Complex Care Hub Manual: Pressure Ventilation on the LTV 1200 Table of Contents 1 Mechanical Ventilation... 3 2 Important information for support worker... 3 3 Commonly used terms... 3 3.1 Inspiration... 3 3.2 Expiration... 3 3.3 Breath rate (machine set breaths)... 3 3.4 Initiate... 3 3.5 Sensitivity... 3 3.6 Triggered breaths... 4 3.7 Peak Inspiratory Pressure (PIP)... 4 3.8 Positive End Expiratory Pressure (PEEP)... 4 3.9 Pressure... 4 3.10 Pressure Control breaths... 4 3.11 Pressure support breaths... 4 3.12 Continuous Positive Airway Pressure (CPAP)... 4 3.13 Synchronised Intermittent Mandatory Ventilation (SIMV)... 5 4 Monitored Information (monitored data)... 5 5 Ventilator controls... 6 5.1 Silence Reset... 6 5.2 Scroll button... 6 5.3 On/Standby... 6 6. Power... 6 7. Oxygen... 7 8. The breathing circuit... 8 8.1 Humidifier (mechanical)... 8 8.2 Inspiratory limb... 9 8.3 Heater wire... 9 8.4 Temperature probe... 9 8.5 Expiratory limb... 9 8.6 Water trap (only in home use wet circuits)... 10 8.7 Exhalation valve... 10 8.8 Expiration drive line... 10 8.9 Wye... 10 8.10 Tracheostomy connector... 10 8.11 Sensor lines... 10 8.12 Oxygen inlet... 11 8.13 Dry circuit (no mechanical humidification)... 11 9. Troubleshooting common alarms... 11 How to silence and turn off the flashing alarm message... 13 Page 1 of 17
10 Care of the ventilated child... 13 10.1 Start of shift equipment checks... 13 10.2 Standard checks of a ventilated child... 14 10.3 Hourly checks... 15 11 Changing and cleaning the circuit... 15 11.3 Cleaning the home circuit... 15 11.4 To clean the exhalation valve... 17 11.5 Cleaning the inlet filter... 17 Version 4.0 Date revised: 2017 Next due: 2019 This core section only includes basic information on the LTV 1200 ventilator features that are relevant to the usual daily care provided by a support worker to a child at home. It does not include all features found on the ventilator. Further information can be obtained from the manufacturers User Manual or by contacting the Clinical Technologists at The RCH. Page 2 of 17
1 Mechanical Ventilation Mechanical ventilation describes the use of a machine (ventilator) to give breaths to someone who can t breathe at all, or to support the breathing of someone who can t breathe well enough on their own. 2 Important information for support worker The support worker will not be required to change any of the settings on the ventilator. This is only to be done by trained medical professionals or appropriately trained family members of the child and always in consultation with the child s medical team. The only buttons the support worker will need to use are: Silence/Reset, Scroll button and On/Standby. These buttons will be further explained in your training. 3 Commonly used terms 3.1 Inspiration Describes the act of breathing in or taking a breath 3.2 Expiration Describes the act of breathing out. 3.3 Breath rate (machine set breaths) The minimum amount of breaths given in one minute as set on the ventilator. Nurses may describe these as mandatory breaths or machine set breaths. The child may be able to take more breaths than the mandatory breaths, but if the child isn t breathing on their own then the machine will deliver the set breaths. 3.4 Initiate Initiate (start) describes what causes a breath to be given by the ventilator. Breaths may be initiated by the child or by the ventilator according to the set breath rate 3.5 Sensitivity The machine has a special function that recognises the child s effort when taking a breath. When the child tries to take a breath for themselves, the air or gas in the ventilator tubing moves. For the ventilator to recognise when the child is trying to take a breath we need to make it sensitive to this gas flow in the ventilator tubing. When a large enough gas flow is detected the ventilator will respond with a breath. The ventilator can be made very sensitive or not at all sensitive by changing the sensitivity dial. We like the ventilator to be sensitive to the child s effort to breathe, but if it detects interference (e.g. water in the tubing or a larger leak around the tracheostomy tube) it may not recognize the child s breathing efforts or deliver too many breaths. An example: 1 = very sensitive this is usually set for smaller patients 4= less sensitive- this is usually set for older children or young adults Page 3 of 17
3.6 Triggered breaths A triggered breath is when the ventilator senses the child is trying to breathe and responds by pushing gas into the lungs to deliver a breath. A triggered breath can also be called an assisted breath. 3.7 Peak Inspiratory Pressure (PIP) During inspiration the ventilator delivers a set pressure to inflate the lungs. For every machine breath this will be the highest pressure that is reached during inspiration. This highest pressure is called PIP. It is important that the child receives the correct PIP as they can become unwell if the PIP is too high or too low. 3.8 Positive End Expiratory Pressure (PEEP) PEEP is the pressure that is held in the airways at the end of expiration. Everyone has a natural PEEP when they breathe out, this pressure helps to stop the small air sacs in the lungs from completely collapsing. By setting a PEEP on the ventilator we guarantee the child s lungs are always kept slightly open at the end of expiration, this makes it easier for the child to take each breath. 