Alarms in Long-Term Home Mechanical Ventilation

Abstract

Home CPAP and noninvasive ventilation (NIV) are increasingly used in pediatric and adult patients. The number of patients with NIV dependence continues to rise, and in some situations, invasive mechanical ventilation remains necessary in both children and adults. In these fragile populations, ventilator alarms may detect significant ventilatory events and alert caregivers to guarantee the patient’s safety. However, guidelines are lacking to optimally set the ventilator and/or monitor alarms at home. Clinical alarms should be sensitive and specific enough to avoid an overabundance of alarms, and patients and family caregivers must be educated to respond appropriately. Moreover, health care teams should regularly monitor alarms and adjust alarm settings if necessary. This narrative review examines the available data literature and describes the usefulness, settings, and monitoring of alarms in long-term home NIV and invasive ventilation in both pediatric and adult populations and CPAP in pediatrics.

Keywords

CPAP NIV invasive ventilation infants NIV dependence

Introduction

Home CPAP and noninvasive ventilation (NIV) are increasingly used in pediatric and adult patients.^1–6 Although the number of patients on invasive mechanical ventilation is decreasing in many countries, some conditions still require invasive ventilation for long-term ventilation at home.^7–11 At the same time, the number of NIV-dependent patients is also increasing.¹²

Ventilator-dependent patients are a high-risk population. Indeed, complications with the ventilator, or tracheostomy tube for invasively ventilated patients, can be life-threatening. Prevention of serious adverse events or even death depends on setting appropriate ventilator alarms.¹³ Home ventilators provide alarms that may detect significant ventilatory events, alert caregivers, and increase the patient’s safety.

However, there is limited evidence regarding the effectiveness of ventilator alarms and how they should be optimally used. The nature of events and the appropriate monitoring parameters depend on the patient condition (invasive ventilation or NIV) and the ventilation mode. A few guidelines on invasive ventilation management recommend pulse oximetry (S_pO₂), in addition to internal ventilator alarms or other monitoring devices, to prevent serious adverse events.^11,14,15 However, studies or guidelines describing how to optimally set the ventilator and/or monitor alarms to guarantee the safety of the children and adults at home are lacking.¹³ Moreover, to the best of our knowledge, no study or guideline provides guidance for alarm settings for NIV-dependent patients or for CPAP/NIV in infants. Clinical alarms should be both sensitive and specific, while avoiding excessive frequency that can lead to alarm desensitization, fatigue, lack of vigilance, and increased stress for patients and caregivers.^9,16 Therefore, clinical alarm settings should be personalized to each patient. Patients and family caregivers must be educated on alarm management to understand their meaning and act appropriately. The healthcare team should monitor alarms on a regular basis and reassess their settings. This narrative review examines the available literature and, based on our clinical experience, provides practical considerations for setting ventilator alarms according to the type of home mechanical ventilation (noninvasive or invasive) or CPAP (for pediatrics) and the age of the patient. We conducted a literature review in PubMed for published clinical studies in English until March 30, 2026, using the terms “alarm” AND “noninvasive ventilation” OR “non-invasive ventilation” OR “invasive mechanical ventilation” OR “home ventilation” OR “continuous positive airway pressure” OR “CPAP”, AND “pediatrics” AND “adverse events”. This review details the settings, monitoring, and education principles of clinical alarms for pediatric and adult patients mechanically ventilated at home.

Rationale for Alarm Settings

Patients dependent on home mechanical ventilation (or on invasive CPAP in pediatrics) should use a ventilator equipped with battery backup.^17–19 Power supply and technical alarms signaling ventilator failure are mandatory and built-in with ventilators. Users and prescribers do not have access to these alarms. Conversely, clinical alarms can be set or deactivated according to the need and clinical situation. When patients are unable to breathe independently for more than a few minutes, the alarms should be set cautiously to alert caregivers in case of ventilation impairment, taking into account the patient’s ability to communicate and move. As the continuous presence of a trained caregiver is not always possible, the monitoring of patients NIV-dependent or receiving invasive ventilation will rely on the ventilator alarms and external monitors and should be optimized to guarantee the patient’s safety. Alarms aim to rapidly detect conditions associated with a risk of adverse events. In children on invasive ventilation or with NIV dependence, external monitors such as a pulse oximeter are recommended.^8,14,15 For patients who can breathe an hour or more without ventilatory support, the risk of an untoward event is lower; clinical alarm settings will depend on their ability to move and communicate, and on the presence of family caregivers to support them.

