Home Respiratory Care

CHAPTER 26 Home Respiratory Care Angela King Bob McCoy OUTLINE Home Care Services Goals of Home Care The Medicare Program Requirements for Home Medical Equipment Companies The Respiratory Therapist as Home Care Provider The Initial Home Visit Bag Technique Home Environment Evaluation Long-Term Oxygen Therapy Home Mechanical Ventilation OBJECTIVES 1. Discuss factors leading to the increase in home respiratory care. 2. Describe the role of the home medical equipment company. 3. Discuss the reimbursement system for home care in the United States. 4. Discuss issues related to home oxygen administration. 5. Compare home oxygen administration systems. 6. Compare mechanical ventilation in the hospital to that provided in the home. 7. List key safety considerations for the ventilatorassisted individual. KEY TERMS backup ventilator bag technique clinical respiratory services compressed gas system continuous-flow oxygen (CFO) demand delivery device durable medical equipment (DME) companies emergency plan equipment management services go-bag ground circuit detector home medical equipment (HME) companies INTRODUCTION home respiratory care intermittent-flow device intermittent-flow oxygen liquid oxygen (LOX) storage system long-term oxygen therapy (LTOT) Medicaid Medicare oxygen concentrator oxygen-conserving device (OCD) portable oxygen concentrator (POC) pulse flow remote alarms transtracheal oxygen The American Association of Respiratory Care defines home respiratory care as [t]hose prescribed respiratory care services provided in a patient s personal residence. Prescribed respiratory care services may include patient assessment and monitoring, such as listening to breath sounds, observing the patient s respiratory rate, chest excursion, and skin tone, and evaluating the patient s sputum. Respiratory care services may involve diagnostic and therapeutic modalities, such as observing the patient s pulse oximetry and transcutaneous carbon dioxide (CO 2 ) values, and performing airway clearance therapy. Importantly, home respiratory care services may include providing education regarding respiratory equipment, disease management, and health-promoting behaviors for the patient and the family caregiver(s). This chapter covers issues related to home respiratory care, with specific emphasis on home oxygen (O 2 ) therapy and home mechanical ventilation. 11

12 CHAPTER 26 Home Respiratory Care Home Care Services The patient s home may be a single-family residence, a multifamily dwelling, an assisted living facility or group home, a retirement community, or a skilled nursing facility. 1 There are four types of home care services: home medical equipment services, episodic home health care, hospice home health care, and chronic home care services. 2 Depending on the equipment ordered, home medical equipment (HME) companies, also called durable medical equipment (DME) companies, can provide service by a technician, respiratory therapist (RT), or a qualified nurse. A hospital bed would most likely be set up by a technician, whereas RESPIRATORY RECAP a suction machine and a mechanical ventilator Individuals Providing Services for DME Companies would be set up by an RT.» Technician Episodic home health care» Respiratory therapist is often ordered for the» Registered nurse time period immediately following the patient s hospital stay, and is usually provided for a finite period of time. Hospice care is provided for the terminally ill and provides palliative end-of-life care. Chronic home care services, sometimes referred to as private duty, are typically provided on an hourly basis and may involve nurses, health aides, chore providers, and companions. RESPIRATORY RECAP Goals of Home Care» Achieve the optimum level of patient function» Educate patients and their caregivers» Administer diagnostic and therapeutic services» Conduct disease management and promote health Improved medical equipment has resulted in an increase in home respiratory care. The Medicare prospective payment system encourages earlier hospital discharge. 3 Modern therapies for the treatment of newborns have resulted in more infants and pediatric patients requiring home O 2 and home mechanical ventilation. 4 Another factor driving the increase in home care is the proportion of the population older than 65 years, which is projected to increase to 19.6% of the total population in 2030. 5 In the United States, approximately 80% of all persons over age 65 have at least one chronic condition, and 50% have at least two. Since the early 1990s, accumulating data have supported the costeffectiveness of home care for respiratory patients (Table 26 1). 6,7 Medicare and other healthcare providers began encouraging the transition of technology-dependent patients from the acute care setting to less costly environments of care. 8 In addition to technological advances, changing demographics, and economic pressures, another key factor increasing home respiratory care is that most patients prefer to be cared for at home if possible. Goals of Home Care The goals of home respiratory care are to achieve the optimum level of patient function through goal setting, educate patients and their caregivers, administer diagnostic and therapeutic modalities and services, conduct disease management, and promote health. 1 The general goals of home care for individuals with respiratory disorder are to increase survival, decrease morbidity, improve function and quality of life, support independence and self-management, encourage positive health behaviors, and, for children with lung disease, to promote optimal growth and development; for patients with a terminal illness, the goals are to provide physical and psychological comfort and to make it possible for the patient to die at home. 2 The Medicare Program As part of the Social Security Amendments of 1965, Medicare was established to provide a health insurance program for aged persons to complement the retirement, survivors, and disability insurance benefits under Title II of the Social Security Act. The Medicare program began on July 1, 1966. In 1973, persons who were entitled to Social Security or Railroad Retirement disability benefits for at least 24 months, persons with end-stage renal disease, and certain other persons became eligible for Medicare benefits. Persons with amyotrophic lateral sclerosis (ALS) were allowed to waive the 24-month waiting period after passage of Public Law 106-554, the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000. Hospital insurance is known as Medicare Part A. Part A covers inpatient care, skilled nursing facility care, and hospice care. Supplementary medical insurance is known as Part B. Most people have to pay a premium for Part B coverage. Part B includes medical services typically delivered in the outpatient setting and includes TABLE 26 1 Hospital Cost Versus Home Care Cost, Per Patient, Per Month Condition Hospital Cost Home Care Cost Savings Adult, ventilator dependent* $21,570 $7050 $14,520 Pediatric, oxygen dependent $12,090 $ 5250 $ 6840 *Data from Bach JR. The ventilator-assisted individual: cost analysis of institutional vs. rehabilitation and in-home management. Chest. 1992;101:26 30. Data from Field AI. Home care cost-effectiveness for respiratory technologydependent children. Am J Dis Child. 1991;145:729 733. Adapted from National Association for Home Care and Hospice. Basic Statistics About Home Care: Updated 2008. Washington, DC: The National Association for Home Care and Hospice; 2008.

Requirements for Home Medical Equipment Companies 13 tests, lab services, and various health screenings. Part B also includes home health services, which are defined as medically necessary, reasonable, and part-time care and services such as skilled nursing care, home health aide services, physical and occupational therapies, speech and language pathology therapy, and medical social services. Part B also includes certain prescribed medical supplies and durable medical equipment, such as wheelchairs, hospital beds, home O 2 devices and mechanical ventilators, and related equipment. The Medicare Advantage program, also known as Part C, was established by Public Law 105-33, the Balanced Budget Act of 1997, which expanded options for beneficiaries to participate in private-sector healthcare plans. In most cases, Part C is a lower-cost alternative to the original Medicare plan, and Part C providers usually offer extra benefits to beneficiaries. The newest part of Medicare is prescription drug coverage, also known as Part D. This legislation was authorized by the Medicare Prescription Drug Improvement and Modernization Act of 2003. It provides seniors and people with disabilities a prescription drug benefit. To qualify for Medicare skilled nursing services, the patient must (1) be under the care of a physician; (2) receive services under a plan of care established and periodically reviewed by a physician; (3) be in need of skilled nursing care, physical therapy, occupational therapy, and/or speech and language pathology therapy on an RESPIRATORY RECAP Medicare Benefits» Part A: hospital insurance» Part B: supplementary medical insurance» Part C: low-cost alternative to Medicare» Part D: prescription drug coverage intermittent basis; and (4) be homebound, meaning that the patient is confined to the home or that leaving the home is a major effort that is seldom undertaken. For example, the patient may leave the home to get therapeutic or psychosocial care or to attend a funeral, graduation, or other infrequent event. Skilled nursing services must be provided by a registered nurse or by a licensed practical nurse under the supervision of a registered nurse. Unfortunately, respiratory therapists are not included in the Medicare home health services benefit. Medicare Part B covers medically necessary durable medical equipment such as O 2 concentrators, nebulizer compressors, and mechanical ventilators, but there is no separate reimbursement for the respiratory therapist s professional expertise. Twenty years ago, a patient with chronic obstructive pulmonary disease (COPD) who was prescribed home O 2 would have received a home safety evaluation and equipment instruction, as well as periodic respiratory assessments, from a home care respiratory therapist. Unfortunately, as Medicare reimbursement for home O 2 has steadily declined over the years, the number of DME providers using technicians, as opposed to respiratory therapists, to set up and monitor the home respiratory equipment has increased dramatically. The majority of home O 2 patients today do not receive inhome clinical monitoring from a therapist. In addition because many patients on home O 2 therapy leave the home frequently to attend religious services or social outings or to go shopping, they do not qualify for Medicare skilled nursing services either. Medicaid Coverage for Home Medical Equipment Many patients who need respiratory-related durable medical equipment but who are not eligible for Medicare may receive DME through the Medicaid program. For example, a child on a mechanical ventilator whose parents do not have private medical insurance will most likely receive coverage from the Medicaid program. In many cases, the DME provider must obtain prior authorization from the Medicaid program to determine whether a specific piece of equipment is covered. The coverage determination criteria for a given piece of respiratory equipment within the Medicaid program can vary by state. For example, one northeastern state does not cover a noninvasive ventilator used with a mouthpiece for a patient with Duchenne muscular dystrophy (DMD), but covers that same ventilator if the patient undergoes a tracheostomy. The best strategy to help the home patient obtain coverage for a given item is to proactively work with the Medicaid case worker, offering relevant educational materials and a detailed letter of medical necessity from the patient s physician. In many cases, appealing a negative coverage decision and presenting additional supporting documentation will result in a favorable outcome. In the case of the patient with DMD mentioned earlier, the Medicaid program did agree to cover the ventilator upon appeal after receiving information about the increased life expectancy of DMD patients when ventilated with noninvasive ventilation and presented with data showing that noninvasive ventilation was a more cost-effective alternative than a tracheostomy. Requirements for Home Medical Equipment Companies Depending on state respiratory care laws and regulations, and depending on the types of services offered, an HME company may require some or all of the following: retail license, HME license, a bedding supplier license, and an O 2 manufacturer/distributor license and possibly other licenses/permits as required by the state. Medicare also requires that all HME companies obtain a surety bond of at least $50,000. A surety bond is issued by an entity on behalf of a second party. It guarantees that the second party will fulfill an obligation to a third party. In the event that the obligation is not met, the third party will recover its losses via the bond. Medicare also requires all HME companies to have liability insurance.

