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OCTOBER  1  998 
VOLUME  43 
NUMBER  1  0 

ISSN  0020-1324-RECACP 


RE/PIRATORy 


4c 


44*  International  Respiratory  Congress 
November  7-10, 1998  •  Atlanta,  Georgia 


A  MONTHLY  SCIENCE  JOURNAL 
43RD  YEAR— ESTABLISHED  1956 


ORIGINAL  CONTRIBUTIONS 

An  Evaluation  of  Asthma  Education  for  School 
Personnel  Using  Peak  Performance  USA 


REVIEWS 


Flexible  Fiberoptic  Bronchoscopy  in  1998 

1998  OPEN  FORUM  ABSTRACTS 


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A  Monthly  Science  Journal 
Established  in  1956 

The  Official  Journal  of  the 

American  Association  for 

Respiratory  Care 


OCTOBER    1998   /   VOLUME   43   /   NUMBER    10 


ORIGINAL  CONTRIBUTIONS 


An  Evaluation  of  Asthma  Education  for  School  Personnel  Using 
Peak  Performance  USA 

bv  Diana  Powell — San  Jose.  California 


REVIEWS,  OVERVIEWS  &  UPDATES 


Flexible  Fiberoptic  Bronchoscopy  in  1998 

by  Robert  H  Poe  and  Robert  H  Israel — Rochester,  New  York 


TEST  YOUR  RADIOLOGIC  SKILL 


Profound  Hypoxemia  in  an  Alcoholic 

by  Jayashree  S  Parekh  and  Charles  G  Durbin  Jr — Charlottesville.  Virginia 


BOOKS,  FILMS,  TAPES,  &  SOFTWARE 

Asthma 

reviewed  by  Christopher  D  Beaty — Seattle.  Washington 


Eicosanoids,  Aspirin,  and  Asthma 

reviewed  by  Marco  Confalonieri — Piacenza.  Italy 

Fishman's  Pulmonary  Diseases  and  Disorders,  3rd  Ed 

reviewed  by  Ati4l  Malhotra  and  David  R  Schwartz — Boston.  Massachusetts 

Principles  and  Practice  of  Intensive  Care  Monitoring 

reviewed  by  Benjamin  D  Medoff^Boston.  Massachusetts 


OPEN  FORUM  ABSTRACTS  1998 

Introduction 
1998  Abstracts 
Author  Index 

AARC  INTERNATIONAL  RESPIRATORY  CONGRESS 

Congress  Exhibitors 


804 


811 


820 

823 
824 
825 
825 

827 
828 
881 

885 


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EDITORIAL  OFFICE 


EDITOR  IN  CHIEF 


Rkspiratorv  Care  dSSN  0020-1324,  USPS  0489- 
I'JOl  is  published  monthly  by  Daedalus  Enlerprises  Inc.  at 
1 1030  Abies  Lane,  Dallas  TX  75229-4593,  for  the  Amer- 
ican Association  for  Respiratory  Care.  One  volume  is 
published  per  year  beginning  each  January.  Subscription 
rates  are  $75  per  year  in  the  US;  $90  in  all  other  countries 
(for  airmail,  add  $94). 

The  contents  of  the  Journal  are  Indexed  in  Hospital  and 

Health  Administration  Index.  Cumulative  Index 

ing  and  Allied  Health  Literature,  EMBASE/Exerpta  Med 

ica,  and  RNdex  Library  Edition.  Abridged 

Respiratory  Care  are  also  published 

French,  and  Japanese,  with  permission  from  Daedalus  En 

terprises  Inc. 

Penodicals  postage  paid  at  Dallas  TX  and  at  additional 
mailing  offices,  POSTMASTER:  Send  address  changes  to 
RESPIRATORY  CARE.  Membership  Office.  Daedalus  En- 
terprises Inc.  1 1030  Abies  Lane.  Dallas  TX  75229-4593. 
Primed  in  the  United  Slates  of  America 
Copyright  ©  /  998.  by  Daedalus  Enterprises  hu. 


David  J  Pierson  MD 
Harborview  Medical  Center 
University  of  Washington 
Seattle.  Wasliingtini 

ASSOCIATE  EDITORS 


Richard  D  Branson  RRT 

Universit}'  of  Cincinnati 
Cincinnati.  Ohio 


Charles  G  Durbin  Jr  MD 

University  of  Virginia 
Charlottesville.  Virginia 

EDITORIAL  BOARD 


Dean  R  Hess  PhD  RRT 
Massachusetts  General  Hospital 
Harvard  University 
Boston.  Massachusetts 

James  K  Stoller  MD 

The  Cleveland  Clinic  Foundation 
Cleveland,  Ohio 


Thomas  A  Barnes  EdD  RRT 

Nnrtheastern  University 
Boston.  Massachusetts 

Michael  J  Bishop  MD 

University  of  Wasliini;ton 
Seattle.  Washington 

Bartolome  R  Celli  MD 

Ttifts  University 
Boston.  Massachusetts 

Robert  L  Chatbum  RRT 

University  Hospitals  of  Cleveland 
Case  Western  Resenr  University 
Cleveland.  Ohio 

Luciano  Gattinoni  MD 

University  of  Milan 
Milan.  Italy 

John  E  Heffner  MD 

Medical  University  of  South  Carolina 
Charleston.  South  Carolina 

Mark  J  Heulitt  MD 
University  of  Arkansas 
Little  Rock,  Arkansas 


SECTION  EDITORS 


Leonard  D  Hudson  MD 

University  of  Washington 
Seattle.  Washington 

Robert  M  Kacmarek  PhD  RRT 
Massachusetts  General  Hospital 
Harvard  University 
Boston.  Massachusetts 

Toshihiko  Koga  MD 
Koga  Hospital 
Kurume.  Japan 

Marin  H  Kollef  MD 

Washington  University 
St  Louis.  Missouri 

Patrick  Leger  MD 
Clinique  Medicate  Edouard  Rist 
Paris.  France 

Neil  R  Maclntyre  MD 

Duke  UniversiTy 
Durham.  North  Carolina 

John  J  Marini  MD 
Univeisity  of  Minnesota 
St  Paul.  Minnesota 


Shelley  C  Mishoe  PhD  RRT 

Medical  College  of  Georgia 
Augusta.  Georgia 

Joseph  L  Rau  PhD  RRT 
Georgia  Stale  University 
Atlanta.  Georgia 

Catherine  SH  Sassoon  MD 

University  i>f  California  lr\ine 
Long  Beach.  California 

Arthur  S  Slutsky  MD 

University  of  Toronto 
Toronto.  Ontario.  Canada 

Martin  J  Tobin  MD 

Loyola  University 
Mawvood.  Illinois 


STATISTICAL  CONSULTANT 

Gordon  D  Rubenfeld  MD 
University  of  Washington 
Seattle,  Washington 


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


Hugh  S  Mathews 
Drug  Capsule 


Charles  G  Irvin  PhD 

Gregg  L  Ruppel  MEd  RRT  RPFT 

PFT  Corner 


Richard  D  Branson  RRT 
Robert  S  Campbell  RRT 
Killiedges  Corner 


Jon  Nilsesluen  PhD  RRT 

Ken  Hargett  RRT 

Robert  Harwood  MSA  RRT 

Graphics  Corner 


Patricia  Ann  Doorley  MS  RRT 
Charles  G  Durbin  Jr  MD 
Test  Your  Radiologic  Skill 


Barbara  Wilson  MEd  RRT 
Jon  Meliones  MD 
John  Palmisano  RRT 
Cardiorespiratoiy  Interactir 


CONSULTING  EDITORS 


Frank  E  Biondo  RRT  Donald  R  Ellon  MD 

Howard  J  Birenbauni  MD  Ronald  B  George  MD 


James  M  Hurst  MD 
Michael  McPeck  RRT 


John  Shigcoka  MD 
Jeffre\  J  Ward  MEd  RRT 


Abstracts 


Sumiiiaries  (if  Pertincnl  Articles  in  Other  Journals 


Editorials,  Commentaries,  and  Reviews  To  Note 

Alternative  Medicine — The  Risks  of  Untested  and  Unrenulated  Remedies  (Editorial) — An- 
gell  M.  Kassirer  JP.  N  Engl  J  Med  IWS;339(  I2):83y-S41 . 

Liquid-Assisted  Ventilation:  An  Alternative  Respiratory  Modality — Wollson  MR.  Greenspan 
JS.  Shaffer  TH.  Pediatr  Pulmonol  199S;26(1  ):42-63. 

Ethical  Aspects  of  Respiratory  Research  in  Infancy  and  Karly  Childhood — Beardsmore  CS 
Pediatr  Pulmonol  1998:26(1  ):64-6S, 

Irregularities  and  Power  Law  Distributions  in  the  Breathing  Pattern  in  Preterm  and  Term 
Infants— Bruce  EN.  J  Appl  Physiol  1998;8.S(3):787-788. 

Unexpected  Endotracheal  Extubations— Sininii  B.  Eancct  l99S;3.'i2(9129):671-672. 

Pulmonary  Arteriovenous  Malformations.  A  State  of  the  Art  Review  (Re\  iew) — Gossage  JR. 
Kanj  G.  Am  J  Respir  Crit  Care  Med  1998;158(2):643-661 . 

Round  Table  Conference.  Acute  Lung  Injury  (Meeting  Report).  .Am  J  Respir  Crit  Care  Med 
1998;1.^8(2):675-679. 


Blastomycosis  as  an  Etiology  of  Acute  Lung 
Injury — Thompson  CA.  McEachern  R.  Nor- 
man JR.  .South  Med  J  1998;91(9):86l. 

Blastomyces  dermatitidis.  a  dimorphic  broad- 
hased  budding  yeast  endemic  to  the  Mississippi 
River  Valley  region,  is  responsible  for  morbid- 
ity in  humans  via  inhalation  and  dissemination. 
The  response  of  acute  lung  injury,  which  pro- 
duces an  illness  with  serious  morbidity  and  an 
approximately  50%  mortality,  unconiinonly  oc- 
curs. Diagnosis  can  be  difficult,  and  a  high  in- 
dex of  suspicion  should  be  maintained  in  en- 
demic regions  for  patients  with  acute  lung  injury 
of  uncertain  etiology,  especially  if  their  condi- 
tion deteriorates  on  broad-spectrum  antimicro- 
bial and  antilubercular  therapy  and  they  have  a 
previous  insidious  respiratory  complaint  and 
constitutional  symptoms.  Diagnosis  should  be 
aggressively  pursued  and  treatment  with  am- 
photericin B  (0.6  to  0.8  mg/kg/day)  initiated  as 
early  as  possible.  Arch  Intern  Med  1998; 
I.SS(I6):1769. 

Benefits  of  hifluen/a  Vaccination  for  Low-, 
Intermediate-,  and  High-Risk  Senior  Citi- 
zens— Nichol  Kl,.  Wiiorcnma  J.  von  Sternberg 
T.  SoiUh  Med  J   199S;9I(9):86I. 

BACKGROUND:  Vaccination  rates  for  healthy 
senior  citizens  are  lower  than  those  for  senior 
citizens  with  underlying  medical  conditions  such 


as  chronic  heart  or  lung  disease.  Uncertainty 
about  the  benefits  of  influenza  vaccination  for 
healthy  senior  citizens  may  contribute  to  lower 
rates  of  utilization  in  this  group.  OBJECTIVE: 
To  clarify  the  benefits  of  influenza  vaccination 
among  low-risk  senior  citizens  while  concur- 
rently assessing  the  benefits  for  intermediate- 
and  high-risk  senior  citizens.  METHODS:  All 
elderly  members  of  a  large  health  maintenance 
organization  were  included  in  each  of  6  con- 
secutive study  cohorts.  Subjects  were  grouped 
according  to  risk  status:  high  risk  (having  heart 
or  lung  di.sease),  intermediate  risk  (having  dia- 
betes, renal  disea.se.  .stroke  and/or  dementia,  or 
rheumatologic  disease),  and  low  risk.  Outcomes 
were  compared  between  vaccinated  and  un\ac- 
cinated  subjects  after  controlling  for  baselnic 
demographic  and  health  characteristics.  RE- 
SULTS: There  were  more  than  20000  subjects 
in  each  of  the  6  cohorts  who  provided  147.'i.'Sl 
person-periods  of  observation.  The  pooled  vac- 
cination rate  was  6Q7r.  There  were  101  610 
person-periods  of  ob.servation  for  low -risk  sub- 
jects. 15  482  for  intermediate-risk.  :irul  M)  450 
for  high-risk  subjects.  Vaccination  over  the  6 
seasons  was  associated  with  an  overall  reduc- 
lion  of  39'/r  for  pneumonia  liospitali/alions 
(P  .001).  a  32%  decrease  iii  hospii.ili/alions 
lor  all  respiratory  conditions  (P  OOl),  and  a 
27%  decrease  in  hospitali/alions  lor  congestive 
heart  failure  (P<.()01 ).  Immunization  was  also 
associated  with  a  50'/f   rediiclion  in  all-cause 


mortality  (P<.001 ).  Within  the  risk  subgroups, 
vaccine  effectiveness  was  29%,  32'7r,  and  49% 
for  high-,  intermediate-,  and  low-risk  senior  cit- 
izens for  reducing  hospitalizations  for  pneumo- 
nia and  influenza  (for  high  and  low  risk,  P<  or 
=  .002;  for  intermediate  risk,  P  =  .11).  Effec- 
tiveness was  19%,  39%,  and  33%  (for  each,  P< 
or  =.008).  respectively,  for  reducing  hospital- 
izations for  all  respiratory  conditions  and  49%, 
64%,  and  55%  for  reducing  deaths  from  all 
causes  (for  each,  P< .001 ).  Vaccination  was  also 
a.s.sociated  with  direct  medical  care  cost  savings 
of  $73  per  individual  vaccinated  for  all  subjects 
combined  (P  =  .002).  Estimates  of  cost  savings 
within  each  risk  group  suggest  that  vaccination 
would  be  cost  saving  for  each  subgroup  (range 
of  cost  savings  of  $171  per  individual  vacci- 
nated for  high  risk  to  $7  for  low  risk),  although 
within  the  subgroups  these  findings  did  not  reach 
statistical  significance  (for  each,  P>  or  =.05). 
CONCLUSIONS:  This  study  confirms  that 
healthy  senior  citizens  as  well  as  senior  citizens 
with  underlying  medical  conditions  are  at  risk 
lor  the  serious  complications  of  influenza  and 
benefil  from  v;iccination.  All  individuals  65 
vcars  or  older  shoulil  be  luiiiunn/cd  uilh  this 


National  I'rends  hi  the  I  se  of  .\nlihiotics  by 
Primary  Care  Physicians  for  .Adult  Patients 
with  Cough— Mclla>  J  P.  SialTord  RS.  Sniger 
1)1:.  .Arch  Inlern  Med  199S:  15S(  16):  18  13. 


774 


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Abstracts 


BACKGROUND:  Increased  anlibioiic  use  for 
OLitpaticnt  illnesses  has  been  itlenlificd  as  an 
imporlanl  determinant  ol  the  recent  rise  in  an- 
tibiotic resistance  anmng  coninicin  respiratory 
pathogens.  Ellorls  to  reduce  the  inappropriate 
use  will  need  to  be  evaluated  against  current 
trends  in  the  outpatient  use  of  antibiotics.  OB- 
JECTIVES: To  examine  national  trends  in  the 
u.se  of  antibiotics  by  primary  care  physicians  in 
the  care  of  adult  patients  with  cough  and  iden- 
tify patient  factors  that  may  influence  antibiotic 
use  for  these  patients.  METHODS:  This  .study 
was  based  on  a  serial  analysis  of  results  from 
all  National  .Ambulatory  Medical  Care  Surveys 
beginning  in  1980  (when  therapeutic  drug  use 
was  first  recorded)  to  1994  (the  most  recent 
survey  year  available).  The.se  surveys  are  a  ran- 
dom sampling  of  visits  to  US  office-based  phy- 
sicians in  1980.  1981.  1985,  and  annually  from 
1989-1994.  Eligible  visits  included  those  by 
adults  presenting  to  general  internists,  family 
practitioners,  or  general  practitioners  widi  a 
chief  complaint  of  cough.  A  total  of  3416  \isits 
for  cough  were  identified  over  the  survey  years. 
Survey  results  were  extrapolated,  based  on  sam- 
pling weights  in  each  year,  to  project  national 
rates  of  antibiotic  use  for  patients  with  cough. 
Additional  analyses  examined  the  rates  of  an- 
tibiotic use  stratified  by  patient  age,  race,  and 
clinical  diagnosis.  RESULTS:  Overall,  an  anti- 
biotic was  prescribed  (>69t  of  the  lime  during 
office  visits  for  patients  with  cough:  599c  of 
patient  visits  in  1980  rising  to  109,  of  visits  in 
1994  (P  =  .()()2  lor  (rend).  In  c\ery  study  year. 
while,  noii-Hispailic  patients  and  patients 
younger  than  65  years  were  more  likely  to  re- 
ceive antibiotics  compared  with  nonwhite  pa- 
tients and  patients  65  years  or  older,  respec- 
tively. CONCLUSIONS:  The  rate  of  antibiotic 
use  by  primary  care  physicians  for  patients  with 
cough  remained  high  from  1980  to  1994,  and 
was  influenced  by  nonclinical  characteristics  of 
palicnls. 

Incidence  of  and  Risk  Factors  for  \  entila- 
tor-.\.s,sociated  Pneumonia  in  Critically  III  Pa- 
tients—Cook DJ.  Waller  SD.  Cook  RJ.  Griffith 
LE.  Guyatl  GH.  I.easa  D.  c(  al.  Ann  Intern  Med 
I998;129{6):4.^.\ 

BACKGROUND:  Understanding  the  risk  fac- 
tors for  ventilator-associated  pneumonia  can 
help  to  assess  prognosis  and  devise  and  tesi 
preventive  strategies.  OBJECTIVE:  To  exam- 
ine the  baseline  and  lime-dependent  risk  factors 
for  venlilator-associaled  pneumonia  and  to  de- 
termine the  conditional  probability  and  cumu- 
lative risk  over  the  duration  of  stay  in  the  in- 
tensive care  unit.  DESIGN:  Prospective  cohort 
study.  SEITING:  1 6  intensive  care  units  in  Can- 
ada. PAflENTS:  1014  mechanically  ventilated 
patients.  MEASUREMENTS:  Demographic 
and  lime-dependent  variables  rellecling  illness 
severity,  ventilation,  nutrition,  and  drug  expo- 
sure. I'neuinonia  uas  classified  bv  usinu  li\c 


methods:  adjudication  committee,  bedside  cli- 
nician's diagnosis.  Centers  for  Disease  Control 
and  Prevention  definition.  Clinical  Pulmonary 
Infection  score,  and  positive  culture  from  bron- 
choalveolar  lavage  or  protected  specimen  brush. 
RESULTS:  177  of  1014  patients  (17.5%)  de- 
veloped ventilator-associated  pneumonia  9.0  ± 
5.9  days  (median.  7  days  (interquartile  range.  5 
to  10  days])  after  admission  to  the  intensive 
care  unit.  Although  the  cumulative  risk  increased 
over  time,  the  daily  hazard  rate  decreased  after 
day  5  (3.3%  at  day  5,  2.39i  at  day  10,  and  1.3% 
at  day  15).  Independent  predictors  of  ventila- 
tor-associated pneumonia  in  multivariable  anal- 
ysis were  a  primary  admitting  diagnosis  of  burns 
(risk  ratio,  5.09  [95%  CI,  1 .52  to  17.03]),  trauma 
(ri.sk  ratio,  5.00  |CI.  1.91  to  13.11]).  central 
nervous  system  disease  (risk  ratio.  3.40  [CI, 
1.31  to  8.81]),  respiratory  di,sea.se  (risk  ratio. 
2.79  [CI,  1.04  to  7.51 1),  cardiac  disease  (risk 
ratio.  2.72  [CI,  1.05  to  7.01]),  mechanical  ven- 
tilation in  the  previous  24  hours  (risk  ratio,  2.28 
(CI.  Ill  to  4.68]),  witnessed  aspiration  (risk 
ratio,  3.25  [CI,  1.62  to  6.50]),  and  paralytic 
agents  (risk  ratio,  1.57  [CI.  1.03  to  2.391).  Ex- 
posure to  antibiotics  conferred  protection  (risk 
ratio,  0.37  [CI,  0.27  to  0.51  ]).  Independent  risk 
factors  were  the  same  regardless  of  the  pneu- 
monia definition  used.  CONCLUSIONS:  The 
daily  risk  for  pneumonia  decreases  with  increas- 
ing duration  of  stay  in  the  intensive  care  unit. 
Witne,s,sed  aspiration  and  exposure  to  paralytic 
agents  are  potentially  modifiable  independent 
risk  factors.  Exposure  to  antibiotics  was  asso- 
ciated with  low  rates  of  early  ventilator-associ- 
ated pneumonia,  hut  this  cITecl  attenuates  oxer 
time. 

Cumulative  Epinephrine  Dose  during  Car- 
diopulmiinary  Resuscitation  and  Neurologic 

Outcome— Behringer  W,  Kittler  H,  Sterz  F. 
Domanovits  H.  Schoerkhuber  W.  Hol/er  M.  el 
al.  Ann  Intern  Med  1 998;  129(61:450. 

BACKGROUND:  Epinephrine  is  the  drug  of 
choice  in  advanced  cardiac  life  support,  but  it 
can  have  deleterious  side  effects  after  restora- 
tion of  spontaneous  circulation.  OBJECTIVE: 
To  investigate  the  association  between  the  cu- 
nuilalive  epinephrine  dose  u.sed  in  advanced  car- 
diac life  support  and  neurologic  outcome  after 
cardiac  arrest.  DESIGN:  Retrospective  cohort 
study.  SETTING:  Universily  hospital.  PA- 
TIENTS: Adults  ailinilled  to  (he  emcrgenc)  de- 
partment with  witnessed,  noiilraiimatic.  normo- 
Ihermic  ventricular  fibrillation  cardiac  arrest  and 
unsuccessful  initial  defibrillation.  MEASURE- 
MENTS: Functional  neurologic  outcome  was 
regularly  assessed  by  cerebral  performance  cat- 
egory (CPC)  within  6  months  after  cardiac  ar- 
rest. A  CPC  of  I  or  2  was  defined  as  favorable 
recovery.  RESULTS:  Among  178  enrolled  pa- 
licnls. ihe  median  cumulative  epinephrine  do.sc 
adiiiinisiered  was  4  mg  (range,  0  lo  50  nig).  In 
I  5  I  palienls(84'i ).  spontaneous ciiciilal ion  was 


restored;  63  of  these  151  patients  (42%  I  had 
favorable  neurologic  recovery.  Patients  with  an 
unfavorable  CPC  received  a  significanlly  higher 
cumulative  dose  of  epinephrine  than  did  pa- 
tients with  a  favorable  CPC  (4  mg  compared 
with  1  mg;  P  <  0.001).  This  finding  persisted 
after  stratification  by  duration  of  resuscitation. 
After  possible  confounders  were  controlled  for. 
the  cumulative  epinephrine  dose  remained  an 
independent  predictor  of  unfavorable  neurologic 
outcome.  CONCLUSIONS:  The  results  indi- 
cate that  an  increasing  cumulative  dose  of  epi- 
nephrine administered  during  resuscitation  is  in- 
dependently associated  with  unfavorable 
neurologic  outcome  after  ventricular  fibrillation 
cardiac  arrest. 


Natural  History  of  Primary  Snoring  in  Chil- 
dren— Marcus  CL.  Hauler  A.  Loughlin  GM. 
Pediatr  Puliiionol  1998;26(  1  1:6. 

It  is  not  known  whether  children  with  primary 
snoring  (PS)  progress  to  develop  obstructive 
sleep  apnea  syndrome  (OSAS).  Therefore,  we 
repeated  polysomnography  in  a  cohort  of  20 
children  diagnosed  1-3  years  previously  with 
PS.  All  children  initially  presented  with  symp- 
toms suggestive  of  OSAS.  They  were  diagno.sed 
with  PS  when  initial  polysomnography  demon- 
strated snoring,  with  less  than  one  obstructive 
apnea  per  hour,  normal  gas  exchange,  and  in- 
frequent arousals.  Of  75  potential  candidates. 
20  were  available  for  reevaluation  (33  could 
not  be  contacted,  8  had  undergone  tonsillec- 
tomy and  adenoidectomy,  and  14  declined). 
Mean  age  was  6  ±  4  (SD)  years  at  the  time  of 
the  initial  study.  The  initial  apnea  index  was 
0.2  ±  0.3.  Sp02  nadir  95  ±  2%.  and  peak 
end-tidal  PC02  was  47  ±  3  mm  Hg.  At  follow- 
up.  all  children  were  reported  by  their  parents 
to  sill!  he  snoring;  in  20';i  snoring  had  leporl- 
edlv  increased,  and  in  70'^-!  there  w  as  no  change. 
Eighty  percent  were  thought  to  have  difficulty 
breathing  during  sleep.  For  the  group  as  a  whole, 
there  were  no  significant  changes  in  apnea  in- 
dex, Sp02.  or  peak  end-tidal  PC02.  However, 
tw<i  children  had  mild  OSAS  on  repeal  poly- 
somnography (apnea  index  of  3).  We  conclude 
that,  in  most  children,  primary  snoring  does  not 
progress  to  OSAS  over  the  course  of  several 
years.  This  study  indicates  that  OSAS  in  the 
lew  individuals  who  do  progress  is  mild.  Pa- 
iciital  concern  about  children's  hieallting  pat- 
terns during  sleep  is  a  poor  predictor  ol  poly- 
somnogiaphic  abnormalities.  Howev er,  because 
many  palicnls  were  lost  to  follow-up  in  this 
study,  luither  prospeclive  studies  are  needed. 


Aerosolized  Albuterol  Improves  \ir»a>  Ke- 
aclivilv  in  Infants  vu(h  Acute  Respiratory 
Kailiire  from  Respiratory  Syncvlial  \irus  — 

Dciish  M.  Hodge  (I.  Dunn  C.  Ari.igno  R.  Pe- 
diali  Piilmoiiol   i99,S;2(,(||:l2. 


776 


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We  re  launching 
ventilation  technology 
into  the  21st  century. 


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display  monitored  data  separately 
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annunciators  that  distinguish  primary 
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©1998  Nellcor  Puritan  Bennett  Inc.  All  rights  reserved. 


Abstracts 


The  objectixe  ol  Ihis  investigation  was  lo  mea- 
sure the  bronchodilator  elTecl  of  aerosolized  al- 
buterol on  infants  with  respiratory  syneytial  vi- 
rus (RSV)-induced  respiratory  failure.  Infants 
uho  required  intubation  and  niechanieal  \enti- 
lalor  support  for  RSV  disease  were  eligible  for 
this  prospeetive.  nonrandomized  study.  Pulmo- 
nary function  tests,  including  respiratory  me- 
chanics by  least  mean  square  analysis,  small 
airway  function  by  rapid  thoraco-abdominal 
compression,  and  functional  residual  capacity 
by  nitrogen  washout  were  performed  before  and 
20  niin  after  inhalation  of  20-40  breaths  of  un- 
diluted (0.5%)  albuterol  solution  via  a  small- 
volume  nebulizer.  Analysis  of  maximum  expi- 
ratory How  at  functional  residual  capacity 
iVmaxFRC)  before  and  after  albuterol  admin- 
istration was  performed  using  a  t-tesi  for  paired 
comparisons.  A  two-tailed  P-value  of  less  than 
0.05  was  considered  statistically  significant. 
Twenty-five  infants  (mean  ±SD  postconcep- 
tional  age  =  45  ±  5  weeks)  were  enrolled. 
Thirteen  of  the  25  infants  had  a  prior  history  of 
prematurity  and/or  cardiorespiratory  disease. 
After  aerosolized  albuterol,  mean  VmaxFRC  in- 
creased significantly  from  4S  ±  4(S  mL/sec  lo 
(i5  ±  59  mL/sec  (P  =  0.03);  however,  only 
three  patients  had  an  increase  into  the  normal 
range.  Three  patients  had  a  substantial  (40-.'iO'(  I 
decrease  in  VmaxFRC.  These  findings  suggest 
that  during  the  acute  phase  of  severe  RSV  re- 
spiratory infection  some  of  this  group  of  very 
young  infants  had  airway  reactivity  that  im- 
proved in  response  to  inhaled  albuterol. 

Hl[;h-l'rc'i)ui'ncy  Oscillation  Versus  Conven- 
tional \ i'ntllatiiin  I'ollowln^  Surfactant  Ad- 
ministration and  Partial  Liquid  Ventila- 
tion—Mro/ek  JD.  Bing  DR.  Meyers  PA. 
C'onnett  JE.  Mammel  MC.  Pediatr  Pulmonol 
iWS;26(l):2l. 

Surfactant  followed  by  partial  liquid  ventilation 
(PLV)  with  pertluorocarbon  (PFC;  LiquiVenl) 
improves  oxygenation,  lung  compliance,  and 
lung  pathology  in  lung-injured  animals  receiv- 
ing conventional  ventilation  (CV).  In  this  study, 
we  hypothesize  that  high-frequency  oscillation 
(HFO)  and  CV  will  provide  equivalent  oxygen- 
alion  m  lung-injured  animals  following  surlac- 
Kiiu  repletion  and  PLV.  once  lung  voUune  is 
opiimi/ed.  After  saline-lavage  lung  injury  dur- 
ing CV.  newborn  piglets  were  randomized  to 
cither  HFO  (n  =  10)  or  CV  (n  =  9).  HFO 
animals  were  siabili/ed  o\cr  15  mm  uilhoiu 
optnni/ation  of  lung  volume;  CV  animals  con- 
tinued treatment  with  time-cycled,  pressure- 
hmiled.  volume-targeted  ventilation.  All  ani- 
mals then  received  100  mg/kg  of  surfactant 
(Survanta).  Thirty  minutes  later,  all  received 
intratracheal  PFC  lo  approximate  functional  re- 
sidual capacity.  Thirty  minutes  after  PLV  be- 
gan, mean  airway  pressure  ( MAP)  in  both  groups 
was  increased  lo  improve  oxygenation.  MAP 
was  directly  adjusted  dinnig  I  HO.  PlJiP  and 


PIP  were  adjusted  durnig  IMV.  maimainmg  a 
pressure  sufficient  to  deliver  15  mL/kg  tidal 
volume.  Animals  were  treated  for  4  h.  The  CV 
group  showed  improved  oxygenation  following 
surfactant  administration  (OI;  26.79  ±  1.98  vs. 
8.59  ±  6.29.  P  <  0.0004).  with  little  further 
improvement  following  PFC  administration  or 
adjustments  in  MAP.  Oxygenation  in  HFO- 
treated  animals  did  not  improve  following  sur- 
factant, but  did  improve  following  PFC  (01: 
27.78  ±  6.84  vs.  15.86  ±  5.53.  P  <  0.005)  and 
adjustments  in  MAP  (01;  15.86  ±  5.5,^  vs. 
8.96  ±  2.18.  P  <  0.03).  After  MAP  adjust- 
ments, there  were  no  significant  inlergroup  dif- 
ferences in  oxygenation.  Animals  ni  the  CV 
group  required  lower  MAP  than  animals  in  the 
HFO  group  to  maintain  sitnilar  oxygenation. 
We  conclude  that  surfactant  repletion  followed 
by  PLV  improves  oxygenation  during  both  CV 
and  HFO.  The  initial  re.sponse  to  administration 
of  surfactant  and  PFC  was  different  for  the  con- 
ventional and  high-frequency  oscillation  groups, 
likely  reflecting  the  ventilation  strategy  used; 
animals  in  the  CV  group  responded  most  to 
surfactant,  whereas  animals  in  the  HFO  group 
responded  most  after  PFC  instillation.  The  ul- 
timately similar  oxygenation  of  the  two  groups 
once  lung  volume  had  been  optimized  suggests 
that  HFO  may  be  used  effectively  during  ad- 
ministration of.  and  treatment  with,  surfactant 
and  pcrlluorocarbon. 


Bronchodilator  Responsiveness  Testinj;  Us- 
ing Raised  Volume  Forced  Expiration  in  Re- 
currently Wheezing  Infants — Hayden  MJ. 
Wildhabcr  JH.  LeSouef  PN.  Pediatr  Pulmonol 
I998;26(l);35. 

We  h\  pothesized  that  a  new  test  of  infant  lung 
function,  less  affected  by  shifts  in  lung  volume, 
might  better  detect  bronchodilator  effects.  Us- 
ing the  raised  volume  forced  expiration  tech- 
nique (RVFET).  the  effect  of  a  bronchodilator 
on  lung  function  was  studied  in  22  infants  with 
a  history  of  recurrent  wheeze  and  five  healthy 
infants.  Forced  expiratory  volume  in  0.75  s 
(FEV0.75).  forced  expiratory  vital  capacity 
(FVC).  and  forced  expiratory  How  at  75'^'f  of 
FVC  (FEF75'/f )  were  measured  h>  forcing  ex- 
piration, using  an  inflatable  jacket  Iroiii  a  lung 
volume  set  by  an  inspiratory  pressure  of  20  cm 
H20.  A  minimum  of  live  measurements  were 
made  at  baselme  and  following  the  administra- 
tion ol  5110  miciog  ol  salhulamt>l  Ironi  a  me- 
tered linse  inhaler  \ia  a  small  \olunie  metal 
spacer.  Changes  in  lung  function  in  the  gr<iup 
of  25  infants  w  ho  received  salbutamol  were  com- 
pared to  seven  infants  who  received  placebo 
aerosol.  No  significant  changes  occurred  in  mea- 
sures of  lung  function  following  salbutamol  ad- 
ministration when  compared  to  baseline  or  pla 
cebo  despite  a  significant  increase  in  heart  rate. 
.\  shill  in  lung  Miliimc  is  iinlikelv  the  icason 
win    int. mis  do  mil  dciiioiislrale  a  chaimc   in 


forced  expiration  following  bronchodilator  ad- 
ministration. 


()2  Kxtraction  Maintains  02  I'ptake  during 
Submaximal  f2xcrcise  with  Beta-Adrenergic 
Blockade  at  4,300  M— Wolfel  EE.  Selland  MA, 
Cynierman  A.  Brooks  GA,  Butterfield  GE. 
Mazzeo  RS.  el  al.  .1  Appl  Physiol  I998;S5(3); 
1092. 

Whole  body  02  uptake  (V02)  during  maximal 
and  submaximal  exercise  has  been  shown  to  be 
preserved  in  the  setting  of  beta-adrenergic  block- 
ade at  high  altitude,  despite  marked  reductions 
in  heart  rate  during  exercise.  An  increase  in 
stroke  volume  at  high  altitude  has  been  sug- 
gested as  the  mechanism  that  preserves  sys- 
temic 02  deli\eiy  I  blood  How  x  arterial  02 
conlcnl)  and  thereby  maintains  V02  at  sea-level 
values.  To  test  this  hypothesis,  we  studied  the 
effects  of  nonselective  beta-adrenergic  block- 
ade on  submaximal  exercise  performance  in  1 1 
normal  men  (26  ±  I  yr)  at  .sea  level  and  on 
arrival  and  after  21  days  at  4,300  m.  Six  sub- 
jects received  propranolol  (240  mg/day),  and 
five  subjects  received  placebo.  At  sea  level,  dur- 
ing submaximal  exercise,  cardiac  output  and 
02  delivery  were  significantly  lower  in  pro- 
pranolol- than  in  placebo-treated  subjects.  In- 
creases in  stroke  volume  and  02  extraction  were 
responsible  for  the  maintenance  of  V02.  At 
4.300  m,  beta-adrenergic  blockade  had  no  sig- 
nificant effect  on  V02,  ventilation,  alveolar 
P02.  and  arterial  blood  gases  during  submaxi- 
mal exercise.  Despite  increases  in  stroke  vol- 
ume, cardiac  output  and  thereby  02  delivery 
were  still  reduced  in  propranolol-treated  sub- 
jects compared  with  subjects  treated  with  pla- 
cebo. Further  reductions  in  already  low  levels 
of  mixed  venous  02  saturation  were  responsi- 
ble for  the  maintenance  of  V02  on  arrival  and 
after  2  I  days  at  4,300  m  in  propranolol-lreated 
subjects.  Despite  similar  workloads  and  V02, 
propranolol-treated  subjects  exercised  at  greater 
perceived  intensity  than  subjects  given  placebo 
at  4,300  m.  The  values  for  mixed  venous  02 
saturation  during  submaximal  exercise  in  pro- 
pranolol-treated subjects  at  4,300  m  approached 
those  reported  al  simulated  altitudes  >8,000  ni. 
riuis  beta-adrenergic  blockade  at  4.300  m  re- 
sults in  significant  reduction  in  02  deliveiv  dur- 
ing submaximal  exercise  due  to  incomplete  com- 
pensation h\  stroke  \olume  for  the  reduction  in 
exercise  hcail  rale.  I'olal  bod\  \'()2  is  main- 
tained at  a  coiisiani  level  by  an  interaction  be- 
tween mixed  venous  02  saturation,  the  arterial 
02-carrying  capacity,  and  hemodynamics  dur- 
ing exercise  with  acute  and  chronic  hvpoxia. 


Does  Resistive  Loading  Decrease  Diaphrag- 
matic (oulraelilily   helore   Task  Kailure? — 

l.aghi  I-.    lopcli  .\.    I  ohm  M.l    I  Appl  l'h>siol 
|90S;S5(3):I  lOV 


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Abstracts 


While  sustaining  a  load  ihal  leads  to  task  fail- 
ure, it  is  unclear  whether  diaphragmatic  fatigue 
develops  progressively  or  occurs  only  at  task 
failure.  We  hypothesized  that  incremental  load- 
ing produces  a  progressive  decrease  in  diaphrag- 
matic conlraclilily  ever  before  task  failure.  Ten 
subjects  generated  60%  of  maximal  transdia- 
phragmatic pressure  (Pdimax)  for  2  min.  4  min. 
and  until  task  failure.  Before  loading.  20  min 
after  each  period  of  loading,  and  approximately 
20  h  after  the  last  period  of  loading.  Pdimax. 
nonpolentiated  and  potentiated  Pdi  twitch  pres- 
sure (Pditw  I.  and  the  pattern  of  respiratory  mus- 
cle recruitment  during  a  C02  challenge  were 
recorded.  Sensation  of  inspiratory  effort  at  the 
4th  min  of  the  task-failure  protocol  was  greater 
than  at  the  same  time  in  the  preceding  4-min 
protocol.  Surprisingly,  potentiated  Pditw  and 
Pdimax  were  reduced  after  2  min  of  loading 
and  decreased  further  after  4  min  of  loading 
and  after  task  failure;  nonpotenliated  Pditw  was 
reduced  after  4  min  of  loading  and  after  task 
failure.  The  gastric  pressure  contribution  to  tidal 
breathing  during  a  C02  challenge  decreased  pro- 
gressively in  relation  to  duration  of  the  preced- 
ing loading  period,  whereas  expiratory  muscle 
recruitment  progressively  increased.  A  rest  pe- 
riod of  approximately  20  h  after  task  failure 
was  not  sufficient  to  normalize  these  alterations 
in  respiratory  muscle  recruitment  or  fatigue-in- 
duced changes  in  diaphragmatic  contractility. 
In  conclusion,  while  sustaining  a  mechanical 
load,  the  diaphragm  progressively  fatigued,  ever 
before  task  failure,  and  when  challenged  the  rib 
cage-to-diaphragmatic  contribution  to  tidal 
breathing  and  recruitment  of  the  expiratory  mus- 
cles increased  pari  passu  with  duration  of  the 
preceding  loading. 

Effects  of  Lung  Volume  on  Diaphrugm  EMG 
.Signal  Strength  during  Voluntary  Contrac- 
tions— Beck  J.  Sindcrby  C.  Lindstroiii  L. 
Grassino  A.  J  Appl  Physiol  1998;8.S(3):  1 123. 

The  use  of  esophageal  recordings  of  the  dia- 
phragm electromyogram  (EMG)  signal  strength 
to  evaluate  diaphragm  activation  during  volun- 
tary contractions  in  humans  has  recently  been 
criticized  becau.se  of  a  possible  artifact  created 
by  changes  in  lung  volume.  Therefore,  the  first 
aim  of  this  study  was  to  evaluate  whether  there 
is  an  artifactual  intluence  of  lung  volume  on  the 
strength  of  the  diaphragm  EMG  during  volun- 
tary contractions.  The  second  aim  was  to  mea- 
sure the  required  changes  in  activation  for 
changes  in  lung  volume  at  a  given  tension,  i.e., 
the  volume-activation  relationship  of  the  dia- 
phragm. Healthy  subjects  (n  =  6)  performed 
contractions  of  the  diaphragm  at  different  trans- 
diaphragmatic pressure  (Pdi)  targets  (range  20- 
lfi()cmH2())  while  maintaining  chest  wall  con- 
figuration constant  at  differctit  lung  volumes. 
The  diaphragm  EMG  was  recorded  with  a  mul- 
tiple-array esophageal  electrode,  with  control 
of  signal  contamination  and  electrode  position- 


ing. The  effects  of  lung  xcilume  on  the  EMG 
were  studied  by  comparing  the  crural  diaphragm 
EMG  root  mean  square  (RMS),  an  index  of 
crural  diaphragm  activation,  with  an  index  of 
global  diaphragm  activation  obtained  by  nor- 
malizing Pdi  to  the  maximum  Pdi  at  the  given 
muscle  length  (Pdi/Pdimax@L)  at  the  different 
lung  volumes.  We  obser\ed  a  direct  relation- 
ship between  RMS  and  Pdi/PdimaxCs^L  inde- 
pendent of  diaphragm  length.  The  volume-ac- 
tivation relationship  of  the  diaphragm  was 
equally  affected  by  changes  in  lung  volume  as 
the  \olume-Pdi  relationship  (60%  change  from 
functional  residual  capacity  to  total  lung  capac- 
ity). We  conclude  that  the  RMS  of  the  dia- 
phragm EMG  is  not  artifactually  influenced  by 
lung  volume  and  can  be  used  as  a  reliable  index 
of  diaphragm  activation.  The  volume-activation 
relationship  can  be  used  to  infer  changes  in  the 
length-tension  relationship  of  the  diaphragm  at 
submaximal  activation/contraction  levels. 

Heavy  Snoring  with  Upper  Airv»ay  Resis- 
tance Syndrome  May  Induce  Intrinsic  Posi- 
tive End-Expiratory  Pressure — Lofaso  F, 
Lorino  AM.  Fodil  R.  D'Ortho  MP.  Isabey  D. 
Lorino  H.  et  al.  J  Appl  Physiol  1998;8.';(3):860. 

We  studied  eight  heavy  snorers  with  upper  air- 
way resistance  syndrome  to  investigate  poten- 
tial effects  of  sleep  on  expiratory  airway  and 
lung  resistance,  intrinsic  positive  end-expira- 
tory pressure,  hyperinflation,  and  elastic  inspira- 
tory work  of  breathing  (WOB).  Wakefulness 
and  non-rapid-eye-movement  sleep  with  high- 
and  with  low-resistance  inspiratory  effort  (H- 
RIE  and  L-RIE.  respectively)  were  compared. 
No  differences  in  breathing  pattern  were  seen 
across  the  three  conditions.  In  contrast,  we  found 
increases  in  expiratory  airway  and  lung  resis- 
tance during  H-RIE  compared  with  L-RIE  and 
wakefulness  (56  ±  24,  16  ±  4,  and  1 1  ±4 
cmH20  .1-1  .  s.  respectively),  with  attendant 
increases  in  intrinsic  positive  end-expiratory 
pre.s.sure  (5.4  ±  1.8,  1.4  ±  0.5,  and  1.3  ±  1.3 
cmH20,  respectively)  and  elastic  WOB  (6. 1  ± 
2.2,  3.7  ±  1.2,  and  3.4  ±  0.7  J/min.  respective- 
ly). The  increa.se  in  WOB  during  H-RIE  is  partly 
caused  by  the  effects  of  dynamic  pulmonary 
hyperinllation  produced  by  the  increased  expi- 
ratory resistance.  Contrary  to  the  Starling  model, 
a  multiple-element  compliance  model  that  takes 
into  account  the  heterogeneity  of  the  pharynx 
may  explain  flow  limitation  during  expiration. 

Primary  Pulmonary  Hypertension  (Re- 
view)—Gaine  SP,  Rubin  LJ.  Lancet  1998; 
352(9129):7I9. 

Primary  puhiionary  hypertension  ( PPH )  is  a  pro- 
gressive disease  characterised  by  rai.sed  pulmo- 
nary vascular  lesislance.  which  results  in  di- 
)ninishcd  right-heart  function  due  to  increased 
right  Ncntricular  aflerload.  PPH  occurs  iiiosi 
connnonlv  in  vouni;  and  nnddlc-a'jcd  uomcn; 


mean  survival  from  onset  of  symptoms  is  2-3 
years.  The  aetiology  of  PPH  is  unknown,  al- 
though familial  disease  accounts  for  roughly 
10%  of  cases,  which  suggests  a  genetic  predis- 
position. Current  theories  on  pathogenesis  fo- 
cus on  abnormalities  in  interaction  between  en- 
dothelial and  smooth-muscle  cells.  Endothelia- 
cell  injury  may  result  in  an  imbalance  in 
endothelium-derived  mediators.  fa\ouring  va- 
soconstriction. Defects  in  ion-channel  activity 
in  smooth-muscle  cells  in  the  pulmonary  artery 
may  contribute  to  vasoconstriction  and  vascular 
proliferation.  Diagnostic  testing  primarily  ex- 
cludes secondary  causes.  Catheteri.sation  is  nec- 
essary to  assess  haemodynamics  and  to  evalu- 
ate vasoreactivity  during  acute  drug  challenge. 
Decrease  in  pulmonary  vascular  resistance  in 
response  to  acute  vasodilator  challenge  occurs 
in  about  30%  of  patients,  and  predicts  a  good 
response  to  chronic  therapy  with  oral  calcium- 
channel  blockers.  For  patients  unresponsive  dur- 
ing  acute  testing,  continuous  intraxenous 
epoprostenol  (prostacyclin.  PGI2)  improves 
haemodynamics  and  exercise  tolerance,  and  pro- 
longs survival  in  severe  PPH  (NYHA  functional 
class  III-IV).  Thoracic  transplantation  is  re- 
served for  patients  who  fail  medical  therapy. 
We  review  the  progress  made  in  diagnosis  and 
treatment  of  PPH  over  the  past  20  years. 

Sleep-Di.sordered  Breathing  and  School  Per- 
formance in  Children — Gozal  D.  Pediatrics 
1998;  102(3  Pt  1):6I6, 

OBJECTIVE:  To  assess  the  impact  of  sleep- 
associated  gas  exchange  abnormalities  (SA- 
GEA)  on  school  academic  performance  in  chil- 
dren. DESIGN:  Prospective  study.  SETTING: 
Urban  public  elementary  schools.  PARTICI- 
PANTS: Two  hundred  ninety-seven  first-grade 
children  whose  school  performance  was  in  the 
lowest  10th  percentile  of  their  class  ranking. 
METHODS:  Children  were  screened  for  ob- 
structive sleep  apnea  syndrome  at  home  using  a 
detailed  parental  questionnaire  and  a  single  night 
recording  of  pulse  oximetry  and  transcutaneous 
partial  pressure  of  carbon  dioxide.  If  SAGEA 
w  as  diagnosed,  parents  were  encouraged  to  seek 
medical  intervention  for  SAGEA.  School  grades 
of  all  participating  children  for  the  school  year 
preceding  and  after  the  o\ernighl  study  were 
obtained.  RESULTS:  SAGEA  was  identified  in 
54  children  (18.1%).  Of  these.  24  underwent 
surgical  tonsillectomy  and  adenoidectomy(TR). 
whereas  in  the  remaining  30  children,  parents 
elected  not  to  seek  any  therapeutic  intervention 
(NT).  Overall  mean  grades  during  the  second 
grade  increased  from  2.43  ±  0.17  (SEM)  to 
2.87  i  0.19  ni  I'R,  although  no  significant 
changes  occurred  in  NT  (2.44  ±  (1.1 3  to  2.46  ± 
(1.1.5).  Similarly,  no  academic  improvements  oc- 
curred in  children  without  SAGEA.  CONCLU- 
SIONS: SAGEA  is  frequently  present  in  poorly 
performing  first-grade  students  in  whom  it  ad- 
\crscly  aflccts  learning  pcrforniancc.   The  data 


782 


Risi'ikAioK^  Cari;  •  October  "98  Voi,  43  No  10 


T    E    C    H    N 


hderside  of  Mouthpiece 
iaturing  exhalation  valve. 

;>Jebulization  on  Inhalation  Only 

Maximizes  Fine  Particle  Dose 

I 

Maximizes  Drug  Delivery 

^nimizes  Drug  Waste 

l^llows  Fast  Track  Delivery 

/laxlmizes  Patient  Compliance 

Product  Availability  Pending  FDA  510(k)  Clearance. 


Introducing 


A  Breath  Actuated 
Aerosol  Delivery  Device 

We  Invented  the  Valved  Holding  Chamber.. 
We  Perfected  the  Peak  Flow  Meter... 
Now  We've  Revolutionized  Nebulizers 


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We  Set  The  Standards 

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'   #1 


Abstracts 


suggest  ihat  a  siihscl  ol  chiMicii  uitli  hcha\ - 
ioial  and  learning  disabilities  eiuild  ha\e  SA- 
GEA  and  may  benefit  from  prospective  niedi- 
eal  exalualicm  and  Ifeatnient. 

Has  the  California  Tobacco  Control  Program 
Reduced  Smoking? — Pieiee  JP.  Gilpin  EA, 
Eniei)  SL.  White  MM.  Rcisbrook  B.  Berry  CC. 
.lAMA  144S;:S()(1()):S^)3. 

CONTEXT:  Compiehensive  eoniniunity-v\ide 
tobacco  control  progratris  are  considered  appro- 
priate public  health  approaches  to  reduce  pop- 
ulation smoking  prevalence.  OBJECTIVE:  To 
examine  trends  in  sinoking  behavior  before,  dur- 
ing, and  after  the  California  Tobacco  Control 
Program.  DESIGN:  Per  capita  cigarette  con- 
sumption data  ( 198.^-1997)  were  derived  from 
tobacco  industry  sales  figures.  Adult  (>  or  =  18 
>earsl  smoking  prevalence  data  were  obtained 
from  the  National  Health  Interview  Surveys 
(1978-1994).  the  California  Tobacco  Surveys 
(1990-1996).  the  Current  Population  Surveys 
(1 992- 1 996).  and  the  California  Behavioral  Risk 
Factor  Survey  and  its  supplement  ( 1991-1997). 
Trends  were  compared  before  and  after  intro- 
duction of  the  program,  with  the  period  after 
the  program  being  divided  into  2  parts  (early. 
1989-199:!:  late.  1994-1996).  MAIN  OUT- 
COME MEASURES:  Change  in  cigarette  eon- 
sumption  and  smoking  prevalence  in  California 
compared  with  the  rest  of  the  United  States. 
RESULTS:  Per  capita  cigarette  consumption  de- 
clined 52Vc  faster  in  California  in  the  early  pe- 
riod than  previously  (froin  9.7  packs  per  person 
per  month  at  the  beginning  of  the  program  to 
6.5  packs  per  person  per  month  in  199.'!).  and 
the  decline  was  significantly  greater  in  Califor- 
nia than  in  the  rest  of  the  United  States  (P<.00 1 ). 
In  the  late  period,  the  decline  in  California 
slowed  to  28%  of  the  early  program  so  lhat  in 
1996  an  average  of  6.0  packs  per  person  pei 
month  were  consumed.  No  decline  occurred  in 
the  rest  of  the  United  States,  and  in  1996.  10.5 
packs  per  person  per  month  were  consumed. 
Smoking  prevalence  showed  a  similar  pattern, 
but  in  the  late  period,  there  was  no  significant 
decline  in  prevalence  in  either  California  or  the 
rest  of  the  United  States.  In  1996.  smoking  prev- 
alence was  18.0%  in  California  and  22.4%  in 
the  rest  of  the  United  Stales.  CONCLUSIONS: 
The  initial  effect  of  the  program  to  reduce  smok- 
ing in  California  did  not  persist.  Possible  rea- 
sons include  reduced  program  funding,  in- 
creased tobacco  industry  expenditures  for 
advertising  and  promotion,  and  industry  pricing 
and  political  activities.  The  question  remains 
hou  the  public  health  communitv  can  modify 
the  pidgiam  to  regain  its  original  momentum. 

The  Tension-rime  Index  and  the  lre(|uencv/ 
Tidal  \  olume  Kalio  Are  the  Major  I'atlio- 
phvsiologie  Delerminanls  of  Weaning  h all- 
ure    and     Siiteess — Vassilakopmilos      1. 


Zakviithinos  S.  Roussos  C.  Am  .1  Respii  Ciit 
Care  Med  1998:I58(2):.'(7S. 

We  have  previously  shown  (Am  J  Respir  Crit 
Care  Med  1995:152:1248-1255)  that  in  patients 
needing  mechanical  ventilation,  the  load  im- 
posed on  the  inspiratory  muscles  is  excessive 
relative  to  their  neuromuscular  capacity.  We 
have  therefore  hypothesized  that  weaning  fail- 
ure may  occur  because  at  the  time  ot  the  trial  of 
spontaneous  breathing  there  is  insufficient  re- 
duction of  the  inspiratory  load.  We  therefore 
prospectively  studied  patients  who  initially  had 
failed  to  wean  from  mechanical  ventilation  (F) 
but  had  successful  weaning  (S)  on  a  later  oc- 
casion, Compared  with  S.  during  F  patients  had 
greater  intrinsic  positive  end-expiratory  pres- 
sure (6.  10  ±  2.45  versus  3.83  ±  2.69  cm  H20). 
dynamic  hyperinflation  (327  ±  180  versus 
213  ±  175  mL).  total  resistance  (Rmax. 
14.14  ±  4.95  versus  11.19  ±  4.01  cm  H20/L/ 
s).  ratio  of  mean  to  maximum  inspiratory  pres- 
sure (0.46  ±  O.I  versus  0.31  ±  0.08).  tension 
lime  index  (TTI.  0.162  ±  0.032  versus  0.102  ± 
0.023)  and  power  (315  ±  153  versus  215  ±  75 
cm  H20  X  L/min).  less  maximum  inspiratory 
pressure  {42.3  ±  12.7  versus  53.8  ±  15.1  cm 
H20),  and  a  breathing  pattern  that  was  more 
rapid  and  shallow  (ratio  of  frequency  to  tidal 
volume.  f/VT  98  ±  38  versus  62  ±  21  breaths/ 
niin/L).  To  clarify  on  pathophysiologic  grounds 
what  determines  inability  to  wean  from  me- 
chanical ventilation,  we  performed  multiple  lo- 
gistic regression  analysis  with  the  weaning  out- 
come as  the  dependent  variable.  The  TTI  and 
the  f/VT  ratio  were  the  only  significant  vari- 
ables in  the  model.  We  conclude  that  the  TTI 
and  the  f/VT  are  the  major  pathophysiologic 
determinants  underlying  the  transition  from 
weaning  failure  to  weaning  success. 

Outreach  Kducation  To  Improve  Quality  of 
Rural  ICLI  Care.  Results  of  a  Randomized 

Trial— Hcndryx  MS.  Fieselmann  JF.  Bock  MJ. 
Wakefield  DS.  Helms  CM.  Bentler  SE.  Am  .1 
Respir  Crit  Care  Med  1998:158(21:418. 

This  study  tests  whether  an  outreach  educational 
program  tailored  to  institutional  specific  patient 
care  practices  would  improve  the  quality  of  care 
delivered  to  mechanically  ventilated  intensive 
care  unit  (ICU)  patients  in  rural  hospitals.  The 
study  was  conducted  as  a  randomized  conliol 
trial  using  20  rural  Iowa  hospitals  as  the  unit  ol 
analysis.  Twelve  randomly  .selected  hospitals 
received  an  outreach  educational  program.  Al- 
ter review  of  the  medical  records  of  eligible 
palieiils.  a  nuillulisciplinarv  team  of  intensive 
care  unit  specialists  hoin  an  academic  mei.iical 
center  delivered  an  educational  program  with 
content  specific  to  the  findings  and  capacitv  nl 
the  hospital.  The  outcome  measures  incluilcd 
paiiciii  care  processes,  patient  morbidity  anti 
iiiort.iliiv  outcomes,  and  I'csource  use.  Results 
imlicalcil  that  the  oiKieach  program  signil  icanllv 


impidv  ed  many  patient  care  processes  i  lab  w  ork. 
nursing,  dietary  management,  ventilator  man- 
agement, ventilator  weaning ).  The  program  mar- 
ginally reduced  hospital  ventilator  days.  Both 
total  length  of  slay  and  ICU  length  of  stay  fell 
markedly  in  the  intervention  group  (by  an  av- 
erage of  3.2  and  2.1  d.  respectively),  while  the 
control  group  fell  only  0.6  and  0.3  d.  respec- 
tively. However,  these  effects  did  not  reach  .sta- 
tistical significance.  Unfortunately,  the  program 
had  no  detectable  effects  on  the  clinical  out- 
comes of  mortality  or  nosocomial  events.  We 
conclude  that  an  outreach  program  of  this  type 
can  effectively  improve  processes  of  care  in 
rural  ICUs.  However,  improving  processes  of 
care  may  not  always  translate  into  improve- 
ment of  specific  outcomes. 

Combined  Surfactant  Therapy  and  Inhaled 
Nitric  Oxide  in  Rabbits  with  Oleic  .\cid-In- 
duced  .4cute  Respiratory  Distress  Syn- 
drome—Zhu  GF.  Sun  B.  Niu  SF.  Cai  YY.  Lin 
K.  Lindwall  R.  Robertson  B.  .'\m  J  Respir  Crit 
Care  Med  1998:158(21:437. 

Intratracheal  administration  of  surfactant  and 
inhaled  nitric  oxide  (INO)  have  had  variable 
effects  in  clinical  trials  on  patients  with  acute 
respiratory  distress  .syndrome  (ARDS).  We  hy- 
pothesized that  combined  treatment  with  exog- 
enous surfactant  and  INO  may  have  effects  in 
experimental  ARDS.  After  intravenous  infusion 
of  oleic  acid  in  adult  rabbits  and  4-6  h  of  ven- 
tilation, there  was  more  than  a  40%  reduction 
in  both  dynamic  compliance  (Cdyn)  of  the  re- 
spiratory system  and  functional  residual  capac- 
ity (FRO.  a  50%  increment  of  respiratory  re- 
sistance (Ris).  a  70%  reduction  in  Pa02  /FI02. 
and  an  increase  in  intrapulmonary  shunting  (Q 
S/Q  T)  from  4.4  to  33.5%.  The  animals  were 
then  allocated  to  groups  receiving  ( 1 )  neither 
surfactant  nor  INO  (control).  (2)  100  mg/kg  of 
surfactant  (S)  administered  inlratracheally.  (3) 
20  ppm  INO  I  NO),  or  (4)  100  mg/kg  of  surfac- 
tant and  20  ppm  INO  (SNO).  and  subseqiientlv 
ventilated  for  6  h.  After  the  period  of  ventila- 
tion, the  animal  lungs  were  used  loranalvsis  of 
disaturated  phosphatidylcholine  ( DSPC)  and  to- 
tal proteins  (TP)  in  bronchoalv  eolar  lav  age  Huid 
(BALE),  and  for  determination  of  alveolar  vol- 
ume density  (VV).  The  animals  in  the  control 
group  had  the  lowest  survival  rale,  and  no  ini- 
piovenienl  in  lung  mechanics  and  blood  o\v- 
gciialion.  whereas  those  in  the  S  group  had  a 
modcsi  butstatisticallv  significant  improvement 
in  Cdyn.  Ris.  Pa02  and  IRC.  reduced  Q  S/Q  T. 
lowered  minimum  surface  tension  (gammamin) 
of  BALE,  and  increased  DSPC/  TP  and  alveo- 
lar VV.  The  NO  group  had  increased  Pa02  and 
reduced  Q  S/Q  T.  The  SNO  group  showed  im- 
proved Cdyn.  Ris.  I-'RC.DSPC/TP.  alveolar  VV. 
and  gammamin  of  BALF  comparable  to  the  S 
group,  but  there  was  a  further  increase  in  sur- 
vival rate  and  Pa02.  and  additional  reduction  in 
Q  S/Q  T  and   1 1'  in  H  \1  f   These  icsiilis  iiuli- 


784 


Risi'iKAioKV  Caki.  •  (X'lOBi.R  "98  Vol,  4.^  No  10 


QUALITY       RESPIRATORY       CARE 

POSSIBIE 


□ 


SunCare 


October  1,1^ 


SunCare  Respiratory  services,  inc.  106. .^college  Avenue 

Tallahassee,  FL  32301 
888.8507377 
850.577.0090 
Fax  850.577.0091 
wNAAft/.sunh.com 


To  SunCare  Therapists: 

c  tbP  United  States  will  celebrate  National  Respiratory 

■Mission  l-ossHk:  «»»«■)■  R'splralor,  Care. 

:?«sKii°e,i  ,„,.s,„g  faciime.  and  home  health  se.hngs, 

„„  ,„, ,,  ,„»  ,he  Heahh  c^-^ ---;«n-srr/sr'^^  °' 

,he  Medicate  prospec.ive  1"?'""' ,^>'"™ ',,''„  „,  Resphatoty  Care  and  other 

thartundihg  10,  these  essehtlal  setvices  cootmues  under  PPS. 

„a.nghee„a.egl.te.edte,plratoryth.,p,s..ota,^^^^^^^^^^^^^^^ 

r.rsS;SrrS;:r:'""sCr.he™tL'olLsplratoryCare... 


Sincerely, 


Tom  R.  Futch,  RRT 
President  &  CEO 


A  member  of  the  Sun  Healthcare  Group 


Circle  134  on  reader  service  card 
Visit  AARC  Booth  701  in  Atlantl. 

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m 


Abstracts 


t.iic  ihal.  in  this  anim;il  iiKidel  of  ARDS.  a  coni- 
hinalion  iif  MniaclaiU  llierap\  and  INO  is  more 
eftecliNc  than  either  treatment  alone. 

Independent  Kffccts  of  Etiolojjv  of  Failure 
and  Time  to  Reintuhalion  on  Outeome  lor 
Patients  Failing  Extubatiun — Epstein  SK. 
Ciubolaru  RL.  Am  J  Respir  Crit  Care  Med  1 998; 
I58(2|;4S9. 

I'atients  rei.|iMring  reintiihatioii  alter  failed  e\- 
luhation  have  a  poor  prognosis,  with  hospital 
mortality  exceeding  30  to  40'*.  though  the  rea- 
son remains  unclear.  To  examine  the  impact  of 
etiology  of  extubation  failure  and  time  to  rein- 
lubation  on  hospital  outcome,  we  performed  a 
post  hoc  analysis  of  prospectively  gathered  data 
on  74  MICU  patients  (47  men.  27  women). 
64  ±  2  yr  of  age  who  required  reintuhalion 
within  72  h  of  extubation.  Cause  for  reintuba- 
tion  was  cla.ssified  as  airway  (upper  airway  ob- 
struction, II;  aspiration/excess  pulmonary  .se- 
cretions. 12)  or  nonairway  (respiratory  failure, 
21;  congestive  heart  failure.  17;  encephalopa- 
thy. 7;  other.  6).  The  duration  of  mechanical 
ventilation  prior  to  extubation  was  139  ±  19  h, 
and  the  median  time  to  reintubation  was  21  h. 
Thirty-one  of  74  patients  (42%)  died,  with  mor- 
tality highest  for  patients  failing  from  nonair- 
way etiologies  (27/51,  53%  versus  4/23,  17%; 
p  <  0.01 ).  Patients  failing  from  an  airway  cause 
tended  to  be  reinlubated  earlier  (21  ±  4  versus 
31  ±  3  h.  p  =  0.07).  Mortality  increased  with 
longer  duration  of  tirne  from  extubation  to  re- 
intubation  (<=  12  h.  6/25  versus  >  12  h.  2.'i/ 
49;  p  <  0.05).  With  multiple  logistic  regres- 
sion, both  cause  for  extubation  failure  and  time 
to  reintubation  were  independently  associated 
with  hospital  mortality.  In  conclusion,  etiology 
of  extubation  failure  and  time  to  reintubation 
are  independent  predictors  of  outcorne  in  rein- 
lubated MICU  patients.  The  high  mortality  for 
those  reinlubated  for  nonairway  problems  indi- 
cate that  efforts  should  be  preferentially  focused 
on  identifying  these  patients.  The  effect  of  time 
to  reintubation  suggests  that  identification  of 
patients  early  after  extubation  and  timely  rein- 
stitution  of  ventilatory  support  has  the  potential 
lo  leduce  the  increased  mortality  associated  with 
extubation  failure. 

Health  Service  U.se  by  African  ,\niericans  and 
Caucasians  v\ith  Asthma  in  a  Managed  Care 

Setting— Zoratti  EM.  Ha\stad  S.  Rodriguez  J. 
Robcns-Paradise  Y.  Lalata  .IH.  McCarthy  B. 
Am  J  Respir  Crit  Care  Med  I99S;I5.S(2):37I , 

Managed  care  plan  members  provide  a  popula- 
tion for  analysis  that  minimi/es  the  financial 
barriers  to  routine  medical  care  that  have  been 
linked  to  high  rates  of  asthma-related  hospital- 
ization, emergency  care,  and  mortality  atnong 
urban  African  Americans.  We  examined  pat- 
terns of  asthma  care  among  464  African  Atncr- 
ican  (AAl  and  1,609  Caucasian  (C)  asthma  pa 


tients.  age  15  to  45  yr.  in  a  southeast  Michigan 
managed  care  system  during  1993.  Compared 
with  C.  AA  had  fewer  visits  to  asthma  special- 
ists (0.32  versus  0.50  visits/yr.  p  =  0.002),  and 
filled  fewer  prescriptions  for  inhaled  steroids 
(1.44  versus  1.74  Rx/yr,  p  =  0.038).  while  be- 
ing more  likely  to  visit  the  emergency  depart- 
ment with  asthma  (0.71  versus  0.28  visit.s/yr, 
p  <  0.  001),  to  be  hospitalized  with  asthma 
(0.08  versus  0.03  admissions/yr,  p  =  0.002),  or 
10  have  filled  prescriptions  for  oral  steroids  (0.91 
versus  0.59  Rx/yr,  p  <  0.001 ).  AA  were  equally 
likely  lo  have  visited  a  primary  care  physician 
foraslhma(0.95  versus  0.93  visits/yr,  p  =  0.81 ). 
Similar  physician  visit  profiles  and  discrepan- 
cies in  the  use  of  oral  steroids  persisted  when 
analyzing  exclusively  low  socioeconomic  sta- 
tus subgroups.  These  results  suggest  that  ethnic 
differences  in  patterns  of  asthma-related  health 
care  persist  within  managed  care  sellings  and 
are  only  partially  due  lo  financial  barriers. 

Peripheral  Muscle  Weakness  in  Patients  with 
Chronic  Obstructive  Pulmonary  Disease — 

Bernard  S.  LeBlunc  P.  Whittom  F.  Carrier  G. 
Jobin  J,  Belleau  R.  Mallais  F.  Am  J  Respir  Crit 
Care  Med  1998;158(2):629. 

Peripheral  muscle  weakness  is  commonly  found 
in  patients  with  chronic  obstructive  pulmonary 
disease  (COPD)  and  may  play  a  role  in  reduc- 
ing exercise  capacity.  The  purposes  of  this  study 
were  lo  evaluate,  in  patients  with  COPD:  ( I ) 
the  relationship  between  muscle  strength  and 
cross-.seclional  area  (CSA),  (2)  the  distribution 
of  peripheral  muscle  weakness,  and  (3)  the  re- 
lationship between  mu.scle  strength  and  the  se- 
verity of  lung  disease.  Thirty-four  patients  with 
COPD  and  16  normal  subjects  of  similar  age 
and  body  mass  index  were  evaluated.  Compared 
with  normal  subjects,  the  strength  of  three  mus- 
cle groups  (p  <  0.05)  and  the  right  thigh  mus- 
cle CSA,  evaluated  by  computed  tomography 
(83.4  ±  16.4  versus  109.6  ±  15.6  cni2,  p  < 
0.0001).  were  reduced  in  COPD.  The  quadri- 
ceps strength/thigh  muscle  CSA  ratio  was  sim- 
ilar for  the  two  groups.  The  reduction  in  quad- 
riceps strength  was  proportionally  greater  than 
that  of  the  shoulder  girdle  muscles  (p  <  0.05). 
Similar  ob.servations  were  made  whether  or  not 
patients  had  been  exposed  to  systemic  cortico- 
steroids in  the  6-mo  period  preceding  the  .study, 
although  there  was  a  tendency  for  the  quadri- 
ceps strength/thigh  mu.scle  CSA  ratio  to  be  lower 
in  patients  who  had  received  corticosteroids.  In 
COPD.  quadriceps  strength  and  muscle  CSA 
correlated  positively  with  the  FEVI  expressed 
in  percentage  of  predicted  value  (r  -  (1.55  and 
r  =  0.  66,  respectively,  p  ■  ().()(l()5).  In  sum- 
mary, the  strength/muscle  cross-sectional  area 
ratio  was  not  different  between  the  two  groups, 
suggesting  that  weakness  in  COPD  is  due  lo 
muscle  atrophy.  In  COPD.  the  distribution  of 
peripheral  muscle  weakness  and  the  correlation 
helwcen  t|iiadriceps  strcn,L!th  and  the  degree  of 


airllow  obstruction  suggests  that  chronic  inac- 
tivity and  muscle  deconditioning  are  important 
factors  in  the  loss  in  muscle  rnass  and  strength. 

The  Natural  History  of  Respiratory  Symp- 
toms in  a  Cohort  of  .Adolescents — Withers  NJ, 
Low  L.  Holgate  ST.  Clough  JB.  Am  J  Respir 
Crit  Care  Med  1998;158(2):352. 

A  cohort  of  2.289  children,  previously  studied 
at  the  age  of  6-8  yr,  were  followed  up  by  means 
of  a  postal  questionnaire  when  aged  14  -16  yr 
to  examine  the  as.sociation  between  potential 
risk  factors  and  the  natural  history  of  respira- 
tory symptoms.  Children  with  current  symp- 
toms, persistent  symptoms,  and  late-onset  symp- 
toms were  identified  and  multivariate  analyses 
were  performed  to  determine  the  independent 
association  between  risk  factors  and  these  var- 
ious symptom-based  subgroups.  Personal  and 
family  history  of  atopy  was  significantly  asso- 
ciated with  all  symptom  groups  and  with  the 
presence  of  doctor-diagnosed  asthma.  Smok- 
ing, either  active  or  passive,  was  shown  to  be 
significantly  associated  with  current,  persistent, 
and  late-onset  symptoms.  Other  factors  shown 
to  be  significantly  associated  with  certain  symp- 
tom groups  were  gender  (late-onset  wheeze), 
single-parent  households  (cuiTent  cough,  per- 
sistent cough),  social  class  (late-onset  wheeze), 
number  of  children  in  the  household  (persistent 
wheeze,  late-onset  cough),  number  of  furry  pets 
in  the  household  (current  wheeze),  birth  weight 
(late-onset  wheeze),  and  gas  cookers  (current 
wheeze,  persistent  wheeze).  In  a  subgroup  of 
children  studied  in  more  detail  in  1987,  bron- 
chial hyperresponsiveness  in  1987  was  posi- 
tively associated  with  persistent  wheeze  in  1 995. 
whereas  positive  skin-prick  testing  in  1987  was 


High-Frequency  Respiratory  Impedance 
Measured  by  Forced-Oscillation  Technique 
in  Infants — Prey  L'.  Silverman  M.  Kraemer  R. 
Jackson  AC.  Am  J  Respir  Crit  Care  Med  1998; 

158(2):.^63. 

Measurements  of  respiratory  input  impedance 
(ZinI  in  infants  using  forced  oscillations  at  the 
airway  opening  up  to  256  Hz  have  been  shown 
to  include  a  first  antiresonance  (ar.l ).  We  won- 
dered whether  features  derived  from  high-fre- 
quency Zin  change  during  methacholine- 
induced  airway  obstruction  in  infants,  whether 
those  changes  could  be  explained  by  a  lumped 
parameter  model  as  in  dogs  (providing  a  value 
lor  respiratory  lesistance  |Rrs]),  or  whether  they 
are  similar  lo  Ziii  ilata  in  human  adults  with 
airua\  obstruction.  In  13  uliee/>  iiil.Mits  (age 
58  ±  19  wk)  Zin(omega)  was  assessed  at  base- 
line, and  in  nine  infants  after  methacholine  chal- 
lenge, using  a  provocation  dose  defined  by  fall 
of  more  than  30%  in  VmaxFRC  (rapid  chest- 
compression  technique).  Following  methacho- 
line challeiiiic.  Vmaxl-RC  decreased  sisznifi- 


7Sft 


RiiSPiRATORY  Care  •  October  "98  Vol  43  No  10 


GALILEO 


The  new  view  of  Ventilation 

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MAKING  TECHNOLOGY  SERVE  MANKIND 


International:  HAMILTON  MEDICAL  AG,  Via  Nova,  CH-7403  Rhazuns/Switzerland,  Telephone  (+41)  81-  641  25  27,  Fax  (+41)  81-  641  26  89 

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Abstracts 


cantly  (p  <  ().()()()5).  ihe  rrcquciKN  al  which 
ar. I  occurred  (  lar. ll  iiicicased  signiricaiill) 
(p  =  ().()007l.  and  the  relative  maximum  in  the 
real  part  al  lar.  1  |Zinre(  far.  1)]  increased  sig- 
nificantly (p  =  0.02).  whereas  Rrs  did  nut 
change.  We  conclude  that  in  wheezy  infants 
ar.l  is  highly  sensitive  to  changes  in  lung  me- 
chanics. Although  ar.l  cannot  be  explained  by 
a  simple  lumped-parameter  model,  it  is  likely 
due  to  wave  propagation  phenomena,  as  in  hu- 
man adults.  In  either  case,  far.l  potentially  con- 
tains information  about  airway  wall  compliance, 
which  is  important  for  the  understanding  of  flow 
limitation  in  infant  wheezing  disorders. 

Pulmonary  Function  Tests  and  CT  Scan  in 
the  Management  of  Idiopathic  Pulmonary  Fi- 
brosis— .\aubct  .A.  .Agusli  C.  Luburich  P.  Roca 
J.  Monton  C.  Ayuso  .MC.  el  al.  Am  J  Respir 
Crit  Care  Med  199S;I.SS(2):4.il. 

Relationships  between  pulmonary  function  test- 
ing and  high-resolution  computed  tomography 
(HRCT)  were  studied  in  .^9  untreated  patients 
with  idiopathic  pulmonary  fibrosis  (IPF)  at  di- 
agnosis. 2i  of  whom  were  followed  during 
7.5  ±  0.3  mo  (mean  ±  SEM).  At  diagnosis,  the 
extent  of  overall  lung  involvement  in  the  HRCT 
scans  showed  a  moderate  but  significant  corre- 
lation only  with  FVC  (r  =  -0.46.  p  =  0.  00.1) 
and  DLCO  (r  =  -0.40.  p  =  0.03).  The  extent  of 
ground  glass  pattern  also  correlated  with  FVC 
(r  =  -0.58.  p  =  0.0001).  Arterial  P02  at  peak 
exercise  (n  =  13  patients)  showed  a  significant 
as.sociation  v\  ith  the  extent  of  both  ground-glass 
pattern  and  overall  lung  involvement  in  HRCT 
(r  =  -0.60.  p  =  0.02;  and  r  =  -0.64.  p  =  0.  01. 
respectively).  On  multivariate  analysis  a  signif- 
icant independent  correlation  between  the  global 
disease  extent  in  HRCT  and  both  FVC  and 
DLCO  was  observed.  Changes  over  time  in  the 
total  extent  of  the  disease  evaluated  with  HRCT 
scans  were  also  related  to  those  observed  in 
DLCO  and  in  FVC  (r  =  -0.57.  p  =  0.01,  and 
r  =  -0.  51,  p  =  0.01.  respectively).  The  present 
study  suggests  that  FVC  and  DLCO  arc  the 
physiological  variables  that  best  rellect  the 
global  extent  of  disease  in  IPF  and  thus  may 
provide  significant  information  for  the  assess- 
ment of  the  disease's  progression 

InliTdhserver  \ariahility  in  Keciigni^inK 
Arousal  in   Respiratory  Sleep  Disorders — 

Drinnan  M.I.  Murray  A.  Griffiths  CJ.  Gibson 
GJ.  Am  J  Respir  Crit  Care  Med  I99S;I5S|2): 
35X. 

DaytiiTie  sleepiness  is  a  cimmion  c(insci|i)cncc 
of  repeated  arousal  m  obsinicli\c  sleep  apnea 
(OSA).  Arousal  indices  arc  sometimes  used  lo 
make  decisions  on  treatment,  but  there  is  no 
evidence  that  arousals  arc  detected  similarly 
even  by  experienced  observers.  Using  the  Amer- 
ican Sleep  Disorders  Association  (ASDAl  def- 
inition ol  arousal  ni  terms  o!  the  accompanying 


electroencephalogram  iFEGl  changes.  \\c  have 
cjuantificd  interobserver  agreement  lor  arousal 
scoring  and  identified  factors  alfecting  it.  Ten 
patients  with  suspected  OSA  were  studied;  three 
representative  EEC  events  during  each  of  light, 
slow-wave,  and  rapid-eye-movement  (REM) 
sleep  were  extracted  from  each  record  (90  events 
total)  and  evaluated  by  experts  in  14  sleep  lab- 
oratories, Obser\'ers  differed  (ANOVA,  p  < 
0.001 )  in  the  number  of  events  scored  as  arousal 
(totals  ranged  from  23  to  53  of  the  90  events). 
Overall  agreement  was  moderate  (kappa  = 
0.47).  but  it  was  best  for  events  during  slow- 
wave  sleep,  moderate  for  REM.  and  poor  for 
light  sleep  (kappa  =  0.60,  0,52,  and  0,28,  re- 
spectively). Agreement  was  unrelated  to  arousal 
duration.  We  conclude  that  the  ASDA  defini- 
tion of  arousal  is  only  moderately  repeatable. 
.Account  should  be  taken  of  this  \ariability  uhen 
results  from  dilTcrcnt  centers  are  compared. 

Development  of  a  Disease-.Speeifit  Health- 
Related  Quality  of  Life  Questionnaire  for 
Sleep  Apnea — Flemons  WW.  Reimer  MA. 
Am  J  Respir  Crit  Care  Med  I998;I58(2):494. 

The  Calgary  Sleep  Apnea  Quality  of  Life  Index 
(SAQLI)  was  developed  to  record  key  elements 
of  the  disease  that  are  important  to  patients.  All 
items  felt  to  intluence  the  quality  of  life  of  these 
patients  were  identified.  Final  questionnaire 
items  were  selected  by  interviewing  113  pa- 
tients with  sleep  apnea  and  50  snorers  who  rated 
each  item  on  whether  it  was  a  problem  and  the 
importance  of  it  to  their  overall  quality  of  life. 
Items  for  the  final  questionnaire  were  .selected 
based  on  the  rank  order  of  the  frequency  xim- 
porlance  product.  The  rank  ordering  was  simi- 
lar across  strata  of  disease  severity  and  between 
sexes.  The  Calgary  SAQLI  has  35  questions 
organized  into  four  domains:  daily  functioning, 
social  interactions,  emotional  functioning,  and 
symptoms.  A  fifth  domain,  treatment-related 
symptoms,  can  be  added  for  clinical  interven- 
tion trials  10  record  the  possible  negative  im- 
pacts of  treatment.  The  SAQLI  has  a  high  de- 
gree of  internal  consistency,  face  validity  as 
judged  by  content  experts  and  patients,  and  con- 
struct validity  as  shown  by  its  positive  correla- 
tions with  the  SF-36  and  the  improvement  in 
scores  in  patients  successfully  coinpleting  a 
4-wk  trial  of  continuous  positive  airway  pres- 
sure l(  includes  items  show  n  lo  he  impoitani  to 
paticnis  Willi  sleep  apnea  aiitl  is  dcsigiicti  as  a 
iiKMsuie  of  outcome  in  clinical  trials  in  sleep 
apnea.  Flemons  WW,  Reimer  MA.  De\clop- 
niciU  of  a  disease-specific  health-related  quality 
ol  lilc  inieslioiinaiie  lor  sleep  apnea. 

Pre(licli^e  \  alue  ofC  onlaci  linestigalion  for 
IdentilNing  Reeeiil  rransinissioii  of  Myeo- 
hacteriuMi  Tuberculosis  liehi  MA.  Ilopeucll 
PC.  Pa/  FA.  Kawamura  LM,  .Schectcr  GF,  Small 
I'M.  Am  J  Respir  Crit  Care  Med  I998;I58(2): 
465. 


ContacI  tracing,  Ihe  e\alualion  of  persons  who 
have  been  in  contact  with  palients  having  tu- 
berculosis, is  an  important  component  of  tuber- 
culosis control.  We  used  DNA  fingerprinting  to 
test  the  assumption  that  tuberculosis  in  contacts 
to  active  eases  represents  transmission  from  that 
person.  Cases  of  tuberculosis  in  San  Francisco 
between  1991  and  1996  with  positive  cultures 
who  had  been  previously  identified  as  contacts 
('contact  cases')  to  acti\e  cases  (index  cases') 
were  studied.  Of  11.211  contacts  e\aluated. 
there  were  66  pairs  of  culture-positive  index 
and  contact  cases.  DNA  fingerprints  were  avail- 
able for  both  nieinbers  of  these  pairs  in  54  in- 
stances (82% ).  The  index  and  contact  cases  were 
infected  with  the  same  strain  of  Mycobacterium 
tuberculosis  in  38  instances  (70%:  95%  CI:  56 
lo  82%);  16  pairs  (30%)  were  infected  with 
unrelated  strains.  Unrelated  infections  were 
more  common  among  foreign-born  (risk  ratio 
|RRj  =  5.22.  p  <  0.001).  particularly  Asian 
(RR  =  3.89.  p  =  0.002)  contacts.  Contact  in- 
vestigation is  an  imperfect  method  for  detecting 
transmission  of  M.  tuberculosis,  particularly  in 
foreign-born  persons.  However,  because  such 
investigations  target  a  group  with  a  high  prev- 
alence of  tuberculosis  and  tuberculous  infec- 
tion, these  efforts  remain  an  important  activity 
in  Ihe  control  of  tuberculosis. 

Decelerating  Flow  Ventilation  Effects  in 
Acute  Respiratory  Failure — Alvarez  A.  Subi- 
rana  M.  Benito  S.  J  Crit  Care  I99S;13(  1 1:7. 

PURPOSE:  The  purpose  of  this  article  is  to 
analyze  the  effect  of  a  pressure-regulated  vol- 
ume-controlled ventilation  mode  on  lung  me- 
chanics and  gas  exchange  in  patients  with  acute 
respiratory  failure.  MATERIALS  &  METH- 
ODS: We  ventilated  10  patients  with  two 
pressure-limited  modes:  pressure-controlled 
ventilation  ( PC)  and  pressure-regulaied  \  olume- 
controlled  ventilation  (PRVC)  in  random  order, 
for  I  hour  each.  Palients  were  stabilized  on 
volume-controlled  \entilation  ( VC)  for  30  min- 
ules  before,  belwecn,  and  at  the  end  of  PC  and 
PRVC  to  reach  baseline  conditions.  Al  the  OKi 
of  every  VC  period  and  at  30  and  60  minutes  of 
PC  and  PRVC,  respiratory  mechanics,  gasomet- 
rics,  and  hemodynamic  parameters  were  col- 
lected. RESULTS:  We  found  no  significant  dif- 
ferences between  Ihe  three  VC  periods. 
Comparing  VC  wiih  Ihe  two  pressure-limited 
\  cntilalion  modes,  peak  pressure  decreased  from 
29.4  ±  9.1  cm  H,0  (VC)  lo  25.9  ±  8.4  (PC  60 
mini  and  26. 1  ±  8.2  (PRVC  60  min).  and  P,(.,,, 
decreased  significantly  from  38.6  ±  3.1  mm 
He  lVCllo36.7  :•  2.8  (PC  60  min)  and  .36.8  ± 
2,9  (PRVC  60  mini.  CONCLUSIONS:  Pres- 
siiic  hmileil  \ciililalioii  allows  mechanical  ven- 
lilalion  lor  ihc  same  lulal  \oliinie  as  VC  hul 
results  ill  a  lower  pc;ik  inspiiatory  piessiiie  and 
a  slightly  lower  P,(„,.  The  mechanism  icspon- 
sihlc  for  this  gas  exchange  effect  is  unknown 
Inn  IS  pi(ibabl\  related  lo  a  belter  an  dislnbii 


788 


Rlspiraior'i  Carl  •  Ociohi.k  "98  Vol  43  No  10 


This  is  not  Kinetic  Therapy. 


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I.onji-l trill  RcdiK'tioii  in  Asthma  Moihiditj 
following  an  Asthma  Self-Management  Pro- 
gramme— DSoiiza  WJ.  Te  Karu  H.  Fox  C. 
Haiper  M.  Gcnimell  T,  Ngatuere  M.  et  al.  Eur 
Respir  J  1WS;I1(3):611. 

The  adult  "eiedil  card"  asthma  self-management 
plan  has  been  shown  to  be  an  effective  and 
aeeeptable  system  for  reducing  asthma  morhid- 
ily  when  introduced  as  part  of  a  6  month  com- 
munity-based asthma  programme.  The  aim  of 
the  present  study  was  to  assess  the  effecti\e- 
ness  of  the  credit  card  plan  2  y  after  the  end  nl 
the  prograinine.  Markers  of  asthma  morbidity 
and  use  of  medical  .services  were  compared  dur- 
ing the  12  months  before  enrollment,  and  2  > 
alter  completing  the  6-month  asthma  pro- 
gramme. Of  the  69  participants  who  originally 
enrolled  in  the  6-month  asthma  programme.  ?S 
were  surveyed  2  y  after  completion  of  the  pro- 
gramme. The.se  participants  showed  a  signifi- 
cant improvement  in  all  but  one  of  the  asthma 
morbidity  measures.  The  proportion  waking 
most  nights  with  asthma  in  the  previous  12 
months  decreased  from  29  to  97c  (p  =  0.02). 
emergency  visits  to  a  general  practitioner  de- 
crea.sed  from  43  to  16%  (p  =  0.001).  hospital 
emergency  department  visits  with  asthma  de- 
creased from  19  to  59c  (p  =  0.02)  and  hospital 
admissions  decreased  from  \7hi59c  (p  =  0.04|. 
Only  24"*  of  patients  reported  that  they  usually 
monitored  their  peak  flow  rate  daily,  but  this 
increased  to  739^  during  a  "bad"  attack  ol 
asthma.  A  long-term  reduction  in  asthma  mor- 
bidity and  requirement  for  acute  medical  ser- 
\  ices  can  result  following  the  introduction  of 
the  adult  credit  card  asthma  self-inanagement 
plan.  Adult  patients  with  asthma  are  inost  likely 
to  undertake  peak  tlow  monitoring  preferen- 
tially during  periods  of  unstable  asthma,  rather 
than  routinely  during  periods  of  good  control. 


Adverse  Asthma  Outcomes  among  Children 
Hospitalized  with  .Asthma  in  California — 

Calmes  D,  Leake  BD,  Carlisle  DM.  Pedialncs 
199S;I0I(?);X4.S. 

OBJECTIVE:  To  use  administrative  data  to  de- 
termine whether  adverse  asthma  outcomes  for 
pediatric  asthma  hospitalizations  are  related  to 
specific  clinical  and  nonclinical  patient  charac- 
teristics. DESIGN:  Cross-sectional  study.  SET- 
TING: All  pediatric  (0  to  17  years  of  age)  asth- 
ma-related hospital  discharges.  1986  to  1993. 
in  California.  PATIENTS:  A  total  of  I  13.974 
eligible  patients  with  asthina-related  discharges. 
MAIN  OUTCOME  MEASURE:  Adverse 
asthma  outcomes  (intubation,  cardiopulmonary 
arrest,  and  death),  RESULTS:  Adverse  asthma 
outcomes  occurred  in  0AS9c  of  subjects.  The 


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fictinency  of  adverse  asthma  outcomes  increased 
during  the  1990s  compared  with  19S6.  After 
controlling  for  differences  in  gender,  age,  spe- 
cific comorbid  conditions,  year,  race,  and  in- 
surance type,  adverse  asthma  outcomes  were 
more  likely  to  occur  in  the  5-  to  11-year-old 
group  (odds  ratio  [OR]:  1.39;  95%  confidence 
interval  [CI|:  1.1. VI. 69)  and  in  the  12-  to  17- 
year-old  group  (OR:  4.48:  CI:  .3.20-6,2 1 )  com- 
pared with  those  children  in  the  0  to  4-year-old 
age  group.  Asian  Pacific-American  childicn 
were^more  likely  (OR:  I.. 59;  CI:  I.24-2..59) 
than  were  white  children  to  experience  an  ad- 
verse asthma  outcome.  Children  who  had  a  sec- 
otidary  diagnoses  of  pneumonia  (OR:  1 .54;  CI: 
1 .  19-2.00)  also  were  more  likely  to  experience 
an  adverse  asthma  outcome.  The  odds  of  an 
adverse  outcome  increased  progressively  after 
1986,  becoming  significant  after  1989.  Gender 
and  insurance  type  were  not  associated  wuh 


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increased  odds  of  experiencing  an  adverse 
asthma  outcome.  CONCLUSIONS:  Adverse 
asthma  outcoines  among  hospitalized  children 
are  increasing  in  the  1990s  and  are  associated 
with  specitic  clinical  and  nonclinical  patient 
characteristics. 

Buccal  Cell  DNA  Mutation  Analysis  for  Di- 
agnosis of  Cystic  Filirosis  in  Newborns  and 
Infants  Inaccessible  to  Sweat  Chloride  Mea- 
surement—Paiad  RB.  Pediatrics  I998;1()1(5|: 

851, 

OBJECTIVES:  To  assess  the  application  of 
DNA-based  cystic  fibrosis  transmembrane  con- 
ductance regulator  (CFTR)  gene  mutation  anal- 
ysis as  a  primary  cystic  fibrosis  (CF)  diagnostic 
test  in  preterm  and  term  newborns  and  infants 
for  whom  the  quantitative  pilocarpine  ionto- 
phoresis test  (QPITl  cannot  be  used.  DESIGN: 


Respiratory  Care  •  October  "98  Vol  43  No  10 


791 


Abstracts 


Reliosp<.-cli\c  sin-\cy.  SETTING;  DNA  Diag- 
nostic Laboratory,  CliilUren's  Hospital.  Boston. 
Massachusetts.  Buccal  cell  DNA  samples  were 
received  from  inpatients,  outpatients,  and  three 
neonatal  intensive  care  units.  OUTCOME 
MEASURE;  Detection  of  at  least  1  of  12  CFTR 
mutations.  PATIENTS;  Between  November  1. 
1992.  and  April  30.  1994.  28  newborns  and 
infants  under  12  months  of  age  at  risk  for  CF 
had  CFTR  DNA  nuilalion  analysis  performed 
because  a  sweat  chloride  (SC)  value  could  not 
be  obtained.  QPIT  was  either  not  performed 
(infant  weight  <  2  kg.  QPIT  not  available  at 
site  of  hospitalization,  or  infant  not  accessible 
to  QPIT  laboratory)  or  was  inconclusive  (sweat 
volume  <  15  mg  or  indeterminate  SC  [3:  40.  < 
60  mEq/L| ).  The  postnatal  age  at  lime  of  test- 
ing ranged  from  1  day  to  1  1  months,  and  ges- 
tational age  at  birth  from  2."*  to  40  weeks.  RE- 
SULTS; Six  (21'.  I  of  2,S  inlanls  with 
unobtainable  or  indeterminate  QPIT  had  1  or  2 
CFTR  mutations  detected.  Immediate  CF  diag- 
nosis by  direct  detection  of  2  CFTR  mutations 
was  made  in  5  of  these  6  patients.  Definitive  CF 
diagnosis  in  the  infant  with  1  CFTR  mutation 
was  delayed  until  an  elevation  in  SC  could  be 
documented.  The  patients  with  no  CFTR  mu- 
tations detected  had  a  low  likelihood  of  CF. 
CONCLUSIONS;  For  infants  in  whom  CF  is 
suspected  but  QPIT  cannot  be  obtained,  buccal 
cell  DNA-based  CFTR  mutation  analysis  can 
be  used  as  a  rapid,  noninvasive  primary  diag- 
nostic test.  This  simple  mode  of  DNA  collec- 
tion may  aid  in  the  diagnosis  of  other  inherited 
disorders  in  newborns. 

Health  and  Developnuntul  ()utc(niies  M  IK 
.Months  In  \  ery  Prderni  Infants  with  Bron- 
chopulmonary Dysplasia — Gregoire  MC.  Le- 
feb\re  F.  Glorieuv  J.  Pediatrics  19yS;101(.S); 
S.S6, 

OBJECTIVE:  To  determine  whether  very  pre- 
term infants  who  are  oxygen-dependent  at  28 
days  of  life  but  not  at  .36  weeks'  gestational  age 
are  at  high  risk  of  morbidities  at  18  months. 
POPULATION;  A  total  of  217  infants  born  in 
a  tertiary  care  center  at  24  to  28  weeks'  gesta- 
tion in  1987  to  1992,  classified  into  three  groups: 
neonatal  comparison  group.  O,  <  28  days  of 
life  (n  =  76);  bronchopulmonary  dysplasia 
(BPD)-I.  O,  >  28  days  but  not  at  36  weeks' 
gestational  age  (n  =  48);  and  BPD-2.  O,  >  36 
weeks  (n  =  93).  OUTCOME  MEASURES; 
Growth,  persistent  respiratory  problems  (asth- 
ma, tracheostomy,  home  oxygen  therapy  i.  sur- 
gery, hospitalizations,  and  neurode\elopmcntal 
impairments.  RESULTS;  Among  the  three 
groups,  no  differences  were  found  in  weight. 
height,  head  circumference,  or  total  number  of 
days  of  rehospitalizations  for  any  causes,  or  in 
rate  of  rehospitali/.ations  to  the  intensive  care 
unit,  persistent  respiratory  problems,  cerebral 
palsy,  or  sensory  impairment.  Children  with 
BI'0-2  needed  ni.nv  hciiii.i  rcpaiis  omip.iivd 


uith  the  other  two  groups  (comparison  group; 
1 2'^*  vs  BPD- 1 ;  1  O'y  \  s  BPD-2;  305^ ).  had  more 
days  of  readmissions  for  respiratory  problems 
(comparison  group;  2.0  vs  BPD- 1 ;  2.0  vs  BPD-2 
6.3  IBPD-1  vs  BPD-2]).  had  a  lower  mean  de- 
velopmental quotient  (comparison  group: 
97.4  ±  l.'S.O  vs  BPD-1:  97.9  ±  1 1.6  vs  BPD-2: 
90.7  ±  19.3).  Intraparenchyinal  cerebral  lesions, 
high  family  adversity,  and  prolonged  ventila- 
tion were  the  most  important  factors  innuenc- 
ing  the  developmental  outcome.  CONCLU- 
SION: Children  with  BPD-1  are  similar  in  all 
respect  at  18  months  to  children  in  the  compar- 
ison group.  Children  with  BPD-2  are  similar  to 
the  other  groups  at  18  months  in  growth,  gen- 
eral health,  and  neurologic  outcome  but  differ 
in  having  a  higher  number  of  days  of  rehospi- 
talizations  for  respiratory  causes,  more  hernia 
repairs,  and  more  de\elopmental  delays. 

Cystic  Fibrosis:  When  Should  High-Resolu- 
tion Computed  Tomography  of  the  Chest  Be 
Obtained? — Sanlamaria  F.  Grillo  G.  Giiidi  G. 
Rotondo  A.  Raia  V.  de  Ritis  G.  et  al.  Pediatrics 
199S;101(-'i);908. 

OBJECTIVE;  To  provide  mdications  lor  high- 
resolution  computed  tomography  ( HRCT)  of  the 
chest  in  patients  with  cystic  fibrosis  (CF).  DE- 
SIGN; We  compared  the  HRCT  and  conven- 
tional chest  radiography  (CCR)  scores  and  as- 
sessed their  correlation  with  clinical  scores  and 
pulmonary  function  tests.  SETTING:  Depart- 
ment of  Pediatrics.  Federico  II  University.  Na- 
ples. Italy.  SUBJECTS;  A  total  of  30  patients 
with  CF  6.75  to  24  years  of  age.  RESULTS: 
CCR  scores  correlated  highly  with  HRCT  (r  = 
-  0.8)  and  clinical  (r  =  0.5)  scores,  whereas 
total  HRCT  scores  were  not  related  to  clinical 
scores.  Of  all  the  specific  HRCT  findings,  only 
bronchieclasis  appeared  related  significantly  to 
the  clinical  score  (r  =  0.6).  Most  pulmonary 
function  tests  were  related  to  CCR  and  total 
HRCT  scores,  hut  nol  lo  HRCT  .scoring  of  spe- 
cific changes.  Forced  vital  capacity  and  CCR 
scores  appeared  the  best  predictors  of  the  HRCT 
score  (multiple  R  =  0.58  and  0.79.  respective- 
ly). In  patients  with  mild  lung  disea.se,  HRCT 
delected  bronchiectasis  and  air  trapping  in  579t 
and  7 1  Vc  of  the  cases,  respectively.  In  patients 
with  inore  abnormal  chest  radiographs,  bron- 
chieclasis and  air  trapping  were  demonstrated 
on  HRCT  in  all  cases.  CONCLUSIONS;  These 
findings  suggest  that  HRCT  of  the  chest  is  most 
useful  m  the  idenlilicalion  ol  early  lung  abnor- 
malilics  in  patients  uilh  CF  uith  nnki  respua- 
lory  symptoms,  whereas  for  established  disease. 
CCR  is  slill  the  first-line  imaging  technique. 
The  advantage  of  detecting  early  changes  on 
CT  imaging  awaits  additional  confirmation,  at 
least  until  early  therapeutic  interventions  affect- 
ing significantly  the  final  outcome  of  the  dis- 
ease are  demonstrated.  In  patients  with  ad\  .meed 
disease.  HRCT  ma\  he  useful  in  the  e\alualion 
1)1  spetitii.  lung  chiingcs  when  more  aggrcssise 


treatnienl  such  as  chest  surgical  interventions  is 
indicated.  Given  the  cost  of  the  procedure  and 
the  high  radiation  dosage  compared  with  CCR, 
a  careful  assessment  of  the  cost;benefit  ratios  of 
HRCT  IS  strongly  recommended  in  CF, 

Effects  of  Positi\e  Knd-F)xpiralor>  Pressure 
and  Different  Tidal  Volumes  on  .M>eolar  Re- 
cruitment and  Hyperinflation — Dambrosio 
M.  Roupie  F.  Mollel  JJ.  Anglade  MC,  Vasile 
N.  Lemaire  F,  Brochard  L.  Anesthesiology  1 997: 
S7(3):495. 

BACKGROUND;  The  morphologic  effect  of 
positive  end-expiratory  pressure  (PEEP)  and  of 
two  tidal  N'olumes  were  studied  by  computed 
tomography  to  determine  whether  setting  the 
tidal  volume  (V,)  at  the  upper  infiection  point 
(UIP)  of  the  pressure-volume  (P-Vi  curve  of 
the  respiratory  system  or  10  niL/kg  have  dif- 
ferent effects  on  hyperinfiation  and  aheolar  re- 
cruitment, METHODS;  Alveolar  recruitment 
and  hyperinfiation  were  quantified  by  computed 
toinography  in  9  patients  with  the  acute  respi- 
ratory distress  syndrome  ( ARDS).  First,  end  ex- 
piration was  compared  without  PEEP  and  with 
PEEP  .set  at  the  lower  infiection  point  of  the 
P-V  curve;  second,  at  end  inspiration  above 
PEEP,  a  reduced  V,  set  at  the  UIP  (rV,)  and  a 
standard  10  niL/kg  V,  (V,l  ending  above  the 
UIP  were  compared.  Three  lung  zones  were 
defined  from  computed  tomographic  densities: 
hyperdense.  normal,  and  hyperinfiated  zones. 
RESULTS:  Positive  end-expiratory  pressure  in- 
duced a  significant  decrease  in  hyperdensities 
(from  46.8  ±  I8'7r  to  38  ±  \5.\%  of  zero  end- 
expiratory  pres.sure  (ZEEP)  area:  p  <  0.02)  with 
a  concomitant  inerea.se  in  nonnal  zones  (from 
47.3  ±  20.9'7r  to  56.5  ±  13.2%  of  the  ZEEP 
area:  p  <  0.05).  and  a  significant  increase  in 
hyperinfiation  (from  8.1  ±  5.9<7r  to  17.8  ± 
\2.1'i  of  ZEEP  area:  p  <  0.01).  At  end  inspi- 
lalinn.  a  significant  increase  in  hsperinfiatcd 
areas  uas  observed  VMlh  V,  compared  with  rV, 
(33.4  ±  17.8  vs  26.8  ±  17.3'/f  of  ZEEP  area: 
p  <  0.05).  whereas  no  significant  difference 
was  observed  for  both  normal  and  hyperdense 
zones.  CONCLUSIONS;  Positive  end-expira- 
tory pressure  promotes  alveolar  recruitment:  in- 
creasing V|  above  the  UIP  seems  to  predomi- 
nantly increase  hyperinfiation. 

Monitoring  (iastric  Mucosal  Carbon  Diox- 
ide Pressure  lising  (las  Ttmometry:  In  Vitro 
and  In  Vivo  Validation  Studies — Creteur  J. 
IX- Backer  D.  Vincent  JI..Anesihesiology  1997: 

S7(3):.504, 

BACKCiROI'NI):  Saline  gasinc  lononicliv  of 
carbon  dioxkle  h.is  hccn  pioposcLl  ;is  .i  mc;ins  lo 
assess  Ihe  .idci|LKic\  ol  splanchnic  pcrlnsion. 
However,  this  technique  luis  vcvcr.il  disadvan- 
l.igcs.  including  Ihe  long  lime  iniciv.il  needed 
lor  g.ises  lo  reach  equilihiuim  ill  s.iline  nulieu, 
I'hiis  Ihe  anlhors  ev  aUialed  a  sv  slein  Ihal  uses  a 


792 


Risi'iKMoin  C\ki  •  OcioBi-K  '98  Vol  4.^  No  10 


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Abstracts 


g;is-nilcd  iiisiead  ol  a  salinc-lillcJ  iiaMiic  hal- 
Uioii.  METHODS:  In  vllm.  v\c  simullaneously 
placed  2  loiionictry  callicters  in  an  equilihrallon 
waler  balli  maintained  at  a  predetermined  and 
eonslant  pressure  of  carbon  dioxide  ^P^,,  i.  Ilie 
first  catheter's  balloon  was  filled  with  an-  and 
the  second  with  saline.  The  perlorniance  of  gas 
tonometry  was  tested  by  comparing  the  Pj.„, 
measurements  of  the  bath  obtained  via  gas 
tonometry  (Pgc  oJ  '"  'he  Pcq,  measurements  of 
direct  bath  samples  (Pbathf,,,).  These  results 
were  also  coEiipared  with  the  P^-,,,  measure- 
ments obtained  simultaneously  by  saline  tonom- 
etry (Psfo,).  The  response  time  of  gas  versus 
saline  tonometry  was  also  studied.  In  vivo,  the 
performance  of  gas  tonometry  was  tested  com- 
paring the  measurements  of  gastric  intramuco- 
sal  P(-o,  obtained  by  Pgco,  "<  different  equili- 
bration times  w  ith  those  obtained  by  Ps,-.,,,  using 
an  eiiuilibialion  time  of  30  min.  Two  nasogas- 
tric tonometry  catheters  were  placed  simidta- 
neously  in  7  stable  patients  in  the  intensi\e  care 
unit.  The  first  balloon  was  filled  with  air  and 
the  .second  with  saline.  RESULTS:  hi  vitro,  there 
was  a  close  correlation  between  Pgco,  ^"^ 
Pbath(.(,,,  for  each  level  of  Pbath(.,,,.  and  for 
each  different  gas  equilibration  tiine.  For  an 
equilibration  time  of  10  min  at  a  Pbatho,  level 
of  approximately  40  mm  Hg,  the  bias  of  the  gas 
device  defined  as  the  mean  of  the  differences 
between  Pbathc,,,  and  Pgco,  <"1<J  i'^  precision 
defined  as  the  standard  deviation  of  the  bias, 
were  -0.,'^  mm  Hg  and  0.7  mm  Hg,  respectively. 
Using  the  same  definitions,  the  bias  and  preci- 
sion of  saline  tonometry  were  1 1.2  mm  Hg  and 
1,4  mm  Hg,  respectively.  If  the  equilibration 
time-dependent  correction  factor  provided  by 
the  catheter  manufacturer  for  saline  tonometry 
was  applied,  the  bias  and  precision  were  -6.9 
mm  Hg  and  2.9  mm  Hg.  respectively.  In  vivo, 
using  an  equilibration  time  of  10  min  for  gas 
and  .^0  min  for  saline  tonometry,  there  was  a 
close  correlation  between  the  2  techniques 
(r2  =  0.986).  A  Bland  and  Altman  analysis 
revealed  a  bias  ( ±  2  SD)  of  0. 1  ±  6.8  mm  Hg. 
The  correlation  between  the  2  methods  was  not 
improved  if  we  prolonged  the  equilibration  time 
of  the  gas  tonometer.  CONCLUSIONS:  Gas 
tonometry  is  comparable  to  saline  tonometry 
for  measuring  gastric  intramucosal  P; ,,,.  Be- 
cause gas  tonometry  is  easier  to  automate,  it 
may  offer  advantages  over  saline  tonometry. 

I  nplanned  lAluhalions  in  the  .Adult  Inlen- 
sive  Care  Unit:  A  I'rospeclive  Miilticenler 
.Study.  Association  dcs  kcarnnialcurs  dii  Ccn- 
tre-Ouest— Boulain  f.  Am  .1  Rcspir  Crit  Care 
Med  I998;l.'>7(4  I'l  li:l  L^l. 

The  predisposing  factors  and  complications  of 
unplanned  extubation  (UEX)  in  inechanically 
ventilated  adult  patients  are  not  well  recogni/ed. 
We  designed  a  prospective  multicenter  obser- 
vational study  to  identify  risk  factors  and  de- 
scribe the  complications  of  UI-;\.  We  lollowcd 


426  \enlilatcd  patients  over  a  2-mo  period.  Clm- 
ical  characteristics  such  as  diagnosis  on  admis- 
sion and  reasons  for  ventilation  were  used  to 
classify  the  patients.  The  presence  or  absence 
of  potential  risk  factors  was  daily  noted,  includ- 
ing the  types  of  ventilators,  tracheal  tubes,  tube 
fixations,  ventilatory  support  modes,  route  for 
intubation,  and  the  use  of  intravenous  sedation. 
Circumstances  and  complications  of  UEX  were 
prcspectively  recorded.  Forty-six  (10.8%)  pa- 
tients experienced  at  least  one  episode  of  UEX. 
Ten  UEX  occurred  during  nursing  procedures. 
At  the  moment  of  UEX,  619'r  of  patients  were 
agitated.  The  rates  of  mortality,  laryngeal  com- 
plications, nosocomial  pneumonia  after  extuba- 
tion. and  the  length  of  mechanical  ventilation 
were  similar  in  UEX  and  non-UEX  patients. 
Patients  were  more  often  reintubated  after  UEX 
(28  of  46)  than  after  planned  extubation  (28  of 
284).  All  the  non-reinlubated  UEX  patients  sur- 
vived. One  death  occurred  as  a  direct  conse- 
quence of  UEX.  By  use  of  multivariate  analy- 
sis, we  identified  4  factors  contributing  to  UEX: 
chronic  respiratory  failure,  endotracheal  tube 
fixation  with  only  thin  adhesive  tape,  orotra- 
cheal intubation,  and  the  lack  of  intravenous 
sedation.  Considering  the.se  factors,  we  hypoth- 
esized that  simple  measures  should  be  adopted 
to  minimize  the  incidence  of  UEX  and  its  re- 
lated complications:  more  vigilance  during  pro- 
cedures at  patients'  bedsides,  adequate  sedation 
of  agitated  patients,  strong  fixation  ot  the  tra- 
cheal tube,  particular  attention  paid  to  orally 
intubated  patients,  and  daily  reassessment  of 
the  possibility  of  weaning  from  the  ventilator. 

Acute  Lung  Injury  in  the  Medical  ICU:  Co- 
nioriiid  Conditions,  Age,  Etiology,  and  Hos- 
pital Outcome — Zilberberg  MD.  Epstein  SK 
Am  J  Respir  Crit  Care  Med  1998:157(4  Pi  1): 
1159. 

The  independent  effects  of  chronic  disease,  age, 
severity  of  illness,  lung  injury  score  (LIS)  and 
etiology,  and  preceding  nonpulmonary  organ- 
systein  dysfunction  (OSD)  on  the  outcome  of 
acute  lung  injury  (ALI)  have  not  been  exam- 
ined in  an  exclusively  medical-intensive-care- 
unit  (MICU)  population.  Therefore,  107  con- 
secutive MICU  patients  with  ALI  (76%  with 
acute  respiratory  distress  syndrome  |ARDS]) 
were  prospectively  investigated.  The  impact  of 
comorbidities,  age  >  65  y,  acute  physiology 
score  (APS),  LIS,  etiology  of  ALI,  and  OSD  on 
hospital  survival  were  studied.  The  overall  mor- 
tality was  62  of  107  patients  (58'i  ),  including 
47  (58%)  with  ARDS.  With  uin\ariate  analysis, 
age  >  65  y,  organ  transplantation,  human  im- 
munodeficiency virus  (HIV)  infection,  active 
malignancy,  chronic  steroid  u.se,  and  a  septic  or 
aspiration-related  etiology  of  ALI  were  associ- 
ated with  a  =•  1 .2-fold  greater  relative  risk  (RR) 
of  hospital  mortality.  With  multiple  logistic  re- 
gression, independent  predictors  of  hospital 
death  were  age  >  65  y,  organ  Iransplanlalion. 


HIV  infection,  cnrhosis.  acti\ e  malignancy,  and 
sepsis.  APS,  LIS.  aspiration-related  etiology  of 
ALI.  preceding  OSD.  and  other  comorbidities 
were  not  independently  predictive  of  hospital 
death.  Multivariate  analysis  of  the  ARDS  co- 
hort showed  similar  results,  although  cirrhosis 
and  malignancy  did  not  reach  statistical  signif- 
icance. We  conclude  that  comorbid  conditions, 
older  age,  and  sepsis  etiology  are  independent 
predictors  of  hospital  death  in  exclusively  MICU 
patients  with  ALI  (76%  of  whom  satisfied  cri- 
teria for  ARDS).  These  factors  should  be  con- 
sidered in  analyzing  studies  of  new  therapies 
and  interpreting  trends  in  mortality  for  ALI  and 
ARDS. 

No.si)comial  Pneumonia  in  Patients  with 
Acute  Respiratory   Distress  Syndrome — 

Chastre  J.  Trouillet  JL.  Vuagnat  A.  Joly-Guil- 
lou  ML.  Clavier  H,  Dombret  MC.  Giberl  C. 
Am  J  Respir  Crit  Care  Med  1998:157(4  Pt  1): 
1165. 

