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Monitoring on LTV Martin Samuels Bristol Course on Long Term Ventilation in Children.
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Transcript of Monitoring on LTV Martin Samuels Bristol Course on Long Term Ventilation in Children.
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