COVID-19 Resources

Home vent and NIPPV users

Download the quick informational patient guide from the CHEST Home-Based Mechanical Ventilation and Neuromuscular Disease NetWork or continue reading below.

NIPPV devices can increase the risk of infectious particles being dispersed into the environment, which can then infect the people around you. This risk is especially concerning with poor fitting mask interfaces, high leak, and open ventilation systems with tracheostomy.

To help limit the spread of these particles, our network of pulmonary and lung health experts, along with the Home Mechanical Ventilation and Neuromuscular Disease NetWork, has provided recommendations and guidelines to help keep you and your loved ones stay has healthy as possible.

Limit the spread of infectious particles

• Use a well fitted full-face mask (covering nose and mouth).
  Add an additional combined bacterial/viral (hepa) filter between the mask and device tubing (non-vented mask ➞ filter ➞ CO₂ exhalation port on tubing device).
  • Device humidifier needs to be off.
• Or, place a mask over the CO₂ exhalation port of your mask (if you are using a vented mask). Caution will need to be exercised to ensure the mask does not stick to the exhalation port of the mask and occlude it, as this would cause CO₂ retention.
• Or, change tubing to a closed system with a double lumen tube and nonvented full-face mask for compatible home ventilators (eg, Philips Evo, ResMed Astral, VOCSN).
• Need to discuss with your DME provider for set up of above options.

Caring for your disposable ventilation device

• Mask interface – Leaking from your mask can be a significant source of infection. Consider cleaning your mask daily with a cleaning wipe (mask cushions made from foam cannot be exposed to water and should not be used when sick). 
• Hoses – Clean your hoses with sterilizing solution (eg, sodium hypochlorite solution of 0.1% or 1000 ppm) every other day. This could be done with commercial solutions (ie, Control III Disinfectant) or by using a 50% hydrogen peroxide solution.
• Humidity chambers – Place fresh water into the chamber daily (distilled, bottled, or boiled). Clean the chamber and the hose every other day.
• Filters – Consider adding an additional viral/bacterial filter in-line with the device (see above). These filters help to reduce droplets and spread of infection to caregivers. (filters can be obtained from on-line sources but are likely available from your DME provider). You should change the filter every 3 days while sick.
• Also see cleaning guides (ResMed or Philips).  

Caring for your ventilation device

• Cleaning- This should be done by your DME provider when you are better.

Caring for your oral and nasal suction device

• Cleaning of the suction device—Clean your suction canister daily with a commercial sterilizing solution or a 50% hydrogen peroxide solution.
• Cleaning and changing tubing and Yankour tip 
  • Yankour – Clean daily with a commercial sterilizing solution or a 50% hydrogen peroxide solution. Between oral suctioning, consider wiping down with a paper towel or gauze with a chlorhexidine solution. Replace Yankour tip at the end of your illness.
  • Suction catheter — Clean after suctioning with a 50% hydrogen peroxide solution. Use one catheter a day and then discard.
• Consider adding additional suction adapters
  • Nose – Consider adding a small silicone adapter for nasal suction. Clean after suctioning with a 50% hydrogen peroxide solution.
  • Deep pharyngeal suctioning – Consider using a directional aid (ie, No BiteV). Clean between uses with a 50% hydrogen peroxide solution.

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Preventing secondary infections (eg, pneumonia)

• Keep the head of your bed elevated to 35°.
• Keep oral care aggressive; use a chlorhexidine solution.
• Consider in-line suction and once weekly tracheostomy tube changes for invasive mechanical ventilation.

What should I do if I have a tracheostomy?

• Tracheostomy tube change/cleaning frequency: once a week while sick
• Tracheostomy cleaning protocol:
  • Get one new tracheostomy tube every 3 months and always have at least 2 tracheostomy tubes at home.
  • Change the tracheostomy tube every week.
  • Use tracheostomy cleaning kits to clean the old tube and when it is very dry, store it in an airtight container until it is needed for the next tube change.
  • At the end of 3 months, discard the oldest tracheostomy, and put a new tube in the rotation.
• Cleaning Instructions: Clean the tracheostomy tube using the brush in the cleaning kit. Put hot soapy water (you can use 50% hydrogen peroxide solution in lieu of soapy water if desired) in the base of the kit, brush clean, and then rinse through with boiling water. When the tube is dry, put in an airtight container and save for the next tracheostomy change in 1 month.  
• Tracheostomy ties and stomal care— Continue with daily tie changes, and change stomal dressing as needed to keep gauze and stoma dry. Remember that these are respiratory secretions and will be densely filled with infectious particles. The ties and dressings should be thrown away into a zippered bag and sealed before putting in the trash. 
• Consider switching to an in-line suction system – switching will reduce exposure to caregivers and reduce the development of secondary infections.
• Leak Speech Ventilation: Controlling particle spread (balloon up ventilation) – Leak speech ventilation is common for those on home-based invasive mechanical ventilation. The concern is that the high leak associated with this mode of ventilation (balloon down) significantly spreads infectious particles. Work with your physician and respiratory therapist to develop a safe alternative setting that will allow you to put in a cuffed tracheostomy and put the balloon up until you are better. If you choose this mode, you will need to plan for alternative mode of communication.

