Reprinted from the December 1995 issue of RESPIRATORY CARE [Respir Care 1995;40(12):1313–1320]
AARC Clinical Practice Guideline
Long-Term Invasive Mechanical Ventilation in the Home
HIMV 1.0 PROCEDURE:
The application of invasive mechanical ventilation and care of the patient-ventilator system in the home, as ordered by a physician.
HIMV 2.0 DESCRIPTION/DEFINITION:
Mechanical ventilation may be defined as a life support system designed to replace or support normal ventilatory lung function.(1) Ventilator dependence is caused by an imbalance between ventilatory capacity and demand.(2) "A ventilator-assisted individual (VAI) may require mechanical aid for breathing to augment or replace spontaneous ventilatory efforts to achieve medical stability" or to maintain life.(3) The patient eligible for invasive long term mechanical ventilation in the home (HIMV) requires a tracheostomy tube(4-6) for ventilatory support but no longer requires intensive medical and monitoring services.(7-9) This guideline refers to patients ventilated by positive pressure via a tracheostomy tube in the home.
The goals of HIMV are
- 2.1 to sustain and extend life;(8,10-19)
- 2.2 to enhance the quality of life;(10-15,17-29)
- 2.3 to reduce morbidity;(8,10,11,13,16,20,30)
- 2.4 to improve or sustain physical and psychological function of all VAIs(7,8,10,13,15,16,18,20,31,32) and to enhance growth and development in pediatric VAIs;(5,7,8,12,17-19,23,28,33-36)
- 2.5 to provide cost-effective care.(7,8,10,11,13-19,22, 23,27,28,32,36-45)
HIMV 3.0 SETTING:
The setting is the home, which for the purposes of this guideline may be the patient's home,(4,5,10,18,19,22, 27,32,34,38,40,41,46-53) a foster home,(10,17) or a group-living environment.(10,51)
HIMV 4.0 INDICATIONS:
- 4.1 Patients requiring invasive long-term ventilatory support have demonstrated:
- 4.1.1 an inability to be completely weaned from invasive ventilatory support or
- 4.1.2 a progression of disease etiology that requires increasing ventilatory support.
- 4.2.Conditions that met these criteria may include but are not limited to ventilatory muscle disorders,(4,5,10,11,14,16-19,21,26,27,33,35,38,42,43,46,52,54-62) alveolar hypoventilation syndrome,(4,5,10,17,18, 19,23,33,34,42,43,46,47,59,60) primary respiratory disorders,(4,10,17,18,19,23,42,46,59,60) obstructive diseases,(5,10,57,58) restrictive diseases,(5,10,16,43,46,56) and cardiac disorders including congenital anomalies.(17,23,19,42,46,59)
HIMV 5.0 CONTRAINDICATIONS
Contraindications to HIMV include:
- 5.1 The presence of a physiologically unstable medical condition requiring higher level of care or resources than available in the home.(4-7,10, 14,16,17,19,20,21,23,26,29,33,52,59) Examples of indicators of a medical condition too unstable for the home and long term care setting are:
- 5.1.1 FIO2 requirement > 0.40(4,5,10,16,35)
- 5.1.2 PEEP > 10 cm H2O(4,5,10,12,16,35)
- 5.1.3 Need for continuous invasive monitoring in adult patients(4,6,16)
- 5.1.4 Lack of mature tracheostomy
- 5.2 Patient's choice not to receive home mechanical ventilation(5,10,16,19,23,26,39,42,52,56,58,63,64)
- 5.3 Lack of an appropriate discharge plan(4,5,8,11, 13,18,33,34,38,39,46,48,51,65)
- 5.4 Unsafe physical environment as determined by the patient's discharge planning team.(10,13,66)
- 5.4.1 Presence of fire, health or safety hazards including unsanitary conditions.(39,51)
- 5.4.2 Inadequate basic utilities (such as heat, air conditioning, electricity).(4,5,10, 19,22,33,38,39,52,67)
- 5.5 Inadequate resources for care in the home:
- 5.5.1 Financial(9,10,13,14,16,18,19,23,25,26,33,35,38-40,44,52,55,56,59,68,69)
- 5.5.2 Personnel
- 188.8.131.52 Inadequate medical follow-up(13,14,16,18,29,33,36,38,39,50,61)
- 184.108.40.206 Inability of VAI to care for self, if no caregiver is available(5,16)
- 220.127.116.11 Inadequate respite care for caregivers(17,19,26)
- 18.104.22.168 Inadequate numbers of competent caregivers(5,13,21,23,25,26,30,38,39,52,68)
HIMV 6.0 HAZARDS AND COMPLICATIONS
- 6.1 Deterioration or acute change in clinical status of VAI. Although ventilator-associated complications in the home are poorly documented, experience in other sites can be extrapolated. The following may cause death or require rehospitalization for acute treatment.