3.9 Pressure The amount (pressure) of gas delivered to the child from the ventilator to help the lungs inflate 3.10 Pressure Control breaths Pressure control describes the pressure that is delivered to the child for the set breath rate (3.3). The pressure delivered (PIP) is a combination of the number seen on the pressure control dial and the number seen on the PEEP dial. For example Pressure control is set at 15 PEEP is set at 5 Which means that PIP is 20 (15 + 5 = 20) 3.11 Pressure support breaths These are the breaths that the child triggers that are above the set breath rate (3.3) on the LTV 1200. All pressure supported breathes are triggered by the child. Usually the pressure delivered to the child in a support breath is less than the pressure delivered during a pressure control breath. This means that the child has a smaller breaths. The LTV 1200 can be programed to deliver only pressure supported breaths. 3.12 Continuous Positive Airway Pressure (CPAP) This is a mode of ventilation on the LTV 1200. In this mode the ventilator will deliver a continuous pressure which means the child s lungs/ airways are always kept slightly open. Keeping some pressure in the lungs continuously makes breathing easier for the child. Imagine the lungs are like a balloon, it is harder to blow up a brand new balloon but it gets easier once there is some air in the balloon. It is the same with the lungs if there is no air in the lungs the child has to work hard to get enough air into them, but if there is a little air in the lungs then the child doesn t have to work as hard to get enough air into them. CPAP can be delivered/given by mask or tracheostomy. CPAP can only be used by patients who are able to breathe on their own. Page 4 of 17
3.13 Synchronised Intermittent Mandatory Ventilation (SIMV) This is a mode of ventilation on the LTV 1200. In SIMV mode the ventilator gives a set number of breaths and can also recognise when a child is trying to take a breath. It is able to synchronise, or give a breath at the same time as the child initiates a breath. If the child does not take a breath within a set time frame then the ventilator will give a mandatory breath. Although the child always receives a set number of mandatory breaths, they are able to take extra breaths. In order to support the child who takes extra breaths SIMV is often used in conjunction with Pressure Support. 4 Monitored Information (monitored data) This table contains data that is displayed on the ventilator. The support worker does not have to record this data and it is included in the manual for information only. Display Monitored Data Units of measurement Explanation PIP Peak Inspiratory Pressure cmh20 The PIP displays the greatest pressure measured during the inspiratory phase MAP Mean Airway Pressure cmh20 The MAP displays a running average of the airway pressure for the last 60 seconds. PEEP Positive End Expiratory Pressure cmh20 The PEEP monitor displays the pressure in the circuit at the end of expiration. F Total breath rate Breaths per minute Displays the breaths per minute based on the last 8 breaths, and includes all breath types Vte Exhaled Tidal Volume millilitres Tidal volume indicates how much air is exhaled in one breath. VE Minute Volume Litres The minute Volume displays how much air is exhaled over the last 60 seconds as calculated from the last 8 breaths I:E I:E ratio Smaller unit normalised to 1 The I:E Ratio displays the unit-less ratio between measured inspiratory time and measured expiration time Page 5 of 17
5 Ventilator controls The only buttons the support workers will need to use are: 5.1 Silence Reset Press once to silence and then press once again to reset the alarm when the issue/problem has been resolved. 5.2 Scroll button Located on the top left hand corner of the ventilator. This takes you through the messages in the display window 5.3 On/Standby It is to be used when transferring the child between ventilators e.g. night ventilator and day ventilator. The support worker should only touch this button when the child is not attached to the ventilator. The support worker may be required to turn off the ventilator if it is not in use. To do this press the control lock to off and press and hold the On/Standby button. Once the ventilator has turned off a constant alarm will sound and can be silenced by pressing and holding the silence/reset button 6. Power Plug the ventilator into mains power whenever possible to ensure the internal battery is fully charged at all times Page 6 of 17