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Extending the use of disposable equipment

Please note, equipment that is typically disposable should only be cleaned and reused when you are unable to procure new equipment from your medical supplier due to the pandemic.

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What your family and caregivers need to know

Space is needed for isolation while using NIPPV – NIPPV is known to spread infectious particles, especially with poorly fitted masks. Full face masks covering nose and mouth limit spread but may necessitate additional monitoring by caregivers in young children and/or those who cannot remove the mask by themselves. Well-fitting masks are best for limiting spread. Allow at least 3 feet of space for isolation. 

Keeping caregivers safe 

• Always wear gloves – Caregivers should wear gloves every time they enter your room and dispose of their gloves immediately after. 
• Always wear masks – Caregivers should wear masks (preferably N95) and eye goggles for protection. They should leave equipment in one location and dispose of the equipment daily. 
• Always wear protective clothing – Caregivers should wear protective gowns/clothing and follow the same protocol as mentioned above.
• Always clean surfaces – Caregivers should clean surfaces with commonly available anti-bacterial/viral sprays. 

Resources to keep at home 

• Extra distilled water
• One-month extra supply of medications
• Extra laundry supplieS
  

Extending the use of disposable equipment

Please note, equipment that is typically disposable should only be cleaned and reused when you are unable to procure new equipment from your medical supplier due to the pandemic.

I think I need to go to the hospital. Now what? 

You should avoid hospitals, if possible, unless you have a fever over 100° F and/or increasing shortness of breath that does not respond to your usual treatment. Please contact your pulmonologist if you are experiencing these symptoms. If you are advised to go to the hospital and admitted, be aware that you may not be able to use noninvasive ventilation.

Before going to the hospital, be sure to know your medication and airway clearance regimen. This will help your medical team provide better treatment. Read more information about going to the hospital while using an at-home ventilation device and what you can expect.

Hospitalization during COVID-19

Hospitals are doing everything they can to take care of people with COVID-19 and prevent the spread of the virus that causes it. Hospital policies for patients with COVID-19 can change frequently.

Treatment and testing guidelines also vary among hospitals and from state to state. Try to stay flexible and understand that policies and treatments do change for important reasons. Expect the unexpected when it comes to this virus, and you can feel better prepared for what comes next.

COVID-19 has disproportionately affected specific minority ethnic groups. Access to health care and continued health-care support outside the hospital can be challenges. The care team will work to recognize and address these issues to ensure that patients have choices about how to obtain the best care after discharge from the hospital.

Health-care providers managing inpatients with COVID-19 who are from racial and ethnic minority groups must understand the health-care beliefs of their patients. These beliefs may have developed after negative experiences in health-care institutions. In addition, the care team must make extra efforts toward educating some patients from socioeconomically deprived areas with reduced health-care literacy.

COVID-19 and the ICU

The COVID-19 virus attacks and damages the lungs. Therefore, people with chronic lung disease are more likely to need treatment in an ICU if they develop COVID-19. If you or a loved one fall into this category, learn more about what you can expect in the ICU.

Download our guide “COVID-19 and the ICU.”

Treatment for COVID-19

The health-care community continues to learn more about COVID-19 and how to treat it. Guidelines can and will change as researchers study the virus.

Ventilators

Many people with acute respiratory distress syndrome need a ventilator. The ICU team places a tube into the patient’s throat (called intubation). The tube is then connected to the ventilator. You may have heard about intubation in the news. It’s a common and safe procedure.

Patients with COVID-19 typically need a ventilator for more than 2 weeks. The good news is that more people in the United States are surviving COVID-19 after being supported on a ventilator. This may be because doctors continue to learn more about the virus and how to use ventilators to treat it. Find out more about how ventilators are used in the ICU.

High-Flow Nasal Cannula

People who contract COVID-19 can develop hypoxemic respiratory failure. Hypoxemia is a lower-than-normal level of oxygen in the blood. It’s a sign of a breathing or circulation problem.

A high-flow nasal cannula can be an alternative to a ventilator in some cases. A cannula is a plastic tube that goes under the nose. It has two small tubes that go into the nose to deliver oxygen at a higher rate than a traditional cannula.

Proning

As doctors have learned more about COVID-19, they’ve found that placing patients on their stomach (called proning) can be an effective treatment for acute respiratory failure. Proning can reduce the need for a ventilator and improve a patient’s oxygen levels.

Limited Contact

Hospitals have implemented stricter visitor guidelines during the COVID-19 pandemic. These restrictions protect patients, their friends and families, and hospital staff. They also limit the spread of the virus.

Visitation rules may change frequently depending on the status of the pandemic. You may also notice tighter restrictions during flu season.

