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AUGUST   2000 


A  MONTHLY  SCIENCE  JOURNAL 

44TH  YEAR— ESTABLISHED  1956 

EDITORIALS 

A.j\.  ^^ 

Medical  Trainee  Experience  Versus  Optimizing  Clinical  Outcomes 

J^ 

Observations  on  tiie  Utilization  of  Long-Term  Home  Oxygen 
Therapy  in  tiie  United  States 

46th  International  Respiratory  Congress 
October  7-10  •  Cincinnati,  Ohio 

ORIGINAL  CONTRIBUTIONS 

Impact  of  a  Respiratory  Therapy  Consult  Service  on 
House  Officers'  Knowledge  of  Respiratory  Care  Ordering 

CASE  REPORTS 

Benzocaine-Associated  IVIethemoglobinemia  Following  Bron- 
choscopy in  a  Healthy  Research  Participant 

SPECIAL  ARTICLES 

w 

Recommendations  of  the  Fifth  Oxygen  Consensus  Conference 

% 


2000  OPEN  FORUM  ABSTRACTS 


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RE/PIRATORy 
CtWE 


RESPIRATORY  CARE  (ISSN  0020-1324,  USPS  0489- 
190)  is  published  monthly  by  Daedaius  Enterprises  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  to  Nurs- 
ing and  Allied  Health  Literature.  EMBASE/Exerpta  Med- 
ica,  and  RNdex  Library  Edition.  Abridged  versions  of 
RESPIRATORY  CARE  are  also  published  in  Italian. 
French,  and  Japanese,  with  permission  from  Daedalus  En- 
terprises Inc. 

Periodicals  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. 
@  Printed  on  acid-free  paper. 
Printed  in  the  United  States  of  America 
Copyright  ©  2000.  by  Daedalus  Enterprises  Inc. 


AUGUST  2000  /  VOLUME  45  /  NUMBER  8 


EDITORIALS 


Medical  Trainee  Experience  Versus  Optimizing 
Clinical  Outcomes:  Achieving  the  Best  of  Both 

by  Marin  H  Kollef—St  Louis.  Missouri 

The  Utilization  of  Long-Term  Home  Oxygen  Therapy 

in  the  United  States:  A  Few  Observations  and  Some  Suggestions 

by  Patrick  J  Dunne — Fullerton,  California 

ORIGINAL  CONTRIBUTIONS 

The  Impact  of  a  Respiratory  Therapy  Consult  Service  on  House  Officers' 
Knowledge  of  Respiratory  Care  Ordering 

fcv  James  K  Stoller,  Irene  Thaggard — Cleveland,  Ohio, 

Craig  A  Piquette— Omaha,  Nebraska,  and  Ralph  G  O'Brien— Cleveland,  Ohio 


938 
940 


945 


CASE  REPORTS 


Benzocaine- Associated  Methemoglobinemia  Following 
Bronchoscopy  in  a  Healthy  Research  Participant 

by  Ware  G  Kuschner,  Rajinder  K  Chilkara,  James  Canfield  Jr,  Lourdes  M  Poblete-Coleman, 
Barbara  A  Cunningham,  and  Priscilla  SA  Sarinas — Palo  Alto,  California 


953 


SPECIAL  ARTICLES 


Recommendations  of  the  Fifth  Oxygen  Consensus  Conference 

fcv  Thomas  L  Petty — Denver.  Colorado  and  Richard  Casaburi  — Torrance,  California 
for  the  Writing  and  Organizing  Committees 


957 


DRUG  CAPSULES 


Introduction  of  a  Single  Isomer  Beta  Agonist 

by  Joseph  L  Rau — Atlanta,  Georgia 


962 


PFT  NUGGETS 


Pulmonary  Function  in  Obesity 

by  Brian  M  Legere  and  Mani  S  Kavuru — Cleveland,  Ohio 

Peak  Expiratory  Flow  vs  Spirometry  in  a  Patient  with  Asthma 

by  Prasoon  Jain — Clarksburg,  West  Virginia  and  Mani  S  Kavuru — Cleveland,  Ohio 


LETTERS 

Testing  Conditions  for  Nebulizers 

by  Dean  Iwasaki — Lakewood,  Colorado 

Response  by  S  David  Piper— West  Sacramento,  California 

Is  the  Health  Care  Financing  Administration  the 
Standard  of  Care  for  the  Oxygen-Dependent  Patient? 

by  Matthew  Daggett — Winston-Salem,  North  Carolina 

Response  by  Yuji  Oba  and  Gary  A  Salzman — Kansas  City,  Missouri 


967 
969 


971 


971 


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CONTINUED 


ALSO 
IN  THIS  ISSUE 


AARC  Membership 
1 039  Application 


BOOKS,  FILMS,  TAPES,  &  SOFTWARE 


912 

Abstracts  from 
Other  Journals 

1048 

Advertisers  Index 
&  Help  Lines 

1048 

Author 
Index 

1038 

Calendar 
of  Events 

1043 

Manuscript 
Preparation  Guide 

1041 

MedWatch 

1037 

New  Products 

Acute  Respiratory  Distress  Syndrome: 

A  Comprehensive  Clinical  Approach  (Russell  JA,  Walley  KR,  editors) 

reviewed  by  Phunsup  Wongsurakial — Seattle,  Washington 


1047 


Notices 


Complexity  in  Structure  and  Function  of  the  Lung 
(Hlastala  MP,  Robertson  HT,  editors) 
reviewed  by  John  J  Marini  and  John  R  Hotchkiss — St  Paul,  Minnesota 


Occupational  Lung  Disease: 

An  International  Perspective  (Banks  DE,  Parker  JE,  editors) 

reviewed  by  Dorsett  D  Smith — Seattle,  Washington 


Respiratory  Care  Calculations,  2nd  ed  (Chang  DW) 

reviewed  by  Will  Beachey — Bismarck,  North  Dakota 


OPEN  FORUM  ABSTRACTS  2000 

Introduction 
2000  Abstracts 
Author  Index 


AARC  INTERNATIONAL  RESPIRATORY  CONGRESS 

Congress  Exhibitors 


973 
974 

975 
976 

"978" 

979 

1030 


1034 


RE/PIRATORy 
Q^RE 


A  Monthly  Science  Journal 
Established  inl 956 

The  Official  Journal  of  the 

American  Association  for 

Respiratory  Care 


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EDITOR  IN  CHIEF 


AMonthly  Science  Journal 
Established  in  1956 

The  Official  Journal  of  the 

American  Association  for 

Respiratory  Care 


David  J  Pierson  MD  FAARC 

Harborview  Medical  Center 
University  of  Washington 
Seattle,  Washington 


ASSOCIATE  EDITORS 


Richard  D  Branson  RRT 
University  of  Cincinnati 
Cincinnati,  Ohio 


Charles  G  Durbin  Jr  MD 
University  of  Virginia 
Charlottesville,  Virginia 


EDITORIAL  BOARD 


Dean  R  Hess  PhD  RRT  FAARC 

Massachusetts  General  Hospital 
Harvard  University 
Boston,  Massachusetts 


James  K  Stoller  MD 

The  Cleveland  Clinic  Foundation 

Cleveland,  Ohio 


Alexander  B  Adams  MPH  RRT 

Regions  Hospital 
St  Paul.  Minnesota 


Thomas  A  Barnes  EdD  RRT 
FAARC 

Northeastern  University 
Boston,  Massachusetts 


Michael  J  Bishop  MD 
University  of  Washington 
Seattle,  Washington 


Bartolome  R  Celli  MD 

Tufts  University 
Boston,  Massachusetts 


Robert  L  Chatbum  RRT 
FAARC 

University  Hospitals  of  Cleveland 
Case  Western  Reserve  University 
Cleveland.  Ohio 


James  B  Fink  MS  RRT  FAARC 

Hines  VA  Hospital 
Loyola  University 
Chicago,  Illinois 


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 
FAARC 

Massachusetts  General  Hospital 
Harvard  University 
Boston,  Massachusetts 


Toshihiko  Koga  MD 
Koga  Hospital 
Kurume.  Japan 


Marin  H  KoUef  MD 

Washington  University 
St  Louis,  Missouri 


Patrick  Leoer  MD 
Clinique  Medicate  Edouard  Rist 
Paris,  France 


Neil  R  Maclntyre  MD  FAARC 

Duke  University 
Durham,  North  Carolina 


John  J  Marini  MD 

University  of  Minnesota 
St  Paul,  Minnesota 


Shelley  C  Mishoe  PhD  RRT 
FAARC 

Medical  College  of  Georgia 
Augusta,  Georgia 


Marcy  F  Petrini  PhD 

University  of  Mississippi 
Jackson,  Mississippi 


Joseph  L  Rau  PhD  RRT  FAARC 

Georgia  Stale  University 
Atlanta,  Georgia 


Catherine  SH  Sassoon  MD 

University  of  California  Irvine 
Long  Beach,  California 


John  W  Shigeoka  MD 

Veterans  Administration  Medical  Center 
Salt  Lake  City,  Utah 


Arthur  S  Slutsky  MD 

University  of  Toronto 
Toronto,  Ontario,  Canada 


Martin  J  Tobin  MD 

Loyola  University 
Chicago,  Illinois 


Jeffrey  J  Ward  MEd  RRT 

Mayo  Medical  School 
Rochester,  Minnesota 


Robert  L  Wilkins  PhD  RRT 

Loma  Linda  University 
Loma  Linda.  California 


STATISTICAL  CONSULTANT 

Gordon  D  Rubenfeld  MD 

University  of  Washington 
Seattle.  Washington 


Hugh  S  Mathewson  MD 
Joseph  L  Rau  PhD  RRT  FAARC 
Drug  Capsule 


Charles  G  Irvin  PhD 

Gregg  L  Ruppel  MEd  RRT  RPFT  FAARC 

PFT  Comer 


Richard  D  Branson  RRT 
Robert  S  Campbell  RRT  FAARC 
Kittredge's  Comer 


Jon  Nilsesnien  PhD  RRT  FAARC 
Ken  Hargett  RRT 
Graphics  Comer 


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


Abstracts 


Summaries  of  Pertinent  Articles  in  Other  Journals 


Editorials,  Commentaries,  and  Reviews  To  Note 

The  Pharmaceutical  Industry:  To  Whom  Is  It  Accountable? — Angel!  M.  N  Engl  J  Med  2000 
Jun  22;342(25):  1902- 1904. 

The  Acute  Chest  Syndrome  of  Sickle  Cell  Disease— Piatt  OS.  N  Engl  J  Med  2000  Jun  22; 
342(25):1904-1907. 

A  Persistent  Challenge:  The  Diagnosis  of  Respiratory  Disease  in  the  Non-AIDS  Immuno- 
compromised Host— Mayaud  C,  Cadranel  J.  Thorax  2000  Jun;55(6):511-517. 

Mycobacterium  Tuberculosis  Transmission  and  HIV  Status — Cayla  JA,  Garcia  de  Olalla  P, 
Galdos-Tanguis  H,  Vidal  R,  Lopez-Colomes  JL.  Lancet  2000  Jun  10;355(9220):2077-2078. 

Upper  Airway  Resistance  Syndrome  Is  Not  a  Distinct  Syndrome  (editorial) —  Douglas  NJ.  Am 
J  Respir  Grit  Care  Med  2000  May;161(5):14l3-1416. 

Upper  Airway  Resistance  Syndrome  Is  a  Distinct  Syndrome  (editorial) — Guilleminault  C, 
Chowdhuri  S.  Am  J  Respir  Crit  Care  Med  2000  May;161(5):  1412-1413. 

In  Defense  of  the  Stethoscope  and  the  Bedside — Weitz  HH,  Mangione  S.  Am  J  Med  2000  Jun 
1;108(8):669-671. 

Debunking  Myths  about  the  Hospitalist  Movement — Wachter  RM.  Am  J  Med  2000  Jun 
l;108(8):672-673. 

Images  in  Clinical  Medicine:  Elemental  Mercury  Embolism  to  the  Lung — Gutierrez  F,  Leon 
L.  N  Engl  J  Med  2000  Jun  15;342(24):1791. 

Abdominal  Compartment  Syndrome:  A  Century  Later,  Isn't  It  Time  to  Pay  Attention? — 

Ivatury  RR,  Sugerman  HJ.  Crit  Care  Med  2000  Jun;28(6):2137-2138. 

What  Is  Really  Important  to  Make  Noninvasive  Ventilation  Work — Brochard  L.  Crit  Care 
Med  2000  Jun;28(6):2 139-2 140. 

Endotracheal  Administration  of  Drugs  during  Cardiopulmonary  Resuscitation — Weil  MH, 
Tang  W.  Crit  Care  Med  2000  Jun;28(6):2144. 

Cost-Effectiveness  of  Noninvasive  Ventilation  for  Acute  Chronic  Obstructive  Pulmonary 
Disease:  Cashing  in  Too  Quickly— Jasmer  RM,  Matthay  MA.  Crit  Care  Med  2000  Jun;28(6): 
2170-2171. 

The  Efficacy  of  Nasal  Continuous  Positive  Airway  Pressure  in  the  Treatment  of  Obstructive 
Sleep  Apnea  Syndrome  Is  Proven — Davies  RJ,  Stradling  JR.  Am  J  Respir  Crit  Care  Med  2000 
Jun  1;161(6):1775-1776. 

The  Efficacy  of  Nasal  Continuous  Positive  Airway  Pressure  in  the  Treatment  of  Obstructive 
Sleep  Apnea  Syndrome  Is  Not  Proven — Wright  J,  Sheldon  T.  Am  J  Respir  Crit  Care  Med  2000 
Jun  1;1 61  (6):  1776- 1778. 

Clinicians  Should  Be  Proactive  in  Testing  for  Asthma  (editorial) — Wardlaw  AJ,  Pavord  ID. 
BMJ  1999  Jan  23;318(7178):258-259. 

Surfactant  Deficiency  in  Hyaline  Membrane  Disease:  The  Story  of  Discovery — Avery  ME. 
Am  J  Respir  Crit  Care  Med  2000  Apr;161(4  Pt  1):1074-1075. 


912 


Respiratory  Care  •  August  2000  Vol  45  No  8 


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Abstracts 


Preemptive  Gastrointestinal  Tract  Management  Reduces  Aspiration 
and  Respiratory  Failure  after  Thoracic  Operations — Roberts  JR,  Shyr 
Y.  Christian  KR,  Drinkwater  D,  Merrill  W.  J  Thorac  Cardiovasc  Surg 
2000Mar;ll9(3):449-452. 

OBJECTIVES:  Respiratory  failure  is  the  major  mode  of  death  after  gen- 
eral thoracic  operations.  However,  respiratory  failure  may  develop  from 
two  very  different  mechanisms:  aspiration,  often  caused  by  ileus,  and 
pneumonia,  which  often  results  from  poor  pain  control.  Epidural  cathe- 
ters help  control  pain  and  prevent  pneumonia  but  contribute  to  ileus  and 
may  increase  aspiration.  We  report  a  decrease  in  the  incidence  of  aspi- 
ration after  changing  postoperative  care  to  include  gastrointestinal  tract 
management.  METHODS:  All  patients  undergoing  elective  thoracotomy 
by  a  single  surgeon  were  evaluated  for  hospital  mortality  and  morbidity. 
For  the  first  21  months,  patients  did  not  receive  an  intraoperative  naso- 
gastric tube  and  were  prescribed  an  "advance  as  tolerated"  diet  after  the 
operation  (n  =  125).  For  the  second  period,  nasogastric  tubes  were 
placed  intraoperatively  and  patients  received  nothing  by  mouth  the  day  of 
operation,  clear  liquids  the  first  day,  and  a  regular  diet  the  second  day 
(n  =  153).  Pneumonia  was  considered  to  have  developed  if  infiltrates 
developed  in  a  single  lobe  or  two  adjoining  lobes  and  culture  of  the  sputa 
grew  a  dominant  organism.  Patients  were  considered  to  have  aspirated  if 
diffuse  infiltrates  developed  or  cultures  grew  multiple  organisms.  Sig- 
nificance of  results  was  determined  by  chi^  testing.  RESULTS:  A  total  of 
278  patients  underwent  elective  lung  resection  over  a  3.5-year  period, 
125  with  ad  libitum  dietary  management  and  153  with  intensive  man- 
agement of  the  gastrointestinal  tract.  Six  patients  (4.84%)  aspirated  be- 
fore the  institution  of  gastrointestinal  tract  management,  whereas  none 
(0.0%)  aspirated  after  the  change.  This  difference  was  significant  (p 
=0.01).  Respiratory  mortality  was  eliminated  in  the  group  with  gastro- 
intestinal tract  management  (p  =0.04).  CONCLUSIONS:  Aspiration  and 
its  subsequent  respiratory  failure  and  mortality  can  be  decreased  with 
preemptive  gastrointestinal  tract  management. 


Prediction  of  Difficult  Mask  Ventilation — Langeron  O,  Masso  E, 
Huraux  C,  Guggiari  M,  Bianchi  A,  Coriat  P,  Riou  B.  Anesthesiology 
2000  May;92(5):  1229-1 236. 

BACKGROUND:  Maintenance  of  airway  patency  and  oxygenation  are 
the  main  objectives  of  face-mask  ventilation.  Because  the  incidence  of 
difficult  mask  ventilation  (DMV)  and  the  factors  associated  with  it  are 
not  well  known,  we  undertook  this  prospective  study.  METHODS:  Dif- 
ficult mask  ventilation  was  defined  as  the  inability  of  an  unassisted 
anesthesiologist  to  maintain  the  measured  oxygen  saturation  as  measured 
by  pulse  oximetry  >  92%  or  to  prevent  or  reverse  signs  of  inadequate 
ventilation  during  positive-pressure  mask  ventilation  under  general  an- 
esthesia. A  univariate  analysis  was  performed  to  identify  potential  factors 
predicting  DMV,  followed  by  a  multivariate  analysis,  and  odds  ratio  and 
95%  confidence  interval  were  calculated.  RESULTS:  A  total  of  1,502 
patients  were  prospectively  included.  DMV  was  reported  in  75  patients 
(5%;  95%  confidence  interval,  3.9-6.1%),  with  one  case  of  impossible 
ventilation.  DMV  was  anticipated  by  the  anesthesiologist  in  only  13 
patients  (17%  of  the  DMV  cases).  Body  mass  index,  age,  macroglossia, 
beard,  lack  of  teeth,  history  of  snoring,  increased  Mallampati  grade,  and 
lower  thyromental  distance  were  identified  in  the  univariate  analysis  as 
potential  DMV  risk  factors.  Using  a  multivariate  analysis,  five  criteria 
were  recognized  as  independent  factors  for  a  DMV  (age  older  than  55  yr, 
body  mass  index  >  26  kg/m^,  beard,  lack  of  teeth,  history  of  snoring),  the 
presence  of  two  indicating  high  likelihood  of  DMV  (sensitivity,  0.72; 
specificity,  0.73).  CONCLUSION:  In  a  general  adult  population,  DMV 
was  reported  in  5%  of  the  patients.  A  simple  DMV  risk  score  was 
established.  Being  able  to  more  accurately  predict  DMV  may  improve 
the  safety  of  airway  management. 


Airway  Management  during  Spaceflight:  A  Comparison  of  Four  Air- 
way Devices  in  Simulated  Microgravity — Keller  C.  Brimacombe  J, 
Giampalmo  M,  Kleinsasser  A,  Loeckinger  A,  Giampalmo  G,  Piihringer 
F.  Anesthesiology  2000  May;92(5):  1237- 1241. 

BACKGROUND:  The  authors  compared  airway  management  in  normo- 
gravity  and  simulated  microgravity  with  and  without  restraints  for  laryn- 
goscope-guided tracheal  intubation,  the  cuffed  oropharyngeal  airway,  the 
standard  laryngeal  mask  airway,  and  the  intubating  laryngeal  mask  air- 
way. METHODS:  Four  trained  anesthesiologist-divers  participated  in  the 
study.  Simulated  microgravity  during  spaceflight  was  obtained  using  a 
submerged,  full-scale  model  of  the  International  Space  Station  Life  Sup- 
port Module  and  neutrally  buoyant  equipment  and  personnel.  Custom- 
ized, full-torso  manikins  were  used  for  performing  airway  management. 
Each  anesthesiologist-diver  attempted  airway  management  on  10  occa- 
sions with  each  device  in  three  experimental  conditions:  ( I )  with  the 
manikin  at  the  poolside  (poolside);  (2)  with  the  submerged  manikin 
floating  free  (free-floating);  and  (3)  with  the  submerged  manikin  fixed  to 
the  floor  using  a  restraint  (restrained).  Airway  management  failure  was 
defined  as  failed  insertion  after  three  attempts  or  inadequate  device  place- 
ment after  insertion.  RESULTS:  For  the  laryngoscope-guided  tracheal 
intubation,  airway  management  failure  occurred  more  frequently  in  the 
free-floating  (85%)  condition  than  the  restrained  (8%)  and  poolside  (0%) 
conditions  (both,  p  <  0.001).  Airway  management  failure  was  similar 
among  conditions  for  the  cuffed  oropharyngeal  airway  (poolside,  10%; 
free-floating,  15%;  restrained,  15%),  laryngeal  mask  airway  (poolside, 
0%;  free-floating,  3%;  restrained,  0%),  and  intubating  laryngeal  mask 
airway  (poolside,  5%;  free-floating,  5%;  restrained.  10%).  Airway  man- 
agement failure  for  the  laryngoscope-guided  tracheal  intubation  was  usu- 
ally caused  by  failed  insertion  (>  90%),  and  for  the  cuffed  oropharyngeal 
airway,  laryngeal  mask  airway,  and  intubating  laryngeal  mask  airway,  it 
was  always  a  result  of  inadequate  placement.  CONCLUSION:  The  em- 
phasis placed  on  the  use  of  restraints  for  conventional  tracheal  intubation 
in  microgravity  is  appropriate.  Extratracheal  airway  devices  may  be  use- 
ful when  restraints  cannot  be  applied  or  intubation  is  difficult. 


False  Alarms  and  Sensitivity  of  Conventional  Pulse  Oximetry  Versus 
the  Masimo  SET'"  Technology  in  the  Pediatric  Postanesthesia  Care 
Unit — Malviya  S,  Reynolds  PI.  Voepel-Lewis  T,  Siewert  M,  Watson  D, 
Tait  AR,  Tremper  K.  Ane.sth  Analg  2000  Jun;90(6):1336-1340. 

We  compared  the  incidence  and  duration  of  false  alarms  (FA)  and  the 
sensitivity  of  conventional  pulse  oximetry  (CPO)  with  Masimo  Signal 
Extraction  Technology '"  (Masimo  SET'";  Masimo  Corporation,  Irvine, 
CA)  in  children  in  the  postanesthesia  care  unit.  Disposable  oximeter 
sensors  were  placed  on  separate  digits  of  one  extremity.  Computerized 
acquisition  of  synchronous  data  included  electrocardiograph  heart  rate, 
Sp(,,,  and  pulse  rate  via  CPO  and  Masimo  SET.  Patient  motion,  respira- 
tory, and  other  events  were  simultaneously  documented.  S^o,  tracings 
conflicting  with  clinical  observations  and/or  documented  events  were 
considered  false.  These  were  defined  as  1)  Data  dropout,  complete  in- 
terruption in  Spo,  data;  2)  False  negative,  failure  to  detect  Spo,—  90% 
detected  by  another  device  or  based  on  observation/intervention;  3)  FA, 
c 


;  90%  considered  artifactual;  and  4)  True  alarm  (TA),  Sp<j,  <  90% 
considered  valid.  Seventy-five  children  were  monitored  for  35  ±  22 
min/patient  (42  h  total).  There  were  27  TAs,  all  of  which  were  identified 
by  Masimo  SET  and  only  16  (59%)  were  identified  by  CPO  (p  <  0.05). 
There  was  twice  the  number  of  FAs  with  CPO  (10  vs4  Masimo  SET;  p  < 
0.05).  The  incidence  and  duration  of  data  dropouts  were  similar  between 
Masimo  SET  and  CPO.  Masimo  SET  reduced  the  incidence  and  duration 
of  FAs  and  identified  a  more  frequent  incidence  of  TAs  compared  with 
CPO.  Implications:  Pulse  oximetry  that  incorporates  Masimo  Signal  Ex- 
traction Technology  (Masimo  Corporation,  Irvine,  CA)  may  offer  an 
advantage  over  conventional  pulse  oximetry  by  reducing  the  incidence  of 


916 


Respiratory  Care  •  August  2000  Vol  45  No  8 


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Techniques  for  Weaning  the  Ventilator  Patient — Weaning  patients  from  the  ventilator, 
both  inside  and  outside  the  hospital,  is  a  hot  topic  that  concerns  practitioners.  Learn  the  pros  and 
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differ,  and  the  differences  in  weaning  from  short-  and  long-term  mechanical  ventilation.  Also 
teaches  the  interpretation  of  measurements  used  in  predicting  ability  to  wean  and  the  main  causes 
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false  alarms  while  identifying  a  higher  number  of  true  alarms  in  children 
in  the  postanesthesia  care  unit. 

High  Frequency  Jet  Ventilation  in  Interventional  Fiberoptic  Bron- 
choscopy—Hautmann  H,  Gamarra  F,  Henke  M,  Diehm  S.  Huber  RM. 
Anesth  Analg  2000  Jun;90(6):  1436-1440. 

High  frequency  jet  ventilation  (HFJV)  is  a  well  accepted  method  for 
securing  ventilation  in  rigid  and  interventional  bronchoscopy.  We  de- 
scribe a  technique  of  HFJV  using  a  14F  nylon  insufflation  catheter  placed 
in  the  trachea  to  support  stent  implantation  or  endobronchial  balloon 
dilation  in  endobronchial  stenoses  with  the  flexible  fiberscope.  One  hun- 
dred sixty-one  cases  were  treated  with  either  a  metal  wire  stent  (n  =  105) 
or  with  balloon  dilation  (n  =  56).  In  addition  to  HFJV,  I.V.  anesthesia 
was  applied  in  132  cases.  Driving  pressure  was  1125-1275  mm  Hg, 
frequency  80-100/min,  and  inspiratory:expiratory  ratio  of  1:2.  Fraction 
of  inspired  oxygen  ranged  from  0.3-1.0.  The  effects  on  alveolar  venti- 
lation were  assessed  by  using  blood-gas  analysis  and  continuous  moni- 
toring of  transcutaneous  oxygen  and  carbon  dioxide  tension  (Pkco  )• 
Complications  consisted  of  hypertension  (n  =  8),  hypotension  (n  =  6), 
bronchospasm  (n  =  5),  and  hypoxia  (n  =  6).  In  52%  of  the  cases,  mild 
hypercarbia  (Pkco,  50-60mm  Hg)  was  observed.  In  two  cases,  a  P.ccoj 
>80mm  Hg  resolved  spontaneously  when  the  patients  returned  to  normal 
breathing  after  intermittent  superimposed  ventilation  with  a  face  mask. 
During  placement  of  stents  in  the  proximal  trachea,  the  jet  catheter  had 
to  be  withdrawn,  resulting  in  displacement  of  the  catheter  into  the  phar- 
ynx in  one  case,  which  was  managed  safely  with  the  bronchoscope.  In 
conclusion,  HFJV  achieves  satisfactory  operating  conditions  and  pro- 
vides adequate  gas  exchange  for  interventional  bronchoscopic  procedures 
with  the  fiberscope.  Implications:  Safe  ventilation  is  desired  when  per- 
forming tracheobronchial  stent  implantation  and  balloon  dilation  with  the 
fiberscope.  High  frequency  jet  ventilation,  applied  with  a  14F  insufflation 
catheter  through  the  nasotracheal  route,  offers  safe  ventilatory  support 
with  minimal  complications.  This  was  evaluated  in  161  procedures  treat- 
ing benign  and  malignant  airway  stenoses. 

The  Chronic  Ventilator-Dependent  Unit:  A  Lower-Cost  Alternative 
to  Intensive  Care — Gracey  OR,  Hardy  DC,  Koenig  GE.  Mayo  Clin  Proc 

2000  May;75{5):445-449. 

OBJECTIVE;  To  evaluate  the  fixed  costs  and  patient  outcomes  of  a 
specialty  hospital  unit  for  medically  stable  ventilator-dependent  patients. 
The  chronic  ventilator-dependent  unit  (CVDU)  was  established  to  facil- 
itate early  dismissal  from  costly  intensive  care  unit  (ICU)  hospitalization 
for  patients  requiring  continued  specialized  care.  PATIENTS  AND 
METHODS:  We  carried  out  a  cost  analysis  of  the  various  ICUs  that 
transferred  patients  to  the  CVDU  by  year  from  1993  through  1998.  In 
addition,  direct  and  indirect  costs  for  the  CVDU  were  established  by  year 
for  the  same  period.  We  then  calculated  the  cost  effect  of  transferring 
these  patients  for  care  from  each  high-cost  ICU  to  the  lower-cost  CVDU. 
Ventilator  weaning  and  mortality  rates  were  also  determined.  RESULTS: 
During  the  6  years  of  this  study,  $4,832,55 1  in  patient  care  costs  were 
saved  by  transferring  care  for  964  patients  froin  ICUs  to  the  CVDU. 
Ventilator  weaning  was  successful  in  64%  of  549  patients,  and  mortality 
was  7%  in  the  same  patient  group.  CONCLUSIONS:  Care  in  the  CVDU 
yielded  lower  fixed  costs  per  patient-day,  and  CVDU  care  was  compa- 
rable to  ICU  hospitalization. 

Incidence  of  Cardiac  Dysrhythmias  in  Patients  during  Pulmonary 
Artery  Catheter  Removal  after  Cardiac  Surgery — Baldwin  IC.  He- 
land  M.  Heart  Lung  2000  May-Jun;29(3):l55-160. 

OBJECTIVE:  No  published  studies  focus  on  determining  the  frequency 
of  dysrhythmias  during  pulmonary  artery  catheter  removal  by  use  of  a 
standard  technique.  The  objective  was  to  as.sess  the  incidence  and  he- 


918 


Respiratory  Care  •  August  2000  Vol  45  No  8 


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Abstracts 


modynamic  effect  of  dysrhythmias  in  patients  who  had  recently  under- 
gone cardiac  surgery  (within  24  hours  of  when  dysrhythmia  was  noted). 
METHODS:  The  study  used  an  electrocardiogram  recording  by  contin- 
uous rhythm  strip  during  removal  of  the  pulmonary  artery  catheter.  Pul- 
monary artery  catheters  were  removed  by  use  of  a  standard  procedure. 
Data  were  collected  with  respect  to  patients'  serum  potassium  levels, 
acid-base  status,  and  if  they  were  receiving  intravenous  antiarrhythmic  or 
inotropic  drugs  during  the  PAC  removal  procedure.  RESULTS:  One 
hundred  pulmonary  artery  catheters  were  removed,  with  the  following 
types  of  dysrhythmia  recorded:  2  patients  had  self-terminating  ventricular 
tachycardia  with  transient  hypotension:  1  patient  had  supraventricular 
tachycardia  without  hypotension;  13  patients  had  isolated  ventricular 
ectopic  dysrhythmia  without  hypotension;  2  patients  had  isolated  atrial 
ectopic  dysrhythmia  without  hypotension;  and  1  patient  had  isolated 
atrial  ectopic  dysrhythmia  and  3-beat  supraventricular  tachycardia  with- 
out hypotension.  CONCLUSION:  The  use  of  a  standard  technique  for 
pulmonary  artery  catheter  removal  demonstrated  a  2%  incidence  of  non- 
sustained  ventricular  tachycardia  associated  with  transient  hypotension. 
Fewer  incidences  of  dysrhythmias  were  noted  in  the  patients  (4  of  29) 
who  had  abnormal  serum  potassium  levels,  abnormal  pH,  or  pharmaco- 
logic association  during  catheter  removal  in  comparison  with  those  pa- 
tients without  this  association  (15  patients  of  71).  No  statistically  signif- 
icant difference  was  noted  in  the  incidence  of  dysrhythmia  during 
pulmonary  artery  catheter  removal  between  these  2  groups  (chi"  =  0.72, 
p  =0.39). 

A  Pilot  Study  Exploring  Mood  State  and  Dyspnea  in  Mechanically 
Ventilated  Patients — Connelly  B.  Gunzerath  L,  Knebel  A.  Heart  Lung 
2000  May-Jun;29(3):  173-179. 

OBJECTIVE:  The  objective  of  this  study  was  to  explore  preweaning 
mood  state  and  dyspnea  in  mechanically  ventilated  patients.  METHODS: 
Before  ventilatory  weaning,  21  critically  ill  patients  completed  the  short 
profile  of  mood  states  (higher  scores  equal  greater  disturbance),  and  a  10 
cm  dyspnea  visual  analogue  scale  (none  to  extremely  severe).  Weaning 
outcome  at  24  hours  was  recorded.  RESULTS:  The  mean  ±  SD  total 
mood  disturbance  (possible  range,  0  to  16)  and  subscale  scores  (possible 
range,  0  to  4)  were  as  follows:  total,  6.10  ±  4.06;  tension,  1.07  ±  0.64; 
depression,  1.16  ±  0.  93;  anger,  1.05  ±  0.82;  vigor,  1.04  ±  0.84;  fatigue, 
1,96  ±  0.  90;  and  confusion,  1.27  ±  0.91.  Mean  dyspnea  was  3.22  ± 
2.26  cm.  Dyspnea  intensity  correlated  negatively  with  vigor  (r  =  -0.38, 
p  <  0.  10).  Lower  preweaning  vigor  tended  to  differentiate  successful 
from  unsuccessful  weaning  (Mann-Whitney  U  =  22.0;  p  =  0.07).  CON- 
CLUSION: Patients  who  weaned  successfully  experienced  greater  mood 
disturbance.  Moderate  mood  disturbance  may  be  a  necessary  stimulus  for 
successful  weaning. 

Asthma  Education:  Creating  a  Partnership — Reinke  LF,  Hoffman  L. 
Heart  Lung  2000  May-Jun;29(3):225-236. 

This  article  advances  the  theory  that  the  key  to  creating  an  effective 
partnership  is  teaching  asthma  patients  what  to  self-treat,  how  to  self- 
treat,  and  when  to  consult  a  clinician.  The  five  comanaging  rules  that  the 
health  educator  is  encouraged  to  emphasize  with  the  adult  asthma  patient 
are:  know  your  own  unique  asthma  symptoms  and  triggers;  keep  written 
records;  see  appropriate  specialists;  know  your  medicines  and  follow 
your  action  plan;  and  accept  no  treatment  you  do  not  understand.  Current 
research  shows  asthma  to  be  a  chronic  inflammatory  disorder  of  the 
airways.  In  susceptible  individuals,  this  inflammation  causes  recurrent 
episodes  of  wheezing,  breathlessness,  chest  tightness,  and  cough,  partic- 
ularly at  night  and  in  the  early  morning.  The  stepwise  approach  to  asthma 
therapy  divides  asthma  into  several  levels  of  severity.  However,  patients 
at  any  level  of  severity  can  have  mild,  moderate,  or  severe  exacerbations. 
Asthma  triggers;  how  to  use  a  metered  dose  inhaler  (MDI),  a  dry  powder 
inhaler  (DPI),  and  a  peak  flow  meter;  and  how  to  follow  an  a.sthma  action 


plan  are  thoroughly  covered.  The  last  section  of  the  article  deals  at  length 
with  the  indications  for  and  actions  of  long-term-control  medications, 
used  to  achieve  and  maintain  control  of  persistent  asthma,  and  quick- 
relief  medications,  u.sed  to  treat  symptoms  and  exacerbations. 

Clinical  Auscultation  Skills  in  Pediatric  Residents — Gaskin  PR,  Owens 
SE,  Talner  NS,  Sanders  SP,  Li  JS.  Pediatrics  2000  Jun;105(6):l  184- 
1187. 

Objective.  The  aim  of  this  study  is  to  determine  the  level  of  clinical 
auscultation  skills  in  pediatric  residents  at  Duke  University  Medical  Cen- 
ter. Methods.  Forty-seven  residents  from  pediatrics  and  joint  medicine/ 
pediatrics  training  programs  at  Duke  University  Medical  Center  were 
enrolled  in  this  study.  They  were  asked  to  examine  the  cardiovascular 
patient  simulator,  Harvey,  and  report  their  findings.  Five  common  con- 
ditions seen  in  the  pediatric  population  were  presented:  ventricular  septal 
defect,  atrial  septal  defect,  pulmonary  valve  stenosis,  combined  aortic 
valve  stenosis  and  insufficiency,  and  innocent  systolic  ejection  murmur. 
The  responses  were  scored  by  the  number  of  features  and  diagnoses 
accurately  reported.  Five  pediatric  cardiologists  and  cardiologists  in  train- 
ing were  also  asked  to  participate  in  a  manner  similar  to  the  trainees. 
Results.  The  mean  score  of  features  identified  for  the  resident  group  was 
11.4  ±  2.6  of  a  possible  19.  The  diagnostic  accuracy  was  33%.  There  was 
no  significant  difference  between  residents  by  year  of  training  or  by  type 
of  residency  program,  although  there  was  a  trend  toward  improved  per- 
formance with  more  training.  The  difference  in  performance  between  the 
pediatric  cardiology  group  and  the  residents  group  was  striking.  The 
condition  that  was  most  frequently  misdiagnosed  was  the  innocent  sys- 
tolic ejection  murmur.  Conclusions.  The  clinical  auscultation  skills  of 
pediatric  residents  in  this  study  were  suboptimal.  There  was  a  trend 
toward  improvement  as  training  progressed,  although  not  statistically 
significant.  These  skills  are  likely  to  improve  further  with  increased 
exposure  to  patients  with  cardiovascular  disease  especially  in  the  ambu- 
latory care  setting. 

Do  Clinical  Markers  of  Barotrauma  and  Oxygen  Toxicity  Explain 
Interhospital  Variation  in  Rates  of  Chronic  Lung  Disease? — Van 

Marter  LJ,  Allred  EN,  Pagano  M,  Sanocka  U,  Parad  R,  Moore  M,  et  al. 
Pediatrics  2000  Jun;105(6):l  194-201. 

Objective.  To  explore  the  hypothesis  that  variation  in  respiratory  man- 
agement among  newborn  intensive  care  units  (NICUs)  explains  differ- 
ences in  chronic  lung  disease  (CLD)  rates.  Design.  Case-cohort  study. 
Setting.  NICUs  at  1  medical  center  in  New  York  (Babies"  and  Children's 
Hospital  [Babies'])  and  2  in  Boston  (Beth  Israel  Hospital  and  Brigham 
and  Women's  Hospital  [Boston]).  Study  Population.  Four  hundred  fifty- 
two  infants  bom  at  500  to  1500  g  birth  weight  between  January  1991  and 
December  1993,  who  were  enrolled  in  an  epidemiologic  study  of  neo- 
natal intracranial  white  matter  disorders.  Case  Definition.  Supplemental 
oxygen  required  at  36  weeks'  postmenstrual  age.  Results.  The  prevalence 
rates  of  CLD  differed  substantially  between  the  centers:  4%  at  Babies' 
and  22%  at  the  2  Boston  hospitals,  despite  similar  mortality  rates.  Initial 
respiratory  management  at  Boston  was  more  likely  than  at  Babies'  to 
include  mechanical  ventilation  (75%  vs  29%)  and  surfactant  treatment 
(45%  vs  10%).  Case  and  control  infants  at  Babies'  were  more  likely  than 
were  those  at  Boston  to  have  higher  partial  pressure  of  carbon  dioxide 
and  lower  pH  values  on  arterial  blood  gases.  However,  measures  of 
oxygenation  and  ventilator  settings  among  case  and  control  infants  were 
similar  at  the  2  medical  centers  in  time-oriented  logistic  regression  anal- 
yses. In  multivariate  logi.stic  regression  analy.ses,  the  initiation  of  me- 
chanical ventilation  was  associated  with  increased  risk  of  CLD:  after 
adjusting  for  other  potential  confounding  factors,  the  odds  ratios  for 
mechanical  ventilation  were  1 3.4  on  day  of  birth.  9.6  on  days  1  to  3,  and 
6.3  on  days  4  to  7.  Among  ventilated  infants,  CLD  risk  was  elevated  for 
maximum  peak  inspiratory  pressure  >25  and  maximum  fraction  of  in- 


920 


Respiratory  Care  •  August  2000  Vol  45  No  8 


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to  your  specific  goals.  When  you  implement  disease-specific  protocols  and  clinical 
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may  lessen  the  need  for  sedation  and  diagnostic  intervention.  When  you  continuously 
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Abstracts 


spired  oxygen  =  1 .0  on  the  day  of  birth,  lowest  pealc  inspiratory  pressure 
>20  and  maximum  partial  pressure  of  carbon  dioxide  >50  on  days  1  to 
3,  and  lowest  white  blood  count  <8  K  on  days  4  to  7.  Even  after 
adjusting  for  white  blood  count  <8  K  and  the  4  respiratory  care  vari- 
ables, infants  in  Boston  continued  to  be  at  increased  risk  of  CLD,  com- 
pared with  premature  infants  at  Babies'  Hospital.  Conclusion.  In  multi- 
variate analyses,  a  number  of  specific  measures  of  respiratory  care  practice 
during  the  first  postnatal  week  were  associated  with  the  risk  of  a  very 
low  birth  weight  infant  developing  CLD.  However,  after  adjusting  for 
baseline  risk,  most  of  the  increased  risk  of  CLD  among  very  low  birth 
weight  infants  hospitalized  at  2  Boston  NICUs,  compared  with  those  at 
Babies'  Hospital,  was  explained  simply  by  the  initiation  of  mechanical 
ventilation. 

First  Intention  High-Frequency  Oscillation  with  Early  Lung  Volume 
Optimization  Improves  Pulmonary  Outcome  in  Very  Low  Birth 
Weight  Infants  with  Respiratory  Distress  Syndrome — Rimensberger 
PC,  Beghetti  M,  Hanquinet  S,  Berner  M.  Pediatrics  2000  Jun;  105(6): 
1202-1208. 

Objectives.  The  lack  of  decline  in  chronic  lung  disease  of  prematurity 
despite  the  generalized  use  of  surfactant  and  alternative  modes  of  ven- 
tilation such  as  high-frequency  oscillation  (HFO)  has  been  attributed  to 
some  misunderstanding  of  how  HFO  has  to  be  used.  We  used  a  new 
ventilatory  strategy  in  very  low  birth  weight  (VLBW)  infants,  by  initi- 
ating HFO  immediately  after  intubation  and  attempting  early  lung  vol- 
ume optimization  before  surfactant  was  administered.  Study  Design.  The 
outcome  of  32  VLBW  infants,  managed  with  first  intention  HFO  over  a 
period  of  24  months  (September  1,  1996  and  August  31,  1998)  was 
compared  by  chart  review  with  39  historical  controls,  consecutively  man- 
aged with  conventional  mechanical  ventilation  (CMV)  over  a  period  of 
24  months  (January  I,  1994  and  December  31,  1995).  Setting.  An  1 1-bed 
tertiary  care  pediatric  and  neonatal  intensive  care  unit  of  a  university 
teaching  hospital.  Results.  The  2  groups  of  patients  were  similar  in  de- 
mographic distribution  of  birth  weight,  gestational  age,  race,  and  gender. 
Patients  on  first  intention  HFO  were  ventilator-dependent  (median  [95% 
confidence  interval]:  5  [3-6]  vs  14  [6-23]  days)  and  oxygen-dependent 
(12  [4-17]  vs51  [20-60]  days)  for  a  shorter  time  than  patients  on  CMV. 
The  incidence  of  chronic  lung  disease  at  36  weeks  of  gestational  age  was 
significantly  lower  in  the  HFO  group  compared  with  the  CMV  group  (0% 
vs  34%).  Conclusions.  First  intention  HFO  with  early  lung  volume  op- 
timization shortened  the  need  for  respiratory  support  and  improved  pul- 
monary outcome  of  VLBW  infants  with  respiratory  distress  syndrome 
significantly. 

Pulmonary  Outcome  in  Extremely  Low  Birth  Weight  Infants — 

Fitzgerald  DA,  Mesiano  G,  Brosseau  L,  Davis  GM.  Pediatrics  2000 
Jun;105(6):1209-1215. 

Objective.  To  determine  whether  infants  with  hyaline  membrane  disease 
(HMD)  superimposed  on  immature  lung  disease  (ILD)  have  more  ab- 
normal lung  function  and  respiratory  drive  during  the  evolution  of  chronic 
neonatal  lung  disease  (CNLD)  in  extremely  low  birth  weight  infants 
(ELBW;  <1000  g).  Methods.  We  measured  lung  mechanics  (respiratory 
frequency,  tidal  volume,  minute  ventilation,  lung  resistance,  lung  com- 
pliance, lung  impedance,  and  work  of  breathing  per  minute)  and  respi- 
ratory drive  (airway  opening  pressure  100  milliseconds  after  initiation  of 
breath  [Po  il  and  maximal  inspiratory  pressure  generated  during  airway 
occlusion)  on  3  occasions  before  term  in  24  ELBW  infants.  Results.  Ten 
infants  with  ILD  (mean  [95%  CI]  gestation:  24.3  weeks  [23.1,25.4];  birth 
weight:  675  g  [553,798])  were  studied  at  27,  3 1 ,  and  35  weeks  of  postcon- 
ceptional  age  and  14  infants  with  HMD  superimposed  on  ILD  (gestation: 
25.1  weeks  [24.4,25.9];  birth  weight:  687  g  [601,773])  were  studied  at 
28,  32,  and  35  weeks  of  postconceptional  age.  There  were  no  statistically 
significant  differences  between  the  groups  for  respiratory  frequency,  tidal 


volume,  minute  ventilation,  lung  resistance,  lung  compliance,  lung  im- 
pedance, work  of  breathing  per  minute,  Pq  ,,  and  maximal  inspiratory 
pressure  generated  during  airway  occlusion.  With  increasing  age,  both 
groups  demonstrated  increased  respiratory  drive  as  measured  by 
Po.i  without  significant  changes  in  respiratory  frequency  or  CO,.  Work  of 
breathing  per  minute  increased  in  the  HMD  group  with  age  and  was 
higher  in  extubated  subjects.  A  similar  trend  with  age  was  demonstrated 
in  ILD  infants.  Regardless  of  whether  the  initial  lung  disease  was  ILD 
alone  or  HMD  +  ILD,  ELBW  infants  developed  a  mildly  reduced  lung 
compliance/kg  (0.8-1.1  mL/cm.HiO/kg)  and  high  lung  resistance  (75- 
125  cm.HjO/L/second)  pattern  of  CNLD,  which  changed  little  after  3 
weeks  of  age.  Survival  to  6  months  was  23/24  (96%).  Oxygen  depen- 
dency was  16/24  (67%)  at  35  weeks,  yet  only  5/23  (22%)  survivors 
required  oxygen  at  discharge  from  the  neonatal  unit  (43  weeks).  Con- 
clusions. The  visco-elastic  and  flow-resistive  properties  of  the  lungs  in 
ELBW  infants  with  CNLD  remain  only  mildly  abnormal,  suggesting  a 
more  favorable  prognosis  for  lung  function  in  later  years  than  previously 
reported. 

An  Evaluation  of  an  Innovative  Multimedia  Educational  Software 
Program  for  Asthma  Management:  Report  of  a  Randomized,  Con- 
trolled Trial — Homer  C,  Susskind  O,  Alpert  HR,  Owusu  Ms.  Schneider 
L,  Rappaport  LA,  Rubin  DH.  Pediatrics  2000  Jul;106(l  Pt  2):210-215. 

BACKGROUND:  Asthma  continues  to  be  a  substantial  cause  of  mor- 
bidity in  pediatric  populations.  New  strategies  are  needed  to  provide 
cost-effective  educational  interventions  for  children  with  asthma,  partic- 
ularly those  in  the  inner  city.  OBJECTIVE:  To  assess  the  effectiveness  of 
a  multimedia  educational  software  program  about  asthma.  SETTING:  A 
hospital-based  primary  care  clinic  and  an  affiliated  neighborhood  health 
center.  DESIGN:  Randomized,  controlled  trial.  POPULATION:  Children 
3  to  12  years  old  with  physician-diagnosed  asthma.  INTERVENTION: 
An  interactive  educational  computer  program.  Asthma  Control,  designed 
to  teach  children  about  asthma  and  its  management.  Using  a  graphic 
display  of  a  child  going  through  simulated  daily  events,  the  game  em- 
phasizes: 1)  monitoring;  2)  allergen  identification;  3)  use  of  medications; 
4)  use  of  health  services;  and  5)  maintenance  of  normal  activity.  Control 
group  participants  reviewed  printed  educational  materials  with  a  research 
assistant.  OUTCOMES:  Acute  health  care  use  (emergency  department 
and  outpatient)  was  the  primary  outcome.  Secondary  outcome  measures 
included  maternal  report  of  asthma  symptom  severity,  child  functional 
status  and  school  absences,  satisfaction  with  care,  and  parental  and  child 
knowledge  of  asthma.  RESULTS:  A  total  of  1 37  families  were  enrolled 
in  the  study  (76  intervention,  61  control).  Both  intervention  and  control 
groups  showed  substantial  improvement  in  all  outcomes  during  the  12- 
month  follow-up  period.  Aside  from  improvement  in  knowledge  after  use 
of  the  computer  program,  no  differences  were  demonstrated  between  the 
2  groups  in  primary  or  secondary  outcome  measures.  Children  reported 
enjoyment  of  program  use.  CONCLUSIONS:  This  trial  of  an  educational 
software  program  found  that  it  did  not  produce  greater  improvement  than 
occurred  with  review  of  traditional  written  materials.  Because  both  groups 
showed  substantial  improvement  over  baseline,  computer-based  educa- 
tion may  be  more  cost-effective.  Alternatively,  improvements  in  illness 
severity  over  time  may  overshadow  the  effects  of  such  interventions. 
Rigorous  comprehensive  evaluations  such  as  this  are  necessary  to  assess 
new  interventions  intended  to  improve  management  and  outcomes  of 
asthma. 

Comparison  of  Premortem  Clinical  Diagnoses  in  Critically  III  Pa- 
tients and  Subsequent  Autopsy  Findings — Roosen  J,  Frans  E,  Wilmer 
A,  Knockaert  DC,  Bobbaers  H.  Mayo  Clin  Proc  2000  Jun;75(6):562-567. 

OBJECTIVE:  To  determine  whether  our  practice  of  requesting  an  au- 
topsy for  patients  who  die  in  the  medical  intensive  care  unit  (MICU) 
continues  to  be  a  valid  approach  to  obtain  clinically  and  educationally 


922 


Respiratory  Care  •  August  2000  Vol  45  No  8 


Fm  Breathing  easy... 
I'm  Protected. 

And,  with  protection  from  Seabury  &  Smith, 
you'll  be  breathing  easy  too. 

The  AARC-sponsored  Professional  Liability  Insurance  Program  for  Respiratory 
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•  Defense  Reimbursement:  up  to 

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# 


THE  AMERICAN  ASSOCIATION  FOR  RESPIRATORY  CARE 

Professional  Liability  Insurance  Application 


Chicago  Insurance  Company 


R  EMPLOYED  AARC  flPPUCJUJTS  ONLY 

^-employed  applicants:  please  contact  the  administrator  for  an  application. 


tE 

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JHESS 

If 

STATE 

ZIP 

m  DATE  (FOR  IDENTIFICAnON) 


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Q  First  Year  Graduate:  Date  of  Graduation □  S  45 

YOn  MUST  ANSWER  THESE  QUESTIONS 

1 )  Have  any  of  the  following  ever  tieen  revoked,  suspended,  refused,  denied  renewal, 
placed  on  probation,  cancelled  or  voluntarily  surrendered? 

(tf  "Yes",  explain  on  a  separate  sheet.  Please  include  dates  and  allegations.) 
State  License  or  Certification  Q  Yes      □  No 

Malpractice  Insurance**  Q  Yes      □  No 

**Notice  to  Missouri  residents:  This  question  does  not  apply. 

2)  Has  any  claim  or  suit  ever  t)een  brought  against  you,  or  are  you  aware  of  any  incident 
that  might  reasonably  lead  to  a  claim  or  suit? 

(If  "Yes",  explain  on  a  separate  sheet.  Please  include  dales,  allegations  and  amounts.) 

□  Yes       □  No 


I  understand  ihal  I  am  nol  covered  by  [his  insurance  if  I  am  any  of  the  following:  physician,  surgeon,  dentist,  nurse  midwife,  perfusionist,  electroneurodiagnostic  technologist,  cytotechnologist.  radiation  therapist. 
Tjpractor.  podiatrist,  osteopath  or  psychiatrist,  I  understand  that  these  professional  occupations  are  excluded  from  coverage,  I  understand  that  this  insurance  will  not  apply  to  any  partner,  principal  or  owner  of  a  residential/overnight 
tity.  The  insurance  described  herein  is  subject  to  the  terras,  conditions  and  exclusions  of  the  insurance  certificate.  This  insurance  is  excess  when  other  insurance  applies  to  a  loss. 

In  order  to  enhance  the  subility  of  this  professional  liabiUty  insurance  program,  coverage  has  been  organized  through  a  purchasing  group,  pursuant  to  legislation,  known  as  the  Federal  Liability  Risk  Retention  Act  of  1986, 
cted  by  Congress.  Coverage  is  provided  to  the  purchasing  group  by  the  Chicago  Insurance  Company,  a  member  of  Interstate  National  Corporation,  one  of  The  Fireman's  Fund  Insurance  Companies.  Once  the  completed 
lication  has  been  approved  and  the  premium  has  been  received,  you  will  automatically  become  a  member  of  the  Allied  Health  I*urchasing  Group  Association,  located  and  domiciled  in  Illinois  and  obtain  the  insurance  coverage 
)rded  through  the  Group  Policy  on  an  annual  term. 

This  application  is  subject  to  the  underwriter's  approval.  Your  completion  of  this  application  and  premium  payment  does  not  bind  coverage  or  obligate  the  insurance  company  to  issue  you  insurance  coverage.  Coverage  will 
ome  effective  following  the  receipt  of  your  acceptable  application  and  premium  payment.  Your  application  cannot  be  processed  unless  it  is  completed  in  its  entirety.  The  application  is  subject  to  the  company's  underwriting  rules. 

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1)  intent  to  defraud  any  insurance  company  or  other  person  files  an  application  for  insurance  containing  any  false  information,  or  conceals,  for  the  purpose  of  misleading,  information  concerning  any  fact  material  thereto,  commits 
audulent  insurance  act. 

Notice  to  New  Vorlt  .Applicants:  any  person  who  knowingly  and  with  intent  to  defraud  any  insurance  company  or  other  person  files  an  application  for  insurance  or  statement  of  claim  containing  any  materially  false 
irmation.  or  conceals  for  the  purpose  of  misleading,  information  concerning  any  fact  material  thenito,  commits  a  fraudulent  insurance  act  which  is  a  crime,  and  shall  also  be  subject  to  a  civil  penalty  not  to  exceed  five  thousand 
lars  and  the  stated  value  of  the  claim  for  each  such  violation. 


.  Date  _ 


.  Enclosed  is  my  check  for  _ 


EfTective  Date  Desired*_ 


lay  nol  be  earlier  than  the  dale  the  adminislrator  receives  and  accepts  this  application.  Make  check  payable  to  appropriate  administrator  Return  your  check  and  this  application  to  administrator 


town  below. 


For  all  resident.^  except  Ohio: 

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75  Remittance  Drive,  Suite  1788 

P.O.  Box  N 

Chicago.  IL  60690-9555 

1-800-621-3008,  ext.  45105 


Ohio  residents  to: 

Maginnis  &  Associates  Agency  of  Ohio 

P.O.  Box  543 

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Administered  by  Seabury  &  Smith 
Underwritten  by  Chicago  Insurance  Company, 
a  member  of  the  Interstate  National 
Corporation,  one  of  the  Fireman's  Fund 
Insurance  Companies. 

CA-OP 


Abstracts 


relevant  flndings.  METHODS:  In  this  retrospective  study  conducted  in 
an  adult  MICU  population  of  a  university  hospital,  the  clinical  diagnoses 
and  postmortem  major  diagnoses  of  100  patients  who  died  in  1996  (au- 
topsy rate  of  93%)  were  compared.  RESULTS:  Eighty-one  percent  of  the 
clinical  diagnoses  were  confirmed  at  autopsy.  In  16%,  autopsy  findings 
revealed  a  major  diagnosis  that,  if  known  before  death,  might  have  led  to 
a  change  in  therapy  and  prolonged  .survival  (class  1  missed  major  diag- 
noses). The  most  frequent  class  1  missed  major  diagnoses  were  fungal 
infection,  cardiac  tamponade,  abdominal  hemorrhage,  and  myocardial 
infarction.  Another  10%  of  autopsies  revealed  a  diagnosis  that,  if  known 
before  death,  would  probably  not  have  led  to  a  change  in  therapy  (class 
II  error).  CONCLUSIONS:  Autopsy  remains  an  important  tool  for  edu- 
cation and  quality  control.  In  contrast  with  historical  series  of  1  to  2 
decades  ago,  there  is  a  clear  shift  in  the  type  of  class  I  missed  major 
diagnoses  toward  opportunistic  infections.  Bedside-applicable  techniques 
such  as  electrocardiography  with  supplemental  posterior  leads,  echocar- 
diography, and  meticulous  abdominal  ultrasonography  might  improve 
the  outcome  in  selected  MICU  patients. 

Pulmonary  Hypertension:  Diagnostics  and  Therapeutics — Krowka 
MJ.  Mayo  Clin  Proc  2000  Jun;75(6):625-630. 

Pulmonary  hypertension  (PH)  may  develop  because  of  a  spectrum  of 
insults  to  the  lungs;  in  some  patients,  there  seems  to  be  no  cause.  Non- 
invasive tests,  such  as  standard  chest  radiography,  electrocardiography, 
and  transthoracic  Doppler  echocardiography,  provide  effective  screening 
if  PH  is  suspected.  This  synopsis  focuses  on  these  screening  studies  and 
the  more  common  clinical  problems,  including  primary  cardiac  abnor- 
malities, obstructive  sleep  apnea,  chronic  pulmonary  embolism,  pulmo- 
nary parenchymal  problems,  connective  tissue  disorders,  cirrhosis  with 
portal  hypertension,  and  u.se  of  appetite  suppressants,  that  should  be 
considered  when  PH  exists.  Treatment  options  for  PH,  including  intra- 
venous prostacyclin  (epoprostenol),  and  investigational  agents  such  as 
subcutaneous  or  oral  prostacyclin  analogues  and  oral  endothelin  receptor 
antagonists  are  described. 

Noninvasive  Positive  Pressure  Ventilation  in  the  Setting  of  Severe, 
Acute  Exacerbations  of  Chronic  Obstructive  Pulmonary  Disease: 
More  Effective  and  Less  Expensive — Keenan  SP,  Gregor  J,  Sibbald 
WJ,  Cook  D,  Gafni  A.  Crit  Care  Med  2000  Jun;28(6):2094-2102. 

OBJECTIVE:  The  use  of  noninvasive  ventilation  for  patients  with  acute 
respiratory  failure  has  become  increasingly  popular  over  the  last  decade. 
Although  the  literature  provides  good  evidence  for  the  effectiveness  of 
noninvasive  ventilation  in  addition  to  standard  therapy  compared  with 
standard  therapy  alone  in  patients  with  chronic  obstructive  pulmonary 
disease  (avoiding  intubation  and  improving  hospital  mortality),  the  as- 
sociated costs  have  not  been  rigorously  measured.  Adding  noninvasive 
positive  pressure  ventilation  (NPPV)  to  standard  therapy  in  the  setting  of 
a  severe,  acute  exacerbation  of  chronic  obstructive  pulmonary  disease 
(COPD)  in  patients  with  respiratory  acidosis  who  are  at  high  risk  of 
requiring  endotracheal  intubation  is  both  more  effective  and  less  expen- 
sive. DESIGN:  Economic  evaluation  based  on  theoretical  model.  SET- 
TING: This  analysis  base  case  was  modeled  for  a  tertiary  care,  teaching 
hospital.  PATIENTS  OR  OTHER  PARTICIPANTS:  Carefully  selected 
patients  with  severe  exacerbations  of  COPD.  INTERVENTION:  The  two 
alternative  therapies  compared  were  standard  therapy  (oxygen,  broncho- 
dilators,  steroids,  and  antibiotics)  and  standard  therapy  plus  NPPV.  MEA- 
SUREMENTS AND  MAIN  RESULTS:  As  the  hypothesis  was  domi- 
nance, the  main  outcomes  modeled  and  calculated  were  costs,  mortality 
rale,  and  rates  of  intubation  between  the  two  interventions.  To  determine 
clinical  effectiveness,  we  used  a  meta-analysis  of  randomized  trials  eval- 
uating the  impact  of  NPPV  on  hospital  survival.  A  decision  tree  was 
constructed  and  probabilities  were  applied  at  each  chance  node  using 
research  evidence  and  a  comprehensive  regional  databa.se.  To  provide 


data  for  this  economic  evaluation,  MEDLINE  literature  .searches  were 
conducted.  Bibliographies  of  relevant  articles  were  reviewed,  as  were 
personal  files.  To  estimate  the  costs  of  the  alternative  therapeutic  ap- 
proaches, eight  types  of  hospitalization  days  were  costed  using  the  Lon- 
don Health  Sciences  Center  costing  data.  Sensitivity  analyses  were  per- 
formed, varying  all  assumptions  made.  The  meta-analysis  yielded  an 
odds  ratio  for  hospital  mortality  in  the  NPPV  arm,  compared  with  stan- 
dard therapy,  of  0.22  (95%  confidence  interval,  0.10-0.66).  By  using 
baseline  case  as.sumptions,  we  found  a  cost  savings  of  $3,244  (1996, 
Canadian),  per  patient  admission,  if  NPPV  were  adopted  in  favor  of 
standard  therapy.  These  findings  present  a  scenario  of  clear  dominance 
for  treatment  with  NPPV.  Sensitivity  analyses  did  not  alter  the  results 
appreciably.  CONCLUSIONS:  We  conclude  that  from  a  hospital's  per- 
spective, NPPV  and  standard  therapy  for  carefully  selected  patients  with 
acute,  severe  exacerbations  of  COPD  are  more  effective  and  less  expen- 
sive than  standard  therapy  alone. 

Effect  of  Inhaled  Nitric  Oxide  on  Key  Mediators  of  the  Inflammatory 
Response  in  Patients  with  Acute  Lung  Injury — Cuthbertson  BH,  Gal- 
ley HF.  Webster  NR.  Crit  Care  Med  2000  Jun;28(6):  1736- 1741. 

