Current Issues in Home Mechanical Ventilation

doi:10.1378/chest.07-0558

Chest

Volume 132, Issue 2, August 2007, Pages 671-676

https://doi.org/10.1378/chest.07-0558 Get rights and content

As modern health care continues to evolve, we expect and are seeing that more sophisticated medical care will be provided outside the traditional acute care environments. Advances in home medical technology, economic pressures, health-care consumerism, and societal changes are all factors playing a role in this evolution. Medically fragile and technology-dependent individuals who were once limited to care in acute and subacute institutional settings are now frequently cared for at home, most often by their immediate family members. Mechanical ventilation has found its way into the patient's home such that physicians and other providers must be prepared for the challenges associated with managing the conditions of complex, ventilator-dependent individuals outside of the walls, controls, and safety of the institutional setting. With little published science and recognized standards of practice, there are fewer rules to guide clinicians through this process. Experience has shown, however, that successful home management of ventilator-dependent individuals can be traced to a smooth and collaborative discharge from the hospital to home. Reimbursement and coverage issues must also be well understood to avoid the aggravation of denials and challenges for necessary equipment and assistance. Once home, a streamlined, patient-centered process supported by effective communication between all care providers can result in a safe and appropriate long-term home ventilation success story.

Section snippets

NPPV

The rapidly expanding home use of NPPV using a nasal or orofacial mask provides an even larger opportunity to allow patients to transition to the home environment without the need of a tracheostomy tube. Portable, lightweight, single-circuit flow generators that are capable of delivering bilevel pressure support with mask leak compensation can actually provide high levels of pressure support near 30 cm H₂O. This treatment initially emerged and quickly proliferated with the successful

Home Noninvasive Mechanical Ventilation Policies and Practice Standards

The practice guidelines were presented in a publication¹⁴ that was based on an expert consensus conference panel precipitated in part by the alarming increase in NPPV use for COPD patients requesting very expensive reimbursement from Medicare. These recommendations included provisions for patients with restrictive thoracic cage disorders and NMD, as well as for patients with severe COPD and hypercapnia/nocturnal desaturation despite oxygen use, and finally those with other primarily nocturnal

Home Invasive Mechanical Ventilation Policies and Practice Standards

One of the biggest obstacles that providers face in the provision of invasive HMV is simply a lack of strong, evidenced-based standards of care. As a result, local practice beliefs and reimbursement restrictions have produced marked regional variations. Unlike other home respiratory technologies (ie, home oxygen therapy and sleep disorder therapy), there is no standardized Medicare national coverage determination governing HMV, or even any local medical review policies or local coverage

Population of Ventilator-Assisted Individuals

Ventilator-assisted individuals (VAIs) are composed of a mix of adult and pediatric patients with a variety of underlying medical conditions contributing to chronic respiratory insufficiency and/or failure. Common disorders may include but are not limited to the following: spinal cord injury; NMD; chronic lung disease (obstructive and restrictive); bronchopulmonary dysplasia; and other birth-related anomalies contributing to respiratory insufficiency and/or failure.

There is very little accurate

Coding and Reimbursement

Although the home has been noted to be one of the lowest cost points of care for VAIs,¹⁷ the lack of published information and recognized standards of care leaves notable gaps in the coding and coverage methodologies. An addition to the current procedure terminology (or CPT) coding may provide some relief in tracking VAI patient services. The new current procedure terminology code 94005 (“Home Ventilator Management Care Plan Oversight”) can be used by physicians who are managing HMV patients.

The HMV Technology

In the 1980s, we saw the introduction of what most clinicians consider to be the modern portable or home mechanical ventilators. Most portable ventilators were relatively small and lightweight (compared to hospital equipment) and typically were housed in cast aluminum frames. Nearly all of the first-generation portable home ventilators used some type of simple bellows or piston design to generate the needed flow, pressure, and volume. Although considered somewhat basic and low technology by

More Than a Ventilator

The management of VAI in the home incorporates more than just a ventilator. Medically complex VAIs often depend on a myriad of medical devices and services to duplicate the care provided in the institutional setting. Commodities such as oxygen, air, and suction, which are available at nearly every bedside in the hospital, must be produced from various devices in the home. For many VAIs, their homes often take on the appearance of a hospital room. The extensive list of adjunctive medical devices