Ventilator alarms are configured by the manufacturers with priorities from low to high, depending on the alarm type. One of the main challenges is reducing irrelevant or false alarms to avoid a high alarm burden for the patient and caregivers. However, alarms should be set with enough sensitivity to avoid serious or permanent harm and death.¹⁵ The volume of audible alarms should be adjusted to the environment, in agreement with the patient and caregivers. Some ventilators also provide a remote alarm system. In addition, visual alarms are consistently displayed, which is particularly important in noisy environments where ambient sound may impair the perception of audible alerts; otherwise, systems with “sensory” alarms should be considered.²⁰

Home ventilators feature different types of alarms, and the settings for the same type of alarms may differ between different devices. The understanding of the alarm definition and its sensitivity is mandatory to correctly set a given alarm for a patient.

Progressive deterioration of respiratory mechanics, which gradually impairs minute ventilation, increasing the risk of alveolar hypoventilation, should be detected by regular monitoring of ventilator data, including event logs when present, and nocturnal recordings. Therefore, they do not need specific clinical alarms. Alarm settings may also be adapted based on the event log to deal with the excessive occurrence of certain alarms without reported clinical consequences, or, on the contrary, to allow a better sensitivity of some alarms (see the Monitoring Alarms section). In pediatric patients, the alarm settings should also be regularly reviewed and adapted in accordance with the child’s growth.

What Events to Detect?

Noninvasive ventilation

Adults

For adult patients on NIV, the highest risk is a circuit disconnection or mask displacement that will lead to large leaks and ineffective ventilation. If the patient cannot reconnect the circuit or replace the mask, severe desaturations may occur, potentially complicated by cardiac arrest. This event is prevented by securing the ventilator circuit and selecting stable masks and headgears. However, in case of disconnection, setting a “disconnection alarm” will alert the patients’ caregivers (Table 1 and Fig. 1). The disconnection alarm is a preconfigured alarm that associates a high inspiratory tidal volume (V_Ti) combined with a low airway pressure and large leaks in pressure-targeted modes such as pressure support. In flow-targeted modes (volume assist and volume-controlled modes), the “disconnection” alarm is activated when airway pressure is low. Some manufacturers propose to set the degree of disconnection in percentage, assessed by a continuous measurement of the circuit resistance, together with an alarm activation time, in order to individualize this alarm to each patient.

Fig. 1.

Main events and corresponding alarm settings according to the ventilatory mode and circuit. This figure illustrates the 2 main events clinicians aim to detect using alarms, their impact on monitored parameters depending on the ventilatory mode, and the appropriate alarms to set according to the selected ventilatory mode and circuit. Circuit on the left side: dual-limb circuit; circuit in the middle: single-limb circuit with leaks; circuit on the right side: single-limb circuit with an active expiratory valve. P_AW, airway pressure; P_MAX, high airway pressure alarm; P_MIN, low airway pressure alarm; VMe, expiratory minute ventilation; VMi, inspiratory minute ventilation; VTe, expiratory tidal volume; VTi, inspiratory tidal volume; VMi _MAX, high minute ventilation alarm; VMi _MIN, low minute ventilation alarm; VTi _MAX, high tidal volume alarm; VTi _MIN, low tidal volume alarm.

Table 1.

Proposed alarm settings according to the ventilation circuit and mode in adults

	P max	P min	V_Ti max	V_Ti min	V_Te max^a	V_Te min^a	MVi min	MVe min^a	High f^b	Disconnection	Rebreathing	Apnea^b	Leaks
NIV—PSV/P(A)C with leak circuit	OFF	ON (leaks)	NA	NA	OFF	OFF	NA	OFF	35	ON	ON	OFF	OFF
NIV—PSV/P(A)C with active expiratory valve	OFF	ON (leaks)	300–500 mL above mean V_T (leaks)	OFF	NA	NA	OFF	NA	35	ON	NA	OFF	NA
Invasive ventilation—PSV/P(A)C with leak circuit	OFF	ON (leaks)	NA	NA	300–500 mL above mean V_T (leaks)	200 mL below mean V_T (obstruction)	NA	OFF	35	ON	ON	OFF	OFF
Invasive ventilation—PSV/P(A)C with active expiratory valve	OFF	ON (leaks)	300–500 mL above mean V_T (leaks)	200 ml below mean V_T (obstruction)	NA	NA	OFF	NA	35	ON	NA	OFF	NA
Invasive ventilation—PSV/P(A)C with dual-limb circuit	OFF	ON (leaks)	300–500 mL above mean V_T (leaks)	200 mL below mean V_T (obstruction)	OFF	200 mL below mean V_T (obstruction and leaks)	OFF	OFF	35	ON	NA	OFF	OFF
Invasive ventilation—V(A)C with active expiratory valve	10 cm H₂O above peak pressure (obstruction)	5–10 cm H₂O below peak pressure (leaks)	OFF	200 mL below set V_T (obstruction)	NA	NA	OFF	NA	35	ON	NA	OFF	NA
Invasive ventilation—V(A)C with dual-limb circuit	10 cm H₂O above peak pressure (obstruction)	5–10 cm H₂O below peak pressure (leaks)	OFF	200 mL below set V_T (obstruction)	OFF	200 mL below set V_T (obstruction and leaks)	OFF	OFF	35	ON	NA	OFF	OFF

The names of alarms are different between manufacturers for the different circuit conditions and ventilation modes.