OBJECTIVE:  Inhaled  nitric  oxide  is  used  to  treat  hypoxia  associated 
with  acute  lung  injury.  Endogenous  nitric  oxide  regulates  infiammatory 
responses,  but  the  effect  of  inhaled  nitric  oxide  therapy  is  unknown.  We 
hypothesized  that  inhaled  nitric  oxide  may  alter  inflammatory  responses 
and  endogenous  nitric  oxide  synthase  activity.  DESIGN:  A  randomized, 
prospective  interventional  study.  SETTING:  A  university  hospital's  gen- 
eral intensive  care  unit.  PATIENTS:  Thirty-two  patients  with  acute  lung 
injury.  INTERVENTIONS:  Patients  who  responded  to  test  doses  of  nitric 
oxide  were  randomized  to  ventilator  therapy  with  and  without  inhaled 
nitric  oxide.  The  inhaled  concentration  of  nitric  oxide  was  determined  by 
dose  titration  at  0,  2,  10,  and  40  ppm  and  the  minimum  concentration 
used,  which  resulted  in  an  increase  in  the  P.,o,/Fiot  r^tio  of  at  least  25%. 
MEASUREMENTS  AND  MAIN  RESULTS:" Patients  were  followed  up 
for  30  days  or  until  death,  and  bronchoalveolar  lavage  (BAL)  was  per- 
formed at  0,  24,  and  72  hrs.  Nitric  oxide  synthase  activity  was  measured 
spectrophotometrically,  and  myeloperoxidase,  elastase,  interleukin-8,  and 
leukotrienes  were  measured  in  BAL  fluid  by  enzyme  immunoassay.  To- 
tal nitrite  and  lipid  peroxides  in  serum  were  measured  colorimetrically. 
Nitric  oxide  synthase  activity  decreased  (p  =  0.01)  and  total  nitrite 
increased  (p  =  0.02)  in  patients  receiving  inhaled  nitric  oxide.  Other 
markers  of  inflammation  in  BAL  fluid  did  not  change.  Lipid  peroxide 
concentrations  also  did  not  alter.  CONCLUSIONS:  The  decrease  in  ac- 
tivity of  nitric  oxide  synthase  in  patients  receiving  nitric  oxide  is  likely 
to  be  the  result  of  feedback  inhibition  of  the  enzyme.  This  study  shows 
that  inhaled  nitric  oxide  has  no  effect  on  several  markers  of  the  inflam- 
matory response  system  and  does  not  lead  to  increased  oxidant  stress. 

The  Incidence  of  Ventilator-Associated  Pneumonia  and  Success  in 
Nutrient  Delivery  with  Gastric  versus  Small  Intestinal  Feeding: 
A  Randomized  Clinical  Trial — Keams  PJ,  Chin  D,  Mueller  L,  Wallace 
K,  Jensen  WA.  Kirsch  CM.  Crit  Care  Med  2000  Jun;28(6):l742-1746. 

BACKGROUND:  Enteral  feeding  provides  nutrients  for  patients  who 
require  endotracheal  tubes  and  mechanical  ventilation.  There  is  a  pre- 
sumed increase  in  the  risk  of  ventilator-associated  pneumonia  (VAP) 
with  tube  feeding.  This  has  stimulated  the  development  of  procedures  for 
duodenal  intubation  and  small  intestinal  (SI)  feeding  as  primary  prophy- 
laxes to  prevent  VAP.  OBJECTIVE:  To  investigate  the  rate  of  VAP  and 
adequacy  of  nutrient  delivery  with  gastric  (G)  vs.  SI  feeding.  DESIGN: 
A  prospective,  randomized,  controlled  trial.  SETTING:  A  medical  inten- 
sive care  unit  of  a  county  hospital.  PATIENTS:  A  total  of  44  endotra- 
cheally  intubated,  mechanically  ventilated  patients  requiring  enteral  nu- 
trition. INTERVENTION:  Subjects  were  randomized  to  receive  enteral 
nutrition  via  G  or  SI  feeding.  Protocols  directed  the  placement  of  the 


924 


Respiratory  Care  •  August  2000  Vol  45  No  8 


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the  American  Respiratory  Care  FoiiiiflatiQii  needs  your  iieip 
I  once  again  by  malting  donations  for  tlie  Fonrtii  Annual 
nient/Liye  Auction.  Any  donation,  wlietlier  it*s  in  the  form  ot 

a  gift  certificate,  artwork,  respiratory  equipment, 

memorahilia  or  a  cash  donation,  would  he  most  appreciated. 

Rememher,  all  donations  are  tax  deductihie. 

The  ARCF  relies  on  your  generous  contrihutions  each  year. 

Your  donation  enahles  the  Foundation  to  continue  henefiting 

patients  and  therapists  worldwide  in  the  areas  of 

research,  educational  programs,  and  health  promotion. 

The  auction  will  begin  on  our  web  site,  www.aaro.ifi, 

and  conclude  at  the  AARC  46th  International  Respiratory 

Congress,  Oct.  7-10,  in  Cincinnati,  Ohio. 


For  more  information,  please  contact  Diane  Shearer 
at  (972)  243-2272  or  by  e-mail  at  shearer@aarc.org 


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Some   leaks   you   can't  compensate  for 

[others   you   can; 


Studies  show  that  nearly  100%  of  bilevel  patients 
experience  mouth  leaiis'  These  ieaiis  interfere  with 
the  triggering  sensitivity  of  most  bilevel  units, 
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0     patient's  own  intrinsic  inspiratory 
I  time.  Other  bilevel  units  try  to 

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*Me)cr  1}.  eLaL  Air  Leakijig  Itirough  the  Mouth  during  NocturnaJ  Nasal  Veniilation 
Ota  on  Sleep  Qtiality.  Sleep  1997;  20  (7):  561-9. 

io2»i9906  ResMed  Corp       usreception@resmed.com 

(800)  424-0737     www.resmed.com 

Circle  136  on  product  info  card 

Visit  AARC  Booth  569  in  Cincinnati 


Abstracts 


feeding  tube  and  the  infusion  of  enteral  nutrition  and  defined  the  radio- 
graphic and  clinical  criteria  for  a  diagnosis  of  VAP.  MEASUREMENTS 
AND  OUTCOMES:  The  incidence  of  VAP  and  the  adequacy  of  nutri- 
tional supplementation  were  prospectively  followed.  The  relative  risk  of 
VAP  with  SI  was  1.1  (95%  confidence  interval  0.96-2.44)  compared  with 
G.  The  SI  group  received  a  greater  percentage  of  their  caloric  require- 
ments (SI  69  ±  7%  vs.  G  47  ±  7%,  mean  ±  SEM,  p  <  0.05).  Mortality 
did  not  differ  between  G  (26  ±  9%)  and  SI  (24  ±  10,  p  =  0.86). 
CONCLUSIONS:  There  is  no  clear  difference  in  the  incidence  of  VAP 
in  SI  compared  with  G  enteral  nutrition.  Patients  given  feeding  into  the 
SI  do  receive  higher  calorie  and  protein  intakes. 

Tolerance,  Withdrawal,  and  Physical  Dependency  after  Long-Term 
Sedation  and  Analgesia  of  Children  in  the  Pediatric  Intensive  Care 

Unit— Tobias  JD.  Crit  Care  Med  2000  Jun;28(6):2122-2132. 

OBJECTIVE:  To  describe  the  consequences  of  the  prolonged  adminis- 
tration of  sedative  and  analgesic  agents  to  the  pediatric  intensive  care  unit 
(PICU)  patient.  The  problems  to  be  investigated  include  tolerance,  phys- 
ical dependency,  and  withdrawal.  DATA  SOURCES:  A  MEDLINE  search 
was  performed  of  literature  published  in  the  English  language.  Cross- 
reference  searches  were  performed  using  the  following  terms:  sedation, 
analgesia  with  PICU,  children,  physical  dependency,  withdrawal;  toler- 
ance with  sedative,  analgesics,  benzodiazepines,  opioids,  inhalational 
anesthetic  agents,  nitrous  oxide,  ketamine,  barbiturates,  propofol,  pento- 
barbital, phenobarbital.  STUDY  SELECTION:  Studies  dealing  with  the 
problems  of  tolerance,  physical  dependency,  and  withdrawal  in  children 
in  the  PICU  population  were  selected.  DATA  EXTRACTION:  All  of  the 
above-mentioned  studies  were  reviewed  in  the  current  manuscript.  DATA 
SYNTHESIS:  A  case  by  case  review  is  presented,  outlining  the  reported 
problems  of  tolerance,  physical  dependency,  and  withdrawal  after  the  use 
of  sedative/analgesic  agents  in  the  PICU  population.  This  is  followed  up 
by  a  review  of  the  literature  discussing  current  treatment  options  for  these 
problems.  CONCLUSIONS:  Tolerance,  physical  dependency,  and  with- 
drawal can  occur  after  the  prolonged  administration  of  any  agent  used  for 
sedation  and  analgesia  in  the  PICU  population.  Important  components  in 
the  care  of  such  patients  include  careful  observation  to  identify  the  oc- 
currence of  withdrawal  signs  and  symptoms.  Treatment  options  after 
prolonged  administration  of  sedative/analgesic  agents  include  slowly  ta- 
pering the  intravenous  administration  of  these  agents  or,  depending  on 
the  drug,  switching  to  subcutaneous  or  oral  administration. 

Physiologic  Evaluation  of  Noninvasive  Mechanical  Ventilation  De- 
livered with  Three  Types  of  Masks  in  Patients  with  Chronic  Hyper- 
capnic  Respiratory  Failure — Navalesi  P,  Fanfulla  F,  Frigerio  P,  Gre- 
goretti  C,  Nava  S.  Crit  Care  Med  2000  Jun;28(6):  1785-1790. 

OBJECTIVE:  The  efficacy  of  noninvasive  mechanical  ventilation  (NIMV) 
in  improving  breathing  pattern  and  arterial  blood  gases  (ABG)  in  hyper- 
capnic  patients  has  been  well  documented;  however,  little  attention  has 
been  given  to  the  choice  of  the  interface  and  the  ventilatory  mode.  We 
evaluated  the  effects  of  three  types  of  masks  and  two  modes  of  ventila- 
tion on  patients'  ABG,  breathing  pattern,  and  tolerance  to  ventilation. 
DESIGN:  Prospective  randomized  study.  SETTING:  Two  respiratory 
weaning  centers.  PATIENTS:  A  total  of  26  stable  hypercapnic  patients 
(pH,  7.38  ±  0.04;  P^coj.  59.2.  ±  10.9  torr)  had  not  received  NIMV  and 
were  affected  by  restrictive  thoracic  disease  or  obstructive  pulmonary 
disea.se.  INTERVENTIONS:  Three  30-min  runs  of  NIMV,  delivered 
using  volume-assisted  (n  =  13)  or  pressure-assisted  modes  of  partial 
mechanical  support  (n  =  13),  were  performed  in  random  order  with  a 
full-face  mask,  a  nasal  mask,  and  nasal  plugs.  MEASUREMENTS:  ABG, 
breathing  pattern,  and  patients'  tolerance  to  ventilation.  MAIN  RESULTS: 
Compared  with  spontaneous  breathing,  the  application  of  NIMV  signif- 
icantly improved  ABG  and  minute  ventilation,  irrespective  of  the  venti- 
latory mode,  the  underiying  pathology  or  the  type  of  mask.  Overall,  a 


nasal  mask  was  better  tolerated  than  the  other  two  interfaces  (p  <  0.005 
vs.  nasal  plugs  and  full-face  mask).  P„co,  was  significantly  lower  (p  < 
0.01 )  with  a  full-face  mask  or  nasal  plugs  than  with  a  nasal  mask  (49.5  ± 
9.4  torr,  49.7  ±  8  torr,  and  52.4  ±  1 1  torr,  respectively).  Minute  venti- 
lation was  significantly  higher  with  a  full-face  mask  than  with  a  nasal 
mask  because  of  an  increase  in  tidal  volume.  No  differences  were  ob- 
served in  tolerance  to  ventilation,  ABG,  or  breathing  pattern,  using  assist 
control  or  pressure-assisted  modes.  CONCLUSIONS:  In  this  physiologic 
study,  we  have  shown  that  in  patients  with  hypercapnic  respiratory  fail- 
ure, irrespective  of  the  underlying  pathology,  the  type  of  interface  affects 
the  NIMV  outcome  more  than  the  ventilatory  mode. 

Physiologic  Effects  of  Early  Administered  Mask  Proportional  Assist 
Ventilation  in  Patients  with  Chronic  Obstructive  Pulmonary  Disease 
and  Acute  Respiratory  Failure — Vitacca  M,  Clini  E,  Pagani  M,  Bian- 
chi  L,  Rossi  A.  Ambrosino  N.  Crit  Care  Med  2000  Jun;28(6):  1791 -1797. 

OBJECTIVE:  To  evaluate  the  physiologic  short-term  effects  of  nonin- 
vasive proportional  assist  ventilation  (PAV)  in  patients  with  acute  exac- 
erbation of  chronic  obstructive  pulmonary  disease  (COPD).  DESIGN: 
Prospective,  physiologic  study.  SETTING:  Respiratory  intermediate  in- 
tensive care  unit.  PATIENTS:  Seven  patients  with  acute  respiratory  fail- 
ure requiring  noninvasive  mechanical  ventilation  because  of  exacerbation 
of  COPD.  INTERVENTIONS:  PAV  was  administered  by  nasal  mask  as 
first  ventilatory  intervention.  The  setting  of  PAV  involved  a  procedure  to 
adjust  volume  assist  and  flow  assist  to  levels  corresponding  to  patient 
comfort.  Volume  assist  was  also  set  by  means  of  the  "run-away"  proce- 
dure. Continuous  positive  airway  pressure  (CPAP)  amounting  to  2  cm 
HjO  was  always  set  by  the  ventilator.  This  setting  of  assistance  (PAV) 
was  applied  for  45  mins.  Thereafter,  CPAP  was  increased  to  5  cm  HjO 
(PAV  -I-  CPAP-5)  without  any  change  in  the  PAV  setting  and  was 
administered  for  20  mins.  Oxygen  was  delivered  through  a  port  of  the 
mask  in  the  attempt  to  maintain  a  target  S,|0,  >  90%.  MEASURE- 
MENTS AND  MAIN  RESULTS:  Arterial  blood  ga,ses,  breathing  pattern, 
and  inspiratory  effort  were  measured  during  unsupported  breathing  and  at 
the  end  of  PAV,  and  breathing  pattern  and  inspiratory  effort  were  mea- 
sured after  20  mins  of  PAV  +  CPAP-5.  PAV  determined  a  significant 
increase  in  tidal  volume  and  minute  ventilation  (-1-64%  and  4-25%  on 
average,  respectively)  with  unchanged  breathing  frequency  and  a  signif- 
icant improvement  in  arterial  blood  gases  (P  „o2  w'th  the  same  oxygen 
supply,  from  65  ±  15  torr  to  97  ±  36  torr;  Paco,'  f™"!  80  ±  1 1  torr  to 
76  ±  13  torr;  pH,  from  7.30  ±  0.02  to  7.32  ±  o'03).  The  pressure-time 
product  calculated  over  a  period  of  1  min  (from  318  ±  87  to  205  ±  145 
cm  H2O  X  sec  X  min ')  was  significantly  reduced.  PAV  -I-  CPAP-5 
resulted  in  a  further  although  not  significant  decrease  in  the  pressure-time 
product  calculated  over  a  period  of  1  min  (to  1 83  ±  1 10  cm  HjO  X  sec  X 
min"'),  without  additional  changes  in  the  breathing  pattern.  CONCLU- 
SIONS: Noninva.sive  PAV  is  able  to  improve  arterial  blood  gases  while 
unloading  inspiratory  muscles  in  patients  with  acute  exacerbation  of 
COPD. 

Endotracheal  versus  Intravenous  Epinephrine  and  Atropine  on  Out- 
of-Hospital  "Primary"  and  Postcountershock  Asystole — Niemann  JT, 
Stratton  SJ.  Crit  Care  Med  2000  Jun;28(6):1815-1819. 

STUDY  OBJECTIVE:  Pulmonary  blood  flow  during  cardiac  arrest  and 
cardiopulmonary  resuscitation  (CPR)  is  <  20%  of  normal,  and  transal- 
veolar  drug  absorption  is  likely  to  be  minimal.  Animal  and  clinical  CPR 
studies  have  not  addressed  the  use  of  endotracheal  (ET)  epinephrine  in 
doses  currently  recommended  for  adults  (twice  the  intravenous  dose). 
The  purpose  of  this  study  was  to  compare  the  effects  of  ET  and  intra- 
venous drugs  on  cardiac  rhythm  in  the  prehospital  setting.  DESIGN:  A 
3-yr  (1995-1997)  retrospective  review  of  all  cardiac  arrests  transported  to 
a  single,  municipal  teaching  institution  was  performed.  PATIENTS:  Pa- 
tients >  1 8  yrs  in  atraumatic  cardiac  arrest  whose  first  documented  field 


928 


Respiratory  Care  •  August  2000  Vol  45  No  8 


VORTRAN 


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Visit  AARC  Booth  320  in  Cincinnati 


Abstracts 


rhythm  was  asystole  with  time-to-defmitive  care  of  slO  mins  (primary 
asystole)  and  patients  found  in  ventricular  fibrillation  who  developed 
postcountershock  asystole  (secondary  asystole)  were  included.  Patients 
were  grouped  according  to  route  of  drug  administration  (i.v.,  ET,  or  no 
drug  therapy)  as  well  as  rhythm  (primary  or  secondary  asystole).  A 
positive  response  to  drug  therapy  was  defined  as  any  subsequent  rhythm 
other  than  asystole  during  continued  prehospital  resuscitation.  MEA- 
SUREMENTS AND  MAIN  RESULTS:  A  total  of  136  patients  met 
inclusion  criteria.  The  following  groups  were  defined:  group  1 ,  primary 
asystole/i.v.  drugs  (n  =  39);  group  2,  postcountershock  asystole/i.v.  drugs 
(n  =  39);  group  3,  primary  asystole/ET  drugs  (n  =  25);  group  4,  post- 
countershock asystole/ET  drugs  (n  =  18):  and  group  5,  primary  or  sec- 
ondary asystole/no  drug  therapy  (n  =  15).  Significant  differences  were 
not  observed  between  groups  with  respect  to  age,  gender,  witnessed 
arrest,  frequency  of  bystander  CPR,  or  time-to-definitive  care.  The  pos- 
itive rhythm  response  rate  was  significantly  greater  in  group  1  (64%)  and 
group  2  (69%)  (both  p  <  0.01)  than  in  Group  3  (12%)  or  group  4  (1 1%). 
The  response  rate  in  the  control  group  was  20%  and  not  significantly 
different  from  either  ET  group.  The  intravenous  groups  also  had  a  sig- 
nificantly greater  rate  of  return  of  spontaneous  circulation  (17%)  when 
compared  with  the  ET  groups  (0%)  (p  =  0.005).  CONCLUSION:  We 
conclude  that  the  currently  recommended  doses  of  epinephrine  and  at- 
ropine administered  endotracheally  are  rarely  effective  in  the  setting  of 
cardiac  arrest  and  CPR. 


Respiratory  Comfort  and  Breathing  Pattern  during  Volume  Propor- 
tional Assist  Ventilation  and  Pressure  Support  Ventilation:  A  Study 
on  Volunteers  with  Artificially  Reduced  Compliance — Mols  G,  von 
Ungem-Stemberg  B,  Rohr  E,  Haberthur  C,  Geiger  K,  Guttmann  J.  Crit 
Care  Med  2000  Jun;28(6):  1940- 1946. 

OBJECTIVE:  To  assess  respiratory  comfort  and  associated  breathing 
pattern  during  volume  assist  (VA)  as  a  component  of  proportional  assist 
ventilation  and  during  pressure  support  ventilation  (PSV).  DESIGN:  Pro- 
spective, double-blind,  interventional  study.  SETTING:  Laboratory.  SUB- 
JECTS: A  total  of  15  healthy  volunteers  (11  females,  4  males)  aged 
21-31  yrs.  INTERVENTIONS:  Decreased  respiratory  system  compliance 
was  simulated  by  banding  of  the  thorax  and  abdomen.  Volunteers  breathed 
via  a  mouthpiece  with  VA  and  PSV  each  applied  at  two  levels  (VA,  8  cm 
HjO/L  and  12  cm  HjO/L;  PSV,  10  cm  HjO  and  15  cm  HjO)  using  a 
positive  end-expiratory  pressure  of  5  cm  HjO  throughout.  The  study  was 
subdivided  into  two  parts.  In  Part  1,  volunteers  breathed  three  times  with 
each  of  the  four  settings  for  2  mins  in  random  order.  In  Part  2,  the  first 
breath  effects  of  multiple,  randomly  applied  mode,  and  level  shifts  were 
studied.  MEASUREMENTS  AND  MAIN  RESULTS:  In  Part  1,  the  vol- 
unteers were  asked  to  estimate  respiratory  comfort  in  comparison  with 
normal  breathing  using  a  visual  analog  scale.  In  Part  2,  they  were  asked 
to  estimate  the  change  of  respiratory  comfort  as  increased,  decreased,  or 
unchanged  immediately  after  a  mode  shift.  Concomitantly,  the  respira- 
tory pattern  (change)  was  characterized  with  continuously  measured  tidal 
volume,  respiratory  rate,  pressure,  and  gas  flow.  Respiratory  comfort 
during  VA  was  higher  than  during  PSV.  The  higher  support  level  was 
less  important  during  VA  but  had  a  major  negative  influence  on  comfort 
during  PSV.  Both  modes  differed  with  respect  to  the  associated  breathing 
pattern.  Variability  of  breathing  was  higher  during  VA  than  during  PSV 
(Part  1 ).  Changes  in  respiratory  variables  were  associated  with  changes  in 
respiratory  comfort  (Part  2).  CONCLUSIONS:  For  volunteers  breathing 
with  artificially  reduced  respiratory  system  compliance,  respiratory  com- 
fort is  higher  with  VA  than  with  PSV.  This  is  probably  caused  by  a  better 
adaptation  of  the  ventilatory  support  to  the  volunteer's  need  with  VA. 

Deadspace  to  Tidal  Volume  Ratio  Predicts  Successful  Extubation  in 
Infants  and  Children— Hubble  CL,  Gentile  MA,  Tripp  DS,  Craig  DM, 
Meliones  JN,  Cheifetz  IM.  Crit  Care  Med  2000  Jun;28(6):2034-2040. 


OBJECTIVE:  Using  a  modification  of  the  Bohr  equation,  single-breath 
carbon  dioxide  capnography  is  a  noninvasive  technology  for  calculating 
physiologic  dead  space  (Vi/V^.).  The  objective  of  this  study  was  to 
identify  a  minimal  Vj/V^.  value  for  predicting  successful  extubation  from 
mechanical  ventilation  in  pediatric  patients.  DESIGN:  Prospective, 
blinded,  clinical  study.  SETTING:  Medical  and  surgical  pediatric  inten- 
sive care  unit  of  a  university  hospital.  PATIENTS:  Intubated  children 
ranging  in  age  from  1  wk  to  18  yrs.  INTERVENTIONS:  None.  MEA- 
SUREMENTS AND  MAIN  RESULTS:  Forty-five  patients  were  identi- 
fied by  the  pediatric  intensive  care  unit  clinical  team  as  meeting  criteria 
for  extubation.  Thirty  minutes  before  the  planned  extubation,  each  patient 
was  begun  on  pressure  support  ventilation  set  to  deliver  an  exhaled  tidal 
volume  of  6  mL/kg.  After  20  mins  on  pressure  support  ventilation,  an 
arterial  blood  gas  was  obtained,  VqA't  was  calculated,  and  the  patient 
was  extubated.  Over  the  next  48  hrs,  the  clinical  team  managed  the 
patient  without  knowledge  of  the  preextubation  V[/Vt  value.  Of  the  45 
patients  studied,  25  had  V^A't  <  0.50.  Of  these  patients,  24  of  25  (96%) 
were  successfully  extubated  without  needing  additional  ventilatory  sup- 
port. In  an  intermediate  group  of  patients  with  Vp/V^-  between  0.50  and 
0.65,  six  of  ten  patients  (60%)  successfully  extubated  from  mechanical 
ventilation.  However,  only  two  of  ten  patients  (20%)  with  a  Vj/Vj  > 
0.65  were  successfully  extubated.  Logistic  regression  analysis  revealed  a 
significant  association  between  lower  V^/V^.  and  successful  extubation. 
CONCLUSIONS:  A  Vj/Vt  £  0.50  reliably  predicts  successful  extuba- 
tion, whereas  a  V[/Vt  >  0.65  identifies  patients  at  risk  for  respiratory 
failure  following  extubation.  There  appears  to  be  an  intermediate  Vj^Vt 
range  (0.51-0.65)  that  is  less  predictive  of  successful  extubation.  Routine 
V[/Vt.  monitoring  of  pediatric  patients  may  permit  earlier  extubation  and 
reduce  unexpected  extubation  failures. 

Prospective  Study  of  Airway  Management  of  Children  Requiring 
Endotracheal  Intubation  before  Admission  to  a  Pediatric  Intensive 
Care  Unit^Easley  RB,  Segeleon  JE,  Haun  SE.  Tobias  JD.  Crit  Care 
Med  2000  Jun;28(6):2058-2063. 

OBJECTIVE:  To  prospectively  identify  complications  related  to  airway 
management  in  children  before  pediatric  intensive  care  unit  (ICU)  ad- 
mission. DESIGN:  A  descriptive,  prospective  study  covering  an  18-month 
period.  A  survey  was  completed  at  the  time  of  admission  to  obtain 
demographic  data,  reason  for  endotracheal  (ET)  intubation,  medications 
administered,  location  of  and  personnel  responsible  for  ET  intubation, 
and  major/minor  variances  associated  with  airway  management.  Major 
variances  were  defined  as  technical  problems  resulting  in  a  significant 
risk  for  airway  trauma  and  increased  morbidity.  Minor  variances  were 
problems  that  should  be  avoided,  but  which  do  not  significantly  increase 
the  immediate  risk  to  the  patient.  Additional  information  obtained  in- 
cluded whether  a  chest  radiograph  (CXR)  was  obtained  and  if  postextu- 
bation  problems  occurred,  such  as  stridor  requiring  treatment  or  reintu- 
bation.  SETTING:  Community  hospitals,  emergency  rooms,  children's 
hospital  emergency  rooms  PATIENTS:  All  children  sl8  yrs  of  age 
receiving  ET  intubation  before  admission  to  the  pediatric  ICU,  except 
those  in  cardiovascular  arrest.  MEASUREMENTS  AND  MAIN  RE- 
SULTS: Data  were  collected  on  250  consecutive  patients.  Major  or  minor 
variances  were  noted  in  135  (54%)  patients  and  in  66%  of  patients  <l  yr 
of  age  (p  =  0.02865;  odds  ratio,  2.0).  Twenty-six  percent  of  patients  si 
yr  of  age  received  an  anticholinergic  agent  before  ET  intubation  com- 
pared with  40%  of  older  patients  (p  =  0.04343;  odds  ratio,  0.504).  Eleven 
patients  received  a  neuromuscular  blocking  agent  (NMBA)  without  a 
sedative/analgesic  agent.  Major  variances  occurred  in  54%  of  patients 
who  did  not  receive  a  NMBA  and  in  27%  of  patients  who  received  a 
NMBA  (p  =  0.00002;  odds  ratio,  0.307).  Forty-one  patients  (16%)  were 
intubated  with  an  inappropriately  sized  ET  tube.  Postintubation  CXRs 
were  obtained  in  65%  of  patients  managed  outside  of  a  children's  hos- 
pital and  in  93%  of  patients  in  a  children's  hospital  emergency  room  (p  < 
0.00001;  odds  ratio,  7.199).  Variances  detectable  by  CXR  went  unrec- 


930 


Respiratory  Care  •  August  2000  Vol  45  No  8 


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Abstracts 


ognized  in  40%  of  patients,  despite  obtaining  a  CXR.  CONCLUSIONS: 
Emergency  airway  management  in  children  can  be  fraught  with  prob- 
lems. Most  variances  could  be  avoided  by  improved  education  regarding 
appropriate  ET  lube  size,  appropriate  medication  use,  and  improved  train- 
ing for  evaluation  of  ET  tube  placement. 

Multiple  Site  Analytical  Evaluation  of  a  Portable  Blood  Gas/Electro- 
lyte Analyzer  for  Point  of  Care  Testing — Chance  JJ,  Li  DJ,  SokoU  LJ, 
Silberman  MA,  Engelstad  ME,  Nichols  JH.  et  al.  Crit  Care  Med  2000 
Jun;28(6):208l-2085. 

OBJECTIVE:  To  evaluate  the  analytical  performance  of  the  SenDx  100 
portable  blood  gas  and  electrolyte  analyzer  (SenDx  Medical.  Carlsbad, 
CA).  DESIGN:  Accuracy  was  evaluated  by  correlation  of  whole  blood 
patient  samples  with  the  Nova  Stat  Profile  5  (Nova  Biomedical,  Waltham, 
MA)  and  the  Ciba  Coming  865  (Chiron  Diagnostics,  Medford,  MA). 
Precision  was  evaluated  using  quality  control  materials  (RNA  Medical, 
Acton,  MA).  SETTING:  Critical  care  laboratories  and  operating  rooms  in 
two  institutions.  MEASUREMENTS  AND  MAIN  RESULTS:  Precision 
studies  performed  at  three  different  concentration  levels  for  each  analyte 
demonstrated  intra-assay  precision  of  s  2.5%  coefficient  of  variation  and 
interassay  precision  of  £  4.0%  coefficient  of  variation  in  all  cases.  Anal- 
ysis of  patient  specimens  in  general  showed  good  to  excellent  correlation 
to  reference  analyzers.  Regression  variables  are  tabulated.  CONCLU- 
SIONS: The  SenDx  100  portable  blood  gas  and  electrolyte  analyzer  is  a 
simple  and  easy  to  use  analyzer  demonstrating  acceptable  performance 
compared  with  reference  methods. 

First-Line  Therapy  for  Adult  Patients  with  Acute  Asthma  Receiving 
a  Multiple-Dose  Protocol  of  Ipratropium  Bromide  Plus  Albuterol  in 
the  Emergency  Department — Rodrigo  GJ,  Rodrigo  C.  Am  J  Respir  Crit 
Care  Med  2000  J un  1;1 61(6):  1 862-1868. 

We  designed  a  larger,  double-blind,  randomized,  prospective  trial  to  test 
our  hypothesis  that  patients  with  acute  asthma  given  combination  high 
dose  therapy  with  ipratropium  bromide  (IB)  and  betaj-agonists  will  have 
greater  improvement  in  pulmonary  function  and  fewer  hospital  admis- 
sions than  those  given  betaj-agonists  alone.  One  hundred  eighty  patients 
(mean  age  ±  SD,  34.3  ±  10.5  yr)  who  presented  to  an  emergency 
department  (ED)  for  treatment  of  an  exacerbation  of  asthma  (baseline 
FEV I  <  50%  of  predicted)  were  assigned  in  a  randomized,  double-blind 
fashion  to  receive  albuterol  and  placebo  (n  =  92)  or  albuterol  and  IB 
(n  =  88).  Both  drugs  were  administered  through  a  metered-dose  inhaler 
and  spacer  at  lO-min  intervals  for  3  h  (24  puffs  or  2,880  meg  of  albuterol 
and  504  meg  of  IB  each  hour).  Primary  outcome  measures  were  im- 
provement in  pulmonary  function  (FEV,  or  peak  expiratory  flow  [PEF]), 
and  hospital  admission  rates.  In  both  groups,  pulmonary  function  im- 
proved significantly  over  baseline  values  (p  <  0.01).  Subjects  who  re- 
ceived IB  had  an  overall  20.5%  (95%  CI:  2.6  to  38.4%)  (p  =  0.02) 
greater  improvement  in  PEF  and  a  48.1%  (95%  CI:  19.8  to  76.4%)  (p  = 
0.(X)1)  greater  improvement  in  FEV,  from  the  control  group.  At  the  end 
of  protocol  (3  h),  39%  (n  =  36)  of  patients  in  the  control  group  and  20% 
(n  =  18)  in  the  IB  group  were  admitted  (p  =  0.01).  The  use  of  high  doses 
of  IB  reduced  the  risk  of  hospital  admission  49%  (relative  risk  =  0.51, 
95%  CI:  0.31  to  0.83).  Five  (95%-  CI:  3  to  17)  patients  would  need  to  be 
treated  with  high  doses  of  IB  to  prevent  a  single  admission.  Kaplan- 
Meier-eslimated  curves  of  the  proportion  of  patients  who  reached  the 
discharge  threshold  during  the  3  h  of  treatment,  showed  a  significant 
difference  in  favor  of  the  IB  group  (log-rank  test  =  0.005).  A  subgroup 
analysis  showed  that  patients  most  likely  to  benefit  from  the  addition  of 
high  doses  of  IB  were  those  with  more  severe  obstruction  (FEV,  £  30% 
of  predicted)  and  long  duration  of  symptoms  before  the  ED  presentation 
(a  24  h).  On  the  contrary,  previous  use  of  inhaled  beta^-agonists  did  not 
modify  the  admission  rate  and  the  pulmonary  function  response  lo  IB.  In 
conclusion,  our  data  support  a  substantial  therapeutic  beneflt  from  the 


addition  of  IB  to  albuterol  administered  in  high  doses  through  MDI  plus 

spacer,  particulariy  in  patients  with  FEV,  less  than  30%.  and  with  long 
duration  of  symptoms  before  the  ED  presentation  (>  24  h). 

High-Flow  Transtracheal  Insufflation  Treats  Obstructive  Sleep  Ap- 
nea: a  Pilot  Study— Schneider  H,  O'Hearn  DJ,  Leblanc  K.  Smith  PL, 
O'Donnell  CP,  Eisele  DW,  et  al.  Am  J  Respir  Crit  Care  Med  2000  Jun 
1;16I(6):I869-1876. 

To  determine  the  effect  of  transtracheal  insufflation  (TTI)  on  obstructive 
sleep  apnea  (OSA),  we  examined  breathing  patterns  in  five  tracheos- 
tomized  patients  with  OSA  at  varying  TTI  flow  rales  when  breathing 
with  a  closed  tracheostomy.  The  breathing  patterns  and  polysomnographic 
responses  to  air  insufflation  were  studied  as  TTI  was  increa.sed  from  0  to 
15  L/min  for  brief  periods  of  non-rapid  eye  movement  (NREM)  sleep 
(Experiment  1).  The  frequency  of  sleep-disordered  breathing  episodes 
remained  high  at  0  and  5  L/min  (87.0  ±  33.7  and  79.4  ±  24.4  episodes 
per  hour  NREM)  and  decreased  significantly  to  41.3  ±  31.5  and  43.4  ± 

31.4  episodes/h  NREM  sleep  at  rates  of  10  and  15  L/min,  respectively 
(p  =  0.003).  At  high  levels  of  TTI  (10  and  15  L/min).  obstructive  apneas 
and  hypopneas  decreased  but  periodic  laryngeal  obstructions  were  in- 
duced during  stage  1  NREM  sleep.  To  prevent  laryngeal  obstructions,  a 
servo-control  system  was  used  to  briefly  interrupt  TTI  during  these  events. 
When  this  system  was  implemented  for  more  prolonged  periods  of  sleep 
(Experiment  2,  total  sleep  time  176.6  ±  12.5  min),  high-flow  TTI  (hf- 
TTI,  15  L/min)  led  to  an  overall  reduction  in  the  combined  frequency  of 
obstructive  apneas  and  laryngeal  obstructions  from  63.8  ±  21.8  to  10.7  ± 
9.1  (p  <  0.03)  and  was  associated  with  a  marked  reduction  in  arousal 
frequency  from  60.0  ±  26.0  to  8.3  ±  5.4/h  in  NREM  sleep,  and  from 

67.5  ±  3.5  to  0  ±  0/h  in  rapid  eye  movement  (REM)  sleep.  Our  tlndings 
demonstrate  that  hf-TTI  stabilized  breathing  patterns  in  apneic  patients, 
and  was  safe  and  efficacious  for  prolonged  periods  of  sleep. 

The  Effects  of  Oxitropium  Bromide  on  Exercise  Performance  in 
Patients  with  Stable  Chronic  Obstructive  Pulmonary  Disease:  A  Com- 
parison of  Three  Different  Exercise  Tests — Oga  T,  Nishimura  K, 
Tsukino  M.  Hajiro  T,  Ikeda  A,  Izumi  T.  Am  J  Respir  Crit  Care  Med  2000 
Jun  1;161(6):1897-1901. 

The  purpose  of  the  present  study  was  to  compare  the  characteristics  of 
three  different  exercise  tests  in  evaluating  the  effects  of  oxitropium  bro- 
mide on  exercise  performance.  Thirty-eight  males  with  stable  chronic 
obstructive  pulmonary  disease  (COPD)  (FEV,  =  40.8  ±  16.5%  pre- 
dicted; mean  ±  SD)  completed  randomized,  double-blind,  placebo-con- 
trolled, crossover  studies  for  each  exercise  test.  The  exercise  tests  were 
performed  60  min  after  the  inhalation  of  either  oxitropium  bromide  400 
mug  or  placebo.  The  patients  performed  6-min  walking  tests  (6MWT)  on 
Days  I  and  2,  progressive  cycle  ergometry  (PCE)  on  Days  3  and  4,  and 
cycle  endurance  tests  at  80%  of  the  maximal  workload  of  PCE  on  Days 
5  and  6.  Spirometry  was  conducted  before  and  at  45  and  90  min  after  the 
inhalation.  Oxitropium  bromide  significantly  increased  FEV,  as  com- 
pared with  placebo.  Oxitropium  bromide  increased  the  endurance  time 
significantly,  by  19%  (p  <  0.001),  and  caused  a  small  but  significant 
increase  in  the  6-min  walking  distance  by  1%  (p  <  0.05).  but  induced  no 
significant  increase  in  maximal  oxygen  consumption  (VO,,„,^)  in  PCE. 
The  responses  in  these  three  exercise  tests  were  different,  and  we  con- 
clude that  the  endurance  test  was  the  most  sensitive  in  detecting  Ihe 
effects  of  inhaled  anticholinergic  agents  on  exercise  performance  in  pa- 
tients with  stable  COPD.  An  endurance  procedure  may  be  performed  to 
detect  clinical  changes  in  evaluating  the  effects  of  oxitropium  bromide  on 
exercise  performance. 

A  Model  of  Obstructive  Sleep  Apnea  in  Normal  Humans:  Role  of  the 
Upper  Airway— King  ED,  O'Donnell  CP,  Smith  PL.  Schwartz  AR. 
Am  J  Respir  Crit  Care  Med  2000  Jun  1;  161  (6):  1979-1984. 


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Respiratory  Care  •  August  2000  Vol  45  No  8 


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Abstracts 


We  determined  whether  upper  airway  obstruction  in  normal  individuals 
with  intact  reflexes  could  produce  the  syndrome  of  obstructive  sleep 
apnea.  Upper  airway  obstruction  was  produced  in  12  nomial  individuals 
by  lowering  nasal  pressure  to  -10  cm  HjO  during  sleep.  Full  night  poly- 
somnography was  performed  during  two  consecutive  nights  of  sleep  with 
subatmospheric  nasal  pressure  and  compared  with  control  nights  before 
and  after  the  negative  pressure  nights.  We  found  that  the  application  of 
negative  pressure  was  associated  with  the  development  of  recurrent  ob- 
structive apneas  (non-REM-disordered  breathing  rate,  32.6  ±  34.8  and 
37.8  ±  29.1  events/h  during  each  of  two  negative  pressure  nights;  p  < 
0.001)  that  were  associated  with  oxyhemoglobin  desaturation,  arousals 
from  sleep,  and  alterations  in  sleep  stage  distribution.  Moreover,  the 
median  daytime  sleep  latency  after  two  nights  of  sleep  with  subatmo- 
spheric pressure  fell  from  6.9  ±  1.1  to  3.4  ±  0.6  min,  and  rose  signif- 
icantly again  to  8. 1  ±  1 .5  min  (p  <  0.03)  after  the  control  night  following 
subatmospheric  pressure  nights.  Our  findings  suggest  that  a  decrease  in 
the  pharyngeal  transmural  pressure  alone  is  a  sufficient  condition  for  the 
production  of  the  sleep  apnea  syndrome  in  normal  individuals. 

Peak  Expiratory  Flow  Profiles  Delivered  by  Pump  Systems:  Limita- 
tions due  to  Wave  Action — Miller  MR,  Jones  B,  Xu  Y,  Pedersen  OF, 
Quanjer  PH.  Am  J  Respir  Crit  Care  Med  2000  Jun  1;161(6):1887-1896. 

Pump  systems  are  currently  used  to  test  the  performance  of  both  spirom- 
eters and  peak  expiratory  flow  (PEF)  meters,  but  for  certain  flow  profiles 
the  input  signal  (i.e.,  requested  profile)  and  the  output  profile  can  differ. 
We  developed  a  mathematical  model  of  wave  action  within  a  pump  and 
compared  the  recorded  flow  profiles  with  both  the  input  profiles  and  the 
output  predicted  by  the  model.  Three  American  Thoracic  Society  (ATS) 
flow  profiles  and  four  artificial  flow-versus-time  profiles  were  delivered 
by  a  pump,  first  to  a  pneumotachograph  (PT)  on  its  own,  then  to  the  FT 
with  a  32-cm  upstream  extension  tube  (which  would  favor  wave  action), 
and  lastly  with  the  PT  in  series  with  and  immediately  downstream  to  a 
mini-Wright  peak  flow  meter.  With  the  PT  on  its  own,  recorded  flow  for 
the  seven  profiles  was  2.4  ±  1.9%  (mean  ±  SD)  higher  than  the  pump's 
input  flow,  and  similarly  was  2.3  ±  2.3%  higher  than  the  pump's  output 
flow  as  predicted  by  the  model.  With  the  extension  tube  in  place,  the 
recorded  flow  was  6.6  ±  6.4%  higher  than  the  input  flow  (range:  0.1  to 
18.4%),  but  was  only  1.2  ±  2.5%  higher  than  the  output  flow  predicted 
by  the  model  (range:  -0.8  to  5.2%).  With  the  mini-Wright  meter  in  series, 
the  flow  recorded  by  the  PT  was  on  average  6. 1  ±  9. 1  %  below  the  input 
flow  (range:  -23.8  to  2.5%),  but  was  only  0.6  ±  3.3%  above  the  pump's 
output  flow  predicted  by  the  model  (range:  -5.5  to  3.9%).  The  mini- 
Wright  meter's  reading  (corrected  for  its  nonlinearity)  was  on  average 
1.3  ±  3.6%  below  the  model's  predicted  output  flow  (range:  -9.0  to 
1.5%).  The  mini-Wright  meter  would  be  deemed  outside  ATS  limits  for 
accuracy  for  three  of  the  seven  profiles  when  compared  with  the  pump's 
input  PEF,  but  this  would  be  true  for  only  one  profile  when  compared 
with  the  pump's  output  PEF  as  predicted  by  the  model.  Our  study  shows 
that  the  output  flow  from  pump  systems  can  differ  from  the  input  wave- 
form depending  on  the  operating  configuration.  This  effect  can  be  pre- 
dicted with  reasonable  accuracy  using  a  model  based  on  nonsteady  flow 
analysis  that  takes  account  of  pressure  wave  reflections  within  pump 
systems. 

Closing  Volume  Influences  the  Postural  Effect  on  Oxygenation  in 
Unilateral  Lung  Disease— Choe  KH,  Kim  YT,  Shim  TS,  Lim  CM,  Lee 

SD,  Koh  Y,  et  al.  Am  J  Respir  Crit  Care  Med  2000  Jun  1;161(6):1957- 
l%2. 

In  normal  adults,  both  blood  flow  and  ventilation  are  distributed  prefer- 
entially to  the  dependent  lung  zones.  In  adults  with  unilateral  lung  dis- 
ea.se,  arterial  oxygenation  improves  when  they  are  positioned  with  their 
good  lung  down  because  of  improved  matching  of  ventilation  and  per- 
fusion. When  the  closing  volume  is  increased,  dependent  airways  are 


closed  during  tidal  breathing,  so  that  reduced  ventilation-perfusion  ratio 
and  hypoxia  develops  and  ventilation  is  preferentially  distributed  to  the 
upper  lung  zones.  We  undertook  an  observational  study  on  the  effects  of 
lateral  recumbency  on  arterial  oxygenation  in  adult  patients  with  unilat- 
eral lung  disease  and  tested  the  hypothesis  that  oxygenation  in  lateral 
recumbency  might  be  influenced  by  an  increase  in  closing  volume.  Ar- 
terial blood  gases  were  analyzed  in  the  supine,  right  and  left  lateral 
decubitus  positions  and  the  AaPO,  was  calculated  in  44  randomly  se- 
lected patients  49.9  ±  18.7  yr  of  age  with  unilateral  pneumonia  (23 
cases)  or  pulmonary  tuberculosis  (21  cases).  In  26  patients,  individual 
P„oj  with  the  normal  lung  in  the  dependent  position  was  higher  than  that 
with  the  diseased  lung;  the  opposite  was  true  for  18  patients.  The  differ- 
ence in  P;,o2  and  AaPO,  between  the  two  positions  was  statistically 
significant  in  both  groups.  In  16  patients  (10  men  and  six  women  49.2  ± 
18.2  yr  of  age),  we  measured  closing  volume  and  determined  the  frac- 
tional ventilation  to  each  lung  by  (133)Xe  lung  scan  in  the  three  posi- 
tions. In  these  16  patients,  the  difference  in  P,,o2  between  the  normal  and 
the  diseased  lung  in  the  dependent  position  was  related  significantly  to 
the  difference  in  the  fractional  ventilation  going  to  the  normal  lung 
between  the  dependent  and  the  supine  position  (r  =  0.642,  p  =  0.(X)7). 
The  latter  was  related  significantly  to  the  %  predicted  closing  volume 
(CVA'C)  (r  =  -0.597,  p  =  0.015).  This  study  has  shown  that  closing 
volume,  as  well  as  posture,  might  be  involved  in  determining  oxygen- 
ation in  lateral  recumbency  in  patients  with  unilateral  lung  disease. 

A  Simple  "New"  Method  to  Accelerate  Clearance  of  Carbon  Mon- 
oxide— Takeuchi  A,  Vesely  A,  Rucker  J,  Sommer  LZ.  Tesler  J,  Lavine 
E,  et  al.  Am  J  Respir  Crit  Care  Med  2000  Jun  1;16I(6):1816-18I9. 

The  currently  recommended  prehospital  treatment  for  carbon  monoxide 
(CO)  poisoning  is  administration  of  100%  O,.  We  have  shown  in  dogs 
that  normocapnic  hyperpnea  with  Oj  further  accelerates  CO  elimination. 
The  purpose  of  this  study  was  to  examine  the  relation  between  minute 
ventilation  (V^)  and  the  rate  of  elimination  of  CO  in  humans.  Seven 
healthy  male  volunteers  were  exposed  to  CO  (4(X)  to  1 ,000  ppm)  in  air 
until  their  carboxyhemoglobin  (COHb)  levels  reached  10  to  12%.  They 
then  breathed  either  100%  Oj  at  resting  V,;  (4.3  to  9.0  L  min)  for  60  min 
or  O2  containing  4.5  to  4.8%  CO2  (to  maintain  normocapnia)  at  two  to  six 
times  resting  Vg  for  90  min.  The  half-time  of  the  decrea.se  in  COHb  fell 
from  78  ±  24  min  (mean  ±  SD)  during  resting  V^  with  100%  O2  to  31  ± 
6  min  (p  <  0.001)  during  normocapnic  hyperpnea  with  O,.  The  relation 
between  Vj.-  and  the  half-time  of  COHb  reduction  approximated  a  rect- 
angular hyperbola.  Because  both  the  method  and  circuit  are  simple,  this 
approach  may  enhance  the  first-aid  treatment  of  CO  poisoning. 

Effect  of  Unplanned  Extubation  on  Outcome  of  Mechanical  Venti- 
lation— Epstein  SK,  Nevins  ML,  Chung  J.  Am  J  Respir  Crit  Care  Med 
2000  Jun  1;161(6):19I2-1916. 

Unplanned  extubation  is  a  major  complication  of  translaryngeal  intuba- 
tion, but  its  impact  on  mortality,  duration  of  mechanical  ventilation  (MV), 
length  of  intensive  care  unit  (ICU)  and  hospital  stay,  and  need  for  on- 
going hospital  care  has  not  been  adequately  defined.  We  performed  a 
case-control  study  in  a  tertiary-care  medical  ICU,  comparing  75  patients 
with  unplanned  extubation  and  150  controls  matched  for  Acute  Physiol- 
ogy and  Chronic  Health  Evaluation  II  score,  presence  of  comorbid  con- 
ditions, age,  indication  for  MV,  and  sex.  Forty-two  (56%)  patients  re- 
quired reintubation  after  unplanned  extubation  (74%  immediately.  86% 
within  12  h).  Thirty-three  (44%)  unplanned  extubations  cKcurred  during 
weaning  trials,  and  30%  of  these  patients  needed  reintubation  (failed 
unplanned  extubation).  In  contrast,  76%'  of  patients  with  unplanned  ex- 
tubation occurring  during  ventilatory  support  required  reintubation.  Al- 
though mortality  was  similar  to  that  of  controls  (failed  unplanned  extu- 
bation 40%,  versus  control  3 1  %,  p  >  0.2),  patients  with  failed  unplanned 
extubation  had  a  significantly  longer  duration  of  MV  (19  versus  1 1  d, 


934 


Respiratory  Care  •  August  2000  Vol  45  No  8 


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Abstracts 


p  <  0.01),  longer  stay  in  the  ICU  (21  versus  14  d,  p  <  0.05),  and  longer 
hospital  stay  (30  versus  21  d,  p  <  0.01),  and  survivors  were  more  likely 
to  require  chronic  care  (64%  versus  24%,  p  <  0.(X)1).  Successfully 
tolerated  unplanned  extubation  was  associated  with  a  reduction  in  time 
from  beginning  of  weaning  to  extubation  (0.9  versus  2.0  d,  p  =  0.06),  but 
with  no  difference  in  overall  duration  of  MV,  mortality,  discharge  loca- 
tion, ICU,  or  hospital  stay  as  compared  with  these  measures  for  controls. 
We  conclude  that  unplanned  extubation  is  not  associated  with  increased 
mortality  when  compared  with  that  of  matched  controls,  although  it  does 
result  in  prolonged  MV,  longer  ICU  and  hospital  stay,  and  increased  need 
for  chronic  care.  These  effects  are  due  exclusively  to  patients  who  fail  to 
tolerate  unplanned  extubation.  Although  successfully  tolerated  unplanned 
extubation  decreased  the  duration  of  weaning  trials,  it  had  no  other  mea- 
surable beneficial  impact  on  outcome. 

Multicenter  Prospective  Study  of  Ventilator-Associated  Pneumonia 
during  Acute  Respiratory  Distress  Syndrome.  Incidence,  Prognosis, 
and  Risk  Factors — Markowicz  P,  Wolff  M,  Djedaini  K,  Cohen  Y,  Chas- 
tre  J,  Delclaux  C,  et  al.  Am  J  Respir  Crit  Care  Med  2000  Jun  1;  161(6): 
1942-1948. 

We  investigated  the  incidence,  risk  factors  for,  and  outcome  of  ventilator- 
associated  pneumonia  (VAP)  in  patients  with  acute  respiratory  distress 
syndrome  (ARDS).  We  compared  134  patients  with  ARDS  with  744 
patients  without  ARDS  on  mechanical  ventilation.  Fiberoptic  broncho- 
scopic  examination  and  quantitative  bacterial  cultures  (protected  brush  or 
catheter  sampling  [threshold:  10'  cfu/mL],  or  bronchoalveolar  lavage 
[threshold:  lO''  cfu/mL[)  were  used  to  diagno.se  pneumonia.  VAP  oc- 
curred in  49  patients  (36.5%).  The  incidence  of  pneumonia  was  23%  (173 
of  744  patients)  among  patients  without  ARDS  (p  <  0.(X)2).  Nonfer- 
menting  Gram-negative  rods  caused  significantly  more  pneumonia  in 
ARDS  patients.  Mortality  rates  were  identical  in  ARDS  patients  with  (28 
of  49  patients,  57%)  and  without  (50  of  85  patients,  59%)  pulmonary 
infection  (p  =  0.8).  VAP  resulted  in  a  considerable  increase  in  attribut- 
able time  on  mechanical  ventilation  of  both  the  overall  population  of 
ARDS  patients  and  of  survivors.  Both  the  use  of  sucralfate  (adjusted  odds 
ratio  [OR]:  4.42:  95%  confidence  interval  [CI]:  2.01  to  9.7,  p  =  0.0002) 
and  the  duration  of  exposure  to  sucralfate  (adjusted  OR:  1 .206;  95%  CI: 
1.095  to  1.328,  p  =  0.0002)  were  associated  with  an  increased  risk  of 
VAP  during  ARDS.  VAP  considerably  prolongs  the  time  on  mechanical 
ventilation  without  affecting  survival.  Patients  given  sucralfate  may  be  at 
greater  risk  of  developing  pulmonary  infection  during  ARDS. 

Oxygenation  Response  to  a  Recruitment  Maneuver  during  Supine 
and  Prone  Positions  in  an  Oleic  Acid-Induced  Lung  Injury  Model — 

Cakar  N,  Kloot  TV,  Youngblood  M,  Adams  A,  Nahum  A.  Am  J  Respir 
Crit  Care  Med  2000  Jun  1:161(6):  1949- 1956. 

Prone  position  and  recruitment  maneuvers  (RM)  are  proposed  as  adjuncts 
to  mechanical  ventilation  to  open  up  the  lung  and  keep  it  open.  We 
studied  the  oxygenation  response  to  a  RM  (composed  of  a  30-s  sustained 
inflation  at  60  cm  H,0  airway  pressure)  performed  in  prone  and  supine 
positions  in  dogs  after  oleic  acid-  induced  lung  injury  using  an  inspired 
Oj  fraction  of  0.60.  In  one  group  (n  =  6)  first  supine  then  prone  positions 
were  examined  after  a  RM  at  8  cm  HjO  and  15  cm  HjO  of  positive 
end-expiratory  pressure  (PEEP).  In  the  second  group  (n  =  6)  the  se- 
quence of  positions  was  reversed.  Prone  positioning  after  supine  position 
always  improved  oxygenation,  whereas  the  decrement  in  P^„,  was  rela- 
tively small  when  dogs  were  returned  to  the  supine  position.  Oxygenation 
improved  in  both  groups  after  a  RM,  and  the  improvement  was  sustained 
(after  15  min)  in  the  prone  position  at  8  cm  HjO  of  PEEP,  but  1 5  cm  HjO 
of  PEEP  was  required  in  supine  position.  Our  results  suggest  that  a  RM 
improves  oxygenation  more  effectively  with  a  decreased  PEEP  require- 
ment for  the  preservation  of  the  oxygenation  response  in  prone  compared 
with  supine  position. 


Role  of  the  Heart  in  the  Loss  of  Aeration  Characterizing  Lower 
Lobes  in  Acute  Respiratory  Distress  Syndrome — Malbouisson  LM, 
Busch  CJ,  Puybasset  L,  Lu  Q,  Cluzel  P.  Rouby  JJ.  Am  J  Respir  Crit  Care 
Med  2000  Jun  1;161(6):2005-2012. 

In  the  acute  respiratory  distress  syndrome  (ARDS),  lower  lobes  appear 
essentially  non-aerated  in  contrast  to  upper  lobes  whose  aeration  can  be 
preserved  in  some  patients.  The  aim  of  this  study  was  to  assess  the 
mechanical  compression  exerted  by  the  heart  on  lower  lobes  in  patients 
with  ARDS.  Fourteen  healthy  volunteers  and  38  patients  with  ARDS  free 
of  left  ventricular  failure  were  studied.  Cardiorespiratory  parameters  were 
recorded  and  the  cardiac  dimensions,  the  pressure  exerted  by  the  heart  on 
subjacent  lower  lobes,  and  the  gas  tissue  ratio  of  lower  lobes  in  the  supine 
position  were  measured  using  computer  tomography  and  Lungview.  a 
specifically  designed  software.  In  patients  with  ARDS,  the  heart  was 
larger  and  heavier  than  in  healthy  volunteers.  The  enlargement  of  the 
heart  was  mainly  related  to  a  left  cardiac  protrusion  and  the  pressure 
exerted  by  the  left  heart  on  the  lower  lobes  was  higher  in  patients  with 
ARDS  than  in  healthy  volunteers  (8  ±  3  g  •  cm-  versus  6  ±  1  g  •  cm"', 
p  <  0.01).  As  a  consequence,  the  faction  of  gas  represented  62%  of  the 
left  lower  lobes  in  healthy  volunteers  and  12%  only  in  patients  with 
ARDS.  The  present  study  demonstrates  that  apart  from  the  already  known 
anteroposterior  and  cephalocaudal  gradients  of  pressure  depending  on  the 
lung  weight  and  abdominal  pressure,  the  heart  plays  an  important  role  in 
the  dramatic  loss  of  aeration  characterizing  lower  lobes  of  patients  with 
ARDS  lying  in  the  supine  position. 


Long-Acting  Bronchodilation  with  Once-Daily  Dosing  of  Tiotropium 
(Spiriva)  in  Stable  Chronic  Obstructive  Pulmonary  Disease — Littner 
MR,  Ilowite  JS,  Tashkin  DP,  Friedman  M,  Serby  CW,  Menjoge  SS, 
Witek  TJ  Jr.  Am  J  Respir  Crit  Care  Med  2000  Apr;  161  (4  Pt  l):l  136- 
1142. 

Tiotropium  (Spiriva;  Ba679BR)  is  a  new-generation,  long-acting  anti- 
cholinergic bronchodilator  that  has  muscarinic  M,  and  M,  receptor  sub- 
type selectivity.  A  multicenter,  randomized,  double-blind,  parallel  group, 
placebo-controlled  study  was  conducted  to  evaluate  the  dose-response 
characteristics  of  tiotropium  inhalation  powder  given  once  daily  to  stable 
patients  with  chronic  obstructive  pulmonary  disease  (COPD).  Patients 
(mean  FEV,  =  1.08  L  [42%  predicted])  were  randomized  to  receive  0, 
4.5,  9,  1 8,  or  36  microg  tiotropium  once  daily  at  noon  for  4  wk,  with 
spirometry  done  before  and  hourly  for  6  h  after  dosing.  Patients  measured 
and  recorded  their  peak  expiratory  flow  rates  (PEFRs)  three  times  each 
day.  Significant  dose-related  improvement  in  FEV,  and  significant  im- 
provement in  FVC  occurred  within  1  h  after  the  first  dose  of  tiotropium 
as  compared  with  placebo.  Over  the  29  d  of  the  study,  all  doses  of 
tiotropium  produced  significant  increases  over  placebo  in  trough  (i.e.,  as 
measured  spirometrically  at  20  to  24  h  after  the  previous  dose  and  just 
before  the  next  dose  of  tiotropium),  peak,  and  6-h  postdose  average  FEV, 
and  FVC,  and  in  PEFR,  without  a  significant  difference  among  the  dif- 
ferent doses  investigated.  PEFR  gradually  returned  to  pretreatmeni  base- 
line levels  over  a  3-wk  evaluation  period  following  the  discontinuation  of 
tiotropium.  The  overall  safety  profile  for  the  tiotropium  doses  was  similar 
to  that  for  placebo.  In  summary,  tiotropium  was  shown  to  be  safe  and 
effective  in  doses  ranging  from  4.5  to  36  microg  delivered  once  daily. 
The  improvements  in  spirometry  with  once-daily  dosing  confirm  the  long 
duration  of  action  of  tiotropium  reported  in  single-dose  studies,  and  its 
sustained  improvement  of  spirometric  measures  over  the  1  mo  of  testing 
in  the  study  points  to  utility  of  tiotropium  as  a  maintenance  bronchodi- 
lator for  patients  with  COPD.  On  the  basis  of  the  comparable  broncho- 
dilator response  at  doses  from  9  to  36  microg.  and  advantages  suggested 
by  the  safety  profile  at  doses  below  36  microg  in  this  study,  a  dose  of  18 
microg  once  daily  was  selected  for  u.se  in  long-term  studies  of  the  safety 
and  efficacy  of  tiotropium. 


936 


Respiratory  Care  •  August  2000  Vol  45  No  8 


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Editorials 


Medical  Trainee  Experience  Versus  Optimizing  Clinical  Outcomes: 

Achieving  the  Best  of  Both 


As  a  practicing  critical  care  physician  in  an  academic 
medical  center,  I  am  regularly  confronted  by  the  concerns 
of  medical  students  and  house  officers  regarding  their  need 
for  autonomy.  This  includes  perceived  conflicts  with  pro- 
tocols, guidelines,  and  clinical  care  paths,  which  are  often 
viewed  as  "cook  book"  medicine.  It  appears  that  this  is  a 
common  sentiment  among  medical  trainees  who  are  con- 
cerned that  protocolized  medical  care  may  limit  their  abil- 
ity to  develop  as  independent  clinicians  with  refined  prob- 
lem solving  skills.'  Similarly,  physicians  in  practice  can 
develop  attitudes  that  form  barriers  to  the  successful  im- 
plementation of  protocols  and  guidelines  because  of  fears 
concerning  loss  of  clinical  autonomy  as  well  as  lack  of 
local  experience  supporting  the  effectiveness  of  such  in- 
terventions.^-^ 

See  The  Original  Study  on  Page  945 

In  this  issue  of  Respiratory  Care,  Stoller  et  al  provide 
evidence  that  respiratory  care  protocols  implemented  by 
respiratory  therapists  do  not  detract  from  house  officers' 
training  and  knowledge  acquisition  in  respiratory  care  man- 
agement.^ This  was  determined  by  comparing  the  correct 
responses  of  house  officers  at  two  academic  medical  cen- 
ters (one  that  uses  respiratory  care  protocols  and  one  that 
does  not)  to  questions  regarding  respiratory  care  manage- 
ment. Although  this  investigation  was  limited  by  the  rel- 
atively small  number  of  individuals  evaluated,  its  findings 
support  the  premise  that  respiratory  care  protocols  do  not 
detract  from  house  officer  training.  Another  important  find- 
ing of  this  study  was  that  the  overall  correct  response  rate 
among  house  officers  was  76.8%.  Therefore,  a  strong  ar- 
gument can  be  made  that  many  house  officers  lack  basic 
knowledge  regarding  respiratory  care  practices.  A  refine- 
ment of  the  study  design  would  have  included  testing  re- 
spiratory therapists  at  the  two  institutions  to  compare  their 
knowledge  base  to  that  of  the  house  officers.  Regardless, 
protocols  and  guidelines  can  be  used  as  tools  to  help  fill  in 
clinicians'  knowledge  gaps. 