Critical Care to Home Care

Invasive HMV is arguably one of the most complex respiratory services delivered in the home. In contrast to many other home-care services, invasive HMV requires much more advanced decision making, planning, training, and oversight. Highly effective hospital discharge planning that includes well-choreographed interdisciplinary support is essential for long-term success.²⁰ Physicians, nurses, professional therapies, home respiratory therapists, insurance case manager and, most importantly,

The Hidden Costs of HMV

Assuming the responsibility for the care and management of a VAI or other technology-dependent individual is a life-altering event for most families and caregivers. There are few available data that capture the myriad indirect costs associated with the care of VAIs in the home. These hidden costs include, but are not limited to, the following: lost wages for a spouse, parent, or child who stays home to care for the VAI; out-of-pocket costs of noncovered medical items and supplies; and the cost

Steps To Promote an Effective HMV Management Program

Although there remains an absence of recognized standards and objective science in this area, years of successful hospital discharge experiences with medically complex patients have produced a series of common-sense techniques that can help produce a smooth transition to home, as follows:

1
Create a safe home environment. The patient's care and safety is central to the home management of any VAI. It is important to ensure that the home environment and caregivers can support the technological

Summary

HMV is an important yet somewhat complex area of medicine that requires appropriate attention and support from all stakeholders. A well-executed HMV program produces a safe and appropriate environment of care for VAIs while concurrently delivering to the health-care system a cost-effective and patient-centric system for servicing the clinical and lifestyle needs of technology-dependent individuals. Even Medicare and Medicaid services are now beginning to recognize this value, and pilot programs

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NIV at home: resource implications

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Cited by (40)

