Monitoring on LTV

Martin Samuels

Bristol Course on Long Term Ventilation in Children

Objectives

• understand monitoring of the child on LTV

• know the methods available and when to

apply them

• develop a framework for assessment &

monitoring of children and young people

on established LTV

Workshop Content

• devise a proforma for assessing the

child on LTV

• discuss components of assessment,

including physiological monitoring

• discuss follow-up

• discuss home monitoring

Devise a Proforma for Assessment

You’re away when the following child attends your unit. A junior member of your team needs help on what needs review...

• 3 year old RTC trach ventilated

• 9 year old SMA pillows

• 15 year old DMD mask ventilated

• 10 year old SLD & SDB mask

Now decide on follow-up arrangements ...

Assessment

1. Clinical progress

2. Equipment

3. Care package

4. Examination

5. Investigations

6. Communications & follow-up

1. Clinical Progress

• Appetite & nutrition• Feeding & swallowing• Mobility• Sleep• RTI’s• Use of antibiotics• Hospital admissions• School attendance /

progress

• Ventilator use• Disturbances:

– alarms– leaks– disconnections

• Secretions / suction• Parental coping• Carers’ charts

2. Equipment

Ventilator:• Settings• Servicing• Hour meter• Dowload

– Tidal volume– Minute ventilation– Leaks – Usage

• Interfaces– Check fit– Cleanliness– Complications

• Monitors• Suction• Tubing• Humidity • Oxygen

3. Care Package

• Carers• Nocturnal disturbances• Supplies• Respite• Community team• Social care & support• Finance

4. Examination

• Growth• Nutrition• Skin / stoma care• Nose• Chest • Cardiac, incl PHT• Spine • Posture

5. Investigations

• SaO2• Spirometry:

– FVC / VC– FEV1 / MEF

• Sleep study:– SaO2– tcPCO2 / ET-CO2– Pmask

– synchrony

5. Investigations

• SaO2• Spirometry:

– FVC / VC– FEV1 / MEF

• Sleep study:– SaO2– tcPCO2 / ET-CO2– Pmask

– synchrony

+ consider:• sputum MC&S• CXR• ECG• peak cough flow• nasal sniff pressure• max Pi & Pe• mouth occlusion P• P0.1 / Pi-max

6. Communications

Check reviews:• Physiotherapy• SALT• Dietician• OT• Psychology• Neuromuscular• Cardiology• Spinal • Community paed

• Immunisation– Flu– Pneumovax

• Emergency care plan• Prescription check

– Ventilator– Medicines

• Follow-up• Transition

Adequacy of Gas Exchange

• O/P v I/P• home• invasive v non-

invasive• duration

Measure• SaO2• tcPCO2• end-tidal CO2• ? bicarbonate

Normal Short period of low baseline

Whole night low baseline

SaO2 Frequency Curves

10 minute page

mask pressure at patient

30 second page

mask pressure synchrony

mask pressure asynchrony

whole night trend

SaO2

tcPCO2

heart rate

ATS Guidelines for DMD

• visit 4-6 years old & before loss of ambulation

• 6 monthly resp OP:– non-ambulant– FVC <80%– >11y old

• 3 monthly resp OP:– NIV– Cough Assist

• Review before surgery

ATS Guidelines for DMD

At each visit:

• SaO2

• awake CO2

• FVC, FEV1, MEF

• Max Pi & Pe

• Peak cough flow

• FBC

• Bicarbonate

• CXR

Follow-up: Personal Practice

• referrals to respiratory OP

• Annual sleep study (DMD 12y)

• 6 monthly SS if SDB present

• Initiate LTV when symptomatic

• SS 3-6 months later

• Annual review

Reasons for Home Monitoring

Recognition of:

• airway obstruction

• failure of respiratory support

• interruption of O2

• prevention of sudden death

• cyanotic-apnoeic episodes

• worsening respiratory failure

Tracheostomy Related DeathAuthor Year n SUDs %

Wetmore 82 420 8 2

Gerson 82 123 1 0.8

MacRae 84 93 2 2

Freezer 90 142 2 1.4

Puhakka 92 33 1 3

Simma 94 108 0 0

Donnelly 96 29 0 0

Shinkwin 96 56 1 1.8

Dubey 99 40 1 2.5

Midwinter 02 143 4 2.8

Total 1187 20 (1 in 60) 1.7

Reasons for Home Monitoring

Recognition of:

• airway obstruction

• failure of respiratory support

• interruption of O2

• prevention of sudden death

• cyanotic-apnoeic episodes

• worsening respiratory failure

Oximetry – Motion Artefact

• Pulsatile component is

1 – 5% of absorbances

• Movement seriously

affects measurement

• Results in frequent

false alarms

Motion Resistant SaO2 – Masimo SET

• small, portable

• battery operable

• few false alarms

Rad5 OximeterRadical Pulse Oximeter

Suggested Home Monitoring

• Respiratory support:

– none

• Life support:

– SaO2

• CCHS:

– SaO2 & CO2

SenTec SaO2 & tcPCO2

Capnocheck SaO2 & ET-CO2

Investigations & Monitoring

Varies between

• individual condition

• Individuals

• centres

Limit in palliative care to

• symptom relief

Summary

• understand monitoring of child on LTV

• know the monitoring methods available

and when to apply them

• develop a framework for assessment of

children and young people on

established LTV