Skip to main content

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

See other formats

October 1996 
Volume 41, Number 10 

ISSN 0020-1 324-RECACP 



42""' International Convention & Exhibition 
November 3-6 • San Diego, California 


The Journal at 40: Over the Hill? 

Inspiratory Effort during Pressure 
Support Ventilation 

Evaluation of a Porlable Pressure 
Support Ventilator 

NO Delivery in High-Frequency Jet 

Special Article 

Respiratory Assessment & Decreased 
ICU Mortality 

1 996 Open Forum Abstracts 

Understand. Adapt. Prosper. 



*• • 

at the American Association 
for Respiratory Care^ 
42nd International 
Convention and Exhibition 

November 3-6 in San Dieqo, CA 
(Sunday through Wednesday) 

A comprehensive overview of the latest in technology, clinical 
advancements, governmental issues, and health care reform — 
all geared specifically for the respiratory care practitioner. 

Look for the program and registration information in the 
August issue of AARC Times. 

Shiley Announces Something Really New In 
Neonatal And Pediatric Tracheostomy Tubes. 

Product Gentleness. 

1- \ - 





The special anatomy of infants 

requires special care. 

New Shiley Neonatal and 

Pediatric TYacheostomy Tlibes 

are designed precisely for 

the delicate tracheal tissue 

of infants. The tuhes are pre- 
cision-crafted of softer, more 
flexible material that becomes pliant at body temperature while 
maintaining shape. Newly designed tie strap holes make changing 
straps easier, and a softer, flexible flange Improves patient 
comfort. Below the connector is a beveled, recessed area which 
is designed to reduce stoma irritation. Improve healing and allow 
more effective cleaning. The connector Itself is longer, too, helping 
to ensure a secure connection to respiratory devices. Sizing 
conforms to international standards. 

Circle 154 on reader service card 
Visit AARC Booth 901 in San Diego 

Shiley Neonatal and Pediatric Tt'acheostomy 1\]bes are 
available In various sizes and lengths to provide greater selection 
and better fit. The Neonatal model has a lower flange angle for a 
more comfortable fit. 

Each Tlibe is packaged In a sterile barrier tray that Is clearly 
marked with size, product designation and lube diameter. Cartons 
are color-coded. 

For more Information about Shiley Neonatal and Pediatric 
TV'acheostomy Tlibes. the only tubes with l)uilt-ln gentleness, call 

Now available in long pediatric and 
pediatric cuffed styles 













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


60 70 


Compare Unl-Vent to any other portable 
ventilator and you will quickly see why 
the Model 750 is In a class by Itself.* 





• Control, Assist-Control and SIMV operating modes, 
optional electronic demand valve - ail PEEP compensable! 

• Comprehensive alarm system and automatic continuous system 
self-checks for maximum safetyl 

• Easy-to-operate, logical control groupings, simplify personnel trainingi 

• Operates from internal battery or external power - consumes no gas! 

• High-reliability, electronic circuitry is unaffected by changes in altitude 

Circle 115 on reader service card \ 

Visit AARC Bootti 822 in San Diego 

For more information on the Uni-Vent^'^ Model 750, or the name of your local Representative, call Impact today! 
IMPACT Instrumentation, Inc., 27 Fairfield Place, P.O. Box 508, West Caldwell, NJ 07006 1-800/969-0750 


A Monthly Science Journal. Hsiablished 19S6. Official Journal of the American Association for Respiratory Care 

Contents ... 


Pat Brousher BA RRT 

Managing Editor 

Ray Masferrer BA RRT 


James K Stoller MD, Chairman 

Cleveland Clinic Foundation 

Cleveland, Ohio 

Richard D Branson RRT 

University of Cincinnati 

Medical Center 

Cincinnati, Ohio 

Crystal L Dunlevy EdD RRT 
Atlanta, Georgia 

Charles G Durbin Jr MD 

The University of Virginia 

Health Sciences Center 

Charlottes\ille, Virginia 

Thomas D East PhD 

LDS Hospital 

University of Utah 

Salt Lake City, Utah 

Dean R Hess PhD RRT 

Massachusetts General Hospital 

Harvard Medical School 

Boston. Massachusetts 

Neil R Maclntyre Jr MD 

Duke University Medical Center 

Durham, North Carolina 

Shelley C Mishoe PhD RRT 

Medical College of Georgia 

Augusta, Georgia 

Joseph L Rau PhD RRT 

Georgia State University 
Atlanta. Georgia 

October 1996 
Volume 41, Number 10 


878 The Journal at 40: Over the Hill? 

by Pat Brougher — Dallas. Texas 

Original Contributions 

880 Regulation of Pressurization Rate Reduces 
Inspiratory Effort during Pressure Support 
Ventilation; A Bench Study 

by Massimo Croci, Paolo Pelosi. Davide Chiumello. and 
Luciano Gattinoni — Milan. ludx 

885 Evaluation of the Puritan Bennett 335 Portable 

Pressure Support Ventilator: Comparison with the 
Respironics BiPAP S/T 

by Nicholas S Hill. Sangeela Mehta. Carol C Carlisle, and F 
Dennis McCool — Providence. Rhode Island 

895 Inhaled Nitric Oxide Delivery with High-Frequency 
Jet Ventilation: A Bench Study 

by Todd W Mortimer. Maiy Cheang. and Carlos A Fajardo — 
Winnipeg, Manitoba, Canada 

Special Article 

903 Establishment of a Respiratory Assessment Team Is 
Associated with Decreased Mortality in Patients Re- 
Admitted to the ICU 

by Elizabeth G Kirby and Charles G Ditrhin Jr — 
Charlottesville. Virginia 

Books, Films, Tapes, & Software 





Clinical Manifestations and Assessment of 

Respiratory Disease 

reviewed b\ Susan Pilbeam — Greenville, South Carolina 

Ste-Anne's Approach to Self-Treatment 

/)v Anne LaRoche — Ste-.\nne-de-Bellevue. Quebec. Canada 

Qualified RCPs in Home Care 

by Hurley R Metcalfe — Liberty. Missouri 
Response by Sam P Giordano — Dallas, Texas 

A Reader Wonders about the Cost of Assessments 

/)v John W Salyer — Salt Lake Cir\: Utah 
Response by Kevin L Shrake — Springfield. Illinois 

Respiratory Care • October "96 Vol 41 No 10 



Most Children Love Baby Bears. 

Others Need Them 

those children in need, fhis is the best Baby Bear. 

Introducing the new BEAR CUB™ 750vs Infant Ventilator with Volume Limit*. Representing the 
evolution of neonatal/pediatric ventilation, the 750vs incorporates and advances today's essential features 
for the critical care management of newborns. 

The Volume Limit feature establishes on upper boundary for deliverable tidal 
volumes so as to enhance volume management and minimize the potential risks of 
volutrauma (i.e. lung tissue overdistention). Volume Limit is an objective guidance 
tool exclusive to the 750vs. 

Comprehensive in its approach, the 750vs provides integrated synchrony and volume monitoring, dual flow 

capability, an internal battery back-up, and a graphics package inclusive of mechanics for patient monitoring. 

Call 1-800-232-7633 to arrange o product demonstration. 

Circle 1 18 on reader service card 

Visit AARC Bootti 601 in San Diego 
BEAR CUB 750vs 

Raising the Standard of Care with Unparalleled Value.™ 

2085 RUSTIN AVE,, RIVERSIDE, CA 92507-2437 
•U.S. Patent No. 5,540,220 

800-232-7633 / 909-788-2460 / (Fax) 909-351-4881 http://www,alliedfipi,com 

Assistant Editor 

Kris Williams BA 

Editorial Assistant 

Linda Barcus BBA 

Production Coordinator 

Karen Singleterry BS 

Section Editors 

Robert R Fluck Jr MS RRT 
MS Jastremski MD 
Blood Gas Corner 

Hugh S Mathewson MD 
Drua Capsule 

Richard D Branson RRT 

Robert S Campbell RRT 

Kiuredge's Corner 

Charles G Irvin PhD 

Jack Wanger MBA RPFT RRT 

PFT Comer 

Patricia Ann Doorley MS RRT 
Charles G Durbin Jr MD 

Test Your Radiologic Skill 

Barbara Wilson MEd RRT 

Jon Meliones MD 

John Palmisano RRT 

Cardiorespiralon. Inleraclions 

Consulting Editors 

Frank E Biondo BS RRT 

Howard J Birenbaum MD 

Robert L Chatburn RRT 

Donald R Elton MD 

Ronald B George MD 

James M Hurst MD 

Robert M Kacmarek PhD RRT 

Michael McPeck BS RRT 

David J Pierson MD 

John Shigeoka MD 

Jeffrey J Ward MEd RRT 


Steve Bowdcn 
Donna Knauf 


Dale Griffiths 

Tim Goldsbury 
Director of Advertising Sales 

Beth Binkley 

Advertising Assistant 

Editorial Office 

11030 Abies Lane 
Dallas TX 75229 
(972) 243-2272 


October 1996 
Volume 41, Number 10 

Historical Note 

912 Reflecting on 40 Years of Respiratory Care: 
AARC International Convention & Exhibition- 


914 1996 Answer Key 

Open Forum Abstracts 1996 

915 Introduction 

916 1996 Abstracts 
960 Author Index 

AARC International Convention & 

964 Convention Exhibitors 


894 Attribution of the Classification of Air Leaks 

Chatburn RL. Vol.sko TA. El-Khatih M. Respir Care 

In This Issue 

981 AARC Membership Application 

863 Abstracts from Other Journals 

984 Advertisers Index & Help Lines 

984 Author Index 

983 Calendar of Events 

977 Call for OPEN FORUM Abstracts 

972 Manuscript Preparation Guide 

979 MedWatch 

970 New Products & Services 

968 Notices 

Respiratory CareiISSN (K)2()-L^24) ispuhlishoJ numihK hy Daedalus hnterpnses Inc, at I 1030 Abies Lane. 
Dallas TX 75229-459?. for the Amencan Assttiation for Respiratory Care, One volume is published per year beginning 
each January. Subscription rates are $65 per year in the US; $80 in all other countries (for airmail, add $84). 
The contents of the Journal are indexed in Hospital and Health Administration Index, Cumulative Index to 
Nursing and Allied Health Literature, and Excerpta Medicu. Abridged versions of RESPIRATORY Care are also 
published in Italian and Japanese, with permission from Daedalus Enterprises Inc. 

Periodicals postage paid at Dallas TX. POSTMASTER: Send address changes to Respiratory Care. Membership 
Office. Daedalus Enterprises Inc. 1 1030 Abies Lane. Dallas TX 75229-4593. 

Copyright © 1996. hy Daeduhts Enlei prises inc. 

Respiratory Care • October '96 Vol 41 No 10 


Respiratory Equipment 


I Full range of portable 
ventilators, including 
positive & negative 

I 28 years of experi- 
ence in invasive 
and noninvasive 

I Clinical expertise 
vi^herever you need it 

I Free consultation 
from any of our 40 
respiratory therapists 
on staff 

I Local 24-hour 
service from 18 
US District Offices 

" ''" ;': ■.'^' - -Vt^i VUbQ Booth .•r&)9.iW Sail p|^:^'^^^^ 

LIFECARE International, Inc. 

1401 W 122nd Avenue 
Westminster, CO 80234-3421 • USA 
800'669-9234 • 303 457-9234 
Fax 303255-9000 


Gewerbeslrasse 1 7 

D-82211 Herrsching • Germany 

49/8152-93060 • Fax 49/8152-930618 

LIFECARE Asia Pacific 

Sales & Service 

Rilz Building, Room 1509 

Mongkok, Kowloon • Hong Kong 

852/2771-1886 • Fax 852/2770-7557 



Respiratory Equipment 

Summaries of Perlinenl Anicles in Other Journals 


Editorials, Commentaries, and Reviews To Note 

Systematic Review of Randomised Trials of Interventions To Assist Patients To Follow Pre- 
scriptions for Medications (Re\iew)— RB Haynes. KA McKibbon. R Kanani. Lancci 

Clinical Applications of Nitric Oxide (Review)— T Mizutani. AJ Layon. Chest 1996; 1 in:?(l6-524. 

Panic Aaxiety, Dyspnea, and Respiratory Disease: Theoretical and Clinical Considerations (State 
of the An) — JW Smoller, MH Pollack. MW Otto. JF Rosenbautii. RL Kradin. Am J Respir Cnt Care 
Med 1996;l.'i4(l):6-17. 

The American Lung Association Conference on Rc-Establishing Control of Tuberculosis in 
the United Stales. Washington DC, March 11-13. 1994 (Conference Report)— JH Bates. Conference 
Chairman. Am J Re.spir Crit Care Med 1996;LS4( 1 );25 1-262. 

Evaluation of Instrument Error and Method 
of Agreement — RL Chatbum. AANA Journal 

Safely operating life support equipment and e\ al- 
ualing new technology both require some basic 
understanding of measurement theory. Mea- 
surement errors fall into 2 main categories: sys- 
tematic errors (predictable problems usually due 
to calibration) and random errors (unpredictable). 
These 2 types of errors can be quantified by exper- 
iments involving repeated measurements of stan- 
dards or "true" values. Systematic error (called 
bias) is usually expressed as the mean difference 
between measured and true values. Random error 
(called imprecision ) can be expressed as the stan- 
dard deviation of measured values. Total error can 
be expressed as an error interval, being the sum 
of bias and some multiple of imprecision. An error 
interval is a prediction about the error of some 
proportion of future measurements (eg. 959f ) at 
some level of confidence (eg. 99'7r) based on the 
variability of the sample data and the sample size. 
Specifically, a tolerance interval gives an estimate 
of the true value of some variable given repeated 
measurements with an assumed valid measure- 
ment system. An inaccuracy interval predicts the 
validity of a measurement system with an esti- 
mate of the difference between measured true val- 
ues (given that a standard or true value is avail- 
able for measurement). An agreement interval 
e\ aluates whether or not one measurement sys- 
tem (eg. a known valid system) can be used in 
place of another (eg, a new unknown system ). Sta- 
tistical analyses such as correlation and linear 
regression are commonly seen in the literature, 
but not usually appropriate for evaluation of new 
equipment. Instrument performance evaluation 

studies should start out with a decision about the 
level of allowable error. Next, experiments are 
designed to obtain repeated measurements of 
known quantities (inaccuracy studies) or of 
unknown quantities by two different measurement 
systems (ie. agreement studies). The first step in 
data analyses is to generate scatter plots of the raw 
data for review of validity (eg, outliers). The next 
step is to make sure the data adhere to the assump- 
tion of normality The third step is to calculate basic 
descriptive statistics, such as the mean and stan- 
dard deviation. Finally, the data should be pre- 
sented in graphic form with the differences plot- 
ted against the reference values and including 
numerical values for the calculated error inter- 
vals. The key idea to remember is that device eval- 
uation and method agreement studies are based 
on the desire to know how much trust we should 
place in single measurements that may be used 
to make life support decisions. 

Continuous versus Intermittent .\lbuterol, at 
High and Low Doses, in the Treatment of 
Severe Acute Asthma in .Adults — M Shrestha. 
K Bidadi, S Gourlay, J Hayes. Chest 1996;1 lU 


Adult patients suffering from acute asthma pre- 
senting to the Emergency Department with an 
FEV| of < 40% of predicted were randomized into 
4 treatment groups. They were treated with neb- 
ulized albuterol at a high (7.5 mg) or standard {2.5 
mg) dose given either continuously through I hour, 
or intermittently every hour, for 2 hours. When 
the FEV I improvements for the different groups 
at 2 hours were compared, the groups seated with 
continuous nebulization had the greatest improve- 
ment The improvements ( 1 .07 L for the high-dose 

group, and 1.02 L for the standard-dose group) 
were significantly greater than the improvement 
seen with standard-dose intermittent treatment 
(0.72 L; p < 0.0.5). The iinprovement in FEV] of 
the high-dose, hourly treated group was inter- 
mediate in magnitude between these (0.90 L). 
There was no difference in the improvement seen 
between the 2 groups U"eated with continuous neb- 
ulization. The potassium fall, present in all groups, 
was more pronounced in the groups treated with 
high doses of albuterol. Only 1 person (high dose, 
continuous treatment group) developed hypo- 
kalemia of less than 3.0 mmol/L. The high-dose 
houriy ffeated group had the highest incidence of 
side effects, and the standard-dose continuously 
treated group had the lowest The standard-dose 
continuous-treatment regimen had the greatest 
improvement in FEVi with the least number of 
side effects. 

Results of a Program To Improve the Process 
of Inpatient Care of Adult Asthmatics — PH 

Mavo. BJ Weinberg. B Kramer. J Richman, O 
Seibert-Choi, MJ Rosen. Chest 1996;l 10( I ):48. 

OBJECTrVE; To assess the effectiveness of a pro- 
gram to improve care of adult patients hospital- 
ized for asthma. DESIGN: Retrospective anal- 
ysis of patient and house staff education, patterns 
of medication use, spacer use, peak flowmeter use, 
and length of stay before and after team inter- 
vention. SETTING: A 960-bed teaching hospi- 
tal in New York City. PATIENTS: All patients 
admitted to the hospital with a primary diagno- 
sis of acute asthma exacerbation for 2 separate 
similar calendar periods, I year apart, before and 
after program intervention. We excluded patients 
w ho were hospitalized for less than 24 hours or 



ii . 


'Gerald didii 't expect 
J itch tcuty pickled cabbage and 
we dldn V expect 
juch a boojt to productivity. 

— Jim Hoh Moffi'tt, Chairnuin d/h^ CEO, Fn-c-port-JIcJIoRan 

Freeport-McMoRan's employees do volunteer work. People like 60-year-old Gerald who 
depend on outreach programs are glad they do. So is Freeport-iMciMoRan. EmpIo\ee 
volunteers Feel good about themselves, and improved morale is always good for business. 
You can do tor your emplo\'ees, community and company what Jim Bob Motfett is doing 
for his. The Points oi Light Foundation can help show you how. Call 1-800-888-7700. 


^^ Points of Light 





A four-year-old is iull ot hope. 
That's one of the reasons there's Head 
Start. We give low-income preschool 
children the chance to learn. To be 
healthy. To be happy. 

It's a big job and we need volun- 
teers. Especially skilled professionals 
like you. Come share your special tal- 
ents and interests with Head Start. 
Because if you change the world of a 
child, you change the world. 

Call 1-800-27-STARTfora 
brochure on volunteer opportunities 

with vour local Head Start. 





AARC &Maginnis... 

we've got you covered. 

Maginnis & Associates, administrator of the American Association for Respirator\' Care-endorsed 
insurance plans, offers you low rates with cpmprehensive coverage. 

Disability Income Protection 

Provides your family wilh financial security 
if you are disabled by a covered illness 
or accident. 

Major Medical 

This plan offers up lo $1,000,000 in lifelime 
medical benefits, with comprehensive coverage, your 
choice of deductible options and a Preferred Provider 
Organization (PPO) benefit program. 

Group Term Life with Living Benefits 

Up to 509f of the benefit can be used during 
your lifetime. Living Benefits helps reduce 
the burden of medical expenses. 

The following plans are also available for 
A.\RC members: 

Excess Major Medical 

Cancer Care 

Hospital Income Protection 

^>T- Cut along dolled line 

Please send me information on the AARC-endorsed coverages checked below. 

O Group Term Life 

O Disability 

G Major Medical 

O E.xcess Major Medical 

O Cancer Care 

D Hospital Income Protection 

D Professional Liability-Employed 

3 Professional Liabilitv-S/E 


Address . 




Maginnis & Associates • A Division of KVI • Professional Insurance Administrators 
332 S. Michigan Ave • Suite 1400 •Chicago IL 60604 

1-800-621-3008. cxt. 456 s C.A 

Circle 119 on reader service card 
Visit AARC Booth 835 in San Diego 


greater than 10 days. The pre-inter\ention group 
comprised 61 patients, and the postintervention 
group 65 patients, well matched in their demo- 
graphic characteristics and se\ erity of disease. 
INTERVENTIONS: Using a team approach, we 
analyzed the process of inpatient treatment of 
asthma exacerbation, identified root causes for 
quality deficiency, and implemented specific im- 
provements in the process. These included ded- 
icated nurses who focused on the education of care 
proMders and patients, a personalized attending- 
intem educational approach, and improvement 
in the supply and delivery of spacers, peak 
flowmeters, and medications to the patients. 
RESULTS: There was a significant increase in 
use of spacers, peak flowmeters, and inhaled cor- 
ticosteroids. Systemic corticosteroid and methylx- 
anthine use declined. Length of stay was reduced 
without increasing early hospital readmission rates. 
CONCLUSIONS: This program impro\ed the 
treatment process of adults hospitalized for asthma. 

Extended Therap> »ith Ipratropium Is Asso- 
ciated with Improved I.unj; Function in 
Patients with COPD: .\ Retrospective .\nal)sis 
of Data from 7 Clinical Trials — SI Rennard. CW 
Serby. M Ghafouri. PA Johnson. M Friedman. 
Chest 19%;I!0<1):62. 

p < 0.0 1 ). In contrast, extended therapy w ith /3 
agonist resulted in significantly less response to 
the short-term administration of j3 agonist for 
both FEV| (49 mL less response; p < O.OIKII ) 
and FVC (74 mL less response; p < 0.0001 ). 
Assessed as the percentage of patients who 
achieved a 15'7c improvement in lung function, 
most patients responded to both treatments both 
before and after extended therapy. There was. 
however, a significant decline in the nuinber of 
patients w ho responded after extended therapy, 
and this was more marked for the /? agonist 
treated group. CONCLUSION: Long-term ben- 
efits of bronchodilator therapy appear to differ 
from short-term effects. Extended administra- 
tion of ipratropium appears to be associated with 
impro\ed baseline lung function and perhaps 
w ith improvement in the response to acute bron- 
chodilation. Extended administration of j3 ago- 
nist, in contrast, appears to have little effect on 
baseline lung function, but may decrease 
response to acute bronchodilation. 

Does Quality of Care .Affect Rates of Hospi- 
talization for Childhood .\sthnia? — CJ Homer. 
P Szilagy i. L Rodewald. SR Bloom. P Greenspan. 
S Yazdgerdi. JM Le\enthal. D Finkelstein. JM 
Perrin, Pediatrics 1996;98( 1):18. 

communities. METHODS: We performed a com- 
munity-wide retrospective chart review. We 
reviewed a random sample of all asthma hospi- 
talizations, from 1988 to 1990. of children 2 to 
1 2 \ears old li\ing in these communities (n = 614). 
.Abstracted data included demographics, illness 
severity, and treatment before admission. RE- 
SULTS: Compared with Rochester children. 
Boston children were less likely to have received 
maintenance preventive therapy ( inhaled corti- 
costeroids or cromolyn |odds ratio (OR ). 0.4 (0.2. 
0.9)]|. acute "rescue" therap\' {oral corticosteroids 
[OR, 0.2 (0.1. 0.4)1 1, or inhaled P agomst ther- 
apy |OR, 0.5 (0..^. 1 .0)]. A larger proportion of 
admitted asthmatic patients in Boston ( 34% ) were 
in the least severely ill group — oxygen saturation 
95^* or above — compared with patients in 
Rochester (20%). CONCLUSIONS: The quality 
of ambulatory care, including choice of preven- 
ts e therapies and thresholds for admission, likely 
plays a key role in determining community hos- 
pitalization rates for chronic conditions such as 
childhood asthma, 

A 1-Vear Comparison of Turhuhaler versus 
Pressurized .Metered-Dose Inhaler in .Vsthmatic 
Patients — RA Pauwels. FE Hargreave. P Camus. 
M Bukoski. E Stahl, Chest 1996; 1 10( 1 ):53, 

OBJECTIVE: Bronchodilators are routinely used 
in the long-temi therapy of patients with COPD, 
These drugs are generally evaluated for their 
short-term bronchodilatory effects. Long-term 
and short-term benefits, however, are not nec- 
essarily equivalent. We evaluated, therefore, the 
effects of extended therapy with inhaled bron- 
chodilators in patients with COPD. DESIGN: 
Data were obtained from 7 clinical trials in which 
ipratropium w as compared w ith a /3 agonist over 
a 90-day treatment interval. This comprised all 
the available data from clinical trials performed 
for registration of ipratropium and included 1 ,445 
evaluable patients. Results of pulmonary func- 
tion tests were evaluated prior to and after short- 
term administration of bronchodilator both before 
and after the 90-day treatment period. In addi- 
tion, data were analyzed after stratification for 
smoking status and for lung function, RESLILTS: 
Long-term therapy with ipratropium resulted in 
improvement in baseline (ie. before short-term 
administration of bronchodilator) FEV| (28 niL; 
p < 0.01 ) and FVC ( 131 mL; p < 0.01 ). while 
long-term therapy with ^agonist resulted in no 
significant change in FEV i ( 1 -mL decline; p > 
0.2) or in FVC (20-mL improvement; p > 0.2). 
The improvement in baseline function in the ipra- 
tropium-tfeated patients was most marked in ex- 
smokers (average duration of abstinence. 9 
years). Short-term administration of ipratropium 
following the 90-day treatment interval resulted 
in similar response in average FEV| (6 mL more 
improvement after the extended therapy; p > 0.2) 
and an increased response in average FVC (44 
mL more improvement after extended therapy; 

BACKGROUND: Hospitalization rates for child- 
hood asthma are 3 times as high in Boston. Mas- 
sachusetts, as in Rochester. New York; Nev\ 
Haven. Connecticut, rates are intermediate. We 
undertook this study to determine how care for 
children admitted for asthma varies across these 

Open, randomized parallel-group study was con- 
ducted to in\ estigale w hether asthmatic patients, 
considered adequately treated w ith a corticosteroid 
and/or short-acting /J-2 agonist via pressurized 
metered-dose inhaler (pMDl), could be transferred 
to a corresponding nominal dose of budesonide 

o<vai Conve^,^^ 


November 3-6, 1996, Sunday- Wednesday 




An Integrated System 

for Compliance with 

Laboratory Regulations 

LabCounts Takes the Headache Out 
of Documentation Procedures 
Volume I: Summary of Clinical 
Laboratory Regulations 

Follows CLIA subpart J and K covering patient test 
management and quality control. Also contains related 
CAP and JCAHO regulation standards. 

Item BK31 $118 ($125 nonmembers) 

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 i'A" 

Item BK32 $118 ($125 nonmembers) 

Volume 3: Blood Gas Laboratory QA Notebook 

An integrated swstem of wt)rksheets that satist\' CLIA 
and CAP standards. Use this manual to record daily 
data on instrument maintenance and calibration. 

Item BK33 $1 18 ($125 nonmembers) 

Volume 4: Blood Gas Policies and Procedures 

A basic set of general policies and procedures that help 
satisfy regulatory requirements, especially CLIA 
subpart J. IBM-compatible Word Perfect text files 
included. Specify 3'/'" or 5'A". 

Item BK34 S118 ($125 nonmembers) 

Order All Four Volumes 
of LabCounts and Save! 

Item BK35 $400 ($425 nonmembers) 

QualityCounts Gives You 
Computerized Quality 
Assurance Tracking 

QualityCounts is an easy-to-use computerized qualit\- 
assurance program designed for respiratorv 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 existing QA system or 
creates a new one. Allows you to define custom QA 
indicators and criteria; offers flexible reporting — 
weekly, monthly, quarterl)', \'earl)-; tracks individual 
staff members' compliance with QA standards; 
itfentifies problems quickly and efficienth'; and is menu- 
driven. Requires IBM PC or compatible, 512K RAM, 
and DOS 2.0 or higher. Includes manual with forms and 
two computer disks. Specify 3'/:" or 5'A". 

Item BK36 $285 ($295 nonmembers) 


Quality Assurance 


M- 1 


PhraseCounts Saves You Time 
Searching for the Right Phrase to Use 
in Performance Evaluations 

It you have struggled tr\ mg to find the right phrase to 

describe an employee at evaluation time, you will 

appreciate PhraseCounts. It contains phrases for 3 1 

different areas so you will never have to grope for that 

just-right phrase. Also helps 

you find a new phrase for 

different employees so that 

your evaluations will not 

look like copies of one 

another. Written by 

respiratory care 

practitioners for the 

respiratory care manager. 

Spiral-bound, 41 pages, 

5'/:" X 8'/:". 

Item BK37 

$26 ($29 nonmembers) 


Mail to: AARC, 11 030 Abies Ln, Dallas TX 75229-4593 • (972) 243-2272 • FAX (972) 484-2720 or 484-6010 

Clinical Practice Guidelines 

AARC Clinical Practice Guidelines (CPGs) are 

systematically developed statements to help RCPs 

deliver appropriate respiratory care in specific clinical 


$1 each ($2 nonmembers) 

Order all 46 CPGs in a Binder and Save! 

Item CPC99 $35 ($60 nonmembers) 

Topics Include: 

Spirometry, 1996 Update Itenn CPC1 

Oxygen Therapy in the Acute Care Hospital ... Item CPG2 

Nasotracheal Suctioning Item CPG3 

Patient-Ventilator System Checks Item CPC4 

Directed Cough Item CPGS 

In-Vitro pH and Blood Gas Analysis 
and Hemoximetry Item CPG6 

Use of Positive Airway Pressure Adjuncts 
to Bronchial Hygiene Therapy Item CPG7 

Sampling for Arterial Blood Gas Analysis ... Item CPGS 

Endotracheal Suctioning of Mechanically Ventilated Adults 
and Children with Artificial Airways Item CPG9 

Incentive Spirometry Item CPG10 

Postural Drainage Therapy Item CPGll 

Bronchial Provocation Item CPG12 

Selection of Aerosol Delivery Device Item CPG13 

Pulse Oximetry Item CPG14 

Single-Breath Carbon Monoxide 
Diffusing Capacity Item CPG15 

Oxygen Therapy in the Home or Extended 
Care Facility Item CPC16 

Exercise Testing for Evaluation of Hypoxemia 
and/or Desaturation Item CPC 17 

Surfactant Replacement Therapy Item CPG28 

Ventilator Circuit Changes Item CPG29 

Metabolic Measurement using Indirect Calorimetry 
during Mechanical Ventilation Item CPG30 

Transcutaneous Blood Gas Monitoring for Neonatal & 
Pediatric Patients item CPG31 

Body Plethysmography Item CPG32 

Capillar\- BUhkI Gas Sampling for Neonatal & 
Pediatric Patients Item CPG33 

Defibrillation during Resuscitation Item CPG34 

Infant/Toddler Pulmonaiy Function Tests ... Item CPG35 

Management of Airway Emergencies Item CPG36 

Assessing Response to Bronchodilator Therapy 
at Point of Care Item CPG37 

Discharge Planning for the Respiratory 
Care Patient .' Item CPG38 

Long-Term Invasive Mechanical Ventilation 
in the Home Item CPC39 

Capnography/Capnometry during Mechanical 
Ventilation Item CPG40 

Selection of an Aerosol Delivery Device for 

Neonatal and Pediatric Patients Item CPG41 

Polysomnography Item CPG42 

Selection of an Oxygen Delivery Device for 
Neonatal and Pediatric Patients Item CPG43 

Selection of a Device for Delivery of Aerosol 
to the Lung Parenchyma Item CPG44 

Training the Health-Care Professional for the Role ot 
Patient and Caregiver Educator Item CPG45 

Providing Patient and Caregiver 
Training Item CPG46 


These protocols come from AARC members; they are 
for information purposes only, to use as a guide in 
dcvelopmg your own. 

$5 each ($8 nonmembers) 

Humidification during Mechanical 

Transport of the Mechanically 
Ventilated Patient 

Resuscitation in Acute Care Hospitals . 

Bland Aerosol Administration 

Fiberoptic Bronchoscopy Assisting Item CPG22 

Intermittent Positive Pressure Breathing ... Item CPG23 

Application of CPAP to Neonates via Nasal Prongs 
or Nasopharyngeal Tube Item CPG24 

Delivery of Aerosols to the Upper Aii-way ... Item CPG25 

Neonatal Time-Triggered, Pressure-Limited, 
Time-Cycled Mechanical Ventilation Item CPG26 

Static Lung Volumes Item CPG27 

Item CPG18 Topics Include: 

Critical Care Item PCI 

Aerosol Therapy Item PC2 

Non-Invasive Monitoring Item PC3 

Volume Expansion Item PC4 

Patient Assessment Item PCS 

Oxygen Therapy Item PC6 

Secretion Management Item PC7 

Item CPG19 
Item CPG20 
Item CPG21 

Critical Pathways 

Examples of multidisciplinary critical pathways have 
been submitted by AARC members and are available for 
\'our informational purposes and review. 

Item PC30 $5 ($8 nonmembers) 

Mail to: AARC, 1 1030 Abies Ln, Dallas TX 75229-4593 • (972) lAi-2271 • FAX (972) 4S4-2720 or 484-6010 


aiid/iir lerbulaline \ iu Turbuhaler. an inspirator)' 
flow-dri\en multidose drj' powder inhaler (Astra 
Draco; Lund. Sweden), without a decrease in the 
effect of treatment. One thousand four patients 
(555 women; mean age, 44 years; mean peak expi- 
ratory flow IPEF]. 102'7f predicted normal salue) 
were randomized and treated with either pMDl 
(current therapy I or Turbuhaler for 52 weeks. The 
variables studied were asthma-related events, 
morning PEF, and inhaler-induced clinical symp- 
toms. Asthma-related events were defined in 2 
ways: ( 1 ) sum of health-care contacts plus dou- 
blings or additions of steroids, and ( 2 1 number of 
2 consecutive days with PEF less than 80% of 
baseline. Baseline was obtained from a 2-week 
run-in period while receiv ing previous therapy. 
No statistically significant difference was found 
in asthma-related events according to definition 
1 . .According to definition 2, there was a statis- 
tically significant difference between the groups 
in favor of Turbuhaler (p = 0.008). The mean num- 
ber of events was 1.7 with Turbuhaler and 2.2 with 
pMDI. The mean number of weeks per patient 
with a PEF less than 90'* of baseline was 4.5 with 
Turbuhaler compared with 6.0 w ith pMDI ip = 
0.(X)2). The sum of inhaler-induced symptoms after 
1 year of use was statistically significantly lower 

with Turbuhaler (0.40) than with pMDl (0.75) (p 
= O.OOO 1 ). In conclusion, budesonide and terbu- 
taline in Turbuhaler offered a superior alternative 
to corticosteroids and bronchodilators delivered 
by pMDIs in the maintenance treatment of asthma. 

Changes in Intubation Rates and Outcome of 
\ er> Low Birthweight Infants: -\ Population- 
Based Stud>— CF PiJcLs. B Sens. Pediatncs 1996; 
98(1 ):24. 

OBJECTIVE; There have been indications of a 
recent decrease in intubation rates of very low 
birthweight (VLBW) infants in Germany. We 
wanted to quantify this decrease and analyze its 
effect on clinical outcome. METHODS: Popu- 
lation-based data on the treatment and outcome 
at hospital discharge from a stalew ide quality as- 
suraiice program were iinalyzed for 2.001 VLBW 
infants (500 to 1 .499 g ) born from 1992 to 1994 
in Lower Sa.xony. North Germany. RESULTS: 
The proportion of patients not intubated and 
mechanically ventilated increa.sed from 1% to 14% 
in infants < 1 .000 g and from 28% to 44% in those 
> 1 .(XX) g (p < 0.02 and < 0.01 , respectively). This 
increase was not associated with any significant 
increase in adverse outcome such as death, intra- 

ventricular hemorrhage, periventricular leuko- 
malacia, or bronchopulmonary dysplasia (BPD). 
Instead, there was an increase in the proportion 
of infants < 1.000 g who survived without BPD 
(from 38% in 1992 to 48% in 1994: p < 0.05) and 
a decrease in the proportion of infants > 1 .000 g 
in whom BPD developed (from 14% to 9%; p < 
0.05). CONCLUSIONS: The data from a statewide 
quality assurance program show a significant 
reduction in the aggressiveness of the treatment 
of VLBW infants, which was not associated w ith 
an increased mortality or morbidity. This obser- 
vational study, however, cannot define whether 
a more selective approach to the intubation of 
VLBW infants will ultimately result in a better 
outcome. A randomized, controlled trial would 
be required to answer this clinically important 
question. See the rekireil commeniary: If Too 
Much of a Good Thing Is BAD, Is Too Much 
oj a Bad Thing BPD'.' G Cassady. Pediatrics 

Mean Airway Pressure as an Index of .Mean 
.Alveolar Pressure: Effect of Expiratory Flow 
Limitation — P Valta. C Corbeil. .VI Chasse. J 
Braidv . J Milic-Emili. .Am J Respir Crit Care Med 




Toxic no 

Water cost low 

Err onmental impact low 

AutOinatic washing yes 

Automatic rinsing yes 

Automatic disinfection yes 

Automatic documentation ..yes 
Vapor Safety yes 

Total Value HIGH 


Liquid Disinfection 


Toxic yes 

Chemical cost high 

Environmental impact high 

Automatic washing no 

Automatic rinsing no 

Automatic disinfection no 

Automatic documentation no 

Vapor Safety no 

Total Value LOW 

HRInc - The Low Cost High Wue Leader 

High Levd Disinfection 

HRInc - P.O. Box 1744 - Bellevue, WA 98009 
(800)426-1042 - (206)881-7761 - FAX (206) 881-3654 

Circle 136 on reader service card 
Visit AARC Booth 609 in San Diego 

Mean airway pressure (Pj,,) has been advocated 
as a useful index for monitoring hemodynamic 
performance and risk for barotrauma during 
mechanical ventilation. This is based on the 
assumption that Pj,, closely reflects mean alve- 
olar pressure (Pji ). In the present study we have 
compared Pa^, with Pjiv in 12 sedated, paralyzed, 
mechanically ventilated patients. External PEEP 
ranged from 0.3 to 8.9 cm H;0. P.j^ w as estimated 
by measuring Pj„ afier rapid flow interruptions 
made at different points in time of the breathing 
cycle, using a modification of the method of 
Fuhmian and coworkers (4). All subjects exhib- 
ited inuinsic PEEP (PEEPi). which ranged from 
0.5 to 9.4 cm H;0. A significant negative cor- 
relation (p < 0.001 1 was found between Pm/Pji, 
and PEEPi. On average, at PEEPi of 10 cm HjO. 
P.„, underestimated Pjis by about 50'7r. We con- 
clude that Pj„ cannot be taken as an index of P,,iv 
m patients who exhibit dynamic hyperinfiation 
and PEEPi caused by expiratory flow limitation. 

Inspiratorv Muscle Training and Whole-Body 
Ki'conditionlng in Chronic ObstructiM' Pul- 
monary Disease: .\ (,'ontrolk'd Randomized 
Trial MJ Bcrrv. NF Adair. KS Sc\ensk\. A 
Quinby. HM Lever. Am J Respir Crit Care Med 

To examine the efficacy of targeted inspiratory 
muscle training (IMT). 25 patients with moder- 
ate COPD were randomly assigned to 1 of 3 
groups. Eight patients received IMT along with 
general exercise reconditioning. GER -i- IMT; 9 
patienLs received general exercise reconditioning. 
GER; 8 patients received sham breathing exer- 



Now you need it. 

Now you don't. 


the ACE Aerosol Cloud Enhancer 

with exclusive, detdchdk mask. 

Universal MDI port 

Dual valve for enhanced 
. coordination 

Clear construction to let you visually 
confirm availabilm- ot prescribed dose 

Coachmt; whisde to help 
patients maintain correct 
inspiratory flowrate 

The universal ACE spacer 
now gives you the oprion of a 
detachable mask for e\'eii greater 
versatil4t\' in MDI delivery! 

ACE eliminates the need to stock multiple MDI spacers. In addition 
to using ACE to deliver aerosolized medications through a mask, you can ^f*^ T^T "WX^ 

also use it m a vent circuit, in conjunction with an endotracheal airway, BM I lii I 1 

connected to a resuscitation bag, and with a mouthpiece for routine, oral "I" J-AIAX-^ 
therapy No other spacer lets you deliver relief in more applications! 

Silicone mask with soft. 

- rolled edges for a comfortable, 

snug'fit, 100% air flow 

The ACE detachable mask is available in three sizes (sold separately), 
and IS easy for patients to remove and clean. For more information on 
the ACE Aerosol Cloud Enhancer with detachable mask, or 
for a I'm catalog of DHD qualitv respirator\' products, call 
toll-tree todav at l'800-847-''""~ 


Canastou, IMY 131132 USA (315)W7-2221 FAX: (315) 697-8083 

Customer Service FAX: (31 i) 697-5191 lmp://mv\ 

reader service card 

Circle 149 on 
Visit AARC Booths 718, 720, and 722 in San Diego 


cises. CONTROL. All griiup> used a spring-loaded 
inspirator)' muscle trainer; houever, the GER and 
CONTROL groups breathed through these devices 
at only 15% of their maximal inspiratory pressure. 
The GER + IMT group increased the load on these 
devices until at 6 weeks the load was equal to 80% 
of their ma,\imal inspiratory pressure. All patients 
exercised 3 times per week for a 12-week period 
in supervised sessions. Analysis of covariance 
revealed no significant differences in spiromel- 
ric measurements. ma.ximal inspiratory pressure, 
or maximal oxygen consumption among any of 
the 3 groups after the intervention (p > 0.05). 
Twelve-minute walk distance was significantly 
greater in the GER + IMT and GER groups than 
in the CONTROL group ( p = 0.03 ). After the inter- 
vention, there was a trend (p = 0.08 1 for U-eadmill 
time to he greater for the GER -i- IMT and GER 
groups than for the CONTROL group. Dyspnea 
ratings at different exercise intensities were not 
found to be significantly different among the 3 
groups after the intervention. These results demon- 
strate that GER + IMT and GER alone are equally 
effective in improving performance in 
patients with COPD. Additionally, the combination 
of GER and IMT does not appear to pro\ ide any 
cimically significant improvements in exercise 
perfomiance or perceptions of dyspnea during 
exercise when compared with GER alone. 

The .Association of Sudden Intxptcttd Infant 
Death with Obstmctive Sleep .\pnea — PV Tish- 
ler. S Redline. V Ferrette. MG Hans. MD Altose. 
Am J Respir Crit Care Med 1996:153:1857. 

We studied the relationship of sudden unexpect- 
ed infant death/apparent life-threatening events 
(ALTE) to obstructive sleep apnea (OSAl in 74 
index probands who had either sleep-laboratory- 
contlrmed OSA or a clinical diagnosis of OSA 
requiring treatment, 62 matched control probands, 
and their spouses and first- and second-degree 
relatives. Sleep was monitored in the home over- 
night, and OSA was defined by respiratory dis- 
turbance indices (number of apneas/hypopneas 
per hour ol' sleep) corrected for normal increases 
w itli age. Inloniiation on sudden unexpected infant 
death/ALTE was obtained by questionnaire and 
was corroborated. For living relatives, data were 
obtained by questionnaire, examination, or study 
(cephalometric radiographs, ventilatory respon- 
siveness to hy[)ercapnia and hypoxia). Eight index 
families had 10 infants with sudden unexpected 
infant death/ALTE: 2 control families had 3 
infants with sudden death (p = 0. 1 1 ). .All told. 91 
of the 136 families (index plus control) included 
members with OS.A. and all 10 intant death/ALTE 
families were among these (versus zero of 45 fam- 
ilies with no OSA; p = 0.03). The sudden infant 
death/ALTE families had a greater frequency of 
2 or more members with OSA (p = 0.06), reported 
more respiratory disease or allergy, were more 
frequently brachv cephalic (p = 0.05). and had a 
smaller mean posterior nasal spine-basion dis- 

tance (p = 0.0001 ) and ratioof anterior mandibu- 
lar/anterior maxillary dental height (p < 0.05). 
Ventilatory responses to hypoxia were reduced 
in members of families with OSA (p = 0.008). 
with a trend toward the greatest blunting in sub- 
jects from families with OS.A plus sudden unex- 
pected infant death/ALTE. Thus. OSA in adults 
and sudden unexpected infant death/.ALTE in their 
biologic relatives appear to be related. Familial 
factors inlluencing this association may include 
the degree of the predileclion for OSA. liability 
for respiratory illness or allergy, dimensions of 
the oral-pharyngeal airway, and ventilatory 
response Ui hypoxia. 

Aerosolized Recombinant Human DNase in 
Hospitalized Cystic Fibrosis Patients with .Acute 
Pulmonary Exacerbations — R\\ \\ ilniotl. RS 
Amin. AA Colin. A DeVault. AJ Dozor. H Eigen. 
C Johnson, LA Lester. K McCoy. LP McKean. 
R Moss. ML Nash, CP Jue, W Regelmann, DC 
Stokes. HJ Fuchs. Am J Respir Crit Care Med 

The goal of this study was to evaluate the safety 
and efficacy of recombinant human DNase (rhD- 
Nase) in hospitalized patients with cystic fibro- 
sis (CF) experiencing aculc pulmonary exacer- 
bations. Eighty patients witli documented CF were 
enrolled at 1 1 CF centers when admitted for antibi- 
otic therapy. Patients wen; at least 5 years old w ith 
a forced vital capacity (FVC) > 35% of predicted 
and an oxygen saturation > 90% on a fraction of 
inspired oxygen (F|0;) < 0.5. Patients were ran- 
domized to receive rhDNase 2.5 mg in 2.5 niL 
excipient twice a day (n = 43) or 2.5 mL excip- 
icnt alone twice daily (n = 37) along with con- 
ventional treatment for exacerbations. Admin- 
isu-ation of was not associated with acute 
adverse events or deaths, and no patients expe- 
rienced allergic or anaphylactic reactions. Although 
forced expiratory volume in I second (FEVi) and 
FVC improved in both treatment groups during 
the double-blind period, there were no statistically 
significant differences in the mean change from 
baseline in FEV] or FVC between the 2 groups. 
rhDNase therapy is safe and well tolerated in CF 
patients v\ ith acute exacerbations requiring hos- 
pitalization, but the study did not demonstrate a 
statistically significant therapeutic effect of rhD- 
Nase when added to a regimen of antibiotics and 
chest physical therapy. 

Tracheal (;as Insufflation: Catheter Effec- 
tiveness Determined by Expiratory Flush A dl- 
unie S.A Rascnscialt. RS Shapiro. .A Nahum. 
WC Burke. AH .Adams. G Nakos. JJ Marini. Am 
J Respir Crit Care Med 1 996: 153:1817. 

Used adjunctively during mechanical ventilation, 
tracheal gas insuftlation (TGI) improves CO: elim- 
ination, principally by decreasing effective ana- 
tomic dead space. Continuing lung defiation at 
end-expiration raises the end-expirator\ COi con- 

centration v\ ithin the proximal airway, and could 
theoretically reduce the efficiency of a given 
catheter flow. To test this possibility, we designed 
a series of experiments that examined the infiu- 
ence of TGI delivery patterns on the efficiency 
of COj elimination. Using a gating device, catheter 
flow was delivered selectiveh dunng desired por- 
tions of expiration. Paralyzed, \entilated dogs were 
studied at short and extended inspiratory time frac- 
tions (Ti/Tt) with inspiratory tidal volume and 
ventilator frequency held constant. The expira- 
tory fiush volume, not the pattern of gas deliv- 
ery, determined the observed decline in Pacn:. pro- 
vided that the end-expiratory period was included 
in the catheter flush period. Despite continuing 
end-expiratory lung deflation (extended T|/Tt). 
catheter effectiveness remained the same at 
matched expiratory flush volumes. To determine 
if enhanced distal mixing at the higher catheter 
flows required during the extended Ti/Tj (to match 
expiratory flush volume) masked a decrease in 
efficiency, we repealed the experiment with a tip- 
inverted catheter. We again found that matched 
catheter delivered expiratory volumes were sim- 
ilarly effective. With or without ongoing lung 
deflation, the volume of gas flushed during the 
expiratory period determined the effectiveness 
of TGI. provided that inspired minute ventilation 
remains unch;inged :uid end-expiration is included 
in the catheter flush period. 

Respiratory Tract Colonization and Infection 
in Patients with Chronic Tracheostomy: A 
I -year Study in Patients l.ivin); at Home — R 

Harlid. G Andersson. CG Frostell. HJA Jtirbeck. 
AB Ortqvist. Am J Respir Cnt Care Med 1 996: 1 54 

The high rate of complications, especially res- 
piratory tract infection (RTI). reported in patients 
w iih chronic tracheostomy (CT) has discouraged 
physicians from using this method. However, pre- 
vious studies of CT have concerned mainly hos- 
pitalized patients. We have followed the bacte- 
rial colonization patterns of the upper and lower 
respiratory tract and recorded all RTIs in 39 out- 
patients with CT during a 12-month period. 
Patients were colonized v\ ith 1 or more potential 
pathogens at the stomal site and in the trachea in 
95% and 83%, respectively, of all sampling occa- 
sitins. Slaphyloipcctis aureus. Gram-negative 
enteric bacteria (GNEB), and Pseiidomoiuis uerug- 
iitosa were the most common colonizing bacte- 
ria at these sites. Seventy percent of bronchial- 
protected brush cultures were negative, despite 
simultaneous heavy coloniziition of the stomal site 
or the trachea. Only I S of 39 (46^-; ) patients were 
treated with antibiotics because of RTIs on a total 
of 30 occasions during the study year. Of these, 
only 5 episodes of pneumonia in 4 patients were 
registered, corresponding to an incidence of about 
10 per 100 person years. We conclude that out- 
patients w ith chronic tracheostomy can be man- 
aged VK ith a low risk for developing severe RTIs. 


Respir.ator'i Care • October '96 Vol 41 No 10 

Kendall puts the 
respiratory products 

of tomorrow 
in your hands today. 






our many other trusted brands welcome the premiere line of 
respiratory products to the Kendall family. 


^^ "^ ^ // 

15 Hampshire Street Mansfield, MA 02048 1-800-962-9888 


Come see us at A ARC #346-348 

Circle 109 on reader service card 
Visit AARC Booths 346 and 348 in San Diego 


despite massive airway coloni/aiion with poien- 
tially pathogenic bacteria. 

Benefits of the I,o« Pressure Multichannel 
Kndotraeheal \ entilalion — D Pinquier. D l\i\ 
lovic, G Boussignac. M Aubier. F Beaullls. Am 
J Respir Crit Care Med 1 996; 1 54( 1 ):82. 

Mechanical ventilation using a modified endo- 
tracheal tube, allowing bypass and washout of 
the endotracheal dead space (McETV). was com- 
pared with conventional controlled mechanical 
ventilation (CMV) in healthy and in surfactant- 
depleted rabbits. In healthy animals, shifting from 
CMV to McETV led to an increase m P.,o, (89 
± 16 vs 104 ± 13 mm Hg; p < 0.05) and a 
in Paco: (41 .5 ± 3 vs 30 + 3 mm Hg: p < 0.05). 
As a result of reducing the peak inspiratory pres- 
sure (PIP) from 21 ± 2 10 12 ± 2 cm H2O (p < 
0.05). it was possible in McETV mode to main- 
tain comparable ventilation to that achieved by 
CMV, In surfactant-depleted animals, compared 
with CMV. McETV produced a rise in P^o, with- 
out change in thoracic volume ( from 1 00 ± 40 to 
150 ± 60 mm Hg. p < 0.05) and a fall in, 
(from 46 ± 5 to 37 + 4 mm Hg. p < 0.05 ). After 
4 hours of ventilation, the surfactant-depleted ani- 
mals from the CMV group developed thoracic 
overdistension quicker (at hour I , p < 0.05) and, 
consequently, more animals died from pneumo- 
thorax compared with the McETV group (5 vs 
2). We concluded that McETV ensured adequate 
gas exchanges w ith lower insufflation pressures 
and could diminish positive pressure ventilalion- 
induced injury. 

Influcn/ii Vaccination of Children during Acute 
Asthma Kxacerbation and Concurrent Pred- 
nisone Therapy — CI. Park. AL Frank. M Sul- 
livan. P Jnulal. BD Baxter. Pediatrics I996;98 

OBJECTIVES: The inlluen/a vaccination rale is 
very low among children w itli moderate (o severe 
a-stlima. This may be p;u1ly because of p<Kir patient 
motivation and failure lo visit clinics for vacci- 
nation. Another important factor may be health- 
care providers" deferral of vaccination because 
of concern about the efficacy and safety of in- 
fluenza vaccination during asthma exacerbations 
and concuiTcnt prednisone therapy . We therefore 
examined the safely and immunogenicity of 
influenza vaccitiatioti during ;icule asthma exac- 
erbation with concomitant prednisone therapy. 
SETTING: A pediatric allergy and pulmonology 
clinic and a pediatric emergency department. 
DESIGN: Children (n = 109) with a known diag- 
nosis of asthma 6 months to 1 8 years of age were 
recruited. All participating patients. 59 without 
asthma symptoms (no prednisone, control group) 
and 50 w iih ;icute asthma exacerbation requiring 
prednisone burst therapy (prednisone group) 
received uiv aleiit subv irion influenza vaccine. Fif- 
teen children in the control group and 12 in the 

prednisone group received a booster dose accord- 
ing to American .Academy of Pediatrics guide- 
lines. Serum antibody tilers to influenza A/Bei- 
jing/32/92 (H3N2), influenza A/Texas/36/91 
( H 1 N 1 ), and intluen/a B/Panama/4.5/9() were mea- 
sured before and 2 weeks after vaccination. 
Adverse effects noted within 48 hours after vac- 
cine dose were ascertained during the follow-up 
visit. RESULTS: The anlibodv response was ana- 
lyzed by comparing mean postvaccine titers, the 
percentage of patients achieving protective anti- 
body levels (> 5log2). and the percentage of 
patients achieving rises in titers of 2log; or greater. 
Antibody responses to intluenza A/Beijing/32/92 
( H3N2 ) and intluenza A/Texas/ 36/9 1 ( H 1 N 1 ) in 
the prednisone-lreated and control groups were 
not different. A significantly belter response to 
the intluenza B/Panama/45/90 antigen was seen 
in the prednisone group for all 3 parameters. Chil- 
dren who received a booster dose and the subgroup 
of children with low prevaccination tilers (< 31og2) 
showed similar patterns. Adverse effects, includ- 
ing asthma exacerbation, local swelling at the 
injection site, fever, rash, and headache, were not 
different in the 2 groups. CONCLUSIONS: 
Intluenza vaccination can be given safely and 
effectively to asthmatic children regardless of 
asthma symptoms or concurrent prednisone ther- 
apy when necessary. Vaccination of all moder- 
ate to severe asthmatic patients visiting clinics or 
emergency departments would improve the over- 
all vaccination rate significantly. 

Effect of Theophylline on Sleep-Disordered 
Breathing in Heart Failure — S Javaheri. TJ 
P:irker, L Wexler, JD Liming, P Lindower. GA 
Roselle. N Engl J Med 1996:335:562. 

BACKGROUND: Theophylline has been used 
to treat central apnea associated with Cheyne- 
Slokes respiration (periodic breathing). We stud- 
ied the effecl of shoil-lenii oral Iheophylline Iher- 
apv on periodic breathing associated with stable 
heart failure due lo systolic dysfunclion. METH- 
ODS; Fifteen men with compensated he;irt fail- 
ure (left ventricular ejection fraction, 45'/f or less) 
participated in the study. Tlieir baseline ptilysom- 
nograms showed periodic breathing, with more 
than 10 episodes of apnea and hypopnea/hour. 
In a double-blind crossover study, the patients 
received Iheophylline or placebo orally Iwice daily 
for 5 days, with 1 week of vv ashoul between ihe 
2 periods. RESL'LTS: .-Xfler 5 days of Ireatment. 
the mean (±SD) plasma theophylline concen- 
tration was 11+2 /jg/mL. Theophylline therapy 
resulted in significant decreases in the number 
of episodes of apnea and hypopnea/hour ( 1 8 ± 
1 7. vs 37 ± 23 with placebo and 47 ± 2 1 at base- 
line: p < 0.(X) 1 ). the number of episodes of cen- 
tral apne;i/hour (6 + 14. vs 26 + 2 1 and 26 ± 20. 
respectively; p < 0.001 ). and the percentage of 
loial sleep time during which the arterial oxy- 
hemoglobin saturation was < 90'J (6 ± 1 ITf . vs 
23 ± 37. 14 ± 149^. respeclively; p < 0.(M). There 

were no significant differences in the charac- 
teristics of sleep, the frequency of ventricular 
arrhythmias, daytime arterial blood gas values, 
or ihe left ventricular ejection fraction during (he 
baseline, placebo, and iheophv lline phases of the 
study. CONCLUSIONS: In patients with stable 
heart failure, oral theophylline therapy reduced 
ihe number of episodes of apnea and hypopnea 
and the duration of arterial oxyhemoglobin desat- 
uralion during sleep. 

The Effects of Albuterol on the Lung Function 
of Hospitalized Patients with Cystic Fibrosis — 

NL Hordv ik. PH Samnuit, CG Judv , SJ Slrizek, 
JL Colombo. Am J Respir Cnt Care Med 1996: 1 54 
(I): 1 56. 

Twenty-four hospitalized patients with cystic fibnv 
sis were enrolled into a 2-day. double-blind, 
placebo-controlled, randomized crossover trial 
comparing albuterol inhalation aerosol with a saline 
placebo. Aerosols were administered with the finit 
3 of 4 chest physiotherapy sessions given 4 hours 
apart. Spirometry was measured before and 45 
minutes after 7:00 .AM and 3:(X) PM therapy and 
before therapy al 7:00 I'M and 7:00 .am the next 
morning. The mean perceni change in FVC. FEVi. 
and FEF:5-75'; at 7:(X) AM was 10.7. 14.8. and 
19.69; with albuterol versus 2.4. 1.0. and -0,8% 
with placebo ( p = 0,00 1 2. < 0,000 1 . and = 0.003, 
respectively). A greater than 89c change in FEV| 
separated changes wilh albuterol versus placebo 
with 969f specificity and occurred in 759!- of all 
palienls wilh albuterol: 719f at 7:00 .AM versus 
249f at 3:00 P.M. The reduction in response al 3:00 
PM (p < 0.01 ) was presumably due lo prolonged 
effects of morning Iherapy (> 4 h). Individual 
changes in spirometry were significanUy more pos- 
itive and homogeneous with albuterol versus 
placebo at both 7:(X) AM and 3:00 PM. The mean 
percent change for the FVC. FEV|. and FEFtj-;;^ 
across the day (7:00 AM pretherapy to 7:00 PM 
prelherapy ) was 8. 1 . I0.1.and9.79r with albuterol 
versus 3.9. 3.5. and 2.69^ with placebo (p = 0.029, 
0.036. and 0.232. respectively). The more pos- 
itive ;ind homogeneous changes in spirometry with 
albuterol, along with greater changes in these mea- 
sures across tlie day when compared with placebo, 
suggest that albuterol improves pulmonary func- 
tion in a majority of hospitalized patients with cys- 
lic fibrosis. 

Mmilh leak «ilh Nasal Continuous Positive 
.\in\av Pri-vstire Increases Nas;il .\ir\(a.v Resis- 
tance— GN Richards. PA Cisiulli. RG Ungar. M 
Bertlioii-Joncs. CE Sullivan, Am J Respir Crit Caie 
Med 1996: 154(1): 1 82, 

Nasal congestion, dry nose and throat, and sore 
throat affect approximately 409r of patients using 
nasal continuous positive airvvay pressure (CPAP), 
The mechanisms causing nasal symptoms are 
unclear, but mouth leaks causing high unidirec- 
tional nasal airflow mav be important. We con- 



If Intubating Him 
Raises Big Concerns 


Here's a Small Suggestion. 

Introducing the Pedi-Cap'" 
Pediatric End-Tidal CO2 Detector. 

The technology of Easy Cap' now 
available in a size suitable for NICU, 
PICU, and pediatric EMS patientsr 

Proven colorimetric technology for objective 
verification of correct endotracheal tube placement. 

A nontoxic chemical 
indicator quickly 
responds to exhaled 
COt with a simple 
color change from 



Easy Cap (pictiireil) ami Pedi-Cap 
attach to the cmltitraihvat tube to 
detect etCOj levels witli breath-to- 
breath response. 

purple to yellow. 

As an adjunct to current practices, Pedi-Cap 
provides a simple, cost-effective approach to 
documenting ET tube position during emergency 
intubations and in the NICU and PICU. So 
with Pedi-Cap and Easy Cap, you can now 
standardize patient protocols regardless of patient size. 

Isn't it time you started using Pedi-Cap? 

For more information on Pedi-Cap and our complete 
family of etCO, detection and monitoring products, 
contact your Nellcor Puritan Bennett representative 
or call 1-800-NELLCOR or 510-463-4000. 


Circle 102 on reader service card 
Visit AARC Booth 301 in San Diego 

Ttili-Ciip is recommended for use on patients weighing 1-15 kg. Eiisv Cap and Petli-Caf) are trademarks of Nellcor Puritan Bennett Inc. © 1995 Nellcor Puritan Bennett Inc. All rights reserved. 

New comfort fit Silicone Mask 
offers flexibility and less 
dead space 

Valve with 
Low Resistance 


• A- ^' ' t. ' ijMkJti^^^ 

Clear chamber for continued 
visualization of MDI 
actuation and valve opening 











10 1 

S 20 

25 30 15 40 45 


&S 60 






The Universal MDI 
receptacle permits use 
of pharmaceutical 
approved actuators 



^^ StP'^wI i St?'"' 

Clinicians, parents and pediatric patients can be confident of improved 
delivery of MDI medications to the limgs. This is accomplished while 
allowing ease of inhalation and exhalation, reduction of dead space in the 
mask and maintaining a proper fit and seal around the mouth and nose. 
Even patients with low Lnspiratory/expiratory pressures and flow rates 
can effectively use the dual valve AeroChambers® with Masks' (see charts 
below, left). 

The AeroChamber® v«th Mask is a cost effective^ and portable system, with 
accelerated delivery capability^ and a choice of two sizes of mask, small and 
medium. You can now provide greater patient comfort, use of a broader 
range of current aerosol medications and realize a faster therapeutic 
response.^ Additionally, the AeroChamber® system will use less medication 

when compared to current Small Volume Nebulizer (SVN) Therapy.* 


The New Dual-Valve Clear 
AeroChamber® with Mask 
is part of the complete 
AeroChamber® Family of 
Aerosol Holding Chambers 
from Monaghan Medical 

1. Drug delivery from holding chambers with attached 
facemaskML Everard et al. Archives of Disease in Children, 
Vol. 67, No. 5, May 1992 

2. Substitution pf Metered Dose Inhalers for Hand Held 
Nebulizers. Success and Cost Savings in a large. Acute Care 
Hospital, Bowton, DL, et al, Chest 101 (2) : 305-8, 1992 Feb. 

3. Metered Dose Inhalers with Spacers vs Nebulizers for 
Btonchodilator Therapy in a Pediatric Emergency Department, 
Chou, KJ, et al, Am. J of Dis of Child, volume 147, No. 4 April 1993 

4. Efficacy of Albuterol Administered by Nebulizer versus Spacer 
Device in Children with Accute Asthma, Karem, E., et a! J. Fed 123 


Sponsors of AARC*S 
Peak Performance USA Program 

AWARD 1993 


P. O. Box 2805, Plattsburgh, NY 12901 
800-833-9653 / 518-561-7330 
Fax: 518-561-5660 
Circle 127 on reader service card 
Visit AARC Booth 843 in San Diego 


dueled a study to iinestijiale the effects of mouth 
leak and the influence of humidificalion on nasal 
resistance in noimal subjects. Nasal resistance was 
measured with posterior rhinomanometry in 6 nor- 
mal subjects who deliberately produced a mouth 
leak for 10 minutes while using nasal CPAP. Nasal 
resistance was measured regularly for 20 minutes 
after the challenge. A series of tests were per- 
formed using air at differing temperatures and 
humidities. There was no change in nasal resis- 
tance when subjects breathed through their noses 
while on CPAP, but a mouth leak caused a large 
increase in resistance {at a How of 0.5 L/s) from 
a baseline mean of 2.2 1 cm HiO ■ L • s"' to a max- 
imum mean of 7.52 cm HiO • L ■ s~' at 1 minute 
after the challenge. Use of a cold passover humid- 
ifier caused little change in the response (maxi- 
mum mean : 8.27 cm H jO L s ' ). but a hot w ater 
bath humidifier greatly attenuated the magnitude 
(maximum mean: 4.02 cm H2O L ■ s ' I and dura- 
tion of the response. Mouth leak with nasal CPAP 
leads to high unidirectional nasal airflow, which 
causes a large increase in nasal resistance. This 
response can be largely prevented by fully humid- 
ifying the inspired air. 

(ireater Ozone-Induced Inflammatory Re- 
sponses in Subjects with Asthma — C Scannell. 
L Chen. RM Aris, 1 Tager, D Christian, R Fcr- 
rando. B Welch, T Kelly. JR Balmes. Am J Respir 
Crit Care Med 19%;154( 1 ):24. 

In order 10 test the hypothesis that ozone (00- 
induced changes in lung function and respiratory 
tract injury/infiammation are greater in subjects 
with asthma than in noniial subjects, we exposed 
18 usihnuilic subjects, on separate days, to Oi (0.2 
ppm) and filtered air for 4 hours during exercise. 
Symptom questionnaires were administered be- 
fore and after exposure, and pulmonary function 
tests (FEV|. FVC, and specific airway resistance 
[SRaw] I were performed before, during, and im- 
mediately after each exposure. Fiberoptic bron- 
choscopy, with proximal airway lavage (PAL) 
of the isolated left main bronchus and broncho- 
alveoky lavage (BAL; bronchial fraction, the first 
10 niL of fluid recovered) of the right middle lobe, 
was performed 1 8 hours after each exposure. The 
PAL. bronchial fraction, and BAL fluids were 
analyzed for the following endpoints: total and 
differential cell counts: total protein, lactate dehy- 
drogenase (LDH). fibronectin. interleukin-8 
(IL-8). granulocyte-macrophage colony-stimu- 
lating factor (GM-CSF). (MPO). 
and transforming growth factor-/3(TGF/J:) con- 
centrations. We found a significant O3 effect on 
FEVi. FVC. SRaw (p < 0.04) and lower respi- 
ratory symptoms (p < 0.001 ) for the asthmatic 
subjects. Ozone exposure also significantly 
increased the percent neutrophils in PAL )p < 
0.01 ); percent neutrophils, total protein, and IL-8 
in the bronchial fraction (p < 0.(K) 1 . p < 0.05. and 
p < 0.01. respectively): and the percent neutro- 
phils, total protein. LDH, fibronectin. IL-8. GM- 

CSF, and MPO in BAL (p < 0.001 . p < 0.01 . p 
< 0.01. p < 0.001. p < 0.05. p < 0.01. and p < 
0.001 . respectively) for the asthmatic subjects. 
There were no significant differences in the lung 
function responses of the asthmatic subjects in 
comparison with a group of normal subjects (n 
= 81) previously studied using an identical pro- 
tocol, although there was a trend toward a greater 
Ovinduced increase in SRaw in the asthmatic 
subjects ( p < 0. 1 3 ). In contrast, the astlimatic sub- 
jects showed significantly greater (p < 0.05) 0\- 
induced increases in several inflammatory end- 
points (percent neutrophils and total protein 
concenu-ation) in BAL as compared with normal 
subjects who underwent bronchoscopy (n = 20). 
Our results indicate that asthmatic persons may 
be at risk of developing more severe Oj-induced 
respiratory tract injury/inflaiumation than nor- 
mal persons, and may help explain the increased 
asthma morbidity associated with Oi pollution 
episodes observed in epidemiologic studies. 

Tuberculosis Screening for Immigrants and 
Refugees: Diagnostic Outcomes in the State of 

Hawaii— PLF Zuber. NJ Binkin. .AC Ignacio. KL 
Marshall. SP Tnbble. MA Tipple. RL Vogl. Am 
J Respir Crit Care Med iy9fi:l.54( 1 ):151. 

The effectiveness of the required overseas tuber- 
culosis (TB) screening for imniignuits and refugees 
to the United States has not been evaluated since 
new guidelines were introduced in 1991. Using 
data from the Hawaii State TB register for 1992- 
199.3. patient records, and data from the U.S. gov- 
ernment notifications of suspect TB among aliens, 
we determined the percentage of persons either 
classified as having active TB(B 1 ). inactive TB 
I1(B2). or considered "nonuiil" overseas, who were 
evaluated and subsequently diagnosed with active 
TB within 1 year of arrival in the United States. 
Of the 1 24 TB cases among immigrants and 
refugees evaluated within 1 year of arrival. 78 
(639f) had been classified overseas as Bl. 17 
( I49( ) as B2. and 29 (23'* ) as '■normal." The pro- 
portion of TB cases diagnosed after arrival in the 
United States was 14.0'?^ for Bis and 2.1% for 
B2s. This proportion decreased with increasing 
age. A positive skin test was a strong predictor 
(OR: 10.7;95'7rCI; L4-80.l)ofculture-conrimied 
TB. These data document that immigrants and 
refugees with B I and B2 TB status have a high 
prevalence of active TB. They should be promptly 
evaluated after ;uTi\ al in the United States to deter- 
mine the need for curative or pie\ entive therapy. 

.\cute .Safety and Effects on Mucociliary Clear- 
ance of Aerosolized I ridine 5'-Triph()sphate 
± Amiluride in Normal Human .\dults — KN 

Olivier. WD Bennett. KW Hohneker. KL Zeman. 
U Edwards. RC Boucher. MR Knowles. Am J 
Respir Crit Care Med 1 996: 1 54( 1 ):2 1 7. 

Impaired mucociliary clearance contributes to the 
pathophysiology of several airways diseases in- 

cluding cystic fibrosis, asthma, and chronic bron- 
chitis. Extracellulartnphosphate nucleotides (adeno- 
sine 5'-triphosphate |ATP]. undine 5'-triphosphate 
[UTP)) activate several components of the mucocil- 
iary escalator, suggesting they may have poten- 
tial as therapeutic agents for airways diseases. We 
conducted initial (Phase 1) studies of acute safety 
and efficacy of aerosolized LTT alone and in com- 
binaiion with aerosolized amiloride. the sodium 
channel blocker, in nomial human volunteers. 
Safety «'as assessed by measurement of pulmonary 
function. Neither UTP alone nor in combination 
with amiloride caused any clinically significant 
adverse effects on airway mechanics, (subdivisions 
of) lung volumes, or gas exchange. Acute efficacy 
of UTP and amiloride alone and in combination, 
was assessed by measuring changes in the clear- 
ance of inhaled radiolabeled particles. A 2.5-fold 
increase in mucociliary clearance was seen in 
response to UTP alone and in combination with 
amiloride. We conclude that aerosolized UTP ± 
amiloride clearly enhiuices mucociliary clearance 
without acute adverse effects in normal adults, and 
may have therapeutic potential to enhance airways 
clearance in diseases characterized by retained air- 
ways secretions. 

Bronchoscopic Surfactant Administration in 
Patients nith Severe .Adult Respiratory Distress 
Syndrome and Sepsis — D Walmratli. A Giinther, 
H.A Ghofrani. R Schemiuly. T Schneider. F Grim- 
minger. W Seeger. Am J Respir Crit Care Med 

The present study was performed on 10 patients 
with severe adult respiratory distress syndrome 
(ARDS). all suffering from sepsis (mean lung injury 
score I LIS] ( 1 ): 3.25 ±0.1: duration of mechan- 
ical ventilation upon study entry : 3. 1 ± 0.6 d). Ex 
vivo analysis of the alveolar surfactant system, 
obtained by bronchoalveolar lavage (BAL). showed 
severe impairment of surfactant function. Three 
hundred milligrams of natural surfactant/kg body 
weight ) Aheofact' ) was delivered bronchoscop- 
ically in separate doses to each segment of both 
lungs. This caused an immediate increase in 
P.,0:/Fio: from 85 ± 7 mm Hg to 200 ± 20 mm Hg 
(p < 0.001 ). mainly due to a decrease in shunt fiow 
(42 ±4 to 20± 2':/f [p< 0.001 1). Reanalysis of the 
alveolar surfactant showed that its function was 
significantly improved. In 5 patients the increase 
in arterial oxygenation was partially lost within 
the next few hours, and a second dose of 2(X) mg/kg 
surtaclant was applied 1 8 to 24 hours later, again 
increasing Pao/Fjo. values. Eight patients survived 
the subsequent 14-day observation peritxl witli pro- 
gressive improvement of gas exchange, and 5 
patients were definitely weaned from the respirator. 
All fatalities were due to nonrespiratory causes. 
We conclude that the bronchoscopic application 
of a high dose of surfactant, aimed at overcom- 
ing inhibitory factors in the alveolar space of these 
patients, may offer a feasible and safe approach 
to improving gas exchange in severe ARDS. 


Respirator\ Care • October '96 Vol 41 No 10 

; ^^■^-■;>^^'''^■ :a.vj^>; 



^^•/9ov^^ SOCIETY 

Pneumonia is the #1 cuisc (it death from infectious dis- 
ease and is the sixtii leading cause ot death in the 
United States. It is also increasing among the eldedv — 
being the fourth leading cause of death. Last year alone, 
moi'e tiian fi\e million people suffered fi-om this illness. 

Pneumonia, All You Need To Know, will be featured 
on an upcoming edition of TIjf C.uttinj) Eiijfc Medical 
Report. C^o-hosted by Dr. Michael Neiderman, a respi- 

rator\' disease specialist at Winthrop Uni\ersit\' Hospital 
in Mineola New York, this timeh' program will examine 
the different npes of pneumonia that exist and will dis- 
cuss the treatments that are currently being used and de\'cloped. 

This program is produced in conjunction with the American Thoracic Society 
and is made possible through imrestricted ctiucational grants from Bayer, 
Zeneca Pharmaceuticals and Pfizer, Inc. 

The Cutting Kdge Medical Report, a production of hifarmntioii Television 
Nctirork, is a 3()-minutc lA' magazine dedicated to showcasing the latest 
developments in medical technology. 

Far more iufonuntiou on air dates and times, and how to obtain a video copy of 
the pnnjram, call 1-800-INFO-IT\' (463-6488). http://-ivw) 






A Business Unit of Zeneca Inc 
Wilmington, Delaware 19850 5437 


The Journal at 40: Over the Hill: 

Well, ihe JoLinial is 40 years old — an anniversary popu- 
larly viewed, at least by those on the nether side, as an occa- 
sion for black crepe and expressions of sympathy. Anniver- 
siiries lend themselves to soul searching — reflection, resolution, 
and, perhaps, regrets. Where is the Journal at 40? Where has 
it been and where is it going? What of reflection, resolution, 
and regrets? 

In 1996. at a time in health care when it is some times dif- 
ficult to distinguish between aggressive action to control and 
mindless chaos, is the Journal, in fact, becoming obsolete and 
irrelevant? Is the Journal "over the hill"? At a time when our 
profession is threatened with loss of identity and loss of auton- 
omy, when therapists and managers sometimes wake to find 
themselves with ongoing responsibility to patients and co-work- 
ers but without the wherewithal to discharge those respon- 
sibilities, when restructuring and the charge to do more with 
less leads to untenable conditions for those who remain and 
a career change for those forced out. does the Journal still have 
a role and a mission? 

Over the years, the mission of the Journal and its role in 
the life of the profession has been clear and unwavering to 
some, vague to some, and totally misunderstood by others. 
What is a science journal — a stuffy, self-conscious applica- 
tion of ink to paper, a platform for the elite; a backdrop to lend 
respectability to the promotion of goods and services — or a 
vehicle for fostering and reporting the scientific basis for a 
discipline: a mechanism for helping to guide the practice of 
that discipline, a sounding board for expressing the issues tliat 
face that discipline? 

I speak for myself, but I am convinced that all those who 
work for the Journal — as editors, board members, reviewers, 
regular contributors — also believe that the Journal's mission 
has been and continues to be 

• to establish the scientific basis for the procedures that com- 
prise respiratory care: 

• to guide and to teach the appropriate implementation and 
application of that scientific basis: 

• ilu icby. to validate respiratory care as a profession. 

W c all know that the clinical and bench studies, evalua- 
tions of methods and devices, and. more recently, assess-and- 
treat protcKols regukirly appciir in the Journal. The field 'knows" 
more about the vagaries of aerosol devices and aerosol admin- 
istration, the function of mechanical ventilators and manual 
resuscitators. the ins and outs of nitric oxide administration. 

and the shortcomings of some 'sacred cow" treatments because 
of sound, credible papers — part of the scientific basis for res- 
piratory care. Does the continued publication of such mate- 
rial have relevance for a field under fire? To respond to a ques- 
tion with a question, how else to validate our profession? 

We have all, probably, at one time or another interpreted 
chest radiographs, pulmonary function tests, and blood gas 
reports from the "comers," used state-of-the-art reviews to bol- 
ster in-service presentations and classroom lectures and to pre- 
pare for credentialing examinations. Many of us have incor- 
porated evidence-based Clinical FVactice Guidelines into policy 
and procedure manuals and our very clinical life. Does the 
continued publication of such material have relevance for a 
field under fire? To respond to a question with a question, how 
else to validate our profession? 

Do pieces that speak to emerging clinical problems and 
techniques belong in the Journal? If you are new to the field, 
spend a rainy afternoon flipping through your library's bound 
volumes of the Journal — The Journal of the 70s was in the 
thick of the controversy over IPPB; the very early 80s brought 
information on the emerging AIDS crisis almost as soon as 
it appeared on the national scene: and during the last 10 years 
caregiver protection, the resurgence of noninvasive ventila- 
tion, and the mechanisms of inverse ratio ventilation have had 
their day. Do such topics deserve recognition while still in 
controversy — before the evidence is in? Yes. if the treatment 
is evenhanded and facts are clearly dissociated from opinion 
and anecdote. To respond to a question with a question, how 
else to validate our profession? 

Do 'issues" papers — commentary on health care financ- 
ing and reform, maintenance and furthering of professional 
standards, educational preparation of practitioners — belong 
in the Journal? We think so — so long as the analysis is crit- 
ical and logical, and the commentary scholarly, credible, ref- 
erenced and documented. Such papers, too, must be based on 
evidence and ciuefully reseairhed — not heiU'say and opinion — 
so that they help prepare the practitioner/manager to face new 
challenges and. yes. new threats. Such papers are appropri- 
ate if they stand up to close scrutiny and speak to issues as 
issues. Does the continued publication of such material have 
relevance for a field untler fire'.' To respond to a question w ith 
a question, how else to validate our profession? 

A lot of reflection — now, are there regrets? The regrets are 
probably most nearly related to the limited success that the 


Respiratory Care • October "96 Vol 41 No 10 


Journal has had in guiding readers ( I ) to think more critically 
and analytically, to question, and to weigh the evidence and 
(2) to stay abreast and aware of clinical and technical advances. 
In regard to ( 1 ): A long time ago a bright, circumspect physi- 
cian laid on me words to the effect that the problem with res- 
piratory therapists is that the last thing they heard is what they 
believe. That scathing remark of almost 30 years ago had some 
ring of truth to it then and, although perhaps to a lesser extent, 
still does today. In regard to (2). as I respond to some of the 
inquiries that come to my desk, the "horse to water" syndrome 
seems to be the most appropriate diagnosis. 

And finally, that third R. resolution. Verbalizing resolu- 
tion is perhaps easier than implementing resolution because 

the uncertainties of the late 90s confront the Journal as surely 
as they do all facets of the profession. So. the Journal's mis- 
sion remains ... scientific basis ... guidance toward appro- 
priate implementation ... validation of the profession. The 
challenge is to continue to fulfill the mission in ways appro- 
priate to prevailing conditions. So. is the Journal over the hill 
at 40? No, the Journal faces the challenges with the maturity 
that comes from having dealt with change and controversy 
and with being 401 

Pat Brougher BA RRT 

Dallas, Texas 

Respiratory Care • October "96 Vol 41 No 10 


Original Contributions 

Regulation of Pressurization Rate Reduces Inspiratory Effort 
during Pressure Support Ventilation: A Bench Study 

Massimo Croci MD, Paolo Pelosi MD, Davide Chiumello MD, and Luciano Gattinoni MD 

OBJECTIVE: In a bench study, we sought to evaluate the influence of reg- 
ulation of pressurization rate (PR) on the imposed work of breathing (W'l) 
and inspiratory flow ( V|) pattern during pressure support ventilation (PSV). 
METHODS: A commercially available mechanical ventilator ( Bear 1000) was 
connected to an active lung simulator; the ventilator was set with PEEP at 
10 cm H2O and pressure support at 10 cm HiO above PEEP. Three differ- 
ent PR levels (-5, 0, and +5, arbitrary units) were tested at 2 different lev- 
els of inspiratory 'effort' (mean V| 0.45 and 0.9 L s '). The time from the onset 
of inspiratory effort to inspiratory flow delivery (ty,) and its pressure-time 
product per minute (PTPi ), the pressure-time product from the onset of \ i 
(PTP2). the duration of the below-PEEP phase of the respiratory circuit pres- 
sure (tp^) and the area of the pressure-volume curve below PEEP ( Wi) were 
measured as well as peak inspiratory flow (PIE) and the time to reach it (tpip). 
RESULTS: No statistically significant differences in t\ , and PTPi were observed 
among different PRs. On the contrary, PTPi, t|>=(i, and W\ were significantly 
reduced b> PR adjustment This variation was more pronounced with the higher 
inspiratory drive. At the same time, PIE was increased and tm shortened. 
CONCLUSION: Adjustments in PR can reduce imposed work of breathing 
during assisted spontaneous breaths and may improve patient comfort. Its 
regulation should be individually tailored to inspiratory effort and flow in 
each patient. [Respir Care 19%:41( IO):880-884] 

lntroducti<m & Objective 

Pressure support ventilation (PSV) has been made avail- 
able on a number of mechanical ventilators as a means to 
increase spontaneously assisted breaths. This is achieved by 
providing a variable amount of positive pressure (ie, pressure 
support) during the inspiraton,' phase of each spontaneous res- 
piratory cycle.' 

The authors are associated with the Institute ot .Anesthesia and Intensive 
Care. University of Milan. Ospedale Maggiore IRCCS. Milan. Italy. 

Dr Croci presented an ahslracl based on this study at the Opi:n FORIM 
during the 4 1 st Annual Convention and F.xhihition of the American .Asso- 
ciation for Respiratory Care in Orlando. Florida. December .^-6. 1995. 

Reprints/Correspondence: Croci Massimo, c/o Inst, of Anesthesia and 
Intensive Care. Ospedale Maggiore, v. F. Sfor/a .^.5. 201 22 Milan. Italy. 

During PSV, the inspiration can be di\ided into three 
phases: ( 1 ) the recognition of the beginning of inspiration 
(trigger phase), (2) the rise to pressure-support level (limit 
phase) and (3) the change from inspiration to expiration 
(cycle phase).' 

Large and well-know n differences exist among machines 
during the triggering phase.- ■* However, once the patient has 
begun the inspiratory effort, respiratory muscles contract 
throughout the whole cycle. ^ Hence, ideal PSV must provide 
not only a Uiggering phase as short as possible but also an inspi- 
ratory flow (Vi) synchronized with the pattern of muscle con- 
Uaction. Because a V| that is tcxi slow and a delayed peak inspi- 
ratory flow (PIF) may result in excessive inspiratory effort 
during a patient-triggered breath,'' ventilators are currently 
designed to dcli\ er maximum V] when a breath is triggered. 
L'ntortunately. this immediate maximum V| may not always 
be the optimal flow to meet a patient's inspiratory effort be- 
cause the high How could result in pressure "overshooting."'' 


Respirator\ Care • October '96 Vol 41 No 10 

Reducing Inspiratory Effort during PSV 

It is probable that a V, that is either too low or too high in- 
creases the work of breathing.** '' 

Some recent commercially a\aiiable mechanical \entilators 
allow manipulation of the pressurization rate (PR) of the res- 
piratory circuit, so that a Vi pattern can be modified and tai- 
lored to the patient's needs. However, at present, informa- 
tion about the effects of PR manipulations are conflicting: 
some authors'"" have found that an intermediate Vj improves 
patient-ventilator synchronization, others that optimal Vj 
depends on individual inspiratory drive.'- and still others'^^'* 
have found the lowest work of breathing for their patients at 
the highest Vi 

The aim of this study was to evaluate in a bench model how 
the PR regulation acaially modifies the work of breathing dur- 
ing PSV. 


In this study, we used a commercially available mechan- 
ical ventilator (Bear 1000).* with a positive end-expiratory 
pressure (PEEP) setting of 10 cm H2O and pressure support 
at 10 cm H2O above the PEEP le\el; pressure-trigger sensi- 
tivity was set at the lowest value (ie. 0.2 cm H2O). 

We connected the ventilator to a previously described active 
lung simulator'^ (Fig. 1) through a standard respiratory cir- 
cuit (180-cm length) without humidification devices. The sim- 
ulator consists of a mechanical ventilator (ABT 4100) able 
to generate a sine-wave flow pattern and modified to create 
a negative pressure in the respiratory circuit during the inspi- 
ratory phase, arranged in parallel with a passive compliance 
(60 mL ■ cm H2O"' ). We measured flow with a Fleisch No. 

2 pneumotachograph, positioned at the Y-piece of the ven- 
tilator circuit, connected to a Validyne MP43 differential pres- 
sure transducer. We calculated tidal volume (Vj) by electronic 
integration of the flow signal (integrator amplifier model 1 3- 
4615-70). We measured pressure in the circuit at the Y of the 
ventilator circuit, through a side port connected to a pressure 
transducer (Gould P23ID). We collected signals with a 4-chan- 
nel pen recorder (Gould Brush 2400s), processed via an ana- 
log-to-digital converter ( 100 samples/s/channel). and stored 
on a personal IBM-compatible computer. We further analyzed 
data using a software sampling of 5 random breaths in each 
experimental condition. 

We regulated the simulator to mimic low (mean-inspira- 
tory flow, or Vj/Ti = 0.43 L ■ s"' ) and high inspiratory "efforts' 
(Vt/Ti = 0.9 L ■ s ' ). With both inspiratory efforts, we tested 

3 different PR regulations (-5. 0. -l-5, arbitrary units). In the 
tested ventilator. PR can be adjusted from -9 to +9 in discrete 
steps of I unit, w hile is a default \ alue; the lowest PR value 
means the lowest V| with the most delayed PIF. 


Active Lung Simulator 
(with passive compliance; 

Mechanical Ventilator 
(with reversed valves) 

Fig. 1 . Schema for experimerntal set-up. EV = electronically mod- 
ulated valve; UDV = unidirectional valve; Pi = pressure mea- 
sured in ventilator circuit; and P2 = differential pressure for flow 

We measured the time from the onset of inspiratory effort 
to the beginning of inspiratory flow delivery (tv,); its pres- 
sure-time product (ie, the area below the PEEP level from the 
onset of respiratory effort to the onset of "Vi delivery, desig- 
nated PTP| ); the pressure-time product from its onset (ie. the 
area below the pressure level at which Vj delivery occurs, des- 
ignated PTP2); the duration of the below-PEEP phase of the 
ventilator circuit pressure, expressed as tp=(i(Fig. 2); the imposed 
work of breathing, or W],"' as the area of pressure-volume 
curve below PEEP (ie, the work associated with the begin- 
ning of inspiration/L of ventilation. Figure 3): the PIF; and 
the time needed to reach it (tpip). 

We reported all results as mean (SD); we performed sta- 
tistical analysis using an ANOVA test and a Bonferroni- 
paired t test when appropriate, accepting p < 0.05 as sta- 
tistically significant. 


Before flow delivery, we observed no significant differ- 
ences among PRs either in tvi or PTP| while respiratory drive 
changes modified tvi as seen in Table 1. 

Table 1 . Variables* Measured before Inspiratory Flow Onset, with 
High and Low Inspiratory Drive 

Pressurization Rate (arbitrary units) 
-5 +.'i 

lvi (ms)* 








64 (5)' 

PTP, (cmH:0 s 










0.030 (O.OtCw 

*Suppliers of commercial products are listed in the Product Sources sec- 
tion at the end of the te.xt. 

* Values are mean (SD); 1*,= time from the onset ol inspiratory effort to the begin- 
ning of inspiratory How delivery; PTP| = its pressure-time product; differences 
between High and Low inspiratory dri\e values are significant. p < 0.01 . 

Respiratory Care • October '96 Vol 41 No 10 


Reducing Inspiratory Effort during PSV 

Time (s) 

Fig. 2. Flow (upper panel) and pressure (lower panel) records with 
measured and calculated variables: a = time from inspiratory effort 
to flow delivery (ty,); b = pressure-time product (PTPi); c = pres- 
sure-time product from the onset of V| (PTP2); d = the duration of 
below-PEEP phase of the ventilator circuit pressure (tp=o). 

After Vi delivery, we observed that, as expected. PIF sig- 
nificantly increased and tpin decreased, in the presence of both 
low and high inspiratory drive, when PR was changed from 
-5 to and then to +5. Accordingly, with these modifications 
we observed also a significant reduction both in PTPi, tp=o. 
and W| with PR adjustment, with the lowest values measured 
at the highest PR. However, these variations were more pro- 
nounced with the high inspiratory drive than with the lower 
one as shown in Table 2. 


Many factors may influence the external work imposed 
by a breathing apparatus on a patient during assisted spon- 
taneous breathing.^ In this study, we demonstrated that not 
only trigger sensitivity" but also PR manipulations can actu- 
ally influence such work. 

Technical .\spects of Bench Measurements 

The e\aluation of the work of breathing of a patient dur- 
ing assisted breaths can be made only using an esophageal 

0.07 -1 

0.06 - 

0.05 - 

0.04 - 

0.03 - 

0.02 - 

001 - 

Pressure (cm H2O) 

Fig. 3. Below-PEEP area of a pressure-volume curve, yielding a 
measure of imposed work of breathing (W|). Solid arrow indicates 
V| onset. 

