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Child Health Guideline Identifier

Respiratory Support/Long Term Ventilation after hours issues

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This information is for staff dealing with children receiving long term respiratory support / ventilation  outside of the Respiratory Department / Laboratory's ordinary working hours.

Key points

  • Respiratory support / ventilation via the Respiratory Department / Laboratory is intended for long term use in children with stable requirements, not acute care. The Laboratory does not currently provide after-hours technical support or equipment.
  • Children receiving community respiratory support / ventilation via the Respiratory Department should have a Respiratory Emergency Management plan on Concerto detailing their underlying condition, respiratory support, degree of 'dependency' and plans for both acute deterioration and equipment failure.
  • Details of a child's respiratory support / ventilation equipment as supplied by the Respiratory Laboratory are detailed in the Physiologist E-note on 3M Chartview.This appears at the very bottom of their Chartview documentation by default.
  • The on-call Respiratory Specialist is available 24/7 via switchboard, ext 21900 or 09 365 4330. Outside of PICU, they should be involved in any changes to respiratory support equipment (masks, circuits, device, addition of oxygen, change in settings).

'Dependency' Categories

Children receiving ventilatory support are diverse in aetiology, needs, dependency and support offered, making it difficult to generalise. The Respiratory Department typically classifies children into broad categories to aid planning and this should appear in the Emergency Management Plan on Concerto.

Category Description
Life support
(continuous or sleep)
These children are highly dependent on their ventilation. They will typically have backup equipment with them and if acutely unwell would be admitted to PICU by default.
Health support  These children (the majority) can typically go several days without ventilation without experiencing severe irreversible harm. They will not usually have backup equipment and technical issues can usually wait until the Respiratory Laboratory / Department's ordinary working hours. If acutely unwell it may be appropriate to discontinue, maintain or escalate their respiratory support. If support requires escalation consider whether they need PICU admission (default).
Fragile health support    These children aren't viewed as highly dependent (can usually go without ventilation for a period) but for a variety of reasons are particularly fragile.
They may have backup equipment and/or additional alarms. They may have very specific plans and specialist discussion is recommended.
Palliative support These children may be highly dependent but may have different therapeutic goals and very specific management plans. They may have backup equipment and additional alarms. They may have Advance Care Plans. 

Acute illness

  • Appropriate action will depend on the child and the nature of their acute illness.
  • Check with the child's Respiratory Emergency Management Plan.
  • See categories above
  • It may be appropriate to discontinue, maintain or escalate their ventilation. Caution is recommended where ventilation is maintained or escalated as this may be a change in indication and the child may now be best managed / monitored in higher intensity environments (i.e. IOA / HDU / PICU).

Admitting a child on respiratory support / ventilation

See the "Respiratory Support on Starship Wards" guideline under Starship Clinical Guidelines. Also note relevant Child Health policy for ward observations.

Starting ventilation acutely

High flow nasal prong therapy ('High flow' / Airvo) may be started acutely in ED or on ward as per prevailing Starship protocols. Other forms of ventilation (CPAP, BPAP, etc) are generally only started acutely within PICU.

Changing pressure settings

Only do this in consultation with the on-call Respiratory or Intensive Care Specialist. Each device is different. Equipment instructions can be found on the Starship L drive. This folder is open access (on ADHB network) - to access copy and paste L:\Groups\STARSHIP\Respiratory\Resp lab\Equipment instructions into your ADHB web browser. There may be specific recommendations regarding this in a child's emergency management plan.

Changing to different mask

Only do this in consultation with the on-call Respiratory or Intensive Care Specialist. Fitting a new mask requires specific skills. Changing a mask or an incorrect fitting may affect ventilation outcomes. Almost all masks used for community / ward Long Term Ventilation (LTV) are vented masks (holes for intentional leak). Using a non-vented mask (from PICU) will lead to rebreathing and clinical deterioration.

Setup instructions

Equipment instructions can be found on the Starship L drive. This folder is open access (on ADHB network) - to access copy and paste L:\Groups\STARSHIP\Respiratory\Resp lab\Equipment instructions into your ADHB web browser. These documents are intended as aids for those already familiar respiratory support / ventilation. The setting up of ventilatory support by untrained staff is not recommended for dependent / fragile children and may lead to serious adverse events.

Replacing failed equipment

Children so dependent that they cannot go at least one night without support should have been supplied with backup equipment (interfaces, circuits, ventilator). Where this is not available, circumstances have changed and/or safety concerns exist, liaison with the on call Respiratory Specialist is recommended. In general admission to PICU/HDU for support on ICU equipment will be the most appropriate outcome until replacement equipment can be sourced and appropriately set up. Setting up equipment by untrained staff is not recommended and may lead to serious adverse events.

Adding oxygen

Supplemental oxygen can be added to all forms of ventilation. Oxygen must not be left running when a device is off (fire / explosion risk).

Device Means Picture Flow
CPAP Icon  Oxygen T-piece in circuit (at either the device or mask end)   respiratory support 1  0-15L/min
CPAP Sleepsense   Oxygen T-piece in circuit (at either the device or mask end)  respiratory support 2  0-15L/min
CPAP other  Likely via oxygen T-piece in circuit (at either the device or mask end)   respiratory support 3  0-15L/min
BPAP Resmed 
VPAP III
Oxygen T-piece in circuit (at either the device or mask end)   respiratory support 4  0-15L/min
BPA Resmed
S9 VPAP
Specific circuit (CLIMATELINE MAX OXY 36996) or via oxygen adaptor T-piece in circuit   respiratory support 5  0-15L/min
Resmed Lumnis  Specific circuit (CLIMATELINEAIR OXY 37357) or via  oxygen adaptor T-piece in circuit  respiratory support 6 0-15L/min 
Resmed Stellar    Oxygen port at rear (white adaptor required) 
respiratory support 7a
 respiratory support 7 0-30L/min 
Resmed Astral    Oxygen port at rear (white adaptor required) 
respiratory support 7a
 respiratory support 8 0-30L/min
0-6L/min in travel bag
F&P Airvo   Oxygen port at side or rear     Respiratory support 9 0-15L/min 

** If a child doesn't already have the correct circuit or adaptor, these may be found on Ward 26b or in the Starship Respiratory Laboratory (Level 3) - consult with the on call Respiratory Specialist

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Document Control

  • Date first published: 14 November 2018
  • Date last published: 14 November 2018
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Respiratory
  • Author(s): Jacob Twiss, Tony Bell
  • Editor: Greg Williams
  • Review frequency: 2 years

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