The ventilator has an internal battery that will power the ventilator for up to 1 hour when fully charged. It is recharged when the ventilator is plugged in to any external power source (including the external battery) In emergencies, or when the child is being transported, the ventilator can be plugged directly into a 12 volt DC supply such as a car cigarette lighter (you will need correct attachment). You must always ensure the car motor is running and the car is in a well ventilated place before plugging in the ventilator or running the ventilator in the car The external battery will run the ventilator for up to 5 hours when fully charged (i.e. each battery is equal to 2.5hours). It is important to remember that battery times can vary. In the event of a power failure the ventilator will automatically change to either the external or internal battery (which ever has the most charge remaining). If the external battery is flat the ventilator will audibly and visually alarm and automatically transfer to the internal battery. You must find a source of external power as soon as possible (and not longer than 1 hour) or the battery will run out of charge. The External Power indicator shows the level of the external power while the ventilator is operating from an external power source When the ventilator is running from the internal battery, the External Power indicator is off External power may be provided by connecting the ventilator to an external battery or LTV AC Power Adapter. When running from external power the Charge Status indicator will show the following levels: LED Colour Green Yellow Red Power Level External Power level is acceptable External Power level is low or checking power level External power is about to run out 7. Oxygen From time to time the child may require oxygen to be delivered through the ventilator circuit. This can be done from a low flow source such as an oxygen concentrator or oxygen cylinder. Oxygen from either source is mixed in the ventilator circuit with air from the ventilator. Oxygen is a medication and the amount of oxygen is prescribed by the child s medical team In the home, the Low Pressure O2 source button on the ventilator should be lit up at all times. This ensures that the ventilator can deliver Page 7 of 17
room air (21% Oxygen) with or without low flow home oxygen attached to the circuit. 8. The breathing circuit Most ventilator s will have a standard set up, though the tubing may look different depending on what has been given to the child. Picture of full wet circuit and the connection from ventilator to humidifier 8.1 Humidifier (mechanical) The humidifier actively warms and moistens the air. It is connected to the ventilator and the child by the inspiratory limb. This is called a wet circuit. Water is held in the humidifier chamber and heated to create water vapour. The humidifier is ideally positioned below the child. There are two types of chambers: A reusable chamber that is refilled by disconnecting the circuit tubing (without the heating wires) and pouring water into the chamber through the opening. A single patient use, automatically filling chamber with a reusable water bag. In order for water to flow from the bag to the chamber, the chamber must be level and the bag must be hung at least 50cm above the chamber. Water bags can be used for two weeks before being replaced. In a dry circuit the mechanical humidifier is removed and a special attachment called a Humid-vent must be added to provide humidification. Page 8 of 17
MR850 humidifier displayed, other types of humidifiers are also in use in the community, see specific instructions for the child s humidifier. 8.2 Inspiratory limb This tubing delivers the air to the child from the ventilator. It is plugged into the ventilator and then connects with the humidifier chamber. A separate piece of tubing goes from the humidifier to the child. 8.3 Heater wire The tubing that goes from the humidifier to the child will usually have a heating wire in it. The heater wire maintains the temperature of the air as it travels from the humidifier to the child. This prevents the air from cooling and reduces rain out (formation of condensation) within the tubing. The heater wire is connected to the humidifier by a heater wire adaptor (not disposable). The heater wire adaptor for the reusable circuits is different to that of the single patient use circuits. 8.4 Temperature probe This plugs into the inspiratory limb both at the patient end and the humidifier end of the tubing. This senses the temperature of the air at each end of the tubing so that the humidifier can safely maintain the correct temperature. The temperature probe at the patient end must be positioned in an upright position to stop it from getting wet. 8.5 Expiratory limb This tubing goes from the child to the expiration valve. It allows the expired air to be removed from the child. Page 9 of 17
Expiratory limb, water trap, expiration valve, sensor lines, wye 8.6 Water trap (only in home use wet circuits) This is a small removable jar with a self-sealing valve in the expiratory limb of the ventilator circuit. It is used to collect the condensed water (rain out) that gathers in the unheated expiratory limb and should be emptied regularly. Single patient use circuits do not require a water trap because the expiratory section of the circuit is heated by the humidifier to reduce rain out. 8.7 Exhalation valve This controls the flow of air during inspiration and expiration. It is also used to control the pressure left in the lungs when the child breathes out (PEEP). It is connected to the expiratory limb and the expiration drive line. 8.8 Expiration drive line This line is used to control the operation of the expiration valve. Shutting it during inspiration and then opening it to control the pressure left in the lungs when the child breathes out (PEEP). The line connects the expiration valve to the ventilator. At the ventilator end this connects to the port marked Exhl Valve. 