To  describe  the  epidemiologic  and  microbial 
aspects  of  ventilator-associated  pneumonia 
(VAP)  in  patients  with  acute  respiratory  dis- 
tress syndrome  (ARDS),  we  prospectively  eval- 
uated 24,^  consecutive  patients  who  required 
mechanical  ventilation  (MV)  for  >  48  h,  56  of 
whom  developed  ARDS  as  defined  by  a  Mur- 
ray lung  injury  score  >  2.5.  We  did  this  with 
bronchoscopic  techniques  when  VAP  was  clin- 
ically suspected,  before  any  modification  of  ex- 
isting antimicrobial  therapy.  For  all  patients, 
the  diagnosis  of  pneumonia  was  established  on 
the  basis  of  culture  results  of  protected-speci- 
nien  brush  (PSB)  (==  10(3)  cfu/mL)  and  bron- 
choalvelolar  lavage  fiuid  (BALF)  (>  10(4)  efu/ 
niL)  specimens,  and  direct  examination  of  cells 
recovered  by  bronchoalveolar  lavage  (BAL)  (a 
5%  of  infected  cells).  Thirty-one  (55%)  of  the 
56  patients  with  ARDS  developed  VAP  for  a 
total  of  41  episodes,  as  compared  with  only  53 
(28%)  of  the  187  patients  witliout  ARDS  for  a 
total  of  65  episodes  (p  =  0.0005).  Only  10%  of 
first  epi.sodes  of  VAP  in  patients  with  ARDS 
occurred  before  Day  7  of  MV,  as  compared 
with  40%  of  the  episodes  in  patients  without 
ARDS  (p  =  0.005).  All  but  2  patients  with 
ARDS  who  developed  VAP  had  received  anti- 
microbial treatment  (mostly  with  broad-spec- 
trimi  antibiotics)  before  the  onset  of  infection, 
as  compared  with  only  35  patients  without 
ARDS  (p  =  0.004).  The  organisms  mo.st  fre- 
quently isolated  from  patients  with  ARDS  and 
VAP  were  methicillin-resistant  Suiphvlocnccus 
aiiicii.\  (23'( ),  nonlcrmcnting  gram-negative  ba- 
cilli (21%).  and  Enterobacteriaceae  (21%). 
These  findings  confirm  that  microbiologically 
provable  VAP  occurs  far  more  often  in  patients 
with  ARDS  than  in  other  ventilated  patients. 
Because  these  patients  are  often  treated  with 
antibiotics  early  in  the  course  of  the  syndrome, 
the  onset  of  VAP  is  frequenlly  delayed  afier  the 
first  week  ol  MV.  and  is  then  caused  mainlv  bv 


794 


Rlsi'Iraiorv  Carl  •  October  "98  Vol  43  No  10 


STOP  THE 
CONFLICT... 

BETWEEN  PATIENT  AND  VENTILATOR 


Draser 


Let  your  patient  cough  or  breathe  unrestricted 
during  controlled  ventilation! 


Drager  has  incorporated  this  idea  in  the 
design  of  Evita  ventilators  since  1988  .  . 


.  .  .  with  eight  years  of  experience 
combining  spontaneous  breathing 
with  controlled  ventilation  in  APRV 
and  PCV+. 


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Station  —  the  evolution 
of  ventilator  manage- 
ment with  AutoFlow®  — 
unrestricted  spontane- 
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controlled  ventilation 
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volume  or  pressure 
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Abstracts 


methicillin-iesislanl  S.  aureus  aud  mhci  uuil- 
tiresistaiit  niicrooiganisms, 

Saf'clj  of  Inducing  Spuluiii  in  l':itii-nls  with 
Asthma  of  Narving  Severity— dc  la  Fucnte 
PT,  Roiiiajiiioli  M.  Godard  P.  BousLjuel  J. 
ChaiKv  P,  Am  J  Respir  Crit  Care  Med  \WH. 
157(4  Pi  ll:li:7. 

Indueing  sputum  using  hypertonic  saline  is  a 
noninvasive  method  to  investigate  airway  in- 
flammation in  people  with  asthma.  However, 
hypertonic  saline  may  also  induce  bronchocon- 
striction  in  some  patients.  The  aim  of  the  study 
was  to  examine  whether  the  overall  .safety  of 
using  hypertonic  saline  to  induce  sputum  in  pa- 
tients with  mild-to-moderate  asthma  could  be 
eviended  to  patients  with  severe  and/or  uncon- 
trolled asthma.  Nine  control  subjects  and  64 
asthmatic  patients  with  varying  severity  of  the 
disease  (FEV|  40- 1 26'7r  predicted  values!  were 
studied.  Twenty-one  of  those  patients  had  un- 
controlled asthma.  Sputum  was  induced  in  a 
standardized  manner  using  hypertonic  saline. 
The  safety  of  the  procedure  was  evaluated  hy 
assessing  the  clinical  response  and  measuring 
FEV,  just  before  and  duiing  sputum  induction. 
The  procedure  was  well  tolerated  in  most  pa- 
tients, but  it  had  to  be  stopped  due  to  side  ef- 
fects in  I  l.6'/l  of  patients  with  severe  asthma. 
None  of  the  side  reactions  were  severe.  Few 
patients  with  uncontrolled  (I7..^'7r)  or  severe 
asthma  (IX.67f)  had  a  drop  in  FEV,  of  10- 
lOVr.  The  fall  in  FEV,  was  significantly  greater 
in  patients  with  severe  asthma  than  those  with 
mild  disease  (p  <  0.02  Mann-Whitney  U  test). 
We  conclude  that  hypertonic  .saline-induced  spu- 
tum is  a  safe  technique  even  in  patients  with 
severe  asthma. 

20- Year  Trends  in  the  Prevalence  of  Asthma 
and    Chronic    Airtlow    Obstruction    in    an 

HMO— VolhiK-r  \\M.  Ushonic  ML,  Buisi  AS, 
Am  J  Respir  Cm  Care  Med  |y9S:l.i7l4  Pi  1 1: 
1079. 

Allhough  asihma  is  on  the  rise  in  the  LInitcd 
Slates  and  elsewhere,  data  on  age-scx-specilic 
patterns  of  change  in  various  types  of  health 
care  utilization  are  scarce.  We  report  on  20-y 
trends  in  the  treated  prevalence  of  asthma  among 
members  of  a  large  health  maintenance  organi- 
zation. Data  are  presented  separately  for  each 
ol  f)  age-sex  categories,  and  include  both  the 
treated  prevalence  of  asihma  as  well  as  ihe 
Irealed  piv\alcnce  of  ihe  broader  calcgory  of 
chronic  airllovi  obsirucllon  (C.AOi.  defined  as 
asihma.  chronic  bronchilis.  or  emphysema.  Dur- 
mg  the  period  1967-19X7  Ihe  Healed  preva- 
lence of  asthma  and  CAO  increased  signilicantly 
111  all  age-sex  categories  except  males  aged  6.5 
and  older.  These  palleins  are  in  conlrasi  lo  pre- 
vious .studies  of  Ihis  popiilalion  llial  showcil 
Ihal  increases  in  .isihiii.i  lio^piiali/.iiioiis  and 
hospital-based  episodes  ol  care  «  CIV  limiled  pi  I 


manly  to  souiig  boys,  Nol  only  do  these  find- 
ings support  other  e\  idence  of  a  real  increase  in 
asihma  prevalence,  but  they  also  highlight  the 
risks  ajisociated  with  drawing  inferences  about 
changing  disease  epidemiology  based  on  a  sin- 
gle type  of  health  care  utilization, 

.Static  Intrinsic  PKKF'  in  COPD  Patients  dur- 
in;;  Spontaneous  Kreathing — Purro  A,  Appen- 
dini  L.  Patessio  A,  Zanaboni  S.  Gudjonsdottir 
M.  Rossi  A.  Donner  CF.  Am  J  Respir  Crit  Care 
Med  1998; 1 57(4  Pt  I): 1 044. 

Intrinsic  positive  end-e\piralory  piessurc 
(PEEPi)  is  routinely  determined  under  static 
conditions  by  occluding  Ihe  airway  at  end-ex- 
piration (PEEPi. St  1.  This  procedure  may  be  dif- 
ficult in  patients  with  chronic  obstructive  pul- 
monary disease  (COPD)  during  spontaneous 
breathing,  as  both  expiratory  muscle  activity 
and  increased  respiratory  frequency  often  oc- 
cur. To  o\  ercome  lhe.se  problems,  we  tested  the 
hypothesis  Ihal  Ihe  difference  between  maxi- 
mum airway  opening  (MIP)  and  maximum 
esophageal  (Ppl  max)  pressures,  oblained  with 
a  Mueller  maneuver  from  the  end-expiratory 
lung  volume  (EELV),  can  accurately  measure 
PEEPi, St.  U.sing  this  method,  we  found  that,  in 
S  ventilator-dependent  tracheostomized  COPD 
patients  (age  71  ±  7  y).  PEEPi.st  averaged 
1.^.0  ±  2.9  cm  H,0.  That  measurement  was 
validated  by  comparison  with  a  reference  sialic 
PEEPi  (PEEPi. sl-Ref)  taken  at  the  same  EELV 
adopted  by  patients  during  spontaneous  breath- 
ing, and  measured  on  the  passive  quasi-static 
pressure-volume  (P/V|  curve  of  ihe  respiratory 
system,  obtained  during  mechanical  ventilation. 
PEEPi,st-Ref  averaged  Ll.l  ±  3.0  cm  H,0.  ie. 
a  value  essentially  equal  to  PEEPi.st  measured 
by  means  of  our  technique.  We  conclude  that 
PEEPi.st  can  be  accurately  assessed  in  sponta- 
neous breathing  COPD  patients  by  the  differ- 
ence between  MIP  and  Ppl  max  during  the  Muel- 
ler nianeuxer. 

Improved  Kxercise  Performance  I'ollowing 
I. ling  \oIunie  Reduction  Surgery  for  Km- 

physema— Ferguson  G'f .  Fernandez  I:.  Zamora 
MR.  Ponieranlz  M.  Buchholz  J.  Make  B.l.  Am 
.1  Respir  Crit  Care  Med  I99H;I57(4  P(  I  ):l  195. 

Lung  \olunie  rcduclion  surgery  (LVRS)  forem- 
physema  has  been  suggested  lo  improve  palieni 
lung  function  and  activity.  The  short-term  ini- 
pacl  of  LVRS  on  exercise  performance  w  as  e\  al- 
ualed  using  maximal  and  submaximal  sleady- 
siale  exerci.se  lesling  in  27  palieiiis  u  iili  se\cic 
hypoxemic  chronic  olisnucluc  piiJiiinn.iiA  dis 
ease  (COPD).  along  \Mih  nicsuicnicnls  ol  pa- 
tient function,  dyspnea,  ami  qu,ilii\  ol  iilc, 
LVRS  significanlly  improicd  exeivise  pciioi 
mance.  due  lo  \eiililalorv  iiH|iio\ciiiciiis  asso 
cialcil  uuh  iikTcasal  \cnldaliii\  ivscnc.  en- 
hanced Iklal  \uliinic  icciiiilmcnl.  .iiul  mipio\eil 
alu'olar\enlilalioii,  Pieopeiali\e  ineasiMvnieiUs 


ol  \enlilalory  reserve  and  dead  space  \eiilila- 
lion  during  exercise  lesling  were  closely  asso- 
cialed  wilh  improved  exercise  performance.  Im- 
provements in  patient  dyspnea,  walk  di.stances. 
and  quality  oflife  also  occurred  following  LVRS 
and  were  associated  with  improvements  in  ex- 
ercise performance.  Surgical  mortality  from 
LVRS  was  low  (49f ).  but  short-term  all-cause 
mortality  was  increased  ( 19% ).  Short-term  mor- 
tality was  associated  with  reduced  expiratory 
muscle  strength  and  markedly  elevated  dead 
space  ventilation.  We  conclude  that  LVRS  pro- 
duces significant  improvements  in  exerci.se  per- 
formance, dyspnea,  and  quality  of  life  in  se- 
lected patients  with  COPD.  Physiologic 
prediction  of  patients  most  likely  to  survive  for 
an  extended  period  and  have  significant  benefit 
following  LVRS  may  also  be  possible. 

Computer-Based  Models  To  Identify  High- 
Risk   Children  with  Asthma— Lieu  TA. 

Ouesenbeny  CP.  Sorel  ME.  Mendoza  GR.  Le- 
ung AB.  Am  J  Respir  Crit  Care  Med  1998; 
157(4  Pt  I):II7.V 

Etfeclive  management  of  populations  with 
asihma  requires  methods  for  identifying  patients 
at  high  risk  for  adverse  outcomes.  The  aim  of 
this  study  was  lo  develop  and  validate  predic- 
tion models  that  used  computerized  utilization 
data  from  a  large  health  maintenance  organiza- 
tion (HMO)  to  predict  asthma-related  hospital- 
ization and  emergency  department  (ED)  visits. 
In  this  retrospective  cohort  design  with  split- 
sample  validation,  variables  from  the  baseline 
year  were  used  to  predict  asthma-related  ad- 
verse outcomes  during  the  follow-up  year  for 
16.520  children  with  asthma-related  ulilization. 
In  proportional-hazard  models.  ha\  ing  filled  an 
oral  steroid  prescriplion  (relalive  risk  [RR]:  1 .9; 
95^;  confidence  interval  |CI|;  \.?,  lo  2.8)  or 
having  been  hospitalized  (RR:  1.7;  95';  CI;  1,1 
lo  2,7|  during  Ihe  prior  6  nio.  and  nol  having  a 
personal  phvsician  lisicd  on  ihc  computer  (RR: 
1,6;  95',  CI:  1,1  lo  2..1)  were  associaled  wilh 
increased  risk  o(  lulure  hospitalization.  Classi- 
lic;ilion  lives  idenlilied  previous  hospitalization 
and  Fl)  visiis.  (i  or  more  j8-agonist  inhalers 
(uiiKsi  during  (he  prior  6  mo.  and  3  or  more 
physicians  prescribing  asthma  medications  dur- 
ing Ihe  prior  6  mo  as  predictors.  The  classifi- 
calion  trees  performed  similarlv  lo  propoilion- 
al-hazards  models,  and  identified  palienls  who 
had  a  threefold  grealer  risk  of  hosphalizalion 
:ind  ;i  Ivvolold  givaler  risk  ol  F;D  visits  ihaii  Ihe 
avei.ige  p:ilieiu.  We  conclude  Ihal  conipiiiei- 
liased  pivdiclion  models  can  idenlifv  children 
;ii  high  risk  for  adverse  asihma  oulcomes,  and 
niav  be  useful  in  popiilalion-based  efforts  to 
improve  :isihma  manageinenl. 

Inflects  of  Mean  .Mrviaj  Pressure  on  Lung 
\  oliime  during  lligh-l'requency  Oseillaloi) 
\enlilalion  of  Preleriii   Inl'anis— 1  home   LI. 


7% 


Ri  SI-IRA  loKY  Carl  •  Ociuuek  "98  Vol  43  No  10 


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vt^here  you  need  it, 

•flespiratory  Care  Pocket  Protocol  Card  &  User's  Manual 

Terry  DesJardins,  MEd,  RRT 

Neonatal/Pediatric  Respiratory  Care  Pocket  Card 
&  User's  Protocol  Manual 

Terry  DesJardins  &  Patricia  Beck  Koff.  MEd,  RRT 


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Tciplcr  A.  Schallcr  P.  Piililandl  F.  Am  J  Rcspir 
Cm  Care  Med  |y9S;l57(4  Pi  I  ):I2I3. 

Measurement  of  mean  lung  volume  (MLV)  in 
high-frequency  oscillatory  ventilation  (HFO) 
may  be  useful  for  optimizing  the  high  lung  vol- 
ume strategy,  but  has  not  been  available  until 
now.  We  have  measured  MLV  by  means  of  the 
sulfur  hexafluoride  (SF,,)  washout  method  in  13 
premature  infants  ventilated  with  HFO  because 
of  respiratory  distress  syndrome  (gestational 
age.  23  to  31  wk  |median,  25  +  6/7  wk]:  birth- 
weight.  630  to  1,140  g  |790  gj;  age  at  measure- 
ment. 2  to  10  d  [4  d];  weight.  675  to  1.250  g 
|S150  g|l.  To  evaluate  the  I'elationship  between 
MLV  and  mean  airway  pressure  (MAP),  (he 
kilter  was  systematically  varied  between  the 
measurements.  With  clinically  selected  MAP. 
MLV  was  between  23.3  and  41.9  mL/kg  (me- 
dian. 33.5  mL/kg)  and  was  strongly  dependent 
on  MAP  in  each  patient;  linear  regression  anal- 
yses resulted  in  slope  factors  between  1.0  and 
6.9  mL/cm  H,0/kg  (median,  2.83  mL/cm  H,0/ 
kg),  with  correlation  coefficients  between  0.77 
and  0.99  (median.  0.94).  Stabilization  of  MLV 
aller  modification  of  MAP  took  2  to  25  min 
I  median.  9  min).  We  conclude  that  the  selection 
of  MAP  on  a  clinical  basis  leads  to  a  wide 
range  of  different  ML  Vs.  Despite  the  strong 
dependence  of  MLV  on  MAP.  the  prediction  of 
MLV  solely  based  on  MAP  was  impossible  be- 
cause of  large  patient  Ui  patient  variability  of 


linear  rcgrcssuins.  Ah  eolar 
recruitment  may  take  up  to 


cruilmcnl  and  de- 
5  min  after  MAP 


changes. 


Tuberculosis  and  Race/Ethnicit>  in  the 
United  States:  Impact  of  Socioeconomic  Sta- 
tus—Cantwell  MF.  McKenna  Ml.  McCray  E. 
Onorato  IM.  Am  J  Rcspir  Crit  Care  Med  I99K; 
1.^7(4  Pi  I  1:1016. 

Despite  the  long-standing  observation  that  tu- 
berculosis (TB)  case  rates  are  higher  among 
racial  and  ethnic  minorities  than  whiles  in  the 
United  States  (US),  the  proportion  of  this  in- 
creased ri.sk  attributable  to  socioeconomic  sta- 
tus (SES)  has  not  been  determined.  Values  for 
six  SES  indicators  (crowding,  income,  poverty, 
public  assistance,  unemployment,  and  educa- 
tion) were  assigned  to  US.  TB  cases  reported 
from  1987-1993  by  ZIP  code-  and  demograph- 
ic-specific matching  U)  1990  US  Census  data, 
TB  risk  between  racial/ethnic  groups  was  then 
evaluated  by  quartile  for  each  SES  indicator 
utilizing  univariate  and  Poisson  multivariate 
analyses.  Relative  risk  (RR)  of  TB  increased 
with  lower  SES  quartile  for  all  6  SES  indicators 
on  univariate  analysis  (RRs  2.6-5.6  in  the  low- 
est versus  highest  quartiles).  The  same  trend 
was  observed  in  multivariate  models  containing 
individual  SES  indicators  (RRs  1.8-2.5)  and 
for  3  SES  indicators  (crowding,  poverty,  and 
education)  in  the  model  cdiitainiiis;  all  (i  indi- 


calois.  Tuberculosis  risk  increa.sed  uniformly 
between  SES  quartile  for  each  indicator  except 
crowding,  where  risk  was  concentrated  in  the 
lowest  quartile.  Adjusting  for  SES  accounted 
for  approximately  half  of  the  increased  risk  of 
TB  associated  with  race/ethnicity  among  US- 
born  blacks.  Hispanics.  and  Native  Americans. 
Even  more  of  this  increa.sed  risk  was  accounted 
for  in  the  final  model,  which  also  adjusted  for 
inlcraction  between  crowding  and  race/ethnic- 
ity. SES  impacts  TB  incidence  via  both  a  strong 
direct  effect  of  crowding,  manifested  predomi- 
nanlly  in  overcrowded  settings,  and  a  TB-SES 
health  gradient,  manifested  at  all  SES  levels. 
SES  accounts  for  much  of  the  increased  risk  of 
TB  previously  associated  with  race/elhnicity. 


Why  Do  Symptomatic  Patients  Delay  Ob- 
taining Care  for  Tuberculosis? — Asch  S. 
Leake  B,  Anderson  R.  Gelberg  L.  .Am  J  Respir 
Ci-it  Care  Med  1 998;  157(4  Pt  1  ):1244, 

The  resurgence  of  tuberculosis  (TB)  has  coin- 
cided with  deteriorating  access  to  care  for  high- 
risk  populations.  We  sought  to  determine  what 
perceived  access  barriers  delayed  symptomatic 
TB  patients  from  obtaining  care.  In  order  to  do 
this,  we  conducted  a  survey  in  Los  Angeles 
County.  California,  using  a  consecutive  sample 
of  patients  with  active  TB  as  confirmed  by  the 
county  TB  control  authority.  The  measures  used 
in  the  study  were  a  self-reported  delay  in  .seek- 


Respiratory  Care  •  October  "98  Vol  43  No  10 


797 


Abstracts 


ins;  irarc  of  more  than  (id  d  licim  s\mplom  on- 
set, a  period  suft'icient  to  cause  skin-lesi  eon- 
version  in  exposed  contacts,  and  self-reported 
access  barriers.  The  county  TB  registry  pro- 
vided supplementary  clinical  data.  We  found 
that  1/5  of  the  248  syniptomalic  respondents 
(respon.sc  rate:  609c)  delayed  obtaining  care 
for  >  60  d  (mean  =  74  d.  SD  =  216  d).  During 
the  delay,  patients  exposed  an  average  of  8  con- 
tacts. As  compared  with  the  rest  of  the  .sample, 
delay  was  more  common  in  those  who  were 
unemployed  (25%  vs  14%),  concerned  about 
cost  (27%  vs  14%),  anticipated  prolonged  wait- 
ing-room time  (26%  vs  14%).  believed  they 
could  treat  themselves  (.^1%  vs  14%).  antici- 
pated difficulty  in  getting  an  appointment  (2S% 
vs  16%).  were  uncertain  about  where  to  get 
care  (3.^%  vs  16%).  and  feared  immigration 
authorities  (47%  vs  18%)  (p  <  0.05).  Logistic 
regression  revealed  that  uncertainty  about  where 
to  get  care,  unemployment,  and  belief  in  the 
efficacy  of  self-treatment  independently  pre- 
dicted delay  >  60  d.  Illness  severity  as  mea- 
sured by  chest  radiography,  sputum  smears,  and 
.symptoms  had  little  impact  on  delay.  We  con- 
clude that  because  access  variables  such  as  lack 
of  employment  and  knowledge  about  where  to 
obtain  care  were  more  closely  associated  with 
clinically  significant  delay  than  was  severity  of 
illness,  these  results  raise  concerns  about  the 
equity  of  access  to  care  among  TB  patients.  The 
results  suggest  that  improving  the  availability 
of  services  for  high-risk  groups  may  substan- 
tially reduce  TB  patients'  delay  in  obtaining 
care,  and  thus  may  limit  the  spread  of  the  dis- 
ease. 

Measuring  Injury  Severity:  Time  for  a 
Change.' — Brennenian  FD.  Boulanger  BR. 
McLellan  BA.  Redelmeicr  DA.  J  Trauma  199S; 
44(4):5S0. 

BACKGROUND:  The  Injury  Severity  Score 
(ISS)  does  not  take  into  account  multiple  inju- 
ries in  the  same  body  region,  whereas  a  New 
ISS  (NISS)  may  provide  a  more  accurate  mea- 
sure of  trauma  severity  by  considering  the  pa- 
tient's 3  greatest  injuries  regardless  of  body  re- 
gion. The  purpose  of  this  study  was  to  evaluate 
the  ISS  and  NISS  in  patients  with  blunt  trauma. 
METHODS:  Consecutive  individuals  treated 
from  January  of  1992  to  September  of  1996  at 
one  institution  were  included  if  they  had  .sus- 
tained blunt  trauma  and  satisfied  triage  stan- 
dards (n  =  2..'!28).  For  each  patient,  we  com- 
puted the  ISS  and  the  NISS  to  determine  how 
often  the  2  scores  were  identical  or  discrepant. 
Discrepant  cases  were  then  further  analyzed  us- 
ing receiver  operating  characteristic  curves  to 
determine  which  score  belter  predicted  short- 
term  mortality.  RESULTS:  The  mean  ISS  was 
25  ±  1.1.  and  the  mean  NISS  was  ?,?,  ±  18.  The 
2  predictive  scores  were  identical  in  }2''/<  of 
patients  and  discrepant  in  68%  of  patients,  Pa- 
lierils  Willi  iilcnlical  scores  had  .i  loucr  morlal 


it_\  rate  than  patients  u  ilh  discrepant  scores  1 10% 
vs.  \y/c:  p  <  0.02).  In  patients  with  discrepant 
scores,  the  area  under  the  receiver  operating 
characteristic  curves  was  greater  for  the  NISS 
than  the  ISS  (0.852  vs  0.799;  p  <  0.001).  and 
greater  amounts  of  discrepancy  were  associated 
with  increasing  rates  of  mortality  (p  <  0.001 ). 
CONCLUSIONS:  The  NISS  often  increases  the 
apparent  severity  of  injury  and  provides  a  more 
accurate  prediction  of  short-term  mortality.  The 
benefit  associated  with  using  the  NISS  rather 
than  the  ISS  must  be  weighed  against  the  dis- 
advantages of  changing  a  scoring  system  and 
the  potential  for  still  greater  improvements. 

A  Comparison  of  Noninvasive  Positive-Pres- 
sure Ventilation  and  Conventional  Mechan- 
ical Ventilation  in  Patients  with  Acute  Re- 
spiratory Failure — Antonelli  M.  Conti  G. 
Rocco  M.  Bufi  M.  De  Blasi  RA.  Vi\ino  G.  et 
al.  N  Engl  J  Med  1998;3.W(7):429. 

BACKGROUND  &  METHODS:  The  role  of 
noninvasive  positive-pressure  ventilation  deliv- 
ered through  a  face  mask  in  patients  with  acute 
respiratory  failure  is  uncertain.  We  conducted  a 
piospeclive.  randomized  trial  of  noninvasive 
positive-pressure  ventilation  as  compared  with 
endotracheal  intubation  with  conventional  me- 
chanical ventilation  in  64  patients  with  hypox- 
eiTiic  acute  respiratory  failure  who  required  me- 
chanical ventilation.  RESULTS:  Within  the  first 
hour  of  ventilation.  20  of  .12  patients  (62  per- 
cent) in  the  noninvasive-ventilation  group  and 

15  of  i2  (47  percent)  in  the  conventional-ven- 
tilation group  had  an  improved  ratio  of  the  par- 
tial pressure  of  arterial  oxygen  to  the  fraction  of 
inspired  oxygen  (Pa02:Fi02)  (P=0.2 1 ).  Ten  pa- 
tients in  the  noninvasive-ventilation  group  sub- 
sequently required  endotracheal  intubation.  Sev- 
enteen patients  in  the  conventional-ventilation 
group  (5.1  percent)  and  23  in  the  noninvasive- 
ventilation  group  ( 72  percent )  survived  their  stay 
in  the  intensive  care  unit  (odds  ratio.  0.4;  95 
percent  confidence  interval.  0.1  to  1.4;P=0.19); 

1 6  patients  in  the  conventional-ventilation  group 
and  22  patients  in  the  noninvasive-ventilation 
group  were  discharged  from  the  hospital.  More 
patients  in  the  conventional-ventilation  group 
had  serious  complications  (66  percent  vs  38 
percent.  P=0.02)  and  had  pneumonia  or  sinus- 
itis related  to  the  endotracheal  tube  (31  percent 
vs  3  percent.  P=0.003).  Among  the  survivors, 
patients  in  the  noninvasive-ventilation  group  had 
shorter  periods  of  ventilation  (P=0.006)  and 
shorter  stays  in  the  intensive  care  unit 
(P=0.(H)2).  CONCLUSIONS:  In  patients  with 
acute  respiratory  failure,  noninvasive  ventila- 
tion was  as  effective  as  conventional  ventila- 
tion in  improving  gas  exchange  and  was  asso- 
ciated with  fewer  serious  complications  and 
shorter  stays  in  the  intensive  care  unit. 

A  Drug  Interaction  lietween  /.allrluliast  and 

■|heoph>lline     K.ilial  RK.  Slcl/le  KC.  Bonner 


MW.  Marino  M.  Cantilena  LR.  Smith  LJ.  Arch 
Intern  Med  1998;15S(  I5):17I3. 

The  apparent  low  adverse  effect  profile  of  the 
new  drug  zafirlukast  has  made  it  an  attractive 
choice  in  the  treatment  of  asthma.  We  present 
the  first  case  (to  our  knowledge)  of  a  poten- 
tially serious  drug-drug  interaction  between 
zafirlukast  and  theophylline.  A  15-year-old 
white  girl  with  asthma  had  been  taking  theoph- 
ylline (Slo-bid.  Rhone-Poulenc  Rorer  Pharma- 
ceuticals Inc.  Collegeville,  Pa)  (300  mg  twice 
daily),  with  drug  levels  of  approximately  61 
micromol/L  ( 1 1 .0  microg/niL)  for  several  years. 
Recently,  her  serum  theophylline  levels  had  in- 
crea.sed  to  the  toxic  range  (133.2  micromol/L 
[24  microg/mL])  shortly  after  the  addition  of 
zafiriukast  (Accolate.  Zeneca  Pharmaceuticals. 
Wilmington.  Del)  to  her  regimen.  Attempts  were 
made  to  stop  and  then  restart  the  theophylline 
therapy  at  progressively  lower  doses:  however, 
with  each  attempt,  the  patient's  reaction  to  the 
drug  became  more  toxic,  with  serum  theophyl- 
line levels  ranging  between  99,9  and  149.9  mi- 
cromol/L ( 1 8  and  27  microg/mL).  So  this  po- 
tential drug-drug  interaction  could  be 
investigated,  the  patient  stopped  taking  both 
drugs  for  1  week.  Then,  she  again  started  taking 
theophylline  (75  mg  twice  daily),  and  over  2 
days  reached  a  steady  state  serum  theophylline 
level  of  12.8  to  14.4  micromol/L  (2.3-2.6  mi- 
crog/mL). On  the  third  day.  zafirlukast  (20  mg 
twice  daily)  was  reintroduced  to  the  regimen. 
and  the  theophylline  therapy  was  continued.  By 
the  fifth  day,  a  dramatic  7-fold  increase  was 
seen  in  the  .serum  theophylline  level  (101,6  mi- 
cromol/L [18.3  microg/mL|).  The  areas  under 
the  curve  for  theophylline  alone  and  theophyl- 
line with  zafirlukast  were  29.3  and  197  (mg  x 
h)/L.  respectively.  One  explanation  for  the  noted 
increase  in  the  theophylline  level  is  that  metab- 
olism occurs  mainly  by  cytochrome  P450  (CYP 
1A2).  an  enzyme  that  is  known  to  be  inhibited 
with  high  concentrations  of  zafirlukast.  Al- 
though the  curtent  metabolism  of  the  2  drugs  in 
combination  is  pooriy  understood,  the  potential 
for  serious  interactions  seems  to  exist  in  the 
rapidly  growing  population  of  persons  with 
asthma,  for  whom  they  may  be  prescribed.  The 
noted  increase  in  the  theophylline  level  after 
zafirlukast  administration  is  in  contrast  to  the 
original  reports  by  the  manufacturer.  Therefore, 
we  recommend  that  physicians  evaluate  serum 
theophylline  levels  closely  when  prescribing  the 
2  drugs  in  combination. 

Cerebral  Blood  Flow  Is  Independent  of  Mean 
Arterial  Blood  Pressure  in  Preterm  Infants 
Undergoing  Intensive  Care  -  r\szc/iik  L. 
Meek  .1.  Elwell  C.  Wyall  .IS  IVdi.iincs  199S: 
Ill2l2  I'l  I  1:337. 

OBJi:Cri\'i;:  Piclenn  inlanls  .ire  often  pie- 
sunicd  lo  lia\e  a  picssuic  passu e  cciehial  cu- 
culalion  iiiiplx  iiig  Ih.il  a  Un\  inc.iii  .iilcnal  hlood 


798 


RlSI'IR.MOK^'  C\\RI    •  OCIOBI.R  "^)S  Voi    4.^  No   10 


Abstracts 


pressure  (MABP)  results  in  reduced  cerebral 
perfusion.  The  aim  of  this  study  was  to  deter- 
mine whether  cerebral  blood  (low  (CBF)  was 
compromised  in  preterm  infants  whose  MABP 
tell  below  30  mm  Hg  (4  kPa).  METHODS: 
Thirty  preterm  infants  undergoing  intensive  care 
were  studied  within  the  first  24  hours  of  life. 
CBF  was  measured  using  near  infrared  spec- 
troscopy. The  infants  were  analyzed  in  two 
groups  on  the  basis  of  their  MABP  at  the  time 
of  study:  group  I  had  a  MABP  below  30  mm 
Hg  and  group  2  more  than  30  mm  Hg.  CBF  in 
the  two  groups  was  compared.  RESULTS:  There 
was  no  significant  difference  in  the  mean  CBF 
between  the  two  groups.  In  group  I  the  median 
MABP  was  27.2  mm  Hg  (range.  23.7-29.9  mm 
Hg)  and  CBF  was  13.9  (standard  deviation. 
±6.9)  mL  .  100  g- 1  .  min-1.  In  group  2  the 
median  MABP  was  35.3  mm  Hg  (range.  30.1- 
39.3  mm  Hg)  and  CBF  was  12.3  (standard  de- 
viation, ±6.4)  mL  .  100  g-I  .  min-I.  Mortality 
and  incidence  of  cranial  ultrasound  scan  abnor- 
malities were  also  not  significantly  different. 
CONCLUSION:  These  results  indicate  that  pre- 
term infants  undergoing  intensive  care  are  able 
to  maintain  adequate  cerebral  perfusion  at  a 
MABP  in  the  range  of  23.7  to  39.3  mm  Hg. 


Impact  of  Chronic  Cough  on  Quality  of  Life — 

French  CL.  Irwin  RS.  Curley  FJ.  Krikorian  CJ. 
Arch  Intern  Med  I99S;I.';8(  I5):I6?7. 


BACKGROUND:  Cough  is  the  most  common 
complaint  for  w  hich  adult  patients  seek  medical 
care  in  the  United  States;  however,  the  rca- 
son(s)  for  this  is  unknown.  OBJECTIVES:  To 
determine  whether  chronic  cough  was  associ- 
ated with  adverse  psychosocial  or  physical  ef- 
fects on  the  i|uality  of  life  and  whether  the  elim- 
ination of  chronic  cough  with  specific  therapy 
impro\ed  these  adverse  effects.  METHODS: 
The  study  design  was  a  prospective  before-and- 
after  intervention  trial  with  patients  serving  as 
their  own  controls.  Study  subjects  were  a  con- 
venience sample  of  39  consecutive  and  uns- 
elecled  adult  patients  referred  for  evaluation  and 
management  of  a  chronic,  persistently  trouble- 
some cough.  Baseline  data  were  available  for 
39  patients  and  follow-up  for  28  patients  (22 
women  and  6  inen).  At  baseline,  demographic. 
Adverse  Cough  Outcome  Survey  (ACOS),  and 
Sickness  Impact  Profile  (SIP)  data  were  col- 
lected and  patients  were  managed  according  to 
a  validated,  systematic  protocol.  Following  spe- 
cific therapy  for  cough.  ACOS  and  SIP  instru- 
ments were  readministered.  RESULTS:  The 
ages.  sex.  duration,  and  spectra  and  frequencies 
of  the  causes  of  cough  were  similar  to  inultiple 
other  studies.  At  baseline,  patients  reported  a 
mean  ±  SD  of  8.6  ±  4.8  types  of  adverse  oc- 
currences related  to  cough.  There  were  signif- 
icant correlations  between  multiple  ACOS  items 
and  total,  physical,  and  psychosocial  SIP  scores. 
Psychosocial  score  correlated  with  total  num- 


ber ol  symploms  (P<.02).  AKer  cough  disap- 
peared with  treatment,  ACOS  complaints  de- 
creased to  a  mean  ±  SDof  1.9  ±  3.2(P<.0()OI) 
as  did  total  (mean  ±  SD.  4.8  ±  4.5  to  1.8  ± 
2.2)  (P=  .004).  psycho.social  (mean  ±  SD. 
4.2  ±  6.8  to  0.8  ±  2.3)  (P  =  .004).  and  phys- 
ical (mean  ±  SD.  2.2  ±  2.9  to  0.9  ±  1.8)  (P  = 
.05)  SIP  .scores.  Multiple  linear  regression  anal- 
ysis showed  that  .54%  of  variability  of  the  psy- 
chosocial SIP  .score  was  explained  by  4  ACOS 
items  while  none  of  the  physical  score  was  ex- 
plained. CONCLUSIONS:  Chronic  cough  was 
associated  with  deterioration  in  patients'  qual- 
ity of  life.  The  health-related  dysfunction  was 
most  likely  psychosocial.  The  ACOS  and  SIP 
appear  to  be  valid  tools  in  assessing  the  impact 
of  chronic  cough. 


Montelukast.  a  Potent  Leukotricne  Receptor 
.Antagonist,  Causes  Dose-RcIated  Improve- 
ments in  Clironic  Astlima — Montelukast 
Asthma  Study  Group:  Noonan  MJ.  Chervinsky 
P.  Brandon  M.  Zhang  J.  Kundu  S.  McBurney  J, 
Reiss  TF.  Eur  Respir  J  1998:1  1(6):1232. 

The  leukotrienes  are  known  to  be  important  me- 
diators of  bronchial  asthma.  The  ability  of  mon- 
telukast, a  potent  and  selective  CysLTl  leuko- 
tricne receptor  antagonist,  to  cause  a  dose- 
related  improvement  in  chronic  asthma  was 
investigated  in  a  placebo-controlled,  multicen- 
tre, parallel-group  study .  After  a  two  week  pla- 


Important  New  Handbook  For  COPD  Patients 

"Courage  and  Information  for  Life 

with  Chronic  Obstructive 

Pulmonary  Disease" 

An  authoritative  explanation  of  causes,  treatments,  and 
rehabilitation  methods  that  teaches  patients  to 
understand  the  importance  of  advice  and  guidance  from 
their  health  care  team. 

Authors  Rick  Carter,  Ph.D.  (rehabilitation 
physiology),  Brooke  Nicotra,  M.D.  (pulmonary 
medicine),  and  Jo-Von  Tucker  (COPD  patient)  explain 
how  patients  can  help  manage  their  COPD. 
Contributions  by  Thomas  Petty,  M.D.  and  Brien  Tiep, 
M.D.  reinforce  the  message  that  patients  can 
dramatically  improve  their  lives  through  a 
comprehensive  rehabilitation  program.  Jo-Von  Tucker 
provides  an  example  of  what  a  patient's  courage  and 
determination  can  achieve  and  thus  encourages  COPD 
patients  to  be  actively  involved  and  compliant. 

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Abstracts 


cehci  nui-iii  pciiiKl.  Lhinnic  aslhiiialii;  pallciils 
Willi  a  forced  expiraloi)  volume  in  one  second 
(FEVI)  4()-S()V,  predicled  witli  >  or  =  15';( 
increase  (absolute  \aliic)  aller  liela2-agonisl 
were  randomly  assigned  lo  one  ol  lour  Ircal- 
ment  groups  (placebo  or  nionlclukasl  2,  10.  or 
50  mg  once  daily  in  the  evening)  lor  a  three 
week,  double-blind  treatment  period.  For  pa- 
tient-reported end-points  (daytime  symptom 
score,  use  of  as  needed  inhaled  beta2  agonist, 
asthma-specific  quality  of  life)  and  frequency 
of  asthma  exacerbations,  montelukasi  10  and 
50  mg  caused  similar  respon.ses.  superior  to  2 
mg  and  significantly  (p<0.()5;  linear  trend  test) 
different  from  placebo.  All  three  doses  caused 
improvements  in  FEVI  and  morning  and 
evening  peak  expiratory  How  rate  (PEER)  that 
were  significantly  (p<0.05)  different  from  pla- 
cebo. Differences  (least  square  mean)  between 
the  pooled  10  and  50  mg  montelukast  treatment 
groups  and  placebo  were;  7.1%  change  from 
baseline  in  FEVI,  19.23  L  x  min(-l)  in  morn- 
ing PEER.  -0.29  in  daytime  asthma  symptom 
score  (absolute  value),  and  -0.82  in  bela2-ago- 
nist  use  (puff  x  day(-l )).  The  incidence  of  ad- 
verse experiences  was  neither  dose-related  nor 
different  between  montelukast  and  placebo  treat- 
ments. We  conclude  thai  montelukast  causes  a 
dosc-rekiled  improvement  in  patient-reported 
asthma  end-points  over  the  range  2-50  mg.  Mon- 
telukast causes  benefit  to  chronic  asthmatic  pa- 
tients by  improving  a.sthma  control  end-points. 

Effect  of  Lo«-I)()SC  Beclomuthasiinc  Dlpio- 
pionate  on  Asthma  Ccintrol  and  Airway  In- 
flammation— Fah)  JV.  Boushev  HA.  Eur  Re- 
spir  J  i99S;ll(6):124(). 

The  effects  of  usual  or  Un\  doses  of  inhaled 
corticosteroids  on  airway  mucosal  infiamma- 
tion  have  not  yet  been  examined.  We  therefore, 
compared  the  effects  of  inhaled  beclometha- 
sone  dipropionatc  (BDP)  336  microg  x  day(-l ) 
on  asthina  control  outcomes  and  markers  of  air- 
way intlammation.  Twenty-four  adult  subjects 
with  mild  and  moderate  asthma  were  random- 
ized to  receive  either  BDP  or  placebo  for  four 
weeks;  then  subjects  entered  a  single  blind  four 
week  placebo  run-in  period.  We  found  thai  the 
BDP  group  had  significantly  greater  improve- 
ments in  forced  expiratory  volume  in  one  sec- 
ond (FEVI).  morning  peak  fiow.  and  rescue 
salbutamoi  use  than  the  placebo-treated  group. 
The  improvement  in  FEV I  largely  reversed  one 
week  after  treatment  was  stopped.  The  decrease 
in  the  median  percentage  of  eosinophils  in  in- 
duced sputum  in  the  BDP  group  from  3.X'/f  to 
3.4%  was  not  significant,  but  because  eosino- 
phils increased  from  8.4%  lo  12.7%  in  the  pla- 
cebo group,  there  was  a  significant  difference 
between  treatment  groups  (p=0.03).  There  was 
no  significant  difference  between  groups  dur- 
ing Ireatmeni  in  the  levels  of  eosinophil  cat- 
ionic  protein  (l-.C'P).  tryptase  mucin-likc  glyco- 
proicin.  or  fibrinogen  in  induced  sputum.   The 


change  in  FEV  I  in  the  BDP  group  did  nol  cor- 
relate significantly  with  the  change  in  eosino- 
phil percentage  or  ECP  levels.  We  concluded 
that  four  weeks  of  trealmeni  with  inhaled  be- 
clometha.sone dipropionatc  336  microg  x  day(- 1 ) 
was  associated  with  significant  improvements 
in  peak  fiow.  forced  expiratory  volume  in  one 
second,  and  rescue  salbutamoi  use  in  asthmatic 
subjects  but  was  not  associated  with  large  re- 
ductions in  markers  of  eosinophilic  infiamma- 
tion.  bionchovascular  permeability,  or  mucus 
hypersecretion. 

Acid  Fo);  and  Hospital  Visits  for  Asthma:  an 
Kpidemiolo^ical  Study — Tanaka  H.  Honma  S. 
Nishi  M.  Igaiashi  T.  Teramoto  S.  Nishio  F.  Abe 
S.  Eur  Respir  J  IWS;I  l(6):l_^()l. 

The  aim  of  this  study  was  to  elucidate  the  ad- 
verse respiratory  effects  of  naturally  occurring 
acid  fog.  In  total.  102  adult  asthmatic  patients 
(44  nonatopic  and  58  atopic)  were  studied  for  a 
2  yr  period  (January  1992  to  December  1993) 
in  Kushiro,  a  city  with  only  a  small  industrial 
area,  located  in  the  northern-most  island  in  Ja- 
pan. Fog  occurred  on  378  out  of  731  days,  and 
the  acidity  of  the  fog  ranged  from  pH  3.32  to 
6.91  (mean  pH  4.95).  The  association  between 
hospital  visits  for  asthma  and  meteorological 
factors  or  air  pollutants  was  investigated.  In 
nonatopic  patients,  fog,  high  ozone  and  water 
vapour  pressure,  low  day-to-day  temperature 
differences,  low  concentrations  of  atmospheric 
NO  and  N02  contributed  significantly  (p<0.05) 
to  increasing  ho.spital  visits.  In  atopic  subjects, 
fog.  high  water  vapour  pressure,  low  levels  of 
atmospheric  N02  and  S02  contributed  signif- 
icantly to  hospital  visits  (p<0.05).  In  Poisson 
regression  analysis  the  remaining  factors  of  sig- 
nificance (p<0.01)  for  nonatopic  asthma  were 
fog  and  low  NO  and  for  atopic  asthma  were 
high  water  \apoin  pressure  and  low  S02 
(p<0.05).  A  weak  but  significant  correlation 
was  observed  between  the  number  of  hospital 
visits  and  the  mean  pH  of  the  foggy  day  (rO.38, 
p<0.05)  in  nonatopic  asthmatic  patients,  not  in 
atopic  asthma.  On  foggy  days,  gaseous  air  pol- 
lutanl  levels  were  significantly  (p<0.()l )  lower 
Ihan  on  log-free  days.  It  was  concluded  Ih.il. 
naturally  occurring  acid  fog  may  have  a  weak 
bronchoconstrictive  effect  which  appears  to  be 
more  infiuential  in  nonatopic  asthmatic  subjects 
iIkiii  111  atopic  subjects. 

NoniinasJM'  Pressure  Support  \  enlilation  in 
COPI)  Palieiils  wilh  I'dslexliihation  Hyper- 
capnic  Kcspiratory  Insulticiencv  ililbcrl  (i. 
Gruson  D,  Portel  I..  Gbikpi-Bciiissan  Ci.  Cai- 
dinaud  JP,  Eur  Respir  J  I99S;I  l(6i:1349. 

P;ilienls  witluhroiiicobsiriiclivepulmonaiA  dis- 
ease (C'OPD)  who  have  been  intubated  and  me- 
chanically ventilated  may  prove  difficult  to 
wean.  Noninvasive  ventilation  may  he  used  in 
an  .illcmpi  lo  avmd  new  eiulolracheal  inluba 


tion.  The  efficacy  of  administration  ot  nonin- 
vasive pressure  support  ventilation  was  evalu- 
ated in  30  COPD  patients  with  postextubation 
hypercapnic  respiratory  insufficiency,  com- 
pared with  30  historically  matched  control  pa- 
tients who  were  treated  conventionally.  Patients 
were  included  in  the  study  if.  within  72  h  post- 
extubation, they  presented  with  respiratory  dis- 
tress, defined  as  the  combination  of  a  respira- 
tory frequency  >25  breaths  x  min(-l),  an 
increase  in  the  arterial  carbon  dioxide  tension 
(Pa.C02)  of  at  least  20%  compared  with  the 
value  measured  after  extubation,  and  a  pH 
<7.35.  Noninvasive  pressure  support  ventila- 
tion was  effective  in  correcting  gas  exchange 
abnormalities.  The  use  of  noninvasive  ventila- 
tion significantly  reduced  the  need  for  endotra- 
cheal intubation:  20  of  the  30  patients  (67%-)  in 
the  control  group  required  endotracheal  intuba- 
tion, compared  with  only  six  of  the  30  patients 
(20%)  in  the  noninvasive-ventilation  group 
(p<0.001).  In-hospital  mortality  was  not  sig- 
nificantly different  between  the  two  groups,  but 
the  mean  duration  of  ventilatory  assistance  for 
the  treatment  of  the  postextubation  distress,  and 
the  length  of  intensive  care  unit  stay  related  to 
this  event,  were  both  significantly  shortened  by 
noninvasive  ventilation  (p<0.01).  In  conclu- 
sion, noninvasive  ventilation  may  be  used  in 
the  management  of  patients  with  chronic  ob- 
structive pulmonary  disease  and  postextubation 
hypercapnic  respiratory  insufficiency. 

References  Values  for  Forced  Spirometry. 
Group  of  the  European  Community  Respi- 
ratory Health  Survey — Roca  J,  Burgos  F,  Su- 
nyer  J.  Suez  M.  Chinn  S.  Anto  JM,  et  al.  Eur 
Respir  J  I998;ll(6):13.54. 

The  European  Coal  and  Steel  Community 
(ECSC)  prediction  equations  exemplify  a  sig- 
nificant effort  carried  out  approximately  15  yrs 
ago  lo  provide  uniform  standards  for  lung  func- 
tion testing,  but  this  set  of  equations  has  not 
been  properly  validated  as  yet.  The  present  study 
evaluates  the  ECSC  reference  values  and  four 
other  sels  of  prediction  equations,  using  spiro- 
inetric  data  collected  in  12,900  nonasthmatic 
subjects  (43%  lifetime  nonsmokers  and  36% 
active  smokers)  aged  20-44  yrs  from  the  Euro- 
pean Community  Respiratory  Health  Survey 
(ECRHS).  Standardi/cd  spirometric  measure- 
ments were  obuiincil  using  a  common  protocol 
in  34  centres  in  14  counlrics.  For  each  predic- 
tion equation,  the  prediction  deviations  (i.e.  ob- 
served miiuis  predicted  value)  for  forced  vital 
capacity  (FVC)  and  forced  expiratory  volume 
in  one  second  (FEVI)  were  examined  for  the 
whole  study  population  and  for  each  centre.  For 
the  age  range  included,  the  errors  about  the 
ECSC  equations  showed  the  most  prominent 
underestimation  of  both  predicted  FVC  (-F355 
and  -^360  niL  on  average  in  males  and  females, 
respeclively)  and  predicted  FHVI  (-F2II  and 
I  20(1  ml.,  rcspcclivelv  I  among  the  live  stuilies 


800 


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Coordinators  & 
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The  Respiratory  Care  Department  at  Strong  Memorial  Hospital, 
in  Rochester,  NY,  is  seeking  experienced  Respiratory  Care 
Practitioners,  Strong  Memorial  Hospital  is  a  750-bed  teaching 
institution  that  offers  a  competitive  salary/benefit  package 
including  tuition  benefits.  If  you  are  looking  for  a  challenging 
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Successful  candidate  must  be  a  RRI  BS  (MS  preferred),  or 
equivalent  combination  of  education  and  experience.  Must  have 
three  years  supervisory  experience  and  possess  a  strong  apti- 
tude to  learn  and  educate  fellow  staff  members,  physicians,  and 
nurses.  Candidate  should  have  ECMO,  Graphic  Waveforms, 
Pulmonary  Function  Testing,  Nitric  Oxide,  HFOV  and  Transport 
experience.  Candidate  should  also  be  familiar  with  research  and 
publication  processes  for  the  above. 

Also  accepting  resumes  for  Full  &  Part-time  Registered  or 
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Abstracts 


examined.  As  expected.  FVC  and  FEVI  in  ac- 
tive smokers  from  the  ECRHS  were  signifi- 
cantly lower  than  in  lifetime  nonsmokers  (each 
p<0.01).  We  conclude  that  the  present  Euro- 
pean recoinmendallons  on  lung  function  refer- 
ence values  should  be  reconsidered,  but  further 
data  for  nonsymptomatic  subjects  above  the  age 
of  44  yrs  are  needed. 

Expiratory  Valves  Used  for  Home  Devices: 
Experimental  and  Clinical  Comparison — 

Lofaso  F.  Aslanian  P.  Richard  JC,  Isabey  D. 
Hang  T.  Corriger  E.  et  al.  Eur  Respir  J  1998; 
11(6):1382. 

A  bench  study  followed  by  a  clinical  trial  were 
performed  to  evaluate  the  mechanical  charac- 
teristics of  five  (commercially  available)  expi- 
ratory valves  used  for  home  ventilators,  as  well 
as  the  potential  clinical  impact  of  differences 
between  these  valves.  In  the  in  vitro  study,  ex- 
piratory valve  resistance  was  evaluated  under 
unvarying  conditions,  whereas  dynamic  behav- 
iour was  evaluated  by  calculating  the  imposed 
expiratory  work  of  breathing  during  a  simu- 
lated breath  generated  by  a  lung  model.  Differ- 
ences in  resistance  and  imposed  expiratory  work 
of  up  to  twofold  and  150%,  respectively,  were 
found  across  valves.  We  then  conducted  a  ran- 
domized crossover  clinical  study  to  compare 
the  effects  of  the  least  resistive  (Bennett)  and 
most  resistive  expiratory  valves  (Peters)  in  10 
intubated  patients  receiving  pressure  support 
ventilation.  There  were  no  significant  differ- 
ences regarding  blood  gases  or  respiratory  pa- 
rameters except  for  the  oesophageal  pressure- 
time  product  (PTPoes).  which  was  significantly 
increased  by  the  Peters  valve  (236±  1 1 3  cmH20 
X  s  X  min(-l)  versus  I94±90  cmH20  x  s  x 
min(-l)).  An  analysis  of  individual  responses 
found  that  the  Peters  valve  induced  substantial 
increases  in  intrinsic  positive  end-expiratory 
pressure  (PEEP).  PTPoes.  and  expiratory  activ- 
ity in  those  patients  with  the  greatest  ventila- 
tory demand.  In  conclusion,  differences  between 
home  expiratory  valve  resistances  may  have  a 
clinically  relevant  impact  on  the  respiratory  ef- 
fort of  patients  with  a  high  ventilatory  demand. 

Magnetic  Resonance  (MR)  Imaging  of  the 
Chest:  State-of-the-Art— Bitlner  RC,  Felix  R. 
Eur  Respir  J  I99X:I  l((i):1.^92. 

To  dale,  magnetic  resonance  (MR)  is  established 
as  an  imaging  modality  in  the  diagnosis  of  chest 
diseases.  Because  of  its  excellent  distinction  of 
ves.sels  and  soft  tissue.  MR  can  be  performed  as 
the  primary  imaging  procedure  before  computed 
tomography  in  patients  with  suspected  vascular 
lesions,  mediastinal  masses,  hilar  lesions,  and 
pathological  changes  of  the  pleura  and  the  chcsi 
wall.  In  these  cases,  MR  is  able  to  provide  all 
the  necessary  diagnostic  information.  In  other 
patients,  a  limited  number  of  MR  images  may 
he  hclpliil  Ml  cases  of  ei|uivocal  or  confusing 


CT  or  clinical  findings.  More  detailed  informa- 
tion can  be  obtained,  using  surface  coils  or  spe- 
cial imaging  sequences,  i.e.  high  resolution  MR 
images  of  the  pleura  or  angiographic  images  of 
mediastinal  and  pulmonary  vasculature.  From  a 
clinical  viewpoint,  the  mo.st  important  ta.sk  for 
thoracic  magnetic  resonance  nowadays  is  the 
prelherapeutic  evaluation  of  intrathoracic 
masses,  the  differential  diagnosis  of  benign  ver- 
sus malignant  lesions,  and  the  accurate  docu- 
mentation of  tumour  extent  in  malignancies  in- 
cluding three-dimensional-display  to  improve 
surgical  or  radiation  planning.  Future  directions 
in  thoracic  magnetic  resonance  will  be  predom- 
inantly influenced  by  postprocessing  ap- 
proaches, specialized  imaging  techniques,  and 
magnetic  resonance-guided  interventional  ap- 
plications. 

Treadmill  Exercise  Duration  and  Dyspnea 
Recovery  Time  in  Chronic  Obstructive  Pul- 
monary Disease:  Effects  of  Oxygen  Breath- 
ing and  Repeated  Testing — Marques-Magall- 
anes  JA,  Storer  TW,  Cooper  CB.  Respir  Med 
1998;92(5):735. 

Oxygen  supplementation  is  known  to  improve 
exercise  capacity  in  patients  with  chronic  ob- 
structive pulmonary  disease  (COPD).  Although 
some  COPD  patients  use  oxygen  after  exercise 
to  relieve  dyspnea,  the  effect  of  oxygen  during 
recovery  from  exercise  is  not  clearly  understood. 
Exerci.se  duration  and  dyspnea  recovery  time 
were  studied  in  18  patients  with  stable  COPD. 
Patients  exercised  at  a  constant  submaximal 
work  rate  on  a  treadmill  ergometer  until  they  no 
longer  wished  to  continue.  Oxygen,  room  air 
and  compressed  air  were  randomly  administered 
in  three  con,secutive  post-exercise  recovery  pe- 
riods. Dyspnea  was  scored  on  a  100  mm  visual 
analog  scale  at  30  s  intervals  until  return  to 
baseline.  An  additional  20  minute  post-recov- 
ery resting  period  was  allowed  between  each 
test.  No  significant  differences  were  found  in 
dyspnea  recovery  time  breathing  oxygen  (271 
s).  room  air  (290  s)  or  compressed  air  (311  s) 
When  the  groups  were  sorted  by  sequence  of 
testing,  there  was  a  highly  significant  increase 
in  recovery  time  (208  s.  307  s  and  358  s  for  the 
first,  second  and  third  tests;  P  <  0.005)  and  a 
non-statistically  significant  decrease  in  exercise 
duration  (89  s.  79  s  and  76  s).  Post-exercise 
oxygen  supplementation  had  no  effect  on  dys- 
pnea recovery  lime  in  these  COPD  patients. 
Repeated  bouts  of  exercise  increased  dyspnea 
recovery  time  and  tended  to  decrease  exercise 
duration.  These  findings  suggest  that,  despite 
recovery  of  symptoms,  physiological  recovery 
from  prior  exercise  is  incomplete. 

Serial  .Sputum  Cell  Counts  in  the  Manage- 
ment  of  Chronic   Airflow    Limitation — 

Paramesuaran  K.  Pi/./ichini  MM.  Li  D.  Piz- 
/Ichini  E,  .lelleiy  PK.  Hargrcave  FE.  Hur  Respir 

J   199S;1  l(6):14()5. 


This  case  study  illustrates  the  usefulness  of  se- 
rial induced  sputum  cell  counts  from  cytospins 
to  investigate  the  nature  of  airway  inflamma- 
tion in  a  patient  presumed  to  have  prednisone- 
dependent  asthma  for  30  yrs.  She  had  bronchi- 
ectasis and  chronic  airflow  limitation. 
Exacerbations  of  breathlessness  were  associated 
with  an  increase  in  chronic  airflow  limitation 
with  little  or  no  sputum.  Induced  sputum  showed 
elevated  total  cell  and  neutrophil  counts  at  each 
exacerbation  with  no  increase  in  the  proportion 
of  eosinophils.  Pathogenic  bacteria  were  cul- 
tured at  each  tlare-up.  The  dose  of  prednisone 
was  reduced  progressively  and  each  exacerba- 
tion was  treated  with  an  appropriate  antibiotic 
without  increasing  the  dose  of  prednisone,  as 
was  the  case  previously.  The  infections  were 
associated  with  bronchiectasis  of  the  right  up- 
per lobe  which  was  removed.  Examination  of 
the  specimen  confirmed  neutrophilic  infiltration 
and  did  not  show  the  usual  airway  structural 
changes  of  asthma.  These  results  provide  fur- 
ther evidence  of  the  value  of  sputum  cell  counts 
in  practice,  in  this  case  to  prevent  overtreat- 
ment  with  prednisone  in  a  patient  with  recur- 
rent deteriorations  in  airflow  which  were  due  to 
recurrent  infections 

Predicting  Survival,  Length  of  Stay,  and  Cost 
in  the  Surgical  Intensive  Care  Unit:  APACHE 

II  Versus  ICLSS— Osier  TM,  Rogers  FB, 
Glance  LG,  Cohen  M.  Rutledge  R,  Shackford 
SR.  J  Trauma  19yX;45(2):2.^4. 

BACKGROUND:  Risk  slratitlcation  of  patients 
in  the  intensive  care  unit  (ICU)  is  an  important 
tool  because  it  permits  comparison  of  patient 
populations  for  research  and  quality  control.  Un- 
fortunately, currently  available  scoring  systems 
were  developed  primarily  in  medical  ICUs  and 
have  only  mediocre  performance  in  surgical 
ICUs.  Moreover,  they  are  very  expensive  to 
purchase  and  use.  We  conceived  a  simple  ri.sk- 
stratification  tool  for  the  surgical  ICU  that  uses 
readily  available  International  Classification  of 
Diseases,  Ninth  Revision,  codes  to  predict  out- 
come. Called  ICISS  (International  Classifica- 
tion of  Disease  Illness  Severity  Score),  our  .score 
is  the  product  of  the  survival  risk  ratios  (ob- 
tained from  an  independent  data  set)  for  all  In- 
ternational Classification  of  Diseases.  Ninth  Re- 
vision, diagnosis  codes.  METHODS:  A  total  of 
5,322  noncardiac  patients  admitted  to  a  surgical 
ICU  during  an  8-year  period  had  their  Acute 
Physiology  and  Chronic  Health  Evaluation 
(APACHE)  II  scores  compared  with  their  ICISS 
as  predictors  of  outcome  (survival/nonsurvival, 
length  of  stay,  and  charges).  RESULTS:  ICISS 
proved  to  be  a  much  belter  predictor  of  survival 
than  APACHE  (receiver  operating  characteri.s- 
tic  (ROC)  APACHE  =  0.806;  Hosmcr-Leme- 
show  (HL)  APACHE  =  22.56;  ROC  ICISS  = 
0.892;  HL  ICISS  =  12.06)  or  the  APACHE 
survival  probabilily  (ROC  =  0.836;  HL  = 
34.47).  These  dilTcrcnces  were  hichlv  statisti- 


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cally  significant  (p  <  0.001).  iClSS  was  also 
better  correlated  with  ICU  length  of  stay 
(APACHE  R2  =  0.06;  ICISS  R2  =  0.32)  and 
ICU  charges  (APACHE  R2  =  0.07;  ICISS 
R2  =  0..^9).  When  combined  in  a  logistic  model 
with  ICISS,  APACHE  11  added  slightly  to  the 
predictive  power  of  ICISS  alone  (combined 
ROC  =  0,903)  but  degraded  the  calibration  of 
the  model  (combined  HL  =  16.29;  p  =  0.038). 
CONCLUSION:  Because  ICISS  is  both  more 
accurate  and  much  less  expensive  to  calculate 
than  APACHE  II  score,  ICISS  should  replace 
APACHE  II  score  as  the  standard  risk  stratifi- 
cation tool  in  surgical  ICUs. 

Hemodynamic  and  Ventilatory  Effects  Asso- 
ciated with  Increasing  Inverse  Inspiratory- 
Expiratory  Ventilation — Gore  DC.  J  Trauma 
1998;45(2):268. 

BACKGROUND:  Increasing  the  percentage  of 
inspiratory  time  during  mechanical  ventilation 
(i.e.,  inverse  inspiratory-expiratory  (I:E)  venti- 
lation) is  frequently  used  to  improve  oxygen- 
ation in  patients  with  acute  respiratory  distress 
syndrome;  however,  an  optimal  I:E  ratio  is  un- 
known. METHODS:  To  assess  for  an  optimal 
I:E  ratio,  hemodynamic,  ventilatory,  and  oxy- 
genation parameters  were  determined  in  eight 
adult  trauma  patients  with  acute  respiratory  dis- 
tress syndrome  supported  with  pressure-control 


ventilation.  An  indwelling  pulmonary  artery 
catheter  facilitated  the  extensive  measurements 
as  I:E  ratios  were  randomly  changed  between 
1:1  and  3:1.  Measurements  were  determined  30 
minutes  after  each  change  in  the  1:E  ratio.  RE- 
SULTS: Increasing  the  percentage  of  inspira- 
tory time  resulted  in  a  progressive  increase  in 
arterial  oxygenation  (p  <  0.05)  in  conjunction 
with  elevations  in  mean  airway  pressure  (p  < 
0.05)  and  a  decrease  in  alveolar-arterial  oxygen 
difference  (p  <  0.05).  Furthermore,  progres- 
sive reversal  of  the  I:E  ratio  significantly  di- 
minished alveolar  ventilation  (p  <  0.01),  with 
worsening  dynamic  compliance  (p  <  0.01). 
There  were  no  demonstrable  changes  in  hemo- 
dynamics. CONCLUSION:  These  findings 
demonstrate  the  effectiveness  of  increasing  in- 
spiratory time  to  improve  oxygenation,  yet  to 
the  detriment  of  ventilation.  This  suggests  that 
within  the  parameter  confines  of  this  study,  the 
preferential  1:E  ratio  is  a  balance  between  ox- 
ygen demands  and  ventilatory  requirements. 

Prehospital  Airway  Management  in  the 
Acutely  Injured  Patient:  The  Role  of  Surgi- 
cal Cricothyrotomy  Revisited — Gerich  TG, 
Schmidt  U,  Hubrich  V,  Lobenhoffer  HP, 
Tscherne  H.  J  Trauma  1998;45(2):3I2. 

BACKGROUND:  Ensuring  an  unobstructed  air- 
way and  adequate  oxygenation  are  first  priori- 


ties in  the  resuscitation  of  the  trauma  patient.  In 
situations  of  difficult  endotracheal  intubation, 
rapid  sequence  protocols  frequently  include  the 
use  of  paralytic  agents  and  cricothyrotomy  for 
airway  management.  Recent  literature  findings 
suggest  that  the  prehospital  use  of  cricothy- 
rotomy is  too  frequent.  The  puipose  of  this  study 
was  (a)  to  evaluate  the  efficacy  of  a  rapid  se- 
quence intubation  protocol  without  the  use  of 
paralytic  agents,  and  (b)  to  determine  the  need 
for  cricothyrotomy  by  using  this  protocol  in  the 
field.  METHODS:  We  prospectively  analyzed 
383  acutely  injured  patients  who  were  in  need 
of  airway  control.  Success  rates,  indications, 
and  complications  of  endotracheal  intubation 
and  cricothyrotomy  were  analyzed.  RESULTS: 
Successful  orotracheal  intubation  on  the  scene 
with  the  use  of  this  protocol  was  performed  in 
373  of  383  patients  (970^ ).  Two  patients  (0.5Vf  i 
arrived  at  the  trauma  center  with  unrecognized 
esophageal  intubation.  Eight  patients  underwent 
cricothyrotomy  in  the  field,  six  without  previ- 
ous attempts  at  intubation.  CONCLUSION:  Ex- 
perienced emergency  medical  services  person- 
nel can  effectively  perform  endotracheal 
intubation  with  narcotic  analgesics  without  the 
use  of  paralytic  agents  in  the  field.  With  proper 
training  for  field  airway  management,  cricothy- 
rotomy in  the  field  can  be  reduced  to  a  few 
indications  with  high  success  rates. 


Respiratory  Care  •  October  "98  Vol  43  No  10 


803 


Original  Contributions 


An  Evaluation  of  Asthma  Education  for  School  Personnel 
Using  Peak  Performance  USA 

Diana  Powell  RRT  RCP 


BACKGROUND:  Kaiser  Permanente  medical  centers  have  been  teaching  school-age  asthmatic 
children  how  to  manage  asthma  at  home,  but  the  program  fails  when  the  children  are  at  school 
because  teachers,  school  nurses,  principals,  and  physical  education  coaches  have  not  been  trained 
to  allow  the  children  to  properly  manage  asthma  at  school.  This  expensive  problem,  which  exists  at 
all  grade  levels,  could  be  corrected  if  school  personnel  understood  asthma  and  what  teacher  and 
child  must  do  to  manage  it.  MATERIALS  &  METHODS:  In  1993  we  adapted  the  American 
Association  of  Respiratory  Care  program.  Peak  Performance  USA,  to  our  health  maintenance 
organization  setting.  The  program  package  included  donated  peak  flow  meters,  spacers,  and  liter- 
ature. We  implemented  an  asthma  education  management  training  program  for  180  school  per- 
sonnel in  2  districts;  school  personnel  in  other  districts  served  as  controls.  RESULTS:  Results  of 
postprogram  evaluation  showed,  despite  a  low  response  rate,  that  school  personnel  learned  from  the 
program  and  that  learning  was  retained  when  either  a  2-hour  or  a  3-hour  class  format  was  used. 
Classes  were  so  well  received  that  additional  districts  asked  to  receive  the  training,  which  we 
provided.  Another  result  of  the  program  was  the  referral  of  parents  to  asthma  management  classes. 
CONCLUSIONS:  Education  about  the  nature  of  asthma,  how  to  treat  it,  and  the  use  of  peak  flow 
meters  and  spacers  allowed  school  personnel  to  better  understand  and  manage  asthma,  although 
California  state  restrictions  on  use  of  teachers'  time  limited  our  program's  success.  [Respii  Care 
1998;43(  l()):804-8IO|  Key  words:  absenteeism,  asthma,  child,  school  health  services,  school  iiiirsiiiii. 
self  care. 


Background 

Asthma  is  one  of  the  most  common  chronic  illnesses  in 
children.  From  3,725,000  to  4,830,000  children  in  the 
United  States  are  affected  by  asthma  each  year  at  a  mean 
overall  cost  of  $1,000  per  child.'  -  Children  spend  much  of 
their  day  in  a  school  setting:  therefore,  how  their  asthma  is 
managed  in  the  school  can  impact  how  their  asthma  is 
managed  overall. 


Diana  Powell  RRT  RCP,  Respiratory  Care  Department.  Kaiser  Peima- 
ncnte  .Santa  Teresa  Medical  Center.  .San  Jo.se,  Calilnrnia. 

This  project  was  supported  by  Kaiser  Permanente  Northern  Calil'ornia 
Region  Innovation  Program  Grant  No.  9.WI47  on  School  Asthma  F.du- 
calion.  Project  tools  were  modeled,  with  permission,  after  (hose  ol  the 
American  Association  for  Respiratory  Care  Peak  Perfornunue  l''.S.\. 

Reprints  and  Correspondence;  Diana  Powell  RRT  RCP,  cA>  Departmeiit 
of  Medicine,  Kaiser  Permanente  Medical  Center,  A270  International  Cir- 
cle, San  Jose  CA  y.Sj  I'). I  lOV  dianapowelKo'ncal, kaipcrm.org. 


Previous  research  suggests  that  school  teachers"  knowl- 
edge about  asthma  is  inadequate.'^  In  our  clinical  practice 
we  noted  that  many  parents  would  complain  that  school 
teachers  and  coaches  did  not  respond  appropriately  to  a 
child's  complaint  that  he/she  was  having  an  asthma  epi- 
sode ('asthma  attack'),'^  often  causing  the  asthma  episode 
to  worsen. 

In  1993  we  decided  to  develop  a  program  for  asthma 
education  taught  directly  to  school  personnel.  Our  pro- 
gram was  adapted  from  Peak  Performance  USA.  a  national 
program  for  schools  recently  developed  by  the  American 
Association  for  Respiratory  Care.'  '-  Peak  Performance 
USA  is  designed  to  assist  respiratory  care  practitioners  to 
help  students  with  asthma  by  distributing  asthma  educa- 
tion materials  and  by  teaching  school  personnel  their  role 
in  the  management  of  children's  asthma  in  the  classroom 
or  playground  setting. 

The  on-site  pediatric  asthma  education  program  began 
at  Santa  Teresa  Community  Hospital  in  1990.  Parents  par- 
ticipating in  the  progiatii  commcntcti  that  the  biggest  asthma 


804 


RriSPiRATORY  Care  •  Octobfr  '98  Vot.  43  No  10 


Asthma  Management  Training  for  School  Personnel 


management  problem  arose  with  school  personnel.  The 
teachers  and  coaches  would  not  listen  to  asthmatic  chil- 
dren's complaints  that  they  were  having  an  asthma  epi- 
sode. The  children  had  to  run  or  exercise  regardless  of 
their  condition,  and  asthma  would  worsen.  Asthmatic  chil- 
dren were  not  allowed  to  take  medication  as  prescribed  or 
to  carry  medication  with  them.  School  nurses  were  not 
regularly  on  site,  but  visited  the  school  only  weekly  or 
even  less  frequently. 

We  hypothesized  that  if  proper  asthma  management  tech- 
niques were  taught  to  school  teachers  and  coaches,  there 
would  be  an  improvement  in  their  knowledge  and  confi- 
dence. We  believed  that  if  school  personnel  were  thus 
trained  in  proper  asthma  management,  the  school  would 
then  become  part  of  the  management  team.  Our  objective 
was  to  implement  Peak  Performance  USA  and  to  develop 
a  partnership  with  children,  parents,  school  personnel,  and 
health  care  providers. 

Methods 

In  each  of  the  6  school  districts  in  our  area,  we  con- 
tacted 2  principals  to  assess  interest  and  to  determine  proper 
contact  persons.  Both  principals  expressed  interest,  and  all 
suggested  the  district  nurse  as  the  appropriate  contact  per- 
son. The  district  nurses  in  the  6  school  districts  in  our 
hospital's  service  area  were  contacted  by  mail  with  an 
invitation  to  attend  an  initial  planning  meeting.  Nonre- 
spondents  were  sent  a  second  mailing  followed  by  tele- 
phone calls.  Training  sessions  for  school  personnel  were 
then  set  up  in  the  school  districts  that  agreed  to  participate. 

Each  school  received  a  package  of  written  materials  on 
asthma  management  training,  as  well  as  actual  peak  flow 
meters  and  spacers  with  instructions  on  how  to  order  a 
one-way  mouthpiece.  These  materials  were  distributed  to 
each  physical  education  teacher.  In  addition,  all  teachers 
received  handouts  from  the  Peak  Performance  USA  asthma 
management  guide."  The  training  protocol  was  based  on 
Peak  Performance  USA.'^  Either  a  2-hour  or  a  3-hour 
class  was  also  presented  as  outlined  in  Table  1."  Class 
participants  were  given  the  peak  flow  meters,  spacers,  and 
literature  on  asthma,  including  the  Peak  Performance  USA 
asthma  management  guide,"  a  student  asthma  action  card 
from  the  Asthma  and  Allergy  Foundation  of  America  '••,  a 
Kaiser  Permanente  Health  Education  booklet  Your  Child 
and  Asthma  ^^,  and  Plant's  One  Minute  Asthma:  What  You 
Need  to  Know.  '*  The  3-hour  version  included  a  videocas- 
sette  with  more  detailed  information.''  The  longer  version 
allowed  more  time  for  group  interaction  and  for  greater 
response  to  more  questions. 

A  preprogram  evaluation  questionnaire  (Appendix  1) 
was  distributed  just  before  the  class  sessions.  A  postpro- 
gram  evaluation  questionnaire  (Appendix  2)  was  admin- 
istered by  mail  6  months  after  the  class  session. 


Table  L       Outline  for  Instruclion  of  School  Staff 

Introduclion 

Incidence  and  asthma  facts 
What  is  asthma? 

Pathophysiology  of  an  asthma  episode 
Definition  of  controlled  a.sthma 
Goals  and  objectives  of  treatment  plan 
Quality  of  life  markers 
Assessment  and  observation 

Objective  measures  of  lung  function 
Triggers  that  cause  an  episode 
Symptoms 
Asthma  management 

Peak  Expiratory  Flow  Rate  Measurement  (PEFR) 

definition 

justification  for  use 
Medications 

importance  of  access  to  medication 

types  and  what  they  do 

correct  use  of  an  inhaler 
Emergency  procedures 
The  Peak  Flow  Meter 

Explanation  and  importance  of  its  use 

need  for  PEFR  measurement 
Demonstration  and  instruction  in  its  use 

factors  affecting  its  use 
Explanation  of  charting  and  its  importance 

explanation  of  child's  personal  best  PEFR 
Using  the  child's  PEFR  as  provided  by  a  physician 
The  Peak  Flow  Meter  and  management  of  asthma 
Implementation  of  the  Peak  Performance  USA  Asthma  Management 

Program 
Staff  actions 

Peak  performance  action  plan 
Record-keeping 
Family  participation 
Physician  participation 
Medication  authorization 
Information  sources  and  resources 
Summary 
Questions  and  answers 


13.  with  pennisv 


Data  analysis  was  performed  using  statistical  software.'^ 
Differences  between  preprogram  and  postprogram  results 
were  compared  using  the  chi-square  test.  Statistical  sig- 
nificance was  accepted  as  p  <  0.05. 

Results 

Two  of  the  6  district  nurses  attended  the  initial  planning 
meeting.  One  of  them  set  a  tentative  class  date.  After  the 
second  mailing  followed  by  telephone  calls,  a  second  dis- 
trict agreed  to  schedule  training.  These  2  districts  included 
65  schools. 


Respiratory  Care  •  October 


Vol  43  No  10 


805 


Asthma  Management  Training  for  School  Personnel 


Number  of  180  Schoiil  Personnel  Completing  Stages  Evaluating  ImpiovcnieiU  In  their  Knowledge  about  Asthma 


Profession 

Pre 

evaluation 
only 

Postevaluation 
only 

Pre-  and  post- 
evaluation 

No  evaluation 
completed 

Tola! 

Teacher 

17 

7 

9 

16 

49 

Teacher  and  coach 

10 

8 

g 

6 

32 

Health  aide 

31 

5 

20 

11 

67 

Coach 

0 

2 

0 

6 

8 

Miscellaneous 

6 

4 

10 

2 

22 

64 

26 

47 

41 

178* 

■  n.11.1  una\.iil.ihk'  lor  : 

Table  3.       Improvement  in  Confidence  and  Knowledge  about  Asthma  fiom  Time  of  Preprogram  Questionnaire  to  Time  of  Postprogram 
Questionnaire 


Questions  about  asthma  with  responses  intended  to  reflect 
postprogram  improvement 


No.  completing  questionnaire(s)  (%) 


Preprogram 
(baseline)  rate  (%) 


Postprogram 
(baseline)  rate  (%) 


Difference  (95% 

Confidence 

Interval) 


How  confident  are  you  that  you  can  help  a  child  manage  his/her 

asthma  at  school?  ["not  at  all") 
What  are  2  things  the  child  can  do  if  his/her  asthma  symptoms 

occur  at  school?  |"Drink  water,"  "breathe  slowly"] 
In  general,  should  children  with  asthma  avoid  exercise  (like 

playing  at  sports  or  running  aroundl?t  ("no"] 


8/19(42%) 
I.V20((i,S%) 
18/21  (86%) 


0/19* 

20/20  (100%) 
21/21   (100%) 


p  =  0.003 
p  =  0.008 
p    =  0.07 


Tola!  responding  to  all  questions  on  pre-  or  postprogram  evaluation  qucstionnairets)  n  =  21. 

•  0  response  indieates  marked  improvement  for  this  question. 

t  All  respondents  correctly  answered  this  question  negatively  postprogram,  although  this  result  < 


At  least  one  person  from  each  of  the  65  schools  partic- 
ipated in  the  program.  Because  of  California  State  regu- 
lations restricting  teachers"  overtime,  we  were  able  to  offer 
only  a  2-hour  session  in  25  schools.  The  3-hour  session 
was  offered  in  the  40  schools  that  had  a  district  nurse 
favorably  disposed  to  the  program.  The  professional  dis- 
tribution of  the  participating  personnel  is  described  in  Ta- 
ble 2. 

Of  the  180  school  personnel  who  participated  in  the 
asthma  management  program,  47  completed  both  a  pre- 
program and  postprogram  questionnaire.  Sixty-four  who 
completed  a  preprogram  questionnaire  only  and  26  who 
completed  the  postprogram  questionnaire  only  were  ex- 
cluded from  the  analysis.  Some  preprogram  data  were  miss- 
ing because  2  versions  of  the  preprogram  questionnaire 
were  administered.  In  addition,  not  all  persons  answered 
all  items  on  each  exam  and  if  a  person  did  not  answer  an 
item,  it  was  counted  as  missing. 

Of  19  school  personnel  who  answered  the  preprogram 
question,  8  (42%)  stated  that  they  were  "not  at  ail"  con- 
fident in  their  ability  to  help  a  child  manage  his  or  her 
asthma  at  school  (Table  ?>).  Of  the  same  19  school  per- 
sonnel in  this  matched  analysis  who  completed  the  post- 
program  question,  none  responded  "not  at  all"  (p  =  0.00.^). 
Of  20  school  personnel  who  answered  the  question  about 


naming  2  things  a  child  can  do  to  manage  symptoms,  13 
(65%)  who  answered  the  preprogram  question  could  name 
2  things,  and  all  20  (100%)  who  completed  the  postpro- 
gram questionnaire  could  answer  this  question  coiiectly  (p 
=  0.008).  Finally,  of  21  who  answered  the  preprogram 
question  of  whether  a  child  with  asthma  should  avoid  ex- 
ercise, 18  (86%)  responded  "no,"  and  all  21  responded 
"no"  on  the  postprogram  questionnaire  (p  =  0.07). 

The  6-month  postprogram  evaluation  included  space  for 
comments.  One  respondent  stated,  "I  received  a  lot  of 
helpful  information  in  managing  students  with  asthma 
problems."  Another  stated,  "I  feel  this  class  should  be 
mandatory.  .  .  .  Very  helpful  information."  After  the  class, 
one  teacher  called  to  say  that  she  realized  she  had  asthma 
and  is  now  being  properly  cared  for. 

After  the  class,  3  school  personnel  called  to  refer  the 
parents  of  3  children  to  an  asthma  education  class  offered 
at  our  medical  center  entitled.  "Health  Skills  for  Pediatric 
Asthma.""*  '■'  The  response  from  school  personnel  was  so 
positive  to  the  initial  class  that  another  district  in  addition 
to  the  2  districts  described  called  and  requested  the  train- 
ing. One  of  the  participating  districts  requested  a  repeat 
class  the  following  year  as  well  as  a  1-hour  review  the  year 
after. 


806 


Rhspiraiory  Care  •  Octohir  "98  Voi  43  No  10 


Asthma  Management  Training  for  School  Personnel 


Discussion 

Asthma  is  a  coinnum  problem  affecting  an  estimated 
79t  to  15%  of  school  children.-"-'  Based  on  our  finding 
that  low  asthma  knowledge  and  confidence  were  improved 
at  6  months  after  a  2-  or  3-hour  asthma  class,  we  recom- 
mend that  school  personnel  should  receive  education  about 
asthma  management. 

Our  results  suggest  that  most  school  personnel  have 
little  confidence  and  a  low  level  of  basic  knowledge  about 
asthma  symptoms  and  about  actions  to  take  in  an  asthma 
tiare-up.  Confidence  levels  and  knowledge  improved  and 
were  retained  for  at  least  6  months  post-class. 

Our  findings  are  compatible  with  those  of  Eisenberg  et 
al.'-  who  found  that  knowledge  about  asthma  improved 
subsequent  to  the  program.  As  in  our  study,  coinpliance 
with  pre-  and  postprogram  evaluations  was  problematic  in 
their  study.  Compared  with  21  of  90  (239c)  in  our  study. 
37  of  90  (41%)  of  their  participants  who  completed  the 
preprogram  questionnaire  completed  the  postprogram  ques- 
tionnaire. Noncompliance  with  evaluations  could  be  either 
random  or  systematic.  If  noncompliance  was  random,  the 
effect  would  be  to  decrease  the  likelihood  of  finding  a 
statistically  significant  difference.  E.xtensive  noncompli- 
ance, if  present,  could  conceivably  bias  the  findings.  One 
could  speculate  that  persons  with  lower  levels  of  knowl- 
edge were  more  likely  not  to  comply  than  tho.se  with  higher 
levels.  If  this  is  true,  then  the  true  level  of  asthma  knowl- 
edge and  confidence  may  be  even  lower  than  estimated  by 
our  data.  Could  this  bias  account  for  our  findings  of  im- 
provement in  confidence  and  knowledge  on  the  postpro- 
gram evaluation?  Although  this  possibility  exists,  the  con- 
cordance between  results  obtained  in  the  entire  participating 
sample  and  the  subsample  of  persons  who  completed  both 
pre-  and  postprogram  evaluations  suggests  that  the  find- 
ings of  significant  differences  are  valid. 

Although  initially  slow  to  gain  acceptance,  the  asthma 
education  program  for  school  personnel  was  very  posi- 
tively received.  One  district  invited  us  back  for  further 
classes.  We  were  referred  to  other  school  districts. 

Cost-Effectiveness 

Putting  a  dollar  amount  on  the  impact  of  a  chronic  dis- 
ease like  asthma  on  student  achievement  is  difficult  and 
includes  direct,  indirect,  and  psychosocial  costs.--  None- 
theless, according  to  hospital  databases,  after  perinatal  con- 
ditions. asthiTia  is  the  leading  cause  of  pediatric  admissions 
in  the  Northern  California  Region  of  Kaiser  Permanente. 
Frequently  occurring  symptoms  lead  to  a  significant  num- 
ber of  days  lost  from  school,  interference  with  physical 
exercise,  and  diminished  performance  at  school  because  of 
interrupted  sleep.  The  impact  on  the  family  can  be  signif- 
icant. The  burdens  on  the  parents  include  time  off  work  to 


care  for  a  sick  child.  nu)re  diligent  housekeeping  to  min- 
imize environmental  factors  such  as  dust  and  chemical 
irritants,  and  a  diminished  social  life.  When  viewed  as 
potential  life-years  lost,  the  burden  is  considerable  in  so- 
cial and  economic  terms.  In  the  United  States,  the  mean 
annual  cost  per  patient  has  been  estimated  to  be  in  excess 
of  $1,000.- 

Limitations 

The  chief  limitation  of  the  study  was  a  response  rate 
among  program  participants  that  was  much  lower  than 
anticipated.  There  are  several  possible  explanations  for  the 
low  response  rates.  A  few  teachers  informed  the  study 
team  that  they  never  received  the  baseline  survey.  Some  of 
the  teachers  who  attended  the  classes  were  not  employees 
of  the  school  district  and  were  subsequently  lost  to  follow 
up.  Others  did  not  lespond  to  either  of  two  mailings  for 
reasons  that  are  unknown. 

Perhaps  because  of  the  high  cost,  strict  rules  on  use  of 
overtime  prevented  teachers  from  participating  in  an 
evening  or  weekend  class.  This  limitation  on  use  of  teach- 
ers" time  was  a  barrier  to  greater  acceptance  of  the  asthma 
education  program. 

Recommendations 

One  could  consider  lobbying  the  state  legislature  to 
change  its  teacher  training  requirements  to  include  educa- 
tion about  common  chronic  childhood  illnesses  such  as 
asthma,  diabetes,  and  epilepsy.  An  alternative  approach 
suggested  by  one  of  the  district  nurses,  which  would  cause 
less  conflict  with  rules  on  use  of  teachers'  time,  would  be 
the  development  of  a  training  video  on  asthma. 

Conclusions 

School  personnel  have  a  low  level  of  knowledge  and 
confidence  about  asthma.  A  single-session  asthma  class 
provided  to  school  personnel  was  able  to  improve  knowl- 
edge and  confidence  about  asthma  according  to  postpro- 
gram evaluation  conducted  6  months  after  the  class.  The 
strict  overtime  rules  that  the  State  of  California  places  on 
teachers'  participation  in  classes  or  activities  after  school 
or  on  weekends  are  a  barrier  to  implementing  an  asthma 
management  program.  State  requirements  limiting  teach- 
ers' training  to  the  required  cuiriculum  that  they  must 
complete  each  year  also  hinder  asthma  program  imple- 
mentation. In  the  meantime,  we  were  unable  to  establish 
that  asthma  education  for  school  personnel  improves  asthma 
management  in  the  schools.  Additional  research  is  needed 
to  establish  that  connection.  We  recommend  that  educa- 
tion about  asthma  be  routinely  provided  to  school  person- 
nel because  the  class  was  so  well  received  by  school  per- 


Respiratory  Care  •  October  '98  Vol  43  No  10 


807 


Asthma  Management  Training  for  School  Personnel 


sonnel  and  because  we  believe  that  asthmatic  children 
generally  would  miss  less  school  if  parents  felt  more  com- 
fortable knowing  that  proper  asthma  management  is  avail- 
able from  informed  teachers. 

ACKNOWLEDGMENTS 

Harold  Farber  MD  and  Al  Barcena  CRTT  RCP  reviewed  the  manuscript. 
Mariah  Callison  CRTT  CPFT  and  Carol  Anderson  RN  NP  provided 
teaching  assistance.  Michael  Debia.se  provided  programming  assistance, 
and  Randy  Watson  MPH  assisted  with  data  analysis.  The  Medical  Edit- 
ing Department,  Kaiser  Foundation  Research  Institute,  provided  editorial 
assistance.  HealthScan/Respironics  (Cedar  Grove  NJ)  provided  peak  flow 
meters.  Monaghan  Medical  Corporation  (Plattsburgh  NY)  provided 
spacers. 


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California:  Kaiser  Permanente,  Northern  California  Region,  n.d. 
Coiro  MJ.  Zill  N,  Bloom  B.  Health  of  our  nation's  children.  Vital 
Health  Stat  10  1994;191:1-61. 

Farber  HJ.  Wattigney  W,  Berenson  G.  Trends  in  asthma  prevalence: 
the  Bogalusa  Heart  Study.  Ann  Allergy  Asthma  Immunol  1997; 
7S(3):265-269. 

Sullivan  S,  Elixhauser  A,  Buist  AS,  Luce  BR,  Eisenberg  J,  Weiss 
KB.  National  Asthma  Education  and  Prevention  Program  working 
group  report  on  the  cost  effectiveness  of  asthma  care.  Am  J  Respir 
Crit  Care  Med  1996;I54(3  Pi  2):S84-S95. 


808 


Respiratory  Care  •  October  '98  Vol  43  No  10 


Asthma  Management  Training  for  School  Personnel 


APPENDIX  1 


PRE-ASTHMA  EDUCATION  PROGRAM  QUESTIONNAIRE 

NAMEOFSCHOOI YOUR  NAME DATE. 

1 .    Name  3  things  that  can  make  a  child's  asthma  worse; 


2.    List  3  common  symptoms  of  an  asthma  flare  (attack): 


3.   What  are  2  things  a  child  can  do  if  his/her  asthma  symptoms  occur  at  school? 


4.    List  2  things  you  can  do  if  a  child  complains  of  asthma  symptoms  at  school: 


5.  Name  the  device  used  to  identify  early  signs  of  an  asthma  flare: 

6.  How  confident  are  you  that  you  can  help  a  child  to  manage  his/her  asthma  at  school? 
LJ  Not  at  all      n  Somewhat      D  Fairly      D  Very 

7.  Do  you  or  any  family  members  have  asthma?      [ !  Yes      l:  No 

8.  How  valuable  do  you  think  it  is  to  educate  school  personnel  about  asthma? 
n  Not  at  all      D  Somewhat      I '  Fairly      n  Very 

9.  is  asthma  usually  caused  by  emotional  or  psychological  problems? 
D  Yes      n  No      n  Don't  know 

10.  In  general,  should  children  with  asthma  avoid  exercise?      □  Yes      D  No      1 1  Don't  know 

11.  Is  there  anything  special  about  managing  children's  asthma  in  school  that  you  hope  to  learn  from 
this  training?  


Respiratory  Care  •  October  "98  Vol  43  No  10  809 


Asthma  Managkmhnt  Training  for  School  Personnel 


APPENDIX  2 


ASTHMA  EDUCATION  PROGRAM  FOLLOW-UP  QUESTIONNAIRE 


NAME  OF  SCHOOL. 


We  are  evaluating  the  Kaiser  Permanente  (KP)  School  Asthma  Program  you  attended  on .  Please  take  a  few 

minutes  to  complete  this  questionnaire  and  return  it  in  the  pre-addressed,  postage-paid  envelope  enclosed.  Your 
answers  will  help  us  learn  if  this  program  is  meeting  the  needs  of  school  personnel  and  how  it  can  be  improved. 

1 .   Name  3  things  that  can  make  a  child's  asthma  worse: 


2    List  3  common  symptoms  of  an  asthma  flare  (attack): 


3.   What  are  2  things  a  child  can  do  if  his/her  asthma  symptoms  occur  at  school? 


4.    List  2  things  you  can  do  if  a  child  complains  of  asthma  symptoms  at  school: 


5.  Name  the  device  used  to  identify  early  signs  of  an  asthma  flare: 

6.  Is  asthma  usually  caused  by  emotional  or  psychological  problems?    n  Yes    □  No    n  Don't  know 
7    In  general,  should  children  with  asthma  avoid  exercise?      n  Yes      D  No      □  Don't  know 

8.    In  which,  if  any,  peak  flow  zone  is  it  safe  for  the  child  with  asthma  to  exercise  or  engage  in  active 

physical  play?      U  Red      □  Yellow      n  Green 
9    How  confident  are  you  that  you  can  help  a  child  to  manage  his/her  asthma  at  school? 

Ij  Not  at  all      D  Somewhat      a  Fairly      Ll  Very 

10.  Have  your  attitudes,  skills,  or  actions  regarding  children  with  asthma  changed  as  a  result  of  the 
School  Asthma  Program?    n  Yes    □  No    If  yes,  please  explain:  

1 1 .  Have  you  had  a  chance  at  school  to  use  any  of  the  knowledge  or  skills  that  you  learned  in  the 
School  Asthma  Program?     u  Yes     u  No      If  yes,  please  describe:  


12.  If  you  or  a  family  member  under  your  care  has  asthma,  did  the  training  improve  your 
management  of  asthma?       u  Not  at  all       i  A  little      n  A  good  deal      l  A  great  deal 

13.  Has  the  asthma  education  inservice  provided  by  KP  been  valuable  to  you  as  an  educational 
professional?       lj  Not  at  all  [  i  Somewhat  Lt  Fairly  u  Very 

14  How  often  should  an  asthma  education  inservice  be  conducted  for  school  personnel? 

! :  Annually     n  Every  2  yrs     n  Every  3  yrs     U  Other:  


15.  Comments  or  suggestions  about  the  KP  School  Asthma  Training  Program: 


810  RiSI'IRATOKY  CaRF  •  OCTOHHR  "98  Voi.  43  No   10 


Reviews,  Overviews,  &  Updates 


Flexible  Fiberoptic  Bronchoscopy  in  1998 


Robert  H  Poe  MD  and  Robert  H  Israel  MD 


Introduction 
Diagnostic  Utility 

Roentgenographic  Abnormalities  Suggesting  Cancer 

Hemoptysis 

Pneumonia 

Interstitial  Lung  Disease  in  the  Immunocompetent  Patient 
Therapeutic  Utility 

Atelectasis 

Other  Uses 
Bronchoscopy  and  Lung  Transplantation 
Commonly  Encountered  Problems 
Emerging  Technologies 
Conclusions 

[Respir  Care  1998;43(  10);81 1-8I9J  Afcv  words:  fiberoptic  bronchoscopy, 
pidmoiuuy  diseases,  diagnosis,  airway  management,  atelectasis,  lung  cancer, 
liemopty^sis.  complications,  biopsy  techniques. 


Introduction 

Bronchoscopy  has  progressed  a  long  way  since  Gustav 
Killian  extracted  a  piece  of  pork  bone  from  his  patient's 
bronchus  in  1897.'  During  the  early  20th  century,  the  use 
of  inflexible  bronchoscopes  prevailed.  Early  instruments 
were  rigid  tubes,  and  imaging  was  enhanced  by  the  devel- 
opment of  the  optical  telescope  for  both  forward  and  an- 
gled vision.-  It  was,  however,  the  introduction  of  the  fi- 
beroptic bronchoscope  in  1970  that  changed  respiratory 
medicine.'  Now,  after  more  than  2  decades  of  revolution- 
izing the  ability  to  diagnose  and  manage  diverse  thoracic 
diseases,  the  fiberoptic  bronchoscope  has  become  virtually 
indispensable  to  pulmonologists.  The  directional  control 
of  the  instrument's  tip  allows  a  bronchoscopist  to  reach 


into  the  depths  of  the  lungs,  and  its  flexibility  allows  better 
visualization  of  the  upper  lobes.  The  development  of  small- 
caliber  scopes  and  new  accessories  have  expanded  the  use 
of  the  instrument  and  enhanced  its  utility  in  a  variety  of 
therapeutic  considerations  and  in  the  diagnosis  of  lung 
cancer,  hemoptysis,  pneumonia,  and  interstitial  lung  dis- 
ease (ILD).  The  years  of  experience  that  have  accompa- 
nied the  evolving  technology,  the  challenge  of  changing 
diseases,  such  as  acquired  immunodeficiency  syndrome 
(AIDS)  and  multidrug-resistant  tuberculosis,  and  the  eco- 
nomics of  the  times  require  continuing  evaluation  of  the 
role  of  fiberoptic  bronchoscopy  (FOB)  and  how  it  is  best 
used  in  medicine.  All  persons  involved  in  FOB  should  be 
familiar  with  the  evolution  of  the  procedure.  This  review 
addresses  a  few  of  the  current  issues  and  problems  that 
face  us  in  1998  and  beyond. 


Robert  H  Poe  MD  and  Robert  H  Israel  MD  are  Professors  of  Medicine 
at  the  University  of  Rochester  School  of  Medicine  and  Dentistry,  Roch- 
ester, New  Yorl<.  Dr.  Poe  is  Director  of  Respiratory  Care  at  Highland 
Hospital,  and  Dr.  Israel  is  Director  of  Respiratory  Care  at  St  Mary's 
Hospital,  both  major  affiliates  of  the  University. 

Reprints  and  Correspondence:  Robert  H  Poe  MD,  Highland  Hospital. 
Rochester  NY  14620.  rpoefe'highland. rochester.edu. 


Diagnostic  Utility 

The  usefulness  of  FOB  in  diagnosis  has  been  addressed 
in  inany  medical  reviews  over  the  past  decade,-*-'  and  the 
indications  listed  in  each  review  are  remarkably  similar. 
One  article  suggests  using  roentgenographic  guidelines  for 
selecting  patients.**  The  authors  recommended  FOB  for 


Respiratory  Care  •  October  "98  Vol  43  No  10 


811 


Flexible  Fiberoptic  Bronchoscopy  in  1998 


Tabic  I.       Diagnostic  Uses  lor  ihc  Eihcroptic  Bronchoscope 


To  evalualc  lung  lesions  of  unknown  etiology  appearing  on  chest  roentgenograph  as  a  dense  mass,  infiltrate,  atelectasis,  or  localized  hyperlucency. 

To  assess  airway  patency. 

To  investigate  unexplained  hemoptysis,  cough  or  change  in  cough,  or  localized  whcczc  or  stridor. 

To  search  for  origin  of  suspicious  or  positive  sputum  cytology. 

To  investigate  the  etiologs  of  unexplained  paralysis  of  a  vocal  cord,  hcniidiapliragni,  superior  \cna  ca\c  syndrome,  chylolhorax,  or  unexplained 

pleural  effusion. 
To  evaluate  problems  associated  with  endotracheal  tubes,  such  as  tracheal  damage,  airway  obstruction,  or  lube  placement. 
To  stage  lung  cancer  preoperatively  and  to  subsequently  evaluate,  if  appropriate,  response  to  therapy. 
To  obtain  material  for  microbiologic  studies  in  suspected  pulmonary  infections. 
To  evaluate  the  airway  for  tear  or  other  injury  after  thoracic  trauma. 
To  evaluate  for  suspected  tracheoesophageal  fistula. 

To  determine  location  and  extent  of  respiratory  tract  injury  after  acute  inhalation  injury  or  aspiration. 
To  obtain  material  for  study  from  the  lungs  of  patients  with  dilTuse  or  focal  lung  disease. 


•  .^diiplcd  fruiii  Rt-rcrciice  v,  « iih  pi 


Tabic  2.      The  Most  Common  Indications  for  Bronchoscopy,  as 
Ranked  by  Opinion  of  871  Bronchoscopists* 


Indication 


Ranking 


Mass.  nodule,  suspicious  lesion,  or  cancer 

Hemopty.sis.  or  bleeding 

Pneumonia,  or  infection 

Diffuse  interstitial  disease  in  immunocompetent  patients 

Therapeutic  bronchoscopy  for  lobar  or  segmental  atelectasi; 

Cough  or  wheeze 

Immunoconipromi.sed  patient 

AIDS/human  immunodeficiency  virus-positive  patient 

Tracheal  disease  or  stridor 

Intensive  care  unit  or  use  of  ventilator 

Other 


96.4 
81.1 
65.1 
6:.l 

.56.4 
23.4 
15.3 


1.5 

4.7 


■  10.  »ilh  pen 


patients  when  lobar  eollap.se,  hilar  abnormality,  pericardial 
effusion,  mass  lesions  (>  4  cm),  and  pleural  effusion  were 
apparent  on  chest  roentgenographs.  Most  patient  series 
refer  to  the  American  Thoracic  Society's  guidelines  for 
FOB  published  in  1987  (Table  I)."  However,  when  871 
bronchoscopists  were  asked  in  an  American  College  of 
Chest  Physicians  survey  4  years  later  to  list  their  .'i  most 
common  indications  for  performing  FOB,  there  were  1 1 
different  answers  (Table  2).  and  while  each  was  included 
in  the  original  guidelines,  it  was  apparent  that  differing 
priorities  prevailed.'"  Of  the  top  .5  indications,  4  were 
diagnostic.  The  top  2  were  roentgenographic  abnormalities 
suggesting  cancer  and  hemoptysis.  These  were  followed 
by  pneumonia  and  ILD,  The  fifth  was  therapeutic  bron- 
choscopy for  lobar  or  segmental  atelectasis.  Herein,  we 
brietly  di.scuss  the  current  status  of  each  of  these  most 
pojiular  diagnoslic  uses. 


Roentgenographic  Abnormalities  Suggesting  Cancer 

Virtually  any  unexplained  lesion  on  a  chest  roentgeno- 
graph can  be  caused  by  cancer.  Mass  lesions,  infiltrates, 
and  atelectasis  are  the  most  common.  Localized  hyperlu- 
cencies  can  result  from  an  endobronchial  tumor.  While 
there  is  little  disagreement  that  FOB  is  indicated  under 
such  circumstances,  the  diagnostic  yield  may  vary,  and  the 
bronchoscopist  should  be  prepared  to  alter  the  procedure 
to  maximize  the  likelihood  of  a  diagnosis  and  to  prevent 
performing  an  e.xpensive  and  fruitless  procedure.  In  pa- 
tients with  an  endobronchial  mass,  the  diagnostic  yield 
with  direct  forceps  biopsy  approaches  100%  and  can  be 
achieved  with  as  few  as  3  biopsies."  When  the  tumor  is 
submucosal  or  peribronchial  in  location,  FOB  has  a  lower 
diagnostic  yield."  Fiberoptic  bronchoscopy  with  needle 
aspiration  through  the  bronchial  wall  can  increase  the  like- 
lihood of  a  positive  diagnosis  in  these  patients.  Shure  and 
Fedullo'-  showed  a  positive  diagnosis  in  557r  of  proce- 
dures with  forceps  biopsy,  71%  with  transbronchial  needle 
aspiration  (TNA).  and  87%  when  using  both  sampling 
modalities. 

Peripheral  lung  nodules  are  usually  seen  on  chest  roent- 
genographs but  not  through  the  bronchoscope.  Performing 
FOB  without  fluoroscopic  guidance  is  a  low-yield  proce- 
dure; however,  with  fluoroscopic  help,  the  procedure  can 
yield  a  diagnosis  in  as  many  as  67%  of  patients,"  A  re- 
tractable needle  has  been  developed  that  can  enhance  the 
diagnostic  yield  even  more  in  this  setting.'^  The  retract- 
able needle  protects  the  bronchoscope  better  than  the  ear- 
lier fixed-needle  devices,  and  an  even  newer  series  of 
devices  have  been  developed  to  facilitate  transfer  of  the 
specimen  onto  a  glass  slide,  v\ith  results  as  favorable  as 
those  with  earlier  needles,"  Clearly,  the  bronchoscopic 
yield  using  such  devices  depends  on  other  factors  as  well, 
inchiiling  the  experience  of  the  btoiichoscopisi  in  using  the 


812 


Ri-spiR.vroRV  C,\Ri:  •  October  "98  Voi  4.^  No  10 


Flexible  Fiberoptic  Bronchoscopy  in  1998 


device."'  The  size  of  the  lesion  (lesions  <  2  cm  in  diam- 
eter have  a  reduced  yield),  roentgenographic  characteris- 
tics of  the  abnormality,  and  of  course,  whether  fluoros- 
copy is  or  is  not  used  in  the  procedure  also  influence 
results. 

Metastatic  disease  can  present  in  a  number  of  ways. 
including  the  presence  of  >  1  peripheral  nodules,  lym- 
phangitic  spread,  mediastinal  or  hilar  adenopathy,  or  en- 
dobronchial lesions.  Breast,  colon,  and  renal  cancers  tend 
to  metastasize  submucosally.'^  Given  the  range  of  possible 
presentations,  FOB  technique  must  be  tailored  to  best  ad- 
dress the  specific  presentation.  We  found  the  highest  yields 
in  patients  with  symptoms  or  signs  of  endobronchial  dis- 
ease or  with  diffuse  infiltrates,  as  determined  by  chest 
roentgenography,  when  transbronchial  forceps  biopsy 
(TBB)  was  added  to  the  procedure.'^  The  spectrum  of 
extrapulmonary  malignancies  that  metastasize  to  the  bron- 
chus has  been  changed  by  the  AIDS  epidemic.  Kaposi's 
sarcoma  is  the  most  common  cause  of  endobronchial  mass 
lesions  in  persons  infected  with  human  immunodeficiency 
virus:  other  sarcomas  and  lymphomas  are  responsible  for 
a  large  number  of  both  endobronchial  and  submucosal 
malignancies.'^ 

Fiberoptic  bronchoscopy  is  also  useful  in  patients  with 
positive  sputum  cytology  results  and  a  normal  chest  roent- 
genograph. Only  609'r-70%  of  occult  tumors  are  detected 
on  initial  FOB.  Repeated  procedures  are  recommended  at 
3-month  intervals  when  the  result  is  nondiagnostic.'"  Fu- 
ture application  of  fluorescent  agents  that  are  preferen- 
tially retained  by  neoplastic  cells  may  allow  earlier  local- 
ization.-" 

Fiberoptic  bronchoscopy  with  TNA  can  be  used  for  stag- 
ing bronchogenic  carcinoma.  Any  lymph  node  adjacent  to 
the  tracheobronchial  tree  can  be  sampled.  A  complete  un- 
derstanding of  the  anatomy,  instrumentation,  and  technique 
is  required  to  maximize  the  sensitivity  of  the  procedure. 
Until  this  is  mastered  by  more  bronchoscopists,  the  pro- 
cedure is  unlikely  to  replace  mediastinoscopy  or  medias- 
tinotomy  as  standard  staging  procedures. 

Hemoptysis 

Hemoptysis  was  the  second  most  common  reason  for 
performing  FOB  according  to  the  bronchoscopists.'"  This 
is  a  frightening  symptom  that  suggests  .serious  disease. 
Bronchitis  is  the  most  frequent  cause  of  hemoptysis  in 
smokers  but.  without  investigation,  cannot  be  assuined  to 
be  the  cause.  Utilizing  selection  criteria  for  FOB  can  re- 
duce the  number  of  unnecessary  procedures.  Most  patients 
with  bronchogenic  carcinoma  will  have  an  abnormal  chest 
roentgenograph.-'  A  study  of  patients  with  normal  or  non- 
localizing  chest  roentgenographs  suggested  that  virtually 
all  patients  with  bronchogenic  carcinoma  would  have  been 
diagnosed  if  FOB  had  been  limited  to  those  with  two  of 


three  characteristics,  namely,  age  30  years  or  older,  male 
sex,  or  a  smoking  history  of  40  or  more  pack  years. -- 
Fiberoptic  broncho.scopy  performed  within  48  hours  of  an 
acute  bleeding  event  has  been  shown  to  enhance  identifi- 
cation of  the  bleeding  site  but  does  not  result  in  more 
definitive  diagnoses.-' 

Pneumonia 

Fiberoptic  bronchoscopy  can  be  useful  in  identifying 
the  cause  of  undiagnosed  pneumonia,  especially  in  immu- 
nocompromised patients.  Among  immunocompetent  pa- 
tients. FOB  is  usually  reserved  for  patients  with  atypical 
pneumonias  where  a  postobstructive  process  is  suspected, 
or  where  there  has  been  lack  of  response  to  broad-spec- 
trum antibiotics:  it  is  also  u.sed  as  an  aggressive  approach 
in  the  acutely  ill  patient  in  the  intensive  care  unit.  Bron- 
choalveolar  lavage  (BAD  is  used  widely  to  assist  in  the 
diagnosis  of  lower  respiratory  tract  infections  in  both  im- 
munocompetent and  immunocompromised  patients.  The 
procedure  is  safe,  with  complications  usually  related  to 
FOB  and  not  to  BAL  itself.  Bronchoalveolar  lavage  re- 
trieves an  alveolar  sample  and  differs  from  bronchial  wash- 
ing, which  is  airway  in  origin.  Large  volumes  (100-300 
mL)  of  pyrogen-free  nonnal  saline  are  instilled  by  30-  to 
60-mL  aliquot  through  the  suction  channel  of  the  bron- 
choscope, with  the  instrument  wedged  in  a  third-  to  fourth- 
order  subsegmental  bronchus.  About  609r  of  the  instilled 
fluid  is  recovered.  The  first  aliquot  is  usually  discarded 
due  to  contamination  by  airway  cells  and  secretions.  The 
greatest  value  of  the  procedure  is  in  the  recovery  of  patho- 
gens not  normally  found  in  respiratory  secretions  (ie.  Pneu- 
mocystis carina.  Mycobacterium  tuberculosis,  and  a  num- 
ber of  fungal  pathogens). 

The  diagnostic  value  of  BAL  became  apparent  w  ith  the 
on.set  of  the  AIDS  epidemic,  and  it  has  proven  invaluable 
in  evaluating  AIDS  patients  with  pulmonary  infiltrates.  It 
is  of  similar  value  in  patients  with  other  forms  of  immu- 
nosuppression, as  .seen  following  organ  transplantation  and 
chemotherapy  for  malignancy.  BAL  is  less  helpful  for 
microorganisms  that  colonize  the  respiratory  tract  without 
causing  infection  (eg.  the  fungi  Candida  albicans  and  As- 
pergillus species,  atypical  mycobacteria,  cytomegalovirus. 
Herpes  simplex,  and  bacteria).  Therefore,  while  the  sensi- 
tivity of  BAL  for  these  organisms  is  high  (up  to  88%).  the 
specificity  is  relatively  low  22%-53%).  which  could  lead 
to  the  overdiagnosis  of  infection.--*  Adding  TBB  to  BAL  is 
helpful  for  identifying  tissue  invasion  by  these  organisms, 
which  is  characteristic  of  pneumonitis. 

