Reprinted from Respiratory Care [Respir Care 1995;40(12):1313-1320]
AARC Clinical Practice Guideline
Long-Term Invasive Mechanical Ventilation in the Home
HIMV 1.0 PROCEDURE:
The application of invasive mechanical ventilation and care of the patient-ventilator system in the home, as ordered by a physician.
HIMV 2.0 DESCRIPTION/DEFINITION:
Mechanical ventilation may be defined as a life support system designed to replace or support normal ventilatory lung function.(1) Ventilator dependence is caused by an imbalance between ventilatory capacity and demand.(2) “A ventilator-assisted individual (VAI) may require mechanical aid for breathing to augment or replace spontaneous ventilatory efforts to achieve medical stability” or to maintain life.(3) The patient eligible for invasive long term mechanical ventilation in the home (HIMV) requires a tracheostomy tube(4-6) for ventilatory support but no longer requires intensive medical and monitoring services.(7-9) This guideline refers to patients ventilated by positive pressure via a tracheostomy tube in the home.
The goals of HIMV are
2.1 to sustain and extend life;(8,10-19)
2.2 to enhance the quality of life;(10-15,17-29)
2.3 to reduce morbidity;(8,10,11,13,16,20,30)
2.4 to improve or sustain physical and psychological function of all VAIs(7,8,10,13,15,16,18,20,31,32) and to enhance growth and development in pediatric VAIs;(5,7,8,12,17-19,23,28,33-36)
2.5 to provide cost-effective care.(7,8,10,11,13-19,22, 23,27,28,32,36-45)
HIMV 3.0 SETTING:
The setting is the home, which for the purposes of this guideline may be the patient’s home,(4,5,10,18,19,22, 27,32,34,38,40,41,46-53) a foster home,(10,17) or a group-living environment.(10,51)
HIMV 4.0 INDICATIONS:
4.1 Patients requiring invasive long-term ventilatory support have demonstrated:
4.1.1 an inability to be completely weaned from invasive ventilatory support or
4.1.2 a progression of disease etiology that requires increasing ventilatory support.
4.2.Conditions that met these criteria may include but are not limited to ventilatory muscle disorders,(4,5,10,11,14,16-19,21,26,27,33,35,38,42,43,46,52,54-62) alveolar hypoventilation syndrome,(4,5,10,17,18, 19,23,33,34,42,43,46,47,59,60) primary respiratory disorders,(4,10,17,18,19,23,42,46,59,60) obstructive diseases,(5,10,57,58) restrictive diseases,(5,10,16,43,46,56) and cardiac disorders including congenital anomalies.(17,23,19,42,46,59)
HIMV 5.0 CONTRAINDICATIONS
Contraindications to HIMV include:
5.1 The presence of a physiologically unstable medical condition requiring higher level of care or resources than available in the home.(4-7,10, 14,16,17,19,20,21,23,26,29,33,52,59) Examples of indicators of a medical condition too unstable for the home and long term care setting are:
5.1.1 FIO2 requirement > 0.40(4,5,10,16,35)
5.1.2 PEEP > 10 cm H2O(4,5,10,12,16,35)
5.1.3 Need for continuous invasive monitoring in adult patients(4,6,16)
5.1.4 Lack of mature tracheostomy
5.2 Patient’s choice not to receive home mechanical ventilation(5,10,16,19,23,26,39,42,52,56,58,63,64)
5.3 Lack of an appropriate discharge plan(4,5,8,11, 13,18,33,34,38,39,46,48,51,65)
5.4 Unsafe physical environment as determined by the patient’s discharge planning team.(10,13,66)
5.4.1 Presence of fire, health or safety hazards including unsanitary conditions.(39,51)
5.4.2 Inadequate basic utilities (such as heat, air conditioning, electricity).(4,5,10, 19,22,33,38,39,52,67)
5.5 Inadequate resources for care in the home:
5.5.1 Financial(9,10,13,14,16,18,19,23,25,26,33,35,38-40,44,52,55,56,59,68,69)
5.5.2 Personnel
5.5.2.1 Inadequate medical follow-up(13,14,16,18,29,33,36,38,39,50,61)
5.5.2.2 Inability of VAI to care for self, if no caregiver is available(5,16)
5.5.2.3 Inadequate respite care for caregivers(17,19,26)
5.5.2.4 Inadequate numbers of competent caregivers(5,13,21,23,25,26,30,38,39,52,68)
HIMV 6.0 HAZARDS AND COMPLICATIONS
6.1 Deterioration or acute change in clinical status of VAI. Although ventilator-associated complications in the home are poorly documented, experience in other sites can be extrapolated. The following may cause death or require rehospitalization for acute treatment.