14 CHAPTER 26 Home Respiratory Care BOX 26 1 Medicare Home Medical Equipment Supplier Standards 1. A supplier must be in compliance with all applicable federal and state licensure and regulatory requirements. 2. A supplier must provide complete and accurate information on the DMEPOS supplier application. Any changes to this information must be reported to the National Supplier Clearinghouse within 30 days. 3. An authorized individual (one whose signature is binding) must sign the application for billing privileges. 4. A supplier must fill orders from its own inventory, or must contract with other companies for the purchase of items necessary to fill the order. A supplier may not contract with any entity that is currently excluded from the Medicare program, any state health care programs, or from any other federal procurement or nonprocurement programs. 5. A supplier must advise beneficiaries that they may rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental equipment. 6. A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable state law, and repair or replace free of charge Medicare-covered items that are under warranty. 7. A supplier must maintain a physical facility on an appropriate site. 8. A supplier must permit Centers for Medicare and Medicaid Services (CMS) or its agents to conduct on-site inspections to ascertain the supplier s compliance with these standards. The supplier location must be accessible to beneficiaries during reasonable business hours, and must maintain a visible sign and posted hours of operation. 9. A supplier must maintain a primary business telephone listed under the name of the business in a local directory or a toll free number available through directory assistance. The exclusive use of a beeper, answering machine, or cell phone is prohibited. 10. A supplier must have comprehensive liability insurance in the amount of at least $300,000 that covers both the supplier s place of business and all customers and employees of the supplier. If the supplier manufactures its own items, this insurance must also cover product liability and completed operations. Failure to maintain required insurance at all times will result in revocation of the supplier s billing privileges retroactive to the date the insurance lapsed. 11. A supplier must agree not to initiate telephone contact with beneficiaries, with a few exceptions allowed. This standard prohibits suppliers from calling beneficiaries in order to solicit new business. 12. A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare-covered items, and maintain proof of delivery. 13. A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such contacts. (continues) Beginning in September 2009, Medicare began requiring all HME companies to be accredited by an approved agency. Box 26 1 lists the Medicare supplier standards. Accreditation of Home Medical Equipment Companies Home care providers must be accredited by one of several accreditation agencies approved by the Medicare program, similar to accreditation for hospitals. There are generally two types of accreditation: Equipment Management Services and Clinical Respiratory Services. Accreditation in Clinical Respiratory Services includes everything required for accreditation in equipment management, plus additional requirements governing actual hands-on patient care and clinical personnel qualifications and requirements. Not all home medical equipment companies are accredited for Clinical Respiratory Services, and that specific RESPIRATORY RECAP Accreditation of Home Medical Equipment Companies» Equipment Management Services» Clinical Respiratory Services accreditation is not required by Medicare to participate in the program. However, if a company provides handson patient care such as performing patient assessment, administering treatment, providing disease management education, and/or monitoring respiratory status, it must be accredited for Clinical Respiratory Services. 9 Several accreditation agencies are approved by Medicare, including the Joint Commission (formerly known as the Joint Commission on Accreditation of Healthcare Organizations), Community Health Accreditation Program

Requirements for Home Medical Equipment Companies 15 Box 26 1 (continued) 14. A supplier must maintain and replace at no charge or repair directly, or through a service contract with another company, Medicare-covered items it has rented to beneficiaries. 15. A supplier must accept returns of substandard (less than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries. 16. A supplier must disclose these supplier standards to each beneficiary to whom it supplies a Medicare-covered item. 17. A supplier must disclose to the government any person having ownership, financial, or control interest in the supplier. 18. A supplier must not convey or reassign a supplier number; i.e. the supplier may not sell or allow another entity to use its Medicare Supplier Billing Number. 19. A supplier must have a complaint resolution protocol established to address beneficiary complaints that relate to these standards. A record of these complaints must be maintained at the physical facility. 20. Complaint records must include: the name, address, telephone number and health insurance claim number of the beneficiary, a summary of the complaint, and any actions taken to resolve it. 21. A supplier must agree to furnish CMS any information required by the Medicare statute and implementing regulations. 22. All suppliers must be accredited by a CMS-approved accreditation organization in order to receive and retain a supplier billing number. The accreditation must indicate the specific products and services, for which the supplier is accredited in order for the supplier to receive payment of those specific products and services (except for certain exempt pharmaceuticals). 23. All suppliers must notify their accreditation organization when a new DMEPOS location is opened. 24. All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare. 25. All suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation 26. Must meet the surety bond requirements specified in 42 C.F.R. 424.57(c). Note: This list is an abbreviated version of the application certification standards that every Medicare DMEPOS supplier must meet in order to obtain and retain their billing privileges. These standards, in their entirety, are listed in 42 C.F.R. pt. 424, sec 424.57(c) and were effective on December 11, 2000. DMEPOS, durable medical equipment, prosthetics, and orthotics supplies. From Centers for Medicare and Medicaid Services. Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, and Orthotics Supplies (DMEPOS) Suppliers, Form CMS-855S. Available at: http://www.cms.hhs.gov/cmsforms/downloads/cms855s.pdf. (CHAP), and Accreditation Commission for Health Care (ACHC). The accreditation survey is normally repeated every 3 years, but the interval may vary based on the accrediting agency. Equipment Management Services Versus Clinical Respiratory Services Equipment management services are not hands-on patient care services. In other words, the patient is not touched by the RT for the purpose of providing care. The RT checks the home medical equipment, such as the FiO 2 of the O 2 concentrator or the ventilator settings and alarms, makes prescribed setting changes, delivers additional supplies, and performs similar equipment-related duties. The therapist does not perform diagnostic or RESPIRATORY RECAP Types of Respiratory Care Services» Equipment management services» Clinical respiratory services therapeutic procedures. Equipment management services require a physician s order for the home medical equipment and settings. If the RT provides professional services in the home beyond that of a service technician, the RT is performing clinical respiratory services, which include performing clinical assessments and diagnostic procedures, administering treatments or medications, providing patient education, and monitoring the patient s respiratory status. If patient education involves more than education on the use of the equipment, the RT is considered to be providing clinical respiratory services.

16 CHAPTER 26 Home Respiratory Care TABLE 26 2 Key Characteristics Required of the Home Care Respiratory Therapist Objective Requirements Licensed or certified (as applicable per state) Driver s license Automobile insurance Subjective Requirements Highly skilled at patient assessment Highly skilled at home safety assessment Excellent critical thinking ability Good teacher Respects people from other cultures and socioeconomic backgrounds Good communication skills Intrinsically motivated Good organizational skills All reputable DME providers hire only licensed/certified therapists. Note: If the therapist will visit patients in multiple states, a current license is required for each state. Most DME providers will obtain an annual copy of the therapist s driving record, and employment is often contingent upon maintaining a clean driving record. Most DME providers will require proof that the therapist has adequate automobile insurance coverage. The therapist often is the only clinician visiting the patient s home, and the patient may be seen by other clinicians only sporadically. The respiratory therapist must be skilled at respiratory assessment for patients ranging from preterm infants to geriatric patients. The therapist often will be the only clinician assessing the patient s home for safety and the proper use of the medical equipment. On occasion, the therapist will need to call the patient s physician or child protective services on an emergent basis. The therapist requires excellent judgment and decision-making skills in order to appropriately handle such situations. The bulk of the home care therapist s job is to teach patients and families. Most DME providers offer equipment and service to a wide variety of patient populations, from preterm infants to geriatric patients; thus, the therapist must be skilled at teaching diverse patient populations. The home care therapist will most likely be visiting patients from a variety of backgrounds, with diverse belief systems and ways of doing things. The therapist must keep in mind that he or she is a guest in the patient s home and treat all patients and families with respect. The therapist will need good communication skills, both verbal and written, to work with a wide variety of patients, families, coworkers, other home care providers (e.g., nursing, PT, OT, SLP, MSW, HHA), and physicians. The home care therapist will most often be working without direct supervision. The home care therapist must be organized regarding prioritizing and planning home visits, ensuring that all required equipment and supplies are ordered and stocked in his or her vehicle, and that all required paperwork is completed in a timely fashion. DME, durable medical equipment; PT, physical therapist; OT, occupational therapist; SLP, speech language pathologist; MSW, master of social work; HHA, home health aide. Orders for Clinical Respiratory Services Orders for clinical respiratory services are considered a part of the care plan and should be included in the HME company s care plan as well as the home health agency s nursing care plan, if applicable. The home care RT should coordinate the care plan with that of the home health agency s personnel (nursing; physical, occupational, or speech therapy) to encourage a collaborative approach. The plan of care describes the planned treatments, education, and services and must be approved and signed by the patient s physician. The Respiratory Therapist as Home Care Provider By virtue of education, training, and competency testing, the respiratory therapist is the most competent healthcare professional to provide home respiratory care. Home respiratory care, particularly for ventilatorassisted individuals, can be highly complex; therefore, the risk of a negative outcome is great if the services are not performed by a highly skilled professional. 1 Requirements for the Respiratory Therapist Providing Home Respiratory Care Table 26 2 lists some of the key characteristics required of the home care respiratory therapist. The ability to assess many different aspects of the patient is probably the most important skill for a home care therapist. 10 The RT must be able to assess respiratory and overall physical status. The home RT is often the first to note a deterioration in the patient s physiologic condition. He or she also needs to evaluate the patient s and family caregiver s ability to learn and retain new information and maintain the prescribed medical equipment. The home care RT teaches pediatric, adult, and geriatric patients and their families, and must be able to work with patients from diverse cultures and economic backgrounds. The RT must be able to assess the family and social support available as well as the safety and appropriateness of the patient s home environment. The RT must also be aware of the requirements of insurance coverage for commonly prescribed home medical equipment. Organizational skills are important because coverage of a large geographic area means that making a trip back to the office to retrieve a forgotten item is often impossible. The daily routine of a home care RT is much different from that of a hospital-based therapist. Although home care RTs see a variety of patients and families each day, they do not enjoy the same camaraderie with their coworkers as experienced by RTs working in a hospital. The home care RT often is on call 24 hours a day, 7 days a week. On the positive side, the home care therapist often develops long-term relationships with patients and their families.

The Initial Home Visit 17 The Initial Home Visit The tasks completed during the initial home visit vary depending on the equipment and services ordered (clinical respiratory services versus equipment management services) and on the policies and procedures of the HME company. For a patient on a ventilator at home, the initial home visit must not be the first time the therapist makes face-to-face contact with the patient. The home environment evaluation should always be done prior to discharge, so that any safety issues or inadequacies are identified and corrected prior to the patient s return home. Equipment can be set up in the home days prior to discharge, but billing for the equipment cannot be started prior to the patient s discharge to the home. During the initial home visit, the RT has several important tasks to complete: Establish a rapport with the patient and family. Evaluate the home environment. Complete the equipment setup and instruction. Perform any ordered patient assessments and diagnostic or therapeutic procedures. Determine if there are unmet needs and make a plan for addressing those needs. Communicate, as appropriate, with other professional caregivers (e.g., home health nurse, physical therapist, physician). Complete the required admission paperwork. The RT should have a company photo identification card visible to allay any security concerns. The RT should address the patient and family using the appropriate titles (e.g., Mrs., Ms., Mr.) unless invited to do otherwise. RTs must keep in mind that, although performing a professional role in the patient s home, they also are guests in the home. The RT should ask where to wash his or her hands or should use an alcohol-based hand sanitizer in view of the patient and family caregivers. The patient rights and responsibilities document explains to the patient the right to refuse service, the right to make a complaint without fear of retaliation, and the right to know how much the services being provided are going to cost. In addition, this document explains the patient s responsibilities for open and honest communication, likes and dislikes with regard to treatment and services being provided, using the equipment in the manner prescribed, voicing grievances or complaints regarding treatment or services, and paying any deductible or copayment as required by regulation or law or the terms of an insurance contract. The patient should also receive a copy of the company s complaint procedure form. This form outlines the procedure the patient needs to follow in order to file a complaint and lists contact numbers the patient can call to issue a complaint, including Medicare, Medicaid, and the accreditation agency by which the company is accredited. The document also includes an overview of the actions the company will take to resolve the issue. If the patient has not already completed an advance directive, he or she should be given written information about advance directives and an explanation. Obtaining a copy of the patient s advance directive for the medical record is crucial so that the RT, or any other caregiver in the home, knows how to respond to a cardiopulmonary arrest. The patient must receive information on the HME company s methods for ensuring Health Insurance Portability and Accountability Act (HIPAA) compliance. This document will inform the patient about how his or her medical information will be stored by the company and who will have access to it. If the patient qualifies for Medicare, the advance beneficiary notice (ABN) and the assignment of benefits (AOB) forms must be completed. The ABN form is to help patients make an informed choice about whether or not they want to receive items or services, knowing that there might be an additional personal cost if the items and services are not covered by their insurance plan. The AOB gives the patient s authorization to the HME company to assign Medicare, Medicaid, or insurance benefits to the company for all covered medical equipment and supplies; for direct billing to Medicare, Medicaid, or other insurers; and for release of personal health information (PHI) to Medicare, Medicaid, or other valid insurance companies and to other healthcare providers. The home environment must be evaluated specific to the type of home medical equipment being provided. For example, if the patient will be receiving home O 2, the RT will need to ensure there are no sources of open flame in the home when O 2 is being used and that a working smoke detector is installed. If the patient will be receiving postural drainage therapy, the RT must evaluate the home to determine whether there is a suitable bed to perform the therapy. The RT may provide the patient and family with additional information, such as a list of community resources. This resource list may include agencies and services such as the American Lung Association (ALA), Better Breather s Clubs, Meals on Wheels, the Area Agency on Aging, hospice services, free or reduced-cost medical clinics in the area, domestic violence hotline information, poison control hotline information, and the closest ALS or muscular dystrophy clinic. If home medical equipment has been prescribed, the therapist will set up the equipment and instruct the patient and family caregivers in the proper use and care of the equipment. The instructional checklist should include common troubleshooting tips and maintenance requirements for the equipment delivered. The instructional checklist may also include instructions for the patient to follow to order additional O 2 or supplies, as well as what to do in the event of home medical equipment failure or patient emergency. All insurance companies, Medicare, and Medicaid require proof of delivery of the equipment and supplies.