- 6.1.1 Medical: Hypocapnia, respiratory alkalosis,(70) hypercapnia, respiratory acidosis,(70) hypoxemia, barotrauma,(5,64,70) seizures, hemodynamic instability,(21) airway complications (stomal or tracheal infection, mucus plugging, tracheal erosion or stenosis),(5) respiratory infection (tracheobronchitis, pneumonia),(57,70,71) bronchospasm,(5) exacerbation of underlying disease, or natural course of the disease
- 6.1.2 Equipment-related: Failure of the ventilator, malfunction of equipment,(10) inadequate warming and humidification of the inspired gases, inadvertent changes in ventilator settings, accidental disconnection from ventilator,(27) accidental decannulation
- 6.1.3 Psychosocial: Depression,(5,10,43) anxiety,(4,10,43) loss of resources--caregiver or financial,(10,19,25,40,43) detrimental change in family structure or coping capacity(5,10,19,25, 34,38,54,55,56,71,72)
HIMV 7.0 LIMITATIONS
In the home care setting, making and implementing changes in the plan of care may take longer than in a health care facility.
HIMV 8.0 ASSESSMENT OF NEED
- 8.1 Determination that indications are present and contraindications are absent.
- 8.2 Determination that the goals listed in 2.1 can be met in the home.
- 8.3 Determination that no continued need exists for higher level of services.
- 8.4 Determination that frequent changes in the plan of care will not be needed.
HIMV 9.0 ASSESSMENT OF OUTCOME
At least the following aspects of patient management and condition should be evaluated periodically as long as the patient receives HIMV
- 9.1 Implementation and adherence to the plan of care
- 9.2 Quality of life
- 9.3 Patient satisfaction
- 9.4 Resource utilization
- 9.5 Growth and development in the pediatric patient
- 9.6 Unanticipated morbidity, including need for higher level site of care.
- 9.7 Unanticipated mortality
HIMV 10.0 RESOURCES
- 10.1 Equipment
- 10.1.1 Ventilator(s)--Choice should be based on patient's clinical need.(5,10,14,22,23, 35,38,67,73) Patient's medical needs may dictate that more than one ventilator be provided.
- 10.1.1.1 Ventilators chosen for home care must be dependable and easy for the intended caregivers to operate; small size and lightweight are desirable
- 10.1.1.2 Mobility is frequently an essential element of the plan of care of the patient. The mechanical ventilator system chosen for such a patient should allow mobility.
- 10.1.2 With portable, volume-cycled ventilators, use of the SIMV mode increases work of breathing, and the addition of an external continuous-flow system reduces portability.(1,10,74-76)
- 10.1.3 Complex and nonportable components are not recommended for HIMV but may be used to meet the needs of certain pediatric patients.(10,13,22,35,75)
- 10.1.3.1 Ventilators powered by external compressed gas sources are less desirable.(10,22)
- 10.1.3.2 A second ventilator should be provided for
- 10.1.3.2.1 patients who cannot maintain spontaneous ventilation for 4 or more consecutive hours;(4,10,13,67)
- 10.1.3.2.2 patients who live in an area where a replacement ventilator cannot be provided within 2 hours;(4,13,39,67)
- 10.1.3.2.3 patients who require mechanical ventilation during mobility as prescribed in their plan of care.
- 10.1.4 An adequate power source must be available to operate the ventilator consistent with patient needs.(4,5,10,13,14,39,67) This may be supplied by one or more of the following methods:
- 10.1.4.1 Alternating current (AC) is the primary power source for most long-term care ventilators. Emergency AC power should be available in the long-term care facility.
- 10.1.4.2 Direct current (DC) by external battery may be used to allow mobility and as an emergency power source. The internal battery of the ventilator should be used only for short-term, emergency use. It should not be used as a primary source of power.
