Care of the Complex Respiratory Patient across the Continuum

Transcription

1 Care of the Complex Respiratory Patient across the Continuum Peggy Lange, BA, RT Director, Respiratory Care St. Cloud Hospital ext Carmen Carlson, NRP, CMPA Community Paramedic Emergency Trauma Center SCH ext May 29, 2018 Outcomes Describe barriers for optimal patient care Understand respiratory equipment and orders for complex patients Know resources available for these patients Introduce the Community Paramedic Program Wellness, prevention, and transition barriers Silo mentality across the continuum Minimal communication amongst care providers, specialists Prescription issues for formulary, payment, dose, administration Mental health concerns Biases and beliefs and aging Inconsistent education for patients, family, caregiver Is the family the best caregiver? Follow up visits At risk discharge, 3-5 days access ETC use inappropriate 1

2 Equipment in the home What is the equipment? Is it used as prescribed? Is it cleaned? Are there enough supplies? Are there skin issues? Is there a DME company support? Any reports? Do families see the DME an extension of the hospital? What is the provider follow-up? Do families know who to call if questions 24/7? Talking oxygen-prescription SIG: Home Oxygen Device Type concentrator and portable (gas) (patient is mobile and needs portable oxygen) Route NC Liter Flow at rest *** Liter Flow at activity *** Frequency *** Duration *** Refills: *** Orders may include goal of maintaining saturation range- min and max- during rest and activity- important if pulse or bolus dosing Oxygen cont d Face to face needed Continue use at home Use oxygen at skilled facility Home oxygen evaluations When to requalify Traveling with oxygen Tanks do not have unlimited supply Liquid vs gaseous tanks Carry or dragchanges breathing patterns Need ability to increase flow delivery as patient disease progresses 2

3 Oxygen: Remember when? Atmospheric air is approximately 79% nitrogen and 21% oxygen Concentrators make their own oxygen from removing nitrogen from the atmospheric air Oxygen passing through the filter system and then is stored within the device Storage volumes vary from device to device Oxygen available is 90% (-3/+5.55%) Now called Portable oxygen concentrators (POC) Concentrators aren t all the same Light weight- some as little as 5 pounds AC 110 current DC outlet found in motor vehicles Rechargeable batteries Higher level POC, heavier in weight, shorter battery life and may have wheels, carts Delivery method: Intermittent Flow and Continuous Flow IF- only delivers oxygen during inhalations, not during exhalation. Can meet needs of many patients. CF Both IF and CF Should meet physiologic needs- relieve hypoxia while doing normal activities of daily living While we generally know liters per minute, some POCs are calibrated in milliliters per breath (also fixed bolus volume) and some millimeters per minute (fixed minute volume) 3

4 Trade offs Meet needs from previous slide, allow to walk, run, climb, skip, hike Light weight vs heavier Easy to carry vs pull Extended battery life or shortened Travel freely Inexpensive or $$$ Always test drive is needed- think of progression Tips by CMS: February 2018 CPAP, NPPV 4

5 CPAP, NPPV (BiPAP)-- everyone gets a machine! Compliance!! Use at skilled facility Skilled facility to transition to home: requirements to qualify NPPV definitions EPAP/CPAP Oxygen bled in Frequency Definition: Two levels: EPAP (CPAP) increases functional residual capacity IPAP (increases tidal volume) Generally a minimum of 4cm H20 apart, can be called pressure support Example settings: CPAP 8 cm H20 Bi-Level: IPAP 18 cm H20, EPAP 6 cm H20, 2 liters bled in, no back up rate Other notes: Downloads: 4 hours per night for 21 of 30 nights. Now use: Wired modem or wireless to communicate. Companies resupply tubings, masks, etc. Indications: Relief of nocturnal hypoventilation (COPD) Restrictive lung diseases (ALS) Obstructive Sleep apnea Central apnea Obesity hypoventilation 5

6 Additional notes CPAP and NPPV (Bi-Level) can be set up quickly, mask is the most problematic Many modes, settings Temporarily assist in patients distress Augments breathing pattern Ramping pressures when more stable Prolonged use may indicate intubation need In ETC use is in HF, COPD, but more 6

7 Exclusion Criteria: In the chronic care setting: Unsupportive family Lack of financial resources Uncooperative patient behaviors Copious secretions High risk of aspiration Anatomic abnormities Ventilatory support most waking hours Acute Respiratory Failure: Apnea Hemodynamic instability Uncooperative behaviors Facial burns, trauma Copious secretions High risk aspiration Anatomic abnormalities Respiratory Assist Device (RAD) qualifying guidelines page 1 Respiratory Assist Device (RAD) qualifying guidelines page 2 7