Table 2. Variables* MeaMired after Onset of Inspiratory Flow . with 
Low and High Inspiratory Drive 

Pressurization Rate (arbitrary units) 
-5 +5 








0.55 (0.0,5)' 

0,40 (0.02 1 

0.32 (0.02) 

PrP:(emH;0 s) 


0.49 (0.04)' 

0.21 (0.04) 


0,42 (0.004) 
0.5 1 (0.008)' 

0.27 (0.007) 

0.21 (0.008) 

\\|(mJ L-') 

192.5 (4.7) 
433.3 (29.5)' 



* Values are mean (SD); difference among pressurization rales is signifieant. p = 
O-Ol; PTP; = tlie area of the pressure-volume (PV)eurve below tlie level at whieh 
inspiratory flow ( V|) delivery occurs; tp=ij = the duration of below-PHHP phase in 
the ventilator circuit; W| = imposed work of breathing (ie. the area of PV curve 
below PEEP, per L of ventilation); PIF = the peak inspiratory flow; tpif = time 
needed to reach PIF; dillerence in results with High and Low inspiratory drive is 
signifieant. p <0.01. 


Respiratory Care • October "96 vol 41 No 10 

Reducing Inspiratory Effort during PSV 

balloon"* because inspiratory muscle contraction cannot be 
easily detected on airway pressure tracings.* Moreover, it 
has been demonstrated that inspiratory activity persists over 
the entire inspiratory phase, once inspiratory muscles are acti- 
vated during the triggering phase.' Our model actually allows 
us to study only the amount of work added by the breath- 
ing system (Wi) because we can measure only the pressure 
at the 'airway opening""* (even though this is not the total 
work load during an assisted breath). Ne\ertheless. we chose 
to study the effects of PR manipulations during PSV using 
a model rather than "in vivo' because the active lung sim- 
ulator, by exerting a reproducible inspiratory effort, excludes 
the main source of measurement variability (ie, die variability 
between patients). These results could be useful to compare 
different ventilatory settings or different mechanical ven- 
tilators. Moreover. Wi is related to patient muscle fatigue, 
so that its reduction could reduce oxygen consumption and 
duration of weaning.''' 

The part of inspiratory time during which airway pressure 
lies below PEEP level can be divided into ( 1 ) trigger and (2) 
post-trigger phases by the onset of inspiratory flow-" (Fig. 2). 
The first phase is characterized by an inspiratory effort, with 
minimal volume changes due to circuit and gas compliances; 
the drop in airway pressure and its duration can describe ade- 
quately this niitial phase. The measurement of the pressure- 
time product before Vi onset (PTPj ) can evaluate the effort 
performed to activate the assisted breath. 

Because only a few milliseconds are needed for V| deliv- 
ered from the machine to surpass the patient's V|, we can mea- 
sure a small pressure drop after V| initiation; we measured 
this difference again using the pressure-time product (PTPt). 
However, after Vj delivery, pressure decrease below PEEP 
is associated with volume changes (Fig. 3). allowing calcu- 
lation of W[ (which has a dimension of work): this can esti- 
mate not only the pressure drop (before and after V| deliv- 
ery) but also the effectiveness of the initial response of the 
mechanical ventilator. Therefore, we consider this index a valu- 
able means to measure all these variables. 

Triggering Phase 

In this study, we observed no changes in the vaiiables mea- 
sured before V| onset at different levels of PR because PR 
manipulation acts only after V] delivery. 

However. tvi shows a significant difference between high 
and low inspiratory efforts, reflecting the different settings 
of the active lung simulator. As previously stated.-" pressure- 
triggered mechanical ventilators deliver V| when a well-defined 
pressure drop is measured in the ventilator circuit; because 
the lesser inspiratory effort in our experimental set-up mod- 
ifies the pressure in the ventilator circuit at a slower rate than 
does the greater inspiratory effort, the machine meets the cri- 
terion to trigger Vi after a longer time. 

On the contrary, we found no sienificant difference between 

PTPi with simulated high and low mspn-atory drives. The 
mechanical ventilator used in this study has a digital polling 
time of 10 ms; this produces a delayed response of the inspi- 
ratory valve of. on average, ."i ms.-" During this time, a much 
greater decrease in the ventilator circuit pressure can be 
expected during tests with the higher inspiratory drive. Then, 
the resulting PTP; is not different from that measured at a lower 
inspiratory drive, even if tv[ is significantly different. 

Post-Triggering Phase 

We found that PR manipulation significantly modified the 
V| pattern (PIF and ipn ) and hence the viuiables involved with 
post-triggering phase (PTPi. W|. and tp=()); however these 
manipulations behaved differently with high and low inspi- 
ratory drives. 

Most of the work associated with mechanical ventilator 
triggering can be related to insufficient fiow delivery after the 
trigger phase, ^ and this work can be reduced by increasing 
the amount of gas delivered to the patient using PS V-" or by 
altering flow.'- Wi is actually greater with high- rather than 
with low-inspiratory effort using PR -3; PR regulation over- 
came these differences when increased to +5. Similar mod- 
ifications can be observed when PTP: or tp=() are considered. 
This means that the Vj delivered by the mechanical ventila- 
tor does not match the inspiratory effort performed by the active 
lung simulator as well at high as at low inspiratory effort when 
PR -5 is used. Because a greater inspiratory effort results in 
a greater peak inspiratory flow,-' increasing PR (ie, increas- 
ing the level of V; available during the inspiratory time) abol- 
ished the differences of Wj. PTP:, and tp=() existing between 
low and high inspiratory effort of the active lung simulator. 
Similar results could he obtained by increasing the level of 
pressure support;" however, this manoeuvre increases air- 
way pressure and at least one author-' has suggested that the 
manoeuvre has the potential for inducing air-trapping, auto- 
PEEP, and an increase in work of breathing, while PR manip- 
ulations did not. 

An excessively high PR could lead to an overshoot in the 
airway pressure tracing.^ However, in our experimental set- 
ting no pressure overshoot was observed, despite a rather large 
variation in Vj/T;. within the range of PR studied. Because 
this phenomenon is usually observed when a mechanical ven- 
tilator delivers a V| that is too high for a patient with high resis- 
tances and/or low compliance.'"' ' it is possible that the rather 
high compliance (60 niL cm HiO ' ) and the low resistance 
(no endotracheal tube was inserted between mechanical ven- 
tilator and lung simulator) can. at least in part, account for this. 


From our "in vitro' observations, we can conclude that 
adjustment of the rate of pressurization can be a valuable tool 
to reduce the imposed work of breathing during pressure sup- 

Respiratory Care • October '96 Vol 41 No 10 


Reducing Inspiratory Effort during PSV 

port ventilation. This regulation could improve patient's com- 
fort during spontaneous assisted breaths, enhancing the patient- 
ventilator synchrony. However, its regulation must be tailored 
to each patient to determine the proper level; further studies 
are needed to determine those variables that can guide the prac- 
titioner to properly set the rate of pressurization. 



Bear 1000. Allied Healthcare Inc. Riverside CA 
ABT4100. Kontron. Milan. Italy 

Measuring & Recording Equipment: 

Integrator amplifier model 1 3-46 1 5-70. pressure transducer model P23ID. 

pen recorder model Brush 2400s. Gould Inc. Cleveland OH 
Differential pressure transducer model MP45. Validyne Engineering Corp. 

Northridge CA 


1 . Brochard L. Pressure support ventilation. In: Tobin MJ editor. Prin- 
ciples and practice of mechanical ventilation. New York: McGraw- 
Hill. 1994. 

2. Cox D. Tinloi SF. Farrimond JG. Investigation of the spontaneous 
modes of breathing of different ventilators. Intensive Care Med 1988; 

3. Gurevitch MJ. Gelmont D. Imponance of trigger sensitivity to ven- 
tilator response delay in advanced chronic obstructive pulmonary dis- 
ease with respiratory failure. Crit Care Med 1989;17(4):354-359. 

4. Bersten AD. Rutten AJ. Vedig AE. Skowronski GA. .Additional work 
of breathing imposed by endotracheal tubes, breathing circuits, and 
intensive care ventilators. Crit Care Med 1989;17(7):671-677. 

5. Marini JJ, Rodriguez RM. Lamb VJ. The inspiratory workload of 
patient-initiated mechanical ventilation. Am Rev Respir Dis 

6. Marini JJ.CappsJS, Culver BH. The inspiratory work of breathing 
during assisted mechanical ventilation. Chest I98.'i;87(5):612-618. 

7. Mclntyre NR. Nishimura M. Usada Y. Tokioka H. Takezawa J. Shi- 
mada Y. The Nagoya conference on system design and patient-ven- 
tilator interactions dunng pressure support ventilation. Chest 1990:97 

8. Civetta JM. Nosocomial respiratory failure or iatrogenic ventilator 
dependency (editorial). Crit Care Med I993:2U2):I71-173. 

9. Fabry B, Guttmann J. Eberhard L. Bauer T. Haberthur C. Wolff G. 
An analysis of desynchronization between the spontaneously breath- 
ing patient and ventilator during inspiratory pressure support. Chest 

10. Czervinske MP. Shreve J. Lester KB. Teague WG. Effects of work- 
ing pressure on respiratory pattern and airway pressure during pres- 
sure support ventilation (PSV) in infants with chronic lung disease 
(CLD) (abstract). Respir Care I988;33( I0):930. 

1 1 . Maclntyre NR. Ho LI. Effects of initial How rate and breath termi- 
nation criteria on pressure support ventilation. Chest I991:99( 1 ): 

12. Branson RD. Campbell RS. Davis K Jr. Johannigman JA, Johnson 
DJ. Hurst JM. Altering flowrate during maximum pressure support 
ventilation (PSVnuO: effects on cardiorespiratory function. Respir 
Care I990;35( 1 1 ): 1056-1064. 

13. Bonmarchand G. Chevron V. Girault C. Jusserand D. Burel F. Moritz 
F. et al. Effects of initial flow rate (IFR) variation in pressure sup- 
port ventilation (PSV) (abstract), .i^m J Respir Cnt Care Med 1995: 

14. Cane R. Campbell R. Goldsben^, D. Huffman J. Nolan J. Hurst J. 
Effect of inspiratory rise time (IRT) setting during pressure support 
ventilation (PSV) on patient work of breathing (WOBp) (abstract). 
Crit Care Med I995:23:A120. 

1 5. Damia G. Cigada M. Solca M. Pelizzola A. A new active model lung. 
Intensive Care Med 1988;14( I ):60-63, 

16. Viale JP. .\nnat G. Bertrand O. Godard J. Motin J. Additional inspi- 
ratory work in intubated patients breathing with continuous positive 
airway pressure system. Anesthesiology 1985:63(51:536-539. 

1 7. Sassoon CSH. Giron AS. Ely EA. Light RW. Inspiratory work of 
breathing on flow-by and demand-flow continuous positive airway 
pressure. Crit Care Med 1 989: 1 7( 1 1 ): 1 1 08- 1 1 1 4. 

1 8. Annat G, Viale JP. Measuring the breathing workload in mechan- 
ically ventilated patients. Intensive Care Med 1 990; 1 6( 7 ):4 1 8:42 1 . 

19. Banner MJ. Blanch PB. Kirby RR. Imposed work of breathing and 
methods of triggering a demand-tlow. continuous positive airway 
pressure system. Crit Care Med 1 993:2 1( 2 ): 1 83- 1 90. 

20. Sassoon CSH. Mechanical ventilator design and function: the trig- 
ger variable. Respir Care 1992:37(9): 1056-1069. 

21. Younes M. Interactions between patients and ventilators. In: Rous- 
sos C editor. The Thorax, 2nd ed. New York: Marcel Dekker, 1995. 

22. Brochard L. Pkiskwa F. Lemaire F. Improved efficacy of spontaneous 
breathing with inspiratory pressure support. Am Rev Respir Dis 
1 987; 1-36(2 1:411-415. 

23. Jubran A. Van de Graaff WB. Tobin MJ. Variability of patient-ven- 
tilator interaction w ith pressure support ventilation in patients with 
chronic obstructive pulmonary disease. Am J Respir Crit Care Med 



Evaluation of the Puritan Bennett 335 Portable Pressure Support 
Ventilator: Comparison with the Respironics BiPAP S/T 

Nicholas S Hill MD, Sangeeta Mehta MD, Carol C Carlisle RN, and F Dennis McCool MD 

INTRODUCTION: We compared performance characteristics and clinical 
efficacy of the Nellcor Puritan Bennett 335 and the Respironics BiPAP S/T 
pressure support ventilators (PSV). METHODS: In the laboratory, triggering 
capabilities of the ventilators were assessed in 3 normal subjects, using changes 
in esophageal pressure. Determinants of delivered tidal volume (Vj) and leak 
compensation were evaluated during controlled breathing on the 335 and in 
the spontaneous/time (S/T) mode on the BiPAP. In the clinical phase, day- 
time blood gas values, pulmonary function, nocturnal gas exchange, and sub- 
jective evaluatioas were compared after 2 weeks of use by patients with chronic 
respiratory failure due to restrictive diseases previously stabilized using the 
BiPAP S/T. RESULTS: The 335 at the most sensitive setting (1 for most, 5 
for least) was more sensitive both for inspiratory triggering and expiratory 
cycling than the BiPAP S/T. During controlled breathing in the A/C mode 
on the 335 or the S/T mode on the BiPAP, determinants of expiratory cycling 
differed substantially, causing marked differences in breathing pattern, deliv- 
ered Vt, and air leak compensation at certain settings. Clinical evaluation 
showed the ventilators to be equally efficacious in supporting nocturnal and 
daytime gas exchange, except that oxygenation improved slightly when patients 
resumed BiPAP use. Daytime vital signs and pulmonary function remained 
stable throughout. Patients judged the ventilators to be equally comfortable 
in terms of airflow and triggering, but deemed the 335 quieter and the BiPAP 
more portable. Of the 6 patients, 4 preferred the 335 ventilator at the end of 
the study. CONCLUSIONS: The 335 is a portable PSV that is as eft^ective in 
supporting patients uith chronic respiratorj failure as is the BiPAP S/T. Because 
it offers adjustable triggering and cycling, it may be preferred by some patients. 
However, close attention must be paid to the difi'ering mechanisms for expi- 
ratory cycling that determine delivered Vt, before switching between ven- 
tilators or ventilator modes. IRespir Care 1996;41( 10);885-894] 

The authors are associated with the Pulmonary Division. Brown Univer- 
sity, Providence, Rhode Island. 

The authors have no financial interest in the devices evaluated; however, 
Dr Hill has done consulting for and has received research awards from 
both Nellcor Puritan Bennett and Respironics. and Dr Mehta is a research 
fellow supported by Respironics. Nellcor Puritan Bennett provided part 
of the funding for the study. 

An abstract Of this paper was presented at the American Thoracic Society 
meeting in New Orleans, Louisiana, in May 1996. 

Correspondence: Nicholas S Hill MD, Pulmonary Division, Rhode Island 
Hospital, 593 Eddy Street. Providence RI 02903. 


Nocturnal nasal positive pressure ventilation (NNV) 
improves gas exchange and symptoms of chronic hypoven- 
tilation, such as morning headache and hypersomnolence, in 
many patients with chronic respiratory failure. ''^^ Early stud- 
ies used volume-limited portable ventilators, but more recently, 
pressure-limited ventilators, such as the BiPAP S/T, have gained 
popularity for this appHcation.^' These pressure support ven- 
tilators (FSVs) may be less expensive, more portable, and, 
perhaps, more comfortable* than their volume-limited coun- 

Respiratory Care • October '96 Vol 41 No 10 


Pressure Support ventilator Evaluation 

terparts, and may be preferred by some patients requiring %en- 
tilatory assistance tor nocturnal hypoventilation. 

However, portable PSVs may have limitations when patients 
have special needs. For instance, some PSV devices lack alarms 
and, thus, may not be sate for patients who require contin- 
uous ventilatory assistance, unless external alarms are added., maximal inspiratory positive airway pressure (IPAP) 
(20 cm H2O on some units), may be inadequate for patients 
with noncompliant chest walls or lungs. Furthemiore, if sen- 
sitivities for cycling between IPAP and expiratory positive 
airway pressure (EPAP) are fixed, optimization of patient syn- 
chrony and comfort may be difficult. The 335 ventilator* has 
alarms that activate during power disconnection or sustained 
air leak. It delivers IPAPs of up to 35 cm HiO and has 
adjustable trigger sensitivities for cycling between IPAP and 
EPAP. Our study was designed to compare performances of 
the standard BiPAP S/T and the 335. We hypothesized that 
the 335 would support ventilation as well as the BiPAP, but 
that individual patients would prefer one over the other, depend- 
ing on personal needs. The study was conducted in 2 phases: 
a laboratory phase to compare trigger sensitivities, effects of 
different settings on delivered tidal volume ( Vj) during con- 
trolled breathing, and ability to compensate for air leaks: and 
a clinical phase in which patient symptoms and acceptance 
and the ability of the ventilators to sustain nocturnal and day- 
time gas exchange were compaied in experienced users of the 


Description of the Ventilators 

The Puritan Bennett 335 (Fig. I ) and the BiPAP S/T are 
both pressure-limited flow generators capable of delivering 
continuous ptisitive ainvay pressure (CPAP) or cycling between 
IPAP and EPAP, using either a patient fiow-triggered spon- 
taneous mode or a spontaneous combined with a time-cycled 
back-up rale (SAT on the BiPAP, A/C on the 335). The BiPAP 
S/T can also provide the time-cycled (T) mode only. Dif- 
ferences between the two ventilators are listed in Table I. 
.'Xdjuslable triggering and cycling sensitivities ( 1 for most to 
5 for least) are available on the 335 but not on tlie BiP.AP. Both 
ventilators have been approved by the Food and Daig Admin- 
istration — the 335 as a ventilatory a.ssist device and tlie BiPAP 
for use in obstructive sleep apnea. 


Phase I was performed on normal subjects in the Respi- 
ratory Physiology Laboratory at Memorial Hospital, Pawtucket 

Fig. 1 . The Nellcor Puritan Bennett 335 ventilator with detachable 
control panel in place. Ventilator tubing is attached to the port 
shown at the lower left of the control panel. 

Table I . Differences between the Puritan Bennett 335 and the BiPAP 
Ventilatory Support Systems 




Weight (kg) 



Dimensions (cm) 


X 30 X 30 


IPAP range (cm H:0) 



Adjustable IPAP and 

EPAP sensitivities 



Digital display 



Delay and ramp function 



Remote control 







♦Suppliers of commercial products are listed in the Product Sources sec- 
tion at the end of the text. 

♦ A version of Ihc BIPAP available outside the t'.S.. BiP.'VP-.TO. provides up to .10 

cm H:0 IPAP. 

^ Available on S/T-D with remote control. 

RI. For Phase 2. patients were recruited from Rhode Island 
Hospital outpatients who had been using the BiPAP S/T \ en- 
tilator nociumally for at least the previous year. All patients 
had chronic respiratory failure caused by severe restrictive 
thoracic, had improved with NNV. and had been free 
of any acute respiratory illness for at least 1 month prior to 
enUA' into the stud\ . Patient characteristics, including age. gen- 
der, diagnosis, body mass index, \ ital capacit) . \ e;irs of NNV 
use, and arterial blood gas values before initiation of NNV 
and after stabilization are show n in Table 2. No patient was 


Respiratory Care • October '96 Vol 41 No 10 

Pressure Support Ventilator Evaluation 

Table 2. Anthropometric Characteristics. Vital Capacities, and Arterial Blood Gas Values before and after Initiation of BiPAP 









Blood Gas 








0.87 (24%)S 
























0.76 (24%) 








0.96 (35%) 

















* BMi = body mass index; FVC = forced vital capacity; MD = limb-girdle muscular dystrophy; KS = kyphoscoliosis. 

t Stable room air daytime arterial blood gas values obtained after 6 or more months of noclumal \ enlilation. 

t Numbers in parentheses are ^t predicted. 

§ Obtained while patient was using O2 (2 L/min). 

using supplemental O2 at the time of the study. The study was 
approved by the Institutional Re\ lew Boards at the Rhode 
Island and Memorial Hospitals, and all subjects gave writ- 
ten, informed consent. 

Phase- 1 Studies 

TTiree normal subjects were studied in the fasting state. Cus- 
tom-made esophageal balloons were passed transnasally. 
inflated with 0.5 niL of air. and positioned, using appropri- 
ate pressure swings during a Mueller maneuver. Esophageal 
pressures (Pes) were recorded using Statham pressure trans- 
ducers. Rib-cage and abdominal excursions were monitored 
using plethysniograph belts. The sum tracing was calibrated 
for Vx measurements using a wedge spirometer. A standard 
nasal continuous positive airway pressure was fitted and com- 
fortably positioned. Mask pressure and airflow were con- 
tinuously recorded on an IBM-compatible computer using data 
acquisition software. 

The 333 ventilator and BiPAP S/T were compared under 
IPAP and EPAP settings corresponding to the range of pres- 
sures commonly used clinically. The ventilators were eval- 
uated for ( I ) the sensitivity of triggers for cycling between 
IPAP and EPAP as determined by changes in esophageal 
pressure; (2) the trigger response time as determined by 
the time delay between patient initiation of inspiratory or 
expiratory airflow and ventilator cycling; (3) the effects 
of IPAP and EPAP sensitivity and inspiratory-to-expira- 
tory-time (I:E) settings on delivered Vj during spontaneous 
and controlled breathing in the A/C (or S/T) modes; and 
(4) the flow patterns generated for air leak compensation 
as determined by measurement of inspiratory-to-total-cycle 
ratio (Ti/Tjot) during the intentional introduction of air 
leaks through the mouth. 

Phase-2 Studies 

Six patients recorded symptoms on a daily diary for a min- 
imum of 2 weeks before daytime studies were peiformed in 
the pulmonary function laboratory. On the night of that test- 
ing, they underwent nocturnal monitoring while using the 
BiPAP device. On the following day, settings on the 335 were 
adjusted so that respiratory rates and delivered Vys matched 
those during BiPAP ventilation. Nasal masks, tubing, and 
exhalation valves remained the same throughout the study. 
Exhaled Vx was measured using a pneiimotachometer inserted 
between the nasal mask and exhalation valve. Patients used 
the 335 ventilator noctumally for the next 2 weeks, followed 
by repetition of daytime and nocturnal studies. Patients were 
then switched back to the BiPAP ventilator using the pre- 
vious settings, and daylime and nocturnal sUidies were repeated 
2 weeks later. 

Laboratory Studies & Nocturnal Monitoring 

Patients underwent daytime laboratory studies at approx- 
imately the same time on 3 separate occasions. Vital signs 
including heart and respiratory rate were counted for 1 minute, 
blood pressure, spirometry, and maximal inspiratory and expi- 
ratory pressures (P|. max and Pn-max) were measured, and arte- 
rial blood was sampled while the patient was sitting upright, 
breathing room air. For spirometry and maximal pressures, the 
best of 3 measurements was used. Minute and Vjs were mea- 
sured for 3 minutes, using a hand-held spirometer. Nocturnal 
monitoring of heart rate, respiratory rate, chest-wall impedance, 
nasal airflow (detected using a themiistor), and O2 saturation 
was peifomied in the patient's home using a4-channel recorder 
and transcutaneous CO2 and O2 monitors. Mean heart and res- 
piratory rates and O2 saturations were obtained by sampling 

Respiratory Care • October "96 Vol 41 No 10 


Pressure Support ventilator Evaluation 

measurements every 10 minutes, and nadir O; saturation for 
the night was recorded. Air leak was defined as > 80% reduc- 
tion in the amplitude of the nasal thermistor signal u ith < 50% 
reduction in chest-wall motion. Sleep-disordered breathing 
"events." defined as > than ,50% reduction both in airflow and 
chest- wall motion for > 10 seconds associated with at least a 
4% reduction in O: saturation, were sought on the continu- 
ous tracing. Transcutaneous Pco: and Pq: measurements were 
recorded every 5 minutes overnight and averaged. 

Symptom Diaries & Subjective Assessment 

Patients recorded daily estimations of general well-being, 
dyspnea, energy level, comfort, nasal congestion, ease of ven- 
tilator use and triggering, comfort of ventilator airflow, noise 
level, and portability, using visual analog scales from 1 (for 
least) to 10 (for most). Visual analog scales have been val- 
idated for dyspnea, but not for other measures. 

Statistical Analysis 

Means for each variable were compiled using analysis of 
variance for repeated measures. When F ratios were signif- 
icant, differences between individual group means were ana- 
lyzed post-hoc using the Scheffe test. Data were considered 
significant when p < 0.05 and are displayed as mean (stan- 
dard dc\ iation. SD). 






2.0 - 

1.5 - 



3 - 




10/5 15/5 20/5 


Laboratory Evaluation 

Comparison of Triggering & Cycling Sensitivities. Inspi- 
ratory triggering sensitivity was measured as the drop in 
esophageal pressure necessary to initiate a breath while sub- 
jects breathed spontaneously in the S/T mode on the BiPAP 
or in the A/C mode on the 335 set at inspiratory sensitivities 
of 1. 3. or 5. Figure 2A shows that triggering on the 335 at 
the Sensitivity 1 setting required the smallest change in P^s 
and, hence, was the most sensitive setting. The changes in Pes 
required for triggering at the 3 and 5 settings on the 335 were 
comparable to those measured during BiPAP use. For cycling 
from IPAP to EPAP, the increase in P^., occuixing at the time 
of cycling wa.s tiiken as a measure of expiratory triggering sen- 
sitivity. Once again, the Sensitivity 1 setting on the 335 required 
the least change in Pes. whereas cycling for the BiPAP and 
the 3 and 5 settings on the 335 required similar pressure changes 
(Fig. 2B). 

The time delay for inspiratory triggering or expiratory 
cycling was measured as the elapsed time between the first 
detectable change in patient-initiated airtlow and ventilator 
triggering or cycling. Although inspiratory and e.xpiratoiy time 
delays at the Sensitivity 1 setting on the 335 were shorter than 
those on the BiPAP (Fig. 3 A & 3B). 

Fig. 2. Inspiratory (A) and expiratory (B) triggering sensitivities of 
the BiPAP SAT and the Puritan Bennett 335, with Inspiratory trig- 
gering sensitivity measured as the drop In esophageal pressure 
(Pes) at the time of ventilator initiation of IPAP. Subjects breathed 
spontaneously in the S/T mode on the BIPAP (■) or in the A/C 
mode on the 335. set at Inspiratory sensitivities of 1 (D). 3 (•). and 
5 (0). and expiratory sensitivity of 5. Expiratory triggering sensitiv- 
ity was defined as the increase in Pes occurring at the time of 
cycling from IPAP to EPAP and was measured while subjects 
breathed spontaneously at the same settings on the BiPAP except 
that inspiratory sensitivity was set at 1 while expiratory sensitivities 
were varied between 1 , 3, and 5. N = 3 subjects. 3-4 measure- 
ments/subject at each setting, 'p < 0.05 compared with BIPAP S/T. 

The sensitivity of cycling from IPAP into EPAP affected 
the spontaneous breathing pattern and delixcred V] . When 
the expiratory Sensitivity 1 setting on the 335 was used, the 
ratio of inspiratory time to total respiratory cycle time 
(T|/Ttot) was significantly lower than that observed dur- 
ing BiPAP use (Fig. 4A). Corresponding to this shortened 
inspiratory cycle, delivered Vt. as measured by impedance 
plethysmography, was significantly smaller when the expi- 
ratory Sensitivity 1 setting was used on the 335 as compared 
to those obtained during use of the same pressure settings 


Respiratory Care • October "96 Vol 41 No lO 

Pressure Support Ventilator Evaluation 




6 - 

5 - 




I I I 

10,5 15/5 20/5 




(T 0.45 

040 - 













10/5 15/5 


— I — 

Fig. 3. Time delays in the 335 before inspiratory triggering (A) or 
expiratory cycling (B). measured as the elapsed time between the 
first detectable change in patient-initiated airflow and ventilator 
tnggering, are plotted at IPAP/EPAP settings of 10/5, 15/5, and 
20/5 cm H2O (*p < 0.05 compared to the BiPAP S/T). BiPAP SAT = 
■ : 335 sensitivity 1 = D, 3 = •, and 5 = 0. 

Fig. 4. Inspiratory time as a function of the total respiratory cycle 
(TiATtot, A) and tidal volume (B) during spontaneous triggenng of 
the BiPAP SAT (■) and the 335. Settings on both ventilators were 
10/5. 15/5, and 20/5 cm H2O, and expiratory sensitivities on the 
335 were 1 , [D] 3. [•] and 5 [o]. *p < 0.05 compared to the BiPAP 

on the BiPAP. At the expiratory Sensitivity settings 3 and 
5 on the 335. Vjs were comparable to those delivered dur- 
ing BiPAP use. 

Determinants of Inspiratory Duration & Delivered Vj 
during Controlled Breathing & Air Leak. The ventila- 
tors were set at a rate of 16/inin and IPAP/EPAP settings 
of 15/5 cm H:0, Subjects were asked to relax and "let the 
ventilators breathe for them." As shown in Fig. 5A, T|/Ttot 
was determined by the '^HPAP setting on the BiPAP in the 
T mode, but not in the S/T mode that renders the '/r IPAP 
control inoperative. During use of the comparable A/C mode 
on the 335, Ti/Tjot w^i^ determined by the I:E setting. Deliv- 
ered Vjs were correspondingly lower during controlled 
breathing at the lower 1:E (Fig. 5B). as might be expected 
because of the shorter inspiratory duration. Thus, switch- 

ing from the S/T mode on the BiPAP to the T mode w ith 
a 9f IPAP setting of 25'7f or on the 335 in the A/C mode w ith 
an I:E of 1 :3 could result in a drop in delivered Vj of 50% 
or more. Unlike the case with spontaneous breathing, how- 
ever, delivered Vx during controlled breathing on the 335 
was not affected by the expiratory sensitivity setting (data 
not shown). 

The duration of inspiration during air leaking also 
depended on the mode selected and the I:E (or %IPAP) set- 
ting. Ventilator settings were a rate of 16 breaths/min and 
IPAP/EPAP of 15/5 cm H:0. Subjects were asked to pro- 
duce a large mouth leak. As shown in Figure 6. Ti/Tjot 
exceeded 0.6 in the S/T mode on the BiPAP. indicating inver- 
sion of the I:E. In contrast, Ti/Ttot in die T mode on the 
BiPAP was determined by the %IPAP and in the A/C mode 
on the 335 by the 1:E setting. Thus, the duration of inspi- 

Respiratory Care • October "96 Vol 41 No 10 


Pressure Support Ventilator Evaluation 

A 06 

0.5 - 










1200 - 



600 - 







(% IPAP) 


Fig. 5. Tin"TOT (A) and tidal volume (B) during controlled breathing 
using the BiPAP SAT in the SfT [■] and T modes [D], and the 335 
in the A/C mode l*]. I:E were set at 1:3. 1:2, and 1:1 on the 335; 
%IPAP on the BiPAP was set at 25%. 33%. and 50%, to corre- 
spond with the l:E on the 335. Measurements in each mode were 
obtained with the ventilator rate set at 16 breaths/mm, IPAP/EPAP 
set at 15/5 cm HjO, inspiratory and expiratory sensitivity settings 
on the 335 set at 1 and 5. respectively, and the subject instructed 
to suspend all spontaneous breathing efforts, 'p < 0.002 compared 

to the BiPAP srr. 

ration during air leaking can differ mari<cdly between ttiese 
ventilatcirs, even at the same rale and pressure settings. This 
may have important implications for their ability to com- 
pensate for leaks. 

Clinical Kvaliiatioii 

Ventilator Settings. Baseline settings for each patient on the 
BiPAP S/T ventilator and settings on the 335 selected to match 
baseline rates and Vjs are shown in Table 3. The BiPAP v\ as 
set in the SfJ mode except in Patient 2. who preferred the T 
nKKle. and the 335 was set in the A/C nnxle w ith an I;E of 1 : 1 .5. 

0.8 - 







0.3 - 

0,2 - 


— 1 — 






(% IPAP) 

— 1 — 


Fig. 6. Effect of air leak on T|/Ttot. The BiPAP was set in the SAT 
[■] and T [D] modes, and the 335 [•] in the A/C mode during con- 
trolled breathing (same settings as for Figure 4). Subjects were 
instructed to induce an intentional air leak through the mouth, "p < 
0.05 compared to the BiPAP SAT. tp < 0.05 compared with BiPAP 
SAT and the 335. 

Ramp and Delay functions on the 335 were not used. Base- 
line backup ventilator rates had been set at 2 breaths/min below 
resting spontaneous breathing rate and were identical on the 
2 ventilators. Vjs were adjusted in awake patients who were 
instructed to exert no breathing effort while the ventilator 
assisted them. In order to achieve the same exhaled Vjs. the 
IPAP on the 335 averaged 1 .6 cm H2O higher than on the 
BiPAP (Table 3). This was partly related to the need for a higher 
IPAP because of the higher minimum EPAP on the 335 (3 
cm H;0 vs 2 cm H:0 on the BiPAP). Despite this, the aver- 
age inflation pressure (IPAP-EPAP) necessary to achieve the 
same Vx was still slightly higher on the 335. Set IPAPs on 
both machines were approximately I cm H:0 higher than the 
IPAPs shown in Table 3. which were measured directly at the 
mask using a calibrated pressure transducer. This was related 
to small inaccuracies in pressure settings and some loss of pres- 
sure to overcome small resistances in the air filter on the 335 
and ventilator tubing. With regard to sensitivity settings, all 
patients coinmented that the 335 seemed to cycle into EPAP 
more easily than the BiPAP, giving them a 'shorter' breath, 
even at the least sensitive EPAP sensitivity setting of 5 (Table 
3). Five patients preferred the most sensitive IPAP Sensitivity 
1 setting, but Patient 2 preferred a setting of 2. 

Daytime Studies. Daytime \ ital signs, tidal and minute vol- 
umes, spirometry, PE-max and Pi-max remained unchanged 
throughout the 3 phases of the trial (Table 4). P.,c(): declined 



Pressure Support Ventilator Evaluation 

Table 3. Ventilator Settings for Each Patient 


Rate (breaths/niin) 

IPAP* ( 

:m H:0) 

EPAP* ( 

cm H2O) 



Exhaled V 

T (niL) 




















428 (25)i 












521 (25) 






















603 (75) 





















301 (28) 







3.2 (2.0) 






* Actually measured at inask (vs set on \cnIilaior) 

' Applies only to 335 ventilator; BiPAP has no adjustable sensitivity. 

f Values are expressed as mean (standard deviation). 

' p = < 0.05 BiPAP compared with 335. 

slightly during the .study, but the change was not statistically 
significant. Although P;iO: did not change when patients switched 
from the BiPAP to the 335, the slight increase that occuned 
after return to BiPAP ventilation was statistically significant. 

irnately twice each hour. Synchronization was readily 
achieved with both ventilators, with patients with muscu- 
lar dystrophy breathing at the back-up rate 95% of the noc- 
turnal monitorinu time. 

Table 4. Means and Standard Deviations (Sl^) for Daytime Vital 

Signs. Pulmonary Functions, and Arterial Blood Gas Values 
on Room Air in 6 Patients. 





Heart rate, mm ' 

Respiratory rate, min^ 

Vt, L 

Vt, L/min 

FVC, mL 


Pi max, cm H^O 

Pe max. cm H:0 


Paco;. torr 

Paoj. torr 

83 (6) 


0.21 (0.08) 


942 (4(») 

793 (394) 






83 (6) 


0. 19(0.06) 


915 (.305) 

775 (284) 


.57 (27) 

7. .36 (0.05) 




0.20 (0.04) 



7.37 (0.04) 
81 (5)* 

* p < 0.05 compared with 33.*i. 

Nocturnal Studies. Baseline mean (SD) values during BiPAP 
use for duration of monitoring, 8.3 ( 1.2) h; daytime sleepi- 
ness score, 1.0 (0.5); nocturnal heart, 81 (10), and respira- 
tory rates, 18(5) min; mean 97 (2) and nadir Oo saturations, 
81 (10)%; and transcutaneous Pco:- 44 ( 15) ton- were unaf- 
fected by the switch to the 335. Severe O2 desaturations 
occurred occasionally with both ventilators, but O2 saturation 
was > 90%, 99% of the time for the BiPAP, and 98% of the 
time for the 335 (p = NS). For both ventilators, an air-leak 
pattern was apparent on the nocturnal tracing 30% of the 
night, and sleep-disordered breathing events occurred approx- 

Subjective Evaluation of the Ventilators. Patients deemed 
the ventilators equally easy to apply and use, and airflow was 
sensed as equally comfortable (Table 5). Inspiratory tiiggering 
and physical appearance were judged to be comparable, and 
overall ratings were the same. The only important differences 
were that the 335 was perceived as quieter, and the BiPAP 
was considered more portable. Nonetheless, at the end of the 
study, 4 of the 6 patients requested continued use of the 335 
ventilator and 2 prefeiTcd to continue of the BiPAP. 

Table 5. Means and Standard Deviations (SD) of Visual Analog 

Scores from Daily Diary for Subjective Evaluation of Venti- 
lator in 6 Patients* 






Easy to apply 
Easy to use 
Comfortable airflow 
Easy to trigger 
Noise level 
Overall rating 

9.2 (1.2) 

9.3 (0.8) 
8.7 (1.0) 
8.5 (2.8) 

6.2 (3.7) 
9.0 (0.8) 
9.0 (0.8) 

8.3 (0.8) 



9.2 (1.2) 

9.3 (0.8) 
8.0 (1.4) 
8.0 (3.0) 
4.2 (2.9) 
8.0 (2.4) 
9.0 (0.8) 
7.2 (2.1) 

* Numbers based on average scores from visual analog scale with ( I least - 10 
p < 0.05 (compared with both baseline and lollow-up on BiP.AP). 

Long-Terni Use. Only two 335s were provided for investi- 
gational use, so long-term use was not possible in most of our 



Pressure Support Ventilator Evaluation 

patients. However, an exception was made for Patient 1 who 
complained of awakening frequently at night w ith a feeling 
of suffocation that she ascribed to an insufficiently sensitive 
inspiratory trigger on the BiPAP. These sensations occuired 
less often while she used the 333. and recurred when she 
switched hack to the BiPAP. As a consequence, she was 
allowed to resume 335 use upon completion of the study. .-Xfter 
more thim 1 8 months of nocturnal 335 use. her da\ time symp- 
toms and arterial blood gas \ alucs remain stable. 


Our suidy demonstrates that nocturnal nasal ventilation using 
the Puritan Bennett 335 maintains ventilation and clinical sta- 
bility in patients with chronic respiratory failure as effectively 
as does the BiPAP S/T. In addition, our laboratory evalua- 
tion of the 2 \entilalors showed a number of differences that 
warrant consideration when initial settings are determined or 
a choice is to be inade between portable PS Vs. For example, 
the most sensitive inspiratory trigger setting on the 335 ren- 
ders it slightly easier to trigger than the BiPAP S/T. Some 
patients, particularly those w ith neuromuscular weakness. ma\ 
prefer the 335 for this reason, as w as the case w ith Patient 3. 
On the other hand, others may find this setting overly sen- 
sitive, as was the case vv ith Patient 4. who used IPAP Sen- 
sitivity 2 setting and preferred the BiPAP overall. 

The mechanisms for cycling from IPAP to EPAP also dif- 
fer substantially between the ventilators. This is clinically 
important because this function is a determinant of inspira- 
tory time. and. in combination with inspiratory flow, deter- 
mines Vi . If the trigger for cycling from IPAP to EPAP is too 
sensitive, cycling occurs prematurely, reducing the length ot 
inspiration and the size of the assisted Vj. If the trigger is too 
insensitive. IPAP may be extended into the early of expi- 
ration, adding to expirator\ work, as was demonstrated by 
Jubran et al." In the S and S/T modes on the BiPAP, sensi- 
tivity is not adjustable, but cycling from IPAP to EP.^P 
becomes easier as inspiration continues.'" In this way. the 
BiPAP avoids excessively short inhalations, and cycles eas- 
il\ into exhalation during longer breaths. In the T mode on 
the BiPAP. the ^i IPAP ciintrols inspiratory duration. In con- 
trast, the 335 has no T mode, and cycling into EPAP is deter- 
mined by the EPAP sensitivity setting during spontaneous 
breathing in the A/C and IP.AP modes. During ■"controlled'" 
breathing in the A/C mode (ie, when the back-up rate deter- 
mines breathing frc(.|uenc\ ). the l:E setting determines inspi- 
rators lime. 

Practical implications of these differences include the need 
to ascertiiin that the '^r IP,\P setting is appropriate before switch- 
ing from tlie S or S/T iiuKies to the T imxle on the BiPAP. Like- 
wise, I:E and EPAP sensitivity settings should be adjusted 
to maintain inspiratory duration when the 335 is substituted 
for the BiPAP S/T. Excessively low I:E or EPAP sensitivity 
settings reduce the duration of inspiratory support and low er 

Vt. Our findings also show that even for the same inspira- 
tory duration. IPAP should be I -2 cm H:0 higher on the 335 
than on the BiPAP to maintain comparable levels of pressure 
support if the lowest EPAP levels are used because these are 
2 cm H2O on the BiPAP and 3 on the 335. 

Air leak through the mouth occurs commonly during nasal 
\ entilalion. ' ' Unlike volume ventilators that deli\ er a preset 
volume during leaking, pressure-limited ventilators like the 
335 and BiPAP can compensate for air leaks by sustaining 
inspiratory airflow until IPAP termination criteria are reached. 
The BiPAP in the S/T mode sustains inspiratory airflow dur- 
ing leiik for up to 3 seconds. At back-up rates commonly used 
( 1 2 or higher), an inverse I:E breathing pattern often occurs 
during air leaking.'- In the T mode on the BiPAP and in the 
A/C mode on the 335. Ti/Ttot during air leiiking is detemiined 
by the 9HPAP and I;E ratio setting, respectively, and inver- 
sion of the I:E does not occur. Thus, the mechanisms used to 
compensate for air leaks differ markedly depending on the 
ventilator and mode used. It is unclear w hether the prolon- 
gation of inspiraH)ry time up to 3 seconds and the consequent 
inversion of the I:E that occurs during air leaking in the BiPAP 
S/T mode is better or worse for le;ik compensation than a con- 
\entional I:E. 

Despite these technical differences between the ventila- 
tors, our clinical evaluation shows that they were equally effi- 
cacious. During a 2-week period of 335 ventilator use. patients 
v\ ho had been previously stabilized using the BiP.AP had sta- 
ble daytime Pacc):^, indicating adequate support of aheolar 
ventilation and experienced no deterioration in daytime vital 
signs or pulmonary functions. Daytime P,,o;S were slightly 
lower during 335 than during BiPAP use, but the PaOjS 
remained sufficiently high throughout the study to maintain 
O2 saturations in the mid-90s. and these differences in oxy- 
genation are unlikely to be clinically important. 

The 335 also supported nocturnal gas exchange during sleep 
as well as the BiPAP S/T. Average and nadir nocturnal O: 
saturations were unchanged by sw itching to the 335 venti- 
lator, and average lUK-tumal heart and respiratory rates remained 
steady. Patients, particularly those with neuromuscular dis- 
ease, breatlied in excellent sy nchronv w ith both de\ ices, allow- 
ing the backup rate to conu-ol their breathing, and thereby pre- 
sumably minimizing breathing work." Subjective evaluation 
of sleep quality and daytime sleepiness was compaiable dur- 
ing use of both ventilators. Breathing patterns suggestive of 
air leaking occurred w ith equal frequency with both venti- 
lators, and the equivalence of nocturnal gas exchange sug- 
gests that the technical differences in leak compensation 
described may not he clinically critical. 

Subjective evaluation of the ventilators by patients also 
revealed them to be roughly equivalent. Patients gave sim- 
iliir ratings to each for ease of use. facilitv of triggering, com- 
fort, and overall acceptability. The onl> important differences 
were for lesser noisiness of the 335 and the greater portability 
of the BiP.A.P. which weighs less and is slightly smaller. Despite 


Respiratory Care • October "96 Vol 41 No 10 

Pressure Support ventilator evaluation 

the similar ratings. 4 of the 6 patients expressed a preference 
for the 335 after completion of the study, mainly because it 
was less noisy. 

Although the 335 and BiPAP S/T demonstrated compa- 
rable clinical effectiveness in our study, several limitations 
of the applicability of our findings should be considered. First, 
ours was a small and highly selected patient population of expe- 
rienced BiPAP users, all of whom had chronic respiratory fail- 
ure due to restrictive thoracic diseases and had responded well 
to nocturnal nasal ventilation. Thus, we cannot comment on 
the relative acceptability of the 2 devices in naive users. We 
can also draw no inferences about relative efficacy in other 
patient populations, including those with chronic obstructive 
pulmonary disease, whose response to nocturnal nasal ven- 
tilation remains controversial '■" or those with acute respira- 
tory failure. It might also be argued that our patients were not 
treated long enough with the 335 ventilator to exclude the pos- 
sibility of later deterioration. However, in an earlier study of 
similar design." we found that worsening of nocturnal gas 
exchange and symptoms occurred within a week of discon- 
tinuation of nocturnal nasal ventilation. 


We conclude that the Puritan Bennett 335 ventilator assists 
nocturnal ventilation in patients with chronic respiratory fail- 
ure as effecti\ely as the BiPAP and appears to be. at least, as 
well accepted by patients. Although it is less portable than 
the BiPAP. it is less noisy and offers additional features, such 
as adjustable and increased inspiratory and expiratory sen- 
sitivities, alarms, digital display, and the capacity to gener- 
ate higher IPAPs that may be important for particular patients. 
However, it is necessary for practitioners to be familiar with 
the peculiarities of each ventilator, particularly the mecha- 
nisms used for terminating inspiration, in order to optimize 
delivery of ventilatory assistance and comfort. Particularly 
with regard to the EPAP sensitivity setting for the 335, we 
recommend the exercise of diligent clinical assessment and 
judgment. The chiiracteristics of the BiPAP de\ice have made 
it a valuable addition to home \'entilators designed to provide 
nocturnal nasal ventilatory assistance. By offering equivalent 
function with additional features, the 335 expands the capa- 
bilities of portable PSVs in the home, and may prove useful 
in the acute care setting, as well. 

Addendum: In response to the findings of this study. Nell- 
cor Puritan Bennett Inc has modified the EPAP sensitivity 
adjustments on the 335 ventilator, rendering them less sen- 
sitive to triggering. These modifications followed submission 
of the manuscript, and the modified ventilator has not been 
evaluated. Although the modifications may impro\e deliv- 
ered Vts at the EPAP Sensiti\ ity I setting, the authors still 
recommend careful titration of assisted Vjs during initiation 
of ventilation. 


The authors ihank Avtar Sidhu of Radiometer Inc. for the loan of the 
TINA transcutaneous gas tension analyzer and Jan Hayden for assistance 
in manuscript preparation. 



BiPAP S/T. Respironics Inc. Murrysville PA 

Puritan Bennett .^35, Nellcor Puritan Bennett. Lenexa KS 

Ventilator Accessories: 

Whisper-swivel valve. Respironics Inc. Murrysville PA 
CPAP mask. Respironics Inc. Murrysville PA 

Monitoring Equipment: 

Inducti\e pleth\smograph, Respitrace Inc, Ardsville NY 

Pneumotachomcter. Fleisch. Zurich, Switzerland 

Pressure transducer (mask pressure). Celesco Transducer Products Inc, 

Canoga Park CA 
Pneumotachomcter, Ohmeda .'i420 volume meter. Ohmeda, Liberty 

City NJ 
Spirometer Renaissance spirometer. Nellcor Puritan Bennett. Wilm- 
ington MA 
Manometers. Boehringer Inc. Wynnewood PA 
Blood gas analyzer — Coming 178, Corning Inc, Medlield MA 
Hand-held spirometer. Wright Respirometer, London UK 
4-channel recorder. Edentech Inc. Eden Prairie MN 
Transcutaneous CO: and O: monitormg — TINA. Radiometer. Copen- 
hagen, Denmark 
IBM-compatible computer, Compu Add Express, Austin T,\ 
Data acquisition software — Codas. Dataq Instruments Inc, Akron OH 


Kerby GR, Mayer LS. Pingleton SK. Nocturnal positive pressure ven- 
tilation via nasal mask. Am Rev Respir Dis l987;l,35(,3):738-740. 
Bach JR. Alba A. Mosher R, Delaubier A. Intermittent positive pres- 
sure ventilation via nasal access in the management of respiratory 
insufficiency. Chest I987;92( I):I68-I70. 

Carroll N. Branthwaite MA. Control of nocturnal hypoventilation 
by nasal intermittent positive pressure ventilation. Thorax I988;43 

Leger P. Jennequin J, Gerard M, Robert D. Home positive pres- 
sure ventilation via nasal mask for patients with neuromuscular weak- 
ness or restrictive lung or chest-wall disease. Respir Care I989;.34(2): 

Heckmatt JZ. Loh L. Dubowitz V. Night-time nasal ventilation in 
neuromuscular disease. Lancet l990;335(8689):.579-582. 
Hill NS, Eveloff SE. Carlisle CC. Goft SG. Efficacy of nocturnal nasal 
ventilation in patients with restnclive thoracic disease. Am Rev Respir 
Dis I992;14.'S(2. Part l):36.';-37l. 

Meecham-Jones DJ. Paul EA. Jones PW. Wedzicha JA. Nasal pres- 
sure support \ entilation plus oxygen compared w ith oxygen therapy 
alone in hypercapnic COPD. Am J Respir Cm Care Med I995;I52(2): 

Stnimpf DA, Carlisle CC, Millman RP, Smith KW. Hill NS. An eval- 
uation of the Respironics BiPAP bi-level CPAP device for delivery 
of assisted ventilation. Respir Care l990;35(5l:4l5-422. 
Jubran A. Van de Graaff WB. Tobin MJ. Variability of patient-ven- 

Respiratory Care • October "96 Vol 41 No 10 


Pressure Support Ventilator Evaluation 


tilator interaction with pressure support ventilation in patients witli 

chronic obstructive pulmonary disease. Am J Respir Crit Care Med 

l'W.'i;152ll): 129-1.16. 

BiPAP Operation Manual. Respironics Inc. Murrysville PA. 

Bach JR. Robert D. Leger P. and Langevin B. Sleep fragmentation 

m kvphoscoliotic individuals with alveolar hypoventilation treated 

by NPPV. Chest li-W.'i;l()7(6);l.S.'52-1558. 

Meyer TJ, Pressman MR, Benditt J, McCool FD, Millman RP. Hill 



NS. Moutli leaking dunng nocturnal nasal ventilation: eflecl on sleep 

quality (abstract). Am J Respir Crit Care Med 1995:1S1(4. Part 


Marini JJ. Rodriguez RM. Lamb VJ. The inspiratory workload of 

patient-initiated mechanical ventilation. Am Rev Respir Dis 19K6; 


Hill NS. Noninvasive Ventilation. Does it work, for whom, and how? 

(commentary) Am Rev Respir Dis 1993;I47(4):1030-10.1S. 


111 the paper "The EtTeet of Airway on Tidal Volume during Pressure- or Flow-Con- 
liolled Ventilation of the Neonate: A Model Study" by Chatburn et al (Respir Care 
19%;4 1 (8):728-73.'i). the classification of leaks as given on Pages 733 and 734 should have 
been attributed to a personal communication from Paul Blanch RRT. who is a.ssociated 
w ith the Department of Anesthesiologs at the Uni\ ersity of Florida College of Medicine. 
We regret the oversight. 


Respir.-xtory Care • October "96 Vol 41 No 10 

Inhaled Nitric Oxide Delivery widi High-Freqiiencyjet Vendladon: 

A Bench Study 

Todd W Mortimer RRT, Mary Cheang M Math, and Carlos A Fajardo MD 

BACKGROUND: Because both high-frequencv jet ventilation (HFJV) and 
nitric oxide (NO) have been shown to be useful in treating persistent pulmonary 
hypertension of the newborn, we sought to characterize NO delivery by HFJV. 
METHODS & MATERIALS: In a patient simulation, we measured NO con- 
centration [NO] at the end of the endotracheal tube, compared results obtained 
with chemiluminescence (CL) and electrochemical (EC I analyzers, and stud- 
ied the effects of compliance and resistance changes and different [NO] on 
NO deliverv at different conventional ventilator (CV I pressures and frequencies 
that did and did not interrupt the jet ventilator flow while jet ventilator vari- 
ables remained constant. Data were collected at 3 measuring sites, under 3 
lung conditions, and with 3 [NO[. Rp;SULTS: The V.C read higher than the 
CL under pressure conditions ( 17-39% ). [NO] at the inspired and expired 
measuring sites varied from 14-29% when flow from the jet ventilator was 
not interrupted. NO delivery as measured by the CL improved as compliance 
and resistance improv ed when a C\ frequency was being deliv ered. NO deliv- 
ery was minimal when CV pressures were not interrupting HFJV: NO% = 
0.21 (0.129), p < O.OOOI. However, NO delivery was adequate when CV pres- 
sures interrupted HFJV: NO% = 102.72 (0.435) p < 0.0001. When CV fre- 
quencies were not interrupting HFJV: NO% = 2.25 (0.187) p < 0.0001. When 
CV frequencies were interrupting HFJV: NO'Zr = 1 1.53 (0.395) p < 0.0001. 
CONCLUSIONS: EC yields higher NO values than does CL. Compliance and 
resistance changes mildlv alter NO deliverv at the endotracheal tube. NO deliv- 
ery via HFJV is unreliable and should be avoided. ]RespirCare 1 996:4 1( 10): 


Persistent pulmonar>' hypertension of the newborn (PPHN) 
is a detrimental clinical condition in which pulmonary vas- 
cular resistance does not decrease after hirth.' - Several forms 
of treatment including high-frequency jet ventilation (HFJV) 

Ttie auttiors are associated w ilh Respiratory Ttierapy Ser\ ices. Commu- 
nity Healtli Sciences, and Pediatrics. Unix ersity of Manitoba. Winnipeg, 
Manitoba, Canada. 

Reprints & Correspondence: Dr C A Fajardo, University of Manitoba, 
WROO.^-Women's Hospital, 735 Notre Dame Ave. Winnipeg MB, 
Canada, R3E 0L8. 

ha\ e been utilized to treat infants suffering from PPHN,- The 
intent of HFJV in these infants has been to facilitate CO2 
removal and increase pH — leading to pulmonary vasodila- 
tion and a decrease in pulmonary vascular resistance, Altliough 
HFJV has been shown to be beneficial in patients with pul- 
monary interstitial emphysema and air leak (presumably by 
avoiding the high-inflating pressures associated with con- 
ventional mechanical \entilation).-''' to our knowledge, ran- 
domized control trials comparing HFJV to conventional ven- 
tilation in patients with PPHN ha\c not been reported. 

Another treatment for the severe pulmonary' va.soconstriction 
associated with PPHN is inhaled nitric oxide (NO), NO is the 
only known selective pulmonary vasodilator used in the treat- 
ment of newbom infants sufferinc from PPHN.' ** Studies have 

Respiratory Care • October "96 Vol 41 No 10 


Inhaled NO Delivery with HFJV 

confirmed the vasddilalory effect of inhaled NO on the pul- 
monary \ ascuialtire. as manifested hy improvements in oxy- 
genation w ilhout systemic hemodynamic collapse.' " Oxy- 
genation is improved as pulmonary hlood flow is redirected 
to areas of impro\ ed \ entilation. ' ' Inhaled NO may also avoid 
the need for neonatal extracorporeal membrane oxygenation 
in some patients with PPHN.'- 

Because both HFJV and inhaled NO arc useful in decreas- 
ing the severity of PPHN. clinicians may be tempted to use 
them together. In this study, which uses a patient simulation, 
we sought to characteri/e NO delivery when it is adminis- 
tered by HFJV. We also compared results from the chemi- 
luminescence (CD and electrochemical (EC) analyzers, and 
the effects of changes in compliance and resistance, and the 
effect of different NO concentrations |N0| on NO delivery. 

Methods & Materials 

Description of Technique 

We set up a Sechrist IV-IOOB ventilator (the conventional 
ventilator. CV) ;md a Life Pulse high-fiequency ventilator (JV)* 
as they are used clinically in our neonatal intensive care unit. 
The JV incorporates an electrically controlled pinch valve, 
which regulates an inllow jet burst of gas; gas passes through 
the jet port of the endotracheal tube (ETT). while a second 
port on the ETT monitors tracheal pressure via a transducer 
located near the ventilator.^ The JV requires a CV in paral- 
lel to work properly. If the CV peak pressure is greater than 
the JV peak pressure, the tlow of the JV is interrupted. The 
CV. a pressure-limited ventilator, with a constant tlow of 10 
L/min was attached through the inspiratory limb to the ETT 
connector. The expiratory limb was attached to the ETT con- 
nector as seen in Figure 1. The JV delivers the gas into the 
jet connector distal to the CV flow at the ETT. 

The ETT was allached to an infant lung-airway simula- 
tor. The expiratory limb of the CV circuit ended in the expi- 
ratory block of the CV. which allowed the gases to be scav- 
enged. We could not maintain high pressures for prolonged 
periods of lime, due to the limitations of the CV: therefore, 
an underwater pressure system had to be adapted to obtain 
constantly high pressures during pail of the experiment (when 
|NO| is measured at constant pressures of 20. 24. 28, 34. 36, 
and 3S lorr). The distal pail of the expiratoi^ limb was attached 
to an underwater pressure column as depicted in Figure 1 . 

NO was added to the inspiratory limb of the CV circuit at 
the base of the tlowmeter block with the tlow of NO deter- 
mined bv a tlowmeter originating at a NO source tank ( 1 .()()() 
ppm by volume, balance nitrogen) set at a working pressure 
of 50 psig. Two NO analy/xMs were placed in series, with the 



Gas Ventilator 
Inlet , ^ 

NO Mixture 

A nalyzer 



*Suppliers of commercial products are listed in the Product Sources sec- 
lion at the end of the text. 

Fig. 1 . Experimental setup and NO measuring locations: A. Inspira- 
tory limb; B. expiratory limb; C. distal to endotracheal tube. 

tap for the EC upstream from the tap for the CL. Measure- 
ments were made in turn at the 3 measuring locations: A. the 
inspiratory limb prior to the humidifier. B. the expiratory limb 
prior to the exhalation block, and C. at the distal end of the 
ETT (Fig. 1). 

A spirometer w ith an accuracy of ± 3'7f was used to mea- 
sure the flow in the inspiratory and expiratorv limbs. The pur- 
pose of this was to detemnine CV flow in the inspiratory limb 
of the CV circuit and total tlow (JV -i- CV) in the expiratory 
liiTib. and then to calculate JV tlow by subtracting CV tlow 
from total flow, relating results to changes in NO conceiiuations 
between the two sites. 

System Calibration 

The EC analyzer was calibrated using the zero calibration 
and reference standard calibration for NO outlined in its clin- 
ical manual." To ensure stability, full reference calibrations 
were performed every 8 hours. Tlie EC reads 90Vr of expected 
value in 20 seconds with an accuracy of ± 1 ppm NO." NO 
zero calibration involves flushing the NO analyzer system with 
oxygen for 2 minutes at ambient pressure and depressing the 
automatic zero button found on the analyzer. Reference stan- 
dard calibration uses a reference of 80 ppm NO to flush the 
system for 2 minutes at ambient pressure. If requireil. the dig- 
ital display is adjusted to read the gas concentration. The cal- 
ibration gas is then discontinued, and the system is flushed 
with oxygen for 2 minutes. If digital NO readings do not rettim 
to zero, the zero calibration is repeated. 

The EC analyzer was zeroed and calibrated prior to data 
collection. '■* Several concentrations of NO ( 10%. KV/c 40'7r. 
(S09f . and 80% at each scale) were calculated and analyzed 
using the analyzer's 20- and 100-scale settings, which allow 
ev aluation of low (5-20 ppm) and high (80 ppm I concentrations. 


Respir.atory Care • October "96 Vol 41 No 10 

Inhaled NO Delivery with HFJV 

Concentrations were calculated using digital tlownieters that 
have an accuracy level of ± 3% of the tlow readings.'^ The 
digital tlownieters measure NO and O: tlow (Fq: 1 0). The 
span is then adjusted to calibrate the CL analyzer to the cal- 
culated concentrations. The CL analyzer reads 907c of expected 
value in 60 seconds with an accuracy of ± Wc.^-^ 

Evaluation Methods 

An infant lung-airw ay simulator pro\ ided the 3 lung con- 
ditions (Table 1): (A) normal, compliance of 5 niL/cm H:0 
and airway resistance of 50 cm H:0 ■ L • s': (B) moderately 
altered, compliance of 2 niL/cm H;0 and an aiway resistance 
of 100 cm H2O • L • S-' : and (C) severely altered, compliance 
of 1 mL/cm H^O and an airw ay resistance of 200 cm H:0 
L • s^'. A constant llow of O: and NO was maintained through- 
out. After 5 minutes of stabilization in each experiment, read- 
ings from both analyzers were taken every 13 to 30 seconds 
for a total of 10 entries for each analyzer. The initial con- 
centration at each level was set using the CL analyzer as the 
standard and was measured in the inspiraton limb using pres- 
sures of cm H:0. O2 (Fo; 1 0), and tlow of 10 L/min from 
the CV. 


The cycling frequency (f) of 420/min and inspiratory time 
(0.02 s) of the .IV and the tlow (10 L/min) of O: fn>m the 
CV were maintained constant throughout all measurements. 
Measurements of NO were made under various conditions 
as indicated in Table 2. As noted. 10 measurements of NO 
with each of the analyzers w ere made at each of the 3 mea- 
suring locations and at each of the 3 selected [NO] with each 
of the 3 lung conditions for a total of 540 measurements at 
each set of pressures on each model. Therefore, there were 
9 experimental conditions (Table 1 ) under which [NO] was 
measured with the 2 analyzers on each of the 4 models (Table 
2). Data are reported as actual NO readings in the 3 sites 
for all experimental conditions in the 4 models. The orig- 
inal [N0| (5. 20. and 80 ppm) were initially measured in 
the inspiratory limb under ambient conditions. Because our 
main goal was to ascertain actual NO delivery to the patient, 
the NO readings at the ETT were also reported as a percent 
of the original NO concentrations. As a control, %N0 deliv- 
ery at the ETT was measured when delivered solely by the 
CV at the same CV frequencies and lung models as our 
experimental design. 

Table I . The 4 Experiniental Conditions under Whicli Nitric Oxide 
Was Sampled* 

Simulator Compliance 
& Resistance 

5 mL/cm H2O. 
SOcmH^O sL' (A) 

2 mL/cm H:0. 
100cmH:O sL '(B) 

1 mL/cm H;0. 
200cmH-O sL' (C) 

Nitric Oxide Concentration (ppm) 
5 20 80 










Statistical Analysis 

Readings from the 2 analyzers were compared by the 
method of Bland and Altman."" which plots differences 
between results obtained with the 2 analyzers against the 
means of the values obtained. When found to be normally 
distributed, the mean differences are then tested in a 1 -sam- 
ple / test for equality to zero. Multifactorial analysis of vari- 
ance is perfomied to model the various conditions and effects 
as they alter NO delivery. Results are presented as mean 
(standard deviation), and critical values are set at 0.05. 
Because 5 or more effects were studied, we further analyzed 
and compared subsets using a Newman Keuls multicom- 
parison procedure. 

Table 2. Conditions under Which Nitric Oxide Was Sampled* 

Experimental Model 

CV Pressures 
(cm H:0) 

JV Pressures 
(cm H2O) 

CV Frequencies 

Model 1— JV flow not interrupted 0. 2. 3. 6. 8 (PEEP) 30 (PIP) 

20. 24, 28 (PIP) 

Model 2— JV flow interrupted 34. 36. 38 (PIP) 30 (PIP) 

Model 3*— JV flow not inteirupted 3 (PEEP) 30 (PIP) 

28 (PIP) 

Model 4*— JV flow interrupted 3 (PEEP) 20 (PIP) 

,34 (PIP) 

*CV = conventional ventilator. JV = jet ventilator; PEEP = posilixe end-expiralory pressure; PIP = pealv inspiratory pressure. 

JV Frequencies 

5. 10. l."^. 20. .30 

5. lU. l.*i.20. ,30 




Respiratory Care • October "96 Vol 41 No 10 


Inhaled NO Delivery with HFJV 

Evaluation Results 

Readings in Inspiratory & Expiratory IJmbs 

Comparison of Analyzers 

The EC analyzer consistently read higher than the CL ana- 
lyzer (range ll-?>99i ). Discrepancies were found between ana- 
lyzers at the 3 measuring sites. Using midrange values of pos- 
itive end-expiratory pressure (PEEP. 6 cm H^O), peak 
inspiratory pressure (PIP. 24 and 36 cm H:0). and frequency 
( 1 and 30 cycles/min). the mean discrepancies found between 
the 2 analyzer readings were 14.5 ( 15.0) at inspiratory limb, 
14.5 (15.0) at the expiratory limb and 0.3 (2.8) distal to the 
ETT when all 9 experimental conditions were compiued. How- 
ever, we found the discrepancies to increase as the average 
NO increased; therefore, we log-transformed the data. The 
ratios at all 3 sites were then 0.14 (0.03). 0. 15 (0.04). and 0. 18 
(0.30), all of which are significant (p < 0.0001 ). It was also 
noted that pressure affects both analyzers; however, the EC 
analyzer is affected to a greater degree, and the discrepancies 
between the analyzers were consistent at all 3 measuring sites. 

The measured |NO| decreased (range 14-29%) between 
inspired and expired limbs as long as the CV did not inter- 
rupt the JV (Models 1 & 3) and the flow in the expiratory 
limb was increased (range. 14-32%) as compared to the 
inspiratory limb. In general, flow increased as JV pres- 
sure increased. On the other hand, when the CV interrupted 
the jet (Models 2 & 4). both analyzers measured |NO) 
changes from the inspired to the expired limbs (range 0% 
to 5%), and the flow in the expired limb did not change. 
Flow increased as ,1V pressure increased and lung condi- 
tions improved. 

Tables 3 and 4 show NO concentration readings at the 3 
sites according to the CL analyzer. 

Readings Distal to the Endotracheal Tube 

Results reported are measurements acquired from the CL 
analyzer. EC analyzer values follow a similar pattern. 

Tiihlc 3. Mean (,SD) Values for Nilric Oxide Concentration |NO] Measured hy Chemiluminescence Analyzer at .3 .Silos during Venlilalion at 
Midranee PHtiP/PIP Levels. 

Delivered jNOl 

Jel Flow 

Measured |N0| (ppml 

m H:0) 

Inspiratory Limb 

Expiratory Limb 

End ETT 



4.9 (0) 
4.91 (0.032) 

4.0 (0) 




.5.23 (0.048) 
5.26 (0.052) 

4.52 (0.042) 
4.52 (0.042) 

0.01 (0.032) 
0.07 (0.048) 


5.7X (0.042) 
5.77 (0.048) 

5.33 (0.048) 
5.3 (0) 
5.32 (0.042) 

5.28 (0.026) 


20.32 (0.063) 
20.49 (0.074) 


0.07 (0.048) 





0.03 (0.048) 
0.03 (0.048) 
0.02 (0.042) 




20.63 (0.048) 
20.66 (0.052) 
20.65 (0.053) 



83.05 (0.053) 
83.23 (0.048) 

70.26 (0.052) 

0.05 (0.053) 
0.05 (0.053) 



80.56 (0.052) 

80.57 (0.048) 

65.46 (0.052) 

0.1 (0) 
0.1 (0) 



80.71 (0.074) 



77.56 (0.084) 
77.58 (0.092) 

77.48 (0.25) 
77.55 (0.053) 

No (Model I ) 

Yes (Model 2) 

No (Model 1) 


Yes (Model 2) 

No (Model 1) 

Yes (Model 2) 








Respiratory Care • October "96 Vol 41 No 10 

Inhaled NO Dhlivery with HFJV 

Table 4. Chemiluminescence Analyzer Values lor Nitric Oxide Concentration [NO] Measured at } Sites during Ventilation at Midrange Frequencies 

Delisered jNOj 

JV Flow 



Measured |NO| (ppnil 


Inspiratory Limb 

Expiratory Limb 

End ETT 


No (Model 3) 



5 (0) 
5 (0) 

3.8 (0) 





5.37 (0.048) 


0.1 (0) 
(1.31 (0.088) 

Yes (Model 4) 




4.99 (0.032) 


5 (0) 

4.1 (0) 




0.77 (0.048) 



5.4 (0) 
5.41 (0.032) 
5.4 (0) 


0.2 (0) 
0.68 (0.042) 


No (Model 3) 








0.2 (0) 




20,8 (0) 
20.8 (0) 
20.8 (0) 





Yes (Model 4) 





20.25 (0.053) 


0.5 (0) 
1.31 (0.074) 











3.57 (0.082) 


No (Model 3) 







62.21 (0.11) 

0.64 (0.052) 
3.01 (0.074) 






61.05 (0.053) 

7.71 (0.19) 

Yes (Model 4) 



79.67 (0.082) 

79.68 (0.092) 

67.31 (0.11) 

4.86 (0.052) 



80.7 (0.082) 
80.36 (0.052) 


29.7 (0.23) 

Delivei7 of NO, for three [NO] (5. 20, and 80 ppm) using 
Model 1 (Fig. 2) is minimal to nonexistent. However, deliv- 
ery of NO using Model 2 is90-126'7f (Fig. 2). NO delivery 
is 1-10% NO using Model 3 (Fig. 3). and 10-38% using Model 
4 (Fig. 3). Table 5 displays means and standard deviations 
for %NO delivery distal to the ETT, with the 4 models. NO 
delivery at the distal end of the ETT as measured by the CL 
analvzer increases in Models 3 and 4. when lung conditions 

improve. For a conU-ol, we measured % NO delivery at the ETT 
when delivered solely by the CV. At various CV frequencies 
and lung models, the CL measured a %NO of 7 1 % to 98%. 


We used the Bland and Altman technique to coinpare the 
CL and EC analyzers. This technique calculates the 95% lim- 

Respiratory Care • October "96 Vol 41 No 10 


Inhaled NO Delivery with HFJV 

120 n 



6 8 20 24 28 
Pressure (cm H2O) 


Fig. 2. Differences in values of N0% (le, % of the 20 ppm intro- 
duced) distal to thie endotracheal tube (ETT) when pressure levels 
(0-8 cm H2O, or 0-0.78 kPa, to mimic positive end-expiratory pres- 
sure levels and 20-28 cm H2O, or 1,96-2.74 kPa, to mimic peak 
inspiratory pressures) are not interrupting jet ventilator flow (Model 
1), versus when peak pressure (34-38 cm HoO, or 3.33-3.72 kPa) 
is interrupting |et ventilator flow (Model 2). Measurements were 
taken under Lung Condition C (severely affected, with compliance 
= 1 mLVcm H2O, and resistance = 200 cm H20 L s '), at a NO 
concentration of 20 ppm. ■ = chemiluminescence analyzer and 
= electrochemical analyzer. 











CV Frequency 



Fig. 3. Differences in values of NO°o (ie, % of the 20 ppm intro- 
duced) distal to the endotracheal tube (ETT) as measured at differ- 
ent frequencies of conventional ventilator, or CV (Models 3 & 4) by 
the chemiluminescence analyzer, not interrupting (D) and inter- 
rupting jet ventilation (■) and by the electrochemical (EC) ana- 
lyzer, not interrupting (0) and interrupting jet ventilation (•). Note 
that the EC readings show greater variability. Measurements were 
taken under Lung Condition C (severely affected, compliance = 1 
mLVcm H2O; and resistance = 200 cm H^O L s ') at a NO con- 
centration of 20 ppm. 

its (if agreement between the 2 devices."' Our results indi- 
cate that the EC consistently reads higher than the chemi- 
luminescence analyzer by a range of 17% to 39%. Similar 
discrepancies were found between analyzers at the 3 mea- 

Table 5. '^'rNO Delivery Disial lo the Endolraclieal Tube 

Effect on Jet Flow 



Variable Not Interrupting Interrupting p value 

Peak in.spiratory 

0.21(0.129)* 102.72(0.435) p<O.OOI 

Cycling frequency: 

?. 10. 1?. 20.30 2.2.5(0.1X7) 1 1.53 (0..395) p<0.001 

*Values are mean (SD) '/cNO. 

soring sites. It should also be noted that pressure affects both 
analyzers: however the EC is affected to a greater degree. Sim- 
ilar discrepancies in measured values have previously been 
found as a result of pressure influences.'^ This increases the 
risk of overestimating NO delivery and could lead lo incor- 
rect interpretation of patient response to specific concentrations. 

E\ en though the CL NO analyzers are affected by third- 
body quenching, a process involv ing preferential de-e.\citation 
of NO2 molecules by body collisions with molecules such 
as HiO. O:. and CO;, we believe that in our study this effect 
is minimized by the fact that we calibrated the analyzer using 
100% oxygen without humidification and made the exper- 
imental measurements under the same conditions. The de- 
e.xcitation associated w ith third-body quenching decreases 
the photons emitted, resulting in lower NO readings. Indeed, 
Tidona and co-workers"* ha\e shown that changes in rela- 
tive humidity can cause substantial errors in NO ineasure- 
ments due to third-body quenching effect. It is important lo 
note that NO can be oxidized to NO: to a greater extent in 
the presence of high O; concentration;'*'-" however, this fac- 
tor does not account for errors in the NO measurements in 
our study because our NO; analyzer did not reveal NO; con- 
centrations greater than 0.2 ppm under any of the 9 experi- 
mental conditions. We have previously described similar 
changes in NO readings due to pressure effects in the CL ana- 
lyzer and speculated that the obsen ed changes are secondary 
to the direct effect of pressure upon the analyzer. '^ 

In regard to the EC analyzer, the marked effect of mean 
airway pressure on NO readings is of great concern w hen one 
is dealing with ventilated patients. The factors accounting for 
the piessure etTect upon the EC NO readings is unknown. A 
possible explanation relates to the fact that the amperomet- 
ric. membraned electrochemical cells are sensitive to pres- 
sure. Regardless of the cause, such a finding is of great clin- 
ical importance because infants with severe pulmonary 
hypertension in need of NO treatment are likely to require fre- 
quent adjustments in airw ay pressure, possibly resulting in 
significant error in the measurement of |NO). 

Because the risks of toxicitN w ith inhaled NO relate to high 
concentrations, clinicians may be justified in cautiously using 


Respir.atorv Care • October "96 Vol 41 No 10 

Inhaled NO Delivery with HFJV 

analyzers that o\enead [NO] to adiiiiiiister and titrate clin- 
ically therapeutic concentrations of NO. 

Variations in |NO| between the inspiratory limb and the 
expiratory limb during use of the jet ventilator c;m be explained 
by dilution. As JV pressure without being interrupted 
by the CV. (Models I & 3), a decrease in [NO] between the 
inspiratory and expiratory limbs is observed. A similar increase 
in total flow between the inspiratory and expiratory limbs as 
a result of tlow added by the Jet is also noted. Furthermore, 
during conditions under which the .IV is intenupted by CV 
(Models 2 & 4) minimal differences in |NO| and measured 
flows are observed. 

It is evident in our study, that predictable concentrations 
of NO gas may not be entrained when the JV is used w ilh an 
infant lung-model. Our findings are similar to those in one 
adult patient study.-' Except for a small percentage, the NO-O: 
mixture bypasses the ETT when the CV does not interrupt 
the JV (Models 1 and 3). During the experimental condition 
under which CV with a PIP that interrupts the JV and. there- 
fore, terminates JV flow (Model 4). larger yet unreliable con- 
centrations of NO are measured at the ETT. 

The percentage of NO reported distal to the ETT is in stime 
cases a higher concentration than was initially introduced into 
the circuit at ambient conditions. The magnitude of the dif- 
ference is greater with the EC than with the CL analyzer. Sev- 
eral possible explanations come to mind. For both measur- 
ing devices, the data representing > lOO^r NO delivery is 
primarily found at the 5-ppm NO level. At this NO level, a 
measured concentration of 1 ppm higher increases the NO dis- 
tal to the ETT by a greater percentage. The fact that the accu- 
racy of the CL device is ± 37r of full scale, and ± 1 ppm of 
the EC, indicates to us that the possibility of error is greater 
in the EC at lower concentrations. Another explanation could 
be that, as mentioned before, the EC readings were affected 
more by pressure than were the CL readings. 

Changes in lung conditions (compliance and resistance) 
used in this study have an effect on the NO delivery distal 
to the ETT (Models 3 & 4). These findings are similar to 
previous studies in animals and adult patients in which a JV 
and CV were used.-' -- It was found that decreased lung and 
thorax compliance decreases air entrainment from the ven- 
tilator circuit during conventional ventilation, resulting in 
decreased tidal volume and increased bypass of CV flow.-'-- 
Low [NO] being delivered to the patient may still be at ther- 
apeutic levels and therefore elicit a favorable response. This 
study shows that NO delivery as reflected by measurements 
on either the inspiratory or expiratory liinbs is unreliable. 
It may be worth investigating the mixing of NO and O: prior 
to the gas sources for both ventilators, thereby providing a 
uniform gas concentration. This alternative is currently unsuit- 
able as the manufacturer does not advocate the use of NO 
in the operation of the JV. Perhaps a ventilator incorporating 
JV and conseiitional \entilation would more effectively 
deliver NO. 


The results suggest that during JV. there is no entrainment 
of NO from the CV circuit. When conditions are such that the 
conventional ventilation intemipts the jet ventilator (Model 
4). larger yet unreliable concentrations of NO are measured 
at the ETT. We recommend that a JV not be used as it is 
described in this study for delivery of NO. Further studies are 
required to explore the addition of NO to the high-frequency 
jet circuit to improve NO delivery. 


The authors thaiik the Department of Respiratory Therapy Services 
and the School of Respiratory Therapy. Health Sciences Centre; the De- 
partment of Respiratory Therapy Services. St Boniface Hospital; the 
MMSF & Children's Research Foundation; and D Mortimer— Winnipeg, 
Manitoba, Canada for their support of this study. 



CheiTiiluminescence analyzer— Model #8940. Monitor Labs, Engelwood 

Electrochemical analyzer — Pulmonox II. F^ilnionox Research and Devel- 
opment Corp. Tofield. Canada 


Conventional ventilator — Sechrist-IV-l(K)B, Sechrist Industries Inc. Ana- 
heim CA. USA 

High-frequency jet ventilator — Life Pulse high-frequency jet ventilator. 
Bunnell Inc. Salt Lake City UT, USA 

Lung Simulator: 

Bourns Life Systems Mixlel LS-130 Infant Lung Airway Simulator. Bourns 
Inc. Maple Grove MN. USA 

Other Components of Experimental Setup: 

Endotracheal lube— Magill 12103.'^. Concord/Portex. Keene NH. USA 
Endotracheal tube connector — Lifeport HFJV connector. Bunnell Inc. 

Salt Lake City UT. USA 
Spirometer— Cat No. 20.630 Model R, Vitalograph, Kansas City KS. USA 
NO Flowmeter— EI-4CI01-E9I0 610 or El -4CI0I-E500 603, Math- 

eson, Montgomeryville PA, USA 
NO — Canadian Liquid Air Ltd. Winnipeg. Manitoba. Canada 
NO Regulator — 3."; 1 0-6(K) regulator. Matheson. Montgomeryv ille PA. USA 
Vacuum pump— Model 607CA32-699A. Thomas Industries Inc. She- 
boygan WI. USA 
Digital flowmeters — Humonics Optitlow 520 and 730, Humonics Inc- 
Precision Flow Measurement, Rancho Cordova CA, USA 

Statistical Software: 

NCSS 6.0 Statistical Package. Portland OR. USA 


I . Boyle KM. Baker VL. Cassaday CJ. Neonatal pulmonary disorders. 
In; Bamhart SL. Czen'inske MP. editors. Penn.ital and pediatric res- 
piratory care. New York; WB Saunders Company, I995;459. 

Respiratory Care • October '96 Vol 41 No 10 


Inhaled NO Delivery with HFJV 


1 1. 

I^'vln DL. Moms FC. Lssenlials of pediatric intensive c;ue. St Louis: 
Quality Medical Publishing Inc. 1990:318-324. 
Gon/ale/ F. Harris T, Black P, Richardson P. Decreased gas flow 
through pneumothoraces in neonates receiving high-frequency jet 
versus conventional ventilation. J Pediatr 1987,1 10:464-466. 
Keszler M. Donn SM. Bucciarelli RL, Alverson DC, Hart M, Lun- 
yong V, et al. Multicenter controlled trial comparing high-frequency 
jet ventilation and conventional mechanical ventilation in newborn 
infants with pulmonai^- interstitial emphysema, J Pediatr 1 99 1 ; 1 1 9( I , 
Part I ):8.S-9.V 

Bunnell JB. High-frequency ventilation of infants in current peri- 
natology. New York: Springer- Veriag, 1990:2:172-200. 
Carlo WA, Beoglos A, Chatbum RL, Walsch MC. Miulin RJ. High- 
frequency jet ventilation in neonatal pulmonary hypertension. Am 
J Dis Child l989;l43(2):233-238. 

Roberts JD, Polaner DM. Lang P, Zapol WM. Inhaled nitric oxide 
in persistent pulmonary hypertension of the newborn. Lancet 1992; 

Pepke-Zaba J, Higenbottam T\V. Dinh-\uan AT. Stone D. Wall- 
work J. Inhaled nitric oxide as a cause of selective pulmonary vasodi- 
lation in pulmonary hypertension. Lancet 1991:338(8776): 
I 1 73- 1 1 74. 

Kinsella JR, Neish SR, Shaffer E, Abman SH. Low -dose inhaled niuic 
oxide in persistent pulmonary hypertension of the newborn. Lancet 

Kinsella JR. Neish SR. Ivy DD. Shaffer E. Abman SH. Clinical 
responses to prolonged treauiient of persistent pulmonitry hypertension 
of the newborn with low doses of inhaled nitnc oxide. J Pediatr 1993; 
Rossainl R, Pison U, Gerlach H, Falke KJ. Inhaled nitric oxide: its 









effects on pulmonary circulation and airway smooth muscle cells. 
EurHeartJ 1993;l4(Suppl I):133-I40. 

Finer NN, Etches PC, Kamstra B. Tierney AJ, Peliowski A. Ryan 
CA. Inhaled nitric oxide in infants referred for extracorporeal mem- 
brane oxygenation: dose response. J Pediatr l994;l24(2):302-308. 
Totleld AB. Pulmonox II dual nitric oxide and nitrogen dioxide ana- 
lyzer clinical manual. Pulmonox Research and Development Corp. 
ML8940 Nitric oxide stack analyzer instruction manual. Englewood 
CO: Lear Siegler Measurement Controls Corp. 
Operation manual: Optitlow .'520 Digital Flowmeter. Rancho Cor- 
dova C.^: Humonics Incorporated, 1991. 

Bland .VIJ, .Altman DG. Comparing two methods of clinical mea- 
surement: a personal history. Int J Epidemiol l995;24(Suppl I):7-I4. 
Fajardo CA, Prokopowich J, Belik J. Inhaled nitric oxide monitor- 
ing. Clin Invest Med 1995: 1 8(2): 1 14- 1 2 1 . 
Tidona RJ. Nizami AA. Cemansky NP. Reducing interference effects 
in the chemiluminescent measurement of nitric oxides from com- 
bustion systems. JAPCA I988:3X(6):806-8I I. 
Fouben L. Fleming B, Latimer R, Jonas .M. Oduro A. Borland C, et 
al. Safety guidelines for use of nitric oxide ( letter!. Lancet 1992:339 

Bouchet M, Renaudin MH, Raveau C, et al. Safety requirement for 
use of inhaled nitric oxide in neonates (letter). Lancet 1993(8850); 

Jones MJ, Mottram SD, Lin ES. Smith G. Measurement of enlrain- 
nient ratio during high-frequency jet ventilation. Br J Anaesth 1990; 
65(2): 197-203. 

Spoelstra AJ, Tamsina TJ. Gas llow distribution in distal high-fre- 
quency jet ventilation and lung thorax compliance, .^cta .Anaesthesiol 
Scand 199l;35(8):7l7-724. 


November 3-6, 1996, Sunday- Wednesday 


Respiratory Care • October % Vol 41 No 10 

Special Aiticle 

Establishment of a Respiratory Assessment Team Is Associated with 
Decreased Mortality in Patients Re-Admitted to the ICU 

Elizabeth G Kirby RRT and Charles G Durbin Jr MD 

Within an institution, opportunities exist to improve the appropriateness, con- 
tinuity, and consistency of respiratory care services. We had the opportunity 
to observe differences in ICU patient outcome associated with improving the 
quality and appropriateness of respiratory care delivered to non-ICLI patients 
on acute hospital floors. After treatment for a critical illness, some patients 
may be re-admitted to an intensive care unit (ICU) due to respiratory dete- 
rioration. ICU re-admission carries a high risk of death. We studied outcomes 
in a group of patients re-admitted to an ICU before the practice of assessing 
patients by a dedicated respiratory therapy assessment team had been estab- 
lished and outcomes in a group admitted several years after that practice had 
been put in place. We found that neither the overall ICU re-admission rate 
(4.7% vs 4.8% p = 0.81 ) nor the percentage of patients re-admitted for res- 
piratory failure (43% vs 54%, p = (».23) had changed. However, a highly sig- 
nificant decrease in mortality for the re-admitted patients ( 12% vs 41 %, p 
< 0.0001 ) and in the proportion re-admitted for respiratory failure ( 19% vs 
47%, p < 0.0001 ) was seen. Reduction in premature discharge (early triage) 
did not seem to contribute to the improvement because the initial ICU length 
of stay remained unchanged and the same percentage was re-admitted for 
worsening of the original problem as for development of a new problem (45% 
vs 40%, p = 0.562, /-). We believe that better patient assessment and treat- 
ment outside the ICU, due to the establishment of a respiratory therapy assess- 
ment team, resulted in earlier identification of developing problems and more 
rapid ICU re-admission, and may have contributed to the reduced mortal- 
ity observed. [RespirCare 1996:41( l()):9()3-907| 


Critical care Is costly. As much as 20% of hospital costs 
is spent in intensive care units (ICUs).' However, the presumed 

Ms Kirby and Dr Durbin arc associated with the University of Virginia 
Health Sciences Center, Charlottesville. Virginia. Dr Durbin is Associate 
Professor in the Department of Anesthesiology. 

Ms Kirby presented an abstract of this paper at the OPEN FORUM during 
the 40th Annual Convention and Exhibition of the American Association 
for Respiratory Care in Las Vegas, Nevada, December 10-1.1. 1494, 

Reprint and/or Correspondence: CG Durbin MD. Box 238. Department 
of Anesthesiology, University of Virginia Health Sciences Center, Char- 
lottesville VA 22908. 

positive effect of critical care treatment on patient outcome 
is difficult to detemiine.--^ Critical care treatment cairies con- 
siderable patient risk. Mortality is high in the critically ill. and 
it has been estimated that more than 50% of ICU resources 
are expended on patients who do not survive/-^ Efficient and 
appropriate use of critical care beds and services is essential. 
Discharge from the critical care unit at the emiiest appropriate 
time helps to control ICU costs. 

If critically ill patients are discharged from the ICU too 
early, the result may be ICU re-admission, prolonged hospital 
stay, or increased mortality. Patients returning unexpectedly 
to an ICU may represent premature discharge, worsening of 
the initial problem, inadequate care on the fioor, or the devel- 
opment of a new problem. In a previously published study/' 
we identified respiratory deterioration as the most frequent 
immediate cause for ICU re-admission, occurring in 54% of 

Respiratory Care • October "96 Vol 41 No 10 


Decreased Mortality in ICU Re-Admissions 

such patients. Mortality oftiie patients re-admitted was high — 
41 %. Following this initial study, we instituted changes in the 
delivery of respiratoi7 care services, histcad ofprox iding only 
treatments ordered by physicians, we established a dedicated 
therapist assessment team for non-ICU patients, which 
improved the appropriateness of deli\ered therapy.' instituted 
the use of respiratory treatment algorithms.^ and developed 
and continued staff education programs'' to improve respiratoiy 
care on the acute care Hoovs. The assessment-treatment team 
was notified of all impending ICU discharges, and these patients 
were seen in a timely fashion, often prior to ICU discharge. 
Transferred patients with respiratory problems were aggres- 
sively treated by the team. These changes were designed to 
improve the continuity and consistency of respiratory care dur- 
ing and follow ing the transition from the ICU to the acute care 
floor. We hoped these changes would reduce the frequency 
of ICU re-admission, in particular those re-admissions for res- 
piratory failure. We report the changes we have documented 
over the years that this approach has been used. 


All patients admitted more than once to an adult ICU dur- 
ing a single hospital admission between July 1992 and June 
1993 at the University of Virginia Health Sciences Center were 
identified from a computerized medical record database (inter- 
vention group). Patients re-admitted during 18 months in 1988 
and 1989 were used lor comp;uison (control grt)up). The rea- 
son for initial ICU admission and the immediate cause for re- 
admission were determined from review of complete med- 
ical records. Patients undergoing staged surgical procedures 
or re-admissions planned for any other reason were excluded. 
A primiu-y respiratory cause was assigned if the patient required 
increasing inspired o.xygen concentration to pre\ ent hypox- 
emia (> 0.6 Fio:). had a rise in spontaneous respiratory rate 
{> 25 ). or demonstrated new chest radiographic findings con- 
sistent with a primiu") pulmonaiy problem w ithoul i)ther organ 
failure change. Unmanageable secretions requiring frequent 
nasotracheal suctioning or the presence of refractory bron- 
chospasm were attiibuted to a respiratory cause if they occurred 
in the absence of worsening cardiac function. Patients who 
required emergency intubation immediateK prior to ICU admis- 
sion or re-admission were assigned a respiratory cause only 
if they had no other significant organ system failure account- 
ing for the worsening clinical picture. 

Other primary causes for ICU admission were: cardiac. 
infectious, neurologic, U"aumatic, ga.stroenterologic. for '"mon- 
itoring." and "other." Only the single most appropriate prox- 
imal cause was assigned to each admission or re-admission 
episode. Both authors evaluated the medical records and came 
to consensus on assignment of the cause. 

