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

OCTOBER 1 998 
VOLUME 43 
NUMBER 1 

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 
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REVIEWS 



Flexible Fiberoptic Bronchoscopy in 1998 

1998 OPEN FORUM ABSTRACTS 



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accurate during motion 

Sixty years ago, Karl Matthes, M.D. envisioned a device 
that would non-invasively, continuously, and accurately 
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Source Barker SJ, Shah NK The Effects of Motion on the Performance of Pufse Oximeters 
in Vofuriteers. Anesthesiology 1997;86(1) 101-108 Masimo', SET" and 5 are registered trademarks 
of Masimo Corporation N3000, OXISMART. and N200 are trademarks of Nellcor 








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AARC Membership 
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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 



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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, 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. 



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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? — 

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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 



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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 






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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 



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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 



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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 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 



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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% 



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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- 



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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 



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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 







2 







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. 

• 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. 



REFERENCES 



1. National Center tor Health Statistics. Vital and health statistics: cur- 
rent estimates from the National Health Interview Survey. US De- 
partment of Health and Human Services. 1990-1993. 

2. Lenney W. The burden of pediatric asthma (review). Pediatr Pulmo- 
nol SuppI I997;I5;I3-16. 

3. Brook U. An assessment of asthmatic knowledge of school teachers. 
J Asthma 1990:27(3): 1 59- 1 64. 

4. Bevis M, Taylor B. What do school teachers know about asthma? 
Arch Dis Child 1990;6.5(6):622-625. 

5. National Asthma Education and Prevention Program: Expert Panel 
Report. Guidelines for the diagnosis and management of asthma. 
Wa.shington DC: NHLBI 1991. 

6. Managing asthma in .school: an ACTION plan |videocassette]. Dal- 
las, TX: Baylor Asthma and Pulmonary Rehabilitation Center, 1992. 

7. Mendoza GR. Peak performance: a strategy for asthma self-assess- 
ment. Fairfax, VA: National Allergy and Asthma Network, 1987. 

8. Millard M, Lawrence G, Johnson P. McEwen M, Neatherlin J, Ad- 
ams R. School vs. home-based asthma therapy. Dallas, TX: Baylor 
Asthma and Pulmonary Rehabilitation Center, n.d. 



Millard M, Lawrence G, Johnson P, McEwen M, Neatherlin J, Ad- 
ams R. A pilot study delivering inhaled anti-inflammatory cortico- 
steroids to asthmatic children at .school. Dallas, TX: Baylor Asthma 
and Pulmonary Rehabilitation Center, n.d. 

Cote J, Golding J, Barnes G, Boulet L-P. Educating the educators: 
how to improve teaching about asthma (review). Chest l994;Ocl: 
106(4 Suppl):242S-247S. 

American Association for Respiratory Care. Peak performance USA: 
a program for managing asthma in the school: asthma management 
guide from your local respiratory care practitioners. Dallas TX. 
Eisenberg JD. Moe EL, Stillger CF. Educating school personnel 
about a.sthma. J Asthma l993;30(5):351-358. 
American Association for Respiratory Care. Peak Performance USA: 
a program for managing asthma in the school: implementation guide 
for the respiratory care practitioner. Dallas TX 
Student asthma action card. Washington. DC; Asthma and Allergy 
Foundation of America, n.d. 

Farber HJ, Mendoza G, Haas A, et al. Your child and asthma. Oak- 
land, CA: Kaiser Foundation Health Plan. Inc. 1992. 
Plaut TF. One minute asthma: what you need to know. Amherst. 
MA: Pedipress, Inc. 1992. 

Dean AG. Dean JA. Coulombier D. Burton AH, Brendel KA, Smith 
DC, et al. Epi Info, Version 6: A word processing, database, and 
statistics sy.stem for epidemiology on microcomputers. Atlanta, GA: 
Centers for Disease Control and Prevention, 1994. 
Kaiser Permanente Medical Center. Health skills for pediatric asthma 
[videocassette]. 

Kayman H, Myers D. Health skills for pediatric asthma. Oakland, 
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 



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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 



814 



Rrsi'ir.atory Care • October "98 Vol 4} No 10 



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- 



REFERENCES 

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1965:82:656-659. 