18 CHAPTER 26 Home Respiratory Care Generally, the delivery ticket lists the patient s name and demographic information and specifies the quantity, manufacturer, and serial number (if applicable) of the home medical equipment provided. For some high-tech equipment, such as mechanical ventilators, it is crucial that the serial number be properly recorded and tracked in the event there is a recall of the equipment. After assessing the home environment and teaching the patient and caregivers about the equipment, the RT will have an idea of the patient s needs and goals. If the patient is receiving only equipment management services, information can be documented on a progress note or any other document that can be incorporated into the patient s medical record. Alternatively, if the patient is on a home ventilator and is receiving clinical respiratory services, a goal might be for the patient to be able to speak. The therapist would document this goal on the patient s plan of care, which must be signed by the physician. For example, the therapist may request an order to determine the patient s ability to tolerate cuff deflation, and, if successful, attempt the use of a speaking valve. Bag Technique It is important for home care RTs to determine whether bag technique should be incorporated into their routine. 11 Most home care RTs carry a bag containing their hand wash, stethoscope, blood pressure cuff, pulse oximeter, CO 2 monitor, peak flow meter, and other necessary implements. Because the RT will be traveling from home to home, it is prudent that the therapist minimize the likelihood of disease transmission. Stethoscopes and other items can be contaminated with various pathogens. 12 It is also important for patients receiving both nursing and RT visits to receive the same standard of care from each discipline. Bag technique means keeping the bag and its contents as clean as possible. The bag should not rest on an unclean area, such as the floor or on the patient s unmade bed. Depending on the space available in the home environment, it may be easiest for the therapist to use a barrier, such as a blue pad or sheet of newspaper, to serve as a clean resting place for the bag. Using a blue pad also helps protect the patient s furniture from damage, which communicates that the RT is respectful of the patient s home. The RT should wash his or her hands before reaching into the bag. Everything needed for the visit should be removed at one time, prior to beginning patient care. When the visit is finished, anything that may have been soiled should be wiped clean before being replaced in the bag. Home Environment Evaluation The home care RT is responsible for evaluating the home environment to ensure that it is appropriate for the planned equipment and services. Some components of the home environment evaluation apply to all patients, such as ensuring that there are adequate means of egress and no fall hazards. Environmental Issues for Patients on Home Oxygen Therapy Patients who receive O 2 at home are exposed to the risk of improper storage and handling of O 2 cylinders, unsafe usage of O 2 in the kitchen or workshop, improper transfer of liquid O 2, inadequate ventilation, and smoking or other unsafe flames. 13 It is important for the RT to evaluate whether there are smoking materials and other fire safety risks, such as candles or open flames, in the home and whether the home has functional smoke detectors. 14 Patients receiving O 2 may also be exposed to risk from not securing portable O 2 properly while driving or riding in an automobile. It is crucial that the cylinders be secured in the event the car brakes suddenly or is involved in an accident. Environmental Issues for Patients on Home Mechanical Ventilation RESPIRATORY RECAP Environmental Issues» Safe storage of oxygen» Electrical safety» Backup electrical/battery power» Emergency plan» Alarms and communication» Local EMS and firefighters If the patient will receive a home ventilator, the environment evaluation should include verifying the adequacy of the home electrical system. Home medical equipment that is double insulated generally does not require grounding. However, most home medical equipment companies do not have a biomedical engineer on staff to verify the electrical safety of each piece of medical equipment; therefore, it is prudent for the therapist to ensure that the electrical outlets used for home medical equipment are properly grounded. 14 Most hardware stores stock a ground circuit detector that can be purchased inexpensively. These devices typically use red and amber bulbs to indicate the outlet status, although the therapist must read the instructions for the particular brand of ground circuit detector being used. In the case of the ground circuit detector shown in Figure 26 1, the outlet is properly grounded if the two amber bulbs illuminate. If the red bulb or a single amber bulb illuminates, there is a problem with the outlet that must be remedied before that outlet can be safely used. Another important aspect of electrical safety in the home is ensuring that the electrical circuit is not overloaded. Most ventilator patients have several pieces of electrical equipment (e.g., ventilator, heated humidifier, nebulizer, O 2 concentrator, suction machine) within the

Home Environment Evaluation 19 Formula Power consumption of vent in watts 1000 Hours per day of use = Kilowatts per day Kilowatts per day Cost per kilowatt 30 days = Cost per month Sample Calculation Note: Get watts from the ventilator manufacturer; get cost per kilowatt from the local electric company. 50 watts 24 hours per day 1000 = 1.2 kilowatts per day FIGURE 26 1 Two LEDs indicating a properly grounded outlet. 1.2 kilowatts per day 0.124 per kilowatt 30 days = $4.46 per month FIGURE 26 2 Estimating the cost of electricity for a home ventilator. Data from Turner J. Handbook of Adult and Pediatric Respiratory Home Care. St. Louis, MO: Mosby; 1994. same room in addition to the standard household items. It is easy to overload the electrical circuit. Sometimes the homeowner will have a diagram detailing which outlets are on the same circuit, but usually testing must be done. To determine which outlets are on the same circuit, turn off the circuit breaker for that room and then insert the ground circuit detector into each outlet. If the outlet circuit detector does not illuminate (no bulbs light), that outlet is controlled by the circuit breaker that was turned off. If the bulbs on the outlet circuit detector illuminate, that outlet is on a different circuit. The therapist should be careful not to plug too many devices into the same circuit. If concerned, the therapist can total the amperes of each item he or she intends to plug into a particular circuit and compare that total to the rated amperage of the circuit breaker. This information can usually be found in the operator s manual for each piece of equipment. Note that some ventilators draw more current on startup and then drop back after the ventilator is operating. 15 The therapist should avoid the use of extension cords for the home medical equipment if at all possible. However, in practical application, there will be times when an extension cord is needed. If an extension cord must be used, ensure that the cord is of high quality, is in good condition, and includes three prongs rated appropriately to carry the anticipated amperage. Of course, the extension cord must be plugged into an outlet that the therapist has already tested with the ground circuit detector. Some new extension cords include a ground fault interrupter (GFI), which can add an additional measure of safety when properly used. Of course, when there is any concern about the home s electrical system, it is imperative that a licensed electrician provides the final word on the home s electrical safety. Some patients who are on home O 2 and/or a home mechanical ventilator will be concerned about the anticipated increase in their electric bill. If the patient expresses a significant concern about the bill, the RT can help the patient estimate the additional electric consumption and the increased cost. 16 See Figure 26 2 for a sample calculation. Some communities allow patients who are dependent on a mechanical ventilator to be placed on a priority restoration service in the event of a power failure. If the patient s electric company offers this service, the therapist should forward a letter to the electric company including the patient s name, address, and reason for the priority designation along with a request signed by the patient s physician. However, even if priority designation is granted, the patient must be cautioned that it is not always possible for the electric company to restore service promptly, and alternate plans must be put into place for whenever electrical power is interrupted. The RT must work with the patient and family to determine the optimal emergency plan for handling a power failure. Some families choose to obtain a generator. Generators vary in complexity of operation. Some generators automatically turn on when necessary, and even perform self-tests at scheduled intervals. However, some generators are difficult to start, and may require physical strength and agility to pull-start. It is imperative that this type of generator be started periodically, per the manufacturer s guidelines. It is wise for the family to identify and train several people who are usually available and able and willing to start the generator should the need arise. All patients who depend on a ventilator should have a battery system in case of emergency and for mobility purposes. 17 Each patient s need for battery duration must

20 CHAPTER 26 Home Respiratory Care be evaluated individually. For example, a patient who has no spontaneous breathing capability and who lives in an area with frequent power outages will require much longer battery duration than FIGURE 26 3 The PowerTech Vent Power Center. a patient capable of spontaneous ventilation who uses a ventilator only at night. All home ventilator manufacturers offer various battery types and sizes. Richardson Products (Frankfort, Ill.) makes a product called the PowerTech Vent Power Center that allows the patient to operate the ventilator from a power wheelchair battery (Figure 26 3). Many patients also have a DC power cord; in an absolute emergency, the patient could use the ventilator in the car. In some communities, the local fire department may allow the patient to wait out a power outage at the fire station if it has power. Firefighter personnel may also help operate the patient s generator if previous arrangements have been made. Determining the optimal plan for handling power outages requires an understanding of the patient s needs, the family s capabilities, and the community services available. An important aspect of the home environmental assessment is to ensure that the ventilator alarms can be heard by the caregiver in all areas of the home. 18 It is not uncommon for the alarms to be inaudible in the basement, or even in the main living areas if a dishwasher or window air conditioner unit is running. Most ventilator manufacturers offer remote alarms that can be placed strategically to ensure that the ventilator alarm is heard throughout the home. Because these alarms work in conjunction with the ventilator, the patient and caregiver can be confident that the alarm has been tested thoroughly. Some families also use commercially available baby monitors in order to hear the patient and ventilator alarms in another room. Some of the latest monitors allow visual observation as well as auditory monitoring of the patient and ventilator. These have served some patients and caregivers well. 19 A caregiver s direct visual observation of the patient offers the most security for the home mechanical ventilator patient; however, it is not always practical or even preferable. Caregivers sometimes need to use the restroom, and patients often prefer their privacy. Therefore, it is crucial that the patient be able to summon assistance if needed. 17 Although ventilator alarms usually activate appropriately, there can be conditions in which the alarm does not sound. Additionally, the patient may have a problem or need that is not ventilator related; therefore, the patient needs a mechanism for calling the caregiver. Finally, the patient needs a means to call for help if something happens to the caregiver. Ideally, patients should FIGURE 26 4 E-Z Call and PA-1. have a means of summoning a caregiver who is in the home with them as well as a means of summoning 911 services. It may be especially important for patients on mouthpiece ventilation to have a means of calling for help because these patients often do not have a low-pressure or disconnect alarm set on their ventilator because the mouthpiece is not in the mouth all of the time. It is important for the RT to recognize that there is no single communication system that will work for all patients. Some patients are able to shout for help, whereas others cannot speak, or more often, cannot speak loudly enough to be heard in another room. Part of the RT s assessment of the patient should include evaluating what method or methods may work reliably for the patient. Some patients may be able to use a wireless doorbell to summon the caregiver, placing the button with the patient and the chimer with the caregiver. It is important to test the range of the device. Other patients use a cellular phone that is programmed to dial their own home land-line telephone so that the home phone will ring, alerting the caregiver, 19 although this method is dependent on the cellular phone battery being properly charged, having sufficient service, and having a good signal. Unfortunately, both of these methods require a degree of finger strength and dexterity. The E-Z Call and the PA-1 portable alarm (Med Labs, Goleta, Calif.) are available for the patient who has very limited movement or strength (Figure 26 4). The E-Z Call can be connected to a hospital call system or can be used in conjunction with the PA-1 portable alarm. The E-Z Call features a square pad that can be placed on the patient s tray-table. The pad is very sensitive, so that a very light tap on the pad will trigger the PA-1 alarm. If the patient can move only his or her head, the alarm pad can be clipped to the pillow. The PA-1 alarm will sound by pressing the head onto the pad. Another model, called the Bite-or-Puff, uses a strawlike device that the patient bites or puffs into in order to trigger an alarm. Most DME companies require the family of homeventilated patients to have a land-line telephone system instead of, or in addition to, a cellular phone. 17 The

