Treating chronic respiratory failure with noninvasive ventilation (NIV) can improve patient outcomes and quality of life. But with so many options for NIV and home mechanical ventilation, clinicians may find it difficult to match a patient with the best device at the correct time in their disease state.
Three experts shared their experiences with the current landscape of ventilation devices in the session In the Age of Recalls, How Do I Manage These Other Devices? on Monday.
Hemant Sawnani, MD, Professor, Department of Pediatrics, University of Cincinnati School of Medicine, discussed BPAP-S, BPAP S/T, and VAPS technologies in the context of respiratory muscle weakness.
Synchronization between the ventilator and the patient is often missed and is an important factor in working with these devices, he said. A balance for the patient between respiratory load and respiratory drive and muscular power is essential.
Dr. Sawnani explained how automatic continuous positive airway pressure (A-CPAP) device sensors monitor air flow and recovery cycles.
“If flow reduction is detected, forced oscillation techniques are sometimes used,” he said. “If airway closure is detected, A-CPAP is increased.”
In addition to optimal pressure support, he also reviewed optimal inspiratory time and noted that as patients’ muscular weakness progresses, their ability to optimize their own inspiratory time will change, and clinicians need to be able to set it appropriately. He also emphasized checking a device’s intentional leak first when asynchronization occurs.
Dr. Sawnani reminded attendees that it is important to understand the operation of the devices their patients use.
“I do feel that whatever piece of equipment you desire to use, it is important that you read the manual,” he said.
Sreelatha Naik, MD, FCCP, Regional Director of Pulmonary and Critical Care Medicine at Geisinger Health System, discussed home mechanical ventilators, particularly Trilogy and Astral devices, because they are some of the most well-known. She highlighted the importance of choosing the right ventilator for patients and provided case studies to illustrate the choices.
Dr. Naik explained the pressure support modes in Trilogy devices and noted that inspiratory time on Trilogy devices is not necessarily controlled. However, additional modes on the devices allow for more control and optimization of inspiratory time.
Clinicians can use their best judgment when setting up a home device, but they can’t always know what a patient will need once they get home. Different modes on the same device can offer patients options that they can change on their own.
“If a patient goes home and is struggling, you can set multiple modes for the same patient and teach the patient and family members to toggle between them,” Dr. Naik said.
The Astral devices are similar, but are a little bit lighter, and have multiple modes, including an iVAPS mode, which sets them apart. This mode has various features, including cycle sensitivity and trigger sensitivity.
These devices also collect data that uploads to the cloud, but there are often cases where patients do not have appropriate internet connectivity.
“We do ask patients to bring their devices to the clinic to share that data from the device,” she said.
Bethany L. Lussier, MD, FCCP, Assistant Professor in Pulmonary and Critical Care at UT Southwestern Medical Center, wanted to give attendees a taste of the wide variety of available devices as she continued the discussion of home medical ventilators.
As she informally polled attendees on which devices they prescribed the most, the familiarity dropped after the Trilogy and Astral machines. But she assured attendees that while the machines are all different, they are also all similar, and knowledge of different devices is beneficial. She discussed features and functions of the Breas Vivo, Lowenstein Luisa, and Ventec VOCSN and compared the three.
“If you’ve never touched these devices, you are less likely to use it or prescribe,” Dr. Lussier said. “So, I tell fellows all the time, touch these devices. You can’t break it. Play around with it.”
Ultimately, familiarity is what’s guiding what patients have access to, she said.
“The best ventilator for your patient is the one they can get hooked up to now,” Dr. Lussier said.