Other  than  Legionella  pneumophila  infection,  which  can 
be  readily  diagnosed  by  BAL,  quantitative  culture  using  a 
double-sheathed  protected  specimen  brush  (PSB)  is  nec- 
essary to  distinguish  bacteria  colonizing  the  respiratory 
tract  from  those  causing  pneumonia.  The  same  quantita- 


Respiratory  Care  •  October  '98  Vol  43  No  10 


813 


Flexible  Fiberoptic  Bronchoscopy  in  1998 


tive  approach  has  been  applied  to  BAL.  For  a  PSB  to  be 
diagnostic,  the  threshold  value  of  10''  colony-forming  units 
(cfu)  is  usually  accepted.  This  breakpoint  has  been  con- 
firmed by  several  studies  in  mechanically  ventilated  pa- 
tients.-''-^s  The  threshold  value  for  BAL  fluid  has  been 
reported  as  high  as  10^  cfu/mL.  Using  this  cfu  threshold 
value,  Thorpe  et  al  -"^  found  a  good  correlation  with  the 
presence  of  pneumonia,  and  of  more  importance,  no  pa- 
tient without  pneumonia  had  a  BAL  fluid  culture  at  or 
above  the  \(f  level.  Unfortunately,  quantitative  culture  of 
unprotected  BAL  fluid  has  not  proven  as  useful  as  the  PSB 
in  mechanically  ventilated  patients  and  remains  controver- 
sial. Torres  et  al-^  found  good  conelation  at  the  10^  cfu/mL 
breakpoint  for  the  two  techniques,  while  Chastre  et  al-" 
found  the  BAL  cultures  to  be  of  little  value  compared  with 
the  PSB  at  the  10'^  cfu/mL  level. 

The  optimal  BAL  volume  has  not  been  established,  and 
the  dilution  used  may  affect  the  semiquantitative  culture 
result.  Whether  the  first  aliquot,  which  is  often  regarded  as 
being  heavily  contaminated  by  bronchial  rather  than  alve- 
olar organisms,  is  discarded  or  not  may  also  alter  the  re- 
sult.-*' A  balloon-tipped  "protected"  catheter  has  been  de- 
veloped that  increases  the  specificity  of  BAL  in  these 
patients."'  Recent  studies  of  BAL  technique  suggest  a  close 
correlation  between  BAL  cells  containing  intracellular  bac- 
teria and  pneumonitis  in  the  corresponding  lung  sample  in 
mechanically  ventilated  patients  who  died  from  nosoco- 
mial pneumonia.^'  Except  for  the  latter  study,  it  should  be 
emphasized  that  almost  all  assessments  of  BAL  and  PSB 
in  pneumonia  have  been  in  patients  who  are  not  receiving 
antibiotics  and  may  not  be  helpful  if  empiric  antibiotic 
therapy  has  been  recently  instituted  or  changed  or  only 
recently  discontinued. 


ease).'-  Other  studies  have  shown  similar  results."'^ 
Lymphangitic  carcinomatosis,  eosinophilic  pneumonia, 
and  pulmonary  alveolar  proteinosis  are  other  ILDs  that 
can  be  diagnosed  by  bronchoscopy."'  "  When  patho- 
logic findings  are  nonspecific,  FOB  with  TBB  may  be 
supportive  but  not  diagnostic.  Idiopathic  pulmonary  fl- 
brosis  is  an  example  of  lung  involvement  that  occurs  in 
a  nonuniform  fashion. 

Early  studies  clearly  favored  open  lung  biopsy  for  chronic 
ILD  patients.-"*  Still,  the  inconvenience,  invasiveness,  and 
discomfort  sometimes  make  surgery  less  acceptable  to  the 
patient.  Modern  thoracoscopic  techniques,  where  avail- 
able, have  made  surgical  biopsy  a  more  attractive  option. 
We  will  usually  perform  FOB  with  TBB  initially  and, 
depending  upon  the  result  and  clinical  course,  proceed  to 
a  surgical  biopsy  if  necessary.  Clinical  outcome  supports 
this  approach.'''  A  majority  of  pulmonary  physicians  ap- 
pear to  favor  FOB  with  TBB  as  the  initial  diagnostic  pro- 
cedure in  ILD."*"  In  situations  in  which  a  large  amount  of 
tissue  is  necessary  for  study,  as  in  some  immunologically 
mediated  diseases,  one  should  forgo  FOB  and  TBB  and 
proceed  directly  to  open  lung  biopsy. 

Bronchoalveolar  lavage  has  no  clear  role  for  diagnosis 
in  ILD.  but  may  provide  clues  to  many  disorders.  Poly- 
morphonuclear cells  are  increased  in  idiopathic  pulmonary 
fibrosis,  collagen  vascular  diseases,  pneumoconioses,  and 
bronchiolitis  obliterans  organizing  pneumonia.-"  Lipid- 
laden  macrophages  are  seen  in  amiodarone  toxicity,  he- 
mosideran-laden  macrophages  are  seen  in  the  hemorrhagic 
syndromes,-'-  and  eosinophils  are  seen  in  eosinophilic  pneu- 
monia and  Churg-Strauss  syndrome.-"  The  T  helper/T  sup- 
pressor ratio  of  lymphocytes  is  altered  in  sarcoidosis,  hy- 
persensitivity pneumonitis,  and  other  granulomatous 
disorders.-'-'-*^ 


Interstitial  Lung  Di.sease  in  the 
Immunuconipetent  Patient 

Many  diseases  manifest  diffuse  lung  infiltration  with 
clinical  clues  suggesting  the  cause  and  appropriate  ap- 
proach for  diagnosis  and  therapy.  Hypersensitivity  pneu- 
monitis may  be  suspected  on  the  basis  of  clinical  history. 
Appropriate  serologic  studies,  antigen  avoidance,  or  re- 
sponse to  systemic  corticosteroid  therapy  may  conflrm  the 
diagnosis  without  resorting  to  tissue  biopsy. 

Fiberoptic  bronchoscopy  with  TBB  is  an  established 
technique  to  evaluate  diffuse  lung  disease  when  clinical 
clues  are  absent.  Sarcoidosis,  pulmonary  alveolar  proteino- 
sis, histiocytosis  X.  and  a  variety  of  tumors,  such  as  bron- 
chioloalveolar  cell  carcinoma  and  lymphoma,  have  patho- 
logic features  that  lend  to  sampling  by  TBB  and  a  definitive 
diagnosis.  We  found  a  success  rate  approaching  '■)b'/r 
with  TBB  in  sarcoidosis  patients  when  parenchymal  lung 
infillralion  was  present  (stage  II  or  more  advanced  dis- 


Therapeutic  Utility 


Atelectasis 


The  fifth  indication  for  FOB  has  therapeutic  implica- 
tions. Therapeutic  bronchoscopy  for  lobar  or  segmental 
atelectasis  has  been  widely  practiced.  Because  atelectasis 
is  most  often  due  to  ventilation  at  low  lung  volumes  with 
subsequent  closure  of  small  airways,  respiratory  therapy  to 
increase  lung  volumes  can  be  effective.  Many  physicians 
believe  FOB  is  a  relatively  nontraumatic  method  to  both 
assess  and  treat  atelectasis.  However,  the  relative  absence 
of  well-designed  clinical  studies  has  led  to  a  series  of  case 
reports  and  empiric  observations  to  support  the  practice. 

A  prospective  study  by  Marini  et  aH"  set  out  in  a  ran- 
dom fashion  to  analyze  the  clinical  outcome  of  patients 
treated  with  respiratory  therapy  preceded  by  FOB.  without 
FOB.  or  with  delayed  FOB.  The  authors  concluded  that 


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Flexible  Fiberoptic  Bronchoscopy  in  1998 


FOB  did  not  add  more  beneCil  than  lespiratory  therapy 
alone  in  treating  acute  lobar  atelectasis.  Unfortunately,  this 
has  been  cited  by  some  to  deny  a  role  for  FOB  in  treating 
acute  atelectasis.  The  data  have  been  interpreted  by  others 
as  showing  a  slightly  better  result  for  FOB  in  intubated 
patients  and  a  definite  superiority  in  nonintubated  patients.-* '' 
We  believe  the  study  by  Marini  et  aF<'  points  out  the 
benefit  of  respiratory  therapy  in  this  setting  but  should  not 
be  used  to  deny  potential  treatment  by  FOB  for  patients  in 
whom  prompt  resolution  of  the  atelectasis  would  avoid 
intubation  and  mechanical  ventilation.  Until  this  indication 
is  studied  further,  clinical  judgment  will  continue  to  be 
required  to  select  which  patients  with  atelectasis  are  too 
unstable  or  unable  to  cooperate  with  therapy  to  benefit 
from  FOB. 

Other  Uses 

The  versatility  of  FOB  is  also  seen  in  situations  involv- 
ing other  therapeutic  interventions.  Both  control  of  the 
airway  with  intubation  and  clearance  of  obstructing  or 
potentially  obstructing  lesions  can  be  accomplished  by 
FOB.  Patients  with  fractures  of  the  cervical  spine  or  sus- 
pected cervical  injury  inay  require  intubation  to  either  pro- 
tect the  airway  or  to  utilize  mechanical  ventilation.  FOB 
facilitates  transnasal  intubation  and  provides  an  alternative 
to  emergency  tracheostomy.  Foreign-body  aspiration  or 
aspiration  of  blood  may  result  in  airway  obstruction  and 
atelectasis.  FOB  can  localize  the  obstruction  and  aspirated 
objects  can  be  removed  by  forceps  or  basket.  Intubation 
prior  to  FOB  will  allow  repeated  introduction  and  removal 
of  the  bronchoscope  and  increase  the  likelihood  of  suc- 
cess. Large  foreign  bodies,  however,  require  a  rigid  bron- 
choscope. Inoperable  obstructing  tumors  can  be  palliated 
with  local  radiation  implants  or  la.ser  resection  using  FOB. 

Brachytherapy  is  an  excellent  technique  for  opening  the 
airway  in  the  presence  of  an  obstructive  endobronchial 
tumor.  This  therapeutic  maneuver  complements  endobron- 
chial laser  resection  and  is  a  technique  for  managing  ad- 
vanced airway  obstructive  disease.  At  present,  there  is  no 
standardization  of  radiotherapy  or  endoscopic  indications. 
A  recent  review  of  365  patients  with  obstructing  endo- 
bronchial tumors  yielded  encouraging  results  with  brachy- 
therapy.-"* Sixty-five  percent  of  patients  treated  achieved  a 
palliative  effect  with  few  complications  and  no  discom- 
fort. Prospective  controlled  trials  will  certainly  be  helpful 
for  future  direction.  Blood  clots  can  be  removed  mechan- 
ically or  locally  lysed  by  the  direct  instillation  of  a  throm- 
bolytic agent  under  FOB  guidance. 

Hemorrhage  from  the  lung  can  be  difficult  to  control 
with  FOB.  Massive  hemorrhage  is  best  managed  by  use  of 
the  rigid  bronchoscope,  which  allows  better  visualization 
and  control.  With  submassive  bleeding,  FOB  can  be  used. 
Identification  of  the  locus  of  bleeding  is  of  prime  impor- 


tance: if  it  is  distal  to  the  major  airways,  wedging  of  the 
bronchoscope  will  limit  the  bleeding  to  a  subsegment  of 
the  lung.  This  technique  is  invaluable  for  the  control  hem- 
orrhages that  occur  during  TBB.  We  do  not  remove  the 
scope  nor  suction  until  the  clot  is  formed.  Our  own  expe- 
rience in  >  200  cases  has  revealed  success  in  using  this 
technique.  Passage  of  a  Fogarty  catheter  through  the  chan- 
nel of  the  bronchoscope  is  also  useful  to  tamponade  hem- 
orrhage.■♦''^"  Other  methods  of  control  include  the  instil- 
lation of  thrombin.^'  Laser  photocoagulation  by  FOB  is 
another  method  of  providing  hemostasis.^-  When  the  air- 
way is  compromised  by  extrinsic  compression  or  loss  of 
tracheal  cartilage,  a  prosthetic  stent  may  be  placed  to  pro- 
vide patency.  While  usually  requiring  rigid  bronchoscopy, 
placement  by  FOB  has  been  done.''' 

Bronchoscopy  and  Lung  Transplantation 

Surgical  advances  coupled  with  better  immune  modu- 
lators have  made  lung  transplantation  a  feasible  therapy 
for  patients  with  end-stage  lung  disease.  Fiberoptic  bron- 
choscopy has  become  a  valuable  tool  for  surveillance  in 
posttransplantation  patients  and  for  diagnosing  the  cause 
of  deteriorating  function  in  such  patients.  There  are  at  least 
three  indications  for  FOB  in  the  post-transplant  patient, 
namely  diagnosing  the  etiology  of  a  changing  clinical  con- 
dition, assessing  the  response  of  the  allograft  to  immuno- 
suppression or  active  treatment  for  infection,  and  as  part  of 
a  surveillance  protocol  to  define  early  rejection. 

Many  recent  studies  have  demonstrated  the  benefit  of 
FOB  in  transplant  patients.  Combined  use  of  BAL  and 
TBB  are  useful  in  diagnosing  lung  rejection  and  infection 
in  transplant  recipients.  This  approach  has  been  shown  to 
be  safe,  with  a  high  diagnostic  yield  and  an  impact  on 
therapy.'^''  There  is  a  range  of  opinion  regarding  the  utility 
of  surveillance  FOB  and  its  impact  on  patient  manage- 
ment. A  recent  survey  of  transplant  centers  assessed  a 
consensus  regarding  the  importance  of  surveillance  bron- 
choscopy.^'' Eighty-one  percent  of  91  programs  responded 
to  a  questionnaire.  A  majority  of  the  programs  (68%)  per- 
formed surveillance  bronchoscopy  with  TBB,  and  91% 
biopsy  more  than  one  lobe.  Ninety-two  percent  of  all  the 
programs  perform  FOB  within  the  first  month  of  trans- 
plantation, and  697f  continue  to  biopsy  on  a  regular  basis. 
The  majority  of  programs  (83%)  believe  the  surveillance 
FOB  impacts  patient  management  at  least  10%  of  the  time. 
Although  the  consensus  supports  surveillance  FOB,  a  ran- 
domized multicenter  trial  or  registry  will  be  required  be- 
fore the  full  effect  of  this  practice  on  the  lung  transplant 
recipient  can  be  determined. 

Commonly  Encountered  Problems 

While  FOB  is  a  well-tolerated  procedure  that  can  be 
performed  in  most  subjects,  no  discussion  of  FOB  would 


Respiratory  Care  •  October  "98  Vol  43  No  10 


815 


Flexible  Fiberoptic  Bronchoscopy  in  1998 


Table  3.      Coniplicalions  of  Fiberoptic  Bronchoscopy 

PrenieJicatiiin 

Respirator)  depression 

Hemodynamic  instability 

Hyperexcitable  stale 
Topical  anesthesia 

Seizures 

Hemodynamic  collapse 

Respiratory  arrest 

Laryngospasm  or  bronchospasm 

Methemoglobinemia  (cetamine) 
Procedure-related  trauma  or  reaction 

Airway  injury 

Laryngospasm  or  bronchospasm 

Hypoxemia 

Cardiac  arrhythmias 

Aspiration 

Bleeding 

Pneumothorax 

Postprocedure  fever 

Pneumonia 


be  complete  without  discussing  potential  problems  asso- 
ciated with  the  proceduie.  The  incidence  of  complications 
from  FOB  is  extreinely  low.  Mortality  is  0.0\9c,  and  major 
morbidity  is  0.087^  .-'^''  More  than  half  of  the  life-threatening 
complications  ai^e  associated  with  premedication  or  topical 
anesthesia  and  not  with  the  procedure  itself.  Table  3  lists  the 
common  problems  that  can  be  encountered  with  FOB. 

A  benzodiazepine  (usually  midazolam  or  diazepam)  in 
combination  with  an  opiate  (eg.  codeine,  morphine,  or 
meperidine)  is  frequently  used  for  premedication  and  is 
recommended  to  achieve  patient  cooperation.  Premedica- 
tion dosing  should  be  reduced  or  even  omitted  for  patients 
at  greatest  risk,  (ie.  the  elderly  with  underlying  cardiac, 
pulmonary,  or  hepatic  disease).  Careful  titration  of  the 
benzodiazepine  dose  is  e.\tremely  important,  and  each  case 
should  be  dealt  with  on  an  individual  basis.  We  usually 
administer  midazolam  at  a  rate  of  1  mg/min  and  do  not 
exceed  a  total  dose  of  10  mg.  Flumazenil  is  a  benzodiaz- 
epine antagonist  that  will  reverse  benzodiazepine  sedation 
but  is  less  reliable  in  reversing  respiratory  depression. '^^ 
With  judicious  use  of  benzodiazepines,  we  find  its  use 
seldom  necessary. 

Topical  anesthesia  makes  FOB  possible.  It  helps  control 
cough,  gagging,  and  excessive  swallowing.  The  agent  is 
usually  applied  to  the  nose,  oropharynx.  larynx,  and  tra- 
cheobronchial tree.  Most  agents  are  rapidly  absorbed  fi\)m 
the  respiratory  tract  and  have  the  potential  to  produce  sys- 
teiTiic  toxicity.  We  prefer  to  use  1 9r  or  2%  lidocaine.  which 
has  a  wide  safety  margin,  and  avoid  exceeding  a  300-mg 
total  dose  in  any  given  patient.  Tetracaine,  which  is  ofleii 
combined  with  benzocaine.  may  produce  an  adverse  reac- 
tion without  warnins:,  and  cetamine  has  been  known  to 


induce  methemoglobinemia;  hence,  neither  is  now  recom- 
mended. 

Cocaine,  a  vasoconstrictor,  is  a  holdover  from  the  days 
of  rigid  bronchoscopy,  and  while  it  is  effective,  toxicity  is 
seen  when  patients  cannot  hydrolyze  the  drug,  and  current 
regulatory  requirements  for  handling  the  controlled  sub- 
stance are  such  that  it  is  regarded  as  an  impractical  choice. 
Superior  laryngeal  nerve  blocks  and  transtracheal  blocks 
are  good  alternatives  when  traditional  analgesia  is  inade- 
quate. Laryngospasm  and  bronchospasm  are  the  result  of 
direct  airway  stimulation  by  the  instrument.  Thorough  ap- 
plication of  the  topical  anesthetic  agent  throughout  both 
the  upper  and  lower  airways  will  usually  prevent  spasm. 
Atropine  administered  intramuscularly  about  30  min  be- 
fore the  procedure  is  useful  for  prophylaxis.  One  study 
found  inhaled  ipratropium  more  protective  than  atropine.'^** 
An  aerosolized  /3  agonist  given  just  before  the  procedure  is 
also  useful.  Asthmatics  are  at  particular  risk  for  broncho- 
spasm during  FOB.  However,  a  recent  study  confirmed  the 
safety  of  use  of  FOB  in  asthmatic  subjects.'^'' 

Bleeding  and  pneumothorax  are  considered  major  com- 
plications of  FOB.  In  1979.  Burgher"'  reported  a  1.3% 
mortality  rate  and  a  30.2%  incidence  of  hemoiThage  and 
pneumothorax  with  TBB.  Simply  avoiding  TBB  in  high- 
risk  patients  has  been  shown  to  substantially  reduce  these 
figures.'"'  Bleeding  may  result  from  minimal  trauma  and  is 
usually  regarded  as  significant  when  in  excess  of  50  mL. 
Bleeding  following  bronchial  biopsy  is  more  likely  to  oc- 
cur in  immunocoinpromised  patients  and  in  those  who 
have  a  chest  malignancy.  Usually.  <  5%  of  patients  un- 
dergoing bronchoscopic  biopsy  have  such  bleeding.  Clin- 
ical history  will  usually  identify  at-risk  patients. 

Coagulopathies,  thrombocytopenia,  or  platelet  dysfunc- 
tion from  either  uremia  or  drugs  may  be  contraindications 
to  the  biopsy  procedure.  One  study  suggests  that  FOB  and 
BAL  can  be  safely  performed  in  thrombocytopenic  pa- 
tients''-; none  of  the  patients  in  the  study  had  major  he- 
moptysis although  one  had  significant  epistaxis.  We  do  not 
perform  TBB  if  the  platelet  count  is  <  50.000  or  the 
prothrombin  time  (PT)  or  partial  thromboplastin  time  (PTT) 
are  not  collected  to  within  1-2  seconds  of  their  control 
values.  We  would  be  especially  careful  to  evaluate  for 
these  parameters  in  any  patient  with  renal  or  liver  disease, 
malabsorption  or  malnutrition,  or  an  acquired  coagulopa- 
thy. Using  the  oropharyngeal  route  in  patients  at  risk  for 
bleeding  may  reduce  the  incidence  of  epistaxis.  Routine 
use  of  the  PT  or  PTT  (or  both)  does  not  identify  patients 
who  bleed  or  those  who  do  not  bleed  from  FOB  with 
biopsy.'''  Perhaps  limiting  such  testing  to  those  patients 
with  a  history  of  abnormal  hemostasis  or  a  disease  asso- 
ciated with  a  bleeding  diathesis  makes  sense. 

Fever  is  sometimes  observed  following  FOB.  Older  pa- 
tients with  endobronchial  abnormalities  undergoing  brush- 
iiio  and  others  undcrizoini;  tnultiseumenl  BAI.  seem  most 


816 


RLSPiRAroKV  Care  •  Ociobek  "98  Vol  43  Nt)  10 


Flexible  Fiberoptic  Bronchoscopy  in  1998 


predisposed  to  fever.  The  fever  and  chills  are  usually  tran- 
sient and  can  be  controlled  with  NSAIDS/'^  Unless  fever 
lasts  >  24  hours,  antibiotic  treatment  is  unnecessary.  The 
American  Heart  Association  does  not  recommend  antibi- 
otic prophyla.\is  for  patients  with  heart  disease  undergoing 
FOB,  whereas  it  had  previously  recommended  antibiotics 
for  rigid  bronchoscopy;  patients  with  prosthetic  heart  valves 
or  surgical  systemic-pulmonary  shunts  or  who  have  had  a 
previous  bout  of  endocarditis  are  the  exception  to  this 
recommendation. 

Fiberoptic  bronchoscopy  is  usually  not  performed  after 
myocardial  infarction  because  of  the  fear  of  complications. 
A  recent  study  found  that  the  use  of  FOB  was  safe  in 
post-myocardial  infarction  patients  as  long  as  active  isch- 
emia did  not  occur  at  the  time  of  the  procedure.''-''  This 
study  was  small  yet  suggests  careful  bronchoscopy,  when 
truly  indicated,  can  be  done  in  the  post-myocardial  infarc- 
tion period.  We  continue  to  refrain  from  performing  bron- 
choscopy in  post-myocardial  infarction  patients  unless  there 
is  an  overwhelming  need  for  the  study.  The  safety  margin 
should  be  improved  in  post-myocardial  infarction  patients, 
with  good  sedation  to  allay  patient  anxiety,  hemodynamic 
monitoring,  and  procedures  to  ensure  that  oxygen  satura- 
tion remains  adequate  throughout  the  procedure. 


essary.  A  new  application  of  the  fiberoptic  bronchoscope, 
utilizing  streptokinase,  has  been  successful  for  dislodging 
blood  clots  blocking  the  airway. ^- 

Conclusions 


The  value  of  FOB  as  a  tool  in  respiratory  medicine 
remains  undisputed.  Changing  times  have  created  new  in- 
dications for  FOB,  while  decades  of  experience  and  out- 
come assessment  have  caused  us  to  reflect  on  its  useful- 
ness in  others.  Fiberoptic  bronchoscopy  is  now  used  in 
brachytherapy  and  thrombolysis,  is  employed  regularly  for 
surveillance  in  lung  transplantation,  has  been  adapted  for 
use  with  ultrasonography,  and  has  found  new  uses  in  the 
staging  of  bronchogenic  carcinoma.  New  thin  scopes  can 
reach  farther  into  the  lung,  and  new  biopsy  accessories 
allow  access  to  lesions  previously  only  accessible  by  other 
means.  Tailoring  the  procedure  to  the  individual  patient's 
situation  is  important  to  avoid  an  unnecessary  or  fruitless 
procedure.  While  FOB  remains  an  extremely  safe  proce- 
dure, constant  vigilance  to  the  potential  of  complications 
remains  ever  important. 


Emerging  Technologies 

Use  of  ultrathin  bronchoscopes  have  shown  utility  in 
managing  pediatric  cases  and  in  obtaining  material  from 
the  small  bronchioles.''''*'^  A  new  directable  ultrathin  bron- 
choscope with  an  external  diameter  of  2.7  mm  and  an 
internal  diameter  of  0.8  mm  can  be  used  in  patients  being 
ventilated  with  a  3.5-min  or  larger  endotracheal  tube.  This 
scope  has  been  found  to  be  successful  for  both  BAL  and 
bronchography.  Five  patients  with  peripheral  lung  tumors 
had  successful  identification  of  their  tumors  using  an  ul- 
trathin bronchoscope.*'''  A  device  used  with  the  fiberoptic 
bronchoscope  has  allowed  measurement  of  mucociliary 
activity  in  the  human  bronchi."" 

Fiberoptic  bronchoscopy  can  be  adapted  to  be  used  for 
ultrasonography  and  brachytherapy  for  early-stage  lung 
cancer  patients:  a  recent  report  showed  a  3-year  survival 
rate  of  88.6%.^'^'  Helical  computed  tomography  with  mul- 
tiplanar and  three-dimensional  imaging  has  allowed  three- 
dimensional  reconstruction  that  will  demonstrate  whether 
a  lesion  is  endobronchial,  submucosal,  or  peribronchial.^' 
This  technique  has  promise  in  providing  guidance  to  the 
bronchoscopist  in  sampling  intrathoracic  adenopathy.  Fi- 
nally, airway  obstruction  from  blood  clots  can  be  life  threat- 
ening. Conventional  treatment  has  been  to  remove  the  clot 
with  forceps  extraction,  suctioning,  lavage,  or  balloon-tip 
embolectomy.  Rigid  bronchoscopy  has  at  times  been  nec- 


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Respiratory  C.^re  •  October  '98  Vol  43  No  10 


817 


Flexible  Fiberoptic  Bronchoscopy  in  1998 


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Respiratory  Care  •  October  '98  Vol  43  No  10 


819 


Test  Your  Radiologic  Skill 


Profound  Hypoxemia  in  an  Alcoholic 

Jayashree  S  Parekh  MD  and  Charles  G  Durbin  Jr  MD 


The  patient,  a  33-yeai-old  chronic  aicohoHc,  was  found 
unresponsive  by  his  family  after  a  drinking  binge  that 
lasted  several  days.  According  to  the  family,  the  patient 
appeared  blue  and  not  to  be  breathing.  A  family  member 
restarted  his  breathing  by  use  of  the  Heimlich  maneuver, 
during  which  a  piece  of  meat  was  reportedly  dislodged. 
When  the  rescue  squad  arrived,  the  patient  was  comatose 
and  breathing  spontaneously  at  a  rate  of  20  breaths/min. 
and  he  had  normal  breath  sounds  and  a  pulse  of  103  beats/ 
min.  The  patient  was  brought  to  the  emergency  ward,  where 
he  was  endotracheally  intubated  for  airway  protection. 
Bloody  vomit  was  seen  in  his  pharynx,  and  the  following 
arterial  blood  gas  (ABG)  results  were  obtained  immedi- 
ately after  intubation:  pH  7.30.  partial  pressure  of  carbon 
dioxide  (Pco,)  '^-  Tirn  Hg.  partial  pressure  of  oxygen  (Pq,) 
56  mm  Hg  on  fraction  of  inspired  oxygen  (F,qJ  =  1.6. 
Additional  laboratory  values  at  that  time  included  an  al- 
cohol level  of  470  mg/dL  and  normal  electrolyte  values, 
white  blood  cell  count,  and  liver  enzyme  values.  Magne- 
sium sulfate  and  folic  acid  were  administered  intravenously. 

The  patient's  history  was  remarkable  only  for  alcohol 
withdrawal  seizures.  He  was  admitted  to  the  intensive  care 
unit  (ICU)  with  diagnoses  of  alcohol-induced  coma,  pos- 
sible hypoxic  encephalopathy,  alcoholic  ketoacidosis,  and 
upper  gastrointestinal  bleeding.  In  the  ICU.  his  blood  gases 
rapidly  improved,  allowing  rapid  weaning  from  high  F,q  . 
His  chest  radiograph  demonstrated  no  infiltrates.  Gastros- 
copy  revealed  a  fundal  ulcer  with  clot  formation.  The  pa- 
tient extubated  himself  2  days  after  admission  but  main- 
tained adequate  respiratory  gas  exchange,  requiring  the 
administration  of  only  2-4  L  of  nasal  oxygen.  His  hemat- 
ocrit remained  stable,  and  he  required  no  transfusions.  The 
patient's  primary  problem  was  alcohol  withdrawal,  which 
required  large  doses  of  benzodiazepines  (up  to  30  mg  of 
lorazepam  per  hour)  and  haloperidol. 


Jayashree  S  Parekh  Ml).  DopaiiiiK-ni  ol  Radicihigy.  iintl  C'hurles  G  nurhlii 
Jr  MD.  Dcparlmenl  nl  Ancslhcsioldgy.  IJnivcrslly  ol  Virjiinia.  Char- 
Idllc'svillc.  Virginia. 

Reprints  &  Correspondence:  Charles  G  Durbin  Jr  MD.  University  ol 
Virginia  Health  .System.  Department  of  Anesthesiology.  Box  10010,  Char- 
Idtlcsville  VA  22y06-(KJl().  cgd8v@virginia.edu. 


On  day  10  of  hospitalization,  the  patient's  pulse  oxim- 
etry saturation  on  room  air  was  90%,  and  the  following 
ABG  values  were  obtained:  pH  7.42,  P^q^  40  mm  Hg,  and 
Pq,  52  mm  Hg.  At  this  time,  bilateral  leg  edema  was 
present,  and  concerns  were  raised  about  the  possibility  of 
an  acute  pulmonary  embolism.  A  chest  radiograph  revealed 
no  obvious  reason  for  his  hypoxemia  (Fig.  1 ).  A  perfusion 
study  was  performed,  using  125  MBq  (megabecquerel)  of 
'^^'mTc  (radioactive  technetium)  macro-aggregated  albumin, 
with  the  standard  6  views,  and  a  ventilation  scan  was  done, 
using  740  MBq  of  '  "^Xe  (radioactive  xenon)  in  several 
optimal  projections  with  computer-subtracted  correction 
for  technetium  spilldown.  Figure  2  shows  representative 
anterior  views  of  the  perfusion  (left  panel)  and  images  of 
the  ventilation  (right  panel)  scintigram. 

Questions: 

1.  What  abnormality  is  seen  in  the  perfusion  scan 
(Fig.  2,  left)? 

2.  What  abnormality  is  seen  in  the  ventilation  scan 
(Fig.  2.  right)? 

3.  What  could  be  the  cause  of  this  patient's  hypoxemia? 

Answers: 

In  the  perfusion  scan  (Fig.  2,  left),  very  little  blood  flow 
is  demonstrated  in  the  left  lung.  This  could  be  caused  by 
a  single  large  pulmonary  embolism  obstructing  the  left 
pulmonary  artery.  However,  the  ventilation  scan  (Fig.  2, 
right)  shows  a  matching  defect  with  no  ventilation  of  the 
left  lung.  This  combination,  called  "reverse  mismatch" 
(ventilation  reduction  greater  than  perfusion  reduction),  is 
often  caused  by  complete  or  partial  airway  obstruction. 
The  blood  flow  decrease  is  believed  to  be  caused  by  active 
hypoxic  pulmonary  vasoconstriction  ( HP V )  in  the  hypoven- 
tilated  lung.'  This  patient's  chest  radiograph  (Fig.  1)  is 
almost  entirely  normal,  giving  no  hint  of  the  significant 
air-llow  abnormality  leading  to  severe  hypoxemia.  If  HPV 
was  cotnplete,  the  decrease  in  ventilation  would  be  per- 
fectly matched  by  a  decrease  in  blood  flow,  and  gas  ex- 
change would  not  suffer.  However,  HPV  is  usually  incom- 


820 


Rhsi'iratory  CARii  •  October  "98  Vol  43  No  10 


Test  Your  Radiolociic  Skill 


Fig.  1 .  Anterior-posterior  thoracic  radiograph 
for  33-year-old  chronic  alcoholic  who  was 
admitted  to  intensive  care  unit  with  diag- 
noses of  alcohol-induced  coma,  possible  hy- 
poxic encephalopathy,  alcoholic  ketoacido- 
sis, and  upper  gastrointestinal  bleeding. 


Fig.  2.  Anterior  views  of  perfusion  scintigram  (left)  and  ventilation  scintigram  (right)  for  33-year-old  chronic  alcoholic  who  was  admitted  to 
intensive  care  unit  with  diagnoses  of  alcohol-induced  coma,  possible  hypoxic  encephalopathy,  alcoholic  ketoacidosis,  and  upper  gastro- 
intestinal bleeding. 


plete.  and  hypoxemia  in  this  instance  occurs  because  blood 
flow  continues  in  excess  of  ventilation  through  the  left 
lung.  This  creates  a  large  shunt  or  venous  adinixture  of 
significant  magnitude  to  explain  the  patient's  degree  of 
hypoxemia. 

For  over  25  years,  ventilation-perfusion  scintigraphy  has 
been  the  standard  method  to  evaluate  symptomatic  pa- 
tients for  the  possibility  of  pulmonary  embolism.  -  Lung 
scintigrams  for  the  ICU  patient  population  offer  a  diag- 
nostic challenge  quite  different  from  those  for  patients 
presenting  in  the  emergency  room  or  to  the  outpatient 
clinic.  Not  only  do  these  patients  have  complex  medical 
conditions,  but  the  radiographic  interpretation  of  diagnos- 
tic scintigraphy  is  complicated  by  a  multitude  of  pulmo- 
nary and  cardiac  diseases.  Because  of  their  reduced  car- 


diac, renal,  and  respiratory  reserves,  ICU  patients  are  at 
increased  risk  for  complications  from  pulmonary  arte- 
riograpy.  Thus,  interpretation  of  scintigrams  is  critical  for 
determining  the  appropriate  care  for  such  patients.  ^ 

Critically  ill  patients  who  are  intubated  pose  substantial 
technical  problems  in  obtaining  satisfactory  ventilation  im- 
ages. For  this  reason,  it  has  been  suggested  that  the  per- 
fusion scan  is  the  only  scan  that  is  necessary  in  such  pa- 
tients: a  normal  perfusion  scan,  which  virtually  eliminates 
the  possibility  of  a  significant  thromboembolism,  is  fre- 
quently found.  ■*  However,  omission  of  the  ventilation  study 
prevents  the  collection  of  other  important  physiologic  in- 
formation for  patients  with  significant  hypoxemia.  In  the 
case  presented  here,  ventilation  scanning  was  essential  to 
explain  the  patient's  status  and  to  direct  corrective  action. 


Respiratory  Care  •  October  "98  Vol  43  No  10 


821 


Test  Your  Radiologic  Skill 


Fig.  3.  Six-view  perfusion  scintigram  of  pulmonary  perfusion  obtained  several  days  following  bronchoscopy  for  33-year-old  cfironic 
alcofiolic  wfio  was  admitted  to  intensive  care  unit  witfi  diagnoses  of  alcohol-induced  coma,  possible  hypoxic  encephalopathy,  alcoholic 
ketoacidosis,  and  upper  gastrointestinal  bleeding. 


Reverse  mismatch  (ie,  ventilation  diminished  out  of  pro- 
portion to  the  decreased  perfusion)  can  be  caused  by  pneu- 
monia, pleural  effusion,  atelectasis,  or  bronchial  obstruc- 
tion. '"'  Treatments  known  to  inhibit  HPV  (eg.  high  positive 
airway  pressure  and  vasoactive  drug  infusion)  increase  the 
likelihood  of  reverse  mismatch.  For  this  reason,  reverse 
mismatch  is  not  an  uncommon  finding  during  scintigraphy 
performed  in  ICU  patients.  We  recently  reviewed  all  ven- 
tilation-perfusion  scans  performed  during  a  15-month  pe- 
riod in  ICU  patients  and  found  that  56%  of  the  66  scans 
had  significant  areas  of  reverse  mismatch,  compared  with 
20%  in  66  consecutive  scans  in  non-ICU  patients.**  The 
cause  of  decrea.sed  ventilation  was  usually  apparent  on 
chest  radiographs:  Pneumonia,  atelectasis,  effusions,  and 
lobar  collapse  accounted  for  >  80%  of  the  cases.  In  the 
current  report,  the  cause  of  hypoxemia  in  the  patient 
was  presumed  to  be  airway  obstruction  because  none  of 
the  other  possibilities  was  identified  on  a  chest  radio- 
graph. 

Following  ventilation-perfusion  scintigraphy,  the  pa- 
tient remained  hypoxemic  and  was  electively  intubated. 
On  bronchoscopy,  a  mucus  plug  was  removed  from  the 
left  main  bronchus.  The  patient's  ABG  values  improved 
over  the  next  2  days,  and  he  was  again  extubated.  A 
normal  perfusion  study  was  obtained  at  this  time  (Fig. 
3). The  patient  was  discharged  home  I  month  after  ad- 


mission with  instructions  to  seek  help  from  the  local 
public  service  substance  abuse  treatment  system  for  his 
alcoholism. 


REFERENCES 


1.  Voelkel  NF.  Mechanisms  of  hypoxic  pulmonary  vasoconstriclion 
(review).  Am  Rev  Re.spir  Dis  1986; LS3(6):1 186-1 19.'i. 

2.  Alderson  PO.  Rujanavech  N.  Sicker-Walker  RH,  McKnight  RC.  The 
role  of  133Xe  ventilation  studies  in  the  .scintigraphic  detection  of 
pulmonary  embolism.  Radiology  1976;12()(3):63.3-640. 

3.  Mills  SR,  Jackson  DC,  Older  RA,  Hea.ston  DK.  Moore  AV.  The 
incidence,  etiologies,  and  avoidance  of  complications  of  pulmonary 
angiography  in  a  large  series.  Radiology  1980;136(2):29.'>-299. 

4.  Drane  WE,  Tonkin  JC.  Evaluation  of  pulmonary  embolism  in  the 
intubated  patient:  ventilation  analysis  is  infrequently  needed.  Radi- 
ology 1996:201:164. 

5.  Sostman  HD,  Neumann  RD.  Gottschalk  A,  Greenspan  RH.  Perfusion 
of  nonventilated  lung:  failure  of  hypoxic  pulmonary  vasoconstric- 
tion. Am  J  Am  J  Roentgenol  1983:141:151-56. 

6.  Fucntes  RT.  Holmes  RA.  Reverse  radioaerosol/radioperlusion  dis- 
tribution in  pulmonary  endobronchial  obstruction.  Clin  NucI  Med 
1990;  15(4 1:2 17-221. 

7.  Bray  ST,  Johnstone  WH.  Dee  PM.  Pope  Tl.  Jr.  Teales  C'D.  Teglm- 
eyer  CJ.  The  "mucus  plug  syndrome"  a  pulmonary  embolism  mimic. 
Clin  Nucl  Med  1984;9(9):5 1.^-5 18. 

8.  Parekh  JS,  Shindc  DS.  Durbin.  Jr.  CG.  Teales  CD.  Ventilation  per- 
fusion imaging  of  patients  in  the  intensive  care  unit  (ab.stract).  Ra- 
diology 1997:205(Pl:527. 


822 


Ri:si>iRAJ()KY  Carl  •October  "^S  Vol  43  No  10 


Books,  Films, 
Tapes,  &  Software 


Listing  and  Reviews  of  Boolis  and  Other  Media.  Note  to  publishers:  Send  review  copies  of  books, 
lilms.  tapes,  and  sollware  to  Rfsi'iRATOKN  Carh.  601)  Ninth  Avenue,  Suite  702.  Seattle  WA  98104. 


Asthma.  Peter ,1  Barnes  MA  DM  DSc  FRCP. 

Alan  R  Left  MD.  Miehael  M  Giainstein  MD 
PhD,  Ann  J  Woolcock  MD  FRACP,  Edi- 
lois.  Hardcover.  2  volumes,  illustrated. 
2,.^68  pages.  Philadelphi;i/New  York:  Lip- 
pincott-Raven;  1997.  $260.00. 

Five  to  seven  percent  of  Americans  suf- 
fer from  asthma,  making  it  the  single  most 
common  chronic  disease  in  the  United  States 
today.  Matters  are  likely  to  get  worse  as  the 
prevalence  of  and  mortality  attributable  to 
asthma  have  increased  steadily  since  the 
early  1980s.  Fortunately,  these  issues  have 
garnered  considerable  attention  in  recent 
years,  which  has  led  to  important  new  in- 
sights and  an  exponential  growth  in  the  as- 
sociated medical  literature.  Asthma  is  an 
ambitious  two-volume  textbook  that  seeks 
to  comprehensively  integrate  this  mountain 
of  information  in  a  manner  that  will  serve 
both  the  basic  scientist  and  the  health  pro- 
fessional. 

Dr  Peter  Barnes,  who.se  .sentinel  works 
over  the  last  three  decades  have  greatly  con- 
tributed to  our  understanding  of  asthma, 
heads  the  editorial  team.  He  has  emerged  as 
one  of  the  most  prolific  researchers  in  the 
Held,  with  important  contributions  in  both 
the  clinical  and  basic  science  arenas.  Drs 
Grunstein  and  Leff  bring  extensive  experi- 
ence in  the  cell  and  molecular  biology  of 
mediators  involved  in  the  pathophysiology 
of  asthma.  Dr  Grunstein's  pediatric  focus  is 
also  evident  in  the  clinical  sections  where 
children's  issues  are  featured.  Dr  Woolcock 
has  written  extensively  on  the  clinical  as- 
pects of  asthma  and  is  a  leading  authority 
on  the  epidemiology  of  asthma.  This  out- 
standing editorial  team  has  attracted  leading 
experts  in  the  field  of  asthma  as  contribut- 
ing authors. 

The  textbook  is  basically  divided  into  two 
volumes,  the  first  of  which  focuses  on  basic 
science  (including  epidemiology),  while  the 
second  is  dedicated  to  the  clinical  aspects  of 
asthma.  By  dividing  the  book  in  this  way 
the  editors  have  created  two  separate  text- 
books, one  that  serves  the  interests  of  the 
scientist  while  the  other  serves  the  interests 
of  the  clinician.  As  a  clinician  with  a  basic 
science  background,  1  am  often  drawn  to 
textbooks  that  provide  an  overview  of  the 
scientific  principles  that  underiie  clinical  in- 


novations, hi  Asthma  I  got  more  than  I 
bargained  for.  with  many  sections  reading 
like  they  had  been  plucked  from  a  textbook 
of  molecular  biology.  Tables  with  titles  like 
"Summary  of  Linkage  Studies  of  Atopy  and 
Loci  on  Chromosome  I  Iql3'"  and  "Devel- 
opment of  Agranular  Endoplasmic  Reticu- 
lum, P450  Reductase,  and  Monooxygenase 
Enzymes  in  Rabbit  Lung"  typify  the  scien- 
tific nature  of  these  chapters  and  would  be 
of  little  interest  to  even  the  most  inquisitive 
clinician. 

The  section  on  epidemiology  that  is  pre- 
sented in  Volume  I  is  full  of  important  clin- 
ical concepts.  Highlights  include:  ( 1 )  an  im- 
pressive table  in  the  chapter  entitled 
"Epidemiologic  Trends,"  which  outlines  the 
prevalence  of  asthma  by  abstracting  a  wide 
variety  of  studies,  and  (2)  a  chapter  on 
asthma  deaths,  which  nicely  summarizes  the 
available  infonnation  and  frames  the  "/B  ag- 
onist controversy'  for  later  discussion.  Chap- 
ters on  issues  such  as  ethnic  variation,  the 
effect  of  diet,  and  the  genetics  of  atopy  are 
well  written  and  add  to  the  diversity  of  the 
book.  The  structural  features  of  the  airways 
are  nicely  integrated  with  the  pathologic 
characteristics  of  asthma  in  Section  3  of  Vol- 
ume I .  Separate  chapters  are  devoted  to  post- 
mortem pathology,  bronchial  biopsies,  and 
bronchoalveolar  lavage.  In  these  chapters 
the  important,  and  topical,  theme  of  airway 
remodeling  is  reviewed  in  extraordinary 
detail. 

Volume  2  contains  five  sections  that  high- 
light the  clinical  aspects  of  asthma.  Major 
sections  in  this  volume  are  directed  at  the 
clinical  assessment,  therapy,  and  manage- 
ment of  asthma.  The  management  section 
of  this  textbook  includes  chapters  on  a  wide 
variety  of  miscellaneous  topics  including: 
environmental  control,  mechanical  ventila- 
tion of  asthmatic  patients,  delivery  systems, 
pregnancy,  asthma  education,  occupational 
asthma,  and  psychological  aspects  of 
asthma.  Clinicians  who  care  for  a  large  num- 
ber of  patients  with  asthma  will  undoubt- 
edly be  attracted  to  Chapter  141  entitled 
"Difficult  Asthma."  The  strengths  of  this 
chapter  include  an  interesting  discussion  of 
premenstrual  asthma  and  steroid-resistant 
asthma.  A  relative  weakness  is  a  rather  ge- 
neric algorithm  that  is  presented  for  evalu- 
ating patients  with  difficult-to-control 


asthma.  Overall,  this  chapter  offers  a  rela- 
tively superficial  discussion,  one  that  ap- 
pears to  be  targeted  at  health  care  providers 
who  have  little  experience  with  asthma  pa- 
tients. There  is  nothing  inherently  wrong 
with  targeting  this  audience.  However,  this 
is  one  of  the  few  chapters  throughout  the 
textbook  of  which  this  could  be  said. 

The  chapter  on  pregnancy  is  very  well 
done  with  a  concise  but  informative  discus- 
sion of  the  physiology  of  a  pregnant  woman. 
In  this  context,  the  effect  of  pregnancy  on 
the  course  of  asthma  is  discussed  in  some 
detail.  The  author  does  not  shy  away  from 
the  difficult  issue  of  managing  pharmaco- 
logic agents  in  this  patient  population.  He 
even  goes  to  the  extent  of  outlining  a  series 
of  steps  that  should  be  taken  before  giving 
drugs  to  pregnant  women.  This  and  a  sub- 
sequent discussion  of  obstetrical  agents  that 
should  be  avoided  in  asthma  patients  make 
this  chapter  an  inxaluable  reference  tool. 

It  appears  that  this  textbook  is  targeted 
primarily  at  a  physician/scientist  audience. 
However,  there  are  a  number  of  chapters 
that  are  likely  to  attract  the  attention  of  re- 
spiratory care  practitioners.  Chapter  129. 
"Delivery  Systems  in  Adults,"  is  one  such 
example.  This  discussion  contains  a  rela- 
tively brief  allusion  to  the  use  of  pressur- 
ized metered  dose  inhalers  and  nebulizers, 
focusing  instead  on  dry  powdered  inhalers 
as  an  alternative  delivery  sy.stem.  The  sub- 
sequent chapter  on  delivery  systems  in  chil- 
dren is  much  more  complete,  including  ba- 
sic data  on  the  efficacy  of  different  delivery 
systems.  Once  again,  this  discussion  focuses 
on  pressurized  meter  dose  inhalers  and  dry 
powder  delivery  systems  with  a  much  less 
extensive  discussion  of  nebulizers.  There  is 
no  mention  in  either  of  these  chapters  re- 
garding the  administration  of  inhaled  agents 
through  an  endotracheal  tube.  The  fact  that 
concepts  related  to  the  delivery  of  aerosols 
are  covered  in  chapters  entitled  "Aerosols." 
"New  Aerosol  Delivery  Systems."  "Deliv- 
ery Systems  in  Adults."  and  "Delivery  Sys- 
tems in  Children"  exemplifies  one  of  the 
few  weaknesses  of  the  textbook — that  re- 
lated chapters  could  be  better  organized  to 
minimize  redundancies.  In  the  case  of  aero- 
sols, each  of  these  chapters  contains  unique 
insights,  some  of  which  are  lost  to  anyone 
who  stops  short  of  reading  all  four  chapters. 


Respiratory  Care  •  October  "98  Vol  43  No  10 


823 


Books,  Films,  Tapes,  &  Software 


Hospiial-based  therapists  are  likely  to  be 
interested  in  Chapter  134.  "Ventilation  of 
Asthmatic  Patients."  This  chapter  contains 
an  excellent  discussion  of  dynamic  hyper- 
inflation (auto-PEEP),  throughout  which  the 
sentinel  works  are  cited  with  their  original 
figures.  The  discussion  of  indications  for 
mechanical  ventilation  is  relatively  superfi- 
cial, but  common  complications  are  well 
covered.  The  author  proposes  a  ventilator 
strategy  that  is  nonspecific  but  well 
grounded  with  respect  to  the  goal  of  mini- 
mizing dynamic  hyperinflation.  Readers 
looking  for  a  discussion  of  the  use  of  pos- 
itive end-expiratory  pressure  (PEEP)  for  un- 
intended positive  end-expiratory  pressure 
(auto-PEEP)  will  be  disappointed.  The  only 
discussion  of  dialed-in  PEEP  is  provided  in 
the  context  of  its  effect  on  dynamic  hyper- 
inflation. Surprisingly,  no  discussion  of  this 
concept  occurs  in  the  section  entitled  "Pa- 
tient-Ventilator Asynchrony." 

Despite  occasional  weaknesses,  Asthma 
is  very  well  written  and  represents  the  most 
complete  textbook  on  the  subject  that  is 
available  today.  The  textbook  is  fairly  priced 
($260).  and  I  strongly  believe  that  it  would 
be  an  as.set  in  virtually  any  medical  refer- 
ence library.  As  a  pulmonary  physician  with 
an  interest  in  asthma,  I  am  delighted  to  have 
a  copy  in  my  personal  library.  However,  I 
suspect  that  most  respiratory  care  practitio- 
ners will  be  .satisfied  to  have  a  copy  of 
Asthma  available  in  their  local  reference 
library. 

Christopher  D  Beaty  MD 

DepI  of  Pulmonary  Disease 
Northwest  Hospital 
Seattle.  Washiniiton 


Eico.sanoid.s,  Aspirin,  and  Asthma,  No. 

1 14,  Lung  Biology  in  Health  and  Disease. 
A  Szczeklik.  RJ  Gryglewski.  and  JR  Vane, 
Editors.  Hardcover,  illustrated.  616  pages. 
New  York:  Marcel  Dckkcr  Inc;  1998. 
$195.00. 

Aspirin-induced  asthma  (AIA).  which  af- 
fects about  109;  of  adult  asthmatics,  is  not 
a  simple,  immune-type  hypersensili\ity  to 
nonsteroidal  anti-inflammatory  drugs,  and 
its  pathogenesis  is  yet  a  challenge  for  the 
researchers.  In  fact,  AIA  is  a  chronic  dis- 
ease that  runs  a  protracted  course  even  if 
aspirin  and  nonsteroidal  anti-inflammatory 
drugs  are  totally  avoided.  The  inhibition  of 
cyclooxygcnasc  (COX)  by  aspirin  that  is 
accompanied  by  release  ol   Icukolricnes 


seems  to  be  a  key  mechanism  of  aspirin- 
precipitated  reactions,  but  the  actual  molec- 
ular basis  of  AIA  remains  a  mystery.  So  it 
happened  that  the  same  group  of  reseiurh- 
ers  shared  investigations  on  AIA  mecha- 
nisms and  the  studies  on  the  eicosanoids 
(leukotrienes,  prostaglandins,  thrombox- 
anes), which  are  a  structurally  and  function- 
ally diverse  groups  of  metabolites  of  the 
arachidonic  acid.  Moreover,  search  for  the 
predisposing  factors  (genetic,  immunologi- 
cal, biochemical,  viral)  might  lead  to  solu- 
tion of  the  enigma  presented  by  AIA. 

Drs  Szczeklik  and  Gryglewski,  pioneers 
in  the  field  of  AIA  research,  and  Sir  Vane, 
the  Nobel  prize  winner,  edited  a  compre- 
hensive, up-to-date  volume  that  reports  con- 
tributions of  the  world's  leading  authorities 
on  AIA  and  eicosanoids.  The  result  of  their 
work  may  be  considered  as  a  very  good 
example  of  specialized  medical  literature 
joining  basic  and  clinical  science  regarding 
not  so  intuitive  topics. 

The  variety  of  the  subjects  of  this  vol- 
ume, broadening  from  biochemistry  to  ther- 
apeutics of  aspirin-induced  reactions,  will 
satisfy  the  curiosity  of  a  wide  audience  of 
readers,  even  if  most  of  the  contents  have 
been  mainly  addressed  to  researchers. 

Eicosanoids,  Aspirin,  and  Asthma  con- 
tains 30  chapters,  an  analytical  subjects  in- 
dex, and  an  index  of  the  referenced  authors. 
The  book  has  more  than  70  contributors 
from  the  United  Stales  and  especially  from 
European  countries.  Black  and  white  tables 
and  graphs  are  sufficiently  distributed 
throughout  the  text.  All  the  material  is  of 
high  scientific  value,  but  it  is  not  always 
well  organized  and  a  division  of  the  book  in 
recognizable  sections  would  have  been  de- 
sirable. The  price  of  this  volume  could  be 
considered  quite  high  for  noninstitutional 
purchasers. 

There  are  many  chapters  of  this  book 
covering  biochemistry  and  molecular  biol- 
ogy that  may  not  be  of  interest  to  physicians 
and  respiratory  therapists  involved  in  day- 
to-day  clinical  practice.  Nevertheless,  there 
are  several  review-style  chapters  that  could 
interest  anyone  who  desires  to  be  kept 
abreast  of  the  latest  developments  on  inno- 
vative fields  of  reseiU'ch.  For  example,  in 
the  first  Chapter,  "Mechanism  of  Action  of 
Anti-Inflammatory  Drugs,"  Prof  Vane  and 
Dr  Botting  present  concisely  and  very  clearly 
new  data  on  mechanism  of  action  of  the 
nonsteroidal  anti-inflammatory  drugs,  with 
emphasis  on  the  i.soforms  ol  cyclooxygcn- 
asc. namelv  COX- 1  and  COX-2.  The  fol- 


lowing chapters  (Chapters  2  to  10)  cover 
different  specialized  topics,  ranging  from 
"Pathways  of  Arachidonate  Metabolism"  to 
"The  Role  of  5-Lipoxygenase  Products  in  a 
Mouse  Model  of  Allergic  Airway  Inflam- 
mation," but  contrary  to  the  first  chapter, 
they  are  not  as  readable  for  the  inexperi- 
enced reader.  Nevertheless,  the  readers  of 
chapters  regarding  recent  basic  researches 
can  gain  new  insight  into  asthma  mecha- 
nisms. Such  is  the  ca.se  of  Chapter  6,  "Cy- 
clooxygenase-2  Expression  in  Airway 
Cells,"  by  PJ  Barnes  and  colleagues,  which 
covers  the  presence  of  inducible  COX-2  in 
the  inflamed  airways  and  its  possible  rele- 
vance in  asthma. 

However,  there  are  no  more  than  eight  to 
ten  chapters  of  this  book  written  mainly  from 
the  perspective  of  a  clinical  practice  of  pul- 
monary medicine,  while  the  remaining  chap- 
ters seem  to  be  written  from  a  basic  science 
per.spective.  The  clinical  point  of  view  is 
well  addressed  in  Chapter  12,  "Intrinsic 
Asthma,"  by  LM  Fabbri  and  co-workers. 
This  chapter  authoritatively  illustrates  the 
classification  of  asthma,  the  epidemiology 
of  intrinsic  asthma,  and  the  topical  patho- 
genic aspects  of  intrinsic  asthma  as  a  dis- 
tinct entity  that  indeed  shares  several  fea- 
tures with  atopic  extrinsic  asthma.  The 
essence  of  epidemiological,  clinical,  and 
pathogenic  .specific  issues  of  aspirin-induced 
asthma  is  condensed  within  5  chapters  of 
the  book:  Chapter  1 8,  "Mechanism  of  As- 
pirin-Induced Asthma,"  Chapter  19,  "Leu- 
kotrienes in  Aspirin-Sensitive  Asthma," 
Chapter  2 1 ,  "Aspects  of  Mechanisms  in  As- 
pirin-Intolerant Asthma."  Chapter  24,  "Air- 
way Ion  Transport  Mechanisms  and  Aspi- 
rin in  Asthma,"  and  Chapter  26,  "Clinical 
Course  of  Aspirin-Induced  Asthma:  Results 
of  AIANE."  This  last  chapter,  which  re- 
ports results  from  AIANE  (European  Net- 
work on  Aspirin-Induced  Asthma),  the  larg- 
est database  on  AIA,  provides  a  particularly 
good  insight  into  the  clinical  course  of  the 
disease. 

In  Chapter  27.  "Nasal  Polyposis"  and 
Chapter  28,  "The  Nose  in  Aspirin-Sensitive 
Asthma."  the  authors  describe  the  involve- 
ment ol  the  nose  in  the  syndrome  and  the 
relationship  between  nose  and  bronchi.  The 
last  two  chapters.  Chapter  29,  "The  Role  of 
Glucocorticoids  in  the  Modulation  of  Eico- 
sanoid  Metabolism  in  Asthma,"  and  Chap- 
ter 30,  "Desensitization  in  Aspirin-Induced 
Asthma,"  cover  the  topic  of  therapy.  Finally, 
mention  must  be  made  of  Dr  WOCM  Cook- 
son,  aullior  of  Chapter  I  1 ,  "Genetic  Influ- 


824 


Resi'iratokv  Care  •  Ociobek  "98  Vol.  4.^  No  10 


Books.  Films,  Tapes,  &  Software 


cnces  on  Asthma."  for  his  ability  to  discuss 
the  cuiTcnt  state  of  the  art  in  genetics  of 
asthma. 

In  my  opinion,  the  addition  of  a  specific 
chapter  on  anti-ieukotrienes  drugs  would 
have  been  topically  interesting,  although 
some  information  about  this  new  class  of 
drugs  is  scattered  throughout  the  volume. 
Otherwise,  given  that  the  research  on  AIA 
allowed  the  commercialization  of  anti-leu- 
kolrienes.  the  lack  of  a  specific  chapter  on 
these  new  drugs  is  a  guarantee  of  the  purely 
scientific  interest  of  this  book.  Al.so.  a  syn- 
thetically conclusive  chapter  by  the  editors 
would  have  been  useful  for  the  common 
readership. 

In  conclusion,  this  book  should  be  con- 
sidered as  the  best  reference  book  on  aspi- 
lin-induced  asthma.  In  fact,  this  is  the  most 
comprehensive  and  authoritative  volume  to 
date  on  this  fomi  of  asthma,  even  if  pails  of 
the  book  are  apt  to  become  outdated  fairly 
rapidly.  Specialized  investigators  will  rec- 
ognize this  volume  as  a  thorough  and  well- 
referenced  te.xt.  but  also  practical  physicians 
may  wish  to  refer  to  it  as  a  unique  resource 
of  information  on  AIA. 

Marco  Confalonieri  MD 

Division  of  Pneumology 

City  Hospital 

Piacenza.  Italy 

Fishman's  Pulmonary  Diseases  and  Dis- 
orders, ,V''  ed.  Alfred  P  Fishman  MD.  Ed- 
itor. Hardcover,  illustrated.  2,777  pages. 
New  York:  McGraw-Hill;  1998.  $350.00 

This  book  of  almost  3.000  pages  pro- 
vides an  exhaustive  review  of  pulmonary 
medicine.  It  spans  the  range  from  signs  and 
symptoins  to  physiologic  mechanisms,  to 
developmental  and  molecukir  biology,  to  the 
latest  therapies.  The  book  is  targeted  to  those 
individuals  involved  in  the  study  or  practice 
of  pulmonary  medicine.  Many  of  the  chap- 
ters dealing  with  rare  diseases  and  molecu- 
lar biology  would  be  of  greatest  interest  to 
pulmonologists  interested  in  academics  and 
research.  There  are,  however,  numerous 
chapters  that  would  be  of  relevance  to  all 
those  involved  in  the  care  of  patients  with 
lung  disease  including  therapists,  nurses, 
technicians,  and  physicians.  These  include 
the  chapters  on  basic  pulmonary  physiol- 
ogy, mechanical  ventilation,  acute  respira- 
tory distress  syndrome,  bronchodilators. 
lung  infections,  asthma,  and  chronic  obstruc- 
tive pulmonary  disease. 


Although  well  written  and  easy  to  under- 
stand, the  pulmonary  physiology  chapters 
are  not  as  detailed  as  those  of  some  of  the 
other  comprehensive  pulmonary  texts.  De- 
spite the  size  and  depth  of  this  textbook, 
there  are  occasional  areas  in  which  impor- 
tant infonnation  is  either  missing  or  under- 
emphasized.  For  example,  the  section  dis- 
cussing the  hepatopulmonary  syndrome 
does  not  discuss  the  "diffusion-perfusion" 
theory  or  inake  an  attempt  to  explain  the 
oxygen  responsiveness  of  many  of  these  pa- 
tients. There  is  also  no  mention  of  the  ther- 
apeutic role  of  hepatic  transplantation  for 
this  entity.  In  the  section  on  primary  pul- 
monary hypertension,  while  intravenous 
prostacyclin  is  mentioned  as  a  therapy,  there 
is  no  reference  to  the  very  important  Feb- 
ruary 1 996  New  England  Journal  of  Medi- 
cine iuticle  by  Barst  et  al '  showing  improved 
outcome.  These  omissions,  however,  are  rel- 
atively rare,  and  for  the  most  part,  the  book 
is  complete  and  cun'ent. 

Some  of  the  p;ulicularly  strong  sections 
include  those  on  the  management  of  acute 
respiratory  distress  syndrome,  lung  trans- 
plantation, surfactant,  idiopathic  pulmonary 
fibrosis,  and  many  of  those  discussing  re- 
spiratory infections.  These  are  just  some  of 
the  chapters  that  provide  extensive  and  thor- 
ough reviews  of  all  of  the  relevant  recent 
literature  combined  with  solid  background 
and  historical  information. 

The  book  successfully  achieves  its  stated 
goal  to  address  the  possible  pathways  to 
solutions  for  the  major  problems  in  lung 
disease,  as  stated  in  the  American  Thoracic 
Society  report,  "Future  Directions  for  Re- 
search on  Disea.ses  of  the  Lung"".-  Although 
the  authors  each  bring  a  different  style,  each 
chapter  is  well  written  with  a  clear  outline 
at  the  beginning  of  each.  With  the  excep- 
tion of  occasional  typographical  eiTors,  the 
information  is  accurately  and  concisely  pre- 
sented with  liberal  use  of  well-organized 
and  readable  tables  and  figures.  The  quality 
of  the  chest  x-rays,  coinputed  tomography 
scans,  histology  and  gross  pathology  repro- 
ductions is  remarkably  good.  The  thorough 
index  allows  the  reader  to  use  this  book  as 
a  quick  reference  to  look  up  a  rare  disease 
or  the  latest  in  treatment. 

Most  of  the  authors  chosen  to  write  this 
textbook  represent  either  the  leaders  in  their 
fields  or  individuals  with  substandal  expe- 
rience in  the  particular  areas  of  their  chap- 
ters. This  provides  the  reader  with  reassur- 
ance regarding  subjects  that  are  controversial 
or  lacking  definitive  data. 


Fishman's  Pulmonary  Diseases  and 
Disorders  is  an  absolute  must  for  physi- 
cians interested  in  the  study  of  pulmon;iry 
medicine.  For  therapists,  medical  residents, 
and  nurses  who  require  a  reference  book,  it 
will  provide  an  authoritative  and  user- 
friendly  source  to  answer  all  of  their  ques- 
tions regarding  lung  function  and  pulmo- 
nary disease. 

AtuI  Malhotra  MD 
David  R  Schwartz  MD 

Clinical  Fellows 

Pulmonary  and  Critical  Care  Unit 

Dept  of  Medicine 

Massachusetts  General  Hospital 

Boston,  Massachusetts 

1.  Biirst  RJ  et  A.  The  Primary  Pulmonary  Hy- 
pertension Study  Group.  A  comparison  of 
continuous  intravenous  epoprostenol  (pros- 
tacylin)  with  conventional  therapy  for  pri- 
mary pulmonary  hypertension.  N  Engl 
J  Med  1996;.^,14(2):296-302. 

2.  American  Thoracic  Society.  Medical  Sec- 
tion of  the  American  Lung  Association.  Fu- 
ture directions  for  research  on  diseases  of 
the  lung.  Am  J  Respir  Crit  Care  Med  1995; 
l.'^2(ll):[71.V|735. 


Principles  and  Practice  of  Intensive  Care 
Monitoring,  Mailin  J  Tobin  MD.  Editor. 
Hardcover,  illustrated.  1.525  pages.  New 
York:  McGraw-Hill  Inc;  1998.  $140.00. 

Critical  care  has  emerged  as  a  discipline 
highly  dependent  on  technology  and  mon- 
itoring. The  book  Principles  and  Practice 
of  Intensive  Care  Monitoring  describes  the 
theory  behind  the  technology  used  in  the 
intensive  care  unit  (ICU).  as  well  as  prac- 
tical applications  and  historical  aspects.  The 
textbook  was  written  as  a  companion  refer- 
ence to  Dr  Tobin's  other  excellent  book. 
Principles  and  Practice  of  Mechanical  Ven- 
tilation. Together  these  two  volumes  are 
meant  to  be  a  complete  resource  on  the  tech- 
nology used  in  the  ICU.  They  exceed  this 
expectation  and  are  so  complete  that  they 
could  almost  serve  as  a  general  reference  in 
critical  care. 

Principles  and  Practice  of  Intensive 
Care  Monitoring  is  an  exhaustive  refer- 
ence text.  It  consists  of  more  that  1,500 
pages,  eight  .sections,  87  chapters,  and  an 
appendix.  Chapters  are  written  by  more  that 
125  authors.  These  authors  represent  the 
creme  de  la  crenie  of  critical  care  medicine 
in  North  America  and  Europe.  The  text- 
hook  is  an  impressive  compilation  of  a  wide 


Respiratory  Care  •  October  '98  Vol  43  No  10 


825 


Correction 


variety  of  topics  that  thoroughly  cover  al- 
most every  aspect  of  monitoring  in  the  ICU. 
Specific  sections  of  the  book  include  respi- 
ratory monitoring,  cardiovascular  monitor- 
ing, neurologic  monitoring,  monitoring 
other  organ  systems,  monitoring  in  special 
situations,  computers  and  monitoring,  and 
regulatory  issues.  In  addition  there  are  gen- 
eral chapters  on  the  history,  standards,  eth- 
ics, and  fundamental  theories  of  monitoring 
in  the  ICU. 

Despite  the  wealth  of  information  in  the 
book,  I  was  initially  skeptical  about  how 
useful  the  text  would  be  as  compared  to  a 
general  textbook  on  critical  care.  I  put  the 
book  to  the  test  during  my  recent  month- 
long  rotation  in  the  ICU.  Whenever  a  ques- 
tion arose  on  monitoring,  I  went  to  the  text 
for  the  answer.  I  was  surprised  to  find  my- 
self using  the  information  at  least  once  ev- 
ery day.  In-depth  discussions  on  esophageal 
balloons,  pressure-volume  curves,  arterial 
pressure  systems,  temperature  monitoring, 
and  impedance  cardiac  outputs  were  all  read- 
able and  very  well  referenced.  Even  more 
impressive,  the  information  was  usually  not 
available  in  any  other  textbook. 

The  logical  organization  of  the  book  and 
the  complete  index  made  the  subjects  easy 
to  fmd.  Once  1  found  my  topic,  it  was  usu- 


ally well  presented  and  illustrated  in  an  easy- 
to-understand  manner.  I  especially  enjoyed 
the  chapters  on  basic  assessment  of  the  re- 
spiratory and  cardiovascular  system  that 
stressed  such  lost  arts  as  observation  of  the 
patient's  breathing  pattern  and  physical 
exam  of  the  heart.  Indeed,  most  chapters 
would  be  an  excellent  starting  point  for 
studying  any  aspect  of  ICU  monitoring.  For 
example,  if  one  wanted  to  learn  about  blood 
gas  analysis,  there  are  chapters  on  quality 
assessment,  respiratory  system  assessment, 
acid  base  assessment,  mixed  venous  blood 
analysis,  and  continuous  monitoring.  These 
chapters  cover  everything  from  the  labora- 
tory handling  of  specimens  to  the  technol- 
ogy involved  and  the  interpretation  of  the 
results.  There  is  similar  thorough  coverage 
of  other  topics  such  as  pulmonary  arterial 
catheters,  respiratory  mechanics,  and  cere- 
bral oxygenation  monitoring,  to  name  a  few. 
I  have  very  few  criticisms  of  this  text- 
book. The  proofreading  was  adequate  but 
there  are  a  few  glaring  typographical  errors 
(such  as  Dr  Marini  being  referred  to  as  JJ 
Warini  in  the  table  of  contents).  If  1  have 
one  major  criticism  of  this  book,  it  is  that  it 
occasionally  did  not  provide  the  depth  of 
information  I  expected.  For  example,  the 
otherwise  excellent  chapter  on  cardiac  out- 


put monitoring  explained  the  theory  of  ther- 
modilution  and  included  the  basic  equation 
but  neglected  to  discuss  the  derivation  of 
the  equation  used  by  most  commercial  cath- 
eters. The  chapter  on  pressure-volume 
curves  di.scusses  the  methods  of  mea.suring 
curves  in  more  detail  than  the  actual  phys- 
iologic meaning  of  the  curves.  Fortunately, 
all  the  chapters  are  extremely  well  refer- 
enced, so  if  an  aspect  of  a  subject  is  not 
thoroughly  covered,  there  is  always  a  source 
referenced  for  further  information. 

All  in  all,  I  found  this  textbook  an  in- 
valuable addition  to  my  personal  library.  I 
think  it  is  a  must  for  any  critical  care  phy- 
sician. Respiratory  therapists  and  ICU  nurses 
will  also  find  the  information  very  u.seful 
and  should  have  ready  access  to  the  book — 
many  will  also  want  a  copy  for  their  per- 
sonal libraries.  I  suspect  that  this  book  will 
become  the  standard  for  technology  and 
monitoring  in  the  ICU. 

Benjamin  D  Medoff  MD 

Clinical  Fellow 

Pulmonary  and  Critical  Care  Unit 

Dept  of  Medicine 

Massachusetts  General  Hospital 

Bo.ston.  Massachusetts 


CORRECTION 

In  the  letter,  "Will  the  Correct  Units  for  Hemodynamic  Monitoring  Plea.se  Come  Forward?"  by 
Robert  R  Fluck  Jr  [Respir  Care  1998;43(8):656],  the  units  were  printed  incoirectly  in  the 
•second-to-last  sentence  of  the  second  paragraph.  The  sentence  should  read: 

Shapiro  and  colleagues  appear  to  have  'gotten  religion'  between  their  third  edi- 
tion,'^ in  which  they  used  the  units  of  dyne/sec/cm  '^  and  their  fourth  edition'"*  in 
which  they  used  the  units  dyne-sec/cm  (which  is  the  algebraic  equivalent  of 
dyne  •  sec  •  cm"  ). 

We  regret  the  error. 


826 


Rl  SPlKATOm'  CaRF.  •  OCTOBFR  "98  Voi.  43  No   10 


m 


199-^ 


ach  year,  Respiratory  Care  ofifers  Minisymposia  that  highlight  important  case  reports, 
method,  device,  and  protocol  evaluations,  and  clinical  studies.  During  this  year's  Open  Forum, 
Presenters  from  around  the  world  will  report  their  findings  in  more  than  loo  abstracts. 

(An  index  of  the  authors,  with  the  Presenters  designated  in  boldface  type,  appears  on  Page  881.) 


Inhaled  Nitric  Oxide; 
Nebulization  of  Drugs 
and  Medications 

Saturday,  November  7,  1998 
2:00  pm  -  3:55  pm 
Room  214E 

Tubes;  B^s;  Oxygen  Therapy 

Saturday,  November  7,  1998 
2:00 pm  -  3:55 pm 
Room  21 5E 

Neonatal/Pedlatric 
Respiratory  Care 

Sunday  November  8,  1998 
2:00 pm  -  3:55 pm 
Room  214E 


Education;  Rehabilitation 

Sunday,  November  8,  1998 
2:00  pm  -  3:55  pm 
Room  215E 

Ventilation  and  Ventilatory 
Techniques — Part  1 

Monday  November  9,  1998 
9:30  am-  11:25  am 
Room  214E 

Monitoring,  Monitoring,  and 
More  Monitoring 

Monday  November  9,  1998 
12:30  pm -2:25  pm 
Room  214E 


Management  of  Respiratory 
Care  Services 

Monday  November  9,  1998 
2:00  pm -3:55  pm 
Room  215E 

Humidifiers,  Nebulizers, 
and  Attachments 

Monday  November  9,  1998 
3:00  pm  -  4:55  pm 
Room  214E 

Ventilation  and  Ventilatory 
Techniques — Part  2 

Tuesday,  November  10,  1998 
1:00  pm -2:55  pm 
Room  21 4E 


Saturday,  November  7,  2:00-3:55  pm  (Room  214E) 


COMPARISON   OF  ALBITEROL   VS  ALBUTEROL  WITH   IPRATROPIUM  IN 
PEDIATRIC    ASTHMA    PATIENTS   REQUIRING    HOSPITALIZATION 

TimoLh^  R.  Mscis  RRT.  Daniel  Craven  MD.  CaroKn  Kcrtsmar  MD  and  Robert  Chaibum  RRT 

Rainbow  Babies  &  Childrcns  HospiUil  and  Case  Western  Rcsenc  Univerwty.  Clc\eland.  OH, 
Objective:    A  double-blind,  randuim/:ed.  placebo  controlled  study  to  determine  if  the  addition  ol" 
[pratropium  to  nebulized  albuterol  in  children  hospilali/cd  with  acute  asthma  would  alter  clinical 
and  piisl  discharge  outaimcs.  Participants:  Asthmatic  children  (ages  1-16  with  IRB  approval), 
admitted  to  an  asthma  care  umt.  Methodology:  All  patients  were  treated  using  an  asthma  care 
path,  consisting  ol  standard  assessment  catena  (wheeze,  air  exchange,  accessory  muscle  usage, 
oximetry  and  rcspirdlory  rate)  and  treatment  (2.5  mg  albuterol  in  saline)  at  prescribed  inlenals. 
Fnxjuency  of  assessment  /'  treatment  was  decreased  in  a  step-w  isc  manner  dependent  on  meeting  a 
pnsdefincd  cntcna.  At  admission,  patients"  were  randomiiMxl  to  standard  care  path  aerosol  therapy 
(amlrol)  or  study  acrtjsol  therapy  (consisting  of  250  micrograms  of  ipratropium  mixed  m  every 
other  albuterol  aerrtsol).  Patients  that  failed  to  respond  to  treatment  received  an  inicnsilicauon 
proUx:ol  (5  mg  albulei"ol  mixed  with  500  micrograms  ipratropium,  and  0.01  mg/kg  SC  cpi)  and 


relumed  ti 
discharge 
disease  sc 


Percentages  we 


if  Q2h.  Phone  surveys  were  administered  to  track  posi 
mparcdby  Fisher  ExactTcsl  and  distributions  by  chmn 


mparcdby  Chi  Square  test.  Results:  Demographic  and  o 
s  (+  SD)  or  percentages.  No  palicnLs  required  ii 
Study 


Gender  (male) 
Raceicaui-usian) 
Chronic  Disease  Scvcnt\  C 
Mild 
Moderate 
Seven- 
Unkn.iwn 
Inpatient   Outcomes 
Length  of  Sta\  (days) 
Tolal  Treatments 
Study  /  Hacebo  Treatments 
Inteasificalion  Percentage 
Oxvficn  Rcquiiemcnt 
HospiLiI  Cost  /  Case 
Post    Discharge    Outcomes 
Daysol  Whcc/jng 
Nocturnal  Symptoms 
Absenteeism 


5.4  (4.3) 
73% 
17% 


1,92  (+0  80) 
11.8  (+6.2) 
4.9  (+2.6) 


$1,44S(+ $583)       $1,4X6  (iS543) 


n.69 

0.57 
0.47 


Cor 


2.8  (+3,2)  2.6  (±2,7) 

l,4(+2.8)  1.2(±2.0) 

3.6  (+2,6)  4.0  (+2,6) 

:lusion:  The  addition  of  ipratropium  to  nebuli/ed  albuterol  in  children  hospitalized  with 
asthma  using  this  protocol  has  no  impact  on  chnical,  financial  or  post  discharge  outcomes 
>ver;  ihc  addition  of  ipratropium  would  increase  the  pharmacology  costs  to  the  hospital. 


DOSE  OUTPUT  FROM  MDI  DISPENSERS  IN  CLOSED-SUCTION  SYSTEMS 
Scott  Foss  BS,  David  Sladek  CRTT.  Rebecca  English  BS.  Jean  Keppel  PhD,  Thayer 
Medical  Corporation,  Tucson  AZ, 

Background:  Closed-suclion  circuits  are  becoming  more  widely  used  because  of  the 
advantage  of  not  having  to  break  the  ventilator  circuit  for  suctioning  The  two  most 
frequently  used  closed-suction  systems  are  the  Ballard  Trach  Care®  and  the  Concord 
Sten-Cath®   Both  have  an  accompanying  metered  dose  inhaler  (MDI)  adapter,  which  is 
placed  on  the  side  of  the  ciosed-suction  manifold  Laboratory  tests  in  this  study  show 
that  the  MiniSpacer®  MDI  dispenser  used  with  the  Allegiance  Trach-Eze'"  closed- 
suction  system  gives  a  signiHcantly  higher  dose  output  than  either  the  Ballard  or  the 
Concord 

Method:  A  ventilator  and  a  humidifier  were  on  the  inspiratory  limb  of  the  circuit.  With 
the  Ballard  and  Concord  systems  the  patient  wye  feeds  into  the  closed-suction  manifold 
and  the  MDI  adapter  is  installed  on  the  facing  side  of  the  manifold  With  the  Allegiance 
system  the  MDI  adapter  goes  directly  between  the  wye  and  the  closed-suction  manifold. 
In  all  cases  the  manifold  feeds  into  the  ET  tube,  which  in  this  study  was  followed 
immediately  by  a  filter.  The  MDI  canister  was  actuated  at  the  starl  of  inspiration  of  the 
ventilator,  and  we  then  assayed  the  total  amount  of  drug/dose  collected  on  the  filter 
The  assay  was  repeated  10  times  for  each  drug/device  combination. 
Results:  The  amount  of  active  ingredient  (tig/dose)  for  each  of  the  three  systems  is 
graphed  below,  for  Alupent®,  Maxair™,  and  Ventolin®   Error  bars  are  one  standanJ 
deviation  On  average  for  the  three  drugs,  the  Allegiance  system  delivered  about  twice 
as  much  as  the  Concord  system  and  three  times  as  much  as  the  Ballard  system  Two- 
tailed  t-tesls  showed  that  the  differences  are  statistically  significant  (p  <<  0  05) 


ALLEGIANCE 


Conclusions:  The  MiniSpacer  differs  from  the  other  MDI  dispensers  in  two  ways; 
(1)  The  nozzle  is  in  the  path  of  the  airflow  instead  of  to  the  side,  so  the  aerosol  plume  is 
more  readily  carried  to  the  end  of  the  ET  tube   (2)  The  dual-spray  nozzle  delivers  higher 
dose  than  a  single-spray  nozzle  (Rau  JL,  Dunlevy  CL,  Respir  Care  1997,42(11)  1093) 


OF-98-014 


AN  EVALUATION  OF  AEROSOLIZED  ALBUTEROL  DELIVERY 
FROM  DIFFERENT  LOCATIONS  IN  A  BI-PAP  CIRCUIT 

David  Blakeman,  AS.  RRT,  Eastern  Idaho  Regional  Medical  Center,  Idaho  Falls. 
ID 

Introduction    An  extensive  literature  review  provided  no  documented  evidence 
regarding  the  best  location  to  place  in  line  and  deliver  albuterol  via  SVN  in  a  Bi- 
PAP  circuit    A  bench  study  was  designed  to  evaluate  the  delivei^  of  albuterol 
from  two  different  locations  in  a  Bi-PAP  circuit 

Study  Question    Does  location  of  SVN  in  Bl-PAP  circuit  effect  medication  deliv- 
ery? 

Methods:  The  SVN's  were  placed  in  line  In  the  Bi-PAP  circuit  at  two  different  lo- 
cations dunng  the  bench  study    Location  #1  was  next  to  the  whisper  valve,  and 
location  #2  was  next  to  the  Bi-PAP  machine    The  five  SVN  s  used  were  from  the 
same  lot  and  were  pretested  for  comparability    Five  tnals  for  each  of  the  Wjo  de- 
livery locations  were  performed.  A  Respiromcs  Bi-PAP  S/T-D  30  was  used  for 
this  bench  study  with  a  standard  70  inch  smooth  bore  circuit  tubing  (pressures  set 
at  10/5)    The  patient  end  of  the  tubing  was  connected  to  a  whisper  valve  and  con- 
nector with  inlet  port  for  Bi-PAP  pressure  monitoring.  This  was  connected  to  the 
following  design  to  simulate  a  spontaneously  breathing  patient    Tygon  tubing  (10 
cm  long,  2  cm  diameter),  collection  chamber,  6  inches  of  large  bore  tubing  which 
was  connected  to  a  Michigan  Instruments  double  sided  test  lung  with  lift  bar.   One 
side  of  the  test  lung  was  attached  to  a  Hamilton  Veolar  ventilator  (Vt  700,  RR 
12/m)n,  sine  wave,  flow  65  L/min,  SIMV,  PEEP  8,  PEEP  was  added  to  keep  the 
Bi-PAP  from  self  cycling)  and  the  other  side  was  attached  to  the  Bi-PAP  setup 
100%  cotton  wadding  was  placed  in  the  collection  chamber    SVN  s  in  both  loca- 
tions were  run  until  sputter,  tapped  6  times,  run  to  sputter  again    The  extracted 
solution  was  filtered  through  a  slow-flow  filter  to  remove  any  cotton  fibers  or  impu- 
nties    Absorbance  was  measured  at  278  nm  (spectrophotometer) 
Results    Location  #1  delivered  5  07%  of  the  total  dose    Location  #2  delivered 
3,47%  of  the  total  dose    Location  #1  had  a  1  6%  increase  over  location  #2 
ANOVA  for  repeated  measures  revealed  significant  differences  behA/een  the  two 
locations  lp<  01) 

Conclusion    The  results  from  this  study  would  indicate  that  when  dehvenng 
aerosolized  medication  to  a  patient  while  on  a  Bi-PAP  system  the  best  location  for 
SVN  placement  would  be  next  to  the  whisper  valve  or  Bi-PAP  mask  under  the 
conditions  set  in  this  study. 

The  author  wishes  to  thank  Jerry  Hunt,  MS,  RRT,  RPFT  for  technical  assistance 
and  support 


OF-98-019 


DELIVERY    OF   NITRIC    OXIDE   WITH   THE   TBIRD-AVSIII    VENTILATOR 

VtfilliamR,  Howard,  MBA,  RRT  Respiratory  Care.  New  England  Medical  Center,  Boston, 


BACKGROUND  Mechanically  ventilated  patients  diagnosed  with  pulmonary 
hypertension  and  hypoxemic  respiratory  failure  hava  received  Nitric  oxide  (NO)  therapy 
at  our  institution  for  approximately  5  years  The  non-neonatal  group  has  received  this 
therapy  using  a  PB-7200  ventilator  There  is  a  problem  however,  in  transporting  these 
patients  within  the  institution  for  various  diagnostic  procedures  This  problem  is  ot 
concern  especially  when  patients  ventilatory  requirements  exceed  the  limits  ol  a 
manual  resuscitation  device,  eg  during  PCV  or  wilh  FlOg  >  85°-  TBird-AVSlM,  flird 
Medical  Products,  Palm  Spnngs  CA,  has  solved  this  problem  by  providing  a  convenient 
and  safe  method  of  uninterrupted  mechanical  ventilation,  regardless  ol  mode  and  FIO2 
We  wanted  to  determine  if  this  ventilator  could  also  provide  a  reasonable  means  ol 
providing  NO  outside  ol  the  ICU  environment  We  will  evaluate  the  capability  ot 
providing  NO  m  conjunclion  with  transport  using  the  TBird-AVSIIl  METHODS:  A 
standard  patient  arcuit  was  connected  to  a  TBird-AVSIll  Oxygen  from  2  Z  size  cylinders 
was  fitted  and  connected  with  high-pressure  hoses  connected  to  a  high-pressure  lee. 
The  tee  was  connected  to  one  of  the  oxygen  inlets  on  the  TBird  A  continuous  (low  ot 
nitric  oxide,  BOC  Gases,  Murray  Hill.  NJ,  was  supplied  to  the  inspiratory  limb  of  the  TBitd 
palieni  circuit,  toDm  a  4(X)ppm  source  tank  using  a  Timeter  Classic  200  model  low-tlow 
tlowmeler.  Allied  Healthcare  Products,  Inc  ,  St  Louis,  MO  We  bench  lested  using  a 
test  lung,  BioFek  VT-?,  Winooski,  VT,  set  lor  a  compliance  ot  15  mi/cmH20  in  the  AC 
and  PCV  modes  with  desired  NO  concenirations  ot  5,  10,  and  20ppm  at  flowrates  ot 
200,  400  and  800  ml/mm  In  the  AC  mode,  settings  were  exhaled  VE  adjusted  to 
achieve  8,  12,  16.  and  20  liters.  RR  10,  15  and  20BPM,  FlO^  95%,  PEEP-  5  and  10 
cmHjO  In  PCV  target  pressure  ad)iisled  to  achieve  exhaled  minute  volume  ot  8.  12 
16,  and  20  lilers,  a1  RR  ol  10,  15,  and  20BPM,  FlO^  95%.  PEEP-  5  and  10  cmHjO 
Testing  consisted  ol  10-minule  runs  at  each  setting  The  delivered  NO  concentration 
was  continuously  sampled  with  an  electrochemical  measurement  device.  Pulmonox  II- 
RT,  Pulmonox  Medical  (^rporation,  Canada,  using  a  side  stream  analysis  method  The 
analyzer  was  calibrated  per  manufacturer's  instructions  Measurements  were  recorded 
at  tO-minute  intervals  RESULTS  The  mean  measurements  ol  NO  with  SD  are  in  the 
following  table  for  the  total  group,  the  PCV  group,  and  the  AC  group  separately 


Dose  (cc/min) 
MEAN  Total 
STDEVTotal 
MEAN  PCV 
STDEV  PCV 
MEAN  AC 
STDEV    AC 


200 


1  8 


1  6 


3  6 


CONCLUSION  NO  administration  with  IBird-AVSIll  was  acceptable  at  desired 
concentrations  ol  5-20  ppm  Stable  NO  concentrations  were  delivered  at  minuie 
volumes  ranging  Irom  8  20  L^M  using  I  b  ratios  o(  1  2  to  ?  1  in  either  AC  or  PCV  modes 
Continuance  ol  identical  lite  support  delivery  needs  outside  the  ICU.  inclusive  of  NO 
administration,  is  possible  with  Ihe  TBird-AVSIII  ventilator 

OF-98-030 


828 


Rr.spiRATORY  Care  •  Octobfr  '98  Voi.  43  No  10 


Patient  to  ICU         Change  Ventilator 


Patient  to  X-Ray         Change  Ventilator 


Patient  to  Operating  Room         Change  Ventilator 


Patient  to  ICU         Change  Ventilator 


How  many  ventilators 
do  jou  need  to  take 
care  of  your  patient? 

-Justone.TBinl. 

The  Seamless  Solution. 

Each  time  \'ou  change  ventilators,  it  can  put 
your  patient  at  risii.  BiitTBird,"  a  revolutionary 
new  turbine-powered  ICU  ventilator  system,  is 
designed  lo  sta)'  with  )Our  patient.  There  are 
no  seams,  no  interruptions,  so  potentially  fewer 
complications  occur  And  since  one  piece  of 
equipment  performs 
so  many  jobs,  costs 
are  lower  too. 
To  take  your 
patient  seamlessly 

through  the  continuum  of  care,  notliing 
performs  likeTBird." 

C;all  your  local  Bird  representative  or 

1-800-328-4139 


for  more  information 


Circle  114  on  reader  service  card 
Visit  AARC  Booth  131  in  Atlanta 


BIRO  PRODUCTS  CORPORA  TION 

A  Thermo  E/ecfron  Compnny 

The  Breath  of  Technology 

Palm  Springs.  CiilifoniUi  •  (,l')^^8.7200 
fti.v  •  6/9r-8.^274 


Saturday,  November  7,  2:00-3:55  pm  (Room  214E) 


BUDESONIDE  NEBULIZING  SUSPENSION  (BNS,  PULMICORT 
RESPULES™)  IMPROVES  PULMONARY  FUNCTION  IN  YOUNG  CHILDREN 
WITH  PERSISTENT  ASTHMA  NOT  WELL-CONTROLLED  ON  OTHER 
INHALED  GLUCOCORTICOSTEROIDS  (IGCs). 

M  Cmz-Rlvera.  PhD    M  P  H  &  K  Walton-Bowen,  M  Sc  ,  C  Stal,  (Aslra  USA, 
Inc  ,  Westtwrough,  MA) 

The  current  NHLBI  guidelines  highlight  the  importance  ol  managing  pediatnc 
persistent  asthma  with  antiinflammatory  agents,  including  IGCs  Budesonide  is  a 
GCS  With  low  systemic-lo-local-etfects  ratio  formulated  for  use  via  nebulizer  in 
pediatnc  persistent  asthma  This  was  a  randomized,  double-blind,  placebo 
(PBO)-controlled.  multicenter,  12-wk  study  assessing  the  efficacy  and  safety  of 
BNS  (0  25,  0  5  or  1  0  mg  BID)  in  178  children  aged  4-8  yrs  with  persistent 
asthma  not  well-controlled  on  IGCs  via  pMDI  Compared  to  PBO,  there  were 
improvements  tn  lung  function  (mean  change  from  baseline  over  12  wks.  adjusted 
for  center  effect:  All  Patients  Treated,  last  value  carried  forward) 


Variable 

PBO 
(n=41) 

BNS  (BID) 

0  25  mg    0.5  mg 

(n=46)      (n=42) 

1  Omg 
(n=45) 

rooming  PEF(L/min): 

-13 
(n=44) 

15  3-- 
(n=47) 

11  8- 

104- 

Evening  PEF(L7min): 

3  0 
(n=44) 

14.9- 
(n=47) 

11  6 

13  2 

FEV,  (L) 

-001 

0  05 

008' 

007 

FEF25-75%(L'sec) 

■0  06 

0  00 

0  14- 

0  14- 

FVC(L) 

0  04 

0  09 

0  06 

0  05 

(p(0  050.  "plOOlO,  and  '"piOOOl  vs   PBO) 

In  addition,  there  were  statistically  significant  improvements  in  nighttime  and 
daytime  asthma  symptoms,  and  statistically  significant  reductions  in  the  use  of 
bronchodilators  in  all  three  BNS  treatment  groups  compared  to  PBO  (p{0  032) 
These  data  support  the  efficacy  of  BNS  in  persistent  pediatric  asthma  not  well- 
controlled  on  other  IGCs  via  pMDI  Supported  by  Astra  USA,  Inc. 


DF.I.IVF.RY    OK   NITROILS   OXIDK   VIA  THR  SKRVO  90QC    VENTIL- 
ATOR   FOR    PAIN    CONTROL    DIIRINC    nRFSSING    CHANnRS.    AND 
WOUND    DEBREIDMENT.    Chns  Cclla.  RRT.  Terr>  Jordan.  RRT.  Josti  Bendill. 
MD.  University  of  Washington  Medical  Cenier,  Seanic  WA, 

In  god  uc  Don-  Nitrous  oxide  (NjO)  k  provided  for  analgesia  lo  suiiable  paiienis  who 
require  sh«t  painful  procedures  at  frequeni  intervals.  Currcnlly  our  institution  uulizcs 
a  program  whereby  the  Acute  Pain  Service  (APS)  is  consulted  foruseof  N.O.  The  APS 
physician  evaluates  the  paucnl  pnor  to  use.  and  is  present  for  the  fu-st  administration  of 
NjO.  Thereafter  at  the  discretion  of  the  physician.  N3O  may  be  administered  by  an 
Respiratory  Care  Practitioner  (RCP),  Patients  arc  carefully  monitored  by  the  RCP  for  level 
of  consciousness.  A  pulse  oximeter  is  used  lo  monitor  heart  rate  and  sp02.  Mixtures  arc 
limited  to  a  maximum  of  .50  nitrous  oxide. 

We  present  a  case  study,  whereby  a  63  yo  female  with  squamous  cell  carcinoma  of  the 
nasopharynx  and  tracheostomy  tube,  was  having  difficulties  weaning  from  mechanical 
ventilation.  The  patient  was  undergomg  painful  dressing  changes  to  her  right  calf  TID. 
She  was  medicated  with  morphine  sulfate  which  was  administered  intravenously  pnor 
to  each  dressing  change.  Her  level  of  consciousness  was  significanUy  decreased  following 
each  procedure  for  2-3  hours,  hindering  weaning  efforts.  At  the  request  of  APS.  .50 
NjO/  50  02  was  delivered  via  a  Bud  N,0A)2  blender  to  the  tow  flow  inlet  of  a  Servo  900C 
ventilator.  R02  was  analyzed  on  the  mspiratory  limb  of  the  circuit,  and  exhaled  gase.s  were 
.scavenged  by  a  ventun  vacuum  device.  The  paLicnt  tolerated  the  dressing  change  well  wiih 
N,0  alone  for  analgesia.  24  hour^  after  the  initiation  of  this  therapy,  the  patient  was  weaned 
from  mechamcal  ventilation,  and  placed  on  humidified  oxygen.  During  the  next  72  hours  N-O 
was  debvered  by  rcsusciiator  bag  (exhaled  gas  was  scavenged  via  a  PEEP  divenor  attached  to 
a  vacuum  ventun  device)  dunng  dressing  changes.  After  this  lime  ihe  patients  condition 
unproved,  and  she  no  longer  requucd  N/l. 

Ptgcusgipn-NjO  can  safely  and  effecuvely  be  delivered  through  the  Servo  900C  venulator 
and  used  as  an  altemative  to  IV  medicauons  for  analgesia  during  short  painful  procedures. 
Careful  monilonng  must  be  done  to  insure  safety  during  this  procedure.  Considerations  must 
be  made  about  NjO  concentrations  set  relative  lo  necessary  F102*s  being  delivered.  Further 
study  of  use  of  this  gas  delivery  system  is  necessary. 


EXAMINATION  OF  CLINICAL  RESPONSE  TO  AEROSOLIZED 
ALBUTEROL  ADMINISTERED  BY  TWO  METHODS 
b>-  Beth  Brottii,  RRT  Macon  Stale  College  Macon,  Georgia 
Bronchia)  smooth  muscle  hvpenrophy  has  been  documented  in  in^ts  uith 
chronic  lung  disease    Some  of  the  high  airway  resistance  may  be  caused  b>' 
bronchospasm.  This  bronchospasm  may  be  reheved  b\'  inhaled  bronchodilators 
The  purpose  of  the  study  is  to  examme  chnical  response  to  aerosolized 
bronchodilator  administered  by  two  methods  of  aerosol  delivery  in 
mechamcally  ventilated  neonatal  subjects.  Albuterol  is  delivered  to  the 
mechamcally  ventilated  infant  tn'  metered  dose  inhaler  and  spacer  or  by  gas 
powered  Mini  Heart"*  nebulizer.  Method:  Measurements  were  taken  pre- 
bronchodilator.  immediately  after  bronchodilator.  30  minutes  after 
bronchodilator.  and  60  minutes  after  bronchodilator.  These  measuremenls 
included  o.vygen  saturation  by  pulse  oximetry  (  Sp02  ).  heart  rate,  airway 
resistance,  work  of  breathing,  and  compliance    Infants  served  as  their  own 
controls  in  a  randomized  crossover  design,  with  a  washout  period  between 
alternate  methods  of  aerosol  deUver^    The  results  arc: 


average  % 
change  m 
compliance 

average  %  change 
in  resistance 

average  %  change 
in  work  of 
breathing 

Mini  Heart 
'™  nebulizer 

47%li 

18%0 

29%^ 

MDI 

21%tr 

S'M 

No  change 

The  univanate  approach  was  used  for  the  test  of  drug  response  over  time  of 
measure  There  were  no  siatistically  significant  differences  to  method  of  drug 
dchver\  for  each  vanable    However  the  univariate  approach  revealed  a 
significant  difference  in  work  of  breathing  between  the  average  of  post  and 
thirty  minutes  compared  to  si.xty  minutes  None  of  the  responses  to  drug  across 
limes  of  measure  was  significant  (  p  >  (I  05  )  with  the  exception  of  work  of 
breathing  The  univanate  approach  revealed  a  significant  difference  in  work  of 
brcathmg  between  the  average  of  post  and  Wi  minutes  compared  lo  60  minutes 
(p=OOI.^  )     There  was  no  difference  between  a  bronchodilator  delivered  by 
Mim  hcail  nebuli/er  or  MDI  in  the  sample  studied  Even  though  there  was  no 
statisucal  significance  in  the  study,  one  can  not  overlook  the  improvement  in 
compliance,  the  dccrca.sc  in  resistance,  and  the  decrease  in  work  of  breathing 
after  the  dchvcry  of  aerosolized  albuterol  by  cither  method  of  drug  delivery. 
Conclusion  With  the  small  number  of  subjects  actually  enrolled  in  the  study  (  n 
=5  ).  the  sample  si/e  was  too  small  to  achieve  statistical  significance  for 
changes  in  the  variables  measured  with  the  two  methods  of  aerosol  delivery 


A   COMPARATIVE   STUDY   EVALUATING    ELECTROCHEMICAL 
FUEL   CELL   VS   CHEMILUMINESCENCE    NITRIC    OXIDE 
ANALYZERS    DURING    MECHANICAL   VENTILATION. 

Elizabeth  A.  Grannan  RRT.  Alicia  A.  Prickett  CRTT,  and  Joseph  N 
Summitt  RRT  Indiana  University  Purdue  University  Indianapolis,  Indiana 

Background.  Nitric  oxide  Is  extensively  used  In  the  treatment  of 
persistent  pulmonary  hypertension  of  the  newborn  and  other  related 
disease  states.  In  the  delivery  of  this  therapy  It  is  imperative  to  analyze 
the  delivered  nitric  oxide  level  and  the  level  of  nitric  dioxide  that  Is 
produced  as  the  gas  mixes  with  oxygen  Chemilumlnescence  nitric  oxide 
(NO)  and  nitnc  dioxide  (NO^)  analyzers  have  been  exclusively  used  for 
this  purpose,  until  recently  Currently  new  electrochemical  fuel  cell  NO 
and  NOj  analyzers  are  being  produced,  which  are  more  cost-effective 
and  practical  Accuracy  of  these  devices  is  imperative  for  proper  use 
Methods.  We  evaluated  two  NO  electrochemical  analyzers  (Pulmonox  II 
and  Ohmeda)  In  comparison  to  the  Eco-Physlcs  CLD  700  AL 
Chemilumlnescence  NO  analyzer  All  were  calibrated  and  used 
according  to  manufacturer's  specifications.  Using  a  VIP  Bird  Ventilator  in 
time-cycled  mode,  the  effects  of  FlO^and  peak  inspiratory  pressure  (PIP) 
were  measured  The  Ohmeda  l-NO  vent  delivered  senal  dilutions  of  NO 
for  5,  10,  20,  &40ppm  F10,  settings  of  21,  50,  and  100%  and  PIP 
settings  of  10,  20,  30  cm  HjO  with  a  PEEP  of  5  cm  H^O  were  used 
Sample  ports  were  placed  on  the  inspiratory  limb  of  the  ventilatory  circuit 
at  a  fixed  distance  from  the  Y-piece  distal  to  the  humidifier  Each  reading 
was  recorded  after  a  time  lapse  of  5  minutes  per  setting  change. 
Results.  Using  a  MANOVA,  there  was  no  significant  difference  between 
devices  with  p  <  O  05  for  Ihe  effects  of  FIO,  with  PIP  constant  A 
significant  difference  was  found  with  p  <  O  05  for  the  effects  of  PIP  with 
FIOj  constant  A  correlation  study  was  done  to  show  the  details  of  the 
difference  The  higher  the  pressure  and  ppm  the  greater  the  difference 
for  the  Pulmonox  II  However,  there  was  no  significant  ditterence 
between  the  Ohmeda  l-NO  vent  and  the  chemilumlnescence 
Conclusion.  The  detection  of  NO  by  the  Pulmonox  II  did  not  correlate 
with  the  chemilumlnescence  Caution  should  be  used  with  the  Pulmonox 
II  when  high  PIP  are  anticipated  and  high  ppm  of  NO  are  delivered. 


830 


Respiratory  Carf,  •  OrroBER  "98  Vol  43  No  10 


Saturday,  November  7,  2:00-3:55  pm  (Room  2I4E) 


Are  Budget  Constraints 
Preventing  You  From 

Buying  the  Equipment 
Your  Facility  Needs? 

Then  check  out  the  1998  Silent  Auction 

at  the  International  Respiratory 

Congress  in  Atlanta,  GA,  Nov.  7-10. 

Thanks  to  generous  donations  by  our 

manufacturing  community,  last  year's  auction 

included  such  items  as  ventilators,  capnographs, 

nebulizers,  filters,  masks,  and  PCs  (as  well  as 

entertainment  packages,  gift  items,  and 

autographed  sports  memorabiHa).  We 

anticipate  an  even  larger  selection  this  yean 

Call  the  American  Respiratory  Care  Foundation 

or  the  A  ARC  at  (972)  243-2272  for  more 
information.  Ask  for  Norma  or  Brenda. 


INHALED  NITRIC  OXIDE  THERAPY  FOR  TREATMENT  OF  SEVERE 
BRONCHOPIXMONARY  DYSPLASIA:  A  CASE  STUDY.  Sandra  R.  Wadlinger.  BA, 
RRT.  CPFT.  P/P  Specialist.  Lorraine  P  Hough.  Med,  RRT.  CPFT,  Beverly  A.  Banks,  MD. 
PhD,  Roberta  A  Ballard,  MD.  Department  of  Respiratory  Care.  The  Children's  Hospital  of 
Philadelphia  and  The  Hospital  of  the  University  of  Pennsylvania.  Department  of  Pediatrics. 
L'luversity  of  Pennsylvania  School  of  Medicine,  Philadelphia,  PA. 

INTRODUCTION:  BroQchopulmonary  Dysplasia  (BPD)  continues  to  be  a  major  source  of 
morbidity  and  mortality  in  premature  infants.  Inhaled  Nitric  Oxide  (NO)  has  been 
demonstrated  to  improve  oxygenation  m  various  disease  states  characterized  by  pulmonary 
hypertension  and  ventilation  perfusion  mismatch.  This  case  report  examines  the  use  of  inhaled 
Nitnc  Oxide  to  improve  oxygenation  m  an  infant  with  severe  BPD 

vas  a  29  day  old  former  8S0  gram  product  of  a  26 
s  comphcated  by  respiratory  distress  syndrome, 

,  pulmonary  hemorrhage,  sepsis  and  pneumonia 
5  including  surfactant  replacement, 
:  and  epinephrine  infusions,  mdocm  therapy,  antibiotic  therapy,  high  frequency 
oscillatory  ventilation  and  dexamethasone  treatment  On  day  of  life  29.  after  two  weeks 
requinng  100%  oxygen,  he  was  given  a  tnal  of  inhaled  NO  as  a  final  effort  to  improve  his 
respiratory  status.  At  the  mitiation  of  NO  therapy,  his  ventilator  settings  were  a  peak 
inspiratory  pressure  (PIP)  of  35cmH;0.  positive  end  expiratory  pressure  (PEEP)  of  ScmH^O. 
ventilator  rate  of  40  breaths/mmute,  100%  oxygen  with  a  mean  airway  pressure  (MAP)  of 
1  ScmH,0,  Followmg  one  hour  of  inhaled  NO,  his  PaO;  mcreased  from  48  mmHg  to  80 
mniHg  After  24  hours  of  inhaled  NO  he  successfully  weaned  to  70%  oxygen.  Durmg  the  first 
week  of  therapy,  the  infant  tolerated  substantial  reductions  m  his  venhlatory  requnement  with 
a  decrease  in  MAP  from  IScmHjO  to  I  IcmH^O,  TTiis  progressive  decrease  in  ventilatory 
support  was  sustamed  throughout  the  treatment  penod.  Methemoglobm  levels  were  obtamed  at 
regular  intervals  and  never  exceeded  0.2%  (acceptable  range  0,0-2,8).  Af^er  33  days,  his 
ventilator  settings  were  a  PIP  of  22cmH,0,  PEEP  of  7cmH;0,  ventilator  rate  of  32 
breaths/mmute,  40%  oxygen  with  a  MAP  of  I  IcmHjO.  NO  therapy  was  discontmued  at  this 
time  with  no  increase  m  ventilatory  support  required.  The  following  chart  s 
oxygenation  status: 


CASE  SUMMARY:  The  study  mfant 
week  gestation  His  neonatal  course 
systemic  hypotension,  patent  ductus 
His  condition  remained  cntica!  despiti 


Treatment  Day 


NOppm 


PaOTFiO, 


Oxygenation  Index 


CONCLUSION:  Inhaled  Nitric  Oxide  therapy  seemed  to  be  valuable  m  this  patient  widi 
severe  ventilator  dependent  Bronchopulmonary  Dysplasia  allowing  him  to  tolerate  lower 

mspired  oxygen  concentrations  and  decreased  ventilator  support. 


See  the  fastest  Nitric  Oxide  analyzer,  utilized 
for  Exhaled  Nitric  Oxide  measurements,  with 
simultaneous  CO2,  O2,  flow  and  volume. 


Booth  #  656  at  the  AARC  Congress  in  Atlanta 


ECO   PHYSICS 

ECO  PHYSICS,  INC. 
3915  Research  Park  Drive,  Suite  A-3 
Ann  Arbor,  Ml  48108-2200 
Tel.  (734)  998-1600     http://ic.net/'-ecophys 


Caution:  For  research  use  only, 
not  for  use  in  diagnostic  procedures 

Circle  138  on  reader  service  card 
Visit  AARC  Booth  656  in  Atlanta 


VARIABILITY  IN  ALBUTEROL  DELIVERY  WITH  PROVENTIL  HFA  AND  VENTOLIN 

METERED  DOSE  INHALERS  (MDIs).  Ralph  A  Lugo,  PharmD,   Jim  Keenan,  BS.  RRT. 
Robert  M  Ward.  MD,  John  W  Salyer,  BS,  RRT    Primary  Children's  Medical  Center 
and  the  University  of  Utah  College  of  Pharmacy,  Salt  Lake  City,  Utah   Introduction 
Aerosolized  albuterol  (ALB)  is  commonly  administered  via  MDI  and  in-line  spacer  to 
mechanically  ventilated  patients  CFC-free  Proventil  HFA  (Key  Pharmaceuticals)  is  novy 
available,  however  its  unique  canister  and  stem  design  vwas  not  intended  for  use  with 
in-line  spacers  This  canister-spacer  incompatibility  appears  to  result  in  significant 
vanability  in  the  visible  quality  of  aerosol  cloud  formation  when  used  with  the  ACE 
spacer  This  is  apparent  upon  repeated  actuation  and  may  result  from  imprecise  drug 
release  from  the  valve  Furthermore,  poor  aerosol  cloud  formation  may  result  in  greater 
impaction  on  the  spacer,  thereby  reducing  drug  delivery  to  the  patient.  The  objective  of 
this  study  was  to  determine  the  precision  (variability)  of  ALB  release  from  Proventil 
HFA  and  compare  it  to  Ventolin  (Glaxo  Wellcome)   In  addition,  we  sought  to  compare 
ALB  impaction  in  the  spacers  following  actuation  Methods  The  ALB  recovery  model 
consisted  of  a  Sims  filter  (#2832)  attached  to  the  patient  end  of  an  ACE  spacer 
Continuous  negative  pressure  (-100  mm  Hg)  was  applied  to  the  open  end  of  the  filter 
Thus,  aerosolized  ALB  flowed  unidirectionally  from  the  spacer  to  the  filter  following 
each  MDI  actuation  Each  experiment  was  conducted  by  actuating  a  single  MDt  into  an 
ACE  spacer.  One  minute  following  actuation,  the  spacer  and  filter  were  nnsed  with  20 
mL  and  45  mL  of  filtered  water,  respectively  Ten  replicates  were  performed  for  each  of 
the  two  brands  of  MDIs  Different  canisters  were  used  for  each  replicate  ALB 
concentrations  in  the  resultant  solutions  were  assayed  using  high  performance  liquid 
chromatography  We  validated  this  methodology  and  assay  by  determining  recovery  of 
a  known  quantity  of  ALB  placed  on  five  filters  Mean  recovery  was  97.2%  ±  3.0%.  All 
data  are  reported  as  mean  percent  of  the  labeled  amount  of  ALB  released  with  each 
actuation  (100  meg)  +  standard  deviation  Results  Total  ALB  recovery  for  both 
Proventil  HFA  and  Ventolin  were  highly  vanable  and  ALB  delivery  commonly  exceeded 
the  labeled  dose  Proventil  HFA  had  a  slightly  larger  standard  deviation  and  range  of 
recovery,  however,  there  was  no  statistically  significant  difference  between  the  two 
MDIs  (p>0  05,  Student  t-test)   Furthermore,  the  2  groups  did  not  differ  in  spacer 
impaction  of  aerosol  (p>0  05,  Student  t-test) 


Filter 


Spacer         Total  Recovery         Range 


Proventil  HFA     59  0%  (22  4%)    40  9%  (11  4%)     99  9%  (27  7%)      47  3-135  4% 
Ventolin 69.7%  (12  2%)    38  9%  (12  5%)    108  6%  (22.1%)     72  2-139  7% 


Conclusion:  Despite  the  visually  apparent  vanability  in  aerosol  cloud  formation  when 
Proventil  HFA  is  actuated  into  an  ACE  spacer,  total  ALB  recovery  and  drug  impaction 
on  the  spacer  did  not  differ  from  Ventolin.  However,  it  is  clinically  important  to  recognize 
that  there  is  large  vanation  in  total  ALB  delivery  from  both  MDIs  when  used  with  an 
ACE  spacer  This  may  result  in  vanability  in  therapeutic  response  necessitating  close 
patient  monltonng  and  dose  titration 


Respiratory  Care  •  October  '98  Vol  43  No  10 


831 


Saturday.  November  7.  2:00-3:55  pm  (Room  214E) 


.AEROSOLIZED  ALBUTEROL  DELIVERY  BY  HIGH  FREQUENCY 
OSCILLATION  AND  BY  CONVENTIONAL  VENTILATION;  A  BENCH 
STUDY.  William  Ouinn  RRT  RPFT,  Marie  McGcttigan  MD,  Ochsner 
Foundation  Hospital,  New  Orleans,  L.'k.  We  sought  to  delennine  whether  a 
small  volume  nebulizer  (SVN)  placed  in  Ime  with  a  high  frequency  oscillator 
(HFO)  delivered  as  much  albuterol  to  a  test  lung  as  it  did  when  placed  m  Ime 
«ith  a  convemional  ventilator  (CV.)  We  also  sought  to  distmguish  how  much 
of  the  delivered  albuterol  was  instilled  in  the  lung  from  large  droplets  which 
form  on  the  interior  of  the  endotracheal  tube  (ETT  )  Our  hypothesis  was  that 
less  total  albuterol  would  be  delivered  with  HFO  than  with  CV.  Methods  and 
materials:  An  SX'N  was  attached  to  the  temperature  port  on  the  inspiratorv' 
side  of  a  ventilator  circuit  which  was  in  turn  attached  to  a  3  0  mm  ETT  held 
in  brackets  in  a  curved  position.  The  other  end  of  the  ETT  was  attached  via  a 
set  of  1 5x22  mm  adapters  to  a  I  ml.  cm  H2C^ 
PcmniagcDcHvemi  tcst  luRg.  THals  A  and  C  wcrc  performed 


I  ^  I     with  a  CV  (Sechrist  lOOOlV)  set  at  a  rate  of 

'    H    H  60,  aPIPof30cmH;O,  CPAPof4cmH,0. 