The  ultimate  goal  of  using  protocols  or  guidelines  is  to 
influence  some  important  aspect  of  medical  care  through 
modification  of  clinician  behavior  in  order  to  improve  out- 
comes, decrease  medical  care  costs,  or  to  accomplish  both. 
However,  simply  developing  a  protocol  will  not  ensure 


that  it  is  followed.'^  Indeed,  it  is  often  difficult  to  track 
compliance  with  clinical  protocols  unless  they  are  auto- 
mated.'' To  be  successful,  protocols  should  integrate  med- 
ical knowledge,  local  experience,  and  patient  preferences, 
and  have  an  organized  approach  for  their  implementation.' 
This  will  often  require  fostering  a  sense  of  cooperation 
among  health  care  workers  in  order  to  achieve  the  goals  of 
the  protocol.  This  process  of  cooperation  or  team  building 
may  be  as  important  or  more  important  than  the  protocol 
itself  in  order  to  achieve  success  in  standardizing  patient 
care.** 

Medical  environments  are  frequently  complex  and  hec- 
tic because  of  the  complex  nature  of  patients'  disease  pro- 
cesses, the  large  amount  of  clinical  information  health  care 
workers  are  exposed  to,  and  differences  in  practice  styles 
among  various  clinicians.  Protocols  and  guidelines  can 
help  to  calm  the  hectic  feeling  by  offering  standardization 
of  medical  care  processes.  By  standardizing  clinical  prac- 
tices, their  association  with  patient-specific  outcomes  (eg, 
mortality,  costs,  or  length  of  stay)  can  be  more  easily 
monitored.  Standardization  of  medical  practices  has  also 
been  used  to  control  for  the  effects  of  potential  confound- 
ing variables  in  the  performance  of  unblinded  randomized 
trials.'''"  Similarly,  protocols  can  serve  as  a  method  for 
assessing  the  influence  of  future  practice  changes  on  clin- 
ical outcomes.  This  type  of  real-time  performance  assess- 
ment can  typically  be  performed  using  relatively  simple 
data  collection  methods."  This  allows  objective  determi- 
nation of  the  impact  of  the  practice  change  on  costs  and 
outcomes.  Finally,  protocols  can  serve  as  useful  instru- 
ments to  educate  health  care  workers  on  best  practices  and 
to  achieve  practice  changes,  especially  when  combined 
with  structured  educational  interventions.'-'^ 

The  success  of  protocol  use  in  respiratory  care  suggests 
that  protocols  are  here  to  stay.  Examples  of  respiratory 
care  practices  improved  by  the  implementation  of  proto- 
cols and  guidelines  include  arterial  blood  gas  utilization,'" 
weaning  of  supplemental  oxygen  from  mechanically  ven- 
tilated patients,'''  prevention  of  ventilator-associated  pneu- 
monia,"'-''' weaning  of  mechanical  ventilation,"*'''  and  ap- 
propriate utilization  of  respiratory  care  therapies  (eg,  chest 
physiotherapy,  aerosolized  medications,  oxygen  adminis- 
tration).-"-' Additionally,  respiratory  therapy  is  frequently 
involved  in  the  management  of  complex  disease  proce.s.ses 


938 


Respiratory  Care  •  August  20(X)  Vol  45  No  8 


Medical  Trainee  Experience  Versus  Optimizing  Clinical  Outcomes 


such  as  respiratory  failure  due  to  chronic  obstructive  pul- 
monary disease  or  acute  respiratory  distress  syndrome. 
Disease-specific  treatment  protocols  have  been  success- 
fully implemented  to  improve  the  outcomes  of  patients 
with  these  disorders. ^--^^ 

The  current  challenge  to  respiratory  care,  as  well  as  to 
other  medical  disciplines,  is  to  develop  strategies  for  the 
optimal  integration  of  treatment  protocols  into  routine  pa- 
tient care.  This  will  include  attention  to  medical  education 
issues,  routine  updating  of  the  protocol  based  on  new  med- 
ical information  or  technologic  advances,  periodic  review 
of  the  protocol's  implementation  to  determine  whether  ero- 
sion of  its  implementation  has  occurred,  and  cooperation 
with  other  health  care  disciplines  to  accomplish  the  stated 
goals  of  the  protocol.  This  will  require  a  concerted  invest- 
ment on  the  part  of  hospitals  and  health  care  organizations 
to  develop  respiratory  care  departments  capable  not  only 
of  developing  protocols,  but,  more  importantly,  of  allow- 
ing them  to  function  in  an  environment  that  optimizes  their 
capability  to  favorably  influence  patient  outcomes. 

Marin  H  KoUef  MD 

Barnes-Jewish  Hospital  and 

Washington  University  School  of  Medicine 

St  Louis,  Missouri 


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4.  Stoller  JK.  Thaggard  I.  Piquene  CA.  O'Brien  RG.  The  impact  of  a 
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5.  Lomas  J,  Anderson  GM,  Domnick-Pierre  K.  Vayda  E,  Enkin  MW, 
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6.  Morris  AH,  East  TD.  Wallace  CJ.  Franklin  M.  Heerman  L.  Kinder  T. 
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7.  Peterson  WL,  Cook  DJ.  Using  a  practice  guideline  for  safely  short- 
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8.  Clemmer  TP,  Spuhler  VJ.  Berwick  DM,  Nolan  TW.  Cooperation: 
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9.  Morris  AH,  Wallace  CJ,  Menlove  RL,  Clemmer  TP,  Orme  JF  Jr. 
Weaver  LK,  et  al.  Randomized  clinical  trial  of  pressure-controlled 


inverse  ratio  ventilation  and  extracorporeal  CO2  removal  for  adult 
respiratory  distress  syndrome.  Am  J  Respir  Crit  Care  Med  1 994;  1 49: 
295-305. 

10.  Valentine  RJ,  Duke  ML,  Inman  MH,  Graybum  PA,  Hagino  RT, 
Kakish  HB.  et  al.  Effectiveness  of  pulmonary  artery  catheters  in 
aortic  surgery:  a  randomized  trial.  J  Vascular  Surg  1998;27:203-21 1; 
discussion  21 1-212. 

11.  Bradley  EH,  Besdine  R.  Outcomes-based  quality  improvement:  re- 
ducing the  data  collection  burden.  J  Am  Geriatr  See  I998;46:534- 
535. 

12.  Civitarese  LA,  DeGregorio  N.  Congestive  heart  failure  clinical  out- 
comes study  in  a  private  community  medical  group.  J  Am  Board 
Fam  Prac  1999;  1 2:467^72. 

13.  Wigder  HN,  Cohan  Ballis  SF,  Lazar  L,  Urgo  R,  Dunn  BH.  Success- 
ful implementation  of  a  guideline  by  peer  comparisons,  education, 
and  positive  physician  feedback.  J  Emerg  Med  1999;17:807-810. 

14.  Pilon  CS,  Leathley  M,  London  R,  McLean  S,  Phang  PT,  Priestley  R, 
et  al.  Practice  guideline  for  arterial  blood  gas  measurement  in  the 
intensive  care  unit  decreases  numbers  and  increases  appropriateness 
of  tests.  Crit  Care  Med  1997;25:1308-1313. 

15.  Rotello  LC,  Warren  J,  Jastremski  MS,  Milewski  A.  A  nurse-directed 
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16.  Joiner  GA,  Salisbury  D,  Bollin  GE.  Utilizing  quality  assurance  as  a 
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monia. Am  J  Med  Qual  1996:11:100-103. 

17.  Kelleghan  SI,  Salemi  C,  Padilla  S.  McCord  M,  Mermilliod  G,  Canola 
T,  et  al.  An  effective  continuous  quality  improvement  approach  to 
the  prevention  of  ventilator-associated  pneumonia.  Am  J  Infect  Con- 
trol 1993;21:322-330. 

18.  Kollef  MH,  Shapiro  SD,  Silver  P,  St  John  RE,  Prentice  D,  Sauer  S, 
et  al.  A  randomized,  controlled  trial  of  protocol-directed  versus  phy- 
sician-directed weaning  from  mechanical  ventilation.  Crit  Care  Med 
1997;25:567-574. 

19.  Ely  EW,  Bennett  PA,  Bowton  DL,  Murphy  SM,  Florance  AM,  Ha- 
ponik  EF.  Large  scale  implementation  of  a  respiratory  therapist- 
driven  protocol  for  ventilator  weaning.  Am  J  Respir  Crit  Care  Med 
1999;  159:439-^446. 

20.  Kollef  MH,  Shapiro  SD,  Clinkscale  D,  Cracchiolo  L,  Clayton  D, 
Wilner  R.  et  al.  The  effect  of  respiratory  therapist-initiated  treatment 
protocols  on  patient  outcomes  and  resource  utilization.  Chest  2000; 
117:467^75. 

21.  Stoller  JK,  Mascha  EJ.  Kester  L.  Haney  D.  Randomized  controlled 
trial  of  physician-directed  versus  respiratory  therapy  consult  service- 
directed  respiratory  care  to  adult  non-ICU  inpatients.  Am  J  Respir 
Crit  Care  Med  1998;158:1068-1075. 

22.  Plant  PK,  Owen  JL,  Elliott  MW.  A  multicentre  randomized  con- 
trolled trial  of  the  early  u.se  of  non-invasive  ventilation  for  acute 
exacerbations  of  chronic  obstructive  pulmonary  disease  on  general 
respiratory  wards.  Lancet  (2000.  in  press). 

23.  Amato  MB.  Barbas  CS,  Medeiros  DM.  Magaldi  RB,  Schettino  GP, 
Lorenzi-Filho  G,  et  al.  Effect  of  a  protective-ventilation  strategy  on 
mortality  in  the  acute  respiratory  distress  syndrome.  N  Engl  J  Med 
1998;338:347-354. 


Correspondence:  Marin  H  Kollef  MD,  Division  of  Pulmonary  and  Crit- 
ical Care  Medicine.  Washington  University  School  of  Medicine,  Campus 
Box  8052,  660  S  Euclid  Avenue,  St  Louis  MO  63110.  E-mail: 
kollefm@msnotes.wustI.edu. 


Respiratory  Care  •  August  2000  Vol  45  No  8 


939 


The  Utilization  of  Long-Term  Home  Oxygen  Therapy  in  the 
United  States:  A  Few  Observations  and  Some  Suggestions 


As  numerous  scientific  studies  have  consistently  con- 
cluded, the  administration  of  long-term  home  oxygen  ther- 
apy (LTOT)  plays  a  vital  role  in  the  optimum  management 
of  certain  patients  afflicted  with  chronic  obstructive  pul- 
monary disease  (COPD).'^^  Specifically,  for  patients  af- 
flicted with  severe  hypoxemia  secondary  to  COPD  in  the 
chronic  stable  state,  LTOT  has  been  shown  to  improve 
survival  and  quality  of  life  and  reduce  the  incidence  of 
hospitalization.''-*  Further,  it  has  been  proven  that  for  these 
patients,  continuous  LTOT  (use  >  18  h/d,  7  d/wk),  is 
clearly  better  than  only  nocturnal  or  no  supplemental  ox- 
ygen at  all.  In  light  of  the  alarming  incidence  of  COPD  in 
the  United  States,  there  will  certainly  be  no  shortage  of 
patients  requiring  this  mode  of  therapy  in  the  years  ahead. ^■'* 
The  recognition  that  the  need  for  this  important  therapeu- 
tic intervention  in  the  United  States  will  only  intensify  was 
a  contributing  factor  behind  the  convening  of  the  Fifth 
Oxygen  Consensus  Conference  in  Washington  DC  in  Sep- 
tember 1999.  The  Conference's  recommendations,  pub- 
lished in  this  issue  of  Respiratory  Care,  are  intended  in 
part  to  ensure  that  the  current  widespread  availability  and 
accessibility  of  this  important  treatment  modality  not  be 
compromised  by  ill-conceived  or  reactionary  reimburse- 
ment policies.'  This  editorial  addresses  several  important 
issues  that  relate  to  the  current  manner  in  which  LTOT  is 
provided  in  the  United  States. 


See  The  Special  Article  on  Page  957 


Background 

Just  recently,  a  study  published  in  Respiratory  Care 
suggested  the  possibility  that  in  the  United  States  perhaps 
as  much  as  $150  million  per  year  might  be  being  made  in 
unnecessary  payment  for  patients  who  do  not  really  need 
LTOT.'"  Given  the  enormous  annual  expenditures  for 
LTOT  in  the  United  States  and  the  disproportionate  per- 
centage of  the  total  sum  paid  by  the  Medicare  and  Med- 
icaid programs,  such  a  suggestion  is  both  troublesome  and 
worrisome.  It  is  troublesome  in  that  the  mechanism  for 
providing  a  proven  therapeutic  intervention  is  being  called 
into  question  and  worrisome  in  regard  to  how  such  find- 
ings might  infiuence  future  reimbursement  decisions.  This 
is  especially  so  in  light  of  several  recent  major  initiatives 
by  the  federal  government  to  contain  Medicare  payments 


for  home  oxygen  equipment  through  massive  cuts  to  tra- 
ditional reimbursement  levels. 

Though  the  scientific  basis  for  the  prescribing  and  ad- 
ministration of  LTOT  has  been  well  established  world- 
wide, data  now  indicate  that  LTOT  use  in  the  United  States, 
on  a  per  capita  basis,  far  exceeds  LTOT  use  in  other  major 
industrialized  countries."'-  Assuming  there  are  approxi- 
mately 750,000  current  LTOT  users  nationwide'^  (some 
believe  the  number  might  actually  be  closer  to  1  mil- 
lion!'-*), this  represents  a  per  capita  incidence  of  240/ 
100,000,  an  astounding  8-fold  higher  than  in  other  major 
industrialized  nations  (Table  1).''^  Various  reasons  have 
been  proffered  to  explain  this  enormously  higher  incidence 
of  LTOT  in  the  United  States,  including  higher  awareness 
of  the  proven  benefits  of  LTOT,  greater  health  care  acces- 
sibility, widespread  availability  of  LTOT,  and  very  favor- 
able reimbursement  criteria.""'''  However,  perhaps  an- 
other explanation  might  be  found  in  the  widespread  practice 
of  prescribing  LTOT  for  patients  who,  at  the  time  of  hos- 
pital discharge,  are  in  a  clinically  unstable  state.'" 

Clinical  Stability  of  Hypoxemia 

Specifically,  the  prescribing  guidelines  of  the  Third  Ox- 
ygen Consensus  Conference  state  that  "once  the  (clinically 
unstable)  patient  has  reached  a  state  of  clinical  stability 
and  is  receiving  optimal  therapy,  which  may  require  a 
period  of  one  to  three  months,  the  need  for  long-term 
(lifetime)  oxygen  therapy  should  be  reassessed  by  the  mea- 
surement of  arterial  oxygen  tension  or  saturation"."'  This 
requirement  echoes  recommendations  published  earlier  in 
the  proceedings  of  the  National  Conference  on  Oxygen 
Therapy  held  by  the  American  College  of  Chest  Physi- 
cians and  the  National  Heart,  Lung,  and  Blood  Institute.''' 
Perhaps  even  more  important  to  note  is  that  ensuring  clin- 
ical stability  was  a  major  condition  for  inclusion  in  the 
Nocturnal  Oxygen  Therapy  Trial  study. ^  In  fact,  as  re- 
ported by  Timms  et  al,  45  patients  initially  recruited  for 
that  landmark  study  were  dropped  after  4  weeks  when 
retesting  revealed  their  arterial  blood  oxygen  tensions  no 
longer  satisfied  the  selection  criteria.'* 

However,  in  the  United  States,  it  is  not  uncommon  for 
patients  to  be  discharged  following  hospitalization  for  an 
acute  exacerbation  of  COPD,  even  though  recovery  to  the 
pre-existing  chronic  stable  state  may  still  be  weeks  or  even 
months  away.'"  Although  still  very  ill,  in  today's  cost- 


940 


Respiratory  Care  •  August  2000  Vol  45  No  8 


Utilization  of  Long-Term  Home  Oxygen  Therapy 


Table  !.      Per  Capita  Use  of  Long-Term  Oxygen  Therapy 


Country 


Use  Per 
100,000  People 


Japan 
England 
France 
Canada 
United  States 


19 
20 
26 
60 

241 


conscious  health  care  system  these  patients  are  nonethe- 
less considered  ideal  candidates  for  early  discharge.  Given 
the  cost-containment  pressures  to  reduce  lengths  of  stay, 
especially  for  elderly  Medicare  patients,  hospital  discharge 
is  often  accelerated.'"*  Typically,  patients  are  discharged  to 
home  on  a  therapeutic  regimen  that  is  an  extension  or  an 
actual  continuation  of  care  that  was  initiated  during  hos- 
pitalization: antibiotics,  corticosteroids,  bronchial  hygiene 
and  airway  clearance  techniques,  and  supplemental  oxy- 
gen. Fortunately,  many  of  these  patients  do  eventually 
recover  to  near  pre-existing  baseline  function  through  a 
combination  of  receiving  home  care  services  and/or  com- 
plying with  prescribed  continuing  self-care  regimens,  in- 
cluding LTOT. 

As  one  would  expect,  the  majority  of  these  patients, 
because  of  their  acutely  damaged  and  stressed  cardiopul- 
monary systems  at  the  time  of  discharge,  will  clinically 
satisfy  the  qualifying  blood  gas  levels  required  for  third- 
party  home  oxygen  reimbursement,  most  notably  those 
promulgated  by  Medicare.  The  requirement  is  a  resting, 
room-air  arterial  partial  pressure  of  oxygen  <  55  mm  Hg 
or  arterial  saturation  oxygen  <  88%.  and  the  qualifying 
test  must  be  measured  within  2  days  of  discharge  from  an 
inpatient  facility  to  home.-°  In  Medicare  parlance,  such 
patients  are  classified  as  Group  I.  making  it  permissible  for 
the  attending  physician  to  prescribe  the  LTOT  for  up  to  99 
months  (also  known  as  "'lifetime"  in  Medicare  parlance). 

For  Group  I  patients,  if  the  initial  estimated  length  of 
need  prescribed  by  the  physician  is  greater  than  1 2  months, 
recertification  to  determine  continued  medical  necessity  is 
required  in  month  1 2.  However,  if  the  estimated  length  of 
prescribed  need  is  for  a  period  of  less  than  1 2  months,  then 
recertification  is  required  during  the  last  month.  In  neither 
case  is  concomitant  retesting  of  the  arterial  blood  oxygen 
tension  or  saturation  actually  required  for  the  recertifica- 
tion of  Group  I  patients. 

In  lieu  of  retesting  during  the  recertification  of  Group  I 
patients,  current  guidelines  call  for  the  "results  of  the  most 
recent  arterial  blood  gas  or  oximetry  test  representing  the 
patient's  chronic  stable  state  (to)  be  included  on  the  form" 
(emphasis  added).-"  In  many  cases,  the  most  recent  test 
may  be  the  results  of  the  original  qualifying  test  or  other 
tests  taken  soon  thereafter  and  might  not  reflect  the  chronic 
stable  state  or  the  magnitude  of  the  hypoxemic  condition 


at  the  actual  time  of  recertification.  Recertifying  the  con- 
tinued medical  need  for  LTOT  in  a  patient  with  advanced 
COPD  without  requiring  concomitant  retesting  of  arterial 
blood  oxygen  tension  or  saturation  is  of  questionable  re- 
liability and  may  indeed  result  in  LTOT  continuing  to  be 
used  unnecessarily  by  those  who  no  longer  qualify. 

It  should  be  noted  that  Medicare  does  require  recertifi- 
cation and  retesting  for  all  Group  II  patients  between  the 
61st  and  90th  day  following  the  initial  prescription  for 
home  oxygen.  These  are  patients  who,  at  the  time  of  initial 
prescription,  present  with  a  resting,  room-air  arterial  par- 
tial pressure  of  oxygen  of  56-59  mm  Hg  or  arterial  oxy- 
gen saturation  of  89%  but  who  also  demonstrate  clinical 
evidence  indicative  of  pulmonary  hypertension,  right  ven- 
tricular hypertrophy,  or  elevated  hematocrit.^o 

The  importance  of  recertifying  and  retesting  all  new 
LTOT  patients  1-3  months  after  initiation  of  therapy  is 
underscored  by  the  work  of  Oba  et  al.  Indeed,  they  ob- 
served that  two  thirds  of  hypoxemic  COPD  patients  dis- 
charged to  home  in  the  clinically  unstable  state  on  LTOT 
(all  initially  satisfying  Group  I  criteria)  were  not  reevalu- 
ated when  the  chronic  stable  state  was  achieved.'"  For 
those  patients  who  were  appropriately  reevaluated  and  re- 
tested  1-3  months  following  discharge.  58%  no  longer 
satisfied  arterial  blood  oxygen  tension  or  saturation  level 
requirements  for  continued  coverage.  Presumably  the 
higher  blood  oxygen  levels  observed  in  these  patients  were 
attributable  to  having  recovered  to  the  chronic  stable  state 
and  the  ability  to  maintain  adequate  oxygenation.  In  these 
cases.  LTOT  was  properly  discontinued. 

Thus,  the  higher  LTOT  incidence  in  the  United  States 
may  well  be  the  result  of  the  widespread  practice  of  pre- 
scribing LTOT  for  COPD  patients  following  acute  exac- 
erbations and  of  not  routinely  conducting  requalifying  lab- 
oratory tests  once  these  patients  have  had  the  opportunity 
to  return  to  the  pre-existing  chronic  stable  state.  Recerti- 
fication and  retesting  of  blood  oxygen  levels  to  requalify 
for  continuation  of  LTOT  is  only  required  for  Group  II 
patients.  Patients  who  initially  satisfy  Group  I  criteria  re- 
quire one  additional  recertification,  which  may  or  may  not 
include  concomitant  retesting. 

This  raises  the  interesting  observation  that  coverage  cri- 
teria for  LTOT  in  the  United  States  is  not  yet  fully  in 
accord  with  the  recommendations  of  the  Third  Oxygen 
Consensus  Conference,  which  evidently  is  not  the  case  in 
other  countries,  where  strict  adherence  to  the  guidelines  is 
reported.'"-'--  This  may  contribute  to  the  very  real  (and 
highly  controversial)  possibility  raised  by  the  Oba  study — 
that  a  substantial  portion  of  the  LTOT  administered  in  the 
United  States,  when  viewed  within  the  context  of  interna- 
tional consensus  standards  for  patient  selection  and  fol- 
low-up, may  be  neither  clinically  indicated  nor  medically 
necessary.'" 


Respiratory  Care  •  August  2000  Vol  45  No  8 


941 


Utilization  of  Long-Term  Home  Oxygen  Therapy 


It  is  important  to  restate  that,  if  once  the  chronic  stable 
state  is  reached  and  retesting  performed  for  the  purposes 
of  quahfying  a  patient  for  LTOT  does  reveal  the  continu- 
ing presence  of  serious  hypoxemia  (ie,  satisfying  Group  I 
criteria),  then  LTOT  should  be  continued  and  additional 
retesting  should  not  be  required  until  or  unless  changes  are 
made  to  the  current  prescription.  Once  continued  need  in 
the  chronic  stable  state  is  established,  it  is  important  to 
ensure  that  LTOT  continues  to  be  used  as  prescribed  and 
in  conjunction  with  other  maintenance  therapeutic  inter- 
ventions, including  smoking  cessation  and,  ideally,  outpa- 
tient pulmonary  rehabilitation.  In  fact,  the  entire  issue  of 
noncompliance  and  the  related  matter  of  payments  con- 
tinuing to  be  made  for  oxygen  equipment  that  is  not  being 
appropriately  used  remain  a  major  problem  in  the  United 
States,  and  warrant  serious  study. '"-'^ 

Routine  Retesting:  Cost  Versus  Benefit 

Additional  requirements  for  retesting  and  requalifying 
patients  for  LTOT  will  contribute  to  an  increase  in  health 
care  utilization.  Repeat  office  or  clinic  visits  coupled  with 
the  added  costs  of  having  additional  laboratory  tests  per- 
formed will  certainly  result  in  increased  costs.  However,  if 
retesting  that  is  conducted  once  the  chronic  stable  state  has 
been  reached  indicates  the  LTOT  can  be  safely  discontin- 
ued, then  the  overall  savings  would  make  the  additional 
costs  of  recertification  pale  in  comparison.  Further,  it  is 
important  to  note  that  patients  with  advanced  COPD,  es- 
pecially those  who  have  recently  experienced  an  acute 
exacerbation  requiring  hospitalization,  need  follow-up  care 
and  continued  medical  oversight.  Again,  the  expense  of 
providing  regular  intermittent  out-patient  care,  if  success- 
ful in  achieving  and  maintaining  the  chronic  stable  state, 
would  be  more  than  offset  by  savings  realized  elsewhere. 
Future  exacerbations  and  possible  rehospitalizations  re- 
sulting from  clinical  deterioration  through  neglect  or  re- 
lapse to  self-destructive  behavior  (eg,  cigarette  smoking) 
could  be  significantly  reduced.  Thus,  rather  than  having 
office  or  clinic  visits  strictly  for  the  purposes  of  qualifying 
for  LTOT,  activities  conducted  during  follow-up  visits 
could  be  part  of  a  more  comprehensive  disease  manage- 
ment program  aimed  at  slowing  the  rate  of  pulmonary 
deterioration  and  the  onset  of  more  debilitating  disability. 

Most  industry  experts  now  agree  that  the  Health  Care 
Financing  Administration's  approach  to  reducing  annual 
Medicare  expenditures  for  LTOT  by  making  indiscrimi- 
nate cuts  in  reimbursement  is  short-sighted  and  misguided. 
Recent  cuts  were  not  predicated  on  reliable  or  valid  data 
showing  monthly  allowed  reimbursement  rates  as  being 
substantially  out  of  line  with  the  true,  overall  costs  of 
providing  the  currently  acceptable  level  of  home  oxygen 
equipment  and  ongoing  services  expected  by  the  medical 
community.  For  example,  the  30%  across-the-board  re- 


duction mandated  in  the  Balanced  Budget  Act  of  1997  and 
already  implemented  nationwide  was  predicated  on  data 
from  a  review  of  the  Department  of  Veterans  Affairs  that 
was  incomplete  and  less  than  accurate.'  And,  in  spite  of 
the  magnitude  and  timing  of  the  30%  cut,  in  Polk  County, 
Florida,  there  is  currently  a  competitive  bidding  demon- 
stration project  underway,  likewise  part  of  the  1997  Bal- 
anced Budget  Act.  For  Polk  County  and  for  the  recently 
announced  second  site  (San  Antonio,  Texas),  home  oxy- 
gen equipment  and  services  was  selected  as  one  of  the  5 
categories  of  durable  medical  equipment  and  prosthetic 
and  orthotic  services  identified  for  study. ^^  It  is  interesting 
that  the  winning  bid  for  home  oxygen  equipment  in  Polk 
County  was  17%  lower  than  the  Medicare  allowable  fol- 
lowing the  implementation  of  the  aforementioned  30% 
reimbursement  reduction  mandated  by  the  Balanced  Bud- 
get Act.  Of  greater  concern  is  that  the  Health  Care  Financ- 
ing Administration  Administrator  Nancy-Ann  Min 
DeParle,  a  scant  6  months  after  implementation  of  the 
competitive  bidding  project  in  Polk  County,  has  already 
declared  the  lower  oxygen  rate  as  "an  additional  17%  sav- 
ings" for  the  Medicare  Program.-"  One  must  therefore  an- 
ticipate federal  policy  makers  soon  starting  to  contemplate 
additional  cuts  based  on  preliminary  (and  some  would 
argue  misleading)  findings  in  the  competitive  bidding  dem- 
onstration projects. 

It  is  clear  that  the  federal  government  will  continue  to 
seriously  study  expenditures  made  for  home  oxygen  and 
that  the  findings  reported  by  Oba  et  al  will  not  go  unno- 
ticed, even  though  questions  regarding  the  study's  meth- 
odology could  be  raised.  There  is  rightful  concern  that 
additional  cuts  will  jeopardize  the  ability  of  some  home 
medical  equipment  providers  to  continue  to  provide  the 
benefit:  reimbursement  levels  must  cover  the  actual  total 
costs  of  providing  the  benefit  or  providers  will  no  longer 
be  able  to  afford  to  offer  the  service.  It  would  be  unfor- 
tunate if  a  much  needed  and  scientifically  validated  med- 
ical intervention  were  no  longer  available  as  a  result  of 
unrealistic  reimbursement  levels  mandated  by  governmen- 
tal fiat  in  reaction  to  the  perception  that  LTOT  providers 
are  being  reimbursed  for  unnecessary  or  unused  home  ox- 
ygen equipment. 

Some  Suggestions 

To  help  address  some  of  the  serious  concerns  and  per- 
ceptions about  how  LTOT  is  provided  in  the  United  States, 
and  to  bring  the  qualifying  process  more  completely  in 
line  with  what  has  worked  quite  successfully  elsewhere, 
the  following  suggestions  are  put  forth  for  consideration 
and  thoughtful  deliberation. 

1 .  All  initial  LTOT  prescriptions  should  be  limited  to  a 
maximum  period  of  90  days,  at  which  time  recertification 
with  concomitant  retesting  is  performed  to  establish  med- 


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Respiratory  Care  •  August  2000  Vol  45  No  8 


Utilization  of  Long-Term  Home  Oxygen  Therapy 


ical  necessity  for  continued  need.  Such  a  policy  would 
lessen  the  mitigating  influence  of  having  initial  qualifying 
tests  performed  while  the  patient  is  in  the  clinically  unsta- 
ble state.  It  would  also  echo  the  recommendations  of  the 
aforementioned  National  Conference  on  Oxygen  Therapy 
and  the  recommendations  of  the  Third  and  Fifth  Oxygen 
Con.sensus  Conferences.'"""'''' 

2.  Recertification  and  retesting  should  be  conducted 
under  the  direct  auspices  of  a  physician  knowledgeable 
and  proficient  in  pulmonary  medicine  and  with  immediate 
access  to  a  qualified  testing/assessment  facility  (eg,  a 
hospital-based  respiratory  care  department  or  outpatient 
clinic).  By  all  accounts,  LTOT  is  a  complex  and  intricate 
undertaking.  The  medical  usefulness  and  correct  applica- 
tion is  still  undergoing  clinical  investigation  and  evolution. 
Indeed.  Oba  et  al  observed  a  striking  difference  between 
LTOT  recertification  conducted  by  primary  care  physi- 
cians and  by  pulmonary  physicians:  the  rate  of  appropriate 
reevaluation  was  significantly  higher  among  pulmonary 
physicians  than  among  primary  care  physicians  (65%  vs 
n%.  p  <  0.01).'"  Thus,  optimum  use  of  LTOT,  including 
determining  the  need  for  continued  use  and  optimum  dos- 
ing, requires  state-of-the-art  knowledge  and  expertise.  This 
suggestion  merely  echoes  the  National  Conference  on  Ox- 
ygen Therapy  guidelines  as  well  as  recommendations  from 
the  Third,  Fourth,  and  Fifth  Oxygen  Consensus  Confer- 
ences.9'* '^^5  Perhaps  more  importantly,  this  requirement 
would  bring  the  United  States  into  full  parity  with  sim- 
ilar requirements  in  other  countries.'^-'-''--'*  Lastly,  the 
precedent  of  requiring  a  physician  specialist  to  establish 
medical  necessity  for  certain  items  of  home  medical 
equipment  already  exists  in  Medicare.  For  example,  doc- 
umentation for  a  power-operated  vehicle  is  expected  to  be 
provided  by  a  physician  acknowledged  as  a  specialist  in 
rehabilitative  medicine,  orthopedic  surgery,  neurology,  or 
rheumatology. -** 

3.  Once  continued  medical  necessity  has  been  estab- 
lished, reevaluation  with  retesting  need  only  be  conducted 
when  there  is  a  change  made  to  the  existing  prescription. 

4.  The  recertification/retesting  process  should  also  in- 
clude an  assessment  (inclusive  of  basic  spirometry)  of  each 
patient's  cardiopulmonary  function  and  disease  status.  This 
suggestion  simply  represents  the  appropriate  disease  man- 
agement strategy  to  help  track  the  natural  progression  of 
the  underlying  COPD.  It  also  mirrors  recommendations 
put  forth  in  the  new  National  Lung  Health  Education  Pro- 
gram guidelines.'*  In  this  context.  LTOT  becomes  one  of 
many  continuing  care  therapeutic  options  intended  to  pro- 
long periods  of  health  for  patients  afflicted  with  a  debili- 
tating and  life-threatening  chronic  medical  condition.  Ide- 
ally, all  of  these  patients  should  likewise  receive  some 
type  of  formal  outpatient  pulmonary  rehabilitation,  the  pos- 
itive, cost-effective  long-term  benefits  of  which  continue 


to  be  scientifically  validated  both  domestically  and  in  the 
international  community. ■'■*'"^"-^' 

5.  All  other  recommendations  of  the  Fifth  Oxygen  Con- 
sensus Conference  should  be  endorsed  and  accepted  in 
their  entirety  by  prescribers,  providers,  and  those  respon- 
sible for  promulgating  coverage  and  reimbursement  deci- 
sions for  LTOT.  Additionally,  funding  for  the  proposed 
scientific  research  is  desperately  needed  and  should  be 
made  available  for  interested  stakeholders. 

These  suggestions,  if  considered  and  implemented,  could 
go  a  long  way  toward  providing  a  solid  foundation  on 
which  a  clinically  proven  and  inherently  cost-effective  treat- 
ment option  would  continue  to  be  available  for  the  grow- 
ing number  of  people  who  will  eventually  need  it.  Other- 
wise, there  is  the  serious  risk  that  government  policy 
makers,  amid  growing  suggestions,  revelations,  and  per- 
ceptions of  over-utilization  and  possible  unnecessary  use, 
will  consider  further  cuts  to  reimbursement  levels  already 
precariously  close  to  breaking  even.  Further  cuts  would 
make  it  financially  difficult,  if  not  impossible,  for  provid- 
ers to  continue  to  render  optimum  and  individualized  LTOT, 
much  to  the  detriment  of  hundreds  of  thousands  of  se- 
verely hypoxemic,  chronically  stable  COPD  patients  in  the 
United  States. 

Patrick  J  Dunne  MEd  RRT  FAARC 

Healthcare  Productions 
Fullerton,  California 


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Medicare  .supplier  manual.  IX:  72,  Jun  1999. 

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Long-term  effects  of  outpatient  rehabilitation  of  COPD:  a  random- 
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P,  et  al.  Optimal  assessment  and  management  of  chronic  obstructive 
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Patrick  J  Dunne  MEd  RRT  FAARC  is  affiliated  with  HealthCare  Pro- 
ductions, Fullerton,  California. 

Correspondence:  Patrick  J  Dunne  MEd  RRT  FAARC,  HealthCare  Pro- 
ductions, Sunny  Hills  Station,  PO  Box  5767,  Fullerton  CA  92838-9998. 


944 


Respiratory  Care  •  August  2000  Vol  45  No  8 


Original  Contributions 


The  Impact  of  a  Respiratory  Therapy  Consult  Service  on 
House  Officers'  Knowledge  of  Respiratory  Care  Ordering 

James  K  Stoller  MD,  Irene  Thaggard  RRT,  Craig  A  Piquette  MD,  and  Ralph  G  O'Brien  PhD 

BACKGROUND:  Although  available  studies  show  that  implementation  of  respiratory  care  proto- 
cols by  respiratory  therapists  can  enhance  the  allocation  of  respiratory  care  services,  concern  has 
been  expressed  that  respiratory  therapists'  involvement  in  assessing  patients  and  in  determining 
treatment  plans  may  detract  from  medical  trainees'  education  and  experience  in  ordering  respi- 
ratory care  services.  OBJECTIVE:  Compare  the  rates  of  correct  responses  to  case-based  questions 
about  respiratory  care  ordering  in  two  groups  of  internal  medicine  house  officers  at  academic 
medical  centers:  one  group  training  at  an  institution  using  respiratory  care  protocols  (The  Cleve- 
land Clinic  Foundation)  and  the  other  group  training  in  an  institution  at  which  respiratory  care 
protocols  have  not  been  used  (University  of  Nebraska).  DESIGN:  Prospective  cohort  study. 
SETTING:  Two  academic  medical  centers,  one  using  respiratory  protocols  and  the  other  not  using 
respiratory  care  protocols.  MEASUREMENTS:  Percent  of  correct  responses  to  questions  regarding 
respiratory  care  management  posed  in  5  case  studies  administered  to  both  groups.  RESULTS: 
Responses  were  available  from  41  and  17  internal  medicine  house  officers  at  The  Cleveland  Clinic 
Foundation  and  University  of  Nebraska,  respectively.  Respondents  represented  postgraduate  years 
one,  two,  and  three,  and  constituted  a  similar  percentage  of  all  internal  medicine  house  officers  at 
each  institution  (33%).  The  rate  of  correct  responses  to  the  20  questions  posed  in  the  5  case  studies 
was  high  overall  (76.8%)  and  similar  in  the  two  house  staff  groups  (77,2  ±  11.6%  at  The  Cleveland 
Clinic  Foundation  and  75.8  ±  12.0%  at  University  of  Nebraska,  p  =  0.69).  The  95%  confidence 
interval  for  the  difference  straddled  zero  (-5.4%,  8.1%),  making  it  very  unlikely  that  any  important 
difference  exists  between  the  two  groups  in  rate  of  correct  responses.  Analysis  of  covariance  also 
showed  no  difference  between  groups,  suggesting  that  postgraduate  training  level  did  not  affect  this 
conclusion.  In  one  of  the  5  case  studies,  the  percent  of  correct  responses  was  higher  among  trainees 
where  respiratory  care  protocols  were  in  use  (86.8  ±  18%  at  The  Cleveland  Clinic  Foundation  vs 
69.1  ±  14%  at  University  of  Nebraska,  p  =  0.0001).  CONCLUSIONS:  In  this  comparison  of 
internal  medicine  house  officers'  knowledge  regarding  respiratory  care  ordering  at  institutions 
using  versus  not  using  respiratory  care  protocols,  the  rates  of  correct  responses  by  both  groups  were 
similar  and  unlikely  to  differ  significantly.  For  one  of  the  5  case  studies,  respondents  from  the 
institution  using  respiratory  care  protocols  scored  significantly  higher.  Taken  together,  these  results 
suggest  that  use  of  respiratory  care  protocols  implemented  by  respiratory  therapists  does  not 
detract  from  internal  medicine  trainees'  expertise  in  respiratory  care  management.  Whether  these 
results  generalize  to  other  institutions  or  reflect  expertise  in  actual  practice  remains  uncertain. 
[Respir  Care  2000;45(8):945-952]  Key  words:  protocol,  training,  trainee,  resident,  ordering,  respira- 
tory care,  algorithm,  guideline. 


James  K  Stoller  MD  and  Irene  Thaggard  RRT  are  affiliated  with  the  Correspondence:  James  K  Stoller  MD.  Department  of  Pulmonary  and 

Department  of  Pulmonary  and  Critical  Care  Medicine,  Section  of  Respi-  Critical  Care  Medicine,  A  90,  The  Cleveland  Clinic  Foundation,  9500 

ratory  Therapy.  The  Cleveland  Clinic  Foundation,  Cleveland.  Ohio.  Ralph  Euclid  Avenue,  Cleveland  OH  44195.  E-mail:  stollej@ccf.org. 

G  O'Brien  PhD  is  affiliated  with  the  Department  of  Biostatistics  and 
Epidemiology,  The  Cleveland  Clinic  Foundation,  Cleveland,  Ohio.  Craig 
A  Piquette  MD  is  affiliated  with  the  Department  of  Pulmonary  and  Crit- 
ical Care,  University  of  Nebraska  School  of  Medicine,  Omaha,  Nebraska 


Respiratory  Care  •  August  2000  Vol  45  No  8  945 


Impact  of  a  Respiratory  Therapy  Consult  Service 


Respiratory  therapy  "evaluate  and  treat"  programs,  in 
which  respiratory  therapists  (RTs)  determine  the  patient's 
respiratory  care  plan  based  on  explicit  algorithms  and/or 
care  plan  guidelines,  are  being  widely  implemented  based 
on  evidence  that  use  of  such  programs  can  enhance  the 
appropriateness  of  respiratory  care  prescribing,  while  less- 
ening costs  of  care  and  averting  morbidity.'"  Despite  these 
advantages,  a  potential  impediment  to  instituting  such  pro- 
grams in  teaching  hospitals  is  the  concern  that  RTs'  in- 
volvement in  assessing  patients  and  in  determining  respi- 
ratory care  treatments  may  detract  from  medical  trainees' 
education  and  experience  with  ordering  respiratory  care. 
In  an  initial  effort  to  address  these  concerns,  a  survey  of 
medical  house  officers  was  conducted  at  The  Cleveland 
Clinic  Foundation  about  our  Respiratory  Therapy  Consult 
Service  (RTCS),  which  showed  that  97%  of  respondents 
regarded  the  RTCS  as  being  helpful  in  the  care  of  their  pa- 
tients, that  56%  regarded  the  RTCS  as  enhancing  their  knowl- 
edge of  respiratory  care  ordering,  but  that  32%  felt  that  the 
RTCS  detracted  from  their  knowledge  of  respiratory  care.' 


See  The  Related  Editorial  on  Page  938 


To  clarify  whether  these  survey  responses  reflect  actual 
expertise  among  medical  trainees  and  whether  use  of  the 
RTCS  actually  affects  house  officers'  knowledge  of  respi- 
ratory care  ordering,  the  current  study  was  undertaken. 
Specifically,  based  on  the  prior  survey  data,  we  hypothe- 
sized that  use  of  the  RTCS  does  not  detract  from  house 
officers'  expertise  in  prescribing  respiratory  care  treat- 
ments. More  specifically,  we  hypothesized  that  respiratory 
care  orders  generated  by  house  officers  in  an  institution 
using  respiratory  care  protocols  were  as  frequently  correct 
as  those  generated  by  house  officers  training  in  an  insti- 
tution where  respiratory  care  protocols  were  not  in  use.  To 
address  this  issue,  the  current  study  compares  house  of- 
ficers' responses  on  clinical  case  studies  regarding  respi- 
ratory care  management  from  two  academic  teaching  hos- 
pitals, one  in  which  a  respiratory  therapy  consult  service 
has  been  in  longstanding  use  (The  Cleveland  Clinic  Foun- 
dation) and  one  in  which  such  a  program  is  not  in  use  (the 
University  of  Nebraska  Hospital). 

Methods 

We  evaluated  internal  medicine  house  officers'  responses 
to  questions  about  the  respiratory  care  management  of  5 
patients  who  were  described  in  brief  written,  clinical  vi- 
gnettes. Specifically,  every  respondent  was  asked  to  re- 
view 5  case  studies  (see  Appendix),  each  of  which  posed 
4  multiple  choice  questions  about  what  types  of  respira- 


tory care  treatments  were  indicated  for  the  patient's  man- 
agement. To  avoid  institutional  practice  bias  that  might 
influence  scores  and  to  assure  fairness  in  comparing  the 
rates  of  correct  responses  from  the  two  participating  insti- 
tutions, all  case  studies  were  drafted  jointly  by  the  medical 
directors  and  selected  RTs  at  both  participating  institu- 
tions. Case  studies  were  adopted  for  study  use  only  after 
concordance  about  all  answers  was  reached  by  reviewers 
at  both  institutions,  using  the  Clinical  Practice  Guidelines 
of  the  American  Association  for  Respiratory  Care. 

Details  of  The  Cleveland  Clinic  Foundation  (CCF)  RTCS 
have  been  described  previously.*-^  In  brief,  the  RTCS  is  a 
service  in  which  RTs  determine  patients'  respiratory  care 
plans  based  on  sign/symptom-based  branched  logic  algo- 
rithms that  reflect  the  Clinical  Practice  Guidelines  of  the 
American  Association  for  Respiratory  Care.  To  advance 
the  educational  mission  of  the  RTCS,  handbooks  contain- 
ing all  the  respiratory  care  algorithms  have  been  distrib- 
uted to  all  CCF  fellows  and  house  officers  yearly  since 
July  1994.  Also,  since  the  inception  of  the  RTCS,  RTs 
have  been  actively  encouraged  to  discuss  the  algorithms 
and  Clinical  Practice  Guideline-based  respiratory  care  or- 
dering with  medical  trainees. 

Eligible  house  officers  were  internal  medicine  residents 
(ie,  intems,  junior  and  senior  residents)  in  the  training  pro- 
grams of  the  University  of  Nebraska  and  CCF.  Visiting  res- 
idents or  trainees  in  affiliated  programs  were  not  included. 

The  case  studies  were  distributed  to  eligible  house  of- 
ficers at  both  institutions  in  early  fall  of  1998  with  a  verbal 
request  for  respondents  to  answer  all  questions.  At  CCF, 
the  case  studies  were  distributed  at  a  routinely  scheduled 
meeting  of  the  internal  medicine  house  staff,  after  a  brief 
introduction  by  the  study  investigators  (JKS,  IT).  Use  of 
reference  materials  (eg,  textbooks,  respiratory  care  hand- 
books) was  permitted,  but  house  officers  were  asked  not  to 
compare  their  responses  with  those  of  colleagues.  Nonre- 
sponding  attendees  were  called  by  one  of  the  study  inves- 
tigators to  encourage  their  submitting  responses.  At  the 
University  of  Nebraska,  the  internal  medicine  house  staff 
was  invited  to  a  special  lunch  conference  to  discuss  respi- 
ratory care.  Participants  were  told  that  the  questionnaire 
was  to  determine  their  knowledge  regarding  respiratory 
care  practices  but  were  not  otherwise  informed  of  the  pur- 
pose of  the  study.  Questionnaires  were  distributed  and 
participants  were  asked  to  answer  the  questions  without 
reference  materials  or  discussion  among  colleagues.  The 
questionnaires  were  collected  when  the  group  had  fin- 
ished, and  the  answers  were  reviewed.  No  attempt  was 
made  to  increase  participation  after  the  initial  session. 

Responses  were  tallied  and  scores  were  converted  to 
percent  correct  for  each  of  the  5  cases  and  for  the  overall 
score.  Means,  standard  deviations,  and  95%  confidence 
intervals  (CIs)  were  computed.  Because  no  critical  distri- 
butional problems  were  found,  differences  between  the 


946 


Respiratory  Care  •  August  2000  Vol  45  No  8 


Impact  of  a  Respiratory  Therapy  Consult  Service 


Table  I .      Characteristics  of  Respondents  in  the  Current  Survey 


Postgraduate 

The  Cleveland  Clinic  Foundation 

Mean  %  Correct  for 
All  Cases 

University 

of  Nebraska 

Mean  %  Correct  for 

Year 

Number 

% 

Respondents 

Number 

%  Respondents 

All  Ca.ses 

1 

21 

51 

77.3 

5 

29 

80,0 

2 

13 

32 

73.7 

5 

29 

64.0 

3 

7 

17 

83.6 

7 

42 

80.7 

Total 

41 

100 

77.2  ±11.6 
95%  CI:  73.6%, 

80.9% 

17 

100 

75.8  ±  12.0 

95%  CI:  69.7%.  82.1% 

Table  2.      Percent  of  Correct  Responses  by  Case  Study 


Case 

The  Cleveland  Clinic 

Foundation  (n  =  41) 

Mean  (%)  ±  SD 

University  of  Nebraska 

in  =  17) 

Mean  (%)  ±  SD 

(The  Cleveland  Clinic 
Mean  (%)  ±  SD 

Difference 
Foundation — University  of  Nebraska) 

95%  CI  (%)                         p 

1 

84.2  ±  20.0 

92.7  ±  14.7 

-9±  19 

-19.2 

0.12 

2 

86.6  ±  17.8 

69.1  ±  14.1 

17  ±  17 

8,27 

0.0007 

3 

67.5  ±  24.2 

72.1  ±  27.8 

-5  ±25 

-19,  10 

0.54 

4 

77.0  ±21.3 

72.1  ±  17.4 

49  ±20 

-7.  17 

0.41 

5 

70.8  ±  14.0 

73.5  ±  16.5 

-3±  15 

-12,61 

0.54 

All 

77.2  ±  11.6 

75.8  ±  12.0 

14  ±  12 

-5.4,  81 

0.69 

two  sites  were  compareti  using  t  tests  with  ^c  =0.01  (all 
tests  two-tailed)  on  the  5  separate  cases  (Bonferoni  cor- 
rection for  multiple  comparisons:  0.05/5)  and  ^  =  0.05  for 
the  test  of  the  overall  score.  Each  mean  difference  was  also 
described  using  95%  CIs.  Analysis  of  covariance  model- 
ing was  used  to  adjust  for  year  of  postgraduate  training. 
Parallel  analyses  were  done  using  the  Welch-type  t  test  (no 
assumption  of  common  variance),  the  Wilcoxon  rank-sum 
test  (nonparametric),  and  using  a  multivariate  profile  anal- 
ysis (Hotelling's  T")  over  the  5  cases.  These  three  alter- 
native approaches  all  gave  results  that  were  congruent  with 
the  r-based  analyses  and  thus  are  not  reported  here.  All 
computations  were  done  using  the  SAS  System  Version  8 
(SAS  Institute,  Cary,  North  Carolina),  including  those  for 
statistical  power,  which  used  the  widely-used  macro  uni- 
fyPow  (www.bio.ri.ccf.org/unifyPow). 

To  assess  the  likelihood  of  detecting  a  difference  between 
the  groups,  a  power  analysis  was  performed  using  the  theory 
of  the  standard  /3-binomial  model  of  outcomes  from  a  mul- 
tiple-choice test  with  k  items.  That  is,  the  distribution  of 
respondents'  unobserved  "true  scores"  (tt,)  was  assumed  to 
be  /3,  whereas  the  distribution  of  each  percent  correct  out- 
come (P,)  was  taken  to  be  binomial  with  tt,  as  the  underlying 
rate.  Such  data  is  well-suited  to  the  common  /  test  and  its 
analysis  of  variance  extension.  Suppose  that  the  groups  had 
40  -I-  20  =  60  observations  total  and  had  means  of  75% 
versus  60%  for  the  underlying  success  rate,  with  a  common 
standard  deviation  of  15%.  For  the  comparison  of  the  overall 
scores  (20  items,  a  =  0.05),  the  power  based  on  the  t  test  is 


0.85,  versus  0.84  for  the  Wilcoxon.  For  testing  a  particular 
case  (4  items,  a  =  0.01),  the  powers  fall  to  0.27  {t  test)  and 
0.24  (Wilcoxon).  Such  a  sample  size  seems  to  adequately 
support  the  overall  test,  but  not  the  tests  of  individual  cases. 

Results 

Forty-one  house  officers  from  CCF  and  17  from  the 
University  of  Nebraska  were  examined,  representing  33% 
of  the  entire  internal  medicine  house  staffs  at  each  of  the 
respective  programs.  Table  1  presents  characteristics  of 
the  respondents  at  each  of  the  respective  programs — in- 
terns (/)  =  20  and  h  =  5  at  CCF  and  University  of  Ne- 
braska, respectively),  junior  residents  (n  =  12  and  5),  and 
senior  residents  (n  =  8  and  7).  Women  constituted  a  similar 
percentage  of  respondents  in  both  institutions  (32.5%  and 
35%). 

Table  2  presents  the  percent  of  correct  responses  on 
case  studies  by  institution  and  by  year  of  training.  The 
overall  scores  for  respondents  from  CCF  and  the  Univer- 
sity of  Nebraska  were  (mean  ±  SD)  77.2  ±  1 1.6%  versus 
75.8  ±  12.0%,  respectively.  The  difference  was  very  small 
and  failed  to  achieve  statistical  significance  (p  =  0.69). 
The  associated  95%  CI  for  this  difference  (CCF  vs  Uni- 
versity of  Nebraska)  was  -5.4%  to  8.1%,  making  it  very 
unlikely  that  any  important  difference  exists  between  the 
groups.  This  conclusion  also  held  after  adjusting  for  year 
of  postgraduate  training  using  analysis  of  covariance. 


Respiratory  Care  •  August  2000  Vol  45  No  8 


947 


Impact  of  a  Respiratory  Therapy  Consult  Service 


Examination  of  the  percent  of  correct  responses  by  in- 
dividual case  study  showed  a  significantly  higher  rate  of 
correct  responses  by  CCF  respondents  on  Case  2  (86.6  ± 
18%  vs  69.1  ±  14%,  p  =  0.0001),  a  difference  that  held 
after  adjusting  for  year  of  postgraduate  training.  As  shown 
in  Table  2,  no  such  difference  was  evident  in  evaluating 
the  percent  of  correct  responses  for  the  other  case  studies. 

Discussion 

The  main  finding  of  this  study  is  that  internal  medicine 
house  officers'  knowledge  of  respiratory  care  ordering  as 
assessed  by  responses  to  case  studies  was  similar  among 
trainees  at  a  teaching  hospital  in  which  respiratory  care 
protocols  were  in  longstanding  use  (CCF)  and  trainees  at 
a  teaching  hospital  where  such  protocols  were  not  in  use 
(the  University  of  Nebraska).  The  rate  of  correct  responses 
for  both  groups  together  was  high  (76.8%),  reflecting  over- 
all good  but  still  imperfect  knowledge  of  respiratory  care 
ordering.  The  overall  rate  of  correct  responses  by  internal 
medicine  house  officers  at  the  University  of  Nebraska  was 
similar  to  the  rate  at  CCF.  Specifically,  the  95%  CI  for  the 
mean  difference  in  percent  correct  responses  for  the  over- 
all score  was  -5.4%  (direction  favoring  the  University  of 
Nebraska)  to  8.1%  (direction  favoring  CCF),  suggesting 
little  or  no  difference.  Furthermore,  analysis  of  covariance 
did  not  suggest  that  house  officers'  year  of  postgraduate 
training  was  related  to  the  scores  or  confounded  the  com- 
parisons. Taken  together,  these  observations  challenge  the 
view  that  the  use  of  respiratory  care  protocols  detracts  from 
house  officers'  knowledge  of  respiratory  care  ordering. 

Although  this  issue  has  received  little  attention  in  pub- 
lished studies  to  date,^  these  results  are  consistent  with 
those  from  an  earlier  survey  of  internal  medicine  house 
officers  from  CCF.  In  that  study,  most  respondents  (56%) 
felt  that  the  use  of  respiratory  care  protocols  and  use  of  a 
respiratory  therapy  consult  service  enhanced  their  knowl- 
edge of  respiratory  care  ordering.'' 

Although  the  current  findings  extend  this  earlier  work 
by  actually  testing  knowledge  rather  than  simply  survey- 
ing house  officers'  impressions  about  knowledge,  the  re- 
sults must  be  interpreted  in  the  context  of  several  potential 
shortcomings  of  the  study.  First,  although  performance  on 
clinical  case  studies  seems  more  likely  to  reflect  clinical 
knowledge  than  house  officers'  subjective  self-assessment 
of  their  respiratory  care  knowledge,  the  relationship  of 
performance  on  these  case  studies  to  actual  respiratory 
care  clinical  decision-making  is  uncertain.  On  the  other  hand, 
assessing  knowledge  and  competence  based  on  written  case 
simulations  is  a  well-established  testing  strategy  in  medicine 
(eg,  certifying  examinations  by  the  American  Board  of  In- 
ternal Medicine  and  the  National  Board  for  Respiratory  Care) 


that  avoids  the  difficulty  and  associated  uncertainties  of  test- 
ing competence  in  actual  clinical  circumstances. 

A  second  caution  in  interpreting  these  results  is  that 
responses  were  elicited  from  only  a  minority  (33%)  of  the 
internal  medicine  house  staffs  at  CCF  and  the  University 
of  Nebraska.  Though  sampling  bias  certainly  cannot  be 
dismissed,  there  is  little  reason  to  suspect  a  differential 
sample  bias  in  the  two  institutions,  ie,  that  the  best  per- 
forming house  officers  were  represented  in  one  institu- 
tional sample  and  the  worst  performers  in  the  other  sam- 
ple. As  such,  we  regard  sampling  as  an  unlikely  source  of 
bias  in  comparing  the  two  groups.  At  the  same  time,  the 
robustness  of  the  findings  and  their  generalizability  to  in- 
stitutions other  than  those  studied  could  be  questioned.  For 
example,  if  a  different  comparator  house  staff  group  had 
less  expertise  in  respiratory  care  ordering  than  the  respond- 
ing University  of  Nebraska  house  officers,  the  results  might 
then  have  more  dramatically  favored  use  of  an  RTCS.  On 
the  other  hand,  if  the  RTCS  had  been  implemented  at  The 
Cleveland  Clinic  Foundation  without  an  accompanying 
teaching  intent  for  house  staff,  the  results  may  have  fa- 
vored nonuse  of  respiratory  care  protocols.  Furthermore, 
notwithstanding  considerations  about  the  "internal"  valid- 
ity of  these  study  findings,^  determining  whether  the  re- 
sults apply  to  respiratory  care  protocols  as  used  in  other 
teaching  settings  (eg,  pediatric  care,  smaller  institutions) 
will  require  future  confirmatory  studies. 

Finally,  we  cannot  exclude  possible  confounding  by  un- 
measured variables.  For  example,  although  our  analysis 
controls  for  the  house  officer's  level  of  training,  similarity 
of  basic  medical  competence  between  the  compared  house 
staff  group  is  difficult  to  measure  and  cannot  be  assured. 

In  summary,  the  current  study  suggests  that  use  of  a 
respiratory  care  protocol  service  does  not  detract  from 
internal  medicine  house  officers'  expertise  in  prescribing 
respiratory  care  treatments.  Subject  to  some  of  the  inter- 
pretive cautions  discussed,  these  findings  weigh  against 
an  objection  to  using  a  respiratory  care  protocol  service. 
In  the  context  of  the  demonstrated  advantages  of  respira- 
tory care  protocols  for  improving  the  allocation  of  respi- 
ratory care  services  while  lessening  costs,  we  believe  these 
findings  strengthen  the  rationale  for  respiratory  care  pro- 
tocols. 

REFERENCES 

1 .  Zibrak  JD,  Rosseti  P,  Wood  E.  Effect  of  reductions  in  respiratory 
therapy  on  patient  outcome.  N  Engl  J  Med  1986;315:292-295. 

2.  Stoller  JK.  The  rationale  for  therapist-driven  protocols.  Respir  Care 
Clin  North  Am  1996;2:1-14. 

i.  Kollef  MH,  Shapiro  SD,  Silver  P,  St  John  RE,  Prentice  D,  Sauer  T, 
et  al.  A  randomized,  controlled  trial  of  protocol-directed  versus  phy- 
sician-directed weaning  from  mechanical  ventilation.  Crit  Care  Med 
1997;25:567-574. 

4.  Stoller  JK,  Mascha  EJ.  Kester  L,  Haney  D.  Randomized  controlled 
trial  of  physician-directed  versus  respiratory  therapy  consult  service- 


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Impact  of  a  Respiratory  Therapy  Consult  Service 


directed  respiratory  care  to  adult  non-ICU  inpatients.  Am  J  Respir 
Care  Med  1998;158:1068-1075. 

5.  StoUer  JK.  Michnicki  I.  Medical  house  staff  impressions  regarding 
the  impact  of  a  respiratory  therapy  consult  service.  Respir  Care 
1998:43:549-551. 

6.  Stoller  JK,  Haney  D.  Burkhart  J,  Fergus  L.  Giles  D,  Hoisington  E,  et 
al.  Physician-ordered  respiratory  care  vs  physician-ordered  use  of  a 


respiratory  therapy  consult  service:  Early  experience  at  The  Cleve- 
land Clinic  Foundation.  Respir  Care  1993:38:1 143-1 154. 

7.  Stoller  JK,  Skibinski  CI,  Giles  DK,  Kester  L,  Haney  DJ.  Physician- 
ordered  respiratory  care  versus  physician-ordered  use  of  a  respira- 
tory therapy  consult  service.  Chest  1996;1 10:422-429. 

8.  Feinstein  AR.  Clinical  Epidemiology:  the  architecture  of  clinical 
research.  Philadelphia,  WB  Saunders,  1985;39-68. 


Respiratory  Care  •  August  2000  Vol  45  No  8 


949 


Appendix 


Case  Study  #1 

A  48-year-old  woman  was  admitted  to  the  hospital  with  a  diagnosis  of  an  intraabdominal  abscess.  She  has  undergone 
surgery  and  is  presently  status-post  distal  colonic  resection.  She  has  a  history  of  asthma  and  has  smoked  one  pack  per  day 
for  26  years.  She  is  presently  on  bed  rest. 


Currently: 

Chest  radiograph 
Arterial  blood  gases 


Fibrotic  changes  at  the  right  lung  base 


PaOj  57  mm  Hg         HcOj    24  mEq/L 


On  room  air 

pH  7.34         Pcoj  45  mm  Hg 

oxygen  saturation  87% 

Wheezing  throughout  all  lung  fields,  diminished  at  the  right  base 

Strong,  productive  of  small  amounts  of  white  mucus 


Breath  sounds 
Cough 
Based  on  these  findings: 

1 .  Does  this  patient  require  an  incentive  spirometer  or  some  type  of  hyperinflation?   Yes       ^No 

2.  Does  this  patient  require  oxygen?  Yes       No 

3.  Does  this  patient  require  an  order  for  a  bronchodilator?  Yes       No 

4.  Does  this  patient  require  bronchopulmonary  hygiene  (chest  percussion  and  vibration)?  Yes       No 

Case  Study  #2 

A  72-year-old  man  was  admitted  to  the  hospital  with  a  diagnosis  of  pancreatitis.  Presently,  he  is  one  day  post  open 
cholecystectomy.  This  patient  has  a  history  of  atrial  fibrillation  and  diabetic  neuropathy.  Pulmonary  history  is  negative 
except  for  smoking  one  pack  per  day  for  40  years;  he  quit  5  years  ago.  The  patient  is  presently  on  bed  rest. 


Currently: 

Chest  radiograph 
Arterial  blood  gases 


Bilateral  pleural  effusions 

On  room  air  (pre-op) 

pH  7.47         Pcoj  32  mm  Hg 

oxygen  saturation  94% 


PaOj  72  mm  Hg         Hco,    23  mEq/L 


Breath  sounds  Decreased  breath  sounds  in  the  bases  bilaterally;  otherwise  clear 

Cough  Fair,  nonproductive  cough 

The  patient  is  presently  on  2  L/min  oxygen  via  nasal  cannula,  and  oxygen  saturation  measured  via  pulse  oximetry  is  97%. 
Based  on  these  fmdings: 

1 .  Does  this  patient  require  an  incentive  spirometer  or  some  type  of  hyperinflation?  Yes       ^No 

2.  Does  this  patient  require  a  bronchodilator?  _^Yes       __No 


(continued) 


950 


Respiratory  Care  •  August  2000  Vol  45  No  8 


Appendix  (continued) 


3.  Does  this  patient  require  bronchopulmonary  hygiene  (chest  percussion  and  vibration)?  Yes       No 

4.  Would  you  (choose  one): 

A:  Leave  this  patient  on  2  L/min  oxygen  via  nasal  cannula 

B:  Decrease  oxygen  to  1  L/min  and  recheck  the  oxygen  saturation  via  pulse  oximetry  after  20  minutes  to  keep  the 

oxygen  saturation  >  88% 

Case  Study  #3 

A  58-year-old  man  was  admitted  through  the  emergency  department  following  a  fall  at  work  that  involved  a  head 
injury.  He  is  presently  status-post  evacuation  of  a  subdural  hematoma  and  has  had  a  #8  nonfenestrated  Shiley  tracheostomy 
tube  placed  because  of  prolonged  weaning  from  the  ventilator.  His  medical  history  is  significant  for  smoking  one  pack  per 
day  for  less  than  40  years,  but  otherwise  negative. 


Currently: 

Chest  radiograph 
Arterial  blood  gases 

Breath  sounds 
Cough 

Based  on  these  findings: 


Right  lower  lobe  infiltrates  with  underlying  atelectasis 


On  35%  humidified  trach  collar 
pH  7.45         Pcoj  36  mm  Hg 
oxygen  saturation  94% 


P^^  83  mm  Hg 


HC03"  25  mEq/L 


Diminished,  with  rhonchi  throughout 

None  on  command;  patient  has  been  suctioned  for  moderate  amounts  of  pale  yellow 
secretions. 


