Transcript Primary Care of Home Ventilator Patients

Adam Turigliatto RT
Amy Light MD
Susan Bray-Hall MD
©AAHCM


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)
©AAHCM
©AAHCM
©AAHCM
©AAHCM





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
©AAHCM
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
©AAHCM
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
©AAHCM
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
©AAHCM
Family members/caregivers responsible for
providing care must complete an overnight
competency stay in the hospital.
©AAHCM






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.
©AAHCM






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
©AAHCM



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
©AAHCM



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
©AAHCM
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
©AAHCM



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.
©AAHCM
©AAHCM


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.
©AAHCM
©AAHCM
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”
 …
©AAHCM

‣
ACP Statement:
◦ 1991 Withdrawing is not different than not
starting life sustaining treatment
◦ 1990 Cruzan case
Home vs. facility
©AAHCM






“I’m going to attend a death”
Checklist
Who is present?
Education
Medication plan
Procedure
©AAHCM
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

©AAHCM






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
©AAHCM

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
©AAHCM



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*
©AAHCM



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
©AAHCM
silence
©AAHCM
Any Questions?
Adam Turigliatto RT
[email protected]
Susan Bray-Hall, MD
[email protected]
Amy Light MD
[email protected]
©AAHCM