Estimated volume for leak circuit, expiratory volume for single-limb circuit with active expiratory valve or dual-limb circuit.

Low f and apnea alarms are not necessary if a back-up f is set.

EPAP, expiratory positive airway pressure; f, breathing frequency; NIV, noninvasive ventilation; PSV, pressure support ventilation; P(A)C, ventilation in assist-control pressure; IPAP, inspiratory positive airway pressure; max, maximal; min, minimal; MVe, expiratory minute ventilation; MVi, inspiratory minute ventilation; NA, not available; P, pressure; V(A)C, ventilation in assist-control volume; V_T, tidal volume; V_Te, expiratory tidal volume; V_Ti, inspiratory tidal volume.

We propose setting a “rebreathing alarm” to prevent carbon dioxide (CO₂) rebreathing caused by occluded intentional leaks or by some diffuser filters placed on top of the intentional leaks (for noise reduction).

Some ventilators provide hybrid modes where prescribers set a target volume. The ventilator uses a pressure-targeted breath and adjusts inspiratory pressure to reach the set tidal volume (V_T). In case of ventilation with hybrid modes, leaks have a different impact according to the type of circuit, and the set V_T may not be reached.^21,22 Clinicians should be aware of this limitation when using a single-limb circuit with an active expiratory valve or dual-limb circuit. They should, therefore, take into account this limitation if they decide to set a “low V_T” alarm.

We believe that “leaks”, “low pressure”, and “high V_T” alarms are not mandatory when a disconnection alarm is set appropriately.

Pediatrics (CPAP/NIV)

The potential risks in young children on CPAP or NIV and in NIV-dependent children include ventilator failure, circuit disconnection, mask removal by the child, hypoventilation because of major leaks, and CO₂ rebreathing.

Young children

When young children (preschool and school ages) are placed on CPAP/NIV, the choice of a ventilator that can detect the child’s breath should guarantee an adequate functioning of the alarms.^18,23,24 In infants and young children treated with CPAP, using a ventilator in CPAP mode, instead of a CPAP device, may be appropriate to ensure additional alarms.¹¹ Moreover, ventilators set in CPAP mode offer the possibility to set an inspiratory trigger that allows the reliable monitoring of breathing frequency. The use of ventilators with alarms should be mandatory for infants, as they may not respond adequately in situations of insufficient ventilatory support or rebreathing.^25,26

We suggest that alarms for CPAP should at least include the “disconnection” and “CO₂ rebreathing” alarms (Table 2). An “apnea” alarm can be added, when available, to prevent residual long-lasting respiratory events. The “apnea” alarm is intended to activate if a patient’s spontaneous breathing rate falls below a specified threshold. However, children with low V_T (eg, newborns), weakened respiratory drive, or insufficient respiratory muscle strength may fail to “trigger” the ventilator (for breath rate monitoring), which leads to frequent false “apnea” alarms. Moreover, as devices are built for adults, shorter apnea lasting <10 s (but considered significant for some children) may be undetected and fail to trigger the alarm.

Table 2.

Proposed alarm settings according to the ventilation circuit and mode in children

	P max	P min	V_Ti max	V_Ti min	V_Te max^a	V_Te min^a	MVi max	MVi min	MVe min^a	High f^b	Disconnection	Rebreathing	Apnea^b	Leaks
CPAP—with leak circuit	OFF	OFF	NA	NA	OFF	OFF	NA	NA	OFF Or 0.2–0.5 L/min depending on child’s age (obstruction)	OFF	10–15 s according to age	ON	OFF Or 30 s	20-30 L/min above intentional leaks
NIV—PSV/P(A)C with leak circuit	OFF	ON (leaks)	NA	NA	OFF	OFF	NA	NA	0.2–0.5 L/min depending on child’s age (obstruction)	Depending on child’s age	10–15 s according to age	ON	OFF	20-30 L/min above intentional leaks
Invasive ventilation—PSV/P(A)C with leak circuit	OFF	ON (leaks)	NA	NA	OFF	OFF	NA	NA	0.2–0.5 L/min depending on child’s age (obstruction)	Depending on child’s age	10–15 s according to age	ON	OFF	20-30 L/min above intentional leaks
Invasive ventilation—PSV/P(A)C with active expiratory valve	OFF	ON (leaks)	OFF	OFF	NA	NA	15–20 L/min depending on child’s age (leaks)	0.2–0.5 L/min depending on child’s age (obstruction)	NA	Depending on child’s age	10–15 s according to age	NA	OFF	NA
Invasive ventilation—PSV/P(A)C with dual-limb circuit	OFF	ON (leaks)	OFF	OFF	OFF	OFF	15–20 L/min depending on child’s age (leaks)	0.2–0.5 L/min depending on child’s age (obstruction)	OFF	Depending on child’s age	10–15 s according to age	NA	OFF	OFF

The names of alarms are different between manufacturers for the different circuit conditions and ventilation modes.