1 .  Does  this  patient  require  hyperinflation  (intermittent  positive-pressure  breathing  or  continuous  positive  airway  pressure 

treatments)?    Yes       ^No 

2.  Does  this  patient  require  a  bronchodilator?   Yes       ^No 

3.  Does  this  patient  require  bronchopulmonary  hygiene  (chest  percussion  and  vibration)?    Yes       No 

4.  Does  this  patient  require  a  routine  suctioning  order?   Yes       No 

Case  Studv  #4 

An  81 -year-old  woman  was  admitted  to  the  hospital  with  a  right  hip  fracture  and  is  awaiting  surgery.  She  has  a  history  of 
chronic  obstructive  pulmonary  disease  (emphysema),  hypertension,  and  has  smoked  half  a  pack  per  day  for  60  years.  She  is 
not  currently  taking  any  home  respiratory  medication  or  using  oxygen  at  home.  Presently,  she  is  confused  and 
nonambulatory. 


Currently: 
Chest  radiograph 
Arterial  blood  gases 

Breath  sounds 
Cough 


Cardiomegaly  with  increased  vascular  markings 

None  currently  available,  but  oxygen  saturation  measured  via  pulse  oximetry  is  83% 
on  room  air 

Scattered  wheezing  throughout 
Fair,  nonproductive 


(continued) 


Respiratory  Care  •  August  2000  Vol  45  No  8 


951 


Appendix  (continued) 


Based  on  these  findings: 

1 .  Does  this  patient  require  an  incentive  spirometer  or  some  type  of  hyperinflation?   Yes       No 

2.  Would  you  (choose  one): 

A:  Leave  this  patient  on  room  air. 

B:  Place  patient  on  2  L/min  oxygen  via  cannula  and  check  arterial  blood  gases. 

3.  Does  this  patient  require  a  bronchodilator?    Yes       No 

4.  Does  this  patient  require  a  routine  suctioning  order?   Yes       No 

Case  Study  #5 

A  68-year-old  woman  was  admitted  to  the  hospital  with  a  diagnosis  of  renal  cell  cancer.  She  has  no  history  of  pulmonary 
disease.  She  has  a  forced  vital  capacity  of  445  mL.  She  is  5'2"  tall  and  is  presently  lethargic. 

Currently: 

Chest  radiograph  Left  pleural  effusion 

Arterial  blood  gases  On  3  L/min  oxygen  via  nasal  cannula 

pH  7.36         Pcoj  37  mm  Hg         P^o^  171  mm  Hg         Hco,"  21  mEq/L 
oxygen  saturation  99% 

Breath  sounds  Slightly  diminished  in  bases  bilaterally 

Cough  Strong,  productive  of  small  amounts  of  white  mucus 

Based  on  these  findings: 

1 .  Does  this  patient  require  hyperinflation  (intermittent  positive-pressure  breathing,  continuous  positive  airway  pressure,  or 
incentive  spirometer)?  Yes       No 

2.  Would  you  (choose  one): 

A:  Leave  this  patient  on  the  3  L/min  oxygen  via  cannula 

B:  Titrate  the  oxygen  down  and  check  oximetry  reading  after  20  minutes 

3.  Does  this  patient  require  a  bronchodilator?  Yes       ^No 

4.  Does  this  patient  require  bronchopulmonary  pulmonary  hygiene  (chest  percussion  and 

vibration)?  Yes       ^No 

Answer  Key 
Case    Question    Answer  Case     Question    Answer  Case     Question    Answer 

1  1  Yes  3  1  Yes  5  1  Yes 

2  Yes  2  No  2  B 

3  Yes  3  Yes  3  No 

4  No  4  Yes  4  No 

2  1  Yes  4  1  No 

2  No  2  B 

3  No  3  Yes 

4  8  4  No 


952  Respiratory  Care  •  August  20(X)  Vol  45  No  8 


Case  Reports 


Benzocaine-Associated  Methemoglobinemia  Following  Bronchoscopy 

in  a  Healthy  Research  Participant 

Ware  G  Kuschner  MD,  Rajinder  K  Chitkara  MD,  James  Canfield  Jr  CCPT, 
Lourdes  M  Poblete-Coleman  RN  MS,  Barbara  A  Cunningham  RN  MS,  and 

Priscilla  SA  Sarinas  MD 


Benzocaine  (ethyl  aminobenzoate)  is  a  local  anesthetic  commonly  used  to  achieve  topical  anesthesia 
of  the  skin  and  mucous  membranes  prior  to  endoscopic  procedures.  Methemoglobinemia,  a  con- 
dition in  which  hemoglobin  cannot  bind  and  deliver  oxygen  normally,  has  been  associated  with 
benzocaine  use  in  various  patient  populations.  This  is  the  first  report  of  benzocaine-associated 
methemoglobinemia  occurring  in  a  healthy  research  participant.  The  research  participant  devel- 
oped a  methemoglobin  level  of  27%  and  marked  cyanosis.  No  adverse  sequelae  other  than  cyanosis 
were  identified.  This  report  extends  the  population  in  which  benzocaine-associated  methemoglo- 
binemia has  been  described.  Additionally,  this  report  supports  the  observation  that  methemoglobin 
levels  approaching  30%  may  be  tolerated  in  otherwise  healthy  individuals,  producing  few  clinically 
important  effects.  Finally,  this  case  also  indicates  that,  in  obtaining  informed  consent  for  a  procedure  in 
which  benzocaine  will  be  administered,  patients  and  research  participants  should  be  specifically  in- 
formed of  the  risk  of  benzocaine-induced  methemoglobinemia.  This  information  is  especially  important 
in  those  settings  in  which  the  manufacturer-recommended  dose  of  benzocaine  may  either  intentionally 
or  inadvertently  be  exceeded.  [Respir  Care  2000;45(8):953-956]  Key  words:  benzocaine,  methemoglobin- 
emia, lidocaine,  bronchoscopy,  adverse  effects,  anesthetic,  anesthesia,  cyanosis,  volunteer. 


Introduction 

Benzocaine  (ethyl  aminobenzoate)  is  an  ester-class  lo- 
cal anesthetic  used  chiefly  to  achieve  topical  anesthesia  of 
skin  and  mucous  membranes.'  It  is  available  in  a  variety  of 
preparations  for  hospital  and  office-based  use,  as  well  as  in 
over-the-counter  lozenges,  gels,  and  suppositories  for  home 
use.  The  clinical  applications  of  benzocaine  include  achiev- 
ing nasopharyngeal  and  oropharyngeal  anesthesia  in  prep- 
aration for  bronchoscopy,  laryngoscopy,  or  endotracheal 
intubation.  Common  formulations  used  in  the  field  of  re- 
spiratory care  include  Hurricaine  20%  spray  (Beutlich  LP 


Ware  G  Kuschner  MD,  Rajinder  K  Chitkara  MD.  James  Canfield  Jr 
CCPT,  Lourdes  M  Poblete-Coleman  RN  MS,  Barbara  A  Cunningham 
RN  MS,  and  Priscilla  SA  Sarinas  MD  are  affiliated  with  the  Medical 
Service.  Pulmonary  Section,  Veterans  Affairs  Palo  Alto  Health  Care 
System,  and  the  Division  of  Pulmonary  and  Critical  Care  Medicine, 
Stanford  University  School  of  Medicine,  Palo  Alto,  California. 

Correspondence:  Ware  Kuschner  MD.  Veterans  Affairs  Palo  Alto  Health 
Care  System,  3801  Miranda  Avenue,  Mail  Stop  HIP,  Palo  Alto  CA 
94304.  E-mail:  kuschner@stanford.edu. 


Pharmaceuticals,  Waukegan,  Illinois)-  and  Cetacaine  14% 
spray  (Cetylite  Industries,  Pennsauken,  New  Jersey).^  These 
aerosol  spray  formulations  permit  easy  directed  applica- 
tion of  the  anesthetic  to  the  oropharynx. 

Benzocaine  is  fast-acting  and  poorly  absorbed — prop- 
erties that  make  it  well  suited  for  topical  anesthesia.'  Ben- 
zocaine is  generally  regarded  as  safe  and  free  of  systemic 
effects.  However,  there  have  been  case  reports  from  a 
variety  of  clinical  settings  of  methemoglobinemia  follow- 
ing topical  administration  of  benzocaine.-*"^  The  patients 
described  in  these  scattered  reports  received  benzocaine  as 
premedication  for  invasive  diagnostic  or  therapeutic  pro- 
cedures. These  patients  had  underlying  diseases,  including 
cardiopulmonary  disorders  and  cancer.  Cardiovascular  and 
pulmonary  coinorbidities  probably  affect  the  dose-toxicity 
response  and  therefore  complicate  interpretation  of  these 
reports.  Put  differently,  healthy  persons  may  tolerate  mod- 
erate methemoglobinemia  better  than  those  with  acute  and 
chronic  illnesses. 

We  report  a  case  of  marked  methemoglobinemia  fol- 
lowing topical  oropharyngeal  administration  of  benzocaine 
in  a  healthy  volunteer  undergoing  bronchoscopy  for  a  clin- 


Respiratory  Care  •  August  2000  Vol  45  No  8 


953 


Benzocaine-Associated  Methemoglobinemia 


ical  investigation.  This  is  the  first  report  of  benzocaine- 
associated  methemoglobinemia  occurring  in  this  setting. 
We  discuss  the  implications  of  this  adverse  event  in  a 
research  participant  and  review  prior  reports  of  benzo- 
caine-associated  methemoglobinemia  and  the  complica- 
tions of  methemoglobinemia. 

Case  Summary 

A  68-year-old  white  male  research  participant  was  ad- 
mitted to  the  bronchoscopy  suite  to  undergo  flexible  bron- 
choscopy with  bronchoalveolar  lavage.  He  was  a  healthy, 
normal  control  participating  in  an  investigation  of  inflam- 
matory biomarkers  in  emphysema.  He  was  physically  fit 
and  performed  aerobic  exercise  on  a  regular  basis. 

Informed  consent  had  been  obtained  during  a  prior  study 
visit.  The  consent  form  delineated  numerous  risks  associ- 
ated with  the  bronchoscopy,  including  adverse  drug  ef- 
fects, but  did  not  specifically  list  the  risk  of  benzocaine- 
induced  methemoglobinemia.  The  participant's  past 
medical  history  was  notable  only  for  borderline  hyperten- 
sion. He  took  no  prescription  or  over-the-counter  medica- 
tions. 

Prior  to  premedication,  the  participant's  heart  rate  was 
55  beats  per  minute,  his  blood  pressure  was  159/98  mm 
Hg,  his  respiratory  rate  was  18  breaths  per  minute,  and  his 
arterial  oxygen  saturation  (as  measured  via  finger  pulse 
oximetry  [SpoJ)  was  100%  while  breathing  room  air.  He 
received  5  seconds  of  benzocaine  20%  (Hurricaine)  aero- 
sol dispersion  topical  in  divided  doses  over  15  minutes  to 
produce  anesthesia  of  the  oropharynx.  During  the  proce- 
dure, 190  mg  of  lidocaine  was  sprayed  topically  to  the 
vocal  cords  and  airways.  No  intravenous  medications  were 
given.  The  bronchoscope  was  advanced  to  the  right  middle 
lobe  and  wedged  into  a  segmental  airway.  A  300  mL 
normal  saline  lavage  was  performed  without  difficulty. 
During  the  procedure,  Spo  ranged  between  95%  and  93% 
while  supplemental  oxygen  was  delivered  via  nasal  canula 
at  a  rate  of  4-8  L/min. 

One  hour  post  procedure,  blue  discoloration  consistent 
with  cyanosis  was  noted  to  involve  the  participant's  hands, 
upper  extremity  digits,  and  lips.  Cyanosis  became  progres- 
sively more  intense  over  the  following  30  minutes.  The 
palms  and  digits  of  the  hands  and  the  lips  darkened  to  an 
eggplant-purple  color.  The  participant  had  no  other  com- 
plaints. He  specifically  denied  shortness  of  breath,  chest 
pain,  dizziness,  or  lightheadedness.  Spo,  was  89%  while 
breathing  room  air,  heart  rate  was  73  beats  per  minute, 
blood  pressure  was  156/102  mm  Hg,  respiratory  rate  was 
16  breaths  per  minute,  and  venous  blood  methemoglobin 
level  was  27%. 

The  participant  was  placed  on  100%  oxygen  delivered 
via  nonrebreather  face  mask.  Spo,  remained  between  90% 
and  94%.  Five  hours  postbronchoscopy,  the  participant 


remained  asymptomatic,  with  some  resolution  of  cyanosis 
and  improving  oxygenation.  A  venous  sample  methemo- 
globin level  was  1 8%.  Two  follow-up  serial  methemoglo- 
bin levels  over  the  next  3  hours  were  10%  and  6%.  During 
the  recovery  period,  the  participant  remained  in  sinus 
rhythm  and  was  normotensive.  Cyanosis  progressively  re- 
solved as  the  methemoglobinemia  resolved.  He  was  ob- 
served for  a  total  of  8  hours  postbronchoscopy  and  then 
discharged  to  home  in  good  condition. 

Over  the  subsequent  5  days,  the  participant  was  evalu- 
ated three  times.  He  was  interviewed  and  examined  once 
in  the  Pulmonary  Clinical  Research  Unit  and  twice  by 
telephone.  He  had  no  complaints,  except  for  a  mild  sore 
throat,  and  was  in  excellent  health.  Seven  months  after  the 
procedure,  the  participant's  baseline  methemoglobin  level 
was  found  to  be  0.3%. 

Discussion 

Benzocaine  and  Methemoglobinemia 

Methemoglobinemia  is  a  condition  in  which  >  1%  of 
circulating  hemoglobin  has  been  oxidized  from  the  ferrous 
state  (Fe'^^)  to  the  ferric  state  (Fe"^^).  Methemoglobin  can- 
not bind  oxygen.  Additionally,  methemoglobin  increases 
the  affinity  of  remaining  normal  hemoglobin  for  oxygen, 
thereby  reducing  oxygen  off-loading  to  tissues  and  further 
reducing  oxygen  delivery.** 

A  low  level  of  methemoglobin,  approximately  1%,  is 
normally  present  in  the  blood.  Equilibrium  between  met- 
hemoglobin and  reduced  (ferrous)  hemoglobin  is  main- 
tained by  the  methemoglobin  reductase  enzyme  system 
(nicotinamide  adenine  dinucleotide  [NADHJ-dehydratase). 
Congenital  methemoglobinemia  may  develop  as  a  result  of 
a  congenital  deficiency  in  the  methemoglobin  reductase 
enzyme  system  or  as  a  consequence  of  a  congenital  ab- 
normality of  the  globin  chain. 

Acquired  methemoglobinemia  is  caused  by  environmen- 
tal chemicals  or  drugs.  Chemicals  used  in  dye  manufac- 
turing such  as  aniline  have  been  reported  to  cause  methe- 
moglobinemia.^ Widely  used  drugs  reported  to  cause 
methemoglobinemia  include  nitrates,'""  dapsone,'-'^  and 
pyridium.'"' 

The  diagnosis  of  methemoglobinemia  should  be  sus- 
pected when  the  following  are  present:  a  history  of  expo- 
sure to  a  chemical  or  drug  known  to  cau.se  the  disorder, 
cyanosis,  and  abnormally  low  oxygen  saturation  with  nor- 
mal arterial  blood  oxygen  tension.  The  diagnosis  is  con- 
firmed when  CO-oximetry  measurement  demonstrates  an 
increased  methemoglobin  level  (normal  =  <  1%).  The 
consequences  of  methemoglobinemia  depend  on  the  se- 
verity of  the  condition.  Data  on  methemoglobinemia  toxic 
responses  are  limited.  Nevertheless,  methemoglobin  lev- 
els >  70%  may  be  fatal.  Methemoglobin  levels  of  20- 


954 


Respiratory  Care  •  August  2(XX)  Vol  45  No  8 


Benzocaine-Associated  Methemoglobinemia 


30%  may  produce  central  cyanosis  but  no  symptoms,  as 
occurred  in  tiiis  case.  Methemoglobin  levels  of  30-70% 
may  result  in  a  variety  of  sequelae,  including  weakness, 
tachycardia,  dyspnea,  nausea,  dizziness,  stupor,  cardiac 
arrhythmias,  and  coma.** 

Retrospective  observational  reports  have  described  ben- 
zocaine-induced  methemoglobinemia  during  anesthesia  for 
endotracheal  intubation,-*  transesophageal  echocardiogra- 
phy,'' orogastric  intubation,*  and  therapeutic  bronchosco- 
py.^ However,  documented  dose-response  data  are  limited. 
In  the  only  large  prospective  evaluation  of  benzocaine- 
associated  methemoglobinemia  among  healthy  adult  hu- 
man volunteers.  Guertleret  al  administered  sustained  2-sec- 
ond  sprays  of  20%  benzocaine  to  the  oropharynxes  of  9 1 
normal  volunteers.'''  Blood  for  methemoglobin  analysis 
was  obtained  at  20.  40,  and  60  minutes  after  benzocaine 
dosing.  The  mean  methemoglobin  level  was  <  1%  at  all 
time  points.  There  were  no  adverse  effects  associated  with 
drug  adminisU"ation.  The  manufacturer-recommended  dosing 
for  this  benzocaine  preparation  was  a  half-second  spray  that 
may  be  repeated.  The  authors  concluded  that  benzocaine  is 
safe  when  a  limited  dose  is  administered.  TTiey  did,  however, 
stress  that  the  study  did  not  address  the  safety  of  benzocaine 
in  doses  substantially  above  those  recommended  by  the  man- 
ufacturer. They  also  noted  that  their  investigation  may  have 
been  underpowered:  a  larger  study  may  have  identified  sus- 
ceptible individuals  not  seen  in  their  study. 

Management  of  methemoglobinemia  should  include  sup- 
portive measures,  including  administration  of  supplemen- 
tal oxygen,  cardiopulmonary  and  neurological  monitoring, 
and  serial  blood  methemoglobin  measurements  to  docu- 
ment progression  and  resolution.  Systemic  effects  such  as 
ischemia,  arrhythmias,  and  mental  status  change  should 
prompt  administration  of  the  antidote  methylene  blue. 
Methylene  blue  promotes  the  reduction  of  methemoglo- 
binemia by  nicotinamide-adenine  dinucleotide  phosphate 
(NADPH)  methemoglobin  reductase."'  Methylene  blue  is 
infused  at  a  dose  of  1-2  mg/kg  body  weight  over  5-10 
minutes.^  Methemoglobin  levels  should  fall  within  an  hour. 
It  is  important  to  note  that  the  NADPH  reductase  system 
requires  glucose-6-phospate  dehydrogenase  (G6PD)  activ- 
ity. Consequently,  methylene  blue  is  ineffective  in  persons 
with  G6PD  deficiency. 

Lessons  from  This  Case 

We  believe  this  is  the  first  report  of  benzocaine-associ- 
ated  methemoglobinemia  occurring  in  a  healthy  research 
participant  undergoing  research  bronchoscopy.  This  case 
report  underscores  the  need  for  physicians  and  respiratory 
therapists  to  limit  benzocaine  administered  for  topical  air- 
way anesthesia.  The  dosage  of  aerosolized  benzocaine  ad- 
ministered via  spray  canister  is  typically  estimated  by  count- 
ing off  the  number  of  seconds  of  spray  dispersion. 


Manufacturers  of  the  benzocaine  formulation  used  in  this 
patient  (Hurricaine  [benzocaine  20%])  recommend  aerosol 
dispersal  of  one-half  second  (Beutlich  LP  Pharmaceuti- 
cals, 2000,  personal  communication).  Manufacturers  of 
another  form  of  benzocaine  spray  (Cetacaine  [benzocaine 
14%])  recommend  administration  of  aerosol  spray  for  no 
more  than  one  second.^  It  is  likely  that  these  doses  are 
commonly  exceeded  in  practice.  Methemoglobinemia  ap- 
pears to  be  a  dose-dependent  untoward  effect  of  benzo- 
caine, so  inadvertent  prolonged  spraying  of  this  anesthetic 
probably  increases  the  risk  of  developing  this  complica- 
tion. Health  care  practitioners  must  maintain  vigilance  when 
spraying  benzocaine,  in  order  to  avoid  excessive  drug  ad- 
ministration that  may  lead  to  methemoglobinemia. 

The  5-second  spray  used  in  this  subject  was  within  the 
typical  dose  range  of  3-8  seconds  that  was  used  in  our 
bronchoscopy  laboratory.  Within  this  range,  benzocaine 
dosing  was  at  the  discretion  of  the  respiratory  therapist 
administering  pre-bronchoscopy  topical  anesthesia  for  all 
bronchoscopists  at  this  institution.  We  no  longer  use  ben- 
zocaine in  our  laboratory. 

A  second  lesson  from  this  case  report  is  that  substantial 
methemoglobinemia  may  compromise  oxygen  delivery 
without  producing  symptoms  at  rest.  In  this  case,  the  re- 
search participant  manifested  marked  perioral  and  upper 
extremity  cyanosis — evidence  of  compromised  oxygen  de- 
livery— but  felt  well.  However,  asymptomatic  hypoxia 
should  not  be  interpreted  as  a  harmless  condition.  More- 
over, a  patient  with  substantial  cardiopulmonary  comor- 
bidities may  have  less  physiologic  reserve  than  the  re- 
search participant  described  in  this  case  and  may  be  unable 
to  tolerate  a  methemoglobin  level  of  27%.  This  patient 
remained  at  rest  during  the  recovery  period.  He  may  not 
have  tolerated  the  elevated  methemoglobin  level  if  he  had 
increased  his  activity.  Accordingly,  this  level  of  methe- 
moglobinemia with  associated  cyanosis  should  not  be  in- 
terpreted as  being  an  unimportant  complication. 

A  final  lesson  suggested  by  this  case  is  that  it  is  impor- 
tant that  clinical  investigators  describe,  in  detail,  all  fore- 
seeable risks  of  bronchoscopy,  including  severe  and  po- 
tentially lethal  drug  toxicities.  This  research  participant 
had  not  been  advised  prior  to  the  procedure  that  methe- 
moglobinemia was  a  risk  associated  with  topical  anesthe- 
sia. Though  the  possibility  of  "adverse  drug  reactions"  was 
described,  the  development  of  methemoglobinemia  was 
not  explicitly  delineated  in  the  consent  form  as  a  risk  of 
participating  in  the  investigation.  In  view  of  increasing 
recognition  of  benzocaine-associated  methemoglobinemia, 
this  potential  complication  should  be  delineated  on  the 
consent  form  whenever  benzocaine  might  be  administered, 
especially  if  higher  than  recommended  doses  may  be  in- 
tentionally or  inadvertently  administered. 

Anesthetic  alternatives  to  benzocaine  may  be  appropri- 
ate to  reduce  the  risk  of  methemoglobinemia.  In  our  clin- 


Respiratory  Care  •  August  2000  Vol  45  No  8 


955 


Benzocaine-Associated  Methemoglobinemia 


ical  research  program,  we  have  eHminated  benzocaine  from 
the  premedication  protocol  for  bronchoscopy  and  now  only 
administer  topical  lidocaine.  Lidocaine  does  not  appear  to 
carry  the  same  risk  for  causing  methemoglobinemia  as 
benzocaine.  Experimental  work  in  macaques'^  and  sheep '^ 
has  shown  methemoglobinemia  can  be  reliably  induced  by 
benzocaine  but  not  by  lidocaine.  In  a  study  of  40  humans 
treated  with  a  continuous  intravenous  infusion  of  lido- 
caine, no  clinically  important  elevation  in  methemoglobin 
levels  was  observed.'''  Patients  were  given  a  1  mg/kg  bo- 
lus of  intravenous  lidocaine  and  then  placed  on  a  mainte- 
nance infusion  of  2  mg/kg,  and  then  given  a  second  bolus 
of  0.5  mg/kg  1 5  minutes  after  the  initial  bolus.  Methemo- 
globin levels  were  measured  at  0,  1,  and  6  hours.  The 
highest  methemoglobin  level  was  1.2%.  Lidocaine  does, 
however,  carry  cardiovascular  toxicities  that  limit  dosing. 

Although  uncommon,  serious  complications,  including 
death,  resulting  from  drug  toxicities  have  occurred  in 
healthy  research  participants  undergoing  bronchoscopy. 
The  recent  lidocaine  overdose  death  of  a  healthy  19-year- 
old  research  participant  undergoing  bronchoscopy  under- 
scores the  fact  that  anesthesia-related  risks  may  be  greater 
than  the  procedural  risks  of  bronchoscopy.-"  Respiratory 
practitioners  need  to  consider  the  risks  and  benefits  and 
the  dosing  limitations  of  both  benzocaine  and  lidocaine 
when  using  these  anesthetic  agents.  All  risks  must  be  clearly 
communicated  to  patients  and  research  participants  under- 
going bronchoscopy.  Patients  and  research  participants 
probably  focus  more  attention  on  the  technical  aspects  of 
invasive  procedures  and  less  attention  on  the  pharmaco- 
logic risks  associated  with  the  procedure. 

In  summary,  this  case  illustrates  methemoglobinemia 
associated  with  topical  benzocaine  administration  in  a 
healthy  research  volunteer.  The  dose  used  (a  5-second 
dispersion  in  divided  doses  over  15  minutes)  was  higher 
than  the  manufacturer-recommended  half-second  disper- 
sion, but  probably  consistent  with  a  wide  variety  of  clin- 
ical practices.  The  markedly  elevated  methemoglobin  level 
produced  severe  cyanosis  but  no  other  clinically  detectable 
adverse  effects.  Strict  adherence  to  the  manufacturer-rec- 
ommended dose  of  benzocaine  will  rarely  permit  the  use 
of  benzocaine  as  a  single  agent  for  adequate  topical  anes- 
thesia for  invasive  procedures  of  the  respiratory  tract  such 
as  laryngoscopy  and  bronchoscopy.  Benzocaine  may  not 
be  appropriate  in  the.se  settings.  The  risk  of  developing 
methemoglobinemia  should  be  detailed  as  part  of  the  con- 
sent process  whenever  benzocaine  might  be  administered, 
especially  if  higher  than  recommended  doses  might  be 
intentionally  or  inadvertently  administered. 


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methemoglobinemia — two  case  reports  related  to  transesophageal 
echocardiography  premedication.  Cardiovasc  Drugs  Ther  1998:12: 
311-312. 

6.  Cooper  HA.  Methemoglobinemia  cau.sed  by  benzocaine  topical  spray. 
South  Med  J  1997:90:946-948. 

7.  Clary  B,  Skaryak  L,  Tedder  M,  Hilton  A,  Botz  G,  Harpole  D.  Met- 
hemoglobinemia complicating  topical  anesthesia  during  broncho- 
scopic  procedures.  J  Thorac  Cardiovasc  Surg  1997;1 14:293-295. 

8.  Beutler  E.  Methemoglobinemia  and  other  causes  of  cyanosis.  In: 
Beutler  E,  Lichtman  MA,  Coller  BS,  Kipps  TJ,  editors.  Hematology. 
New  York:  McGraw-Hill;  1995:654-663. 

9.  Kearney  TE,  Manoguerra  AS,  Dunford  JV  Jr.  Chemically  induced 
methemoglobinemia  from  aniline  poisoning.  West  J  Med  1983:140: 
282-286. 

10.  Paris  PM,  Kaplan  RM,  Stewart  RD,  Weiss  LD.  Methemoglobin  lev- 
els following  sublingual  nitroglycerin  in  human  volunteers.  Ann 
EmergMed  1986;15:171-173. 

1 1 .  Gibson  GR,  Hunter  JB,  Rabbe  DS  Jr,  Manoney  DL,  Ittleman  FP. 
Methemoglobin  produced  by  high-dose  intravenous  nitroglycerin. 
Ann  Intern  Med  1982:96:615-616. 

12.  Trillo  RA  Jr,  Aukburg  S.  Dapsone-induced  methemoglobinemia  and 
pul.se  oximetry.  Anesthesiology  1992;77:594-596. 

1 3.  Erstad  BL.  Dapsone-induced  methemoglobinemia  and  hemolytic  ane- 
mia. Clin  Pharm  1 992;  1 1:800-805. 

14.  Jeffery  WH,  Zelicoff  AP,  Hardy  WR.  Acquired  methemoglobinemia 
and  hemolytic  anemia  after  usual  doses  of  phenazopyridine.  Drug 
Intell  Clin  Pharm  1982:16:157-159. 

15.  Guertler  AT,  Pearce  WA.  A  prospective  evaluation  of  benzocaine- 
associated  methemoglobinemia  in  human  beings.  Ann  Emerg  Med 
1994;24:626-630. 

16.  Curry  S.  Methemoglobinemia.  Ann  Emerg  Med  1982;11:214-221. 

17.  Martin  DG,  Watson  CE,  Gold  MB,  Woodard  CL  Jr,  Baskin  SI. 
Topical  anesthetic-induced  methemoglobinemia  and  sulfhemoglo- 
binemia  in  macaques:  a  comparison  of  benzocaine  and  lidocaine. 
J  AppI  Toxicol  1995:15:15.3-158. 

18.  Guertler  AT,  Lagutchik  MS,  Martin  DG.  Topical  anesthetic-induced 
methemoglobinemia  in  sheep:  a  comparison  of  benzocaine  and  lido- 
caine. Fundam  Appl  Toxicol  1992:18:294-298. 

19.  Weiss  LD,  Generalovich  T.  Heller  MB,  Paris  PM,  Stewart  RD,  Kaplan 
RM.  et  al.  Methemoglobin  levels  following  intravenous  lidocaine 
administration.  Ann  Emerg  Med  1987:16:323-325. 

20.  Day  RO.  Chalmers  DRC,  Williams  KM.  Campbell  TJ.  The  death  of 
a  healthy  volunteer  in  a  human  research  project:  implications  for 
Australian  clinical  research.  Med  J  Aust  1998;168:449-451. 


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Respiratory  Care  •  August  2000  Vol  45  No  8 


Special  Articles 


Recommendations  of  the  Fifth  Oxygen  Consensus  Conference 

Thomas  L  Petty  MD  and  Richard  Casaburi  PhD  MD 
for  the  Writing  and  Organizing  Committees 


The  Fifth  Oxygen  Consensus  Conference  was  convened 
in  Washington  DC,  September  21-22,  1999.  The  purposes 
of  the  conference  were: 

( 1 )  To  reconsider  and  expand  on  the  scientific  basis  of 
home  long-term  oxygen  therapy  (LTOT), 

(2)  To  address  present  challenges  in  prescribing  LTOT 
and  limitations  in  access  to  LTOT  because  of  reimburse- 
ment restrictions. 

(3)  To  determine  how  LTOT  education  among  physi- 
cians, manufacturers,  suppliers,  and  payers  can  be  im- 
proved so  that  evolving  LTOT  knowledge  and  technology 
can  be  widely  and  cost-effectively  disseminated,  and 

(4)  To  discuss  new  challenges  for  LTOT  research  and 
technology  development  for  the  new  millenium. 

There  were  54  invited  attendees  (see  Appendix),  repre- 
senting physicians,  other  health  care  professionals,  manu- 
facturers, suppliers,  and  patients.  The  conference  used  the 
Delbecq  Nominal  Group  Interactive  Process'  to  develop 
specific  recommendations.  The  first  day  of  the  conference 


Thomas  L  Petty  MD  FAARC  is  affiliated  with  the  Department  of  Med- 
icine, University  of  Colorado  Health  Sciences  Center,  and  the  National 
Lung  Health  Education  Program.  Denver.  Colorado.  Richard  Casaburi 
PhD  MD  is  affiliated  with  the  Division  of  Respiratory  and  Critical  Care 
Physiology  and  Medicine.  Harbor-UCLA  Medical  Center.  Torrance.  Cal- 
ifornia. 

Thomas  L  Petty  MD  is  on  the  Advisory  Board  of  In-X  Corporation. 
Denver.  Colorado.  Richard  Casaburi  PhD  MD  is  a  consultant  for  Mallink- 
rodt.  St  Charles,  Missouri. 

Author  affiliations  of  possible  relevance  to  the  subject  of  this  document: 
Kent  L  Christopher  MD  RRT  is  the  developer  of  a  transtracheal  oxygen 
therapy  patent  now  licensed  to  Transtracheal  Systems,  Englewood.  Col- 
orado. Jacqueline  McClure  RRT  is  employed  by  Respironics.  Pittsburgh. 
Pennsylvania.  Jonathan  C  McLellan  RRT  is  employed  by  Mallinkrodt. 
St  Charles.  Missouri.  For  the  other  affiliations  of  the  Writing  Committee 
and  other  conference  attendees,  see  the  Appendix. 

The  following  corporations  provided  support  for  travel  and  lodging  of 
some  of  the  conference  participants;  AirSep  Corporation.  Apria  Health- 
care Inc.  Lincare  Inc.  Mallinckrodt  Inc.  Respironics  Inc.  Rotech  Medical 
Corporation,  and  Walgreens  Health  Initiatives  Inc. 

Correspondence:  Thomas  L  Petty  MD,  1850  High  Street,  Denver  CO 
80218.  E-mail:  tlpdoc@aol.com. 


featured  a  series  of  presentations  that  summarized  the  cur- 
rent science  and  practice  of  oxygen  therapy.  During  the 
second  conference  day,  participants  divided  into  working 
groups  (each  group  having  approximately  balanced  repre- 
sentation from  physicians,  other  health  professionals,  man- 
ufacturers, suppliers,  and  patient  groups).  Each  group  an- 
alyzed a  current  area  of  controversy  in  oxygen  therapy  and 
formulated  recommendations.  In  a  subsequent  meeting  of 
all  conference  attendees,  each  subgroup's  recommen- 
dations were  debated  and  consensus  was  achieved.  These 
recommendations  amplify  and  supplement  the  recommen- 
dations of  the  four  previous  Oxygen  Consensus  Confer- 
ences--'' and  offer  new  LTOT  guidelines. 

LTOT  Is  the  established  standard  of  care  for  patients 
with  chronic  obstructive  pulmonary  disease  (COPD)  and 
chronic  stable  hypoxemia.  Ambulatory  oxygen  equipment 
is  preferred  for  patients  who  are  capable  of  participating  in 
ambulatory  activities  of  daily  living.  Recently,  the  United 
States  Health  Care  Financing  Administration  (HCFA)  im- 
plemented a  30%  reduction  in  LTOT  reimbursement,  with 
Congressional  approval.  The  reimbursement  reduction  de- 
cision was  based  primarily  on  an  analysis  of  LTOT  reim- 
bursement in  Department  of  Veterans  Affairs  (VA)  hos- 
pitals, which  has  been  less  than  reimbursement  outside  VA 
hospitals.  Some  VA  hospitals'  costs  are  lower  because  of 
arbitrary  limits  on  the  kinds  of  systems  provided,  regard- 
less of  patient  need.  Most  VA  hospitals  simply  provide  an 
oxygen  concentrator  and  a  small  number  of  wheeled  high- 
pressure  oxygen  tanks  (usually  E-cylinders).  Ambulation 
is  restricted  when  the  patient  must  pull  a  wheeled  cart. 
Some  VA  hospital  contracts  for  LTOT  are  "a  la  carte"  and 
therefore  do  not  include  charges  for  regulators,  tubing, 
cannulae,  etc.  The  reimbursement  reduction  is  causing  some 
suppliers  to  restrict  the  use  of  ambulatory  oxygen  systems 
in  the  private  sector,  even  though  they  are  medically  nec- 
essary and  prescribed  by  physicians. 

Statements  and  Recommendations 

1 .  LTOT  must  be  viewed  as  a  high-technology  service 
that  includes  provision  of  a  prescription  of  oxygen  as  well 
as  a  wide  range  of  patient  and  equipment-focused  services. 


Respiratory  Care  •  August  2000  Vol  45  No  8 


957 


Recommendations  of  the  Fifth  Oxygen  Consensus  Conference 


It  should  be  viewed  as  a  compendium  of  services,  includ- 
ing assessment  of  the  patient's  oxygen  needs,  provision  of 
the  oxygen  prescription,  patient  education,  monitoring  ther- 
apeutic benefits,  evaluating  patient  compliance,  commu- 
nicating with  prescribing  physicians,  and  providing  and 
maintaining  necessary  equipment. 

2.  Minimum  service  standards  should  be  established 
with  respect  to  supply  of  LTOT  services  by  home  care 
providers,  such  as  respiratory  care  professionals,  on  a  24- 
hour-a-day  basis. 

Recent  emphasis  on  health  care  cost  containment  has 
promoted  earlier  hospital  discharges  and  caused  patients  to 
be  discharged  at  higher  acuity  levels.  This  increases  the 
need  for  supportive  management  of  chronically  ill  patients 
in  the  outpatient  setting.  In  particular,  in  many  patients 
hypoxemia  has  not  stabilized  at  the  time  of  hospital  dis- 
charge, which  has  increased  the  frequency  of  need  for 
home  LTOT.  Therefore: 

3.  Patients  who  are  discharged  from  hospitals  following 
an  exacerbation  of  respiratory  disease  requiring  oxygen 
therapy  should  be  retested  (recertified)  90  days  after  dis- 
charge, either  by  arterial  blood  gas  analysis  or  oxygen 
saturation  measurement.  Repeat  oxygenation  measurements 
are  necessary  ( 1 )  to  evaluate  the  course  of  the  disease,  (2)  to 
determine  adjustments  to  the  oxygen  prescription  (ie,  change 
oxygen  flow  rates),  and  (3)  to  discontinue  LTOT  if  it  is  no 
longer  necessary.  If  an  ongoing  need  for  LTOT  is  determined 
at  the  90-day  retesting,  then  additional  arterial  blood  gas  or 
saturation  measurements  are  unnecessary. 

Patient  compliance  is  essential  to  the  efficacy  of  LTOT. 
Compliance  can  be  improved  by  initial  and  ongoing  pa- 
tient education,  and  by  ensuring  patient  access  to  appro- 
priate LTOT  services,  systems,  and  choices  that  best  meet 
their  medical  needs.  Health  care  professionals  should  monitor 
and  promote  patient  compliance  with  LTOT  prescriptions. 

4.  A  more  active  approach  to  the  education  of  patients, 
caregivers,  and  medical  professionals  is  recommended.  An 
LTOT  Education  Consensus  Conference  should  be  orga- 
nized to  assess,  improve,  innovate,  and  standardize  LTOT 
education.  The  mission  of  this  conference  should  include 
dissemination  of  the  findings  of  the  current  literature,  def- 
inition of  new  educational  tools,  and  exploration  of  more 
effective  ways  to  assure  patient  compliance. 

5.  Additional  lobbying  and  education  programs  are 
needed  to  increase  LTOT  awareness  on  a  national  level. 
Involved  groups  should  include  the  National  Home  Oxy- 
gen Patients  Association,  the  American  College  of  Chest 
Physicians,  the  American  Thoracic  Society,  the  American 
Association  for  Respiratory  Care,  the  American  Associa- 
tion of  Cardiovascular  and  Pulmonary  Rehabilitation,  the 
National  Association  for  Medical  Direction  of  Respiratory 
Care,  the  Pulmonary  Education  and  Research  Foundation, 
the  Department  of  Veterans  Affairs,  the  HCFA,  oxygen 
providers,  and  LTOT  equipment  manufacturers.  The.se  or- 


ganizations should  be  encouraged  to  form  a  coalition  to 
promote,  improve,  and  increase  education  and  awareness 
among  patients,  medical  professionals,  and  others  involved 
with  LTOT  and  related  services. 

6.  Ambulatory  oxygen  is  the  standard  of  care  for  pa- 
tients who  are  able  to  be  active  both  inside  and  outside  the 
home,  beyond  the  limits  of  a  stationary  system.  Ambula- 
tory oxygen  equipment  must  be  able  to  be  carried  by  most 
patients  on  their  person  during  activities  of  daily  living. 
Ambulatory  LTOT  equipment  must  weigh  less  than  10 
pounds  and  provide  at  least  the  equivalent  of  2  L/min  of 
continuous  flow  oxygen  for  4  hours  or  more.  Appropriate 
systems  should  be  selected  by  the  prescribing  physician 
for  the  specific  needs  of  the  individual  patient. 

7.  Technology  development  should  focus  on  devices 
that  are  more  compatible  with  patients'  life  styles,  such  as 
lighter  ambulatory  oxygen  systems. 

8.  The  Fifth  Oxygen  Consensus  Conference  partici- 
pants agree  that  the  United  States  Government  Accounting 
Office  report  on  the  impacts  on  access  to  LTOT  resulting 
from  the  recent  Congressionally-mandated  reimbursement 
restrictions''  is  inadequate  because  it  did  not  measure  ac- 
cess to  LTOT  prior  to  the  payment  cuts,  thereby  making  it 
very  difficult  to  assess  the  impact  of  the  cuts.  The  report 
failed  to  define  "access,"  and  it  did  not  use  a  random 
sample  of  the  Medicare  LTOT  population.  Therefore,  more 
thorough,  better-designed,  and  more  accurate  studies  con- 
cerning LTOT  access  should  be  conducted. 

9.  To  assure  patients'  rights  and  informed  choices  of 
LTOT  delivery  systems  that  meet  medical  needs,  an  ac- 
cepted definition  of  "access"  should  be  developed  by  cli- 
nicians. This  definition  should  address  issues  such  as  ac- 
cessability  of  medical  care,  pulmonary  rehabilitation,  as 
well  as  selection  and  service  of  oxygen  equipment  and 
related  supplies.  Once  the  definition  is  established,  it  should 
be  presented  and  promoted  to  the  HCFA  and  other  third- 
party  payers. 

10.  Support  of  patients  requiring  oxygen  therapy  during 
travel  should  be  readily  available.  In  particular,  patients 
have  a  right  to  medically  necessary  oxygen  during  air 
travel.  The  airline  industry  should  develop  and  promote 
industry  guidelines  regarding  provision  of  and  pricing  of 
supplementary  oxygen  during  air  travel.  Tho.se  guidelines 
should  include  provision  that  the  oxygen  equipment  pro- 
vided aboard  airplanes  delivers  metered  and  adjustable 
oxygen  flow  sufficient  to  meet  the  patient's  oxygen  pre- 
scription. 

1 1 .  Upon  initial  setup  and  periodically  thereafter,  all 
oxygen  therapy  devices,  particularly  oxygen-conserving 
devices,  should  be  titrated  to  the  proper  flow  rate  at  rest, 
exercise,  and  sleep,  to  achieve  maximum  benefit  for  pa- 
tients. 

12.  Professional  respiratory  therapy  organizations 
.should  create  clinical  practice  guidelines  for  the  evaluation 


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Recommendations  of  the  Fifth  Oxygen  Consensus  Conference 


and  monitoring  of  LTOT.  This  should  include  both  short- 
term  and  long-term  plans. 

13.  An  LTOT  patient  bill  of  rights  should  be  developed 
to  assure  minimum  standards  of  care  to  be  used  by  all 
patients  and  health  care  providers.  Supporting  documents 
should  include  education  checklists,  defined  patient  re- 
sponsibilities, and  a  statement  of  the  role  of  the  respiratory 
care  practitioner  in  the  care  of  LTOT  patients. 

14.  A  system  of  patient  advocacy  should  be  developed 
to  represent  LTOT  users  and  providers.  The  system  should 
include  a  mechanism  to  resolve  complaints  and  concerns, 
which  could  improve  patient  compliance  and  satisfaction. 
HCFA  needs  to  understand  the  importance  of  patient 
advocacy. 

15.  The  full  and  actual  costs  of  LTOT,  including  the 
cost  of  electrical  power  to  operate  home  LTOT  equipment, 
should  be  recognized. 

1 6.  Additional  research  is  needed  to  determine  the  med- 
ical efficacy  and  cost-effectiveness  of  various  LTOT  tech- 
nologies and  strategies.  Among  the  highest  research  pri- 
orities, a  study  is  needed  to  compare  outcomes  of  LTOT 
delivered  via  stationary  systems  with  LTOT  delivered  via 
ambulatory  systems.  Total  costs,  survival,  quality  of  life, 
and  utilization  of  hospitalization  and  nursing  home  ser- 
vices should  be  compared,  and  the  study  should  be  in  the 
form  of  a  randomized  prospective  controlled  clinical  trial 
similar  to  the  Nocturnal  Oxygen  Therapy  TriaF  and  Brit- 
ish Medical  Research  Council  studies  of  oxygen  therapy. 
Research  is  also  needed  on  other  indications  for  oxygen 
therapy,  including  exercise-related  hypoxemia  and  sleep- 
related  hypoxemia  in  patients  with  daytime  normoxia. 

Summary 

It  should  be  recognized  that  the  advent  of  LTOT  created 
a  new  health  care  system  that  is  based  on  powerful  scien- 
tific data.  Oxygen  therapy  studies  such  as  those  by  the 
Nocturnal  Oxygen  Therapy  Trial  Groups  and  the  British 
Medical  Research  Council  study^  clearly  demonstrated  that 
LTOT  improves  both  the  length  and  quality  of  life  of 
hypoxemic  COPD  patients.  Keeping  patients  at  home  and 
out  of  the  hospital  or  nursing  home  has  both  psychosocial 


and  economic  benefits.  Efforts  should  be  towards  enhanc- 
ing, not  limiting,  the  availability  of  LTOT. 

The  Fifth  Oxygen  Consensus  Conference 

Writing  Committee: 

Thomas  L  Petty  MD  (Chairman) 

Richard  Casaburi  PhD  MD  (Co-Chairman) 

Mary  R  Burns  RN 

Brian  W  Carlin  MD 

Kent  L  Christopher  MD  RRT 

Michael  Cutaia  MD 

David  C  Levin  MD 

Gail  Livingstone 

Jacquelyn  McClure  RRT 

Jonathan  C  McLellan  RRT 

Paul  A  Selecky  MD 


REFERENCES 


1 .  Delbecq  AL,  Van  de  Ven  AH.  Gustafson  DH.  Group  techniques  for 
program  planning;  a  guide  to  nominal  group  technique  and  Delphi 
processes.  Scott  Foresman:  Glenview.  Illinois.  1975.  p  174. 

2.  Problems  in  prescribing  and  supplying  oxygen  for  Medicare  patients. 
Summary  of  a  Conference  on  Home  Oxygen  Therapy  held  in  Den- 
ver, February  28  and  March  1.  1986.  Am  Rev  Respir  Dis  1986:134; 
340-341. 

3.  Further  recommendations  for  prescribing  and  supplying  long-term 
oxygen  therapy.  Summary  of  the  Second  Conference  on  Long-Term 
Oxygen  Therapy  held  in  Denver.  Colorado,  December  11-12,  1987. 
Am  Rev  Respir  Dis  1988;138;745-747. 

4.  New  problems  in  supply,  reimbursement,  and  certification  of  med- 
ical necessity  for  long-term  oxygen  therapy.  Summary  of  the  Third 
Consensus  Conference  held  in  Washington,  DC,  March  15-16,  1990. 
Am  Rev  Respir  Dis  1990;  142:721-724. 

5.  Petty  TL,  O'Donohue  WJ  Jr.  Further  recommendations  for  prescrib- 
ing, reimbursement,  technology  development,  and  research  in  long- 
term  oxygen  therapy.  Summary  of  the  Fourth  Oxygen  Consensus 
Conference,  Washington,  DC.  October  15-16,  1993.  Am  J  Respir 
Crit  Care  Med  1994:150:87.5-877. 

6.  U.S.  General  Accounting  Office  Report  to  Congressional  Commit- 
tees: Apr,  1999.  Medicare  access  to  home  oxygen  largely  unchanged; 
closer  HCFA  monitoring  needed.  Washington  CXT.  24  pp.  GAO  Pub- 
lication No.  GAO/HEHS-99-56. 

7.  Continuous  or  nocturnal  oxygen  therapy  in  hypoxemic  chronic  ob- 
structive pulmonary  disease:  a  clinical  trial.  Nocturnal  Oxygen  Ther- 
apy Trial  Group.  Ann  Intern  Med  1 980:93(3  ):39 1-398, 
Long  term  domiciliary  oxygen  therapy  in  chronic  cor  pulmonale 
complicating  chronic  bronchitis  and  emphysema.  Report  of  the  Medical 
Research  Council  Working  Party.  Lancet  198l:l(8222):681-686. 


8 


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Recommendations  of  the  Fifth  Oxygen  Consensus  Conference 


Appendix 


Fifth  Oxygen  Consensus  Conference 

Final  Attendee  Roster 

September  20-22,  1999 


Ron  Allen  RPh  PA-C 

Jill  Eicher 

Walgreens  Health  Initiatives  Inc 

American  Association  for  Respiratory  Care 

Deerfield,  Illinois 

Alexandria,  Virginia 

Peter  L  Bliss  BME 

David  H  Eubanks  EdD  RRT 

Valley  Inspired  Products  LLC 

American  College  of  Chest  Physicians 

Savage,  Minnesota 

Northbrook,  Illinois 

Ronda  Bradley  RRT 

Gary  Ewart 

Mallinckrodt  Inc 

American  Lung  Association/ American  Thoracic 

St  Charles,  Missouri 

Society 

Washington,  DC 

Fred  Brown 

Mallinckrodt  Inc 

Robert  Fary  RRT 

St  Charles,  Missouri 

Apria  Healthcare 

Costa  Mesa,  California 

Tim  Buckley  RRT 

Walgreens  Health  Initiatives  Inc 

Dennis  Fitzgerald 

Deerfield,  Illinois 

AirSep  Corporation 

Buffalo,  New  York 

Susan  Bunning 

Mallinckrodt  Inc 

Nancy  Goebel 

St  Charles,  Missouri 

Walgreens  Health  Initiatives 

Deerfield,  Illinois 

Mary  R  Bums  RN 

Pulmonary  Education  and  Research  Foundation 

Jerry  Gorby 

Lomita,  California 

Breathin  Easy  Travel  Guide 

Napa,  California 

Brian  W  Carlin  MD 

American  Association  of  Cardiovascular 

Charles  Henry 

and  Pulmonary  Rehabilitation 

In-X  Corporation 

Pittsburgh,  Pennsylvania 

Lakewood,  Colorado 

Richard  Casaburi  PhD  MD 

Kathy  Keating  CRT 

Harbor  UCLA  Medical  Center 

Walgreens  Health  Initiatives 

Torrance,  California 

Elmhurst,  Illinois 

Kent  L  Christopher  MD  RRT 

Sharon  LaPine 

University  of  Colorado  Health  Sciences  Center 

Lincare 

Englewood,  Colorado 

Clearwater,  Florida 

Pierre  Clause 

David  C  Levin  MD 

AGA  Medical  SA 

Oklahoma  University  Health  Science  Center 

Rueil-Malmaison,  Cedex  France 

Oklahoma  City,  Oklahoma 

Michael  Cutaia  MD 

Joe  Lewarski  RRT 

University  of  Pennsylvania 

American  Association  for  Respiratory  Care 

VA  Medical  Center 

Mentor,  Ohio 

Philadelphia,  Pennsylvania 

Gail  Livingstone 

Rick  Davis 

National  Home  Oxygen  Patients  Association 

Mallinckrodt  Inc 

Mercer  Island,  Washington 

St  Charles,  Missouri 

Daryl  Lowrey 

Scott  Dunn  RRT 

Invacare  Corporation 

Chad  Therapeutics 

Elyria,  Ohio 

Chatsworth,  California 

(continued) 


960 


Respiratory  Care  •  August  2000  Vol  45  No  8 


Recommendations  of  the  Fifth  Oxygen  Consensus  Conference 


Appendix  (continued) 


Jacquelyn  McClure  RRT 

Cindy  Price  CRT 

Respironics  Inc 

National  Home  Oxygen  Patients  Association 

Pittsburgh,  Pennsylvania 

Driggs,  Idaho 

Robert  W  McCoy  RRT 

Joseph  Priest 

Valley  Inspired  Products 

AirSep  Corporation 

Savage,  Minnesota 

Buffalo,  New  York 

Jonathan  C  McLellan  RRT 

Michael  Samuelson 

Mallinckrodt  Inc 

Mallinckrodt  Inc 

St  Charles,  Missouri 

St  Charles,  Missouri 

Frederick  Mindermann  RRT  MBA 

Mary  Scanlon 

AGA  Health  Care 

Invacare  Corporation 

Brentwood,  Tennessee 

Elyria,  Ohio 

Bob  Mogue 

Paul  A  Selecky  MD 

Chad  Therapeutics 

National  Association  for  Medical  Direction  of 

Chatsworth,  California 

Respiratory  Care 

Newport  Beach,  California 

Bob  Murdoch 

Respironics  Inc 

Rick  Snyder  RRT 

Marietta,  Georgia 

VitalAire  Healthcare 

Calgary,  Alberta 

Craig  Murga 

Pulmonary  Education  and  Research  Foundation 

Ralph  Sperry  RRT 

Torrance,  California 

VitalAire  Healthcare 

Edmonton,  Alberta 

Louise  Nett  RN  RRT 

National  Lung  Health  Education  Program 

Greg  Spratt  RRT  CPFT 

Denver,  Colorado 

Rotech  Medical  Corporation 

Kirksville,  Missouri 

Marcia  Nusgart  RPh 

Coalition  of  Respiratory  Manufacturers 

Jo- Von  Tucker 

Bethesda,  Maryland 

Cape  COPD  Support  Group 

Chatham,  Massachusetts 

Jennifer  Pedersen  RRT 

National  Healthcare  Services  Manager 

Bob  Vrlik  RRT 

Clearwater,  Florida 

Walgreens  Health  Initiatives 

Schererville,  Indiana 

Phil  Petersen 

Raven  Publishers 

Bob  Wardwell 

Charlotte,  North  Carolina 

Health  Care  Finance  Administration 

Baltimore,  Maryland 

Thomas  L  Petty  MD 

National  Lung  Health  Education  Program 

Cheryl  West 

Denver,  Colorado 

American  Association  for  Respiratory  Care 

T-\-...;-j  T  n: \Ar\ 

Alexandria,  Virginia 

David  J  Pierson  MD 
Harborview  Medical  Center 
Seattle,  Washington 

Phillip  Porte 

National  Association  for  Medical  Direction  of 

Respiratory  Care 
Chevy  Chase,  Maryland 


Respiratory  Care  •  August  2000  Vol  45  No  8 


961 


Drug  Capsules 


Introduction  of  a  Single  Isomer  Beta  Agonist 


Joseph  L  Rau  PhD  RRT  FAARC 


Beta  (/3)  adrenergic  bronchodilators,  or,  more  simply, 
/3  agonists,  are  all  derivatives  of  epinephrine  (adrenaline), 
the  naturally  occurring  neuromediator.  It  is  well-known  to 
respiratory  therapists  that  epinephrine  and  its  analogues 
are  stereoisomeric  molecules  and  that  the  naturally  oc- 
curring form  of  epinephrine  is  the  levorotatory  (L)  or 
"R  isomer"  form  of  the  molecule.  The  synthetic  form  of 
epinephrine,  used  as  an  inhaled  aerosol,  is  the  racemic 
mixture,  also  termed  a  "racemate,"  a  50:50  mixture  of 
the  R  isomer  and  S  isomer  forms.  It  is  less  well-known 
to  practitioners  that  the  j3  agonist  derivatives  of  epineph- 
rine, both  catecholamines  and  noncatecholamines,  have  all 
been  racemic  mixtures  or  racemates.  This  includes  albu- 
terol as  well  as  salmeterol. 

Figure  1  illustrates  the  two  mirror  image  isomers,  or 
enantiomers,  of  racemic  albuterol,  with  the  conventions 
for  designating  the  right-handed  and  left-handed  isomers. 
In  March  1999,  the  first  single-isomer  /3  agonist,  levalbu- 
terol  (Xopenex,  developed  by  Sepracor  Pharmaceuticals), 
was  approved  in  the  United  States  as  an  inhaled  broncho- 
dilator  aerosol,  and  is  seen  as  the  R  isomer  form  of  albu- 
terol in  Figure  1.  A  second  /3  agonist,  the  long-acting 
investigational  drug  R,R  formoterol,  is  under  development 
as  a  single-isomer  agent.  A  current  racemic  form  of  that 
drug  is  available  outside  the  United  States  from  Astra 
Pharmaceuticals  and  Novartis.  Bakale  et  al  provided  an 
excellent  review  of  the  chemistry  of  isomeric  forms  of 
albuterol.'  The  August  1999  supplement  of  the  Journal  of 
Allergy  and  Clinical  Immunology  (Vol  104,  No  2,  Part  2), 
devoted  to  single-isomer  jS  agonists,  termed  "third  gener- 
ation jS  agonists,"  also  offers  comprehensive  information. 

Physiologic  Effects  of  P  Agonist  Isomers 

It  had  been  accepted  in  the  past  that  only  one  of  the 
stereoisomers  of  epinephrine  analogues  is  physiologically 


Joseph  L  Rau  PhD  RRT  FAARC  is  affiliated  with  CardiopulniDiiary  Care 
Sciences.  Georgia  State  University,  Atlanta,  Georgia. 

Correspondence:  Joseph  L  Rau  PhD  RRT  FAARC,  Cardiopulmonary 
Care  Sciences,  Georgia  State  University,  Atlanta  GA  iOMB.  E-mail: 
jrau(S>  gsu.edu. 


active,  but  because  of  the  technical  difficulty  and  cost  of 
separating  out  the  isomeric  forms,  a  racemic  mixture  of 
adrenergic  agonists  has  been  used  for  inhalation.  This  was 
historically  exemplified  with  the  synthetic  form  of  epi- 
nephrine, racemic  epinephrine  (MicroNefrin,  Bird  Corpo- 
ration). Only  the  levo  form  (R  isomer)  was  believed  to  be 
active,  and  the  dextrorotatory  form  (S  isomer)  was  con- 
sidered inactive  in  the  body.  Since  the  50:50  racemic  mix- 
ture was,  in  effect,  only  50%  active,  a  2.25%  strength 
solution  was  utilized,  as  opposed  to  the  1%  strength  solu- 
tion of  the  natural  single-isomer  extract  available  in  in- 
jectable formulations. 

Recent  in  vitro  and  clinical  data  suggest  that  the  S  iso- 
mer of  albuterol  may  be  physiologically  active  and  that  it 
may  actually  antagonize  the  bronchodilating  effects  of  the 
R  isomer.  Table  1  summarizes  the  physiologic  effects  of 
the  S  isomer  of  albuterol. 

Templeton  et  al  found  that  S  isomer  salbutamol  (S  iso- 
mer albuterol)  enhanced  the  contractile  response  of  iso- 
lated human  bronchial  tissue  to  stimulation  by  histamine 
and  leukotriene  C4.-  Their  results  suggest  that  the  capacity 
of  the  S  isomer  of  salbutamol  to  augment  contraction  of 
airway  smooth  muscle  might  contribute  to  the  hyperreac- 
tivity to  spasmogens  in  asthma. 

Mitra  et  al  showed  that  S  albuterol  increases  intracellu- 
lar free  calcium  in  bovine  tracheal  smooth  muscle  cells. ■* 
Both  S  albuterol  and  R,S  albuterol  increased  calcium  con- 
centrations. In  contrast,  R  albuterol  decreased  calcium  con- 
centrations in  the  same  study.  More  interesting  was  the 
finding  that  the  increase  in  calcium  from  S  albuterol  was 
blocked  by  atropine,  implying  reactivity  of  this  isomer 
with  muscarinic  receptors  and  not  /3  receptors. 

Work  by  Volcheck  et  al  found  that  the  S  isomer  of 
albuterol  significantly  enhanced  superoxide  production  by 
eosinophils  in  response  to  interleukin  5  stimulus  in  vitro, 
whereas  racemic  mixtures  containing  both  the  R  and 
S  isomers  inhibited  such  production.''  As  a  marker  of  in- 
flammatory activity,  superoxide  production  implies  that 
the  S  isomer  of  albuterol  has  a  proinfianmiatory  effect. 
A  study  by  Lipworth  et  al,  using  healthy  volunteers,  found 
no  detectable  activity  of  S  salbutamol  at  extra-pulmonary 
P-2  receptors,  based  on  finger  tremor,  heart  rate,  and  plasma 
potassium  changes.''  Inhalation  of  nebulized  R  and  R,S 


962 


Respiratory  Care  •  August  2000  Vol  45  No  8 


Introduction  of  a  Single  Isomer  Beta  Agonist 


Albuterol  Isomers 


HOCHj 


HO 


^ 


OH 

i      CH,NHC-CH3 

^  I 

"  CH, 


CH3 

CHj-CHNCHj^ 

CH, 


OH 

V 

c 


CH20H 


^<^ 


OH 


D  or  (S)-albuterol 


L  or  (R)-albuterol 
(Xopenex) 


Fig.  1 .  The  S  isomer  (left)  and  R  isomer  (right)  of  albuterol,  indicating  the  naming  conventions  for  the  stereoisomers.  The  two  isomers  are 
mirror  images  (enantiomers)  and  are  designated  as  dextrorotatory  (D)  or  S  albuterol,  and  levorotatory  (L)  or  R  albuterol.  Levalbuterol  is  the 
levorotatory  (R  isomer)  form. 


salbutamol  produced  dose-related  responses  on  a  1:2  mi- 
crogram basis.  Higher  plasma  levels  of  the  S  isomer  were 
found  than  of  the  R  isomer.  Page  and  Morley  reviewed  the 
contrasting  properties  of  albuterol  stereoisomers.'' 

A  difference  in  the  rate  of  metabolism  of  the  two  iso- 
meric forms  of  albuterol  has  also  been  found.  Boulton  et  al 
examined  the  bioavailability  of  the  racemate  and  each  iso- 
mer individually  in  12  healthy  males,  using  oral  dosing  of 
albuterol.  They  found  higher  plasma  levels  of  the  S  isomer 
than  of  the  R  isomer.*  Schmekel  et  al  also  found  that  the 
bioavailability  of  S  salbutamol  was  significantly  larger 
after  oral  dosing,  tracheal  instillation,  or  inhalation  from  a 
dry  powder  inhaler  with  single-dose  racemic  salbutamol.' 
A  recent  study  by  Dhand  et  al  reported  that  inhalation  of 
racemic  albuterol  via  either  metered-dose  inhaler  (MDI) 
alone  or  via  MDI  with  holding  chamber  gave  higher  areas 
under  the  curve  for  plasma  levels  of  R  albuterol  than  S 
albuterol,  a  finding  that  contrasts  with  the  studies  previ- 
ously cited. '°  The  authors  concluded  that  there  was  a  pref- 
erential retention  of  the  S  isomer  in  the  lung  with  MDI 
delivery,  resulting  in  lower  plasma  levels  of  the  S  isomer. 
Higher  plasma  levels  of  S  albuterol  with  nebulizer  or  dry 
powder  inhaler  delivery  would  suggest  that  gastrointesti- 
nal absorption  contributes  more  to  systemic  levels  with 
these  delivery  techniques,  whereas  MDI  delivery  gives 
greater  lung  absorption.*'"* 

Preferential  retention  and  accumulation  of  the  S  isomer 
in  the  lung  with  MDI  administration  or  increased  plasma 
levels  with  other  routes  of  administration  indicate  a  need 
for  further  clinical  investigation  of  the  exact  effects  of  S 
albuterol  in  asthmatics. 

