CPAP on the unit

1 I recently had a man with broken ribs as a patient, he told us he usually has CPAP overnight, and brought his machine and mask in. I was on night shift, and when I assisted him with the setup it was clear that the mask and harness had about four flaws that destroyed the seal. I'd McGyver the thing with tape and something else would give. It was unusable.

i called RT to obtain a mask for him to use temporarily, and the tech said they don't have any. Well, yeah they do...we use hospital CPAP on CHF patients routinely. Then he said the hospital mask is not compatible with the patient's machine. I didn't think anyone could say that without actually looking at the patient's machine, so I asked the RT to come to the unit, with the mask, please. He refused to bring a mask, but he came, took one look, and said the hospital mask couldn't be used.

The RT says that each machine must be paired with a mask specifically designed for a particular machine. He said by using one of the hospital masks with an outpatient machine, the air flow wouldn't be correct, and we would risk patients dying of co2 toxicity. I've thought about this since....I think the CO2 toxicity issue is bogus. Those masks must hold less than 50ml of air, and it's air that's constantly flowing with the pressure. Even without the machine turned on, tidal volume is what, 500ml? It just doesn't jive for me.

Second, the issue of needing a specific mask with each make of CPAP machine. Also doesn't ring true. The machine and the mask don't communicate with each other. Every machine will generate the required air pressure, and if a mask has more or less ventilation the pressure will be maintained. If a mask has safe airflow with one machine, what changes to make it unsafe with another machine?

If anyone has information that supports or negates what I've said, could you let me know?

i'm thinking that this is all about which department has to pay for the equipment.
The masks are interchangeable aren't specific to a particular machine. Hospitals can bill when using hospital provided CPAP, they can't bill for equipment the patient owns. A patient using their own machine but a hospital provided mask would be tricky to bill for which was probably the real reason why the RT didn't want to give you a mask since you are correct, the RT's reasoning was bogus.

We no longer allow home CPAP/BIPAP machines in our hospital due to the many safety concerns. This is also the trend in other hospitals.Increased levels of CO2 is just one concern. It is a very real factor. It is being preached enough in patient home education so that it is routinely a discussion on patient forums. Patients are told to notify their sleep physician immediately if experiencing headaches or more drowsiness. You do not know how well that home machine is functioning or the last time it was serviced. What type of mask interface and exhalation system is being used? What are the actual settings? Many patients now are on some hybrid setting. When was the last time the machine, humidifier, filter and circuit was cleaned or changed? Infection leading to death is one sentinel mentioned in ECRI reports. The RT would have to chart to justify just a mask charge on a home CPAP machine which opens up the issues about maintenance. When the RTs set up BiPAP or CPAP machines on CHF patients, especially in acute situations, I would hope they are not using the little CPAP macines which have few to no alarms and no ventilating monitoring capabilities. There is also the issue of oxygen titration. Bleed in O2 is not the best for emergent situations and may be resticted to 4 liters or less. The bigger machines (V60, Vision) more commonly used in acute situations are capable of blending air and oxygen as well as achieving flows of 240 lpm. These machines also require a pre test to monitor exhalation port flow or the masks have an identifying number to be set in the machine identifying its characteristics. There are also several brands and styles of mask with variations in exhalation ports to fit certain machines. Some are very brand specific which means a company wants you to buy their masks.If you alter a home CPAP machine in any way, you are setting yourself up for huge liability. This includes McGyver stuff involving tape. Review your hospitals policy. Obtain a copy of the patient's script from the DME. Yes, they will fax it if you submit the request properly. Ask the RT staff to set up their own equipment per an order AND a policy. Contact Case Manager to assist patient with getting a new mask. Most insurances will pay for 2 sets of gear per year. But, if your patient cannot provide proof of a script or admits to getting his stuff from ebay or a friend because he thought he has OSA, be careful. This is now more common than you think. This might be the first time a doctor is admitting a patient and might chart what the patient states as fact before getting other records.Many of the home style CPAP/BiLEVEL machines used in the hospital are auto titrating which make it nice for OSA screening but all equipment is machine or brand specific.