Estimated volume for leak circuit, expiratory volume for single-limb circuit with active expiratory valve or dual-limb circuit.

Low f and apnea alarms are not necessary if a back-up f is set in PSV/P(A)C modes.

CPAP, continuous positive airway pressure; EPAP, expiratory positive airway pressure; f, breathing frequency; NIV, noninvasive ventilation; PSV, pressure support ventilation; P(A)C, ventilation in assist-control pressure; P, pressure; IPAP, inspiratory positive airway pressure; max, maximal; min, minimal; MVe, expiratory minute ventilation; MVi, inspiratory minute ventilation; NA, not available; V_T, tidal volume; V_Te, expiratory tidal volume; V_Ti, inspiratory tidal volume.

We suggest that alarms for NIV modes should also include the “disconnection” and “rebreathing” alarms (Fig. 1). The “low V_T” alarm can be used to detect upper-airway obstruction in pressure-targeted modes, but based on our clinical experience, it is particularly sensitive in infants and is often linked to a high rate of false alarms. This is because of the ventilator difficulty in accurately estimating V_T in this specific population. Therefore, the “low minute ventilation” (low MV) alarm may be more appropriate. In nondependent children, we believe this alarm is not required.

The “leaks” alarm may be helpful to detect mask displacement or removal by the child during CPAP/NIV. Finally, ventilators with “power failure” alarm should be prioritized; therefore, level 1 ventilators (ie, ventilators without internal battery) should not be used in this population.¹¹

The alarm trigger delay depends on the ventilator characteristics. Indeed, some ventilators have pre-programmed alarm options with no possibility to set the timing, whereas for others, the timing can be adapted according to the patient’s characteristics. We therefore suggest that the younger the child is, the shorter the delay before the alarm is triggered should be (Table 2).

NIV-dependent children

In children who are dependent on NIV, we propose that the alarm settings should at least include the “disconnection” and “rebreathing” alarms (Table 2 and Fig. 1).

The “disconnection” alarm may be set at 10–15 s depending on the breathing frequency of the child. However, the “disconnection” alarm may not always be reliable, as it may fail,²⁷ which may lead to serious adverse events in patients with a limited ventilatory autonomy. The activation of a “low pressure” alarm is therefore also recommended. If available, we propose to also set the “leaks” alarm. Generally, we configure this alarm at 40–60 L/min for ventilators that calculate total leaks, or 20–30 L/min above intentional leaks for those using unintentional leaks.

We discourage the use of a “low V_T” alarm to detect upper-airway obstruction in pressure-targeted mode in infants, as explained above. Both “low V_T” alarms and “apnea” alarms can be problematic in infants. Based on our experience, the most effective alarm for low ventilation is the “low MV” alarm, set at 0.2 L/min in infants and 0.5 L/min in older children. This alarm is less sensitive to physiological low V_T (such as those in infants) and activates in cases of upper-airway obstruction during ventilation, such as laryngospasm or inhalation (Fig. 1).

Level 3 (life support) ventilators are recommended in NIV-dependent children.^17,18 Additionally, it is essential for NIV-dependent children to have a second ventilator with similar settings available at home to anticipate any technical malfunctions with the primary ventilator. Some children, such as patients with congenital central hypoventilation syndrome, may not be awakened by alarms.²⁸ The Canadian Thoracic Society recommends that patients unable to awaken, to breathe spontaneously, and/or at risk of adverse events if disconnected from the ventilator should have an external home monitor in addition to an awake and alert trained caregiver.¹⁵ Indeed, nighttime caregiver surveillance and/or other monitoring systems should be mandatory for these patients.^14,15,19 Pulse oximetry is more reliable than a cardiorespiratory monitor, as hypoxemia is likely to be an early indicator of inadequate ventilation^14,15; however, it may falsely alarm but also misleadingly reassure parents and caregivers.¹⁹ For children depending on their ventilators, we propose to use the “low S_pO₂” alarm with pulse oximeter monitors set to alarm for S_pO₂ ≤ 85% (or ≤ 90%, according to the local practice).

Invasive ventilation

Adults

Large leaks or disconnection

In tracheostomized patients, disconnection of the ventilator circuit is a major complication and justifies the activation of the “disconnection” alarm, particularly if the patient is ventilator-dependent (Table 1 and Fig. 1). In the worst-case scenario, the disconnection may result from a decannulation while the tracheostomy tube remains connected to the ventilator circuit. In this instance, as the tube generates some resistance to air flow, the airway pressure may remain above the “low inspiratory pressure” alarm.²⁹ Therefore, it is recommended to set the sensitivity of the “disconnection” and “low inspiratory pressure” alarms with the circuit connected to a tracheostomy tube with a lower diameter outside the trachea.