- 10.1.5 Alarms
- 10.1.5.1 A patient-disconnect (eg, low-pressure10 or low-exhaled-volume) and a high-pressure alarm are essential.
- 10.1.5.2 If patient disconnection is likely to produce a serious adverse effect, a remote alarm and a secondary alarm may be indicated. A secondary alarm may be based on chest-wall impedance and cardiac activity, exhaled volume, end-tidal CO2, or pulse oximetry with alarm capabilities.(42)
- 10.1.6 Humidification system(s) are essential for invasive mechanical ventilation. The type of system used is determined by the patient's medical needs(77) and the patient's need for mobility.(10,13,35) It may be appropriate for the patient to use more than one type of system, based on those needs.(1,15,78,79-81)
- 10.1.6.1 Heated humidifier (temperature probes should be provided).
- 10.1.6.2 Heat and moisture exchanger can be used during transport and to enhance mobility.(1,77,81)
- 10.1.7 Ventilator circuit and accessories as medically indicated.
- 10.1.8 Self-inflating resuscitation bag with tracheostomy attachments and mask of appropriate size(5,10,21-23,39,67)
- 10.1.9 Replacement tracheostomy tube of appropriate size plus a tube one size smaller should be available at all times.
- 10.1.10 Suction equipment(5,10,13,21-23,39,62,67) including a battery-powered aspirator for patients who leave the home or when indicated as an alternate source in the event of a power failure
- 10.1.11 Supplemental oxygen as medically indicated(10,13,39,67).
- 10.1.12 Patients must have an adequate means of communicating their needs and desires and to summon help in the case of emergency.(10)
- 10.2 Personnel:
- 10.2.1 Lay caregivers (eg, family members, personal care attendants, and non-credentialed health care personnel such as nurse's aides) can be taught skills and techniques of care for a specific VAI. Appropriately trained lay caregivers must demonstrate competency in
- 10.2.1.1 proper set up, use, troubleshooting, and maintenance of the equipment and supplies;(10,23,32,33,39,40,50,65)
- 10.2.1.2 patient assessment and ongoing response to invasive mechanical ventilation;(10,23,32,33,35,40,65)
- 10.2.1.3 responding to the hazards of invasive mechanical ventilation;(22,23,26,33)
- 10.2.1.4 responding to emergencies;(10,23,32,39,40) in the case of
- 10.2.1.4.1 power failure;
- 10.2.1.4.2 acute life threatening events such as accidental decannulation(22) or other need for tracheostomy tube replacement,(10) other unexpected events, or medical deterioration of the patient
- 10.2.1.4.3 failure of equipment or supplies;
- 10.2.1.5 complying with appropriate infection control procedures;(10,39,65)
- 10.2.1.6 providing appropriate return demonstrations in the use and application of any additional techniques required for the ongoing care of the VAI, such as suctioning and use of ancillary equipment;(10,39,40,50,65)
- 10.2.2 Level-II practitioners are health-care professionals capable not only of providing direct patient care but also possessing demonstrated competencies to monitor and assess both the patient and equipment. Level-II practitioners are capable of training and evaluating lay caregivers. Level-II practitioners should be credentialed health care professionals (eg, RRT, CRTT, RN) with documented knowledge and demonstrated competencies to:
- 10.2.2.1 provide knowledge and understanding of the patient's disease, goals and limitations of invasive mechanical ventilation;(32,33,39)
- 10.2.2.2 assess patient's response to invasive mechanical ventilation;
- 10.2.2.3 make recommendations for changes in respiratory management of patient, including weaning as necessary;(10,33)
- 10.2.2.4 train and monitor caregivers;(4,5,10,32,33,40,50)
- 10.2.2.5 monitor patient's ongoing ventilatory status;
- 10.2.2.6 communicate results of assessment to the health care team.(5,39)
- 10.3 Finances: HIMV can only be instituted and maintained with adequate financial resources to provide the necessary equipment and personnel to manage the patient's care.(10,13,35,43)
HIMV 11.0 MONITORING
The frequency of monitoring should be determined by the ongoing individualized care plan and be based upon the patient's current medical condition. The ventilator settings, proper function of equipment, and the patient's physical condition should be monitored and verified: (1) with each initiation of invasive ventilation to the patient, including altering the source of ventilation, as from one ventilator or resuscitation bag to another ventilator; (2) with each ventilator setting change; (3) on a regular basis as specified by individualized plan of care.(35)
All appropriately trained caregivers should follow the care plan and implement the monitoring that has been prescribed. These caregivers may operate, maintain and monitor all equipment and perform all aspects of care required by the VAI after having been trained and evaluated on their level of knowledge for that equipment and the VAI's clinical response to each of the interventions.
