Home Mechanical Ventilation HMV

Stoller described ICU-discharge survival rate as 32% at two years, with a slower decline up to five years for ventilator-independent patients (43). We found the use of NIV at home in 31.5% of patients following PMV (16). Survival rates were poor (49% at one year and worse) in patients with COPD. In a research series by Pilcher, 38% of patients were fully weaned and 35% required HMV, most of the latter needing only nocturnal noninvasive support. Patients with NMD and transfusion-related diseases (TRD) were less likely to be weaned but had a reduced mortality, compared with those with COPD in whom survival rate was 58% at one year and 47% at three years (17). 

HMV is not without technical issues, and a recent European survey noted that quality control procedures showed considerable inter- and intra-country variability, there was poor communication between the prescribing centers and equipment suppliers, equipment quality control was limited, and only a few centers were associated with HMV-patient associations (44). 

Clinical experience supported by observational studies would suggest that weaning success is higher in dedicated WFs, with improved outcomes at reduced costs, provided patients are selected carefully. An international consensus on the management of difficult and prolonged weaning was recently published (48). Prospective randomized controlled trials that evaluate the influence of WF on weaning success are yet to be established. 

Scheinhorn DJ, Stearn-Hassenpflug M. Provision of long-term mechanical ventilation. Crit Care Clin 1998 14 819-832. 

Cohen IL, Booth FV. Cost containment and mechanical ventilation in the United States. New Horiz 1994 2 283-290. 

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Successful assisted ventilation depends critically upon adapting mechanical ventilation to the patient s needs. This is particularly true when the noninvasive mode is used, because the patient is conscious and if ventilation is ineffective or uncomfortable, the patient may reject it. In patients with chronic respiratory failure (CRF), noninvasive ventilation (NIV) is performed during sleep and comfort is particularly important if sleep is not to be compromised. An understanding of the technical equipment, in partieular the elassiQeation and modes of ventilation and the potential problems with each, is cmcial, as is the selecticm of an appropriate interface. This chapter deals with the equipment needs for home mechanical ventilation (HMV), in particular the major ventilator types and modes, interfaces, accessories, and monitoring. 

Skills related to home mechanical ventilation (HMV) technology and home care... 

During the 1970s, more patients with respiratory failure due to neuromuscular disorders and chest wall deformities received long-term ventilatory assistance at home, either via tracheostomy or body ventilators, which provided effective nocturnal noninvasive ventilation (NIV) (5,6). In the 1970s, the development of home respiratory therapy companies improved support for home mechanical ventilation (HMV). Respiratory therapists could now set up ventilatory equipment, educate the patient and caregivers about using the equipment, and be available to deal with problems. 

Chronic health care in Europe, like the rest of the developed world, is characterized by an increasingly aging population often with complex medical problems, an increase in societal expectations, and an increase in the dependence on expensive technology. Chronic respiratory failure is no different and is expected to rise in prevalence because of the aging population and possibly because of increased tobacco use. The expansion in Europe (1-3) and the United States (4) over the last three decades in the use of home mechanical ventilation (HMV) mirrors this trend. HMV is used to treat chronic hypercapnic respiratory failure in both adults and children and is usually delivered non-invasively (NIV) with the majority of patients using only nocturnal or nocturnal plus part daytime NIV. NIV has been shown to reduce mortality and morbidity (5,6) and to improve quality of life (7). 

Home mechanical ventilation (HMV) has been a reality in Brazil since 1994, although it is only available for people with private insurance (28% of the population). Public programs to help the low-income population receive HMV were started a few years... 

In contrast to some countries, the polio epidemics of the 1950s did not trigger the initiation of long-term ventilation (LTV) in Japan (1). The first patient to receive LTV at home was in Tokyo in 1975, when an adult with neuromuscular disease (NMD) received tracheal invasive positive pressure ventilation (TIPPV) (2). Despite the introduction of public assistance for costs associated with home mechanical ventilation (HMV), fewer than 200 patients were receiving HMV between 1990 and 1993 (Fig. 1) (2). 

Abbreviations-. CRF, chronic respiratory failure HMV, home mechanical ventilation. 

Figure 1 Median (interquartile range) year of starting HMV for each country. Demnark shows the median and full range as only two centers were included. Abbreviation HMV, home mechanical ventilation. Source From Ref 15.

Figure 1 Transition of the number of patients with HMV. Abbreviations HMV, home mechanical ventilation NPPV, nasal positive pressure ventilation TIPPV, tracheal invasive positive pressure ventilation.

Preventive actions and assessment are related to systematic follow-up, especially just after discharge, including physical, psychosocial, social, and cognitive dimensions. In patients on HMV, it is mandatory to try to solve specific needs like tracheostomy care or acute care during exacerbations. Home visits need a more complete appraisal of the situation in which prolonged mechanical ventilation (PMV) is carried out. The health care professional has more time at patient s home. With more information, it is easier to restructure care plans after the home visit, rather than after consultation in the hospital. Service coordination is very important when several professionals participate in the care of patients on HMV. 

In this chapter, we have highlighted the basic principles of managing the discharge home of the patient who requires prolonged mechanical ventilation. Although this may present major challenges to all concerned, the benefits in health-related quality of life and life expectancy may be substantial. Although some patients do find that the burden of HMV to be very difficult, most adjust with the help of home supports and many go on to achieve the unexpected (16). 

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