Three intensive care units are included in this report: Sur- 
gical Intensive Care Unit, or SICU (10 beds): Medical Inten- 
sive Care Unit, or MICU ( 12 beds), and Neuroloiiic Inteii- 

si\e Care Unit, or NICU ( 12 beds). The modified Acute Phys- 
iology Score (APS) was used to assess degree of physiologic 
disorder at the time of ICU re-admission. The APS is part 
of the Acute Physiology and Chronic Health Evaluation 
(APACHE) scoring system, which has been validated and 
used to predict hospital mortalitv in ICU patients. This sys- 
tem can predict hospital mortality in groups of patients when 
calculated in the first 24 hours of the ICU stay. APACHE 
scoring is based on age, chronic conditions, diagnosis, the 
clinical area from which the patient came, and a weighting 
of physiologic variables depending on their degree of devi- 
ation from normal.'" The worst value in a 24-hour period is 
used to calculate the APS. The higher the score, the more 
severe the illness and the greater the predicted mortality. The 
APS can range from (entirely normal) to a maximum of 
60 points. The variables and range of assigned w eights are 
shown in Table I . The use of this scoring system to predict 
mortality on ICU re-admission has not been rigorously val- 
idated, but has been used by some authors to estimate degree 
of illness. We used the APS component of this score to objec- 
ti\ely identify and quantitate the degree of physiologic 
derangement at the time of re-admission rather than to pre- 
dict mortality. Differences in APS in various subgroups of 
patients were compared using ; tests, with p < 0.05 consid- 
ered significant. In addition, the frequency of causes for re- 
admission, mortality of the patients re-admitted, and first ICU 
length of stay were determined and compared with the pre- 
vious study period using x~ analysis or / test, w ith differences 
considered significant at the p < 0.05 level. 

Tahle 1 . The Phv^iologlc Variables. Extremes of Values, and Ranye of 
Weights tor the Aeute Physiology Score. 



Abnormal Value 


Respiratorx rate 

>5(), <5 





Glasgow Coma Scale 




>60%. <20 


White blood cell count 

>4().()0().<l. ()()() 


Mean arterial blood pressure 



Pulse rate 




>3.5, <0.6 





Serimi sodium 



Serum potassium 



* Double value if renal failure is uculc. 

Diffcrenl tormulas fur Fio;> 0..'> or < 0.5. can he dolemiineii from P,,o;. or serum 


Duiing the current study period, 120 patients were re-admit- 
ted to one or more of the ICUs. Complete chails were axail- 


RESPIRATORY Care • October "96 Vol 41 No 10 


able for 94 patients (80' < ). ot w hich 23 vveie planned re-admis- 
sions and were excluded from the analysis. The 69 unplanned 
re-admissions were studied in detail and form the basis of this 
report. This intervention group was compared to the 82 con- 
trol patients from the previous period. The percentage (and 
number) of patients re-admitted ft>r each reason from both 
groups are listed in Tables 2 and 3. Re-admission for respi- 
ratory deterioration occurred in 43% of the intervention group 
compared to 54'^( of the control group. This difference failed 
to reach statistical significance (p = 0.23. X''^- The percent- 
age of patients re-admitted for the same problem that initially 
resulted in ICU admissiiMi was 45'7( compared to 40'7f in con- 
trols (p = 0.562. X')- Those data are shown in Table 3. 


Mortality was markedly less in the intervention group. 8 
out of 69 ( 1 2'7i ) versus 34 out of 82 (4 F;{ ) in control group, 
(p < 0.0001, X-, Table 2). The moilality in intervention-group 
patients re-admitted for respiratory decompensation was also 
lower— 6/31 (19%) versus 21/45 (47<7< ) in controls, (p < 

0.0001. r)- 

ICU Length of Stay 

The number of days spent in the ICU on first admission. 
repi)rted as mean (.SD) was 6.3 (6.8) days in the intervention 
group. This was less than the 8.3 ( 15.8) days seen ui the con- 
trol group; however, because of the large standard deviation 
(one control patient stayed in the ICU for 99 days) this dif- 
ference did not reach statistical significance (p = 0. 165. ? test). 
Tlie cuiTcnt group of patients remained out of the ICU 5.9 (7.1) 
days prior to re-admission; control patients remained out of 
the ICU 6.7 (7.9) days between ICU admissions (p = 0.255, 

Physiologic Derangement 

The average APS at the time of re-admission in the inter- 
vention-group patients was 5 points higher than at initial ICU 

Table 3. De\ckipiHL-m of a New or a Reeuncm Problem and the BITeet 
on Mortality in the 2 Groups. 



Mortality (7f) 

Intervention group 
New problem 
Same problem 

Control group 
New problem 
Same problem 








discharge. 1 2.5 compared to 7.5. (p < 0.0(K) I . t test). The APS 
w as increa.sed less in the patients re-admitted for the same prob- 
lem, from 7.2 to 9.8. than for those w ith a new problem, from 
7.8 to 14.8. (p = 0.0015, f test). Although not different on dis- 
charge (7.75 vs 7.76, p = 0.42. t test), the APS was much higher 
in patients expiring after re-admission compared to those dis- 
charged alive (17.5 vs 1 1.9. p = 0.0064. i test). Equivalent data 
from the control patients was not available for comparison. 


The major finding of this study is that the mortality of 
patients requiring re-admission to intensive caie has decreased 
significantly following the introduction of a dedicated ther- 
apist assessment-treatment team, use of respiratory care pro- 
tocols, and delivery of appiopriate, seamless respirator care 
to a high-risk patient population. Respiratory deterioration 
remains the most frequent reason for ICU re-admission in our 
hospital, justifying continued study of this problem. Patients 
re-admitted to an ICU with respiratory failure also experience 
a higher than average death rate compiued to patients re-admit- 
ted for other reasons. 

What other factors could have contributed to our findings? 
Was the mortality rate in our control group excessive? The 
high mortality rate we initially observed has been reported 
elsewhere. In smaller studies generally confined to a single 
unit, mortality rates of about 60% have been reported." '- 

Table 2. Causes and Mortalitv of ICU Re- Admissions in Both Groups. 








Intervention group 

Number of patients 








% of patients re-admitted 








9c Mortality 






Control group 

Number of patients 








% of patients re-admitted 








9c Mortality 








Respiratory Care • October "96 Vol 41 No 10 


Decreased Mortality in ICU Re-Admissions 

Another possible explanation lor the lower mortality is 
that the patients may have been less often discharged pre- 
maturely. We did open more ICU beds during the intenention 
period, and the pressure to move patients out before they 
were optimally treated may have been less." Against this 
explanation is the fact that average ICU length of stay was 
2 days shorter during the intervention period (although this 
difference did not reach statistical significance). Also against 
this explanation is the fact that a slightly higher percentage 
of patients were re-admitted for worsening of their origi- 
nal problem (possibly signifying early triage) in the inter- 
vention group than in controls. Other studies mentioned have 
used re-admission for the same problem us a marker of too- 
early discharge. The facts that the re-admission rate was iden- 
tical between the two time periods, that length of ICU stay 
shortened, and that the percentage of patients re-admitted 
for the worsening of their initial problem was the same sug- 
gest that patients were not kept in the units longer during 
the intervention and were not in better condition on initial 
discharge at our institution. 

A problem with all retrospective clinical studies is that unde- 
tected changes other than the studied intervention may ha\ e 
produced some or all of the observed findings. In addition to 
the changes in care mentioned, several other institutional fac- 
tors were different between the 2 study periods. A new hos- 
pital building was built and occupied, the number of avail- 
able ICU beds was increased (from 26 to 34), and several new 
ICUs were developed to accommodate selected patient pop)- 
ulations (separate cardiac and neurosurgery units). The over- 
all number and individual qualifications of the respiratory care 
staff also increased. The individual contributions of these 
changes to the observed differences is not known but are 
believed to be small. 

Another possible reason for tlie differences is that the patient 
populations studied may not be identical. Changes in diag- 
noses or disease prevalence ciiuld have also affected outcome. 
We have no data regarding this issue. 

Other changes in quality of medical care may have con- 
tributed to the improved survival. Survival from the adult res- 
piratory distress syndrome ( ARD.S) is now significantly bet- 
ter than during the extracorporeal membrane oxygenation, or 
ECMO, trials reported in the early 70s and has improved over 
the past decade.''' Actual versus predicted mortality based on 
the APACHE 11 seining system and other mortality predic- 
tors have also shown general improvement of outcome over 
the past several years. '^ Many ICUs are experiencing about 
half the original predicted mortality. The exact reason for this 
change is unknown. This has lead to the development of new- 
systems to predict mortality nH)re accurately "'including the 
APACHE III system, which uses a large continuously updated 
database retlecting current treatment. 

When in the course of Illness a patient is admitted to an 
ICU can influence outcome. Rapoport et al'^ demonstrated 
that patients with the same degree of physiologic derange- 

ment initially admitted to an ICU experience a lower mor- 
tality than if they were first admitted to a floor for a day or 
more. Actual versus predicted mortality was lower in the ini- 
tial ICU-admission group than in the late-admission group. 
The change in outcome that they observed is believed to be 
due to delay in treatment. In our study, we believe that patients 
in the intervention group were re-admitted sooner, and this 
may have contributed to the lower mortality seen. 

Even if the precise reasons for change in outcome between 
these studies cannot be determined, the usefulness of ex- 
amining the population of patients requiring re-admission 
is apparent. Ascertaining the causes for ICU re-admissions 
and the outcome of patients re-admitted gives useful infor- 
mation about hospital systems and care. Opportunities for 
improvement can be identified and the effects of instituted 
changes monitored by following this selected group of high- 
risk patients. The expenses involved in caring for ICU re- 
admissions are considerable and may be influenced by appro- 
priate acute care management strategies. The use of step- 
down units for patients at risk has been suggested as an alter- 
native to prolonging ICU stays. We suggest that improved 
floor care and aggressive assessment by respiratory ther- 
apists can increase the likelihood of survival in patients requir- 
ins ICU re-admission. 


1 . Berenson RA. Intensive care units: clinical outcomes, costs and deci- 
sion making (Health Technology Case Study. U.S. Congress. OTA- 
HCS-28). Washington DC: Otfice of Technology Assessment. 

2. Sage WM. Rosenthal MH. SiUemian JF. Is intensive care worth it? 
An assessment of input and outcome for the critically ill. Crit Care 
Med 19Sfi;14(9):777-7S2. 

3. Kalb PE. Miller DH. Utilization strategies for intensive care units. 
JAMA 1989;261(16):2389-2395. 

4. Cullen D. Results and costs of intensive care. Anesthesiology 1977; 

5. Oye RK. Bellamy PE, Patterns of resource consumption in medical 
intensive care. Chest 1996:99:685-689. 

6. Durbin CG Jr. Kopel RF. A case-control study of patients re-admit- 
ted to the intensive care unit. Cnt Care Med 1 993:2 1 (10): 1 347- 1 .S53. 

7. Han SK. Dubbs W. Gil A, Myers-Judy M. The effects of therapist- 
evaluation of orders and interaction with physicians on the appro- 
priateness of respiratory care. RcspirCarc 1989:34:185-190. 

8. Browning J A. Kaiser DL. Durbin CG. The effect of guidelines on 
the appropriate use of arterial blood gas analysis in the intensive care 
unit. RespirCare 1989:34:269-276. 

9. Beasley KL. Darin JM. Durbin CG. The effect of lespiratory care 
department management of a blood gas analy/er on the appro- 
priateness of arterial blood gas utilization. Respir Care 1 996:37: 

1 0. Knaus WA. Draper EA. Wagner DP. Zimmennan JE. APACHE II: 

a sev erity of disease classification system for acutely ill patients. Crit 

Care Med 1985:13(101:818-829. 
1 1 . Franklin C. Jackson D. Discharge decision-making in a medical ICU: 

characteristics of unexpected readmissions. Crit Care Med 1983:1 1 




Decreased Mortality in ICU Re-Admissions 

1 2. Rubins HB, Moskin\ It/ MA. Discharge decision-making in a med- 1 5. 

ical intensive care unit. Identifying patients at high risk of unexpected 

death or unit re-admission. Am J Med I988;84(.'i):863-8fiy. 
I .^. Marshall MF, Schuen/er KJ. Orsina M. Fletcher JC. Durbni CO Jr. 1 6. 

Intluence of pohlical power, medical provincialisni, and economic 

incentives on the rationing of surgical intensive care unit beds. Crit 

Care Med l9y2;20l3):387-394, 
14. Milberg JA. Davis DR. Steinberg KP, Hudson LD. Improved sur- 17. 

vival of patients with acute respiratory distress syndrome ( ARDSl: 

1983-1993. JAMA 1995;273(4):306-309. 

Civetta JM. Hudson-Civetta J A. Nelson LD. E\ aluation of APACHE 

U for cost containment and quality assurance. Ann Surg 199(1:2 I 2 

(3): 266-276. 

Knaus WA. Wagner DP. Draper E.A. Zimmerman JE. Bergner M. 

Bastos PC. et al. The APACHE III prognostic system. Risk prediction 

of hospital mortality lor ciitically ill hospitalized adults. Chest 1991; 


Rapoport J, Teres D. Lemeshow S, Harris D. Timing of intensive care 

adiiiission in relation to ICU outcome. Crit Care Med 1990; 1 8( 1 1 ); 


^ Conve^^. 

;an dieg© 

November 3-6, 1996, Sunday- Wednesday 



Books, Films, 
Tapes, & Software 

Listing and Reviews of Books and Otlier Media 

Note to publishers: Send review copies of books, films, lupes. and software to 
Rtsp|RATOR^ Carp, I Kl.W .Abies Lane. Dallas TX 7.' 

Clinical .Manifestations and Assessment 
of Respiratory Disease. Ihiid edkion, by T 
Des Jatdms and GG Burton. Sot'tcover. 584 
pages, illustrated. St. Louis, Mosby, 1995. 
Cost: .$45.75. 

The fundamental abilities to e\ ;iluate clin- 
ical data, assess thorouylils the available 
infoimation. delemiinc a patient's problem. 
and establish a care plan are essential to the 
practice of respiratory care. This te.\t seeks 
to provide students with a background in dis- 
ease pathology and skills for assessment that 
will help them work in an environment that 
uses therapist-driven protocols. The authors" 
third edition continues the tradition of well- 
illustrated, detailed anatomic alterations of 
the lung caused by various respiratory dis- 
ease states. It is written in a readable, well- 
organized, and thorough manner and con- 
tains full-color plates that show pathologic 
changes. (Tim Phelps of Johns Hopkins Hos- 
pital created these outstanding illustrations.) 
In addition to a presentation of each disease 
entity, the authors have included illustrative for each pathology. In all these respects. 
1 believe this te.\t currently outranks simi- 
lar texts on the market. 

The book is designed to correlate with 
respiratory care curriculums and could be 
used by hospital departments to review data- 
gathering, assessment, care-plan-develop- 
ment, and documentation skills. Both res- 
piratory care practitioners and nurses could 
benefit from this strong resource. 

The first section, titled "How to Use this 
Book," describes the format of the text. 
Chapter 1 — Patient Assessment — provides 
a review of physical findings, laboratory data, 
cardiovascular findings, o.xygenation indices. 
and pulmonary functions. Radiologic Exam- 
ination of the Chest (Chapter 2) summarizes 
the skill of evaluating normal chest films. 
It also includes examples of magnetic res- 
onance imaging, computerized totiu)graphy, 
bronchogram, and pulmonary angiogram 
which are not only helpful, but also bring this 
text up to current standards of practice. I 
noted one error in this chapter, h'igures 2- 1 
and 2-2 are switched. Kigure 2-1 is labeled 
a standard posterior-anterior (PA) chest radio- 
graph on full inspiration. This radiograph 
actually shows the diaphragm at about rib 
number 9 (a Ixirderline insptratoiy film). Fig- 
ure 2-2 labeled a standard P.\ chest radio- 

graph on expirulion shows the diaphragm 
at about rib number 1 1. making it more 
nearly a full inspiratory film. Chapter .■!. 
Recording Skills — the Basics for Data Col- 
lection, Organization, Assessment Skills 
(Critical Thinking), and Treatment Plans, 
walks the reader thriiugh a problem-oriented 
medical record and reviews the use of sub- 
jective, objective, assessment, and plan 
(SOAP) progress notes. 

It is important to point out that the authors 
use the term "assessment" to mean "criti- 
cal thinking/problem-solving." In other 
words, assessment does not simply imply 
the collection of data, such as breath sounds 
and chest percussion note, that is commonly 
used in discussing 'patient assessment." An 
assessment encompasses the ability to look 
at the collected clinical data, determine the 
patient" s possible problems, and establish 
a c;ire plan appropriate for that patient"s prob- 
lems. As a respiratory care practitioner, I 
appreciate that we all must think critically 
about gathered infomiation and recommend 
treatment for the patient" s respiratory dis- 
order; and because I believe an abilit) to 
assess continues to be extremely important 
to the profession, 1 appkiutl its being included 
in the text. 

The final section of the te.\t includes a 
discussion of respiratory disorders. Tlie for- 
mat of these chapters and the consistency 
with which they are presented includes fi\e 
topics and is the key aspect of the presen- 
tation of the text. 

"Anatomic Alterations of the Lungs"" 
begins with an illustration of the changes in 
the lungs associated with the disease. Rather 
than attempting to be anatomically acciinile. 
the ;irtist provides a draw iiig that emphasizes 
the pulmonary strucnires affected by the dis- 
order. One of my personal favorites is the 
illustration of croup syndrome: laryngotra- 
chcobronchitis and acute epiglottitis. The 
comparison of subglottic sersus epiglottic 
edema is the best approach I've seen. This 
section also includes a description of the 
changes that ;ire associated w ith the disease. 

"luiology" gives an explanation ol the 
cause(s) of the disease. 

"Overview of the Cardiopulmonary 
Clinical M;mifestations .AsscK'iated \\ ith the 
Disorder" is presented in a box Ibrmat and 
systematically provides a brief listing of 
clinical findings. .\ number of the chap- 

ters also include chest radiographs, which 
are helpful. 

"General Management or Treatment of 
the Disease" emphasizes appropriate res- 
piratory and medical care. For example, in 
lung abscess, the text briefly re\iews poten- 
tial treatment modalities including the use 
of ;mtibiotic ageiils. mobilization of bronchial 
secretions. h\ perinfialion techniques, sup- 
plemental oxygen, and surgery. All disor- 
ders are treated in a similar fashion with 
enough information included but without 
going overboard with detail. 

"Case Study" is the final section given 
for each disease. Students and instructors 
alike may find this an extremely valuable 
resource. It gives an overview of the patient 
including related history and clinical data. 
A short section follows, titled "Respiratory 
Assessment ;md Plan." in which the authors" 
provide a problem-oriented medical review 
giving the SOAP overview of the patient. In 
appropriate cases, the overview contains the 
patient's response and modification of ther- 
apy based on the patient" s response. 1 under- 
stand that candidates frequenth have dit"- 
ficulty modifying therapy on the national 
examinations in respiratory care. Here, again, 
is an area in which this text may be useful. 

At the end ot each chapter are a number 
of self-assessment questions — primarily 
multiple choice, multiple true-false, fill-in- 
the-blank. or matching. Many questions are 
at the recall, recognition, and application 
level. Although the case studies pros ide an 
introduction to analysis and problem-solv- 
ing, it would have been nice to see more 
questions on the analysis level. 

As a final note, the appendixes provide 
a quick reference for phamiacologic agents 
used in patients with cardiopulmonary dis- 
orders; techniques used to mobilize bronchial 
secretions; hyperinfiation techniques; and 
symbols, abbreviations, units of measure- 
ment, equations, and related physical prin- 
ciples. The glossary defines important terms. 

1 belies e this book achieves its intended 
purpose and that instructors \\ ill not be dis- 
appointed in this thiid edition, which con- 
tinues a tradition of being a classic in res- 
pirators care. 

Susan Pllbeam MS RRT 

Faculty, Respitalors Care Program 

Greenville Technical College 

Greenville. South Carolina 



Letters addressing topics of current interest or maleru: ni RESPIRATORY CARE « ill be considered tor publication. The Editors may accept or 
decline a letter or edit without changing the author's views. The content of letters as published may simply reflect the author's opinion or inter- 
pretation of information— not standard practice or the Journal's recommendation. .Authors of criticized material will have the opportunity to 
reply in print. No anonymous letters can be published. Type letter double-spaced, mark ii 'For Publication." and mail it to RESPIRATORI 
CARE. 1 1030 Abies Lane, Dallas TX 75229-45<).\ 


Ste-Anne's Approach 
to Self-Treatment 

I read with much interest the editorial by 
Mr Giordano "What We Say versus What 
We Do" [RespirCare 1996:41(6):504-506| 
and thought it important to share what we 
at Ste-Anne's Hospital, a 650-bed medical 
and psychiatric chronic care faciUty for vet- 
erans in Ste-Anne-de-Bellevue. Quebec 
(Canada), have been doing in that respect 
since 1990. It should be noted that 30'^f of 
our residents have a diagnosis of COPD; and 
before 1990, certain of our COPD residents 
often missed their inhalation treatments 
because they were making full use of the 
many activities that are available at our cen- 
ter (bingo nights, arts & crafts, outings, con- 
certs, visiting hours). They insisted on being 
able to take the treatments on their own 
because they had been doing so at home. 
This was the instigation for our developing 
a program through which certain residents 
could be on "automedication" for their inhala- 
tion treatment. 

We created different categories of res- 
idents that resemble those described in your 
editorial. Our first category includes those 
residents who require the full attention of a 
respiratory care practitioner (RCP) for the 
entire duration of the treatment ( 55% of sam- 
ple). The residents in a second group meet 
specific criteria (stable health status, relia- 
bility, adequate manual dexterity, low-anx- 
iety level, full autonomy ) and ha\ e had their 
case discussed by our staff. The third group 
includes those residents who are often away 
from their room, who lack the necessary 
manual dexterity, or who ha\ e somewhat lost 
the notion of time but who can handle one 
treatment at a time if it is prepared for them. 
The second and third groups (21% of sam- 
ple) are often reminded that their participation 
in this program is conditional upon continued 
compliance. A fourth group (239'f of sam- 
ple) is mobile enough to come to the Inhala- 
tion Therapy Department for their treatment 
during specific clinic hours, thus allow ing 
a one-to-six ratio w hile maintaining a high 
quality of care. All these residents are seen 
and evaluated at least once a day (usually in 
the morning) and any change in their health 
status can be noted and brought to the nurs- 
ing staff's attention. Tlie nursing slaft'. m luni. 

informs us of an> pertinent information or 
noncompliance on the patient's part. 

Our ultimale goal was to ensure that otir 
residents who met certain criteria cotild main- 
tain their autononi) as long as possible w hile 
Inhalation Therapy staff kept strict control 
over their medication. It was also a cost-effi- 
cient use of qualified RCPs. With an in- 
creased workload and decreased staff since 
1990. we cannot imagine returning to the 
one-on-one basis with these autonomous res- 
idents — and 1 don't think they could either! 

Anne LaRoche. BSc, RRT 

Ste-Anne's Veterans' Hospital 
Ste-Anne-de-Bellevue, Quebec. Canada 

Qualined RCPs in Home Care 

1 read with great interest Sam Giordano's 
editorial "What We Say versus Wlial We Do" 
[RespirCare 1996:41 (6):504-5061 in the June 
issue of the Journal. 1 sincerely hope that all 
respirator, ciire practitioners (RCPs) read the 
editorial, understand the significance of his 
points, and take positive action on the issue. 

During the late 70s and eariy 80s. 1 had 
the privilege of learning respiratory care at 
St Luke's Hospital in Kansas City. The 
department, at that time, was under the lead- 
ership of Sam Giordano; the education of the 
staff was the responsibility of the late Sam 
Runyon. Both gentlemen emphasized the 
necessit) for individualized treatment of 
patients and also for therapist input into pre- 
scribed treatment modalities and protocols. 
This resulted in a very strong, respected 
department, and a consistently high level of 
patient care. 

Certainly, the health-care environment 
has changed, but the need for the same indi- 
\'idualized care has not. As a matter of fact, 
the respiratory patient now needs our un- 
divided attention more than ever. If these 
patients are being discharged earlier due to 
insurance plans that limit length of stay, 
shouldn't we w ork diligently to ensure proper 
education, proper understanding of therapy, 
and an appropriate therapy-intensity level 
w hile they are in our care'? 

The earlier release of more acutely ill 
patients has an impact on RCPs in home c;ire 
also. The same indi\ idualized attention that 

Sam stressed in the editorial should be con- 
tinued at home as well. However, 1 have seen 
an unfortunate trend evolving — delegation 
of the respiralon patient to individuals who 
have not had respiratory training. This prac- 
tice can ultimately compromise patients and 
limit our profession as well. It is not rea- 
sonable to have only RCPs on a home-care 
payroll because of the general lack of re- 
imbursement for our services in the home; 
however, it is our responsibility to select the 
qualified indi\ idual to perform the proper 
task at the proper time. 

Home-care RCPs can provide a valuable 
service by managing complex patient sit- 
uations and by pert'omiing the initial assess- 
ment and patient and caregiver training on 
manv' respiratoiy refeirals. We can act as the 
'eyes and ears" for physicians and play an 
important role in increasing patient com- 
pliance with prescribed therapy. This will 
result in savings in health-care expenditures 
and in increased qtialitv of life for the patients 
we serve. I believe all who have a part in the 
home-care referral process should seriously 
ask "Who is taking care of my patient at 
home''" B\ doing so. not only :ire we empha- 
sizing the importance of our profession, but 
we are also establishing a continuity of qual- 
ity care for that patient. In spite of the con- 
sistent pressure tti lower reimbursement for 
respiratory equipment in the home, the pres- 
ence of qualified RCPs on home-care staffs 
must always be viewed as an in\ estment in 
quality, not an expendable cost. 

In closing. 1 applaud Sam Giordano's 
insight and wish to expand his thought to 
include the home-care environment as well. 
It is our responsibility, regardless of cre- 
dential, to make "What we say" equivalent 
to "What we do." Once that occurs, our pro- 
fession will begin to gain a strong foothold 
on solid ground in all arenas of health care. 

Harley R Metcalfe RRT 

General Manager 

Home Medical Specialty Equipment 

Libertv. Missouri 

Giordano responds: 

We thank Ms LaRoche for sharing infor- 
mation about the self treatment program at 

Respiratory Care • October "96 Vol 41 No 10 



Ste-Anne"s. It is obvious froiii your letter that 
you and your colieayues have tal<en a eoui- 
inon sense approach in establishing a pro- 
gram that enables qualified patients to self- 
administer respiratory treatments. 

Your elassilkatiiin system underlines the 
importance ot having a thorough knowledge 
of the patient population in your institution. 
That knowledge, coupled with compliance 
monitoiing and assessment, bring about a 
more appropi iate match ol respiratoiy care 
resources to need. 

I hope that you aie documenting the qual- 
ity outcomes for your program and will be 
able to picsent results sometime in tlie future. 
Success stories such as yours are what our 
profession needs if we are to successfully 
balance respiratory care costs and quality. 

It is unfortunate that health care in the 
United States is. in large part, based on reim- 
bur.sement rather than the needs of the 
patient. Harley Metcalfe's letter speaks elo- 
quently to that issue. After all. if we look 
at the reimbursement scheme in place, we 
find a paradox in terms of clinical need and 

• Respiratory care practitioners are needed 
Ireimbuised) in hosjiitals. 

• Respiratory care practitioners are not 
needed (not reimbursed) tor sen ices ren- 
dered in the home. 

We know that, if allied health profes- 
sionals with tested and dix'umenled education 
and training and demonstrated ability to ren- 
der respiratory care ser\ ices are needed to 
treat patients in acute care settings, it is only 
logical that these similarly qualified indi- 
viduals air needed in other care settings, such 
as the home. 

Over the past few years, we have wit- 
nessed e\er-incrcasing etforts to shorten hos- 
pital length ot stay — not necessarily because 
patients no longer need that level of support 
but because the reimbursement system man- 
dates earlier discharges. Many of these ear- 
lier discharges result in sicker patients being 
supported in their homes — not for clinical 
reasons birt because of icimbirrsement issues. 
The discharge of sicker' patients increases 
the need for qualified respiratory care pro- 
fessionals (RCPs) in the home. 

The AARC has, time and time again, 
approached the Health Care financing .Ad- 
niinistratiou submitting evidence that home 
respiratory care is cost-effective, but the 
response has been that a change in the law 

is necessary. The AARC has repeatedly 
approached Congress in an effort to change 
the law, but the Congressional Budget Office 
has pronounced that to do so would add to 
Mediciire spending, which is, as we all know, 
not politically expedient today — and. sadly, 
little or no publrshed research confirms the 
value of the qualified RCP to home care. 
We must document the added value that 
qualified RCPs pr'o\ ide in alternate care set- 
tings, such as the home. This added \ alue 
lies, as Harley states, in being the eyes and 
ears of the attending physicians. We must 
go beyond rendering treatments atid continue 
to penetrate the realm of case management, 
demand management, and caie coordination. 
Moreover, we must docuirrent our success 
in these relatively new areas so that public 
policy and private insurance support deci- 
sions to allow qualified RCPs to reali/.e their 
potential as caregivers, patient educators, uti- 
lization coordinators, and adjuncts to physi- 
cians and nurses. 

Sam P Giordano MBA RRT 

Executive Director 

American Association for Respiratory Care 

Dallas. Texas 

A Reader Wonders about the 
Cost of Assessments 

It is with great interest that 1 read the 
report of Shrake and colleagues |Resprr Care 
1 9%;4 1 ( 8 ): 703-7 1 3 1 concerning their pro- 
gram of respiratory care assessments. The 
authors are to be commended for develop- 
ing this forward-looking program. Indeed, 
it seems to me that the true value respiratory 
care practitioners (RCPs) bring to the health- 
care team is not in administering respiratory 
care procedures, which are generally tech- 
nically simple (with some important excep- 
tions), but. instead, their value comes from 
(what should be) their knowledge of the 
available interventions to treat respiratory 
conditions, and their training and experience 
in assessing the nature and degree of res- 
piratory disease. 

I'hese skills should help the health-care 
industry to manage what has been our 'dirty 
little secret' of o\ertreatment that in the end 
should conserve resources (ie, save money). 
Although the authors have done an excel- 
lent job of describing the subtleties of vari- 
able costs. 1 am conccriied that they may not 
have reported the true cost impact of their 
program to the hospital. They are certainly 

correct in pointing out that every unneces- 
sary treatment incrementally increases the 
hospital's costs under a diagnosis related 
group (DRG) reimbursement system, but 
they have not told us what their assessment 
program costs to administer. RCPs who per- 
form assessments are being paid. Each as- 
sessment incrementally increases the hos- 
pital's costs, unless, of course, the RCP staff 
is not volume adjusted, and the same num- 
ber of them is there all of the time regard- 
less of the work load. If this is the case, the 
hospital can. of course, save a lot of money 
in a big hirnA'. The costs of these assessments 
should be used to determine the true cost to 
the hospital. 

As hard as it might be simpls to consider 
skipping all assessments, implementing all 
of the ordered therapy with technician-level 
staff (ie. those who are lower paid) might be 
more economical for the hospital. This of 
course does not consider the other related 
consequences of unnecessary treatment, but 
e\ en the hard core among us would have to 
agree that aerosolized bronchodilators. chest 
physiotherapy, incentive spirometry, oxy- 
gen therapy, and humidity therapy do not 
generally pose a serious risk to patients who 
don't need them 

1 suspect (and hope) that an asscrtrve, 
highly trained staff of RCP assessors who are 
empowered to fashion I'espii'atory care plans 
can indeed save a hospital money. 1 am not 
sure that Shrake et al have proven this. 

John W Salyer BS RRT 

Director Outcomes Research Service 

.Administratis c Director 

Respiratory Care Service 

Assistant Professor Pediatric Pulmonology 

Primary Children's Medical Center 

University of Utah. School of Medicine 

Salt Lake City, Utah 

Shrake responds: 

Thank you for your interest in the ret- 
rospective study of our patient assessment- 
treatment systeiTi at Memorial Medical Cen- 
ter. First. I would like to say that, although 
1 am a respiratory care practitioner by back- 
ground, my job for the last se\ eral years has 
been as an administrator over the cardio- 
pulinonary service line. In this capacity. I 
have had to cast aside any personal biases 
iirising from m\ love for the respiratory care 
profession and evaluate every new program 
with a critical eye in terms of its ability to 


Respir.atory Care • October "96 vol 41 No 10 


add \ alue — either by improving quality or 
reducing costs. 1 shared some of your con- 
cerns about the costs of providing patient 
assessments when we were developing the 
initial sffategies for our assess-and-treat sys- 
tem. This program was developed from a 
pilot project conducted on the orthopedic 
floor of our institution [RespirCare 1994:39 
(7):715-724]. Through that project, we were 
able to determine what worked and what 
didn't before the program was exp;mded hos- 
pital-w ide. We learned two iinportant things 
during that study. (1 ) We were doing loo 
many assessments initially because of our 
desire to do a "perfect' job. and ( 2 ) the paper- 
work system that we were employing foi' the 
assessments was too labor intensive, .^s a 
result of these experiences, we refined the 
frequency of assessments and the papeiivurk 
mechanism to allow the majont> of the work 
to be perfonned w ithin the time frames allo- 
cated for treatment deli\ery within our exist- 
ing productivity model. In essence, our per- 
sonnel were functioning as true professionals 
during the patient's treatment time slot by 
making assessments, reviewing data, and 
communicating with nursing staff, rather 
than siiTiply putting nebulizer mouth pieces 
in patients' mouths. We added no additional 
time to our productivity model to operate 
this program. Our productivity has remained 
at or near I OO'/r during the past 3 years, as 
staffing levels have been adjusted to cor- 
respond with work loads. Overall, the res- 
piratory care staffing has increased over the 
past few years even though our staffing 
requirements for inpatient care has declined 
due to more appropriate utilization of ser- 
vices. This is due to a comprehensive, multi- 
competency, multisite operation that has seen 
the role of the RCP at our facility expand 
into home care, physician-clinic support. 24- 
hour emergency room coverage, clinical 

resource management, and. very soon, trans- 
fer agreements for subacute care. We plan 
to continue to identify areas where RCPs can 
add value to our changing health-care sys- 
tem and pkin to employ the s&ategy of a cen- 
tralized, multiskilled labor force that can pro- 
vide decentralized services, wherever and 
w henever they are needed. As an adminis- 
trator, I am much in favor of cross-training 
entry-level personnel to perform simple 
tasks, and we have implemented some of 
those strategies at our own institution. 

I disagree with your .statements, however, 
regarding the potential cost-effectiveness of 
eliminating assessments and delivering all 
the ordered care regardless of its appro- 
priateness. Costs are important, but ulti- 
mately we must develop programs with the 
patient's best interest at heart. Our medical 
director felt strongly that there are inherent 
dangers in some of the modalities that we 
use on patients including oxygen and bron- 
chodilators. For that reason, safeguards were 
built into our protocols that require the RCP 
to make a physician contact under certain 
circumstances. An example of this is when 
the patient experiences adverse reactions to 
a drug. Because the protocols are published 
as an appendix to the ;irticle. you can review 
the other built-in safeguards at your leisure. 

One of the things that our study at- 
tempted to do was to identify true cost-sav- 
ings, not charge-savings; to track variable 
costs; and to report actual cost-savings, rather 
than 'paper-savings'. Failure to do these 
things has been the shortcomings of soine 
of the studies that have been reported in the 
limited body of literature on this subject.'"" 
We believe that we ha\ e identified some true 
cost-savings and that those cost-savings are 
actually understated. As noted in the paper, 
we evaluated only the cost impact of patients 
in the top 20 diagnosis related groups 

(DRGs) that utilized respiratory services. 
There were undoubtedly additional sax ings 
associated with other DRGs. We were also 
unable to quantify the cost-savings froin 
patients for whom we chose to do nothing. 
We are glad that this article has stimu- 
lated thought on \our part. We would chal- 
lenge you to take our experience and use it 
as a stepping stone to improve on cost-sav- 
ings documentation. We will offer one warn- 
ing, however. If it were easy to do. the med- 
ical literature would be full of such reports. 
Our future plans are to take the successes 
that we have demonstrated with our exist- 
ing program ;ind expand them into a protocol 
process for ventilator patients. Good luck 
in your future endeavors, and thank you 
again for your interest m our article. 

Kevin L Shrake MA RRT 


Cardio-Pulmonary Services 

Memorial Medical Center 

Springfield. Illinois 


1 . Hail SK. Duhbs W. Gil A. Myen,-Judy M. 
The effects of therapist-evaluation of 
orders and interaction with physicians on 
the appropriateness of respiratory care. 
RespirCare 1 989:34(3): 185- 190. 

2. Nielsen-Tietsort J, Poole B. Creagh CE. 
Repsher LE, Respiratory care protocol: an 
approach to in-hospital respiratory ther- 
apy. RespirCare 1981:26(.^):4,W-436. 

3. Kester L. Sloller JK. Ordering respiratory 
care services for hospitalized patients: 
practices of overuse and underuse. Cleve 
Clm J Med I992:.'i9(6):581-58_*i. 

4. Mahlmeister MJ, Fink JB. Cohen NH. A 
strategy for reducing costs associated with 
pulse oximetry in noncritical care areas. 
RespirCare 1993:38(9): 1005- 101 3. 



As part ot our ceicbraiion. the editors ha\e chosen to repuhhsh articles or e\eni mlornialioii that have appeared in past 
issues o( the Journal. During the coniins months, our readers are invited to enjoy this historic reflection \\ ith us. 

Reflecting on 40 Years of RESPIRATORY CARE: 

AARC International Convention & Exhibition — ^A Timeline 

Since its inception in 1955, the AARC International Convention & 
Exhibition has been the source of ideas, research, education, and. 
yes, fun for respiratory care professionals from around the world. 
Each year, fellowships arc earned and awarded; expert and expe- 
rienced well-knovvns in respiratory c;ue lecture and instmct; exhibitors 
hrini; their most innovative equipment to explain and display, 
researchers present their latest findings during the Open Forum; 
and the Sputum Bowl excites competition. It's safe to say that the 
convention is a 'warp speed.' friend-meeting, hands-on. poster-view- 
ing, information-collecting, good time, .^nd. just in case you have 
missed a few of the highlights from previous years — take a look at 
these pages. 










-»"gglFLee Bai e 









MltIiii K DiiVal MD 


Onin Hatch 


1 97,' 

John W Severinghaus MD 
William M Thurlbock MD 


Richard D Lamm 
Jack Anderson 



Jcilin P Holdrcn 

Mark Zilter 


Herbert A Sail/man mi:) 


G Michael Durst 



Meyer SakladMD 

."Arthur Sehlesinger 


Leslie Rcndell Baker .MD 


Ralph Nader 


Tom Brokaw 


Patrick Reynolds 


Issae .-ksimdv 

1 99 1 

Linda Kllcrbee 


Howard K .Smith 

Louis Sullivan MD 


K Lee Bailey 

Gail R Wilcnsky 


Irving R I.evine 


Henry Cisneros 


Bob Dole 

Roger Staubach 

Jane Bryant Quinn 


Paul E Tsongas 


BaiTV Goldwater 
C E\erett Koop MD 


Gloria Dunn 
Richard D Lamiu 


Alfred Softer MD 
.'\ndreu 'iduns 


William C Dement MD PhD 
Henrv W Foster MD 

Donald F Egan Scientific Lecture 

John F Murray MD. Oxyi^cn Triiii\piiri: New Coinepls. New 


Lynne Reid MD. New Perspectives in Piiliiioiuiry Hyperlensimi 

David V Bates MD. Early Deleclion ofAinmy Obslruclion 

George G Burton MD. Hinv To Siieceeil in Respiratory Therapy 

by Really Tryin!> 

John Hedley-Whyte MD, Ventilatory Care 

Albert P Fishman MD, Changing Concepts of Piilmoiiury Edema 

and the Respiratory Distress Syndrome 

Alan K Pierce MD. Respiratory Therapy: State of the Art 

John W Severinghaus MD. Transciitanenits P,). and Pcoi 


Reuben M Chemuick MD. Pitfalls in Piilinonun Function Testing 

Roger C Bone MD. 77ic Adult Respirator\- Distress Svndrome: 

Treatment in the Next Decade 

Thomas L Petty MD, Pulmonuiy Rehuhilitation: Better Living 

with New Techniques 

Irwin Zimenl MD, Five Thousand Years of Attacking Asthma 

Ronald A Harrison MD, Ventilatory Support Techniques: A 

Resource for Discovety 

Da\ id R Dant^ker MD, PEEP and Oxygen Consumption: Is Oi 

Deliverv Really Our Goal.' 

John B West MD. Severe Hypoxia: Lessons from High Altitude 

Leonard D Hudson MD. The Prediction and Prevention ofARDS 

Mary Ellen Avery MD. 25 Years of Progress in Hyaline 

Membraiw Disease 

E Regis McFadden Jr MD. Fatal Asthma 

John J Marini MD, Patient-Ventilator Interaction: Rational 

Strategies for Acute Ventilatory Management 

Lee B Reichman MD MPH. Tuberculosis: An Old Enemy Is 


C James Carrico MD. The Trauma Patient: Our Responsibilities 

in the ICV and m Sccietv 

Jerome H Modell MD. What Have We Learned about Lung 

Injury from the Management of Near-Drowning? 

1983 Bob Dole 



Historical Note 

Program Committee Special Lecture 

1985 Bam A Shapiro MD, The Impact of Respimlory Care 
Professionals on Techniques of Airway Pressure Therapy 

1986 A Jay Block MD. Alcohol. Sex. Sleep, and Breathing 

1987 David J Picrson MD, Respiratory Care as a Senice 

1988 Walter J O'Donohue MD, The Future of Home Oxygen Therupx 

1989 Ronald B George MD, Respiratory Care and the Era of 
Pre\cnti\c Medicine 

1 990 Ron J Anderson MD, The Safety Net Runneth Over: Is It Time for 
Universal Health Access in America'.' 

199 1 Robert M Kacmarek PhD RRT, The Respiratory Care 
Practitioner: Carpe Diem.' 

1992 John M Luce MD, HIV. AIDS, aiul the Respiraton Care 

1993 Susan K Pingleton MD, Nutrition. Mahuitntion. and the 
Ventilator Patient 

1994 Ke\in L Shrake. RCPs and Health Care Reform: Demonstrating 
Value. Creating Opportunity 

1 995 Dean R Hess PhD RRT, Respiratory Care at the Crossroads: 
Evolution or Extinction ? 

Speakers at Early Conventions 

1956 Edwin Levine MD 

Inhalation Therapy in Controlling Disea.\es of the Chest 

1957 Henn, A Zimmerman MD 

Inhalation Therapy and the Practice of Medicine 
1962 Hurley Motley MD, IPPB 
1968 JohnGWegMD 

Prolonged Endotracheal Intubation in Respiratory 

Convention Firsts! 

The Open Forum first appeared in the 1972 Convention held in Las Vegas, 
Nevada Then the pnssentations only included 2 papers. Now, the OPEN FORUM 
features authors from around the world, and each year more than 150 abstracts 
are presented. 

During the 1992 Annual Convention in San Antonio. Texas, a program called 
the Special Research Program featured tips about research fundamentals, 
study design, and statistics. Now. the esent continues each year as the Research 

In 1988, Richard D Branson RRT chaired the first symposium, "Controversies 
in Respiratory Care." The event which features discussions of pros and cons 
continues with the 1996 Convention. 


The World of Gambling was presented by Bill Friedman, an instructor from 
the University of Las Vegas, during the 1972 Convention in Las Vegas, 

The highlight of the Annual Banquet during the 198.1 Convention in Kansas 
City, Missouri was a performance by Billy Crystal. Then, the now-famous 
actor had the television show, "Soap," to his credit. 

In 1986 at the Dallas Convention Center in Texas, entenainment featured 
The Coasters and Bo Diddley. 

Bill Friedman in 1972 

Sputum Bowl Winners 


Idaho: Tom Gable. Keith 
Hopper, Teri Norrell. 


Antoinette Rene 



Idaho: Tom Gable. Keith 
Hopper. Teri Norell. 

Antoinette Rene 



Idaho: Tom Gable. Keith 
Hopper. Teri Norell 


Colorado: Robert Clothier, 
James Haenel, Marsee 
Vander Plyum 



California: Peter Doyle. 
Pat Tobin. Mel Welch 



Missouri: Steve Bricknell. 

Bill Logan, Richard 


Moore, Bob Stone 


New York: Robert Fluck, 

Claire Goike, Thomas Hill. 


Joseph Sorbello 


California: Lillian Fifer, 

Jim Fink, Mike Mahlmeis- 


ter. Katherine Sabato 


Colorado: Phil Goodman. 
Jim Haenel. Mike McDon- 
ald. William Shipley 


Texas: Gary Elliott, Terry 
Gilmore, Boh Weidman 
Arkansas: Scott Keller. 
Ken LeJeune. Mike 
McDonald, Roger Talley 
Colorado: Phil Goodman, 
Jim Hannaford, Richard 
Losh. Steve Boss 
Indiana: Forest Dipzinski, 
Mathew Keusch, Arnold 

North Carolina: Mike 
Casey, Sammy Cecil, Dan 
Grady, Jim Whitley 
Michigan: Albert Moss, 
Homer Engert, Bruce 
Brenn, James Taylor 
Michigan: Jan Fields, Anna 
Ibrahim, Roben Mcintosh, 
David Panzlau 
Pennsylvania: Cheryl Kreider. 
Linda Napoli, Ethel Wise 
Louisiana: Jackie Bush, 
Hope Hanks, Roben 
Nelson, Rebecca Vidrine 

Top Left: Billy Crystal in 1983; Top Right: Bo Diddley and 
The Coasters (bottom photo) in 1986 



CRCE through theJoiirnal-1996 
Answer Key 

For your information, the correct answers to the 50 questions tor CRCE through 
the Jounuil. which appeared in the August 1 996 issue of RESPIRATORY CARE, are 
given below. No scores will be available from the A ARC until 1996 transcripts 
are released in early 1997. Deadline for submission of answer sheets for CRCE 
credit was September 30, 1 996. 

1. a 







41. a 

2. a 







42. d 

3. b 







43. a 

4. c 







44. b 

5. b 







45. e 

6. e 







46. c 

7. d 







47. a 

8. a 







48. c 

9. d 







49. a 

0. a 







50. a 


Respiratory Care • October "96 Vol 4 1 No 10 

Respiratory Care 
Open Forum Abstracts 

Tlt^r^ (^ nio S(jJ)etit(j(U 

Just as there is no substitute for the respiratory core professional, 

there is no substitute for the perspective and insight of the Open Forum. 

Each year, Respiratory Care offers AAinisymposia that highlight important case reports, 

method, device, and protocol evaluations, and clinical studies. 

During this year's Open Forum, Presenters from around the v/orld will report 

their findings in more than 130 abstracts. (An index of the authors, 

with the Presenters designated in boldface type, appears on Page 960.) 

mmlSyjnjsosfuni #2 

A; HumJdificatton — Relatively interesting, 

Absolutely Essentia! 

Moderator: Robert L Chatbum BRT—Clev-'"-^' '^^■" 

B: Changing Perspectives in the Classroom 

Moderator: Shelley C Mishoe PhD RRT— Augusta, Georgia 

MiniSymposium #3 

Pulmonary Diagnostics: 

Innovations plus New Twists on Classic Procedures 

Moderators: Jack Wanger MBA RRT— Denver, Colorado, 
and Susan Blonshine BS RPFT RRT— Lansing, Michigan 

MiniSymposium #4 

A Fresh Look at Some Old Problems in Pediatric & 

Neonatal Care 

Moderators: Cynthia Matinowski MA RRT—Loma Linda, 
California, and John Salyer BS RRT— Salt Lake City, Utah 

MiniSymposium #5 

Aerosols: Fitting Together More Pieces of the Puzzle 

Moderators: Dean Hess PhD RRT— Boston, 
Massachusetts, and Jon Nilsestuen PhD RRT— Galveston, 

Right Across the Contmu 
Rehabilitation & Long-Term Care 

..._, . ,^// Maclntyre MD— Durham, North Carolina. 

and Lucy Kester MBA RRT—Cleveland, Ohio 

MiniSymposium #9 

Techniques & Protocols Impacting LOS & 

Patient Outcome 

Moderators: Charles G Durbin Jr MD— Charlottesville. 
Virginia, and Patricia Ann Dorley — Charlottesville. Virginia 

MiniSymposium #10 
Mechanical Ventilation — We're Still Learning 

Moderators: Richard D Branson RRT— Cincinnati, Ohio, and 
Jack Covington BA CPFT RRT, San Francisco, California 

MiniSymposium #11 
Protocols & Care Plans- 
Implications for Managers, Educators, & Clinicians 

Moderators: William H Dubbs MEd RRT— Dallas, Texas, 
and Joseph L Rau Jr PhD RRT, Atlanta, Georgia 

Respiratory Care • October '96 Vol 41 No 10 

Sunday. November 3. 12:45-2:40 pm (Rooms 1 A-B) 


K. Knaus Kinninqer RCP RPFT F. Wayne Johnson RCP RPFT, 

Kathy Jacobson RDA, Uavid M Burns MD 

University California San Diego Medical Center, San Diego California 

Introduction. Metabolic testing of Ifie critically ill ventilator dependent patients 
is of particular concern to the practitioner. It is imporlanl to accurately measure 
the patients metabolic requirements because of the link between a patients 
nutritional needs and ventilator dependency. The accuracy of indirect 
calorimeters may detenorate when measurements are made on patients 
mechanically ventilated with high levels of PEEP or high concentrations of 
FI02. the very patients lor which the delermination of oxygen consumption 
{V02') and carbon dioxide production (VC02) would be most useful. The 
Quinton Metabolic Cart (QMC) (Quinton Instrumentation, Bothell.WA.) is a 
non-invasive portable monitor, employing an open circuit technique of indirect 
calonmetry. The system was designed to operate with the spontaneously 
breathing or mechanically ventilated patient We examined the performance 
characteristics of the QMC in a laboratory simulation to determine whether 
changes in PEEP, FI02, VT and rate influence the measurement of V02 and 
VC02 dunng mechanical ventilation. Methods: Our laboratory simulation of 
V02 and VC02 was modeled after an established technique of infusing known 
flows of N2 and C02 into a constructed lung model The N2 and C02 gas 
flows were controlled by precision rotometers and venfied volumetncally before 
and after each tnal. The predicted values for V02 and VC02 to be used as the 
method for companson measurements, were calculated using the following 
equations: V02 = (VN2 added)(FI02/1-FI02)(STPD) 

VC02 = (VC02 added)(STPD) 
Independent FI02 measurements were analyzed with a 1 100A mass 
spectrometer (Perkin-Elmer, Pasadena, CA). All simulations were perfonned 
with a PB7200ae ventilator with a heated wire circuit, humidificalion al 35 C, and 
the lollowing settings; CMV; ramp waveforms; peak flow of 60 l/min. PEEP of 
0. 15cmH20. FI02ol 21, .40, .60; VI .500 and .700 L; f of 12. 18, and 20. Our 
test matrix established a predicted V02 and VC02 of .300 L/min Results: 
The mean difference between methods (Bias) and the standard deviation 
(Precision) were determined to express agreement between data sets (Bland & 
Altman, Lancet, Feb. 1986) 



It of measurements 



Bias % 



Precision % 



Conclusion; The QMC provides stable and accurate measurements of V02 
and VC02 over a range of ventilator settings typically seen in the ICU critical 
care patient. Measurements ot bias and precision were comparable and within 
acceptable limits of measurements obtained by devices currently utilized in 
clinical practice. OF-96-023 


Petrea Monsnn MS. RD. Maria T Pascual RN, MPH, F Wayne Johnson RCP, 
Ravindra L Mehta M.D., UCSD Medical Center. 200 West Arbor Drive, 
San Diego, CA, 92103-8375 

Introduction: The provision of adequate calories is an essential component 
of nutrition support in patients with catabolic acute renal failure (ARF). Recent 
advances in continuous renal replacement therapies (CRRT): conlinuous 
arteriovenous hemodialiltration (CAVHDF) and continuous venovenuous 
hemodiafillration (CVVHDF) have allowed lor the delivery ot lull nutrition 
support in these patients, yet tools available to assess energy expenditure 
(EE) In mechanically ventilated patients with ARF have been limited. 
Predictions of EE using the Harris Benedict Equation (HBE) with applicable 
stress factors (HBE+F) under- and overestimate EE. A technique to 
accurately measure 24-hour EE, continuous indirect calorimelry (CIC), Is now 
available with the use of the Nellcor Puritan Bennett 7250 metabolic monitor 
(NPB7250MM) (Nellcor Puntan Bennett, Carlsbad, CA) which integrates into 
the Nellcor Puritan Bennett 7200ae Ventilator (NPB7200ae). The purpose of 
the study is to compare EE differences between CIC and HBE-i-F during 
CRRT. Methods: CIC was performed over 38 days lor a total of 810 hours in 
4 patients treated with CRRT (3F, 1M. Ages 34-37) to determine daily values 
for oxygen consumption (VOj), carbon dioxide production (VCO,). respiratory 
quotient (RQ), and EE. Daily'delivety of non-protein calones via parenteral, 
enteral, and dialysate sources was recorded. Results: Predicted EE using 
HBE+F matched measured EE-CIC ± 5% on 10/38 days while HBE+F EE 
under- and overestimated EE-CIC on 21/38 and 7/38 days, respectively. The 
range by which HBE+F EE under- and over predicted EE-CIC was ± 40%. 
Dally calorie delivery based on HBE+F exceeded EE-CIC by 15% due to 
increases in dextrose-containing intravenous solutions which contributed 7% 
of total calories delivered. 



Calories Delivered/d 



EE-CIC (calories/d) 



HBE+F (calones/d) 



Conclusions: Use of CIC as a routine component of nutritional assessment 
assists In the accurate determination ot 24 hour EE. Use of CIC should 
therefore permit optimal calorie delivery while preventing overfeeding in ARF 
patients on CRRT. 


PROCr.DURLS - C Worth Brnnks Ir MFd. RRT . Frank Dcnnison, MEd. RPFT. 
RRT, Stielky C IvlishM. PhD, RRT, Rob Gillmn, BS, RRT, Rick Hall, BS, RR T, 
Ardiur Taft. MHS, RRT 
Medical College of Georgia, Augxista, GA 

The purpose of measuring maximal inspiratory pressure (MIPI is to determine 
respiratory muscle strength Reseaidi literature suggests a MIP thai is greater than 
-30cmHjO indicated adequate respiralory muscle suengUi lo sustain spontaneous 
ventilation and prm'ide an effective cough ITie purpose of this study was to 
compare two clinical methods of measuring MIP The study included twenty 
mechanically venUlated patients in ICUs who were deemed weanable by the 
attending physician Methods. The patienLs were tested by two methods using a 
coin toss lo determine order of assignment for eadi method. One method, the 
manual method (MM), involved taking the patient off the Purilan Bennett 7200 
(PB) Ventilator and performing the MIP with an OUM Manumctcr and Nif-Tee 
Non-Rebreatliiiig T-Fiece to penuit cxlialation while mspiration was ocdudcd for 
twenty seconds. The other method was done by using the MIP procedure offered 
by tiic respiralory mediajucs software through the PB Tlie PB method measures 
the most subPEEP inspiratory press created by the patient against a block airway 
over a thrcc-serond period. Each procedure was performed three limes Tlie 
patients were monilored for changes in heart rale, blood pressure and Oj 
Sflluralion. RestJls: Cronbach's Alpha was used lo assess interprocedure 
variability Our results show that there was high internal consistency within eadi 
of the three trials for both methods PB = 83, MM - M Independent 
san\ples t-tesl showed a significant difference in MIPs when comparing the PB 
mclhod ( 16±e.9) lo the MM method (-42±18.5): but llicrc were no statistically 
significant differences between methods in terms of success of exlubalion 
However, we found clinically important differences between melliods. In our 
sample, five patients (25%) were ejctubaled the same day because we obtained 
salisfaclop.' MIPs wiili the MM method These patients would not have been 
extubaled that day il only liie PB method was used. There were no significant 
differences with cither method on dinical outcomes such as heart rale, blood 
pressure, and oxygen saturation Condusions: Patients in the study would not 
have generated a MIP greater tlian -30cinHjO if the procedure was done llirough 
the PB versus the MM Research literature states occlusion of ihe airway for 20 
seconds and llie use of a one-way valve optimizes llic negative values Thus the 
M.M prodiu-ed higher .MIPs which mdifated greater respiratory niusdc sucngth 
Based on our dau and similar studies, the PB method underestimates true MIP 
The MM method is probably a better indiralor of respiratory musde strength 



David Mayo RRT. Edwin Kohl, RRT, Charies Durbin, MD, University of Virginia 
Health Sciences Center, Charlottesville, Virginia 

IJiJTRODUCTION Carbon dioxide is used to msuflate the pentoneal cavity to 
facilitate laparoscopic surgery because it does not support combustion allowing 
safe use of the electrocautery and because any residual pneumopentoneum 
remaining at the end of the procedure is rapidly absorbed Occasionally, 
massive amounts of CO; are absorbed and can precipitate hypercarbic 
respiratory failure We report a case of severe hypercarbia secondary to 
subcutaneous insufiation of CO; dunng laparoscopic cholecystectomy (LC) 

CASE REPORT A 76 y/o female was admitted for repair of a fractured hip 
following a fall Her past medical history was remarkable for coronary artery 
disease with previous CABG history of CHF. and bradyan-hythmias requinng 
permanent cardiac pacing After repair of her hip fracture, she developed 
abdomnal distention secondary to gallstone pancreatitis On resolution, pnor to 
discharge she was scheduled for LC General anesthesia was induced, she 
was intubated and the pentoneal cavity entered with a trocar Moderate difficulty 
was encountered due to a pervious lower abdominal incision End-tidal CO? 
(ETCO;) was 38-40 lorr until 2 hours into Ihe procedure when it was noted to 
rise acutely to 54 torr Despite doubling minule ventilation the ETCO^ remained 
above 50 torr, indicating continued and rapid absorption of msuflated CO? 
Massive subcutaneous emphysema was noted on the patients face, neck and 
upper abdomen Al the end of Ihe procedure, the patient had the following 
ABGs PaO?= 92. pH=7 12 PaCO2=110 Mechanical ventilation was continued 
and over the next several hours and the hypercarbia resolved 

DISCUSSION Believed to be benign, LC can cause significant physiological 
derangements Cardiovascular effects of the pneumopentoneum include 
decreased venous return, reduced cardiac output and lower renal blood flow 
Hypoxemia from dependent lung segment atelectasis and resulting shunt is 
common Less frequently seen is hypercarbia from pentoneal resorption of CO; 
After the abdominal cavity is initially distended, continuing gas flow between 1-6 
L/mm maintains pressure between 10-15 torr System leaks account for most of 
this continuing flow, however, at least 200-500 cc'min of CO? are normally 
absorbed across tne peritoneal surface The massive persistent hypercarbia 
seen in this case is due to Ihe larger CO? load and more rapid absorption that 
occurred with subcutaneous insufiation Complications of hypercarbia including 
hypertension, increased cerebral blood flow increased ICP, and cardiac 
arrhythmias were not seen m this patient OF-96-054 


Respiratory Care • October "96 Vol 41 No 10 

Sunday, November 3. 12:45-2:40 pm (Rooms lA-B) 

RRT . MS Benson, BS RRT. S Deem. MD. ILirtoonicw Mcdi^dl Cenlcf. SealUc. WA Lntroduc- 
lion Failure to dciccl csoplwgcal inlubaiioii ma> lead lo irre\erbible brain damage or deaih In 
Uie uptraling room (OR) llic gold sundard" Tor conTintiine correct plncement of tlie endo- 
Iraclical lube (ETT) is the dcieciion of expired C02 Oviisjde of the OR. a portable mfr.ircd 
dcMce IS available along with t«u other ponable devices 1) the portable colorrmeinc .inal\/er 
and 2)thcself-ii\naiinnbulboTS>nngelcchniciuc These tuo devices appear to be reliable iii 
the OR- however, there is little inrormaiion to suppon their use outside of the OR m aii cmcr- 
gciKv or tniensivccare (iCU) setting Wc compared the colonmeinc C02 analyzer and bulb 
s>nnge wilh infrared C02 anaUsis during emergent inmbaiion lo test ihcir efTicacv outside tlie 
OR Mctliods "100consccuIi\epalients(2l'Jmale, 81 female, mcanage -197 jy) undergoing 
endotracheal iniubaiion in the Emergeno Trauma Center (ETC), the ICU. and general wards 
had their ETT position tesied All uiliibalions were dont m the ETC (15%). ICU t^6"/<.) or else- 
where (9"/o) b> an anesthesiologist [mmedialcly posi-uiiubaiion but pnor lo ETT cuf>" inflation, 
the following sequence was stncilv adhered to 1) tJic sell" inflating bulb (Tube Chek B. Ambu 
Inc ) was compressed and connected to the ETT and released A Ml second penod was allowed 
for bulb rciiinalion 2) Tlic ETT cuff was inflated T) A colonmeinc C02 analyzer (TIasi-Cap. 
Nellcor. Inc ) was attached to the ETT and 5 manual brc.iihs were deli\ercd via a self-mflating 
bag. 4) an infrared C02 analy?cr (Stai-Cap. Nellcor, Inc 1 was attached to Ihc ETT and 5 man- 
ual breaths were delivered The final decision on ETT position was made from the findings of 
the three tests along with clinical evahiation by the RCP and Anesihesiologisi Results 300 
consecutive patients underwent Mu attempts al trachejil intubation U5/3UO (4S%) were intu- 
bated for acute r£Spiraior\' failure, 123 (41%) for airway prolcclion or lu facililaie pulmonar, 
toilet fhe remaining 32 ( I l"'o) were intubated for various diagnostic pioccdures 42 ( lA"*,) had 
known COPD. 3 1 { lO*^,.) had pulmonao edeiiu. 55 1 18%t were obese and 104 (35%) had copi- 
ous secrelions, 9 (0 3%) had ARDS There were 19 esophageal inlubations (0% incidence), 2 
patients required surgical air^vavsfor failed intubation (0 6%mcidcnce) 269 pis ( 90%) had all 
3 ineihods tested All pis had at least 2 methods tested The bulb was not a\ailable dunng 3 
iniubalion attempts, the colonmetric device dunng 2 atlempis; the infrared dclcclorwas un- 
available during 32 attempts due to mechanical problems or batter,' failure { 10% failure rate) 
All 3 devices had a IIX)% sensitivity detecting esophageal intubations The 3 devices had 99% 
specificity detecting tracheal placements The 3 false negatives obtained with the bulb occurred 
during 1 case each of COPD, copious secretions and obesity The 2 false negatives with the 
C02 analvzers occurred dunng CPR Conclusion All devices had lt)0% sensitivity detecting 
esophageal inlubations Howe\er the portable infrared device is not sufficicnlly reliable in 
emergency sellings due to mechanical and baiicn- failure The cost of this device makes it pro- 
hibitive to stock in all areas or on all crash cms The bulb and the colonmeinc dc\ ice provide 
equally reliable techniques for confinTiing ETT position in the emergency settings providing a 
rigid protocol for their use is followed Practitioners need lo be aware that secretions, obcsily, 
COPD and ongoing CPR may affect the reliability of these devices and other clinical evalua- 
tions stiould be taken into account The cost of the bulb is considerably less tlian Uiat of the 
colormcinc device, which along vuth its reliability and portability make it an altraciivc alicma- 
live for confirming ETT position in the cmcreena setting 



Ja mes E Main BS R RT, Hany F Aziz MD John J Moore MD, Decdrtments of 
Pediatrics and Pulmorary Services. MetroHealUi Medical Cente- Cleveland OH 

Introduction Enniidal carbon dioxide has been useo with great success for confirming 
endotracheal ntubatian A pediatric disposable colorimetnc device Pedi-CAP'"(Nellcor 
Pur tan Bennett, Pleasarton CA ) is now available for detecting me presence of exhaled 
CO- in infants weighing 1-15 Kgs. We sought to determ ne if the device could enhance 
conf rmatior of endotracheal intubation when comDined with clinical assessment (CA) and 
vital signs (VS) Method Infants requiring intubation for posrtive pressure ventilation in 
the Necnatai Intensive Care Unit and Delivery Room we'e considered candidates for the 
study Intubation in the standard fashion was oerfo'-med by a sk.lled resusciiation team 
;SRT) consisting of 3 or more caregivers Immediately following intubation, the device 
was placed between the patients endotracheal luCe and the flow inflated anesthesia bag 
A study investgator (81) who was not part of the 'esuscitation teaTt blinded the SRT 'rorr 
the resu ts of the exhaled CO. detector The Si recorded the presence or absence of CO; 
follow ng 6 manual ventilations by a n^enbei of the SKT The SI contirued to monitor and 
record the time needed by the SRT to confirm intubation The recording tme was 
slopped when the SRT confirmed intubation by clinical assessment (auscultation of the 
thorax and epigastrium, symmetrical chest rise color, activity) and stabilizing or 
increasng vital Signs (MR, ScO^ ), or if the patient was extubated The chest x-ray was 
the definitive confirmation of intubation Positive and Negative predictive values for the 
presence of CO were calculated using CA and VS as tne standards Results Of 3 1 
patients studied data from 27 infants was analyzed 4 patients were excluded, 2 due to 
SI participation in tne resuscitation, and 2 when msufficiert time was allowed for VS 
changes PatlC^t weight 470-3100 grams, age at time of tntubatior 30 mm - 2 months 
recorded time after C0_ detected 4 -10 seconds (mean 5 74), confirrrabon of intubation 
Cy the SRT (climcal assessment + stable or increasing vrtai signs) 15-55 seconds 
(mean 28 29) Statistical significance between Ihe confinnation nmes for the 2 methods 
was determined using a paired t-test (P< 0001} The devices positive and negative 
preaictive values, specificity, and sensitivity al' were 100% 

Intubated (VS) 

Not Intubated (VS) 


Intubated (CO.) 



Not Intiibaled (CO,) 






Conclusion: Tne preliminary results suggest that this device is accurate in identifying 
the presence of CO- and significantly reduces the time spent venfying endotracheal 
intubation in newborn ana infants 


IXmo Hess. PhfJ. RRT. Luca Digatello. MD, Ali Ai-Him\ary, MD. Robert M Kacmarek, PhD, 
RKT, William E Hurford, MD Rcspiialory Care and IJepartmenl of Anesthesia. Harvard 
MediL^dl School. Massachusetts General Hospital. Boston, Liniversit> iif Nebraska, Ohmaha. 

[| has been suggested that the condensate PCO. collected from the expiralon.' water trap 
correlates well with the mixed expired PCO, collected u^ing a Douglas bag (Cheil 1192,101 
1 601 ). We previously reported that the conden^te PCO, systematically overestimated the 
PCO; from a Douglas bag and evaluated a leniperalure correction factor lo compensate for ihis 
discrepancy (Am J Resp Cril Care Med 1^'>6.153 A603I We conducted Ihe present study lo 
determine whether temperature correction would eliminate the discrepanc) between 
condensate PCO, and mixed expired PCO. in a mechanically ventilated lung model. .Methods 
A 5-L anesthesia bag was connected to a 7200ae venlilaior (Nellcor Punlan-Dennetl) and a 
humidifier (Cascade la). The lempeniturc althe Y-piece was set to 37-38 X, A constant flow 
of CO; was injected into ihe bag lo establish 20, 30, 40, 50. 60, and 70 torr of end-tidal PCO.. 
measured al Ihe Y-piece (Traverse Medical) After equilibralion (2 M) min), Ihe condensate in 
the expiratorv limb was drained into a water trap (Ballard) and lis temperature measured wnh a 
digital thermometer (Fisher Scientific) llie condensate was collected anacrobically and 
analyzed immediately for PCO, using a calibrated blmid gas analyzer (Coming 170) at 37X 
Mixed expired gas was collected simultaneously into a bag and lis PCO, wa_s measured using 
the same analy?er The vcntilakir was set at 20 breaihs/min, PEGP 2 cm H;0. FiO;0,21. tidal 
volume S or 1 I, IE ratio of 1 6 or 1:2 2 Gas PCO, was calculated from temperature (T) 
and condensate PCO; using the following equation: 

<3as PCX); = Condensate PCO, ■ 10"'"""\ where aT = 37- T. 
Results 1 he correlation between the mixed expired PCO, by condensate (after temperature 
correction) and the actual mixed expired PCO, (by gas collection) was 
Condensate PCO, ^ 1 .02 ■ (Actual PCO;) 96 (R= = 0.%> The bias i precision between 
condensate PCO; and actual PCO. was 3^3 2 torr {limits nf agreement, -6 lto6 8 ton-) 
Conclusions' tven with temperature compensation, we failed to precisely piedici mixed 
expired PCO, from condensate PCO,. This may be due to poor mixing in the e.\piralory limb 
it IS unlikely that condensate Pt^O is an accurate indicator for mixed expired PCO,. 


Actual - CoTKli^nsaif PCO; 
!0 torr 




Shan L. Bailey, RRT., Ronald E. Dechen, MS. .RRT.. Beth Callan. RRT. . 
Jorge Rodriquez. MD, 

Background: Connnuous cardiac output (CCO) is achieved through the use 
of a modified pulmonary artery (PA) catheter. This PA catheter contains an 
external thermal filament located near the distal dp of Ihe catheter, and when 
activated, will intermittently heat the surface of the catheter. The blood 
temperature changes are delected by the thermistor located at the distal tip of the 
catheter. These temperaiuns changes arc then processed by the CCO computer 
and CO values are calculated, displayed continuously, and updated every .10 
seconds. Previous studies have uidicated that this technology is consistent with 
inlermittenl thermal bolus (TBCO) measurement in postoperative patients. 
However, few studies have been performed in the hemodynamically challenged 
trauma population. Method: All patients admitted to the Trauma Bum 
Emergency Service who required PA catheterization were considered for 
inclusion in this comparative study. Patients with a known tricuspid valve 
dysfunction or prosthesis were excluded. Once the need for uivasive 
hemodynamic monitoring was confirmed, the Ba.xter Edwards Swan-Ganz 
CC0/Sv02/VIP TD catheter (models 7468F and 746H8F. Baxter Healthcare 
Corporation, Edwanls Crincal Care Division. Irvine CA.). was inseried and 
comparison data points were collected. Each data point consisted of a 
continuous and TBCO value obtained through the Edwanls Critical Care 
Vigilance Monitoring System. Simultaneous data collection is not possible with 
dus technology, therefore, documentation of the CCO was made, the thermal 
filament was deacUvated. and the TBCO value was then detcmiined. Thermal 
dilution bolus was performed in triplicate and the average was the result;uit 
TBCO. Comparison data points were collected at least once daily. ResulU: 
Thirty-thite patients were included in this comparative study. A toud of 183 
data points were collected. We observed significani correlation (r'= 0,778, 
p<0,001) between the CCO and TBCO values obtained. The bias for the entire 
populaion was 0.63% difference. The confidence interval (95%) for the total 
population companson was +32.23 to 30,97% difference. Experience: The 
Vigilance Monitoruig System provided valuable information regarding the 
patients hemodynamic stanis by supplying continuous display of Sv02, CCO, 
cardiac index, and patient core temperature. All patient parameters responded 
appropnately to changes in various patient condmons, such as sepsis, fluid 
overload, D02A'02 mismatch, and to tin-auon of cardiac drugs. Conclusion: 
The association between the two techniques indicates that CCO and TBCO will 
trend appropriately with each other in this population. However, there is a 
potential significant error when companng the absolute values obtained from the 
two techniques. This error prevents the inicrchangeability between the two CO 

™'""- OF-96-097 

Respiratory Care • October "96 vol 41 No 10 


Sunday. November 3. 12:45-2:40 pm (Rooms lA-B) 


Riihcfl lylcC nnncll. RRT. Nalahe MSc. Kalrjn Bcraen, ML). Richard E Miiiin. 

MD, Br>anl W. Slulp. MD. PhD 

Dukr Universiiy Medical Centei. Durham. NC 

InirnHiirrinn and Background: uf ihc low amhicnl presiurv ai altitudes greater than 40.000 feel life 

support of fighter piloLs who expcnence ciKkpit dcprcssun^auon at these 

altitudes n:quircs both l(K)* inspired O; and the application ol high levels of 

CPAP. Physiological studies ol pilot life support provide the opportunity to 

examine the cardiopulmonary cfleets of extremely high levels of CPAP. 

Previous studies have demonstrated that high CPAP is a.ssociate<J with 

involuntary hyperventilation and hypocapnia to a degree which would impair 

cerebral Oj delivery. The present study was performed in order to examine the 

cardiopulmonary effects of breathing supplemental COj during administration 

of CPAP of 311 mmHg (40.8 cmHjO). 

Methods : 

After Instiiulional Review Board approval and inlormed consent 10 healthy 

volunteers (M=7. F=3; mean age=27.6 years. rangeil'J-??! were instrumented 

With KKCi and radial artcrv catheters Artcnal blood samples were obtained at 

ba.scline and after 10 minutes of exposure to CPAP. at which time minute 

ventilation iVkI, hean rate (HR) and mean arterial pressure (.MAP) were 
recorded. Dunng CPAP the subjects breathed air with or without 4.4% added 

Results are shown in the table below: 

CPAP Insp CO2 

(mmHgl (%) 








33 9113.3* 

34.0±12 0' 







imin'' I 




"SS57 PIT 
86±I3* y8±8* 
82±14« 92±13« 

' P < O.'i compared to CPAP 

CPAP .30mmHg cau.scd a significant increase in bloix] pressure, heart rate. 

minute ventilation and Pa02. and a decrease in PaCO; 


The addition of 4.4'7f CO2 to the in.spircd mix prevented the hypocapnia 

a-s.sociated with a CPAP of .30 mniHg. without any adverse effect on minute 

ventilation, heart rate or blootl pressure 



Barbara G. Wilson. MEd. RRT. Pediatric Critical Care & Respiratory Care 
Services. Duke University Medical Center, Durham, NC. 

Introduction: AGA displays patient-ventilator interactions in children by 
measuring tidal volume, pressure and flow at the endotracheal nibe during CMV. 
AGA can be used to identify pulmonary overdistention (OD). intrinsic PEEP 
(PEEPi) and causes of patient-venlUalor dys-synchrony (dyssync). The purpose of 
this study was to determine the incidence of adverse ventilatory effects and 
examine the effects of continuous vs. intermittent AGA in mechanically ventilated 
children. Incidents of dys-synchrony were examined to identify the cause (e.g. 
trigger failure, inadequate inspiratory tlow or excessive inspiratory time). 
Method: PICU RCPs had 3 years experience with AGA interpretation prior to 
this smdy. Practice standards were in place to examine AGA to identify adverse 
ventilatory effects and direct ventilatory suategies to correct effects. Twenty-eight 
CMV patients, 2 days to 15 years of age were studied. AGA was assessed daily 
by one ulvestigator for the presence of OD. FBEHi and dys-sync. Thirteen patients 
received continuous AGA via a Bird VIP ventilator widi Partner Hi and graphics 
monitor (Bird Products Corp., Palm Springs, CA). Fifteen patients received 
intermittent AGA monitoring via a "snapshot" study using a VenTralc Respiratory 
Mechanics Monitor (Novamelrix Medical Systems, Inc . Wallingford, CT). The 
incidence of adverse events was compared in die two groups. Data was compared 
using chi square analysis, with p< .05 considered significant('). 
Results: Significant differences were found between groups for all adverse 
effects. 100% of dys-synchrony events were caused by trigger failure. The rate of 
pressure trigger failure was 92% (11/12)* (p < 001) as compared to a flow 
trigger failure rate of 8% (1/12). 

Int. AGA Com. AGA p Value 

Dys-sync 9/36 (25%)* 3/32(9%) .004 

PEEPi 6/36 (17%)* 2/32(6%) 004 

OD 5/36 (14%)* 1/32 ( 3%) 005 

Total 20/108(19%)- 6/96(6%) .001 

Conclusions: Intermittent AGA fails to adequately identify adverse ventilatory 
effects. Failure of pressure triggers contribute,s greatly to patient-ventilator dys- 
synchrony in children. Continuous AGA monitoring is recommended to identify 
adverse ventilatory effects PICU staff can then correct ventilatory strategies to 


minimize occurrence 

THE SAME LEVELS OF AirrO-PEF.P. Fdear Dclgado. BS. RRT : Adclaida M Miro, 
MD. Frederick J TasMa. MS, RN; Leslie A Hoffman, PhD, RN; Thomas McCormick, AS: 
Michael R Ptn^ky. MO, Departments of Respiratory Care and Ancsthcsiology/CCM 
University of Piltshurgh Medical Center and University of Pinsburgh School of Nursing, 
Pittsburgh, PA. 

Tracheal gas insufflation (TGI) is used in conjunction with mechanical ventilation 
to enhance CO; elimination, but it- has been described to cause the development of aulo- 
PFF.P, TGI may be delivered continuously during the entire respiratory cycle (C TGI) or 
il may be synchronized to flow only during the expiratory (K-T(it). Although bolh 
delivery techniques augment C(J^ elimination, it h.« been prop<iscd that F-TCil is associated 
with less auto-PEEP than C-TOI One pulential explanation for Ihis observation is that C- 
TGI will increa-sc total minute ventilation (\^f) if the ventilator circuitry is not properly 
adapted to venl excess TGI, In order to avoid this problem, we have previously described 
(Resp Care 1W5. 4t) 11.11%) insertion of a pressure relief valve in the ventilator drcuilry 
to keep ^g coastant during C-TGI, Because both C-TGI and ETGI prixluce the same 
"backpressure" and thus, similarly expiratory resistance, we hypothesized (hat is 
long as ^E was kept constant auto-PEEP levels would be identical under both conditions. 

MtTHODS; A catheter was inserted into the airway of a calibrated adult training lest lung 
model ( rri, #2r<()0i) for Ttjl. Peak intrapulmonary inspiratory pressure (P;„J and end- 
expiratory intrapulmonary pressure (Auto-PEEP) were measured with a calibrated pressure 
transducer, Tf>tal \\ represents the sum of the ventilatur-derivcd volume and TCil 
contribution, Prcssiirc-conliol vcntilalion (Puritan Bennett 72(X)) with set pressure -35 cm 
H;0. frcqucncy = 20 bpm. and PKEP = () w;is used. Fixed artificial lung parameters were 
compliance -0112 L/cm H,() and resistance - 20 cm H^O/L/sec, l:H ratio was varied at 1:1 
and 2:1, During the experimental protocol, a control and 3 separate TGI conditions at 10 
L/min were evaluated: (!) Control (no TGI), (2) (,:ontinuous TGI (no valve). (3) 
Conlinuows TGI (yes valve), (4) Fjcpiralory Ttil. 



Icm HjO) 


•niinuout 1(11 
(No V»lv^) 

rnntinuou* TCI 
(Vt» ViU«) 

Fj(piratnr> tXit 



CONCmSKlN: We conclude that the increase in aulo-PEEP levels during C-TGI is 
sectmdary in an increase in V^ resulling inadequate venting of the excess gxs. When 
^f is kept constant by insertion of a pressure relief vaUe. C-TGI ss E-TGl produce the 
same levels of auto-PFFP. OF-96-1 50 



Yuii I ujino Mr>. Masuji Nishimura MD. Nobusuki Ficnidta MD. Ikuto Yoshiya 

MD. Intensisc Care Unit, Osaka Umvcrsity Hospital, and Hjogo College of 


TGI is a method to facilitate cirhon dioxide elimination. It may increase 
cxpirators' resistance and cause intrinsic PEEP. It is impossible to measure 
intrinsic PEEP with the existence of TGI, and we evaluated gas trapping by 
nicicsuring FRC 

Methods: We cbose argon washout mcthixl to mcsisure FRC of a lung model 
during Nslh continuous and expiralors IGI. Ten percent argon in oxygen (Ar) 
iind lonr.^ oxygen (0.) cvlindcrs were a>nnected to a CTossovcr solenoid valve in 
piirallcl. The outlet of the vulse was conncacd to a \ cntilator oxygen inlet and a 
flowmeter for TGI via a Y shape hose. To perfonn cxpiriitory TGI. the second 
solenoid s.dvc was placed into the hose between die Y ;uid TGI flowmeter. The 
valve was controlled by a signid from the ventilator to synchronize with the 
expiratory valve of the ventilator. Flow and Ar concentration were measured at 
dow nstrejim of die expiratory vaKc with a hot-wire flowmeter (Minato Medical, 
lapiui) and a iimss-spcctlonicter (Marquette 1100). icspcctively. Those signals 
were fed to a microaimputci. The settings of the ventilator were as follows: PCV 
mode. PIP IScmH.O, RR 15 min. and T, 1 and 2 sec, with continuous and 
expiratory TGI of 4, 8. and 12 Lmin tlow .After Ar concentration in Ihc lung 
model became constiint. tbc gas w:is changed to O. , The computer controlled the 
first solenoid vaKe to change Ar to O, according to a signal from the ventilator at 
an end-expiration, and sLirtcd integration of the signals of flow and Ar 
concentration, simultaneously. 

Results: Table shows IRC in each scning of the ventilator and TGI flow. /V T, 1 
sec, FRC did not differ significantly during continuous iind expiratory TGI. At T, 
2 sec, FRC in ci^ntinuous TGI was significantly greater with :ill TGI flow. 
Conclusion: IRC measurement is the altem:itivc method of intrinsic PEEP 
maisurcment to evaluate air trapping during TGI, Expimtory TGI caused less 
dvn;imic hvpcnnflation tluin continuous TGI. and cxpiratorv TGI may be safer. 

TGI flow 

Ti 1 


Ti 2 Osec 1 









436 ± 6' 





606^ 15' 




903 = 10 

713 + 17" 

(ml) (•p<0 05) 

OF-96-1 79 


Respiratory Care • October "96 Vol 41 No 10 

Sunday, November 3. 12:45-2:40 p\i( Rooms ia-B) 

SEDATED DOGS. A McKibben. AB Adams . S Becker, T Takahashi. JJ 
Manni. University of Minnesota and St. Paul Ramsey Medical Center. 
Minneapolis/St. Paul, MN, 

The knowledge of functional residual capacity (FRC). its absolute 
value and changes with intervention, may assist optimal ventilator 
management For the measurement of FRC in the clinical setting both open 
and cbsed system methods Uave been described using inert gas dilution or 
washout. Equipment for such methods requires technical expertise, is 
expensive and bulky. In an animal study requiring FRC measurements, we 
evaluated two relatively simple methods of helium (He) dilution tor 
obtaining FRC values. The open "expiratory washout" nwthod involved the 
infusion of He in the inspiratory limb during the inspiratory phase only. 
After a steady slate was confirmed by a constant He concentration delected 
in the expiratory limb, the He Inlusion was stopped and exhalate captured 
In a Douglas bag for 4 minutes. He concentration and exhalate volume 
were determined The closed "equilibration" method used a super syringe 
with a known volume and concentration of He. At end exhalation a valve to 
the animal was opened to connect the airway to the syringe, which was 
used to apply and withdraw 10 manual inflations at an peak ain*iay 
pressure approximating 20 cm H2O Methods : In each paralyzed, sedated 
animal study. FRC was measured by both methods prior to study 
intervention. The animals were ventilated at 10 mlvKg and f-10 while on 
5 cm HjO PEEP. The open method was followed by the closed method with a 
15 minute interval of fresh gas flushing between. Five comparison 
sessions were made in 4 dogs whose mean weight was 22,0 ±1 .3 Kg, 
Results : Reproducible values were found by both methods. The mean FRC 
by the ctosed method was 940 mL. 18% less than the mean FRC by the 
open method whH;h was 1146 mL Canclusion : Although further evaluaton 
of these He dilution methods for FRC determination is necessary, both 
methods provkJe reproducible FRC measurements within the range of 
prevkjusly reported studies. We speculated that minor differences 
between methods may result from incomplete gas equilibration, leading to 
a systematic underestimation of FRC by the closed method. 


A Pii 1 Analyzer for hed side application : A prototype 

Shin;i Fukasaw.i RCET . Hin.mi Su-ruki' CET. Jun Ucki- MD. Temo Miyagawj' 

RRT.RPT.RCET. Toyoki Kugimiya-* MD Depanmenu af Inhalation Tlicrapy. Clinical 
Engineering'. Rcsprraiory Medicine-. Aneslhesiology*. Junlcndo University school of 
Medicine. Tokyo. Showa University' scho^il of Medicine. Tokyo Japan 
Introduction: Ain^ay Occlusion Pressure (Pu ! ) is one of the impnrlanl monitoring 
piiniincicrs for the respiratory management The a-isessmeni <i| Po i is hec4> more popular 
mainly as the improvement ot the micrDprocessor built-in the ventilator However. Po i 
ohiatned by convcnuonal analyzers and venlilalori are rather unsLihle and the equipments are too 
large lor the hed side mominnng To solve these prohlj-ms. v.c focused oureffnn on making 
computenzed Jteurjle prototype Po i analyzer which i*; compact jnd easily usable 
Method: A one-way closing shutlcr dnvcn hy a pulse motor wa5 scleeled tor the occlusion 
section, since the pulse motor is light, compact and has large Uiii|ue With these suitable 
characteristics, it was able to shut and open a shutter very quickly wiihou! disturbing 
measurement and. more importantly, the noise was minimum , To make the valve as light as 
possible, we chose ihin aluminum plate To minimise airway resistance, ibe diamcier of airway 
was decided :o be 22mm Tiic shutter was made of stainless steel ;ind shaped like a half-closed with movable angel of 30 degrees to cover ihc airway completely The shutter wus 
1.1'rneciec to the conlroller which conmtis iKclusion lime. It can cillier be shut automatically 
just at the beginning of inspiration with cich duration lime of OOI. OOV n I t)r 2 seconds, or 
he manually shut for any desired duraiion The process ot the measurement was as follows ( I i 
detect a point when ihe speed of inhalation reaches 50mi/second. i2) generate a pulse for one 
measurement by turning on a .switch. (3) send a pulse to the airway shulicr controller. f4) make 
the controller send a command to the valve. (5* close the airway long enough to measure the 
pressure. (6) measure the occlusion pressure. (7) analyze Ihc airway occlusion pressure with A/D 
convei-sion computer A Macintosh iPowerBook 150) is used lor the wave analysis using 
sollware. Acknowledge' by Biopack Sys'Ltrm wiihout any odiusnocnl 
Results: By using our prototype analyzer, mouth occlusion pressure was measured in 20 
tieallhy volunleers with ;tccIusion time of 0.01, 0.05. 1. 0.2 sccorids The mean occlusion 
pressure wen: less than -IcttiH^O at the occlusion lime of O.liP; i; and 0,2 seconds The mouth 
tvclusion pressi-re lines oblHined at the occlLsion lime of 1 and 2 seconds were quia- linear 
and showed good rcproducihilily 

Occlusion Timcisccond) Po : (niean±SD cmHiOl 

0.01 -2.25X0.10 

0-05 -1.33±0.46 

O.I -0.97±0 63 

2 -0.65 +0S4 

Conclusion: Our proiolype Po i analyzer is aLCurate and compacl. and is a\ailabie as a 
ruivable hed side rcspirainr^' monitor The pnitnty in designing out prniotypc analyzer IS the 
development of computelizcJ valve closure system ccuipped with the large torque pulse motor 


\^\ Singapore General Hospital 

The Singapore General 
Hospital is the largest 
acute care and teaching 
hospital In Singapore with 
1660 beds and 29 clinical 
departments offering the 
most comprehensive range 
of patient services. 

We invite a suitably 
qualified candidate to join 
us as: 


You will be nnainly responsible 
for providing respiratory therapy 
in the Intensive Care Units as 
well as training the Nurses. 

You should possess a Bachelor 
of Science Degree majoring in 
Cardiorespiratory Sciences or its 
equivalent, preferably with 2 
years' working experience in a 
similar capacity. 

The successful candidate can 
expect a competitive salary 
which will commensurate with 
qualifications and experience, in 
addition to an attractive benefits 
package such as medical and 
insurance coverage, vacation 
leave and yearly bonus. 

Applications stating full personal 
particulars, educational and 
professional qualifications, career 
history, present and expected 
salary with at least two work 
testimonials and contact or fax no. 
should be sent or faxed to: 

The Manager, 

Employee Relations 

Singapore General 


Block 6, Level I 

Outram Road 

Singapore 169608 

Fax No: 65-2242671 





















Respiratory Care • October "96 Vol 41 No 10 

Circle 140 on reader service card 


Sunday. November 3. 3:00-4:55 pm (Rooms 5A-B) 

Alden Flclcher MD,. phl>.. Siavosh Khimsari M.D . John CVlMall B S . R R.T . 
Kaiser Permanent Uis Angeles Medical Cenlcr. Cardiac Surgaal Lnil 

INTRODUCTION: Heal Moislure l-:xchangers (HNtFj) have heen utlli/ed fur several 
years in the hnspilal sciUnp tor humidifiealion (if mechanieally ventilated palienls. 
To dale there have heen lew repined studies of Ihcir use in Open llean patients post 
iipt-ralivelv. In 19')2 we cimdueteil a six month priHluel evaluation i4 an HMh on 
elective cotonary artery by pass graft (CABC.I palienls. We evalualed relrospeclively 
and compared the erfecls'<il an UMI, lo a eonvcnlional humidilier h> numitored 
cardiac and respiratory luncllons. The focus was nil seaelinn chatacieristics, pul- 
monary capillarv we<lge pressure (PCWP) and work ot ha-alliine (WOUi. 44 palienls 
09 male. 5 female) n^el irileria lor the evaluation. :2 in each iiroiip noth groups 
were similar in age. smoking history and baseline characteristics Ml THdU. The 
product evaluation was conducled tin ihe Pall BB 50T HMF and compared to the 
Conchatherm III plus I'alienl critcna was to he over 16 years of age. have no pre- 
existing lung disease and had eleclivc CABCi The airway was pniiied with lllccs of 
normal saline bctcire inserting Ihe HMl'.. Pulmonary mechanics, cardiac function 
and sec-retion eliaractcristics were observed upon admission and prior lo exiuhation. 
I'allents were observed lor changes in secrelion amuunl. color and consistency, 
increased (Wtjni anil cleeTcased (PCWP) Data was collectc-d and analyzed by our 
stalislieiaas using Fisher's Hxael.. Sluan & Maxwell and McNeiiier tests. RtSU T.S: 
After review il was notc-d Ihal only 2 subsets of Ihe variables had a p«:O.II5 PCW pre- 
HMT-, was higher In the study group and secrelion nmsisieiKA pre-snidy was higher 
In the conlriil group. All other vanahles had no slalisiiially signitlcanl diflerence. 
Inlubatlon lime ami lengUl iif stay was similar lor both groups, II was noled Itiai loi 
the lime pailoms werc innibaicd only one HMF. was needed as was one humidificT 
column and biiltle ol waler. 