Clinical  Effects  of  R  and  S  Albuterol 

One  of  the  most  serious  concerns  with  the  use  of  ^ 
agonists  in  the  management  of  asthma  comes  from  data 


showing  that  the  regular  use  of  these  agents  can  increase 
airway  hyperresponsiveness.  Work  by  Cockroft  et  al  and 
by  O'Connor  et  al  showed  a  decreased  PDjo  (provoca- 
tional  dose  causing  a  20%  decrease  in  forced  expiratory 
volume  in  the  first  second)  with  various  airway  challenge 
agents  such  as  methacholine,  allergen,  or  adenosine,  after 
subjects  were  on  inhaled  /3  agonists,  thus  providing  evi- 
dence of  a  loss  of  bronchoprotection  with  regular  use  of 
the  /3  agonist."'-  One  possible  explanation  for  this  effect 
is  the  contractile  and  proinflammatory  activity  of  the  S 
isomer  of  albuterol,  which  would  accumulate  with  its  slower 
metabolism  and  clearance.  A  randomized  controlled  study 
by  Perrin-Fayolle,  using  mildly  asthmatic  volunteers,  found 
that  R  albuterol  and  R,S  albuterol  suppressed  methacho- 
line-induced  bronchoconstriction,  that  suppression  with  R 
albuterol  was  more  pronounced  than  with  R,S  albuterol, 
and  that  sensitivity  to  methacholine  was  increased  after 
inhalation  of  S  albuterol.'-'  These  results  were  not  con- 
firmed in  subsequent  studies  by  Cockcroft  et  al,  who  re- 
ported in  1997  that  a  single  dose  of  1.25  mg  of  nebulized 
R  salbutamol  produced  equivalent  bronchoprotection  to 
2.5  mg  of  racemic  salbutamol,  and  that  S  salbutamol  had 
a  weak  bronchoprotective  effect  (although  not  greatly  dif- 
ferent from  placebo).'-'  The  authors  acknowledged  that  the 


Table  1.      Summary  of  the  Physiological  Effects  of  S  Albuterol 

Increases  contractile  response  of  bronchial  tissue  to  histamine  or 

leukotriene  C4  (LTC4)- 
Increa.ses  intracellular  calcium  concentration' 
Binds  to  muscarinic  receptors' 
Enhances  eosinophil  superoxide  production  with  Interleukin-5 

stimulation'' 
Enhances  experimental  airway  responsiveness' 


S  albuterol  =  dextrorolalory  form  (S  isomer)  of  albulerol 


Respiratory  Care  •  August  2000  Vol  45  No  8 


963 


Introduction  of  a  Single  Isomer  Beta  Agonist 


45  , 
40  . 
35 


2,    30 


Id     25 


a,  20-^ 


15 

10  -I 
5 

0  -I 


I 
u 


45 

40 
35 
30 
25  . 
20  . 
15  . 
10 

S-l 

0 


Day  0  (Week  0) 


— ♦— LevI25(n=«8) 
— ♦— Lev0j63(n-92) 
— A— R*c2^(n=!74) 
— B— Racl25(n»«8) 
— K— PBO  (n-^5) 


Pre 


2  3  4 

Time  (hours) 


Day  28  (Week  4) 


-♦-Levl25(n=62) 

-♦— Lev0^3(n'«8) 

-A— Rac2J(n=«9) 

-e— RacI25(n=63) 

■PBO(n=68) 


Pre 


2  3  4 

Time  (hours) 


Fig.  2.  Mean  percent  change  in  forced  expiratory  volume  in  the  first  second  (FEV-,)  from  baseline  at  the  beginning  (week  0)  and  end  (week  4) 
with  different  doses  of  levaibuterol  (Lev),  racemic  albuterol  (Rac),  and  placebo  (PBO).  (From  Reference  16,  with  permission.) 


S  isomer  may  have  had  partial  contamination  with  R  sal- 
butamoi.  In  1999,  Cockcroft  et  al  reported  that  regular 
treatment  with  racemic  or  R  salbutamol,  but  not  S  salbu- 
tamol,  resulted  in  some  loss  of  bronchoprotection,  when 
measured  before  and  after  a  single  dose  of  racemic  salbu- 
tamol with  methacholine  challenge.''*  In  short,  regular  use 
of  the  S  isomer  did  not  show  a  decrease  in  PDjo  with 
methacholine  in  the  asthmatic  subjects  studied. 


Levaibuterol  (Xopenex  ) 

Levaibuterol  inhalation  solution  is  currently  supplied  as 
a  3  mL  unit  dose  nebulizer  solution.  The  unit  dose  is  free 
of  preservatives,  and  is  available  in  two  strengths:  a  0.63 
mg  and  a  1 .25  mg  dose  of  the  single  isomer.  The  solution 
is  contained  in  a  protective  foil  pouch  and  should  be  pro- 
tected from  light  or  excessive  heat  (>  25°  C).  The  man- 


964 


Respiratory  Care  •  August  2000  Vol  45  No  8 


Introduction  of  a  Single  Isomer  Beta  Agonist 


ufacturer  recommends  using  the  vials  within  two  weeks 
once  the  foil  pouch  is  opened.  Prechnical  trials  of  leval- 
buterol  were  performed  with  the  Pari  LC  Plus  and  the  Pari 
LC  Jet  nebulizer,  both  of  which  are  breath-enhanced,  re- 
usable, small-volume  nebulizers  with  less  ambient  aerosol 
loss  than  disposable  devices.  The  manufacturer's  drug  in- 
sert warns  that  efficiency  with  other  nebulizers  has  not 
been  established. 

The  0.63  mg  dose  is  approximately  one  fourth  of  the 
dose  of  R  albuterol  found  in  the  racemic  mixture,  whereas 
the  1 .25  mg  dose  is  approximately  half  of  the  racemic  dose 
of  R  isomer. 

Nelson  et  al  compared  the  two  doses  of  single-isomer 
levalbuterol  against  equivalent  amounts  in  a  racemic  mix- 
ture, along  with  a  placebo  comparison  group,  in  362  mod- 
erately to  severely  asthmatic  patients  >  12  years  of  age. '^ 
Each  study  drug  was  given  via  nebulization  three  times 
daily  for  28  days.  Improvements  in  FEV,  were  similar  for 
levalbuterol  0.63  mg  and  racemic  albuterol  2.5  mg.  Figure 
2  shows  the  percent  change  in  FEV,  relative  to  subject 
baseline  for  each  of  the  5  treatment  groups.  The  authors 
found  the  greatest  bronchodilation  with  levalbuterol  1.25 
mg  and  the  weakest  bronchodilation  with  racemic  albu- 
terol 1.25  mg.  Since  the  2.5  mg  racemic  mixture  contains 
1.25  mg  of  R  albuterol,  it  would  be  expected  that  the  2.5 
mg  racemic  dose  should  be  equivalent  in  bronchodilation 
to  the  1 .25  mg  R  albuterol  dose  rather  than  the  0.63  mg 
dose.  The  fact  that  0.63  mg  of  levalbuterol,  less  than  the 
amount  of  R  albuterol  found  in  the  racemic  mixture,  bron- 
chodilates  equally  with  the  2.5  mg  50:50  racemic  mixture 
of  R,S  albuterol  is  consistent  with  the  hypothesis  that 
S  albuterol  antagonizes  the  bronchodilating  effect  of  the 
R  isomer.  Adverse  effects,  including  heart  rate  increase, 
serum  potassium  decrease,  glucose  increase,  nervousness, 
and  tremor  were  less  with  levalbuterol  0.63  mg  than  with 
racemic  albuterol  2.5  mg.  Adverse  effects  with  the  1.25 
mg  levalbuterol  dose  were  similar  to  those  with  2.5  mg  of 
racemic  albuterol.  However,  greater  improvement  in  FEV, 
was  seen,  and  over  a  longer  duration  (up  to  8  hours).  Note 
that  the  predose  FEV,  value  at  the  time  of  dose  testing 
(representing  a  measure  of  lung  function  maintenance  dur- 
ing the  study)  was  found  to  be  greater  in  subjects  receiving 
levalbuterol  or  placebo  than  in  those  receiving  racemic 
albuterol.  The  authors  concluded  that  the  clinical  results 
support  the  concept  that  S  albuterol  may  have  detrimental 
effects  on  pulmonary  function. 

In  a  dose-response  study  of  moderately  asthmatic  sub- 
jects (resting  FEV,  50-80%  of  predicted)  2-1 1  years  old, 
Gawchik  et  al  found  FEV,  responses  similar  for  levalbu- 
terol 0.31  mg  and  0.63  mg,  compared  to  racemic  albuterol 
2.5  mg,  using  a  Pari  LC  Plus  nebulizer.'^  FEV,  values 
were  greatest  after  levalbuterol  1.25  mg.  All  patients  in  the 
2.5  mg  racemic  albuterol  arm  of  the  study  had  detectable 
plasma  levels  of  S  albuterol,  indicating  slower  metabolism 


of  the  S  isomer,  which  was  undetectable  in  most  patients 
in  the  levalbuterol  arms.  Subjects  continued  their  regular 
asthma  medication  therapy  during  the  study,  with  adren- 
ergic bronchodilators  withheld  for  a  period  of  S:  8  hours 
prior  to  dose  testing.  As  a  result,  some  subjects  receiving 
test  doses  of  levalbuterol  would  have  been  exposed  to 
racemic  albuterol  as  part  of  their  regular  therapy  between 
times  of  testing  and  had  detectable  levels  of  the  S  isomer. 
The  authors  concluded  that  levalbuterol  improved  FEV, 
significantly  more  than  placebo,  that  levalbuterol  was  com- 
parable to  or  better  than  racemic  albuterol,  and  that  /3-me- 
diated  adverse  effects  were  less  for  an  equipotent  dose  of 
levalbuterol  than  for  racemic  albuterol. 

Summary  and  Conclusion 

The  release  of  levalbuterol  offers  the  first  approved  sin- 
gle-isomer /3  agonist  for  oral  inhalation.  Data  from  in  vitro 
studies  support  the  concept  that  S  albuterol  is  not  inactive 
and  may  have  properties  antagonistic  to  bronchodilation. 
There  is  some  variability  in  the  results  of  clinical  studies 
with  the  separate  isomers  of  albuterol,  which  suggests  the 
need  for  further  study.  The  introduction  of  levalbuterol 
into  general  clinical  use  in  managing  asthma  and  chronic 
obstructive  disease  should  begin  to  offer  additional  infor- 
mation on  the  effects  of  a  single  isomer  j3  agonist  in  com- 
parison to  previous  racemic  mixtures. 


REFERENCES 

1.  Bakale  RP,  Wald  SA,  Butler  HT,  Gao  Y.  Hong  Y,  Nie  X,  et  al. 
Albuterol.  A  pharmaceutical  chemistry  review  of  R-.  S-.  and  RS- 
albuterol.  Clin  Rev  Allergy  Immunol  1996:14:7-35. 

2.  Templeton  AGE.  Chapman  ID.  Chilvers  ER.  Morley  J.  Handley  DA. 
Effects  of  S-salbutamol  on  human  isolated  bronchus.  Pulm  Pharma- 
col Ther  1998:11:1-6. 

3.  Mitra  S.  Ugur  M.  Ugur  O.  Goodman  HM,  McCullough  JR.  Yamagu- 
chi  H.  (S)-albuterol  increases  intracellular  free  calcium  by  musca- 
rinic receptor  activation  and  a  phosphoplipase  C-dependent  mecha- 
nism in  airway  smooth  muscle.  Mol  Pharmacol  1998:53:347-354. 

4.  Volcheck  GW.  Gleich  GJ.  Kita  H.  Pro-  and  anti-inflammatory  ef- 
fects of  beta  adrenergic  agonists  on  eosinophil  response  to  IL-5. 
J  Allergy  Clin  Immunol  1998:101:535. 

5.  Johansson  FJ.  Rydberg  I,  Aberg  G,  Anders.son  RGG.  Effects  of 
albuterol  enantiomers  on  in  vitro  bronchial  reactivity.  Clin  Rev  Al- 
lergy Immunol  1996:14:57-64. 

6.  Lipworth  BJ.  Clark  DJ.  Koch  P,  Arbeeny  C.  Pharmacokinetics  and 
extrapulmonary  beta-2  adrenoceptor  activity  of  nebulised  racemic 
salbutamol  and  its  R  and  S  isomers  in  healthy  volunteers.  Thorax 
1997:52:849-852. 

7.  Page  CP,  Morley  J.  Contrasting  properties  of  albuterol  stereoiso- 
mers. J  Allergy  Clin  Immunol  1999;104:S31-S41. 

8.  Boulton  DW.  Fawcett  JP.  Pharmcokinetics  and  pharmacodynamics 
of  single  oral  doses  of  albuterol  and  its  enantiomers  in  humans.  Clin 
Pharmacol  Ther  1997;62:138-144. 


Respiratory  Care  •  August  2000  Vol  45  No  8 


965 


Introduction  of  a  Single  Isomer  Beta  Agonist 


Schmekel  B,  Rydberg  I,  Norlander  B,  Sjosward  KN,  Ahlner  J,  Anders-  14. 

son  RGG.  Stereoselective  pharmacokinetics  of  S-salbulamol  after 
administration  of  the  racemale  in  healthy  volunteers.  Eur  Respir  J 
1999;13:1230-1235.  15. 

Dhand  R.  Goode  M,  Reid  R.  Fink  JB.  Fahey  PJ,  Tobin  MJ.  Prefer- 
ential pulmonary  retention  of  (S)-albuterol  after  inhalation  of  race- 
mic  albuterol.  Am  J  Respir  Crit  Care  Med  1999:160:1 136-1 141. 
Cockroft  DW,  McParland  CP,  Britto  SA,  Swystun  VA,  Rutherford  16. 

EC.  Regular  inhaled  salbutamol  and  airway  responsiveness  to  aller- 
gen. Lancet  1993:342:833-837. 

12.  O'Connor  BJ,  Aikman  SL,  Barnes  PJ.  Tolerance  to  the  nonbron- 
chodilator  effects  of  inhaled  betaj-agonists  in  asthma.  N  Engl  J  Med  17. 
1992;327:1204-1208. 

13.  Perrin-Fayolle  M.  Salbutamol  in  the  treatment  of  asthma.  Lancet 
I995;346:I10I. 


10 


II 


Cockcroft  DW,  Swystun  VA.  Effect  of  single  doses  of  S-salbutamol, 
R-salbutamol,  racemic  salbutamol,  and  placebo  on  the  airway  re- 
sponse to  methacholine.  Thorax  1997:52:845-848. 
Cockcroft  DW.  Davis  BE.  Swystun  VA,  Marciniuk  DD.  Tolerance 
to  the  bronchoprotective  effect  of  p,  agonists:  comparison  of  the 
enantiomers  of  salbutamol  with  racemic  salbutamol  and  placebo.  J 
Allergy  Clin  Immunol  1999:103:1049-1053. 
Nelson  HS,  Bensch  G,  Pleskow  WW.  DiSantostefano  R,  DeGraw  S, 
Reasner  DS,  et  al.  Improved  bronchodilation  with  levalbuterol  com- 
pared with  racemic  albuterol  in  patients  with  asthma.  J  Allergy  Clin 
Immunol  1998;102:943-952. 

Gawchik  SM,  Saccar  CL,  Noonan  M,  Reasner  DS,  DeGraw  SS.  The 
safety  and  efficacy  of  nebulized  levalbuterol  compared  with  racemic 
albuterol  and  placebo  in  the  treatment  of  asthma  in  pediatric  patients, 
J  Allergy  Clin  Immunol  1999;103:615-621. 


966 


Respiratory  Care  •  August  2000  Vol  45  No  8 


Mani  S  Kavuru  MD  and  James  K  Stoller  MD,  Series  Editors 


PFT  Nuggets 


Pulmonary  Function  in  Obesity 

Brian  M  Legere  MD  and  Mani  S  Kavuru  MD 


Case  Summary 

A  70-year-old  hypertensive,  ex-smoker  presents  with 
dyspnea.  His  complaints  of  shortness  of  breath  began  2 
years  prior  to  evaluation  and  have  not  substantially  wors- 
ened. The  patient  associates  his  symptoms  with  a  30  lb 
weight  increase.  Bending  at  the  waist  also  exacerbates  the 
dyspnea.  He  denies  symptoms  of  obstructive  sleep  apnea 
syndrome.  He  smoked  3  packs  of  cigarettes  per  day  for  25 
years,  but  quit  25  years  ago.  There  is  no  history  of  under- 
lying lung  disease  or  coronary  artery  disease. 

Physical  examination  reveals  an  obese  but  otherwise 
healthy-appearing  elderly  male.  Lungs  are  clear  to  auscul- 
tation, cardiac  exam  is  normal,  and  the  remainder  of  the 
physical  exam  is  also  within  normal  limits.  The  patient  is 
165  cm  tall,  weighs  127  kg,  and  his  body  mass  index 
(BMI)  is  63.2  kg/m-.  Table  1  shows  the  results  of  a  full 
pulmonary  function  survey. 

What  pattern  of  abnormality  is  shown  in  this  pulmonary 
function  survey? 

Is  the  pattern  suggestive  of  parenchymal  or  extraparen- 
chymal  disease? 

Why? 

Discussion 

The  spirogram  is  consistent  with  moderate  restriction. 
The  forced  vital  capacity  (FVC)  and  forced  expiratory 
volume  in  the  first  second  (FEV,)  are  both  well  below 
predicted  and  the  FEV|/FVC  ratio  is  normal.  The  reduced 
total  lung  capacity  (TLC)  confirms  the  presence  of  a  re- 
strictive process.  The  functional  residual  capacity  (FRC)  is 
also  reduced,  but  the  residual  volume  (RV)  is  normal.  The 
lung  diffusing  capacity  for  carbon  monoxide  (D,  cq)  is 
significantly  reduced,  but  the  ratio  of  Dlco  ^o  alveolar  gas 
volume  (W^)  is  normal.  This  latter  finding  suggests  a  non- 


Brian  M  Legere  MD  and  Mani  S  Kavuru  MD  are  affiliated  with  the 
Department  of  Pulmonary  and  Critical  Care  Medicine,  The  Cleveland 
Clinic  Foundation,  Cleveland,  Ohio. 

Correspondence:  Mani  S  Kavuru  MD.  Department  of  Pulmonary  and 
Critical  Care  Medicine.  Desk  A90,  The  Cleveland  Clinic  Foundation, 
9500  Euclid  Avenue.  Cleveland  OH  44195.  E-mail;  kavurum@ccforg. 


parenchymal  disorder.  These  findings  are  all  consistent 
with  a  restrictive  process  related  to  the  patient's  marked 
obesity. 

Numerous  studies  have  been  conducted  to  characterize 
the  consequences  of  obesity  on  pulmonary  function,  and 
most  authors  have  found  evidence  of  restriction,  with  re- 
duced TLC  and  FRC.-"'  Zerah  et  al  found  that  restriction 
(defined  as  a  >  20%  reduction  in  TLC)  was  present  in  8% 
of  patients  with  BMIs  of  25-29  kg/m",  25%  of  patients 
with  BMIs  of  30-40  kg/m',  and  56%  of  those  with  BMIs  > 
40  kg/m~.2  Note  that  the  RV  is  usually  normal  or  above 
normal  in  these  patients.-'''  The  presence  of  a  reduced  FRC 
with  a  normal  RV  results  in  a  reduced  expiratory  reserve 
volume  (ERV).  If  the  ERV  exceeds  the  closing  volume,  air 
trapping  may  result.'  One  author  has  stated  that  the  ERV 
is  the  most  sensitive  indicator  of  obesity-related  change  in 
lung  function.^  Changes  in  lung  function  have  been  shown 
to  correlate  with  progressive  weight  gain.  In  a  prospective 
study  of  1 ,202  patients  with  significant  weight  gain,  Chen 
et  al  determined  that  each  kilogram  weight  gain  in  men 
was  associated  with  a  26  mL  FVC  decrease  and  a  23  mL 
FEV,  decrease.*  These  abnormalities  have  been  postulated 
to  result  mainly  from  decreased  chest  wall  compliance  due 
to  increased  deposition  of  adipose  tissue."^ 

The  Dlco  '^  often  low  in  patients  with  morbid  obesity ."♦ 
However,  the  Dlco  corrected  for  alveolar  volume  (Dlcc/ 
V^)  is  usually  normal  or  above  normal,  as  seen  in  this 
patient.-^  It  is  postulated  that  the  increased  blood  volume 
resulting  from  obesity  results  in  increased  pulmonary  blood 
volume,  and  thus  a  higher  Dlcc/^a"  ''  ^^^  ^l^o  been 
suggested  that  increased  pulmonary  blood  volume  is  re- 
sponsible for  air  flow  limitation  in  morbidly  obese  pa- 
tients. Pulmonary  vascular  engorgement  may  lead  to  air- 
way submucosal  thickening,  which  in  turn  decreases  the 
caliber  of  small  airways.-*  Others  have  found  that  increases 
in  airway  resistance  are  due  to  low  lung  volumes.''  It  is 
possible  that  the  etiology  of  small  airways  dysfunction  in 
morbidly  obese  persons  is  multifactorial. 

Unfortunately,  none  of  the  commonly  used  predictive 
equations  for  normal  values  of  lung  function  take  patient 
weight  into  account.  Furthermore,  there  have  been  no  stud- 
ies evaluating  the  accuracy  of  these  equations  in  obese 
patients.  It  is  also  unclear  which  technique  of  measuring 


Respiratory  Care  •  August  2000  Vol  45  No  8 


967 


Pulmonary  Function  in  Obesity 


Table  I.      Pulmonary  Function  Test  Results 


Normal 


Test 


Predicted 


Actual 


Predicted  =  mean  predicted  values  per  Crapo  et  al.' 

FVC  =  forced  vital  capacity 

FEV|  =  forced  expiratory  volume  in  the  first  second 

FEV,/FVC  =  ratio  of  FEV,  to  FVC 

FRC-He  =  functional  residual  capacity  by  helium  dilution 

RV-He  =  residual  volume  by  helium  dilution 

TLC-He  =  total  lung  capacity  by  helium  dilution 

ERV-He  =  expiratory  reserve  volume  by  helium  dilution 

Diro  =  Lung  diffusing  capacity  for  carbon  monoxide 

Dio/V^  =  Ratio  of  diffusing  capacity  to  alveolar  volume 


%  Predicted 


FVC(L) 

3.75 

1.99 

53 

FEV,  (L) 

2.93 

1.45 

49 

FEV, /FVC 

0.78 

0.73 

93 

FRC-He 

3.40 

2.18 

64 

RV-He 

2.17 

1.95 

90 

TLC-He 

6.01 

3.90 

65 

ERV-He 

- 

0.23 

- 

D,^„  (mUmm  Hg/s) 

25.5 

13.9 

54 

D,^</Va 

4.40 

4.44 

101 

lung  volumes  (eg,  nitrogen  washout,  helium  dilution,  or 
body  plethysmography)  is  the  most  accurate  in  this  pop- 
ulation. Clearly,  more  research  needs  to  be  conducted  to 
answer  these  questions. 

Obesity  can  result  in  a  number  of  pulmonary  function 
abnormalities.  Pathologic  obesity  should  be  considered  as 
a  potential  cause  of  the  pattern  of  values  suggesting  ex- 
traparenchymal  restriction.  Figure  1  illustrates  the  divi- 
sions of  lung  capacities  and  volumes  in  normal  subjects,  in 
intraparenchymal  disease,  and  in  extrapulmonary  processes 
such  as  obesity.  This  pattern  typically  includes  low  TLC, 
FRC,  and  Dlco'  whereas  RV  and  Dlcq/^a  are  normal. 


s 


TLC 


FRC 
RV 


Restriction  - 


TLC 


FRC 
RV 


TLC 

FRC 
RV 


Fig  1 .  Lung  capacities  and  volumes  in  (left)  normal  subjects,  (mid- 
dle: A)  intraparenchymal  disease  such  as  pulmonary  fibrosis,  and 
(right:  B)  extrapulmonary  processes  such  as  obesity.  TLC  =  total 
lung  capacity.  FRC  =  functional  residual  capacity.  RV  =  residual 
volume.  Hatched  areas  represent  the  expiratory  reserve  volume. 

REFERENCES 

1.  Crapo  RO,  Morris  AH,  Gardner  RM.  Reference  spirometric  values 
using  techniques  and  equipment  that  meet  ATS  recommendations. 
Am  Rev  Respir  Dis  1981;123:659-664. 

2.  Ray  CS,  Sue  DY,  Bray  G,  Han.sen  JE,  Was.serman  K.  Effects  of 
obesity  on  respiratory  function.  Am  Rev  Respir  Dis  I983;128:501- 
506. 

3.  Zerah  F.  Harf  A,  Perlemuter  L,  Lorino  H,  Lorino  AM.  Atlan  G. 
Effects  of  obesity  on  respiratory  resistance.  Chest  1993;  103;  1470- 
1476. 

4.  Rubinstein  I,  Zamel  N,  DuBarry  L,  Hoffsten  V.  Airflow  limitation  in 
morbidly  obese  nonsmoking  men.  Ann  Intern  Med  1990;!  12:828- 
832, 

5.  Luce  JM.  Respiratory  complications  of  obesity.  Chest  1980;78:626- 
631. 

6.  Chen  Y.  Home  SL.  Dosman  JA,  Body  weight  and  weight  gain  re- 
lated to  pulmonary  function  decline  in  adults:  a  six  year  follow-up 
study.  Thorax  1993;48:375-380. 


968 


Respiratory  Care  •  August  2000  Vol  45  No  8 


Peak  Expiratory  Flow  vs  Spirometry  in  a  Patient  with  Asthma 


Prasoon  Jain  MD  and  Mani  S  Kavuru  MD 


Case  Summary 

A  70-year-old  nonsmoking  woman  with  a  lifelong  his- 
tory of  moderate  chronic  asthma,  rhinitis,  and  documented 
atopy  presented  with  a  3-month  history  of  chest  tightness, 
wheeze,  and  cough.  She  uses  an  albuterol  inhaler  as  needed, 
about  4-6  times  a  day  now.  She  is  not  on  any  other 
therapy  for  asthma.  She  does  not  monitor  her  asthma  with 
a  peak  flow  meter.  Examination  (after  a  bronchodilator) 
indicated  the  chest  to  be  clear.  Chest  radiograph  was  nor- 
mal. Her  postbronchodilator  peak  expiratory  flow  (PEF) 
(measured  with  a  hand-held  device.  Assess,  HealthScan)  is 
320  L/min.  Table  1  shows  spirometry  results  obtained  at 
the  same  time. 

1.  What  is  the  patient's  peak  flow  by  spirometry? 

2.  What  is  the  relationship  between  forced  expiratory 
volume  in  the  first  second  (FEV,)  and  PEF? 

Discussion 

PEF  is  the  highest  expiratory  flow  achieved  with  a  max- 
imally forced  effort  from  a  position  of  maximum  inspira- 
tion or  total  lung  capacity.-  For  spirometers,  peak  flow  is 
expressed  in  body  temperature  and  pressure  saturated  with 
water  vapor  conditions  (BTPS),  usually  as  liters  per  sec- 
ond (Us).  Peak  flow  is  sometimes  referred  to  as  forced 
expiratory  flow  maximum  or  maximum  expiratory  flow. 
Peak  flow  values  obtained  with  hand-held  portable  devices 
are  usually  expressed  under  ambient  conditions  (without 
BTPS  correction).  The  convention  is  to  express  peak  flow 
from  commonly  used  hand-held  devices  in  liters  per  minute 
(L/min).  PEF  is  usually  obtained  within  the  initial  100 


Prasoon  Jain  MD  is  affiliated  with  the  Department  of  Medicine.  Louis  A 
Johnson  Veterans  Affairs  Medical  Center.  Clarksburg,  West  Virginia. 
Mani  S  Kavuru  MD  is  affiliated  with  The  Cleveland  Clinic  Foundation. 
Department  of  Pulmonary  and  Critical  Care  Medicine.  Cleveland.  Ohio. 

Correspondence:  Prasoon  Jain  MD,  Department  of  Medicine.  Louis  A 
Johnson  VA  Medical  Center.  One  Medical  Center  Drive,  Clarksburg 
WV  26301.  E-mail;  RPPJ@msn.com. 


milliseconds  of  forced  expiration,  thereby  making  a  pro- 
longed expiratory  maneuver  unnecessary  for  an  accurate 
measurement.' 

Variation  in  the  predicted  expiratory  flow  values  in  the 
normal  population  is  largely  due  to  age,  sex,  race,  height, 
and  smoking  history.*  Because  PEF  is  effort-dependent, 
respiratory  muscle  strength  and  patient  motivation  affect 
peak  flow.  When  these  confounding  factors  are  accounted 
for,  a  change  in  peak  flow  predominantly  reflects  alter- 
ation of  the  caliber  of  large  airways,  as  opposed  to  rav,, 
which  is  affected  by  change  in  caliber  of  both  large  and 
medium  sized  airways.^ 

A  number  of  studies  have  compared  PEF  and  FEV, 
regarding  reproducibility,  correlation,  and  accuracy.*-*  The 
reproducibility  of  PEF  is  reported  to  be  very  good,  with  a 
coefficient  of  variation  of  5-14%  (for  PEF  obtained  by 
mini-Wright  peak  flow  meter)  and  7-18%  (for  PEF  ob- 
tained via  spirometer)  in  well-trained  nonsmoking  sub- 
jects.'' The  variability  is  probably  greater  in  subjects  with 
air  flow  obstruction.  However,  low  precision  error,  or  the 
difference  between  successive  measurement  by  the  same 
instrument,  of  an  individual  peak  flow  meter  does  not 
ensure  a  good  inter-device  reproducibility,  especially  when 
peak  flow  meters  of  different  commercial  brands  are  com- 
pared. Investigators  have  found  poor  agreement  among 
different  brands  of  peak  flow  meters.'  Therefore,  once 
chosen,  the  peak  flow  meter  from  the  same  manufacturer 
should  be  used  for  all  future  monitoring. 

The  relationship  between  PEF  and  FEV ,  obtained  at  the 
same  time  for  a  forced  expiratory  maneuver  has  been  eval- 
uated. A  high  correlation  has  been  reported  for  PEF  ob- 
tained both  by  portable  peak  flow  meters  and  spirometers, 
with  correlation  coefficients  of  0.78-0.95  for  absolute  val- 
ues and  0.74-0.91  for  percent-of-predicted  values.*"  How- 
ever, despite  a  high  correlation  between  PEF  by  mini- 
Wright  peak  flow  meter  and  FEV,,  over  50%  of  the  asthma 
patients  in  one  study  displayed  a  s  10%  difference  be- 
tween their  percent-of-predicted  values  for  FEV,  and  PEF, 
and  one  third  of  all  individuals  showed  a  ^  20%  discrep- 
ancy.'" When  PEF  and  FEV,  are  measured  in  the  same 
subjects,  the  standard  deviation  for  PEF  readings  is  con- 
sistently larger  than  that  for  FEV,,  indicating  a  greater 
variability  in  PEF  readings  than  in  FEV,  readings." 

In  general,  PEF  tends  to  underestimate  the  degree  of  air 
flow  obstruction.  In  many  studies,  the  predictability  of 


Respiratory  Care  •  August  2000  Vol  45  No  8 


969 


Peak  Expiratory  Flow  vs  Spirometry  in  a  Patient  with  Asthma 


Table  1 .      Pulmonary  Function  Test  Results 


Test 

Predicted 

Prebronchodilator 

Postbronchodilatoi 

Mean 

LLN 

Measured 

%  Predicted 

Measured 

%  1 

Predicted 

FVC(L) 

2.90 

2.23 

2.19 

75 

2.88 

99 

FEV,  (L) 

2.21 

1.65 

1.44 

65 

1.78 

80 

FEV|/FVC 

0.76 

0.67 

0.66 

- 

0.62 

- 

PEF  (Lis) 

5.50 

3.77 

3.04 

55 

4.29 

78 

Predicted  =  mean  predicted  values  per  Crapo  et  al.' 

LLN  =  lower  limit  of  normal 

FVC  ~  forced  vital  capacity 

FEVi  =  forced  expiratory  volume  in  the  fii^t  second 

FEV,/FVC  =  ratio  of  FEV,  to  l^C 

PEF  =  peak  expiratory  flow 


FEV,  from  PEF  was  at  most  moderate  (r^  <  0.8).*  Fur- 
thermore, PEF  is  less  sensitive  than  standard  spirometry  in 
detecting  reversibiHty  of  air  flow  obstruction  after  bron- 
chodilator  administration  or  of  worsening  of  air  flow  lim- 
itation or  response  to  inhalational  challenge. 

In  summary,  these  studies  suggest  that  peak  flow  values 
obtained  by  hand-held  devices  cannot  substitute  for  FEVj 
measured  by  either  hand-held  spirometers  or  office-based 
equipment,  at  least  for  initial  assessment  of  patients  with 
suspected  air  flow  limitation.  In  this  patient,  PEF  calcu- 
lated from  the  spirometry  data  in  Table  1  is  3.04  L/s  (182 
L/min)  before  bronchodilator  inhalation,  and  4.29  L/s  (257 
L/min)  after  bronchodilator  inhalation.  The  latter  value 
differs  by  20%  from  that  obtained  using  the  hand-held 
peak  flow  meter. 

REFERENCES 

1.  Crapo  RO,  Morris  AH,  Gardner  RM.  Reference  spirometric  values 
using  techniques  and  equipment  that  meet  ATS  recommendations. 
Am  Rev  Respir  Dis  1981;I23(6):659-664. 

2.  Jain  P,  Kavuru  MS,  Emerman  CL,  Ahmad  M.  Utility  of  peak  expi- 
ratory flow  monitoring.  Chest  1998;1 14:861-876. 


10. 


11 


American  Thoracic  Society.  Standardization  of  spirometry,  1994  up- 
date. Am  J  Respir  Crit  Care  Med  1995;152;1 107-1 136. 
Gregg  I,  Nunn  AJ.  Peak  expiratory  flow  in  normal  subjects.  Br  Med  J 
1973;3:282-284. 

Robinson  DR,  Chaudhary  BA,  Speir  WA  Jr.  Expiratory  flow  limi- 
tation in  large  and  small  airways.  Arch  Intern  Med  1984:144:1457- 
1460. 

Paggiaro  PL,  Moscato  G,  Giannini  D.  Di  Franco  A,  Gherson  G. 
Relationship  between  peak  expiratory  flow  (PEF)  and  FEV,.  Eur 
Respir  J  1997  24:39S^1S. 

Kelly  CA,  Gibson  GJ.  Relation  between  FEV,  and  peak  expiratory 
flow  in  patients  with  chronic  airflow  obstruction.  Thorax  1988;43: 
335-336. 

Gautrin  D,  D'Aquino  LC,  Gagnon  G,  Malo  JL,  Cartier  A.  Compar- 
ison between  peak  expiratory  flow  rates  (PEER)  and  FEV,  in  the 
monitoring  of  asthmatic  subjects  at  an  outpatient  clinic.  Chest  1994; 
106:1419-1426. 

Eichenhom  MS,  Beauchamp  RK,  Harper  PA,  Ward  JC.  An  assess- 
ment of  three  portable  peak  flow  meters.  Chest  1982:82:306-309. 
Meltzer  AA,  Smolensky  MH,  D'Alonzo  GE,  Harrist  RB,  Scott 
PH.  An  assessment  of  peak  expiratory  flow  as  surrogate  mea- 
surement of  FEV,  in  stable  asthmatic  children.  Chest  I989;96: 
329-333. 

Gardner  RM,  Crapo  RO,  Jackson  BR,  Jensen  RL.  Evaluation  of 
accuracy  and  reproducibility  of  peak  flowmeters  at  1 ,400  m.  Chest 
1992;101:948-952. 


Q7n 


Rf.spiratory  Care  •  Aiinii.sT  20{X)  Vol  45  No  8 


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600  Ninth  Avenue,  Suite  702,  Seattle  WA  98104.  Letters  may  also  be  submitted  electronically  at  www.rcjoumal.coni/online_resources. 


Testing  Conditions  for  Nebulizers 

This  letter  is  in  response  to  the  article 
"In  Vitro  Comparison  of  the  Circulaire  and 
AeroTee  to  a  Traditional  Nebulizer  T-Piece 
with  Corrugated  Tubing"  by  David  S  Piper, 
which  appeared  in  the  March  2000  issue  of 
Respiratory  Care.  '  As  the  manufacturer  of 
the  Circulaire  Drug  Delivery  System  and 
the  VixOne  Nebulizer,  we  would  like  to 
respond. 

We  would  caution  your  readers  that  the 
results  reported  in  the  study  by  Mr  Piper 
may  not  be  indicative  of  what  your  readers 
would  experience  under  different  testing 
conditions.  For  instance,  the  AeroTee  is  pro- 
vided with  a  different  nebulizer  than  what 
was  used  in  the  testing  reported  in  the  study. 
A  more  accurate  comparison  would  have 
been  to  compare  the  AeroTee  and  Circu- 
laire as  they  are  provided  from  each  man- 
ufacturer and  then  compare  the  traditional 
nebulizer  T-piece  with  corrugated  tubing  us- 
ing both  of  the  standard  nebulizers.  This 
would  have  provided  a  fair  comparison  of 
the  merits  of  both  products  and  how  they 
compare  to  the  T-piece, 

There  are  two  other  jwints  we  would  like 
to  clarify.  First,  Mr  Piper  states  that  the  Cir- 
culaire only  comes  equipped  with  the  Vix- 
One nebulizer.  This  is  not  true.  We  sell  the 
Circulaire  device  as  a  stand-alone  product; 
however,  most  of  our  customers  prefer  to 
purchase  it  with  the  VixOne  nebulizer  be- 
cause of  its  outstanding  performance.  Sec- 
ond, our  product  has  a  patented  one-way 
valve  system  to  ensure  that  there  is  no  pos- 
sibiUty  of  rebreathing.  The  AeroTee,  how- 
ever, allows  rebreathing,  bringing  up  the  is- 
sues of  CO2  rebreathing  and  infection 
control. 

As  a  leading  manufacturer  of  pulmonary 
drug  delivery  and  disease  management  prod- 
ucts, our  fcxus  is  to  partner  with  clinicians 
to  provide  solutions  that  improve  their  pa- 
tients' quality  of  life,  outcomes,  and  make 
cost-effective  sense  in  the  challenges  of 
health  care  today. 


Dean  Iwasaki 

Vice  President  of  Marketing 

Westmed 

Lakewood.  Colorado 


REFERENCE 

1 ,  Piper  SD,  In  vitro  cotnparison  of  the  Cir- 
culaire and  AeroTee  to  a  traditional  nebu- 
lizer T-piece  with  corrugated  tubing.  Re- 
spir  Care  2000;  45(3):313-319. 


The  author  replies: 

I  would  like  to  make  several  observa- 
tions. 

It  was  a  primary  objective  of  the  study  to 
determine  the  effect  of  the  different  nebu- 
lizer deUvery  systems  independent  of  the 
performance  of  the  various  nebulizers. 
Given  that  the  AeroTee,  the  nebulizer  with 
T-piece,  and  presumably  the  Circulaire  are 
available  to  be  used  with  any  hand-held  neb- 
ulizer, there  is  simply  no  scientific  basis  for 
comparing  the  different  devices  using  dif- 
ferent nebulizers 

Furthermore,  the  rebreathed  volume  of 
all  3  devices  were  measured  and  reported. 
The  results  showed  that  the  AeroTee  and 
the  nebulizer  with  T-piece  allowed  for  the 
same  amount  of  rebreathed  gas  and  that  both 
devices  had  approximately  three  times  as 
much  rebreathed  gas  as  the  Circulaire,  The 
study  demonstrated  that  the  Circulaire  does 
allow  the  patient  to  rebreathe  some  gas  ( ~  1 5 
mL),  Other  claims  regarding  rebreathed  gas 
were  outside  the  scope  of  the  paper  and 
should  be  determined  by  the  evaluation  of 
scientific  evidence. 

S  David  Piper  PE 

President 

Piper  Medical  Products 

West  Sacramento,  California 

Is  the  Health  Care  Financing 
Administration  the  Standard 

of  Care  for  the 
Oxygen-Dependent  Patient? 

An  article  in  the  April  issue  of  Respira- 
tory Care,  "Reevaluation  of  Continuous 
Oxygen  Therapy  after  Initial  Prescription  in 
Patients  with  Chronic  Obstructive  Pulmo- 
nary Disease,"'  was  quite  troubling  to  me 
as  a  respiratory  therapist,  on  several  ac- 
counts. 

First,  the  article  seems  to  suggest  that 
the  Health  Care  Financing  Administration 


(HCFA)  guidelines  have  become  the  stan- 
dard of  care  for  the  oxygen-dependent  pa- 
tient, I  believe  the  HCFA  guidelines  use  in- 
appropriately low  blood  oxygenation  values. 

Second,  Oba  et  al  seemed  to  suggest  that 
all  long-term  oxygen  patients  should  un- 
dergo reevaluation  60-90  days  after  initiat- 
ing oxygen.  Sending  all  oxygen-dependent 
patients  to  a  pulmonologist  60-90  days  af- 
ter initiating  oxygen  sounds  like  spending 
$206-253  million  dollars  a  year  to  save 
$106-153  million  a  year. 

Third,  is  the  60-90-day  reevaluation  to 
be  based  on  Medicare's  guidelines  (arterial 
oxygen  tension  55  mm  Hg  and  arterial  ox- 
ygen saturation  88%)?  I  think  diese  guide- 
lines were  intentionally  set  so  low  a  patient 
practically  has  to  be  blue  to  qualify  for  home 
oxygen. 

However,  not  all  oxygen  patients  must 
meet  Medicare's  abominably  low  oxygen- 
ation values  to  qualify  for  oxygen.  For 
example,  the  Medicaid  oxygen  guidelines 
in  North  Carolina  are  arterial  oxygen  ten- 
sion 60  mm  Hg  and  arterial  oxygen  satu- 
ration 90%. 

Most  insurance  companies  adopt  Medi- 
care guidelines  because  they  are  accepted, 
but  this  does  not  mean  the  guidelines  are 
appropriate.  Try  using  those  guidehnes  in 
the  hospital:  Do  physicians  decide  not  to 
order  oxygen  for  their  chronic  obstructive 
pulmonary  disease  (COPD)  patients  because 
the  oxygen  saturation  is  89%?  Certainly  not. 
Oxygen  flows  freely  in  the  hospital,  but  not 
at  home  where  it  may  be  needed  the  most. 

My  experience  with  stable  COPD  patients 
who  do  not  qualify  for  oxygen  at  rest  is  that 
they  do  qualify  on  exertion  and  during  sleep 
(as  measured  via  overnight  oximetry).  Is  this 
clinically  important?  Do  patients  benefit 
from  using  oxygen  on  exertion  and  at  night 
even  in  a  chronic  stable  state?  It  has  been 
well  documented  that  some  COPD  patients 
experience  sleep  disorders  from  multiple 
awakenings  related  to  their  blood  oxygen 
fluctuations,^  Moreover,  mortality  studies 
based  on  stable  COPD  patients  who  use  ox- 
ygen for  exertion  and  at  night  are  lacking. 
There  is  great  interest  and  possibly  a  study 
brewing  at  our  local  university  pulmonary 
department  on  that  very  subject. 

So  before  we  start  removing  oxygen  from 
people's  homes,  let  us  see  if  that  oxygen 


Respiratory  Care  •  August  2000  Vol  45  No  8 


971 


Letters 


may  benefit  the  patient.  Countless  times  I 
have  removed  oxygen  equipment  from  pa- 
tient's homes  only  to  return  it  a  couple  of 
days  later. 

Matthew  Daggett  RRT 

Winston-Salem,  North  Carolina 


REFERENCES 

1.  Oba  Y.  Salzman  GA,  WilKsie  SK.  Reeval- 
uation  of  continuous  oxygen  therapy  after 
initial  prescription  in  patients  with  chronic 
obstructive  pulmonary  disease.  Respir 
Care  2000:45:401-406. 

2.  O'Donohue  WJ,  Bowman  TJ.  Hypoxemia 
during  sleep  in  patients  with  chronic  ob- 
structive pulmonary  disease:  significance, 
detection,  and  effects  of  therapy.  Respir 
Care  2000;45:188-193. 


The  authors  reply: 

As  we  showed  in  our  study,  most  of  the 
patients  on  continuous  oxygen  therapy  were 
acutely  ill  at  the  time  of  initial  evaluation 
and  up  to  60%  of  the  patients  had  improved 
after  medical  treatment,  to  the  point  where 
they  did  not  qualify  for  continuous  oxygen 
therapy. '  The  benefit  of  continuous  oxygen 
therapy  in  this  population  is  not  clear  be- 
cause the  Nocturnal  Oxygen  Therapy  Trial 
(NOTT)  and  the  Medical  Research  Council 
(MRC)  studies^-^  (that  proved  mortality  ben- 
efits in  chronic  hypoxemic  COPD  patients) 
excluded  such  patients.  The  standard  of  care 
for  the  initiation  of  continuous  oxygen  ther- 
apy was  established  by  the  NOTT  study 
and  was  adopted  by  Medicare.  In  terms  of 
reevaluation  or  recertification  of  continuous 
oxygen,  as  we  mentioned  in  our  study,  the 


HCFA  regulations'*  are  inconsistent  with  the 
recommendations  from  the  Third  Oxygen 
Consensus  Conference,  which  are  based  on 
evidence  shown  by  previous  clinical  sntd- 
ies.  We  completely  agree  with  Mr  Daggett 
that  the  HCFA  regulations  never  were  the 
standard  of  care  and  nor  should  they  ever 
be.  We  suggest  that  the  HCFA  should  adopt 
the  guidelines  from  the  Third  Oxygen  Con- 
sensus Conference,  especially  with  regard 
to  the  reevaluation  of  continuous  oxygen. 
We  also  agree  with  Mr  Daggett  that  Medi- 
care guidelines  for  continuous  oxygen  ther- 
apy should  not  be  applied  to  acutely  ill  hos- 
pitalized patients,  because  they  are  a 
completely  different  patient  population. 

Based  on  die  NOTT  and  MRC  studies, 
there  is  general  agreement  among  pulmo- 
nary physicians  that  hypoxemic  COPD  pa- 
tients should  receive  oxygen  at  least  1 5  hours 
a  day  to  enhance  their  survival.  The  entry 
criteria  into  those  two  studies  were  almost 
identical  in  terms  of  demographics,  and  sur- 
vival of  the  control  group  (no  oxygen  group) 
in  the  MRC  study  was  similar  to  the  pa- 
tients who  received  oxygen  12  hours  a  day 
in  the  NOTT  study.  Based  on  that  fact,  it  is 
unlikely  that  oxygen  use  for  <  12  hours  a 
day  (ie,  nocturnal  oxygen  or  oxygen  for  ex- 
ertion for  hypoxemic  stable  COPD  patients) 
improves  survival. 

The  timing  of  removing  oxygen  is  very 
important  because  improvement  of  oxygen- 
ation after  3  months  of  continuous  oxygen 
therapy  may  be  derived  from  "reparative 
effect  of  oxygen"  and  in  such  cases  remov- 
ing oxygen  can  be  hazardous  and  is  not  jus- 
tified.*^ We  are  currently  conducting  a  pro- 
spective study  to  evaluate  the  effect  of 
removing  oxygen  after  1-3  months  of  ini- 
tial prescription.  Most  of  our  patients  are 


doing  well  after  the  removal  of  oxygen  if 
they  are  evaluated  in  a  timely  fashion. 

As  we  discussed  above,  prescription  of 
home  oxygen  can  be  very  complex  and  we 
still  recommend  that  oxygen-dependent  pa- 
tients with  chronic  lung  disease  be  seen  by 
a  pulmonary  specialist  for  cost-effective  use 
of  oxygen. 

Yuji  Oba  MD 
Gary  A  Salzman  MD 

Section  of  Respiratoi^  and 

Critical  Care  Medicine 

Truman  Medical  Center  West 

University  of  Missouri-Kansas  City 

School  of  Medicine 

Kansas  City,  Missouri 


REFERENCES 

1.  Oba  Y,  Salzman  GA,  Willsie  SK.  Reeval- 
uation of  continuous  home  oxygen  therapy 
after  initial  prescription  in  COPD  patients. 
Respir  Care  2000;45(4):401^06. 

2.  Nocturnal  Oxygen  Therapy  Trial  Group. 
Continuous  or  nocturnal  oxygen  therapy  in 
hypoxemic  chronic  obstructive  lung  dis- 
ease: a  clinical  trial.  Ann  Intern  Med  1980; 
93:391-398. 

3.  Medical  Research  Council  Working  Party. 
Long-term  domiciliary  oxygen  therapy  in 
chronic  hypoxic  cor  pulmonale  complicat- 
ing chronic  bronchitis  and  emphysema. 
Lancet  1981:1:681-685. 

4.  Health  Care  Financing  Administration. 
Medicare  carriers  manual,  claim  process- 
ing. 1994.  Part  3.  HCFA  Pub.  14-3:  PB 
94-954799. 

5.  O'Donohue  WJ.  Effect  of  oxygen  therapy 
on  increasing  arterial  oxygen  tension  in  hy- 
poxemic patients  with  stable  chronic  ob- 
structive pulmonary  disease  while  breath- 
ing ambient  air.  Chest  1991;100:968-972. 


972 


Respiratory  Care  •  Augu.st  20()0  'Vol  45  No  8 


Reviews  of  Books  and  Other  Media.  Note  to  publishers:  Send  review  copies  of  boolcs.  films, 
tapes,  and  software  to  Respiratory  Care.  600  Ninth  Avenue.  Suite  702.  Seattle  WA  98104. 


Books,  Films, 
Tapes,  &  Software 


Acute  Respiratorj'  Distress  Syndrome:  A 
Comprehensive  Clinical  Approach.  James 
A  Russell  and  Keith  R  Walley .  editors.  Cam- 
bridge. United  Kingdom:  Cambridge  Uni- 
vei^ity  Press.  1999.  Softcover,  illustrated, 
356  pages,  $49.95. 

This  handbook  aims  to  provide  a  com- 
prehensive approach  to  the  clinical  manage- 
ment of  patients  who  have  acute  respiratory 
distress  syndrome  (ARDS).  The  authors  fo- 
cus heavily  on  underlying  pathophysiology 
and  provide  recommendations  for  investi- 
gation and  management  of  ARDS,  informa- 
tion regarding  controversial  areas  in  ARDS, 
and  updates  on  the  results  of  clinical  trials 
of  new  therapy  in  ARDS.  The  book  is  or- 
ganized into  14  chapters. 

Chapter  1  gives  an  overview  of  clinical 
evaluation  and  chest  radiology  of  ARDS. 
including  definition,  epidemiology  and  risk 
factors,  pathology,  pathophysiology,  clini- 
cal evaluation,  and  radiologic  assessment. 
For  the  definition,  epidemiology,  pathology 
and  pathophysiology,  it  provides  short,  con- 
cise, stand-alone  summaries  of  these  topics, 
which  are  discussed  in  much  greater  detail 
later  in  the  text,  in  order  to  provide  a  gen- 
eral context  for  subsequent  discussions.  The 
section  on  clinical  evaluation  gives  more 
details.  It  presents  a  very  good,  practical 
guideline  in  bedside  diagnosis  and  initial 
assessment  of  ARDS  patients.  The  section 
on  chest  radiology  is  also  superb.  Not  only 
does  it  discuss  how  to  use  a  chest  radio- 
graph to  establish  the  diagnosis  and  differ- 
ential diagnosis  of  ARDS.  it  also  gives  the 
details  of  assessing  tube  and  line  placement 
and  detection  of  complications,  especially 
pneumothorax,  on  chest  radiographs. 

Chapter  2  addresses  the  epidemiology  of 
ARDS.  The  authors  begin  by  describing  pos- 
sible study  designs  used  in  determining  ep- 
idemiologic features  of  any  disease,  includ- 
ing ARDS,  and  present  an  approach  to 
review  and  better  appreciate  the  strengths 
and  weaknesses  of  the  existing  literature. 
Then,  the  major  studies  regarding  the  inci- 
dence, risk  factors,  mortality  and  morbidity 
from  ARDS  are  described,  commented  on, 
and  summarized. 

Chapter  3  presents  a  concise  review  of 
the  pathology  of  ARDS,  from  early-phase 
to  late-phase,  with  many  illustrations.  Also 
covered  are  some  pathologic  features  sug- 


gesting specific  etiologies  of  ARDS  and 
some  clues  to  differentiate  ARDS  from  other 
conditions. 

Chapter  4,  "Cytokine-Induced  Mecha- 
nisms of  Acute  Lung  Injury  Leading  to 
ARDS,"  reviews  the  molecular  mechanisms 
of  acute  lung  injury  and  delineates  die  im- 
portance of  the  balance  of  pro-  and  anti- 
inflammatory mediators  in  determining  the 
outcome  of  the  inflammatory  response  char- 
acteristic of  ARDS.  The  complex  networks 
of  signaling  molecules  and  inflammatory  ef- 
fector cells  that  initiate  and  maintain  the 
pulmonary  inflammatory  response  are  also 
discussed  in  this  chapter. 

Chapter  5  discusses  pulmonary  physiol- 
ogy, pathophysiology,  and  approaches  to 
monitoring  the  respiratory  system  in  ARDS. 
First,  this  chapter  gives  a  general  review  of 
oxygen  transport  from  the  alveolus  to  pul- 
monary capillary  blood  and  mechanisms  of 
hypoxemia.  Second,  abnormalities  and  clin- 
ical assessment  of  oxygenation  and  ventila- 
tion in  ARDS  are  discussed.  Finally,  respi- 
ratory mechanics  and  control  of  respiratory 
drive  are  explained.  The  parts  are  brief  and 
succinct,  but  cover  all  aspects  of  the  patho- 
physiology of  ARDS. 

Chapter  6  is  on  cardiovascular  manage- 
ment of  ARDS.  Its  begins  with  a  review  of 
cardiovascular  physiology  and  oxygen  de- 
livery-consumption relationships,  discusses 
the  controversy  about  abnormal  dependence 
of  oxygen  consumption  on  oxygen  delivery 
in  ARDS  patients,  and  covers  principles  of 
cardiovascular  management  in  ARDS,  in- 
cluding fluid  management,  vasopressors,  tri- 
als of  supranormal  oxygen  delivery,  effects 
of  ventilation  strategies  and  positive  end- 
expiratory  pressure,  and  the  role  of  hemo- 
globin. The  role  of  blood  lactate  level,  pul- 
monary artery  catheter,  and  gastric 
tonometry  in  the  assessment  of  cardiovas- 
cular function  are  also  covered. 

Chapter  7  reviews  the  fundamental  is- 
sues of  mechanical  ventilation  in  ARDS. 
This  review  of  physiology  is  used  as  a  basis 
for  understanding  conventional  and  newer 
modes  of  ventilation,  which  are  briefly  dis- 
cussed. The  second  half  of  this  chapter  deals 
with  various  problems  related  to  mechani- 
cal ventilation.  This  part  is  problem-oriented 
and  composed  of  many  practical  guidelines 


to  approach  various  problems  in  the  venti- 
latory management  of  ARDS. 

Chapter  8  addresses  the  respiratory  mus- 
cles and  liberation  from  mechanical  venti- 
lation. Pathophysiologic  determinants  of 
weaning  outcome,  how  to  predict  weaning 
outcome,  and  mediods  of  weaning  are  thor- 
oughly discussed.  Most  of  the  details  in  this 
chapter  are  about  weaning  in  general,  not 
specific  to  weaning  in  ARDS. 

Chapter  9  covers  clinical  assessment  and 
management  of  common  clinical  problems 
and  complications  in  various  organ  systems 
in  ARDS.  Assessment  and  management  of 
trauma  and  sepsis,  which  are  common  causes 
of  ARDS,  are  also  covered.  Each  part  is 
discussed  in  detail,  step  by  step,  including 
the  dosage  of  drugs  u.sed  in  the  treatment  of 
these  conditions,  which  make  the  book  ready 
for  use  at  the  bedside. 

Chapter  1 0  concerns  innovative  therapies 
for  ARDS.  Based  on  the  molecular  mech- 
anisms of  ARDS,  the  innovative  therapies 
that  are  potentially  useful  and  have  been  or 
are  under  investigation  in  basic  science  and 
clinical  studies  of  ARDS  are  discussed  and 
summarized. 

Chapter  II  is  on  nosocomial  pneumonia 
in  ARDS.  The  authors  begin  by  reviewing 
the  pathogenesis  of  nosocomial  pneumonia, 
including  the  role  of  oropharyngeal  and  gas- 
tric colonization,  contamination  of  respira- 
tory therapy  equipment,  and  the  changes  of 
host  factors  in  ARDS  that  predispose  to  the 
development  of  pneumonia.  The  diagnosis 
of  pneumonia,  which  focuses  on  the  collec- 
tion of  samples  from  the  tracheobronchial 
tree,  is  discussed,  and  a  stepwise  approach 
is  provided  for  diagnosis  and  management 
of  suspected  nosocomial  pneumonia  in 
ARDS.  Guidelines  for  initial  empiric  and 
specific  antimicrobial  therapy  are  recom- 
mended. Preventive  measures  are  covered 
in  the  final  part  of  this  chapter. 

Chapter  12,  "Resolution  and  Repair  of 
Acute  Lung  Injury,"  reviews  recovery  of 
normal  lung  function  after  acute  lung  in- 
jury. The  first  section  reviews  the  mecha- 
nisms of  removal  of  alveolar  edema  fluid. 
The  second  section  describes  the  pathophys- 
iology of  fibrosis  that  can  develop  as  a  re- 
sponse to  acute  lung  injury.  The  third  sec- 
tion discusses  the  potential  contribution  of 
growth  factors  in  remodehng  of  the  vascu- 


Respiratory  Care  •  August  2000  Vol  45  No  8 


973 


Books,  Films,  Tapes,  &  Software 


lar  endothelium,  the  interstitium,  and  the 
alveolar  epithelial  barrier. 

Chapter  13  covers  those  aspects  of  mul- 
tiple system  organ  failure  (MSOF)  that  are 
relevant  to  ARDS.  First,  several  definitions 
of  MSOF  are  presented.  Second,  the  epide- 
miology of  MSOF  is  described.  Finally,  the 
chapter  includes  a  discussion  of  evidence 
for  and  against  the  hypothesis  that  occult 
tissue  hypoxia  causes  MSOF. 

Chapter  14  is  on  outcome  and  long-term 
care  of  ARDS .  The  chapter  first  covers  mor- 
tality in  ARDS  and  reviews  the  evidence 
that  and  fwtential  explanations  why  ARDS 
mortality  may  be  decreasing.  Then,  long- 
term  outcome  of  ARDS  survivors  is  dis- 
cussed in  all  aspects,  including  symptoms, 
radiographic  changes,  and  pulmonary  func- 
tion test  abnormalities.  Abnormalities  in  spi- 
rometry, airway  resistance,  airway  hyjjerre- 
activity,  lung  volumes,  dead  space,  diffusing 
capacity,  and  arterial  blood  gases  are  all  cov- 
ered, together  with  the  changing  of  these 
abnormalities  over  time  after  the  period  of 
clinical  ARDS.  Though  the  sections  are 
short,  they  are  well  concluded.  The  final 
part  of  this  chapter  discusses  medical  man- 
agement of  ARDS  patients  after  discharge. 
Most  of  this  part  outlines  how  to  differen- 
tiate post-ARDS  respiratory  problems  from 
other  causes  of  respiratory  complaints. 

This  book  is  intended  for  all  physicians 
who  are  interested  in  the  field  of  critical 
care.  The  chapters  regarding  pathology,  car- 
diopulmonary pathophysiology,  and  me- 
chanical ventilation  would  be  helpful  for 
medical  students  to  appreciate  the  relation- 
ship between  their  basic  knowledge  and  clin- 
ical management  in  critical  care.  Respira- 
tory therapists  and  nurses  who  take  care  of 
ARDS  patients  are  encouraged  to  read  Chap- 
ters 1,  7,  8,  9,  and  1 1,  as  the  data  in  these 
chapters  may  help  solve  clinical  problems 
in  everyday  practice. 

Overall  the  authors  have  succeeded  in 
their  aims  of  providing  a  comprehensive, 
clinically  oriented  handbook  on  ARDS  to 
assist  clinicians  who  manage  ARDS  pa- 
tients. The  data  in  this  book  are  up-to-date 
and  extensively  referenced,  and  the  text  is 
in  a  well-written  and  consistent  style.  Every 
chapter  concisely  discusses  the  current  con- 
cepts and  controversies  regarding  the  rele- 
vant issues,  and  provides  a  clear  summary. 
The  chapters  regarding  clinical  issues  also 
provide  the  authors'  own  recommendations 
and  clinical  practice  guidelines.  There  are 
numerous  well-organized  tables  that  help 


readers  quickly  find  and  review  informa- 
tion, especially  at  the  bedside. 

The  text  is  well  produced,  with  clear  type- 
face, and  readable.  The  pictures  and  figures 
are  clear  and  very  helpful,  especially  in  un- 
derstanding the  pathology  and  pathophysi- 
ology of  ARDS.  Three  typographical  errors 
were  detected  (Pages  223,  227,  and  340), 
but  these  were  minor  and  should  not  cause 
confusion.  Considering  the  wealth  of  infor- 
mation it  provides,  this  book  is  a  very  good 
bargain  for  its  price  of  $49.95  .Iwouldhighly 
recommend  this  book  as  an  addition  to  in- 
tensive care  unit  libraries. 

Phunsup  Wongsurakiat  MD 

Division  of  Pulmonary  and 

Critical  Care  Medicine 

Department  of  Medicine 

University  of  Washington 

Seattle,  Washington 

Complexity  in  Structure  and  Function  of 
the  Lung.  Michael  P  Hlastala  and  H  Thomas 
Robertson,  editors.  (Lung  Biology  in  Health 
and  Disease,  Volume  121,  Claude  Lenfant, 
Executive  Editor.)  New  York/Basel:  Mar- 
cel Dekker.  1998.  Hardcover,  illustrated,  65 1 
pages,  $195. 

Conceptual  simplification  is  a  time-hon- 
ored way  of  attempting  to  understand  bio- 
logical systems.  In  fact,  by  first  construct- 
ing and  then  extrapolating  from  simplified 
models,  we  have  succeeded  in  explaining  a 
great  deal  about  many  aspects  of  physio- 
logic behavior.  As  useful  as  such  modeling 
may  be  for  describing  overall  "average"  be- 
havior, it  has  become  increasingly  clear  that 
structural  and  functional  heterogeneity 
("complexity")  is  fundamental  to  the  oper- 
ation and  stability  of  many  dynamical  pro- 
cesses— such  as  those  that  govern  pul- 
monary mechanics  and  gas  exchange. 
Unfortunately,  these  complex  systems  are 
not  well  characterized  by  classical  models, 
but  rather  require  such  recently  developed 
tools  as  computed  tomography,  positron 
emission  tomography,  "chaos"  mathemat- 
ics, and  fractal  analysis  to  explain  and  pre- 
dict the  details  of  pulmonary  structure  and 
function.  Inspired  by  insights  gained  from 
these  remarkable  technical  advances,  this 
volume  describes  the  complexity  observed 
in  a  normal  lung  as  approached  from  the 
perspectives  of  mechanics,  circulation, 
lung  architecture,  ventilation,  and  gas  ex- 
change. To  compile  this  state-of-the-art 
review,  the  editors  have  assembled  con- 
tributions from  scientists  of  unquestioned 
ability  and  reputation. 