8 E0470 or E0471 Based on the treating physician s judgement. E0470 Bi-level without backup rate E0471 Bi-level with a back up rate CMS revision effective December 2014 RAD qualifying Guidelines Trilogy ventilator Auto track for synchrony Multiple ventilation modes Leak compensation, for NIV mode Personable therapies for sleep apnea and COPD Artificial airways 8

9 Trach tubes, supplies, speaking valves Trach patients needs: Suction machine and kits Inner cannulas Velcro ties Q tips Sterile water Dressings, gauze Trach tubes, changes, q 30 days Education, resources Help needed for a team- let me know if interested!! AARC Clinical Practice Guideline: Effectiveness of Nonpharmacologic Airway Clearance Therapies in Hospitalized Patients Airway clearance therapy (ACT) is used in a variety of settings for a variety of ailments. Includes: CPT, IPV, PEP, Directed cough, Mechanical In/Ex (Cough Assist), HFCWC (High Frequency Chest Wall Compression- Vest) 9

10 Airway clearance: Some types of airway obstruction decrease the cross-sectional area of the lumen due to smooth muscle spasm, congestion, and/or mucus plugging. PEP may be effective on mucus plugging but not the other types of airway obstruction shown here. PEP (Positive Expiratory pressure) Therapy Benefits Helps to mobilize secretions (airway dilatation, mucous shearing) Prevents small airway collapse Reduces air trapping Allows more complete lung emptying Used in chronic disease management Benefits: The first and earliest recognized benefit of PEP was in patients with COPD, particularly emphysema and small airways disease, because it helps prevent small airway collapse and splints the airways open during exhalation, when they would normally be prone to collapse. 10

11 PEP Products: HFCWC: Vests Mechanical Insuflation- Exsuflation: Cough assist 11

12 IPV- Percussionaire: Generates high energy bursts up to cycles per minute (hertz) Patient airways at pressures of cm H20 Treatments generally minutes Percussionaire- Pulsatile flow ventilation Well.. 12

13 Vibralung Acoustical Percussor Applies vibratory sound waves During Inspiration and exhalation Frequencies ~5 to 1,200 HZ Vibrates the column of gas in respiratory tract Mucous is loosen and separatedsympathetic resonance Vest therapy, Cough assist, IPV, Vibralung, Where to get - DME Letter of necessity Delivered and educated at home Payment concerns, does Medicare cover? Device settings example: Cough Assist: covered diagnosis, mode, frequency, inspiratory pressure and seconds, expiratory pressure and seconds, route Vest: covered diagnosis, vest size, frequency IPV: covered diagnosis, pressure, frequency Vibralung: diagnosis, failure for other devices, programing Resources for Respiratory Patient PCP DME providers: many with chronic disease program offerings Transition coaches, transition pharmacists Community paramedics Tobacco cessation specialists Home care agencies Health Care Home CMS, Insurance carriers Pulmonary Rehab Programs 13

14 Goals: Live more comfortably and independently Improve your daily living Control your illness Avoid hospital admissions Program covers: Lung function and treatments Managing shortness of breath, symptoms, and when to seek help Living wills, palliative care Medications side effects and self care Tobacco cessation Oxygen therapy Ways to manage diet Supervised exercise Pulmonary Rehab Support Group More information: Discussions beginning for CCH Paynesville Medical fitness after programs Others: Buffalo, Cambridge, Cuyuna, Alexandria, Wadena, Little Falls, Aikin, Princeton, Brainerd My thoughts: Mechanical ventilation is pushing the envelope. Fewer RTs employed with DME companies Technology keeps moving, novel items enter the market More features and options on equipment Not enough trials blurred lines Coverage and reimbursement falls behind. Complex RAD coverage Prolonging life? Patient wants? Where I want to be: Home sweet home! 14

15 References The Long-Term Oxygen Treatment Trial Research Group. A randomized trial of long term oxygen for COPD with Moderate desaturations. N Engl J Med 2016:375: Doyle, A., Eberhart, M., Forry, L., Medicare Reference Guide 2010 Gardenhire, D., Ari, A., Hess, D., Myers, T., A Guide to Aerosol Delivery Devices for Respiratory Therapists, 4th Edition Produced by AARC 2017 Strickland, S., Rubin, B., Hess, D., et al, AARC Clinical Practice Guideline: Effectiveness of Nonpharmacologic Airway Clearance Therapies in Hospitalized Patients, Dec Manufacturer s websites: Vest, Cough Assist, Vibralung, IPV, Aerobika One hour closer to Summer! Thank you! 15