6.1.1 Medical: Hypocapnia, respiratory alkalosis,(70) hypercapnia, respiratory acidosis,(70) hypoxemia, barotrauma,(5,64,70) seizures, hemodynamic instability,(21) airway complications (stomal or tracheal infection, mucus plugging, tracheal erosion or stenosis),(5) respiratory infection (tracheobronchitis, pneumonia),(57,70,71) bronchospasm,(5) exacerbation of underlying disease, or natural course of the disease
6.1.2 Equipment-related: Failure of the ventilator, malfunction of equipment,(10) inadequate warming and humidification of the inspired gases, inadvertent changes in ventilator settings, accidental disconnection from ventilator,(27) accidental decannulation
6.1.3 Psychosocial: Depression,(5,10,43) anxiety,(4,10,43) loss of resources–caregiver or financial,(10,19,25,40,43) detrimental change in family structure or coping capacity(5,10,19,25, 34,38,54,55,56,71,72)
HIMV 7.0 LIMITATIONS
In the home care setting, making and implementing changes in the plan of care may take longer than in a health care facility.
HIMV 8.0 ASSESSMENT OF NEED
8.1 Determination that indications are present and contraindications are absent.
8.2 Determination that the goals listed in 2.1 can be met in the home.
8.3 Determination that no continued need exists for higher level of services.
8.4 Determination that frequent changes in the plan of care will not be needed.
HIMV 9.0 ASSESSMENT OF OUTCOME
At least the following aspects of patient management and condition should be evaluated periodically as long as the patient receives HIMV
9.1 Implementation and adherence to the plan of care
9.2 Quality of life
9.3 Patient satisfaction
9.4 Resource utilization
9.5 Growth and development in the pediatric patient
9.6 Unanticipated morbidity, including need for higher level site of care.
9.7 Unanticipated mortality
HIMV 10.0 RESOURCES
10.1 Equipment
10.1.1 Ventilator(s)–Choice should be based on patient’s clinical need.(5,10,14,22,23, 35,38,67,73) Patient’s medical needs may dictate that more than one ventilator be provided.
10.1.1.1 Ventilators chosen for home care must be dependable and easy for the intended caregivers to operate; small size and lightweight are desirable
10.1.1.2 Mobility is frequently an essential element of the plan of care of the patient. The mechanical ventilator system chosen for such a patient should allow mobility.
10.1.2 With portable, volume-cycled ventilators, use of the SIMV mode increases work of breathing, and the addition of an external continuous-flow system reduces portability.(1,10,74-76)
10.1.3 Complex and nonportable components are not recommended for HIMV but may be used to meet the needs of certain pediatric patients.(10,13,22,35,75)
10.1.3.1 Ventilators powered by external compressed gas sources are less desirable.(10,22)
10.1.3.2 A second ventilator should be provided for
10.1.3.2.1 patients who cannot maintain spontaneous ventilation for 4 or more consecutive hours;(4,10,13,67)
10.1.3.2.2 patients who live in an area where a replacement ventilator cannot be provided within 2 hours;(4,13,39,67)
10.1.3.2.3 patients who require mechanical ventilation during mobility as prescribed in their plan of care.
10.1.4 An adequate power source must be available to operate the ventilator consistent with patient needs.(4,5,10,13,14,39,67) This may be supplied by one or more of the following methods:
10.1.4.1 Alternating current (AC) is the primary power source for most long-term care ventilators. Emergency AC power should be available in the long-term care facility.
10.1.4.2 Direct current (DC) by external battery may be used to allow mobility and as an emergency power source. The internal battery of the ventilator should be used only for short-term, emergency use. It should not be used as a primary source of power.
10.1.5 Alarms
10.1.5.1 A patient-disconnect (eg, low-pressure10 or low-exhaled-volume) and a high-pressure alarm are essential.
10.1.5.2 If patient disconnection is likely to produce a serious adverse effect, a remote alarm and a secondary alarm may be indicated. A secondary alarm may be based on chest-wall impedance and cardiac activity, exhaled volume, end-tidal CO2, or pulse oximetry with alarm capabilities.(42)
10.1.6 Humidification system(s) are essential for invasive mechanical ventilation. The type of system used is determined by the patient’s medical needs(77) and the patient’s need for mobility.(10,13,35) It may be appropriate for the patient to use more than one type of system, based on those needs.(1,15,78,79-81)