The  overarching  theme  of  this  book  is 
that  the  lung,  as  scientists  now  understand 
it,  is  no  "balloon  on  a  stick,"  and  its  detailed 
behavior  cannot  be  well  understood  by  the 
simplified  models  that  have  served  as  the 
instructional  basis  of  our  field  for  a  very 
long  time.  Consequently,  empirically  ob- 
served departures  from  the  idealized  behav- 
iors predicted  by  those  rather  naive  con- 
structs should  not  necessarily  be  viewed  as 
random  noise,  but  rather  considered  as  a 
possible  expression  of  the  spatial  and/or  tem- 
poral heterogeneity  that  is  a  fundamental 
property  of  all  biological  processes  and 
structures.  Such  heterogeneity  and  complex- 
ity is  now  understood  to  enable  the  indicate 
regulation  and  adaptive  responses  that  serve 
the  best  interest  of  the  healthy  organism. 

This  new  focus  on  heterogeneity  has 
opened  many  new  avenues  of  exploration 
into  diverse  areas  of  bioscience.  In  reading 
this  work  one  often  gets  a  sense  of  the  ex- 
citement that  present-day  investigators  ex- 
perience as  they  explore  this  important  but 
unfamiliar  intellectual  landscape.  Lung  bi- 
ologists, physiologists,  and  mathematicians 
will  be  amply  rewarded  for  time  invested  in 
reading  it. 

Although  this  is  a  book  of  considerable 
scientific  merit,  it  is  clearly  not  intended  for 
the  average  respiratory  therapist  or  for  the 
average  pulmonary/critical  care  physician. 
As  a  treatise  on  the  normal  lung,  it  contains 
little  for  the  caregiver  that  directly  applies 
to  individual  patients  with  pulmonary  dis- 
orders. Whatever  its  practical  shortcomings 
may  be  for  the  latter  audience,  however,  it 
offers  a  rich,  new,  and  challenging  collec- 
tion of  ideas  that  will  alter  their  perspective 
and  lead  to  a  deeper  understanding  of  the 
intricate  processes  at  work  in  health  and 
disease.  Against  this  background,  the  mech- 
anisms and  consequences  of  such  "simple" 
clinical  interventions  as  body  positioning, 
permissive  hypercapnia,  and  tracheal  gas  in- 
sufflation may  eventually  be  viewed  differ- 
ently, with  a  future  possibility  for  refining 
their  clinical  application. 

The  book  is  organized  into  5  parts:  Me- 
chanical Properties,  Airway  Exchange  of 
Gas,  Pulmonary  Ventilation  Heterogeneity, 
Pulmonary  Perfusion  Heterogeneity,  and 
Matching  of  Ventilation  and  Perfusion.  Vir- 
tually all  chapters  are  of  high  scientific  qual- 
ity, but  like  any  edited  text,  the  individual 
contributions  are  uneven  in  tone,  perspec- 
tive, assumed  knowledge  base,  and  interest 
value.  Some  chapters  are  both  readable  and 
informative,  almost  devoid  of  mind-numb- 


974 


Respiratory  Care  •  August  2000  Vol  45  No  8 


Books,  Films,  Tapes,  &  Software 


ing  jargon:  others,  unfortunately,  are  such 
tough  sledding  for  the  uninitiated  into  the 
fields  of  higher  mathematics,  statistics,  and 
physiology,  that  they  defy  comprehension. 
However,  a  few  entries  stand  out  for  their 
clarity  and  ability  to  lead  an  uninitiated 
reader  through  uncharted  territory.  The  last 
two  chapters  (one  on  ventilation-perfusion 
heterogeneity  by  Susan  Hopkins  and  Frank 
Powell  and  one  on  concepts  and  measures 
of  heterogeneity  by  Robb  Glenny)  should 
engage  most  readers  with  a  solid  background 
in  pulmonary  physiology.  The  perspective 
of  these  two  chapters  is  broad  enough,  the 
writing  clear  enough,  and  the  power  of  the 
messages  strong  enough  that  they  deserve 
to  be  read  first — before  attempting  to  un- 
ravel the  intricacies  of  mechanical,  hemo- 
dynamic, structural,  and  gas  exchange  com- 
plexity. 

The  chapter  by  Eric  Hofftnan  and  Lynne 
Olson  regarding  computed  tomography  is  a 
masterful  summary  of  a  technique  that  is 
increasingly  important — not  only  for  the 
clinical  setting  but  also  for  understanding 
the  microstructure  and  function  of  the  lung. 
Through  arresting  images,  the  point  is  clearly 
made  that  such  tools  hold  promise  for  re- 
fining diagnosis  and  in  so  doing  for  helping 
us  to  more  precisely  target  therapy  of  the 
specific  problem  at  hand. 

The  chapter  by  Theodore  Wilson  and  the 
one  by  Jeffrey  Fredberg,  Ning  Wang,  Dimi- 
trije  Stamenovich,  and  Donald  Inberg  are 
elegant  discussions  of  how  we  now  believe 
that  intrapulmonary  stress  and  strain  are  dis- 
tributed— balloons  and  soap  bubbles  only 
take  us  so  far!  Robb  Glenny  and  Thomas 
Robertson  put  forth  a  withering  challenge 
to  the  gravitational  hypothesis  for  explain- 
ing the  distribution  of  pulmonary  blood  flow 
and  ventilation:  they  convincingly  argue  that 
any  new  model  of  perfusion  and  ventilation 
must  incorporate  the  concept  of  heteroge- 
neity as  a  principal  property  of  these  sys- 
tems. They  point  out  that  as  a  consequence 
of  heterogeneity  in  a  vascular  network,  dif- 
ferences in  driving  pressures  at  the  capillary 
level  may  exist  that  govern  the  spatial  dis- 
tribution of  blood  flow  in  any  isogravita- 
tional  plane. 

The  inadequacy  of  the  classical  gravita- 
tional model  in  explaining  the  distribution 
of  pulmonary  blood  flow  is  echoed  several 
times  in  different  chapters — perhaps  no 
more  clearly  than  in  the  chapter  by  Wiltz 
Wagner  and  Robert  Presson,  which  explores 
the  intricacy  of  pulmonary  perfusion  net- 
works in  the  lung's  gas  exchanging  vessels. 


Detailed  images  beautifully  illustrate  the 
profound  shortcomings  of  the  single  airway, 
single  alveolus,  single  capillary  model. 

In  their  description  of  the  physiologic  ef- 
fects of  oxygen  and  carbon  dioxide,  Erik 
Swenson,  Karen  Domino,  and  Michael 
Hlastala  continue  the  emphasis  on  nongravi- 
tational  controls  by  focusing  on  the  com- 
bined influence  of  the  two  respiratory  gases 
on  the  lung's  regulation  of  ventilation  and 
perfusion.  Oxygen  and  carbon  dioxide  not 
only  play  important  roles  on  the  local  level 
in  maintaining  efficient  gas  exchange  in  the 
normal  lung,  but  also  act  to  minimize  any 
deterioration  of  gas  exchange  that  occurs 
under  diseased  conditions. 

As  stated  earlier,  this  book  was  intended 
neither  for  the  average  respiratory  therapist 
nor  the  practicing  physician.  It  is  also  ex- 
pected that  some  entries  in  this  diverse  col- 
lection will  hold  limited  appeal  even  for 
advanced  students  of  microanatomy  and 
lung  function.  Yet,  taken  together,  these  es- 
says form  a  valuable  reference — portions  of 
which  serve  to  confirm  the  editors'  conten- 
tion that,  despite  the  many  exciting  devel- 
opments in  molecular  biology  of  the  lung, 
diere  are  unique  scale-dependent  properties 
of  this  organ  that  can  be  elucidated  only  by 
integrative  physiologic  approaches.  This  is 
a  unique  resource  and  an  admirable  contri- 
bution to  the  Lung  Biology  in  Health  and 
Disease  series. 

John  J  Marini  MD 
John  R  Hotchkiss  MD 

Department  of  Pulmonary  and 

Critical  Care  Medicine 

Regions  Hospital 

St  Paul,  Minnesota 

Occupational  Lung  Disease:  An  Interna- 
tional Perspective.  Daniel  E  Banks  and 
John  E  Parker,  Editors.  London:  Chapman 
&  Hall  Medical.  1998.  Hardcover,  illus- 
trated, 515  pages,  $110. 

Daniel  Banks  and  John  Parker  have  at- 
tempted to  provide  not  only  a  textbook  about 
the  recognition,  pathogenesis,  treatment,  and 
prevention  of  many  common  occupational 
lung  diseases,  but  also  a  global  perspective 
on  occupational  lung  disease.  They  invited 
many  experts  from  around  the  world  to  ad- 
dress common  conditions,  such  as  pneumo- 
conioses related  to  asbestos,  silica,  and  coal 
dust.  These  experts  include  physicians  from 
Australia,  Belgium,  Canada,  China,  Finland, 
Great  Britain,  India,  Italy,  Russia,  Scotland, 


South  Africa,  Spain,  and  Sweden,  as  well  as 
the  United  States. 

The  textbook  is  divided  into  4  parts.  Part 
I  is  an  introduction  to  occupational  lung  dis- 
ease, which  includes  a  very  good  chapter  on 
industrial  hygiene  by  Roy  Rando  (Louisi- 
ana) and  one  on  airways  obstruction  and 
occupational  organic  dust  exposure  by  Mei- 
Lin  Wang  and  Daniel  Banks  (West  Virgin- 
ia). There  is  also  a  very  useful  chapter  on 
worker's  compensation  for  occupational 
lung  disease,  which  compares  the  German 
and  United  States'  systems. 

The  second  section  is  on  pneumoconio- 
ses and  includes  a  chapter  on  novel  thera- 
pies for  pneumoconioses  that  is  not  usually 
found  in  standard  textbooks.  In  addition, 
there  is  a  very  good  chapter  on  the  mecha- 
nism of  pneumoconioses,  by  Ken  Donald- 
son (Edinburgh).  There  is  an  excellent  chapn 
ter  on  quartz  and  silicosis  by  William 
Graham  (Vermont).  Many  of  the  chapters 
from  other  nations,  such  as  "Coal  Workers' 
Pneumoconiosis  in  Developing  Nations"  by 
Changqi  Zou  and  Guo-An  Shen  (Beijing), 
were  good,  but  just  too  short  and  provided 
very  little  new  information.  The  chapter  on 
asbestos-related  disease,  by  Raymond  Be- 
gin (Quebec),  was  weak,  but  the  companion 
chapter  on  "Changing  Patterns  of  Asbestos- 
Related  Pulmonary  Diseases,"  by  Colin 
Woolf  (Toronto),  was  short  but  well  written 
and  informative.  There  is  an  excellent 
chapter  on  man-made  vitreous  fibers  and 
their  respiratory  health  effects,  by  Jacques 
Ameille  (Paris),  JC  Pairon  (Paris),  and  P  De 
Vuyst  (Brussels).  Benoit  Nemery  (Belgium) 
wrote  an  excellent  chapter  on  lung  disease 
from  metal  exposure. 

The  third  section  is  on  occupational 
asthma,  respiratory  illness  due  to  dust  ex- 
posure, and  organic  dust  diseases.  This  sec- 
tion has  an  excellent  chapter,  by  Susan  Tarlo, 
Neil  Alexis,  and  Frances  Silverman  (Toron- 
to), on  the  assessment  of  airways  respon- 
siveness relevant  to  occupational  exposures, 
and  another  excellent  chapter  on  the  mech- 
anisms of  occupational  asthma,  by  Chris 
Stenton,  Gavin  Spickett,  and  David  Hen- 
drick  (England).  The  chapter  on  occupa- 
tional asthma  due  to  low-molecular-weight 
compounds,  by  P  Maestrelli  (Italy)  et  al, 
was  very  well  done.  The  chapter  on  isocya- 
nate-induced  asthma,  by  Cristina  Mapp 
(Italy),  is  what  one  would  expect  from  a 
world  expert  on  the  subject.  The  chapter  on 
occupational  asthma  due  to  high-molecu- 
lar-weight agents,  by  Jeremy  Beach,  Fran- 
cis Thien,  and  E  Hadyn  Walters  (England) 


Respiratory  Care  •  August  2000  Vol  45  No  8 


975 


Books,  Films,  Tapes,  &  Software 


was  nicely  summarized.  This  section  also 
includes  a  review  of  the  effects  of  cotton 
dust  on  the  lung,  by  Ragnar  Rylander  (Swe- 
den), and  a  companion  chapter  about  bys- 
sinosis  in  India  and  the  developing  world 
by  Rohini  Chowgule  (Bombay).  The  final 
two  chapters  in  this  section  are  on  hyper- 
sensitivity pneumonitis,  by  John  Salvaggio, 
Ann  Vockroth,  and  Manuel  Lopez  (New 
Orleans),  and  a  section  on  acute  chemical 
exposures,  by  Paul  Cullinan  and  Anthony 
Newman  Taylor  (London).  These  are  good 
short  reviews  of  the  subjects. 

The  fourth  and  final  section  in  the  book 
consists  of  two  chapters,  from  the  group  at 
Harvard,  on  "Pulmonary  Carcinogenesis, 
Molecular  and  Cellular  Mechanisms"  and 
"Occupationally  Induced  Pulmonary  Malig- 
nancy." Both  of  these  chapters  are  well  done 
but  not  exhaustive  reviews. 

In  summary,  the  book's  goal  to  provide  a 
short,  concise  review  of  occupational  lung 
disease  from  an  international  perspective  has 
largely  been  met.  On  average,  most  of  the 
chapters  are  good  to  excellent,  with  only  a 
few  chapters  that  1  would  characterize  as 
poor  to  average.  Some  of  the  chapters  are 
really  unique  to  this  book  and  would  not  be 
found  elsewhere,  such  as  the  chapter  on 
worker's  compensation  in  Germany  and  the 
United  States,  and  the  chapter  on  occupa- 
tional health,  tuberculosis,  silicosis,  and  hu- 
man immunodeficiency  virus  in  the  South 
African  mines.  This  and  other  chapters,  such 
as  "Silicosis  in  Developing  Countries"  and 
"Asbestos-Related  Lung  Diseases  in  Rus- 
sia," provide  information  that  is  not  gener- 
ally available  elsewhere  in  other  competing 
pulmonary  texts. 

The  writing  is  generally  good  and  quite 
readable.  The  text  should  appeal  primarily 
to  pulmonary  and  occupational  medicine 
physicians  as  well  as  other  professionals 
with  an  interest  in  occupational  lung  disease 
from  an  international  perspective.  There  are 
better  texts  available  for  a  general  review  of 
the  subject  of  occupational  lung  disease,  such 
as  Morgan  and  Seaton's  Occupational  Lung 
Diseases,  or  Occupational  and  Environmen- 
tal Respiratory  Diseases  by  Harber,  Schen- 
ker.  and  Balmes,  or  the  classic  volume  by 
Parkes,  Occupational  Lung  Disorders.  Any 
of  those  three  books  provide  a  better  survey 
of  occupational  pulmonary  disease  than  does 
this  b(X)k,  but  Occupational  Lung  Disease, 
an  International  Perspective  is  a  well  writ- 
ten niche  publication  that  provides  informa- 
tion not  available  elsewhere  on  research  and 


progress  in  managing  occupational  lung  dis- 
eases around  the  world. 

Dorsett  D  Smith  MD 

Division  of  Pulmonary  and 

Critical  Care  Medicine 

University  of  Washington 

Seattle,  Washington 

Respiratory  Care  Calculations,  2nd  edi- 
tion. David  W  Chang  EdD  RRT.  Albany: 
Delmar.  1999.  Softcover,  illustrated,  325 
pages,  $31.95. 

This  book  is  organized  into  6  sections: 

(1)  review  of  basic  mathematics  functions, 

(2)  respiratory  care  calculations.  (3)  basic 
statistics  and  educational  calculations, 

(4)  answer  key  to  self-assessment  questions, 

(5)  symbols  and  abbreviations,  and  (6)  units 
of  measurement.  In  addition,  13  appendixes, 
a  bibliography  and  an  index  are  included. 
Section  2  is  by  far  the  bulk  of  the  text  (pag- 
es 7-257),  containing  83  chapters,  each  de- 
voted to  a  single  equation.  In  this  sense,  the 
author  does  not  meet  the  goal  stated  in  the 
preface,  ". . .  to  provide  a. . .  concise  refer- 
ence source  for  respiratory  care  calcula- 
tions." Some  of  the  "equations"  (as  the  au- 
thor calls  them)  are  merely  definitions  (eg, 
time  constant,  static  and  dynamic  compli- 
ance, forced  expiratory  volume  in  /  seconds 
(FEV,),  forced  expiratory  flow  (FEFjjx) _ 1 200 


and  FEP-, 


5,),  and  some  are  a  reitera- 


tion of  time-honored  scientific  laws,  such  as 
the  classic  gas  laws,  Graham's  law, 
LaPlace's  law,  and  Poiseuille's  law. 

Although  the  author  states  the  book  is 
intended  for  classroom,  laboratory,  and  clin- 
ical use,  its  8.5"  X  11"  format  and  self- 
assessment  exercises  make  it  an  unlikely 
candidate  for  clinical  use.  The  brief  section 
on  basic  statistics  and  "educational"  calcu- 
lations seems  somewhat  overshadowed,  if 
not  misplaced,  in  this  textbook.  The  format 
of  each  chapter  is  geared  more  to  the  class- 
room than  to  the  clinical  setting.  A  typical 
chapter  includes  the  equation,  the  definition 
of  each  term,  normal  values,  example  cal- 
culations, exercises  with  answers,  support- 
ing references,  and  several  self-assessment 
exercises.  Comments  appear  in  small  print 
in  the  left  page  margin,  briefly  clarifying 
some  aspect  of  the  equation,  and  in  some 
cases  attempting  to  capsulize  a  complex 
physiologic  concept,  a  task  not  in  the  scope 
of  this  book. 

The  book  would  be  more  concise  if  a 
number  of  the  conceptually  equivalent  equa- 
tions were  pre.sented  in  their  general  forms. 
For  example,  the  concept  of  oxygen  content 


can  be  represented  in  one  chapter  by  one 
general  equation  rather  than  devoting  three 
chapters  to  three  separate  equations  (venous, 
arterial,  and  end-capillary  contents).  Simi- 
larly, the  concept  of  resistance,  whether  air- 
way or  vascular  resistance,  can  be  repre- 
sented in  one  chapter  by  a  general  equation 
and  specific  applications.  The  same  applies 
to  right  and  left  ventricular  stroke  work  and 
the  concept  of  indexing  various  hemody- 
namic measurements  to  body  surface  area: 
each  indexed  variable  does  not  require  a 
separate  chapter.  General  equations  help  stu- 
dents see  interconnected  conceptual  pat- 
terns. 

Some  of  the  symbols  and  abbreviations 
shown  in  the  section  on  symbols  and  abbre- 
viations are  either  not  current  or  do  not  con- 
form to  standard  convention,  and  some  key 
symbols  are  missing  altogether.  Examples 
include: 

•  "BD"  for  base  deficit  instead  of  "±BE" 

•  "vol%"  instead  of  "mL/dL" 

•  "g%"  instead  of  "g/dL" 

•  Lack  of  "f '  for  respiratory  rate 

•  Lack  of  "V"  for  air  flow  or  "Q"  for 
blood  flow 

•  "RA"  instead  of  "RAP"  for  right  atrial 
pressure 

•  Lack  of  "CVP"  for  central  venous  pres- 
sure 

•  Using  "SWI"  to  indicate  "simplified 
weaning  index"  instead  of  "stroke  work 
index" 

•  Using  "RSBWI"  to  denote  "rapid  shal- 
low breathing  weaning  index"  instead 
of  "RSBI"  (or  "f/Vx")  to  denote  "rapid 
shallow  breathing  index." 

Curiously,  some  of  the  missing  abbrevi- 
ations and  symbols  appear  elsewhere  in  the 
book. 

The  equations  presented  are  comprehen- 
sive and  appear  to  be  accurate.  However, 
the  author  occasionally  tackles  complicated 
subjects  in  the  limited  space  of  the  left  page 
margin,  tending  at  times  to  oversimplify  and 
present  inaccurate  or  incomplete  infonna- 
tion.  Undertaking  such  subjects  opens  the 
book  to  a  broader  critique  than  might  be 
ordinarily  appropriate  for  a  textbook  on 
equations.  For  example,  the  notes  in  Chap- 
ter 10  state  that  a  cardiac  index  "less  than 
1 .8  may  be  indicative  of  cardiogenic  shock." 
Of  course,  it  may  ju.st  as  well  be  indicative 
of  hemorrhagic  shock.  Chapter  8  presents  a 
formula  for  calculating  how  much  sodium 
bicarbonate  to  administer  to  patients  in  car- 
diac arrest.  According  to  the  notes,  the  en- 
tire calculated  dose  should  be  given  if  per- 


976 


Respiratory  Care  •  August  2000  Vol  45  No  8 


Books,  Films,  Tapes,  &  Software 


fusion  is  "unsatisfactory."  No  precautions 
or  hazards  are  noted.  An  acknowledgment 
that  the  American  Heart  Association  does 
not  recommend  sodium  bicarbonate  ther- 
apy in  cardiopulmonary  resuscitation  only 
confuses  the  issue. 

The  notes  in  Chapter  18  on  the  Vj/Vy 
(ratio  of  dead  space  to  tidal  volume)  equa- 
tion emphasize  reduction  in  pulmonary 
blood  flow  as  a  major  cause  of  increased 
Vj/Vt,  listing  various  conditions,  but  no 
mention  is  made  of  the  most  common  cause 
of  increased  W^/V-y^,  which  is  shallow 
breathing. 

The  notes  in  Chapter  40,  "Helium/Oxy- 
gen Flow  Rate  Conversion."  state  that  this 
gas  mixture  provides  "relief  from  hypoxia" 
in  obstructive  disease  because  it  has  a  higher 
diffusion  rate  than  oxygen  alone,  as  though 
the  objective  of  this  therapy  is  to  speed  up 
oxygen  diffusion  across  the  alveolar-capil- 
lary membrane.  The  therapeutic  objective 
of  helium/oxygen  therapy  is  to  reduce  the 
work  of  breathing  for  a  given  amount  of 
ventilation,  not  "relief  of  hypoxia"  per  se. 
In  narrowed  airways,  a  helium/oxygen  mix- 
ture's lower  density  allows  a  greater  bulk 
flow  or  ventilation  for  a  given  pressure  gra- 
dient (effort).  Another  conceptual  error  re- 
garding diffusion  rates  appears  in  the  an- 
swer to  a  self-assessment  question  that 
implies  that  the  higher  diffusion  rate  of  car- 
bon dioxide  compared  to  oxygen  explains 
why  "hypercapnia  is  easier  to  treat  than  hyp- 
oxia." This  is  a  common  misconception,  but 
the  answer  is  more  complex,  having  to  do 
with  the  slopes  of  the  carbon  dioxide  and 
oxygen  hemoglobin  dissociation  curves. 
Well-ventilated  alveoli  can  compensate  for 
the  high  carbon  dioxide  of  poorly  ventilated 
alveoli  because  of  carbon  dioxide's  linear 
dissociation  curve.  This  is  not  true  for  ox- 
ygen because  of  its  nonlinear  dissociation 
curve. 

A  question  asking  why  carbon  monoxide 
instead  of  oxygen  is  used  in  diffusion  ca- 
pacity tests  promulgates  another  common 
misconception  about  diffusion  rates.  The 
reason  for  using  carbon  monoxide  is  not 
because  it  has  a  higher  diffusion  coefficient, 
as  the  answer  implies.  In  fact,  oxygen  is 
more   diffusable   than   carbon   monoxide 


(Dl 


Di  CO  ^  1  -23).  Carbon  monoxide 


is  used  because  hemoglobin's  capacity  for 
it  is  so  great  that  carbon  monoxide  cannot 
diffuse  across  the  lung  fast  enough  to  satu- 
rate the  blood  before  it  leaves  the  capillary, 
even  in  resting  conditions.  If  oxygen  is  used, 
hemoglobin  saturation  occurs  before  blood 
leaves  the  capillary,  which  means  diffusion 
across  the  alveolar-capillary  membrane 
ceases  at  the  point  of  saturation.  This  inter- 
feres with  the  test's  objective,  which  is  to 
assess  the  alveolar-capillary  membrane's  in- 
herent opposition  to  diffusion. 

The  notes  in  Chapter  44  defining  abbre- 
viations for  lung  volumes  and  capacities 
summarize  the  distinction  between  obstruc- 
tive and  restrictive  patterns  as  follows:  ". . . 
restrictive  diseases  show  decreases  in  lung 
volumes  and  capacities,  whereas  obstruc- 
tive lung  diseases  have  increases  in  residual 
volume."  The  major  hallmark  of  obstruc- 
tive disease,  decreased  expiratory  flow  rate. 
is  not  mentioned. 

Various  inaccuracies  are  scattered 
throughout  the  book,  some  of  which  may 
seem  small  and  inconsequential.  However, 
a  textbook  on  equations  should  be  precise. 
"F,o2  "  is  defined  as  "inspired  oxygen  con- 
centration in  percent,"  and  "a/A"  ratio  is 
called  "alveolar/oxygen  tension  ratio  in  per- 
cent." Treating  these  values  as  percentages 
(decimal  fraction  X  100)  in  calculations 
would  produce  grossly  inaccurate  results. 
Moreover,  the  "normal"  value  for  the  a/A 
ratio  is  given  as  ">  60%,"  which  is  cer- 
tainly not  a  normal  range  for  a  healthy  per- 
son. Minimally  acceptable  values  in  criti- 
cally ill  patients  are  not  "normal."  To 
appreciate  the  impact  of  illness,  students 
need  to  know  "healthy"  normal  values. 

The  Pick  cardiac  output  equation  in  Chap- 
ter 1 1  uses  the  factor  "130  X  body  surface 
area"  as  an  estimate  of  oxygen  consump- 
tion. This  factor  may  be  reasonable  in 
healthy,  resting  persons,  but  is  useless  in 
critically  ill  patients. 

Chapter  12  gives  a  "normal"  value  of 
30-40  mL/cm  HjO  for  static  compUance, 
which  is  also  extremely  low  for  a  healthy 
individual.  Curiously,  Chapter  14  uses  ap- 
propriate compliance  values  of  0.2  L/cm 
H2O  for  the  chest  wall  and  0.2  L/cm  H^O 


for  the  lung,  yielding  an  acceptable  normal 
total  compliance  of  0.1  LVcm  H^O,  or  100 
mL/cm  H2O!  Much  later  in  the  book.  Chap- 
ter 27  presents  the  definition  of  "elastance" 
as  though  this  is  a  fundamentally  different 
concept  from  "compliance."  Elastance  and 
compliance  should  be  presented  together  to 
lend  insight  into  why  reciprocals  of  lung 
and  chest  wall  compliance  must  be  added  to 
compute  total  compliance. 

A  common  error  appears  in  Chapter  62 
("Pco,  to  H2CO,").  Pco,  X  0.03  is  equal  to 
dissolved  CO2  in  the  plasma,  not  to  HjCOj 
concenu-ation.  Plasma  H2CO3  concentration 
is  about  l/500th  the  concentration  of  dis- 
solved CO2.  Thus,  it  is  the  20:1  concentra- 
tion relationship  between  plasma  HCO,"  and 
dissolved  COj  that  produces  a  blood  pH  of 
7.40,  not  a  20: 1  relationship  between  HCO3" 
and  H2CO,,  as  stated  in  Chapter  63. 

Bringing  a  comprehensive  group  of 
equations  together  in  one  book  is  a  good 
idea.  The  equations  are  accurate  and  pro- 
vide a  good  reference  for  students.  I  am 
not  aware  of  another  book  in  respiratory 
care  devoted  exclusively  to  this  task,  al- 
though a  number  of  current  textbooks  use 
the  inside  of  the  front  and  back  covers  to 
list  common  equations.  This  kind  of  book 
is  needed  in  the  field.  Its  size  and  orga- 
nization make  it  best  suited  for  classroom 
or  laboratory  use.  To  make  the  book  use- 
ful and  practical  in  the  clinical  setting, 
future  editions  should  be  in  a  smaller, 
pocket-sized  format.  Trivial  "equations" 
(ie,  mere  definitions)  should  be  eliminated 
and  terms  and  symbols  should  be  updated. 
The  erroneous  notes  in  the  margins  should 
not  present  a  problem  for  the  seasoned 
therapist,  but  because  students  are  likely 
to  be  the  primary  consumers  of  this  book, 
I  recommend  it  with  the  caution  that  they 
should  use  it  only  to  look  up  equations, 
not  as  a  source  of  information  about  phys- 
iologic concepts. 

Will  Beachey  MEd  RRT 

School  of  Respiratory  Care 

University  of  Mary/St  Alexius 

Medical  Center 

Bismarck,  North  Dakota 


Respiratory  Care  •  August  2000  Vol  45  No  8 


977 


2000  Open  Forum 


at  the 


International  ^J(esptratory  (Jongress 

The  Annual  Convention  &  Exhibition  of  the 
American  Association  for  Respiratory  Care 
October  7-10,  2000  •  Cincinnati,  Ohio  U.S. A 


^1^, 


nee  again  respiratory  care  professionals  have  stepped  forward  and  analyzed  the  things  they  do  with  critical  eyes.  The 
results  of  these  investigations  will  be  available  during  the  OPEN  FORUM  symposia  at  the  largest  respiratory  care  meeting  in  the 
world,  the  46th  International  Respiratory  Congress  this  October  in  Cincinnati.  Abstracts  and  posters  of  their  work  will  be 
presented  in  a  format  that  encourages  discussions  and  interactions  among  investigators  and  observers.  It  is  a  well  accepted  fact 
that  the  OPEN  FORUM  is  the  most  significant  and  interesting  portion  of  the  Congress. 


In  this  issue  of  RESPIRATORY  CARE  we  publish  all  the  abstracts  of  the  papers  to  be  presented  in  Cincinnati  (pages  979-1029). 
We  hope  their  publication  raises  your  interest  and  not  only  encourages  you  to  come  to  Cincinnati,  but  also  motivates  you  to 
look  at  your  work  environment.  Hopefully,  you  will  also  be  stimulated  to  analyze  the  facts  through  research,  prepare  an  abstract 
for  presentation  at  next  year's  Congress,  and  publish  your  work  in  a  peer-review  journal  like  RESPIRATORY  CARE.  We  all  want 
to  do  the  right  thing,  but  respiratory  care  medicine  is  a  science  and  procedures  should  be  supported  by  the  proper  data. 

We  encourage  you  to  come  to  Cincinnati  and  to  participate  in  the  exchange  when  the  abstracts  and  posters  are  presented.  The 
Open  Forum  is  a  unique  experience  that  will  charge  you  up  and  that  you  will  remember  for  the  rest  of  your  life. 


See  you  in  Cincinnati! 


Aerosols  and  Delivery  Devices 

Saturday,  October  7,  12:30 pm-2:25 pm 
(Rooms  200,  201) 

Respiratory  Care  Potpourri 

Saturday,  October?,  12:30 pm-2:25 pm 
(Rooms  213,  214) 

Mechanical  Ventilation  in  the 
Neonatal/Pediatric  Patient 

Saturday,  October  7,  3:00  pm  -  4:55  pm 
(Rooms  200,  201) 

Device  &  Method  Evaluations 

Saturday,  October  7,  3:00  pm  -  4:55  pm 
(Rooms  213,  214) 


Mechanical  Ventilation  -  Part  1 

Sunday,  October  8,  2:00 pm-3:55  pm 
(Rooms  200,  201) 

RC  Education 

Sunday,  October  8.  2:00  pm-3:55  pm 
(Rooms  213,  214) 

Neonatal/Pediatric  Respiratory  Care 

Monday,  October  9,  9:30  am- 1 1:25  arn 
(Rooms  200,  201) 

Mechanical  Ventilation  -  Part  2 

Monday,  October  9.  9:30  am- 1 1:25  am 
(Rooms  213,  214) 


Inhaled  Nitric  Oxide 

Monday  October  9,  2:00 pm-3:55  pm 
(Rooms  200,  201) 

Asthma:  Education,  Protocols,  Knowledge 

Monday,  October  9,  2:00 pm-3:5S pm 
(Rooms  213,  214) 

Management  Issues:  Protocols,  Outcomes, 
Scope  of  Practice 

Tuesday  October  10,  1:30  pm-3:25  pm 
(Rooms  200,  201) 

RC  Outside  the  Hospital 

Tuesday,  October  10,  1 :30 pm-3:25  pm 
(Rooms  213,  214) 


Saturday,  October  7, 12:30-2:25  pm  (Rooms  200,201) 


CC»l?AfaNG  TVe  USE  OF  A  HIGH  CONCENTRATION  AEROSOL  DEUVERY 
(HCAD)  WITH  A  CIRCULAiRE™  VERSUS  CONVENTTONAL  SMALL  \K)UME 
HEBUU2ER  FOR  ADMNISTERJNG  ALBUTEROL  IN  TME  BKRGENCY 
DEPARTMENT  USING  A  RAPID-SEQUENCE  PROTOCOL  Rik  nonaJiaf  RPFT-RRT. 
Mission-SL  Joseph's  Health  System,  AshevUte,  NC 

Backgnwid:  Our  facility  currently  uses  a  rapd-sequence,  patient-<tiven  pititocol  for  tfie 
xtniiiialimlor  of  betfragonisl  brondiodlatore  (abUenil)  to  treat  dyspnaic  patients 
presenting  wilti  acute  tyonchospasins  in  the  emenjency  depaitinent  Slidnidi  etai<  had 
previously  teponad  success  with  f  mad,  high  concentration  aerosols  using  the 
Oculaire™  (WestMod.  inc ,  Tucson  AZ),  but  only  for  intemiltent  use.  Mason  and  Milai' 
had  utilized  the  device  in  a  rapid-sequence  method  but  no(  wtfi  Ngh  concentration.  As  a 
potenlii  pnx»ss  improvement,  our  ladSty  chose  to  combine  these  two  ideas  and 
investigae  the  oftdency  and  eflicacy  of  a  rapid-sequence,  HCAD  protocol  with  1  oc 
undluted  5  m^  abuteid,  versus  our  current  method  of  therapy  utilizing  a  MstyNeb 
(AUegiwce  HeaAhcare  Corporation,  McGaw  Park,  IL)  and  standard  urH  dote  aixiterol. 
IMIiod:  We  iMIad  a  polKY  and  procedure  paHsmed  sAar  oir  eidsthg  emergency 
dapartment  protocol  incorporating  HCAO.  Using  a  randomizBd  method,  wa  focused  on 
two  sees:  patient  outcomes  and  efliciett  use  of  hospital  resources.  Palients  mealing 
otteria  for  l)eta-agonist  theispy  would  bie  treated  under  our  previous  protocol,  or  under 
the  HCAO  protocol.  The  data  coiection  and  docunentabon  took  place  in  addtion  to  our 
ragular  charting  on  a  data  coiecton  tool  developed  spedlcally  for  the  study  For  patient 
oulcanMe.  m  monitarad  pm  and  post-treatment  heart  rate,  peak  expratory  flow  rates, 
and  whether  ornot  the  protocol  had  to  t)e  repeated  For  rrxxitoring  efficiancy,  we 
examined  total  treatments  requred  total  treatment  time,  and  adnission  rates  to  the 
hospital.  RaauNs:  In  the  course  of  the  study  49  patients  were  examined  The  average 
change  in  heart  rate  HMS  10.75  beats  per  rr^nute  (bprn)  for  the  CirculairB  and  10.8  bpn 
fcr  the  smal  vduiie  netxizer.  Average  change  in  peak  fkiw  rate  data  between  the  two 
methods  was  within  2%  of  eech  other.  A  similar  lincing  was  noted  with  respect  to  hospitl< 
amission  rates  among  the  two  ?0H5S.  The  average  total  length  of  treatment  per 
oampMed  protocol  was  1 9.6  minutes  for  the  Qrculaire  versus  37  minutes  for  the  smal 
vdurm  mbtiizer.  Condusioits:  in  examining  pabent  response  to  therapy,  txjth  methods 
appear  aqunocal,  neither  method  dstingushing  itself  sigrificantly  fmm  the  other  in  this 
respect.  Hoi*e«er,  tn  Citaiaim  and  HCAO  (id  cutpetfcrm  the  MistyMeb  by  reducing 
the  total  ttaatnart  ana  M|^  mere  than  a  quarter  hour  per  protocol.  Our  data  suggests 
that  the  CiiaMra  using  a  rapid^aquance  HCAO  protocol  is  an  squivslent  therapy 
modaHy  to  conventional  methods,  and  offers  a  potential  improvement  In  eflident  use  of 
hospitai  raeouma  and  personnel. 


'  Stolridi  X.  Bsacli  WJ,  Garcia  R  Hotaman  L  The  Safely  and  Efficacy  o(  RspU  High 
Concentration  Nebiiization  of  Beta  Agonist  BronchocSator.  Chest  1977;  112  (38)  p.  11. 
'Mason  JW,  Miler  WC  Abtxeviated  Aerosol  Therapy  for  Improved  Efficiency.  JoimBi  o( 
Aarosol  htedone  1998  Fall:  11(3)  p.  127-31. 

OF-00-003 


yirrESSFLIL  tSf  OF  RFSPIROMCS  RiPAPUITH  CONTIM  OfS  AEPO$CH^  F9B 
TOF  AC^TE  ASTHMA  PAT[E.NT  IN  THF  EMERGENCY  PEP.MtTMECJI  A  C^e  SUKly: 
RichtrdP.  Btpntn  RS.  RR.T..  MetroHMllh  Medical  Center.  Cleveland,  Ohio. 

■■tnxlnctioa'  This  is  a  32-year-old  female,  in  acute  asthma  exacertMtion,  who  w«s  set  H)  on 
non-uivasive  ventilation  using  a  Respironic's  BiPAP  ST-D20  model  in  the  Emergency 
Department.  Once  the  patient  was  stabilized  on  the  BiPAP,  continuous  aerosol  therapy  was 

Caae  summary:  The  patient  was  admitted  to  the  Emergency  Room  for  asthma  exacertiation.  THe 
patient  had  past  medical  history  of  asthma,  used  home  medication  (albuleroL  atrovent,  and 
azmacon  inhalers),  and  hislor>'  of  inlutialion  (X's  2)  because  of  asthma.  Tlie  patient  was 
tachypoeic  with  marked  use  of  accessory  muscles,  breath  sounds  diminished  bilaterally  with  baO 
an  inspiratory  and  expiratory  wheeze,  and  the  patiem  was  not  getting  relief  from  mtermittent 
aerosol  therapy-  The  palients  admitting  Emergency  Department  anerial  blood  gas  values  on  room 
air  were;  pH  7.37,  PaC02  29,  Pa02  54,  HC03  16.4,  02  Sat  87%,  and  BE  -7  8    The  patient  was 
placed  on  non-invasive  ventilation  per  physician  request  with  the  following  settmg;  IPAP  14 
cmH20  EPAP  4  cmH20,  Spontaneous  Mode,  and  a  4  1/m  oxygen  bleed  m.  Conlmuous  aerosol 
therapy  was  added  in  line  to  the  BiPAP  unit  with  continuous  Albuterol  (unit  dose)  and  mterminent 
(Q4  hours)  Atrovem  (unit  dose).  The  paiicm's  arterial  blood  gas  values  drawn  one  half  hour  after 
initiation  of  non-invasive  ventilation  and  continuous  aerosol  therapy  were;  pH  7.34,  PaC02  35, 
Pa02  91  HC03  18.8,  02  Sat  96%.  and  BE  -6  5   The  palieni  was  in  the  Emergency  DepaitmeiU 
for  approximately  4  hours  on  both  continuous  aerosol  therapy  and  non-invasive  ventilation   The 
patient  was  transported  to  die  Medical  Intensive  Care  Unh  on  just  contmuous  aerosol  therapy. 
The  patient  upon  admission  u,  the  Medical  Intensive  Care  UnH  no  longer  required  non-mvasive 
ventilation  and  the  continuous  aerosol  therapy  was  changed  to  Q2  boms  Albuterol  and  Atrovent 
04  hours   The  patient  was  discharged  from  the  Medical  Intensive  Care  Unit  8  hours  later  and 
from  the  hospital  6  hours  after  that. 

Coiclusion:  Application  of  both  non-invasive  ventilation  and  contmuous  aerosol  therapy 
prevented  possible  mtubation  of  this  patient  in  asthma  exacerbation.  The  use  of  noiMnvasive 
vaitilatioa  and  coodnuous  aerosol  therapy  needs  further  evaluation- 


OF-00-024 


CLIMCAJL  EVALUATION  OF  A  BREATH  ACTUATED  SMALL  VOLUME 
NEBULIZER  (BA-SVN) 


RXT, 


Steven  Klopf .  CRT.  Noiman  Schneidennan',MD,  FACE?,  HoUy  Payne', 
OifT  Schramm',  RRT,  Mark  W.  Nagel'  H  B.Sc  and  J  P  MilcheU'  Ph.I 
'Miami  Valley  Hospital,  Dayton,  Ohio 
'TnidcU  Medical  International,  London,  Ontario 


Back(r«uiMl:  In  prior  in-vitro  studies  using  laser  diffiactometry,  the  aerosol  produced  by  a 
novel  breath-actuated  nebulizer  (BAN),  the  AeroEclipse™  (Monaghan  Medical  Corp. 
Plattsburgh,  NY)  has  been  shown  to  contain  a  high  proportion  of  droplets<4.8nm  diameter 
(80.9%  ±  2.4%).  Such  droplets  art  more  likely  to  penetrate  beyond  the  oro-pharyngeal 
region  where  bronchodilation  is  achieved.  These  in-vifro  results  should  therefore  be 
predictive  of  improved  m-vrvo  delivery  of  nebulized  medications  to  the  respuatory  tract. 
This  study  explored  the  clinical  performance  of  die  AeroEclipse™  BAN  m  the  delivery  of  a 
beta2-agonist  (albuterol  2.5  mg/mi  accon^tanicd  by  antjcholeninergic  (ipratroprium 
bromide  250  mg/ml)  bronchodilator  in  some  cases. 

Methods:  Patients  (n=48)  with  a  previous  diagnosis  for  asthma  presenting  to  the 
Emergency  Depaitmeni  for  acute  exacerbation  of  asdiraa  were  included  in  this  study.  Upon 
piraentation.  an  asthma  care  path,  an  assessment  driven,  algorithm-based  tool  was  used  to 
place  patients  in  one  of  three  stages  of  severity  as  recommended  by  the  NIH-NAEPP 
Guidelines  for  the  Diagnosis  of  Asthma.  Each  patient  was  assigned  to  receive  inhaled 
aerosol  treatment  using  the  AeroEclipse™  BAN.  Stage  1  asthmatics  were  given  0.5-ml  of 
albuterol  with  0.5-ml  normal  saline  delivered  until  sputter.  Patients  categorized  in  stage  two 
and  three  were  given  0.5-inl  albuterol,  with  the  addidon  of  1 .5-mi  of  ipratroprium  bromide 
unit  dose.  Treatments  repeated  every  20  minutes  times  three  if  necessary  by  protocol. 
Results: 

Asthma  Severity  Sage  1 

Number  10 

Treatments  Given  2.4 

Treatment  Duration  (min)  3.7 

Mean  Increase  in  PEP  (%,  range%)  44(0-120) 
Four  patients  had  greater  than  20%  mcrease  in  heart  rate,  three  patients  noted  trenwr 
following  treatment.  Twenty  four  patients  had  positive  comments  about  the  device  focused 
on  shorter  treatment  time  and  imiaoved  relief  ftom  dyspnea.  Two  immiiient  intubations 
were  avoided  with  the  use  of  the  BA-SVN. 

Conclusions:  Use  of  the  AeroEclipse™  BAN  appears  to  result  in  good  clinical  outcomes. 
Minimum  number  of  treatments,  shorten  treatment  duration  and  minimal  side  effects  were 
noticed  with  this  device.  Further  outcome  smdies  are  needed  to  assess  this  impact  on  other 
groups  of  patients. 


OF-00-045 


Stage  2 

Suge3 

30 

8 

2.03 

2JJ 

3.78 

5 

67.7(-2.7-580) 

120.7(28^20) 

DRUG  DELIVERY  OF  HYDROFLUOROALKANE-ALBUTEROL 
SULFATE  USING  INLINE  MDI  ACTUATORS  IN  MECHANICALLY  VEN- 
TILATED LUNG  MODEL.  A.  M.  Al-Bagaawi,  B.S..  RRT.  J.  L.  Rau.  Ph.D.. 
RRT,  A.  Ari,  M.S.,  CRT,  CPFT.  R.  Restrepo.  MD.  RRT.  V.  E)eshpande.  M.S.. 
RRT,  Georgia  State  University,  Atlanta,  GA 

Previous  research  has  shown  that  the  type  of  metered  dose  inhaler  (MDI)  actuating 
device  can  have  an  effect  on  drug  delivery  from  an  MDI  during  mechanical  ventila- 
tion. Purpose:  The  purpose  of  the  study  is  to  investigate  the  effect  of  hydrofluo- 
roalkane  (HFA)-formulated  albuterol  sulfate  by  MDI  (ftx>venlil(  HFA)  on  drug 
delivery  in  a  mechanically  ventilated  lung  model  using  various  MDI  actuating 
devices.  Methods:  MDI  delivery  of  HFA  albuterol  sulfate  was  assessed  using  a 
dual  spray  nonreservoir  dispenser,  the  AirlifeTM  Dual  Spray  MiniSpacer  (MiniS- 
pacer.  Allegiance),  the  Hudson  RCI  Inline  MDI  Adaptor  (Hudson  Inline),  and  the 
AirlifeTM  MediSpacer  (MediSpacer.  Allegiance)  in  a  mechanically  ventilated  lung 
model  using  humidified  air.  All  devices  were  placed  in  the  inspiratory  limb  of  the 
ventilator  circuit,  with  the  nonreservoir  devices  22  cm  above  the  patient  wye  and 
the  MediSpacer  at  the  patient  wye.  The  patient  wye  and  a  right  angle  adaptor  were 
connected  to  an  8.0  mm  endotracheal  tube  (ETT).  An  MA-2  provided  ventilation 
at  a  rate  of  10/min,  inspiratory  flow  of  60  L/min  and  VT  =  8(X)  mL.  Twelve  MDI 
actuations  were  given  for  each  trial  and  synchronized  with  the  beginning  of  inspira- 
tion. Drug  dose  was  collected  at  the  end  of  the  ETT  on  a  filter  and  analyzed  by 
spectrophotometer  at  276  nm.  Five  samples  of  each  device  were  tested.  Results: 
Drug  delivery  at  the  ETT  is  expressed  as  a  percent  of  the  dose  per  puff  measured 
from  the  MDI. 

Hudson  Inline  MiniSpacer  MediSpacer 


Mean  (SO) 


4.5%  (0.48) 


14.8%  (1.96) 


19.5%  (1.43) 


There  were  significant  differences  across  device  types  (p  <  0.0001)  when  tested  by 
one-way  analysis  of  variance  ( ANOVA).  A  Scheffe  post-hoc  comparison  showed 
significant  differences  among  each  of  the  three  device  types  (p  <  0.05). 
Conclusion:  These  data  suggest  that  albuterol  sulfate  from  an  HFA  MDI  is  deliv- 
ered more  efficiently  through  a  reservoir  chamber  (MediSpacer)  than  nonreservoir 
devices,  and  that  the  dual  spray  MDI  adaptor  (MiniSpacer)  was  superior  to  the  uni- 
directional Hudson  Inline  ad^tor. 


OF-00-050 


Respiratory  Care  •  August  2000  Vol  45  No  8 


979 


Saturday,  October  7, 12:30-2:25  pm  (Rooms  200,201) 


LEV  ALBUTEROL  USE  IN  THE  EMERGENCY  DEPARTMENT  (ED) 
INCREASES  PEF  OVER  RACEMIC  ALBUTEROL.  Debbie  Ford,  RRT.  Steven 
Dilley.  CRT.  Dean  Handlev.  PhD.  MBA^  'Southern  Maryland  Hospital  Center, 
Respiratory  Care  Services,  Clinton,  MD  ^'Sepracor  Inc,  Marlborough,  MA 
Racemic  albuterol  [(R,S)-aIbuterol]  is  the  most  widely  used  6  agonist  for  the  treat- 
ment of  acute  airway  obstruction.  However,  only  50%  of  the  clinical  dose  of 
racemic  albuterol  has  bronchodilatory  activity;  (R)-albuterol  or  levalbuterol 
(eutomer).  (S)-albuterol  (distomer)  provides  no  clinical  benefit  and  may  be  detri- 
mental to  airway  tissue  and  cells.  Recently,  levalbuterol  (Xopenex™)  became 
available  in  nebulizer  solution.  Southern  Maryland  Hospital  Center  performed  an 
open  labeled  trial  of  levalbuterol  (n=57)  in  comparison  to  racemic  albuterol  (n=47) 
in  asthma  patients  who  reported  to  the  emergency  department.  Patients'  peak  expi- 
ratory flow  (PEF)  and  heart  rates  were  measured  and  compared.  Additionally,  each 
participant  completed  a  survey  for  historical  evaluation  of  adverse  events.  Patients 
6  years  and  older  were  given  1.25  mg  of  nebulized  levalbuterol,  those  5  years  and 
under  received  0.63  mg  of  nebulized  levalbuterol.  In  cases  where  racemic  albuterol 
and  Atrovent™  were  prescribed,  levalbuterol  and  Atrovent™  were  administered  for 
an  equivalent  comparison. 


Drug 

Average  change 
in  PEF  (ml) 

Dosel 

Average  change 
in  PEF  (ml) 

Dose  2 

Average  total 
increase 
in  PEF  (ml) 

Racemic 
albuterol 
2.50  mg 

27 

23 

50 

Levalbuterol 
0.63  mg 

32 

42 

74 

Levalbuterol 
1.25  mg 

53 

41 

94 

The  average  total  increase  in  PEF  for  0.63  mg  and  1 .25  mg  of  levalbuterol  was 
48%  and  88%  greater,  respectively,  than  2.50  mg  of  racemic  albuterol.  The 
increased  efficacy  of  levalbuterol  over  racemic  albuterol  may  relate  to  the  removal 
of  (S)-albuterol. 

OF-00-056 


DELIVERY  OF  ALBUTEROL/IPRATROPIUM  BROMIDE  VIA  A  SMALL 
VOLUME  VALVED  HOLDING  CHAMBER  (VHC) 

Jolyon  P.  Mitchell.  Sara-Lou  Bates,  Kimberly  J.  Wiersema,  Mark  W.  Nagel. 

Robert  W.  Morton  and  James  N.  Schmidt 

Trudell  Medical  Aerosol  Laboratory.  London.  Canada 

Background:  Valved  holding  chambers  (VHCs)  permit  patients  with  imperfect  coor- 
dination to  use  metered  dose  inhalers  (MDIs)  effectively  and  minimize  systemic 
absorption  of  drug  deposited  as  coarse  particles  in  the  upper  respiratory  tract.    We 
compared  the  in  vitro  performance  of  a  149  ml  small  volume  VHC  (AeroChamber^^- 
Plus  VHC  (AC+),  Monaghan  Medical  Corp.,  Plattsburgh.  NY  (n=5  devices))  with  that 
of  the  pMDI  alone  for  the  delivery  of  a  combination  B-agonist/anticholinergic  formula- 
tion (Combivenl*:  103  ^g/dose  salbutamol  (albuterol)  sulfate  (SAL)  +  18  ^g/dose  ipra- 
tropium bromide  (IPR)  ex  actuator  mouthpiece  of  the  pMDI,  Boehringer-Ingelheim 
Pharmaceuticals  Inc.). 

Methods:  Each  VHC  was  washed  with  an  ionic  detergent  and  drip-dried  prior  to  test  to 
minimize  the  influence  of  electrostatic  charge.  Measurements  of  fine  particle  dose 
(FPD  -  particles  <  4.7  pm  aerodynamic  diameter)  and  total  emitted  dose  (ED)  were 
made  with  an  Andersen  8-stage  cascade  impactor  at  28.3  ±  0.5  1/min,  representative  of 
inspiratory  flow  rates  seen  in  adult  patients.  5-doses  were  initially  delivered  from  a 
pre-primed  and  shaken  pMDI  canister  at  45-s  intervals  directly  into  the  induction  port 
of  the  impactor  (5  replicates).   The  procedure  was  repeated  ( 1  measurement  with  each 
VHC),  with  the  pMDI  inserted  into  the  VHC  adapter.   The  stages  of  the  impactor  and 
the  VHC  were  then  assayed  for  SAL  and  IPR  as  separate  components  by  HPLC  -UV 
spectrophotometry. 


Results: 

mean  ±  S.D 

IPR 

SAL                          1 

pMDl  alone 

pMDI  with  AC+ 

pMDl  alone 

pMDl  with  AC+ 

ED  (%  label 
claim  dose) 

86.0  ±  2.0 

51.0±5.0 

86.1  ±1.5 

59.7  ±4.1 

FPD  (%  label 
claim  dose) 

35.0  ±  2.0 

47.0  ±4.5 

46.2  ±  2.7 

56.2  ±  3.6 

FPF(%) 

40.8  ±  2.8 

90.5  ±1.3 

53.6  ±  2.9 

94.1  ±  1.6 

Discussion:  ED  of  both  IPR  and  SAL  components  was  decreased  by  the  presence  of 
the  VHC  lun-paired  l-test,  p  <  0.001  ].    However,  FPD  of  both  components  was 
increased  compared  with  the  pMDl  alone  |p  <  0.004],  and  the  fine  particle  fraction 
(FPF)  of  either  component  delivered  by  the  VHC  was  close  to  90%  of  ED. 
Conclusion:   The  VHC  markedly  reduced  the  portion  of  the  dose  from  either  compo- 
nent of  Combivenl*  contained  as  coarse  particles.    At  the  same  time,  FPD  was  better 
than  that  available  from  the  pMDl  alone.   The  AC+  VHC  greatly  reduced  the  propor- 
tion of  the  dose  delivered  as  coarse  particles  >  5  pm  aerodynamic  diameter  that  have 
Ultle  therapeutic  benefit  to  patients  with  chronic  lung  disease.  OF-00-066 


AEROSOL  DELIVERY  DURING  PRESSURE  CONTROLLED  VENTILATION  (PCV). 

Christine  Oillman,  BA  RRT,  Robert  M.  Kacmarek  PhD  RRT  FAARC.  Dean  Hess  PhD 
RRT  FAARC.  Respiratory  Care,  Massachusetts  General  Hospital  and  Harvard 
Medical  School,  Boston,  MA. 

Background:  Inspiratory  flow  with  volume  controlled  ventilation  (VCV)  can  be  either 
constant  or  decelerating  With  PCV,  inspiratory  flow  varies  with  lung  compliance  and 
resistance-  We  investigated  the  effect  of  these  flow-related  factors  on  aerosol  delivery 
during  mechanical  ventilation  Methods:  We  used  an  in-vitro  model  with  a  Puritan 
Bennett  7200ae  ventilator  and  adult  circuit  (dry),  a  jet  nebulizer  (Hudson  RCI  Micro- 
Mist),  and  a  test  lung  (Michigan  Instruments  TTL).  A  filter  (Puritan-Bennett  D/Flex) 
was  placed  between  the  ventilator  Y-piece  and  the  lung  model  to  collect  aerosolized 
albuterol,  A  4  mL  solution  containing  5  mg  of  albuterol  was  placed  into  the  nebulizer 
cup.  The  nebulizer  was  powered  by  the  ventilator  for  one  cycle  of  30  min.  Albuterol 
was  washed  from  the  filter  and  analyzed  by  ultraviolet  spectrophotometry  at  276  nm 
(Beckman  DU  620),  We  evaluated  2  inspiratory  times  (1  &  2  s),  3  inspiratory  flow 
patterns  (constant  flow,  decelerating  flow,  &  PCV),  2  compliance  settings  (0  02  Ucm 
HjO  &  0  05  L/cm  HiO)  and  2  resistance  settings  (5  cm  HjO/L/s  &  50  cm  HjO/L/s).  The 
ventilator  was  set  to  deliver  a  tidal  volume  of  0  6  L,  PEEP  5  cm  HjO,  and  respiratory 
rate  of  1 5/min  for  all  evaluations.  The  experiment  was  repeated  3  times  for  each  set  of 
experimental  conditions  (n=3).  Results:  With  a  1  s  inspiratory  time,  albuterol  delivery 
was  not  different  between  flow  patterns  (P=0  35).  Albuterol  delivery  increased  with  a 
longer  inspiratory  time  (P=0.001),  but  this  was  less  pronounced  with  PCV.  For  PCV, 
albuterol  delivery  was  significantly  affected  by  resistance  and  compliance  -  particularty 
for  the  2  s  inspiratory  time  (P<0.001),  Conclusions:  Albuterol  delivery  by  nebulizer  and 
mechanical  ventilation  was  affected  not  only  by  inspiratory  time,  but  also  by  the 
inspiratory  flow  pattern.  For  PCV,  the  inspiratory  flow  is  affected  by  the  resistance  and 
compliance  of  the  lungs.  Nebulizer  flow  stops  when  the  inspiratory  flow  decelerates  to 
zero  during  PCV  and  thus  lung  characteristics  that  produce  a  rapid  deceleration  in 
flow  (e.g,,  tow  resistance  &  low  compliance)  result  in  no  increase  in  albuterol  deliver 
with  increased  inspiratory  time.  This  effect  should  be  considered  when  nebulizers  are 
used  with  PCV, 


OF-00-057 


DOSE  OUTPUT  COMPARISON  OF  PAPERBOARD  AND  PLASTIC  HOLDING 
CHAMBERS 

Scott  A,  Foss  BS,  Jean  W.  Keppel  PhD,  David  T  Sladek  CRTT,  Thayer  Medical 
Corporation,  Tucson  AZ. 

Background:  This  laboratory  study  compares  the  performance  of  two  hand-held 
valved  holding  chambers  for  metered  dose  inhalers  (MDIs):  the  LileAire™.  whteh  is 
made  of  foldable  paperboard,  and  the  AeroChamber®,  whfch  is  made  of  injection- 
molded  plastic  Total  dose  output  was  measured  for  six  drugs:  Proventil®  HFA, 
Serevent®,  Alupent®,  Flovent®.  Vanceril®,  and  Tilade®.  Method:  Output  of  the  MDI 
chamber  went  into  a  USP  throat  model,  which  fed  into  a  filter.  A  Harvard  Breathing 
Machine  inhaled  and  exhaled  through  the  system  (filter,  thnsat  model  and  MDI  device) 
at  a  rate  of  5  breaths/min  and  a  volume  of  760  mL.  Any  medicatton  inhaled  through  the 
device  impacted  on  the  filter  for  analysis  In  all  tests  the  MDI  drug  canister  was  actuated 
at  the  start  of  inspiration,  and  the  amount  of  active  ingredient  collected  in  the  filter  was 
assayed  by  ultraviolet  (UV)  spectroscopy  Ten  different  devices  of  each  brand  were 
tested  with  each  dnjg.  Results:  The  graph  below  shows  the  mean  for  each  device/drug 
combination,  in  micrograms  per  dose.  Error  bars  are  one  standard  deviation. 


Total  Dose  Output; 
LiteAire  and  AeroChamber 


^LileAire 

■  AeroChamber 


S  so 


M ,  iw^-JBLjBL-gaiLJL 


Aluplll 


Two-tailed  t-tests  with  unequal  variances  virere  done;  any  differences  between  the 
averages  would  be  considered  statistically  significant  if  p  <  0.05. 
Conclusions:  For  all  six  drugs,  the  LiteAire  and  the  AeroChamber  were  statistcally 
equivalent  in  total  dose  output,  with  p-values  ranging  from  0.053  for  Serevent  to  0.98  for 
Alupent  The  comparable  performance  of  papert>oard  and  plastic  devices  has  some 
significance  because  of  the  novel  character  of  a  dual-vatved  holding  chamber  made  of 
paperboard.  The  portability  and  disposabllity  of  the  LiteAire  may  increase  patient 
compliance  and  thereby  extend  the  benefits  of  a  holding  chamber  to  a  wider  population 
of  MOI  users. 

OF-00-067 


980 


Respiratory  Care  •  August  2000  Vol  45  No  8 


Saturday,  October  7, 12:30-2:25  pm  (Rooms  200,201) 


THE  COVLMON  CANISTER  PROTOCOL  USING  THE  MONAGHAN 
AEROCHAMBER  REVTIALS  NO  CROSS-CONTAMINATION  AND  POTENTIAL 
COST  SAVINGS 

Steven  G.  Sheils.  RTS.  Jennifer  L.  Duncan,  RTS,  William  V.  Wojciechowski,  MS.  RRT. 
Department  of  Cardiorespiratory  Care.  UniveRity  of  South  Alabama,  Mobile.  AL. 

Objective:  Many  respiratory  therapy  departments  have  implemented  the  common  canister 
protocol  (CCP)  as  a  cost-saving  measure.  The  purpose  of  this  study  was  to  determine  the 
incidence  of  cross-contamination  when  using  the  Monaghan  Aerochamber  under  the  CCP 
and  the  potential  cost-savings  as  a  result  of  the  protocol.  Methods:  Human  subjects 
approval  was  obtained  and  data  were  collected  at  a  university  teaching  hospital.  The  hospi- 
tal's CCP  was  followed  using  the  Monaghan  Aerochamber.  The  study  involved  collection 
and  culture  of  three  specimen  collections  (cultures  A.  B,  and  C)  on  each  subject,  on  two  dif- 
ferent media:  sheepi's  blood  and  chocolate  agar.  A  was  obtained  firom  the  inside  of  the  MDI 
mouthpiece  following  swabbing  with  an  alcohol  pad.  Specimen  B  was  obtained  from  the 
MDI  mouthpiece  following  actuation  and  removal  fipom  the  Aerochamber.  Specimen  C  was 
obtained  from  the  MDI  mouthpiece  after  removing  it  from  the  Aerochamber  and  swabbing 
with  an  alcohol  pad.  Specimens  were  incubated  for  72  hours.  Probabilities  for  the  number  of 
positive  cultures  were  calculated  from  a  binomial  distribution,  with  a  significance  level  of 
0.05.  Pre\ious  studies  indicated  a  potential  hospital  cost-savings  of  55%  for  CCP  over  pro- 
viding each  patient  with  their  own  unique  MDI.  The  current  cost  of  MDIs  at  another  univer- 
sity hospital  that  provides  each  patient  with  their  own  MDI  was  multiplied  by  0  J5  to  deter- 
mine the  potential  cost  savings.  Results:  The  sample  included  a  total  of  17  patients  (6  males 
and  1 1  females)  with  a  mean  age  of  54  years.  MDI  medications  administered  to  the  subjects 
included  Flovent  (fluticascme).  Serevent  (salmeterol).  Aerobid  (flunisolide).  Atrovent  (iiwat- 
ropium  bromide),  and  Ventolin  (albuterol).  There  was  no  growth  from  any  sample  at  24. 48. 
OT  72  hours.  ConduacHi:  There  was  no  cross  contamination  of  MDIs  when  using  the  Mon- 
aghan Aerochamber  under  the  CCP.  The  possibility  exists  that  a  55%  reduction  in  MDI  pur- 
chase costs  may  be  realized  when  implementing  the  CCP.  This  represents  a  savings  of 
S 1 3,922  from  the  present  S25,3 1 2  spent  fw  individually  supplied  MDIs  at  another  local  hos- 
pital. 