Home health nurses for children with invasive mechanical ventilation (IMV): Perspectives on gaps and opportunities for recruitment
2023, Journal of Pediatric Nursing
Children with medical complexity (CMC) dependent on invasive mechanical ventilation (IMV) often require private duty home nursing; however, there are ubiquitous shortages. Home health is an especially vulnerable nursing sector because of less competitive wages and less prominence during nursing education. We sought to understand nurses' perspectives on gaps and opportunities for recruiting home care nurses for children with IMV.
Home health nurses experienced with children with IMV were recruited for semi-structured interviews. The interview guide served as the initial codebook which was iteratively modified as themes emerged. This study presents an analysis of quotes related to field entry and home health experiences.
Twenty interviews were completed with primarily female (95%) participants. The majority worked full-time (60%) and had an average of 11 years of experience. During nursing education, participants described a lack of exposure to private duty home health nursing. Many entered the field serendipitously, because of a passion for care of CMC or to continue care for a hospitalized patient. Challenges to employment included lack of competitive wages and benefits. Nurses remained in the field because of the rewarding work with patients and families, schedule flexibility, slower pace, and one-on-one care.
Home health nurses for IMV describe lack of employment benefits. However, the opportunity to work longitudinally and individually with patients was rewarding.
Creative solutions must be explored to recruit and sustain this essential workforce, including exposure during nursing education, improved training and benefits, and targeted recruiting.
Infrastructure- and workforce capacity for the provision of health care to people with invasive home mechanical ventilation: A scoping review of indicators and norms
2023, Zeitschrift fur Evidenz, Fortbildung und Qualitat im Gesundheitswesen
Both the availability and adequacy of infrastructure- and workforce capacity are critical to provide integrated and continuing care, especially to people with complex care needs such as those with invasive home mechanical ventilation (HMV). This review aims to synthesise indicators and norms that are available for assessing this infrastructure- and workforce capacity.
A scoping review was conducted by searching PubMed, Livivo, the grey literature, specific registries, and the websites of relevant professional societies for international publications on specific infrastructure- and workforce capacity indicators or norms on HMV from January 2000 up to and including March 2021. Exclusion criteria comprised missing indicator/norm information, differing populations/care settings, and secondary literature. Indicators and norms were extracted, clustered, and analysed by applying the WHO Monitoring and Evaluation Framework and qualitative content analysis.
Fifteen publications met the inclusion criteria. Forty-five indicators and 44 norms on HMV-related infrastructure- and workforce capacity were synthesised. The synthesis revealed a heterogeneous set of indicators and norms (mainly from cross-sectional surveys and guidelines). The methodological information on their definition, rationales, disaggregation, and evidence is scarce.
To enable integrated care in HMV and comparable populations with complex care needs, the identified limitations in assessing infrastructure- and workforce capacity should be addressed.
Für eine integrierte und kontinuierliche Versorgung sind sowohl die Verfügbarkeit als auch die Angemessenheit von Infrastruktur- und Personalkapazitäten von entscheidender Bedeutung. Dies gilt insbesondere für Menschen mit komplexen Versorgungsbedarfen wie häuslich invasiv beatmete Personen. Die vorliegende Übersichtsarbeit zielt daher auf eine Beschreibung und Synthese von Indikatoren und Normen ab, die für die Erfassung und Evaluation von Infrastruktur- und Personalkapazitäten zur Verfügung stehen.
In einem Scoping-Review wurden PubMed, Livivo, graue Literatur, spezifische Register und Webseiten relevanter Fachgesellschaften international nach relevanten Veröffentlichungen bis einschließlich März 2021 durchsucht. Eingeschlossen wurden Quellen mit Informationen zu spezifischen Indikatoren und Normen für Infrastruktur- und Personalkapazitäten. Ausschlusskriterien umfassten fehlende Informationen zu Indikatoren/Normen, abweichende Populationen/Versorgungssettings sowie Sekundärliteratur. Identifizierte Indikatoren und Normen sowie ihre Charakteristika wurden mit einer in Orientierung am WHO-Monitoring and Evaluation Framework entwickelten Vorlage extrahiert und qualitativ inhaltsanalytisch ausgewertet.
Aus 15 eingeschlossenen Publikationen wurden 45 Indikatoren und 44 Normen zu HMV-spezifischen Infrastruktur- und Personalkapazitäten identifiziert. Die Synthese offenbarte eine ausgeprägte Vielfalt und Heterogenität zwischen den einzelnen, hauptsächlich aus Querschnittserhebungen und Leitlinien stammenden Indikatoren und Normen. Zudem liegen selten hinreichende methodische Informationen zu ihrer Definition, Begründung, Gliederungstiefe und Evidenz vor.
Für eine den komplexen Versorgungsbedarfen häuslich beatmeter Personen und vergleichbarer Bevölkerungsgruppen angemessene integrierte Versorgung sollten zunächst die identifizierten Limitationen bei der Erfassung und Evaluation von Infrastruktur- und Personalkapazitäten adressiert werden.
Mental health reported in adult invasive home mechanical ventilation through a tracheostomy: A scoping review
2022, International Journal of Nursing Studies Advances
Citation Excerpt :
The purpose of the present scoping review was therefore to close this knowledge gap in relation to people receiving invasive home mechanical ventilation through a tracheostomy. Home mechanical ventilation is a versatile and complex treatment area provided outside a hospital setting for people with chronic respiratory failure (Hind et al., 2017; Lewarski and Gay, 2007; Simonds, 2016). Both invasive (tracheostomy) and non-invasive (mask) ventilator treatment can be used in the home setting (MacIntyre et al., 2016; Park and Suh, 2020).
Although people receiving invasive home mechanical ventilation through a tracheostomy are facing both physical and mental health challenges, healthcare services often focus mainly on physical symptoms. To ensure well-functioning treatment and care for people receiving tracheostomy ventilation in a home setting, their mental health needs to be promoted and seen as an integral part of their health in general.
This scoping review aimed to provide a summary of the current knowledge on the mental health of people receiving invasive home mechanical ventilation through a tracheostomy.