,    H    H  andT,  of  0,4  seconds.  Trials.  Band  D  were 

^B    tMt    mm  performed  with  an  HFO  (Sensonnedics 

'    ■    B-H    ■       3 100a)  set  at  a  rate  of  I. 5  Hz,  a  A?  of  33  cm 
°      A         B    '  ?^-^-^     H,0,  and  a  P.„  of  1 5  cm  H,0.  In  trials  A  and 
■  «  Bso  ^  "  (cotton  ball  was  placed  inside  the  adapters 

directly  on  the  end  of  the  ETT.  In  trials  C  and 
D  the  adapters  between  the  ETT  and  the  test  lung  were  arranged  so  that  a 
"drip  trap"  was  below  the  ETT  opening  and  gas  went  through  a  right  angle 
turn  before  reaching  a  cotton  ball.  Ten  repetitions  of  each  trial  were  done.  In 
ail  trials  the  nebulizer  was  operated  at  7  L.'minute  with  2  5  mg  of  albuterol  in 
a  3  ml  solution.  The  nebulizer  was  run  until  e>diausted,  after  which  the  cotton 
ball  was  removed  and  washed  with  20  ml  of  saline  solution.  This  solution 
was  analyzed  by  spectrophotometry  to  determine  the  albuterol  content,  which 
was  then  expressed  as  a  percentage  of  total  albuterol  in  the  nebulizer.  Results 
(see  table)  were  subjected  to  ANOVA  and  the  Krusskal-Wallis  H  test.  A  and 
B  were  NSD  (P-\ alue  >.4. )  C  was  significantly  less  than  A  and  B.  and  D  was 
significantly  less  than  all  other  trials  (P-value  <.0I.)  Conclusion:  Roughly 
equal  amounts  of  albuterol  reach  the  lung  fi-om  an  SVN  whether  HFO  or  CV 
IS  employed,  but  when  HFO  is  used,  more  of  the  drug  is  instilled  at  the  carina 
instead  of  being  delivered  as  a  mist 

OF-98-105 


LAB  EVALUATION  OF  A  NITRIC  OXIDE  BREATHING  SYSTEM  UTILIZING 
THE  OHMEDA  INO-VENT.  Ji.lin  Ncwhari  RCP.  Elsie  M,  CollaJo  B,S.  RRT  RCP,  F. 
Wayne  Johnson  RCP,  R.  N.  Channick  MD.  UCSD  Medical  Ccnlcr  San  Diego  California. 
BACKROUND:  Tiic  use  of  inhaled  nitric  oxide  (INO)  lo  ucal  pulmonary  hypcrlension 
and  hypoxia  has  been  previously  described  in  the  literature,  in  our  insuiulion  wc  utilize 
Uie  Ohmeda  INO-Venl  to  deliver  INO  lo  mechanically  ventilated  paUenls.  We  sought  to 
adapt  the  INO-Venl  for  use  on  spontaneously  breathing  patientji  via  facemask. 
METHODS:  Selectable  inspired  oxygen  concentrations  were  generated  by  a  Bird  3800 
air/02  blender  with  available  flow  controlled  by  a  0-75  Ipm  flowmeter.  The  patient  draws 
gas  from  a  "T"  piece  through  the  INO-Venl  flow/injeclor  module  where  a  proportionate 
amount  of  NO  is  injected  into  Uie  inspired  gas.  This  gas  flows  through  a  6  inch  length  of 
22mm  comigalcd  tube,  through  a  gas  sample  adapter  and  into  a  Vital  Signs  CPAP  mask. 
Exhaled  gas  passes  through  the  exhalauon  port  in  the  mask.  To  bench  lesl  Ihc  syslem  we 
altachcd  the  complete  mask  to  an  open  30mm  port  in  one  chamber  of  a  Michigan 
InsUTimenls  TTL.  The  other  chamber  of  die  lung  wa.s  driven  by  a  NPB  7200  venlilalor.  A 
bar  was  attached  to  die  ventilator  driven  side  in  such  a  way  as  to  lift  the  mask  side 
(simulating  a  patient  breathing)  when  the  ventilator  cycles.  We  tested  the  syslem  at 
different  ventilator  volume,  respiratory  rate  and  peak  flow  rates.  In  all  runs,  the  ventilator 
was  in  CMV.  square  wave,  and  used  a  standard  ventilator  circuit.  The  INO- Vent  was 
calibrated  prior  to  use  and  an  external  oxygen  analyzer  (MSA  Mini-Ox  III)  was  u.scd  to 
determine  Fi02. 

RESULTS: 


Ventilator  sellin(!s:  Vt  .51..  RK  12.  ^.'^  Ipm 

02  % 

lOppra 

(N0/N02I 

Zllppm 

lNO/M)21 

Jllppm 

1NO/N021 

50% 

8.5/0 

I8/.I 

.t7/.l 

90% 

8.2/0 

18/0                1  .37/.!                   1 

Venlilalor  sellincs:  VI  .SL.  RR  20,  45  torn                  i 

02% 

lOppm 
(N0/N02I 

20ppm 

(N0/N02) 

40ppm 

(N0/N02I 

50% 

8.7/0 

18/0 

38/0 

90% 

8.4/0 

18/0 

37/.  1 

Ventilator  seltines:  VI  I.OL,  RR  20, 65  Ipm                1 

02% 

lOppm 

(N0/N021 

20ppni 

IN0/N02I 

40ppm 

(NO/N02) 

50% 

8.4/0 

18/0 

.37/0 

90% 

8.5/0                    18/0 

37/0 

In  all  runs.  NO  was  held 
analy/cd).  Nitrogen  dioxide  was  in  ull 
5ppm  as  well  as  the  commonly  accept 
delivery  of  NO  can  be  safely  accompli 
minimal  additional  hardware.  Aclu:il  i 
response  NO  analyzer. 


ithinlhcOhmcib 


OF-98-117 


EVALUATION  OF  A  PORTABLE  NITRIC  OXIDE  SYSTEM  FOR  INTERHOSPITAL 
TRASNSPORT  DURING  NEONATAL  MECHANICAL  VENTILATION 

Michael  Tracv,  RRT  .  Robert  L  Chatburn,  RRT.  Eileen  Stork.  MD, 
University  Hospitals  ol  Cleveland.  Ohio 

BACKGROUND:  Rainbow  Babies  &  Children's  hospital  is  a  tertiary  referral  center  tor 
ECMO  We  frequently  transport  newborns  with  persistent  pulmonary  hypertension  to  our 
hospital  lor  medical  management  and  ECMO.  Patients  who  qualify  are  placed  on 
inhaled  nitric  oxide  therapy  (NO)  in  an  attempt  to  avoid  ECMO  Initialing  NO  at  the 
referring  hospital  may  provide  increased  stability  for  transported  patients.  The  purpose 
of  this  study  was  to  evaluate  a  portable  NO  delivery  system  that  could  be  used  on 
ventilated  neonates.  METHODS:  V\!e  designed  a  syslem  composed  of  a  transport 
ventilator  (Biomed  MVP-l  0).  a  D  cylinder  of  nitric  oxide  at  800  ppm  (Ohmeda)  and  a 
combined  NO,  N02  analyzer  (Printer  Nox,  Micro  Medical)  illustrated  below  We  selected 


ialienl'*H 


expiratory  limb 


the  Biomed  transport  ventila- 
tor lor  Its  compatibility  with 
our  transport  isolette.  The 
Ohmeda  D  cylinder  was 
selected  lor  its  light  weight/ 
small  size  with  800  ppm  con- 
centration lo  minimize  gas 
consumption    The  Printer 
Nox  was  selected  alter  an 
inaccuracy  study  This  study  compared  the  Printer  Nox  to  a  "gold  standard"  chemilumi- 
nescent  analyze  (ECO  physics)-  Both  analyzers  were  connected  to  a  patient  circuit  and 
NO  was  delivered  at  9  concentrations  over  the  range  of  1  ppm  to  40  ppm.  The  differ- 
ences between  the  two  measurements  at  each  level  were  used  to  construct  an  inaccu- 
racy interval  (covering  95%  of  future  measurements  at  the  99%  confidence  level).  The 
final  system  was  assembled  by  mounting  the  analyzer  to  an  autosyringe  clamp  and  rail 
mounted  to  the  isolette.  The  NO  source  tank  was  mounted  in  a  spare  tank  slot  at  the 
base  of  the  Isolette  The  system  was  evaluated  under  simulated  patient  conditions  in  the 
transport  vehicle.  Environmental  testing  consisted  ol  measunng  NO/  N02  inside  the 
vehicle  where  passengers  would  sit,  without  scavenging  ventilator  exhaust 
RESULTS:  The  inaccuracy  ol  Printer  Nox  measurements  was  only  -i  ,07  ppm  to  0,99 
ppm  During  simulated  use.  desired  NO  levels  were  steady,  ±1  ppm  Environmental  test 
results  are  shown  below  (readings  ol  N0/N02  after  stabilization  at  various  distances 
from  ventilator) 

40  cm 
0.75/0-10 


Delivered  NO(ppm)      0  cm 

20  19.4/0.10 

40  38.8/0  17 

80  77  3/1,9 


1  4/0.15 


BO  cm  160  cm 

0  55/0  10  background 

1  05/0  15  0  80/0  15 
1  55/0  15  1  10/0,15 


.90/0.19 

EXPERIENCE  :The  system  added  little  weight  and  did  not  impair  the  ease  or  speed  ol 
loading/unloading  or  Isolette  portability  CONCLUSIONS:  A  simple,  practical  device  can 
be  constructed  to  safely  provide  NO  lo  ventilated  neonates  during  transport. 


OF-98-111 


AUDIT  OF  METERED  DOSE  INHALER  TECHNIQUES  IN  A 
RESPIRATORY  CARE  PROTOCOL  PROGRAM,  P.  Haney  RRT, 
Ed  Hoistn^on,  RRT.JuhoBurkhart,  BS,  RRT.  J.  K.  Stoller,  M.  D. 

The  Cleveland  Cliiuc  Foundation.  Cle\eland,  Ohio 

Introduction:  Metered  Dose  Inlialers  (MDI's)  are  widely  used  for  inpatients  at 
The  Cleveland  Clinic  Foundalion  where  30,399  MDI's  were  administered  in  1997, 
Wilhin  our  Respiratory  Therapy  Consult  Ser\ice  (RTCS).  patients  (pis)  are 
instructed  in  proper  MDI  use  with  allowance  for  patients  to  seif-adniinister  MDI's 
once  they  demonstrate  proper  technique.  To  assess  whether  patients  retain  the 
abilit>'  to  use  MDI's  properly  after  RTCS  "sign-off",  we  conducted  lliis  current 
audit    Methods    All  patients  using  MDI's  are  instructed  by  the  RTCS  therapist 
with  altenlion  to  proper  dose,  teclinique.  and  spacer  use.  An  instructional  iiandout 
IS  gi\en  routinely.  For  a  con\enience  sample  of  patients  assigned  lo  MDI 
self-adminlslralion  after  demonstrating  competent  MDI  technique,  a  therapist 
mvcstigalor  re-assessed  tlie  patient's  MDI  technique  24  hours  after  "sign-off" 
A  list  of  techniques  was  graded  using  a  standard  questionnaire  assessing  patients' 
ability  10  dispense  canister,  breath  hold,  pause  between  puffs,  proper  position  and 
shaking  of  canister,  Results:  Of  tlie  58  patients  assessed.  91%  had  used  MDI's  at 
home  before  admission  and  65%  previously  used  a  spacer    In  all.  96%  of  patients 
administered  the  proper  number  of  prescribed  puffs,  ;uid  94%  were  aware  of  the 
proper  frcquenc>'  of  administration.  Also,  93%  demonstrated  tlic  proper  MDI 
icchnique  with  proper  position  and  breath  hold.  On  the  other  hand.  45%  of  these 
patients  weie  unable  to  determine  how  much  medication  remained  in  the  canister 
liiid  21%  of  patients  did  not  recall  recei\Tng  an  instructional  handout. 
Conclusion:    Wc  conclude    1    In  tlus  convenience  sample,  the  rale  witii  which 
patients  retained  proper  MDI  Icchnique  after  previous  sign-offs  \ras  high  (i  93%). 
suggesting  that  RTCS  "sign-off"  was  generally  appropriate    2.  However,  more 
ailcnlion  to  inslrucdng  patients  in  some  aspects  of  MDI  use  (i,c.  delecting  canister 
emptiness  and  the  elTecls  of  their  MDI  medication)  is  needed 

OF-98-119 


832 


Ri.siMkAiom  Cari:  •  OcTOBiik  '98  Vol  43  No  10 


l&?aeJ3iv:-Vfi 


as  easy  as  riding  a  bike 


ib 


)r-V 


'-'^ 


Nitric  Oxide  measurement  has  never  been 
so  easy.  PrinterNOx  is  a  portable  nitric  oxide 
and  nitrogen  dioxide  monitor  that  combines 
accuracy  with  ease  of  use. 

And  when  you're  juggling  life-critical  tasks 
in  the  pressured  environment  of  an  operating 
theatre,  anything  that  makes  your  job  easier, 
and  safer  for  your  patient,  is  to  be  welcomed. 

Call  for  further  information  and  find  out  how 
PrinterNOx  will  put  a  smile  on  your  face. 


Micro 


Direct 

PO  Box  239,  Auburn,  ME  042 1 2-0239  Telephone  800-588-338 1    Fax  207-786-7280 

Email  sales@micro-direct.com  Circle  119  on  reader  service  card 

Home  page  http;//wvm.micro-direct.com  yig^  y^y^RQ  Booths  442  and  444  in  Atlanta 


Saturday,  November  7.  2:00-3:55  pm  (Room  214E) 


1998 

LITERARY 

AWA  R  DS 


Made  possible  by  the  American 
Respiratory  Care  Foundation 

Allen  DeVilbiss  Technology  Paper  Award 

$2,000  &  ARCF  Certificate  PLUS  Airfare  &  1  Night's  Lodging 

During  the  44th  International  Respiratory  Congress 

in  Atlanta,  Georgia,  November  7-10,  1998 

Best  Original  Paper 

$  1 ,000  &  ARCF  Certificate 

Radiometer  Awards  for  Best  Features 
-3  Awards- 

$333  &  ARCF  Certificate 


CASE  STUDY  EXAMINING  RESPONSE  TO  BRONCHODILATORS  USING 

VENTILATOR  GRAPHICS  AND  MECHANICS  IN  A  PREMATURE    John 

Emberger  BS  RRT  Mike  Western  RRT  PPS,  Sean  Motoyoshi  RRT,  Dave  Lapham 

BS  RRT,  Robert  Locke  DO,  Departments  of  Respiratory  Care  and  Neonatology, 

Chnstiana  Care  Health  System,  Newark,  Delaware 

Introduction:  The  use  of  bronchodllators  for  premature  infants  requinng  prolonged 

mechanical  ventilation  has  increased  Our  experience  with  bronchodllators  in 

ventilator  dependent  premature  infants  is  that  a  percentage  have  significant 

response  Methods  of  determining  the  efficacy  of  bronchodllators  in  premature 

infants  have  been  documented  using  adjunct  spirometry  equipment    This  case 

demonstrates  the  use  of  "live"  ventilator  graphics  by  Respiratory  Care  Practitioners 

(RCP)  to  assess  response  to  a  bronchodilator  in  a  premature  infant  Case 

Summary:  This  is  the  case  of 

a  28  week  gestation  female 

premature  infant    The  patient 

was  ventilator  dependent  for 

approximately  seven  weeks 

after  birth  Bronchodllators 

were  started  on  the  fifth  week 

after  birth  The  ventilator 

FlowA/olume  loop  shown 

here  demonstrates  the  pre 

and  post  albuterol  treatment 

(Ventilator  settings   SIMV, 

PIP  =  26cmH20,  PEEP  =  5 

cmH20,  and  set  rate  =  30 

breaths/minute) 


Posl 

i 

(I   -10 

Pre 

\ 

]n1/s 

w  1 

fr 

k 

-5 

1 

s' 

>^ 

Table:  Ventilator  mectiamcs  values  for  the  above  FlowA/olume  loop: 

Pre-Treatment 

Post-Treatment 

dynamic  compliance  (ml/cmH20) 

04 

07 

peak  resistance  (cmH20/L/second) 

1280 

609 

peak  exhalation  flow  (ml/second) 

42 

53 

mechanical  tidal  volume  (ml) 

8 

15 

Discussion:  This  is  the  case  of  a  premature  infant  that  has  dramatic  changes  in 
both  graphics  and  mechanics  before  and  after  albuterol  treatments,  With  utilization 
of  the  graphics  and  mechanics  that  are  on  the  ventilator,  RCP's  may  be  able  to 
help  determine  which  patients  may  benefit  most  from  bronchodllators  and  which 
patients  seem  to  not  respond  to  bronchodllators    This  may  help  decrease 
inappropriate  treatments  for  patients  with  no  response  and  could  help  decrease 
ventilator  days  in  those  with  response  without  the  use  of  adjunct  spirometry 
equipment. 

OF-98-131 


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TRANSPORTABLE  ISOFLURANE  SYSTEM  FOR  STATUS  ASTHMATICUS 
USED  BY  RESPIRATORY  CARE  PRACTITIONERS:  A  CASE  STUDY    John 
Emberger  BS  RRT.  Patricia  Resnik  BS  RRT,  Rick  Ermak  RRT,  Pete  Grossweiler 
AS  RRT,  Dean  Bonsall  BA  RRT,  Wendy  Connor  BS  RRT.  Billie  Speakman  RRT, 
Mark  Jones  MD,  Department  of  Rspiratory  Care,  Chnstiana  Care  Health  System, 
Newark,  Delaware 

Introduction:  Due  to  increased  numbers  of  patients  presenting  to  the  emergency 
department  (ED)  with  severe  asthma  exacerbations,  our  Respiratory  Department 
obtained  a  ventilator  equipped  to  deliver  Isoflurane  to  patients  with  status 
asthmaticus  The  portable  system  includes  Servo  900C,  Isoflurane  Vaporizer, 
scavenging  system.  Isoflurane  Agent  Monitor,  battery,  and  a  tank  system 
Respiratorv  staff  was  trained  to  use  the  Isoflurane  system  and  the  Respiratory 
Department  helped  to  educate  nursing  about  Isoflurane  therapy  in  status 
asthmaticus    We  developed  the  Isoflurane  system  as  a  mobile  unit  so  we  could 
receive  the  patient  m  the  ED  and  safely  transport  the  patient  to  the  medical  ICU 
(MICU)  for  care    Case  Summary:  A  40  year  old  black  female  presented  to  the  ED 
with  status  asthmaticus,  spontaneously  breathing  in  severe  distress  (ABG  pH  = 

5  98,  PaC02  =  122.  Pa02  =  87  on  100%  mask)    The  patient  was  sedated, 
paralyzed,  intubated,  and  mechanically  ventilated.  Breath  sounds  were  very 
decreased  bilaterally    Continuous  Albuterol  via  nebulizer  was  started  on  arrival 
without  significant  response    Ventilator  settings  were    assist/control  mode.  550cc 
tidal  volume,  12  breaths/minute,  100  %  Fi02  and  +0  cmH20  PEEP  (ABG  pH  = 

6  97,  PaC02  =  127,  Pa02  =  396)    Peak  inspiratory  pressure  (PIP)  =  70  cmH20 
Static  plateau  pressure  =  24  cmH20    Calculated  inspiratory  airway  resistance  (Ri) 
was  84  cmH20/L/sec    End  expiratory  hold  revealed  AutoPEEP  of  +20  cmH20 
Isoflurane  administration  was  initiated  at  0  5%  for  15  minutes  and  then  increased  to 
1  0%    After  25  minutes  of  Isoflurane  therapy,  PIP  decreased  by  10cmH20,  Fi02 
was  decreased  to  60%  and  ABG  values  improved  fpH  =  7  05.  PaC02  =  98.  Pa02 
=  115)    The  patient  was  transported  on  1  0%  Isoflurane  from  the  ED  to  MICU 
After  2  hours  the  ABG  further  improved  (pH  =  7  15,  PaC02  =  64,  Pa02  =  275} 
PIP,  Ri,  and  AutoPEEP  trended  downward  dramatically  over  the  next  12  hours  and 
the  ABG  continued  to  improve  (pH  =  7  34.  PaC02  =  45,  Pa02  =  78  on  35%  Fi02) 
The  Isoflurane  was  discontinued  24  hours  from  initiation    The  patient  was 
extubated  44  hours  after  intubation  and  transferred  to  a  general  floor  bed 
Discussion:  Isoflurane  (an  anesthetic  agent)  has  been  documented  as  a 
bronchodilator  i1,2)    Literature  supports  its  use  in  status  asthmaticus  (1.2)    We 
had  a  positive  outcome  in  this  case  of  status  asthmaticus,  and  we  wanted  to 
document  the  use  of  a  portable  Isoflurane  delivery  system  maintained  by 
Respiratory  Care  practitioners 

References: 

1  Parnass  SM,  Feld  M.  Chamberlin  WH,  el  a1.  Status  asthmaticus 
treated  with  Isoflurane  and  Enflurane    Anesth  Analg  1987;66  193-5 

2  Johnston  RG,  Noseworthy  TW.  Fnesen  EG.  et  al    Isoflurane  therapy 
for  Status  Asthmaticus  in  children  and  adults    Chest  1990,97  698-701 

OF-98-133 


834 


Respiratory  Cari;  •  Octobhr  '98  Vol  43  No  10 


RIENTHTIDH  AND  COMPETENCY  HSSURflNCE  MflNUHL  EOR  RESPIRATORY  CORE 


teAmfoK  meetifia 

iin  H.  Riggs,  PhD,  RRT 


Iiarner  some  applause  of  your  own! 

With  the  Orientation  and  Competency  Assurance  Manual  for  Respiratory 
Care,  you  can  ensure  that  your  staff  receives  a  structured  orientation  and 
that  competence  is  periodically  assessed  and  documented.  The  Manual 
provides  you  with  a  resource  and  examples  to  create  a  customized  orien- 
tation and  competency  assurance  system  for  respiratory  care  services. 
And,  it  provides  the  information,  assessment  tools,  and  models  necessary 
to  demonstrate  that  the  competence  of  employees  is  documented 
according  to  JCAHO  requirements. 

"The  Clinical  Performance  Evaluations  in  the  manual 
were  a  great  way  to  get  all  my  staff  working  at  the 
same  performance  level,  regardless  of  where  they 
went  to  school.  Consistency  of  care  are  key  words  in 
health  care  today,  and  everything  I  needed  to  devel- 
op a  staff-leveling  program  was  right  there." 

-  John  H.  Riggs,  PhD,  RRT 

The  Only  Orientation  and 

Competency  Assurance  Manual 

that  Gives  You  All  This. . . . 


'  Initial  Assessment  and  Document  of  Employee 
Experience.  Education,  and  Credentials 

'  Competency  Validation  in  Critical  Organizational 
System  Safety  Practices 

'  Departmental  Orientation 

'  Orientation  and  Competency  Validation  for  General 
Respiratory.  Adult  Critical.  Neonatal/Pediatric 
Respiratory  Care.  Diagnostic  Testing, 
and  Age-Specific  Patient  Populations 

'  Orientee  Progress  Evaluations 

'  Preceptor  Training  and  Competency  Validation 

'  System  for  the  Selection.  Ongoing  Assessment, 
Maintenance,  Improvement  of  Skills, 
and  Competency 


•  Construction  of  Clinical  Competency  Checklists 

•  Improvement  of  Competency  Assessment  Congruency 

•  Reporting  of  Competence  Patterns  and  Trends 

•  Integration  of  Competency  Assessments  with 
In-Services  and  Continuing  Education 

•  System  for  Linkage  of  Job  Description.  Competency 
Level.  Annual  Performance  Evaluation. 

and  Performance  Improvement 

•  Appendix-Self-Learning  Module  for  Critical 
Organizational  System  Safety  Practices 

•  Appendix-Orientation  and  Competency  Validation 
for  Multi-Skilling  and  Cross-Training  in  Perinatal  Care 

•  Appendix-Sample  Performance  Evaluation  Instrument 


By  Daniel  Grady,  MEd,  RRT;  Valerie  Lawrence,  RRT;  Tammy  Caliri,  RRT; 
and  Mitzi  Johnson,  RNC,  MSN.  258  Pages,  Binder  1997 

$65  for  AARC  members,  $90  for  nonmembers-ltem  BK55 

Cadd  $8  for  shipping  and  handling) 

Texas  customers  only,  please  add  8.25%  sales  tax  Oncluding  shipping  charges).  Texas  customers  that  are  exempt  from 
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T]  d  I  Jii  I 


on  the  P  R  E  IVI  IE 

care  meeting  in  ti 


44th  International 
Respiratory  Congress 

of  the  American  Association  for  Respiratory  Care 

November  7-10,   1998   (Saturday-TUesday) 
Georgia  World  Congress  Center    Atlanta 


1998  EGAN  LECTURE  -  The  1998  Donald  F.  Egan  Lecture,  ARDS:  New  Approaches  to  a  Seriou 
Respiratory  Illness,  will  be  presented  by  Dr.  Gordon  R.  Bernard  from  the  Pulmonary  and  Critical  Can 
Medical  Division  of  Vanderbilt  University  in  Nashville.  Dr.  Bernard's  lecture  will  cover  the  recent  change 
in  the  ARDS  definition,  mechanisms  of  development,  and  new  therapeutic  maneuvers.  Dr.  Bernard  will  dis 
cuss  the  new  approaches  to  the  life  support  of  these  patients,  emphasizing  the  progress  made  in  the  under 
standing  of  patient-ventilator  interactions,  fluid  management,  clinical  pathways,  and  outcome.  He  will  als( 
present  data  that  will  show  whether  the  improvements  in  critical  care  and  mechanical  ventilation  hav( 
improved  survival  rates. 

SYMPOSIUM   ON  ASTHMA  MANAGEMENT;    EVOLVING   ROLES   FOR   RESPIRATORll 


THERAPISTS  -  This  symposium  on  Saturday,  November  7,  will  review  and  identify  several  issues  of  sig 
nificance  to  anyone  involved  with  asthma  management.  The  following  presentations  will  be  made:  Diseasi 
Management  Program  Development  by  Respiratory  Therapists;  Managing  Pediatric  Asthma  in  the  Innei 
City:  Results  of  the  National  Cooperative  Inner  City  Asthma  Study;  and  How  Do  You  Justify  Youi 
Therapists  in  the  Emergency  Room? 

ABOUT  ATLANTA  -  The  August  issue  of  AARC  Times  features  a  special  piece  on  the  history  of  this  year's 
Congress  host  city,  Atlanta.  Also,  most  other  recent  issues  of  the  magazine  provide  highlights  of  the  citj 
including  suggestions  for  fun  family  activities  and  great  little-known  facts  about  the  city.  For  more  abou 
the  city  made  famous  by  the  1996  Olympic  games,  visit  the  Atlanta  Convention  and  Visitors  Bureau  wel 
site  at  www.acvb.com. 

CONTROVERSIES  SYMPOSIUM  -  The  1 1th  Annual  Symposium  on  Controversies  in  Respiratory  Care 
will  be  presented  on  Monday,  November  9.  This  symposium  is  designed  to  generate  lively  discussions  and 
enable  the  audience  to  get  a  good  look  at  both  sides  of  each  issue,  enabling  them  to  make  an  informed  deci- 
sion about  their  own  opinion.  This  year's  topics  are  Respiratory  Therapists  Should  Peiforiii  Intubation 
Hypercapnic  Ventilator  Patients  Should  Be  Ventilated  Overnii>ht,  and  Routine  Ventilator  Checks  Should  Be 
Abandoned. 

Oi'KN  Forum  -  Today's  respiratory  therapists  are  making  incredible  inroads  in  respiratory  care  research.  The 
results  of  more  than  130  research  projects  will  be  presented  and  discussed  in  a  series  of  Open  Forum 
Minisymposia  throughout  the  4-day  Congress.  The  nine  minisymposia  are:  ( 1 )  Inhaled  Nitric  Oxide; 
Nehuliz.ation  of  Drugs  and  Medications;  (2)  Tubes,  Bags.  Oxygen  Therapy,  (3)  Neonatal/Pediatric 
Respiratory  Care;  (4)  Education.  Rehabilitation;  (5)  Venlilalion  and  Ventilatory  Techniques  -  Pt.  I;  (6) 
Monitoring,  Monitoring  and  More  Monitoring;  (7)  Management  of  Respiratory  Care  Services;  (8) 
Humidifiers,  Nebulizers,  and  Attachments;  (9)  Ventilation  and  Ventilatory  Technitpies  -  Pt.  2. 


Saturday,  November  7,  2:00-3:55  pm  (Room  215E) 


EARLY  POSTOPERATIVE  PERCUTANEOUS  DILATATIONAL 
TRACHEOTOMY  AFTER  CARDIAC  SURGERY 


Rees 


Hubner    N. 
,  Warnecke  H. 


Seufert  K.  ,* 
Bockelmann  M.  ,  Warnecke  H.  ,  *  Christmann  U. 
Dept.  Cardiac  Surgery  ,  *  Dept.  Cardiac 
Anesthesia   Schiichtermann  Klinik 


METHODS:  From  11/95  until  12/97  69  (1,4%) 
percutaneous  dilatational  tracheostomies  were 
performed  in  a  nonselected  patient  series  of 
4322  open  cardiac  surgery  cases. 
RESULTS:  Tracheotomy  was  performed  as  early 
as  postop.  day  (mean.  6,  range  2  -  14),  when 
extubation  was  not  foreseen  within  the  next 
few  days.  Duration  of  intubation  was  13  days 
(mean) .  In  five  patients  we  observed  6 
complications  (8.6  %) ,  including,  bleeding, 
misplacement  of  the  tube,  subcutaneous 
emphysema  and  superficial  infection  of  the 
tracheostoma .  Mediastinitis  and  wound 
infection  of  the  sternal  wound  did  not  occure 
in  a  single  case.  Overall  mortalitity  was 
24,6  %.  No  death  occured  because  of 
tracheotomy.  Underlying  desease  was  reason 
for  the  mortality.  Clinically  evident 
tracheal  stenosis  and  unadequate  granulation 
of  the  stoma  were  nor  seen  after  extubation. 
CONCLUSIONS:  Percutaneous  dilatational 
tracheotomy  is  feasible  with  good  results  and 
minimal  risk  early  after  cardiac  surgery  with 
midline  sternotomy.  Increasing  incidence  of 
mediastinitis  or  infection  of  the  sternal 
wound  was  not  seen.  In  our  opinion, 
percutaneous  dilatational  tracheostomy  is 
superior  to  standard  surgical  tracheotomy 
early  after  cardiac  surgery  . 


PROSPECTIVE  RANDOMIZED  DOUBLE-BLIND 
CROSSOVER  STUDY  ON  THE  EFFECTS  OF  OXYGEN  ON 
ANALYTICAL  PERFORMANCE  IN  NORMOXIC 
SUBJECTS  Karl  Knoblauch  CRIT.  RCP  Meritcare  Hospilal 
Fargo,  ND  Jill  Kieltv  CR'IT  Mentcare  Hospital  Fargo,  ND 

BACKGROUND.  A  new  trend,  in  some  countnes,  is  to 
frequent  "oxygen  bars"  to  inhale  pure  oxygen  for  a  prepaid 
amount  of  time  The  customers  claim  to  have  mcreased  energy 
and  increased  cognitive  clanty  (Goldstein.  Science  World 
IWd,  53  7(1))  (Scott,  Advance  IW7;  Vol  10,  N26:  5(1))  A 
review  of  the  literature  has  not  found  studies  which  validate 
these  claims,  and  no  short  term  cognitive  effects  of  increased 
oxygen  consumption  in  normoxic  people  arc  known 
METHODS:  Twenty  subjects  were  enrolled  for  this  random 
double-blind  study  Initial  oxygen  saturations,  with  a  Nellcor 
Pulse  Oximeter,  were  taken  to  determine  normoxemia  They 
were  then  blinded  and  randomly  assigned  to  one  of  two  groups 
Each  group  took  the  analytical  portion  of  the  Graduate  Record 
Exam  (CjRE)  twice  The  software  for  the  GRE  was  obtained 
from  PowerPrep  software  Group  One:  while  taking  the  first 
GRE  the  subjects  were  assigned  oxygen  via  nasal  cannula  (NC) 
(SJ  31pm  or  compressed  air  via  NC  (a)  3Ipm.  For  the  second 
GRE,  the  subjects  did  not  receive  a  compressed  gas  Group 
Two  while  taking  the  first  GRE,  the  subjects  did  not  receive  a 
compressed  gas  For  the  second  GRE,  the  subjects  were 
assigned  oxygen  via  NC  @  31pm,  or  compressed  air  via  NC  @ 
31pm.*  RESULTS:  Repeated  measures  ANOVA  showed  no 
significant  difference  among  the  treatment  in  Group  One 
( Wilks'  Lambda  p=0  3412)  or  in  Group  Two  ( Wilks'  Lambda 
p=0  7293)  CONCLUSION  We  found  no  relationship  befween 
the  two  inspired  gases  and  the  test  results 

*Study  Design  Group 


First  Group 


Oxygen  31pm 
Compressed  air  (ai  31pm 


No  compressed  gas 


No  compressed  G 


Oxygen  @  31pm  or 
Compress^  air<5j  31pm 


THE  ACCURACY  OF  OXYGEN  LITER  FLOW  INDICATION  BY  BOURDON 
GAUGE  E-CYLINDER  REGULATORS,  WITH  AND  WITHOUT  NASAL  CANNULA 
Felipe  Rodriguez,  BS  RRT.  Leslie  Ramirez,  BS.  RRT  Arthur  Jones,  EdD,  RRT 
David  Shelledy.  PhD,  RRT  The  University  of  Texas  Health  Science  Center  at  San 
Antonio  Questions  What  is  the  degree  of  accuracy  for  flow  indication  by  Bourdon 
gauge  E-cylinder  regulators'  Does  attachment  of  a  nasal  cannula  significantly  affec 

he  flow  delivered  by  the  regulators''  Methods   A  Timeter  RT-200  (TH/I)  calibration 
analyzer  measured  the  flow  delivered  by  Bourdon  gauge  transport  regulators  that 
were  in  clinical  use  at  a  large  medical  center  The  measurements  were  applied  to 
48  different  regulators  at  flow  rates  set  to  2,  4.  and  6  liters/min,  respectively  The 
measurements  also  were  made  both  with,  and  without  nasal  cannula  attached  Flow 

ndication  and  delivered  flow  were  recorded  for  each  cannula  condition  and  (iter  flow 
adjustment  A  spreadsheet  computed  statistics  of  variability  and  the  independent 
samples  t-test  for  differences  between  flows,  with  and  without,  cannula  Results: 
There  were  no  sigmflcant  differences  in  delivered  flow  attributable  to  attachment  of 
nasal  cannula  at  any  of  the  set  flow  rates  (  2  L/min  p  =  0  48.  4  L/mm  p  =  0  48,  6 
Umin  p~  0  46)  Descriptive  statistics  for  the  performance  of  the  flow  regulators 

N=48)  appear  in  Table  1 

Table  1  Descriptive  statistics  for  measured  02  liter  flows 

Without  cannula 

With  cannula 

Set  flow 

N 

2  L 

4  L 

6L 

2L 

4L 

6L 

Measured 
Mean 

48 

2  70 

5  21 

7  65 

2.71 

5  20 

7  68 

Measured 
SD 

48 

0  861 

1295 

177 

0  884 

1266 

1  807 

Measured 
Mm 

48 

0  95 

368 

5,80 

0  94 

366 

5  80 

Measured 
Max 

48 

6  40 

1210 

16  40 

660 

11  80 

16  80 

Conclusions:  Bourdon  gauge  E-cylinder  transport  regulators  demonstrate 
excessive  levels  of  variability  between  set  and  delivered  flow  rates.  Attachment  of  a 
nasal  cannula  to  a  Bourdon  gauge  regulator  is  not  associated  with  statistically 
significant  differences  m  delivered  flow  rate 

OF-98-01C 

5 

IDENTIFYING  HIGH  RISK  PATIENTS  USING  HOME  OXYGEN  WITH 
THE  ASSESSMENT  TOOL  FOR  EQUIPMENT  MANAGEMENT  (ATEM) 
OF  OXYGEN  CONCENTRATORS.  Karen  M.  Pfaff  RN.  Larry  E.  Johnson 
MD,  PhD,  Lora  A.  Hasse,  PhD,  Franciscan  Home  Health  Service,  Cincinnati,  OH 

45247. 

Background:  The  ATEM  has  been  shown  to  comprehensively  assess  the 
knowledge  and  functional  ability  of  clients  and  caregivers  to  safely  manage  home 
oxygen  concentrators.  This  study  was  conducted  to  assess  the  risk  characteristics 
of  clients  using  home  oxygen. 

Methods:  Seven  regional  home  care  companies  participated,  using  the  ATEM  5- 
30  days  after  initial  equipment  set-up  and  training,  in  the  assessment  of  clients 
with  COPD  (n=150;  ave  age=71),  CHF  (n=50:  ave  age=78),  pneumonia  (n=24; 
ave  age=73),  and  lung  cancer  (n=39;  ave  age=64).  Other  characteristics 
measured  included  current  smoking  status  and  subjective  nutritional  state. 
Re_sults:  COPD  CHF     PNEUM  LUNG  CA 

ATEM:  Client/care  giver  does  NOT  know: 

proper  liter  flow  8%  8%        12%  7% 

hours/day  use  9  12         8  15 

safe  concentrator         3  4  17  8 

operation 
oxygen  safety  16  16         25  18 

equip  maintenance      9  6  17  8 

proper  storage  9  10         12  3 

backup  tank  use  20  10         17  15 

time  left  in  tank  16  18         29  26 

response  to  equip         7  4  4  10 

malfunction 
response  to  medical     3  2  0  3 

emergency 
Other:  current  smokers  17  6  8  13 

poor  nutrition  4  8  8  13 

Conclusions:  Many  clients  using  home  oxygen  concentrators  demonstrate 
knowledge  deficits  following  initial  training  regarding  safe  oxygen  use.  Ceriain 
diagnoses  are  associated  with  different  risk  characteristics,  and  perhaps  the  need 
for  different  intervention  strategies.  Continuing  assessments  on  these  same 
clients,  including  occurrence  of  adverse  outcomes,  will  suggest  farther  innovative 
educational  opportunities. 


Respiratory  Care  •  October 


Vol  43  No  10 


837 


Saturday,  November  7,  2:00-3:55  pm  (Room  215E) 


HOME  OXYGEN  EVALUATION  PROJECT 

Joe  Dwan.  RRT.  Sheila  Jiroch.  RRT.  Kaiser  Permanente  Clackamas, 
Oregon 

BACKGROUND:  In  1996,  our  HMO  had  848  patients  receiving  home  02 
through  a  contract  vendor  Our  re-evaluation  system  was  thru  the 
pnmary  care  physicians  ordenng/monitonng  their  patients  02  needs 
Home  02  orders  are  received  from  multiple  hospitals,  physician  ottices, 
home  health  referrals,  and  clinics  We  perceived  an  overutilization  of 
oxygen  We  believed  we  could  achieve  improved  quality  of  care  by 
appropriate  use  of  home  02,  improved  pt  satisfaction  thru  education  & 
monitoring,  and  cost  savings  by  designating  an  RCP  to  monitor  usage, 
qualify  new  02  pts  and  re-evaluate  current  pts  in  a  timely  manner 
METHOD  We  created,  in  essence,  a  centralized  RCP  Care  Manager  for 
home  02  pts  Created  a  20  hr/wk  RCP  position  to  develop  the  program. 
Utilized  in-patient  home  02  protocol  Developed  a  communication 
system  between  the  home  oxygen  vendor,  insurance  coordinators, 
physicians  and  the  RCP  Initiated  electronic  charting  &  ordering  system. 
Provided  pt  education  Created  a  link  between  RCP  evaluation  system 
in  the  hospital  to  the  RCP  evaluation  of  outpts  Collected  data  on  #  of  pts 
receiving  new  02  evaluation  &  re-evaluation,  status  post  evaluation:  # 
discontinued  per  Medicare  critena,  #  of  pts  whose  02  needs  changed,  # 
of  new  pts  evaluated,  an  #  of  pts  on  home  oxygen  RESULTS  In  the  first 
year  of  this  project.  441  pts  were  seen  from  December-October, 
including  108  as  new  evaluations  and  333  as  re-evaluations  for  home 
oxygen  Utilizing  the  Medicare  cntena  (Pa02£55  torr  or  Sa02s88%),  31 
new  pts  began  home  02  (29%)  and  I20(36%)  re-evaluated  pts  were 
discontinued  on  home  02  The  time  between  discharge  from  hospital 
and  re-evaluation  also  improved  Communication  amongst  those 
involved  significantly  improved  Annualized  cost  savings  for  the  36%  of 
reevaluated  pts  was  $288,000  Annualized  cost  savings  for  new  pts  was 
$184,000  Total  annualized  savings  for  the  project  was  $472,000, 
CONCLUSION  An  RCP  as  a  care  manager  for  home  02  pts  has 
improved  quality  of  our  care  by  providing  home  02  when  pts  need  it  and 
removing  it  when  it  is  no  longer  needed.  Patient  education  was  essential 
in  improving  the  care  Our  experience  shows  that  pts  lack  an 
understanding  of  oxygen,  of  SOB  &  its  relation  to  hypoxia  &  activity  A 
large  cost  savings  realized  by  the  ,5FTE  RCP, 


RJiMOVAL  OF  INNER  CANNULA  DECREASES  WORK  OF 
BREATHING  (WOB)  AND  AIRWAY  RESISTANCE  (Raw)  IN 
TRACHFX)STOMY  niBf-S. 

T'onv  Cowan  BS,  Cyndi  Gegenheimer  BS,  Timothy  B.  Op't  Holt 
Ed.D.,  R.R.  I .,  Depl.  of  Cardiorespiratory  Care,  Seth  Izenberg, 
MD,  Dept.  of  Surgery,  University  of  South  Alabama,  Mobile,  AL. 
INIKODUCnON:   Tracheotomy  has  been  ased  to  help  liberate  hard  to 
wean  patients  from  mechanical  ventilation.  Some  patients  have  been 
observed,  in  spite  of  already  having  a  tracheostomy  tube,  who  fail  to  be 
liberated  from  the  ventilator  after  several  attempts.  It  was  hypothesized 
that  by  removing  the  inner  cannula  from  the  tracheostomy  tube,  the 
WOB  and  Raw  may  be  decreased  enough  to  facilitate  more  successful 
weaning.  Ihc  hypothesis  was  tested  by  measuring  the  change  in  WOB 
and  Raw  of  tracheostomy  mbes  when  the  inner  cannula  was  removed 
using  a  lung  model  MF'THODS:  A  mechanical  lung  model  was 
developed  using  the  Michigan  Instruments  26(K)i  dual  adult  training  test 
lung  to  simulate  a  spontaneously  breatliing  patient  WOB  and  Raw 
were  measiu'ed  with  the  Bicore  CP- 100  (Bear  Medical  Corp.,  USA)  in 
sizes  6, 8,  and  10  nonfenestrated  tracheostomy  tubes  with  the  inner 
caimula  in  and  out.  Breathing  conditions  varied  using  tidal  volumes  (Vt) 
of  300  and  500  cc  matched  with  respiratory  rates  (RR)  of  12  and  24 
bpm  by  using  the  Emerson  3MV-PED  ventilator  to  reproduce 
spontaneous  breathing  through  the  right  side  of  the  test  lung. 
Rl^^SULTS:  The  WOB  and  Raw  in  all  breathing  conditions  through  the 
three  tracheostomy  tubes  were  significantly  reduced  (p<.05)  when  the 
imier  camiula  was  removed.  CONCLUSIONS:  Recent  literature  stales 
that  normal  WOB  is  0.3  to  0.6  Joules/L.  The  WOB  of  the  three 
tracheostomy  mbes  exceeded  normal  when  the  Vt  and  RR  were  the 
highest.  Removing  the  imier  caimula  may  reduce  the  WOB  and  Raw 
significantly  enough  in  patients  to  facilitate  successful  weaning  from 
the  ventilator.  Further  study  of  the  clinical  significance  of  removing  the 
inner  cannula  on  WOB  and  Raw  in  the  patient  is  being  planned. 

OF-98-048 


USE  OF  THE  LARYNGEAL  MASK  AIRWAY  (LMA)  DURING  PERFORMANCE 
OF  PERCUTANEOUS.  BEDSIDE  TRACHEOTOMY 

Charles  G  Durbin,  Jr.  MP.  Wanda  Seay.  RRT.  University  of  Virginia  Health 
System.  Charfottesville.  Virginia 

Bedside,  fiberoptic  bronchoscope-guided  tracheotomy  is  a  sale  and  cost- 
effective  alternative  lo  open  tracheotomy  performed  in  the  operating  room. 
Occasionally  tracheotomy  is  indicated  for  prolonged  airway  protection  in  patients 
with  depressed  gag  and  poor  cough  who  are  not  already  intubated    II  has  been 
suggested  Ihat  topical  anesthesia  of  the  upper  airway  and  placement  of  an  LMA 
could  tje  used  to  avoid  the  need  lor  endotracheal  intubation  during  the  procedure 
Using  an  LMA  In  Ihese  patients  facililates  bronchoscopy  and  protects  the  scope 
from  damage  from  the  seeking  needle    We  report  a  series  of  6  patients  in  whom 
percutaneous  tracheostomy  was  performed  under  bronchoscopic  control  through 
an  LMA  placed  with  topical  anesthesia  and  light  sedation 
Results  Palients  ranged  from  19  lo  79  years  of  age.  4  were  female  and  2  were 
male    One  patient  had  a  severe  closed-head  injury  with  an  inlravenlncular  bleed, 
5  had  intracranial  hemorrtiage  due  to  mptured  cerebral  aneurysms  (3), 
hypertension  (1),  or  as  a  consequence  ol  a  cerebral  emtjolization  attempt  (1)    All 
were  al  least  5  days  out  from  their  neurologic  injury    Ail  were  able  to  maintain 
adequate  gas  exchange  with  spontaneous  ventilation  on  low  inspired  Fi02  (2-5  I 
0?/mln  nasal  prongs)    Patients  at!  had  depressed  ainway  rellexes  and  were  not 
expected  lo  have  significant  recovery  ol  ttiese  tor  at  least  several  weeks  Upper 
airway  anesthesia  was  provided  by  topical  instillation  ol  1%  lidocaine,  Iranctieal 
and  laryngeal  anesltiesia  by  bronchoscopic  application  ol  5%  etidlcaine    Light 
sedation  with  propolol  was  used  in  all  patients,  one  patient  required 
neuromuscular  blockade  with  rocuronium  due  to  inability  to  suppress  a  vigorous 
cough    One  patient  developed  mild  laryngospasm  dunng  ainway  manipulation    All 
patients  were  successfully  and  easy  visualized  with  the  bronchoscope  inserted 
through  ttie  LMA,  and  correct  placement  ol  the  tracheotomy  wire  and  dilators  were 
crjntirmed  Manual  ventilalkjn  was  successful  in  all  cases  and  no  patient 
experienced  a  signilicani  fall  in  oxygen  saturation  during  the  procedure  No 
bleeding  or  other  acute  complications  occurred  in  this  group  ol  patients  The  entire 
procedure  look  an  average  ol  20  to  30  minutes  to  complete 
Conclusions   I  he  LMA  lacililates  percutaneous  tracheotomy  in  the  unintubated 
patient  ensuring  adequate  gas  exchange  dunng  ttre  procedure  as  well  as 
protecting  tfie  bronchoscope 


OF-98-079 


EVALUATION  OF  TWO  ADULT  DISPOSABLE  MANUAL 
RESUSCITATORS. 

T)ioma.s  A  Barnes.  EdD.  RRT.  Sarah  K  Melville.  Stephanie  A  Masick. 
Kimberly  A  Santos.  Christine  M  MacLellan  BS  RRT,  Department  of 
Cardiopulmonaiy  Sciences,  Northeastern  University,  Boston,  Massachusetts. 

We  evaluated  the  performance  and  safely  of  two  disposable  majiuaJ 
resuscilators:  DMR2  (Nellcor-Purilan  Bennett),  and  Adult  Manual  Resuscilator 
(Baxter  Healthcare).  Method:  We  used  standards  and  melhods  approved  by 
American  Society  for  Testing  and  Materials  (F  920-93.  ASTM  Committee  on 
Standards,  Philadelphia,  1993)  and  International  Organization  for 
Standardization  (ISO  8382:1988E,  New  York,  1988).  A  Bio-Tek  VT-1 
Ventilator  Tester  was  used  as  a  lung  model  wiih  C=0.02  L/cm  H,0 
[0.20UkPa]  and  R=20cm  H,0.s.L'  (2  kPa.s.L').  Results:  the"DMR2  and 
Baxter  resuscilator  met  ASTM  and  ISO  standards  lor  V,  (600  mL),  f  (20/min), 
and  I:E  (<1:2).  The  ASTM  and  ISO  standards  specify  an  FDO,  of  >  0.85  wiih 
O,  reservoir  and  O,  flow  ol  15  L/min  and  V,.  of  7.2  L/min  (V^  600  mL, 
f  i2/min).  DMR2  and  Baxter  resuscilator  with  wide-bore  tube  O,  resei'voirs  in 
the  collapsed  storage  position  had  a  FDO,,  mean  (SD),  of  0.65  (0.02),  0.72 
(0.02),  respccuvely.  When  tested  with  coliapsible  wide-bore  O,  reservoirs  fully 
extended  or  with  bag-type  or  small  bore  O,  reservoirs  both  DMR2  and  Baxter 
resusciUilors  passed  the  FDD,  specificalion.  When  tested  with  simulated 
vomilus  bolh  DMR2  and  Baxter  resu.scitators  were  able  lo  be  restored  to  proper 
function  within  20  seciinds.  Both  DMR2  and  Baxter  resuscilators  passed  tests 
for  O,  How  of  .3(1  Umin.  forward  and  backward  leakage,  and  10-,second 
immersion-in-water,  expiratory  resistance,  and  inspiratory  resistance.  The 
DMR2  failed  the  drop  lest  from  1  meter.  The  DMR2  passed  and  the  Baxter 
resu.sciiator  tailed  the  specificalion  for  user  manual.  DMR2  and  Baxter 
resuscilators  were  subject  to  accidental  disassembly.  Conclusions:  The 
DMR2  and  the  Baxter  resu.scitators  wciv  in  substantial  compliance  with  ASTM 
and  ISO  requiremcnti  but  failed  one  or  more  specficalions.  We  recommend  Ihe 
following:  that  a  brighUy  colored  label  reading  ■'EXTEND  BEFORE  USE"  be 
placed  on  the  laige-bore  oxygen  reservoirs  of  the  DMR2  and  Baxter 
lesuseilalors;  thai  the  FDO,  delivered  by  resuscilators  with  large  bore  O, 
reservoirs  in  the  collapsed  position  be  included  in  user  manual:  that  the 
1 5mm/22mm  patient  connection  of  the  DMR2  be  pemianenlly  affixed  lo  the 
patient  valve  pon  and  manufactured  from  material  thai  is  shtx;k  resistant. 


838 


Rf.si'iratory  Care  •  October  '98  Vol  43  No  10 


Quickly  and  easily  assessing 

WHAT  HAVE 

your  patient s  ventilator  requirements 

YOU  DONE  FOR 

begs  the  question  you  should  be 

ME  LATELY? 


asking  your  equipment 


Continuous  and  accurate  moni- 
toring of  your  patient's  respiratory 
status  can  make  the  difference  for  a 
quick  recovery.  Our  CO^SMO  P/us/ 
Respiratory  Profile  Monitor  combines  airway 
mechanics  with  mainstream  capnography  and 
pulse  oximetry  into  a  precisely  integrated  monitor. 

CO2SMO  P/us.'  takes  the  guesswork  out  of  the 
weaning  process  with  non-invasive  monitoring  of  alveolar 


ventilation  to  perfusion  relationships. 
COjSMO  P/us.'  helps  you  determine  when  to  switch  from 
support  to  weaning  modes  of  ventilation,  verifies  the 
patient's  progress  during  weaning  and  can  continue  monitor- 
ing the  patient  even  after  the  ventilator  has  been  removed. 

Bedside  monitoring  requires  consistency  and  reliability. 
So  ask  your  equipment  what  it  has  done  for  you  lately,  then 
ask  us  what  COjSMO  P/us.'  can  do  for  you!  For  more  infor- 
mation, call  1-800-243-3444  or  203-265-7701. 


NOVAMETRIX 

MEDICAL  SYSTEMS  INC. 

...simply,  the  leading  edge 

www.novametrix.com 


Circle  109  on  reader  service  card 
Visit  AARC  Booth  915  In  Atlanta 


Saturday,  November  7,  2:00-3:55  pm  (Room  215E) 


american 
respiratory 
care 
foundation 


Silent 
Auction 


After  its  first  year  success  in  New  Orleans,  the  ARCF  will 
again  conduct  a  Silent  Auction  during  the  International 
Respiratory  Congress  in  Atlanta.  Stop  by  Auction  Head- 
quarters and  place  your  bid  for  one  or  more  items  ranging 
from  respiratory  care  equipment  to  entertainment  packages 
and  weekend  getaways.  Catalogs  listing  items  for  bid,  their 
value,  and  individual  bid  increments  will  be  available. 

Here's  how  it  works... 

•  Browse  through  the  items  shown  on  the  photoboard. 

•  Place  your  bid  on  the  bid  sheet  numbered  to  correspond 
with  the  item  tag  number  you  wish  to  bid  on  (staff  people 
will  be  on  hand  for  assistance). 

•  Others  may  overbid  you.  But  you  may  bid  as  often  as  you 
like  using  the  specific  bid  increments  on  each  bid  sheet. 


Most  items  will  be  shipped  from  the  donor  to  the  high 
bidders  after  the  convention. 

Remember,  this  is  a  charity  event.  Proceeds  from  your 
participation  will  go  toward  furthering  the  endeavors  of  the 
Foundation  in  support  of  education  awards,  fellowships, 
international  fellowships,  consensus  conferences,  literary 
awards,  research  grants  and  other  programs.  Here's  an 
opportunity  to  support  the  ARCF,  exercise  your  competitive 
spirit,  and  walk  away  with  a  bargain. 

Take  advantage  of  the  October  pre-bidding  by  browsing  the 
AARC  website.  This  allows  everyone  the  opportunity  to 
participate,  whether  you  plan  to  travel  to  Atlanta  or  not. 

www.aarc.org 


EVALL'ATION  OF  AN  INSPIRATORY  IMPEDANCE  VALVE 

Thomas  A  B,irm-.s  EtlD  RRT.  Sarah  K  Melville.  Keith  G  Lurie*  MD, 
Departmem  of  Cardiopulmonary  Sciences.  Northeaslern  University,  Boston. 
Massachusetts,  'Arrhythmia  Center,  Department  of  Medicine,  University  of 
Minnesota,  Mmneapohs. 

We  evaluated  the  performance  and  safety  of  a  prototypic  inspiratory 
impedance  valve,  Resuscitator  Valve™  (CPRx  Inc).  The  valve  when  attached 
to  the  patient  connection  of  a  manual  resuscitator  is  designed  to  increase  the 
duration  and  magnitude  of  negative  intrathoracic  pressure  during  CPR.  In 
animal  models  of  venuicular  fibrillation  the  Resuscitator  Valve  has  been 
reported  to  enhance  venous  return  and  vital  organ  perfusion  during  CPR. 
This  device  was  awarded  United  States  Patent  .'),692,248  on  Dec.  2,  1997. 
The  Resuscitator  Valve  was  tested  while  connected  to  a  Spur  manual 
resuscitator  ( Ambu  Inc).  Method:  We  used  standards  and  methods  approved 
by  American  Society  for  Testing  and  Materials  (F  92(1-9.1,  ASTM  Committee 
on  Standards.  Philadelphia,  l"9.1)  and  Inteniaiional  Organization  lor 
Standardization  (ISO  X3S2:  I9XXE,  New  York,  19881.  A  Bio-Tck  VT- 1 
Ventilator  Tester  was  used  as  a  lung  model  with  C=ll.()2  L/cm  1 1,() 
|0.2(lL/kPa|  and  R=2I)  cm  H.O.s.L  '  (2  kPa.s.L  ').  Results:  The 
Resuscitator  Valve  u.sed  widi  the  Spur  met  ASTM  and  ISO  standards  for  V^- 
(6fX)  mLl.  f  {2(l/mm).  and  1:E  (<l:2).  The  ASTM  and  ISO  standards  .specify 
an  FDO,  of  >  (I.8.S  with  O,  reservoir  and  (),  How  of  15  L/min  and  Vjof  7.2 
IVmin  (V,  61)0  mL,  f  l2/m"in)  The  Resuscitator  Valve  u.sed  with  the  Spur  had 
a  FD(X,.  mean  (SD).  of(l97  ll).(ll).  When  tested  with  simulated  vomitus  the 
Resuscitator  Valve  attached  to  the  Spur  manual  rcsu.scitalor  was  able  to  be 
restored  to  proper  lunciion  within  20  .seconds.  The  mechanical  deadspacc  of 
the  Resuscitator  Valve  was  detcrmmed  to  be  less  than  57,  of  the  tidal  volume 
recommended  by  the  American  Heart  Association  lor  resuscitation  of  adults. 
Inspiratory  and  cxpiratoiy  resistance  were  measured  at  a  How  of  50  L/min. 
The  Resu.scitator  Valve  when  attached  to  the  Spur  manual  resu.scilator  passed 
the  test  for  expiratory  resistance  (pressure  <5  cm  H ,( ))-  The  Resu.scilator 
Valve  when  attached  to  the  Spur  rcijuired  an  iaspiralorv  pressure,  mean  (SD), 
of -22,4  (  (II 1  cm  ll.O.  Conclusions   Wc  conclude  (hat  Ihc  Resuscitator 
Valve  when  attached  to  the  Spur  nianu.il  lesuscilaloi  generates  the  intended 
negative  inspiialory  Inipedanee,  Ihe  Resuscitator  Valve  used  with  the  Spur 
does  not  significantly  effect  the  expiratory  resistance,  FDO,.  valve  eleaiance 
of  vomitus.  tidal  volume,  or  cycle  rate.  Becau.se  the  valve  adds  deadspace 
and  requirvs  >  -5  cm  H,<)  to  open,  we  recommend  that  it  be  removed  from  a 
manual  resuscitator  when  return  of  spontaneous  circulation  and  breathing 
occurs.  We  conclude  ba.sed  on  testing  that  the  Resuscitator  Valve  is  in 
substantial  compliance  with  ASTM  and  ISO  standards. 


OF-98-087 


EVALUATION  OF  A  NEW  ENDOTRACHEAL  TUBE  FIXATION  DEVICE 

Teresa  A  Volsko.  RRT.  Robert  L  Chatbum,  RRT.  Theresa  Schultz*.  RRT, 

Enrique  Gnsoni.  MD.  Michelle  Walsk-Sukys,  MD 

University  Hospitals  of  Cleveland,  OH  and  'Childrens  Hosptia!  of  Philadelphia.  PA 

BACKGROUND;  Accidental  extubations  may  complicate  the  patient's  course  The 
relatively  short  trachea,  use  of  uncuffed  endotracheal  tubes  (ET).  bedside  care,  infant's 
size  and  activity  level  along  with  method  of  ET  fixation  contribute  to  the  incidence  of 
accidental  extubations  in  infants  and  children  (Respir  Care  1997.42  228-291)  We 
evaluated  a  new  ET  secunng  method,  the  Neobar  (Neotech  Products  Inc  )  This  device 
IS  a  small,  plastic  arch  with  adhesive  cheek  pads  The  ET  tube  is  taped  to  the  arch 
rather  than  to  the  patient's  upper  lip  as  in  conventional  ET  fixation  We  tested  the 
hypothesis  that  the  new  fixation  device  would  reduce  the  incidence  of  accidental 
extubations,  be  easier  to  apply,  would  improve  skin  integnty,  and  the  ability  to  perform 
oral  care  METHODS:  This  pilot  study  enrolled  infants  from  our  Level  III  Neonatal 
Intensive  Care  Unit  requiring  intubation  and  mechanical  ventilation  Infants  with  limb 
restraints,  sedation  or  paralytic  drugs  that  inhibited  activity,  along  with  those  who  had 
neurological  impairment  that  prevented  purposeful  movement,  and/or  those  whose 
positive  pressure  ventilation  requirements  were  less  than  one  day  {24+  1  hours)  or 
greater  than  30  days  were  excluded  from  the  study  The  infants  were  randomized  to 
either  Neobar  or  conventional  tape  The  hydrogel  adhesive  on  the  cheek  pads  of  the 
Neobar  was  applied  to  dry  skin  without  additional  fixatives  A  piece  of  adhesive  tape 
was  used  to  secure  the  ET  to  a  vertical  bar  on  the  arch  The  conventional  taping 
method  required  the  application  of  tincture  of  benzoin  to  the  area  of  the  upper  lip  pnor 
to  the  application  of  a  piece  of  Elastoplast  One  piece  of  cloth  tape,  approximately  five 
inches  long  was  applied  to  the  ET  by  wrapping  it  around  the  tube  hwice  and  anchonng  it 
to  the  opposite  side  of  the  face,  over  the  Elastoplast  This  procedure  was  repeated  with 
a  second  piece  of  tape,  which  started  at  the  opposite  side  ot  the  face  A  survey  was 
completed  by  the  bedside  respiratory  therapist  or  nurse  ranking  the  following 
categones,  on  an  ordinal  scale  (good,  fair  or  poor,  higher  score  =  better  condition)  Skin 
condition  was  documented  upon  extubation  using  an  ordinal  scale  {nonnal,  red,  rash, 
broken,  blistered)  Distributions  of  extubations  per  100  ventilator  days  and  survey 
scores  were  compared  with  a  Mann-Whitney  U  test  Significance  was  set  at  p<  0  05 
RESULTS:  Data  below  are  mean  +  standard  deviation: 

Neobar  Tape  p  Value 

Number  in  study  14  18 

ExIubations/lOO  vent  days  48*10  3       15  6  i  32  0  0  40 

Total  survey  score         155+13         144  +  14  0  05 

CONCLUSIONS:  For  this  study,  there  was  no  significant  difference  in  extubations  per 
100  ventilator  days,  but  there  is  evidence  that  a  larger  sample  size  might  be  more 
informative  Clinical  data  from  the  survey  showed  that  the  Neobar  was  supenor  to  tape, 
particularly  in  the  categones  ot  skin  condition  and  ease  of  venfying  ET  placement 


840 


Ri  si'iuxroRY  Carf;  •  Octobhr  "^S  Vol  4.'^  No  10 


Saturday,  November  7,  2:00-3:35  pm  (Rcxjm  2I5E) 


PERFORMANCE  OF  DEMAND  OXYGEN  DELIVERY  SYSTEMS  IN  A 
SIMULATION  OF  LOW  FLOW  OXYGEN  USE:  Pelc  Bliss  BME.  Robert 
McCoy  RRT,  Alexander  B.  Adams  RRT.  Regions  Hospital,  St.  Paul,  MN 
Background:  Demand  oxygen  delivery  systems  (DODS)  are  in  widespread 
use  in  conjuncUon  with  oxygen  cylinders  or  liquit"  oxygen  resen'oirs  and 
misal  cannula  The  interposed  DODS  are  designed  to  deliver  oxygen  dunng  all 
or  portions  ol  inspirauon  to  provide  a  comparable  FI02  to  low  ilow 
conUnuous  owgcn  and  lo  conserve  oxygen.  Eiach  mtxici  of  device  delivers 
oxygen  in  a  dillcreni  manner.  We  evaluated  the  R02  delivery  capabilities  and 
oxygen  con.scn  aUon  ol  currently  a\  ailable  mcxiels  ot  DODS  compared  to 
continuous  low  flow  oxygen.  Methods:  An  apparatus  was  constructed  to 
simulate  the  narcs,  conducUng  airways  and  an  aheolar  chamber  with  a  nasal 
cap.  flex  tube  ( 150  ml  of  deadspace)  and  one  limb  of  a  mechanical  test  lung 
(TTL-Michigan  Instruments).  A  respiratory  pattern  of  mild  tachypnea 
( VT=505  ml,  f=20/min,  Ti/Ttot=0.33,  decelerating  How  wave)  was  generated 
in  the  "respirating"  limb  of  the  test  lung  as  dn\'en  by  a  linked  \entilator 
(Quantum  -  Healthdync).  The  R02  delivery  lo  the  alveolar  chamber  was 
measured  at  1 .2  and  4  L/mm  setungs  for  each  DODS  by  a  Ceramatee  model 
OM-25A  oxygen  analyzer.  Oxygen  pulses  from  the  DODS  were  measured  by 
a  pneumolachometcr  and  extrapolated  to  02  use  per  minute  for  cylinder 
duration  calculations.  Results:   %  oxygen  measured  and  duraUon  of  cylinder 
use  for  DODS  (actual  R02  would  be  reduced  by  02  aiasumpUc 

Device 
Continuous  oxygen 
Chad  -  Oxymatic  301 
Devilbiss  -  EX2(XX)D 
Invacare  -  Venture 
Nellcor  PB  -  CR50 
Transtracheal  -  DOC2000 
Western  -  02Adv  antage 
All  DODS  triggered  their  oxygen  pulses  as  anticipated.  There  is  vanability  in 
n02  between  dcv  ices  at  each  setting.  At  each  setUng,  continuous  oxygen  had 
higher  R02  than  DODS,  probably  due  to  jetung  of  oxygen  dunng  exhalation 
into  our  simulated  conducting  ainvays.  For  the  condition  tested.  DODS 
allowed  an  extension  of  cylinder  use  ranging  from  2.6  to  6.9  times  that  of 
continuous  oxygen  use.  Conclusion:   The  DODS  allow  prolonged  cylinder 
use  but  settings  must  be  made  to  meet  therapeutic  goals  rather  than  expected 
compansons  between  devices  or  to  conUnuous  02  use. 


How 

Setting 

Hrs/M9  cylinder 

1 

2 

4 

(at 

setting  41 

26.3 

29.9 

35.7 

1.0 

23.8 

26.3 

31.7 

6.9 

24.5 

27.7 

33.0 

3.7 

23.5 

25.3 

29.3 

2.9 

26.3 

27.8 

31.6 

2.6 

23.5 

25.3 

29.0 

4.7 

25.0 

26.3 

29.2 

S.6 

USE  OF  A  NASAL  DILATOR  DEVICE  DURING  EXERCISE  IN  PATIENTS  WITl  I 
CHRONIC  OBSTRUCTIVE  PULMONARY  DISEASE.  Phillip  D,  Hobertv   EdP.RRT  The 
Ohio  Slate  University.  Columbus,  Ohio   Background:  Patients  wilh  COPD  are  taught 
pursed-Iip  breathing  dunng  pulmonary  rehabilitation  to  reduce  and  control  dyspnea  at  rest  and 
during  exercise.  Correct  performance  of  this  techmque  includes  mhalation  through  the  nose. 
It  is  also  known  that  the  use  of  a  functional  nasal  dilator  stnp,  eg,  Breathe  Right  Nasal  Stnp® 
(CNS,  Inc.),  increases  nasal  valve  area,  reduces  nasal  airflow  resistance,  and  contributes  to 
performance  dunng  submaximal  exercise  in  nomial  subjects    This  study  was  conducted  to 
determme  if  use  of  the  Breathe  Right  Nasal  Strip®  by  subjects  wilh  COPD  who  performed 
pursed-lip  breathing  during  submaximal  exercise  allowed  them  to  exercise  longer  or  maintain 
a  VuSpOj  closer  to  baseluie.  Method:Twelve  subjects.  7  men  and  5  women  with  mild  to 
moderate  COPD,  who  had  completed  6-8  weeks  of  pulmonary  rehabilitation  volunteered  to 
participate  in  the  study   They  performed  submaximal  exercise  via  an  mcremental  modified 
Balke  treadimll  protocol  (maximal  speed  =  3  mph)  under  3  conditions  offered  in  random 
order:  control  (no  nasal  device),  placebo  (nasal  device  without  plastic  center  core  provided  by 
the  manufacturer),  and  Breathe  Right  Nasal  Strip'&    Patients  proceeded  through  the  protocol 
until  they  reached  level  "7"  (severe  breathing  or  SOB)  on  a  modified  Borg  scale  of  perceived 
dyspnea  (range  0  -  10)   Elapsed  time  m  protocol  and  %Sp02  were  recorded  at  each  level  of 
exercise   Percent  change  SpO,  was  computed  for  each  subject.  Data  were  analyzed  using 
analysis  of  variance  using  an  alpha  level  of  0  05.  ResuIts:Table  1  presents  the  results. 
Although  some  subjects  reported  a  subjective  improvement  in  airflow  through  the  nose  wilh 
either  placebo  or  Breathe  Right  Nasal  Strip®,  there  was  no  statistically  significant  increase  in 
exercise  time  nor  difference  in  percent  change  SpOj  as  a  result  of  using  either  placebo  nor 
Breathe  Right  Nasal  Strip® 


Table  1    Mean  (SD) 


s  and  percentage  of  o\7gen  desaturation  during  submaximal 


ConU^ol                       Placebo 

Breathe  Right 
Nasal  Strip® 

Exercise  Time 
(minutes) 

12  93 
H88) 

13  38 
(2  70) 

13  37 

(254) 

Desuturation 
(%  change  SpO, 
txom  baseline) 

5.50 
(2.70) 

4  63 

(188) 

610 
(2.86) 

CoDclusioD:  I  concluded  that  using  the  Breathe  Right  Nasal  Stnp®  did  not  contribute  to 
lengthenmg  the  duration  of  submaximal  exercise  performance  nor  to  preventing  oxygen 
desaturation  in  this  sample  of  COPD  patients  dunng  submaximal  e 


Partial  funding  for  this  project  was  provided  by  CNS,  Inc  ,  Minneapolis,  MN. 


OF-98-106 


A  COMPARATIVE  ANALYSIS  OF  ARRANGING  IN-FLIGHT  OXYGEN 
ABOARD  COMMERCIAL  AIR  TRAVELERS,  Ed  Hoisington.  RRT.  James  K 
Stoller.  M  D  .  Glenn  Auger.  RRT,  The  Cleveland  Clinic  Foundation.  Cleveland.  Ohio 

Introduction:  As  air  travel  has  become  more  conmionplace  in  today's  society,  so  too 
has  air  tra\el  by  o\7gcn-dependent  individuals  Because  there  is  little  oversight  or 
standardization  of  in-flight  oxygen  by  the  Federal  Aviation  Administration,  individual 
airlines'  policies  and  practices  may  vary  greatly    On  the  premise  that  such  vanation 
may  cause  confiision  by  prospective  air  travelers,  we  undertook  the  current  study  to 
describe  individual  air  carriers'  policies  and  practices  and  to  provide  guidance  to  fiiture 
air  travelers 

Methods:  Data  were  collected  by  a  sencs  of  telephone  calls  placed  by  the  study 
iiuestigators  to  all  commercial  air  earners  listed  in  the  1997  Cleveland  Metropolitan 
Yello"  Pages   The  callers  were  registered  respiratory  tlierapists  who  identified 
[lieinselves  as  inexperienced  o.xj'gen -requiring  travelers  wishing  to  arrange  in  flight 
ovigcn  for  an  upcoming  tnp    Standard  questions  were  asked  of  each  earner  which 
included    Did  tiic  earner  have  a  special  "help  desk"  to  assist  with  cxygen 
arrangements'  What  o\7gen  s>slenis.  liter  flow  options,  and  interface  devices  were 
available'^  What  was  the  cost  of  ox> geni'  Hou  was  the  cost  determined''  What 
aocumenialion  fi-om  the  physician  was  required'  How  much  notification  was  required 
b\  the  airline  before  the  actual  flight'^  In  addition  to  recording  these  responses,  tlie  total 
amount  of  time  spent  on  the  telephone  by  the  caller  was  logged  along  with  tlie  number 
of  telephone  calls  and  number  of  people  spoken  to  in  arranging  in-flight  o.xygen   To 
compare  oxygen  costs  between  airlines,  we  calculated  costs  based  on  a  "standard  tnp". 
w  Inch  was  defined  as  a  non-stop,  round-trip  lasting  6  hours  in  which  the  traveler  used  a 
flow  rate  of  2  liters  per  minute 

Results:  Of  tlie  33  commercial  air  carriers  listed  in  tlie  directory.  1 1  were  domestic  only 
and  22  were  inlemational.  Seventy-six  percent  of  the  airlines  offered  in-flight  o.xygen 
For  the  25  earners  offering  in-flight  o\"ygen,  mean  phone  lime  required  to  make  the 
arrangements  was  10  2  minutes  (range  4-20  minutes)    No  more  than  2  telephone  calls 
were  required  to  make  o.xygen  arrangements.   Most  earners  required  48-72  hours 
advance  notice,  with  a  single  earner  requiring  I  month  advanced  notice    Most  carriers 
required  some  notification  of  oxygen  needs  by  the  traveler's  physician,  There  was  a 
great  \anation  in  oxygen  device  and  liter  flow  availability    Liter  flow  options  ranged 
from  onh  2  flow  rates  (36%  of  carriers)  to  a  range  of  1-15  liters  per  minute  (I  carner). 
A\\  earners  offered  nasal  cannula,  wluch  was  the  only  device  available  for  21  carriers 
(84''o)    Actual  costs  for  in-flight  oxvgen  also  vaned  greatly.  Six  earners  supplied 
oxygen  free  and  IS  earners  chargeda  fee  (range  $64  00  lo  $1,500  00)    One  airline 
allowed  the  traveler  lo  bnng  one  "E"  cylinder  with  no  fee  assessed.  For  14  of  the  18 
earners  that  charged,  the  cost  of  the  ■standard  Inp"  ranged  from  $100  00  to  $200  00 

Conclu 


1.  As  expected  from  the  lack  of  standard  regulations,  the  availability. 
costs,  and  case  of  implementing  in-flighl  oxygen  vanes  greatly  among  commercial  air 
earners    2    Because  the  cost  of  in-flight  ox>'gen  is  usually  borne  by  the  traveler 
(rather  than  by  insurers),  prospective  travelers  should  consider  costs  of  o.vygen  usage 
uhen  choosing  an  airline    3    We  speculate  that  because  such  variability  exists  in  an 
mirc^ilaicd  en\  ironmeni.  higher  government  standards  might  be  considered  to  reduce 
:irbitr.irv  varinuon 

OF-98-118 


Delivered    Oxygen    Concentration   and    Wort*    of    Breathing   when    Spontaneously 
Breathing    through    Disposable    Manual    Resuscitatoi    Bags     Mark  Rogers,  BS  RCP, 
HRT  Randy  Scot!.  BS,  RCP,  HHT  Thomas  Malinowski,  BS,  RCP,  RRT  Deparlmenl  ot  Respiralory 
Care,  Lonia  Linda  Umveraiy  Medical  Center.  Loma  l  tnda,  Calilomta 

Introduction:    The  purpose  ot  this  bench  study  was  to  evaluate  delivered  oxygen  (FDO.l  and 
imposed  worV  ol  breathing  (WOB)  during  spontaneous  breafriing  in  a  cohort  ot  disposable  manual 
tesuscitator  bags  (MHB)  Methods:   We  evaluated  live  inlant,  nine  pediatric  and  eight  adull 
MRBs  Oxygen  flo*  inio  each  MRB  was  sel  at  1 5  LPM  Reservoirs  were  tuHy  extended  (When 
applicable)  A  dual  chamber  lest  lung  was  moditied  lo  simulate  spontaneous  breathing  A 
rriechanical  ventilator  powered  one  side  of  the  test  lung  simulating  spontaneous  brealhing  in  the 
other  lung  The  test  lung  compliance  was  set  at  0  1  mL/cmHp  Age  specific  parameters  were 
used  Intant  f  =  30,  Vl  ^  70mL,  Ti  =  6  seconds,  ETT  =  3  Smm,  Pediatric  1=  1ft,  Vt^?00mL,  Ti  ^  95 

allowed  to  stabilize  and  ware  measured  at  the  endotracheal  tube  connector  using  a  Perkin-Elmer 
1  too  Medical  Gas  Analyzer  Work  ot  breathing  measurements  were  taken  from  a  ten  breath 
average  and  were  obtained  using  the  Venlrak  1 500  ( Novametncs  Medical  Systems) 
Result3;(See  table)  Intam  and  pediatric  MRBs  thai  employed  a  one-way  valve  in  the  exhalation 
valve  yielded  a  significantly  dtfferent  (p<0  005,  I-lesi  I  FDO,  and  WOB  than  those  MRBs  thai  do  noi 
use  a  one-way  valve  In  the  adult  group,  only  the  FOO,  was  signidcanlly  diHerenI  (p«;0  00b,  t-test) 
in  those  MRBs  that  employed  Ihe  one-way  valve 

MRB 

FDO, 

WOB 
(J/L) 

Type 

Vital  Signs  Baby  Glue  -  Infant 

23 

Simms  -  tntani 

34 

0457 

none 

Life  Designs  System  Pulmanex     Inlant 

7b 

0648 

none 

Ambu  Spur  ■  Pedialnc/lnfant 

96 

1409 

one  way 

Nellcor  PB  DMR2  -  Infant 

96 

1367 

oneway 

Vital  Signs  Pedi  Blue  (tail  reservoir)  ■ 
Pediatftr 

22 

1563 

Vital  Signs  Pedi  Blue  (neck  reservoir)  - 
Pediatric 

22 

1581 

none 

Simms-  Pediatnc(lalex) 

57 

2881 

none 

Hudson  RCI  Life  Saver  -  Pediatnc 

59 

1544 

none 

Simms  ■  Pediatnc 

73 

319 

nnne 

Lite  Designs  Syslem  Pulmane.<  ■  Pediatric 

84 

3235 

none 

Nellcor  PB  DMR2    Pediatric 

99 

3041 

one-way 

Kirk  Specialty  Systems  CapnoFio  ■  Pediatric 

99 

4-167 

one-way 

Ambu  Spur  ■  Pediatnc/lnlant 

1  0 

3681 

ons-way 

Hudson  RCI  Life  Saver  -  Adull 

52 

3435 

none 

Life  Designs  System  Pulmanex    Adult 

6e 

6949 

none 

Respirunios  BaqEasy  -  Adult 

.75 

5084 

none 

Simms  -  Adult 

.76 

7146 

none 

Vital  Signs  Adult 

.85 

8749 

none 

Kirk  Specially  Systems  CapnoHo  -  Adult 

93 

8543 

one-way 

Ambu  Spur    Adult 

98 

6878 

one-way 

Nellcor  PB  DMR2  -  Adult 

98 

614 

one-way 

Conclusion:    MRBs  with  an  expiratoy  one-way  valve  yield  higher  FDO-s  than  MRBs  Ibat  do  not 
incorporale  a  one-way  valve  Inlant  and  pediatric  MRBs  with  an  expiratory  valve  in  general  yield  a 
higher  W06  than  MRBs  without  an  expiratory  valve 

OF-98-128 

RE.SPIRATORY  CaRE  •  OCTOBER   '98  VOL  43  No   10 


841 


Sunday,  November  8,  2:00-3:55  pm  (Room  214E) 


COMPLIANCE  WITH  THE  1997  NATIONAL  ASTHMA  EDUCATION  & 
PREVENTION  PROGRAM  (NAEPP)  GUIDELINES  AMONG  MINORITY 
CHILDREN.  Lynda  Thomas  Goodfellow.  MBA.  RRT.  Crystal  L,  Dunlevy,  EdD, 
RRT.  GA  State  University.  Marie  Schuster.  BA.  RN..  Scottish  Rite  Medical  Center, 
Atlanta,  GA 

IntroductioD:  Asthma  is  the  most  common  chronic  disease  of  childhood,  affecting 
nearly  5  million  children.   Hospitalization  rates  for  asthma  are  the  highest  among 
blacks  and  children,  and  death  rates  are  consistently  highest  among  15-24  year  old 
blacks.  The  medical  literature  suggests  low  compliance  with  asthma  therapy, 
infrequent  use  of  peak  flow  monitoring  (especially  among  minorities  and  those  with 
low  socioeconomic  status),  and  inadequate  knowledge  levels  concerning  asthma,  The 
purpose  of  the  study  was  to  assess  compliance  of  urban  minority  children  with  the 
1997  NAEPP  guidelines.  Materials  &  Methods:  Subjects  consisted  of  22  minority 
children  who  participated  in  the  "Air  Zones  Games",  sponsored  by  the  Asthma  and 
Allergy  Foundation  of  America  Georgia  Chapter;  Scottish  Rite  Medical  Center  and 
Georgia  State  University,  and  held  in  Atlanta,  GA    The  games  allowed  students  to 
participate  in  medically  supervised  athletic  events.  Subjects  completed  a  20-item 
questionnaire  designed  by  the  American  College  of  Allergy.  Asthma,  and 
Immunology,  and  a  17-item  questionnaire  designed  by  the  investigators  and  based  on 
the  1997  NAEPP  guidelines.  Subjects  also  demonstrated  use  of  an  MD!  and/or  peak 
flow  meter.  Technique  was  evaluated  as  either  correct  or  incorrect.  Descriptive  data 
was  compiled.  Results:  Mean  age  of  subjects  was  10.  67%    Only  one  subject  was 
fully  compliant  with  the  1997  NAEPP  guidelines.  64%  report  excess  tension/stress 
because  of  their  asthma.  68%  do  not  own  a  peak  flow  meter  Of  the  remaining  32%. 
43%  do  not  use  it,  28%  were  not  currently  being  treated  for  their  asthma.  64%  avoid 
exercise  sometimes  due  to  cough  and/or  dyspnea.  57%  occasionally  cannot  sleep 
through  the  night  due  to  cough  and/or  dyspnea,  79%  have  more  difficulty  breathing  in 
cold  weather  93%  reported  worsening  of  symptoms  when  exposed  to  cigarette  smoke, 
re  emergency  room  visits  in  the  past  year  due  to  their  asthma.  28% 
tion  for  their  asthma  within  the  past  year.  43%  report  that 
s  control  them  more  than  they  would  like,  40%  live  in  households 
where  at  least  one  person  smokes.  Only  53%  know  what  asthma  medication  to  take 
for  maintenance  therapy;  86%  know  which  to  take  during  an  attack,  79%  do  not  use  a 
spacer  with  their  MDI,  91%  demonstrated  correct  use  of  a  peak  flow  meter  93% 
demonstrated  correct  use  of  an  MDI   70%  report  that  they  can  tell  when  an  asthma 
attack  is  coming  on,  77%  have  informed  the  school  nurse  that  they  have  asthma;  64% 
have  informed  their  physical  education  teacher  Discussion:  This  pilot  data  suggests 
that  urban  minority  children  do  not  demonstrate  compliance  with  the  1997  NAEPP 
guidelines.  They  would  likely  benefit  from  an  intervention  program  that  provides 
education  and  follow-up  monitoring 


36%  had  one  or  mo 
required  hospitaliza 
breathing  difflcultie 


Ol'TCOMES    FOR    HOSPITALIZED    ASTHMATICS    BASED   ON    RSV   STATUS 

Tipiolhv  R   M\crs.  RRT.  Carohn  Kercsmar  MD  and  Robert  Chatbum  RRT  Case  Western 
Rcscnc  Uni\cn;tt\  and  Rainbtivv  Babies  &  Children'^  Hiwpnal.  Cleveland.  OH 
Aim:  To  deiemiine  if  clinical  oulcomes  lor  children  hospitalized  »iih  stilus  aslhmalicuswere 
altected  by  their  respiraloiysyncvlial  viral(RSV)  status  History:  Children  admitted  Ui  our 
asthma  unil  (ACU)  Tor  status  aslhmaucus  since  Sept.  1996  have  been  treated  with  an  asthma  care 
path  (ACP)  The  ACP  developed  at  our  hospital  is  an  assessment-dnven  protoco!.  which  uuU^es 
an  intensive  regimen  of  standard  therapy  The  ACP  includes;  asthma  histoiy ,  clinical  and  objeciive 
assessments,  aJ^onthm  cues  for  the  nc\i  step,  a  ircatmenl  record  and  discharge  cnlena.  Specific 
cntena  arc  outlined  for  decreasing  trealmeni.  augmenting  treatment  for  pauenis  that  fail  to  respond, 
and  irinslemng  patients  to  the  intensive  care  unit  (ICU)  The  ACP  has  successfully  decreased  the 
jverugc  length  of  sta\  (LOS)  Irom  >3Udaysio  I. «  days.  About  16%  oJ  ACP admission.-i  require 
trcaiment  uith  an  mtensincation  protocol  for  failure  to  respond  /  progress  Participants:  All 
children  s  4  yean;  of  age  admitted  loan  ACU  forasduna  from  Jan  -  Apnl  97  Methodology: 
All  asthma  admissions  were  treated  using  die  ACP  and  swabbed  na.sally  for  the  presence  of  RSV 
PaUenLs  were  e\alualed  as  being  RSV  (  +  l  or  RSV  (-)    The  ACP  trealmeni  consisted  of  standard 
assessment  cntena  (wheeze,  air  exchange,  accessory  muscle  u-sage,  SpO,  and  respiratory  rate)  and 
standard  therapy  (supplemental  Oj.  albuterol  aenastils.  corticosteroids)  Specific  (assessment- based) 
cntena  were  outlined  for  decreasing  ireaimeni  m  a  stepwise  fashion.  PaticnLs  that  failed  to  respond 
to  this  standard  therapy  were  administered  an  intensification  pronxrol  (high-dose  albuterol  mixed 
with  ipratmpium,  SC  epmephnne  and  corticosteroids)  All  pauents  were  immediately  admitted  into 
the  ACP.  and  all  palicnLs  were  discharged  aJier  rec'ening  2  aerosols  6  hours  apart  (q6h)  Patients 
initially  admitted  to  ICU  were  excluded.  Morbidity  was  measured  by  phone  survey  alter  discharge 
Mean  values  lor  demographic  and  outcome  vanables  were  compared  with  t-tests.  Percentages  by 
race  and  gender  were  c-omparcd  using  a  Fisher  exact  test  DistnbuUons  by  chronic  seventy  class 
were  compared  with  the  Chi  Square  test  Results:  Demographic  and  outcome  vanables  are  shown 
in  the  tabic  as  w  hole  numbers  pcrccniagcs.  or  mean  \aJucs  (SD),  Companng  groups  by  RSV 
iograph<c  \anables  or  m  distnbuUon  by  chronic  seveniv 


status,  there  were  nt 
class  There  were  nt 

dilTcren 
deaths  o 

Demographics   (r 

Age  (years) 
Non  Caucasiai 
Males 
Severe  Chron 

c  Aslhm 

60^. 


44<)f 


1)63 


Length  of  Slay  (days)  2.18  (0  79) 

Aerosol  Treatments  12.3    (5  4) 

PaUcnis  Intensified  (n=)  9 

Hospital  Cost  /  Case  $  1 ,6()5  (S475) 

Post  Discharge  Morbidity  (days)        3  8     (2.6) 
iclusions:    Asthmatic  children  s  4  years  of  age  and  RSV  (+),  have  a  longer  LOS.  a  higher 
tn  treat,  and  a  longer  post  discharge  morbidity  than  those  RSV  (■).  On  average,  asthmatics 
are  RSV  (+)  require  more  dicrapy  and  are  intensified  at  tnpic  the  rate  as  RSV(-)  asthmaucs 


1-57  (0,52) 

<0,01 

9  4     (3-8) 

0,02 

3 

013 

$1,233  ($408) 

<0,OI 

2,3     (2,4) 

0,04 

CHEST  WALL  MOTION  IN  ADOLESCENTS  WITH  CONGENITAL 
NEUROMUSCULAR  DISORDERS  OFF  AND  ON  VOLUME  CYCLED 
MECHANICAL  VENTILATION  Chene  Johnson.  B  S  ,  Sheila  Horan,  B  S  . 
Robert  Warren.  M  D  ,  Arkansas  Children's  Hospital.  Little  Rock.  AR 

The  objective  of  this  study  was  to  review  changes  in  chest  wall  motion  in  adolescents 
with  congenital  neuromuscular  disorder;  obtained  during  spontaneous  breathing  and 
while  receiving  volume  cycled  mechanical  ventilatory  support  The  study  was  a 
retrospective  evaluation  of  pulmonan  function  and  chest  wall  motion  in  patients  who 
had  been  seen  in  the  Jones  Pulmonarv'  Function  Laboratory  at  Arkansas  Children's 
Hospital  Five  bo>^  were  diagnosed  with  Duchenne  muscular  dystrophy  and  one  girl  wzs 
diagnosed  with  nemaline  rod  myopathy  Ages  ranged  between  1 5  and  20  year;  During  a 
spontaneous  breathing  penod  and  again  while  patients  were  attached  to  an  LP-10 
volume  venlilalor.  chest  wall  measurements  (%  nbcage.  labored  breathing  index,  phase 
angle,  tidal  volume,  and  brcaths/min)  were  made  with  a  calibrated  respiratorv'  inductive 
plethysmograph  (Respitrace  FT)  VenUlator  settings  were  based  on  the  child's  weight. 
age.  and  expected  respirator>  frequencv  Respiratory  inductive  Plethysmography  (RIP). 
is  iIk  most  widely  used  technique  of  bod>-  surface  measurement  of  chest  wall  motion 
Results  of  the  study  off  and  on  ventilatory  support  were 

Subject        Age 


16 


In  all  subjects,  the  degree  of  chest  wall  motion  asynchrony  with  spontaneous  breathing 
was  reduced  as  measured  by  one  or  more  of  the  RIP  parameters  All  subjects  had  an 
increase  in  VT  on  mechanical  ventilation  ranging  from  1 1%  lo  ^4(t^A>  All  subjects  had  a 
reduction  in  respiratory  rate  This  data  suggests  that  in  each  of  our  subjects,  the  degree 
of  work  of  breathing  as  charactcn/cd  by  Iheir  spontaneous  asynchronous  breathing 
pattern,  improved  with  mechanical  vcniilalor>  support  Data  obtained  from  RIP  may 
further  be  useful  m  determining  vcniilalory  settings  in  ihe  individual  patient 


%RC 

LBI 

Phase 

VT 

Brealhs/m 

ofi/on 

off/on 

ofi/on 

off/on 

ofl/on 

67/24 

13/11 

81/59 

495/550 

30/33 

78/52 

1,2/1,0 

37/14 

263/770 

20/14 

92/63 

16/15 

138/53 

75/330 

16/13 

50/46 

11/10 

24/16 

316/810 

19/12 

59/59 

10/10 

13/9 

205/430 

34/20 

88/25 

1  9/1  1 

132/40 

520/830 

17/14 

OF-98-008 


AIRWAY  PRESSURE  RELEASE  VENTOATION  FOR  A  PEDL\TRIC 
PATIENT  ON  ECMO:  A  CASE  STUDY  SuzanneMJDummg^BS,RRL 
P/PSoec.  Theresa  R  Schuitz  BA.  RRT,  CPFT,  P/P  Spec..  Linda  A.  Napoli. 
BS,  RRT,  RPFT.  P/P  Spec  .  R I  Godinez,MD.  PhD  The  Children's  Hospital  of 
Philadelphia,  Philadelphia.  PA 

Backgrouod:  Jhis  is  a  one  year  old,  9  6  kg  former  32  week  gestational  age 
twin  male  who  was  admitted  to  our  Asthma  Care  Umt  and  treated  with 
steroids  and  contmuous  albuterol  He  was  diagjiosed  w\\h  parainfluenza 
pneumonia  and  was  transferred  to  the  Pediatnc  Intensive  Care  Umt  secondary 
to  worsening  respiratory  distress  despite  aggressive  bronchodilaior  therapy  and 
steroids   The  patient  was  mtubated  and  mechamcally  ventdated  upon  transfer 
to  the  PICU  He  subsequently  developed  bilateral  pneumotho races,  requiring 
four  chest  tubes    He  was  placed  on  Veno-Artenal  ECMO  pump  flow  1  2 
liters  per  minute,  sweep  flow  I  liter  per  minute.  FiO;  1  0  0\'er  the  next  few 
days,  chest  x-rays  revealed  worsenmg  radiodensit>'  with  diffuse  white  out. 
While  this  IS  a  common  findmg  for  patients  on  ECMO,  conventional  treatmeni 
such  as  mcreasmg  PEEP  and  lung  conditiomng  were  ruled  out  secondary  to 
severe  air  leak  and  increased  peak  airway  pressures  Mechamcal  ventilation 
was  manipulated  with  the  goal  to  mmimize  the  perpetuation  of  lung  mjun  In 
an  attempt  to  realize  the  benefit  of  spontaneous  breaihmg  while  uiilizmg 
minimal  airway  pressures.  Airway  Pressure  Release  Ventilauon  (APRV)  was 
initiated  at  1650  Settings  were  mampulated  while  attemptmg  to  maximize 
SvO:  (an  mdwelhng  catheter  was  in  the  ECMO  cuxmit)  The  final  setimgs  and 
corresponding  ABG  results  as  follows 


1400 
SIMV 

RR 
lObpm 

Ti 
Isec 

FiO, 
10 

Peak 
35cmH,0 

PEEP 
5cmH,0 

MAP 
9cmH,0 

ABG 
1400 

PH 

7  47 

pCO: 

37 

PaO, 
62 

HCO, 

27 

BE 
45 

SaO, 
92% 

0300 
APRV 

RR 
lObpm 

T,=3sec 
Tj'3sec 

FiO, 
21 

Pmax 
25cmH!0 

Pnun 
5craH,0 

MAP 
15(3nH,0 

0330 
ABG 

pH 

7  38 

pCO: 

40 

P»0, 

67 

HCO, 

24 

BE 
-0,6 

SaOi 
93% 

Hemodynamic  status  remained  imchanged  with  BP  83/64.  MAP  60,  heart  rate 
1 14  per  minute    Subsequent  chest  x-ray  results  over  the  new  48  hours 
revealed  improvement  in  the  opacificalion  of  the  lung  fields  bilaterally  and 
resolving  pneumothoraces 

Conclusion:  This  application  of  APRV  enabled  us  to  achieve  adequate 
ventilauon  and  oxygenation  at  lower  inflating  pressures  for  this  spontaneously 
breathing  paueni 


842 


Rkspiratory  Cark  •  OcTOBKR  "98  Vol  43  No  10 


Sunday,  November  8,  2:00-3:55  pm  (Room  214E) 


Buyer's  Guide  Online 

The  1998 
Buyer's  Guide  of 
Cardiorespiratory 
Care  Equipment 
&  Supplies  is  also 
available  on  the 
Internet.  Visit  the 
AARC  web  site  at 
www.aarc.org  and  select  Buyer's 
Guide  from  the  main  menu. 


EVALUATION  OF  THE  SENSICATH  SYSTEM  IN  NEONATES  WITH 

CONGENITAL  HEART  DISEASE 

Jenni  L.  Raake.  RRT.  P/P  Specialist  Roozbeh  Taeed,  MD, 

Staen  Schwartz.  MD,  David  Nelsotu  MD,  PbD 

Cardiac  Inienave  Care  Unit.  Children's  Hospiial  Medical  Center.  Cincinnati.  OH 

Background:  Blood  gas  analysis  is  e\lrenicl\  important  because  venlilator  manipulations 
pla>'  a  central  role  m  penoperative  management  of  neonates   Neonates  with  cyanotic 
congenital  heart  defects  have  a  lower  pOr  due  to  shuntmg   Blood  gas  analysis  is  often  delayed 
or  compromised  by  the  need  to  transport  samples  to  a  central  laboratory  which  can  complicate 
ventilator  managemenL  We  exaluated  a  Sensicath  System  (OpOcal  Sensors  Incorporated, 
Eden  Praine,  MN)  on  neonates  after  palliative  surgery  for  congcmtal  heart  defects    We  also 
recorded  the  specimen-result  turn  around  time  for  simultaneous  specimens  analyzed  by  a 
central  laboratory'    Methods:  After  patienis  relumed  from  the  operating  room,  the  Sensicath 
System  was  connected  to  the  arterial  line    Blood  was  pulled  across  the  sensor  and  reinfiised  to 
the  patient  afkr  analysis    A  sample  of  blood  was  sent  to  the  central  laboratory  simultaneously, 
and  analy7-ed  on  a  Coming  855  blood  gas  electrolyte  analyver  (Chiron  Diagnostics.  Norwood, 
MA)    Results  of  pH,  pCO;.  and  pO:  analysed  by  the  Sensicath  System  were  compared  to 
central  laboratory  values   The  speamen-result  turn  around  time  was  recorded  Conelations 
were  made  between  results  Ir.' examining  accuracy  and  prcision.  Results    Correlations  were 
pOj-  rMi  878.  accuracy  -  -t  3  mm  Hg.  precision- 12  1,  pCOr-r  =0  587.  accuracy  -  -()  6  mm 
Hg:  pTCCTSion  5  5.  pH-r^)  8t)l.  accuracy-0  034  mm  Hg.  precision  0  028    Specimen-result 
turn  around  time  was  13  8+71  minutes   The  Sensicath  System  prmided  results  after  a  60 
second  analysis  tune  with  no  blood  loss  to  the  patient   Experience:  Traditional  blood  gas 
analysis  results  m  blood  loss    A  major  advantage  of  the  Sensicath  System  is  elimination  of 
iatrogemc  blood  loss    The  blood  is  pulied  across  the  sensor  and  reinftised  into  the  paDeni  after 
analysis    The  sensor  ehminates  blood  loss  in  two  ways    there  is  no  iatrogemc  blood  loss,  and 
there  IS  no  waste  or  samphng  necessary    Conclusions:  The  Sensicath  System  was  found  to 
provide  reliable  blood  gas  values  when  compared  to  a  Coming  855  blood  gas  analyser,  while 
reducing  iatrogemc  blood  loss   This  system  may  be  considered  especially  helpful  m  pati^ts 
with  congenital  heart  defects  (especially  neonates  and  infants)  when  rapid  results  arc  required 
for  optimal  pauent  c 


Table  1 

Sensicath  Blood  Gas  System  v 

s  Coming  855 

pH 

pC&. 

p02 

pO:<50inmHg 

,  of  samples 

97 

97 

97 

68 

range 

7.26  -  7  57 

23-64  mm  Hg 

33  6-181 

nmHg 

336-49  Inui 

nHR 

r 

0.803 

0.587 

0  878 

0.077 

slope 

0912 

0860 

0  743 

0532 

mlercept 

068S 

5492 

10.462 

18.633 

accuraa' 

0.034 

^16 

-t.3 

-0.5 

[decision 

0028 

5  5 

121 

79 

NASAL  INTERMITTENT  MANDATORY  VENTILATION  CNIMV)  REDUCES  THE  NEED 
FOR  INTUBATION  IN  IMPENDING  RESPIRATORY  FAILURE  INFANTS 
Mci-ju  Shih  MSN  RT  RN.  H  J.  Hsiao  RT  RN,  M.J.  Young  RT  RN 
Chang  Gting  Memorial  Hospital.  Taoyuan,  Taiwan,  R.O-C. 

Introduction:  Nasal  CPAP  (NCPAP)  has  shown  that  it  can  reduce  the  need  for  mtubation  and 
mechanical  ventilation  in  mild  to  moderate  respiratory  distressed  infants.  However,  there  are 
slill  some  infants  who  would  fail  tins  trial  and  need  to  be  intubated  and  mechanically  ventilated. 
In  this  study,  we  proposed  an  NIMV  treatment  for  the  impending  respiratory  failure  infants  who 
fail  the  trial  of  02  therapy  or  NCPAP  in  our  NICU  The  incidence  of  intubation  and  the  gas 
exchanges  before  and  after  application  of  NIMV  were  evaluated. 

Method:  We  reviewed  43  infants  (BBW  1467.0  ±  580.9  gm,  GA  30.4  +  3.4  wks,  BW  on 
NIMV  1633.2  ±  706.5  gm)  who  have  been  placed  with  a  NIMV  due  to  respiratory  failure, 
frequently  or  severe  apnea,  or  respiratory  distress  from  Feb.  1995  to  Dec.  1997  in  our  NICU. 
All  the  subjects  received  NIMV  via  a  nasal  prong  (Hudson,  CA.  USA)  and  a  neonatal  venlilator 
(Infant  Star  or  VIP  Bird).  The  initial  settings  of  NIMV  were:  flow,  6-15  Ipm;  PEEP,  5  cmH20, 
PIP,  10-15  cmH20,  IMV  frequency  6-20  BPM;  inspiratory  lime,  0  5-0.6  sec.  Fi02  were  titrated 
to  keep  Pa02  between  55  and  70  mmHg.  PIP  were  increased  to  25  cmH20  by  1-2  cmH20 
increments.  IMV  frequencies  were  increased  to  25  BPM  by  2-4  BPM  increments.  The  patient's 
characteristics,  incidence  of  intubation,  associated  complications,  and  gas  exchanges  before  and 
after  NIMV  were  collected  from  chart  review. 

Result:  72.09%  (N=3 1 )  patients  were  successfully  ventilated  and  weaned  from  NIMV  without 
intubation  and  invasive  mechanical  ventilation  Tlie  Pa02  were  increased  and  the  l>aC02  were 
decreased  significantly  after  Uie  treatment  of  NIMV.  Only  one  patient  (2.32%)  developed 
pneumothoiax  and  6  patients  ( 13  95%)  developed  abdominal  distension  during  NIMV 
Gas  exchanges  before  and  alter  NIMV  fN=43) 


Before  NIMV 

After  NIMV 

Result 

61.17  -1-  16.29 

82.49  ±  28.83 

P<0001 

PaC02(mmHs) 

52.20  ±  14.09 

45.46  ±  10.05 

P<  0.001 

J 

044  ±  0.24 

0.50  ±  0.23 

P<  0.001 

Pa02/Fi02 

205.59  ±  86.81 

263.02  ±  109  92 

P<0001 

Conclusion:  The  high  successfiil  rate  of  NIMV  in  our  study  suggests  that  it  may  be  an  effective 
and  safe  method  of  ventilatory  support  for  infants  who  suffer  from  respiratory  distress  and  fail 
the  treatment  of  NCPAP  or  02  therapy.  It  may  reduce  the  need  for  intubation  and  improve  the 
ventilation  as  well  as  oxygenation  in  ftiese  patients. 


