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Tips and tricks for transitioning from hospital to home

Jim Laging RRT Philips Ventilation Solutions

Disclosure

I work for Philips Healthcare North AmericaThat’s how I can go on road trips!

Harvard Business ReviewOctober 2013

“In healthcare, the overarching goal for the providers, as well as for every other stakeholder, must be improving value for patients, where value is defined as the health outcomes achieved that matter to patients relative to the cost of achieving those outcomes.”

“Improving value requires either improving one or more outcomes without raising costs, or lowering costs without compromising outcomes, or both.

Failure to improve value means, well, failure.”

Learning objectives

• Overview of Non Invasive Ventilation (NIV)

• Discuss potential Uses of new modes for hospital and home use

• How can NIV help with your COPD needs

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Goals of NIV• Alleviate respiratory distress by

• Improving gas exchange

• Reducing work of breathing Decrease rapid shallow breathing

• Augmenting alveolar ventilation

• Achieve patient-to-ventilator synchrony

• Reverse atelectasis

• Minimize risks and avoid complications associated with endotracheal intubation

Clinical keys to success• Early intervention

• Consider NIV as the first mode of ventilator support

• The earlier the initiation, the higher the success rate

• Availability of equipment and staff

• Trained staff

• Appropriate interface

• High performance equipment

• Cardiopulmonary monitoring

Patient selection considerations• Strong evidence

• CHF

• COPD exacerbation

• Facilitating weaning of COPD

• Immunocompromised patients

• Moderately strong evidence

• Asthma

• Cystic fibrosis

• Postoperative RF

• Avoidance of extubation failure

• DNI patients

Strong = multiple controlled trials

Moderately strong = single controlled trial or multiple case series

Weaker = a few case series or case reports

Acute Applications of Noninvasive Positive Pressure Ventilation; T. Liesching, H. Kwok, N. Hill; Chest 2003;124:699-713

• Weaker evidence– Partial UAW – ARDS– Trauma

Interface selection• Estimate length of use

• Compatibility with device

• Safety features

• Facial features• Skin condition

• Facial abnormalities

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Failure to fit and apply the mask appropriately

• Even if the mask is not too tight, it must fit and be applied appropriately

• If the mask is uncomfortable or leaking Patients will become agitated and remove the mask

Or they may not settle down which leads to NIV failure

Selecting the appropriate size mask or a one size fits all mask may lead to increased patient comfort and acceptance

New Modes in NIV

• PCV (Hospital)

• C-Flex (Hospital / Home)

• AVAPS (Hospital)

• AVAPS-AE (Hospital / Home)

Difference between S/T and PCV modes• In PCV all breaths look the same, as machine determines I-time

• In S/T each breath is different, patient determines I-TimeP

cmH2O

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0

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PcmH2O

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PCV on the V60 versus an ICU ventilator

• PCV on an ICU ventilator is PEEP compensated

• If PEEP is 5 cmH2O and set pressure is 15 cmH2Oo PIP is 20 cmH2O

• On the V60 as well as on all dedicated NIV ventilators, PEEP is not compensated

• If EPAP is 5 cmH20 and IPAP is 15 cmH20o PIP is 15 cmH2O

• Changes in EPAP without an equal change to IPAP

• Results in a change in pressure support (delta pressure)

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Patients who may benefit from using PCV

• Patients who may not be able to sustain a breath

• Neuromuscular disorders Muscular dystrophy, ALS

• Chronic disease processes Restrictive diseases

• Patients who are not tachypneic and are experiencing muscle fatigue, may VT by time at IPAP pressure

C-Flex

• The amount of pressure relief is determined by the C-Flex setting and the expiratory flow of the patient

• The higher the setting number (1, 2 or 3)

• And the greater the expiratory flow

• The greater the pressure relief o During the active part of exhalation only

C-Flex

Reduces pressure at the beginning of exhalation and returns to therapeutic pressure just before inhalation

Pressure relief varies on flow and C-Flex setting

C-Flex: Potential new indications

• Acute settings• Acute respiratory failure in OSAS• Acute respiratory failure in OHS

• Chronic settings• OSAS to improve tolerance and use

•Should not be used in patients requiring CPAP for oxygenation purposes

Just remember – it’s CPAP!

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AVAPS

• Neuromuscular disorders• With standard bi-level therapy, a patient’s tidal volume declines

as disease process worsens

• Restrictive thoracic disorder• Chest wall deformities (e.g. kyphoscoliosis) • Slow progressive disease

• Obesity hypo-ventilation syndrome• A change in body position increases airway resistance• Without an increase in pressure support, VT declines

• In short, any chronic disease process that is past the acute phase (e.g. COPD, CHF)

