Monitoring on LTVMartin SamuelsBristol Course on Long Term Ventilation in Children

Objectivesunderstand monitoring of the child on LTVknow the methods available and when to apply themdevelop a framework for assessment & monitoring of children and young people on established LTV

Workshop Content devise a proforma for assessing the child on LTVdiscuss components of assessment, including physiological monitoringdiscuss follow-updiscuss home monitoring

Devise a Proforma for AssessmentYoure away when the following child attends your unit. A junior member of your team needs help on what needs review...3 year oldRTCtrach ventilated9 year old SMA pillows15 year oldDMDmask ventilated10 year old SLD & SDBmaskNow decide on follow-up arrangements ...

AssessmentClinical progressEquipmentCare packageExaminationInvestigationsCommunications & follow-up

1. Clinical ProgressAppetite & nutritionFeeding & swallowingMobilitySleepRTIsUse of antibioticsHospital admissionsSchool attendance / progressVentilator useDisturbances:alarmsleaksdisconnectionsSecretions / suctionParental copingCarers charts

2. EquipmentVentilator:SettingsServicingHour meterDowloadTidal volumeMinute ventilationLeaks Usage InterfacesCheck fitCleanlinessComplicationsMonitorsSuctionTubingHumidity Oxygen

3. Care PackageCarersNocturnal disturbancesSuppliesRespiteCommunity teamSocial care & supportFinance

4. ExaminationGrowthNutritionSkin / stoma careNoseChest Cardiac, incl PHTSpine Posture

5. Investigations SaO2Spirometry:FVC / VCFEV1 / MEFSleep study:SaO2tcPCO2 / ET-CO2Pmasksynchrony

5. Investigations SaO2Spirometry:FVC / VCFEV1 / MEFSleep study:SaO2tcPCO2 / ET-CO2Pmasksynchrony+ consider:sputum MC&SCXRECGpeak cough flownasal sniff pressuremax Pi & Pemouth occlusion PP0.1 / Pi-max

6. CommunicationsCheck reviews:PhysiotherapySALTDieticianOTPsychologyNeuromuscularCardiologySpinal Community paedImmunisationFluPneumovaxEmergency care planPrescription checkVentilatorMedicines Follow-upTransition

Adequacy of Gas Exchange

O/P v I/Phomeinvasive v non-invasivedurationMeasureSaO2tcPCO2end-tidal CO2? bicarbonate

Normal Short period of low baselineWhole night low baseline SaO2 Frequency Curves

10 minute pagemask pressure at patient

30 second pagemask pressure synchrony

mask pressure asynchrony

whole night trendSaO2tcPCO2heart rate

ATS Guidelines for DMDvisit 4-6 years old & before loss of ambulation6 monthly resp OP:non-ambulantFVC 11y old3 monthly resp OP:NIVCough AssistReview before surgery

ATS Guidelines for DMDAt each visit:SaO2awake CO2FVC, FEV1, MEFMax Pi & Pe

Peak cough flowFBCBicarbonateCXR

Follow-up: Personal Practicereferrals to respiratory OPAnnual sleep study (DMD 12y)6 monthly SS if SDB presentInitiate LTV when symptomaticSS 3-6 months laterAnnual review

Reasons for Home MonitoringRecognition of:airway obstructionfailure of respiratory supportinterruption of O2prevention of sudden deathcyanotic-apnoeic episodesworsening respiratory failure

Tracheostomy Related DeathAuthorYearnSUDs%Wetmore8242082Gerson8212310.8MacRae849322Freezer9014221.4Puhakka923313Simma9410800Donnelly962900Shinkwin965611.8Dubey994012.5Midwinter0214342.8Total118720 (1 in 60) 1.7

Reasons for Home MonitoringRecognition of:airway obstructionfailure of respiratory supportinterruption of O2prevention of sudden deathcyanotic-apnoeic episodesworsening respiratory failure

Oximetry Motion ArtefactPulsatile component is 1 5% of absorbancesMovement seriously affects measurementResults in frequent false alarms

Motion Resistant SaO2 Masimo SET small, portablebattery operablefew false alarmsRadical Pulse Oximeter

Suggested Home MonitoringRespiratory support:noneLife support:SaO2CCHS:SaO2 & CO2SenTec SaO2 & tcPCO2Capnocheck SaO2 & ET-CO2

Investigations & MonitoringVaries betweenindividual conditionIndividualscentresLimit in palliative care tosymptom relief

Summary understand monitoring of child on LTVknow the monitoring methods available and when to apply themdevelop a framework for assessment of children and young people on established LTV

***************Use of multi-channel studies to assess effectiveness of ventilation.Include mask pressures for synchrony, adequacy of ventilator response to variable leaks, etcCould use single device at home for SaO2 & CO2.Not always needed, eg severe disability / palliation avoid monitoring.*17y old with DMD and poor synchrony with ventilator (rate 15/min, resp rate 43/min)************