>5 

n 


Respiratory  Care  •  October  '98  Vol  43  No  10 


843 


Sunday,  November  8,  2:00-3:55  pm  (Room  214E) 


WATCH     FOR 
SSU  E 
R  E  S  P      R  A      O 

A    SPEC    AL 
O  F 

R  Y    Care 

PEDIATRIC 

ARDS 

N  0  V  E  M  B  E 

R 

19  9  8 

AN  IN  VITRO  COMPARISON  OF  TWO  METHODS  OF  AEROSOLIZED 
BRONCHODILATOR  DELIVERY  TO  INTUBATED  MECHANICALLY 
VENTILATED  NEONATES  Beth  Brown.  MS.  RRT.  Macon  State  CoUege. 
Macon,  Georgia,  &  Bob  Harwooi  MSA.  RRT.  Georgia  Sute  Universm, 
Atlanta,  Georgia 

Mechanically  ventilated  neonates  are  often  candidates  for  aerosol  therap>' 
because  of  pre-existing  lung  conditions    We  report  here  the  results  of  two 
methods  of  aerosol  debveiy  to  mechanically  ventilated  neonates 
Method    A  Sechrist  IV  neonatal  ventilator  in  the  IMV  mode  was  used  to 
ventilate  a  lung  model  with  standard  settings  IMV  mode.  PIP  25cmH20, 
respiratory  rate  25  bpm.  inspiratory  time  of  0  5  seconds,  and  PEEP  of  5  cm 
H20   A  disposable  neonatal  circuit  was  attached  to  a  3  0  ETT  and  test 
lung   The  ETT  was  attached  to  a  template  that  simulated  the  curvature  of 
the  upper  airway  fashioned  from  a  lateral  neck  radiograph  of  a  neonate    A 
heated  humidifier  was  used  In  method  one  2  5mg  of  albuterol  was 
delivered  bv  a  MiniHeart  ™  nebulizer  at  2  I7M  in  line  through  the 
inspiratory  hmb  of  the  patient  circuit  18  inches  from  the  wye  adapter   In 
method  two  25  puffs  fh)m  an  MDI  attached  to  a  spacer  and  placed  between 
the  wye  adapter  and  the  inspiratory  limb  of  the  patient  circuit  was  dehvered 
Drug  exiting  the  ETT  was  captured  by  a  filter  attached  to  the  end  of  the 
ETT.  dissolved  with  alcohol  and  measured  by  spectrophotometer 
The  results  are  as  follows 


Trial 

MiniHeart 

(meg) 

%  of  Total 
Dose 

MDI 
(meg) 

%  of  Total 
Dose 

1 

1455 

58 

197  1 

88 

2 

50 

2,0 

182.5 

81 

3 

53 

2  12 

158  3 

7.0 

4 

42 

168 

1297 

58 

5 

115 

46 

1848 

82 

Mann-Whitney  U  Test  a  non  parametric  lest  for  unpaired  samples,  showed 
that  each  method  differed  sigmficantJy  from  each  other  (p=0  016) 
Conclusion    Use  of  an  MDI  with  spacer  de\icc  has  a  greater  %  of  dose  at 
the  end  of  the  ETf  as  compared  to  the  MiniHeart  nebulizer  when  placed  ir 
hne  on  the  inspiratory  Umb  with  a  heated  humidifier 


DESCRIPTION    OF   ASTHMA    CARE   PRIOR   TO   APPEARING   IN   AN    INNER 
CITY    PEDIATRIC    EMERGENCY    DEPARTMENT 

TimolhyR  Myers  RRT,  Carolyn  Kercsmar  MD,  and  Robert  Chalbum  RRT  Rainbow 
Babies  &  Childrens  Hospital  and  Case  Western  Reserve  University,  Cleveland,  OH 
Asthma  is  one  ot  the  most  frequent  reasons  for  visits  m  emergency  departments  (ED)  As 
part  ot  our  ED  care  path  for  pediatrics,  all  patients  receive  a  standardized  asthma  history 
interview  This  is  a  descriptive  study  of  an  inner  city  population  that  utilized  our  hospital 
ED  for  asthma  care  in  1997  Methods:    Residents  gave  a  standardized  interview 
containing  information  regarding  triggers,  routine  medications,  pre-ED  treatment,  severity 
ol  illness,  and  healthcare  utilization  to  all  asthma  ED  patients.  Results:   There  were  a  total 
of  1,555  ED  visits  lor  asthma  Visits  resulted  in  571  admissions  (36  7%),  984  discharges 
(63.7%),  and  no  deaths  The  patient  population  was  87%  non-caucasian,  64%  males  with 
a  mean  age  of  6  3  years  Mean  values  for  vital  signs  at  presentation  were  respiratory  rate 
38  breaths/  minute  and  Sp02  =  95'^'o  Patient  data  Irom  interviews  18  7'''o  had  a  written 
treatment  plan,  26%  contacted  their  private  physician  prior  to  coming  to  the  ED.  24  5% 
had  no  medications  at  home,  7%  had  used  oral  steroids  m  the  past  24  hours,  and  34%  of 
children  (>  7  years  of  age)  had  a  peak  flow  meter  at  home  Below  are  additional  data 
acquired  from  the  history  interviews  Chronic  asthma  seventy  determined  by  scohng 
mechanism  as  descnbed  in  Resp  Care  98  43(1). p  25 
Current  Visit  Triggers  Duration  of  Symptoms     Chronic   Asthma 


ity 


URI 


33°/ 


>  12  Hours 
<  12  Hours 
Unknown 


36% 


Weather         22% 

Exercise        20% 

Allergen         1 8% 

Smoke  1  % 

Unknown         6% 
Routine   Medications    Prescribed 

Albuterol  87% 

Cromolyn  Sodium  44°o 

Inhaled  Corticosteroids     15% 
Pre  ED  Treatment  in  past  12  hrs 

>  3  treatments  34°b 

No  treatment  61 '^o 

Unreported  treatment      5"'c. 
ED  Visits  in  Past  Month         ED  Visits 


Mild  36% 

Moderate  15% 

Severe  47% 

Unknown  2% 


Oral  Steroid  Burst  3% 

Other  5% 

No  Medications  Wo 

Pre  ED  Treatment  in  past  i 

>  2  treatments  1 6% 

No  treatment  Tb^'a 

Unreported  treatment  9°'o 
n  Past  Year    Admissions 


Past 


0  Visits  65% 

1  Visit  27% 
>  1  Visit  0% 
Unreported       8% 

Conclusion:   Asthmatic  families 


0  Visits 

1  Visit 

>  2  Visits 
Unreported 


0  Visits  1 9% 

1  2  Visits  34% 
>  3  Visits  (y/o 
Unreported  46% 
em  lo  have  adequate  knowledge  of  asthma  triggers 

and  prescribed  medications,  but  appear  not  to  pertorm  the  appropriate  procedures  prior 
lo  utilizing  the  FO  However,  this  study  indicates  that  these  families  are  not  always 
adequately  equipped  with  appropriate  treatment  plans  or  peak  flow  meters,  or  prescribed 
appropriate  classes  ot  medications  based  on  disease  severity 


OF-98-076 


844 


RisiMRATORY  Cark  •  OCIOBI-R  "98  Voi   43  No  10 


Sunday,  November  8,  2:00-3:55  pm  (Room  214E) 


THE  EFFECT  OF  THE  VENTILATOR  CIRCUIT  ON  THE  SV  300 
DELIVERY  OF  PRESSURE-CONTROLLED  VENTILATION  FOR 
THE  PEDIATRIC  RANGE   Kalte  Kinninaer  RCP.  Wayne  Johnson  RC P. 
Elzbicia  Bilk  MS.  John  Ntwharl  RCP.  Rick  Ford  RCP.  David  Bums  MD 
VCSD  Medical  Center.  San  Diego.  California 

BACKROUND:  Al  (he  onset  of  inspiration  during  clinical  use  of  the  Servo  Ventilator 
300  (SV  300)  (Siemens-Elema  AB.  Solna.  Sweden)  with  pressure-conlrolled  ventilation 
selected  for  the  pediatric  range,  we  observed  a  rapid  inspiratory  flow  resulting  in  an 
airway  pressure  overshoot  "spike".  The  presence  of  overshoot  has  no  clinical 
significance,  because  il  is  not  Iransmillcd  to  the  alveolar  level.  It  can.  however,  cause  the 
microprocessor  controls  of  the  ventilator  to  delect  upper  pressure  limits  and  unnecessarily 
activate  alarm  limits  of  the  system  and  cause  ihe  loss  of  delivered  inspiratory  lidal 
volume.  The  overshoot  could  be  eliminated  by  selecting  the  adult  range  or  by  replacing 
the  pediatric  ( 1 5mm  diameler)  disposable  vcnlilaior  circuit  with  a  reusable  neonatal 
( 1 0mm  diameter)  circuit    The  objective  of  Ihis  study  was  to  document  Ihe  effect  of 
different  pediatric  and  neonatal  ventilator  circuits  on  the  SV  300  delivery  of  pressure 
controlled  ventilation  in  pediatric  and  adult  ranges    METHODS:  Utilizing  these 
previously  observed  clinical  conditions,  a  bench  test  was  performed  on  a 
single -compartment  lung  model  with  seven  commercial  ventilator  circuit  brands:  Siemens 
#6697023  silicon  circuit  (SV),  Simplex  #N2723  Tygon  circuit  (SS).  Marquest  #1555203 
Tygon  circuit  (MS).  Simplex  #P3945  healed  wire  circuit  (SHW).  Marquesl  #156545 
heated  wire  circuit  (MHW),  Hudson  #780-24  heated  wire  circuit  (HHW).  and  Hudson 
#780-22  circuit  with  a  water  trap  (HWT).  The  SV,  SS  and  MS  are  neonatal,  smooth-bore 
circuits  with  an  internal  diameler  (I.D  )  of  10  mm  while  SHW.  MHW.  HHW  and  HWT 
are  corrugated  pediatric  circuits  with  ID.  of  15mm    The  pressure  and  flow  transducers 
were  inserted  between  the  inspiratory  outlet  of  the  SV  300  and  the  proximal  end  of  the 
inspiratory  limb  of  the  tested  ventilator  circuit.  The  following  parameters  were 
measured:  peak  inspiratory  flow  (PIF).  volume  delivered  during  inspiration  (Vi)  lo  the 
TTL  lung  model  system  including  volume  in  the  ventilator  circuit,  and  Ihe  PEEP  level. 
The  overshoot  pressure  (Pov)  was  defined  as  the  difference  between  the  peak  inspiratory 
pressure  (pressure  at  the  peak  of  the  spike)  and  the  plateau  pressure  (pressure  al  the 
inspiratory  plateau,  before  the  point  of  flow  reversal  that  begins  expiration). 
RESULTS  Vi  (L)  PIF  (Us)  Pov  (cmHjO)         PEEP  (cmH.Ql 


CIRCUIT 

PeJ 

Aiiu 

Pcd 

Adu 

Ped 

Adu 

Ped 

Adu 

SV 

247 

237 

432 

397 

1  9 

07 

5  1 

69 

SS 

244 

237 

427 

.392 

18 

08 

48 

6.2 

MS 

238 

,230 

.442 

.407 

2.0 

09 

5.3 

6.3 

SHW 

272 

.257 

513 

.462 

2.3 

0.6 

4.3 

6.1 

MHW 

276 

256 

553 

.487 

30 

06 

4  1 

64 

HHW 

284 

268 

.586 

.503 

3.0 

00 

44 

63 

HWT 

296 

.277 

608 

.543 

3.5 

0.9 

4.3 

6,6 

CONCLUSIONS:  The  diameter  size  of  the  ventilator  circuit  can  have  clinically 
significant  influence  on  the  characteristics  of  the  pressure  controlled  ventilation  mode  ii 
the  pediatric  range  delivered  by  the  SV  300  ventilator.  Potential  clinical  problems  can  I 
avoided  by  monitoring  pressure  and  flow  waveforms 


PERFORMANCE  COMPARISON  OF  4  SPACERS  IN  A  NEONATAL  MECHANICAL 
VENTILATOR -LUNG  MODEL.  Jim  Keenan  BS.  RRT,  Ralph  A  Lugo,  PharmD,  John  W 
Saiyet  BS,  RRT,  Roben  M  Ward,  MD   Primary  Children's  Medical  Center  and  the 
University  of  Utah  College  of  Pharmacy,  Salt  Lake  City,  Utah  Introduction  Aerosolized 
albuterol  (ALB)  is  commonfy  administered  to  mechanically  ventilated  neonates  Many 
institutions  have  favored  switching  from  nebulized  ALB  to  metered  dose  inhalers  (MDIs) 
since  the  latter  is  more  cost-effective  To  administer  ALB  to  intubated  neonates  via  MDl. 
several  in-lme  spacers  are  commercially  available  Stnce  there  are  few/  data  in  ventilated 
neonates,  we  sought  to  compare  the  efficiency  of  ALB  delivery  jsing  4  commercially 
available  spacers  Since  previous  studies  in  mechanically  ventilated  neonates  have 
demonstrated  limited  drug  delivery  from  MDI/spacers,  a  secondary  objective  was  to 
determine  where  ALB  is  lost  and  thus  unavailable  for  patient  delivery  Methods:  The 
model  consisted  of  a  VIP  Bird  ventilator  m  a  time  cycled,  pressure-limited,  continuous 
flow  mode  with  ventilator  settings  selected  to  simulate  a  neonate  with  moderate  chronic 
lung  disease   PIP  25  cm  H,-,0.  rate  30,  Ti  0  35  sec.  PEEP  4  cm  H^O,  FiOj  0  40,  flow  9 
L/min,  T  35'  C.  and  humidi'fied  chamber  control  -1    The  test  lung  compliance  was  -   0.4 
mUcm  HjO  and  was  adjusted  with  each  replicate  to  obtain  a  V,  of  6  4-6  6  mL  The 
circuit  wye  was  attached  to  a  3  0-mm  endotracheal  tube  (ETT)  and  then  lo  a  neonatal 
test  lung  Four  spacers  were  tested  in  this  mode!  (ACE,  Aerochamber  Aerovent  and 
Medspacer)  and  were  placed  between  the  circuit  v/ye  and  the  ETT  A  Sims  filter  (# 
2632)  was  placed  between  the  ETT  and  the  lest  lung  to  measure  ALB  delivery  to  the 
patient  A  second  filter  was  placed  between  the  wye  adapter  and  the  expiratory  limb  to 
trap  aerosolized  ALB  lost  from  the  spacer  via  retrograde  flow  to  the  expiratory  limb 
Each  of  7  MDIs  was  actuated  5  times  al  30  second  intervals,  immediately  prior  to 
inspiration  After  each  expenment,  filters  were  rinsed  3  times  with  1 5  ml  of  filtered  water 
and  spacers  were  nnsed  once  with  20  mL  Concentrations  of  ALB  in  the  resultant 
solutions  were  analyzed  by  high  performance  liquid  chromatography,  which  was 
determined  to  be  accurate  and  precise  Results:  ALB  delivery  to  the  patient,  retrograde 
loss  of  ALB,  and  spacer  impaction  are  presented  in  Ihe  table  All  values  are  represented 
1  percent  of  ALB  released  with  each  actuation  (100  meg)  ±  SD 


Spacer  Brand 

Patient 

Retrograde 

Spacer 

Total 

ACE 

4  r  (0  9) 

186(341 

54  9(6  1) 

87  6(7  1) 

Aerochamber 

1  2(0  5) 

265(3  11 

66  7(1  8) 

94  4(2  9) 

Aerovent 

1  5  (0  3) 

169(56) 

630(11  3) 

101  4(139) 

Medispacer 

2  4t  (0  8) 

10  9(0  9) 

82  9  (5  4) 

96  2  (4  5) 

*  p  ^  0  01  for  ACE  vs  all  spacers,  tP*=0  05  for  Medispacer  vs  Aerochamber  (ANOVA 
with  Tukey  all  pairwise  comparison)  Conclusion  There  were  statistically  significant 
and  clinically  important  differences  in  ALB  delivery  between  4  commonly  used 
spacers  The  ACE  spacer  demonstrated  superior  performance  when  tested  with  this 
model  Unanticipated  findings  included  the  significant  amount  of  ALB  lost  to  retrograde 
flow  and  spacer  impaction  Optimizing  drug  delivery  to  ventilated  neonates  may 
require  redesign  of  in-line  spacers  to  limit  drug  loss 


OF-98-092 


NORMAL  SATURATIONS  IN  A  MIDDLE  SCHOOL  AGE  POPULATION  AT  AN 

ALTITUDE  OF  4480  FT  (1366  M)    Kathy  Poll,  RRT.  Jim  Keenan,  BS  RRT,  John 
Salyer,  BS  RRT,  Pnmary  Children's  Medical  Center,  Salt  Lake  City,  Utah 
Introduction:  There  is  a  lack  of  data  of  normal  saturations  m  pediatric  patients  at 
varying  altitudes    This  lack  of  normal  data  may  be  leading  (o  over  or  under  treatment  of 
hypoxemia  and  possibly  contributing  to  unnecessanly  prolonged  hospitalization  due  to 
what  some  consider  marginal  Sa02  readings    Pnmary  Children's  Medical  Center  is 
located  in  the  foothills  of  the  Wasatch  mountain  range  in  north  central  Utah  Because 
we  are  at  approximately  5000  feet  elevation,  we  set  out  to  find  some  standard  of  normal 
saturations  m  a  school  age  population  at  a  similar  altitude  Methods  Data  were 
gathered  during  a  health  fair  at  a  middle  school  in  metropolitan  Salt  Lake  City    All 
subjects  were  volunteers  who  came  to  the  hospitals  health  fair  booth    Sa02  was 
measured  with  an  Ohmeda  3700  pulse  oximeter  A  clip  on  type  finger  probe  was  used 
AH  subjects  were  standing  dunng 
sampling  and  readings  were 
taken  after  a  steady  heart  rate 

was  displayed  All  subjects 

appeared  m  general  good  health 

and  were  in  no  apparent 

distress    Results:  The  table  at 

the  nght  descnbes  the  population 

tested  The  mean  age  was  13  2  years  (SD  =0.8,  median  =  13)    Then 

96  0  (SD  =  1  8,  median  =  96)  The  following  chart  describes  all  saturatio 

Ihe  number  of  subjects 


Age 

(years) 

males 

# 
females 

total 

12 

39 

38 

77 

13 

83 

79 

162 

14 

53 

53 

106 

15 

12 

7 

19 

364 

n  Sa02  was 
5  Obtained  per 


90    91     92    93    94    95    96    97    98    99    100 
Sa02 

Conclusion  Nearly  10%  of  these  apparently  healthy  subjects  had  saturations  of 
<  92%  The  local  practice  of  considenng  salurations  of  greater  than  92%  to  be  "normal" 
while  less  than  92%  to  be  "abnormal"  may  overestimate  the  presence  of  hypoxemia 
that  IS  clinically  important    This  assumes  that  none  of  the  lower  saturation  readings,  m 
this  population,  were  reflective  of  disease  processes,  since  we  assume  these  school 
age  children  to  be  m  reasonable  health 


AIRWAY  PRESSURE  RELEASE  VENTILATION  IN  PEDIATRICS:  A  CASE 

SERIES^  Theresa  R    Schultz.  BA.  RRT.  Suzaiwe  M  Doming.  BS.  RRT.  Linda  A  Napoli. 
BS.  RRT.  Gregory  Schears.  MD  The  Children's  Hospital  of  Philadelphta.  Philadelphia.  PA 

Previous  investigators  have  reported  that  Ainvay  Pressure  Release  Ventilation  ( APRV) 
provides  ventilation  at  lower  air^vay  pressures  llian  Volume  Control  VenoIaUon  (VCV)  in 
adults  In  1995.  we  took  a  conservative  approach  to  invesUgating  APRV  in  children  At^cr 
studying  eight  patients,  we  found  that  pediatnc  patients  can  be  adequately  ventilated  with 
lower  airway  pressures  utilizing  APRV  when  compared  to  conventional  ventilation 
Unrestricted  spontaneous  breatfung  was  noted  to  tie  an  addiuonal  benefit  While  considenng 
these  outcomes,  it  was  decided  to  utilize  APRV  outside  the  cntena  for  study,  on  pediatnc 
patients  with  Adult  Respiratori,'  Distress  SyTidrome  (ARDS) 

This  IS  a  one  year  old  former  premature  infant  with  paramfluenza  pneumoma  who  progressed 
to  respuatory  failure  despite  aggressive  medical  mtenenoon  The  patient  required  intubation 
and  mechanical  venulation  upon  amval  lo  the  PICU  He  was  placed  on  V-A  ECMO  for 
pulmonar,  rest  after  he  developed  bilateral  pncumothoraces.  requiring  four  chest  lubes  Chest 
\-rays  revealed  worsenmg  radiodensit>'  with  diffuse  white  out  Mechanical  venulauon  was 
manipulated  with  the  goal  lo  minimize  the  perpetuation  of  lung  injury'  These  inampulations 
included  CPAP  alone  as  well  as  Pressure  Control.  Volume  Control,  SIMV.  Assist  Control, 
with  vanabic  levels  of  pressure,  volume  and  time  In  an  attempt  to  realize  the  benefit  of 
spontaneous  breathing  while  utilizing  mmimal  mechanical  aimay  pressures.  APRV  was 
initialed  Blood  gas  analysis  confirmed  adequate  ventilation  CXR  improved 


1400 


0300 


SIMV 


APRV 


Ti=!  s 


FiQ:=10    I  Pcal;"35crnH;0     PEEP=5cmH:0 


5cinH:0 


'^^-5cmH:0 


■This  IS  a  5  year  old  who  developed  respiratorv  failure  secondan  to  Influenza-A  She 
progressed  lo  ARDS.  requiring  mechanical  ventilation  and  subsequently  V-A  ECMO  After  all 
reversible  processes  were  alleviated,  the  patient  was  hberated  from  ECMO  Unable  to  wean 
the  patient  from  the  mechamcal  \entilator.  it  was  decided  to  place  the  patient  in  APRV  The 
goal  was  to  ttain  the  patient  to  breathe  spontaneously  while  giving  her  adequate  pressure  levels 
Ventilation  seemed  to  occur  effectively  and  tiie  patient  was  successfull>  liberated  from 
mechamcal  \entilauon  m  less  than  two  weeks     This  is  a  6  mos  old  with  Epsteins  Anomaly 
s/p  ECMO  as  bndge  to  heart  transplant.  Post  transplantation,  weamng  this  patient  from 
mechamcal  ventilation  became  difficult  Most  methods  of  weamng  this  patient  were  attempted 
and  failed  Despite  many  mampulations  in  all  parameters  and  sensitivity,  this  patient  had 
difficulty  tnggering  the  ventilator  Airway  Pressure  Release  Ventilation  was  used  m  this 
situauon  to  foster  this  patient's  ability  to  spontaneously  breathe  This  patient  became 
successful  m  her  abiUty  to  spontaneously  breathe  m  APRV 


srMv 


300       APRV 


RR=14/mm 


RR=l6/min 


Ti=0  8 


Peak=40cmH,0       PEEP=7cmH;0        FiOj=  30 


25cmH:0      P™,=7  cmH:0 


FiO-  30 


Cooclusion:  In  these  patients  it  seems  Uiat  Airway  Pressure  Release  Ventilation  v 
effective  alternative  to  comentional  mechanical  ventilation 


Respiratory  Care  •  October  "98  Vol  43  No  10 


845 


Sunday,  November  8,  2:00-3:55  pm  (Room  214E) 


THE  EFFECT  OF  PASSIVE  TOBACCO  SMOKE  ON  PULMONARY 
FUNCTION  IN  SECOND  GRADE  STUDENTS.  Crystal  L.  Dunlew.  EdD. 
RRT.  Georgia  State  University.  Atlanta.  GA. 

Introduction:  Children  exposed  to  environmental  tobacco  smoke  have 
been  shown  to  have  increased  rates  of  upper  and  lower  respiratory 
infections  and  middle  ear  infections,  as  well  as  diminished  pulmonary 
function  values.  It  is  unclear  at  what  age  the  pulmonary  function  declines 
begin  to  be  significant.  The  purpose  of  this  study  was  to  compare  forced 
vital  capacities  (FVC)  and  forced  expiratory  flowrates  at  1  second  (FEV-1) 
of  second  graders  who  were  exposed  to  passive  tobacco  smoke  in  their 
home,  with  second  graders  who  were  not  exposed  to  environmental  tobacco 
smoke.  Materials  &  Methods:  98  second-grade  students  from  an  urban 
elementary  school  comprised  the  study  population.  Students  were  asked 
whether  or  not  anyone  living  in  their  house  smoked.  Subjects  performed 
FVC  with  appropriate  coaching,  using  the  Foster  handheld  spirometer. 
Highest  FVC  and  FEV-1  was  recorded.  FEV-1 /FVC  values  were  calculated. 
Pulmonary  function  results  of  subjects  from  the  two  groups  were  compared, 
using  a  two-tailed  Mest  for  independent  groups,  p  <  0.05  was  considered  to 
be  statistically  significant.  Descriptive  data  was  also  reported.  Results:  55 
subjects  were  female  (56%);  43  subjects  were  male  (44%).  Mean  age  was 
7.46  years.  28  (29%)  students  reported  that  someone  who  lived  in  their 
house  smoked  cigarettes.  When  the  groups  were  compared,  FEV-1,  FVC, 
and  FEV-1/FVC  were  all  significantly  reduced  (p  0.024;  0.022;  0.012. 
respectively)  in  the  passive  smoking  group.  Conclusion:  This  study 
suggests  an  adverse  effect  on  lung  function  among  7-8  year  old  children 
who  are  exposed  to  environmental  tobacco  smoke.  The  effects  of  these 
deficits  on  future  lung  function  is  not  known,  but  is  likely  to  be  important. 


THE  USE  OF  THE  SECHRIST  BREATH  TRACKER  AS  AN  AUXILIARY 
AUDIBLE  VENTILATOR  MONITOR  FOR  NEONATAL  TRANSPORT. 

Ryan  Qmeber,  BHS.  RRT  University  Hospital  and  CUnics,  Columbia  Missouri 

The  transport  of  premature  and  sick  neonates  frequently  requires  mechanical 
ventilation    One  of  the  mainstay  neonatal  transport  ventilators  is  the  MVP  -  10 
ventilator  from  the  BIO  -  MED  DEVICES  Corporation    This  has  been  a 
workhorse  ventilator  for  the  last  twenty  years  in  the  neonatal  and  pediatric 
populations    One  of  this  ventilators  main  attributes  is  its  continuous  flow  feature. 
This  is  especially  usefiil  for  newborns  and  small  pediatric  patients    The  main 
drawback  of  this  ventilator  is  its  lack  of  built  in  alarms  Neonatal  transport  is 
many  times  carried  out  in  very  cramped  quarters  and  air  transport  by  helicopter 
can  be  an  especially  constraining  environment    Many  times  Neonatal  transport 
isolettes  have  the  MVP  -  10  transport  ventilator  built  into  the  isolette  housing 
This  is  a  common  setup  as  with  the  Airborne  Neonatal  Transport  Isolette, 
making  for  a  complete  package    This  is  also  good  for  safety,  in  the  case  of  a 
crash  all  equipment  is  firmly  secured  to  the  isolette    One  major  drawback  to  this 
setup  is  that  many  times  the  pressure  manometer  of  the  transport  ventilator  is 
obscured  by  the  presence  of  the  caregivers  legs    It  is  common  to  have  caregivers 
sitting  right  next  to  the  transport  isolette    This  is  especially  true  when 
ttansporting  in  a  helicopter    Another  problem  is  that  even  with  the  optional  low 
pressure  alarm  in  line,  caregivers  cannot  hear  this  alarm  over  the  noise  of  the 
helicopter  The  BIO  -  MED  DEVICES  Corporation  now  offers  an  auxiliary  low 
pressure  alarm  for  this  ventilator    Unfortunately  this  unit  does  not  solve  the 
problem  of  visual  interference  and  the  inability  to  hear  ventilator  disconnect 
One  solution  this  facility  came  up  with,  was  to  mount  a  Sechrist  Breath  Tracker 
Ventilator  Monitor  on  to  the  top  of  the  neonatal  transport  isolette    A  line  fi^om 
the  pressure  port  of  the  Breath  Tracker  is  put  in  Ime  with  the  proximal  pressure 
line  of  the  MVP  -  10    The  Breath  Tracker  is  a  small  hand  held  electronic 
pressure  manometer  powered  by  two  9  volt  batteries    This  monitor  also  has 
audible  indicators  of  achieving  set  peak  inspiratory  pressure,  loss  of  PEEP. 
respiratory  rate  or  inspiratory  time    Additionally  this  monitor  features  a  radio 
type  ear  jack  that  allows  for  an  earplug  to  be  attached  to  it    By  mounting  it  high 
on  the  isolette  it  gives  the  caregivers  a  readily  visible  indicator  of  venrilation  or 
disconnection  It  also  gives  the  transport  crew  a  way  of  hearing  the  audible 
indications  of  ventilation  and  presence  of  PEEP,  while  wearing  helicopter 
headphones    This  set  up  has  given  the  neonatal  transport  team  additional 
capabilities  of  ventilation  monitoring  for  the  last  six  years  without  any  adverse 
incidents. 


OF-98-116 


CASE  STUDY  EVALUATING  A  NEONATAL  RESPIRATORY  MONITOR: 
VOLUMETRIC  EXHALED  CARBON  DIOXIDE  (VC02}  MONITORING  OF  A 
PREMATURE  RECEIVING  SURFACTANT  John  Emberger  BS  RRT.  Mike  Western 
RRT  PPS.  Sean  Motoyoshi  RRT.  Dave  Lapham  BS  RRT,  Robert  Locke  DO, 
Departments  of  Respiratory  Care  and  Neonatology,  Chnstiana  Care  Health  System, 
Newark,  Delaware 

Background:  The  Novametrix  COSMO  Plus  Respiratory  Monitor  (Novametnx 
Medical  Systems,  Wallingford  CT)  previously  used  in  adults,  now  has  neonatal 
capabilities  The  capabilities  include  ventilation  mechanics,  ETC02,  and  Volumetric 
C02  monitonng  {VC02  -  C02  volume/breath  or  002  production)  We  want  to 
investigate  the  correlation  of  VC02  to  respiratory  effort  in  premature  infants  Case 
Summary:  A  29  week  gestation  premature  infant  required  mechanical  ventilation  at 
birth  (IMV  mode,  PIP  =  25  cmH20.  PEEP  =  5  cmH20,  rate  =  30  breaths/minute) 
The  COSMO  Plus  Monitor  was  started  with  mechanical  ventilation  Physicians 
determined  that  surfactant  replacement  was  required  The  graphic  shown  here 
represents  the  trend  of  the  VC02  and  the  ETC02  dunng  the  period  before  and  after 
surfactant  was  given  {Note  the  arrow  where  surfactant  was  given)  The  ETC02  was 
noted  to  correlate  with  the  ABG  {ETC02  was  1-3  torr  below  PaC02)  both  before 
and  after  surfactant  was  given  The  premature  infant  was  noted  to  have  Increased 
respiratory  effort  (paradoxic  breathing  pattern  with  intercostal  and  subcostal 


retractions)  After  the  surfactant  was  given,  the  retractions  subsided  and  the  patient 
appeared  comfortable  on  the  current  ventilator  settings  Discussion:  The  premature 
infant  had  increased  respiratory  effort  against  the  low  compliance  of  the  lungs  After 
surfactant  was  given  respiratory  effort  appeared  to  dramatically  decrease  The 
COSMO  Plus  showed  a  dramatic  decrease  in  VC02  which  we  believe  correlated  to 
a  dramatic  reduction  in  respiratory  effort  as  the  surfactant  increased  lung 
compliance  Future  studies  of  many  prematures  may  reveal  if  monitonng  VC02  is  of 
value  in  trending  work  of  breathing  in  correlation  to  weaning  prematures  from  the 
ventilator 


COMPARISON  OF  FOUR  NEBULIZER-PATIENT  INTERFACES  IN  A  PEDIATRIC 
LUNG  MODEL.  Bob  Dickerson.  MS  HCA.  RRT.  Children's  Hospitals  and  Clinics. 
Minneapolis.  Minnesota.  Nick  Delich.  SRT.  Gary  Sakomoio,  SRT.  St  Paul  Technical 
College.  St.  Paul.  Minnesota. 

Background:  The  recommended  patient  nebulizer  interface  for  infants  is  a  face  mask 
Many  infants  do  not  tolerate  the  use  efface  masks  and  cry  throughout  nebulizer 
u-eatmenls.  Lung  deposition  of  aerosolized  drugs  is  known  to  decrease  significantly  with 
crying  Current  literature  does  not  recommend  alternative  interfaces  when  a  face  mask  is 
not  tolerated  The  purpose  of  this  study  was  to  compare  two  alternative  interfaces, 
currently  used  in  clinical  practice,  with  an  aerosol  face  mask.  The  alternatives  are  blow-by. 
aerosol  is  directed  into  the  patient's  face  using  an  elbow  adapter,  and  a  head-box.  aerosol 
is  directed  into  a  head  box  placed  over  the  infant's  head.  Methods:  An  infant  lung  model 
was  constructed  using  an  infant  CPR  mannequin  and  a  double  sided  test  lung  with  a  lift 
bar.  driven  by  an  LP-6  ventilator  (Aequitron  Medical  Inc.)  at  a  rate  of  30  and  inspiratory 
time  of  0.6  seconds.  Aerosol  concentration  was  measured  using  an  APS  (Aerodynamic 
Panicle  Sizer)  Model  3320  (TSI  Inc.).  The  mannequin  head  was  connected  to  a  "T" 
adapter  with  a  10  cm  section  of  5  mm  tubing.  One  branch  of  the  "T"  was  connected  to  the 
open  side  of  the  test  lung.  The  other  branch  of  the  "T"  was  connected  to  the  sampling  port 
of  the  APS  3320.  Tidal  volume  was  adjusted  to  achieve  50  ml,  measured  with  a  Wright's 
respirometer  at  the  "T"  Six  nebulizers  of  the  same  brand  were  filled  with  0.5  ml  of 
albuterol  and  3  ml  of  normal  saline  and  powered  by  8  Lpm  of  oxygen,  Four  interface 
configurations  were  tested:  aerosol  face  mask,  blow-by  2  cm  from  the  face,  blow-by  4  cm 
from  the  face  and  a  1 0  inch  collapsible  head  box.  All  nebulizers  were  tested  in  each 
configuration.  The  face  mask  and  blow-by  trials  ra 
for  2  minutes  prior  to  sampling.  Results:  The 
graph  shows  the  mean  concentration  of  aerosol 
particles  in  the  1  to  5  micron  range,  for  each 
interface.  The  aerosol  mask  yielded  the  highest 
concentration.  Concentration  for  blow  by  at 
2  cm  was  not  significantly  lower  than  the  aerosol 
mask.  Blow-by  at  4  cm  delivered  significantly 
less  than  the  mask  (p<0  05),  The  head-box 
delivered  a  significantly  lower  concentration  "^        "^        *^ 

than  both  the  mask  and  blow  by  at  2  cm(p<0,01)      -^'^^I'^^lt*^*  k^faiaw^Ji^ix 
(Mann  Whitney  Rank  Sum  Test).  Conclusions:  The  results  support  the  use  of  aerosol  fact 
masks  as  the  recommended  interface  for  infants.  Blow-by  held  close  to  the  face  (2  cm) 
should  be  considered  for  infants  who  do  not  tolerate  the  use  of  a  face  mask,  if  it  will 
prevent  crying  and  the  distance  fi-om  the  face  can  be  maintained.  Differences  in  clinical 
effect  remain  to  be  determined, 


OF-98-141 


1  for  30  seconds  and  the  head  box  ran 
ConoentTBtion  of  Partides  ItoSUcjons 


846 


Ri;,si>iRAT()R'i-  Cari-;  •  Octobhr  "98  Vol  43  No  10 


A  new  tool  for  subacute  care 


Uniform 
Reporting  Mannal 


FDR    subacute:    care: 


It's  a  new  tool  that  helps  you... 

►  Determine  productivity 

►  Promote  standardization  of  care 


►  Benchmark  and  track  trends 

►  Match  resources  and  demand 


Prospective  payment  systems  in  post-acute 
possess  the  tools  to  identify  the  resources 
services. The  Uniform  Reporting  Manual 
for  Subacute  Care  is  that  tool. 

The  Uniform  Reporting  Manual  for  Subacute  Care  is  a 
tool  to  determine  productivity,  track  trends  in  the 
utilization  of  respiratory  care  services,  assist  in  determining 
personnel  requirements,  and  measure  demand  for  and 
intensity  of  services. 

The  Uniform  Reporting  Manual  for  Subacute  Care 
includes  time  standards  for  126  activities  in  Resident 
Assessments  and  Documentation,  Airway  Care,  Breathing 
and  Adjunctive  Devices,  Mechanical  Ventilation,  Bronchial 
Hygiene,  Diagnostic  Tests  and  Resident  Monitoring, 
Supplemental  Oxygen  and  Continuous  Aerosol  Therapy, 
Resident  Care,  Support,  Equipment  and  Supplies, 
Management  and  Supervisory  Skills.  There  are  also 
sections  on  Clinical  Activities  without  Time  Standards, 
Non-Allocated  Hours,  and  an  Appendix  with  worksheets  to 
compute  your  own  workload  hours. 

Binder,  122  Pages,  1998. 


care  require  that  respiratory  care  managers 
for  efficient  administration  of  respiratory  care 


□  RUSH  ME  MY  COPY  oftk 
Uniform  Reporting  Manual  for  Subacute  Care 

(Item  BK2A) 
$75  forAARC  Members,  $  I  15  for  Nonmembers 

(add  $8  for  Shipping  and  Handling) 

Name 

AARC  Member  No.  

Institution   

Address  

City 


State 


Zip 


f]  Payment  Enclosed  LI  Charge  to  my  Purchase  Order  No. 
Please  Charge  to  my:  _  MasterCard  LJ  Visa 

Card  Number Expiration  Date 

Signature 

(required  for  Purchase  Order  and  Credit  Card) 

American  Association  for  Respiratory  Care 

Order  Department 

I  1 030  Abies  Lane 

Dallas.TX  75229-4593 

Call  (972)  243-2272  •  Fax  (972)  484-2720 


Sunday.  November  8,  2:00-3:55  pm  (Room  215E) 


TEACHING  ASTHMA  GUTOELINES  TO  RESPmATORY  CARE 

STUDENTS-  I.i-;anavisBSRRT.  J  S  Hata  MD,  Frederick  R  Bode  MD, 

University  of  Missouri.  Columbia,  Missouri 

BACKGROUND:  In  1997.  The  National  Asthma  Education  and 
Prevention  Program  (NAEP)  published  their  revised  guidelines 
identifying  asthma  as  an  inflammatory'  and  bronchospastic  disease. 
Patient  education,  pulmonary  function  testing,  and  proper  administration 
of  inhaled  corticosteriods  and  bronchodilators  are  important  respiratory 
care  practices.  We  decided  to  look  at  our  success  in  teaching  the 
guidelines  to  respiratory  care  students  in  their  second  year  of  formal 
training.  METHODS:  We  used  a  10-question  pretest,  distribution  of 
guideline  summar>',  30  minute  lecture,  and  10-question  post  test  format 
with  16  second  year  students.  The  entire  project  was  designed  for  only 
one  hour  of  classroom  time.  Total  study  costs  were  under  $50.00. 
RESULTS:  The  average  pretest  score  was  63.6  ±  15.5%.  The  average 
post  test  score  was  98.6  ±  3.6%.  (P-value  <  0.001  by  Wilcoxon  signed 
rank  test.)  One  hundred  percent  of  the  students  judged  the  exercise 
worthwhile.  CONCLUSION:  Our  results  provided  objective  data  of 
improved  scores  after  a  short  exposure  (one  hoiu-)  to  the  material.  This 
format:  pretest/lecture  with  handout/post  test,  has  modest  time  and 
material  expense  and  should  be  readily  applicable  to  most  teaching 
environments.  Teaching  the  new  asthma  guidelines  to  students  and 
respiratory  care  practitioners  would  appear  to  be  beneficial  with  the 
expanding  number  of  asthma  patients  in  this  country.  With  our 
knowledge  explosion  and  with  the  challenges  of  what  to  teach,  time 
available,  and  expenses,  methods  like  these  are  easily  within  the  reach  of 
most  educators  and  curriculum  designers. 


OF-98-009 


JMPACT  OF  A  PULMONAHY  REHABILITATION  PROGRAM  ON  FUNCTIONAL 
CAPACITY,  QUALITY  OF  LIFE.  PERCEPTION  OF  DYSPNEA  AND  HEALTHCARE 
LTTILIZATION     Grelchen  Horetman,  RRT.  RCP.  Paul  Tsivitso,  MD.  Department  0l 
Pulmonary  Rehabilitation.  Marymount  Hospital,  Gartietd  Heights,  OH 

Background:    Pulmonary  Rehab  has  been  shown  to  improve  exercise  capacity, 
desensitize  participants  to  dyspnea  and  improve  quality  of  life  in  individuals  with  chronic 
lung  disease  The  purpose  ol  this  study  was  to  evaluate  the  eftect  of  a  Pulmonary 
Rehab  Program  on  exercise  capacity,  quality  ot  life  {QOL),  dyspnea  and  health  care 
utilization  We  hypothesized  exercise  capacity  and  OOL  would  increase,  the  perception 
of  the  seventy  ol  dyspnea  and  health  care  utilization  would  decrease  post  completion  ot 
Pulmonary  Rehab  In  order  to  evaluate  the  eftectiveness  of  our  program  we  followed  84 
participants  completing  the  Pulmonary  Rehab  Program  at  f^arymount  Hospital 
Methods  Graduates  exerased  twice  a  week  for  a  total  ol  12  weeks,  and  were  taught 
disease  management  education  by  a  multi*disdplinary  team  of  t>ealthcare  prolessionals 
Participants  had  an  average  FEV1  of  1  2  L  (tSTD  0  46)  We  measured  participants 
exercise  capacity  on  the  treadmill  and  stationary  bike.  Quality  01  Life  (QOL)  using  SF-36 
Health  Survey,  and  Psychological  General  Well  Being  Index  (PGWBI)  Survey  dyspnea 
using  University  of  California  San  Diego  (UCSD)  Shortness  Ot  Breath  (SOB) 
Questionnaire,  pre  and  post  program  We  tracked  51  graduates  (1995/1996)  from  the 
Rehab  Program  for  2  years  (1  yr  pre/ 1  yr  post  program)  Graduates  were  followed 
tracking  hospital  admissions,  LOS,  and  hospital  charges  generated  while  in  Ihe  hospital 
Results:  reported  as  average  improvement  in  the  chart  below 

Mode  Duration/Minute  Intensity  Distanced   Mile 


Treadmill  Walking 

8  06                       0  70  mph 

0  39 

Stationary  Bicycle 

6  66                            8  61rpm 

1  38 

Survey 

Points  Avg.  Pre        Points   Avg. 

N=number   of 

Post 

surveys 

completed/retur 

ed 

n  =  21 

SF  -36  Health  Survey 

87  40                           102  19 

PGWBI  Survey 

63  29                              77  78 

n  =  41 

UCSD  SOB  Survey 

59  09                            48  21 

n  =  34 

Graduates 

Hosp.            Hosp.   Days         LOS 

Hosp.    Charges 

1995/1996 

Admits 

1  yr  pre  Rehab 

32                        199                  7  37 

$274,383 

1  yr  post  Rehab 

18                         99                    3  67 

$145,352 

Differences 

(43%                       (50%                  (50% 

$129,031 

Conclusion:   Our  muitidisciplinary  Pulmonary  Rehabilitation  is  ettective  in  signiticantly 
improving  the  exercise  capacity  in  patients  with  severe  CQPO.  improves  their 
perception  of  the  impact  of  dyspnea  on  their  activities  of  daily  living,  and  improves  OOL 
Our  Program  reduced  hospital  admissions,  shortened  LOS,  and  reduced  health  care 
utilization  in  patients  with  severe  COPD 


KACTOR.S  INFLUENCING  ATTRITION  AND  RETENTION  OF  STUDENTS 
[N  KESPIRATORX  THERAPY  PROGRAMS  by  Larry  Arnson,  Ph.D., 
R.R.T.  Gwinnett  Technical  Institution,  Lawrencoville, 
Georgia  30043 

PROBLEM  Far  too  many  students  fail  to  complete  the 
respiratory  therapy  program.  Attrition  rates  for 
respiratory  therapy  programs  are  higher  than  any  other 
allied  health  program.  However,  a  paucity  of 
information  exists  on  attrition  and  retention  of 
students  in  allied  health  education  programs,  and  no 
studies  have   been  conducted  in  respiratory  programs. 
METHODOLOGY  Using  Tinto's  (1975)  model  of  student 
attrition,  the  Student  Involvement  Questionnaire 
Respiratory  was  sent  to  respiratory  therapists  that 
were  enrolled  in  a  program  of  study  at  two-year 
technical  institutions  in  the  spring  of  1997.  Two 
quarters  later  these  participants  were  identified  as 
persisters  or  nonpersisters .  Supportive  data  were  also 
gathered  from  persisters  and  nonpersisters  of 
respiratory  therapy  programs  throughout  the  state  of 
Georgia  from  technical  institutions,  two-year  colleges, 
and  four-year  universities.  Follow-up  interviews  were 
also  conducted  on  first-year  and  second-year 
respiratory  therapy  students  throughout  the  state. 
RESULTS  There  was  no  significance  to  the  variable  of 
academic  and  social  integration,  goal  and  institutional 
commitment,  and  support  and  encouragement  of  others  and 
persistence  in  a  respiratory  therapy  program.  Follow-up 
interviews  revealed  a  lacl^  of  perceived  support  from 
respiratory  therapy  program  faculty  and  staff. 
CONCLUSIONS  These  results  may  be  helpful  to  otlier 
respiratory  therapy  programs  and  institutions  of  higher 
education  concerned  about  attrition/retention.  Further 
exploration  in  other  institutions  and  other  health 
programs  would  add  to  the  wider  body  of  knowledge  of 
student  persistence  and  withdrawal  behavior. 


OF-98-035 


CURRENT  STATUS  OF  CLINICAL  TEACHING  ROLES  AND 
COMPENSATION  IN  RESPIRATORY  CARE  EDUCATION 
PROGRAMS  Karia  Solesbee  BSRT,  Tinn  Op't  Holt.  Ed  D,  R  R  T 
Cardiotespiratory  Care,  University  of  South  Alabama,  Mobile,  AL 

Background:  Cutbacks  and  downsizing  in  the  health  care  industry 
may  ettect  who  is  responsible  for  the  clinical  education  of  respiratory 
therapy  students    In  recent  years,  respiratory  care  service 
departments  have  been  told  to  do  more  with  less,  subsequently 
clinical  education  may  be  one  ot  the  first  cutbacks  We  engaged  in  a 
mail  survey  of  respiratory  therapy  programs  throughout  the  United 
States    The  obiectives  were  to  determine  the  nature  of  clinical 
respiratory  care  education  if  hospital  respiratory  staff  instruct  or  if 
others  are  brought  in  from  outside  the  regular  staff  to  instruct 
respiratory  therapy  students  in  the  clinical  setting  and  how  schools 
compensate  their  clinical  instructors  Methods:  A  7  item 
questionnaire  was  developed  and  mailed  fo  125  respiratory  therapy 
programs  systematically  sampled  from  the  directory  of  the  Joint 
Review  Committee  foi  Respiratory  Therapy  Education  The 
questionnaire  asked  respiratory  therapy  program  directors  to 
delineate  their  clinical  instructors  by  compensation,  the  nature  of 
clinical  instruction,  and  the  rewards  for  clinical  instruction    Descnptive 
statistics  were  used  fo  descnbe  the  results  Results;  Sixty-eight 
percent  (n=  85)  of  the  respiratory  therapy  education  program  directors 
responded  to  the  questionnaire  59%  ot  programs  had  volunteer 
instructors  Non-volunteers  were  comprised  of  hospital  staff  and 
external  individuals  22°o  (highest  plurality)  of  paid  clinical  instructors 
received  $17  22/hr  for  instruction  The  benefits  provided  to  respiratory 
staff  and  clinical  instructors  included  clinical  faculty  appointments 
(26%),  library  access  (20%),  inservice  education  (19° o),  and 
computer  access  (18%)  Paid  clinical  instructors  provided 
supervision,  demonstrations,  check-offs,  assessments,  grades,  role 
modeling,  and  liaison  services  Nonpaid  instructors  provided  the 
same  services,  though  less  frequently  Conclusions:  Substantial 
clinical  instruction  is  provided  by  volunteers  However,  this  number  is 
decreasing  compared  with  previous  studies  The  respiratory  care 
program  is  increasingly  required  to  provide  clinical  instructor  support 
Various  non-monetary  compensation  is  afforded  fo  voluntary  clinical 
instructors  In  Ihe  future,  programs  may  need  to  budget  to  a  greater 
extent  to  provide  for  clinical  instruction 


848 


Ri  si'ik AioRt  C  \K\  •OcToHik  "yS  Vol.  4.^  No  10 


a'^'i 


P>W'>^ 


■rm...      •: 


'.^ 


rsir.  j~^ 


Quality    Respiratory    Care 

MISSION:  POSSIBLE 


Highlights  of  the  44th  International  Respiratory  Congress. 

November  7-10, 1998 
Georgia  World  Congress  Center  •  Atlanta,  Georgia  USA 

Events/Activities/Opportunities  planned  for  the  Congress!  How  much  can  you  squeeze  in,  in  4  days? 
Over  99  CRCE  credit  hours  are  available.  More  than  60  programs/lectures  to  choose  from. 


Postgraduate  courses  on  the  day  before  the 

Congress  begins 
'  Keynote  Address  by  famous  Olympian  Jackie 

Joyner-Kersee 

'  Egan  Lecture  on  the  latest  in  ARDS 
'  New  Horizons  Symposium™  on  ethical  issues 
I  Kittredge  Memorial  Lecture  by  Forrest  Bird 

>  More  than  220  speakers  discussing  all  areas  of 
respiratory  care 

'  Nine  symposia  presenting  original  scientific  studies 
in  respiratory  care 
'  Respiratory  physiology  course 

►  The  latest  in  drugs,  medications,  and  delivery 
devices 


•  Special  symposium  on  the  latest  in  asthma 
management 

•  How  to  get  reimbursed  properly  for  services 
provided 

•  Everything  you  ever  wanted  to  know  about 
ventilators  and  ventilatory  techniques 

•  Special  exhibit  on  the  history  of  credentialing 

•  Exhibits  by  all  the  manufacturers  of  respiratory 
care  equipment  and  supplies 

•  Tutorial  sessions 

•  Continuing  Education  Credit  (CRCE)  for  all 
educational  programs 


...  and  much  more.  Keep  up  with  the  latest  information  on  the  44th  International  Respiratory 


American  Association  for  Respiratory  Care 


Sunday,  November  8,  2:00-3:55  pm  (Room  2I5E) 


THE  AFFEC  IS  OF  GRADE.  RACE  AND  TYPE  OF  SCHOOL  ATTENDED-  ON  THE 

SMOKING  HAIJITS  AMONG  FEMALE  STUDENTS, 
by  Rhonda  Bcms.  MS.  RR  I.  Macon  Stale  College.  Macon  Gcor&ia 
Today,  women  are  smoking  more  than  men.  lhe>  are  smoking  longer,  and  they  are  the 
fastest  growing  populauon  of  health  problems  as  a  result  of  smokmg     Little  research  has 
been  done  to  e\'aluatc  smoking  patterns  by  race  Thus,  race,  grade  and  type  of  school 
attended  wert  ke\  vanables  in  this  rx^ajcb  It  suneycd  the  altitudes  and  behanors 
conceramg  smoking  among  females  of  jumor  high  school  and  high  school  age  This  study 
was  looked  at  the  reasons  why  so  many  adolescent  women  conlinue  to  mitiate  smoking 
A  questionnaire  was  admmistered  by  teachers  m  three  schools-  a  count>'  public  middle 
school  and  high  school  and  a  pnvate  middle  and  high  school     Students  dctermmed  which 
pattern  of  cigarctle  smokmg  they  fit.  and  answered  questions  conceramg  then"  opinions  and 
bebefs  about  sTnokmg    They  were  asked  quesUons  about  why  they  started,  why  they  didn't 
start.  wh>  ihe\  stopped,  and  ijf  they  had  tncd  to  stop  smoking  and  were  unable,  why  lhe\ 
couldn't  stop 

Cirade  and  the  type  of  school  attended  was  not  predictive  of  reasons  young  female  students 
mitialed  smokmg.  Most  female  adolescents  imtialed  s-mokmg  because  of  fnends  who  smoke. 
Large  numbers  of  adolescents  m  both  age  groups  obtamed  then-  mitial  cigarette  from  friends 
who  smoked. 

Race  was  predictive  of  reasons  young  female  students  mitiated  smokmg,  A  higher 
percenUge  of  African- American  female  students  were  mfluenced  by  smoking  famUy 
members  than  other  races.  Although  less  African-Amencan  students  smoked,  they  were  not 
as  likely  to  obtain  cigarettes  from  close  or  ca.sual  fnends  as  were  the  white  students 
Grade,  race  or  thet>peof  school  attended  was  not  predictive  of  reasons  young  female 
students  stop  sTnokmg    Although  little  research  has  been  done  on  the  Afncan-Amencan 
female  adolescent  who  smoked,  they  indicated  they  stopped  smoking  for  the  same  reasons  as 
the  white  adolescent  females    The  same  reasons  for  smokmg  cessation  was  found  al  both 
t\-pes  of  schools 

Young  female  students  mitialed  smokmg  because  of  smokmg  friends.  Ihis  is  substantiated 
by  the  fact  that  most  adolescent  female  students  oblamed  their  first  cigarette  from  friends. 
Young  female  students  attempt  smokmg  cessation  because  of  the  health  effects  on 
themselves. 

Students  in  this  study  were  concerned  about  the  current  and  future  effects  of  smoking  on 
themselves  Perhaps  this  will  be  a  key  tor  smokmg  cessation  programs    The  fact  that  health 
hazards  caused  by  smokmg  may  prevent  accompUshmenls  m  the  field  of  athletics  or  sports 
may  be  a  strong  reason  for  smokmg  cessation  program  development  using  adolescent  health 
as  a  key  point. 


PRKOIflUKS  OF  GRADUATE  PERFORMANCE  ON  SELECTED  RESPIRATORY 
CARE  PROGRAM  OUTCOME  MEASURES:   THE  RESULTS  OF  A  PILOT  STUDY. 
Terry  S.  LeGraod,  PbD.  RRT  and  David  C.  Shelledy,  PhD.  RRT,  The  University  of 
Texas  Health  Science  Center  at  San  Antonio,  San  Antonio,  T\. 

Respiratory  care  (RC)  programs  seek  to  prepare  competent  practitioners.   Success  in 
achieving  this  goal  is  often  assessed  by  outcome  measures  including  NBRC 
examinations,  employers"  evaluations  of  graduates  and  graduates'  evaluations  of  the 
program.   OBJECTIVE:   We  sought  to  determine  the  ability  of  students'  entering  GPA 
(EGPA),  program  prerequisite  GPA  (PGPA),  pre-admission  interview  score  {[), 
general  critical  thinking  ability  (CT)  as  as.sessed  by  the  Watson- Glaser,  end-of-first-year 
competency  exam  (FYEX).  in-program  GPA  (RCGPA)  and  performance  on  an  NBRC 
written  registry  self- assessment  exam  (WRRTSAE)  to  predict  graduate  outcomes. 
METHOD:   Easting  records  of  all  graduates  {n=20)  of  a  new  baccalaureate  RC 
program  were  reviewed  to  obtain  the  scores  for  specific  predictor  variables.  Outcome 
measures  obtained  were  NBRC  CRTT  scores,  end-of-program  competency  assessment 
results  utilizing  a  restricted  version  of  the  NBRC  written  registry  exam  (WRTT)  and 
information  gathering  (IG)  and  decision  making  (DM)  scores  on  a  clinical  simulation 
exam  given  near  program  completion.   Graduates  and  employers  were  surveyed  to 
assess  achievement  of  cognitive  (CS),  psychomotor  (PS)  and  affective  (AS)  program 
standards.    Pearson  product-moment  correlations  and  forward  step-wise  regression 
analyses  were  performed  to  determine  the  ability  of  the  independent  variables  to 
predict  specific  outcomes.   RESULTS:   CRTT  exam  scores  were  significantly  correlated 
with  EGPA  (r=0.54.  p<0.05).  PGPA  {r=0.65.  p<0.01),  CT  (r=0,63.  p<0.01)  and 
FYEX  (r=0.66,  p<0.01).   WRRT  scores  were  significantly  correlated  with  EGPA 
(r=0.49.  p<0.05),  PGPA  (r=0.61.  p<0.01)  and  WRRTSAE  {r=0.48,  p<0.05).   DM 
was  significantly  correlated  with  I  (r=0.49.  p<a05).  FYEX  (r=0.62,  p<0.01)  and 
RCGPA  (r=0.47,  p<0.01).   Graduate  evaluations  for  CS  (r=0.61,  p<0.01).  PS  (r=:0.54, 
p<0.05)  and  AS  (r=0.60.  p<0,01)  were  significantly  correlated  with  FYEX.   The 
coefficient  of  multiple  correlation,  R",  indicated  that  in  combination,  the  independent 
variables  accounted  for  77%  of  the  variance  observed  in  CRTT  scores,  61%  of  the 
variance  in  the  WRRT,  and  78%  of  the  variance  in  DM.    For  graduates'  evaluations, 
38%  of  the  vanance  in  CS.  29%  of  the  variance  in  PS.  and  50%  of  the  variance  in  AS 
was  explained.   For  employers'  evaluations  of  graduates,  60%  of  the  variance  in  AS 
was  explained.   The  strongest  predictors  of  outcome  variables,  based  on  regression 
analysis,  were  I.  EGPA.  PGPA,  FYEX  and  WRRTSAE.   There  was  no  relationship 
between  predictor  variables  and  IG  scores  or  employer  evaluations  for  CS  and  PS. 
CONCLUSION;   Applicant  interview  scores,  EGPA,  PGPA.  CT,  FYEX  and 
WRRTSAE  may  be  useful  in  predicting  graduate  performance  on  selected  program 
outcome  I 


EFFECTS  OF  PULMONARY  REHABILfTATION  IN  PATIEriTS  WITH  CHRONIC 
BRONCHIAL  ASTHMA 

Tetsuo  Mivaqawa  Ph  D.RRT.RPT.RCET.  Showa  Umversity.  College  ot  Medical 
Sciences,  Dept-  of  Physical  Therapy,  Yokohama.  Japan  Hideko  Kobayashi  MD. 
and  Nono  Kthara  MD.  Dept  of  Pulmonary  Medicine.  Kihara  Hospital.  Tokyo,  Japan 

Introduction:  Pulmonary  retiabilrtalion  have  l^een  sttown  to  reduce  dyspnea, 
increase  exercise  capacrty,  reduce  hospitalization,  and  improve  quaJrty  of  life  in 
patients  wrth  COPD  However,  previous  studies  have  been  relatively  lew   about 
the  effect  ol  pulmonary  rehabtlrtation  in  patients  wrth  chronic  bronchial  asthma  The 
purpose  of  our  study  was  to  evaluate  the  effect  of  pulmonary  rehatxiitation 
Molhods:  Seventeen  patients  with  chronic  bronchial  asthma  were  entered  tn  this 
study  All  patients  were  very  stable  clinical  course  but  not  at)le  to  reach  personal 
best  peak  flow  in  sprte  of  the  inhaled  cortKxisteroKJs  or  beta-adrenergic 
brochoditators  They  were  treated  the  same  medication  before  and  after  6  weeks 
pulmonary  rehabilitation  program  They  pertormed  1 )  relaxation  techniques  and 
diaphragmatic  breathing  (2  sessions  of  10  minutes  of  training,  daily).  2)  respiratory 
muscle  stretch  gymnastic  (3  sessions  of  5  RMSG  patterns  4  times  each,  daily),  3) 
upper  extremity  training  (5  sessions  of  10  repetitions  o(  arm  elevation  against 
gravrty  wrth  weights,  daily).  4)exercise  trainirrg  (1  session  ol  20  minutes  walking  of 
the  target  speed,  daily)  Before  and  after  data  were  evaluated  wrth  paired  t  tests 
Two  pahents  dropped  out  due  to  predetermined  crrtena 
Results:  Resurts  shown  are  mean  value  and  1  SD  (n=  1 5) 


before 


Plmax(cmHp)  71.7±25.9 

PEmax  (cmHp)  69,2±24,0 

chest  expansion  (cm),  lower  chest  wall    3  7  ±  2.0 

VC(0)  252±058 

FVC(P)  239±0  61 

FEV,„(0)  1  52±0.57 

FEV,^(%)  626±11  9 

MEFR((?/sec)  0  99±0  68 

PFR(0/sec)  4,03±169 

V^(0/sec)  0  40±0  29 

R„(cmHp/0/sec)  6.95  ±1,78 

6^in  walking  distance  f6MDl  fm)         3133 ± 65  0 

('.  P  <  0  05,  **,  P  <  0  01  companng  values  before  and  after  rehabilrtatton  ) 

Almost  all  the  pahents  were  reduced  dyspnea  and  asthma  attack,  and  improved 

HRQL 

ConcluatonrThe  results  suggest  that  pulmonary  rehabilitation  were  effective  lor 

chest  wall  stiffness,  respiratory  muscle  strength,  exercise  lolerarwe  and  HROL  in 

patients  wrth  chronic  bronchial  asthma  Pulmonary  rehabilitation  were  also 

improved  lur>g  volume  but  not  obstruction  of  the  airway 


after_ 
81.6±28.8 
85,2±29,6 
6-2  ±2,0 
2  77±0  71 
2  53  ±0  67 
160±060 
60,4  ±12  7 
1  03±0  79 
4  4911  87 
0  41  ±0,32 
7  23  ±149 
..3487  ±719 


OF-98-101 


CUSTOMIZED  COMPREHENSIVE  PULMONARY  REHABILFTATION 

Penny  Gaqne  Plouff.  RRT 
Respiratory  Rehabilitation  &  Therapy,  PA,,  Portland,  Maine 

Employed  patients  hesitate  to  commrt  to  pulmonary  rehabilitation  programs  offered 
durirKi  normal  business  hours  Respiratory  RehabiHtation  &  Therapy,  PA.  offers  a 
program,  which  is  pnvately  operated  by  a  registered  respiratory  therapist.  The  program 
offers  flexible  scheduling  and  has  a  maximum  patient  to  staff  ratio  of  3: 1  This  low  ratio 
allows  the  program  to  be  customized  to  the  specific  needs  of  each  patient  The  flexibility 
of  the  pnagram  also  allows  class  to  be  rescheduled  due  to  illness  or  weather  The 
program  works  with  both  the  primary  care  physician  and  pulmonologist  for  each  patient. 
Chest  Medicine  Associates  referred  patients  for  pulmonary  rehabilitation  The  patients 
ranged  fn3m  47  to  64  years  of  age  All  were  diagnosed  with  severe  COPD 
Appointments  were  scheduled  twice  a  week  for  twenty-four  sessions.  The  time  frame  to 
complete  the  program  was  variable  between  thirteen  weeks  and  twenty-two  weeks 
Each  two-hour  session  consisted  of  an  educational  topic  and  two  to  three  exercise 
stations  (for  a  minimum  of  thirty  minutes  of  sustained  exercise)  Exercise  stations 
included  chair-based  aerobics,  upper  body  cycle,  respiratory  muscle  training,  treadmill, 
and  recumbent  bike  All  exercise  sessions  were  limrted  based  on  symptoms  of 
shortness  of  breath  (using  the  Rating  of  Perceived  Exertion)  and  target  heart  rate.  Two 
of  the  patients  had  brief  hospitalizations  dunng  the  program  and  resumed  their 
appointments  within  days  of  discharge  One  patient  was  placed  on  supplemental 
oxygen  therapy  during  the  program  and  successfully  weaned  to  room  air  by  completion 
of  the  program  One  patient  started  the  program  as  an  active  smoker  and  successfully 
became  a  nonsmoker  several  weeks  before  graduation  from  the  pnagram  Of  the  five 
patients  who  have  now  completed  the  program,  three  attended  classes  alone  and  two 
attended  together  Figure  1  compares  the  inrtlal  six-minute  walk  study  for  each  patient 
to  the  six-minute  walk  study  at  program  completion  The  average  improvement  was 
97%  over  baseline  distance  Inrtially,  patients  tolerated  an  average  of  thirty  minutes  of 
By  completion  of  the 


program,  the  patients  averaged  fifty- 
five  minutes  of  exercise  per  session 
Three  continue  full-time 
employment,  one  has  resumed  part- 
time  work,  and  the  last  has  been 
been  cleared  from  housebound 
status  by  his  physician  In 
conclusion,  the  patients  made 
excellent  progress  in  a  private  setting 
for  comprehensive  pulmonary 
rehabilitation  They  are  all  cun^entty 
following  a  regular  exercise  regimen  of  at 
least  thirty  minutes  of  exerase  twice  per 
week 


Figure  1  Distances  ambulated 
during  six-minute  walk  study  at 
initial  and  completion  sessions 


850 


Rn.spiRATORY  Care  •  October  '98  Voi,  43  No  10 


Introducing 

BreathLab  PTS. 

The  hardest  working  biomed 
tool  since  the  screwdriver. 


If  you're  waiting  for  a  better 
respiratory  Performance  Test 
System  than  BreathLab"'  PTS,  don't 
hold  your  breath. 

The  heart  of  BreathLab  PTS  is 
the  PTS  2000"^'  tester.  This  advanced 
device  combines  the  functions 
of  ventilator  and  oxygen  test 
systems  into  a  small,  fast,  affordable 
unit  that  measures  not  only 
pressure,  flow  and  volume,  but 
oxygen  concentration  and 
barometric  pressure  as  well. 


You  can  optimize  your  testing 
by  connecting  the  PTS  2000  tester 
to  your  PC  and  using  our 
BreathLab  PTS  ventilator  software 
to  produce  graphic  displays, 
trending  information  and  reports. 

For  more  information  or  to 
arrange  a  demonstration  of 
BreathLab  PTS,  put  down  that 
screwdriver  and  call  your  local 
NPB  sales  or  service  representative, 
**^  67.  Or  visit  our 


BreathLab    ^ 
PTS  2000 

Circle  124  on  reader  service  card 


ritan  Bennett.  All  lights 


!  NELLCOR 
^  PURITAN     • 

1         BENNETT.;-''' 

A  UnitofMallinckrodtlnc. 

;d.  www.nellcorpb.Gora   ^  A-FR?!M-pft;Kev.B 


Monday,  November  9.  9:30-1 1:25  am  (Room  214E) 


HiiiU FRFyiENCV Oscillators  Vkn niv\Ti(>N (HFOV) in  Li  pls Pneimonitis indi ced 
AciTE  Respdutohy  DisTKESs Svndrome  (ARDS).    Barn  Varner.  BS  RRT.  Critical  Care 
Coordinator,  Fan  a/  Akbik  M.D..  South  FuHon  Medical  Center.  East  Point,  Ga. 
Introduction:  There  arc  few  reported  cases  njgardiag  successful  application  of  HI-'OV  in  the 
adult  popuUtioD  Id  this  case  study  uc  describe  how  the  Sensonnedies  3  lOOA  oscillator  was  used 
fur  3  20  year  old.  70  kg  female  with  ARDS  seeondan'  lo  lupus  pneumonitis 
Case  Summary-;  A  21)  \/o  female  was  admitted  \ia  emergency  services  after  a  3  day  history  of 
hemoptysis,  shortness  of  breath,  hematiina.  and  left  pleuritic  chesl  pam,  Chest  radiograph 
revealed  left  pleural  efliision  aad  bibasilar  atelectasis  AIKi's  on  4  L/m:  pi  I  7  42.  PaCO-  29  torr, 
PaO;  8a  torr,  SaO,  y4'*b  The  patient  was  admitted  lo  the  general  medical  floor  with  I  V 
antibiotics  where  she  delenorated  over  the  nc\t  9  hours  ABCi's  ou  a  non-rebreathmg  mask  pi  I 
7  39.  PaCOj  32  torr.  PaO.  48  ton  She  was  subsequently  intubated  and  mechanically  ventilated  m 
the  assistycontrol  (A/C)  mode  ,'q  V,  800  ml.  f  12.  and  FiOj  10  PFFP  was  appbed  at  the  lower 
tnJiection  point  which  increased  from  5  to  1 2  cm  1  l.O  over  36  hours  as  peak  inspu'alon  pressure 
(PIP)  mcrcased  from  35  to  58  em  H,0  ABGs  a  V,  800  ml.  f  22.  FiO,  I  0.  PFFP  12  cm  IFO. 
mean  airway  pressure  {P„)  =  22  em'n.O  pH  7  43.  PaCOj  36  torr.  PaO.  6U  torr  (Oxygenation 
mdc\  (01]  =37.  PaO^TiO.  raUo  =  60)  Chest  radiograph  revealed  compjcte  bilateral 
opacification  HlOV  was  miUated  usmg  the  Sensonnedies  3  lOOA  :S'  5  Hz  ,  T.  45%,  P„  30  cm 
H-O  (mcreased  to  35  cm  H.O  to  achie\e  a  Sp02  >  90%).  amphtude  A  p  55  cm  H;0.  FiO,  1  0 
Chest  radiograph  after  I  hour  revealed  lung  e\-pansion  at  8  5  poslenor  ribs  with  dramatically 
improved  alveolar  recruitment  ABGs  after  2  hours  on  HFOV    pH  7  32.  PaCOj  5 1  torr, 
PaO.  199  tOTT  (01  =15.  PaO.TFiO-  ratio  =  199)  Dopamme  iniusiou  :a  5-12  mcg/kg/min  was 
required  for  maintenance  of  sys-toiic  blood  pressure  in  the  100- 1 20  lorr  range  Propofol  and 
atracununi  mfusions  were  necessary  lo  facilitate  toleration  of  HP' OV  which  was  mamlamed  for  7 
days  ABGs  wctc  within  acc^lable  hmits  and  hemodynamic  status  was  relatively  stable  On  day 
7  the  palieul  developed  subcutaneous  eiuphysema  with  a  small  amount  of  mediastinal  air  on  chesl 
radiograph  I IFOV  settmgs  4  Hz.  T.  49%.  P„  25.  amplitude  A  p  53  cm  HjO.  FiOj  0,6  ABG  s 
pH  7  29,  PaCO.  36  ton.  PaO^  62  loir  (OI  =24.  PaOj/FiO,  ratio  =103).  In  view  of  overall 
miprovemeni  m  chest  radioigraph.  Ol.  and  hemodynamic  status  the  patient  was  transitioned  to 
convcntioual  mechanical  ventUaUon  m  the  /VC  mode  <a  V,  700  nil  (PIP  38  cm  H,0),  f  20.  FiO-, 
0  7.  PFFP  10  cm  H.O.  P^  19  cm  H.O  Chest  radiograph  after  1  hour  revealed  lung  expansion  at 
the  9th  posterior  nb  with  a  notable  decrease  ui  mcdiastmal  air  Subcutaneous  emphysema 
duisipated  sigmficanlly  o^cr  the  ueM  4  hours  Atracunum  and  propofol  infusions  were  ueaned 
and  withdrawn  as  com entional  ventilation  was  mamtamed  over  7  davs  with  lucrementally 
impro\ing  pulmouary  mechanics  Ventilator  mode  was  changed  to  SIMVwith  pressure  support 
on  day  12  Wcaningof  mechanical  ventilation  was  accomplished  successfully  and  the  patient  was 
e\tubaltfd  on  ventilator  day  16  She  was  transferred  to  the  general  medical  floor  on  dav  21  with  O, 
by  nasal  cannula  a  ^  I,/ni.  and  discharged  home  on  dav  27  w  ith  no  fuucliunal  deficit 
Diacusaion:  HFOV  is  yet  to  be  well  eslablished  ui  the  adult  cntical  care  arena,  however, 
depletion  ofconventionai  ventilation  options  mav  perpetuate  lung  injurv  and  consume  valuable 
tmie  Due  to  rapid  detenoration  of  gas  exchange  and  progression  of  puhuonarv  mfiltrates.  gentle 
ventilation  m  the  form  of  HFOV  was  considered  to  be  the  best  option  for  this  pabeni  Literature 
exists  m  the  fotin  of  a  pilot  study  supportmg  the  use  ol  1 D-  O V  for  adult  patients  w  ith  ARDS 
This  case  provides  additional  cttmcal  evidence  in  support  of  pilot  study  data 


PREOrCTING  SUCCESS  WrTH  A  VENTILATOR  SPEAKING  VALVE  Thomas 

R  Nielson  BA,  RRT  Wendy  C  Marshall  MA,  CCC-SLP,  Hospital  for  Special 
Care,  New  Bntain,  CT 

Background  A  ventilator  patient  with  a  cuffed  artificial  airway  in  place  is  at 
nsk  of  Significant  resistance  to  airflow  when  attempting  to  exhale  around  a 
deflated  cuff  Placement  of  an  in-line  speaking  valve  requires  100%  of  the 
exhaled  gas  to  pass  around  the  deflated  tracheotomy  tube  The  literature 
encourages  the  consideration  of  tracheotomy  tube  size  as  a  factor  in 
determining  candidacy  but  we  hypothesized  that  if  more  than  50%  of  the  gas 
exited  through  the  upper  ainway  during  cuff  deflation,  the  patient  would  not 
expenence  significant  increase  m  the  work  of  breathing  when  required  to 
push  100%  of  the  gas  through  the  upper  airway  In  order  to  prevent  undue 
distress  to  the  patient  dunng  an  in-line  valve  tnal  and  to  maintain  cost 
effective  practice  in  issuing  in-line  valves  to  patients  we  chose  to  quantify  the 
gas  exhaled  through  the  upper  airway  versus  through  the  ventilator  circuit 
dunng  cuff  deflation  and  use  that  figure  (percent  leak)  as  a  predictor  of 
success  Method  Seventeen  patients  using  a  variety  of  trach  tube  sizes  from 
6  lo  9  participated  in  the  study  The  method  used  was  spirometric 
measurement  of  exhaled  gas  dunng  full  cuff  deflation  to  be  followed  with 
monitored  tnals  of  placement  of  an  in-line  speaking  valve  Gas  measured  by 
spirometry  was  compared  to  the  set  tidal  volume  of  the  patient  and  percent 
leak  was  calculated  A  protocol  was  established  and  measurements  of 
magnitude  of  leak  as  well  as  patient  perception  of  comforl,  Sp02,  heartrate 
and  quality  and  length  of  sustained  phonatton  were  taken  A  30  minute  trial 
with  an  in-line  valve  in  place  with  no  signs  of  distress  was  considered  to  be 
successful  Results  There  was  significant  difference  (p<  03)  between  the 
percent  leak  through  the  upper  ainA^ay  dunng  the  initial  cuff  deflation  trial 
among  those  who  were  eventually  successful  dunng  speaking  valve  tnal 
(mean=69%)  and  those  who  failed  the  speaking  valve  trial  (mean-41%) 
There  was  no  significant  correlation  between  the  magnitude  of  leak  observed 
during  cuff  deflation  and  the  size  of  the  tracheotomy  lube  Conclusion  Our 
facility  has  elected  lo  designate  50%  leak  through  the  upper  airway  as  the 
lower  limit  m  selecting  a  patient  for  an  in-line  trial  Predicting  success  in 
placement  of  a  one-way  speaking  valve  in  a  ventilator  dependent  patient 
using  an  easily  obtainable  airflow  indicator  is  a  useful  and  inexpensive 
patient  assessment  tool 


OF-98-051 


TIDAL  VOLUME,  ALrrOPLEP  AND  INSPIRATORY  TIML  RESPONSE  OF 
BILEVHL  PRESSURE  VENTILATORS  (BPV)  TO  A  RANGE  OF 
IMPEDANCE  CONDITIONS.  Pete  Bliss  BME.  Robert  McCoy  RRT. 
Alexander  Adams  RRT.  Regions  Hospital.  St.  Paul,  MN. 
Background:  Nonnuasivc  ventilation,  as  delivered  b>  BPV,  is  being 
administeicd  lo  vi\  md  trachc.d  mtubatton  and  as  a  lorm  ol"  chronic  \  cntilaloi^ 
support.  While  \(>lumc-o>Llcd  \cnliIators  deliver  a  set  Iidal  \olunie  ( VT).  bilcvei 
de\  ices  dcli\(_r  \olumc  delcrmincd  by  the  set  pressure,  inspirator)  tlow  profile, 
expiratory  lri^'j:ei  setting  and  response  to  the  respin,itory  s)siem  impedance 
condition.  BPV  have  not  been  tested  extensively  and  may  not  rcspt^nd  well  lo 
adverse  or  changing  respirator)  sssiem  impedance  conditions.  We  h)pt)lhesi/ed 
that  deliv  cred  VT  would  be  predictable  v\  iihin  a  range  of  impedance  conditions 
and  consislenl  helueen  BPV  at  similar  settings.  Method:  We  constructed  a 
bench  imnJcl  s\slcni  tor  testing  triggered  breaths  on  a  mechanical  lest  lung 
(TTL-  Michigan  Instruments).  Three  BPV  in  common  use  (BiPAPSAr-D30  - 
Respirumcs,  ^3>5  -  Ncllcor-PB,  Quantum  -  Hcallhd>iie)  were  tested  at  IPAP  15 
cmH20,  EPAP  3  cmH20,  f  =  lO/min.  Their  volume  deliv  ery  capabilities  were 
challenged  by  combinations  ol  linear  resistance  (R)  (5.20,30  cmH20/Usec)  and 
compliance  (C)  {.U2.  .05.  .08. .  i  I  L/cmH20).  We  also  measured  autoPEEP. 
Ti,  and  How  and  pressure  waveforms  for  the  vanous  conditions.  Results: 
Tidal  \'olumc  dch\ery  for  the  tested  devices  (VT  -  ml): 

BiPAP  335  Quantum 

R/C  .02     .05    .OS     .11         .02    .05     .08     .11  .02     .05    .OK    .11 


5  224  syi  s*^!  1127 
20  222  4(-M  6(17  u^2 
50      201    301    328   338 


210  546  789  1030  207  429  615  7^2 
214  473  629  699  131  222  323  388 
214    351    326     361        134    161     164    182 


Tidal  volume  decreased  m  response  to  decreasing  compliance  and  increasing 
resistance  for  each  BPV  but  more  so  for  the  Quantum.  AutoPEEP  developed  lor 
C=.  1 1/R=50  for  the  BiPAP  and  335  (4.3. 4.2,  respccU\ely)  associated  w ith 
higher  VT,  an  increased  Ti  and  decreased  Te  compared  to  the  Quantum. 
Conclusions:  BPV  had  a  wide  range  of  VT  response  to  ihc  tested 
impedance  conditions.  Although  the  response  was  somcwhal  predictable, 
dillcrences  between  cxpiraton,  Inggcralgoiithni^  and  inspirator)   How  proliles 
partially  account  tor dilfcrcnccs  between  devices  MomUningoi  adcqiiale 
supported  v  enlilalion  b)  BPV  must  be  scrupulous  under  adv  crse  and  changing 
impedance  conditions. 


OF-98-049 


HIGH  FREQUENCY  OSCILLATORY  VENTILATION  (HFOV);  RESCUE 
THERAPY  FOR  SEVERE  OXYGENATION  FAILURE  IN  ADULTS.  R 
MacDonald  RRT.  AB  Cooper  MD.  TE  Siewan  MD.  RJ  Groll  BsC.  The  Wcllcslcy 
Central  Hospital,  University  of  Toronto,  Critical  Care  Medicine  Program,  Toronto. 
Canada. 

High  Frequency  Oscillatory  Ventilation(HFOV)  has  many  potential  advantages  in 
patients  with  ARDS.  however,  largely  due  lo  equipment  problems,  it  has  been 
infrequently  used  in  adults.  More  recently  these  difnculties  have  been  overcome. 
We  evaluated  the  physiologic  impact  of  HFOV  in  the  first  5  patients  who  received 
it  as  rescue  therapy  for  severe  oxygenation  failure  (All  values  Mean+_S.D.).  Five 
adults  (2M.  3F:  age  57.8  +  15.2  years,  vveight  62.3  +  16.5  kg..  Apache  II  score 
25.2  +6.0)  with  severe  ARDS  (LISS=3.55  +  0.33.  Pa02/Fi02=  91.4  +  39.2  and 
oxygenation  index  (OI)=38.9  +  24.5)  who  were  considered  to  be  failing 
conventional  ventilation  were  given  a  trial  of  HFOV  (initial  settings:  frequency=5 
Hz,  PAW=4cmH20  greater  than  conventional  mean  PAW,  1:E=33%.  FiO2+L0, 
power=6).  We  report  grouped  observations  of  the  study  cohort  over  small  intervals 
of  elap.sed  time 

(0-2.8  hrs.)  for  a  72  hour  period  for  Uie  following  oxygenation  and  hemodynamic 
cndpoints:  Pa02/Fi02  ratio,  01  fFi02  x  PAW  x  100  /  Pa02),  estimated  shunt 

ir.iciion  iQs/Qi';  ^  icc'o:  -  c.io:wi  v.s  +  a\r)?.  -  (\io:)ii 


I'ar;inul.r 

IU.S II 7:,,..                       Ij 

(11 

IsS  ♦    11(1 

i'j(i:/Ti(): 

iD'i:  +  :5'i 

lis  :  +  4s  ! 

24S.,  ,    1  !4(, 

(,)s/(Jl 

M  '1  4    -1  M 

12,2  ±  7.S 

::  1  tjs  ; 

iip.ict  of  ihcsc  physiological  hcnefiis 


852 


Risi'iKAroRV  Cari;  •  Orn)Bi;R  "^X  Voi,  4.'^  No  10 


Monday,  November  9,  9:30-1 1:25  am  (Room  214E) 


HIGH  FREQUENCY  OSCILLATORY  VENTILATION  IN  ACUTE  RESPIRATORS' 
DISTRESS  SS'NDROME:  AN  ADULT  CASE  STUDY  Micbat-I  A.  GcniUc,  RRT. 
John  M.  Daviea,  RRT,  Donna  S.  Tnpp,  RRT,  Ira  M.  Chuilelz.  MD.  Joseph  A.  Goven. 
MD.  Duke  University  Medical  Center,  Durham,  NC. 

Introduction:  Patients  with  Acute  Respiratory  Distress  Syndrome  (.-VRDS)  often  have 
extremely  poor  gas  exchange  on  conventional  mechamcal  vaitilation  (CiVrV).  There 
have  been  only  anecdotal  reports  ot  the  use  of  High  Frequency  Oscillatory  Ventilation 
(HFOV)  in  adult  patjents.  '  HFOV  may  provide  a  mode  of  vojlilalion  that  reverses 
atelectasis  while  avoidmg  overdistendmg  of  alveoh.  Thus,  secondary  lung  mjur>'  may 
zed  by  HFOV  m  patients  with  ARDS. 


Case  Summary:  We  are  rcportmg  the  case  of  a  23  year-old  female  with  a  history  of 
bulimia  but  without  other  sigmficani  medical  history.  She  reportcil  lo  the  Emergency 
Department  febnle  with  a  chesi  radiograph  that  showed  mfiltrales  m  the  left  upper,  left 
middle  and  nght  lower  lobes.  An  artenal  blood  gas  ( ABG)  drawn  on  room  air  revealed; 
pH  7.49,  PaO:  59  mniHg,  and  PaCO-  25  mmHg.  The  patient  was  admitted  with  the 
diagnosis  of  Pneumococcal  pneumoma.  On  day  thrc-e  of  hospitalization,  the  patient 
required  endotracheal  mtubation  and  CM\'  rorrespiraior>'  failure.  The  patienfs 
condition  continued  to  daenorate  and  by  day  U).  three  pneumothoracics  were  present 
w^th  significant  oir  leaks  from  chest  tubes  bilaterally.  Treatment  mcluded  Pressure 
Control  Ventilation  (PCVl,  inhaled  Nitnc  Oxide,  and  prone  positioning.  On  day  19. 
ABG  analysis  revealed:  pH  7.09,  PaCO:  200  mmHg.  Pa02  46  mmHg,  HC03  62.  These 
results  were  obtamed  on  PCV  rate  }2.  PEEP  14  cm  H.O.  Fi02  10%,  PIP  38  cm  H.O, 
mean  airway  pressure  of  24  cm  H;0.  and  tidal  volumes  of  200-300  ml.  The  patient  was 
placed  on  HFOV  (Senstinnedics  3100A.  Yorba  Lmda.  CA).  The  milial  setting  were 
Fi02  1 .0.  inspiratory  ome  40'''o,  amphmde  62,  frequency  5  hertz,  and  mean  ainvay 
pressure  29  cm  HjO.  Her  ABG  after  three  hours  of  HFOV  was  pH  7.39,  PaCO; 
SlmmHg,  and  PaO;  125  mmHg.  Aftec  14daysof  HFOV,  the  patient  was  reftimed  to 
CVrV  and  weaned.  On  day  66.  the  patient  was  discharged  from  the  hospital. 

Discussion:  While  HFOV  in  the  adult  population  with  ARDS  is  still  m  the 
developmental  stages,  this  case  dcmonsfrates  HFOV  as  an  effective  sfrategy  m  those 
patients  who  are  faihng  CMV.  Cases  such  as  the  one  presented  here  mdicale  that  a 
randomized  confrolled  tnal  is  warranted. 
1.  Fort  P.,  et.  al.  Cnt  Care  Med  1997. 


OF-98-056 


THE  USE  OF  NEGATIVE  PRESSURE  YEN  TILATION  TO  IMPROVE  SHCRE'nON 
CLEARANCE  IN  TWO  PATIENTS  FAILING  CONVENTIONAL  THERAPIES 

Hilary  Klonin.  Mivl"Jlle  Peters.  Parakkel  Raffeeq',  Andrew  Durward*.  Joii  Meliones,  Ira 
Cheifclz.  Divisions  of  Pediatric  Critical  Care  at  Duke  University  Medical  Center,  Durham, 
North  Carolina  and  Hospital  for  Sick  Children*.  Toronto.  Ontario. 

Introduction.    Negative  pressure  ventilation  may  be  beneficial  for  improved  secretion 
clearance  in  select  patients  either  alone  or  in  cdmhination  wilh  positive  pressure 
vcnlilalion.  High-frequency  external  chest  wall  compression  has  been  shown  to  improve 
peripheral  and  central  mucus  clearance  in  a  canine  model. '■^  We  report  two  pediatric 
patients  m  whom  the  secretion  clearance  mode  of  the  negative  pressure  Hayek  Oscillator 
(Brcasy  Medical,  London)  improved  pulmonary  function. 

Case  1 :    The  first  case  is  a  4  month  old  infant  with  chronic  lung  disease  of  prematurity 
who  had  been  recently  cxiubated  after  recovery  from  ARDS.  This  infant  subsequently 
developed  complete  collapse  of  (he  left  lung  and  right  upper  lobe.  This  patient  was 
ventilated  using  external  chest  wait  oscillation  wilh  intermittent  secretion  clearance  in  order 
to  avoid  positive  pressure  ventilation  and  its  associated  risk  of  barotrauma,  especially  in 
vulnerable  lungs.  The  lungs  were  re-expanded  in  3  days  and  the  need  for  reintubation  was 
avoided. 

Case  2:  The  second  case  is  a  16  montli  old  child  with  bronchiolitis  obliterans  and 
plastic  casts  of  the  airway  who  failed  to  improve  after  18  days  on  ECMO.  The  secretions 
were  successfully  mobilized  only  after  negative  pressure  ventilation  was  commenced.  This 
patienfs  dynamic  compliance  increased  from  0.35  mL/cm  HjO  lo  0.72  mL/cm  HjO  over 
[he  first  24  hours  on  the  Hayek  Oscillator.  The  oxygenation  index  decreased  from  15  to  5 
(without  a  change  in  the  oxygen  delivery  via  the  ECMO  system).  After  48  hours  of  using 
the  secretion  clearance  mode,  the  child  was  weaned  from  ECMO  Two  days  later  the  child 
was  successfully  extubated. 

Discussion.     Negative  pressure  venUlation'is  a  non-invasive  form  of  respiratory  support 
which  when  used  alone  avoids  the  complications  associated  with  endotracheal  intubation 
and  positive  pressure  ventilation,  When  used  in  association  with  positive  pressure 
ventilation,  negative  pressure  ventilation  may  shorten  the  duration  of  ventilation.  The 
Hayek  Oscillator  has  the  advantage  of  a  highly  effective  secretion  clearance  mode  which 
consists  of  oscillation  around  a  negative  pressure  baseUne  followed  by  a  "cough"  mode 
which  has  a  prolonged  inspiration  and  a  forced  short  expiration.  The  effects  of  this 
relatively  new  mode  of  ventilation  on  mucocilliary  clearance  are  largely  unexplored  in 
humans.  The  laboratory  data  and  case  reports,  such  as  presented  here,  support  the  need  for  a 
clinical  trial  of  negative  pressure  ventilation  for  secretion  clearance. 


OF-98-058 


PRESSURE  ASSIST  AS  A  FORM  OF  PATIENT  TRIGGERED.  PRESSURE 
TARGETED  VENTILATION.  Robert  McConnell.RRT  and  Nei!  Maclntyre.  MD.  Duke 


Uni\ 


sity  Medical  Center,  Durham  NC 


Pressure  Assist  (PA)  is  a  patient  friggered,  pressure  targeted,  lime  cycled  form  of 
\entilatory  support  We  reasoned  that  this  type  of  support  could  be  used  as  an  alternative  to 
pressure  support  (PS)  under  circumstances  when  clinician  set  time  cycltng  could  offer 
better  patient  synchrony  than  the  automatic  flow  cycling  of  pressure  support.  Accordingly, 
we  designed  a  study  lo  measure  patient  ventilatory  patterns,  oxygenation  and  inspiratory 
cffon  during  PA  and  compared  them  to  PS.  Our  hypothesis  was  that  providing  PA  with  an 
inspirator)  time  (Ti)  comparable  to  PS  would  have  no  effect  but  that  shortening  or 
extending  the  Ti  would  induce  changes  in  both  effort  and  ventilatory  pattern.  Nine 
ventilator  dependent  patients  receiving  stand  alone  PS  (mean  setting  of  16.8  cmH20)  were 
recruited  for  the  study  The  lest  protocol  included  baseline  measurements  on  PS  and  then 
supplying  PA  at  the  same  inspiratory  pressure  but  with  the  set  Ti  adjusted  to  match  the  Ti 
of  PS.  exceed  the  Ti  of  PS  by  0.3  sec  and  be  below  the  Ti  of  PS  by  0.3  sec.  At  each  setting, 
tidal  volume  (VT),  frequenc>  (0-  pulse  oximetry  (Sp02),  and  the  maximal  esophageal 
pressure  generated  (Pes)  were  recorded.  ANOVA  was  used  to  assess  statistical  differences 
in  the  various  PA  settings  vs  PS  Our  results  showed  no  significant  differences  in  any 
measurement  when  the  set  Ti  during  PA  matched  the  observed  Ti  of  PS.  However,  there 
were  significant  increases  in  VT  and  decreases  in  fas  the  set  Ti  of  PA  was  increased. 
Moreover,  there  was  a  trend  that  did  not  reach  statistical  significance  towards  lower  Pes 
values  as  the  set  Ti  was  increased  (TABLE) 

PA(shonTi)  PA(Ti=PSTi)  PA  (long  Ti) 

-102+/- 109'  +36+/-52  +i02-f/-95* 

+5.2+/-3.6*  -I.8+/-2.8  -6.2+/-3,3' 

-.6^-/-2.5  -.l-t-/-l,7  +.5+/-I.3 

PS)  +.25+/-,5  -9+y-l,3  -l,3+/-l  1 

•P<0.05  compared  to  PS 
We  conclude  that  PA  is  an  alternative  form  of  patient  triggered,  pressure  targeted 
ventilation  that  is  time  cycled  it  has  similar  effects  to  PS  when  the  Ti  is  comparable  The 
ability  to  change  Ti  with  PA,  however,  may  offer  an  advantage  over  PS  in  patients  in  whom 
breath  cycling  dys-synchrony  exists. 


VT(v 


Sp02  (vs  PS) 
Pes  (vs  PS) 


OF-98-059 


A  SIMPLE  LUNG  MODEL  THAT  MIMICS  DYNAMIC  AIRWAY  COLLAPSE, 
AND  DEMONSTRATES  UPPER  AND  LOWER  INFLECTION  POINTS  ON  A 
PRESSURE  VOLUME  CURVE.  Robert  McConnell.RRT.  Dennis  Yetsko.RRT. 
Michael  Gentile, RRT.  Neil  MacImyre,MD.  Duke  University  Medical  Center,  Durham. 
NC 

The  use  of  static  or  slow  flow  pressure  volume  (PV)  curves  to  evaluate  critical  opening 
pressure  (lower  inflection  point)  and  maximal  lung  mflation  (upper  inflection  point)  has 
been  well  documented  The  ability  lo  easily  demonstrate  this  phenomenon  for  the 
purpose  of  leaching  and  discussing  methods  of  treatment  has  required  assembly  of 
inconvenient,  cumbersome,  and  relatively  unpractical  models.  We  devised  a  simple 
model  that  is  easy  to  use.  and  can  be  assembled  using  devices  and  materials  common  lo 
most  respiratory  care  dcpanments.  The  equipment  needed      hard  plastic  canister  from 
an  HCH/HME  with  lucr-lock  gas  sample  port  (humidification  and  filter  media 
removed),  large  Penrose  drain  tube,  variety  of  adapters  (15mni,  22mm.  etc),  and  a 
dual  chamber  mechanical  lung.  The  Penrose  tubing  is  cut  and  placed  inside  the  canister 
with  the  ends  stretched  over  the  outer  connections.  The  assembled  device  functions  to 
represent  the  dynamic  closure  and  collapse  of  airways   Pressurizing  the  canister  (using 
a  syringe  and  stopcock  to  die  gas  sample  port)  at  various  levels,  collapses  the  tubing, 
requiring  airway  pressure  to  open  the  tubing  durmg  inspiration  Graphically  diis  will  be 
represented  as  the  lower  inflection  point  of  a  PV  curve  (see  figure). 


Using  adapters  the  device  is  placed  between  ihe  circuit  wye  of  the  ventilator  and  one 
chamber  of  the  mechanical  lung  (main  chamber).  The  other  chamber  (dependent  lung) 
should  be  outfitted  with  a  tic  bar  to  facilitate  lifting  when  the  main  chamber  is  inflated. 
The  maximal  lung  inflation  or  high  cost  of  pressure  for  volume  change  is  demonstrated 
by  splinting  open  the  dependent  chamber  of  the  lung  to  some  volume  thereby  creating  a 
point  at  which  the  pressure  would  rise  sharply  as  the  main  chamber  of  the  lung  is  forced 
to  lift  the  dependent  chamber  This  point  is  graphically  represented  as  the  upper 
inflection  point  of  a  PV  curve  (see  figure).  Once  connected  to  the  mechanical 
ventilator,  pressure  volume  curves  can  be  uaccd  and  measurement  of  the  mflection 
points  can  be  made  (figure  from  COSMO-Plus.  Novameuix.  Wallmgford.  CT)  This 
same  model  could  be  utilized  with  a  super  syringe  for  static  pressure  volume  curve 
demonstrations.  CONCLUSION:  This  mode!  can  be  an  important  demonsu-ation  of  the 
effect  of  PEEP  in  lung  recruitment,  and  the  identification  of  maximal  lung  volume 
during  mechanical  ventilation 


Respiratory  Care  •  October  '98  Vol  43  No  10 


853 


Monday.  November  9,  9:30-1 1:25  am  (Room  214E) 


COMPARISON  OF  A  TRADITIONAL  OPEN  CIRCUIT 
TECHNIQUE  TO  THE  SENSORMEDIC  VMAX 
SYSTEM  FOR  DETERMINING  REE: 

Carl  D  Moltram.  RRT  RPFT;  Kenneth  C  Beck,  Ph  D  ,  Naomi 
Kothenbeutel,  DeeAnn  Pease  CPFT,  Mayo  Clinic,  Rochester,  MN 
55905 

Introduction:  Indirect  calorimetry  is  a  method  of  determining  caloric 
energy  requirements  (Resting  Energy  Expenditure,  REE)  in  patients  to 
allow  for  nutritional  assessment  and  management    Our  out-patient 
laboratory  uses  a  traditional  open  circuit  method  involving  direct  expired 
gas  collection  into  a  Tissot  spirometer  and  gas  analysis  using  a  mass 
spectrometer    This  study  was  performed  to  compare  the  Sensormedics 
Vmax  229  canopy  system  with  this  traditional  methodology    Methods: 
Twenty  consecutive  patients  (16  female  4  male,  age  22-66,  mean  BMl  41, 
range  19-77)  scheduled  for  an  REE  study  were  tested  on  both  systems 
sequentially,  randomizing  which  test  was  performed  first    Patients  were 
instructed  to  fast  after  midnight,  and  to  avoid  strenuous  activity  shortly 
before  the  test.  Both  systems  were  calibrated  on  each  study  day    Patients 
rested  in  the  supine  position  for  35  minutes  and  data  collected  over  the 
last  10  minutes  were  averaged.  Results: 


V02 

KCALS/24  Hr 

RQ 

VC02       j 

Tissot 

SM 

Tissot 

SM 

Tissot 

SM 

Tissot 

SM 

Mean 

278 

273 

1918 

1931 

0,80 

086 

219 

232 

SD 

114 

109 

770 

732 

005 

0.06 

80 

80 

R- 

0  98 

0  98 

036 

096 

T-Test 

p  =  010 

p  =  0  56              p  <  .0001 

p  =  .002 

Conclusion:  Our  results  indicate  that  the  Sensormedic  Vmax  system  was 
highly  comparable  to  our  traditional  method  in  measurement  of  V02  and 
Kcals/24  Hr  but  that  there  was  a  statistically  significant  difference  in  the 
RQ  and  VC02  values  measured    The  between  difference  the 
Sensormedic  Vmax  and  the  Tissot  measurement  of  these  variables  were 
biased  exclusively  high 


SYNCHRONIZED  PARTIAL  LIQUID  VENTILATION 
IMPROVES  GAS  EXCHANGE  AND  DECREASES  BREATHING 

EFFORT.  Patricia  A.  Mcveis  RRT.  EM  Bendel-Sten/£l  MD,  DR  Bing 
RRT,  JE  Conneit  PhD,  MC  Mammel  MD.  Infant  Pulmonaiy  Re.search 
Center,  Childivn's  Ho,spital-St,  Paul.  Minnesota  and  DepLs.  Of  Pediatrics 
and  Bioslatistics,  University  of  Minnesota,  Minneapolis,  MN. 

Introduction:  Does  mode  of  assisted  ventilation  alTecl  breathing  etfon  and 
ga.s  exchange  during  partial  liquid  venlilaiion  (PLV)  in  an  animal  model  of 
neonatal  RDS?  We  compared  IMV,  SIMV,  and  A/C  modes  during  PLV 
with  pcrtlubron  (Liquivent®,  Alliance  Phannaceuticals)  in  surfactant 
depleted,  spontaneously  breailiing  newborn  pigleli. 
Method:  Ten  piglets  (1.19±0.04  kg)  were  .sedated,  but  not  paraly/ed.  and 
ventilated  using  a  volume  target  of  15cc/kg  (Driiger  Babylog®).  We  induced 
lung  injury,  defined  as  PaO2<10(>  lorr  at  Fi02  1.0  and  lung  compliance 
ix-'duction  by  >  30%,  wiUi  repeated  saline  lavage.  We  randomized  the  piglcLs 
to  sequential  30  minute  periods  of  either  1MV>SIMV>A/C,  or 
A/C>SIMV>IMV,  during  PLV.  Respiratory  rale  (RR)  and  minute 
ventilation  (Ve)  were  detennined  as  1  minute  moving  averages.  For  each 
breath,  we  measured  tidal  volume  (Vt),  mean  airway  pressure  (MAP),  and 
esophageal  pressure-time-  rate  index  (PE'RR).  PE'RR,  an  estimate  of  non- 
venlilaliir  breathing  effort,  is  defined  as  the  area  below  bajieline  of  the 
esophageal  pressure  time  cui-ve  x  RR  (Novameirix  VenTrak®).  A 
continuous  inU'a-  ailerial  monitor  (Diameuics  Paraux"nd7®)  recorded  blood 
gases  every  30  seconds;  we  calculated  a/A  with  period  means.  We  assessed 
Vt  vaiiability  using  die  coetTicient  of  variation  (Vuf  Vt,  SD/ mean  x  KW). 
Dat;i  were  analyzed  using  paired  t-tests  with  Bonfenoni  cori-ection; 
Wilcoxon  rank-sum  test  for  nonparametiie  data. 

Results:  Breathing  effort,  estimated  by  PE"RR,  was  significantly  lower  with 
.VC  than  SIMV  during  PLV  (A/C  vs  IMV,  p=(>.n6).  a/A  was  significantly 
better  with  A/C  than  either  IMV  or  SIMV.  Ve  and  MAP  increased  dunng 
A/C.  RR  was  significantly  less  in  AC  v.s  SIMV,  and  uended  lower  in  A/C 
IMV  (p=(l.(l7)  Vi  was  always  more  consisieni  dunng  /VC 


M..il>' 

a/\ 

V.           1        MA|. 

KK 

IM>I(R 

\    c.(  \  I 

IM\ 

1 1 : ~  ■  1 1  11 

h  S-(l  5 

1  i:.-i(. 

4'i  -■  1  ; 

^4-  111',' 

.SI.M\ 

II  :o-iiii: 

11  7^:ll  15 

IM'll. 

Jos    III') 

"71 1:'': 

A/C 

o,.V^±u,u.'.' 

U.DStll.i.V 

I0  71U7- 

77±1U>- 

H  7iM-  ■ 

iii:'.7  • 

P<(),(I5  A/C  vs  IMV,  SIMV;  **p<(U15  A/C  vs  SIMV. 

Conclusions:  in  spontaneously  breathing  animals,  fully-synchronized  PLV 
using  AJC  mode  required  the  least  bnsathing  effort,  increased  Ve  and  a/A  at 
the  lowest  RR  and  least  variable  Vt.  These  data  suggest  physiologic  benefit 
fioin  A/C  during  PLV  in  nonparalyzed  subject. 


OF-98-071 


ASSIST  CONTROL  VENTILATION  DECREASES  BREATHING 
EFFORT  IN  AN  ANIMAL  MODEL  OF  RESPIRATORY 
DISTRESS  SYNDROME.  Paincia  A.  Meveis  RRT.  EM  Bendel-Stcnzel 
MD.  DR  Bing  RRT,  JE  Connetl  PhD,  MC  Mammel  MD.  Infant  Pulmonai^ 
Research  Center.  Children's  Hospilal-St.  Paul,  Minnesota  and  Depts.  Of 
Pediatrics  and  Biostatistics,  University  of  Minnesota.  Minneapolis,  MN. 

Introduction:  Synchronous  mechanical  ventilation  is  now  readily  available  for 
small  infants.  Does  a  fully  synchnmized  patienl-  uiggored  mode  of 
ventilation  reduce  breathing  effort  and  provide  adequate  gas  exchange  in  an 
animal  model  of  RDS?  We  compared  A/C  to  IMV  and  SIMV  in  a 
spontaneously  breathing,  surfactant  depleted  newborn  piglet. 
Method:  Ten  piglets  ( 1.9±().4  kg)  were  sedated,  but  not  paralyzed,  and 
ventilated  using  a  targeted  tidal  volume  ol  1 5cc/kL'  (Diager  Babylog®).  We 
induced  lung  injui-y,  defined  as  Pa02<l(H)  tmr  al  Fi()2  1.(1  and  lung 
compliance  reduction  by  >3()'7(',  with  repealed  saline  lavage.  We  randomized 
the  pigleLs  to  .sequential  30  minute  periods  of  either  1MV>S1MV>A/C,  or 
A/C>SIMV>IMV.  Respiratoi-y  rate  (RR)  and  minute  venlilaiion  (Ve)  were 
detciTnined  as  1  minute  moving  averages.  For  each  bieatli  we  measured  tidal 
volume  (Vt),  mean  aiiAvay  pressure  (MAP),  and  esuphageid  pivssiirc-iime- 
ratc  index  (PE-RR).  PE'RR,  an  estimate  of  palieni  brealhing  erioii,  is 
defined  as  the  area  below  baseline  of  the  esophageal  pressure-  time  cune  x 
RR  (Novameu-ix  VenTrak®).  A  eonlinunus  inna-ailenal  moniloi  iDiametries 
Paratrend?®)  recorded  blood  gases  e\eiy  «)  seconds,  we  cakul.iled  a/A  with 
period  means.  We  asses.sed  Vt  variability  using  llie  eoelTicienl  of  vanaiion 
(Vof  Vt,  SD/mean  x  100).  Data  were  analyzed  using  paired  1-lests  wiih 
Bonferroni  coiTection;  Wilcoxon  rank-sum  test  lor  nonpaianielne  daui. 
Results:  Breadiing  effort,  estimated  bv  PE'RR.  was  sicnilicanily  lower  with 
A/C  than  either  SIMV  or  IMV.  Statisiicallv  signilieani  dilferences  in  A/C  vs 
IMV  and  SIMV  included  lower  RR  and  iiu  le.ised  Ve  and  MAP.  No 
differences  in  a/A  were  seen.  Vi  was  .ilw.ivs  less  xiiiiahle  during  A/C 


Mi.dt 

a/A 

\'.' 

MAI' 

KK 

I'l'-KK 

I  iif  \1 

IM\ 

(1  111-11  111 

IIKJ-OIIK 

7  7MI  7 

UJilS 

S7  X>  ll.ll 

.sill  i:'7 

MNfV 

11  14'IHll 

IIKj'IMIS 

1-14  till 

'14111';;, 

A/(-' 

1),  14t 

1,03 

1  (I7±()]l' 

«S+<I' 

15  7,1'* 

1)1 1 ',?  • 

*p<0.()5  A/C  v.s  IMV,  SIMV 

Conclusion:  In  spunianeou.sly  breathing  aniinal.s,  ful!y-syiichioni/cd  A/C 
ventilation  produced  the  highest  Ve  and  the  mn.st  cnnsisieni  Vi.  vviili  the 
lowest  breathing  efl'ort  as  estimated  hy  PR»RR. 


OF-98-072 


THE  RELATIONSHIP  BETWEEN  VENTILATORY  MECHANICS 
AND  THE  LOWER  INFLECTION  POINT  OF  THE  P-V  CURVE 
DURING  PARTIAL  LIQUID  VENTILATION. 

Gabriela  Feireyra  PT,  Sven  Goddon  MD.  Yuji  Fujino  NfD,  Robert  M.  Kacmarek 
PhD  RRT.  Anaesthesia  &  Respirator^'  Care,  Massachusetts  General  Hospital  and 
Harvard  Medical  School,  Boston,  MA. 

Introduction:  PaniaJ  Liquid  Ventilation  (PLV)  with  Perflubron  (PFB)  has  previously 
been  shown  to  be  an  effcciive  way  of  improving  gas  exchange  in  models  of  lung  injury 
and  in  infants  with  IRDS   However  linle  is  known  about  how  to  approach  optimal 
ventilator  settings  during  PLV.  We  have  previously  shown  thai  PEEP  set  above  the  lower 
inflection  point  (LIP)  markedly  improves  gas  exchange  during  PLV  (I)  The  goal  of  this 
study  was  to  investigate  whether  a  change  in  ventilatory  mechanics  (VM)  could  be  used  to 
determine  the  LIP  during  PLV, 

Methods:  Detennination  of  static  P-V  curves  using  a  super-syringe  were  performed 
before  and  after  filling  the  lungs  with  30  ml/kg  PFB  in  5  healthy,  anaesthetized  sheep 
(27.5+3  kg).  Measurements  were  made  in  increments  of  100  ml.  inflating  the  lungs  to  a 
maximal  airway  pressure  of  50  cm  H,0,  A  blinded  investigator  identified  LIP  Each 
sheep  was  ventilated  wiUi  both  Pressure  Control  Ventilation  (PCV)  and  Volume  Control 
Ventilation  (VCV)  with  increasing  levels  of  PEEP  in  increments  of  2.5  cm  H;0  al  an  I:E 
ratio  of  1 : 1 ,  In  PCV  driving  pressure  was  set  to  achieve  a  V,  of  10  ml/kg  at  PEEP  10.  in 
VCV  V,  was  set  al  10  ml/kg   Airway  pressure  and  flow  waveforms  at  the  opening  of  the 
ETT  were  recorded  and  compared. 

Results:  Before  filling  no  LIP  could  be  identified.  After  fUling  LIP  was  1 3  ±  1 .2  cm 
H20   Dunng  PCV  lime  to  peak  flow  (t  to  PF)  was  used  as  a  reflection  of  resistance  and 
V,  as  a  reflection  of  compliance.  During  VCV  inspiratory  resistance  was  calculated  and 
the  difference  between  Ppi^y  and  PEEP  was  used  as  a  reflection  of  compliance 
(Mean±SD.  p-;0  05  =  *  vs.  PEEP  0.  #  vs.  PEEP  10) 
PCV 


PEEP(tinrDO) 

0 

5 

75 

10 

125 

15 

lloHi(s) 

065«),23 

U,-17rt24 

0  2M),I2' 

0,15«)01' 

ni5<<)02' 

015«)02' 

VM.nl) 

OI3<0,OS 

0.2140,07 

0J5«107' 

ajotooT- 

034.0  07- 

0  37*«06'» 

VCV 

P|ij:i'laiilCOI 

(1 

5 

7  5 

10 

125 

15 

RilcrJClvlM 

:hS>l(l7 

H)3K.6* 

78+lh' 

7  2' 1.1* 

ft7M  1' 

h,3-i  1  0' 

IVIa.I'lJl'miJDill 

:ii  (,.<,!, 

I8  1..S7 

16  4*5  2 

14'>f5  1 

13  'W  8- 

I28<4  4'« 

Conclusion:  During  PCV  VM  were  optimized  at  PEEP^IO  cm  HjO  and  in  VCV  at 
PEEP^7.5  cm  HjO.  VM  as  determined  underestimated  the  PEEP  level  equal  to  LIP  ( 1 
Fujino  Y  ct  al.;  AJRCCM  155:A745  (1997). 

This  abstract  is  funded  in  part  by  Alliance  Pharmaceutical  Corp.  (San  Diego.  CA)  and 
HiK'chst  Marion  Roussel  Inc  (Frankfun,  Germany). 


OF-98-084 


854 


Rl.SI'IRATORV  CaRP;  •  OCTOBFR  "98  Voi.  4.^  No  10 


Monday.  Novembhr  9.  9:30-1  1:25  am  (Room  214E) 


j:  j^mos:>^  Ih^  Sp^ctru/rj 


<^  ffO-  ^^'/ii-i  (^^c'yi'-i. 


March  14-17 
1         t999 

CARIBE  ROYALE 
RESORT  SUITES 

Course  Director: 

arry  Make,  MD,  FCCR 
FACR  FAACVPR 

Co-Director: 

ominique  Robert,  MD 

>ntinuing  education 
credits  available: 

CME,  CRCE,  AACN, 
and  AAPA 


More  than  1 ,000  people  are  expected  to  gather 

March  14-17,  1999,  in  Orlando  to  participate  in  a  program 

for  anyone  involved  with  noninvasive  ventilation — from 
physicians,  respiratory  therapists,  and  nurses  to 
ventilator  users  and  their  families. 


Come  be  part  of  this 
comprehensive  program 
featuring  spectacular 
educational  exhibits  and  an 
international  faculty  focusing  on 
a  myriad  of  noninvasive 
ventilation  and  other  timely 
issues.  This  will  be  a  truly 
enlightening  educational 
experience!  For  more 
information  please  contact  the 
American  College  of  Chest 
Physicians  at  (800)343-2227. 


TOPICS  WILL  INCLUDE: 

*  noninvasive  ventilatory  assistance  in  the  home, 
ICU,  emergency  room,  and  long-term  care  sites 
nutritional  issues  for  ventilated  patients 
diagnosis  and  diagnostic  methods 
ethical  issues 
telemonitoring  in  the  home 
COPD  patient  quality-of-life  issues 
presentation  of  original  investigation 


in  cooperation  with  National  Jewish  Medical  and  Research  Center,  the  Journees 
Internationale  de  Ventilation  a  Domicile,  and  the  International  Ventilator  Users  Network 


HIGH  STRETCH  LIOMG  INJURY  DOES  OCCUR  DURING  BOTH  GAS 
AND  PARTIAL  LIQUID  VENTILATION  IN  HEALTHY  SHEEP 

Yuii  Fuiino  MD.  Max  Kinnse  MD,  Jean-Daniel  Chiche  MD,  Jonathan  Hromi  BA.  Robert  M, 
Kacmarek  PhD  RRT  Anesthesia  and  Respiratory  Care,  Massachusetts  General  Hospital  and 
Harvard  Medical  School.  Boston  ^dA 

Partial  liquid  ventilation  (PLV)  was  introduced  by  Fuhrtnan  et  al  and  has  been  shown  to  be 
effective  in  improving  gas  exchange  in  animal  models  and  patients  with  IRDS.  The  aim  of  this 
study  was  to  investigate  the  effect  of  high  tidal  volume  ventilation  with  the  same  end  inspiratory 
plateau  pressure  (Pplat)  on  gas  exchange  and  lung  mechanics  of  normal  sheep  lungs  during  GV 
and  PLV 

Methods.  Sixteen  fasted  Hampshire  sheep  (  28.4±3.9  kg  body  weight)  were  investigated- 
Following  baseline  measurements  the  animals  were  randomly  assigned  to  the  following  4 
groups;  Group  CV-L  (n^):  gas  ventilation  with  normal  tidal  volume  (12mL/kg)  and  PEEP 
ScmHjO,  Group  GV-H  (n=4):  gas  ventilation  with  high  tidal  volume  (target  Pplat  "^  SOcmH.O) 
and  PEEP  5cmH,0.  Group  PLV-L  {n=4);  partial  liquid  ventilation  with  normal  tidal  volume 
(12mL/kg)  and  PEEP  set  lcmH;0  above  the  lower  inflection  point  on  the  pressure  volume 
curve.  Group  PLV-H  (n=4);  partial  liquid  ventilation  with  high  tidal  volume  (target  Pplat  = 
SOcmHiO)  and  PEEP  5cmH:0,  Following  5  hours  of  ventilation  animals  were  sacrificed  and 
ological  examination  were  performed    Results, 


vival 


Bulla 


Pneumothorax 


PLV-H  (n=4) 
PLV-L  (n=4) 
GV-H  (n=4) 
GV-L    (n=4) 


3- 


'  X'  p<0,05  vs  OV-H 

Pi(VF,0,nlio[GV  group] 


Pi(VF,02i3t]o|PLV9n>iip] 


Histological  examination  showed  severe  lung  injury  during  high  volume  ventilation  with  both 

GV  and  PLV, 

Conclusion.  The  use  of  PLV  does  not  protect  the  lungs  of  healthy  sheep  from  the  ventilator 

induced  lung  injury  observed  with  high  stretch  ventilation. 

This  abstract  is  funded  in  part  by  Alliance  Pharmaceutical  Corp,  and  Hoechst  Marion  Roussel 

Inc 


OF-98-085 


RESPONSIVENESS  OF  THE  T-BIRD  VS  VENTILATOR  COMPARED  TO  THE  BIPAP  ST/D 
30:  A  BENCH  TEST  STLtDY  Michael  D  Coutls,  RRT,  Vancouver  Hospital  &  Health  Science 
Centre.  Vancouver.  Britisfa  Cohimbia,  C!"«"'^» 


Introdactlon;  As  the  use  of  noninvasive  pressure  targeted  ventilators  (PTV)  c 
different  studies  will  be  conducted  to  en.<ure  that  n^e  of  these  machines  is  appropriate  There  have 
been  studies  that  indicated  that  then;  is  potential  for  CO,  buih  up  in  the  single  limb  circuit  of  a  PTV 
Also,  all  of  the  PTV's  available  do  not  have  a  built  m  battery  ,system  wfiich  make  them  diificull  to 
be  used  for  patien!  transports  fhc  T-Bird  VS  Ventilatory  System  incorporates  on  mlemsl  battery 
and  uses  a  dual  huib  cucuil.  The  purpose  of  this  study  is  to  determine  and  compare  the 
respon-siveness  of  the  T-Bird  VS.  for  the  use  of  nonivasive  ventilation,  to  the  Respiromcs  Bipap 
ST/D  30  Methods:  A  two  chambered  hmg  model  was  used  with  one  side  of  the  chamber 
cotmected  to  the  testmg  machines  and  the  other  chamber  connected  to  a  ventilator  to  be  used  to 
simulate  patient  effort  The  T-Bml  VS  was  set  m  the  Cpap  mode  with  PEEP  of  4  cniH-O  and 
Pressure  Support  of  6  cmH.O  The  ST/D  30  was  .set  at  Epap  of  4  ctnHjO  and  Ipap  of  10  ctnHjO 
Responsiveness  was  tested  at  30,  60 ,  and  90  L/min   Respoasiveness  was  also  test  during  oxygen 
titration  at  30  IVnun  with  5  I7mm  oxygeiL  60  L/mni  with  10  \Jram  oxygen  and  90  l-/oiin  and  15 
L/rmn  oxygen.  Response  time  (Tr),  rise  time  and  ma,\UQum  negative  deflection  below  baseline 
(Pneg)  were  determmed  Statistical  analy,sis  was  done  by  ANOVA  with  differences  considered 
significant  when  p  <  0,05,  ResuHs:  During  the  oxygen  btration  testing  the  T-Bird  had  a 
significantly  shoiter  Tr,  rise  time  and  higher  Pneg  {p<  0  05)    Howev^,  during  the  mspiratoty 
demand  tests  with  no  oxygen  titration  the  T-Bird  VS  had  a  significantly  longer  Tr  and  higher  Pneg 
al  60  L/min  (p  <  0,05),  At  90  Umm  the  T-Bird  VS  had  a  significantlj'  longer  Tr  (p  <  0  05),  Mean 
vahies  at  ventilator  flowrates  of  60  L/mm  and  90  IVmin  are  lisled  below 

ST/D  30  T-BndVS         ST/D -10  T-Bid  VS 

60  L/mm  60  L/min  90  L/min  90  L/min 


Rise  Time  (msec) 

183  ±12* 

338  ±  13 

262  tl2 

238  ±23 

Tr(msec) 

153  ±  15 

133  ±22 

I48±29# 

187  ±  14 

PnegCcmHiO) 

-69  ±  0 04  $ 

-1  14±0  05 

-1,27  ±0,02 

-145±014 

*  p  <  0  05  ST/D  30  significanlly  sborter  nse  lime  vs  T-Bird  VS 

#  p  <  0  05  ST/D  30  significantly  shorter  Tr  vs  T-Bird  VS 
$  p  <  0  05  ST/D  30  significantly  Iowct  Pneg  vs  T-Bird  VS 

Conclusions:  As  the  data  indicates  there  are  significant  responsiveness  differences  between  die 
machines  tested.  From  a  bench  test  perspective  it  appears  tbal  the  T-Bird  VS  cao  be  used  as  a 
noninvasive  PTV  However,  the  T-Bird  VS  was  not  tested  with  a  leak  m  the  system  In  the  clmical 
setting  il  is  sometimes  difficnlt  to  maintain  a  leak  free  envtronmenl  when  usmg  iionin\'asive 
ventilation.  Further  studies  need  to  be  done  on  the  T-Bird  VS  lo  deteroiine  whether  il  can  be  used  in 
the  clnucal  settm^  when  there  are  leaks  in  the  circmt  due  to  mask  mierface 


Respiratory  Care  •  October  '98  Vol  43  No  10 


855 


Monday,  November  9.  9:30-1 1:25  am  (Room  214E) 


AUTOTRIGGERING  DUE  TO  CARDIOGENIC  OSCILLATION 
DURING  FLOW-TRIGGERED  MECHANICAL  VENTILATION 
AFTER  CARDIAC  SURGERY. 

MunRyiiki  Takpiirhi.  MD,  Hideaki  Imanaka,  MD.  Masaji  Nishimura,  MD'.  Naoki 
Yahagi,  MD,  Kuraon  Kumtin,  MD.  ICU.  National  Cardiovascular  Cenler  and  Osaka 
Universily  Hospital*.  Osaka,  JAPAN. 

