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Full text of "Respiratory care : the official journal of the American Association for Respiratory Therapy"

November 1994 
Volume 39, Number 11 

ISSN 0020-1 324-RECACP 



RE/PIRATORy 



A MONTHLY SCIENCE JOURNAL 
39TH YEAR— ESTABLISHED 1956 




American Association for Respiratory Core 

40th Annual Convention and Exhibition 

December 10-13, 1994 • Las Vegas, NevacJa 



Controlling Carbon Dioxide Delivery 
during Mechanical Ventilation 

Clinical Comparison of Two Aerosol 
Holding Chambers: ACE vs 
Aerochamber 



Airway Compromise in Two Patients 
with Aplastic Anemia and Coagulation 
Abnormalities 

1994 Open Forum Abstracts 



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DIEMOLDING HEALTHCARE DIVISION 

(onaitolo, NY 13032 USA 

1800) e-l? 8000 FAX 1315) 697 8083 

(315)697 2221 

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RE/PIRATORy C&RE 

A Monthly Science Joumal. Established 1956. Otiicial Journal of the American Association tor Respiratory Care 



EDITORIAL OFFICE 

11031) Atiles Lane 
Dallas TX 75229 
1214)243-2272 

EDITOR 

Pal Brougtier BA RRT 

ASSOCIATE EDITOR 

Kaye Weber MS RRT 

ASSISTANT EDITOR 

Donna Stephens BBA 

MANAGING EDITOR 

Ray Maslerrer BA RRT 

EDITORIAL BOARD 

Dean Hess PhD RRT. Chairman 
Thomas A Barnes EdD RRT 
Richard D Branson RRT 
Crystal L Dunievy EdD RRT 
Charles G Durbin Jr MD 
Thomas D East PhD 
Neil R Maclntyrc MD 
Shelley C Mishoe PhD RRT 
Joseph L Rau PhD RRT 
James K Stoller MD 

CONSULTING EDITORS 

Frank E Biondo BS RRT 
Howard J Birenbaum MD 
Robert L Chatbum RRT 
Patricia Ann Doorley MS RRT 
Donald R Elton MD 
Robert R Pluck Jr MS RRT 
Ronald B George MD 
James M Hurst MD 
Charles G Irvin PhD 
MS Jastremski MD 
Robert M Kacmarek PhD RRT 
Hugh S Mathewson MD 
Michael McPeck BS RRT 
David J Pierson MD 
John Shigeoka MD 
Jack Wanger MBA RPFT RRT 
Jeffrey J Ward MEd RRT 

JOURNAL ASSOCIATES 

Stephen M Ayres MD 
Reuben M Cliemiaek MD 
Donald F Egan MD 
Gareth B Gish MS RRT 
George Gregorv' MD 
Ake Grenvik MD 
H Fredenck Helmholz Jr MD 
John E Hodgkin MD 
William F Miller MD 
Thomas L Petty MD 
Alan K Pierce MD 
Henning Pontoppidan MD 
John W Severinghaus MD 
Barry A Shapiro MD 

PRODUCTION STAFF 

Linda Barcus Donna Knauf 
Steve Bowden Denise Ditzenberger 



CONTENTS 



November 1994 
Volume 39, Number 11 



ORIGINAL CONTRIBUTIONS 

1039 Controlling Carbon Dioxide Delivery during Mechanical Ventilation 
by Robert L Chatbum and Susan M Anderson — Cleveland. Ohio 

1047 Clinical Coinparison of Two Aerosol Holding Chambers: ACE vs 
Aerochamber 

by Robert J Perry, Edward G Lcmgenback, and Jonathan S 
llowite — Stonv Brook, New York 



TEST YOUR RADIOLOGIC SKILL 

1051 Airway Compromise in Two Patients with Aplastic Anemia and 
Coagulation Abnormalities 

by Loretta D Gleaton and Frederick P Ognibene — Bethesda, 
Maryland 



CORRECTIONS 

1050 Errors in Two CPGs Published in August (Neonatal Time- 
Triggered, Pressure-Limited, Time-Cycled Mechanical Ventilation 
(Respir Care 1994;39(8):812-816] and Application of Continuous 
Positive Airway Pressure to Neonates via Nasal Prongs or 
Nasopharyngeal Tube [Respir Care 1994;39(8):817-823] 

BOOKS, FILMS, TAPES, & SOFTWARE 

1057 Lung Function: Assessment and Application in Medicine, 5th edi- 
tion, by JE Cotes 
reviewed by Charles G Inin — Denver. Colorado 

1057 Snoring and Obstructive Sleep Apnea, 2nd edition, by David NF 
Fairbanks MD and Shiro Fujita MD 

reviewed by Timothy R Chappell — Piano, Texas 

LETTERS 

1058 Enors in August CPGs 

by Stephen M Picca — East Meadow, New York 



Respiratory Care (ISSN 0020-1324) is a monthly publication of Daedalus Enterprises tnc for the American Association for Respiratory Care. Copyright ® 1994 by Daedalus 

Enterprises Inc. 1 1030 Abies Lane, Dallas TX 75229. All rights reserved. Reproduction in whole or in part without the express, written permission of Daedalus Enterprises Inc 

is prohibited. The opinions expressed in any anicle or editorial are those of the author and do not necessarily reflect the views of Daedalus Enterprises Inc. the Editorial Board. 

or the American Association for Respiratory Care. Neither can Daedalus Enterprises Inc. the Editorial Board, or the Amercian Association for Respiratory Care be responsible 

for the consequences of the clinical applications of any methods or devices described herein. Printed in L'SA. 

Respiratory Care is indexed in Hospital Literature Index and in Cumulative Index to Nursing and Allied Health Literature. 

Subscription Rates; $5.00 per copy; $50.00 per year (12 issues) in the US; $70.00 in all other countries (add $84.00 for airmail). 

Second Class Postage paid at Dallas, TX. POSTMASTER: Send address changes to Respiratory Care, Daedalus Enterprises, Inc, 1 1030 Abies Lane, Dallas TX 75229. 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1 



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MANUSCRIPT SUBMISSION 

We attempt to print Instructions for Authors and 
Typists near the end of Respiratory Care on a 
quarterly basis leg, Jan. Apr. July. Nov). Call the 
Editorial Office for a copy if you're unable to 
locate. 

PHOTOCOPYING & QUOTATION 

PHOTOCOPYING. Any material in this journal 
that IS copyrighted by Daedalus Enterprises Inc 
may be photocopied for noncommercial purposes 
of scientific or educational advancement. 



QUOTATION. Anyone may, without pen 
quote up to 500 words of material in this journal 
that is copyrighted by Daedalus Enterprises Inc, 
provided the quotation is for noncommercial use, 
and provided Respiratory Care is credited. 
Longer quotation requires written approval by the 
author and publisher. 

SUBSCRIPTIONS/CHANGES OF 
ADDRESS 

Respiratory Care 
1 1030 Abies Lane 
Dallas TX 75229-4593 

(214)243-2272 

SUBSCRIPTIONS. Individual subscription rates 
are $50.00 per year (12 issues) in the U.S. and 
Puerto Rico. $70.00 per year in all other countries; 
$95.00 for 2 years in the U.S. and Puerto Rico, 
$135.00 in all other countries; and $140 for 3 years 
in the U.S. and Puerto Rico, $200.00 in all other 
countries {add $84.00 per year for air mail). 
Annual subscriptions are offered to members of 
associations according to their membership enroll- 
ment as follows: 101-500 members— $6.00, 501- 
1,500 members— $5.50. 1,501-10,000 members— 
$5.00, and over 10,000 members— $4.00. Single 
copies, when available, cost $5.00; add $7.00 air 
mail postage to overseas countries. 

CHANGE OF ADDRESS. Six weeks notice is 
required to effect a change of address. Note your 
subscription number (from the mailing label) your 
name, and both old and new address, including zip 
codes. Please note your subscription number on 
the envelope. Copies will not be replaced without 
charge unless request is received within 60 days of 
the mailing in the U.S. or within 90 days in other 
countries. 

MARKETING DIRECTOR 

Dale Griffiths 

ADVERTISING ASSISTANT 

Beth Binkley 

ADVERTISING, Display advertising should be 
arranged with the advertising representatives. 
Respiratory Care does not publish a classified 
advertising column. 

PRODUCT ADVERTISING: 
RATES & MEDIA KITS 

Jim Burke 
Williams & Wilkins 
428 E. Preston St. 
Baltimore, MD 21202 
(800)528-1843 
fax (410) 528-4452 

RECRUITMENT ADVERTISING: 

Beth Binkley 
Respiratory Care 
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Dallas TX 75229-4593 
(214)243-2272 
fax (214) 484-6010 



CONTENTS, c„„„„„.,, 

Open Forum ABSTRACTS 
1059 Open Forum Abstracts 
1116 Open Forum Authors 



CALL FOR Open Forum ABSTRACTS 
1124 1995 Call for Open Forum Abstracts 

AARC CONVENTION EXHIBITORS 

1120 AARC Convention Exhibitors 

INDEXES 

1128 Authors in This Issue 
1128 Advertisters in This Issue 



November 1994 
Volume 39, Number 11 



RESPIRATORY CARE • NOVEMBER "94 Vol 39 No 1 1 



1021 



Abstracts 



of Pertinent Arlicle 



Editorials, Reviews, and Commentaries To Note 

Neonatal Sedation: More Art Than Science (commentary) — AR Wolf. Lancet 1994:344:628. 
(Pertains to the paper by Jacqz-Aigrain et al abstracted on Page 1022.) 

Evolution of Therapy for Cystic Fibrosis— PB Davis. N Engl J Med 1994:331( 10):672. (Pertains to 
the paper by Fuchs et al abstracted on Page 1026.) 



Multisite Evaluation of a Continuous 
Intraarterial Blood Gas Monitoring 
System — CP Larson Jr, J Vender. A Seiver. 
Anesthesiology 1994;81(3):543. 

BACKGROUND: We compared the perfor- 
mance of a new. continuous intraarterial blood 
gas (CIABG) monitor with arterial values ob- 
tained periodically and analyzed by conven- 
tional equipment. METHODS: A CIABG 
monitoring system consisting of a sterile, dis- 
posable, fiberoptic sensor and a microproces- 
sor-controlled monitor with a self-contained 
calibration unit and detachable display panel 
was used. The sensor was inserted through a 
20-G radial artery cannula. Light was transmit- 
ted from the monitor to the sensor tip where it 
reacted with fluorescent dyes sensitive to oxy- 
gen or hydrogen ions (analytes). The change in 
the intensity of the photoluminescent radiation 
caused by the analytes was measured every 20 
s and derived blood gas values were displayed. 
Twenty-nine sensors were evaluated in 29 sur- 
gical or intensive care unit patients at one of 
three institutions (Stanford University 
Hospital, Evanston Memorial Hospital, and the 
Palo Alto Veterans .Administration Hospital). 
The duration of study averaged 6 h (5-8 h) in 
the operating room, and 46 h (7-121 h) in the 
intensive care unit. A total of 552 values were 
compared with those obtained at regular inter- 
vals and analyzed in the hospital blood gas lab- 
oratory. Average bias (mean difference be- 
tween lab value and CIABG). precision (SD of 
difference), and drift (change in the bias with 
time) were determined. RESULTS: At arterial 
oxygen tension (Pq,) values of 32-528 mm Hg. 
the average bias was - 1 % meaning that the 
average CIABG monitor values were 1% 
lower than those obtained by conventional 
equipment. The precision was 15%. At arterial 
Pf). values of 32-99 mm Hg, average bias and 
precision were -0.3 ± 8.9 mm Hg. Al arterial 
carbon dioxide tension (Pco;) values of 24-54 
mm Hg, average bias and precision were 1 .3 ± 



3.3 mm Hg, and at pHa values of 7.23-7.57. 
average bias and precision were 0.01 ± 0.04. 
Observed drift per day was — 1.2% for arterial 
Po;. 0.3 mm Hg for arterial Pco;. and 0.01 for 
pH. Bias and precision for samples compared 
in two pairs of like-model in vitro blood gas 
analyzers were 0.4 ± 4.6% for arterial Pq; 
over the full range, and 0.4 ± 3.7 mm Hg for 
values less than 100 mm Hg, -0.5 ± 1.8 mm 
Hg for arterial Pco;. and 0.01 ± 0.01 for pHa. 
Although the occasional marked discrepancies 
between one or inore CIABG and in vitro val- 
ues could sometimes be corrected by flushing 
the arterial catheter or repositioning the sensor, 
usually we could not determine the cause of the 
discrepancy or which values were the more ac- 
curate. CONCLUSIONS: Over the range of 
values and under the clinical conditions stud- 
ied, CIABG monitoring provides immediate 
blood gas results and trend information with 
sufficient agreement with in vitro results to be 
reliable for decision making in most clinical 
circumstances. Generally, the differences in 
the values between the two methods of analy- 
sis were the result of the combination of the in- 
herent errors of each method. Additional stud- 
ies need to be undertaken to evaluate the per- 
formance of the CIABG monitor across wider 
ranges of blood gas values, especially for arte- 
rial Po; values less than 60 mm Hg and arterial 
Pco; values greater than 50 mm Hg. 

Assessment of the Ability of Young 
Children To Use a Powder Inhaler Device 
(Turbuhaler) — A Gorcn, N Noviski, A 
Avital, C Maayan, E Stahl, S Godfrey, C 
Springer. Pediatr Pulmonol 1994:18:77. 

The puq»se of the study was to delermine the 
age at which young asthmatic children could 
master the use of a new powder inhaler device 
(Turbuhaler). We studied 59 children with 
asthma between the ages of 3 and 6 years who 
consecutively attended the asthma clinic of the 
pediatric department. Efficiency of inhalation 



and the pharmacological effect of the terbu- 
taline in the inhaler were measured by scores 
for inhalation technique and clinical response. 
None of the 3-year-old children used the de- 
vice efficiently, but 43% of the 4-year-old, 
67% of the 5-year-old. and 80% of the 6-year- 
old children used the inhaler correctly. 
Although inhaler technique was not perfect in 
the younger age group, 50% of the 3-year-old 
children demonstrated clinical improvement of 
asthma symptoms after inhalation. In the older 
age groups, 79%, 92%, and 100% of the 4-, 5-, 
and 6-year-old children demonstrated clinical 
improveiTient of asthma symptoms after in- 
halation. It is concluded that the new mode of 
dry powder delivery system (Bricanyl 
Turbuhaler) can be used in young asthmatic 
children who are 4 years of age and above. 

Placebo-Controlled Trial of Midazolam 
Sedation in Mechanically Ventilated 
Newborn Babies — E Jacqz-Aigrain. P Daoud. 
P Burtin, L Desplanques. F Beaufils. Lancet 
1994:344:646. 

Although midazolam is used for .sedation of 
mechanically ventilated newborn babies, this 
treatment has not been evaluated in a ran- 
doiTiised trial. We have done a prospective 
placebo-controlled study of the effects of mi- 
dazolam on haemodynamic variables and seda- 
tion as judged by a five-item behavior score. 
46 newborn babies on mechanical ventilation 
for respiratory distress syndrome were ran- 
domly assigned to receive midazolam (n = 24) 
or placebo (n = 22) as a continuous infusion. 
Doses of midazolam were calculated to obtain 
plasma concentrations between 200 and 1000 
ng/niL within 24 h of starting treatment and to 
maintain these values throughout the study. 
Haemodynamic and ventilatory variables were 
noted every hour, as were complications and 
possible side-effects of treatment. Mean (SD) 
duration of inclusion was 78.7 (30.9) h. I pa- 
tient in the trealnienl group and 7 in the place- 



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Respironics Inc., a leader in the 
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ABSTRACTS 



RESPIRONICS INC. 



bo group were withdrawn because of inade- 
quate sedation (p < 0.05). Midazolam gave a 
significantly better sedative effect than place- 
bo, as estimated by the behaviour score (p < 
0.05). Heart rate and blood pressure were re- 
duced by treatment but remained within the 
normal range for gestational age and there was 
no effect on ventilatory indices. The incidence 
of complications was similar in the two groups. 
No midazolam-related side-effects were noted. 
Continuous infusion of midazolam at doses 
adapted to gestational age induces effective se- 
dation in newborn babies on mechanical venti- 
lation, with positive effects on haemodynamic 
variables. The course of the respiratory distress 
syndrome was not influenced by this treatment. 
Midazolam was given over only a few days 
and the limited effects on heart rate and blood 
pressure that we report should not encourage 
long-term administration. 

The Effect of Frequency on Carbon Dioxide 
Levels during High Frequency Oscillation — 

V Chan, A Greenough. J Perinat Med 

1994;22:I05. 

The aim of this study was to assess if, during 
high frequency oscillation (HFO), a frequency 
of 10 or 15 Hz was associated with lower car- 
bon dioxide levels. Twelve infants were re- 
cruited, median gestational age 27 weeks. All 
infants were studied at both frequencies, ap- 
plied in random order and the carbon dioxide 
level checked after 30 minutes on each fre- 
quency. Carbon dioxide levels were lower in 
10 of the 12 infants at 10 compared to 15Hz(p 
< 0.004) and, in the study population, overall 
were significantly lower at 10 Hz (p < 0.05). 
The difference in Paco: levels at the two fre- 
quencies, however, was small, thus these re- 
sults suggest the clinician should rely primarily 
on changes in oscillatory amplitude, rather 
than frequency, to effect changes in carbon 
dioxide levels. 

Permissive Hypercapnia in Acute Respiratory 
Failure — A Bidani. AE Tzouanakis, VJ 
Cardenas Jr, JB Zwischenberger. JAMA 
1994:272:957. 

OBJECTIVE: To evaluate the potential effica- 
cy of pressure limitation with permissive hy- 
percapnia in the treatment of acute respiratory 
failure/adult respiratory distress syndrome on 
the basis of current theories of ventilator-in- 
duced lung injury, potential complications of 
systemic hypercarbia. and available human 
outcome studies. DATA SOURCES: Articles 
were identified through MEDLINE, reference 
citations of published data, and consultation 
with authorities in their respective fields. 
S TLIDY SELECTION: Animal model experi- 
mcnlalion and human clinical trials were se- 
Icclcd on the basis of whether thcv addressed 



the questions of pressure limitation with or 
without hypercapnia. the pathophysiologic ef- 
fects of hypercapnia, or the concept of ventila- 
tor-induced parenchymal lung injury. 
Frequently cited references were preferentially 
included. DATA EXTRACTION: Data were 
analyzed with particular emphasis on obtaining 
the following variables from the clinical stud- 
ies: peak inspiratory pressures, tidal volumes, 
minute ventilation, and Pco;- Quantitative as- 
pects of respiratory physiology were used to 
analyze the theoretical effects of permissive 
hypercapnia on ventilatory requirements in 
normal and injured lungs. DATA SYNTHE- 
SIS: Extensive animal model data support the 
hypothesis that ventilator-driven alveolar 
overdislention can induce significant 
parenchymal lung injury. The heterogeneous 
nature of lung injury in adult respiratory dis- 
tress syndrome, with its small physiologic lung 
volume, may render the lung susceptible to this 
type of injury through the use of conventional 
tidal volumes (10 to 15 mL/kg). Permissive hy- 
percapnia is an approach whereby alveolar 
overdislention is minimized through either 
pressure or volume limitation, and the potential 
deleterious consequences of respiratory acido- 
sis are accepted. Uncontrolled human trials of 
explicit or implicit permissive hypercapnia 
have demonsttated improved survival in com- 
parison with models of predictive mortality. 
CONCLUSIONS: Avoidance of alveolar 
overdislention through pressure or volume lim- 
itation has significant support based on animal 
models and computer simulation. Deleterious 
effects of the associated hypercarbia in severe 
lung injury do not appear to be a significant 
limiting factor in preliminary human clinical 
trials. Although current uncontrolled studies 
suggest benefit, controlled trials are urgently 
needed to confirm these findings before adop- 
tion of the treatment can be endorsed. 

Impact of Quality-of-Care Factors on 
Pediatric Intensive Care Unit Mortality — 

MM Pollack, TT Cuerdon. KM Patel. UE 
Ruttimann, PR Getson, M Levetown. JAMA 
1994:272:941. 

OBJECTIVE: To determine the importance of 
the following care factors previously associat- 
ed with hospital quality on survival from pedi- 
atric intensive care: size of the intensive care 
unit (ICU). medical school teaching status of 
the hospital housing the ICU, specialist status 
(pediatric intensivist). and unit coordination. 
DESIGN: After a national survey, consecutive 
case series were collected at 16 sites randomly 
selected to represent unique combinations of 
quality-of-care factors. SETTING: Pediatric 
ICUs. PATIENTS: Consecutive admissions to 
each .site. MAIN OUTCOME MEASURE: 
Patient mortality adjusled for physiologic sta- 
tus, diagnosis, and other mortalitv risk factors. 



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RESPIRATORY CARE • NOVEMBER "94 Vol ?<9 No 1 1 



lo One Sensor Can Meet M Patients Needs 



3 H S S 



What sets the Nellcor family of sensors apart is their 
success in providing dedicated sensor solutions for unique 
patient-care environments. From the optimum performance 
of OXISENSOR'^II, to cost-saving alternatives such as 
QX/CL/Q* or the Sensor Recycling Program, to a selection 
of reusables for your short-term needs, Nellcor sensors 
are there when you need them. 

In addition, compatibility with monitoring systems* from 
leading manufacturers ensures that Nellcor sensors can 

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travel with your patient throughout the hospital-helping 
you standardize your sensor usage and costs. From 
performance, to versatility, to cost savings, with Nellcor 
sensors the choice is yours. 

For more information, contact your local representative 
or call 1-800-NELLCOR or 510-463-4000. Internationally, 
call our European office in the Netherlands at +31.73.426565 
or our Asia/Pacific office at 

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ABSTRACTS 



RESULTS: There were 5415 pedialric ICU ad- 
missions and 248 ICU deaths. The ICUs dif- 
fered significantly with respect to descriptive 
variables, including mortality (range. 2.2% to 
16.4<7r). Analysis of risk-adjusted inortality in- 
dicated that the hospital teaching .status and the 
presence of a pediatric intensivist were signifi- 
cantly associated with a patient's chance of 
survival. The probability of patient survival 
after hospitalization in an ICU located in a 
teaching hospital was decreased (relative odds 



PneuViet^ 

TESTING & TRAINING SYSTEMS 



of dying, 1.79: 95% confidence interval [CI|. 
1.23 to 2.61; p = 0.002). In contrast, the proba- 
bility of patient .survival after hospitalization in 
an ICU with a pedialric intensivist was im- 
proved (relative odds of dying, 0.65; 95% CI, 
0.44 to 0.95; p = 0.027 ). Post hoc analysis indi- 
cated that the higher severity-adjusted mortali- 
ty in teaching hospitals may be explained by 
the presence of residents caring for ICU pa- 
tients. CONCLUSION: Characteri.stics indica- 
tive of the best overall hospital quality may not 



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training, and testing? The PneuView System is the answer to 
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be associated, or may be negatively associated, 
with quality of care in specialized care areas, 
including the pediatric ICU. 

Effect of Aerosolized Recombinant Human 
DNase on Exacerbations of Respiratory 
Symptoms and on Pulmonary Function in 
Patients with Cystic Fibrosis— HJ Fuchs. DS 
Borowilz. DH Christiansen, EM Morris. ML 
Nash, BW Ramsey, et al. for the Pulmozyme 
Study Group. N Engl J Med 1994;331(I0):637. 

BACKGROUND; Respiratory disease in pa- 
tients with cystic fibrosis is characterized by 
airway obstruction caused by the accumulation 
of thick, purulent secretions, which results in 
recurrent, symptomatic exacerbations. The vis- 
coelasticity of the secretions can be reduced in 
vitro by recombinant human deoxyribonucle- 
ase I (rhDNase), a bioengineered copy of the 
human enzyme. METHODS: We pert'ormed a 
randomized, double-blind, placebo-controlled 
study to determine the effects of once daily and 
twice-daily administration of rhDNase on ex- 
acerbations of respiratory symptoms requiring 
parenteral antibiotics and on pulmonary func- 
tion. A total of 968 adults and children with 
cystic fibrosis were treated for 24 weeks as 
outpatients. RESULTS: One or more exacerba- 
tions occurred in 27% of the patients given 
placebo, 22% of those treated with rhDNase 
once daily, and 19% of those treated with 
rhDNase twice daily. As compared with place- 
bo, the administration of rhDNase once daily 
and twice daily reduced the age-adjusted risk 
of respiratory exacerbations by 28% (p = 0.04) 
and 37% (p < 0.01 ), respectively. The adminis- 
tration of rhDNase once daily and twice daily 
improved forced expiratory volume in one sec- 
ond during the study by a mean (±SD) of 5.8 
± 0.7%. and 5.6 ± 0.7%. respectively. None 
of the patients had anaphylaxis. Voice alter- 
alion and laryngitis were more frequent in the 
rhDNase-treated patients than in those receiv- 
ing placebo but were rarely severe and re- 
solved within 21 days of onset. CONCLU- 
SIONS: In patients with cystic fibrosis, the ad- 
ministration of rhDNase reduced but did not 
eliminate exacerbations of respiratory symp- 
toms, resulted in slight improvement in pul- 
monary function, and was well tolerated. 

Modeling the Severity of Illness of ICU 
Patients: A Systems Update — S Lemeshow, 
J-RLe Gall. JAMA 1994;272;I049. 

OBJECTIVE: To review recent revisions of 
systems for estimating the probability of hospi- 
tal mortality of adult intensive care unit (ICU) 
patients. Emphasis on comparison of compo- 
nents of systems and potential uses. DATA 
SOURCES: Published articles in which the 
systems were presented. STUDY SELEC- 
TION: Aculc l>livsiiiloi;v and Chronic Health 



1026 



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RESPIRATORY CARH • NOVEMBER "94 Vol .W No 1 1 



Management Tools... 

For A Better Respiratory Care Department 



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Volume 2: Clinical Laboratory Standards Workbook 

Contains detailed explanations and worksheet for each CLIA standard 
(subparts H, J, K, M) that calls for documentation. All you have to do is 
fill in the blanks for validation of instruments and procedures. Lotus 
spreadsheets in IBM format are included. Specify 3'/2" or 5'/4". 
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Volume 3: Blood Cas Laboratory QA Notebook 

An integrated system of worksheets that satisfy CLIA and CAP 
standards. Use this manual to record daily data on instrument 
maintenance and calibration. 
Item BK33 $118 ($125 nonmembers) 

Volume 4: Blood Cas Policies and Procedures 

A basic set of general policies and procedures that help satisfy 
regulatory requirements, especially CLIA subpart J. IBM-compatible 
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program designed for respiratory care by respiratory care professionals. 
Requires no computer experience and no programming. QualityCounts 
simplifies data management for JCAHO and CLIA '88 standards and 
automates your existmg QA system or creates a new one. Allows vou to 
define custom QA indicators and criteria; offers flexible reporting — 
weekly, monthly, quarterly, yearly; tracks individual staff members' 
compliance with QA standards; identifies problems quickly and 
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ABSTRACTS 



Evaluation (APACHE HI). Simplified Acute 
Physiology Score (SAPS 111. and Mortality 
Probability Models (MPM II) are the major 
severity systems for ICU patients. DATA EX- 
TRACTION: Information on variables collect- 
ed in the systems, characteristics of databases 
from which they were developed, and reported 
performance of models were evaluated from 
published articles. DATA SYNTHESIS: 
APACHE III and SAPS II produce a score and 
probability of hospital mortality based on 
worst values of several variables during the 
first 24 hours in ICU. The MPM II system has 
four models, one at ICU admission and one at 
24. 48. and 72 hours into the ICU stay. The 
SAPS II and MPM II models can be imple- 
mented from published information. The 
APACHE III score can be calculated from 
published information; weights to convert 
score to probability are proprietary. All report- 
ed good areas under receiver operating charac- 
teristic curve. Goodness of fit was good for 
SAPS II and MPM II models and was not re- 
poned for APACHE III models. CONCLU- 



SIONS: All models were based on rigorous re- 
search and reported performance is good. All 
can be used to assist in assessing prognosis, to 
compare ICU performance, and to stratify pa- 
tients for clinical trials. Direct comparison on a 
common cohort is needed. 

Transmission of Mycobacterium tuberculosis 
Associated with Air Travel — CR Driver, SE 
Valway, WM Morgan, IM Onorato, KG 
Castro. JAMA 1994;272( 13): 10.^1. 

OBJECTIVE: To investigate potential trans- 
mission of Mycobacterium tuberculosis in air- 
craft from a crew member with tuberculosis. 
DESIGN: Retrospective cohort study and sur- 
vey. SETTING: A large US airline carrier. 
PARTICIPANTS: A total of 212 crew mem- 
bers and 59 passengers who were exposed to a 
crew member with tuberculosis during a poten- 
tially infectious period (May through October 
1992). Comparison volunteer sample of 247 
unexposed crew members. MAIN OUTCOME 
MEASURES: Positive tuberculin skin test 



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(TSTi result or tuberculosis. RESULTS: Rates 
of positive TST results were higher among for- 
eign-bom persons in all study groups. Among 
US-bom comparisons and contacts, rates of 
positive TST results did not differ between 
comparisons and contacts exposed from May 
through July (5.3% vs 5.9%, respectively). 
However, contacts exposed from August 
through October had significantly higher rates 
of positive TST results than did contacts ex- 
posed from May through July {-W% vs 5.8%. 
respectively; p < 0.001 ); two had documented 
TST conversions between September 1992 and 
February 1993. The risk of infection increased 
with increasing hours of exposure to the index 
case. Four (6.7%) of 59 frequent flyers were 
TST-positive: all flew in October. CONCLU- 
SIONS: Data support the conclusion that M tu- 
berculosis was transmitted from an infectious 
crew member to other crew members on an air- 
craft. Because of the clustering of TST-posi- 
tive frequent flyers in October when the index 
patient was most infectious, transmission of M 
tuberculosis to passengers cannot be excluded. 

Hemodynamic Effects of Manual 
Hyperintlation in Critically III Mechanically 
Ventilated Patients — M Singer, J Vermaat, G 
Hall. RG Latter. M Patel. Chest 1 994; 106:1 182. 

SUBJECT OBJECTIVE: To assess the hemo- 
dynamic effects of manual lung hyperinflation 
in mechanically ventilated patients and to mea- 
sure the different inspiratory pressures and 
tidal volumes generated by different operators. 
DESIGN: Measurements of aortic blood flow 
(by esophageal Doppler ultrasonography), sys- 
temic blood pressure, tidal volumes (by 
respirometry), and inspiratory pressures in the 
ventilator circuit were measured on the ventila- 
tor, during six intended manual hyperinflations 
(tidal volume > 150% that delivered by venti- 
lator) using a 2-L rebreathing bag, and at 1,5, 
10, and 15 min after reconnection to the venti- 
lator. SETTING: Intensive care unit. PA- 
TIENTS: Eighteen mechanically ventilated pa- 
tients with normovolemia and stable circulato- 
ry status were assessed on a total of 20 occa- 
sions. INTERVENTIONS: Patients were dis- 
connected from the ventilator to enable six 
inanual hyperinflations to be given. 
Measurements were made before and at 5-min 
intervals until no further hemodynamic 
changes were seen. MEASUREMENTS AND 
RESULTS: Hyperinflation (50%- iiicrea.se in 
tidal volume) was achieved only in 10 of 20 
studies. Large variations were seen in percent- 
age change in peak inspiratory pressure 
( -.^0% to +250% ) and tidal volume ( -33% to 
+ 1277f ) generated. Falls in cardiac output cor- 
related to the increase in tidal volume but not 
to the increase in peak inspiratory pressure and 
took up to 1 5 min to recover to baseline \ alues. 



1028 



r-{li.SPIRATORY CARE • NOVEMBER "94 Vol 39 No 1 1 




Mercedes-Benz* cars are renowned for comfort, 
safety and high performance. Just like our humidifiers. 
Bicycles, on the other hand, will only get you some- 
where if you're fit enough to pedal. And 
f^^soil^^^ that reminds us of passive devices, which 
' *" ■" are strictly patient-powered. 
\;-pr^ — __ .^. , Sadly, Mercedes cost a lot more than 

bikes. But - ±ankfully - the total cost of using 
our humidifiers all the time is no more than 
^^ that of u.sing alternati\e systems. 



So why make critically ill patients supply their own heat 
and humidity, when they could have it delivered? 

For further information, and detailed cost 
comparisons, ring Baxter toll-free from anywhere in 
the US on 1-800-321-3832, or speak to us direct on 
+64-9-570-5655. 

Fisher ^Pdykel 



Fisher & Paykel Healthcare: 25 Carbine Road P.O. Box 14-348 Panmure, Auckland NEW ZEALAND Tel: +64-9-570 5655 Fax: +64-9-570 9500. 

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ABSTRACTS 



Changes in cardiac output were independent of 
lung compliance and concurrent vasoactive 
drug support. No consistent ciiange was noted 
in either blood pressure or heart rate. CON- 
CLUSIONS: Lung hyperintlation is frequently 
not achieved by the manual technique. 
Significant changes in cardiac output can occur 
and appear to be related to the tidal volume 
rather than pressure generated. 

.Arterial Oxygen Tension of Patients with 
.Abnormal Lungs Treated with Hyperbaric 
Oxygen Is Greater Than Predicted — LK 

Weaver, S Howe. Chest 1994:106:1 134. 

The arterial oxygen (O;) tension (Pao,) of pa- 
tients with normal gas exchange treated with 
hyperbaric oxygen (HBO:) can be predicted 
from their pre-HBOi arterial to alveolar O: 
tension ratio (a/A) which remains constant up 
to a PaO: of 2,000 mm Hg. We observed that 
the a/A could not be used to predict the PaO; of 
patients with impaired gas exchange (reduced 
pre-HBO: a/As) treated with HBOi. Our study 
provides information about the PaO: of patients 



with abnormal lungs treated with HBOi. For 
clinical reasons, we measured the PaO; of 24 
patients treated with HBOi. We obtained arte- 
rial blood gas values from patients with lung 
dysfunction (a/A < 0.75) prior to, during, and 
after HBO;. The pre-HBO: a/A = 0.45 ±0.17 
(mean ± I SD). During HBOi the a/A ranged 
from 0.7 to 0.8 depending on chamber pressure 
and returned to the pre-HBOi baseline after 
HBOi. We conclude the following: ( 1 ) The hy- 
perbaric PjO;S of patients with a/A < 0.75 is 
greater than expected. (2) However, the PaO: is 
lower than in patients with normal lung func- 
tion (a/A > 0.75). Possible explanations in- 
clude improvement in ventilation/perfusion 
matching, reduction of venous admixture, 
and/or extraalveolar uptake of Oi. (3) 
Exposures to HBO: treatment pressures 
greater than recommended by existing proto- 
cols may be required in patients with impaired 
transfer of O: across the lung to achieve PaOjS 
similar to patients with normal lung function 
treated with HBOi. 



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RKSPIRATORY CARK 



NOVEMBER "94 Vol 39 No 



For Patients Witti Asthma 





Twice-Daily 

Sere\^f 

(solmeferol xinofoote) 

Inhalation Aerosol 

Morning and Evening Inhaiation 
for Active Days and Restful Nigiits 



SEREVENT is indicated for maintenance treatment of asttima and prevention of bronchospasm in 
patients 12 years of age and aider with reversibie obstructive airway disease, inciuding patients witti 
symptoms of nocturnal asttima, who require regular treatment witt) inhaled, short-acting B2-agonists. 

Dosing should be two puffs (42 \jg) of SEREVENT inhalation Aerosol, twice daily, morning and evening, 
approximately 12 hours apart. 

IMPORTANT: SEREVENT should not be used to relieve acute asthma symptoms. 

The most common drug-related adverse events reported in clinical trials were 
headache (10%), tremor (3%), and cough (3%).' 

Please consult Brief Summary of Prescribing Information on adjacent pages. 



Serevent® 

(salmeterol xinafoate) 
Inhalation Aerosol 



BRIEF SUMMARY 



Bronchodilator Aerosol 
For Oral Inhalation Only 

The following is a brief summary only. Before prescribing, see complete prescribing information 
in Serevent' Inhalation Aerosol product labeling 

CONTRAINDICATIONS: Serevent' Inhalation Aerosol is contraindicated in patients with a history 
of hypersensitivity to any of the components. 

WARNINGS; 1 Not for Use to Treat Acute Symptoms: Watch for Increased Need for Short-Actino 
Beta ? -Aoonists: Serevent' Inhalation Aerosol should not be used to relieve acute asthma symp- 
toms. If the patient's short-acting, inhaled beta^-agonist becomes less effective, e g , the patient 
needs more inhalations than usual, medical evaluation must be obtained immediately and 
increasing use of Serevent Inhalation Aerosol m this situation is inappropriate Serevent Inhalation 
Aerosol should not be used more frequently than twice daily (morning and evening) 
at the recommended dose When prescribing Serevent Inhalation Aerosol, patients must be 
provided with a short-acting, inhaled betaj-agonist |e g , albuterol) for treatment of symptoms 
that occur despite regular twice-daily (morning and evening) use of Serevent 

Asthma may deteriorate acutely over a period of hours or chronically over several days. In this 
setting, increased use of inhaled, short-acting beta2-agonists is a marker of destabilization of 
asthma and requires re-evaluation of the patient and consideration of alternative treatment regi- 
mens, especially inhaled or systemic corticosteroids. If the patient uses four or more inhalations 
per day of a short-acting bela2-agonist on a regular basis, or if more than one canister (200 
inhalations per canister) is used in an 8-week period, then the patient should see the pliysician 
for re-evaluation of treatment 

2 Use With Short-Actinq Beta j -Aoonists, When patients begin treatment with Serevent 
Inhalation Aerosol, those who have been taking short-acting, inhaled beta2-agonists on a regular 
daily basis should be advised to discontinue their regular daily-dosing regimen and should be 
clearly instructed to use short-acting, inhaled beta^-agonists only for symptomatic relief if they 
develop asthma symptoms while taking Serevent Inhalation Aerosol (see PRECALITIONS: Drug 
Interactions) 

3. Serevent Inhalation Aerosol Is Not a Substitute for Oral or Inhaled Corticosteroids: Patients 
must be warned not to stop or reduce corticosteroid therapy without medical advice, even if they 
feel better when they are lieing treated with Serevent 

4- Do Not Exceed Recommended Dose: As with other beta-adrenergic aerosols. Serevent 
Inhalation Aerosol should not be used in excess Fatalities have been reported in association with 
excessive use of inhaled sympathomimetic drugs Large doses of inhaled or oral salmeterol (12 
to 20 times the recommended dose) have been associated with clinically significant prolongation 
of the QTq interval, which has the potential for producing ventricular arrhythmias 

5. Paradoxical Bronchospasm: As with other inhaled asthma medications, paradoxical 
bronchospasm (which can be life-threatening) has been reported following the use of Serevent 
Inhalation Aerosol If it occurs, treatment with Serevent Inhalation Aerosol should be discontinued 
immediately and alternative therapy instituted 

6, Immediate Hypersensitivity fieactions. Immediate hypersensitivity reactions may occur after 
administration of Serevent Inhalation Aerosol, as demonstrated by rare cases of urticaria, rash, 
and bronchospasm. 

PRECAUTIONS: 

General: 1 Us e with Spacer or Other Devices: The safety and effectiveness of Serevent® 

Inhalation Aerosol when used with a spacer or other devices have not been adequately studied. 

2 Cardiovascular and Other Effects: No effect on the cardiovascular system is usually seen 
after the administration of inhaled salmeterol in recommended doses, but the cardiovascular and 
central nervous system effects seen with all sympathomimetic drugs (eg , increased blood pres- 
sure, heart rate, excitement) can occur after use of Serevent Inhalation Aerosol and may require 
discontinuation of the drug Salmeterol, like all sympathomimetic amines, should be used with 
caution in patients with cardiovascular disorders, especially coronary insufficiency, cardiac 
arrtiythmias, and hypertension, in patients with convulsive disorders or thyrotoxicosis; and in 
patients who are unusually responsive to sympathomimetic amines. 

As has been described with other beta-adrenergic agonist bronchodilators, clinically significant 
changes in systolic and/or diastolic blood pressure, pulse rate, and electrocardiograms have 
been seen infrequently in individual patients in controlled clinical studies with salmeterol 

3. Metabolic Etfi;cts_ Doses of the related beta2-adrenoceptor agonist albuterol, when adminis- 
tered intravenously, have been reported to aggravate pre-existing diabetes mellitus and ketoaci- 
dosis No effects on glucose have been seen with Serevent Inhalation Aerosol at recommended 
doses Administration of beta2-adrenoceptor agonists may cause a decrease in serum potassi- 
um, possibly through intracellular shunting, which has the potential to increase the likelihood of 
arrhythmias The decrease is usually transient, not requiring supplementation 

Clinically significant changes in blood glucose and/or serum potassium were seen rarely dur- 
ing clinical studies with long-term administration of Serevent Inhalation Aerosol at recommended 
doses. 

Information for Patients: See illustrated Patients Instructions for Use. SHAKE WELL BEFORE 
USING. Patients should be given the following information: 

1 Not..fgr Use to Treat Acute Sympt oms: Serevent Inhalation Aerosol is not meant to relieve 
acute asthmatic symptoms Acute symptoms should be treated with an inhaled, short-acting 
bronchodilator that has been prescribed by a physician for symptom relief. 

2. Dj^Not Exceed Recommended Dose, The bronchodilator action of salmeterol usually lasts 
for at least 1 2 hours therefore it stiould not be used more often than every 1 2 hours. 

3. !Js_e with Other ti/ledications. While using Serevent Inhalation Aerosol, other inhaled medi- 
cines should be taken only as directed by the physician 

4. Use w ith Short-Acting. Inhjiled Bela-Agqnisis: While using Serevent Inhalation Aerosol, 
medical attention should be sought immediately if the short-acting bronchodilator treatment 
becomes less effective for symptom relief, if more inhalations than usual are needed, or if more 
Uian the maximum number of inhalations of short-acting bronchodilator treatment prescribed for 
a 24-hour period are needed. II the patient uses four or more inhalations per day of a short-act- 
ing beta2-agonist on a regular basis, or if more than one canister (200 inhalations per canister) is 
used in an e-week period, then the patient should see the physician for re-evaluation of treat- 
ment 

Patients should be cautioned regarding potential adverse cardiovascular effects, such as palpi- 
tations or chest pain, related to the use of additional beta2-agonist 

5. Use of S y stemic or Inhaled Steroids : Serevent Inhalation Aerosol does not replace oral or 
inhaled corticosteroids; the dosage of these medicines should not be changed and they should 
not be stopped without consulting the physician, even if the patient feels better 

6. Use for Exe rcise-Induced Bronchospasm: When using Serevent Inhalation Aerosol to prevent 
exercise-induced bronchospasm. the dose should be administered at least 30 to 60 minutes 
before exercise. 



Drug Interactions: Short-Acting Beta-Agonists: In the two 3-month, repetitive-dose clinical 
tnals (n= 1 84), the mean daily need for additional beta2-agonist use was 1 to 1 V2 inhalations per 
day, but some patients used more Eight percent of patients used at least eight inhalations per 
day at least on one occasion Six percent used 9 to 12 inhalations at least once. There were 15 
patients (8%) who averaged over four inhalations per day Four of these used an average of 8 to 
1 1 inhalations per day In these 1 5 patients there was no observed increase in frequency of car- 
diovascular adverse events The safety of concomitant use of more than eight inhalations per day 
of short-acting beta2-agonists with Serevent" (salmeterol xinafoate) Inhalation Aerosol has not 
been established. In 1 5 patients who experienced worsening of asthma while receiving Serevent 
Inhalation Aerosol, nebulized albuterol (one dose in most) led to improvement in FEV, and no 
increase in occun'ence of cardiovascular adverse events 

Monoamine Oxidase Inliibitors and Tricyclic Antidepressants: Salmeterol should be adminis- 
tered with extreme caution to patients being treated with monoamine oxidase inhibitors or tncycllc 
antidepressants because the action of salmeterol on the vascular system may be potentiated by 
these agents. 

Corticosteroids and Cromoglycate: In clinical trials, inhaled corticosteroids and/or inhaled 
cromolyn sodium did not alter the safety profile of Serevent Inhalation Aerosol when administered 
concurrently. 

Methylxanthines: The concurrent use of intravenously or orally administered methylxanthines 
(eg., aminophylline, theophylline) by patients receiving Serevent Inhalation Aerosol has not been 
completely evaluated In one clinical trial, 87 patients receiving Serevent Inhalation Aerosol 42 
meg twice daily concurrently with a theophylline product had adverse event rates similar to those 
in 71 patients receiving Serevent Inhalation Aerosol without theophylline Resting heart rates 
were slightly higher in the patients on theophylline but were little affected by Serevent Inhalation 
Aerosol therapy 

Carcinogenesis, Mutagenesis, Impairment of Fertility: In an 18-month oral carcinogenicity 
study in CD-mice, salmeterol xinafoate caused a dose-related increase in the incidence of 
smooth muscle hyperplasia, cystic glandular hyperplasia, and leiomyomas of the uterus and a 
dose-related increase in the incidence of cysts in the ovaries. A higher incidence of leiomyosarco- 
mas was not statistically significant: tumor findings were observed at oral doses of 1 .4 and 10 
mg/kg. which gave 9 and 63 times, respectively, the human exposure based on rodent:human 
AUC comparisons. 

Salmeterol caused a dose-related increase in the incidence of mesovarian leiomyomas and 
ovarian cysts in Sprague Dawley rats in a 24-month inhalation/oral carcinogenicity study Tumors 
were observed in rats receiving doses of 0.68 and 2 58 mg/kg per day (about 55 and 21 5 times 
the recommended clinical dose [mg/m^]) These findings in rodents are similar to those reported 
previously for other beta-adrenergic agonist drugs The relevance of ttiese findings to human use 
IS unknown 

No significant effects occurred in mice at 2 mg/kg (1 3 times the recommended clinical dose 
based on comparisons of the AUCs) and in rats at 0.21 mg/kg (1 5 times the recommended clini- 
cal dose on a mg/m2 basis). 

Salmeterol xinafoate produced no detectable or reproducible increases in microbial and mam- 
malian gene mutation in vitro. No blastogenic activity occurred m vitro inhuman lymphocytes or 
in vivo in a rat micronucleus test. No effects on fertility were identified in male and female rats 
treated orally with salmeterol xinafoate at doses up to 2 mg/kg orally (about 1 60 times the rec- 
ommended clinical dose on a mg/m^ basis) 

Pregnancy: Teratogenic Effects: Pregnancy Category C: No significant effects of maternal 
exposure to oral salmeterol xinafoate occurred in the rat at doses up to the equivalent of about 
1 60 times the recommended clinical dose on a mg/m2 basis Dutch rabbit fetuses exposed to 
salmeterol xinafoate in ufero exhibited effects charactenstically resulting from beta-adrenoceptor 
stimulation; these included precocious eyelid openings, cleft palate, sternebral fusion, limb and 
paw flexures, and delayed ossification of the frontal cranial bones. No significant effects occurred 
at 0,6 mg/kg given orally (12 times the recommended clinical dose based on companson of the 
AUCs). 

New Zealand White rabbits were less sensitive since only delayed ossification of the frontal 
bones was seen at 1 mg/kg given orally (approximately 1 .600 times the recommended clinical 
dose on a mg/m2 basis) Extensive use of other beta-agonists has provided no evidence that 
these class effects in animals are relevant to use in humans There are no adequate and well- 
controlled studies with Serevent Inhalation Aerosol in pregnant women. Serevent Inhalation 
Aerosol should be used dunng pregnancy only if the potential benefit justifies the potential risk to 
the fetus. 

Use in Labor and Delivery: There are no well-controlled human studies that have investigated 
effects of salmeterol on preterm labor or labor at term. Because of the potential for beta-agonist 
interterence with uterine contractility, use of Serevent Inhalation Aerosol during labor should be 
restricted to those patients in whom the benefits clearly outweigh the risks 
Nursing Mothers: Plasma levels of salmeterol after inhaled therapeutic doses are very low (85 to 
200 pg/mL) in humans. In lactating rats dosed with radiolabeled salmeterol. levels of radioactivity 
were similar in plasma and milk. In rats, concentrations of salmeterol in plasma and milk were 
similar The xinafoate moiety is also transferred to milk in rats at concentrations of about half the 
corresponding level in plasma. However, since there is no expenence with use of Serevent 
Inhalation Aerosol by nursing mothers, a decision should be made whether to discontinue nursing 
or to discontinue the drug, taking into account the importance of the drug to the mother Caution 
should be exercised when salmeterol xinafoate is administered to a nursing woman 
Pediatric Use: The safety and effectiveness of Serevent Inhalation Aerosol in children younger 
than 12 years of age have not been established. 

Geriatric Use: Of the total number of patients who received Serevent Inhalation Aerosol in all 
clinical studies. 241 were 65 years and older Geriatric patients (65 years and older) with 
reversible obstructive airway disease were evaluated in four well-controlled studies of 3 weeks' 
to 3 months' duration. Two placebo-controlled, crossover studies evaluated twice-daily dosing 
with salmeterol for 21 to 28 days in 45 patients. An additional 75 geriatric patients were treated 
with salmeterol for 3 months in two large parallel-group, multicenter studies. These 120 patients 
experienced increases in AM and PM peak expiratory flow rate and decreases in diurnal variation 
in peak expiratory flow rate similar to responses seen in the total populations of the two latter 
studies The adverse event type and frequency in geriatric patients were not different from those 
of the total populations studied 

No apparent differences in the efficacy and safety of Serevent Inhalation Aerosol were 
observed when genatrc patients were compared with younger patients in clinical trials As with 
other bela2-agonists, however, special caution should be observed when using Serevent 
Inhalation Aerosol in elderly patients who have concomitant cardiovascular disease that could be 
adversely affected by this class of drug. Based on available data, no adjustment of salmeterol 
dosage in geriatric patients is warranted 

ADVERSE REACTIONS: Adverse reactions to salmeterol are similar in nature to reactions to other 
selective beta2-adrenoceptor agonists. 1 e.. tachycardia; palpitations; immediate hypersensitivity 
reactions, including urticaria, rash, bronchospasm (see WARNINGS); headache; tremor: nervous- 
ness; and paradoxical bronchospasm (see WARNINGS) 

Two multicenter. 12-week, controlled studies have evaluated twice-daily doses of Serevent' 
Inhalation Aerosol in patients 1 2 years of age and older with asthma The following table reports 
the incidence of adverse events in these two studies. 



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Serevenf^ (salmeterol xinafoate) Inhalation Aerosol 

Adverse Experience Incidence In Two Large 12-Week Clinical Trials* 



Adverse Event Type 


Percent of Patients | 


Placebo 
n=187 


Serevent 
42mcgbid, n=184 


Albuterol 
180mcgq.i.d.n=185 


Ear, nose, and throat 
Upper respiratorv 

tract infection 
Nasopharyngitis 
Disease of nasal 

cavity/sinus 
Sinus headache 


13 
12 

4 
2 


14 
14 

6 
4 


16- 

11 

1 
<1 


Gastrointestinal 
Stomachache 





4 





Neurological 
Headache 
Tremor 


23 
2 


28 

4 


27 
3 


Respiratory 
Cough 

Lovier respiratory 
infection 


6 
2 


7 
4 


3 
2 



• Ttie only adverse expenence classified as serious was one case of upper respiratory tract infection in a patient 
treated with albuterol. 

The table above Includes all events (whether considered drug related or nondrug related by the 
investigator) that occurred at a rate of over 3% in the Serevent- (salmeterol xinafoate) Inhalation 
Aerosol treatment group and were more common in the Serevent Inhalation Aerosol group than in 
the placebo group. 

Pharyngitis, allergic rhinitis, dizziness/giddiness, and influenza occurred at 3% or more but 
were equally common on placebo. Other events occurring in the Serevent Inhalation Aerosol 
treatment group at a frequency of 1 % to 3% were as follows: 

Cardiovascular: Tachycardia, palpitations. 

Ear, Nose, and Throat Rhinitis, laryngitis. 

Gastrointestinal: Nausea, viral gastroenteritis, nausea and vomiting, diarrhea, abdominal 

pain 

Hypersensitivity: Urticaria, 

Hfoutli and Teeth: Dental pain 

Musculoskeletal: Pain in loint. back pain, muscle cramp/contraction, myalgia/myositis, 

muscular soreness 

Neurological: Nervousness, malaise/fatigue, 

flesp/rato/y.-Tracheitis/bronchitis, 

S/</n.- Rash/skin eruption. 

Urogenital: Dysmenorrhea, 

In small dose-response studies, tremor, nervousness, and palpitations appeared to be dose 
related, 

OVERDOSAGE: Overdosage with salmeterol may be expected to result in exaggeration of the 
pharmacologic adverse effects associated with beta-adrenoceptor agonists, including tachycar- 
dia and/or arrhythmia, tremor, headache, and muscle cramps. Overdosage with salmeterol can 
lead to clinically significant prolongation of the QTq interval, which can produce ventricular 
arrhythmias Other signs of overdosage may include hypokalemia and hyperglycemia 

In these cases, therapy with Serevent' Inhalation Aerosol and all beta-adrenergic-stimulant 
drugs should be stopped, supportive therapy provided, and judicious use of a beta-adrenergic 
blocking agent should be considered, bearing in mind the possibility that such agents can pro- 
duce bronchospasm. Cardiac monitoring is recommended in cases of overdosage 

As with all sympathomimetic pressurized aerosol medications, cardiac arrest and even death 
may be associated with abuse of Serevent Inhalation Aerosol, 

Rats and dogs survived the maximum practicable inhalation doses of salmeterol of 2 9 and 0,7 
mg/kg. respectively. The maximum noniethal oral doses in mice and rats were approximately 
1 50 mg/kg and >1 .000 mg/kg, respectively. 

Dialysis is not appropriate treatment for overdosage of Serevent Inhalation Aerosol, 



AUmfHanburys 

Research Triangle Park, NC 27709 



February 1 994 
RL-096 



Reference: I. Data on file, Glaxo Inc. 



Men8Hariburys ^ Glaxo Pharmaceuticals 



SER185R0 Printed in USA September 1994 

;ircle 112 on reader service card Visit AARC Booth 309 in Las Vegas 



INTRODUCING THE NEW RESOURCE 
STANDARD IN RESPIRATORY CARE 



Respiratory Care 
Equipment 

F.t/ua/Hy 

Richard D. Branson, RRT 
Dean R. Hess, PhD. RRI' 
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The lights went off and 
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On January 17, 1994 at 4:31 
a. m. , the lights went out at St. 
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"All of our ventilators stopped 
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care for other patients, but one of the 
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Learning Objectives for 
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Original Contributions 



Controlling Carbon Dioxide Delivery during 
Mechanical Ventilation 

Robert L Chatburn RRT and Susan M Anderson RRT 



BACKGROUND: Pediatric cardiac patients are sometimes given carbon dioxide (CO2) 
postoperatively to manipulate pulmonary vascular resistance and thus reapportion pul- 
monary and peripheral blood flow. We de\ ised a double-blender system for controlling 
the delivered CO2 (Fdco:) and oxygen concentrations (Fdo;) and evaluated the utility of 
a nomogram to predict blender settings for required gas concentrations. DESCRIP- 
TION OF DEVICE: Two Bird 3800 MicroBlenders were connected in series. The first 
(a) was supplied by CO2 and air and fed into the second blender (/3), which was also sup- 
plied by O2. System equations were derived and a nomogram constructed to predict set- 
tings for desired Fdcx): and Fdo: expressed as CO. % and O2 %. EVALUATION METH- 
ODS: Values predicted using the nomogram were compared to measured values. 
Analyzers were calibrated with standard gases. Blender calibrations were verified. Using 
nomogram-derived blender settings. 4 levels of O2 (21. 40. 60, and 80% ) and 2 levels of 
CO2 (25 or 30% ). in random order, were analyzed in triplicate. The mean and standard 
deviation of differences (predicted - measured values) were used to estimate inaccuracy 
intervals that would include 95% of future observations at the 99% confidence level. 
EVALUATION RESULTS: The inaccuracy interval (mean difference ± 2.97 standard 
deviations) for CO2 % was 0.06 ± I.IO %. For O2 % the interval was 4.0 ± 2.94 %. CON- 
CLUSIONS: The inaccuracy intervals for COi % and O2 % were clinically acceptable. 
The nomogram should be an efficient bedside tool for the clinician, expediting system 
setup and changes in the gas mixture. [Respir Care 1994;39( 1 1 ): 1039- 1046] 



Background 

Introducing small amounts of carbon dioxide (CO2) in in- 
spired gas before and after surgery can help to limit pul- 
monary blood flow by increasing the pulmonary vascular re- 
sistance.' The survival of infants with hypoplastic left heart 
syndrome (HLHS) is critically dependent upon the presence 



Mr Chatburn is Instructor, Department of Pediatrics, Case Western 
Reserve University, and Director, Pediatric Respiratory Care, 
Rainbow Babies & Childrens Hospital, and Ms Anderson is a respira- 
tory therapist. Pediatric Respiratory Care, Rainbow Babies & 
Childrens Hospital — Cleveland Ohio. 

A version of this paper will be presented by Ms Anderson during the 
RESPIRATORY Care OPEN FORUM at the 1994 AARC Annual 
Meeting, to be held in Las Vegas, Nevada, December 10-13, 1994. 

Reprints: Robert L Chatburn, Director, PediaUic Respiratory Care, 
Rainbow Babies & Childrens Hospital, 1 1 100 Euclid Ave, Cleveland 
OH 44106. 



of (1 ) a patent ductus arteriosus, (2) adequate interatrial mix- 
ing of blood, and (3) a balance between pulmonary (PVR) 
and systemic (SVR) vascular resistance as reflected by a 
PVRiSVR near unity. Because SVR is normally much 
greater than PVR. unequal pulmonary and systemic blood 
flow results in systemic hypoperfusion and metabolic acido- 
sis in children with HLHS. Jobes et al- have reported that the 
most important physiologic variable in preserving an ade- 
quate ratio of PVR to SVR is the maintenance of Paco: at or 
above 40 torr. Undesirable decreases in PacO: may occur dur- 
ing induction of general anesthesia and during the transition 
from spontaneous to mechanical ventilation. Body surface 
cooling before bypass decreases the metabolic rate and CO: 
production, which may further contribute to reduced PacO:- 
Attempts to maintain PacO: at the desired level by reducing 
tidal volume (Vj), respiratory rate (f), or both often result in 
arterial desaturation.- It has been hypothesized that desatura- 
tion occurs because of decreased functional residual capacity 
(FRC), closure of small airways, atelectasis, and hypoxemia.- 
Maintaining FRC with appropriate Vj and f minimizes these 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 



1039 



CONTROLLING CARBON DIOXIDE DELIVERY DURING MECHANICAL VENTILATION 





C02 

Blender 






02 

Slender 






°0 




^0 






02 — > 




C02 — > 






















* 1 








1 1 






FDO2 

Mlni'Oxlll 
oxygen 
analyzer 


FDCO2 

Dalex 
carbon 
dioxide 
analyzer 





final Fdo; and Fqco: are functions of the settings of both a 
and /8 blenders. 



. ,^ /„ ,. [1 - « setting] [1-6 setting] „ „ , \ 

Foo:= 1.27 (0.21 ' 0.822-0 L setting -^ sett,ng-0.2l) 



Fdco:=1.27 



(1-/3 setting) (0.85 a setting -0.178) 
0.822-0.15 a setting 



m 



[2] 



We used these equations to design an alignment nomo- 
gram'* relating the settings of the two blenders to Fdo2 and 

FDCO:(Fig. 2). 



Fig. 1. Diagram of the double-blender system used to simultane- 
ously control oxygen and carbon dioxide concentrations, Including 
the experimental setup used to validate nomogram predictions. 



effects. Adding CO2 allows control of Paco:- independent of 
ventilator settings. 

The reports of Morray et al' and Jobes et al- do not describe 
the techniques u.sed to administer CO2. We found no other re- 
ports in the literature. Therefore, we developed a double- 
blender system consisting of two Bird 3800 MicroB lenders* to 
deliver controlled amounts of CO2 and oxygen (O2) during me- 
chanical ventilation (Fig. I ). The system was used with moder- 
ate success in one infant. However, system adjustments were 
no longer straightforward because the blender calibrations do 
not hold for alternative gas mixtures. Therefore, we developed 
a nomogram to predict the blender settings required to deliver 
any desired combination of CO2 and O2. The purpose of this 
study was to detennine the performance of the nomograin 
compared to actual gas concentration measurements. 



Methods 



System Equations 



To create the nomogram, we first derived the equations 
that describe the blender system operation, taking into ac- 
count the different physical characteristics of CO2 and O2' 
(see Appendix). 

In the equations, the first blender, connected to CO2 and 
air, was designated as a. The second blender, connected to 
O2 and to the first blender and controlling the final deliv- 
ered concentration of O2 (Fpo;) and C02(Fnco:)' was des- 
ignated /3. Actual blender settings are labeled as percents 
but are entered into the equations as decimal fractions. The 



'Manufacturers and suppliers arc idcnlificd in the Product .Sources sec- 
tion al the end of the text. 



Experimental Procedure 

The CO2 control system was assembled by connecting two 
air-oxygen blenders in series. Before conducting the experi- 
ment, the calibration of the blenders at settings of 2 1 , 30, 40, 
50, 60, 70, and 80% was checked using the O2 analyzer of a 
metabolic cart. The analyzer was calibrated according to man- 
ufacturer's instructions (0.01% = specified error). 

The CO2 blender (a) was connected to air (50 psig wall out- 
let) and CO2 (50 psig regulator and H cylinder), and the output 
of this blender was connected to the air inlet of the second 
blender (/3). The oxygen inlet of the second blender designated 
the O2 blender was connected to O2 (50 psig wall outlet). The 
output of the second blender was connected to a flowmeter set 
at 3 L/min. The flowmeter was connected to a manifold and 
reservoir tubing attached to sampling tubes for the CO2 ana- 
lyzer and an O2 analyzer. The MiniOx analyzer was selected 
for this experiment because it represents the type of analyzer 
that would be used clinically. The CO2 analyzer was calibrated 
with 5% CO2. The O2 analyzer was calibrated with room air 
and checked with 100% oxygen. TTie experimental setup is il- 
lusU'ated in Figure I . 

Both blenders were initially set at 21% to provide baseline 
measurements of O2 and CO2. In subsequent experiments, the 
CO2 blender was set at either 25 or 30% in combination with an 
O2 blender setting of 21, 40, 60, or 80% (ie. 8 possible combi- 
nations). These settings were selected to yield representative 
values for O2 % and CO2 % over most of the nomogram's 
range. Steady-state measurements of O2 and CO2 were then 
made. Each exjDeriment was perfonned, at random, in triplicate, 
yielding 24 measurements for each gas. The nomogram was 
used to predict the resultant O2 % and CO2 % from each combi- 
nation of settings. Nomogriun readings were obtained without 
reference to actual measurement data to avciid reader bias. 

Statistical Analysis 

Step 1. Scatter plots of the raw data (ie, differences between 
predicteii and measured gas concentrations) weiv constmcted to 



1040 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 



CONTROLLING CARBON DIOXIDE DELIVERY DURING MECHANICAL VENTILATION 



CM 
O 

■o 
o 

0) 

> 
■3 

o 




10 




CO2 Blender Setting (%) 



a' 



I I I ' I ' I ' M I ' I ' I ' I ' I ' I ■ I ' 



10 5 

Delivered CO2 (%) 



Example 

1 . Draw vertical line through desired CO2 (eg, line a, a' at 7%). 

2. Draw horizontal line through desired O2 (eg, line b, b' at 48%). 

3. Draw line from intersection of first two lines to O2 Blender Setting scale (eg, line c, c' at about 50%). This line should be 
parallel to CO2 Blender Setting scale and perpendicular to O2 Blender Scale. 

4. Find isopleth closest to intersection of three lines. Read down along isopleth to CO2 Blender Setting scale (eg, 31%). 

Fig. 2A. Illustration of the application of a nomogram for predicting oxygen and carbon dioxide concentrations for various settings of the dou- 
ble-blender system. 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1 



I04I 



CONTROLLING CARBON DIOXIDE DELIVERY DURING MECHANICAL VENTILATION 



100 -^ 



90 — E 



80 



^ 

o^ 


70 


'^— ^ 




CM 
O 


60 


"O 




0) 


50 







> 




1^ 


40 


a> 




Q 






30 



20 —E. 



10 -^ 



I ■ ' 'I I .1 ■ I ■ 1. 1 





CO2 Blender Setting (%) 



I ' M I ' I ■ I ■ I ■ I ' I ' I ' I ' I ' I 

10 5 

Delivered CO2 (%) 

Instructions 

1. Draw vertical line through desired CO2. 

2. Draw horizontal line through desired O2. 

3. Draw line from intersection of first two lines to O2 Blender Setting scale. This line should be parallel to CO2 Blender 
Setting scale and perpendicular to O2 Blender Scale. 

4. Find isopleth closest to intersection of three lines. Read down along isopleth to CO2 Blender Setting scale. 

Fig. 2B. An unmarked version of the nomogram for predicting oxygen and carbon dioxide concentrations for various settings of ttie double- 
blender system. (See Figure 2A for example.) 



1042 



RESPIRATORY CARE • NOVEMBER "94 Vol 39 No I 



CONTROLLING CARBON DIOXIDE DELIVERY DURING MECHANICAL VENTILATION 



inspect for outliers and to check that measured values were not 
associated witli the measurement level, as detemiined by a corre- 
lation coefficient.'" The hypothesis tliat the correlation coefficient 
was not different from zero was tested with Fisher's tiansforma- 
tion.'' Outliers were defined using a mcxiified Thompson t tech- 
nique^ as any value greater than 1 .9 standard deviations away 
from the mean value, based on a sample size of 24 and a 95% 
confidence level. 

Step 2. The construction of symmetrical enor intervals based on 
standard deviations assumes that the data confomi to a nomial or 
Gaussian distribution. This assumption was confimied using the 
Kolmogorov-Smimov test. 

Step 3. Predicted values were compared to measured values by 
calculating a statistic, similar to the method proposed by 
Altman and Bland.' '^ However, the "limits of agreement" con- 
cept proposed by these authors is only a point estimate, which 
includes simplifications that may not always apply, particularly 
for sample sizes less than 30.'' An alternative is to calculate an 
error inteival. '" The error interval is based on the concept of 
tolerance intervals, which are extremely important in evaluat- 
ing production and quality in manufacturing and service indus- 
tries."'- The error interval takes into account the uncertainty of 
estimating sample mean and standard deviation. TTius. the gen- 
eral form for an error interval (EI) comparing two values is 

El = Xa ± kSDj. [.^1 

where Xj is the mean value of the differences between 
paired data, SDj is the standard deviation of differences, and 
k is a constant whose value depends on the sample size, the 
desired proportion of observations to be included in the error 
interval, and the desired confidence level. 

If the paired data are two measureinents of the same quanti- 
ty made by two different measurement systems (neither of 
which is assumed to represent the "true" value), then the error 
interval can be inteipreted as an agreement inteiyal. An exam- 
ple of this would be the comparison of blood gas values from 
split samples assayed on two different analyzers. If the paired 
data represent the comparison of a measured or estimated 
value and a standard or assumed true value, then the error in- 
terval can be interpreted as an inaccuracy intenxil. An exam- 
ple of this would be the comparison of measured blood gas 
values froin a tonometered blood sample with standard (ie, 
theoretical) values based on barometric pressure and tonome- 
ter-gas concentration. 

In the study described here, the measurements made by gas 
analyzers were assumed to represent the true gas concentra- 
tions because they are u.sed to make clinical decisions. The 
nomogram values were considered to be estimates of the true 
values. Thus, the error interval was constructed using the dif- 
ference between predicted and true values (ie, nomogram 



value - measured value, so that if the difference is positive we 
can say that the predicted value overestimates the true value 
and vice versa). Therefore, the error interval can be interpreted 
as an inaccuracy intenxd. The value of k in liquation 3 was se- 
lected froin standard tolerance limit tables" to include 95% of 
future observations at the 99% confidence level. This value 
was 2.972 for a sample size of 24. 

Results 

The results of the blender calibration verification procedure 
are shown in Table 1 . Both blender dials tended to overesti- 
mate the delivered oxygen concentration, particularly at the 
higher concentrations. However, they were both within the 
manufacturer's specification for maximum eiTor (±3%). With 
both blenders set at 21%, the measured Ot % was 21.8% and 
the measured CO: % was 0. 

Table 1 . Results of Blender Calibration Verification Using Air and 
Oxygen Inputs (Manufacturer's Error Specification ±3%) 







Measured Val 


ues (%) 




Setting (%) 


CO: Blender 


Error 


O 


2 Blender 


Error 


21 


21.14 


-0.14 




22.96 


-1.96 


30 


31.10 


-1.10 




28.34 


1.66 


40 


39.30 


0.70 




41.78 


-1.78 


50 


48.68 


1.32 




50.56 


-0.56 


60 


58.53 


1.47 




59.52 


0.48 


70 


68.78 


1.22 




68.89 


1.11 


80 


77.58 


2.42 




78.46 


1.54 



Scatter plots of the experimental data are shown in Figure 
3. No outliers were identified. There was no linear association 
between the differences between measured and predicted val- 
ues and the measured CO: values (r = 0.2, p = 0.35), but there 
was an obvious correlation between O: differences and mea- 
siired Oi. Even when data near O: % = 2 1 % were removed, 
the correlation persisted (r = 0.8, p = < 0.000 1 ). In general, this 
means that describing the data with a single mean and standard 
deviation may underestimate the errors at high values of the 
measurand and overestimate them at low values. However, the 
magnitude of the effect was small (about 2%) and seemed to 
mostly affect bias. Therefore, it was ignored and results were 
calculated using data above 21% as a wonst case estimate. 

Results of the Kolmogorov-Smimov test showed that the 
CO: and the O: data (above O: % = 21) were not different 
from the normal distribution (p > 0.999 and p = 0.82, respec- 
tively). 

For CO: %- the mean difference was 0.06% with SD = 
0.37%. The inaccuracy interval (Eq 3) was 



inaccuracy interval (%) 



= 0.06 + 2.97x0.37 
= 0.06± I. ID 
= (-1.04. 1.16) 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 



1043 



CONTROLLING CARBON DIOXIDE DELIVERY DURING MECHANICAL VENTILATION 



1 

0.75 

0.5 

0.25 



-0.25 

■0.5 

-0.75 

-1 







•• • 

• • •• 

• 


. 






• • 
• • 

• •• 

• 
• • 


■ 




■ 



■fl.QSD — 



1.9 SD 



.••-• 



J^ 



• •• 



••• 



Mean 



Observations 



Observations 




8- 
6- 






t 


1 


4 ■ 
2- 




7 




■ 


?■ 


* 



2 3 4 5 6 7 
Measured CO: (%) 



10 20 30 40 50 60 70 
Measured O2 (%) 



Fig. 3. Plots of the raw data comparing the differences between predicted gas concentrations (from the nomogram) and measured gas con- 
centrations to the measured gas concentrations. Outliers were defined as data points greater than 1 .9 standard deviations from the mean. 
(A, C) plots to identify outliers, (B, D) plots to evaluate correlation between differences (ie, predicted - measured) and measurement level. 



For O2 %, the mean difference was 4.01 % with SD = 0.99%. 
The inaccuracy interval was 

inaccuracy interval (%) = 4.01 ± 2.97 X 0.99 
= 4.01 ±2.94 
= (1.07,6.95) 

These inaccuracy intervals are illustrated in Figure 4. 

Discussion 

The calculation of inaccuracy intervals allows judgments 
to be made concerning the error of the nomogram in predict-^ 
ing gas concentrations. The results indicate that 95% of pre- 
dicted gas concentrations using the nomogram are within 1 % 
of actual measured values for CO2 and within 7% for Oi. 
Furthermore, we are 99%) sure that the predicted values are 
within these limits.'* The error forCOi was negligible, and in 



fact was less than the specified error of the CO; analyzer 
(±2%). The error for O2 was larger but still acceptable for 
clinical use. The specified error for the blenders was ±3%''* 
and for the MiniOx III, ±1%.''* 

The propagation of errors through a system is generally 
treated by taking the square root of the sum of individual 
squared enors.'"' However, in this case, the procedure does 
not seem so straightforward because the blenders are connect- 
ed in series. For example, the concentration of CO2 from tlie 
first blender was lower than expected from the blender setting 
due to calibration error. However, the second blender also pro- 
duced a lower O2 concentration thiin expected, thus making 
the CO2 higher than expected and tending to cancel the error 
of the first blender. To make matters more complicated, the 
blender error tended to change direction and magnitude at 
higher settings. In light of these complications and Ihe relative- 
ly small error observed for the system, it did not seem practical 
to conduct a lull Iheorelical eiror propagation analysis. 



1044 



RESPIRATORY CARE • NOVEMBER "94 Vol .^9 No 



CONTROLLING CARBON DIOXIDE DELIVERY DURING MECHANICAL VENTILATION 



8- 




^ 


7- 






- 


6 - 






- 


5 - 






- 


4 - 




(» 


3- 






- 


2- 






■ 


1 - 




h 


- 

1 - 

o - 


( ) 


'- 


d 




' 




Predicted 
CO2 


Predicted 
O2 



Fig. 4. Inaccuracy intervals for CO2 % and O2 %. These intervals were 
constructed to include 95% of future nomogram readings at ttie 99% con- 
fidence level. 



One possible limitation of the study was that it in- 
cluded measurements made at only one level of total 
flow through the blender (3 L/min). Blender error may 
change slightly at other flowrates. However, the manu- 
facturer specifies blender error as ±3% over a flow range 
of 2 to 90 L/min. Given that blenders tend to be more in- 
accurate at lower rather than higher flows (personal 
communication, John Gose, product engineer. Bird 
Products Corp, 1994), our study was intended to repre- 
sent a worst case scenario. We later confirmed the utility 
of the nomogram by repeating the experiment for two 
gas concentration levels (Oi = 40%, C02= 25% and O2 = 
40%, CO2 = 30%, selected to be representative, widely 
separated points on the nomogram) and three flows (5, 
10, and 15 L/min). The observed errors (ie, predicted - 
measured gas concentrations) all fell midrange of the in- 
accuracy interval determined from the original study. 

Conclusions 

The nomogram provides a quick and accurate way to pre- 
dict blender settings required to deliver precise concentra- 
tions of oxygen and carbon dioxide through a double-blender 
system. However, gas concentration should be measured 
continuously to verify the correct operation of the system. 



PRODUCT SOURCES 



Statistical Software: 

StatView, Abacus Concepts, Berkely CA 



Air/Oxygen Blenders: 

3800 MicroBlender. Bird Products Corp, Palm Springs CA 



CO2 Analyzer: 

Datex Medical Instrumentation Inc. Tewksbury MA 



O2 Analyzer: 

MiniOx III. MSA - Medical (Catalyst Research). Pittsburgh PA 



Metabolic Cart: 

MetaScope Model II, Cybermedic, Louisville CO 



REFERENCES 

1 . Monray JP, Lynn AM, Mansfield PB. Effect of pH and Pco; on pul- 
monary and systemic hemodynamics after surgery in children with 
congenital heart disease and pulmonary hypertension. J Pediatr 
I988;113(3):474-479. 

2. Jobes DR, Nicolson SC, Steven JM, Miller M, Jacobs JL, Norwood 
WI Jr. Carbon dioxide prevents pulmonary overcirculation in hy- 
poplastic left heart syndrome. Ann Thorac Surg 1 992;54( 1 ): 1 50- 151. 

3. Mushin WW. Jones PL. P Macintosh, Mushin & Epstein. Physics for 
the anaesthetist, 4th ed. Oxford; Blackwell Scientific Publications, 
1987. 

4. Levens AS. Nomography. New York: John Wiley & Sons, 1937. 

5. Blond JM. Altman DC Statistical methods for assessing agreement 
between two methods of clinical measurement. Lancet 
1986;1(8476):307-310. 

6. Devore JL. Probability and statistics fro engineering and the sciences. 
Monterey CA: Brooks/Cole Publishing Co, 1982:457^58. 

7. Measurement uncertamty (ANSI/ASME PTC 19.1-1985). American 
Society of Mechanical Engineers. United Engineering Center, 345 
East 47th Street, New York, NY, 10017. 

8. Alrnian DO. Bland JM. Measurement in medicine: the analysis of 
method comparison smdies. Statistician 1983;32:307-317. 

9. Chinn S. The assessment of methods of measurement. Statistics in 
Medicine 1990;9:351-362. 

10. Chatbum RL, Hess D. Research and statistics for the clinician. In: 
Dantzker D, Maclntyre N, Bakow ED, eds. Comprehensive respirato- 
ry care. Philadelphia: WB Saunders Co (in press). 

11. Walpole RE, Myers RH. Probability and statistics for engineers and 
scientists. New York: Macmillan, 1989:264-266,242-244,638-639. 

1 2. Mason RL, Gunst RF, Hess JL. Statistical design & analysis of exper- 
iments. New York: John Wiley & Sons. 1989:247-248,623. 

13. Odeh RE, Owen DB. Tables for normal tolerance limits, sampling 
plans, and screening. New York: Marcel Dekker, 1980:6. 

14. Bird 38(X) MicroBlender instruction manual. Palm Springs CA: Bird 
Medical Products. 

15. MiniOx III Operating manual. Pittsburgh PA: Catalyst Research. 

16. Chatbum RL. Fundamentals of metrology: evaluation of insmiment 
error and method agreement. Respir Care 1990;35(6):520-545. 



Appendix begins on next page. 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 



1045 



CONTROLLING CARBON DIOXIDE DELIVERY DURING MECHANICAL VENTILATION 

APPENDIX 

Derivation of Blender Equations for Delivering O2-CO2 Mixtures 



Assumptions: Fo; of air = 0.2 1 . Fco: of air = 0.0. 