Long-Term Oxygen Therapy 21 placed on the refrigerator, or worn on an alert bracelet so that it is easily visible should they be called to the home in an emergent situation. FIGURE 26 5 X10 Personal Assistance Voice Dialer rationale is that caregivers will most likely take the cell phone with them if they leave the patient in the care of the nurse, potentially leaving the home nurse without a means to summon emergency services should the need arise. Another important reason for the requirement of a landline is that most emergency services providers may be able to more quickly pinpoint the address and location of the individual calling for help when the call comes from a land line. X10 (Renton, Wash.) makes a relatively inexpensive product called the Personal Assistance Voice Dialer that may be helpful for some patients (Figure 26 5). It consists of a base unit connected to the home telephone. It can be activated by pressing a button that can be mounted on the patient s wheelchair tray or worn like a wristwatch or pendant. When activated, the device flashes its lights, sounds a siren alarm, and dials up to four preprogrammed telephone numbers. When the dialed party answers, the Personal Assistance Voice Dialer plays the prerecorded outgoing voice message and then allows the dialed party to listen into the patient s home. Working with Local Emergency Medical Services and Firefighters It is a good idea for some home care patients, particularly O 2 and ventilator patients, to meet with their local emergency medical services (EMS) personnel or firefighters before there is any type of emergency. In most communities, EMS personnel or firefighters will visit the patient s home, free of charge, to help perform the home environment evaluation. This visit also allows them to learn where the patient s home is, to note if the house numbers are sufficiently visible, and to learn about any special conditions or needs. If the patient has a do-not-resuscitate order, it should be discussed with the EMS squad during the visit. In some communities, the EMS squad may ask that a copy of the order be taped over the patient s bed, The Physician Order The initial order for home respiratory equipment often comes to the DME company on a prescription from a physician s pad or on a discharge note from the hospital. If the patient is in the Medicare program, an additional document called a certificate of medical necessity (CMN) may be required. If the patient is to receive clinical respiratory services, a concise description of the planned services must be documented and signed for by the physician. Some therapists refer to these physiciansigned orders as a care plan, which is the same terminology used by home health nurses. Other therapists refer to the signed orders as a plan of treatment, and still others refer to the orders as the prescription. Unfortunately, there is no standardized terminology across all home care disciplines. In recent years, guided self-management has become more commonplace. 20 Guided self-management means that patients or caregivers have appropriate knowledge or are adequately trained so that they know when they can make adjustments to the treatment plan, what adjustments they can make, and when they need to seek medical attention. 21 For the patient who is mechanically ventilated at home, it is now relatively common for a range of ventilator settings to be prescribed by the physician, allowing the patient or caregiver to make adjustments within the prescribed range in order to meet the patient s changing needs. Long-Term Oxygen Therapy The Evidence Supporting Home Oxygen Therapy Oxygen therapy in the home or alternate-site healthcare facility is indicated for the treatment of hypoxemia and has been shown to significantly improve survival in hypoxemic patients with COPD. 22 The Nocturnal Oxygen Therapy Trial (NOTT) and Medical Research Council (MRC) multicenter studies created the foundation for studies showing that continuous use of O 2 improves survival. 23,24 A later review of the NOTT study (Figure 26 6) reported that home long-term oxygen therapy (LTOT) reduced healthcare costs by reducing hospitalizations. 25 Key Issues in Oxygen Therapy The goal for efficient O 2 delivery is proper arterial O 2 saturation at all activity levels. 26 The degree of pulmonary disease is the major determinant of a patient s inspired O 2 requirement. It is important to note that saving O 2 is considered accomplished only after the patient is adequately oxygenated and is a secondary objective for device performance. Even if an O 2 delivery device

22 CHAPTER 26 Home Respiratory Care Cumulative Survival Proportion (%) 100 80 60 40 20 RESPIRATORY RECAP Long-Term Oxygen Therapy» The goal is to maintain adequate arterial O 2 satuation.» Studies show that O 2 therapy is life prolonging in patients with chronic obstructive pulmonary disease.» Respiratory rate affects the amount of O 2 the patient receives. 0 0 NOT (24 hours) MRC male (13 hours) NOT (12%) MRC male controls 1 2 3 is providing consistent O 2 delivery, results can vary for an individual patient from moment to moment, and between groups of patients using similar devices. Increased respiratory rate will shorten inspiratory time and may reduce the amount of O 2 a patient will receive (Figure 26 7). In the past, the general rule of thumb was to double the patient s flow rate (e.g., from 2 L/min to 4 L/ min) during exercise. Any change in respiratory rate or pattern may affect the patient s oxygenation. The lack of attention to this variable in the past has created the misperception that some O 2 delivery devices, especially conserving devices, are not effective. Oxygendependent patients should be tested on their O 2 system at different activity levels reflecting real-life conditions sleep, rest, and exercise, as well as at altitude. A titration test is the standard method of Time (Years) FIGURE 26 6 Nocturnal Oxygen Therapy Trial study results. FIO 2 (%) 33 32 31 30 29 28 27 26 25 24 Continuous flow 15 20 25 30 Respiratory Rate (BPM) 4 5 6 FIGURE 26 7 An example of the impact increased respiratory rate has on FIO 2 between continuous flow and a variety of oxygenconserving devices. measuring patients O 2 needs with exercise. There is no standard for O 2 titration. Most clinicians use a simple method that only requires an oximeter and exercise. If a patient will be doing more strenuous activity, every attempt should be made to simulate that activity to see whether the device properly oxygenates the user. Overnight oximetry is strongly recommended for intermittent-flow O 2 delivery devices to determine whether the device is triggering with each breath and maintaining patient SpO 2. 22 Altitude has an impact on the pressure of O 2 and not necessarily on the amount of O 2. Oxygen delivery devices deliver approximately the same volume of O 2 at higher altitudes (or in an airplane), but the pressure at different altitudes may have an impact on blood oxygenation. It is important to understand that if an O 2 system is able to meet a patient s O 2 needs at a lower altitude, it is possible that that same system may not be able to meet the patient s needs at a higher altitude. It is generally unfeasible to test patients on their O 2 systems at pressures that they would be experiencing at varying altitudes. A common practice is to double the setting when the patient is at altitude. However, if the O 2 system the patient is using is already running at its top setting at a lower altitude, another system should be considered for use at higher altitudes. By selecting one breathing pattern and one breath rate, a delivered dose volume of O 2 can be made equivalent to the volume taken in during continuous flow of O 2. 27 As a result, manufacturers select a volume of O 2 for a given oxygen conserving device setting that they feel would be equivalent to continuous-flow oxygen (CFO) and make that the flow setting on their device. However, this only works if the patient never changes his or her breathing pattern. Most oxygenconserving devices have a number on the selector dial and, though they claim to deliver O 2 equivalently to CFO at that same setting, are not equivalent to CFO, let alone another conserving device at that setting (Figure 26 8). There is a wide variety in delivered FIO 2, and no device can be considered to have delivered therapy equivalent to CFO. Flow 0 33 ml Inhale Dead space Exhale 20 BPM = 3 seconds per breath I:E = 1:2; 1 second inspiration 10 LPM O 2 = 167 ml per second Delivery time ~0.2 seconds = 33 ml 1 second 2 seconds Patient flow FIGURE 26 8 Increasing peak flow on an oxygen-conserving unit can provide more gas delivery to useful sections of the lung, preventing delivery of oxygen to dead space.

Long-Term Oxygen Therapy 23 Patients on home O 2 therapy need to stay active to maintain a healthy lifestyle and prevent complications associated with a sedentary lifestyle. 25 Activity is important to health, yet patients requiring supplemental O 2 are challenged by the need to carry or transport the O 2 necessary to maintain proper oxygenation. In the hospital, patients are requested to stay in their beds, and when transportation is necessary, an assistant carries the O 2 and moves patients to their destinations within the hospital. In the home, this is not possible or practical, so patients will need to be provided an O 2 system that is both light enough to transport and capable of providing the required O 2 to meet their needs with activity. In the NOTT study, patients who were high walkers with 12 hours of O 2 had a higher survival than low walkers on 24 hours of O 2 (Figure 26 9). This finding indicated that activity had a greater impact on survival than continuous-flow O 2 delivery. Methods of Oxygen Delivery Surviving (%) 100 90 80 70 60 50 40 30 20 10 0 0 RESPIRATORY RECAP Methods of Oxygen Delivery» Continuous flow» Intermittent flow Continuous-flow O 2 delivery is the standard for O 2 delivery in the hospital and in institutional settings with unlimited O 2 supply, typically from an industrial liquid O 2 source. This is the simplest form of O 2 delivery because the only requirements are a device to meter the flow of O 2 and a patient interface. With an unlimited supply of O 2, simply increasing flow when patient O 2 demands increase is a viable solution. With a limited supply of O 2, however, alternatives are required. In the home, stationary O 2 from a concentrator (Figure 26 10) can be thought of as unlimited because the O 2 source is dependent only on electricity, which is usually available. If a packaged gas is used, such as liquid oxygen or compressed gas, refill and distribution issues as well as cost become a consideration. Intermittent-flow oxygen was a technical challenge until the mid-1980s, when the first intermittent-flow O 2 delivery system was introduced. 28 Sensing a patient s inspiratory effort and triggering a dose of O 2 at the beginning of the patient s inspiratory cycle was an engineering challenge because technology had not evolved to accomplish the objective. Fluidic amplifiers and sensitive pressure switches were included in the first intermittentflow devices, and the technology has evolved to a high level of sophistication at this time. The challenge to provide a device that is as sensitive as possible to trigger consistently, yet not too sensitive to cause the device to auto-trigger, continues. At this time, all intermittentflow devices sense breathing through a nasal cannula. Low walk 12 hrs High walk 12 hrs Low walk 24 hrs High walk 24 hrs 0.5 1 1.5 2 2.5 3 3.5 4 Years in Study FIGURE 26 9 A retrospective analysis of the Nocturnal Oxygen Therapy Trial data shows the value of exercise to the survival of patients on long-term oxygen therapy. Eighty patients matched for age, treatment group, and FEV 1. They were spilt into activity groups by walking level measured by pedometer at baseline study. No oxygen during 1-week trial. Medial level was 0.68 miles per day. FIGURE 26 10 Example of three stationary oxygen concentrators.

24 CHAPTER 26 Home Respiratory Care Home Oxygen Delivery Devices Oxygen concentrators have been the standard for stationary O 2 delivery in the home for decades. The convenience of producing O 2 in the home eliminated the need to refill package gas systems such as high-pressure cylinders and liquid O 2. Using pressure swing adsorption (PSA) methodology, O 2 is separated from nitrogen, and FIGURE 26 11 Transfilling concentrators. the net result is an FIO 2 of 0.93 0.03. Over the years these systems have become more reliable and smaller, and consume less electricity than previous models. Today s typical home stationary O 2 concentrator weighs about 35 pounds (16 kg) and can provide up to 5 L/min continuous-flow O 2. These smaller systems produce less noise and heat, which had been an issue RESPIRATORY RECAP Home Oxygen Delivery Devices» Oxygen concentrators» Compressed gas systems» Liquid oxygen systems» Concentrators that fill compressed gas systems» Portable oxygen concentrators in years past. Stationary concentrators have become the anchor for most home O 2 programs, yet for an ambulatory patient, a portable O 2 system must be provided. Compressed gas systems were the standard for home O 2 therapy until other options became available. Large cylinders were used in both the hospital and the home as the only source of O 2. When concentrators and liquid oxygen systems became available for the home, cylinder usage decreased. Small cylinders are still used with stationary O 2 when appropriate and in conjunction with a concentrator transfilling system (Figure 26 11). Small cylinders come in a variety of sizes and shapes designed to provide the lightest system for the patient, along with the greatest operating range. A typical fill pressure for a cylinder is 2000 psig, yet 3000 psig is available for newer cylinders designed for that operating pressure. Cylinders that are transfilled from a home concentrator will be at a purity equal to the source concentrator, which typically produces 93% 3% O 2. Cylinders filled at an industrial gas supplier are at 99% purity. Liquid oxygen (LOX) storage systems have the greatest storage capacity for O 2 (Figure 26 12). Most hospitals use large cryostats to supply the large volume FIGURE 26 12 A liquid oxygen base unit with portables.