Sec anit pr^ 


^'c color pre/ptisl 
.Sec Cons pre/pttsF 



C.'nirol Ci.'iip 

iii^jy I III 


IV v; I \h.i'i 



p. Value 

n no< / ciiK 

!\n<i ! i\Mi 

r, IV /I'ifti 

nojs /(Will 

DI.Sc:iiSSI()N During mechanical venlilalion adequate humidincalion has an 
importani etiecl on pulmonary secretions. In ihis study we observed no adverse 
ettects on pulmonary or cardiac hinclion nor was iheie any signihcanl change in 
Ihe quantity or characteristics of pulmonary secretions. Our firsi day csisi lo use an 
MMi: was 70% less ihan Ihe conventional humidincr setup. CONCl USION: Despiie 
Ihe facl that in some cases HMFs provide less ihan KKl* relative huniidily. we 
lound Ihal there was no significant diflerence between the use ot HMl-.s and 
eonvcnuonal humidilieis for posl-op open heart patients with legards to sec-relioii 
characleristies. cardiac function and WOB. This sludy shows Ihal HMFs can be used 
effectively for most open heart patients and al a reduced cost saving. 



Russell 1 Rcid. RR 1 CI'FI. and Mark Goldstein. RRT Mciev American Rivera San luan 
■lospilal. CarniKliacl. ( alilornia 

This sludy exainineJ die cfTcci ol varying \cnlilalor (low rale and sel Iminidificr temperalurc on 
he iclaloc huinidilv dclocicd by Ihe Hiidson'RCI ileniecula. CAl Contlia IV healed 
luiiiidifieaiion s\slein Mclhods .^ Hudson <. oncha IV healed hiiiTiidifier equipped with a low 
compiessible volume UiaiiiberUhidsoii'RCI Model ixs.iii) and 72 healed wire cimiil 
Hudsoa'RCI Model 780-i2) was allathed to a Hamilton Vcolar (Reno. NV) mechanical 
vcniilator The volume control mode Willi a square inspiralory flow \\a\c form was used A 
lealcd huimditv chambci (HCl. t7 1 C (t 2 1 CI was conslruiied to accommodate Ihe probe 
ol a capacitance ivpc digital hygrometer tCM Scicnurit. Biisliaiic CA. Model #?44-isS) uilh 
medial Ihermislor Inspitalory gas passed lluough Ihe IK lor rclalive himiidily measuTemcnl 
llic licalcd wire coiilrollei was sel foi C° dilTcrcntial liv c rep;al. slabili/ed measures, were 
collected al 1 miniiu; inlervals al all combinations of flow rate and icinpcralurc Poor to iesung 
all equipment was calihialed to the manufactuiei s speeilic^lioiis Results Data was analyzed 
using Analysis of Variance ( ANOVAI Statistical signirieanec existed wilhin and between all 





Flow Rale 




(C» iSD) 

Relative Humidity 

Absolulc Humidity 
img UlOfL iSD) 



10 62 (±0 05) 

10 45 (±0 46) 

9 56(10 16) » 



11 37 (±0.20) 

f.8 12 (±0 88) 

29 40(10 37) t 



1 1 77 (± 06) 

82 39 (til 681 

10 72(10 211 



17 71 (±0 28) 

90 81 (1 36) 

41 41 (1067) 



11 21 (±0 21) 

16 95(1 1 22) 

12 02 (±0 32) J 



11 't6(t001) 

73 18 (±0 15) 

26 97(10 18) » 




82 22 (±0 43) 

35 33 (i 0.75) 



17 30(±0 18) 

99 88(10 26) 

44 79 (r 0.46) 



11 27 (±0 1.5) 

41 46(1043) 

13 51 (±0 15) t 



11 11 (±0 18) 

82 22(14 46) 

29 90 (± 1 46) t 



15 33 (±0 75) 

84 81 (± 20) 

34 62 (1 1 96) 



15 45(t 2 70) 


40 90(15 56) 



11 54t±ll 14) 

4 3 52(10 29) 

I4 39(1112l)t 




80 25(10 22) 

28 72(10 56)* 



35 37(±OOV) 

87 10(10 54) 

35.36(1 1 05) 



37 28l±0 IS) 

100 110(1 110) 


t- Unable to mcel Ihe ANSI Slandards for heated humidirication 

Conclusion The Hudson RCI Concha IV was unable lo meel the American National Sundards 
Inslilute (ANSI) standards for healed humidincalion wilh any of the four flowralc combination, 
at sel lempcralures of 12 C" and 14 C° 


Russell T Rcid RRT CPfT, and Mark GoIcMcm, RRT Mercy American Rivet/ San Juan 
Hospital, Caimicliael, California 

This sludv csamined Ihe elfccl of vaiving ventilator How late and sel hiimidifier lempcralure on 
the lelalivc humidilv delivered bv the Fit P(, Auckland New Zealand i MH-730 licated 
humidiUcalion svstcm using two dillcicnl humidilicalion chambers Methods A K&P MR-730 
healed hunudifiel equipped wilh etlher a LAP MR-190 oi MR 290 huntidilcalion chamber and 
Isolhcrmal 72" healed wire circuit (Valencia, (.'A Model 1704-1107) was attached to a Hamilton 
Veolar iRcno NV) iiic-clunical vertilalor ITie volume conlrol mode with a square inspiialory 
now wave form was used \ lu-ated hmiiidilv chamber (HC) 17 7 C ( *: 1 K C°). was conslniclcd 
to avcominodale the probe ol a capacitance lv(x digital hygromeler (CM Scientific. Dnsbane. 
CA, Model l'244-3SS) with inlegral thermistor Invpiraiors gas passed Ihrough Ihe HC for 
relalivc hunuditv measuicmcm Ihe healed wire conliollci was ss-l lor C" differcnlial Five 
lepi'at, slabdi/ed measures, were collecled al 1 minute intervals al all combmalions of flow rate 
and lempcralure Prioi lo lesling all eqiupnienl was calibiated lo the manufacturer's 
specifications Results Data was analv/ed using Analv sis ul Vaiiansc lANOVA) Slalislical 
signiricancc existed wiiliin and between all gioups d •- 0I8'1 









(C" ±SD) 




(C" ±SD1 




(nigH201, tSD) 




(iiig H20/L ±SD) 



11 71 (±0113) 

11 99 1*0 117) 


13 94110 14) 



31 19(10 11) 

1261 l;0 10) 

33 37(10 42) 

35 08110 20) 



14 68(10 15) 

14 59 ( -. 2 1 1 

34 93(10 41) 

18 85(10 Sll 



1c 22(1 11 7S| 

16 11 (10 116) 

18 92 (1 1 65) 

40 56(1 1 15J 



11 64(1(104) 

11 96(1(102) 

19 15(10 I7)t 

33 79 (1 IKl) 



33 03(10 OS) 

32,85(10 10) 

34 15(10 16) 

35 48 (1 IXl) 

15 04(10 01) 

34 76(10 12) 

36 06(10 II) 

39 13(1 3S) 



17 07(10 02) 

35 94 (1 05) 

41 63 (±0 09) 

42 0S(+ 11 1X1) 



11 55(10 051 

31 72 U 181 

20 94 (1 24) t 

31 19(1033) 



3 3 07(10 04) 

32 77(11106) 

33 43 (10 10) 

3S 37 (+0 12) 



34 80(10 41) 

14 74(10 07) 


39 07(10 13) 



37 no (±0 59) 

36 06(10 011 

41 8S(i 1 29) 

42 05 110 00) 



31 41 |±0 10) 

11 53(10 16) 

26.S9(t II4l)t 

33 10(10 27) 



12 96 110 06) 

32 43 (1 26) 

33 77(111 26J 

14 72 (1 57) 



15 lollOOl) 

14 77(1005) 

.18 22(11) 12) 

19 24(10 11) 



16 11 11 17) 

35 95(10 47) 

4128(10 50) 

41 41(1 1 21) 

t- Did no! meel the ANSI standards for heated humidincalion 

Conclusion The FAR MR-390 humidincauon chamber failed lo meet the Amcnean National 

Si-indards Insuiule standard for healed huiiudiTiers of 10 ing H20d for all now rates at 32 C 


McConnell.RRT, Heather Fredencksen.RRT. Neil R. MaLlnt)rc.MD. 
Duke University Metlical Center. Durham, NC 

BACKGROUND: A hygroscopic contiensing humnJiticr (HCH) is a passive 
humidifiealion device thai coiiec U heat and huraidily fn>m expired gas of a patienl on h 
mechanical ventilator and ..-onJitions ins»"^ ga^ ^"^ »' passe<, hack Ihrough the device-. A 
heated wire circuit (HWC) aclivcJy add-; heat and humidifiealion lo tbc inspiratory limb of 
a warmed circuit after passing Ihrough a healed water canister 

METHODS: All patient-; requiring mechanical vejitilalion betwcro 2''22/96 and 4/24/96 
were eligible for the study PalienU were randomly as.sigt>ed lo mei^c either a 
hygmscopic conden.sing humidifier ( ThermoFlo tm ARC Mcdiial, loci or a heated wire 
circuit {Bear 5 cirvuil Hy Murquest). Sputum was categonzed on eaih day of the 
mechanical ventilation as; watery («;putum that can he suctioned like water, after 5aiclion 
is terminated, no stxrclions remain attached to the inner surface of the su^jtion catheter) . 
moderate (spulum of moderate viwosity. after suction is terminaied, some secretions 
remain attached to the inner surface of the s-uction catheter) or if na. lous (thick sputum, 
after suction is lemiinafed. most sccrelions are still attached to the inner surface of the 
cathelL-r. and they cannot he easily removed by suctioning waler through the cathcler). If 
during different suctioning episodes on the same day. .sputum was judged diflerently. both 
categones wcrv used. Chi square analysis was used to compare sputum calegonc-s m each 
group wilh P< .0^ taken as MgnitKani. 

RESULTS; Fifty eight patients were rrcruited and 286 paticnl-days of sputum 
categonzalion were performed (12J in the HWC group, l&l in the HCH group). Sputum 
catcgones in each group (^ of patient days): 


Watery McxJenite 
12. 4« 79.5^ 

112% 88% 


There w.»s no significant difference is i^julum categories between the two groups. 

CONCLUSION: Sputum con-islency wa.s similar using either HCH or HWC 
humidification systems. 



Respirator'i Care • October "% Vol 4 1 No 10 

Sunday, November 3, 3:00-4:55 pm (Rooms 5A-B} 


Richard Bnmson RKT. Roben Campbell RRT. Kenneth Davis Jr . MD 
Dqjartmenl of Surger> . University of Cincmnati, Cincinnati, Ohio 

Background: ISO 9360 is a test method for determining the moisture output of a passive 
humidifier (PH> Ai a tidal volume of 1 L and /of lObrcathimin. 1 E is supposed to be set 
at 1:2 (Insp Flow - 5 Us & Insp Time = 2 s). However, expiraior\' flow panem and tune 
arc not specified U'e studied the effects of varying expiratory flow' on the measured moisfure 
output of two PH Methods: The ISO 9360 iung model was constructed from Cascade 
humidifier, temperature controller, 2 test lungs, and a series of tubing and one way valves to 
separate mspired and expired gases txpired temperature entermg the PH was set at 34'*C 
The model was ventilated at a \\ of 1 L./of 10 b/mm and flow of 5 IVs Expiratory flow 
was controlled by adju5ting compliance of the tesi lungs and placement of linear resistors in 
the expiratory gas path This resulted in 3 expiratory descending flow waveforms I ) mean 
expiratory flow - 25 Us. 2) mean expiratory flow - 33 Ls, and 3) mean expiratory flow - 
0.5 Us At these 3 settings the duration ofexpir^lory flow was J s, 3 s. and 2 s The latter two 
settings had a pause of I s and 2 s respectively prior to the ncxl inspiration Two PH were 
used, an ARC Themioflo filter (dcadspace ^ 90 mL) and a Poncx 600 (deadspace - 10 mL) 
Three of each PR were tested at each of ihe three expiratory flow conditions for a penod of 
three hours Results: As mean expiratory flow increased moisture output fell The decrease 
was much greater in the PH with a low deadspace Results are shown below {mean + SD) and 
analysis was performed using ANOVA. A p < 005 was considered significant 

Moisture Output m mg HjO/ L 


Exp Flow 

■ 25 I7s 

Exp, Flow = 0,33 L/s 

F.xp Flow = 0,5 L's 


.13.9 (0 7) 

327(1 1) 

29 4(1 Ay« 

Porte X 

25-1 (0,9) 

23 0(1 O)' 

19 7 10 7V » 

• p <0.05 vs 0,25 Us, S p <0 05 vs 0.33 L/'s 

Conclusion: Moisture output can be significantly effected by expiratory flow of the lung 
model This is probably due to a reduction in the contact time between warm, moist gas and 
the PH media This effect is exacerbated by a PH with a low deadspace Additionally, 
patients with high expiratory flow (low compliance) may receive gas at a lower moisture 
conteni than described by the manufacturer ISO 9360 should define the shape and duration of 
expiratory flow to allow fair comparison of different devices 


P Seakins BE R Williams PhD. E Meyer Fisher & Paykel Healthcare. Auckland. New 

Introducti on By observing the relationship between inspired and expired humidity rt is 
possible to gain some insight into the humidifying load imposed on the airways The 
depth tnlo Ihe ainA-ays al which inspired gases are conditioned to core temperature and 
are saturated - termed the isothermic saturation boundary (ISB) - is dynamic It vanes 
with the temperature and humidity of the inspired gas on a breath by breath basis 
Evidence that the ISB is moving can be found In the variation of temperature and 
humidity of the expirea gas Measurements of brealh-by-brealh humidity and 
temperature requires a fast response hygrometer and thermometer Development of 
such a device has allowed us to make these measurements tfesponse lime 20QmSec). 
Method Normal healthy volunteers were asked to breathe each ot seven different gas 
condrtions simulating a vanety of dmical temperatures and humidities The order of the 
gas conditions was randomised and the subjects were blinded to the particulars of each 
gas The subjects core temperature, the room temperature, the breath-by-breath 
inspired and expired temperature and humidity, and a subjective comfort score for each 
gas were recorded Each gas was breathed through the mouth for 2 minutes while 
humidity waveforms were recorded (see figure for typical waveform) A 2 minute rest 
period was required t>etween gases, dunng which the instmment calibrations were 
checked The gas conditions and typical uses were 1)Dry room air [23X, OmgH:0/L] - 
non-rebreathing anaesthesia 2) Room air |23°C. 1 0mgH;O/L] - room air 3) Saturated 
room air [23''C, 21mgH:0/L] - LFG flow anaesthesia 4) fsCC, 30mgH:O/L] - IS08185 
5) [34'C, 3BmgHpO/L] - Humidifier set low 6) [37°C. 44mgH:0/Ll - core temperature 
saturated 7) [40X. 51mgH;0/L] - above core temperature saturated The 23°C gases 
were from a dry air source with cold passover humidifier All other gases were 
conditioned by Fisher & Paykel MR730 humidifier vinth healer v«nre circuit and MR290 
autofeed chamber Results Expired absolute humidity (AH) was between inspired AH 
levels and core temperature saturated m all cases Gases delvered at less than core 
temperature saturated cool the airways dunr^g inspiration, resulting in expired gases 
that are saturated at less than core temperature The converse applies with inspired 
gases at)ove core temperature saturated Gases inspired at core temperature saturated 
are expired at the same level Only the dry gases (1&2) were found to be 
uncomfortable Conclusions An air conditioning load is imposed on the airways for all 
inspired air conditions other than core lemperalure saturated 

Normal breathing Room air 

■ 'V . 

^Tempe'alure/* -^ 

i, § » I ■' I 


|- 1 .0 f - 

5 10 15 2D 

Time [Sec] 
1 Wilson AC, Barnes Th, Seakms PJ. Rolfe TG, Meyer EJ. 1995, A low cost high 
speed near infrared hygrometer, Rev Sci. Instrum 66(12) 5618-5624 


Robert S Campbell RRT , Richard D Branson RRT, Kenneth Davis Jr MD 
University of Cincinnati Medical Center. Cincinnati, OH 45267 
Introduction: Three HT's may be used to condition inspired gas 1 } Passive 
Humidifier (PH), 2) Heated Humidifier with heated wire arcuit (HWC), and 3) Heated 
Humidifier with conventional circuit (NHWC) The NT used also affects temperature 
and humidity of expired gas Because temperature and humidity affect volume 
measurement, effects of HT on volume measurement accuracy of three ventilators 
was evaluated lUtothod: Each ventilator (Bird 8400STi, Hamilton Veolar, Nellcor/ 
Puntan-Bennett 7200ae) was attached to a test lung (TTL, Michigan Instruments) 
equipped with volume, pressure, and flow momtonng software using a 48* Baxter 
dual-lumen heated-wire circuit and a Fischer-Pay kel MR 730 humidifier A heated 
humidifier was placed between the test lung and breathing circuit to condition expired 
gas to 34=C and 100% RH Ventilators were set to deliver both 800 and 400 ml Vt at 
flow of 60 L/min using a rectangular flow profile, rate of 6 bpm, PEEP, and 21% O3 
Test lung settings included C^ of 06 and 03 L/cmHjO, resistance ot 5 
cmHjO/L/sec, and volume was reported in BTPS A Gibeck Humid-Vent 2S was 
placed at the proximal end of the breathing circuit to pnDvide PH For HWC testing, 
dual heated wires were active, the humidi^er was set to provide 34°C at the proximal 
ainway, and a neutral "ram-out" setting of was used For NHWC. the heated wires 
were disabled and humidifier was set to provide 34''C at the proximal ainA^ay Paired 
t-Test was used to compare measured V^ with each HT and measured vs delivered 
Vy Results: The table shows volume measured by each ventilator at 800 and 
400ml Vt at C^ of 03 and the mean V- delivered to ttie test lung at each setting All 
results are Mean ♦ SD 


eoo. 03 

800 03 


400 03 

400 03 
















' 753120 












■=p<0 05 compared to HWC at same V, lt=P<0 05 compared to PH at same V, 

Measured Vj was highest with use of HWC Measured V^ was lowest with PH on the 
7200 and with NHWC on the Veolar and 8400 V, delivered to the test lung was 
highest using PH and lowest using NHWC Each ventilators Vt measurement 
adequately reflected lung inflation volume with all HT Mean expired temperature for 
each HT was PH = 25 1 HWC = 31 3. NHWC = 28 4 Conclusion: Use of different 
HT has a measurable but clinically insignificant effect on the accuracy of each 
ventilators volume measurement Each ventilator tested uses different volume 
measurement techniques, measurement sites, and algorithms to account for Ihe 
condition of expired gas Measurement site appears to effect ventilators 
measurement of delivered lung volume more than measurement technique. HT, or 
measurement algorithm OF-96-165 

1997 Respiratory Care 
Open Forum 

Next year you, too, can submit an abstract for 
publication in Respiratory Care. If your 
abstract is accepted, you will be invited to 
present it at the 43rcl International Convention 
& Exhibition in New Orleans, Louisiana. 

Respiratory Care welcomes scientific reports 
on any area of respiratory care presented as 

• an original study 

• the evaluation of a method, device or protocol 

• a case or case series. 

See page 977 for full details. 





















Respiratory Care • October "96 Vol 41 No 10 


Sunday, November 3, 3:00-4:55 pm (Rooms 5A-B) 

PRACTITIONERS IN GEORGIA I vnila Thonias Ocxxlfello». MBA. RRT. Georgia 
Stale Unncrsit>'. Atlanla, Georgia 

lnlf;Hluclion As Rcspiralon Care Practitioners (RCPs) adjust to the cunenl healll care 
agenda, health promotion is emphasized more than ever helcire RCPs deliver 
respirator^' care services in a variety of settings and can do health promotion cducaUon 
The purpose of this study was to learn the nature of health promotion education 
currently pro\ idcd bv KCl's in Geori:ia Methods Names and addre«cs were obtained 
from (Georgia Hospital Association (GHA) and Georgia Association lor Medical 
Equipment Suppliers (GAMES) 2\(< Technical directors of tcspiraton. care 
dcpannients in hospitals and managers of respiratory home health agencies were 
suncved using a 2-page questionnaire Activities suivcvcd m this study were according 
to ±<:Hcallhy People 2II0II goals and prionUes These iiKludcd tuberculosis testing 
and prcvcnuon; smoking cessation, pulmonary rehabilitation. HIV.'AIDS 
counseling/prcvenuon; tobacco and niconne nsk counseling, heart and stroke 
information, lung cancer prevention and treatment, environmental exposure and nsks, 
asthma education, and allergy wammgs The questionnaire also asked for demographic 
information, a description of the acUv lUcs, who arc the programs targeted to. how often 
Ihev arc offered and die kind of cv aluation or follow-up gn en gssuUs K3 
questionnaires were relumed (41%) 85"/o of these returns were from hospitals 1 5% 
were from home health care managers cmplov mg RCPs Hospitals with less than I (Kl 
beds accounted for 40% of the returns 87'i of die RCPs working in hospitals are 
involved in some form ofhealdi promoUon education Activities arc reported in order 
of decreasing frequency asthma education (78), smoking cessation (48), pulmonan 
rehabilitation I V-). allergy warnings (32 1, tobacco and mcouiie risk counseling (281. 
environmental exposure and nsks 1 25 1, tuberculosis testing and prevention (17). heart 
and stroke mfomiation( 1 7), lung cancer prevention and UcaUncnl (17). and HIV/ AIDS 
counseling/prevention (7| 15 of the 78 asthma ediicauon programs are targeted to 
adolescenLs Individual wisUuction was listed as the most common form of instruction 
(.5 1 1 with self-dircclcJ insUuclioii listed as die least common form of instrucUon (15) 
Types of follow-up included, phone calls (24), follow-up visits (20), and self evaluation 
by Uk patient (14) 27 reported no follow-up or cvaluaUon process for asscssmg 
effectiveness Conclusion These resulb suggest diat I ) hcaldi promotion acuvities by 
RCPs in Georgia (in ihe hospital setting! arc conccnUated within the two calegones of 
asthma education and smoking cessation, and 2 ) no conclusions can be drawn about the 
actu lUes of RCPs in the home care setung regarding hcaldi piomotioa Health 
promotion acUviUes bv RCPs in the hospital are geared to all patients widi a few 
targeted to adolescent and gcnatnc populauons This baseline Ibundation of die nature 
and scope of activities ma\ help to direct future efforts in die sludv of licalUi promoUon 
and RCPs in Georgia, as well as m odier slates Not only are health promotion acUvitics 
good for the public, they are good for the piofession 


A Student Survey on the Essential Selection Cntena of Eleven Textbook Selctlioo Models 

David W. Chang . EdD, RRT, Columbus College. Columhu-s. Georgia 

Introduelion In 1992. (here were nKire than 177 respiratory care related textbooks. For 
this reason, selecting a textbook can be time-consunung and difficult. Some instructors use 
textbook s*:lection modcLs beenuse ihey provide an objective evaluation of die essential 
cnlena of a textbook. Smce lcxlbook.s are intended for use by the students. I sought to 
evaluate the opinion of students on the selection erileria described in Uie recent textbook 
selection models. 

Methods Eleven textbook &eIex:tion models published m pe*:r- reviewed journals since 
1988 were used in this study. The essential selection cnlena in Oicsc models were 
classified and grouped into eight areas: (1) appropnale contents. (2) low cost. (3) useful 
examples. (4) clear illastnUions, (5) good organization. (6) well known publrsher or 
auUior, (7) easy to lead, and (8) clear writing style. A survey was developed usmg Uiese 
eight areas. One question in the survey asked Ihe respondents to 'select from eight 
areas diree most important cnlena of « u-xtbook." The survey was adminislraUxl U> 31 
uniiergraduale students (3 freshmen, 10 sophomores, II juniors, 7 seniors). All but two 
studenLs majored m allied healdi programs (11 respiratory dierapy, 9 nursing, 9 healdi 
.sciences. I conuniinicalion. and 1 educaliun). The response lale was obtained by 
frequency count and its percentage was calculated by dividing each frequency 
count by 3 1 , the number of respondents. 

Results Frequency count and percent of the responses are shown in the table. 

Selection t:ritenon 


84 « 

Easy to lead 


■Appropriate contents 



Useful examples 



Good organization 



Clear wnting style 


29 « 

Clear illu.strations 


26 « 

Low cost 



Well known publisher or author 


CuncJusions In the opinion of the survey respondenLs in Uus study, readability of die 
textbooks is die most important cnterion. Well known pubh.sher or audior is die Uasi 
important criterton. 


University of Texas Medical Branch, Galvesion, TX OBJECTIVE To develop .ind 
evaluate the Health Information Simulation System (HISS), a computer-based 
instructional system DESCRIPTION HISS is an ongoing instructional development 
project that involves a team of experts in computer-based education and faculty from 
vanous hcallh professions lis goals are to ( 1 ) familiari?e students widi computerized 
hospiul information systems; (2) patient assessmeni and management skills, and 
(3l foster interprofessional collaboration The core of HISS is a collection of electronic 
patienl records (EPRs) that simulate patients with v,inous diagnoses, such as filV, spina 
bifida and lipid embolus lnform.inon in the EPRs includes history & physical, lab 
values. ECG tracings, imaging studies. SOAP notes, etc Students use die EPRs to 
complete assignments mlended to provide practice in mfomialion-galheriug and care- 
planmng METHODS A summative evaluation addressed the question, "What are die 
effects of HISS on knowledge, expectations and atiitudes regarding computers'" The 
evaluanon used a pre-, post-lest. cohort design measured ch.-uiges in the dependent 
vanables between 1991 and 1995 Subjects entering the study (N-121) were students in 
the health infonnation management (HIM. n=pi, medical technology (MT, n-2Sl, 
occupational ther-ipy lOT. n=34) and physician's assisLint (PA. n-^2l programs Atliludc 
toward computer based instruction was measured with Allen's (1986) validated 
instrument Odier measuremenis were made with uislrunients designed in-house a 
semanlic differential scale for amiude toward coinpuiei-bascd information in paiient 
managemenl. a tcu-itciil as^essmcnl of computer knowledge and a scale to assess 
expectations about computing, that is, number of ye.irs alter graduation ihat subjects 
expect their computer usage to become routine In-house instruments were content- 
validated by HISS staff, theu pilot-tested on a sample of faculty Insmiments were 
administered dunng die subjects' first semester on campus, before exposure lo HISS 
Then, subjects used HISS to complete assignments during Ihe two-year mienal Post- 
testing was done during the subjects' final semester RESLLTS A total of 99 subjects 
completed the study, dislnbuled as follows: HIM (n-l2|. MT (n-25), OT (n=29l and PA 
(n-33) programs Between 1993-95. the mean scores changed as follows: computer 
knowledge. 6 65 (I 43) to 7 14(1 23l. computer allhude regarding computer-assisted 
instruction. 4 97 ( 98) to 5 44 ( 1 03). attitudes tow.vd computer-based information in 
patient management. 4 86( 75) lo 5 63 (82). computer expectations. 1 52( 83) to 1.33 
( 701 CONCLUSIONS Participalion in the HISS proiecl appears to lucrease knowledge 
and attitudes regarding conipuiing and shorten the expected tune to routine computer use. 
The effects of history and mortality could have confounded the study Respiratory care 
(RCl students enleteid the study in 1994 Data on this group are not yet av^lable There 
is no apparent reason why RC students would differ from those studied Future studies 
.should address the effects of HISS-based instruction on skills in infonnaiion galhenng. 
decision-making and collaborating Pl.AN'NED ENHANCENfENTS Enhancements under 
development include video and sound for gait analysis and simulated patient interviews 
DFMONSTRATION .Attendees see HISS onsiie 

OF-96-01 1 

L. Dunlevy. EdD. RRT , The Ohio State University, 
Columbus, Ohio. INTRODOCTION: In today's healthcare 
enviroiunent, all personnel are expected to work 
together in order to provide optimal patient care. 
Therapist-driven protocols and patient-focused care 
itiodels shift emphasis from high productivity & task- 
oriention to critical thinking skills and shared 
leadership. This is true for respiratory care 
practitioners (RCPs) , as well as for other members of 
the healthcare team. In order to adequately prepare 
students for entry into this environment, it is 
important for educators to assess the leadership styles 
of students entering their professions. METHODS: A 35- 
item questionnaire was administered to 177 students (40 
males, 137 females) immediately prior to their 
beginning baccalaureate programs in respiratory 
therapy, circulation technology, radiolotjic technology, 
medical dietetics, medical records administration, 
medical technology, physical therapy, & occupational 
therapy. The instrument required students to thinJc as 
the leader of a work group, rating aspects of 
leadership behavior on a 5-item Likert-type scale. Each 
respondent receiving a T score representing concern for 
task, and a P score, representing concern for people. 
Means and standard deviations were calculated tor each 
score. Two-tailed t-tests were utilized to detect 
differences between males and females; ANOVA with 
repeated measures was used to detect differences 
between allied health professions, p values < 0.05 were 
considered statistically significant. REStlLTS: Concern 
for task scores were significantly higher for males 
versus females (p=0.045). P scores were not 
significantly different between sexes (p=0.52). There 
were no significant differences between professions on 
either T (p=0.77) or P (p=0.83) scores. T scores were 
significantly higher than P scores for both males and 
females (p<0.01). CONCLDSION8: Allied health students 
enter academic programs with a high level of concern 
for task, indicating a trend toward autocratic versus 
shared leadership. In today's healthcare climate, 
educators need to encourage the development of shared 
leadership skills. 



Respiratory Care • October '% Vol 41 No 10 

Sunday, November 3. 3:00-4:55 pm (Rooms 5A-B) 

GuiHermo Fnederichsen. RRT and Marvin Weiss, MD 
Kaiser Permanente Hosprtal 
San Diego, California 
Bac Hground. We report on a simple way lo provide mservice training to employees m 
our Respiratory Care deparlment Wrth budgetary cutbacks facing us on one s«Je and 
Ihe need to compty with Human Resources Standards of the Joint Commission on the 
other, we decided to augment our skills checklists arxj inservice training with computer 
akJed tutonals using an educational software program for the Macintosh Version 2 1 
of the Digital Chisel® (by Pierian Spring Software, Portland. OR ), is an easy-to-use 
rrxjltimedia authonng tool specifically designed for educators and students There is no 
need to leam a programmjrtg language and H comes with a built-in database that 
automatically scores and records the answers Most important rt is easy to use and 
corrws with many templates to cut down on development lime Criteria for choosing 
tutonals were limited to tasks or equipment with low utilization or inlrequent usage 
Members are required to use the tutorials annually and pass with a score of 90% 
EvalualiQ n Three tutonals were developed and put on a Macintosh m Ihe deparlment 
Access to the computer was limited to the tutorials Two of the tutorials were on 
equipmem recently purchased and with limrted-use potential (the Impaci Transport 
Ventilator and the Proneb Home Nebulizer system) The last tutorial was on 
Continuous Bronchodilator Therapy (CBT) which has the highest utilization during the 

rrwnths Employees were asked lo arrange coverage with the shift supervisor while 
they used the tutonals They had access to the tutorials 24 hour&day 
The program r\as Ihe capability to run video and can handle digitized images For the 
Irrpact Transport Ventilator tulonal. images of the front parx;l and each of the controls 
were scanned and then linked to text so that the employee can simply choose any 
control and have all of its charactehstics displayed Some animation was used to show 
gas flow through the ventilator Another tutorial in development is on 4 channel sleep 
studies SirKe one of the question templates allows placement of two pictures (EPS, 
PICT or TIFF are supported ) into the question, the employee simply clicks on Ihe 
correct image and the program does Ihe rest Scanned sections of 4 channel tracings 
are chosen and placed into the program This has potential for EKG interpretations as 

Results. Within one month 30% ol the employees had completed and passed all three 
tLrtoriafs A Macintosh computer with at least twelve megabytes of RAM is needed lo 
use this program We are cun-ently using a Quadra 630 with 24 megs of RAM to njn the 

The buift-in database will be valuable for verrficaiion of on-going education 
Conclusions , With much emphasis from the Jotnl Commission on competencies, 
training and assessment of employees, we feel Ihe tutonals can be a useful adjunct lo 
annual skills checklists and other training techniques in this department as well as in 
other health care departments 


When lights are low 

Call the Editorial Office (972) 243-2272 

for information, or see the 

Manuscript Preparation Guide in this issue. 

Trust what you see 
from someone you know 

The AmbuTubeChek esophageal intubation detector 
is a device that uses the anatomical differences 
between the esophagus and the trachea to determine 
endotracheal tube placement. 

In studies involving over 4000 patients the 
esophageal detector device was found to be 100% 
effective in detecting esophageal intubation. 

• Fast 
Immediate Results 
No Calibration 

No Risk ofVentilaing 

• Reliable 

Even in Cardiac Arrest 


Easy to Use 


Usable in Low Light 


Long Shelf Life 






TubcChek-U or lo rcccivt a catalog 
on our complete product line. 

at 1-800-262-8462. 


Saves lives worldwide 

Ambu Inc. 

61 1 North Hammonds Ferry Road 
Linthicum.MD 21090-1356 
Phone: 1-800-262-8462 
Fax: 1-800-262-8673 















Respiratory Care • October "96 Vol 41 No 10 

Circle 123 on reader service card 
Visit AARC Booths 419 and 421 in San Diego 



Ventilator Management 

The OnlineABG'" blood gas 
monitoring system offers a 
sensible, fast and accurate 
approach] to ventilator manage- 
ment. Streamlining methods of 
obtaining patient information 
makes sense, but only if quality 
of information is maintained 
or improved 

OnlineABG delivers point- 
of-care ABGs in 60 seconds with 

lab accuracy- Attached to the 
arterial line, this easy-to-use 
system measures pO,, pCO, and 
pH, Data is presented on the 
bedside display and added to 
the patients cardio-pulmonary 
profile, permitting faster time 
to treatment. 

Fiber-optic technology 
ensures stablility and lab 
accuracy which are important 

elements in effective ventilator 
management. Closed sampling 
means no blood handling for 
the clinician and no blood loss 
for the patient. 

OnlineABG may be just the 
edge your ventilator patient 
needs. "The Clinical Challenge" 
video explains this sensible 
approach. Call today for your 
copy. 1-800-917-6000, ext. 4315. 

AARC Booth 249 

Corometrics Medical Systems 

a Marquette Company 


I Medical Systems 

8200 West Tower Avenue 
Milwaukee.WI 53223 USA 

Marquette is a registered trademark of Marquette Electronics. \nc 

Circle 142 on reader service card 

Monday, November 4. 12:45-2:40 pm (Rooms lA-B) 



— — Author — 

Debra Park. CI EdD, RRT . Harriet Long. KRJ. Bekcic Afessa, MD, Uiuvcrsit> 

Medical Center, Jacksonville. Florida 

_ - Bodv 

Background Ma.\u!lum \oluntar> venulauon (.MVV) rs used to determine a person's 
brcatliing reserve The direct \1\'V measurement involves a fatiguing lest and it is 
dependent on patient training and motnalion Because of the difficulties in mcasunni; 
MVV, formulas such as FKV..\35 and FEV,X40 have been proposed to predict the 
MVV This slud> was undertaken to determine the relationship between the direclK 
measured MVV and tiie indirect MVV calculated from the FEX', Meth od The stiid> 
invokes the retrospective review of pulmonary function tests performed in the two 
vear period between January 1994 and December I99.> Data collecled included age, 
race, gender. FVC, FFV,. FEV/FVC, predicted FVC°o. predicted FEV,%, predicted 
FEV /FVC%. and M\'\' The presence and t\pe of ventilalorv impaimicnt (obstructive 
vs restrictive) was dctenimicd according to ATS criteria All means are expressed as 
±SD Differences between the means are compared bv pau-ed student's t test using 
StatVievv 4 .^ software P values less than 05 were considered significant J^csults 
The studv population included 27f) Caucasian. 2 1 4 Afncan-.-Vmencan. 5 Hispanic, and 
5 Asian for a total of 500 There were 196 males and .104 females Tlieir mean age was 
52 fi ±14 2 vears Spirometrv' showed that 219 (4.1 8°o) of the subjects had normal PFT 
resulLs. 200 (40 0%) had obstructive defects, and S I (16 2°/.) had restnctive defects 
The mean FEV, was 2 2l->- 89 Liters The mean MVV was 82 43 ± 35 59 Liters, 
compared to 77 40 ± 31 03 Liters of FbV,X35 (p=< 0001 1 and 88 45 >35 49 Liters of 
FEV X40 (p -< 0001 ) The difference between the MVV and l'HV|X35 was less than 
15%'in 263 (53%) patients, 15°. - 25% mil? (22%) and higher tlian 25"o in 125 
(25%) The difference between the MVV and FEV X40 was less than 15% in 255 
(51%) of our patients. 15%-25»oin 1 14 (23'^o) and higher than 25% m 131 (26%) 
The mean .MV\' ul our patient populauon could have been determined bv the equauon 
MW-5 564+(34 802XFEV|) Conclus ions There arc statisticallv significant 
discrepancies between the measured NfVV' and the MVV calculated from FEV, in our 
patients We aincludc thai v alidation smdies and modifications arc necessary before 
apph ing these formulas in different patient populations 




Jack Wa nger RRT RPFl". Rich.ud Martin MD. Charles Irv in PhD. National 
Jewish Center for Immunology and Respiratory Medicine, Denver, Colorado. 

It has been suggested by the European Respiratory Society, .American 
Assocaition for Respiratory Care, and others that the lowest limit of ventilatory 
function for bronchial provocation (BP) testing is an FEVi value of 1.0 to 1,5 
liters, or a percent predicted FEV 1 value of 60 to 70'.'i', Indeed, the American 
Thoracic Society only states " ,, those with moderate to severe impairments of 
lung function should be tested with caution. ' The reasoning for these 
rcconmiendations appears to be related more to impression than actual 
mfonnation. Yet. there are a few studies that have reponcd BP testing in small 
numbers of COPD subjecis with severe airflow limitation. We questioned if BP 
testing could he (wrtormed sately in subjects with a st;>ning FEV 1 value < 1 .$ 
liters and 60% of predicted. Methods: We retrospectively renewed all 
niethacholine and histamine BP tests performed on adults over ihc past 5 yciu-s in 
our laboratory. Tests that were included in the analysis had: ( I ) baseline FEV j 
<1,.50 liters and 60% of predicted, (21 reproducible baseline FEVi nieasurcments. 
and 1.3) at least a 20^' fall in FFVi from the post-dilueni FEVj We used the .5 
breath dosimeter technuiue w ith doubling concentrations of the challenge ageni, 
Resullj: We perloriiied 4,53 I tests from 1991 ihrough 1995, with S3 studies 
(77 niethacholine. 6 histaiiiinel in 8! subjects meeting incliision criteria. The 
niean±SEM baseline FT.V] was 1 32 ±0.017, range 0.64 to 1,40 L; baseline 
F"EVi percent predicted was 45 2.5 ± X47%. range 22 to 59%; post-diluent 
FEV I was 1 .3.3 ± 0.02 1 , range 65 to 1 .65 L: post-last dose of agonist was 
0.97±0.OI8, range 0.40 to 1 .35 L; post-bronchodilator FEV; was 1.51 + 
0.0.38, range 0.62 to 2,7.* L. There were 12 subjects with baseline FEVi values 
between 1 .0 and 1.2 liters, and 3 subjects with FEV | values below 1 liters, and 
10 subjects with a F'EVi percent predicted values 35%. In all 83 tests, a 
bionchodilalor was administered when the test became [xisitive (i.e., at least a 
20% fall in FEV 1 1 In only 4 lesLs. we found that the siibiccts did not reverse to 
within 90% of their baseline FEVI value. These 4 individual's reversibility 
values were 86, 85, S4 and 61% of their baseline FEVj value. The results oi 
repeat spirometry following a second bronchodilator treatment in these 4 subjects 
was not recorded, but wc know from a review of the chtuts that none oi these 
individuals needed further intervention. Conclusion While there may he an 
occasional need to adntinister additional tieatmenis. in 95% of the one 
bronchodilator treatment is adequate to reverse the effects of the challenge. Even 
in siih|ccls with severe airflow Itnutation (i,e.. FEVj values of less than 1.5 liters 
,tntl 60% of predicted) bronchial provocation testing with melhacholine anil 

liisiaminc can be performed safely. 



California Pacific Medical Center, San Francisco, Ca 


Dilulional lung volume rneasurements of TLC become progressively less reliable m the 
presence of si^niHcant maldistribution or trapped gastVlrapi This maldistribution is 
delennined by the severity of obstructive lung disease Body Plethysmography, although 
less intluenced by maldisn-ibution, is not always available We evaluated ihe effect of 
(~)AD on Single Breath TLC { TLCsb) and the efficacy of correction factors derived from 
spirometric variables 


Plelhysmographic (TLCp) and spirometry measurements were evaluated for 478 patients 
with OAD TLCsb determinations were made as pan of the assessment ofditfusing 
capacity Vlrap was defined as the difference between FLt p and TLCsb Results were 
correlated vvith bolh the degree and type of 0.\D Analysis of variance (ANOVA). 
discriminan: analysis and least squares regression for best fit were determined for several 
spirometric variables These regressions were used to evaluate a correction for TLCsb lo 
minimize Vtrap 



cum r 

p value 



631 1 


•; ono 1 


472 8 


■ 0,0001 




• 0,0001 


529 7 


•: 0001 




Fq Match 

y=a + b exp(-x/c) 
y^a + bx 
y=a + b exp{-x/c) 
y=a + bx 

Previously, a correction fuLlor was evaluated for a specific dilutional lung volume 
lechmque compared \vi:h raJiographic TLC using a small number of mixed type OAD 
patients Our Jau confirms the leasability of correcting for OAD and provides an 
allemalive means of adj'Jslinc al\eolar volume determinations already available from 
DLCO mea-surements Thii expandt-'d utility can significantly reduce testing time and 
cquipement expense as well as permit evaluation of patients previously unlestablc 



California Pacific Medical Center, San Francisco, Ca 


Bronchodllatam \Mth albuterol iscommonK perfortiicd lo assess air-way responsiveness. 
Since the onset olmaxmial response is not immediate, iypicall> a 10-15 minute delay is 
interposed berwecn pre and post bronchodilator testmg. Many laboratories use this time 
period 10 assess limp diffusion ratber than increase testing lime. There is evidence tbat 
isoproieroiiol cm cause an increase in DLCO Albuterol, a hiylil) bcla-2 speciHc agen:. 
IS not hclieved to alter DLCO although there is no supponing li:eranjre The purpose of 
this stud) IS to document Ihe effecl of albuterol on the measurement. 


Pkthysmographic. spirometric and DLCO measurements were evaluated for 26 subjects 
before a:id^after ndiliiniitrstiuii oflhree puffs albuterol MDI All tests -.vere perforPied as 
recommended bv ATS guidelines and bronchodilator response was evaluated using ATS 
criteria Data analvsis used paired t test comparisons with significance at the 05 level 
am: cross correlation 


p value 

FVC 0110 


FEVI 00001 




FEF2575'/o 0,0001 


TCV 0,0077 


RV/TLC 0001 


TLC 0002 

• = Sla 



DLCO versus FEVI 


DLCO versus SGaw 


p value 

0,0001 * 
0,0001 * 
0,0000 * 
Slalislicallv sicnificant 

0/Z6 subjects met ATS response criteria (200ml and 12%) 


Spiroinetnc and plethysmnsraphit differences weie statistically significant, although 
oiilv 6/26 subiects met AT.S criteria for response DLCO was not significantly different 
and correlated poorly with changes in FEVI and SGaw There is no evidence for a 
resullant change in DLCO due to administration of albuterol MDI. As a result, testing 
sequences which interpose DLCO measurement after bronchodilator administration 
would no: seem lo mnoduce d bia^ 


Respiratory Care • October "96 Vol 41 No 10 


Monday, November 4. 12:45-2:40 pm (Rooms lA-B) 

Danigl Laskuwsk i RPFT. V'ane*isj Jensen Psy.D, Kay Sttlmach RN.RRT, Ke\in 

Paradoxical vocal cord dysfunciion is charactenzed by ir.voluniary adduction of ihe vocal 
cords ihat produces dyspnea, stridor and wheezing, usually in an episodic fashion Vocal Cord 
dysfunciion is often confused with aslhma. including exercise induced asthma. Endoscopic 
examination is normal between episodes ITie purpose of this study is to repon our experience 
with 2'1 patients age 8 to 1 9 {55% male), referred :o our instinirion over :hi: last 36 months 
predominately for exercise induced asthma. Sixteen of 24 patients were positive for vocal 
cord adduction of greater than 30'!i llic majoriiy of the positive patients were well trained 
athletes whose attacks frequently occurcd during exercise. This was prevetilmg them from 
exercismg or advancing to the next level of competition 

After a comprehensive history and physical examination each patienl had an upper airway 
endoscopy to rule out any fixed airway obstruction. Patients were then asked to hyperventilate 
while an Olympus video assisted infant bronchoscope was m place above the patients vocal 
cords Seven patients were positive for vocal cord adduction from hyperventilation alone 

I'hosc patients who did not exhibit vocal cord dysfunction with hyperventilation were then 
exercised to their maximum exercise tolerance or until symptoms limited further resting 
Patients exercised on a bicycle ergometer with the video-assisted infant bronchoscope in 
place Flow and volume were measured simultaneously using a CODAS system (Data 
Inslr\imcnts AKRON. OH) A modified Vital Signs {Totowa. NJ) exercise mask which 
accommodated both ilie scope and a heated pneumoiach was used; this allowed us to measure 
flow and volume during testing 

Vocal cord d> sfunclion does not respond to routine medical treatment for asthma It has been 
shown to signitlcantiy mterferc with daily functioning in young patients including absence 
from school, and frequent medical intervention Treatment includes clinical interviews with 
the patient and parents A cognitive behavioral treatment program is instituted including 
education regarding vocal cord adduction .diaphragmatic breathing exercises, muscle 
relaxation and stress management techniques. All patients reported asignificanl decrease in 

In conclusion, comprehensive challenge with direct visualization allows separation of VCD. 
asthma, and dcconditioning Recognition of VCD directs therapy away from asthma and 
allows the patient to be^in psychotherapy which in our patients population has been met with 
a great deal of success. We are becoming more confident in predicting vocal cord adduction 
from viewing flow and volume alone during e.xcrcise. however comprehensive challenge 
with direct visualisation durmg exercise continues lo be the definitive diagnostic tool 



Andrea M Pierce PhD, Charles Morash RRT, Bruce Randall MS RRT, Lynn Maillel MS. 
Instrumenlation Laboratory, Lexington MA and Boston Regional Medical Center. 
Sloneham MA 

BACKGROUND IL has developed a new CO-Oxin:^eter instrument for ihe 
mult I component analysis ol hemoglobin denvatives The /L6fl2 CO-Oximeter uses the 
same principle as its predecessors for determining the percentages of O; Hb. CO Hb. 
Met or Fe^ Hb, and HHb (Deoxy Mb) in a whole blood sample The /L $82 CO- 
Oximeter uses ihe differences In the molar absorptivities of hemoglobin in the visible 
wavelength region to determine these Hb species Subtle differences in Ihe 
absorbance spectra of fetal hemoglobin {Mb F) result in some inaccuracy when 
analyzing fully oxygenated neonatal or cord blood samples with high Hb F 
concentrations Typically a false elevation in the %COHb and a concomitant decrease 
in the %0-Hb occuis when these samples are measured In the adult mode 
METHODS IL has generated an algorithm for calculating the % HbF in whole corrl 
Wood samples which was correlated to the alkali denaturation reference method {t - 
9678. n= 5) Using this data, a unique set of HbF coeflicients was generated based on 
Ihe absorbance spectra of fetal hemoglobin and incorporated into a new fetal 
hemoglobin channel on the IL 682 CO-Oximeter In this study, vrt analyzed 31 cord 
blood samples run in Ihe fetal hemoglotwn mode on the tL 682 CO-Oximeter and on 
the Radiometer OSM3 Hemoximeter Routine quality control of the IL 682 was 
performed using IL s Multi 4 ® CO-Oximeter control (CV %'s of 97%, 28%, and 
0.74% (or THb. %0; Hb, and % COHb) RESULTS Analysis using the two tailed l-tesl 
for paired data gave no statistical difference of the means (calculated value of 
0.003894. n-1=27 vs 2 052 critical value. 95% C I ) and acceptable correlation (r = 
881 . n= 28) for Ihe estimalion of % Hb F Similarly, no statistical differences were 
observed for Ihe means ot % COHb, % O^ Hb, and % Met Hb when using the two-tailed 
paired l-test {t= 8384, 3129. and 0000, respectively, n-1 = 27 vs 2 052 cnlical 
value, 95% C 1 ) Bias plot analysis revealed a trend v/here the mean value ot % Met 
Hb for the IL 682 CO-Onrmeter was sJrghtly higher than lhat of the OSM3 (mean value 
of the IL 682 = 31 vs mean of the OSM3 = -0 02, and did give a statistical difference 
between Ihe standand devialions (F=1 84 calculated vs F= 1 83 cntical value) 
Additionally we tested the Hb F extinction matnx in the presence ol elevated bilirubin 
concentrations, since bilirubin is a common interferent in neonatal specimens Samples 
wilh concentrations of bilirubin equal to 1(X) mg/L or less showed no statistical 
difference from baseline samples (0 mg/L bilirubin concentration) Al concentrations of 
300 mg/L. bilinjbms presence did not affect the % MetHb and % HHb but had a slight 
effect on the other speaes wfrere the measured % O.- Hb was decreased by an 
average of 1 4% (mean values 99 72% al mg/L bilirubin vs 98 30 +/- 35% at 300 
mg/L), and Ihe % COHb was increased by 2 5 % from baseline samples (means -2 81% 
at mg/L vs - 36 ♦/- 34% at 300mg/L) CONCLUSIONS This study then confirms 
that Ihe IL 682 CO-Oximeler can accurately determine Ihe percentage Hb species in 
neonatal or cord blood specimens when analyzed m the (etal Hb mode and is not 
affected by bilirubin in samples at concentrations up lo 100 mg/L 


CONTROL _PR00yClS KA grown. BS ■ RRT, RPFT ; R Kozlpwsk i -Tempi in. 

BA, CPFI. Pulmonary Diaqnostic Services. University of Wisconsin 
Hospitalb and Clinics, Madison, Wl and Central Blood Gas 
Laboratory, Northwestern Memorial Hospital, r.hicago. R. 
Introduction: Our study was designed to evaluate the stability 
and reproducibility of commercial products having extretne pH and 
blood gas values which are then intended for use as materials to 
validate reportable ranges as required by regulatory agencies. 
Two laboratory settings having dissimilar instrumenrs [C1ba- 
Corning and Radiometer versus Instrumentation Laboratory [ILl) 
were employed in the study. Methods: Each laboratory measured a 
minimum of 25 runs/level tof the same lot number) on consecutive 
days, using calibrated pH/blood gas analyzers. Meticulous 
attention was paid to adhering to manufacturer recommendations 
regarding instrument calibration for normal operation, 
standardizing analyte preparation, as well as assuring 
continuous solid samples were introduced into each instrument. 
All runs were performed after instrument performance was deemed 
acceptable by internal OC. Recovered values were transcribed 
exactly as displayed by each instrument (data were not rounded 
up or down). Results: 

Mean Recovered Values fron Single Analyzer Runs 









Badioieter 50C (6 







a X 







Sadioietcr 50C (7 







CV i 







lUdioKtcr 500 (8 







c\' » 







Cibd-Cominq 28B 







CV > 







IL 1306 







r.' ! 



15. •" 




AH recovered values (standard units) were within the product 
manufacturer's instrument and model specific ranges. Coefficient 
of Variation (CV% - [SU./Mean] X 100) reflects relative 
variability among analyzers. Conclusion: Ihese products are 
acceptable materials to validate the reportable ranges of these 
analyzers. Each laboratory is responsible for establishing 
performance acceptability criteria. 



Paincia A. Mcvcrs. RRT . Dennis Bing. KRT. Edric Murphy, BS, CLS, 
Mark Mammcl. MU. iriim Infant Pulmiuiary Rcseja-h Center, Children's 
Health Care St. Paul. MN 

InlroJuction : Poml-ol-eare blood gas analysis in ilie ICU is now available. 
Can these new device.s he used in place of conventional inlab analysis? This 
study compares results from two Ix'dside hliKid gis analyzers and a standard 
clinical laboratory measua-ment in a ncttnatal lung injury animal model. 
Method : We compared 2 point-ol-care hlood gas analyzers. IRMA, 
(Diametrics Medical Inc.. St. Paul. MN), and StatPal U. (ScnD.x Medical. 
Inc.. Carlsbad, CA), and one in lah analy/cr, ABL 62(1 (Radiometer. 
Copenhagen, Denmark). 10 newborn piglcLs were sedated, inluhated and 
ventilated at an ri02 ranging from .51) to Ml. Wc induced lung injury by 
repeated .saline lung lavage, producing a wide variety of arterial blixid gas 
values. The StalPal II and lUMA were calibrated just prior to each sample. 
The ABL 62(1 auio<alibrales on timed cyclcv Using Snuwih-E aiu-rial 
blood gas synngci (Radiometer. Copenhagen. Denmark) we drew samples 
for analysis by StalPal II. IRMA and .AHL. corrected for body temperature. 
We collected 4!( comparative points of pH, PC02, and P02, and separately 
analyzed 41 data points with I'02 values less than .KK) torr. We asses-M-d 
agreement using ilie Bhiiid-Altman comparative technique. Results : Mcjns 
of the diffen.-nces for each data point (bias) and "^ of data within 2 standard 
deviations ol the mean are reported below. 


ABL Slat 



mean difference 



-0 03 

% within 2 SD 



95 8 


mean difference 



"i, within 2 SD 






mean difference 




°. within 2 SD 





mean difference 




% within 2 SD 




We found close agn;emcnt between the point of caro analyzers and the in- 
lab analyzer for pH and PC02. Mean dilferencts for all P02 data were 
wide. We analyzed P02 data separately in a mote physiologic range «.'^(K) 
ton-) and found bias to be aeceplahlc. Conclusion : The two pomt-of-carc 
insti-umcnus evaluated in this study. IRMA and SiatPal. are accuraU- 
altematives to in lah analyzxTS in common clinical practice. 



Respir.atory Care • October "96 Vol 41 No 10 

Monday, November 4, 12:45-2:40 pm (Rooms lA-B) 

CRTT. David C, ShcU c Jv. PhD, RRT , ["he Lmvcrsity nt Ttxjs Ikdlth Scjcnie 
Center al San Antonin, San Antonio, Texas, 

BACKGROUND: The i-STAT system (i-STA'C Corp.. Princeton. NJ) is j poirit- 
ot-cate blood nniily^is dcvitc allowing for measurement of arterial blood gas 
values at the hedsidi. We compared the performance of the i-STAT to the 
conventional Ciirninji 27.S blood gas analv'zcr (Ciba Corning Diagnoities Corp.. 
Norwood. MA), METHOD: One hundred nineteen consecutive bluod gas 
samples were anal\v,cd using the i-STAT syMeni and Coming 21H concomitantly. 
Mean pH. PaCO. and pH values were compaied usmg the t-lesl foi dependent 
samples to determine il there were bignificant diftcrcnces (p < 05) Pearson 
product moment correlations were calculated to dctermme if there were correlations (p < ri5) between ihc Iwu instnimenls RESULTS: 
Means, standard deviations, t and p values weie as lollows: 

Cotninn I7S 





7.11)24 (.06) 

7 407."; (.1)7) 




42 *)*)27 (Q.9) 

4.V442 (1U.2) 




107 S5 (73,1) 

109.73 (76.61 

-1 SK 


Regression equations were; 

i-STAT pH = -.2174 + 1.03U1 .\ Corninj pH 

i-STAT PaCO, = -.1724 -I- 1 0145 x Corning PaCOj 

I-STAT PaO. = ■2.13« + 1.0373 x Coming PaO, 

There were small, but statistically significant dillerenccs between the rwo 
instruments for pH and PaCO.. There was no significant dilfcrcnce tor PaO,. 
There were signifieanl correlations between values obtained with the i-STAT 
when compared to the Corning 278 tor pH (r = .V)2. p < .01). PaCO. 
(r = 9804. p< 01) and PaO; (r = .9904. p < 01). CONCLUSIONS: Arterial 
blood gas results nhtamed via the i-STAT system correlated well with results 
obtained with the Coming 278. There were small, hut statistically significant 
diKcrenees between the two instruments on pH and PaCO., however. Ihese 
diilercnces were probably not clinically signific-anl. 


Don't miss the 

presentation of the 

abstracts shown on these pages 

at the 

Open Forum 

at the 

1996 hiternational 

Convention & Exhibition 

of the 

American Association 

for Respiratory Care 

San Diego, CaUfornia 
November 3-6 

Pnili'SNoi's Itoiiiids ill l{rs|iii'aloi'v (arc 

hiani ( Itl i: I'rniil !» Vin\lii<> a Milcolapr nilli a 
Tt>l('|ili<Mii' i\ii\ NcsNioii (Ir liv Mcwliiji l,ivi' 

Capturing Respiratory Services 
Outside tlie Hospital Part II: 
Subacute Care 

• Live Satellite Broadcast 
-October 15. 12:30 to 2 p.m. EST 

• Tape with Teleconference 
■November 18. 12:30 to 1 p.m. EST 

Explains how respiratory services are reimbursed by Medicare and 
examines the different types of subacute care Also discusses what 
skills are needed by respiratory care practitioners to practice in 
subacute care. 
Featuring Kevin Cornish. RRT. and Sam Giordano. IVIBA. RRT 

Site Registration for Your Entire Staff is $260 
for AARC iVlembers and $295 tor Nonmembers. 


/WcJAe cliecl<s payabie to tiie AARC Mail to: 
American Association for Respiratory Care, 
AARC Videoconferences. 1 1 030 Abies Lane, 
Dallas. TX 75229-4593. Purchase orders and 
credit card orders may be faxed to (972) 484-2720 
or 484-6010. or call (972) 243-2272. 

You IVlust Indicate How You Wisti to Receive tlie Program 
(select one only): 

Live Satellite Broadcast Registration 

(KU Band analog/C Band analog) or 
C Videotape with Teleconference 

Registration (no satellite dish necessary) or 
r Videotape Only (CRCE credit not available) 

Supported in Part by an Educational Grant from 

Respiratory Care • October "96 Vol 41 No 10 


Monday, November 4. 1 2:45-2:40 pm (Rooms 5A-B) 


Teresa VoLsko RRT Sl ELiabah Health Center Youngsiown. OH. and 
Robert L. Chaibum RRT. Rainbow Babies & ChJldrcm Hospital. Cleveland. OH. 
Accidental endotracheal extubauons with infanLs re^jiunng mechanical veniilation have been 
associated vjnh acute hypoxia. [ar>ngo trauma, cardiopulmonary compromise and subglotlic 
sicnosis. Securing ihc uncuffcd endoirachcal lube is imperauve in order to prevent complications 
associated with unplanned extubauons In this study we evaluated the efTcci of two endotracheal 
tube taping methods on the incidejice of spontaneous cxiubalions, 

METHOD; Two hundred fony-four infants admitted to our level two NICL' were studied. 
Infants tjualifled for the study if ihey rcquuxd intuhaiion and mechanical ventilaUon. Exclusiun 
criteria included infants with su.?pccted or confinned neurological impairmenls that prevcnied 
purposeful movement, iransfcrs to Level 3 care facilitres", and /or those requiruig mechanical 
ventilation for less than 72 hours Infants requiring restraining devices and/or the use of scdanon 
were excluded from the study Infants enrolled in the study had then oral endotracheal lube 
affixed by one of two methods i 1 ) adhesive tape was used to fasten ihc endotracheal lube to the 
infant's upper lip or (2) the endotracheal tube was held in place by an oral fixation device (aka 
Logan Bow or nuchal arch; Pcd Nursing 1992.18:267-70) The device used to secure the 
endotracheal lube in place was chosen on the basis of device availability The outcome variable 
was the rate of spontaneous extubauons per 100 ventilator days. A spontaneous cxtubation was 
defined as any unplanned dislodgcmcni of the endotracheal tube wiihoul regard to precipitani oi 
the event (ic; cxiubauon dunng rctaping. while reposiuonmg infani, dunng a procedure, etc ) The 
data were compared with Fisher"*: Exact Test- RESULTS: 1 he data are shown below: 

Logan Bnw Arihf<;ivp Tane jLlalu£ 





Number of pdticnu; (U)tal) 


Number by weight f kg) 



1 - 1.5 






2.5 - 4.4 



Total exlubauons(%) 


Hxtiibations/1 00 vent days 


F.xlubations <^) by weight (kg) 

0- I 


1 15 


15 -2.0 


2 - 2.5 


2 5-4.4 










CONCLUSION: The use of a logan bow to secure an uncuifcd endotracheal tube in place may 
reduce the unplanned cxtubauon rate on mechanically venulated infants weighing less than 


Steven F Sittie RRT. P/P SpecialisL Douglas P, Dcrieth. M.D,; Mayo Clinic. Rochester, 

Introduction: While nxsal ventilation has incTeased in popularity with the adult and pediatric 
populauon, there is very btiJe lo the lileraiurc regarding Its application to noninvasive support 
of the premaiure infani 

Case Summary : The patient was a 23 aod 4/7 week gestation. SI5-gm female bom 
precipitously ui a breecb presentation after a placental abniplioo. The infant was intubaced and 
Survanta was ilxninisicred I'he paucni was placed on SIMV, rate 70; peak preisurc, 23 cm 
HjO; PEEP. 4 cm HjO (23/4); inspiratory time (IT). 2 sec; and FIOj. 10 Tidal volumes 
ulUuing a Bear NVM I were kept Dear 6 mlTkg (3 2 cc). The pauent was siaru^d on low-dose 
dexameihasone (0 03 mg b i d ) and aminophylline On day 3 of life, a bead ultrasound was 
negative The ventilaior senings were gradually weaned over a 4-day period to a SIMV rate of 
20. 12/2,0.15 sec IT. and RO, of 0.23 The paiiem was extubatcd and placed oo an Infr^onic 
Infant Siar with Starsync module and a RCI Hudson Nasal CPAP circuit and a CPAP hat with 
thin strap of our own design An orogastnc tube was in plajc to vent swallowed air The 
paucni was placed on an assist control rate of 30. 19/3. 15 fT, and 23% FIO; via nasal 
prongs An Inline aerosol with raccinic epinephrine was dcUvcred dunng the assist control mode 
to posi-cxtubation edema. The TcPCOj deaeased Erom 55 to 36. TIk patient was 
changed loanaAaJ SIMV rate of 30. 19/3.0 2 sec fl. and 24 FlOj. CKXxlcbesi excursion was 
seen with synchronized breaths Over 1 hour, the SIMV mtc was deaeased lo 10 bpm and 
pressures to 14/4 Twelve hour* posi-exlubatjoo. the palieni was placed on nasal CPAP 4 cm 
H;0 with a 10-sec delay ui a temporary apnea backup rate of 30 bpm An artcnal blood ga* 
(ABG) drawn dunng a spontaneous respiratory rate ol 50 bpm was PaOj. 72. PCO,. 27; plL 
7 40 with base -6 A post-entubation chest x-ray showed no atelectasis The patient wai. 
mainlained on ibcse sellings for 4 days At 8 days of age. the patient exhibited rctraclions. 
apr>ea spells ( 13 in 7 hours) and mcicased TcPCOj readings An ABG drawn at this time 
revealed a combined respu^ory and metabolic acidosis. Pat^^. 60; PCO;. 63; pJI. 7 |7 with 
base -6 The paucni was placed on nasal assist control rate of 20. 18/4, 2 TT, and 0.22 ITOj 
while another mhnc raccmic cpmcphrine aerosol was given arxl a doxapram drip was added. 
Good chest excursion was seen with synchronized breaths A follow-up ABG revealed PaOj. 65; 
PCO;, 54; pH 7 30 with base -1 Ihe patient was returned to nasal CPAP 4 cm H.O with a 
backup apnea rale of 30 and a 10-sec alarm delay activation time The paiicnt rtquired periods of 
nasal SIMV on three other occasions for a loial of 6 days I'he CPAP was slowly weaned to 3 
cm HjO. the apnea delay uroc increased lo 20 sec, then tnab off CPAP began and gradually 
increased in duration On day 82 of life, the CPAP was djsconunued. The paiicnt was 
discharged at 13 weeks of age, weighing 2020 gm. without home oxygen ordiurchc 

Distussipp; Uiilizauoii of nasal veniilaiion/CPAP is an opoon in support of early 
extubation in the prcu^rm populatjon Over ihe past 5 years, we have found both the apnea 
backup feature and nasal SIMV useful in supporting the early exiuhauixi of premature babies, 
Na'^ SIMV can be used lo support a baby ihrough difficult pcnods while the underlyuig 
problem IS solved wtihoul resorting lo reintubaiion. 


SM, FRCPC, FAAP Dept of Respirator. Care. Beth Israel Hospital, Boston. MA. & Centre 
for Evaluation Sciences, B C, Research Instihite for Child & Family Health, and Dept. ot 
Pediatrics. B.C 's Children's Hospilal. University of British Columbia. Vancouver, EC, 

IN IRODUCTION; Jarcho-Levin Syndrome (Spondylolhoracic Dysostosis) is a congenital 
disorder characterized by extensive malformations and abnormal fusion of thoracic vertebrae 
and ribs, resulting in severely deformed thoracic cages, and a hinh neonatal mortahry from 
respiratory insufficiency (only 7 survivors were reported in a scries of 27 cases) We report a 
first case of Jarcho-Levin Syndrome successfiilly treated wiih HFOV, 

CASE SUMMARY A lemi. male infant was delivered to a 32 year old gravida 3. para I 
white woman bv spontaneous vj^;inal delivery Prenatal ultrasounds of the patient revealed 
multiple vertebral anomalies Apgars were 6 at I minute, and 7 al 5 minutes Shortly after 
delivery, the infant developed severe chest retractions, cyanosis, and decreased breath sounds 
and required endotracheal intubation and assisted ventilation Despite extremely high peak 
inspiratory pressures of 50 cm H;0 and FiO; of I 0, the infant remained poorly ventilated, 
with minimal chest movements, diminished breath sounds, and uansculaneoiis oxygen 
salutations in the 70s. Chest radiograph confirmed extensive vertebral and nb anomalies, 
including hemivertebrac, hurtcrflv vertebrae, and absent vertebral bodic with pedicles BotJi 
lungs appeared small and opacified. The infant was then placed on the Sensor Medics 3 lOOA 
HFOV with a frequency of 10 Hr. mean ainvay pressure of 17 cm ILO. delta p of 40 cm H-0, 
IT ratio utO 33. and FiO, of 1 Initial venous blood gas was pH 7 22. PaCO, 70, PaO; 207, 
total COj 30 and base excess Acidosis was corrected w ith intravenous sodium bicarbonate 
infusion, delta p was increased to 48 cm ILO, and amplitude adjustments were based on 
visual assessment of chest vibrations The infant developed persistent pulmonary hypertension 
of the newborn, confirmed b> echocardiography and posi-ductal desaturation, and required 
trcaltnenl wiih sodium bicarbonate and vasopressor mfus'ons Gradually, the infant's 
condition improved, and aflci three da>s, HFOV was changed to conventional ventilation with 
PIP 22. PEEP 5. rate 20 min. IT ratio 4, and FiO; I On the fif^h day of life, ihe infant 
was extubated to oxygen via nasal cannula at 100 CG'min and discharged home shortly after 

DISCUSSION HFOV is an effective method of treatment for rcspiialorv failure due to 
restnclivc rcspuTitor\' disease II achieves oxygenation b\ mauitnining or recniilins an 
'■optimal luny volume" which maximizes ventilation-perfusion matching without 
compromising venous return and cardiac output It is therefore an ideal method of treatment 
for Jarcho-Levin Syndrome, in which asmall, deformed thoracic cage compromises 
ventilation During the critical period following delivery. HFOV permits stabilization of the 
infant's card lo- pulmonary status while the lungs have an opportunity to become more 
compliant and adapt to cxlra-ulenne life. HFOV can therefore be life-saving, and may 
improve the survival of patients with Jarcho-Levin Syndrome, who often lead full healthy 
lives if the\ survive the neonatal period 


PcierBeniRRT . Daphne Munhall RRT. Barn- Grcnicr RRT. Jay Wilson NtD 
Childrens HospitaL Boston. .VLV 

INTRODCCnON: The trend in ventilation strategies for congenital 
diaphragrnatic hcnua (CDH") patients has shifted from the use of muscie paralysis 
and hvpervenblaDon, to the preservation of spontaneous breathing and permissive 
hN"percapnea ' . The objectives of this trend are to provide adequate |as e:^change 
while minimizing ventilator induced lung injurv. In our institution now-triggered 
now<ycled vcnniaticn (FTCV') (Bind VIP. Palm Springs. CA). is used to achieve 
this straiegy. We report our experience with FTC\' in CDH patients. 
SUMNL^Y; From 3-93 to 3/96. FTCV was utilized in 36 CDH paricnts. mean 
weight 3.3-4 x 0.68 kg. Twelve patients were managed with FTC\' following 
rCNiO and 24 did not rtquire ECMC. FTCV «is iniuattd onct muscle iclaxants 
and sedanves were reversed and spontaneous breathing resumed. Sedaricn was 
Qtrated to maintain analgesia without compromising respiratory effort. Tngger 
and cvclc thresholds were adjusted to ensure paricni. ventilator svrKrhronv. Each 
triggered breath was supported wuh an injiiaj AP (PiP-PEEP) of 23.06*4.29 
cniH^O. which was weaned incrementaJly PEEP ranged from 3 to 5 cinH20and 
adequate gas exchange was n:\ainlained- Mean Vt was 5.24 =: O.Sl ml/kg and mean 
RR was53JG = 805. The total ventilator duration was 20.S2 ± M.21 da\s with 
16.69 ± 10.77(80 2^) FTCV days. The AP at which patients were extubated was 
1M2± 1.75cmH20 withamean Vrof 4.S4± 1 05 ml "kg The duration spent at 
the cxtubation AP was 1 .97 * US days. Fxrubarion was successful in 34.36 
(94 4^) patients. Reintubation was required in 2 patients, one due to upper 
airwav edema and the other due to rurcotic -induced hypoventilation. Survival rate 
was 35'36 {97.2''c). One ^.^ost-ECMO pabent died from sepsis. There were no 
significant differences between posi-ECMO and ncn-ECMO patients with respect 
to the above panimeters except for vendlator duration. The total ventilator 
duration was 29. 17 ± 14 66 davs for post-ECMO patients versus 16.27 x 1 1.96 
days fornon-ECMO patients [p =0.021. DISCUSSION: FTCV enhances 
pane nL' ventilator synchrony by providing vcndialory support that allows the 
patient to regulate ^e and I:L Periods in which FTCV were not feasible were 
related to sedation levels thai limited spontaneous breathing and were typically 
dunng admission, in the immediate post -operative period and following separation 
from ECMO. The difference in ventilator duration between post ECMO arid non- 
ECMO patients may be related to the severitNof illness. We speculate that the 
high extubatjon success rate nay indicate that exiubation could be attempted 
earlier and potentially reduce the total ventilator durarion and potennal 
complications- We have found FTC\ to be well suited for the trend in ventilation 
strategics for CDH patient?. 

I . Wung JT. Sahni R, Moffin ST. Lipsitz E Stolar CJH. Congenital diaphragmatic 
hcmia; Survival treated with verv delaved surgery, spontaneous respiration, 
and no chest tubes. J Fed Surg. 1995: 30(3) -.406-40'; 



Respiratory Care • October '96 Vol 41 No 10 

Monday. November 4. l2:4?-2:40 pm (Rooms 5A-B) 



LESS THAN 2000 GRAMS Hn-^n]. Buck . RRT. Debra R. Jones. RRT 

David E Woodrum, MD University nfWaifiington MeJical Cenler. Seatlle, 


BACKGROUND Preniamrt neonates frequently require endotracheal inmbalion. 

Misplacement ot" the endotracheal lube in Ihe esophagus can result in delay in the 

initiation of ventilatory support cnlicai for establistung effective ventilation 

Capnomelry or colonmetn are standards for confirming intubation in 

populauons weighing > 2tXX) gnuiis Capnography has been used in infants < 

2000 grams but the previously developed coionmetnc devices have had too much 

dead space for thts population The utility and accuracy of a disposable, 

coionmetnc ETC02 detector with only 3 cc dead space, made by Nellcor and 

called a Pedi-C.AP®, was evaluated and compared to a mainstream capnometer. 

the Novainetnx 1265. dunng .31 intubation anempts The study population 

consisted of 24 infants weighing less than 2000 grams Less than IfKIO grams 

(n=6(, 1000-1200 gramsln=9). 1200-1500 grams m='',i. 150O-20(» ln=2) 

METHOD Data was collected on each infant consisung of weight, number of 

brrallis given for exhaled C02 to be detected, if any. length of time infant was 

inask-bag venulated. if any. adrmnistration of CPR. if applicable, color change, 

if any, delected with the Pedi-C,\P® Immediately after iniubauon anempts the 

Novametnx ETC02 sensor was attached between the ETT and Ihe vcntilauon 

bag and digital readings and waveforms observed for at Ica^t 6 positive pressure 

venlilauons (PPVs) and data noted The Pedi-CAPt® was then attached and at 

least 6 PPVs given and color cfianges noted. HR. RR, oximetry, and breath 

sounds were also monitorwl dunng and after inrubauon attempts .\ posiuve 

identification of tracheal iniubauon by the capnometer was a digital number 

readout with the typical phasic waveforms of rcspirauons within 6 PPVs A 

positive idcnuficauon of esophageal intubation was a zero reading or a digital 

readout < 10 quickly decreasing to zeru within 6 PPVs A posiuve identification 

of tracheal intubalion with the Pcdi-CAP® was a color change from purple to 

yellow and back again to purple in sync with inspiration and expiration within 6 

PPVs. A posiuve identification of esophageal intubation was no color change. 

or a very weak color change decreasing to purple wiifnn 6 PPVs RESULTS: 

24 tracheal intubauons were confirmed with both devices within 6 PPVs 7 

esophageal intubauons were confirmed with both devices witfun ? PPVs ,-MI 

infants had spontaneous circulauon 12 of the 24 infants were mask bag 

ventilated before or between intubation attempts EXPERIE.NCE Weloundlhis 

3cc ETC02 sensor to be easy to use and well liked by all the staff in the NICU 

it IS disposible. portable and simple to use, requinng no maintenance, calibrauon 

or cleaning CONCLUSION It is concluded that the Pedi-CAP® is as reliable 

as capnography in confirming endotracheal tube placement in infants less than 

2000 grams OF-96-096 



MiLs:i]i Nishimura MD. ,-\kiloshi Ohara MD. Yhuji Fujino MD. Narlaki Malsuura 

MD. Intensive Ctirc Unii, Hyogo College of Medicine, and Dcptirtnienls of 

Anesthesiology. ICU and Palhology. Osaka University Medical School 

Tidal recruitmenl and collapse are considered to be imponanl in venlilator-induced 

lung injun,'. In Ihe prone position, pleural pressure tuld ventilation dislribulion aje 

more uniform than in the supine position. We therefore hypolhesized thai 

ventilator-induced lung iniui7 due 10 lidal recruitmenl and collapse was less in the 

prone position than in the supine. 

Methodi: Ten anesthcli/ed. paralyzed and Iracheoslomized rabbits y*'erc 

randomized to either the supine or prone position. The internal carotid artery was 

cannulaled to monitor arterial pressure and to aspirate blood for respiratory gas 

measurements. Respiratory gases were measured every hour alter starting 

mechanical ventilation. The animals were all ventilalcd s^ith an infant ventilator 

( V.l.P. Bird) al a l^tc of 30/mm. Ti 0,6 sec. peak inspiratory pressure (PIP) M) 

cmH:0. inspiratory How l.i Umin and no applied PEEP in CMV mode. All 

animals were ventilated lor ,i hours or until the PaOi value was below IfX) mmHg. 

At the end of Ihe protocol, the lungs were removed. 

Results: In the supine group. PaCh was below IflO mmHg wilhin 2 hours m one 

animal, and within ."^ hours in 3 p^Q, 

animals. The lungs were reddish. 

especially in the dependent regions. ^° 

PaO: remained above 2IKI mmHg in 

all prone animals. The lungs of this ^^ 

group revealed a normal appearatKe 

at the end of the protocol. 

Conclusions: In the setting of the i o 

study, the lungs were significantly 

injured by positive pressure 

ventilation in the supine position. 

Position has a .!>real effect on lung 

injury during mechanical ventilation. 

PaO: of each group (mean of five rabbits) 


Jmni L Raake RRT A.\S 
Children's Hospital Medical Center 
Cincinnati, Ohio 
Background: Manv clinicians use swivel adapters to connect ventilator circuits 10 
endotracheal tubes The adapters, usually elbow' shaped, allow for flexibility ui 
mamtaming patient airways These adapters, however, can be sources of volume loss 
Method: Eight adapters were evaluated using three diflferent tests «l) a "tightness" 
test, ftl] a water-leak test, and #31 mechanical ventilation tests The tightness test, a 
standard lest performed on the Hamilton Veolar ventilator, allowed the cimician to check 
the arcuit for leaks by rnaintammg a set pressure The water-leak lest was performed 
With the adapter inverted into a basm of water while connected to a test lung As volume 
was passed through the viattilalor circuit, air bubbles commg from the adapter indicated 
a loss of volume The mixhanical ventilation test was performed with the Hamilton 
Veolar connected to the Biotek VT-1 ventilator tester The ventilator was set at a rate of 
20. PEEP of 5 cm HjO. and V, of I OOcc. 200cc, 300cc. 400cc. and ."^OOcc The set 
volume minus the compressible volume loss (0 76cc/fbcit on an 8 fbc« Ic^ig Baxter circuit 
»IOI<>-703), was considered to be the optimal volume The test focused on which 
adapterts) had the greatest optimal volumes Results: Four of the adapters passed the 
tightness test Two of these adapters also passed the water-leak test These same two 
adapters consistently delivered volumes ckjsest to those that were optimal The chart 
bekjw demonstrates the results of the adapters tested Eiperience; Some volume loss 
dunng mechanical ventilation is expected due to compression of gases within the circuit 
This testmg examined volume lost within the swivel adapters One manufectut«r 
reported acceptable volume loss through their adapter .^s .Sec at I20cm HiO 
However, the loss through this adapter was greater at Ifjwer pressures Conclusion: 
Based on die above tests, the Diemokluig Healthcare Division's (DHD) Swivel Elbow 
(66-|0<)5)wrthout Suction Port, and die Concord/Portex Swivel Adapter (525350) with 
PEEP Keep was able to pass alt three tests without oven volume loss 
LaLi IcsLi Isi2 peoxjil 

MedKomp w/pon MC^UTS 







51 94 

50 82 

52 64 

51 25 
$1 5(1 



Dennis Bint ! RRT . Jeanne Mrozck MD, Kendra .Smith MD, Patricia Meyers 
RRT, RavcAnn deRegnier MD. Jnhn Conncil PhD. Mark Mammel MD, 
Children's Health Care - St. Paul, and DepLs of Pediatrics and Biostausiics. 
University of Minnesota. Minneapolis. MN. 

Surfactant replacement is now a standard treatment for IRDS; partial liquid 
ventilation (PLV) is just on the honzon. Both improve oxygenation and lung 
compliance. Are henefiLs additive when the two surfac-e-active agenfs are 
intermixed'' Diws order of adminisiraiion matter'? We evaluated the eft'ects 
of PLV using a perlluorocarbon (Liqui Veni(B) and surfactant (Survanta®) 
alone and given together in 32 newborn piglets ( 1,5 1± (1.38 kg) with saline 
lavage-induced lung in|ury (Pa02<WI lorr. Fi02 10), We randomized 
animals into four groups of S each: surfactant only (S). .surfactant lollowed 
by PLV (S-PLV), PLVonly. and PLV followed by suifaclani (PLV-S). S 
and S-PLV animals received surfacLint after induction of lung injury PLV 
began .30 minutes alter surlaelani, PLV and PLV-S animals had 
perfluorocarhon instilled inlratraeheally (30- .50 miykc) alter lung injury. 
PLV-S animals received surfactant 30 minutes after stalling PLV. Using a 
conventional neonatal ventilator (Driiger Bahylog®). we adjusted PIP to 
maintain tidal volume at 15 cc/kg and Fi02 in an attempt to keep Pa02 100- 
150 torr. We mea.sured arterial blood gases, arterial and central venous 
pressures, heart rates, and dynamic and static respiratory system mechanics 
and calculated A/a ratio and Ol every 30 minutes for two hours Ibllowing 
final treatment. We analyzed absolute values and '7< A from baseline alier 

al 60 minutes 

at 120 minutes | 

% A Cdyn 

% .\ 0! 

% A Cdyn 

% A 01 


138 • 



47 5 • 














44 5 


■ p < t),ll5, S vs other groups. 
Physiologic parameters were not different S-PLV produced the largest 9!-A 
Cdyn throughout the study period. S alone .showed less improvement in 
Cdyn and OI compared to S-PLV. PLV, or PLV-S, 
Conclusions : In this model of neonatal RDS. improvement in oxygenation 
and compliance was better in all gioups employing PLV than .surtactanl 
alone. Benefits of combining surfactant with PLV in either older wcie not 
consistent, (l.iquiVent® supplied by Alliance I'harniaceulical Corp; 
Survanta® supplied by Ross laboratories, Inc) 


Respiratory Care • October "96 Vol 41 No 10 


Monday. November 4, 12:45-2:40 pm (Rooms 5A-B) 

Lynne K. Bower RR1 . Dano O faua M D., R Cleveland M D . 
Mae Jacobs;.'!!. Ja\ M Wilson M.D Children's llospiial. Bcislon. MA 

INTRODUCTION: Circuil changes arc soraclimcs netessan during 
cslcndcd extracorporeal life support (ECLS) runs It has generall> been 
assumed Ihat these circuit changes result in a detenoration in the patient's 
respiratory status. This a.ssumption is based on the opacilic^alion of the 
chest .\-ra> and worsening ol lung compliance encountered alter the 
iniUalion of ECLS. a change atlnbulcd to inllanunalor^ rcspcmse trom 
interaction ol blocxi with bioacU\e surtacxis tA the ECLS circuit. In order 
to prospetuveh evaluate whether subsecjuenl cin-uit changes (CC) are 
also asstvialcd with u similar detenorauon, we prospecti\el\ evaluated 
the impact that changing the ECLS circuit has on certain complement 
levels (C3A and C5A). ccxigulation factors, lung compliance (Cdyn). and 
appearance of the chest \-ray (CXR). METHODS: CoagulaUon factors, 
hemalocnl. ACTs. platelet consumption, hepiinn requirement, and Cdyn 
were recorded 24 hciurs belore and 24 hours alter each CC. C3A and 
C5A levels were drawn poor to and at ^. 12 and 24 hour* IcjIIow ing 
circuit change The CXR was blinded ^tnd Nith subjecuvely and 
objecuvely evaluated 12 hours pnor to anvl 24 h<mis alter CC Objective 
asses-sments were macie by senal ci>mparauve measurements of lung 
Tield/air density raUt) Ihniugh an -X-Rile model 301 light densitometer. 
SlaUstical analysis was by ANOVA and the Schelfe F lest, with 
significance set at O.O.S RFJiUl.TS: Twelve circuit changes were 
perlVirmed in eight palienLs due to either e\cessiv e circuit cIoLs t)r 
coagulopathy Ratelel count significantly increased following CC 
(p=.(H). libnnogin levels also rose but not significantly Hct, PT, ACT 
and hc[)ann requirement did mil change. By both subjccuve and objective 
evaluauon, the C.XRi did not change signiiicanlly after CC Cdyn was 
also mH affected by the circuit change C.3A and ('."iA levels were not 
sigmricantly different either, h4mever. C3A was elevated both pntir li) 
and after CC CONCLUSION From dus preliminarv data »c conclude 
thai circuit changes during the course of ECl .8 do ni>t appear to adversely 
affect the patient's hematologic or respiratory statas, Therclore, decisions 
regarding circuit changes should be made based on the condition of the 
circuit and not tfic patjcnL 



Cralc Black PhD, RRT . Pulmonary Services Division and Douglass 
Laboratory. St. Vincent Medical Center, and Department of Biology, 
Uruvcrslty of Toledo, Toledo, Ohio. 

latrodnetlon : Published studies suggest that volume control fVC) 
ventilation Is superior to traditional tJme-cycled. pressure limited (TO) 
venUlaUon In treatment of several disorders which cause severe neonatal 
respiratory failure: specifically. VC yields superior oxygenaUon. Analysis of 
flow-volume IF/V) and pressure-volume (P/V) curves generated from tliese 
two modes with a neonatal test lung should suggest a possible explanation 
for clinical observations Methodt : A BlCore CP- 100 measured respiratory 
mechanics of VC and TO breaths generated by a VIP Bird hooked to a two- 
compartment neonatal lest lung (iNoMsR MedicaiJ. Three levels of airway 
resistance IRaw) and system dynamic compliance ICdyn) typical of neonatal 
respu^tory failure were utilized. Including one where one compartment was 
set to mimic "slow lung units (high Raw/low Cdynl and the other -fast" lung 
units (lower Raw/higher Cdyn). Constant respiratory rate (20/mln), PEEP 
(3cmH20). and flow rale I8lpm) were maintained. Achieved Udal volume 
(20ccl was maintained constant by adjusting PIP for TC breaths and 
delivered Vx for VC breaths 

Reanlta : No significant differences IP<0 05) between TC and VC breaths 
were observed for Raw. Cdyn, Time Constant, or PIP, at any of the three test 
lung setungs MAP was significantly (P<0.051 lower for VC breaths In all 
Instances, and F/V curves of VC breaths showed a marked (laltenuig of the 
Inspiratory limb In all Instances. Two representative F/V curves are shown 



1 nn 1 

.- ■ i 

,— 1 : 

i_ [ 

" i 

W 1 " ■ " 

ml 1 

/s 1 
iuOi 1 

: - 1 J' 1 


F 1 


1 _ 



W 1 

. -Ji 


1 1 

£ 1 


1 1 


^^ ■■ 1 

AD U»-> J umn 

Conclusions : Aiidtysls of F/V curves shows that maximal flow is more 
sustained during the VC breaths than during the TC breaths. This could 
result in increased recruitment and stabtllza'uon of lower compliance/higher 
resistance lung units and thereby improve ox>genatlon- OF-96-181 


Ja mes G. Bisgaard RRT. Auguslo Sola MD Intensive Care Nursery, Umversity of California 
at San Francisco, San Francisco Ca. 

Introductioa: Helium has long been recognized for its' therapeutic value in treating various 
form-s nf pulmonary disease TIic low density inherent to the physical properties of this gas 
may lend particular clinical value in the treatment of condiaons associated with increased 
airway resistance (RAW). At our institution, helium gas mixtures have been introduced 
through mechanical venulators to treat various forms of both acute and chrome lung disease 
Past bench studies by our staff have shown this practice to be safe in the clmicaJ arena. 
However, since these vcntilaln!-; have bten designed to operate with conventional gas sources 
(ie osygen, compressed air), wc decided lo further investigate if the use of hcbum would affect 
airway resistance and other important values associated with mechanical ventilation. 
Methods: A Sechrisi fV-iOO time cycled, pressure limited ventilator was used to deliver 
various mixmres of medical gases The ventilator was set to deliver PIP 22cmH20, PEEP 
5cmH20. RR 20/min,Ti SOsec. Row 10 Ipm and Fi02 .-lO Baseline data values were 
obuined using conventional gas sources of oxygen (02) and compressed air (02.N2). Helium 
was introduced to the ventilator gas supply by means of connecting the compressed an gas 
inlet hose directly lo a pressure regulated H cylinder of HelioxtHe 80%, 02 20%) 
Compliance of the test lung was set to remain fixed at 002 l/cmH20 RAW was set ai 200 
cm/l/s and later increased lo 400 cmA/s. RAW data was measured by a Bicorc CP 100 
pulmonary moniionng device. Flow iraniducers to Bicore unit were placed at the ventilator 
circuit/test lung interface When heliox was m use, specially calibrated flow transducers were 
used to ensure reliable test results at all studied concentrations of gas mixmrcs. Oxygen 
concentration (Fi02) was continuously monitored by a Teledyne Oxygen Analyzer. All devices 
were calibrated according to manufacturers" specification. Results: When u,sing convennnna! 
gas sources through the ventilator with inline resistance fixed at 200 cmH20/Vs. the Bicore 
monitor measured a RAW value of 120 cmH20/l/s With helium introduced to our gas supply, 
this value dropped significantly to90cmH20/Vs When inline resistance was increased to 400 
cmH20/l/s , RAW of conventional gas souce venulatjon was recorded at 177 cmHlOWs. This 
value decreased to 133 cmH20/l/s when helium was used At both levels of fixed inline 
circuit resistance, monitored values reflected a decrease in RAW equal to 25% when heliox was 
in use 

Fi02 Added Fixed RAW Measured RAW Change 

Helium cm/I/s cm/l/s w/Helium 
















Conclusions: The use of hehum gas mixtures delivered through a time cycled, pressure 
limited venulator significantly decreased measured Airway Resistance in a test lung model Wr 
therefore suggest, that the clincal usage of this gas can be effectively and safely used to treat 
pulmonary disease associated with increased airway resistance 


RC Protocol 

The AARC now has a Respiratory Care Protocol Clear- 
inghouse. RCPs interested in developing therapist-driven 
protocols (TDPs) for their departments can turn to the 
information available through the clearinghouse to get a 
head start on the process. 