The equations for both blenders were deri\'ed from basic mass 
balance equations: 



(F0..I I V,„,) = (Fo;) (V<,xyEC„l+ (FO;) {V„„ 

V,„, = (V„„,g,„) + (V,i,) 
where F is ihe fractional eoncenlration and V is gas flo 



lAl] 

|A2J 



Gas flow through a constriction is a function of density 
and viscosity. If the constriction takes the form of an ori- 
fice, as in the blenders, the density of the gas plays a domi- 
nant role in determining the rate of flow. For an ideal ori- 
fice, across which the pressure difference is kept constant, 
the following equations apply:' 



to carbon dioxide inputs. Using Equation A4, we estimated 
that the actual flow of carbon dioxide through the blender 
would be SS'/f of the expected flow if oxygen were con- 
nected, due to carbon dioxide's higher density: 

Vcartx,„d,o<,do = (0.85)(Va„). 1A51 

Substituting this result into Equation A2 and using A2 with 
AI yields the equation for the CO2 (a) blender Fq,: 

_ 0.21(1 -setting) 



0.822 -0.15 (setting) 



where "setting" refers to the Fo; setting of the blender expressed as 
a decimal fraction. 

Substituting this result into Equation Al provides the O2 
(P) blender Fq:: 



Vdensityofga 



if Gas A is passed through an ideal orifice in a meter cali- 
brated for Gas B: 



ctual now of Gas A 



.V 



density of Gas B 
densilv of Gas A 



)(no 



/ expected through B meter) 
|A41 



The density of oxygen is 32 g/mol and its viscosity is 
201 micropoises. The density of carbon dioxide is 44 
g/iTiol with a viscosity of 148 micropoises. The viscosities 
of the two gases are not very different to begin with and as- 
suming that density dominates flow, we ignored viscous 
effects on blender calibration when switching from oxygen 



F^,= 1.27(0.21 [l-g setting] II -/3 setting] ^^„.„^_,,|) 
'^- ^ 0.822 -0.15 a setting - |A7] 



The Fco:S for the two blenders are derived in a similar 
fashion: 



0.85 a setting -0.1 78 
^0.822-0.15 a setting 



[A8] 



_ (1-/3 setting) (0.85 g setting - 0. 1 78 ) 
'*^°'" ■' 0.822-0.15 a setting |A9] 



A more complete derivation is available upon request. 



1046 



Ri;SPlRAI()RY CARE • NOVEMBER '44 Vol .V) No I 1 



Clinical Comparison of Two Aerosol Holding Chambers: 
ACE vs Aerochamber 

Robert J Perry BS, Edward G Langenback PhD, and Jonathan S Ilowite MD 

BACKGROUND: Aerosol holding chambers (HCs) have proven to be an effective 
enhancement to the administration of aerosolized medications by metered-dose in- 
haler (MDI). Recent bench tests demonstrating different performance characteris- 
tics among HCs, which have unknown clinical relevance, suggest the need for pa- 
tient studies to confirm the clinical effectiveness of each new HC-MDI combination. 
We compared the Aerochamber with the Aerosol Cloud Enhancer (ACE) combined 
with albuterol MDI in stable asthmatics. METHODS: Ten subjects were selected 
whose FEV| (the volume exhaled in the first second of a forced exhalation) in- 
creased by at least 15% following an albuterol aerosol. On separate study days, sub- 
jects withheld asthma medications for 8 hours, then inhaled 2 puffs of albuterol 
MDI (90 ng/puff) using both HCs. Patients performed FEVi before (pre) and at 30, 
60, and 120 minutes after (post) albuterol. Pulse, blood pressure, and incidence of 
side effects were recorded. Change in FEVj was expressed using "% possible" 
FEVi [%possible = (pre - post FEV,)/(predicted - pre FEV,)]. RESULTS: Mean 
(SD) % possible at t = 30, 60, and 120 minutes for ACE were 37.7 (10.1), 35.0 (12.6), 
and 25.7(16.2) and for Aerochamber were 28.1 (14.6), 21.8 (20.3), and 25.4 (27.1). 
The differences in % possible between ACE and Aerochamber were not statistically 
signiHcant at any time period (p > 0.05, paired / test). CONCLUSIONS: Our results 
confirm that the ACE- and Aerochamber-MDI combinations function comparably 
in adult patients with stable asthma. On average, the difference between HCs was 
also not clinically important. [Respir Care I994:39( 1 1 ): 1047-1050.] 



Background 

Aerosol holding chambers (HC) have been developed as an 
adjunct to metered-dose-inhaler (MDI) delivery of bron- 



Mr Perry and Dr L^angeiiback ore from the Department of Medicine. 
Pulmonary Disease/Critical Care Division, State University of New 
York at Stony Brook, Stony Brook, New York. Dr Dowite is Director of 
Respiratory Care, Winthrop-University Hospital, Mineola, New York. 

This study was supported in part by Allen & Hanburys, Division of 
Glaxo Inc, Research Triangle Park, North Carolina, and by 
Diemolding Healthcare Division. Canastota, New York. 

The authors have no fniancial interest in any of the products men- 
tioned in this paper or in any competing product. 

A version of this paper was presented by Mr Perry during the 
Respiratory Care Open Forum at the 1993 AARC Annual 
Meeting, held in Nashville, Tennessee. 

Reprints: Robert J Perry, SUNY at Stony Brook, Pulmonary 
Disease/Critical Care Division, HSC-T-17 Room 040, Stony Brook 
NY 11794-8172. 



chodilators, a common therapy for asthma. A well-designed 
HC eliminates most patient-generated errors (ie, poor coordina- 
tion of MDI actuation and inhalation) that occur in use of 
MDI'" and that prevent aerosolized medication from reaching 
the lungs. TTie HC should also minimize the deposition of drug 
in the mouth and oropharynx' "" because of propellent evapora- 
tion and particle impaction (ie, with one-way valves^) that re- 
duce the proportion of large nonrespirable particles and be- 
cause it encourages slow inhalation of the medication.'''^ This is 
typically achieved through the use of a flow sensor* that acti- 
vates an audible warning (whistle) when the patient inhales at 
or above the manufacturer-determined maximum allowable in- 
spiratory flow. Other patient errors, such as failing to inhale the 
medication, are only discouraged by devices that allow visual- 
ization of the collapsing reservoir during inhalation."''^ Failure to 
shake the MDI before use or to perform a sufficient breathhold 
of the medication are. to date, not controlled by HC devices. 

The first HCs were well characterized in vitro and in vivo 
before being widely accepted.^'"'- New HC designs, howev- 
er, have been developed and distributed without thorough clin- 
ical evaluation. In 1993 alone, we have seen at least two new 
HC models being marketed with little, if any, published evi- 
dence of clinical effectiveness. In order to receive the Food 



RESPIRATORY CARE • NOVEMBER "94 Vol 39 No 1 1 



1047 



COMPARISON OF ACE TO AEROCHAMBER 



and Drug Administration approval that allows them to be mar- 
keted in the United States. HCs are characterized in vitro by 
assay of total deposition/dose (etficiency). particle size distri- 
bution, and amount of aerosolized drug exiting each device 
under predetermined sampling conditions. When four HCs 
with substantial design differences were compared in this 
manner using an albuterol MDl aerosol, the data reported in an 
abstract by Dolovich et al" demonstrated differences among 
the devices. Unfortunately, many of the factors that contiibute 
to the clinical effectiveness of various HCs are not known, and 
some that are known may not be taken into account during in- 
vitro testing. Therefore, we believe that the clinical equivalen- 
cy of a particular device must be directly ascertained in vivo. 

We selected two HCs. the Aerochamber and the ACE. 
Dolovich et al" reported a 45'y^ difference in efficiency be- 
tween these particular HCs using a 45 L/min sampling 
flowrate. In our study, the HCs were combined with the same 
albuterol MDI that was used in the in-vitro study, and our 
suidy consisted of a clinical comparison in asthmatic subjects. 
The results of this and other in-vivo studies, when compared to 
those using in-vitro data, may enable us to determine the clini- 
cal relevance of bench testing these devices. 

Methods 

Following informed consent and physical exam, potential 
subjects — stable adult asthmatics — were screened to docu- 
ment reversible airway obstruction. Subjects were excluded 
if they had an upper respiratory infection; had been hospital- 
ized for asthma within the past 30 days; had emphysema, 
chronic bronchitis, significant cardiovascular, hepatic or 
renal disease, or a metabolic disorder; were current smokers; 
or were pregnant. The best of 3 trials to perform FEVi was 
our measure of reversibility and was made before (pre) and at 
30, 60, and 120 minutes after (post) administration of al- 
buterol using a small volume nebulizer (SVN)-compressor 
combination.* Subjects had not taken any asthma medica- 
tions for 8 hours prior to screening or HC study. 

For the HC study, subjects arrived at the study site at the 
same time of day for each of two study days. They received 
instruction and were allowed to practice to ensure conect HC 
technique. Most subjects initially triggered the flow sensor of 
the ACE and were instructed to reduce their inspiratory 
flowrate so as not to trigger the flow sensor. None triggered 
the Aerochamber flow sensor. 

Using a randomized crossover study design, we then ad- 
ministered 2 puffs of albuterol by MDI (90^g/puff) using the 
ACE or Aerochamber HC. Specifications of the two HCs se- 
lected for clinical evaluation are given in Table 1. Baseline 
rev I was performed, and the best of 3 efforts is reported. 



Then a new MDI was shaken, primed with 2 puffs,''' attached 
to the HC, and placed in the subject's mouth. The HC was 
then charged with 1 puff of aerosol, and the subject inhaled 
slowly from residual volume to total lung capacity, held his 
breath for 5 seconds, and then exhaled normally. The second 
puff was inhaled after a 1 -minute rest. FEV] was measured at 
30, 60, and 120 minutes after the second puff. In addition, 
pulse, blood pressure, and incidence of side effects (includ- 
ing tremors, nervousness, dizziness, nausea, or headache) 
were recorded before and after bronchodilator. The albuterol 
canister was saved for use on the subsequent HC study day. 

Table 1. Specifications of Holding Chambers Selected for Study 



Aerochamber 



ACE 



Shape 

Chamber volume (mL) 

Flow sensor sensitivity* (L/min I 

MDI interface 

Internal valve design 



Tube Cone 

140 160 

156 32 

Actuator + canister Canister only 

Center opening Side opening 



*Manufacturers and suppliers are identified in the Product Sources sec- 
tion at the end of the text. 



Bronchodilation was assessed by analyzing changes in 
FEV I using an index, % possible FEV], calculated by divid- 
ing the difference between baseline and post-albuterol FEV| 
by the difference between the predicted and baseline FEV| 
and multiplying by 100% — (pre - post )/( predicted - pre) X 
100%.""' This method of analysis has been reported to be 
the most accurate way of comparing ITiVi data.'^ 

% possible FEVi was statistically compared between de- 
vices using a paired Student's / test. '^ Probability values < 
0.05 were considered significant. A post-hoc power analysis 
was also performed to detemiine how sensitive our study 
was for detecting a meaningful difference between the two 
HCs. 

Results 

Of the 12 subjects screened, 2 did not achieve a 15% in- 
crease in FEV] after albuterol by SVN, and 10 subjects qual- 
ified for the study and completed the study protocol. Table 2 
describes the characteristics of this group of patients. Mean 
values for % possible FEVi over time are shown in Figure 1. 
No differences were statistically significant for any time pe- 
riod. The probabilities from the paired t test on ACE vs 
Aerochamber at 30 minutes was 0.068. at 60 minutes 0.056, 
and at 1 20 minutes 0.962. A post-hoc power analysis .showed 
an 80% chance of detecting a 13% difference between % 
possible FEV|S (for each HC) at the 0.05 level of signifi- 
cance. No patient experienced a significant change in heart 
rale or blood pressure after bronchodilator by any method. 
The incidence of side effects was minimal, with 1 patient ex- 
periencing headache and 1 patient experiencing dizziness — 
both with albuterol by SVN. 



1048 



RESPIRATORY CARE • NOVEMBER "94 Vol 39 No 



COMPARISON OF ACE TO AEROCHAMBER 



Table 2. Mean (SD) Values for Patient Characteristics Prior to Study 



Variable 


Value 


Total subjects 


10 


Male gender 


5 


Age (years) [range] 


38 (15) [21-60] 


FEV, (L) 


2.47 (0.49) 


Predicted'" (%) 


75(14) 


FEV|/FVC(%) 


65(8) 


Medication use 


10 


adrenergics 


9 


inhaled steriods 


7 


theophylline 


3 



Discussion 

The purpose of thi.s study was to compare the bronchodila- 
tor response to albuterol MDI aerosol delivered using two 
holding chambers — the ACE and the Aerochamber. The data 
demonstrate comparable results between the two devices over 
a 2-hour post-treatment period in these patients. The MDI- 
nebulizer dose ratio for albuterol was 1 : 14 in our study. Both 
HCs performed remarkably well considering a study in asth- 
matics by Blake et al'** that estimated that 10 puffs from an 
MDI (0.9 mg) would be required to deliver the same amount 
of albuterol to the lung as 2.5 mg of nebulizer solution ( 1 :2.7 
ratio). Of our 10 subjects. 6 did not achieve the 15% increase 
in FEV, with 2 puffs of albuterol via HC (2 ACE, 4 
Aerochamber) that they exhibited after nebulized albuterol 



1 00% 



^ 50%- 




SVN 



Aerochamber 



ACE 



Aerosol Delivery Device 



Fig. 1. % possible FEVi before albuterol MDI and at 30(IZZ]), 
60(IZZ1), and 120(^) minutes after albuterol using SVN only, 
MDI with Aerochamber, and with ACE, Bars are mean + SD. Only 
Aerochamber and ACE were statistically compared. 



piior to entry into the study. This is not suprising because our 
study was designed to avoid the plateau of the bronchodilator 
dose-response curve, which might have prevented any differ- 
ences between HCs from being detected. 

Our results could not have been predicted from previous in- 
vitro testing of the HCs alone that have claimed a substantial 
advantage of the Aerochamber over the ACE." Other investi- 
gators found a similar variation when comparing another HC. 
the InspiiEase, to the Aerochamber.-" In that study, a small 
benefit of the InspirEase over the Aerochamber was demon- 
strated that also would not have been predicted by the earlier 
in-vitro studies. In another study. Nelson et al-' found a slight- 
ly lower response to 2 puffs of albuterol MDI via Aerochamber 
in 18 asthmatics. 

We, therefore, conclude that the ACE is equivalent to the 
Aerochamber in terms of clinical effectiveness when used 
with albuterol MDI in adult asthmatics and. although in-vitro 
testing is an important step in designing and validating these 
devices, in-vivo extrapolations should be made with caution. 

ACKNOWLEDGMENTS 

The authors thank Ms Edie Fenster for her invaluable assistance with the 
implementation of this study. 

PRODUCT SOURCES 

Bronchodilator: 

Albuterol (Ventolin Inhalation Aerosol, Ventolin Inhalation Solution), 
Allen & Hanburys, Division of Glaxo Inc, Research Triangle Park NC 

Holding Chambers: 

Aerosol Cloud Enhancer (ACE) MDI Spacer. Cat No. DHD 11-1010, 

DHD Medical, Diemolding Healthcare Division. Canastota NY 
Aerochamber Spacer. Monaghan Medical Corp, Pittsburgh NY 

Small Volume Nebulizer: 

Hospitak Power Mist Medication Nebulizer, Cat No. 3759, Hospitak Inc, 
Lindenhurst NY 

Compressor: 

Pulmo-Aide, Model 5610D, DeVilbiss Health Care Inc, Somerset PA 

Spirometer: 

Renaissance Spirometry System, Model PB-100, Puritan-Bennett Corp, 
Wilmington MA 



REFERENCES 

1 . Crompton GK. Problems patients have using pressurized aerosol in- 
halers. Eur J Respir Dis Suppl 1982;119:101-104. 

2. Oprehek J. Gayard P, Grimaud C, Charpin J. Patient error in use of 
bronchodilator metered aerosols. Br Med J 1976;1(6(X)1):76. 

3. Newman SP, Pavia D, Moren F, Sheahan NF, Clarke SW. Deposition 
of pressurized aerosols in the human respiratory tract. Thorax 
1981;.16(I):52-55. 

4. Newman SP. Woodman G, Clarke SW, Sackner MA. Effect of 



RESPIRATORY CARE • NOVEMBER "94 Vol 39 No 1 1 



1049 



COMPARISON OF ACE TO AEROCHAMBER 



InspirEase im the deposition of inetercd-dose aerosols in the human 
Inspiratory tract. Chest 1986:89(4):551-556. 

Newman SP. Millar AB, Lennard-Jones TR. Moren F. Clarke SW. 
ImproveiTient of pressurised aerosol deposition with Nebuhaler spacer 
device. Thorax 1 984;39( 1 2 ):935-94 1 . 

Lawford P, McKenzie D. Does inspiratory flow rate affect bron- 
chodilator response to an aerosolized ft agonist (absu-act)'.' Thorax 
1981:36:714. 

Newman SP, Pavia D. Clarke SW. Simple instructions for using pres- 
surized aerosol bronchodilators. J R Soc Med 1980:73( I 0:776-779. 
Perry RJ, Langenback EG. Bergofsky EH. llowite JS. Differences in 
aerosol holding chamber flow sensors may alter MDl therapeutic ef- 
fect (abstract). .-Xm Re\ Respir Dis 1993:147(4. Part 2):A996. 
Vichyanond P. Chokephaibulkit K, Kerdsomnuig S. Visitsuntom N, 
Tuchinda M. Clinical evaluation of the "Siriraj Spacer" in asthmatic 
Thai children. Ann Allergy 1992:69(5):433-438. 
Corr D. Dolovich M. McCormack D. Ruffm R, Obminski G. 
Newhouse M. Design and characteristics of a portable breath actuated, 
particle size selective medical aerosol inhaler. J Aerosol Sci 
1982;13:1-7. 

Tobin MJ. Jenouri G. Dania I. Kim C, Watson H, Sackner MA. 
Response to bronchodilator drug administration by a new reservoir 
aerosol delixen, system and a review of other auxiliary delivery sys- 
tems. Am Rev Respir Dis 19S2: 1 26(4):670-675. 
Dolovich M, RufUn R, Corr D. Newhouse MT. Clinical evaluation of 
a simple demand inhalation MDl aerosol delivery device. Chest 
1983:84(l):36-4i. 
Dolovich M. Chambers C, Mazza M. Newhouse MT. Albuterol dose 



■spir 



available from four MDl add-on devices (abstract). Am Re\ Re 
Dis 1993;I47:A996. 

Blake KV. Harman E. Hendeles L. Evaluation of a generic albuterol 
metered-dose inhaler: importance of priming the MDl. Ann Allergy 
1992:68(2): 169- 174. 

Knudson RJ, Slatin RC. Lebowitz MD. Burrows B. The maximal ex- 
piratory flow-volume curve: normal standards, variability, and effects 
of age. Am Rev Respir Dis 1976:1 13(5):587-6(X). 
Knudson RJ, Lebowitz MD, Holberg CJ, Burrows B. Changes in the 
normal maximal expiratory flow-volume curve with growth and 
aging. Am Rev Respir Dis 1983:127(6):725-734. 
Dompeling E. van Schayck CP, Molema J, Akkermans R, Folgering 
H, van Grunsven PM, van Weel C. A comparison of six different 
ways of expressing the bronchodilating response in asthma and 
COPD: reproducibility and dependence of prebronchodilator FEV|. 
Eur Respir J 1992;5( 81:975-981. 

"Student." The probable error of the mean. Biometrika 1908:6:1. 
Blake KV, Hoppe M, Harman E. Hendeles L. Relative amount of al- 
buterol delivered to lung receptors from a metered-dose inhaler and 
nebulizer solution: bioassay by histamine bronchoprovocation. Chest 
1992:101(21:298-299. 

Crimi N, Palermo F, Cacop;irdo B. Vancheri C, Oliveri R. Palermo B. 
Mistretta A. Bronchodilator eft'ect of Aerochamber and Inspirease in 
comparison with metered dose inhaler. Eur J Respir Dis 
1987:71(31:153-157. 

Nelson HS, Loffert DT. Comparison of the bronchodilator response to 
metered dose inhaler ( MDl ) alone or with the Aerochamber or opti- 
haler (abstract). J Allergy Clin Immunol 1993,91 ; 167. 



CORRECTIONS 

Errors were made in two Clinical Practice Guidelines printed in the August issue. 

In the AARC Guideline: Neonatal Time-Triggered, Pressure-Limited, Time-Cycled Mechanical Ventilation 
Section 1 3. 1 states "The Clinical Practice Guideline: Ventilator Circuit Changes, the CDC. and reported experi- 
ence suggest that use periods of < 5 days are acceptable when the humidifying device is other than an aerosol 
generator." Section 13. 1 should have read "suggest that use periods of > 5 days are acceptable when the humid- 
ifying device is other than an aerosol generator." [Error occurred on Page 812.] 

In the AARC Guideline: Application of Continuous Positive Airway Pressure to Neonates via Nasal Prongs or 
Nasopharyngeal Tube Section 13.2 states "The Clinical Practice Guideline: Ventilator Circuit Changes, the 
CDC, and reported experience suggest that use periods of < 5 days are acceptable when the humidifying device 
is other than an aerosol generator." Section 13.2 should have read "suggest that use periods of > 5 days are ac- 
ceptable when the humidifying device is other than an aerosol generator." j Error occurred on Page 820.] 

Clinical Practice Guideline reprints have been coirected. We regret the errors. 



1050 



RESPIRATORY CARE • NOVEMBER '94 Vol M) No I 



Patricia A Doorley MS RRT and Charles G Durbin Jr MD. Section Editors 



Test %ur 
Radiologic Skill 



Airway Compromise in Two Patients with Aplastic Anemia 
and Coagulation Abnormalities 

Loretta D Gleaton BA RRT and Frederick P Ognibene MD 



Case Summaries 

A 49-year-old Caucasian woman (Patient A), with a his- 
tory of aplastic anemia, presented to the Warren G 
Magnuson Clinical Center of the National Institutes of 
Health for the administration of anti-thymocyte globulin 
(ATG), cyclosporin A, and glucocorticosteroid therapy. Her 
physical examination on admission revealed oral mucosal 
bleeding, facial ecchymoses. and menorrhagia. Laboratory 
tests revealed a hemoglobin of 8.7 g/dL and a platelet count 
of 3,000/mm\ In addition, blood cultures were positive for 
an a-hemolytic streptococcus. On the fourth day after admis- 
sion, she continued to have vaginal bleeding with sponta- 
neous mucosal hemorrhage, oral hematomas, and a new right 
periorbital hematoma. She complained of inability to swal- 



Ms Gleaton is a critical care respiratory therapist and Dr 
Ognibene is Medical Director, Critical Care Section, Warren G 
Magnuson Clinical Center of the National Institutes of Health, 
Bethesda, Maryland. 

Reprints: Loretta D Gleaton BA RRT, Critical Care Medicine 
Department, Warren G Magnuson Clinical Center, National 
In.stitutes of Health, 10 Center Drive, MSC 1662, Building 10, 
Room 7D43, Bethesda MD 20892-1662. 



low secretions and of "pain in her neck." Her physical exam- 
ination was negative for stridor, neck swelling, and tracheal 
deviation. A lateral-neck radiograph (Fig. 1) was performed, 
and she was transferred to the medical intensive care unit. 

Another patient, admitted to our center, was a 5 1 -year-old 
African- American woman (Patient B) admitted for adminis- 
tration of ATG, cyclosporin A, and glucocorticosteroids for 
treatment of apla.stic anemia. Physical examination revealed 
vaginal and rectal bleeding. Her admission platelet count was 
3,000/mm' and hemoglobin 6.5 g/dL. Blood culture was pos- 
itive for Bacteroides fragilis and Clostridium species. Prior 
to receiving her immunosuppressive therapy, she was admit- 
ted to the medical intensive care unit for placement of a cen- 
tral venous catheter necessary for administration of ATG, cy- 
closporin A, glucocorticosteroids, and antibiotics. The right 
internal jugular vein was cannulated instead of the femoral 
vein because of the femoral vein's proximity to the gastroin- 
testinal tract and the uterus, the presumed origins of her bac- 
terial infection. One posterior and two anterior approaches 
were attempted without adequate blood return. A small 
hematoma developed in her neck, and local pressure was ap- 
plied over the sternocleidomastoid region for approximately 
3 minutes. Swelling continued to develop progressing to the 
suprasternal notch and then to the contralateral side from the 
clavicle to the angle of the right jaw. An anteroposterior 
chest radiograph was performed (Fig. 2). 



How would you answer these questions? 

What abnormalities are present in both Figures 1 and 2? 



What diagnoses should be considered based on Figures 1 and 2'; 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1 



1051 



TEST YOUR RADIOLOGIC SKILL 




Fig. 1. Lateral-neck radiograph of Patient A 
who complained of dysphagia. 



What tiiilher testing would be appropriate to confirm the diagnosis? 



What are the appropriate interventions for both of these patients? . 



1052 



RKSPIRATORY CARL • NOVEMBER "94 Vol 39 No I 



TEST YOUR RADIOLOGIC SKILL 




Fig. 2. Anteroposterior sitting chest radio- 
graph of Patient B after cannulation of the 
right-internal-jugular vein. 



Answers and Discussion on Next Page 



^ J| Learn the ■ ■ 

Mechanics 



of Mechanical Ventilation 

Explains how physical and mathematical models are developed and 
applied, how such models are incorporated into ventilator design to 
provide estimates of mechanics, and some of the problems that can 
develop because of the limitations of the models. Chatburn points out 
that lack of consistency among manufacturers in the way in which 
compliance and resistance ore measured and temperature 
conversions are applied and how the lack of published accuracy and 
precision information make data interpretation difficult. 

Item VT30 — VHS (60 minutes), $40 (AARC Member $35). 
Add $3.25 for shipping. 

Call (214) 243-2272 or Fax Your Order to (214) 484-2720 • American Association for Respiratory Care 11 030 • Abies Lane, Dallas, TX 75229-4593 



Noniiorino Respiraiorij 

Neclionics Durinp 

NeclianicolVenhlotion 

By Robert L. Chatburn, RRT 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No II 



1053 



TEST YOUR RADIOLOGIC SKILL 




Fig. 3, Computerized transaxial tomography scan of Patient A. The 
section is taken through the larynx and shows a 3-cm hematoma (A) 
deviating the trachea anteriorly and compressing It to less than half 
its normal size. Other structures are labeled to show (B) the trachea, 
(C) a vertebral body, and (D) the hyold bone. 



Answers 

Radiographic Finding: Figure 1 shows a letrophaiyngeal 
mass that impinges on the trachea and bilateral interstitial 
reticular infiltrates. Figure 2 reveals a widening of the superi- 
or mediastinum with narrowing and displacement of the tra- 
chea toward the left. The extrathoracic airway appears to be 
compressed. 

Diagnosis: The probable diagnosis in Figure 1 is a 
hematoma formation in the soft tissues of the neck secondaiy 
to bleeding. In Figure 2, the widening of the mediastinum is a 
result of soft-tissue swelling due to bleeding. 

Diagnostic Confirmation: Further testing with computer- 
ized transaxial tomography (CTT) scans of the neck should 
yield a more definite evaluation (Fig. 3). These scans are fre- 
quently used diagnostically because of their fine soft-tissue 
discriininating capabilities. Although examination with oral 
contrast medium is useful in determining esophageal versus 
tracheal involvement. Patient A's CTT .scan was perfonned 
with intravenous contrast because of her dysphagia. Figure ?> 
shows soft-tissue fullness posterior to the trachea and withui 
the retropharyngeal tissues. 

Action and Therapy 

The initial appropriate intervention in a patient with soft- 
tissue swelling and bleeding into the retropharyngeal space is 
to moniior the [xilient's airway patency. This is accom- 



plished by physical examination and assessments of respira- 
tory distress and the ability to swallow. Serial lateral-neck 
and chest radiographs should be obtained as well. 
Oxyhemoglobin saturation by pulse oximetry (SpO:) may be 
useful in assessing oxygenation. Supplies for endotracheal 
intubation, with or without fiberoptic bronchoscopy, should 
be readily available in case an emergency intubation is re- 
quired. 

Assessments of chest retractions, dyspnea, tachypnea, and 
stridor are required to identify impending respiratory failure. 
Radiographs are valuable for determining the size and loca- 
tion of obstruction. Lateral-neck radiographs offer discrimi- 
nating views of the hyoid bone and esophagus. 
Anteroposterior chest radiographs reveal tracheal deviation 
or compression. Upper airway landinarks inay be obscured 
when laryngoscopy is attempted; therefore fiberoptic bron- 
choscopy may facilitate a difficult endotracheal intubation. 
Bronchoscopy may also be used as a diagnostic tool and to 
examine the degree of swelling in the retropharyngeal space, 
assessing the trachea's size for evidence of external compres- 
sion. 

Patient A was given 50% oxygen via aerosol face mask. 
Her heart rate and rhythm and SpO: were monitored continu- 
ously, and daily lateral-neck and chest radiographs were ob- 
tained. Two days after admission to the intensive cai"e unit, 
the patient expectorated a large blood clot. The lateral-neck 
radiograph showed improvement with a patent airway (Fig. 
4). 

Patient B was orally intubated by direct laryngoscopy due 
to increasing stridor and dyspnea. The intubation was facili- 
tated by the use of a short-acting sedative to help relieve anx- 
iety and to facilitate visualization of upper airway structures. 
Her course of therapy was further complicated by pneumoni- 
tis, hepatic and renal dysfunction, and hyperglycemia. The 
patient experienced cai'diac airest and expired. 

Discussion 

Aplastic anemia is a disease resulting from failure of the 
bone miirrow to produce adequate numbers of eiythrocytes, 
leukocytes, and thrombocytes. This disorder may be caused 
by drags, chemicals, or viral agents that may directly or indi- 
rectly damage the bone m;uT0w. leading to pancytopenia. The 
main causes of death from aplastic anemia iue hemonhage 
and infection. Therefore, the goals of therapy iue manage- 
ment and prevention of bleeding and infectious complica- 
tions, pending bone manow reccwery.' 

These patients generally require frequent transfusions of 
red cells and platelets. Due to the frequent transfusions and 
the common need for parenteral therapies, a central venous 
catheter may be indicated. Percutaneous catheters have been 
incriminated as sources of infection and hematoma fonna- 
tion.' AlteiUion to site selection for peivutaneous catheteri/a- 



1054 



RHSPIRATORY CARH • NOVEMBER '94 Vol 39 No 1 1 



TEST YOUR RADIOLOGIC SKILL 




Fig. 4. Lateral-neck radiograph of Patient A 
after expectoration of a large blood clot. Tfie 
appearance of tfie airway fias improved 
from Figure 1 . 



tion and platelet transfusion prior to catheterization may re- 
duce complications.- Such complications may be more likely 
to occur in immunosuppressed patients.- 

The internal jugular vein may be the best route for central 
venous catheterization. If there is evidence of local bleeding, 
good hemostasis can usually be achieved by local compres- 
sion. This approach also avoids the pleura and subclavian ar- 
teries, and the right internal jugular vein has an anatomically 
direct pathway into the right atrium. As a consequence, this 
site also has a lower risk of pneumothorax and hemothorax.""* 

Two previous case reports of upper airway obstruction 
secondary to abnormal coagulopathies have been published. 
Knoblanche' reported complications from intemal-jugular- 
vein cannulation that precipitated the requirement for endo- 
tracheal intubation. One patient developed a large hematoma 



in the neck after two attempts had been made to cannulate the 
right internal jugular vein.' Genovesi and Simmons*" reported 
on a patient who had been taking oral anticoagulants and de- 
veloped bleeding into the retropharyngeal space after a sneez- 
ing episode. For 3 days, the patient complained of sore throat 
and dysphagia and subsequently required a tracheotomy be- 
cause of sudden difficulty breathing.^ 

The retropharyngeal space lies between the pharynx and 
cervical spine and allows the pharynx to move during swal- 
lowing.' Bleeding into and subsequent hematoma formation 
within the retropharyngeal space can occur easily. Caregivers 
must have knowledge of various emergency airway tech- 
niques to prevent life-threatening emergencies caused by 
masses in this space. Endotracheal intubation via the oral or 
nasal route may be facilitated with the use of a fiberoptic 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1 



1055 



TEST YOUR RADIOLOGIC SKILL 



bronchoscope. In circumstances in which laryngoscopy is not 
successful, cricothyroidotomy, tracheotomy, and translaryn- 
geal intubation may be successful. An esophageal-tracheal 
tube (Combitube. Sheridan Catheter Corp, Argyle NY) may 
be used to stabilize the airway until conditions are better con- 
trolled and a more definitive method of airway protection can 
be established. 

The main objective in management of upper airway ob- 
struction is to gain control of the airway by bypassing the ob- 
struction.* Oral intubation by laryngoscopy is the most fre- 
quently employed method. This technique allows the clini- 
cian to visualize the upper airway structures; however, it also 
causes the greatest stimulation of airway reflexes. The use of 
intravenous sedation helps relieve the patient's anxiety and 
maintains lower esophageal tone. Risks associated with oral 
endotracheal intubation apply to all patients and include po- 
tential injuries to the lip, palate, and teeth.*'" 

Blind nasotracheal intubation does not require visualiza- 
tion of vocal cords but may cause tissue trauma with a risk of 
aspiration from bleeding or rupture of hematoma," and in our 
unit is not recommended in patients with thrombocytopenia 
or coagulopathy. Fiberoptic bronchoscopy is the most useful 
aid for managing difficult airways. The bronchoscope func- 
tions as a stent over which to guide the endotracheal tube 
through the mouth or nose. In addition, the bronchoscope pro- 
vides improved visualization of upper airway structures, and 
may help prevent local tissue damage.**' However, intubation 
using fiberoptic bronchoscopy is not always an option due to 
the availability of equipment and the expertise required to 
pyerform it. 

Cricothyroidotomy and tracheotomy may not be practical 
solutions for bleeding and edematous neck obstructions be- 
cause landmarks may be distorted due to the hematoma and 
swelling. There is also a risk of development of further hemor- 
rhage, incorrect placement of tracheotomy, pneumothorax, 
and subcutaneous emphysema.** However these techniques are 
recommended as adjuncts for emergency airway management. 

Translaryngeal intubation is a retrograde technique ac- 
complished by passing a guidewire through the cricothyroid 
membrane, and then advancing it cephaladly until it emerges 
from the mouth or one of the nares. The proximal and distal 
wire ends are pulled tightly, and an endotracheal tube is guid- 
ed into the larynx. Application of the Combitube has been de- 
scribed as a relatively quick and easy procedure for temporary 
airway management. The Combitube is a double-lumen tube 
resembling an endotracheal tube and an esophageal obturator 



airway. When positioned properly, the mouth and nasal cavi- 
ties are sealed, a pharyngeal balloon blocks the oropharynx, 
and a distal cuff blocks the esophagus. This helps ensure ade- 
quate ventilation and protection from pulmonary aspiration 
of gastric contents.** '- 

We present just a few of the techniques that may be em- 
ployed in managing difficult airways due to obstruction by 
hematoma. It is important for health-care professionals to 
recognize impending airway emergencies and to act quickly. 
Retropharyngeal hematomas are not uncommon occurrences 
in trauma patients with cervical or spinal injuries. The cases 
we present are unusual because the threat to the patient's air- 
way was secondary to a bleeding disorder. The outcome for 
each patient was different, but careful attention to ensuring 
airway patency was required and appropriate in both cases 
for management of upper airway obstruction. 

REFERENCES 

1. Young NS. Alter PA. Aplastic anemia acquired and inherited. 
Philadelphia: WB Saunders Co, 1994:3-19. 

2. Matsumoto T. Simonian S. Kholousy AM. Manual of vascular ac- 
cess procedures. Norwalk: Appleton-Century-Crofts, 1987:59-75. 

3. Sladen A. Invasive monitoring in the intensive care unit. St Lxiuis: 
CVMosby. 1990:110,115. 

4. McGee WT, Mallory DL. Cannulation of the internal and external 
jugular veins. In: Kirby RR. Taylor RW. eds. Problems in critical 
care: vascular cannulation. Philadelphia: JB Lippincott, 
1988:221,223. 

5. Knoblanche GE. Respiratory obstruction due to haematoma fol- 
lowing internal jugular vein cannulation (letter). Anaesth Intensive 
Care 1979:3:286. 

6. Genovesi MG, Simmons DH. Airway obstruction due to sponta- 
neous reU'opharyngeal hemorrhage. Chest 1975;68(6):840-842. 

7. Kuhn JE, Graziano GP. Airway compromise as a result of retropha- 
ryngeal hematoma following cervical spine injury. J Spinal Disord 
1991;4(3):264-269. 

8. Barratt GE, Coulthard SW. Upper airway obsUTJCtion: diagnosis 
and management options. Contemp Anesth Pract 1987:9:73-96. 

9. Benumof JL. Management of the difficult adult airway. 
Anesthesiology 1 99 1 :75( 6): 1 087- 1 1 1 0. 

10. Somerson SJ, Sicilia MR. AANA journal course: update for nur.se 
anesthetists — beyond the laryngoscope: advanced techniques for 
difficult airway management. AANA -J 1993 ;6 1 ( 1 ):64-7 1 ; quiz 7 1 - 
72. 

11. Woodmansee VA. Rodriguez A, Mirvis S, Fitzgerald B. 
Genioglossus hemorrhage after blunt facial U-auma. Ann Emerg 
Med 1992;21(4):440-444. 

12. Klauser R. Roggla G. Pidlich J. Leithner C, Frass M. Massive 
upper airway bleeding after thrombolytic therapy: successful air- 
way management with the Combitube. Ann Emerg Med 
1992:21(41:431-433. 



1056 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1 



Listing and Reviews of Books and Other Media 

Note to publishers: Send review copies of books, films, tapes, and software to 
RESPIRATORY CarE. 1 1030 Abies Lane, Dallas TX 75229-4593. 



Books, Films, 
Tapes, & Software 



Lung Function: Assessment and Application 
in Medicine, 5th edition, by JE Cotes DM DSc. 
Hardcover, illustrated, 768 pages. Oxford: 
Blackwell Scientific Publications, 1993. 
$135.00. 

This book purports to describe "the res- 
piratory function of the lungs in a variety of 
circumstances and indicates how the func- 
tion can be assessed." Thus, it is a combina- 
tion pulmonary physiology textbook and 
technical manual for the performance of 
lung-fiinction testing. The author suggests 
that this book would be useful to scienUsts 
from a variety of disciplines. This is the fifth 
edition, and the author has attempted to in- 
corporate the many changes in pulmonary 
medicine since the fourth edition ( 1979). 

The book is organized into 17 chapters. The 
first 4 chapters deal primarily with the topics of 
historical perspective and terminology, equip- 
ment, and technical issues. In general, the treat- 
ment is adequate but disappointing in its lack of 
synthesis and failure to establish a perspective 
for topics to come. Some of the material seems 
dated — eg, the relative space given to old-fash- 
ioned strip-chart reconders (2 pages) compared 
to computer data capture ( 1 paragraph). Many 
of the techniques described just are not used 
anymore. 

The next chapters (5-14) are paired — a 
chapter on basic physiology is followed by a 
chapter on the technology used to assess a par- 
ticular a.spect of that physiology. Thus, there are 
paiied chapters on lung mechanics, gas ex- 
change (V/Q), diflfiisioa control of breathing, 
and exercise. 

Rather than attempt an exhaustive evalua- 
tion of each pair of chapters (the book is over 
7(X) pages long), 1 evaluate in detail one chap- 
ter pair of particular interest to me, lung me- 
chanics, and one pair that is the author's par- 
ticular expertise, diffusion. Chapter 5 is a 
chapter on the mechanical properties of the 
lung. Although the figures are interesting and 
the chapter has all the right subheadings, the 
content seems superficial. For example, in de- 
scribing the equal-pressure-point theory, it is 
important to clearly explain the concept of ui> 
stream resistance using the analogy of the wa- 
terfall. This analogy was introduced, albeit 
briefly, but without a clear example. The au- 
thor also attempted to explain the choke 
point/wave speed theory, but this was done in 
a confusing way. Perhaps the most disap- 



pointing part was the superficial way that 
flow-volume and volume-time issues were 
covered in only 2 pages of a chapter that is 50 
pages long. Peak flow is given 1 paragraph, 
hardly in line with its current importance, 
when work of breathing got 2 pages and a fig- 
ure! Chapter 6 is a description of the practical 
measurement of lung mechanics and begins 
with a table that grades the practical aspects of 
many lung function tests on a scale fix)m A to 
D. 1 fail to see why such a subjective evalua- 
tion is useful and believe many of the grades 
are incoirect. Further, the degree of detail pro- 
vided for many of the tests is inadequate. For 
example, on Page 1 36, we are told to have the 
subject practice the forced expiratory maneu- 
ver and then "three technically satisfactory 
blows are recorded." What happens if you 
don't get three? How many do you maximal- 
ly do? (Answer no more than eight). What is 
meant by satisfactory? The start and end of 
test are not adequately explained. No explana- 
tion of back extrapolation is provided, and I 
could not find the term in the index. The 
Ttffeneau index (FEVi/TVC or SVC) is men- 
tioned, but why some clinical scientists think 
this is a better index is never explained. On the 
other hand, the discussion of bronchodilator 
response is good. Again, however, there is a 
curious lack of balance where great detail is 
given to measuring pressure-volume curves 
with esophageal balloon, but little space is 
given to basic spirometry, a test that we all 
use. 

JE Cotes, the author, is best known for 
his work on the diffusion of gas. 
Accordingly, I was not surprised to find that 
the two chapers on diffusion were better 
than the mechanics chapters. Chapter 9, the- 
oretical basis for this text, is technical at 
times but is a generally well-written discus- 
sion of the measurement of diffusing capac- 
ity, which in this book is referred to as trans- 
fer factor — probably a better term. The con- 
tent of Chapter 10, the technical aspects of 
diffusion capacity, is adequate, although 
again I find it short on specific detail. 

Finally, I find the book well referenced but 
the references are difficult to use. They are not 
found at the end of chapters but rather are col- 
lected at the end of the book. In Chapter 6, spe- 
cific authors are referred to, but I could find no 
references. Many of the tables and figures are 
only marginally helpftil. In additioa many of the 
tables seem to serve no ital purpose other than 



to summarize the te,sL Although some of the fig- 
ures are good, others are difficult to interpret 

In summary, this is the fifth edition of a clas- 
sic book on lung function, but it lack-s a certain 
degree of polish. At best, this is a better than av- 
erage book on lung physiology. Although the 
intended audience Ls wide, 1 think that only 
physiologists and pulmonary specialists will 
find it of much use. Given the cost of this book, 
its purchase is probably only justified for the de- 
partment reference library. 

Charles GIrvin PhD 

Direaor 

Pulmonary Physiology Unit 

National Jewish Center for Immunology & 

Respiratory Medicine 

Denver, Colorado 



Snoring and Obstructive Sleep Apnea, 2nd 

edition, by David NF Fairbanks MD and Shiro 
Fujita MD. Hardcover, illustrated, 266 pages. 
New Yoifc Raven Press, 1994. $72.00. 

Snoring and Obstructive Sleep Apnea is a 

cond.se well-written review of a complex clini- 
cal disorder. Edited by two prominent stugeoas 
in the field it provides an extensive review of 
operative approaches, but nonsurgical treat- 
ments are also considered in depth. The first 
chapter, "Snoring: An Overview with Historical 
Perspectives," was actually fun to read. Chapters 
6-12 provided more surgical detail than I (as an 
internist) needed, but I do now have a better un- 
derstanding of what the surgeons consider when 
I refer a patient for possible operation. This will 
make it easier to discuss possible surgical op- 
tions with my patients. Chapters 7 and 8 related 
to uvulopalatopharyngoplasty are particularly 
timely given the recent explosion of public inter- 
est in this technique, especially laser-assisted 
uvulopalatoplasty. 

I think those who deal with snoring and sleep 
apnea patients as a part of their practice will find 
this book a helpftil and informative review. It is 
easy to read, well edited, and worth including in 
your reference library. 

Timothy R ChappeD MD 

Pulmonary Medicine 

Medical Center of Piano 

Piano, Texas 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 



1057 



Letters 



Lcllers on topics of current interest or commenting on material m RESPIRATORY CARE will be considered for publication. The Editors may 
accept or decline a letter or edit without changing the author's views. The content of letters a.s published may simply reflect the author's 
opinion or interpretation of information— not standard practice or the Journal's recommendation. Authors of criticized material will have the 
opportunity lo reply in print. No anonymous letters can be published. Type letter double-spaced, mark it "For Publication," and mail it to 
RE.SPIRATORY CARE Journal, 1 1030 Abies Lane, Dallas TX 75229-459.1. 



Errors in August CPGs 

The recently published AARC 
Guideline: Neonatal Time-Triggered, 
Pressure-Limited. Time-Cycled Mechanical 
Ventilation' states in Section 13.1 "The 
Clinical Practice Guideline: Ventilator 
Circuit Changes . . . suggests that use peri- 
ods of < 5 days are acceptable when the hu- 
midifying device is other than an aerosol 
generator." Likewise the AARC Guideline: 
Apphcation of Continuous Positive Airway 
Pressure to Neonates via Nasal Prongs or 
Nasopharyngeal Tube- states in Section 13.2 
"The Clinical Practice Guideline: Ventilator 
Circuit Changes . . . suggests that use peri- 
ods < 5 days are acceptable when the humid- 
ifying device is other than an aerosol genera- 
tor." 

However, the ventilator circuit change 
Guideline' actually states in Section 12.2.2 
". . . circuits employing heated Cascade-type 
devices (bursting-bubble humidifiers), as 
humidifiers, ... or other vapor-phase humid- 
ifiers may be changed at an interval of > 5 
days." That is. it recommends changing the 



circuits after intervals greater than 5 days — 
not less than 5 days. 

It appears that one or more typographical 
errors are present here. It seems likely that 
practitioners might read one or both of the 
pediatric Guidelines without referring to the 
ventilator circuit change Guideline. If so. 
they may be misled about the recominended 
frequency of circuit changes. Because many 
institutions are now making the transition 
from circuit changes every 24 or 48 hours to 
circuit changes every 5-7 days, it is impor- 
tant to clarify the AARC's recommenda- 
tions. 

Stephen M Pieca MD 

Nassau County Medical Center 

East Meadow. New York 



REFERENCES 

American Association for Respiratory 
Care. Clinical practice guideline: neonatal 
time-triggered, pressure-limited, time-cy- 
cled mechanical ventilation. Respir Care 
1 994:39(8 ):8 12-8 16. 



American Association for Respiratory 
Care. Clinical practice guideline: applica- 
tion of continuous positive airway pressure 
to neonates via nasal prongs or nasopharyn- 
geal mbe. RespirCare iyy4;.W(8):8l7-823. 
American Association for Respiratory Cai^. 
Clinical practice guideline: ventilator circuit 
changes. RespirCare 1994;39(8):797-801. 



77?^ Editor replies: 

Our sincere thanks to Dr Picca for point- 
ing out the errors in the Guidelines. We are 
taking the following steps to minimize the 
'damage': ( 1 ) publication of Dr Picca" s let- 
ter: (2) publication of a notice of Correction 
in this issue of the Journal: and (3) correc- 
tion of Clinical Practice Guideline reprints. 

Pat Brougher BA RRT 

Editor, Respiratori Care 

Project Manager 

AARC Clinical Practice Guidelines 

Dallas, Texas 




American Association for Respiratory Care 

40th Annual Convention and Exhibition 

December 10-13, 1994 • Las Vegas, Nevada 



10.58 



RESPIRATORY CARE • NOVEMBER 94 Vol 3*^ No 



Respiratory Care 
Open Forum Abstracts 



The 1994 RESPIRATORY CARE OPEN FORUM 

Each year a highlight of the Annual Meeting of the American Association 
for Respiratory Care, the RESPIRATORY Care Open Forum, provides a 
platform for the reporting and discussion of some of the clinical studies, 
method and device evaluations, and case reports completed by members 
and friends during the previous year. During the 1994 OPEN FORUM in Las 
Vegas, Nevada, December 10-13, more than 175 papers will be presented, 
clustered into 15 minisymposia. The abstracts of those papers are published 
here, sequenced as they will be presented. An index of the authors appears 
on Page 1116, with Presenters designated by boldface type. 



RESPIRATORY CARE • NOVEMBER "94 Vol 39 No 1 1 1059 



Open Forum ABSTRACTS 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 



Initul Negative Inspiratory presslre <p|) To 
Maximal Negative inspiratory presslire (PI max) 
Ratio Fails To Predkt Swcessful Extlibation 
For iNTiiBATED Children. Mohamad F. ElKhanh. 
MS. Brenda Baumcisler. MD. Roben L Chaihum, RRT, 
PaulG. Smith. IX). Jeffrey LBlumer. PhD. MD. Rain- 
bow Babies & Childrens Hospital and Case Wcslem Re- 
serve Umversity. Cleveland, OH. 
lNTRODLt.TION; In adults success of enluhation can be 
predicted by PI/PI max ratio uiden {Pl/Plmax 50.3. Yang 
KL. Intensive Care Medicine. 1993; Vol.19. [^,2(») 
Objective; We tested whether the cut-off vaJue of <0.3 
for Pl/Plmax could be used m paOents in a pediamc in- 
tensive caie unit (PICU). METHODS: Thirty infanLs and 
children (0 lo 14 years) mechanicaJly ventiialed m the 
PICU. climcally stable and considered ready to be exlu- 
baied by the aaending physician were studied. Before the 
estubalion trial, a one-way valve that allows exhalaaon 
but not inhalation was insened at the patient airway 
opening to determine PI and Plmax. PI and PImaji were 
measured as the most negaove deflections produced by 
the first and the maximum inhalation effort (in contrast lo 
the adull study thai use PImax al 20 sec) during airway 
occlusion respectively. Measurements were repealed 
three times and mean values were used for data analyses 
Failure was defined as reiniubation within 24 hours of 
extubauon. Calculations of sensitivity, specificity, posi- 
iive and negative predicted values were made to deler- 
mme whether the Pl/Plmax index is a good predictor of 
successful extubauon. Reslilts: Figure 1 shows that 
only 6 (207^) of 30 patienLs had ratios <0.3 and all 6 were 
successfully extubated. Of the 24 remaining patients with 
ratios >0.3. 16 (67%) were successfully extubated and 8 
(33%) were noL In those 24 patients, a cut-otT value for 
Pl/Pimax thai discnminates between success and failure 
groups could not be identified. 



Table 1 



F'^ ' 



Index 


PI/Plmax<0.1 




0.27 




1 


Posilive 
predicted 


1 


Negalive 
predicted 
value 


0.3? 




CONCLL'SION: Pi/Plmax may noi be a good predictor for 
exiubation in children, Speculation: Because of the 
difference in their physiology (e.g.. respu^tory rate), 
indices thai predict exiubation in adults should not be ex- 
trapolated to children before testing and validation. 



SKIN CONTACT AND BREATHING IN 
PRETERMS. S. Ludington, Ph.D. -UCLA; 
S. Irwin, RRT; J. Swinth, RNC; J. 
Becker, RNC; S. Rao, RNC; A. Hadeed, 
MO -Kadlec Med Ctr, Richland WA 

Because separation between 
mother and preterm infant is 
detrimental to the infant's 
development, skin-to-skin contact 
(SSC) (nude preterm between maternal 
breasts) has been used but is 
associated with warming (de Leeuw, 
1991). Warming is associated with 
increased apnea. The effects of skin 
contact on apnea, bradycardia, and 
periodic breathing as measured by 9 
consecutive hours of 4-channel 
pneumography (Edentec) was tested 
using a pretest-posttest (in Ohio IC 
incubator) randomized (Zellen method) 
control group (in incubator onlyl 
design. Nellcor N-200 measured SaO;, 
nasal air flow and 3-lead impedance 
plethysmography recorded chest wall 
movement and heart rate on print-outs 
(3cm/min) that were manually scored 
by certified neonatal pneumographer 
blind to design and assignment. NIH 
(1987) definitions of short and long 
apnea, bradycardia and periodic 
breathing were used with data from 
1 5 KC and 1 3 control infants who 
were tested for 3 hours each of 
incubator (pre & posttest), and SSC 
periods and compared to controls (9 
hrs in incubator). Repeated measures 
ANOVA revealed significantly fewer 
apneic and periodic breathing episodes, 
no obstructive apnea and acceptable 
SaOj during SSC only. SSC may be a 
useful adjunct to theophylline for 
apnea of prematurity. 

Research supported in part by NIH- 
NINR R0102551. of r,. i 



PULMONARY RESPONSE TO AN INHALED 
BHONCHOOILATOR IN INFANTS WITH 
SUSPECTED AIRWAY REACTIVITY. Wilham J 
Holt. RRT RPFT Jay S Greenspan, MD, Michael J 
Antunes. MD. James A Cullen, RN, Thomas E 
Wiswell, MD, Alan R Sp.tzef. MD Depi ot Pads, 
Thomas JeHerson Mad Col and Hosp Phila. PA 

concern lor infants on prolonged ventilator support. 
The decision to utilize mbated broncnodilator therapy 
IS frequently based on the presence of intermrnenl 
wheezing and broncnospasm on examination and 
history, and the response to this iherapy is often 
difficult to quantify We evaluated pulmonary 
compliance (Cl, ml/cmH20/Vg,) and res-stance (Ri 
[mspiraloryj, Re [expiratory |. Rt (lotal), 
cmH20/L/sec) by esophageal manometry and 
pneumotachographv, before (PRE) and 20 minutes 
after (POST) 1 actuation (90 meg 



Rt 



: SD Study weight 1 5 : 
eks. gestational age 
ical ventilator suppon i 



PRE 
5.5 ± 0.3B 
0.48 ± 0.04 
107 ± 13.9 
193 ± 29.4 
129 ± 16.7 



25 intubated mtant: 
9 kg, study age 5 9 t 



POST 
5.4 r 0.39 
0.46 t 0.04 
119 ± 16.9 
154 ± 15.4 
137 ± 17.1 



There were no diHerences between PRE and POST 
with respect to tidal volume, minute ventilation, or 
peak airway pressure Ten infants had a > 20% 
decrease. 6 had a >20% increase, and 9 had a <20% 
change in Rt from PRE to POST. In the study 
population. 60% of ventilated preterm mtanls 
clinically suspected of airway reaaivity failed to 
respond to bronchodilator therapy with decreased Rt 
or Re. or increased Cl. Mean FRC was 21 ± 5 ml/kg 
PRE, Several of the non-responders demonstrated 

Neither FRC. nor Rt or Re PRE could be utilized to 
differentiate response to inhaled therapy We 
speculate thai increased airway reactivity may be 



obstruction or tracheobronchomalcia Measi 
of lung function is imperative m assessing 
to bronchodilator Iherapy in preterm infants 



THE CARDIOPUlJvlON AR Y EFFECTS OF INHALED C02 
DURING APNEA TESTING IN CHILDREN 
John Kuluz MD. Tom Mahon RRT. Joseph Dallessio 
MD. Gwenn McLaughlin MD. Pau-icia CaniwcU MD, 
Charles Schleien MD. U Miami School of Medicine. 
Miami. FL 33101 

Problems associated with the apnea test during brain 
deatl) determination include hypoxemia, hypotension 
and failure lo achieve a PaC02 > 60mmHg. and are most 
common in patients with cardiopulmonary failure 
Prevenung these complications may avoid secondary 
insults to vital organs, parUcularly those thai may be 
used for U-ansplantaiion We compared the changes in 
PaC02. Pa02 and mean artenal pressure (MAP), in 6 
children (3mos-10 yrs, mean 4.5yrs) during the 
uadiuonal apnea test (TAT) and during apnea testing 
using 5-10% inhaled C02 Five of 6 patients were 
receiving vasopressors and 3 of 6 required PEEP ^ 8 cm 
H20 at the lime of apnea testing All paticnis were 
preoxvgenaled wiiti Fi02 1 for 5 min prior to apnea 
Dunng TAT. IMV was decreased lo with Fi02 1 for 8 
minuies During the C02 apnea lest. 510% C02 was 
administered via the inspiratory limb of the ventilator 
with Fi02 90- 95 for 5 min pnor lo decreasing IMV lo 
for 3 mmules The apneic period was terminated early if 
Sa02 < 90% or MAP < 45mmHg Values are mean ± 
(SEM). "p < 0.05 compared to baseline (start) by paired t 



End 



Start 



End 



TAT £02 CQ2 CQ2 



Pa02 328 



(60) 



(3 7) 



(3( 



(5 5) (3 7) 



The apneic period was terminated early in 4/6 paUcnts 
witb each lest because of decreasing Sa02 or MAP 
However, all C02 apnea tests were considered 
sausfaclory (PaC02 > 60mmllg al the end of the apneic 
period) whereas only 3 of 6 TAT were satisfactory At the 
end of ihc apneic pcnod, the PaC02 was signiHcantly 
higher dunng the C02 apnea Icsl than dunng TAT Al the 
end of TAT. the Pu02 fell significantly from baseline 
(by 49%). wherca.<i Pa02 did not change dunng ihe C(^2 
apnea tcsl Administration of C'02 did nut prevent ttic 
fall in MAP during apnea We conclude that Ihc 
adminisuulion of uibalcd C02 during Ibc apnea Icsl 
achieves a PaC02 > 60n^mHg before severe hypoxemia 
nr hypotension develop in children with 
cardiopulmonary failure and offers significant 
advantages over ihc UadilionnI method of apnea testing 



OUTCOME OF MECHANICAL 
VE?«mLATION IN A PEDIATRIC ICU 

Robert L. Chatbum. RRT. Jeffrey L. Blumer. PhD. 
MD, Rainbow Babies & Childrens Hospital. 
Cleveland. OH, 

Outcome studies are becoming mote imponani as health 
caie providers atlempt lo benchmark performance. One 
area thai has not been well described is the outcome and 
demographics of mcchamcally ventilated pediatric 
patients- METHODS: We conducted a retiospecuve 
chaii review of all patients undergoing mechanical 
ventilation in oui intensive core unii from 9/7^0 lo 
2/21/93. Descriptive sutislics were compiled for major 
demographic and outcome variables. RESULTS: 
Records of 21 1 paUenis were reviewed. 
Demographic Data' 
Dia gnosis #. Age (mo) Venl Days Death % FE %' 



164.2 



10,7 (34-7) 
6.2(6.0) 
5,8(8.8) 
5 J (4,4) 
2.7(1,6) 
5.0(2.0) 

18.0(23.3) 



12 



Cardia 

Pulmonary 64 

Nemo 26 

Gastio 10 

Neurosurg 7 

Oncology 5 

Renal 3 

Orthopedic 1 208 4 

ABG Data' 

pH PC02 P02 ££. ABG/pl ABG/oi/d 

7,26(0,14) 59(24) 92(88) 14(34) 48 13 

Ventilator Data' _ 

VT EXiration of Oxygen (X hrs) 

(ml/kel <40% 40-59% 60-79% 80-100% 

12(5.7) 1.959(26.509) 19(38) 6(19) 6(21) 

Extubalion Criteria % of Pl5 

19 
5 



Successful CPAPtnal 




Adequate spontaneous 


dal volume 


Adequate negative inspiratory force 


Adequate respiratory ra 


te 


Adequate ABGs 




Unknown 




Complications 




TVB« 


%0fDlS 


Pneumothorax 


19 


Accidental extubaUon 


3 


Nosocomial pneumonia 


1 


Endotracheal tube obstruction 1 



CONCLUSIONS: Oerall mortality and complicauon 
rates were relatively low (22%, 11%). GI. Pulmonary, and 
Neuro patients had die highest complicauon rales (20%, 
14%. 12%). Monality wasnol linked locomphcations, 



X or X (SD): ABG data are pre 
ABG dau are for all diagnoses 
failed Hrsi exiubation 



OF-94-1 



RESPIRATORY RATES OF SEVERELY 
BURNED CHILDREN UNIFORMLY ELEVATED 
BUT UNAFTECTED BY PRESENCE OF 
INHALATION INJURY 

R Mlcak. RRT. E Robinson. CRTT. MH Dcsai. 
MD, RL McCaulcy, MD, RJ Nichols. MD, L 
Broemeling. PhD. DN Hcrndon. MD. 
Shriners Bums Institute and the 
University of Texas Medical Branch, 
Galveston. Texas 77550 
INTRODUCTION: Severe bum injury in- 
duces pain, anxiety and a hypenneubolic 
sute. all of which can lead to increased 
respiratory rale. Normal ranges of vital 
signs such as respiratory rate for differen' 
ages and biun size have not been widely 
promulgated. Knowledge of the lower limit 
of normal is particularly important for 
those who care for burned children who re 
ceive respiratory depressant drugs. 
PURPOSE: The purpose of this study was to 
determine the range of respiratory rates in 
severely burned children in the early post 
bum period. METHODS; Medical records of 
fifteen children with bums £50% TBSA. 
were examined from post bum day 1-14.. 
Eight patients had bronchoscopically 
identified inhalation injury. Respiratory 
rates were noted and averaged for day and 
night lime periods. Normal rates were 
obtained from standard tables. RESULTS: 
Presence of inhalation injury, post bum 
day. gender and day/night did not have any 
effect, while temperature had only a minuie 
effect on respiratory rate. 



Age 



Younger 1 5 



AV NORM 

RESP RESP 

(y) (bpm) (bpm) 

15±2 26±7 18±2 

3±1 34±7 25±4 



Dau presented as means +SD. Years:y; 
breaths per minute: (bpm). CONCLUSION: 
Respiratory rates were increased above 
normal by 30% in the older group and 36% 
in the yoimger group. Wc conclude thai in 
our group of severely burned children, 
respiratory rates were elevated by at least 
30% of normal and thai inhalation injury or 
time of day did not effect this increase. 

OF-94.17B 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1 



Open Forum ABSTRACTS 



LONGTERM PULMONARY STATUS OF 
INFANTS WHO WERE <750g AT BIRTH Regino 
Ykorulc. CRH. Mary McGowan, CRH, VK 
Bhutani, MD, E Sivieri, MS, Newborn Pulmonary 
Laborotory, Pennsylvania Hospital, Philadelphia, 
Pennsylvania 

With increasing survival of extremely low 
birthweight (ELBW) infants, their pulmonary well 
being during the first year of life remains an 
open quesHon, We followed 28 bobies (BW 
661 ±60 SDg, GA25±1 6 SD wics) who were 
discharged from the NICU and monitored for 
their respiratory status and pulmonary function 
during the first year of life. Two died during 
infancy (7%) The remainder showed: 
rehospitalization 7%, pneumonia 7%, upper 
respiratory infection 44%, otitis media 20%, 
wheezing 29%, and reactive airway disease 
54% The mean values of pulmonary function at 
term and at 9 months corrected age (CA) are 
shown with their percentile rank based on 
healthy non-ventilated very low birthweight 
(VLBW) infants (n=42,BW: 1242+213 SDg, 
GA: 3 1 , 1 ± 1 9SDwksl 



Mean Value 



12. 2± 6 
22± 13 

76 3147 
1,1+ 7,1 



{9 mos CA) 



Mean Value 



55 6± 12,6 
13. 5± 52 
26 3+ 20,8 
17± 4,2 



(TV = tidal volume, mL, CL = lung compliance, 
mL/cmHjO, RT = pulm resistance, cmHjO/ 
l/iec, AP = driving pressure, cmH.O) 
The most frequent problem wos reloted to 
abnormal airflow function By one year, most 
infants had oge appropriate normalized 
pulmonary function * and this was associated 
with age appropriate neurodevelopmentol status 
(90%), Our observations suggest a potential for 
an optimum pulmonary outcome with continued 
individualized care. 



CONCERNS WITH HFV IN NEONATAL TRANSPORT 

Roben J. Kopolic. R,R T,. R,N, 

San Diego. California 



Frequency 

h'ospiials begin HFV programs, 

.porl'is ofien noi toleraled. Initially most insUlulions doing HFV 
.earcti performed Extracorporeal Life Support (ECLSj 



INTRODUCTION The need for transport 
Ventilation (HFV) increases 
Returning an infant on HFV 



n option, Wilhrr 



■s acquinng 



HFV lo an ECLS c 
HFV devices exist but nol all lend themselves lo i 
demands of the iransporl selbng METHOD: Three HFV devices 
itcd: the Bunnell Life Pulse Jei Ventilator iSall Lake City. 
: Infrasonics Infant Star High Frequency Ventilator (San 
Diego. CA). J 



mOOA Oscillatory Ventilator 






ambulance. : 



e and tested tl 
nenlal chamber and in silu (in the NICU 
id between these) RESL'LTS AND EXPERIENCE 
ind Infrasonics devices are amenable to iranspoi 
However, the SensorMedics unit is problematic in thai the ek 
ower and gas consumption are extreme, the ngid airway con 
i cumbersome, and the size would be prohibitive. Findings c 
3 the Bunnell and Infrasonics' HFV devices are: 
They have been used successfully 



aircraft and rolocraft a 



The units operate satisfactorily ii 

from ambient lo lO.tKX) feel. 

Auscultalory assessment can be thwarted by amb 

Changing ihe endotracheal lube (ETT) position c 

iL-ally jffccl the delivery of HFV amplitude, 

HF\' yas use is greater that with conventional vei 

The u^LT should anticipate gas capacity needs pn' 



adversely affected ii 

ances is nose-io-iail. Subsequently, t 
I the humidifier's water level sensor 
sume the level is low and over fill 1 
follow; (a) the front of the Bunnell 



.u]dt> 



iloflt 



ler inlet lube should be clamped off in 
conditions of extreme and variable axis vibrBlion. 
4 Noise level emanating from the Patient Interface Box can 

exceed 80 dBA Precautions should be taken lo protect the 
infant's ears. e,g,. insulating the Box and ear plugs or 

.■i A portable power supply is required for continuous opera- 

Thc Infrasonics' Infant Star HFV device has unique attributes: 
I Given typical settings, gas use of the Infant Star is 1 LPM 

HFV mode the consumption can be up to 40 LPM. 



How 



It least 30 n 



ETT.l 



use from an AC or 1 2 VDC 
3 It contains a standard ventilator, i.e 

itonal concerns than Bunnell, e.g.. i 

Interface Box, sensitive humidifier, or separate controls, 
CONCLUSION; Transport of the acutely ill newborn often require; 
adaption of bedside NICU techniques to the transport setting. We 
reviewed the efficacy of providing HFV dunng neonatal transport. 
Air worthiness, battery operation, gas consumption, and predictable 
operation in Ihe various modes of transport were addressed 
Continuity of neonatal High Frequency Ventilation therapy dunng 
transport is possible. OF-94-222 



DOES RESOLUTION OF RESPIRATORY DISTRESS 
SYNDROME IN PRETERM INFANTS SUGGEST 
NORMALIZATION OF LUNG FUNCTION AT 
DISCHARGE? Mory McGowon. CRH. Regina 
Ykoruk, CRH, V.nod K Bhutani, M D., Emidio 
Sivieri, MS Newborn Pulmonary Laboratory, 
Pennsylvania Hospital, Philadelphia, 
Pennsylvania, 

To determine if the clinical diagnosis of broncho- 
pulmonary dysplasia (BPD) has an impact on the 
functionol residual capocity (FRC) and pulmonary 
mechanics: lung compliance (CL, mL/ cmH.O/kg), 
pulm resistance (RT, cmHp/L/sec), and resistive 
work (WOB g-cm/kg), we studied two groups of 
infants prior to discharge Group I consisted of 14 
infonis with respiratory distress syndrome (RDS); 
GA:32±2 4 SDwks,BW: I 773+628 SDg. 
Group II consisted of 1 8 infants with RDS who 
also developed BPD GA 27+ 1 8 SD wks, 
BW:889±332 SD g Group I was tested at 
discharge or term post conceptual age (PCA) 
36±2.4 SD wks aher a hospital stay of 4 wks. 
Group II was tested ol discharge or term PCA 
40± 1 ,8 SD wks aher o hospital stoy of 1 3 wks. 
FRC was measured by the helium dilution 
technique (solenoid value switched automatically 
at end expiration by computerized technique). 
Lung mechanics were measured by the leost meon 
squares technique Pulmonary Function data is 
shown as meantSD with percentile (%ile} based 
on previously reported healthy non-ventilated low 
birth weight PFT data: 





RDS 


BPD 


Dischorgs 


Mean±SD 


%ile 


Mean+SD 


%ile 


FRC/lg 


17 8±4 7 


-16 


15 1 ±4 7 


-10 


CL/lg 


1 2±0 3 


25 


1 1±0 4 


24 


RT 


37 9±129 


56 


48 3+187 


68 


Cl/FRC 


07±0 02 




08±0 02 




WOB 


20i±e8 


-60 


20 1±6 5 


-60 


Frequency 


71±12 


67 


69±10 


65 



Tliere was no statistical difference in the above 
parameters between the RDS and BPD babies. 
Tliis finding breaks with the traditional belief that 
only BPD babies have residual pulmonary 
dysfunction (,CL, .FRC, ' RT, i CL/FRC, WOB, 
Frequency) T>ie pulmonary status of RDS and 
BPD babies deserve equal oHention at 
discharge. ^. „_ 



DOES FREQUENT SKIN CONTACT 
IMPROVE RESPIRATORY 
PATTERN IN PREEMIES? 



Caria Fen 



■ RCP 



san Ludington, CNM, Ph.D.. 

Associate Professor 

University of California 

at Los Angeles. California 



Frequent touch has been associated with 
respiratory compromise (Gorski 1989). 
This study examines the effect of 5 
consecutive days of three hours of skin- 
lo-skin contact (SSC) holding against the 
mother's chest on infant Respiratory Rate 
(RR), oxygen saturation {SA02), Apnea 
(A), Bradycardia (B), Periodic Breathing 
(PB) and Respiratory Sinus Arrylhmia 
(RSA) during quiet sleep as measured by 
Gould physiograph recorder with real 
time data collection at 10 Hz over 36 
hours in premature infants, gestational 
age > 28 weeks, 1000-1600 gms. on room 
air, randomly assigned by computer 
minimization technique (Conlon & 
Anderson, 1992) to Irealmenl {N = 6) and 
control groups. The control infants stayed 
in the incubator through pretest, test. 

Impedance plethysmography results, 
tested by repeated measures ANOVA. 
showed SSC group results to be: RR 
mcreased by 5 bpm, Sa02 increased (with 
ai^'iuunly more values of 1U0% and a 
2% increase over control group mean, A 
and PB markedly decreased, B never 
occurred and RSA improved, in the SSC 
group. However, no change was evident 
)□ these measure on the 5th day as 
compared to the fu^sl day in pre &post- 
test periods before and after treatment. 

CONCLUSION 

Frequent SSC does not compromise 
respiratory status and benefits are limited 
to the SSC period. 



) TRANSPORTER 



,lloMiinn- «.m,iiL't>.f.., i.rMrtMlr.m-.l-.fll-.ir.^iMiulLCMOcCn- 
ki Ml IMMl) \\,-,k-^>ln|v>l.mii,k--[.,K>ir,.n.,M,\,,-..rMlalECMO 
Transp..n>:rM'NI-li W . r, ■. ,> ■^^.■a iIk I,m Kut.- .iiuHc^IcJ the PNET 
inMiudntheOR, M< i m ■■ i ■ .i i-imJ .imt'uljnce.andbe- 

twcenthcsc), RILSI II • II i' II ,1 I Several findings sur- 
faced: 
I Eacheomi-. ■. ■ '■ .uuiljiing ihesetlingof 

use(vibrjUon mi.,. ■■ ..-.phcm pivssure), The 

equipmenl muslniit.iiKi ! ■■! i.iM .i, mriKs. 

' Transport lcmpcraiun.s ,11 i ^nithe 

IVICU. AwurcenposuK I.- ■ \ ■■ ■ ■ .■■■■■ i|k heatex- 
changcr and healer puni|.. II. nih. i. ni ^ nimizecir- 

1 A "bladder box" ispniNL-tn.m^ in ili.it liiL- dk-iin.' s sensitivity 

is highly gravity dcpendaiil Tin; tiinfincJ irjrisporl quartern 
dictate a minimal and mm-vanahle height Ivu^t-en the infant 



.GRVI, tank, UPS, 
aintrd. The Rack can 
ECMO can in the area vacated 
hv the drawers in an Air-Shiclds" IICS-W radiant warmer, 
CONCLUSION . Transpon dlten itquires adaptation of a beside ICU 



: PNET IS a platform for advanced 
Addilionail> , Oil- niixlular rack allows the ECMO pack 
r Iron) the Can m j radianl vvumicr OF-94-2: 



Assessment of Endotracheal Tube (ETT) 
Placement in Neonates With a Rberoptic Stylete 

J Kallstrom. RRT. Roben L, Chalbum. 



Th. 



RRT, Bonnie R..v-I,mski. RRT. Michclc C 
Wdl:,h-Suk>s. MD Rainbvi« Babies and Childrens 
Haspital. Cleveland. OH 

IntanLs m the NICU arc subjected to repealed chcsl 
roentgenograms (CXR) to \cnty hll placement 
We e\ alualcd a new dc\ ice designed to check tube 
placemen! using a lighted fibemplic stylet (Infinil) 
FibcmpiK Slylcl. Fiberoptic Medical Products Inc) 
Method: All mlubalcd neonates in our NICU over 
J 3 week pcnod were entered into ttic siud\ Wiihm 
60 minulcs of CXR. ttic lighted up ni ihc si\ let «as 
placed at Ihe distal lip (b\ measurement) til the 
ETT ir Ihc light WJ.S visible through the skin at the 
sternal notch, the ETT uas tnnsidered lo tje 
ciirreclh placeil II ihc iigtil shoHed at a potnl above 
the sternal nokh or il Ihc lighl disappeared after 
passing below the sternal m>tch. the ETT vva-s 
judged to be mcorrcttly placed. The prtxedurc 
lasted no more than ten seconds The RCP 
preforming this pnxedurc ^ as blinded lo CXR 
results. Sp02 was measured bclorc and dunng ttic 
examination. Assessment ol ETT placement (correct 
or incorrect) using the titxrroplic stylet wa^ 
compared loas,sessment b\ CXR using the Fisher 
E\acl tesl Posiuve and ncgainc predictive values 
•c\ hbcroplic assessment was also calculated using 
CXR as the standard Sp02 dala were analyzed by 
paired t-tcsi. Results: Twelve paucnus were enrolled 
in the study Weight range: 675 lo 3.048 gms: ETT 
si/e 2 5 to 3 5 mm ID; age 2 hours lo 57 days 

Three pQiicnts had .ncorrccilv placed ETTs as 
judged b> CXR compared lo two b\ FiberopUc 
asscssmcnl (p = ()(M6) Fiberoptic assessments 
agreed wilti CXR in 1 1 of 12 cases. Positive 
prediclivc value of liljcroplic assessment was 90^; 
negauvc predictive value was 100^, One false 
positive occured for an ETT coiled in the mouth, 
with tip m oropharynx, Sp02 (mean ± SD) dunng 
the prtxcdutc. 95'^ ±39? was slaUslically different 
l"rt>mba.seliney7';i±.-<';5 (p^(.,<«XT7). Experience: 
The lighted slylcl is much smaller, quicker, and 
more convenient to use lor checking lube placement 
than CXR cquipmcnl Conclusions: Evaluation of 
ETT pldcemcnl b\ lighted stylci may be accurate 
enough [o replace CXR in neonalcs when combined 
«tth clinical obscrvalKins The prtx'edurc caused a 
clinically msigmricant drop m saiuralion and no 
otticr complications OF-9<1-109 I 



Open Forum Abstracts 



RESPIRATORY CARE • NOVEMBER "94 Vol 39 No 1 ! 



IMPACT OF INDIRECT CALORIMETRY ON 
THE PHYSICIAN'S NUTKITIONAL ORDERS. 
Gaf>' Mdne BS RRT . Punian-Bcnncii Corp.. 
Carlsbad. California. 

For ihe past six ycar^ at St. Francis Hospital 
(Beech Grove. IN), physicians have been exploring 
Indirecl Calonmelry (!C). which was insututcd Ui 
detect under* and over-feeding. The purpose of this 
study was to see how often i( indicated, physicians 
adjusted their prescnbed calones when resung 
energy expenditure iREEt was reported. (Dunng 
study penod of this pro;ect I was a pracucing 
therapist at St. Francis). Methods: All ICs 
performed dunng 1991 and 1992 were included 
REE was determined with 2900 metabolic can by 
collection of Minute Ventilauon, Inspired and 
Enbaled gases. All pauents had to be on a FI02 
of less than bCisj . Once the test was completed, 
REE was reported in the chart As a measure of 
compUance. pauents' charts whose prescribed 
calones were not within +/- 10% of the REE were 
reviewed for the next 72 hours to see if physiaans 
changed their calonc prescnpuons to fail within +/- 
10% of the REE. Excluded were those pauenus 
who died or physically could not be adjusted to 
within 10% of REE (i.e.. slow enteral UtraUon) 
within 72 hours. In addition, those pauents who 
were extubaied dunng the post-REE 72-hour 
period were not mcluded if they were switched id 
normal oral feedmgs when calonc intake is more 
difficult to monitor. Results: In 1991. 60 of 175 
tests were excluded. Of the remainmg 1 15 tesLs. 
feeding changes were indicated in 74. and feedings 
were adjusted to within 10% of REE in 49 cases 
(66%). In 1992, 30 of 147 tests were excluded, 
changes were indicated in 69 tests, and changes 
were made in 56 cases (81%). 



Pernal otPby>lcl.D Compllinci| 








'm ' 


60^ — H^ 

40' ^ 

20' ^ 




= 


1«1 1M2 1 



Conclusion: Physiaan comphance to 
recommendations based for prescnbcd calones 
based on REE has a growing acceptance. 

