initiating long term ventilation
Post on 14-Jan-2016
44 Views
Preview:
DESCRIPTION
TRANSCRIPT
Martin Samuels
University Hospital of
North Staffordshire
why?
when ?
how ?
where?
what with?
Failure of
resp pacemaker
nerve conduction
muscle contraction
airway patency
gas exchange
combination
CCHS
infection, trauma
DMD, SMA
severe TBM
CLD of prem, CF
neurodisability,
obesity
at presentation:
birth
after trauma
after infection
with acute
respiratory illness
eg
CCHS, CLD
operative, RTC
myelitis
myopathy, CF
Conditions Presenting with
Progressive Respiratory
Failure
myopathy
neurodisability
obesity
Hereditarymuscular dystrophiesmyopathiesspinal muscular atrophyhereditary sensory nmyotonic dystrophy
Work with colleagues in muscle disorders
AcquiredpolioGuillain-Barrepolymyositismyasthenia gravis
Dubowitz et al (from JTSMA)
myotonic dystrophy
spinal muscular atrophy
II
neuropathy
nemaline rod myopathy
Duchene MD
- median fall FVC 0.18L/y
- median survival 3.1y
- 5y survival 8%
Phillips et al, 2001
early recognition
symptoms
LFT’s
SaO2 & CO2 monitoring
awareness of treatment options
SenTecSaO2 & tcPCO2
Capnocheck SaO2 & ET-CO2
Apr 2002 - 14y - DMD care plan for terminal care: no CPR,
intubation or ‘active’ intervention referral for respiratory assessment
May 2002 Found unresponsive at home… A&E CO2 found to be 11.6 kPa
May 2002
admitted for sleep study
would not wake: pCO2 27 pH 7.0
bagged: pCO2 19
nPPV no better – agreed not for ETT
family counselled
Intubated for 3/7
Prednisolone
Extubated
Discharged nPPV
Cough Assist
Insidious onsetpatients appear normal when awake
REMsleep
all sleep awake
• Nocturnal arousals
• Behavioural and cognitive problems
• Daytime drowsiness / poor concentration
• Failure to thrive
• Morning headaches
• Recurrent / severe LRTI’s
• Cor pulmonale (late)
Fall in VC hypoxaemic-apnoeic episodes rise in CO2 & fall in SpO2 in REM sleep first lastly, during day
Overnight record of SaO2 & CO2 ? age 10 – 12y ? VC <30%, 50%, 60% …
SaO2
Whole night: 8h
Heart rate
Transcutaneous pCO2
Mail questionnaire: Canadian physicians
Response rate 45/60
25% do not discuss mech vent with all
patients & families
Most frequently cited reason for advising
against / withholding ventilation was
poor quality of life (52.6%)
progressive respiratory failure quality of life reduced:
symptoms repeat / severe LRTI hospitalisation
compliance likely
improves symptoms
keep out of hospital
ease care by parents
reduce complications
use in overall care
plan
“No purpose” situation: degree of physical or mental impairment will be so great that it is unreasonable to expect them to bear it
“Unbearable” situation: child and/or family feel that in the face of progressive and irreversible illness further treatment is more than can be borne
Assessment Consult Discuss with family “Decisions must
never be rushed and must always be made by the team with all evidence available.”
Hospital v Home
training
troubleshooting
adjustments
PICU v HDU v ward
Breas Vivo
Respironics Synchrony
Resmed VPAP
B&D Nippy
Face v nasal mask v prongs
Sizing Humidity Complications Monitoring
Mask intolerance
Skin sores
Dry eyes
Rhinitis
Air swallowing
? Facial deformity
30 second page
physiotherapy
immunisation
antibiotics
nutrition
Rx of GORD
in-exsufflator
Why are we initiating this?
Have we consulted / discussed?
How are we going to do it?
Where are we doing this?
What are we going to monitor?
What about discharge?
top related