Long-Term Oxygen Therapy 25 of O 2 gas required by the hospital. Home LOX systems became available in the mid-1960s when Union Carbide introduced the first home LOX system. The benefit of the home LOX system is the ability to transfill a smaller, lightweight, portable O 2 system. Liquid O 2 has an 860:1 expansion ratio, so 1 liter of LOX will expand to 860 liters of gaseous O 2 with more efficiency and greater weight-to-operating-time ratio than packaged gas. LOX became the choice for patients who were highly ambulatory and required more functionality from their portable O 2 system. Limitations of a LOX system are that it has a finite amount of gas and requires refilling from a larger base unit. Both the base units and portable units come in a variety of sizes, allowing for refilling options for both patients and O 2 distributors. Concentrators that fill compressed gas cylinders in the home entered the market a few years ago. Models differ among manufacturers, but the principles remain the same. A concentrator generates O 2 and then transfers the O 2 as compressed gas to the portable cylinder. O 2 monitoring equipment ensures gas purity. This allows patients to refill cylinders themselves, and it saves the home care provider from visiting patients homes to exchange cylinders. Concentrators that fill LOX portables have just become available for commercial use. The concentrator generates O 2 for the portable, but rather than pressurizing the gas, it is liquefied and transfills to the portable. This allows patients the advantage of both a lightweight and long-term-use portable. O 2 purity in the portable that is transfilled, with both compressed gas and LOX, is about 94% due to the concentrator being the source gas. The variable with these systems is often the conserving device used with the portable because the source gas for all the systems is similar. Options available for a transfilling system are interchangeable regulators with post valve cylinders, pressure ranges that affect operating times with 2000- and 3000-psig fill pressures, and an option for a combined or separate gas pumping unit for cylinders. Portable oxygen concentrators (POCs) manufacture O 2 ; they do not store O 2 (Figure 26 13). This requires the POC to produce enough O 2 per minute to allow for an acceptable dose of O 2 to the patient with each breath. POC O 2 production is similar to the larger stationary systems, used in the home since the mid-1970s, that use PSA technology to generate O 2. POC manufacturers have been able to reduce the size of the sieve bed, improve compressor performance, utilize O 2 -conserving technology, and integrate sophisticated battery systems to make these systems as small as possible. Each manufacturer has determined how much O 2 the device will produce, which determines maximum O 2 delivery, weight, and operating time. 29 These differences will have an impact on patient therapy, and the clinician needs to know the capabilities of a POC to determine the appropriate device to use for the patient. Patient needs vary as much as the POCs, so there is no one right POC for all patients. Knowing the capabilities of FIGURE 26 13 Portable oxygen concentrators: 20 lb (9 kg) continuous flow capable, and 10 lb (4.5 kg) intermittent flow only.

26 CHAPTER 26 Home Respiratory Care the POC, the needs of the 50 patient, and the activities the patient will be doing while using the POC are 45 important points of information for the clinician 40 to consider when working with the patient to determine therapy options. 35 Recommendation 8 from the 1987 LTOT Consensus Conference states, 30 Clinical evaluation should include regular 25 assessments of patients compliance with prescribed therapy, potential 20 complications, potential Pneumatic hazards and the need for continued education. Patients receiving LTOT share responsibility with the prescribing physicians for remaining in communication with their physician in order to assure continued appropriate care for their condition. 30 This recommendation emphasizes that patients be titrated on the O 2 system they will be using, at all activity levels at which they will be using the device. Portable O 2 concentrators have the potential to be used at rest, exercise, sleep, and altitude. Each one of these situations needs to be evaluated with the patient and the specific POC. Portable O 2 concentrators provide the benefit of making O 2 rather than storing it, which allows patients to use electricity to charge batteries so as to use the concentrator when they travel from home. These advantages are tempered by other constraints on the system s operation. Portable O 2 concentrators use the same technology as stationary O 2 concentrators, only in smaller sizes. That means that the maximum O 2 produced and the dosing of the O 2 differ by concentrator. These two variables restrict the system because the concentrator cannot make more O 2 than it was originally intended to produce. If the patient increases the demand with a higher dose setting or respiratory rate, either delivered dose, O 2 purity, or both will decrease. 31 These limitations must be considered when prescribing and monitoring patients on this system, as well as any portable O 2 system, due to the limited maximum amount of O 2 that can be provided (Figure 26 14). Systems weighing less than 10 pounds (4.5 kg) only use oxygen conserving technology and therefore are suitable for use in a car, airplane, or wheelchair (patient seated); they may have variable effectiveness with exercise. Systems weighing more than 10 pounds (4.5 kg) are capable of continuousflow and O 2 -conserving and can be used for most purposes, including exercise and sleep. CR-50 EasyPulse 5 EconO2Mizer EscO2rt Home Fill O2nDemand II O2Xpress Oxy-Serv II Respond O2 Tru-Dose epod Impulse Elite (A Mode) Impulse Elite (B Mode) Liberty MiniO2 PD1000 PD4000 EasyMate EscO2rt (Single) EscO2rt (Dual) Helios Marathon Spirit 300 Spirit 600 Spirit 1200 Eclipse Freestyle Inogen One LifeStyle OxyTec 900 Electronic Liquid Portable POC FIGURE 26 14 Maximum FIO 2 delivery among a variety of home portable oxygen systems. FIGURE 26 15 Reservoir cannulas. Oxygen-Conserving Devices In the past, patients were prescribed a default setting of 2 L/min continuous flow for O 2 delivery. If the patient s O 2 levels were appropriate, rarely did the clinician test to determine whether a lower setting would accomplish the same objective. Doing so would have conserved some O 2. 32 With the introduction of oxygen-conserving devices (OCDs), regular CFO therapy from O 2 cylinders is being used much less than in the past for home care applications. Reservoir cannulas, often referred to as moustache or pendant cannulas depending on the design and use characteristics, have approximately 20 ml of reservoir space that stores O 2 during exhalation (Figure 26 15). On inhalation, the patient receives that stored O 2, essentially adding a bolus volume to the ongoing continuous-flow delivery. These devices are simple, effective, and, when used properly, can allow a patient to receive the same therapy at a lower CFO flow rate, thus conserving O 2.

Long-Term Oxygen Therapy RESPIRATORY RECAP Oxygen-Conserving Devices Reservoir cannulas Intermittent-flow devices Pulse-flow devices Demand delivery devices Transtracheal oxygen»»»»» Although they are effective, their app e arance ha s been a limiting factor. Intermittent-flow devices operate by turning O2 delivery on during some portion of inhalation and off for the balance of the breathing cycle. In this way, O2 that would otherwise be wasted as the patient exhales is conserved. This often allows a supply of O2 to last two to four times as long as it would if it were delivered continuously. One benefit of the use of intermittent-flow conserving devices is that a smaller O2 supply may be carried. With intermittent-flow devices, the way in which O2 is delivered to the patient differs greatly from one device to another, and no device delivers O2 in the same way as continuousflow devices. Intermittent-flow devices can be separated into two broad categories, pulse and demand, and within these categories there are many variants. Pulse flow is defined as the device responding to the patient s inspiratory effort and terminating flow at a predetermined time that is controlled electronically.33 Pulse delivery devices deliver O2 in the form of a relatively high flow rate bolus beginning early in inhalation. Some pulse delivery devices vary the dose of O2 by changing the duration of the bolus. Others increase the peak flow rate at which the dose is delivered as the user increases the setting number. Some devices do a combination of both. Most pulse delivery devices deliver volumes at a given setting regardless of the breathing rate. As respiratory rate increases, the volume of O2 inhaled from a CFO device over time does not change. With a typical pulse delivery device, however, the bolus volume is always the same, and so the O2 volume inhaled per minute increases as the breath rate increases (assuming the entire bolus volume is inhaled; at high rates and/or high settings this may not be the case). As a patient moves from rest to activity and his or her breath rate increases, a pulse device operating in this manner may maintain oxygenation better than a continuous-flow or a demand device. However, this has not been proven clinically and it is impossible to say that pulse-type delivery is equivalent to continuous-flow delivery across a wide variety of breathing patterns. Device manufacturers, however, label their products with the same setting numbers used for continuous flow (1, 2, 3, etc.), and so there is often confusion about why a conserving device set at 2 is not oxygenating a patient like a continuous-flow device at 2 L/min. Pulse systems typically need a power source, so batteries are a factor to consider. Demand delivery devices have evolved from the initial idea of creating an oxygen-conserving device that uses the patient s breathing to turn on the device during inhalation and off during exhalation. Demand flow FIGURE 26 16 Transtracheal placement of oxygen delivery catheter. senses the patient s inspiratory effort, yet flow is terminated on exhalation. The amount of O2 delivered will vary with inspiratory time. These units are not as efficient as pulse-flow devices in utilization of O2, yet have the advantage of not requiring batteries. Most demand systems use a dual-lumen cannula, with one channel of the cannula sensing inspiration and the other channel delivering O2. A set rate of O2 is delivered over the entire inhalation cycle only. These devices are sometimes called hybrids because they act like both a pulse and demand device, delivering a fixed pulse volume at the onset of inhalation and then continuing to deliver O2 until the device senses the beginning of exhalation. Transtracheal oxygen (Figure 26 16) uses a catheter that is placed during a surgical procedure to bypass the upper airway.34 The catheter is placed through a small hole made in the front of the neck and into the trachea. O2 conservation is achieved because the patient is usually able to be given the equivalent of CFO therapy with nasal breathing at a lower continuous-flow setting. A single-lumen intermittent-flow conserving device can be used with transtracheal delivery, but the O2 savings are about the same as using nasal breathing with that same intermittent-flow device. A benefit of transtracheal O2 therapy is an increase in patient compliance with therapy because it is hidden from others to see the catheter. With the manufacturers focusing on O 2 savings rather than patient oxygenation, OCDs have had an acceptance problem. 35 Because the devices 27

28 CHAPTER 26 Home Respiratory Care 20 18 16 14 12 10 8 6 4 2 0 CR-50 EasyPulse 5 EconO2Mizer EscO2rt Home Fill O2nDemand II O2Xpress Oxy-Serv II Respond O2 Tru-Dose epod Impulse Elite (A Mode) Impulse Elite (B Mode) Liberty MiniO2 PD1000 PD4000 EasyMate EscO2rt (Single) EscO2rt (Dual) Helios Marathon Spirit 300 Spirit 600 Spirit 1200 Eclipse Freestyle Inogen One LifeStyle OxyTec 900 Pneumatic Electronic Liquid Portable POC FIGURE 26 17 The average dose volume per setting for a variety of oxygen-conserving devices, indicating the high variability of dose volume among products. differ in dose delivery (Figure 26 17), patients should be tested on the unit they will be using in the home and at the activity levels at which they will use the device. Clinicians need to be informed about the performance capabilities of each piece of equipment that a patient uses. A respiratory-rate-regulated OCD monitors the patient s respiratory rate and has an algorithm that switches the dose setting to a higher dose with a higher respiratory rate. As the patient breathes faster, the dose will increase; as the patient breathes slower, the dose will return to a lower setting. This technique allows the patient to increase the dose of O 2 with demand without manually changing the dose setting. An oximeter-regulated OCD monitors the patient s SpO 2. An algorithm in the device changes the O 2 dose based on SpO 2. There is an approved product with this feature, but it is not currently commercially available. A motion-regulated OCD senses movement and changes the O 2 dose to a higher setting. When movement stops, the OCD then switches back to the lower dose setting. An approved product featuring this ability to change dose setting as a result of movement is currently on the market. High-Flow Oxygen Delivery in the Home Typically, home O 2 therapy is provided in a range of 1 to 6 L/min, yet flows of up to 10 L/min are possible from some O 2 concentrators. Home LOX systems can provide up to 15 L/min with units designed for that flow. Industrial LOX units can be used for flows higher than 15 L/min. Home portable O 2 systems can operate at higher flows, yet for a very short time. Patients requiring high-flow portable O 2 typically use a LOX system for the efficient operation. Special delivery tubing and cannulas need to be used for higher-flow systems to compensate for the resistance to the higher flows. Diagnostics Systems for Long-Term Oxygen Therapy Personal oximeters are used to assess a patient s SpO 2. Small, simple-to-operate units can be used by patients to assess their O 2 status. Patients ability to understand the oximeter values and the variability of both the oximeter and the O 2 delivery system have caused some concern, yet many patients are purchasing personal oximeters. Education is key to the safe and effective use of a personal oximeter, and clinicians should take every opportunity to reinforce the issues related to their use. Home care providers check continuous-flow units with devices that monitor O 2 concentration and flow. A simple liter meter can verify flow in the home and determine whether the O 2 delivery device is providing the flow correctly or whether extended O 2 supply tubing has created a drop in flow. There is a device that monitors both flows and O 2 concentrations. Basic O 2 monitors are also used for doing routine checks on home O 2 equipment. Pulse-dose O 2 delivery from an oxygen-conserving device requires a test unit that can measure volume rather than flow. These O 2 systems deliver a specific amount (ml) of O 2 that can be measured to determine whether the device is operating within specifications. Each oxygen-conserving device provides a different volume of O 2 at a specific setting, so the manufacturer s specific value is needed to determine whether the device is working within the specifications.