OF-94-010R 



Bedside respiratory measurements al the time of 
discontinuation of mechanical ventilation predict 

success. Gail Pataky. RRT, Mary Shore MEd. RRT and 
JocatboD Truwil, M.D. University of Virginia Health 
Sciences Center. Charlottesville, VA INTRODUCTION: 
Maximal inspiratory pressure (MLP). spontaneous tidal 
volume (sVj, muiute ventilation (V^) are basic parameters 
used to detenmne if oiecbanical support can be 
discoDtinue»J(DOMV). We hypothesiied that use of these 
parameters along with an artenal blood <;ample would 
predict success of DOMV. METHODS: The study 
transpired between 9/92 and 05/94. We studied DOMV 
ui medical intensive care unit patients ventilated for >_ 72 
hours. Patients expected to die from withdrawal of 
support were not mcluded. When patients were deemed 
ready for DOMV by the health care team the parameters 
were obtained. Patients were classified as appropnate 
(AP) for DOMV if parameters were collected and basic 
mechanical and oxygenation cntena were met. 



Mechanics (need 2/41 Arlenal Blood Sample 

MIP < -20 cm HjO PaOj > 60 mm Hg 

sV. >. 4 ml/kg PEEP ^ 5 cm H,0 

RR < 35 br/min FiO, <. 0,40 
V. < 10 1/min 



MIP, Vp and RR were obtained dunng sponUmeous 
ventilation and average V, was calculated; V^/RR. 
Adequacy of oxygenation was established by obtaming an 
artenal blood gas sample dunng mechanical ventilation. 
RESULTS: 128 paltenLs have been studied. Of the 122 
AP patients 7 (5.7%) required reinstitution of mechanical 
support wilhm 24 hours as compared to 4 of the 6 INAP 
paticnU(66.7*); p < 0.0005 (Fisher's Exact Test), In 
companson using f/sV, to classify patients; < 105 as AP 
and > 105 as INAP did not reliably predict weaning 
success Of 112 AP patients 8 (7,1%) required 
mechanical support within 24 hrs as compared to 3 of 16 
{18.8%)lNAPpalicnts;p = 0.14(NS). CONCLUSION: 
Patients mecling basic cntena on the day mechanical 
ventilation is to be diKconlinucd are more likely to sustain 
KpontaneouH ventilation for >24 houm than those failing 
to meet the cntena. The quolieni f/sV, (rapid shallow 
breathing index) was nut reliable in predicting success 
from failure. Our data suggest thai patients failing to meet 
the ba.sic cnlcna (above) should not be cxiuhatcd nn 
planned. Thi% data should not he extended (o indicate 
when mechanical ventilation can be disi.-on(inucd as ihiN 
decision was establiKhcd by the hrallh cure (ciim and not 
the cntena 



EVALUATION AND COMPARISON OF 
RESTING ENERGY EXPENDITURE BY 
INDIRECT CALORIMETRY AND HARRIS- 
BENEDICT MICHAEL E. FISHER. MBA. 



RPFT. RCPT. RCVT. PRESBYTERIAN-ST. 
LUKE'S MEDICAL CENTER, DENVER, CO 
Calculations for resting energy 
expenditure (REE) by HarriB-Benedict 



(HB) 



rphi 



body function and size result 
over or under estimations of 
REE. Indirect calorimetry (IC) 
measures O. , CO;, V^ to providi 

needs . Our cr 
include stable level of conscious- 
ness, FlO, ± 0.005 and, VO, & VcOj ± 
10% of respective means. 145 
patients were studied, 79 of whom 



alid IC 



IC 



alidity. Mean 



i of obaer- 
detennined as the 
principal outcome. REE by IC (mean = 
1713, SEM = 63) was compared to REE 
by HB (mean = 1414, SEM = 35) at p < 
0.0001 (paired T-test). Prescription 
for actual calories provided can 



ity le 



ipli 



aubJG 

appli 



HB. A 


jecond test 


compared REE by 


IC to actual calor 


es prescribed a 


the time of test ( 


:b-) (mean = 192 


SEM =63) at p < 


0032. Our 


findings demonstrate a more accura 


determination of r 


>Bting energy 


expenditure by ind 


rect calorimetr 


when compared to e 


ther the Harri.a 


Benedict predictor 


or HB with 


activity level multiplier. 


IC VS. REE BY HB OR HB + 


2100 














>.200O 




. 




< 1900 




r 




Q1800 








t/! 1700 
dl600 
O 1500 


^ 


















^ 1400 




■ 




1300 









IC HB HB + 
MEAN +/- 1 SEM 



PARADOXICAL BREATHING PATTERN PREDICTS 
ABILITY TO WEAN FROM MECHANICAL VENTI- 
LATION IN SURGICAUTRAUMA ICU PATIENTS 
— Michael M Badellino. M.D,, Robert F Buckman Jr . 
M.D.. Ercele Reyes, R.N.. John Mullarkey. RRT 
Depanmenl of Surgery, Temple University School of 
Medicine. Philadelphia, PA 

INTRODUCTION: The ratio of Respiratory Ralen'idal 
Volume (RRA/T) has been proposed as the strongest in- 
dependent predictor of ability to wean from mechanical 
ventilation in medical ICU patients. This study tested 
whether the RRA'T ratio was a valid predictor of wean 
ing ability in acutely ventilated Surgical/Trauma ICU pj 
tienis. and tf this predictor was influenced by the 
presence of Paradoxical breathing pattern (PEP). METH 
ODS: Twenty Surgical/Trauma ICU patients were 
weaned (25 attempts) according to a standardized prcic 
col by either T-Piece/Trach Collar or IMV/CPAP wilh 
Pressure Support Prior to each wean attempt, patienls 
were removed from mechanical venilation and 
spontaneous Tidal Volume (VT) and Respiratory Rale 
I RR) were mcisured, RR/VT was calculated. The pres- 
ence I'l .■Xbdominal Paradoxical breathing Pattern was 
determined by inspection and palpation. Wean termma 
lion and e,\lubation decisions were effected by clinicians 
blinded to Ihe measured parameters. Results were 
analyzed using unpaired student and Fisher Exact test for 
data within each variable group and by stepwise regres 
sion for combined vanable dala RFSUI.TS Fourteen of 
siMccn weans (SS'.; ) -.veie MK.essliil \Uien RR/VT --■. 
IIH). andonly 4ol 'H44', ushenKK/V!' • 1(I(H|..:() (I.Si 
No differences were m.lcd in llu- .ibsnlnie \.ilue ol 
RK/VT between successful and failed atktupis ujihm 
cich group ( RR/VT > l(X): successful. RR/V I = I>1 t 
-IS. tailed RR/VT = I7(i ± 75, RR/VT < KH) mk.cssIuI, 
RR/Vr54±2?. failed. RR/VT=72± l(..p-nsi All l(> 
« r.iiis v^ere sueoessUiI when PBP were absem ;in.l : nt " 
Uule.l v^hen PHP ^^as present (p < 0.01 ), When iIk van 
..lik-s ^^ere oimhincd. all 12 weans wilh .ibseni VW and 
RR/VI <- inn vMTe'.iKtess!nl..na no alK-MiptsMk needed 



I'ltP 



KR/VI --. |(l()vvc.inedlRU/\l 
{ ONCI I SION lliesedat.iM 



DIFFERENCES IN PULMONARY 
MECHANICS DUE TO BODY 
POSITION IN MICU PATIENTS BEING 
WEANED FROM MECHANICAL 
VENTILATION. S K, Hanneman. RN. 
PhD. P, Lindlev . LVN. RRT. W. Kehr. RN. 
ESN, and J, Wiiherspoon, RN. ESN. Texas 
Woman's Univ. and Hermann Hospital. Houston. 

Because lung volumes change with body 
position changes, we compared pulmonary 
mechanics in 3 body positions in MECU 
patients being assessed for readiness to 
wean. Using a counterbalanced repeated 
measures design, with subjects serving as 
their own controls; vital capacity (VC). 
negative inspiratory pressure (NIP), and 
minute volume (Vg) were measured in the 
0-. 30^ and 90^ head elevation positions. 
Simple random sampling, without 
replacement, was used to determine the 
sequence of body position and order of 
measurement. HeatJ of bed elevation was 
measured with a pnatractor; VC, NIP. and 
Vg with prccalibratcd instruments. A 
doubly multivariate repeated measures 
design was used lo analyze the data for 29 
subjects (14 women and 15 men), wilh a 
mean age of 56 years, who were clinically 
stable and whose physicians considered 
them weaning candidates, 48% were 
Caucasian. 38% Afro-American, and 14% 
Hispanic, f*neumonia was the modal (31%) 
diagnosis. The mean FIO; was 0.35. Mean 
values of VC, NIP. and Vh lor each position 
are shown below. Within subject positional 
differences were not signficantly different. 
Because of upper range restrictions on NIP. 
a Friedman ANQVA was done; positional 
differences were not significant. Multivar- 
iate power was .63; thus, sampling will 
continue until the estimated sample size of 
45 is achieved. The preliminary findings 
suggest that VC, NIP. and Ve may be meas- 
ured in any body position. Patients may 
not need to be placed in a head-elevated 
position to optimize pulmonar>' mechanics. 
30 90 



1093 1106 Iil4 



12.3 11.6 \2-A 



Award and He 



OF-94-028R 



BAXTER VIGILANCE® CONTINUOUS CARDIAC 
OUTPUT MONITORING SYSTEM (COO) VS, 
BOLUS THERMODILUTION CARDIAC OUTPUT 
(TOCO) 

Steven E Desiardins RRT and 8 Stephen Pralo MA 
Maine Medical Center, Portland. Maine 
Introduction Cardiac output (CO) measurements 
provide valuable intormation for the management of 
patients m the critical care setting Bolus 
tfiemiodilution CO measurements have been 
available for over ten years Recent technological 
advances make such analysis possible on a 
continuous rather than the current intemnittent basts 
This study compared the measurement ot CO using 
the continuous technique (CCO) to trie currently used 
intennittent bolus themiodilution technique (TDCO) m 
adult post-open heart patients. Method CO 
measurements were obtained from one hundred and 
torty-nine patients Baxter (Baxter Healthcare 
Corporation. Irvine, CA) pulmonary artery catheters 
were inserted intra-operatively and attached to the 
Baxter Vigilance® CartJiac Output Monitor in the 
critical care unit. Pnor to obtaining bolus outputs 
(TDCO), baseline cardiac output from the Vigilance® 
Monitor (CCO) was recorded TDCO from the Baxter 
COM-2 Cardiac Output Computer was then obtained 
via iniecton of 10 cc of iced (0° C) 5% dextrose The 
recorded value for TDCO was derived from the mean 
ot at least three in|ections that were within 5% of 
each other Following TDCO, an additional 
measurement of CCO was recorded from the 
Vigilance® monctor and compared to the initial CCO 
observation for agreement Results One hundred 
and forty-nine measurements of CO were obtained 
using both the TDCO and the CCO method. The 
mean TDCO measurement was 5 19 s 1 77 L/min 
The mean CCO measurement was 5 32 » 2 40 
Umin The mean bias tor CCO-TDCO was ♦0 13 
and the precision was i 12 when all measurements 
were compared Statistically significant difference by 
paired T-iest was not observed (p=0 59) It should be 
noted that 37% of Ihe measurements differed by 500 
ml behveen CCO and TDCO Conclusions In the 
post -open heart population, the method of 
determining cardiac output, whether by intermittent 
bolus thermal dilution with iced dextrose (TDCO) or 
by the new technique of continuous monitonng 
(CCO) are both acceptable The issue (or the 
practitionef concerns the difference observed m tbe 
individual case A difference of 500 ml m cardiac 
output for an individual patient, while not statistically 
important m the aggregate, may represent clinical 
significance for patients with low cardiac outputs 

OF 94071 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1 



Open Forum Abstracts 



CLINICAL EVALUATION OF A MATHEMATICAL 

MODEL TO PREDICT RESPIRATORY MECHANICS 

DURING MECHANICAL VENTILATION 

Dean Hess. MEd. RRT, Kevin Foley, RRT. Robert M 

Kacmarck. PhD, RRT Departments of Anesthesia and 

Respiratory Care, Massachusetts General Hospital and 

Harvard Medical School. Boston. MA 

Several mathematical models thai describe respiratory 

published (1-3) Although ihey have been validated in lung 
models, they have not been tested clinically. The purpose of 
this project was to collect data on mechanically ventilated 
patients to evaluate the validity of these models during 
volume-targeted, decclerating-flow mechanical ventilation 
METHODS: The study population consisted of 25 patients 
(16 males, mean age 61 5±I7 4 yrs). all mechanically 
ventilated using the Puritan- Bennett 7200 Patients were 
relaxed and breathing m synchrony with the ventilator at the 
time of data collection, Flow (integrated to volume) and 
pressure were measured at the proximal airway using a 
calibrated lung mechanics analyzer ( Ventrak. Novamelny ) 
End- inspiratory plateau pressure was measured during an 
cnd-inspiralory pause, and aulo-PEEP was measured during 
an end-expiratory pause using a Braschi valve Resistance 
and compliance were calculated using standard methods (41 
The values for peak inspiratory pressure (PIP), peak alveolar 
pressure (Ppk). mean airway pressure (MAP), and aulo-PEEP 
(PEEPi) were calculated using Iheir predictive equations 
These values were compared to the actual values measured 
by [he lung mechanics analyzer The relationship between the 
mathematically predicted values and the actual values were 
evaluated using correlation and regression analysis, and bias 
lalysis, RESULTS 





' 


slope 


inlcrcepl 


SEE 


bias ± precision 
(prcdictcd-aclual) 


PIP 


89 


88 


-11 


38 


-1 68 ±3 95 


Ppk 


97 


9^ 


15 


2 15 


-0 58 ±2 01 


MAP 


97 


94 


92 


146 


-0 I2± 1 59 



PEEPi values were too low ( i6 cm H,0) to allow statistical 
comparisons CONCLUSIONS Although the predictions 
were better for Ppk and MAP than PIP. these mathematical 
models generally produced reasonable predictions of lung 
mechanics Further work is needed to evaluate the usefulness 
of PEEPi predictions Additional work is also needed to 
evaluate the usefulness of these mathematical equations to 
achieve target levels of Ppk and MAP during manipulations 
of mechanical ventilator settings 

1 Marini JJ. Crooke PS Am Rev Respir Dis 
1993.14714-24 

2 RavenscrafI SA. Burke WC. Marini JJ Chest 
1992.101 1342-1351 

3 Marini JJ. Ravcnscraft SA Crit Care Med 
1992;20 1461-1472.1604-1616, 

-1 Hess D. Tabor T J Clin Monil 1993.9 275-282 

(supported in pan by Puntan-Bennell Corporation) ^^_^^_^^^ 



FREQUENCY OF RESPIRATORY CAUSES FOR 
ICU READMISSION 

Charles G, Durbin. Jr . MD, Elizabeth A, K,irby. 
B£i Depamnent of Respiratoi^' Care. University 
of Virginia HSC, Charlotlesviile. VA, 
rNTRODUCTION: Patients discharged from an 
ICU who subsequeniK require readmission may do 
so because of worsening inilial disease, 
development of a new condition, a critical 
complication, or premature initial discharge 
Respiratory causes for readmission were found 
frequently in a previous study at this institution ' 
Previously. 54% of 82 patients, had pulmonary 
deterioration as the cause for readmission. Since 
then, a number of hospital changes have occurred, 
including formation of a therapist-directed floor 

METHODS We reviewed all ICU readmissions 
from July IQQZ through June. 1993 and determined 
the frequency of pulmonary-precipitated 
readmissions. A pulmonary cause was diagnosed if 
the patient required greater than 60% Fi02, 
frequent suctioning, intubation, or had a respiratory 
rate greater than 30; and there was no other organ 
failure causing the readmission (same criteria as 
first study). Analysis with Chi-square, 
RESULTS: 120 patients were readmitted to the 
Surgical, Medical or Neurologic ICU dunng this 
time (34 ICU beds). In 67. complete records were 
located (56%), 25 had planned readmissions for 
staged surgical procedures, leaving 42 patients for 
evaluation, 34% of these patients had a pnmary 
respiratory cause for their readmission. A 
pulmonary cause was sigjiificantly less frequent 
than in the previous study (p= 023), Readmission 
rates were 4.6% in 1989-90 and 4 8% in 1992-93. 
Mortality in the readmission group was 10% 
compared to 42% previously 
CONCLUSIONS: Respiratory failure as a cause 
ICU readmission has decreased since the initiation 
of a respiratory therapy consult team. This team is 
notified of any marginal patient being discharged 
from the ICU, By early, aggressive, pulmonary 
intervention fewer patients return with respiratory 
compromise, 

' Durbin CG, Kopel Rf : A case-control study of 
patients readmitted to the intensive care unit. Crit 
Care Med 21:1547-1553. 1993 

OF-94-1C 



COMPARISON OF 3 METHODS TO MEASURE TIDAL 
VOLUME (Vt) with THE PURITAN-BENNETT 
7200AE VENTILATOR Judv Trahev, RRT. Daniel 
Fisher, BS, RRT. Dean Hess. MEd, RRT. Robert M. 
Kacmarck, PhD. RRT Departments of Respiratory Care 
and Anesthesia. Massachusetts General Hospital and 
Harvard Medical School, Boston, MA 
A unique feature of the Puritan-Bennett 7200 ventilator is 
Its ability to compensate for circuit compressible volume 
when delivering a V,^ lo the patient This is based upon a 
circuit compression factor determined during the extended 
self test procedure The ability of this ventilator to display 
a Vj corrected for compressible volume (i.e , the actual Vj 
exhaled by the patient) has not been accepted by all 
clinicians This skepticism has resulted in the practice at 
some hospitals of periodically measuring exhaled V^ with a 
volume monitoring device such as a Wright respiromeier. 
We conducted this study to compare the Vj measured at 
the patient airway connection, Ihe Vy measured distal to the 
exhalation valve with a Wright rcspirometer, and the 
exhaled Vy displayed on the ventilator panel. METHOD 
Purl tan- Bennett 7200 ventilators were used after a total 
extended self test procedure was performed, and were 
attached to a Michigan Instruments Test Lung A 1 s 
inspiratory time, a decelerating waveform, and SIMV mode 
were used The absence of leaks in the system was 
confirmed We used 2 compliance settings (0 02 and 06 
L/cm HjO), 2 resistance settings (5 and 10 cm HjO/L/s), 2 
PEEP settings (0 and 10 cm HjO). 2 V^ (0 5 and 1 L). and 
3 ventilators Five breaths at each of these combinations 
were evaluated, for a total of 240 data sets V^ between the 
ventilator Y-piece and the test lung was measured using a 
Bicore lung mechanics analyzer, and Vt distal to the 
exhalation valve was measured with a Wright respiromeier 
The accuracy of both of these devices was confirmed with 
a I L calibration syringe The Vy from the ventilator 
display, the Bicore. and the Wright were recorded 
simultaneously for each breath Bias and precision were 
calculated for V^ delivered lo ihe test lung (Bicore) and 
displayed on the ventilator, and for volume delivered to the 
test lung and through the exhalation valve (Wright) 
RESULTS There was close agreement for the Bicore and 
the venlilalor display (bias ± precision = 007 ± 051 L) 
The Vy delivered lo the test lung was overestimated by the 
Wrighl respiromeier (bias ± precision = -0 093 ± 108 L) 
CONCLUSIONS With the variety of conditions used in 
this study, the Vj display of Puntan-Bennell 7200 
ventilators agreed well with the V^ measured 
independently with a Bicore at the airway connection The 
\j measured by the Wright respirometer overestimated the 
Vt measured at the patient airway, which is due in large 
part to Ihe effect of circuit compressible volume. These 
results suggest that the volume display of the Puritan- 
Bennett 7200 ventilator is an acceptable indicator of V^ 
exhaled from ihe patient and corrected for the effect of 
compressible volume (supported in part by Puritan- 



OF-94-C 



RESPIRATORY DYSFUNCTION AS RESULT 
OF MEDULLOCERVICAL CORD 
COMPRESSION ANOMALY, Mark) E. 
CadaTJd. RRT . Robert R. McCooneU, RRT, 
NeU R. Maclntyre, MD, Duke University 
Medical Center, Durham. NC. A 69 y.o. white 
Temale brought to the emergency department 
(ED) with a chronic history oX rheumatoid 
arthritis (RA), COPD, recent development of 
altered mental status (AMS), and recurrent 
apoetc episodes. In the ED her ABG's indicated 
severe respiratory acidosis and moderate 
hypoxemia, for which she was intubated and 
mechanically ventiUted. Brain CT and MRI 
concluded that respiratory and neurologic 
changes were due to medultocervical cord 
compression ( MCC) as a result of the dens 
protruding through the foramen magnum. The 
Tmdings were found to be consistent with 
rheumatoid erosion about the area of the dens. 
Flexion/extension MRI concluded that the apnea 
and hypoventilation were related to neck 
flexion, which depressed the neurotegic centers 
of respiration. Treatment included 
immobilization of the cervical spine (c-spine), 
regular monitoring of respiratory function and 
mechanical ventilation. The neurosurgeons ruled 
out c-spine Tixation due to her underlying 
medical condition. The patient currently has a 
tracheostomy and requires intermittent low 
levels of pressure support ventilation because of 
her severe COPD. No further apneic episodes 
have occurred. The findings and conclusions of 
this case are supported by Krieger, e( at, 
(Journal of Neurosureerv . 1969) , and H. 
Sherk, fOrtho Clinics of N.A.. l978).The 
disease process has been described by Sherk as 
atlantoaxial instability and acquired basilar 
invagination. The hazards of surgical 
intervention is well documented by Bharucha 
and Dastur, (Brain . 1964) who report 4 deaths 
out of 20 surgical procedures for this disorder. 
Patient presentation of MCC may be mistaken 
for chronic respiratory failure and/or COPD 
exacerbation, lo this case the history of RA and 
apneic episodes was important. Immobilization 
of the c-spine may only be a temporary 
measure, further compromise may be seen with 
disease progression. A clinician awareness of 
skeleto-mu.scle disorders and their effect is 
important to recognition and treatment. 



COMPARISON OF CONTINUOUS 
CARDIAC OUTPUT AND BOLUS 
CARDIAC OUTPUT DETI-RMINATIONS 
IN NORMAL AND HYPERDYNAMIC 
POSTOPERATIVE PA I lENTS 
Shari L. Mink. RRT . Ronald E. Dechert. MS. 
RRT. David Bliss. MD, Brian Woodcock. 
MBChB. Robert H. Bartlett. MD. University of 
Michigan Medical Center. Ann Arbor. MI. 
INTRODUCTION: Bolus thermal dilution 
cardiac output (COTD) is a common practice 
for the assessment of hemodynamic status in 
postoperative patients. Recent introduction of 
the Baxter Vigilance system allows for 
continuous cardiac output (CCO) 
determination. Previous reports have 
indicated an excellent correlation between 
CCO and COTD in hypo and normodynamic 
postoperative cardiac patients. No reports 
have examined CCO correlation in other 
surgical populations. METHOD: 10 Baxter 
CCO catheters were placed, 7 in General 
surgical patients (Gl. Vascular) and 3 in 
cardiac patients (MVR. CABG). 56 COTD 
measurements were obtained in these patients 
as part of routine monitoring. The CCO value 
was recorded immediately before and after 
each COTD measurement. COTD(s) were 
performed in triplicate for each comparison. 
RESULTS: CCO demonstrates a significant 
correlation (r-0.801) with COTD for all 
measurements. The mean difference between 
CCO and COTD was -0.045 ±1-56 L/M (-1.7% 
+ 18.5%). Range analysis of CO showed 
substantial clinical differences between the 
two methods (40% of paired comparisons were 
>2L difference). Aggregation of the data to 
produce an average CCO and COTD per patient 
improved our observed correlation (r=0.887). 
Stratification of the data (COTD <8L and >8L) 
demonstrates a correlation of r=0.735. n = 27 
andr=0.228. n=29 (for COTD <8L and >8L 
respectively). CONCLUSIONS: Obser\ed 
coirelaiion between CCO and COTD was less 
than previously reported. We observed 
clinically important differences between 
measurements. The heterogeneity of our study 
population may account for the 
dissimilarities between our data and previous 
reports. 



ATTENUATION OF INCREASED PHYSIOLOGIC 
RESPONSE TO CPT WITH PROPOFOL 
M Kemper. BA.CRTT, K Horiuchi MD, C Weissman MD, 
Columbia Presbyterian Medical Center. Departments of 
Medicine and Anelhesiology. New York.NY 
Inlroduci.on Propofol given at 75 mg/kg allenualed 
increases in hemodynamics, melabohcs and respiration 
during CPT However, it also caused a decrease in blood 
pressure in some palienis which required CPT to be initiated 
earlier ihan protocol We studied a lower dose of Propofol 
(0,35 mg/kg) lo determine if the increased physiologic 
responses could be blunled wiihout the allendant decrease in 
blood pressure seen with 7Smg/kg Methods Sixteen 
postoperative, ventilator dependent, hcmodynamically stable 
SICU patients were shjdied All patients had indwelling 
peripheral and pulmonary artery catheters They were 
vcnlilaled with the PB 7200 .(Carlsbad CA) metabolically 

(SensorMedics. Yorba Linda CA) and hemodynamically 
monitored with the Hewlett-Packard Merlin system 
(Wallham MA) Palienis were given two sessions of CPT in 
the AM, one with drug and the other wilh plac«bo that were 
randomly selected There was a rest period before and after 



hCPTs. 






dCPTs. 



mples of blood froi 
lalysis 



I fore 



lenlTtc 



Results REST CPT REST 

V02 Propofol 243(38) 348(88)' 240(41 ) 

(ml/mm) Placebo 239(43) 413(85)'* 237(44) 

D02 Propofol 1187(242) 1382(488)" 1115(219) 
(ml/min) Placebo 1122(243) 1623(536)* 1129(258) 
ER Propofol 21(0 04) 26(0 06)* 22(0 04) 

Placebo 22(0 04) 27(0 06)' 22(0 04) 
HR Propofol 98(19) 106(20)" 96(20) 

Placebo 97(18) 113(17)"+ 97(19) 

SBP Propofol 121(14) 129(24) 117(13) 

mmHg Placebo 122(13) 149(26)"+ 120(14) 

VC02 Propofol 202(37) 255(57)* 202(34) 

ml/min Placebo 197(34) 294(63)"+ 202(38) 

VE Propofol 92(28) 113(3 7)' 90(23) 

Um.n Placebo 8 9(2 6) 12.5(3,6)'+ 9,2(2 9) 

PaC02 Propofol 36 0(2 6) 37,9(3,3)* 34.9(2 9) 
mmHg Placebo 34.7(2 9) 39 9(3 6)' 36 2(3 10) 

VA Propofol 4 9(1 0) 5 8(1 3)' 5 0(1 0) 

L/min Placebo 5,0(1 1) 6 4(16)* 49(1 1) 

•Different lhan resl(p<0.05) +signiricanily different when 
drug and placebo compared (p<0 05) D02=0xygen 
Dclivery.ER-FJClraction ratio. VA=Alveolar Ventilation 
Discussion Signiilcant increases were seen with the placebo 
group in hemodynamics, metabolics and respiration 
Propofol given al 75mg/kg attenuated all the above 
Propofol given al 35 mg/kg attenuated increases in SBP 
and partially ailenuated increases in V02, HR. and PaC02 
It did nol signiHcanlly affect the increases in D02 The 35 
mg/kg dose of propofol was associated wilh less of a 
decrease in blood pressure than the above higher dose so 
prolocol did nol have lo be broken by initiating CPT sooner 



Open Forum Abstracts 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1 



STABILITY OF ARTERIAL TO END TIDAL CARBON 
DIOXIDE DIFFERENCES DURING SHORT TERM 
MECHANICAL VENTILATION 
JM Gravbeal. CRTT . GB Russell. MD Dcpanmcniof 

, PSU CoUcge of Medicine Herehey. Pa. 1 7033 



C«pnography for momionng mechanically vcnQlaicd 
pauents is the accepted scwdard of care during surgery and 
IS becoming more common in ihc Intensive Care Unit. End- 
Uda! carbon dioxide (PetC02) is used clinically as an 
positive indicator of endotracheal intubation, a disconnect 
aJarm, and as a reflection of the arlcnal panial pressure of 
carbon dioxide (PaC02) In normal volunleers. the PaC02 
usually e^ccedi PciC02. the P(a ct)C02 is about 4 mm Hg. 
Recent studies, m mechanically ventilated ICU palienLs. 
demonstrated a larger P(a-el) C02 (8.2 mmHg) and a 
significant vanaiion between changes in the PetC02 and 
PaC02 {APetC02 and iiPaC02 respectively) (Rcspu^tory 
Care 38:923-928.1993), This has also shown in neuro- 
intensive care patients (J Neurosurg Anesthesiology 4:245- 
249. 1992). To evaluate the influence of ume and changes in 
other physiologic variables, we compared the iPeiC02 and 
APaC02 in a group of pauents receiving mechanical 
ventilation for a shorter penod of ume with conuolled 
cardiorespiratory variables. Following insliruuonal approval, 
23 surgical patients undergoing craniotomy were studied 
intraoperauvely dunng volume controlled vcntilauon. When 
clinically indicated (baselme after induction, after cranium 
operung prior to dural incision, and at start of closure), 
artenaj blood gases (with PaC02) were measured, the 
PetC02 was determined from the capnograph (Hewlett 
Packard 78520A infrared capnomeier). The P(a-ei)C02 was 
evaluated for effects of changes in heart rate (HR), systemic 
blood pressures (MAP), central venous pressure (CV'P). 
respiratory rate <RR). tidal volume (Vi), positive end- 
expiraiory pressure (PEEP), and inspired oxygen fraction 
(Fi02) flegression analysis was used to determine the 
relationship between PaC02 and Pe[C02 as well as the P(a- 
et)C02 and other assessed variables. Student t-test was used 
where applicable Correlation coefficients and p values 
<0.05 determined significance. The PaC02 was 32,1±4.1 
mmHg (range 24 8-16.7), (Values are mean ± s.d.) and 
PerC02. 24*4 mmHg (range 16-34). with a P(a-el)C02 of 
8,1±3 mmHg (range 3-17 3). Dunng the study penod HR 
was 70±16. MAP. 78±I4 mmHg; CVp. 8±5 mmHg. RR. 
1 1±2 bpm. TV, 765±221 ml; Fi02. 0,40±0.I3: and PEEP 
1.8±1 4 cmH20 There was a significant positive correlation 
between P(a-et)C02 and PaC02 (r=0.43. slope=0,31 1. 
p<0-0001 ) but poor predictability (r2=0 19). The range of 
aPaC02 was -10 to 6,9 mmHg and APeiC02 was 9 to 7 
mmHg Although aPelC02 and APaC02 correlated 
staiisucally {p<0 001. r=0 79. slope=0 72. T^=0b2). on 
successive measurements 24 % of APetC02 and APaC02 
occurred ui opposite direcuons P(a-et)C02 did not change 
with ume. Despite a positive correlation between individual 
PctC02 and PaC02 pairs, the P(a-et)C02 increassed with 
increasing PaC02 and 24% of APetC02 and APaC02 
occurred in oppwsiie directions We conclude therefore that 
PetC02 does not provide a stable, reliable reflection of 
PaC02 dunng mechanical ventilation of relative shon 
duration, OF-94-185 



EFFlCAa OF MANUAL CHEST COMPRESSION TEChWIOUE 
AND INHALED BRONCHOO I LATOR USING BIRO MARK 7 0^ 
PATIENTS WO REQUIRED MECHANICAL VENTILATION DUE 



, Yoshiak 

lO. Uasazuni Mizuma. bD. Fumihi to Kasai , 
Adachi, Id. Showa Univ. School 
Japan, Shin] 



Juntendo Unn 
Introduction 

asthmat icus < 
of mechanica 
peak inspira 



VD. 

Df 

ROE. 









Tokyo. Japan 

the forr 
, the 

equi red to 

the patient at r i sk for 
tzed bronchodi latofs on 



Unfori 



therapy rnay i 

have administered 
mspi rat ion manua 
coordinated each t 



I zed bronchodi ■ 
I the Bird Mark 

M.th the manual 



the stalu 




.ntubalic 


and venlilalofy support (Se 




osolized bronchodi latofSlO.5 


Salbutamo 


sulfate. l.Occ Brarhemne 


hydrochio 


ide. l.Occ NSi "ere adm.nis 


by Ihe B 


d llBtk 7 We attempted to 


different 


ate and corpare Ihe results 



'tded I 

on expiration and those without compr( 
Pr lOf to thefapY, PIP. mspi ratory 
pause'EIP).autoPEEP,stat ic conpl lancei 
dynamic ccnpl lance(Co^) . aifway 
'esistance(HaJ.and oxygen saturation 
measured. These ' 






admir 



for each pat n 



chest compri 

narxial conpi 

conpression on expiration coordinated with 

inhaled bronchodi lator therapy has efficacy for 

patienis present inp t -■ - - -.^-.. 

PtPiatHfi) 

EIP(cnHp) 

mjtoPEEP(Cfl«/))^ 

C^,(m\ /aitifi) 

C^im\ /ofHfi) 

SpO,0i) 









43.6±17.7 


27.9±9.9 


P<0.01 


20.9±5.8 


15.5±4.6 


P<0.01 


16.1 ±9. 7 


10.3±6.8 


P<0.01 


25.4±n. 


33.2±13.3 


P<0.01 


12.7±5 


18.7±7,9 


P<0.01 


35.0±20.6 


21.1±12.8 


P<0.01 


%.6±1.7 


98.8±l.e 


P<0.01 

OF.94-244 



WASH-OUT VOLUMES OF CURRENT 
GENERATION VENTOATORS: STILL A PRE- 
OXYGENATION CONSIDERATION - Robert A 

Bonner. Jr.. MEd.. RKT . Anastassla Grtgorlcva. 
Hlghllne College, Des Moines. WA.. Louie J 
Boltano. BS,, MS.. Seattle Community College. 
Michael S Benson. BS.. RRT. Kenneth P. 
Steinberg. MD.. Harboniew Medical Center. 
Seattle. Washington. 

Introductloii: Pre-cxygenalion with 100% oxygen 
prior to endotracheal suctioning is still 
recommended to prevent hypoxemia. A previous 
wash-out study with older generation ventilators 
demonstrated signlllcant difference in the volume 
necessary to "wash-oul ' one FIO2 with another, 
(Respir Care, Vol, 24, 1979) To continue the work 
of Benson et, al.. we studied six current generation 
ventilators to determine their wash-out volume to 

100% oxygen as it may sUll be significant if the 
ventilator is used for pre-oxygenatlon. Method: 
The venUlators studied: Bear 1000. Bird 8400 ST. 
Hamilton Veolax, Puritan Bennett 7200ae, 
Siemens Servo 300 and Infrasonics Adult Star A 
Hudson 5590 oxygen analyzer (Hudson RCl., 
Temecula, CA.) was placed on the Inspiratory limb 
of the ventilator circuit just before the patient wye 
The inspiratory limb of the circuit was isolated 
from both the test lung and the expiratory limb by 
a one way valve placed between the patient wye 
and the oxygen analyzer .The same length 
Inspiratory circuit was used for each ventilator and 
the humldlRcatlon devices were bypassed. Each 
ventilator was connected to the test lung. (TTL, 
Michigan Instruments, Grand Rapids. MI), set at 
compliance of .04L/cmH2O and placed on SIMV f- 
5. The FIO2 was recorded at the beginning of each 
breath Wash-out volume was calculated based on 
the number of breaths it took to reach 100% from 
FI02S of .21 and .40- Each machine was tested at 
Vj's of 400, 800 and 1200 mis. All measurements 
were made three times and the values were 
meaned. Results: 

WASH-OUT VOLUME' 

Vt 400 Vt 800 Vt 1200 

ltoF!02of 1.0) 

.21 AO :21 AO .2I_ -40 

BEAR 1000 7.6 6.8 12.2 10.4 13.9 12 

BIRD 8400 ST 9.6 8.8 13.3 13 14.4 13,6 

HAMILTON 21.0 22 1 22.6 21.8 24.7 22 

PB 7200 2,8 2.8 3.4 3.2 4.8 3 6 

SERVO 300 1 .6 1 .2 1.2 1,2 1,2 1 .2 

ADULT STAR 2,8 2 8 4.5 3 7 4 8 4 8 

'All volumes are in liters and have been meaned. 
Conclusions /Reconunendatlons: There remains 
signlllcant variability in wash-out volume among 
ventilators studied. Ventilators with accumulators 
require more wash-out volume than those wilh 
bias flow or those without accumulators. We 
recommend clinicians consider wash-out volume 
when usmg the ventilator for preoxygenation 
prior to suctioning. 



A NON-INVASIVE METHOD FOR 
PREDICTING P1CO2 IN INTUBATED 
PATIENTS. Whitng L Schwartz. B A.. RRT . 
Stephen J Connell. B A.. R.RT . Nina Chiles. 
M S , Amy Staiano B A.. Don D MiUer. R.RT , 
James J O'Connor. M D . Herbert Patrick. M D 
Departmenis of Respirator^' Care and Medicine. 
Thomas Jefferson Umversit\, Philadelphia. PA_ 

Although non-imasive methods for measunng 
oximetn' and end iidal CO: ^re popular, arterial 
blood gases (ABG's) remain the standard for 
measuring pH. paCOj and pa02 In multiple 
studies, substantial differences have been 
demonstrated between end-udal CO2 (PETCO2) 
and paC02 We hypothesized that measurement of 
the dead space/ udal volume rauo iVdA/i) for an 
indi\idiial patient recciMng a fixed mode of 
ventilation would permit correcuon of the 
PETCO2 sigiuficantJy impro\ing correlation with 
paC02 ^e studied 12 intubated adult paucais m 
the Medical Respiratorv Intensive Care Umt 
PETCO2 was measured with 3 Hewlett Packard 
mainstream sensor integrated into the bedside 
monitor to provide 24 hour trending A single 
Vd/Vt was computed using the Bohr equation with 
the average exhaled CO2 measured b\' a 
SensorMedics DeluTrac Metabolic Momtor A 
Vd/Vt correction for the pETCOo (Chest 1987. 
92:832-835) was used to denve the predicted 
PQCO2 from the momtored PETCO2 A total of 44 
paC02's from ABGs drawn mthin 72 hours of the 
Vd/Vt delermination were retrospectively 
compared with the predicted paCOj The mean 
and standard dcMation for pETCOi and Vd/Vt 
were 22 6 + 6 1 and 64 + 02 respecuvely The 
3\'erage difference between the measured paC02 
and predicted paCOj was 4 1+57 ton 
Ehrainaling 3 pauents with measured - predicted 
paCOi > 5 ton at the baseline Vd/Vt 
determmauon reduced the average difference for 
32 ABG's to 2 4 + 41 ton We conclude thai our 
non-in\asive method for predicting paC02 is 
accurate and praciicaJ We have imtiated a 
prospective stud\' to examine the impaa of 
predicted paC02 on quality of care and utilizauon 
of resources. 

Supported in pan b> the Respirators Care 
Education and Equipment Fund 



Zfv Tony Dal Nogare, AID 

ARDS was onginallv described in 1967 and 

has since undergone much scrutiny. This 

review ot ARDS discusses the latest 

developments in risk factors and treatment. 

Also covers the 5 diagnostic criteria that 

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diagnosis ol ARDS, including clinical, 

I'iidiographic, and physiologic criteria. 

Item VT31 - VHS (60 minutes) 
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I 1030 Abies Ln.. Dallas, T\ 

75229-4593 



RESENTING 

THE FIRST 

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l/ENTILATOR 

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"Respiratory Care Magazine, 
January 1992, Vol. 37, No. 1. 



Blender 



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weaiiiig liiiii off the vent. 




a 



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Weaning protocols that use capnography 
can help take the guesswork out of 
weaning decisions. 

Considering tlie time, resources, and quality-of-care 
issues involved in weaning ventilated patients, the 
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patients from the ventilator is arbitrary, it creates variability 
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There is an alternative. Close, continuous monitoring 
of end-tidal COt- as part of a weaning protocol -provides 
timely information to help 
you gauge your patient's 
ability to be weaned off the 
ventilator. Instituting a 
protocol that leads to fewer 
ABGs and reduced ventilator 
time per patient can save 
money, potentially improve 
quality of care, help reduce 
MLOS, and make bed 
utilization more efficient. 



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the effects of ventilator settings 
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rather than after the 10- to 20- 
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RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1 



Open Forum Abstracts 



QUANTITATION OF PULMONARY ALVEOLAR 
MACROPHAGE PHAGOCYTOSIS USING 
FLUORESCENT LIPOSOMES. 

Douglas G Perry , PhD, RRT and William J Martin II, 
MD School ot Allied Health Sciences and Division of 
Pulmonary and Critical Cafe Medicine, Indiana Uniuer- 
sity School ot Medicine. Indianapolis IN 46202 

A new phagocyte assay based on liposome in- 
geston by alveolar macrophages (AMs) is presented 
Fluorescent liposomes weie formed by aqueous re- 
consOtuton of phospholipids in the presence of fluor- 
escein^polystyrene (F-PS) beads The emission spec- 
trum of the F-PS/liposomes was similar to that of free 
F-PS microspheres The amount of fluorescence as a 
funcfion of liposome concentraton was calibrated by 
linear regression Rat AMs were incubated with F-PS/- 
liposomes for 1 hr At the beginning of incubation, AMs 
showed no visible interaction with adjacent liposomes, 
and AMs were nonfluorescent After 45 mm, AMs 
could be seen engulfing liposomes, and many AMs 
had a fluorescent label v^lhin vacuolar compartments 
After 60 mm, AMs were intensely labelled throughout 
the cytoplasm To determine that the AM uptake of 
fluorescent label was due to bona hde phagocytosis, 
dichlorodihydrofluorescein (DHF)-zymosan micro- 
spheres were encapsulated in liposomes After 1 hr in- 
cubation, fluorescence was exclusively seen in AMs, 
not free liposomes To establish a tme course of pha- 
gocytosis. AMs were incubatedv^th F-PS/liposomes 
for up to 1 hr The number of phagocytosed liposomes 

by grid cytometry Phagocytosis was quantified as the 
number of engulfed liposomes per AM (liposomes/- 
cell) The number of phagocytosed liposomes per cell 
increased monolonically over time, to a maximum of 
14 9 ± 6 liposomes/cell at 60 mm (^0 05) To deter- 
mine if the phagocytosis assay could measure a bio- 
logic response, AMs were incubated for 18 hr with or 
wnthout lipopolysacchande (LPS) The phagocytic ac- 
tvity of LPS-pretieated AMs was significantly greater 
than control AMs (5 3 ± 1 vs 10 ± 9 liposomes/- 
ceil, p< 05) To determine whether phagocyte activ- 
ity could be influenced by liposome compositon, fluor- 
escent liposomes were prepared with or without vitro- 
nectn (Vn) AMs were incubated for 1 hr with either 
control or Vn/liposomes AMs significantly engulfed 
more Vn/liposomes than control (3 7 ± 3 vs 16 5 ± 
6 liposomes/cell, p-=^ 05) These findings demon- 
strate that 1 ) liposomes can entrap F-PS microspheres 
and retain their spectroscopic charactenstcs. 2) lipo- 
somes can be enumerated by fluorometry 3) AMs can 
phagocytose FP-S/liposomes and the fluorophore is 
transferred to the cytoplasm, and 4) AM phagocytosis 
of liposomes car be measured over tme, is increased 
v/ith AM actvaton, and can be directly influenced by 
liposome composition OF-94-063 



Beth PuFault.RiiT ^'^' David Carton, CRTT^'^- 
Gerald A. Nystron, HD;; Rene Fitzpatrick, MSIr; -, 
Douglas D. Detinq, KD^; Kerby C. Oberq, HD, PhTH'-* 

Departnent of Patholoqy, Division of Hunan 
Anatony^; Departient or Respiratory Care*^; 
Departnent or Surgery, Division of Plastic and , 
Reconstuctive Surgery'; Departnent of Pediatrics'*. 
Lona Linda University, Hedical Center i Children's 
Hospital, Lona Linda, California 

IKTHODOCTIOB: An inportant factor responsible for 
the deiise of prenature neonates is inaturity of 
pulnonary structure and function, including 
pulnonary cytodifferentiation and surfactant 
■etabolisi. Epidental groirth factor (EGF) has been 
associated vith accelerated developnent of fetal 
lung tissue, increased fetal lung phospholipids, 
and protection fron both hyaline nenbrane disease 
and oxygen toxicity. However, the physiologic role 
for EGF has been difficult to denonstrate. The 
goal of this study 'Jis to denonstrate the effect 
of EGF on rabbit lung developnent through the 
introduction of exogenous EGF into the anniotic 
fluid of developing fetal rabbits. METHODS: 
Pregnant New Zealand vhite rabbit doe? (gestation 
day 23-24;tem 31 days) were anesthetized and the 
gravid uterus surgically exposed. Four (4) fetuses 
per litter underwent agent adninistration via a 
continuous infusion nicro-osnotic punp (Alza 
Corp). One fetus received vehicle fNaOB/NaCl) 
only, another received an anniotic bolus of 
retinoic acid (RA: kno^Ti to enhance the expression 
of pulnonary EGF Receptors and EGF responsiveness) 
and vehicle infusion, the third received EGF (4 
ncg/tl/day) in vehicle solution. and the last fetus 
received an RA bolus and EGF/venicle infusion. 
Following three days of infusion, the pups were 
harvested either for norphologic exanination to 
detemine lung naturity [phase I) or nechanical 
ventilation and subsequent analysis of physiologic 
variables to assess lung function (phase II). 
KESOLTS: Fetuses treated with EGF showed a 
significant increase in lung naturation as 
detenined by the percentage of lung volune 
available for qas exchange (air space: 41. 5i) in 
conparison to controls or vehicle infused fetuses 
(33. 8i and 34.11 respectively). This increase 
occurred with or without the addition of RA. EGF 
infusion also appeared to enhance pulnonary 
conpliance (0.32 nl/ca B20/Kg conpared to 0.27 for 
controls-15t increase), total lung capacity (TLC: 
87.9 nl/Kg conpared to 62.3 for controls-z9i 
increase), and deflation stability (56.31 conpared 
to 34.51 for controls-38i increase). COMCUJSIONS: 
These findings denonstrate that anniotic EGF nay 
accelerate lung developnent in fetal rabbits by 
increasing airspace. Furthemore, this increase in 
air space appears to correlate with inproved lung 
conpliance. TLC, and deflation stability in 
techanically ventilated prenature pups. These 
studies suggest that anniotic delivery of EGF nay 
have the potential to enhance lung developnent and 
pulnonary function of prenature neonates. 



CHARACTERIZATION OF ULTRASONIC AEROSOLS 
CONTAINING LIPOSOMES, 

Nicole C Payne. BS RRT . Diane Kachel, BS, and 
Douglas G Perry, PhD RRT School of Allied Health 
Sciences and Division of Pulmonary and Critical Care 
Medicine, Indiana University School of Medicine, 
Indianapolis IN 46202 

Introductionr Liposomes are artificial vesicles com- 
posed of phospholipid bilayers Liposomes have practi- 
cal applications in drug delivery, due to their ability to 
encapsulate toxic or hydrophobic drugs Liposomes 
are currently being developed as a mode of delivery of 
therapeutc agents to the lung The direct administra- 
tion of liposomes to the lung would be greatly im- 
proved if liposomes could be delivered by aerosoliza- 
tion Previous work on the nebulization of liposomes 
employed pneumatic nebulizers, which were found to 
destroy the liposomes by the shear forces created by 
the jet and/or impactor In this study we investigated 
the feasibility of using a specially modified ultrasonic 
nebulizer to generate liposome-laden aerosols 
Methods: Liposomes were prepared by aqueous re- 
consttution ot phospholipids in the presence of fluor- 
escem-conjugated polystyrene (F-PS) beads A modi- 
fied DeVilbiss Aerosonic ultrasonic nebulizer was 
placed in (me with a Mercer cascade impactor Flow 
was generated by a downstream vacuum pump and 
controlled by a high precision Thorpe tube upstream to 
the nebulizer Aerosol partcle size distnbuton was 
quantified by weighing the impacted residue on the 
collection stages of the Mercer impactor Mass median 
diameter (MMD) and geometnc standard deviation (n^) 
were determined by slope analysis of the cumulative 
weight distribution of liposome-laden aerosols com- 
pared to pure aqueous aerosols Liposome morphol- 
ogy and F-PS entrapment were documented by differ- 
ential interference contrast and epifluorescence micro- 
scopy Liposome samples obtained before nebuliza- 
tion, after nebulization, and in the final delivered aero- 
sol were observed wnth this technique Results: MMD 
for pure aqueous aerosol was 1 4 |jm with n,-^=3 4. m 
contrast, MMD for liposome-laden aerosol was 3 4 tjm 
wnth a(-=2 4 Liposomes pnor to nebulization were mul- 
tlamellar vesicles (MLVs) with a typical diameter of 
5 tjm, liposomes after nebulization were MLVs with a 
typical diameter of -4 tjm, m contrast, liposomes m 
the final delivered aerosol were only -1-2 ym 
Conclusions: 1) Liposomes can successfully be incor- 
porated m aqueous aerosol by ultrasonic nebulization 
2) Those liposomes that were incorporated in aerosol 
partcles were markedly smaller than the onginal lipo- 
somes 3) Liposome-laden aerosols are larger but 
more homogeneous than pure aqueous aerosols Ul- 
trasonic nebulization promises to be a feasible method 
of aerosol delivery of liposomes to the lung 

OF- 94 -064 



ATTENUATION OF LUNG INJURY IN A RABBIT 
ACID ASPIRATION MODEL USING GM-1925. A 
NOVEL SELECTIN INHIBITOR 

Kelley M. Cornell MD and Mark W. Bov/yer MD, 
Department of General Surgery, David Grant 
USAF MC, 60th Medical Group, Travis AFB. CA 



Aspiration Is a major cause of puin 


nonary 


dysfunction and mortality In surglc 


al patients. 


The Inflammatory reaction to this 1 


njury Is 


mediated by neutrophil binding to 


he 


endothelium of venules. NeulrophI 


adhesion 1 


regulated by selectlns and Integrln 


s. GM.1925 


(Glycomed Inc. Alameda, CA) Is a 


selectln 



specific neutrophil adhesion blocking agent. 
Methods : New Zealand White Rabbits had 
endotracheal Instillation of pH 1.5 HCI (4 cc/kg). 
Six rabbits (control) received add alone. 6 
received 2Smg/kg/hr and 5 received 10 mg/kg/hr 
of GM-192S Intravenously 5 minutes prior to 
and at hourly Intervals after add Instillation. 
Vital signs, serial CBCs and arterial blood 
gases were collected. Rabbits were sacrificed al 
six hours and lungs analyzed. 
Results : GM-1925 decreased lung Injury when 
compared with controls In a dose dependent 
fashion. A-a DO, values (figure) were 
statistically different (p <■ .05 by ANOVA) from 
90 minutes on In the 25 mg/kg/hr group and 
from 4 hours on In the 10 mg/kg/hr group. 
Significant differences were also noted In pOj 
and pCO, values between groups. Histologic 
examination confirmed the attenuation of acid 
aspiration lung Injury In rabbits that received 
GM-1925. 

Conclusion: Attenuation of acute lung Injury In 
a rabbit add aspiration model occurs In a dose 
dependent fashion with GM-1925. Application of 
this and simitar compounds In the treatment of 
acute lung Injury warrants further Investigation 



m'""! 






T T 


X soo- 

|«0- 




Control 


^^^Omg/kg/hr 


^.300- 


J 




S^ 


Ujoo- 


ng/kg/^r 


« 100- 
"* 0- 


25 




1 1 


1 1 


1 1 1 



Time in Hours 



EFFECT OF HEPARIN-LADEN UPOSOMES ON 
PHAGOCYTIC ACTIVITY OF PULMONARY 
ALVEOLAR MACROPHAGES. 

Lorraine E Gallivan . AS RRT and Douglas G 
Perry, PhD RRT School of Science, Purdue 
University and School of Allied Health Sciences, 
Indiana University School of Medicine, 
Indianapolis IN 46202 

Introduction: Pulmonary alveolar macro- 
phages are mobile, phagocytic cells which are 
responsible for engulfing and disposing of 
airborne particles and microorganisms Due to its 
central role in pnmary lung defense, the mechan- 
ism of phagocytosis is currently under active 
study Clathnn-coated pits, found on the inner 
surface of macrophage membranes, may provide 
membrane recycling dunng phagocytosis Lipo- 
somes are phospholipid vesicles that can entrap 
bioactive compounds The purpose of this study 
w/as to investigate whether increased coated pit 
formation would enhance phagocytosis Methods: 
We used liposomes as Trojan Horses to deliver 
hepann to the cytoplasm of intact, living macro- 
phages Heparin is a known promoter of clathrin 
coated pit assembly /n vitro Liposomes were 
prepared by aqueous reconstitulion of phospho- 
lipids in the presence of 10% hepann, then 
added to rat alveolar macrophages obtained by 
lung lavage After 18 hr of heparin/liposome 
pretreatment, the celts were nnsed and chal- 
lenged for phagocytosis with fluorescent lipo- 
somes containing fluorescein-conjugated polysty- 
rene beads Control cells were pretreated with 
empty liposomes and challenged in the same 
manner Phagocytic activity was assayed by 
measuhng the amount of engulfed liposomes as 
a function of fluorescence intensity Results: 
Fluorescence intensity of hepann-treated cells 
was significantly greater than control cells (238 ± 
21 vs 134 ± 30 mV, respectively, p^O 05 by T- 
test) Conclusk>ns: As measured by fluorescence 
intensity, phagocytosis was markedly increased 
by liposome-delivered hepann, consistent with 
the hypothesis that clathrin coated pit formation 
enhances phagocytosis This suggests that 
clathnn-coated pits are centrally involved in the 
mechanism of phagocytosis, possibly through 
membrane recycling 

OF-94-093 



1994 Annual 
Convention 

of the 

American 

Association for 

Respiratory Care 

to be held in 

Las Vegas, 

Nevada 

December 

10-13,1994 



Open Forum ABSTRACTS 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1 



AN EVALUATION OF THREE FACE SHIELDS 

FOR VOLUME DELIVERY DURING RESCUE 

BREATHING 

Mark Simmons MSEd, RPFT, RRT; Dan Deao 



BS, RRT, Laura Moon BS RRT; York Hospital. 
York, PA 

INTRODUCTION Due lo the fear of disease 
transmission dunng rescue breathing, many 
barner devices exist, the newest of these being 
the face shiekl (FS) CPR barner devices The 
purpose of our study was to evaluate the 
volume delivered to a mannequin (Resusci 
Anne. Laerdal Corporation) using three different 
FS models METHOD Ten rescuers, each 
certfied in BLS, were asked to ventilate a 
mannequin as they woukJ an aduft dunng 
rescue breathing Three devices were tested 
Kiss of Ufe (KOL), MicroSHIELD (MICRO) and 
Res-Cue Key (RCK) After a penod of practice 
with each device, the rescuers randomly 
performed mouth to mouth (M-M) and FS 
breathing with each device for two minutes A 
five minute rest penod was given between each 
senes All volumes were measured ustng a VM- 
90 ventilation monitor (Bear Medical) placed in- 
line between the mannequins "trachea" and 
"lungs" Mean VT and SD values were 
calculated Differences among the four methods 
were evaluated using ANOVA p < 05 was 
considered significant RESULTS The mean 
VT and SD tor each method of ventilation m L 
was as follows M-M 99 i 26, KOL 25 t 
Oil. MICRO 75 + 22 and RCK 64 + 15 
There was a significant difference between the 
volumes obtained among the four methods of 
ventilation (ANOVA, p < 001) and significant 
differences were found for each paired 
companson (Scheffe. p < 05) 
CONCLUSIONS Only M-M ventilation resulted 
in an average VT delivery of at least 0.80 L as 
recommended by the AHA for rescue breathing 



THE EFFECTS OF CHANGES IN LUNG COMPLIANCE ON THI 
FRACTION OF DELIVEEIED OXYGEN {HX>;) AND MINUTE 
VENTILATION (VEl DELIVERED BY SEVEN DISPOSABLE 
ADULT MANUAL RESUSCrTATORS (DAMRsI 
B..»rll T Ri^.d RRT. Tem Cook. RRT, RN. UC Davis Mcd.eal 



Seven DAMRs * 
compliance ctuingi 
DAMR 



ccted lo a Ttaimnj 



ive rcFwai mea&urcs «ere performed for each DAMF 
^cle rale and TTL compliance scningi were randoml 

f FD02 Each of ihe seven DAMRs were leslcd by il 

te DAMR Each DAMR was tested on a differeni da 
ossiblc effect of hand fatigue Airway pressure data 
fi electronic pressure transducer (Pncumogaid 1230^ 



;n now R 



I ;< Umin and 



1 1 E ratio of I 
riofmals 



nanutactureri recomrrrndations Results Data was analyzed u 
rhree Way ANOVA There wen: iignificam changes in deliver 
p < 01 ) in oil wvcn DAMRs Five of ihe seven DAMRs tested 
.ignificant changes in FDO? (P < 01 ) 



1068 



RESISTANCE TO FLOW THROUGH THE 
VALVES OF THREE FACE SHIELD CPR 
BARRIER DEVICES 
Mark Simmons MSEd, RPFT, RRT, York 



Hospital, York, PA 

INTRODUCTION Few published evaluations 
have been performed on face shield (FS) CPR 
barner devices The purpose of this study was 
to determine inspiratory back pressure and flow 
resistance of the one way vatves of three FS 
models METHOD The three FS brands 
evaluated were, Kiss of Life (KOL), 
MicroSHIELD (MICRO) and Res-Cue Key 
(RCK) A continuous flow of air was directed 
through each valve at 10 to 60 L/min in 
increments of 10 Umin The vatves were held ir 
the position as they wouW be, when used on a 
victim Two devices from each manufacture 
were tested Three measurements were made 
at each flow setting for each device, Back 
pressure was measured proximal to the valve 
using a Timeter Calibration Analyzer and mean 
values reported Resistance was calculated by 
dividing back pressure by the flow The 
metfiodology was similar to that of others 
performing back pressure studies to evaluate 
resistive pressure through vatves Differences 
among the three brands were evaluated using 
ANOVA p < 05 was considered significant 
RESULTS At a flow of 50 Umin the mean and 
SD inspiratory back pressures in cm H;0 
produced by the devices were 7 22 ± 12. 
16,70 1 1.17 and 2 15 lO 15 for KOL, MICRO 
and RCK respectively The mean and SD 
resistance in cm H^O/Usec was 8 66 i 15, 
20.04 ± 1 41 and 2 58 + 18 for KOL, MICRO 
and RCK respectively There was a significant 
difference among the mean values for each 
brand tested at 50 Umin (ANOVA, p < 001) 
and significant differences were found for each 
paired companson (Scheffe, p < 05) 
CONCLUSIONS The resistance of some of 
these vatves may be considered excessive and 
only one. RCK, met the ISO standard of back 
pressure < 5 cm H,0 at 50 L/min 



MANUAL VENTILATION DURING 

CARDIOPULMONARY RESUSCITATION 
Richard Branson. RRT . Kcnnclh Davis Jr, MD. Robert 
Johnson. MD. Robert Campbell. RRT. Ted Tabor 
Department of Surgery. University of Cincinnati Medical 
Center, Cincinnati. Ohio 

Purpose: Ventilatory support during CPR is typically 
provided by manual ventilation with a sclf-mOating bag 
(SIB) We undertook this study lo determine the 
cfficieticy of manual ventilation provided m the 
emergency department (ED) to intubated patients dunng 
CPR Methods Twenty patients amvmg ui the ED 
under fuU CPR were entered into the study All patients 
were manually ventilated with a disposable SIB by a 
member of the ED suff {RN, resident. MD. RRT) A 
disposable vanablc onficc pncumotachomclcr and 
pressure Up were placed between the SIB and 
endotracheal tube Row and pressure signals were 
processed by a porUble respiratory monitor (VcnTrak. 
Novametr«. Waltingford CT) and saved to an IBM 
compaubic computer Personnel were blinded to the 
volume and pressure measurements Tidal volume (V,), 
peak inspiratory pressure (PIP), frequency (f), and IE 
ratio were calculated on a breath to breath basis and 
averaged on a minute lo minute basis Results The 

Ventilation was provided by an RN=6. residenl = 8. 
MD = 2, RRT = 4 Results for measured vanublcs in 



tSD 8 



1 below 





Minulc 1 


Final Minulc | 


V, (mL) 


571 (90) 


595 172) 


PIP (cm H,0) 


41 19) 


40 (i:) 


f (b/min) 


24 (6) 


20 18) 


- 


1 ; 3 


129 



Conclusions These daU demonstrutc that dunng CPR 
ventilatory support is typically provided at a higher f and 
lower Vf than suggested by AHA guidelines Time did 
not effect performance, as there were no differences in 
values during the first minute compared to the final 
minute of ventilation This study cannot relate outcome 
to ventilatory support Future research should consider 
the use of a ventilator to provide ventilation dunng CPR 
and the effceU of diiplaying V^ and f on ctregiver 



COMPAFBSON OF METHODS OF EMERGENCY 
TRAI^TRACHEAL JET VE^^'ILATION (ETTJV) 
Gregory Neil Foust. RRT ■ Baptist Hospital- 
Memphis, TN, 

In the Advanced Cardiac Life Support 
(ACLS) literature ETTJV via a cricothyroid 
puncture is deserved as a viable means of 
interim emergerKy ventilatory support for 
patients with a ditTtcull airway A variable 
pressure regulator and stopcock is depicled 
as the flow source, however, resuscitation 
bag adaptations to the transtracheal catheter 
have tjeen alluded to in lectures and in some 
journals. To assess the adequacy of these two 
techniques, a simulatior) was cteveloped utl- 
lizirig a variable resistance and compliance 
test lung A 17 cm long segment of 15 mm. 
ID. tygon tubing which served as the simu- 
lated trachea which was punctiired by a 14 
gauge angiocath. A 5 cm. PEEP valve was 
placed at the proximal end of the tygon tubing 
10 simulate the normal physiologic resis- 
tance to exfialalion Three different compli- 
ance settings were assessed: 0.6, 0.4. and 
0.2 L/cm. H20. Ten ventilations were de- 
livered using both techniques at each com- 
pliance setting. With the resuscitation bag 
technique volume delivery via bellows dis- 
placement was 150 mis.. 0. and respec- 
tively. The Precision Medical flowmeter on 
flush with the stopcock technique resulted in 
volume delivery of 2200. 1400. and 600 
mis. respectively. Conclusions: ETTJV 
seems worth consideration in certain dire 
airway emergencies where endotracheal in- 
tut)ation seems impossible by the personnel 
avatl^te. Methods that take advantage of the 
high driving pressure available from a stan- 
dard 50 psi. 02 outlet are far superior to 
methods geared to utilizing a resuscitation 
bag and have been reported as effective in 
the anesthesia literature. A potential exha- 
lation pathway must exist, otherwise trach- 
eostomy is indicated- RCP's should be famil- 
iar wrth the optimal method of achieving 
ventilation, if physcians deem it necessary to 
perform a trarislracheal puncture. 



(HPM). or by the 
!V!ce {MRD). MH 

dvantages of 



use of a manual resuscitation dc 
and MPH ventilation are easy to 
however they have the potential c 
delivering inadequate oxygen level 
an env . ronment for cross contami n; 
Conversely a MRO delivers consistently f 
oxygen level s. and potential ly decrease; 
possibility of cross-contami nation between rt 
and patient. The ability, however, of untr 
personnel to deliver adequate and consistent 
volumes with the MRD Is a significant limil 



aluated a modlfti 



irgenc: 



ing. 



:e (MMRO) which enable: 
DESCHIPTIOM OF DEVICE: th. 



sealed at both ends A mouth piece inserted 
through the plastic shell allows for cormunKation 
to the area between the MRO bladder and the outer 
plastic shell. The rescuer's exhaled positive 



the patient EVALUATION METHOD: T« 
year Respiratory Therapy students * 
compare tidal volumes delivered by * 



to perf 


:nii 


ten 


Laerdol 


Hed 


cal 


aled sp 


rum 


eter 



EVAt.UAIION RESULTS^ 



•/- 1 


ml anc 


1280 ml . 


■ 34 ml 


respective! 


Ihe t 
signif 
standa 


rd M«0 » 
5H ml 


mes deliver 
greater tha 
th mean tlda 
»/- 18 ml r 


d using 

those 
1 volume 


the MHRD we 
del ivered by 
s of 846 •/- 
ely Both t 


standa 


rd HBO 


and HHRO d 


elivered 


significant 









techniques COHCLUSIOM: Our results demonstrated 
the MHRD provides greater delivered t>dal volumes 
than a MRD. allows the rescuer to use both hands 
to achieve a patent airway and mask seal, allows 
for a minimum FiO, of 21 and significantly 
decreases the opportunity for cross contamination 



To CREATE AN EASY-TO-USE, PATIENT-FRIEND 
PEAK FLOW METER, 
WE CONSULTED A VUvletu OF PRODUCT DESIGNERS. 



,^ 



The peak: the patient-friendly peal< flow meter from Baxter. 
Compact. Durable. Accurate. Perfect for both adult and pediatric 
patients. Able to be personalized with patient information stickers 
that can be placed directly on the meter. We've even included some 
cool, kid-pleasing stickers (Awesome!]. Choose the peak flow meter 
your patients would — The PEAK. ,^ 

For more information contact your Baxter sales rep or call 1-800-933-0303. 



I The PEAK peak flow 



ed trademark ot MultiSPIRO, Inc 



booth #B37 at the AAPC Conu 



Circle 114 on reader service card 



Open Forum ABSTRACTS 



RESPIRATORY CARE . NOVEMBER '94 Vol 39 No 1 1 



DOES A COMPREHENSIVE COMtlUNITY 


HOSPITAL OUTPATIENT PULMONARY 


REHABILITATION PROGRAM REDUCE 


INPATIENT HOSPITAL ADMISSIONS 


AFTER PROGRAM COMPLETION? 


Debbie Loqan, B.S., RRT, 


Brian W. Carl in, H.D. , 


Richard Pellegrini, RRT, 


The Washington Hospital, 


Washington, PA 


In order to evaluate the cost 


effectiveness of our out- 


patient Pulmonary Rehab 


Program, a retrospective 


study was performed on 69 


patients who completed the 


program from 1989 to 1992. 


All hospital admissions for 


exacerbation of lung disease 


were compared one year prior 


to the program and one year 


following program completion. 


Of the 69 patients reviewed. 


4 have died since 1989. The 


patients average age was 64 


SD (+ 9 years) and had an 


average FEV of 1.007 SD 
(+ .1975). +heir diagnosis 


ranged from emphysema 72%, 


chronic bronchitis 24%, 


alpha. -antitrypsin deficiency 
2% ani pre-lung transplant 


2%. The paired t-test was used 


to compare the average number 


of hospital days per patient. 


The mean number of hospital 


days per patient the year 


prior to the program was 7.44 


days. The average number of 


hospital days the year follow- 


ing the program was signifi- 


cantly reduced with an aver- 


age patient stay of 3.60 


days (p <.001). These findings 


correlate with other studies 


which document the cost 


effectiveness of Pulmonary 


Rehabilitation Programs by 


the reduction in the need for 


repeat hospital admissions. 


OF-94-001R 




VENTILATOR WEANING FOLLOWING A 


HIGH LEVEL SPINAL CORD INSULT- 


F. Dipzinski, RRT; The Rehabil- 


itation Institute at Tri-StaCe 


Hospital. Buchanan, Michigan 


A 25 y.o. male was admitted s/p 


C-3 spinal coed infarction with 


resultant quadraplegia and vent 


dependence. In time, some ac- 


cessory muscle use was regained 


but, as observed by flourosco- 


pic examination, diaphragmic 


movement never was. Along with 


PT and OT. we began a program 


designed to train the accessory 


muscles to carry the ventilato- 


ry load. Initial pulmonary 


mechanics were: V <I00 mis, VC 


150 mis. NIF 2 cm'n 0. With the 


7200 a, we used maximal pres- 


sure support (PS) levels until 


he was accustomed to initiating 


ventilation. Serial measure- 


ments of spontaneous and assis- 


ted breaths was done, and once 


preset goals were met, PS and 


sensitivity levels were lowered 


to aid in the training process. 


Pulmonary nechanic studies were 


performed weekly to assess the 


strengthening process. Flow-by 


and then capping trials were 


initiated and continued until 


ventilator use was nocturnal 


only. Negative pressure venti- 


lation via the NEV-IOO was in- 


troduced, and once tolerated. 


an Olympic button replaced the 


tracheostomy tube. Pulmonary 


mechanics prior to home dis- 


charge were; V 450-700 mis, VC 


2.3 L, NIF 60 cmH 0. 6 weeks 


after discharge he was decannu- 


lated. SIGNIFICANCE: Breathing 


retraining can be accomplished 


following high level spinal 


cord injury without diaphragma- 


tic sparing if some accessory 


muscle (unction can be re-est- 


*"''••""• OF-9J067 



USE OF BI-LEVEL POSITIVE AIRWAY 
PRESSURE VIA TRACHEOSTOMY IN A 
PATIENT WITH MORBID OBESITY. AG 
Kendall RRT . SG Peters. MD. PC Gay. MD, RW 
Viggiano. MLXMayo Foundation. Rochester, Mn. 
55905, 

Non-invasive assisted ventilallon (NAV) with 
BiPAP™ (Respironics. Inc.) iias been advocated 
for use in pis. with hypcrcapnic respiratory 
failure. Problems with pt. intolerance due to 
mask fit. gastric distention, secretion control, and 
inadequate ventilation can produce 
unsatisfactory results with NAV especially in 
extremely obese pis. We successfully used 
BiPAP via tracheostomy in a pt. with respiratory 
failure due to morbid obesity, alveolar 
hypoventilation, obstructive sleep apnea (OSA), 
and COPD, A 53-year-old non-smoking male 
with chronic bronchitis and asthma had a 
height=5'8" (172 cm). weighl=675 lbs (307 kg) 
and receni spirometry showed FVC=1.78 L 
(40% pred), FEVi = I.O L (29% pred). and 
MVV=28 L/min (19% pred). Overnight 
polysomnography revealed severe non-posilionaJ 
OSA and hypoventilation. Nasal CPAP was 
unsuccessful and although nasal BiPAP resulted 
in improved sleep quality, severe hypoxemia and 
hypoventilation persisted. He was admitted for 
progressive dyspnea after futher weight gain 
with an arterial blood gas (ABG) on 2 L/min O2 
showing the Pa02=34 mmHg. PaC02=84 
mmHg, and pH=7.26 which was not improved 
with further nasal O2 and BiPAP adjustment. 
Following prolonged conventional mechanical 
ventilation, a permanent tracheostomy was 
placed, and he was weaned to nocturnal 
ventilatory support with BiPAP set in the "S/T" 
mode with rate=16 bpm and inspiratory (IPAP) 
and expiratory (EPAP) positive airway pressure 
levels=20 and 6 cmHiO respectively. An exhala- 
tion port was positioned in the circuit and a 
minimal tracheostomy cuff leak was allowed. 
Therapy was well tolerated and after 3 months, 
an ABG on 1 L/min O2 showed a 
Pa02=88 mmHg. PaC02=46 mmHg and 
pH=7.44. We conclude that nocturnal BiPAP via 
tracheostomy can be efficacious in COPD pis. 
with severe obesily-hypoventilalion syndrome 
unresponsive to non-invasive measures due to 
need for high IPAP level or minute ventilation 
settings. Advantages over conventional volume 
ventilation include ease of operation and 
portability, reduced cost, lack of sleep-disrupiing 
ventilator alarms, and better acceptance by 
family and other caregivers. 



COPD DYNAMIC MANAGEMENT IN 
"PULMO-CLUB" AND ITS ANALYSIS 
Lucjmila Borisenko . State S^ioitiif ic 
Research for FMlrronology . St 
Petersburg, Prussia. The purpose of 
the research was to make an attenpt 
of a long-term c3ynamic management 
in chronic obstructive pulmonary dis- 
eases (COPD) on the basis of reveal - 
ing main pathopl^sical mechanisms 
and correcting them in circumstances 
of long-term patients cfcservaticn in 
"Pulmo-Club." According to the 
results of multi-purpose examinaticn 
of 98 bronchial asthma and 64 COPD 
patiaits individual programs of a dis- 
ease management and its 
corprehensive rehabilitation were 
developed. These included the educa- 
tion programs different for both 
groups, smoking cessation, psychoso- 
cial assessment of patieits and their 
psychological treatment provided by 
a psychologist, optimum medical 
_ therapy in combination with non- 
remedial methods. Salutary influence 
of the ccntrollable microclinate with 
NaCl ions on the metabolic lung func- 
fiicn and the state of callecrein-cinini 
i"/stem was brought to 1 ight . The cor - 
relation between respiratory muscle 
force, hypeririflaticn, and perfusicn 
was demonstrated as well as their 
teing influenced hy AMBU Resistance 
Muscle Training Syston (Denmark) . 
[)ependence between the degree of 
obstruction and respiratory muscle 
force vras not registered. 
Plasmapheresis was applied under im- 
rrurralogical control. The results of 
dynamic examination affirm the pos- 
^iibility to attain clinical and functiovil 
stability, to ireiintcdn both capacity to 
irtork and quality of life. 

OF-94075 



THE ROLE OF STEROID INHALATION IN THE 
TREATMENT OF PATIENTS WITH STABLE COPD 
Chong Chen Lu RRT. MP . Guang Ming Shiao MD. 
Rcury Pcmg Pcrng MD, Chesl Deparlment. RICU. 



Introduction: It is gener^ly agreed that steroid therapy 
may add to the benefits ot adequate sympathomimetic and 
theophylline dosages in the subset ol COPD patients. The 
objective of this study was firsUy to find the edccl ol 
two kinds of inhaled steroid on airway hyperresponsivcncss 
and pulmonary (unctions. Secondly, tried to find an index 
as a guide to initiation of steroid aerosol treatment. 
Method: Alter measurements of baseline rc,, 

. FEV,. FVC. FEV,/FVC and BT 



(32 patients 
(31 patients 
daily. The 
after trealn^ 



ide dry powder 
, 400 ng inhalai 



signed I 



placed at P<0.05. 

Results: Sixty Hhree patients were completed 1 

For the whole group, all the 

significant difference between I 

treatment. With the same dose, two kinds of aei 

therapy also made no difference. The BT posiliv 



loline 
:r group 



I PC„ 



1 FEV, after 



sec Table) 



PC 


Base 


2 wks 


4 wks 


2 wks 


4 wks 




line 


aflcr 


after 


slopping 


slopping 


<mg/ml) 




drug 


drug 


dnig 


drug 


BT+ 


1.04 


1.23 


1.12' 


1.19 


0.95 


027 




(0.04) 


(0.44) 


(0.511 


(0.97) 


BT- 


3.72 


4.64 


3.47 


3.36 


2.95 


n:36 




(0.521 


(0.68) 


(0.59) 


(0.16) 


Tola! 


2.57 


3.18 


2.47 


2.43 


2.06 


0:63 




(0.091 


(0.401 


(0.391 


(0.32) 



leftt. Further study 



in patients with COPD. 



HEART-LUNG TRANSPLANTATION 
EN ITALY : LONG-TERM EFFECTS 
OF REHABILITATION PROGRAMS 

G.Callegari S.Brega, S.Bagliani, 
LZocchi, GPiaggi, F DeMaria, 

C.Fracchia, N.Ambrosino. ClinJca del 
Lavoro Foundation IRCCS. Centro 
Medico di Montescano (Pavia). Italy. 

The time-course of exercise, skeletal and 
respiratory muscle (RM) performance and 
of lung function tests was evaluated in 10 
patients undergone heart-Iiing 

transplantation (HLT) and observed at our 
Institution for rehabilitation programs. 
Rehabilitation program 'included: I) 
Supervised incremental exercise until 30 
minutes twice a day of continuous 
treadmill walking were attained (at 70% of 
heart rate achieved on a subniaximal 
treadmill test); 2) RM training ; 3) 
Resistive upper and lower hmb muscle 
training: 4) Education , 5) when necessary 

Postural drainage Patients completed in- 
hospilal and tailored rehabilitation 
program and were followed up to 18 
months after surgery Exercise tolerance, 
RM strength, limb muscle function, blood 
gas analysis and lung function tests 
improved after an in-hospital program of 
rehabilitation as follows (mean (SD)): 

admission discharf^e 12 m 



patients 


10 


10 


10 


FEVl,%pril 


56(12) 


63(171 


68(12) 


MIP.cmHJO 


54(21) 


60(23) 


75(17) 


MEP,cmH20 


58(10) 


70(18) 


100(40) 


6mwd.m 


351(66) 


422(60) 


511(100) 


lFX.Nxni 


28(12) 


33(11) 


44(7) 


lE.\.Nxm 


48(16) 


55(16) 


82(16) 


PaO;,mmM6 


70(10) 


88(10) 


80( 1 1 ) 



We conclude that improvement in 
exercise and muscle performance may be 
observed up to 12 months after a 
rehabilitation program in patients 
undergone HLT OF-94-105 



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should be homebodies. . . 




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The tiny 4.5 lb. OXYLITE-mini 
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Open Forum ABSTRACTS 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1 



We conclude: 1) invasive BLPAP can be 
included as a venlilaiory suppon option in ihe 
outpatient management of pediatric chronic 
obslniciive lung disease; 2) BLPAP ventilation 
s an effective mode of bolfi invasive and 
loninvasive home ventilatory support in 
hildrcn with chronic respiratory failure due 
■ wide range of clinical etiologies; (3) based 
D parent interviews, home BLPAP provides 
overall improvement in quality of patient aod 
family life by allowing fewer respiratory 

tions and improved nutritional status, 
daytime "energy" and sleep quality. r.cQ,ii = 



INVASrVt BILEVEL POSmVE AIRWAY 
PRESSURE (BLPAP) HOME VENTILATION FOR 
CHRONIC RESPIRATORY FAILURE IN 
CHILDREN. RW Brown. MD. MPH; EA Gradv. 
RRT: CI VanLaanen. RRT; IM Dean. MSN; EA 
Hurviiz, MD. VS Nelson. MD; DW Roloff. MD. 
Department of Pediatrics, University of 
Michigan Medical Center. Ann Arbor, MI. 