• Upon patient and NIV stabilization consider AVAPS

• IPAP

• EPAP

• Rate

• O2

• Rise

Mode: S/T

IPAP: 15 cmH2O

EPAP: 7 cmH2O

VT measured: ~450mL

Rate: 10 bpm

Mode: AVAPS

Min P: 12 cmH2O

Max P: 18 cmH2O

EPAP: 7 cmH2O

VT (set): 450mL

Rate: 10 bpm

AVAPS• This mode is not a PRVC type mode

• It will not respond quickly

• Not intended for patients with high resistance and low compliance

• Patients should be through their acute phase

• It is ideal for stabilized chronic patients

• The use of a nasal mask in AVAPS mode is not recommended

Average volume-assured pressure supportAVAPS automatically adapts pressure support per minute to

guarantee an average tidal volume

IPAP MinEPAP

Target VT

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AVAPS= so far promising results in obesity-hypoventilation in STABLE patients

Benefits of AVAPS in ICU

Benefits of AVAPS in ICU

Clinical

• Lowest pressure support to achieve target volume

• Less sedation1

• Improves gas exchange1,2,3

• Small changes to PaCO2 lead to significant

outcomes

• Improves patient comfort and compliance1

• Improved Health-Related Quality of Life (HRQL)3

• Improved sleep quality3

AVAPS for the COPD patient during sleepSupplemental Oxygen Needs During Sleep. Who Benefits? Robert L. Owens, MDRespir Care 2013;58(1):32-44.

• With lung disease, changes in ventilation lead to Nocturnal Oxygen Desaturation.

• Up to 70% of COPD patients with awake oxygen saturation of 90-95% experience substantial desaturation at night, particularly during REM sleep.

• In those with severe COPD, the desaturation during sleep is more profound even than during exercise.

• Alveolar hypoventilation likely accounts for most of the oxygen desaturation.

Clinical Benefits of Bi-Level with Volume Assured

• Maintains ventilatory support and tidal volume during

• progressive ventilatory changes of the patient

• positional changes during sleep

• Alarms to indicate that tidal volume is not being maintained

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AVAPS-AE

AVAPS-AE is a auto-titration mode of noninvasive ventilation designed to better treat respiratory insufficiency patients (OHS, COPD and NMD) in the hospital and homecare environments

• Proven performance of AVAPS

– Maintains targeted tidal volume

• Auto EPAP

– Maintains patent upper airway at comfortable pressure

• Auto backup rate

– Applies an auto backup rate near a patient’s resting rate

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AVAPS: proven effective • Automatically titrates pressure support

• Changes in body position

• Sleep stage

• Changes in respiratory mechanics

• Delivers average tidal volume

• Within the night

• Long-term progression

• AVAPS produces results comparable to sleep lab titration of PS1

• CO2 reduction

• Health-related quality of life

• Sleep quality

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1Murphy, PBThorax thoraxjnl-2011-201081: Published Online First: 1 March 2012 doi:10.1136/thoraxjnl-2011-201081

EPAP

Target Vt

IPAPPS min

PS max

AVAPS-AEMaintaining tidal volume and airway patency

EPAP min

EPAP max

Resistance

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AVAPS-AE suggested settings

OHS* COPD – OSA*Vt Target 6 -8 ml/Kg of ideal

bodyweight6-8 ml/Kg of ideal

bodyweight

Max P 35 cmH2O 30 cmH20

PS Max 19- 35 cmH2O 30 cmH2O

PS Min 14 -19 cmH2O 12 cmH2O

EPAP Max 14 cmH20 14 cm H2O

EPAP Min 4 cmH2O 4 cm H2O

Breath Rate Auto Auto

AVAPS Rate 2 5

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AVAPS-AE Settings

Settings Range Trilogy v 13.0

Rate From 1.0 AVAPS to 5.0 cmH2)/min in 1.0 cmH2O increments

Tidal volume 50 – 2000ml

Maximum pressure 6 – 50 cmH20

Pressure support Max 2 – 40 cmH20

Pressure support Min 2 – 40 cmH20

EPAP Max pressure 0/4 – 25 cmH20

EPAP Min pressure 0/4 – 25 cmH20

Breath rate Auto/0 – 60BPM

AVAPS-AE suggested settingsOHS* COPD – OSA*

Vt Target 8 -10 ml/Kg of ideal bodyweight

6-8 ml/Kg of ideal bodyweight

Max P 35 cmH2O 30 cmH20

PS Max 19- 31 cmH2O 26 cmH2O

PS Min 14 -19 cmH2O 12 cmH2O

EPAP Max 14 cmH20 14 cm H2O

EPAP Min 4 cmH2O 4 cm H2O

Breath Rate Auto Auto

AVAPS Rate 5

* AVAPS-AE protocol Dr. N. Hart, Dr. P. Murphy, Lane Fox Respiratory unit, St. Thomas’ Hospital London UK* AVAPS-AE Multi Center Trial protocol l,Prof Jean François MUIR, France

Proven to reduce readmissions

*All receiving NIV and meeting program eligibility requirements. All subjects were admitted at least twice in the prior 12 months before enrollment.1. Coughlin S., Liang WE, Parthasarathy S. RetrospectiveAssessment of Home Ventilation to Reduce Rehospitalization in Chronic Obstructive Pulmonary Disease. J Clin Sleep Med. 2015 Jun 15;11(6):663-70.

88% reductionIn a review of 398 COPD patients*

in hospitalreadmissions1

Managing COPD patients is a major issue

SOURCE: American Lung Association.