Home Mechanical Ventilation 29 FIGURE 26 18 Clinical Oxygen Dose Recorder system. A system has been developed that can monitor both the O 2 delivery device and the patient (Figure 26 18). This unit can determine the delivery capabilities of the O 2 system and how the patient is responding. Given the great variability of performance in portable O 2 systems, this unit can help clinicians determine which home O 2 system should be used based on patient requirements. Oxygen Delivery Accessory Items Carts have helped patients be more mobile with their O 2 systems. Originally O 2 carts were the same as those used in the hospital, with weight and aesthetics being an issue. Now lightweight functional carts are available for the home O 2 patient s use. Backpacks became a request of patients who wanted to have more free use of their hands. A user-friendly backpack allows for more mobility for an active LTOT patient performing the activities of daily living than is typically possible with a shoulder strap. Shoulder straps have also evolved to more comfortable, aesthetically pleasing options. Some shoulder straps are made of elastic material that can act as a shock absorber for the pressure transferred to the shoulder. Liter meters are devices that are used to spot-check the continuous flow from a low-flow O 2 device. These devices are used by home care providers to check the accuracy of the flow setting, yet patients can do the same spot check with proper training and availability of the tool. Pulse meters are devices that check the pulse volume of a pulse-style intermittent-flow device. These products are used by home care providers yet are more expensive than a liter meter, so may not be an option for patient purchase and use. Batteries are an option for POCs because the operation time of a POC away from an AC or DC source is determined by the use time of the battery. If necessary, additional batteries can extend use time and are an important factor for air travel. Pulse-style conserving devices have a set battery life, so extra batteries should be available for the system as a backup. Patient Delivery Interface Devices The nasal cannula has been the standard for low-flow O 2 delivery. Cannula options have included multiple lengths for specific applications, different materials (e.g., plastic, silicone) different-diameter nasal prong lumens, and accessories for comfort. Lumen size and tubing length have an impact on O 2 delivery, and if the cannula is changed to a different capability, the flow and FIGURE 26 19 Oxy-View glasses. patient oximetry should be checked. Single-lumen cannulas are typical and account for the majority of cannula options. Dual-lumen cannulas are used with demand flow-conserving devices and can be used for other gas monitoring, such as CO 2 monitoring. Headset low-flow O 2 delivery was originally designed to provide an alternative to the cannula putting pressure on the ears and cheeks. Headsets are used with prolonged phone use, so they appear to be a good option for patients using home O 2. Oxygen glasses have the same potential as the headset (Figure 26 19). The oxygen glasses also add an aesthetic value because often patients using these devices are not known to be wearing oxygen. Nasal masks are an alternative to the cannula. The nasal mask cups O 2 around the nose to eliminate the prongs entering the nose. If the nasal cannula prongs are causing irritation, the nasal mask can be used as an option. The nasal mask must be used with continuousflow O 2 because the conserving-type systems would not be able to sense an inspiration and function properly. Home Mechanical Ventilation There is no general agreement on the definition of a home mechanical ventilator. Some clinicians refer to a bilevel flow-generator that includes a backup rate, known in Medicare parlance as a respiratory assist device (RAD), as a mechanical ventilator. Other clinicians reserve the term mechanical ventilator for devices that include an exhalation valve (as opposed to a passive exhalation port) and the ability to set a breath rate and alarms. The Medicare program has categorized devices with exhalation valves, adjustable breath rates, and alarms as mechanical ventilators and places them in the group of devices requiring frequent and substantial service. Medicare will rent a mechanical ventilator for qualified patients as long as medical necessity exists. However, Medicare

30 CHAPTER 26 Home Respiratory Care TABLE 26 3 FDA Classification of Home Mechanical Ventilators FDA Code FDA Definitions Common Use Description CBK Conventional, continuous ventilator Life support ventilator for patients with respiratory failure NOU Conventional, continuous ventilator, home use Life support ventilator for patients with respiratory failure MNS Ventilator with fixed or passive exhaust port, continuous, non life support Non life support, for patients with respiratory insufficiency or obstructive sleep apnea places respiratory assist devices in the capped rental category. For capped rental equipment, the DME provider receives a monthly rental fee for 13 months, after which the ownership of the equipment is transferred to the Medicare beneficiary. It is imperative for the home care RT to periodically reevaluate patients receiving any type of home ventilation, including those who are using respiratory assist devices. Some patients with deteriorating conditions such as ALS or Duchenne muscular dystrophy who are using a respiratory assist device may ultimately need to transition to a mechanical ventilator appropriate for life-support ventilation. The plan for managing the patient s respiratory needs throughout the disease process should be discussed in advance with the patient and the physician, as well as the patient s family when appropriate. The Food and Drug Administration (FDA) classifies mechanical ventilators as described in Table 26 3. Note that all of the home ventilators classified by the FDA as life-support ventilators have been placed in the Medicare category that requires frequent and substantial service. In the United States, individuals who have a tracheostomy and need home mechanical ventilation have traditionally been placed on a CBK device. The FDA has recently created a new code, NOU, for home mechanical ventilators. The new code s purpose is to clarify that home mechanical ventilators must be tracked by the home medical equipment company so that, in the event of a recall, the device can be located. The FDA broadly defines the intended use of each device; individuals who need noninvasive home mechanical ventilation for respiratory insufficiency are often placed on a CBK, NOU, or MNS device, depending on the acuity of the patient s condition and the expected course of the disease, and the physician s preference. An accurate count of the number of individuals receiving home mechanical ventilation in the United States is unknown. Unlike many European countries, the United States does not have a central registry or database tracking individuals receiving either invasive or noninvasive home mechanical ventilation. In 1998 there were an estimated 10,000 to 20,000 patients on home mechanical ventilation. 19 Using Medicare claims data from 2005, a rough estimate of 3100 patients can be derived. Based on the estimated number of Medicare home ventilator patients, the actual number of invasively ventilated patients at home is likely close to 10,000. Medicare claims data for 2005 for noninvasive positive pressure ventilation (NIV) suggests there are approximately 7600 patients using NIV with a backup rate. 8 Diagnoses and Indications for Home Mechanical Ventilation A number of medical conditions and indications may result in the need for home mechanical ventilation (Box 26 2 and Box 26 3). Note in particular that the indication for invasive ventilation (as opposed to noninvasive ventilation) for individuals requiring more than 20 hours of ventilatory support per day is not a hard and fast rule. Some individuals can be successfully ventilated with noninvasive methods for 24 hours per day for many years. 36 However, some patients prefer invasive ventilation if the need for support is continuous or almost continuous. Also note that the indications listed are similar to, but not exactly the same as, the Centers for Medicare and Medicaid Services (CMS) requirements for coverage of respiratory assist devices. The American Association of Respiratory Care and the American College of Chest Physicians both have drafted goals for the management of mechanical ventilation in the home (Table 26 4). Discharge Planning for the Patient Going Home with a Mechanical Ventilator If a hospitalized patient is prescribed home mechanical ventilation, a comprehensive team approach to discharge planning is required (CPG 26 1). Most home care RTs TABLE 26 4 Goals for Home Mechanical Ventilation American College of Chest Physicians Provide an environment that enhances the individual s potential Improve physical and physiologic function Reduce morbidity Extend life Provide cost-effective care VAI, ventilator-assisted individual. American Association for Respiratory Care Sustain and extend life Enhance the quality of life Reduce morbidity Improve or sustain physical and psychological function of all VAIs and enhance growth and development in pediatric VAIs Provide cost-effective care Modified from Make BJ, Hill NS, Goldberg AI, et al. Mechanical ventilation beyond the intensive care unit: report of a consensus of the American College of Chest Physicians. Chest. 1998;113:5(suppl):289S 344S.

Home Mechanical Ventilation 31 BOX 26 2 Medical Conditions That May Be Appropriate for Home Mechanical Ventilation Central Nervous System Disorders Arnold-Chiari malformation Central nervous system trauma Cerebrovascular disorders Congenital and acquired central control of breathing disorders Myelomeningocele Spinal cord traumatic injuries Neuromuscular Disorders Amyotrophic lateral sclerosis Guillain-Barré syndrome Muscular dystrophies Myasthenia gravis Phrenic nerve paralysis Polio and postpolio sequelae Spinal muscle atrophy Myotonic dystrophy Skeletal Disorders Kyphoscoliosis Thoracic wall deformities Thoracoplasty Cardiovascular Disorders Acquired and congenital heart disease Respiratory Disorders Upper airway Pierre-Robin syndrome Tracheomalacia Vocal cord paralysis Lower airway Bronchopulmonary dysplasia Chronic obstructive pulmonary disease Cystic fibrosis Complications of infectious pneumonias Pulmonary fibrotic diseases Modified from Make BJ, Hill NS, Goldberg AI, et al. Mechanical ventilation beyond the intensive care unit: report of a consensus of the American College of Chest Physicians. Chest. 1998;113(5 suppl):289s 344S. BOX 26 3 Indications for Home Mechanical Ventilation Indications for Noninvasive Ventilation Patient has chronic stable or slowly progressive respiratory failure: Significant CO 2 retention ( 50 mm Hg) with appropriately compensated ph or Mild daytime nocturnal CO 2 retention (45 to 50 mm Hg) with symptoms attributable to hypoventilation (e.g., morning headaches, restless sleep, nightmares, enuresis, daytime hypersomnolence) Significant nocturnal hypoventilation or oxygen desaturation The following conditions have been met: Patient has had optimal medical therapy for underlying respiratory disorders Patient is able to protect airway and adequately clear secretions Patient s reversible contributing factors have been treated (e.g., obstructive sleep apnea, congestive heart failure, severe electrolyte disturbance) The diagnosis is appropriate. Indications for Invasive Ventilation Patient meets indications for noninvasive ventilation and has the following: Uncontrollable airway secretions despite use of noninvasive expiratory aids or Impaired swallowing leading to chronic aspiration and repeated pneumonias Patient has persistent symptomatic respiratory insufficiency and fails to tolerate or improve with noninvasive ventilation. Patient needs round-the-clock ( 20 hours per day) ventilatory support because of severely weakened or paralyzed respiratory muscles (e.g., high spinal cord injury or end-stage neuromuscular disease) and patient or provider prefers invasive ventilation. Modified from Make BJ, Hill NS, Goldberg AI, et al. Mechanical ventilation beyond the intensive care unit: report of a consensus of the American College of Chest Physicians. Chest. 1998;113(5 suppl):289s 344S.