If the “high V_T” alarm is used, we suggest that it should be set 300 mL above the average usual V_T but should be readjusted in case of large variability of V_T.

Obstruction

Another critical situation for tracheostomized patients is tracheostomy tube obstruction. It may result from the obstruction of the inner lumen by thickened secretions or a tracheostomy tube displacement when the tip of the tube abuts the trachea wall. In these situations, ventilation ceases, leading to oxygen desaturation, potentially resulting in cardiac arrest. The adequate alarms to detect this complication depend on the ventilation mode (Figs. 1 and 2). In flow-targeted modes, the obstruction will lead to a rise in the inspiratory pressure, which can be detected by the “high airway pressure” alarm. In pressure-targeted modes, there will not be a variation in the airway pressure, but tube obstruction can be detected by a “low V_T” alarm (Table 1). In case of invasive ventilation with hybrid modes, a tube obstruction will induce an increase in inspiratory pressure to a certain point and will eventually activate a “low V_T” alarm, as target V_T cannot be reached. Clinicians should therefore also set the alarm on “low V_T”.

Fig. 2.

Consequences of tracheostomy tube obstruction on ventilation. (A) On volume-controlled ventilation, a partial obstruction of the tube leads to a decreased tidal volume and is associated with peaks in insufflation pressure (red arrows) which can be detected by the “high pressure” alarm. (B) The complete obstruction of the tube during pressure-targeted ventilation cannot be detected by the pressure alarm (as insufflation pressure remains constant [dotted line]); obstruction can be suspected by a drop of tidal volume (arrows) and therefore detected by the “low tidal volume” alarm.

We suggest setting the “low V_T” alarm 200 mL below the average actual V_T, but it may be adapted in case of large V_T variations. However, in the dual-limb circuit setting, leaks may lead to an incapacity of the ventilator to calculate delivered V_T and can therefore indicate a volume at 0 mL; in that situation, the “low V_T” alarm can fail to detect obstructions.

Pediatrics

The potential risks in invasively venetilated children include ventilator failure, airway mucus plugs, tracheostomy-related complications, respiratory tract infection, and feeding problems.^8,30–32 Some studies have reported that respiratory equipment failure is rare and not associated with serious adverse events.^33,34 In contrast, accidental decannulation or airway obstruction because of mucus plugs appears to occur more frequently in children on invasive ventilation.³⁵

In pediatric invasive ventilation, the use of uncuffed tracheostomy tubes is standard practice because of concerns that cuffs may cause mucosal damage and subglottic stenosis. For this reason, in children, flow-targeted ventilator modes are not used in this scenario, as they do not compensate for leaks; however, hybrid modes have been used in this context.³⁶

As for the NIV-dependent child, level 3 (life support) ventilators are mandatory in invasively ventilated children.¹⁷ Additionally, it is essential to have a second ventilator with similar settings available at home to address any technical malfunctions with the primary ventilator. The type of circuits used depends on the center's practice. At the present time, we predominantly use dual-limb circuits; however, a single-limb circuit with an active expiratory valve or a single-limb circuit with a calibrated leak (such as the Whisper Swivel 2, Philips Respironics) can be utilized while ensuring effective humidification of inspired gas. To the best of our knowledge, no study has reported the rate of incidents, such as mucus plugs, based on the type of circuits.

In our practice, we do not adjust alarm settings based on the time of day (daytime vs nighttime). When setting the different alarms, one must be aware that some alarms may fail to work in some circumstances.^27,29,37 Accidental decannulation or ventilator disconnection with the cannula still attached to the circuit may not trigger the “low inspiratory pressure” alarm on the ventilator, as the smaller tracheotomy tubes used in children may significantly increase resistance to air flow and prevent a pressure drop sufficient to trigger the alarm.²⁹ Moreover, disconnection alarm may not always be reliable.²⁷ As in adults, to avoid missing an accidental decannulation, we recommend using the “low inspiratory pressure” alarm and the disconnection alarm, ensuring that the ventilator is calibrated with a smaller-caliber tracheostomy tube attached to the end of the circuit.

Additionally, the alarm that may be used in children on invasive ventilation is the “low MV” alarm (Table 2 and Fig. 1).¹⁹ The advantage of this alarm is its quick activation in the event of circuit obstruction or disconnection, and it has been demonstrated in pressure-controlled mode of ventilation that setting this alarm at 0.5 L/min is more effective to detect decannulation than the “disconnection” alarm or the “low MV” alarm set at the manufacturer’s recommended minimum value.³⁸ The “high MVi” alarm can also be used as an additional safety measure to detect accidental decannulation. When set at 15–20 L/min, it may help identify disconnection in children ventilated with a dual-limb circuit or with an active expiratory valve system attached to an uncuffed tracheostomy cannula (Table 2).