OF-00-076 


Use  of  the  AeroEdipse^^  Breath  Actuated  Nebulizer 
to  Detiver  Aerosc^ized  Pentamidine 

Bobby  Terrell  RRT,  Mark  Siobal  BS  RRT.  Respiratory  Care  Services. 
San  Francisco  General  Hospital,  UCSF  Department  of  Anesthesia 

IntroductMHi:  The  AeroEclipse™  Breath  Actuated  Nebulizer,  {Monaghan  Medical  Corp.. 
Plattsburgh,  NY)  incorporates  a  unique  design  which  allows  the  patientis  respiratory  effOTt 
to  activate  nebulization  during  inspiration  only.  This  distinctive  feature  improves  the  effi- 
ciency of  drug  delivery  by  eliminating  medication  wastage  during  expiration.  The  follow- 
ing is  a  case  report  on  the  trial  use  of  this  device  to  administer  aerosolized  Pentamidine. 

Case  Summary:  A  5 1  year  old  male  with  HIV  disease  received  aerosolized  Pentamidine 
300  mg  in  6  ml  of  sterile  water  every  4  weeks  for  ftieumocystis  Carinii  pneumonia 
prophylaxis.  The  patient  had  been  treated  on  fcwty-four  prior  occasions  using  either  the 
Respirgard  IP*  (Vital  Signs  Inc.Totowa.  NJ),  or  Iso  Neb'^  (Hudson  RCI,  Temecula,  CA) 
continuous  flow  medication  delivery  systems  with  filtered  exhalation.  The  patient  had  no 
prior  history  of  asthma  or  any  chronic  or  acute  respiratory  ilhiesses.  Following  all  previ- 
ous treatments,  the  patient  exhibited  no  adverse  effects  from  inhaled  Pentamidine  (wheez- 
ing, brcHichospasm,  or  cough).  The  AeroEclipse™  was  setup  using  a  valved  configuration 
that  allowed  activation  of  the  nebulizer  during  inspiration  and  exhalation  directed  through 
an  expiratory  filter.  Use  of  the  AeroEclipse™  doubled  the  usual  treatment  time  to  40  min- 
utes. At  the  end  of  the  treatment  the  patient  de\  eloped  airway  irritation  to  aerosolized  Pen- 
tamidine, as  evidenced  by  high  pitched  expiratory  wheezing  and  cough.  The  patient 
required  subsequent  tre^ment  with  aerosolized  Alupent  to  relieve  symptoms. 

DiscussHHi:  The  AeroEclipse™  delivers  a  high  output  small  particle  size  aerosol  (MMAD 
=  2.8  microns  ♦)  during  inspiration  cmly.  This  unique  design  improves  the  efficiency  of 
aerosolized  medication  delivery  when  compared  to  continuous  flow  nebulization  by  elimi- 
nating medication  waste  during  the  expiratory  (rfiase.  The  high  respirable  fraction  (parti- 
cles <  4.8  microns  =  80%  *)  and  the  reduction  in  drug  wastage  during  expiration  results  in 
an  increased  aerosol  mass  deposited  in  the  lung.  The  previously  undetected  irritant 
rersponse  to  aerosolized  Pentamidine  in  this  patient  was  most  likely  due  to  this  effect 
Although  the  duration  of  the  treatment  was  lengthened  fcH*  this  single  trial,  the  improved 
dmg  delivery  to  the  lungs  using  the  AeroEclipse™  should  allow  a  reduction  in  the  total 
dose  administered,  as  well  as  the  diluoit  volume  used.  This  should  allow  an  overall  reduc- 
tion in  treatment  time. 

CondusHHi:  Further  evaluation  of  the  AeroEclipse™  is  needed  to  quantify  the  change  in 
the  ratio  of  Pentamidine  delivered  to  the  lungs  to  the  total  dose  administered  when 
compared  to  other  nebulizer  delivery  systems.  In  addition,  the  potential  savings  in  drug 
and  labor  costs,  as  well  as  changes  in  the  environmental  impact  to  health  care  woricers. 
should  be  assessed. 


(*  Based  on  Monaghan  Medical  CopcHi^CHi  pnxluct  testing.) 


OF-00-080 


METERED  DOSE  INHALER  (MDI)  DRUG  DELI\^RY  WITH  THE 
GENTLE-HALER(§).  J.  L.  Rau,  Ph.D..  RRT,  Ami  Ari.  M.S..  CRT.  CPFT. 
Bedianne  Tinkler,  M.Ed.,  RRT,  Cardiopulmonaiy  Care  Sciences,  Georgia 
State  University,  Atlanta,  GA. 

Introduction.  Previous  research  has  shown  that  different  reservoir  devices 
with  integral  MDI  adaptors  do  not  provide  consistent  or  equivalent  emitted 
doses  (ED) J  The  Gende-Haler*  is  a  spacer  device  accepting  the  MDI  canis- 
ter of  any  drug.  Purpose.  The  purpose  of  this  study  is  to  measure  total  and 
fine  particle  fraction  (FPF)  emitted  dose  using  the  Gentle-Haler*  with  a  beta 
agonist  and  a  corticosteroid.  Methods.  Three  samples  of  the  Gentle-HaleT* 
were  tested  with  three  MDI  canisters  of  CFC-formulated  albuterol 
(Ventolin^^O  and  beclomethasone  dipropionate  (VanceriF^*)-  Emitted  doses 
with  the  universal  spacer  device  were  compared  in  paired  fashion  to  the  dose 
from  the  manufacturer's  mouthpiece  actuator  alone.  Total  dose  and  FPF 
were  measured  using  an  Andersen  8-stage  impactor.  with  a  metal  USP 
throat,  operated  at  28.3  L/min  (±0.5).  After  discharging  5  actuations  to  waste 
with  all  MDI's  tested,  5  actuations  were  dehvered  for  both  drugs  at  30 
second  intervals  with  impactor  sampling,  with  shaking  between  actuations. 
The  impactor  was  allowed  to  run  for  an  additional  20  seconds  after  the  last 
puff.  I>rug  collected  in  the  impactor  was  analyzed  using  a  spectrophotome- 
ter at  276  nm  and  239  nm  for  albuterol  and  beclomethasone  respectively. 
Results.  Total  and  FPF  emitted  doses  are  summarized  as  means  (SD). 


Albuterol 
MDI  GentieHaler 

Total,  Mg  109.7  (8.8)  56.6  (5.5) 
FPF,Mg  49.3(5.4)  47.6(6.1) 
FPF,  %        44.9%  (1.4)     83.9%  (3.2) 


Beclomethasone 
MDI  GentieHaler 

56.5(2.8)     41.6(0.19) 
24.9(3.6)     28.5(2.4) 
44.0%  (5.7)  68.6%  (6.1) 


Conclusion.  There  was  no  difference  in  emitted  FPF  dose  for  albuterol  (p 
=1 .0)  or  for  beclomethasone  (p  =  0.285)  using  a  Wilcoxon  Signed  Ranks  test. 
1.  Ahrens  R,  Lux  C,  Bahl  T,  Han  T  Choosing  the  metered-dose  inhaler 
spacer  or  holding  chamber  that  matches  the  patient's  need;  Evidence  that  the 
specific  drug  being  delivered  is  an  important  consideration.  J  Allergy  Clin 
Immunol  1995:%:288-94. 


OF-00-089 


IMPROVING  RESOURCE  UTILIZATION  WITH  NEW  TECHNOLOGIES 

Authors  Lewis  MA,  Harris  SS.  Campbell  SL,  Hodges  AL,  Clark  DM 

Affiliation  Baptist  Health  Medical  Center.  9601  Interstate  630,  Exit  7;  Little  Rock, 

AR  72205-7299 

Background         To  meelpatient  care  needs  during  the  peak  respiratory  season  using  leval- 
buterol  (LEV)  (Sepracor  Inc.,  Marlboro,  MA)  and  AeroEclipse  Breath 
Actuated  Nebulizer  (BAN)  (Mon^han  Medical  Corp.  Plattsburgh.  NY). 
Both  pilot  [MDJects  were  approved  by  the  Respiratory  Care  Advisory  Cwn- 
mittee. 

Methods  LEV  1 .25  mg  delivered  \\a  nebulization  q^  was  substituted  for  albuterol 

2.5  mg  CTdered  q4h  in  October  1999.  Patients  coukl  also  receive  LEV  as 
needed.  A  standardized  subjective  questionnaire  to  determine  side  effects 
of  LEV  was  completed. 

BANs  were  utilized  on  patients  meeting  specified  criteria  during  Novem- 
ber 1999.  Standard  nebulizers  were  used  for  all  other  patients  who 
required  nebulized  treatments.  Treatment  times  were  extracted  from  the 
ClmiVision  InfMrnation  Management  System  database. 

Results  LEV  was  substituted  for  albuterol  in  25  padents.  Indicaticms  for  nebulizer 

ther^y  included  asthma  (8%).  COPD  (32%).  communis  acquired  pneu- 
monia (20%).  and  other  (40%).  The  average  number  of  LEV  treatments 
per  day  was  3.7.  This  compared  favorably  to  albuterol,  which  historically 
required  ( 6  treatments  per  day.  No  patients  requested  breakthrough  treat- 
ments or  noted  side  effects  due  to  LEV. 

A  total  of  298  treatments  were  delivered  using  BANs  versus  322  delivered 
using  a  standard  nebulizer.  The  average  time  per  treatment  using  BANs 
was  9.9  minutes  versus  14.76  minutes  with  the  standard  nebulizer. 

The  results  of  these  pilot  programs  prompted  changes  in  respiratory  ther- 
apy practice  throughout  the  hospital.  LEV  was  added  to  the  Patient  Driven 
ftotocols  and  BANs  are  now  used  for  nebulizer  treatments  in  patients 
meeting  criteria.  Hospital  census  data  indicate  a  1 3.5%  increase  for  2000 
versus  1999.  Thus,  total  treatments  for  Januarv  and  Februarv  1999  and 
2000  were  30,089  and  32.923,  respectively.  During  this  period.  1 6.000 
LEV  vials  were  dispensed  from  an  automated  dispensing  unit  vs  8.9(X) 
vials  of  albuterol.  ConcurrenUy.  overtime  (OT)  hours  utilized  in  2(KX)  were 
decreased  by  693  hours,  resultingin  a  savings  of  516,632,  despite  the 
increased  number  of  treatments.  TherefcHie,  treatments  were  delivered  to 
more  patients  with  less  OT  utilized  in  2000. 

OxiclusioDS        These  data  illustrate  the  cost-effectiveness  of  two  new  technologies  utilized 
in  our  hospital,  while  patient  care  and  satisfaction  were  maintairksd.  OT 
hours  decreased  by  25%  while  treatments  were  delivered  to  mcwe  patients 
throughout  the  hospital.  The  use  of  LEV  has  resulted  in  a  33%  decrease  in 
the  number  treatments  per  day  with  few  "pm"  treatments,  while 
BAN  has  decreased  the  time  to  deliver  therapy  by  33%.      OF-00-090 


Respiratory  Care  •  August  2000  Vol  45  No  8 


981 


Saturday,  October  7, 12:30-2:25  pm  (Rooms  200,201) 


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SELF- ADMINISTERED  METERED  DOSE  INHALER  THERAPY:  AN  ANAL- 
YSIS OF  INSTRUCTION,  TECHNIQUE,  AND  EFFICACY.  CR  Hall.  MS.  RRT. 
RPFT.  RR  Baker.  PhD,  RRT,  RCPT,  SC  Mishoe,  PhD,  RRT,  AA  Taft,  PhD,  RRT, 
FH  Dennison,  M.Ed,  RRT,  RPFT.  Medical  College  of  Georgia,  Augusta,  GA. 
BACKGROUND:  Adult  patients  are  frequently  left  to  self-administer  their 
metered  dose  inhaler  bronchodilator  therapy  in  the  hospital.  These  treatments  are 
often  ineffective  for  the  following  reasons:  spacers  may  not  be  used,  instruction 
may  not  be  given,  patient  technique  may  be  poor  even  after  instruction,  or  patients 
may  not  be  responsive  to  bronchodilator  therapy.  Ineffective  MDI  treatments  can 
add  unnecessary  medical  costs.  This  study  assessed  the  source  of  initial 
instruction,  the  MDI  technique,  and  bronchodilator  efficacy  in  hospitalized 
patients  self-administering  their  treatment.  METHODS:  This  study  examined  16 
hospitalized  adult  patients  who  were  currently  performing  self-administered  MDI 
bronchodilator  therapy  without  a  spacer  (saMDI).  Each  patient  was  assessed 
within  72  hrs  of  the  initial  physician  order.  No  treatment  was  given  within  6  hours 
of  a  previous  treatment.  Each  patient  was  told  to  perform  their  MDI  treatment 
exactly  as  they  were  originally  instructed.  No  further  coaching  or  instruction  was 
given.  Patient  MDI  technique  was  assessed  using  steps  derived  from  the  Expert 
Panel  Report  2:  Guidelines  for  the  Diagnosis  and  Management  of  Asthma  from  the 
National  Asthma  Education  and  Prevention  Program.  To  determine  efficacy  of 
bronchodilation,  saMDI  was  compared  to  metered  dose  nebulization  (MDN)  using 
a  crossover  design.  Baseline  spirometry  was  performed  prior  to  each  treatment. 
Subjects  initially  received  180  pg  of  albuterol  via  either  saMDI  or  MDN.  Spirom- 
etry was  performed  15  minutes  later  to  assess  bronchodilator  response.  A  second 
180  pg  dose  was  given  and  spirometry  was  performed  after  15  minutes.  No 
adverse  sequelae  were  noted  in  any  treatment  method.  RESULTS:  Of  the  16 
study  patients,  44%  (n=7)  were  initially  instructed  by  a  nurse,  19%  (n=3)  by  a  res- 
piratory therapist,  and  37%  (n=6)  received  no  initial  instruction.  As  a  group,  the 
respiratory  therapy-instructed  patients  correctly  performed  90%  of  the  assessed 
MDI  steps,  nursing-instructed  patients  correctly  performed  53%,  and  the  non- 
instructed  patients  correctly  performed  only  38%.  Of  patients  in  the  therapist- 
instructed  group,  100%  (n=3)  performed  greater  than  50%  of  the  steps  correctly  as 
compared  to  57%  (n=4)  in  the  nursing-instructed  group  and  33%>  (n=2)  in  the  non- 
instructed  group.  Only  44%  of  the  total  patients  performed  less  than  half  of  the 
MDI  techniques  correctly.  Eight  of  1 3  patients  responded  to  any  bronchodilator 
therapy  but  only  3  responded  to  MDI.  Three  of  the  16  patients,  2  in  the  nursing- 
instructed  group  and  1  in  the  non-instructed  group  were  unable  to  perform  PFTs. 
CONCLUSIONS:  Self-administered  MDI  therapy  may  not  result  in  optimal  ther- 
apy. Patients  have  better  saMDI  technique  when  instruction  is  provided  by  a  respi- 
ratory therapist.  Bronchodilator  therapy  should  be  attended  by  a  health-care 
provider  and  outcomes  monitored  to  assure  treatment  efficacy.  nc  nn 


IN-VITRO  COMPARISON  OF  THE  PERFORMANCE  OF  VALVED  HOLDING 
CHAMBERS  FOR  DELIVERY  OF  SEREVENf  INHALATION  AEROSOL. 

Anne  Leslie  Stevens.  BS.  RRT,  CPFT:  Mark  Holmes,  BSc  (Hons);  Anna 
Furlong,  BS;  and,  Colin  Reisner,  MD.  GlaxoWellcome,  Inc.,  Research  Triangle 
Park,  NC. 

Background:  The  dose  of  inhaled  dmgs  delivered  to  the  lung  from  a  metered 
dose  inhaler  (MDI)  depends  on  factors  such  as  ainway  anatomy,  disease  state 
and  inhalation  pattern.  Timing  MDI  actuation  with  inhalation  is  difficult  and 
using  a  valved  holding  chamber  (VHC)  may  decrease  coordination  issues.  Yet. 
the  respirabie  fraction,  fine  particle  mass  (PPM),  of  drug  delivered  from  VHCs 
must  be  comparable  to  the  FPM  from  the  MDI.  This  study  compares  the 
delivered  dose  of  Serevent  via  three  brands  of  VHCs. 
Method:   The  delivery  of  Serevent*  (total  unit  dose  21mcg  ex-actuator, 
GlaxoWellcome,  Inc.)  via  Aerochamber*  (Monaghan  Medical  Corp  [ACfi, 
Aerochamber  Plus*  (Monaghan  Medical  Corp  [AC+])  and  Optichamber 
{Healthsoan  Products,  Ino,  [OPT])  was  compared.  The  dose  delivered  from  the 
VHCs  was  obtained  using  an  Andersen  cascade  impactor  All  VHCs  were 
washed  with  detergent  per  package  instructions.  Three  different  Serevent* 
Inhalers  were  evaluated  with  each  VHC  (n=3,  AC  and  AC+;  n=6.  OPT).  The 
VHC  was  attached  to  the  throat  of  the  impactor  and  sampling  flow  was 
established  at  approximately  28.3  l/min.  The  inhaler  was  shaken  >5  seconds 
and  attached  to  the  VHC,  fully  depressed  for  one  second  then  left  in  place  for 
30  seconds.  This  process  was  repeated  to  deliver  10  doses  to  each  VHC.  The 
stages  of  the  impactor  and  the  VHC  were  assayed  for  Serevent*  by  HPLC.   A 
Serevent*  control  was  assessed  with  every  analysis. 

Results:  The  mean  dose  from  stages  4.  5,  and  6  (FPM)  of  the  impactor  for  the 
Serevent*  controls  was  14.00  meg.  The  table  below  compares  the  FPM  of  the 
VHCs  to  the  control: 


VHC 

mean 
FPM* 
(meg) 

Difference 
VHCvs 

Serevent* 

S.E. 

95%  Confidence 
Interval 

Lower 

Upper 

AC 

13.67 

-0.33 

0.30 

-0.97 

0.31 

AC+ 

15.01 

1.01 

0.33 

0.29 

1.73 

OPT 

14.01 

0.01 

0.38 

-0.77 

0.79 

*particles  0.7-3.3  |im  in  diameter 

Conclusions:  These  in-vitro  data  demonstrate  that: 

•  FPM  is  clinically  comparable  across  VHCs  and  to  the  original  product 
and. 

•  the  tested  VHCs  are  reasonable  for  administration  of  salmeterol. 


OF-00-150 


t       our       W 


Get  Your  Head 

Out  of  the  Sand! 


• 


the 


More  than  35,000  respiratory  professionals 
have  gotten  the  message!  The  AARC  is  the 
place  to  be  for  professional  growth,  network- 
ing, continuing  education,  and  much  more. 


JOIN  TODAY, 
by  calling 
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or  visiting 
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The  American  Association 
for  Respiratory  Care 


982 


RESPIRATORY  CARE  •  AUGUST  2000  VOL  45  NO  8 


The    .  ^  . 


M 


of  an  MDI 
small  volume 


lizer 


^ero^ciip 


AeroEcliosG'  ^.™. 

Breath-Actuated 

Nebulizer  ("BAN")  ^ 

A  new  technology. 

Breath  actuation  is  the  most  significant  advancement  in  the  history  of  small 
i/olume  nebulizers  (SVN).  Only  the  AeroEclipse™  BAN  can  deliver  the 
precision  of  an  MDI  in  an  SVN. 

Match  delivery  to  demand. 

The  AeroEclipse^"  BAN  creates  aerosol  only  in  precise  response  to  the 
patient's  inspiratory  maneuver.  This  is  patient  on-demand  therapy  and 
means  less  medication  waste,  safer  environments  and  clinical  dose 
assurance.  Truly  exceptional  aerosol  performance  delivers  more  drug  - 
faster  and  to  the  right  place  -  creating  a  treatment  modality  without  equal. 

First  time  precision. 

So  why  not  do  it  right  the  first  time  with  the  AeroEclipse™  BAN. ...  After 
all,  when  will  you  have  the  time  to  do  it  again? 

Circle  127  on  product  info  card 


ZENITH 
AWARD  1999 


Now  available  from: 


CO)  monaghan 


Monaghan  Medical  Corporation 

PO  Box  2805  •  Piattsburgh.  NY  12901-0299 

Customer  Service  800-833-9653 

'*AemEclipse  is  a  trademark  of  Monaghan  Medical  Corporation;, 

©1999  Monaghan  Medical  Corporatioi  ' 

Visit  AARC  Booth  269  in  CIncin 


Saturday,  October  7, 12:30-2:25  pm  (Rooms  213,214) 


CHYLOTHORAX:  A  RARE  LATE  PRESENTATION  OF  ANTERIOR  THO- 
RACIC INTERBODY  FUSION.  Jain  Hilender.  MP.  Albomoz  MA,  MD.  Green- 
blatt  JM,  MD,  Draganescu  JM,  MD,  Korman  M,  MD,  McMaster  J,  DO,  Taheer  M, 
MD.  Mercy  Catholic  Medical  Center,  Darby,  PA. 

Chylothorax  is  the  accumulation  of  opalescent,  milky  fluid,  rich  in  triglycerides 
(TG)  and  chylomicrons  in  the  pleural  space.  Chylothorax,  unless  diagnosed  quickly, 
carries  a  50%  mortality  rale.  It  is  a  rare  immediate  postoperative  complication  of  an 
anterior  approach  to  fusion  of  the  thoracic  spine,  with  only  few  case  reports  cited  in 
the  literature.  It  is  reported  to  occur  in  0.2%  of  intra-thoracic  operations  and  is  most 
common  with  cardiac  surgery,  neck  operations,  sympathectomy  and 
esophagectomy.  We  present  a  patient  with  chylothorax  that  developed  4  weeks  after 
anterior  fusion  of  the  thoracic  spine. 

Case:  A  30  year  old  female  with  cerebral  palsy  and  HTN  was  admitted  with  paraple- 
gia after  a  fall  at  home.  She  was  diagnosed  as  having  a  T 1 0  hemangioma-induced 
pathological  fracture.  She  underwent  transthoracic  corpectomy  at  TIG  via  an 
anterior  approach  with  excision  of  the  hemangioma  and  interbody  fusion  and 
fixation.  Following  a  week  stay,  the  patient  was  discharged  paraplegic,  but  in  stable 
condition.  Approximately  four  weeks  after  the  operation,  the  patient  was  admitted 
with  repeated  vomiting.  She  was  found  to  have  paralytic  illeus  and  a  moderate  right- 
sided  pleural  effusion.  Thoracocentesis  yielded  750cc  of  yellow,  cloudy  opalescent 
fluid  with  WBC  count  of  1700, 92%  lymphocytes,  protein  4.6  gm,  amylase  15  and 
LDH  124.  All  pleural  fluid  cultures  including  AFB  and  fungal  were  negative.  A 
PPD  test  was  negative  and  a  chest  CT  revealed  a  right  sided  pleural  effusion  and  no 
mass  or  adenopathy.  Rapid  accumulation  of  the  pleural  effusion  resulted  in  moder- 
ate respiratory  distress.  Chest  tube  drainage  produced  2.5  liters  of  opalescent  fluid. 
Because  of  previous  spina!  surgery,  chylothorax  was  suspected.  Pleural  fluid  TG 
levels  was  found  to  be  170  mg/dl  (serum  TG  level  1 10  ing/dl).  The  pleural  fluid 
also  showed  presence  of  fat  globules.  The  patient  responded  to  supportive 
nutritional  management  and  chest  tube  di^nage  initially  and  has  been  symptom-free 
for  i  1  months. 

Discussion:  The  hallmark  for  the  diagnosis  of  chylothorax  is  an  elevated  pleural 
fluid  triglyceride  level  greater  than  1 10  mg  /dl.  Typically  it  presents  4-5  days  after 
resumption  of  regular  diet  postoperatively,  and  only  rarely  4-6  weeks  after  surgery. 
If  conservative  management  with  parentral  medium  chain  triglycerides  and  chest 
tube  drainage  with  continuous  suction  fails,  ligation  of  thoracic  duct, 
pleuroperitoneal  shunt,  pieurodesis,  and  sealing  of  fistula  with  thoracoscopic  fibrin 
glue  are  other  treatment  modalities  that  have  been  shown  to  be  beneficial.  In  appro- 
priate clinical  setting,  physicians  are  well  advised  to  maintain  a  high  index  of  suspi- 
cion for  chylothorax,  as  early  diagnosis  and  treatment  are  associated  with  a  signifi- 
cant reduction  in  mortality.  OF-00-005 


EXAMINING  THE  CONSEQUENCES  OF  SELF-EXTUBATION 
John  M.  Welton  PhD  RN  and  Daniel  G.  Gassaway  BS  RRT.  University  of 
North  Carolina  Hospitals,  Chapel  Hill,  North  Carolina. 

Background:  Introduction  of  a  temporary  endotracheal  tube  for  pulmonary 
support  in  the  intensive  care  unit  is  coinplicated  by  the  risk  of  premature 
removal  of  the  tube.  Extubation  under  uncontrolled  circumstances  jeopar- 
dizes the  patients  cardiorespiratory  status  and  may  result  in  death.  In  an 
effort  to  quantify  the  scope  of  this  problem,  we  gathered  data  over  an  1 8 
month  period.  Methods:  Concurrent  and  retrospective  data  were  collected 
by  staff  nurses  and  clinical  nurse  supervisors  for  each  unplanned 
extubation  in  six  adult  intensive  care  units  of  a  major  teaching  medical 
center.  Results:  A  mean  of  13.28  (SD  5.29)  self-extubations  per  1000  ven- 
tilator days  occurred  each  month.  Of  these  events,  5 1  %  were  routinely 
reintubated,  48%  remained  extubated  and  less  than  1  %  were  reintubated 
with  complications.  Conclusion:  Unplanned  extubation  is  a  common  prob- 
lem in  the  ICU  that  is  usually  well  tolerated  by  the  patient.  These  results 
suggest  that  many  patients  may  be  ventilated  unnecessarily,  emphasizing 
the  need  for  expedient  weaning  and  termination  of  ventilator  support  when 
warranted. 


OF-00-042 


CLINICALUTILITY  FOR  MEASURES  OF BREATHLESSNESS 

Deborah  L.  Cullen.  EdD,  RRT,  FAARC,  Respiratory  Therapy  Program, 
School  of  Allied  Health  Sciences,  Indiana  University  School  of  Medicine, 
Indianapolis,  IN. 

Background:  Measures  of  dyspnea  have  been  debated  in  the  medical  com- 
munity as  to  their  clinical  utilization.  Although  breathlessness  may  be  eval- 
uated through  multiple  instruments,  the  most  effective  measure  for  a 
specific  patient  population  or  for  measuring  treatment  effectiveness  remains 
uncertain.  Understanding  primary  and  corollary  validation  work  for  these 
instruments  may  provide  a  key  to  appropriate  clinical  application.  The  pur- 
pose of  this  study  was  to  evaluate  the  validity,  reliability  and  responsiveness 
for  measures  of  breathlessness.  Methods:  Scientific  studies  describing  the 
original  patient  population  and  methods  related  to  validity,  reliability  and 
responsiveness  were  chosen  for  analysis.  The  dyspnea  measures  analyzed 
included  the  Borg  Scale,  Visual  Analogue  Scale  (VAS),  Oxygen  Cost  Dia- 
gram (OCD),  Medical  Research  Council  Breathlessness  Scale  MRC),  Base- 
line/Transition Dyspnea  Index  (BDI/TDI),  Chronic  Respiratory 
Questionnaire  (CRQ/dyspnea  scale),  St  George's  Respiratory  Questionnaire 
(SGRQ/activity  domain).  Content  analysis  for  six  constructs  was  cairied 
out  from  the  data  presented  in  each  study.  All  data  was  sorted  by  common- 
alities resulting  in  rating  for  clinical  utility  among  the  various  measures  of 
biieathlessness.  Results:  Measures  of  dyspnea  varied  as  to  evidence  of  gen- 
eralizability  to  various  patient  populations  (COPD,  asthma,  lung  transplant), 
concurrent  and  construct  validity,  internal  consistency,  inter-observer  relia- 
bility and  responsiveness.  The  Borg,  VAS,  OCD,  MRC  were  more 
appropriate  for  dyspnea  related  to  exercise,  ADL's,  and  benchmarks.  The 
BDI/TDI,  SGRC,  CRQ  were  clinically  applicable  to  dyspnea  related  to  out- 
comes, responsiveness  and  clinical  trials.  Conclusion:  Since  instrument 
construction  and  validation  may  limit  the  effectiveness  for  measuring  clini- 
cal change  (intra-patient  sensitivity)  as  well  as  comparison  among  patients 
(inter-patient  sensitivity),  instrument  appropriateness  should  be  a  primary 
consideration  for  selection. 


OF-00-055 


Timing  of  Tracheostomy  following  Critical  Illness  or  Injury  John  H.  Bovnion  Jr. 
R.R.T..  Grant  O'Keefe  M.D.,  Kenneth  Hawkins  R.R.T.  Parkland  Health  &  Hospital  Sys- 
tems and  The  University  of  Texas  Southwestern  Medical  Center.  5201  Harry  Hines 
Blvd.  Dallas,  Texas  75235 

Introduction:  The  optimal  timing  of  tracheostomy  in  the  management  of  patients  with 
prolonged  respiratory  failure  is  controversial.  Translaryngeal  intubation  is  associated 
with  a  distinct  set  of  complications,  the  frequency  of  which  increase  with  the  duration  of 
intubation.  In  addition,  it  has  been  suggested  that  early  tracheostomy  can  hasten  libera- 
tion from  mechanical  ventilation  following  resolution  of  acute  respiratory  failure.  There- 
fore, we  undertook  this  .study  to  determine  whether  tracheostomy  performed  prior  to 
active  weaning  resulted  in  more  rapid  weaning  and  an  overall  shorter  period  of  mechani- 
cal ventilation. 

Methods:  Surgical  patients  requiring  >72  hours  of  MV  were  prospectively  enrolled  into  a 
study  examining  the  utility  of  weaning  parameters.  Clinical  respiratory  care,  including 
the  use  of  tracheostomy,  was  at  the  discretion  of  the  attending  physicians  and  respiratory 
therapists.  Patients  undergoing  tracheostomy  prior  to  any  active  weaning  attempts  (early 
tracheostomy;  ET)  were  compared  to  patients  in  whom  initial  weaning  attempts  were 
made  with  the  translaryngeal  tube  (selective  tracheostomy:  ST).  Patients  who  underwent 
emergency  tracheostomy  for  airway  control  and  patients  who  were  immediately 
extubated  once  readiness  to  wean  criteria  were  met  were  not  included.  Differences 
between  the  groups  were  compared  with  the  Mann-Whitney-U  and  chi-square  tests.  Cox 
regression  was  used  to  compare  the  timing  of  tracheostomy  on  the  duration  of  weaning. 
Results:  A  total  of  74  patient  (of  the  initial  95  requiring  >72  hours  of  MV)  met  inclusion 
criteria.  The  21  in  the  ET  group  were  compared  to  53  in  the  ST  group  and  25  (47%)  of 
the  ST  group  underwent  tracheostomy.  The  ET  group  underwent  tracheostomy  after  a 
median  of  7  days  of  MV  and  the  ST  group  after  a  median  of  1 4  days  of  M  V.  ET  actually 
delayed  the  onset  of  active  weaning  (3  vs.  1  day).  The  figure  indicates  the  duration  of 
weaning  in  ET  vs.  ST  patients.  Mean  duration  of  weaning  in  the  ET  was  3  days 
compared  to  7  days  in  the  ST  group  (p  =  0.06) 

Conclusion:  Tracheostomy  prior  to  active  weaning  may  decrease  the  time  of  active 
weaning.  However,  this  does  not  reduce  the  overall  duration  of  MV,  and  may  delay  the 
.start  of  active  weaning. 


Weaning  Duration 


tracneoHofrryOiTMna 


THT|«  ITOm  meeting  readiness  to  wean  criteria  (days) 


OF-00-061 


984 


RESPIRATORY  CARE  •  AUGUST  2000  VOL  45  NO  8 


Saturday,  October  7, 12:30-2:25  pm  (Rooms  213,214) 


HIGH  FREQL'ENO  CHEST  WALL  OSCILLATION:  VIDEO 
DOCUMENTATION  OF  EFFECT  ON  A  PATIENT  WTTH  DLCHENT^EiS  MUS- 
CULAR DYSTROPHY  AND  SEVERE  SCOLIOSIS.    Ann  Gomez  RCP  Ph.D.. 
Isabelo  Elisan  RPFT.  Karen  Hard)  NID.  Children's  Hospital  Oakland,  Oakland,  CA. 
INTRODUCnON:   High  Frequency  Chest  Wall  Oscaialion  (HFCWO  or  Vest  Therapy) 
is  a  method  of  chest  physical  therapy,  used  for  the  past  1 1  years.   Indications  that  require 
aggressive  airway  clearance  include  secretion  removal  for  diseases  like  Cystic  Fibrosis  and 
brcmchiectasis.  Therapy  is  deli\ered  in  the  hospital  and  at  home.  It  is  most  often  ased  for 
patients  with  Cystic  Fibrosis,  both  in  the  hospital  and  as  a  home  therapy.  We  present  here 
another  indication  fw  Vest  Therapy. 

CASE  SUMMARY:  JB  has  had  Duchenne's  Muscular  Dystrophy  since  the  age  of  six.  He 
is  now  16  years  old  and  has  profound  kyphoscoliosis.  His  pulmonary  function  shows 
restrictive  and  obstructive  airway  disease,  and  poor  tidal  volume.  His  cough  is  ineffective. 
JB  was  hospitalized  in  1997,  and  required  a  prolonged  stay  in  the  intetisive  care,  with  five 
bronchoscopies  to  remove  thick  secretions  and  treat  persistent  atelectasis.   Nocturnal 
BiPAP  was  instituted  to  treat  persistent  atelectasis.  After  discharge,  airway  clearance  at 
home  included  Albuterol  nebulization  followed  by  postural  drainage  and  percussion 
(PD&P)  BID.  However,  the  PD&P  was  severely  limited  due  to  JB's  profound  kyphoscol- 
iosis. This  December  JB  was  hospitalized,  for  progressive  difficulty  feeding  over  three 
months,  with  significant  weight  loss,  aixl  the  need  for  continuous  BiPAP  resulting  in  facial 
necrosis.  JB  received  aggressive  nutritional  supplementation  and  a  tracheostomy  to  ease 
the  application  of  BiPAP  and  enhance  airway  clearance.  Despite  Albuterol  arnl  modified 
PD&P  TID,  he  continued  to  have  thick  secretions  requiring  deep  suctioning.  Two  weeks 
after  tracheostomy,  JB  had  an  acute  respiratory  decompensation  with  pH  of  7.0,  and 
PaC02  of  123,  requiring  hand- ventilation  and  repeated  lavage  and  suctioning  of  bloody 
secretions.  Pediatric  Pulmonology  was  ccmsultod.  Video  bronchoscopy  (performed  by 
KH.)  revealed  severe  diffuse  traclKitis,  extensive  mucous  plugging  was  present,  with  ftill 
obstruction  of  left  mainstream.  Airwav  clearaiKe  methods,  hydration,  arxl  deep  suctioning 
needed  to  be  re-evaluated.  We  instituted  Vest  Therap\  for  30-minute  intervals  at  a 
jxessure  of  4  and  a  fiequency  of  15  Hz  during  Albuterol  aerosol.  QID.  Heated  humidity 
was  initiated  and  a  cut-off  suction  catheter  or  olive  tip  was  used  to  remove  secretions. 
There  was  significant  clinical  improvement  in  Pa02,  PaC02  aiKl  patient  comfort.  Days 
later,  a  subsequent  %  ideo  bronchoscopy  showed  healing  mucosa  and  minimal  secretions. 
Intraprocedure  Vest  Therapy  documented  significant  movement  of  distal  secretions  fix>m 
the  lung  periphery  to  the  central  airways  for  removal  by  bronchoscqie. 
DISCUSSION:   Vest  Therapy  in  Duchenne's  Muscular  Dystrc^y  has  not  been 
previously  reported.  However  there  have  been  two  publications  describing  Vest  Therapy. 
one  in  an  MS  patient,  and  another  in  8  p^ents  with  neuromuscular  weakness.  As  these 
diseases  progress,  they  have  increasing  skeletal  deformity  causing  worsening  pulmonary 
ftincticm  and  decreased  ability  to  clear  secretions  fiT)m  the  lower  airways.  Their  deformity 
severely  limits  the  effectiveness  of  conventional  airway  clearance  techniques.  We 
conclude  that  Vest  Ther^y  is  effective  to  mobilize  distal  airway  secretions  for  easier 
removal  as  documented  by  video  bronchoscopy.  We  recommend  this 
therapy  be  applied  to  other  patients  with  similar  pathophysiology.  OF-00-099 


UTILIZATION  OF  HIGH  FREQUENCY  CHEST  WALL  OSCILLATION  (Vest 
Therapy)  DURING  THERAPEUTIC  PEDUTRIC  FLEXIBLE  FIBEROPTIC 
BRONCHOSCOPY.  Ann  Gomez  RCP.  Ph.D..  Isabelo  Elisan  RPFT.  Karen  Hardy 
MD.  Children's  Hospital  Oakland.  Oakland.  CA. 

INTRODUCTION:  Flexible  bronchoscopy  was  first  described  in  infants  and  children 
in  1978.  The  indications  for  flexible  bronchoscopy  are  extensive.  And  in  the  hands  of 
well-trained  [^ysicians  the  procedure  is  a  safe  and  effective  tool  for  the  exploration  of 
the  pediatric  airway.  Indications  for  use  include  diagnostic  and  management  of  inflam- 
matory, infectious  and  malignant  disorders  of  the  chest.  Removal  of  secretions  and 
bronchial  alveolar  lavage  often  produces  approximately  a  50%  return.  We  were 
interested  in  a  method  to  increase  clearance. 

CASE  SERIES:  We  present  a  case  series  of  three  patients  where  video  flexible 
bronchoscc^y  was  dor»e  with  a  3.0  size  bronchoscope.  Patient  one  was  a  16-year-old 
male  with  Ducheene's  Muscular  Dystrophy  involving  respiratory  failure  from  severe  res- 
piratory muscle  weakness,  reduced  lung  compliance  and  retained  secretions. 
Bronchoscopy  was  performed  as  a  follow-up  to  [wevious  respiratory  arrest  due  to  mucus 
plugging.   Patient  two  was  a  9-year-old  child  with  severe  cerebral  palsy  following  non- 
accidental  tiaimia  and  asphyxia  as  an  infant  Bronchoscopy  was  performed  because  of 
persistent  atelectasis  and  to  evaluate  the  airway  for  tracheobronchitis.  We  collected 
specimen  for  testing.  Patient  three  was  a  IS-mcmth-old  child  with  cystic  fibrosis.  Bron- 
choscopy was  done  for  lavage  to  determine  if  Pseudomonas  was  pnesenL  We  collected 
specimen  for  testing.  Vest  Therapy  was  used  in  each  flexible  broiKhoscopy  to  enhance 
mobilization  of  distal  airway  secretions. 

FINDINGS:  Patient  one  a  3.0  broiKhoscc^  was  introduced  through  a  5.5- 
tracheostomy  mbe.  During  Vest  therapy  (ftessure  of  3,  Heitz  13)  application  there  was 
visualization  of  distal  airway  secretions  that  were  mobilized  to  the  bronchoscope  for  sik- 
ticwiing.  There  was  no  airway  trauma  from  the  oscillaticffi  of  the  VEST.  Patient  two  a  3.0 
bronchoscope  was  introduced  through  the  patients  left  nostril  through  to  the  distal 
airways  after  Vest  therapy  KPressure  of  3.  Hertz  of  1 3)  was  utilized  for  approximately 
two  minutes.  Bronchoscope  was  advanced  to  the  left  lower  lobe  secretions  were  easily 
aspirated  with  VEST  Therapy.  With  bronchoscope  in  place  it  was  noted,  mild  pink- 
tinged  secrclicms  were  coming  ftx>m  above.  VEST  therapy  was  stopped.  Hemoptysis 
was  not  coming  from  any  visible  lesion,  but  generally  present  in  the  carinal  area.  Evalu- 
ation flowing  lavage  showed  no  bleeding  sites.  There  was  minimal  inflammatory 
change  at  the  base  of  the  glottis  at  the  removal  of  the  bronchoscope.  Patient  three  a  3.0 
bronchoscope  was  introduced  through  a  4.0  endotracheal  tube.  VEST  Therapy  was 
started  (pressure  of  3  Hertz  of  13).  Distal  airways  viewed  and  secretions  obtained  for 
sampling.  There  was  no  evidence  of  airway  trauma. 

CONCLUSION:  Two  of  the  three  patients  had  improved  secr^cMi  clearance  with  hi^ 
frequency  chest  wall  oscillation  during  suctioning.  This  small  series  suggests  a  roll  for 
VEST  Therapy  needs  to  be  ftirther  defmed  but  was  safe  in-patient  with  artificial  airways. 

OF-00-100 


EVALUATION  OF  MASIMO  SET  PULSE  OXIMETRY  IN  PATIENTS  IN  WHOM  CON- 
VENTIONAL OXIMETRY  FAILS  TO  PROVIDE  RFI  lABLE  MONITORING 
Stephanie  Rostow.  RRT.  Charles  Duibin.  Jr..  MD.  FCCM.  Universitv  of  Virpnia  Health  Sys- 
tem, Charlottesville,  Va, 

INTRODUCTION-  Pulse  oximetiy  is  an  integral  pail  of  monitoring  critically  ill  patients  in 
the  intensive  care  unit,  operating  room,  recovery  room,  and  other  locations.  It  is  in  many  of 
these  critically  ill  patients,  that  pulse  oximetiy  has  been  shown  to  fail  to  obtain  a  signal.  The 
failure  rate  for  conventional  pulse  oximetry  has  been  reported  to  range  from  72%  to  9^  of 
patients  ( 1 .2).  This  failure  rate  increases  with  patient  acuity  (2).  New  pulse  oximetry 
technology,  Masimo  SET*  reports  to  have  increased  accuracy  during  low  perfusion  and  noise 
conditions.  We  prospectively  evaluated  the  ability  of  Masimo  SET  oximetry  (MSO)  to  obtain 
reliable  pulse  oximetiy  values  in  patients  in  whoin  conventiotial  pulse  oximetiy  (CPO)  failed. 

METHODS-  We  prospectively  evaluated  MSO  in  our  cardiac  surgery  critit^  care  unit 
Upon  admission,  patients  in  whom  CPO  (Ohmeda  3740)  failed  to  obtain  reliable  saluiation 
readings  were  enrolled.  Unreliable  readings  were  defined  as  complete  inability  of  CPO  to 
obtMn  a  pulse  signal,  or  display  of  an  obviously  spurious  saturation  or  pulse  rate  value  on  CPO. 
MSO  was  then  apphed  and  if  MSO  obtained  a  stable  pulse  oximetiy  reading,  aiterial  blood 
gases  were  obtained  for  validation  of  the  SpO;  and  the  pulse  rate  was  validated  by  ECG  heart 
rate. 

RESULTS-  Eight  postoperative  (CABG  =  5,  Ventricular  Assist  Device  placement  =  1  ,TAA 
=  1 ,  CABG  and  A VR  =  1 )  adult  patients  (age  range  52  -  8 1  years)  were  identified.  In  7  of  8 
(88%)  patients  MSO  obtained  pulse  oximetiy  readings.  The  SpOi  difference  (MSO  to  ABG) 
was  1.1  ±  1  '5^  (mean  ±S.D.)  in  these  patients  (see  Table).  In  the  one  patient  in  whom  we  were 
unable  to  obtain  MSO,  we  were  also  unable  to  obtain  ABG  data  as  he  suffered  cardiac  anest 
requiring  CPR 
TABLE 

Spurioas  Condition 

CPOSpOi 

MASIMO  SpO, 

ABGSaCh 

Failed  SpOi 

0 

100 

99 

Failed  SpO: 

0 

98 

99 

Failed  SpO^ 

0 

98 

97 

Failed  PR  1!) 

89 

92 

93 

Failed  SpO; 

■'low  quality  signal" 

99 

99 

Failed  SpO; 

■"low  quality  signal" 

98 

97 

Failed  SpOj 

"low  quality  signal" 

"pulse  search" 

(•) 

HighSpCh 

100 

88 

91 

(!)  lack  of  correlation  between  pulse  rate  and  ECG  heart  rate,  causing  question  of  SpC>2  accu- 
racy (* )  patient  expired  prior  to  obtaining  arterial  blood  gas 

DISCUSSION-  hi  88%  of  patients,  in  whom  CPO  failed,  Masimo  SET  pulse  oximeoy 
obtained  accurate  SpOi  values.  This  allowed  for  continuous,  accurate  monitoring  of  SpCb  via 
MSO  in  critically  ill  postoperative  patients  where  CPO  failed,  thereby  resulting  in  a  significant 
increase  in  patient  safety,  h  is  interesting  to  note  that  conventional  pulse  oximeny  failure  may 
include  sinjations  when  Sp02  values  arc  inaccurately  high  (as  in  one  patient  in  our  study).  Even 
in  this  situation  MSO  was  able  to  obtain  a  reliable  Sp02  value. 
1.  Anesthesiology  1996;  84:  859-64. 2.  Anesthesiology  1993;  78: 436-44. 
Some  technical  support  and  equipment  was  provided  by  the  Masimo                  OF-00-101 
Cortxjration,  Inine,  CA 

PULSE  OXIMETRY  PERFORMANCE  CAN  AFFECT  CLINICIAN  EFFE(mVENESS 
Charles  G.  DurbJn,  Jr..  MD.  FCCM.  Stephanie  K.  Rostow.  RRT.  University  of  Virginia 
Health  System,  Chariottesville,  VA. 

INTRODUCTION-  Recent  interest  in  human  error  aiKl  patient  safety  has  identified 
"untrustworthy  alarms  and  indicators"  as  being  one  of  many  "latent  conditions"  leading  to 
human  error  [1,2].  We  investigated  the  impact  of  an  oximeter  using  a  new  signal  processing 
technology  [Masimo  SET  pulse  oximetry  (MSO)  Masimo  C(Mp,  Irvine,  CA]  on  the 
ftiequency  of  oximeter  malfunction  (downtime  aiKl/or  inaccurate  alarm  conditions). 
METHODS-  We  prospectively  compared  MSO  to  conventional  pulse  oximetiy  (CPO),  the 
Ohmeda  3740  (Datex-CWuneda,  Louisville.  CO).  After  obtaining  Human  Use  Committee 
aj^)roval,  68  adult  cardiac  surgery  patients  with  good  preoperative  ventricular  function,  fol- 
lowing CABG  surgery,  were  enrolled.  On  arrival  in  the  ICU,  both  CPO  and  MSO  were 
attached  to  the  same  hand  of  each  patient  The  outfHit  from  both  monitors  was  continuously 
recorded  to  a  computer  recording  system  until  4  hours  following  extubation  or  for  a 
maximum  of  24  hours  postc^ratively.  The  digits  to  which  the  monitors  were  attached  were 
randomly  chosen  by  the  bedside  clinician.  Patients  were  randomly  assigned  to  have  the  dis- 
play of  only  one  of  the  devices  available  to  the  bedside  caregivers  with  the  other  device 
"blinded".  No  other  clinical  management  was  altered.  From  the  computer  records  we  deter- 
mined episodes  of  device  failure  (reading  0%  saturation),  inaccuracy  as  determined  by  coin- 
cidental ABG  (difference  >  59c),  and  obvious  artifacts  were  identified  and  tabulated  as 
downtime,  the  total  time  the  device  was  non-functional.  The  percentage  of  monitwing  time 
during  which  each  device  was  non-fiinctional  in  each  patient  was  then  determined.  Differ- 
ences were  analyzed  using  Studentis  t  test  Significance  was  determined  at  p<0.05. 
RESULTS-  Totol  monitoring  time  per  patient  was  867  ±  362  (mean  ±  SD)  minutes.  Non- 
functional time  (when  used  as  caregiver  device):  CPO  3.6  ±  5.6  %  (Q,  0. 1  -  20.7  %);  MSO 
0.3  ±0.4%,  (a,  0  - 1.2%)  p=0.03.  Non-fiinctional  time  (blinded  device):  CPO  9.4  ±  1 1.7  % 
(CI,  0. 1  -  38.7  %);  MSO  0.3  ±  0.5%,  (CI.  0  -  1 .8%)  p=0.01 . 

DISCUSSION-  Increased  non-fiinctional  monitoring  time,  which  was  significantly  greater 
with  the  CO  device,  resulted  in  caregivers  needing  to  respond  to  the  device  failure,  diverting 
them  firom  patient  care.  It  is  assumed  that  clinicians  had  to  devote  additional  time  evaluating 
or  questioning  the  fiinctionalily  of  either  device,  however  this  could  not  be  quantified  in  the 
current  study.  Inaccurate,  invalid,  and  incorrect  pulse  oximetry  consumes  caregivers'  time 
when  they  are  forced  to  care  for  the  monitor  and  not  the  patient.  Masimo  SET  pulse  oxime- 
try provides  significandy  less  oximeter  non-ftinctional  time  than  CPO  aiKl  reduces  the  num- 
ber of  iuntmstwOTthy  alarms  and  indicators!.  This  performance  benefit  existed  regardless  of 
blinding,  implying  the  potential  for  imfxoved  monitor  reliability  in  unattended  settings. 
Recent  studies  on  human  error  and  patient  safety  point  to  caregiver  cognitive  overioad  and 
distraction  (termed  latent  conditions)  as  one  cause  of  patient  injury  or  enw.  Data  from  this 
pilot  study  suggests  larger  studies  may  reveal  the  extent  of  the  impact  of  these  decreased 
latent  conditions  and  the  benefit  of  increased  clinician  confidence  on  human  error  and 
patient  safety. 
[1]BMJ  2000: 320:768-70. 

(2]  Instimte  of  Medicine.  To  Err  is  Human.  National  Academy  Press,  1 999. 
Some  technical  suppOTt  and  equipment  was  provided  by  the  Masimo 
Coqxxation,  Irvine,  CA  OF-00- 1 02 


Respiratory  Care  •  August  2000  Vol  45  No  8 


985 


Saturday,  October  7, 12:30-2:25  pm  (Rooms  213,214) 


IMPROVED  PULSE  OXIMETER  TECHNOLOGY  CHANGES  CAREGIVER  PRACTICE 
PATTERNS:  MASIMO  SET^  VS.  CONVENTIONAL  PULSE  OXIMETRY 
Charles  G.  Durbin.  Jr..  MP.  FCCM.  Stephanie  K.  Rostow,  RRT.  Univereity  of  Virginia  Health 
System,  Charlottesville.  VA. 

INTRODUCTION-  Monitors  provide  data  upcm  which  decisions  about  patient  care  are  based, 
ICU  practice  patterns  have  been  based  largely  upon  the  technology  incorporated  in  monitoring 
systems.  Recent  advances  have  produced  pulse  oximeters  with  increased  sensitivity  and 
decreased  interference  fixim  artifact.  TTie  Masimo  SET*  pulse  oximeter  (Masimo  Corporation, 
Irvine,  CA)  (MSO)  uses  a  novel  signal  processing  technology  to  identify  arterial  saturation, 
which  is  resistant  to  movement  artifacts  and  low  flow  states.  Using  the  Masimo  SET  pulse 
oximeter  (MSO),  we  sought  to  test  the  hypothesis  that  improved  technology  would  change 
chnicianis  practice  patterns.  Specifically,  we  examined  the  time  to  wean  to  an  Fi02  of  0.4,  the 
time  to  extubation,  the  number  of  ventilator  changes  and  the  number  of  arterial  blood  gases 
(ABGs)  obtained  during  tiiis  weaning  process. 

METHODS-  We  prospectively  evaluated  the  effects  on  caregiver  practice  patterns  of  two  pulse 
oximetry  technologies.  We  compared  the  MSO  technology  to  a  conventional  pulse  oximeter 
(CPO).  the  Ohmeda  3740  (Datex-Ohmeda,  Louisville  CO).  After  obtaining  Human  Use  Com- 
mittee approval,  68  adult  cardiac  surgery  patients  with  good  preoperative  ventricular  function, 
following  CABG  surgery,  were  enrolled.  On  arrival  in  the  ICU,  both  a  CPO  and  a  MSO  were 
Mtached  to  the  same  hand  of  each  patient.  The  output  from  both  monitors  was  continuously 
recorded  to  a  computer  system  until  4  hours  following  extubation  or  for  a  maximum  of  24 
hours  postoperatively.  The  digits  to  which  the  monitors  were  attached  were  randomly  chosen 
by  the  bedside  clinician.  Patients  were  randomly  assigned  to  have  the  display  of  either  the  CPO 
or  MSO  available  to  the  caregivers  with  the  other  device  iblindedi.  No  other  routine  clinical 
management  was  altered  during  the  study.  We  determined  the  time  until  weaning  to  Fi02  =  0.4, 
time  until  extubation,  and  the  number  of  ABGs  obtained  during  weaning.  Differences  were 
analyzed  using  Student's  t  test.  Significance  was  determined  at  p<0.05. 
RESULTS-  There  was  no  difference  in  time  to  extiibation  [647  (  335  (MSO)  vs.  705  (  338 
(CPO)  minutes]  or  the  number  of  ventilator  changes  [2.6  (MSO)  vs.  2.5  (CPO)]  in  weaning  to 
Fi02  =  0.4.  However,  there  was  a  significant  difference  in  the  time  required  to  wean  oxygen  to 
F1O2  =  0.4,  the  MSO  group  in  168  ±  99  minutes  vs.  324  ±  263  minutes  for  the  CPO  group, 
p=0.02.  "Oiere  were  significantly  fewer  ABGs  performed  when  the  MSO  oximeter  was  used, 
2.2(0.9  vs.  3.8(1.8  for  the  CPO  group,  p<0.01 . 

DISCUSSION-  Our  data  supports  the  hypothesis,  that  clinician's  practice  patterns  will  change 
when  provided  with  improved  pulse  oximetry  technology  as  with  the  Masimo  SET  pulse 
oximeter.  Although  extubation  time  was  not  different,  the  number  of  ABGs  obtained  and  the 
time  to  wean  to  a  low  Fi02  was  nearly  half.  This  change  in  practice  reduces  the  costs  of  oxy- 
gen supply  and  dehvery  and  the  associated  risk  of  morbidity  fi-om  excessive  oxygen  exposure. 
Clinicians  achieved  these  efficiencies  while  decreasing  the  number  of  blood  gases  obtained. 
This  change  in  practice  could  result  in  a  savings  of  over  1 200  ABGs  in  our  cardiac  intensive 
care  annually.  While  accuracy  of  monitored  data  is  often  reported  in  studies  of  monitors, 
impact  on  caregiver  behavior  is  a  more  relevant  method  of  monitor  evaluation. 

Some  technical  support  and  equipment  was  provided  by  the  Masimo  Corporation,  Irvine,  CA 

OF-00-103 


COMPARISON  OF  CHEST  PHYSIOTHERAPY  TECHNIQUES 
Yoshihiro  Uzawa  RPT;  The  Universitv  of  Toledo  Respiratory  Care  Program.  Toledo 
Ohio.  Ya.sunari  Yamaguchi  RPT,  Norihiro  Kaneko  MD;  Kameda  General  Hospital, 
Kamogawa,  Chiba,  Japan. 

(Background)  Chest  physiotherapy  is  performed  to  facilitate  airway  clearance. 
Although  there  are  many  techniques  reported,  only  percussion  and  vibration  are 
commonly  used  in  the  United  States.  The  purpose  of  this  study  is  to  compare  the  charac- 
teri.stics  of  each  technique. 

(Method)  The  subjects  were  10  healthy  males  (mean  age  23.9  yrs,  mean  VC  4.72L)  on 
which  three  chest  physiotherapy  techniques  (Squeezing,  Vibration,  and  Percussion)  were 
performed  in  standard  fashion  and  randomized  order.  Squeezing  was  performed  by  hav- 
ing a  therapist  place  his  hands  over  the  area  of  the  subject's  chest  wall,  then  during  expi- 
ration, increased  amounts  of  pressure  were  applied  in  a  medial  caudal  direction.  Just 
before  they  began  inspiration,  the  therapist  relea.sed  his  hands  from  the  chest  wall  and 
allowed  them  to  inhale.  The  therapist  performed  percussion  by  using  the  therapist's 
hands  in  a  cupped  position,  and  applied  kinetic  energy  to  the  subject's  chest  wall.  Vibra- 
tion was  performed  by  placing  the  therapist's  hands  on  the  subject's  chest  wall  and 
applied  a  vibratory  motion  caused  by  the  arms.  Subjects  were  placed  in  the  lateral  posi- 
tion, and  each  technique  was  performed  on  the  right  lower  lobes.  The  subjects  were 
instructed  to  breathe  normally  until  three  techniques  were  completed.  Tidal  volume  and 
flow  rates  were  measured,  and  flow  volume  curve  was  observed  by  using  a  spirometer 
(Chesdac  55,  CHEST  Co.).  Baseline  was  measured  in  the  lateral  position  and  then  all 
three  techniques  were  performed  for  five  minutes  each  to  the  subjects  in  the  same  posi- 
tion. Between  techniques,  the  subjects  were  allowed  to  return  to  baseline.  ANOVA  was 
used  to  analyze  these  data. 
(Result)     'Table  1  DifTerent  value  between  during  each  technique  and  baseline 

Squeezing 

Percussion 

Vibration 

Tidal  Volume  (ml) 

605.4±276.0  * 

247.8±184.6 

241.4±I39J 

Peak  Flow  Rate(ml/sec) 

379.2±227.1  ** 

22S.4±137.1 

75.0±74.4 

Flow  Rate  at  75%  TV  (niVsec) 

366.4±273.1*** 

158.0±116.4 

101.4±73.6 

Flow  Rate  at  50%  TV  (ml/sec) 

289.8±178.1***'* 

76.6±78.9 

37.6±89.1 

Flow  Rate  at  25%  TV  (ml/sec) 

266.2±135,S* 

76.2±79.0 

30.2±74.6 

*p<0.(X)l  Squeezing  vs.  Percussion  and  Vibration,  **p<0.001  Squeezing  vs.  Vibration 
***p<0.05  Squeezing  vs.  Percussion,  p<0.01  Squeezing  vs.  Vibration 
****p^Q  Qj  Squeezing  vs.  Percussion  and  Vibration 

(Conclusion)  Results  indicate  that  Squeezing  increased  tidal  volume  and  flow  rate  dur- 
ing the  expiratory  phase,  augmenting  airway  clearance.  It  appears  Squeezing  increases 
the  flow  rate  both  at  high  and  low  volume.  It  shows  that  Squeezing  maintains  peripheral 
airway  patency  during  expiration.  Therefore,  it  appears  that  the  use  of  Squeezing  for 
patients  who  need  to  remove  secretions  is  more  effective  than  the  use  of  Percussion  and 
Vibration,  especially  for  patients  who  have  peripheral  airway  collapse  and  obstruction, 
such  as  asthma  and  bronchitis.                                                                OF-00-104 

DIGITAL  PASS-THROUGH  PULSE  OXIMETER  PROBES  ARE  NOT  ACCURATE  OR 
PRECISE  WHEN  USED  AS  A  REFLECTANCE  DEVICE 

Lori  faigalls.  Christine  Fogarty,  Rebecca  Fasnacht,  Alelsha  Kuehne,  Sivom  Ouk,  Kory 
Bowc,  Jeff  Ward  RRT,  James  Pringnitz,  RRT,  Fred  Helmholz,  MD.  David  Plevak,  MD. 
Rochester  Community  &  Technical  College-Mayo  Clinic.  Rodiester.  MN. 

Objective:  Digital  pulse  oximetry  prc^KS  are  designed  to  be  placed  on  a  finger  tip  using  a 
pass-through  (eduiique  (FIT).  We  noticed  that  patients  in  our  institutim  were  being 
monitored  by  fordiead  placement  of  these  probes,  utilizing  reflectance  methodology  (RM). 
We  wished  to  determine  the  |»'ecision  and  accuraQ'  of  the  digital  pulse  oximeter  probes  in 
estimating  oxygen  saturation  (Sp02)  w^eri  utilizing  RM.  Methods:  Forty  adult  hospital 
patients  were  studied.  The  pulse  oximeters  (  MallinCTodt-Nellcor®  with  D-25  single- 
patimt  use  probes),  and  co-oximeto's  (Chirm  Diagn(»tics)  wctc  calibrated  using  standard 
protocols.  Two  digital  pulse  oximeter  prc^ies  wax:  simultaneously  ^pUed  to  each  patioit. 
One  probe,  secured  to  the  forehead,  used  RM  to  estimate  Sp02.  A  second  probe  was 
secured  to  a  fingertip  and  utilized  the  PTT.  IViw  to  placement  of  the  pM-obes,  each  probe 
site  was  rubbed  with  an  alcohol  swab  for  30  seornds  to  improve  local  circulaticm.  The 
forehead  probe  was  secured  by  a  strip  of  tape.  The  finger  probe  was  placed  on  the  hand 
opposite  the  radial  artery  cannula.  If  no  cannula  was  presoit,  a  radial  artery  aspirate  was 
pCTfonned,  and  the  finger  ptobe  was  placed  on  the  hand  opposite  the  aspiration.  After 
application  to  the  patient,  the  probes  were  allowed  to  stabilize  for  1  minute.  As  an  arterial 
blood  sample  was  beii^  drawn  from  the  patient,  values  were  rec^vded  from  both  pulse 
oximeters.  These  readings  were  compared  to  the  "gold  standard"  co-oximeter 
ox>^emogtobin  values  (Sa02).  Accuracy  and  precision  for  both  pulse  oximeter  methods 
were  determined  and  Bland-Altman  plots  wo-e  used  to  provide  a  visual  display  of  the 
comparison. 

RcraHt:  The  mean  diflference  from  Sa02  values  for  the  RM  was  4.58%  (accuracy).  The 
standard  deviation  of  theses  differences  (Sa02  minus  RM)  was  9.98%  (p-ecision).  Fig.  I 
displays  a  Bland-Altman  plot  of  these  data.  In  contrast,  the  mean  difference  from  Sa02  fat 
PTT  was  2. 1 8%.  The  standard  deviation  of  these  differences  (Sa02  minus  PT)  was  3.23%. 
CoacbuioBt:  The  digital  pulse  oximeter  probe  is  not  acarate  or  precise  when  used  as  a 
reflectance  probe. 

ng.!. 