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chial needle aspiration of peripheral pulmonary lung nodules. Chest 
1984:86(61:819-823. 



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



817 



Flexible Fiberoptic Bronchoscopy in 1998 



15. Wang KP. Sclcuk ZT, Erozan Y. TransbroiiLhia! needle aspiialinn 
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35. Khan MA. Corona F. Masson RG. Whitcomb ME. Transbronchial 
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bronchoscopy in lung Iransplani recipients. Chest 1997:1 1 1(2):377- 
381. 



818 



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Flexible Fiberoptic Bronchoscopy in 1998 



5(x Credlc WF ]i\ Sniiddy JF, Hlliolt RC. CiMiipliLiiliciiis o\ lilx-niplic 
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63. Kozak EA, Bralh LK. Do "screening" coagulation tests predict bleed- 
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Chest I9y4;IO6(3):7O3-705. 

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65. Dwcik RA, Mchla AC. Meeker DP, Arroliga AC. Analysis of the 
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for airway obstruction due to blood clots. Mayo Clin Proc 1996: 
71(6):595-596. 



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 << 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) 

Conclusio n 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 




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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, 5 or 1 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) 

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 
(n=44) 


14.9- 
(n=47) 


11 6 


13 2 


FEV, (L) 


-001 


05 


008' 


007 


FEF25-75%(L'sec) 


■0 06 


00 


14- 


14- 


FVC(L) 


04 


09 


06 


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 DIIRIN C nRFSSIN G 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. 

P tgcusgip n-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 
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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 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 ) cm 

20 19.4/0.10 

40 38.8/0 17 

80 77 3/1,9 



1 4/0.15 



BO cm 160 cm 

55/0 10 background 

1 05/0 15 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. 



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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 



You need it now. 

Not next week. 

Not next month. 



NOW! 



And you can have it. 

The fastest answers to your questions about products and 
services advertised in tlie current issue of RESPIRATORY CARE 
are just a "Click" away when you go online: 

littp://www.aarc.org/resources/html 



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 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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11030 Abies Lane / Dallas, Texas 75229 / Phone C972) 243-2272 / Fax (972) 484-6010 



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 = 48. 4 L/mm p = 48, 6 
Umin p~ 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 


861 


1295 


177 


884 


1266 


1 807 


Measured 
Mm 


48 


95 


368 


5,80 


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 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< 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 40 

Total survey score 155+13 144 + 14 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 - 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 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 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 


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\'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 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 


878 




0.077 




slope 


0912 


0860 


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, 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 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 5 seconds, and PEEP of 5 cm 
H20 A disposable neonatal circuit was attached to a 3 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 



Visits 65% 

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

Conclusion: Asthmatic families 



Visits 

1 Visit 

> 2 Visits 
Unreported 



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 35 sec. PEEP 4 cm H^O, FiOj 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 ^ 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 (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 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 



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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 
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Non-Allocated Hours, and an Appendix with worksheets to 
compute your own workload hours. 

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



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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) 

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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 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 70 mph 


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. Ma con Stale Co llege. 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) 



b efore 



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) 99±0 68 

PFR(0/sec) 4,03±169 

V^(0/sec) 40±0 29 

R„(cmHp/0/sec) 6.95 ±1,78 

6^in walking distance f6MDl fm) 3133 ± 65 

('. P < 05, **, P < 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 
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 



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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 
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-, 
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- 


98 


98 


036 


096 


T-Test 


p = 010 


p = 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) 





5 


75 


10 


125 


15 


lloHi(s) 


065«),23 


U,-17rt24 


2M),I2' 


0,15«)01' 


ni5<<)02' 


015«)02' 


VM.nl) 


OI3<0,OS 


0.2140,07 


0J5«107' 


ajotooT- 


034.0 07- 


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< 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 < 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 ± 04 $ 


-1 14±0 05 


-1,27 ±0,02 


-145±014 



* p < 05 ST/D 30 significanlly sborter nse lime vs T-Bird VS 

# p < 05 ST/D 30 significantly shorter Tr vs T-Bird VS 
$ p < 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. 

MunRyiik i 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 breaths/min. pressure support (PS) of 1 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 g rou p (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: = 100 131 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 + 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 
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upgraded. 