The clearinghouse makes available more than 1 00 TDPs 
submitted to the AARC by members from across the 
nation who have already instituted these protocols in 
their hospitals. 

The protocols have been divided into seven packets, most 
of which contain ten or more saniple protocols. Packets 
are available from the AARC at ^5 each and currently 
cover the following subjects: 

•" Patient assessment 
•" Oxygen therapy 
•" Aerosol therapy 
•" Volume expansion 
•" Critical care 
•" Noninvasive monitoring 
•• Secretion management 
• • • 
American Association for Respiratory Care 
1 1 030 Abies Ln., Dallas TX 75229-4593 
Call (972) 243-2272 or fax to (972) 484-2720 
(MasterCard, Visa or Purchase Order accepted] 


Respiratory Care • October "96 Vol 41 No 10 

Stop by and see us for 
new information 







Glaxo Wellcome Booth #219 

CAUTION: Adrenal insufficiency may occar when transferring 
patients from systemic steroids (see WARNINGS). _ 

Please consult Brief Summary of Prescribing Information 
for FLOVENT on adjacent page. 

Circle 126 on reader service card Visit AARC Booth 219 in San Diego 





{fluticasone propionate}A 


r^M l 

For Oral Inhalation Only BRIEF SUMMARY 

The !■: :■ . ■ ; ■■ .1 ; !iet summary only: see full prescribing inlormalion lor complete product mtorrnation 
CONTRAtNOlCATIONS: FLOVENT Inhalation Aerosol is contraindicated in the primary treatmenl ot 
status aslhmaticus or other acute episodes ol asthma where intensive measures are required 

Hypersensitivity to any ot the ingredients of these preparations contraindicates their use 


Particular care is needed tor patients who are transferred from systemicaliy active corticosteroids to 
FLOVENT Inhalation Aerosol because deaths due to adrenal insufficiency have occurred in asthmatic 
patients during and after transfer from systemic corticosteroids to less systemicaliy available inhaled 
corticosteroids. Atter withdrawal from systemic corticosteroids, a number of months are required for 
recovery of hypothalamic-pituitary-adrenal iHPA) function. 

Patients who have been previously maintained on 20 mg or more per day of prednisone (or its equiva- 
lent) may be most susceptible, particularly when their systemic corticosteroids have been almost com- 
pletely withdrawn During this period ol HPA suppression, patients may exhibit signs and symptoms ot 
adrenal insufficiency when exposed to trauma, surgery, or infection (particularly gastroenteritis) or other 
conditions associated with severe electrolyte loss. Although fluticasone propionate inhalation aerosol 
may provide control ot asthma symptoms during these episodes, in recommended doses it supplies less 
than normal physiological amounts ot glucocorticoid systemicaliy and does NOT provide the mineralo- 
corticoid activity that is necessary for coping with ttiese emergencies 

During periods of stress or a severe asthma attack, patients who have been withdrawn from systemic 
corticosteroids should be instructed to resume oral corticosteroids (in large doses) immediately and to 
contact their physicians for further instruction. These patients should also be instructed to carry a warn- 
ing card indicating that they may need supplementary systemic corticosteroids during periods of stress 
or a severe asthma attack. 

Patients requiring oral corticosteroids should be weaned slowly from systemic corlicosteroid use after 
transferring to fluticasone propionate inhalation aerosol. In a trial of 96 patients, prednisone reduction was 
successfully accomplished by reducing the daily prednisone dose Ijy 2 5 mg on a weekly basis during 
transfer to inhaled fluticasone propionate. Successive reduction of prednisone dose was allowed only 
when lung function, symptoms, and as-needed beta-agonist use were better than or comparable to that 
seen before initiation of prednisone dose reduction Lung function (forced expiratory volume m 1 second 
[FEV.l or morning peak expiratory flow rate [^U PEFR]). beta-agomsl use. and asthma symptoms should 
be carefully monitored during withdrawal of oral corticosteroids In addition to monitoring asthma signs 
and symptoms, patients should be observed for signs and symptoms of adrenal insufficiency such as 
fatigue, lassitude, weakness, nausea and vomiting, and hypotension. 

Transfer of patients from systemic corticosteroid therapy to fluticasone propionate inhalation aerosol 
may unmask conditions previously suppressed by the systemic corticosteroid therapy, e.g , rhinitis. 
conjunctivitis, eczema, and arthritis. 

Persons who are on drugs that suppress the immune system are more susceptible to infections than 
healthy individuals Chickenpox and measles, for example, can have a more serious or even fatal course 
in susceptible children or adults on corticosteroids In such children or adults who have not had these 
diseases, particular care should be taken to avoid exposure. How the dose, route, and duration of corti- 
costeroid administration attects the risk of developing a disseminated infection is not known. The contri- 
bution of the underlying disease and/or prior corticosteroid treatment to the risk is also not knov;n. If 
exposed to chickenpox, prophylaxis with varicella zoster immune globulin (VZIG) may be indicated If 
exposed to measles, prophylaxis with pooled intramuscular immunoglobulin (IG) may be indicated. (See 
the respective package inserts for complete VZIG and IG prescribing information ) It chickenpox devel- 
ops, treatment with antiviral agents may be considered. 

Fluticasone propionate inhalation aerosol is not to be regarded as a bronchodilator and is not indicat- 
ed for rapid relief of bronchospasm 

As with other inhaled asthma medications, bronchospasm may occur with an immediate increase in 
wheezing after dosing. If bronchospasm occurs following dosing with FLOVENT Inhalation Aerosol, it should 
be treated immediately with a fast-acting inhaled bronchodilator. Treatment with FLOVENT Inhalation Aerosol 
should be discontinued and alternative therapy instituted. 

Patients should be instructed to contact their physicians immediately v/hen episodes of asthma that are 
not responsive to bronchodilators occur during the course of treatment with fluticasone propionate inhala- 
tion aerosol During such episodes, patients may require therapy with oral corticosteroids 


General: During withdrawal from oral corticosteroids, some patients may experience symptoms of 
systemicaliy active corlicosteroid withdrawal, eg, joint and/or muscular pain, lassitude, and 
depression, despite maintenance or even improvement of respiratory function 

Fluticasone propionate will often permit control of asthma symptoms with less suppression of HPA 
function than therapeutically equivalent oral doses of prednisone. Since fluticasone propionate is 
absorbed into the circulation and can be systemicaliy active at higher doses, the beneficial effects of 
fluticasone propionate inhalation aerosol in minimizing HPA dysfunction may be expected only when 
recommended dosages are not exceeded and individual patients are titrated to the lovjest effective 
dose, A relationship between plasma levels of fluticasone propionate and inhibitory effects on stimulat- 
ed Cortisol production has been shown after 4 weeks of treatment with fluticasone propionate inhalation 
aerosol Since individual sensitivity to effects on Cortisol production exists, physicians should consider 
this information when prescribing fluticasone propionate inhalation aerosol 

Because of the possibility of systemic absorption ot inhaled corticosteroids, patients treated with these 
drugs should be observed carefully for any evidence of systemic corticosteroid effects. Particular care 
should be taken in observing patients postoperatively or during periods of stress for evidence of inade- 
quate adrenal response 

It is possible that systemic corticosteroid effects such as hypercorticism and adrenal suppression may 
appear m a small number of patients, particularly at higher doses. If such changes occur, fluticasone 
propionate inhalation aerosol should be reduced slowly, consistent with accepted procedures for 
reducing systemic corticosteroids and for management ot asthma symptoms 

A reduction of growth velocity m children or teenagers may occur as a result of inadequate control of 
chronic diseases such as asthma or from use of corticosteroids for treatment Physicians should close- 
ly follow the growth of adolescents taking corticosteroids by any route and weigh the benefits of corti- 
costeroid therapy and asthma control against the possibility of growth suppression if an adolescent's 
growth appears slowed 

The long-term effects ot fluticasone propionate in human subiects are not fully known. In particular, the 
effects resulting from chronic use of fluticasone propionate on developmental or immunologic processes in 
the mouth, pharynx, trachea, and lung are unknown. Some patients have received fluticasone propionate 
intialation aerosol on a continuous basis tor periods of 3 years or longer. In clinical studies with patients 
treated for nearly 2 years with inhaled fluticasone propionate, no apparent differences m the type or severity 
of adverse reactions were observed after long- versus short-term treatment. 

Rare instances of glaucoma, increased intraocular pressure, and cataracts have been reported follow- 
ing the inhaled administration of corticosteroids. 

In clinical studies with inhaled fluticasone propionate, the development of localized infections of the pharynx 
with Candida albicans has occurred When such an infection develops, it should be treated with appropnate 
local or systemic (i.e , oral antitungal) therapy while remaining on treatment v/ith fluticasone propionate 
inhalation aerosol, but at times therapy with fluticasone propionate may need to be interrupted 

Inhaled corticosteroids should be used with caution, if at all, in patients with active or quiescent 
tuberculosis infection of the respiratory tract; untreated systemic fungal, bacterial, viral or parasitic 
infections; or ocular herpes simplex 

Information lor Patients: Patients being treated with FLOVENT Inhalation Aerosol should receive the 
following information and instructions This information is intended to aid them in the safe and effective 
use of this medication. It is not a disclosure of all possible adverse or intended effects 

Patients should use FLOVENT Inhalation Aerosol at regular intervals as directed Results of clinical 
trials indicated significant improvement may occur within the first day or two of treatment, however, the 
full benefit may not be achieved until treatment has been administered for 1 to 2 weeks or longer. The 
patient should not increase the prescribed dosage but should contact the physician if symptoms do not 
improve or if the condition worsens 

Patients should be warned to avoid exposure to chickenpox or measles and. if they are exposed, to 
consult their physicians without delay 

For the proper use ot FLOVENT Inhalation Aerosol and to attain maximum improvement, the patient 
should read and follow carefully the Patient's Instructions for Use accompanying the product 
Carcinogenesis. Mutagenesis. Impairment ot Fertility: Fluticasone propionate demonstrated no tumon- 
genic potential in studies of oral doses up to 1 .000 mcg/kg (approximately two hmes the maximum human 

daily inhalation dose based on mcg/m") for 78 v/eeks in the mouse or inhalation of up to 57 mcg'kg (approx- 
imately 1/4 the maximum human daily inhalation dose based on mcg/m^) for 104 weeks in the rat 

Fluticasone propionate did not induce gene mutation m prokaryotic or eukaryotic cells in vitro No sig- 
nificant clastogenic effect was seen m cultured human peripheral lymphocytes m vitro or in the mouse 
micronucleus test when administered at high doses by the oral or subcutaneous routes. Furthermore, 
the compound did not delay erythroblasi division in bone marrow 

No evidence of impairment ot fertility was observed in reproductive studies conducted in rats dosed sub- 
cutaneously with doses up to 50 mcg/kg (approximately 1/4 the maximum human daily inhalation dose 
based on mcg/m-) in males and females However, prostate weight was significantly reduced in rats 
Pregnancy: Teratogenic Effects: Pregnancy Category C: Subcutaneous studies in the mouse and rat at 45 
and 100 mcg/kg. respectively (approximately 1/10 and 1.'2 the maximum human daily inhalation dose based 
on mcg/m-. respectively), revealed fetal toxicity characteristic of potent glucocorticoid compounds, including 
embryonic growth retardation, omphalocele, cleft palate, and retarded cranial ossification 

In the rabbit, fetal v;eight reduction and cleft palate were observed follov,fing subcutaneous doses of 4 
mcg/kg (approximately 1/25 the maximum human daily inhalation dose based on mcg/m-) However, fol- 
lowing oral administration of up to 300 mcg'kg (approximately 3 times the maximum human daily inhala- 
tion dose based on mcg/m-) of fluticasone propionate to the rabbit, there were no maternal effects nor 
increased incidence ot external, visceral, or skeletal fetal defects No fluticasone propionate was detected 
in the plasma in this study, consistent with the established low bioavailability following oral administration 
(see CLINICAL PHARfVlACOLOGY section ot full prescribing information). 

Less than 0,008% of the administered dose crossed the placenta following oral administration of 100 
mcg/kg to rats or 300 mcg/kg to rabbits (approximately 1/2 and 3 times the maximum human daily 
inhalation dose based on mcg/m-. respectively) 

There are no adequate and well-controlled studies m pregnant women. Fluticasone propionate should be 
used during pregnancy only if the potential benefit justifies the potential risk to the fetus 

Experience with oral glucocorticoids since their introduction in pharmacologic, as opposed to physio- 
logic, doses suggests that rodents are more prone to teratogenic effects from glucocorticoids than 
humans In addition because there is a natural increase in glucocorticoid production during pregnancy, 
most women will require a lower exogenous glucocorticoid dose and many will not need glucocorticoid 
treatment during pregnancy. 

Nursing Mothers: It is not known whether fluticasone propionate is excreted in human breast milk. 
Subcutaneous administration of 10 mcg/kg titrated drug to lactating rats (approximately 1/20 the maximum 
human daily inhalation dose based on mcg/m) resulted in measurable radioactivity in both plasma and 
milk Because glucocorticoids are excreted in human milk, caution should be exercised when fluticasone 
propionate inhalation aerosol is administered to a nursing woman. 

Pediatric Use: One hundred thirty-seven (137) patients between the ages of 12 and 16 years were 
treated v;ith fluticasone propionate inhalation aerosol in the US pivotal clinical trials The safety and 
effectiveness of FLOVENT Inhalation Aerosol m children below 12 years of age have not been estab- 
lished Oral corticosteroids have been shown to cause a reduction m growth velocity in children and 
teenagers v;ith extended use If a child or teenager on any corticosteroid appears to have grovi/th sup- 
pression, the possibility that they are particularly sensitive to this effect of corticosteroids should be 
considered (see PRECAUTIONS) 

Geriatric Use: Five hundred seventy-tour (574) patients 65 years of age or older have been treated with 
fluticasone propionate inhalation aerosol in US and non-US clinical trials. There were no differences in 
a[]vercp ro.rirtionc r nm|i,irpft to thosB rcported by younger patients 

ADVERSE REACTIONS " -^ following incidence of common adverse experiences is based upon seven 
plat-.-. icil trials in which 1.243 patients (509 female and 734 male adolescents and 

adulb pieviuubiy iiccitcij v/ith as-needed bronchodilators and/or inhaled corticosteroids) were treated 
with flubcasone propionate inhalation aerosol (doses of 88 to 440 meg twice daily for up to 12 weeks) 
or placebo. 

Overall Adverse Experiences Willi yZ^'o Incidence on Fluticasone Propionate in US Controlled Clinical 
Trials With MDI in Patients Previously Receiving Bronchodilators and/or Inhaled Corticosteroids 




88 meg 

220 meg 
tv<ice daily 

440 meg 
twice daity 


twice daily 

(n = 475) 

(n = 4881 

(n = 951 

(n = 185) 

Adverse Event 





Ear, nose, and throat 






Nasal congestion 










Nasal discharge 










Allergic rhinitis 





Oral candidiasis 






Upper respiratory infection 
















Average duration of exposure (days) 





The table above includes all events (whether considered drug-related or nondrug-related l)y the inves- 
tigator) that occurred at a rate of over 3°. in the combined fluticasone propionate inhalation aerosol 
groups and were more common than in the placebo group In considering these data, differences in 
average duration of exposure should be taken into account 

These aijverse reactions were mostly mild to moderate in seventy, with <2% of patients discontinuing the 
studies because of adverse events Rare cases ol immediate and delayed hypersensitivity reactions, including 
uriicana and rash and other rare events of angioedema and bronchospasm, have been reported. 

Systemic glucocorticoid side effects were not reported during controlled clinical trials with fluticasone 
propionate inhalation aerosol If recommended doses are exceeded, however, or if individuals are particu- 
larly sensitive, symptoms ot hypercorticism, e g , Cushing's syndrome, could occur. 

Other adverse events that occurred in these clinical trials using fluticasone propionate inhalation aerosol 
Vflth an incidence of 1 % to 3% and which occurred at a greater incidence than v/ith placebo v;ere 
Ear, Nose, and Throat: Pain in nasal Sinus(es), rhinitis 
Eye: Imiation of Iheeye(s) 

Gastrointeslinai: Nausea and vomiting, diarrhea, dyspepsia and stomach disorder. 
Miscellaneous: Fever, 
Mouth and Teeth: Dental problem 

Musculoslreletal: Pain in joint, spram/strain, aches and pains, pain in limb. 
Neurological: Di:2tness/giddiness, 
Respiratory: Bronchitis, chest congeshon 
Skin: Dermatitis, rash/skin eruption 
Urogenital: Dysmenorrhea 

In a 16-week study in asthmatics requiring oral corticosteroids, the effects of fluticasone propionate 
inhalation aerosol. 660 meg tv/ice daily (n = 32) and 880 meg twice daily (n = 32). were compared with 
placebo. Adverse events (whether considered drug-related or nondrug-related by the investigator) 
reported by more than three patients in either fluticasone propionate group and which were more com- 
mon with fluticasone propionate than placebo are shown belovj 

Ear, Nose, and Throat: Pharyngitis (9% and 25°o): nasal congestion (19% and 22%): sinusitis (19% 
and 22°,i): nasal discharge (16% and 16%), dysphonia (19°« and 9%), pain in nasal sinus(es) (13% 
and 0%); Candida-like oral lesions (16°o and 9°t), oropharyngeal candidiasis (25% and 19%), 
Respiratory: Upper respiratory infection (31°= and 19°o), influenza (0°o and 13%) 
Other: Headache (28% and 34%), pain m lomt (19°o and 13%); nausea and vomiting (22% and 16%); 
muscular soreness (22% and 13%); malaise/fatigue (22% and 28%); insomnia (3% and 13%), 
OVERDOSAGE: There are no data available on the effects of acute or chronic overdosage with FLOVENT 
Inhalation Aerosol Inhalation by healthy volunteers of a single dose of 1 ,760 or 3,520 meg of fluticasone 
propionate inhalation aerosol v/as well tolerated Fluticasone piopionate given by inhalation aerosol at doses 
of 1 ,320 meg tv/ice daily for 7 to 1 5 days to healthy human volunteers v;as also well tolerated Repeat oral 
doses up to 80 mg daily for 10 days in healthy volunteers and repeat oral doses up to 20 mg daily for 42 
days in patients were well tolerated Adverse reactions were of mild or moderate seventy, and incidences 
were similar in active and placebo treatment groups Chronic overdosage may result in signs/symptoms ot 
hypercorticism (see PRECAUTIONS) The oral and subcutaneous median lethal doses in rats and mice were 
>1.000 mg/Vg (>2.000 times the maximum human daily inhalation dose based on mg.m-i 

Glaxo Wellcome Inc. 
H/lade in England June 1996 RL-323 Research Triangle Pork. NC 27709 

1996 Glaxo Wellcome Inc, Printed in USA 

SER786R2 August 1996 

Monday, November 4. 3:00-4:55 pm (Rooms 1 A-B) 


Scon Fedn7.7i BVE. RRT Earl Davis. Paul Na\.inO- Buite Community College, Orovtlle, CA, 

Introduction : There n, vcr) Iitile in ihe lilcrature regunling the delivery of aeroso]i«J bronchodilator 
ucatments to p;ilienl:> on conlmuous high flow masl^ systems As such, we cJcvclopecJ a bench niixlul to 
evaluate } meihods for delivering aetnjsolizcd btrtnchodilaior via Smjil VolutiK- Nehuh/er (SVN) 
irealmenis to a sponUneous breaihing model auached to a coniinuous high flow mask system. 

S^ yjdv Question : Docs niethixl of delivery aflect mcdicalion dcsposilion' 

Methods : Five SVN's from ihe same lot were pretested for conipjrdbilitv Tlie 3 methods useJ fur 
delivery of the SVN treatments arc as follows, Method I) SVN pljcird itilinc IS' from high flow mask. 
Method 2) SVN attached lo large hore hose connector on high flow m^sk with high flow tubing placed 
thru maik entrainmcnt port and Method 3) a new method, mask on mask ihcr.ipy Md^^k on mask 
luhnique consists of using two standard aerosol masks. Mask one is placed directly on the patient's face 
with SVN connected to ihc Inrge bore hose connector. The second mask is attached to a high How gas 
source placed directly on top of the first mask Five trials for each of the three delivery meihixls were 
performed. A dnuhle sided test lung with lift bar was used to simulate spontaneous breathing One side 
of the test lung was attached to a Hamilton (rate 12/min, Vj 7(X) ml, sine wave, flow 60 I7min) 
and the other side was attached to an mlubation mannequin miended to simulate the airway of a 
spontaneously bnrathing patient. Cotton wadding was placed in a collection chamber distal to the 
mainsteni bronchi, SVN's used in each of the 3 meihods were run until dry. Albuterol drug wai 
extracted from the cotton u^mg a pn:viou,s[y described method (RespirCane 1^2 3 7" 1 233). The 
extracted solution wns filtered through a slow-flow paper filter to remove any cotton fibers or impunties 
Absorbance wa-s tneasured at 278 nm (Perkin Elmer low beam specimphotometer). TTie amount of 
albuterol extracted from the coUon was calculated based on the known standanJ Milulion {0.05 mg/ml) 
using a modification of Beer's Law, 

Results - Method I delivered 0.55% of the total dose Method 2 increased drug delivery to I 22'S of the 
total dose, .Method 3 increased drug delivery further to 2, It)"? ANOV A for repeated mea-surcs revealed 
significant differenccN between the 3 methods (p < fX>I 1. 

Menn Percent of Dose DHKered 




Conclusion : MeUiod 3, mask on mojik therapy. consistentJy demonstrated greater ilepoiilion as comparc4 
lo the alicmaie methods evaluated Based on our findings, the choice of delivery method may be an 
important consideration in the delivery of aerosolized bronchodilatot in the spontaneously breathing 
patient on a high How oxygen system It is our contention that mask on mask therapy represents a 
superior n»eihod for delivering aeiusolized medication under ihfse panicular condilions 



Billv M Lamb. BS. RJ^T. CPFT. Bmce K Rubin MD, FCCP, Albert Nakanishi, MD. 
Edmond Smith. MA, RRT, RPFT. David Gcller MD. Glennon Chiidren's Hospital. 
St Louts. MO and All Children's Hospital (DG). St Petersburg, VL 
INTRODUCTION Clinicians ha\e been hesitant to use mclcrcd dose inhalers (MDl) for 
Irealmenl of the young child based upon concerns foi pauenl ability lo cooperate and 
unccnajniy about cffccti\cness of medication delivery ,A holding chamber with mask (HCM 
AeroChambcr. Monaghan Medical Inc ) has recently been ,illcrcd with a clear body to permit 
visual corifirmation of medicalion deliver.', mask deadspacc volume was reduced and an 
exhalation \3lvc was built into the mask lo impro\e patient comfort The purpose of this 
study was to evalujic the HCM. the HCM with exhalation valve (HCMV) and jet ncbulization 
(/N) for trcaUng young children with asthma Patient comlort. asthma svmptoms. and paiicnt 
compliance were measured I he HCMV was compared to the HCM and JN METHODS 
Fifteen children ages l-o years (mean 3 ? years! seen in the emergency deparimeni (ED) were 
enrolled in this prospective nnblinded Inal Entn. into the study required an age of 1-6 years 
and a diagnosis of aaile asthma, confirmed by a positi\c response lo an imual JN treatment 
(TXl widi iilbuierol tALB) 2 5 mg in 2 cc normal saline (NS) Informed consent was obtained 
from the parent and patients were randomized into one of three groups to receive 2 weeks of 
therapy group ( 1 1 ALB 2 5 mg in NS by JN, (2i ,\LB 450 meg given by MDl with >1CM, or 
(3) ALB 450 meg administered b\ MDl and HCMV Fxclusinn cnleria patients with chest 
disease other than aslhmn patterns regularly taking bronchodilators, or if hospital admission 
v*as required Patients & parents were given a set of instructions and daily diarv' cards for 
recording medication administration and 4 point scales to record response to medication and 
asthma symptoms The parent was asked lo score how well the child tolerated each treatment 
{tolerated well, iiu Id discomfort, cried, unuiljing lo lake ireaimenl} The mean scores for 
tolerabilitv each da\ were compared using the Kruskat-Wallis test Participants were 
instnjcted and required to demonstrate the use of the nssipncd device before discharge from 
the ED and upon their return \isil Study participanli »cic scheduled for follow up in the 
Asthma Center in 2 weeks, on compleuon ol Ihe siudv RESULTS One 14 month old child 
raiidomizcd to HCMV was excluded because T\ plan was not followed Imtial asthma 
severm assessed b> ED ph\sician was similar in each group (p=0 80) There was similar 
compliance with the first 2 TX's each day but fewer reccncd the third JN TX when compared 
with the HCM deMces (p=oni! JN was tolerated less v\cll ih.^n cither HCM (p=0 01)or 
HCMV (p=0 112) The HCMV was tolerated sigmricanth better than the HCM or JN and 
(here were no differences in iioclumal asthma s^mptoms between groups (p=0 53 1 Analysts 
of patient costs lo non-stud> patients for tvio weeks of Ihcrnpv (equipment and medicaUons) 
show 3 total cost per patient of S15 yO for HCM or HCMV iherapv and S52 06 for JN thcrapv 
fJN TX require a monthU rental charge of S35) CONCLUSION These daU show that 
aerosoli/cd albuterol can be efTeclively adminisicred to \oiing children using either a MDl 
and HCM, MDl and HCMV or JN Use of HCM or HCMV is a convenient alternative to JN 
use and mav improve the compliance with the respirator, thcrapv care plan Unifomiit>, 
consistene-y and inier-rater reliability of patents* assessments cannot be assured and is a 
recognized liimlalion of this sltidv Supported bv Monaghan Medical Corporation 


MDI/HOLDING CHAMBER, R.J. Perry B.S , E.G. Langenback Ph.D. and 
S.A. Vilkun M.D. Departments o( Medicine and Anesthesiology, SUNY at 
Slony Brook, Stony Brook, NY 11794. 

Aerosol therapy has proven lo be an edective modality in Ihe treatment 
ot asthma. However, many aerosol devices are developed, bench tested 
lor equivalence with current devices and become available to patients 
without clinical efficacy data. The present study compares the 
clinically accepted Aerochamber®{AC) with a new handheld ultrasonic 
nebulizer, Ihe DeVilbiss Pulmosonic™(PS), both combined with 
albuterol and administered to asthmatics. To enter the protocol a 
subject first demonstraled a bronchodilator response of at least 15% 
(increase in FEV1) to a Ventolin®(VT) unit dose (2 5mg albuterol/ 
3ml saline) via jet nebulizer. On separate study days 3 subjects 
inhaled 2 puffs ol VT MDl (90 nq albuterol/pufO through the AC or VT 
unit dose via PS afler withholding all asthma medications for 8 hours. 
Spirometry was performed before and 30, 60, 120, 180 and 240 
minutes after bronchodilator treatment using a Puritan Bennell 
Renaissance'^ spirometry system. Pulse, blood pressure and incidence 
of side effects were also recorded. Bronchodilalion was assessed by 
evaluating changes in FEV1 using a "% possible" index which 
normalizes for dilferences in Ihe baseline FEV1 between study days. 
AFEV1%P is defined as the dillerence between the baseline FEV1 and 
each post bronchodilator FEV1 divided by the difference between Ihe 
predicted FEV1 and Ihe baseline FEV1 and was calculated lor all lime 
points. Mean AFEV1%P + S.E. at T=30, 60, 120, 180 and 240 
minutes were as follows. PS: 37.8+5.9. 45.1t6 0, 45.2±10.0, 
39.5+9.9. 33.9 + 11.7 and AC. 35.3+7.7. 38.0+7.7, 39.6+11.0. 
31.8111.6, 18.5+10.6. This data verifies Ihe effectiveness of the 
PS/VT combination m asthmatics The greater aFEV1%P observed at 
240 minutes (p=0.02, paired ttesi) in the PS over the AC may be 
explained by differences in drug dosage delivered by the devices. The 
PS nebulizer may be more effective because it delivered a higher dose 
of albuterol lo the lung resulting in a prolonged efficacy compared to 
the AC system. Further evaluation will determine if the PS will allow 
patients to maintain adequate bronchodilalion with fewer treatments 
per day. 


ARE .MDIs STILL COST-EFFECTIVE? -- Michael McPeck RRT , Deraese 
S LeBlanc RRT and Gerald C Smaldone MD PhD Departments of Respiratory 
Care and Medicine, University Hospital. SUNY al .Stony Brook 

Compared lo SVNs. MDIs are wHdely believed lo be very cost-efteclive 
because of the reduced labor component associated with iheir use However, in 
recent years, wilh the advent of TDPs. plus widespread use of spacers and 
single patient u^e peak flow meters (PFMs). overall cost comparisons between 
MDIs and SVNs should be reevaluated lo account for these added incremental 
costs The aim of this study was lo compare therapy costs of the two devices in 
a population treated wiih a TDP Methods We analyzed data from 199 adult 
general medical patients treated by RCPs with an aerosol bronchodilator 
protocol that included conversion from SVN lo MDl and adjustment of 
treatment frequency according lo a severity score folal treatinenls/palient plus 
cost of SVN or MDl vv/spacer, PFM, drugs and labor were detemiined Total 
accumulated costs for treatment by SVN/PFM only, or Irealmenl by MDI/PFM 
only, were compared Results Of 199 consecutive patients enrolled in the 
TDP, 67 were immediately dropped from consideration of MDl conversion on 
the basis of technical factors Of the remaining 1 32 patients, 109 (82 6%) were 
successfully converted from a SVN to an MDl as per protocol and received a 
median of 12 and a mean (SD)of 14 2 (10 6) treatments prior to discharge The 
cost of the initial treatment for SVNs and MDIs was $12 60 and $.30 19 
respectively However, the cumulative costs were essentially identical ($6131 
and $60 99, respectively) at the Xih treatment Beyond the "crossover point" 
occurring at the 8th Irealmenl. SVN therapy became progressively more costly 
than MDl, primarily as a function of the labor component At Ihe mean of 14.2 
treatments'palieni for example, SVTx' was 15 2% higher than MDl cost 
($103 08 vs $87 39) Coiiclusion: MDIs, despite the added costs of a spacer 
and PFM, were less costly than SVNs in our adult patients who received more 
than 8 treatments during their hospitalization Total treatment costs by either 
device are sensitive to incremental costs of supphes and labor and can be 
managed accordingly The "crossover point" analysis may provide different 
results in different patient populations, and with different combinations of 
supplies, drugs and personnel, and might therefore be a useful tool for aerosol 
therapy cost management 


Respiratory Care • October "96 Vol 41 No 10 


Monday, November 4, 3:00-4:55 pm (Rooms 1 A-B) 


01 TPl'l - Ravi Tandon MD, M ichael McPeck RR T and Gerald C Smaldone 
MD PhD Departments of Medicine and Respiratory Care. University Hospital. 
SIJNY at Stony Brook, (supponed by LH operational grant #371318) 

The measurement of output of SVNs has often been conducted by 
gravimetric methods, i e . by weighing the nebuli/ers liefoie and after 
nebulization Newer techniques determine the aerosol output directly by 
measuring aerosolized dmg or radioactive tracer ('*Tc) panicles captured on 
absolute fillers Because of evaporation, the equivalence of these methods is 
uncertain The aim of this study was to determine if the gravimetric method is a 
close measure of aerosol production under different conditions of aerosol 
generation (e g . nebulizer brand, flowraie. pressure, volume fill and 
concentration of solution) Methods We measured the aerosol output of 9 
commercially available SVNs simultaneously using gravimetrics and absolute 
fillers under standard conditions (2 5 mL volume fill, normal saline diluent, 
flowrate of 6 Umin and pressure of 10 5 - 19 psig) liach data point represented 

2 minute serial runs to the end point of dryness Ihe change in the weight of the 
nebulizer and radioactivity captured on the filter were expressed as % of the 
total originally in the nehuli/et Next, additional gravimetric and filter data were 
collected as each of the standard conditions was varied individually for each 
nebulizer Results Total weight loss for SVNs ranged fi'om 25 to 64 6"!i> 
and total aerosol captured varied from 12 6 to 38 8% While diflTerent. the % 
weight loss and % aerosol captured were closely correlated {y - -0 519 - 

6l2x, r - 922, p - 0001 ) Weight loss exceeded the corresponding aerosol 
captured by 35-40'!i Change in volume fill and concentration did not affect this 
relationship (p - 88 and 36, respectively) However, changing flowrate from 
fi to 10 l./niin significantly affected the relationship (y - -3 703 + 829x). but 
both techniques still had good corrclarion (r - 934. p ^ 04) Conclusion 
The gravimetric method of assessing nebulizer output over-estimates the actual 
aerosol output by about 35.4(1%. presumably because of the loss of solvent by 
evaporation during nebulization However, the relationship between the methods 
is predictable and appeal s unafl'ected by changing the brand of nebulizer, fill 
volume or drug concentration Flowrate alone significantly changed the 
correlation The gravimetnc method can be used as a simple and convenient 
method for predicting aerosol output in SVNs under a wide range of 
experimental conditions 


ETHANOI ,AS .A SOLVENT I yn'l'' f homas Cioodfellow Mn,-\ RRT . 
Randy De Kler MS. RRT. Vijay Deshpandc MA. RRV. Joseph L Rau, Ph D . 
RRT Georgia State University. Atlanta, Georgia 

Pui pose A vanety of filter mateiials are potentiallv available to collect 
aerosolized drug in studies of aerosol delivery This study examined the 
exiractable level of three types of filter materials Icotton. rayon, and glass 
wiwl) using ethanol as a solvent The level of extract is defined as the 
absorbance of the fillei material per unit weight (grams) with the solvent 
ethanol It was hvpothesized that there would be no significant ditVerence 
between the mean extiactable level of cotioii. rayon, and glass wool when 
ethanol was used as the solvent at a wavelength of 278 nm 

Method s Ten samples each, of cotton, rayon, and glass wool were weighed 
separately in a Mettler Af. 200 balance to ensure comparable size Each filler 
sample was then placed in a glass vial with 20 ccs of ethanol and washed for one 
minute Next the resulting solution was analyzed by spectrophotometer (Beckman 
Dl ■ 640) at 278 nm A One-way .ANOVA was used to compare the mean 
absorbance with each filter material A significance level of o 01 was used 


Mean iil2 N 

Matenal "1 (glass wool) 063176 026388 10 

Material "2 (rayon) 207.517 .099674 10 

Material » 3 icotlon) 045402 017054 10 

f he F ratio was 21 7137 at 2 and 27 degrees of freedimi. (p 001) 

Conclusions There was a statistically significant ditVerence which suggests that 
there was a significant dilTerence among the mean extractable levels of filter 
materials, in relation to the degiee of vanabililv within each matenal group 
Based on these results, cotton is a better filter than rayon or glass wool These 
results can only be genctali/ed to laboratory research studies investigating in vitro 
deposition studies when using ethanol as a solvent at a wavelength of 278 nm 





I. Fink, R Dhand, D Navcn, P Fahey, M J. Tobin 

Mines VA Hospital and Loyola Univ Chicago, Hines II, 

Differences in aerosol delivered in-vitro and deposited in the 
lower respiratory tract in-vivo may be due to the ainount of aerosol 
filtered in models that are normally exhaled by patients To 
determine the amount of aerosol exhaled by ventilated patients, we 
administered albuterol by metered dose inhaler (MDI) with spacer 
chamber into the inspiratory hmb of a wet (35'C, >99% RH) 
ventilator circuit during control mode (CMV). Albuterol deposition 
(246run) was determined at the expiratory limb of the ventilator 
circuit. An in-vitro model was used to identify drug passing directly 
from the inspiratory to expiratory limb of the ventilator circuit 
under similar condihons. Drug exhaled in-vivo (8.7 %) was greater 
than that measured in-vitro (3.9%) (p<O.CX)l). 


4.8% of the nominal dose of the MDI is exhaled by the patient. 
Subtracting drug exhaled (4%) from previously reported in-vitro 
delivery (167o) results in correlationwith adjusted deposition 
reported in-vivo (11-12%), 

In ronrlusion. adjusting in-vitro measurements for exhaled aerosol 
improves the correlation of in-vitro delivery with in-vivo 
deposition during mechanical ventilahon. nFqfilRq 

RRT Georgia State University, Atlanta GA 

Introduction; No data exist to compare the dose delivery of the prototype MDI 
spacer, MV-Aerochamber (Monaghan Medical Corp), and the ACE (Diemolding 
Healthcare Corp) Spacer device Purpose This study examined the dose delivery of 
MDI albuterol through an adult, heated, humidified ventilator circuit using the MV- 
Aerochamber and ACE spacer devices. Methods Albuterol sulfate (Proventil, Scher- 
ing) was delivered using 6 samples each of the MV-Aerochamber and ACE spacer 
devices An MA-1 ventilator set to deliver a Vt ol 800 mL, 1 o( 10/min. and a flowrate 
of 60 L'min. Ventilation was delivered to a Manley test lung (Ohmeda Corp) set on 
Cl 50. Raw through a size 8 endotracheal tube (ETT) A servo-controlled Fisher- 
Paykel heated humidifier (model MR-480) was used to provide approximate satura- 
tion ol inspired gas between 30-35 C Each lest dose measurement used 5 MDI 
actuations, and each actuation was spaced 5 breaths apart Cotton filter matenal 
placed al the distal end ol the ETT collected the aerosolized daig The filler was then 
washed in a glass vial conlaining 20 mL ol ethanol Spectrophotometnc assay al a 
wavelength of 278 nm was used to measure each sample solution Statistical analy- 
sis was then applied to the collected data Results: 

MV-AiTnchiimber ACE 

Ulul « 

IXise iincji) 

Dost 1 " . 1 

Dose< nic^ 1 




41 ^ 

41 n 

45 5 




42 3 




43 8 

30 9 





35 2 

30 1 


31 S 

35 3 


49 3 


3b '1 



43 1 



43 7 


43 1 



5 88 

4 98 

5 53 




inclusions The MV-Aerochamber pertormed equally as well as the ACE under the 
timed study methodology There was no statistical difference (p = 0,8728) 
lecled in the measure of the 6 units tested for the 2 brands using a Mann Whitney 

'^'" OF-96-05E 



Monday, November 4. 3:00-4:55 pm (Rooms 1 A-B) 

DEVICES Dcbi Hinson. RRT. JL Rau, PhD, RRT Dcpartmcnlof Respiralorv' 
Care. Gwinnetl Hospital System, LawTcnceville. GA, CardiopulmcMiar> Care 
Sciences. Ga State Umvca^it>-, Atlanta, GA 

IntroductiCTi The use of a single MDI canister for multiple palicnls using spacer 
devices may offer cost savings to both the patient and the hospital, while promoting 
direct respu-alon. care practitioner (RCP) instruction and assessment of aerosoU/cd 
medication deliver* lo the patient 

Purpose Concern for potential cross -conLanunation prompuxl a pilot surveillance 
program to assess the presence of pathogens on MDI canisters being used with 
spacer devices from multiple patients 

Methods The surveillance was m three phases- Phase I. 2 1 MDI camstcrs (6 
Atrovent. S Provcntil. 4 Azniacorl. 3 VanccnI. 2 Inlal and I AeroBid) were 
collectively used in dehvcnng > 300 MDI treatments to at least 25 different patienLs 
o\er a one week period A 'common canister protocol' was followed for these 
treatments which provides for a single canister to be taken lo a patient, the canister 
nozzle Up wiped with an alcohol prep pad, then inserted uito a DHD ACH spacer, 
and the prescnption administered The same canister was then taken to the next 
patient, and just prior to administration, the canister no/yle lip was wiped with an 
alcohol prep pad The common canister protocol was nol used for patients on 
isolation precautions At the end of the week, on July 8. t '^92 after completing AM 
tiealmcnl rounds, the 2 1 canisters were collected, each canister no/zJe lip was wiped 
with an alcohol prep pad to simulate preparation for patient delivers' and then 
environmentally cultured Phase 11 On March 1,1993, the same process as 
described in Phase I occurred with 1 8 canisters and approvimalcly the same 
treatment/patient volume, however the canister no/-/lc tips were not wiped with an 
alcohol prep pad just prior to tlic culture m an etTort to assess the potential results of 
failure to wipe the camsler no7jlc tip v,ith an alcohol prep pad pnor to patient use 
Phase III OnMav' 10,1993. the method in Phase I was repeated uuli/ing 16 
canisters whose nozzle tips were cleaned with an alcohol prep pad just pnor lo the 
environmental culture. 

Results Phase I 21/21 cultures resulted m no growth Phase 11 17/18 cultures 
resulted in no growth. 1 / 1 H culture resulted in growth of Streptococci Group D 
Entcrococcus Phase 111 16/16 cultures resulted in no growth 
C onclusions We conclude that cross contamination of MDI canisters lo spacer 
devices IS unlikely when following the common camsler protocol as described 


M W Nagel. BScV D Coppolo, RRT»". JL Rau. PhD. RRT "* 'Trudel] Medical 
Group, London, Canada. ••Monaghan Medical Corporation, Ssxacusc. NY. 
'••Cardiopulmonary Care Sciences. Georgia State University, Atlanta. GA 

Introduction The development of non-CFC propcllanl formulations for pressurized 
metered dose inhjlers (pMDIs) mdicates a need for comparative evaluation of small and 
large volume holding chambers 

Purpose This stud>' evaluated the respirablc and total dose delivered from HFA- 
albutcrol pMDI (Aironur^ 100 pg unit dose (3M Health Care Ltd . LTC)) in small (145 
mj) and large (750 ml) volume holding chambers 

Methods The respirable and total imit doses from three prc-washed AeroChamberl) 
with FLOWSlGnal'^' valved holding chambers (AC, Monaghan Medical Corp ) and the 
same number of Volumalic holding chambers {V, Glaxo-Wellcome Inc ) were 
determined with Auomir™ using an Andersen cascade impactor operated al a 
contmuous flow rate of 28 3 * 5 l/rrun One actuation from each of five prc-pnmcd 
pMDls was delivered at 30 s iniervals mio each device, samplmg the aerosol with no 
delay following Similar measurements were made for the pMDls alone The albuterol 
collected in the impactor was assayed b> HPLC 

Resul ts (a) The respirablc and total imit doses (n=3 replicates, mean + I SD) from the 
Aifonur™ pMDI alone, the AC and V holdmg chambers were as follows 

pMD[ alone 


respirablc mass + ISD 

46 .Si2 7|ig 

74 3+3 .Vg 

81 4+3 0^g 

total mass + 1 SD 

97 6r5 8Mg 

77 1+3 6^g 

83 8+4 3(ig 

Conclusions . The AC provided a similar respirablc dose to the V with 
Airomir™ (unpaired t-test, p = 056) A smaller volume holding chamber is 
therefore just as effective as a large volume chamber with the new HFA- 
formulated albuterol The available dose from both AC and V with Airomir^^ 
was more than 95% respirable (particles 'A 7 pm aerodynamic diameter) 



^'^> '^ 

























Rfspiratory Care • October '96 Vol 41 No 10 


Monday, November 4. 3:00-4:55 pm (Rooms 5A-B) 

FLOW IN THE NICl AND A SOI,irHf)N. I homus J Kallslrom 
R K I anil Robcn I. C'halbum R.R I Rainixm Hahieb and Childrens 
Hospital. Cleveland. OH Inlmduclion: II lias been a long-sianding 
convention in our NICU that -,c\f mflaling re>useilali<in bags arc readily 
accessible tor the purposes ol hand ventilating inlants I o accommodate 
this, all ot our tlowmeters attached to resuscitation bags continually run 
at 10 l.PM ol owgen Anything less than KM)';; oxygen is delivered 
with a blender In keeping v*ilh our dcparlments practice o( Irugalily. 
we sought to detennine the economic impact of this policy Methods: 
We assigned our RCl's to go to the bedside twice a day tor 14 consecu- 
tive days. Ihey were instructed to take inventory ol all bed spaces and 
to note il a bag was turned or and at what How and H02 We did not 
take blender bleed factor into consideration. If any delivered gas was 
less than IOC? oxygen, we ciilculaled the actual How ol oxygen in the 
delivered gas After 14 days we totaled the amount ol oxygen that wa.s 
actually used. An average daily census of the unit was determined, 
hrom this data we extrapolated what the wasted oxygen would be given 
the census trtim the previous year ( 1994) The amount ol oxygen that 
was wasted was calculated at our cost of S.I.S.'l/cubic loot. Because 
oxvgen is delivered in I.I'M wc converted l.PM to cubic loot using a 
conversion factor of O.O.^.S.^ Kv Results: The average daily amount ot 
oxygen that was displaced into the nursery but not clinically used was 
10!6.S6 liters per patient per day Based on our 1994 |iaiienl census in 
this unit we found that 1 1 .S.9()'s,.^ 1 2 liters of oxygen was wasted Ihis 
generated an annual cost of $I(),.1.SI Ol). Conclusion: We found we had 
significantly misspent our resources on oxygen nol ulili/ed for patient 
care. I his data was presented to our NICl ! Interdisciplinary Council 
along with a proposal that we use an a How limiting deMce (Instrumen 
tation Induslnesl Ihe device is used to hang a resuscitation bag and 
How IS only generated once the bag is lifted from the bar. presumably 
for Ihe purpose of manual ventilation Ihe cost of these were 
SI(M)(M)/unil Wc purchased these units lor each bed and wc expect to 
recoup Ihe cost of the initial investment in less ihan .> months. 



EDtjert Mpssenaer BS. RR T. Wlancel Enarekson BS, 
Alfred F. Connors, Jr . MD. ResDiratory Care Division - Pulmonarv 
Services Department. MetroHealtn Medical Center, Cleveland, OH 

introduction: The N 6000 capnometer (Nellcor-Puntan-Bennett Haywood 
CA) emplovs a disposable single patient use only" mainstream airway 
adapter iadap-uC) we sought to determine the effect of repeated clinical 
use and sterilization ot the mainstream airv/ay adapter on the accuracy of 
this capnometer Method: 30 new airway adapters were labeled and 
numbered Each adapter was evaluated using a calibrated capnometer 
which was restricted to use only for this study A certified gas 15.07% COj). 
meeting the manufacturer s specifications for sensor verification was 
passed at 2 Ipm through the adaoter via a sampling system designed to 
eliminate contamination with ambient air, and the resulting values were 
recorded After the initial test, all of the adapters were placed Into clinical 
service until cither the capnographic waveform dampened or end-tidai 
monitoring was no longer indicated Next the adapters were cleaned of 
gross matter using either a nylon tube brush or cotton tipped swabs then 
sterilized by soaking in a cold activated giuteraldehyde solution for 50 
minutes followed By a 20 minute water rinse and drying in a tube dryer 
Each adapter was tested again by the previously described method and 
the results recorded 26 of the original 30 adapters underwent 10 use- 
sterllization-testing cycles, while 4 adapters were lost or disposed of 
before completing 10 cycles during the 5 month testing period Results: 
At no point in the study did any adapter yield a CO, value outside of the 
5 07 1 0,3% range specified By the manufacturer see table below: 

Adapters n = 

26 Test gas ICO 

1= 5,07% 

Test inltia 

1 2 

3 a 

5 ' 6 

7 8 



Mean 5 13 





5.15 5,14 





High 5 3 





5.3 5.3 





LOW a9 


50 a.9 


S.O 50 





SO 0.09 


310 bio 


D,07 008 





There was no significant difference among test groups using one-way 
ANOVA (p-O 9151 conclusion Following cold sterilization, these 
disposable adapters continue to provide accurate CO^ concentration 
values, and can Be safely recycled 10 times. Further study is necessary to 
determine the maximum number of adapter reuses that are consistent 
with safe and reliable performance 



Thomas J Kallstrom RRT and Robert I, ( hathum R R 1 Rainbow 
Babies and Childrens Hospital, Cleveland Introduction: In I98.S the 
CIX' revoked iheir earlier stance against the a-priKCssing and reuse of 
single-use items However. Ihey did state that anyone who reprocesses 
single-use equipment must consider the safely and elTicacy ol such a 
practice Disposable ventilator circuits are manufactured with the intent 
thai the user will discard the circuit after one use With the lightening of 
our suppU budget we sought to ascertain il it w<iuld be sale to reuse 
these circuits We also wanted lo determine il this would result in a cost 
savings. Methods: We obtained healed wire resistance speed ications 
Irom Ihe manulacturer I Baxter) for pcdialnc. inlani and adult circuits 
All used ventilator circuits not v isibly soiled were placed into a HtPA 
rdtercd air drver Visibly soiled circuits were discarded .Mter a drying 
cvcie the circuits were placed inin plastic bags, sealed and disinteeled 
with ethylene oxide gas After disinfection the circuil resistance was 
asepticallv measured by an equipment technician U the healed wire 
circuil rcriiained wiihin tolerance it was judged acceptable for reuse. It 
not il was discarded Results: In a one year period we reused 1 ,087 cir- 
cuits. Our policv wa.s to change circuits every 7 days unless the patient 
was extubaled before this time Wc lound that there were only 4 infant 
circuits and I pediatric circuit that had failed alter disinletlion 

Reuse (annual ) 

l.->bor(7.Whrs,'yr '" SI0 74/hr,) S7.84fl 
Cleaning and slerilizalion S7.942 

Purchase of new circuits SI 2,40 (> 


No Reuse (annual ) 


Reuse costs Sl.88.*;year more than single use. Conclusions: We have 
been able to demonstrale that wc can reuse heated w ire circuits safely 
and with minimal damage lo Ihc circuit Our circuit failure rate was 
U-V/v. Reusing disposable ventilator circuits musl be weighed carelully 
in relation to the cost, inconvenience, space that reprocessing equipmeni 
entails. Also, the salct) and ctTicacy of reprocessing disposable equip- 
meni must bejudged on an individual inslilulional h.asis Ultimately the 
burden of paxif is on Ihe respirati>ry care dcpartmeni More research 
should be done as liltle can he found in Ihe lileratiirc on this topic. 



Authors linda Zimcoskv . RRT. Morris Brown. MD, 

Nadia Makled. RRT. Andiony Lawless. RRT. and Michael Chamey. RRI 

Sinai Hospital DelToil. Michigan 

BACKGROUND Today's healthcare environment is increasingly 
governed by customer satisfaction Patients with a positive experience 
lend 10 return when future hospitalizations are reqiured In this competitive 
healthcare market, most hospitals monitor patient satisfaction Our 
hospital-w-ide patient satisfaction survey asks p.ilicnts onlv one ques-tioD 
related to respiratory care serv-ices. We wanted more feedback on patient 
.satisfaction with respiratory care services Wc leport our experience with a 
new respiratory care services patient satisfaction siincy toot MF.lllODS: 
A Respir.ltory Caie Services-I'atienl Salisfaction Survey is mailed to all 
discharged patienls along vvi(h the hos-pital surv ey l*Te\iously, surveys 
were distributed by the RCP to all inpatients and collected prior to 
discharge We tl;lt patients were more likely to return candid suneys 
anonyniouslv through the mail lalher than in peison Patieiil responses 
were based on a 5 point scale rangmg from I (verv poor) (o 5 (very good), 
in SLX areas greeting introduction, coiinesy, professional appearance, 
technical skill, explanations aboui ihcrapv and timeliness Patients were 
also asked to lale the overall quality of respiratory care services 
Comments and suggestions were also solicited Results are compiled, 
presented to the department and integrated into the department Ql plan, 
RHSULl S RCPs distributed and collected surveys from January. 1993 
through August. \'")4 During this 20-montli pcnod a total of 381 surveys 
were relumed ( \^ survey^nionth) Surveys were mailed bejtimiing in 
September of 1914 For the lo-month period through December. 1995. a 
total of 852 surv c-ys were relumed (53 surveys. month) This represents a 
1 24''o mcrease in surxcy data tetiimed CONCLUSIONS Survey results 
provide valuable feedback Ui the depanmenl as a monitor of cu.storaer 
satisfaction and QI pcrtomiance improvement activities We conclude 
maihng of patient satisfaction surveys significantly mcreases survey return 
over RCP distribution Benchmark goals for these patient satisfaction 
ratings can also be established and incorporated into a departmental 
perfonnance appraisal program OF-96-073 


Respiratory Care • October '96 Vol 41 No 10 

Monday. November 4. 3:00-4:55 pm (Rooms 5A-B) 

R.O.C-? Mauo-Yina Bien MS RPT CRTT . Ling-Ling Chiang RPT RT, Jia-Homg Wang MD 
Chia-Chen Criu BS CRTT Veterans General Hospital-Taipei. Taiwan. R.O.C. 

Introduction: Home ventilatory care for prolonged ventilator-dependent patients (VDPs) 
has been implemented in many developed countries in order to improve the patient's 
quality of life (QOL) and reduce medical cost (MC) In Taivi/an. t>ecause National Health 
Insurance does not pay for home respiratory care and well-organized care system is 
locking, most such patients still stay in acute hospital or even ICU for a long period of 
time Only a small number of VDPs are cared at home at their ow/n expenses, but their 
quality of care does not be assured The purpose of this study is to investigate wtiettier 
VDPs cared at home have better QOL and less MC than VDPs cared tn the hospital 
Methods: Seventy-mne VDPs hospitaltzea in 11 medical centers and 34 VDPs cared at 
home were included The monthly cost for ward .' personnel, equipment, supplies and 
others were reconJed by U S donors Four dimensions of life quality - activity of daily 
living (ADL), family relationship, social role function and emotional function, were 
assessed by a semistnjctured questionnaire The level of ADL was assessed by the 
modified Barthel Index Scnnng system while the other other 3 dimensions were assessed 
by a 5-point Linker! type scale in which validity and reliability were tested All patients and 
care-givers were interviewed by a trained respiratory therapist and to complete all the 
questions m the questionnaire Data were expressed as mean (SD) Student t-tesi was 
used to compare the results A p value of < 05 was considered to be significant 

Medical CosI 

Hospital G'ot.p 

Home Grojp 

WardPersonnel 3370 36(1559,04} 100593;1019 98)* 

Equipments 2731 57(1761 77) 597 40( 384 09) * 

Supplies 1148 30(1317 37) 315 14(240 64)* 

OlhMS 478 69(685 50; 36( 5 61)' 

QOL Dimer^sions Hoswtal Group 

Horn* Gron; 


7729 20 (3416 28; 1919 42;12t5 95)' 

'Statistical significance compared with hospital group, 

Sarthiel ADL scwe 8 61(16 70) 

Fa>~ily 'elalionship sat>sfa=tK)n with 

famry 3 47( 59) 

spojse 3 46( f8) 

Scdal role f jncticn satisfication wrth 

•fiend 3 23( ' 01) 

leasure aclivity 2 7S( 86) 

activity level 1 23( 73) 

Negative emotion 2 954 81) 

3 85( 77)* 
3 9^0 90) 

3 83<0 71)* 
3 36(0 781* 
2 24(1 37)- 
2 44(C 58)' 


.cul sijrificjrc* corrpafOd wrth hospral graup. p<0 OS 

Although there was no significant difference in satisfication with the spouse between 
home VDPs and hospitalized VDPs the home VDPs did have better ADL score, family 
relationship, social role function and less negative emotional responses Their monthly 
MC was only 1/4 of the VDPs Conclusion: Home ventilatory care can really improve 
VDPs' QOL and reduce MC This result should encourage our govermeni to reorganize 
reimbursement and care system (or VDPs. 



Timothy R. Mvei^ RRT. Roben L, Ctuiibum RRT. Karen McDowell MD. Carolyn Kercsinar 
MD Raintww Babies & ChUdrcns Hospital. Cleveland, OR 

The purpose of this study was to dctemime the effects of an assessmeni-driven. algonihm- based 
care path (ACP) on length of stay, cost, and charges to third pany payers for children admitted to 
our hospital with asthma. METHOH: Dunng the pcnod from 10/1/95 lo 12/31/95 pauents were 
entered into the study if they were > 1 year of age. had a history of asthma, and were excluded if 
they had BPD. CF or congenital anomalies. A control group was established on a separate 
paueni division diinng the same lime span. An histoncal control group was comprised of data 
from 1/1/94 through 6/1/95. The ACP is an algonthm to treat asthma pancnts with standartlized 
assessments and therapy (supplemental onygen, albuterol aerosols, comcostcnodsj at prcscnbcd 
intervals. The frequency of the asscssmenis and/or creatmenLs was decreased in a step-wise 
manner dependent on assessment of au" exchange, presence ol wheezing, accessory muscle 
usage. oxygenaDon and FEVi . For those patients that did not respond to this standard treatment 
path, an intensification protocol was admmisteicd (high-dosed albuterol mixed with ipratropimn. 
SC cpmephnne, and corticostenods). Mean values for demographics and outcome vanablcs were 
compared with i-tesLs. Poxentages by race were compared using a Fisher exact tesi. 
Discnhuuons by seventy class were compared with the Chi Square tesu RESULTS: 
Demographic and outcome variables arc shown in the table as mean values. Companng the care 
path and matched control groups, there were no differences m dcmographK variables or in the 
distribuuons by severity class (p> 0.999j; there were 4 ICU admissions for the care path group vs 
3 in the control group, and there were no deaths. 

Matched Historical 

Control p Value Cnntrnl 


Age (years) 
SeverUy Class 






Length of stay (days) 
Hospital cosi/casc 
Pauent chargeycase 

Care Path 





p Value 









< 0001 



15 3.4 0.0005 

$1,820 $2,667 0.0016 

S3J58 S4.987 0.0042 

CONCLUSION; A care path U3 treat pediatric asthma inpaDents significanily reduced hospital 
length of slay, while alsorcsultuig in a more cost-effective use of resources, Average cosKie, 
hospital fixed plus variable cosil savings per case was S847 Esumatcd hospital cost savings per 
year (based on census of 90(J per year) is at least $762,300 PaUcnl charges to third pany payers 
were also reduced over S 1 .629 per c ase , 




Timothy R.Mvers RRT. Robert L. Chaibum RRT. Kaicn McDowell MD, Caroly-n Kercsnur 

MD, Rainbow Babies & Childrcns Hospital Cleveland. OH 

The purpose of this study was to determine the clTccis of an asses,sment-dnven, algorithm -based 
care path (ACP) on length of stay, hospital cost, and charges to third party payers for children 
admitted wiih asthma to the pcdiatnc intensive care unit (PICU) METHOD: Dunng the penod 
from 10/1/95 U) 3/31^6. 27 PICL. asthma admissions were studied Entry cntcria: > i year of 
;ige.and cither a history of a-sihmaor acute s>-mptoms of cough, whcc7C or shortness of breath 
Oxclusion criteria BPD. CF or congenital heart disease PaUenis were assigned an asthma 
severity score based on their chrome disease history, chronic symptoms, and therapeuLc drug 
usage The patients were placed on ihc care path at random. The ACP is an algorithm to u^eal 
asthma patients with standardized assessments and therapy (supplemental oxygen, altxilcrol acro- 
■>ols, corljcostcriodi.) at preicnbcd micrvals, The care path was initiated when the patients' 
aerosol frequency reached every two hours. The frequency of the assessments and/or treatment: 
was decreased m a siep-wise manner dependent on assessment of air exchange, presence of 
wheezing, accessory muscle usage, oxygenation and FEVl. For those pauents that did not 
respond to this standard treatment path, an mtensificatinn protocol was administered (high-dosejj 
albuterol mixed with ipratropium, SC epinephrine, and conicasleriods). Patients were discharged 
from die PICU at the discretion of the attending physician. LengLh of sLay in the ICU was not 
available. Mean values for demographics and outcome variables were compared with t-tests. 
Race and gender were compared using a Fisher exact test Distnbuuons by seventy class were 
uompa/ed with ihc Chi Square test- RESULTS: Demographic and outcome variables are shown 
below by count or mean (SD). Comparmg the care path and control group, there were no 
differences in demographic \anables or in the disuibulions by seventy class (p> 993) 





Age (years) 
Severity Class 













Length of slay (days) 
Hospital cost/case 
Palienl charge/case 

3.4 (1.0) 
S3.927 (S1.126) 
56.737 (S6.3(M) 

5.5 (2.9) 
57,670 (S2.491) 
513.153 (SI3,7J2) 


CONCLUSION: A pediatric asthma care path that is initiated in an ICU setting can result in 
significant decreases in hospital length of stay, while also resulung in a more cost -effective ase 
of resources. Starting pauents on a care path pnor to ICU discharge saved $2,810 per palienL 
This also resulted m a decmsc to third party payers of S5.4I>3 per paUenl. 



Andrew Egol DO . William Jovcc RRT. LisaColsky RKT. 1 Alan Fein MD, Richard Pragcr 
MD Baptist HospitaJ of Miami. Respiratory Care Services. Miarm, R. 

Introductio ti - TDP has been advocated as a mcthodoIog\ of improving distribution of 
respiratory lherap> b\ empowenng therapists to work. «ittim a protocol cnuronmeni thea-by 
achieving effiacncy b> imniniizing vanauon in ordenng practices In order for a TDP program 
to be effective, il must have outcomes at least equal to those pnor to the institution of TDP In 
addition, demonslraung cost benefit uhile mainiaming equivalent outcomes would be ideal 
The purpose of ihis stud>' was to examine whether such a cost benefit exists 

Methods- A full service TDP program was begun at a 5 1 .1 bed acute care leruary community 
hospital m March. 1995 The TDP program functions as a consultative scnicc with both 
modality specific and symptom specific protocols Nine months after beginning the TDP 
program, records from 90 patients participating in the TDP scrvnce were randomly selected In 
addition, 89 patients in the same penod of lime who were rccciung respiratory therapy but not 
participating in the TDP program were randomly selected and served as the control group 
Demographics such as age. length of sta> (overall hospital and ICUl were compared to 
determine group equivalenoi Billing information v\as obtained through the hospital's financial 
database Financial \anjbles extracted included Gross billing dotal hospital charges). Percent 
of Gross billing (percent of gross billing attributed lo all respiratory care), and Daily protocol 
charges (daily charges related to items only covered by protocol use) All of the above variables 
were abstracted and entered into a relational database for analysis Stausiical analysis was then 
performed by SPSS 7 Independent l-test anal>-sis was used to analyze all vanables 

Results^ There were no difTcrcnces between the groups in age, or length of stay There were 
differences between ICU length of stay (TDP > Noi.-TDP) These differences (wnlhoul changes 
in overall length of stay) likely evplains the differences m gross billing between the TDP and 
Non-TDP groups (TOP -$47,911. Non-TDP - 5.^4.059. p<0018) All respiratory care as a 
per«nt of gross billing was lower in the TDP group (7 52% - TDP. 14 20% - Non-TDP. p< 
0.0005) Thert was a difference of $ 1 1 f>/day between the TDP and Non- TPP daily protocol 
charges I $195/day - TDP. $31 1/day - Non-TDP. p < (1IK15) 

CoDclusioos- There is significant decrease in protocol charges between the two groups of 
$1 16/day When extrapolated o\cr the length of stay of 1 3 da>s this calculates to a savings of 
$1508/patient If 45 new TDP patienis are seen/month, this represents a savings of 
$814.320/>ear When the increased TDP cofls are factored in. the net savings is equal to 
$682,960 Howirver, ihe 45 new pauents/monlh that arc seen represents onlv a 6 5% penetration 
into the 688 new respiratory patients/ month If there were a TDP penetration of 100%. this 
savings m respiralorv cart would increase to over S12. 450.048 with a net savings (afler an 
increase of TDP expenses of $2,0(18.3481 of SIO 441. 70fi Based on this data, u appears thai 
TDP is cost-bencficial without negatively impacting outcome A larger prospective randomized 
trial would be beneficial todctcnmnc if ihisTDPcost advantage persists with outcome 


Respiratory Care • October "96 Vol 41 No 10 


Monday, November 4, 3;00-4:55 pm (Rooms 5A-B) 

Miry Beth Pan, MSN. RN. CCRN. h.l.r Millm. MA, RCT. RRT, Brad Coftaaa. 
Congem Gregg. Dan Roseobaum, John Saundm. Michael E Kalafer. MD Sharp 
McmonaJ Hospital. San Diego. CA, fnir^^t 

Transfer of long tcnn. chronic, critlcaJ care paaenli to an inlemMjiale cart unit (IMtU) 
has been demonsnated to provide a cost savings fKnegcr 1990. Elpem 1991 1- This 
abstract will review the ejpenetKes with use of respiratory inductive plethysmography 
(RIP) in a 400 bed conmnmily hospiul RIP can be used to monitor changes m breatiUDg 
rate tidal volume and Labotcd breadung index The cunvm RIP system includes a central 
sunon wndi the capacity to monltot 8 panems in the IMCU The system has been m place 
for over two yean, Original costs of S140.000 included purchase and instaUanon of the 
equipment and staff education. 

MfllloiL Daily coUccuon sheets were completed by the respiratory therapist and included 
such itetiB as reasons foi monitoring, number of blood gases, number of cardiac and 
respiratory arrests. This infottnanon provided demographic data along with potenuaj cost 
savings and quality data points. 

EialiBgi. We have momioied 181 panems for a total of 381 patient days from DecembCT 
199.1 undl January 1996. widi an average length of moniujnng of 2 I days with a range 
fnim I day to 20 days Reasons for momlonng included impending respiratory failure 
(29 9»). sleep motuionng (I7«). ventilator weaning {14 7«i. neuromuscular (12 5«1. 
nauma(7 3%) nonmvasive ventilation (4 2 * ) and miscellaneous (14 4%), The total 
number of aitenal blood gases (ABCs) was 2 1 for the 2 year penod Dunng the evaluaooo 
period there was one cardiac arrest ai«) one emergent intubation for the momtored panems 
Cost savings were calculated by comparing the average daily cost of the ICU verses the 
cost of the IMCU , Average daily cost is defined as cost of direct patient care and includes 
nursing care, ivspiratory therapy and pharmacy. Fiscal year 1994 and 1995 data were used 
to determine average daUy cost for die cost savings c<luation An esnmalod 50% of the 
panems in die IMCU would have betn housed m the ICU if the RIP system was not m 
place This was based on a 1992 pre -purchase survey of patients in the ICU who potennaity 
could have been housed in IMCU. The total cost savings is conservanve as the cuireM 
IMaJ populanon has a higher acmry dial Uwse reviewed in 1992 The total costs savings 
foi the two year period, based on the transfer (torn die ICU to the IMCU. was $74,965 
roiiclu.sion. The RIP system has enabled us to provide appropriate level of caie in die 
IMCU fiir populations who otherwise consume resources in die in) The cost savings data 
are sigmficam but also important is dK quality of care provided Widi one attest and one 
emergent inlubadon, we coiKludcd that earbet imcrvennons were look place due lo die 
informanon provided from die RIP Also, the decrease in ABGs can be contributed to 
better lespitalory momlonng The RIP system housed in an IMCU has sigmficam cost 
savings potential At fidl capacity, with 8 panents pet day. Uic potential for cost savings is 
$ I S40 300, In addiuon 10 cost savings, we have cared for patients at a lower level of care 
while connDumg lo nBmioi die respirauiry system. The task at hand now is 10 cominiie 
education and maiteting of medical and healUi care staff to increase utilijanoa 


HOSPriAL, Ralph A Lugo, I'harmD. lolin W, Salver. BS. RRT. J. Michael nean. MD 
Primiir, Children's Medical Cenler. Sail 1 ilke City, 1 "tali, 

/NTFODl'CTION: The llierapeutic role ol p.-agonisls in Ihe Ircatmcnt of bronchiolitis is 
conltoversial Studies suggest little to no improvcmenl following their use There is a 
clinical impression Ihat a subpopulaliun orpaticnis may respond. Iliiis iuslif)ing a rnal ol 
albuterol, ,Accordingly. discontiniialion of .llbuterol is warranted if no improvement is 
nolcd; however, Ihis practice is infrequently Trnplemented since albuterol is perceived as a 
benign and inexpensive drug. While the cost of albuterol is nominal, aggregate labor .ind 
material costs associated with nebulizer treatments may be significant. The objective ot 
this telrospeclive sltidy was lo determine patient charges associated with the 
administration of P;-agonisLs to children wilh bronchiolitis. In addition, we cyalii.iled the 
utili7ation and response to p.-agonists in a subset of patients and detetmincd Ihe frequency 
ofcontinued p. -agonist iherapy. despite documentation of no clinical response. 
MF.TIIOnS: Hospital Transaction data lor all palienls discharged from 1992 lliroiigh 1 99-1 
wilh the principal diagnosis orbionchinlitis were analyzed for all billed procedures, I he 
medical records of 80 noncrilically ill children, aged two years or less, svere randomly 
scleclcd from this database for analysis of albuterol iitilizarion. The following data were 
obtained: I ) patient demograpliics; 21 administration and a-sponsc to nebulized albuterol 
.administered in the emergency department I LDI; 31 adminislralion and response 10 
nebulized albuterol after admission lo the tloor, and 4) discharge with a prescription for 
oral albuterol, RESULTS: 1 156 patients were admitted witll Ihe principal diagnosis of 
bronchiolitis in die 3-ycar period Administration of bronchodilators wis the third most 
costly inlervenlion in this patient population. Ninely-two percent of patients iitili/ed Ih-.s 
intervention during their admission for a total of S190.997 over Ihe Ihree-year period, 
Sixly-lour of the 80 randomly chosen patients were tiealcd with alhiilcrol in Ihe F.D prior 
to admission, I'wenty-ihrec p.itienls (36%) were documented iioiircspondcrs lo Iherapy 
and 22 oflhese patients (96%) continued lo receive albuteiol after admission Seventy- 
one of the 80 patients received nebulized albuterol following admission to Ihe hospital, 
including both ditcct admissions and those admitted through the TD, Thirty-one patienls 
(43,7%) had no response to therapy, and in 27 of these nonrcsponders (87 1%) albuterol 
therapy was continued Fifiy-lwo percent of the documented nonresponders were 
discharged home on albuterol CONCLVSION: The cumulative cost of administering 
nebulized P;-agonisls to children with bronchiolitis may be significant. Children w itii 
bronchiolitis often do not respond to nebulized albuterol, nevertheless, therapy is often 
continued. Ihe cost of treating children with bronchiolitis may be reduced by 
discontinuing P--agonists in cases where children do not respond, 


SUCTION CATHETER CHANGES Marin H Kollef MD . Donna Prenuce MSN, 
Steven D, Shapiro MD,, Patricia Silver MEd . Darnetta Baker-Clinkscale MBA. 
Benjamin Von Harz RRT, Pulmonarv and Critical Care Division, Washington 
University School of Medicine; and Departments of NursinQ and Respiratory 
Therapy. Barnes Jewish Hospital, St, Louis. MO, 

Background: Current medical practice requires the daily changino of in-line suction 
catheters for patients receiving mechanical ventilation (MVl, However, the need 
for daily in-line suction catheter changes has never been prospecbvely validated, 
subjects patients to daily disruptions of their ventilator circuit, and may represent a 
needless cost. Therefore, we performed a prospective, randomized, controlled trial 
comparing patients receiving daily in line suction catheter changes to no routine in- 
line suction catheter changes. Method Patients were randomized at The start of 
mechanical ventilation to receive either daily in line suction catheter changes versus 
no routine changes The mam outcome measure was the occurrence of ventilator- 
associated pneumonia (VAP) Secondary outcomes incluftod hospital monality, 
duration of mechanical ventilation, and hospital length of stay. Results: To date. 
283 patients have been enrolled in the study. Patient demographics, seventy of 
illness using APACHE II. and outcomes were similar between the two study arms 

Variable No Routine Daily P Value 

Catheter Catheter 

Changes Changes 

In = 1381 In -1451 

Age, yr: 

58.6i20 5 

57,4j!_20 1 






APACHE 11 Score: 




VAP. n(%): 


19(13 11 


Hospital Monality, n(%l 


36124 81 


Suction Catheter Change 



3 4j_5,9 


Durabon of MV, days. 




Hospital Length of Stay. 





Conclusions: A practice of no routine in-hne suction catheter changes is safe and 
reduces the number of ventilator circuit disruptions We estimate that a policy of 
no routine in-line suction catheter changes will result m a cost savings of 554,000 
per year at our hospital. We recommend that in-line suction catheters only be 
changed rf they are visibly soiled or develop mechanical malfunction- 


Is a staff position 

at your facility? 

Then why not recommend the AARC 

clcissifted ad section to your 

Hunicin Resources Department? 

Simply tell them to call 

Beth Binkiey at (972) 243-2272. 

The American Association for 

Respiratory Care has the best 

classified ads in respiratory care. 



During the time you were finding out 
wliat was wrong witli tlie otiier liand-lieltl 
oximeters, we were building tlie right ones. 

Ohmeda hand-held 
oximeters. Designed to 
work the way you work. 

From full-featured to spot check 
monitoring, interchangeable 
NiCads to AA battery packs, and 
compatibility with a wide range 
of sensors, you'll find the Ohmeda 
hand-held pulse oximetry system 
one of the most convenient 
systems you've ever used. 

And the new model 3770 and 
3775 hand-held pulse oximeters 
Save Time ^nd Trouble because 
they are backed by our 
STAT Program: 

• 3-year warranty 
on oximeter module 

• 24-hour delivery 
on service loaners 

• Interchangeable Sensor 
and Power Options 

Call us to find out how Ohmeda 
hand-held oximeters can work 
for you, 1-800-345-2700. 

Dedicated to Anesthesia 
and Critical Care 

Own for 
as low as 

Meets Military Standards 81 OE: 
EC 68-2-32; lEC 529 

© Copyright Ohmeda Inc 1995 

Circle 121 on reader service card 
Visit AARC Booth) 1207 in San Diego 

TUESDAY, Novembers, i 2:4^-2:40 pm (Rooms lA-B) 


Edward Snvdcr AE. CBET. M.clutl Aniunes VID. William Holt RRT. RPFT. 
Sean Wcckcrly AE. CBFT. Dicicr Kiu, and Alan Spii/£r MD 
Thomas Jefferson University lluspilal, Philadelphia, PA 
and 1 hermo Environmental Instruments Inc., Franklin MA 

BACKGROUND: Inhiilalional nitric oxide (NO) therapy has been shown to improve 
oxygcnaiion and morbidity jn some infanLs with sc%crc respirator)' failure. 
AsiCssmcni ot inspired oxides of nitrogen is cniically imporiaiit lot response and monitoring 
loxicily. Che mi luminesce nee is a technique for monitoring NO and NOx concentrations in 
which NO reacts with ozone to form electrically excited N02. which produces a characieruitic 
luminciccnce that can be spettruscopically measured. In the presence of sigmricani 02. C02. 
or water vapor conccnuaiions. an alternative reaction pathway can Imiit die luminescent 
energy proii jced. This proccis is commonly refercd to as "quenching." and can cause an 
undetestim;trion of actual NO .«iJ NOx- In clinical apj)litations. the chemilumincsceni 
analyA'r';nrc typically calihiatcd with known concentrauonsof NO m N2. but actual 
measurements jre made in a mixture lar different than the calibration gas (usually Fi02 > 
0.90). thus iniroducing error in measured mirgen oxides due to quenching. This error caii he 
;ivcricd through calibrBnon of the analywrr under sampling conditions (high Fi02). 

METMOO: To investigate possible alterations in measurement with ihis technique at high 
Fi02. we used a c hem i luminesce nee analyzer (Model ■42H, Thermo Environmental 
In.-itruments, Franklin MA), calibrated with known NO at 0.90 FiO?. (Oxygen Call and m N2 
( Nitrogen Calj lo detect differences in delivered NO and NOx liactions. NO was delivered 
ilirough our clinical circuit, gas flow at 1 2 1pm consisted of 0.90 02. NO. wnd ilie rciitauulcr 
gas N?. Sampling of non humidified gas was performed at the same sue wiih the analyser 
calibrated in 02, ihen in N2, NO conccntraiions were viuied Irom 2^ to 100 ppm. 







A NO i NOx 


23 6 

20 6 


-14 46 


39 2 

39 3 

38 3 


-2 35 

-6 5 


60 9 





80 5 

8: 5 





100 1 




-9 16 

-1 1 48 

CONtl.l SION: Ihisdala .sPu)*s ihjl iTicjsurcmenl ul NO jnd NOx ai high F)02 uMiig .in 
;tnul>zcr L-;iIJb:ale(t with NO in N2 tan lead loan undcrcslimalion of attual NOand NOx. ;hL- 
magnilutli; iif ihc rcducuon vanal from 2.35 in 17.88 lor NO. and 6 5 10 22.29 for NOx. and 
was pri;s;n( al all LOnccnlraliuns studied. Ibis siiggChU. thai Ihc chemilumincsLCnl lechniqm' 
may ntcd lo be modified uhcn used at high Fi02 lo account for the effcct.s of quenching 


WITHOUT REDUCING Fin.-- lee U Fvsv Bs. RRT : Jon K Moon. P.nD. 
vuko S Moon. MO. PhD: Alfred L. Gest. MO: Mary E Wearden. MO. 
Texds Children's Hospital - Houston, Texas 

IMTRODUCTION ; N'tric oxide (NO) therapy fo-- the treatment of 
PPHN IS wdespread. Most institutions use a source gas of 
approximately SOOppr to deliver NO concentrations of I-30ppm 
This source gas mixture is composed mostly of nitrogen, which, 
when instilled into a ventilator circuit, reduces the delivered 
FIO-, by up to 10*. This reduction in FIOj may adversely affect 
some patients, 

METHODS: M designed a low-deadspace system to deliver NO 
•■roni a 10* (lOO.OOOppm) source directly into the mail" f^ow 
of gas in the ventilator circuit A 25ml/min nass-flow 
controller (630 Sierra Instruments. Monterrey, CA) was used 
to control NO flow. We conducted an acute toxicity trial on 
9 rabbits that were mechanically ventilated with 100* 0^ for 
4 hours Six rabbits received SOppn NO from a 10* source and 
3 control rabbits received Oj. NO. nitrogen Dioxide (NOp 
and 0, concentrations were monitored in the circuit 
Concentrations of NO we'e analyzed oy cnemi luminescence 
(42h. Ihermoenvironmental Instruments. Franklin. MA) and NOj 
was analyzed using an elect-ochemical 'uel cell (100. 
Detcon. The Woodlands. TX), 0^ concentrations were 
determined with an electrnchemical fuel cell (5590. 
hudson/RCI. Temecula. CA). Ail devices were calibrated 
according to manufacturers reconmerdations. Methemoglobin. 
arterial blood gases, heart rate and blood pressure were 
recorded ql. 

RESULTS: At SOppm NO an average of 11 +/-0.2 of NOj was 
oelerted n the ventilator c rcuit Artenal metncmoglobin 
in rabbits who receiveo NO rose by 0.5* froir baseline 
compared to a 2* rise for controls (P = 0.001), This 
difference is not s-gni'icant. Using a 10* source of NO gas 
we can deliver 1 SOppii NO while maintaining 99.9* FIO^ with 
no sign-ficant increase 'n NOj. ihere were no significant 
differences between the groups in pOj. heart rate and mean 
arverial pressure 

CONCLUSIONS; NO therapy can be safely and accurately 
delivered from a 10* ppm source of NO. Because our system 
does not reduce inspired 0, it may be app'-opriate for 
testing the efficacy of inhaled NO compared to conventional 
management . 


OF CARE William I Hnli RR I' RPKl' . Edward Snyder Ah, Jay S Greenspan MD. and 
Michael J Antuncs MD Dtpanment of Pediatrics. Thomas Jeffersoa Meillcal College 
and HospilaK Philadelphia. PA. 

BACKGROUND; Iraditional therapies such as hyper oxygenation, hyperventilauon. and 
intravenous vasodilators have had limited success in reversing persistent pulnionar>* 
hypertension of the newborn, and hypoxemic respiratory failure rhc recent introducuon of 
nllnc oxide (NOt as an invcsugational new drug for the tn;alnient ot these disorders has been 
reported to have bcnefiaal effects Several regional centers have been granted approval to 
investigate the effects of NO Some infants require emergency irarsponauon to a ternary care 
center in spite of any benefit from NO The need to continue NO therapy dunng transpon 
becomes evident, as these infants detenorate with its discontinuation We developed a transport 
NO delivery system dcscnbcd here Oxygen and NO idOO ppm balance nitrogen) in 33 ft-^ 
alutiunum tanks arc atuched directly to the transpon isolette on an aluminum earner tray. ITws 
uay has a back board with mounting brackets fur a bleed anesthesia blender. O; (Mini-Ox ill! 
and NO analyrers iDrager electrochenucaj). and an 0^ flow meter The Os line between the 
tank and the blender was fitted w idi check valves to allow lor unjnteiTu|>lcd connection to the 
ambulance Oi to conserve the tank supply The system weighs bO LB and adds S inches lo tlic 
overall length of the isolette, METHODS: Bench testing was pcnormed determine the ability 
of this system to deliver 20 ppm NO in a high O2 concentration, and to deterrmne the duration 
of the 33 ft-' tanks. Testing consiitcd of 4 one hour runs w ith a mix of 96'^> Oj. and 20 ppm 
NO. at I2LPM continuous flow The vcntiiatof 1 I*reemiccarc 200'Iranspolt) vvas set to IMV 
60. peak inspiratory pressure 40 cmHjO. and 5 ctiiHiO of PEEP Dunng each of the I hour 
trials the venulator gas was momtored at the pauenl connection of tlic circuit for NO through 
electrochemical analysis al 15 minute intervals Analysis through chenulununcsence (Thermo 
Environmental model 42H) was also performed for companson of measurements, and 10 check 
for the presence of nitrogen dioxide The electrochemical analyser was used to monitor ambient 
air 12 inches below the exhalation valve of the ventilator between circuit measurements 
RESL'LTS: The gas analysis remained stable throughout each of the 4 one hour trials, O2 @ 
96 %. NO @ 20 ppm. with no niu-ogen dioxide detected in die pauent coanccuon of die 
circuit We were unable to delect NO in ambient au The 33 ft-^ Ot tanks lasted I hour each 
with 2200 psig at die begmning of the run. Oxygen tanks were changed at 200 psig The 33 
ft^ NO tank pressure declined at rate of 100 psig per hour, extrapolating to a 20 hour tank life, 
CONCLUSION: This NO transport system has die ability to deliver 20 ppm NO in a high 
concenffalion of oxygen at a maxiinum level of conventional suppon The 33 ft- O2 lank 
provides an adequate supply ol Oo for transpon Ijom the nursery to and from Uic ambulance, 
and the NO tank provides many hours of NO even at high venulator suppon Funhct tcsung in 
the closed quarters of die ambulance is required to detennine if scavenging mechanisms are 



Chris Henderson RCP. I..arry .Schdlcnberg RRT, Wade Rich RCP. Ellen 
Knodcl RRT. University of C'.difomia at .San Diego. .Medical Center, 
Division of Neonatology. 

rahfomia/OSHA slalidaids icslnet the amount ol nitnc oxide (NO) icicascd 
into the work area in 8 hours to 2'' ppm and the :unoiinl ol nitKigen dioxide 
INO ) 10 1 ppm' I'sc of |x)tassium pcmianganale to scavenge exhaled 
gas lias proven ii.sclul dunng tran.spoil of paacnts requinng NO therapy At 
our faciUlv we have transported 6 neonatal patienti on NO usm.e this type of 
niliT altatiicd to a custom enclosetl expiratory valve This meUlod has proven 
useful when a sucdon system thai venLs to tlic external cnvuotiment is not 
availiible as may be the case dunng ambulance, tiir. or inlcr-bospilal 

We evaluated the efficiency of Pura-lTl' in the removal ol NO and NO, from 
a ceruncd NiUogen/NO mixnirc Pura fil' is a Idler material used 10 
remove coiitaliunanLs from industrial sources The illcUia consists of 
aluminum oxide spheres coaled with polasium permanganate. We 
consinKled a filter using a 10 inch by 2 inch diameter acrylic tube with 
l.V22mm :irt.iplers scalc-d on each end. Polyester fiber vv.ts used 10 
keep die I'ura-til' in placr. and a n:movablc c.ip allowed for lelillmg. To 
validate the effectiveness of the filter, we fdlcd it widi :(.«.>, 4<I0. and 60(1 
grams of media and analyzed lot NO and NO, at 3 dieiapcuuc levels plus 
800 ppm using a cbemilumincsccnt analy/cr (API. liic). At 15 liters per 
minute anil 800 ppm we measured the foLowing; 
Pura-ni" (gms) NO out (I'PM) NO; out (PPM) 

01 4.2 


0.0 0.0 

No mensurable amounts of NO or NO; wen: rclca.sed al 20. 40. or 80 ppm 
We conclude thai Puia-lil'» is a useful filler media for scavenging NO and 
NO; from vcnnlator w.lsle gas 
' Cjlilortia rode ni R(guUUt«*. Tille It 51 !5 (CalOrti.v SiindudJ) 




Respiratori Care • October "96 vol 41 No 10 

Tuesday. November 5. 12:45-2:40 pm (Rooms ia-B) 


Pure Maunce RRT.H.II W rae B Sc RRT, MilW Chn^ BA RRT tiC ( htlJrcn s Haspiiul 
laiicouwr. KFSHiifiC. Rn-aSt. ItespirainnCare Di'parmcin.y I.HC. r.xpvnmami/ \ 
Inlroduction: Inhaled mtnc oxide iherapv (r\Oi may improve pulmonan. h^pener-iion and 
vcniilaiion-pcrfusron mismatchine in The cnlicallv ill Salety sidelines Ibi safe administralion of 
INO deliver\ have c\ol\ed over the lasl few years One ofthese safety prccaulions is the need for 
continuous mcnitonny of mine oude ( NO) dosage and production of nitrogen dio\ide (NO; ) 
Electrochemical measurement technique of NO and NO^ in conjunction uith 
CNcled infant ventilators has been established as a effective methodologv during I>.0 administralion 
It has been suggested that INO ma> be a useful adjunct therapy along with high frequency 
oscillatory ventilation (HhON'i ll is unknown how eleciroLhemical NO and NO; sensors will react 
in ihisnew enwronmeni The purpose of ihi'; sludv was to bench test the ciTecK of HFOV on these 
sensors and repon .in\ ohservaiions that may be useful to reseaichcs ulilizing these r\so modes o: 
lherap> locetber Methods: A HFO\ ventilator (3 100 A. ScnsorMedics, I'SA) was used with the 
following therapeutic settings Bias flow ^ 20 Lpm, Mean airway pressuie mair.iamed between I > - 
30cmH:O. Frequency 28- 15H2, Inspiratorv time = 31%. and change in pressure (A P) 20 - S(; 
CTnH:0 \itnc oxide was delivered from a source tank (liquid Air Canada) of 200n pans per 
million (ppm) with a standard Jlow-rotometei and a double-stage stainless steel regulator Nunc 
oxide was bled intc the \ enlilator circuit just pnor to tne humidifier NO and NO: was conlinuousK 
monitored utilizing two electrochemical momlors (Pulmonox II. Pulmonox Medical Corporation 
Canadat Samples were drawTi from the inspiratory limb of the ventilator circuit lusi pnor to liie 
paiienl-wve Both analyzers v-cre calibrated as per manufacturers instructions using side-stream 
sample lechnique ai a rate of 1 50 cc mm Base line measurements of SO and NO: were made 
without oscillations at a mean airway pressure of 20 cmH^O. biai flow of 20 Lpm and 20 ppm NO 
dosaae Measurements of NO and NO: were recorded while independent alterations in mean 
airway pressure and frequency were made (2 8, 5- 7 5. 10. 12 5 and 1 ^ Hz and A P of 20. 40, b(i 
and SO cmH:0) The suggested side-stream sampling circuit was then altered by either deleting 
and'Or exchanging the following items 1 ) smail hygroscopic t'llter 2) large bacterial filter. -1) 
standard high-pressure anenal sampling line and 4) oxygen lubinc Results: There was no 
significant dItTerencc between the two analyzers (p-O 05) AJtenng meanairwa\ pressure and 
frequencv riad ro signficanl effect on NO and NO: readings (p -0 nS) ChanoLe in S P had no 
significant effect on NO:- measurements but a highlv significant (p'OO'iOl) directly proportional 
etfeci on NO readings at all levels - 20 cmH^Oand Changes were as great as 100 ppm at a A P of 
80cmK2O This could be significanilv ameliorated (p--0 05) by changing the manufacturer s 
suggested sampling svstem as follows 1 1 Adding a srrull hygroscopic filter and 2l replacing the 
oxvgcn tubing sampling line with a smaller bore high-pressure artena! sampling line Conclusion: 
This studv suggests that oscillatory changes of the A P parameter in HFOV has a highly s'gnificani 
efTect on the NO reading of this electrochemical ana]\zer We h>pothe5ize iha: the same high 
firequencv amplitudes which enhance alveolar diffusion mav indeed increase molecular acIiMi\ ir 
thedeclrochemical NO sensor resulting in abnonriallv high NO readings Hov\ever fhisobsened 
effect can be fijily ameliorated by alienng the sampling line to function as a lo» /xiss filict -/ikt 
system which eliminates h:gh frequencies with large amplitudes but allowing low sampling flows 
This study also underscores the importance of bench testing systems when diftereni modes of 
theraov and equipment are combined to ensure thai one does not adverscK affect the other 



KliewerK RRT. Hill W BSt RRT 
King Faisal Specialist Hospital & Research Center. Riyadh, Kingdom of Saudi Arabia. 
Backemand: The delivery of inhaled mtnc oxide ( NOi presents a challenge lo faalilics 
mvoKcdin therapeutic trials, because no comtrKrcial deli\ery system isvei available 
Methods of deli\cn arc generally developed and fabricated in-housc and niay differ 
significantly from hospital to hospital lo a recent cdiional in Respimtur x i 'arc. the 
"ideal" NO delivery system was dcscnbcd as follows It should 1 ) be simple and 
dependable, 2) dclivcT prtcisc and stable doses of NO, i) limit N(3: production. ^)ix 
capable of rromtonng both NO and NO: - *•) permit sca\enging of NO. and 6) maintain 
pnjper ventilator hinction Metliod: The NOPORT nunc oxide delnerv system has been 
developed by our department over a n\o year penod NOPORT is built around a 
modified cylinder truck, which prm idcs slmotiral support for .ill control and analysis 
equipment Storage containers on the can hold all ncc«sar> equipment for bedside 
ai^hcauon Two sucuon outlets and a power source arc the only penpheral 
requirements The unit is easily transported b> a single person and provides a compact 
(4 ft^' I and stable platform for bedside NO dclivcrv NOPORT utili/es inspiraiorv limb 
litiauon of NO Dunng iniemuticnl flow modes of ventilation, we use a noncompliant 
mixing chamber beivsecn the NO inlet and the humidification chamber to ensure 
complete mixing of constant flow NO gas with the intermittent gas flow of the 
ventilator NOPORT pro\ idcs continuous sidesircam sampling and analvsis of mixed. 
inspired gas b> an elocirochcmtcal NO^'O: analyser [Pulmon-n ll. Pulmonox Research 
& Development Corporauon) and a fuel cell oxvgcn anah/er Sampling rate is 
controlled bv the Pulmonox cxiernal flow contrt>l (EFC) . powered by low sucuon 
Exhaled gases are scavenged bv isolation of exhalation valvesor cxhalauon perls The 
scavenger circuit, powcitd b> -140 mmHg suction, is open to ambient air distally to 
a\ Old compromising \ cnblaior function Rc$uH4 / Experience: We ha\c used this 
method of NO delivery in ^'^ adult and pediatric patients since ffctobcr 1994 < PPHN 21, 
Cardiac surgical 25. ARDS 7 i Inspiratory limb NO.- production has been limited to f> I 
- 2 ppm at NO concentrations up to 60 ppm The highest NO^ conccntiauon measured 
was 4 7 ppm at a NO dose of 7? ppm Mclbcmoglobm levels have been less than ^''o in 
all cases We have dclivcicd 2 ■ SO ppm NO. in minute ventilation ranges from % ■ 16 
L/min in both constant flow (pediatnci & intcrmincni flow ventilators in AJC. SIMV & 
PS. PCV, PC-IRV & IIFOV modes Conclusion: NOPORT application is done at the 
bed&ide using a small number of common adapters and can generallv be accomplished in 
just a few minutes Svstem components arc easiU accessed and monitored allowing for 
ease in both applicauon and troubleshooting NOPORT has proven itself, under a 
variety of conditions, to be adaptable and technically reliable the key lo its success being 
Its e\ oluuon towards simpliaty The e\oluUon continues but NOPORT cmrcnily meets 
and exceeds all conditions of the 'ideal" NO dcUv cry s) stem 



HiIIW BSc RRT, Miller C C BA RRT Dyer D BSc RRT 
King Faisal Specialist Hosi»tal & Research Center. Riy-adh. Saudi Arabia 

Backgroand : With intcrmittcnl positive pressure venlilaiicm (IPPV). constant flow NO 
titration into the inspiratory limb of the breathing circuit might theofcticalh expose the patient 
to undeteaed boluses of NO and N02 cspccialh if longer exhalation times are used, because 
constant flow gas conanues to fill the arcuii dunng the ventilator's exhalation time Method : 
We evaluated circuit gas mixing by measunng the peak baseline ratio ( P B ratio ) on a 
capnograph of a tracer ga.s ( 5% CO: ) titrated into an adult \entilator circuit < Siemens . yottC, 
Sweden ) 9% COj gu mta used as a surrogate (tracer) lest gas in place of NO for three 
reasons : I) ?% CO: has the same densin as NO gas ( 1 (I4 g ' m " j 2) Currently available 
electrochemical mtnc oxide anal^sc^s are too slov* lo detect bolus effects ( - 90% response in 
20 seconds or less} in the f'utmonux If Pulmonox Medical Corporation, Alberla . Canada J) 
Capnograpbers are designed to delect breath to breath CO: fluctuations.! - 9t\ % response in 
75 ms )in the Sovametnx COS_\fO . Wallmgford USA METHOD: Dunng IPP\' at 7 5 L of 
minute vcnDlation. RDil ppm NO gas wus titrated into the inspiraton limb, at the ventilators 
mspiraton outlet to give concentrutions of 5 - 45 ppm NO & NO; were measured in the 
iospuaiory Urab , adyaccni to the patient v>ye 5% CO: was then dclrvercd at the exact sanK 
flowrates as the NO gas had been, and the P B ratios of CO; wcrr then measured in the 
inspiratory arcuit adjacent to the patient wye Inspiratory F\pirTilor> (I F) raPos woe set al 
I 'i. 1 2, 1 1. 2 1 and 3 1 In a second expenment, P B ratios were measured at 5 points ra the 
inspiratory limb, wiih and without a 950 mL nrcuit mixing chamber 
Itoaolts : Measured NO & N02 & NO and COi f1w%s daring IPPV ff 7. 5 L / min 

NO ppm 












U 1 


(1 7 


0. 9 

NO or CO- (tVmm) 










Figure 1 : Site of complete gas in the iD<q)irator> circuit 

normal orcuil 

Overall 1 E ratios , the mcasurrd PR ratios of CO; were I indicatmg complete gas mtxingat 
patient w-ye In the second 
expenment (Figure I ) the veniilator 
gas and the constant flow gas t5% 
CO.) were completely mixed I A » ^^ 
before they reached the humidifier coi 
.(P B ratio = I ) when the mixing 
chamber is used. Mixing occurred 
much nearer the pauem (Bi when a 
normal circuit is used 

Cooclusioo : Wc found complete mixing of the surrogate ( CO: ) gas at the patient nye under 
all condinons. simulating NO delivery up to 45 ppm Conditions thai favour complete gas 
mj.xing are lower doses of required gas rmxiure. inlroduclion of the constant flow gas before 
the humidifier, normal or imersed I E ratios ( shorter exhalation time ) and the addition of a 
mixing chamber between the gas inlet OF-96-080 

Complata mliing 

lalri RcMn-Mr Prr hitmtlirirr 

MECHAMCAL VENTILATION. Hideaki Imanaka . MD. Dean Hess. PhD, RRT. 
Mav Kirmse, \1D, Luca M Bigatello, MD. Roben M Kacmarck. Phf^. RJtT, Wolfgang 
Steudel. MD, William L Hurford. MD Respiratory Care and Dcpanmeni of Anenhesia. 
Harvard Medical Schoo*., Massachusetts General Hospital. Boston. 

