Monitoring on LTV Martin Samuels Bristol Course on Long Term Ventilation in Children.
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Transcript of Monitoring on LTV Martin Samuels Bristol Course on Long Term Ventilation in Children.
![Page 1: Monitoring on LTV Martin Samuels Bristol Course on Long Term Ventilation in Children.](https://reader036.fdocuments.in/reader036/viewer/2022070406/56649e035503460f94aee0c1/html5/thumbnails/1.jpg)
Monitoring on LTV
Martin Samuels
Bristol Course on Long Term Ventilation in Children
![Page 2: Monitoring on LTV Martin Samuels Bristol Course on Long Term Ventilation in Children.](https://reader036.fdocuments.in/reader036/viewer/2022070406/56649e035503460f94aee0c1/html5/thumbnails/2.jpg)
Objectives
• understand monitoring of the child on LTV
• know the methods available and when to
apply them
• develop a framework for assessment &
monitoring of children and young people
on established LTV
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Workshop Content
• devise a proforma for assessing the
child on LTV
• discuss components of assessment,
including physiological monitoring
• discuss follow-up
• discuss home monitoring
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Devise a Proforma for Assessment
You’re away when the following child attends your unit. A junior member of your team needs help on what needs review...
• 3 year old RTC trach ventilated
• 9 year old SMA pillows
• 15 year old DMD mask ventilated
• 10 year old SLD & SDB mask
Now decide on follow-up arrangements ...
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Assessment
1. Clinical progress
2. Equipment
3. Care package
4. Examination
5. Investigations
6. Communications & follow-up
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1. Clinical Progress
• Appetite & nutrition• Feeding & swallowing• Mobility• Sleep• RTI’s• Use of antibiotics• Hospital admissions• School attendance /
progress
• Ventilator use• Disturbances:
– alarms– leaks– disconnections
• Secretions / suction• Parental coping• Carers’ charts
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2. Equipment
Ventilator:• Settings• Servicing• Hour meter• Dowload
– Tidal volume– Minute ventilation– Leaks – Usage
• Interfaces– Check fit– Cleanliness– Complications
• Monitors• Suction• Tubing• Humidity • Oxygen
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3. Care Package
• Carers• Nocturnal disturbances• Supplies• Respite• Community team• Social care & support• Finance
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4. Examination
• Growth• Nutrition• Skin / stoma care• Nose• Chest • Cardiac, incl PHT• Spine • Posture
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5. Investigations
• SaO2• Spirometry:
– FVC / VC– FEV1 / MEF
• Sleep study:– SaO2– tcPCO2 / ET-CO2– Pmask
– synchrony
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5. Investigations
• SaO2• Spirometry:
– FVC / VC– FEV1 / MEF
• Sleep study:– SaO2– tcPCO2 / ET-CO2– Pmask
– synchrony
+ consider:• sputum MC&S• CXR• ECG• peak cough flow• nasal sniff pressure• max Pi & Pe• mouth occlusion P• P0.1 / Pi-max
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6. Communications
Check reviews:• Physiotherapy• SALT• Dietician• OT• Psychology• Neuromuscular• Cardiology• Spinal • Community paed
• Immunisation– Flu– Pneumovax
• Emergency care plan• Prescription check
– Ventilator– Medicines
• Follow-up• Transition
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Adequacy of Gas Exchange
• O/P v I/P• home• invasive v non-
invasive• duration
Measure• SaO2• tcPCO2• end-tidal CO2• ? bicarbonate
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Normal Short period of low baseline
Whole night low baseline
SaO2 Frequency Curves
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10 minute page
mask pressure at patient
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30 second page
mask pressure synchrony
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mask pressure asynchrony
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whole night trend
SaO2
tcPCO2
heart rate
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ATS Guidelines for DMD
• visit 4-6 years old & before loss of ambulation
• 6 monthly resp OP:– non-ambulant– FVC <80%– >11y old
• 3 monthly resp OP:– NIV– Cough Assist
• Review before surgery
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ATS Guidelines for DMD
At each visit:
• SaO2
• awake CO2
• FVC, FEV1, MEF
• Max Pi & Pe
• Peak cough flow
• FBC
• Bicarbonate
• CXR
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Follow-up: Personal Practice
• referrals to respiratory OP
• Annual sleep study (DMD 12y)
• 6 monthly SS if SDB present
• Initiate LTV when symptomatic
• SS 3-6 months later
• Annual review
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Reasons for Home Monitoring
Recognition of:
• airway obstruction
• failure of respiratory support
• interruption of O2
• prevention of sudden death
• cyanotic-apnoeic episodes
• worsening respiratory failure
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Tracheostomy Related DeathAuthor Year n SUDs %
Wetmore 82 420 8 2
Gerson 82 123 1 0.8
MacRae 84 93 2 2
Freezer 90 142 2 1.4
Puhakka 92 33 1 3
Simma 94 108 0 0
Donnelly 96 29 0 0
Shinkwin 96 56 1 1.8
Dubey 99 40 1 2.5
Midwinter 02 143 4 2.8
Total 1187 20 (1 in 60) 1.7
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Reasons for Home Monitoring
Recognition of:
• airway obstruction
• failure of respiratory support
• interruption of O2
• prevention of sudden death
• cyanotic-apnoeic episodes
• worsening respiratory failure
![Page 25: Monitoring on LTV Martin Samuels Bristol Course on Long Term Ventilation in Children.](https://reader036.fdocuments.in/reader036/viewer/2022070406/56649e035503460f94aee0c1/html5/thumbnails/25.jpg)
Oximetry – Motion Artefact
• Pulsatile component is
1 – 5% of absorbances
• Movement seriously
affects measurement
• Results in frequent
false alarms
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Motion Resistant SaO2 – Masimo SET
• small, portable
• battery operable
• few false alarms
Rad5 OximeterRadical Pulse Oximeter
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Suggested Home Monitoring
• Respiratory support:
– none
• Life support:
– SaO2
• CCHS:
– SaO2 & CO2
SenTec SaO2 & tcPCO2
Capnocheck SaO2 & ET-CO2
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Investigations & Monitoring
Varies between
• individual condition
• Individuals
• centres
Limit in palliative care to
• symptom relief
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Summary
• understand monitoring of child on LTV
• know the monitoring methods available
and when to apply them
• develop a framework for assessment of
children and young people on
established LTV