Quote from GrannyRRTWe no longer allow home CPAP/BIPAP machines in our hospital due to the many safety concerns. This is also the trend in other hospitals.Increased levels of CO2 is just one concern. It is a very real factor. It is being preached enough in patient home education so that it is routinely a discussion on patient forums. Patients are told to notify their sleep physician immediately if experiencing headaches or more drowsiness. You do not know how well that home machine is functioning or the last time it was serviced. What type of mask interface and exhalation system is being used? What are the actual settings? Many patients now are on some hybrid setting. When was the last time the machine, humidifier, filter and circuit was cleaned or changed? Infection leading to death is one sentinel mentioned in ERCI reports. The RT would have to chart to justify just a mask charge on a home CPAP machine which opens up the issues about maintenance. When the RTs set up BiPAP or CPAP machines on CHF patients, especially in acute situations, I would hope they are not using the little CPAP macines which have few to no alarms and no ventilating monitoring capabilities. There is also the issue of oxygen titration. Bleed in O2 is not the best for emergent situations and may be resticted to 4 liters or less. The bigger machines more commonly used in acute situations are capable of blending air and oxygen as well as achieving flows of 240 lpm. These machines also require a pre test to monitor exhalation port flow or the masks have an identifying number to be set in the machine identifying its characteristics. There are also several brands and styles of mask with variations in exhalation ports to fit certain machines. Some are very brand specific which means a company wants you to buy their masks.If you alter a home CPAP machine in any way, you are setting yourself up for huge liability. This includes McGyver stuff involving tape. Review your hospitals policy. Obtain a copy of the patient's script from the DME. Yes, they will fax it if you submit the request properly. Ask the RT staff to set up their own equipment per an order AND a policy. Contact Case Manager to assist patient with getting a new mask. Most insurances will pay for 2 sets of gear per year. But, if your patient cannot provide proof of a script or admits to getting his stuff from ebay or a friend because he thought he has OSA, be careful. This is now more common than you think. This might be the first time a doctor is admitting a patient and might chart what the patient states as fact before getting other records.Many of the home style CPAP/BiLEVEL machines used in the hospital are auto titrating which make it nice for OSA screening but all equipment is machine or brand specific.

What type of whisper valve or exhalation port is on the mask or hose? How much deadspace does that machine model compensate for? Different mask brand can vary in deadspace. Does the machine have external pressue lines? Is the machine set up for adaptive flow with varible pressures? How do you know what pressure the machine is achieving and when the last time it had a tuneup for accuracy?The machines uses in the hospital for acute situations will usually have a very different tubing with separate pressure lines for feedback to the machine. The exhalation port will be diiferent to accomondate the high flows. Home machines may have only a solid hose and have and exhalation port built in to the face mask. An additional safety valve may also be present on full face masks in case of power failure or disconnect.The home CPAP machines today are sophisticated with complex sensors for optimum performance. Hopefully the brown ST boxes with a couple of spin knobs have all gone to a museum.A few hospitals learned the hard way when they used extra 22 or 15 mm adapters to attach the masks to their equipment and ended up doing Rapid Responses later and some hefty paperwork to the state. The point, don't make it fit and use the style recommended with the correct exhalation assembly.Face masks designed for homecare are more easily adaptable but not the short term disposable ones designed for the hospital CPAP/BiPAP machines. If you want to get your Respiratory Therapist in deep trouble, send the mask from the ICU machine home with the patient to use on their home unit.

Quote from GrannyRRTWe no longer allow home CPAP/BIPAP machines in our hospital due to the many safety concerns. This is also the trend in other hospitals.

I have been a registered sleep technologist for 14 years and I have seen CPAP being used in the hospital during nursing clinicals. The disposable masks used in the hospitals are cheap versions of the home masks. I agree that the use of their home machine opens up to all the above concerns (maintenance, mold, accurate pressure (which can be easily verified with a CPAP meter). Although some home machines have a setting for certain masks, the problem is the home machine lasts 5-7 years and new mask models come out every 6 months. It would be way too cost prohibitive for the patient to replace their machine each time they got a newer model of mask not available on their machine. Patients bring in their own masks and hoses for their overnight CPAP titration study in my sleep lab. They bring in one of a dozen different masks from 3-4 different manufacturers. So for the RT to say that their mask is incompatible to the patient's machine is BS. Every mask and hose is interchangeable regardless of the manufacturer.