Various systems to administer inhaled nitric oxide (NO) have been used in patients and 
experimental animals We have hypothesized that the Nt')dose is affected by the design of ihe 
deliveiy system, the response time of :he analyser, and the sample site We used a lung modi;! 
:o evaluate five \0 delivery systems during mechanical ventilation with a variety ol 
ventilatory patterns VIethods' An adult mechanical ventilator (7200ae. Nellcor-Punlan- 
Bcnnctl) was attached to a test lung (model 1600. Michigan Instruments) configured to 
separate inspired and expired gases Four injection systems were evaluated w ith NO injected 
either into the inspiraTory circuit QO cm proximal to the Y-piccc or directly at the Y-piecc. and 
delivered either continuously or only dunng the inspiratory phase, Attemalively, NO was 
mixed with air using a blender (Bird' 3 M) and delivered to the high-pressure air inlet of the 
ventilator NO concentration ([NO]) was measured from the mspir^iorv- limb of the ventilator 
circuit and the tracheal level using rapid (280NOA. Sievers) and slow (CLD700AL. Eco 
Physics) response chemiluminesccncc analyzers. The ventilator was set forcoi:stant-ncw 
volume control ventilation, pressure control ventilation (PCV). spontaneous breathing wiih 
pressure support ver.ti'.aiion or synchronized interminent mandatory ventilation. Tidal volumes 
of 5 L and i L were evaluated vvirh inspiratory times of 1 s and 2 s Results; The system that 
prcmixed NO proximal to the ventilator was the onl> one that maintained constant NO 
delivery reuardlesi of venlilaiorv' partem The other systems delivered variable [NO] durmg 
PCV and spontaneous breathing modes. Systems that injected a continuous flow of NO 
delivered peak |NOI greater than the calculated dose. [NO] measured at the tracheal level is 
shown below with PCV, lida! volume 5 L. inspiratory lime I s. and tai^et [NO] 20 ppm. 
These variations were not apparent when a slow response analyzer was used {thin lines) 
Conclusions NO del'ver> sysrems which inject NO ai a constant rate, cither cunlinuously or 
during inspiration onlv. into the inspiratoo' limb of the ventilator circuit produce highly 
variable and jnpredictable (NO] when inspirator\' flow is not constant Such svstems mav 
deliver a vcrv high [NO] to the lungs which is not accurately reflected by measurements 
perfomicd w nh slow response analvzers 

pm Coniinuous injcctton into 


Inspiratory' phase injection tnio 
inspiratorj' limb V-pitfce 




Respiratory Care • October "96 Vol 41 No 10 


Tuesday, November 5. 12:45-2:40 pm (Rooms lA-B) 


John Newhart RCP .. T. Wavne Johnson RCP . Richard N. Channick 
MD L'CSD Mediuil Center, San Diego Ca INTRODUCTION: We 
reccnily embarked on a study at our institution to analyze endogenous 
exhaled nitric oxide (KNO). KNO is being studied for a variety of 
itiiplieations including its concentration relative to asthma and other 
puhnonary illnesses. lo eliminate error in our studies due to ambient 
levels of nitric oxide (NO), a scrubber was fabricated to remove .NO 
from inspired gas. It is worth noting that the ambient NO in the 
laboratory was 25 parts per billion (ppb). This level of background 
NO could easily influence KNO studies if not scnibbed. METHODS: 
We fabricated the scrubber from a six inch long four inch l.D. clear 
plastic tube. We filled four inches of the tube with potassium 
permanganate pellets iPurafill) and two inches with activated charcoal 
(walnut charcoal). Ambient air is passed through the tube where 
PurafiU converts the NO into nitrogen dioxide (N02) aiid in this 
reaction most of the N02 is absorbed. The gas then Hows through the 
charcoal which absorbs the balance of the N02. To evaluate the 
effectiveness of the scrubber lOOppb and 400ppb respectively were 
nowed through the scrubber at Slpin Gas exiting the scrubber was 
analyzed with an API 200.^ nitrogen oxides analyzer (Advanced 
Pollution Instrumentation, San Diego Ca.). The analyzer's NO range 
was set on to .SODppb . '[he analyzer was first calibrated with an API 
700 Dynamic Dilution Calibrator for span. Zero calibration was done 
with a API 701 Zero Air Module. RESULTS: Data collection 
utilizing a source of lOOppb NO resulted in Oppb at the outlet of the 
scrubber. A source of 400pph resulted in .Ippb CONCLUSION: 
NO free air (less than Ippb) can be easily made with a properly 
assembled plastic canister containing potassium permanganate and 
activated charcoal. 



Robert Whilesidc BS. RRT. Kirk Lundc RRT. Jonathan Kiein MD. 
University of Iowa Hospitals & ClmiCi, Iowa City lA. 52242 
BackKround: Inhaled Nunc Oxide (NO) is a birlctlivc pulmonar, vasodilator Inhaled NO is 
administered by titrating source N()(SOO ppm) m to ihc- total gas flow of the \ennlaior circuit 
lo obtain the prescribed dose (5-80 pptr^) There arc adverse effects of inhaling excessive NO. 
thus knowing Ihc total circuit gas flow is essential in calculating the flow of ihc source NO 
Most mechanical ventilators provide a constant or minute total gas flow value However, the 
Infant Star (Infrasonics Inc.. San Dicgo. CA) has a variable and non-displayed total gas flow 
during HKV, The HrV circuit lolal iias flow must be climated 

Method: In the high frequency ventilation (HFV) mode, the Infant Star ventilator varies the 
opening of 10 solenoid valves tor a duration of 18 milliseconds to provide a total gas flow 
from 12 to 120 Lpm An estimate of the total gas flow in HFV can be calculated Kst Total 
CiasFlow - Freq (BPM) x 018 sec x Fst flow (Lpm>/6Uscc HFV flow is estimated b\ 
comparing the known range of HhV flows to the range of amplitudes mea-sured on the Infant 
Star The typical amplitude range using the Baxter ventilator circuit I'598-4HI wuh the Fishei 
& Paykel water chamber MR220 is 1 Mo 5 1 cmH^O The total estimated gas flow is divided to 
match the range of amplitudes used during HFV. llie total gas flow from the following chart 
using Ihc measured amplitude and set frequenc> is then used to dclcrmine the flow of source 
NO The NO is analyzed in the circuit. If the analyzed NO is not the dose prescribe than the 
total gas flow is recalculated by applying the analyzed NO value to this formula. Total Gas 
Flow (Lpm)- Set NO (Lpm) \ 800 (ppm) ' Analyzed NO (ppm) The new total pas flow is 
then used lo determine the source NO flow and the circuit NO is re analyzed. 

\mpliIitdc(cmH2U) 4 f Iz 6 Hz 


10 Hz 

12 Hz 1 IS Hz 

11-15 1 2 



4 1 5 


1 2 



4 ; 5 


2 3 






3 5 






4 6 






5 7 

































52 or greater 







Results; This method of estimating the total gas flow and recalculating the total gas flow 
during HFV has been bench tested using a wide range of }{F V senings The NO analy zed in 
the circuit was found to be *- 2 ppm This method has since been used successfully on 3 

Conclusions: This method provides an estimated starting point for the titration of NO during 
HFV with an Infant Star ventilator The use of an estimated HFV total gas flow can prevent 
over- or underesumattng the source NO flow titrated to the circuit at the initiation of inhaled 
NO Ihcrapv- 


DRAGER Pac It ANALYZER JoanneJ. Njcls5. BEL Michael A Becker. RRT, Ronald E 
Dechert, MS, RRT, Kenneth P Bandy. BS, RRT Deparlment ot Cnlical Care Support 
Services. University of Michigan Medical Center, Ann Artwr, Michigan 
Background: A bench study was performed evaluating the accuracy of Nitnc Oxide 
(NO), analyzed by the Drager Pac II Anafyrer (DR), using two companson methods, a 
mathematically denved calculation of the NO concentration (CALC) and analyzation with 
the Thermo Environmental Chemiluminescence Analyzer Mode) 42 H {TE) 
Methods: Two different bench studies were performed on two separate occasions. 
Phase 1 and Phase 2 Phase 1 compared NO concentrations analyzed with both the 
DR and TE analyzers to the mathematically derived calculation ot delivered NO parts per 
million (ppm) The fonnula for the calculated NO is as follows 

Delivered NO ppm = source NO pom X source NO flowrate fbml 
bias ftowrate (lpm) 

NO at a tank concentration of aoo ppm was delivered into an open reservoir (12 ft length 
o1 aerosol tubing) through which a constant bias flow of non-humidified oxygen was 
rLffining The DR and TE analyzers were calibrated according to manufacturers 
recomrDendation aixl inserted in line The How of NO was adjusted to achieve vanous 
concentrations of NO between 5 and 50 ppm Flowrales for the bias flow and ihe NO 
flow were measured using the Timeter Instrument RT 200 Calibration Analyzer The 
calculated ppm of NO and the mrasurerr^enls of NO analyzed using the DR and TE were 
documenled Twenty paired observations, CALC vs DR and CALC vs TE, were 
compared Phase 2 compared NO concentrations ranging between 5-80 ppm 
ariafyzed wnh both DR and TE analyzers NO at a tank concentralion of 900 ppm was 
introduced at the outlet ot the Bird VIP Ventilator al vanous flowrates The gas from the 
ventilator was heated and humidified (36 degrees C) The analyzers were calibrated and 
inserted m-line on inspiration before the proxin^l patient connector The patient 
connector was attached to an infant test lung with a compliance of Icc/cmHjO The 
ventilator was adjusted to deliver continuous flow, pressure limited ventilation with an 
F1O2 1 0, f 40 IT 4 sec, FR 10 lpm PIP and PEEP of 30 and 5 cm H20, respectively 
Nine paired observations. DR vs TE, were compared 

Results: All paired observattons were statistically ar^lyzed using Student's T-test, 
Values are reported as Mean ± S D Significance was reached al p <0 05 
phase 1: Companson of 20 paired samples 

CALC vs TE 30 3 +t4 39 vs 30 ± 14,16 p = 055 

CALCvsDR 30 3 ±14 39 vs 31 15 i 14 83 p < 001" 

Phase 2; Comparison of 9 paired samples 

TE vs DR 38 78 ± 24 82 vs 40 33 ± 26 24 p = 01 5* 

Experience: Nitnc Oxide fias been used m our NICU as pari of an NIH regulated 
clinical study Prior to using the DR anafyzer ciinicalfy framing and bench testing were 

Conclusion: There was a stalislKally significant difference between the CALC and 
DR NO in Phase 1 and between the TE and DR m Phase 2 While the dltferer>ces were 
stattsttcalty signrfcant, it is doubtful that they are clinically relevant The DR 
overestimated the NO levels by a maximum of 2 ppm at levels > 40 ppm The usual 
therapeutic level of NO is s 40 ppm. There was no difference at levels betow 40 ppm 


Garton. Leo M Langga. Ricardo L Pocnm, DougLis D Dcming. Andrew O Hopper Lonta 
Lirtda Umvcr5it>' Children's Hospilal. Department of Respiratory Care. Lama Linda, CA 
iKTHODlicnoN; WepreMously repwrlcd a twief (30 minutes) admimslrauoo of inhaled 
mine oxide (fNO) to premature lamtw resulted in a worsening Udal volume and d>'iiaraic 
compliance To determine if Ifus effect is sustained, wc measured lung mecfianics m 
premature UttUk randomized lo receive ctlher fNO or r»o« (Control) for four tiours methods: 
Wc studied aglti sets of prcmarure lamb twins (119- 126 days gesiauon, =-08 icnn) Anenal 
and vcrrous catheters, and tracheal lubes were placed and a modified natural surfactant 
(bcractani) given pnor 10 mectunical venulation Lsmbs were delivered, subili/ed and 
rTKxhanically venulaied for approximalcly iwo hours pnor to twseliiK lunB mechanic 
measurcmcnis One luin was randomly assigned to receive 20 ppm P^O while Ihc other did 
not for the next four hours Lung mechanic measurements - inspiralor>- tidal volume (V'tJ. 
dynamic compliance iC[,,n). rcspira(or> svsiem compliance (Crs). and respiratory system 
resistance (Raa) - were made hourly (SensorMedics 2(>i)0) One lamb died before entry into 
the studv results: There w^erc no significant differences in the lung mechatuc 
mcasuieii<eni5 between ihc INO and Conlrot groups fJaia in the table are mean ± SE al 
baseline and four hours DaU was ana[>7cd by 1-lcst for independent samples 

Baseline -Ih 

136i27 il It 1 y 

8 7 

14 31 2 I II 7± 2 5 

(mUcm IlJD/kg) 
BAscIinc 'th 

n6tO I 610 I 

8 7 

06t004 06±0I 

(mlA-m HjO/Vg) 
Baseline 4h 

I 1107 09t02 

8 7 

9t02 06tOl 

B*seline 4ti 

I27±21 12^121 

8 7 

12018 11813 

Conclision: We conclude that a four hour administration of INO does not adversely affect 
lung mechanics in preterm lambs wiih cxpcnmental respiratory distress syndrome We 
speculate thai INO may be used in prcm-ihirc infants wiIJkxjI compromising lung mechaiucs. 



Respiratory Care • October '96 Vol 41 No 10 

^Vhen Sternal infection or respiratory complication is related to 
ivound stability, the responsible choice is HEART HUGGER. 

The postoperative cost in lives and dollars is too great to risk 
pow that maximum wound stability can be achieved. 


sternum Support Harness 

Reduces sternal wound complications 
Improves patient mobility & movement 
Increases patient confidence & independence 
Faster return to premorbid respiratory levels 
Contributes to reduced length of stay 
Improves outcomes — reduces costs 
800-798-2667 • 1-408-399-5141 • FAX 1-408-399-5144 

Circle 151 on reader service card 

Tuesday, November 5, 12:45-2:40 pm (Rooms 5A-B) 

The Children's Medioil Cenlei, Da>lon, Ohio A Richard D Branson, RRT, Universm of 
Cinciiinaii McdicaJ Ccnicr. Cincimiali Ohio 

Background: The concern for proMSion of safe andeffccii\c qualii> hcalih care in an era 
ol cost conLaiiunenl has affected ho\s care in the home is provided Disposable \enliIator 
arcuils arc costl> Reduction in home care costs could be ai.hic\cd uiih less frcqucncl 
circuit changes Also to be con^iidercd is the nsi of palieni injun dunng circuit changes 
and ihe care giver's time Recent irludics document the safety and cost sanng-i in the 
hospital environment uiih \cntilaior cuout changes ai frequencies greater than 48 hours as 
prcviousK recomnKnded (CDC guidelines) No guidelines airrcntlv exisl for the frcquena, 
of circuit changes in the home cnvironmeni Puipoae: \Vc developed two survevs m an 
aiiempi lo dirtcrmmc the patterns related (o v"cntilaior circuit change frequency in the home 
Methods: Ti>u itparatc survevi vvcre mailed to home aire rcspiratorv iherapists through 
Aequitron Medical's clinician network and 10 home vcniilator users through The 
Inlcmauonal VenUlalor Users Network (IVTIV) and The CongeniLiI Central 
HvTwvcniilation Sv-ndrome Network (CCHS) In March of I W4, 4^0 sunevs were mailed 
through the clinician's network Three hundred and fifty sur\c"vs uere nulled in May of 
I9ys and m August of 14y5 lo the home ventilator users through Ihe IVUN and CCHS 
networks RfMilla: Valid responses were received from 45/277 ( l(S%) home care 
Ihenpisis Recommcnda lions for circuit change frequency were as follows 1 1 at >^ days 
to weekly. 13 at every i da\s, 14 at every 2 dj>sand 1 at 2 to .1 times per wt-ek For heated 
wire circuits, the most frequent recommendation was weekly ((> responses) Valid n^sponses 
were received from 2iiX/isi) |6(i'*oi ventilator users or family mciubers There was no 
consislcncv in the freqncTKry of circuit changes in the home The frequency of ventilator 
arcuit changes ranged from daily to every ^-4 months One hundred and twenty si.\ 
respondents reported iJie ui*; of the invasive posiuve pressure ventilation Of this group. 
the reported frequency of vcnliLilorarcuil changes is QOO (n=21). 3 times per week 
(n=27) and weekly (n-27) The lota! number of hospitali/alions for both invasive and 
iion-invasive groups witlun the past twelve months was low 7'J*''o of respondents reponed 
no hospital izanons ( IM/211K1. and 1 ''"o reponed one hospitalization (26/2tiS) during the 
previous n*el\e months Di»cuwion: The onfy published guidelines for ventilator circuit 
changes are for (hecnticnl care setting Ihe validity ol application of these standards m liie 
home care arena must be studied and documented This siirvev validates the need for 
controlled clinical trials of less frcqueui \ciuilaior circuit changes in the home 
enviromnent This survey also documents the need for useful guidelines for ventilator 
arcuii change frequency- at home We believe the low number of hospitalizations could 
indicate thai circuit change frequency does not influence infecuon rate m ihc home due to 

decreased chance of nosocomial infecuon 



C Freund. BS RRT, S l.cmer, M D . FCCP, V Urn M.D . FCCP. B Schwartz. 

MD. FCCP. J Pielilcr. MD 

St Luke's Hospital. Kansas City. Missouri 


Lung volume reduction is a surgical option for patient.'; with severe, debilitating 

emphysema thai docs not improve despite nuLumum medical treatment. Patients 

meeting acccpLince cntena are required tn undergo a ngoruus 6 week pulmonary 

rchabibtaljon program A prospective study was done to evaluate if there is an 

improvement in lung (Unction, eodurancc and subjective improvement in levels of 



Pulmonary function tests, t minute walks, anenal bhjod gases and dyspnea indexes 

were performed pre and post operauvely. 


Mean results of patients that are 6 months post lung volume reduction are bsted in 

table below 

^^nr — 


n.O;i- ■: 
CH'spnca Index 


M l.'U 
0.6 (2l)l0 6 (19)vb.8 (21))0g2 (21) I0.86 (21))<0 01 

•■ K? |2(,) 
8.12 (23) 

v> 1241 
45 (20) 

_l |1'))»3 14 (211 

: 953, (16) in? (ISJ 


+1 IS (18) 
1170 (16) 

Rrc-opjjB.jvcdcs ~\i mo Pa* ;^-.nw. PosTp-valuc'^Big 
■RTsclinc iHog'felrib PcraJLVR LVR -— i^'UrR. -'- yS-Smg'.^; 

a'a • 8" 


-4 74 (23) 

1302 -aja: 

n/a 6.44 (23; 6.48 (23) <0.01 

-■i n (24 

l348--.<}7 SOfly.» 


n/J41 (2el|4r ' ■iSZOM.OnilXi'g 

•;|J 01 



• Sample Si7£ in ParenUitsis 

P-vaiuc from stauslical anlaysis b> ANOVA 

A positive change in DI over ba.'iclinc indicates a pert 

\cd improvement in overall 


Lung volume reduction surpcrv doe.*! contribute to an inipiovemcnt in lung function 
and endurance in the first (> months Continued evaluation of Ihis data would be 
helpful in detemuning rhe lon^ term benefits of tlic surgerv' 


OUTCOMES :N severe COPD ?.\TIEMTS using .1 10-DAV ?-JL.MON'ARY 

J. Bouen 3.S., C.R.T.T., C. 'JollscliLager M.D., P. Scalise M.3., 
D. Gerardi M..N.. J. Vol:to D.D. Hospital for Special Care, 
New Britain, CT, University of CT School of Medicine. 
Fannlngcon, CT, U.S.A. 

With managed care and capitation now dictating reimburse- 
ment, the ability to be able to provide efficient, effective 
and quality patient care has become crucial. Since May of 1995, 
Che use of a 10-dav critical path in our comprehensive, rcultl- 
disciplinary inpatient pulmonary rehabilitaticr. program (PRP) 
has allowed us to achieve this goal. (Random chart audits of 
fifteen prior PRP patients resulted in a compilation of 
supportive data to base our 10-day critical path on.) Patients 
admitted to our PRP have advanced COPD (FEVI, less Chan 50J; 
FVE, less Chan 2.5 Liters). During its first year in use, 
forty-five (45) patients have successfully completed Che PRP 
using the critical path. We have been able Co document both 
objective and subjective benefits. The path has been utilized 
as a benchmaris for rapid evaluation of patient progress. It 
has resulted in Che delivery of quality patient care and has 
facilitated a true team approach, by the professionals who 
deliver the care. Continuous outcome monitoring (i.e., variance 
data) is simplified by the critical path worksheet and allows 
us Co adjust the path as necessary. 

') of Pacs. 



12 Mln. 
A p PRP 

" D/C to 

Before Path 
Apr. 1994- 
Mar. 1995 


:0 days 



After Pach 

Apr. 1995- Aug. 1995- 
July 1995 Jcc. 1995 



6 davs 


Nov. 1995- 
Jan. 1996 

a days 







E.K.Shikhmirzaeva. A.P.Zilber 

Petrozavodsk University, Petrozavodsk. Russia 

We evaluated the effect of special respiratory muscles training on 23 
patients with chronic obstructive pulmonary diseases on lung functions 
and central neural regulation of breathing in comparison with 37 
nontrained patients and 48 normals 

Changes and correlation oi pulmonary mechanics tests (parameters 
of MEFV curve and respiratory resistances), inspiratory (Plmax' and ^^^ 
piratory (PE„„) muscular efforts and neural respiratory drive (P|oo) 
were compareif A special method of occlusion pressure measurement 
was worked out for simultaneous noninvasive determination of all these 

The results of the study showed that the initial level PIm„ and 
PE^3j, in patients without training were lower PL^g, in patients and in 
normals were (M±m) 56,67±8.1S and 106.38±8,48 cm HjO respec- 
tively In the same groups PE„„ was 10O.27±14.26 and 180,74*12.56 
cm HjO 

Neurorespiratory drive (P|oo) increased in keeping with the decrease 
of respiratory muscles efforts, and in the same group it was 3,36*0,34 
and 1,35±0.'22 cm HjO respectively 

A special 3 months training of patients by using calibrated artificial 
resistances improved all parameters of ventilation - respiratory 
muscles efforts, neurorespiratory drive and pulmonary mechanics After 

the training PI„ became 89±8.4. PE„ 

1I4.4±I7.3. P|| 

3.1 ±0,27 cm H2O Parameters of respiratory mechanics improved by 

The best correlation was observed between P|no (neurorespiratory 
drive) and PI„,, (r=-0,68), VC (0.65). FVC (■0.63). Rrs (+0.63). 
FEF2S/.5 (-0.55). and Raw (+0.53) 

It is evident that all studied mechanisms of respiratory failure are al- 
ways interdependent By influencing one of them (in our study - mus- 
cular efforts), we can improve others The special training of respira- 
tory muscles is quite an effective noninvasive method of respiratory 
care to improve not only respiratory muscles activity, but the neuro- 
respiratory drive and mechanics of breathing 

the individual selection of a training regime allowed not only to im- 
prove the effectiveness oi the method, but to make the training more 
pleasant for patients 



Respir.atory Care • October "96 Vol 41 No 10 

Tuesday, November 5, 12:45-2:40 pm (Rooms 5A-B) 


AUTHORS WTPcnj7Zi_MD, ML AiUt \\D. ML Franklin Ml) TA 5k>ndergeld RR 1 

PR Me>cr MD. RD Cane MD. BA Shapiro MO 
AFFILIATION Depannicnt of Anesthesiolog). Nortliwcsicni Uni\erstt\' Medical Scliool. 

Chicago. I L 6()61l(Res Gram « nn:>M-<-iiKH)8) Recogmiion lo The 

Fninkei Foundation 
Inlroductiun: Using roentgenographs to e\aluiite the presence ofpulnionan abnoniialilics 
such as alslec(.isis and iiifiltr:itc5 is a common practice Bedside parameters such as \nial 
c;ipacit> (VCI and negative lospirator^ force (MP) been used to assess Ihe abilit) to 
iniiiaie a deep breaUi prior to a coujih Since these parameiers reflect onI> the iimiaiion of 
the cough response other factors such as the abilm to generate posiUve airwav pressure 
remain unmeasured Spinal cord in)uries (abo\e the Uinibar level) nu> interfere with ihc 
.ibihiN 10 generate enough positive pressure Therefore, we h>poU»csizcd Uial forced 
expinilorv pressure inea_surenicnts (FFP) ina> be a better predictor of llic spinal cord in|ur> 
patients mabiht>' to pariicipatc in bronchial h\eieiic thcrcb> le;idmg lo atelectasis and'or 
inlillrates on chest \-Ta\ ' Methods: IRB approval was obtained, and all ummubaled 
paltenis ndniincd to our spinal cord injun mlensne cue unit in a twehe monih period 
were approached for consent D:iil\ me;isure incuts of VC (ni&isurcd by Wnghl spirometer 
model #"'(H)-n3(i). K-.H and \IF (both measured b\ Boehnnger manometer model W41001 
were obtained for a nia\imum of 5 consecutive da\s in enrolled patients Chesi \-r.i>s were 
obiamed and read b> blinded attending radiologists when clinically indicated over the same 
consecutive davi I he average VC. FFP, and MF values were then compared between iJie 
iwo toeutgeiiograph groups classified as either absence (CLR) or presence (PCS) of 
atelectasis and/or infiltrate Statistical analysis was then pcrlbmied using an unpaired 
Student's i-tesi Results: Sevenry-six pauenis wiih vaning levels of cervical and ihnnicic 
injun consented for enrollment in the srudv A total of 123 chest \-rays were evaluated 
The table demonstrates Ihe differences in respiratory parameter values between the two 
roenigenograpli groups Conclusion: It was our original hypothesis tiial FEP would best 
predict an effecUvc cough However, our data do not snppon this hypothesis We have 
detQomitrated thai VC is a better predictor of roentgenograph ev idence of inadequate 
bronchial hygiene Mcisurements of airvvay pressure changes may be unreliable indicators 
of cough elTecuveness because these factors indicate only respiratorv muscle fimcuon VC 
IS- however, dependent upon botii fespirafor> muscle (iinetion and functional lung 
parenchvma Thus, vilal capacity iiiav be the most sensitive indicator of chest \-rav 
abnormalities in this palieni population 

X POS (n=35) 


S CLR (n=88) 



VC 1400 





FEP 76 





NIF -84 

rT4i I" 




' Shapiro BA et al Clinical Applicilion of Respiralon Care. 4lli ed , wyi. pp 448-45: 



Karen M. Pfa». RN . Philip J. Savage, CRTT, Larry E. Johnson, MU. 
Ph.D., John R. Kues, Ph.D., Franciscan Home Medical, Cincinnati, 
OH 45247. This study was conducted to validate the .MEM in measuring 
cUent or caregiver knowledge and ftinclional abilities to accurately and 
safely manage Ilie home oxygen equipment. The ATF.M addresses the 
standards for assessment defined hy JCAllO, including knowledge ol 
liter flow, hours of daily use, oxygen safety and emergency procedures, 
equipment maintenance and storage, use of back up supplies, and 
equipment malfunction. Five regional home c:u-e companies participated 
to recruit 70 client subjects. All were first time users of home oxygen 
concemrators who had no preWous experience with the equipment, 
hospice clients were excluded. All participants were interviewed twice 
during in-home visits by different employees. The tirst assessment 
occurred within '.'-5 days of the initial home set-up; the second followed 
an average 3 .' days later The clients were randomized lo receive initially 
either the A FHM or Ihe standard company documentation lorm Tlie 
second interview then used the remaining method The standard 
documentation was then independently scored using the Al EM format 
Results: The .ATEM provided useful information 98 4% of the time, the 
standard documentation methods were much less thorough, providing 
information required by JCAHO only .3.4% of the time The A I EM also 
identified high-risk situations related to equipment management 94 I % 
more often llian current documentation methods. Conclusion: Use of die 
ATEM greatly facilitates documentation in all categories required for on- 
going care by providing both visual cuing and well defined cnleria for 
scoring. It more accurately and completely assesses client/caregiver 
knowledge and functional abilities. The sttidy is now expanding with 
more clients to determine how well it identifies risk over time and directs 
appropriate intervention. 


Sleptianie S. Dichl. RRT. Ktnl L Chnslopher. MD. RRT Denver, CO BACKGROUND: A 
new demand (n>gen delivery system (TX)DS) has recently been mlmduceJ The demand oxygen 
conuoller (IXX":mXI TranMr,«.hcal SyMems. Inc.. Englcwood, CO) uses a pres,sijit iransducer 10 
sense inspiratory effort A bolus of 18 lo20mlofO2 is administered per breath over a 
selectable inspiralory ume (IT) of ,5 lo 1 .5 seconds, A toggle switch selects conunuous or 
demand flow. In contrast, the OxymaLic (CHAD Therapeulics, Inc . ChaLswonh. CA) DODS 
delivers a constant solume of 16,5 ml wiih an adjustable pulse delivery/breath rauo (1:1, 1:2, 
1:3. 1:4), Tlic purpose of this study was lo evaluate the adequacy of Sp02 utilizing the 
DOC2000 wiih both nasal cannula (Ts'C) and uanslracheai oxygen (TTO) dunng nssl (R) and 
exeruon (E), METHODS: Ten subjects with chronic hypoxemui secondary to C0PD(9) or 
I1,D(1) were studied. All subjects had a mature TTO trait, and R llowsof 1 to4Ummwilha 
mean TTO durauon of 22 I months. Baseline studies iniluded spirometry and room air ("RA) 
Sp02 measuremenLs TESTING: Individuals were iniually placed on conunuous (low (CF)NC 
and utraltd lo an Sp02of 92-94% (Ohmcda Biox 3740, Louisville, CO) and Sp02 results were 
downloaded to a stop chart recorder (B Braun MeLsungen AG, Germany} ABG's were 
simultaneously obtained toa.ssess ihe Sp02and Sa02 relationship Each subject was tested on a 
differeni [X>C20Cin unit connecled 10 a single liquid system (Companion I , Puriian Bennell, 
Indianapolis, IN), The system was filled at least l.'i minutes prior lo use and the accuracy of flow 
rates was documenied with the use of a calibrated mlameler CFishcr-Poner. Warminster. PA). 
The subjects were then ambulated at their normal pace on level ground for 180 feel, E CFNC 
rates were titrated in an effon to mainuun an Sa02 90-92% Similarly, R and E titralions wiih 
DOC2000 (IT of 5. 9 and 1 , 5) were done wiih NC and TTO In ihe eveni ihai an adequale 
SpO2l>90% al resi and iR8% wiih Ejwas not achieved wiih maximum flow selQng.s(R L/min) 
on the DOC2000, protocol was rrpcau^d using Ihe Oxymalic at maximum delivery (1 1), As per 
manufacturer's rccommcndauons. the Oxymatic was used with compr&ssed gas 02 and 22 psi 
regulator. EXPERIENCE: Both authors have exiensive clinical and research expenence with 02 
dependent patients as well as several pulse devices RESULTS; Results (V^SD) .showed severe 
hypoxemia (RA Sp02 x 87%+2 21, The group's mean age was 7-t 2 years and included 4 
women and 6 men The Sp02 correlated wiUim I -2% of the measured Sa02, Spirometry showed 
severcimpairmenlofFEVl (1 10L± S) and FVC (1,97L±6) Dunng R conditions, Sa02 was 
adequate wiih CFNC (94%i2). CFTTO (97%±2). and DODS 11 of 5 (NC 93%±1 .5, TTO 
95%±l-5), 9 (NC 94%«;1,I, TTO %%±1.S). and 1,5 (NC 94'"iil,6.1TO 95%+l 6), Of note, 
R flow settings with DOCJOOO did not need lo be mcreascd Throughout E. Sa02 was adequate 
(>88*) in 9 of 10 subjects CFNC t''l%+2). CFTTO (9S%+ J,2). and DODS 5 (NC 9l<;fi2,3, 
TT093»+2 2). 9 (NC <)2<ii± I 8, TTO 93%±1,9). and I 5 (NC 92%±2 5, 1T0 93*±2,a). 
Flow seaings generally needed to be increased. In the lOlh subject, Sa02 was adequate with 
CFTTO but inadequate with CFNC. DOC20O0 and Oxymalic CONCLUSION: Dunng R 
condiuons. Sa02 achieved wilh DOC2000, with a vanely of IT. was cxjuivalenl lo CF sciungs 
wiih both NC and ITO, Generally (9 of 10 subjects) adequate Sp02 was achieved wilh Ihe 
tX)C2000 but flow rales were increased 1-2 L/min One palicnl wiihouladequau: E Sp02 values 
on CTNC (1 of 10) was not adei|ualely oxygenated with either D(X'2000 or Oxymalic We 
suggest that R and E Sp02 Ulralion should be performed when considering a DODS, 


Allen G Kendall RRT . Arlcnc Wenzel RN, Peter C Gay MD Mayo Foundation. 
Rochester, Mn 55905 

We have seen an exponential increase in the use of NAV in the hospital setting and 
have now adapted our pracUcc to lake advantage of a therapist-dnvcn protocol 
Several reports have documented the results of NAV therapy in the acute care setting 
but bttle mformalion is available rcgardmg the follow-up of these patients beyond the 
ICU and following dismissal from the hospital Wc rcutmcly monitor paucnt care and 
outcome with a non-m\asivc ventilation rcgistrx and now report our most recent 
results over the last 5 months The registn. includes informauon regarding pauent 
demographics and diagnosis, resuscitation and previous mtubaUon sutus. venulator 
settings, nasal vs ftill-facc mask use. length of tunc on NAV. and outcome The 
present patient populaUon of 46 pts includes 26 males/20 females with a mean age of 
65 6 VTS (range 17-92 vrs) with the following diagnoses COPD- 2.5 pts. 
neuromuscular disease- 5 pis, obesity hvpoventilation- 5 pts. cancer- 5 pts, 
kyphoscoliosis- .3 pts, other- 3 pts There sserc 20 pts who were prmously intubated 
dunng the present hospital admission and only 12 pts were a do not resuscitate 
status " The mean inspiratory and expiratory pressure scHulgs were 118^26 (Std 
Dcv) and 4 6 + 16 cmH;0 rcspecuvely There were 45 7»o of patients that used a 
triggered mode onlv while 54 3% also had a timed machine rate A full face mask was 
utilized by 64 3% with the remainder using a nasal mask The mean actual NAV use 
was 27 8 + 26 5 hours over 3 7 -i- 4 days dunng a total of 16 1 + 14 8 hospiuil days 
After dismissal from the ICU, 13 pts continued nocturnal or periodic daytime use of 
N.AV and 9 pLs were dismissed with equipment for home use During the hospital stay, 
there were 25 pts who were either stabilized or unproved and 21 pts either refused to 
continue (12 pts) or tailed the therapy (9 pts) with 8 failed' pis opnng for intubation 
Four pts expired in the hospital and 4 additional pts were not alive dunng our post- 
hospital inquirs' penod Nine pts continued post-hospital use of nocturnal NAV and 
28 of the 42 pts mth follow-up contact are either stable or improved since discharge 
For the COPD subgroup. 50% were stable or improved with NAV 20''o required 
mmbation Wc conclude that only 19 6% of pts actually failed NAV therapy and 2/3 
of patients mtroduced to NAV for acute respiratory therapy continue to be stable or 
unproved after discharge from the hospital The refusal to continue NAV therapy does 
not ncecssanly portend a bad prognosis, as 8 of our 12 refiising paUents arc stable 
since hospital dismissal We continue to utilize this therapy for patients with acute 
respiratory failure and hope to use the registn, to clanfy indicators of success for 
patients usuig NAV OF-96-135 

Respiratory Care • October "96 Vol 41 No 10 


Tuesday. November 5. 12:45-2:40 pm (Rooms 5A-B) 

Vacciro, BS. RRT Hcrberi Palnck MD Susan Ha\-\\oocL AS RRT lohn Schmiiie MD 
Vijiiy Njdipclli- MS. DeparlmcnLs of Rcspiralon Caic ;ind Health Polic\.'( linical Oiiitomc. 
Thomas JcfTcrson LnixersrU Hospital Int . Plulacklplua PA 

rntrodiiclion and H>iK>lhesi\: Hospice programs otTer a cost cffccliNC alitriiali\c method of 
care for icrminaliv ill patients uith appro \i match si\ months to live Wc iniiialed a project lo 
dcccmiinc uhich poraiiicicrs idciilify «.hori term prognosis, 1 1 , si\ months. Tor oulp-iiicnis uitti 
ad\anced COPD Method Wc selected lifiecn COPD p.iiienis wiiii sc\cn; VOVD b\ FE\' and 
\Mlh past medical raordi a\ailable Tor a nuninium ottwo \ears l>.itd was obtained b\ both a 
rctruspcLtnc than analysis using hospital and otTicc records and a prospcetnc stud> lasting six 
niomlis from March lo August I 'J'J*i Ilie patients were divided nito lv\o groups according to 
wheihcr tlic\ v\crc living or expired b\ the prospccuxc siudy cutoff ditc Patients received a Sl- 
36(qualit\ of life) questionnaire and karnofsk> Scoring Scile (i)-lill». UH) is normal daiK 
function) «iih the prospecn\c chnical obscr^allon 

\ jrijhie 


1- \|>ircd 

|i \ alue- 




Age. Mi 

7; s » XI. 

O'J 1 • UK. 


Sc\ ,n 

Male ! 

Female 5 

Male 4 ' Female ' 

Race n 

Call 2 

Can ^' 

Cau i 

Can 2 

Afr.Mn 1 

.\rr Mn 2 

Afr Am 1 

ATr Aincr I 

Owiicn Usage 



U 2U 

n V "„ 

18 ') I 20 :. 

27 6 ■ 5 4 

(1 m 

lnp( Xdm / vr 

2 11 = 1 611 

871 i5 11 


Oulpl Vvsils/it 

19 5 = III' 

15 1 s 114 

11 21 

t R VisiLV V r 

24 I i-J 

84 ±6 1 


Diurt'Uc Lsa^c 

1 NX :^ 1 80 

1 2') i: 1 38 


Digilalis l.sjge 

IK,'. 1 1 7(, 



AiUibiiMic IJsjgc 

1 88 . 1 46 

1 2-) I 1 ?8 



62 51 1 ■> 6 

76 ' i 1 4 '1 

II 18 

l-Iesl e\Cfpl o.wgen usage from Fisher c\ael. p^ n Ii5 is sigmncani 
Results Palients are di\ ided Iri clinical slatus group nuti data sliou ii as mean . S D Ihrec 
paticnis cspircd before imlialing Ihe prospcclne sludv and four p;ilienli espiied during Ihe 
prospective stud> llie F'L\ , and o\>gen us;ige was iiol sigititicanlh Uinerenl in pulienls who 
expired The SF-16 testing disclosed no signifieanl diffcrxince bch.een [he two groups, although 
both were bclovv L S potxilation norms The mean number of inpiitienl admissions-'\ r ip- Ii07) 
and Fmcigcncv Room visits'. r ip- 02 > ucre significanlK .^ealer in palienis ..ho expired 
Cunelusion 1 lie increased use nl hospital scrv ices and not the pli.sioiogic variables such as 
M;\ and owgcn usage offers a predictor of SIX month terminal status A larger studs is 
indicalc-d lo belter define six iiionth prognosuc factors m Ct>PD patients M frctjiienl 
liospitali/alions or eniergcnc. care begin to occur, more cost efTecli.e supponive care 
allernatives such as hospice care ma> need lo he considered 

Sponsored in part bv Vitas Healthcare Corporation 



lames B. Fink. MS. RRT .. Hines VA Hospital aruJ Loyola Lniv. 
Chicago, Stritch School of Medicine, Hincs IL. 

Several devices have been recently approved by the FDA for use 
in airway clearance with scant data demonstrating physical effects of 
the devices on airway and lung mechanics. AARC clinical 
guidelines for Positive Airway Pressure identifies fixed orifice (FO) 
resistors as the mechanism used to apply Positive Expiratory 
Pressure (PEP) The aim of this study was to compare and 
characterize three fixed orifice resistors marketed as PEP devices The 
Resistex (Mercury Medical), TheraPEP (DHD) and VVestmed PEP 
(Westmcd) resistors were attached to a CP-IOO Pulmonary Monitor 
(Bicore) to determine effects on airway pressure patterns, peak 
expiratory flows (PEER, L/min), peak expiratory pressure (Pcxp; 
cmH20), work of breathing ( Wpt;Jottle/L), pressure time product 
(FTP) of passive exhalation (Vj 500 ml, PIF 40 L/min) simulated 
with a test lung driven by a mechanical ventilator. A comparison of 
the devices' largest (L) and smallest (S) orifices are showm below; 





Resistex (L) 





Resistex (S) 





TheraPEP (L) 





TheraPEP (S) 





WestMed (L) 





WestMed (S) 





Range of PEER, WOB and PTP differed between devices (p<0.05; 
ANOVA). Pexp was lower than recommended therapeutic levels of 
10 - 20 cmlijO for all devices studied Passive exhalation, as 
simulated, may not be adequate to generate therapeutic pressures 
with these devices. 

In conclusion, there are signficant differences in the ranges of 
flow restriction with the tliree fixed orifice PEP devices studied. 


CYSTIC IIBKOSIS POR'LATION- Ilawn M (iei,u.]ue. RRT. MjUjlKJ. JaudhanH, CRIT. "PPT- 
,\llT<d 1 duPonI [nslilulc Thomj. JeffcrsiHi Medical llnivcn,i[y. Wilnnngliin. IJI; .'-1K99 
Previous sludics have shown thai the Seandiphram FluUer^ auxvjy elcaranec ilcvice ha. increased 
the ability r..r cystic fibrosis patients to exp^clcralc mucus However, studies to show the effect of 
the Flutter dcvic-e on puhnonary function amonp Ihe pediauic cystic fiHrnsis palicnis arc linrncd 
METHODS: The long tcmi cffecl of :be Fluner™ devKe on Puhnonaiy Function Tests IPFT.) 
contpard u. rlhcr ai.-way clearance technique, .uch a.s Chcsl Physiotherapy (CPT) and Vital Signs 
Ills ytHHtPfiFP^ Posuive Expirau.ry Pre.siirc (PKP) Ihei^py. were studied ujnong 15 cysuc 
fibmci. patient., ages 5 17 with mild lo mixlciaic disease Of ilic 15 jialicnl. thai qualified for the 
study 5 were excluded due to hospital admi..ioo for acme pulmonary cxaccrbauon 4 wilhdicw 
themselves fnan the sludy and 6 conunucd through the study Fach palieni served as then own 
control thmughoat the study The paucncs were evaluated jsing McdGiaphics 10H5D Body 
PIclhsinograph Unit and PIVTH Pulmonary Fur.cDon Sy sum"** (PITsial ihe beginning and end ot 
each new therapy fhc darauon of each therapy was 1 month AliMig with each PFT a respiratory 
a.ssc..incnl was nhtamcd which uicluded Respiratory rau. oxygen saturalioij. produetivc versus 
nonpnxjucuvc cough, mclications. breath sounds and general comments 

RESLT-TS; tXerali. none of the respiratory assessment parameters changed between the therapies 
soidied All patients that used the Flutter device preferred it over (he other 2 therapies The 
pauent. slated they tell cluliCally better, were able to expectorate more mucus easier and fell more 
ui ol ;.-,eu mctapic. Pair T Test slaUslical analysis Ihe PF1 ddUl, indicated no ehangcs in FFVl. Fl:r25 75. Raw or .Ciaw among Ihe 1 Iheraine. studied 


MEAN STOV :CPT 5,6 28.7 














21 7 


■Jl'' aT"- 1 












COlVflaUSlON: Allhougb previous studies have showr. an incrcAsc nmoiini nf tnucu-* 
cxpccioraUi>n uMng the Flutter device, this Mudy ha shewn nr significant change in rcsinrali'r^ 
d.\sc-\^meot piramctcfi ht pulmonary tuncQon over Ihe tonne o;' the Mudy l-tirihcr *iudics aft 
»*;irTanled involving nuiltii; enter tnal; 10 evaluole the effects of the Rutu:! device ixi puli»iiii«r> 



Tctsuo Miyagawa.RHTRPT RCET, Fumthito Kasai.MD. Masazumi Mizuna. MD, 
Yoshia<i MoriMD, Dep'. ol Rehao Wed. cine, Showa Univ Schooi ol 
Medicine. Tokyo, Japan Shmn Fukasawa.RCET, Dept ol Inhraton Therapy. 
Juntendo Univ School of Medicine. Tokyo.Japan, 

inlriaductipn I r recent years, a variety of airway clearance modalities have 

been developed They include the flutter valve ". positive expiratory pressure 

(Tiera ^EP "). and ajlogenic drainage Convenl'Onal chest ohystcal theraoy 

(CPT) for enhanced m jcus clearance involves Ihc use of postjrai drainage and 

percussion Since CPT has been associated with some complications, we 

administered a modi'led drainage position and squeez ng lechniauc This sludy 

was designed to compare :he acute eidcacy ot airway clearance techniques 

Methods A randamized crossover trial consisting ol tour :reatemert reg mens 

(CPT. flutter vaivc'^. Thera PEP'". and autogenic drainage) was administered to 

seven pat ents Three had chrome oronchilis and lour w Ih brorchiectasis On itie 

lifst day. each patient was received to 30 mmules of one ol the four treatement 

'cgir^en A different treatement regimen would oe randami2ed and administered 

on subsequent day Pulmonary function lesting (PFT), respiratory muscle function. 

and arler al blOOd gas (ABG) analysis were measured before and after each 

treatement The quantity of sputums expecirated was determmed by volume and 

weight Results Thre was a 'arge vanance in sputum production between the 

four treatement regimen CPT 24 55-3 8g. Mutter valve'" 1 6 7±2 5y. Thera PEP"* 

1 3 0± 1 5g. autogenic drainagel 1 02.2 Og (ANOVA p<C 01 ) The results o* PFT. 

respiratory muscle str«!ng;h and ABG analysis were not significantly different 

between the tour treatement regimen There were significant improvement m 

FVC %VC, FEV. t,. Pmax and "tnax after each of the four treatemenls was 

administered (p<0 05) We could not identify any stgnificani change in ABGs after 

administration of Ihe treatement Conclusion We concltded CPT (mod f ed 

drainage position and squeezing techinlque) resulted in a significanity greater 

volume of sptilum expectoration Than (luMer valve " , The'-a PEP . and ajlogenic 

drainage No other signi'icant difference m PFT. respiratory muscle strength and 

ABGs. between the tour airway clearance modalities, were identified. All four 

modalities were found to be equally safe and ettectivo in clearance of bronchial 




Respiratory Care • October "96 Vol 41 No 10 

Tuesday, November 5. 12:45-2:40 pm (Rooms 5A-B) 


F. Kaki7i«ki. R.PT. 
" " .M.Sibuya. M.D. 

.T- Yamazaki, R.PT. 
.M.Narushima. M.D. * 

.K. Tanaka. MX) 
.H. Suzuki. M,D, ' 

.M. Yamada, M.D. 
,1. Homraa. Ml). 

1) Dcparlmeui uf Rehabililation, Fujigaoka Rchabililalion Hospital, Yokohama, Japan 

2) Dcparmient of Physiology. Showa University School of Medicine, Tokyo. 

3) Dcpartmcnl of Inlcrnal Medicine, Toyosu Haspilal. Tokyo. Japan 

4) Dcpartmcnl of Respiratory Medicine. Fujigaoka Hospital. Yokohama, Japan 

Introduction: We studied the effects of 8 weeks of training in rcspirBtory muscle sueich 
gymnastics (RMSG) on chcsl uall motion and peak expiratory flow (PEF) in paticuLi with 
chronic asthma. Mclfiods: Tlic subjects were 10 paticnls with chronic asthma (mean age 
6D.4 years, mean FEVi L8SU mean FEVi% 46.7%). The patients were taught to do 5 
different RMSG exercises. They were instructed to do each exercise 10 times each morning 
and each evening for 8 weeks. To ensure that the training was being done correctly, the 
patients' technique was evaluated 1 week and 4 weeks after the study began. They were 
instructed again ou the correct technique whenever necessary. Ccst wall motion and PEF 
were measured before and after the 8 weeks of Uaining. TTie diameter of the chest wxs 
measured wiih a tape measure, at the levels of the axilla, the xiphoid process, and the 
lOih rib. At each level, each measurement was made twice: at residual volume and at 
total lung capacity. The difference between the two was used as an index of the ability to 
move the chest wall, PEF was measured three times, with a Mini-Wright peak flow 
meter, and the hightc^t value was usedJRcsults: 

Ccst wall motion 


Xiphoid process 

lOlh rib 

Before traning(cm) 
4J ± 0.4 
5.9 ± 0.5 

5.7 ± 0.7 

After lrainiiig{cm) 
7.2 ± 0.4- 
7.5 ± 0.6*" 
7.7 ± 0.6** 

Data shown are mean ± SEM.'pcO.OOl. "p<0.005 
PEF increased significantly: the base-line value was 375 ± 34 Umm and the value 
measured after training was 429 ± 43 L/min-Conclusions; In these patients with chronic 
asthma, 8 weeks RMSG training increased the ability to move Uie chest wall, and also 
increased PEF. RMSG may be a very useful form of physical conditioning in patients with 
chronic asthma. 



N. K:»icko. MP M. Y.imada. MD ' ,F Kaki/aki. R P.T ' ' .M, 

Sibiiya. M.D. ^ .T Aki/aua. MD. ' .M. Narushima , MD. .H. Su/uki. M.D, ' . 
I. Homma, M.D. ' 

l)Dcparimcni of Respiratory .Medicine. Fujigaoka Hospital, Yokohama. Japan 

2)Dep.irimcnt ol Reliabiliiaiion.. Fujigaoka RchabiliUlion Hospital. Yokohama, 


-l)Dcaparimcni of Physinlugv. Showa University School of Medicine . Tokyo. Japan. 

Introducbon: Rcbpiialory muscle stretch gymnastics (RMSG) were developed to 
stretch Ihc chest wall respiratory muscle during the coniraclitin phase. We studied 
the immediate elfcci of RM.SG and effect of 4 weeks of RMSG training in COPD 

Methods i l ) immediate effect of RMSG: Thity-four patients with COPD 
consecutively performed four RMSG palicms, four limes each. The ilyspnea rating 
on a I5n-mm visual analog scale ( VAS ) was measnred- (2) Effect of 4 weeks of 
RMSG tiainiug: 10 COPD patients (9 males,! tcmale.age 71 ± 6 yrs: FEV 1.25 
^ 0.70 L). The patients were iiistmcled to perform 5 RMSG paltenis.4 limes each. 
3 times a day for 4 weeks. Six-minute walking distance ( bMD ) aiut pulmonary 
function tests were performed before and after 4 weeks of RMSG. 
Results: (1) The dyspnea rating on a 150-mm visual analog scale (VAS) was 1 1.6 
± 3.4 mm before RMSG and was significantly decreased to 6.2 ± 2.2 mm< p < 
O.OK 5 mitiutcs after RMSG. (2) 6MD was siguificanily increased from 330 ± 85 
m to 378 ± 66 m( p < 0.01). The residual volume. fimctional residual capacity and 
total lung capacity ( TLC ) were all significantly decreased from 3.55 ± 1.03 L lo 
3.06 ± 0.79 L. 4.-18 ± 1,12 L to 4 U it 0.92 U and 6.26 ± 1.15 L to 5.87 
± 1.04 U p < 0.02). The rati.) of RV to TLC was significantly decreased from 
56,4% to 52.1% ( p < 0.01). 

Conclusions: Tlicse resuhs suggest Ihal RMSG is effective physical conditionnme lo 
improves pulmonary function and decreases dyspnea at rest and or exertion in 
COPD patients. 



[CDBR"') Co 

zed Diaphrogrr 

teothing Reli 


shed by RFB Te 

rfield Beach Flor 

18001 850 4 136 


An Important third abstract of a three part study conducted by Dr. 
Jerome Holliday Is featured in the AARC Convention issue of 
Respiratory Care. October, 1996. Dr. Hollidays study demonstrates 
the efficacy of CDBR Computerized Diaphragmatic Breathing 
Retraining for ventilator weaning. The previous two parts were pub- 
lished by Amencan Review of Respiratory and Critical Care 
Medicine and presented at the 1994 and 1995 ALA meetings. The 
full poster presentation may be viewed at the 1996 AARC meeting in 
San Diego. 

"We have found a direct correlation between excessive neural respi- 
ratory drive and EEC frequencies," said Dr. Holliday from St. Louis 
Regional Medical Center. "Lowenng BEG activity to theta and delta 
levels will simultaneously decrease over stimulated respiratory drive. 
In our 1991 study, we were able to show a 12 day reduction in 
weaning time using conventional feedback systems." said Dr. 
Holliday. "However, that method isn't always therapist friendly 
enough to perform on ventilator patients. Therefore, we sought to 
carefully replicate, or improve upon these results using a new, and 
highly unique device, the RFB System-I™ for CDBR (RFB 
Technologies, Deerfield Beach. PL). Over the past two years, we 
have published papers showing that CDBR performs this function 
quite efficiently." 

This noninvasive system is dedicated to exercising the diaphragm 
and lowering EEG frequencies by stimulating the autonomic nervous 
system. The RFB System-I uses a unique remote noncontact optical 
sensor, analog computer, and a headset to monitor and deliver a 


symbolic representation of the patient's breathing directly to the 
reticular formation of the brain, thereby lowering EEG and respirato- 
ry dnve. Unlike conventional biofeedback, the RFB System-I also 
has the distinct advantage of being simple enough for any therapist 
to operate. "After publishing the effects of CDBR on EEG and respi- 
ratory drive, I was asked to work with several difficult to wean 
patients here at St. Louis Regional. These patients all had difficulty 
breathing on the T-tube. The time between CDSR treatments and 
final extubation shows the efficacy of this modality for weaning venti- 
lator patients ' 

Pt. # 


Days on Vent 

Days from CDBR 
to Extubation 


Cerebral Vascular Disease 
















Renal Failure 


same day 


Respiratory Failure COPD 



"We're not surprised at Dr. Hollidays success. " said Sheldon Annus. 
President of RFB Technologies "This modality simply recognizes 
that the brain is an integral part of the respiratory system. We have 
received CDBR case studies of patients who have been weaned 
after 3 to 6 years on a ventilator; one was a quadrapleglc." Dr. 
Holliday believes that "CDBR holds great promise for patients expe- 
riencing difficulty weaning from ventilators." 

For reprints and information, contact RFB Technologies. (800) 856- 

Respiratory Care • October "96 Vol 41 No 10 


Tuesday, November 5, 3:00-4:55 pm (Rooms I A-B) 

Kollef, MD. Steven D. Shapiro, M O.j Patricia Silver, MEd; Robert E. St. John MSN; 
Donna Prentice MSN; Sharon Sauer BSN; Tom S. Ahrens. DNS; William Shannon, 
PhD; Damons Baker-Clinlcscale, MBA; Department of Internal Medicine, Pulmonary 
and Critical Care Division. Division of General Medical Sciences, Washington 
Universilv School of Medicine, Departments of Nurslnfl and Respiratory Therapy, 
Barnes and Jewish Hospitals of ths BJC Health System; St Louis, MO 631 10 
Background: To compare a practice of protocol-directed weaning from mechanical 
ventilation implemented by nurses and respiratory therapists to physician-directed 


Method: Randomized controlled trial of 357 patients in the medical and surgical 
Intensive care units of two universitv-afliliated teaching hospitals. Patients were 
randomly assigned to receive either protocol-directed In = 1 791 or physician-directed 
(n-17B) weaning from mechanical ventilation. The primary outcome measure was 
the duration of mechanical ventilation Other outcome measures included need for 
reintubation, length of hospital stay, hospital mortalltv, and hospital charges. 
Results: The median duration of mechanical ventilation was 35 hours for the 
protocol directed group (first quartile, 1 6 hours; third guartile, 1 1 4 hours! compared 
to 44 hours for the physician-directed group (first quanile, 21 hours; third quartile, 
209 hoursi Kaplan-Meier analysis demonstrated that patients randomized to 
protocol-directed weaning had significantly shorter durations of mechanical 
ventilation compared to patients randomized to physician-directed weaning tX' «= 
3.82, P = 057, Log-Rank test; X" = 5 12, P = 0.024, Wilcoxon test). Cox 
proportional-hazards regrBssion analysis, adjustino for other co-variatos, showed that 
the rate of successful weaning was significantly greater for patients receiving 
protocol-directed weaning compared to patients receiving physician-directed weaning 
(risk ratio, 1.31; 95 percent confidence interval. 1.15 to 1 50; P = 0.0391. The 
hospital mortalitY rates for the two treatment groups were similar (protocol-directed, 
22.3% versus physician-<)lrected, 23.6%; P = 0.779l. Hospital charges for patients 
in the protocol-directed group averaged S3866 less than hospital charges for patients 
in the physician-directed group. 

Conclusions: Pfotocol-fluided weaning of mechanical ventilation, as performed by 
nurses and respiratory therapists, is safe and led to extubation more rapidly than 
physician-directed weaning. 


JM Craybeal CRTT . CB Ruadl. .MD, E Taylor- RRT. D Olscn' RRT. .M Wccicr- RRT 
Dcpt of Anesihesia. Peon Stale University College of Medicine and •Respiniory Cjrc Services. 
University Hospital. Hcrshey. Pa. 17033 

The cost of caring for paucnts in the intensive care unit has come under close 
mspcCLon. The expense of and demajxb placed on highly [rained cnlical care physicians has 
limited their availability. In an cffon to extend ihcir availability in the surgical intensive care 
unit {SICU^. we insutuied protocols for weaning, by respiratory therapists, of patients from 
mechanical ventilators. We evaluated the efficiency and safety of these therapist driven protocols. 

Following institutional IRB approval, mechanical ventilation weaning pmtocols woe 
instituted in our SIC'J Protocols were developed for SIMV. 1 -piece and Pressure Support (PS) 
weaning methods Patients wen: enrolled in the protcxols following a wntten order from the 
SICU physician Respiratory therapist cvaluauon. uulizing esublished weaning parameters such 
as inspiratory force, vital capacity, stauc compliance, s-ponumeous tidal volume, the adaj 
volume respiratory frequency ratio, and spontaneous minute vcntilauon. determined which 
weaxiing prottKOl was uiiiizicd tor spec-ific patients. All protocols were condutual by SICU 
respuaujrx' therapists. A database of weaning piotocol use. failure to wean, cause of failure, 
durauon of wean and duriuon of veniilanon poor to wean was maintained, Chi-squan; analysis 
was used to evaluate differences between gioups. with p < 005 determining significance 

There were 151 pauents enrolled in the weaning protocols, trauma (38). neurosurgical 
(25). general s-urgery (25). vascular surge.-y (19). scpsis/ARDS (13). renal surgery (10). other P) 
Sl'^D of these pauents were succe.ssful!y weaned trom mechanical venulation within 12 hours of 
enrollm.enL Of these 151 pancnts, 1 1 1 were weaned by SIMV. 18 by T-piece and 22 by PS The 
total failiue rate of 3 3% was not different between weanmg methods. There was a difference in 
the ume toquned to wean, between methods (p < O.OOl) (Table 1). More PS pauents (41%) 
required > 2-1 hours to wejn than other methods Palieiils ncnuinng longer penods of vendlaiton 
pnor to weaning were weaned more frequently by PS (p < 0.001) (Table 2). 

A failure to wean/exnibate rate of J J% suggests that respiratory therapists, using 
insuiuuonaJ approved protocols can safely wean patients from mechanical ventilatory support. 
Use of the PS protocol appears to result m longer duration of weaning than ilic other protocols. 
Patients with a longer durauon of ventilation pnor to weaning uulized the PS protocol moie 
frequently Institution of respiratory therapist dnven weaning protocols is safe and may reduce 
time requirements of cniical care physicians, increasing their availability for other critical care 
issues ^___ 

Table 1 Duration of Wean (# of pauents 
weaned within specific uine mler%'alsi 
H.iius SIMV T-Diece El 



Table 2 

Duration of Prior Ventilation (1 ol | 




T.piece PS 

12 hr^ 


10 1 

24 hrs 


2 2 

-18 hrs 


6 2 




>5 days 





VENTILA 1 OR WTANING Jo^hnjinberger BS RRI- Don Miller RRT, Rcspualor^ Care 

SlalT. Ilcrbcn Patrick MD. Dcpl of Rcspiratot> Care. Thooiiis JclTcrson Untversits Hospital, 

Inc. Philadclplua PA 

Backismund: In 1<>')1. ihc Department ofRespiratort Care tmplcmenled a Venlilatot 

Maiuigemciil and Esalualion Program l\'enlM.nnl looplimi/c (ciililalor sctMCes through 

education and OA & I daLn gathciint: (Jul ncantng approach centers oti educating the 

bedside icim (therapists nurses, and plissictaiisl on denning ucjning progress using 24 

tiour rcspiralors rate trend monilonne «ilh lilralion within a "can mode in response 10 the 

trend of each patient H>polh»is: We believed thai would shohcit the weaning 

pcnod Methods VcnlMan weaning data were retrospccnneh .inalyrcd from Juls 1993 10 

Apnl 1995 from foul adult ICU s (Medical, Surgical. Ncuroscnsorv ) The 

-wcamng pcnod wasdcnncd as the da\s from the first weatuitg Inal until the patient was 

independent of Ihe ventilator ■ 4« huuts 24 hour respitnlors rale monitoring by impedance 

was obtained using the Hcv>lclt-Pack.ird monitoring ssslcm We tdcnttftcd ^''t paticnls who 

h.ld a length ol stav on ihc ventilator (l.OSs ) • 4 days (pauents not qiiickh evtubalcdl and 

separated them into thrtx groups based on weaning modes 

1 Resptralorv Muscle Endur.-UKe Iraintng with PSV (RIMET/PSV) - PSV was Ittratc-d lo 

maintain respiratory rate trends 2ti to 30 BPVl during the day Patients "tesied' on Assist 

Conltol during each night 

2, T- lube (TT) - T -piece and iracli collar Inals cither once or several times daily wilh scl 

durations indcpendcnl of respirators rate trends 

3 Other Combinations lOTHERl - SIMW PSV/SPvlV. or swilchmg between modes das 10 

da> independent of respiratory rate trends 

Weaning "failure?. ' were defined as paticms inilialing weaning b> one mode and 

subsequently weaned by another mode, due to intolerance 


. total - '''6 

Aserage l.OSs dass* 

Asg davs before weaning 

A\v, Weanins; Pcnod days 

80"o vcntilatui indcpendcnl. days 

Wcininn r.iilutes. l^ 







p < 11 tun 

•v:irianc-e liclween RMFT/PSV and OTHER, p < 05 
The most comiiion weamng approach used was RMET/PSV (52"'/o), followed b> TT (27%), 
and OTHER (21%) 

Conclunkin: ■\ patient focused bedside team approach lo weanini: using RVIH r,'PS\ appears 
to hasc significantls decreased the weanmg period, length of sla\ on Ihe ventilator and the 
number of weaning failures In future studies, olliet faclors conlnbuttng to LOSv need 10 Ik 
studied such as pauenl diagnoses, age. and co-morbtdilies. 


Emberger BS RRT. Gars Gradwell BS RRT. Herbert Patrick MD, Department of Respirators 
Care. Thomas Jefferson Uiuvctsits Hospilal Inc. Philadelphia PA 

Backisraiiiid Ihe Respirators Care Department implemented llie VenlMan Program which 
collects wcaiung data on all scnlilalor patients and also prinides education of the bedside 
team (therapists, nurses and phisiciansi on scntilator weanini; VcoLVlan weaning 
education includes a noti-tiiandatcd ptotocoli/cd guideline for PSV wluch is Ulraled 
according to 24 hour trends of respirators rale as a measure of each p.ittenfs wcatung 
progress Our prolocoli/ed weaning guidelines have bc-eii identified as the most efficient 
method for weaning patients at our institution, howeser they leinain non-mandator> 
Hypothesis: Wc wanted to determine if educational elTorts would result in a shift iii wean 
m^e iis.ige in Surgical ICU (SlCUl paucnts with a length of stav on iJic ventilator (1 OSv) 4 
lo 14 davs and • 14 dass Methods: Wc letrospcclivels ;inal>/ed SICU scnul.ilor weamng 
dala in two penods before VenlMan weaning education. Jiih91 to Apnl94 I Prc-Educauon) 
.and dunng education )uh94 to Apnl95 (EducauonI Wc separated SICU patients (post 
trauma or posl-opetausci utlo two groups I OSs 4 lo 14 dass i e . pauents not we;ined 
immediatelv post-op and lOSv ■ 14 dass i e . paucnts after consersion from endotracheal lo 
Itacheostoras nibc The two groups were anajszed bv Pre-Education or Education pcnod. 
aiid b\ wean mode used We-rn modes included 

1) Prolocoli/ed PSV (P-PSV) based on 24 hour respiratory rate trends 

2) T-picce and Irach collar. \enlilalor-£ree breathing once or sescral umes dills (TTl 

3) SIMV reducing die SCI rcspiralory rats- as tolerated 

4) OTHER SIMV with PSV. oi dail) switching between wean modes, or 
Non-Protocoli/ed PSV 

Rciulli: 1 1 1 patients ml were ev.aniined Dala is shown as n 1%) 1". = percent within 
period I 


loss: 4 
to 14 days 



14 davs 




31 178)' 

10 (•'II- 






8 123) 







81- ] 40(100) 

4 |18| ■ 22(100) 

3 121) : 14(1011) 

chi-sqiiare variance between penods 'p ^ 001 , - p ■: 05 

Weamng signiricanlh shincd lo P-PSV (17% to 7S°4| in Ihe LOSs 4 10 14 diss group 
Weamng also significantls shifted lo P-PSV (59% to 71%) in Ihe LOSs > 14 days group 
CiinclujioD: The Large shift to P-PSV in both groups of patients appears to be attnbuled lo 
the educational cffons of \cntMan in the SICU In liilurc studies, other factors need to be 
studied such .as patient diagnoses, age. and co-morbidities 



Respiratory Care • October "96 Vol 41 No 10 

Tuesday, November 5. 3:00-4:53 pm (Rooms lA-B) 

Sl-RC.FRY (CABCi) John Embcrgcr BS RRT. Herbert Patrick MD. Dept of 

Rcspiraion Care. Thomas Jefferson Unnersil\ Hospital Inc Philadelphia PA 

Background: We ha\c observed that post-op patients «ilh obslnjclivc ainvavs lend 
to remain intubated longer than patients \Mthout underKing airv\a> problems 
Specialized \ent1l3tor management and cxtubatiun practice for patients \Mth 
oDstrucli\e airvsavs ma> need to be part of our educational programs for these 
patients Hypothesis: We wanted to determine if obstnictne airways increased 
1,0S\ in patients undeigoing elective CABC Methods: Data was collected 
prospecti\ci> from Jan 'Ift -"Klar 16 on CABG patic-nts in our Surgical Cardiac Care 
Unit (SCCL'I Data included L0S% , Ventilator Settings, presence absence of 
AuloPEEP (PEEPi). presence of pulmonar. consult, and patient outcome PHFPi was 
defined as > 5 cmll.-O of intrinsic PEEP with a ventilator respinuorv rate : 1 5 BPM. 
and adequate exhalation time To prevent skewing of statistics patients with LOSv ■' 
14 da\s were separated from patients with I OSv .-> 14 davs Results: 17:^ C.M3G 
patients were examined and separated into LOSv ^ 14 davs or LOSv 1: 14 davs 

Data for CABC patients: 
LOSv ' Udnjs. 






LOSv' Avi- t SD 


4 1 t 25 

LOSv Ran«e. davs 


2 to 9 

Had Pulnionarv Consultation, ^0 



Wean Tnals Failed, "^o 



LOSv > 14 days. 




LOSv m SCCU. AvR ^ SD 

21 8 + 74 

Transferred to Medical 
ICU for Weaiun^ I 



•.•\nova variance betwem groups, p < 001 ••Two patients expired 

f Che patients with LOSv ■ 14 davs. patients with PEEPi had a significantlv 1 
eragc LOSv (4 1 versus 2 4) and failed the majonlv of weaning trials (,'5,'"d) 
ticnts with LOSv 2 14 davs aixi all of the patients iraiisfencd out of the unit 
:re patients with PEFPi Conclusion: Obstructive airwave appear to increa, 
3Sv in patients undcrgomg elective C.\BG We now plan to increase our ed 
management of patients with PEEPi detected immcdialelv post-op Future 
ould expand on other factors such as age and co-morbidities 


to wean 




JE Holliday PhD . R Haake DO, M Range RRT, St Louis Regional Medical Cen- 
ter, St Louis MO 

We previously showed that biofeedback reduced weanmg failures and time 
on the ventilator by 12 days (Am Rev Respir Dis 1990;141:121-140). We 
hypothesized that the underlying mechanism related to the effects of 
biofeedback was the reduction of high neural respiratory drive (PlOO > 4 5 cm 
HjO) A biofeedback instrument, "Computerized Diaphragmatic Breathing 
Retraining (CDBR)" (RFb Technologies, Deerlield Beach FL) was used to test 
the hypothesis In order to determine if biofeedback could reduce neural respira- 
tory drive, we studied 9 [5 males & 4 females with mean age 56.22 ± 3 38 (mean 
± SE) yrsj hard-to-wean ventilator patients (on ventilator longer than 7 days) 
who could respond to verbal commands. 20 minutes of T-tube with O2 
saturation of at least 90°o, and be off all sedative type drugs tor 4 hours. 
Patients rebreathed 7°o C02/93% O2 for 2 5 mm of baseline & 2.5 mm of CDBR 
biofeedback For the CDBR session compared to baseline there was a 
significant shift to the right in the end-lidal CO2 (PETCO2) response curve At 
maximum PETC02 (70 mm Hg) the reduction in Pi 00 = -2 904 ± 3.05 cm H20 p 
<001. EEG = -93*355 c/sp<G 05. minute ventilation (Vi) = -2,15 ±2 99 
Umin p < 05, mean inspiratory flow (VtTTi) = -102 8 ± 99 5 p < 0.05 mUs & 
respiration rate (RR) = -1 7 ± 1 44 br/min p < 0.05, The results showed that 
CDBR feedback significantly reduced neural respiratory drive. To study reduc- 
tion in neural respiratory drive dunng weaning, 6 internal medicine ventilator 
patients were selected over a period of one year with P100 > 4.5 cm H2O, who 
were willing to sign the informed consent & had failed their initial weaning trial 
(could not tolerate T-tube longer than 15 mm after 24.8 ± 1 04 mean ventilator 
days) because of high RR (mean RR = 40 br/min) reflecting their high mean 
PlOO = 7.15 ± 1.02. They were then given between one (3 Pts) and three 30 mm 
CDBR sessions over a period of 1-2 days At the end of CDBR feedback the 
mean PlOO was 4.28 ± 1 04 cm H2O, which was a significant reduction (p < 
0.01), the mean RR = 32 br/min & no failed weaning trials resulting in 1.91 ± 
49 mean days from start ol CDBR till extubation. The above results support 
the hypothesis that biofeedback does reduce neural respiratory drive & appears 
to reduce weaning failures. 



David P. Wheelpr.RRr, Kathryn Hal^.MD, Ken Harget t , RP.T . Cathy 
Meents.RRT. The Methodiet Hospital. Houston, Texas 

Baclcgroundt Coronary Artery Bypass (CAB) surgery with and 
wiLhout catheterization waa a highly utilized service at our 
institution. In response to managed care i ssuea and cost 
reduction initiatives, we developed a clinical pathway and 
evaluated its impact on hospital cost, utilization of services, 
and length of Gtay(LOS)- Hsthoda: A mult idiscipl inary work 
group was formed to define the issues wi th CAB and develop the 
pathway- All aspects of patient management during their 
hospitalization were analyzed and the pathway(PW) developed to 
streamline prc-op, ICU. and floor care to reduce cost and LOS. 
Two Vey components of the pathway were the Respiratory Care 
Post-Op Weaning/Extubation Protocol and the CAB Oxygen Weaning 
Protocol. The Extubation Protocol utilized respiratory 
mechanics, saturation monitoring and f/TV as key indicators for 
the reduction of venti la tor support . The number of blood gases 
obtained was reduced from non-pathway (NPW) . Extubation criteria 
were incorporated along with Fi02 reduct ion . After discharge 
from the ICU, the Oxygen Wean Protocol allowed therapist to 
reduce Fi02, titrate nasal cannula flows and remove the patient 
from oxygen. Discharge criteria related to removal of oxygen 
need. The pathway was implemented and data collected from April 
1994-April 199S. 371 patients were enrolled in the PW and 396 
were NPW. The two populations were selected by physician 
preference and comparable in all aspects , i.e. age, ASA score, 
previous surgery. Rvsultst LOS was reduced in the PW population 
vs. NPW. (Mean 10.6 vs. 14.5 days, a decrease of 26.8%) PW 
CAB/cath was mean of 9.3 days, down from 13.2; CAB without cath 
was mean of 11.9 days, down from 158 days. PW TCU LOS was mean 
of 2.8 days for CAB/cath, down from 4.2 days NPW; 2.0 days for 
CAB without cath, down from 3.0 NPW. Oxygen utilization after 
ICU was reduced from 6.8 days NPW to 4.2 days with the PW, 
Respiratory Department Cost/patient was reduced from mean 
SI. 322 CAB with cath to S792 and from S1230 to $709 CAB without 
carh, Concl4i«loni The use of a Clinical Pathway resulted in 
both fixed (LOS) and variable cost reductions (RT blood gases, 
oxygen utilization and vent days). The integration of TDP ' s was 
a major determinant in these savings. Accelerated discharge 
from the ICU and reduction in oxygen time allowing discharge 
home were both posit ively influenced hy utilizing TDP' s . 


SURGERY PATIENTS. Keith^ A._La^:es, 
A. A . 5. ,R.R . T. , George &rown, M.D., r.A.C.S., 
F. A. C.C. , Laura hi del let on, R.N. , C.C.R.N. , 
Miami Valley Hospital, Dayton, DH . 

Introduction: Our open he^rt Firogram 
pHr^arms about 400 coronarv bypass gra-ft 
larger 1 es per year . Through a benchmark 1 ng 
process, we identi + ieri three arenas with 
apportuni t y -for improvement . Fi rst , 1 ess 
than 5X of the patients were e^:tubated the 
day of t^iur gery with an average ventilator 
length ot stay of 13.6 hours. Second, 
b rone hod 1 1 at or uti 1 ization postuperat i vel y 
was 100*/.. Third, an average of 6.4 arterial 
blood ga«ies were performed. Methods: A 
mul ti-di SCI pi 1 nary group began meeting to 
address tf-e?5e issues. The group included 
repr f senud t 1 ves of respiratory care, nursing, 
anesthesj a and a car di othoraci u surgeon . Wfc^ 
developed a rapid extubation protocol, 
Liwilinng end tidal C02 monitoring and pulse? 
oximetry to dr'ive an aggressi ve weaning 
Bchedulp. This profocol included a decreasE-d 
need for bl ood gases and specific indications 
for bronchodi lator therapy. Results: Af tpr 
three months of this protocol 106 patients 
were 1 nt Kided in the study. 59/; of the 
patients were e::tubated the day of surgery 
with an averctge ventilator length of stay of 
7 1/2 hours. 507. of the patients received 
bronchodi 1 ator therapy and 4.4 blood gases 
wH-re performed. Nc patients required 
^21 ritub.^f 1 on and no negati ve pat i ent outcomev, 
wfre i dent 1 f I ed. Concl u^-ii on: We concl uded 
that a patient dri ven protocol usi ng end 
1 1 dal cor and ox i met ry monitoring combi ned 
with an aggressive weani ng approach by the 
respiratory therapist ana nurse would resuli: 
i n shorter veciti 1 ator 1 1 mes anci more 
effective utilization of respiratory care, 


Respiratory Care •October '96 Vol 41 No 10 


Tuesday, November 5, 3:00-4:55 pm (Rooms 1 A-B) 

William M ruplm. MD. Kaihy D Coolcv. RRT . Gordnri D Rubcnleld. MD; Daviil 
J Picrson. MD. Hartxirvicw Medical Ccnier. Universiiy of Waslungion. Scatlic. WA 

Background: Previous studies on ihe prediction of successful weaning have tended 
to lump logcihcr bolh disconiinuaiion of mechanical venulation and succe^ful 
cxrubauun as Uic end point. Acute brain injury is one clinical scenario where ihe 
needs fur venulaiory suppon and cndoiraciieal iniubauon may be separate: 
patients (pts) may fuinil weaning cnlcria yei still require airway protection against 
aspiration. This study soughi to dcicrminc whether a six-pan airway care score 
(ACS) could prrrdici successful csiuhation once acme brain injury pts met siandanj 
sponiancous ventilatory parameters with adequate gas exchange. 
Method: All intubated pts admitted to a Harborvicw miensive care unit over a 6 
month period were screened tor stud) entry. Significant exiracranial trauma, organ 
failure, loxic or metabolic coma, and admission trticheoiomy excluded pis We 
idcntillcd the day when pis met standard weaning parameters and no longer had 
any indicauon for mechanical ventilation There was daily recording tuniil hospital 
discharge, death, or tracheotomy) of the Glasgow Coma Scale (GCS). factors 
defining pneumonia (CDC criiena). and the ACS (sum of 6 components, from 

(besll in 18 


Spontaneous Cough 



Soutum Ouanutv ' 



None ! 

1 ModeraE 




1 pass 


2 , Weak 




2 passes 

3 None 




> 3passes 

Spulum ViscosHY 

Sucuonins FieauencY/S hr 

Sputum Character 



1 > 3 hr 




1 Ia2.3hr 





2 al-2hr 





3 < q 1 hr 



Results: For 107 pts eventually cxlubated, median .\CS when Ihcy first met 
Iheorclical cxlubauon rcaiJincss cnlcna (SVP) was « (1 12), at the time of actual 
extubalitm (EXT) it was 8 (1-161 Coma (GCSS8) correlated with wotsc ACS 
scores (P=0 fX)3). Eleven pis were rcinrubatcd for pulmonar\7airway reasons 'l"he 
ACS. at cither .SVP or EXT. did nol predict successful cxlubauon (P=NS), Two 
components predicted extubauon success: spontaneous cough (P=n014) and 
suction frequency (P=0015i, but no component or combinalion predicied 
reinlubalion in individual ptS- 

Cunclusions: Spontaneous cough and suclioning frequency independently 
correlated with successful extubation in these brain-injured pts. but neither .'VCS 
nor tt-s components could identify pts who would be reiniubated. Whether 
ventilatory mechanics and other clinical data can improve prediction of extubauon 
success once pts meet weaning critcna. and whether neurological status contnbutes 
to pneumonia and other complications, deserve further study 

Supported in part by NIH NS Mm)5 (WMC) 




DISEASE Mary K Dekeon RRT . Thomas J Kulik M D Kennnlh P Bandy 

R R T .Michigan Congenital Heart Onter. University of Michigan Medical Center. Ann 

Arbor, Michigan 

Objective: The development ol a multidisciplinary task lorce to identity areas of 

improved efficiency This unique group consisted ol operating room and intensive 

care personnel who attended regular meetings to discuss changes that coukl tie 

implemented to improve cost effectiveness and at the same lime enhance the 

transition from the operating room to Ihe intensive care unit 

Methods: We began bi-monlhiy meetings with the director ol the intensive care unit, 

a Ihoraac surgeon, stall nurses, the director ol pediainc anesthesia and Ihe respiratory 

care cl^ical specialist Irom Ihe intensive care unit The loJIowing goals wore targeted 

1 Reduce the duplicate use ol disposable respiratory equipmeni, medication and 
blood products 

2 Identify procedures and tests that weie redundant or unnecessary 

Prior to our meetings venhlalor circuits, pressuie transducers and oxygen saturation 
probes wore set up in txilh areas Tfiis practice was changed so that these items were 
only set up m the operating room and then transferred to Ihe intensive care unit with 
Ihe patient, elimnaiing waste Problems with transfers were carefully tracked and 
addressed through subsequeni meetings 

Eetlmaled Savinga of Disposable Eouipmen t 

Item Cost 

Ventilator circuit 8.33 

Humidilier 7,34 

Oxygen saturation probes 15 bb 

Pressure transducers _ 

$3 54oa X 2-3 B8 5 

Total per patient $ 4007 

Annual savings (based on 

approx 500 palienls/year) $20,035,00 

Duplicalkxi of laboratory tests were also examined Our practice was to run electrolytes 
with blood gases at our point ol care lab in the ICU to obtain ionized calcium, whole 
blood sodium and [Xiiassium values Additional blood was drawn tor serum K-^ every 
six hours and sent to our central lab We conducted an in hospital companson ol whole 
blood potassium levels with seium potassium levels this companson demonstrated 
no cDnically significant dillerence, therelore, routine sampling tor serum polasslum was 
discontinued, reducing Ihe total amount ol blood drawn, and reducing Iho amount of 
personnel time A similar evaluation was made comparing hematocrit values obtained 
by conductivity on the blood gas analyzer with those obianed by spun hematocnt 
Similar results were demonstrated, eliminating the need tor spun hematorcrits 
Conclusion: The development ol a multidisciplinary task (orce was initiated to 
identity cost saving issues tiecame a process which unified disciplines to achieve 
consistency, cost ellectiveness and cooperalK>n for a total team approach to quality 
operative and post-operative management of infants and children with congenital 
heart disease „ 


(RcSCU) .A.T THE CLHVELAND Cl.lNlC FOin^TlATlON Rjchard_DRi.(aRi<I. 
James K Stollct -MD The Cleveland Climc Foundation. Cleveland. Ohio. 

