Quality control of mechanical ventilation at the patient's home

Technology for noninvasive mechanical ventilation: looking into the black box

Current devices for providing noninvasive respiratory support contain sensors and built-in intelligence for automatically modifying ventilation according to the patient's needs. These devices, including automatic continuous positive airway pressure devices and noninvasive ventilators, are technologically complex and offer a considerable number of different modes of ventilation and setting options, the details of which are sometimes difficult to capture by the user. Therefore, better predicting and interpreting the actual performance of these ventilation devices in clinical application requires understanding their functioning principles and assessing their performance under well controlled bench test conditions with simulated patients. This concise review presents an updated perspective of the theoretical basis of intelligent continuous positive airway pressure and noninvasive ventilation devices, and of the tools available for assessing how these devices respond under specific ventilation phenotypes in patients requiring breathing support.

Current devices for intelligent noninvasive ventilation should be tested to better understand clinical performance http://ow.ly/XAS6Z

Clients' experiences of living at home with a mechanical ventilator

AIM

This paper reports on a study of how clients experience living with home mechanical ventilation and how they experience care and supervision of healthcare personnel.

BACKGROUND

The number of people living at home with mechanical ventilators is increasing, and this is considered a successful approach to reducing incapacity and mortality.

METHOD

Qualitative interviews were conducted with 10 service users in 2006. The informants were 18-75 years old and had varying diagnoses and levels of functioning. The interviews were tape recorded, transcribed and analysed by qualitative content analysis.

FINDINGS

Two main themes emerged: Theme 1. Having a home ventilator enhances quality of life--a life worth living. The ventilator treatment builds up strength and improves well-being. Participants emphasized that it was important to feel in control of their own situation and had an overriding wish to live a normal and active life; Theme 2. Competence and continuity of healthcare personnel are factors for success. The experience was that competence and follow-up by healthcare personnel varied, and that good quality teaching and information were important.

CONCLUSION

Users of home mechanical ventilators should be active partners in their own care so that their experience is taken into account. It is important for clients having home mechanical ventilation to be empowered and have control in their daily lives, as well as having competent caregivers and continuity of care.

On being dependent on home mechanical ventilation: depictions of patients' experiences over time

In this study, the authors describe the meanings of experiences of being dependent on a ventilator (HMV) and living at home as narrated by 13 people who had been using a ventilator via a mask or tracheostomy for half a year. The analyses revealed various movements across time toward the goal of using the ventilator successfully, and some narratives depicted suffering caused by care. The analyses also yielded different representations of embodiment. These findings were abstracted into two contrasting meanings of the experience of using HMV over time: a closing in or an opening up of the lived body, oneself, to other people and to the world. The authors illustrate this interpretation with two images. Ignorance and negative attitudes on the part of professionals working and/or managing care in the patients' homes are interpreted as causing suffering and intensifying a closed-in mode of being.

A retrospective survey of outpatients with long-term tracheostomy

BACKGROUND

The Respiratory Unit (RU) at Danderyd University Hospital opened in 1982, with the expressed goal of supporting outpatients with long-term tracheostomy. The primary aim of this retrospective study in tracheostomized patients was to compare the need for hospital care in the 2-year period before and after the tracheostomy.

METHODS

Data were collected from patient medical records at the RU, from the National Board of Health and Welfare, Sweden and from the Official Statistics of Sweden. The subjects were RU patients in 1982 (Group 1, n = 27) and in 1997 (Group 2, n = 106) with long-term tracheostomy surviving at least 4 years after the tracheostomy.

RESULTS

Both groups had few and unchanged needs for hospital care after tracheostomy. They spent > or = 96% of their time out of hospital. In 1997, (group 2) the number of patients, diagnoses and need for home mechanical ventilation had increased. Life expectancy was assessed for patients in Group 1. Data showed that they lived as long as an age-matched and gender-adjusted control cohort.

CONCLUSIONS

Long-term tracheostomy may not increase the need for hospital care and does not reduce life expectancy. These clinical observations were made in a setting where patients had regular access to a dedicated outpatient unit.

Performance of mechanical ventilators at the patient's home: a multicentre quality control study

BACKGROUND

Quality control procedures vary considerably among the providers of equipment for home mechanical ventilation (HMV).

METHODS

A multicentre quality control survey of HMV was performed at the home of 300 patients included in the HMV programmes of four hospitals in Barcelona. It consisted of three steps: (1) the prescribed ventilation settings, the actual settings in the ventilator control panel, and the actual performance of the ventilator measured at home were compared; (2) the different ventilator alarms were tested; and (3) the effect of differences between the prescribed settings and the actual performance of the ventilator on non-programmed readmissions of the patient was determined.

RESULTS

Considerable differences were found between actual, set, and prescribed values of ventilator variables; these differences were similar in volume and pressure preset ventilators. The percentage of patients with a discrepancy between the prescribed and actual measured main ventilator variable (minute ventilation or inspiratory pressure) of more than 20% and 30% was 13% and 4%, respectively. The number of ventilators with built in alarms for power off, disconnection, or obstruction was 225, 280 and 157, respectively. These alarms did not work in two (0.9%), 52 (18.6%) and eight (5.1%) ventilators, respectively. The number of non-programmed hospital readmissions in the year before the study did not correlate with the index of ventilator error.

CONCLUSIONS

This study illustrates the current limitations of the quality control of HMV and suggests that improvements should be made to ensure adequate ventilator settings and correct ventilator performance and ventilator alarm operation.