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Download Primary Care of Home Ventilator Patients
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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