If you can’t visit the patient in the ICU, hospital staff can help you stay in touch. You can use other forms of communication, such as:

• Phone calls
• Video calls
• Cards

Some hospitals may require a negative COVID-19 test before you can enter the facility. Others may screen when you arrive.

People with COVID-19 must stay in isolation rooms. These rooms have special equipment that helps keep the virus from spreading to other parts of the hospital. Many hospitals also have dedicated staff who only treat patients with COVID-19.

Hospitals have implemented stricter visitor guidelines during the COVID-19 pandemic. These restrictions protect patients, their friends and families, and hospital staff. They also limit the spread of the virus.

Visitation rules may change frequently depending on the status of the pandemic. You may also notice tighter restrictions during flu season.

If you can’t visit the patient in the ICU, hospital staff can help you stay in touch. You can use other forms of communication, such as:

• Phone calls
• Video calls
• Cards

Some hospitals may require a negative COVID-19 test before you can enter the facility. Others may screen when you arrive.

People with COVID-19 must stay in isolation rooms. These rooms have special equipment that helps keep the virus from spreading to other parts of the hospital. Many hospitals also have dedicated staff who only treat patients with COVID-19.

An Ever-Changing Environment

Remember that doctors and researchers discover more about COVID-19 each day. As they learn, treatments will improve and change. The health-care team will guide you through the treatment and recovery processes.

Health-care providers are invested in building a relationship based on mutual respect with the patient and caregiver. This approach helps to ensure that medical care is given in a safe, equitable, and effective manner and that the outcomes are good.

Hospitalization with an NIPPV device

• Bring ALL of your home devices as the hospital may not have what you are used to and they may be out of devices. Some hospitals will not allow use of home equipment, but it is a safe precaution to bring them.
  • Know your settings (ask your provider to give you a one-page list that includes your PAP device/home ventilator settings, cough assist, suction, nebulizer therapy).
  • Confer with the hospital medical providers on options:
    • Convert the NIPPV device tubing/mask circuitry into a closed system, which is a double-lumen tube with a nonvented full-face mask.  This will limit risk of infectious particle spread to the surrounding. (New home ventilators are capable of double-lumen tubing (eg, Philips Evo, ResMed Astral, VOCSN).
    • Add a combined bacterial/viral filter between the mask and device tubing to reduce particle spread (nonvented mask ➞ filter ➞ CO₂ exhalation port on tubing ➞  device).
  • Know your medication regimen.
  • Know your airway clearance regimen.
    • Limit cough assist and nebulizer therapy to as needed.
    • Operator will need to wear personal protective equipment (PPE).
  • Go to the “take charge not chances” program from the International Ventilator Users Network (IVUN) and fill out the following:
    • Home Ventilator User’s Emergency Preparation Checklist
    • Caregiver’s Emergency Preparation Checklist
    • Patient’s Vital Information for Medical Staff
    • Treating Neuromuscular Patients Who Use Home Mechanical Ventilation: Critical Issues
• Advocate for frequent and scheduled airway clearance. Bring your home devices (cough assist, therapy vest, etc). You may need to have your caregivers give you the airway clearance treatments as the hospital may only have basic suction available.
• Challenges around the use of oxygen – If you have chronic respiratory failure causing CO₂ retention, the use of supplemental oxygen can be risky, causing steep escalation in blood carbon dioxide (CO₂) levels. You may have been instructed that you should never be treated with oxygen. You should be aware that in the setting of infectious pneumonia – you may need oxygen in order to maintain adequate oxygen saturation with noninvasive ventilation. As long as oxygen is delivered through your positive airway pressure (PAP) device or ventilator – you will be protected as the CO₂ will be washed out by your PAP device/ventilator.
• Patients supported on home NIPPV infected with COVID-19 will need both NIPPV and oxygen.
• For patients who are severely ill or showing signs of deterioration, intubation and mechanical ventilation may be required.

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Authors

Michelle Cao, DO, FCCP
Pulmonary, Critical Care, Sleep Medicine
Division of Neuromuscular Medicine & Division of Sleep Medicine, Stanford University

Megan Carreon, MHA, RRT
Assistant Professor
Division of Respiratory Care, School of Health Professions, UT Health San Antonio

De De Gardner, DrPH, RRT, FCCP
Associate Professor
College of Health Professions, Department of Respiratory Care, Texas State University

Sherri Katz, MD, FCCP
Pediatric Pulmonology and Sleep Medicine
Division of Pediatric Respirology, Department of Pediatrics, University of Ottawa

Burt Lesnick MD, FCCP
Pediatric Pulmonology
Children’s Healthcare of Atlanta

Richard Wettstein, MMed, RRT
Program Director, Associate Professor
Division of Respiratory Care, School of Health Professions, UT Health San Antonio

Lisa Wolfe, MD, FCCP
Pulmonary, Critical Care, Sleep Medicine
Division of Pulmonary and Critical Care, Department of Medicine, Northwestern University