However, the downside of more sensitive alarms is the frequent nuisance of inappropriate alarm activations. We discourage the use of expiratory alarms with dual-limb circuit (such as “low V_Te” and “low MVe”), because the estimation of expiratory volumes can be significantly inaccurate when there are open leaks caused by the use of uncuffed tracheostomy tubes in a no-leaks system. We suggest to set the “disconnection” alarm at 10–15 s, depending on the breathing frequency of the child. We also recommend to set a “low pressure” alarm to detect major leaks.

The use of “high V_Ti or V_Te” or “high pressure” alarms is not of particular interest in case of pressure-targeted ventilation. Indeed, as children are mainly ventilated using uncuffed tracheostomy, the level of leaks may vary widely, leading to inaccurately reported high values of V_T and therefore false “high V_T” alarms. Moreover, in the context of uncuffed tracheostomy tube ventilation, the use of the “leaks” alarm may be counterproductive because it leads to frequent nuisance alarms.

The Canadian Thoracic Society recommends that children receiving invasive ventilation through a tracheotomy tube smaller than 5 mm ID should be monitored with an external monitor to detect circuit disconnection and decannulation, in addition to an awake and alert trained caregiver.¹⁵ Home cardiorespiratory monitors that monitor heart rate and chest wall movement may be less reliable than pulse oximetry, as obstructive events will not be detected with monitors that use variations in thoracic movement for respiration detection, and central apneas usually occur later in cases of a serious event.^14,15 Moreover, significant hypoxemia will precede bradycardia. Hypoxemia is indeed likely to be an early indicator of airway obstruction or inadequate ventilation because of ventilator malfunction. We therefore recommend using a “low S_pO₂” alarm for children on invasive ventilation using pulse oximeter monitors, set to trigger at S_pO₂ levels of ≤85% (or ≤90%), depending on local practices.

How to Set Alarms in Volume (Assisted)-Controlled and Pressure Support Modes

Which parameters to set?

As discussed previously, alarms aim to detect severe events that impair ventilation. Therefore, “V_T” (or “MV”), “airway pressure”, and “disconnection” alarms are the most important (Fig. 1). As clinicians usually set a back-up frequency regardless of the ventilatory mode used, alarm on “low respiratory rate” and “apnea” alarm are not required. We believe that the “apnea” alarm is needed only for dependent patient using mouthpiece ventilation with no back-up rate to remind the patient to resume mechanical breath.

The “high respiratory rate” alarm may be useful to detect acute respiratory distress; however, we suggest it should not be overly sensitive as nursing procedure and patient’s mobilization are frequently associated with an increase of breathing frequency. Likewise, patients may increase their frequency when they speak during invasive ventilation. Alarms targeting MV can be used in adults, but they may be redundant with the 2 components of MV, namely V_T and breathing frequency.

Initial settings

To our knowledge, best practices for setting ventilator alarms have not been established for adults. Moreover, to the best of our knowledge, no study has addressed the settings of alarms in children on CPAP/NIV or in children with NIV dependence, and no specific standards/guidelines for the management of children with high NIV dependence were identified.^11,13 Only one study has described a methodology to determine ventilator alarm settings for 2 devices in children on invasive ventilation.¹³ Another study proposed several risk management considerations, adapting the type of alarm according to the risk situation.³⁷ Therefore, a specific team of caregivers should try to standardize their approach for setting and monitoring alarms. Some rules can be set to decide on the initial settings of alarms according to the current monitoring. However, as the normal variability of volumes, breathing frequency, and pressures of each specific patient is unknown, these settings may be too sensitive initially, leading to frequent noninformative alarms. Therefore, monitoring of the alarm is essential to adjust the initial settings. Alarm settings should be documented in the patient’s electronic health record and be precisely prescribed to the home care provider.

Monitoring Alarms

Monitoring of alarms relies on patient’s and family caregiver’s anamnesis and examination of the event log recorded by the ventilator (Fig. 3). We recommend that clinicians regularly ask patients and caregivers about the number of alarms per day, whether alarms occur overnight, and if alarms are informative. Event log monitoring offers an objective assessment of the frequency, type, and timing of alarms. This objective data, combined with the anamnesis, helps determine whether alarm settings are appropriate or overly sensitive. Indeed, if an alarm occurs frequently and/or does not provide any useful information to the caregivers, the sensitivity should be reduced. Conversely, an alarm that helps caregivers to recognize when an action is needed (such as airway suctioning) is considered appropriate.

Fig. 3.