Flow-triggering  (FT)  sensitively  detects  the  patient's  inspiratory  effort.  We 
noticed  iji  some  patients  after  cardiac  surgery  when  FT  was  used  that  cardiogenic 
osctUation  was  liable  to  trigger  the  ventilator  as  autotriggering.  In  a  prospective  study 
we  evaluated  the  incidence  and  factors  as.sociated  with  autotriggering. 
Methods:  One  hundred  and  four  consecutive  adult  patients  were  enrolled.  All  patients 
underwent  cardiac  surgery:  50  had  acquired  valve  disease,  44  had  coronary  artery 
disease,  and  10  had  atrial  septal  defect.  They  were  paralyzed  and  ventilated  with 
SIMV  at  a  rate  of  1 0  breaths/min.  pressure  support  (PS)  of  1 0  cm  H,0,  and  FT  with  a 
sensitivity  of  1  Umin.  After  15  minof  the  ventilation,  blood  gases,  cardiac  output,  and 
flow  were  measured.  Because  there  should  have  been  no  PS,  we  separated  the  patients 
into  2  groups  according  to  the  number  of  PS  breaths  observed  during  a  2-min 
measureinenl:  an"  AT  group"  when  PS  breaths  >  10  and  "  non-  AT  group"  when< 
10.  If  PS  breaths  occurred,  we  decreased  the  sensitivity  until  PS  disappeared.  Then  the 
intensity  of  cardiogenic  oscillation  was  assessed  as  the  peak  inspiratory  flow 
fluctuation  at  end  expiration. 

Results:  Twenty-three  patients  (22%)  showed  >  10  autotriggered  breaths.  The  AT 
group  showed  larger  inspiratory  flow  fluctuation,  cardiac  output,  higher  central 
venous  pressure  (CVP),  larger  heart  size  on  chest  X-ray,  lower  respiratory  system 
resistance  (Rrs),  and  hyperventilation  than  the  non-AT  group. 

AT  group  (2.^)      non-AT  group  (Kl) 
Peak  inspiratory  flow  fluctuation  (L/min)    4.67  +    1.26         2.03  ±  0.86* 
Cardiac  output  (Umin)  5,47  +   1,49        4.18  ±  0.91  • 

CVP  (mm  Hg)  9,2  +  2.8  7.2  +  2.9  • 

Cardiothoracic  ratio  (%)  61.4  ±  6.1  57.8  ±  4.6  # 

Rrs(cmH!0's*L')  8.5  +  2.1  10.0  ±  2.8' 

Respiratory  rate  (/min)  19.9  ±  2.7  10.3  ±  0.8  • 

Minute  ventilation  (Umin)  8,54  +  1.46        5,79  +  0.99  • 

PatXIj  (mmHg)  30.8  +  4.0  37.6  +   4.4  • 

(•  p<0.01,  #p<0.05) 
Conclusions:  Autotriggering  due  to  cardiogenic  oscillation  is  common  in  post 
cardiac  surgery  patients  when  flow-triggering  is  applied.  Autotriggering  occurred 
more  often  in  patients  with  hyperdynamic  states. 


CLINICAL  EVALUATION  OF  A  NEW  CLOSED  LOOP  VENTILATION 
MODE  ADAPTIVE  SUPPORTIVE  VENTILATION  (ASV)    Robert  S 
CatTipbell  RRT,  Reynaldo  P  Sinamban  MD,  Jay  A  Johannigman  MD,  Fred 
A  Luchette  MD,  Scott  B  Frame  MD,  Kenneth  Davis  Jr  MD,  Richard  D 
Branson  RRT  University  of  Cincinnati  College  of  Medicine,  Cincinnati,  OH 
45267-0558 

INTRODUCTION:  ASV  (Galileo,  Hamilton  Medical)  is  a  mode  of 
mechanical  ventilation  (MV)  with  a  closed  loop  program  to  determine  and 
adjust  ventilator  settings  with  the  exception  of  PEEP  and  FJO2  ASV  is 
capable  of  adjusting  the  number  of  mandatory  breaths,  the  1  E  of 
mandatory  breaths,  and  the  pressure  of  both  mandatory  and  spontaneous 
breaths  We  compared  ventilator  parameters  and  gas  exchange  during 
initiation  of  MV  with  ASV  to  physician  determined  ventilator  settings 
METHODS;  Post-operative  pts  (n=19)  requiring  MV  due  to  continued 
neuromuscular  blockade  were  entered  in  the  study  following  informed 
consent  from  next  of  kin  Settings  ordered  by  the  physician  were  noted  and 
each  pt  was  placed  on  those  settings  or  ASV  in  random  sequence  ASV 
requires  input  of  pt  ideal  body  weight  (IBW)  and  a  %  Minute  Volume  to  be 
delivered  (100%=100mL/Kg/min)  IBW  was  determined  from  standardized 
tables  and  %MinVol  was  set  to  100%  PEEP  and  FiO-  were  determined  by 
the  attending  staff  and  kept  constant  Artenal  blood  gases  (pH,  PaC02, 
PaO;.  SaO,)  and  cardiopulmonary  variables  (f,  Vr,  Ve.  T.  PIP,  Pa».  HR, 
MAP,  and  VCO?)  were  measured  and  recorded  after  30  mm  on  each 
mode  Data  were  compared  using  student's  t-test  and  p<Q  05  was 
considered  significant  RESULTS:  Mean  IBW  was  88  8  Kg  There  were  no 
differences  in  ABGs  between  ASV  and  conventional  ventilation, 
respectively  (pH  =  7  40  ±  07  vs  7  39  t  .06.  PaCO,  =  37  6  ±  5  vs  38  6  ±  5, 
PaO:  =  100  0  131  vs  106  1  +33)  VdA/t  was  lower  during  ASV  (51  3  ±  6 
vs57  4  +  8%)  Ve  (96  ±2vs9.5  +  2  Umin)  and  T  (1  5  +  05vs  1  43  +  0  3 
sec)  were  similar  between  ASV  and  conventional  ventilation,  respectively 
Respiratory  rate  was  higher  with  ASV  (14  4  +  3  vs  10  1  1  2  bpm)  PIP  (25  2 
+  8  vs  31  9  +  9  cmH20)  and  Vt  (690  +  121  vs  863  ±  133  mL)  were 
significantly  lower  with  ASV  There  were  no  differences  in  HR  (87  ±  16  vs 
89  +  16),  MAP  (73  ±  15  vs  72  +  19).  or  VCO,  (262  ±  48  vs  265  i  56  ml/min) 
between  ASV  and  conventional  ventilation  Vj  duhng  ASV  was  more 
consistent  with  "lung  protective "  strategy  (7  8  mUKg)  than  was 
conventional  Vy  (9  7  mL/Kg)  CONCLUSIONS:  Use  of  ASV  to  initiate  MV  in 
non-spontaneous  breathing  pts  provides  equivalent  gas  exchange  to  MV 
ordered  by  the  physician  MV  with  ASV  is  more  efficient  as  evidenced  by 
lower  VoA/t  values  and  may  be  safer  as  a  result  of  the  lower  Vt  and  PIP 


TREATMENT  OF  SEVERE  TRAUMATIC  BRONCHOPLEURAL  FISTULA  WITH 
UNILATERAL  HIGH  FREQUENCY  JET  VENTILATION  -  CASE  PRESENTATION 

John  Emberger  BS  RRT  Andrew  Ginn  RRT,  Rick  Ermak  RRT,  Dennis  Witmer  MD, 
(Vlarc  Zubrow  MD.  Department  of  Respiratory  Care.  Christiana  Care  Health  System. 
Newark  DE 

Background  High  frequency  jet  ventilation  (HFJV)  and  independent  lung  ventilation 
(ILV)  have  been  used  to  treat  severe  pulmonary  air  leaks  (1,2.3)  We  present  a  case  of 
severe  bronchopleural  fistula  which  required  both  ILV  and  HFJV,  also  called  unilateral 
high  frequency  jet  ventilation  (UHFJV)  Case  Summary  Fifty  four  year  old  male 
presented  with  a  self-mflicted  gunshot  wound  to  the  right  chest  wall  Volume  ventilahon 
would  not  achieve  oxygen  saturation  above  84%  Pressure  control  ventilation  (PCV) 
was  initialed  with  rate  =  18  breaths/minute.  100%  Fi02  and  +5  PEEP  (ABG  pH  =  7  31. 
PaC02  =  48  torr.  Pa02  =  65.  Sa02  =  88%)  Chest  X-ray  showed  metallic  fragments, 
shattered  ribs,  and  parenchymal  opacity  consistent  with  severe  pulmonary  contusion 
of  the  nght  lung  Within  eight  hours  ILV  was  initiated  A  tracheostomy  was  done  to 
place  a  double  lumen  tube  Right  lung  ventilator  settings  were  Assist  Control  mode. 
rate  =  4  breaths/minute,  no  PEEP  Left  lung  ventilator  settings  were  PCV,  rate  =  16 
breaths/minute  +7  PEEP    The  ABG  improved  to  pH  =  7  42,  PaC02  =  45  torr,  Pa02  = 
122  torr.  Sa02  =  98"/n  on  100%  Fi02  The  air  leak  noticeably  decreased  The  patient 
deteriorated  over  the  next  day  (Pa02  =  60  torr  on  100%  Fi02)  as  the  lung  injury 
worsened  on  chest  X-ray  The  decision  was  made  to  initiate  UHFJV  on  the  right  lung 
(HFJV  on  the  right  lung  and  PCV  on  the  left  lung)  The  ABG  improved  (pH  =  7  48, 
PaC02  =  37  torr  Pa02  =  116  torr)  A  decrease  in  the  air  leak  was  again  noted  The 
patient  was  maintained  on  UHFJV  lor  1 1  days  When  the  patient  was  converted  back 
to  conventional  ventilation  on  day  13  after  admission,  the  double  lumen  tube  was 
pulled  from  the  tracheostomy  site  and  a  regular  tracheostomy  tube  was  placed  The 
patient  was  placed  on  Pressure  Support  Ventilation  and  began  to  wean  The  patient 
was  weaned  horn  the  ventilator  to  tracheostomy  collar  17  days  after  conversion  to 
conventional  ventilation  (day  30  after  admission)  Three  days  later  the  patient  was 
decannulated  Three  days  after  decannulation  (day  36  after  admission)  the  patient  was 
discharged  Discussion  This  is  an  example  of  a  patient  that  benefited  from  the  use  of 
UHFJV  (both  ILV  and  HFJV)  Cases  of  UHFJV  are  reported  in  the  literature  (1.2.3)  and 
we  wanted  to  describe  the  positive  results  that  we  expenenced  with  this  case 
References 

1  Wipperman  C.  Schranz  D.  Baum  V  et  al  Independent  right  lung  high 
frequency  and  left  lung  conventional  ventilation  in  the  management  of 
severe  air  leaks  during  ARDS  Paediatric  Anaesthesia  1995.5(3)  189-192 

2  Mortimer  A.  Laurie  P.  Garreft  H.  et  al  Unilateral  high  frequency  jet 
ventilation  Reduction  of  leak  in  bronchopleural  fistula  Intensive  Care 
Medicine  1984.10(1)  39-41 

3  Cnmi  G.  Candiani  A.  Conti  G,  et  al  Clinical  applications  of  independent 
lung  ventilation  with  unilateral  high-frequency  jet  ventilation  (ILV-UHFJV) 
Intensive  Care  Medicine  1986,  12(2)  90-94 


PRONE  POSITION  INCREASES  DORSAL  TRANSPULMONARY 
PRESSURE  IN  NORMAL  DOGS.  Adams  AB,  Shapiro  RS,  Goldncr  M. 
Marini  J.I,  RcgKin.s  Hdspiial,  St,  Paul,  MN.  Background:  AlcleLla.sisimd 
radiographic  abnomialilics  in  adult  rcspiralorx'  distress  syndrome  (ARDS) 
are  predomin;uill\  gra\il\-dc[X'ndcnt  (dorsal),  B)  increasing 
transpulmonary  pressure  (Pip),  PEEP  recruits  lung  units,  thus  reducing 
shunt  and  impro\ing  oxygenation.  Prone  posilioning  also  improxes 
oxygenation  in  a  majority-  of  patients  u  ilh  ARDS.  We  reasoned  thai  prone 
positioning  decreases  dorsal  Ppl  dispr<iportionalely  creating  a  regional 
PEEP-Iike  effect.  To  determine  dorsal  Rp,  a  measure  of  regional  Ppl  is 
needed  since  esophageal  pressure  may  lenecl  o\  erall  rather  than  dorsal  Ppl. 
Methods:  Wafers  sensing  lung  surface  pressure  were  affixed  \  la  right 
thoracolonn  lo  the  dorsal  and  ventral  pleural  lining  in  4  ventilated, 
ancsllieli/ed.  and  paralyzed  mongrel  dogs.  In  three  dogs,  end  expiratory  Ppl 
was  measured  in  Ihc  supine  and  prone  positions.  To  simulate  and  amplily 
the  polential  effect  of  lung  edema,  Ihe  same  measuremenLs  were  made  in  one 
dog  alter  Ihe  lungs  were  filled  lo  FRC  with  pernubron  (S.G.  =  1.93) 
Results:  Pressures  in  cmH2Q 


Air-lilled  (n=-l.  means) 

Ventral 

Dorsal 


Liquid-filled  (11=1) 

Vciilial 

Dorsal 


Prone 


-8.2 


Dorsal  Pip  increased  in  the  prone  ptisilion  by  4,1  cmH20  in  normal  lungs 
and  by  14,2  cmH20  in  nuid-filled  lungs  due  to  decreases  in  doiNul  pleural 
pressure.  Conclusions:   The  prone  p<isition  may  Ciiuse  a  regional  incrca.se 
in  Pip  thai  exerts  Iraclion  on  those  areas  mosi  su.sccplibic  lo  aleleclasis.  This 
"regional  PEEP"  could  hi'  an  iinportanl  niechanism  lor  iiicieascd 
oxygenation  seen  in  pionc  positioning  and  ihe  eflcci  ma\  be  amplilied  by 
Ihe'presenceof  ah eolar  fluid.  Supported  by  SCOR  HI  Jk  1.^12. 


856 


Ri:si'iKAroRY  Cari-;  •  October  "98  Vol  4.'^  No  10 


Draser 


Neonatal  Volume  Ventilation  -  Do  It  Right! 


Adapting  to  the  needs  of  the  patient  while 
providing  the  means  for  protection  from  the 
serious  side  effects  of  ventilation. 


Ventilation  support  is  one  of  the  most  invasive 
procedures  performed  in  neonatal  intensive 
care.  The  new  Babylog  8000  plus  brings  total 
synchronization  to  ventilation.  Adapting  to 
interference,  such  as  tube  leaks,  allows  the 
patient  maximal  room  to  breathe  while 
providing  support  in  all  modes  of  ventilation. 
Improving  ventilation  perfonnance,  monitoring 
and  new  operating  concepts  give  clinicians  the 
tools  they  need  to  optimize  ventilation  and 
enhance  weaning. 


The  new  Babylog  - 
Babylog  SOOOplus 

The  plus  in  terms  of 
function  and  operation: 


Integrated  lung 
function  monitoring 
New  ergonomic 
operating  concept 
Unique  automatic  leak 
adaptation  improving 
total  synchronization. 
High  contrast  EL- 
display 

Improved  measuring 
technology 
Optional  -  Pressure 
Support  and  Volume 
Guarantee 


B 


It  goes  without  saying 
that  your  existing 
Babylog  8000  can  be 
upgraded. 

Babylog  SOOOplus  setting 
new  standards 


Drager  Inc.     Critical  Care  Systems     3136  Quarry  Road  Telford,  Pa.  1 8969 

Tel:  l-800-4Drager  Fax:215-721-6915      Internet:  http://www.draeger.com 


Circle  129  on  reader  service  card 
Visit  AARC  Booths  1300  - 1305  in  Atlanta 


Monday,  November  9,  12:30-2:25  pm  (Room  214E) 


^E  IMPACT  OF  OXlMEmY  ON  CARDfOPllMONAR^'  PROFILE  AND  ARTERIAL  BLOOD  G 


M  M  I  M  M  n  M 


CONTINUOUS  INDIRECT  CALORJMETRY  COMPARED  WITH  INTERMITTENT 
INDIRECT  CALORIMETRY  IN  THE  CRITICALLY  ILL  PATIENT. 
Jennifer  R.  Burriji  MAEd.  RRT.  Assistant  Professor  of  Medicine,  Director  of  Clinical 
Education,  The  University  of  Alabama  at  Binningham,  Birmingham,  AL 

Background:  Changes  in  body  con^Kisition  that  affect  body  weight  and  metabolic  active 
tissue  make  it  difficult  for  clinicians  to  evaluate  the  cnticaJly  ill  patient  for  nutritional 
si^porL  Allard  and  associates  in  1993  showed  that  miproper  support  of  a  patient 
nutritionally,  whether  that  be  overfeeding  or  underfeeding,  may  adversely  affect  that  patient's 
ICU  outcome  Patients  who  do  not  re^wnd  as  expected  to  estimated  evaluation  may  be 
better  assessed  usmg  a  method  known  as  indirect  calonmetry  (Allard,  1993)  There  are 
essentially  two  methods  of  indirect  calonmetry,  a  continuous  method  and  an  intermittent 
method.  This  study  was  designed  to  evaluate  vO,  (oxygen  consumption),  ^CO,  (carbon 
dioxide  production),  and  REE  (resting  eno-gy  expenditure)  via  both  methods  of  indirect 
calonmetry  to  deiennine  if  an  intenmttent  spot  check  for  VOj,  ^CO^,  and  REE  would 
accurately  determine  a  patient's  nutntional  needs.  Method:  Patients  were  recnuted  frcwn 
UAb's  MICU  (medical  mtensive  care  umt)  and  monitored  continuously  for  24  hours.  The 
Nellcor  Puritan  Bennett  (NPB)  7250  metabolic  momtor  m  conjunction  with  the  NPB  72{X) 
venlil^or  were  used  to  study  each  patient  m  the  MICU.  Sixteen  patients  were  recruited,  9 
males  and  7  females  ranging  in  age  from  1 9  to  88  year3  of  age    APACHE  11  scores  were 
detennined  from  each  patient  i^xm  entrance  into  the  study.  An  external  computer  was  then 
attached  to  the  monitor  and  set  to  gather  data  every  1 0  minutes  for  a  period  of  24  hours.  The 
computer  was  programmed  to  place  an  asterisk  at  2:00am,  which  is  considered  to  be  a  time 
in  the  patients  day  most  reflective  of  REE  Resuiu:  A  paired  t-test  analysis  was  performed 
on  the  data.  The  researcher  found  no  significant  difference  m  the  two  methods  of  indirect 
calonmetry  with  respect  to  VOj,  VCOj,  and  REE  in  these  cntically  Ul  patients.  Experience: 
The  researcher  has  completed  two  years  of  intensive  care  therapy  as  a  registered  respiratpry 
therapist,  two  years  of  research  e?q>eriexice  with  a  concentr^on  on  mechanical  ventilation  in 
a  university  hospital,  and  has  three  years  of  educational  expenence.  Conclusions:  From  the 
study  performed,  the  researcher  found  that  there  is  no  significant  difference  in  the  two 
methods  of  indirect  calorimetiy.  The  typical  intermittent  spot  check  does  accurately  predict  a 
patient's  ^Oj,  ^COj,  and  REE.  The  twenty  minute  spot  checks  were  within  10%  of  the  24- 
hour  values.  This  is  important  fn*  clinicians  to  understand,  so  that  they  are  reassured  that  the 
method  currently  being  used  is  adequate  for  cntically  ill  patient  populations. 


OF-98-029 


EFFECTS  OF  PATIENT  RESPIRATORY  MECHANICS  ON  THE  LfNLOADING  OF 
INSPIRATORY  MUSCLES  IN  PSV-  A  SIMULATION  STUDY 
Hong-LJn  Du.  MD,  Newport  Medical  Instruments.  Inc.  Costa  Mesa.  CA9:627 
Purpose:  To  investigate  how  the  patient  respiratory  mechanics  (patient  demand,  resistance,  and 
compliance)  affect  the  efficiency  of  PSV  m  unloading  the  inspiratory  muscle 
Method  A  drive-dependent  test  lung  model  (Michigan  TTL)  was  used  to  simulate  spontaneous 
breathing.  The  dnvmg  compartment  of  the  model  was  driven  by  a  Bear-5  ventilator  with  srne- 
flow  pattern  The  compliance  of  the  driving  compartmenl  was  set  at  200  m!/cmH20  (i.e  .  chest 
wall  compliance)  and  the  pressure  in  this  compartment  was  therefore  taken  as  the  pressure  of 
the  inspiratory  muscles  (Pmus)  Integration  of  the  Pmus  with  volume  provided  the  work  of  the 
inspu^tory  muscles  (Wmus)  The  flow  rate  of  the  Bear-5  was  adjusted  to  obtain  a  peak 
inspiratory  flow  rate  (PF)  at  the  airway  openmg  of  the  dependent  lung  of  30  or  60  LPM  when 
no  ventilator  was  attached  to  ihe  dependent  lung,  at  the  dependent  lung  compliance  of  80.40 
or  20  ml/cmH20  with  a  resistor  of  Rp5  or  Rp20  A  Newport  Wave  E200  ventilator  or  Servo 
300  ventilator  was  then  attached  to  the  dependent  lung  and  PSV  10  cmH20  was  applied  with 
trigger  sensitivity  of -0  5  cmH20  The  Wmus  when  no  ventilator  (Wmus-0)  was  attached  was 
compared  that  when  PSVIO  was  applied  (Wmus-p).  and  the  percent  unloading  of  the  Wmus 
was  calculated  by  (Wmus-0  -  Wmus-p)/Wmus-0.  The  percent  unloading  of  the  Pmus  was 
calculated  in  the  same  way  as  Wmus.  Mean  values  from  3  breaths  for  each  setting  were 
calculated  and  presented  because  the  variation  among  the  3  breaths  was  negligible. 
Results  At  the  same  patient  demand  level,  unloading  efficiency  of  PSV  decreased  as  the 
resistance  increased  and/or  the  compliance  decreased.  At  normal  resistance  and  compliance 
with  PF  of  30  LPM.  PSV  1 0  unloaded  90%  of  patient  inspiratory  muscle  work.  However,  when 
PF  increased  to  60  LPM.  PSVIO  only  unloaded  40%  of  the  patient  inspiratory  work.  The 
inspiratory  muscles  was  rarely  unloaded  at  high  resistance  with  high  demand  by  PSV  10  There 
was  no  recognizable  difference  between  the  Wave  E200  and  Servo  300 


Figure  Unloadings  of  Wmus  and  Pmus  by  PSV  10  (the  Wave  E200) 
Conclusion:  Although  both  ventilators  provided  nearly-square  pressure  waveform  during  PSV. 
the  targeted  pressure  in  these  ventilatory  is  the  pressure  at  the  Y  connector  (e  g.,  the  E200)  or  at 
intra-vcniilator(e-g.,  the  Scr^o  300).  instead  of  the  pleural  pressure  As  the  result,  as  the 
patient  airway  resistance  increases  {or  the  inspiratory  demand  increases  /  compliance 
decreases),  the  efficiency  of  PSV  in  unloading  the  inspiratory  muscle  decreases.  From  the 
work-unloading  standpoint,  PS  level  should  be  set  individually  based  on  the  patient  respiratory 
mechanics  and  inspiratory  effort 


OF-98-036 


DEMAND    OXYGEN    DEVICES:    TISSUE    OXYGENATION    IN   THE   CONTEXT 
OF    CONSERVATION 

Gecirgc  G,  Bur1t>n.  MD.  Wnghl  Stale  Uni\ere]t>'/Kettenng  Medical  Center, 

Kcttennj:,  Ohio.  Diannah  Henderson,  RN,  Kettenng  Medical  Center,  Kctlcnng, 

Ohio.  Sallcc  Hamngion,  CRTT,  Kettenng  Medical  Center.  Kcllcnng,  Ohio 


1  Row  oxygen  adraimstrauon  (CFO2)  is  the  reference  slandaid  for  evaluation  ol"  tlcniand 
oxygen  ddivcrv  devices  CI''02  is  effecuvc  because  il  is  availaMe  tbroughoul  the  rcspiralorj 
cycle  Cuirent  demand  oxygen  devnces  deliver  burst  doses  of  oxygen  during  inspiration  onlj .  and 
art  marketed  using  lenns  such  as  "flow -equivalence"  and  "savings -ratio"  when  coinpanng 
themselves  lo  C'f-02  We  bavc  obsened  that  these  devices  may  fail  lo  oxygenate  palicnLs 
adequately,  particularly  dunng  exerase.  and  we  .suspect  that  there  may  be  an  optimal  "w  indow  "  in 
the  respiratory  cycle  in  which  burst  oxygen  will  majnlain  alveolar  Wt-t  and  oxygen  uptake  This 
'Vmdovv"  prohaWy  occurs  dunn^  early  inspuation,  and  eiuichmenl  of  HC)->  then  should  result  id 
improved  oxygcnauon.  We  assessed  pcnpheral  oxygen  saturation  (Spt>>)  dunng  rest  and  exerdsc 
in  stable  oxypen-dcpcndcnl  COPH  paucnts  We  evaluated  Uirec  conunercially  available  oxygen 
CCTiserving  devices  and  a  demand  oxygen  ooaservation  device  (rxXA))  currently  under 
development.  Patients'  ability  to  maintain  a  "safe"  SpC)2  (  92*^  was  determined  and  the  results 
expressed  as  a  surrogate  for  oxygen  coosumplion  using  a  "^Icage"  analog  {fl-kg'! .  of 
supplemental  O2  consumption)  A  custom  data  acqmsiUon  device  was  used  lo  identify  the 
tnggcnog  of  each  demand  device  in  rdatjon  to  events  in  the  respiratory  cycle  The  amount  ol 
oxygen  delivered  per  breath  was  detemuned  by  t^culaUog  the  output  flow  and  Row  durabon  of 
each  device  The  study  was  unMinded.ordcrof  device  testing  was  randomi/ed    I'otir  devices  were 
tested;  DeVilbiss  Pulsc-Dose.  Nellcor  Puritan -Bennett  tT<-50.  Cliad  TherapeuUc  Oxyraalic.  and 
the  IXX'D  prototype  Results    The  devices  smdied  required  40-6*(''r  of  the  oxygen  flow 
requirements  of  the  CFO2  "gold  standard"  Only  the  [X)CD  device  pcrmined  more  "safe"  work 
output  than  CF(>2  ITw:  other  devices  permitted  66-79%  of  the  work  output  allowed  by  CI  Ot 
However.  IXK1>  allowed  a  suipnsiog63'J  more  work  output  than  CI'Ot  Conclu.Mon  (1) 
Tissue  oxygenation  dunng  excrase  is  more  important  than  oxygen  savings  alone  This  is  true 
since  ()2COiiscrvers  are- designed  for  ambulatory  patients  who  nctxl  supplemental  O^  >o  maintain 
an  active  lifestyle  (2)  O2  conscrvcrs  that  deliver  substantial  O2  savings  but  w  hich  fail  lo  increase 
the  pabcnt's  excrxase  tolerance  do  not  achieve  the  intended  effect  ol  increasing  mobility  while 
insiinng  panent  salcty,  (3)  Devices  thai  tnggcr  oxygen  flow  after  the  onset  of  inhalation  may  not 
mi'ct  the  "Window  "  for  opbmum  tissue  oxygenation 


OF-98-054 


858 


Rf.spiratory  C,^R^•;  •  0(T()Bi:r  "98  Voi,  43  No  10 


Monday,  November  9,  12:30-2:25  pm  (Room  214E) 


PUl-SE  OXIMETRY  DURING  WALKING  AND  BICYCLE  EXERCISE.  Douglas 
Maclnlyre.  Barbara  McMullen.RRT  Rebecca  Crouch.RPT.  Neil  Maclntyre.MD, 
Duke  University  Medical  Center,  Durham  NC 

Exercise  training  in  pulmonary  patients  during  pulmonary  rehabilitation  requires 
careful  assessment  and  monitoring  of  oxygenation  as  ventilation-perfusion 
relationships  can  change  markedly  with  exercise.  This  is  often  assessed  by  pulse 
oximetry  using  probes  on  various  skin  surfaces.  We  reasoned  that  the  different  types 
of  exercise  might  have  different  effects  on  oxygenation  and  that  the  oximeter  probe 
site  might  have  its  measurements  affected  by  local  perfiision  changes  as  well  as  limb 
motion  changes  that  occur  with  exercise.  Accordingly,  we  undertook  a  study  of  pulse 
oximetry  during  exercise  training  in  a  group  of  chronic  lung  disease  patients 
undergoing  pulmonary  rehabilitation.  Our  null  hypothesis  was  that  oximetry  readings 
not  be  affected  by  probe  location  or  type  of  exercise  performed  at  a  given  exercise 
heart  rate  METHODS.  All  patients  with  chronic  lung  disease  undergomg  exercise 
training  were  eligible  for  study  These  patients  exercised  daily  for  15  minutes  on  a 
bicycle  ergoraeter  (BIKE)  and  15  minutes  of  track  walking  (WALK).  On  the  day  of 
testing,  pulse  oximetry  readings  were  performed  using  either  a  Nellcor  or  a 
Novametnx  device  at  the  end  of  each  exercise  period.  Readings  were  taken  with  the 
probe  on  the  finger  (FIN)  or  on  the  temple  (TEM).  Exercise  heart  rate  (HR)  was  also 
recorded.  Analysis 
RESULTS  Sixty  I 


BIKE 
WALK 


1  patients  \ 


I10+/-II) 
1I2+/-I7 


i  performed  with  significance  taken  as  P<0.05. 
e  studied.  Group  data  is  given  in  the  table: 

Sp02(FIN)  Sp02(TEM) 

04,4  +  /.3.5'  PaS+M*)' 

93.0+/-4.2'  94.6+/-4.4* 

•  P<0.05  for  BIKE  vs  WALK  (both  probe  sites)  and  FIN  vs  TEM  (both  exercises) 
CONCLUSIONS.  For  a  given  HR.  bicycle  exercise  is  associated  with  higher  pulse 
oximetry  readings  than  walking  exercise.  This  may  reflect  different  central 
cardiorespiratory  responses  or  different  peripheral  perfusion  responses  during  the 
different  exercises.    In  addition,  temporal  probes  read  higher  than  finger  probes  during 
both  forms  of  exercise.  This  probably  reflects  ditTerent  scalp  vs.  digit  perfusion  changes 


OF-98-057 


IMPLEMENTING  A  POINT-  OF-CARE  BLOOD  GAS  TESTING  SYSTEM  IN  A  NICl) 

Julie  Ballard  BS  RRT.  John  Salver  BS  RRT.  DavE  Pedersen  MT  (ASCP),  Phil  Bach  PhD. 
Ramsey  Worman  GET.  Sharon  Froehlic  RN  Respiratory  Care  Service,  Primary  Children  s 
Medical  Center,  Sail  Lake  Cily,  Utah 

Introduction:  A  year  ago,  our  NICU  satellite  lab  averaged  I  4  blood  gases/hour     It  became 
apparent  that  mamlaining  their  infrequently  used  blood  gas  analyzer,  the  ABL520  (Radiometer 
America,  Wesllake  OH),  in  the  NICU  Satellite  Lab  was  not  financially  feasible,  so  an 
interdisciplinary  team  was  created  to  evaluate  ways  to  decrease  costs  without  compromising 
care    Our  NICU  is  a  35  bed  ICU  with  4754  vent  days  in  1997    Proposal:  We  designed  a  6 
month  pilot,  in  which  routine  NICU  blood  gases  would  be  sent  to  the  main  lab  via  a  pneumatic 
tube  transport  system,  and  poinl-of-care  testing  using  an  i-STAT  system  (i-STAT  Corp, 
Princeton  NJ)  would  be  available  for  new  admits,  unstable  patients,  or  when  the  lube  system 
was  down    NiCU's  ABL520  could  then  be  transferred  to  the  main  lab,  allowing  them  to  retire 
their  ABL300  without  additional  capital  expense.  Phlebotomists  and  a  limited  H  of  RCP's  would 
be  u-ained  to  use  the  i-STAT    Lab  would  be  responsible  to  maintain  i-STAT  QA  controls  and 
Respiratory  Care  would  be  responsible  for  their  own  proficiency  testing     During  the  6  month 
pilot  we  would  track  capillary  tube  loss  or  breakage  while  using  the  pneumatic  tube  system,  ft 
cartridges  used,  W  of  cartridge  failures,  and  reasons  for  using  i-STAT  Before  we  could  begin 
the  pilot,  It  was  necessary  to  update  the  pneumatic  bjbe  system  to  increase  its  reliability  and 
decrease  downtime  Results:  Tube  system  downtime  was  34 1  hrVyr  prior  to  the  upgrade,  and 
20  hrs/yr  after  the  upgrade    Retiring  the  A8L300  saved  us  $20,4 80/year  (cost  of  reagent, 
service  contracts,  QC  controls  and  materials)    We  analyzed  4679  NICU  blood  gases  during  the 
6  monlh  pilot,  wiUl  only  102  (2%)  of  them  run  on  i-STAT    Of  the  i-STAT  cartridges  used.  47«/. 
of  them  were  G3+ (blood  gas,  S4  75/each)and  53%  of  them  were  EG7  (blood  gas  and 
electrolyte.  $7.00/each)    There  was  no  report  of  capillary  njbe  breakage  or  loss  during 
transport    There  were  2  cartridge  failures,  both  due  to  operator  error  during  the  first  month  of 
the  pilot   A  review  of  the  unit's  quality  management  reports  yielded  no  episodes  of  pt  care 
being  effected  due  to  a  delay  in  blood  gas  results    The  yearly  material  cost  of  running  these  i- 
STAT  tests  would  be  $  1 537  including  service  contracts  and  cartridges    Since  analyzing  a  blood 
gas  takes  about  7  min  of  a  therapist's  time,  NICU  RCP's  would  save  an  additional  1067 
hours/year  (-3  hrs/day)  by  sending  routine  blood  gases  to  the  main  lab,  and  only  performing  the 
poinl-of-care  testing    Personnel  in  ihe  mam  lab  handled  the  increased  load  from  NICU  (~  I  I  - 
1  9  blood  gases/hr),  by  having  ihe  faster  ABL520  machine    Mam  lab  turnaround  time  on  NICU 
blood  gases  averaged  15  minutes    Reasons  for  utilizing  poinl-of-care  testing  were  unstable  pt 
(72%).  new  admit  (16%).  inadequate  sample  volume  (5%).  and  miscellaneous  (7%) 
Oiscussion:  Probably  the  most  important  factor  in  the  success,  is  education  on  when  to  use  i- 
STAT    Ovemtilization  of  i-STAT  decreases  cost  savings  due  to  the  cost  of  the  cartridges 
Underutilization  of  i-STAT  on  critical  pis  decreases  satisfaction  and  may  compromise  pt  care 
I-STAT  results  are  available  immediately  through  both  a  printout  and  automatic  download  from 
the  receiving  station  to  Ihe  bedside  computer    I-STAT  can  be  used  on  pis  with  an  otherwise 
insufficienl  sample,  as  it  only  requires  2-3  drops  of  blood    We  have  kepi  the  w  of  RCP's 
running  i-STAT  small  (cun^cnlly  21  RCP's  or  47%  of  staff),  due  to  the  logistics  of  training  and 
maintaining  proficiency  of  all  staff  on  this  low  volume  procedure  By  selectively  using  poinl-of 
care  testing,  it  is  possible  to  cut  costs,  without  compromising  pi  care 


A  COMPARISON  OF  THE  NONIN  ONYX  9500  PULSE  OXIMETER  TO  THE 
CRITICARE  SYSTEMS  503  PtLSE  OXIMETER  AND  THE  CORNING  482 
CO-OXIMETER.    l.lliannaRaitak.  BS.  RRT.  Asthildur  Gudmundsdonir.  BS.  RRT  and 
David  C.  Shelledy,  PhD,  RRT.    The  University  of  Texas  Health  Science  Center  at  San 


BACKGROUND:  Pulse  oximetry  was  introduced  into  rou 
oximeters  provide  a  fast,  accurate  and  non-invasivc  method 
oxygen  levels     Pulse  oximetry  utilr 


clinical  use  in  1984.    Pulse 
ssess  patients'  arterial 
wavelengths  of  light  which  pass  through  a 
fingertip  or  earlobe  to  determine  oxy-hemoglobin  saturation  fSpO,).    Prior  to  routme 
clinical  use  of  pulse  oximetry,  an  arterial  blood  sample  was  required  to  detennine  oxy- 
hemoglobin sanitation     The  Nonin  Onyx  9500  pulse  oximeter  (IMonin  Medical  Inc.. 
Plymouth.  MN)  is  a  minianire  device  used  to  measure  SpO,  at  the  bedside     We  compared 
the  Nonin  Onyx  system  to  a  larger  and  less  portable  Cnticare  Systems  Inc  503  (Criticare 
Systems  Inc    Milwaukee,  Wl)  conventional  pulse  oximeter  and  to  the  results  of  arterial 
blood  co-oximetry  using  the  Coming  482  Co-oximeler  (Ciba  Coming  Diagnostics  Corp  . 
Norwick.  MA).    METHOD:    Following  infonned  consent.  56  hospitalized  patients  had 
simultaneous  measurements  of  SpO,  using  the  Nonm  Onyx  9500  and  Criticare  Systems 
Inc   503  (CSI  503).    Of  the  56  measures.  26  patients  also  had  concun-ent  artenal  blood 
samples  drawn  and  analyzed  using  the  Coming  482  Co-oximeter     Mean  SpO,  and  SaO, 
values  were  compared  using  the  t-test  for  dependent  samples  to  detennine  if  diere  were 
significant  differences  (p<.05)  between  the  Nonin  Onyx  SpO,  values  and  those  obtained 
via  the  CSI  503  or  Coming  482.    Pearson-product  moment  correlations  were  calculated  to 
detennine  if  there  were  significant  conelalions  (p- 05)  between  instruments     RESULTS: 
Means  and  standard  deviations  for  the  thre 


II    Nonin  Onyx  9500                 CSI  503 

Coming  482 

Oxygen  Saturation    ||           96  4(3  1)                      95.0(3  5) 

95.0(3  1) 

There  was  no  significant  difference  between  the  Nonin  system  and  the  Coming  482  values 
(t=-.21:  p=83;  n=26).  There  was  also  no  significant  difference  between  SpOj  as  measured 
by  the  CSI  503  and  values  obtained  using  the  Coming  482  (t=l-32;  p-  20.  n»26l  There 
was  a  significant  difference  between  the  SpO,  obtained  by  the  Nonin  Onyx  9500  and  the 
CSI  503  (t-6.17,  p<.0001,  n=56)-  There  were  significant  conelallons  between  the  Nonin 
Onyx  9500,  the  CSI  503  (r>.86;  p<.0001)  and  the  Coming  482  (r-  74;  p..00002). 
Regression  equations  were 

Nonm  Onyx  SpO;  =  3.7106  +  .96217  x  Coming  SaO, 

Nonin  Onyx  SpO,  =  24  187  +  .76086  x  CSI  503  SpO, 
CONCLUSIONS:    There  was  no  significant  difference  between  SpO,  as  measured  by  the 
Nonin  Onyx  9500  pulse  oximeter  and  the  results  of  arterial  blood  co-oximetry  using  the 
Coming  482.    There  were  significant  differences  between  the  SpO,  as  measured  by  the 
Nonin  Onyx  9500  and  the  CSI  503,  however,  these  differences  were  probably  not 
clinically  important. 


OF-98-067 


SYSTEt^ATIC  REVIEW  OF  THE  LITERATURE  REGARDING  THE 
DIAGNOSIS  OF  SLEEP  APNEA    I  Elaine  Allen,  PhD,  Susan  D  Ross,  MD, 
FRCPC,  Katharine  J  Hamson,  BA,  Marion  Kvasz,  MD,  MPH,  Janet  Connelly, 
BS   Ins  Rheinhail,  MA,  MetaWorks,  Inc  Boston,  MA 

Objective:  To  establish  the  evident*  base  for  the  diagnosis  of  sleep  apnea 
(SA)  Diagnostic  tests  covered  vitere  all  sleep  monitonng  devices,  radiologic 
imaging,  laboratory  assays,  and  clinical  signs  and  symptoms  posited  'or  iJse  in 
screening  or  diagnosis  ol  SA  The  standard  sleep  lab  polysomnogram  (Pb(j) 
was  the  gold  standard  The  evidence  base  was  derived  using  systematic  review 
methods  Methods:  A  literature  search  conducted  back  to  1980  using  Medline 
and  Current  Contents,  was  supplemented  by  a  manual  review  of  Ihe 
bibliographies  of  all  accepted  papers  The  search  cut-olf  date  was  November  I. 
1997  Included  diagnostic  studies  had  to  report  Ihe  results  of  any  test  to  establish 
or  support  a  diagnosis  of  SA,  in  relation  to  a  PSG-denved  apnea  index  (Al). 
apnea-hypopnea  index  (AMI)  or  respiratory  distress  index  (RDI)  Studies 
Included  a  minimum  ol  10  adult  patients  suspected  ot,  or  diagnosed  with  SA  as 
determined  by  a  standard  PSG  Eligible  languages  were  English.  German. 
French  Spanish  or  Italian  Papers  reporting  prevalence  or  clinical  comorbidities  ot 
SA  were  also  accepted  147  studies  met  or  exceeded  minimum  evidence  scores. 
Fiom  these  data  on  study,  patieni,  and  test  characlenstics.  and  on  outcomes 
were  collected  Non-diagnostic  studies  reporting  prevalence  or  clinical 
comorbidities  were  separately  extracted  Study  and  patient-level 
covanates  were  summarized  Outcomes  were  analyzed  using  Fixed  effects 
models  and  using  summary  receiver  operating  characteristic  curves  (ROC)  where 
data  were  available  Results:  In  71  analyzable  studies  (7,572  patients)  the 
sensitivity  and  specilicity  of  partial  channel,  and  partial  time  PSGs  appeared 
most  promising  as  pre-screening  tests,  or  replacements  (or,  full  PSG.  Prediction 
models  also  achieved  high  sensitivity  and  specilicily  Portable  devices  were  very 
variable  due  to  study  and  device  heterogeneity  Radiology  studies  and  studies  ot 
questionnaires  anthropomorphic  signs,  and  ENT  exams  were  too  heterogeneous 
to  be  analyzed  Global  clinical  impressions  and  oximetry  provided  similar 
sensitivity  and  specificity  but  may  be  insufficienl  as  substitutes  for  pre-selection 
for  full  PSG  Least  accurate  were  flow  volume  loops  The  review  and  analysis 
were  limited  by  variability  in  PSG  delinitions  of  apnea  and  thresholds  for 
diagnosis  SA  prevalence  studies  were  reviewed  covering  different  patient 
populations  (eg  elderly,  hypertensives).  Few  studies  utilized  PSG  to  diagnose 
SA  and  diagnosis  was  based  upon  unvalidated  tests  Conclusions:  Progress 
has  been  made  in  establishing  reasonable  sensitivity  and  specilicity  ol  other 
tests  Standardization  of  temis  and  criteria  would  expedite  development  and 
enhance  the  utility  of  this  liteiature  in  the  tutute  When  compared  to  the  gold 
standard  no  diagnostic  achieved  consistently  high  sensitivity  and  specificity 
This  report  was  developed  under  contract  with  the  Agency  lor  Health  Policy  and 
Research  Contract  #290-97-0016. 


Respiratory  Care  •  October  '98  Vol  43  No  10 


859 


Monday.  November  9,  12:30-2:25  pm  (Room  214E) 


USEFUL  LIFE  OF  PULSE  OXIMETER  SE^SORS  IN  A  NICU. 

Alison  Thomas.  BSN.  RN.  Michael  Holmes.  BS.  RRT.  John  Vogt,  MD. 
Emeslo  Gangitano.  MD.  Carolina  Stephenson.  MD.  Richardo  Liberman.  MD, 
Dept.  of  Neonatology,  Huntington  Memorial  Hosp.,  Pasadena,  CA 

Background:  Although  multiple  types  of  pulse  oximeter  sensors  are  available, 
disposable  sensors  are  most  commonly  used  in  the  NICU.  During  lengthy 
hospitalization,  the  sick  newborn  may  utilize  many  pulse  oximeter  sensors  due  to 
sensor  failure,  hygiene,  or  unsightliness.  Increasing  the  useful  life  of  pulse  oximeter 
sensors  would  directly  reduce  the  costs  of  NICU  care.  A  new  pulse  oximeter 
technology  and  family  of  sensors  have  been  introduced  using  novel  materials, 
however,  sensor  longevity  has  not  been  studied.  Method:  Sixteen  sick  newborns 
with  gestational  ages  of  25  to  41  weeks  and  weights  of  465  to  3600  gms-  were 
studied,  A  prototype  Masimo  SET  pulse  oximeter  (Masimo  Corp.,  Irvine.  CA)  and  a 
Nellcor  N-200  oximeter  (Nellcor  Puritan  Bennett,  Pleasanlon.  CA)  used  the 
Masimo  neonatal  sensor  and  Nellcor  N-25  sensor,  respectively  The  start  time,  and 
the  time  a  sensor  was  replaced  or  removed,  along  with  the  reason  for  replacement  or 
removal  were  recorded  Both  sensors  were  removed,  the  site  assessed  and  the 
sensors  repositioned  every  12  hours  Results:  56  sensors  were  used  for  a  total  of 
21 1  days.  The  Masimo  neonatal  sensors  had  a  significantly  longer  useful  life  than 
the  Nellcor  N-25:  111  versus  5-7  days  (range  of  5  to  22.5  and  4  to  7.5  days 
respectively,  p  <  0.01 ).  The  reasons  for  replacing  the  sensors  were:  failure  to  adhere 
or  display  a  value  {3/19  for  Masimo  and  6/37  with  Nellcor).  soiled  condition  (0/19 
for  Masimo  and  24/37  with  Nellcor).  What  was  impressive  was  that  13/16  times 
(8 1  %)  the  original  Masimo  sensor  applied  to  the  neonate  was  used  until  monitoring 
was  discontinued,  compared  to  only  1/16  times  (6%)  with  Nellcor  No  difference  in 
appearance  of  the  monitoring  sites  was  found  between  manufacturers.  Experience: 
We  have  used  Masimo  oximetry  for  16  months  and  have  been  impressed  with  the 
longevity  of  the  Masimo  sensors.  Reasons  for  the  phenomenon  include  that  the 
Masimo  sensors  are  constructed  of  water-resistant  material  whereas  the  N-25 
utilizes  a  cotton/elastic  application  tape  The  cotton  absorbed  perspiration,  bodily 
fluids,  bath  water,  and  parenteral  fluids.  Within  days,  the  N-25  would  exhibit  an 
odor  noticeable  by  the  parent  or  staff  which  often  dictated  disposal.  Whereas,  the 
surfaces  of  the  Masimo  sensor  can  be  cleaned  of  debris  with  an  alcohol  wipe 
allowing  repeated  applications.  The  disposal  of  the  Masimo  adhesive  sensors  was 
almost  exclusively  due  to  the  neonate  no  longer  needing  monitoring  and  not 
because  of  Masimo  adhesive  sensor  failure.  Conclusions:  if  the  sensor  cost  to  the 
hospital  was  identical,  a  nearly  twofold  savings  could  be  realized  with  the  Masimo 
SET  neonatal  pulse  oximeter  sensors. 


CO-OXIMETRY  VALIDATION  OF  A  NEW  PULSE  OXIMETER  IN 
SICK  NEWBORNS.  Michael  Holmes.  BS.  RRT.  Alison  Thomas.  BSN. 
RN,  John  Vogt.  MD.  Ernesto  Gangitano.  MD.  Carolina  Stephenson  MD,  Richardo 
Liberman,  MD,  Neonatal  Dept.,  Huntington  Mem.  Hosp..  Pasadena,  CA 

Background:  Pulse  oximetry  (SpOi)  has  been  used  for  over  a  decade  as  a  indicator 
of  the  percent  oxygen  saturation  of  arterial  blood.  A  new  pulse  oximeter  has  been 
introduced  which  uses  a  novel  approach  for  determination  of  the  SpOT.  Using  the 
patented  Discrete  Saturation  Transform  (DST).  Masimo  SET  pulse  o\imetr>' 
(Masimo  Corp..  Irvine,  CA)  works  despite  low  perfusion  and  patient  motion  (prior 
studies).  Method:  A  protot>'pe  Masimo  SET  pulse  oximeter  and  a  Nellcor  N-200 
oximeter  (Nellcor  Puritan  Bennett.  Pleasanton.  CA)  were  attached  to  opposing  feet 
and  covered  to  prevent  LED  cross-talk.  Data  (ECG  heart  rate.  SpQi  and  pulse  rate) 
were  collected  every  second  ( 1  Hz)  by  a  system  composed  of  a  laptop  computer,  8- 
channcl  multiplexer,  and  data  acquisition  software,  Sixty-eight  samples  of  arterial 
blood  were  analyzed  from  18  sick  newborns.  Demographics  were:  gestational  ages 
of  26  to  41  weeks  and  weights  of  825  to  4055  gms.  All  infants  were  intubated  and 
on  various  forms  of  continuous  mechanical  ventilation:  8  IMV,  6  SIMV,  and  4 
HFOV,  An  AVL  OMNI  blood  analyzer  (AVL  List  GmbH  Medizintechnik.  Graz, 
Austria)  was  used  for  analysis  of  pH,  PCO2.  POj.  %COHb.  %MetHb,  total  Hb,  and 
functional  %Sa02.  The  AVL  OMNI  uses  an  array  of  66  wavelengths  to  determine 
its  oximetry  calculations.  Results:  The  bias  and  precision  for  each  manufacturer 
versus  the  measured  functional  blood  oxygen  saturation  was  0,9  and  2.4  for  Masimo 
and  1 .0  and  5  1  for  Nellcor  respectively.  The  Nellcor  findings  included  a  spurious 
point  of  63%  (97%  SaOj  and  99%  SpO:  Masimo)  where  the  Nellcor  pulse  rate 
matched  the  ECG.  Three  N-200  zero-outs  were  ignored  in  the  calculations  where 
low  perfusion  adversely  affected  the  Nellcor  even  though  Masimo  read  through 
these  events  without  anv  problem  (97/97/97%  SaO^  and  99/100/99%  SpO: 
Masimo).  All  Masimo  data  points  were  included-  Blood  gas  values  were  either  non- 
significant (e.g..  %COHb  and  %MetHb  within  normal  limits)  or  revealed  a 
diversely  ill  population  (e.g.,  pH  of  7. 1 9  to  7.57.  PCO2  of  25,5  to  69, 1 .  PO2  of  46.5 
to  505.3,  and  total  Hb  of  9,4  to  17.3).  Experience:  We  have  used  Masimo  SET  for 
16  months  and  have  published  on  the  dramatic  improvement  i 
measurement  and  reduced  false  alarms  compared  to  conventional  pulsi 
However,  accuracy  has  not  been  reported  in  sick  infants.  Conclusions:  Masimo 
SET  accurately  reflects  the  Sa02  in  sick  infants.  Our  prior  findings  of 
reduced  false  alarms  and  continuous  operation  during  motion  and  low 
perfusion  compared  to  a  conventional  pulse  oximeter  occurs  without  a 
loss  in  accuracy  of  the  Sp02  displayed. 


OF-98-104 


CONTINUOUS  ARTERIAL  BLOOD  GAS  MONITORING  DURING  CARINAL  PEEP  TITRATION  AND 
INTRATRACHEAL  PULMONARY  VENTILATION  IN  A  LUNG  INJURY  MODEL 
Karl  Hullauist  BSRRT.  Ellis  Hon  MO,  Bala0ansadhar  Totapally  MD,  Dan  Torbati  PhD, 
Andre  RatzynskI  MD,  Jack  Wollsdori  MD. 
Division  of  Critical  Care  Medicine.  Miami  Children's  Hosprtai.  Miami.  FL  33155. 
Introduction   The  pnmary  objective  ot  intralracheal  Pulmonary  Venlilation  (ITPV)  is  PaCO?  reduction. 
This  effect  may  be  assessed  either  by  intemiittefit  artenal  blood  gas  analysts  (lABG)  or  by  continuous  Wood 
gas  monitonng  (CoABG),  the  latter  is  mslanlaneous  and  cost  effective    The  purpose  of  this  study  was  to 
assess  1)  Ihe  effect  of  PEEP  titration  on  PaOj  and  PaCO;  during  ITPV,  ar>d  2)  to  compare  the  PaCOj 
values  obtained  dunng  CoABG  with  those  of  lABG  in  a  rabbit  lung  tn|ury  model 
methods:  Five  New  Zealand  dwarf  rabbits  {3-5  kg  body  weight)  were  anesthetized  and  tracheostomized 
(4  0 1  d  multi-lumen  ET  tube)  and  cannulaled  in  one  carotid  artery  and  intemal  jugular  vein    Conventional 
ventilation  (CV)  was  instituted  (FiOj  1  0,  frequency  80  bpm,  cannal  PEEP  2,  flow  IL/kg/min)   A  nonnal 
range  of  lABG  was  established  by  adiusling  I  E  ratios   Lung  injury  was  than  insliluted  by  repeated  saline 
lavage    lABG  and  CoABG  were  measured  dunng  one  hour  of  CV,  followed  by  one  hour  on  ITPV  and  return 
toCV(F,0;=1)    ITPV  was  established  using  a  reverse  thrustefcalheler  (Cook,  Inc  )  with  a  flow  of  1 
L/kg/min    The  flow  was  delivered  and  humidified  through  an  in-line,  servo,  pressure  limited  system  (Hudson 
RCI)    Dunng  both  CV  and  ITPV,  the  frequency  was  set  at  80  bpm    The  blood  gas  effect  of  vanable  levels 
of  PEEP  from  2  to  8  cmHi'O  was  then  assessed  dunng  a  one  hour  continuation  of  ITPV  (n=3)   Arterial 
pressure,  heart  rate,  and  carinal  pressures  were  continuously  recorded    The  lABG  profiles  were  detennined 
by  a  blood  gas  analyzer  (ABL  30,  Radiometer  Copenhagen).  The  CoABG  was  continuously  recorded  by  a 
fiberoptic  sensor  probe  placed  inside  a  20G  1  5  inch  carotid  artenal  catheter    The  sensor  was  connected  to 
a  blood  gas  monitor  (Paralrend  7,  Diamelncs  Medcal,  Inc  St  Paul,  MN)    Extreme  light  Inggers  an  internal 
safety  discontinuation  of  CoABG  monitonng   We  utilized  foil  to  shield  the  catheter  and  connecting  wires 
from  this  effect    The  continuous  readngs  (pH,  PaCO?  and  PaO/)  were  initially  calibrated  with  the  steady- 
stale  t)lood  gas  data  and  subsequently  compared  to  the  mlennitlenl  readings  every  10-15  mm    The  arterial 
Wood  gas  values  obtained  by  both  methods  were  analyzed  with  repealed  measures  ANOVA,  followed  by 
TuheyKramer,  and  precision  (or  both  methods  were  determined 

Results:  The  data  showed  lower  PaCO;  dunng  ITPV  as  measured  both  by  lABG  and  CoABG    Dunng 
ITPV,  PaO/  increased  significantly  with  a  slepwise  increase  in  PEEP  from  2  to  8  cm  H?0  (n=3:  repealed 
ANOVA  and  Tukey  Kramer),  no  significant  changes  occurred  in  PaCO;  with  vanable  PEEP   Companson  of 
gas  exchange  parameters  between  lABG  and  CoABG  showed  matching  values  and  a  high  preosion  for 
PaCO?  dunng  both  CV  and  ITPV    Stepwise  changes  in  the  Wood  gas  values  dunng  Ihe  acute  injury  were 
demonstrated  by  Ihe  continuous  monitonng 

Conclusions:  Dunng  ITPV,  increases  in  cannal  PEEP  were  associated  with  higher  PaO;  but  had 
slatisUcally  insignificani  effect  on  PaCOj    Direct  continuous  monitonng  of  PaCO;  lo  assess  adequacy  of 
ventilation  dunng  txith  ITPV  and  CV,  is  achievaWe  and  may  be  preferable  to  EtCO;  monilonng  which  is 
subject  to  inaccuracy  (shuntir>g,  dead  space  ventilation,  and  low  cardiac  output  stale)    Attention  lo  external 
light  effect  is  advisaWe  when  cunent  CoABG  monitonng  is  utilized   Dunng  lung  injury,  progressive  hypoxia 
occuned  with  each  lavage  in  a  stepwise  fashion    Continuous  Wood  gas  monitonng  may  be  more 
appropnale  lor  assessn^ent  of  any  acute  expenmental  or  clinical  process  thai  involves  evolving  hypoxia  and 
hypercarbia 


OF-98-112 


TRACKING  OF  ALVEOLAR  MACROPHAGE  MEMBRANE  RECYCLING 
DURING  PHAGOCYTOSIS 

Brook  R  Ballard.  BS  RRT.  Andrea  L  May,  BS  CRTT,  Matthew  A  Roth,  BS  RRT, 
Neal  D  fylorgan,  BS  CRTT,  Patricia  A.  Smith.  BS,  and  Douglas  G  Perry,  PhD 
Respiratory  Therapy  Program,  School  of  Allied  Health  Sciences,  and  Division  of 
Pulmonary  and  Critical  Care  Medicine,  Indiana  University  School  of  Medicine. 
Indianapolis  IN 

Background    Pulmonary  alveolar  macrophages  (AMs)  provide  the  pnmary 
defense  in  the  lung  against  foreign  organisms  and  inhaled  particulates  One  of 
the  immunological  roles  of  the  AM  is  to  clear  these  from  the  lung  This  cellular 
clearance  is  accomplished  by  phagocytosis,  which  involves  AM  recognition, 
internalization,  and  digestion  of  these  foreign  targets  Membrane  recycling  has 
been  shown  to  occur  in  endocytosis  and  cell  migration,  it  is  possible  that  this 
process  also  occurs  during  phagocytosis  The  purpose  of  this  study  is  to 
visualize  and  quantify  membrane  recycling  dunng  phagocytosis,  and  correlate 
membrane  turnover  with  phagocytic  activity  Methods    Rat  AMs  were  obtained 
by  whole  lung  lavage  AM  plasma  membrane  was  labeled  with  10  mg/ml  FITC- 
Ijpophilic  dextran  Fluorescence  of  the  external  label  was  quenched  with  25  mM 
NaHC03  titrated  to  pH  5  0  Internalization  of  membrane  was  measured  as 
fluorescence  intensity  of  the  dequenched  label  AM  membrane  recycling  was 
observed  using  a  Zeiss/Meridian  confocal  microscope  while  employing  AM 
interaction  with  an  immunoreactive  substrate  as  a  two-dimensional  model  of 
phagocytosis  For  data  collection,  AMs  were  randomly  selected  by  panning  the 
field  Fluorescence  and  phase  contrast  images  of  AMs  were  acquired  every  5 
minutes  for  one  hour  Membrane  turnover  was  quantified  as  persistence  (total 
label  area  over  time)  and  as  relative  label  size  (ratio  of  label  penmeter  to  area 
over  time),  and  phagocytic  activity  was  quantified  as  pleomorphism  (shape 
factor  residuals  over  time)  Results    AMs  demonstrated  phagocytic  activity 
under  the  conditions  of  this  expenment    Pleomorphism  ranged  from  0  01  to  0  35 
mean  squared  residuals  (MSR)  Membrane  turnover  increased  for  any  given 
level  of  phagocytic  activity    Persistence,  which  is  inversely  proportional  to 
membrane  turnover,  had  a  moderate  negative  correlation  with  phagocytic 
activity  (r  =  0  60)  Relative  label  size,  which  is  also  inversely  proportional  to 
membrane  turnover,  had  a  strong  negative  correlation  (r*'  =  0  92)  Conclusions. 
Membrane  turnover  increased  as  phagocytic  activity  increased  These  results 
suggest  that  membrane  recycling  occurs  dunng  phagocytosis  This  may  be  the 
mechanism  by  which  membrane  malenal  is  replenished  at  the  leading  edges  of 
fjlopodia  and  pseudopodia  during  phagocytosis 
Supported  by  NIH  HL50128  (D  G  P ) 


OF-98-136 


860 


Ri  SIMI-; AioRV  Carh  •  OcroRi  R  '98  Voi.  43  No  10 


Monday.  Novembrr  9.  12;3()-2:25  pm  (Room  214E) 


RESP 

RATORY 

HOME 

CARE 

PROCEDURE 

MANUAL 

The  only  Procedure  Manual  Available  lor  Home  Care 

^\f\  h     '^fO'i^  the  Patient  Care  and  Home  Care  Committee 

^!^!^\J1iM^y^     of  the  Pennsylvania  Society  for  Respiratory  Care,  inc. 

The  new  Respiraloty  Home  Care  Procedure  Manual  is  especially  designed  lor  Ihe  hone  care  selling.  And,  il  is 


easily  adaplable  to  any  allernate  care  site  from  subacute  to  home  medical  equipment  companies  and  nursing 


tioner  General.  This  section  includes  a  Standard  tor  Providers  ot  Respiratory  Care;  a  Patient/Client  Bill  of 
Rights:  and  provides  intormation  on  Discharge  Planning  Routine  Respiratory  Care.  This  section  includes 
procedures  on  Disintection  ot  Home  Respiratory  Equipment,  Oxygen  Therapy,  Oxygen  Delivery  Systems:  Aerosol 
Therapy,  Bland  Aerosol  Therapy:  Ultrasonic  Nebulizer:  Intermittent  Positive  Pressure  Breathing:  Cleaning  and 
Disintection  ot  Aerosol  Therapy  Equipment:  Bronchodilator  fvlelered  Dose  Inhaler:  Steroid  Metered  Dose  Inhaler: 
Peak  Flo*  Meters,  CRT,  Bronchial  Drainage,  Percussion,  and  Vibration  Techniques,  Cough:  Mucus  Clearance 
Therapy:  and  it  also  includes  a  Treatment  Form,  Traveling  Form,  and  a  Daily  Care  Form  tor  both  the  practitioner 
and  the  patient  Specialized  Respiratory  Care.  Includes  Suctioning:  Tracheostomy  Care,  Nasal  CPAP/ 
BiPAP:  and  Apnea  Monitoring  Mechanical  Ventilation.  Covers  Mechanical  Ventilation:  Home  Environmenl 
Assessment:  Humiditication,  a  Mechanical  Ventilation  Settings  Form:  Daily  Care  Forms:  Skills  Checklist:  Nega- 
tive Pressure  Ventilation:  Negative  Pressure  Ventilation  Checklist:  and  Pediatric  Ventilation  Ancillary  Care. 
Includes  Activities  tor  Daily  Living  and  Energy  Conservation  Techniques:  and  Nutrition, 

245  pages  Second  Edihon  by  Ihe  Pennsylvania  Society  lor  Respiratory  Care,  Inc 


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COMPARISON  OF  NON-DISPOSABLE  AND  DISPOSABLE 

OXIMETER  PROBES  DURING  ANESTHESIA 

INDUCTION 

Allysa  Adkins  RRT,  Jon  A.  Tucker  CRTT.  and  Br>.ce  Click  CRTT 


BACKGROUND:    To  manage  costs,  we  compared  the  pertbrmance  of  disposable 
versus  non-disposable  oximeter  probes  in  the  surgical  setting.  We  compared 
performance  of  two  non-disposable  Nellcor  oximeter  probes  during  anesthesia 
induction  to  the  currenUy  used  disposable  probe.  Noninvasive  measurement  of 
oxyhemoglobin  saturation  by  pulse  oximetry  (Sp02)  has  become  one  of  the  most 
important  monitoring  advances  in  the  care  of  anesthetized  and  seriously  ill  patients; 
its  use  is  the  accepted  standard  of  care  intraoperatively.  We  hypothesized  that  the 
accuracy,  precision,  and  performance  of  the  reusable  (non-disposable)  probe  will 
be  comparative  to  that  of  the  currently  used  Nellcor  probe  and  provide  a  cost 
saving.  MATERIALS  AND  METHODS:  Children  receiving  general  anesthesia  and 
greater  than  one  year  of  age  were  incorporated  into  our  study.  Nellcor  Oxiband 
(OB)  and  Dura-Y  (DY)  reusable  probes  were  each  attached  to  a  separate  pulse 
oximeter,  and  placed  simultaneously  in  the  same  vicinity  of  the  same  extremity  of 
each  patient  with  the  disposable  probe.  Foam  and  band-aid  type  wraps  were 
alternated  throughout  the  study.  Sp02  and  heart  rate  measurements  were  taken  at 
one  minute  intervals  for  the  first  ten  minutes  of  anesthesia  induction.  Waveform 
consistency  and  motion  artifact  were  also  obtained.  The  results  of  the  disposable 
probe  were  compared  to  the  results  of  the  non-disposable  probe  by  a  one-way 
ANOVA.  RESULTS:  We  found  that  there  was  no  staristical  difference  between  the 
mean  hean  rates  using  the  DY  or  the  OB  oximeter  probes.  There  was  a  significant 
statistical  difference  between  the  mean  saturation  with  both  oximeter  probes.  We 
found  this  not  to  be  clinically  significant  based  on  current  literature. 
CONCLUSIONS:  From  all  of  our  data,  we  can  conclude  that  the  DY  and  OB 
reusable  oximeter  probes  demonstrate  compararive  performance  to  the  disposable 
N-25  probe.  We  believe  that  reusable  probes  are  reliable  in  the  OR  setting  and 
represent  a  substantial  cost  saving  for  the  hospital. 


i-STAT  '"  IS  NOT  ACCURATE   AT  ESTIMATING  OXYGEN  TENSIONS 
GREATER  THAN  350  TORR.     SMITH   R,   BROVIAK  A,   FAIRBANKS   B, 
HARRINGTON  J,   POGULIS   M,  TENG   E,  WARD  J.  RRT.   HELMHOLZ  H, 
MD,   FINDLAY   J,   MD,   PLEVAK   D,   MD.  ROCHESTER   COMMUNITY  AND 
TECHNICAL  COLLEGE-MAYO  FOUNDATION,  ROCHESTER,   MN. 
Background    The  i-STAT  '"  Portable  Clinical  Analyzer  (i-STAT  Corp, 
Princeton,  NJ)  is  being  used  to  estimate  arterial  oxygen  tension  (PaO;), 
A  previous  study  demonstrated  acceptable  accuracy  when  PaO;  values  were 
<  200  lorr  (Shelledy  DC.  Smith  WA._BSSE!LCar£     1997;     42(7):693-697), 
We  perlormed  Ibis  investigation  to  determine  If  Ihe  i-STAT  was  accruale  in 
measrunng  PaO;  at  high  oxygen  tensions 

Methods:  To  be  clinically  useful  at  high  PaOj,  we  felt  that  the  i-STAT  values 
should  be  within  75  torr  of  those  measured  by  a  conventional  IL-1306  blood 
gas  analyzer  (Instrumentation  Industries,  Lexington,  MA).  We  used  bias  and 
precision  data  as  previously  described  (Shelledy  i  Smith)  to  determine  study 
sample  size.  An  IL-237  tonometer  (Instrumentation  Industries.  Lexington, 
fvlA)  was  used  to  increase  oxygen  tensions  of  twenty-two  2ml  discarded  human 
blood  samples.  The  samples  were  split  to  be  analyzed  simultaneously  in  the 
i-STAT  and  111  306.  Values  lor  both  readings  were  recorded  and  plotted  using 
a  Bland-Altman  plot  (see  Fig.  1). 

Results:  Mean  bias  was  +  48  torr.  Data  variability  was  large  (±  standard 
deviation  -80  to  +  120  torr)  and  exceeded  the  limits  we  had  previously  set 
(±    75    torr). 

Conclusion:  The  i-STAT  portable  analyzer  may  not  be  accurate  when 
measuring  high  oxygen  tensions.    Underestlmations  in  PaO;  which  averaged 
48  torr  and  exceeded  120  torr  could  effect  clinical  care. 
Fig.  1  200 -] 


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Q 

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-J  SO 

Respiratory  Care  •  October  "98  Vol  43  No  10 


You'd  be  surprised  what  New  EasiVent"  will  hold. 


And  so  will  your  patients. 

Any  holding  chamber  will  hold  a  dose  of  respiratory 
medication.  But  only  the  EasiVent™  Valved  Holding  Chamber 
is  designed  to  hold  the  complete  MDI  kit  inside.  Or  any 
other  personal  treasure  of  modest  size. 

T  Physicians,  respiratory  therapists,  and  patients  indicate  a  preference  for  the 

unique  design  of  EasiVent'".*  Since  EasiVent"  improves  the  portability  of  asthma 
treatment,  it  encourages  patient  compliance. 

NAEPP  guidelines  also  recommend  that  all  patients  using  corticosteroids  use 
a  holding  chamber  to  maximize  dose  delivery.  Which  is  exactly  what  EasiVent'"  is 
designed  to  do. 

EasiVent'"  improves  medication  delivery  and  simplifies  patient  training,  with 
advanced  features  such  as  a  dual,  low-resistance  valve,  universal  MDI  port,  graphic 
instructions  |)rinted  on  the  unit,  and  built-in  coaching  signal. 

Help  your  patients  with  compliance.  Specify  the  EasiVent'"  Valved  Holding  Chamber. 
It  not  only  holds  the  complete  MDI  kit  inside,  its  advanced  design  also  helps  the  patient 
get  maximum  benefit  from  their  medication.  And  that's  no  fish  story.  •oaiaonfiie 

Circle  113  on  reader  service  card 
Visit  AARC  Booths  614,  616.  and  618  in  Atlanta 


l-800-75S-55fiO 

^ms  DEY 
All  rights  reserved. 
0'!-527.00   Sm 


Monday,  November  9,  2:00-3:55  pm  (Room  215E) 


THE  FREQUENCY  OF  BASIC  RESPIRATORY  CARE  PROCEDURES  THAT  ARE 
ORDERED  BUT  NOT  INDICATED  IN  A  PATIENT  POPULATION  IN  AN  ACUTE 
CARE  MEDICAL  CENTER  Terr>  S.  UCrand.  PhD.  RRT.  Arthur  P.  Jones.  EdD. 
RRT.  Wavnc  Law  son.  MS,  RRT.  Oliver  J.  Dnimhellcr.  EdD.  RRT.  and  Da«d  C. 
Shellcdy.  PhD.  RRT.  The  Uoiversilv  of  Texas  Health  Science  Center  at  San  Antonio.  Sai 
Antonio,  TX. 


Managed  care,  cos«ontainmcn(,  and  capilalion  arc  trends  thai  oirrcnlly  dioatc  the  pronsion 
of  health  care    Rising  costs  have  been  instrumental  in  csublishmg  ihcsc  trends,  thus  it  is 
\itall>  important  lo  carefully  assess  patients  rcccmng  medical  services,  including  rcspirator> 
care  services,  to  determine  the  appropriateness  of  ordered  therapy'    Objective:  To  determine 
if  respiratory  care  assessment  specialists  could  play  an  important  role  in  contributing  to  the 
cost-e£fectn  cncss  of  administered  respirators  therapies    It  would  be  the  task  of  such 
specialists  to  establish  whether  ordered  procedures  are  indicated  for  a  given  patient,  based  on 
cntcna  set  forth  in  Ihc  AARC  Clinical  Practice  Guidelines    Methods:   An  mlcmal  quality 
control  audit  of  patients  rccci\ing  basic  respiratory  caic  was  conducted  at  a  186-bcd  acute 
care  medical  center     Full  patient  asscssmenu  including  chart  rc\ncw,  patient  interview, 
physical  assessment,  and  assessment  of  therapy  were  performed  during  a  onc-wcck  pcnod  by 
respirator,  care  pcrsoruicl  on  71  patients,  utilizing  a  patient  care  assessment  instrument 
designed  for  this  purpose  and  previously  ficld-tcsicd   The  audit  included  determination  of 
ordered  therapy,  as  well  as  systematic  analyses  of  indications  for  thcrap>'    Audited  ircatmcnl 
modalities  included  oxygen  therapy,  small  volume  nebulizer  treatments,  MDI  administration, 
IPPB.  and  chest  physical  therapy  (CPT)     Results:  Of  65  pauents  receiving  O:  therapy, 
67  7%  (44)  of  the  ordered  therapy  was  not  indicated  according  to  AARC  Clinical  PracUcc 
Guidelines    Of4l  patienU  receiving  small  volume  nebulizer  therapy,  43  9%  (18)  exhibited 
no  mdicauons  for  the  therapy  Other  therapeutic  procedures  compnscd  a  small  percentage  of 
ordered  therapies,  thus  findings  about  those  procedures  may  not  be  conclusive     Six  MDI 
orders  were  evaluated,  of  which  100%  were  indicated    Four  patients  were  receiving  IPPB 
treatments,  yet  there  were  no  indications  shown  for  any  of  the  paucnis  receiving  the 
Ucatment    Of  the  4  CPT  orders  identified,  ail  were  indicated    Based  on  available  daU  from 
fiscal  year  1996  provided  b\  this  hospital,  elimination  of  inappropriately  ordered  small 
volume  nebulizer  therapy  alone  would  save  approximately  $191,700  annually    Conclusions: 
The  findings  from  this  study  show  that  a  significant  proportion  of  oxygen  therapy,  as  well  as 
an  appreciable  number  of  small  volume  nebulizer  treatments  and  perhaps  other  respiratory 
care  services  ordered  for  this  patient  population,  were  nol  indicated  according  to  a  complete 
patient  assessment  and  documentation  of  signs  and  symptoms  in  the  hospital  record     The 
addition  of  full  time  assessment  specialists  to  the  respirator>  care  services  siafT.  whose 
function  It  is  lo  perform  detailed  chart  audits  and  patient  assessments,  would  be  expected  lo 
reduce  the  overall  cost  of  delivered  respirator^'  care  semccs    Furthermore,  assessment 
specialists  would  ensure  that  patients  do  not  receive  unmeded  therapies,  and  that  they  do 
receive  those  therapies  that  arc  not  ordered  but  arc  in  fact  indicated     Unncccssarv'  and 
inappropnatc  care  increases  costs  and  may  lower  the  quality  of  care  provided 


F  MECHANICAL  VCNTILArOH 


OF-98-016 


ASTHMA  EDUCATION  DECREASES  ANNUAL  EMERGENCY  DEPARTMENT  VISITS, 
INPATIENT  ADMISSIONS  AND  HEALTH  CARE  COSTS    Diana  L  DIugolenski,  RRT; 
Shirle\  Paghano.  RRT,  Scott  Wolf,  DO.  Pal  Hemandci.  RN  Hartford  Hospital,  Hartford.  CT 

Background:  Enhanced  awareness  of  environmenlal  triggers,  as  well  as  early  recognition  and 
intervention,  will  result  in  significantly  lower  emergency  resource  utilization,  lower  inpatient 
admission  rate,  improved  functional  status,  and  an  overall  improvement  in  quality  of  life  Method: 
Referrals  to  the  Asthma  Control  and  Education  (ACE)  program  were  received  from  two  areas 
within  the  hospital-  the  flight  respiratory  therapist/emergency  department  (FRT/ED)  team 
anending  to  asthmatic  patients  in  the  Emergency  Department  (ED)  and  ihe  Medical  Team 
Respiratory  Care  Praclitioners  (RCP's)  covering  inpatient  asthmatics  Criteria  for  ACE  referral 
from  the  ED  included  1 ,  moderate  and  severe  asthmatics  based  on  National  Institute  of  Health 
Guideline  criteria  2  repeated  demonsu-ation  of  non-compiiance/misundersianding  of  treatment 
plan  or  medication  use  3  city,  state  and  ward  patients  and  4,  discharge  home  Management 
included  initial  patient  assessment  of  exacerbation,  provide  respiratory  care  as  per  critical  pathway, 
reassessment  of  patient  and  either  admit  or  discharge  Prior  lo  discharging  an  asthmatic,  the  Flighl 
Respiratory  Therapist  (FRT)  promotes  the  ACE  program  and  administers  a  "quick  teach"  The 
quick  teach  includes  metered  dose  inhaler  (MDI)  instruclion  with  a  spacer,  delivering  a  peak 
flowmeter  and  leaching  its  importance,  recognizing  triggers,  signs  and  symptoms  of  worsening 
asthma  and  use  of  medications,  A  brochure  is  given  to  the  patient  which  describes  the  ACE 
program  and  is  wrinen  in  both  English  and  Spanish    As  time  allows,  the  FRT  may  elect  to  do 
further  teaching    A  house/key/broom  analogy  is  one  resource  to  describe  the  different  medications 
and  their  roles  Those  asthmatics  admitted  were  followed  and  referred  by  the  medical  team  The 
medical  team  RCP's  worked  in  collaboration  with  the  nursing  staff  and  MDs  to  help  identit>  and 
enroll  inner  city  patients  into  the  program  Prior  to  discharge,  the  medical  team  RCP's  would 
conduct  a  "quick  leach"  The  ACE  program  consists  of  three  visits,  each  focusing  on  a  different 
issue  Included  in  the  sessions  are  prior  medical  history,  goal  sening,  discussion  on  disease 
process,  pulmonary  function  testing,  medications,  triggers,  how  lo  handle  an  exacerbation  and  a 
home  environmental  survey  Results:  For  the  period  of  1/23/97  to  10/31/97.  178  patients  had  at 
least  an  initial  visit  by  October  31,  1997  Eighty-eight  (49,4''/o)  had  an  initial  visit  but  did  not 
complete  ACE  education  within  3  months    Ninety  (50.6%)  are  currently  enrolled.  Forty  six  have 
completed  the  ACE  educational  program  and  provided  follow-up  data  by  October  31.  1997    The 
mean  age  of  these  46  patients  is  45,5  years  (range  =  t3-73yrs).  In  1996,  23  patients  pre- ACE  had 
47  ED  visits  (3  92  ED  visits/month)    Total  cost  $18,859  05  (Ave  $401  26)   In  1997.  these  same 
23  patients  PosI-ACE  had  17  ED  visits  (2  06  ED  visils/month)    Tola!  cost  $7,500  20  (Ave 
$44 1  89)  This  is  a  47%  reduction  in  the  number  of  ED  visits.  For  patient  hospilaiizaiions  in  1 996. 
II  patients  pre-ACE  had  16  inpatient  (IP(  visits  (I  33  IP  visits/monih)    Total  cost  $94,753  09 
(Ave  $5,923  07)  In  1997,  these  same  1 1  patients  post-ACE  had  3  IP  visits  (0-38  IP  visiis/month) 
Total  cost  $4.4 10  47  (Ave  $  1 470  1 6)  This  is  a  7 1  %  reduction  in  the  number  of  IP  visits  and  a 
95''/b  reduction  in  total  cost  Conclusion:  Educating  the  asthmatic  patient  on  their  disease  process 
leads  to  better  medication  compliance  and  avoidance  of  triggers  thus  leading  to  healthier  lives,  a 
decrease  in  annual  ED  visits  and  inpatient  admissions,  and  drastically  reduces  healthcare  costs 
More  mvesligation  and  effort  is  needed  lo  improve  the  percentage  of  patients  who  complete  the 
ACE  program. 


OPTDVIIZINC  TRANSITION  TO  HOME  VENTILATION 


BACKGROUND:  Transitioning  mechamcally  ventilated  patients  to  home  ventilation  in  a  imiely 
manner  is  a  pnonty  m  the  transitional  care  center  We  examined  a  methtxl  to  optimize  vcntilaliun 
through  the  LP6  ventilator  utilizmg  a  Pulmonary  Mechanics  Momtor 

METHOD:  We  utilized  the  Bicore  Neonatal  CP  100  Pulmonary  Mechamcs  Momtor  (Bear 
Medical  Systems,  Inc  ,  2085  Rustin  Avenue,  Riverside.  CA)  on  a  26  month  old  patient  ventilated 
with  the  Servo  300  ventilator  (Siemens  Medical  Systems,  Inc.,  1 4  Electromcs  Avenue.  Danvers, 
MA)  to  determme  Peak  Inspiratory  Flow  Rate  (PfFR)    A  pulmonary  report  was  printed  out  for 
reference    This  patient  was  then  transferred  to  an  LP6  ventilator  (Nellcor  Puntan  Bennett,  Inc., 
420  Hacienda  Dnve,  Pleasanlon,  CA)  at  which  pomt  a  second  pulmonary  report  was  generated 
The  Rerastar  CP/VP  umt  (Respiromcs,  Inc  ,  1 00 1  Murry  Ridge  Dnve,  Murrysville,  PA)  was 
added  lo  the  inspu"atory  hmb  of  the  LP6  to  provide  continuous  flow    We  then  utilized  the  Bicore 
Ncunatal  CP  1 00  to  again  measure  PIER  on  the  LP6/Remstar  umt. 
RESULTS: 


SV300 

LP6 

LP6/RerasIar 

mode: 

PC/PS 

Mode:  SMV 

Mode:  SIMV 

rate; 

15  bpm 

rate:      1 5  bpm 

rate:       1 5  bpm 

3 1  cml  120 

Din:        50  cmH20 

pip:        40  omH20 

OceD: 

7  cmH20 

peep:     7  5  cmH20 

peep:     7  5  cmH20 

PIFR: 

391/s 

PIFR:    291/s 

PIFR:    39  1/s 

Etc02:     52 

Etc02:    46 

Etc02:    40 

Can,  Blood  Gas:  Ph      7  42 

Cap.  Blood  Gas:  Ph      7  39 

Iimen9:l.i;           Pcll2     37 

time  13:20:           Pd)2     39 

P02      64 

P02      98 

HcU2     23 

Hc02     23 

BE      -7 

BE.    -17 

S.i()2      93 

<i,l02    97 

This  paper  demonstrates  that  by  utilizing  PIFR  measurements  on  the  Bicore  Pulmonary 
Mechanics  Momtor.  you  can  eflectively  transition  patients  from  Cntical  Care  to  home  ventilaloi 


OF-98-024 


Respiratory  Care  •  October  "98  Vol  43  No  10 


863 


Monday,  November  9,  2:00-3:55  pm  (Room  215E) 


INTEGRATION  OF  MANDATORY  MINUTE  VOLUME  VENTILATION  INTO  AN 
EXISTING  POST  CARDIOTHORACIC  SURGERY  WEANING  PROTOCOL 

Don  Renaghan  RRT.  Respiratory  Care  Services 

Stanford  University  Medical  Center         Stanford,  California 

Purpose  Our  ongoing  study  (N=40  to  date)  integrates  the  mode  of  Mandatory  Minute 
Volume  ventilation  {MMV),  as  delivered  by  the  Drager  Evita  ventilator,  into  our  existing 
postoperative  cardiothoracic  surgery  v^eaning  protocol  By  design,  the  MMV  mode  will 
allow  a  complete  transition  to  unassisted  spontaneous  breathing  once  the  patient 
initiates  and  maintains  a  predetermined  Vg  Upon  completion  of  the  study,  data  from  a 
non-MMV  group  {N=62)  will  be  compared  to  identify  differences  in  hours  intubated, 
days  in  ICU.  and  number  of  parameter  changes  between  MMV  and  non-MMV  patients 
within  the  same  weaning  protocol 

Methods  Randomly  selected  post  operative  cardiothoracic  surgery  patients,  who  meet 
the  clinical  criteria  in  the  existing  rapid  weaning  protocol,  are  placed  on  the  Drager 
Evita  ventilator  in  the  MMV  mode  The  only  weaning  protocol  modification,  in 
conjunction  with  the  inclusion  of  MMV.  eliminates  the  need  for  incremental  rate 
decreases  during  the  "weaning  phase"  of  the  protocol  Continuous  patient/ventilator 
data  IS  collected  through  a  dedicated  Digital  HiNote  laptop  computer  utilizing  EvitaView 
monitonng  software  CareVue  (Hewlett-Packard)  information  systems  provide  complete 
clinical  profiles  during  the  post-operative  period 

Results  Early  comparative  data  reveals  a  decrease  in  hours  intubated  in  the  MMV 
group,  although  not  statistically  significant  MMV  did  allow  for  significantly  fewer 
parameter  adjustments,  not  including  FiO,  changes,  in  the  transition  to  spontaneous 
breathing  The  time  to  onset  of  complete  spontaneous  breathing  in  the  MMV  group 
averaged  6.8  +  4  8  hours,  compared  to  the  average  duration  of  parameter  adjusted 
weaning  (non-MMV)  lo  spontaneous  breathing  of  10.2  +47  hours 


Comparative  Data 

Non-MMV  (N^62)  MMV  (N=40todate) 

(Mean  +  SD) 
Hrs  Intubated  119  +  53  108  +  50 

Time  to  Spont 

Breathing  (Hrs  )  102  +  4  7  68+4  8 


Conclusions  MMV,  as  delivered  by  the  Drager  Evita  ventilator,  can  enhance  a  rapid 
weaning  protocol  by  allowing  the  patient's  drive  to  breathe  to  be  the  determining  factor 
in  a  transition  to  unassisted  spontaneous  breathing  with  few,  or  no,  incremental 
adjustments  in  set  rate  or  mode  The  inclusion  of  MMV  in  a  weaning  protocol  can 
provide  an  opportunity  for  earlier  extubalion  and  a  potentially  shorter  duration  of 
mechanical  ventilation  for  stable  post-operative  cardiothoracic  surgery  patients 


HME  COMPANY  BASED  ASTHMA  PROGRAM  REDUCES  THE  COST  OF  CARE 

Joseph  Lewarski.  RRT.  Jason  Chao.  MD,  James  Stegmaier.  RRT,  Thomas 
Kallslrom.  RRT.  Vicki  Lohser.  RN.  Leila  Woehrle,  RN  Hytech  Homecare  and 
QualChoice  Health  Plan,  Inc  .  Cleveland,  Ohio 

Background:  In  June  of  1996,  Hytech  Homecare.  a  HME/Respiratory  provider, 
began  a  pilot  program  with  QualChoice  (HMO),  a  health  insurance  organization,  to 
provide  home  based  asthma  education  and  intervention.  Asthma  is  the  HMO's 
number  one  pediatric  diagnosis  for  both  service  utilization  and  cost    The  purpose  of 
this  pHot  study  was  to  detennine  if  the  program  could  reduce  the  utilization  of  health 
care  services  for  this  population    Our  hypotheses  were  that  mean  values  for  cost, 
emergency  department  (ED)  visits,  admissions  and  pnmary  care  physician  (PCP) 
visits  would  be  signiHcantly  less  after  the  program    Methods  Patients  were 
identified  and  refen^ed  to  the  program  by  the  HMO  case  managers  Physician  orders 
for  the  program  were  required    Eligible  patients  were  any  idenlified  by  the  case 
managers  as  having  multiple  health  care  contacts  related  to  asthma  (ED  visits, 
admissions,  etc  )  The  program,  known  as  AsthmaCare.  is  provided  by  registered 
respiratory  therapists    A  total  of  4  to  5  hours  of  interactive  time  was  spent  with 
patients  In  their  home  Time  was  divided  into  3-4  sessions  over  a  one  month  period- 
Sessions  began  with  a  review  of  their  current  treatment  plan  and  a  detailed 
environmental,  clinical  and  asthma  knowledge  assessment    Following  the  initial 
visit,  an  individualized  education  and  treatment  care  plan  was  developed  based  on 
NAEPP  recommendations  and  the  specific  patient  needs    This  was  reviewed  with 
the  patient,  case  manager,  phannaclsl,  and  physician    The  cost  of  the  program 
included  therapist  lime,  and  if  needed,  an  aerosol  machine,  peak  flow  meter,  MDl 
spacer,  plastic  mattress/pillow  case  covers,  education  matehats  and  miscellaneous 
supplies    Patient  cost  and  resource  utilization  were  supplied  by  the  HMO.  Mean 
costs  were  compared  with  a  paired  t-test.  the  mean  number  of  ED  visits,  hospital 
admissions,  and  PCP  visits  were  compared  with  2-factor  ANOVA  for  repealed 
measures  ResuHs:  Comprehensive  pre  and  post  program  data  were  only  available 
for  the  first  9  participants  who  completed  the  program  The  mean  age  was  7  3  years 
(range  1-6-12  8).  7  were  male  and  5  were  black.  Data  below  are  mean  (tSD) 


Time  (months) 

Cost/Month 

$1,065  ($927) 

ED         Admit 

PCP 

Pre-Program 

10  3(8  8) 

1  1  (0  6)    16(10) 

2  6(1,9) 

Post-Program 

153(17) 

$55  ($41) 

0  2  (0  4)     0  2  (0  4) 

12(13) 

The  program  resulted  In  a  signlficani  cost  savings  ($1,010/month;  p  =  0  001)  due  lo 
a  significant  reduction  in  encounters  with  health  care  providers  (p  <  0  0001) 
Conclusions  The  HME  based  aslhma  education  program  patients  demonstrated  a 
signiricant  reduction  in  resource  utilization  and  cost  For  an  initial,  one  lime  $400 
Investment,  the  HMO  earned  a  projected  annual  cost  savings  of  more  than  $12,000 
per  patient    Allhough  this  current  study  Is  limited  by  Ihe  small  sample  size,  11 
strongly  supports  the  theory  that  disease  specific  education,  provided  by  HME 
based  respiratory  care  practitioners,  can  have  a  substantial  impact  on  the  cost  of 
care  tor  asthmatic  patients  enrolled  in  an  HMO    Further  Investigation,  including 
control  group  comparison  and  long  term  outcome  monitoring  are  needed  to  help 
substantiate  these  preliminary  findings 


OF-98-040 


EFFECTIVE  ALLOCATION  OF  PEDIATRIC  RESPIRATORY  CARE 
USING  PATIENT  CENTERED  RESPIRATORY  CARE 
PROTOCOLS 


Otwell  Timmons.  MD  ,    Lucy  Brucoli.  RRT..    David  Fisher,  M.D., 

Caroiinas  Medical  Center,  Charlotte,  N.C.,  atid  John  Salyer, 

R.R.T.  Primary  Children's  Medical  Center,  Salt  Lake  City,  Ut. 

Background: 

We  identified  inappropriate  use  of  chest  physlotherapy(CPT), 

inappropriate  use  of  bronchodilators  by  hand-held 

nebulizer(HHN),  and  under-use  of  metered-dose  inhalers  (MDl) 

in  the  pediatric  areas  of  our  hospital. 

Method: 

We  adapted  successful  therapist-driven  protocols(TDPs)  from 

Primary  Children's  Medical  Center  to  fit  the  local  practices  and 

preferences  We  made  MDIs  with  spacers  our  default 

brochodilator  delivery  devices.  Operation  of  the  TDP  requires 

historical  information  and  current  physical  exam,  done  by  the 

RCP.  The  TDP  is  entirely  patient-focused.  Care  decisions  are 

based  on  published  trials  TDPs  have  operated  for  over  one  year 

in  our  hospital. 

Results: 

Though  the  number  of  patients  admitted  with  respiratory 

diagnoses  increased  compared  with  the  previous  year,  we 

decreased  the  number  of  CPT  and  HHN  treatments.  We 

increased  the  usage  of  MDIs,  as  desired.  Department  costs 

declined  $23,000  and  patient  charges  decreased  $76,000  in  the 

first  year  of  the  TDP.  Per  patient  charges  declined  22%,  from 

$712  to  $555.  As  we  gave  fewer  treatments,  we  saw  no  increase 

in  length  of  stay  or  in  transfers  to  the  ICU  for  respiratory 

diagnoses. 

Conclusions:  1 )  Successful  TDPs  can  be  generalized  to  other 
hospitals;  2)  Patient-centered  TDPs  preserve  quality  and  reduce 
costs. 

OF-98-027 


INITIAL  EXPERIENCE  WITH  A  RESPIRATORY-THERAPIST  ARTERIAL  LINE 
PLACEMENT  SERVICE 

Daniel  D  Rowley.  RRT,  CPn  .  David  F  H/layo,  RRT.  Charles  G  Durbin,  Jr ,  MD 
Surgical  Services,  University  of  Virginia  Health  System,  Charlollesville,  VA 

Introduction  Indwellinq  artenal  lines  are  often  placed  in  critically  ill  patients 
lo  facilitate  frequent  blood  sampling  and  tor  continuous  artenal  pressure  monitoring 
and  manipulation  Surgical  housestalt  and  medical  students  usually  place  these 
lines  With  a  varying  degree  of  efficiency  and  success 

Methods  In  order  to  improve  efficiency  and  quality  of  line  placement,  1 1 
respiratory  care  practilioners  (RCPs)  completed  a  competency  program  for  artenal 
catheterization  and  stabilization  Success  m  the  educational  program  consisted  ol 
demonstration  of  cognitive  and  psychomotor  skills  and  included  use  ot 
subcutaneous  local  anesthesia  and  securing  the  line  vwith  surgical  sutures 
Following  completion  of  the  program,  timeliness  and  quality  data  was  collected  on 
all  arterial  lines  placed  by  RCPs    Success  rate  and  complicalions  were  determined 
tor  n  artenal  cannulations  attempted  by  RCPs 

Results 

Artenal  Site 

»  Attempts 

#  Successful 

C>omments 

Radial 

60 

57 

Dorsal  Pedal 

11 

i1 

8  in  Burned  Patients 

Successful  on 

#  Lines 

Cumulative  % 

Comments 

First  Attempt 

57 

81 

Second  Attempt 

6 

89 

1  hird  Attempt 

5 

95 

5  MDs,  3  nCPs 

Never 

3 

(4°i) 

^ 

1 

d 
t 

s 
e 

Jverall  success  rate  lor  HCP  placement  was  yo°o   1 
lematornas,  kx:al  infections,  neurologic  delicits,  skin  Ic 
3  line  placements  Several  lines  were  inadvertently  r 
gitated  patients  without  complications  In  addition  to 
escribed  above,  several  existing  lines  that  became 
uccessfully  replaced  by  RCPs  using  the  Seldinger 
3chnique    The  average  time  required  for  line  insertio 
atheters  were  placed  in  less  than  30  minutes 

Conclusions  RCPs  can  easily  learn  to  safely 
uture  indwelling  arterial  lines  in  critically  ill  patients 
Iteclive  alternative  to  physician  placement 

here  were  no  significant 
•sions,  or  distal  emboli  relatec 
emoved  accidentally  by 
he  primary  line  placements 
dysfunctional  were 
catheter-over-a-wire) 
1  was  1 6  minutes,  9Cc  ol 

and  effectively  place  and 
=lCPs  may  provide  a  cost 

OF-98-04e 

864 


RisiMUAioRV  Carb  •  OcroHi.R  "98  Vdi  43  N(i  10 


Monday.  November  9,  2:00-3:55  pm  (Room  215E) 


RtSPIRATORYCARK  PRACTITIONRR  VhNTILA TOR  MANAGtMENF 
PROTOCOL  DKCREASES  LENGTH  OF  VENiri.ATION.  Donna  Tripp.  RRT.  Susan 
Rinaldo-Gallo.  RRT.  MEd.  and  Jon  Melioncs.  MD.  and  Ira  M  Cheifctz,  MD.  Duke 
IJniversily  Medical  Center,  Durham,  North  Carolina 

Background   Pediatric  Respirator)  Care  Pracrilioners  (RCP).  along  with  the  Department  of 
Pediatrics  began  a  process  to  evaluate  the  utilization  of  health  care  resources  A  RCP 
driven  ventilator  management  protocol  was  developed,  in  a  effort  to  manage  patients  more 
efHcientl)    The  protocol  established  guidelines  for  RCPs  to  manage  each  phase  of 
ventilator  management  from  the  initial  ventilator  set  up  through  weaning  patients  from 
mechanical  ventilation  without  having  to  obtain  a  physician  order  prior  to  every  change 
Exclusion  criteria  include:  (a)  alveolar  hyperventilation,  (b)  controlled  hypoventilation  and 
(  c  (  non-conventional  modes  of  vcnlilation  (i,e  HFOV).  Other  patients  may  be  excluded 
at  ihe  discretion  of  their  attending  physician.  The  protocol  is  initiated  by  a  written 
Physician  order  for  ■■Ventilator  Management  Protocol".  A  formal  respiratory  care 
assessment  is  conducted  at  the  initiation  of  ventilation,  every  12  hours,  and  followmg  any 
ma|or  change  in  ventilatory  status  The  following  is  a  limited  description  of  the  protocol 
1 1  )    I  he  ventilator  rate  is  adjusted  to  maintain  end-tidal  C02  35  -  45  torr.  (2.)  The  pH  is 
mainiamed  at  ^7  28  (3  )  The  pressure  or  volume  is  limited  to  deliver  a  tidal  volume( Vt) 
of  7- 10  ml  kg.  (4)  The  PIP  is  limited  to  35  cmH20  (5)  FI02  is  titrated  to  maintain  Sa02 
J  92%  (in  absence  of  a  mixing  congenital  heart  defect!.  (6  )  PEEP  is  initially  set  at  4-5 
tmH20and  titrated  using  a  PEEP  titration  protocol  (7  )  Pressure  support  is  set  at  10 
LniH20  and  iiiraied  to  maintain  a  spontaneous  Vt  of  approximately  6  ml/kg.  Pressure 
support  ni.i\  be  set  to  deliver  a  tidal  volume  of  10  ml/kg  if  complete  support  ventilation  is 
lo  be  used   Phvsicians  may  order  specific  variations  in  the  ventilatory  goals  as  indicated 
.ind  arc  always  notified  of  any  major  changes  in  the  patient's  ventilatory  status.   The 
protocol  was  implemented  in  the  PICU  F-cbruary  I.  If 98  Methods:  Data  were  extracted 
from,  a  RC  information  system  (Clinivision).  February.  March  and  April  of  !Q97  and  the 
same  months  in  I<I98   Results 


Total  Pts 

Total  Days 

Mean 

February  -  April  1997 

151 

1013 

6  7 

February  .  April  1998 

132 

800 

6  1 

l-xperiente   The  Ventilator  Management  Protocol  received  positive  acceptance.  I00'*o  of 
ihe  eligible  patients  were  placed  on  the  protocol.  Conclusion:  We  found  an  average 
reduction  m  ventilator  length  of  .6  days  per  patient,  during  the  3  months  evaluated  This 
represents  7Q  2   fewer  ventilator  days  for  this  3  month  period 


OF-98-062 


AN  ASSESSMENT  OF  THE  APPROPRIATENESS  OF  RESPIRATORS    CARE 
DELIVERED  AT  A  450-BEU  ACUTE  CARE  VETERANS  ADMINISTRATION 
HOSPITAL     David  C,  Shelledy.  PhD.  RRT.  Terry  S   LcGrand.  PhD.  RRT.  Arthur  P 
Jones.  EdD,  RRT,  Wayne  Lawson.  MS.  RRT.  Roben  Holmes.  BS.  CRTT.  Ryan  J    fibball. 
BS.  CRTT     The  University  of  Texas  Health  Science  Center  at  San  Antonio.  Texas 


INTRODUCTION:    The  c 

have  produced  significant  pressures  c 


.  of  health  care  delivery  in  the  acute  care  sell 
i  providers  to  reduce  the  cost  of  care     Respiratory 


ing 


r  and  the  provision  of  inappropriate 
Further,  a  failure  to  provide  neces.sar>  and  appropriate 
I  adverse  impact  on  palieni  outcomes     In  an  attempt  to  improvt 
sts.  and  reduce  length  of  stay,  some  providers  have  developed 
nts  receive  appropriate  care  and  that  inappropriate  or 
:d     The  purpose  of  this  study  was  to  determine  the 


may  waste  sc 

respiratory  care  may  have  a 
patient  outcomes,  control  ci 
protocols  to  insure  that  pali 
unnecessary  care  is  minimi; 
appropriateness  of  basic  respiratory  care  delivered  at  a  450-bed  veterans  administration 
hospital  during  a  three-month  time  interval     Specific  questions  addressed  were      I)    What  is 
ihf  frequency  of  ordered  and  provided  basic  respiratory  care  which  is  not  indicated  based 
on  the  AARC  clinical  practice  guidelines''  and  2)    What  is  the  frequency  of  basic 
respiratory  care  which  is  indicated  based  on  the  AARC  clinical  practice  guidelines  but  NOT 
ordered  or  provided"*    METHODS:    Five  assessment  days  beginning  in  January  and  at  two- 
week  intervals  ending  in  March  of  1998  were  selected  lo  conduct  the  study     All  patients 
admitted  to  the  hospital  and  receiving  basic  respiratory  care  received  a  complete  respiratory 
care  assessment  including  medical  records  review,  patient  interview,  physical  assessment 
and  measurement  of  SpO,  and  inspiratory  capacity     Patients  in  the  intensive  care  units  were 
excluded  from  the  study     The  assessment  inslrumcnl  provided  a  standardized  format  for 
assessment  of  respiratory  care  based  on  AARC  clinical  practice  guidelines.    RESULTS: 
Seventy-five  patients  received  complel 


Of  these.  52  patient 
receiving  aerosol  bronchodilalor  therapy. 
receiving  lung  expansion  therapy,  eight  v^ 
were  receiving  anti-inflammatory  inhaled 
ordered  therapy 
(bronchodilator; 


iciving  oxygen  therapy,  58  patients  wcr 
e  receiving  mucolytic  therapy.  13  were 
ing  chest  physiotherapy  and  six  patient 
For  oxygen  therapy.  17  65%  of  the 
indicated     For  all  categories  of  aerosolized  medications 

inflammatory  agents),  32  4%  of  the  ordered  respiratory 


care  was  not  indicated     The  percentages  of  ordered  therapy  that  was  not  indicated  for  chest 
physiotherapy  and  lung  expansion  therapy  was  37  5'*'o  and  7  7%,  respectively     On  average. 
1 1  825''q  of  the  patients  assessed  were  not  receiving  respiratory  care  which  was  indicated 
based  on  clinical  practice  guidelines     Of  these.  5  3%  of  patients  met  criteria  for  oxygen 
therapy  but  were  not  receiving  the  care,  5.3%  of  patients  met  criteria  for  bronchodilator 
therapy,  and  36'"o  of  patients  met  criteria  for  lung  expansion  therapy  which  was  not  ordered 
or  received     CONCLUSION:    On  average.  24  i°/a  of  basic  respiratory  care  procedures 
ordered  were  not  indicated  and  about  1 1  8%  of  patients  reviewed  were  not  receiving  care 
that  was  indicated     Inappropriate  utilization  of  respiratory  care  services  may  increase  costs 
and  produce  undesirable  outcomes  in  terms  of  morbidity,  mortality  and  length  of  stay 


POOSPHCTTVE  EVALUATION  OF  A  RESPIRATORY  PRACTmONER 
CL  NSULT  SERVICF.    Marin  H.  Kollef.  MD:  Steven  D.  Shapiro.  MD;  Lisa 
Cracchilo,  RRT:  Donna  Qayton.  BS;  Russ  Wilner.  RRT;  Dametta  Clinkscalc.  MA. 
Pulmonary  and  CnlicaJ  Care  Division,  Washington  University  School  of  Medicine, 
Department  of  Respiratory  Therapy,  Bamcs-Jewish  Hospital,  St.  Ixtuis.  MO  631 10. 

Background:  Medical  orders  for  rcspu-atory  therapy  frequentJy  vary  according  to  the 
Uaining  and  level  of  cxpenence  of  the  ordenng  physician.  Several  preliminary  studies 
have  suggested  that  increased  input  from  respiratory  care  pracbuoncrs  can  improve  the 
utilization  and  effectiveness  of  respiratory  therapy    Therefore,  we  wanted  to 
prospectively  test  the  hypotheses  that  a  rcspu-atory  care  practiuoner  consult  service 
would  improve  the  overall  adimnistrabon  of  respu^tory  therapy  in  a  large  urban 
leaching  hospital 

Method!::  The  Internal  Medicine  Service  of  Barnes-Jewish  Hospital  is  made  up  of 
three  "fiims"  which  are  independent  functiomng  organizations  of  dedicated  attending 
physicians  and  houscstaff  physicians    Patients  assigned  to  these  firms  receive  all  of 
their  inpatient  and  outpatient  medical  care  from  firm  physicians    We  prospectively 
implemented  a  respiratory  care  practitioner  consult  service  on  Firm  A    All  patients  on 
firm  A  requested  to  receive  respiratory  therapy  were  formally  evaluated  by  a  registered 
therapist    These  formal  evaluations  were  performed  in  accordance  with 
recommendations  from  the  Barnes-Jewish  Hospiial  Respiratory  Care  Protocol  Resource 
Guide  (  1997  EdiUon)    PaUents  in  Firms  B  and  C  had  dieir  respiratory  therapy  orders 
wntlen  by  fum  physicians  without  a  formal  respiratory  care  consult    The  main 
outcome  evaluated  was  the  presence  of  a  discordant  order    Discordant  orders  were  defined 
as  any  order  which  did  not  include  a  treatment  for  which  there  was  a  clinical  indicaUon 
(e  g..  chest  physiotherapy  for  lobar  atelectasis)  or  wntlen  orders  for  which  there  was  no 
clinical  indication  (eg  .  inhaled  bronchodialators  without  clinical  evidence  of  airway 
obstruction).  A  blinded  study  investigator  made  the  delemunation  of  a  discordant  order 
based  upon  the  hospital's  Respiratory  Care  Protocol  Resource  Guide 

Result! 


Finn 

n 

APACHE  11 

Average 

Patienu;  with 

Average  Number 

Score 

number  of 

Discordant 

of  Discordant 

RTOnlers 

Onlei5(%) 

Oders 

A 

75 

9  4±4  9 

12,4±17-8 

18(24) 

0  3±0.5 

B 

68 

8  4±4  4 

n.8±l2.3 

35(51) 

0  7±0  7 

C 

8.1 

8  8±4  8 

107111.2 

43(52) 

0  6±0  7 

Rvalue 

- 

0  503 

0  603 

eO.OOl 

<0  001 

RT=rcspiratory  therapy.  APACHE^acutc  physiology  and  chronic  health  evaluation 

Experience.  Our  expenence  demonstrated  that  a  respiratory  care  practitioner  consult 

service  can  decrease  the  number  of  discordant  orders  resulting  in  either  unnecessary 

treatmcnis  or  inadequate  treatments  for  patients 

Conclusions:   Formal  application  of  a  respiratory  care  practitioner  consult  service. 

uulizJng  consensus  driven  protocols  and  practice  guidelines,  can  reduce  the  numbers  of 

discordant  rcspu^tory  therapy  orders. 

Funded  by  a  grant  from  the  Amcncan  Association  for  Respiratory  Care 


OF-98-073 


REDUCTION  OF  DURATION  OF  MECHANICAL  VENTILATION  BY  USE  OF  A 
VENTILATION  MANAGEMENT  PROTOCOL     Laura  Mandel  RRT  .  Thomas 
Arrowsmilh,  RRT,  Nancy  Collar,  R  R  T,  B  J  Kingsley  H  N  ,  James  Lambertt, 
M  D  ,  Inova  Fairfax  Hospital) 

Background:    We  screened  patients  daily  to  identify  those  able  to  breathe 
spontaneously  and  notified  physicians  of  a  passing  screen  We  requested  two- 
hour  trials  of  spontaneous  ventilation  and  notified  physicians  of  a  passing 
spontaneous  ventilation  trial    We  stixJied  whether  this  ventilation  management 
protocol  affected  physicians'  behavior  and  improved  patients'  outcomes 
Methods:    A  randomized,  controlled  tnal  m  adult  patients  receiving  mechanical 
ventilation  (Ely  E,  N  Engl  J  Med  1996,  335  1864-9)  documented  a  significant 
decrease  in  duration  of  rnechanical  ventilation  and  cost  of  intensive  care    We 
followed  the  methods  of  this  trial,  including  all  adult  patients  in  our  medical  and 
surgical  intensive  care  units  receiving  mechanical  ventilation  Patients  requiring 
ventilation  >  21  days  were  excluded  from  analysis    October  1996  to  March  1997 
served  as  the  control  period    In  April  1997,  we  began  daily  screening  of  patients 
(provided  that  F1O2  <  0  50,  PEEP  5  5.  no  vasopressors  or  intravenous 
sedatives)    A  passing  screen  was  defined  as  fA/j  <  105    We  notified  physicians 
of  the  daily  screening  results  and  beginning  in  September  1997  we  requested  a 
two-hour  trial  of  spontaneous  breathing  in  patients  passing  the  screen  (7Q°'o 
compliance  by  physicians)    If  the  breathing  trial  was  successful  we  notified  the 
patient  s  physician  who  independently  decided  upon  discontinuation  of  mechanical 
ventilation    October  1997  to  December  1997  represented  the  first  three  month 
penod  following  complete  institution  of  our  protocol  (intervention  group) 
Results: 

End  Point  Intervention  Group       Control  Group         p  value 

(n-    188)  (n-  358) 

median  (interquartile  range) 
mechanical  ventilation  2  5  (1-  6  25)  days  3    (2  -  8)  days  0  01 

hospital  days  9  (4 -18}  days  11  (4 -21)  days  Oil 

hospitalization  cost       S19,701  $21,999 

(S9,315  -  $35,328)  ($12,226  -  $38,857)      0  06 

Experience:    The  authors  wort<ed  as  a  team  to  implement  the  protocol,  educate 
physicians,  collate,  and  analyze  data 

Conclusions:  A  ventilation  management  strategy  including  daily  screening  of 
patients  and  two-hour  trials  of  spontaneous  ventilation  reduced  time  on  mechanical 
ventilation    A  trend  toward  reduction  in  tx)spital  time  arxJ  hospital  cost  was  noted 
Utilizing  a  median  cost  reduction  of  52,298  per  patient,  we  postulate  an  annual 
cost  savings  of  $1,728,096 


OF-98-075 


Respiratory  Care  •  October  '98  Vol  43  No  10 


865 


Monday.  November  9,  2:00-3:55  pm  (Room  215E) 


inchcliDv 


THE  IMI>A(  T  OK  ADl  LT  ASTHMA  EDl'CATION  IN  THE  EMEROEN*  V 
DEPARTMENT  SETTING  -  I  hcrc-a  Bcrquisl  BS  KRT,  UiralJ  ChMMopKcrM>n  US 
RRT.  Trjiv  Chn5Uiphcn.on  KRI.  Tii.1.1  Smilh  BS  RRT  ;  Biillcrourlh  Hospilal.  CiunJ 
Rapid!..  Ml 

BACKGROUND:  II  j  pilicnl  laiks  basii-  kno\\lcdi:c  .ib.>ul  aslhiTi...  Ihcir  Irc.ilmcnl  rucimcn 

Mill  likcK  l.ul  IxvaiiM-  llK  palicnl  l^  unaware  ol  appi..pn.ilc  Jim.im-  manapilicnl  slips      A 

suivcv  oi  ..slhmalK  p,ilii'fiLs  in  oui  i-mcrpciin  dciralimnl  (HDl  I. Hind  Ihat  4:vl  rciyivcd  Ihc 

majotiu  I'l  llK'ir  iikxIk.iI  cue  in  Ihe  tD  Ttic  piii(».sf  ,.j  iliis  m. 

ll  an  asthma  cdiKaln-n  pioyrani  .idniinislcrcd  lo  aslhnialK  paliii 

sell  nianap-incnl  ol  lliiii  .uslhma   Inipr.ncnicnl  «as  dclinc\l  as  a  icdaclii.n  in  ihi-  nuniKi  ..I 

1£D  \isils,   hiispiul   .idmissions,   and  da\s  c.l    scli.»il   or    «.ilk    missed   due    Ui   aslhmj 

MLTHOD    KiK  aschm.i  ivilienls  >      13  jeals  ,.l  ape  uhii  "ere  seen  and  e\.ilualed  in  llie 

cnKn:cne\  deparlniem  liom  Mareli  |uy<i  u.  Dcscmlvi  |vu7  cnnsinled  u.  be- plaeed  ml.,  llic 

slud\      Ail  subjeecs  had  a  pnni.u^   ED  di,i[in..sis  ..I  .isilima  and  inhaled  br.iiKhi»lilal.ics 

»ecc   adniiiuslered     ^   c|UCsli..nnaire    »as    .idininisleied    lo   caeh    eligible    palieni    b\    a 

respiraliin   Iherapisl      Ihc  nucslii.nnaire  assisled  die  ihcrapist  in  idcnLhmg  Ihc  (uUcnLs 

kii.nv ledge  level  lelalcxl  1..  aslhma  .rnd  Us  ni.inapenicnl,  is  well  as  llie  patients  health  earc 

systems  ullli/auim  p.ilteni  l.ir  the  past  t..ui  months     I  oILming  assessment  .ind  treatment 

the  cdueahon  program  was  stalled     hducatioii  insluded  wiilkii  malenals  and    viewing  a 

Mdcti  containing  iiil..niiation  ..n  asthma  liiggeis,  ph>si..l..gic  dianges,  medieaU.ms.  peak 

e\piator>  Mow  m.iniloiing.  MDI  teehnique  with  spacei,  and  cleaning  ol  eqinpmen' 

respiratory  therapist  rc\  icued  w  nh  Ihe  patient  all  ol  the  ml 

had  lo  demonstrate  the  use  ol  MDIs  using  a  placeb.i  inhal. 

telephone  inlcrv  lews  at  two  and  tout  months  .iller  entry  ir 

I6K  subjects  cnlcrcd  into  the  stuc 

The  number  ot  BD  \  isits  in  iht 

months  belore  edueati.in  was  signilicaniK  l..wer  (mc.m  I  o:  hel. 