A scoping review of published and gray literature based on the framework developed by Arksey and O'Malley and refined by the JBI was performed. The Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews checklist was used for reporting the findings.
A literature search was conducted by two researchers independently in the PubMed, CINAHL and PsycINFO databases. Additional searches for gray literature were conducted in Google, Google Scholar, websites of selected organisations, and the reference lists of included studies. The software system Covidence was used in the study selection process. For critical appraisal, the Mixed Methods Appraisal Tool was used.
Thirteen studies were included in this review, of which six used qualitative, six quantitative, and one mixed methods. The majority of studies were authored in Europe (n = 10), followed by the Americas (n = 2) and the Western Pacific (n = 1). Mental health was investigated both directly and indirectly (61.5% vs. 38.5%). Categorizing the reported mental health outcomes, we found that emotional well-being was reported widely across the studies (n = 13), while psychological well-being (n = 5) and social well-being (n = 4) were less widely reported.
The mental health of people receiving home tracheostomy ventilation has received some scholarly attention. A heterogeneity of mental health outcomes was reported in the literature with emotional well-being being an important mental health area both in relation to the sub-components positive affect and quality of life appraisal. Mental health outcomes in relation to psychological well-being and social well-being were fragmented and only sparsely investigated.
Chronic respiratory failure: Utilization of a pediatric specialty integrated care program
2017, Healthcare
Citation Excerpt :
Technologic innovation, coupled with a growing appreciation of the broader social contributions of individuals with disabilities, have allowed children with CRI to remain at home and integrate into their communities with life-sustaining mechanical support 1. The need for intensive supports (e.g., transtracheal or noninvasive ventilation, assisted cough, home nursing, parenteral and assisted enteral nutrition, and continuous monitoring) reflects a range of underlying conditions, including neuromuscular disorders, spinal cord injuries, parenchymal pulmonary diseases, and respiratory dysfunction (e.g., central hypoventilation), as well as a burgeoning population of children with complex congenital heart disease.1 Approximately 6/100,000 children in Utah in 2004 require transtracheal mechanical ventilator assistance2; authors extrapolated that an estimated 4000–6000 children receive ventilator support at home throughout the US.
Describe utilization and satisfaction in a specialty integrated care program for children with severe, chronic respiratory insufficiency (CRI).
Enrollees of the Critical Care, Anesthesia, Perioperative Extension (CAPE) and Home Ventilation Program.
Children with CRI received home visits, care coordination, and “on-demand” 24/7 access to physicians. Program activity and outcomes were recorded for 3 years using an adapted Care Coordination Measurement Tool© version. Parents completed the Consumer Assessment of Healthcare Providers and Systems (CAHPS). Patient characteristics, program activity, clinical outcomes, utilization, and satisfaction were summarized using descriptive statistics.
CAPE provided care for 320 patients from 2012 to 2014 with a median of 7 encounters per year. Neuromuscular (n=132, 41%), chronic lung disease (n=37, 12%), and congenital heart disease (n=13, 4%) represented the majority of underlying conditions. Services included 905 home, 504 clinic, and 3633 telephone encounters, of which 43.6% included a care coordination activity. CAHPS (n=102) revealed that 92.1% (n=93) of children had at least one non-urgent (i.e., routine) visit and nearly two-thirds (64.7%, n=66) reported the need for urgent or emergency care. Overall, parents were highly satisfied with CAPE, with a mean satisfaction rating of 9.3 (±1.3) out of 10. Most parents reported that the CAPE team understood the child’s (96.0%, n=95) and family’s day-to-day life (86.9%, n=86).
When given open access to an intregated care program, children in our highly complex population required a median of 7 encounters per year. We believe that this experience is scalable and may inform other organizations contemplating similar services.
SEPAR Year of the Chronic Patient and Domiciliary Respiratory Care. Points for Reflection
2014, Archivos de Bronconeumologia
Acute and chronic respiratory failure
2014, Handbook of Clinical Neurology
Citation Excerpt :
The technology is available with portable, lightweight, single-circuit flow generators that are capable of delivering bilevel pressure support with mask leak compensation at high levels of pressure support near 30 cmH2O. Invasive HMV is one of the most complex respiratory services delivered in the home and requires much more advanced decision-making, planning, training, and oversight (Lewarski and Gay, 2007). Not too long ago, therapeutic nihilism was governing the approach to the care of the patient with a NMD.
Respiratory failure (RF) can be attributed to a plethora of neuromuscular diseases (NMDs) and manifests clinically in a multitude of overt or more subtle ways. The basic principles of pathophysiology, diagnosis and treatment of neurologic diseases and of RF apply concomitantly to this subset of patients. Various entities should be approached according to the latest evidence-based recommendations. Treatment follows the natural disease progression, from minimal respiratory assistance to mechanical ventilation (MV). A comprehensive treatment plan has to be formulated that takes into consideration the patient’s wishes.

View all citing articles on Scopus

: The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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Chest

Topics in Practice ManagementCurrent Issues in Home Mechanical Ventilation

Section snippets

NPPV

Home Noninvasive Mechanical Ventilation Policies and Practice Standards

Home Invasive Mechanical Ventilation Policies and Practice Standards

Population of Ventilator-Assisted Individuals

Coding and Reimbursement

The HMV Technology

More Than a Ventilator

Critical Care to Home Care

The Hidden Costs of HMV

Steps To Promote an Effective HMV Management Program

Summary

Chest

Chest

Chest

Mayo Clin Proc

Lancet

Mayo Clin Proc

Chest

Semin Neonatol

Resuscitation

Comparative costs of home care and residential care

Gerontologist

Long term care of the patient with a tracheostomy

Respir Care

NIV at home: resource implications

Thorax

State of the art: noninvasive ventilation

Am J Respir Crit Care Med

Topics in Practice Management
Current Issues in Home Mechanical Ventilation