Monitoring of alarms. Clinicians should focus on high and medium priority alarms and monitor how many alarms are triggered per day and at which time. In this example, there are 4 clusters of alarms during the 24 h period. They combine “disconnection” with “high V_Ti” and “high MVi.” They correspond to periods during which this tracheostomized patient is disconnected from the ventilator to use in-exsufflation to clear his airways. MVi, inspiratory minute ventilation; V_Ti, inspiratory tidal volume.

A regular review of alarm settings, the event log, and sound level is necessary as part of a quality control protocol.²⁷ Indeed, reviewing alarm settings is an integral part of the monitoring protocol at every hospital appointment and during each home visit conducted by a clinician or home care provider. Alarm parameters may need adjustment over time, as changes in respiratory mechanics can alter delivered pressures (in volume-targeted modes) or V_T (in pressure-targeted modes). This is especially important in pediatric patients, since growth is associated with evolving respiratory mechanics and changes in physiological breathing frequency. Therefore, in pediatrics, some of the alarms will be adapted to the growing age of the child.

Nowadays, alarm telemonitoring is possible with some platforms. However, as telemonitoring is not continuous, it cannot be a substitute for home caregivers. Nevertheless, the observation of repeated alarms by the telemonitoring team may trigger a call to the patient.

The availability of equipment, such as pulse oximeters, may be an issue in some countries and vary according to insurance coverage.³⁹ Therefore, ventilator alarms should be set to guarantee maximum safety.

Education on Alarms

Setting alarms cannot prevent incidents or accidents if patients and their caregivers are not educated to understand their meaning and respond appropriately. Therefore, education should emphasize the meaning of each alarm, identify what should be checked, and present the different solutions. For instance, an alarm on minimal pressure, V_Ti max, V_Te min, or disconnection alarm may indicate a large leak or circuit disconnection. In this situation, the circuit should be inspected from the ventilator port to the patient. If no disconnection or leak on the circuit is found, the issue might be a faulty expiratory valve or a displaced tracheostomy tube. Family caregivers should be trained to change from the ventilator to the emergency equipment and to perform manual bag ventilation for the worst cases.

Family caregivers of patients on home mechanical ventilation (or CPAP in pediatrics) should receive comprehensive training prior to hospital discharge, especially for NIV-dependent patients and patients on invasive ventilation. Indeed, caregivers would need to complete a 24-h independent stay in the hospital before discharge. However, even though some guidelines highlight the need for caregivers to be trained to manage home mechanical ventilation and ventilator alarms,¹⁴ there is a lack of standardized training programs.^40–42 A few studies have emphasized the importance of proper education and training in alarm management, especially for patients on invasive ventilation.^{9,16,35,43,44} In a 2012 article, Boroughs et al¹⁰ reported a 27% accidental death rate in children invasively ventilated at home, which has remained constant over decades despite technological advances in home monitoring. The main causes of preventable deaths were insufficient training, inappropriate responses to emergencies, and a lack of vigilance among the clinicians responsible for patient care.^10,16 More recently, Neunhoeffer et al³⁴ reported that most of the serious adverse events that occurred at home or in a specialized nursing care facility were tracheostomy related (46%), but that no children died. They also found that significantly more tracheostomy-related incidents (and infections) occurred in the home care setting.

Potential incidents that may occur in young children on CPAP/NIV, NIV-dependent patients, or patients on invasive ventilation should be identified and discussed with the patients and/or their caregivers. Once these risks are understood, education regarding alarm management can be provided.

Regarding the steps involved in alarm education, the first priority is to ensure that the hospital teams clearly understand the meaning of each alarm, so they can appropriately set ventilator alarms according to their level of priority and emergency.³⁵ All alarms are set and written in physician orders and should be shared with patients and/or caregivers prior to discharge. Then, the patients and/or caregivers should be taught whether the alarm is categorized as low, medium, or high priority and what action is necessary when the alarm occurs.¹⁴ Ultimately, the patients and/or caregivers should be able to manage the different alarms and act accordingly.

What caregivers should know?

The caregivers should be able to understand and manage the ventilator and external monitors’ alarms. Caregivers should also be able to recognize and mute ventilator or external monitor alarms while addressing the underlying issue. However, they should never disable the alarm settings configured by the hospital team. Although, in case of excessive alarms, potential alarm fatigue can be reduced by customizing alarm parameters in collaboration with the hospital team, to decrease false alarms in the safest way.⁹ Caregivers should be taught that tube obstruction is the most common cause of severe respiratory distress in the patient with a tracheostomy and must be treated as an emergency.⁴⁵ Table 3 proposes a summary of the educational objectives for family and professional caregivers regarding ventilator and tracheostomy.

Table 3.