32 CHAPTER 26 Home Respiratory Care CLINICAL PRACTICE GUIDELINES 26 1 Oxygen Therapy in the Home or Alternate-Site Healthcare Facility Indications Long-term oxygen therapy (LTOT) in the home or alternate-site healthcare facility is normally indicated for the treatment of hypoxemia. LTOT has been shown to significantly improve survival in hypoxemic patients with chronic obstructive pulmonary disease (COPD). LTOT has been shown to reduce hospitalizations and lengths of stay. Laboratory indications: Documented hypoxemia in adults, children, and infants older than 28 days as evidenced by (1) PaO 2 less than or equal to 55 mm Hg or SaO 2 less than or equal to 88% in subjects breathing room air or (2) PaO 2 of 56 to 59 mm Hg or SaO 2 or SpO 2 less than or equal to 89% in association with specific clinical conditions (e.g., cor pulmonale, congestive heart failure, erythrocythemia with hematocrit above 56). Some patients may not demonstrate a need for oxygen therapy at rest (normoxic) but will be hypoxemic during ambulation, sleep, or exercise. Oxygen therapy is indicated during these specific activities when the SaO 2 is demonstrated to fall to 88% or below. Oxygen therapy may be prescribed by the attending physician for indications outside of those noted above or in cases where strong evidence may be lacking (e.g., cluster headaches) on the order and discretion of the attending physician. Patients who are approaching the end of life frequently exhibit dyspnea with or without hypoxemia. Dyspnea in the absence of hypoxemia can be treated with techniques and drugs other than oxygen. Oxygen may be tried in these patients at 1 to 3 liters per minute, to obtain subjective relief of dyspnea. All oxygen must be prescribed and dispensed in accordance with federal, state, and local laws and regulations. Contraindications No absolute contraindications to oxygen therapy exist when indications are present. Precautions and Possible Complications There is a potential in some spontaneously breathing hypoxemic patients with hypercapnia and chronic obstructive pulmonary disease for oxygen administration to lead to an increase in PaCO 2. Undesirable results or events may result from noncompliance with physicians orders or inadequate instruction in home oxygen therapy. Complications may result from use of nasal cannulas or transtracheal catheters. Fire hazard is increased in the presence of increased oxygen concentrations. Bacterial contamination associated with certain nebulizers and humidification systems is a possible hazard. Possible physical hazards can be posed by unsecured cylinders, ungrounded equipment, or mishandling of liquid oxygen. Power or equipment malfunction and/or failure can lead to an interruption in oxygen supply. Modified from AARC clinical practice guideline: oxygen therapy in the home or alternative site health care facility. Respir Care. 2007;52:1063 1068. Reprinted with permission. suggest a minimum of 2 weeks of preparation to ensure that the home environment is appropriate and that all required education has been performed. Most home care companies require that a minimum of two family or lay caregivers be identified and trained prior to discharge of the home mechanically ventilated patient. Appropriately trained lay caregivers must be able to explain and demonstrate the proper use, troubleshooting, and routine maintenance of the ventilator and all related equipment (Table 26 5). The caregiver must know how and when to order supplies, and must be able to maintain good infection control processes. Importantly, the caregiver must verbalize and demonstrate the proper response to emergencies such as power failures, equipment failures, or serious patient events such as accidental decannulation. 37 Ideally, the home care RT works with the appropriate hospital staff to jointly complete an instructional checklist to ensure that the patient and family are properly trained (Table 26 6). Education of the patient and of family caregivers should promote positive interactions in a low-key manner. 38 Depending on the patient s

TABLE 26 5 Common Home Medical Equipment and Supplies for a Patient Ventilated at Home Home Medical Equipment Bedside ventilator and wheelchair ventilator Power wheelchair Heated humidifier Portable suction machine (stationary suction machine optional) External battery and charger or universal power supply (UPS) Oximeter Oxygen concentrator Portable oxygen cylinder system (regulator, cart, or carry bag) Nebulizer compressor and/or 50-psi compressor Hospital bed Portable battery and charger End-tidal CO 2 monitor Home Mechanical Ventilation 33 Enteral pump Special mattress surface (to promote skin integrity and to avoid pneumonia) Cough assist device Intermittent percussive ventilator (IPV) Lymphedema pump Remote ventilator alarm and/or patient monitoring system Supplies Oxygen tubing Oximeter probe Tracheostomy tubes and inner cannulas (patient size and one size down) Flex tubing (tracheostomy tube to ventilator circuit) Tracheostomy care kits Heat and moisture exchangers Bacterial filters for ventilator and cough assist Water traps (if not using heated tubing) Suction tubing and canister End-tidal CO 2 tubing and connector Syringes (for cuff maintenance) Ventilator circuits Tracheostomy ties Humidifier chambers Tubing for cough assist Enteral pump sets Nebulizer cups Gloves Suction catheters Speaking valve Elbows (tracheostomy tube to flex tubing) Distilled or sterile water for humidifier (per prescription) IPV circuit Lymphedema stockings TABLE 26 6 Predischarge Joint Instructional Plan for Home Mechanical Ventilation Instructions for form completion: 1. List the topic that will be covered. 2. Jointly determine whether the hospital RN, hospital RT, or home care RT is responsible for instruction of each topic. 3 6. Record the instructor s name, the date(s) of the verbal instruction, and the date(s) of the demonstration. Record your initials and date in column 5 if the patient/family demonstrated with verbal assistance and in column 6 if patient/family demonstrated skill completely independently. 1. Topic 2. Person Responsible for Instruction 3. Verbal Instruction Provided (Also note WM if written materials provided) 4. Demonstration Provided 5. Patient/Family Performed Satisfactory Demonstration with Verbal Assistance 6. Patient/Family Performed Satisfactory Demonstration Without Assistance Use of resuscitation bag When to use Connect to O2 Adjusting O2 flow How hard to squeeze bag Rate of squeeze Suctioning Check suction pressure Supplies used at home (glove[s], kit) When to suction Preoxygenation Remove from ventilator Insert catheter Remove catheter Number of passes Back on ventilator condition and on family caregiver availability, it helps if each educational session is limited to 30- to 60-minute time periods over several days. These sessions may be taught by the RT and reinforced by the hospital nursing staff, or vice versa. It is also crucial that patients (when able), as well as family caregivers, perform return demonstrations without prompting. Home care RTs usually recommend a minimum 24-hour live-in demonstration, during which the family caregivers perform all of the patient s care without help from the RT or hospital staff,

34 CHAPTER 26 Home Respiratory Care FIGURE 26 20 Life Products LP3. as the final indication that the patient and family are ready for discharge. Evolution of Positive Pressure Home Mechanical Ventilators The first generation of positive pressure home care ventilators were piston driven and offered volume-controlled breaths only (Table 26 7). These ventilators weighed over 30 pounds (14 kg) and had very limited internal battery duration. First-generation devices had few options for external batteries other than large, sealed lead acid batteries. Bulky external positive end-expiratory pressure (PEEP) valves also contributed to the lack of easy portability. First-generation home care ventilators included the Life-Products LP-3 (Figure 26 20) and Lifecare Services PLV-100 portable ventilators. Many patients still use first-generation devices. With a few exceptions, the second generation of home ventilators switched from piston driven to turbine driven. Another major difference between first- and RESPIRATORY RECAP Home Mechanical Ventilators» First-generation ventilators were piston driven and offered only volumecontrolled breaths.» Second-generation ventilators switched from piston driven to turbine driven and offered a variety of modes.» Third-generation ventilators are turbine driven and include significant advances in portability and features. second-generation ventilators was the addition of modes such as pressure control, pressure support, and synchronized intermittent mandatory ventilation (SIMV). The second-generation ventilators also offered significant improvements in battery options, as well as enhanced portability. Most of the second-generation ventilators allow supplemental O 2 to be FIGURE 26 21 User interface showing A/C PRVC (assist/ control, pressure-regulated volume control mode) on the ivent 101. connected to a port directly on the ventilator rather than titrated into the patient circuit. Additionally, most of the second-generation devices changed from using an external PEEP control to a PEEP control integrated into the ventilator. There are many patients using secondgeneration devices. All of the third-generation ventilators are turbine driven and include significant advances in portability and features. Some allow the use of both passive circuits (such as found on a traditional bilevel device) and active circuits (which include an exhalation valve rather than an exhalation port). Some third-generation ventilators allow both single-limb active circuits and dual-limb active circuits. Generally, the dual-limb circuit offers exhaled volume monitoring. Additionally, the portability of the third-generation ventilators has increased significantly, and the first hot-swappable battery was introduced. The ivent 101 (GE Healthcare, Waukesha, Wisc.) is the first ventilator to offer pressure-regulated volume control for home patients. The latest home ventilators also feature graphics (Figure 26 21) and allow various reports to be downloaded and printed, including waveforms, ventilator settings, alarm history, patient compliance data, and summary reports (Figure 26 22). These additional data are quite helpful for the RT when troubleshooting ventilator problems. Backup Ventilator and Emergency Supplies There is wide variation across the United States with regard to when a backup ventilator is provided to the patient. The Medicare system generally does not pay for a backup ventilator, but may pay for a secondary ventilator when medically indicated. 39 Generally, in order for

Home Mechanical Ventilation 35 TABLE 26 7 Evolution of Positive Pressure Home Mechanical Ventilators Generation 1 Generation 2 Generation 3 Name LP 3 to LP 20 PLV Series T-Bird Series LTV Series HT 50 Achieva ivent 201 PB 540 Trilogy 100 ivent 101 Current manufacturer Covidien (Boulder, CO) Phillips Respironics (Murrysville, PA) CareFusion (San Diego, CA) CareFusion (San Diego, CA) Newport Medical (Costa Mesa, CA) Covidien (Boulder, CO) GE Healthcare (Madison, WI) Covidien (Boulder, CO) Philips Respironics (Murrysville, PA) GE Healthcare (Madison, WI) Weight (lb) 34 28.9 34 14.5 15 32 22 9.9 11.5 14.7 Dimensions (in.) 9.75 14.5 13.25 9 12.25 12.25 13.0 11.0 13.5 3.25 10.5 13.5 10.63 7.87 10.24 10.75 13.30 15.60 13 9.5 10.3 6.0 9.2 12.4 4.5 6.88 9.5 13.70 4.72 11.42 Flow generator Piston Piston Turbine Turbine Dual pistons Piston Turbine Turbine Turbine Turbine FDA approval date 1977 10/20/83 5/3/96 10/30/98 8/4/00 10/18/00 7/18/01 10/31/08 3/13/09 11/23/09 FDA code CBK CBK CBK CBK CBK CBK CBK CBK CBK CBK, NOU Minimum patient weight (kg) Not specified Not specified 10 5 10 5 5 5 5 5 Modes A/C vol; A/C vol. with press. limit; SIMV vol.; SIMV vol. with press. limit; press. cycle Control vol.; A/C vol.; SIMV vol. Control (vol. or pres.); A/C (vol. or pres.); SIMV (vol. or pres.); CPAP; pressure support A/C (vol. or press.); SIMV (vol. or pres.), pressure support, CPAP A/C (vol. or press.); SIMV (vol. or press.); spontaneous A/C (vol. or pres.); SIMV (vol. or press.); spontaneous, CPAP, PS+CPAP A/C (vol. or pres.); SIMV (vol. or pres); adaptive bilevel; CPAP; pressure support CPAP; PSV, A/C (vol. or pres.); SIMV (vol. or pres.) Pres. modes: CPAP ; S ; S/T ; T ; PC ; PC-SIMV Vol. modes: A/C; SIMV + PS; CV A/C (vol. or pres.); SIMV (vol. or pres.); adaptive bilevel; CPAP; PRVC Single-limb passive No No No No No No No Yes Yes Yes Single-limb valve Yes Yes No No Yes Yes No Yes Yes Yes Dual-limb valve No No Yes Yes No No Yes Yes No Yes Tidal volume (ml) 100 2200 200 3000 50 2000 50 2000 100 2200 50 2200 50 2000 50 2000 50 2000 100 2500 Breath rate (breaths/min) 1 120 2 40 2 80 0 80 1 99 1 80 1 80 1 60 1 60 4 40 Pressure control (cm H 2 O) No No 1 100 1 99 5 60 No 5 80 0 60 4 50 4 50 Pressure support (cm H 2 O) No No 1 60 1 60 0 60 0 50 0 60 5 55 0 30 0 40 Inspiratory time 0.5 5.5 s 10 120 L/min? 0.3 9.9 s 1.1 3.0 s 02 5.0 s 0.3 3.0 s 0.3 6.0 s 0.3 5.0 s 0.3 5.0 s Trigger Pressure Pressure Flow Flow Pressure Flow Flow Pressure Flow Flow and pressure A/C, assist/control; SIMV, synchronized intermittent mandatory ventilation; CPAP, continuous positive airway pressure; PSV, pressure support ventilation; S, spontaneous; S/T, spontaneous-timed; T, timed; PC, pressure control; CV, control ventilation; PRVC, pressure-regulated volume control; VCV, volume control ventilation; PCV, pressure control ventilation.