To assess the utility of chronic outpatient 
BLPAP use m children, we reviewed the 
records of 105 patients followed in the U of M 
Pediatric/Adolescent Home Ventilator Clinic, 
32 (30%) of whom used BLPAP as their mode of 
home ventilatory suppon. 15 (47%) of the 
BLPAP patients were ventilated via 
tracheostomy tube (it), while the remainder 
received ventilation via nasal mask (nm). 11 
(73%) BLPAP (tt) patients had obstructive 
pulmonary disease (OPD) +/• airway anomaly 
and 4 (27%) had restrictive respiratory 
dysfunction (RRD), including spinal cord 
injury, spinal muscular atrophy, and primary 
myopathy. The medians and ranges for age at 
initiation of BLPAP (AIB). daily ventilatory 
duration (DVD), span of BLPAP use, and levels 
of inspiratory and expiratory positive airway 
pressure (IPAP/EPAP) are presented here: 





<yrs) 


(hrs) 


(mos) 


(cm 
H20I 


(cm 


OPDtt 

(n=in 


.9 
0.4-1.7 


16 
8-24 


16 
7-24 


10 




RRD-tl 

(n=4) 


8 

OS-11 6 


8 
8-24 


14.5 
2-23 


11 


4 


RRD-nr 
(11=17) 


a 12 
2.1-16.7 


8 

8-24 


18 


12 


4 


All pts. 
(n-321 


5.1 
0.4-lfi7 


8 
S-24 


18.5 
1-41 


12 

4-20 


4 

3-12 



FEASIBILITY OF GIVING REGULAR ASTHMA 
MEDICATIONS IN SCHOOL- G Lawrence. BA. 
RRT . MW Mdlard. MD. Baylor Asthma Ccnlcr. 
Baylor Univcrsily Medical Ccnlcr. Dallas. TX 

Factors leading to increased asthma symptoms and 
school absenteeism include improper physician 
prcscnbing habits, lack of patient undersLanding 
about medications and asthma control, as well as 
non-compliance with presented medications Usmg 
NAEPP guidelines for appropriate management, our 
center, local nursing school faculty and a local 
elementary school evaluated the feasibility of giving 
inhaled anti- inflammatory (lAl) and inhaled 
bronchodilator (IBD) medication in school before 
(BS) and after school (AS) on a regular basis to 
Iwenly-two students with documented asthma 
Students, parents and students' private physicians 
were informed and consented to participate Students 
were randomised into two groups a) fixed dose of 
bcelamelhasonc II00ug/m21 and b) vanablc dose 
(either t00iig/m2 or 200ug/m21 based on measured 
peak now (PF) with lower dose given if PF > 80% 
of predicted, or after IBD if PF < 80% pre BD 
Algorithms using green, yellow and red 'zones" 
were created and served as a guide to medical 
mtcrvcnlion PFMi, medications and idcnlically 
appcanng algonthms were provided for 
weekend/holiday use. with compliance assessed by 
weighing returned canisters and review of home 
peak flow dianes Students were taught huw to 
measure PF, record data and Ukc medications 
properly using Acrochambcr At study inception, 
using two staff members, it took 15" for each child 
in (he Tixcd-doRC group and 30" for the vanablc- 
dose group (if PF < 80% , requinng IBD) to 
complete PF monilonng. recording and self- 
medication After four week*, it took less than 5" 
for students in cither group to complete the process 
if PFs were normal (green /one) and 20" if PFs in 
the vanable-doic group were < 80% predicted 
Several children could be monitored concurrently, 
and once studenU became familiar with all tasks, the 
entire process took less than 30' BS and AS 
Teachers, administrators and parents reported that 
participation did not negatively impact classroom 
participation CONCLUSION Using simple 
algonthms, it is feasible to administer inhaled 
asthma medicalioni to multiple students in school 
BID using minimal lupervmon and without 
interfenng with school routine Analysis of dau to 
assess improvement ( < symptoms, < absenteeism, 
< need for BD and > PFs) is pending. 

OF-94-1 



AN OXYGEN CONSERVING PEDIATRIC 
TRACHEOSTOMY TUBE 
Todd M. Austin. BS. RRT. RPFT . 
Mark C. Wilson. MD, Childrens Hospital. 
Department of Pediatric Pulmonology, 
Creighton University Department of 
Pediatrics. Omaha, Nebraska 

Oxygen delivery to tracheostomy 
dependent pediatric patients is inefficient 
and cumbersome. We assessed a 
tracheostomy tube (Portex) with a small 
bore hole through the lateral wall of the 
15mm adapter (Simms) to which small bore 
tubing could be luer-lock connected for low 
flow oxygen delivery. 
Ten oxygen and tracheostomy dependent 
patients were studied and served as self 
controls. Underlying diseases included: 
BPD, static encephalopathy, cerebral palsy, 
Arnold-Chiari malformation, and trisomy 21. 
Comparably sized adapted tracheostomy 
tubes were placed in the Pediatric 
Pulmonology Laboratory. Oxygen 
requirement and ventilation were assessed 
noninvasively. A follow-up 8 hour home 
trend oximetry was performed one to two 
weeks later. Four patients dropped out due 
to secretions (n=1), and non-compliance 
(n=3). One patient died secondary to an 
unrelated cause- 
There was a statistically significant 
decrease in oxygen requirement {p<0.05) in 
all patients (mean 1 Ipm). There was no 
significant change in Sa02, ETC02. 
TCpC02. respiratory rate or heart rate. 
There were no reported complications. In 
addition to substantial oxygen savings, 
other advantages of this device include 
ease of concealment and portability. This 
device merits further study. 



DYSPNEA AS AN OUTCOME MEASURE IN 
PULMONARY REHABILITATION Tnna 

Limberq. BS. RRT . Andrew Ries. MD. MPH, LeIa 
Ptewrtt, Robert Kaplan, PhD University of 
California, San Diego, CA 

Pulmonary rehabilitation helps patients vwth 
CORD to reduce symptoms, improve indepen- 
dence and increase functon Dyspnea measures 
can be important in evaluatng these patients Our 
goal was to evaluate dyspnea as an outcome 
measure of pulmonary rehabtlitaton and to 
examine fts relationship vflth other physiologic and 
psychosocial n 



METHODS \Ne used the UCSD Shortness of 
Breath Questionnaire (SOBQ) to obtain setf-re- 
porled dyspnea in 1 1 9 patents with COPD {FEV, 
= 1 2 L+ 5 SD) participating in a randomized 
tnal o( comprehensive pulmonary rehabilitatton 
(Rehab) versus education (Educ) with 6 years of 
follow-up Rehab included supervised exercise 
training, education, and psychosocial support 
Educ received education only Other physiologic 
and psychosocial measures used for these 
analyses included FEV,, maximal and endur- 
ance exercise. Quality of Well-Being (QWB), Self 
Efficacy for Walking (SEW), and the CES-D 
Depression Scale 

RESULTS There were no significant baseline 
group differences Baseline SOBQ was correlated 
(p<0 01) with FEV, (- 24), QWB (- 33), SEW 
(- 49). CES-D ( 37), maximum (• 40) and endur- 
ance (- 30) exercise After treatmenl, SOBQ im- 
proved significantly for Rehab at 2, 6, and 12 
months Mean(SD) 



Baseline 


2 Mos 


6 Mos 


12 Mos 


35 8 


27 2 


28 7 


29 2 


(185) 


(14 8) 


(15 9) 


(1741 


32 8 


33 9 


31 4 


32 3 


(192) 


(17 0) 


(19 3) 


(191) 



Rehab 



From 18 to 72 months. SOBQ was not different 
between groups Stepwflse. multiple regression of 
4 vanaWes (Group, FEV,, SEW, CES-D) in pre- 
dicting change in SOBQ indicated that only 
rehab group assignment was a significant pre- 
dictor of improvement in dyspnea 

CONCLUSIONS SOBQ is a useful instrument in 
assessing dyspnea in patients with COPD Pul- 
monary rehabilitation produced significant im- 
provement in dyspnea up lo 12 months of follow- 
up The effect diminished after 18 months 



I \ll I RI ( )r A DEMAND FLOW O: 
C()NSI.K\ ING DEVICE TO MAINTAIN SATU 
KAIION DURING ACTIVITY 
1 M Ha t;artv. MS. RN . W E Lungbcin. PhD. M 
Sknnidm, MD. C Hullman. PhD. J Fink, MS. RRT 
Hiiics VA Hospital and Loyola Univ of Chicago 
SiniLh School of Medicine. Hines IL 
Oxygen (Oijconserving devices may make extend- 
ed ambulation with supplemenlal Oi more feasible 
and reduce the costs of long-term home O2 provid- 
ed effective arterial oxygenation is maintained. To 
dctcmime the ability of oxygen delivery devices lo 
niainlain adequate Sp02 during Activities of Daily 
Li\ing (ADL's) we compared Uie standard nasal 
cannula (SNC). a reservoir nasal cannula (RNC) 
and a demand flow device (DFD) during five exer- 
tional activities with 16 COPD patients who were 
hypoxemic at rest (mean Sp02 < 88<7f ) with mild 
exercise , Subjects were male, age 68.9 ± 9, with 
40.2 ± 16 pack year smoking history, FEVj % pred. 
33.5±20.9. PaO; 57.2±4 mmHg with complaints of 
dyspnea on exertion. A five minute corridor walk 
was used to titrate oxygen flow rate to achieve 
SpO:of>88%(mean) with both SNC and RNC. 
The DFD was set to same flow as the SNC. Each 
subject used all 3 devices on separate occasions, in 
randomized order, during incremental cycle ergom- 
etry (CE) and a 4 station circuit simulating ADL (3 
mm rest between stations): 1 ) lift, push and carry 
(LPC). 2) undress and dress (U/D). 3) arm work 
above shoulder height (AS) 4) ascending and de- 
scending stairs (Stairs). Oxygen flow required was 
1 .8±0.85 Lymin (RNC) and 2.8 1 ±0.85 Umm 
(SNC).(p<0.0001), SpO; was 91.4+3.59^ during the 
last 30 sec on cycle exercise (pooled[mean of all 3 
visits]), with no differences among devices. SpO; 
decreased to significance with DFD during U/D 
(patient undresses removing shirt, pants, socks and 
shoes and redresses immediately) and decreased 
(p=.09) during AS . CONCLUSION: DFD may be 
less effective than SNC or RNC in maintaining 
SpO; during activities involing upper extremities. 
The five minute corridor walk and cycke do not ad- 
equately predict oxygen requirements during some 
,'\DL when using DFD devices. 

SpO; % (Last 30 Second at Each Station ) 



CE 



LPC 



U/D AS Stain. 
91 93 
93 93 



SNC 91 94 

RNC 92 94 

DFD 92 93 89 90 92 

p value 0,93 0.45 0.005 0,09 0,62 



Supported by VA Health Servici 
Research and Development 



EMERGENCY ROOM ASTHMA TREATMENT 
WITH POSITIVE EXPIRATORY PRESSURE 
(PEP) EFFECT ON HOSPITALIZATION Gary 
Gnidwel l. BS. RRT , Linda D KJcm. RRT. Gen 
Brosbc. BS. RRT. Jerome Ta>lor, CRTT. Cccih 
FitzGerald. MD, Edward Jasper, MD, HcrtJcrt 
Patrick. MD, Departments of Emcrgcnc> 
Medicine and Respirator. Care. Thomas Jefferson 
UniNcrsitk Hospital. Philadelphia. PA 
INTRODUCTION To determine if posiU\c c\pirator> 
pressure (PEP) added to small \olumc conventional 
ncbuli/er (SVN) treatments would decrease hospital 
admissions of asthmauc patients from our Emergency 
Room. «e conducted a prospective, randomi/ed, 
ph\sician-nursc-patient-blmdedstud> METHODS 25 
patients (18 vcars or older) were enrolled into our IRB 
appro\ed stud> This sample population was divided 
into t\io groups. PEP and NO PEP Both groups were 
given idenucal set-ups consisting of a SVN and a PEP 
(AMBU) attachment covered with a cardboard shroud 
All patients received ? SVN treatments with 2 5 mg 
albuterol and 5ml NSS. 20 minutes apart \ la 
compressed air PaUcnts were randomi/cd lo receive 
either HI cm H.O PEP (n-12) or received NO PEP 
(control. n-H) Data collected (pre/post) peak 
e.vpiratorv flow rates (PEFR). pulse o\imetr>. sputum 
production, pulse rate, and a 10 point subjective 
breathing scale ( I being the worse and 10 the best) 
RESULTS Of the 2? patients studied, 4 were 
admilled The mean PEFR "o increase for both groups 
were not signincanlly difTcrent However, a subgroup 
comparison of patients with pre-PEFR's < 200 L/min 
showed (n- 14) 

PRE-PEFR < 20(1 L/min PEP NO PEP 

n ADMin'ED 4 

« NOT ADMITTED h 4 

{p<(l 0^ b> Chi squared! 
Three of the 4 NO PEP paUents w ho were admitted 
had a mean PEFR increase of onI> 2(."rt (SDt.U ')) as 
compared to the 6 PEP patients not admitted with '>4"b 
(SD171 5) and the 4 NO PEP patiems not admitted 
with Hli"o(SD±l'> 6) There were 4 patients with a pre 
treatment subjcctnc breathing score of -^ .'• who did 
noi increase b> 3 or more post treatment. 1 were in the 
NO PEP group and I was in the PEP group 
CONCLUSIONS PEPthcrapv significanth decreased 
hospital admissions for the group of patients with 
PF.FRs- 200L'min Also, the mean PEFR "o 
increase wa.s lowest for the NO PEP admitted group 
The PEP group had greater subjective improvement 
for those patients with a pre-ircatmeni subjective score 
of < 5 np-qd- 99 



RESPIRATORY CARE • NOVEMBER "94 Vol 39 No 1 1 



Open Forum ABSTRACTS 



SUCCESSFIL ISE OF THE BlPAP' MACHIVE IN 3 
VEAR OLD TWINS ELIMINATING THE NEED FOR 
TRACHEOTOMY AND OXYGEN THERAPY-KaI.e 

Sabaio MS RRT. John McOuiiry. MD, Children's H.ispital 
Oakland, Califorrua 

Thrtw year old twins were scheduled for uacbeoioniy B(Hh 
n*ins suffered severe COj reiennnn and oxygen depnvaiion 
when asleep due to a genelic defea. Crouzons. which 
results in progressive obstruciiOD of the upper airway due 
to excessive dssue growth The rwins were sleep deprived, 
had severe night sweats, nionung headaches, and were ofien 
agiiated and cranky ihioughoul the day Prior lo 
tracheotomy, the twins were evaluated for use of BiPAP" lo 
reduce the severe obstrucove sleep apnea The children 
were sedaied in our Pulmonary Function Lah with 
chlorohydrate and monitored on and off BiPAP" wiih the 
uses of (VCO, mass specffonieiry. Oj/CO, TCM, pulse 
owmetery, chest and ahdominat respidace. and EKG 
monitor The Iwuis were fust place on (be EPAP/CPAP 
mode, however both pnent's exhibited penods of 
desaiurations assixiated with bypopnea To eliminate the 
desaiurations, the BiPAP" system was placed m the 
Sponuneous mode to deliver a pressure support of 8, PEEP 
of 4 cmHjO The tables below represent mioal sleep snidy 
results prior to BiPAP* and afier 2 weeks of home BiPAP* 
Of interest, during the second sleep study, the twins did not 
require sedaDon as they readily placed their mask on 
themselves and look their naps The twins have been home 
for one month on their BiPAP machines and have 
completely normalized their sleep paiiems Mom reports no 
mght sweats, a deaease in mominf: headaches, ihey are 
alen and energetic during the day and are now gauiuig 
weighi appropriately 




TWl^ 1 StXEfTMi 




ONB**f 




F.0, 


J..0O. 


Jl 


E»>T^C«B^, 


«.>», 


>•_» 


rcMCO, 


n_^, 


J1_«, 


O.S.r«»« 


»«. 


911 


Rop^lc^ «.- 


n 


1! 


Ha"R.« 


mm 


mm 


0<»™.., ,p.,«l«. 


™„ 


», 


S^n^ 


,.»«x.J 


n. 


CBC WLirQ„o,i 


5»-)>-)I 


7J*!VW 




r — ~i 




n» 




„ 


i^r^„^„. 


ts..x. 


11_»l, 


ICMCO, 


■S «.H, 


••..H, 


C^S,r«D« 


ant 


^1 


l.=p«c^ «.. 


» 


1. 


M„l>.. 


.IM!1 


I«.lll 


o«™,., w.j= 


„., 


=. 


s..™. 


„^^ 


,„. 


CBCijtOLai 


ni4t.M 


1.^.1 « 






OF-94-232 



ADAPTION OF A BIPAP FLOW OBNEBATOR TO 


PROVIDE INFANT NASAL CPAP FOR HOME CARE. 




Haven Hospital, New Haven. Ct, 








provide Nasal CPAP 




They are complex. expensive and require 


high capacity gas supplies to operate. 


making them difficult for home care 


application. Described here is a low 


cost adaptation of a commercially 










unit model S/T-D was 








used to monitor NCPAP and high/low alarm 


pressures. A Fisher i Paykel MR 428 


humidifier provided moisture. Oxygen was 


bled in just after the BIPAP unit and 


was analyzed at the humidifier. We were 




other systems in which the set flow 


regulates the CPAP, this system allows 


the set CPAP level to regulate the flow 






clinical observat 


ion of patient comfort. 


RR, ABG-s, SdO, and CXR . Experience ; We 




of Homozygous Achondroplasia (dwarf ism) . 


Normally fatal in the neonatal period. 


vigorous support may extend life 




weaned and extubated to Nasal CPAP. 


Repeated attempts to wean to Nasal 




increase work of breathing, and 




stabilized, the parents requested he be 


discharged to home on NCPAP. After 2 




system and thorough training of all 


caregivers. the infant was discharged to 








provt 


de patient comfort and ventilatory 1 


support easily in the home setting for 


th,s terminally ill infant. 


"■""" = [H] 


• ^-[o] 


lo o| Jy<"^' 




1 °l=:^ 


^^ / / 










..„ I 


_(_,_,^^^ij^U^ll^. 






^"..-^]\5- 


&S^. 


OF-94-246 



THE QUALITY OF LIFE IN PATIENTS WITH HOME 
MECHANICAL VENTILATION 

Mauo-Ymg Bien MS RPT CR'IT Ling-Lmg Chiang BS 
RPT RT. Jia-Homg Wang MD. Chia-Chen Chu BS RT, 
Ling-Yee Cheng MS Vclenins General Hospilal- 
Taipci. Taiwan. Rqjublic of China 

lolroduction: Although improvmg quality of life (QOL) 
IS quoted as the major benefit of home mechanical 
ventilation for ventilator-dependent patients, few studies 
have investigated m this topic The purpose of this study 
13 to mvestigale whether the life quality of ventilator- 
dependent patients could be improved after using home 
mechamcal ventilation when compared with staying m 
the hospital Metbodi: Thirty-four adult, ventilator- 
dependent patients cared at home ( 1 9 males and 15 
females) were mcludcd m this study A semistructured 
questionnaire was used for assessment of four 
dimensions of life quality activities of daily livmg(ADL), 
family relationship, social role function and emotional 
function The level of ADL was assessed by the modified 
Barthel Index Scoring system, while the other 3 
dimensions were assessed by a 5-point Likcrt type scale 
which validity and reliability were tested All patients 
and care-givers were interviewed by a tramed respiratory 
therapist and answered all the questions m the questioiaire 
by giving scores to all dimensions of life quality when they 
were hospitalized and at home Oata were expressed as 
mean (SD) Paired t test was used to compare the results, 
PO 05 was considered to be sigmficant Reiulti: 

QOL Dimensions In Hospital At Home P value 

Barthel ADL score 1985(21 72) 2441(2969) 0.0507 

Farmly relationship satisfaction to 
farmly 3 51 (0 75) 3 85 (0 77)0 0101" 

spouse 3 88 (0 86) 3 94 (0 90) 3322 

Social role function satisfaction to 

fncnd 3 41(0 95) 3.83(0 71)0 0157* 

leisure aclivily 2 68 (0 82) 3.36 (0.78) 0.0021 * 

activity level 1.59 (0 92) 2.24 (1.37) 0.0005' 



•P<0 05 

There was no sigmficant change in ADL and satisfaction to 
the spouse wlien the ventilator -depentent patients were 
moved from hospital to home However, the social role and 
emotional functions improved significantly when ventilators 
were used at home The satisfaction to the family members 
improved as well Concluiion: The quality of life m patients 
with home ventilators did really improve when compared 
with that w the hospitals 

OF-94-25C 




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To order yours, 
call (214) 243-2272 or 
Fax (214) 484-2720 with 
your Mastercard or VISA 
number, or send your 
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AARC, to: AARC, 11030 
Abies Lane, Dallas, TX 
75229-4593. 



(Lapel pin is shown actual size, but Rex is a towering 8 inches tali) 



item CV1 Lapel Pins— $5 
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1073 



An Innovative Soluhon 




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Simplifies reading of Peak Expiratory Flow Rate (PEFR) 
One unit satisfies the standards for both children and adults 

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Reliable and accurate readings - 
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Prevents inadvertent changes to the 
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Open Forum ABSTRACTS 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 



VALIDATION OF A NOMOGRAM FOR 
CONTROLLING C02 DF.LIVERY DURING 
MECHANICAL VENTILATION 

Susan Anderson. RRT. Roben L, Chalbum.RRT. 
Rainbow Babies Hospital, Cleveland. OH. 

Posloperauve cardiac pediatric patients are 
sometimes given C02 to manipulate pulmonary 
vascular resistance, thus affecting pulmonary vs 
pcnpheral blood flow (Ann Thorac Surg 
1992;54:150), We devised a double blender system 
for controlling FiC02 and Fi02, System equations 
were denvcd and a nomogram constructed to predict 
settings for desired FiC02 and Fi02. This study was 
to assess the agreement of nomogram values with 
measured gas concentration values. METHODS: 
Two Bu-d 02 blenders were connected in senes. The 
first (o) was supplied by C02 and air and fed uito 
the second blender (P), also supplied by 02. 
Predicted values of FiC02 and Fi02 were compared 
to values measured with a Daiex C02 analyzer and 
MiniOX 02 analyzer. The MiniOX was used as a 
clinical rather than a laboratory standard. Analyzers 
were calibrated with standard gases. Blender 
cahbrations were verified with an 02 analyzer from 
a metabolic carl. Usmg nomogram-denved blender 
settings. 8 levels of 02 (20-75%) and 8 levels of 
C02 (1-9%). in random order, were analyzed in 
triplicate. The mean and standard deviation of 
differences (predicted-measured values) were used 
10 esumaie upper and lower agreement limits. 
System equations: 



--='4-'^^^S^-^^-- 



_ , ^■, (l-ppO2)(Q.85FaO2-0.18) 
nuu-:-!.^/ o.82-0.15Fa02 

RESULTS: The agreement interval (mean 
difference ± 2 standard deviauons) for predicted 
minus measured FiC02 was 0, 1 ± 0,8 %. For Fi02 
near 21% agreement was -0.7 ± 0.2 %. For higher 
Fi02s the agreement interval was 4.1 ± 2.2 %. 
CONCLUSIONS: The agreement intervals for 
FiC02 and Fi02 were clinically acceptable. The 
nomogram should be an efficient bedside tool for 
the clinician, expediting system set-up and changes. 



DYNAMIC COMPUANCE DECREASES 
DURING OPEN HEART SURGERY IN 
CinLDRKN 

B<: Wilson. RRT. F Kern. MO. J Meliones, MD. 
Duke University Medical Center. [)urham, NC 

Respiratory dysfunction after surgery for 
ronf>eniUil heart disease in children can lead to 
signincanl morbidity and mortality. The effects of 
cardiopulmonary bypass (CPB) on respiratory 
mechanics have be«n difncull to obtain in the 
operating room, until recently. Portable, on-line 
devices are now available which allow precise 
measurement of lunf; mechanics. This study 
investigated the efTect of CPH on airway resistance 
and dynamic compliance using a mobile 
respiratory mechanics device. MKTIIOn: 23 
children, who underwent CPB fur surgical 
correction of congenital heart disease were 
studied. Ages ranged from 1 week to 48 months. 
Body weights ranged from 2.9 to 2J.9 Kgs. A 
stand akine respiratory mechanics monitor 
(Ventrak, Novametrix Medical Systems Inc., 
Wallingford, CT) was placed in-line with a 
conventional anesthesia ventilator (Draeger IIB, 
Oraeger, Inc., Chantilly. VA| in the operating 
room. PKKP was held constant at 4 cm 1120. 
delivered tidal volume wa.s adjusted to Iti ml/kg, 
before and after CPB. No changes were made in 
Row rate or pattern. All patients had an open 
chest via median sternotomy. Airway resistance 
<Raw) and dynamic compliance (Cdyn) were 
measured immediately before and after CPB. 
Values were averaged over a five minute study 
peri(»d. Results are listed as the mean value +/■ 
standard deviation. Student's paired l-lesi was 
used to assess inlra-grniip differences. A p-value 
of < 0.05' was considered tignificanl. Ri-SULTS: 
In the prt^hypass period, mean dyn. 



™iplia 



and a 



I ml/cm 
, respectively. After 
decreased IS% 



Il2()and l.t? ml/1120/1. 

CPB. dynamic complia 

(p = .00H6)*, changes in airway resLitanc 

signifiCRnt (p = .59l2). 

Before CPB After CPB 
Mean Cdyn 6.1 + 1.3 5.0 + 

Mean Raw 1.17.4 + lO.U 143. 2_t I; 
CONCLUSIONS; Ahnormalilies of lunx 



after CPB are common and cii 
difTirully in the imme<liNte pos 
%ltidy suggrsLs that a signinrai 
compliance occurs after CPU. 
directed at improving complia 
warranled. Mobile bedside pii 
until were brnericial in dritvli 
and dirfTting Ihnr inlervenlio 



nlrihute to venliUtory 
1 CPB period. This 



t (he abnnrmalilicn 



EFFECT OF PEEP IN CONGENITAL 

DIAPHRAGMATIC HERNIA 

l.vnneK Bower RRT . John H. Arnold MD. 

John E. Thompson RRT. Patrice Benjamin 

RRT, and Jay M. Wilson MD 

Children's Hospital • Boston, MA 

Introduction: The high risk congenital 
diaphragmatic hernia (CDH) infant 
continues to be a challenge to ventilate. 
Little has been published on the u.se of 
PEEP in these infants post-ECMO. We 
evaluated the effects of PEEP during trials 
off of ECMO on lung compliance (Cdyn). 
physiologic dead.space (VDAT). PaCOo and 
Pa02 in CDH infants. Methods: 

Patients were sedated, paralyzed, and 
ventilated in the pressure control mode on 
the Servo 900C. Standard ventilator 
setungs were a PIP/PEEP of 30/5 cm H2O 
and a rale of .10 breaths/min. Cdyn, VDrVT 
ratios, and arterial blood gases were 
obtained during routine separations from the 
ECMO circuit. PEEP levels were lowered 
to 2 cmH20 while maintaining the same 
peak inspiratory pressure. Measurements 
were then repeated. Results: Seventeen 
CDH infants who required ECMO were 
evaluated. There was a significant 
improvement in Cdyn (p=.006), VD/VT 
(p=.011). and Vt/kg (p<.001) when 
decreasing the PEEP from 5 cmH20 to 2 
cmH20. The PaCOi also significantly 
improved on a lower PEEP (p=.02), 
hovever, there was no significant difference 
in the Pa02. Discussion: We conclude 
that both VOWT and Cdyn in the CDH 
infant significantly improves on low levels 
of PEEP. Concurrently, the lowering of the 
mean airway pressure does not adversely 
affect the Pa02. This suggests that PEEP 
levels greater than 2 cmH20 worsens 
physiologic deadspace and compliance 
during trials off of ECMO potentially 
altering the clinical assessment. Future 
studies will be directed to determine whether 
it is the anatomic and/or alveolar deadspace 
that increases with higher PEEP levels. 



INTRAOPERATTVE MEA.SURES OP DYNAMIC 

COMTI-IANCE 1NCRF.A.SE WITII 

OPEN CIIF.ST VENTII.ATION IN ClIILnREN 

BC Wibon.RRT .F Kern. MI), J Melmnes.Mn. Ouke 
UniversilJ M«lic«l Cenur, niirhum, NC 

MechanicAl venlilnlion wilh an open chesl occurs 
daily in Ihe oprralinf; room for children who 
undergo repair of complex cardiac anomalies. The 
efTect of open versus closed chest mechanical 
ventilalion on respiralnry mechanics ha>e previously 
been dirTicuIl to ohtain in this population. Bedside 
devices are now available which allow precise 
measurement o( lung mechanics. This study 
investigated the effect of intra-operative open versus 
closed chest ventilation on airway resistance and 
dynamic compliance using a mobile respiratory 
mechanics device. MF.TIIOD.S: 16 children who 
underwent surgical correction of congenital heart 
disease were studied intraoperatively. Ages ranged 
from I to .10 months. Body weights ranged from 
2.9 to 14.8 Kgs. A stand alone respiratory 
mechanics monilnr (Ventrak, Novametriv Medical 
.Systems Inc.. Wallingford, CII was placed in line 
with a conventional anesthesia ventilator (Oraeger 
IIB, Draeger, Inc.. Chantilly, VA). Airway 
reslstanrr (Bawl and dynamic compliance (Cdyn) 
were measured immediately before aod after mediao 
slernnloiny. I'Kl.l" was held constant at 4 cm 1120 
and delivered tidal volume was adjusted to 10 
ml/kg. No chaoges were made in now rale or 
pattern. Measurements were averaged over a five 
minute study period. ResulLs are listed as the mean 
value +/. standard deviation. .Student's paired t- 
lesLs were used to assess intra-group difference. 
A p < O.O.'i was considered signifu-anl. K l-:,Sll| ,TS: 
Mean dynamic compliance and airway resistance 
with chest closed were .S.2 inl/cm 1120 and 147 
ml/l./sec. Dynamic compliance increas.,d 17% wilh 
the chest open (p= .020)-. change* in airway 
resistance were not signincanl (p = .tS0721. 

Cheit ClKinI <:heil Opeii 
Cdyo ."1.2 + 0.7 6.1 t I ■'• 

Raw 147+11.7 1.17 + in.l 

CONCl.ti.SIONS: This stiiily suggests that dynamic 
compliance increases with open chest mwhanical 
ventilation. Assessmeot of improved compliance in 
these children li warranted. Due to the increase iii 
rnmplianre and tidal volume with chest opening, we 
ohservetl instances of lung nver-dislention (6/16. 
34'*) when conventional tidal volume strategies were 
applies!. The improvement in compliance with chest 
opeing may actually he deliterious if prarti<mers do 
not identify and attjtist for changes in polmnnary 
mechanics ■ntra.operatively. 

OF.94-I3I 



THE CORRELATION BETWEEN FLOW RATE. ET 
TUBE DIAMETER. POsnTVE PRESSURE. AND TIDAL 
VOLUME IN A NEONATAL MECHANICAL TEST 
LUNG Lon J Wen BS. CRCP. Lisa J Schuli BS. CROP 
Rcaptratory CaxK Services. Mcrib^art MolicaJ Center - 
Fargo. Nonh Dakota 

Inlnxjuction The cflcct of flow rate on tidal volume 
dclivcied. thiDugh very small mfani endotracheal ttjbca. has 
not been ajmplctcly studied Hypothesis We hypothesized 
that an mcrcaae in flow. Ousjugh very small cndouachcal 
lut^cs. would dcLvcr a larger uda] volume Evaluation 
Methods A bench study fomiat was designed lo eshaust- 
ivcly sujdy the relationships of PIP. PEEP, flow, and ET 
tube diameter on Udal volume delivered A Scchnst IV l(X) 
B (time cycled, pressure hmilcd) inlant ventilator set at a 
rate of 40 bpm and IT of 35 sec. and Mictugao Insuuments 
TTL sunulator set with an mfaot lung (compLa/Kc of 005 
Ucm/H:0. and a lesisUincc of 50 cm H20/tJs) were used 
m this study Positive pressures nuigcd from PIPs of 10 to 
30 cm H20, and PEEPs of 2. 4. and 6 cm H20 Rows 
tested WTie 4, 6. 8. and 10 1pm Tidal volume was measur- 
ed usmg Pnucmoview software from a TTL. cahbmled to 
manufacluie's tecommendauons Mallinckrodt brand Lt t 
sizes lungcd from 2 5 lo 4 ID. each 13 cm m length 
Evaluation Results The results revealed that once the 
How to generate desired PIP was met. further 





ISC in flow did n 


ot resull in 


ncreaacd 


tidal 


volume. 




TV remained l 


^K same, or 


decreasec 


significantly. 


Thcr 


nost significant 


TOults were 


shown wi 


ihs 


^25 ET 


tube. 


We found up U: 


a 22% dec 


r^xsc in tidal 


olumc whc 


flow 


was increased o 


CT ihc minir 


num flow 


req 


uired to 


pn>Ju 


ce desired PIP (See Graph) 










Conclusion This data suggests that equal or greater tidal 
volumes may be delivered al lower flow rates. These lower 
flows may provide for Iowct ventilating pressures This 
could potentially roiuce the likelihood of some 
complications due to mechanical ventilation, such as 
barotrauma, pneumothorax, and prolonged intubation. 

OF-94-070 



COMPARISON OF MEAN AIRWAY PRESSURE 

MEASUREMENTS IN THREE INFANT 

VENTILATORS 

OQ Wilson. RRT; Hnkf Univrrsily Medicnl 

Cenler.Durham. NC 

Mmn airway prn^ure (MAP) ^ ii^H clinically lo 



tilalnry reqiii 



and t 



ventilHtnr management strategies in infants.The 
accuracy of MAP comparison tMHween ventilator 
maniiraclurers is unknown. MAP measuremenU 
reported by three infant Tenlilators were compared 
using an infant lung model to determine the intra- 
■nd inter-Tenlilator accuracy of MAP valties. 
METHOnS:The VIP Bird{VIP) (Bird Products 
Corp.), Rear-Cuh(BC) (Rear Medical Systems, 
Inc.), and Infant Star OS) (Tnfrasonics. Inc) 
ventilators were operated in (he time^ycled, 
pressure limited, IMV mode wilh a non<omplianl, 
small-bore ventilator circuit. PIP, ventilator rale, 
and inspiratory flow and time were varied to 
simulate increasing ventilatory reiju 



t held c 



I 100 



cm 1120 ll.lset. Lung compliance was held constant 
at I ml/cm II20. Simiillaneoiis MAP valuer were 
recorded from each ventilator and a Novametrix 
Pneiimogard (Novamefrix Medical Systems, Inc.) 
monitor off the provimal airway pressure line of the 
icy of the Pneiimngartt was 



rined I 



ansditi 



and planimetry (r = .<»9). Vjtch ventilator was 
compared lo (he Pnetimogard, and then the other 
ventilators, using miilliple linear regression. 
Ri:.StlLTS: MAP reported by each ventilator versi 
the Pnruinogard had high correlations (VIP Rird r 
= I.O, Rear Cub r - 1.0, Infanl.Slar r = I.O). 



npan 



( betw 



lilators varied 



-.►efncie 

and was lower (VIP Hird/Rcar Cub r ^.^O, 
IntantSlar/VIP llird r = .95, Hear Cub/Infant .Star 
r = .9ft). 

Table I. Ventilalor vs. Pntuinog ard 
Rear Ciib y = .94x + 2.24, r = 1.0 

VIP Rird y = .97x + 1.8.1, r = 1.0 

Infant Star y = l.0.1« -0.0.1, r = l.fl 

Table 2. V ynlilator vs. Ventilator 



RC vs.lS 



1.31k 



(-4.68), 



.9ft 



IS vs. VIP y = l.2.S« + (• O.ftS), r = .95 

VIP vs. RC y = I.OSk + 1.7ft. r = .90 

CONCLUSIONS: MAP reported by three infant 
venlilalors rompared to an external measurement 
standard are highly reliable. Inlrr-venlilalnr 
comparison of MAP is not as reliable. If ventilators 
must be changed lo a different manufacliirer for a 
given patient, MAP valuer should he compared lo 
an external measurement standard tn farililale 
inlerpretalinn between venlilalors. __ _ ., 




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Open Forum ABSTRACTS 



RESPIRATORY CARE • NOVEMBER "94 Vol 39 No 1 1 



SYNCHRONIZED ASSISTED VENTI- 
LATION OF INFANTS(SAVI) : 
EXPERIENCE AND EFFICACY; 
N.Visveshwra,M. D. 
B. Freeman, CBET; W.CaliwagRCP 
M. Peck, MSN, Valley Childrens 
Hospital, Fresno, CA. : 
SAVI, using modified 
impedance technology was 
applied to sick infants 
over a three year period. 
The respiratory output 
signal from a neonatal 
monitor was processed 
through a ventilation 
synchronizer to trigger a 
Sechrist 100-IVB ventilator. 
On active exhalation the 
ventilator cycling ceased. 

Survivors 96/110 (87%) 
<500g: 2/3 (66%) 
<750g: 36/41 (88%) 
<lkg: 32/33 (97%) 
<2kg: 20/25 (80%) 
Of the 110 cases: 
Inadequate trigger: 6 (5. 4%) 
PIE: 8 (7%) PTx:6 (5%) 
IVH <II:6(14%); <IV:3(3%) 

Randomized study comparing 
SAVI vs. Conventional 
Ventilation (CV)+ Exosurf 
surfactant on infants with 
RDS (a/A<0.22) was then done 
Results: 

SAVI CMV p 
Wt.(g) 914+37 1033+37 NS 
a/A admit0.13 0.11 NS 
a/A 6hrs 0.2 0.2 NS 
01 admitl2.6 13.9 NS 

01 6hrs 7.3 13.0 NS 
Vent. days 20.6 31.4 <.05 

02 days 26.3 43.9 <.05 
Ptx. 6% 19% NS 
IVH>III 8 
Deaths 3/34 12/42 <.05 
Charges S4486K $5409K 17% 
RT " 45. 9K 54. IK 15% 
CONCLUSION: SAVI decreases 
mortality, IVH and air leaks 
with cost savings. OF-94-1. 



A COMPARISON Of TECHNIQUES FOR DETERMINING 
RESISTANCE OF TWE REPIRATORY SYSTEM (Rrs) IN 
INFANTS AND CHILDREN RECEIVING MECHANICAL 
VENTILATION. John Snlvr RS RRT Kaihryn Poll 
RRT . Respiratory Caie Service, Primary Childrens 
Medical Center. Sail Lake Cily. Utah, 
INTRODUCTION: The Infrasonics Star Calc 
Pulmonary Diagnostic System reports total Rrs using 
two different formulae: (1) mid-volume (MVRrs) and 
least squarcsfLSRRs)- We use the term "respiratory sys 

termined using transrcspiratory pressure, not transpul 
monary (no esophageal manometry was employed) We 



lughl t 



s for Rfts reported by these 
METHODS: We retrospectively rcvie 
pulmonary function let 
in our NICU and PICU 






excluded for (1) airway 1 
(3) if the least squares c< 



1 July 91 and April 94 
ileal breaths only and wcr 
10%. (2) generally poor 
or patient dysynchrony, 



: test with sigmncance set at < 0.05. We then 
Id die dau according to mid-volume R,s. to dc 
if differences were more pronounced when Rrj 
;her. RESULTS: 84 snjdies were reviewed, of 
lb were eacludcd |8 for bad quality. 18 for leak > 
lone tot correlation coefficient < 0,91, The uble 
lists the values of mean, (standard deviations), 
ngcl; 

All Pts with Pts with Pts with 



Age 
months 


(58) 
|1-2:«| 


11 2281 


|1-2'28| 


m'-'Ai 


Wt 
Kg 


10 

(11) 

11 501 


1) 

(12) 
11 50| 


(38) 
11-501 


(J) 
12121 


Vt 
inL 


129 
(121) 


179 
1148) 

in 5.151 


(38) 
111 1«9| 


57 

(30) 
115 1211 


MVRks 
cm/L/s 


(52) 
12-2811 


)6 

12 5il| 


152 9 11 


1102 28 11 


LSRk, 
cm/L/s 


(501 


l''-'«l 


|-1(,94| 


|l(»l-2«.| 



Hire were itaiiiiically iinnihtani iiiilcrcncci ociwccn 
i iwn icchniquc* (P<0 05) in all tirali csccpl in ihoic 
t with Rks^I If^^cm/Ui. DISCUSSION: As 
own in the tabic, ihc actual magmiudc or ihc diffcT- 
cGi arc probably nni clinically important considcnnii 
B high degree of the intra- and inter pi vanabilily be 
i reported for bcdiide pulmonary mechanics tystems. 
lui. It appcori that there ore no important differences 
how ihc*c lechniquci determine Rkj. although 
ti«i«tanlly reporting ihc »ame value for Rns "'^uld ** 



TRIGGER SENSITIVITV OF FOUR PEDUTRIC 
VENTILATORS DURING PRESSURE SUPPORT 
VENTILATION AND CONTINUOUS IN-LINE FLOW 

r go I anpga. BS RCP RRT. David Carton RCP CRTT. 
Mark Rogers BS RCP RRT Tom Malmowski BS RCP 
RRT. Loma Lmda University Children's Hospital. 
Department of Respiratory Care, Loma Linda, CA 
Introduction: Continuous in-linc flow has been shown to 
inhibit tnggcnng of supportive breaths dunng pressure 
support ventilation (PSV) in an adult model We equipped 
four vcnlilalors (Sicmcns-Elcma Servo 900C. Puntan- 
bcnnen 7200ae. Newport Medical WAVE, and Bird VIP) 
for pediatric use and evaluated their breath tnggcnng 
capabilities dunng PSV with continuous in-line flow 
Method: The ventilators were set 10 deliver a pressure 
support breath of 10 cn\HiO with PEEP Breath 
tnggehng was fixed at the most scnsiuve setting without 
auto-cycling the ventilator To simulate patient effort, one 
half of a dual-bellowed lest lung (compliance 04 U 
crnHjO ) was ventilated with a Servo 900B set on 100 ml 
tidal volume every 3 sec We used two different inspiratory 
percent times (20'''o and 50%) Measured mean inspiratory 
flows at these inspiratory times were 1 5 8 and 7 7 LPM 
respectively The other half of the test lung was connected 
to the test ventilator via a 4 endotracheal tube 
Continuous flow was added to the inspiratory limb of a 
pediatnc circuit 1 5 cm from the patient wye at 8 LPM 
Each ventilator was evaluated to determine if continuous 
flow would adversely affect the ability to tnggcr a pressure 
support breath A vanable onfice pncumotach was used to 
record pressure, flow, and volume from the test ventilators 
and Servo MOB Results: All ventilators tnggcred a 
pressure support breath without the continuous in-line 
flow With the addition of in-line flow, only the WAVE 
tnggcred at both inspiratory limes. The VIP triggered only 
at the shorter inspiratory time and higher inspiratory flow 
rate Both the 900C and 7200ae failed to tnggcr during 



continuous tn- 


incflo 


w 










900C 


7200 


7200 
fb 


WAVE 


WAVE VIP 
bf 


20% IT nf 


Y 


Y 


Y 


Y 


Y Y 


S0% I T nf 


Y 


Y 


Y 


Y 


Y Y 


20% I T flow 


N 


N 


N 


Y 


Y Y 


50% IT now 


N 


N 


N 


Y 


Y N 



n>=flow-by at 5 LPM bf= bias flow at 5 LPM. IT - 
inspiratory times nf=no flow Y= pressure breath 
triggered N= no pressure breath triggered. 
ConclusioD): The sensitivity mechanism of vanous 
ventilators may be inhibited by the introduction of 
continuous in-line flow A failure to sense patient effort 
and deliver supported breaths could lead to clinical 
deterioration, Tnggering sensitivity with in-line flow may 
vary with different ventilators, and caregivers must have an 
s of this variation. 

OF-94-174 



EVALUATION OF DIFFEREKT TVTES OF PEDIATRIC 
NEONATAL VOLUME MOmTORS. I.m K^nMi, BS. 
RRT. Joanna Lvnch BS. RRT, Jobo Salyer BS. RRT 
Primary Children* Medical Center. Salt Lake City. UT 
tNTRODUCnON; Volume moniiors arc now 
available thai are reported to work in Ibc neonaiaJ & 
pediamc range Wc sought to bench lest the 
performance of the Bear Neonatal Volume Morutor 
(NVM). and ibe VIP Partner Hi. METHODS: 5 
Partoer Oi* were tested using new mfaol & pediatric 
tensors (for flows of < 20 Urn A > 20 Urn 
respeccivelyl. 7 NVM'i from our currenl working fleet 
were i£sl£d All monitor? were calibrated in accordance 
with manufacturen rccommeDdations Both devices 
were tested agamsi a resistive onficc 
poeumotacbograpb [Star Calc. Infnsomcs Inc. San 
Diego CA). which was calibrated volumeincaiiy 15 
breaths for each monitor were compared lo the Star Calc 






was used for the NVM's which was equal 
tnstrumeai readmg x 12 (Salt Lake City 
ft) Bear pubLsbcs 



factors. Bird d 



used for the Qi's T 
Qi pediatnc lensor must be placed at the eihalalion 
valve instead ai the proumal airway (as with the 
Deooatal sensor) Thus, when such a placement was 
used, volume lost lo circuii comprcAsi 
and subtracted fium readings Differences under c 

set at 05 RESULTS: Data are reported as me. 
(standaid deviation 



TEST 

CONDmONS 
Mode 
SeiVt(mL) 

PIP (cm H201 
PEEP(cmH20) 
Flow (L/m) 
RESULTS 

Partner Ci •• 



nmL- 



PCV 


VCV 


VCV 


VCV 


1 150 


250 


400 


04 


61 


067 


93 


20 24 


28 


30 


4 4 


4 


4 


6 15 


20 


26 




26 1 
(26) 


132 8 
(17) 


235,1 
(4,1) 








(391 


332 4 

(7,2) 


23.2 
(061 


1306 
(34) 


232,6 
(26) 




24,3 
(06) 


132-4 
(0 6) 


234 7 

(27) 


360 9 

(4 7) 


07 


26 


0001 


0007 



Dbcuialon: When th< 
the Partner Hi. there <* 
lUUiUcally important 
1 A 4 We have ipecul 
ne«d for an aluiude cu 
should alai) he teen wl 
We bavc made the man 
findingi. and are curre 



PRELIMINARY REPORT OF VENTILjMTNG 
PRESSURES. PC02 AND NEONATAL AIR LEAK. Julie 
Ballard BS. RRT. John Salycr BS. RRT. Tom McGcc 
BS. RRT, Terry Madsen BA. RRT Respiratory Care 
Service. Primary Childrens Medical Cenicr. Salt Lake 
Ciiy. Utah 

INTRODUCTION: There has been liiilc published 
regarding the mechanical veniilaiion of infants wiih 
neonatal aiileak. especially in the posi- surfactant era, 

were'vcniitaied in our 35 bed. level HI NICU. 
METHODS: RCPs manually reviewed the charts of pis 
who had airlcak bciwcen Jul 90 and Feb 94, This period 
coincides with our use of surfactanL Airlcak was denned 
as radiographic evidence of; (1) PIE. (2) pneumothorax, 
or (3) pneumomediastinum- Pis were excluded whose 
•irieak developed prior to admission or as a result of 
surgery. We then randomly developed a matching list of 
ventilated non-airlcak patients who were wiihin 2 
weeks EGA of the airleak pis. Whenever possible, pis 



data were ihen exuactcd from both these samplcs. 
Vcntilaior data from non-airlcak pis were obtained from 
ihe same posmaial lime period as the matching airleak 
pL Mean values were compared using Studeni's ttcsi 
with significance sei at P< 0.05. RESULTS: There 
were 37 pis in each group. The airleak pts had a mean 
B.W. of ]513g ±1 1 18. range 468^60. while non- 
leak were 1475g ± 1167. range 360-4450. P>0 05 
EGA was 29 wks ± 6. range 23-40 for the 



t 5 foi 



airleak, range 24-41. P > 05 




f^^++iii+++'*"*+++V+++4 



Hours Bslore Onset ol fi 



:ally 



stausiical sifniflcance for any mean PC02 
differences. SPECULATION: The large differences m 
PlPs between the two groups is probably due lo 
differences in seventy of illness. However, since PC02 
was not different in the two groups we speculate thai 
permiiiing more hypcrcapnca in sicker pis might allow 
the use of lower veniilating pressures, thus possibly 
reducing lung overdistension and hence ihe incidence of 
airleak. Wc plan to further analyze the relationship 
bciwcen airlcak and other variables including fluid 
balance. PDA, surfactant administration and sepsis. 



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Open Forum ABSTRACTS 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1 



USING A CKRririCATION I AIR IC) SATISI^f 
ANNIJAI. CI^RTiniC^llON & i;i)[KJ\'llON 

RrQUiRr.MnN'i's 

Scon Pculnicht. RRI' 
Chlldrcirs Mospllal Mcdkal Ctiilcr 
Cincinnati, Oil 4S229 

INim)l>lK:ilON: I ikvt.l(i|K.d a format in 
whuh employees of the Respiratory Care 
Department could complete mandalory skill 
check olTs and competency of therapy in two 
hours. Previously In a department of 57 
therapists (HCP's) annual cerlificalions look 3 5 
h on average to complete (199 5 h total) In 
tabulating compliance in the 2 years prior to the 
Ccrtincalion Fair, staff compliance was IDOX 
However this occurred over a period of 3 
months at a lalM)r cost of J30(K) MliHIOI) A 
Ccrtincalion Fair running continuously for 54 li 
to accommodate all 3 shifts was used- Set up of 
the fair was done by Respiratory Care 
l-quipment Supervisor and myself at a cost of 
J9U In labor Hie fair was slarfcd by myself and 
2 other supervisors at a cost of |l(>50 in labor 
Hie Ccrlincatjon I-air consisted of 12 stations 
liach RCP demonstrated proficiency in set-up 
and operation of all equipment used in 
Respiratory C:are, profRienty of skills and Cl'lt 
rcccrlification RC~P's dcmonsiraied proricienc7 
by answering 5 questions involving hands on 
demonstration, A 25 question test was given 
with questions covering l-.lectrical/fire safely, 
emergency preparedness, infection control, 
charting and billing policies Ki;Sl]I.IS Of 57 
RCP's. 47 participated {HZ% compliance) I he 
goat was 100% The 10 that did not participate 
were followed up and completed the 
requirements Ihe mean time to complete all 
requirements in the follow up was 3 5 h. as 
compared to 2 h for those using the 
Ccrtincalion Tair (129 h loial) 
CONCLUSION llic Certifiiation Tair proved to 
be a valuable tool in alUnving all RCP's to 
complete their clicckofTs for the year in 2 h. 
compared to 3 5 h with the follow \ip mcthoil 
By demonstrating clinical skills In a mock 
clinical setting, it ensures eonsisiency in the 
level of clinical prottcicncy demonstrated by the 
Respiratory Care Department, as well as a cost 
savings 

" OF-94-006R 



AN EVALUATION OF INTERACTIVE 
TELECOMMUNICATION TECHNOLOGY 
IN THE EDUCATION OF ASSOCIATE 
DEGREE RESPIRATORY THERAPY 
STUDENTS Randal Robertson PhD RRT, 
Lisa Montiel MAEd RRT , Susan PerXins MA 
RRT - The University of Alabama at 
Birmingham (UAB), Birmingham. Alabama. 
INTRODUCTION: In order to provide a high 
quality education in the neld of respiratory 
care to residents of rural west central 
Alabama, and to address the problem of a 
shortfall of respiratory care personnel in that 
area. Ihe Respiratory Therapy Program at 
UAB offers its integrated 
tech nicj an/the rapist curriculum at an off- 
campus training site located 60 miles from 
Birmingham, Comparable classroom 
instruction is provided at both sites through 
the use of interactive teleconference 
instruction conducted by program faculty. 
DESCRIPTION OF METHOD Classrooms 
at both locations are linked by a large 
screen, live, voice- activated video hookup. 
The video and audio signals, transmitted by 
nberoptic telephone cable, allow lectures to 
originate at either site and give students at 
both sites equal opportunity to participate In 
discussions A control panel at the podium 
allows the lecturer to show videotapes, 
transparencies, slides, or handwntten notes. 
Hand-outs and exams are transmitted by 
fax machine EVALUATION METHOD: Due 
to Ihe small sample size (n = 35), an 
analysis of vanance and a median lest were 
used to determine if scores on course 
examinations and Ihe NBRC's Certincation 
Self -Assessment Examination differed 
between students at the two sites 
RESULTS Analyses revealed that there 
were neither practical nor statistically 
signiHcant differences in the pertormance of 
the two student groups EXPERIENCE: The 
authors have used Inleradlve 
teleconference inslfuctlon in the training of 
respiratory care practitioners for two 
consecutive years CONCLUSION: 
Interactive telecommunication technology is 
an effective means of assunng the 
equivalence of instmctlonal outcomes 
among multiple traming sites 



COMPARISON OF EXAM ITEM 
CORRELATION COEFHCIENTS 
CALCULTED BY THE POINT-BISERIAL 
METHOD AND THE HIGH LOW ABILITY 
GROUP METHOD David W. Chane. EdD. 
RRT Columbus College. Columbus. Georgia 

Inlroduclion: Exam item correlation coefficients 
(CC) have been used to refine and revise an 
exam. Among other criteria, items with low or 
negative CC are often evaluated for possible 
revision or deletion. Two methods to calculate thtj 
CC arc the poinl-biserial (PB) method and the 
high-low ability group (HLAG) method. Method: 
A %-ilcm multiple-choice exam was given to 14 
RT students. The exam items were analyzed by 
Scantron 6400 and Form 262-L- With the PB 
method, the Scantron calculated the CC for each 
exam item by: (Mp ■ Mq) x Square root (Np x 
Nq) / N x SD, in which Mp |Mq] = Mean total 
score of students thai had the item correct 
(incorrect). Np |Nq| = Total number of students 
that had the item correct [incorrect], N = Total 
number of student, SD - Standard devialion of 
scores on the whole exam With the manual 
HLAG method, the students were ranked from 
highest to lowest test raw scores. The 
performance of the upper 27% of students, high- 
ability group (HAG), was compared to that of the 
lower 27% of students, low-ability group (LAG), 
The CC for each exam item was calculated by 
subtracting the percent of correct responses in the 
LAG from the percent of correct responses in the 
HAG. Pearson Product-moment correlation (r) 
and linear regression were used to evaluate the 
overall correlation between these two methods 
The power table and standard error of estimate 
were used to establish the reliability of the 
results. Results; The CC using the PB method 
range from 0.71 to -0.45 (mean = 0.20) and the 
CC using the HLAG method range from 1.0 to 
-0.5 (mean = 0,18), The Pearson r was 0,80 
where Y intercept: F(X) = 0.83X + 0.02. The 
power of r is >0.99 and the standard error of 
estimate is 0.18, Conclusions: There was strong 
positive correlation between the PB method and 
the HLAG method. Since the CC calculated by 
the PB method is provided during test scoring, it 
IS Ihe preferred method. The CC with the HLAG 
method is more time-consuming but it is a 
valuable alternative if equipment is not available. 



POST-DISCHARGE SURVEY OF AN MDl 
PATIENT EDUCATION PROGRAM 

Jaan A. Retharford. RRT. RCP 

Randal Clirfc. RRT, RCP 

IWIichael Mahlmeirter, MS, RRT. RCP 

Memorial Medical Canter 

Modesto, Calrfomia 

Introductksn The transrtion of hosprtaleed 
pabents from nebuleer therapy to setf-administered 
Metered Dose inhaler (S-MDI) has been descnbed 
as therapeubcalty sound and cosl-effectrve 
However, Irttle is knovm about the eftectrveness of 
in-patient S-MDI educabon programs post- 
discharge We initiated a follow-up phone sun/ey to 
assess recall of proper MDl and PEFR use in 
patients transitioned to S-MDI MettiodB: We 
attempted to contact every patient transitioned to 
our S-MDI protocol dunng the first 60 bays of it's 
implementation 55% (31/56) of the S-MDI patients 
wore abie to be contacted post-discharge (range of 
contact 2 - 18 days post-discharge) Twenty eight 
of those contacted were ordered for home MDl 
use A senes of questions were asked by one RCP 
familiar wrth the S-MDI protocol, but not directly 
involved in any patient's care Pabents were asked 
to respond "yes" or "no" to questions, to identify a 
senes of 4 steps in taking an effective MDl 
b-eatment, and to report on PEFR use where 
applicable ReaulU 93% (26/28) indicated that 
they felt mstnjctions tor using their MDl were 
helpful Accuracy m identifying four steps in proper 
MDl use were as follows shake MDl (96%). breath 
in stow and deep (93%). activate inhaler at 
beginning of inspiration (93%) hold breath after full 
inspirabon (93%) 19 of those surveyed continued 
to perform PEFR a minimum of QD DIscuMlon & 
Conclusions These results indicate that the 
majonty of patients retained MDl instructions 
recetved as in-patients, but opportunities exist for 
improvement The use of pnnted handouts could 
enhance the pabenfs retenbon of instructions, 
given the age of our patient population (mean age 
60 5 years, range 19-89 years) Greater emphasis 
should also be placed upon the importance of 
regular PEFR monrtonng These results 
demonstrate the valuable role RCPs can play m 
patient education, and the importance of follow-up 
assessment of petient oducation programs post 
discharge Anecdotely. individuals contacted were 
pleased with the foltow-up call by respiratory care 
potentially enhancing pattent-institotion relations 

OF-g-iioi 



CHARACTERISTICS OF 
GRADUATES IN TWO 
TECHNICIAN PROGRAMS--AK 
Pctcmian-BIack. MPH, RRT. Erwin 
Tech Center. Tampa. FL. JR Black . 
PhD, Veierans' Hospital. Tampa, FL 

INTRODUCTION: The purpose of this 
original study was to determine which 
combination of 15 academic, ecorwmic. 
psychological, and social factors best 
describe graduates of two technician 
programs. 

METHOD: The design of the study was 
ex post facto or retrospective. The 
subjects were 333 students at two 
postsecondary vocational-technical 
institutions in west-cenuaJ Florida. All 
enrollees at one institution over eight 
years and all enrollees at a second facility 
over three years were included. The 
collected data were analyzed by 
discriminant function analysis. 
RESULTS: Of the 333 students. 223 
indivkduals (70%) completed their 
training Discriminant function analysis 
identified that students most likely to 
complete the two technician training 
programs (F = 7.9496) (1) tested at the 
11th grade level or higher in language 
usage on their first anempt (beta 
wt.=-.56I). (2) were not receiving 
financial assistance while a student (beta 
wt. = .36), (3) did not have a history of an 
emotional handicap (beta wt. = .46), (4) 
were married (beta wt. = -.22). and (5) 
were less than thirty years old (range= 18- 
56 years) (beta wt. = . 39). The 
classification summary by group 
membership for the graduates (jack -knifed 
cross-validation or percentage correctly 
classified) was accurate at a 94 6% level. 
CONCLUSIONS: For the programs 
studied, the five correlated factors could 
be used in the recruiting of individuals 
into the uaining programs. The ex post 
facto design of this study precludes 
extrapolation of the finding into other 
programs. of.94-009R 



RESEARCH INSTRUCHON IN 
RESPIRATORY CARE ADVANCED 
PRACTITIONER PROGRAMS: A SURVEY. 
Arthur lones EdD, RRT, Mdnlyn Childcrs, 
BS, RRT- University of Texas Medical 
Branch, Galveston, TK. According to a 1992 
delphi study, 75% of the panelists 
considered rest^rch interpretation skills 
miportant to advanced respiratory care 
practitioners (ARCPs). Considering that 
fmdin^;, we sought to descnK^ the status of 
research tnlucation among ARCP pmgrams. 
METHODS: After several educator- 
rt^stMrchers evaluated face validity and 
n^adabihty of the Rt^seaah Education 
Qui^tionnaire (REQ), an m-house 
instrument, we mailtnl it to all ARCP 
protrranis hstcxl by the JRCRTE, The REQ 
consists of 32 items to descnK' prO(p-ams, 
faculty, and research education. To follow 
up, we contacted 25 randomly-st^ected non- 
respt^ndenls by phone six wcvks after 
mailout. Data were analy/-ed using Microsoft 
Excel spn-adshixH. RESULTS: Including 
phone surveys, M% (N=180) responded. Of 
25 phone contacts, 17 were not available to 
survey. Of respondents, 21% have research 
course's; by pmgram type, 71% of BS and 
9.5% of AD. Mean contact hours for research 
courses = 36. The most common course 
goals wea' for students to n>ad n'search and 
interpret statistical results, llie most 
conimon Reason for not leaihing n-st^arch 
was insufficient time. Ot pmj'.rams without 
n-seanh courv-s, 69% devote MO (iiiran) 
conla. I hours lo journal studies Oi 
respvtndenLs, 93% nxjuia' students lo rt^d 
researxh, 26% prxwide a formal to evaluate 
it, CONCLUSIONS: Formal n^'anh courses 
are largely n-slncti\l lo BS programs. But, 
K>th AD and BS progran\s, in general, 
nxjum' students lo road reseanh and leach 
them lo interprx'l it. LIMITAHONS: 
Ri-spt>n,se rale (64%) may have influencisj 
n-sulls; a misworded REQ item n^ay have 
taus**d Its mis interpretation. 



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Open Forum ABSTRACTS 



RESPIRATORY CARE • NOVEMBER 94 Vol 39 No 1 1 



THE EFFECT OF EDUCATION ON STAFF 
UNDERSTANDING OF THE SAFE MEDICAL 
nFViriri; apt ^SMDAI David L.PqILS BS. RRT. 
Roben L. Chaibum. RRT Rainbow Babies and Chi!- 
drens Hospital. Cleveland. OH. 

INTRODUCTION: Since the miroduction of ihc SMDA 
of 1990. health care facihlics are required lo identify, doc- 
ument and report medical device incidents. Wc devel- 
oped an educauonal approach using an algorithm for dc- 
termining reportable mcidcnls and performing apjiofiiaie 
documenlation- The purpose of this study was to lesi the 
effecl of the education program on the staffs knowl- 
edge level. METHODS: An algorithm (see Figure) was 
developed usiiig the the current hospital policy after con- 
ferring with OUT 




(3)aposttesl 
identical to the 

All phases were 
adminisured within 60 minutes. Staff and students were 
selected at random to enter the study. The hypothesis that 
learning occurred was evaluated with pre and post test 
scores using a paired t-tesL RESULTS: Twelve people 
were enrolled in the study: 4 RRTs. 1 CRTT. 3 students. 
3 OJTs. and 1 noncredenlialed assistant. Post-test scores 
(x = 81, SD = 10) increased an average of 19 points 
(p=0-0006) compared lo pretest scores (x = 62, SD = 14). 
CONCLUSION: Historically greater than 20% of re- 
portable incidents occur in ICUs where RC staff are fre- 
quently assigned We conducted an informal phone survey 
of 13 hospitals revealing only 2 that educated staff regard- 
ing SMDA. Education about the SMDA is important not 
only to comply with the law. but also to protect patients. 
Oui education progiam yielded only modest improve- 
ment perhaps due to the complexity of the topic. We sug- 
gest incorporating an aggressive and ongoing education 
method to assure compliance with the SMDA. 

OF-94-121 



AN ASSESSMENT OF LEARNING STYLE AND 
MYERSBRIGGS PERSONALITY TYPES IN 
BACCALAUREATE RESPIRATORY CARE 
STUDENTS BL Gregg MS RRT Universitv of 
Kansas Medical Center, Kansas City, Kansas 



Allied \ 









lave been reported to 
ed learning styles. An 
assessment of student learning styles and 
personality types was undertaken to determine II 
if there was a predominant learning style (LS) 
among baccalaureate respiratory care students at 
KUMC. 2) if any Myers Briggs personality types 
(MB) dominated a particular LS, and 31 if any 
style/type combination resulted in significantly 
higher or lovwer grades in RC laboratory courses 
Materials/Methods: Fifty lumor RC students were 
given the Learning Style Inventory (LSI) and Myers 
Briggs Type Indicator (MBTI) at the beginning of 
their RC program. The LSI is a 12-item self report 
instrument with a reliability coefficient of 82 
The LSI by Kolb was designed to measure an 

Based on the experiential learning theory, Kolb 
describes four stages of the learning process as 
concrete experience (CE), reflective observation 
(RO), abstract conceptualization (AC), and active 
expenmentation (AEI The tour LS are 

jator (AE/CEI, Diverger (CE/ROl. 

r (RO/ACI, and Converger (AC/AE). A 

:tric test for significance of difference 



Accommoi 
Assimilalo 
nonparamt 

significant LS. The expected proportion for each 
LS was 25%. The MBTI is a 94 question survey of 
an individual's preferences Individuals are scored 
m four categories: Extraverted/lntroverted, Sensing 
(Sl/lntuitive (N|, Feeling (F)/ThinkinQ (F), and 
Perceiving {P|/Judging (J) Proportions for the 
general population are E/l 75:25. S/N 75:25, F/T 
50:50, P/J 50:50 Individual grade averages for 
the two lab courses during the lunior year were 
grouped according to LS, MB, or both. Groups 
were then tested for a significant difference in the 
proportion of each group above or below a 30 
GPA The only lab instructor was an INTP AC/RO 
Results: There was no significantly dominate LS. 
Not surprisingly, there were more concrete sensors 
and abstract intuitives (p< 05). There were 
more intuitive RC students than typically found in 
the general population (p< 05) There was no 
significant difference in lab course GPAs based on 
LS, MB, or both There was no MB dominating any 
LS. 40% of the AE/AC were ESTJs or INTPs 53% 
of the AC/RO were ISTJs or ENFPs Conclusions: 
There is no significant LS or difference in lab 
course grades based on LS, MB, or both for this 
sample. OF-94-154 



CLINICAL CASE STIJDY EXERCISES FOR 
EDUCATION AND MONITORING IN A 
RESPIRATORY THERAPY CONSULT SERVICE 
Lucy Kester. MBA. RRT. Kevin McCarthy. RRT, 
James K SioUcr. MD. Cleveland Clituc Foundaiion, 
Cleveland, Ohio 

In an effort to train therapists to use algonlhms, 
and to monitor the uniformity of their use in our 
Respiratory Therapy Consult Service, clinical case 
studies were corwlrtjcted and dislnbuled every 3 to 
4 months (see table) to the clinical staff of the 
Secuon of Respiratory Therapy All Respiratory Care 
Pracuiioners (RCPs) were expected to complete 
and return care plans for a set of 4 individual case 
studies that were developed from actual pauenl data. 
The case studies included information necessary to 
establish indicauons for aerosol, bronchopulmonary 
hygiene, hypennflauon, oxygen therapy, and pulse 
oximetry The care plans, which were to be based 
on algonlhms that were formulated for each 
respiratory care procedure, were then graded by 
comparing ihem to -correct" care plans These 
"correct" plans were predetermined by the consensus 
of the medical director, manager, supervisors, and 
educauon coordinator Corrclauons were examined 
between the RCP's grades and their educaUon level, 
experience, and type of credcnuals The Uble below 
suimnanzes the overall rate of correct responses for the 
5 sets of case studies The trend toward improvement 
in overall grades (77 8%± 10 9% to 85 0% + 8 9%) 
suggests improving performance and farmliarity with 
the algonlhms over Ume However, reasons for less- 
Ihan-pcrfect grades include I) first time participation 
by new department members in laler exercises, and 2) 
imperfect performance even by expenenced deparlmeni 
members We conclude that I ) admimstenng case 
study exercises is a useful method to monitor RCPs" 
performance using algonthms, 2) senal use of case 
studies permits identificaUon of poor perforrmng 
individuals and difficull-lo-use algonthms. 3) though 
increasing grades over ume suggest improving 
performance, imperfect grades suggest the need to 
continue traiiung in algonlhm use. both for new and 
veteran department members 




American Association for Respiratory Care 

40th Annual Convention and Exhibition 

December 10-13, 1994 • Las Vegas, Nevada 



1082 



Learn the 



Mediaims 



of Mechanical Ventilation 



Honitoring Respiratory 

Mechanics During 

Mechanical Uentilation 



Explains how physical and mathematical models are developed and 
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develop because of the limitations of the models. Chotburn points out 
that lack of consistency among manufacturers in the way in which 
compliance and resistance are measured and temperature 
conversions are applied and how the lack of published accuracy and 
By Robert L. Chatburn, RRT precision information make data interpretation difficult. 

Item VT30 — VHS (60 minutes) 
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Open Forum ABSTRACTS 



RESPIRATORY CARE • NOVEMBER "94 Vol 39 No 1 1 



DELIVERY OF CONTINUOUS ALBUTEROL IN 
CONJUNCTION WITH RIBAVIRIN - A CASE STUDY 
Linda Allen Napoli. B S - RRT. RPFT . P/P Spec . Lorraine 
F Hough. M Ed . RRT. P/P Spec . R I Godincz, M D . 
PtD . The Childrcns Hospital of Philadelphia. 
Philadctfriua. PA 

A 4 year old male child presented to the Emcrgencv 
Department (ED) with a 3 day history of a "cold" and a 
dry cough Vital signs revealed respiratory rale 80/minule, 
heart rale 160/nunutc, temperature lOl'V. and SpOj on a 
3L nasal cannula of 99% There was significantly 
increased work of breathing and breath sounds revealed 
coarse rhoiKhi and expiratory wheeze Hypermflalion was 
evident on the chest x-rsy This patient had a past medical 
history of a diaphragmatic hernia repair at 4 davs of life, 
wth extracorporeal membrane oxygenation for 1 1 davs. 
mechanical ventilation for 2 months and supplemental 
oxygen for 1 year He requu-cs daily treatments (tx) with 
albuterol 2 5mg q4°, cromolyn sodium 20mg QID, and 
tnamcmotone acetonide by metered dose inhaler (MDI) 
TID for his severe residual reactive air%^'sys disease Pnor 
to admission, his home treatment regimen had been 
escalated to albuterol tx ql°(2 5mg), aerosalizcd atropine 
sulfate 4mg qS", tnamcmolone acetonide MDI q8 and 
prednisone 2mgA;g BID bv mouth In the ED, the patient 
was started on solumedral TV and continuous albuterol at 
1 5mg/hr via a high flow aerosol mask set up with a 
HEART™ nebulizer The child was momtored for 
unacceptable side cfTects from the albuterol via eonimuous 
cardiorespiratory momtonng. pulse oximetry and ql" 
physical assessments The patient was diagnosed with 
impending respiratory failure due to a respiratory rale > 
95% for his age He was found to be positive for 
respiratory synclial vims via nasal aspirate The 
continuous albuterol was stopped so that Ribavuin could 
be admuustered but the palicnl deteriorated significantly 
Subse<iuenUy. the recommendation was made lo deliver 
both therapies simultaneously Ribavinn (6mg/300cc) was 
dcUvcred via a small particle aerosol generator for 
12hr/day x 5 days and wyed mto the contmuous albuterol 
set up. six inches down from his aerosol mask, at an FiOj 
of 30 During the 5 days, his albuterol therapy was slowly 
decreased to 5mg/hr Aerosolized atropme sulfate 4mg 
04° and cromolyn sodium 20mg QID were started on day 
3 By day 7. the contmuous albuterol was disconlmued and 
the patient was placed on albuterol tx 5mg q2'' The 
atropme sulfate and cromolyn sodium therapies remained 
unchanged On day 8, his SpOj on room air was 97% By 
day 9, the albuterol tx were decreased to q4 at 2 5mg On 
day 10, the patient was discharged on his home regimen 
CONCLUSION Ribavirin and contmuous albuierol were 
successfully admuustered simultaneously on this child 



OF-94-C 



PARTICLE SIZE DELIVERY OF MEDICATION 
NEBULIZERS Daniel Fisher. BS, RRT . Dean Hess, MEd. 
RRT. Rums Williams, BS. RRT. Sharon Pooler. RRT, 
Robert M Kacmarek. PhD. RRT Departments of 
Anesthesia and Respiratory Care. Massachusetts General 
Hospital and Harvard Medical School, Boston. MA 
Nebulizers are commonly used lo administer medications 
such as beta agonists Wc conducted this study to evaluate 
particle size dehverv from 17 commercially available small 
volume nebulizers METHOD Nebulizers were provided 
by their manufacturers and evaluated at flows of 6. 8 and 
10 L/min Three of each type were evaluated at each flow 
Albuterol (0 5 mL of 5%) was added lo the nebulizer cup 
and diluted with 2 5 mL saline The nebulizers were 
attached lo a ring stand m a vertical position Aerosol was 
sampled from ihe outlet of the nebulizer at a flow of 2 
L/min to an Iniox (Albuquerque. NM) eleven stage cascade 
impactor (stages of 12. 9 52. 7 56. 6. 5. 4. 3. 1,8. L 0.4. 
25 *i The cascade impactor was used according to 
manufacturer's specificaltons Albuterol was washed from 
each stage and analyzed spcclropholometrically (Bcckman 
DU 30 Spectrophotometer. Irvine. CA) at 278 nm A slock 
solution of albuterol (0 05 mg/mL) was prepared from 
powdered drug (Sigma. St Louis, MO), and a standard 
curve was constructed from serial dilutions Mass median 
aerodynamic diameter (MMAD) and geometric standard 
deviation ((iSD) were determined, as well as the proportion 
of particles 1-5 u- Statistical analysis consisted of repeated 
measures ANOVA. with nebulizer brand as the grouping 
factor and flow as the repealed measures factor 
RESULTS: There was a significant difference in MMAD 
between nebulizers (P<0,001) and Rows (P-: 001), and 
there was a significant interaction effect (P-0 045) For 
GSD. there was a significant difference between nebulizers 
(P=0 023). no dilTercncc between flows (P-0 0H5). and a 
significant interaction (P<0 001 ) For the proportion of 
particles 1-5 w, there was a significant dtffcrcnce between 
nebulizers (P=0 034) and between flows (P<0 001 ). bul 
there was no intcraclmn (I'-O 21^1 Ihc following data 





., 1 „mi 


«l „„„ 


111 L /mm 


MMAD 


4 17.1 ■.? 


1 v. 1 IK 


Ullil 111 


(,SI1 


? ll.uj., 


: I'l'dii, 


3 SI, 1141 


prnpom™ 1-5 „ 




(1 SI, ,11 n 





()N( I.USIONS I 
particle size with an increase in flow Although there were 
significant differences. GSD was relatively constant with 
changes m flow There was an increase in the proportion 
of particles in the I -3 u range when (low was increased 
from 6 IJmin to 8 I-/min. but hlllc change from 8 L/min ti 
10 Umin Nebulizer conslmclion has a signincani effects 
on particle si/c. regardless of the delivered flow 
(supported in part by Ihc Puntan-Hcnnelt, Hudwn RCI. 
Marqucst. Professional Medical. SIMS. Inspired Medical) 

OF 94-078 



DEPOSITION OF BRONCHODILATOR (8D) 
IMPROVES WITH HEUUM:OXYGEN(80:20) 
BREATHING C Popq RRT . C Slrgl MD. 
K Guntupalli MD, V BarxJl MD. C MilOffl PhD, 
J WorxJt MD. R Wendt PhD 
Baylor College of Medlclrw, Houston, Texaa 
We hypothesized that a greater quantity of BD 
would t>e delivered to the periphery ol the lung rt it 
drrven by helium oxygen(heliox) rather than 
nitrogen:oxygen due to less turbulent flow patterns 
Method: Thirteen, controlled asthmatics were 
recruited for the study After obtaining informed 
consent, all subjects withheld medications 
(theophylline-24 hrs, p-agonists. inhaled steroids- 
8hrs) before reporting for study Each performed 
spirometry and flow volume loop pre- and [Xist- 
labeled BD delivery All were evaluated to determine 
that s5% change occurred between Week I and 2, 
two subjects did not meet these cnteria and were 
excluded. Subjects were randomized lo receive 
either oxygen or helium oxygen (heliox) (or delivery 
of 5 ml albuterol radiolat>elled with 30 milicuhes of 
*^c (technetium-99), total solution = 2 5 ml 
Labelled BD was delivered using a shielded 
AEROA'ENT~ radioaerosol nebulizer v/ith either the 
therapist or physician in attendance to monitor 
breathing pattern Immediately follovwng 

administration of BD. all subjects were scanned for 
1 ,000.000 counts on an ADAC Genesis Scanner 
Subjects repeated the study, after 1 - 2 weeks, 
breathing BD driven by the "other' gas To evaluate 
penetration of BD. the perimeter o( the lungs were 
defined by an autoedge detection method; skew 
and pixel count were then calculated to determine 
peripheral deposition of the particles Both 
decreased skew and increased pixel count 
suggests greater peripheral deposition Results: 
Skew in the heliox driven aerosol decreased by 
45% (p<0 0001 ) from oxygen driven aerosol. Pixel 
count increased by I0%(p<0 0001) after breathing 
heliox driven BD 





H.l„. 