- 11.1 Lay caregivers should monitor the following regularly:
- 11.1.1 Patient's physical condition: respiratory rate, heart rate, color changes, chest excursion, diaphoresis, and lethargy, blood pressure, body temperature.
- 11.1.2 Ventilator settings: The frequency at which alarms and settings are to be checked should be specified in the plan of care.
- 22.214.171.124 Peak pressures
- 126.96.36.199 Preset tidal volume
- 188.8.131.52 Frequency of ventilator breaths
- 184.108.40.206 Verification of oxygen concentration setting
- 220.127.116.11 PEEP level (if applicable)
- 18.104.22.168 Appropriate humidification of inspired gases
- 22.214.171.124 Temperature of inspired gases (if applicable)
- 126.96.36.199 Heat and moisture exchanger function
- 11.1.3 Equipment function:(10,13)
- 188.8.131.52 Appropriate configuration of ventilator circuit(82)
- 184.108.40.206 Alarm function
- 220.127.116.11 Cleanliness of filter(s)--according to manufacturer's recommendation
- 18.104.22.168 Battery power level(s)--both internal and external
- 22.214.171.124 Overall condition of all equipment
- 126.96.36.199 Self-inflating manual resuscitator--cleanliness and function
- 11.2 A Level-II practitioner should perform a thorough, comprehensive assessment of the patient and the patient-ventilator system on a regular basis as prescribed by the plan of care. In addition to the variables listed in 11.1.1-11.1.3. the Level-II practitioner should implement, monitor, and assess results of other interventions as indicated by the clinical situation and anticipated in the care plan.
- 11.2.1 Pulse oximetry--should be used in patients requiring a change in prescribed oxygen levels or in patients with a suspected change in condition.(10,35)
- 11.2.2 End-tidal CO2--may be useful for establishing trends in CO2 levels during weaning.(10,23,33,35,59,83,84)
- 11.2.3 Specimen collection (and analysis as applicable) as prescribed by physician--including but not limited to sputum and blood work (eg, arterial blood gas analysis and complete blood counts).(5,10,32,37)
- 11.2.4 Cardiorespiratory monitoring (electrocardiogram, heart-rate trending)(10)
- 11.2.5 Pulmonary function testing
- 11.2.6 Ventilator settings
- 11.2.7 Exhaled tidal volume
- 11.2.8 Analysis of fraction of inspired oxygen
- 11.3 Level-II personnel are also responsible for maintaining interdisciplinary communication concerning the plan of care
- 11.4 Level-II personnel should integrate respiratory plan of care into the patient's total care plan.(10) Plan of care should include
- 11.4.1 all aspects of patient's respiratory care(66) and
- 11.4.2 ongoing assessment and education of the caregivers involved.
HIMV 12.0 FREQUENCY:
- 12.1 The frequency of ventilation (and the patient's ventilator-free time) is dictated by the patient's physiologic needs and is determined in consultation with the patient's physician.
- 12.2 The frequency of assessment of the VAI and the patient-ventilator system must be noted in the evolving total care plan as determined by the health care team, in conjunction with the VAI and their caregivers.
HIMV 13.0 INFECTION CONTROL
Respiratory Home Care Focus Group:
- 13.1 Both professional and lay caregivers should be aware of the potential for transmission of both chronic and acute infection from patient to caregiver and from caregiver to patient and should take the steps necessary to avoid that transmission. Aspects of avoidance include:
- 13.1.1 careful handwashing and barrier protection when appropriate
- 13.1.2 careful disposal of medical waste
- 13.1.3 adequate environmental air exchange
- 13.1.4 maximizing protection of patient, family, and caregivers (eg, influenza immunization) and minimizing exposure to persons with acute infections (eg, limiting visitors with upper respiratory infections).
