The recent recall and subsequent exit of a giant in the home mechanical ventilation market has increased knowledge gaps for clinicians who care for patients with chronic respiratory failure.

During CHEST 2024, experts presented an overview of the available home ventilators in the market following the Philips Trilogy recall and offered instruction on different settings in the session, Addressing the Recall and Exit: Transitioning Between Modes on Home Mechanical Ventilators.

Understanding VAPS mode

Michelle Cao, DO, FCCP, Clinical Professor of Pulmonary, Allergy and Critical Care Medicine at Stanford University, focused on transitioning modalities from the Trilogy’s proprietary AVAPS (average volume assured pressure support) to the more widely offered VAPS (volume assured pressure support).

“Understanding the application of specific settings and the indication for VAPS enables the clinician to apply this advanced mode of ventilation to any device that offers this mode,” Dr. Cao said.

In VAPS, the pressure support regulates up and down to meet the target tidal volume (Vt). Understanding the pressure waveform curve depending on which disease you’re dealing with is essential to understanding how to program these different settings to change tidal volume, Dr. Cao said.

It is important to understand that the terminology may be different across ventilators but that this mode can be applied to any ventilator, she said. 

Transitioning to iVAPS mode

Jorge I. Mora, MD, FCCP, Professor of Medicine at the University of Pennsylvania, explored the transition from AVAPS on the Trilogy Evo to the iVAPS (intelligent volume-assured pressure support) mode used on the ResMed Astral 150 ventilator.

iVAPS targets alveolar minute ventilation (Va), with input provided by the clinicians. This represents the useful portion of ventilation that reaches the alveoli and participates in gas change.

“The alveolar ventilation is magically calculated based on a table based on your height. My point is that someone with a perfect BMI compared to somebody the same height with end-stage COPD and bullous disease does not have the same alveolar ventilation,” Dr. Mora said.

In comparing key features with the Trilogy Evo, he noted that the Astral 150 ventilator Vt/Va analysis is done breath-by-breath, the PS change is set to 0.7-2.0 cm H₂ rather than decided by the user, and it uses an intelligent backup rate (iBR) to adapt a respiratory rate window. The Trilogy Evo and Astral 150 ventilators use different languages to determine trigger sensitivity but the same cycle language.

Setting up a multifunction ventilator

Jeremy Orr, MD, Associate Professor of Pulmonary and Critical Care Medicine at the University of California San Diego, discussed features on the multifunction VOCSN ventilator from Ventec Life Systems.

VOCSN, which stands for ventilation, oxygen, cough, suction, and nebulization, is currently the only multifunction ventilator approved for adult and pediatric patients.

“The big idea with this device is that you simplify things,” Dr. Orr said. “It took multiple different devices that a patient with respiratory failure might need that can weigh up to 55 pounds and brought them into one device. It’s 18 pounds with one machine.”

For a patient to qualify for this device, they must have a ventilation need and two other needs, which could be cough, oxygen, or suction.

“I think it’s not about the ventilation per se with this device, it’s about who needs this kind of therapy,” Dr. Orr said. “I think it’s most appealing to patients who are mobile outside the home who have multiple device needs. But I will say that for patients who are not so mobile or more homebound, we shouldn’t discount the simplicity that comes with having one package.”

Comparing new ventilators

John Coleman, MD, Associate Professor of Medicine at Northwestern University Feinberg School of Medicine, compared two new ventilators, the LUISA from Movair and Lowenstein and the VIVO 45LS from Breas.

Both the LUISA and VIVO 45 ventilators have VAPS mode with automatic expiratory positive airway pressure, plus multiple programs, remote capabilities, and high flow. They can also perform mouthpiece ventilation and oxygen saturation monitoring and connect to a nurse call system.

The LUISA has a high-flow nasal cannula (HFNC) capability of 5 to 60 liters. It also has an oxygen bleed-in of about 30 liters per minute and a touch screen. The VIVO 45 has integrated humidification, is lightweight, can monitor total carbon dioxide content, and has HFNC capabilities.

“There’s no one right device. You’re going to see that there are a lot of new devices out there. They all have unique features. They’re all a little bit different,” Dr. Coleman said. “Pick a device that you’re most comfortable with and use that one. Explore, because this is where we’re going now.”