ATS GUIDELINES Bundle

4 Management ➤ Recommendation 4b: For children requiring chronic home invasive ventilation, we recommend regular maintenance of home ventilators and all associated equipment as outlined by the manufacturer. • Although states have differing regulatory requirements for DME providers, and the data supporting the value of equipment maintenance are lacking, the Workgroup believed strongly that maintenance of all home equipment by appropriately trained DME employees as recommended by the manufacturer should be standard of care. Care should be taken to assure that the actual ventilator settings as seen on the control panel match the prescribed settings. Twenty-four hour a day service and phone support must be available. This recommendation places a high value on the likely clinical benefits of properly functioning equipment programmed with the correct patient settings and low value on increased resource use. ➤ Recommendation 4c: We suggest the following pieces of equipment for use in the home when caring for a patient on home mechanical ventilation: the ventilator, a back-up ventilator, batteries, a self- inflating bag and mask, suctioning equipment (portable), heated humidifier, supplemental oxygen for emergency use, nebulizer, and a pulse oximeter (nonrecording). (conditional recommendation; very low quality evidence) • On the basis of experience, the Workgroup believed the presence of specific pieces of equipment could prevent the development of life-threatening situations and/or reduce their severity. This recommendation places high value on the potential to avoid emergent situations due to the presence of important reserve and emergency equipment and low value on increased resource use and increased equipment costs. ➤ Recommendation 4d: We suggest that a mechanical insufflation– exsufflation device be used to help maintain airway patency in patients requiring home mechanical ventilation with ineffective cough, including, but not limited to, those with neuromuscular disease with poor respiratory muscle strength. (conditional recommendation; very low quality evidence) • Equipment to facilitate airway clearance is essential in reducing the risk of acute airway obstruction in patients with ineffective cough. This recommendation places high value on the potential to avoid emergent airway plugging and low value on increased costs and resource use.

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