8.9 Wye The inspiratory and expiratory limbs connect to this; the Wye is connected to the patient. It measures flow and pressure using the sensor lines. 8.10 Tracheostomy connector This connector has swivels in two directions to minimise the effect of the circuit pulling on the tracheostomy tube. The patient end of the connector should be visibly clean at all times. The tracheostomy should be cleaned in warm soapy water, rinsed and dried at least once per week or more often if required. Wye with sensor lines, top of inspiratory limb (with temperature probe) top of expiratory limb. Tracheostomy connector. 8.11 Sensor lines Sensor lines monitor the flow of air to and from the patient. They go from the ventilator to the Wye (please do not try to remove them from the Wye). They must always point upwards to stop them from getting wet. At the ventilator end they connect to the ports marked Flow Xdcer. The sensor lines cannot connect to the wrong ports. Page 10 of 17
Top of picture shows the three Sensor lines connecting to the ventilator. The bottom connector is the inspiratory limb connected to the ventilator. 8.12 Oxygen inlet This is used to add in extra oxygen to the circuit. It can be added to the circuit on the inspiratory side between the ventilator and humidifier. 8.13 Dry circuit (no mechanical humidification) In a dry circuit, mechanical humidification is replaced with a humidivent which is a special filter to moisten and warm the air. The humidivent is inserted between the top of the wye and the tracheostomy connector. The humidivent is single use and should be replaced daily or if soiled with secretions. Dry circuits are usually used when taking the child out of the house (e.g. shopping), or when the child is up and about in their wheelchair. See the child specific care page for the times when the child uses a dry circuit. 9. Troubleshooting common alarms The ventilator has alarms that are set to alert the support worker that there is a problem. When an alarm goes off you must always check the child before you take any further action, including silencing the alarm. When an alarm occurs you will See a flashing alarm message in the display window e.g. Disc/Sense Hear an alarm tone Page 11 of 17
See the control that is connected to the alarm flashing e.g. if the High Pressure alarm goes off then the High Pressure control on the ventilator will flash When the cause of the alarm is fixed The alarm tone stops The alarm message will continue to flash until you press the reset button The control button will continue to flash until you press the reset button 9.1 Possible alarms The table lists the alarm displays that you will see on the machine and what you may need to do (after checking the child) to fix the cause of the alarm. A complete list of alarms is contained in the LTV 1200 manual. Alarm message What it might mean What to do (if required) Disc/sense High PRES (high pressure) Low Pressure alarm Tubing has come off the tracheostomy. A connection along the tubing has come apart Sensor lines loose or disconnected Child is coughing Child is upset and crying Kink in tubing Partial/complete blockage of tracheostomy or humidivent Water in tubing Tubing has come off the tracheostomy A connection along the tubing has come apart Hole in the circuit Large leak around the tracheostomy Accidental decannulation Put tube back on to tracheostomy Check tubing for broken connection and fix Monitor child & suction if required. If tracheostomy completely blocked, change tracheostomy Comfort child if upset. Remove kinks (may need to replace circuit). Replace humidivent Remove any water that may be in tubing Reconnect the tubing Reconnect the tubing or do a circuit change Find the leak and repair/replace tubing Check the ventilator circuit and tighten any loose connections Check the child; ensure the tracheostomy ties are tight. Page 12 of 17
Bat Low The ventilator has been running on internal battery and it is running out of power Plug the ventilator into mains power within 5 mins Apnoea The child has stopped breathing Commence DRSABC If the child is ok and still breathing, troubleshoot the circuit and check tracheostomy is clear. Bat Empty LMV (Low Minute Volume) Locked The internal battery level is dangerously low The child is breathing out (exhaling) less volume than the machine has been programmed for (low minute volume alarm) Tracheostomy leak/disconnection Increased secretions The LTV is in locked mode and the settings can t be changed You must plug the ventilator into mains power immediately. If you don t the child will require bag and mask ventilation Check position of tubing and tracheostomy. Try to stop the pulling on the tubing. Check that the child s chest is rising and falling equally on the left and right side Keep airway clear with suctioning Inform the child s parents if alarm continues despite troubleshooting measures. Do not unlock the machine. Support workers are not allowed to change the settings on the ventilator How to silence and turn off the flashing alarm message Once you have seen the child is safe you may press the silence/reset button once. When you have fixed the cause of alarm you can press the silence/reset button again to stop the flashing alarm message. Repeating Alarms If the child has multiple events of the same alarm with no obvious cause this may indicate an illness with the child or a problem with the ventilator. Please tell the parents if the machine is repeatedly showing the same alarm and the support worker is not able to fix the problem with the usual trouble shooting methods outlined above. It is helpful to make note of what the child is doing during the repeated alarms as this can help medical staff troubleshoot the problem. 10 Care of the ventilated child 10.1 Start of shift equipment checks Ventilator Page 13 of 17