10.1.6.1 Heated humidifier (temperature probes should be provided).
10.1.6.2 Heat and moisture exchanger can be used during transport and to enhance mobility.(1,77,81)
10.1.7 Ventilator circuit and accessories as medically indicated.
10.1.8 Self-inflating resuscitation bag with tracheostomy attachments and mask of appropriate size(5,10,21-23,39,67)
10.1.9 Replacement tracheostomy tube of appropriate size plus a tube one size smaller should be available at all times.
10.1.10 Suction equipment(5,10,13,21-23,39,62,67) including a battery-powered aspirator for patients who leave the home or when indicated as an alternate source in the event of a power failure
10.1.11 Supplemental oxygen as medically indicated(10,13,39,67).
10.1.12 Patients must have an adequate means of communicating their needs and desires and to summon help in the case of emergency.(10)
10.2 Personnel:
10.2.1 Lay caregivers (eg, family members, personal care attendants, and non-credentialed health care personnel such as nurse’s aides) can be taught skills and techniques of care for a specific VAI. Appropriately trained lay caregivers must demonstrate competency in
10.2.1.1 proper set up, use, troubleshooting, and maintenance of the equipment and supplies;(10,23,32,33,39,40,50,65)
10.2.1.2 patient assessment and ongoing response to invasive mechanical ventilation;(10,23,32,33,35,40,65)
10.2.1.3 responding to the hazards of invasive mechanical ventilation;(22,23,26,33)
10.2.1.4 responding to emergencies;(10,23,32,39,40) in the case of
10.2.1.4.1 power failure;
10.2.1.4.2 acute life threatening events such as accidental decannulation(22) or other need for tracheostomy tube replacement,(10) other unexpected events, or medical deterioration of the patient
10.2.1.4.3 failure of equipment or supplies;
10.2.1.5 complying with appropriate infection control procedures;(10,39,65)
10.2.1.6 providing appropriate return demonstrations in the use and application of any additional techniques required for the ongoing care of the VAI, such as suctioning and use of ancillary equipment;(10,39,40,50,65)
10.2.2 Level-II practitioners are health-care professionals capable not only of providing direct patient care but also possessing demonstrated competencies to monitor and assess both the patient and equipment. Level-II practitioners are capable of training and evaluating lay caregivers. Level-II practitioners should be credentialed health care professionals (eg, RRT, CRTT, RN) with documented knowledge and demonstrated competencies to:
10.2.2.1 provide knowledge and understanding of the patient’s disease, goals and limitations of invasive mechanical ventilation;(32,33,39)
10.2.2.2 assess patient’s response to invasive mechanical ventilation;
10.2.2.3 make recommendations for changes in respiratory management of patient, including weaning as necessary;(10,33)
10.2.2.4 train and monitor caregivers;(4,5,10,32,33,40,50)
10.2.2.5 monitor patient’s ongoing ventilatory status;
10.2.2.6 communicate results of assessment to the health care team.(5,39)
10.3 Finances: HIMV can only be instituted and maintained with adequate financial resources to provide the necessary equipment and personnel to manage the patient’s care.(10,13,35,43)
HIMV 11.0 MONITORING
The frequency of monitoring should be determined by the ongoing individualized care plan and be based upon the patient’s current medical condition. The ventilator settings, proper function of equipment, and the patient’s physical condition should be monitored and verified: (1) with each initiation of invasive ventilation to the patient, including altering the source of ventilation, as from one ventilator or resuscitation bag to another ventilator; (2) with each ventilator setting change; (3) on a regular basis as specified by individualized plan of care.(35)
All appropriately trained caregivers should follow the care plan and implement the monitoring that has been prescribed. These caregivers may operate, maintain and monitor all equipment and perform all aspects of care required by the VAI after having been trained and evaluated on their level of knowledge for that equipment and the VAI’s clinical response to each of the interventions.
11.1 Lay caregivers should monitor the following regularly:
11.1.1 Patient’s physical condition: respiratory rate, heart rate, color changes, chest excursion, diaphoresis, and lethargy, blood pressure, body temperature.
11.1.2 Ventilator settings: The frequency at which alarms and settings are to be checked should be specified in the plan of care.
11.1.2.1 Peak pressures
11.1.2.2 Preset tidal volume
11.1.2.3 Frequency of ventilator breaths
11.1.2.4 Verification of oxygen concentration setting
11.1.2.5 PEEP level (if applicable)
11.1.2.6 Appropriate humidification of inspired gases
11.1.2.7 Temperature of inspired gases (if applicable)
11.1.2.8 Heat and moisture exchanger function
11.1.3 Equipment function:(10,13)
11.1.3.1 Appropriate configuration of ventilator circuit(82)
11.1.3.2 Alarm function
11.1.3.3 Cleanliness of filter(s)–according to manufacturer’s recommendation
11.1.3.4 Battery power level(s)–both internal and external
11.1.3.5 Overall condition of all equipment
11.1.3.6 Self-inflating manual resuscitator–cleanliness and function
11.2 A Level-II practitioner should perform a thorough, comprehensive assessment of the patient and the patient-ventilator system on a regular basis as prescribed by the plan of care. In addition to the variables listed in 11.1.1-11.1.3. the Level-II practitioner should implement, monitor, and assess results of other interventions as indicated by the clinical situation and anticipated in the care plan.
