In addition to being used in clinical environments, ventilators can also support patients in home and care settings.
What is Ventilatory Support?
Ventilatory support is a life-saving intervention taken when a patient is unable to facilitate their own breathing due to low oxygen levels, severe shortness of breath or other causes of respiratory distress (ATS 2020).
Ventilation takes over the work of breathing by delivering oxygen into the lungs, reducing the level of effort required by the patient (ATS 2020).
A patient can receive ventilatory support in a number of ways:
Mechanical ventilation is invasive and involves the insertion of an endotracheal tube through the patient’s mouth or nose into the trachea. This tube is connected to a mechanical ventilator, a machine that moves air in and out of the patient’s lungs.
Non-invasive ventilation is the provision of ventilatory support through an external interface (mask or helmet). Intubation is not required.
Patients with a tracheostomy may receive ventilatory support through mechanical ventilation.
Under these standards, NDIS providers must meet the following quality indicators:
Clients are enabled to participate in the assessment and development of a ventilator management plan. This plan identifies possible risks, incidents and emergencies, and what actions need to be taken to manage these situations, including the escalation of care, if necessary. The client’s health status is reviewed regularly (with the patient’s consent).
Staff members managing ventilation are informed by appropriate policies, procedures and training plans.
Staff members managing ventilation have received all necessary training that relates to each specific patient, either from a qualified health practitioner or another appropriately qualified individual.
The following skills are required by NDIS providers performing ventilation management:
Confirming the patient’s need for ventilation.
Following instructions to identify, connect or assemble components of ventilator equipment.
Following instructions to operate the ventilator and prepare it for operation.
Fitting the breathing interface.
Commencing ventilation and ensuring it is functioning effectively.
Following troubleshooting procedures in order to appropriately respond to alarms and maintain equipment.
Following hygiene and infection control procedures.
What is a Ventilator?
A ventilator is a machine that supports a patient’s breathing. It delivers moist, warm, oxygen-rich air through either an endotracheal tube or interface (depending on whether the ventilatory support is invasive or non-invasive) and into the patient’s lungs using positive pressure. The patient will either exhale on their own or the ventilator will do so for them, depending on their condition (idsMED 2019; Elsevier 2019).
The ventilator will assist the patient to intake and expel adequate amounts of oxygen and carbon dioxide respectively. The amount of oxygen delivered to the patient, as well as the size and frequency of each breath depends on how the patient normally breathes and can be controlled by staff through the ventilator’s monitor (idsMED 2019; Elsevier 2019).
Using a ventilator will reduce the energy and work of breathing required by the patient to breathe (idsMED 2019).
Mechanical ventilation is complex and requires advanced specialist training, however, there are four basic functions:
Delivering oxygen (fraction of inspired oxygen: FiO2);
Setting a respiratory rate if the patient is unable to breathe on their own;
In addition to being used in clinical settings, ventilatory support may also be provided in a patient’s home or another care setting (e.g. residential aged care) if the patient is experiencing chronic respiratory impairment. Home ventilation can be either mechanical or non-invasive (NHS 2018).
Patients with the following conditions may require home ventilation:
Chronic respiratory failure;
Conditions causing impaired respiratory control;
Central alveolar hypoventilation;
Spinal cord injury;
Nerve or muscle disease (e.g. muscular dystrophy);
Chest wall diseases;
Guillain Barré Syndrome;
Lung transplant; and
(ICA Home 2013)
There is evidence suggesting the prevalence of home ventilation has been greatly increasing for patients experiencing neuromuscular conditions, parenchymal lung disease, sleep-disordered breathing and chest wall deformities (Dale et al. 2017).
As patients requiring prolonged ventilatory support comprise a significant portion of acute care service users, there is a need for a well-timed and optimised transition process from acute care to the home (Dale et al. 2017).
What are the Benefits of Home Ventilation?
Allows patients with chronic respiratory illness to live in the community with greater autonomy;
Small, portable ventilators are available, enabling patients to be more mobile and independent while receiving ventilatory support;
Prolongs patient survival;
Reduces the burden of symptoms; and
Enhances the patient’s health-related quality of life.
(Dale et al. 2017)
Essential Care Principles of Ventilation
Caring for a patient receiving ventilatory support may involve:
Communicating effectively with the patient and other members of the care team;
Checking the ventilator settings and identifying any changes in the patient’s condition;
Responding appropriately to ventilator alarms and determining what they mean;
Checking the bag valve;
Appropriate emergency equipment and regular equipment checks;
Suctioning the patient;
Checking the position of the endotracheal tube (in intubated patients);
Assessing the patient for pain or anxiety and providing appropriate sedation;
Ensuring the patient is haemodynamically stable;
Ensuring there is a backup plan in the event of ventilator failure;
Maintaining all necessary documentation; and
Providing education to the patient’s family and allowing them to passively contribute to care (e.g. holding the patient’s hand, speaking to the patient).
(Williams & Sharma 2020)
Caring for the Ventilator-Dependant Patient in the Home
Note: Always refer to your organisation’s policies and procedures.
Adhere to standard precautions for infection control.
It is important to note that intubated patients are at risk of developing ventilator-associated pneumonia (VAP), which is estimated to occur in 9 to 27% of patients (Furesz 2016). Strategies to decrease the likelihood of VAP include:
Maintaining a bed elevation of 30 to 45 degrees if possible;
Assessing the patient’s need for mechanical ventilation daily, as the risk of VAP increases the longer the patient is intubated;
Maintaining the patient’s oral cavity hygiene if possible;
Encouraging the patient to sit up if possible, as this improves lung compliance and gas exchange;
Providing enteral nutrition if possible, as adequate nutrition will improve the immune system;
Suctioning visible secretions; and
Practising aseptic technique (adhere to your facility’s protocol).
(Williams & Sharma 2020)
Other Complications of Ventilation
In addition to VAP, mechanical ventilation is associated with other complications including:
Barotraumna (alevolar rupture e.g. pneumothorax);
Volutrauma (ventilator-associated lung injury);
AutoPEEP (hyperinflation of the lungs);
Loss of electrical power to the ventilator;
Less severe complications of home ventilation may include:
Wind or distended abdomen;
Facial sores from NIV interface;
Eye soreness from NIV interface air leakage;
Dry mouth; and
Nasal irrigation or congestion.
In order to facilitate safe home ventilation and decrease the risk of complications, it is essential to thoroughly monitor and care for patients.
Note: This article is intended as a refresher and should not replace best-practice care. Always refer to your organisation’s policy on home ventilation.