0»VQen 


p„, 


2123-I0) 


11127'(»1 


Sk~ 


OO-(OO) 


144-10 




e lea 


St me 


ans squared (SU) 



(inclusion: No significant spirometric changes 
were found Driving the nebulizer with Heliox 
appears to increase peripheral deposition of 
aerosolized bronchodilator Using heliox to power 
a nebulizer may have future application in the 
delivery o( other medications, such as antibiotics, 
steroids or vaccines 

OF-94-035R 



VARIABILITY OF DOSE DELIVERED BY 
METERED DOSE INHALER (MDI). 
Daniel Fisher. BS. RRT . Dean Hess, MEd. Robert M 
Kacmarek, PhD. RRT Departments of Respiratory Care 
and Anesthesia, Massachusetts General Hospital and 
Harvard Medical School, Boston. MA 
MDI are commonly used to deliver aerosolized 
medications Much has been written about the effects of 
technique on dose delivered to the patient, but Ihe 
device Itself has not been evaluated for consistency of 
dose output This study was designed to answer the 
following questions: I ) Docs the amount of drug and 
propellent in the canister have an effect on delivered 
dose? 2) Is the dose output consistent for the first 3 
puffs from a new MDP 3) Is there a difference in dose 
delivery between MDIs from the same manufacturing 
lol^ METHODS: Six new, previously unopened 
albuterol (Proventil, Schering) MDI were used Prior to 
each actuation, the canister was shaken vigorously for 
about 15 s. The canister was then discharged into a 50 
mL centrifuge lube and washed with 6 mL of 0, 1 M 
NaOH The amount of drug delivered per puff was 
determined spectropholomclrically at 243 nm using a 
Beckman DU-30 single beam spectrophotometer. A 
stock solution of albuierol was prepared from powdered 
drug (Sigma, St Louis, MO), and a standard curve was 
constructed from serial dilutions For each MDI, we 
compared the dose delivered at 6-10 puffs (Group 1 ), 
50-54 puffs (Group 2). 100-104 pufls (Group 3). 150- 
154 puffs (Group 4). and 196-200 puffs (Group 5) We 
also evaluated the dose delivered from the first 3 puffs 
of the new MDI The results were analyzed using 
repealed measures ANOVA RESULTS: There was a 
signincani difference in dose (meg) delivered between 
the MDIs (90 (H8 7. 83.5±6 7. 87,6^ 5 2. 82 U4.6. 
82 7t4 0. 88.U4 9, P-OOOI) There was also a 
significant difference in dose (meg) between Groups 
(88 41 8 9 for Group I. 83.4i6 7 for Group 2. 83 8i 5 4 
forGroup3. 84 8+5 I for Group 4. 88, 7*4. 5 for Group 
5. P- 001). The dose delivered for Ihe first 3 puffs 
(pooled dala from all MDIs) was I22..3i3l,8 meg 
( ONCLUSIONS: There was a statistically significini 
dillcrcncc for dose between MDI and Ihe number of 
puffs remaining in the canister With the exception of 
the first 3 puffs, however, these differences are probably 
too small to be clinically important. The considcrahli 
variability m dose delivered for the first 3 actuations 
may be due to priming of the valve assembly, and 
strongly stiggcsls that the first 3-4 puffs should be 
wasted prior lo clinical use. (supported in pari by 
Puritan -Bennett Corporation) 

OF-94-088 



A COMPARISON OF ULTRASONIC AND 
STANDARD JET NEBUUZER THERAPY IN 
A PEDIATRIC ASTHMATIC SAMPLE. 
Teresa Volsko. BS. RRT and Donald Milligan, 
MD. St. Elizabeth Hospital Medical Center 
Youngstown, OH. Comparisona of ultrasonic 
and standard jet nebulization of broncbodilatory 
agents have been documented with adult 
asthmatics. However, sparse research exists 
utilizing a pediatnc sample. In this study we 
evaluate the effectiveness of the ultrasooic and 
standard jct oebulizers in eliciting and EusLainiog 
a maximum bronchodiUtory response while 
minimizing the risk of hospital ization m 
pediatric asthmatics presented to the emergency 
department in acute exacerbation. During an 8 
month study penod, 28 pediatric patients (ages 
4-16) met the study cntena (previous confirmed 
diagnosis of asthma upon presentation to the 
emergency department in acute exacerbation and 
ability to perform a measurable peak flow 
maneuver) and were randomly assigned to 
ultiasomc or standard jet nebulization of 
albuterol at 0.03 cc per kg. Pre and 
post-treatment evaluation of each patient 
consisted of peak expiratory flow measuremrats 
accompanied by clinical assessments, performed 
by one of 5 board certified pediatric house 
officers, blinded to the deUvery method. The 
decision matrix for treatment and admission 
criteria mirrored the flow chart published by the 
NIH for Emergency Room management of acute 
asthmatic exacerbations m children. The 
analysis revealed a 4% greater improvement in 
pre-and post treatment evaluations of the 
ultrasonic as compared to the standard jet 
nebulizer. Additional aerosol therapies were 
required in 65% of the patients treated with the 
standard jet nebulizer compared to S0% 
receiving ultrasomc nebulizer therapy. Results 
indicate a difference (p= .08) between the 
ultrasonic and the standard jet treatment groups 
when the number of hospital admissions were 
compared (0 admissions with the ultrasomc 
group and 7 admissions with the standard jet 
group). The small sample size and large 
variation among patients made it difficult to 
statistically substantiate the superiority of 
ultrasonic nebulization in eliciting and 
main tainin g a broncbodilatory response when 
compared to the standard jet nebulizer. It is, 
however important to recognize the ment of the 
reduction of hospital admissions with the 
administration of beta 2 agonist therapy with 
ultrasonic nebulization, especially in the climate 
of managed health care. OF-94-059 



Pooler. RRT. Daniel Fisher. BS. RRT. Robert M 
Kacmarek. PhD. RRT DeparttncnU of Respiratory Care 
and Anesthesia. Massachusetts General Hospital and 
Harvard Medical School. Boston. MA 
A significant dead volume remains trapped in the reservoir 
of medication nebulizers Previous studies have typically 
evaluated this using a gravimetric method, in which the 
nebulizer was weighed at the beginning and at the end ofa 
nebulization period (Respir Care I989;34 717-723. Chest 
1992.101 .3 16-3 19) Because the solution output exceeds 
ihc drug output, gravimetric methods may be inaccurate 
(Eur J Ped 1989;148:473-474). Spcctrophotomctric 
methods allow quantification of drug remaining in the 
nebulizer dead volume Wc conducted this study lo 
compare gravimetric and spectropholometric methods to 
determine dead volume of medication nebulizers 
MtTHODS Wc evaluated 17 commercially available 
nebulizers Nebulizers were evaluated at flows of 6, 8. and 
10 L/min and at solution volumes of 3. 4. and 5 mL Three 
of each nebulizer type were evaluated at each flow and 
solution volume The solution contained 5 ml- of 5% 
albuterol solution (2 5 mg) A double-sided test lung with 
lil^ bar was used to simulate spontaneous breathing. One 
side of the lest lung was attached to a Puritan-Bennett 7200 
(rate 12/min. VyO? L. sine wave flow 30 17min). and the 
other side was attached to the nebulizer The nebulizer was 
weighed empty, allcr adding solution, and at the end of the 
trial The percentage of solution that was nebulized was 
calculated from Ihc mass changes Spectrophotometry al 
278 nm (Beckman DU Spcctrophoiomclcr. Irvine. CA) was 
used to determine albuterol concentration A slock solution 
of albuterol (0 05 mg/ml.) was prepared from powdered 
drug (Sigma. St Louis. MO), and a standard curve was 
constructed from serial dilutions Ten ml. of saline was 
used to wash the nebuli/er cup. and Ihc amount of albuterol 
trapped in ihc dead volume was then calculated from its 
absorbance Statistical analysis consisted of ANOVA 
RFSVILTS ihe spcdropholomclnc dead volume {45 2 
± 1 2 3''b) was significantly greater than that determined 
pravimclrically (12 4i9 9"^o)(P-:0 001 ) There was a 
significant dccrca.sc in dead volume (spcclrophotomcinc) 
with an increase in How (48 Ih 12 2%at 6 l7mm. 44 I 
I I2 0''.,ai 8 I mm. 44 St 12 3'^«ut 10 L/min. P-0 007) and 
with ;iii iiurcasc in sulution volume (52 4i:l 1 l%al 3 ml.. 
44 III I 2% .11 4 ml. 40 1»11 3% at 5 ml.. P<0 001) 
There was also a significant difTercncc between ncbuli/crs 
in percent dead volume (P<0 001 ). CONCLUSIONS: A 
significant amount of drug was trapped in Ihc dead volume 
of medication ncbulixcrs. and this is underestimated using 
gravimetric techniques There arc differences in the amount 
of drug trapped in the dead volume for different ncbuli/crs 
brands. The dead volume amount can be decreased by 
using higher flows and larger volumes of solution 
(supported in pan by Purilan-Rennelt. Hudson RCI. 
Marqucsl, Professional Medical. SIMS. Inspired Medical) 




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Open Forum ABSTRACTS 



RESPIRATORY CARE • NOVEMBER "94 Vol 39 No 1 1 



DRUG DELIVERY BY MEDK ATIUN NEBULl/ERS 
AEROSOL INHALED Sharon Pewler. RRT . Dear Hess, 
MEd. RRT. Pums Wiltiams. BS. RRT. Daniel Fisher. BS. 
RRT. Robert M Kacmarek. PhD. RRT Departmcnis of 
Rcspirator> Core an<l Anesthesia. Massachusetts General 
Hospital and Harvard Medical School. Boston. MA 
Vanous aspects of mcdtcaiion nebulizer performance (c g.. 
dead volume, particle size) have been previously reported 
by our group and others However, little uttcnlion has been 
given 10 the concept oi aerosol inhaled, which is the actual 
amount of drug delivered by a nebulizer to the mouthpiece 
of the device for a specific breathing pattern (J Aerosol 
Med I99I.4 229) We evaluated uf»-ojo/ inAo/et/ from 17 
commercially available nebulizers at 3 flows and 3 solution 
volumes METHOD The nebulizers were evaluated at 
flows of 6. 8. and 10 L/min and at solution volumes of 3. 4, 
and 5 mL Three of each nebulizer type were evaluated at 
each flow and solution volume The solution contained OS 
mL of 5% albuterol solution (2 5 mg) A double-sided test 
lung with lift bar was used to simulate spontaneous 
breathmg One side of the test lung was attached to a 
Punian-Bennetl 7200 (rate 1 2/min. Vj 7 L. sine wave 
(low 30 L/minl, and the other side was attached to the 
nebulizer. Aerosol inhaled was evaluated using a 
modification of a previously described method (Respir 
Care 1992.37 1233) The mouthpiece of the nebulizer was 
replaced with a slcpdown adapter, and cotton wadding was 
placed into the adaptor to trap aerosol The nebulizer was 
operated until nebulizalion was complete Albuterol was 
then extracted from the cotton using 20 mL of 9% saline 
with gentle agitation by vortex The resulting solution was 
centnfuged at 5000 G for 10 mm to remove all cotton 
fibers, and absorbance was measured ai 278 nm (Bcckman 
DU Spectrophoiomclcr. Irvine. CA) A standard curve for 
albuterol was constructed from the absorbance of serial 
dilutions of a stock solution of 005 mg/mL prepared from 
powdered drug (Sigma. St. Louis. MO) The amount of 
drug extracted from the cotton was determined from the 
standard curve The percent of the albuterol placed into the 
nebulizer cup that was delivered to the conon wadding 
{aerosol inhaled) was calculated Statistical analysis 
consisted of ANOVA RESULTS Aerosol mhaled v^^ 
significantly less with a flow of 10 L/min (20 3±6 8% for 6 
Umin. 19 6*6 4 forSUmin. 18 1±6 I^/ofor lOL/min. 
P=0 01 ) Aerosol inhaled was also significanlly less with a 
smaller solution volume (17 5±5 8%for3mL, I9 8±6 6% 
for 4 mL. and 20 7±6 7% for 5 mL. P-0 000 1 ) There was 
a significant difference between nebulizers in aerosol 
.nAo/^<^(P<OOOI) CONCLUSIONS Overall, about 20% 
or less of the albuterol placed into the nebulizer cup was 
delivered to the mouthpiece of the device Although 
aerosol inhaled v^as affected by flow, solution volume, and 
nebulizer brand, the clinical importance of these 
difTcrcnccs remains to be determined Wc believe that the 
concept of aerosol inhaled is a useful method to 
characterize aerosol delivery systems 
(supported in pan by Puritan -Bennett Hudson RCI, 
Marqucst, Professional Medical, SIMS, Inspired Medical) 

OF-94-080 



IMPACT OF HUMIDITY ON RESPIR- 
ABLE VOLUME OF MEDICATION DE- 
LIVERED VIA VENTILATOR William 
W. Quinn RPFT RRT Ochsner 
Foundation Hospital New Orleans, 
Louisiana. Previous reports have 
suggested that continuous flow 
nebulization is more successful 
in delivering medication when 
the nebulizer is placed upstream 
from the patient wye. However, 
these same studies did not 
include a humidifier. I sought 
to observe the impact of various 
humidif ication conditions on 
respirable volume of medication 
delivered by a nebulizer in a 
ventilator circuit to a test 
lung. Method: A Laser particle 
counter (PC) was adapted to the 
02 sensor port of a Michigan In- 
struments Training Test Lung 
(TTL) so that a sample could be 
aspirated from the TTL into the 
PC. Three methods were tested 
five times each, data being 
collected after the system had 
run connected to a ventilator 
with nebulizer running for three 
minutes. Results were converted 
from counts of various particle 
sizes into cubic volume of all 
particles 1-4 microns in size. 
Summary of results, in milfions 
of cubic microns(SD): 1) Nebu- 
lizer in ventilator position 
{VP), 120 cm upstream from wye, 
with dry gas: .58(.03) 2) Nebu- 
lizer in VP with gas humidified 
to 34 C at the airway: .52{.03) 
3)Nebulizer in VP with gas 
humidified to 34 C in a heated 
wire circuit: .51(.02) 
Respirable volume of medication 
delivered by the VP with dry gas 
was Significantly higher (p^.05 
by ANOVA) than all other methods 
t.-stfd. Conclusion: When using a 
nebulizer in the VP, bypassing 
the humidifer can enhance 
medication delivery. „^_. 



EXHALATION RESISTANCE WHEN USING THE 
AEROSOL CHARGING ADAPTER WITH ADULTS 
S- David Piper. P.E. . Vorlran Medical Technology. 
Inc (VMT), Sacramento, CA Otlo G Raabe. Ph D , 
University of California. Davis, CA. Introduclion: 
Placing the Aerosol Charging Adapter (ACA) (VMT 
Model* 100746) between ihe patient w^e (PW) and 
the Endotracheal Tube (ETT) irwreases Ihe medication 
available for mhalalion by about 7-fold when used with 
a UiniHEART nebulizer{VMT Modeld 100612) and a 
continuous flow ventilation system. The ACA has pre- 
viosly been used with neonates but may increase 
exhalation resistance when used with aduHs Melhod: 
In-vrlro testing was perlormed using a Michigan 
Instmments Venl Aid TTL artificial lung, and a Purilan 
Bennett 7200A ventilator with Mode 50 FLOW-BY. 
Pressures were measured proximal lo the ETT and at 
the PW using two Dwyer Magnehelic pressure gauges 
calibrated at and 10 cm HjO. AuloPEEP indicat- 
ed by the ventilalor{VENT} was also recorded FLOW- 
BY and MiniHEART flows were maintained at 8 and 2 
L/min respectively- IE ratio was mamlained at 1 2. 
compliance at 05 Ucm-HjO. PEEP was set to 
cm-H20. and a 7 5 mm ETT was used for all lesls 
Control values were established by removing Ihe ACA. 
setting FLOW-BY to 10 L/min and repeating Ihe tests. 
The parameters tested were: 

Respiratory Rate(RR) 14, 24. 30 BPM 
Tidal Volume(TV) 600. 600. 1000. 1200 mL 

The in-vitro setup included a Purilan Bennen baclena 
filler, humidifier and water traps, all measurements 
were repeated 3 times in separate runs Results: There 
was no measured autoPEEP lor combinations of 
parameters which included RR's of 14 and 24 BPM. 
AutoPEEP for RR's of 30 BPM are listed below 
(meanistandard deviation): 
TV (mL) 600 800 1000 1200 

ETTCcmHjO) 0±0 910 1 2 7±0 1 3 8±0 1 
PW(cmH20) 0±0 0*0 1,1±0 1 2.1±0,1 
VENT{cmH20) a±0 0±0 a±0 1 OiO 
AutoPEEP for the control tests at 30 BPM were: 
TV (mL) 600 800 1000 1200 

ETTCcmHjO) 0.0±0 0.a±0 O.OIO 1 0±0 1 
PW(cmH20) 00±0 0±0 0±0 1,0±0.1 
VENT(cmH20) 0.0+0 0±0 a±0 0,0±0 
Experience: S David Piper, P E. is a Regis " 
Professional Engir 
been developing and conducting research on 
respiratory products lor over 4 years, and has received 
patents tor nebulizer and aerosol delivery lechnologies- 
Otlo G Raabe. Ph D. is a Professor of Environmental 
Engineering at the University of California Conclusion: 
The ACA may be used with adults under ordinary 
respiralory settings at RR"s up to 30 BPM with minimal 
autoPEEP, For Ihose conditions in which autoPEEP 
exists, the ventilator may not accurately indicate 
autoPEEP at the ETT. 

OF-94-140 



T the State of California, has 



EVALUATION OF THREE NEBUUZERS FOR 
LENGTH OF NEBULIZATION TIME 

Stephen F. Wehrman RRT. Warren Sakamoto CRH, 
Wesley Caner CRTT, Anthony de Nectxhea CRTT 
Kafiiolani Community College. Honolulu. Hawaii 

Introduclion: The length of time ii lakes a small 
votume netxilizer to deliver a standard amount ol 
sdubon affects total time spent performing this 
therapy and could impact on productivity. Previous 
research try Hemstreet et al. published in an abstract 
in Respiratory CareV olume 38, Number 1i suggests 
that nebulization beyond "sputter time' (the 
spasmodic release of aerosol at l5-30s without 
visible release of aerosol) is unproducbve A review 
of five respiralory care textbooks suggests operating 
the nebulizer at six to eight liters per minute We 
compared the length of time it look three different 
brands ol nebulizers to reach 'sputter lime' at two 
different flow rates. 

Hethod: Five Baxter •Airlile', Marquest Acorn II. 
and Satter Laboratories model #6911 nebulizers from 
two lots were tested using a three ml unit dose of 
normal saline at six and eight tilers per minute 
respectively. An accurate Puntan Bennett air 
flowmeter was used lor the lesls. 
Results: Results are shown in the table betow 



Average Nebulization Time {mm ) 
Flow Baxter Marquest Salter 

6 L/M 6.66 8-91 6. J 

8 L/M 5,47 7.37 



The difference between the Baxter and Marquest 
nebulizers was significant (t= 6 56. p = 0.000; two 
tails, i-test) The difference between the Baxter and 
Salter nebulizers was noi significant 
Experience: Our experience in the clinical setting i: 
that saving two to three minutes per ireatmeni over 
a busy shiH makes a diflerence in practitioner 
productivity and ability to complete a workload in a 
timely manner. 

Conclusion: Use ol a Mow rale ol eight UMin. a 
llme-eHicient nebulizer, and termination ol therapy 
at the 'sputter time' could increase a practitioner's 
produaive time Managers shoukJ evaluate the 
delivery ol small volume nebulizer therapy lo 
maximize productivity. 

OF -94 192 



EFFECT Ol- \ lUMIOm' AND SIMULATED PA- 
TIENT EFR^RTON AEROSOL DEPOSITION 
DURING MECTL^NICAL VENTII j\TION: 
A LABORAT(::>RY BENCH ?rUDY 

I- Fink. MS, RRT. R. Dh^d MD, ]. Jenne MD, 

M.J.TobinMD 

l^\'ision of Pulmonary and Critical Care Med 

1 lines VA Hnspital and Loyola Ur\iv, of Chicago 

Stritch School of Mtxiicine, Hines IL 

Heated humidificabon wath mechanical ventila- 
bon has been shown to decrease delivery of 
aerosol to the lun^ with STnall volume nebulizer. 
We developed a bench mtxiel to detemTii>e the 
effect of changes in relabve humidity (RH) and 
spontaneous effort cffi aerosol delivery to the 
lower respiratory tract using metered dose inhalCT 
(MDl) in intubated, mechanically ventilated adult 
pabents. METHODS: A model consisting of an 
endobacheal hibe (8.0 mm ID x 26 cm) in a plasbc 
model of a trachea (16 mm ID x 100 mm) and 
major bronchi (11 mm ID x 40 mm) was attached 
to a two aimpartment test lung ainnected in par- 
allel by a metal bar. Inflabtm of one compartment 
simulated spontaneous breaths in the other com- 
partmenL A ventilator with wick humidifier was 
used with a chamber type MDI adapter 
( AenziVent) placed in the inspiratory limb 1 5 cm 
proximal to the ET. Twelve puffs of albuterol MDI 
( lOHO pg) were given at the begirtning of inspira- 
tion during a) a>ntrol, b) pressure support (PS) of 
10 cmH^O and c) spontaneous breaths . 
Experiments were performed under dry (27° C, < 
10 % RH) and wet (35° C, llXf'/o RH) conditions 
(n=3). Albuterol deposition on filters placed at the 
ends of the main bronchi was measurt?d by spec^ 
trDpho-tometry(246nm). RESULTS: Under wet 
conditions, delivery of albuterol was greater with 
spontaneous breaths (220 ± 21|ig) tfwi cMitrol 
(182±21pg)orPS10(172±27pg)(p<0.01) Tlie 
fraction of albuterol delivered to the lower respira- 
tory tract under dry conditions (30 - 35%) was 
greater than wet ( 17 - 20"/..) in all modes (p<0.005). 
CONCLUSION: Heated humidity reduced deliv- 
ery of albuterol in this model of a ventilated sjxin- 
taneously breathing patient 

Supported by V A Research Service 



OF-S 



FFECTIVENESS OF METERED-DOSE INHALER 
■ERSUS NEBULIZED DELIVERY OF ALBUTEROL IN 
NFANTS WITH BRONCHIOLITIS. A 
M Heulitt MD. M Anders RRT, 
G Lowe RRT . P Andei 



Ark 


ansas 


Children 


s Hospi 


al. Little Rock 












INTROCnCTION: Nebu 


lized INEB) delivery o 


alb 


jtero 


IS curre 


ntly the most widely 


ace 




adminisci 


ation f 


rm used in the 


tre 




of bronc 


hospasm 


in children. 












rlem 


anstr 


ted that 


HDI del 


very is advan- 




sous 


o NEB de 


ivery b 


cause of its 








n cost to 






and to hospitals 


and time saved 


by 




ratory the 


rapists 


V Since the 


.■ff 








rtpl 


ivered via MDI 




pacer to in- 




jted 


nfants ha 


s not b 


en documented. 


the 


purpose of CJi 


s study 


was to compare 


nrii 








thi 


3 sub 


set of pat 





ade fev 
cutivel 



and NEB deli 



the Sensormedi' 



and docume 


nte 




present 


naly 


ed w 






Icoxin 






ed 


est . 


RKSOLTS : 




ultur 


e . 






Che 


tudy 


Th 


mean % change 






NKH 




ery of 






fie 


ntly 


different 


. 2h 


and 


4 h 


(26 v 




of a 


buter 


ol 


oxic 


ty with 


-y fo 


-m. CONCLnSIOK 


MDI 




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Open Forum ABSTRACTS 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1 



PULMONARY DEPOSITION OF SALBUTAMOL 
AEROSOL DELIVERED BY METERED DOSE 
INHALER (MDI), JET NEBULIZER AND 
ULTRASONIC NEBUUZER IN 
MECHANICALLY VENTI1j\TED RABBITS. 
TW FJok, MD; Mazan MAI-Essa, MD; 
Shelley Monkman. RRT: Myma RDolovich, PEng; 
Geoffrey Coaics, MD; Barry BowcQ,MScPhm; 
Haresb M. Kirpalani, MD. 
Dep( of Pediatrics, MedidDC & Nuclear Medicioe, 
McMaster Uoiversity, Hamiltoa, Ootario, Canada. 
This study was cooduclcd to compare, under 
fiiodardized experitneatal coaditioas, tbe pulmooary 
dcpositioQ and distributioo aad tbe fractiooal 
depositioQ in tbe veotilator circuit and airway, of 
xalbutamol delivered by MDI, Jet nebulizer, and 
Ultiasooic nebulizer. Salbutamol was cbosen as it is 
tbe nxist commonly used broncbodilator in infants 
suffering from bronchiolitis and BPD. Tecbnetium'99m 
labelled Salbutamol was administered through a 
tracbcostooiy (o ventilated rabbits by either an MDI 
(S puCEs, 100 ug/puff) aided with a spacer placed 
directly betweeo the ETT connection and the patient 
wye (MV15 Aerochamber, TrudcII, Canada) 
(Group 1, n=7); or by nebulization (100 ug/kg 
in 3 ml techoetium-99m labelled S% albumin). 
Nebulization was carried out for 20 mia with a Jet 
(FX-O-THRU, Hudson, USA) (Group 2 0=11) or 
Ultrasonic device (Siemens,Sweden) using either a 
standard (Group 3, n=6) or a small (Group 4, n=7) 
reservoir. Lung deposition was estimated by gamma 
counting of the autopsy lung specimens: mean(sd): 



1 7 a22(ai4) a2Z(ai4) 

2 11 L13((U1) a48(ai7) 

3 ( 334(L93) a90(a33) 

4 7 i29(202) 1QS0-3I) 



a48(ai9) 

a78((U7) 
105{L31) 



"Op 4> an other (loupi, p<aiO01 

>albutamol was imiformly distributed in the 
lungs in group 1 and 2, but showed a 
■predilection for the right anterior azygous 
lobes and the central lung regions in 
^up 3 and 4. Conclusion: in delivering 
Salbutamol to ventilated rabbits, this 
Ultrasonic device provides greater lung 
deposition but less uniform distribution than 
either Jet or MDL Reducing reservoir volume 
enhances its efficiency of delivery further, 
but also yields differential dc[X)siiion 

^ OF-94248 



DELIVERY OF SALBUTAMOL (S) TO INFANTS 

WITH BRONCHO-PULMONARY DYSPLASIA 

(BPD) BY METERED DOSE INHALER (M) AND 

JET NEBULIZER (J). TaiJJok, MD; 

Myrtia B-Dolovich, P£ne Michael TJ^ewhouse, MD; 

Sbari Gray, BScPhm; Geoffrey Coales, MD; 

Shelley Monlcman. RRT: Bosco Paes, MD; 

Haresb Kirpalani, MD. Dept^f Pediatrics 

aod Medidoe, McMaster Univer^ty, Baniett 

Aerosol Lab. Sl Joseph's Hospital, Hamiltoa, 

Ontario, Canada. 

rhis study was conducted to assess the eCOdeocy 

of aert3S0l depositioa in the lungs of in^ts using 

a direct method. There is mounting evidence that 

bronchodilaton delivered as aenisols to the 

respiratory tract can Improve the lung functioo 

and clinical state of infants with BPD. 

We compared the eCGdcncy of M and J (Medic-Aid 

Sidestream) in 2 groups of BPD infants: 

a Doo-veotilated group, Group 1 (N=9; birth weight 

STC+.^2g, post natal age S2+. 31d) and a ventilated 

group. Group 2 (N=5; birth weight 814+.252g. post 

natal age S2+.31d). Each received, in random order, 

cither *^ lechnitium labelled S from either M 

(2- lOOug puEb, 5 breaths/puff) or J (lOOug/kg in 

3ml S% albumin for 5 min); followed 24hr. later by 

the other modality. Group 1 received the aertssot 

through a £acc mask aided by a ^>accr (Aerocbamber*). 

For Group 2, M was discharged into a spacer (MV15 

Aerocbamber) placed between the ventilator circuit 

and the tracheal lube; J was inserted in the 

inspiratoiy limb of the circuiL A signiOcantly 

greater lung deposition (gamma camera estimate) 

as % of amount delivered was actiieved by J in 



Group 


1; differences were not significant in 


Group 2 


but trend favoured M: 








Bodr.«iiiu 


M: lung •• « or 


J: hmg u « of p 




(ki) 


aaouDi dcUvetcd 


.iDMii.ldclJvc.cd (p.lredl) 








meaii<ad) 




0««pl 


129(031) 


a7S<ai8) 


1.^7(030) 


aooTs 


Onxip2 


L7S(a53) 


un(a3S) 


a&S(aoe) 


030 



We conclude that in delivering S to non-ventilated 
BPD ioCants, J appears to be more effideoi than M. 
For ventilated infants M is as good as J. 



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Open Forum ABSTRACTS 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1 



Carol Hui 



, RRT 



University of Medicine and Dcnlislry of New Jersey, 
Gerry CancUi BS. Ciba-Coming DiagnoBlics Mcdficld. 
Mass Ted Konopinslci BS. RRT. Univcraily of 
Medicine & Dcnlislry of New Jersey (1) Unusual 
mixed-venous results were obuincd from a Ciba- 
Commg M270 CO-oximetcr. Initially .more than 200 
ABG-CO-oximelcr results were identified Ihal met 
the cntcria of a low Pa02 and high Sa02 
Surpnsingly, these results were consislcnlly being 
reported from chtical care patients. A total of 
greater than 40 pis were studied whose abg-CO or 
rcsulls consistently met this critena AdJilional 
pu meeting Ihc above critena continued lo he 
included CO-oximetry is routinely performed on 
mixed-venous samples to obtain information necessary 
for cardiac profiles Common among patients were 
combinations of one or more of 1) Tylenol cherry 
elixir 2) Toul Parenlcral Nutrition (TPN contaming 
greater than 10% lipids) via a tnple lumen catheter. 
This investigation was undertaken to identify possible 
causes of unusual mixcd-vcnous results.(2) We 
compared mixed-vcnous results of twenty-two control 
patients receiving 650mg cherry Tylenol elixir &/or 
TPN via a triple lumen catheter A full spectral scan 
on spectrophotometer was performed on Tylenol spiked 
venous (in-vilro). and Tylenol mixcd-venous (in-vivol 
obtained via triple lumen catheter In a non-controlled 
test, two blood donors mgcsted Tylenol elixir in a 
dosage of 650mg Venous samples were dr^wn al 30mm, 
45min. and 1 l/2hr intervals Donor venous blood 
containing concentrations of 10%,20%. 30% & 53% 
TPN (20%intralipid) tonomelcred to a po2 & pco2 of 
40mmHg. were analyzed by CO-oximetry (3) The spectral 
scan of "normal" blood and that of Tylenol spiked 
blood (in vitro) overlay profiles are identical 
Spectral scan overlay profiles of Tylenol blood 
(in vivo) vs "normal" blood showed a shift in multiple 
wave lengths of light above 625 00 nanometers 
The CO-oxuncter results of TPN concentrations of 30% 
& 53% in venous blood were consistent with our initial 
findrngs of an abnormally high 02Hb and S02 with a 
relatively low Po2 Results of non-controlled donor 
blood showed a short term drop in Po2 30min after 
ingestion of Tylenol elixir (4) We concluded ihal 
high concentrations of mtrahpids found in TPN 
caused interference in results reported by the 
M270 CO-oximetcr The cause of the resultant shift 
in wave lengths of light seen on spectral scan of 
in-vivo Tylenol blood could not be identified 
However, the components of Tylenol are unknown 
and would have to be identified and quantified 
for further study. 

OF 94-01 5R 



A NEW INTERPRETATIVE PARAMETER FOR 
SPIROMETRY PA Haiper, RFFT. MA True. RRT, 
RPFT. LB Graf. MSBME, FJ Martinez, MD Dept of 
IntonaJ Medicine, Division of Pulmonary and CnticaJ 
CareMedicme UMMC, Ann Arbor, Michigan, USA 



I Evidence 



As an adjunct to ihe inlcrprelative process w. 
lacorporaled the FEF25.75 ppd/FVC ppd ral 
suggests the FEF-,5.75 raiher than the FEV, is a more 
soisitive predictor of the presence of morphologic change 
in the lung. Early pCTipheral airway dyslimction can be 
determined and easily identified utilizing the FEFiS-TS 
ppd/FVC ppd. The dmumshed raUo when coupled with a 
reduction in sGAW provides clear evidence of penphcral 
auways dysfimction- Of the 1 672 studies reviewed for 
spmjmctiy and lung volumes, 103 studies were disallowed 
&tim the study due to premature cessation of flow and 
1099 were disallowed due to FVC values above 80% of 
predicted- Data was analyzed from 470 subjects 
successfully meeting the admission study cntcnon. 
Admission 10 the study required an FVC value of less than 
80% and good tcmuniil etTon {plateau of 2 sec. or more) 
Lung volumes were measured utilizmg the Medical 
Graphics 1085 Plcthysmograph. Spwometnc 
dctcrmiiiauons were oblamcd from ihe McdScience 3000 
and Medical Graphics 1070 systems Because FEF2S.75 is 
a calculated value, early ccsaaUon of fiow will artificially 
elevate the value thereby reducing the elTcctiveness of the 
rmio In cases v4icre spirometry is Ihe only data available 
It IS difTicult to deuamme whether the reductions observed 
m the FVC are the result of restnciive or obstrwUve 
disease alone or possibly a combination of both disease 
entibca Reduction in FEF;5.75 values establish the 
presence of airway obstruction, while mamlcnance of flow 
rates with a reduction ui FVC are indicaLve of a 
ftamcuve process The FEF25.75 ppd/FVC ppd works 
well m dclectmg restrictive and modcralc- severe 
otMtnictive panems From spirometry alone we have 
esUblished that a redo of 40% or less is an extremely 
good predictor of an increase in R V with a normal or 
increased TLC, This usually denotes significant an 
trsppmg and suggests that an associated restrictive 
disorder is highly unlikely With a ratio of 1 20% or greaia 
the lung volumes may be reduced and flow rates will he 
incjeued as related to lung volume which is suggestive of 
increased elastic recoil The FEF25.75 PPd/FVC ppd 
>^ih»nr« the mlerpretauon process 10 cases of early 
limitation lo airflow when Ihe FVC is above 80% 
predicted values This is cspeoally true when the 
FEV,/FVC IS normal or borderline The ability lo 
disunguish lung volume utilising this ratio is negated in 
cues of lung resection, neuromuscular disease and poor 

lexmmaJ effort. 

OF 94-09 



EV ALUATWN OF FOUR PORTABLE PEAK 
FLOWMETERS. Rj Sa l v MBA.RPFT. DJ Sallons 
BS,RRT Dcptof Medical Services, The Stamford 
Hospital. Siamford, CT 

Ih Introduction : The measurement of peak expuatory 
flow (PEF) IS widely accepted u an important mdicaior : 
the assesimcnt of bronchospasm The use of portable 
peak flowmeierWPFM) has gained increased acceptance i 
this regard The National Asthnu Education Program 
(NAEP) has act uandards" lo which these meters should 
adhere This study was designed to evaiuaie four of the 
newer PFM on the maikci. Personal Besi~(PBl Poekei 
Pcak™lPPl The Peak™(Pl and Spu--o-rtow™tSFl. 
(21 Method Tarpel Hows of ATS wavefomi *24 were 
produced using a cabbraicd waveform generator. Ten um 
of each brand mcttr were tested ai four fkiw rates, each 
flow was repealed five times Readings were taken by a 



^gleo 



rfor. 



Qdevic 



nearest 5 L/M The data obi 
to NAEP guidchnea lor ace 
device vanability 
(31 Resulls 



target flow 125 6 L/M 



largci flow 300.3 L/M 



target flow 5005 L/M 



target flow 719.1 L/M 



00 






2.7 



•• some dau off scale, — scale ends at 720 L/M 
A = ACCURACY = % difference trom target 
V = INTER-DEVICE VARLABOJTY ^ % cocfSaert of var. 
R = REPRODUClBlLrrY - % wHhin 5% range or 10 L/M 

(4) EB, penenge : Portable PFM should be easy to read and 
reliable enough lo ensure that readings obtained are useful 
rellecUons of current patient conditions. Many devices 
used in the past have not been rcluble for home use 

(5) Conclusions . There are large variations in ihe products 
tested as they compare to the standards set by the NAEP. 
The PB was the most accurate as wcU as ihc easiest lo read. 
Although no PFM lesied completely met NAEP standards 
at aU flows, only the SP faded Ihe standards al flow rates 
commonly encountered in the assessment of patients with 
airways disease The PP and P had problems with the high 
flow tested Clinicians should be aware of specific product 
performance before they recommend PFM for patient use 



PATTERNS OF AIRWAY RESPONSIVENESS IN 
ASTHMA PA Harper. RPFT, CM Foss. RRT. RPFT. 
MA True. RRT, RPFT. LB Graf. MS BME. FJ Martinez, 
MD. DcpL of Internal Medicme. Division of Pulmonary 
and Cnucal Care Medicme 
UMMC. Ann Aibor, MI. USA 

To date, a positive response to methacholine challenge has 
been viewed as an obstructive process characterized by 
changes m FVC. FEV, and sGaw The UMMC laboratory 
designates a positive response based on a decrease m 
FEVj >= 20% Although the seventy of obstiucUon has 
been quantified in most laboratoncs based on a change m 
FEVj It has been noted that mdjviduals expencnong 
cpisoaic bronchospasm may present with a preserved 
F^Vj/FVC raUo Anecdotal cxpenence has suggested that 
a similar situation can be observed m bronchoprovocation 
testing. We hypothesized that patients could be divided 
into catcgones based on the pattern exhibited with 
spirometnc measuronents during the chaflenge A 
restnctive pattern is defined, for purposes of Ihis study, as 
one m which the FEV,/FVC raUo is mamlamed to withm 
3% of flic baselme value An obstructive pattern is defined 
as one m which the FE V, /FVC raUo decreased by 4% or 
more as a result of the testing procedure. We 
retrospectively examined bronchoprovocation tests 
performed m the pulmonary laboratory spanning a six year 
period. The study populaUon was comprised of 1 1 1 
subjects, mcludmg 4 1 moles and 70 females, age 1 7-71 
yeBi3, height 61-73 mches, and weight 110-265 pounds 
Spirometry was performed utiltzmg the Medical Graphics 
1070 system and the MedScicnce 3000 system 
Calibration and spirometnc measurements were performed 
in accordance to current ATS guidclmcs Hyper-rcacuve 
responsiveness was associated with a dccbne in ihe FEVj 
>a 20% Sixtv-thrce subjects wac classified a.s non- 
reacuve and did not demonstrate a drop of 20% m the 
FEV| Forty-eight subjects were classified as reactive and 
demonstrated a decline m the FEV, >= 20% Of flicsc 48 
subjects. 14 (29%) preserved the FEVj/FVC raUo to 
withm 3% of Ihe base line value This group with the 
restncuve patlcm not only maintamed then FEV, /FVC lo 
withm 3% of their baseline, but also rruuniainod their 
FEF25,75/FVCppd, thus exhibiting a prescrvaUon of the 
Dow to volume relationship at low lung volumes (FEF25. 
75 %prediclcd / FVC % predicted is a new raUo uUlized 
ID the UMMC lab to assist m flie inlcrpietaUon of 
peripheral airways dysfunction ) The 34 rcmaimng 
reactive subjects (71%) were classified as obstructive 
This group exhibited greater declines in FVC, FEVj. 
FEF25.75. and reF25.7; /TVC ppd ihnn the restnciive 
group The flow to volume relationship may be nuunuimcd 
in the face of significant bronchospasm A prospective 
study of pulmonary mechamca dunng brondiopTOVocation 
testing moy be valuable in identifying the physiology of 
this restnctive pattern 

OF-94 1 



MAINTENANCE OF THE RV/TLC RATIO IN 
RESTRICTIVE DISEASE PA Hmper. RPFT. MA 
True. RRT. RPFT. LB Graf. MSBME, FJ Mflitincz, MD. 
Dept of Internal Medicine. Division of Pulmooary and 
Critical Care Medicme. UMMC. Ann Arbor. Michigan, 
USA 



Id a Dormal population the residual volume 1 
approximately 20-30% of the total lung volume. This ratio 
of residual volume to total lung capacity is essenUally the 
same regardless of size. A retrospective analysis was 
conducted on subjects tested at the University of Michigan 
Pulmonary Laboratory dunng the year^ of 1991 through 
1 994 In reviewmg 4.5 1 2 subject tests the RV/TLC rauo 
ranged from 10% lo 80% with the greatest distnbution 
occumng between 30% and 40% All subject tests were 
uicluded m this analysis regardless of their respective 
respiratory status. The subject population mcluded 2.238 
males and 2J.14 females, aged 17 to 94. height 51 uiches 
to 80 mcbes and weight 60 pounds to 465 pounds. The 
subject populauon was divided mto three broad catcgones 
based on ethnic backgrounds: Black 634. Caucasian 3,806 
and Other 72- All fimcUonal residual capaciUes were 
measured utilizing a Medical Graphics 1 085 
Plethysmograph. All spirometnc determinations were 
measured utilizing the Med Soence 3000 and Medical 
Graphics 1070 systems. Predicted values from Moms and 
Miller were utilized m the stiwly All procedures were 
performed m accordance to ATS standards. From the 
4.512 snidy populauon, 59 subject tests (1,3%) exhibited a 
R V/TLC ratio of less than 20% Twenty one of the 59 
subject tests were clearly identified as Quality Assurance 
issues while 10 subjects were the restilt of the vanancc of 
the measurement at such small volumes. Only 3 subject 
tests were identified as having a residual volume of less 
than 50% which could not be attnbuted to methodology or 
quality assurance issues. This data is supportive of the 
theory that the area of apposition establishes a boundary to 
which no greater reduction m volume can occur. Tbis 
enables the maintenance of a RV/TLC ratio equal to 20% 
in even the most severe restnctive ventilatory disease. 



METHACHOLINE PROVOCATION TESTING ; ITS 
SAFETY IN A DIVERSE PATIENT POPULATION, 
LaskowtkiDlVlR.PFT- . Unge PA MD,. Stoller JK 
MD . Kavuru M M.D , McCarthy K, RCP T The 
Cleveland Clinic Foundalioo. Cleveland. Ohio. 44I9S. 

Melhacholinc Provocation testing (MPT) is a 
safe and sensitive test that aids ihe chniaan in the 
diagnosis of asthma 0\'cr the last two years we have 
noted a significant increase m quenes from outside 
physicians and techmcians regarding patient selection 
for MPT and the safet> of the procedure We rc\iewed 
MPTs done over a 1 7 month penod m our outpatient 
department 

Six hundred and twent>' five patients 
under^eni MPT between 5/89 and 9/90 Clinical 
indications for testing included cough, dyspnea and 
chest tightness Two hundred sevcnl>' eight of those 
tested (44%) had a decrease of > 20% in the FEVl, of 
whom 64% were females Twenty nine percent were 
currently on or had been on bronchodilaiors (when 
possible none x 24 hrs) pnor to testing 

Average age was 48 years (range 7 - 90). 62% 
were females. 13 4% were mmonlies The lowest FVC 
al baseline was 1 23 L (40% of predicted), the lowest 
FEVl at baselme was 96 L (37% of predicted) and 
the largest decrease in FEVl was 69% at 5 cumulative 
dose Ufuts (CDU's) There were no scr 
warranting physician intervention 



Patienis si 


ratified bv degrw of obstruction 


% 

PREDICTED 

FEVl 


« of PIS. 


• 
Positive 


% 
Positive 


>80% 


ifS 


164 


36 


66-79% 


iro 


59 


.54 


46-65% 


44 


32 


73 


<45% 


14 


n 


93 



Wc conclude thai MPT can be safeh pcrfonncd in a 
dixcrsc paticnl population, including those Mith 
moderate to severe air\\a\ obstruction 




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Open Forum ABSTRACTS 



RESPIRATORY CARE • NOVEMBER 94 Vol 39 No 1 1 



PRESSURE APPLICATION TIME 
AND THE INCIDENCE OF 
HEMATOMAS FOLLOWING 
ARTERIAL PUNCTURES. 

Tom Taylor RRT . Sandee Cegielski RRT. 
Leonard Spechl MD, School of Allied Health 
Professions. Victor Valley College and Loma 
Linda University, Jerry L Pettis Memorial 
Veterans' Medical Center. I 120! Benton 
Street. Loma Linda. California 92357 

Previously we reported that direct 
application of pressure for 10 min to the site 
of an artenal puncture compared to the use 
of a pressure dressing had a lower incidence 
of hematomas The purpose of the present 
quality improvement investigation was to 
determine if pressure applied to the site of an 
arterial puncture could be reduced to the 
minimum time required to achieve 
hemostasis without increasing the incidence 
of hematomas For 12 months our 
respiratory care slatTwas instructed to hold 
arterial puncture sites for 10 min in the tlrst 
group of patients For the next 3 months, we 
advised the statT to hold pressure to the 
arterial puncture site until hemostasis was 
achieved and record this time in the second 
group Patients were examined at random 
within 24 hours of the arterial puncture A 
hematoma was judged to be present if an 
area of induration of J 10 mm in diameter 
was present We tbund in the first group that 
10 of 145 (7%) patients that had pressure 
held for 10 min had hematomas In the 
second group of patients that had pressure 
held only as long as needed to achieve 
hemostasis (3 6+ 1 6 min ). 10 of 141 (7%) 
developed hematomas (p^ns) We conclude 
the lime required to achieve hemostasis 
following arterial puncture is usually much 
less than 10 min Holding pressure beyond 
the lime needed to achieve hemostasis does 
not decrease the rate of hematomas 



EVALUATION OF LOW FLOW RANGE OF THE 
ASTECH PEAK FLOW METER (PFM). Gail Ellison 
RS. CPFT. RRT . Jim Kccnan BS, RRT, John Salycr 
BS. RRT. Respiratory Care Service. Primary 
Children's Medical Center. Sail Lake City. Utah. 

INTRODUCTION: The Aslcch PFM {Center Labs. 
Port Wa-shingion. New York) is described by the 
manufacturer as a full range device and is graduated 
from 30 lo 880 L/m, Wc sought lo test the accuracy 
of mcasurcmenis made in ihc low (pediatric) range of 
the device. METHODS: 10 PFMs were tested. A 
Servo 900 C was configured lo generate How wave 
forms m volume control mode of = 40. 80, & 120 
Urn. Flow rale was measured with a Timclcr RT 200 
scl in the 0-180 L/m range (reported accuracy 1% of 
reading). 10 mcasurcmenis were taken on each Asicch 
followed by 10 mcasurcmenis on ihc Timclcr. Mean 
and SD were computed for each device and then all 
PFM's and differences at each level of flow were 
tested with Student's t-lcsl, wiih signincance set at 
005 RESULTS: 

Row in L/m 
Mean SD P Value 

Timclcr @ 40 L/m 

Aslcch @ 40 L/m 

Timclcr @ 80 L/m 

Aslcch @ 80 L/m 

Timclcr @ 1 20 L/m 

Aslcch @ 120 L/m 



40.2 


.73 




34.2 


3.6 


0.002 


79.4 


1.1 




71.9 


4.1 


0.001 


120.3 


1.0 




ins. 7 


iJ 


0.0001 



DI.SCLSSION: There arc clearly both clinically 
important and stalislically significant differences 
between flow rales measured by ihc Timclcr versus the 
PFM's. A broadly accepted standard for testing peak 
flow meters is ihc use of the 'Waveform 24" flow 
generator from the American Thoracic Society 
Siandard Test Waveform Set. However, software for 
this device is nnl currently available for testing of the 
lowest now rate of PFM's. Thus, we developed our 
model. Clinicians wanting to know the accuracy of 
PFM's in Ihc pediatric range currently have little 
choice but lo develop their own testing models. The 
Bllcmalive is lo uncrilically accept the manufacturers 
claims. Wc intend lo further lest these PFM's when 
better wave form generating minJcls bcci>me 
available. Our model may not allow us lo draw strong 
conclusions about the accuracy of ihcsc PFM's, but it 
leads us to be concerned that there may be considerable 
differences between PFM's in the low How range, We 
intend to reproduce our curreni study using nihcr 
brands of PFM's. 



DIFFERENCiiS IN DICO VALUluS C-AUSIilJ HY 
DIFFERENCES IN AUFOMAlTiD ANALYSIS 
TECHNIQUE Kimbcriy R. Batch. RPFT . CamI A. 
Nagcl. BS RPFT. WillJam A. Slivka. RPFT. Frank C. 
Sciurba, M-D.; Umvcmty of Pittsburgh Medical 
Center. Pittsburgh. PA. 

Automated analysis techniques made possiNe by 
advances in computer and analyzer technology have 
resulted in many commercial products for the 
detcrminalion of carbon monoxide diffusing capacity 
(DLCO). Individual or longitudinal measurements are 
used for diagnosis and Irealmcnl of lung disease and 
as an epidemiological tool. Accurate and repnxlucible 
roeosuremenls arc thus paramount. While equipment 
quality control and performance standards have been 
established (ARRD 136:1299). we propose that the 
very different approaches used by industry to meet 
these standards may result in potentially significant 
differences in measurement values. We present 
preliminary data supporting the existence of this 
problem in our laboratory, wc also sampled the 
frequency of this problem in outside laboratories and 
suggest potential mechanisms which may account for 
these differences. Five consecutive normal patients 
were evaluated using 3 distinct technologies to 
measure DLCO. as well as six selected patients with 
emphysema using at least 2 different machines. AIS 
standards were followed and optional vanablcs were 
standardized. We informally surveyed twenty outside 
laboratories lo assess their documentation of the 
problem. We obtained specifications and other 
information from manufacturers in order lo elucidate 
potential causes for these differences. The greatest % 
difference between any devices in normal individuals 

individual, and for the emphysema patients 33 +/- 
16% with an extreme of 51%. Seventeen of twenty 
outside laboratories surveyed had not observed a 
problem and were not aware that such a problem 
could exist. Three laboratories had observed 
qualitatively similar differences and had modified 
laboratory procedure in an attempt to compensate for 
these differences- Differences in equipment design 
which can account for this variability include: 
diflerences in analyzer response time, accuracy and 
stability; inspiratory pressure required to activate 
demand valve Dow and idiosyncratic mathematical 
adjustment factors and hardware differences in dead 
space washout and collection technique. We conclude 
that diffeienccs in DLCO measurements can be due 
entirely to differences in equipment design. This 
problem is not widely appreciated. Our data supports 
increased standardization of technologies and internal 
laboratoiy control ensuring longitudinal testing on 
similar equipment. Supported by the George Love 
Research Fund. 
OF-94.183 



SINGLE BREATH CARBON MONOXIDE: 
DIFFUSING CAPACmr (DlCO): A 
COMPARISON OF TWO TECHNigUES. 

. MS. 



National Jewish Center for Immunology 
and Respiratory Medicine, Denver. CO. 
Introduction: The guidelines recommended 
by the American Thoracic Society state 
that systems that have modified the 
traditional bag-In-the-box technique 
should be compared to that traditional 
technique to ensure that the DlCO value is 
not altered. TTie purpose of this study was to 
compare DlCO measurements between the 
traditional bag-in-thebox (BB) and the 
relatively new real-time gas analysis 
technique (RTGA). Methods: Twenty-five 
ibjects |15 healthy {Group 1) and 10 non- 
heaJthy (Group 2)| perlbrmed at least two 
acceptable DlCO trials on each technique 
randomized order. The raw data from 
each technique (le.. gas concentrations. 
Inspired volume, breathhold time) was put 
Into a single computer for calculations of 
DlCO and alveolar volume (Va). A paired t 
test was performed on the mean DlCO and 
Va values from each technique and each 
group. RestUts: The mcaji DlCO and Va 
values (± 1 SU) for the BB technique were 
29.62 ± 12.53 ajid 5.58 ± 1.66 respecUvely. 
The mean DlCO and Va values (± 1 SD) for 
die I^'GA technique were 27.12 ± 1 1.56 and 
5.47 ± 1.65 respectively. The difference in 
DlCO values between the two techniques 
(2.50 ml/inln/mmMg) was statisUcally 

Ignlficant (p-0,0001) but were highly 
correlated (R-^=0.958). The difference In Va 
values between tlic two techniques (0. 103L) 
: not statistically significant and were 
also highly correlated (r2=0.936). The ratio 
of DlCO/Va had a dllTcrcncc between the 
two techniques of 0.331. which was 

taUstlcally significant (p=0.0026). 
Conclusion: We conclude that there Is a 
statistically significant mean difference 
between the two techniques, but that this 
dlficrcnce may or may not have clinical 

IgnlHcancc. Additionally, wc conclude 
that separate predicted values should be 
used. ^c «^ o. 



INTEROPERATOR VARIABILITY USING A NONIN 
8500 HAND HELD OXIMETER: John Salver BS. 
RRT . Jeff Wnght, BS. RRT. Respiratory Care 
Service. Primary Children's Medical Center. .Salt 
Lake City. Utah 

INTRODUCTION: It is commonly held among 
clinicians that hand held pulse oximeters can yield 
different fmdings on the same patient if operated by 
different practitioners. Thus we set out to determine 
if different practitioners obtained signincantly 
different data on the same patient using the same 
oximeter on successive readings. METHODS: 
Pulse oximeter determinations of SaO; and heart rale 
were obtained on 27 non-neonatal pediatric patients 
using Nonin 8500 hand held oximeter. All subjects 
were non-ICU inpatients and had variety of medical 
and surgical conditions. Three immediately 
consecutive readings were lakcn from each patient 
by ihrcc different clinicians who were each blinded 
to the others findings. Two of the three clinicians 
were respiratory care praciiiioners while third was 
the nurse assigned to the patient. All pcrsoruicl had 
been trained in the proper application of a pulse 
oximeter, although no special training took place at 
the lime data gathering took place. TTic site of 
protx: application was not controlled, as this sludy 
was intended lo mimic clinical practice. Data were 
not obtained if heart rate displayed by the pulse 
oximeter did not agree with the patients true heart 
rate ± 5 bcais per minute. Mean values and siandard 
deviations were determined for each group of 
clinicians and differences in saturation readings 
between each different group of clinicians were 
tested for significance using ANOVA with 
significance set at 0.05. RESULTS: Paiienis 
ranged in weight from 3.9 to 350 Kg (mean 11.2 
months), and in age from 1 to 132 months (mean 
23.1 months). SaOjdaia are summarized in the 
tabic below: 



SD 



3.8 



4.5 



There were neither clinically important nor 
stalislically significant differences in the data 
reported by each diffcrcnl group of clinicians 
(P-0,98) CONCLUSIONS: There appears lo be an 
acceptable amount of interoperaior variability when 
using ihis device in a pediatric population when all 
personnel arc properly trained in oximeter 
application. 



ASSOCIATIONS BETWEEN RESPIRATORY 

SYMPTOMS ALGORITHMS AND LUNG 

FUNCTION PARAMETERS. 

SF Knulscn.PhD. J Pelcrs.MD . P Enright.MD. 
R Burchcttc MPH. and D Abbey. PhD. 
Department of Preventive Medicine. Loma Linda 
University. Loma Linda. CA 92350 

The purpose of the present study is lo investigate the 
association between symptoms of respiratory disease &s 
ascertained by mailed questionnaire and lung function. 
Our study population is part of a cohort which has been 
followed since 1977 with questions on respiratory symp- 
toms, smoking and exposure to air pollutants ouldoon, at 
home and in the work place Lung function was assessed 
in 888 females and 526 males, aged 40-79 and included 
spirvmctry pre- and pust-bronchodilator and three or 
more days of acceptable peak expiratory (low measure- 
ments. In addition, the participants completed a question- 
naire containing standardized respiratory symptoms 
questions from the American Thoracic Society question- 
nain: as well as questions on smoking and medication 
use Computer algorithms were used a priori lo classify 
individuals as having dcfinile possible or no symptoms of 
AOD and aslhma based on individual responses to the 
respiratory symptoms questions. The mean values for 
FEV, and FEV./FVC according to respiratory disease 
category differed significantly as shown below 





N (») 


FEV, 


FEV./F^C 


P (ANOVA) 


< 001 


<00l 


Aon 








MALES 








Dcfmilc 


86(16 3) 


2,91 


680 


Possible 


122 (23.2) 


3,14 


739 


None 


3IB(60S) 


3 29 


74 7 


FEMALES 








Dcrmilc 


126(14 2) 


2 15 


74 1 


Pi.siible 


182 (20 5) 


2 19 


76 


None 


580 (65 3) 


2 31 


75 9 


ASTHMA 








MALF^S 








Definite 


31 (5.9) 


2 71 


61 4 


nmlblc 


23 (4 4) 


3 20 


70 6 


None 


472 (89 7) 


3 22 


74 2 


FEMALES 








Derinile 


52 (6 0) 


2 05 


72 1 


Pl>S!llblC 


45 (5 1) 


223 


778 


None 


790 (89 0) 


228 


75 8 



The findings for FVC. FEVy,, and PEF will al.s» be 
presented Our findings indicate Uial using standar\li/cd 
re.%itiratory symptoms questions to identify persons with 
dcfmilc. (HLNkiblc and no AOD or asthma is fcasihlc 

OF-94-219 



The Most Versatile Pulse 
Oximeter I 



Simple, Durable 
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1 00 Hours Typical 
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Printer Capability 



:18 



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The Nonin Model 8500 has 
redefined the industry 
standard for hand-held pulse 
oximeters. The bright LED 
displays, simple operation, 
and outstanding battery 
performance make it ideal 
for spot checks or transport 
monitoring. Amazingly 
durable, the 8500 may be 
used with Nonin reusable or 
disposable sensors to con- 
veniently monitor infants, 
children and adults. The 
new memory option offers 
documentation capabilities 
previously not available in a 
hand-held oximeter. 

If you are looking for a 
hand-held oximeter to use 
in the hospital, ambulance, 
or aircraft, the Nonin 8500 
offers reliability, accuracy, 
and simplicity in a uniquely 
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612-555-9968 
800-356-8874 



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Open Forum ABSTRACTS 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1 



IDENTIFICATION OF OLDER 
ASTHMATICS USING PEAK FLOW 
LABILITY 

DE Abbey. PhD. SF Knulscn. MD. PhD. R 
Burchcttc. MS. WF McDonnell. MD. BA Pelcrs. 
RRT. Center for Health Research. Loma Linda 
Univcrsily, Loma Linda, CA. USA. 

Idcnlification of asthmatics who present 
with esscntjally normal spirometry requires a 
careful history, and for objective conFir- 
maiion, a bronchial challenge test which is 
neither inexpensive nor without patient 
discomfort. Peak expiratory flow (PEF) 
lability based on multiple daily measures 
may be helpful in identifying patients with 
increased bronchial reactivity. The Mini- 
Wright Peak Row Meter was used to compare 
the lability index (PEF max - PEF mm / mean 
PEF) with the National Heart. Lung, and Blood 
Institute (NHLBl) Respiratory Symptom 
Questionnaire (RSQ) on self-reported asthma. 
The RSQ was admmistercd to all subjects and 
they were mstructed m PEF measures. The 
best of three PEF measures four limes a day 
were recorded on a pre -printed diary and 
returned after seven days. Subjects consisted 
of 1414 male and female non-Hispanic. White, 
non-smoking. California residents from an 
Adventist Health Study cohort who have been 
followed since 1977 with periodic assessment 
of RSQ. A total of 1251 subjects, 771 women 
(mean age 65,2 years, range 43-79) and 480 
men (mean age 66.4 years, range 43-80), had 
accepuble PFTs and PEF measures and RSQ 
data. As determined by RSQ, there were 42 
cases of definite asthma in women (5.6%) and 
29 cases in men (5,9%). PEF lability in women 
asthmatics was 14.5% (SD 8.0); non-asthmatic 
women had an index of 10.9% ( SD 6.4); for 
men 14.9% (SD 7.5) and 10.0% (SD 5.8) 
respectively. These differences were 
significant by t-Test {women p=0.001; men p 
<0.0001). The sensitivity of PEF lability for 
detection of self-reported asthma in women 
was 54.8% with a specificity of 69.4%; for 
men. 58.6% and 73.4% respectively. These 
results suggest that PEF lability can be a 
simple, cost-effective method to assist in 
identifying and following older asthmatic 

subjects. Funding provided by • gruU from the EPA 

OF 94-245 



COMPARISON OF PEFR OF MINI WRJGHTS AND 
ASSESS PEAK FLOWMETERS TO VOLUME 
DISPLACEMENT SPIROMETRY Gayc BsdgweU RRT, 
Pat Wahcn BA RRT RPFT. Vanthiyi G»n MD. 
ChUdrcn's Medical Center of Dallu, D&llu, Tcua 75235 

STUDY PURPOSE: To determine which brand of peak 
flowmeter la the moat accurate as compared to the volume 
displacement spirometer 

SETTING Clinical, objective, observaliotial study. 
SUBJECT Convenience sampling of 34 children ranging 
in age from 4 yean to 17 years, all of whom have 
diagnosed reactive airways disease. 
MATERIALS ATOD METHODS: Each patient 
performed a pre and post bronchodilator flow-volume 
loop on a P K. Morgan Spiro-Qow volume displacement 
xpuDmclcr, as part of their outpatient visit. Each subject 
was then asked to perfonn the PEFR maneuver on the 
Assess peak flowmeter (x 3 trials), and again on the Mini- 
Wright's (x 3 txiab) within thirty minulca of Oieu- post 
bronchodtlator apiiomeUy measurement. Every other 
subject was asked to use the Mini-Wright's first with the 
Assess second and vice vcraa. Using the student T-test 
statistical analysis program, the PEFR'i were compared 
as follows; Spirometer to Assess. Spirometer to Mini- 
Wright's, Assess to Mini-Wrighfs. 

RESULTS: PEFR's obtained from the Assess and Mini- 
Wright's were both significantly different when compared 
to the volume displacement spirometer (P = <0,05). 
PEFR's obtained from both peak flowmdera when 
compared to each other were NOT significanUy different 
(P= >0 05), Comparing the Aascss's values to the Mini- 
Wright's also revealed the following trend: The Assess 
PEFR value was lower than the MW's 55% of the time. 
The Assess PEFR value was higher Oian the MW's 32% 
of the time, Tlie two peak flowmeters were actually equal 
12% of the time 

CONCLUSIONS: The Assess peak flowmeter and the 
Mini-Wnghfs peak flowmeter do not accurately reflect 
PEFR when comftared to a volume displacement 
spirometer. When meter are compared to each other, the 
readings are similar. An Assess peak flowmeter costs our 
hospital around $15,00. whereas a Mini-Wright's peak 
flowmeter costs us around $28,00, Both meters have a 
one year warranty issued by their manufacturer. We 
conclude that it is more cost-effective using the Assess 
peak flowmeter rather than the Mini-Wright's in certain 
populations It is suggested that more research be done to 
determine how each meter ages, how many meters 
patients lose, etc This would help understand overall cost 
effectiveness. What is most important to remember, 
however, is that due to the trend of the peak flowmetcra 
lo be equal only 12% of the time, it is recommended that 
the same brand of peak flowmeter be used when 
measuring a patient's Peak Expiratory Flow Rate trends. 

OF-94-24: 



COMPARISON OF TRANSMITTED VS, 
REFLECTIVE SP02 VALUES IN PATIENTS 
WITH DIGITAL CLUBBING 

Timnlhv A William,-! . AS . RRT. 

Children's Hospital Medical Center. Cincinnati, i 



INTRODUCTION: Pulse oximetry is i 



, The I 



controversy as to 
whether transmitted (TPO) or reflective pulse 
oximetry (RPO) is better in patients with digital 
clubbing. For this reason, some caregivers have 
chosen RPO over TPO in pcdiatnc patients with 
digital clubbing This study analyzed the difference 
between these two methods in a population of 
pedialnc Cyslic Fibrosis patients METHODS: A 
Ncllcor N-IO pulse oximeter, verified with die PT-10 

index finger (DS-lOO transmitted sensor) and from 
1cm above Uie right eyebrow (RS-10 refleclive 
sensor. Nellcor Inc.. Hcyward. CA). Three samples 
were obliiined from each site. The patients were 
placed into three groups according to the level of 
clubbing; control (Nil), mild (N = 19) and severe 
(N =23) as described by Kendig Et. Al. (Disorders of 
The Respiratory Tract in Small Children). 
RESULTS: Siudenfs T-Tcst was performed on all 
samples on each group Control TPO = 96.4 SD 75. 
RPO 97 2 SD 1,16- Mild TPO 96.3 SD .74. RPO 
96 6SD 111 Severe TPO 92.6 SD .98. RPO 94.5 
SD 1 .56 The analysis of Oie variance between the 
mean differences of RPO and TPO between the 
groups was not sutislically significant. The control 
group compared to mild and severe was P = 0.17 and 
P = 13 respectively. Comparison of mild to severe 
clubbing was P=0 09 CONCLUSIONS: A trend of 
RPO values 2% higher than TPO was observed in the 
severe group. No statistical evidence that rcncclcd 
SjOZ values read higher than transmitted values in 
patients with digital clubbing was found Although 
this study was limited by patient population, a larger 
multi-center study lo include CO-Oximctry may be 
indicated nF-Od-nifil 




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Open Forum ABSTRACTS 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1 



SAFETY AND EFFICACY OF MINI- 
BRONCHOALVEOLAR LAVAGE (MINI-BAL) 
PERFORMED BY RESPIRATORY 
THERAPISTS FOR THE DIAGNOSIS OF 
VENTILATOR-ASSOCIATED PNEUMONIA 
(VAP). 

Kevin R. Bock. OS. RT : Rodger Richards. CRTT; 
Mann H. Kollef, M.D. Washington University 
School of Medicine, St, Louis, MO 

Introduction: The current diagnostic standard 
for the evaluation of suspected VAP is the 
broochoscopically guided protected specimen 
brush (PSB). We evaluated the safety and 
accuracy of mini-BAL. performed by respiratory 
therapists using a telescoping catheter (BAL 
Oath, Ballard Medical Products. Draper. Utah) as 
a non-bronchoscopic technique for suspected 
VAP. Method: Definitions for the presence or 
absence of VAP were modified from those taken 
from the ACCP (Chest 1992; 102:5535)and used 
to delermme the individual test's performance 
charactenstics (i.e., sensitivity and specificity). 
Mmi-BAL was performed by instilling 25 cc of 
sterile salme through the BAL-Cath with a synnge 
and then respiniting. Safety was assessed by 
comparing patient head rate, mean artenal 
pressure, and artenal oxygen saturation (using 
pulse oximetry) at baseline to the worse value 
obtamed dunng or withm 5 minutes of the 
procedure. Quantitative thresholds of > 10^ 
cfu/mL were required for both the PSB and mim- 
BAL to be supportive of a diagnosis of VAP. 
Results: No complications occurred in the 
performance of 41 mini-BAL procedures. Safety 
profile data is shown in the table below. Twenty- 
four PSB samples were obtained for companson 
with 18 of these paired samples obtained in 
patients already receiving antibiotics. The 
respective sensitivity and specificity values for 
these 24 paired samples are as follows: mini-BAL 
100%, 93%; PSB: 57%, 100%. Experience: Our 
experience suggests that respiratory therapists can 
safely perform mim-BAL m mechanically 
ventilated patients. Conclu^iion: Future studies of 
nonbroDchoscopic techniques, performed by 
respiratory therapists, to sample lower airway 
secretions appear warranted based on these 
preliminary data demonstrating their safety, 
relative accuracy, and cost savmgs ($587 for PSB 
versus $95 for mini-BAL). 



Prior t 



= 41) 



i-BAL 



^ value p valui 



SaO, (%) 96.8jL3.2 96.0±3,1 0.2568 

Heart rate 99.6jLlO,8 I00.7±10.5 0.6425 



PULMONAHY REHABILITATION REFERRALS 
FROM A RESPIRATORY CARE 
ASSESSMENT/TREATMENT PROGRAM 
JONI D. COLLE B5,RRT,RN 
KEVIN L. SHRAKE MA, RRT 
Me:norial Medical Center 
Springfield, Illinois 

INTRODUCTION: A respiratory care 
assessment/treatment: program was 
initiated m our 530 bed teaching 
facility in July 1993. By May 1994, 
Respiratory Care Practitioners (RCPs) 
were performing assessments and 
utilizing physician approved 
protocols on 70% of our patient 
load. In addition to lowering costs 
and improving communication, the 
assessment process has provided an 
additional mechanism for pulmonary 



ehabi 



itati 



tha 



improved quality outcomes. METHODS: 
Patient assessment sheets were 
retrospectively audited for 
suggested referrals to our pulmonary 



ncide 



ell 



itor 



RESULTS: Over a nine month period, 
650 surgical and 100 medical 
patients were evaluated for their 
respiratory needs. Five new 
referrals to pulmonary 
rehabilitation were generated 



suit 



.ng 



four 



hom 



xyge 



EXPERIENCE: The RCPs 
was expanded beyond cask orientation 
to include enhanced patient 
assessment skills. When patients did 
not respond to titration from 
oxygen, further intervention was 
required from pulmonary 
rehabilitation. Consults obtained 
directly from the assessment process 
resulted in identification of new 
home oxygen patients. In addition, 
these patients were provided with 
instruction on breathing control and 
self care techniques. 
CONCLUSIONS: The presence of a 
patient assessment/treatment program 
resulted in improved patient 
outcomes by identifying and reacting 
to home oxygen needs that were not 
being addressed through traditional 
care plana. 



BHNHFITS A.SSfKlATED WITH A RESPIRATO 
RV CARi: A.SShSSMENT-TREATMENT 
PRlXiRAM RESULTS OF A PILOT STUDY 
Kevin L.Shrjke MA RRT . John E Scaggs BS RRT, 
Kevin R England BA, Joseph Q Henkle MD. 
and Lanie E Eaglcton MD 

BACKGROUND: During ihc months of July. 
.-\ugust. and September 1993, we implemented a res- 
piratory care asscssment-lrealment pilot study on Ihc 
orthopedic surgery tloor in our liospii.il The purpose 
».f Ihc sliidy was to detcmiinc Icasihilily and establish 
cosl-ellci.li\c Ircalmenl pLuis with quality palieni oul- 
tomes, while maintaining appropnalc 
communications with physicians and nursing staff. 
STUDY DEVELOPMENT & 
IMPLEMENTATION: The study's Task Force 
developed protocols for oxygen ^erapy. aerosolized 
medication therapy, volume expansion therapy, and 
bronchial hygiene therapy using the American 
Association for Respiratory Care's Clinical Practice 
Guidelines xs supporting documents. Meetings wen: 
held with the orthopedic surgeons and nursing staff to 
inform them of the key components of the pilot pro- 
gram. Ten patient evalualors were trained to assess 
patients ;ind implement treatment plans. EVALUA- 
TION METHODS: A reference book was established 
that contained the protocols and support material. 
Patient outcomes were evaluated using previously es- 
tablished quality assurance plans. The length of stay, 
procedural volume, and cost data were collected. 
EVALUATION RESULTS: More than 50% of the 
orders received dunng the pilot program were for 
"Respiratory Care Protocol." This allowed the patient 
c;u"e evalualnr the tlexibility to initiate one of the ap- 
proved protocols if indicated. No changes in patient 
outcomes were noted and average length of shy 
remained unchanged during the pilot study compared 
to the base period. Treatment volumes decreased, re- 
sulting in identified cost savings of $5.3 1 8 during the 
study. Nurses and physicians supported protocol im- 
plementation, and increased communication among 
caregivers was documented. We believe that profes- 
sionalism of the RCPs was enhanced without comprtv 
mising the ultimate decision- making re.sponsibilities 
of the physician. CONCLUSIONS: The use of respi- 
ratory care protocols is an acceptable method of de- 
veloping clinically effective and fiscally responsible 
care plans. RCPs at our hospital were able to imple- 
ment care plans that resulted in cost savings without a 
measured change in patient outcomes. Approval has 
been extended from the Executive Committee of the 
medical staff to expand hospital-wide. [Respir Care I 
994;39(7)7l5-724] 

OF-94-052 



VALIDATION OF THE TRIAGE RATING 
SYSTEM 

IN THE RESPIRATORY THERAPY CONSULT 
SERVICE 

Dennis K. Giles . RRT. E, Lucy Keslcr, MBA, RRT. 
James K Sloller, MD. Cleveland Clinic Foundation 
(CCF). Cleveland Ohio 

As pari of Ihe Respiratory Therapy Consult Service 
<RTCS) at the Cleveland Clinic Foundation, a 
system lo rale palienis' scverily of illness lias hccn 
used to determine ihe frequency of respiratory 
ireatmcnl and patient re-evaluation. This system us 
called Ihe Tnage Rating System (TRS) and rates 
paltents on 8 separate axes, assigning up to 4 poinis 
per axis for a maximum of 32 Triage Pomis, Tnage 
Poinls are ordinalized into 5 Tnage Scores (1-5), 
where a Triage Score of 1 is assigned to patienis 
with Ihe highest number of Triage Poinls (i.e , nio-ii 
severe illness). Although we have found this raling 
system useful over the past 2 years, validation of ihc 
system is not yel available, To ascertain whether 
Tnage Ralings correlate with clinical measures of 
patients' seventy of illness, the current research 
examines the association between the TRS (both 
Triage Poinls and Triage Scores) and clinical 
measures of severily of illness in 98 palienl 
receiving respiratory care at CCF Between 1/22/92 
and 7/14/93, Tnage Points and Scores were assigned 
to a convenience sample of 98 patients ordered to 
receive respiratory care As shown in Ihc table 
below, lor both Triage Points and Triage Scores, 
significant correlations (Spearman's rho) were 
observed with clinical measures, including length of 
slay, total hospital charges, charges for rcspiralory 
care acliviiics, and numbers of days receiving 
respiratory care The number of deaths among 
patients in this senes (N = 4) was too small to 
provide meaningful analysis of association with the 
TRS 



Wc conclude: I in Ihe current scrics. itic TRS 
ratings currclaied signincanily with clii ' 
of patient acuiiy. and 2 although further study 
needed, these data suggest that the TRS is a v.i 
indicator of pnticnls' severity of illness 



MULTI-MODALITY PATIENT ASSESSMENT 
PROTOCOL John Wright MBA BS RRT, Jerry 
Gordon BS RRT, Henri Guidrv BS RRT . UCLA 
Medical Center, Los Angeles, CA 

Introduction: Therapist Driven Protocols and 
other algorithms used as practice guidelines 
for respiratory therapy usually focus on the 
administration of one modality- A 
comprehensive patient assessment protocol for 
multiple treatment modalities and other 
common interventions is not available. The 
Multi-Modality Patrent Assessment Protocol 
minimizes the chance of overlooking 
any one type of routine respiratory therapy 
intervention. It also standardizes the 
process of patient assessment, 
increasing the consistency of clinical 
application as well as the recommendations 
by respiratory therapists to physicians. Method 
A patient assessment form (screen) has been 
used as the primary data collecting device at 
the bedside for several years. The assessment 
results Vtfere then reviewed by a supervisor, A 
detailed algorithm (the Multi-Modality Patient 
Assessment Protocol) was developed so that 
supervisors could evaluate the patient 
assessment according to the specific 
steps of the algorithm Supervisors were 
given a "pre-test" whereby they evaluated 
the screens according to the existing 
technique. This group was then inserviced 
on the use of the algorithm [the Multi-Modality 
Patient Assesment Protocol). A "post-test" was 
then given to determine if consistency had 
improved with the use of the Multi-Modality 
Patient Assessment Protocol. Consistency was 
defined as the percentage of similar answers. 
Accuracy was defined as the precise choice 
of modality according to the protocol. 
Detrimental therapy was the term used to 
describe assessments that could potentially 
harm the patient. Results: Pretest: 37% 
consistency, 46% accurate, 0% detrimental 
therapy. Post-test: 91% consistency, 96% 
accuracy, 0% detrimental therapy. 
Conclusion: Single modality protocols can 
overlook the optimal choice of therapy. 
Although RTs avoid harmful choices of 
modality, consistency in choosing the optimal 
modality is significantly improved with the use 
of a multi-modality patient assessment protocol. 
OF-94-05 



Reductions in Oxygen and O.ximelry Hours 

with the ItnplementJtion of Patient Driven 

PnitcKols 

Richard M Ford BS RRT, Jan E Phillips BS RRT . 

David M Bums MD 

Introduction: Patient Driven Protocols (PDPs). 
also known as Therapist Diiven Protocols, were 
developed at UCSD to reduce the consumption of 
department resources spent in providing care thai 
was not medically necessary. PDPs for oxygen 
and oxymctPi' allowed the rcspiraloiA' care practi- 
tioncrfRCP) to miii.ik-. hukIiIn. crdisLonlinuc 
these sen kvs h.iscd <'n incdiLal si.ili.ippnncd 
guidelines. We e\.ilualed the impact PDPs had on 
the hours of oxygen and oxymetry utilization and 
the potential to reduce cost. Methods: Patients on 
the pulmonary tloor with request for oxygen 
and/or Continuous Oximeln,' were enixilled in the 
prot(K-ol program RCPs pro\ jded an initial evalu- 
ation to assess the appn>pnalencss ol therapy and 
re-cvaluatn>ns e\ er\ 24 hours lu assess the lieed to 
continue sen leos io deieniiine it there was an\ 



Ihc 



..I the 



en I 



charge ivci'ids were nbtamed loi a d mnnlh pentKl 
prior to llie PDP program iuid lor a 4 month penod 
after the prt>tocols had been phased in. The nunv 
ber of hours of oxygen and oximetry per patient 
were detemiined pre and post PDPs. For patients 
in which owgeii or oximetry service was ordered, 
but iic\ci HiiiKikil as, I result of the initial cvalua- 
lioii lorapproprialciK-ss. a dcffcrrcd nx'ord was 
mainlained. Results; 



II.l 



IS 



For oxygen, 1 2.8% of rxx^uest were delcrred and 
houn. of use per patient deci^eascd by 32.8% reduc- 
ing total t)xygen houtN hv 1 1. 762. 1-'or oximetry, 
I .S,()';; of reqiicsi wlil- d'efcnv.l and hour, of use 

[HT paiK-iii (kvuMsi\l I'\ M-i y . [I'dik mi: oximetry 
hours h> 7,')W (oiulusion krsulis iikiiuilc that 
signifR-.inl raliKlmns uii Iv aJiu'val in oxygen 
aiuloMTncin houiMliioiigh pioUKi>ldiivctcd ther- 
apy. W hilc no atKcisi- p.iiieni ris|>oiisc was 
obsenetl. snbsi.uitial li>sI sa\ ings i.m Ik ahicvcd 
as labor demand is redticed and Icwcr supplies 
ctmsumed. 

OF-94-099 



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RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1 



Open Forum ABSTRACTS 



TRANSITIONS TO LESS COSTLY 

TREATMENT BY UTILIZING PATIENT DRiV 

EN PROTOCOLS 

Richard M Ford BS RRT. 