Growing COPD population Changing COPD reimbursement

Medicare has recently made readmissions a major performance 

indicator needed for full reimbursement

12 millionMore than

Americans diagnosed

24 millionUp to

May be undiagnosed

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COPD is now part of Medicare’s Hospital Readmissions Reduction Program• Chronic obstructive pulmonary disease (COPD) ranks 4th among the most

costly hospital readmissions, with the rate of readmission for Medicare beneficiaries at 23% within 30 days post-discharge.

• Medicare beneficiaries with two or more chronic conditions, including COPD and asthma, accounted for almost 98% of all hospital readmissions in 2010 at a cost of $300 billion, according to an analysis of Medicare claims data.

• Effective October 1, 2014, COPD was added to Medicare’s Hospital Readmissions Reduction program and hospitals will face a 3% payment penalty if they are not able to reduce the rate of excess readmissions.

• www.aarc.org

Preventable COPD readmissions remain high

1. Jencks et al. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009;360:1418-28.

Of 1 million COPDadmissions for acute exacerbation in 2012

23%were readmitted to the 

hospital within

And your institution may be financially responsible

SOURCES: http://khn.org/news/half-of-nations-hospitals-fail-again-to-escape-medicares-readmission-penalties/ and http://kff.org/medicare/issue-brief/aiming-for-fewer-hospital-u-turns-the-medicare-hospital-readmission-reduction-program/.

2592In 2016, Medicare fined a record 

number of  hospitalsnationwide

77 of hospitals were penalized

%

Hospital to Home OpportunitiesTime For Disease Management

• COPD was predicted to be #3 cause of death by 2020

• It reached this milestone in April 2011 according to CDC

• Population >65 will increase 73% by 2025• Baby Boomers are over 80 million strong.

• PCP shortages of 20-27% by 2025.• Allergists, PCP, anesthesiologists.

• There are over 100 Million patients in the US classified as having chronic conditions

Kallstrom, T. “The Long Term Implications of the Affordable Care Act”. AARC Times, Oct 2012. pg 20-21

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Pulmonary Issues Aren’t Going Away!Respiratory have Opportunities

RT as a Physician Extender• Work in PCP office assessing patients

RT as Case Managers and RT Navigators• Teach self management• Modify patients behavior at home• Coach, encourage and give advice• Regular communication between patient and RT• Identify unmet health needs• Keeps patients:

• Out of Hospital

• Out of ED

• Out of Physician office

RT case managers are the lifeline for COPD Management

Home Health

Rehab

Long Term Care

Durable Medical

Equipment

Improved Care in Hospital

Treat Exacerbation

Address Root Causes:-medication skills-smoking cessation-other

CARE PROTOCOL

ImprovedPatientEducation

HOSPITAL

COMMUNITY CARE

Rea

dmis

sio

n

Admission

Discharge

MD TreatmentWhen/IfOffice Visit Occurs

Identify asCOPD Patient

ER Used As Solution to Problems

Transition

• Third visit to the Emergency Room in 2 months complaining of increasing shortness of breath

• This visit reveals extreme dyspnea, hypercarbia, and hypoxemia via ABG

Familiar patient

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Identify and target patients with Readmission Factors

• Chronic conditions prone to exacerbation• Co-morbidities• Patients with longer than average LOS – Frequent Flyers• Admissions via nursing homes or home health services• Identified psychosocial challenges

Readmission factors

Source: AARC webcast August 28, 2012 “Hospital to Home-efforts at Reducing Hospital Readmissions”. Greg Spratt BS, RRT; Kimberly Wiles BS, RRT; Becky Anderson RRT.

69%Medication

Non-compliance

51%Lacked Device

Knowledge

45%Lacked

Medication Knowledge

42%Unable to self

care

37%No follow-up

with physicain

31%Infection post

discharge

The Hospital RT Could Also Address Other Root Causes• Earlier transition to post-discharge medications

• Better patient education about post-discharge medications and Therapy

• Testing alternative medications to address problematic side effects or affordability

• Better education, physical therapy, occupational therapy, Pulmonary Rehab. etc. to support better self-care and condition management after discharge.

Today’s healthcare landscape should connect hospital and home

A smooth transition tohome‐based care will empower the care team to do more

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Comprehensive solution

Durable Medical Equipment

-5365

-365

0 1530

Long Term Care

Home Health

Rehab

Long Term Care

RT Navigator/COPD Case

Manager

Systematic approach for COPD management

RT’s can take the lead with COPD Patients hospital to home transition. Education is KEY Effective COPD Management Plans

Ultimate Goals

Prevent and treat exacerbations

Prevent and treat complications

Moderate mortality

Overall Goals

Ultimate Goals

Stable COPD Patient

Overall Goals

Inhibit disease progression

Alleviate symptoms

Increase exercise tolerance

Improve health status

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Leading the way to a healthy society

Our role

Failed Approach

ED - ICU General ward Home Repeat

Noninvasive ventilation…

A safe effective way to successfully ventilate or oxygenate and manage

many patients and decrease readmissions

Jim.lagging@Philips.com 773-573-9155

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A1 Author, 7/5/2019

A2 Author, 7/5/2019