suction catheters, etc.

Equipment /Supplies

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Multidisciplinary communication mandatory; who is arranging the travel, bed, lift, power chair??

Has DME company completed home inspection? Have caregivers successfully completed training

and overnight stay? Patient safety concerns from family, patient or

team members? Home health ordered if needed RT transports the patient’s first initial discharge to

home

Discharge Home

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Vent management just like any other support modality; think dialysis

Hardest part; not the vent, but multiple comorbidities

Caregiver is responsible for the day-to-day ventilator care

Vent Basics for a Primary Care Doc

Patient baseline◦Oxygen requirements◦Peak pressure◦Sputum production

All orders in one quick place Back up support system:

◦RT for supplies, process issues, routine respiratory needs

◦DME company for vent, supplies, maintenance◦Pulmonologist writes orders and available for

urgent vent or pulmonary needs

Vent Basics for a Primary Care Doc

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HOME VENTILATOR PATIENT ORDERS

Date of initiation of home ventilator orders: 1999 Date of renewal of home ventilator orders: Dec 12,2012 Date of most recent RCS home vent check: Jun 13,2012 Diagnosis: ALS Mechanical ventilator make and model: Make: xxxxx Model: 950 DME ID #: Ventilator settings: Mode: A/C (Assist control) Rate: 12 breaths per minute Tidal volume: 700 mL Insp time: 1.5 sec PEEP: 2 cm H2O pressure Oxygen: 0.21. May have 2 oxygen tanks in the home for emergencies Sensitivity 3

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No recommendations for routine changing Change on visits to hospital if possible At home prophylactically or for urgent

reasons◦Train caregiver, primary care provider◦Specialist to the home.

Trach Changes

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Cases

59yo admitted to hospital with respiratory failure. Dx with ALS. Placed on ventilator.

69yo previous dx of ALS. Admitted for elective tracheostomy and ventilator support.

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Experience

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Ongoing Discussions

What is the trigger for discontinuing the vent? “I cannot consider that right now” “When I cannot write to communicate

anymore” “When I cannot walk anymore” “The next time I get a pneumonia” …

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Ethics

ACP Statement:◦1991 Withdrawing is not different than

not starting life sustaining treatment◦1990 Cruzan case

‣ Home vs. facility

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Preparation & Day of Event

“I’m going to attend a death” Checklist Who is present? Education Medication plan Procedure

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Plan for Home Ventilator Removal

Fentanyl SQ PCA (3 days prior) IVs in place (1 day prior) Day of Event: Care team meets Chaplain and social worker for family

activities, rituals Medical team arrives; ensure all cell

phones and pagers on vibrate/silence Preparations for continuous care if needed

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Team Self-Care

All questions about plan are welcome. Every member of team should feel

comfortable with the overall plan and role. Bring water bottle, light snack—eat, if

appropriate with family. Expect all day. Cell phones & pagers silenced Other personal care items Call with any questions at any time

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Extubation Counseling Goal alignment

◦ Die from natural causes; NOT “taking his own life” No intent to expedite death Time course: minutes, hours, days, a week.

Prepare Change ventilator settings Family Presence Absolute silence Hearing preserved Vital signs Education about breathing changes Music, Candles, Chair, Tissues

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Palliative Sedation Draw up medications for push. PCAs functioning Best location for RN managing meds 30 minutes prior:

◦ phenobarbital IV push◦ atropine ophth. solution 3 drops delivered on tongue/SL◦ Switch fentanyl SC PCA to IV, add midazolam IV PCA

10 minutes prior:◦ midazolam loading dose 7.5 mg (peak effect 10 min)◦ fentanyl 25 mcg (peak effect 6-10 min)

Time of vent removal:◦ fentanyl 25 mcg (higher dose, if needed) + midazolam 5 mg prn

After vent removal:◦ fentanyl and midazolam q 8-10 minutes as indicated by sxs*

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Ventilator Removal (No Extubation)

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Alarms are off on ventilator and oxygen Suction Dependence on ventilator?

◦ Over-breathing vent◦ AC or pressure controlled ventilation◦ reduce respiratory rate in ½ to assess distress◦ switch from AC to pressure support ventilation 5/5◦ Turn oxygen to room air, turn off concentrator

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silence

Adam Turigliatto RTadam.turigliatto@va.gov

Susan Bray-Hall, MDsusan.bray-hall@va.gov

Amy Light MDamy.light@va.gov

Any Questions?

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