Educational objectives for caregivers on ventilator and tracheostomy management in the context of invasive mechanical ventilation

	Caregivers should be able to:
Ventilator^14,46	Identify electrical power sources Assemble ventilator circuit and humidification system Describe routine cleaning of equipment Add oxygen to circuit if indicated Verbalize that ventilator alarms must be audible throughout the home Turn the ventilator on, test the ventilator before use, and view and verify settings Recognize ventilator alarms and how to troubleshoot the alarms Remove water from the ventilator circuit, down and away from child Keep battery-operated for the main and back-up ventilators charged and ready for use Connect and use the external battery for the ventilator if applicable Recognize the approximate battery life for each piece of equipment Switch from the main to the back-up ventilator
Tracheostomy^45,46	Manage tracheotomy tube care (verification of tube and cuff patency, opening, cuff, suctioning, tube changes, cleaning, consumable maintenance, liner, and ties) Identify a tube malposition Use a bag valve mask State actions to be taken in the event of tube obstruction, accidental decannulation, bleeding, and ventilator failure When in doubt, change the tracheostomy tube (if the caregiver is trained and authorized to do so)

Caregivers should be able to:

Ventilator^14,46

Identify electrical power sources
Assemble ventilator circuit and humidification system
Describe routine cleaning of equipment
Add oxygen to circuit if indicated
Verbalize that ventilator alarms must be audible throughout the home
Turn the ventilator on, test the ventilator before use, and view and verify settings
Recognize ventilator alarms and how to troubleshoot the alarms
Remove water from the ventilator circuit, down and away from child
Keep battery-operated for the main and back-up ventilators charged and ready for use
Connect and use the external battery for the ventilator if applicable
Recognize the approximate battery life for each piece of equipment
Switch from the main to the back-up ventilator

Tracheostomy^45,46

Manage tracheotomy tube care (verification of tube and cuff patency, opening, cuff, suctioning, tube changes, cleaning, consumable maintenance, liner, and ties)
Identify a tube malposition
Use a bag valve mask
State actions to be taken in the event of tube obstruction, accidental decannulation, bleeding, and ventilator failure
When in doubt, change the tracheostomy tube (if the caregiver is trained and authorized to do so)

Adapted from Sterni et al,¹⁴ Joseph et al,⁴⁴ and HAS guidelines.⁴⁶

How education on alarms should be managed and assessed

We recommend that an educational program should be planned for the caregivers with an appropriate number of sessions and training duration. Indeed, alarm education is part of the overall training for CPAP/NIV or invasive ventilation, which should also highlight the role and importance of humidification (including the avoidance of water condensate in the tubing), especially during invasive ventilation to limit mucus plugging, and the management of complications (mucus suctioning, tracheostomy tube change, resuscitation bag).⁸ The learning program may be influenced by factors such as language skills, educational and developmental level, and the family’s understanding of the illness and situation^39,44; therefore, it should be individualized whenever necessary.

Educational materials may include booklets, videos, and mannequin with ventilation simulators.^{14,42–44,47} To the best of our knowledge, only 2 studies assessed the effectiveness of pediatric simulators for the training of family carers of children on invasive ventilation and concluded that simulation-based education improved parents’ confidence in case of emergencies.^47,48

Only a few studies have proposed protocols for training programs, mainly for invasively ventilated children.^42,49–51 Training duration and contents varied between studies but ranged from 6 to 8 weeks for invasive ventilation and 1 week for NIV.^8,15 However, the knowledge and skills required to care for a patient on home mechanical ventilation have not been thoroughly investigated, and consequently, no validated educational programs currently exist.¹⁵

Questionnaires, education requirement lists, and case-based scenarios may be helpful to assess education and to determine whether the objectives have been reached or if the training period needs to be extended.^14,35,42,43

Good coordination between the hospital team, the family and/or home caregivers, and the home equipment providers is essential to guarantee a safe management of NIV-dependent patients or patients on invasive ventilation.^40,49 Indeed, family or home caregivers should inform the home equipment provider in case of recurrent false alarms or any change in equipment performance. In turn, the home equipment provider should contact the hospital team if unusual trends or alerts are detected on the monitoring or telemonitoring data.⁴⁴ Moreover, periodic assessment and maintenance of the ventilator and home equipment is crucial.⁵²

Conclusions

Alarms in home care ventilation are necessary for patients on invasive ventilation, ventilator-dependent patients, or young children. They should provide early alerts in case of large leaks, disconnection, or tracheal tube obstruction that can lead to serious adverse events. Alarm settings should be tailored to the individual’s condition, type of circuit, and ventilatory mode. Proper functioning of the ventilation setup should be tested before hospital discharge to prevent unnecessary alarms. Monitoring alarm frequency and appropriateness helps to readjust the settings. Family caregivers must be educated to understand the meaning of alarms and to respond appropriately.

Footnotes

Author Disclosure Statement

The authors declare no conflicts of interest.

Funding Information

This study received no funding.

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