BY FRANCIS CALIFANO
It’s a warm summer afternoon. A string of strong thunderstorms has just run through town. Trees and power lines are down across a large area. Several localized power outages are being reported. The alarm sounds. Your station is being special called to assist a homebound patient who has an emergency. A power loss at the patient’s home caused the ventilator to stop. As you respond, you and your crew run though a plan of action. What are you going to need: O2 bag, bag valve mask (BVM), and patient assessment equipment?
With the everrising cost of health care, the option of home care for what would have been a hospitalized or nursing home ventilatordependent patient is growing. As medical technology has advanced, home mechanical ventilation has become an option for an increasing number of patients. A study done in Minnesota identified a 110percent increase in the number of ventilatorassisted individuals outside hospital settings over a sixyear period, with the largest increase being in patients <10 years of age.1 Ventilatordependent patients being cared for at home by family members or public health nursing services have become commonplace. Patients can range from infants to pediatrics to adults. Some patients may be ambulatory; some may be confined to a bed or a wheelchair. Even with the introduction of compact and highly reliable portable ventilators, it is quite possible that you will have to deal with a ventilatordependent patient. Emergencies involving ventilators can be a result of a lack of oxygen (gas), vent failure or loss of power, as well as a change in the patient’s condition. The key is to treat the patient, not the ventilator.
When confronted with an emergency situation involving a home ventilator patient, the following basic equipment should be part of your response plan: basic life support (BLS) jump kit, supplemental oxygen, suction equipment including portable suction with suction catheters (various sizes), sterile saline for suctioning, BVM, capnography2 or endtidal CO23 device, and pulse oximeter.
AT THE PATIENT’S HOME
On arrival at the patient’s home, first make contact with the patient to determine if there is a true medical emergency. If so, treat the patient accordingly. It should be noted that most homevented patients are capable of breathing on their own. The ventilator is often used to compensate for inadequate respiratory efforts, especially when the patient is sleeping. Second, determine the status of the ventilator. Most likely, if the ventilator is not functioning properly, a caregiver has initiated ventilatory support for the patient. Your team should be ready to take over that task with a BVM. Assess the patient’s respiratory efforts. As with any patient, conduct a quick ABC assessment. Is the patient’s airway intact? For the vented patient, this often will require examination of the tracheostomy tube (trach tube) placement (photo 1). Ensure that that trach tube is clear and secure. If not, you may have to use the portable suction and a soft, flexible suction catheter to suction it. These supplies may be available on site, but it is always a good idea to have them as part of your response kit.
|(1) Typical tracheostomy tubes. (Photos by author.)|
If the vent emergency is the result of a power failure, adequate lighting may be at a minimum, and finding the patient’s supplies may be difficult. Ventilated patients may develop a partial occlusion of their tracheostomy during vent failure. Secretions may build up in their trach tube. You should know how to properly suction the trach tube. Trach tube suctioning does not differ significantly from endotracheal tube suctioning, except that trach tube suctioning is performed as a clean procedure, whereas endotracheal suctioning is a sterile procedure.
The following is an outline of the procedure for tracheostomy suctioning:
- (a) Explain the procedure to the patient. Put on gloves and a fluid shield mask for standard precautions. Turn on the suction apparatus and test to make sure that the vacuum pressure is <150 mmHg (for an adult and 80 to 100 mmHg for pediatric patients).
- (b) Open/expose only the vacuumcontrol segment of the suction catheter, and attach to the suction tubing.
- (c) Put on gloves and remove the suction catheter from the protective sleeve or package.
- (d) Maintaining clean technique, insert the suction catheter with NO suction applied until resistance is met, then pull back about 12 centimeters before applying continuous suction as the catheter is smoothly withdrawn from the airway.
Note: Recommended suction time (i.e., from insertion to removal of suction catheter) is less than 15 seconds.
Use sterile saline to clear the catheter between passes. No more than three passes are recommended per catheter.
- (e) On completing the procedure, ensure patient comfort, discard equipment as per department policy, wash your hands, and document the procedure on your Patient Care Report.
Once a patent airway is verified, assess the patient’s ventilation (breathing). Check for bilateral and equal breath sounds, symmetrical chest rise, and adequate inhalation and exhalation while being assisted with a BVM. As defined by the American Heart Association: “When rescue breaths are provided without chest compressions to the victim with a pulse, the healthcare provider should deliver 12 to 20 breaths per minute for an infant or child and 10 to 12 breaths per minute BPM for an adult.”5
Manual ventilation with the use of a BVM requires some skill. With an unconscious, apneic patient, rescue breathing is done at a rate of 1012 BPM. With a vented patient who may be capable of breathing on his own, you have to “track” the breathing and assist the effort during inspiration with the BVM and relax your effort to allow for passive exhalation. If any abnormalities are discovered while assisting respirations, they should be corrected. The use of capnography or an end tidal CO2 device (photo 2) will aid in determining if the patient’s own respiratory efforts and/or your assisted ventilations are adequate.
|(2) Disposable end tidal CO2 detector.|
There are several key elements for proper patient perfusion. The first two basic elements are tidal volume (VT) and BPM. Tidal volume is the lung volume representing the volume of air displaced between normal inspiration and expiration when extra effort is not applied. Typical values hover around 600 milliliters (ml), or 6 to 7 ml per kilogram of bodyweight. Most caregivers are familiar with these terms, know what they should be for the patient, and are aware of these values for proper ventilator settings.