- 13.2 Evidence is lacking to support an optimal plan for changing and processing ventilator circuits and ancillary equipment in the home. However, studies from institutional settings(85,86) suggest that ventilator circuits need not be changed more often than once each week. Further, it appears that the less often a circuit is entered, the less likely contamination is to occur.
Peggi Robart RRT RCP, Chairman, Boston MA
Barry J Make MD, Denver CO
Susan L McInturff RRT RCP, Bremerton WA
Dennis W Tureson Sr RRT CRTT, Minneapolis MN
Melissa P Weimer, RRT, McKeesport PA
- American Association for Respiratory Care. AARC consensus statement on the essentials of mechanical ventilators--1992. Respir Care 1992;37(9):1000-1008.
- Marini JJ. The physiologic determinants of ventilator dependence. Respir Care 1986;31(4):271-282.
- Goldberg A. Home care for life-supported person: is a national approach the answer? Chest 1986;90(5):744-748.
- Gilmartin ME. Long-term mechanical ventilation: patient selection and discharge planning. Respir Care 1991; 36(3):205-216.
- Gilmartin ME. Transition from the intensive care unit to home: patient selection and discharge planning. Respir Care 1994;39(5):456-480.
- O'Donohue WJ Jr, Branson RD, Hoppough JM, Make BJ. Criteria for establishing units for chronic ventilator-dependent patients in hospitals. Respir Care 1988; 33(11):1044-1046.
- Goldstein RS, Pierson DJ. Long-term mechanical ventilation as elective therapy. Respir Care 1991;36(4):288-289.
- Health Care Financing Administration. Ventilator dependent demonstration. Technical Advisory Panel Meeting. Washington DC, 1990.
- Prentice WS. Placement alternatives for long-term ventilator care. Respir Care 1986;31(4):288-293.
- O'Donohue WJ, Giovannoni RM, Goldberg AI, Keens TG, Make BJ, Plummer AL, Prentice WS. Long-term mechanical ventilation: guidelines for management in the home and at alternate community sites. Chest 1986; 90(1):1S-37S.
- Goldstein RS, Avendano, MA. Long-term mechanical ventilation as elective therapy: clinical status and future prospects Respir Care 1991;36:297-304.
- Gilmartin ME, Make BJ. Home care of the ventilator-dependent person. Respir Care 1983;28(11):1490-1497.
- Plummer AL, O'Donohue WJ Jr, Petty TL. Consensus conference on problems in home mechanical ventilation. Am Rev Respir Dis 1989;140(2):555-560.
- Gilmartin ME, Make BJ. Mechanical ventilation in the home: a new mandate. Respir Care 1986;31(5):406-412.
- Make B, Gilmartin M, Brody JS, Snider GL. Rehabilitation of ventilator-dependent subjects with lung diseases: the concept and initial experience. Chest 1984;86(3):358-365.
- Make BJ, Gilmartin ME. Mechanical ventilation in the home. Crit Care Clin 1991;6(3):785-796.
- Canlas-Yamsuan M, Sanchez I, Kesselman M, Chernick V. Morbidity and mortality patterns of ventilator-dependent children in a home care program. Clin Pediatr 1993; 32:706-713.
- Brook Lodge Invitational Symposium on the Ventilator-Dependent Child, October 16-18, 1983. Sponsored by American Academy of Pediatrics. Children's Home Health Network of Illinois, La Rabida Children's Hospital and Research Center, and Upjohn Health Care Services.
- U.S. Department of Health and Human Services, Public Health Service, Health Resources and Services Administration, Bureau of Health Care Delivery and Assistance, Division of Maternal and Child Health in conjunction with the Children's Hospital of Philadelphia. Report of the Surgeon General's workshop on children with handicaps and their families. Case example: the ventilator-dependent child. December 1982.
- Leone M, Cassara EL, Stein M. Home care for pulmonary diseases. Respir Care 1990;35(12):1203-1205.
- Alexander MA, Johnson EW, Petty J, Stauch D. Mechanical ventilation of patients with late stage Duchenne muscular dystrophy: management in the home. Arch Phys Med Rehabil 1979;60:289-292.
- Banaszak EF, Travers H, Frazier M, Vinz T. Home ventilator care. Respir Care 1981;26(12):1262-1268.
- Donar ME. Community care: pediatric home mechanical ventilation. Holistic Nurse Pract 1988;2(2):68-80.