Jan E Phillips BSRRT . David M Bums MD 

UCSD Medical Cenler. San Diego CA. 

Introduction: Patient Driven Protocols (PDPs) 
allow the respiratory care practitioner (RCP) to ini- 
tiate, modify, or discontinue therapy based on med- 
ical staff approved guidelines, PDPs were 
developed al UCSD to reduce the consumption of 
department resources spent in providing care that 
was not medically necessary The protocols were 
also structured to make therapy transitions to types 
of respiratory treatments demonstrated to be less 
costly and could eventually be self administered by 
the patient. We evaluated the impact PDPs had in 



facil 



L- ihei 



Methods. The Bronchodilalor PDP incorporated 
the transition Irom hand held nebuli/er (HHN) to 
metered dose inhaler (MDI) when the patient 
demonstrated the physical and cognitive capabili- 
ties to use an MDI. The Secretion Clearance PDP 
incorporated the transition from postural drainage 
and percussion I PD&P) to autogenic drainage 
(AD) when the palieni uas physically able to per- 
fonn the required breathing patterns associated 
wilh AD and had a willingness to learn the 
technique Palienis wilh request for aerosol bron- 
chodilators and/or PD&P were enrolled in the pro- 
tocol program RCPs provided an initial evaluation 
to assess the appropnaleness of therapy and re- 
evaluations every 24 hours to assess the patients 
readiness lor transitions to MDIs and/or AD as out- 
lined in each PDP. Results: For the Bronchodilator 
PDP, 498 patients were initially evaluated. 38 
were not started on bronchodilators as there was no 
indication for therapy, i 4 1 were able to start treat- 
ment using MDIs rather than HHN, and 136 made 
MDIs during the coarse of their 
For the Secretion Clearance PDP. 439 
patients were initially evaluated. 120 were not 
started on chest physiotherapy as there was no indi- 
cation for therapy. 38 made the transition to AD 
during the coarse of their treatment. Conclusions: 
As well as identifying therapy request that may not 
be medically necessary, PDPs can be structured to 
facilitate transitions to less costly therapy. The re- 
sults demonstrate substantial numbers of patients 
can make these transitions. The provision of these 
alternative therapies at UCSD require less RCP 
time, fewer supplies, and provide another mecha- 
nism to reduce department expenses. 



EFFECT OF EXPANDED AUTOMATIC MDI 
SUBSTITUTION PROTOCOL FOR 
BRONCHODILATOR THERAPY 



T AlfredsopJlRI . D HauptmanJlRT C 
Vander^va^f.RRT. D Posi.RRT. P J Fahey.MD 
Loyola Umv Med Ctr, Ma\'wood H, 



Numerous studies have demonstrated comparable 
efiTicacy of metered dose lobaler w ith spacer 
(MDI/spacer) to medication nebuluer (MN) id the 
admmistratioD of bronchoddalor therapy to adults. 
infants and children We pre\'ioush' adopted a 
protocol that allowed for automatic substitution by 
respirator,' care s1af1 of MDI/spacer for ordered MN 
therapy for adult inpatients who were able to self 
admmister or were mechanicalK ventilated We 
administered 6 1 .496 bronchodilator treatments from 
1 1/92-3/93 under thai protocol of which 56 6% were 
deUvered by MN and 43 4% b\ MDI As we 
expanded this protocol we dctermmed changes in 
procedure volume, cost and length of stay Our 
expanded substitution protocol included adults who 
requned assistance with MDl/spaccr. as well as 
neonatal and pediatric patients MD[/spaccr use 
mcreased to 87 9% of the 62.240 treatmeDls given by 
the respiratory care department from 1 1/93-3/94 
This program reduced s-taffing requirements by 7 75 
fiill lime equivalent (FTF) registry therapists 
representmg $304,990 in annualized salary Supply 
and medication costs were decreased by $ 1 1 . 1 67 
($26,801 annualized) Mean length of stay for 
patients with asthma. COPD. pneumoma and 
bronchitis was compared for 1 1/92-3/93 and 1 1/93- 
3/94 and found to be 5 5 and 4 9 days respecliveh 
(p=0 22) We conclude that our expanded protocol 
for substitution of MDl/s-pacer for MN bronchodilatoi 
therapy decreased labor and suppl>' costs witboul 
negatively' impactmg the length of stay 



MONITORING RESULTS OF PDP 
IMPLEMFNTATION N.inrv Ti^ml^l BS. RRT 
RCP . Jan E. Phillips. RCP. RRT, David M. Burns. 
MD 

Introduction; Protocol Driven therapy has been 
inslituted at UCSD Medical Center since January, 
1993. Wilh any new program, careful planning anil 
monuoring is essential lo success. The fiscal 
impact of protocol dnven therapy has been reported 
and has significant impact on the number and 
intensity of therapies performed. We soughi lo 
create a mechanism to deternune if our protocols 
would provide quality care lo our palienis. Method 
We selected the high volume service of aerosolized 
bronchodilalor therapy. Monilonng for the success 
of conversion from small volume nebulizer therapy 
(SVN) to metered dose inhaler (MDI) device for drug 
delivery was accomplished using an algorithm 
incorporating infonnation from the physical exam. 
Daily evaluations were performed for each paiieni 
with orders for bronchodilalor therapy. The 
evaluation documents the physical exam, review of 
[he lab data, chest xray results. PFT's, secretion 
production, cough effectiveness and respiratory 
hisiory. A plan for therapy is formulated utilizing 
ihe algorithm, which provides a lemplale for 
consistent decision making and goal oriented 
therapy. The physician is contacted and the care plan 
is finalized. Selected inrormaiion from tlie evaluaiion 
IS entered into a database managemeni system 

each 24 hour reevalualion From this database, 
monitoring is performed for the following: 1) 
Number of patients wiih orders for bronchodilalor 
therapy. 2) Number of patients meeting MDI 
conversion cntena as indicated on the protocol 
algorithm. 3) Number of palienis who were 
convened lo MDI. 4) Documentation of response lo 
MDI therapy, 5) Number of patients who were 
reslaned on SVN's. Results: A loial of 343 paiients 
were reviewed. Successful conversion to MDI 
therapy, as evidenced by improvement m PFT's or 
improvenient in breath sounds, was considered an 
outcome indicator For the year, the average 
success rate for successful conversion to MDI, 
utilizing the protocol algoriihm. was 98% (213 
patients). Therapy failures occurred at a rate of 2% 
(4 patients). Reversion to SVN therapy after 
conversion to MDI was considered a therapy failure 
Conclusion; The rate of success for this protocol 
prompted a change in depanmental policy which 
makes MDI the method of choice for all patients 
requiring bronchodilators, who meet the protocol 
conversion crilend OF-94-15 



PRELIMINARY EVALUATION OF A PRACimONER- 
DRIVEN OXYGEN THERAPY PROTCXXJL— r-rlFHaM 
Mt-'tRRT RandeU Mcrrcn BS RRT. Coniue Une RRT. 
EhzAbcih VanCamp RRT. Ivin Nicoletti RRT. David 
Cilkui RRT. Mark A Konkle MPA RRT. John G Weg MD 
FCCP. University of Michigan Medkal Cenier. Ann 
Arbor Ml 

latroductloD: A Continuous Quality Improvement team 
studied die oxygen (O^) therapy service at our University 
Hospiitl. Using a pulM oximeciy saturaiion (S[02) of 92- 
94% u the urgei range, ii was found ftom a umple of 454 
adult palienis on general care floon receiving O2 therapy 
thai 37% should be decreased (Sp02 >94% on O2), 15% 
were within target. 18% should be increased (SpOj <92% 
on O2). and 30% should be disconiuiued (SpO, ^92% on 
air). Methods: A protocol was developed requiring a 
daily Sp02 and allowing respiratory care pracbtioners lo 
increase, decrease arid discontinue O2 based on S;02 - 
Target ranges iruluded an SpO^ of 90-92% for COj 
retaining COPD paiients; 95-97% during the fu^l 72 hr of 
acute myocardial infarction (AMI) or with unsubte angina 
(UA); and 92-94% tor all others, unless ordered by a 
physician. The protocol was piloted on three 32-bcd 
general medicine palienl care centers, one of which is 
pulmonary. On seven pre-prolocol days (n=126 patients) 
and sbi post-protocol days (n=105 patients), all patients 
with O2 ordered had an SpOj obtained. Concurrent records 
of the post-protocol patients were also reviewed (466 
patient-days) for protocol compliance. Results: An 
average of l.S Sp(32 measurements were done per patieni- 
day. CompUance for daily SpO^'s was 95%: 57% of 
palieni-days had only 1 SpOj. 24% had 2. 9% had 3. 3% 
had 4 and 2% had 5 Sp02's per patient-day. Clinical 
actioiu dictated by Sp02 measurements before aitd after 
the protocol was implemented are shown below (target 
range): 



Pre-prolocol 
(92-94%) 

Post -pro toco I 
(92-94%) 

Post-protocol* 



Redux 


Maintain 


Increase 


0, 


O2 


O2 


44* 


15» 


19* 


37* 


38% 


23* 


38* 


39% 


16* 



4% 



(*pauent in prescribed protocol range of 90-92%, 92- 
94% or 95-97%.) Only 5.6 % of the total SpOj's were 
c88%; 3J% obclweoi 85-87% and 2.1% between 83- 
84%. Length of therapy did itoi change (4J vs 4.2 days). 
CoBciuslona: A practitioner-driven O2 therapy 
protocol facilitates discontinuing unnecessary oxygen 
and hastens the titration process. After a longer 
implemenlaiion period, a cost analysis, lime study and 
comparison of length of slay will be done to fully 
determine the program's impacL We have revised the 
SpOj targets 10 90-92% for all but patients with AMI or 
UA. The proux:ol has been expanded lo goieral surgery 
floors. OF-94-167 



an overview of the scope of practice of 

licensure regulations and identify 
potential areas of need for educational 
offerings- MBTHODS:The survey covered 



aditional 



:^d pr. 






ned. 



hospitals and 13(161) were sub-acute care 
facilities Responses indicating yes or 
shared were reported as a percent for each 

traditional respiratory car- was high, as 

hospitals participating in expanded 
practice and non- traditional areas was 
higher than all other types of facilities 

low (9 respondents) and indicated a 
narrower scope of practice which appears to 

difficulties Responses from sub-acute care 

considered routine. The use of TDP's was 
very limited (26 reported in five 
categories) Conclualona sThe data ran 
be used by respiratory care managers in 

training and expanding the scope of 



practice beyond traditional respi 



THE EFFECT OF GUIDELINES FOR ThE USE OF 
CONTINUOUS PULSE OXIMETRY IN A PEDIATRIC 
POPULATION John W Salver BS. RRT. Karen Bunoi 
RN, RRT. Jon Keenan RRT Rcspiraiory Cut Service 
Primary Children's Medical Ccnier, Sail Lake Ciiy. 
Uiah 

INTRODUCTION: We speculated ihal commuous 
pulse oximetry (POX) was being over uulized m our 
facility and thus sought 10 measure the impact of a 
program to optimize its use in our non-ICU 
population. METHODS: Guidelines for the use of 
POX were developed and approved by ihe hospital 



of < 93 %. (5) on pt controlled anesthesia. (6) having 
received sedation within the last 12 '. O) undergoing 
special procedures- RCP's were encouraged to use the 
guidelines to initiate a dialogue with medical and 
nursing staffs about opumaJ POX i, 



iiupo 



if or*] 






applic 



c inappropriate. An extensive 
hospital wide training program was conducted tj 
included over 80 small group sessions for the m 
staff on the use of the guidelines Approximate 



e iCU's wa; 
icrminc if i 



dby J 



applK 






: guidelines. These data were analysed with respect 
lo the proportion of all oximeters that were 
inappropriately applied, and reported to all ihe 
medical and nursing services involved at least 
quarterly. The program was implemented in August of 
1992. RESULTS: POX uuhuuon is described 



paiient day have declined 21 % between 
1992 and 1993 wuh an 18 % drop in paiienl charges 
(aficr adjustment for inflauon). The most frequent 



requires a significant 
follow-up, However. 
impact of the prograi 



Open Forum ABSTRACTS 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1 



USING NON-MANDATED INTERVENTIONS WmnN A 
VENTILATOR MANAGEMENT AND EVAI.UATION 
PRtXlRAM (VENTMANl TO REDUCE AVERAGE 
VENTllJ^TOR LENGTH 0¥ STAY (Al.OSv) Jamie 
Vnccaro. R R T . Oregon Roach. R R f , IJnan Clart. 
R R T . Donann Miller R R T , Herbert i'alnck M D . 
Dcparunent of Respiralor> Care ThomiLs JclTerson 
Uiiivcr5it\ ilospilal. Philadelphia, PA 
The Venulaior Managemcni and Evalualion ["rogram 
( VenlMan I u-as designed lor venulator palienis b\ oiu 
Dcpanmenl lo 1 ) opiimue respiralorv care services. 2 ) 
i:ollaboraie care ihrough imcrdisciplmaPr rounds. 3) 
provide educatiQiul inscrvices. and 4) collccl and 
inlerprcl QA&I dala A tull-timc Respiratorv Therapisl 
WHS assigned as Coordinalor for ihis program We were 
inlcrcstcd m quaniitaimg inlcrvcnlions by the Coordmator 
for ihc fir^i year ol VenlMan We retrospectively 
reviewed a subgroup ol adull paUenis wilh ventilator 
length ol Slav iLOSvp' 4U days Tins subgroup ot -13 
patients represented only 3 I % ot all ventilator patients m 
FY92 but created a large economic burden and high 
departmental workload RESULTS Thirteen non- 
mandalcd interventions were identified and compiled 
from most to least uulized Six most common 
interventions were I ) structured and ongomg educational 
lortim I lOO^^'ol. c g , scheduled inservices for Residents, 2) 
nutrition support (96%), e g , prompting for feeds within 
72 hours. 3)optinuzmg equipment (93%), c g . upgrsdmg 
and downgrading ventilators. A) stniclurcd physical 
assessments (86%). eg . paUent/data base acquisition, 5) 
optimizing wean (86%), e g . patient/ ventilator synchrony 
and respiratory rate momtonng. and 6) airway 
maintenance (54%), e g , airway duration, Pip': 
wean, enhance speech Four less com 
were I ) promptmg on daily weanmg parameters (26%), 
2) expediting hospila! stay (21%), e g , mleidisciplinary 
discussions with Residents and Departments of Social 
Work and Home Care. ?) request for rehabilitation ( 19%). 
c g . bedside OT/PT/Speech. and 4 1 secretion 
management (19%). e g , mucolytic Iherapv Three least 
common interventions were I ) changing the wean 
modality ( 12%). 2) homecare educaUon for nurses and 
family (12%), 3) discharge transport (5%) The ALOSv 
for these 43 patients w^ 60 days and the average hospital 
length of stav (ALOSh) was 88 days In FY91 (Pre- 
VcnlMan I, there were 48 paUents ( 3 6% of total ) with 
ALOSv of 74 days and ALOSh of 95 days 
CONCLUSION Non-mandated mtervenlions appear 
essential in reducmg ALOSv and ALOSh It cannot be 
proven that anv smgle one intervention was more 
importanl than than another As VentMan interventions 
contmue lo be updated, tabulated and analyzed lor 
elTectivcness, our slalTtherapisU will mcorporale them 
more commonly Our program serves as a model lor 
Respiratory Care Departments in hospitals containing 
-open- ICU's 

OF-94-24' 



"stalled" 



MARK YOUR 
CALENDARS! 

FUTURE AARC CONVENTIONS 

December 2-5, 1995 
Orlando, Florida 

November 3 - 6, 1996 
San Diego, California 

December 6 - 9, 1997 
New Orleans, Louisiana 

November 7 - 10, 1998 
Atlanta, Georgia 




American Association for Respiratory Care 

40th Annual Convention and Exhibition 

December 10-13, 1994 • Las Vegas, Nevada 



lino 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1 



Open Forum ABSTRACTS 



IHE EFFECT OF PEAS FUKIPFI SEITIIIC OH HE KDMCI OF 
»i?rO-PEE?(AP) KEMJDIEW OSIHC TIE 3IIASC8I VM,VE(BV|. 

iimiMi t.~lM rbt nn.oF ?EmiSiLv«iiA le. 

Cn.FHILUELPBIA.F*. LOWS «. HARMS Ed.D RDT.FIETO) 
J.PASCAli Ed.O yOUIGSTOW STATE JJiV. YOMSTMll.Oa. 
Ttie BV IS used to leasure AP. It is i device with a one- 
way vaive and a port tiat can be opened to Uie 
atiosphere. The BV indirectly causes tie exiialation 
valve[EV) Ui close for a tiBe feriod based on tlie set PF 
and set tidal voluieiWi. Sitll hi^ PF settings tie EV 
lay be closed for too short a tiie period to allow 
circuitiCTl and lung pressures(P) to equilibrate. Tiis 
lay effect tie accuracy of AP leasurejents. In tils 
study, PF's were varied froi 10 to 120 L/« in 5 L;i 
increients at fiied AF values of 5 and Id ci B20. Tiese 
AP levels were cbosen because a study showed 961 of 
patients bad 10 ci B20 or less of AP(Respir Care 
19Ii;31;1069-71). A Biotek 'VT-KBVTl ventilator tester 
was used as tie lung Kdel. Ite BVT linuui lung P was 
used to record actual AP. Tie BVT coipliance was set at 
0.05 l/oBiO for boti AP values. For S ciH20 A? a 5 
ciHiO/1/s resistoriBlwas placed at tie wye witi an 
additional B of 20 cil20/l/s in tie eiqjiratory liib of 
tie a. For 10 cia20 of AP a 50 ciE20/l/s R replaced tie 
20 R. A Purtian-Bcmett 72O0ae witiout buiidifier was 
used to record experiiental AP values off tie peaX 
pressure digital readout. The 7200 was set for TV of 
0.9*l,R« 20/tin,and PF 39 L/i to create 5 ci 820 of AP. 
A W of 0.95l,«E16/iin,and PF <2 L/i was set for 10 ci 
B20 AP. Budson disposable tubing was used for tie CT. 
Tie BV was placed 25 ci troi the wye on the inspiratory 
side of the n. lie PF levels were cimged to the desired 
levels for leasureient during the eiipiratory pbise so 
that when the leasureient was lade tie desired PF was 
(Stained. Five Kasureaents were ude at each PF setting 
and averaged for both 5 and 10 a B20 AKn=190|. He BVT 
iean(SDlwas t.97|0.071aKl 9. 96(0. Ilia B20. Bie 7200 
leanlSDIwas 5.*8(0.43)anl 9.37|0.09)ci B20. An 
indepenknt t-test(p<0.05) collaring BVT vs. 7200 AP was 
perfoned for boti levels of AP. A statistically 
significant but clinically irrelevant difference was 
found at l»ti AP levels. AJOVA showed no difference in 
AP in regard to PP at tie 10 d 820 level. At 5 ci 820 
level significant differences were found. He data were 
amiqed into ( Sgroups|C)|Gl 10-50,02 55-75,G3BO-10O,G( 
105-120 L/1). Tie Sheffe' test sho«d C4 flows caused 
tie significant difference in AP due to tie PF. In a lung 
Bdel PF does not effect tie accuracy of icastired AP at 
10 ci 820 level but at the 5 ci B20 level PF froi 105- 
120L/i effect accuracy of AP leasureient. 



CLINICAL [MPACT OF P1_IRITAN-BENNF,TT 7200 
EXTENDED SELF TEST (EST) UNDER VARYING 
CONDITIONS Vincenl Rigei. RRT . Dean Hess. MEd. 
RRT. Christopher Hirsch. MPH. RRT. Robert M 
Kacmarck. PhD. RRT Respiratory Care and Anesthesia. 
Massachusetts General Hospital and Harvard Medical 
School, Boston MA 

A unique feature of the Puritan-Bennett 7200 venlilalor is 
Its ability 10 compensate for (he dynamics of (he patient 
circuit based upon an EST In our community, it is 
common practice to perform the EST Ijetween padents with 
a new circuit and without water in (he humidifier We 
conducted (his study to determine whe(her the dynamics of 
the circuit change over time, and if there is a best (ime (o 
perform (he EST METHODS Six 7200 ventilators were 
evaluated under the conditions of SIMV. V, 5 L, 1 2/min, 
60% O,. 5 cm H,0 PEEP, peak flow 60 L/min V, and 
peak inspiratory pressure (PIP) were recorded from the 
7200 digital display, and PEEP was recorded from the 
analog display The circuit consisted of 72" of disposable 
tubing, a cascade humidifier, in-line water [raps, and a Y- 
piece. The Y-piece was connecled to a rubber test lung An 
EST was conducled with the circuit cold and dry (time I ), 
after adding water to the humidifier (time 2), after 24 hrs 
(time 3), and after 104 hrs (time 4) The temperature 
delivered from the humidifier was 42 5±0 5 C EST values 
recorded were leak (cm H.O), circuit compliance (mL/cm 
H,0). and area-volume ratio (A/R) RESULTS 





leak 


compliance 


A/R 


V, 


PIP 


PEEP 


cold& 
dry(l) 


8 43 

(1 05) 


4 43 

(0 151 


10 021 


051 
(001) 


33 3 
(1 5) 


50 
(0 0) 


(2) 


4 75 
(1 01) 


3 78 
1008) 


10 02) 


53 
(001) 


32 7 
(08) 


5 
(00) 


24 hrs 
(3) 


57 
(1 57) 


3 78 
(0 13) 


1 41 

(0 02) 


52 
(0 01) 


31 5 
(08) 


48 
(0 4) 


104 hrs 

|4) 


5 42 
II 18) 


3 73 
(021) 


1 41 

(0021 


53 
(0 011 


31 5 
(06) 


48 

(0 41 


P-value 


<0 00l 


<0 00l 


001 


001 


22 


42 



CONCLUSIONS Changes in leak and circuit compliance 
when the humidifier was filled were expected. All other 
differences were small, and none were considered clinically 
important Of particular interest, the A/R remained nearly 
constant throughout the study period, which is important 
because of the relationship between A/R and trigger 
sensitivity Because there were no important differences m 
the ability of the ventilator to compensate for the dynamics 
of the patient circuit after the initial EST. we believe that it 
IS a valid practice to conduct the EST only at initial 
ventilator set-up (cold and dry) (supported in part by 
Puritan-Bennett Corporation) 



GAS EXCHANGE AND MYOCARDIAL STRESS IN 
PRESSURE SUPPORT VERSUS VOLUME SUPPORT 

KuenShan Jih MD. Jyh-Her Chow MD. 
Chih-Chihng Yen MD. Vuh-Un Wang RRT 
Cntical Care & Respiratory Therapy, Tatchung Veterans General 
Hospilal Taichung. Tawan 40705, ROC 

INTRODUCTION Volume support (VS) venblaton employs a 
decelerating inspiralory flow waveform while the limited 
inspiratory pressure will be regulated to a value based on the 
pressure / volume calculation for the previous brealti compared 
to the preset tdal/minute volume II is very similar to pressure 
support (PS) ventilation, and theoretically superior to PS with a 
guarantee o( preset tdal / minute volume The purpose o( thrs 
study IS to compare the impact of VS and PS on the gas 
exchange and myocardial stress 

METHOD 10 patients with acute respiratory failure on weaning 
protocol with a minute ventilation (Ve) < 12 L/min on Simens 
Servo 300 ventlator \Nete recruited for this study All patients 
stjil had pulmonary artery catheter in place for hemodynamic 
monitonng Patients were randomeed to either VS mode or PS 
mode for 30 minutes, then aossed over to the other mode for 
the next 30 minutes The VS mode was set with a preset VI of 
10 mL/Kg, and the PS mode was to preset an inspiratory 
pressure to achieve a Vt of 10 mUKg The external applied 
PEEP levels were the same m both modes Al ttie end of both 
modes the following data were collected FiO;, RR, Ve, peak 
Paw, mean Paw, artenal blood gases (PaO?. PaCO^. PH), 
mean expiratory CO2 (PeCO?), 
pufrnonary arlenal pressure , CVP . PCWP and cardiac index 
The oxygenabon index ( 01 ) 
FiO? ) / PaO?, the deadspace ratio ( 
PeC02 ) / PaC02, and pressure timi 
systolic BP The analyzed variables w 
standard enor Wilcoxon matched-pai 
used for inferential stabsQcs. and a two-tailed P value of less 
than 05 was chosen as statistic significance 
RESULTS. Pressure Volume Wilcoxon 2-tailed 

Support p value 

229' 19 1851 

9 2*09 1 0000 
17 12 1851 

10 8*06 6356 



*/d / Vt ) as ( PaCO? 
index ( PTl ) as HR 
re expressed as mean 
; signed-ranks test wa 



Peak Paw {cmHjO) 20 81 14 

Mean Paw (cmH?0) 9 2 1 6 

RR (frequency/mm) 19*2 

Ve (liter/min) 109* 06 

BPs{mmHg) 129 + 5 

HR (beats/min) 97 ♦ 5 

Pa02(mmHg) 148+10 

PaC02(mmHg) 35; 2 

PH 7 44 * 



2367 



991*0 002 6121 



01 024 * 002 024 ; 003 9594 

Vd/VI 209 + 01 1 206 * 001 4008 

PTl 12559*841 11592*671 1731 

CONCLUSSION: The venblatory. oxygenation effect and 
myocardial stress were not stabstcally different dunng short 
penod of PS and VS np-cu^fii 



ABILITY OF BILEVEL CPAP DEVICES TO MEET 
HIGH VENTILATORY DEMAND A LUNG 
MODEL STUDY Masaii Nishimut^. MP . Dean 
Hess. Ph D . R R T . Robert M Kacmarek. Ph D . 
R R-T Department of Respii^lory Care and 
Anaesthesia, Massachusens General Hospital and 
Harvard Medical School, Boston MA 
Bilevel CPAP devices are being increasingly utilized 
during acute ventilaioi^ failure and exercise We 
questioned if these units were capable of meeting the 
increased ventilatory demand in these settings 
METHODS A bellows-m-a-box lung model was 
developed to simulate spontaneous breathing The box 
was connected to a low compliance "T" tube through 
which Jet flow was injected to created negative 
pressure. Resistance was established by modified 
endotracheal rubes (6 9 cm H.O/L/sec) and compliance 
(73 5 mL/cm H.O) was altered by springs on the 
bellows The lung model was set at an inspiratory time 
of I 1 sec, rate I 5/min, square inspiratory flow pattern 
and peak inspiratory flows (V) of 1 10. 80. and 50 
L/min At each V, inspii^tory and expiratory delay 
time (![,, Ep) and trigger pressure (Ip, Ep) were 
determined. The NIPPY (Thomas Respiratory 
Systems. London. England), 320I/E, 335 and 7200ae 
(Puritan -Bennett. Carlsbad, CA), ARM 25 (Air 
Ligiude, Paris. France) and O'NYX (Pierre Medical, 
Paris, France) were evaluated at their lowest PEEP 
setting and 5 cm H.O PEEP with peak inspiratory 
pressures (PIP) of 10. 15, and 20 cm HjO Three 
breaths were evaluated at each experimental condition 
for each ventilator Statistical analysis consisted of 
ANOVA RESULTS The following data were 
obtained with the lung model V at 80 L/min and the 
ventilators set at the lowest CPAP level and 1 5 cm H,0 
PIP 



r. [, E„ E, 



CONCLUSION Difference existed between indi- 
vidual units. For all units ability to meet inspiratory 
demand decreased as ventilatory drive increased. 
(Supported in part by Puritan-Bennett Corporation) 

OF-94-127 



EVALUATION OF BIPAP WITH Al_iXILIARY HIGH 
FLOW Ann Tavlor. RRT . Christopher Hirsch. MPH, 
RRT. Dean Hess, MEd. RRT. Robert M Kacmarck. PhD, 
RRT Departments of Respiratory Care and Anesthesia, 
Massachusetts General Hospital and Harvard Medical 
School. Boston. MA 

BIPAP IS being used increasingly with patients in the 
hospital and in the home The use of a high flow nebulizer 
system in conjunction with BiPAP is used by some 
clinicians to deliver supplemental humidity and oxygen 
We evaluated the performance of the BIPAP system with 
an auxiliary high flow METHODS Three BIPAP units 
were evaluated using a iwo-chambered test lung with lif) 
bar to simulate spontaneous breathing Flow (Hans Rudolf 
pneumotachomclcr and Validync ±2 cm H,0 transducer) 
and pressure (Validyne 1 100 cm H]0 transducer) were 
measured at the outlet of the BIPAP unit and between the 
whisper swivel and lest lung Pressure and flow signals 
were captured using a computerized system (CODAS) 
The drive chamber of the test lung was powered by a 
Puritan-Bennett 7200 with a rale of 1 5/min. a decelerating 
waveform and 3 ventilatory patterns V^ 1 I L, flow 90 
L/min. Vt 6 L, How 60 L/min. Vt 35 L. flow 30 
L/min Flow from a Misty-Ox nebulizer (dry) was added 
1 2" proximal to the whisper swivel at 0. 20, 30, and 40 
L/min BIPAP settings of 15/3 cm H^O (spontaneous mode 
(S})and t0cmH,O(EPAPmode) were used Trigger 
pressure was calculated as the difference between PEEP 
and the most negative inspiratory pressure Delay lime 
during IPAP was calculated as the difference between 
initiation of inspiration and the beginning of BIPAP 
response All combinations of the above settings were 
evaluated with each unit, and 3 breaths were evaluated at 
each experimental condition Statistical analysts consisted 
of ANOVA RESULTS There was no significant 
difference in trigger pressure for the 4 Misty -Ox flows 
(P=0 1 1 for IPAP and P=0 78 for EPAP) With IPAP. 
delay time increased slightly with increased Misty-Ox flow 
( 1 19 3±9 6 ms for L/min, 122 2±7 5 ms for 20 Umin, 
128 5± 1 2, 3 for 30 Umin, and 133 7±8 8 ms for 40 L^mm. 
P<0 001 ) With increasing flow from the Misty-Ox. there 
was increasing backflow detected into the BIPAP unit 
during expiration (P<0 001 ) The following table indicates 
the flows at the BIPAP unit during the expiratory phase 



negat 


vcflow 


ndicales flow in 


BIPAP uni 


1 




Misty-OxFlow(L/min) | 







20 


30 


40 


(S) 


8 4±0 6 


-7 g±0 b 


-168±06 


-28 2±l 2 


EPAP 


22 8il 2 


6 0±0 6 


-3 6±2 1 


-ISfctI 2 



Lihary flow into the BIPAP 
circuit did not affect the ability to trigger in any clinically 
important manner However, we are very concerned about 
the retrograde tlow into the BIPAP unit with this method. 
which could result in equipment malfunction - panicularly 
when aerosols are delivered from the auxiliary device 
(supported in part by Puritan-Bennett Corporation) 

OF-94-0 



INCIDENCE OF INTRINSIC PEEP AND THE 
MECHANICAL RESPONSE TO EXTRINSIC PEEP 
IN PATIENTS WITH OBSTRUCTIVE AIRWAY 
DISEASE REQUIRING MECHANICAL 
VENTILATION Robert R McConnell . RRT. Neil R 
Maclniyrc. MD. Duke University Medical Center, 
Durham. North Carolina Air trapping with intrinsic 
PEEP (PEEP,) 15 a well known phenomenon in 
mechanicaUy ventilated patients with obstructive airway 
disease (OAD) One of its consequences is to act as an 
inspiratory threshold load on respiratory muscles To 
determine the incidence of significant PEEP, in patients 
with OAD, we measured airway pressures (P„), 
inspiratory gas flow (V). delivered tidal volume (VT) 
and esophageal pressure (P„)(CP 100 Monitor. Bicorc. 
Irvine. CA) in 25 patients with a diagnosis of COPD 
who required mechanical ventilatory support using 
either volume assist control, pressure assist control or 



high level pressure support 
studied and PEEp was deter 
drop in Pj, dunng sponlaneo 
before changes were noted i. 



mined by measunng the 
js efforts that occurred 
1 P... or V Additional 
tal inflation pressure (P^ = 
peak airway pressure + maximal esophageal pressure 
change) and effective compliance (Cl = V^/P.^) In 
those patients in whom significant PEEP, existed ( > 10 
cm H;0), PEEP, equivalent to 75% PEER was applied 
and all measurements were repeated Paired I tcsU 
were used with P < 05 being significant We found 
significant PEEP in 19 of 25 (76%) patients with OAD 
with a mean (ISD) of 15 34 ± 3 6 cm H,0 The 
response to adding PEEP, of 75% PEEP is given 

Mean Change (jfSD) with Application of PEEP. 
Patients on: Patients on: 

Volume Target Pressure Target 

{n = 4) (n = 15) 



the 



VT 

PEEP, 
■P < 01 
Our result 
majority o 




+5-83i3.7 
-15±3-1« 


+ 39+.546 
+ 5-6±3.5- 
■11 9i3.8' 


indicate that sign 


ficant PEEP, ex 



viih OAD 
In addition, adding PEEP, up to 75% of the PEER has 
several effects: 1) It docs not change baseline P„ 
suggesting no change in FRC 2) It reduces the 
inspiratory threshold effect of PEEP, by reducing the 
change in P„ required for breath Inggenng 3) This 
lower imposed load appears to decrease spontaneous 
dnve as reflected in a lower P.,, with a constant P.„ 
4) It improves the apparent C^ since less airway 
pressure is used to overcome PEEP, and is therefore 
available for gas delivery 

OF-94-i; 



Open Forum ABSTRACTS 



RESPIRATORY CARE • NOVEMBER "94 Vol 39 No I 



ELDCIDATIOH AND TREATMENT OF 
PATIENT/VENTILATOR DYSSYNCHRONY 
CAUSED BY ADTO-PEEP (PEEP^) 
Albert Rlzio, MD. , Joe Clirlo, BA 
RRT, Tom Blackgon. RJ^T. Medical 
Center of Delaware. 
It has been euggeeted that the use 
of extrLnalc PEEP (PEEPj) may 
improve patient/ventilator synchrony 
In patients with dysaynctirony caused 
by PEEPj^. However, a review of the 
literature reveals little 
documentation eupporting this 
treatment. The following case 
involves a 60 year old, ventilator 
dependant, female with bullous 
emphysema, respiratory failure, and 
a dya synchronous ventilatory pattern 
that waa aucceaBfully reversed 
through application of PBEPf The 
patient waa maintained on pressure 
support ventilation (PSV) of 15 
cmHjO Ln the CPAP mode with 5 cmH^O 
of PEEP^. Dalng the Blcore CP-100 
monitor, dyaaynchrony, as evidenced 
by eaophageal pressure (Pes) 
deflections without ventilator 
triggering, was documented (Fig. 1). 
PEEPji, was determined to be 15 cmR20. 
The patient was subsequently treated 
with 15 cmH20 of PEEPj; which 
significantly Improved 
patient/ventilator aynchrony (Fig. 
2). Thia case demonstrates that 
PEEPe may be used successfully in 
the treatment of patient/ventilator 
dyaaynchrony caused by PEEPjj. 



.^ 


^^m 


#4=+ 


55 


•*'n' 




frfT 


s 


-iS 


k^^ 


i 



fig- 1 DVSSYNCHROHY 



^^ 



? 1/ h I Ir -r-r I i; 1 



Fig. 2 SYWCHROHY 



m 



DOBS AUTO-PIEP CREATED BT ACTIVE 
EXPIRATION INCREASE THE THRESHOLD OF 
VENTILATOR TRIGGER? 
HAOTO KUWATAMA.mi. . JUN 
TAKEZAWA.MD., TOSHIRO HOTTA, MD., 
TOSHIO FUKUOKA, MD., KIYOKAZU 
SHIMIZU,MD., TARO MARUKAWA, MD., 
TURII EONYUKOV, MD., TASUHIRO SHIMA- 
DA,MD. 
ICU.HAGOTA UNIVERSITY HOSPITAL, JAPAN 

We evaluated the effect of active 
expiration on auto-PEEP (PEEPl) and 
the threshold of ventilator trigger 
In the mechanical lung model. <METH- 
ObS>The apring loaded double bellows 
type lung model (C^=0.12 and 
C, =0.086 L/cmHoO) was connected to 
the time cycled, bidirectional Jet- 
flow generator which simulated 
Inspiratory and expiratory efforts. 
During inspiration, diaphragm 
bellows was compressed by jet-flow 
creating Venturl mechanism. During 
expiration, the )et-flow push the 
diaphragm bellows as active expira- 
tory effort which started 100 msec 
after the end of inspiration. Airway 
resiBtance{R ) was varied as 20 and 
50 crnHjO/L/seo using an airflow 
reslster. A Puritan-Bennett 7200a 
ventilator was used in the CPAP mode 
without PEEP at the varying pressure 
support(PS) levels from 10 to 20 
cmHjO with sensitivity (SENS) of 
0.5 or 2 cmHjO. The airway, pleural 
alveolar and jet pressure were meas- 
ured by transducers and displayed 
on the strip chart recorder, we 
determined the PEEPl level and 
triggering delay. 
<RBSULTS> 
R PS SENS EXP VT PEEPi DELAY 



20 
20 


10 
10 




PASS 

ACT 


650 
680 


2.5 
3.5 


280 
200 


20 
20 


20 
20 




PASS 
ACT 


770 
820 


3.5 
6.5 


400 
280 


50 
50 


10 
10 


0. 
0. 


J PASS 
J ACT 


360 
390 


5.0 
8.0 


320 
300 



PEEPl (mmHg) , DEIAY(it 



! pa B B 1 V 



xpir 



tio 
tidal 



ACTK 
ilur 



PASS 
ctlv© 
«(ml) 



expii 

<COHCLUSIONS>The auto-PEEP created 

by the active expiration did not in- 

croaaed the threshold of ventilator 

trigger. 



AUVE NASI -QIC ACTIVITY AS AN 
EARLY INDICATOR OF PATIENT- 
VENTILATOR DYSSYNCHRONY. 
Rose Meiler. BS.RRT ; 
R. CaetiRlione Jr.BS; 
N . Schubert. . BS . RPSGT ; 
L. Permutt. RPSGT; C.Nadeau; 
A. Schwartz. MD. Johns Hopkins 
University Sleep Disorder 
Center. Baltimore MD. 

Increased respiratory drive 
has been previously shown to 
auKment alae nasi (AN) - 
e 1 ectroayeoRran ( aiG ) 
activity. The frecruency 
and saRnitude of aechanical 
ventilator triKKer desiKn 
problens were deaonst rated 
by identifying AN-»1G 
activity as an early 
indicator of patient- 
ventilator dyssynchrony , as 
well as Its potential value 
as a trlRRer mechanism for 
initiation of an assisted 
breath. AN-aiG siRnals in six 
mechanically ventilated 
pat lents were recorded 
simultaneously with 
ventilator pressure and flow 
siKnals. 83% had AN activity 
and 83% of the piatients" 
breaths studied had AN 
activity . When AN activity 
was compared with ventilator 
electrical flow and pressure 
on time. AN preceded the 
vent i lator by an average of 
.31+/-. 12 sec. AN preceded 
the onset of true ventilatory 
flow excursion by an average 
of .41+/-. 17 sec. Similarly, 
AN preceded the lowest po 1 nt 
of patient inspiratory 
negative pressure by an 
average of .44+/-. 16 sec. Our 
data indicates Rross patient- 
venti lator dyssynchrony , and 
the potential use of the AN- 
QAG signal as a trlK^er 
mechanism. OF-94-ij 



CREATING Al/rO-PEEP DURING MECHANICAL 
VENnLATlON- Prtnk Denrmon MEd RPFT RRT, Worth 
Brooks BS RRT. An T«ft MHS. RRT Medicd College of 
Georgia, August*. Georgit 



^tilai 
rucally U 



"mechanic*]" AP The puipose of this sttidy was to 
deuaminc whai [. VE . and c;(pir«iory dme (Tc) would 
creile low Irvels of AP { 1 0-2 cm H20) when usmg 
typic*] vcndlalot circuii tysicms and ETT Methods: A 
Purii*n Bcnncn 7200i venulaioi was interfaced to one 
lung of a TTL (Michigan Instnimcnis) using a disposable 
ventilator cucuit (Seamless), HME (Engsiiom Edith) and 
6, 7, 8. and 9 mm ID ETT (Mallinckiodl) TV were icl al 
10, 0.8. and 0.6 L and delivered dry (n = 30) al 60 L/min 
as lest lung compliance (Cli) was aJlemalcly set al 100 
and 60 mUcm H20 A Timeler RT 200 Calibiauon 
Analyzer was used to measure delivered (low, volume. 
pressure, and lime Results: Slatistical analysis hy 
ANOVA showed a ugmficanl mleracUon between f. TV. 
Te. CU uvi ETT si« (P<0 001) As ETT size was reduced, 
AP was produced at lower f and longer Te Also. AP 
occurred al lower f and longer Te as TV artd VE weie 
UKTeased- AP could not be measured al f less than those 
presented for a Cli setting of 100 mL/cm H20 (see Table) 
Higher f and VE levels were required to create AP al the 60 
mL/cm H20 CU setting (not shown) as compared lo the 
100 ml/cm H20 Ctl setting 

T"; 1^-ondsl AP (cm H20) 



6ETT 14 16 19 3.1 2 8 2 J 1 1 1 1.0 

7 ETT 17 19 22 25 2J 20 1.5 10 11 

SETT 19 22 25 20 18 17 17 19 15 

9Err20 23 27 19 17 ii 16 18 19 



Conclusion: Case 


tudics 


have 


sho 


wn thai 


Is 


itings of 


20 32 bpm created 


sever 


AP 




echanic 


dly 


venulaled 


patients Our dau 


URR" 


IS tha 




hhigh 


f se 


iimgs may 


impose mechanic* 


APo 




31 tS 


which 


jOlt 


d augment 


toiaJ AP Although 
conoborale our 'me 


futthe 




„ 


h^m 


o^b. 


ciling. f 


and VE may have 


o be t 


cl low 


Cl 


lanprc 




sly ihoughi 


lo prevent aeaiing 


mcch 


anical 


AP 


Clmic 




should be 



EFFECT OF AUTO-PEEP ON NEW SERVO- 
CONTROLLED VENTILATORY MODES; 
VOLUME SUPPORT VENTILATION (VSV) 
AND PRESSURE AUGMENT VENTILATION 

(PAV) Ju/i Takezawa, MP, Yurii 
Konyukov, MD, Toshiro Hotta, MD, 
Naoto Kuwayaina, MD, Toshio Fukuo- 
ka, MD, Kiyokazu Shimizu, MD, 
Taro Marukawa, MD, Yasuhiro 
Shimada, MD. ICU, Nagoya Univer- 
sity Hospital, Nagoya, Japan. 

We evaluated the effects of auto- 
PEEP on the performance of VSV 
and PAV using a mechanical lung 
model. [METHODS] We used a bel- 
lows-in-box type lung model. The 
Cl and R were set as 0.09 L/cmHjO 
and 20 cmH^O/L/sec, respectively. 
C„ was 0.12 L/cmHjO. The I/E 
ratio was 1.0. The Vf during T- 
piece breathing was set as 250 ml 
at any RR . VSV and PAV were de- 
livered by the Servo 300 and Bear 
1000 ventilators, respectively. 
At first, pressure support levels 
were adjusted to obtain the V,p of 
500 ml at 15 breath/min ;PS level 
of 6 and 8 cmH20, with the Servo 
and Bear, respectively. With 
increasing RR, at the same PS 
level, V~ was guaranteed with 
adjusting the MV in VSV and by 
adapting constant flow of 20 
L/min which was 50% of peak 
inspiratory flow in PAV. The SIMV 
RR was equaled to spontaneous RR 
so that each breath was supported 
by PAV. [RESULTS] with increas- 
ing RR, auto-PEEP was increased 
gradually, and trigger failure 
occurred eventually in both modes 
at 24 breath/min in PAV and at 28 
breath/min in VSV. The auto-PEEP 
level at 23 breath/min was 5.6 
cmH20 in PAV and 5.4 cmHjO at 27 
breath/min in VSV. [DISCUSSION] 
Although both modes attempted to 
grantee the set V.j, trigger 
failure occured in the presence 
of auto-PEEP. Thus, a special 
caution is required in the appli- 
cation of both modes to the lung 
with auto-PEEP. 



CONTROLLED Fi02 DELIVEBY WITH 
THE BIPAP S-T/D WilliM 
W. Buinn RPFT BBT Ochaner 
PouDdatJon Hospital New 
Orleans, Louisiana. The noraa 
■ethod of operating a BiPap 
3-T/D (STD) with suppl 



ills for 



fl 



(LF) 
esulting 
hing high 
endor 
of up to 
tyOx Laai- 
r(LDH). I 



oxygen 

to a Bask port. The 
difficulty in establi 
Fi02s has inspired a 
recoaaeodation for us 
40 LFN flow froa a Mi 
nar Diffuser Huaidifi 
sought to assess whether adding 
the LDH to the STD iapaired 
sensitivity to patient effort. 
Method: A training teat lung was 
used to generate siaulated spon- 
taneous respirations and was at- 
tached to an STD circuit via the 
head of a resuscitation duaay. 
An Adult Lung Function Analyier 
(ALFA) was used to assess Work 
of Breathing (WOE, in kg-ca) and 
negative deflection of siaulated 
alveolar pressure (ND, in ca H20) 
in baseline condit ionB(BC) with a 
tidal voluae of 500 and an inspi- 
ratory flow or .8 Usee, with LF 
added, with filtration added{PA), 
with LDH added near the STD (HD), 
and with LDH added proxiaal to 
the aask (HP). Each aethod was 
tried five tiaea with a tight 



aask 



ith 



controlled leak introduced, and 
five tiaes with both a leak and 
a decreased inspiratory flow 
of .4 L/sec. Results (SD)n=15: 

WOB ND 
BC 2.3(.5) 2.5(.4) 

LP 2.5(.3) 2.5(.6) 

FA 2.0(.4) 2.6(.3) 

HD 2.0(.7) 2.6(.l) 

HP 1.9(.2) 2.2(.3) 

Results in WOB and ND were NSD 
by ANOVA. Conclusion: 40 LPM 
froa an LDH aay be added to the 
STD with no iapairaent of 
triggering or increase in WOB. 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1 



Open Forum ABSTRACTS 



P{-:RF0R\UNCE characteristics of FOLfR F:\PIRATa 
RY POSITIVE PRESSURE VALVES. 

RusseL T. Reid. RRT, Teresa Cook. RN. RRT TaT>' J. Victra. RRT. 
UC Davis Medical Center, Sacramento, California 
INTRODUCTION: A companson ot peak expiralory llow ( PEF). 
Expiratory airway n^lance (RE), and accuracy of expiratory positive 
pressure (EPP) was completed on four EPP valves. METHODS: A 
Servo 900C (Siemens-Elema. Solna, Sweden) powered one chamher 
of the training test lung (TTL model 1600, Michigan lastmments. 
Grand Rapids, MI), simulating spontaneous breatfung on the other 
chamber. A 10 mm I.D. endotracheal tube was used Mcusurt'nienLs 
were taken using a Stanialc pneumotach (IntriLsonics. Inc , San Diegt i. 
CA).Paramcleriusedonthe900C»ereViOSUII2..indIE 1 3 
Tests were completed at 2 EPP levels ( 10 and 1 5 cmH:( ) I and 2 TTl. 
compliance (Cl) settings (0.2 and 0.4 L/cmH20i. PEF was detined as 
maximum How during the exhaled breMh and RE was defined as 
iPplat - PEEPtotaiyilow at onset of exhalation. For each \'alve and 
condibon, 5 breaths were measured and the mean (SD) was calculat- 
ed RESULTS: 



(UcmmO 


(cmH:0) lcmHX)( 


(a-iH:cviys, 


,Unun, 


Omin.lt ,02 
(^mlmlt ,(M 


I 


° 


0.32(0.05) 


sss; 


5S i 


l 


9,89 (0J3I 
10,29 I0.33J 
112910,161 


S,02(0,92| 

8.19(0.71) 

730(0.75) 


6853(0.6!) 


ms w 


10 


:SE; 


337(0.63) 
957(1.28) 

5.93(0.86) 


10437 |4J8| 

86.15(2261 


[jfcguard fi; 
Ijfeguard (M 
Ufeguiud ,02 
Lifeguntd (M 


i^ 


4,23(0,00) 
8J5 (0.031 
522(0,10) 


5.22(0^1 
554(1,18) 

4.89(0-45) 
1432(052) 


65.90(0,211 


Vital Signs 02 

Vital Signs m 
V,Ld Signs m 


in 


liE 


257(0.43) 


i;i; 


(Interiech Inspuon model PL-2958, Life Design Systems model 8874, 
Lifeguard model 1 1 346, Vital Signs model 90 1 and 90 1 5 ) 
• TTL compliance setting 

t Control group used a Rp 5 paraboljc naistor inline to simulate nor- 
mal airway resistance 



EXPERIENCE: The Lifeguard. Inlertech, and LDS valves resonated 
badly during exhalaticsi. 

CONCLUSIONS: Significant non-Iinear ditfensnces existed in deb\- 
ered EPP, PEF. and RE values. The Vital Signs device had the lowesi 
resistance of the valves tested. Due to the vanability of deliveiwl EPP 
compared to set EPP. we would stongly reaimmend the use of a ptcv 
ure accurate EPP in applying these devices. 



OF-94-157 



UNIFORM REPORTING 
MANUAL 



The Uniform Reporting Manual provides you with 

nationally recognizee^ standar(js for documenting 

workload units and time standards. Includes patient 

assessment activities and covers bronchial hygiene, 

supplemental oxygen, airway care, diagnostic tests, 

and cardiovascular diagnostics. 

In addition, there are chapters on 

"Clinical Activities Without Time Standard" 

and "Management Support Activities." 

By the AARC. 1990, updated 1993. 

Binder, 165 pages. 

Item BK1 

$65 

($85 nonmembers) 




American Association for Respiratory Care 

40th Annual Convention and Exhibition 

December 10-13, 1994 • Las Vegas, Nevada 



1103 



Open Forum ABSTRACTS 



RESPIRATORY CARE • NOVEMBER "94 Vol 39 No 1 1 



HIGH FREQUENCY CHEST WALL 
OSCILLATION (HFCWO) IN SPINAL 
MUSCULAR ATROPHY; ChinnpciiaA. 
Beckerman R; Tulani.- Hospiinl for 
Children. New Orlcnns, La. 

The purpose of this outpatient evaluation 
was to asseis the effects of HFCWO as a 
method of airway clearance in a patient 
with Spinal Muscular Atrophy (SMA). A 
ten year old patient with SMA using 
nocturnal negative pressure ventilation 
due to chronic respiratory muscle 
insufficiency was selected for evaluation. 
The patient was clinically stable, but 
required daily bronchial drainage therapy 
because of a weak cough and secretion 
retention. HFCWO was administered 
twice per day via the ThAIRapy System 
following the manufacturer's 
recommended protocol. All HFCWO was 
delivered by the patient's family. 
Measurements were taken and the 
collected data are as follows: 



Measured 


Base 
lint 


.1 
Wks 


Wks 


Cllg 


FVC(L) 


0.60 


1)70 


075 


25 


FEVl 
(L/sec) 


0.55 


0.55 


0.64 


16 


MEF 
(cm/H20) 


50 


45 


fil) 


20 


MIP 
(cm/H20) 


78 


SO 


100 


2S 



Alter SIX weeks ol ihcrapy, the HFCWO 
system was found to be well tolerated. 
Also, the pntient showed improvement in 
pulmonary function parameters, which 
may be the result of a stronger cough 
{>MEP) and better secretion clearance. 
These results indicate that additional 
studies exploring the utilization of 
HFCWO in patents with SMA should be 
performed. Q^.g^.^^ 



HUMIDITY OUTPLT OF HEATED NEBULIZERS 
Yun Dashevskv. Joseph Kraiohvil. RRT. Dean Hess. MF.d. 
RRT, Pums Williams. BS. RRT. Robert M Kacmarck. 
PhD. RRT Dcpanmcnls of Rcspirator> Care and 
Anesthesia. Massachusetts General Hospital and Harvard 
Medical School, Boston. MA 

Heated nebulizers arc commonly used to provide humidity 
for patients with anificial airways We conducted this 
study to evaluate the effects of fullness level. FIG] setting, 
and brand on the humidity outputs of these devices 
METHODS Wc evaluated 5 each of the following brands 
Hudson RCI (adjustable and nonadjustablc temperature). 
Baxter {adjustable temperature). Travcnol (nonadjustablc 
tcmpcralure). ALP (nonadjustablc temperature), Misty-Ox 
(adjustable temperature). Professional Medical Products 
(adjustable temperature) Units with adjustable temperature 
were set at the highest level Each brand was evaluated at 3 
FtOj sellings (0 4. 6. I 0) and al 3 fullness levels (0 2 L, 
5 L, I L| Aerosol leaving the nebulizer passed through 
6 ft of wide bore tubing to a patient adapter Temperature 
(Fisher Scicniific Dual Channel Thermometer) was 
measured at the nebulizer outlet (T-out) and at the patient 
adapter (T-paticnt) The patient adapter lead directly to 
wide bore lubing passing through an Isolelte, lo which 
vacuum of 2 L/min was applied Within the wide bore 
lubing at 2 5 ft into the Isolette. temperature and relative 
humidity were measured wilh a ihcrmomcter-hygromctcr 
(calibration traceable to NIST. Fisher Scientific) The 
Isolette was warmed lo - 35 C. and an equilibration time of 
1 5 mm was used Absolute humidity wa.^ calculated from 
the temperature and relative humidity, from which percent 
body humidity (%BH) wa.^ calculated. Statistical analysis 
consisted of ANOVA RESULTS There was a significant 
difTercncc in %BH between manufacturers (P<0O01 ). but 
no difference for FIG, (P=0 098) or levels of fullness 
(P-0 0741 The'aBH was greater (or adjustahlc (SO f.±4 0) 



ha/i nonadjuMatilc 


C«lCf!(7| I), 


f, SkI'-IIIK 


II 




".Bit 


1 (uull 


1 (palicnt) 


Hudson RCI 
(adjuslublc) 


no !±2 8 


41 6.8 8 


52 4*.1 9 


Hudson RCI 
(nonddiusuMcl 


71 2i3 4 


'*'•" 


26IHI 7 


llaMci 


^« 1 1 1 u 


wi-:ii 


:')•(»; 1 


l,j>cnnl 


i« l..l« 


(1.4.; 'J 


;» w,i 1 


M 1' 


w, ; , 4 1 


1M.-4 s 


27 Ml 8 


M.sly.lK 


79 8»4 6 


41 :.»f. 


1)812 7 


I'rofciMonal 
Medical 


84 Ol 1 7 


44 <„'i 1 


H 1.28 



CONCLUSIONS There was a diffcrc 
in humidity delivered by heated nebuli/ers, bui no 
difference between levclt of fullne« and Fl()2 \ctiingv 
The (tifferencH m delivered humidity between dcvico wu' 
panially. but not completely, explained by diflcrenccs m 
delivered temperature (supponed in purl by Puritan- 
Bennett) OF.94-C 



William Baches BS RRT , David Of! BA RRT, Kns Conrad RRT, 
University of Wisconsin Hospital 

BACKGROUND There are recognized nee* to reduce tubing 
condensate and hixnidification costs This study looks at the ability 
of three HME hunidificatjon systems to maintain adequate sputum 
quality in a ^oup of surreal & mechcai patents From tun ICLTs 
METHOD & MATERIALS The devices used vwre Bird 3001 and 
Beer VH- 820 heated humidifie*^ (HH), the Pall PATH (PP) system 
utilEing the Bird 3001 and Pall HME 15-22, the ARC 6000. and the 
Gibeck 1991 (GB) Study prolocol excluded patients with excess or 
bkxxty secrelrons, lung transplants, minute ventilations* 15 LPM. 
and tidal volumes less than 150 ml Pat)ents meetng study 
protocol were landonKzed to heated humidifical)on or alternative 
humxification based on odd vs even mecical record nimbers 
Patients were evaluated for consistency and amount of sputum 
once per shift Consisterxry was judged to be in one ol three 
categones (watery-W. moderate-M. or tenacious-T) based on 
definitions trom the Suzul^avra, study The amount of mucus vas 
judged to be m one of three catagones (smalt-S. moderate-U, a 
large-L) The defimOon of amount was not precisely quantitated 
RESULTS. The table below lists the results tor consistency and 
amount of sputum tor each device and each calagory 

Ckinsistency Amount 



Device 


W 


M 


T 


S 


M 


L 


HH 


62 


187 


37 


79 


162 


45 


ARC 


11 1 41 1 9 


26 


24 


11 


OixA 


9 1 59 1 11 


44 


32 


3 


Pall PATH 


6 


" 


24 


,41 


60 


6 



Of 1 1 9 patients studed. 1 5 patients were excluded from the study 
for not meeting protocol and 4 patients tor incomplete data The 
table below lists the number of patient5(Pts), patient days (PtDays), 
measurements (Msmts), and patients switched to heated 



hunidificabon (To 


n 








Device 


Pis 


PIDays 


Msmis 


tohh| 


HH 


50 


157 


286 


WA 1 


AFC 


15 


32 


61 


5 


Giieck 


23 


46 


79 


2 


Pall PATH 


12 


46 


107 


3 



Each HME device was compared with heated humidification 
through the chi square test of homogeneity(p < 05) There was no 
statistical difference found in sputum consistency with the ARC or 
GibecK devtces when compared to heated humidificaton 
Increased spufem consistency was found with the Pall PATH 
There was no statistical difference found in sputum amount with tht 
ARC and Pall PATH devices when compared to heated 
humidificalion Decreased sputum volume was found with the 
Gt«ck HME device 

CONCLUSIONS We conclude that patients meeting a standard 
oilena can be adequately humidified with the latest generabon ot 
HME & HMEF devices We feel the Pall path system offers no 
benefit over these HME devices, increases the complexity of the 
arcuU. reduces but doesn't eliminate tubing condensate 
1 Suzuhawa M Respiratory Care 1989. 34 976-&4 



CL[NICAL EFFECTS OF OSCILLATING 
POSITIVE EXPIRATORY PRESSURE IN 
PATIENTS WITH BRONCHIAL 

HYPERSECRETION 

G.Callegan . S Brega, S Bagliam. L Zocchi, G Piagg). 
F Lte Mana. N Ambrosino Clinica del Lavoro 
Foundation IRCCS. Medical Center of Monlescano. 
Pavia, Italy 

The aim of ttiis study was to evaluate the acute 
eflfectiveness of a commercial device (Flutter VRP) 
advised for home CP in companson to postural 
drainage (PD) and chest percussion m removing 
secretions in patients with high spontaneous sputum 
production due to diseases other than cystic fibrosis 
Fourteen patients (Diagnosis COPD 8. Chroruc 
bronchitis 3. Bronchiectasis 2. ILEK bronchiectasis 1, 
Silicosis I. sex 9 m. mean (SD) age 65 (6) y. 
spontaneously producing more than 25 ml/day 
sputum underwent on different days, m random order 
two sessions each of two treatment modaliiies. with a 
resting day between each session Treatment A 
consisted of PD and manual chest percussion 
Treatment B included breathing through Flutter 
VRPI, The amount of sputum produced during the 
30 minutes preceding iTl), dunng each treatment 
session (T2) and during 60 minutes af\er completing 
each treatment session tT3) was recorded together 
with the sensation of "chest bulkness due to 
secretions" which was assessed by means of a 
modified visual analogue scale (VAS) also at the 30th 
minute tjefore beginning each treatment session (TO) 
The mean time the patients tolerated treatment was 
18 7 (5) and 1^*3 (5) minutes for A and B 
respectively) Sputum significantly increasaed dunng 
trealmenis and in the same amount for the twtj 
modaliiies (Tl vs T2 2 9 (2 9) to 10 9 (7 1) and 2 8 
(3 1) to 10 I (10 8) ml for A and B respectively, 
p<0 00l) During 60 minutes following the end of 
treatment (T3) patients produced a similar amount of 
sputum for the two treatments both showing a 
significant reduction in comparison to T2 (p*:0 01) 
Mean VAS at TO andT I was 46 4 (15 5) and 46 (17) 
% for treatment A and 40 4 (12 4) and 45 (9) % for 
treatment B respectively At T2 VAS showed a 
significant reduction for both treatments ( down to 35 
(16) and down to 17 5 (11)% for treatment A and B 
respectively, p-OOOl) No change in expiratory 
flows nor in Sa02 was observed dunng of each 

We conclude that Flutter VRPI is effective in acutely 
enhancing sputum production and in relieving related 
symptoms of "spontaneously producers" with diseases 
other than cystic fibrosis 

OF-94-106 



RELATIVE HUMIDITY (RH) DELIVERED BY A 
NEONATAL HEATED WIRE CIRCUIT Lvnn tvi 
Sullivan. RRT. Kevin Strong, RRT, Judy Trahcy. RRT. 
Dean Hess. MEd. RRT. Robert M Kacmarek. PhD, RRT 
Dcpanmcnls of Respiratory Care and Anesthesia. 
Massachusetts General Hospital and Har\ard Medical 
School, Boston. MA 

Clinical problems related to inadequate humidity with 
healed M(irc circuits has been reported Miyao el al (Crit 
Care Med 1992.20 674) suggested that RH. noi absolulc 
humidily (AH), is important when using a humidifier with a 
healed wire circuit Whereas AH determines the total 
amount of HjO deprived of the respiratory tract, RH 
dctennines from where the H,0 is deprived At a low RH. 
HjO is deprived of the upper rcspiralor> tract and UBchea. 
This could result in drying of secretions in artificial airways 
and large central airways We previously showed that RH 
can be low wilh healed wire circuits (Rcspir Care 1993. 
38 1249) We further evaluated RH with additional 
neonalat heated wire circuit systems METHODS Wc 
evaluated 2 each of the Hudson-RCI Concha-therm 111 Plus 
wiih Hudson-RCI Circapak Nconalal Universal Circuit, 
Fisher and Paykel MR730 Respiratory Humidifier, 
Marquesl SCT-3000, and Bird Humidi-How DSC- 1 7000 
humidifiers with Baxter Isothermal Custom Breathing 
Circuits An Airshiclds Isolette warmed the disial ventilator 
lubing and patient Y-piccc to of 36 5 ± 6"C The circuit 
lemperaiurc probe was eKtemal to the Isolene for all 
evaluations RH was measured at least 15 mm after 
stabilization at each scning wiih a Fisher Scientific 
hygrometer (calibration traceable to NIST) Humidifier 
settings of minimum (mm), mid-r^ngc(mid). and maximum 
imax) were evaluated at temperatures of 3 1 . 33. 35, 37"C 
The following ventilator settings were used on a Sechrist 
Infant Ventilator Model IV-IOOB at each combmation of 
humidificr/lemperalure settings IMV 20, pressure 20/5 cm 
HjO, T=0 75 s. flow 8 L/min. IMV 40, pressure 40/10 cm 
HjO, T =0 75 s, flow 12 L/min Humidifiers and circuits 
were used per manufacturers' specifications RESULTS 
Due lo no important differences between brands. RH was 
pooled in the following table 



temperature 
setting 


humidifier setting 


mm 


mid 


mK 


31- 


!2 91120 


68 2i6 8 


77 7±4 


33- 


58 6±I2 5 


73 8±7(i 


86 U5 


35- 


<i')4i9 8 


81 6i7 2 


93 l±6 8 


37- 


78 1±7 9 


89 6i7 5 


98 913 



There was a significani difTcrencc in RH delivered between 
temperature and humidity settings (P<0 001 by ANOVA in 
both cases) CONCLUSIONS Although further work is 
needed to determine the clinical importance of our results, 
the data shows that at low temperatures and humidity 
settings. RH delivered can be low with ihe heated wire 
circuits that wc evaluaied, additional data supports thai Ihe 
degree of condensate visualized in the tubing is a reliable 
indicator of RH (supported in pan by Puritan-Bennett) 

OF-94-083 



REMOVAL OF A CLOSED- SYSTEM, DIRECTIONAL TIP 
SUCTION CATHETER FROM THE MURPlTi' EYE OF AN 
ENDOTRACHEAL TUBE Rob<n A MiliB ch MEd, RRT, 



The use of dosed-sysiemtCS) direcuonal-up sucuon 
ialhelere(DTSC) has been credited with preventing 
desaturauon. bradycardia and hypotension tn venulaied 
pauems DTSC's allow for, but do not guarantee, selective 
entry into either mamstem bronchus Few comphcations 
with die use of CS. DTSC's tiave been reponcd .^ 6'' y o 
female underwent thoracotomy for the removal of 
squamous cell carcuiomas of the RUL and RML Following 
surgery the psuenl was mainiauied on a volume ventilator 
IPRVC, Vl'i50. f 16, Flo: 61), PEEP'') A healed 
huimdilier was uiduded m the cucuu due lo icnanous 
1 a 14 Fr CS, DTSC was employed to dear 
)ugh (he Qze 8 endoiraLheal nil>e(ET) which 
was in place al Ihe Ume Dunnf routine aucDorun^ the 
DTSC was easily paraed on the firai Bttempt The ptCient was 
?ubsequent]y saUnc lavsged and the DTSC was passed a 
second tunc Dunng insertion the patient coughed and the 
DTSC became shick ui the ET Successive attempts to 
remove the DTSC were unBuccesBftil The F102 was 
increased lo 1 and \}ie pabenl was rwuched to the volume 
LonU^I mode The paUenlB Sp02 was suble ei 90-94% The 
pouenCs resp rale mcreased slightly and the Ve remamed 
stable Because the paueni was stable wiih Ihe cHheter 
lodged in [he FT a decision was made io assess a X-ray 
prior [0 taking acuon It was iniUaUy thought that the DTSC 
hail hooked ttiound the up of the ET Upon t\mhei re\icw, 
Ihe X-ray revealed thai the DTSC had exiled the ET tube 
through the murphy eye and had hooked toward the vocal 
lorda n distance ot appTox I cm It was postulated Ihst 
removal of ihe ET wiih the DTSC hooked proximally would 
rcniJi m damage to ihc trschea or vocal cords II was then 
decided lo advance ihe ET lo Ihe level of the carina where 
ihcre was room for ihe DTSC lo t>ecome dulodged Upon 
advancing the ET to the level of the canna the DTSC was 
rotated and allowed to ilraightsn itself From there the 
DTSC was eaaly removed and the ET was relumed lo lU 
prupor potibun We epeculMe thai ihe palieni was Epared 
tracheal or larvngea) damage because the ET and DTSC 
were not remiived together as would be the case if the same 
problem had occurred wiih an open-syWcm DTSC The Cs 
DTSC allowed the paueni to be adequately vcnulalod while 

in no injury to the pauent According to the manufacnirer of 
Ihe CS. DTSC. ihiB type of complicaDon has never been 
toiHtned praviouNly The only reported complication had lo 
do wiih the use of an endotracheal DTSC on a patiwit with a 
imchcoitomy liit>c Cart mufi be laken to insert the DTSC 
with the Tee adapter pnrollel to the chin and the uidicalor 
tmc centered in ihc ET Even with these prccaulions, undtr 
cenain circumstances, it jQi^be possible ihai a DTSC can 
hook arotmd the murphy eye of the ET This case 
demoiistralM the proper way to remove H stuck calheter 

OF-94-138 




There comes a time when 
all the valuable features become invaluable 



BagEasy'"' Dispos^ible iM;uiu;il Resiiscitatoi's have away of becoming 

essentid to tlie people who use tliem. Some say it's because tliey 

can iLse PEEP witliout fii-st seaithing for a separate valve. 

BagEasy's PEEP valve is built in. Otliers say it's because they 

know exxtly when to increase flow BagEasy's oxygen reservoir 

is sensibly placed up front, where you can see it. Still otliers 

find B;igEasy remarkable because it lets tliem change position 

in a crowded space witliout interrupting flow. BagEasy has 

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RESPIRONICS INC 

The First Namk 1\ 1\\(i\ati\i-; Rkspiratory Care 



1001 Murry Ridge Drive • Murrysviile, Pennsylvania 15668-8550 USA 
Phone: 1-800-345-6443 within the USA and Canada or 1-412-733-0200 • Fax: 1-412-733-0299 



Available December 1994 



© Respiruiiics. Inc 1994 



Circle 125 on reader service card 
Visit AARC Booth 1109 in Las Vegas 



Open Forum ABSTRACTS 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1 



COMPARISON Ol A M W III A Ihl) WICK HU- 

MIDII H M H'\ S> Ml M lO 111 AriiDWIRH 

AM) SI \\|>\Kl)\i\lll. MORflRfUITS 

\SnH \Mt K ni'LIILMlDUIHR. 

A LABORATORY BBNCH STUDY 

Ed Bclingon. RRT. J, Fitik. RRT. 



of Pulmoniiry and Critical Care Med 
i VA Hospital und Loyola Univ of Chicago 
Stritch School of Medicine. Hines IL 



A new heated wick humidificution system 
(AnaMed) actively humidifies gas by healing a 
moist wick within the inspiratory limb of a dispos- 
able ventilator circuit. We wanted to determine 
how patient work of breathing, circuit compliance 
and operating efficiency compared to standard and 
heated wire circuits (Hudson/RCI) used with a 
passover wick humidifier (Concha Three-plus, RCI) 
. A bench model was developed to compare patient 
work of breathing dunng spontaneous breaths, cir- 
cuit compliance and lime required to reach 1007f 
relative humidity (RH) at set temperatures. METH- 
ODS: A model consisting of a two compartment test 
lung connected in parallel by a metal bar was 
attached to a PB 7200ae (Vent A) so that inflation oi 
one compartment simulated a spontaneous breath in 
the other compartment. A second PB 7200 ae (Vent 
B) was used to ventilate the "patient " model incor- 
porating either: a) a wick humidifier with a dispos- 
able heated wire circuit, b) a wick humidifier with a 
disposable non heated wire circuit, and c) the new 
heated wick humidification system. A respiratory 
monitoring system (Ventrak) was placed between 
the ventilator circuit and test lung to determine pa- 
tient work in Joules/Liter (J/L) during spontaneous 
breaths (n=3). Vent A was set lo simulate sponta- 
neous breaths with tidal volume of 500 ml. rate of 
1 2. peak inspiratory fiow of 40 Umin with Vent B 
in CPAP mode at cm H;0 with flow-by set at 10 / 
3 L/min. Time required to bring the delivered gas to 
> 95'7r RH at 35° C from ambient conditions was 
determined by placing a digital hygrometer/ 
thermometer (Labcrafl) in the inspiratory limb prox- 
imal lo the patient connection. Compliance of each 
circuit was determined by performing an EST on the 
Vent B, RESULTS: The patient work of breathing 
was greater with the standard healed wire circuit 
(0 4(U ±.0 1 2 J/L I than either the sLiiidard (0.3X1 ± 
OJ/Ij or wick svsiem III 37^1 ± 01 J/l„ p<0.nO01 ). 
The heated wick system reached y5':i RH at 35 C 
faster (4,8 ± .6 minutes) than either circuit with the 
wickhumidifier(2l.3 ±2,1 minutes) (p<0,001). 
Differences in compliance did not approach signitV 
cance. CONCLUSION: The heated wick system 
reached desired conditions with less patient work of 
breathing than either the standard or heated wire cir- 
cuit used with a passover wick type humidifier. 
OF-94-162 



LABORATORY EVALUATION OF ARTIFICIAL 

NOSES 

Richard Branson. RRT . Kenneth Davis Jr. MD 

Department of Surgery. University of Cmcmnati Medical 

Ccmcr. Cincinnau. Ohio 

Introduction Artificial noses (AN) are passive 
humidiricaiion devices used lo condition inspired gases 
during mechanical ventilation. Wc evaluated llie 
moisture output, resistance, and dcadspace of 18 AN's 
accordmg to the ISO standard (ISO 9360 1992) 
Methods A patient model consisiing of a cascade 
humidifier, temperature controller. 2 test lungs and a 
sencs of tubuig and one way valves to separate 
mspiratory and expiratory flows was constructed This 
model was venlilaied usmg compressed air (absolute 
humidity < 7 mg/L) at 1) V^ = 500 mL and f = 20 
b/min. 2) V, = 1000 mL and f = 10 b/min. and 3) V^ 
= 1000 mL and f = 20 b/mm Dunng ventilation gas 
exiting the palicnl model was controLcd to maintain a 
temperature of 34±1'C The ventilator used a square 
flow waveform and 1 E of 1 3 The model was weighed 
and then ventilated for 3 hr and weighed agam to 
determine water loss (mg/L) Three of each AN were 
tested for three hours at each vcnUlation scUing and the 






:sicd) 



Mouturr output was dctcrmuicd by Ihe ISO equation 
moisture output = 37 6 x (1- water loss with AN/mean 
moisture loss without AN) Rcsisunce was dctermmcd 
by monitoring pressure drop across each device usmg a 
RT 200 calibration analyzer fTimctcr) at a flow of 1 Ui 
Results at V, = 1000 mL and f = 10 b/min are shown 
below listing the moisture output (mg HjO/L) and 
reiisuncc (cm HjO/L/s) 

Aqiu + H (27 9. 85). Aqua + FH (28 5 , 1 .65); Edith 
(26.5. 1 47). Edith 500 (21 3. I 73). Edith 1000 (24 6. 
2 01); Edith 1500 126 9, 3 52). Rocarc "L" (26 7. 1 59); 
Gibeck HVF (30 1, I 95). Hygrobac (30 5. I 94). 
Hygrobac "S" l27 1. 2 41j. Hygroslcr l31 3. 2 53), 
Intertech 2841 (26 4, I 75). Intcrtech HEPA (2t 4, 
1 64). Pill HME (19 9. 1 67), Portex 600 (23 4. 2 84). 
Portex 1200 (26 1. 1 23). Viuil Signs HCH (28 1. 2 24); 
ViUl Signa HCH/F (27 2. 2 46) 

Concluiioni The AARC Conceniui Conference of 
Mechanical VentUiton recommends a minimum absolute 
humidity of 25 mg Hp/L Several of these devicca are 
incapable of meeting (hii standard at a V, of 1000 mL 
Several dcvicca are capable of delivcnng 30 mg H,0/L 
which meet! the ASTM tUndard for heated humidifiers 
None of the devices exceeded the maximum reiistancc of 
5 cm HpiUt citablished by ISO Praclitioncn should 
be aware of die performance of AN'i pnor to purchase 



NEW SAFETY FEATURES INCORPORATED WITH 
HEATED WIRE HUMIDIFIERS (HWH). SHINJI 
FUKASAWA. BS. RCE. TETSUO M 1 YAGSTOT 
RPT, RCE, RRT. MURAT SABAH, BS.MBA. 
JUNTENDO UNIVERSITY, SCHOOL OF 
MEDICINE, TOKYO, JAPAN. 
We conducted this study to evaluate 
the safety features and perfortnance of 
a new HWH (HPD Medical, San Clemente, 
CA). Performance of the new HWH is 
compared to Fisher and Paykel MR-730, 
whose perfofmance has previously been 



MET 


inns: 


A cont 


niio 


s flow 


r, 


r 14 1pm 


was 


appi 


ied lo 


HPI) 


3000-1 


Mil 


nidifying 


Chamber. 


Chambc 


wa 


fille 


i w 


th water 


per 


man 


ufaclurt 


r 's 


instr 


ipt 


ons. HPD 


Med 


r«\ 


^WH was 


CO 


nected 


fn 


a 18 OHM 


HHI) 


Hpflt 


ed Wire 


FiP HWH w 


^s 


:onnected 


tn 


l< 


.5 OHM 


K»P 


Heated 


Wi 


re. Doth 


Hea 


pd V 


ires wf 


re 




h 


1 130 cm 


Smooth 


Boar 


r 








Tern 


lerat 


ure pat 


ern 




non 


tored by 



Chino Hybrid Multi-Channel 

Water, chamber outlet, airway and hose 
heater temperatures monitored and 
recorded at HWH temp settings of 36"C. 
36°C and 370C. Chamber control was set 
at -1 during the tests. Room temp was 
liept constant at 23°C. In addition. 
HPD Medical HWH was tested with hose 
heaters ranging from 11 OHM to 30 OHM 
to confirm a new safety feature called 
"Automatic Heater Wire Resistance 



Detection" a 
heater produc 
RESULTS: 


gainst 


misuse of hose 




MI-500 


MR-730 1 


MIN 


Ti 


T2 


Ti 


Tz 


2 


22,7 


24.3 


22.7 


31,6 


4 


25.4 


24.9 
25.7 


25.2 _ 
30,6 


37 .4 
36,9 


6 
8 


28.8 


31,8 27.2 


32,4 


36,9 


10 


35.0 36.8 


32,7 


37,0 


[12 


35.9 J37.0 


36,0 


37.0 


T. = C 
T? = A 


lainber 
1 rway t 


Jutlet temperalu 
^mperature 


" 



CONCLUSION: "Wan 



featur 
between 
dry gas 



period dry-gas 
! keeps the 
Ti and T? low 
del ivery during 
heater detection 
the risks that 
' using different 
with the HWH. 