S.2ft  p  =  <.ll<)ll    Woikor  sch.s.l  da)s  missed  due  t,..isthnia  » 

alter  education  when  c.mpared  I.,  belore  cducati.in  (me.ui  3  16  t 

I  -  2  15  p  =   034)      Ihe  number  ..I  hospital  admissions  w 

(mean  -23   belore  t.i    14  alter,  paired  I  =  2.15  p  =    I  32) 


cducaUon    administered 
management  ol  asthma  i 


dcd    Rilients  also 

All  subjects  recenc.d  h.ll.iw  up 

lo  Ihe  study     RESULTS:    CK  the 

r  month  lollow  up  questionnaire 

inlhs  I. ill. .wing  education  eomp.ucxl  to  the  lour 

■  47  alter,  paired  I  = 

U.1S  also  signilieanlty  lower 

beh.ie  to  I  4>!  alter,  paired 

h.wcr  but  not  signilicmlly 

CONCLl-lSIONS     Asthma 

ipi.ne    Ihe    sell 


,  I. SI  Is  and  1 


.ch.iol 


A  SUB-SET  OF  FINDINGS  FROM  A  SURVEY  OF  RESPIRATORY  CARE  SERVICES: 
CLINICAL  PRACTICE  GUIDELINES  AND  RESTRUCTURING. 
John  W  Salver  BS,  RRT   Karen  K  Baldesare-Burton  RN,  RRT  Respiratory  Care 
Service,  Primary  Children's  Medical  Center  School  of  Medicine,  University  of  Utah 
Introduction   Restructuring  and  the  use  of  clinical  practice  guidelines  are  two  topics 
that  have  generated  considerable  interest  in  the  respiratory  care  community  As  part  of 
a  larger  survey  we  sought  to  assess  some  aspects  of  two  important  issues  Methods 
In  early  1996  a  100  question  survey  instrument  v^as  developed  and  mailed  to  3854  RCS 
in  the  U  S  and  Canada  The  mailing  list  was  developed  from  a  listing  of  department 
heads  that  are  members  of  the  AARC   Responses  were  scored  by  a  computenzed 
scanning  system  We  report  only  questions  related  to  the  topics  mentioned  above 
Results  There  were  1 093  responses  of  which  1 5  were  unreadable  due  to  damage  to 
the  answer  sheet,  leaving  1078  (28%)   Responses  were  received  from  all  50  states. 
Canada  (n=1 1),  Guam,  and  the  Virgin  Islands  The  distnbution  of  responses  by 
geographic  region  was  very  similar  to  the  distribution  of  all  hospitals  reported  by  the 
American  Hospital  Association  The  tables  below  descnbes  our  findings 

Restructuring  Issue 

%  All 
Res  ponders 

t- 

ke 
f 

-088 

Currently  or  about  to  start  cross-training  RN's/LPN's  to  do 
respiratory  procedures 

44.9  % 

Currently  or  about  lo  start  cross-training  non-hcensed  staff  to  do 
respiratory  procedures 

18  0% 

Currently  or  about  to  start  cross-traJning  RCP's  to  do  nursing 
procedures 

58  2  % 

Hospital  has  brought  in  outside  consultants  to  significanlly  redesign 
hospital  operations 

38.0  % 

Respiratory  department  has  experienced  a  reduction  in  force  in  past 

18  months 

37  4  % 

Type  of  Clinical  Practice  Guidelines  : 

(currently  being  used  or  about  to  start) 

%  All 
Responders 

Aerosolized  bronchodilator  administration 

72 

Chest  physiotherapy 

53 

Continuous  pulse  oximetry 

52 

Weaning  from  mechanical  ventilation 

60 

Oxygen  therapy 

77 

Use  of  respiratory  "assessor"  program 

24 

Discussion  We  did  not  attempt  to  contact  non-responders,  thus  our  sample  is  se 
selected,  and  potentially  biased  However,  the  large  size  of  our  sample  should  ma 
these  findings  of  interest  to  the  respiratory  care  community  There  is  clearly  a  lot  o 
restructuring  activity  taking  place  in  hospitals  that  affect  the  practice  of  respiratory 
Our  results  indicate  that  the  respiratory  care  community  is  actively  embracing  the 
of  clinical  practice  guidelines  We  believe  this  is  important  to  the  future  of  patient  c 

0F-9£ 

WWWii'^'!!Jy'!!^rnyiliCOIH 


moving'. 

The  expressway  to  Respiratory  Care  is  a  no-parkin}(  zone.  Be  sure  to  bookmark  www.rcjournal.coiii 
for  fast  access  to  a  host  of  convenient  features  such  as  the  author  guide  for  manuscript  preparation, 
plus  keyword  searches  of  all  available  issues.  Don't  forget  the  Online  Resources  section;  you  can  con- 
tact the  editorial  staff,  view  the  annual  indexes  for  1997,  or  e-mail  your  1998  Open  Forim  absti'act. 

RE/PIRATORy  CARE 

online 

Browse  safely 


866 


Risi'iK.MORY  Cari;  •  OcTOBiiR  "98  Vol.  43  No  10 


Monday.  November  9,  2:00-3:55  pm  (Room  215E) 


THE  PEDIATRIC  EXPERIENCE:  INITIATION  OF  AN  INTERDISCIPLINARY  FLOOR 
ASSESSMENT  TEAM  (FAT).  Karen  Baldesare-Burton  RN  RRT.  John  Saiyer  BS, 

RRT  Primarv  Children's  Medical  Center,  Salt  Lake  City,  UT  Background   In  1995-96. 
at  our  240-bed  tertiary  care  pediatric  center,  non-ICU  nurses  were  cross  trained  to 
adminisler  certain  high-volume,  low  risk  respiratory  care  procedures,  including  chest 
physiotherapy  (CPT).  pulse  oximetry  (Pox)  and  aerosolized  bronchodilators  (ABD) 
Patient  driven  protocols  existed  for  each  of  these  interventions  From  a  previous  study 
(Lugo  et  al    Pharmacotherapy  1998.18(1)  198-202)  we  determined  that  ABD  were 
overuttlized  in  our  bronchiolitis  population,  w\lh  over  94  %  of  patients  who  did  not 
respond  to  ABD's  m  the  ED  continued  to  receive  treatments  after  admission,  and  87% 
who  did  not  respond  lo  ABD's  after  admission  continued  to  receive  the  therapy   For  the 
1996-97  winter  season  we  introduced  a  clinical  practice  guideline  (CPG)  to  reduce 
these  unwarranted  variations,  specifically  m  patients  with  bronchiolitis  After  one 
season,  we  found  no  reduction  in  these  variations  We  then  developed  a  dedicated 
interdisciplinary  team  (FAT)  to  help  reduce  variations  in  the  use  of  these  interventions 
and  thereby  lower  costs  to  the  community   Five  RCP  and  three  support  role  RN 
positions  were  created  to  oversee  all  existing  protocols  Actual  treatments  would  still 
be  given  principally  by  RN's  We  speculated  that  this  new  delivery  model  would 
improve  communication  and  cooperation  between  services  Costs  &  Utilization: 
Training  was  extensive  and  cost  $8282  (excluding  nursing  hours)  All  eight  employees 
attended  an  intensive  two  week  orientation,  which  included  lectures  on  chest- 
radiography,  pulmonary  assessment,  pharmacology,  the  scientific  basis  for  the  use  of 
all  four  respiratory  interventions,  basic  CQI  principles,  and  the  outcome  measures  we 
would  be  assessing  The  RN's  are  granted  6  to  12  hours  each  per  pay  penod  to 
perform  the  functions  of  the  support  role,  such  as  unit  education,  data  gathering, 
meetings,  and  in-services  Two  RCP's  were  assigned  to  the  general  medical  surgical 
units  on  days  and  one  on  evenings,  7  days  per  week  and  charged  with  assessing  all 
bronchiolitis  patients  and  reducing  when  possible  the  overutilization  of  the  previously 
mentioned  interventions  Results  We  admitted  540  bronchiolitis  patients  as  of 
3/16/98  Mann-Whitney  U-test  revealed  statistically  significant  {P<0  05)  decreases  in 
utilization  between  the  96-97  &  97-98  bronchiolitis  season  for  aerosolized 
bronchodilators  (decreased  38%),  continuous  pulse  oximetry  (decreased  34%),  and 
chest  physiotherapy  (decreased  27%)  We  also  discovered  that  only  19%  of  patients 
who  did  not  respond  to  ABD's  continued  to  receive  treatments  after  admission   During 
this  penod.  no  patients  were  re-admitted  after  discharge  from  the  hospital  Length  of 
slay  in  this  population  was  not  statistically  different  than  in  the  previous  year 
Discussion:  Had  we  been  under  treating  this  population  we  would  have  expected 
prolonged  lengths  of  stay  or  possible  readmissions  due  to  exacerbation  of  their 
bronchiolitis  We  attribute  these  decreases  in  unwarranted  vanation  to  the  presence  of 
FAT  RCP's  working  together  with  the  physicians  and  nurses,  and  the  application  of  our 
patient  driven,  intervention  based  protocols  for  CPT,  ABD.  and  Pox  We  believe  this 
has  resulted  in  a  basic  change  in  culture  on  these  medical  surgical  units 


A  CARE  PATH  DECREASES  RESOURCE  USE 
FOR  NEONATES  WfTH  RESPIRATORY  DISTRESS  SYNDROME  (RDS) 

Robert  L  Chatbum  RRT  Michele  C  Walsh-Sukys  MD,  Patricia  M  DePompei,  RN, 
Vickey  L  Moroney.  RN    Rainbow  Babies  &  Childrens  Hospital  Cleveland,  OH 

The  purpose  ol  this  study  was  to  determine  the  effects  of  a  respiratory  therapy  focused 
care  path  for  neonates  with  RDS  treated  in  a  Level  III  nursery  METHOD:  A  team  o( 
physicians,  respiratory  therapists,  nurses  and  other  caregivers  developed  a  care  path 
after  a  cntical  literature  review  Consensus  based  indications  standardized  decisions  for 
intutjalton.  surlactant  administration,  amtnophylline  treatment.  ABG  analysis, exiubation, 
CPAP,  and  oxygen  therapy  by  hood  The  care  path  encouraged  patient  triggered 
ventilation  (le,  pressure  controlled  SIMV  rather  than  IMV).  aggressive  weaning,  and  use 
of  the  Infant  Flow  CPAP  system   Respiratory  therapists  were  responsible  for  keeping 
the  patient  on  the  path,  documenting  therapy  using  an  algoform  {see  Respir  Care 
1997,43  22-29)  and  for  ventilator  changes  to  achieve  ordered  target  values  lor  gas 
exchange  Outcome  data  and  care  path  variances  were  tracked  by  a  dedicated  RDS 
care  manager  (registered  nurse)  All  very  low  birlhweight  (<  28  weeks  plus  s  1 ,500  g) 
infants  were  eligible  lor  care  path  entry  Data  (or  a  care  path  group  were  compared  to  a 
matched  control  group  who  were  in  the  NICU  iDefore  care  path  implementation 
Demographic  data,  seventy  ol  illness  (Score  lor  Acute  Physiology),  and  outcome  data 
were  compared  with  two-tailed,  unpaired  t-tests  or  Fisher's  Exact  test  Cost  data  were 
not  available    RESULTS:  The  study  group  was  composed  of  32  infants  admitted  from 
1/97  to  8/97  The  control  group  had  44  infants  from  1/96  to  12/96  Compliance  with  care 
path  standards  was  good  timely  surfactant  (74%),  use  of  SIMV  (67%),  aminophylline 
(90%)  CPAP  (90%)   Data  are  shown  below  as  mean  ±  standard  deviation 

p  Value 


Demographics 

Control 

Careoalh 

birlhweight  (g) 

885  ±219 

931  ±202 

gestational  age  (wks) 

26  2  ±  1  5 

26  4  ±  1  3 

%  white 

34 

58 

%  male 

52 

68 

seventy  score 

174  ±95 

173  ±88 

Outcomes 

ventilator  days 

26.7  ±16  9 

20  5  ±16  0 

oxygen  days 

36  8  ±  28  8 

34  0  ±  28  0 

hospital  length  of  stay  (days) 

84  5  ±28  7 

82  1  ±  22  3 

CONCLUSION:  A  monitored  care  path  which  focused  on  the  respiratory  management 
of  infants  with  RDS  significantly  improved  outcomes  Key  success  factors  included  the 
use  of  practical  data  gathering  forms  and  a  care  manager 


OF-98-098 


CAN    THERAPISTS    OPTIMIZE    VENTILATION 
BASED   ON    GRAPHIC    ANALYSIS 

Steven  Slaughter,  RRT  ,  Timothy  Myers,  RRT,  Robert  L  Chatbum,  RRT 
University  Hospitals  of  Cleveland.  Ohio 
The  purpose  of  this  study  was  to  determine  if  experienced  ICU  therapists  coukJ  (1)  klentily 
basic  ventilator  modes  based  only  on  pressure,  volume  and  flow  waveforms,  (2)  recognize 
comnxin  problems  using  waveforms,  and  (3)  optimize  ventilator  settings  on  a  simulated 
patient  based  only  on  the  output  of  a  bedside  mechanics  monitor    We  also  hypothesized 
that  therapists  might  perform  better  with  the  ventilator  set  to  volume  control  mode  versus 
pressure  control    METHODS:  All  adult  and  pediatric  ICU  therapists  were  eligible  to  enter 
the  study  In  Phase  I,  therapists  were  asked  to  identify  8  different  rTK>des  of  ventilation  In 
Phase  II.  therapists  were  sfrown  waveforms  ol  common  problems  In  Phase  IN.  therapists 
were  asked  to  optimize  settings  in  volume  and  pressure  controlled  continuous  mandatory 
ventilation  (CMV)  with  the  ventilator  (NPB  7200)  connected  to  a  lung  model  (modrtied 
IngMar  Medical)  Tlierapists  could  only  see  waveforms,  loops,  tidal  volume,  minute 
ventilation,  resistance,  and  compliance  The  model  simulated  both  upper  and  tower 
inflections  points  on  the  volume/pressure  curve  The  only  clinical  data  given  were 
diagnosis  (ARDS)  and  baseline  ABGs  Waveforms  {Phase  I  &  II)  arxj  graphic  displays 
iPhase  HI)  were  generated  with  a  Novametrix  C02SM0+  connected  to  a  computer  Data  for 
volume  vs  pressure  control  were  compared  with  Wilcoxon  Signed  Rank  tests  with 
significance  al  psO  05  RESULTS:  Twenty  six  therapists  entered  the  study.  Of  these, 
only  3  did  not  complete  Phase  III.  All  had  ICU  experience  (rar>ge  2-21  years,  median  8)  with 
access  to  graphic  monitors  (NPB  7200,  BICORE.  or  Ventrack)  No  therapist  got  a  perfect 
score  on  all  three  phases  A  passing  score  was  defined  as  75%  or  more,  58%  of  therapists 
passed  Phase  I.  35%  Phase  M.  and  9%  Phase  ill  There  were  no  differences  in  distributions 
of  scores  between  volume  and  pressure  control  modes  Test  results  are  shown  below  as  a 
percentage  of  therapists  giving  correct  responses,  grouped  by  mode  or  clinical  problem 
Phase  I  CMV         SIMV       SIMV  +  PS      PS       CPAP 

Volume  Conlrol:  69%  73%  58%  —  — 

Pressure  Conlrol:  77%  54%  46%  69%       73% 

Phase  II        Water  In  Tubing     Alrwav  Leak        Obstruction     autoPEEP 
50%  46%  58%  46% 

Phase  lit  Optimizing  the  ventilator  was  defined  as  ( i )  decreasing  tidal  volume.  (2) 
mainlainir>g  the  same  minute  ventilation,  (3)  no  change  of  l:E,  (4)  increasing  rate.  (5) 
increasing  PEEP  Results  tjekjw  show  patterns  of  correct  responses  : 

S  of  5      4  Ol  5      3  Of  5    20f   5     1  Ol  5    0  Ol  5 
Volume  Control:        5%  4%         39%      26%        26%         0% 

Pressure  Control        0%>  9%        39%      26%        26%        0% 

CONCLUSION,     ased  on  these  data,  therapists  can  recognize  basic  ventilator  patterns, 
but  get  conlusec     ilh  complex  breath  patterns  They  seem  unable  lo  recognize  comnxsn 
problems  or  to  optimize  ventilator  settings,  despite  using  the  equipment  on  a  daily  basis 
These  baseline  data  will  be  used  in  a  process  improvement  educational  program. 


OUTCOMES  STUDIES  TO  ASSESS  ASTHMA  EDUCATION 
PROGRAM  IN  AN  ALLERGY  AND  ASTHMA  PRACTICE 

Donna  Daver.  BS.  RRT  and  Deanna  Ruddell,  M.D. 
Little  Rock  Allergy  and  Asthma  Clinic,  Little  Rock,  Arkansas 

Little  Rock  Allergy  and  Asthma  Clinic  began  an  outcomes 
study  in  May  1997  with  the  goal  to  utilize  data  to  improve 
health  care  for  patients  with  asthma.  Newly  diagnosed 
patients(adult  and  pediatric)  are  given  surveys  prepared  by  the 
Joint  Council  of  Allergy,  Asthma  and  Immunology  initially  and 
on  subsequent  visits  quarterly  and  at  sick  visits.  These 
surveys  assess  changes  in  a  patient's  health  status  based  on 
clinical,  humanistic  and  economic  measures. This  "real  world" 
data  can  be  used  to  show  which  treatments  and  practice 
patterns  best  maximize  patient  satisfaction  as  well  as 
improve  functional  status  and  quality  of  life.  Specifically  the 
surveys  and  eventual  data  when  it  is  analyzed    should  help 
guide  the  educational  and  medical  management  of  the  patient. 
We  intend  to  show  by  our  outcomes  monitoring  the  need  for 
repetitive  teaching  by  the  R.T.  of  MDI  and  PF  techniques,  diary 
keeping,  teaching  understanding  of  the  different  functions  of 
asthma  medications  and  inhalers,  the  role  of  triggers  and 
trigger  control,  and  the  importance  of  routine  follow-up  either 
by  clinic  visit  or  by  the  respiratory  therapist  doing  phone 
follow-up.  in  maintaining  a  quality  asthma  program.  This  will 
decrease  patient  need  for  overutilization  of  the  health  care 
system,  i.e.,  expensive  ER  visits,  missed  school/work  days, 
etc.  Furthermore  it  is  our  intention  to  expand  the  concept  of 
outcomes  analysis  from  a  study  into  an  ongoing  program  for 
our  clinic.  This  would  directly  benefit  our  patients  by 
providing  continuous  feedback  regarding  the  quality  of  our 
asthma  education  program  with  ongoing  measureable  outcomes. 


Respiratory  Care  •  October  '98  Vol  43  No  10 


867 


Asthma  Disease  State  Management 
Establishing  a  Partnership 

This  new  videotape  offers  comprehensive  directions  on  how  to  create  an  effective 
asthma  disease  management  program  within  your  facility. 

All  four  segments*  of  DSM  are  addressed: 

•  Diagnosis  •  Pharmacological  Therapy 

•  Environmental  Controls  •  Patient/Family  Education 

•  NAEPP  Guidelines  are  discussed  within  each! 

CRCE  Credits  are  available  and  workbooks  will  be  provided  with  each  order. 
Objectives: 

•  Understand  the  asthma  disease  process 

•  Which  procedures  are  essential  to  the  assessment  and  diagnosis  of  asthma 

•  Classify  asthmatic  patients  using  the  new  guidelines 

•  Know  the  various  categories  of  asthma  medications  and  when  to  use  them 

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COMPARISON  OF  THE  LC  STAB  AND  AEROTECH  II  NEBULIZERS,  USING  THE 
PRONEB  TURBO  AND  A  0,  TANK  FOR  COMPRESSOR  FLOW.  D  Todd  Lottert. 
M.H  S  .  Kim  Francis  BS.  PARI  Respiratory  Equipmenl.  13800  Hull  Street  Road, 
Midlothian,  VA.  23112, 

Jet  nebulizers  differ  in  ttieir  output  and  cfiaracteristics  of  ttieir  aerosol  profile  because 
ot  differences  in  let  orifice  size,  internal  surface  area,  sfiape  and  type  of  auxiliary 
vents,  durability,  and  compressor  source  Ttie  intent  ol  Itiis  study  is  to  compare  the 
LC  STAR  and  Aerotech  II  nebulizers  using  the  Proneb  Turbo  and  a  0^  tank  for 
compressor  flow.  We  believe  that  there  will  be  a  significant  pedormance  difference  in 
ml/min  ,  percentage  of  particles  in  the  respirable  range(<5Mm),  and  respirable  particle 
delivery  rate.  Both  nebulizers  will  be  run  with  both  of  the  compressor  sources 

Two  different  nebulizer  systems  were  analyzed  with  two  different  compressor 
systems  for  aerosol  characterization.  Aerosol  characterization  includes:  total  output 
(ml/mm  ),  percentage  of  particles  <5Mm,  and  Respirable  Rate.  Output  was  determined 
gravitmetncally  and  particle  size  was  ascertained  by  laser  light  scattering  {Malvern 
MasterSizer  X)  The  compressor/nebulizer  combinations  studied  were:  PARI  Proneb 
turbo  compressor  w/LC  STAR,  02  tank  w/LC  STAR®  12LPM,  Proneb  turt)0 
compressor  w/Aerotech  II,  02  TANK  w/Aerotech  ll@  12LPM,  The  nebulizers  were 
operated  with  an  additional  continuous  flow  of  20  Liters  per  minute  {to  simulate 
average  adult  inhalation). 

RESULTS 

PARI  PRONEB  TURBO  COMPRESSOR  W/LC  STAR 

-MI/MJn  average  =  0  47  ml/mm. 

-<5nm  average  =  77.45  °o 

-To  combine  the  previous  vanables  RPDR  was  calculated.  =  Ml/Min  multiplied  by 

<5Mm    RPDR  average  =  0  36  ml/mm  of  1-5  micron  particles 

02  TANK  COMPRESSOR  W/LC  STARB  12LPM 

-Ml/Min  average  =  0  62  m!/min. 

-<5Mm  average  =  80  %. 

-To  combine  the  previous  variables  RPDR  was  calculated.  =  Ml/f^in  multiplied  by 

<5^m    RPDR  average  =  0.50  ml/min  of  1-5  micron  particles. 

PARI  PRONEB  TURBO  COMPRESSOR  W/AEROTECH  II 

-Ml/Min  average  =  0.20  ml/min. 

-<5pm  average  =  66.50  %. 

■To  combine  the  previous  variables  RPDR  was  calculated,  =  Ml/Min  multiplied  by 

<5Mm,   RPDR  average  =  0  13  ml/min  of  1-5  micron  particles 

02  TANK  COMPRESSOR  W/AEROTECH  lia  12LPM 

-Ml/Min  average  =  0  39  ml/mm, 

-<5fim  average  =  77  46  % 

-To  combine  the  previous  vanables  RPDR  was  calculated,  =  Ml/Min  multiplied  by 

<5um    RPDR  average  =  0,30  m^min  of  1-5  micron  particles. 


COMPARATIVE  ASSESSMENT  OF  A  SMALL  V0LUA1E  VALVED 
HOLDING  CHAMBER  (VHC)  WITH  A  SMALL  VOLUME  SPACER 
FOR  TILE  DELIVERY  OF  FLUTICASONE  PROPIONATE 
J  P  Mitchell.  M  W.  Nagel  and  A  Archer  Trudell  Medical  International. 
London,  Canada 

Fluticasone  propionate  (FP)  is  becoming  widely  prescribed  as  a 
corticosteroid  for  the  treatment  of  asthma     This  study  compared  the 
performance  of  5  VHCs  (AeroChambeng,  Monaghan  Medical  Corp  , 
Platlsburgh,  NY')  with  5  spacers  (MicroChamber™,  Respiratori/  Delivery 
Systems  Inc  ,  Chelmsford,  MA)  with  Flovent®  (110  ng/dose  FP, 
GlaxoWellcome  (Canada)  Inc  )  delivered  by  metered-dose  inhaler  (pMDl) 
Total  and  fine  particle  (<  4.7  pm  aerodynamic  diameter)  unit  doses  from 
each  group  of  devices  were  measured  using  an  Andersen  cascade  impactor 
(Graseby  Andersen,  Smyrna,  GA)  equipped  with  USP  Induction  Port  to 
collect  the  aerosol  delivered  by  the  pMDI  at  a  constant  flow  rate  of  28  3  ± 
0  5  1/min.    The  mass  of  FP  collecting  in  each  of  the  impactor  components 
was  assayed  by  HPLC-UV  spectrophotometry     Both  fine  particle  (FD)  and 
total  (TD)  unit  doses  from  the  AeroChamber®  VHCs  (56,0  ±  0  8  ng  (FD), 
60.9  ±  0  8  |ig  (TD))  significantly  exceed  that  delivered  by  the 
MicroChamberT"  spacers  (38  2  ±  6  5  )ig  (FD),  44  0  ±  3  6  pg  (TD))  {paired 
t-test,  p  <  O.OOI)     The  mass  fraction  of  the  aerosol  contained  in  fine 
particles  (91 .9  ±  0  3%  (AeroChamber®),  86  1  ±  8  7%  (MicroChamber™)) 
were  comparable  (p  =  0  1 5)      The  larger  volume  of  the  .AeroChamber® 
VHC  (1 35  ml)  appears  to  have  both  improved  the  output  of  FP  delivered  in 
comparison  with  the  MicroChamber™  spacer  (100  ml),  and  at  the  same  time 
maintained  a  high  proportion  of  the  dose  as  therapeutically  useful  fine 
particles      The  inter-device  variability  for  the  group  of  spacers  was 
noticeably  greater  than  that  observed  with  the  VHCs,  suggesting  that  an 
inhalation  valve  may  improve  uniformity  of  dose  deliver^' 


OF-98-038 


MIS-TIMING  BETWEEN  ACTUATION  OF  A  METERED-DOSE 

INHALER  (pMDl)  /WD  INHALATION  EXPERIENCE  WITH  A 

VALVED  HOLDING  CHAMBER  (VHC)  COMPARED  WITH  A 

SPACER 

JP  Mitchell,  M  W,  Nagel  and  A  .\rcher  Trudell  Medical  International. 

London,  Canada 

Add-on  devices,  such  as  spacers  and  VHCs,  have  the  advantage  of  reducing 
losses  if  a  patient  fails  to  have  perfect  coordination  between  actuation  of  a 
pMDl  and  inhalation  of  the  delivered  medication    This  study  compared  the 
performance  of  5  VHCs  (AeroChamber®,  Monaghan  Medical  Corp  , 
Plattsburgh,  NY)  with  5  spacers  (MicroChamber^",  Respiratory  Delivery 
Systems  Inc  ,  Chelmsford,  MA)  using  Flovent®  (1 10  pg/dose  fluticasone 
propionate  (FP).  GlaxoWellcome  (Canada)  Inc  )     Each  device  was  tested 
using  a  breathing  simulator  that  was  based  on  a  mechanical  ventilator 
connected  to  the  master  side  of  a  test  lung    The  mouthpiece  of  the  device 
on  test  was  connected  via  an  aerosol  filter  to  the  slave  side  of  the  test  lung. 
A  rigid  bar  was  placed  between  the  two  compartments  of  the  test  lung,  so 
that  inflation  of  the  master  compartment  also  inflated  the  slave  side 
Measurements  were  made  at  a  tidal  volume  of  500  ml,  I/E  ratio  of  1/1,  rate 
of  10/min,  with  the  peak  inspiratory  flow  rate  close  to  28  1/min     In  the  first 
part  of  the  study,  pMDI  actuation  was  timed  to  coincide  with  the  onset  of 
inhalation  (optimum  use),  whereas  in  the  second  part,  actuation  coincided 
with  the  onset  of  exhalation    5  doses  of  medication  were  delivered  at  30  s 
internals,  and  aerosol  collected  on  the  filter  was  assayed  by  HPLC-UV 
spectrophotometry  for  FP      The  ,AeroChamber®  VTiCs  provided  58  9  ± 
5  1  Jig  FP  compared  with  39  4  ±  7  6  pg  from  the  Microchamber'r^i  spacers 
when  actuation  occurted  at  the  same  time  as  inhalation     The  output  from 
the  X'HCs  declined  to  35  6  ±  5  4  pg  FP  when  actuation  coincided  with 
exhalation,  due  largely  to  gravitational  settling  of  the  aerosol  during  the  3  s 
delay  (each  breathing  cycle  lasted  6  s)     However,  the  mass  of  FP  delivered 
by  the  spacer  declined  to  4  7  ±  7,7  pg  under  these  conditions     It  appears 
that  the  inhalation  valve  of  each  VHC  substantially  protected  the  aerosol 
retained  within  the  device  from  mixing  with  exhaled  air     The  open-ended 
geometry  of  the  spacer  allowed  mixing  and  consequent  dilution,  so  that  the 
:  of  drtJg  inhaled  with  the  next  breath  was  greatly  reduced 


PARTICLE  SIZE  AND  OLITPUT  COMPARISON  OF  THE  BREATH- 
RITE  AND  AEROCHAMBER  AEROSOL  HOLDING  CFiAMBERS. 
R.J.  Pen^  B.S.,  W.  Chiang  and  J.S.  llowite  M.D.  SUNY  at  Stony  Brixik, 
NY  1 1794,  California  Mcasurcmenls,  CA  91024  and  Winlhrop- 
Unncrsity  Hospital,  Mincola,  NY  1 1501. 

The  Brcathnlc  ( Vcntlab  Corp.)  is  a  new  aerosol  holding  chamber  (HC), 
which  has  the  ad\  antagc  of  collapsibiltly  and  increased  portabilitj-, 
potentially  improving  compliance  among  patients  that  benefit  from  holding 
chambers  but  are  reluctant  to  carty  bulk\  devices  outside  their  home.  Pnor 
to  clinical  use.  new  HC  design  chanictcnstics  arc  bench  tested.  Therefore  we 
measured  the  aerosol  particle  si/c  and  output  efficiency  of  the  Brcathiitc 
(BR)  and  iilsoof  the  FDA  approved  Acrtx-hamberl}  (AC)  for  conip;irison. 
Both  dc\  ices  were  combined  with  bcclomclha.sonc  (D#I),  albuterol  (D#2)  or 
cromlvn  (D#3)  MDIs  ;uid  tested  in  triplicate  using  previously  published 
techniques  (Kim,  C.S.ctal.,ARRD  1985;  132:137-142  &  19H7;  135:157- 
164)  of  cascade  impaction  (for  particle  si/ing)  and  filter  sampling  (for  output 
efficiency).    Cascade  data  vv  as  analyzed  v  ia  log  probabilit)'  plot  lo  determine 
the  ma.ss  median  acrcxiynamic  diameter  (MMAD)  in  microns  (^m)  and 
cfliciencv  data  was  calculated  as  the  aerosol  ina.ss  prcxluced  Ifom  each  HC 
div  idcd  b)'  the  MDI  dose  per  pull  and  expressed  as  a  percent.    Results  are 
summari/cd  m  the  following  table. 


Dev  ICC 


D#l 


D#2 


D#3 


MMAD{;<m)±SD 

BR                         0.99  ±  .07 

1.62  ±.03 

2.59  ±  .09 

AC                          0.95  ±  .06 

1.62  ±.09 

2.40  ±  .09 

Efficiency  ('7r)±SD 

BR                         74.6  *  7.3 

61.5  ±4.6 

53.5  ±  3.2 

AC                          48.4  +  3.6 

47.4+  1.3 

37.5  ±  K3 

For  the  three  drugs  tested,  our  analysis  demonstrated  a  42'/J  greater 
criicicncy  of  the  Brcathrile  over  the  AercK-hambcr  vv  ith  nearly  identical 
aerosol  particle  sizes.    Wc  believe  Ihal  patients  should  hav  e  similar  drug 
acnisol  deposition  patterns  in  the  lung  with  cither  HC  and  a  significantly 
higher  inhaled  drug  dose  v  la  the  Bre;ithrite.  The  cliracal  relevance  of  these 
data  remains  lo  be  determined,  however. 


Respiratory  Care  •  October 


Vol  43  No  10 


869 


Monday,  November  9,  3:00-4:55  pm  (Room  214E) 


THE  EFFECTIVENESS  OK  THE  MISTY  OX  HIGH  FIO,  -  HIGH  FLOW 
NEBULIZER  IN  DELIVERING  HIGH  OXYGEN  CONCENTRATIONS.    Jason  T 
Hipgins.  BS.  CRTT.  John  A.  Hemandez,  BS,  CRIT.  Jay  I.  Peters.  MD,  and  David  C 
Shelledj .  PhD.  RRT    The  University  of  Texas  Health  Science  Center  at  San  Antonio- 

BACKGROUND:    The  Misty  Ox  (MO)  high  FIG,  -  high  flow  nebulizer  (MMCA,  Cosa 
Mesa,  CA)  was  developed  to  overcome  shortcomings  of  conventional  air-entraintnent 
devices    Tte  MO  is  designed  to  deliver  FIO.s  from  .60  to  .96  with  total  gas  flows  trom 
42  to  80  L'min.    We  sought  to  detemime  the  actual  delivered  FpO,  when  using  the  MO 
via  aerosol  mask  m  normal  subjects.    METHOD:    Following  informed  consent,  23  healthy 
volunteers,  ages  22  to  41,  were  placed  on  a  MO  connected  to  54"  of  large  bore  tubing  and 
a  standard  aerosol  mask  (SIMS,  Ft.  Myers.  FL).    Prior  to  initiation  of  the  MO.  each 
subject  had  a  10  trench  nasal  catheter  (NO  inserted  through  the  nares  with  the  tip 
positioned  immediately  above  and  behind  the  uvula.    Oxygen  therapy  was  then  initiated  at 
a  set  FIO,  of  .60,  ,75  and  .96  at  40  IVmin  flow  using  a  high-flow  flowmeter  (Precision 
Medical.  Inc.,  Northampton,  PA)  for  a  period  of  five  minutes  at  each  FIO,.    Gas  was 
analyzed  at  the  MO  outlet  and  at  the  subjects'  lip  using  a  previously  calibrated  oxygen 
analyzer  (Hudson  RCI.  Temccula.  CA).    With  the  subject  breathing  normally,  a  180  ml 
gas  sample  was  then  aspirated  from  the  NC  to  a  "T"  piece  and  oxygen  sensor.    Three 
pharyngeal  gas  samples  were  obtained  at  each  FIO,  sening  and  the  mean  values  were 
calculated.    RESULTS:    The  means,  standard  deviations  and  ranges  for  the  analyzed 
oxygen  c 


Misty  Ox  High  FIO,  -  High  Flow 

Nebuhz 

er  via  Aerosol  Mask  at 

40  Urn 

Location 

ol  Gas  Analysis 

Nebulizer  Outlet 

Subiects  Lip 

Oropharynx          | 

Sel  FIO, 

60 

,75 

96 

60 

75 

96 

60 

,75 

96 

Analyzed  FIO.' 
tSDI 

59 
(02) 

70 
(02) 

89 
(111) 

(  02) 

68 
(01) 

,87 
(02) 

55 
(03) 

63 
(05) 

77 
(09) 

Range 

,54- 
,62 

,64- 
,74 

,87- 
9.1 

60 

,62- 
72 

,81- 
91 

,46- 
,57 

.50- 
72 

56- 
88 

mean  (SO)  of  al 

subject 

Based  on  pharyngeal  gas  analysis,  the  F|,0,  averaged  7%  less  than  the  set  value  on  .60. 
\2%  less  than  sel  on  75  and  19%  less  than  set  on  .96.    Mean  FIO,  analyzed  al  ihe  lip 
averaged  5-10%  greater  than  pharyngeal  FdO;.    CONCLUSIONS:    Actual  delivered  FnO, 
when  using  the  MO  nebulizer  can  vary  considerably  from  the  set  value.   Care  should  be 
taken  when  interpreting  patients  clinical  response  to  oxygen  therapy  when  using  this 
device  in  that  patients  may  be  receiving  an  FpO,  much  less  than  anticipated  based  on  the 
nebulizer  sening.  OF-98-066 


CLINIC.\L  EVA!  ,LI ATION  OF  CIRCULAIRE™  (CIRC)  VS  CONVENTIONAL  SMALL 
VOLUME  NEBULIZER  (SVN)  FOR  THE  TREATMENT  OF  ACUTE  BRONCHOSPASM 
ASSOCIATED  WITH  ASTHMA  OR  ASTHMATIC  BRONCHITIS  IN  AN  EMERGENCY 
DEP.\RTMENT    Rebecca  I..  Meredidi.  RRT.  PhyUis  L.  Bajusz.  RRT    The  Cleveland  Clinic 
Foundation,  Cleveland,  Ohio. 


Background:  The  Circulaire'^"  nebulizer  incorporates  a  reservon  bag,  one-way  valve,  and 
variable  resistor  into  the  system.  Through  these  features  it  has  been  shown  to  produce  smaller 
particles  enabling  greater  pulmonary  and  less  pharyngeal  deposiUon.  Therefore,  it  should 
decrease  systemic  ?idc  effects,  unprove  bronchodihiahon.  and  ultimately  decrease  the  length  of 
slay  (LOS)  in  the  emergency  department  (ED),  The  aim  of  this  randomized,  single-blind  clinical 
trial  was  to  compare  the  effecl  of  the  two  devices  on:  peak  expiratory  flow  rate  (PEFR),  heart 
rate  (HR),  respiratory  rate  (RR),  ED  length  of  stay  (LOS),  and  discharge  disposiuon.  Method: 
The  shidy  took  place  al  an  inner-city,  tertiary  referral  center.  The  sample  was  compnsed  of  137 
patients  presenting  to  the  ED  with  a  primary  diagnosis  of  asthma  or  asthmatic  bronchitis  and 
peak  expiratory  flow  rate  (PEFR)  <80%  of  Ihe  national  standard  based  on  age  and  height. 
Patients  received  Albuterol  5  Omg  with  SVN  nebulized  for  10  mmutes  (N=68)  or  CIRC  for  6 
minutes  (N^69)  Vanables  uicluded  demographics;  diagnosis;  PEFR,  HR,  and  RR  before/after 
each  treatment,  hours  in  ED  (LOS);  and  discharge  disposihon.  Between  group  analyses  were 
conducted  usmg  Chi  square  tests  for  categoncal  variables  and  Mann-Whitney  U  tests  for  ordinal 
level  vanables.  Results:  The  groups  were  comparable  on  age,  gender,  and  diagnosis  The  table 
presents  change  in  PEFR.  HR,  and  RR  before  and  after  the  first  and  second  0 


Treatment  (TXl) 

TX2                                              1 

SVN  (N-68) 

CIRC  (N=69) 

SVN{N=57) 

CIRC  (N-59) 

APEFR  (L/min) 

44,60  ±  53.3 

75  1  ±65.7* 

17,7  ±31,6 

36,9i45,S" 

AHR  (.'ram  ) 

0,94  ±  10  50 

32±12.2 

3,0  ±7,9 

8,2  ±9,6++ 

ARR  (/min.) 

0.79  ±3.5 

1.6±3.l 

0.21  ±2.4 

0.17  ±2.4 

•  p=0.002  **  p=0.006 

++p=0.001 
significandy  greater  for  the  CIRC  group  compared  to  the  SVN 
The  change  in  heart  rate  was  sigmficanUy  higher  for 
No  significant  differences  occurred  between  the  two 
The  LOS  was  significantly  shorter  for  the  CIRC  group  ( 1 ,6 
±0.8  VS  2.2  ±  1.2,  p^O.0004)-  Although  not  statistically  sigmficant,  there  was  a  trend  toward  a 
greater  percentage  of  the  SVN  group  requiring  hospital  admission  (  10%  vs  6.9%,  p=  0.09) 
Conclusion:  We  found  CIRC  to  be  supenor  to  SVN  as  evidenced  by:  unproved  PEFR  after  the 
first  and  second  treatments;  decreased  length  of  stay  m  the  emergency  department;  and  a  trend 
toward  fewer  hospital  admissions.  Despite  the  increased  HR  after  the  second  treatment  with 
CIRC,  the  benefits  outweigh  the  risks. 


The  rate  of  change  in  PEFR  wa 
group  after  the  first  and  second 
the  CIRC  group  after  the  second 
groups  m  change  of  respiratory 


HOLDING  CHAMBERS  DELIVhH  MOHE  AEROSOL  THAN  MDI  AND 
SPACERS  WITH    RANDOM  ACTUATIONS 

James  B  Fink,  MS,  RRT.  Greg  Ligman,  RCP,  Hines  VA  Hospital,  Loyola  Siritch 
School  o(  Medicine,  and  Tnlon  College  Respiratory  Care  Program,  Hines,  IL 
Background:    Aerosol  delivery  tn^m  a  metered  dose  inhaler  (MDI)  is  reduced 
when   actuation  is  not  synchronized   with   inspiration       Spacers   and   holding 
chambers  are  prescritKd  lo  protect  patients  trom  loss  of  dose  secondary   to 
asynchrony,  but  their  relative  merits  have  not  been  well  established 
Method:  Five  puffs  of  albuterol  (90/;g/puf1)  were  administered  from  a  MDI  alone, 
chamber  spacer  (toilet  paper  roll),  small  volume  spacer  (Optihaler)  and  valved 
holding  chamber  (Aerochamber)  into  a  lung  model  (AJRCCM   1998    157A636) 
simulating  spontaneous  ventilation  (Vt  500.  f  50  bpm,  PIE  80  IVmin)  The  MDI  was 
actuated  at   the   beginning   ol   inspiration   (SYNCH)    and    at    30   sec    intervals 
irxJependenI  of  respiratory  cycle  (RANDOM)      Aerosol  was  collected  on  a  tiller 
distal  to  a  USP   throat",  analyzed  by  spectrophotometry  and  reported  as  ug  of 
albuterol  with  standard  enor  bars    ANOVA,  p<0  05  is  significant 
Results:  During  SYNCH,  ttie  small  volume  spacer  delivered  less  aerosol  than  all 
other  devices  (p<0  01)    RANDOM  actuation  delivered  less  drug  than  SYNCH  tor 
ttie  MDI  alone  and  both  spacers  (p<0  02)    With  RANDOM  actuation,  ttie  valved 
fxjiding  chamtjer  delivered  more  drug  than  the  other  devices    (p<Q01).    and 
comparable  drug  as  the  MDI  alone  during  synchronized  actuation  (p-  0  36) 


Conclusion:    When  syrKhrony  ot  MDI  with  inspiration  is  unreliable,  the  valved 
hoWing  chamber  protects  Irom  loss  of  drug  dose 


SECONDARY  FLOW  OF  AIR  AND  HELIOX  THROUGH  A  CLOSED 
DILUTION  NEBULIZER  IMPROVES  BRONCHODILATOR  DELIVERY 
James  B.  Fink.  MS.  RRT.  RCP.  Jotin  D.  Calebaugh,  RRT,  RCP,  and  Rajiv 
Dhand.  MD,  Hines  VA  Hospital  and  Loyola  Striich  School  of  Medicine,  Hines,  IL. 
Background:  Large  volume  nebulizers  have  been  used  to  deliver  continuous 
bronchodilator  therapy  to  treat  refractory  acute  airway  obstruction.  He:02  has  been 
advocated  in  these  patients  to  reduce  airway  resistance  and  improve  aerosol 
delivery,  but  has  been  shown  lo  reduce  aerosol  output  and  efficiency  when  used  to 
operate  pneumatic  nebulizers  as  a  primary  gas  source.  We  wanted  to  determine  the 
effects  of  both  air  and  He:02  on  bronchodilator  delivery  when  used  as  a  secondary 
gas  in  a  closed  dilution  nebulizer. 

Methods:  A  prototype  closed  dilution  nebulizer  (Hope,  B&B  Mediciil)  was  used 
to  nebulize  a  solution  of  30  mg  of  albuterol  sulfate  with  normal  saline  to  a  fill 
volume  of  50  niL.  The  nebulizer  was  operated  with  oxygen  at  13  L/min  as  the 
primary  gas  flow,  with  a  seconar^'  flow  of  air  and  70:30  He:02  at  22  L/min,  and 
with  no  secondary  flow  (n=3).  The  standing  cloud  method  was  employed  with 
aerosol  collected  on  a  filter  attached  lo  a  mouthpiece,  distal  to  6  feel  of  standard 
aerosol  tubing.  Aerosol  was  sampled  for  2  minute  intervals.  Albuterol  deposition 
was  determined  with  spectrophotometry  (276  nm).  and  expressed  as  |igstandard 
error.  ANOVA  was  performed  with  p<().05  considered  significant. 
Results:  Delivery  of  albuterol  with  oxygen  as  the  primary  gas  driving  the 
nebulizer,  with  no  secondary  tlow  was  lS9.9±6.5|ig.  The  addition  of  air  as  a 
secondary  gas  flow  increased  aerosol  delivery  (333.6±7.2|ig:  p<0.0004).  while 
use  of  70:30  He:02  as  secondary  How  resulted  in  even  greater  deliver.' 
(43O.4±l7.07;p<O.0O5). 

Conclusion:  While  using  oxygen  as  a  primary  gas  source,  an  auxiliary  flow  of  22 
L/min  of  both  air  and  He:02  significantly  increased  aerosol  delivery.  In  contrast  to 
use  as  a  primary  gas.  He:02  introduced  as  a  secondary  gas  improved  the  efficiency 
of  the  nebulizer  delivery  system. 

Funded  bv  a  CTani  from  B&B  Medical  Technologies.  Inc. 


OF-98-078 


870 


RnsPiRATORY  Carp:  •  Octobi-r  '98  Vol  43  No  10 


WITW 


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Consumer  InformationCatalog  online 

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Fast  Forward youT  patients 
healing  progress  with 


CONTINUOUS  MEDICATION  NEBULIZER 


LARGE  VOLUME  NEBULIZER  COMPARISON         HOPE 

Yes 
Yes 
Yes 

Yes 


Connects  directly  to  the  flowmeter 
Precice  FiO:  without  blenders 
510K  approved  Heliox  compatibilty 
Provides  up  to  78%  respirable  particles 


Yes 


Provides  up  to  40  Ipm  output 

Change  medication  without  patient  disconnection  Yes 

Reduces  environmental  plastics  waste  Yes 

User  Friendly  Yes 

Highest  cost  per  nebulizer  NO 

For  a  free  sample  call 
B&B  Medical  Technologies  Inc. 

HTTP:/AVWW.BandB-MedicaLcom 

800.242.8778 


▼   Nebulizer 

No 
No 
No 
No 
No 
No 
No 
No 
YES 


Circle  105  on  reader  service  card 


Circle  102  on  reader  service  card 
Visit  AARC  Booth  801  in  Atlanta 


Respiratory  Care  •  October 


Vol  43  No  10 


871 


Monday.  November  9.  3:00-4:55  pm  (Room  214E) 


IS  STERILE  WATER  NECESSARY  IN  WICK  TYPE  HUMIDIFIERS:  PART  II   Jim 

Keenan  BS   RRT   Karen  Burlon  RRT,  RN.  John  Salyer  BS,  RRT   Primary  Children's 
Medical  Center.  Salt  Lake  City  Utah   Introduction   This  is  an  ongoing  study  testing  the 
feasibility  of  using  other  than  sterile  water  in  wick  type  humidifiers   The  CDC  guidelines 
for  infection  control  recommend  the  use  of    "stenle,  distilled  or  tap  water  to  fill  wick 
humidifiers"  [fVlMWR  1997,46(RR-1)  48]   Substituting  other  water  types  for  expensive 
stenle  water  will  reduce  the  costs  of  mechanical  ventilation  Therefore,  we  set  out  to 
investigate  whether  bactena  inoculated  in  the  chambers  of  wick  type  humidifiers  could 
later  be  found  at  the  patient  airway   Methods   Stenle  test  lungs  were  constructed  with  a 
buill  in  bacterial  filter  (Nalgene  model  1 30-4045)  between  the  lung  and  the  ventilator 
circuit  (Keenan  etal   Respir  Care  1997,42  1081)   Three  Servo  900  C,  and  three  V  I  P 
Bird  ventilators  were  operated  with  a  Fisher  &  Paykel  MR  730  wick  humidifier,  proximal 
temp  setting  35 '  C  with  a  chamber  control  setting  of  -2 '  C  Adult  circuits  were  used  with 
the  Servo  s   neonatal  circuits  with  the  Bird's,  each  with  dual  heated  wires  Each  circuit 
and  humidifier  were  assembled  as  we  do  clinically,  using  no  extra  stenle  precautions  to 
mimic  clinical  conditions   Pseudomonas  aeruginosa,  Klebsiella  pneumoniae, 
Acinetobacter,  and  Escherichia  coli  were  prepared  in  1  0  mL  aliquots  of  10'  colony 
forming  units  per  mL   The  four  solutions  were  added  to  sterile  water  in  the  humidifiers 
The  Servo's  settings  were  selected  to  mimic  adult,  high  flow  (50  Lpm)  conditions  The 
Bird's  settings  were  selected  to  mimic  neonatal,  continuous  low  flow  (10  Lpm) 
conditions  The  ventilators  ran  for  approximately  24  hours  after  which  the  filters  were 
removed  aseptically  and  placed  on  agar  plates  for  the  standard  48  hr  gross  growth 
analysis  All  test  conditions  were  repeated  four  times  for  a  total  of  24  runs  Results 
One  of  24  filters  exhibited  growth  of  Pseudomonas  aeruginosa   The  positive  grov/th  was 
from  the  Bird  neonatal,  continuous  low  flow  condition  Conclusion  The  single  run  of 
our  experiment  which  yielded  growth  might  indicate  ttiat  bacteria  in  a  wick  could 
contaminate  the  patient  airway    Speculation   Theoretically,  organisms  of  this  type 
cannot  be  carried  in  a  gas  stream  that  contains  only  water  in  the  vapor  phase  We 
discussed  these  theoretical  aspects  in  our  previous  abstract  It  is  possible  that  this 
single  episode  of  growth  could  be  attnbuted  to  the  development  of  microaerosols  by  the 
wick  type  humidifier  It  is  also  possible  that  organisms  were  earned  in  condensate  up 
the  inside  of  the  circuit  by  the  gas  flows  A  third  possibility  is  laboratory  contamination, 
either  in  our  testing  lab  or  in  the  microbiology  lab  These  findings  cast  doubt  on  the 
CDC  guidelines  for  using  non-stenle  water  in  wick-type  humidifiers  However,  if  our 
contamination  was  a  result  of  laboratory  error,  then  the  practice  of  using  sterile  water 
may  not  be  warranted  We  plan  to  continue  to  study  this  issue 


OF-98-090 


PLACPMENT    OF    AN    ULIRASONIC     NEBULIZER    AT    THE    VENTILATOR 
CIRCUIT  WYE  DOES  NOT  REDUCE  AEROSOL  DELIVERY  Dunftg  CMV 
Jarnes  B    f  ink^  MS   RRT,  Martin  J   Tobin.  MD  and  Rajiv  Dtiand,  MD    Mines  VA 
Hospital,  Division  of  Puimunary  and  Cntical  Care  Medicine,  Loyola  Sirrtch  School 
ol  Medicine,  Mines,  IL 

Background  During  controlled  mechanical  ventilation  (CMV).  placement  ot 
pneumatic  small  volume  nebulizers  (SVNs)  in  the  inspiratory  limb  ot  a 
ventilator  circuit  18  inches  from  the  wye  provided  more  aerosol  to  the 
lower  respiratory  tract  than  placement  at  the  ventilator  circuit  wye  Our 
goal  was  to  determine  the  most  etiicient  site  tor  operation  of  an  ultrasonic 
nebulizer  (USN)  during  CMV 

Method    To  determine  the  effect  ot  the  placement  ot  a  protoype  USN 
(Nellcor  Puntan  Bennet)  {n=3)  in  each  ot  5  sites  in  a  ventilator  circuit,  we 
nebulized  albuterol  sulfate  during  CMV  (V^  680  ml,  PIF  40  Umin  rate 
1 2)  Drug  was  collected  on  a  filter  in  a  tracheal  model,  distal  to  a  9  0  mm 
ET  tube    Humidity  was  provided  with  an  active  humidifier  (MR  730 
Fisher-Paykel)  and  a  heated  wire  circuit  (Isothermal,  Baxter  Health 
Care)    Albuterol  was  collected  on  the  filter  and  assayed  (276  NM) 
ANOVA  was  performed  with  p<0  05  considered  significant 
Results  Placement  of  the  USN  at  sites  C,  D,  and  E  delivered  more  drug  to 
the  trachea  than  site  A  and  B  (■p<0  0001 ) 


Site  of  USN  in  Circuit 


A  -  proximal  to  vent,  before  heater 

B  -  immediately  distal  to  heater 

C  -  18  inch  from  wye 

D  -  between  inspiratory  limb  and  wye 

E  -  between  wye  and  ET  tube 
Conclusion  In  contrast  to  previous  reports  with  SVNs,  the  placement  of  the 
USN  at  or  before  the  wye  provided  similar  or  greater  aerosol  delivery 
than  placement  at  other  sites  in  the  ventilator  circuit  dunng  CMV 

FundcJ  b\  .1  grant  Irmn  Ncllctir  )*unuin  Bciinci 


Deposition 

fjg  (MeaniSD) 
51  6±21  0 
49  8±11  1 
200  3±  6  1* 
223  6±31  5" 
210  6±46  0* 


OF-98-097 


calculated.  =  Ml/Mln  multiplied  by 


COMPARISON  OF  THE  LC  PLUS  AND  LC  STAR  NEBULIZERS  USING  THE  PULMO 
AIDE,  PARI  MASTER  AND  PARI  PRONEB  TURBO  COMPRESSORS.  D  Todd  LolTert 
M  H  S  IJohns  Hopklnsl.  and  Kim  Francis.  BSIVirgmla  Commonwealth  University) 

Three  commercially  available  compressors  were  studied  using  LC  PLUS  and  LC 
STAR-  The  nebulizers  were  operated  using  an  PARI  PRONEB  TURBO  compressor 
and  reanalyzed  with  a  PARI  MASTER  compressor  and  Devllbiss  Pulmo-Alde 
compressor    Delivery  rate(Ml/Mln).  percent  Particles  In  the  Resplrable 
RangelPRRl.  and  Resplrable  Particle  Delivery  RatclRPDRl  were  analyzed.   All 
nebulizers  were  filled  with  3  0  ml  of  saline.   PRR  was  measured  by  continuous 
sampling  by  Laser  Particle  Analyzer.  Malvern  MasterSlzer  X.  The  nebulizers  were 
sampled  at  a  simulated  How  rale  of  20  liters  per  minute. 

PARI  PRONEB  TURBO  COMPRESSOR  W/LC  PLUS 

Ml/Mln  average  =  0  47  ml/mln. 

PRR  average  =  68  %. 

To  combine  the  previous  variables  RPDR  was  calculated.  =  Ml/Mln  mulUplled  by 

PRR   RPDR  average  =  0.32. 

PULMO-AmE  COMPRESSOR  W/LC  PLUS 

MI/Min  average  =  0  43  ml/min 

I'RR  average  =  66  % 

To  combine  tile  previous  variables  RPDR  v 

PRR   RJ'UR  axeragc  =  0  28 

PARI  MASTER  COMPRESSOR  W/LC  PLUS 

Ml/Mln  average  =  0  47  ml/mln. 

PRR  average  =  69  %. 

To  combine  the  previous  variables  RPDR  was  calculated.  =  Ml/Min  multiplied  bv 

PRR   RPDR  average  =  0.32. 

PARI  PRONEB  TURBO  COMPRESSOR  W/LC  STAR 

Ml/Mm  .iv.-rscr  =  0  40  ml/mln 
I'RH.iv.r.igc  =  74  <„ 

To  lomblne  Ihf  previous  variables  RPDR  waf 
I'KR.    Rl'DR  average  =  0  2'i 

PULMO-AIDE  COMPRESSOR  W/LC  STAR 

Ml/Mln  aveiage  =  0.40  ml/mln. 

PRR  average  =  72  %. 

To  combine  the  previous  variables  RPDR  wa; 

PRR   Rl'DR  average  =  0.28 

PARI  MASTER  COMPRESSOR  W/LC  ST/VR 

Ml/Mir.  average  =  0  47  ml/mln 

I'RR  average  =  69  %. 

To  combine  the  previous  variables  RPDR  was 

PRR.   RPDR  average  =  0.32 


ted.  =  Ml/Mln  multiplied  by 


calculated.  =  Ml/Mln  multiplied  by 


■alculated.  =  Ml/Mln  multiplied  by 


PERFORMANCE  CHARACTERISTICS  OF  VARIOUS  PNEUMATIC  JET 
NEBULIZERS,  Kiiiibcrlv  Francis.  B  S  .  Nirjiniii  Conimon\ieallh  Uiiivcrsily,  D  Todd 
Loffert.  MHS  .  lohns  Hopkins  Univcrsily 

The  efficiency  of  eleven  jcl  nebulizers  uas  analyzed  using  Ihc  Laser 
Mastersizer  X    The  outpul  (miymin).  percent  resplrable  range  tl-5  ^m).  and  Ihc 
resplrable  rate  (inl/min  in  1-5  nm)  were  the  parameters  recorded    This  stud\  shows  the 
wide  range  of  performance  cliaractcnstics  of  jet  nebulizers 

The  resplrable  range  was  measured  using  Ihc  Laser  Mastersizer  X    Each 
nebulizer  was  filled  with  3  ml  of  II  9%  saline  solution  and  was  ran  for  1  63  minulcs  Willi 
a  Pan  Proneb  Turbo  compressor  Then  the  nebulizers  were  filled  with  5  ml  of  U  9% 
saline  solution  and  were  nebulized  with  the  same  Pan  Proneb  Tuito  compressor  unit  for 
4  mmules   An  air  flow  of  20  l/inin  was  ran  through  ihe  nebulizers  lo  simulate  adull 
mspiraloi^*  flow    Each  nebulizer  was  weighed  before  and  after  nebulization  for 
gra\iinetnc  analysis  of  medicalion  oucput  (inl/min)    The  resplrable  rale  in  llic  I-.''  pin 
range  was  Ihen  calculated  by  muhiplymg  the  pcrceni  rcspirablc  range  wilh  llie  oulpul  of 
each  nebulizer    The  following  table  s 


%  Respirahle  range 

Output  (ml/min) 

ReS|ll 
Iml/mi 

fable  rale 
n  l-Spml 

Meridian 

fi  (.'1 

13 

11(17 

Whiiper  Jet 

44ro 

17 

0  07 

LIniheurt 

4')  211 

11 

0  05 

Acorn 

45. SS 

.16 

007 

Cirrus 

43  48 

18 

0  08 

Beta: 

32  13 

20 

0  0„ 

.\&M 

82  (.3 

15 

0  i: 

DItrainiM 

3f,  5') 

54 

0  ]') 

Aerobid 

31  1)5 

63 

0  19 

Mtnjheart 

61141 

10 

0  06 

Pari  LC  Plus 

60  00 

45 

0  27 

OF-98-109 


87,2 


Ri;.spiRAT()io  C\R[-  •  October  'W  Voi  43  No  10 


Monday-,  November  9,  3:00-4:55  pm  (Room  2I4E) 


COMPARISON  OK  CONVENTIONAL  HEATED  HUMIDIFICA  I  ION  TO  A  NEW 
ACTIVE  HEAT  AND  MOISTURE  EXCHANGER  IN  THE  iCU      Richard  D  Branson  BA 
RRT,  Roberts  Campbell.  RRT.  Michael  Ottawa)  BS.  EMT-P.  Jav  A  Johannigman 
University  of  Cincinnati.  Department  of  Surgery 

Background    Healed  humidiflcation  (HH)  is  commonly  use  J  with  or  without  a  healed  wire 
circuil  (HWC)  to  humiditS  inspired  gases  during  mechanical  ventilation  (MV)    We  compare' 
HH  and  HH  with  a  HWC  to  a  new  active  heat  &  moisture  e\changer{AHME).  The  AHME 
iGibeck,  Sweden)  consists  of  a  typical  HME  and  a  heat  and  water  source  delivered  between 
the  patient  and  the  HME  The  volume  of  water  delivered  and  heal  output  are  based  on  a  set 
minute  ventilation    A  pre-set  airway  temperature  of  ?7°C  is  used    Methods'   Thirty  patients 
requiring  MV  for  -  72  h  were  studied    Pts  received  humidificalion  via  a  HH.  HH  +  HWC 
(Fisher  &  Paykel).  and  AHME  in  random  sequence  for  24  h  each     All  devices  were  set  to 
deliver  .^T^C  at  Ihe  proximal  airway.  During  each  period  of  venttlalion.  the  following  were 
measured:  airway  temperature,  min  and  max  body  temperature,  U  of  suctioning  anempts. 
volume  of  secretions,  consistency  of  secretions.  «  and  volume  of  saline  instilled,  water  usage, 
condensate,  ventilator  settings,  minute  volume,  #  of  circuit  disconnections    Water  usage  was 
measured  by  weighing  the  water  bag  before  and  after  24  h  use    Consistency  of  secretions 
were  judged  as  thin,  moderate,  or  thick  as  previously  described  (Suzukawa.  Respir  Care 
1 989,34.976)    Condensate  was  measured  by  empty  ing  fluid  into  a  graduated  container  and 
sputum  volume  measured  by  collecting  secretions  in  a  Luken's  trap    Airway  temperature  vva: 
measured  ai  the  EI  lube  using  a  rapid  response  thermisior,   Resistance  of  Ihe  AHME  was 
measured  before  and  after  use  Results:   There  vvere  no  differences  in  any  of  the  variables 
related  to  humidificalion  efficiency  (secretion  volume  and  consistency.  #  of  suctioning 
attempts,  or  volume  of  saline  used).   Water  usage  and  volume  of  condensate  were 
significantly  different  between  devices,  bui  delivered  airway  temperatures  were  not 
Statistical  analysis  was  done  with  ANOVA  •p<0.05  See  Table. 


DEVICE      1  Waler  Usage  (ml) 

Condensate  (mL) 

Airway  Temp  (°C) 

HH 

2039±  387 

930  ±  271 

36-3  ±  1  2 

HH  +  HWC 

766  ±  281 

12  ±  16* 

37.1  ±  1.0 

AHME 

135  ±  53 

1  ±3- 

36  4  ±  1  7 

Minute  volume  was  similar  between  groups  (1 1.6  ±  3  3  vs  1 1.9  ±  3-4  vs  11 ,8  ±  2  7  L.'min)as 
was  bias  flow  during  flow  triggering  (5,8  ±  2,5  vs  5,4  ±  2,6  vs  5,9  ±2  3)    AHME  resistance 
before  and  after  use  was  unchanged  ( 1 .66  ±  0  1 1  vs  2  28  ±  0,82  cm  H;0/L/s)  Conclusions: 
In  a  pilot  study,  the  AHME  provided  equivalent  humidificalion  as  HH  and  HH  +  HWC  with  a 
lower  water  usage    fhis  occurs  because  the  HME  portion  of  the  AHME  returns  =  32  mg 
H:0/L.  which  only  requires  the  active  portion  to  add  s  12  mg  H-O/L  to  reach  44  mg  H:0  L 
Additionally,  by  placing  the  AHME  between  the  patient  and  ventilator  circuit,  continuous 
flow  from  flow  triggering  systems  is  not  humidified    No  other  differences  were  noted 
Disadvantages  of  the  AHME  include  deadspace  (=  70  mL).  weight  on  the  ET  tube  and  the 
heat  source  near  the  patient.  Measured  external  temperature  of  Ihe  AHME  did  not  exceed 
38''C    Further  long  term  studies  are  required  to  define  the  role  of  the  AHME 


OF-98-123 


A  NtW  MLTHOD  TO  CHARACI  URlZli  TI  lU  EHTiiCrS  OI-  SPACERS  AND 
HOLDING  CHAMBIiRS  ON  IXXJR  HAND-BREAl  H  COORDINATION  DURING 
MDl  USH'^JBFiDk.W   Wilkes.  K  Dhand.  PJ  Fahc>.  MJ  Tobin    Mines  \\  Hospital 
and  Ixiyola  Stntch  School  of  Medicine.  Hines,  II. 

Background    Spacers  and  holding  chambers  arc  recommended  to  minimi/x  the 
common  clinical  problem  of  poor  hand-breath  coordination  (dysynchrony)  while 
using  metered-dose  inhalers  (MDls).  however  their  ability  to  decrease  the  effects  of 
dysynchrony  by  design  have  not  been  differenitalcd     Methods     In  a  model  that 
simulated  spontaneous  respiration,  we  tested  albuterol  deposition  from  9  devices  in 
combination  with  a  MDl,  when  actuation  was  or  was  not  synchronized  with 
inspiration    We  characten/ed  tlie  devices  as  shirnn  bel.ow    Results    With  actuation  1 
Sec  before  inspiration,  spacers  and  all  HCs  delivered  more  drug  than  the  MD!  alone 
or  low  volume  spacers(p<0  0()l).  During  exhalation,  more  albuterol  was  delivered 
with  valved  HCs  than  Spacers  or  MDl  alone  (p<OOOOI) 


Holding 

Holding 

Chamt>er 

Chamber 

Bag 

Valve 

Conclusion     Valved  holding  chambers  should  be  recommended  for  patients  with 
poor  hand-breath  coordination  while  using  MDls   VA  Research  Service 


OF-98-129 


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The  School  of  Sleep  Medicine  inc 


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Respiratory  Care  •  October  "98  Vol  43  No  10 


873 


The  Weaning  Combination: 

Flow  Synchronization  +  Termination  Sensitivity 
=  Total  Flow  Synchrony 


Flow  Synchronization 

Improves  patient/ventilator  synchrony  and 
reduces  the  work  of  breathing.  Consistent 
volume  delivery  is  accomplished  at  lower 
peak  inspiratory  pressures  improving 
dynamic  compliance. 

Termination  Sensitivity 

A  user  selectable  "expiratory"  trigger  allows  the 
infant  to  control  the  inspiratory  time  of  the 
positive  pressure  breath.  This  eliminates  the 
pressure  plateau  routinely  seen  in  time-cycled, 
pressure-limited  ventilation. 

Total  Flow  Synchrony 

The  combination  of  Flow  Synchronized 
Ventilation  and  Termination  Sensitivity, 
unique  to  the  V.I. P.  Bird®,  provides  complete 
and  Total  Flow  Synchrony.  These  features 
along  with  Bird's  superior  graphics  and 
volume  monitors  offer  the  clinician  an 
unbeatable  weaning  combination. 


For  Total  Flow  Synchrony,  call  Bird  Products  at  1-800-328-4139. 


i 


Circle  114  on  reader  service  card 
Visit  AARC  Booth  131  in  Atlanta 


ui.rgu 


The  Breath  ofTechnttlogy 

P<ilm  Spring,.  Cilifomia  '  760.778.7200 
Fax  '  760.778.7274 


Tuesday,  November  10,  1:00-2:55  pm  (Room  214E) 


LABORATORY  EVALUATION  OF  TWO  TRANSPORT  VENTILATORS 

Teresa  A.  Volsko,  BS,  RRT.  Robert  L.  Chatbum.  RRT.  Enrique  R.  Grisoni,  MD 
University  Hospitals  Health  Systems.  Cleveland,  Ohio 

INTRODUCTION:  Mechanical  ventilators  are  often  used  during  transport  of 
critically  ill  patients.  It  has  been  suggested  that  transport  ventilators  should 
deliver  stable  tidal  volumes  (writhln  1 0%  of  set)  in  the  face  of  changing 
pulmonary  mechanics,  to  ensure  adequate  ventilation  (Resp  Care  1992;37;775- 
795).  The  purpose  of  this  study  was  to  detennine  if  the  transport  ventilators 
evaluated  met  this  criterion  under  both  low  and  high  load  conditions. 
I\/IETH0DS:  Two  transport  ventilators,  the  Hamilton  Max  and  Biomed  Crossvent 
4  were  evaluated.  A  single  compartment  lung  model  (TTL.  Michigan  Instruments) 
was  used  to  simulate  high  load  (C  =  0.02  L/cm  HjO,  R  =  20  cm  H^OIUs).  and 
low  load  (C  =  0.1  L/cm  HjO,  R  =  5  cm  HjO/L/s)  conditions.  The  model  was 
disconnected  for  the  baseline  no  load  condition.  The  same  standard 
nondisposable  patient  drcuil  was  used  on  each  ventilator.  To  measure  Vj 
delivery,  a  Bicore  flow  transducer  was  placed  inline  between  the  TTL  and 
ventilator  circuit,  after  calibration  verification  with  a  500  mL  syringe.  For  each 
set  Vt  (0.05  L,  1.0  L  and  1 .5  L)  three  measurements  were  obtained  for  each 
load.  Acceptable  perfomiance  was  judged  as  volume  delivery  within  10  %  of 
target.  RESULTS:  The  results  for  each  combination  of  Vy  and  load  are  shown  in 
the  figure  (mean  values  only,  standard  deviation  too  small  to  show  on  scale). 
Dotted  lines  represent  accuracy  intervals  defined  as  ±  10  %  of  target  volume. 

1.60  - 
2"  l.'IO  - 
o"  1.20  ■ 
3    1.00- 
>    0.80  ■ 
1    0.60- 
1-    0.40  • 

0.20- 

9      Crossvent 
-O-    Max 

D — 2-              . 

\^ 

^\ 

° ^  >-.-^.__^_^ 

31    __^ 

CONCLUSIO 

load  levels.  T 
at  high  load, 
adequate  Vt 

No  Load            Low  Load           High  Load 

NS:  Both  ventilators  performed  acceptably  ur 
>e  Hamilton  Max  venfilator  did  not  perfomi  wi 
Exhaled  Vt  monitoring  during  transport  may  b 
delivery  In  patients  with  tow  compliance  and/ 

der  no  load  and  low 
bin  the  defined  limits 
3  Indicated  to  ensure 
3r  high  resistance. 

OF-98-002 

THE  EFFECTS  OF  VARIATIONS  OF  INSPIRATORY  FLOW  WAVE  PATTERN  ON 
CARDIOPULMONARY  FUNCTION  AND  BREATHING  COMFORT  DURING 
LONG-TERM  MECHANICAL  VENTILATION  OF  PATIENTS  WITH  CHRONIC 
OBSTRUCTIVE  PULMONARY  DISEASE.    David  C   Shelledv.  PhD.  RRT.  Brenda 
Galindo,  BS.  RRT,  Dora  A   Galvan.  BS,  RRT.  Clanssa  M   Villacorta,  BS.  RRT 
Respiratory  Care  Departinent,  Vencor  Hospital  of  San  Antonio  and  The  University  of  Texas 
Health  Science  Center  at  San  Antonio.  Texas. 

BACKGROUND:    Little  is  known  about  the  advantages,  if  any.  of  particular  flow  wave 
panenis  during  mechanical  ventilation  of  long-term  ventilator  patients.    We  examined  the 
effects  of  three  inspiratory  flow  wave  patterns  on  measures  related  to  cardiopulmonary 
function  and  breathing  comfon.    METHOD:    A  prospective,  randomized  blocks  repeated 
measures  design  with  subjects  serving  as  their  own  controls  was  used  to  study  eleven  stable 
long-term  ventilator  patients  with  a  pnmary  diagnosis  of  COPD,    Three  inspiratory  flow 
wave  patterns  (square,  down  ramp,  sine)  were  assigned  in  a  random  sequence  for  a  twenty 
minute  period  each  followed  by  collection  of  the  following  data:    peak  airway  pressure 
(PIP),  mean  airway  pressure  (MAP),  dynamic  compliance  (Cdyn),  static  compliance  (Cst), 
SpOj.  pulse,  blood  pressure,  and  breathing  comfort.    Patients  were  asked  to  indicate 
breathing  comfort  using  a  seven-poini  scale  where  7=extremely  comfortable  and 

ely  uncomfonable.    Mean  values  for  vatiables  were  compared  using  repealed 
;  ANOVA.    A  significant  difference  (p  <  .05)  on  ANOVA  was  followed  by  a 
Scheffe'  post-hoc  significance  test,    RESULTS:    Means,  standard  deviations,  and  ANOVA 


MEANS  (SDl 

Variable 

Down  Ramp 

Sauare  Wave 

Sme  Wave 

F 

Peak  Ai^^vay  Pressure 

30.68    (7.3) 

42.37    (9.0) 

38,17    (9.2) 

21.35 

Mean  Airway  Pressure 

9.1     (2.9) 

8.08   (2,6) 

7.85    (2,4) 

2.58 

Dynamic  Compliance 

26.03   (7.7) 

17.95    (4,4) 

2050    (6.4) 

14.46 

Static  Compliance 

37.59   (9.8) 

33.43    (7,6) 

37.16    (9.9) 

2.01 

SpO, 

96.27  (3.1) 

97.09   (2.5) 

96.36   (3.2) 

3.26 

Pulse 

88.45  (17.2) 

89.45  (16.6) 

84,0  (16.1) 

3.26 

Mean  Arterial  Pressure 

8034    (9.4) 

81.94(14.7) 

79,93  (11,9) 

0.42 

Breathing  Comfort 

4.3     (1.6) 

4.22    (1.3) 

5,0    (1.5) 

0.69 

*  p  <  .05 

There  were  significant  differences  by  flow  wave  pattern  for  PIP  and  Cdyn.   Post-hoc 
comparisons  indicated  that  the  down  ramp  resulted  in  a  significantly  lower  PIP  than  the 
square  wave  (p  =  .00001)  or  sine  wave  (p=  002)     CONCLUSIONS:    The  down  ramp 
flow  pattern  resulted  in  a  significantly  lower  PIP  and  improved  Cdyn  when  compared  to  the 
square  or  sine  wave.    There  were  no  significant  differences  by  flow  wave  panem  for  MAP. 
Cst,  blood  pressure  or  breathing  comfort,  though  the  differences  for  heart  rate  and  SPOj 
approached  statistical  significance     The  use  of  a  down  ramp  flow  wave  pattern  may  be 
useful  in  reducing  peak  airway  pressures  in  long-term  ventilator  patients  with  COPD 


OF-98-011 


INDEPENDENT  LUNG  VENTILATION  IN  A  PA  PIENT  WITH  COMPLEX 
CONGENITAL  HEART  DISEASE.  Donna  Uvine  MEd.  RRT.  Tina 
Carmichael  RRT,  Peter  C.  Laussen  MB-BS.  Children's  Hospital.  Boston.  MA 

Independent  lung  ventilation  (  ILV)  has  been  beneficial  in  treating  unilateral 
lung  disease  when  there  are  significant  differences  in  mechanics  between  the 
two  Iungs'-2.  We  report  the  use  of  ILV  in  a  22  year  old  women  with 
respiratory  failure  and  circulatory  collapse  who  was  referred  to  our  ICU  for 
ECMO.  She  had  a  history  of  complex  congenital  heart  disease  including 
double  outlet  right  ventricle,  pulmonary  atresia  and  hypoplastic  left  ventricle. 
She  underwent  several  surgical  palliations  resulting  in  a  single  ventricle  heart 
with  limited  pulmonary  blood  flow  (PBF).  An  aortic-lo-pulmonary  artery 
central  shunt  supplied  pulsatile  PBF  to  the  left  lung  and  RUL.  A  "classic" 
Glenn  shunt  (SVC  -to-right  pulmonary  artery)  supplied  non-pulsatile  PBF  to 
the  RML  and  RLL.  Effective  PBF  to  the  RML  and  RLL  was  therefore 
dependent  on  passive,  non-puIsatile  flow  and  a  transpulmonary  pressure 
gradient  between  the  SVC  pressure  and  the  left  atrial  pressure.  Prior  to  this 
illness  she  was  active  with  a  baseline  room  air  Sp02  of  85%.  Her  admission 
ABG  was  Pa02  42  mmHg,  PaCOo  44  mmHg.  pH  7.15  on  PCV.  Fi02  I.O, 
PiP/PEEP  28/6  cmH20.  rate  12.  Sp02  was  55%,  CXR  showed  opacification 
of  the  left  lung  and  hyperinflation  of  the  right  lung  and  she  required 
vasopressors.  There  was  no  response  to  40  ppm  of  inhaled  nitric  oxide. 
Because  of  the  variable  lung  pathology  and  pulmonary  vascular  physiology,  a 
35FG  left  endobronchial  tube  was  placed  and  ILV  instituted.  Two  Servo  9Q0C 
ventilators  were  synchronized  and  a  Vt  of  5  cc/kg  was  delivered  to  each  lung. 
PiP/PEEP  on  the  right  lung  was  17/4  cmH20  and  28/8  cmH20  on  the  left 
lung.  The  24  hour  CXR  showed  the  right  lung  with  normal  inflation  and  the 
left  lung  was  expanded.  Sp02  was  85%  on  Fi02  of  0.55.  Vasopressors  were 
reduced.  ABGs  and  hemodynamics  improved.  She  was  extubated  on  day  5 
and  discharged  on  day  8.  This  case  demonstrates  the  advantage  of  ILV  in  a 
patient  with  abnormal  pulmonary  blood  flow  and  variable  lung  mechanics. 
Following  a  Glenn  anastomosis,  effective  passive  PBF,  and  therefore  venous 
return  to  the  systemic  ventricle,  may  be  severely  limited  by  the  use  of  high 
intrathoracic  pressure  during  mechanical  ventilation.  ILV,  in  this  case,  enabled 
reduced  ventilator  pressures  and  normal,  inflation  to  the  lung  supplied  by  the 
Glenn  shunt,  with  immediate  improvement  in  arterial  oxygenation  and  blood 
pressure, 

1 .  Ost  D,  Corbridge  T:  Independent  lung  ventilation.  Clinics  in  Chest  Med 
17:591-601.1996 

2.  Schmitt  HJ,  Mang  H,  Kirmse  M:  Unilateral  lung  disease  treated  with 
patient- triggered  independent  lung  ventilation:  a  case  report.  Resp  Care 
39:906-911,  1994 


VENTILATOR  ASSOCIATED  PNEUMONIA  (VAP)  REDUCTION  IN  A 
COMMUNITY  HOSPITAL,  METHODS  AND  OUTCOMES  Peter  Hansen  RRT. 
Madeline  M.  Emanuelsen  MS.  Bayley  Seton  Hospital  Stalen  IslandNY 
BACKGROUND:  198  bed  community  hospital  with  a  low  VAP  rate  (#  VAP/1.000  mech. 
vent,  Pt.  days)  further  reduced  VAP  niie  and  cost  of  care  \ia  multidisciplinaiy  effort 
between  Resp.  Care.  Infection  Control  Dept  and  Nursing. 

METHODS:  Retrospective  re\iew  of  VAP  rale  determined  rates  for  years  1992-1994  to 
be  2.71.  2.55,  0.88  respectively  and  nsmglo  4  3  in  1995  The  majority  of  the  year  1995 
cases  (9)  occurred  dunng  ihe  first  sl\  months  of  1995.  AH  suspected  cases  of  VAP 
undergo  a  muliidisciplinar>  review  b>  the  Infection  Conirol  Dept.  and  Respirator>'  Care 
Depl.  to  determine  if  CDC  cntena  for  Nosoconual  Pneumoma  are  met  Ventilator 
equipment  protocol  was  the  use  of  heated  wire  circuits  with  heater/humidifiers  exclusively 
throughout  stay  on  M.V  .  with  circiut  changes  ever\  48  hrs  and  use  of  disposable 
bacterial/viiaJ  filler  on  manual  resuscitator  ai  pt  interface  with  filter  changes  every  48 
hrs.  Patient  suctionmg  was  accomplished  with  smgle  use  catheters  In  Sept.  1995.  when 
clinically  appropriate,  heat  and  moisture  exchangers  were  utilized  for  the  first  96  hrs.  of 
M.V.  Then  pts  are  ventilated  with  heated  wire  circuits  and  heater/humidifiers  which  were 
changed  every  48  hrs.  In  October,  the  Nursing  Dept  imlialed  (he  use  of  closed  system 
suaion  catheters  with  24  hr.  changes    VAP  rate  for  1996  decreased  to  1  78  (4  cases  in 
2243  M.V,  pt.  days).    In  Febniar.  1997  a  six  month  pilot  program  of  weekly  circuit 
changes  commenced.  For  the  first  96  hrs,  HMEs  are  used  on  M.V  circuits,  then  heated 
wire  circuits  with  heater/humidifiers  are  utilized  and  changed  at  7  da>-s;  closed  system 
suction  is  still  utilized  as  is  change  of  bactenal/viral  filler  on  manual  resuscilators  every 
48  hrs 

OUTCOMES:  VAP  rate  showed  no  increase  during  the  pilot  penod  of  weekly  circuit 
changes  and  therefore  polic>-  was  altered  to  provide  for  weekl\'  circuit  changes.  Resource 
utilization  was  enhanced  as  M  V  pt,  days  increased  40  %  dunng  this  period  compared  to 
the  previous  year,  but  ventilator  supply  item  consimiption  excluding  oxvgen  remained  the 
same  Our  VAP  rale  for  1997  as  a  total  year  decreased  to  I  50  (4  cases  in  2659  M,  V  pt. 
days),  demonstrating  that  hi^  qualitv  care  can  be  maintained  while  managing  the 
steadily  tncreasmg  costs  of  healthcare 


Respiratory  Care  •  October  "98  Vol  43  No  10 


875 


Tuesday,  November  10.  1:00-2:55  pm  (Room  214E) 


THE  EFFECT  OF  AIRWAY  LEAK  ON  RESPrRATORY  MECHANICS  CALCULATIONS 

Harlan  J   Brick.  RRT.  Robert  L   Chatbum.  RRT, 
University  Hospitals  of  Cleveland,  Ohio 

BACKGROUND:  Many  ventilators  and  bedside  monitors  display  values  of  resistance 
and  compliance,  regardless  of  whether  underlying  assumpttons  of  the  mathematical 
models  they  use  are  met   For  example,  an  airway  leak  would  theoretically  cause 
displayed  resistance  to  be  falsely  low  and  compliance  to  be  falsely  high.  The 
purpose  of  this  study  was  to  determine  If  monitors  react  according  to  theory  and  how 
much  of  an  error  Is  Introduced  by  a  simulated  airway  leak.  METHODS:  Airway  leak 
during  mechanical  ventilation  was  simulated  with  an  IngMar  Medical  Adult/Pediatric 
lung  model    We  ventilated  one  side  of  the  lung  model  using  an  NPB  7200  ventilator 
using  volume  controlled,  continuous  mandatory  ventilation  with  a  rectangular  flow 
waveform.  Two  load  levels  (high  resistance/  low  compliance  and  low  resistance/high 
compliance)  and  two  tidal  volumes  (400  mL  and  800  ml)  were  set   The  lung  model 
allowed  a  simulated  ET  tube  leak  (approximately  40%)  to  be  switched  on  or  off 
Measurements  of  dynamic  resistance  (R)  and  dynamic  compliance  (C),  using  a  linear 
regression  model,  were  made  with  either  the  NPB  7200  or  the  Novamatrix  COjSMO+, 
Each  of  the  8  experimental  conditions  (ie.  load  high  and  low.  tidal  volume  high  and 
low.  leak  on  and  ofO  was  examined  6  limes  using  the  NPB  7200  and  6  times  using 
the  CO;SM0+   The  effects  of  airway  leak  on  mean  values  for  R  and  C.  under  different 
loads  and  tidal  volumes  were  compared  using  paired  t-tests  (significance  set  at  p  £ 
0.01),  RESULTS:    For  every  combination  of  tidal  volume  and  load,  ainway  leak  had  a 
significant  effect  on  R  and  C  Thus,  combined  results  are  Illustrated  below 


tSD) 


soj*  7200  T 


leak  off 


leak  off 


CONCLUSIONS:  An  airway  leak  causes  significant  error  in  displayed  values  of 
dynamic  resistance  and  compliance   The  error  was  as  much  as  19%  for  R  and  118% 
for  C,  which  may  be  clinically  important.  Furthermore,  the  CO2SMO+  showed  an 
increase  In  displayed  resistance  with  a  leak,  contrary  to  the  theoretically  expected 
result   The  NPB  does  notify  the  operator  of  questionable  results  for  static  mechanics 
if  a  leak  causes  unstable  plateau  pressure   But  neither  the  NPB  7200  nor  the 
COjSMO+  questioned  results  for  dynamic  mechanics.  Clinicians  should  be  aware 
that  monitors  behave  differently  due  to  differences  in  calculatton  algorithms  as  well 
as  tubing  compliance  effects   Manufacturers  should  (a)  strive  for  universal  standards, 
(b}  evaluate  device  perfonnance  under  error  causing  conditions  like  airway  leaks  and 
(c)  use  rejection  criteria  that  prevent  display  of  R  and  C  when  airway  leak  is  detected. 


THE  EFFECT  OF  EXTENDED  CIRCUIT  CHANGE  INTERVALS  ON 
THE  INCIDENCE  OF  VENTILATOR  ASSOCIATED  PNEUMONIA.  Mary 
Turlev.  RRT,  John  Votto,  DO,  Janet  Brancifort.BS,  RRT,  M  Collins,  RN, 
Hospital  for  Special  Care,  New  Britain,  CT 
Hospital  for  Special  Care  is  a  200  bed  cfironic  disease  and 
rehabilitation  hospital  With  the  steady  growth  of  our  ventilator 
dependent  patient  population  and  the  need  to  provide  quality  cost 
effective  patient  care  we  reviewed  all  areas  of  our  practice  for 
improvement  This  study  compares  the  ventilator  associated 
pneumonia  (VAP)  rates  and  cost  reductions  with  7  day,  14  day,  and  21 
day  ventilator  circuit  changes    METHODS  During  Phase  1  circuits 
were  changed  every  7  days,  dunng  Phase  2  circuits  were  changed 
every  14  days  and  during  Phase  3  circuits  were  changed  every  21 
days  Data  was  analyzed  for  a  6  month  time  period,  from  January  to 
June,  during  each  phase  Infectious  Disease  monitored  the  occurrence 
of  VAP  during  this  penod,  using  clinical  cnteria  consistent  with  the 
CDC  Data  was  also  obtained  for  ventilator  circuit  costs  and 
practitioner  time  spent  doing  circuit  changes  There  was  no  change  in 
mechanical  ventilation  practice  during  this  time  Heated  wire  circuits 
and  heat  moisture  exchange  systems  were  used  and  patients  were  on 
a  closed  suction  catheter  system.  RESULTS  Based  on  8,760 
ventilator  days  (48  patients)  in  Phase  1  the  VAP  rate  was  1  75/1000 
ventilator  days  Practitioners  spent  416  hours  doing  circuit  changes 
and  circuit  costs  were  $25,444  during  this  time  In  Phase  2  there  were 
10,950  ventilator  days  (60  patients)  and  the  VAP  rate  was  1  64/1000 
ventilator  days  Practitioners  spent  260  hours  doing  circuit  changes 
and  circuit  costs  were  $18,639    In  phase  3  there  were  14,118 
ventilator  days  (  75  patients  )  and  the  VAP  rate  was  1  47/1000 
ventilator  days    Practitioners  spent  208  hours  doing  circuit  changes 
and  circuit  costs  were  $13,090    CONCLUSION  Our  results  would 
suggest,  that  in  the  long  term  ventilator  dependent  patient  population, 
ventilator  circuits  can  be  changed  at  a  21  day  interval  without  a 
significant  change  in  the  occurrence  of  VAP  and  with  a  significant 
savings  in  circuit  costs  and  practitioner  time. 


OF-98-050 


THE  EFFECT  OF  A  HELIUM/OXYGEN  MIXTURE  ON  THE  ACCURACY  OF 
TIDAL  VOLUME  MEASUREMENTS  OF  MECHANICAL  VENTILATORS. 
Michael  A.  Gentile,  RRT,  John  M.  Davies,  RRT,  Robert  R.  McConncIL  RRT,  ira 
M.  Cheifetz,  MD,  Duke  University  Medical  Cento-,  Duriiam,  NC. 

Background:  The  use  of  Helium/Oxygen  mixtures  (Heliox)  may  be  useliil  when  U-cating 
patients  with  airway  obstnictive  disease  due  to  lis  Iowa  density.  We  hypothesized  that 
Hdiox  would  have  an  effect  on  the  tidal  volumes  (VI)  measurements  of  various 
mechanical  ventilators  based  upon  the  different  technologies  useti  to  measure  Vt. 

Method:  We  pertbnned  bench  evaluations  on  four  vi-nlilators:  Puntan-Bcnnelt  7200ae, 
Saraens  Servo  900c,  Bird  840{lsti,  and  Bear  1000.  All  four  ventilators  were  connected  to 
a  test  lung  and  placed  in  the  Assist  Cond-ol  Mode,  with  set  tdal  volume  500  ml,  rate  20 
breaths  pa  minute,  FiO,  30%,  PEEP  i  cm  H.O,  and  a  square-wave  inspinilory  How 
pallem  and.  An  external  monitoring  device  (Cosmo  Plus!,  Novamdrix)  which  could  be 
adjusted  for  various  gas  densities  was  placed  in  hne.  The  first  tests  were  done  on  a 
standard  hook  up  to  wall  air  and  oxygen  with  a  set  FiO;  of  .30%,  The  venldators  were 
next  tested  with  the  air  supply  hose  attached  to  a  Heliox  tank  (70%  HeUum/30%  Oxygen) 
scl  at  50  PSIG.  Each  ventilator  served  as  il  own  control. 

Results: 


Air/Oxygcn 

Hehox 

Vcntilalor 

Expircil  Vt 

Expu-ed  VI 

Dilfcrencc 

PB  7200ac 

460  ml 

1000  ml 

+  540 

Servo  900e 

481  ml 

479  ml 

-3 

Bear  1000 

500  ml 

3580  ml 

+  3180 

Bird  840(lsti 

4Mml 

478  ml 

+  14 

Conclusions:  Oases  with  IigliiLT  densities  lh:m  air  have  a  vanal  elTect  on  mechanical 
vaitilalors.  II  is  miportant  lo  the  chnieiaii  to  be  aware  of  how  different  gas  doisities  will 
elTect  the  function  of  the  ventilators.  If  Ihc  clmieian  is  using  a  vintilalor  that  is  efTcclcd 
by  Heliox,  it  may  helpful  lo  have  an  external  monitoring  device  which  cui  be  adjusted  for 
various  gas  densities  verify  exhaled  tidal  volumes. 


OF-98-061 


A  COMPARISON  OF  THE  EFFECT.S  OF  DEMAND  FLOW,  FLOW-BV  AND 
PRESSURE  SUPPORT  ON  IMPOSED  WORK  OF  BREATHING  AND 
VENTILATORY  EQUIVALENT.    David  C  Shelledv.  PhD.  RRT  and  Lynda  fhomas 
Goodfcllow.  MBA.  RRT    The  Universily  of  Texas  Health  Science  Center  at  San  Antonio, 
San  Antonio.  Texas  and  Georgia  State  University,  Atlanta.  Georgia. 

BACKGROUND    Flow-by  is  a  newer  technique  ihal  is  designed  to  reduce  ihe  spontaneous 
work  of  breathing  during  mechanical  ventilatory  support     We  compared  the  imposed  work 
of  breathing  and  venlilatory  efficiency  of  flow-by  (FBI,  demand  flow  (DP)  and  pressure 
support  (PS)  at  5  and  10  cm  H,0  in  spontaneously  breathing  volunteers  being  ventilated  via 
mouthpiece  using  Ihe  Bennett  7200ae  ventilator.    METHOD    A  randomized  blocks, 
repeated  measures  design  was  used  lo  compare  DF.  FB  and  PS  at  5  and  10  cm  H.O. 
Twenty  healthy  volunteers  served  as  their  own  controls,  breathing  in  each  of  Ihe 
experimental  conditions  in  a  random  sequence   For  DF  and  PS,  sensitivity  was  set  a  - 1  cm 
H,0,    FB  was  set  with  a  base  flow  of  10  L/min  and  a  flow  sensitivity  of  3  L'mm.    Data  was 
collected  continuously  for  5  minutes  and  the  mean  values  at  Ihe  end  of  that  time  were 
reported    Ventilatory  equivalent  (VFQ)  for  oxygen  is  a  measure  of  the  efliciency  of 
vcnlilalion  at  various  work  loads  and  was  calculated  b>  dividing  VE  (BTPS)  by  VO, 
(STPD)    Imposed  work  of  breathing  (WOBI)  was  estimated  by  sublraclmg  VO.  during 
spontaneous  breathing  without  Ihe  ventilator  from  VO,  during  DF.  FB  and  PS     RESULTS 
The  mean  VLQ  and  WOBI  for  Ihe  four  conditions  was 


Demand  Flow 

Flow-by 

PS  .5  cm  H.O 

PS  10  cm  H;0 

Mran  WOBI  (SD) 
(ml.  mm) 

8,2(23  3) 

-3  3  (32  0) 

3,2.s  (2')9) 

4  8  (214) 

Mean  VEQ  (SDl 
IL'I.  VO.l 

27  0  (3  7) 

32 -S  (5  4) 

35  I  (8  ?)• 

41  1  (U)7)v 

•  significantly  greater  than  DF  (p-;.05);  "  significantly  greater  than  FH  (p-  05 

There  were  significant  differences  in  VEO  for  DF,  FB  and  PS  at  5  and  10  cm  H.O  >\lieri 
compared  using  ANOVA.    Pairwise  followup  comparisons  found  that  there  were  no 
significant  differences  in  VEQ  between  FB  and  DF  and  FB  and  PS  at  5  cm  H.O  (|>    05) 
There  were  significant  differences  in  VEQ  between  DF  and  PS  of  5  cm  H;0;    1)1  .ind  I's 
of  10  cm  1I,0,  and  FB  and  PS  at  10  cm  H,0  (p--  051,    Flow-by  produced  the  lowest 
WDBl.  however,  this  difference  was  not  statistically  significant  (p>.05).   CONCLUSIONS: 
Micrc  was  no  significant  difference  between  FB  and  PS  at  5  cm  H,0  m  lenns  of  ventilatory 
erficiency.    PS  at  10  cm  H,0  produced  Ihe  greatest  VLQ  and  was  the  most  efficient  of  Ihc 
tour  conditions  studied,    FB  produced  Ihe  lowest  WOBI,  however,  this  finding  was  not 
slalislically  significant.    We  believe  measurement  of  ventilatory  equivalent  may  provide  a 
sensitive  method  for  a.ssessing  ventilatory  efficiency  during  mechanical  ventilalion. 


OF-98-068 


876 


Rl  Sl'IKATORY  C,\Ki:  •  OcTOBIiR   "98  Voi    4.^   N(1    10 


SIEMENS 


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Danvers,  MA    01923 
Tel:  (9781  907  -  6300 
(800)  333  -  8646 


Tuesday,  November  10.  1:00-2:55  pm  (Room  214E) 


EFFECT  OF  IMPLEMENTING  MULTIPLE  INFECTION  CONTROL  PR.\CT1CE 
CHANGES  ON  VENTILATOR  RELATED  PNEUMONIA 

Bruce  Malms  BS  RRT  .  Paul  Bettencourt  MD.  Rose  Pachas  RN.  Bonnie  Fallon  RN. 
Margaret  Ferguson  RRT.  Faulkner  Hospital.  Boston  Mass 


INTRODtCTION:  Using  ihe  CDC  diagnosis  guideli 
related  pneumonia  (VRP)  rate  tor  over  1 0  years  Our  r 
VRP's  per  1 .000  ventilator  days  until  i  '^'14  when  ; 
focus  group,  the  Pneumonia  Task  Force  (PTF)  wa 
recent  practice  changes  concluded  the  most  likely 
decrease  in  use  of  closed  tracheal  suction  catheter 
of  H2  blockers  The  committee  recommendati 


nes  wc  have  followed  our  ventilator- 
ate  had  consisiemlv  been  less  than  1 5 
of  2 1  occurred  An  inierdepartmenial 
oruanized  The  PTF.  following  a  review  of 
luses  of  the  VRP  increase  were  I )  a 
(CSC)  and  2)  a  possible  increase  in  the  use 
I  use  CSC's  on  all  intubated  patients  and  lo 
reduce  the  use  H2  blockers  were  approved,  implemented  and  monitored  The  VRP  rate  for 
1995  however  increased  from  21  to  24 

METHOD:  The  task  force  made  the  decision  lo  develop  and  implement  a  list  of  all  infection 
control  practices  that  could  be  improved    Particular  importance  was  placed  on  a  quote  from 
the  IQ'J4  CDC  publication  "Guidelines  for  Prevention  of  Pneumonia",  which  staled  "most 
bactenal  pneumonias  occur  by  aspiration  of  the  bactena  colonizing  the  orophyaranx  or  upper 
yasiromiesimal  tract"    A  review  of  the  I)  \'^^A  CDC  guidelines.  2)  recent  published  ventilator 
related  pneumonia  studies  and  3)  our  respiratory  department  and  nursing  ventilator-related 
procedures  resulted  in  a  list  of  seven  recommended  infection  control  practice  changes  The 
seven  interventions,  which  were  implemented  in  February  \9<i$  and  are  monitored  diligeniK  to 
this  day,  are 


I'n. 


^  S'eniilator  tubing  replaced  twice  a  week 

4  Rcspiraiorv  medications  delivered  via  small 
nebulizer  or  MDl 

5  Manual  resuscitators  uncapped  between  use 

6  Endotracheal  tube  cuff  sometimes  dellaied 

7  Head  of  the  bed  at  different  levels 
possible 


PiiKlicf  cfia/igc 
■  Performed  every  4  hours 

-  Mouth  care  solution  ro  be  S0«o 

peroxide  and  SO^o  mouth  wash 
-Changed  once  a  week 
•All  medications  delivered  by  MD! 

-  Capped  between  use 

-  Dellated  only  for  e\tubalion 

-  Head  of  the  bed  ai  .10  degrees  whei 


RESULTS: 

l«92 

MO 

19<)3 
1994 

21  1 

24  0 

1995" 

84 

1W6 

'Praclnf  ibalig 
CONCLUSION:   Insulul 
procedures  decreased  our 

10  0 
\  implemfnlej  2  95 
ng  and  assunny  com 
VRP  rale  t)5"b 

THE  EFFECT  ON  VARYING  INSPIRATORY  FLOW  AND  AIRWAY 
RESISTANCE  ON  CONTINUOUS  POSITIVE  PRESSURE  (CPAP)  MACHINES 

Daniel  Fisher  BS  RRT.  Yuii  Funno  MD,  PeeEi  Roban  RRT.  and  Robert  M   Kacmarek  Ph  D 
RRT  Anesthesia  and  Respiratory  Care,  Massachusetts  General  Hospital  and  Harvard  Medical 
School,  Boston  MA 

INTRODUCTION:  Conlinuos  positive  airway  pressure  (CPAP)  is  frequently  used  for  the 
treatment  of  obstrtjctive  sleep  apnea  (OSA)    We  have  evaluated  the  ability  of  4  CPAP  machines 
to  maintain  the  desired  level  of  CPAP  distal  to  a  resistor  in  the  airway  during  inspiration  at 
various  inspiratory  flow  rates  and  resistances 

METHODS:   The  units  studied  were.  Respironics  Solo  and  BiPAP  S/T  (Respironics, 
Murrysville,  PA)  Sullivan  V  (ResMed  Corp  San  Diego,  CA).  and  Tranquility  Quest 
(Healthdyne  Technologies,  Marietta,  GA)    The  CPAP  unit  was  connected  to  a  spontaneously 
breathing  test  lung  (SMC  AR200.  SMC  Inc  Tokyo,  Japan)  at  two  different  airway  resistances 
(5  cmH,0/L/s  and  20  cmH,0/L/s)  and  three  levels  of  CPAP  4,  8  and  12  cmH,0,   Airway 
pressure  and  flows  were  monitored  by  inline  transducer  and  pneumontachometer  distal  to  the 
resistor    The  signal  was  then  digitized  and  recorded  using  WINDAQ  software  (DATAQ 
Instnjments,  Akron,  OH),  RESULTS:   The  data  was  analyzed  using  a  two  way  ANOVA  with 
the  p<0.05  Pharyngeal  pressure  ±  standard  deviation  (cmH.O)  at  the  various  flows  and  Raw  are 
presented  below: 

Flow  LPM 

30 

60 

90 

Raw 

5 

20 

5 

20 

5 

20 

Solo 
4 
8 

12 

2.5  ±  0.03 
5.5  i  0.03 
9.5  ±  0,12 

-1.4  ±  0.04 
-1.5  ±  0.00 
-1.3  ±  0.03 

-2,4  ±  0,04 

1.7  ±  0,08 

5.8  ±  0,04 

-5,5  ±  0,00 
-1,4  ±  0  04 
2  7  *  0,03 

-8,0  ±  0,04 
-3,4  ±  0,20 
1,3  ±  0,05 

-14  ±  0  03 
-9  0  ±  0,06 
-4,4  *  0,04 

Sullivan 

8 
12 

1.4  ±  0.04 
4  7  ±  0,04 
8  8  ±  0.04 

0.6  ±  0.04 
3,8  ±  0.04 
8,0  ±  0.03 

-2,7  ±  0,53 
0,7  ±  0  00 
4,4  ±  0,03 

-5  6  ±  0,06 
-2,1  t  0  03 
1,5*  0,03 

-8,7  ±  0,00 
-5,5  ±  0,06 
-1,7  ±  0,09 

-14  *  0,06 
-11  *  0,04 
-7. 1  1  0,06 

Tranquility 

8 
12 

08*  0  04 
5.5  ±  0.04 
9  1  ±  0  03 

-0.0  ±  0,04 
4,2  1  0,04 
8,2  ±  0,05 

-3  0*  0,05 
1,2*  003 
5,6  ±  0,05 

-6,1  *  0,04 
-2,0*  0,18 
2,3  *  0,03 

-9,4  *  0,06 
-4,6  ±  0  06 
-0,5  ±  0,04 

-15  i  0,03 
-11  ±  0,04 
-6,5  *  0,04 

BiPAP 

8 
12 

23  ±  0.15 
6.2  ±  0.08 
10  ±  0.04 

1  4  ±  0,03 
5,4  ±  0,05 
9,3  ±  0,59 

-1,5*  0  04 
2,1  ±  0,04 
5,7  ±  0,03 

-4,5  *  0,06 
-1,0*  0,04 
2,6  *  0,03 

-7,4  ±0,11 
-3  8  *  0,06 
-0,3  ±  0,06 

-13  *  0,08 
-9  7  *  0  05 
-6.1  ±  0.09 

CONCLUSION;  As  the  inspiratory  flow  demand  and  pharyngeal  resistance  increased,  the 
pressure  measured  distal  to  the  pharynx  during  inspiration  decreased  significantly  (p<0.00 1 ) 
withm  all  three  flow  groupings.  Significant  differences  (p<0.00l)  existed  between  machines  at 
each  flow  settings 

OF-98-081 

EXPIRATORY  SYSTEM  PERFORMANCE  OF  THE  NPB  840  AND 
EVITA  4  VENTILATORS  DURING  PASSIVE  EXHALATION 

Wame  Jnhnson  RCP.  Katie  Kinninger  RCP.  ElzbifUi  Buk  MS.  Rick  Ford  RCP. 
Jolm  Newhar:  RCP.  David  Bums  MD.  UCSD  Medical  Center.  San  Diego  California 
BACKGROUND:  This  study  was  designed  to  assess  the  performance  of  the  PB  84(1 
(Nellcor  Puritan  Bennett,  Carlsbad.  California)  and  the  Evita  4  (Drager.  Liibeck, 
Germany)  ventilators  during  passive  exhalation,  METHODS    The  evaluation  of  the 
exhalation  system  characteristics  was  performed  for  adult  and  pediatric  ventilator 
ranges  and  for  two  levels  of  end-expiratory  pressure.  OcmH;0  (ZEEP)  and  10 
cniH:0  (PEEP),  Both  ventilators  were  configured  as  specified  tor  patient  use  and 
connected  to  the  Vent  Aid  TTL  lung  model  via  adult  or  pediatnc  disposable 
ventilator  circuit  and  endotracheal  lube  with  ID  of  7,0  or  4,0  nim.  The  TTL 
compliance  was  set  to  50  ml/cmH;0  (adult  model)  or  to  10  ml/cmH;0  (pediatric 
model).  The  ventilator  was  set  to  deliver  pressure-controlled  ventilation  with  peak 
pressure  of  15  cmH,0  above  PEEP  level    The  flow  and  airway  pressures  (Paw)  were 
measured  at  the  proximal  end  ol  the  endotracheal  tube.  The  volume  was  obtained  by 
numerical  integration  of  the  Mow,  The  resistance  related  energy  dissipation  (E) 
during  passive  exhalation  (MariniARRD  1985;  131  (150-854)  wa,s  used  to 
characterize  resistive  properties  of  expiratory  valves.  The  E  was  calculated  as  an 
area  enclosed  by  a  plot  of  exhaled  volume  against  the  pressure  and  normalized  to  the 
exhaled  tidal  volume  (Vj),  Additionally,  the  fraction  of  Vx  remaining  in  the  lung  at 
different  expiratory  times  (Te)  was  measured  as  an  index  of  potential  air-trapping 
(Richard,  AJRCCM  1998;  I57(3):A686) 
RESULTS 


ADULT  RANGE 

PEDIATRIC  RANGE                | 

Fraction  ot  Vj  Remaining  In  Lung  at  Different  Expiratory  limes 
(VT-Ve«hjlcd)/VT(») 

Tc 

ZEEP 

PEEP 

Te 

ZEEP 

POEP           1 

EV4 

PBa40 

EV4 

PB  840 

EV4 

PB 

EV4 

PB  840 

05 

45  0 

46  3 

486 

511  1 

0  1 

44  0 

46  4 

51  0 

516 

0,9 

148 

18,2 

20  3 

24  2 

(15 

17  y 

206 

27,7 

31  5 

1  ! 

00 

3  1 

46 

10  1 

(17 

1  r< 

1  2 

13  1 

16  6 

1  7 

00 

0  0 

0  4 

4(1 

0  9 

(11 

00 

4,8 

75 

Energy  Dissipation  P 

cr  Lit 
'Vrd 

rof  Exhaled  Volume 

ZEEP 

PEEP 

ZEEP 

PEEP 

EV  4     1  PB  840 

EV4     1  PB840 

EV  4    1    PB 

EV  4      1  PB  840 

0  769     j    0  706 

0  714     1    0  702 

0  837     1  1)802 

0,764      1    (1 754 

CONCLUSIONS;  Expiratory  sysicrr 
pcrlbrmancc  during  passive  exhalalioi 


t  both  veniilaiors  showed  s 


OF-98-082 


STATIC  vs  DYNAMIC  VOLUME-PRESSURE  (VP)  CURVES  IN  ARDS 
Carl  Hflflfi  MLS.  RRT:  Lauren  Siapp,  RRT;  Roben  Bartlett,  MD.  Critical  Care  Support 
Services  and  the  Department  of  Surgery,  University  of  Michigan  Health  System.  Ann  Arbor  MI 
iaHirP(*M^t'"°  Static  VP  curves  help  tailor  ventilator  settings  lo  specific  pathophysiology. 
PEEP  is  set  at  or  slightly  above  the  lower  inflection  point  (LIP)  lo  prevent  collapse  and 
nunimize  injury  from  repealed  opening  and  closing.  Tidal  volume  or  distending  pressure  is  set 
below  the  upper  inflection  point  (UIP)  to  minimize  overdisiending  lung  umls  and  causing  a 
stretch  injury.  Study    Objective  To  compare  LIP  &  UIP  values  obtained  from  static  VP 
curves  vs  dynamic  VP  curves  from  ventilator  graphics,  jyiethod  Nineteen  studies  were  done  on 
10  paralyzed  ARDS  patients.  Static  VP  curves  were  obtained  using  the  super-syringe  technique. 
After  disconnecting  the  ventilator  for  1 5  seconds,  a  3  L  syringe  contairung  pure  Oi  was  attached 
lo  the  padenL  Airway  pressure  was  graphed  as  100  mL  inflations  were  injected.  Each  inflation 
was  held  for  2-3  seconds  to  obtain  a  plateau.  Volume  was  limileJ  lo  1 .5  L  and  pressure  to  50 
cm  H,0,  HR.  BP.  and  SpOj  were  monitored  on  all;  SvOj  and  continuous  CO.  if  available.  UP 
was  identified  as  the  pressure  at  the  iniersection  of  a  tangent  to  the  mitial  part  of  the  curve  with 
a  tangent  to  Ihe  steep  pan  of  the  curve  (LIPii)  and  the  UIP  as  the  pressure  at  the  intersection  of 
a  tangent  to  the  steep  part  of  the  curve  with  the  tangent  to  the  fmal  portion  of  the  curve. 
Dynamic  VP  curves  were  obtained  using  a  constant  flow  of  60.  30,  and  15  L/m  with  the 
ventilator  (Nellcor  Puntan  Bcnneu  7200)  sei  lo  a  VT  =1.5  L.  PEEP=0  cm  HjO.  rate=5.  and 
pressure  pop-off  at  50  cm  HjO.  LIP  and  UIP  were  obtained  in  the  same  manner  as  described 
above.  The  pressure  where  the  tangent  to  the  steep  pan  of  the  inspiratory  Umb  crossed  the  X- 
axis.  referred  lo  as  the  extrapolated  LIP  (LIPie).  was  calculated.  The  pressure  at  the  intersection 
of  the  langenls  of  the  initial  and  final  portion  of  the  deflation  limb,  referred  to  as  ihe  deflation 
LIP  (LlPdi).  was  calculated.  Results  LIP:  The  table  presents  die  data  as  mean  ±  SD  (cm 
HjO).  All  dynamic  methods,  except  LIPie  at  15  L/m  (p=0.99).  were  slalisucally  different  from 
the  static  LIP  (•  p<0.05).  As  flow  increased,  inflation  LIP  increased.  Deflation  LIP  was 
minimally  affected  by  inspiratory  flow,  but  was  significantly  lower  than  the  static  LIP. 