- Fischer DA, Prentice WS. Feasibility of home care for certain respiratory-dependent restrictive or obstructive lung disease patients. Chest 1982;82(6):739-743.
- Thomas VM, Ellison K, Howell EV, Winters K. Caring for the person receiving ventilatory support at home: care givers' needs and involvement. Heart Lung 1992; 21(2):180-186.
- Smith CE, Mayer LS, Parkhurst C, Perkins SB, Pingleton SK. Adaptation in families with a member requiring mechanical ventilation at home. Heart Lung 1991;20(4): 349-356.
- Splaingard ML, Frates RC Jr, Harrison GM, Carter E, Jefferson LS. Home positive-pressure ventilation: twenty years' experience. Chest 1983;84(4):376-382.
- Downes JJ, Pilmer SL. Chronic respiratory failure--controversies in management. Crit Care Med 1993;21 (9, Suppl):S363-S364.
- Purtilo RB. Ethical issues in the treatment of chronic ventilator-dependent patients. Arch Phys Med Rehabil 1986;67:718-721.
- Dunkin LJ. Home ventilatory assistance. Anaesthesia 1983;38:644-649.
- Affeldt JE, Bower AG, Dail CW, Aratan N. Prognosis for recovery in severe poliomyelitis. Arch Phys Med Rehabil 1957;38:290-295.
- Make BJ. Long-term management of ventilator-assisted individuals: the Boston University experience. Respir Care 1986;31(4):303-310.
- American Thoracic Society Ad Hoc Committee of the Scientific Assembly on Pediatrics. Home mechanical ventilation of pediatric patients. Am Rev Respir Dis 1990;141:258-259.
- Massachusetts Department of Public Health, Burr BH, Guyer B, Todres ID, Abrahams B, Chiodo T. Home care for children on respirators. N Engl J Med 1983;309 (21):1319-1323.
- Kacmarek RM, Thompson JE. Respiratory care of the ventilator-assisted infant in the home. Respir Care 1986;31(7):605-614.
- Whitcomb ME. Care of the ventilator-dependent patient: public policy considerations. Respir Care 1986;31 (4):283-287.
- Clark K. Psychosocial aspects of prolonged ventilator dependency. Respir Care 1986;31(4):329-333.
- Dunne P. Demographics and financial impact of home respiratory care. Respir Care 1994;39(4):309-320.
- Feldman J, Tuteur PG. Mechanical ventilation: from hospital intensive care to home. Heart Lung 1982; 11(2):162-165.
- Fields AI, Rosenblatt A, Pollack MM, Kaufman J. Home care cost-effectiveness for respiratory technology-dependent children. AJDC 1991;145:729-733.
- Fischer DA, Prentice WS. Feasibility of home care for certain respiratory-dependent restrictive or obstructive lung disease patients. Chest 1982;82(6):739-743.
- Frates RC Jr, Splaingard ML, Smith EO, Harrison GM. Outcome of home mechanical ventilation in children. J Pediatr 1985;106(5):850-856.
- Sivak ED, Cordasco EM, Gipson WT. Pulmonary mechanical ventilation at home: a reasonable and less expensive alternative. Respir Care 1983;28(1):42-49.
- Goldberg AI, Frownfelter D. The ventilator-assisted individuals study. Chest 1990;98(2):428-433.
- Goldberg AI, Faure EA. Home care for life supported persons in England: the Responaut approach. Chest 1984;86:910-914.
- Goldberg A. Children on ventilators: breathing easier at home. Cont Pediatr Vol. 59-79.
- Oren J, Kelly DH, Shannon DC. Long-term follow-up of children with congenital central hypoventilation syndrome. Pediatrics 1987;80(3):375-380.
- Goldberg AI. Mechanical ventilation and respiratory care in the home in the 1990s: some personal observations. Respir Care 1990;35(3):247-259.
- Peters SG, Viggiano RW. Home mechanical ventilation. Mayo Clin Proc 1988;63:1208-1213.
- Thompson CL, Richmond M. Teaching home care for ventilator-dependent patients: the patients' perception. Heart Lung 1990;19(1):79-83.
- Prentice WS. Transition from hospital to home. In: Gilmartin ME, Make BJ, (editors). Prob Respir Care 1988;1(2):174-191.
- Nochomovitz ML, Montenegro HD, Parran S, Daly B. Placement alternatives for ventilator-dependent patients outside the intensive care unit. Respir Care 1991; 36(3):199-204.