OF-94-229 



EfTecta of Flow-Triggered Ventilation on Closed Circuit 
Suctioning Systems Thomas P. M almowski BS, 
RRT,RCP Michael Hagclgantz 8S. RRT. RCP. Lawrence 
Totaro, MA. RRT, RCP. Department of Respiratory Care. 
Loma Linda University Medical Center, Loma Linda. CA 
Introduction Endotracheal suctioning dunng mechanical 






Oncn 



for this desaluration 

secondary to aspiration 
that flow triggered 



FIO] during the procedi 

duction in resting lung voli 
inspired gases. Wc hypolhi 



iling 



lied 



tuldb 



> aspirated dunng closed circuit 
suctioning (CCS) than pressure triggenng, and 
consequently would limit the reduction m lung volume thai 
occurs dunng the procedure Method^ A Bird 8400sii and 
Pun tan-Bennett 7200ae ventilator were evaluated. Both 
ventilators incorporate flow and pressure tnggenng 
c^abilities Each ventilator was set in CPAP mode at 10 
cm H20 and alternately connected to a two compartment 
adult test lung The 7200ac settings were Pressure 
triggered, sensitivity -2 cm HjO (control). Flow-by - 5. 10. 
15. and 20 Ipm, with flow tnggenng at I 1pm and 3. 5, 7. 
and 10 1pm respectively The 8400 sti settings were 
Pressure triggered, sensitivity -2 cm H2O (control), Flow 
support IS preset at 10 Ipm, with flow triggenng at I and 5 
Ipm, Tests were run at two lung compliances, 016 and 
■15L/cm H2O A calibrated pneumotach was placed at die 
tracheal bifurcation of a 9 U mm ID simulated tracheal tube, 
distal to the aspiration tip of the 16 Fr Cobe closed-circuit 



Walls 



catheter The pneumotach wa 


able to detect th 


of volume aspirated from the 


est lung (AFRO 


ctionwasI20mmHgofvacu 


urn Continuous 



addiii 



removed from the lung (usually <5 sec). Ten (10) sample 
points were gathered for each trigger level at each 
compliance Statistical analysis was by student t test 
ficiulll There was a statistically significant difference 
(p< 005) between Af RC when comparing pressure and 
flow tnggenng for both ventilators at both lung 
compliances In addilion, there was a significant difTercncc 
m AFRC between lung compliances (p. 005) 

& FRC at Varying Compllancei (ml) 

Bird 8400 sti PB 7200ac 





Pr™ T 


1. FlowTri 


P..U TrI 


Flo. Tri. 


.ISUcm 


lUtt 


81 i4' 


99.6 


70±2' 


H20 


252 ±9 


19813 


• 264122 


2201 
34- 



• - p^ 005 compared to pressure trigger 
<'onclmlon CCS simulaled a sponumcous inspiratory 
elTttn, aflcf nn initial gas volume was aspirated (AFRC). 
the venlilalor demand valve opens, supplying additional gas 
through the circuit In this model, flow tnggenng was more 
sensitive than pressure tnggenng, opening the demand 
valve sooner, limiting die reduction in AFRC Tlte clinical 
vigniricanceof thisohservation is that How triggered 
ventilation moy preclude die need for elevating FIOj during 
the procedure This warrants clinical investigation. 

OF -94 -253 



■AN ALTERNATE HUMIDIFICATION 
SYSTEM FOR INTRATRACHEAL 
VENTILATION Williai W, fluinn 
RPFT RRT , Erick Fajardo MD 
Ochsner Fountiation Hospital Ne 
Orle 



LA, The 
acheal ve 



ntilati 



offers great protoise f 
ventilator-associated 
and mortality in infan 
However, the technique 



mber 



He 



aluale the huniditi 



;difi- 
sought 



the Bunnell Lifepul 



lato 



site 



Venti- 

native. Method: 

a compliance of 

lated using ITPV 

erent humidifi- 



A test lung 
1 ml/cm was 
with the two 
era on standardized settings 
(Rate: 60, Mean Airway Pressure 
7 cm H20, Minute Voluite: ,65 L) 
A digital thermometer/relative 
humidity meter was placed at a 
simulated carinal level to mea- 
sure temperature(T) and relativ 
humidity(RH), Result3(SD), n=5: 

Conchas Bunnell 
T 34.5C(,3) 35.0C(.2) 
RH 95,8X(.4) 96%(0) 
Comparison of results by ana- 
lysis of covariance reval 
between relative humidity 
levels. Temperature achieved 
with the Bunnell was signifi- 
cantly higher (p<,01) by the 
same test, but this may not b 
clinically significant. Con- 
clusion: Based on this preli- 
minary evaluation, the Bunnel 
humidifier appears to perform 
well enough that we intend to 



NSD 



:lude 



aluati 



of ITPV in animal subjects, 
l.Muller E, Kolobow T et al 
Intratracheal Pulmonary 
Ventilation (ITPV) A new 
technique to ventilate lungs as 
small as lOX normal (abstract) 
Soc, of Ped. Res. 1991 

OF.94-236 



THE 

AMERICAN 

ASSOCIATION 

FOR 
RESPIRATORY 

CARE 

IS HOLDING 

ITS 

1994 ANNUAL 

CONVENTION 

IN 

LAS VECAS, 

NEVADA, 

DECEMBER 

10-13,1994. 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 



Open Forum ABSTRACTS 



A TWO YEAR EXPERIENCE WITH 
TEN DAY VENTILATOR CIRCUIT 
(VC) CHANGE OUTS. James A. 
Tyra, BS, RRT , Jimmy W. 
Norwood, BA, RRT; The 
University of South Alabama 
Medical Center, Mobile, Al . 
INTRODUCTION : Based on 
available research studies we 
extended our VC change out 
interval from every 48 hours 
to every 10 days. METHODS : On 
9/1/91 we began changing VC 
every 10 days. Data for VC 
cost and nosocomial pneumonia 
(NP) levels were collected 
for the study period 1990- 
1993. NP is defined as per 
institutional policy, various 
combinations of clinical, 
radiographic & laboratory 
evidence of infection . During 
the study period there were 
no changes in ventilator 
protocol. RESULTS : For the 
year prior to 10 day changes 
S47580 was spent on VC with 
total NP levels of 120 or 
10/month. In the 2 years 
since we have been doing 10 
day changes there have been a 
total of 234 NP or an average 
of 9.75/month. Ventilation 
levels remained constant 
throughout. The average 
length of stay on a 
ventilator in the ICN was 
6.43 days, and for Adult 
patients was 4.78 days. In 
1992 $30,865 was spent for 
VC, and in 1993 $21,014. Our 
experience shows that 10 day 
change outs was a sound 
economic and patient care 
decision. CONCLUSION : Our 2 
year experience has shown a 
total savings of $43280 while 
NP levels have remained 
constant.lt is our conclusion 
that change outs can be 
safely extended to 10 days. 



THE EFFECT OF WEEKLY CIRCUIT CHANGES ON 
VENTILATOR-ASSOCIATED PNEUMONIA (VAP) 
RATE Dean Hess. MEd. RRT. Eduard Bums. RKT, 
David Romagnoli. MS. RRT. Roben M Kacmarek. PhD. 
RRT Departments of Respiratory Care and Anesthesia. 
Massachusetts General Hospital and Harvard Medical 
School. Boston, MA 

Frequent changes of the ventilator circuit were once 
thought to be important to prevent nosocomial pneumonia 
m mechanically ventilated patients There is increasing 
evidence that the frequency of ventilator circuit changes 
does not affect nosocomial pneumonia rate (Dreyfuss. Am 
RevRespirDis 1991.143 738) The practice of frequent 
circuit changes is costly m terms of both materials and 
personnel time We conducted this study to compare VAP 
rates and cost reductions with 48 hr versus 7 day circuit 
changes METHODS The control group consisted of all 
adult mechanically ventilated patients for the 6 month 
period of 11/92-4/93, in which circuits were changed at 48 
hr intervals On 5/ 1 5/93. the circuit change frequency was 
changed to a 7 day interval The study group then consisted 
of ventilated patients from 6/93-1 1/93 No changes in 
mechanical ventilation practice occurred during this period 
Heated cascade humidifiers and unhealed circuits were 
used VAP were identified using clinical criteria consistent 
wiih the CDC The cost of circuit changes with 48 hr 
versus 7 day circuit changes was calculated from the 
dislribulion of ventilator days for the control group and the 
study group Patients were suhgrouped per medical versus 
surgical patients, and ICU versus non-ICU patients 
RESULTS There were 9858 ventilator days ( 1 708 
patients} in the control group and 9 1 60 ventilator days 
( 1 7 1 5 patients) in the study group The VAP rate for the 
control group was 9 64^ 1 000 ventilator days ( SE 98. 95*4 
CI 7 7-1 1 6) and the VAP for the study group was 
8 62/1000 ventilator days (SE 97, 95% CI 6 7-10 6) By 
univariate analysis, there was no difference in VAP 
between the study group and the control group ( P=0 5 1 , 
Power^O 85) Using logistic regression analysis, the odds 
ofVAPwere 1 77 (P=0 02) for surgical patients. 1 54 
(P=0 05) for ICU patients, and 82 (P=0 22) for 7 day 
circuit changes For the 12 month period of this study, the 
cost of materials to change circuits at 48 hr intervals was 
$50,725 and the cos! lo change circuits at 7 day intervals 
was 1 1 .896 The annual time savings for 7 day circuit 
changes was 1335 hrs CONCLUSIONS These results 
indicate that ventilator circuits can be changed at 7 day 
intervals without a significant change in VAP. and we have 
adopted this practice at our large university-affiliated 
hospital Weekly ventilator circuit changes can be adopted 
with the use of cascade humidifiers and unheated ventilator 
circuits Changing circuits at 7 day intervals can result in 
important cost savings (supported in part hy Puritan- 
Bennett Corporation) 

OF-94-082 



FACTORS AFFECTING LATEX GLOVE 
USAGE IN A BLOOD GAS LAB 

E)ebbie DiNicoia. Roben L. ChatbumJ^RT. Rain- 
bow Babies & Children's Hospital, Cleveland. OH. 

Universal precauuons mandate use of latex gloves 
when handling blood samples. In our lab.use of 
powder filled gloves appai^nily led to more frequent 
handwashing, dry irritaied skin, allergy lo powder, 
and higher glove usage compared lo powder free 
hypoallergenic gloves. Powder free gloves arc 
thicker, more durable and can be worn longer , with 
less irritation to the hards This study was to test ihe 
hypothesis ihai ihe higher cosi of powder free 
gloves would be offset by their lower rate of usage. 
METHODS: Normal usage of powdered gloves 
(Kendall brand) and powder free (SafeSkin brand) 
was recorded for 10 days each. The number of 
blood gas assays performed dimng the same period 
was also recorded. Staff were blinded lo study 
results but not glove brand because of obvious 
differences between glove types, Average glove 
usage (pairs/blood gas) was compared using a 
non-paired l-tesl. Annual glove costs were 
calculated from mean glove usage and projected 
blood gas volume, RESULTS: Glove usage {mean 
± SD) was less for SafeSkm than Kendall (p<0.001. 
see figure below). Skin condition (ie, presence of 
redness, cracked cuticles and finger pads) appeared 
noticeably improved with SafeSkin. although this 
observauon was highly subjective. At 8c/pair, the 
annual cost for Kendall gloves is estimated at 
$1,756 (assuming 50.000 blood gases/year). At 
4 8«/pair. annual cost for SafeSkin is $5. 160 
CONCLUSIONS: WhUe the cost of the SafeSkin 
gloves is 500% more per pau- than Kendall, iheu- 
construction allows for longer wear, resulting in less 
than 200% increase in annual glove costs, Ub staff 
found that because the Safeskin gloves were thicker 
they could wash theu- hands with gloves on. 
contribudng to longer use. Improved skin condition 
and staff satisfaction might justify the increase in 
cost. 




r^TTq : 



DEVELOPING A PROGRAM FOR 
MONITORING VENTILATOR-ASSOCIATED 
NOSOCOMIAL INFECTIONS George 
(^odhaii.. RR T. Craig Gilliam, BSCIC, 
Arkansas Children's Hospital, Little Rock, AR 



During an evaluation of heated-wire 
numidifier^ventilator circuits (HWC), we 
sought approval to extend our ventilator circuit 
change interval from 48 hours to 7 days. Our 
presentation to Infection ControldCC) and ICU 
committees GCUC) emphasized an unproved 
closed system with reduced employee hand 
contact- We received approval with the 
condition that an appropriate monitoring 
system would be developed without the expense 
of obtaining cultures: l)The number of 
ventilator dayfVlCU/month was obtained from 
RCS shift report forms; 2)An Epidemiologist 
determined ventilator- associated nosocomial 
infections fVAJ) by review of ICU routme 
culture reports and data from ICU rounds; 3)In 
Feb. 1993, mstituted use of HWC and started 
data collection: 4)retrospectively collected data 
from previous year; 5) VAl reported to ICC 
monthly, and to ICUC quarterly. 

VAVIOOO VENTILATOR DAYS 
1992-48 hr. tubing 1993-HWC 

5.1 CVICU 2.8 
5.6 PICU 3.3 

2.2 NICU 1.2 

CONCLUSION: Our VAI has decreased since 
implementing a 7 day circuit change policy with 
HWC. Permanent system for monitormg VAI in 
our hospital has been developed (NNIS System 
- threshold less than 5 VAI/1000 ventilator 



Increased Expiratory Resistance 
Due to the Normal use of a 
Expiratory Filter- Ryan 

Grueber,B HS,RRT University 
Hospital and Clinics. Columbia 
Missouri INTRODUCTION; Normal 
use of expiratory filters on 
mechanical ventilators may 

The STAR EXHALATION ISOLATION 
SYSTEM is regularly used on 
Servo 900C ventilators. 
HYPOTHESIS: Expiratory filters 
increase expiratory resistance 
despite normal monitor ing of the 
ventilator and the patient. 
METHODS AND MATERIALS; A 
calibrated Servo 900C ventilator 
with the STAR EXHALATION SYSTEM 
and an unmodified patient 
circuit was attached to a 
mechanical model of the lung. 
The ventilator was then measured 
for inspiratory and expiratory 
resistance without the filter 
system to get a base-line 
measurement. A set of filters 
were marked and measured for a 



bas 



The 



filters were then put on Servo 
ventilators in use on patients. 
The filters were taken off of 
the patients ventilators 
randomly from one to sixty seven 
days and resistance was 
remeasured. RESULTS: Thirty- 
nine filters were measured for 
expiratory resistance. The time 
on the ventilator was days to 
67 days. The least amount of 

was 0.85cm 
'he greatest amount 
e recorded was just 
iH20/L/sec. The 

lidered to be 



by a filte 
H20/L/sec. 



under 



OF-94-057 



EfTect of Ethylene Oxide Gas Sterilization on 
Accuracy of BICORE Transducers 

Thomas J. Kallstrom.RRT. Roben L, Ch«tbum,RRT. 
Diane Moms.RRT. Rainbow Babies and Children's 
Hospital, Cleveland, OH 

iDtroductloD : The purpose of this study was to evaluate 
and describe the perfonnance of a new pneumotachomelci 
(Neonatal/Infant VarRex Row Transducer. BICORE) and 
to detcimine the effect of repeated sierilizadon using 
ethylene oxide (EtO). This transducer is intended to be a 
single use item. However, the manufactuier does stale that 
it can be stcnlized once before use. Method: We 
evaluated 10 new flow transducers. Each was calibrated 
with the CP-100 Neonatal Pulmonary Monitor (Bicore) 
before making measurcmenis. A calibrated syringe (Hans 
Rudolph) set at a volume of 60 mL was used as the 
standard. The syringe was pumped al a rale of 30 breaths 
per minute for approximately one minute. The inspiratory 
and expiratory volumes (averages of 10 txeadis) were 
recorded from die CP-100 display (al ATPD)- After 
baseline measurcmenis. each transducer was sterilized 
with EtO at a temperature of IZS-UCF for 4 hours 
followed by a 4 hour aeration period. The experiment was 
repeated until each transducer had been sterilized a total 
of 4 tunes The transducers were not used on patients 
Inaccuracy was expressed as limits of agreement (mean 
diffcrCTKe, measured minus actual volume, ± 2 SD) for 
each experimental condition (ie, baseline, and first 
through fourth steriUzaiions). 

Results: The worst case inaccuracy interval for new 
probes was -3.9 lo 1.7 mL (inspiraiion. see Figure below). 
Bias increased with sterilization and after the founh time 
was -43 tnL. Imprecision (SD) increased dramatically 
after the first sienliz^on but did rtoi change much 
thereafter Total worst case enor observed 
([ measured- tniej/true, as %) after four sterilizadons was 
-24%. Both inspired and expired volumes tended to 
underestimate the true values. Conclusions: Sterilizing 
these transducers with EtO even once dramabcally 
degrades accuracy. If these transducers are to be reused, 
other methods of decontaminabon must be evaluated. 



— inspiratory volume — 
expiratory volume 



1st 2nd 3rd 41h 



Open Forum ABSTRACTS 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1 



PERSONNEL COSTS ASSOCIATED WITH 

UNIT-DOSE VS. MULTI-DOSE 

MEDICATIONS 

MIchaal J. Mahlmelate r. MS. RRT. RCP 



Brian M. Daniel, RRT, RCP 

U. of California Medical Center 

San Francisco. California 

Introduction: The cosi-elfectiveness of unil- 
dosG bronchodilaior medicalions (UD) versus 
multi-dose bonles (MO) is usually based upon a 
number of supply factors We studied the 
contribution of personnel factors to the cost- 
effectiveness of UD versus MD. Methods: 
Twenty one RCPs parlicipated in the study, all 
with previous experience using both UD and MD. 
Each RCP was timed prepanng a hand nebulizer 
treatment with a UD ampule (albuterolDey 
Laboratories), and a MD bottle (albulerol- 
Schering) + an ampule of normal saline. All RCPs 
were instructed to prepare the treatment at 
their normal therapy pace, not to speed Each 
RCP was timed twice for both UD and MD. and an 
average was obtained for each technique 
Results: The average time to prepare the 
treatments were as follows: UD 13.95 seconds 
(range 9.87 ■ 22 15). MD 32 68 seconds (range 
18,56 - 52.80) MD treatment preparation took 
an average o( 18,73 seconds longer than UD. 
Discussion: The additional time necessary to 
prepare a MD treatment represents an added 
cost factor Assuming an institutional cost of 
$24.00/hour (salary + benefits) for an RCP. 
18.73 seconds equals an additional cost of 
approximately 12 5 cents per MD treatment 
versus UD treatment Conclusions: Over a six 
month period, our staff administered 13,342 MD 
treatments Using the figure of 12.5 cents/MD 
treatment, added personnel costs for MD 
therapy amounted to $1,667. We believe that 
these personnel costs should be considered when 
evaluating the cost-effectiveness of UD versus 
MD medications. 



EFFECT OF EXTE^a)ING VENTILATOR 
CIRCUIT CHANGES FROM 2-J TO EVERY 7 
DAYS 

T AJfredson.RRT . A Earl.RN. R LtrsooJlN. J 

Cronm.RRT. D HtuptniMi.RRT. P J Faho.MD and P 

O'KeefeMD 

Loyola Uoiversin,' Medical Center- Maywood, Illinois 

In tbeir 1994 drafi sidelines, the CDC states that 
veoiiiator circuitii should be routmeh' changed no more 
frequenth than Q48 hours but does not recommend a 
maximum duration for use We have reccnlty altered 
our pobc> so thai ventilator circuits are changed Q7 
days rather than oui pre\ious Q2-3 day c>cle The 
mean rale of venlilalor a.ssociated pncumoma (YAP) 
per 1 (KX) days of ventilation was tracked lor two 
comparable 7 month penods pnor to and affer this 
change m procedure ITie mean VAP/l<XMf ventilator 
days was 11 9( 2.958 palienls venlilaled for 13.468 
days) from 8/92-2/93 After the mstitution of 7 day 
circuit changes the VAP rate decreased to 4 8 {p=6 01 ) 
from 8/93-2/94 ( 2,500 patients ventilated for 12,356 
days) Average duration ol ventilation for patients with 
VAP increa-sed from 6 2 to 6 7 days (p=0 19) Circmls 
m the NlCt I/IMCI I had previoush been changed Q 
Monday Wednesday and J-ndav Adult circuits were 
changed Q48 hours Healed wire (HW) circuil« were 
used pre and posl thangc in NiCU/I'ICU (TV<500 
ml ) Non-llW circuits were inilialty used for alt other 
patJcnLs but were replaced at 48 hours with HW circuits 
with the 7 day prokMx>l for paticni-s on prolonged (>48 
hours) ventilation (, osl for suppbes decreased bv 
t62.949iD7[Donth>(uuiualt/cdtuS107.9l3 with a 
4 1 % de«;lmc m cncuils purcha.scd/ ventilator day) and 
labor costs decreased by S 1 5,825^caj We conclude 
that Q7 day ventilator cucuil changes did not increase 
rale of VAP and rcniltcd in subsluilial nivings m 
nrppK'/labor costs 



COSTS ASSOCIATED WITH DRUG 

WASTAGE WHEN USING MULTI-DOSE 

rHEDICATIONS 

Brian M. Daniel . RRT. RCP 

Michael J. Mahlmeister, MS, RRT, RCP 

U. or CaliforDia Medical Center 

Sao Francisco, California 

lolroduction: Multiple factors contribute to 
determining the cosl-effcctiveness of unit-dose 
(UD) versus multi-dosc (MD) bronchodilator 
medicalions. We evaluated the contribution of 
the wastage factor of MD use. by comparing 
the amount of MD medication administered 
with the amount of MD medication purchased 
by Respiratory Care from Pharmacy over a six 
month period. Methods: We conducted a 
retrospective count of all MD bronchodilator 
treatments (albuterol solulion-Schenng) over a 
SIX month period Dau was compiled 
identifying the precise dosage administered 
each treatment, so that a total volume of 
medication use could be calculated for this six 
month period. This medication consumption 
was compared to the volume of medication 
purchased from Pharmacy for that same time 
period. Results: A total of 13,639 
both small volume neb and large volu 



albuier 
Total 



>l solution 
olume of r 



SIX month period. 
ion used for these 

10,260ml of 
:. this amounted tc 



albuterol- At 20ml/bottli 
513 bottles of medication consumed to 
provide therapy. During this six month lime 
period. Respiratory Care purchased a total of 
1.292 bottles of medication. Discussion and 
Conclusions: A wastage factor of 779 bottles 
can be calculated from the difference between 
medication used versus medication purchased. 
At $3.26 per bottle, this represents a wastage 
cost of S2.539 dollars, or approximately 18 
cents/MD treatment. A variety of factors are 
associated with the failure to consume a full 
bottle of MD medication, such as bottles left 
at the bedside, bottles discarded if opened and 
undated or low on volume, or taken home m 
lab coats. This can contribute to medication 
wastage, and added costs lo the Respiratory 
Care department and the institution. Practices 
which enhance consumption of the maximum 
volume of purchased bronchodilator 
medications, which may include the use of UD 
in specific clinical situations, should be 
explored for their potential cost-savings. 

OF-94-11 



REDUCTION OF VENTILATOR ASSOCIATED 

PNEUMONIAS (VAP) WITH SEVEN DAY CIRCUIT 

CHANGES 

S. Krause. RN. M. Fisher. CRTT . J. Fink. MS. RRT . 

Hines VA Hospital. Hines n. 



Ventilator circuit change frequency ts established to 
minimize YAP If the frequency of circuit changes can 
be safely decreased, the costs associated with the care of 
ventilated patients could be significantly reduced. This 
study was designed to determine whether extending 
ventilator circuit changes from 2 days to 7 days 
significantly impacts VAP. A secondary consideration 
was the reduction in supply and labor costs associated 
with extended circuit changes. MEFHODS: All 
ventilated patients in our 6 bed RICH and 8 bed MICU 
were studied prospectively over a three year period lo 
determine prevalence of ventilator associated pneumonia 
(VAP), During 1991 and 1992 all venulator circuits 
were changed every C}48 hours. In December 1992, we 
began changing ventilau>r circuits on a 07 day basis 
All patients were mechanically ventilated with a 
Siemens Servo 900C™ or Puritan Bennett 7200A 
ventilator equipped with Conchalberm Thite™ 
humidifier and Hudson No. 161 3 Ventilator tubing set 
(Hudson RCI) with water traps (I5art No. 5275)) placed 
in both tlie inspiratory and expiratory limb of the 
circuit WTien compared to the same time period ( 1 1 
months) in the two previous years. VAP per 1000 
ventilator days decreased in both RICUand MICU 
(p<0.01 ) as shown below. Ihe number of ventilated 
patients and duration of ventilator days did not change 
significantly. In 1993. using seven day circuit changes 
our costs for labor and supplies were reduced by 
$32,517 over previous years (048 hour circuit changes), 
CONCLUSION: This study confirms that the 
prolonged use of wick-type bumidifler with standird 
circuit does not increase the incidence of nosocomial 
pneumonia, even in high risk patienLs. lliese findings 
suggest that proposed CIX' recommendations for 
ventilator circuit changes ^ 48 hours can be extended to 
7 days using wick humidifiers and standard circuiLs, 
with reduction m both VAP and cost. 




Year and I'rcquoncy of Vent Circuit Change 



COST SAVINGS AND AMORTI/ATKJN PKRIOD 
WHEN CONVHR1 INt; FROM DISPOSABLH TO 
PHRMANENT OXIMETER SENSORS. John Newharl 
RCP. David Bums MD, Corbeu Mask RRT MS. Richard 
Ford RRT BS 

Introduction: We are a 450 bed teaching hospiial. As 
pan of a hospital wide Cost Competitive Swaiegy at 
UCSD. a 29% reduction in operating cost was established 
as a target for Respiratory Care Pan of the cost reduction 
stragedy within RC included an analysis of maienal 
resources consumed, particularly those ilems of high 
volume/high cost. In fiscal year 92-93 disposable 
oximeter sensors cost S85.000 We evaluated the cosi of 
utilizing permanent sensors (PS) rather than disposable 
sensors (DS) Methods: Criteria for evaluation includes: 
The sensor would have to be applicable lo infant through 
adult All sensors would have to be reasonably easy to 
apply and stay attached to ambulatory palienls. The 
oximeters would have to correlaie closely with anenal 
blood gasses, have good ariifaci rejeciion. and function on 
pauents with reduced penpheral perfusion. Sensors were 
lested for a one month period on ICU patients. 
Approximately 30 palienls were u^ailed wiih both 
oximeters using DS and oximeters using PS Results: 
hi a SIX montli period before conversion lo PS we spent 
S35.838 on DS to administer 142.838 hrs of oximetry. 
Subsiiiuiing PS would require a one time start up cost of 
purchasing 70 permanent sensors with a 90 day warranty 
ai S75 each initially costing $5,250 This amount can be 
amortized over 21.000 hrs of oximetry. In our institution 
this equaled 28 days. In the six months since we convened 
to PS we administered 130.233 hours of oximiiry costing 
$ 1 1 .250 The operational cost for PS dunng this time 
penod included $900 for 12 PS that failed and were no 
longer under warranty. $1,2(X) for 16 PS lost . $2,475 for 
33 PS desux)yed. and adhesives at S 1 each x 7075 adhesive 
wraps used = $7,075 Conclusion: After the 
amortization of the initial 70 PS. the cost of oximeu> 
went from $250/1000hrs for DS to $80/I000hrs for PS 
for a decrease of 68% 



THE IMPACT OF CHANGING VENTILATOR 
CIRCUITS AT 72 HOURS vs 7 DAYS ON 
VENTILATOR ASSOCIATED PNEUMONIA 
D Orens MBA. RRT , JK Sioller, MD 
E>eparmienl of Pulmonan and Cntical Care Medicine 



Section of Respiraton Therapy 
Cleveland Climc Foundauon 
Cleveland. Ohio 44195 



Despite early recommendations thai frequeni changes 
of venulator mbing lessened the nsk of vcnulator- 
associaied pneumoma (VAP), more recent studies 
suggest the value of changing circuits no more than 
even 48 hours or, in a single available smd>, c\cn 
7 days To assess whether less frequent venulator 
tubing changes reduced the nsk of VAP at ihe 
Cleveland Clinic Foundauon, ihe currcni study assesses 
Ihe rale of VAP in the Medical Intensive Care Uml 
(MICU) before and aflcr changing our policy of tubing 
changes from e\en 72 hours to 7 days All adull 
patients admined to ihc MICU were studied for 12 
months pnor and 12 months alici implementing a new 
policy of changing venulator tubing every 7 days The 
venulator used was Punian Bennett 7200ae wTth 
Cascade 1 humidifiers and disposable non-heated 
wire circuits Vcnulalor circuits ot reservoir chambers 
were changed sooner if gross coniaimnauon with 
sccrcuons and/or blood became apparent Policies 
regarding delivery . hurmdity , and icmpcraturc did 
not change over the swdy penod Also, VAP was 
standardly defined using insututional guidelines 
developed by our infection conuol department who 
assessed the results over the 24 month study penod 
Monlhly rates of VAPs were calculated per 100 
vcnulator-davs for 12 months before and 12 months 
after implemenung the new policy and average rales 
yvcre rrponed No significant differences in VAP 
rates before or affcr our policy change was noted 
Overall, the average rate of VAP/pcr 100 vcnUlalor 
days y^-as 40 for the 12 month penod before the 
policy change (range \9-i) b}). and the average 
rate of VAP/pcr HX) vcnulalor days was S9 for the 
12 month penod after the policy change (range 28-0 65) 
We conclude ( I ) non-hcaied wire circuits on vcnula- 
tors uulizing rouunc circuit changes oery 7 days was 
not associaiod wnlh higher rates of VAP when com- 
panng to circuil changes cyery' 72 hour^ (2) Annualized 
savings associated wilh weekly changes yvcre 57% ($17,911) 
Our preliminary cxpcncnce docs not suggest a higher 
frequency of VAP when changing vcnttlnlot tubing c\'cry 
7 days but further data will emerge from this ongoing study 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1 



Open Forum ABSTRACTS 



DOES A PROTECTIVE SHEATH ALLOWING REUSE 
OF DISPOSABLE PULSE OXIMETER PROBES ALTER 
SENSITIVITY AND RESPONSE TIME? 
fl^ Gravbcal. CRTT . GB Russell. MD Department of 
Anesthesia, PSU College of Medicine. Hershey. Pa. 17033 

Conlinuous momtohng of artenal oxygen saruralion by pulse 
oximetry (Sa02) has gamed widespread use As cost 
controls have become more vital, money-saving measures 
have also been developed to reduce the instituiional cost of 
disposable oxuneter sensors Medical Taping Systems 
(Glcnmort. PA, 19343) has developed a Probe Shield, 
allowing reuse of disposable sensors A regular disposable 
probe is laminated increasing longevity For each cUnical 
use, the lammated probe is inserted into a disposable 
protective cover. We hypothesized that lamination and 
covering of disposable Sa02 sensors with Probe Shields will 
not alter clinical accuracy and response times in dcsaturaied 
humans. After informed consent and uisutuuonal approval, 5 
normal adult male volunteers were positioned supine and 
monitored continuously by a 5 lead EKG, RR and systemic 
blood pressure. Two Nellcor D25 probes were applied, one 
each to the Hrst and second digits of the subject's left hand. 
Two Nellcor N200 oxuneters were used Respiratory gases 
(carbon dioxide, inspired and expired oxygen, and nitrogen) 
were measured by Raman Spectrometry (Rascal D. Ohmeda 
Inc.. Louisville. CO, 80027). Each subject breathed a 90% 
heUum : 10% oxygen mixture to desaturate twice, with Fi02 
controlled so thai Sa02 went to approximately 70%, Then 
each subject breathed 50% oxygen (baJancc helium), with 
remm of Sa02 to 100% At the end of this first test 
(comparing two regular Nellcor D25 sensors) one Nellcor 
probe was removed, larmnaled and covered with the Probe 
Shield, and reattached to the same digit. The second 
desaruration followed. Sa02 values were recorded every 10 
seconds. Response tunes to 5 % changes in Sa02 were 
compared. The oxygen saturation values for each of the 
probes and the pre and post -lam mated probe was compared 
siaiisucally The difference between the two probes, pre and 
post-lammaBon. was calculated- The 95 % confidence 
iniervals of the mean differences were calculated for each 
subject. A total of 447 Sa02 measurements were made for 
each sensor in 5 subjects, Sa02 ranged from 62% to 100% 
All subjects desacurated to below 70%. The range of subject 
mean difference between control and pre-lammaiion was 
0.4-1 7 % and between control and post -lamination was 04- 
2,6 % There was no statistical difference between Nellcor 
sensor controls and the post-laminaLon Sa02s in 3 subjects 
For the Nellcor sensors, differences were slaDstically 
significant in 2; m one the laminated probe Sa02 was 0.8 % 
higher than the control probe, but in the other the laminated 
probe Sa02 was I 3 % lower than the control sensor 
Differences are wiihm the error range of the pulse oximeters 
The response umes were no different between all probes for 
each desaturalion Covcrmg disposable oxygen salurauon 
sensor probes with a protective laminate did not result in a 
clinically significant difference in Sa02 measurements in 
humans dcsaturated to less than 70 %. The response lime to 
desatiiration was also not altered. 

This research was funded in part by Medical Taping 
Systems. GUnmore. PA 19343 

OF-94-184 



THE EFFECT OF 7 DAY cmCUIT CHANGES ON 
LX)WER RESPIRATORY TRACT INFECTION RATES IN 
THE NICU AND Piru John W. Salver BS. RRT. 
Primary Children's Medical Center, and the University 
of Utah School of Medicine, Salt Lake City, Utah 



INTRODUCTION: Thcr 
ventilator circuit changes 






of low 



respiratory tract infections (LRI) However, there is 
little published information regarding this relationship 
in neonatal and pediairic populauom Thus we sought 
to determine whether decreasing the frequency of our 
ventilator circuit changes in the NICU and PICU had 
any affect on the incidence of LRI METHODS: Over a 
period of 33 months (June 91 through Feb 94) the 
circuit changing frequency was decreased from every 48 
lo 96 hours and finally to weekly (June 91-Feb 92 every 
48 hours. Mar 92-Mar 93 every 96 hours. Apnl 93-Feb 
94 weekly). During this iime. all LRI were identified 
and recorded by the hospital's infection control nurse 
A rate of LRI per ventilator day was computed for both 






NICU 
LRI/Veni Day 


PICU 
LRI/Veni Day 


hours 


0102 


oom 




(0 0079) 


(0 0075) 


hours 


0072 


00164 






(00081) 






0.0088 




(0.0025) 


(00058) 



table a 



nand(SD) 



Linear regression for ihc LRI rates from June 91 
ihrouch Feb 94 were; (PICU) Y=2.363E^X * 0.11. 
r2=0.158. (NICU) Y=I.994E^X + 0.15. r2=0.0,057. 
ANOVA of the LRI raics for each unit during the 
different tunc periods yielded P values > 0,05 
CONCLUSIONS: The is clearly no impact 



angcs frcqui 



eLRIr 



FINANCIAL IMPACT OF A COMPREHENSIVE 
VENTILATOR MANAGEMENT PROGRAM 
COORDINATED BY A DEPARTMENT OF 
RESPIRATORY CARE nnr..;anne Miller. RRT. 
Nina Chiles. MS. George Weir. Linda Weitzel. MBA. 
Elaine Yuen, MBA, Amy Siaiano. BA. Herben 
Pairicit. MD, Departments of Respiratory Care. 
Financial Administration, and Center for Research in 
Medical Education and Health Care. Thomas Jefferson 
University Hospital, Philadelphia. PA 

In July 1992. our Deparuneni of Respiratory Care 
implemented a Ventilator Management and Evaluation 
Program (VeniMan) based on the hypothesis that a 
hospital -wide, early intervention, interdisciplinary 
process for managemem of ventilator patients would 
decrease veniilator average length of stay (ALOSv) 
and significantly decrease utilization of resources in 
this patient population The program links daily QA&l 
data collection with a system for concurrent clinical 
imervcniion and in-depth financial aiulysis by DRG 
scored for severityof illness. We chose to focus on 
our four most frequent DRG categories exhibiting high 
ALOSv and lo compare resource utilization. ALOSv. 
seventy of illness, and mean costs for FY92 and 
FY93, Employing the University's Cluiical Financial 
Management System (CFMS) 1 .305 ventilator patients 
(FY92) and 1,341 ventilator patients (FY93} were 
categorized by DRG and ICD-9-CM diagnosis and 
procedure codes, with each category analyzed for 
ALOSv and use of specific hospital resources. Direa. 
indirect, fixed and variable costs were compiled to 
arrive at total cost adjusted to 1993 dollars. Disease 
seventy score (DSS> was computed by an algontJim 
within CFMS with values nornulized to an average 
hospiulized patient = 100, RESULTS: For all 
ventilator patients. ALOSv decreased from 7 09 to 
6.88 between FY92 and FY93 despite an increase in 
DSS from 315 to 334 (p< 05). 




For DRG 483 alone, mean costs / patient FY92 to 
FY93 were broken down as: Laboratory 
$ll.298±7.937 to $8,826±6.418 (p< 05); Pharmacy 
$12.542±8.675 to $12.783^1 1 .650: ICU 
S46.597±33.360 to S40.621±24.166 with ICU days 
30 9±23 to 25iLl4 5 (p< ,05); and Respiratory Care 
S9.485±6,872ioS8.309±5.52], We conclude that 
our VentMan Program has a significant impact in 
reducing hospital costs through both reduced 
utilization of resources and a reduced ALOSv 




American Association for Respiratory Care 

40th Annual Convention and Exhibition 

December 10-13, 1994 • Las Vegas, Nevada 



1109 



Open Forum ABSTRACTS 



RESPIRATORY CARE • NOVEMBER "94 Vol 39 No 1 1 



CompansonofWorkof BrealhinE(\VOB)and Aimaj 
RcMiIante(Ra")in Endotrathcar (ETT) and 
Tnichcii*(om> (TT) Tube* on a T- Piece- JohoJjnNrrgcr 
BSCRIT . Sicphtn J Connell BA RRT. Horbcn Paincic 
MD. Ocpl of Rcspiraion Care. Thomas JcfTerson Univcr- 
sn\ Uospilal. Phi/atielp/iia P.l 

liilrDducrion Since T-piece and trach collar Inals are often 
the final stq) in weaning a patient from mechanical 
venlilstion, il is of importance lo know standard values lor 
the WOB and Raw imposed due lo diHerent ETT and TTs 
Although this pnncipa! is the well known outcome of 
Pouisilles law. Uierc is surprisingly little documcntaiion ol 
measured values m the literature Wc determined a 
graphical set of standard values for WOB and Raw of 
various [TIT and TTs over a range of mmuic vcnulations 
( Ve( Methods A bench study using a double test lung 
setup to simulate a spontaneously brcathmg patient was 
performed to examine WOB and Raw of size 6- 1 E ITs 
and size 6 and 8 TTs over minute ventilations of 5-20 Ipm 
I changing both respiratorv rate and Vt and using peak flow 
to maintain an 1 E [alio of 1 2 with ihe Bear 5 vcnUlatorl 
The Adult Lung Function Anaiszer ( ALFA. Pulmonary 
Technologies Industries, Ltd ) was used lo measure WOB 
and Raw The data was then examined and graphed 
Results At a Ve of on]> 5 Ipm, the #6 ETT demon- 
strated a three fold mcrease m Raw over the HI 5 ETT and 
a four fold mcrease over the «8 ETT At a Ve of 12 1pm. 
ihc inspiraion cannal pressure necdmg to be generated m 
the #8 ETT. Ihe 87 5 ETT, and the #7 ETT were -12cm 
il:0. -2t)cmJI:0. and -35cmHK5 respectively The «6 TT 
imposed twice the Raw of the «8 TT Graphically, the 
1*6 I) TT proved to be identical lo a »7 5 FTT m WOB and 




Conclusions There are dramatic dilTerences m Ihe WOB 
and Raw imposed bv the various sizes of endotracheal tubes 
which musi be considered wiien inmbaling a patient There 
IS a dramatic dilTerencc m WOB of vanous tracheostomy 
tubes, which is especially important for trachcostomv 
paiienis who are dilTicuii to wean with limited reserve to 
overcome the imposed WOB and Raw We have initialed a 
study to compare Ihcse bench results lo those in the climcal 
setting to assess tube patcnev OF-94-242 



TRACHEOSTOMY IN THE 1990's CURRENT 
CLINICAL PRACTICE IN AN URBAN TEACHING 
HOSPFTAL CL Kasoer RRT. CR Stubbs RRT, JA Barton, 
KS Hazel MS. JR Hedges MS, DJ Picrson MD, Harborview 
Medical Center. Seattle, WA. Introduction/ Background 
Tracheostomy (Trach) is a commonly performed procedure 
m hospitals, done for multiple reasons, by several services, 
with pts located throughout the hospital in Ihe absence of a 
defmed institution wide procedure for assessment, and wilh 
no recenl literature to descnbc current trach management, 
wc conducted Ihis retrospective study Malenals and Meth- 
ods Harborview Medical Center is a university operated 
murucipal hospital, and level I trauma center, with 320 
beds ( 38 ICU. 1 87 acute care, and 26 rehab) Trach pts arc 
dispersed throughout all of these areas We reviewed Ihe 
medical records of all pts for the fiscal year 1 992-93 coded 
bv the OA&I Department as havmg trach status by dx code 
or undcrgomg trach by procedure code We attempted lo 
answer the following questions I ) How many irachs were 
performed on what population'' 2) Who performed/managed 
the Irachs"* 3) What post care was given, especially by 
RCP's'' 16.491 pis were admitted m the fiscal year 1992- 
93, of whom 1 20 were identified as havmg a trach Wc 
reviewed the records of 109 pts, (3 were unobtamablc and 8 
were miscoded) These records compnscd 147 admits Re- 
sults 0{ Ihc 1 09 pts. 74% were male and 26% were female 
Age ranged from 13 lo 83 (mean±SD = 44 5±19 8) 11% 
died, 29% were discharged lo home, 39% to subacute care 
ccnlCTS. 12% to another hospital. 5% to nursing homes, 
and 5% to other inslituuons Pt dx mcludcd trauma 43%, 
CVA 12%. pncumoma 10% . CA 7% and other 26% Pts 
underwent trach for ihc following reasons 21% prolonged 
ventilation. 20% closed head injuries, 5% spmal cord inju- 
ncs. 22% facial injunes. 3% epiglotitis, 6% other H&N 
surgery, 1 6% other intracranial bleeds and 8% other Ad- 
mitting services were Gen Surg 29%. Medicine 25%, Ncu- 
rojurg 20%. Ncuro 1 1%. OTO/HNS 5%. Rehab 5% and 
other WTviccs 3% Length of stay ranged from I to 1 36 
days, (mcanlSD 32 4t30 4, median 24) 63% were Inched 
that admiision The procedure was almost always done in 
the operating room Services pcrformmg were Cicn Surg 
(17%), oro/FIN (29%). Neurosurg(14%). OMFS (1%). 
Bums Plastics (2%) 47% of those trached were ventilated 
on admission, 63% were ventilated ut some pomt m thcu 
hospital iitav. 38% were never on ventilator Of the pt.i wilh 
trochs 2/3 had orders and 85% had progress notes pertain- 
ing to trach marugcmcnl In 36% another service vnu con- 
sulted for trach management 100/147 admissions hod RT 
notes regarding trach. the fii<l one on days post trach 
(mcanlSI) 1 2l5 5) 81/147 had notes pertaining to cuff 
volume K8/M7 had notes rego/dinit cufT pressure C^ oflclu - 
UOO Wc determined that many difrcrcnt servicc!i, locations 
and dx ore involved in pts with trochs We conclude there m 
a need for access to all Iroch pu by multidisciplinary exper- 
tise A natuiol role for RCP's is to coordmotc this expertise 
and lo facilitate this management We have initialed a 
mullidiscipltnarv trach team and plan to study its impact 

OF-94-212 



INCIDENCE OF RESPIRATORY COMPLICATIONS 
AND ENDOTRACHEAL TUBE (ETTI UNPLANNED 
EXTUBATION IN 16,861 PEDIATRIC ADMISSIONS 
OVER FIFTEEN YEARS Lea Lua, M.D., Mark Carroll. 
RRT, Luis Toro-Figueroa, M D., Dan Levin. MO. 
Children's Medical Center and The University of 
Texas Southwestern Medical Center, Dallas, Texas 
75235 

INTRODUCTION; The incidence and types o( ETT 

complications over a prolonged period of time m 

large pediatric populations are not well known. We 

reviewed 15 years of experience in 16. 861 

admissions, 

METHODS: Data were collected prosoectively on a 

daily basis by the PICU attending from Jan 1, 1977 

to July 31, 1992, The data were tabulated and 

collected monthly. The tabulations were 

retrospectively reviewed. 

RESULTS: 01 16, 861 admissions, 49% were 

medical and 51% surgical with an unselected 

mortality rate of 094. There were 7,106 initiations 

of mechanical ventilation and 8,61 

intubations. Of those. 2,520 were 

1,667 nasotracheal and 4,427 not specified. There 

were 1.311 respiratory complications or 15% of all 



The r 



tiplic 



unplanned extubations 570 (43%), pneumothorax 
214 (16%), post extubation croup 200 (15%1, 
mucous plugging of tube 149 (11%), right 
bronchus intubation 39 (3%), other 139 (11%) 
"Others* occurred less than a few times each and 
include cardiorespiratory arrest, bleeding from ETT, 
pneumomediastinum, subcutaneous emphysema, 
aspiration pneumonia, bradycardia, teeth trauma, 
pneumopericardium, tracheostomy decannulation, 
tube malposition, nose bleed, left mainstem 
bronchus intubation, kinked tube Of the unplanned 
extubations the cause was stated for 59 (10.5%) 
and included seif-exiuoaiion 14 (25.7%i; during CPT 
12 (20.3%). X-ray 7 (11.9%), weighing 5 (8 5%), 
retapmg 4 (1.6%) moving patient 3 (5,1%), aerosol 
therapy 2 (3.4%), bathing 1(1.7%), stanmg IV 1 
{1,7%1; or secondary to coughing 6 (10.2%), 
secretions 2 (3 4%), or maternal factors 2 (3 4%). 
CONCLUSIONS: The incidence o( complications of 
intubation is relatively high (15%), with unplanned 
extubation (43%) being the most common of these 
Of unplanned extubation, the most common causes 
are patient self extubation; during CPT. X-ray. and 
weighing; and secondary to coughing. 



INSPIRATORY WORK OF BREATHING 
IMPOSED BY THE ENDOTRACHEAL TUBE 
AND VENTILATOR DEMAND VALVE DURING 
PRESSURE SUPPORT & T- PIECE WEANING . 
VALIDATION OF A WEANING PROTOCOL. 

V^irae Hill BSc RRT Military College o( Health 
Sciences. DHAHRAN Chnslopher C Miller BA RRT 
David Dyer BSc RRT. Vicki Foulkrod BA RRT.RCPT & 
Mahmoud Et Barbara MD King Faisal Specialist 
Hospital and Research Center RIYADH, 
Kingdom of Saudi Arabia 

INTRODUCTION The Pressure Supporl (PS) weaning 
protocol used by Respiratory Care Department in Ihe 
CSICU al King Faisal Specialist Hospital , allows the 
therapist to discontinue ventilator weaning al PS 5 - 10 
cm H3O, and progress lo an extubation protocol. 
It is assumed that a PS level of 5 - 10 cm 8,0 
overcomes Ihe resistive load imposed by the ETT 
and the Siemens 900C venlilalor If this ossurnplion 
IS valid we should be able to safely exiubate Irom this 
level of ventilatory support which simulates the work of 
breathing (WOB) post eidubation 
METHOD: We prospectively studied (9) post 
operative, cardiac surgical patienis wilh no pre-existing 
lung disease on the day of extubation We measured 
WOBp (patent) using Ihe BiCore CP-100 Pulmonary 
Monitor dunng six stages of PS weanmg, T-Piece 
weaning and alter exiubalion using a mouthpiece (MP) 
+/or Facemask(FM) connected to Die (low transducer 
Nomial Range WOB= 3-0 6 J/L 
RESULTS: WOB ( J/L) vs Weaning Condition 

PSMax PS15 PS10 PS5 PSO PSO TP 
CPAP 5 5 5 5 

Mean 0.03 04 13 0,39 0.66 91 67 

SO 0.04 0,07 0,12 0.26 17 0,29 0,19 

In all patients, WOBp increased above J/L when 
PS was reduced below 5 cm H O & CPAP 5 cm H -O 
and decreased after exiubalion The gf eatest WOBp 
was seen when both PS and CPAP were reduced to 
0cm H.Op^ 0005 The WOBp at PS 5 cm H;0. 
CPAP 5 cm HjO was wiihin the normal range of WOBp 
(p > 10) There was no diMerence in WOBp between 
T-Piece&PSO, CPAPScmH.O p>0 10 The CP-100 
monitor displayed post extubation WOB as WOBv 
(ventilator) 07 ♦/-0 01 J/L when the MP wos used 
When the same measurements were taken using FM 
(in 2 jf 9 cases ) . the CP-100 displayed WOBp 58 & 
86 J/L respectively 

CONCLUSION: The PS level of 5 cm H.O & CPAP 
of 5 cm H;0 most closely matched the normal range of 
WOBp ( +/- 33% ) The results in this group of patienis 
validates Ihe use of the weaning prclocol in the CSICU 
However more study 15 required lo ovnluate the WOBp 
In recently exiubaled pationls using both mouth piece & 
face mask lechniquos OF-94-ii9 



REDUCTION OF SELF-EXTUBATION 
USING COMFIT TRACHEAL TUBE 
HOLDER - J McAndrew RRT . P Brown 
CRTT,CPFT, Somen/ille Hospital, Somerville. 
MA 

BACKGROUND The catastrophic effects of an 
untimely self or accidental extubation is well 
documented We are a small community hospital 
and the multidiscipline ICU care team consisting of 
MDs. RNs. RRTs discovered dunng a TQM 
process that self-extubation had reached an 
unacceptable level OBJECTFVE To reduce the 
number of self-extubalions METHOD In study 
**l, 59 patient's medical records were 
retrospectively received (after TQM report) and a 
cntcna based policy/procedure was instituted to 
reduce the number of vanables (le restraints, 
sedation. air\vay management, alamts) between 
patients In study #2 (after critena instituted), 
another retrospective study was performed with the 
same basic results For study #3. the team decided 
to investigate, research and use commercialK 
produced tube holders on the market, as opposed to 
the old stand-by, adhesive tape or cloth trach ties, 
thereby removing the last vanable TTie case team 
deemed the Comfit trach tube holder supenor 
because heavy dut\', use ui all settings, reliable, 
comfortable, ease of use. enhanced patient care, 
stable and secure All patients in the study were 
orally intubated according to protocol Our 
infectious disease physician advises against 
nasotracheal intubations as the complications 
outweigh the advantages RESULTS Given a 
national average of approximatelv 10% our studies 
found Study* I sclf-extubation-15% (9/59) Studv 
Ml Selfext{ibation-9% (6/34) Study «3 No self 
extubations-0% (0/24) after existing policy of using 
the Comfit with the cntena in Study U2 
CONCLUSION Endo tubes have been a part of 
intensive care medicine since the late 19th centur> 
Accidental extubations are statistically relevant and 
with enough senous complications to warrant 
constant vigilance Our cxpenence along with 
others, that heightened awareness (Hawthorne 
effect), patient, family, staff inservice, sedation and 
restraints are key ingredients in reducmg unplanned 
extubations Unfortunately, not enough attention 
has been paid to the actual tube and its secunng 
device Our experience has been and continues to be 
-the proper ENDO TUBE PROTECTOR (ETP), 
the Comfit, the incidence of self- extubations 
decrease significantly 

OF-94-091 



AIRWAY RESISTANCE TIIROUCn 
NEONATAL A PEDIATRIC 
ENDOTRACHEAL TUBES 

A Sanloro.RRT . BG Wilsoo.RRT, J Mclioncs, 
MD. Duke Universilj Medicnl Center, 
Durham, NC 

Increased work or hreathinft (WOB) can 
prolnng the need For renlilalnry .support. 
Airway resi.slance (Raw) is altered hy 
endotracheal tuhe (Ell ) sir* and in.'jpiratory 
flow rale, thereby efTeclinj; the imposed WOB 
for Ihe pntient. MeASurementt or Raw thrntif;h 
ndult El I's (uhefi have been puhli.shed. 
However, (he men.'^ured Raw thrnuch sinndard 
neonatal and pediatric ETT's i.s not known. To 
determine the relnlinaship, we examined (he 
Rnw or neonnlnl ond pedialric ETT's a( 
varying Dow mles u^ing a bench model. 
METHODS: ETT si7c 2.0 - 5.5 were sdidied. 
Flow ra(cs were vnrird from 3 - 25 LPM 
(hrough each (iihe. The Calihra(ion Annly/fr, 
Scries RT-200 fTimeler Ia';(rumenL<; Corp. 
Lnnca.';(er, PA) was used In measure Raw in 
cm ll20/L/sec. Three mea.surcmenLs were made 
a( each seKinf; and averaced. The calihra(ion 
nnaty7£r was /rroed prior lo each chnnge. 
RESULTS: Rnw increai^es wi(h decreases in 
ETT sire and incren-ses in (low ra(es. See 
(trnph. 




CONCLUSION: Using our nomogram, one ran 
predic( impmed Raw For a given ETT size and 
flow. 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1 



Open Forum ABSTRACTS 



COMPARATIVE EVALUATION OF 
ENDOTRACHEAL TUBE RESISTANCE IN 
RECENTLY EXTUBATED INFANTS AND 
CHILDREN 

Tom Malinowskj BS RCP RRT. Ranc^y Scott BS RCP 
RRT. Leo Langga BS RCP RRT. Louis Thnh BS RCP 
RRT, Mark Rogers BS RCP RRT. Loma Linda 
University Children's Hospital. Departincnt of 
Respiratory Care, Loma Linda, CA 
Introdiirdon: Pediatnc veniilaior managemeni aid 
weaning is dependent on airway patency Wc 
hypothesize that partial occlusion of pediatric 
endotracheal tubes occur more of^en than is recognized, 
in spite of adequate humidification and hydration We 
sought to compare Ihc patency of endotracheal tubes 
extubaicd from mechanically ventilated patients in our 
neonatal and pediatnc inlcnsive care units against control 
endotracheal tubes Methods: Wc collected fifty (SO) 
endotracheal tubes of varying sizes from patients recently 
extubated in the NICU and PICU Two evaluations were 
performed on the study tube' 1 ) a visual inspection. 2) a 
proximal pressure comparison Each Oibe was visually 
inspected for obstruction and given a score of through 
4 (0 = clear. I = <25%, 2 = <50%. 3 = <7i%. 4 = 
complete obstruction) The pressure comparison 
introduced continuous flows of 4. 6. 8. 10 and 12 LPM 
into the ET tubes and measured proximal pressures to 
determine the resistance to flow caused by obstruction 
(AR) Flow rates used on the study rubes coincided with 
the flow rates used on the mechanical vcnlilalors prior to 
extubation Control tubes of matched size and length 
were used for comparison against the study tubes 
Results: Of the 50 tubes. 16% (8 tubes) had some degree 
of visual obstruction ( 4 tubes ■ score of 1 . 2 tubes - score 
of 3. and 2 tubes - score of 4) Comparisons were made 
of proximal pressure changes between the study tubes 
and the post extubation t\ 

z 30 matched comparisons (: 



ETT 


2J 


3.0 


3J 


4.0 


4J 


5.0 


ARI 


NS 


S 


NS 


NS 


""i ■ 


NS 


aR2 


S 


s 




S 


S 


NS 


AR3 


NS 


s 










&R4 


S 






NS 


s 


S 


iR5 


NS 






NS 


s 


s 



■ dR - ProK Press /] 
Of the 30 matched comparisons, 20 had a sutistically 
significant increase in proximal pressure when compared 
to the control (ANOVA. p<05) Pressures generated by 
all of the major obstructed ET tubes were equal to or 
greater than the ventilating pressures Conclusion: There 
IS a statistically and clinically significant decrease in ET 
tube patency in some pediatric patients at the time of 
extubation Ventilating parameters and ventilator 
triggcnng may be ineffective due to ajrway obstruction 
This may have a profound affect on weaning from 
mechanical ventilatory support. 



INCIDENCE. CONTRIBUTING FACTORS, AND 
OUTCOMES OF UNPLANNED EXTUBATIONS 
IN THE INTENSIVE CARE UNIT (ICU). 



r.flmph)ell Rnh e rt S. RRT . Gotdsberi7 David T. 
MD. Delhlefsen Michaela RN. Hurst James M. 
MD*. Department of Surgery, University of South 
Florida. Tampa, FL. 



INTRODUCTION: The incidence, coninbuting 
factors, and outcomes of all UE were monitored 
dunng two 90-day penods beginning 1/93 and 
12/93, METHODS: All UE were reviewed dunng 
the study penods. The following data was 
recorded: adtnitting service. ICU day, vent days. 
time of extubation, route of initial intubation, 
method of secunng tube, vent settings, neuro 
status, pt, restraints, adequacy of sedation, pt. 
i^mtubated. and if pt. status was compromised. 
RESULTS: There were 34 UE (one event per 60 
pt/venlilatordays). Nine (45%) of 20 medical pts. 
required remtubation. Five (36%) of 14 surgical 
pts. were reintubated. Tweniy-eight (82%) pts, 
were restramed. Twenty-seven (79%) pts. were 
orally intubated. Thirteen (38%) pts, were 
inadequately sedated upon review by the attending 
physician. On 24 (71%) occasions the endotracheal 
tube was not secured circumferentially. Three 
(9%) pis. expenenced a compromise in cimical 
condition. Two pis. required cricothyroidolomy 
and I pt, expired, DISCUSSION: UE is common 
in the ICU, Although greater than 60% of pts. do 
nol require remtubation, the effects of losing a 
patent airway may be devastating. Stncl alienlion 
to each pis sedation and appropnate use of 
restraints is essential. Circumferentially taping the 
endotracheal tube resulted in less frequent UE 
CONCLUSIONS: Twenty-four hour coverage by 
staff trained in airway management and intubation 
skills may reduce complications and time lo 
remtubation. 



THE DIFFICULT AIRWAY. 

RETROGRADE INTUBATION AND 

THE RESPIRATORY CARE 

PRACTITIONER 

Mark Rogers . RRT, BSRT* 

Daved van Stralen, MD" 
Tom Malinowskt, RRT, BSRT* 

'Department of Respiratory Care, 
Loma Linda University Medical Center, 

Loma Linda. California 
"Center for Pediatric Prehospital Care, 
Loma Linda University Medical Center, 

Loma Linda, California 

PURPOSE The respiratory care practitioner 
(RCP) participates in the care of patients with 
drfficurt airways in which laryngoscopy fails or 

facility transport The use of retrograde 
intubation (Rl) m these patients has not been 
reported in the respiratory care literature In 
this study we evaluated the ability of RCPs to 
perform Rl 

METHODS Descriptive study using a cohort 
of 20 RCPs and 68 emergency medical 
service (EMS) personnel We taught the 
retrograde technique in 30 minute sessions 
with an Rl kit (Cook Retrograde intubation 
set, Bloomington, Indiana) We trained with a 
prototype Rl mannequin (Medical Plastics 
Laboratory, Gatesville, Texas) Time of 
intubation was measured from placement o( 
hand on the trachea to inflation of the 

RESULTS All personnel successfully 

position on their first timed attempt after 30 
minirtes of training RCPs performed Rl in a 
mean time of 81 seconds (95% confidence 
level ±6 seconds), and EMS personnel 
performed Rf in a mean time of 69 seconds 
(95% confidence level ±4 seconds) 
CONCLUSIONS Rl IS a skill easily 
obtainable with minimal training RCPs had 
a longer mean time compared to the EMS 
personnel, which we attributed to the RCPs 
concern for the airway The mean times were 
significantly different (p<0 05|, but not 
clinically significant, as a second caregiver 
could hand ventilate throughout the 
procedure Rl should be considered an 
alternate to standard larygoscopic techniques 
in those patients having a difficult airway or in 



ftflODIFIED PERCUTANEOUS 
RETROGRDE INTUBATION 
TECHNIQUE 



Oral endotracheal intubations attempted by 
emergency personnel have a documented 10 to 
30% failure rate. Most wire guided retrograde 
Intubations fail because the wire is used as a 
guide and the endotracheal tube (ETT) deviates 
off the epiglottis. Could a wire be attached to an 
ETT and be used to then pull the ETT into the 
trachea? 

METHOD : Ten post mortum mongrel dogs 
were intubated using a retrograde technique, A 
16 gauge, 1,25 inch angiocath is attached to a 
12cc syringe filled with 6cc of H20. The 
angiocath is introduced at or below the 
cricothyroid membrane at a 30 degree angle The 
syringe is aspirated as the angiocath is advanced 
into the trachea, observing for air bubbles to 
indicate entry into the trachea. After entering the 
trachea the needle is removed and a J-wire is fed 
Into the angiocath. Using a laryngoscope, a 
second practitioner observes the oropharynx for 
the wire to emerge, and grasps the tip wire with 
McGill forceps. A pair of large hemostats are 
used to put a 180 degree bend at the tip of the 
wire. The wire is then hooked into the eyelet of 
the ETT and pulled into the trachea Placement 
is confirmed by auscultation and radiography. 
Once placement is confirmed the wire may be fed 
back through the ETT and removed. 

RESULTS: The procedure was performed a 
minimum of 5 times on each dog with a total 
success rate of 90%. 

Each attempt was deemed successful if; the 
procedure was done in less than 45 sec. there 



nd the 



trachea was intubated. Faitu 


es oc 


:urred 


the wire was fed into the nas 


ophay 


nx. thu 


taking longer than the 45 sec 


time 


imit. 


CONCLUSIONS: Based o 


the r 


BSUltS o 


study, further investigation u 


sing a 


live an 


model is warranted. 







vhen 



RELIABLLITY OF END-TIDAL CO: 
MONITORING TO ASSESS TRACHEAL 
INTUBATION IN A NEONATAL ICU Sandra R. 
WadlinEcr. AS.. RRT. P/P Spec . Linda Allen 
Napoli. BS,. RRT. RPFT. P/P Spec, Lorraine F 
Hough. M.Ed., RRT. P/P Spec The Children's 
Hospital of Philadelpfua, Philadelphia, PA 

The Ncllcor® Slat Cap™ Airway CO: Indicator is a 
device which provides a semi -quantitative estimate 
of COi in the airway The manufacturer's suggested 
application of tliis device is to verify proper 
endotracheal tube (ETT) placement (tracheal vs 
esophageal) We sought to ascertain whether this 
device was appropnate for determining ETT 
placement in neonates Methods A Slat Cap™ CO3 
Indicator was available in the Infant Intensive Care 
Unit at all times This device was brought 10 the 
bedside during the intubation of neonates Following 
ETT placement by trained personnel, the airway 
sensor was placed proximal to the ETT and manual 
ventilation was instituted utilizing a flow inflating 
resuscitator bag The presence of CO; was 
demonstrated by audible and visual indicators 
Patient assessment included breath sounds, chest 
wall movement, direct vocal cord visualization, and 
heart rate Chest x-rays (CXR) were obtained after 
stabilizauon of the ETT to confirm placement 
Results and Experience Twelve infants were 
studied with a mean weight of 1702 grams (1010 - 
2700 grams) There were 2 females and 10 males 
with a mean ETT size of 3 (2 5 - 3 5 range) 
Eleven patients had respiratory distress syndrome 
(RDS) secondary to prematurity, while one had 
congenital heart disease in addition to RDS In 8 
patients, there were audible and visual indications of 
COi after 1-3 manual breaths Patient assessment 
demonstrated bilateral breath sounds and chest wall 
movement Heart rale was stable or increased. Each 
had a follow-up CXR showing proper ETT 
placement In 4 patients, no CO: was detected. 
Questionable breath sounds and chest wall 
movemenL followed by direct visualization of the 
vocal cords, proved the lube was nol in the trachea. 
Subsequently, these patients underwent successful 
tracheal intubation Conclusion End-tidal CO; 
detecuon with the Slat Cap™ appears lo indicate the 
presence of CO2 in neonates when applied with tiand 
venulauon It can provide the praciiiioner with an 
indication of successful tracheal intubation and may 
be a valuable assessment tool in this population 

OF-94-186 



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RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1 



Open Forum ABSTRACTS 



NITRIC OXIDE (NO) DELIVERY WITH HIGH 
FREQUENCY JET VENTILATION (HFJV) 
WITH THE BUNNELL LIFE PULSE 

Joanna Masi-Lvnch BS. RRT. Kathleen Richards 
RRT. John SaJyer BS. RRT. Ronald Day. MD. 
Dcpartmeni of Rcspuaiory Care and Dcparunenl of 
Pcdialrics. Primary Children's Medical Cenier and 
University of Utah. Sail Lake City. Utah, 

INTRODUCTION: We sought to lesl ihe uuliiy of a 
system for adminislenng and monitoring niiric oxide 
concentration [NO] during HFA'. METHODS: We 
measured [NO] with an elccuochcmical analyzer in 
both a icsl lung (500 mL ngid flask) and an ETT 
adapter during HFJV w.ih conventional vcniilator 
(CV) rales of (CPAP). 5 and 10 per minuie. HFJV was 
set at a f = 420. PIP = 20 cm HjO. on time 020 sec 
and Fi02 3 The CV was scl ai PIP I7 cm H2O. PEEP 
3 cm H2O. T[ 0.4 sec.. FiOj 0.3. an. 
was delivered through rigid IV luh 
circuit wiih a plasiic Y-connector between ine siiicom 
and the green filter tubing immediaiely distal lo the 
pinch valve. (N0| was sampled from a port in the 
boilom of the test lung, A 3 mm Hi-Lo jel tube was 
inserted through a rubber stopper al the top of the 
flask. [NO] was also sampled at the ETT using a side 
port sampling adapter. [NO] {mean ± SD) from the icsi 
lung and ETT adapter porl were compared using 
ANOVA with significant established as a p < 0.05, 
Addilionally. we measured [NO] al the ETT adaplcr and 
in ihe gas evacuated from a chesi lube in three palienis 
during HFJV as well as methemoglobm levels 
(HbMET). RESULTS: Results for [NO] are reported ir 
parts per million. 

IN VrfRO DATA 
CVraic n |N0] Test Lung [NO|FT 



NO 
: HFJV 



INVTVODATA 










Wcghl 


HFA- 


HFJV 


[NO| 


[NOI 


HbMe 


Kg 


rale 


PIP 


Chest lube 


frr 


g/dL 


6.7 Kg 


300 


34 


33.8 


31.5 


1.7 


3,4 Kg 


420 


36 


14.1 


22.2 


0.9 


3.1 Kg 


420 


26 


13.3 


18 


2.2 


SPF.CLLATIONS: Wc a 


re unaware of 


any ex 


sling 


syslcm for mcasunng dcliv 


ercd |N01 during HFJV 


While ou 


syslcrr 


docs no 


measure |NO 


Ullhe 


ung. 



durmg 

HFJV there may be a near sieady stale of (NO) in ihe 
airways and ETT durmg HFJV. However, the relaiivelj 
slow speed of ihc analyzer make measurement dunng 
HFJV problematic. We call for clinicians and 
cngmccrs lo develop more precise methods of 
dcicrminmg |NO] during HFJV 



EVALUATION OF THE BKDFONT EC90 NITRIC 
OXIDE MONITOR Dean Hess. MEd. RRT . Masaji 
Nishimura. MD. Ray Ritz. BA. RRT, C Alvin Head. MD. 
Roben M Kacmarek. PhD. RRT Departments of 
Respiratory Care and Anesthesia, Massachusetts General 
Hospital and Harvard Medical School. Boston. MA 
Inhaled nitric oxide CNO) is being used increasingly lo 
improve arterial oxygenation and to decrease pulmonary 
artery pressure For mechanically ventilated patients. NO 
IS mixed with O- and delivered through the ventilator 
circuit It IS important lo know ihc NO and NO; levels 
being administered NO doses 100 low may be ineffective. 
and doses loo high can result m methemoglobinemia or 
dependence Bedside NO monitors are now commercially 
available thai allow moniloring of NO in breathing circuits 
at the bedside. Accuracy in ihe NO range of 0-80 ppm is 
important Interference by pressure, oxygen, or NOj 
should be minimized We designed a bench evaluation of 
Ihe Bedfoni EC90 NO monitor This is a small, portable. 
battery operated device thai uses an electrochemical sensor 
lo measure NO According to the manufacturer, it can be 
used in ihe pressure range of 5-50 cm H;0 and at 0-100% 
relative humidity, it has a response time <30 s at 90% 
FSD METHODS The monitor was calibrated at and 80 
ppm following manufacturer's specifications A Puritan- 
Bcnnclt 7200 was used to produce serial dilutions of 
primary standard NO (cylmders of 80 ppm. 40 ppm, and 
20 ppm with balance Nj) with O,. resulting in NO levels m 
Ihe range of 0-80 ppm The ventilator was scl at pressures 
of 1 5/5 and 30/10 cm HjO. rate 1 5/min. and Ti 1 5 s in 
pressure control mode The ventilator was attached lo a 
Michigan Instruments TTL (resistance 20 cm H,0/L/s and 
compliance 20 mL/cm H^O) NO was analyzed from the 
inspiratory limb of the circuit using asideslrcam 
technique NO levels displayed on the monilor were 
compared to the NO levels calculated from the FIO, setting 

determined using the method of Bland and Altman The 
effect of NOj interference was evaluated by exposing the 
monitor to 9 ppm NO, in Nj RESULTS The bias between 
Ihe Bedfont NO monitor and the calculated level was -0 53 
ppm. with a precision of I 69 ppm (limits or agreement 
2 85 to -3 9) When exposed lo 9 ppm NO3 in Nj. the 
monitor displayed ppm NO EXPERIENCE We have 
used this monitor routinely with adult and pediatric 
mechanically ventilated patients who are receiving inhaled 
NO We have found it easy to use and clinically reliable, 
lis cost is attractive when compared to chemiluminescent 
devices CONCLUSIONS: The bias and precision of the 
Bedfoni EC90 is acceptable for clinical use to evaluate NO 
levels during mechanical ventilation It is not affected by 
FIOj or NO. in the ranges that we studied We have found 
ihis device useful and reliable when used with 
mechanically venlilated patients receiving inhaled NO 
(supported in part by Punlan-Bennett and Bedfont) 

OF-94-081 



PRELIMINARY DETERMINATION OF AMBIF^JT NTIRIC 
OXIDE DURING MEOIANICAi. VENTIIATION AT THE 
PATIENTS BEDSIDE, Joanna fvnch BS. RRT John 
Salycr BS. RRT. Ronald Day MD. Respiratory Care 
Service and Department of Pediatrics, Primary Childten's 
Medical Cenier and University of Utah. Salt Lake City, 



INTRODUCTION: Many centers administering nitric 
oxide utilize exhaled gas scavenging syslfois to protect 
clinicians However, ihere is bttle information that 
such systems arc necessary We sought lo determine 
what concentrations of nitric oxide (NO) and nitrogen 
dioxide (NO2) could be measured in the room of 
ventilated patients if a NO scavenging system was not 
utilized for the exhaled gas METHODS: Using a 
cbcmi luminescent analyzer we sampled gas at 3 sites in 
patients receiving NO Ventilators used included the 
Bear Cub. Ihc Bmd VIP, ihe Servo 900C, and the 
Sensormedics 3100A HFOV VcntiJalor flowrates 
ranged from 6 to 40 L/min. modes used included 
pressure and volume control, with continuous and 
demand flow configurations Target values for deUvered 
NO concentrations were " 20 ppm and were analyzed on 
the inspiratory limb of the ventilator cu'cuit proximal 
to the patient 'y" (site #1) using a chemiluminescent 
NO. N02 analyzer (Model 2108. Dasibt Environmental 
Coip,, Glendale CA), Gas was also analyzed at two 
other sites; (Site #2) outside the ventilator circuit 
immediately adjacent to the exhalation valve, and (Site 
#3) - 12 inches from this site (eg farther away from 
the ventilator) Mean and SD for NO and NO2 
concentrations from the various sites were compared by 
ANOVA with significant sei at P s 05 RESULTS: 
10 patients were sampled f 
patients sampled from sile 
to 70 kg 



sight of 986 gm 
Range (ppm) 



Mean SD 
(ppm) (ppm) 
Sile I [NO] 20 I 2 17 1-23 6 
SiteUNOjl 76 4 2-13 
Site 2 [NO] 1,3 2 1 0-6 5 
Sile21NC:^| 1.0 18 1-6,3 
Site3[N01 3 1 1-0,5 
Sile3(N02l 4 2 2-0,8 
ANOVA repeated measures yielded a P <0 05 
DISCUSSION: The chemiluminescent analyzer 
specification for precision is listed by the manufacturer 
as ± 1% Thus, at a [NO| of 20 ppm. the device might 
well be in error by 2 ppm The OSHA permissible 
exposure level for NO is 25 ppm and NO2 is 5 ppm 
(time weighted average) Our Iwo means for NO and 
N02measur«d outside the ventilalor cu-cuil are well 
below the OSHA standards These low readings are 
probably attributable to the rapid aii exchange rate of 
our PICU and NICU which ranges between = 7-9 times 
per hour SPECULATION: This preliminary data 
seams to indicate thai scavenging exhaled gas may not 
be necessary in ICU environments with high exchange 
rates. Further testing is necessary before we can 
recommend a change in practice, 
OF-94-205 



J Harvard 



; inspiratory 



ADMINISTRATION OF NITRIC OXIDE WITH A 
CONTINUOUS FLOW INFANT VENTILATOR 
Kevin Strong. BS, RRT, Dean Hess. MEd. RRT. Ray Ril? 
BA. RRT. Masaji Nishimura, MD, Robert M Kacmarek. 
PhD. RRT Dcparimcnls of Respiratory Care a 
Anesthesia, Massachuseiis General Hospiial ar 
Medical School. Boston MA 
Inhaled nitric o\idc (NO) is being used mcrea^ 
care of infants, children, and adults When adn 
infants who are mechanically ventilated with c 
flow ventilators, NO is typically titrated into if 
limb of Ihe circuit In the past, we have accomplished this 
by mixing NO with N. to reduce the NO concentration 
before introducing it into Ihe ventilator circuit (using either 
a blender or double flowmeter syslcm) We conducted this 
study 10 evaluate a method m which undiluted NO (800 
ppm) IS introduced into the ventilator circuit METHOD 
Using a bench model, a Scchrist IV-IOOB infant vcniilator 
was used at flows of 10 or 16 L/mm. pressure 30/5 cm H,0. 
T, 1 s. r^te 20/min FIO, settings of 1 0. 6, and 2 1 were 
used NO (800 ppm) was introduced into the inspiratory 
limb of Ihe circuit 30 cm from the patient connection using 
a Timeler 0- 1 or 0-3 flowmeter lo produce [NO] =0-80 ppm 
NO concentration was calculated using the equation: P'JO) 
= fNO flow source ppm)-fNO flow + ventilator flow) NO 
was measured at the patient connection using a 

alyzer (Model 10. Thermo 
I following calibration at and 
80 ppm. Correlation and regression analysis, and bias ± 
precision, were used to evaluate the relationship between 
calculated [N0| and measured [N0| RESULTS The 
predicled NO was consistently less than the n 
and the bias was better for the 0-1 flo' 




1 for NO 
eluding 

high frequency oscillation We have found il simple, safe, 
and reliable Because the additon of NO decreases the set 
FIO,. Il IS important lo monitor oxygen concentration when 
Ihis method is used CONCLUSIONS Although wc found 3 
high correlation between calculated and measured NO. the 
calculated NO underestimated the measured NO The 
reasons for this could be imprecision in setting the 
venljlator and NO flowmeters. Because NO is titrated lo a 
physiologic effect (e g . increased oxygenation, decreased 
pulmonary artery pressure), mathematical c 
[NO) IS practical and periodic 
prudent The calculated dose, however.must be confirmed 
by analysis (supported in part by Puritan-Bennelt 
Corporation) _p_._ 



ASSESSMENT OF LUNG FUNCTION PRE- 
NITRIC OXIDE THERAPY: A PREDICTOR 

OF RESPONSE? William J Hnli RRT. RPFT 
Michael J Anlunes MD, James Cullcn RN, BSN. Jay 
S Greenspan MD. Dena S Vallieu RRT. Alan R 
Spiuer MD, Depi of Peds Thomas Jefferson Med 
College and Hospital. Phila. PA 
Inhaled nitric oxide gas (NO) has been shown to 
improve oxygenation only in some neonates with 
pulmonary hypertension (PHN) We hypothesized 
ihat response to this therapy may be related to pre- 
NO pulmonary function. We evaluated Pa02. 
oxygenabon index (01). pulmonary compliance (CL, 
mI/cmH20/kg). and functional residual capacity 
(FRC. ml/kg) prior to NO ifierapy in 14 lerm infants 
with severe PHN (from asphyxia, aspiration, or 
sepsis) (mean ± SD. weight 3.0 ± 1.1 kg). Infants 
were then treated with inhalational NO, mitially at 
20 ppm and weaning 10 5 ppm over 24 hours, 
delivered with conventional ventilation. Infants were 
considered rcsponders if they were successfully 
managed with NO alone, while non-responders were 
those who failed ventilation with NO and required 
Extracorporeal Membrane Oxygenation (ECMO) 
support. Mean ± standard deviauon for each of the 
measured values were: 



FRC 

CL 

Pa02 Pre 

Pa02 NO 

01 Pre 

01 NO 

' Kniskal-Wall 



Responde 

(N=8) 
18.4 ± 4.i 



55.8 ± 14.0 

157 ± 75.2t 

32.3 ± 11.3 

.9±8.1t 



Non-Responders | 
(N=6) 
8.1 ± 4.3 .OC 

0.25+ 0.10 .OC 
62.8 + 16.9 .£ 

59.3 + 16.8 .OC 
28.8 ±12.3 .5 

29.8 + 13.2 .C 

ly ANOVA. t differs fn 



pre-NO. p<0,05. Wilcoxon signed 

All of the infants recovered from their pulmonary 
disease. Seven of the 8 responders maintained 
improved oxygenation through 24 hours of NO; one 
required ECMO. Five of the 6 non-responders 
required ECMO withm 12 hours of NO iherapy, with 
a mean 01 at ECMO of 44 ± 7, One Non-responder 
improved after 8 hours of NO. and recovered 
without ECMO. These data suggest thai response to 
NO therapy is dependent upon adequate lung 
function, and that measures of oxygenation do not 
predict response. Volume recruitment maneuvers 
and measures of FRC may be useful in improving 
the effecuveness of NO therapy in neonates with 
PHN. Failure to respond to NO therapy with an 
adequate FRC may indicate pulmonary pathology m 
addition to PHN. 