Make sure ventilator circuit is attached to child (via tracheostomy or mask) Check that the settings and alarm limits are correct Starting from the ventilator check the circuit for leaks and ensure connections are tight Check for water in the circuit and drain back to the humidifier or water trap Empty the water trap Make sure the ventilator is plugged into the mains power Check that all the batteries are plugged into the ventilator and that they are fully charged Humidifier Check that humidifier is on the right setting (is it mask or tube ventilation?) Check the water level and add cooled boiled water if needed Check the temperature probe on the wye is facing up Is the humidifier at the right temperature? Oxygen If oxygen is required check if there are enough oxygen equipment (O2 cylinders, concentrators, tubing, connectors) for your shift and the next shift. Suction Check that suction is available, working and fully charged or charging. Resuscitation equipment Make sure the resuscitation equipment is available and working Make sure the emergency tracheostomy kit is available and fully stocked (if required) If any of the equipment used for ventilating the child is not working, or needs servicing or repairs, please inform the parents. The parents will need to arrange to return the equipment to the ICU clinical technologists. 10.2 Standard checks of a ventilated child Along with equipment checks, there are a number of other checks that the support worker should attend to at the beginning of the shift. The support worker should get a handover from the family or support worker in attendance and together you should check the following: Is the child breathing normally (for them)? o o o o Is the breathing faster or slower than normal? Are they working harder to breathe than normal? Is the breathing softer or shallower than normal Can you hear normal breath sounds? Page 14 of 17
Do the settings on the ventilator match the ventilation order for the child? Does the child need suctioning? Is the tracheostomy secure? Is the ventilator circuit properly connected to the tracheostomy and lower than the tracheostomy? Is the ventilator plugged into mains power? If not then how long has the ventilator been on battery power? Is there enough water in the humidifier? Is the ventilation tubing free of water? ( rain out or condensation). If not, drain the water out, always keeping the circuit lower than the child and their tracheostomy (so water doesn t enter the tracheostomy). You may need to disconnect the circuit from the child to do this and they will need manual bagging while you drain the water out. 10.3 Hourly checks During the shift the support worker needs to complete standard checks of the child every hour (or more if required). Check the child looks/acts like their usual self Does the child need suctioning? Is the ventilator circuit properly connected to the tracheostomy? Check the pressures on the ventilator Is there enough water in the humidifier? Is the ventilation tubing free of water? ( rain out or condensation) Check the child specific care pages for any other checks required. During the support worker s shift they may be required to record information from the ventilator. The child specific care page will tell you what you need to record and when to record it. 11 Changing and cleaning the circuit A disposable circuit is changed every week. The temperature probe is not disposable but the rest of the circuit can be thrown out. These are used in hospital and generally not used at home. A home use circuit needs to be changed and washed weekly (or more frequently if required). 11.3 Cleaning the home circuit Make sure circuit is removed from the ventilator remove heater wire from the inspiratory limb Wash the inspiratory and expiratory limbs in warm soapy water. Rinse well and allow to dry completely in room air Wipe temperature probe Put heater wire back in the inspiratory limb when it is dry Page 15 of 17
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11.4 To clean the exhalation valve Disassemble and remove the diaphragm. Wash gently in warm soapy water Rinse well and leave to dry Store the clean dry reassembled circuit in a clean, dry pillowcase. 11.5 Cleaning the inlet filter Remove the inlet filter by gently pinching the foam filter and pulling it out Inspect the filter for damage and replace if necessary Hand wash the filter using warm soapy water (a mild dish liquid detergent) Rinse the filter thoroughly in warm water to remove all detergent Allow filter to air dry before replacing it into the ventilator Spare filters can be obtained from the Clinical Technologists at The RCH Caution: do not install a wet or damp filter into the ventilator, as this could result in damage to the ventilator. Page 17 of 17