- American Medical Association Home Care Advisory Panel. Guidelines for the medical management of the home care patient, 1992.
- Miller JR, Colbert AP, Schock NC. Ventilator use in progressive neuromuscular disease: impact on patients and their families. Dev Med Child Neurol 1988;30 (2):200-207.
- Moss AH, Casey P, Stocking CB, Roos RP, Brooks BR, Siegler M. Home ventilation for amyotrophic lateral sclerosis patients: outcomes, costs, and patient, family, and physician attitudes. Neurology 1993;43:438-443.
- Sivak ED, Cordasco EM, Gipson WT, Mehta A. Home care ventilation: the Cleveland Clinic experience from 1977 to 1985. Respir Care 1986;31(4):294-302.
- Hänninen P, Wendelin H, Räsänen O, Panelius M. Chronic respiratory paralysis. Acta Paediatr 1972; 228(Suppl):1-32.
- Gilgoff I, Prentice W, Baydur A. Patient and family participation in the management of respiratory failure in Duchenne's muscular dystrophy. Chest 1989;95(3): 519-524.
- Schreiner MS, Downes JJ, Kettrick RG, Ise C, Voit R. Chronic respiratory failure in infants with prolonged ventilator dependency. JAMA 1987;258(23):3398-3404.
- Strumpf DA, Millman RP, Hill NS. The management of chronic hypoventilation. Chest 1990;98(2):474-480.
- Pierson DJ. Home respiratory care in different countries. Eur Respir J 1989;2(7, Suppl):630S-636S.
- Adams AB, Whitman J, Marcy T. Surveys of long-term ventilatory support in Minnesota: 1986 and 1992. Chest 1993;103(5):1463-69.
- Silverstein MD, Stocking CB, Antel JP. Amyotrophic lateral sclerosis and life-sustaining therapy: patient's desires for information, participation in decision making, and life-sustaining therapy. Mayo Clin Proc 1991;66:906-913.
- Snider GL. Thirty years of mechanical ventilation: changing implications (commentary). Arch Intern Med 1983;143:745-749.
- Daley White K, Walsh Perez P. Your ventilator patient can go home again. Nursing 1986;12:54-56.
- American Association for Respiratory Care. AARC clinical practice guideline: discharge planning for the respiratory care patient. Respir Care 1995;40(12): 1308-1312.
- Kacmarek RM, Spearman CB. Equipment used for ventilatory support in the home. Respir Care 1986;31 (4):311-328.
- Hodgkin JE. Non-ventilator aspects of care for ventilator-assisted patients. Respir Care 1986;31(4):334-337
- DeWitt PK, Jansen MT, Davidson Ward SL, Keens TG. Obstacles to discharge of ventilator-assisted children from the hospital to home. Chest 1993;103(5):1560-1565.
- Pierson DJ. Complications associated with mechanical ventilation. Crit Care Clin 1990;6(3):711-724.
- Harrison GM Jr, Mitchell MB. The medical and social outcome of 200 respirator and former respirator patients on home care. Arch Phys Med Rehabil 1961;42: 590-598.
- Quint RD, Chesterman E, Crain LS, Winkleby M, Boyce WT. Home care for ventilator-dependent children. AJDC 1990;144:1238-1241.
- Drinker P, McKhann CF. The use of a new apparatus for the prolonged administration of artificial ventilation: a fatal case of poliomyelitis. JAMA 1929;255(11):1473-1475, 1658-1660.
- Kacmarek RM, Stanek KS, McMahon K, Wilson RS. Imposed work of breathing during synchronized intermittent mandatory ventilation (SIMV) provided by five home care ventilators. Respir Care 1990;35(5):405-414.
- Kacmarek RM. Essential gas delivery features of mechanical ventilators. Respir Care 1992;37(9):1045-1055.
- Robart P, Hirsch C, Barker S, Kacmarek R. Work of breathing imposed during spontaneous breathing in the SIMV mode of home care ventilators (abstract). Respir Care 1992;37(11):1358-1360.
- American Association for Respiratory Care. AARC clinical practice guideline: humidification during mechanical ventilation. Respir Care 1992;37(8):887-890.
- Branson RD, Chatburn RL. Humidification of inspired gases during mechanical ventilation (editorial). Respir Care 1993;38(5):461-468.