Our hospital allows use of the home CPAP machine and mask without any restrictions. I've asked for a replacement mask before when the patient's equipment was just repulsive, and possibly why they ended up with an infection in the first place. Never been able to get any assistance from the RT department, they don't even want to come look at the situation. What gives? Even to the point of not replacing the straps of the patient's setup.I'd be totally happy if they just allowed an in hospital mask and machine during the admission, but they say it would require an ICU admit order. It sounds like hospital politics are interfering with patient care to me.I came on duty at 7:30pm, to a patient that needs respiratory support, and his equipment is nonfunctional. The patient is admitted with a respiratory concern, we need to provide the support he needs. What the hell?granny RRT it sounds like you are imagining a more complex system than we encounter for home based care. There's no feedback from the mask. I would like to educate myself though...do you have any links, or reliable sites I could look at to learn about CPAP use and standards of care?

I had a family member with a home bipap machine. Was told something about a valve was different and thus why the hospital mask we brought home wouldn't work. I don't think every machine requires its own mask, but could see there being a few different kinds. I don't know, will defer to the RTs in this thread on that one.As for policies and liability:RTs don't mess with home bipap because RTs get to bill for their services unlike nurses. So while we're tucked into the room charge, everything the RTs do can be reimbursed. But if they're just helping with home stuff, they're opening themselves (and the hospital) up to liability for things they aren't being reimbursed on. What hospital is going to allow that?When nurses help with non-hospital approved/biomed checked equipment, we're also opening ourselves up to liability. Do you know if the machine has been maintained? (Especially if you can immediately see problems with the mask/equipment, what else is going on with it that you can't see?) Anytime we have patients/families that want to use home equipment they bring in, it has to be checked by our biomed team first (which can at times be ridiculous, things like a feeding pump are pretty obvious when they aren't working right, but with breathing equipment, not so obvious so I'd agree a good thing to check) and generally we can't touch them, patient/family has to do all the adjustments. Unless there is a really good reason the home equipment is superior, using hospital equipment is just easier and avoids all sorts of liability issues.The bigger question is why on earth does CPAP require transfer to ICU? It makes sense if a patient out of nowhere is requiring it (because why they suddenly need it likely requires close monitoring), but on a patient that regularly uses it at home?

i called RT to obtain a mask for him to use temporarily, and the tech said they don't have any. Well, yeah they do...we use hospital CPAP on CHF patients routinely. Then he said the hospital mask is not compatible with the patient's machine. I didn't think anyone could say that without actually looking at the patient's machine, so I asked the RT to come to the unit, with the mask, please. He refused to bring a mask, but he came, took one look, and said the hospital mask couldn't be used.

Quote from MunoRNI can't find anything that says this is a "trend", maybe you could direct me to a source? There are certainly compelling reasons not to allow home CPAP, but it's based on billing, not safety.The only current information on the use of home CPAPs in hospitals makes no reference to safety concerns, but does point out that requiring patients to use hospital provided CPAP costs the patient an additional $416 per day. Financial incentive of home continuous positive... [Laryngoscope. 2014] - PubMed - NCBII think your confusing the machine and mask. If the patient requires PPV functionality or monitoring capability that exceeds what a home machine can provide then absolutely they need to be on hospital equipment. We're talking about someone who just needs their baseline PPV and needs a functional mask. Masks are not specific to machines and are intentionally interchangeable which is why the major manufacturers use a single standard fitting size for home equipment.

Quote from Don1984 So for the RT to say that their mask is incompatible to the patient's machine is BS. Every mask and hose is interchangeable regardless of the manufacturer.

to GrannyRRT,I had a patient die from complications of Legionella pneumonia. The Health Department identified the source of the infection was his home CPAP machine.It sounds like if the pt is sick enough to be admitted for a cardiac or pulmonary diagnosis, we need to use the hospital BiPap/CPAP and obtain a physicians order for the pressures and to titrate the Fi02. I would prefer to see the waveforms, resp rate and pressures anyway.