Two other elements that may be of value to understand are positive endexpiratory pressure (PEEP) and peak inspiratory pressure (PIP). PEEP maintains airway pressure above atmospheric pressure at the end of exhalation by means of mechanical impedance, usually a valve within the vent circuit. The purpose of PEEP is to prevent atelectasis (collapse of alveoli). PEEP increases the volume of gas remaining in the lungs at the end of expiration to decrease shunting of blood through the lungs, thereby improving gas exchange. Increased levels of PEEP are often required for patients with acute respiratory distress syndrome (ARDS) to allow reduction in the levels of oxygen being administered.6
PIP may be the means in which the patient is being vented (i.e., pressurecontrolled ventilation), whereas volumecontrolled ventilation delivers a given volume of air to the patient. Pressurecontrolled ventilation delivers air until a peak pressure in the airway is achieved. The following are two common mechanical ventilator modes:
- Volume ventilation. A predetermined tidal volume (VT) is set for the patient. The set volume is delivered with each inspiration. The amount of pressure (PIP) necessary to deliver this volume fluctuates from breath to breath, based on the resistance and compliance of the patient and ventilator circuit. If the tidal volume is set at 500 ml, the ventilator will deliver gas until it reaches its goal (500 ml). On completion of the inspired volume, the ventilator will open a valve, allowing the patient to passively exhale.
- Pressure ventilation. A predetermined PIP is set, determined by the patient’s condition and pathophysiology. The ventilator flows gas into the patient until this set pressure is reached. On reaching the preset PIP, the ventilator cycles off to allow for passive exhalation. Caution and close observation are needed when using this mode because of the potential for hypoventilation or hyperventilation because of the variable tidal volume.
Once the patient’s condition is determined to be stable, attention can be turned toward the vent. As previously mentioned, today’s ventilators are small compact machines, unlike the large cumbersome units of the past (photos 3, 4). Typically, home caregivers are very familiar with operating and troubleshooting these units. Battery backuppower supplies are usually standard equipment with these vents. They are often used during transport of patients to and from doctors and hospital visits and, therefore, can run without direct power.
|(3) A large, vintage ventilator.|
|(4) A contemporary home care ventilator, which is also used in transport.|
Power loss is one common cause for vent emergencies. What makes power outages emergent is not knowing when power will be restored. Home ventilators rely on one of three power sources: electric AC power (household current), internal or external DC power (batteries), or a combination of both. Battery life depends on the type of ventilator used—some last for 35 minutes, others for four hours. External batteries, which are attached to the ventilator by cable, vary greatly in size, weight, and charge capacity (ranging from four to 20 hours). During power outages, the switch from electric power to external or internal battery power is seamless and usually requires no intervention. The ventilator alarm sounds with each switchover and again if there is a low battery charge.7 Some batteries are an integral part of the ventilator. An integral battery setup is most common in portable ventilators.
In case of complete failure of the vent, there are some alternative means of patient ventilation besides a BVM. Several compact emergency transport ventilators are available on the market. The simplest type delivers a given number of BPM at a given tidal volume (photo 5). Most often, these units are oxygen powered and deliver 100 percent O2. This is something to consider if the patient will have to be on this type of vent for an extended time. Additional O2 cylinders may be required. Another type of compact ventilator that has recently come into use is what is commonly called a “surge or masscasualty” ventilator device (photo 6). These devices are also oxygen powered but have the capability of setting PIP. These vents are well suited for an emergency where it is anticipated that the patient would be on the device for an extended time.
|(5) A simple prehospital vent.|
|(6) A compact “mass-casualty/surge” ventilator.|
Consider transporting the patient with the ventilator. Several scenarios may lead to the patient’s having to be transferred to a hospital or an alternative care site. They may include the the inability to restore power to the residence or the lack of an adequate gas supply. As mentioned earlier, many ventilators are designed for transport. Several considerations are necessary when deciding whether to transport a patient and ventilator. If the patient’s vent is going to accompany the patient during transport, can your ambulance supply 110 volts AC power? In addition, does your ambulance have the necessary adapters to provide the vent with gas (oxygen) if needed? Consider how to secure the ventilator. If it is not possible to transport the patient’s vent, manual ventilation by BVM would be required during transport. You may also use an emergency or transport vent device, as mentioned previously.
Having a basic understanding of what to expect when dealing with a ventilatordependent patient will reduce anxiety for the patient and your crew. Most often these emergencies are perceived to be worse than they are. The simplest solution may be to get the patient’s ventilator onto generator power. This may be a shortterm solution, but it will buy you time to formulate a longterm plan. Hospital Respiratory Care departments may be a good resource for information on the ventilators used in your area as well as a source for training in your department.
1. Saumini Srinivasan, Sharon M. Doty, Tanya R. White, Victor H. Segura, Mary T. Jansen, Sally L. Davidson Ward, and Thomas G. Keens. Frequency, Causes, and Outcome Home Ventilator Failure: Chest 1998; 114; 1363136.
4. Airway Care: Tracheostomy Care, Tube Change, and Artificial Airway Cuff Management; http://www.youtube.com/watch?v=u6vb7P23Vk.
7. Sandra L. Stuban. Home Mechanical Ventilation: American Journal of Nursing, May 2010, Vol 110:No. 5, 6367.
● FRANCIS CALIFANO, BS, EMTP, CHSP, is an emergency management coordinator for North Shore LIJ Health System, Protective Services in Syosset, New York. He is assigned to the Emergency Management Division. He is a 30year member of Rescue Hook & Ladder Co. #1 of Roslyn, New York. He is a company safety officer and has served as captain of EMS. He has a bachelor of science degree in community services/emergency management from State University of New York, Empire State College. Califano has been a speaker at the Fire Department Instructors Conference as well as other national conferences. He is a certified hazardous materials specialist and a certified Healthcare Safety Professional.