Babylog SOOOplus setting 
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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 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 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 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 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 01 to 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 = 60) Relative label size, which is also inversely proportional to 
membrane turnover, had a strong negative correlation (r*' = 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 



I ORDER FORM 

I PSRC/AARC Member Price $80 t\lonmember Price $1 50, Item #BK3. 

I Add $8 stiipping and liandling for first manual, $5 eacti additional 

' SEND COPY(IES) OF THE RESPIRATORY HOME CARE PROCEDURE MANUAL 

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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 -] 







o o 







t2SD 


O 00 






Q 




o^ 


" Mean 


o 






o 


o 


o 
















-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 DIugole nski, 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) 


2 (0 4) 2 (0 4) 


12(13) 



The program resulted In a signlficani cost savings ($1,010/month; p = 001) due lo 
a significant reduction in encounters with health care providers (p < 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) 


3±0.5 


B 


68 


8 4±4 4 


n.8±l2.3 


35(51) 


7±0 7 


C 


8.1 


8 8±4 8 


107111.2 


43(52) 


6±0 7 


Rvalue 


- 


503 


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 < 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 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) 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£ 



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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 Bald esare-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 


oxygen days 


36 8 ± 28 8 


34 ± 28 


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 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 
Establishin g a Partnershi p 

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: 

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• 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 

• Identify potential environmental hazards 

• Outline the steps in asthma self management 

This new information is presented by a highly credentialed staff of experts. Michael Anders, BS, RRT; Rose Boehm, RRT; 
Melalne Giordano, MS, RN, CPFT; Thomas J. Kallstrom, RRT; Gretchen Lawrence, BA, RRT; and Mark 1/1/ Millard, MD provide 
the latest information in a manner that's comprehensive and easy to understand. 

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Monday, November 9. 3:00-4:55 pm (Room 214E) 



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 = 47 ml/mm. 

-<5nm average = 77.45 °o 

-To combine the previous vanables RPDR was calculated. = Ml/Min multiplied by 

<5Mm RPDR average = 36 ml/mm of 1-5 micron particles 

02 TANK COMPRESSOR W/LC STARB 12LPM 

-Ml/Min average = 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 = 13 ml/min of 1-5 micron particles 

02 TANK COMPRESSOR W/AEROTECH lia 12LPM 

-Ml/Min average = 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 ± 
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 ± 8 ng (FD), 
60.9 ± 8 |ig (TD)) significantly exceed that delivered by the 
MicroChamberT" spacers (38 2 ± 6 5 )ig (FD), 44 ± 3 6 pg (TD)) {paired 
t-test, p < O.OOI) The mass fraction of the aerosol contained in fine 
particles (91 .9 ± 3% (AeroChamber®), 86 1 ± 8 7% (MicroChamber™)) 
were comparable (p = 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 



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- 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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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 
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YES 



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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 B S 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 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 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 
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 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 = 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 = 43 ml/min 

I'RR average = 66 % 

To combine tile previous variables RPDR v 

PRR RJ'UR axeragc = 28 

PARI MASTER COMPRESSOR W/LC PLUS 

Ml/Mln average = 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 = 40 ml/mln 
I'RH.iv.r.igc = 74 <„ 

To lomblne Ihf previous variables RPDR waf 
I'KR. Rl'DR average = 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 = 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 




07 


LIniheurt 


4') 211 


11 




05 


Acorn 


45. SS 


.16 




007 


Cirrus 


43 48 


18 




08 


Beta: 


32 13 


20 




0„ 


.\&M 


82 (.3 


15 




i: 


DItrainiM 


3f, 5') 


54 




]') 


Aerobid 


31 1)5 


63 




19 


Mtnjheart 


61141 


10 




06 


Pari LC Plus 


60 00 


45 




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 ± 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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-IS 11,1,11 141 



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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 (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 



Now weaning begins 
when you intubate. 