LIPii 

LIPie 

LfPdi 

•Static 

•  Dynamic,  15  L/m 

•  Dynamic.  30  Urn 

•  Dynamic,  60  L/m 

11.5  1  3,4 

13.5  ±4,1* 
18,9  ±  6,0* 

27.6  ±  6,8* 

11.5  ±4,3 
17,3  ±  5,5' 
25,2  ±  5,6" 

6,5  ±  1,9* 
6,9  ±  1,8" 
5,9  ±  1,5* 

UIP:  Sixteen  of  17  (94%)  studies  had 
patients  did  not  have  a  UIP  on  the  s 
dynamic  curve.  Fewer  dynamic  curv 
pressure-cycled  bef<KC  one  could  be 


eiUicr  the  s 
;  only  4  did  not  have  an  UIP  on  the  15  L/m 
demonstrated  a  UIP  as  flow  increased,  as  the  veniilaiw 
m.  Dynamic  UIP  increased  as  inspiratory  flow  increased. 


Dynamic:  15  L/m      Dynamic:  30  L/m       Dyi 


36,3  ±  4.1 
15/0.29 


40.0  ±  3.7 
p=0005 


45.9  ±  4.2 
p=0.0003 


Conclusion  1)  LIP  cannot  be  »:curatcly  measured  from  dynamic  VP  curves  at  inspiratory 
flows  commonly  used  lo  ventilate  patients.  2)  Dynamic  LIP  overestimates  static  LIP.  although 
Ihe  lowest  flow  studied  { 1 5  L/m)  was  clinically  close.  Exlrapolabng  back  to  the  X-axis  was  no 
different  than  sialic  LIP.  3)  UIP  may  be  overestimated  using  dynamic  VP  curves  with  a  cotistant 
inspiratory  flow. 


878 


Ri;spiu,\T()RY  Cari:  •  OcTOHiiR  '9H  Voi.  43  No  10 


Tuesday.  November  10.  1:00-2:55  pm  (Room  214E) 


LABORATORY  EVALUATION  OF  AUTOMATIC  TUBE  COMPENSATION 
(ATC)    Knstv  M  Bates  CRTT,  Robert  S  Campbell  RRT,  James  J  Lawson 
RRT,  Richard  D  Branson  RRT  University  of  Cincinnati  Medical  Center, 
Cincinnati,  OH  45267-0558 

INTRODUCTION:  ATC  is  a  new  feature  available  on  ttie  Evita  4  (E*) 
ventilator  (Drager,  Telford.  PA)  designed  to  eliminate  the  work  of  breathing 
(WOB)  imposed  by  the  artificial  airway  We  designed  a  lung  model  study  to 
evaluate  the  influence  of  ATC  on  imposed  WOB  (WOB,),  patient  WOB 
(WOBp,),  and  ventilator  output  METHODS:  A  two-chambered  test  lung 
(TTL)  was  modified  with  a  lift  bar  to  mimic  spontaneous  breathing  A 
Hamilton  Veolar  was  used  to  "dnve"  the  model  and  set  to  create  demand 
conditions  of  0  5  L  Vt  @  60  L/min  using  a  50%  decelerating  flow  pattern 
E'  was  connected  to  the  "patient  lung"  via  a  6  0  ID  and  8  0  ID  endotrachea 
tube  (Mallinckrodt),  and  a  7  0  ID  trach  tube  (Shiley)  TTL  was  set  to  a  C  of 
60  mL/cmH20  and  Raw  of  5  cmH;0/L/sec  Baseline  measurements  were 
made  with  no  tube  in  place  and  were  repeated  with  ATC  active  and 
disabled  for  each  airway  used  Bicore  CP-100  was  used  to  measure 
WOBp,,  WOB,,  PIFR,  PEER,  Vy,  PIP,  P,,,,  pressure-time-product  (PTP), 
peak  negative  pressure  in  the  airway  (PNPaw)  and  in  the  esophagus 
(PNPes)  Five  breaths  were  measured  and  recorded  at  each  condition  Dats 
were  compared  using  students t-test  and  p<0  05  was  considered 
significant  RESULTS:  WOBp,  measured  without  an  ET  tube  in  place  was 
1  59  J/L  Table  1  reveals  baseline  data  with  no  ET  tube  in  place  and 
measured  data  with  ATC  active  and  off  with  a  6  0  ID  ET  tube  and  7  0  ID 
trach  tube  in  place 

Table  1. 

WOB„ 
(J/L) 

WOB, 
(J/L) 

Vt 
(mL) 

PIP 
(cmHiO) 

PTP 
(cmHiO/sec) 

PNP„ 
(cmHjO) 

No  Vent,  No  ET 

1  54 

012 

500 

3 

135 

-17  7 

6  ET  ATCon 

1,67- 

0  00* 

580- 

21* 

162* 

-219* 

6  ET  ATCoff 

2  26 

0  48 

460 

4 

195 

-26,6 

7  Tr  ATCon 

1  53 

0  10# 

520# 

10# 

131 

-20  3 

7  Tr  ATCoff 

167 

0  51 

480 

4 

144 

-22  1 

•  =  p<0  05  versus  6  ET  ATCoff,  #  =  p<0,05  versus  7  Tr  ATCoff 
CONCLUSIONS:  Use  of  ATC  eliminates  the  WOB,  by  the  artificial  ainway 
WOBp,  with  ATC  active  is  similar  to  that  measured  with  no  airway  in  place 
ATC  results  in  increased  PIP  and  Vt  delivery  to  the  lung  Clinical  studies 
are  required  to  assess  patient  response  and  benefit  from  ATC  use 

OF-98-12 

LABORATORY  COMPARISON  OF  AUTOMATIC  ET  TUBE  COMPENSATION 
(ATC)  AND  TRACHEAL  PRESSURE  TRIGGERING  (TP,,)  Robert  S  Campbell 
RRT,  Richard  D  Branson  RRT,  James  J  Lawson  RRT  University  of  Cincinnati 
Medical  Center,  Cincinnati,  OH  45267-0558 

INTRODUCTION:  TP,,  reduces  imposed  work  of  breathing  (WOB.)  and  patient 
WOB  (WOBp,)  ATC  IS  a  method  of  overcoming  the  WOB,  by  ET  tube  We 
compared  WOB,  and  WOB„  dunng  TP„  with  ATC  in  a  lung  model  METHODS:  A 
two-chamber  test  lung  (TTL,  Michigan  Instr )  was  modified  to  mimic  spontaneous 
breathing  using  a  lift  bar  A  Hamilton  Veolar  powered  the  drive  lung  using  a  50% 
decelerating  flow  pattern  and  set  to  create  demand  of  0  6  L  V,  @  peak  flow  of  50 
L/min  at  the  ain«ay  of  the  "patient"  An  8  0  ID  ET  tube  and  trachea  simulator  were 
used  to  connect  each  vent  to  the  "patient"  which  had  C,  of  60  mL/cmHjO  and  R„ 
of  5  cmHjO/L/sec  An  E4  (Drager  Inc  )  and  a  7200ae  (Mallinckrodt)  ventilator  were 
attached  to  the  "pt "  and  set  to  CPAP-5  and  PSV-5  E4  was  used  with  ATC  on  at 
100%  for  an  8  0  ET  and  without  ATC  7200ae  was  used  with  TP„  at  the  carina  and 
without  TPt,  Bicore  CP-100  was  used  to  measure  pressure,  volume,  flow,  and 
WOB  5  breaths  were  recorded  at  each  condition  and  measurements  included 
WOBp,  WOB,,  peak  insp  flow  (PIFR),  peak  pres  prox  (PIPp,),  peak  neg  pres  aira/ay 
(PNP„)  and  esophageal  (PNP.J,  response  time,  and  PTP  Results  were  compared 
using  t-test  and  p<0  05  was  considered  significant  RESULTS:  TP,,  and  ATC 
reduce  WOB,  and  WOBp,  compared  to  standard  flow-tng  PIP„  is  higher  with  TP„ 
and  ATC  which  increases  work  contributed  by  the  ventilator,  increases  V,  delivery 
and  minimizes  PNP„  All  work  indices  were  lowest  during  TP„  with  the  7200ae 
Table  1  reveals  values  for  each  tng  technique 


PlPprox 
cmHjO 

PNPes 
cmHpO 

WOB, 
J/L 

WOBpi 

WOBvent 
J/L      " 

PTP 
cm/s 

Vt 

mL 

7200  TPjr 

18* 

-9  4* 

0  0* 

124* 

1  23* 

85* 

510* 

7200  FT 

12 

-15  6 

0  24 

1  64 

0  38 

118 

450 

E'ATC 

19# 

-14  3# 

0  11# 

1  54 

1  16# 

114 

570# 

E<FT               11 

-175          042 

1  76 

0  52 

127 

470 

*=p<0  05  versus  7200  TP,,  off,  #  =p<0  05  versus  E'  ATC  off 
DISCUSSION:  TPt,  and  ATC  reduce  the  WOB,  TP„  reduces  WOB„  more  than 
ATC  TPt,  and  ATC  increase  pressure  and  volume  delivery  causing  WOB  to  fall 
TP„  requires  modification  of  the  vent  and  placement  of  a  distal  sensor  while  ATC 
can  be  implemented  with  current  vents 


OF-98-122 


LABORATORY  EVALUATION  OF  DIFFERENT  METHODS  TO  PROVIDE 
TRACHEAL  PRESSURE  TRIGGERING  (TPj,)  Robert  S  Campbell  RRI.  James  J 
Lawson  RRT.  Richard  D  Branson  RRT  University  of  Cincinnati  Medical  Center. 
Cincinnati,  OH  45267-0558, 

INTRODUCTION:  TPt,  has  been  shown  to  eliminate  imposed  worit  of  breathing 
(WOB,)  and  reduce  patient  work  of  breathing  (WOBp,)  TP,,  requires  use  of  a  special 
ET  tube  witfi  a  distal  pressure  port  or  the  use  of  a  separate  sensing  tube  either 
through  or  around  the  ET  tube  We  compared  work  characteristics  with  various  TP,, 
techniques  in  a  lung  model  METHODS:  A  two-chamber  lest  lung  (TTL,  Michigan 
Instruments)  was  modified  to  mimic  spontaneous  breathing  with  a  lift  bar  A  Hamilton 
Veolar  powered  the  drive  lung  using  50%  decelerating  flow  and  was  set  to  create 
demand  of  0  5  L  V,  @  peak  flow  of  30  Umin  at  the  airway  of  the  'pi  lung'  A  8  0  ID 
high/low  (Mallinckrodt)  and  standard  6  0  ID  ET  tube  were  used  to  connect  a  7200ae 
ventilator  (Mallinckrodt)  to  the  pt  lung  7200  was  set  at  CPAP  -  5  cmH^O  and  PSV  -  5 
cmHjO  TPt,  was  accomplished  via  the  distal  pressure  port  of  the  high/low  ET  tube 
(H/L),  8  fr  pediatric  feeding  tube  (FT)  threaded  through  ET  (8FT).  5  fr  pediatnc  FT 
threaded  through  ET  (5FT),  and  with  a  side  port  adaptor  placed  at  the  canna  (CAR) 
Measurements  were  also  made  with  standard  pressure  tnggenng  (SPT)  Pressure 
sensitivity  was  set  at  -2  0  cmH^O  for  all  conditions  Resistance  (R)  of  each  ET  was 
measured  with  and  without  the  5  and  8  fr  feeding  tubes  in  place  Bicore  CP  100  was 
used  to  measure  pressure,  volume,  flow,  and  WOB  Data  was  compared  using 
student's  t-test  and  p<0  05  was  considered  significant  RESULTS:  Table  1  reveals  the 
1  measured  parameters  with  each  triggering  method  with  8.0  ID  ET  tube 


Table  1. 

PIFR 
(L/min) 

PEER 
(L/min) 

V, 
(mL) 

WOB^ 
(J/L) 

WOB, 
(J/L) 

PTP 
(cmH20/s) 

H/L 

52 

25 

730 

1,02 

0,21 

40 

CAR 

58 

27 

760 

1,04 

0  17 

31 

5FT 

67 

27 

650* 

186* 

0.45* 

126* 

BFT 

54 

22 

700 

1.2 

0.20 

35 

SPT 

46 

25 

720 

0  67* 

0  35* 

68* 

'=p<0  05  versus  all  other  triggering  methods 
ET  tube  R  was  6  6  and  21  1  cmHjO/L/sec  for  8  0  and  6  0  ID  respectively  With 
addition  of  8  fr  FT,  R  increased  to  1 1  7  and  50  7  cmH^O/Lysec  for  the  8  0  and  6  0  ID 
ET  tubes  respectively  R  was  8  9  and  31  1  cmH.O/L/sec  with  a  5  fr  FT  placed  through 
the  8  0  and  6  0  ID  ET  tube  respectively  CONCLUSION:  Use  of  5  fr  FT  to  accomplish 
TPt,  results  in  increased  WOB  and  patient-ventilator  dysynchrony  as  a  result  of  the 
sensing  delay  caused  by  the  small  diameter  Use  of  larger  sensing  ports  is 
recommended,  even  with  smaller  ET  tubes  TP,,  allows  the  ventilator  to  overcome  the 
added  resistance  imposed  by  the  sensing  line  by  measuring  and  targeting  pressure 
distal  to  the  artificial  airway  Future  work  evaluating  the  effects  of  TPt,  with  smaller  ET 
tube  sizes  is  warranted,  TPj,  with  H/L.  CAR,  and  8  fr  FT  results  in  equivalent  WOB 


LABORATORY  EVALUATION  OF  THREE  -DUAL-CONTROL*  (DC)  MODES  OF 
lulECHANICAL  VENTILATION  ((«IV1  James  J  Lawson  RRT,  Robert  S  Campbell 
RRT.  Reynaldo  P  Sinamban  MD,  Jay  A  Johannigman  MD.  Kenneth  Davis  Jr  (V1D, 
Scott  B  Frame  (yiD,  Richard  D  Branson  RRT.  University  of  Cincinnati  College  of 
Medicine,  Cincinnati,  OH  45267-0558 

INTRODUCTION:  DC  modes  of  MV  combine  the  positive  altnbutes  of  volume- 
controlled  (VCV)  (safety,  preset  guaranteed  minute  ventilation)  and  pressure- 
controlled  (PCV)  (improved  gas  distnbution/exchange,  lower  ventilating  pressures, 
improved  patient-ventilator  synchrony)  MV  We  designed  a  lung  model  study  to 
determine  ventilator  output  of  three  ventilators  set  to  provide  DC  ventilation  in  the 
face  of  varying  ventilatory  toad  conditions  [altered  Compliance  (C)  and  Resistance 
(R)]  METHODS:  Three  DC  ventilator  modes  were  tested  auloflow  (Evita4, 
Drager,  Telford,  PA),  adaptive  pressure  ventilation  (APV)  (Galileo,  Hamilton 
Medical,  Reno,  NV),  pressure  regulated-volume  control  (PRVC)  (300,  Siemens 
Medical,  ,  New  Jersey)  and  compared  with  VCV  Each  technique  utilizes 
pressure-limited,  time-cycled  breath  delivery  and  allows  the  PIP  to  vary  breath-to- 
breath  in  order  to  maintain  the  target  Vt  Each  vent  was  set  to  provide  a  Vt  of  0  7 
L,  Tiof  1  6  sec,  PEEPof5cmH20.  and  rate  of  16  bpm  to  one  side  of  a  two- 
chambered  test  lung  (TTL),  TTL  C  was  set  to  20.  40,  and  60  mL/cmH,0  and  R  was 
set  to  5  or  25  cmHjO/L/sec  Bicore  CP-100  was  used  to  measure  pressure, 
volume,  and  flow  in  the  proximal  airway  Parameters  measured  by  each  ventilator 
included  PIP,  Vt,  V,.  P„,  R„,  C„s,  PIFR,  and  PEFR  RESULTS:  DC  MV  provides 
decelerating  flow  with  higher  PIFR  than  VCV  (54  vs  26  L^min)  Table  1  reveals 
measured  data  with  each  DC  mode  with  varying  C  and  set  R  of  26 

Table  1. 

C 

PIP 

P« 

VTlung 

Vt  vent 

PIFR 

Ve  lung 

Ve  vent 

APV 

20 

41 

18 

660 

666 

60 

99 

98 

40 

28 

14 

650 

665 

46 

9,7 

99 

60 

25 

13 

660 

654 

42 

9,8 

99 

Autoflow 

2U 

3/ 

16 

575 

674 

62 

8.5 

98 

40 

23 

12 

572 

717 

49 

84 

10  1 

60 

19 

10 

570 

699 

43 

8.5 

98 

PRVC 

20 

3b 

17 

535 

588 

62 

81 

89 

40 

24 

13 

575 

614 

54 

87 

94 
94 

60 

21 

12 

590 

614 

47 

90 

PIP,  Vt  and  Vf  delivered  to  the  lung  were  highest  with  APV  Drager  and  Siemen 
overestimate  Vt  and  Ve  delivered  to  the  lung  during  VCV  and  DC  MV  V,  and  Vj 
measured  by  the  Hamilton  accurately  reflects  volume  delivery  to  the  lung  dunng 
VCV  and  DC  MV  CONCLUSIONS:  DC  algorithms  vary  between  ventilator 
manufacturer  Accurate  measurement  of  Vt  is  essential  to  assess  differences 
between  DC  and  VCV  and  to  determine  pt  benefit  from  DC  use 

OF-98-1 

26 

Respiratory  Care  •  October  '98  Vol  43  No  10 


879 


Tuesday,  November  10,  1:00-2:55  pm  (Room  2i4E) 


IMPROVED  RESPONSE  TO  VENTILATOR  ALARMS  IN  A  SUBACUTE  NURSING 

FACILITY  John  Emberqer  BS  RRT.  Phd  Santoro  BS  RRT,  Cathy  Hart  RRT.  Sue 

Redden-Bailey  RRT  Department  of  Respiratory  Care.  Chnstiana  Care  Health  System, 

Newark  DE 

Background  In  a  subacute  ventilator  facility,  there  are  many  reasons  respiratory  and 

nursing  staff  may  not  respond  to  ventilator  alarms  within  an  appropriate  time    Some 

reasons  may  include,  less  staff  to  patient  ratio  than  in  an  acute  care  facility,  alarm 

desensilization  of  the  staff  and  greater  distance  over  which  alarms  must  be  heard  We 

could  find  no  standard  in  the  literature  for  appropnate  time  to  respond  to  alamis  We 

gathered  baseltne  ventilator  alarm  time  data  (see  Initial  Data  chart)  which  showed 

intolerable  time  penods  of  ventilators  alarming  with  no  response  of  staff  Hypothesis 

We  wanted  to  improve  the  performance  of  staff  response  time  to  ventilator  alarms  at 

our  subacute  nursing  facility  Methods  At  our  sub-acute  nursing  facility,  a  printer 

connected  to  the  Puntan  Bennett  7200  ventilators  collected  data  Printers  recorded 

duration  of  the  active  ventilator  alarms  Baseline  data  was  collected  (for  2  weeks),  then 

an  interdisciplinary  performance  improvement  process  took  place  {two  month 

implementation)  Follow-up  data  was  then  collected  (for  2  weeks)  The  performance 

improvement  process  included   1 )  ventilators  were  all  placed  in  the  same  unit,  2) 

agency  nurses  no  longer  cared  for  ventilator  patients,  3)  less  rotation  of  nursing  staff, 

4)  nurses  spent  time  in  the  acute-care 

weaning  unit  to  learn  the  importance  of 

responding  to  alarms.  5)  improved 

respiratory  and  nursing  communication 

concerning  who  will  respond  at  any  given 

time,  6)  respiratory  and  nursing  staff 

coordinated  coverage  during  shift  report 

7)  nurses  were  aware  when  respiratory 

staff  was  not  in  the  unit  Results  See  the 

charts  for  the  Initial  Data  and  Follow-up 

Data  Average  ventilator  alarm  time  of 

the  Initial  Data  ^  4  05  minutes,  and  the 

average  of  the  Follow-up  Data  =  1  45 

minutes  Discussion  The 

interdisciplinary  performance 

improvement  dramatically  decreased  the 

average  time  to  respond  to  ventilator 

alarms,  and  increased  awareness  of 

responding  appropriately  to  ventilator 

alarms  After  the  improvement  {in  the 

Follow-up  Data)  there  were  no 

occurrences  longer  than  five  minutes, 

whereas  in  the  Initial  Data  there  were 

multiple  alarms  lasting  six  minutes  or 

greater 


OF-98-132 


James  B.  Fink.  MS.  RRT.  Mines  VA  Hospital.  Division  of  Pulmonary  and  Critical 
Care  Medicine,  Loyola  Stritch  School  of  Medicine,  Mines,  IL 

Background:  Me:0,  has  been  advocated  for  use  during  controlled  mechanical 
ventilation  (CMV)  of  patients  with  severe  acute  airway  obstruction  to  reduce  work 
of  breathing  and  lung  pressures,  but  most  ventilators  will  not  reliably  deliver  the  set 
volumes  and  flows  with  a  low  density  gas.  Our  goal  was  to  determine  whether  a 
new  ventilator,  utilizing  a  piston  with  a  50  micron  gap,  would  reliably  administer 
MeiOj  at  set  parameters. 

Method:  To  determine  the  effect  of  He:02  during  CMV,  a  new  piston  drive 
ventilator  (Nellcor  Puritan  Bennet  740)  was  attached  to  a  test  lung  (TTL,  Michigan 
Instruments).  Humidity  was  provided  with  an  active  humidifier  (MR  730  Fisher- 
Paykel)  and  a  heated  wire  circuit  (Isothemial,  Baxter  Health  Care).  The  ventilator 
was  set  to  parameters  reflecting  the  range  of  the  device,  V-,.  50  to  1500ml,  peak 
inspiratory  flow  10  to  150  L/min  with  both  oxygen  and  He:0;  70:30.    ANOVA 
was  performed  with  p<0.05  considered  significant. 

Results:  At  all  settings  tested,  the  delivered  volumes  and  flows  were  similar  with 
both  He:03  70:30  and  oxygen  (p>0.86). 

Conclusion:  The  NPB  740  ventilator  provided  accurate  tidal  volumes  and 
inspiratory  flow  rates  with  both  HeiO,  70:30  and  oxygen,  across  the  full  range  of 
parameters  tested. 

Funded  by  a  grant  from  Nellcor  Puritan  Bennett 


•^^ 

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^^^iWmmksocifjg 


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880 


Ri  si'iRAroRY  Cari-:  •  Oc  touhr  "9S  Voi,  43  No  10 


Open  Forum  Author  Index 

Open  Forum  Author  Index 


Boldface  type  indicates  presenters. 


A 

Adams  Alexander  B 841,  852,  856 

Adkins  Allysa 861 

Akbik,  Fawaz 852 

Allen  1  Elaine 859 

Amin  Raouf 863 

Archer  A 869  (2) 

Arnson  Larry 848 

Arrowsmith  Thomas 865 

Auger  Glenn 84 1 

B 

Bach  Phil 859 

Bajusz  Phyllis  L 870 

Bak  El^Jiieta 845,  878 

Baldesare-Burton  Karen  K 866,  867 

Ballard  Robed  A 831 

Ballard  Brook  R 860 

Ballard  Julie 859 

Banks  Beverly  A 831 

Barnes  Thomas  A 838,  840 

Bartlett  Robert 878 

Bates  Kristy  M 879 

Beck  Kenneth  C 854 

Bendel-Stenzel  EM 854  (2) 

Benditt  Josh 830 

Berquist  Theresa 866 

Bettencourt  Paul 878 

Bevis  Rhonda 850 

Bing  D  R 854  (2) 

Blakeman  David 828 

Bliss  Pete 841,  52 

Bockelmann  M 837 

Bode  Frederick  R 848 

Bonsall  Dean 834 

Brancit'ort  Janet 876 

Branson  Richard  D 856,  873,  879  (4| 

Brick  Harlan  J 876 

Broviak  A 861 

Brown  Beth 830,  844 

Brucoli  Luch 864 

Burkhart  John 832 

Burns  David 845.  878 

Burns  Jennifer  R 858 

Burton  George  G 858 

Burton  Karen 872 

C 

Calebaugh  John  D 871 

Campbell  Robert  S 856,  873,  879  (4) 

Carmichael  Tina 875 

Cella  Christopher  M 830 

Channick  R  N 832 


Chao  Jason 864 

Chatburn  Robert  L  .  .  .  828,  832,  840,  842.  844.  867  (2).  875.  876 

Cheifetz  Ira  M 853  (2).  865.  876 

Chiang  W 869 

Chiche  Jean-Daniel 855 

Christmann  U 837 

Christopherson  Gerald 866 

Christopherson  Tracy 866 

Clayton  Donna 865 

Click  Bryce 861 

Clinkscale  Darnetta 865 

CoUado  Elsie  M 832 

Collar  Nancy 865 

Collins  M 876 

Connelly  Janet 859 

Connett  J  E 854  (2) 

Connor  Wendy 834 

Cooper  A  B 852 

Coutts  Michael  D 855 

Cowan  Tony 838 

Cracchiolo  Lisa 865 

Craven  Daniel 828 

Crouch  Rebecca 859 

Cruz-Rivera.  Mario 830 

D 

Davies  John  M 853,  876 

Davis  Kenneth  Jr 856,  879 

Davis  Lisa 848 

Dayer  Donna 867 

Delich  Nick 846 

DePompei  Patricia  M 867 

Dhand  Rajiv 871,  872,  873 

Dickerson  Bob 846 

Dlugolenski  Diana  L 863 

Di-umheller  Oliver  J 863 

Du  Hong-Lin 858 

Dunlevy  Crystal  L 842,  846 

Durbin  Charles  G  Jr 838,  864 

Duniing  Suzanne  M 842,  845 

Durward  Andrew 853 

Dwan  Joe 838 

E 

Emanuelsen  Madeline  M 875 

Emberger  John 834  (2),  846,  856,  880 

English  Rebecca  E 828 

Ermak  Rick 834.  856 

F 

Fahey  PJ 873 

Fairbanks  B 861 

Fallon  Bonnie 878 


Respiratory  Care  •  October  1998  Vol  43  No  10 


Open  Forum  author  Index 


Ferguson  Margaret 878 

Ferreyra  Gabriela 854 

FindlayJ 861 

Fink  James  B 871  (2).  872,  873.  880 

Fisher  David 878 

Fisher  David 864 

Ford  Ricic 845.  878 

Foss  Scott 828 

Frame  Scott  B 856,  879 

Francis  Kimberly 869.  872  (2) 

Froehlic  Sharon 859 

Fujino  Yuji 854,  855,  878 

G 

Galindo  Brenda 875 

Galvin  Dora  A 875 

Gangitano  Ernesto 860  (2) 

Gegenheimer  Cyndi 838 

Gentile  Michael 853  (2),  876 

Ginn  Andrew 856 

Goddon  Sven 854 

Godinez  RI 842 

Goldner  M 856 

Goldstein  Mark 873 

Goodfellow  Lynda  Thomas 842,  876 

Govert  Joseph  A 853 

Grannan  Elizabeth  A 830 

Grisoni  Enrique 840,  875 

GrollRJ 852 

Grossweiler  Pete 834 

Grueber  Ryan 846 

Gudmundsdottir  Asthildur 859 

H 

Haas  Carl 878 

Haney  David 832 

Hansen  Peter 875 

Harrington  J 861 

Harrington  Sallee 858 

Harrison  Katherine  J 859 

Hart  Cathy 880 

Harter  Vicki 858, 863 

Harwood  Bob 844 

Hasse  Lora  A 837 

Hata  JS 848 

Helmholz  H 861 

Henderson  Diannah 858 

Hernandez  John  A 870 

Hernandez  Pat 863 

Higgins  Jason  T 870 

Hoberty  Phillip  D 841 

Hoisington  Ed 832.  841 

Holmes  Michael 860  (2) 

Hon  Ellis 860 


Horan  Shelia 842 

Horstman  Gretchen 848 

Hough  Lorraine  P 83 1 

Howard  William  R 828 

Hromi  Jonathan 855 

Hsiao  HJ 843 

Hubner  N 837 

Hultquist  Karl 860 

I 

Ilowite  JS 869 

Imanaka  Hideaki 856 

Izenburg  Seth 838 

J 

Jiroch  Shelia 838 

Johannigman  Jay  A 856.  873.  879 

Johnson  Cherie 842 

Johnson  Larry  E 837 

Johnson  Wayne 832.  845,  878 

Jones  Arthur 837.  863.  865 

Jones  Mark 834 

Jordan  Terry 830 

K 

Kacmarek  Robert  M 854,  855.  878 

Kallstrom  Thomas 864 

Keenan  Jim 831,  845  (2).  872 

Keppel  Jean 828 

Kercsmar  Carolyn 828.  842.  844 

Kielty  Jill 837 

Kihara  Norio 850 

Kingsley  BJ 865 

Kinninger  Katie 845,  878 

Kirmse  Max 855 

Klonin  Hilary 853 

Knoblauch  Karl 837 

Kobayashi  Hideko 850 

Kollef  Marin  H 865 

Kothenbeutel  Naomi 854 

Kumon  Kumon 856 

Kvasz  Marion 859 

L 

Lamberti  James 865 

Lapham  Dave 834,  846 

Laussen  Peter  C 875 

Lawson  James  J 879  (4) 

Lawson  Wayne 863,  865 

LeGrand  Terry  S 850,  863.  865 

Levine  Donna 875 

Lcwarski  Joseph 864 

Liberman  Ricardo 860  (2) 


882 


Rl-SF'IRATORY  Care  •OCTOBF-R  1998  Voi.  43  No  10 


Open  Forum  Author  Index 


Ligman  Greg 871 

Locke  Robert 834,  846 

Loffert  D  Todd 869,  872  (2) 

Lohser  VIcki 864 

Luchette  Fred  A 856 

Lugo  Ralph  A 83 1 ,  845 

Lurie  Keith  G 840 

M 

MacDonald  Rod 852 

Maclntyre  Douglas 859 

Maclntyre  Neil 853  (2),  859 

MacLellan  Christine  M 838 

MaHnowski  Thomas 84 1 

Mammel  Mark  C 854  (2) 

Mandel  Laura 865 

Marini  JJ 856 

Marshall  Wendy  C 852 

Masick  Stephanie  A 838 

Mattus  Bruce 878 

May  Andrea  L 860 

Mayo  David  F 864 

McConnell  Robert 853  (2),  876 

McCoy  Robert 841,  852 

McGettigan  Marie 832 

McMullen  Barbara 859 

Meliones  Jon 853,  865 

Melville  Sarah  K 838,  840 

Meredith  Rebecca  L 870 

Meyers  Patricia  A 854  (2) 

Mitchell  JP 869  (2) 

Miyagawa  Tetsuo 850 

Morgan  Neal  D 860 

Moroney  Vickey  L 867 

Motoyoshi  Sean 834,  846 

Mottram  Carl  D 854 

Myers  Timothy  R 828,  842,  844.  867 

N 

Nagel  MW 869  (2) 

Napoli  Linda  A 842,  845 

Nelson  David 843 

Newhart  John 832,  845,  878 

Nielson  Thomas  R 852 

Nishimura  Masaji 856 

O 

Op't  Holt  Timoth  B 838,  848 

Ottaway,  Michael 873 

P 

Pachas  Rose 878 

Page  H  Lody 858 

Pagliano  Shirley 863 


Pease  DeeAnn 854 

Pedersen  Dave 859 

Perry  Douglas  G 860 

Perry  RJ 869 

Peters  Jay  I 870 

Peters  Michelle 853 

Pettinichi  Scott 863 

Pfaff  Karen  M 837 

Plevak  D 861 

Plouff  Penny  Gagne 850 

Poogulis  M 861 

Poll  Kathy 845 

Prickett  Alicia  A 830 

Q 

Quinn  William  W 832 

R 

Raake  Jenni  L 843 

Raffeeq  Parakkel 853 

Rajtak  Lilianna 859 

Ramirez  Leslie 837 

Raszynski  Andre 860 

Redden-Bailen  Sue 880 

Rees  W 837 

Reid  Russell  T 873 

Reneghan  Don 846 

Resnik  Patricia 834 

Rinaldo-Gallo  Susan 865 

Robert  Peggi 878 

Rodriguez  Felipe 837 

Rogers  Mark 841 

Ross  Susan  D 859 

Roth  Matthew  A 860 

Rowley  Daniel  D 864 

Ruddell  Deanna 867 

S 

Sakomoto  Gary 846 

Salyer  John  W 831,  845  (2),  859,  864,  866,  867,  872 

Santoro  Phil 880 

Santos  Kimberly  A 838 

Schears  Gregory 845 

Schultz  Theresa 840,  842,  845 

Schuster  Marie 842 

Schwartz  Steven 843 

Scott  Randy 841 

Seay  Wanda 838 

Seufert  K 837 

Shapiro  RS 856 

Shapiro  Steven  D 865 

Sheinhait  Iris 859 

Shelledy  David  C 837,  850,  859,  863,  865,  870,  875, 876 

Sherrill  Anita 863 


Respiratory  Care  •  October  1998  Vol  43  No  10 


883 


Open  Forum  Author  Index 


Shih  Mei-Ju 843 

Sick  Scott 863 

Sinamban  Reynaldo  P 856,  879 

Sladek  David 828 

Slaughter  Steven 867 

Smith  Joseph  L 858.  863 

Smith  Patiicia  A 860 

Smith  Roger 861 

Smith  Todd 866 

Solesbee  Karia 848 

Speakman  Billie 834 

Stapp  Lauren 878 

Stegmaier  James 864 

Stephenson  Carolina 860  (2) 

Stewart  TE 852 

Stoller  James  K 832.  841 

Stork  Eileen 832 

Summitt  Joseph  N 830 

T 

Taeed  Roozbeh 843 

Takeuchi  Muneyuki 856 

TengE 861 

Thomas  Alison 860  ( 2 ) 

Tibbell  Ryan  J 865 

Tinimons  Otwell 864 

Tobin  Martin  J 872.  873 

Torbati  Dan 860 

Totapally  Balagangadhar 860 

Tracy  Michael 832 

Tripp  Donna  S 853.  865 

Tsivitse  Paul 848 

Tucker  Jon  A 861 

Turley  Mary 876 


V 

Varner  Barry  D 852 

Villacorta  Clarissa  M 875 

Vogt  John 860  (2) 

Volsko  Teresa  A 840,  875 

Votto  John 876 

W 

Wadlinger  Sandra  R 831 

Walsk-Sukys  Michele 840.  867 

Walton-Bowen  K 830 

Ward  J 861 

Ward  Robert  M 831.  845 

Warnecke  H  837 

Warren  Robert 842 

Western  Mike 834,  846 

Wilkes  W 873 

Wilner  Russ 865 

Witmer  Dennis 856 

Woehrle  Lelia 864 

Wolf  Scott 863 

Wolfsdorf  Jack 860 

Worman  Ramsey 859 

Y 

Yahagi  Naoki 856 

Yetso  Dennis 853 

Young  MJ 843 

Z 

Zubrow  Marc 856 


884 


Rhspiratory  Cari-;  •October  I  W8  Vol  4.3  No  10 


Congress  Exhibitors 


Exhibitors 

at  the  44th  hiternational  Respiratory  Congress 
of  the  American  Association  for  Respiratory  Care 

November  7-10,  1998 
Atlanta,  Georgia 

Thousands  of  examples  of  respiratory  care  equipment  and  supplies  are  displayed,  discussed, 

and  demonstrated  in  the  exhibit  booths  at  the  International  Respiratory  Congress. 

The  AARC  thanks  the  firms  that  support  the  Association  by  participating. 

(Exhibitors  confirmed  by  October  1.  1998  are  listed.) 

Exhibit  Hours 

Saturday.  November  7  II  AM  to  3  PM 
Sunday.  November  8  11  am  to  3  PM 
Monday.  November  9  1 1  AM  to  3  PM 
Tuesday,  November  10    1 1  AM  to  3  PM 


Exhibitor 


Booth 


Exhibitor 


Booth 


A 

Advance  Newsmagazines 920 

Airborne  Life  Support  Systenis/Sleeptrace 926  &  928 

AirSep  Corporation 347  &  349 

Allegiance  Healthcare  Corporation 500 

Allergy  and  Asthma  Network/ 

Mothers  of  Asthmatics,  Inc 556 

Allied  Healthcare  Products,  Inc 307 

Ambu,  Inc 916  &  918 

American  Academy  of  Allergy, 

Asthma  and  Immunology 924 

American  Biosystems,  Inc 938 

American  HomePatient 1048 

American  Lung  Association  of  Georgia 463 

American  Mobile  Therapists 1039 

American  Sleep  Apnea  Association 363 

American  Society  of  Electroneurodiagnostic 

Technologies,  Inc 361 

Anew,  Inc 952 

Apria  Healthcare 843 

ARC  Medical.  Inc 529 

Arcadia  Healthcare.  Inc 956 

Armstrong  Medical  Industries,  Inc 949 

Asthma  &  Allergy  Foundation  of  America 462 

Astra  USA,  Inc 1007 

Atlanta  School  of  Sleep  Medicine 839 


AVL  Scientific  Corporation 625 

B 

B  &  B  Medical  Technologies.  Inc 801 

Ballard  Medical  Products 5 14  &  5 16 

Bay  Corporation 1052  &  1054 

BCI  International 515  &  517 

Bear  Medical  Systems  Incorporated 131 

Bedfont  Scientific,  USA 910 

Beta  Biomed  Services,  Inc 620 

Bio-logic  Systems  Corporation 126  &  128 

Bio-Med  Devices 1306,  1307,  1308 

Bird  Products  Corporation 131 

Blairex  Laboratories 5 1 8  &  520 

BLD  Medical  Products 131 

Breas  Medical 661  &  663 

Bunnell  Incorporated 553 

Burdick,  Inc 825  &  827 

C 

Cadwell  Laboratories,  Inc 822 

CAIRE,  Inc 719 

California  College  for  Health  Sciences 548 

Cardiopulmonary  Technologies,  Inc 455 

Cardiopulmonary  Corporation 815,  817,  819 

CHAD  Therapeutics 523 


Respiratory  Care  •  October  1998  Vol  43  No  10 


885 


Congress  Exhibitors 


Exhibitor 


Booth 


Exhibitor 


Booth 


Chiron  Diagnostics 30 1 

Clary  Corporation 1 156 

Clear  Medical 1314 

Clement  Clarke 421 

Collins  Medical,  Inc 353 

Committee  on  Accreditation 

for  Respiratory  Care 457 

Criticare  Systems,  Inc 818 

D 

Dale  Medical  Products,  Inc 453 

Datex-Engstom.  Inc 253 

Delmar  Publishers 439 

Dey  LP 614,  616,  618 

DHD  Healthcare 415  &  417 

Diametrics  Medical.  Inc 715&717 

Drager,  Inc 1300-  1305 

E 

ECO  Physics,  Inc 656 

Epic  Medical  Equipment  Services,  Inc 542 

F 

Ferraris  Medical,  Inc 353 

Fisher  &  Paykel  Healthcare 519  &  521 

Florida  Hospital 1 153 

Flotec 946  &  948 

Futuremed 1317 

G 

Genentech,  Inc 803  &  805 

General  Biomedical  Service,  Inc 130 

General  Physiotherapy 445 

Glenn  Medical  Brokering 624 

Goldstein  &  Associates/ 

Neonatal  Intensive  Care 954 

Grass  Instrument/ 

Division  of  Astro-Med,  Inc 824  &826 

H 

Hamilton  Medical,  Inc 635 

Hans  Rudolph,  Inc 914 

Health  Providers.  Inc 1315 

Health  Tour 821 

Healthcare  Clinical  Consultants,  Inc 546 

Heart  Hugger/ 

General  Cardiac  Technology 250 

Hospitak,  Inc 814 

Hudson  RCI 427  &  429 

Hy-Tape  Corporation 522 

I 

I-Stat  Corporation 927 

I.P.I.  Medical  Products 1 20  &  1 22 

I.V.  League  Medical 1053 

Impact  Insiruinentation.  Inc 348 

IngMar  Medical 725 


Inova  Health  System 855 

Instrumentation  Industries,  Inc 435  &  437 

Instrumentation  Laboratory 735 

Invacare  Corporation 607 

J 

Jaeger 907 

Jones  Medical  Instrument  Company 1312 

K 

Karmel  Medical  Acoustic  Technologies  Ltd 327  &  329 

KCI 143 

Kelly/Waldron  &  Company 658 

Kendall  Healthcare  Products  Company 709  &  71 1 

King  Systems  Corporation 140  &  142 

Kirk  Specialty  Systems 443 

Korr  Medical  Technologies,  Inc 554 

L 

La  Mont  Medical,  Inc 953 

Lambda  Beta  Society 558 

LeMans  Industries  Corporation 856 

Linear  Tonometers,  Inc 1057 

Lippincott-Raven  Publishers 1310 

Louis  Gilbeck  AB 447  &  449 

M 

Maginnis  and  Associates 544 

Mallinckrodt,  Inc Ill 

Maril  Products,  Inc 955 

Mascot  Metropolitan 461 

Masimo  Corporation 1001 

Med  Trac 845 

Medcare  Diagnostics 345 

Medic-Aid  Ltd 138 

Medical  Graphics  Corporation 935 

MEDIQ/PRN 721  &  723 

MediServe  Information  Systems,  Inc 411 

Mercury  Medical 934  &  936 

Michigan  Instruments,  Inc 908 

Micro  Direct,  Inc./ 

Micro  Medical  Limited 442  &  444 

Monaghan  Medical  Corporation 547 

Mortara  Instrument.  Inc 760  &  762 

Mosby 448 

MSA 419 

N 

National  Board  for  Respiratory  Care.  Inc 560  &  562 

National  Heart.  Lung  and  Blood  Institute 459 

National  Sleep  Technologies,  Inc 859  &  861 

Neotech  Products,  Inc 249 

Network  Concepts,  Inc 816 

Newport  Medical  Instruments 227 

Nicolet  Biomedical,  Inc 809 


886 


RHSPIRA  CORY  CaRK  •  OCTOBLR  1998  VOL  43  NO  10 


Congress  Exhibitors 


Exhibitor 


Booth 


Exhibitor 


Booth 


Nidek  Medical  Products,  Inc 460 

Niihon  Kohden  America,  Inc 428 

Noniii  Medical,  Inc 808  &  810 

Nova  Biomedical 526  &  528 

Novametrix  Medical  Systems.  Inc 915 

Nurses  RX 252 

Nutec  Medical  Products,  Inc 658 

O 

Ohmeda  Medical 1002 

Olympic  Medical  Corporation 944 

Optical  Sensors  Incorporated 1047  &  1049 

Orlando  Regional  Healthcare  System 922 

Owens-BriGam  Medical  Company 423  &  425 

P 

Paico  Labs 942 

Pall  Medical/Critical  Care  Division 1035  &  1037 

PARI  Respiratory  Equipment,  Inc 524 

Passy-Muir,  Inc 557 

PDS  Instrumentation 757  &  759 

Pegasus  Research 1000 

Percussionaire  Corporation 820 

Perry  Baromedical 1027  &  1029 

PhysioMetrics,  Inc 763 

Pitt  County  Memorial  Hospital 132 

Plastimed  LLC 1023 

PneuPac,  Inc 139 

Posey  Company 622 

Praxair,  Inc 828 

Precision  Medical,  Inc 811 

Prentice  Hall 1025 

Presbyterian  Healthcare  System-Texas 1 36 

Pro-Med  Pharmacies 947 

Pro-Tech  Services.  Inc 343 

Pulmo-Dose  Pharmacy/ 

Nephron  Pharmaceuticals 902  &  904 

Pulmonetic  Systems,  Inc 426 

Pulmonox  Medical  Corporation 1044  &  1046 

Q 

QRS  Diagnostic 1015 

R 

Radiometer  America,  Inc 601 

ResMed  Corporation 243 

Respironics,  Inc 535 

Rhone-Poulenc  Rorer 

Pharmaceuticals,  Inc 511 

RNA  Medical 829 

Ross  Products  Division  of  Abbott  Laboratories 536 


RT  Magazine 525  &  527 

RT  Temps  Inc./RT  Career  Education 1045 

Rusch 134 

S 

Salter  Labs 901  &  903 

Scandipharm,  Inc 940 

Sechrist  Industries,  Inc 727  &  729 

SensorMedics  Corporation 131 

Sepracor,  Inc 906 

Siemens  Medical  Systems,  Inc 615 

SIMS  Portex,  Inc 123 

Sleep  Multimedia,  Inc 823 

Sleep  Sciences,  Inc 1043 

SleepNet  Corporation 1017  &  1019 

Smooth-Bor  Plastics 1021 

Sontek  Medical,  Inc 1041 

Spiracle  Technology 853 

Spirit  Medical  Systems,  Inc 900 

Spirometries  Medical  Equipment  Company 1309 

Spirotech/MEK  &  Associates 1409 

SUMMETRIC  Interactive  Software,  Inc 1 24 

SunCare  Respiratory  Services.  Inc 701 

Sunrise  Medical 626  &  628 

Superior  Products,  Inc 552 

Symphony  Respiratory  Services 534 

T 

Telefactor  Corporation 841 

Thermo  Respiratory  Group 131 

3M  Pharmaceuticals 857 

Tiara  Medical  Systems,  Inc 945 

TSI  Incorporated 1 157 

U 

UltraPar,  bic 1313 

University  Hospital  Services,  Inc 146 

University  of  Rochester/Strong  University 441 

University  of  Texas  Medical  Branch 

Memorial  Hospital  446 

University  of  Virginia  Medical  Center 1316 

V 

Via  Medical  Corporation 538  &  540 

Victor  Medical 807 

Vital  Signs.  Inc 653  &  753 

Vortran  Medical  Technology,  Inc 849 

W 

W.  B.  Saunders  Company 1311 

Western  Medica 835  &  837 

Western  Michigan  University 461 

Westmed,  Inc 847 


Respiratory  Care  •  October  1998  Vol  43  No  10 


887 


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 

lo  RHSPIRATORV  CARE.  New  Products  &  Services  Dept,  1 1030  Abies  Lane.  Dallas  TX  75229-4593. 

The  Reader  Service  Card  can  be  found  at  the  front  of  the  Journal. 


New  Products 
&  Services 


Cardiology  Monitoring.  The  Electromed- 
ical Division  of  Siemens  Medical  Systems 
Inc  announces  three  cardiology  monitoring 
capabilities  that  are  now  part  of  its  Infinity'" 
System.  The  new  features  are  the  MultiMed 
12'"  Pod,  the  MultiView  Workstation'"  Rest 
EGG  Analysis  software  option,  and  the 
Gardiology  Review  Station'".  Siemens  says 
the  MultiMed  12  provides  the  Infinity  Mod- 
ular Monitoring  Series  with  diagnostic- 
quality  12-lead  Resting  EGG,  12-lead 
ST  segment  analysis  functions,  and  on-line, 
multi-lead  ischemia  analysis  with  diagnostic 
accuracy.  The  company  describes  the  Mul- 
tiView Workstation  Rest  EGG  Analysis 
as  a  software  option  that  integrates  the 
Siemens  Megacart'"  Algorithms  with  the 
12-lead  capability  of  Siemens  Infinity  Mod- 
ular Monitors.  Siemens  says  the  Cardiology 
Review  Station  provides  12-lead  full 
disclosure  of  ST  complexes  and  ST  trend 
storage.  For  more  information  from  Siemens 
Medical  Systems  Inc,  circle  number 
1 6 1  on  the  reader  service  card  in  this  issue, 
or  send  your  request  electronically  via 
"Advertisers  Online"  at  http://www.aarc.org/ 
buyers_guide/ 

Reaction  Cuvettes  and  Halogen  Lamps. 

AIko  Diagnostic  Coiporation  rcccnily  intro- 
duced reacfion  cuvettes  and  halogen  lamps 
for  use  with  BM/Hitachi  Chemistry 
Analyzers.  According  to  the  company,  all 
of  their  consumables  serve  as  functional 
equivalents  to  those  distributed  by  the 
original  equipment  manufacturer,  and  they 


offer  correlation  data  upon  request.  Alko  says 
the  cuvettes  and  lamps  are  used  in  the  quan- 
titative determination  of  chemistry  assays 
on  the  BM/Hitachi  iinalyzer.  For  more  infor- 
mation from  Alko  Diagnostic  Corporation, 
circle  number  162  on  the  reader  service  card 
in  this  issue,  or  send  your  request 
electronically  via  "Advertisers  Online"  at 
hllp://\\ WW  .aarc.org/huyers_guidc/ 


Sleep  Diagnostic  System.  Respironics 
introduces  the  Alice'"4  Sleep  Diagnostic 
System.  Respironics  says  the  stand-alone  unit 
combines  the  features  and  components  sleep 
professionals  need  most  often,  including 
oximetry,  GPAP  remote  control,  graphical 
touch  screen  technology,  battery  backup, 
and  a  network  interface.  Corporate  literature 
calls  the  Alice  4  a  computerized  polysomno- 
graphic  system  with  quality  precision  in  col- 
lecting and  storing  data  and  says  it  consists 
of  a  main  unit  used  for  data  collection  and 
computer  software  used  for  data  analysis  and 
archiving.  The  main  unit  is  a  multipro- 
cessor digital  data  recorder  controlled  by 
an  Intel'"'  .^86EX  computer  board.  For  more 
information  from  Respironics,  circle  num- 
ber 16.'^  on  the  reader  service  card  in  this 
issue,  or  send  your  request  electronically  via 
"Advertisers  Online"  at  http;//www.aarc.()rg/ 
buyers_guide/ 


Blood  Gas  Analyzer.  Radiometer  intrixiuces 
its  new  blood  gas  analyzer,  the  ABL'"700. 
According  to  Radiometer,  this  new  product 
is  user-friendly,  offers  an  advanced  help 
system  which  includes  shoit  videos  providing 
visual  instruction,  and  requires  less  than 
2  hours  of  maintenance  per  year.  A  company 
press  release  says  the  ABL700  will  perform 
an  accurate  analysis  of  the  15  most  requested 
STAT  parameters,  requiring  only  3  drops 
of  whole  blood.  Radiometer  says  the  unit 
is  based  on  a  Windows  format,  and  that  they 
have  also  developed  a  software  package, 
"Radiance'","  that  enables  hospital  staff  to 
monitor  and  control  all  instruments  from  a 
central  location.  For  more  infonnation  from 
Radiometer,  circle  number  1 64  on  the  reader 
service  card  in  this  issue,  or  send  your  request 
electronically  via  "Advertisers  Online" 
at  http://ww'w. aarc.org/buyers_guide/ 


Spirometer.  Burdick  Inc  announces  the 
release  of  its  Spirotouch  spirometer.  A 


888 


RllSPIRATORY  CARF:  •  OCTOBF.R  1998  VOI,  4.^  NOIO 


New  Products  &  Services 


company  press  release  says  new  featnres 
include  a  dynamic  touchscreen,  detailed  help 
screens,  and  automatic  operation  and  that 
a  bright  LCD  provides  clear,  easy-to-read 
patient  information,  test  data,  and  system 
information  under  any  lighting  condition. 
Burdick  says  real-time  graphics  provide 
diagnostic  information,  instant  quality 
control  checks,  and  audio/visual  patient 
incentives  to  ensure  compliance.  The  com- 
pany also  says  the  device  has  a  rechargeable 
battery  that  allows  more  than  eight  hours 
of  continuous  use  and  that  the  system  can 
save  145  patient  records  for  later  printing  or 
PC  storage.  For  more  information  from  Bur* 
dick  Inc,  circle  number  1 65  on  the  reader  ser- 
vice card  in  this  issue,  or  send  your  request 


electronically  via  "Advertisers  Online"  at 
http://www.aarc.org/buyers_guide/ 

Oxygen  Conserver.  Victor  Medical 
introduces  its  "Gin  Demand"  oxygen  con- 
server.  According  to  a  company  press 
release,  this  device  is  the  first  and  only 
pneumatically  driven,  no-battery,  single- 
tube  cannula  oxygen  conserver  avail- 
able. Victor  describes  it  as  a  complete 
unit,  regulator  and  conserver  in  one  that 
provides  five  flow  setting,  1-3  LPM, 
in  either  continuous  or  conserve  mode. 
The  company  says  the  unit's  flow  dial  is 
easy  to  set  and  that  it  is  recessed  to  pre- 
vent accidental  change  of  flow.  Victor  also 
says  the  conserver  can  accept  cylinder 


pressure  up  to  3.000  psi  and  is  compati- 
ble with  all  CGA  40  valved  and  CCA  870 
post  style  cylinders.  Company  literature 
lists  the  following  features  available  with 
the  unit;  an  optional  shoulder  system  fea- 
turing a  Universal  bag,  an  M-6  cylinder, 
cannula,  and  wrench;  a  compact  easy-to- 
read  gauge,  which  is  recessed  to  protect 
against  damage  and  color-coded  for  cylin- 
der content;  and  the  patented  EZ-Key 
yoke  adjusting  screw  for  easy  attachment 
to  the  cylinder.  For  more  information  from 
Victor  Medical,  circle  number  166  on 
the  reader  service  card  in  this  issue,  or 
send  your  request  electronically  via' Adver- 
tisers Online"  at  http;//www. aarc.org/ 
buyers_guide/ 


# 


^^^^V*lw«i"n/Is%,/^^^ 


fo. 


'% 


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% 


RE/PIRATORy  CARE 

online 


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RESPIRATORY  CARE  •  OCTOBER  1998  VOL  43  NO  10 


American  Thoracic  Society 
Pulmonary  Function  Laboratory 
Management  and  Procedure  Manual 


New! 


A  Comprehensive,  Practical  Tool  to  Help  Manage  the 
Important  Aspects  of  a  Pulmonary  Function  Laboratory- 
you  get  both  print  and  an  electronic  versions 


YOUR  LAB  CANT  BE  WITHOUT 
THIS  MANUAL! 

It  includes: 

■  Chapters  on  the  methods  and  procedures  for  all 
administrative  aspects  of  your  lab 

■  Procedure  manual  set  up 

■  Glossary  of  terms  and  abbreviations 

■  Personnel 

■  Hygiene  and  Safety,  quality  control 


'ulmonary 
Function 
Laboratoiy 
Management 
and  Procedure 
Manual 


APmiccloHhc 
American  Thoracic  Society 


And  much  more! 

■  Chapters  on  procedural  information  on  commonly 
performed  pulmonary  function  tests 

■  Spirometry 

■  Lung  Volumes 

■  DLCO 

■  Exercise  testing 

■  Blood  gas  analysis 

■  Plus  information  on  pulse  oximetry,  bronchodilator  administration  and  a  section 
of  useful  equations  and  tables. 

YOU  ALSO  GET  A  COMPLETE  SET  OFTHE  ATS  STATEMENTS  RELATEDTOTHE 
PULMONARY  FUNCTION  LABORATORY  AS  PART  OFTHE  PACKAGE. 

We  have  arranged  to  offer  the  manual  to  AARC  members  at  the  ATS  members  rate. 

Complete  the  following  form  to  order  your  ATS  Pulmonary  Function  Laboratory  Management  and 

take  advantage  of  this  ATS/ AARC  cooperative  arrangement  TO  DAY  I 


Prices: 

Q  AARC  members:  $225  (includes  shipping) 

□  Non-AARC  Members:  $273  (includes  shipping) 


AARC  Membership* 


Name  _ 
Address  _ 
City 


_State_ 


_Zip/Postal  Code . 


_Country 


e-mail 


Telephone  Fax 

□  Visa    □  Mastercard     □  Amex    Number 

Expiration  Date Signature 

Plca.se  allow  4  -  6  wcek.s  for  delivery.  Thank  you! 

Send  or  Pax  this  l-orm  To:  Ruth  Kasloff,  AmcTic.iii  Thoracic  Society,  1740  Rroadwav,  NYC  W  10019  FAX:  (212)  .M.S-R870 


Circle  133  on  reader  service  card 


J 


1999  Respiratory  Care  Open  Forum 


The  American  Association  for  Respiratory  Care  and  its 
science  journal,  RESPIRATORY  CARE,  invite  submission  of 
brief  abstracts  related  to  any  aspect  of  cardiorespiratory  care. 
The  abstracts  will  be  reviewed,  and  selected  authors  will  be 
invited  to  present  posters  at  the  Open  Forum  during  the 
AARC  International  Respiratory  Congress  in  Las  Vegas. 
Nevada,  December  13-16,  1999.  Accepted  abstracts  will  be 
published  in  the  November  1999  issue  of  RESPIRATORY  CARE. 
Membership  in  the  AARC  is  not  required  for  participation. 
All  accepted  abstracts  are  automatically  considered  for  ARCF 
research  grants. 

SPECIFICATIONS— READ  CAREFULLY! 

An  abstract  may  report  (1)  an  original  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  have  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  FORLiM. 
Therefore,  the  abstract  must  provide  all  important  data,  find- 
ings, and  conclusions.  Give  specific  information.  Do  not  write 
general  statements,  such  as  "Results  will  be  presented"  or 
"Significance  will  be  discussed." 

ESSENTIAL  CONTENT  ELEMENTS 

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  permit  judgment  of  validity;  (3)  Results:  state- 
ment of  research  findings  with  quantitative  data  and  statis- 
tical analysis;  (4)  Conclusions:  interpretation  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  validity;  (3)  Results:  findings  of  the  eval- 
uation: (4)  Experience:  summary  of  the  author's  practical  expe- 
rience or  a  lack  of  experience;  (5)  Conclusions:  interpreta- 
tion of  the  evaluation  and  experience.  Cost  comparisons  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- 
standing the  case.  (2)  Case  Summary:  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. 


FORMAT  AND  TYPING  INSTRUCTIONS 

Accepted  abstracts  will  be  photographed  and  reduced  by 
40%;  therefore,  the  size  of  the  original  text  should  be  at  least 
1 0  points.  Abstracts  should  he  400  words  or  less  and  max 
have  I  clear,  concise  table  or  figure.  A  font  like  Helvetica 
or  Geneva  makes  the  clearest  reproduction.  The  first  line  of 
the  abstract  should  be  the  title  in  all  capital  letters.  Title  should 
explain  content.  Follow  title  with  names  of  all  authors  (includ- 
ing credentials),  institution(s),  and  location;  underline  pre- 
senter's name.  Type  or  electronically  print  the  abstract  sin- 
gle spaced  in  a  single  paragraph  in  the  spcwe  provided  on 
the  abstract  blank.  Insert  only  one  letter  space  between  sen- 
tences. Text  submission  on  diskette  is  encouraged  but  must 
be  accompanied  by  a  hard  copy.  Data  may  be  submitted  in 
table  form,  or  a  simple  figure  may  be  included  provided  it 
fits  within  the  space  allotted.  No  figure,  illustration,  or  table 
is  to  be  attached  to  the  abstract  fonn.  Provide  all  author  infor- 
mation requested.  A  clear  photocopy  of  the  abstract  fonn  may 
be  used.  Standard  abbreviations  may  be  employed  without 
explanation;  new  or  infrequently  used  abbreviations  should 
be  spelled  out  on  first  use.  Any  recurring  phrase  or  expres- 
sion may  be  abbreviated,  if  it  is  first  explained.  Check  the 
abstract  for  ( 1 )  errors  in  spelling,  grammar,  facts,  and  fig- 
ures; (2)  clarity  of  language;  and  (3)  conformance  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  RESPIRATORY  CARE 
at  (972)  406-4667, 

Early  Deadline  Allowing  Revision.  Authors  may  choose 
to  submit  abstracts  early.  Abstracts  postmarked  by  April  2. 
1 999  will  be  reviewed  and  the  authors  notified  by  letter  only 
to  be  mailed  by  May  7.  1999.  Rejected  abstracts  will  be  accom- 
panied by  a  written  critique  that  should,  in  many  cases,  enable 
authors  to  revise  their  abstracts  and  resubmit  them  by  the  Final 
Deadline  (June  11.  1999). 

Final  Deadline.  The  mandatory  Final  Deadline  is  June  1 1 , 
1999  (postmaik).  Authors  will  be  notified  of  acceptance  or  rejec- 
tion b\  letter  only.  These  letters  will  be  mailed  by  August  25, 
1999. 

Mailing  Instructions.  Mail  (do  not  fax!)  2  clear  copies 

of  the  completed  abstract  form,  diskette  (if  possible),  and  a 

stamped,  self-addressed  postcard  (for  notice  of  receipt)  to: 

1999  Respiratory  Care  Open  Forum 

11 030  Abies  Lane 

Dallas  TX  75229-4593 


submit  your  Open  forum  abstract  electronically 

,    visit  www.rcjournaUom    . 


1999  Respiratory  Care  Open  Forum  Abstract  Form 


13.9  cm  or  5.5" 


Name  &  Credentials 


Mailing  Address 


Voice  Phone  &  Fax 


^    Name  &  Credentials 


Mailing  Address 


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,  includ- 
ing credentials  (under- 
line presenter's  name), 
institution,  and 
location. 

3.  Do  not  justify 

(ie,  leave  a  'ragged' 
right  margin). 

4.  Do  not  use  type  size 
less  than  10  points. 

(Do  not  exceed  400 
words.) 

3.  All  text  and  the  table, 
or  figure,  must  fit  into 
the  rectangle  shown. 
(Use  only  I  clear,  con- 
cise table  or  figure.) 

6.  Submit  2  clean  copies. 
This  form  may  be  pho- 
tocopied if  multiple 
abstracts  are  to  be 
submitted. 


Mail  original  &  1 
photocopy  (along  with 
postage-paid  postcard)  to 

1999  Respiratory 
Care  Open  Forum 
11030  Abies  Lane 
Dallas  TX  75229-4593 


Eurlx  Deadline  is 
April  2.  1999 
(postmark) 

Final  Deadline  is  I 

June  11.  1999(posmiark)      \ 


Electronic 

Submission  Is  Now 

Available.  Visit 

www.rcjournal.com 

to  find  out  more 


\  Voice  Phone  &  Fax 


vlEE^O&rCH 


For  VOLUNTARY  reportint; 

by  health  profussicii^als  of  adverse 

events  and  prt>duct  problems 


Form  Approved   0MB  No.  0910-0291  Expires  4/30/96 
See  0MB  slalEimenI  on  reverse 
FOA  Use  Only  (Resp  Care) 


)  A    \t  K  I)  1  (  A  I 


)1)U(.    Is    KH'OK  1  I  ^ 


Page 


Patient  information 


Patient  identifier 


In  confidence 


2    Age  at  time 
of  event; 


Date 
of  birtfi: 


3  Sex 

I     I  female 
I     I  male 


Adverse  event  or  product  problem 


I     I  Adverse  event      and/or  [ |  Product  problem  (e  g  ,  defects/malfunctions) 


Outcomes  attributed  to  adverse  event 

(cfieck  all  that  apply) 

I     I  death    

Imo'day/yf) 

I    I  life-threatening 

I     I  hospitalization  -  initial  or  prolonged 


[~|  disability 
I     I  congenital  anomaly 
I     I  required  intervention  to  prevent 
permanent  impairment/damage 

□  other 


Date  of 
jvent 


4  Date  of 
this  report 


Describe  event  or  problem 


Relevant  tests/laboratory  data,  including  dales 


Other  relevant  history,  including  preexisting  medical  conditions  (eg.  allergies, 
race,  pregnancy,  smoking  and  alcohol  use.  hepalic/renal  dysfunction,  etc  ) 


Mail  to:     MinWATCH  or  FAX  to: 

5600  Fishers  Lane  1 -800-FDA-01 78 

Rockville,  MD  20852-9787 


C.  Suspect  medication(s) 


I    Name  (give  labeled  aliength  &  mlr/labeler.  if  known) 


2    Dose,  frequency  &  route  used 


3    Therapy  dates  (if  unknoviin.  give  duration) 


4    Diagnosis  for  use  (indication) 


6    Lot  #  (if  known) 


7.  Exp.  date  (if  known) 


9    NDC  #  (for  product  problems  only) 


5    Event  abated  after  use 
stopped  or  dose  reduced 

#1  Dyes  Dno    DgggPv"' 


#2n/esnno    □igep"' 


8    Event  reappeared  after 
reinlroduction 

#1  Dyes  D  no    n&'' 


#2UyesD™  n^ggpy"' 


10    Concomitant  medical  products  and  therapy  dates  (exclude  treatment  of  event) 


D.  Suspect  medical  device 


2    Type  of  device 


3    Manufacturer  name  &  address 


model  #  _ 
catalog  # 

serial  # 

lot#  


other  n 


Operator  of  device 

I    I  health  professional 
I     I  lay  user/patient 
□  other: 


8    If  explanted,  give  date 


9    Device  available  for  evaluation?  (Do  not  send  to  FDA) 

I     I    yes  [_J  no  Q  relumed  to  manufacturer  on 


10    Concomitant  medical  products  and  therapy  dates  (exclude  treatment  of  event) 


E.    Reporter  (see  confidentiality  section  on  back) 


1      Name  &  address 


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     I      user  facility 
ri      distnbulor 


SubiTtisslon  of  a  report  does  not  constitute  an  admission  that  medical  personnel  or  the  product  caused  or  contributed  to  the  event. 


ADVICE  ABOUT  VOLUNTARY  REPORTING 


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: 

•  death 

•  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 
event 

•  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 

more  information 
•1-800-822-7967     for  a  VAERS  form 
for  vaccines 

If  your  report  involves  a  serious  adverse  event 
with  a  device  and  it  occurred  m  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  patients  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  for  this  coile 
has  been  estimated  to  average  30  mm 
including  the  tin 


ing  data  sources,  gathering  and  mamta 
and  completing  and  reviewing  the  col 
Send  comments  regarding  this  burden 
aspect  ot  this  collection  of  information, 
for  reducing  this  burden  to 


ling  the  data  needed. 

estimate  or  any  other 
nciuding  suggestions 


'loject  (0910-0291] 


fiington    DC   20201 


Please  do  NOT 
return  this  form 
to  either  of  these 
addresses. 


J  S  DEPARTMENT  OF  HEALTH  AND  HUMAN  SERVICES 


DA  Form  3500  back       Pleasc  Usc  Acldrcss  Provided  Below  -  Just  Fold  In  Thirds,  Tape  and  Mail 


Department  of 

Health  and  Human  Services 

Public  Health  Service 

Food  and  Drug  Administration 

Rockville.  MD  20857 

Official  Business 

Penalty  for  Private  Use  $300 


NO  POSTAGE 

NECESSARY 

IF  MAILED 

IN  THE 

UNITED  STATES 

OR  APO  FPO 


BUSINESS  REPLY  MAIL 

FIRST  CLASS  MAIL    PERMIT  NO.  946    ROCKVILLE,  MD 


POSTAGE  WILL  BE  PAID  BY  FOOD  AND  DRUG  ADMINISTRATION 


MElJ^TCH 


The  FDA  Medical  Products  Reporting  Program 
Food  and  Drug  Administration 
5600  Fishers  Lane 
Rockville,  MD  20852-9787 


|,,l,llli,ilMli,ltlHilill,l,ilililLilllM.litlill 


American  Association  for  Respiratory  Care 


Please  read  the  eligibility  requirements  for  each  of  the  classifications  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 
application  on  reverse  side  and  type  or  print  clearly.  Processing  of  applica- 
tion takes  approximately  15  days. 

n  Active 
Associate 

D   Foreign 

D   Physician 

U   Industrial 
D   Special 
D  Student 


Last  Name  _ 
First  Name 


Social  Security  No. 

Home  Address 

City 

State Zip 


Phone  No. 


Primary  Job  Responsibility  fcfieck  one  only) 

u  Technical  Director 

□  Assistant  Technical  Director 

D   Pulmonary  Function  Specialist 

D   Instructor/Educator 

U   Supervisor 

a   Staff  Therapist 

D   Staff  Technician 

D   Rehabilitation/Home  Care 

n  Medical  Director 

U   Sales 

U   Student 

n   Other,  specify 


Type  of  Business 

'J  Hospital 

J  Skilled  Nursing  Facility 

D  DME/HME 

D  Home  Health  Agency 

D  Educational  Institution 

n  Manufacturer  or  supplier 

D  Other,  specify 


Date  of  Birth  {optional) 


U.S.  Citizen? 


Sex  (optional) 


Have  you  ever  been  a  member  of  the  AARC? 


so,  when?  From 


4c 


Preferred  mailing  address:     Lj   Home    l    Bu 
American  Association  for  Respiratory  Care  • 


For  office  use  only 


FOR  ACTIVE  MEMBEH 

An  individual  is  eligible  it  he/she  lives  .n  Ihe  U  S  or  ils  lerntoties  or  wos  an  Active  Member 
prior  to  moving  outside  its  borders  or  terntones,  and  meets  ONE  of  the  following  criteria  II )  is 
legally  credenlioled  as  o  respiratory  core  professionol  if  employed  in  a  state  that  mondates 
such  OR  12)  IS  a  graduate  or  an  accredited  educational  progrom  in  respiratory  care,  OR  (3| 
holds  o  credential  Issued  by  the  NBRC   An  individu   ■     '  ■■—  ■  ■• 

standing  on  December  8,  1994,  will  continue  c 
good  standing 

PIEASE  USE  THE  ADDRESS  OF  THE  LOCATION  WHERE  YOU  PERFORM  YOUR  JOB.  NOT 
THE  CORPORATE  HEADQUARTERS  IF  IT  IS  LOCATED  ELSEWHERE 


1  AARC  Active  Membei 
ich  provided  his/her  membership  re 


Place  of  Employment 

Address 

City 


.Zip 


State  

Phone  No. 


Medical  Director/Medical  Sponsor 


and  Industrial  (individuals 
ufacture,  sole,  or  distribu- 
e  those  not  working  in  a 


FOR  ASSOCIATE  OR  SPECIAL  MEMBER 

Individuals  who  hold  o  position  related  to  respiratory  care  but  do  not  meet  the  requirements  of 
Active  Member  sholl  be  Associole  Members  They  have  all  the  rights  and  benehts  of  the  Asso- 
ciolion  except  to  hold  office   vote,  or  serve  as  choii  of  a  standing  committee   The  folic  '- 

classes  of  Associate  Membership  are  available  Foreign,  Physicic 
whose  primary  occupation  is  directly  or  indirectly  devoted  to  the  i 
lion  of  respiratory  care  eauipment  or  suppliesl  Special  Member 
respiratory  core-related  field 

PLEASE  USE  THE  ADDRESS  OF  THE  LOCATION  WHERE  YOU  PERFORM  YOUR  JOB,  NOT 
THE  CORPORATE  HEADQUARTERS  IF  IT  IS  LOCATED  ELSEWHERE 

Place  of  Employment 

Address 

City_^ 


State  

Phone  No. 


-Zip 


FOR  STUDENT  MEMBER 

Individuals  will  be  classified  os  Student  Members  if  they  meet  all  the  requirements  for  Associate 
Membership  ond  are  enrolled  in  on  educational  program  in  respiratory  core  accredited  by,  or 
in  the  process  of  seeking  accreditation  from,  an  AARC-recognized  agency 

SPECIAL  NOTICE  —  Sludenl  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 

Ci' 


'ty- 
State 


Zip 


Phone  No   ( ] 

Length  of  program 

D   1  year 
n  2  years 


Q  4  years 

D  Other,  specify . 


Cxpetted  Date  of  Graduation  (REQUIRED 
INFORMATION) 


Month 


Year 


1 1030  Abies  Lane  •  Dallas,  TX  75229-4593  •  [972]  243-2272  .  Fox  [972]  484-2720 


American  Association  for  Respiratory  Care 


Demographic  Questions 

We  request  that  you  answer  these  questions  in  order  to  help  us 
design  services  and  programs  to  meet  your  needs. 


Check  the  Highesf  Degree  Earned 

,  J  High  School 

D  RC  Graduate  Technician 

D  Associate  Degree 

D  Bachelor's  Degree 

D  Master's  Degree 

n  Doctorate  Degree 


Number  o1  Years  in  Respiratory  Care 

0-2  years  _j    I  1-13  Years 

lJ  3-5  years  U    1  6  years  or  more 

U  6- 10  years 


Job  Status 

,   Full  Time 

LJ   Part  Time 

Credentials 

RRT 

U  CRH 

D  Physician 

u  CRNA 

D  RN 

Salary 

n  Less  than  $10,000 

D  $10,001-$20,000 

a  $20,001 -$30,000 

U  $30,001  $40,000 

n   $40,000  or  more 

D  LVN/LPN 

D  CPFT 

D  RPFT 

D  Perinotai/Pediatric 


PLEASE  SIGN 

I  hereby  apply  for  membership  in  the  American  Association  for  Respiratory  Core 
and  hove  enclosed  my  dues  If  approved  for  membership  m  the  AARC,  I  will  abide 
by  its  bylaws  and  professional  code  of  ethics  I  authorize  investigation  of  all  state 
ments  conloined  herein  and  understand  that  misrepresentations  or  omissions  of 
facts  called  for  is  couse  for  rejection  or  expulsion 

A  yeorly  subscription  to  RESPIRATORY  CARE  journal  and  AARC  Times  magazine 
mcludes  on  allocation  of  $1 1 .50  from  my  dues  for  each  of  these  publications 

NOTE:  Contributions  or  gifts  to  the  AARC  are  not  tax  deductible  as  charitable  con- 
Inbulions  for  income  tax  purposes  However,  they  may  be  tax  deductible  as  ordi- 
nary and  necessary  business  expenses  subject  to  restrictions  imposed  as  a  result  of 
association  lobbying  activities  The  AARC  estimates  thai  the  nondeductible  portion 
of  youi  dues  -   the  portion  which  is  allocable  to  lobbying   ~  is  26%. 


Signature 
DafB 


Membership  Fees 

Payment  must  accompany  your  application  to  the 

AARC.  Fees  are  for   12 

months.  (NOTE:  Renewal  fees  ore  $75.00  Active,  Associate-Industrial  or  Associ- 

ate-Physician,  or   Special   status,    $90.00   for   Associate-Foreign   status;   and 

$45.00  for  Student  status). 

D  Active 

$  87,50 

n  Associate  (Industrial  or  Physician) 

$  87.50 

n  Associate  (Foreign) 

$102.50 

D  Special 

$  87.50 

D  Student 

$  45.00 

TOTAL 
Specialty  Sections 

$ 

Established  to  recognize  the  specialty  areas  of  respiratory  care,  these  sections 

publish  a  bi-monthly  newsletter  that  focuses  on  issues 

of  specific  concern  to  that 

specialty.  The  sections  also  design  the  specialty  programming  at  the  national 

AARC  meetings. 

n  Adult  Acute  Core  Section 

$15.00 

D   Education  Section 

$20,00 

n   Perinatal-Pediotric  Section 

$15.00 

n  Diagnostics  Section 

$15.00 

n  Continuing  Care- 

Rehabilitation  Section 

$15.00 

n  Management  Section 

$20.00 

D  Transport  Section 

$15.00 

D  Home  Care  Section 

$15.00 

D  Subacute  Care  Section 

$15.00 

TOTAL 
GRAND  TOTAL  =  Membership  Fee 

$ 

plus  optional  sections 

$ 

D  Total  Amount  Enclosed/Charged       $ 

D   Please  charge  my  dues  (see  below) 

A 

To  charge  your  dues,  complete  the  following:             A 

kAj^ 

[1  MasterCard                                         ^J 

Itnl^ 

n  Visa                                                  -^- 

1% 

Card  Number 

.M.m. 

Card  Expires                  / 

Signature 

Mail  application  and  appropriate  fees  to: 
American  Association  for  Respiratory  Care  •  1 1030  Abies  Lane  •  Dallas,  TX  75229-4593  •  [972]  243-2272  •  Fax  [972]  484-2720 


RE/PIRATORy  QiRE 


Manuscript  Preparation  Guide 


General  Information 

RESPIRATORY  CARE  welcomes  original  manuscripts  related  to  the 
science  and  technology  of  respiratory  care  and  prepared  accord- 
ing to  these  Instructions  and  the  Uniform  Requirements  for 
Manuscripts  Siihmitteil  to  Biomedical  Journals  [Respir  Care  1 997; 
42(6):623-634].  Manuscripts  are  blinded  and  reviewed  by  pro- 
fessionals who  are  experts  in  their  fields.  Authors  are  responsible 
for  all  aspects  of  the  manuscript  and  receive  galleys  to  proofread 
before  publication.  Each  accepted  manuscript  is  copyedited  so  that 
its  message  is  clear  and  it  confonns  to  the  Journal's  style.  Published 
papers  are  copyrighted  by  Daedalus  Inc  and  may  not  be  published 
elsewhere  without  permission. 

Editorial  consultation  is  available  at  any  stage  of  planning  or  writ- 
ing. On  request,  specific  guidance  is  provided  for  all  publication  cat- 
egories. To  receive  these  Instructions  and  related  materials,  write 
to  RESPIRATORY  CARE,  600  Ninth  Avenue.  Suite  702.  Seattle  WA 
98104,  call  (206)  223-0558,  or  fax  (206)  223-0563. 

Publication  Categories  &  Structure 

Research  Article:  A  report  of  an  original  investigation  (a  study ). 
It  includes  a  Title  Page,  Abstract,  Introduction,  Methods,  Results, 
Discussion,  Conclusions,  Product  Sources,  Acknowledgments,  Ref- 
erences. Tables,  Appendices,  Figures,  and  Figure  Captions. 

Evaluation  of  Device/Method/Technique:  A  description  and  eval- 
uation of  an  old  or  new  device,  method,  technique,  or  modification. 
It  has  a  Title  Page,  Abstract,  Introduction.  Description  of  De- 
vice/Method/Technique, Evaluation  Methods,  Evaluation  Results, 
Discussion,  Conclusions,  Product  Sources,  Acknowledgments,  Ref- 
erences, Tables.  Appendices,  Figures,  and  Figure  Captions.  Com- 
parative cost  data  should  be  included  wherever  possible. 

Case  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.  Introduction,  Case  Summa- 
ry, Discussion,  References,  Tables,  Figures,  and  Figure  Captions. 

Review  Article:  A  comprehensive,  critical  review  of  the  literature 
and  state-of-the-art  summary  of  a  pertinent  topic  that  has  been  the 
subject  of  at  least  40  published  research  articles.  Title  Page.  Out- 
line, Introduction,  Review  of  the  Literature,  Summary,  Acknowl- 
edgments, References.  Tables,  Appendices,  and  Figures  and  Cap- 
tions may  be  included. 

Overview:  A  critical  review  of  a  pertinent  topic  that  has  fewer  than 
40  published  research  articles. 

Update:  A  report  of  subsequent  developments  in  a  topic  that  has 
been  critically  reviewed  in  this  Journal  or  elsewhere. 


Point-of-View  Paper:  A  paper  expressing  personal  but  substanti- 
ated opinions  on  a  pertinent  topic.  Title  Page.  Text,  References,  Tables, 
and  Illustrations  may  be  included. 

Special  Article:  A  pertinent  paper  not  fitting  one  of  the  foregoing 
categories  may  be  acceptable  as  a  Special  Article.  Consult  with  the 
Editor  before  writing  or  submitting  such  a  paper. 

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:  A  signed  communication,  marked  "For  publication," 
about  prior  publications  in  this  Journal  or  about  other  pertinent  top- 
ics. Tables  and  illustrations  may  be  included. 

Blood  Gas  Corner:  A  brief,  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,  pharmacokinetics, 
and  pharmacotherapy. 

Graphics  Corner:  A  briefcase  report  incorporating  waveforms  for 
monitoring  or  diagnosis — with  Questions,  Answers,  and  Discussion. 

Kittredge's  Comer:  A  brief  description  of  the  operation  of  respiratory 
care  equipment — with  information  from  manufacturers  and  edito- 
rial comments  and  suggestions. 

PFT  Corner:  Like  Blood  Gas  Corner,  but  involving  pulmonary 
function  tests. 

Cardiorespiratory  Interactions.  A  case  report  demonstrating  the 
interaction  between  the  cardiovascular  and  respiratory  systems.  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  RESPIRA- 
TORY Care  for  more  detail. 

Test  Your  Radiologic  Skill:  Like  Blood  Gas  Corner,  but  involv- 
ing pulmonary  medicine  radiography  and  including  one  or  more  radio- 
graphs; may  involve  imaging  techniques  other  than  conventional 
chest  radiography. 

Review  of  Book,  Film,  Tape,  or  Software:  A  balanced,  critical 
review  of  a  recent  release. 

Preparing  the  Manuscript 

Print  on  one  side  of  white  bond  paper,  8.5  in.  x  1 1  in.  (216  x  279  mm) 
with  margins  of  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 


RESPIRATORY  CARE  Manuscript  Preparation  Guide,  Revised  2/98 


Manuscript  preparation  Guide 


do  not  use  italics  except  for  special  emphasis.  Number  all  pages  in 
uppei-right  corners.  Indent  paragraphs  5  spaces.  Do  not  justify .  Do 
not  put  authors'  names,  institutional  afl'iliations  or  allusions  to 
Institutional  affiliations  in  the  text,  or  other  identification  any- 
where except  on  the  title  pa^e.  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.  Ref- 
erences, each  Table,  and  each  Appendix.  Use  standard  English  in 
the  first  person  and  active  voice. 

Center  main  section  headings  on  the  page  and  type  them  in  cap- 
ital and  small  letters  (eg.  Introduction.  Methods,  Results,  Discus- 
sion). Begin  subheadings  at  the  left  margin  and  type  them  in  cap- 
ital 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  references:  desig- 
nate the  accepting  journal,  followed  by  (in  press),  and  provide  3  copies 
of  the  in-press  article  for  reviewer  inspection.  Cite  references  in  the 
text  w  ith  superscript  numerals.  Assign  numbers  in  the  order  that  ref- 
erences are  first  cited.  On  the  reference  page.  list  the  cited  works 
in  numerical  order.  Follow  the  Journal's  style  for  references.  Abbre- 
viate journal  names  as  in  Index Medkus.  List  all  authors. 

Article  in  ajournal  carrying  pagination  throughout  volume: 

Rau  JL.  Harwood  RJ.  Comparison  of  nebulizer  delivery  methods 
through  a  neonatal  endotracheal  tube:  a  bench  study.  Respir  Care 
1 992:37(11):  1233- 1240. 

Article  in  a  publication  that  numbers  each  issue  beginning  with 
Page  I : 

Bunch  D.  Establishing  a  national  database  for  home  caie.  AARC  Tijnes 
1991  :l5(Mar):61. 62.64. 

Coiporate  author  journal  article: 

American  Association  for  Respiratory  Care.  Criteria  for  establish- 
ing units  for  chronic  ventilator-dependent  patients  in  hospitals.  Respir 
Care  1988:33(1 1):l()44-I046. 

Article  in  journal  supplement:  (Journals  differ  in  their  methods  of 
numbering  and  identifying  supplements.  Supply  sufficient  infoimation 
to  promote  retrieval.) 

Reynolds  HY.  Idiopathic  interstitial  pulmonary  fibrosis.  Chest  1986: 

89(3.Suppl):l39S-l43S. 

Abstract  in  journal:  (Abstracts  citations  are  to  be  avoided.  Tln)se  more 

than  3  years  old  should  not  be  cited.) 

Stevens  DP.  Scavenging  ribavirin  from  an  oxygen  hood  to  reduce  envi- 
ronmental exposure  (abstract).  Respir  Care  1990:35(1 1 ):  1087-1088. 

Editorial  in  journal: 

Enrighl  P.  Can  we  relax  during  spiromcUy','  (editorial).  Am  Rev  Respir 
Dis  I993:I48(2):274. 

Editorial  with  no  author  given: 

Negative-pressure  ventilation  for  chronic  obstructive  pulmonary  dis- 
ease (editorial).  Lancet  1992:340(8833):  1440- 144 1 , 

Letter  in  journal: 

Aelony  Y.  Hlhnic  norms  lor  pulmonary  function  tests  (letter).  Chest 
I991;99(4);I().5I. 


Paper  accepted  but  not  yet  published: 

Hess  D.  New  therapies  for  asthma.  Respir  Care  (year,  in  press). 

Personal  author  book:  (For  any  book,  specific  pages  should  be  cited 
whenever  possible.) 

DeRemee  RA.  Clinical  profiles  of  diffuse  interstitial  pulmonary  dis- 
ease. New  York:  Futura:  1990.  p.  76-85. 

Corporate  author  book: 

American  Medical  Association  Department  ot  Drugs.  AM  A  drug  e\  al- 
ualions.  3rd  ed.  Littleton  CO:  Publishing  Sciences  Group:  1977. 

Chapter  in  book  with  editor(s): 

Pierce  AK.  Acute  respiratory  failure.  In:  GuenterCA.  Welch  MH.  edi- 
tors. Pulmonary  medicine.  Philadelphia:  JB  Lippincon;  1977:26-42. 

Tables.  Use  consecutively  numbered  tables  to  display  information. 
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  nonstandaid  abbreviations  and  symbols.  Key  the  foot- 
notes with  conventional  designations  (*,  t,  +,  §,  Iff,  **,  ft)  in  con- 
sistent order,  placing  them  superscript  in  the  table  body.  Do  not  use 
horizontal  or  vertical  rules  or  borders.  Do  not  submit  tables  as  pho- 
tographs, reduced  in  size,  or  on  oversize  paper.  Use  the  same  type- 
face as  in  the  text. 

Illustrations.  Graphs,  line  drawings,  photographs,  and  radiographs 
are  figures.  Use  only  illustrations  that  clarify  and  augment  the  text. 
Number  them  consecutively  as  Fig.  1 .  Fig.  2.  and  so  forth  accord- 
ing to  the  order  by  which  they  are  mentioned  in  the  text.  Be  sure 
all  figures  are  cited.  If  any  figure  was  previously  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  essen- 
tial, consult  the  Editor  for  more  information.  In  reports  of  animal 
experiments,  use  schematic  drawings,  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  diiigs  and  chemicals  used,  giving  gener- 
ic 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. 

Commercial  Product.s.  In  parentheses  in  the  text,  identify  any  com- 
mercial product  (including  model  number  if  applicable)  the  tlrst  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  man- 
ufacturers in  the  text:  instead,  list  them  on  a  Product  Sources  page 
at  the  end  of  the  text,  before  the  References.  Pro\  ide  model  num- 
bers when  available  and  manufacturer's  suggested  price,  if  the  study 
has  cost  implications. 

Kthics.  When  reporting  experiments  on  human  subjects,  indicate 
that  procedures  were  conducted  in  accordance  with  the  ethical  stan- 
dards of  the  World  Medical  Association  Declaration  of  Helsinki 
I  Respir  Care  1W7:42(6):63.5-636|  orof  the  institution's  committee 


Rl-.Sl'lRAKJKY  CARK  Manuscript  Preparation  Guide.  Revised  2/98 


Manuscript  Preparation  Guide 


on  human  experimentation.  State  that  informed  consent  was 
obtained.  Do  not  use  patient's  names,  initials,  or  hospital  numbers 
in  text  or  illustrations.  When  reporting  experiments  on  animals,  indi- 
cate that  the  mstitution'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.  Iden- 
tify any  general-use  or  commercial  computer  programs  used,  nam- 
mg  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;  tem- 
peratures in  degrees  Celsius;  and  blood  pressures  in  millimeters  of 
mercury  (mm  Hg).  Report  hematologic  and  clinical-chemistry  mea- 
surements in  conventional  metric  and  in  SI  {Sy.steiiie  liitenialioiuile) 
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  con- 
version to  SI,  see  RESPIRATORY  Care  I988;33(  I0);861-873  (Oct 
1988).  1989;34(2):145(Feb  1989).  and  1997;42(6):639-640  (June 
1997). 

Conflict  of  Interest  Authors  are  asked  to  disclose  any  liaison  or  finan- 
cial arrangement  they  have  with  a  manufacturer  or  distributor  whose 
product  is  part  of  the  submitted  manuscript  or  with  the  manufacturer 
or  distributor  of  a  competing  product.  (Such  arrangements  do  not 
disqualify  a  paper  from  consideration  ;uid  are  not  disclosed  to  review- 
ers.) A  statement  to  this  effect  is  included  on  the  cover-letter  page. 
(Reviewers  are  screened  for  possible  conflict  of  interest. ) 

Abbreviations  and  Symbols.  Use  standard  abbreviations  and  sym- 
bols. Avoid  creating  new  abbreviations.  Avoid  all  abbreviations 
in  the  title  and  unusual  abbreviations  in  the  abstract.  Use  an  abbre- 
viation only  if  the  term  occurs  several  times  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  mea- 
surement can  be  abbreviated  without  explanation  (eg,  10  L/min, 
IStoiT,  2.3kPa). 

Plea.se  use  the  following  fomis:  cm  HiG  (not  cmH20),  f  (not  bpm), 
L  (not  I).  L/miii  (not  LPM,  l/min.  or  1pm).  mL  (not  ml),  mm  Hg  (not 
mniHg),  pH  (not  Ph  or  PH).  p  >  0.001  (not  p>0.001 ),  s  (not  sec), 
SpO;  (pulse-oximetry  saturation).  See  RESPIRATORY  CARE: 
Standaid  Abbreviations  and  Symbols  (Respir  Care  1997;42(6):637- 
642]. 

Submitting  the  Manuscript 

Mail  three  copies  1 1  copy  with  author(s)  name(s),  affiliation(s).  2 
copies  without  name(s)  and  affiliation(s)  for  reviewers]  of  the  manu- 
script, figures,  and  I  diskette,  and  the  Cover  Letter  &  Checklist  to 
RESPIRATORY  CARE.  600  Ninth  Avenue,  Suite  702,  Seattle  WA 
98104.  Do  not  fax  manuscripts.  Protect  figures  with  cardboaid.  Keep 
a  copy  of  the  manuscript  and  figures.  Receipt  of  your  manuscript 


will  be  acknowledged. 

Computer  Disliettes.  Authors  are  encouraged  to  submit  electron- 
ic versions  of  manuscripts  as  well  as  printed  copies  (3.5  in.  diskettes 
in  Macintosh  or  IBM-DOS  format).  Label  each  diskette  with  date; 
author's  name;  name  and  version  of  word-processing  program  used; 
and  filename(s).  Software  used  to  produce  graphics  and  tables  should 
be  similarly  identified.  Do  not  write  on  diskette  labels  except  with 
felt-tipped  pen.  If  revision  of  a  manuscript  is  required  as  a  condi- 
tion of  acceptance  for  publication,  we  ask  that  an  electronic  version 
of  revision  be  supplied  to  facilitate  copyediting  and  production. 

Prior  and  Duplicate  Publication.  Work  that  has  been  published 
or  accepted  elsewhere  should  not  be  submitted.  In  special  instances, 
the  Editor  may  consider  such  material,  provided  that  permission  to 
publish  is  given  by  the  author  and  original  publisher.  Please  con- 
sult the  Editor  before  submitting  such  work. 

Authorship.  All  persons  listed  as  authors  should  have  participat- 
ed in  the  reported  work  and  in  the  shaping  of  the  manuscript;  all  must 
have  proofread  the  submitted  manuscript;  and  all  should  be  able  to 
publicly  discuss  and  defend  the  paper's  content.  A  paper  with  cor- 
porate 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  sim- 
ilar services.  Persons  who  provide  such  ancillaiy  .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  Acknowl- 
edgments section. 

Reviewers.  Please  supply  the  names,  credentials,  affiliations,  address- 
es, and  phone/fax  numbers  of  three  professionals  whom  you  con- 
sider expert  on  the  topic  of  your  paper.  Your  manuscript  may  be  sent 
to  one  or  more  of  them  for  blind  peer  review. 


Editorial  Office: 

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kreilkampfS' aarc.org 


RESPIRATORY  CARE  Manuscript  Preparation  Guide.  Revised  2/98 


COVER  LETTER  &  CHECKLIST 

A  copy  of  this  completed  form  must  accompany  all  manuscripts  submitted  for  publication. 


Title  of  Paper: 


Publication  Category: 


Corresponding  Autfior: Phone: FAX: 

Mailing  Address: 

Reprints:      □  Yes     □  No  E-mail  Address: 


"We,  the  undersigned,  have  all  participated  in  the  work  reported,  proofread  the  accompanying  manuscript,  and  approve  its  sub- 
mission 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.* 

"First  Author: 


Author  Signature/Date_ 


"Second  Author: 


"Third  Author: 


Author  Signature/Date_ 


Author  Signature/Date^ 


"Fourth  Author: 


Author  Signature/Date, 


Has  this  research  been  presented  in  any  public  forum?        □  Yes     □  No 
If  yes,  where,  when  and  by  whom? 


Has  this  research  received  any  awards?         □  Yes     □  No 
If  yes,  please  describe. 


Has  this  research  received  any  grants  or  other  support,  financial  or  material?       □  Yes     □  No 
If  yes,  please  describe. 


Do  any  of  the  authors  of  this  manuscript  have  a  financial  interest  in  (or  a  commercial  or  consulting  relationship  to)  any  of  the 
products  or  manufacturers  mentioned  in  this  paper  or  any  competing  products  or  manufacturers?        [_J  Yes     □  No 


If  yes,  please  describe. 


§ 


□  Have  you  enclosed  a  copy  of  the  manuscript  on  diskette? 

□  Is  double-spacing  used  throughout  entire  manuscript? 

□  Are  all  pages  numbered  in  upper-right  corners? 

□  Are  all  references,  figures,  and  tables  cited  in  the  text? 

□  Has  the  accuracy  of  the  references  been  checked,  and  are  they  correctly  formatted? 

□  Have  SI  values  been  provided? 

□  Has  all  arithmetic  been  checked? 

□  Have  generic  names  of  drugs  been  provided? 

□  Have  necessary  written  permissions  been  provided? 

□  Have  authors'  names  been  omitted  from  text  and  figure  labels? 
I_|  Have  copies  of  'in  press'  references  been  provided? 

□  Has  the  manuscript  been  proofread  by  all  the  authors? 

□  Have  the  manufacturers  and  their  locations  been  provided  for  all  devices  and  equipment  used? 

Rli.SI'IRA  roRY  Carf  MuiuisL-ript  Preparation  Guide.  Revised  2AJ8 


Not-for-profit  organizations  are  offered  a  free  advertisement  of  up  to  eight  lines  to  appear,  on  a  space-available 

basis,  in  Calendar  of  Events  in  RESPIRATORY  CARE  Ads  for  other  meetings  are  priced  al  $5.50  per  hne  and  require 

an  insertion  order.  Deadline  is  the  20th  of  the  month  two  months  preceding  the  month  in  which  you  wish  the  ad  to  run. 

Submit  copy  and  insertion  orders  to  Calendar  of  Events.  RESPlRAtORV  CARE.  I  1030  Abies  Lane.  Dallas  TX  75229-4593. 


Calendar 
of  Events 


AARC  &  AFFILIATES 

November  7-10 — Iiitenuilioiicil 
Re.spircilory  Congress,  Atlanta.  Georgia 
The  American  Association  for 
Respiratory  Care  hosts  its  44th 
annual  International  Respiratory 
Congress  at  the  Georgia  World 
Congress  Center  in  Atlanta.  GA. 
More  than  7.000  people  will 
experience  programs  appealing  to  all 
levels  of  health  care  providers  — 
from  clinicians  to  managers  and 
administrators,  to  manufacturers  and 
distributors  of  equipment  and 
supplies.  Program  content  will 
include  neonatal,  pediatric,  and  adult 
critical  care;  acute,  continuing,  and 
rehabilitative  care;  diagnostics; 
management;  and  case  and  disease 
management  —  truly  a 
comprehensive  program  on 
respiratory  care.  Exhibits  by  all 
manufacturers  of  cardiopulmonary 
equipment  in  the  world  will  be 
featured. 

Contact:  For  program  brochure  and 
registration  information,  contact  the 
AARC  at  1  1030  Abies  Lane,  Dallas, 
TX  75229-4593;  (972)  243-2272;  fax 
(972)  484-2720;  meetings@aarc.org; 
or  www.aarc.org. 

November  17 — Videotape 

Teleconference 
After  viewing  a  tape  of  the  eighth 
installment  of  the  AARC's  1998 
"Professor's  Rounds"  series, 
"Techniques  for  Weaning  the 
Ventilator  Patient,"  participate  in  a 
live  telephone  question-and-answer 
session  with  the  expert  (from 
12:30-1  pm  EST).  Dean  R  Hess  PhD 
RRT  will  analyze  the  pros  and  cons 
both  inside  and  outside  the  hospital. 
CRCE:  One  credit  hour. 
Contact:  To  receive  the  90-minute 
videotape  and  register  for  the 
teleconference,  call  the  AARC  at 
(972)243-2272. 


April  7-9,  \9W— Gulf  Shores.  Alabama 
The  Alabama  Society  for  Respiratory 
Care  will  be  hosting  their  state 
educational  meeting  at  the  Gulf  State 
Park  Resort  Hotel  and  Convention 
Center. 

Contact:  David  Howard 
(205)  761-4573  or  e-mail 
William.Howard@bhsala.com. 


Other  Meetings 


October  30 — West  Point.  New  York 
The  Hudson  Valley  Respiratory 
Directors  Association  presents  its 
annual  educational  seminar  at  The 
Hotel  Thayer  located  on  the  grounds 
of  The  U.S.  Military  Academy. 
Contact:  Mike  Aiello 
(914)  83 1-2769  or  e-mail 
myke456@aol.com. 

December  2-4 — Brussels.  Belgium 
The  fourth  postgraduate  refresher 
course  in  Cardiovascular  and 
Respiratory  Physiology  Applied  to 
Intensive  Care  Medicine  will  be  held 
at  the  Free  University  of  Brussels  at 
Campus  Erasme. 

Contact:  Ana  Maria  de  Campos  at 
32.2  555  3215  or  e-mail 
sympicu@resulb.ulb.ac.be. 

February  13-20,  1999— 5r.  Moritz. 

Switzerland 
The  Seventh  Winter  Symposium  on 
Intensive  Care  Medicine  will  be  held 
in  St.  Moritz  and  is  jointly  sponsored 
by  the  European  Society  of  Intensive 
Care  Medicine  and  the  Society  of 
Critical  Care  Medicine  (USA). 
Contact:  Ana  Maria  de  Campos  at 
32.2  555  32 15  or  e-mail 
sympicu@resulb.ulb.ac.be. 


March  16-19,  199*)— Brussels. 

Belgium 
The  19th  International  Symposium 
on  Intensive  Care  and  Emergency 
Medicine  will  be  head  at  the 
Congress  Center  in  Brussels. 
Contact:  Ana  Maria  de  Campos  at 
32.2  555  3215  ore-mail 
sympicu@resulb.ulb.ac.be. 

Junel2-16,  1999 — International 
Society  for  Aerosols  in  Medicine 
12th  International  Congress  at  the 
Austria  Center  in  Vienna.  Austria. 
Topics  include  aerosol  drug 
delivery,  aerosol  deposition  and 
clearance,  cellular  and  molecular 
interactions,  environmental 
aerosols,  standardization,  aerosol 
diagnostics,  and  aerosol  therapy. 
Contact:  Vienna  Academy  of 
Postgraduate  Medical  Education  and 
Research.  Alser  Strasse  4.  A- 1090 
Vienna,  Austria.  Phone  (-I-43/1 ) 
405  13  83-22,  fax  (-^43/1) 
405  13  83-23,  e-mail 
medacad@via.at. 


Respiratory  Care  •  October  1998  Vol  43  No  10 


901 


Notices 


Notices  of  competitions,  scholarships,  fellowships,  examination  dates,  new  educational  programs. 

and  the  like  will  he  listed  here  free  of  charge.  Items  for  the  Notices  section  must  reach  the  Journal  60  days 

before  the  desired  month  of  publication  (January  I  for  the  March  issue.  February  1  for  (he  April  issue.  etcK  Include  all 

pertinent  information  and  mail  notices  to  RESPIRATORY  CARE  Notices  Dept.  1 1030  Abies  Lane,  Dallas  TX  75229-4593. 


"^itUmia 


A  4-'"     I  NTERN  ATIQN  AU 


N  a  VEMBER    7-}- 1  D  ,  J  J^  9  a 

Atlanta,    Georgia 


EORGI  A 


ooo 


in  Helpful  lUeb|Sites 

American  Association  for  Respiratory  Care 

http://www.aarc.org 

—  Current  job  listings 

—  American  Respiratory  Care  Foundation 
fellowships,  grants,  &  awards 

—  Clinical  Practice  Guidelines 

National  Board  for  Respiratory  Care 

http://www.nbrc.org 

Respiratory  Care  online 

http://www.rcjournal.com 

—  1997  Subject  and  Author  Indexes 

—  Contact  the  editorial  staff 

The  American  College 
of  Chest  Physicians 

http://www, chestnet.org 


The  National  Board  for  Respiratory  Care — 1999  Examination  Dates  and  Fees 


Examination 

CRT  Ex;iniinali<in 


RRT  F.xamination 


CPFT  Rxamination 


Examination  Date 

March  1.^,  19W 

Application  Deadline:  January  I.  1999 

JuncS.  1999 

Application  Deadline:  February  1.  1999 

JuncS.  1999 

Application  Deadline.  April  I.  199') 


Examination  Fee 

$120  (new  applicant) 

80  (reapplicant) 

120  written  only  (new  applicant) 

SO  written  only  (reapplicant) 

1.^0  (new  applicant) 

l.SO  (reapplicant) 


l-or  information  ahoiit  other  services  or  fees,  w  rite  to  the  National  Board  for  Respiratory  Care. 
8.^10  Nienian  Road.  I.enexa  K.S  Mi214.  or  call  (91.^)  599-4200.  FAX  (913)  541  1)1, Sd.ore  mail:  nhrc-inroC^nhrc.ori; 


902 


Rr.SPIRATORY  CARH  •  OCTOBFR  1998  VOI   4.^  NO  10 


Notices 


WATCH     FOR 

A 

SPECIAL    ISSUE 

O  F 

R  E  S  P  1   R  AT  O 

R  Y 

CARE 

PEDIATRIC 

ARDS 

November    1998 

New  Federal  Register  notices  Now  Available 

The  Center  for  Devices  and  Radiological  Hcaltli  announces  tlie 
publication  of  new  Facts-on-Demand  FOD  notices  in  the 
Federal  Register.  The  new  publications:  FOD#774 — Medical 
Devices;  Preemption  of  State  Product  Liability  Claims; 
Proposed  Rule;  FODi'607 — Rebuilders,  Reconditioners, 
Services,  and  "As  Is"  Remarketers  of  Medical  Devices;  Review 
and  Revision  of  Compliance  Policy  Guides  and  Regulatoj-y 
Requirements;  Request  for  Comments  and  Information; 
Proposed  Rule:  and  FOD#513 — Medical  Devices;  Reports  of 
Corrections  and  Removals;  Stay  of  Effective  Date  of 
Information  Collection  Requirements;  Stay  of  Effective  Date 
of  Final  Regulation.  For  more  information  about  Facts-on- 
Demand  call  (800)  899-0381  or  (301)  826-0111.  The  FOD  sys- 
tem is  also  on  the  Internet  at  viww.fda.gov'cdrh/fedregin.html. 


NAMES  1998  Education,  Conference 
Schedule  Set 

The  National  Association  for  Medical  Equipment  Services 
(N.AMES)  announces  its  1998  national  conferences  and 
regional  education  seminars.  For  information  about 
upcoming  events,  call  the  NAMES  Education  &  Meeting 
Department  at  (703)  836-6263.  or  visit  the  web  site; 
www.names.org. 


(2^n  this  issue 

1999  %dt 


(^ee  pam  891 


Web  Site  Link  to  Fellowships,  Scholarships, 
&  Grants 

The  Ainerican  Association  for  Respiratory  Care's  web  site  con- 
tains important  information  about  fellowships,  scholarships, 
and  research  grants.  International  fellowships,  education 
scholarships,  research  fellowships,  and  other  grand  programs 
are  described  in  detail.  The  site  also  contains  information 
about  the  $1,000,000  Research  Fund,  a  restricted  fund  to 
sponsor  research  initiatives  that  document  the  clinical  and 
economic  impact  of  respiratory  care  professionals  in  the  deliv- 
er)' of  health  care.  To  apply,  a  "Research  Plan  Abstract"  must 
be  submitted  to  the  AARC  by  February  1. 1999.  To  find  out 
more  about  these  programs,  log  on  at  www.aarc.org. 


year  2000  Date  Problem  Addressed  by  FDA 

On  .lune  24, 1998,  the  Food  and  Drug  Administration 
announced  the  availability  of  the  document,  "Guidance  on 
FD.A"s  E.xpectations  of  Medical  Device  Manufacturers  Concern- 
ing the  Year  2000  Date  Problem."  The  document  is  available 
via  telephone  (800)  899-0381  or  (301)  827-0111  or  via  the 
Internet  at  www.fda.gov  cdrh-'yr2000  'y2kguide.html. 


New  Address  for  Asthma  Group 

The  .Allergy  and  .■Xsthina  Network  Mothers  of  .Asthmatics  Inc 
has  moved.  The  organization's  new  address  is  2751  Prosperity 
Avenue.  Suite  150.  Fairfa.\  V.A  22031.  The  telephone  numbers 
are  (800)  878-4403  or  (703)  641-9595,  Fa,x  (703)  573-7794. 
Information  about  the  group  and  their  activities  is  available  at 
their  Internet  address:  www.aanma.org. 


Respiratory  Care  •  October  1998  vol  43  No  10 


903 


Authors 

in  This  Issue 


Beaty.  Christopher  D 823 

Confalonieri.  Marco 824 

Durbin.  Charles  G  Jr 820 

Isreal,  Robert  H 811 

Malhotra.  Atul 825 


Medoff,  Benjamin  D 825 

Parekh.  Jayashree  S 820 

Poe,  Robert  H 811 

Powell.  Diana 804 

Schwartz,  David  R 825 


Advertisers 
in  This  Issue 


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classified  advertising  contact  Belh  Binkley,  Marketing  Assistant  for  RESPIRATORY  CARE,  at  (972)  243-2272, 
Fax  (972)  484-6010.  Rick  Owen  is  the  Marketing  Director  for  RESPIR.ATORY  CARE. 


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904 


RESPIKAIORY  CARE  •  OCTOBER  1998  VOL  43  NO  10 


Portex®  Arterial  Blood  Sampling  Devices 


When  the  chemistry  is  right, 
the  possibilities  are  endless. 


The  right  chemistry  can  spark 
great  relationships,  inspire 
genius,  and  produce  medical 
breakthroughs.  Case  in  point: 
SIMS  Portex  advanced  formula 
heparm  makes  arterial  blood 
sampling  easier,  more  accurate, 
and  more  efficient,  permitting 
1 1  tests  from  a  single  sample. 
With  such  inspired 
innovations,  the  relationship 
between  our  ABS  products  and 
discriminating  clinicians  will 
go  on  forever. 

Our  chemistry  is  so 
right  that  one  sample  is 
all  you  need  for  11  tests. 

Our  advanced  formula  heparin 
combines  the  necessary 
anticoagulant  effect  with 
calcium-neutral  heparin  for 
more  accurate,  more  extensive 
testing  from  a  single  sample. 
Ours  is  the  first  and  only 
heparin  formula  that  can 
measure  1 1  indications  from 
one  arterial  blood  sample. 


Endless  possibilities, 
more  products,  lots  of 
safety  features. 

SIMS  Portex  offers  more 
product  choices  than  any  other 
manufacturer — liquid  and  dry 
heparin,  with  syringe  sizes 
ranging  from  250  |jL  to  3  cc. 


For  hirther  information,  contact: 


We  also  help  to  eliminate  the 
frightening  possibility  of 
needlesticks  with  our  patented 
Needle-Pro*  needle  protection 
device;  the  Filter-Pro'  air 
bubble  removal  device  is 
standard  on  all  our  syringes. 

That  special  spark? 

There  is  a  special  chemistry 
between  SIMS  Portex  and  the 
clinicians  who  use  our 
products,  a  relationship  built 
on  trust,  support,  and 
reliability.  Clinicians  prefer 
our  blood  sampling  devices  for 
obvious  reasons;  they  are  safer, 
easier  to  use,  and  less 
traumatic  for  patients. 

Newly  released  on 
videotape. 

Call  us,  toll-free,  to  get  your 
tape  of  our  newest  video 
release  on  arterial  blood 
sampling  devices  and 
techniques.  Ask  for  Nicole 
Hall,  1-800-258-5361, 
prompt  4,  ext  226. 


SIMS  Portex  Inc. 

800-258-5361  or  Fax  603-352-3703 
www.portexusa.com 


Needle-Pro* 
Needle  Protection 

Devices  for 

Maximum  Needle 

Protection  for 

Clinicians 


Filter-Pro" 

Devices  for  Easy 

Removal  of  Air 

Bubbles 


Pro-Vent*  Plus 
Microsampling 
Devices  for  Small, 
Fixed  Volume 
Blood  Samples 


Sims 


SMITHS  INDUSTRIES 

Medical  Systems 


Complete  Family 
of  Line  Draw 
Syringes  for 
Direct  Blood 


Visit  AARC  Booth  123  in  Atlant 


ACE  goes 

\rfiere  no  other  spacer 

has  gone  before. 

Everywhere. 


When  used  with  a  metered  dose 
inhaler  (MDI),  the  universal  ACE 
Aerosol  Cloud  Enhancer  by  DHD  lets 
you  deliver  aerosolized  medications  in  a 
\anet\'  ot  settings: 

In  the  ventilator  dfcuit. 

•  ACE's  patented,  cone-shaped  chamber 
captures  and  delivers  up  to  46%  of 

aerosolized  medication  to  the  end  of  the  endotracheal  tube.' 
'  Standard  fittings  on  the  ACE  allow  for  a  convenient  connection 

between  the  patient  circuit  wye  and  inspiratory  Hnib. 
'  Medication  is  actuated  away  from  the  patient,  allowing  time  for 

the  aerosol  cloud  to  form  while  minimizing  impaction. 

In  routine,  oral  therapy. 

•  ACEs  clear  holding  chamber  helps 
asthma  patients  visually  confirm 
availability  of  prescribed  bronchodilator. 

•  One-way  valved  mouthpiece 
encourages  patient 

coordination. 


•  Coaching  whisde  is  calibrated  to  acrivate  at  30  Ipni,  renunding 
patients  to  slow  their  inspiratory  rate  and  promoting  ma.ximum 
drug  deposirion.- 

•  Durable,  dishwasher-safe  ACE  is  easy  to  clean  and  reassemble 
at  home. 

In  other  MDI  delivery  applications. 

ACE  can  also  be  used  with  an  incenrive  spirometer,  a  non- 
rebreathing  T-piece,  in  conjunction 
with  an  endotracheal  airway,  and 
direcdy  connected  to  a 
resuscitation  bag. 

Ihe  benefits  are  universaL 

By  stocking  only  one  type  ot 
MDI  spacer  instead  of  two  or  three, 
you'll  save  money  and  inventory 
space.  And  because  ACE  works  for 

multiple  aerosol  delivery  situations,  you'll  reduce  staff  training 
time  and  ma.ximize  efficiency  For  more  information  on  the 
universal  ACE  Aerosol  Cloud  Enhancer,  or  a 
free  catalog  of  DHD  respiratory  care  products 
call  DHD  toll-free  todav  at 

1'800«847'8000. 


o 


DHD 

Healthcare 


hmdvuiitins  Jor  it'\ptnilory  care 

(jnaitou.NY  1JU32  USA    (800)847-8000      (315)697-2221 

Cusiomer  Strvicc  FAX:  (315)  697-5111     http://www.dhd.C0Tii 


Circle  123  on  reader  service  card 
Visit  AARC  Bootiis  415  and  417  In  Atlanta