BACKCROIIM): The Respiratory Special Care Unit (ReSCU) was implemenleij in 
August \*)^'^ as a 6-bed venulator unit outside Ihe Intensive Care Unit with two major 
goals I To w^an ventilator-dependent pauents wUeie possible, and 2 When weaning 
was ncil deemed possible, to opunuze pauent and family inslniction for patients going 
home OTih ventilator, suppon METHODS: Features of ihe RcSCU include 6 pni-alc 
beds arrayed on a puiiiionari specially ward staffed by nurses with special pulmonary 
and rehabihutioii expertise. 24 hour respirator, therapy siipenision. non-invasive 
monitonng (conliiiuous pulse oximetry, end tidal capnometry, and \enUlator alarms) 
with signal output at each bedside and at a central monitonng station, and a 
multidisciplinarv approach involving dietitians, physical therapists, and speech 
thcnipisls Eligibility cntena include hemods-namic si:ihilily. absence of an arrhythmia 
requinng Iclenielty. and. in the attending physician's judgment ability to henefit from 
the ReSCU Admission priority was given to patients who were deemed weanable 
RESULTS: Between Aiigu-st 22. 199^ and December 31. l';')5. 109 unique patients 
were admitted lo the RcSCU, of whom 1 1 were rc-adniitted twice (' on separate 
hospilali7iitionsl, 2 were admilled ihrec times (1 on three separate hospitalizations). 1 
patient four times and 1 patient admitted seven times (total ReSCU admissions were 
I4')l Of the 109 unique palienls. fePJo (n-671 were women, and the mean age was 64 
years Eleven pet cent <n=l21 died during the hospitalization Among the 97 survisors. 
complete ventilator independence wasaclucval in 73% (ii=71). whereas 18% (n=P) 
were unweanable. (>% (n=6) required noctuinal ventilation, and 3% (n=.'>) required 
nocturnal ventilation and parUal dayunie suppon 1 he rate of weaning success vaned 
slightly hv year (62% in 1993,81%in 1994. and 7(1% in 1995) Overall, mean length of 
ReSCU stay was 20 days (range 1 to 1(KI davs) and ReSCU days accounted for '1% of 
total hospital length of slay Assuming that vcntilaioi -supported patients would have 
remained in an intensive care unit witliout the availabililv ofthc RcSCU. we assessed 
the impact of the ReSCi: on the percentage of liospital days spent in the ICU In 1 993, 
patients would have spent 73<!;, ofthc liospitalizjilion in the ICU vs .15% observed, in 
1994 84% vs 47°.i observed, and m 1995 89% vs 53% observed Based on lower 
charges for care in the RcSCU ($56(1/day difference in daily room charges) and 
assuming no prolongation of hospitalization because of ReSCU care, this decrease in the 
percentage of ICU d.ays suggests a substantial savings ($1,224,720) associated willi the 
RcSCU CONCLUSIONS: (1) Consistent with other sencs. the rate of successful 
weaning from mechanical ventilation of selected pitienls in a dedicated unil can be very 
high (2) In the absence of more dcfinilivc data from a randomized controlled uial. this 
experience suggests tliat a Respiratory Special Care Unit can be a cost-elTeclive icsoutcc 


PROGRAM ON VENT ILATOR C'ARF Rayiniind.MaJloi BS RRT. John Embcrgcr 
BS RRT. Alan SpiUei MD Herbert Patrick MD, Departments of Respiratory Care 
and Pediatncs. Thomas JcfTcrson L'nucrsitv Hospital Inc. Philadelphia PA 

Background: The Rcspiralon Care Ventilator M.inagcmcnt Fvalualion Program 
added a nconjul ventilator OVAI program to tlv existing adult program which 
gathers dailv coniprchi.-nsive d.ita on ventilator patients Our Intc-nsive Care Nuisery 
(ICN) Neonalologists were consulted for QA&l data ranges Hypnthcsis: Wc wanted 
to determine if nci>natal ventilator QA&I and education about ventilator management 
would impact the ventilator care given to prematures Methods: Data including 
ventilator settings. .ABG's. ovygcnahon .and ventilalion weaiung and tube 
characterisucs were gadicrcd Data was analyzed qiuinerly by respiratory care 
personnel and reported to ICN group meetings for physician and nursing Icedback 
The dau for the initial three quarters ventilator weaning of prematures were examined 
Indicators I and 1 shown below assess the aggressiveness of weaning oxygenation 
and venulation paramders Indicators .3 and 4, shsiwn below, assess if weaning is too 
aggressive and a rc-bound effect is occurring There was an emphasis placed on these 
weanmg parameters after first quarter was gathered Results: ITic toLiI number of 
prematures (N) was .5 1. with a loLil of 4X: dailv encounters (n) 

QA & 1 Indicators 

Apr-Jun.95 Jul-Sep, 95 

(Before Fducation) N -4 
N- 12. n= 1-35 n - IM8 

Oct-Dec, 95 

N - 20 
n- LW 

1 F or PEEP weaned 
if P,0 80 torr 

54% 67% 


: PIP or IMV R.ile weaned 
iflastP.CO - -"'8torT 

58% 71% 


3 F : or P F F P nol I nc re,ised 
after being weaned 

100% 91% 


4 PIP or IMV Rate not 
increased after bemp weaned 

m% fli'i 


Conclusion: A neonalal VLTiltlator QA&l program uicreascd aware-ness of appropriate 
parameters for weaning ventilators in the ICN The increase in indicators 1 and 2 
show that weaning has beeonK more aggressive with increa.sed awareness of 
appropriate paraitieters and indicators 3 and 4 show that we have nol become over 
a«grcvsive though Iheic was a slight lapse m indicators 3 and 4 during Jul-Sep "5 
Other factors need lo be analyzed'tn the future such as rotating house staff, and 
scvenlv of the prcnialures 




Tuesday, NovEMBtR 5, 3:00-4:55 pm (Rooms I A-B) 

EXTUBATION. Mohamad liL Khaiib . Div. Pcdiairic Phannacology & 
Critical Care. Rainbow Babies and Children^ Ilospilal, Cleveland, OH. 
Introduction: Many studies have established critena to predict outcoine of 
exiubaiion from mechanical ventilation in the ICU seiungs. Most of these 
studies have combined simple respiratory variables (eg., the number of 
breaths per minute, tidal volume, blood gas analysis, etc) and combined them 
in integrative indexes that are supposed to be superior than traditional 
parametrs in predicting outcome of mechanical ventilation. Ho%vever a value 
for an integrative index can be achieved with int'mite combinations of values 
for the individual parameters constituting this index and such without a quali- 
tative evaluation of the respiratory pattern, these indexes might be misleading. 
Objective: Geometnc and numerical techniques from non-linear dynamics 
were used to chaiactenre the spontaneous respiratory pattern dunng SIMV 
ventilation in an ICU setting for patients who passed and failed exuibaiion. 
Methods: Houny-onc children (0-15 >ts) mechanically ventilated in the 
PICU, clinically .stable and considered extubatable by their attending physi- 
cians were studied. A respiratory monitoring system (VF.NTRAK. Novanic- 
trix. CT) was used to measure the spontaneous volume and flow signals. 
Patients were then extubated. Failing extuhation was defined as reintubaiion 
within 24 hours of extubation. Observations of the spontaneous breath trajec 
tones within the two dimensional (ie. volume and flow) respiratory phase por- 
trait were used to qualitatively assess the dynamical breathing behaviors of 
the two patients groups successful vs. unsuccessful extubations. llie 
Kulmogorov enu-opy, or the net exponential rate at which adjacent 
spontaneous respiratory trajectories diverge in the volume-flow space, which 
is a dynamic propcny related to chaotic behavior, was derived. The diver- 
gence constantly produces new information (ie, hits) over time. .Mso the di- 
mension of the pattern, or the number of clusters of nearby trajectories of 
spontaneous breaths, was denved. High values for both entropy and 
dimension reflect a more chaotic breathing pattern. Result.s: Of the 41 
patients included, 33 extubations (80%) were successful and 8 (20%) were 

Successful (n=33) Unsuccessful (n=8) 

Entropy (bits/cycle) 0.()5±0.03 0.32±0.05 (p<0.0,'i) 

Dmtension 1.06±0.08 3.03±0.35 (p<0.05) 

Both the Kolmogorov entropy and die dimension of the breathing pattern 
were significantly smaller in the successfully extubated group. Conclusion: 
The spontaneous breathing pattern during SIMV ventilation is more chaotic in 
patients who failed extubation whereas it is stable and more reproduciablc in 
patient s who failed extubation. Thus charactenzing the spontaneous 
breathing pattern might be a useful tool in differentiating between extubation 
success and failure. OF-96-153 

WITHDRAWAL. J Hoyl. A McKibben, AB Adams F Indihar, JJ Manni, A 
Nahum. University ot Minnesota, Bethesda Lutheran Medical Center and 
SI, Paul Ramsey Medical Center. MplsjSt. Paul. MN. 

TGI flushes the deadspace free o( CO2 Irom ttie catheter tip to the 
airway opening This effect may decrease minute ventilation requirements 
ot ventilator dependent individuals and allow them to tolerate less or no 
ventilator support. To our knowledge, TGI has not been evaluated as a 
technique to assist weaning from the ventilator. In a chronic ventilator 
unit, we obtained consent for such an assessment from 10 individuals 
deemed ventilator dependent after multiple unsuccessful weaning 
attempts. Methnds : Pressure support ventilation (PSV) was set to provide 
a tidal volume of 10 mL/Kg. Pressure support level was then reduced by 
15% every 15 minutes until intolerance developed. This served as a 
weaning "stress test" to assess length and ease ol ventilator support 
withdrawal. Each patient was randomized to tjegin either TGI or no TGI, 
and to cross over 10 the other limb after an hour of rest with full 
ventilator support Monitoring during the study included airflow, airway 
pressure, esophageal pressure, respiratory inductance plethysmography, 
oximetry, capnography. and EKG. Intolerance to a reduction in PSV was 
assessed by preestablished criteria. Expiratory TGI was delivered at 10 
LVmin (blended to the FiOs of the ventilator) with the catheter positioned 
1 cm above the carina Results : With TGI, the subjects tolerated 
reduction from full support lor a mean of 67,2 ± 26,7 minutes while 
tolerating 60 5 ; 19.2 minutes during the control limb (p=0-29). One 
patient with a narrowed upper airway (confirmed by bronchoscopy) 
demonstrated intolerance within 21 minutes of TGI (compared to 44 
minutes during the control limb) by increased breathing frequency. 
During TGI. all patients inspired part of their tidal volume from TGI gas 
flow prior 10 triggering the venlilalor. Several patients took shallow 
breaths entirely trom TGI gas flow without triggering the ventilator. 
Conclusions : Patients tolerated gradual withdrawal of ventilator support 
with TGI but their tolerance was not significantly different during PSV 
alone (without TGI). In some patients. TGI may impair ventilator 



Richani Bran.s on RRT . Robert Campbell RRT. Ken Davis Jr. MD. Fred Luchcltc MD, 
Jay Johannigman MD Dcparmient of Surgery, University of Cincinnati. Cinciiiiiali, 

Baclv^round: Ventilalory support in sub-aculc tare hai become more common and 
more sophislicalcd as a method of cost reduction Current portable vemilalors are 
small, sunple. and inexpensive yet lack demand valves, monitoring, and PSV 
Currcnl ICU ventilatory allow necessary functions, but are large, expensive, and 
complicated Purpose; To compare a new ponabic ventilator with a buill-in gas 
source, capable of PSV and flow u-iggenng 10 an cstablistied ICU venlilalor 
Mettiods: Thirty palienls <2l men. 9 women, mean age 42 ( 14) vts) ventilated lor a 
mean duralion of !(> (5) days were studied Venlilalor senings were SIMV RR =- 4 
12). PEEP - 6 ( I ), FIO, - 37 (0 06). PSV - 1 4 (4) cm H,0 and V, - 7 1 (0 16) 
Palients were ventilated with a TBird or 7200ae venlilalor in random sequence at 
identical ventilator sellings for a penod of 4 hrs Cardiorespiralors variables were 
monilorcd continuously by bedside monitors tBiCorc CP- 100 wilh variable orifice 
flow irajisducer and Sirecusl) Ever> 30 nuns sponl V,. spont, RR. and V^ were 
recorded Arterial blood gases were drawn and analyzed every 2 hr Data are shown 
below mean (SD). Data were analysed by ANOVA and a p<0 05 was signiticanl 


4 llr 





/sponl (RR) 





V, sponl (L) 


37( 151 

40( 17) 

.36 ( 14) 


8 5(24) 

1 1 (2 1) 

87(2 1) 

9.1 (2 S) 

PaO; (loiT) 





PaCO, (ion) 





Results; There were no sigmficani differences bctueen measured variables Palienls 
appeared comfortable using boih ventilators There were also no changes in 
hemodynamic variables Conclusion: In this celling, die TBtrd provided ventilator^' 
suppon equivalent to the 72(X)ac The TBird appears lo meet the needs of the sub- 
acute care facility, combining portabiht> and built-in gas source with responsive 
tnggerine and pressure support 


Respiratory Care • October '96 Vol 41 No 10 

8:1 A.M. -5:| P.M. 

The essentials of a complete and accurate 

program. Come to San Diego a 

day early and find out 

what it's all about. 

Call lor more Inlormation and rcgislration form 


Sponsored by Lxiuisa Ruesch and Doug .Meyer. 

C.\ CEUs available. 












Wednesday, November 6, 12:45-2:40 pm (Rooms 1 A-B) 


Timmhy B O p'i Holl Ed D . R R T. . University of South Alabama. 
Mobile, Alabama 

BACKGROUND: Trarispon of mechanically vemilaled patients using a 
resuscitation bag may cause hyperventilation and an inconsistent tidal 
volume (Vi) and h,,,,. hence the development of transpon ventilators. The 
AARC has issued a consensus statement and clinical practice guideline 
containing criteria for transport ventilators 1 hi» is the first evaluation of 
this ventilator to determine its consistency with specifications and 
guidelines, and ease of cimical use DESCRIPTION OF DEVICE: The 
ventilator is pneumatically powered, microprocessor controlled, time or 
pressure triggered, pressure limited, and time cycled and provides breaths 
in the control, assist control, SIMV or CFAP modes All funcliuns are set 
by rotating function-labelled knobs EVALUATION .ME THODS: 
Compliance of the ventilator with published guidelines and specifications. 
Vt delivery at 5, 1 0, and I 5 L at 02. 04 and 10 L/cm ILO 
compliance, pressure trigger and demand valve responsiveness, were 
evaluated on two ventilators borrowed from clinical sei^ice. using 
Michigan Instruments Training Test Lung and PneuView software Alarm 
functions and clinical ease of use were also evaluated EVALUATION 
RESULTS: I'ldal and sigh volumes, ventilatory rates, and inspirator)' times 
weie clinically consistent between the two ventilators tested I he delivered 
Vts varied fiom -« S% to t I 2% from the set value Assist and demand 
valve sensitivities weie within I 0cm H,0 [0 IkPaJ of the set values When 
using the ANffiU PEbP valve, expiratory pressures were I 1-1.) cm H,0 
( II- n kPa] above baseline Alarms Rinclioned within specifications Gas 
consumption was 3 S and 6 6 L/min for the two ventilators studied 
CONCLUSIONS: The Avian confoims to the standards set in the 
liteialure and functions within manufacturer's specifications Assist and 
demand valve sensitivities are consistent with that set on the ventilator and 
are .sensitive to simulated patient eilbrt There is potential for increased 
expiratory work when using the AMBII PEEP valve 



Robert S Campbell RRT. Richard D Branson RRT. Jay A Johannigman MD. 
University of Cincinnati Medical Center, Cincinnati. OH 45267. 
Purpose: To evaluate a new transporl ventilator in respect to delivery of set tidal 
volume (Vt) and PEEP, accuracy of minute ventilation (Ve) and ainway pressure 
measurement, demand valve responsiveness, alann function, and battery 
duration Method: The Oxylog 2000 was attached to a two-chambered test lung 
(TTL. Michigan Instmments) equipped wi\U pressure, flow, and volume monitortng 
softw/are Ten breaths were recorded at each combination of Vi (0 1 . 5, 1 0, and 
15 L), Cl (0 1, 04, and 02 UcmH^O), and air-mix (AM) swrtch (on. off) with the 
ventilator in the CMV mode at a rate of 10 using a 11 5 1 E ratio PEEP was 
randomly set to 0, 5, 10, and 15 cmH,-0 and measured within the TTL using an 
RT-200 calibration analyzer Volume and pressure measured within the TTL were 
compared to those reported by the ventilator (Student's T-test) Responsiveness 
of the demand valve was evaluated by measunng the peak negative pressure 
(PNP) at CPAP levels of 0. 5. and 10 cmH:0 aher modifying the TTL to simulate 
spontaneous breathing with demand flow of 30 and 60 L/min All alarm functions 
were evaluated by creating known conditions above or below each alarm 
threshold Both the alkaline and NiCd battery duration was evaluated by njnning 
the unit until the low battery alarm sounded and gas delivery ceased Results: 
Table 1 shows the Vi (L) delivery and V^ (Umin) measured at all Ci and AM 
settings using a 1 L Vi at a rate of 1 bpm Table 2 shows the actual PEEP level 
and PNP with 60 L/min demand flow lor each PEEP setting 

Table 1 Table 2 









1 11 






1 20 

1 1 

1 1 






9 4- 

7 6'$# 











•^p<0 05 vs AM off $=p<0 05 vs Cl 1 #=p<0 05 vs Cl 04 
The NiCd battery provided ventilation for 5 hours, 5 minutes The Alkaline battery 
pack provided ventilation for 3 hours, 37 minutes The "change battery" warning 
provided three minute notice pnor to termination of ventilation All alarms 
operated to manufacturers specifications Discussion: Delivered Vi dropped 
predictably as C^ was reduced witti the AM on Measured V, adequately reflects 
actual minute ventilation delivery Applied PEEP exceeded both set and 
measured PEEP at all settings Demand valve tnggenng was sluggish and 
worsened with increasing PEEP Conclusion: The Oxylog 2000 provides 
adequate Vt delivery and V^ measurement m both CMV and SIMV modes at 
normal and moderately reduced C AM setting should be used cautiously when Cl 
Is greatly reduced Patients should be closely monitored dunng spontaneous 
breathing for signs of increased work of breathing 



Robert S Campbell RRT , Richard Branson RRT Jay A Johannigman MD. 
Kenneth Dauis Jr MD University of Cincinnati Med Cnir, Cincinnati, OH 45267 
BACKGROUND: Moulh-to-mouth and mouth-to-mask ventilation are fast 
becoming dinosaurs in the prehospital environment even among trained 
professionals This is mainly due to concerns over infection control issues Most 
patients presenting to our emergency department without an instrumented airway 
are receiving bag-valve masic ventilation (BVMV) from a paramedic or EMT 
Though each squad is equipped with a transport ventilator, it s use is generally 
reserved for intubated patients This study was designed to compare the efficacy 
of mask ventilation provided by BVM, two commercially available demand valves 
(DV). and a transport ventilator when used by paramedics and EMTs METHOD: 
Eleven paramedics ventilated a lung model consisting of a mannequin head, 
tracheal model, simulated esophagus, and training test lung using each 
ventilation technique for 10 minutes A disposable adult anesthesia mask (King 
Systems Corp ) was used for all tests A disposable resuscitation bag (DMR II. 
Nellcor/Puritan -Bennett) was used to provide BVMV Two manual pneumatic 
demand valves were used (LSP Model 575 and CPR Medical devices Oxylator 
EM-IOO) to provide manual triggered ventilation An Impact 750 transport 
ventilator was used to provide ventilator to mask ventilation Lung compliance 
was set at 04 L/cmH;0 and resistance at 5 cmH,0/L/s Paramedics were 
instructed to ventilate the test lung with an 800 mL V, at a rate of 12 Dunng each 
test period, delivered Vy. respiratory frequency (0. Gl volume and ainway 
pressures were measured and lecorded for each breath using a test lung 
software package Mean values for each minute were calculated from these 
measurements RESULTS: Delivered V, and Gl volume using each technkjue 
are shown at 1 and 10 minutes Results are mean (mL) t SO 


Vi-1 min 

VrlO min 

GI-1 mm 

61-10 min 












78 USB- 




Impact 750 





•p<0 05 vs BVM «p<0 05 vs LSP Jp<0 05 vs EM 100 
Mean PIP (cmH;0) using each technique was BVM = 27 1, LSP - 20.5, EM-100 
= 22 3. Impact 750 = 17 7 DISCUSSION; Though BVM is the most commonly 
used technique, it resulted in significantly lower V, delivery compared to all other 
techniques tested Gl was highest using BVM technique due to the associated 
higher PIP CONCLUSION: Both manually tnggered demand valves and the 
transport ventilator provided superior V, delivery compared to BVM. but only the 
transport ventilator lowered the Gl volume. 


Robert R. McCoimell.RRT . Hcjlher FrederickiKn.RRT. Sharun Day. RRT, Neil R 
MacInlyrt.MD. Duke Univeniily Medical Center. Durham. NC BACKGROUND: The 
TBirtt veatllator system (Bird ProdueUi. Inc.. Palm Springs. CA.) is the first venlilalor 
system to combine pressure support and tialter^ powered opcraUon uUUzmg a turbme tor 
high pressure air. We conducted pre-markel evaluation of the pcitonuaoce of the TBird in 
the prt-vsure support mode wtlile operating on DC battery p<iwcr METHODS^ Thirteen 
stable patients in the ICLl being ventilated in the pressure suppoit mode wuh other cntical 
caje venlilanirs where chosen for the evaluation The patients were se^uenually managed 
using the enact same settings on their ba.selme ventilator, on TBird with AC power, on 
TBird with DC power, and after return to haselme ventilator. Data measured mcluded; tidal 
volume. PEEP, respiralory rate. Fl02, .Sp02. and ABC Analysis was by ANOVA wuh 
P < .05 taken as sigtufieant RESULTS Mean ± standard deviation (STD) differences 
between baseline ventilator and TBird on AC and DC power are given m TABLE: 

FK)2 H02 E02 P»02 Pa02 Pa02 PaC02 PaC02 P»C02 

61- TBtAC) BI-TBlEX) B 1-62 61 TBiAC) BI-TBtt X:) B1-B2 B1- TB(AC) BI-T8<0C) B1-B2 

M«an 00 I -0 00 | <iOO" 1 - 15 " ' -2 68 5 aS -0 15 92 1 -0 15 , 

STCa ~002~ 1 02 " loot I 15 73 21 56 22 29 I 3 38 ~' 369 I 4 11 

Vt Vt vt PEEP PEEP PEEP Rate Rale Rate 


Meanl 002 j 001 I 02 37 029 I -0.661 04« T ~-0.a5 I -0.06 
STD 0l3 0.12 *'" 



10 27 



T56g i 

BI^Baseline Ventilator. TB(AC) = TBird 120v. TB(DC)-TBird on Baitery. 

B2^Post Evaluation Haselme 

None of these differences reached sutisticat significance 

EXPERIENCE: The THcrd worked well in the pressure support mode, the patient appeared 
comfortable and stable. aJJitionall) Ihe turbine provided a sUble Fi02. with very quiet 
operation and a lightweight design. CONCLUSION. The TBird Vcnlilator System will be a 
usehil device for delivenng pressure support m a variety of settings includuig cntical care, 
subacute, or when batter) operation is nece&sary. 



RESPIRATORY Care • October '96 Vol 41 No 10 

Wednesday, November 6. 12:45-2:40 pm (Rooms IA-B) 

PEj\K pressure. Kctlv Jatfcr. RR T. Martin Tweeddalc. MB, PhD. Vanmuvcr HospitaJ 
and Health Sciences Center, Vancouver, Brilish Columbia, Canada. 

BACKGROUND: High pealc airway pressures (Paw) have been associated with ventilator 
induced lung injury. However, in intubated patients a significant pressure drop can occur 
acros-s the endotracheal tube (ETT) thereby making intratracheal peak airway prcviure 
(Plrach) more accurate than proximal (Paw) for the proper determination of lung 
mechanics. Gottfried ct al have reported in-Mtro constants, to assist in che estimation of 
ETT resistance (RETT) TTic purpose of this study was to determine whether a simple 
equation based on their constants could be used at the bedside to accurately estimate 
Plrach (cPtrach) in ventilated criUcal care patients. 

METHODS; The equation used was cPtrach = (estimaled Rp( x flowralc) + Pplaleau, 
(where Rpl is patient resistance delcrmincd as respiratory system reiislance minus RETT, 
esliraaled from Goltfried's constants) Estimated Ptracb was compared to Ptrach measured 
(mPtrach) usmg a small bore catheter placed distal to the lip of the ETT. In 10 patients 
(group 1) proximal Paw, Plrach and Pplateau were measured and averaged over 1 breaths 
at the patients' set flowrale In a second set of 10 patients (group 2), ihc same 
measufemcnts were made at 4 different flowrates. In Kith groups, bias ± prccLsion were 
used to compare ePlrach to mPlrach using the methods of Bland and Altman Bias was 
plotted against the mean of ePtrach and mPtrach, We defmed limits of agreement of l 3.0 
cm H;0 as clinically acceptable In group 2 patients, Friedman's n on -parametric test was 
used to compare the bias and precision of the 4 different flowrates. 

RESULTS: In group 1, bias i precision was 53 ± 4.24 cm H2O. The calculated limits of 
agreement were -3.1 to 13.7 cm H^O. All data points for flowrates < 85 L/min were 
within the clinically acceptable limits of agreemenl. Results for group 2 are shown in the 

Flow (L/mir) 






29 7 1 54T 

302 ±405 

31 6 ± 3 44 

31 1 1 2.77 


310 ± 470 

31 2 t 368 

284 1 4W 

26_2 t 5 79 

bias 1 precision' 

-I 3 t 164 

-1,0 ± 2,71 

3 2 1 4 nut 

4 9 t 4 67+ 

• cm H,0 

t p < 0.05 compared to flowrates of 60 and 80 L/min, 

CONCLUSIONS: The results of this study indicate that the equation based on Gotlfneds' 
conslants can be used in estimate Plrach m patients with ventilator flowrates < 85 L/min, 
however, with flowrates above this level, Plrach should be measured directly. 





Rand\ DcKJcr.MS.RRT Jonathan B Waugh. PhD, RRT. CPFT, Georgia Stale 

Umversm-, yMIanla. GA 

RackgrrHind The t.)u3ntiini/PSV .1 recent K-re leased \eniiinioi- designed\e 
\ entilolorv ■rapport, incorporaies a new control culled "nse time ' Rise time controls the 
time requtfed for set IPAP to be achieved We examir.eJ thi% device lo determine what 
efTect alterations in the nse time sdttmg would have nn delivered tidiil \olunie (V-) and ihc 
inspiratorv flourale rcquu-ed lo tngper 3 breath Meth^.'d'* /\n carU proUuciuMi nnxlel i^f the 
Quanlum'VSV was used for Ihc stud\ Data acquisition uas made itssng the VaiidvTie I TC 
s\ stem ( Valid>ne Engineennp Corp . Norlhiidge. CA ) and a Hans Rudolf 
pneiunotachomeier model 3813 (,Hans Rudolf. Inc . .St Louis. MO) Calibration of all 
ui-~lrumeni'- was completed .md all \alaesmet A IS {+ 3%) and ASTM(i2%)cnlena A 
Manlev lesi lunj; i ( )limeda Madi-^w. Wl ) served as the lung simulator for the V^. 
nieasuremcnls with C, 50 ml/cm H;() and R^^^ 2 cm H.O/l/sec QuanHim/PSV .setlmgs 
were IPAP-'EPAF = 20/d. % inspirator}' time = 25%, trequencv - lO/mm.tbrihe V, 
mea<nircment.s A custom-built, dual chamber lung model was used for the flow ingger 
measurements Rise time was changed in C I second increnient> ac^o^5 most of the range of 
the parameter [0 2 • ') sec > Results 













(0 1) 

41 II IS 
II I) 


(0 4) 

41 III 1 
(0 4) 

TJl 5 
(0 2) 

191 4 

38(1 9 
(0 2) 




1 (110) 


( 005) 



( 002) 


1 (iioi 

Conclusions The siud\ data suggest that Umger rise time \ alucs pnxluct smaller patient V,s 
at a given IP,^P'EP.M^ setting This ma\ be due to n lower mean ainvnv pressure associated 
with more m*<de\l llow rates at the longer nsc lime >ellings Changing a pahenl from shorl 
to a long nsc lime scttini: ma\ retjuire a slight increase in the pressure bi.>«i>.l setting to 
maintain the pre\ ions V^ level The mean How requu'cd lo ingpei a brealh \va> significnnth 
lower at a nsc lime of 9 seconds ihan the ingger levels at 2. 4. aiid 6 second nse time 
I p<0 05 ) 



KG Ong. GDA-Coun . P Bng. YY Ong 

Department of Respiratory & Critical Care Medicine. Singapore General Hospital 

Ideal position of the endotracheal htbe (ETT) within the trachea is 5:2 cm from the 
carina w ith the head in neutral position (Goodman's criteria) Previous studies in 
Western populations have shown that it was possible to achieve ideal positioning of oral 
ETTs in nearly all patients by placing the ETT at the reference marks of 23cm in men 
and 21cm in women However, our previous study using these reference marks for our 
local population did not result in ideal positioning in a significant proportion of cases 

We therefore conducted a prospective cohort study to assess the possibility of achie\ ing 
ideal ETT position by placing ETTs at reference marks of 21cm in men and i9cm in 

All patients orally intubated in the Medical Intensive Care Unit. SGH between May- 
December 1995 had their ETTs positioned according to the new reference marks. 
Patients beyond normal height range (l54-184cm-males. 144-l71cm-femflles) were 

Eighty men and 53 women were studied (n=l 33 ) The median distance of ETT tip lo 
carina was 5.0 cm with a range of 2.0-10.0 cm. Ideal positioning were achieved in 
107(80 5%). Nine (6,8%) had the ETT tip <3cm from the carina and I7(12.8%)>7cm. 
The proponion with ideal ETT positions was significantly larger compared lo our 
previous study (p=0 OOOOS) 

Adopting the new reference marks resulted in more cases with appropriate ETT 
positioning Routine use of these reference marks as a guide for ETT placement in our 
Asian population may reduce complications associated with ETT malposition. 



Prian Jent: CRTT . Gr-i:iC Liacon RRT, JoEeph Bailey BS, and William 
Burke PhD RRT, Indiana univeisity Hospital, Indiana University 
Respiracory Therapy Piogram, Indianapolis, IN 46202 and 
Midwestern State university. Respiidtoiy Therapy Progiam, 
Wichita Falls. TX 76308 

BACKOROUifD Woi k of breathing (WOB) is an iirporcant variable 
Lhat: Respira::ory Therapists attempt to use to evaluciCe a 
patients ability to suppoi t sp.ontaneous breathing. There are 
two methods used to evaluate a patients WOB. One is to measure 
the mechanical work of inflation by exarr.ining the driving 
pressure- volume curve. In spontaneous breathing subjects t:u8 
is typically done with the aid of an esophageal balloon, 
however, this method does not measure total WOB only woi K done 
on the lung is quantified. The total WOB of a specific 
ventilatory task can be measured by comparing the change of 
tot a 1 body oxygen consumption (VOj) before and after a load is 
placed on the ventilatory pump. Ventilator sensitivity, when not 
set appropriate, can cause a significant increase in the 
patients WOB. In addition, because of pathology, many patients 
who are venLilatoi dependent have high minute volume (MV) 
requirement's. We Investigated how minute ventilation affects th*? 
oxygen cost associated with increasing efforts needed to 
initiate inspiration in normal subjects. BCBTHODS We stimulated 
subjects to breathe by having them turn the peddles of bicycle 
eigometer, set to zero resistance, at 3 different speeds: 0, "io 
and 88 revolut ions/min . All subjects were attached to a PB7200 
ventilator, set in the CPAP of O mode, via a standard exercise 
mouth piece. The ventilator's sensitivity was adjusted to three 
levels: -2, -5 and 10 cm H^O. Expired gas was analyzed with a 
Sensormedics Deltatiac metabolic monitor. We tested 6 subjects 
at each speed and sensitivity setting. We used a repeated 
measures ANOVA model to determine statistical significance. 
BISDLTS MV at the three cycling speeds averaged (iSE) 8.2t0.4 
(normal), 11.5±0.4 (moderate) and l7.6to.4 (high) liters, 
respectively, for the three cycling speeds. Although there was 
a significant increase in VO, as t^V increased, at each MV level 
.iecreasing the sensitivity did not result in an increasing vo. . 
CONCLUSICM In normal subjects there is no oxygen cost associated 
with the increased effort needed to initiate inspiration. Even 
high KVs tini1 -10 cm H,0 trigger sensitivity resulted in no 
increase in VO, . 


Respiratory Care • October "96 Vol 41 No 10 


Wednesday, November 6, 12:45-2:40 pm (Rooms lA-B) 

Shelledv. PhD. RRT . Robert W Lawson. MS. RRT. Oliver J Dnimheller, EdD. RRT. The 
Universiiy of Texa.^ Health Science Center ai San Anionio. San Antonio. Texas 

BACKGROL'ND Volume suppon (VS) is a newer mode of mechanical ventilation that 
combines aspects of pressure support and volume ventilaljon We compared the veniilator\ 
efficiencv of VS with variable inspiraton. flow to traditional assist ventilaiion (AV) with 
three different ft\ed inspirators flow (FlFj rates METHOD A prospective, randomized 
blocks repeated measures design with subjects serving as their own controls was used to 
studv 10 hcalthv volunteers, aged 12 to 49 Baseline spontaneous ventilation data 
collection was followed by mechanical ventilation b> mouthpiece using variable flow VS 
and AV with FlFs of 40, 60 and 80 Lmin applied m a random sequence All modes used a 
VI of lOcc kg of ideal body weight and a sensiiivirv of -I cm H.O [-0 0981 kPa] delivered 
via a Siemens Servo >()0 ventilator <Siemcns-E!ema. Solna, Sweden) Data was collected 
continuously for 5 minutes using the MetaScope metabolic can (Colorado MEDiech Inc 
Boulder. Co ) and the mean values were reponed Ventilatory equivalent for oxygen 
(VhQ) IS a measure of the efficiency of the ventilatory pump ai various workloads and was 
calculated by dividing V'e (BTPS) by VO; (STPD). RESULTS: 

Means iSDI 


Assist Ventilation 


flow rate 


40 Lmin 60 1-min 801,'min 


rate ibpmi 

15 (J) 

l8-(7) 20(8) 21(8) 


V, (mil 


1033(320) 998(234) 995(230) 




17.2(5.8) 18.9(6-2) 20 3(6 4) 

18 5(9 6) 

VO. (mltnln) 


277(52) 292(47) 276(37) 



34,0 («.6) 

615(13,2) 646(16.7) 72 8"(I6.5) 

64 7(20 7) 

* significantly different (p = 05) than AV with FIF 80 L min. 

•* significantly different (p < 05) than AV with FIF 40. AV with FIF 60 and VS 

There were significant differences in VEQ (p ^ 007) and respiratory rate (p = ,039) using 
ANOVA There were no significant differences in V. (p- 14). V, (p - 37)or VO. (p = 
.35) Neuman-Keuls pairwise foMowup comparisons found thai a FIF of 80 L min produced 
asignificant!> greater VFQ Ihan FIF 40 Lmin (p- 0051. FIF 60 L mm (p - 032|and VS (p 
» 014) AV with an FIF of 40 L'min produced a significantly lower rale than FIF 80 L mm 
(p ' 03) There were no significant differences in VEQ between MF 40 Lmin and FIF 60 
L'mm(p- 32I.FIF40L minand VS(p- 55). FIF 60 Lmin and VS (p - 97) 
CONCLUSIONS AV wilhaFIFofSOL minwassupenorin ventilatory elTiciency to VS. 
AV with FIF 40 L/min and AV with FIF 60 Lmin VS did not significantly improve 
ventilatory efficiency when compared to AV. regardless of inspiratory flow rale used 



Lynn Mellecker. RRT. D Michael Shasby. MD. LuAnn Wilford. RRT. University of 
Iowa Hospitals & Clinics, Iowa City, lA 52242 
Introduclion: A military smoke grenade contains hexachloroethane, zinc oxide. 
aluminum powder, silicon and potassium nitrate Upon detonation these substances 
create zmc chloride. When inhaled, zinc chionde is highly caustic to mucous 
nwmbranes and has been associated with fatal, necrotizing pulmonary lesions A 
literature review confirmed the seventy of respiratorv failure and extreme mortality 
with conventional therapy We descnbe the use of the Adult Star 1010 (Infrasonics 
Inc , San Diego, CA) Ultra High Frequency Ventilator in a case of high exposure to a 
detonated "wnite" smoke grenade Case Summary: A 21 year old male was 
transferred to the medical center three days post exposure to detonation of a smoke 
grenade in the confines of a cave Pnor treatment included aerosolized 
bronchodilators. steroids and supplemerial oxygen The arterial blood gas upon 
admission was 7 46/35/41 (pH/PCO;/PO; respectively) on 6 Lpm oxygen cannula 
After 10 days of accelerated aerosolized bronchodilator, steroid and supplemental 
oxygen therapy, his blood gas was 7 43/44/69 on 100% oxygen by mask Chest 
radiograph revealed diffuse, opacified pockets without evidence of a pneumothorax 
Thereafter, a tension pneumomediastinum developed and was treated with bilateral 
chest tubes Secondary to tachypnea and hypoxemia, he was intubated Pressure 
Regulated Volume Control (PRVCl and Pressure Control (PC) modes of ventilatory 
support were used After 12 days of aggressive ventilation and nitnc oxide therapy, 
the air leak worsened and on PC Inverse Rabo Ventilation with 100% oxygen, the 
blood gas was 7 37/58/35 resulting in an Oxygenation Index (01) of 63 (an Ol > 40 
has been associated with a mortality of 90%] UHFV was initiated in hopes of 
reducing the magnitude of air leak and the intrathoracic mean pressure while 
maintaining acceptable blood gases, i e , an improved 01. Within 5 minutes ol 
initiating UHFV, the pulse oximeter rose from 56 to 80% and within 24 hours to a 
mean value of 98% with an 01 of 23 (7 44/43/81 on 90% oxygen) Over the next 31 
days of UHFV, his respiratory status stabilized, while vanous infections were treated 
The deciston to establish a tracheotomy for an airway resulted m returning the 
patient to ccnventiona) ventilation Following 82 days of aggressive rehabilitation and 
conventional ventilatory SLOport. the patient weaned to a 2 Lpm oxygen cannula with 
a blood gas of 7 39/49/72 (DlCO at 22% predicted) Tracheostomy and jejunostomy 
tut>es were removed 14 days later Foltowing two months of horT>e-based 
rehabilitation, a repeat pulmonary function test revealed an improved 0^00 at 41% 
of predicted No untoward results could be associated with UHFV compared to 
conventional ventilation therapy Discussion: Reports descnbing the concentrated 
inhalation of the contents of a detonated smoke grenade associate a 1 00% fatality 
rale with conventional ventilation Ultra High Frequency Ventilation can be life 
sustaining m the face of severe respiratory failure unresponsive to aggressive 
conventional ventilatory support 



Jaine s J Lawson RRT . Kenenng Medical Center. Da>lon, Ohio 45429 
latroduction: The incidence of PEEP, has t>een previously reported to be 
between 10 and 46% in mechanically ventilated (MV) ICU patients PEEP, 
may cause hypoxemia, hypercarbia, increased work of breathing, and 
hemodynamic compromise in MV patients. This study was designed to assess 
the incidence of PEEP, ubing two techniques: I) assessing tlic expiratory- flow- 
waveform, and 2) measuring ai^^^'ay pressure during an expiratory hold. 
fVfetbod: During the two month study period beginning January 1996. each 
MV patient in SICU and MICU was evaluated for the presence of PEEP, using 
each technique. All patients were ventilated with a Nellcor/Purilan-Bennel 
7200ae. Siemens 300. or Siemens 900C ventilator. Expiratory flow waveform 
was evaluated using the 7200ae graphics package or with a bedside monitor 
{Navigator, Newport Medical) for any patient on a Siemens ventilator. PEEP, 
was determined to be present if the expiratory flow did not return to zero prior 
to the onset of the next inspiration Expiratory hold was provided by use of 
each ventilator's expiratory hold feature. An expiratory hold of 2 seconds was 
attempted witli each meisurcmeni. PFFP, was determined to be present if. in 
the absence of patient effort, pressure in the breathing circuit was above set 
PEEP at the end of the 2 second expiratory hold. Measurements were made 
BID, three days per week during the study period Results: I hiriy patients 
were monitored and a total of 150 PEEP, assessments were made Eleven 
(36 6%) patients had PHFP, according to the expiratory flow waveform 
assessment on 80 occasions Only four (13.3%) of those patients had 
measurable PEEP, using the expiratory port occlusion technique on 30 
occasions. Eight of the eleven (71%)paticnls with PEHP, were admitted to the 
MICU with a primary respiratory diagnosis. Discussion: incidence of PEEP, in 
our pt population is similar to thai reported by others. Ilie majoril>' of 
expiratory port occlusion maneuvers were aborted due to presence of patient 
effort Use of airway pressure and flow graphics has increased our awareness 
of PEEP, and patient-ventilator interaction during MV in the ICU. Limitations 
to the use of flow waveform assessment to confirm PEEP, are that PEEP, may 
not be quantitated using this technique and PEEP, may be present while 
expiratory flow is zero due to dynamic airways collapse. Conclasioo: The 
overall incidence of PEEP, is highest when using expiratory flow waveform 
monitoring Furtiicr work is needed to correlate the expiratory flow waveform 
to the quantitatively measured Pf-.RP,. 



M.iv Kir mse. MD. Dean I less, PhD, RRT. Hidcaki Imanaka. MD. Robert M. 
kacmarek. PhD, RRT Respiratory Care and Dcpartmcnl of Anesthesia. Harvard 
Metlicai Schtxjl. MassacliusctLs General Hospital. Boston 

Helium oxygen mixtures (He/02) may be useful in the management of severe 
airvva\ obslructinn and asthma. I he use of He'O? mixtures during mechanical 
\eniilation may alter the function of a ventilator. We developed a mathematical 
correction for tidal volume at different He'O, mixtures. Methods: Air. oxygen and 
heliox (He SO*?-©/ O, 20'!-o) were altached 10 the \m'> pressure inlet of a Servo 900C. A 
total flow of 1 5 Lmin of air or five different Hc'O. mixtures (80/20. 70'30. 60/40. 
50.:'0, O/IOO) were used Tlic ventilator was set on volume control ventilation, rale 
l^'inin, inspiratory time fraction 33% or 50% without plateau, and minute ventilation 
adjusted to display V- (V,..j,) between 300 and 800 mL in steps of 100 mL A single- 
companment lung model (Model 1600, Michigan Instruments) was used to obtain the 
actual deli\ercd V, (V,^,) Prior to the experiment, a pressure-volume cur\'c oflhe 
hvstem was established. allt>winp us 10 calculate V^. as measured by the end- 
inspiratory pressure in the model Hefore using UdO, mixtures, the accuracy of the 
ventilator pncumoiachomeier was evaluated with air, by comparing Vj.,^ vs. V,^. The 
error was < 3% in all sellings. ITiree breaths at each setting were obtained and used to 
perform a multiple regression analysi>. predicting the V,, according to V^^p and FiOj. 
Results: The relationship to calculate the delivered V^ , according lo Vj,^ and the 
FiO; was: V^, = 0,94 ' V^,^ - FiO;-*"' (R' - 998) The bias i precision for this 
correction was 0.8 -^ 23-4 ml, (see belovv). Calculating separate regression equations 
for each inspiratory time did not improve the results I he largest error, 40mL, was 
seen with FiO. - 1 .0. Cunclusion: This correction allows prediction of the delivered 
volume according to the displayed value for any He/()> mixture v^hen the Servo 900C 
is used in volume txinirol mode 

*_ -20 -■ 

200 400 600 urn 1000 

200 400 600 800 1000 



Respiratory Care • October "96 Vol 41 No 10 

Wednesday, November 6. 1 2:45-2:40 pm (Rooms lA-B) 

Successful ApplitHtiui) of th* Kespirunics BiPAP'*' SH Df*ic« for \ endlaliun uf Iwo 
Prenialure Neon»le» V'lii 1 r:Khecrtloni> Kur rr^iisition lo ;i Hume i nre Setting l. tio ni 
Belda RRT P'P Rc^p, Spccialisi (iarlh As*y M.l>. Mayo t.ugenio t.iiia Children's 
Mospilal. Rochester. M.N. Bacxij^round Curreiilly. the onU available in-honie poaabk 
veniilaior> are relaiuelv insensilive to very small inlanls (espiiatoiv ilcinaiids I hese home 
^enlilatorsdu tici ptovLdc conlinuoLis flow as do mfant vcimlaiors designed forlhc inrcnsivc ca/e 
selling This major hmilation niake^ ihein ill-suiied for providing mechanical vcniilaiion to 
mt'ants needing positive presstire vcnitlaiory support apan from an iiilensive care bei'.ing Thii is 
especially irje in cases mvolvinit neuromuscularly challenged palieiils hurlhcmiore. il is not 
tJiac'.ical ic cmoloy ventilators designed for the Neonatal ICL' in the home care environment 
Introduction We report a case m which two premature male nennatcs bom al our msliiulion 
required the iraiisiiior* to home care selling involving neonatal specific, positive pressure 
vemilatior Each of ihe infants was bom wiih Myolubulai C'enlionuclear Myopaihv Ihc clmtcal 
course of this disease otlen includes proercssior to complete tcspuatory failure due to extreme 
muscle weakness This neuromuscular Cisease is very rare and often fatal unless the commitment 
to continuous mechanical \fnlilaiion is made Tne first of these infants was born al >U weeks and 
the other ai IJ weeks liestationa! age Each of these infants si:i\ivcd ihe newborn period bui. ii 
wit> deiermiiieJ that wcaninit tVom ventilatory support "^)uld nol be possible Bach paiient 
underwent irachccstomy lo facilitate pulmonary hygiene We then sought out all available 
options 10 provide cost effective, home mechanical ventilatory support thai was infant specific 
MvtfHid-^ Bv mcidilvinu; Ihe patient interface and cncuii of a Bil'AP"^ device, v^e found ii 
possible to take advantage of the continuojs flow charactei istics and pressure limited delivery of 
venitlatOA 5uppon similar lo ihai found in full featured neonatal ventilator? In each ol the two 
situations the ciraiit consisted of a smooth inner lumen lubinij with a heated "wick" type ot 
humidifier and a water trap in line An Isothermal Omni-Mcx'"' connector (Baxici Healthcare 
Corp ) ivas attached to the "whisper swivel ' exhalation p^iri as ihe circuit connection to the trach 
lube Mechanical deadspace was reduced by shonenmg the length of the "whisper swivel" 
design A desired leak around the uschcoslomv tube was picscnl and well cumpensaied for bv 
Ihe mechanics of flow delivery of ihe BiPAP"* device Oxygetiation was maintained by adding 
low tlow ovvgen in lo ihe ventilator circuit as needed IPAP was adjusted to provided adequate 
expired tidal volumes (Vt) = 6-9 ml/Kg as measured initially bv a Bicore^^ CP-IOO Neonaral 
monitor This ir.oiulor also confirmed synchronous ventilation of each patient as represented by 
piessure and How waverorms PosKivc Fnd Kxpiratory pressure - EPAP was maintained Jt A 
CinH20 Airway pressures were mcasu-ed using a Ntnximcinx^ PiK-timo^'iuJ mean airwav 
pressure monitor which also tiinctioned as the disconnect alanii The limed mode was seleelcd 
to delivei a backyiourid lale Percent IPAP was set at l-^'/o in each case f-.videtn.e of etTeciivc 
ventilation was cbs^rrved by monilonng of Hr , RR , BP . TcP<'02 Sp02 and hkwd gasses 
Inch intani was mainiained on this form of ventilator, assist for the duration of their hospital 
Slav A respiratory home care provider outfitted the home s of these patients with a BiPAP'*' 
"X'T device and a Reipiromcs Airway Pressure Moniior /''vvm/fw^To dale I here continues to 
oe a lack of appropriate home ventilatory assist devices for infants and most notably for infants 
Willi neuromuscular respirator>' failure Our experience indicates thai the BiPAP^' device may 
be modified to safely dclivci untisi\v posilive pressure vcnliialion lo patients of this select intaiii 


With the 

Reader Service Reply Card, 

You Can Stop Searching 

and Start Buying. 

Get the facts on all the products and 
services advertised in this issue 
easily and quickly. The computerized 
Reader Service Reply Card does it 
all. Simply remove the perforated 
card from the back page of this 
journal, fill in your name and 
address, check the appropriate 
boxes, and mail or fax it. 

PRESSURE VENTILATOR Jonathan B Waugh. I>h D , RRT, Randv M Dc KlCf. M S . 
RRT Georgia State Lni\crsil>. Cardiopulmonan' Care Sciences Depannienl, Atlanta, 

INTRODUCTION: Ventilators used for NIPPV do not have an oxygen control 
setting so praclilioncrs t\picallv "bleed-in" 1 110% o\\gcn into the patient circuit. The 
purpose of this slud\ was to measure the elTect of manipulating supplemental o\\gen flow 
rates on F,0; delivered to the patient METHODS: A Ouantum-PS\ MPPV (Healthd\nc 
Technologies. Marietta, G.A) uas used with the constant settings of a rise time = 05 
seconds, percent inspirator, time " 2>%, and fTeqiicnc> = !(' bpnl 1 he Quantum NIPPV 
was connected to a Manley test lung (Ohnieda. .Madison. Wl) set at a s\stem compliance of 
50 mb'cm H.O and an airwa\ resistance of 2 cm H,0/L-sec The mean delivered F,0.. 
was measured al the nasal mask while van iiig the ONvgcn tlow rates and the site at which 
oxygen flows were added REStXTS: 

0, Lpiii 

Delivered P.O. mcaniSD 
(hleed-in al machine i 

Delivered F,0; mcairtSD 
Ibleed-inat mask) 


25 f)J,0 1 


^: ^±0 1 

26 7+0 2 


's 4±u : 


44 7±0 1 

it) 4±0 2 


^7 'un ) 

45 (,+ii 4 


6'J H±0 3 


S5 8iO 2 

sn 5±I) 2 

Supplemenlal 0; added into ihc paticnl circuit next to the NIPPV yielded significanily 
higher delivered F,0- values ihan the mask sitc(p =0 016 by repeated measures ANOVAl 
Supplemenlal O uith CPAP levels or4-I0 cm H.O uith sponianeou5 rale of 10 bpm and 
a V- of 300 mL produced mean F,0; values of 71-0 48 a |0 Lpm O, and 98-0 70 a 
1 5 Lpm 0: CONCLUSIONS: Mean delivered F|0.'s increased f.-S"r for each liter per 
mmuie increase m supplemenlal 0; introduced at llie site most dislal from ihe patient for 
these study conditions Introducing supplemenlal oxygen into Ihe paiieni Lircuil at the site 
most distal from the patient appears to provide higher delivered F;0; \alues than near the 
palicni mask 0\> gen flow rates of 10-15 Lpm are sufficient to deliver a high FjO; al 
niodesl tidal breathing in CP.\P mode 



Finally, an 
endotracheal tube 
holder that meets a 
the needs of long- 
term patients! The 
Thomas Long Term 
Endotracheal Tube 
Holder is ergo- 
nomicolly designed 
lo hold securely, yet 
provide the greatest level of comfort 
for your patients Because it allov«s full 
access to the mouth and it allows side to 
side adjustment of Ihe lube, il v«ill 

prove to be a true 
lime saver 

The Thomas LT 
features thickly 
padded Velcro head 
and neck straps for 
a secure and 
comfortable fit, a 
removable bile 
block made of 
soft and durable thermoplastic rubber, 
built-in noso-gaslric lube holders and 
replaceable cheek pads. You'll never 
need to hassle v«ith messy tape again! 

The most tomhrtcbk endotratheal 
tube holder ever irealed. 

Allows complete oral/nasal auess. 

Includes removable bile block. 


\■^ S I I \j j II I I \ I !■ K II II I I I S 


Polenf Pending 
















Circle 153 on reader service card 
Visit AARC Booth 655 in San Diego 

Respiratory Care • October "96 Vol 41 No 10 


Wednesday, November 6, 12:45-2:40 pm (Rooms 5A-B) 



Sieve DesJardins RRT . Sally WhtHen RRT Maine Medical Center, Portland, 


INTRODUCTION: Patients requmng long term mectianical ventilatory care 
may benefit from a tracheostomy Bedside Percutaneous Dilatational 
Tracheostomy (BPDT) has been shown to be safe, quick, convenient and cost 
effective Additionally, the length of stay in the intensive care unit (ICU) has 
been decreased According to Rodnquez el al, "early tracheostomy decreases 
dependency on the ventilator' Patient comfort and ease of care for the airway 
was improved All patients required mechanical ventilatory support for 
respiratory insufficiency BPDT procedures were pertormea al the patients 
bedside in the ICU A respiratory care praclitioner (R C P ) was present for 
each procedure METHOD: BPDT was performed on forty-eight patients m oun 
multi-disciplinary ICU The pilot study was from January of 1995 to January of 
1996 BPDT procedures were performed by a staff surgeon and assisted by a 
respiratory therapist and an ICU nurse without the presence of an 
anesthesiologist The nurse was responsible for Ihe sedation and general care 
of the patient dunng the procedure The R C P was responsible for 
maintaining the airway dunng and after the procedure The therapist advances 
the ET lube (to prevent rupture of ET cuffl and eventually extubates the patient 
when the tracheostomy tube is inserted Additionally the R C P monitors the 
patients end-lidal (ETCO,) to assure proper placement of Ihe tracheostomy 
lube and monitors Ihe patients SpO, m assure adequate oxygenation 
RESULTS: Patients undergoing BPDT suffered from a vanety of illnesses Of 
Ihe 48 patients, two had ETT cuffs mpture during insertion of the 18-gauge 
needle lor tracheal access These two cases did not expenence any further 
complications Due to Ihe small incision and the vasoconstrictive properties of 
lidocaine, blood loss was minimal Tracheostomy wound infection was not 
seen nor were any of the 48 patients sent to Ihe OR for BPDT related issues 
BPDT eliminates Ihe need for consumption of OR resources and personnel as 
well as the risk of transporting these cnlically ill patients The cost benefit lo 
the patient was considered to be substanlial slandard tracheostomy 
performed in the OR with the assistance of anesthesiologist was S2642 The 
cost for BPDT pertonned in the ICU utilizing R C P 'S and ICU nurses was 
S997, representing a cost savings of SI 645 CONCLUSIONS: We find doing 
BPDT in the ICU to be safe, cosl effective and may decrease Ihe length of stay 
in Ihe ICU BPDT procedure average duration was 15-20 minutes Involvement 
in BPDT offers benefits lor the RCP that include role expansion and more 
direct involvement m patient care Patients benefit from decreased cost and 
potentially decreased ICU length of stay 


Ku low K RRT, Stolln JK MD, Cleveland Clinic Foundation, Cleveland, Ohio 

Background The hands of a caregiver can easily acl as a vehicle to transmit 
pathogens from one patient to another In an effort to both evaluate and 
improve infection control in the Medical Intensive Care Unit (MICU) of Ihe 
Cleveland Clinic Foundation, a study obset\ing handwashing practices and use 
of gloves was performed Methods: The study consisted of si.\ two hour 
observation penods (three on day shift and three on evening shift), dunng 
which the siafTwas unaware they were being observed regarding handwashing 
and use of gloves while performing routine patient care Results: 
Handwashing piior to patient contact was observed with 17% of respiratory 
care practitioners (RCPsI, 6% of nurses, and 0% of physicians Overall, for 
1 1 1 separate patient encounters, handwashing was practiced before the 
encounter in 10% of instances After patient contact, rales of handwashing 
were 43% for RCPs. 2b'o for nurses and 20% for physicians At the 
conclusion of the study. Ihe total rate of handwashing after the patient 
encounter was 32'"o Donning gloves was practiced by all 21 RCPs observed 
()00%), but only 13 (72%) removed their gloves after completing the patient 
encounter These obser>.'ations suggests that handwashing was int'reqiienlly 
practiced during routine patient care in the MICL' .Mtliough use of gloves 
was more commonly obse^^'ed. providers frequently failed to change gloves 
between patients To improve handwashing and glove practices, several 
measures were undertaken: 1 Inservice lectures were delivered to all shifts 
regarding the study findings and current handwashing guidelines, 2 
Permanent labels were place on every ventilator in the .MICU to remind each 
therapist to wash hands, 3 A summary of the observational study findings was 
distnbuted to each respiralorv- therapist in the MICL. along with several 
journal articles regarding infection control and the importance of 
handwashing Conclusion: With the goal to assure complete compliance 
with handwashing practices, a follow up study is planned as an ongoing 
monitonng activity 



•(i 7m<ji A Vol-ko , RRT. .Si, i;Uijbccti Hcullh Ccnlor. YounEilnwn, OH. 
Robert L, rhalbum. RRT. L'nivfn,il> Ho.ipilals of ricvelaixl. OH 
Aslhma aflccLs approximately three million children each year and has conlnbulcd lo increased 
health costs due lo emergency treatment and hospilalizatinns. The purpose of this study was lo 
dclermine whether a physician direciled medical plan inlegraled with self management education 
could improve palicnl oulci»ncs in a clmic selling We hypolhe,(i/eJ a rcducuon in emergency 
room visiL\ and inpatient tiospilati/auon.s along wilh subsequent cnsLs, MF.THOUS PaDcnLs 
enlereit into the study were pediatric clienLs. aged 1-18 years, with a hisuiry of aslhma and ixi 
dotiimented medical trealmcnl plan Children wilh chronic pulinonar> and/or cardiac problems 
or neurological impairmenis were excluded from die study group (ic. cysuc fibrosis, congenital 
cardiac dcfccls. or cerebral palsy) Palienls visilod the clinic an average of ^ umes. A detailed 
assessment and mdisidualized plan was cominlcd for each child by a muludisciplinary team 
directed by a pedialncian with input from the pauenl and family. An cdiicaunnal plan was 
created and implemented by die respiratory iherapisl, ll covered early recogniuon of signs and 
symptoms, physiological components of an acute exaccrbalion. precipitant rcs.ugmuon. and a 5 
step action plan mcorporaling the use of peak flow mcasuremenLs and medicauon The dietitian 
provided rc-commendacions fur wcighl reducuon, food allergies, and meal planning as needed. 
The social worker helfie^ with lran,s|»ortation, insurance, and medical equipmeiit is.sues. The 
nurse obtained intake data and administered immiinizalions Outcome data were collected on 
each subject, for equivalent linic spans pnor to and after panicipalion in the Aslhma Clinic, F.ath 
patient serscd as their osro ciinliol, Clmic daia were collected over a seven month pilot period. 
Before and after clinic data woe evaluated wilh paired l-tests RF.SLLT.S Tlie demographic 
and outcome data an; shown below; 
Demographic Data 

number ol patients 
mean age (years) 

Outcome Variables 

Toml ED visits 
H!) visits/pt 
Total hospitaliz^lions 
Eslimalcd ED cosl/pt 
Esunialed hospital cosiypt 
Total costypt (ED & inpatient) 
Tliere was a concomitant improvement in the paticniyfamity's compliance in keeping regularly 
scheduled pediatnc cliric app<iinlnienLs (.S0% no-show before, 25% aflcr). 
Conclusions: These preliminary results suggest dial aslhma education in an outpatient clinic 
selting fosters an understanding of the disease process and improves compliance to medical 
management, tt significanUy reduces use of emergency department services, hospilalizations. and 
thus cost of care. Estimated total cost savings per patient was S 1 .544 



race (*) 


Caucusian 1 1 







s 'iilue 











$4 SO 







Karlj Babsko RRT . Robert Chaibum RRT Universiiy Hospilals ol Cleveland. OH. 

EvaJuale and ireai protocols have been shov-ii lo improve reipiraior> care resource uuli/ation 
{Rc>pirCarc 1993;38:263-26.S). We developed a consult service ihai links ohjecuve evaluation of 
paticni hisior> and status to recommended licatment schedules (ic. aerosol, IPPB. airway 
clearance, incenuve spirometiy). The purpose of this study wa<i to deiermirw it the consult 
service decrcases die frequer>cy of inappropnaic aerosol ire-aimenLs and decreases cosl of care 
comparfd to standard physician orders, MKTHOI); The LonsuU senicc incorporate.*; a paucnt 
history lABGs. chest x-ray), clinical as,>«-ismcnt i,>ireaih sounds. rc^plratOTy rate, cough, sputum 
producuun.workof breathing), and pulmonar)' funcuon icsis (peak flow. KRVI!, Bronchodilaior 
response is assessed by pre- aiwl posl-brorKhodjlaux PFTs A positive response is defined as 
greater than 1 5% increase in FE V 1 or peak flow. Based on these data, one of two treaimcnl plans 
IS selected (MDI/wei neb either QID or Q^l Hnxry criteria were adult paucnis with DRG code 
?■; (pnaimonia), 127 (ClIFl,u/K8 (COPD) with orders for aerosol IR-ainienlS- Patient charts 
were reviewed randomly bawccn 2/5/96 and ?/?5/'^6 A ueamient was judged appropnalc if it 
met at Iea.stone cntcnon m each ol two categories (I) Physiologic need: accessory muscle use. 
dyspncji. respiratory mic > 30/nun, whee/mg, history of reversible airways disease; (2) Outcome: 
deanng of chest X-ray. >15'?t PKI post bronchodilaior. improved breath sounds. 
Respiratory care charting noted whether ihc aerosol order was under a consult or not. The 
proporuon of appropriate versus non-appropriate ireatmcnis was compared for orders under 
consult versus non-consult using a Fisher Exact lest. Sigmncancc was set at p=0.05. Cost 
Lalcutations were based on vanablc suppbcs = $1.17. vanabic labor = S5.40. fucd indirect = 
SI OC). and ueatment volume of 79,096 treaimenis/year. RESIXTS: A total of 542 aerosol 
ireaimcnLs were reviewed- Tlic raw data are showTi in the Ilgure below: 






224 318 

(Jvcrall, 1 5% of aerosol ireatnienLi wac Judged inappropnaie. 
Tlic total cosl of inappropriate acrostil treatments is estimated to 
bcS89.813/ycar. Comparing consult service vs non-consult 
service, there were less than half is many inappropnaie treatments 
when tJic consult service was used (19% vs 9%. p<0.001 . odds 
ratio = 0.4 1 ), I"hc potential cosl savings of applying the current 
consul! .scT\'icc to all aerosol orders is about S27,933/year, The 
associated potential bbor tinie savings is 0.62 FTEs, 


System,^tic evaluation of physiologic need and clinical outcome dccrciiscs the frequency of 
inappropnaie aerosol ueatmcnLs. Because the department performs more than 79.000 aerosol 
ircaimcnts per year, a 40% reduction in inappropnaie therapy {le. from \S% to 9%) by universal 
applicationof the consult service would represent a sigmfiLant savings m cost and bbor hours. 
We are currently trying to improve the discrimination ability of the consult service to achieve 
further reductions. 




Wednesday. November 6. 12:45-2:40 pm (Rooms 5A-B} 


Iimolbj^R Mun RRT . R.^bert U Ctwibum RRT. Nl^ha Wnghl KfD 
Rainbow Bjbics i Children-- Hospital Cievcland. OH 
The purpose of ihis siudy was m benchmark Uic eltecLs t>f an ai&essmcnl-dnvcn, algonthm-hased 
care paih (ACP) on emergency room length of suy, number of ircaimcnUi, and prubabilil) ol 
adrm:>sion. m the absence of ci^m parable histoiiLal data METHOD: Froin 1 ' I'9(^ — ?/3l/9(S. 332 
palicntv were entered mio (he care path Enlr> ontena > I vcai ol uge and either a hislory ol 
asthma or acute sympioms of cough, wheeze. (M- shortness ol breaih E\clusion cntena BPD.CF 
or ci^gcnilaJ bean disease Respirator> distress w adjudged b\ vtial sign^. Sp02 and lung exam 
then Ireaied «ith o\\gcn and SC epincphnnc The ACP standardized a-ssessments and lhcrap\ 
io\>gcn. albuierol aerosols, cortit-oslemxls) at prescnbcd intervals Patients were adminisiered a 
dose of conicoslcmxis u uhm ihc Iit^l 30 minutes if they were steroid dcperxlent or had rtceu eiJ 
>3 bronchodilator aerosols in the previoiis 12 hours or > 2 in the prcMoub 2 hours Assc«menii 
and'or treaimenLv wea delivered every 20 minutes Treatment « as discontinued when discharge 
cntena were met gvxxl air exchange, miid or abscni end cxpiraUM^, wJlec^lng, noaccessor\ 
muscle usage. Sp02> 9?'J . respraior. rale<4J> mm and peak How > HY^ predicted PalienLs 
were observed Inr one hour alter their last treatment then discharged Patients not meeting 
discharge cntena after six aerosols or 1 hour ol continuous aert»sols were admitted A sevcnlv 
sicore tt as assigned based on history . symptoms, and iherapculiL drug usage A Fisher F.-ukti lest 
was used to compare race, gender, and admi nislralion o{ SC epi lor admit \s discharge Chi 
square was used to compare se\ent\ score disinbuiions Unpaired t-lcsLs were used to compare 
age and the outcome data Significance was set at p= 05 RESUTTS: Demographic and 
oulLomc data are shown below m ct">uni '* or mean (SD> 
Dvtnographics Pktlents Discharged Patients 4dmltted 




2 0(1.0) 
2.4(1 6) 



4 5(3.9) 


p - Value 






Age (mean) 



Gender (%) 
Otiteomc Variables 

LOS on hourst 

Aercsols delivered 

AsscssmcnLs performed 

Administered SC Epi 

Received s 4 aerosols 

Received £5aciosols 
Ten percent of admit paUcnls went to the ICL' The probability of being admined aJter receiv ing 
i 4 aerosols was 9<>. aJier > 5 aerosols it increased m 3 n There was no 5igmficani difference 
in the distnbuiion of seventy -laires between admits and discharges. 

CONCLUSION: The ACP soems to maintain acceptable vanation in patient outcomes ( mean 
coefficient ol vanauon lor outcome v anaWes was 42'^ ) Use ot SC Epi and de!lver^ a 5 aerosols 
were both predictive ol admission. Seventx' score was not predictive of admission 





< 0,(X)01 







Barbara Hendon, BA, RRT, Woody V. Kageier. MD, Accul-ub Diagnostics, 
L.P.. Dallas. TX. 

Disease management programs (DMP) are designed lo prolong the peritxi of 
healthiness, reduce healthcare utilization (HU) and improve the overall quality oflife 
(QOL). Asthma and COPD are chronic conditions with a high incidence of HU and 
increased morbidity, therefore Managed Care Organizations (MCO) have become 
increasingly interested in DMP tor both diseases. Respiratory Care Pracliiioncrs (RCP) 
can be an integral part in DMP METHOD: Customized DMP, adapted from the 
National Institute of Healths (NIK) guidelines for the management of asthma and 
Muriugcmeni of Chrome Obstructive Pulmonary Disease (Ferguson, et al, NtJM 328. 
April. 1993) for COPD, are delivered b\ RCP to MCO members Outcome data are 
collected using instruments adapted from Health Outcomes Institute (HOI). Several 
weighted response questions and objective data determine the member's inlenenlion 
level (II-) Fach II outlines a medication plan, action protocols and trigger control The 
member monitors peak How and s>mptoms and adjusts therapeutic treatment 
accordingly. Other weighted response questions determine ihe frequency for follow-up 
intervention bv RCP DMP enrollment period is for one >ear RESULTS: 57 
individuals witii either asthma or COPD have completed 6 months in the DMP Ages 4 
to 78 vears Individuals var\' in race and socio-economic background Severity levels 
for asthma ranged from mild persistent to severe based on NIH classification Pre- 
program intervention (PreP) is defined as HU 6 months prior to program enrollment 
and initial visit HOI collected mformation. and post-program (PostP) is HU and HOI 6 
months following initial intervention. Statistical analysis by paired T-test. Results are 
presented as mean (SD) 



P value 

Emergency room visits 

1,75 (1 11) 

0..i: (080) 



o>)6 (1 :i) 

0.11 (0.56) 


Hospital davs 

5 12 (822) 

0.44 (2,57) 


Lost productive days n=38 


!.58 (3.55) 


EXPERIENCE: RCP can intervene proactiveh with members in the convenience 
of their homes lo promote wellness The RCP is the coritcrstone in the priKess of 
developing a partnership with the member and PCP. who has final approv.Tl over IF. 
medication and action prottKols CONCLUSION: DMP ofl'ered to MCO for Asthma 
and COPD results in; 1 ) reduced HU. thereby reducing healthcare costs, 2) reduced lost 
productive days. 3) improved QOl . 4) expanded role for the RCP. 



J. Sesiiio. RR 1 . P \mn^lot\. liRl Wi Mn^oro. Rf< I H.Pai-vsky. MD . D. Sh.ilki:^. M O, 
J HatisenFIaic''tn. M.D., D. Reily. RRT. Universir>- ofPcnnsshania Mr.cici' Ccnrsr. 
Philadelphia. Pi. 

JNTRODUCrfC''" ^'c have teen mc i.itonng ir'-ipriopri.>le nrdtfrinc of lerinri-io--* cfiI'^ I i' 
the past four '.ears '\i: have reporie.! this phenomrnoii in scveial stui.lici Inapi-rupnaie or.^fr^ 
r-.ll under a \3ricr> of caiegone*^ v^hich includ'- over ut:li^ation underutilization or iii-fTeclivc 
prescribed therapy Efforts to reduce irappropnate ordering and subsequent delivery ofcaic 

-deluded the following esiablishnritfni ot respiratory therapj clinical eu.Jplines by a mulli- 
disciplir.arv team, approval otihese guidelines by the :nstilulion's Medical Board, anu 
educatior, etTons coordinated b\ the respiratory care departmeni EdLcation eUons included 
publication of these guidelines ti the hospital policv and procedure book, and distribution of 
a respiratory care booklet which included al! the established guidelines !"or appropnateh 
orcerirg respirator, c^:; Distribution was targeted at interns, resident and anendir.E ph\sicians 
MFTHODS; A consutt service, consistina of a core group of remstcred respiratory therapists 
«as established The concept ot 'he service v^as approved b> ihc hospital medica". board Tfic 
consul: serv reincorporated ;herapy guidelines previouslv approved. The consult service in 
essencewould evaluate tjhvsician/equcsis lor Therapy and make recomn:enda:ions The consul: 
iherapist received additional training in assessmen: workshops which included physician 
pannerships in an outpa;ieni clinic setnne and were incorporated m the Pulrronary physician 
consult serMCC This srudy compared the percent of ;narpropriale inhaled medication orders 
before and after implementaiion of the consult concept Two hundred and sixty two (262) orders 
\*ere studied pre- and one hundred and sixty eight orders f I68l studied post- implementation 

Pre consul! Post consul! P 

2fi2 orders 168 orders 

79 inappropriate IS inappropriate 

■.0"^ -aie t I'r mte (P<0.0003) 

Pre and Post Consult! 

iCO ] 


'eta' C'oe's 
rnacP'^Cf ate Onsr 
^e-zeri: 'n-.acsropna 

CONCLUSION linplementaiion of a respiratory care consultaiion service improved compliance 
with clinical guidelines and sisnificarTly reduced the rate of inappitJpriate ordering of inhaied 
medicaTion therapy The consult service was significani in decreasing the rate of inappropriate 
ordering of inhaled rredicalion therapy at our institution 


James K Stoller, MD Douglas OrciiL MBA, RRT, Kevin McCanhy, RCPT. Lucy Kcstcr. 
MBA. RRT, David Haney. RRT. The Cleveland Clinic Foundalion. Cleveland. Ohio 

Background: As therapist -driven protocol programs become more prevalent, there is a 
continued need to evaitiate their impact and cfTcctivcness Recent expenence suggests that 
use of respiratory care protocols can enhance the allocalion of respiratory cire services By 
reducing "over-ordenng". defined as prescribing services unlikely to prov ide benefit, cost 
savmgs are expected and have been demonstrated in recent studies As pan of our ongoing 
analysis of respiratory- care ser\ices at the Cleveland Clinic Foundalion. we reviewed the 
differences in volume and costs of providing respiratory care serMcesovera five year period 
starting in 1991 and ending in 1995 Methods: The Respiratory Therapy Consult Service 
(RTCS) was first implemented for hospital-uide use at physician discretion in February 1992 
and was mandated for most non-ICU adult inpaiiejii care in August 1994 Using true 
variable and fixed costs for prov iding respiratory care scrxices and a management 
informauon system that tallies all respiratory care serv ices delivered, we calculated the 
volume and costs associated uiih the fi\e higircst volume adult non-ICU respiraiory care 
services at the Cleveland Clmic Hospital: aerosol medication delivery iSVN). metered dose 
mhalers (MDl). oxygen thcrapv. brorKhoptJmonan' hygiene (BPH), and incentive 
spirometry 1 o assess the impact of the RTCS on volume and costs of respiraiorv care 
services, 1991 data ("before RTCS) were compared with l'>95 data (RTCS superxised most of 
the non-ICU adull inpatient care delivered ) Results: Despite a stable hospital census 
between 199] (16.989 patients) and 1995 {16.997 patients), the total number of these five 
therapies admimsiercd decreased (202. 72S in 1991 to 169,097 in 1995) The accompanying 
decrease in cost for these scrxices was $.127. .1.53 over this inienal The average cost per 
patient for providing the five therapies was reduced from S93 98 in 1991 lo $74 68 in 1995 
Most of the sav mg uas associated wiih a decline in the volume of lime-consuniing services 
(ie.. SVNandBPH)by .18.594 rreaimenis, producing a cost decrease of 5104,466 Delivery 
of aerosolized bronchodilalors (SVN, MDI) increased bv 2.903 ircaiments Notably, this was 
offset by the increase of Ihe proportion of brnnchodilator therapies administered by MDIs 
(less costly than S\'Ns). from 25% of all bronchodilators (22.51,1) in 199] to 44 *»'o (41.300) 
in 1995. resulting in a cost decrease of $37,655 Oxygen therapy was reduced by 10.156 
patient-days over the fi^e year period, resulting m a cost savings of S10I,489 Conclusions: 
We conclude I Beiween 1991 and 1995. changing patterns of use for the highest volume 
Tcspiralorv- care services delivered to non-ICU adull inpatients associated with a 
substantial decrease in the number of therapies and associated costs 2 Implementation of 
Ihe Respiratorv' Therapv Consult Service during this interval effected a cost savings by 
encouraging the use of effeciivc but less e.xpensive respiratory care modaliiies (eg . MDIs vs 


Respiratory Care • October '96 Vol 41 No 10 


Wednesday, November 6. 12:45-2:40 pm (Rooms 5A-B) 

EDUCATIONAL PROGRAMS bv Phillip D Hobgrtv Ed D . R R T . The Ohio Stale 
University. Columbus. Ohio Backsruund: PrcsUgious national study commissioiu and 
professional associaUoas. including the AARC, have mdicaled that the future allied health 
practiuoncr will be the tnulu-campetenl health care professional who is trained and proficient in 
skills not limited to a single allied health profession. HospiuJ rcsinictuimg and clunmaUon of 
ccnliaJ Respiratory Care (RC) departments hdvc added to the pressure to create the muki-sJtiUed 
praclitioncr The purpose of this study was to deicrminc the cxlcnl of mulu-skjllmg cducauon 
(MSE) in the curricula of the RC programs approved by the Conuiussion fur the Accreditation of 
Allied Health EducaUotiHrogrania(CA.AiIEP) Method SLXtccn-item qucsUoonaiR-s were 
mailed to the program directors at 378 uisUtuUons listed m the June 1995 JRCRTE duectory 
Program directors wac asked to report on the amount of uistnielion in 10 cumcular skill arws 
which, although not traditionally included in rcspu^torv' care, have been identified in the 
literature as npc for cross- traming or 'multi-skiliing' of RC pcrsoimel includuig non-invasive 
and mvasive cardiolo^ . sleep disorders studies. ncurt*>diagnostics, extra-corporeal membrane 
oxygenation, assisting with bronchoscopv, intravenous inftision. performmg sunple radiographic 
and HKdical laboratory procedures and pcrlorming basic patient care skills The directors also 
identified the scttuigs for instruction (classroom, laboralixy or tlmic). the t>pe of faculty 
(program, clmical or other) and t\pc of students for each of the 10 areas The directors were also 
asked to speculate whether tbcy foresaw offering more MSE in the next 1 2 months in basic or 
advanced skills Rciulls: Usable questionnaires were returned by 62% of the uisUlulions 
oftonng accredited RC educational programa at the lechmcian or therapist level The returns 
reponcdon233 accredited programs The degree of cumcular commitment ranged from a high 
of 88'/o of programs offering some instnjcuon m assisting with brotichoscopy. to a low of 6% of 
programs oScnng some in-smicuon ui performing simple radiographic procedures such as takuig 
chest radiographs and processmg films In other areas of MSH, from more to less common. 19% 
offered instrucuon in sleep disorders studies. 74% m invasive cardiology. 66% ui non-mvaaive 
cardiology, 40% m basic paUcni care skills. 38% m ECMO. 30"/o m simple medical laboratory 
procedures. 18% m infusion therapy, and 1 3% in neurodiagnosUcs The vast majority of this 
inslTJCtion consisted of from I to several class hours of a course The pcreenUge of programs 
offering instruction ui the form of 1 or more courses of at least I quana hour aeUit ranged from 
a high of 7% of programs in invasive cardiology, to a low of 0% in performing simple 
radiographic proccdtires Only 14% of MSE is conducted through the full tnmty of classroom, 
laboratur. and cbnical instruction Only 38% of MSE reported is conducted so that program and 
clinical, or program and outside faculty ntTcr mstruction Nmety-ninc percent of MSE uistmction 
is offered to RC studoils, graduates or pracUUoners Dacctors in 5 1 % of the programs indicated 
that wilhm the ne>ci 1 2 months lhe> uitcnd lo offer more MSE. with 36% of that being at basic 
level skills only, 21% at advanced level skills only and 43% at both levels Concltutoa: 
Although MSE has broad support in the literature, il has made a minor unpact on the current 
cumcula at approved RC programs A relatively small portion of that inslrucLon is offered 
through the ftill range of inslrucuonal settings and faculty Almost all MSH is directed toward 
those m or enlcnng RC About half of the directors reported plans lo offer more MSh m the next 
year m a mix of basic and advanced level skills. 


Medical College of Georgia. Augusta. Georgia 

lntf <;>dticlion: The purpose of ihis study was to identify and describe the cnucal Ihinkmg skills 
and trails of respiratory care practitioners using a descriptive quahtalive rcscaich inelhodotogy 
The reflective, ojniniiniicative. practical, and expenenUal aspects of tntical thinlore ui respiratory 
caic practice were identified Cnlical Uunkmg (CT) is dcsciibed m terras of practical knowk-dge 
ipounded within the acuial performance, culture, and gonlcvt of clinical practice Mcthodoloyv: 
i he research methodology consisted of observations of 18 rejiisteTed lespiratory therapists (RRTs1 
followed by in-dcpth mtcrviews I he purposeful sample was selected through nomuialions of 
experts usmg rcputalional-easc selection The obscrvaUons served »s a basis for identifying and 
describing context-hound situalions thai require CT, as well as the essential skills and related trails 
hicldnotes and mtervicw transcnpls were eootmuously analyzed ihroughoul the sUidy usmg the 
tunbtaiit-comparatn.'e method described bv Glascr and Sitauss Flndiaji: The fuidmgs suggest 
diat CT in respiratory care pracUcc uivolvcs the abilities lo pnonii/e, anticipate, uoubkshoof 
communicate, negotiate, reflect, and make decisions ttTien. how, and why respiratory therapists 
ftic able to use these CT skills is uiftiienccd by dispositional traits and otgani/^lioual factors 
described m this study The traits tliat affect CT in practice mcludc willuigncss to reconsider and 
thallen^c others, appicciation of multiple perspectives and coiilmucd learning, understanding of 
departmental and professional perspectives that unpad the protessinn, and openness lo conUnuing 
change m llieu personal and professional hvcs This study was not designed to investigate the 
ort-ani/ational factors thai affect C T m cluneal practice I lowcver. it appears thai the sctlmg where 
the rcspu-atory therapist works ii another consideration that can either faciUtaic or uihibii critical 
Ihmkuig m practice ,'Vdditional findings ftom ihis study suggest tliai these organizational factors 
affect CT in respustory care practice involvement and lc\cl of support from the medical director 
and departmental admuiistration, scope of pmtiitc duties and responsibilities, and role dclmeations 
between RRTs and ccrtilicd respuafory lechmcims (CRTTs) fhc therapists were most likely to 
use CT and make rccoinmendalions regarding palienl care at institution^ vvhcrc there was strong 
mvolvcmcnl and support from iJie medical ducclor The therapists m this study were also keenly 
awaic of the level of support and expeclaiions from management The therapists' wilhngness to 
lake risks and initiate change were rnusi evident in progressive departments with supporti\'e 
directors Opportunities for CT were detenmned in part by scope of piacliee Kvery mstinition had 
differences and variaUons in duties and responsibiblics which mfluenced CT Performing technical 
skills m aud of iiself did not necessarily facUitate C F However, if the therapists were able to 
perform tasks which increased the opportunities for decision makmg, then CT was enhanced 
Fmally. the role dehnealioiis between RRTs and CRTTs m pracbcc affected ( \ ui respiratory care 
It was found that RRTs had greater opportunities to communicate, ncijouate and make patient care 
decisions when tlierc were distinct roles in practice beiwecn KK 1^ and (. RFTs These role 
distmctions m practice appeared to be based on differsnces specitled for accrcdiiaiion of 
educaiioDal programs and credeniialmg for therapists and technicians CgnclHWn*: Hie 
mienclation and mteraction of the essential skills for CT can be descnbcd However, dispositional 
trails and ott;ani7^tioiial factors and thcu collective impact on CT in rcspiratorv caie practice must 
be considered Hie summary of fmdmgs and discussion of literature builds subsiantive iheoiy by 
proposing interrelationships among the skills, traits, and organualional factors that affect CT in 
clinical practice The work context and llie role of the organization, includmg managers, must be 

addressed when attcinptmi; lo explain or facilitate CT ui respiratory care practice 



Tracy Chnsiopherson. R.R.T, . Jerry Chnslopherson. R R.T , 

Tharesa Bergquist, B.5., R.R.T Butterworth Hospital, Grand Rapids, Ml 

Introduction: A worX bamplirg study was conducted by the Respiratory Care Depanmeni in trie 
adult cnlical care intensive care units ot a 530 bed ternary care facility The pupose o( the study 
was to evaluate and measure the wortt done tiy the respiratory care practilionei (RCP) lor 
analysis ol joti design and worMoad djstrtbulion 

Method: Activities were divided into tnree categories, dKect care, activities periormed m the 
prcsetica ot the patient and/o' lamily mditecl care, activities done away irom the patient but on 
a speciHc patient s t)enalt and personal lime, personal activities not related lo paliani care or unrt 
activities Random activity samples were obtained every ten minutes dunng scheduled four riour 
otiservalioP sessions by a trained observer with a rehaWlrty rating of 80 A twenty-four hour day 
was used and sessions were randomly scheduled Keeping it propoitional foi shift and weekends 
Samplir>g m tfiis study reflects a bnet moment m time so it is eisential lo deiermtne a suffiaent 
samcie size The (ollowing formuld as utilized to identify the required sample size 9 of units x 
shifts X # of activities k 40 (90% confidence) = required sample size Data was evaluated by the 
survey methodologies descnbed by Barnes, 1968, McCormicK 1979 

Activity Catsgory 

•A Time Per 24 Hours 

11 of Samples 

Direct Care 


Ventilalof Managemenl 









Transportjna Paltenls 



Patient/Family InleracKon 



Indirect Cara 



21 03% 





Stai Lab Activily 









Standby Time 



Personal Time 




This Oaseline measurement identified (or us three laipet areas that vre could focus on: 

1 Ventilator management 

2 Assessmenl/monilonr>g 

3 Documentation 

The managemenl team was somewhat surpnsed Dy the amount ot time spent m ventilator 
management Withm the study ventilator system checks were defined under two separate 
categooes One including hands on management and the othei doaimentation This may 
contntHite to the small amount ot time spent in ihis activity Documentation seems to require the 
most time Assessment and monitonng of our patients can help us individualize the care we 
provide to our patients, thus decreasing over utrttzation o( services Our study shovft we 
certainly have room to improve in this area Our ultimate goal is to tmng the RCP closer to the 
patient and increase the amount of time spent in direct care As we redesign our clinical praaice 
and worldoad drstnbution, we will lood for a corresponding increase in the amount ot dired care 
and decrease m the amount of indirect care This study has demonstratfld that worV samplir>g 15 
an effeaive tool lo measure staff time utilization tor analysis ol |ob deiign and worWoad 




n^;IlI^e_S)laniUe^RRI; Tracy Christopherson. RR 1; Mike hilltinworlh. BS. RRT, Deb 
Roiiwens. RRT, Sandy Weber. RRT; Carla Gianoli. RRT. Karen Warmouth. RRT; 
Matt Kilro\.BS. RRT, 
Burterworth Hospital Respiratory Care Oepariment 

Introduction: From Nmcriher through December 1995, v,v implcinenied a 
broiKhodilator protocol pilot study on two pediatric and 1\m> general tnedictne floors at 
our institution Tiic purpose at the protocol wai to ensui^ ihiit patients rcccncd ihc 
appropriate bronchodilator therapy, to decrease the amount ofnon-mdicated therapy, 
and to demonstrate that Respirator,-, Care Prai.titioners (RCI'I were capable of adjusting 
bronchodilatorlherapy within protocol guidelines Method i ollowing literature 
review, a protocol was developed that enabled the RfP lo adjust Oie Irequency and 
modalir> of brotichodilator therapy w ithoui a direct ph\ sician order Physician 
consensus was obtained. An aggressive statT education plan was developed and 
instituted. All credcntialcd RCPs panicipated in the protocol implementation- All 
patients admitted to the selected floors and ordered lor bronchixiilaTor therapy were 
entered into the pilot study Data was collected and compared to thai available from 
November through December. 1994 Results: Two-hundred and eleven patients were 
enrolled into the pilot study, RCPs made i U changes per protowd (hrequency of 
therapv decreased: 53. MDIs turned over to nursing for adrninisiratioii: -10. modality 
changes: 16; Therapy discontinued: 15, fherapN reordered without changing 
frequency: 7; frequency of therap> increased: 2), Phvsicians ordered "No protocol" 
four times (3%) and disagreed with RCP changes eight times (5%). No adverse palieni 
incidents were reported as a result of the protocol. Tlie average amount of time a 
patient required our services dropped from T91 days pre protocol to 2.37 days during 
the pilot studv RCPs saved approximatelv 20 hours of time in contacting a physician 
for changes This resulted in an estimated cost savings of S201HI a year on these fltJors. 
Conclusion: Our data demonstrates that hy using the pmtocol. our RCPs were able lo 
ensure that patients were receiv mg appropnate bronchixJilator therapy while reducing 
the amount of non-indicated therapy Ihe success of our program is due to the 
education and strength of our siatT along with the support of our medical directors. 
Communication skills and networking also played an important role. Because ot its 
success, the pilot study vvas continued through March and then implemented house 
widein Aprtl. 1996. 



Rhspiratorv Care • October "96 vol 41 No 10 

Wednesday, November 6, 12:45-2:40 pm (Rooms 5A-B) 

FLORIDA ACUTE CARE HOSPITALS. Qlry?' j, prumhelleF, EdD. RRT. David C Shelledy, PhO, fiRT, 
Dougias L. Murphy. PhO. The University of Texas Health Science Center at San Antonio. Sin Artonro, 

BACKGROUND: We assessed the ertent to which pb redesign factors (JRF^ were utilized for cross- 
training of respirala^ care practitioners (RCPs) in Florida acute care hospitals, The four categories of 
JRF stidied were work characteristics, education and trainng, satisfaction and mcenlives fof cross- 
training. METHOD. Education Directors at all 240 acute care hospitals in Flonda were surveyed using 
an instrument walidateC Cy a pane of experts Each was asked to respond to the use of JRF utilized m 
cross-Uaininq o1 RCPs at their hospital. RESULTS: There were 109 usable surveys returned (45%). 
Of these, 45 (41 %) had cross-trained RCPs using JRF. Results are reported as percentage of 
respondents performing crcss-traming of RCPs using specific |ob redesrgn elenwnts. 

Pefcentaae Usmo JRF for Cross Training 

Work Characteristics 

Employee Allowed Choice for Cross Training 

Supervisor Prepared to Support RCPs for Cross-Training 

Cross-Traming Increased Skill Compleiity 

Cfoss-Traming Increased Level of Job Challenge 

Cross-Traming Increased Skill Diversity 

Education and Trammp 

Included Cognitive Content 91 

Included Affective & Human Relations Content 55 

Included Clinical Decision Making Content 77 

IfKluded Safety Content 93 


Cross- Training Included Stress Management 40 

Cross- Training Allowed lor RCP Skil Maintenance 100 

Programs Monitored Qualitv of Patient Care 91 

Programs Allowed for Job Streamlining to Perform Whole Job 66 

Programs Allowed for Employee "Buy In* 75 

Incentives for Cross-Training 

Increased Pay for Cross-Training 34 

Increased Paid Time Otf for Cross-Training 7 

Increased Recognition lor Cross Training 64 

Increased Career Promohon Opportunities 45 

All listed JRF were used The most frequently used JRF were allow lor HOP skill maintenance 
(100%). inclusion of safety content (93%), cognitive content (91%). monitoring for quality of care 
(91%), allowed for increasing skill diversitv (89%), allo'wed for increasing level of (oS challenge 
(87%) and supervisor prepared to support RCPs for crosstrammg (84%) The least used JRF 
elements were increased paid lime otf for cross-trainino (7%) and increased pay for cross training 
(34%) Other iess frequently used JRF were inclusion of stress management (40%). increased career 
promotion opporluntics (45%), affective and human relations conlenl (55%) and employee allowed 
ctnice for cross-training (60%) CONCLUSIONS All acute care hospitals cross-trammg RCPs 
included JRF as part of their cross-trainmg progiams Allowing maintenance of RCP skills was 
universally supported as part of |0b redesign There was little support lor use of financially based 
incentwes to motivate RCPs to be cross-trained as a part of hospital lob redesign. Attention to job 
redesign factors may improve success of RCP cross-training. 