36 CHAPTER 26 Home Respiratory Care For Patients Receiving Invasive Ventilation Spare tracheostomy tube (one size smaller) Tracheostomy ties and gauze Syringes for cuff inflation/deflation Spare heat and moisture exchangers Battery-operated suction machine and catheters Normal saline vials Nebulizer circuit adapter FIGURE 26 22 Sample report downloaded and printed from the Trilogy ventilator. Medicare to consider coverage for a secondary ventilator, there must be documentation from the physician stating that the patient cannot maintain spontaneous ventilation for 4 or more hours, that a ventilator is required on the patient s wheelchair or mobility device as part of the patient s rehabilitation plan, or that the expected response time from emergency services is greater than 2 hours. Unfortunately, lack of reimbursement often means that patients who have a clearly demonstrated clinical requirement for a second ventilator do not receive one. All home mechanically ventilated patients should have a go-bag prepared to accompany them on any trips outside the home. The detail-oriented RT should include a check of the go-bag during each visit to the patient s home. The most important item in the go-bag is a manual resuscitation bag. It must be stressed to the patient and family that the resuscitation bag always goes with the patient. Other important items for the go-bag may include the following: For Patients Receiving Invasive or Noninvasive Ventilation Copy of prescription Copy of important phone numbers, including referring physician Second power supply for ventilator (external battery or DC power cord) Hand wash gel Flashlight Ventilator circuit (including metered dose inhaler and/or nebulizer port) Extra patient interface and headgear (if noninvasive) Cylinder wrench (if on O 2 ) O 2 tubing (if on O 2 ) Battery-operated nebulizer and medications Inhaler(s) Setting Ventilator Alarms Unfortunately, patients sometimes die at home from accidental ventilator disconnections, even patients who have been home for a long period of time and presumedly have experienced caregivers. 40 Continuous visual monitoring of the home mechanically ventilated patient is best, but there are times when the family caregiver must rely on the audible alarms. One of the most important and problematic tasks faced by the RT is determining appropriate alarm settings. Some RTs may simply duplicate the alarm settings that were in use at the hospital prior to the patient s discharge. However, this method of alarm setting may not be adequate at home. While in the hospital, the patient s SpO 2, respiratory rate, and heart rate were undoubtedly monitored via a central monitoring system that added another layer of protection above and beyond the ventilator alarms. Many payers do not cover a home continuoususe pulse oximeter, however. RTs may think that because the doctor signed off on the ventilator settings, the therapist is not responsible for the alarm settings. Realistically, the physician cannot be expected RESPIRATORY RECAP Setting Ventilator Alarms» A balance between safety and nuisance should be maintained.» The RT should test ventilator alarms, with special caution for pediatric pressure ventilation. to know the intricacies of every home ventilator. Clearly the RT is the expert on the ventilator and must make appropriate recommendations to the physician if the proper orders are not received. Particularly for pediatric patients, there has been a move toward the use of pressure control ventilation. While in the hospital, if the patient partially decannulates, the low SpO 2 alarm and the high respiratory rate alarm will alert the staff, even if the ventilator did not sound a low-pressure alarm. Many of the second- and third-generation home ventilators have superior flow capabilities and are able to reach the pressure control setting even in the face of significant leaks. At home, a patient who decannulates in pressure ventilation, particularly if the diameter of the tracheostomy tube is small, may not trigger a low-pressure ventilator alarm because the ventilator will most likely be able to achieve the prescribed pressure control setting. In this situation, a properly set low exhaled volume alarm, low exhaled

Home Mechanical Ventilation 37 minute volume alarm, high inspired volume alarm, or high inspired minute volume alarm would most likely sound. Another problematic situation can occur for patients who are prone to mucous plugging and who are on pressure control ventilation at home. If the patient develops a mucous plug that occludes a significant portion of the lung, or even a plug that completely blocks the tracheostomy tube, a high-pressure alarm will not sound. The same situation can develop if the heat and moisture exchanger becomes occluded, or if the patient rolls over on the ventilator circuit. 41 In these situations, a properly set low exhaled volume alarm, low exhaled minute volume alarm, low inspired volume alarm, or low inspired minute volume alarm would most likely sound. The RT should test the ventilator alarms per the manufacturer s instructions during every home visit, but some additional tests beyond the manufacturer s recommendations may be prudent. Many pediatric patients use uncuffed tracheostomy tubes with varying leaks, which complicates the use of exhaled volume alarms. Especially for pediatric patients on pressure control ventilation, the vigilant RT can simulate an accidental decannulation using a tracheostomy tube one size smaller than the patient s usual tube to ensure that an alarm will sound if the tube accidentally comes out and remains attached to the Y piece of the circuit. If indicated for the patient s clinical condition, the RT may simulate a mucous plug by occluding the Y-piece and observing whether an alarm sounds. If an alarm does not sound, it is crucial that the RT obtain the proper order to take one or more of the following actions, as appropriate: adjust the alarm settings, change the ventilator settings, change the ventilator to one that has the necessary alarm, or provide a pulse oximeter with audible alarms. When there is no insurance coverage for a pulse oximeter, the RT must become a vigorous advocate for the patient s safety. Often a letter to the insurance company describing the potential safety issues, signed by the physician and the respiratory therapist, may help the family obtain the needed device. Safety Tips It is important that the RT make frequent and regular visits to the ventilator patient s home to check the ventilator and related equipment. These visits are especially important for pediatric patients because they provide an opportunity to observe the patient s growth and development and how that may affect the respiratory care plan. For example, most ventilator-dependent infants are placed in a crib while sleeping for the first several months of life. Typically, a heated humidifier rests on a table near the crib. One possible safety hazard can occur when parents allow the infant to play and crawl while on the floor. The vigilant therapist needs to make sure the parents understand that the baby should never be placed below the heated humidifier. Similarly, as the infant becomes stronger, care must be taken to prevent the infant from pulling the ventilator down off a table or bureau, perhaps sustaining an injury in the process or damaging the ventilator. Toddlers are often fascinated by the lighted O 2 concentrator flow meter, as well as the lights and buttons on the front of the ventilator, and inadvertent setting changes can be the result. Another safety hazard for the pediatric patient is accidental decannulation as the toddler tries to walk beyond the length of the ventilator circuit. Note that some ventilator manufacturers offer longer circuits to allow increased physical activity for the patient. Also, most parents know they have to secure the pediatric patient in a car seat while in a vehicle, but parents also need to be taught that they must secure the ventilator as well. There are some safety considerations for school-aged children as well. A resuscitation bag should always travel with the patient, including on the school bus. Some schools may allow the patient to keep an extra power cord and/or battery and charger at the school, rather than carry them back and forth each day. It may be helpful for the therapist to offer to visit the child s classroom to give a simple talk on what the ventilator is and how it helps the patient. The school nurse may appreciate a brief overview of the ventilator as well. Older children who hang their ventilator on the back of their wheelchair must be cautioned not to hang a heavy backpack over their ventilator and not to allow the backpack to block the ventilator s air intake. Older children may also appreciate a longer circuit, which allows them to shower while keeping the ventilator a safe distance away. Note that special ventilator covers can be purchased to protect the ventilator from moisture (Freedom Vent Systems, West End, N.C.). Care must be taken to prevent water from entering into or around the tracheostomy tube. A tracheostomy mask or sheet of plastic wrap placed over the area may be helpful. Active children may have trouble with their ventilator circuit disconnects from the tracheostomy tube. A number of commercial products are available to secure the circuit. Figure 26 23 shows one patient s ingenuity. Each day she chooses a grosgrain ribbon, color-coordinated with her outfit, to secure her circuit. Caregiver Burden There is a high incidence of depression among family caregivers. 42 The home care RT should be mindful that the family caregiver may be at risk for depression and may consider discussing with the physician the use of a depression screening tool for caregivers, such as the Center for Epidemiological Studies Depression Screening Index (CES-D). When appropriate, the RT may consider querying the caregiver about his or her quality and amount of sleep to determine whether nuisance ventilator alarms are interrupting sleep. The RT should also be knowledgeable about local respite programs, daycare facilities that accept ventilator patients, camps

38 CHAPTER 26 Home Respiratory Care FIGURE 26 24 This young adult uses mouthpiece ventilation all day, and mask ventilation at night. He works part time and enjoys raising puppies. FIGURE 26 23 Example of patient and caregiver ingenuity: MJ uses a color-coordinated ribbon to secure her trach tube. for ventilator-dependent children, or other agencies that may provide some respite for the family caregiver. Ventilator User s Quality of Life Many healthcare workers underestimate the ventilator user s quality of life. 36 In a report of 621 ventilator users with neuromuscular conditions, it was found that about one-third of patients were employed; a few others reported they were active on a daily basis as volunteers or students. Healthcare professionals underestimated the satisfaction of severely disabled, ventilator-assisted people. The RT who has internalized that ventilatordependent patients can have meaningful, productive lives can have a significant positive impact on the patient and family s quality of life (Figure 26 24). KEY POINTS Depending on the equipment ordered, durable medical equipment (DME) companies can provide service by a technician, respiratory therapist, or qualified nurse. The goals of home respiratory care are to achieve the optimum level of patient function through goal setting, educate patients and their caregivers, administer diagnostic and therapeutic modalities and services, conduct disease management, and promote health. Unfortunately, respiratory therapists are not included in the Medicare home health services benefit. A DME or home medical equipment (HME) company may be required to have a retail license, HME license, a bedding supplier license, an O 2 manufacturer/distributor license, and/or possibly other licenses/permits as required by the state. There are generally two types of accreditation for a DME or HME: Equipment Management Services and Clinical Respiratory Services. The respiratory therapist is the most competent healthcare professional to provide home respiratory care. The home environment must be evaluated specific to the type of home medical equipment. Bag technique means that the respiratory therapist s bag and its contents must be kept as clean as possible. Patients who receive O 2 at home are exposed to the risk of improper storage and handling of O 2 cylinders, unsafe usage of O 2, improper transfer of O 2, inadequate ventilation, and smoking or other unsafe flames. The environmental evaluation should verify the adequacy of the home electrical system for patients with a home ventilator. An important aspect of the home environmental assessment is to ensure that alarms can be heard by the caregiver in all areas of the home. It is a good idea for some home care patients, particularly O 2 and ventilator patients, to meet with their local EMS personnel and/or firefighters before there is any type of emergency. For patients with COPD, long-term O 2 therapy prolongs life and decreases overall cost of care. The goal for efficient O 2 delivery is proper arterial O 2 saturation at all activity levels.

References 39 Methods of O 2 delivery in the home include continuous-flow oxygen and intermittent-flow oxygen. Home O 2 delivery devices include oxygen concentrators, compressed gas systems, liquid O 2 systems, concentrators that fill compressed gas systems, and portable O 2 concentrators. Oxygen-conserving devices include reservoir cannulas, intermittent-flow devices, pulse-flow devices, demand delivery devices, and transtracheal O 2. Medicare categorizes devices with exhalation valves, adjustable breath rates, and alarms as mechanical ventilators. The indication for invasive ventilation (rather than noninvasive ventilation) for individuals requiring more than 20 hours per day of support is not a hard and fast rule. A comprehensive team approach to discharge planning is required. The first generation of positive pressure home care ventilators were piston driven and offered only volume-controlled breaths. 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