OF-94-038R 



IkACIIIAI C.ASINSDI-IT., 
NrrRiCOXIDF Ray Kit/ B / 
KRI , Kobcn Kacmarek Phil, RR I I )q)aniiiciits of 

Hospital and Harvard McdK.il S^Ium.I llosinn MA 
Inhaled nitric oxide (NO) coiiccnlrjlinns ol (<() ppb lo 20 
ppm can nnprove oxygenation in ARDS Reductions or 
discontinttalion of the NO can re^ull in a dtilenonition of 
SpOj and PaOi Other invusligalors have used Tracheal 
GaH Insufflation (TCil) to reduce FaCOi dunng mechanical 
venlilalioii and avoid excessive MAP and PIP's We 
combined IGI therapy and mcchaiiiuil ventilation with 
NO in an attempt lo reduce PaC(^ without altcnng airwa\ 
pressures and NO concentration A 27 year old male Willi 
AKDS and bilateral bronchopleural airlcaks was 
ventilated with pressure control ventilation and the PCO2 
allowed to nse to 86 mm Wg Ventilator setting pre- 101 
were Vt = 590 ml., rale - IK/m. PKI-P = 10 cm IW, KV 
= 27 cm I I7O. liO; = H 90 Total air leak/ breath was W- 
1 10 ml, NO was administered at 20 ppm and monitored 
by electrochemical NO analysis (Bedfont I:C-90. Kent. 
UK) Previoas altempLs lo reduce the delivered level of 
NO below 20 ppm resulted in a rapid deterioration of 
Spf>: MirniOOS no was admimslCRxl through the 
ventilator by adding NO to tlie high pressure air inlet of 
the ventilator via gas blender A IXil lube was configured 
by passing an R Fr pediatric feeding lube (hrougli a 
bronchoscopy swivel adapter and into the patient's 8 
Fn . extending 1 cm beyond Ihe end of the FTT The T(;i 
provided continuous flow of humidified, heated gas and 
NO concentralion and FiOj were controlled to match that 
of the ventilator as follows A gas blender provided an 
FiO; of 9(t at flows of 4, 8. and 12 Umin and 800 ppin 
NO was added al 1 , 2. and 3 lymin by pediaUic fiow 
meter lo achieve a delivered dilution of 20 ppm TTie 
accuracy of this delivery system was tested previoasly 
dunng bench analysis VeiiUlalor settings were held 
coaslant dunng tnat evcept at a KH How of 12 lymiii 
when PRFP wa.s reduced to 8 cm II^O to manilain MAP at 
20-2!cmH?O RHSW.TS No significant change in I IK, 
HP. or CVP was noted dunng the tnal 

Oiymm 4 I7niin 8 \Jmm 12 IVmin 



pH 
SpOj 



850/. 



47 



84*'-i 



47 
89 
721 
85% 



48 

%^ 

721 
85"/.'. 



PclCO; 61 41 35 30 

CONCUISION.S No sigiuficanl impiovcmenl in hl^xl 
gases was achieved dunng ihis tnal The ability to 
maintain a slahlc SpOj in a patient who previously 
demonstrated intolerance to NO reductions indicates 
concentrations can he maintained dunng I'CII with this 
teclmique Patients with persistent bronchopleural air 
leaks may not benefit from TGI 
(Supported in pari by Puntan-Hennetl Coqi ) 



Opkn Forum ABSTRACTS 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1 



SI i n I 



\in, Johmu 

r, rXirham. NC 

hxlnicdqxircal Membrane (H>pcnalnin (ECMdl 
cl> used Ki licut rmnulL-s uith uifili<>a-<ipir3Uir> 



Kilha 



I rrpinlfd m ihu 



nrgisin The number itT pnliainc palienis ire^lt-J uiih 
|-jE',MO 15 sigiuiicaniK smaller « ith less imprevsn k sur* i* j1 
mus {072. kfi ) Ihc usei'l Ll MO m the pcdiauii 

of FX'.MO 1(1 Ileal a -1 >car oM male with Acule ( hesl 
S>Tidromc (ACS) a-^Mviaicd wilh Sickle Cell Hcmoglnhin 
(SSIIb) 

JR had a hisIinA ol mullipk- liospKal admiviiims 
due (ocnmpticalH>n.Na.vMX'iated uithSSHh He prcscnledki 
the I.K with a line da> hislur> ol hack & abduminal pain He 
Ma> jdmilU-d Mith a Sp02 '~>' W^ i>n luum ait and a 
hemoglobin o( f> d gm dl I'hj-.ital c\am revoaled moderate 
respiratno distress with a rcspirat(«> raic of 49, pulse of 
130. BP of 1 10 fiO and a Icmpctalurc of ^9 1 degrees 
centigrade Initial C'\R revealed iioair space disease The 
patient was treated wilh supplemental o\>gen\ia nasal 
cannula at 2 1 I'M 2-4 hmirs later ;i repeat <'\R re»eakd 
LLL itiTilUatc & cltusion Ik «as iranslerred to Diike 
liuver^il> Mcduaii enlerlof lunhcrliealmem Wotkupal 
DL MC: mcliukd a ( ' \ 1 scan w hith re. caled consi.lidation 
of the left lung, increased opacii\ in the nghl lower lobe and 
pnihable ikcIuskhi of the left main stem bfimchus The 
paUent was intubated appioxiinatel} I7 hour> aUcr 
admi«ion to !)l MC for mechanical * entilation and to 



Mihn 

iiKludin^; liitih I (ii|UtiK\ i )-.iill.]iot\ \ inltlaln'n < AK at 
htvtpital hnur IM) revealed complete upaciflcaunn of hHh 
lungs The patient was deemed to have a greater than 9(yi 
chance ol monalit> Uronchi.tscopic removal of secretions 
was not piMsible due to hemtxixnamic instabilil) and \'cno 
Artenal f:CMO .las initiated I he patient was suppt'>ncd 
withhCM()at lluMsni llKml kg min panided by a ft" 



roller 



nnga 






Therapcuuc hronthoscopy was perl ormed twice a da> whili 
K!M() support was maintained witheMcnsive mucous pluj 
removed dunng each bmnchoscop) The patient shnwed 
remarkable improvement & bilateral clearing of the C\R 
over U»c bCMO course LC'MO was discontinued after 106 
hours and mechanical ventilation was discontinued 6 days 
after decannulation fmm I (Sfn [ht- piitient was 
discharged on hospital d.i> 2H w iih normal neurolngit 
function, no supplemental I >\\t:Lii. and a normal C\R 
The i;i-SO kejiisin rL(>.>its 1-1 cases of ACS 
treated with RCMO with a loial survival rateof 26T We 
report the Hrst pedia 



ofLt 



bC\' 

aggressive and luxurious bro[Khi>s4.op\ 
obstniction. ECMO should he considcrc 
theiap) in patterns with refractory airwa; 
brought on h> severe mucous plugging 



AEROSOL DELIVERY IS AFFECTED BY 
AEROSOL GENERATOR POSITION IN HIGH 
FREQUENCY OSCILLATOR VENTILATOR 
CIRCUITRY. 

Davi d SGanonCRTT .Douglas D Deming MD. Gerald 
A Nyslrom MD: Departments of Respiratory Care and 
Pediatrics Loma Linda University Medical Center and 
Loma Linda University School of Medicine. Loma 
Linda, CA 

With the increasing use of high frequency 
oscillatory ventilators (HFOV). clinicians have begun 
delivering aerosolized medications through HFOV 
circuitry We asked whether the location of the aerosol 
generator in HFOV circuits would affect the volume of 
aerosol delivered to the end of the endotracheal tube Wc 
aerosolized a 41 mot phosphorus solution through a 
commercially available aerosol generator (AG) (Hudson 
« 1 790. mass median diameter 5 1 \xm) placed into a 
HFOV (ScnsorMedics 3100) circuit The baseline 
ventilator senings were; frequency 10 Hz, amplitude 25 
cm HjO. mean airway pressure 15 cm H^O. inspiratory' 
lime 33%. and circuit bias flow rate 15 L/m We 
positioned the AG's in the inspiratory limb of the 
ventilator circuit at three different locations: immediately 
distal to the humidifier (62 cm proximal to the patient 
wye), 10 cm proximal to the patient wye. and between 
the patient wye and the endotracheal tube We collected 
the aerosol sample on a glass filter paper ((ielman) 
located in line between the end of" an endotracheal lube 
(3 5. length 15 cm) and an artificial lung (compliance I 
ml/cmH;0) The AG's were run for 15 min at a driving 
now rate of 8 L/min. We removed the filter paper and 
placed it in 10 ml of deionizcd water to resuspend the 
phosphorus, I wo samples of the resuspendcd phosphorus 
solution were analyzed in duplicate by a 
spcctruphomeiric iiiclhoiJ Five aerosol izat ion were dune 
at each location with five AG's (25 studies for each 
location) Wc calculated the percent of phosphorus 
delivered and analyzed the difference between the A(i 
locations by I -way ANOVA 

Fhc mean amount of phophorus delivered to the filter 
paper was between I and 5% for 
Ihc three AG locations. The mean 
amount of phosphorus delivered ti 
the niter paper increased as the 
distance between the AG and the 
patient wye decreased, however, 
the variability also increased Wc 
conclude thai locating the A(i 
closer to the patient in Ihc HFOV 
circuit increases the amount of aerosol that is delivered 
through the endotracheal lube However. Ihc trade-off I 
ing the percent of aerosol delivery is increased 



m 



nobility in the a 



It delivered, 



Paiiei 



(ARDS) patients who may also benefii from 
ronlrul'lnvcrse Ratio VentilaUon (PC-IRVi. 

) therapy n»]Uire inline analysis of 



i NO 



The t 



f NO analyzer 



n types 
It (CLI 



.linically arc Chemilui 
and electrochemical (EC) Observation of clinical gas 
analyzers has shown the accuracy of measurement to be 
influenced by the duration of inspiratory pressures We 
evaluated a CL and an EC analyzer to determine if varying 
duration of inspiratory pressure by changing I.E ratio would 
influence the accuracy of measurements Methods We used a 
Puritan Bennett 7200 (Punlan Bennett Carlsbad CA i 
ventilator with "Pressure Cycled Ventilation'' sofiware The 
ventilator was connected to a rubber lest lung via a standard 
disposable circuit devoid of a humidifier NO SOOppm source 
gas was mixed via a special stainless steel Bird Blender (SSD) 
(Bird Corporation Palm Springs CA ) wiih Pure Nitrogen 

ventilator The oxygen inlet of the ventilator was connected 
to cUnical oxygen. Gas exiling the ventilator was NO-N2-02 
as set by the ventilator oxygen control and the external SSB 
dial Thus oxygen and NO concentrations can be manipulated 
The No analyzers an API 200 (Advanced Pollution 
Instrumentation San Diego CA t CL type and a Micro Medical 
(Micro Medical Kent England) EC type were connected to the 
circuit twelve inches from the ventilator outlet The tests 



Hing II 



rpla. 



ventilator without changing the results. Data was collected a 
I.Erabosof 1:3. 12. It, 2 1, 3 1.4 1 At all IE sellings 
the ventilator was set ai a PIP of 50cm H20 1 1 breaths per 
min. and 22% oxygen Al each setting change the system wa 
allowed to equilibrate fur two minutes. A mean was derived 
with both devices at each IE setting by collecting readings 
over one minute Results The following table shows the 
mean readings of each device at each IE ratio, with a 



l:E RATIO 1:3 



ECmean 34 7 35 1 



II 



as compared 
ordinal regression 
levels for 



1:3 V 



e NO val 
as 0. ( 



values for (he successiv 
Tirm signiricantly increa 
s for NO at P< 0001 Conclusion Each instrum 
similar pattem of increasing values on each IE le 
ugh the mean values for successive levels of IE r 
atistacaUy signincant it remains 
s clinically signiHcani 



PREDICTORS OF FAILURE IN NEONATAL HFOV 
1 vnng K Bower RRT, Peter Belit RRT, 
Uurcn Pcrlman RRT. John E Thompson RRT. 
James C Fackler MD. and Jay M Wilson MD 
Children's Hospital • Boston. MA 
An oxygenatioo index (01) of greater than 40. is a 
widely accepted indicator for initiating extracorporeal 
life support (ECLS) in neonates on conventional 
ventilation (CV). However, many infants who fail CV 
undergo a trial of high frequency oscillatory ventilation 
(HFOV) prior to ECLS Unfortunately, Oierc arc no 
accepted guidelioiis'to indicate HI=OV failure Wc. 
therefore, evaluated critena for the use of ECLS in 
neonates treated with HFOV (SensorMedics 3100A) 
usmg a high volume strategy Ventdaior and blood gas 
daU on all potenUal nonsurgical ECLS neonates 
treated with HFOV between 1/92 and 5^4 were 
retrospccdvely gathered from a 






(Ol) 



ygen tension ratio (P(a/A)02). were 
calculated Additionally, a ventilation oxygenation 
index (PaCOj x OI=VOI) was developed to include data 
on the efficiency of ventilation. Criteria for institution 
of ECLS in Uicsc patients was highly variable and based 
solely on an individual practitioner's impression ihot 
HFOV had failed. The Ol. P(a/A)02. and VOI. were not 
calculated prospectively to aid in patient management 
decisions Seventy-four outbom neonates were 
evaluated 40 MAS/PPHN. 26 sepsis, and 8 with oOier 
diagnoses. Forty-one neonates (55%) responded (R) to 
HFOV avoiding ECLS (68% MAS. 35% sepsis, 63% 
other) while 33 (45%) did not respond (NR) requiring 
ECLS Seven (5 septic. 2 MAS) of the NR required 
emergent cumulation making data acquisition 
impossible These patients were excluded from further 
analysis There was a slaiistically significant 
dilTcrcnce between the R and NR groups with regard lo 
initial and highest Ol, P(a/A)02. and VOI (p< 001) 
(table). Eighty-seven percent of the patients with an 
Ol>60 required ECLS. while only 29% of those widi an 
OI<60 required ECUS In the latter puUcnts, ECLS was 
instituted due lo pcrsistint air leak or cardiac arrest. 
There were no deaths ui the R group and 6 deaths in the 
NR group Within die NR group die uiitial and highest 
mean Ol in nonsurvivors was significantly greater dian 
the lorvivors (36 3 vs 98 5. p=005) Wc conclude: 1) 
Ol. P(a/A>02 and vol ire all capable of predicting ECLS 
requirement in HFOV patients often within the first 
hour of HFOV 2) A retrospectively calculated high 
mean Ol > 60 waj wsociUcd widi an 86% requirement 
for ECLS, 3) The fact that 6 desthi occured in Oiia 
scrict and that die Ol was highest in the non-survivors 
would suggest that delayed initiaUon of ECLS may 
contribute to morbidity and mortality 4) Based on the 



pnoT 3 con 


luiloni il w 


DUld 


appear pru 


Ol or M u 


an indicjlor 


ot HI OV (.Ju 


ECLS rc.cu 


e enpodiliou 


•ly 








I4ELE 




UKfl; 




EOS 


Ol 


10 7t2 4 




83 018 5 


P(./A)02 


385t.02 




102±01 


vol 


102±1 2 




32.6i5 7 



AIRWAY PRESSURE MONITORING DURING ULTRA- 
HIGH FREQUENCY JET VEf^TILATlON— C«l F H w MLS 
RRT. Cn^t,T^r H Wise HS RRT. Mvk A KonUe MPA 
RRT. John G Weg MD. University of Michigan MecUcAl 
Cenier, Ann Arbor, Michigan 

Bkckfround: Diatal airway preasure ihould be 
monitored duriiig high frequency jet ventilation. 
Specially designed endotrschcal tubes (ETT) allow 
monitoring ai the distjal aid. but reintubation may not be 
pouibk. An altemale ii to iruert a caiheter into the ETT 
to monitor preuive. We studied: 1 ) the accuracy of ETT 
distal pretsun: mcAsuremenU (DPM)^ 2) the effecu of 
catheun en DPM; and 3) the accuracy of DPM through the 
inserted cuheten. McUiocU: An ultrahigh frequeiKy 
ventilator (Adult Star 1010. Infrasonics) was auached to 
•n 8.0 mm ID ETT (Ultracheal. Infrasonics) (UETT) for 
DPM. connected to a test lung (TTL, Michigan 
InsmuTtenu) with • comphance of 03 L/cm H^O Three 
catheters were studied: t 16 gauge single-lumen 20 cm 
catheter (CS-(M300, Arrow International Inc) and two 
lengths of pressure monitoring tubing (Abbott 
LaboTiiories)— 20 cm (short; tame length ts CVP) and 34 
cm (long: positioned near the end of the ETT ). Each 
catheter was irtserted through the suction port of tlie jet 
injector adapter. The ventilator was set to rates (0 of 2.5, 
5 and 10 Hz, drive pressures (DP) of 20. 30 and 40 psi, and 
% irupiruory limes (%Ti) of 22. 36 and 50%. When one 
of the 3 parameters changed, the other two assumed the 
midrange setting (eg. f with DP=30. %Ti= 36; DP with 
f=300. %Ti=36; %Ti with f=300. DP=30). An adApter was 
placed in the 'airway' at the level of ttw UETT for direct 
DPM. All fressures were measwed with the ventilator 
pressure monitoring system. Suuistics were done using 
Microsoft Excel 4.0. Results: The UETT underestimaied 
the directly measured distal peak (34.6 ± 8.7 vs 38,0 ± 9.0 
cm HPX mean (16.2 ± 6,1 vs 21.0 ± 7.3 an HjO). and 
minimum (5,6 ± 2.5. vs 110 ±5.5 cm HjO) pressures- all 
p<O.O0L Comparison of direct distal pressures for 
baseline (without catheter) vs with catheter in ETT; mean 
(±SD) in cm HjO; • pcO,05: 

Baseline Long Short Airow 

peak 38.019.0 35.3±8.4' 34.3±7.5» 37,9±9-l 
mean 2I.O±7.3 20.8±7,1« 19-5±6.6» 2l.5±7.8» 
min 11.015.5 11.915. 5* 10.914.9 U.8±5.6» 
Comparison of direct distal pressures of the long, short, 
cid Arrow catheters, ts above, vs pressure meamred by 
each catheter 

Long Short Ansa: 

peak 29.618,8- 35.818, 1» 29-517.7* 
mean 18-517. 3" 18. 616.7" 19.617. 3* 
min 13. 716, 5- 9, 114,9" 12-414.9* 
CoDcluslons: The UETT underestimated distal pressure 
by "S cm HjO, Alternate catheters reliably track pressim 
with mmimtl influertce on directly measured pressure. The 
short catheter had the least impact on direct distal 
pressures and most closely tracked direct distal pressure. 
Although this study did not evaluate the catheters' efTect 
on entrained volume, observation of the TTL irtdicated 
negligible impact. OF-94-166 



Peter Bctii RRT. Patnce Benjamin RRT. 

John Thompson RRT. Ian Adatia FRCP(C), 

Children s Hospilal. Boston. MA 

Ideally, an inhaled mine oxide (NO) delivery' system 
should be of simple design, deliver precise doses, 
mtmmize mlrogen dioxide (NO2) production and 
allow scavenging without compromtsing ventilator 
parameters or alarms We investigated the deli\er\' of 
NO with the VIP Bird venQlator connected to a test 
lung. The venulaior was set m the Dme cycled IMV 
mode at PiP/PEEP 25/5 craH20. rate 25. Ti 0,6 sees 
and Paw 10,4 emH20 NO (source SfX) ppm) was 
Uiratcd pre- humidifier according to the equauon [NO 
dose = NO source ppm (NO flow rate/lotal How 
rale)). Vt. airway pressures and Fi02 were 
momtorcd. The effect of a scavenging device on 
PEEP and the sensitivity of the low ainvay pressure 
alarm with two types of NO supply tubing (3 & 5 
mm) was assessed NO and NO2 levels were 
analyzed by ehemilumincscence (molybdenum 
convener) at baseline and after each 100 ml/min 
increase in NO flow rate, with three O2 
concentrauons (,30..60. &1,0) and ventilator flow 
rates (8.10 &12 Umin), Measured levels of NO 
(NOM) were compared to calculated values (NOC) 
in 81 samples over a range of 6-80 ppm NOM and 
NOC conflated well (»r-= 99) for each flow i^te and 
RO2. NO2 was < 3.2 ppm (mean 1.2 SD+/- -7) and 
always < 1.5 tf NO was< 40 ppm for each How rate 
and F1O2. Airway pressure and Vt remained stable. 
25+/-0cmH2Oand2l.2ml +/-J5ml rcspccuvcly, 
RO2 fell by (B- 1^7 with NO flow rates >500 
ml/min Scavenging did not alter PEEP We conclude 
1) accurate NO doses can be delivered 10 the 
inspirator, limb of the VIP Bird in the umc cycled 
IMV mode 2) companson ol NOM and NOC may be 
useful lo identify system or analyvcr malfunction 3) 
NOdases <40 ppm will ensure that NO2 remains 
< 15 ppm 4) if a dose > 40 ppm is needed and it is 
cnucal to maintai' a F1O2 of > 93. then a higher 
concentration NO source tank is requtird 5) a 
scavenging system can be incorporated 6) 5 mm NO 
supply tubing is irt^uired to preserve the LAP alarm. 
This system pcrmiis precise and safe NO deliver) 
and IS currently used to treat infants with pulmonan. 
hypertension. 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1 



Open Forum ABSTRACTS 



EARLY VERSUS 


LATE RECOU 


RSE TO ECMO FOR 


RESCUE OF NEONATES WtTH 


SEVERE 


RESPIRATORY 


AILURE DUE 


TO MECONIUM 


ASPIRATION SY 


JDROME 




Donna Maqro RRT BSN, Charles W Bfeaux. Jr , | 


MD Debbie Laney, RN, MSN, K 


ith E Georgeson, 


MD 






The Children's Hospital of Alaba 


na, Birmingham 


Exlracorpofeal m 


mbrane oxyge 


aHon (ECMO) is an 


invasive therapy v 


vilh the potentia 


1 for significant 


complications, bu 


\:ir:z: 


e salvage Iieatment 
espiiatorv failure 
management Sorrie 


patients qlJall^ for ECMO early i 


their disease 


course but others 


take several days lo do so From j 


November 1987 t 


3 May 1994, 72 


neonates with 


meconium aspiral 


on syndrome (MAS) requited | 


ECMO Forcomp 


anson, Ihe pati 


nts weie divided into 


two groups, those 


placed on ECMO at s 36 hr age | 


("early'' group, n = 


47, mean age 


21 hr) and (hose 


placed on ECMO 


at > 36 hr age 


fate" group, n - 25 


mean age 84 hr) 
data prior to, dun 


Hospital Chan 
g. and after Ih 


ECMO course 


Students I test w 


s used to com 


Dare group means 


percentages betw 


een groups 






ECMO Groups P 1 




Early 


Late '^'"' 


Gestational age 


wk) 40 2 


39 8 34 


Birlhweight (gm) 


3552 


3306 08 


Apgaf 1 mm 


4 1 


5 16 


5 mm 


67 


7 44 


Pre- IMV 


71 


67 31 


ECMO PIP 


38 6 


405 16 


settings WAP 


16 4 


17 9 07 


Pre- pH 


7 55 


7 66 002 


ECMO pco 
'^^' PC. 


33 6 
319 


291 13 
41 4 001 


Oxygenation Ind 


« 63 


48 10 


ECMO Duration 


hr| 123 


142 35 


Complications/pt 


07 


07 10 


Survival 


89% 


88% 1 


When exiubated 


(hr) 44 


50 59 


NICU LOS (d) 


128 


154 16 


Total LOS (d) 


236 


191 35 


Home O, 


0% 


0% 1 


There were no significant ditferen 


ces in tCMO course 


or outcome betwe 


en infants wtth 


severe MAS placed 


on ECMO early o 


late 


OF-94-230 



BIPAP' INSTEAD fN A PlCU- Kaoe Sabalo MS. 

RRT. Vivienne Newman MD. Ctuldicns Hc^iial Oaklaod. 
California 

INTRODUCTION: BlPAP' has been successfully utilized 
in adults as a noninvasive means to eliniiiute obstructive 
sle«p apnea and/or to reduce respiratory insufficiency, 
somenraes eluninating the ne«d tc place an endotracbeaJ 
tube and u^ mechanically ventilate Minimal research has 
been publushed supporting the effectiveness of the BiPAP* 
system in the pediadic populaiion. ^ciftcally in the PICU 
We report succe&sful use of the BiPAP system over a 6 
month time frame METHOD In each of the reported 
cases the children met intubation chtena Patients ranged 
in age from I to 9 years of age (mean 3 5 years of age) 
Blood gases and vital signs below represeni one hour prior 
to appUcahno of BiPAP* and 1-2 hour^ post application of 
BiPAP" Etiology of respiratory distress UKluded 

pneumoraa. post exmhation stridor, lonsilar bypertrophy, 
and post-op atelectasis assixiaied with cardiomegaly and 
pulmonary edona Duration of Qrae on BiPAP* varied 
acc*irding to the severity of the underlying pathology 
None of these patients requireJ either intubation or 
reintubation All patients exhibited a marked improvement 
in theit level of air hunger and a decrease in chmcal WOB 
once the nasal mask was appbed RESULTS Results are 
listed below Significant improvement in venblatjon and 
vital signs are illustrated All FiO, requirements were 
decreased CONCLUSION: The BiPAP* system may be 
a viable, nomnvasive ventilatory option for certain pediatric 
patients with severe respiratory distress More research is 
needed to identify target populations In addinon to 
avoiding infuhation, the BiPAP" system offers other 
significant cost savings In many of the cases, costty 
respiratory care interventions (such as continuous 
vaponephrinc or albuterol, ICW% 0, therapy) were 
discontinued once BiPAP" was instituted 





Pre BIPAP" 


Post BIPAP* 


P 


HR 


148 8. 35 7 


115 61 25 6 


- 001 n-8 


RR 


58 75115 5 


32 51 9 29 


< .001 D-8 


CO, 


57 41 7 5 


39 91 4.3 


< .001 n-7 



Dollar 

for dollar^ 

you Just 

can^t beat a 

great 

reprinti 



This is a great time to 

have AARC Times and 

Respiratory Care 

journal articles and 

advertisements 

reprinted. Why not call 

today? 
It makes good "cents"! 
For more information, 

contact 

the Marketing Dept., 

(214)243-2272. 




American Association for Respiratory Care 

40th Annual Convention and Exhibition 

December 10-13, 1994 • Las Vegas, Nevada 



1115 



Index of 1994 OPEN FORUM Authors 



Boldface Type Indicates Presenters 



Abbey. D 1092, 1094 

Adachi, Mitsuru 1064 

Adatia. Ian 1114 

Al-Essa, Mazan M 1088 

Alfredson, T 1099, 1108 

Ambrosino, N 1070, 1 104 

Anders, M 1086 

Anderson, P 1086 

Anderson, Susan 1076 

Andruschak, John 1068 

Antunes, Michael J 1060, 1113 

Arnold. John H 1076 

Austin, Todd M 1072 

Backes. William 1104 

Badellino, Michael M 1062 

Badgwell. Gaye 1094 

Bagliani, S 1070, 1 104 

Ballard, Julie 1078 

Bandi, V 1084 

Bartlett, Robert H 1063 

Barton, JA 1110 

Batch, Kimberly R 1092 

Baumeister, Brenda 1060 

Becker, J 1060 

Beckerman. R 1 104 

Belingon, Ed 1106 

Benjamin. Patrice 1076, 1 1 14 

Benson. Michael S 1064 

Betit. Peter 1114 (2) 

Bhutani. Vinod K 1061 (2) 

Bien, Mauo-Ying 1073 

Black, JR 1080 

Blackson, Tom 1102 

Bliss. David 1063 

Blumer, Jeffrey L 1060 (2) 

Bock, Kevin R 1096 

Boitano, Louie J 1064 

Bonner, Robert A Jr 1064 

Borisenko. Ludmila 1070 

Bowen, Barry 1088 

Bower, Lynne K 1076, 1114 

Bowyer, Mark W 1067 

Branson, Richard 1068, 1 106 

Breaux, Charles W Jr 1115 

Brega, S 1070. 1 104 

Broemcling, L 1060 

Brooks, Worth I 102 

Brosbe, Geri 1072 

Brown, P 1110 

Brown. RW 1072 



Buckman, Robert F Jr 1062 

Burchette, R 1092, 1094 

Bums, David M 1096, 1099 (2), 1 108 

Bums, Edward 1 107 

Burton, Karen 1099 

Cadavid, Mario E 1063 

Caldwell, Arthur 1073 

Caliwag, W 1078 

Calkin, David 1099 

Callegari, G 1070, 1104 

Campbell, Robert 1068, 1111 

Canelli, Gerry 1090 

Cantwell, Patricia 1060 

Carlin. Brian W 1070 

Carroll, Mark 1110 

Carter, Wesley 1086 

Castiglione, R Jr 1102 

Cegielski, Sandee 1092 

Chang, David W 1080 

Channick, Richard 1114 

Chatbum, Robert L 1060 (2), 1061, 1076, 1082, 1 107 (2) 

Cheng, Ling-Yee 1073 

Chiang, Ling-Ling 1073 

Chiappetta, A 1104 

Childers, Marilyn 1080 

Chiles, Nina 1064, 1 109 

Chow, Jyh-Her 1101 

Chu, Chia-Chen 1073 

Ciarlo, Joe 1 102 

Clark, Brian 1 100 

Clark, Randal 1080 

Clark, William T 1101 

Coates, Geoffrey 1088 (2) 

CoUe, Joni D 1096 

Connell, Stephen J 1064, 1 1 10 

Conrad, Kris 1 104 

Cook, Teresa 1068, 1103 

Cornell, Kelley M 1067 

Cronin, J 1 108 

Cullen, James A 1060, 1 1 13 

Curley. Frederick 1099 

Dallessio, Joseph 1060 

Daniel, Brian M 1107 (2) 

Dashevsky, Yuri 1104 

Davis, Kenneth Jr 1068, 1 106 

Day, Ronald 1 1 13 (2) 

de Necochea, Anthony 1086 

Dean, JM 1072 

Deao, Dan 1068 

Dechcrt, Ronald E 1063 



1116 



RESPIRATORY CARE • NOVEMBER 94 Vol 39 No 1 1 



Open Forum AUTHOR INDEX 



DeMaria, F 1070, 1 104 

Deming. Douglas D 1067. 1 1 14 

Dennison, Frank 1102 

Desai, MH 1060 

Desjardins, Steven E 1062 

Dethlefsen, Michaela 1111 

Dhand. R 1086 

DiNicola, Debbie 1107 

Dipzinski, F 1070 

Dolovich, Myma B 1088 (2) 

DuFault. Beth 1067 

Durbin, Charles G Jr 1063 

Dyer, David 1110 

Eagleton, Lanie E 1096 

Earl, A 1108 

El Barbary, Mahmoud 1110 

El-Khatib, Mohamad F 1060 

Ellison, Gail 1092 

Emberger, John 1110 

England, Kevin R 1096 

Enright, P 1092, 1094 

Fackler, James C 1114 

Fahey, PJ 1099, 1 108 

Fajardo, Erick 1 1 06 

Ferreira, Carla 1061 

Fink, J 1072, 1086, 1 106, 1108 

Fisher. Daniel 1063, 1084 (3), 1086 

Fisher, M 1 108 

Fisher, Michael E 1062 

FitzGerald, Cecily 1072 

Fitzpatrick. Rene 1067 

Fok, Tai F 1088 (2) 

Foley, Kevin 1063 

Ford. Richard M 1096. 1099. 1 108 

Foss, CM 1090 

Foulkrod, Vicki 1110 

Foust, Gregory Neil 1068 

Fracchia, C 1070 

Freeman, B 1078 

Fukazawa, Shinji 1064, 1106 

Fukuoka, Toshio 1 102 (2) 

Gallivan, Lorraine E 1064, 1067 

Gan, Vanthaya 1094 

Garton, David 1067, 1078, 1114 

Gay, PC 1070 

Georgeson, Keith E 1115 

Giles. Dennis K 1096 

Gilliam. Craig 1107 

Godinez, RI 1084 

Goldsberry, David T 1111 

Goodhart, George 1107 

Gordon, Jerry 1096 

Gradwell, Gary 1072 

Grady, EA 1072 

Graf. LB 1090 (3) 

Gray. Shari 1088 

Graybeal, JM 1064, 1109 

Greenspan, Jay S 1060. 1 1 13 



Gregg. BL 1082 

Grigorieva. Anastassia 1064 

Grueber. Ryan 1107 

Guidry. Henri 1096 

Guntupalli. K 1084 

Haas. Carl F 1099. 1 1 14 

Hadeed, A 1060 

Hagarty, EM 1072 

Hagelgantz. Michael 1 106 

Hanneman, SK 1062 

Hansen. Douglas R 1114 

Harper. PA 1090 (3) 

Harris. Louis N 1101 

Hauptman. D 1099, 1 108 

Hazel, KS 1110 

Head, C Alvin 1113 

Hedges, JR 1110 

Henkle, Joseph Q 1096 

Hemdon, DN 1060 

Hess, Dean 1063 (2), 1084 (3), 1086, 1 101 (3), 1 104 (2), 

1107.1113(3) 

Heulitt, M 1086 

Hill, Wrae 1110 

Hirsch, Christopher 1099, 1 101 (2) 

Holt, William J 1060, 1113 

Horiuchi, K 1063 

Hotta, Toshiro 1102 (2) 

Hough, Lorraine F 1084, 1111 

Hultman, C 1072 

Hunte. Carole 1090 

Hurst, James M 1111 

Hurvitz, EA 1072 

Irwin, S 1060 

Jasper, Edward 1072 

Jenne, J 1086 

Jih, Kuen-Shan 1101 

Johnson, Robert 1068 

Johnson, Wayne 1114 

Jones, Arthur 1080 

Kachel, Diane 1067 

Kaemarek. Robert M . . . 1063(2), 1084(3), 1086. 1101 (3), 1 1(M(2), 1 107, 
1113(3) 

Kallstrom, Thomas J 1061, 1107 

Kaplan, Robert 1072 

Kasai, Fumihito 1064 

Kasper. CL 1110 

Kavuru. M 1090 

Keenan, Jim 1078, 1092, 1099 

Kehr, W 1062 

Kemper, M 1063 

Kendall, AG 1070 

Kern, F 1076 (2) 

Kester, Lucy 1082, 1096 

Kirby, Elizabeth A 1063 

Kirpalani. Haresh M 1088 (2) 

Klein, Linda D 1072 

Knutsen, SF 1092, 1094 

Kollef, Marin H 1096 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1 



I1I7 



Open Forum AUTHOR INDEX 



Konkle. Mark A 1099, 1 1 14 

Konopinski. Ted 1090 

Konyukov, Yurii 1102 (2) 

Kopotic. Robert J 1061 (2) 

Kratohv il, Joseph 1 104 

Krause, S 1108 

Kuluz. John 1060 

Kuwayama, Naoto 1102 (2) 

Lane. Connie 1099 

Laney . Debbie 1115 

Langbein. WE 1072 

Lange, PA 1090 

Langga, Leo 1078, 1111 

Langlois, D 1068 

Larson, R 1108 

Laskowski, DM 1090 

Lattin, Chris D 1092 

Lawrence, G 1072 

Levin, Dan 1110 

Limberg. Trina 1072 

Lindley. P 1062 

Logan, Debbie 1070 

Lowe, G 1086 

Lu, Chong-Chen 1070 

Lua,Lea 1110 

Ludington. Susan 1060, 1061 

MacCallum, Madeleine 1099 

Maclntyre. Neil R 1063, 1101 

Madsen, Terry 1078 

Magro, Donna 1115 

Mahlmeister, Michael J 1080, 1108 (2) 

Mahon, Tom 1060 

Malinowski, Tom 1078, 1106, 1111(2) 

Martin, William J II 1067 

Martinez, FJ 1090 (3) 

Marukawa, Taro 1 102 (2) 

Masi-Lynch, Joanna 1078, 1113 (2) 

Mask, Corbett 1108 

Mathews, Les 1068 

McAndrew, J 1110 

McCarthy, Kevin 1082, 1090 

McCauley, RL 1060 

McConnell, Robert R 1063, 1101 

McDonnell, WF 1094 

McGee, Tom 1078 

McGowan, Mary 1061 (2) 

McLaughlin, Gwenn 1060 

McQuitty, John 1073 

Meiler, Rose 1102 

Meliones, J 1076 (2), 1 1 10, 1 1 14 

Merren, Randall 1099 

Mcssick. WJ 1111 

Milisch, Robert A 1104 

Millard, MW 1072 

Miller, C 1084 

Miller, Christopher C 1110 

Miller, Dorisanne 1064, I 100, 1109 

Milligan, Donald 1084 



Milne, Gary 1062 

Mink, Shari L 1063 

Miyagawa, Tetsuo 1064, 1 106 

Mizuma, Masazumi 1064 

MIcak, R 1060 

Monkman, Shelley 1088 (2) 

Montiel, Lisa 1080 

Moon, Laura 1068 

Mori, Yoshiaki 1064 

Moras, Diane 1 107 

Mullarkey, John 1062 

Nadeau, C 1 102 

Nagel, Carol A 1092 

Napoli, Linda Allen 1084, 1111 

Nelson, VS 1072 

Newhart, John 1 108, 1114 

Newhouse, Michael T 1088 

Newman, Vivienne 1115 

Nichols, RJ 1060 

Nicoletti. Ivan 1099 

Nishimura, Masaji 1101, 1 1 13 (2) 

Norwood, Jimmy W 1 107 

Nystrom. Gerald A 1067, 1 1 14 

O'Connor. James J 1064 

O'Keefe. P 1108 

Oberg, Kerby C 1067 

Off, David 1 104 

Orens, D 1108 

Paes, Bosco 1088 

Pascale, Pietro J 1101 

Pataky, Gail 1062 

Patrick, Herbert 1064, 1072, 1 100, 1 109, 1110 

Payne, Nicole C 1067 

Peck, M 1078 

Pellegrini. Richard 1070 

Perkins, Susan 1080 

Perlman, Lauren 1114 

Permutt, L 1 102 

Pemg, Reury Pemg 1070 

Perry, Douglas G 1067 (3) 

Peterman-Black, AK 1080 

Peters, BA 1094 

Peters, James A 1092. 1094 

Peters, SG 1070 

Pettinichi, Scott 1080 

Phillips, Jan E 1096, 1099 (2) 

Piaggi, G 1070, 1 104 

Pierson. DJ 1110 

Piper, S David 1086 

Poll. Kathryn 1078 

Pooler, Sharon 1084 (2), 1086 

Pope, C 1084 

Post, D 1099 

Potts, David L 1082 

Prato, B Stephen 1062 

Prewitt, Lela 1072 

Quinn, William W 1086, 1 102, 1 106 

Raahe. Otlo G 1086 



1118 



RESPIRATORY CARE • NOVEMBER "94 Vol 39 No 



Open Forum AUTHOR INDEX 



Randolph. PE 1111 

Rao, S 1060 

Reid, Russell T 1068, 1 103 

Retherford, Jean A 1080 

Reyes, Ercele 1062 

Rho, David 1 104 

Richards, Kathleen 1113 

Richards, Rodger 1096 

Ries, Andrew 1072 

Riggi, Vincent 1101 

Ritz, Ray 1113 (3) 

Rizzo, Albert 1 102 

Roach. Gregory 1 100 

Robertson, Randal 1080 

Robinson, E 1060 

Rogers, Mark 1078, 1111 (2) 

Roloff, DW 1072 

Romagnoli, David 1 1 07 

Rosolowski, Bonnie 1061 

Russell, GB 1064. 1 109 

Sabah, Murat 1 106 

Sabato, Katie 1073, 1115 

Sakamoto, Warren 1086 

Salkins, DJ 1090 

Salvi, RJ 1090 

Salyer, John W 1078 (3), 1092 (2), 1099, 1109. 1 1 13 (2) 

Santoro. A 1110 

Scaggs, John E 1096 

Schell, Sheila 1 104 

Schleien, Charles 1060 

Schubert, N 1 102 

Schuiz, Lisa J 1076 

Schwartz, A 1 102 

Schwartz, Whitney L 1064 

Sciurba, Frank C 1092 

Scott, Randy 1111 

Shanks, Thomas 1114 

Shiao, Guang-Ming 1070 

Shimada, Yasuhiro 1 102 (2) 

Shimizu, Kiyokazu 1 102 (2) 

Shore, Mary 1 062 

Shrake, Kevin L 1096 (2) 

Simmons, Mark 1068 (2) 

Sirgi,C 1084 

Sivieri, Emidio 1061 (2) 

Skorodin, M 1072 

Slivka, William A 1092 

Smith, Paul G 1060 

Specht, Lennard 1092 

Spitzer, Alan R 1060, 1113 

Staiano, Amy 1064, 1 109 

Steinberg, Kenneth P 1064 

Stoller, James K 1082, 1090, 1096, 1 108 

Strong. Kevin 1 104. 1113 

Stubbs.CR 1110 

Sullivan. Lynn M 1104 

Swinth. J 1060 

Tabor. Ted 1068 



Taft. Art 1 102 

Takezawa. Jun 1102 (2) 

Taylor. Ann 1101 

Taylor. Jerome 1072 

Taylor. Tom 1092 

Tendal. Nancy T 1099 

Thompson. John E 1076, 1 1 14 (2) 

Tobin, MJ 1086 

Toro-Figueroa, Luis 1110 

Torres, A 1086 

Totaro, Lawrence 1 106 

Trahey, Judy 1063, 1 104 

Trant, Charles A 1114 

Trinh, Louis 1 1 1 1 

True, MA 1090 (3) 

Truwit, Jonathon 1062 

Tyra, James A 1107 

Vaccaro, Jamie 1100 

Vallieu, Dena S 1113 

van Stralen, Daved 1111 

VanCamp, Elizabeth 1099 

Vanderwarf, C 1099 

VanLaanen, CJ 1072 

Vierra, Terry J 1 103 

Viggiano, RW 1070 

Visveshwra, N 1078 

Volsko, Teresa 1084 

Wadlinger, Sandra R 1111 

Walsh-Sukys, Michele C 1061 

Walters, Pat 1094 

Wang, Jia-Horng 1073 

Wang, Yuh-Lin 1101 

Wanger, Jack 1092 

Warren, R 1086 

Weg, John G 1099, 1 1 14 

Wehrman, Stephen F 1086 

Weir, George 1 109 

Weissman, C 1063 

Weitzel, Linda 1 109 

Wendt, J 1084 

Wendt, R 1084 

Wert, Lori J 1076 

Williams, Purris 1084 (2), 1086, 1 104 

Williams. Timothy A 1094 

Wilson, Barbara G 1076 (3), 1 1 10 

Wilson, Jay M 1076, 1 1 14 

Wilson, Mark C 1072 

Wise, Constance H 1114 

Wiswell. Thomas E 1060 

Witherspoon. J 1062 

Woodcock. Brian 1063 

Wright. Jeff 1092 

Wright. John 1096 

Yen. Chih-Chihng 1101 

Ykoruk, Regina 1061 (2) 

Yuen. Elaine 1109 

Zocchi. L 1070. 1 104 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 11 



1119 



EXHIBITORS 

at the 40th Annual Meeting and Exposition of the 
American Association for Respiratory Care 

December 10- 13, 1994 
Las Vegas, Nevada 



Thousands of examples of respiratory care equipment and supplies are displayed, 
discussed, and demonstrated in the exhibit booths at the Annual Convention. 
The AARC thanks the firms that support the Association by exhibiting. 
(Exhibitors confirmed by October 25, 1994, are listed.) 

Exhibit Hours 



Saturday, December 10 
Sunday, December 11 
Monday, December 12 
TXiesday, December 13 



12:00 noon - 4:00 pm 
11:00 am -4:00 pm 
11:00 am -4:00 pm 
11:00 am -3:00 pm 



Exhibitor 



Booth Exhibitor 



Booth 



B 



Abbey Healthcare Group 113 

Ackrad Laboratories, Inc 1410 

Advance Newsmagazines 1046 

Advanced Lifeline Services, Inc 849 

Aequitron Medical, Inc 231 

AirSep Corporation 1341 & 1343 

Allen & Hanburys, Division of Glaxo, Inc 309 

Allied Healthcare Products, Inc 1225 

Ambu 405 & 407 

American Biosystems, Inc 1251 

American College of Chest Physicians 1450 

American HomePatient 121 

American Lung Association 1451 

AnaMed International 746 & 748 

Anesthesia Associates, Inc 944 

Arbor Medical 1424 

ARC Medical, Inc 646 & 648 

ARTEC, Inc 529 

Asthma and Allergy Foundation 

of America 1 447 

Automatic Liquid Packaging, Inc 137 & 139 

AVL Scientific Corporation 937 



B & B Medical Technologies, Inc 846 

Ballard Medical Products 710, 913, 915 

Baxter Healthcare Corporation, 

I.V. Systems Division 637 

Bay Corporation 1331 & 1333 

BCI International 618 & 620 

Bear Medical Systems, Inc 1119 

Becton Dickinson and Company 1414 

Bellofram 249 & 25 1 

Bicore Monitoring Systems, Inc 1219 

Bio-Med Devices, Inc 626 & 628 

Bio-Rad Laboratories 1 301 

Biomedical Sensors/Pfizer 

Hospital Products Group 448 & 450 

Bird Products Corporation 319 

Bivona Medical Technologies, Inc 1313 & 1315 

Boehringer Ingelheim 

Pharmaceuticals, Inc 619 

Boston Medical Products, Inc 1340 

Breasy Medical Equipment (US), Inc 1319 

Bunnell Incorporated 850 

Burdick. Inc 143 



1120 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 : 



CONVENTION EXHIBITORS 



Exhibitor 



Booth Exhibitor 



Booth 



California College for Health Sciences/California 

College Press 1026 

Cardiopulmonary Corporation 1344 

Center Laboratories 1432 

Cemer Corporation 419 

Chad Therapeutics, Inc 1050 

Children's Medical Center of Dallas-TX 224 

Ciba Corning Diagnostics Corporation 501 

Clement Clarke 204 

CNS, Inc 437 

COBE Cardiovascular, Inc 1246 

Consentius Technologies 1245 

Core-M. Inc 1349 

Creative Biomedics 1437 

Criticare Systems. Inc 1007 

Curant Communications, Inc./RT Magazine 1033 

Cybermedic 1013 



D 



Dale Medical Products, Inc 345 

Data Base Managers 1441 

DataStar Education Systems 

and Services Inc 1 425 

Delmar Publishers, Inc 105 

DeVilbiss Health Care, Inc 509, 511, 513 

Dey Laboratories 920 

DHD-Diemolding 

Healthcare Division 611, 613, 615 

Diametrics Medical, Inc 443 

Diamond Software 133 

Drager, Inc 1336, 1337, 1338, 1339 



E 



EdenTec 336 & 338 

Entech 551 

Epic Medical Equipment 

Services, Inc 103 



F.A. Davis Company/Publishers 207 

Ferraris Medical, Inc 523 

Fisher & Paykel Healthcare 630 & 632 

Fisons Pharmaceuticals 1300 

FloCare Medical 240 



Flotec, Inc 649 

Forest Pharmaceuticals, Inc./ 

UAD Laboratories 239 

Fukuda Denshi America. Inc 1427 

Futuremed America, Inc 1307 

G 

Genentech, Inc 1401 & 1403 

General Physiotherapy, Inc 547 

Gibeck, Inc 1400, 1402, 1404, 1406 

The Gideons International 1431 

GO-MI, Inc 1148 

Golden Care, Inc 1207 

Goldstein & Associates 1345 

H 

Hamilton Medical, Inc 337 

Hans Rudolph, Inc 1302 

Health Educator Publications, Inc 200 

Healthdyne Technologies 1231 

HealthScan Products 1327 & 1329 

Health Way Products, Inc 35 1 

Homedco, Inc 814 

Hospitak, Inc 1201 & 1203 

HR Incorporated 909 & 91 1 

Hudson RCI 1023 

Hy-Tape Surgical Products Corporation 1408 

I 

I-Stat Corporation 948 & 950 

ICN Pharmaceuticals, Inc 1351 

Impact Medical Corporation 1325 

Indiana University School of Continuing Studies .... 1444 

Infrasonics, Inc 737 

IngMar Medical 109 

Innovative Medical Marketing 1407 

Innovative Medical Systems, Inc 549 

Instrumentation Industries, Inc 413&415 

Instrumentation Laboratory 901 

Integrated Health Services Ill 

InterMedway 1309 & 1311 

International Biomedical, Inc 1426 & 1428 

Invacare Corporation 301 

IPI Medical Products 500 & 502 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 11 



1121 



CONVENTION EXHIBITORS 



Exhibitor 



Booth Exhibitor 



Booth 



N 



J.B. Lippincott Company 115 

J.H. Emerson Company 1150 

Johnson Enterprises, Inc 951 

Jones Medical 306 

K 

Kaiser Permanente 24 1 

King Systems Corporation 444 & 446 

Kirk Specialty Systems 650 

L 

Laboratory Data Systems 1346 & 1348 

Laerdal Medical 515 

Lambda Beta Society 1446 

LeMans Industries Corporation 246 

LIFECARE International, Inc 219 

Linear Tonometers, Inc 1419 

Liquid Carbonic 712 & 714 

M 

Maginnis and Associates 847 

Mallinckrodt Medical, Inc 1037 

Marquest Medical Products. Inc 608, 610, 612, 614 

Marquette Electronics 1149 & 1151 

Martell Medical Products, Inc 622 & 624 

MBNA Marketing Systems, Inc 250 

Medical Data Electronics 512 & 514 

Medical Graphics Corporation 1 129 

Medical Plastics Laboratory, Inc 449 

Medical Taping Systems, Inc 1249 

MEDIQ/PRN Life 

Support Services, Inc 525 & 527 

MediServe Information Systems, Inc 1019 

Medisonic USA, Inc 230 

MedRehab Incoiporated 1411 

Mercury Medical 236 & 238 

MES, Inc 206 

Michigan Instruments, Inc 747 & 749 

Micro Medical Limited 101 

MMCA/Misty Ox 433 

Monaghan Medical Corporation 813 

Mosby 214 

MSA 504, 506, 508 

MultiSPIRO, Inc 1423 



NASCO 1438 

National Board for Respiratory 

Care. Inc 1443 & 1445 

National Center for Home 

Mechanical Ventilation 1449 

National Safety Technologies. Inc 1429 

Nellcor Incorporated 329 

Newport Medical 

Instruments, Inc 919, 921, 923, 925 

Nicolet Biomedical. Inc 1241 & 1243 

Nidek Medical Products, Inc 1250 

NMC Homecare 232 

Nolato Medical 346 

Nonin Medical, Inc 401 & 403 

NOVA Biomedical 149 & 151 

Nova Health Systems. Inc 1244 

Nova-VentRx. Inc 1305 

Novametrix Medical Systems. Inc 1 137 

Nth Systems. Inc 548 & 550 

Nutec Medical Products. Inc 147 

O 

Ohmeda 719 

Omni-Tech Medical. Inc 1347 

Omron Healthcare. Inc 1342 

Ottawa University Kansas City 510 

Oxigraf. Inc 946 

P 

RK. Morgan Instruments. Inc 1018 & 1020 

Palco Laboratories 945 

Pall Biomedical Products Company 711. 713. 715 

PARI Respiratory Equipment. Inc 342 

Passy-Muir. Inc 1 146 

Peace Medical. Inc 226 & 228 

Pegasus Research Corporation 202 

PeiTy Baromedical Corporation 1 145 & 1 147 

PHI Enterprises, Inc 243 

Phoenix Diagnostics. Inc 1412 

PPG Biomedical-Sensors 931 & 933 

Precision Medical. Inc 949 

Presbyterian Hospitals of New Mexico 347 

Primedica 211 

Pro-Tech Services 1421 

Professional Medical Products, Inc 810 & 812 



1122 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1 



CONVENTION EXHIBITORS 



Exhibitor 



Booth Exhibitor 



Booth 



ProMed Pharmacies 1 044 

Pryon Corporation 245 & 247 

Pulmo-Dose, Inc 1413 

Pulmonary Data Service 

Instrumentation, Inc 1047 

Pulmonox Research & Development 1247 

Puritan-Bennett Corporation 700 

Q 

Quinton Instrument Company 819&918 

R 

R. Lewis, Inc 1049 

Radiometer America, Inc 1101 

RCS Health Care Services 851 

Res Care, Inc 1440 & 1442 

Resp-I-Care 349 

Respiflow & Affiliates 1248 

Respironics, Inc 1 109 

RFB Technologies 212 

RNA Medical 409 & 41 1 

Ross Products Division 

Abbott Laboratories 1014 

Rusch, Inc 201 

Rx Concepts 129 

S 

S & M Instruments Company 1010 & 1012 

Salter Labs 519 & 521 

Scandipharm, Inc 242 

Schiller America, Inc 208 

Sechrist Industries, Inc 423 

Selco Products Company 127 

SensorMedics Corporation 625 

Seven Harvest International 348 

Sherwood Medical 220 & 222 

Siemens Medical Systems, 

Electromedical Group 537 

Smiths Industries Medical Systems, Inc 1213 

Sontek Medical, Inc 1303 

SpaceLabs Medical, Inc 123 & 125 

Stackhouse Incorporated 107 

Summit Interactive Software 344 

Superior Healthcare 1051 

Superior Products, Inc 1436 

Support Systems International, Inc 225 

Synectics Medical, Inc 145 



Tamarac Systems Corporation 751 

TECME S.A 451 

Teledyne Brown Engineering- 
Analytical Instruments 927 & 929 

Telefactor Corporation 244 

Tenet Information Services, Inc 1030 & 1032 

3M Pharmaceuticals 210 

Thumbprint Solutions, Inc 131 

Total Medical Sales, Inc 1439 

Transitional Hospitals Corporation 947 

Transtracheal Systems, Inc 1022 & 1024 

Tri-Medical Supply, Inc 248 

U 

University Hospital Consortium 1430 

University of Rochester Medical Center-NY 647 

University of Texas Medical Branch 340 

University of Virginia Health Sciences Center 350 

V 

Vacumed 1008 

Vital Signs, Inc 837 

Vitalog Monitoring, Inc 1048 

Vitalograph, Inc 1237 & 1239 

Vitaltrends Technology, Inc 651 

VORTRAN Medical Technology, Inc 848 

W 

W.B. Saunders Company 218 

W.T. Farley, Inc 237 

Warren E. Colhns, Inc 1001 

Washington Hospital Center-DC 1405 

Wave Energy Systems, Inc 1433 

Western Medica 531 & 533 

Western Michigan University 1448 

Westmed, Inc 141 

Williams & Wilkins/Medi-Sim 119 

Y 

Yale New Haven Hospital-CT 1415 

Z 
Zymed Medical Instrumentation 1028 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 11 



1123 



1995 Call for Abstracts 



Respiratory Care • Open Forum 



The American Association for Respiratory Care and its sci- 
ence journal. Respiratory Care, invite submission of brief 
abstracts related to any aspect of cardiorespiratory care. The 
abstracts will be reviewed, and selected authors will be invit- 
ed to present papers at the OPEN FORUM during the AARC 
Annual Meeting in Oriando. Florida, December 2-5, 1995. 
Accepted abstracts will be published in the November 1995 
issue of Respiratory Care. Membership in the AARC is 
not necessary for participation. 

SPECIFICATIONS— READ CAREFULLY! 

An abstract may report ( 1 ) an original study, (2) the evalua- 
tion of a method or device, or (3) a case or case series. 

Topics may be aspects of adult acute care, continuing 
care/rehabilitation, perinatology/pediatrics, cardiopulmonary 
technology, health-care delivery. The abstract may have 
been presented previously at a local or regional — but not na- 
tional — meeting and should not have been published previ- 
ously in a national journal. The abstract will be the only evi- 
dence by which the reviewers can decide whether the author 
should be invited to present a paper at the OPEN FORUM. 
Therefore, the abstract must provide all important data, find- 
ings, and conclusions. Give specific information. Do not 
write such general statements as "Results will be presented'" 
or "Significance will be discussed." 



Abstract Format and Typing Instructions 

Accepted abstracts will be photographed. First line of abstract 
should be the title in all capital letters. Title should explain 
content. Follow title with names of all authors (including cre- 
dentials), in.stiaitions(s), and location. Underline presenter's 
name. Type or electronically print the abstract single spaced 
in the space provided on the abstract blank. Insert only one 
letter space between sentences. Text submission on diskette is 
encouraged but must be accompanied by a hard copy. 
Identifiers will be masked (blinded) for review. Make the ab- 
stract all one paragraph. Data may be submitted in table form 
and simple figures may be included provided they fin within 
the space allotted. No figures, illustrations, or tables are to be 
attached to the abstract form. Provide all author information 
requested at the bottom of abstract form. A cleai" photocopy of 
the abstract may be used. Standard abbreviations may be em- 
ployed without explanation. A new or infrequently used ab- 
breviation should be preceded by the spelled-out term the first 
time it is used. Any recurring phrase or expression my be ab- 
breviated if it is first explained. Check the abstract for (1) er- 
rors in spelling, grammar, facts, and figures; (2) clarity of lan- 
guage; and (3) conformance to these specifications. An ab- 
stract not prepared as requested may not be reviewed. 
Questions about abstract preparation may be telephoned to 
the editorial staff of Respiratory Care at (214) 243-2272. 



Essential Content Elements 



Deadline Allowing Revision 



An original study abstract must include ( 1 ) Introduction: 
statement of research problem, question, or hypothesis; (2) 
Method: description of research design and conduct in suffi- 
cient detail to permit judgment of validity; (3) Results: state- 
ment of research findings with quantitative data and statisti- 
cal analysis; (4) Conclusions: interpretation of the meaning 
of the results. A method/device evaluation abstract must 
include ( 1 ) Introduction: identification of the method or de- 
vice and its intended function; (2) Method: description of 
the evaluation in sufficient detail to permit judgment of its 
objectivity and validity; (3) Results: findings of the evalua- 
tion; (4) Hxperience: summary of the author's practical ex- 
perience or a lack of experience; (5) Conclusions: interpre- 
tation of the evaluation and experience. Cost comparisons 
should be included where possible and appropriate. A case 
report abstract must report a case that is imcommon or of 
exceptional teaching/learning value and must include ( 1 ) pa- 
tient data and case summary and (2) significance of case. 
Content should reflect results of literature review. The au- 
thor(s) should have been actively involved in the case and a 
case-managing physician must be a co-author or must ap- 
prove the report. 



Authors may choose to submit abstracts early. Abstracts re- 
ceived by March 1 5 will be reviewed and the authors notified 
by April 22. Rejected abstracts will be accompanied by a 
written critique that should in many cases enable authors to 
revise their abstracts and resubmit them by the fmal deadline 
(May 27). 

Final Deadline 

The mandatory Final Deadline is May 27 (postmark). 
Authors will be notified of acceptance or rejection by letter 
only — to be inailed by August 15. 

Mailing Instructions 

Mail (Do not fax!) 2 clear copies of the completed abstract 
form and a stamped, self-addressed postciud (for notice of 
receipt) to: 

Respiratory Care Open Forum 

11 030 Abies Lane 

Dallas, TX 75229-4593 



124 



RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1 



1995 Respiratory Care Open Forum 

Abstract Form 



13.9 cm or 5.5" 



1 . Title must be in all upper 
case (capital) letters, 
authors' full names and 
text in upper and lower 
case. 

2. Follow title with all 
authors' names including 
credentials (underline 
presenter's name), institu- 
tion, and location. 

3. Do not justify (ie, do 
leave 'ragged' right 
margin). 

4. Do not use type size less 
than 10 points. (See 
reduction samples 
below.) 

5. All text, tables, and 
figures must fit into the 
rectangle shown. 

6. Submit 2 clean copies. 
This form may be photo- 
copied if multiple 
abstracts are to be 
submitted. 



Mail original & 

1 photocopy 

(along with postage-paid 

postcard) to 

Respiratory Care 
Open Forum 

11030 Abies Lane 
Dallas TX 75229-4593 



Early deadline is 

March 15. 1995 

(abstract received) 

Final deadline is 

May 27. 1995 

{abstract postmarked) 



Presenter's Name & Credentials 



Presenter's Mailing Address 



Presenter's Voice Phone & Fax 



Corresponding Author's Name & Credentials 



Corresponding Author's Mailing Address 



Corresponding Author's Voice Phone & Fax 



This is 14-point type, with 
necessary reduction. 

This is 1 2-point type, with 
necessary reduction. 

This is 10-pointtype, 
with necessary reduction. 



Calendar 
of Events 



Not-for-profil organizations are offered a free advertisement of up to eight lines to appear, on a space-available basis, in Calendar of Events in 
RE,SP!RAT0RY Care. Ads for other meetings are priced at $5.50 per line and require an insertion order. Deadline is the 20th of the month two 
months preceding the month in which you wish the ad to run. Submit copy and insertion orders to Calendar of Events. RESPIRATORY CARE. 
1 1030 Abies Lane, Dallas TX 75229-4593. 



AARC & AFFILIATES 

December 9 in Las Vegas. Nevada. The AARC and its 

Board of Medical Advisors present a postgraduate course 
for medical directors and other physicians the day before 
the Annual Meeting, The program is approved for 6 
Category I credit hours of the Physician's Recognition 
Award of the American Medical Association, Lecture 
topics include ethical dilemmas in the ICU. TB as an 
occupational hazard, cost-effective management of criti- 
cal illness, and all aspects of providing respiratory care by 
protocol. Contact the AARC at (214) 243-2272 or fax 
(214) 484-2720 to request that a complete course descrip- 
tion and registration form be sent to your medical director 
or other interested physician, 

December 10-13 in Las Vegas, Nevada. The AARC pre- 
sents its 40th Annual Convention and Exhibition, "A New 
Vision," at the Las Vegas Convention Center. For infomia- 
tion, contact the AARC at (214) 243-2272, fax (214) 484- 
2720. 

February 14-17, 1995 in Reno, Nevada. The NSRC and 
the American Lung Association of Nevada present the 14th 
Annual High Sierra Critical Care Conference at the Pepper- 
mill Hotel/Casino. The 4-day conference covers critical care 
topics in adult, pediatric, and neonatal medicine. Contact 
Colleen Banghart, American Lung Association of Nevada, 
PO Box 7056, Reno NV 89510, 

March 12-15, 1995 in Denver, Colorado. The AARC 

and the National Jewish Center for Immunology and 
Respiratory Medicine announce the call for abstracts for 
the 5th International Conference on Pulmonary Rehabil- 
itation and Home Ventilation at the Hyatt Regency Hotel, 
The abstract deadline for poster/oral presentations on 
original research/clinical observations is Nov 30, 1994, 
Pre- and post-conference postgraduate workshop topics 
include pulmonary rehabilitation, home ventilator care, 
respiratory sleep disorders, nicotine dependency treat- 
ment, and transtracheal oxygen. The program is endorsed 
by the American College of Chest Physicians; program 
chairman is Barry Make MD, Contact the National 
Jewish Office of Professional FAlucatit)n at (303) 398- 
1000, 

OTHER MEETINGS 

November 18-21 in New Orleans, Louisiana. The 

American .Speech-Langiiagc-Hearing Association pre- 



sents Its annual meetmj: 
mation. 



Call (301 ) 897-5700 for infor- 



November 18-22 in Atlanta, Georgia. The Gerontolog- 
ical Society of America presents its annual meeting. Call 
(202) 842-1275 for information. 

November 30-December 1 in Washington, District of 
Columbia. The Bureau of Health Professions. Depart- 
ment of Health and Human Services, hosts its national 
conference, "Multiskilling and the Allied Health Work- 
force," at the Key Bridge Marriott, Featured topics 
include education and training models; multiskilling and 
patient-centered care systems; restrictions to practice; 
competency assessments; and state initiatives and strate- 
gies. Registrants receive the white papers written on con- 
ference topics in a pre-conference mailing. For a 
conference brochure and registration form, fax your 
name and address to Lana Phillips, Continuing Education 
Coordinator, Allied Health Education Center, Methodist 
Hospital, Indianapolis IN, at (3 1 7 ) 929-2 1 02 or call her at 
(317) 929-8925 with questions about registration and 
hotel reservations. For information on speakers and the 
program, contact Sherry Makely at (317) 929-3282 or fax 
(317)929-2102, 

February 5-8, 1995 in Breckenridge, Colorado. The 

American College of Chest Physicians sponsors "Cardio- 
pulmonary Wellness and Rehabilitation" at The Village 
at Breckenridge Resort, Contact Arlene Karavich, 
American College of Chest Physicians, 3300 Dundee Rd. 
Northbrook IL 60062-2348, (708) 498-1400, 

April 1-7, 1995 in Miami, Florida. The Ventilation 
Assisted Children's Center (VACC) of the Division of 
Pediatric Pulmonology in Miami Children's Hospital 
hosts its annual VACC Camp for ventilation assisted 
children and their families. The program includes 
swimming, field trips, structured games, and campsite 
entertainment. The campsite, the Leisure Access 
Center at metro Dade county's AD Barnes Park, is a 
handicapped-accessible urban park located 2 miles 
from the hospital. Medical staff and equipment are 
available 24 hours-a-day. Contact Cathy Klein, 
VACC Program Coordinator, Division of Pediatric 
Pulmonology, Miami Children's Hospital, Suite 203, 
3200 SW 60 Court, Miami FL 33 155-4076, (305) 662- 
VACC, 



1126 



RESPIRATORY CARE • NOVEMBER "94 Vol 39 No 1 1 





-rr 






American 






Association 






for 






Respiratory 






Care 











The AARC Human 
Resources Survey: 
A Study of 
Respiratory Care 
Human Resources 
in Hospitals 

Covers a wide range of human resource 

issues, including compensation, number 

of full-time equivalents, job vacancy 

rates, education, credentialing, and 

licensure. Even includes information on 

age, sex, and years of experience. Includes comprehensive summary, 

position profiles, salaries, education, experience, credentials, and regiona 

demographics. Vacancies are inventoried. 68 pages, 66 tables. 

Item BK12 J35 ($50 nonmembers) 



A Study of 
Chronic Ventilator 
Patients in the 
Hospital 

chronic ventilator-dependent patients 
are costing American hospitals more 
than $9 million per day according to 
this Gallup study conducted for the 
AARC, This important study provides 
information on patients who depend on 
life-support systems; why, how, and 
where they are being treated; and the 
cost of treatment. 47 pages, 9 tables, 12 
figures. 
Item BK20 $25 ($50 nonmembers) 

A Study of 
Respiratory Care 
Practice 

This study examines the practice of 
respiratory care in today's health care 
environment and how hospital 
reorganization is affecting the 
profession. Includes chapters on medical 
direction, current respiratory care 
services, nontraditional services, 
respiratory care protocols, and hospital 
service reorganization. 38 pages, 
34 tables, 15 charts. 
Item BK1 7 $20 ($40 nonmembers) 







■~™rf- 




American 




Association 




for 




Respiratory 




Care 









American 
Association 

for 

Respiratory 

Care 



Policy & 

Procedure 

Manual 



Policy and 
Procedure 
Manual 

Save time and money by 

making your department 

more efficient with the 

Policy and Procedure 

Manual. Its 130 pages of 

policies and procedures 

cover the aspects of 

administrative and clinical 

respiratory care for both 

adult and pediatric practice. 

Sections on administrative 

policies, therapeutics, clinical 

monitoring, and mechanical 

ventilation. Standardized formats include objectives, indications, 

equipment, policies, contraindications, troubleshooting, procedures, 

hazards, and assessment of effectiveness. 

Item BK6 $60 ($70 nonmembers) 



Respiratory 
Home Care 
Equipment 




Respirator)' Home Care 

Equipment exclusively 

covers home care 

equipment with practical 

applications and charts on 

oxygen concentrators, 

liquid units, air 

compressors, and home 

care ventilators. An 

invaluable book for the 

home care practitioner and 

equipment technician. 

Details home care devices, 

cleaning, disinfecting, and 

monitoring procedures to 

minimize infection. Includes guides for educating staff on 

equipment, therapy, patient assessment, and safetv. Features 

procedures for gas administration and monitoring devices, 

humidifiers and nebulizers, artificial airways and resuscitators, 

respirators, and ventilators. By Steven P. McPherson. Hardcover, 

192 pages, 141 illustrations, 6 tables. 

Item BK7 $9 ($12 nonmembers) 



Orders with credit cards or P.O. numbers may call 
(214) 243-2272, or Fax to (214) 484-2720. 
If ordering by mail, send coupon to: 
AARC Order Department, 11030 Abies Lane, 
Dallas, Texas 75229-4593. 



V two days for order processing for regular and express slitpping. Addresses o 



con(/nen(d/ U S require an additional S5foro 

Order Total UPS Reg. 



^upto SrOO. add S10 for oncers a 



UPS 2nd Day 

600 



UPS Next Day 

14.00 



$16 to $30 


3.75 


8,00 


18.00 


$31 to $50 


4.50 


11.00 


24.00 


$51 to $75 


5.50 


13.00 


31.00 


$76 to $100 


7.00 


16.00 


38 00 


$101 to $125 


8.00 


19.00 


50.00 


$126 to $150 


10.00 


22.00 


60 00 



D Please send 
Item 



me the items I have Indicated below. 

Description Quantity 



Price Eacfi Total Price 



Ship via UPS n Regular d 2nd Day d Next Day 
Please use the chart to the left to calculate shipping. 

D Check or Money Order enclosed payable to the AARC 
D Bill me, my RO. No. is . 



Shipping, 
Merchandise 
TOTAL _ 



D Charge to my n Visa d MasterCard 

Card # Exp. Date Signature ><_ 

AARC Member # Name 

Institution 

Address City/State/Zip 



Authors 

in This Issue 



Anderson, Susan M 1039 

Chappell, Timothy R 1057 

Chathurn. Robert L 979 

Gleaton, Loretta D 1051 

Ilowite. Jonathan S 1047 



hvin. Charles G 1057 

Langenback, Edward G 1047 

Ognibene, Frederick P 1051 

Perry, Robert J 1047 

Picca, Stephen M 1058 



Advertisers 
in This Issue 



Allen & Hanburys 1031, 1032, 1033 

Automatic Liquid 1079 

Baxter Healthcare Coip 1069 

Bear Medical Systems 1081 

Ceramatec 1020 

Chad Therapeutics 1071 

CNS 1023 

DHD Diemolding Healthcare Div 1018, 1077 

Driiger Critical Care Cover 3 

Fisher & Paykel 1029 

HealthScan Products Inc 1036, 1037 

HR Incorporated 1028 

Impact Instrumentation 1065 

Int'rasonics 1035 

J B Lippincott 1033 



Lifecare 1087 

Medical Graphics 1089 

Mercury Medical 1030 

Michigan Instruments 1026 

Monaghan Medical 1074, 1075 

Nellcor 1025, 1066 

Newport Medical 1091 

Nonin Medical 1093 

Passy Muir Cover 2 

Pedipress Inc 1034 

Puritan-Bennett Corp 1095 

Radiometer America 1097 

Respironics 1024, 1105 

Sechrist Industries 1098 

Sherwood Medical Cover 4 




American Association for Respiratory Care 

40th Annual Convention and Exhibition 

December 10-13, 1994 • Las Vegas, Nevada 



RESPIRATC^RY CARH • NOVHMBKR '94 Vol 39 No 



ror raster service, 

your reader service card 

to (609) 786-4415 



81 AARC 

Membership Information 

82 Respiratory Care 
Subscription Information 

112 Allen & Hanburys 

Serevent 

113 Automatic Liquid 

Interchangeable Reservoirs 

114 Baxter Healthcare Corp 
Peak Flow Meter 

115 Bear Medical Systems 

Bear 1000 Ventilator 

116 Ceramatec 

Oxygen Analyzer 

117 Chad Therapeutics 

Portable Oxygen 

118 CNS 

CIMSSIeepLablOOOP 
94 DHD 

Incentive Spirometer 

111 DHD 

MDI Spacer 
101 Drager 

Ventilator 

128 Fisher & Paykel 

Humidifiers 

129 HealthScan Products 

Peak Flow Meter 

114 HR Incorporated 

Sterilization Equipment 
96 Impact Instrumentation 

Portable Ventilator 

120 Infrasonics 

Star Ventilator 

126 J B Lippincott 

Books 

150 Liiecare 

PLV-100 



141 



Medical Graphics 

Prevent Pneumotach 



95 Mercury Medical 

CPR Bag 

121 Michigan Instruments 

PneuView Testing & Training 
Systems 

122 Monaghan Medical 
Peak Flow Meter 

123 Nellcor 
Sensors 

148 Nellcor 

UltraCap Monitor 

151 Newport Medical 
Ventilator 

152 Nonin Medical 

Pulse Oximeter 

145 Passy Muir 

Tracheostomy & Ventilator 
Speaking Valve 

124 Puritan-Bennett Corp 

7200 Series Ventilator 
127 Radiometer America 

ABL System 620 

125 Respironics 

Disposable Resuscitator 

139 Respironics 
Recruitment 

140 Sechrist Industries 
Synchrony System 

134 Sherwood Medical 

Pulmonary Function/Ventilation 
Monitor 



RE/PIRATORy CMS 

Expires February 28, 1995 



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J^ 



Information Requests or 
Change of Address 



Tvpe <jf tnstn/Pracllce 

J Hosp ? SOO or more beds 

■ J Hosp 300 to 499 beds 
; J Hosp 200 to 299 beds 

-1 Hosp 1 00 TO 199 beds 

> J Hosp < TOO Of less bed 

> J Skilled Nursing Facility 
J Home Care Praclioe 

i JSctTOOl 

I Oepartmeni 

h J Respiratory Therapy 

I J Cardiopulfnonarv 

y -J Anesttiesia Service 
3 ^ Emergency Oept 

II Speciatty 

J Clinical Practice 
! J Perinatal Pediatrics 
1 J Critical Care 

■ J Clinical Research 

I -J Pulmonarv Function Lab 

I _1 Home Care/Rehab 

' -1 Education 

I J Management 

V Posilion 

k J Dept Head 

i J Chief Therapist 

; J Supen/isor 

) J Staff Technician 

■ J Staff Therapist 
- J Educator 

3. J Medical Director 
< J Anesthesiologist 

■J Pulmonologist 
I JOlherMO 
i J Nurse 
f. Are you a member of the AAHC^ 

J Yes 2 J No 



Type ot tnsin/Practice 
J Hosp > 500 Of more beds 
' J Hosp 300 to 499 beds 
; J Hosp 200 to 299 beds 

■ J Hosp 100 to 199 beds 

> J Hosp < 100 or less bed 
. J SVilled Nursing Facility 

J Home Care Pradice 
; J School 

Department 
I .J Respiratory Tlierapy 
1 J Cardiopulmonary 
; O Anesthesia Service 
) iJ Emergency Oept 
I Specialty 

J Clinical Practice 
' J Pennatai Pediatncs 
; J Critical Care 

J Clmical Research 
. J Pulmonary Function Lab 

> J Home Care/Rehab 
J Education 

1 J Management 
*/ Position 
k J Dept Head 
i J Chief Therapist 
; J Supervisor 
) J Staff Technician 
; J Staff Therapist 

■ J Educator 

» J Medical Director 
\. -J Anesthesiologist 

Q Pulmorwtogist 
, J Other MD 
: J Nurse 
'. Are you Q member o4 the AA 

J Yes 2 J No 



Please complete the card below 

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11030 ABLESLN 
DALLAS TX 75229-4593 



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CPAP 



Always 

A Step Ahead! 

Evita makes work of breathing 
even easier! 



0.5 t(s) 



Occlusion-pressure 



10= ■ I. 

1 2 



Intrinsic PEEP 



Now Drager provides you with two more 
powerful tools to optimize weaning of your 
patients. 

Introducing Flowtrigger without increase of 
expiratory resistance, combined with P01 
measurement to determine the patients 
ventilatory drive. 

To extend monitoring capabilities Evita now 
includes the ability to measure Intrinsic 
Peep with the display of Trapped Volume. 

With Drager you can stay one step ahead in 
providing safe, patient friendly ventilation. 
For the difference your patients can feel, 
choose... 

Drager: Technology for Life 




Drager 

Technology for life 

4101 Pleasant Valley Road Suite 100 Chantilly, VA 22021 
Tel (703) 817-0100 Fax (703) 817-0101 

Circle 101 on reader service card 

Visit AARC Booths 1336, 1337, 1338 and 1339 in 

Las Vegas 



RESPIRADYNE^n 

•* -^ [PLUS 

PULMONARY FUNCTION/VENTILATION MONITOR 
''' ^aphic Printouts... Multi-Patient Memory.. .and Easy to Use 



Results-Oriented Features At Cost Effective Prices 

■ New Graphic Forced Vital Capacity (FVC) document printout of Flow vs Volume and 
Volume vs Time ■ New 10 patient memory with 8 pre-bronchodilator and 8 post- 
bronchodilator tests per patient and automatic calculation of % change ■ New customizing 
software package ■ New Slow Vital Capacity (SVC) monitoring ■ Automatic determination 
of "best test" ■ Knudson, ITS and ECCS reference nomograms ■ Easy to operate 




Performs A Complete Range Of Test IVleasuremeni,;* 

Forced Exhalation Parameters 

■ Forced Vital Capacity (FVC) ■ Forced Expiratory Volume in One Second (FEV,) 

■ FEV, /FVC Ratio ■ FVC Time ■ Peak Flow ■ Forced Expiratory Flow Between 25% 
and 75% of Vital Capacity (FEE 2S.75,,) ■ Percent Extrapolated Volume (Vol. ^xtra*) 

Weaning/ Extubation Parameters 

■ Respiratory Hate (RR) ■ Tidal Volume (TV) ■ Minute Volume (MV) ■ Slow Vital 
Capacity (SVCl ■ Maximum Voluntary Ventilation (MVV) ■ Negative Inspiratory 
Force (NIF) 



For further information, call: 



1-800-325-7472 (outside Missouri) 



1-800-392-73 18 (in Missouri) 



ik Sheriuood 

^^ MEDICBL 



Circle 134 on reader service card 
Visit AARC Booths 220 and 222 In Las Vegas