Irene Michnicki RRT. Lucy Kester MBA RRT. Shannon larancik BS RRT, 
Marianne Potts RRT. .Andy Young RRT, James K Sloller MD, The Cleveland 
Clinic Foundation. Cleveland. Ohio 

Background: Patient care technicians (PCTs) arc health care extenders who 
perform simple patient care tasks as members of work-redesiiin or patient- 
focused care teams Since January 1995. pilot studies of work-redesign have 
been undertaken at the Cleveland Clinic Foundation with PCTs assuming 
simple respiratory care tasks such as patient follow-up visits to assure 
compliance and correct use of incentive spirometers As part of their multi- 
task training. PC Is undergo a 6 hour course on respiratory care topics 
(including incentive spirometry) administered by respiratory therapists Back- 
demonstration of appropriate mcentive spirometry (IS) technique was required 
for successful course completion Methods: To evaluate PCTs" performance 
in conducting incentive spirometry follow-up and to compare their 
performance with respiratory therapists, random spot check audits were 
implemented Using a check Ust of 5 steps deemed necessary to correctly 
conduct an IS follow-up (Was the patient instructed to 1 Inhale slowly'' 2 
Keep indicator between arrows'' 3 Raise the blue float as far as possible'' A 
Repeat maneuver at least 10 times^ 5 Use the incentive spirometer ever\' hour 
while awake''), respiraton,' therapist auditors observed 16 PCTs and 16 
respiratory therapists as they performed IS follow-ups Auditees were 
unaware of the specific study goal and were rated on the number of items (of 5 
total) that were correctly performed Results: Of a maximum of 80 correct 
Items, PCTs scored -45 (56*'/o correct) vs 69 (86% correct) by therapists 
(p=0 007) Two of 16 PCTs {12 5%) achieved correct ratings on all 5 items vs 
9/16 (56°/o) of respiratory therapists Conclusions: We conclude that I 
Despite prior training, pertbrmance by PCTs in conducting incentive 
spirometry follow-up visits showed less prol'iciency than respiratory therapists 
2 Respiratory therapists' imperfect performance suggests the need for 
remedial training and emphasizes the importance of ongoing quality 
management in respiratory care 3 Successtlil implementation of work- 
redesign programs will require increased attention to assuring patient care 
technicians' proficiency in performing patient care tasks 


The 1 995 bound 
volume of 

Respiratory Care 

is now available 

Volume 40 is bound in a blue buckram cover and may be imprinted, 
free of charge, with your name or the name of your organization. 
Each volume is MO for current AARC members and ^80 for non- 
members. Shipping is included for U.S. and Canadian residents. 

Available for a limited time, the 1 988 - 1 991 bound volumes ore 
discounted to ^30 (members) and 70 (nonmembers). The 1 992 
and 1993 bound volumes ore available for ^35 (members) and 
^75 (nonmembers). 

Orders must be prepaid; include check, institutional purchase order, 
or valid credit cord rtumber. 

J 1995 volume at MO/^BO 
□ 1 994 volume at MO/^BO 
:J 1993 volume at 535/75 
_l 1992 volume at 535/75 

_l Check _I Purchase Order 

C.C or P.O. # 


AARC Member* 





1991 volume at 530/70 
1990 volume at 530/70 
1 989 volume at 530/70 
1 9B8 volume at 530/570 

_l Visa _l Mastercard 
Exp. dote 



Nome 10 imprint 

Daedalus Enterprises Inc 

PO Box 29686 • Dallas TX 75229 

FAX (972) 484-6010 

Respiratory Care • October "96 Vol 41 No 10 


Open Forum Author Index 

Boldface type indicates presenters. 


A'Court GD MS.^ 

Adams AB 919. 951 

Afessa B 923 

Ahrens TS 948 

Akizawa T 947 

Al-Himyary A 917 

Anderson BD 925 (2) 

Antunes MJ 940 (2) 

Arrington P 957 

Asay G 955 

Ault ML 945 

AzizHF 917 


Bailey J 953 

Bailey SL 917 

Baker-Clinkscale D 938. 948 

Balasko K 956 

Bandy KP 950. 942 

Becker MA 942 

Becker .S 914 

Belda T 955 

Benson MS 917 

Bergquist T 958 

Bernett K 918 

Betit P 928 

Bien M-Y 937 

Bigatello LM 9 1 7. 94 1 

Bing D 929. 926 

Bisgaard JG 930 

Black C 9.V) 

Bouwens D 95S 

Bowen JB 944 

BoxMT LK 930 

Bo\Miian C 928 

Branson RD 951. 921 (2). 952 (2). 944 

Brooks CW .Ir 916 

Brown G 949 

Brown M 936 

Brow n R,\ 926 

Buck SL 929 

Burke W 953 

Burns DM 916 


CallanB 917 

Campbell R 951, 921 (2). 952 (2) 

Cane RD 945 

Ccfaratt J 920 

Chang DW 922 

Channick RN 942 

Charney M 936 

Chatburn RL 956 (2), 957, 928, 936 (2). 937 (2) 

Chiang L-L 937 

Christopher KL 945 

Christopherson J 958 

Christopherson TA 958 (2) 

Chu C-C 937 

Cleveland R 930 

Coffman B 938 

Colsky L 937 

Connett J 929 

Connors AF 936 

Cooley KD 950 

Coplin WM 950 

Coppolo D 935 

Curbin C 916 


Davis E 933 

Davis K Jr 95 1 . 92 1 (2). 952 

Day S 920. 952 

de Regnier RA 929 

Dean JM 938 

Dechert RE 917. 942 

DeemS 917 

DeKeon M 950 

DeKler R 934 (2). 953. 955 

Delgado E 918 

Deniing DD 942 

Deiiiiison F 916 

Derleth DP 928 

Desjardins S 956 

Desphande V 934 

Dh.ind R 934 

Diehl SS 945 

Druinheller OJ 959, 954 

Dunlevy CI 922 

DurbinC 916 

DyerD 941 


Egol A 937 

El-Khatib M 951 

Emberger J 948 (2). 949. 950 

Endrekson M 936 

Eng P 953 

Engelhardt M 946 

Evey L\\ 940 


FaheyP 934 

Fallal RJ 925 (2) 

Fauza DO 930 

Fedrizzi S 933 

Fein lA 937 

Fillenworth M 958 

Fink J 934,946 

Fletcher A 920 

Franklin ML 945 

Fredericksen H 920. 952 


Respiratory Care • October '96 Vol 41 No 10 

Open Forum Author Index 

Freund C 944 

Friederichsen G 923 

Fujino Y 918, 929 

Fukasawa S 919 


Carton DS 942 

Gay PC 945 

Celler D 933 

Geouque DM 946 

Gerardi D 944 

Gest AL 940 

Gianoli C 958 

CillumR 916 

Goldstein M 920 (2) 

Goodfellou LT 922, 934 

GradwellC 94S 

Gra.vbeal JM 948 

Greenspan JS 940 

Gregg C 938 

Grenier B 928 


Haake R 949 

Hale K 949 

HallR 916 

Haney D 957 

Hansen-Flaschen J 957 

Hargett K 949 

Haywood S 946 

Henderson C 940 

Hendon B 957 

Hess D 917, 954, 941 

HillW 941(3) 

Hinson D 935 

Hoberty PD 958 

Hoffman LA 918 

Holliday JE 949 

HoltVVJ 940(2) 

Hommal 947(2) 

Hopper AO 942 

Hoyt J 95 1 

HurfordWE 917. 941 


Imanaka H 917. 954. 941 

IiidiharF 951 

Irvin C 925 


Jacobson K 916 

Jacobson M 930 

Jager K 953 

Jarancik S 959 

Jensen V . ; 926 

.JentB 953 

.lohannigman JA 951, 952 (2) 

Johnson FW 916 (2), 942 

Johnson LE 945 

Jones A 922 

Jones DR 929 

Joyce W 937 


Kacmarek RM 917, 954, 941 

Kageler WV 957 

Kakizaki F 947 (2) 

Kalafer ME 938 

Kallstroni TJ 936 (2) 

Kaneko N 947 

Kasai F 946 

Kasper CL 917 

Kendall AG 945 

KercsmarC 937 (2) 

Kester L 957, 959 

Khonsari S 920 

Kilroy M 958 

Kinninger KK 916 

Kirmse M 954, 941 

Kita D 940 

Klein J 942 

KliewerK 941 

Knodel E 940 

KohlE 916 

Kollef MH 948, 938 

Kozlowski- Tenipliii R 926 

Kues JR 945 

Kugimiya T 919 

Kulik TJ 950 

Kulow K 956 


Lakes KA 949 

Lamb BM 933 

Langenback EG 933 

Langga LM 942 

Laskowski D 926 

Lawless A 936 

Lawson JJ 954 

Lawson RW 954 

LeBlanc DS 933 

LeeS 928 

LemV 944 

Earner S 944 

LewN 918 

Liston G 953 

Long H 925 

Luchette F 951 

Lugo RA 938 

Lunde K 942 


Maclntyre NR 920, 952 

MailletL 926 

Makled N 936 

Mallett J 938 

Respiratory Care • October "96 Vol 41 No 10 


Open Forum Author Index 

Malloy R 950 

Mammcl M 926. 929 

Marini JJ 9 1 9. 95 1 

Martin JE 917 

Martin R 925 

Malsuuru N 929 

Mayo D 916 

McCarthy K 926. 957 

MeConnell R 918, 920. 952 

McComiick T 918 

McDowell K 937 (2) 

McKibben A 919. 951 

McPeck M 933, 934 

Meents C 949 

Mehta RL 916 

Mellecker L 954 

Mtssenger R 936 

Meyer E 92 1 

Meyer PR 945 

Meyers P 929 

Meyers PA 926 

Michnicki 1 959 

Midclletiin L 949 

Miller CC 941(2) 

Miller D 94S 

Miro AM 9 1 S 

MisiioeSC 916.958 

Mitchell JP 935 

Miyagawa T 919, 946 

Mi/uma M 946 

.Monson P 916 

Moon JK 940 

Moon RE 9 1 K 

Moon YS 940 

Moore JJ 917 

Morash C 926 

Mori Y 946 

Mrozek J 929 

Munhall D 92S 

Murphx DL 959 

Murphy E 926 

Myers TR 957. 937 (2) 


Nadipelli V 946 

Nagel MW 935 

Nahiini A 95 1 

Nakanishi A 933 

Narushima M 947 (2) 

Navarro P 933 

Naven D 934 

Newhart J 942 

Nicks JJ 942 

Nishimura M 918. 929 

Nobluyiiki N 918 


Ohara A 929 

Olsen D 948 

Ong KC 953 

Ong YY 953 

Op't Holt TB 952 

Orens D 957 


Palevsky H 957 

Park D 925 

Parr MB 938 

Pascual MT 916 

Patrick H 948 (2), 949. 950, 946 

Perry RJ 933 

Peruzzi WT 945 

Pe\erini RL 942 

Pfaft K.M 945 

Piehler J 944 

Pierce AM 926 

Pierson DJ 950 

Pierson CD 950 

Pinsky MR 918 

PilreM 941 

Potts M 959 

Prager R 937 

Prentice D 948. 938 


Raake JL 929 

Randall B 926 

Range M 949 

Rau JL 934 |2), 935 (2) 

Reid RT 920 (2) 

Rcily D 957 

Rice R 950 

Rich W 940 

Rodriquez J 917 

Rosenbaujn D 938 

Riibenfeld GD 950 

Rubin BK 933 

Russell GB 948 


Salyer JW 938 

Santoro M 957 

.Sauer S 948 

Saunders J 938 

•Savage PJ 945 

Scalise P 944 

Schellenberg L 940 

Schrogie J 946 

Schwanz B 944 

Scott R 942 

Seakins P 921 

Sestito J 957 

Shangle D 958 

Shannon W 948 

Shapiro BA 945 

Shapiro SD 948, 938 


Respiratory Care • October "96 Vol 41 No 10 

Open Forum Author Index 

Shasbv DM 954 

Shelledy DC 954, 927, 959 

Shikmirzaeva EK 944 

Shoo L 928 

Shulkin D 957 

Sibu\ a M 947 ( 2 ) 

Silver P 948. 938 

SittigSE 928 

Smaldone GC 933. 934 

Smith E 933 

Smith K 929 

Smith WA 927 

Snow MG 925 (2) 

SnvderE 940(2) 

SoiaA 930 

Sondergeld TA 945 

Spitzer A 950. 940 

St John RE 948 

Siehnach K 926 

SteudelW 941 

StillwellP 926 

Stoller JK 950. 956. 957. 959 

StolpBW 918 

Suzuki H 947 (2). 919 


Taft A 916 

Takahashi T 919 

Taenaka N 918 

Tanaka K 947 

Tandon R 934 

TasotaFJ 918 

Taylor E 948 

Tobin MJ 934 

Tweeddale M 953 


UekiJ 919 


\'acarro J 946 

Vitkun SA 933 

Volsko T 928, 956 

Von Harz B 938 

Votto J 944 


Wang J-H 937 

VVanger J 925 

Waimouth K 958 

VVaugh JB 953. 955 

Wearden ME 940 

Weber S 958 

Weckerly S 940 

Weeter M 948 

Weiss M 923 

Wenzel A 945 

Wheeler DR 949 

Whiteside R 942 

Whitten S 956 

Wilford L 954 

Williams R 921 

\\ ilson EG 918 

Wilson J 928 

Wilson JM 930 

Wilson TN 944 

Wollschlager C 944 

Woodrum DE 929 

Wright M 957 


Yamada M 947 (2) 

Yamazaki T 947 

'I'oshiyal 918 

^ oung A 959 


Zilber AP 944 

Zimeoskv LK 936 

Respiratory Care • October "96 Vol 41 No 10 


Convention Exhibitors 


at the 42nd International Convention and Exhibition 
of the .Ajiierican Association for Respiratory Care 

November 3-6, 1996 
San Diego, California 

Thousands of examples of respiratory care equipmeni and supplies are displayed, discussed, and 

demonstrated in the exhibit booths at the International Con\ enlion & Exhibition. 

The AARC thanks the firms that support the .Association by participating. 

(Exhibitors confirmed by .September 17. 1996 are listed.) 

Exhibit Hours 

Sunday. November } 1 1 .AM to 4 PM 

Monday. November 4 1 1 AW to 4 PM 

Tuesday. No\ ember .'> 1 1 .AM to 4 PM 

Wednesdav . November 6 1 1 AM to ?• PM 






A-M .Systems 1418 

Advance Newsmagazine 748 

Aequilron Medical. Inc 1227 

Aerosport. Inc 105 1 

Air-Shields 209 

Airsep Corporation 534 & 536 

Allegiance Healthcare Corporation 200 

Allergy and Asthma NeIv\ork/ 

Mothers of Asthmatics Inc 147 

.Allied Healthcare Products, Inc 601 

Alpha I National Association 149 

Ambuinc 419 & 421 

American Academy of Allergy, Asthma, and 

Immunology 1 1 49 

.American Biosystems. Inc 65 1 

American College of Chest Physicians 250 

American HomePatient 85 1 

American Society of Electroncurodiaanostic 

Technologists, Inc 155 

.Apria Healthcare 523 

ARC Medical. Inc 543 & 545 

.Asthma & .Allergy Foundation of America 151 

Automatic Liquid Packaging, Inc 1037 

AVL Scientific Corporation 1001 


B & B Medical Technologies, Inc 746 

Ballard Medical Products 524 & 526 

Bay Corporation 437 & 439 

BCI International 719. 721, 723 

Bedfont Scientific USA 542 

Bio-logic Systems Corporation 546 & 548 

Bio-Med Devices 519 & 521 

Biomedical Sensors 62 1 

Bird Products Corporation 331 

Bivona Medical Technologies 724 & 726 

Blairex Laboratories, Inc 447 & 449 

Boehringer Ingelheim Pharmaceuticals. Inc 618 & 620 

Branching Logic Simulations, Inc 142 

Brcasy Medical Equipment (US) Inc 222 

Bunnell Incorporated 108 & 1 10 

Burdick, Inc 927 


CAIRE, Inc 752 & 754 

California College for Health Sciences 809 

Cardiopulmonary Corporation 1243.1245,1247 


Respir.ator'i C.\re • October "96 Vol 41 No 10 

Convention Exhibitors 





CDX Corporation 25? 

Center Laboratories 1047 

Chad Therapeutics. Inc ICO 

Ciba Coming. A Chiron Business 314 

Clement Clarke 1 1 *< 

CNS. Inc 619 

Concept Poly Enterprise 1052 

Corometrics Medical Systems, Inc 249 & 25 1 

Creative Bioniedics 35 1 

Criticare S\ stems. Inc 1 137 


Daedalus Enterprises. Inc 919 

Dale Medical Products. Inc 938 

Delmar Publishers/ITP 1 .36 

DeVilbiss Health Care. Inc 431. 433. 435 

De\ Laboratories 347 

DHD Diemolding Healthcare Division 718. 720. 722 

Diametrics Medical. Inc 443 & 445 

Drager. Inc. /Critical Care Systems 119 


Environmental Tectonics Corporation 753 

Epic Medical Equipment Services. Inc 1 105 & 1 107 

EPM Systems 237 & 239 

Evergreen-Total Care 352 & 354 


F..^. Davis Company * Publishers 336 

Ferraris Medical. Inc 1 143 & 1 145 

Fisher & Paykel Healthcare 530 & 532 

Florida Hospital 646 

Flotec. Inc 549 & 55 1 

Fluid Propulsion Technologies. Inc 75 1 

Focus Publications. Inc 425 


Genentech. Inc 242 & 244 

General Physiotherapy. Inc 547 

Gibeck. Inc 932. 934. 936 

The Gideons International 112 

Glaxo Wellcome. Inc 219 

Golden Care. Inc 1213 


Hamilton Medical. Inc 93 1 

Hans Rudolph. Inc 343 

Health Educator Publications. Inc 116 

Healthdyne Technologies 819. 821. 823 

HealthEast Bethesda Lutheran Hospital & 

Rehabilitation Center 1426 

HealthQuest Management Serv ices. Inc 450 

HealthScan Products. Inc 818 & 820 

Heail Hugger/General Cardiac Technology 1049 

Hill-Rom 1337 

Home Health Products 353 

Hospitak. Inc 900 & 902 

HR Incorporated 609 

Hudson RCI 1019 

Hy-Tape ' Corporation 1 20 


I-Stat Corporation 137 

I.P.I. Medical Products 813 & 815 

l.V. League Medical 1 242 

Impact Instrumentation. Inc 822 

IngMar Medical 1 327 

Instrumentation Industries. Inc 924 & 926 

Instrumentation Laboratory 911 

International Biomedical. Inc 130 & 132 

Invacare 229 


J.H. Emerson Company 755 

Jones Medical Instrument 623 


Kendall Healthcare Products Company 346 & 348 

King Systems Corporation 423 

Kirk Specialty Systems 114 


Laboratory Data Systems. Inc 102. 104. 106 

Lambda Beta 1 50 

LIFECARE International. Inc 1009 

Linear Tonometers. Inc 45 1 

Lippincott-Raven Publishers 854 

LuSal Enterprises. Inc 126 


Mada Medical Products. Inc 247 

Maginnis & Associates 835 

Mallinckrodt Medical. Inc 901 

Mallinckrodt Sensor Systems. Inc 652 & 654 

Marquest Medical Products. Inc 743 

Martell Medical Products. Inc 525 & 527 

Med Point/Jaeger 1 235 

MedCare Medical Group. Inc 1 226 

Medic-Aid Limited 350 

Medical Graphics Corporation 1029 

Medical Plastics Laboratory, Inc 749 

Medical Taping Systems. Inc 853 

Medlmmune . Inc 1327 


Respiratory Care • October "96 Vol 41 No 10 


Convention Exhibitors 





MediScrve Int'ormation Systems, Inc 831 & 833 

Medisonic USA, Inc 922 

Mercury Medical 837 & 839 

Methapharm. Inc 1 34 

Michigan Instrumenis, Inc 122 

Micro Direct. Inc./ 

Micro Medical Limited 1 3 1 9 & 1 32 1 

Monaghan Medical Corporation 843 

Mosby 72.5 

MSA 801 & 803 

Muro Pharmaceutical. Inc 1048 


National Board for Respiratory Care. Inc 152 & 154 

NCCLS 153 

Nellcor Puritan Bennett 30 1 

Neonatal Intensive fare Magazine 95 1 

Neotech Products. Inc 246 

NewMed Corporation 953 

Newport Medical Instruments 413 

Nicolet Biomedical, Inc 538 

Nidek Medical Products, Inc 143 

Nilt'isk of America, Inc 1212 

NMC Homecare 1038 

Nolato Polymer AB 1210 

Nonin Medical. Inc 642 & 644 

Nova Biomedical 209 

Nova Health Systems, Inc 338 

Novamelrix Medical Systems. Inc 1119 

Nth Sy.stems. Inc 144 <& 146 

Nutec Medical Prodiicls, Inc 355 


Ohmeda 1 207 

Ohmeda. Inc 852 

Omron Healthcare. Inc 1 147 

Optical Sensors Incorporated 1 244 

Ottawa University Kansas City 825 

Oxigraf 140 


I'alco Labs 446 

Pall Biomedical Products Company 622. 624. 626 

PARI Respiratory Equipment, Inc 339 

Pa.ssy-Muir. Inc 1127 

Pegasus Research Corporation 647 

Percussionaire Corporation 438 

Perry Baromedical Corporation 1 33 1 & 1 333 

Piieutronics Division. Parker Hannifin 

Corporation 750 

Posey Company 949 

Praxair. Inc 727 

Precision Medical. Inc 930 

Presbyterian Hospitals of New Mexico 1325 

Pro-Tech Services 948 

Protocol Systems. Inc 128 

Pulmonary Data Service 908 & 910 

Pulmonox Medical Corporation 1342 & 1344 


Radiometer America. Inc 513 

ResMed Corporation 339 

Respiratory Outreach Management. Inc 448 

Respironics. Inc 109 

RNA Medical 427 

Ross Products/Division of Abbott 

Laboratories 1 208 

Roxane Laboratories. Inc 648 

RT Magazine/ 

CurAnt Communications. Inc 327 

Rusch. Inc 850 


S & M Instrument Company. Inc 345 

Salter Labs 912 & 914 

ScanMed of Medic. Inc 1 200 

Schiller America. Inc 650 

Sechrist Industries. Inc 805 & 807 

SenDx Medical. Inc 943 

SensorMedics Corporation 531 

Seven Harvest International Import & 

Export. Inc 248 

Sherwood-David & Geek 918 & 920 

Siemens Medical Systems 709 

Sievers Instruments. Inc 649 

SIMS. Inc 1131 

Smooth-Bor Plastics 349 

Sontek Medical. Inc 444 

SpaceLabs Medical. Inc 824 & 826 


Spiller & Reeves Research 849 

Spirometries Medical Equipmcnl Company 811 

St. Elizabeth Hospital 1420 

STI Medical Products Corporation 655 

SUMMIT Interactive Software. Inc 1111 

Superior Products. Inc 1214 

Symphony Respiratory Services 1 343 


3M Pharmaceuticals 904 & 906 

Teledyne Anahtical Instruments/ 

Sensor Technologies 1 101 & 1 103 

Tiara Medical Systems. Inc 1422 

Transtracheal Systems. Inc 5I8& 520 


Respiratokv Care • October "96 Vol 41 No lo 

Convention Exhibitors 






U. S. Army Recruiting Command 950 & 952 

University HealthSystem Consortium 1 24 

Uni\ersity of Rochester-Strong Memorial 

Hospital 848 

University of Texas Medical Branch 1 109 


Vacumed 442 

Via Medical Corporation 1323 

Victor Medical Products 1202 & 1204 

Vital Signs. Inc 129 & 852 

Vitalograph. Inc 1 1 13 & 1 1 1 5 

Vortran Medical Technology, Inc 1206 


W.B. Saunders Company 939 

W.T. Farley. Inc 1 146 

Warren E. Collins. Inc 313 

Western Medica 625 & 627 

Western Michigan University 148 

Westmed. Inc 138 

Williams & Wilkins/Medi-Sim 550 


Yale-Hew Haren Hospital 1246 


Zymed Medical Instrumentation 544 

Respiratory Care • October "96 Vol 41 No 10 



Notices of compeiilions. scholarships, t'ellowships. examination dates, new educational programs, and the like will be listed here free of 
charge. Items for the Notices section must reach the Journal 60 days before the desired month of pubhcation (Januar)' I for the March issue. 
February 1 for the April issue, etc). Include all pertinent information and mail notices to RESPIRATORY CARE Notices Dept. 1 1030 Abies 
Lane. Dallas TX 75229-4593. 

1996 Publication Awards 

Take Note of New Area Code for AARC: 



Radiometer Awards for Best Feature Articles 

from Test Your Radiologic Skill, Blood Gas Corner. 

Kittredge's Corner. PFT Corner, and Cardiorespiratory 

Interactions accepted for publication from 

November 199.S through September 1996 

Sponsored by Radiometer America 
(Divided equally among three v\ inners) 

Effective September 14. our previous area code (214) 
changed, and the American Association for Respiratory 
Care received a new area code (972). Our 7-digit numbers 
remain the same. Please make note of this in your records. 
Frequently called AARC numbers: 

Phone: (972)243-2272 

Fax (972) 484-2720 or (972) 484-6010 


Best Papers by 1995 OPEN FORLM Participants 

Who Ha\ e Ne\er Published as First Author 

Authors must have presented the abstract at the Annual 

Meeting and submit a paper based on the abstract 

to the Editorial Office by October 1. 1996 

(Two winners - $500 each) 


Best Paper based on an OPEN FORUM Presentation 

Papers accepted for publication from November 1995 

through September 1996 based on any 

Open Forum presentation 


Best Paper Published in RESPIRATORY CARE 

Original Study. E\ aluation. or Case Report 

are the categories for consideration for 

papers accepted for publication 

December 1995 through September 1996 


Or Allen DeVilbiss Technology Paper Award 

Best paper published from 

November 1995 through October 1996 

that addresses new technology or a new application 

of current technology in respiratory care 

(Plus travel expenses to the .A.^RC .Annual 

Inteiiiational Con\cntion & Exhibition) 

Helpful Web Sites 

American Association for Respiratory Care 

National Board for Respiratory Care 

Applied Measurement Professionals Inc 

Food and Drug Administration 

Tuberculosis Information 


November 3-6, 1996, Sunday- Wednesday 


Respiratory Care • October '96 vol 41 No 10 


The National Board for Respiratory Care — 1997 Examination Dates and Fees 


CRTT Ex;imination 

RRT Examinalion 

CPFT ExamiiKition 

RPFT Examination 

Examination Date 

March 8. 1997 

Applicalion Deadline; January 1, 1997 

Jiil> 12, 1997 

Application Deadline: May 1, 1997 

Novembers. 1997 

Application Deadline; September 1. 1997 

June 7, 1997 

Application Deadline; February I. 1997 

December 6. 1997 

Application Deadline; August 1. 1997 

June 7. 1997 

Application Deadline; April 1. 1997 

December 6. 1997 

Application Deadline; September 1, 1997 

Examination Fee 


(new applicant) 




(new applicant) 




(new applicant) 




Written only (new applicant) 


Written only (reapplicant) 


CSE only (all applicants) 


Both (new applicant) 


Both (reapplicant) 


(new applicant) 




(new applicant) 




(new applicant) 



Perinatal/Pediatric Respiratory March 8, 1997 

Care Specialty Examination Application Deadline; November 1, 1996 

For information about other services or fees, write to the 
National Board for Respuatory Care. 83 10 Nieman Road. Lenexa KS 66214, or call (913) 599-4200. FAX (913) 541-0156. email 

While at the Convention, Don't Miss 

Open Forum's Wall of Fame 

Stop by the Exhibit Hall and peruse abstract posters from 
more than 200 presentations on the following topics: 

• Bedside Diagnostics &. Monitoring: You Want Me To Do What? 

• Humidification — Relatively Interesting, Absolutely Essential 

• Changing Perspectives in the Classroom 

• Pulmonary Diagnostics: Innovations Plus New Twists on Classic Procedures 

• A Fresh Look at Some Old Problems in Pediatric &. Neonatal Care 

• Aerosols: Fitting Together More Pieces ot the Puzzle 

• Walking the Fine Line — Good Outcomes and Cost Reduction 

• Nitric Oxide — A Lite of Its Own? 

• Right Across the Continuum — Rehabilitation (&. Long-Term Care 

• Techniques & Protocols Impacting LOS & Patient Outcome 

• Mechanical Ventilation — We're Still Learning 

• Protocols &L Care Plans — Implications for Managers, Educators, &. Clinicians 



New Products 
& Services 

News releases about new products and services will be considered for publication in this section. There is no charge for 
these listings. Send descriptive release and glossy black and white photographs to RESPIRATORY CARt: Journal. New 
Products and Services Depi, 1 1030 Abies Lane. Dallas TX 7.S22')-4593. 


Futurenied releases the EZ-3 electro- 
cardiograph (ECG) with 3-chaiinel trac- 
ing. The EZ-3 weighs < 7 pounds and 
is the size ot a small notebook. Future- 
med claims that the EZ-3 collects data 
on 12 simultaneous leads at a rate of 
1 .000 data points/s/channel. The ECG 
is equipped witli a high resolution printer 
tor paper that measures 90 mm in width. 
Hie user caii adjust rectjiding s|5eed. sen- 
sitivity, filters, and duplicate tracings at 
a variety of settings. Circle reader ser- 
vice card number 160 for more infor- 
mation about the EZ-3. 

Drug Delivery System. The Opti- 

haler ' drug delivery system by Health- 
scan Products Inc is now available in 
a clear, impact-resistant polycarbon- 
ate unit. According to the company, the 
clear unit allows healthcare profes- 
sionals and patients to view how the 
Optihaler works to improve metered 
dt)se inhaler (MDl) drug delivery while 
eliminating the problems of patient tim- 
ing and inhalation technique. The 
design limits the patient's air intake 
until the MUl is depressed to coordi- 
nate actuation of the canister with the 
beainnine of inhalation. Patients can 

store their MDI canister inside the Opti- 
haler' s main body for portability and 
convenience. The Optihaler is dish- 
washer-safe for easy cleaning. Details 
are available, circle reader service card 
number 161. 

ASTHMA Therapy. GlaxoWellcome 
Inc releases Flovent ' (Fluticasone Pro- 
pionate) inhalation aerosol in 3 dosage 
strengths — 44 meg, 1 10 meg. and 220 
meg. The multiple strength dosages 
received Food and Drug Administra- 
tion clearance as a prophylactic ther- 
apy for asthma in patients 1 2 years and 
older, according to Healthscan. The in- 
haled corticosteroid may. over time. 
improN e lung function and reduce the 
use of oral corticosteroids. However. 
Flovent should not be used to relie\e 
acute asthma symptoms and is a\ail- 
able by prescription t)nly. For a prod- 
uct informatit)n sheet and more infor- 
mation about indications and contra- 
indications, circle reader ser\ ice card 
number 162. 

Ane.sthesia Gas Monitor. Criti- 
care Systems Inc announces the .^- 
Agent POET IQ" Anesthesia Gas 
Monitor. The POET IQ features simul- 

taneous 3-agent identification and quan- 
tification, continuous inspired and ex- 
pired \'alues of each agent, "high- 
infrared" analysis technology, and 
sidestreani gas sampling. The company 
claims that the POET IQ enhances 
patient safety by alerting the clinician 
to equipment malfunction or misfilled 
vaporizers, facilitates the use of lower 
tlow anesthesia techniques, offers con- 
tinuous monitoring of anesthetic gases, 
and is unaffected by the presence of 
ethyl alcohol or metabolic ketones. In 
addition, the monitor aids in the assess- 
ment of oxygen reser\e prior to extu- 
bation. provides an early v\ arning for 
potentially life-threatening hypoxia, and 
increases versatility by monitoring both 
intubated and nonintubated patients. 
Pulse oximetry monitoring is also an 
option. Circle reader service card num- 
ber 163 for details. 

Patient- Management SoFT\\ ARE. 

Healthcare Information Sciences Inc 
offers the bedside, personal coinputer- 
based Respiratory Care Patient Care 
Management Software, \ersion 7.0. 
I'he company claims that this software 
enables faster patient charting by using 
light weight, inexpensive laptop com- 
puters at the bedside. The software can 
interface with other computers for 
orders, charges, and patient results. In 
addition, quality assurance, clinical 
practice guidelines, and therapist-driven 
protocols can be user-defmed and pro- 
cedure specific or performed concur- 
rently or retrospectively. The software 


Respir.atory Care • October '96 'Vol 41 No 10 

New Products & Services 

operates on any 386 or 486 personal 
computer that uses MS-DOS ' or Win- 
dows^, and it will operate in a network 
environment. For specific information 
about the software and training agree- 
ments, circle reader circle card num- 
ber 164. 

Pedl\tric COi Detector. Nellcor 
Puritan Bennett releases Pedi-Cap'^'. a 
version of the Easy Cap- disposable 
end-tidal CO: detector. .According to the 
company. Pedi-Cap is a simple device 
tliat changes color — from purple at inspi- 
ration to yellov\' at expiration — as CO: 
levels rise and fall during breathing. The 
detector has 3.0 mL of dead space and 
can be used w ith pediatric patients who 
weigh 1 to 15 kg. The Pedi-Cap can be 
attached between the endotracheal tube 
and breathing de\ ice and is compatible 
w ith many neonatal and pediatiic resus- 
citators. The detector may be useflil dur- 
ing emergency intubations for verif\ - 
ing correct endotracheal tube placement. 
Nellcor Puritan Bennett offers CO: mon- 
itoring and measuring products that are 
compatible v\ ith the Pedi-Cap. For more 
information, circle reader service card 
number 165. 

Rapid Tl BERCII.OSIS Test. Gen- 
Probe hicoiporated offers the Amplified 
Mycobacterium Tuberculosis Direct 
(MTD) Test, which yields results in 4 
to 5 hours. The test uses genetic probe 
technology to identify the presence of 
eenetic information of Mycohacrcriiini 

tiiheiriilosi.s in patient samples and is 
appro\ed by the Food and Drug Admin- 
istration for use with smear-positi\e 
specimens, according to Gen-Probe. Tlie 
test takes about 1 .5 hours for laboratory 
personnel to complete and benefits 
smeai"-positi\ e patients by quickly con- 
firming the presence of A/, tuberculo- 
sis for treatment initiati\es. For details 
about the test, circle reader service card 
number 168. 

Spirometry Flow Sensor \nd 
SotTWARE. Burdick Inc inuoduces the 
Spirosense". a flow sensor and spirom- 
etry softv\are package for diagnostic 
pulmonary testing. According tt) Bur- 
dick. the flow sensor connects to the 
standard serial port of most personal 
computers, laptops, notebooks, and net- 
works, with no modification to the inter- 
nal computer board. SpiroSense can 
pro\ ide inhalation challenge routines 
and trend analysis in addition to test- 
ing functional residual capacity, flow - 
volume loops, ma.ximal voluntary \en- 
tilation, slow vital capacity, and pre- and 
postbronchodilator administration \ al- 
ues. Softw are options for pediatric and 
adult predicted nonnals. respiratory his- 
tory questionnaires, real-time graphs, 
expanded graphs for pediatric patients, 
chronic obstructive pulmonary disease 
risk, lung-age calculations, and a silent 
second option are available. For details 
about the package, circle reader service 
number 167. 

Heat and Moisture Exchanger. 

The Duration ' extended-use heat and 
moisture exchanger (HME) is now 
available from Nellcor Puritan Ben- 

nett. According to the company, the 
HME provides 30 mg/L humidifica- 
tion at 34° C continuously for 7 days. 
The extended use performance of the 
Duration HME can reduce circuit 
breaks, material and labor costs, and 
can potentially reduce infection lev- 
els. The Duration uses a hygroscopic 
paper that has heat and moisture ex- 
change properties similar to hygro- 
scopic salts, but won't degrade over 
time from salt wash out. A biplanar 
mesh between the paper creates air- 
flow channels that provide maximum 
distribution of expired air. To learn 
more about the HME. circle reader ser- 
vice number 166. 

Data Management Plateorm. 

The MultiView Workstation™ and Infin- 
ity Network'" data management platfonn 
are available from Siemens. Tlie system, 
designed to work with the Pick and Go'" 
Concept for Continuous Monitoring, 
allows clinicians to assess patient infor- 
matin from various areas within the hos- 
pital setting. Siemens says that the Mul- 
tiView Workstation allows clinicians to 
view 8 patient records on a full screen 
or 16 patient records on a split screen. 
The station offers both Basic Level and 
optional Enhanced Level software; both 
feaaire automatic w av efomi display and 
a 17 in. color monitor. The Infmitv Net- 
work incorportates the latest in open sys- 
tems architecture for fast, reliable, and 
cost-effective use hospital-wide. Circle 
reader service card number 169. for 
information about the software system. 

Respiratory Care • October "96 Vol 41 No 10 



Manuscript Preparation Guide 

liuiicral Infuriiiation 

Rl.SI'IkAIOKV CARt, wclctJincs original manusciipls related lo 
respiratory care and prepared according to these Instructions. 
Manuscripts are blinded and reviewed by prolessioiials who are 
experts in their fields. Authors are responsible tor all aspects of 
the manuscript and receive galleys to proofread before publica- 
tion. Kach accepted manuscript is copyedited so that its message 
is clear and it conforms to the Journal's style. Published papers 
are copyrighted bs Daedalus Inc and may not be published else- 
where without permission. 

L pdale: A report ot subsequent dexelopnients in a topic that has 
been critically reviewed in this Journal or elsewhere. 

I'oint-ol'-View Paper: A paper expressing personal but substan- 
tiated opinions on a pertinent topic. Title Page. Text. References. 
Tables, and Illustrations nia\ he included. 

Special Article: A pertinent paper not fitting one of the forego- 
ing categories ma> be acceptable as a .Special Article. Consult 
with the Editor before writing or submitting such a paper. 

Editorial consultation is available at any stage of planning or writ- 
ing. On request, specific guidance is provided for all publication 
categories. These Instructions and related materials are available. 
Write to RESPIR.VIORY Care. 11030 Abies Lane. Dallas TX 
75229-4593, call (972) 243-2272. or fax (972) 484-6010. 

Publication Categories & Siriielure 

Editorial: A paper drawing attention to a pertinent concern; it 
may present an opposing opinion, clarify a position, or bring a 
problem into focus. 

Letter: .X signed comnuinication about prior publications in this 
Journal or about other pertinent topics. Tables and illustrations 
may be included. Mark "For publication." 

Research Article: A report ol an original investigation (a studv ). 
It includes a Title Page. Abstract. Introduction. Methods. Results, 
Discussion. Conclusions. Product Sources, Acknowledgments, 
References, Tables, Appendices, Figures, and Figure Captions. 

Evaluation of Device/Method/Technique: A description and 
evaluation of an old or new device, method, technique, or mod- 
ification. It has a Title Page. Abstract. Introduction. Descrip- 
tion of Device/Method/Tcchnique. Evaluation Methods. 
Evaluation Results. Discussion. Conclusions. Product Sources. 
Acknowledgments. References. Tables. Appendices, Figures, 
and Figure Captions. Report: A report of a clinical case that is uncommon, or 
was managed in a new way. or is exceptionally instructive. All 
authors must be associated with the case. A case-managing 
physician must either be an author or furnish a letter approving 
the manuscript. Its components are Title Page. Abstract. Intro- 
duction. Case Summary. Discussion, References, Tables, 
Figures, and Figure Captions. 

Review .\rticle: A comprehensive, critical review ol the litera- 
ture and state-of-the-art summary of a pertinent topic that has 
been the subject of at least 40 published research articles. Title 
Page. Outline, Introduction, Review of the Literature. Summary. 
Acknowledgments. References. Tables. Appendices, and Figures 
and Captions may be included. 

Blood (ias Corner: A hriel". instructive case report involving 
blood-gas values — with Questions. .Answers, and Discussion. 

Drug Capsule: A mini-review paper about a drug or class of 
drugs that includes discussions of pharmacology, pharmacoki- 
netics, and phaiinacotherapy. 

Kittredge's Corner: A brief description of the operation of res- 
piratory care equipment — with information from manufacturers 
and editorial comments and suggestions. 

PET Corner: Like Blood Gas Corner, but involv ing pulmonary 
function tests. 

Cardiorespiratory Interactions. A case report demonstrating 
the interaction between the cardiovascular and respiratory sys- 
tems. It should be a patient-care scenario; however, the case — the 
central theme — is the systems interaction. CRI is characterized 
by figures, equations, and a glossary. See the March 1996 issue 
of RFSPIRATORV CakI; for more detail. 

Test ^ (lur Radiologic Skill: Like Blood (ias Corner, but invulv- 
ing pulmonaiy medicine radiographv and including one or more 
radiographs, may involve imaging techniques other than conven- 
iional chest radiography. 

Overview: A critical review of a pertinent topic that has fewer 
than 4(1 published lescuvh .irticles. 

Re\iev> of Book, Him, lape, or Software: .A balanced, critical 
review of a recent release. 

Manuscript Preparation Guide 

Preparing the Muiiuscript 

Prim on one side of white bond paper. 8.5 in. \ 11 in. (216 x 279 
mm) v\ith margins ol at least 1 in. (25 mm) on all sides of the 
page. Use double-spacing throughout the entire manuscript. Use 
a standard font (eg. Times. Helvetica, or Courier) at least 10 
points in size, and do not use italics except for special emphasis. 
Number all pages in upper-right corners. Indent paragraphs 5 
spaces. Do not justify. Do not put authors' names or other iden- 
tification anywhere except on the title page. Repeat title only (no 
authors) on the abstract page. Begin each of the following on a 
new page: Title Page. Abstract. Text. Product-Sources List. 
Acknowledgments. References, each Table, and each Appendix. 
Use standard English in the first person and acti'.e voice. 

Center main section headings on the page and type them in cap- 
ital and small letters (eg. Introduction. Methods. Results. 
Discussion). Begin subheadings at the left margin and t>pe 
them in capital and small letters (eg. Patients. Equipment, 
Statistical Analysis). 

References. Cite only published works as references. 
Manuscripts accepted but not yet published may be cited as ref- 
erences: designate the accepting journal, followed by (in press). 
Please provide 3 copies of the in-press article for reviewer 
inspection. Cite references in the text with superscript numerals. 
.Assign numbers in the order that references are first cited. On the 
reference page, list the cited works in numerical order. Follow 
the Journal's style for references. .Abbreviate journal names as in 
Index Medicus. List all authors. 

Article in a journal carrying pagination throughout volume: 

1. Rau JL. Harwood RJ. Comparison of nebulizer delivery methods 
through a neonatal endotracheal tube: a bench study. Respir Care 
1992:37(1 ll: 1 2.\V 1240. 

Article in a publication that numbers each issue beginning with 
Page 1 : 

2. Bunch D. Establishing a national database lor home care. AARC 
Times 1991 :I5(Mar):61. 62.64. 

Corporate author journal article: 

3. American Association for Respiratory Care. Criteria for estab- 
lishing units for chronic ventilator-dependent patients in hospi- 
tals. Respir Care I9S8:33( 1 1 ):1()44-1()46. 

Article in journal supplement: (Journals differ in their methods of 
nuinbering and identifying supplements. Supply sufficient infor- 
mation to promote retrieval.) 

4. Reynolds HY. Idiopathic interstitial pulmonary fibrosis. Chest 
1986;89(3, Suppl):l.39S-l43S. 

Abstract in journal: (.Abstracts citations are to be avoided. Those 
more than ,3 years old should not be cited.) 

5. Stevens DP. Sca\enging ribavirin from an oxygen hood to reduce 
en\ ironmental exposure (abstract). Respir Care 1990:35(11); 

Editorial in journal: 

6. Enrjght P. Can «e relay dunng spirometry? (editorial). .\m Rev 
Respir Dis I993;I48|2);274. 

Editorial w ith no author gi\en: 

7. Negative-pressure ventilation for chronic obstructive pulmonary 
disease (editorial). Lancet I992;.340(8833):I440-144I. 

Letter in journal: 

8. .Aelony \ Ethnic norms for pulmonary function tests (leller). 
Chest 1 99 1:99(4): 1 05 1. 

Paper accepted hut not \et published: 

9. Hess D. New iherapies for asthma. Respir Care (year, in press). 

Personal author book: (For any book, specific pages should be 
cited whenever possible.) 

10. DeRemee RA. Clinical profiles of diffuse interstitial pulmonary 
disease. New York: Futura, 1990:76-85. 

Corporate author book: 

11. American Medical .Association Department of Drugs. W\.\ drug 
evaluations. 3rd ed. Littleton CO: Publishing Sciences Group. 1977. 

Chapter in book with editor(s): 

12. Pierce .^K. Acute respiratory failure. In: Guenter CA. Welch MH. 
editors. Pulmonary medicine. Philadelphia: JB Lippincott. 1977. 

Tables. Use consecutnely numbered tables to display informa- 
tion. Start each table on a separate page. Number and title the 
table and give each column a brief heading. Place explanations in 
footnotes, including all nonstandard abbreviations and symbols. 
Key the footnotes with conventional designations (asterisk, dag- 
ger, double dagger, etc) in consistent order, placing them super- 
script in the table body. Do not use horizontal or vertical rules or 
borders. Do not submit tables as photographs, reduced in size, or 
on oversize paper. Use the same typeface as in the text. 

Illustrations. Graphs, line drawings, photographs, and radio- 
graphs are figures. Use only illustrations that clarify and aug- 
ment the text. Number them consecutively as Fig. 1, Fig. 2. and 
so forth according to the order b\ which they are mentioned in 
the text. Be sure all figures are cited. If any figure was pre\ i- 
ously published, include copyright holder's written permission 
to reproduce. Figures for publication must be of professional 
quality. Data for the original graphs should be available to the 
Editor upon request. If color is es.sential. consult the Editor for 
more information. In reports of animal experiments, use 
schematic draw inas. not photographs. A letter of consent must 
accompany any photograph of a person. Do not place titles and 
detailed explanations on figures: put this information in figure 
captions. If possible, submit radiographs as prints and full-size 
copies of film. 

Drugs. Identify precisely all drugs and chemicals used, giving 
generic names, doses, and routes of administration. If desired, 
brand names may be given in parentheses after generic names. 
Drugs should be listed on the product-sources page. 


Manuscript Preparation Guide 

Commercial Products. In parentheses in the text, identify any 
commercial product (including model number if applicable) the 
first time it is mentioned, giving the manufacturer's name. city, 
and state or country. If four or more products are mentioned, do 
not list any manufacturers in the text; instead, list them on a 
Product Sources page at the end of the text, before the Refer- 
ences. Provide model numbers when available and manufactur- 
er's suggested price, if the study has cost implications. 

Ethics. When reporting experiments on human subjects, indicate 
that procedures were conducted in accordance with the ethical 
standards of the institution's committee on human experimenta- 
tion. State that informed consent was obtained. Do not use 
patient's names, initials, or hospital numbers in text or illustra- 
tions. When reporting experiinents on animals, indicate that the 
institution's policy, a national guideline, or a law on the care and 
use of laboratory animals was followed. 

Statistics. Identify the statistical tests used in analyzing the data. 
and give the prospectively determined level of significance in the 
Methods section. Report actual p-values in Results. Cite only text- 
book and published article references to support choices of tests. 
Identify any general-use or commercial computer programs used, 
naming manufacturers and their locations. These should be listed 
on the product-sources page. 

Units of Measurement. Express measurements of length, height. 
weight, and volume in metric units appropriately abbreviated; 
temperatures in degrees Celsius: and blood pressures in millime- 
ters of mercury (mm Hg). Report hematologic and clinical-chem- 
istry measurements in conventional metric and in SI (Systeme 
Internationale) units. Show gas pressures (including blood gas 
tensions) in torr. List SI equivalent values, when possible, in 
brackets following non-SI values — for example. "PEEP. 10 cm 
H2O 10.981 kPa]." For conversion to SI. see RESPIRATORY CARE 
1988;.^3(10):86l-87.3(Oct 1988) and 1989;34(2):14.=1 (Feb 1989). 

Conflict of Interest. .Authors are asked to disclose any liaison or 
financial arrangement lhe_\ ha\e w ith a manufactuier or distribu- 
tor whose product is part of the submitted manuscript or w ith the 
manufacturer or distributor of a competing product. (Such 
arrangements do not disqualify a paper from consideration and 
are not disclosed to reviewers.) A statement to this effect is 
included on the co\er-letter page. 

Abbreviations and Symbols. Use standard abbreviations and 
symbols. Avoid creating new abbreviations. Avoid all abbrevia- 
tions in the title and unusual abbre\ iations in the abstract. Use an 
abbreviation only if the term occurs several limes in the paper. 
Write out the full term the first time it appears, followed by the 
abbreviation in parentheses. Thereafter, employ the abbreviation 
alone. Never use an abbreviation without defining it. Standard 
units of measurement can be abbreviated without explanation 
(eg. 10 L/min. 1.^ torr. 2.3 kPa). 

Please use the following forms: cm H:0 (not cmH20). f (not 
bpm). L (not 1). L/min (not LPM. l/min. or Ipm), niL (not ml), 
mm Hg ( not mmHg ). pH ( not Ph or PH ). p > 0.00 1 ( not p>0.00 1 ), 
s (not sec). Spo; (pulse-oximetry saturation). 

Submitting the .Manuscript 

Mail three copies of the manuscript, figures, diskette, and the 
Cover Letter & Checklist to RESPIRATORY CARE, 1 1030 Abies 
Lane. Dallas TX 75229-4593. Do not fax manuscripts. Protect 
figures with cardboard. Keep a copy of the manuscript and fig- 
ures. Receipt of your manuscript will be acknow ledged. 

Computer Diskettes. A manuscript may be submitted on a 
Macintosh or lB.\I-DOS diskette. Macintosh documents on 3.5 
in. diskettes written in Microsoft Word versions 4.0 and 5.0 are 
preferred. However, we can convert most documents (including 
PC-DOS format) to our format. Label each diskette with date: 
author's name; name of word-processing program and version 
used to prepare documents; and filename(s). Do not write on a 
diskette except with a felt-tipped pen. Tables and figures must 
be in their own separate files, with software identified. Supply 3 
hard copies of the manuscript with the diskette. 

Prior and Duplicate Publication. Work that has been pub- 
lished or accepted elsewhere should not be submitted. In spe- 
cial instances, the Editor may consider such material, provid- 
ed that permission to publish is given by the author and orig- 
inal publisher. Please consult the Editor before submitting 
such work. 

.Authorship. All persons listed as authors should have partici- 
pated in the reported work and in the shaping of the manuscript: 
all must ha\e proofread the submitted manuscript: and all should 
be able to publicly discuss and defend the paper's content. A 
paper with corporate authorship must specify the key persons 
responsible for the article. Authorship is not justified solely on 
the basis of solicitation of funding, collection or analysis of data, 
provision of advice, or similar services. Persons who provide 
such ancillary services exclusively may be recognized in an 
Acknowledgments section. 

Permissions. The manuscript must be accompanied by copies of 
permissions to reproduce previously published material (figures 
or tables): to use illustrations of. or report sensitive personal 
information about, identifiable persons: and to name persons in 
the .Acknowledgments section. 

Reviewers. Please suppK the names, credentials, affiliations, 
addresses, and phone/fax numbers of three professionals whom 
you consider expert on the topic of your paper. Your manuscript 
may be sent to one or more of them ft)r blind peer review. 

Editorial Office: 

Respiratory Care 

11030 Abies Lane 

Dallas TX 75229-4593 

(972) 243-2272 (telephone) 

(972) 484-6010 (fax) 

Respirator^- Care 

Cover Letter & Checklist 

A copy of this completed form must accompany all manuscripts submitted for publication. 

Title of Paper: 

Publication Category: 

Author to be Contacted: ^Phone: FAX: 

Mailing Address of Contact Author: 

Repnnts: Yes No 

"We, the undersigned, have all participated in the work reported, proofread the accompanying manuscript, and approve its 
submission for publication." Please print and include credentials, title, institution, academic appointments, city and state. If 
more than 4 authors, please use another copy of this form." 

•Author Data: 

•Author Data: 

'Author Data: 

•Author Data: 

Author Signature/Date 

Author Signature/Date 

Author Signature/Date 

Author Signature/Date 

Has this research been presented in a public forum? Yes No 
If yes, where, when and by whom? 

Has this research received awards? ^ Yes No 
If yes, please describe. 

Do any of the authors have a financial interest in the products mentioned in this paper or competing products? 
C Yes " No If yes, please disclose: 


G Is double-spacing used throughout entire manuscript? 

D Are all pages numbered in upper-right corners? 

C Are all references, figures, and tables cited in the text? 

n Has the accuracy of the references been checked, and are they correctly formatted? 

D Have SI values been provided? 

D Has all arithmetic been checked? 

n Have generic names of drugs been provided'' 

D Have necessary written permissions been provided? 

D Have authors' names been omitted from text and figure labels? 

n Have copies of 'in press' references been provided? 

D Has the manuscript been proofread by all the authors? 

Respiratory Care 

Don't Miss the 

Research Symposium 

at the 42"^ International 

Convention & Exhibition 

in San Diego 

Presented by the Editorial Board of 

Respiratory Care 

Wednesday, November 6 

9:00-10:55 am • Rooms lA-B 

9:00-9:15 am 
Program Overview 

Joseph L Rau Jr PhD RRT 

Georgia State University, Atlanta GA /Chairing 

Introduces and reviews the 1993-1995 

symposium topics and the key topics of 

knowledge in a research project. 

9:20-10:05 am 

Ethics of Human Research and 

Institutional Review Boards 

Dean R Hess PhD RRT 

Massachusetts General Hospital. Boston MA 

Defines "ethics." Explains the rationale for 

board regulations, using examples. 

Outlines regulations: exempt, expedited, full 

review studies. Details the key elements in an 

Informed Consent Form. 

10: 1 0-1 0:55 am 
Population and Samples: 
Concepts and Examples 

Joseph L Rau Jr PhD RRT 

Describes two examples of sample results. 
Defines terms: target population, accessible pop- 
ulation, sample. Explains analysis of examples 
using these distinctions. 
Details example of population criteria used 
to select a nonrandom sample. 

Respiratory Care 


Medical Direction 

in a Changing World 

Saturday, November 2 

During the 42"'' International Convention & 
Exhibition, the AARC and Vanderbilt 
University will present this one-day post- 
graduate course for physicians only. 

The program is approved for 7 hours in Cate- 
gory I of the Physician's Recognition Award 
of the American Medical Association. Topics 
include the future of respiratory care, a 
primer on concepts and terms in health care 
today, the role of the medical director in 
today's hospital, medical direction beyond 
the acute care hospital, an update on ARDS, 
patient protocols and clinical pathways in 
respiratory care, clinical practice guidelines, 
departmental restructuring, and how to 
select ventilators. 

Encourage your medical director to attend this 
informative program. The $225 tuition entitles 
physicians to complimentary registration to the 
AARC International Convention & Exhibition. 

Contact Robert Czachowski. PhD, Director 
of Education, AARC, today at 972-243-2272 
(Fax 972-484-2720) and request that a 
complete description of the course and regis- 
tration form be sent to your medical director 
or other interested physician. 


Respiratur'i Care • October "96 Vol 41 No 10 

1997 Call for Abstracts 

Respiratory Care • Open Forum 

The American Association for Respiratoiy Care and its sci- 
ence journal. Respiratory Care, invite submission of brief 
abstracts related to any aspect of cardiorespiratory care. The 
abstracts will be re\iev\ed. and selected authors w ill be in\ ited 
to present posters at the Open Forum dunng the AARC hiter- 
national Convention and Exhibition in New Orleans, Louisiana, 
December 6-9. 1997. Accepted abstracts will be published 
in the November 1997 issue of Re.spiratory Care. Mem- 
bership in the AARC is not required for participation. 


An abstract may report ( 1 ) an orifjinal study, (2) the eval- 
uation of a method, device or protocol, or (3) a case or 
case series. Topics may be aspects of adult acute care, con- 
tinuing care/rehabilitation, perinatology/pediatrics, cardio- 
pulmonary technology, or health-care delivery. The abstract 
may have been presented previously at a local or regional — 
but not national — meeting and should not ha\e been published 
previously in a national journal. The abstract is the only evi- 
dence by which the reviewers can decide whether the author 
should be invited to present a poster at the OPEN FORUM. 
Therefore, the abstract must provide all important data, find- 
ings, and conclusions. Give specific infonnation. Do not write 
such general statements as "Results will be presented" or "Sig- 
nificance will be discussed." 

Essential Content Elements 

Abstract Format and Typing Instructions 

Accepted abstracts will be photographed and reduced by 
40'7f ; therefore, the size of the original text should be at least 
10 points. A font like Helvetica or Geneva makes the clear- 
est reproduction. The first line of the abstract should be the 
title in all capital letters. Title should explain content. Fol- 
low title with names of all authors (including credentials), 
institution(s), and location; underline presenter's name. Type 
or electronically print the abstract single spaced in a single 
paragniph 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. Data 
may be submitted in table form, and simple figures nuiy be 
included provided they fit within the space allotted. No fig- 
ures, illustrations, or tables are to be attached to the abstract 
form. Provide all author information requested. A clear pho- 
tocopy of the abstract form may be used. Standard abbre- 
viations may be employed without explanation; new or infre- 
quently used abbreviations should be spelled out on first use. 
Any recurring phrase or expression may be abbreviated, if 
it is first explained. Check the abstract for ( 1 ) errors in spelling, 
grammar, facts, and figures; (2) clarity of language; and {?•) 
confomiance to these specifications. An abstract not prepared 
as requested may not be reviewed. Questions about abstract 
preparation may be telephoned to the editorial staff of RES- 
PIRATORY Care at (972) 406-4667. 

Original study. Abstract must include ( 1 ) Background: 
statement of research problem, question, or hypothesis; (2) 
Method: description of research design and conduct in suf- 
ficient detail to pemiit judgment of \ alidity ; ( .^ ) Results: state- 
ment of research findings with quantitative data and statis- 
tical analysis; (4) Conclusions: inteipretation of the meaning 
of the results. 

Method, device, or protocol evaluation. Abstract must 
include ( 1 ) Background: identification of the method, device, 
or protocol and its intended function; (2) Method: descrip- 
tion of the evaluation in sufficient detail to permit judgment 
of its objectivity and \'alidity; (3) Results: findings of the eval- 
uation; (4) Experience: summai^ of the author's practical expe- 
rience or a lack of experience; (5) Conclusions: interpreta- 
tion of the evaluation and experience. Cost compaiisons should 
be included where possible and appropriate. 

Case report. Abstract must report a case that is uncom- 
mon or of exceptional educational value and must include ( 1 ) 
Introduction: Relevant basic information important to under- 
st;uiding the case. (2) Case Summiu'y: Patient data and response, 
details of interventions. (3) Discussion: Content should reflect 
results of literature review. The author(s) should have been 
actively involved in the case and a case-managing physician 
must be a co-author or must approve the report. 

Deadline Allowing Revision 

Authors may choose to submit abstracts early. Abstracts 
postmarked by March 17. 1997 will be reviewed and the 
authors notified by letter only to be mailed by April 25, 1997. 
Rejected abstracts will be accompanied by a written cri- 
tique that should, in many cases, enable authors to revise 
their abstracts and resubmit them by the final deadline (May 
27, 1997). 

Final Deadline 

The mandatoiy Final Deadline is May 27. 1997 (postmark). 
Authors will be notified of acceptance or rejection by letter 
oidy. These letters will be mailed by August 15, 1997. 

Mailing Instructions 

Mail (Do not fax! ) 2 clear copies of the completed abstract 
fomi. diskette (if possible), and a stamped, .self-addressed post- 
card (for notice of receipt) to: 

Respiratory Care Open Forum 

11030 Abies Lane 

Dallas TX 75229-4593 

Respiratory Care • October '96 Vol 41 No 10 


1997 Respiratory Care Open Forum 

Abstract Form 





13.9 cm or 5.5" 

1 . Title must be in all 
uppercase (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), institution, and 

?<. Do not justify (ie, 
leave a 'ragged' right 

4. Do not use t> pe size 
less than lOpoinLs. 

5. All te.xl. tables, and 
figures must fit into 
the rectangle shown. 

6. Submit 2 clean copies. 
This fonii may be 
photocopied if 
multiple abstracts are 
to be submitted. 

Mail original & 
I photocopy 
(along with postage- 
paid postcard) to 

Respiratory Care 
Open Forim 

110.10 Abies l.ane 
Dallas T\ 75229-4593 

Earix deadline is 

March 17. 1997 


Final deadline is 

May 27. 1997 


Name & Credentials 

Mailing Address 

Voice Phone & Fax 

Name & Credentials 

Mailing Address 

Voice Phone & Fax 

TVU I l> A Mll)I( U rk<ll>UC IS Kll'ifkllSt. I'kCM.kVM 

A. Patient information 

For VOLUNTARY rcrortin^ 

h\ liL-altli professionals of ad\ crsc 

events and product problems 

FDA Use Only (Rcsp Care) 


Patient identifier 

In confidence 


of birtfi: 

I I male 


B. Adverse event or product problem 

Adverse event and or 

Product problem le g defects/malfunctions) 

2 Outcomes attributed to adverse event 

(Check all Ihat apply! 

Q death 

I I life-threatening 

I I hospilalizalion - initial or prolonged Lj o'her 

I I disability 

I I congenital anomaly 

[ I required intervention to prevent 
permanent impairment/damage 

3 Date of 

4 Date of 
this report 

5 Describe event or problem 

6 Relevant tests/laboratory data, including dates 

7 Other relevant history, including preexisting medical conditions le g . allergies 
race, pregnancy, smoking and alcohol use. hepatic/renal dysfunction, etc.) 

Mail to: \lll)\V\l(ll or FAX to: 

5600 Fishers Lane 1 -800-FDA-01 78 

Rockville, MD 20852-9787 

Trtage unit 
sequence » 

C. Suspect medication(s) 

1 Name (give labeled strength & mfr labeler. if knowni 

2 Dose, frequency & route used 


3 Therapy dates (if unknown, give duration) 

4 Diagnosis for use (indicationi 

6 Lot # (if known) 



7 Exp. date (it known) 

9 NDC # (for product problems only) 

5 Event abated after use 
stopped or dose reduced 

#1 Dyes D no Dgg^Py"'' 

#2 Dyes n no D^g^Py"'' 

8 Event reappeared after 

"l Dyes D no Dgg^fy"' 

#2 Dyes Dno D^ggfy""' 

10 Concomitant medical products and therapy dates (exclude treatment of event) 

D. Suspect medical device 

1 Brand name 

2 Type of device 

3 Manufacturer name & address 


model # _ 

catalog # 

serial # 

lot # 

other # 

4 Operator of device 

I I health professional 
I I lay user/patient 
□ other: 

5 Expiration date 

If implanted, give date 


8 If explanted. give date 

9 Device available for evaluation? (Do not send to FDA i 

I I yes Qj no lH returned to manufacturer on _ 

10 Concomitant medical products and therapy dates (exclude treatment of event) 

E. Reporter (see confidentiality section on back) 

Name & address 

phone # 

2 Health professional? 

□ yes □ no 

3 Occupation 

5 If you do NOT want your identity disclosed to 
the manufacturer, place an " X " in this box. | ] 

4 Also reported to 

I I manufacturer 
[ I user facility 
I I distributor 

FDA Form 3500 1/96) 

Submission of a report does not constitute an admission tfiat medical personnel or ttie product caused or contributed to the event. 


Report experiences with: 

• medications (drugs or biologies) 

• medical devices (including in-vitro diagnostics) 

• special nutritional products (dietary 
supplements, medical foods, infant formulas) 

• other products regulated by FDA 

Report SERIOUS adverse events. An event 
is serious when the patient outcome is: 

• deatfn 

• life-threatening (real risk of dying) 

• hospitalization (initial or prolonged) 

• disability (significant, persistent or permanent) 

• congenital anomaly 

• required intervention to prevent permanent 
impairment or damage 

Report even if: 

• you're not certain the product caused the 

• you don't have all the details 

Report product problems - quality, performance 
or safety concerns such as: 

• suspected contamination 

• questionable stability 

• defective components 

• poor packaging or labeling 

• therapeutic failures 

How to report: 

• just fill in the sections that apply to your report 

• use section C for all products except 
medical devices 

• attach additional blank pages if needed 

• use a separate form for each patient 

• report either to FDA or the manufacturer 
(or both) 

Important numbers: 

• 1-800-FDA-0178 to FAX report 

• 1-800-FDA-7737 to report by modem 

• 1-800-FDA-1088 to report by phone or for 

• 1-800-822-7967 

more information 
fora VAERS form 
for vaccines 

If your report involves a serious adverse event 
with a device and it occurred in a facility outside a doc- 
tor's office, that facility may be legally required to report to 
FDA and/or the manufacturer. Please notify the person in 
that facility who would handle such reporting. 

Confidentiality: The patient's identity is held in strict 
confidence by FDA and protected to the fullest extent of 
the law. The reporter's identity, including the identity of a 
self-reporter, may be shared with the manufacturer unless 
requested otherwise. However, FDA will not disclose the 
reporter's identity in response to a request from the 
public, pursuant to the Freedom of Information Act. 

The public reporting burden lor this collection of information 
has been estimated to average 30 minutes per response, 
including the time for reviewing instructions, searching exist- 
ing data sources, gathering and maintaining the data needed, 
and completing and reviewing the collection of mformalion 
Send comments regarding this burden estimate or any other 
aspect of this collection of information, including suggestions 
for reducing this burden to: 

DHHS Reports Clearance Office 
Paperworit Reduction Project (09tO-0291) 
Hubert H Humpfirey Building. Room 531-H 
200 Independence Avenue, S W 
Washinglon. DC 20201 

An agency may not conduct or sponsor, 
and a person is not required to respond to. 
a collection of information unless il displays 
a currently valid OhtB control number 

Please do NOT 

return this form 
to either of these 

Public Health Service • Food and Drug Administration 

FDA Form 3500-back 

Please Use Address Provided Below - Just Fold In Thirds, Tape and Mall 

Department of 

Health and Human Services 

Public Health Service 

Food and Drug Administration 

Rockville, rvlD 20857 

Official Business 

Penalty for Private Use S300 













The FDA Medical Products Reporting Program 
Food and Drug Administration 
5600 Fishers Lane 
Rockville, MD 20852-9787 


American Association for Respiratory Care Membership Application 


Please read the eligibility requirements for each of \he classifi- 
cations in the right-hand column, then complete the applicable 
section. All information requested below must be provided, 
except where indicated as optional. See other side for more 
information and fee schedule. Please sign and date applica- 
tion on reverse side and type or print clearly. Processing of 
application takes approximately 15 days. 

n Active 

u Physician 
n Industrial 
D Special 
i: student 

Last Name . 
First Name _ 


Social Security No. 

Home Address 




Phone No. 


Primary Job Responsibility (check one only) 

Technical Director 
L_ Assistant Technical Director 
D Pulmonary Function Specialist 
C Instructor/Educator 
n Supervisor 
D Staff Therapist 
D Staff Technician 
D Rehabilitation/Home Care 
D Medical Director 
C Sales 
D Student 
n Other, specify 

Type of Business 

D Skilled Nursing Facility 
n Home Health Agency 
C Educational Institution 
C Manufacturer or supplier 
Z Other, specify 

Date of Birth (optional) _ 

Sex (optional) . 

US. Citizen? Yes No 

Have you ever been a member of the AARC 
If so. when? From to 

Preferred mailing address; Home 



An individual is eligible if he/she lives in the US or its lerntones or was an Active Member 
pnor 10 moving outside its borders or territories, and meets ONE of the following criteria 
(1) IS legally credentialed as a respiratory care professional if employed in a state that 
mandates such, OR (2) is a graduate of an accredited educational program in respiratory 
care, OR (3) holds a credential issued by the NBRC An individual who is an AARC Active 
Member in good standing on December 8. 1994 will continue as such provided his/her 
membership remains in good standing. 

Place of Employment 




Phone No. ( . 



Medical Director/Medical Sponsor _ 


Individuals who hold a position related to respiratory care but do not meet the re- 
quirements of Active Member shall be Associate Members They have all of the nghts and 
benefits of the Association except to hold office, vote, or serve as chair of a standing 
committee The following subclasses of Associate Membership are available Foreign, 
Physician, and Industrial (individuals whose pnmary occupation is directly or indirectly 
devoted to the manufacture, sale, or distribution of respiratory care equipment or supplies) 
Special Members are those not working in a respiratory care-related field 


Place of Employment 

Address , 



Phone No. (_ 


Individuals will be classified as Student Members if they meet all the requirements for 
Associate Membership and are enrolled in an educational program in respiratory care 
accredited by, or in the process of seeking accreditation from, an AARC-recognized 

SPECIAL NOTICE — Student Members do not receive Continuing Respiratory Care 
Education (CRCE) transcripts Upon completion of your respiratory care education, 
continuing education credits may be pursued upon your reclassification to Active or 
Associate Member 

School/RC Program 

Address . 




Phone No. ( . 

Length of Program 

1 year 4 years 
D 2 years Other, specify^ 

Expected Date of Graduation (required information) 

Month Year 

American Association for Respiratory Care • 11030 Abies Lane • Dallas, TX 75229-4593 • (972) 243-2272 • Fax (972) 484-2720 

American Association for Respiratory Care Membership Application 

Demographic Questions 

We request that you answer these questions in order to help 
us design services and programs to meet your needs. 

Check the Highest Degree Earned 

^ High School 

n RC Graduate Technician 

D Associate Degree 

D Bachelor's Degree 

D Master's Degree 

n Doctorate Degree 

Number of Years in Respiratory Care 

0-2 years 11-15 years 

D 3-5 years Cj 16 years or more 

n 6-10 years 

Job Status 

Full Time 

_ Part Time 


_ RRT 




D Physician 



n Perinatal/Pediatnc 



Less than $10,000 
D $10,001 -$20,000 

$20,001 -$30,000 
^ $30.001 -$40,000 
n $40,001 or more 


I hereby apply for membership in the American Association for Respiratory Care 
and have enclosed my dues. If approved for membership in the AARC. I will 
abide by its bylaws and professional code of ethics I authorize investigation of 
all statements contained herein and understand that misrepresentations or 
omissions of facts called for is cause for rejection or expulsion. 

A yearly subscnption to Respiratory Care lournal and AARC Times magazine 
includes an allocation of $6.50 from my dues for each of these publications 

NOTE: Contributions or gifts to the AARC are not tax deductible as charitable 
contributions for income tax purposes. However, they may be tax deductible as 
ordinary and necessary business expenses subject to restrictions imposed as a 
result of association lobbying activities. The AARC estimates that the 
nondeductible portion of your dues - the portion which is allocable to lobbying - 
is 26% 



Membership Fees 

Payment must accompany your application to the AARC. 
Fees are for 12 months. (NOTE: Renewal fees are $65.00 
Active, Associate-Industrial or Associate-Physician, or Special 
status; $80.00 for Associate-Foreign status; and $35.00 for 
Student status.) 

D Active $77.50 

D Associate (Industrial or Physician) $77.50 

D Associate (Foreign) $92.50 

D Special $77.50 

D student $35.00 



Specialty Sections 

Established to recognize the specialty areas of respiratory 
care. The sections publish a newsletter four times a year that 
focuses on issues of specific concern to that specialty. The 
sections also design the specialty programming at the 
national AARC meetings. 

D Adult Acute Care Section 

$ 5.00 

n Education Section 


D Pennatal-Pediatnc Section 

$ 5.00 

D Diagnostics Section 

$ 5.00 

D Continuing Care- 

Rehabilitation Section 

$ 5.00 

D Management Section 


D Transport Section 

$ 5.00 

D Home Care 

$ 5.00 

n Subacute Care 

$ 5.00 



GRAND TOTAL = Membership Fee 

plus optional sections S 

" Total Amount Enclosed $ 

Please charge my dues (see below) 

To charge your dues, complete the following: 
D Visa 

Card Number 

Card Expires /_ 


Mail application and appropriate fees to: 
Ameriton Association for Respiratory Care • 11030 Abies Lane • Dallas, TX 75229-4593 « (972) 243-2272 « Fax (972) 4 84-2720 

Not-for-profit organi/alions are offered a free advertisement of up to eight Mncs Ui appear, on a space-available basis, in Calendar of Events in 
Respiratory Carl Ads for other meetings are priced at $5.f\0 per line and require an insertion order. Deadline is the 2()th of the month two 
months precedmg the month in which you wish the ad to run. Submit copy and insertion orders to Calendar of Events. RRSPIRATORV CaRF. 
1 1030 Abies Lane. Dallas TX 75229-4593, 

of Events 


October 1 1 — Tlie Soutliern 
Chapter of the Colorado Society 

3id Annual Southern Colorado 
Puliiionai y Medicine Symposium 
at the Holiday Inn Garden of the 
Gods. Colorado Springs, Colorado. 
Lunch is included in the $15 fee. 
Contact: Barry Beard at (719) 
776-52 1 1 . fax (7 1 9) 776-2535. 

October 15— AARC Video 

"Capturing Respiratory Services 

Outside the Hospital — Part II: 

Subacute Care."" Part 6 of the 1996 

7-part video conference '■Professor"s 

Rounds in Respiratory Care," from 

12:30 to 2 p.m. Eastern Time. 

Live telephone question-and-answer 

session airs Nov. 18. 

CRCE: 1 credit hour. 

Contact: AARC at (972) 243-2272. 

October 25 — The Southwest 
Region of the Texas Society 

Early Winter Forum in 

EI Paso, Texas. 

Contact: Tony Baird at (915) 


November 14 — The South Region 
of the Texa.s Society 

The Victoria District presents the 

Fall Seminar in Victoria. Texas. 
Contact: Dennis Alhrecht. 
Citizen's Medical Center, at 

November 15 — The South Region 
of the Texas Society 

""One Stop Shop CRCE Express"" 
in Houston, Texas. 
CRCE: 6 credit hours have been 
requested. Contact: Keni Poole at 


November 15 — Puget Sound 
Chapter of the Washington 

1 8th Annual Adult Critical Care 
Conference at the Urban 
Horticulture Center of the 
University of Washington campus. 
Seattle, Washington. 
Contact: Deb Jones at (206) 

December 10— AARC Video 

"Airway Management: Tricks of the 
Trade."" The final segment of the 
1996 7-part video conference 
"Professor"s Rounds in Respiratory 
Care,"" from 12:30 to 2 p.m. Eastern 
Time. Live telephone question-and- 
answer .session airs Dec. 19. 
CRCE: 1 credit hour. 
Contact: AARC at (972) 243-2272. 

.January 31, 1997 — Texas Society 

Annual Winter Forum, 

"The RCP as an Entrepreneur"" 

and "Respiratory Care Plans: 

Development and Implementation,"" 

in Austin, Texas. 

Contact: TSRC Executive Offices, 

PO Box 515239, Dallas TX 75251. 


March 5-7. 1997 — .lournces 
Internationales de Ventilation a 
Domicile (JIVD) 

6th International Conference on 

Home Mechanical Ventilation, 

sponsored by the AARC and 

JIVD, in Lyon. France. 

The official languages of the 

conference are English and 

French: simultaneous translation 

will be provided. 

Abstracts are due by Dec. 15. 

For guidelines on abstract 

submissions and for more 

information on the conference, 

contact the Congress Secretariat at 

JIVD, Hopital de la Croix Rousse, 

Service de Reanimation Medicale et 

Assistance Respiratoire, 

93 Grande Rue de la Croix Rousse, 

69317 Lyon Cedex 04, France. 

or call (33) 78 39 08 43, 

fax (33) 78 39 58 63, 

or send E-mail to 


Mark Your Calendars! 

Future AARC Conventions 

December G-O, 1997 
New Orleans, Louisiana 

November 7-10, 1998 
Atlanta, Georgia 

Respiratory Care • October '96 Vol 41 No 10 



in This Issue 

Brougher. Pat S78 

Carlisle, Carol C 885 

Cheang, Mary 895 

Chiumello, Davide 880 

Croci. Massimo 880 

Durbin Jr. Charles G 903 

Fajardo, Carlos A 895 

Gattinoni, Luciano 880 

Giordano. Sam P 909 

Hill, Nicholas S 885 

Kirby. Elizabeth G 903 

LaRoche. Anne 909 

McCool, F Dennis 885 

Mehta, Sangeeta 885 

Metcalfe. Harley R 909 

Mortimer, Todd W 895 

Pelosi, Paolo 880 

Pilbeam. Susan 908 

Salyer, John W 910 

Shrake. Kevin L 910 

in This Issue 

To advenise in Respiratory Cark, contact Tim Goldsbury, 20 Tradewinds Circle. Tequesia 1-L .13469 at |56I) 745-6793. 
Fax (561) 745-6795. email: timo2 69076? for rates and media kits. For recruilmentyclassified advertising contact 
RESPIRATORY Care's Marketing .Assistant. Beth Bmkle\. at (972l 243-2272, Fa\ (<)72| 4S4-6()I() Dale CrilTiths is 
Respiratory Care's Marketing Director- 

Allied Healthcare Products Inc 860 

Circle Reader Service No. 1 1 8 Call (S()(l) 232-7633 

Ambu. Inc 923 

Circle Reader Sen ice No, 123 Call (800) 262-8462 

DHD Diemolding Healthcare Division 869 

Circle Reader Serxice No, 149 Call (800) 847-8000 

General Cardiac Technology 943 

Circle Reader Service No, 151 Call (800) 798-2667 

GlaxoWellcome 931-932 

Circle Reader Service No, 126 See Ad 

HRInc 868 

Circle Reader Service No. 136 Call (800) 426-1042 

IMPACT Instrumentation, Inc 858 

Circle Reader Serx.ce No, 1 15 Call (800) 969-0750 

Information Television Network 877 

Call (800) JNFO-ITV 

Kendall Respiratory 871 

Circle Reader Service No, 1(19 Call (800) 962-9888 

LIFECARE International. Inc 862 

Circle Reader Service No, 141 Call (800) 669-9234 

Mallinckrodt Medical 857 

Circle Reader Service No 1 S4 Call (800 1 833-8842 

Maginnis & Associates 864 

Circle Reader Service No, 1 19 Call (800) 621-3008 

Marquette Medical Systems 924 

Circle Reader .Service No, 142 Call (800) 917-6000 

Monaghan Medical Corporation 874-875 

Circle Reader SerMce No, 127 Call (800) 833-9653 

Nellcor Puritan Bennett 873 

Circle Reader Service No. 102 Call (800) NELLCOR 

Ohmeda 939 

Circle Reader Service No. 1 2 1 Call (800) 345-2700 

RFB Technologies 947 

Circle Reader Service No, 1.30 Call (800) 856-4138 
SensorMedics Cover 3 

Circle Reader Service No. 138 Call (800) 231-2466 
Sherwood Medical Cover 4 

Circle Reader Serv ice No, 1 29 Call (800) 325-7472 

Singapore General Hospital 919 

Circle Reader Sen ice No, 140 See Ad 

.STI Medical Products 955 

Circle Reader .Service No. 1 53 Call (800) 216-1 500 

Copyright Information. Respiratory Care is copyrighted h> 

Daetialus Enterprises Inc. Reproduclion in whole or in part without the 
express written permission of Daedalus Enterprises Inc is prohibited. 
Permission to photocopy malerial in this Journal for noncommercial pur- 
poses of scientific or eilucalional advancement is granted. .Anyone may. 
wilhout permission, quote up to ,500 words of material in this journal pro- 
vided the quotation is for noncommercial use and Rhspiratorv CarI-; is 
credited. Longer quotation requires written approval by the author and 
publisher. Single reprints are available only from the authors. Reprints for 
commercial use may be purchased from Daedalus Enterprises Inc, For 
information and prices call (972) 243-2272. 

Dl.sci.,MMER. The opinions expressed in any article or editorial are those 
of the author and do not necessarily refiecl the views of the Editors, the 
American Association for Respiratory Care (AARC). or Daedalus 
Enterprises Inc. Neither arc the Editors, the AARC or the Publisher 
respimsible for the consequences of the clinical applications or of any 
methods or devices described in any article or advertisemenl, 

StliSCRlPTION Rates, hidividual subscription rates are S65 per year (12 
issues). $125 for 2 years, and $185 for 3 years in the US and Puerto Rico. 
Rates are $80 per year, $155 for 2 years, and $230 for 3 years in all other 
countries (add $84 per year for air mail). Single copies when available cost 
$5; add $7 for air mail postage to overseas countries. Checks should be 

m.iile pay able to Resp1RATDR\ Care and sent to the subscription office at 
1 1030 Abies Lane. Dallas TX 75229-4593. 

Subscription Rates for Associations. An association may offer 

individual subscriptions of RESPIRATORY CARE to its members at a 
reduced rate. The rates based on membership are: $6 per year for 101-500 
members: $5.50 for 50 1-1. .500 members; S5 for 1.501-10.000 members; 
S4 for more than 10.000 members. For information, contact Ray Masferrer 

C1I.\N(;E ok .\UURtSS. .Notily RESPlRATtJRI CARE as soon as possible of 
any change in address. Note the subscription number (from the mailing 
label) and your name, old address, and new address. Allow 6 weeks for the 
change. To avoid charges for replacement copies of missed issues, requests 
must be made v\ ithin fiO days in the US and 90 days in other countries. 

Manuscripts. The Journal publishes clinical studies, method/device 
evaluations, reviews, and other materials related to cardiopulmonary med- 
icine and research. Manuscripts may be submitted to the Editorial Office. 
Respiratory Care. 110.30 Abies Lane, Dallas T.X 75229-4.593. 
Instructions for authors are printed in every issue. An expanded version of 
the Insinictions is available from the editorial office. 

Copyright © 1W6. by Dcieduhis Enterprises Inc. 


Respir.ator'i Care • October "96 Vol 41 No U) 


October 1996 Reader Service Reply Card 


Expires 1/31/97 



City/State/Zip . 

For faster service, FAX to (609) 786-4415 

Send Free Information 

on the Items Circled Below 

(Please Circle No More Than 15 Items) 

























































































































For AARC Memberstilp Information, C 


For Respiratory Care Subscription Information, Circle 82. 


October 1996 Reader Service Reply Card 


Expires 1/31/97 

_ Phone 


City/State/Zip . 

For faster service. 

FAX to (609) 786-4415 

Send Free Information on the Items Circled Below 

(Please Circle No More Than 15 Items) 

























































































































For AARC Membership Information, Circle 81 . 

For Respiratory Care Subscript 

on Information, Circle 82. 

1. Type of Institution/Practice 

1 - J Hosp 500 or more beds 

2. -1 Hosp 300 to 499 beds 

3. J Hosp 200 to 299 beds 
4 J Hosp 100 to 199 beds 

5. J Hosp 100 orless beds 

6. U Sliilled Nursing Facility 

7. U Home Care Practice 

8. CJ School 

II. Department 

A J Respiratory Therapy 
B J Cardiopulmonary 
C J Anesthesia Service 
D J Emergency Dept 

III. Specialty 

1 , 3 Clinical Practice 
2- □ Perinatal Pediatrics 

3. □ Critical Care 

4. □ Clinical Research 

5. D Pulmonary Function Lab 

6. Q Home Care/Rehab 

7. J Education 

8. J Management 

A J Dept Head 

B. ui Chief Therapist 

C. 3 Supervisor 

D. □ Staff Technician 

E. Q Staff Therapist 

F. -I Educator 

G. _) H/ledical Director 
H. ^Anesthesiologist 
I. -J Pulmonologist 
J- □ Other MD 

K. :3 Nurse 

V. Are you a member of the AARC? 

1 . J Yes 2. J No 

1. Type of Institution/Practice 

1 - -J Hosp 500 or more beds 

2. U Hosp 300 to 499 beds 

3. 3 Hosp 200 to 299 beds 

4. 3 Hosp 100 to 199 beds 

5. U Hosp 100 or less beds 

6. □ Skilled Nursing Facility 

7. □ Home Care Practice 

8. -I School 

II. Department 

A. 3 (Respiratory Therapy 

B. 3 Cardiopulmonary 

C. D Anesthesia Service 
D J Emergency Dept 

III. Specialty 

classic motorcycle, you can 
the highway at heart-racing 

y for those who demantJ power 
performance. And so is the 

om SensorMedics. 

formance gives you the power 

our diagnostic system to your 

ation needs. 

lary Function Analysis 

^ulmonary Exercise Testing 

tory Mechanics 

nal Assessment 

a Clinical Practice 
Q Perinatal Pediatrics 

□ Critical Care 

□ Clinical Research 

□ Pulmonary Function Lab 
3 Home Care/Rehab 
J Education 

8. ^ Management 
A, Zi Dept Head 
J Chief Therapist 

□ Supervisor 

□ Staff Technician 

□ Staff Therapist 
J Educator 
-J Medical Director 

H- J Anesthesiologist 

I. J Pulmonologist 

J. a Other MD 

K. CI Nurse 

V. Are you a member of the AARC? 

1. QYes 2. UNO 

you combine them all into a single 
nto separate systems. And if the 
;! on changes, Vmax flexibility 
josition as leader of the pack by 
pplications later 
, the Vmax Five Year Warranty 
and Annual Supply Kit make your operating 
expenses predictable. Simply put, you'll do 
more tests with less gas. So go ahead. Throttle 
up and accelerate your laboratory into the 
power of Vmax performance. Call our toll free 
"Hot Line" at l-800-23'l-24bb, extension 8558, 
or send us a fax at 1-714-283-8439. 

i/isit us ai the mARC in San Diego, Booth 531 

Circle 138 on reader service card 
^m Visit AARC Booth 531 in San Diego 

^^ SersorMeoics 

The Cardiopulmonary Care Company'" 

in This Is: 

Brougher, Put 

Carlisle, Carol C 

Cheang, Mary 

Chiumello. Davide 

Croci. Massimo 

Durbin Jr. Charles G .... 

Fajardo, Carlos A 

Gattinoni, Luciano 

Giordano. Sam P 

Hill. Nicholas S 

in This Is: 

Allied Healthcare Produ 

Circle Reader Service No. 

Ambu. Inc 

Circle Reader Ser\ ice No. 

DHD Diemolding Healt 

Circle Reader Service No. 

General Cardiac Technc 

Circle Reader Service No. 


Circle Reader Service No. 


Circle Reader Service No. 

IMPACT Instrumentatic 

Circle Reader .Ser\ice No. 
Information Television I 

Kendall Respiratory 

Circle Reader Service No. 

LIFECARE Internation; 

Circle Reader Service No. 

Mallinckrodl Medical... 

Circle Reader Service No. 

Copyright Informatk 

Daedalus Enterprises Inc. 
express written permissioi 
Pennission to photocopy n 
poses of scientitlc or cduc 
without permission, quote i 
vided the quotation is for n 
credited. Longer quotation 
publisher. Single reprints ai 

commercial use may be p _ 

information and prices call (972) 243-2272. 

Disci. AIMKR. The opinions expressed in any article or editorial are those 
of the author and do iiol necessarily retlect the views of the Editors, the 
American Association for Respiratory Care (A.'^RC). or Daedalus 
Enterprises Inc. Neither are the Editors, the AARC or the Publisher 
responsible for the consequences of the clinical applications or use of any 
methods or devices described in any article or advertisement. 

Subscription Rates. Individual subscription rates are $65 per year ( 1 2 
issues), $125 for 2 years, and $185 for 3 years in the US and Puerto Rico. 
Rates are $80 per year, $155 for 2 years, and $230 for 3 years in all other 
countries (add $S4 per year for air mail ). Single copies when available cost 
$5; add $7 for air mail postage to overseas countries. Checks should be 





AARC Publications 

PO BOX 11605 

RIVERTON NJ 08076-7205 






AARC Publications 

PO BOX 11605 

RIVERTON NJ 08076-7205 


.1.. I.I.I 

Chan(;e of Address. Notify RiiSPiRATORv Care as soon as possible of 
any change in address. Note the subscription number (from the mailing 
label) and your name, old address, and new address. Allow 6 weeks for the 
change. To a\ iiid charges for replacement copies of missed issues, requests 
inusi he made within 60 days in the L'S and 90 days in other countries. 

MaMiscRIPTS. The Journal publishes clinical studies. nielhod/de\ ice 
evaluations, reviews, and other materials related to cardiopulmonary med- 
icine and research. Manuscripts may be submitted to the Editorial Office. 
RESPIRATORY Care. 11030 Abies Lane, Dallas TX 75229-4593. 
Instructions for authors are printed in every issue. An expanded version of 
the Insiruclions is available from the editorial office. 

Copyrighl © IW6. hy DaecUiliis Enterprises Inc. 


RESPIRATORY Care • October "96 Vol 41 No 10 



With this classic motorcycle, you can 
scream down the highway at heart-racing 
speed. It's only for those who demand power 
and maximum performance. And so is the 
Vmax Series from SensorMedics. 

Vmax performance gives you the power 
to customize your diagnostic system to your 
specific application needs. 

"■ Pulmonary Function Analysis 

► Cardiopulmonary Exercise Testing 
►■ Respiratory Mechanics 

► Nutritional Assessment 


Vmax lets you combine them all into a single 
instrument or into separate systems. And if the 
road you travel on changes, Vmax flexibility 
secures your position as leader of the pack by 
adding more applications later 

Best of all, the Vmax Five Year Warranty 
and Annual Supply Kit make your operating 
expenses predictable. Simply put, you'll do 
more tests with less gas. So go ahead. Throttle 
up and accelerate your laboratory into the 
power of Vmax performance. Call our toll free 
"Hot Line" at 1-800-231-2466, extension 8558, 
or send us a fax at 1-714-283-8439. 

Visit us at ttie AAHC in San Diego, Booth 531 

Circle 138 on reader service card 
^ym Visit AARC Booth 531 in San Oiego 

^^ SersorMedics 

The CardioPulmonarv Care ComDanv'*' 


Volumetric Incentive Deep-Breatliing Exerciser 

The accuracy of Voldyne, in a new size, matched to geriatric 
patients and patients with smaller lung capacities. 


Voldyne 2500 ... 

■ A smaller lighter flow cup reduces the work of breathing, thus 
improving patient performance and progress. 

■ Every unit is individually tested and calibrated for performance, 

reliability and superior accuracy of inhaled lung volume 

■ Volume incentive spirometry improves assessment of patient 

progress by eliminating the guesswork associated with spirometers 
that only measure flow. 

■ Graduations printed on both sides of the unit allow the therapist to 
conveniently observe volumes while instructing and encouraging 
the patient. 

For further injormatton. contact your Sherwood OR /Critical Care 

Representative or call , onf\ -yte -7 Ait 

1-800-325-7472 loutslde Missouri) 

1-800-392-7318 n Missouri) 
Visit AARC Booths 918 and 920 in San Diego 

©1991 Sherwood Medical Company 

ii Sheriuaod 


ST .(XJIS y^O 63103US A 

Circle 129 on reader service card