11.2.1 Pulse oximetry–should be used in patients requiring a change in prescribed oxygen levels or in patients with a suspected change in condition.(10,35)
11.2.2 End-tidal CO2–may be useful for establishing trends in CO2 levels during weaning.(10,23,33,35,59,83,84)
11.2.3 Specimen collection (and analysis as applicable) as prescribed by physician–including but not limited to sputum and blood work (eg, arterial blood gas analysis and complete blood counts).(5,10,32,37)
11.2.4 Cardiorespiratory monitoring (electrocardiogram, heart-rate trending)(10)
11.2.5 Pulmonary function testing
11.2.6 Ventilator settings
11.2.7 Exhaled tidal volume
11.2.8 Analysis of fraction of inspired oxygen
11.3 Level-II personnel are also responsible for maintaining interdisciplinary communication concerning the plan of care
11.4 Level-II personnel should integrate respiratory plan of care into the patient’s total care plan.(10) Plan of care should include
11.4.1 all aspects of patient’s respiratory care(66) and
11.4.2 ongoing assessment and education of the caregivers involved.
HIMV 12.0 FREQUENCY:
12.1 The frequency of ventilation (and the patient’s ventilator-free time) is dictated by the patient’s physiologic needs and is determined in consultation with the patient’s physician.
12.2 The frequency of assessment of the VAI and the patient-ventilator system must be noted in the evolving total care plan as determined by the health care team, in conjunction with the VAI and their caregivers.
HIMV 13.0 INFECTION CONTROL
13.1 Both professional and lay caregivers should be aware of the potential for transmission of both chronic and acute infection from patient to caregiver and from caregiver to patient and should take the steps necessary to avoid that transmission. Aspects of avoidance include:
13.1.1 careful handwashing and barrier protection when appropriate
13.1.2 careful disposal of medical waste
13.1.3 adequate environmental air exchange
13.1.4 maximizing protection of patient, family, and caregivers (eg, influenza immunization) and minimizing exposure to persons with acute infections (eg, limiting visitors with upper respiratory infections).
13.2 Evidence is lacking to support an optimal plan for changing and processing ventilator circuits and ancillary equipment in the home. However, studies from institutional settings(85,86) suggest that ventilator circuits need not be changed more often than once each week. Further, it appears that the less often a circuit is entered, the less likely contamination is to occur.
Respiratory Home Care Focus Group:
Peggi Robart RRT RCP, Chairman, Boston MA
Barry J Make MD, Denver CO
Susan L McInturff RRT RCP, Bremerton WA
Dennis W Tureson Sr RRT CRTT, Minneapolis MN
Melissa P Weimer, RRT, McKeesport PA
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Additional Bibliography
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Indihar FJ, Walker NE. Experience with a prolonged respiratory care unit: revisited. Chest 1984;86(4):616-620.
Wagner DP. Economics of prolonged mechanical ventilation. Am Rev Respir Dis 1989;140(Suppl):S14-S18.
Gracey DR, Viggiano RW, Naessens JM, Hubmayr RD, Silverstein MD, Koenig GE. Outcomes of patients admitted to a chronic ventilator-dependent unit in an acute-care hospital. Mayo Clin Proc 1992;67:131-136.
American Association of Respiratory Care. Guidelines for disinfection of respiratory care equipment used in the home. Respir Care 1988;33(9):801-808.
Chatburn RL. Decontamination of respiratory care equipment: what can be done, what should be done. Respir Care 1989;34(2):98-109.
Davis PB, di Sant’Agnese PA. Assisted ventilation for patients with cystic fibrosis. JAMA 1978;239(18):1851-1854.
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Stauffer JL, Olson DE, Petty TL. Complications and consequences of endotracheal intubation and tracheotomy: a prospective study of 150 critically ill adult patients. Am J Med 1981;70:65-76.
Craven DE, Kunches LM, Kilinsky V, Lichtenberg DA, Make BJ, McCabe WR. Risk factors for pneumonia and fatality in patients receiving continuous mechanical ventilation. Am Rev Respir Dis 1986;133:792-796.
Dreyfuss D, Djedaini K, Weber P, Brun P, Lanore JJ, Rahmani J, Boussougant Y, Coste F. Prospective study of nosocomial pneumonia and of patient and circuit colonization during mechanical ventilation with circuit changes every 48 hours versus no change. Am Rev Respir Dis 1991; 143:738-743.
Craven DE, Goularte TA, Make BJ. Contaminated condensate in mechanical ventilator circuits: a risk factor for nosocomial pneumonia? Am Rev Respir Dis 1984;129:625-628.
Pierson DJ, George RB. Mechanical ventilation in the home: possibilities and prerequisites. Respir Care 1986;31 (4):266-270.
Interested persons may copy these Guidelines for noncommercial purposes of scientific or educational advancement. Please credit AARC and Respiratory Care Journal.