The Servo 300A allows your patients 
to drive their own ventilatory needs, 
making interactive ventilation a reality. 
The result is effective and dependable 
treatment for your patients. 



fx.vi^o' 




S.iV'P^ 



The Automode function provides: 

• fully interactive respirator/ therapy 

• automatic weaning 

• reduced sedation requirements 

• fewer alarms 

Contact your local sales consultant to find out 
how the Servo 300A can help your patients 
help themselves. 



nteractive 



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Interactive Ventilation 



Siemens Medical Systems, Inc 
Electromedical Systems Division 
14 Electronics Avenue 
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 M alms BS RR T . 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 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 




1995" 


84 


1W6 

'Praclnf ibalig 
CONCLUSION: Insulul 
procedures decreased our 


10 
\ 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 ± 04 
2 7 * 0,03 


-8,0 ± 0,04 
-3,4 ± 0,20 
1,3 ± 0,05 


-14 ± 03 
-9 ± 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 ± 00 
4,4 ± 0,03 


-5 6 ± 0,06 
-2,1 t 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* 04 
5.5 ± 0.04 
9 1 ± 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 ± 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* 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 * 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 


46 3 


486 


511 1 


1 


44 


46 4 


51 


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 





4 


4(1 


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 




769 j 706 


714 1 702 


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 
C arl H flfl fi 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 
iaHir P( * 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, j yiethod 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 5 L Vt @ 60 L/min using a 50% decelerating flow pattern 
E' was connected to the "patient lung" via a 6 ID and 8 ID endotrachea 
tube (Mallinckrodt), and a 7 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 ID ET tube and 7 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- 


00* 


580- 


21* 


162* 


-219* 


6 ET ATCoff 


2 26 


48 


460 


4 


195 


-26,6 


7 Tr ATCon 


1 53 


10# 


520# 


10# 


131 


-20 3 


7 Tr ATCoff 


167 


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 6 L V, @ peak flow of 50 
L/min at the ain«ay of the "patient" An 8 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 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* 


124* 


1 23* 


85* 


510* 


7200 FT 


12 


-15 6 


24 


1 64 


38 


118 


450 


E'ATC 


19# 


-14 3# 


11# 


1 54 


1 16# 


114 


570# 


E<FT 11 


-175 042 


1 76 


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 5 L V, @ peak flow of 30 Umin at the airway of the 'pi lung' A 8 ID 
high/low (Mallinckrodt) and standard 6 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 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 


17 


31 


5FT 


67 


27 


650* 


186* 


0.45* 


126* 


BFT 


54 


22 


700 


1.2 


0.20 


35 


SPT 


46 


25 


720 


67* 


35* 


68* 



'=p<0 05 versus all other triggering methods 
ET tube R was 6 6 and 21 1 cmHjO/L/sec for 8 and 6 ID respectively With 
addition of 8 fr FT, R increased to 1 1 7 and 50 7 cmH^O/Lysec for the 8 and 6 ID 
ET tubes respectively R was 8 9 and 31 1 cmH.O/L/sec with a 5 fr FT placed through 
the 8 and 6 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 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 Embe rq er 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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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/ 






# 



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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 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. 



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Seattle WA 98 104 

(206) 223-0558 (voice) 

(206) 223-0563 (fax) 

e-mail: icjournal@aarc.org 

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. 



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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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ai (561 ) 745-6793. Fax {561 ) 745-6795, e-mail: goldsbury@aarc.org, tor rates and media kits. For recruitmenty 
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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University of Rochester/Strong Memorial 801 

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of Daedalus HiUerprises Inc is prohibited. Permission to photocopy a single article in this 
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DiSLT.AIMKR. The opinions expressed in any article or editorial are those of the au- 
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the AARC. or the Publisher n;sponsible for the consequences of the clinical applications 
or use o! any methods or devices described in any article or advertisement. 

SUBSCRIPTION RATKS. Individual subscription rales are $75 per year ( 1 2 issues), 
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SUBSCRIPTION RATES FOR ASSOCIATIONS. Basic annual subscriptions are of- 
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For information, contact Ray Masferrer at (972) 243-2272. 

CHANGE OF ADDRESS. Notify the AARC at (972) 243-2272 as soon as possible of 
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MANUSCRIPTS. The Journal publishes clinical studies, method/device evaluations, 
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Oi/nriX'/it O / W.S. hy nimhius Eiuvrprm's Im. 



904 



RESPIKAIORY CARE • OCTOBER 1998 VOL 43 NO 10 



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