- Shelly MP. Inspired gas conditioning. Respir Care 1992;37(9):1070-1080.
- Misset B, Escudier B, Rivara D, Leclercq B, Nitenberg G. Heat and moisture exchanger vs heated humidifier during long-term mechanical ventilation. Chest 1991; 100(1):160-163.
- Branson RD, Hurst JM, Laboratory evaluation of moisture output of seven airway heat and moisture exchangers. Respir Care 1987;32(9):741-747.
- Gietzen JW, Lund JA, Swegarden JL. Effect of PEEP-valve placement on function of a home-care ventilator. Respir Care 1991;36(10):1093-1098.
- Carlon GC, Ray C, Miodownik S, Kopec I, Groeger JS. Capnography in mechanically ventilated patients. Crit Care Med 88;16(5):550-556.
- Stock MC. Capnography for adults. Crit Care Clin 1995;11(1):219-232.
- Hess DR, Burns EC, Romagnoli DM, Kacmarek RM. Weekly ventilator circuit changes. A strategy to reduce costs without affecting pneumonia rates. Anesthesiology 1995;82(4):903-911.
- Kollef MG, Shapiro SD, Fraser VJ, Silver, P, Murphy DM, Trovillion E, et al. Mechanical ventilation with or without 7-day circuit changes. A randomized controlled trial. Ann Intern Med 1995;123(3):168-174.
Goldberg AI, Monahan CA. Home health care for children assisted by mechanical ventilation: the physician's perspective. J Pedriatr 1989;114(3):378-383.
Bone RC. Long-term ventilator care: a Chicago problem and a national problem. Chest 1987;92(3):536-539.
Indihar FJ, Forsberg DP. Experience with a prolonged respiratory care unit. Chest 1982;81(2):189-192.
Indihar FJ, Walker NE. Experience with a prolonged respiratory care unit: revisited. Chest 1984;86(4):616-620.
Wagner DP. Economics of prolonged mechanical ventilation. Am Rev Respir Dis 1989;140(Suppl):S14-S18.
Gracey DR, Viggiano RW, Naessens JM, Hubmayr RD, Silverstein MD, Koenig GE. Outcomes of patients admitted to a chronic ventilator-dependent unit in an acute-care hospital. Mayo Clin Proc 1992;67:131-136.
American Association of Respiratory Care. Guidelines for disinfection of respiratory care equipment used in the home. Respir Care 1988;33(9):801-808.
Chatburn RL. Decontamination of respiratory care equipment: what can be done, what should be done. Respir Care 1989;34(2):98-109.
Davis PB, di Sant'Agnese PA. Assisted ventilation for patients with cystic fibrosis. JAMA 1978;239(18):1851-1854.
Zwillich CW, Pierson DJ, Creagh CE, Sutton FD, Schatz E, Petty TL. Complications of assisted ventilation: a prospective study of 354 consecutive episodes. Am J Med 1974;57:161-170.
Stauffer JL, Olson DE, Petty TL. Complications and consequences of endotracheal intubation and tracheotomy: a prospective study of 150 critically ill adult patients. Am J Med 1981;70:65-76.
Craven DE, Kunches LM, Kilinsky V, Lichtenberg DA, Make BJ, McCabe WR. Risk factors for pneumonia and fatality in patients receiving continuous mechanical ventilation. Am Rev Respir Dis 1986;133:792-796.
Dreyfuss D, Djedaini K, Weber P, Brun P, Lanore JJ, Rahmani J, Boussougant Y, Coste F. Prospective study of nosocomial pneumonia and of patient and circuit colonization during mechanical ventilation with circuit changes every 48 hours versus no change. Am Rev Respir Dis 1991; 143:738-743.
Craven DE, Goularte TA, Make BJ. Contaminated condensate in mechanical ventilator circuits: a risk factor for nosocomial pneumonia? Am Rev Respir Dis 1984;129:625-628.
Pierson DJ, George RB. Mechanical ventilation in the home: possibilities and prerequisites. Respir Care 1986;31 (4):266-270.
Interested persons may copy these Guidelines for noncommercial
purposes of scientific or educational advancement. Please credit AARC and Respiratory
Reprinted from the December 1995 issue of RESPIRATORY CARE [Respir Care 1995;40(12):1313–1320]