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OF-00-143 


UTILIZATION  OF  PRONE  POSITIONING  IN  LATE  PHASE  ARDS 
Kenneth  Miller.  RRT.  MEd:  Stephen  Matchen,  MD;  Frederick  Wieand,  RRT,  BA: 
Phillip  Huffhian,  MD;  Wanda  Perich,  RN.  Lehigh  Valley  Hospital.  Allentown,  PA,  USA, 
18105-1556 

Introduction:  Turning  patients  from  the  supine  to  the  prone  position  has  been  proposed  as  a 
useful  supportive  therapy  that  can  improve  oxygenation  in  many  patients  in  ARDS.  Chnical 
studies  in  ARDS  patients  have  reported  that  changing  to  the  prone  position  improves 
oxygenation  in  60-70%  of  patients  and  has  no  deleterious  effect  on  hemodynamics'.  Atoiost 
50%  of  these  patients  maintained  their  improvemenl  when  returned  supine=.  Theoi«ically,  a 
beneficial  response  lo  prone  positioning  would  be  most  likely  during  the  early,  edematous 
phase  of  ARDS,  when  lung  edema  and  atelectasis  predominate.  However,  clinical  feedback 
has  been  lacking  to  define  the  optimal  time  to  institute  prone  positioning  during  the  clinical 
course  of  ARDS.  Case  Summary:  A  forty-one  year-old  female  was  admitted  with  Diabetic 
Ketoacidosis  and  possible  sepsis.  Post  admission  the  patient  suffered  a  cardiac  arrest.  The 
patient  was  successfijlly  resuscitated  following  ACLS  guidelines,  however  prior  to 
intubation,  gastric  aspiration  occurred.  Post  resuscitation  x-ray  revealed  clear  lungs.  Initial 
ventilator  setting  were  600ccxl2x50%  with  a  PIP  of  38cm/H:0,  EIP  of  24cro/H,0  and  P/F 
ratio  255.  Several  hours  later,  pulmonary  compliance  deteriorated,  P/F  ratio  decreased  to 
100.  and  a  repeat  x-ray  demonstrated  bilateral  iniilu-ates  consistent  with  ARDS.  Despite 
aggressive  ventilatory  management,  pharmological  paralysis,  kinetic  bed  therapy,  and 
tracheostomy  the  P/F  ratio  remained  around  100  and  compliance(Clt)  below  20cc/cm/H;0. 
During  the  early  course  of  pulmonary  compromise  the  decision  to  utilize  prone  ventilation 
was  discussed  but  not  instituted  secondary  to  hemodynamic  instability  which  was  maintained 
by  titration  of  Levophed  and  Dopamine.  Over  the  next  several  days  the  patient's 
oxygenation  status  remained  critical  with  an  average  P/F  ratio  of  120  on  a  range  of  FIO; 
between  60-90%  and  PEEP  levels  greater  than  1 2cm/H!0  Pulmonary  compliance  remained 
less  than  20cc/cm/hj0,  On  the  nineteen  day,  after  the  diagnosis  of  ARDS,  the  decision  was 
made  to  attempt  prone  positioning.  Prior  to  beginning  prone  positioning  the  P/F  ratio  was  60 
and  CIt  l8cc/cm/H;0.  After  12  hours  of  prone  positioning  the  P/F  ratio  improved  lo  120  and 
FIO,  was  titrated  below  60%  for  the  first  time  during  the  patients  clinical  course  A  chest  X- 
ray  twenty-fours  after  starting  prone  positioning  demonstrated  a  decrease  in  interstitial 
edema.  Prone  positioning  was  maintained  for  a  total  of  forty-eight  hours  withoul  any 
hemodynamic  compromise  The  patient  was  relumed  to  the  supine  position  without  any 
deterioralion  in  pulmonary  status.  Subsequently  the  FIO;  was  reduced  and  pressure  support 
was  initiated  lo  start  ihc  weaning  process  days  Conclusion:  It  has  been  theorized  that  the 
maximum  benefit  from  prone  positioning  would  occur  early  in  the  clinical  course  of  ARDS. 
Our  case  presentation  demonstrates  Ihat  prone  positioning  can  improve  oxygenation  later  in 
the  clinical  course  of  ARDS.  The  therapeutic  utilization  of  prone  positioning  should  not  be 
limited  to  the  early  phase  of  ARDS 

1  Langer  M,  Mascheroni  D,  Ganinoni  L    The  Prone  Fotilltm  In  ARDS paitna.  Clwa 
l')88;94:103-107 

2  Lamm  W,  Graham  M.  Albeit  R,  Mechanism  By  Which  The  Ftone  Fosilion  Improves 
OyixenalumlnAculeLunglriiury    Am  J  Resp  Cril  Care  Med  I994;  I50:l«4-I93 

L/f"-UU-140 


986 


Respiratory  Care  •  August  2000  Vol  45  No  8 


Saturday,  October  7, 12:30-2:25  pm  (Rooms  213,214) 


TOOTH  ASHRATION  DISCOVERED  ON  REINTUBATION.  M«a 
Smnt  KRT.  Akundo-  B.  Aduw  RRT,  Chrii  Carter  M  J).  Reborn 
Hospttal,  SI.  Paul.  MN. 

latnrtlKUwi:  Foreign  body  aspirukn  (FBA)  u  cMldm  has  been  wdl 
documented.  Objects  such  as  peanuts  and  other  Ofganic  material  aic  inuet 
cooimoniy  repontAl  with  rcpcrls  ol  talaliues  due  to  balloon  aspiration.  The 
incidence  of  adult  FB A .  ho»e% er.  is  less  common  and  lelalcd  more  to  the 
patient's  a^  and  ph>?ticaj  condition.  Adujis  aspirate  objects  such  as  vegcUible 
matter,  meat,  bones,  dental  appiianccs,  with  icports  of  ispiraluij  beverage  can 
pulltahi.  a  bnllo  pad  crack  acnea,  a  apinhaler  piupeller.  and  a  small  dental 
scirwdnver. 

Cm  Sumnaa;:  A  «6  year  old  man  presented  in  the  ER  with  complaints  of 
chest  pain,  dyspnea,  and  syncope  over  a  two  day  period.  02  sauiratioo  »!b  75* 
on  luom  air  and  !!K-92<*  on  via  non-iTbrcather  mask.  After  a  short  run  ol 
asystole  the  patient  was  emergenlly  intubated,  plated  on  mechanical  venlilauon 
and  slahli/cd  in  the  MICU.  A  subse^juent  CXR  found  a  nght  pleural  effusion 
without  identifying  a  focal  lesion  a  diat  time.  A  transcutaneous  pacemaker  was 
used  to  control  the  asysolic  episodes.  An  attempt  at  extubauon  failed  due  to 
desatuiation  and  respiratory  distress.  During  reintubauon.  a  foreign  body  was 
seen  in  the  left  mainstcm  bronchus.  The  foreign  body  aiuld  not  be  utracted  by 
neuble  bronchoncope.  Iheiefoic.  ngid  bronchoscopy  was  performed  Under 
anesthesia,  a  n.Snim  Store  ngid  broochoicopc  aliened  the  cxtracuon  ot  a 
molar  tooth  with  an  alligator  forceps.  Owing  tiK  procedure  the  patient  was 
ventilated  with  a  Saunders  Ventnn  Jet  venulalur.  The  patient  remained  stable 
thioughou  die  remaining  hospital  coom  and  was  discharged  in  Us  tsual  stale 
of  health 

MkihAiq;  The  HcxiUe  fibeioplic  bronchoscope  was  rirel  introduced  in  the 
lalel9M)'s.  While  it's  use  in  the  sale  removal  of  foreign  bodies  in  adult  FBA  u 
successful  in  meet  patienB,  the  rigid  bronchoscope  is  required  for  difficult 
extractions  of  large  foreign  bodies.  Aspiialioo  in  adults  is  seen  in  all  dedlei 
with  peak  incidence  in  the  6*  decade  Certain  faclMs  prcdispoae  to  FBA  such  as 
neurological  disoidere  affecting  protection  of  the  upper  airway  and  dental 
procedures.  In  this  case,  a  FBA  was  not  evident  until  the  roots  ol  a  molar  kxxh 
were  seen  during  reintubauon.  After  canvassing  local  hospiuils.  adult  large  FBA 
incidence  is  esumaled  at  l/100,00(Vycar,  a  relatively  tare  event  lequinng  the  use 
of  rigid  broochoacopy. 


OF-00-154 


A  COMPARISON  OF  TOTAL  PATIENT  WORK  OF  BREATHING  (TPWOB) 
BETWEEN  VOLUME  SUPPORT  (VS)  AND  ASSISTED  VOLUME 
CONTROL  (VC)  VENTILATION  IN  A  LUNG  MODEL  David  L. Vines.  MHS. 
RRT,  David  C.  Shelledy,  PhD,  RRT.  The  University  of  Texas  Health  Science 
Center,  San  Antonio,  Tx.  PURPOSE:  VC  has  been  thought  to  provide  the 
lowest  work  of  breathing  (WOB)  in  spontaneously  breathing  patients  as 
compared  to  other  modes  of  mechanical  ventilation.  To  test  this  assumption, 
we  compared  TPWOB  between  VS  with  a  variable  inspiratory  flow  and  VC 
with  fixed  inspiratory  flows  of  40  Umin  (VC40)  and  60  L/min  (VC-60)  using  a 
two-compartment  mechanical  lung  model  (Michigan  Instniments  Inc.,  Grand 
Rapids,  Ml)  to  simulate  spontaneous  breathing.  METHOD:  WOB  was  first 
nwasured  on  lung  B  alone  at  tidal  volumes  of  200,  300, 400,  and  500  with  a 
peak  ftow  of  60  Umin  and  a  sine  wave  flow  pattern  using  the  Ventrak  1550 
Respiratory  Mechanks  Monitoring  System  (Movametrix  Medfeal  Systems, 
Inc.,  Wallingford  CT).  Then  WOB  was  measured  at  these  volumes  for  lung  B 
to  drive  lung  A  at  nonnal  compliance  (0.05  UcmH20)  and  resistance  (2.7 
cmH20/L/sec),  decreased  compliance  (0.02  UcmH20),  and  increased 
resistance  (17.6  cmH20/Usec)  while  lung  A  received  assistance  from  either 
VS,  VC-40  or  VC-60  at  set  tklal  volumes  of  400, 600,  and  800  mL.  TPWOB 
was  cateulated  by  subtracting  WOB  for  lung  B  atone  from  the  WOB  for  lung 
B  to  drive  lung  A.  [TPWOB=  W0B(b-a)  -  WOBe]  RESULTS:  TPWOB  during 
VS  (0.379  ±  0.260  J/L)  was  significantly  tower  (p<  0.000001)  than  VC40 
(0.896 10.199  J/L)  or  VC-60  (.614  +  0.195  J/L).  VC-60  had  a  signiftoantly 
tower  TPWOB  than  VC40.  Peak  inspiratory  pressure  during  VS  (18  +  10 
cmH20)  was  signiftoantly  less  (p<  0.004)  than  VC-60  (25  +  9  cmH20)  but 
not  VC40  (21+  9  cmH20).  There  was  no  difference  between  the  modes  in 
exhaled  spontaneous  tWal  volume  or  mean  airway  pressure.  When 
spontaneous  effort  exceeded  set  tklal  volume,  TPWOB  increased  in  all 
modes  (VS-  0.942  J/L,  VC40- 1.059  J/L,  and  VC-60-  0.818  J/L). 
CONCLUSION:  VS  results  in  a  signiftoantly  tovwr  TPWOB  compared  to  VC 
at  a  fixed  inspiratory  flow  of  40  or  60  L/min  during  varying  inspiratory 
volumes  and  changing  lung  mechantos  as  tong  as  inspiratory  effort  does  not 
exceed  set  tklal  volume.  OF-oo-i  59 


USE  OF  TRAMSCirTANEOUS  COI  (?»cC02)  MONITOMNG  IN  ADULTS 

MiA  Siotal  RKT.  Fdna  WiroeAe  RRT,  Rich  Kalla  RRT.  Reyrauay  Care  Servioei. 
Sai  Fianosco  General  Hoipital.  UCSF  DepC  of  Anesdaais 

gatltgromd:UwrfPtoC02awiSorillgiaifdn'dpractiocionecoital  mlcnsivT  care  units  and 
diirin«  slixp  diaynslie ftadaa.  D«  to4w lifh  diflliabilitiy  of  CU2.  PtcCU2  as  a  surrogate  for 
P«C02  IS  less  depeodM  «•  heMdsmmc  «s««  Md  *in  pertisMi  thin  trsnsraiunoous  P02'". 
Deapile  strong  to  moderstt  condBion  with  P.C02  "  and  e»M«W  C02  (PeC02) ",  P1CC02 
nmiilcnng  remains  under  utilized  in  aduha  We  report  results  that  confinn  the  clinical  uliHty  of 
P1cC02  moQitonng  m  adulu 

MeikadK  A  convenience  sraple  of  two  oomparusoos  of  PlcC02.  PaC02,  and  P«C02  lensioii 
were  made  in  6  Griucally.ill  adults  lequning  mcchmical  voitilatiao  usmg  a  Novsmelnx 
Capoogard,  Radiometer  TINA,  and  an  AVL  0mm  Wood  gas  analyzer  The  PlcC02  sensor  was 
platx  on  Uie  forearm  or  chest  30  minutes  prior  to  dau  oolleciiur  with  the  sauor  tempcranae  al 
44^  anl  ccciwiwn  factor  =  4.  Patients  were  hemodynamicaily  stable  dunng  all  measuitnienu. 
teaaks:  Men  (±  standard  deviation)  values  of  PetC02  (43  2i4,8).  PtcC02  (41*4,9)  and  PaC02 
(45.4±7  1)  were  not  diffocnl.  Simple  irpessKKi  showed  a  strong  ootidauaa  between  PeaC02  and 
P8C02  (r  =.91,  p<.OC101)  and  a  moderately  strong  oonelaticii  between  PtcCt>2  and  PaC02  (r  =.78, 
p  =.(X)3).  Bland-Altman  lest  revcaksl  Uiat  ihe  mean  difference  between  PeiC02  and  PaC02 
(-2.25*3.42)  was  less  than  ihc  difTcreooe  between  PicC02  and  P»C02  (-i.42+4-S2X 
Cmmelmkm:  Our  data  suggests  that  PetC<^2  may  be  a  mote  accurate  surrogate  or  PaCOl 
Howevvi.  PioC02.  as  a  correlate  of  PsC02.  appears  lo  be  a  useful  altemalive  fcr  monitoring 
bcokodynamicalty  aublc  adult  pauents  when  F«C(-I2  is  unavailable  or  impracUcal  (e.g  durmg 
non-invasBve  face  mask  venntatMTn"')  and  shouki  not  be  overiooked. 


Martin  RJ.  Transcutaneous  monitoring:  msuumeatation  and  clinical  applicalica.  Respr  Care 

199(«S;5T7-583. 

Goliknan  MD.  et  al.  Trmscutaoeoos  P<J02  in  aduhs  Anaesdiesia  1982,37  944-946. 

Blaiehetle  T,  et  al.  TnBscultfMous  PC02  and  eod-tidal  PC02  in  vtntilaled  aikihs.  Resfiar  Care 

1992;37  240.248. 

Jnsseos  JP,  et  al.  Transcutaneous  PC02  to  oHaiilor  nonmvasnn  mechanical  venulatkai  m 

aduhs  assessment  of  a  new  tran>BilanoousPC02  device  Cheat  1998,113  768-773 


OF-00-158 


M 


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A      2000 


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#       #  contact  (972)  406-4684 


Respiratory  Care  •  August  2000  Vol  45  No  8 


987 


I  can. 


Introducing  iVentzorfrom  VersaMed 


i  can  manage  all  of  your  ventilator  needs.  Sub-acute.  Home  care.  Emergency  Department.  Transport. 
And  Hospital.  This  makes  me  the  most  versatile,  full-function  ventilator  available. 

In  fact,  i  can  be  the  only  ventilator  you  may  ever  need.  At  less  than  25  pounds,  i  can  perform  invasive  and 
non-invasive  ventilation,  i  can  provide  volume  and  pressure  control  modes  in  SIMV  or  A/C,  even  pressure 
support.  My  self-contained  turbine  produces  sufficient  flow  and  pressure  to  ventilate  a  diverse  range  of  patients. 

What's  more  i  am  PC-based.  That  means  i  can  perform  multiple  tasi<s  simultaneously,  while  providing 
accurate,  rehable  breath-by-breath  delivery  and  analysis,  i  can  display  pressure  and  flow  waveforms,  trending, 
and  data  browsing.  As  well  as  dynamic  and  static  Cl  and  R^^^  plus  other  valuable  weaning  information. 

What's  best  is  my  affordable  price  and  low  cost  of  ownership. 

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at  800.475.9239.  Or  visit  versamed.net. 


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Imagine  it. 


Distributed  to  U.S.  Hospitals  by: 

Siemens  Medical  Systems,  Inc. 


i)f^U  IS  a  trademark  of  \^!rsaM«d. 


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Visit  AARC  Booths  264,  266  In  Cincinnati 


Saturday,  October  7, 3:00-4:55  pm  (Rooms  200.201) 


An  Inlerdisciplinar>  Protocol  for  Ventilator  Weaning  in  Pediatric  Cardiac  Patients 

Jenni  L.  Raake.  BS.  RRT.  Susan  Ryckman,  RN,  MSN, 

Karen  Uzark,  RN,  PhD,  PNP,  Dawn  Sweeney,  MD, 

Peter  Manning,  MD,  Jeffrey  Pearl,  MD, 
Steven  M.  Schwartz,  MD,  David  P.  Nelson,  MD,  PhD 

The  Heart  Center 
Children's  Hospital  Medical  Center,  Cincinnati,  Oh 

Background:  Patients  undergoing  cardiac  surgery  often  require  mechanical  venti- 
lation and  intensive  care  during  their  postoperative  course.  Extended  time  on 
mechanical  ventilation  prolongs  length  of  stay  (LOS)  in  intensive  care  and  the  hos- 
pital. We  developed  an  interdisciplinary  program  involving  anesthesia,  cardiology, 
cardiothoracic  surgery,  nursing,  and  respiratory  care  to  decrease  the  need  for 
mechanical  ventilation,  intensive  care,  and  hospital  care  in  postoperative  pediatric 
cardiac  patients.  Methods:  The  ventilator  weaning  protocol  was  implemented  for 
selected  patients  greater  than  three  (3)  months  without  evidence  of  lung  disease  or 
hemodynamic  instability.  Patients  ranged  between  4  months  and  16.4  years  of  age. 
Retrospective  review  was  performed  for  comparison  with  focus  on  total  mechani- 
cal ventilation  hours,  CCU  LOS,  and  hospital  LOS.  Results:  Patients  enrolled  in 
the  program  experienced  a  reduction  in  MV  hours,  CCU  LOS,  and  hospital  LOS 
(see  table). 


Pre  protocol 
Post  Protocol 


Vent  hours    CCU  days    Hospital  days      n  avg.  age 

12.4  2.6  5.1  20  4.09  years 


8.9 


1.7 


3.75 


20 


6.59  years 


Conclusions:  Patients  enrolled  in  a  ventilator  weaning  protocol  experienced  a 
reduction  in  mechanical  ventilation  time  without  a  need  for  reintubation,  and  a 
reduction  in  intensive  care,  and  hospital  care. 


OF-00-015 


ADAPTIVE  SUPPORT  VENTILATION  REDUCED  PEAK  PRESSURES,  IMPROVED 

BLOOD  OASES,  AND  MINIMIZED  AIR  TRAPPING  IN  A  CHILD  WrTH  STATUS 

ASTHMATICUS. 

Melissa  K.  Brown  RRT,  Susan  E.  Duthie  M.D.  Department  of  Critical  Care,  Children's 

Hospital  and  Health  Center,  San  Diego,  California. 

latiwlMtioa:  Adaptive  Support  Ventilation  (ASV,  Hamilton  OALILEO,  Hamilton 
Medical,  Reno,  NV.)  is  a  closed-loop  ventilator  mode.  It  uses  respiratory  mechanics 
measurements  from  a  variable  orifice  flowmeter  positioned  at  the  patient's  airway  to 
provide  feedback  to  the  ventilator  on  the  patient's  status.  The  Least  Square  Fit  method 
allows  the  simultaneous  measurement  of  Airway  Pressure,  Airway  flow.  Tidal  Volume, 
Compliance,  Resistance,  and  Auto  PEEP.  The  target  tidal  volume  and  rate  is  calculated 
using  Otis'equation  for  the  least  work  of  breathing.  Inspiratory  pressure  and  machine  rate 
are  then  adjusted  by  the  controller  to  meet  the  targets  with  the  secondary  priority  of 
maintairung  tliree  expiratory  time  constants  to  minimize  air  trapping.  ASV  employs  a 
lung  protective  strategy  to  minimize  barotrauma.  The  operator  sets  the  minimum  minute 
volume,  body  weight,  PEEP,  and  ?\(h  Case  Simmary:  The  patient  is  a  13  year  old,  50 
kg  male,  who  is  a  known  asthmatic,  with  a  one  day  history  of  cough  and  URI.  He 
presented  to  an  outlying  Emergency  Department  in  respiratory  distress  and  was  intubated 
when  he  failed  to  improve  with  thoapy.  He  was  transported  to  CHSD  PICU.  Upon 
admission  he  was  placed  on  a  Hamilton  OALILEO  ventilator  with  the  settings  P-SIMV, 
40/5,  rate  12,  hispiratory  time  ( Ti)  of  1.2  seconds,  I:E  ratio  of  1 :3.2,  70/30  heliox. 
/Arterial  blood  gases  on  these  settings  were  pH  7.13,  PCOj  68,  BE  -«.9,  PO2  75.  He  was 
treated  with  IV  Terbutaline,  Atrovent,  IV  Magnesium,  heliox,  and  steroids.  After  24 
hours  the  patient's  blood  gases  were  pH  7.40,  PCO243,  BE  +1.7,  POj90  with  an 
expirstory  minute  volume  (Ve)  of  4.3  l/min.  The  patiem's  ventilator  mode  was  changed 
to  ASV  with  the  settings  of  50kg  body  weight.  95%  minute  volume.  The  ventilator  chose 
reduced  pressures  of  24/5,  rate  of  10-12,  ri«2.0  seconds,  Vt  =400cc,  Ve  of  4.6  l/min  and 
l:E  ratio  varied  between  1:1.5  to  1 :2  to  maintain  zero  air  trapping.  Follow  up  ABG  was 
pH  7.44,  PCD,  26,  BE-6.7,  PO2  94.  The  %  minute  volume  was  weaned  to  85V..  The 
patient  was  weaned  to  70%  minute  volume  ventilation  over  three  days.  After  a  brief  trial 
of  Pressure  Support  of  5,  he  was  successfully  extubated  to  a  heliox  75/25  mask. 
Diicauion:  The  ASV  algorithm  has  as  its  first  priority  a  lung  protective  strategy  to 
minimize  peak  pressures  and  barotrauma.  Its  second  priority  is  to  ensure  adequate  time 
for  complete  emptying  of  the  lung.  This  pediatric  case  report  shows  the  use  of  ASV  in  an 
asthmatic.  It  also  shows  the  ability  of  the  controller  10  tailor  the  settings  to  patient  disease 
with  subsequent  improvement  in  gas  exchange.  There  was  a  reduction  in  peak  pressures 
and  no  air  tr^iping  or  Auto  PEEP  was  observed.  There  are  already  studies  documenting 
ASV's  ability  to  choose  settings  that  provide  adequate  gas  exchange.  There  is  one  stiidy 
showing  ASV's  ability  to  adapt  to  changing  lung  mecharucs.  More  documentation  is 
needed  on  how  the  ventilator  controller  will  respond  to  difficult  to  ventilate  respiratory 
patients  and  its  effect  on  their  outcome. 

OF-00-032 


TDJAL  VOLUME  BASED  THERAPIST  DRIVEN  PROTOCOL  IN  THE  NEONATAL 
INTENSIVE  CARE  UNIT:  A  2  YEAR  REVIEW.  C  Oanli  Rllbms.  R-ItT  ,  Sue  Ciarlariello, 
R.R.T.,  GeoffPeisuup  R.R.T..  The  Claldrens  Medical  C:cnler.  Dayton.  QUO. 

BackgrxMnd:  Literature  supports  overventiiation  contributes  to  ncooaial  lung  damage  aod 
Dltimalely  chroiic  lung  disease.  We  fell  that  a  Iheiapist  diiveii  ventilator  managemcnl  protocol 
based  on  tidal  volume  monitoring  could  proMde  consistent  tidal  volume  delivci)  and  insure  tirody 
weaning  of  ventilator  settings  The  protocol  also  allows  an  easih  understood  approach  to  neonatal 
\entilator  management  for  resident  and  nursmg  education. 

Method:  A  protocol  »-as  developed  emphasiziog  a  udal  volume  based  approach  10  ventilator 
roanagemcnl  Tidal  \ohinKs  were  monilorcd  frequently  and  iaspirator;  pressures  adjusted  to 
mainlained  an  exhaled  TOlnmc  of  5-6cc/kg  and  a  aneiial  blood  pH>7.25  and  a  pC02<70,  Volumes 
were  calculalcd  usmg  measurements  from  the  Dragci  Babylog  venulator  or  the  Bicorc  CP-100 
neonatal  raonilor.  Only  exhaled  volumes  from  rentilator  assisted  breaths  were  used.  If  the 
calculated  volumes  fall  out  of  the  desired  range  the  dierapist  will  make  peak  mspiralon  pressure 
adjusunents  ui  mcrements  of  1-2  cmH20.  If  volumes  are  appropnate.  venlUalor  raic  is  adjusted 
hispiratoi)  time  is  esalualed  using  flow  graphics  to  maximize  volume  dcli\-etcd  witlioul  providing 
an  inspiratoy  hold.  Fi02  is  adjusted  to  maintain  an  oxygen  satundon  of  88-95%  based  on  the 
gestational  age  of  the  patient  A  simple  fkm  chart  was  created  and  posted  in  the  unit  to  explain  the 
pn:per  sequence. 

Rcanlts:  Patients  on  the  psotocol  are  reviewed  monthh'  and  reported  to  the  NICU  quality 
ssmance  committee.  Documentation,  ventilator  paramctos,  ventilator  changes,  blood  gases  and 
complicatioiis  are  reviewed  as  well  as  patients  requiring  re-innibation  Results  are  as  follows 


1998niedical 


Nmnba  Ave. 

of  patients    Gestage 


Ave. 

WL. 


TO 


1998  surgical  j        38 


1999  medical 


97 


1999  surgical  |       28 


33.5 


31.2 


#  Days  on 
protocol 


1.75  days 


Patients  req. 
Re-uaubation  CompMcarions 


2. 15  days 


3.57  days 


I.Sdajis 


*  I-  Pulmonary  interstitial  emphysema,  I-  Ptilmonaiy  hentonhage 

Eipcrience:  All  patients  requiring  re-imubation  are  reviewed  by  the  neonatologist  in  the  quality 
assurance  comminee.  No  paliails  have  been  found  to  have  required  rc-mlubation  due  to 
inappropriate  weaning.  No  complications  have  been  attnbuted  to  ovcrvcnUlation.  Ventilator 
chaiges  and  blood  gas  tesulu  are  reviewed  with  the  resident  staff  daily  tn  rounds  to  provide 
leaming  oppommiues  The  respiratory  therapist  also  anends  patient  rounds  and  discusses 
management  plans  for  ihe  next  24  hours  The  protocol  and  daily  management  rounds  have 
provided  a  svstcmaUc  approach  to  vxntilator  management 

Coacfaisioiu:  We  feci  ventilator  management  has  been  improved  at  The  Childiens  Medical  Ccnta 
in  our  NICU  due  to  implementation  of  the  therapist  driven  ventilator  protocol.  The  protocol 
provides  safe,  prompt  weaning  24  hours  a  day.  Weanini  of  respiratory  settings  is  not  dclajed 
dunng  night  hours  uaiung  for  physician  orders.  We  feel  venulator  management  protocols  work 
wel  m  Ihe  neonatal  mtentive  care  emirnomem  while  still  providing  oppotuiniues  for  medical 
educatioB. 

OF-00-034 


PILOT  COMPARISON  OF  POSITIVE  EXPIRATORV  PRESSURE  (PEP) 
THERAPY  VERSUS  INCENTFVE  SPIROMETRY  IN  ACUTE  SICKLE 
CELL  CRISIS.  B.  Batts.  MPH.  RRT.  Hughes  Spalding  Children's  Hospiul,  L. 
Hsu  MD,  PhD,  Emory  University,  Hughes  Spalding  Children's  Hospital,  &  OA 
Comprehensive  Sickle  Cell  Center,  J.  L.  Rau,  PhD,  RRT,  Georgia  State  University, 
Atlanta,  GA. 

IntrodQCtwn:  Positive  expiratory  pressure  (PEP)  dierapy  offers  an  alternative  to 
ti^ditional  incentive  spirometiy  (IS)  in  preventing  atelectasis  and  subsequent  acute 
chest  syndrome  in  sickle  cell  disease.  Pnrpose:  This  study  examined  the  effect  of 
PEP  therapy  in  comparison  with  conventional  IS  therapy  in  reducing  pulmonary 
complications  and  progression  to  acute  chest  syndrome  (ACS)  in  pediatric  sickle 
cell  patients  admitted  for  pain.  Methods:  Pediatric  patients  with  acute  sickle  cell 
pain  with  or  without  concurrent  fever,  pulmonary  infiltrates,  pneumonia  or  asthma 
were  eligible  and  randomly  assigned  to  receive  either  IS  or  PEP  therapy.  Baseline 
measures  included  vital  signs,  pulse  oximetry  on  room  air,  and  level  of  oxygen 
suppon.  Other  clinical  measures  were  obtained  per  usual  protocol  in  the  hospital. 
All  patients  recruited  were  instructed  in  use  of  either  the  IS  (Coach-2™)  or  PEP 
(TheraPEP™)  device,  both  DHD,  Inc.,  Canastota,  NY.  Witii  IS  therapy,  patients 
were  instiiicted  to  take  10  maximal  inspirations  q.  1  hour  while  awake,  with  5  deep 
breaths  every  15  minutes  approximately.  With  PEP,  patients  were  given  the  same 
frequency  schedule  but  told  to  take  10  normal  or  slightly  larger  breaths,  and 
expiratory  resistance  was  adjusted  to  give  an  approximate  I:E  ratio  of  1  to  3  or  4, 
with  a  pressure  between  10  and  20  cm  H20.  Primary  outcome  measures  were 
length  of  stay  (LOS)  and  patient  satisfaction  widi  the  therapy.  Due  to  the  small 
sample  size  in  this  pilot  trial,  only  descriptive  statistics  are  reported.  Remits: 
Baseline  measures  on  admission  were  similar  for  the  two  groups  except  for  age  and 
gender.  Means  (standard  deviations)  are  given. 

Baseline:  Age         Sex       Resp  Rate     Temp  SsQi  BQi 

IS(n-5)  7.6(4-12)     M-3      24(5.8)       36.0(3.5)      97.2(1.9)      0.21  ((0) 

PEP(n-5)      12.6(9-18)    M-I      23(3.9)       36.8(0.4)      98.6(1.5)     0,22(0.01) 

The  mean  (standard  deviation)  LOS  for  IS  compared  to  PEP  was  4.4  days  (2.3) 
versus  6.6  days  (2.9)  respectively.  For  the  IS  and  PEP  groups,  patient  satisfaction 
scores  were  4.4  (0.5)  and  4.8(0.4)  respectively.  Conclusioiu:  PEP  therapy  was 
accepted  as  well  as  IS,  as  indicated  by  responses  on  ease  of  use  and  comfort,  with  a 
slight  advantage  seen  with  PEP  on  these  scores.  A  larger  n-ial  is  needed  to 
determine  if  LOS  and  other  clinical  outcomes  differ  between  the  two  forms  of 
bronchia]  therapy. 

Study  partially  funded  by  DHD  Healthcare,  Ibc,  Canastota,  NY. 

"^  OF-00-037 


Respiratory  Care  •  August  2000  Vol  45  No  8 


989 


Saturday,  October  7, 3:00-4:55  pm  (Rooms  200,201) 


A  COMPARISON  OF  THE  THERAPEUTIC  EFFECTIVENESS  AND  ACCEPTANCE  OF 
PD&P,  IPV  AND  HFCC  IN  HOSPITALIZED  PATIENTS  WITH  CYSTIC  FIBROSIS 
Sarah  M.  Vafckoiis.  MS.  RRT  and  F.  Hcibert  Douce,  MS,  RRT.  Respiratory  Thcrap>'  Division, 
The  Ohio  State  University,  Columbus.  Ohio;  Robert  Flucke.  AS,  RRT,  David  Filbrun.  AS,  RRT. 
Jill  Ticc,  MS,  RN.  Karen  McCoy,  MD  and  Robert  Castile.  MD,  MS,  Section  of  Pulmonary 
Medicine,  Children's  Hospital,  Columbus,  Ohio 

Badigrouiid:  A  significanc  clinical  manifestation  of  cystic  fibrosis  (CF)  is  abmxmally  abundant 
and  viscous  bronchial  secretions,  which  leads  to  obstruction  of  bronchi  in  the  lungs  and 
{xediqMMes  the  individual  to  chnmic  pulmonary  infections.  BronchopulmtHiaiy  hygiene  is  an 
essential  port  of  the  care  ofpatioits  with  cystic  fibrosis  in  order  to  mhance  mucociliary 
clearance  CuncnUy,  several  modalities  of  therapy  are  available,  including  postural  drainage  and 
perxni&sion  (PD&P).  high  frequency  chest  wall  compression  (HFCC)  and  intrapulmonary 
percussive  vcntilaticxi  (IPV).  The  priraaiy  purpose  of  this  study  was  to  compare  the  therapeutic 
rffectiveness  of  PD&P,  HFCC  and  IPV  b>'  measuring  wet  and  dry  weights  of  sputum  cleared  by 
hospitahzed  patients  with  cystic  fibrosis  using  all  3  modalities.  Using  a  questionnaire,  the 
sccondaiy  purpose  was  to  compare  subject  preference  for  each  form  of  bronchopulmonary 
hygiene,  using  comfort,  convenience,  perceived  efficacy  ami  ease  of  use  as  criteria.  Methods: 
This  was  a  randomized  cross-over  design.  Tw«nty-four  patients  with  CF  hoi^italized  for  an  acut 
pulmonary  exacerbation  completed  the  study  protocol.  Each  p^ent  received  two  consecutive 
days  of  each  form  of  therap>'  in  random  order.  All  therapies  were  delivered  three  times  a  day  for 
thirty  minutes.  All  sputum  iwoduced  during  the  trcatmem  time  was  expectorated  and  collected. 
Sputum  was  collected  for  a  total  of  sixty  minutes:  fifteen  minutes  before  the  treatment  during 
aerosol  dcliN-ery,  during  the  thirty  minute  treatment  time  and  for  fifteen  minute  post  therapy. 
Sputum  was  collected  in  pre-weighed  cups,  wd^ied  wet,  then  dried  in  a  fiS^CVlSCF  own  and 
weighed  again  Participants  rated  their  preferences  for  each  modality  using  Likert-type  scales. 
The  scale  was  established  as  0  being  "not  at  all"  and  4  being  "extremely."  Participants  rated  each 
inodaIit>'  on  comfort,  convenience,  perceived  efficacy  and  case  of  use  as  well  as  overall 
preference.  Mean  wet  and  dry  weights  were  compared  among  modalities  using  analysis  of 
%ariaiu;e  with  repeated  measures  and  Tukey's  Honest  Significant  Difference  post-hoc 
comparison.  Patient  preterences  were  also  compared  using  analysis  of  variaruK  as  well  as 
Friedman's  test  Besults:  The  mean  (SD)  wet  sputum  wcighu  (gm)  were  5.53(5.69)  for  PD&P, 
6.84(5.41)  for  IPV,  and  4.77(3.29)  for  HFCC.  The  mean  wet  sputum  weights  difBawl 
sipiificanUy  (p=0.035).  Wet  ^mtum  weights  reulting  fi-om  IPV  were  sipiificanlly  greats 
those  resulting  from  HFCC  (p  <  0.05),  The  mean  (SD)  dry  sputum  weights  (gm)  were  0.35(0.28) 
for  PD&P,  0.34(0.25)  for  IPV.  aiul  0.26(0. 19)  for  HFCC,  The  mean  diy  sputum  weights  were  nol 
npiificanily  different  The  overall  (reference  ranking  for  each  modality  was  as  follows:  PD&P 
2.00(0.74),  IPV  1,92(0.77),  HFCC  2.04(0.98).  Using  the  preference  raidang  and  its  individual 
aHnponents,  none  of  the  3  bronchopulmonary  hygiene  tecluwpies  was  preferred  over  the  others 
by  the  subjects  Conchisions:  We  conclude  that  HFCC  and  IPV  are  at  least  ss  effective  as 
PD&P  for  ho^italized  patients  with  CF  and  that  each  of  the  3  modalities  was  equally  acceptable. 
Ths  significantly  greater  wet  weights  of  sputum  i^oduced  by  IPV  can  most  likely  be  explained 
by  the  fact  that  this  modahty  delivers  an  aerosol  and  percussion  simultaneously  through  a 
mouthpiece.  The  aatwol  and  salivation  related  to  the  use  of  the  mouthpiece  may  increase  the 
moisture  content  of  the  ^lutum  samples  collected  using  this  device.  This  difference  is  not 
dinically  significant.  The  results  of  this  study  suggest  patients  should  have  the  (^)portuttiQ/  to 
expeheacc  each  tho^py  and  to  choose  their  preferred  modali^. 


COMPARISON  OF  VENTILATOR  LENGTH  OF  STAY  (VLOS)  IN  PEDIATRIC 
PATIENTS  USING  A  PATIENT-DRIVEN  PROTOCOL  (PDF)  VS  A  PHYSICUN- 
DIRECTED  PROTOCOL:  A  PILOT  STUDY. 

R.  D.  Restrepo,  MD,  RRT,  Georgia  State  University  (GSU)  and  Children's  Health  Care 
of  Atlanta  al  Egleslon  (CHOA),  L.Thomas.  EdD,  RRT  (GSU),  C.  Spainhour.  RRT, 
J.  Fortenberry.  MD,  J.  Stockwell,  MD,  (CHOA).  Atlanta,  GA. 

BACKGROUND:  Patient-driven  protocols  (PDF's)  have  been  widely  used  to  guide  sev- 
eral aspects  of  respiratory  care  including  mechanical  ventilation.  Several  studies  have 
focused  specifically  on  weaning  from  mechanical  ventilation  in  the  adult  population.  The 
use  of  POP'S  in  these  patients  resulted  in  less  expensive  care  and  without  detriment  to  the 
quality  of  care.  Few  studies,  however,  have  reported  the  use  of  PDP's  in  mechanically 
ventilated  pediatric  patients.  PURPOSE:  To  compare  the  ventilator  length  of  stay  (VLOS) 
using  a  PDF  vs  physician-directed  protocol  in  a  tertiary  pediatric  ICU.  METHODS:  His- 
torical review  of  ventilated  patients  both  prior  to  (physician-directed)  and  post  implemen- 
tation of  the  PDP.  Patients  with  head  injury  were  excluded  from  the  study.  PRISM  and 
Murray  Lung  Injury  scores  were  obtained  prior  to  initiation  of  mechanical  ventilation.  The 
VLOS  was  divided  in  four  subsequent  phases:  adjustment:  time  to  make  changes  on  the 
ventilator  settings  to  keep  SpO:  >  0.9,  pH  >  7.25,  PaCOz  <  80  mmHg  immediately  after 
intubation;  weaning:  time  necessary  to  have  the  patient  on  minimal  settings;  minimal  set- 
tings: time  on  arate=  10-12,  FiO2=0.25,  PEEP  <  5  cniH20;  spontaneous  mode:  time  on 
either  volume  support  (VS)  or  pressure  support  (PS)  before  extubalion.  The  study 
endpoinl  was  extubation.  RESULTS:  34  patients  were  reviewed,  17  on  each  group.  Age 
in  years  averaged  3.7.  Independent  t-tests  for  equality  of  means  were  used  to  compare 
VLOS  on  both  groups.  Means  '  standard  deviations  are  reported  In  the  table  below. 


PRISM 


Murray 


VLOS  (days) 


Physician  n=  17 
PDP        n=17 


10  ±6.6 
8.8  ±6.1 


2.9  ±  2.8 
2.3  ±  2.9 


6.0  ±  6.47 

2.3  ±2.47*        *p<0.05 


^PtivikttnBPDPi 

. 

i  m                            1 

.-.*.. 

■  -zm  \ 

CONCLUSIONS:  These  data 
suggests  that  the  use  of  a  PDP 
may  significantly  reduce  VLOS 
in  pediatric  patients  when  com- 
pared to  the  traditional 
physician-directed  approach. 
The  use  of  PDP  allowed  more 
rapid  changes  on  the  initial 
phase  of  ventilation  that  could 
potentially  reduce  the  time 
patients  are  exposed  to 
relatively  high  initial  ventilator 
parameters. 

OF-00-051 


USE  OF  SHORT  RELEASE  TIME  IN  AIRWAY  PRESSURE  RELEASE 
VENTILATION.  A  PEDIATRIC  CASE  STUDY. 

James  Martin.  RRT.  Dennis  M.  Super,  MD,  Jason  Poland,  MD,  Terry  Novotny,  RRT,  Maroun 
Mhanna,  MD,  Departments  of  Pediatrics,  and  Pulmonary  Services,  MetroHealth  Medical  Cen- 
ter, Cleveland.  OH 

INTRODUCTION:  Airway  Pressure  Release  Ventilation  (APRV)  is  a  mode  of  respiratory 
support  that  incorporates  an  intermittent,  time  cycled  reduction  in  airway  pressure  during  con- 
dnuous  positive  airway  pressure  (CPAP).  During  APRV.  CPAP  is  maintained  allowing  the 
patient  to  breathe  spontaneously  without  a  significant  fluctuation  in  airway  pressures.  Sponta- 
neous breathing  at  elevated  pressures  (P  high)  with  a  prolonged  inspiratory  time  (T  high)  pro- 
motes oxygenation.  A  rapid  change  to  exhalation  (T  low)  to  a  lower  pressure  (P  low)  allows  for 
p}assive  exhalation  and  induces  carbon  dioxide  elimination,  this  is  also  known  as  release  time. 
We  sought  to  use  APRV  on  a  patient  with  Acute  Respiratory  Distress  Syndrome  (ARDS)  to 
improve  oxygenation  and  ventilation  by  prolonging  the  inspiratory  time  (T  High)  and  shorten- 
ing the  expiratory  time  (T  Low)  allowing  for  a  quick  dump  of  exhaled  gases.  CASE 
SUMMARY:  A  2  and  a  half  year  old.  1 7  Kg,  male  with  mental  retardation  and  cerebral  palsy 
was  admitted  to  the  Pediatric  Intensive  Care  Unit  for  Respiratory  Synclial  Virus  (RSV)  induced 
respiratory  failure,  requiring  intubation  and  mechanical  ventilatory  support.  On  admission  his 
Chest  X  ray  revealed  a  LLL  infiltrate  which  evolved  within  a  few  days  into  ARDS.  Initially  the 
patient  was  volume  ventilated  on  the  Drager  Dura  2  Ventilator  in  the  SIMV  /  PS  mode  with 
Auto-Flow.  Later  a  rapid  deterioradon  in  the  padent's  oxygenation  despite  bag-valve  and  con- 
vendonal  ventilation  warranted  a  trial  of  APRV.  Initially  the  release  time  was  set  at  2.2  seconds 
then  reduced  to  0.2  seconds  resulting  in  a  marked  improvement  in  oxygenation  (see  chart).  The 
patient  tolerated  well  the  short  release  time  and  prolonged  T  high  without  further  sedation  or 
use  of  neuromuscular  blockade.  5  days  later  the  patient  was  successfully  extubated. 


Mode 

FiOj 

Ti/Te 

End  Pressure 

Peak 

MAP 

SpO, 

MV 

SIMV  /  PS 

.50 

0.7/2.3 

PEEP  8 

31 

14 

94 

2.6 

APRV 
Long  Release 

1.0 

1.8/2.2 

PLOW  8 

28 

16 

95 

2.8 

ABG    pH7.37     P,C02  69    P.022  78    (P.Oa  /  F,02  =  69)                                                  | 

APRV 
Shon  Release 

1.0 

1.5/0.2 

PLOW  8 

26 

22 

100 

2.7 

ABG    pH  7.32    P.CO2  65     P.O2  250  (P.Oj  /  F,0:  =  250|                                                  1 

Ti  =  inspiratory  time,  Tc  =  expiratory  time.  MV  =  minute  ventilation 

DISCUSSION:  The  use  of  APRV  with  a  short  release  time  improved  oxygenation  and  main- 
tained ventilation.  Both  long  and  short  release  times  produced  peak  pressures  lower  then  con- 
ventional vendlaiion.  APRV  seems  to  be  a  safe  and  effective  alternative  to  conventional 
mechanical  ventilation  in  children  with  ARDS  secondary  to  RSV. 

OF-(X)-065 


VOLUME  MONITORING  ACCURACY  OF  CRADLE  TO  THE  GRAVE 
VENTILATORS  IN  THE  NEONATAL  RANGE, 

Richard  D.  Branson  BA.  RRT.  Robert  S.  Campbell  RRT,  FAARC.  University  of 
Cincinnati,  Department  of  Surgery,  231  Bethesda  Avenue,  Cincinnati,  OH. 

Background:  In  recent  years,  ventilators  capable  of  operating  in  the  neonatal  to 
adult  range  (cradle  to  the  grave)  have  been  introduced.  We  evaluated  the  accuracy 
of  tidal  volume  (Vt)  measurement  of  three  of  these  ventilators  during  pressure  con- 
trol ventilation  (PCV)  compared  to  a  traditional  neonatal  ventilator. 
Method:  Four  venUlators  were  studied:  1 )  Drager  Babylog,  2)  Drager  E-4  with 
NeoFlow,  3)  Siemens  300,  and  4)  Hamilton  Galileo.  All  were  set  to  deliver  Vts  of 
4,  16,  and  32  mL  in  the  PCV  mode.  Changes  in  Vts  were  accomplished  by  increas- 
ing pressure  or  flow  (Babylog).  FIO2  was  set  at  0.60,  PEEP  at  4  cm  H2O,  and  fre- 
quency at  28  breaths/min.  Ventilators  were  connected  to  a  neonatal  lest  lung  (Bio- 
Tek  VT-1)  set  at  compliance  and  resistance  combinations  of  1  mL/cm  H2O,  3 
mL/cm  H2O,  20  cm  H2O/L/S,  and  50  cm  H2O/L/S.  Wjs  were  measured  with  a  cali- 
brated, pneumotachograph  (Hans  Rudolph  #001)  and  signals  recorded  to  a  PC  for 
analysis  using  Excel.  At  each  condition  (3  Vxs,  4  compliance  &  resistance  combi- 
nations) the  Vt  of  5  breaths  were  recorded  from  the  calibrated  system  and  the  Vj 
display  of  each  ventilator.  With  the  Siemens  300,  tests  were  repeated  with  and  with- 
out correcUon  for  circuit  compliance  of  0.25  mL/cm  H2O.  PIP  was  also  recorded. 
Data  were  analyzed  using  a  students  T-test  and  bias  and  precision  determined  using 
the  method  of  Bland  and  Altman.  Percent  error  was  calculated  as  actual  VT  -  mea- 
sured Vr/actual  Vj.  Results:  Table  I  shows  results  from  a  set  VT  of  4  mL,  compli- 
ance of  1  mL/cm  H2O,  and  resistance  of  50  mLycmH20/L/s. 


Actual  Vt 

Vt  ventilator 

PlP(cm  H2O) 

%  error 

Babylog 

4.0  ±0.02 

3.48  ±  0.08 

9.1  ±0.2 

0.13 

E.4 

4,0  ±0.01 

4.04  ±  0.03 

8.4±0.3 

0.01 

Siemens 

4.0  ±0.08 

4.46  ±  0.09 

5. 7  ±0.6 

0.11 

Galileo 

4.0  ±  0.03 

5.40  ±0.54 

9.2  ±  0.04 

0.35 

Conclusions;  Accuracy  of  Vt  measurement  with  each  of  the  ventilators  tested  was 
good.  There  were  differences  in  accuracy  between  instruments,  but  the  clinical  rel- 
evance of  these  differences  would  appear  minor,  OF-00-073 


990 


Respiratory  Care  •  August  2000  Vol  45  No  8 


Saturday,  October  7, 3:00-4:55  pm  (Rooms  200,201) 


INTRAPULMONARY  PERCUSSIVE  VENTILATION  IN  THE  TREATMENT  OF  THE 
SMOKE  INHALATION  IN  THE  PEDIATRIC  PATIENT. 
Kathleen  Deakins  RRT.  Robert  Chatbum  RRT,  FAARC 

INTRODUCTION:  Smoke  inhalation  injury  to  the  aiiways  can  cause  insult  to  the 
pulmonary  and  other  organ  systems.  The  severity  of  the  insult  is  dictated  by  the 
pulmonary  involvement.  Pulmonary  edema  can  be  induced  by  changes  in  the 
microcirculation  and  activation  of  polymorphonuclear  cells  along  with  the  pfoductlon  of 
free  radical  oxygen  molecules.  The  most  serious  pathologic  change  occurring  from 
smoke  inhalation  is  the  reduction  of  respiratory  epithelium  and  the  development  of 
tracheobronchial  casts.  Intrapulmonary  Percussive  Ventilation  (IPV)  has  been  used  in 
the  adult  population  on  patients  with  smoke  inhalation  to  promote  mobilization  of 
retained  secrelions  to  remove  tracheobronchial  oasts  and  improve  atelectasis  caused  by 
obstruction  from  secretions.  An  increase  in  oxygenation  has  been  associated  with  the 
reduction  of  ventilation/perfusion  mismatch  as  atelectasis  improves. 

CASE  SUMMARY:  The  subject  is  a  five  year  old  female  who  presented  to  our  institution 
with  smoke  inhalation  evidenced  by  soot  mariungs  on  the  face  The  patient  received 
CPR  due  to  canjiopulmonary  an^st,  was  intubated  and  placed  on  mechanical 
ventilation.  Initial  chest  radiographs  revealed  peribronchial  thickening  and  RUL  collapse. 
Secretions  suctioned  v»ere  described  as  cartxinaceous.  thin  and  in  small  quantities.  Five 
hours  post  admission.  IPV  was  initiated  via  endotracheal  tube  using  9cc  of  normal  saline 
lavage  IPV  peak  pressure  was  set  equal  to  the  that  of  the  ventilator  (25  cmhbO).  The 
IPV  frequency  was  set  at  160  cycles  per  second.  The  volume  of  carbon-containing 
secretions  obtained  during  suctioning  increased.  Tracheobroncial  casts  requiring 
additional  lavage  during  suctioning  were  also  observed  Secretions  became  dear  after 
six  treatments  (24  hours  latere  Chest  radiographs  showed  an  improvement  in 
atelectasis.  Mechanical  ventilation  was  discontinued  76  hours  after  admission.  The 
patient  was  transfen^d  out  of  the  pediatric  intensive  care  unit  on  day  four  and 
discharged  from  the  hospital  on  day  six.  Discharge  from  the  hospital  was  accomplished 
without  need  for  additional  respiratory  support. 

DISCUSSION:  Previous  studies  done  at  our  institution  (Respir  Care  1999;44:124a)  have 
shown  that  IPV  is  a  safe  and  effective  treatment  that  improves  atelectasis  in  pediatric 
intubated  patients.  IPV  has  been  shown  to  mobilize  and  facilitate  the  removal  of  retained 
secretions,  and  increase  the  deposition  of  aerosolized  particles  while  improving 
oxygenation.  In  this  case,  the  administration  of  IPV  was  used  as  an  adjunct  for  airway 
clearance,  improving  mobilization  and  removal  of  secretions  We  believe  this  facilitated 
weaning  from  mechanical  ventilation,  by  improving  atelectasis. 

In  summary,  IPV  seemed  to  be  an  important  adjunctive  treatment  for  this  patient  with 
smoke  inhalation  injury.  np  nn  1 1 7 


SELECTION  OF  APPROPRIATE  VENTILATION  PARAMETERS: 
OUTCOMES  ACCORDING  TO  MODE  OF  VENTILATION 

Kathletn  Deakins  RRT.  RDbeo  L.  Cluttnini  RRT  FAARC.  aiul  Timolh)  R.  Myeis  BS  RRT 
Rainbow  Babies  &  Children's  Hospital  Clewland,  OH 
INTROIlllCTION:  Pauenis  often  require  mechanical  ventilation  due  to  impaired  gas  exchange 
in  various  disease  stales.  The  goal  of  mechanical  ventilation  is  to  achieve  adequate  ventilation 
aul  oxygenation  without  causing  advene  effects  on  the  cardiovascular  5>-stem  or  lung  tissue 
damage   Respiratory  Care  Practitioners  (RCP)  pla)  an  important  role  in  initiating  mechanical 
ventilation  that  includes  selection  of  an  appropriate  mode  of  ventilation  The  purpose  of  Ihia 
soxi)-  was  to  evaluate  the  ability  of  Uk  RCP  lo  sdccl  an  appropriate  mode  of  ventilation  and 
settings  to  achieve  adequate  gas  exchange  confirmed  by  blood  gas  analysis  METHODS  Two 
hundred  tvro  patients  admitted  to  our  PICU  and  NICU  were  placed  on  mechanical  ventilators 
during  a  ihree-monUi  period  (1-8  to  4-8-00).  RCPs  completed  a  Mcdiamcal  Ventilation 
InitiaUon  Data  Sheet  for  each  patienc  ventilated.  DaU  collected  included  age,  weight,  diagnoeil, 
initial  ventilator  settings,  mode  of  ventilation  and  initial  blood  gas  results  following  ventilatioa. 
Enrolled  patients  that  required  reintubalioo  were  excluded  from  data  recollection.  Blood  gas 
values  were  analyzed  separately  by  pH/  PCO:  for  ventilation  and  POj/  SaOj  for  oxygenation. 
Mode  of  ventilation  was  separned  inlo  categories  of:  Presairc  Control  (PC).  Volume  Control 
(VC).  Dual  Mode  (DM),  and  High  Frequency  Ventilation  (HFV)  Ventilation  panmeteis  were 
judged  appropriau:  if  Uk  first  set  of  blood  gas  values  were  within  acceptable  ranges  Respiratory 
alkalosis  was  defined  as  pH  >  7.45  and  PaCOj  <  35  torr  for  all  patients  in  all  modes  Respiratory 
acidosis  was  defined  as  pH  <  7  35  and  PaCOj  >  45  lorr  (for  PICU  patienls;  pH  <  7  25  for  NICU 
patients).  Hyperoxic  slatiis  was  defined  as  Pad  >  100  torr  (NICU  patienls  only).  Hypoxic  slami 
was  defined  as  PaOj  <  55  toir  (NICU  patienls)  and  SaO,  <  93%  or  SvO,  <  70%  (PICU  patienls). 
RESULTS:  The  Table  below  categorizes  the  percentage  of  patients  by  acid-base  and  oxygenaliot 
slatils  for  each  mode  of  ventilation.  Non-percenlagc  numbers  are  patients  that  did  not  have  add- 
faase  status  or  oxygenation  slams  assessed  (excluded  from  percentage  calculations),  Twc  patienls 
in  Dual  mode  are  not  i~-i"/i^  (1  acidotic  and  I  normal  add  base,  2  normal  oxygenation). 
Add-BaacStatti  HQ  V£  ££ 

oBtaJoUc  (n-14)  8%  5%  9^4 

normat(n-lSl)  61%  81%  «J% 

acidotic  (,1-23)  31%  14%  9% 

no  gas  or  capillary  gas  ^  =  13}  0  7  5 


OiyteulioB  Sana 

HFV 

1£ 

E£ 

hyperoxic  ^"27) 

- 

31% 

normal  (n  -123) 

«(!% 

90% 

52% 

hypoxic  fn''24) 

31% 

10% 

17% 

no  gas  or  capilltBygas 

0 

7 

21 

CONCLUSION;  Successful  initiation  of  mechanical  ventilation  was  better  achieved  in 
conventional  modes  (VC  and  PC)  for  boih  \'cnlilation  and  oxygenation.  Optimization  of  blood 
gas  parameters  by  con\'entional  modes  for  ventilation  was  similar,  but  optimization  of  blood  gas 
paiameteis  for  oxygenation  was  best  achieved  in  Volume  Dmin^.  OF-00-120 


EVALUATION  OF  PROTOTYPE  -ADLTLT"  CIRCUIT 
FOR  PEDIATRIC  MECHANICAL  VENTILATION 

Timothy  R.  Mvcrt  BS.  RRT.  Michael  Tracy  RRT  and  Robert  Chatbum  RRT,  FAARC. 
Rainbow  Babies  &  Chiidren's  Hospital.  Cleveland.  OH. 
UtrodnctMHi.  The  goal  of  mechanical  ventilation  is  adequate  gas  cxdiange  wiUi  minimal  lung  tissue 
damage  and  minimal  circulatory  disturbance.  Tidal  vohimc  (Vt)  selection  in  pediatric  volume 
vcniilaiion  is  dependent  on  disease.  Set  vcntilaior  vtilumes  now  equal  delivered  vohimes  at  the 
patient  airway,  due  to  the  fact  that  the  ventilator  circuit  has  its  own  compliance  (compliance  of 
tubing  material  plus  compressibility  of  gas)  and  resistance.  This  results  in  set  voltunes  being  higher 
than  dehvrred  volumes  due  to  the  effective  circuit  compliance.  Circuit  manufocturers  have 
traditionally  produced  three  circuits  |ae<Hiatal.  pediatric  and  adult)  to  offset  for  compressiUe  volume 
loss.  Fisher-Paykcl  has  developed  a  prototype,  "adult"  ventilator  circuit  that  purportedly  delivers  safe 
pediatric  Vt.  Wc  hypothesized  mimmal  difference  m  circuit  compliance  between  the  Fisher-Paykel 
and  our  standard  Baxter  pcdiatnc  circuit  priat  to  use;  and  with  simulated  ventilation  condibons.  no 
clinical  diflcrence  in  delivered  Vt  under  hi^  (high  resistance;  tow  compliance)  and  normal  load 
(high  ccHnpUance;  low  resistance).  Methods:  Circuit  oMi^liancc  was  measured  by  connecting  4 
circuits  ofeach  brand  10  a  pressure  maiwmeter  and  injected  calibrWed  volumes  (20-100  ml  at  20  ml 
increnKnts).  To  test  our  hypothesis  of  no  clinical  difference  in  the  delivered  pcdiatnc  Vt,  5  circuits 
of  each  brand  were  tested  under  simulated  ventilation  using  an  Ingmar  lomg  Simulator  as  our  patient. 
A  HamiltMi  Galileo  and  a  Fisfaer-Paykel  humidifia  served  as  our  ventilator  system  Rand(»nly  set  Vt 
(80  to  300  ml  <U  10-20  ml  increments)  were  tested  with  resulting  exhaled  volumes  measured  by  the 
Galileo's  flow  sensor  software.  We  tested  Vt  under  nomial  (high  compliance;  low  resistance)  aixl 
high  (high  resistance;  low  compliance)  load  conditions.  Results:  Pressure  volume  plots  yielded 
circuit  compliances  of  1 .59(i  0.52)  cmHAml  (Fisber-Paykel)  and  0.98  (+  0  07)  cmH;0/ml  (Baxter). 
Volume  delivery  was  not  different  between  the  two  circuits  under  nonnal  load  (p  >  0.05).  Under  high 
load,  the  Fisher-Paykel  circuit  delivered  less  volume  (p  <  0.05).  Data  below  are  mean  Vt  difference 
(1 1  SD)  unda  normal  and  high  load  conditions. 


3    -3 

I: 


I'llllil 


s  8  8  S  S  «  I  g  ?  i  §  I  g  «  g  I S 

SMTdHVOtJHMlfll) 


SafTi«aValimM|nAl 

:  The  Fisher-Paykel  circuit  demonsnated  comparable  pedianic  lidal  volumes  under 
DOrmal  wofic  conditions.  Due  10  a  sligfaler  higher  ckcuit  compliance,  pediatric  tidal  wlumes  under 
tugh  work  conditions  was  2-6  ml  lower,  but  the  difference  is  nol  expected  to  be  clinically  impoilant 
The  new  Fisher-Paykel  cneuil  can  be  cuiKidercd  a  universally  applicable  for  all  patients. 

OF-00-122 


ACAPELLA  VS  FLUTTER:  PERFORMANCE  COMPARISON 

Teresa  A.  VcHsko  RRT.  Julie  DeFiorB  BSEE,  Robert  L.  Chatbum  RRT,  FAARC 
Case  Western  Reserve  University,  Cleveland,  Ohio 

Ocillatory  positive  expiratory  pressure  (PEP)  using  the  Flutter  device 

(Scandlpharm  Inc.)  has  been  shown  effective  in  secretion  retnoval  (J  Padlatr 

1994:124:689).  A  new  device,  the  Acapella,  (DHD  Healthcare  Corp.),  has 

become  available.  In  the  Flutter,  a  steel  ball  vibrates  in  a  cone  causing  airflow 

vibrations.  The  Acapella  uses  a  counterweighted  plug  and  magnet  in  place  of  a 

steel  ball.  It  comes  in  two  sizes,  one  for  patient's  with  expiratory  flows  of  >15 

..^  „ L/min  (green  in  color)  and  one  for 

wmi  Raw** 


0 

25 

.-20 

i§15 

5 
0 


4       • 


flows  <15  L/min  (blue  in  color).  We 
hypothesize  that  the  Acapella  and 
Rutter  would  produce  similar  mean 
pressure  (PEP),  osdilatofy  pressure 
amplituiJe  and  frequency  over  a 
range  of  flows.  METHODS: 
Oscillatory  amplitude,  PEP  and 
frequency  were  measured  with  data 
acquisition  software  designed  for 
blood  pressure  measurement 
(Biosystems  XA,  Buxco  Electronics 
Inc.)  The  sample  rate  was  200  Hz. 
Data  were  collected  as  mean  values 
every  second  over  a  5  second 
sample  period  as  flow  through  the 
device  was  varied  from  5  to  30  L/min, 
in  5  L/min  increments.  The  devices 
were  adjusted  to  give  low  and  high 
range  oscillations  (Flutter  angle  at 
0  °  and  30  °,  Acapella  by  dial  setting). 
F       B      o  F       B      G      RESULTS:  Data  in  figure  are  mean  + 

standard  error  over  all  flows  (F  = 
Flutter,  B  =  blue  Acapella,  G  =  green  Acapella)  The  Acapella  gave  less 
consistent  wavefonns  than  Flutter  at  low  range  but  was  more  consistent  than 
Fkjtter  at  high  range.  Both  devices  gave  similar  amplitudes  and  frequencies,  but 
the  Acapella  produced  a  wider  range  of  PEP  When  data  were  plotted  against 
flow,  both  devices  tended  to  increase  amplitude  and  PEP  but  not  frequency  with 
increasing  flow.  CONCLUSIONS:  The  Acapella  and  Flutter  are  flow  operated 
oscillatory  PEP  devices  with  similar  performance  characteristics.  The  Acapella 
is  not  gravity  (ie,  positionally)  dependent  and  is  therefore  easier  to  adjust 

OF-00-123 


Respiratory  Care  •  August  2000  Vol  45  No  8 


991 


Saturday,  October  7, 3:00-4:55  pm  (Rooms  200,201) 


EVALUATION  OF  AIRWAY  PRESSURE  BY  MANOMETRY  IN 
TRACHEOSTOMIZED  CHILDREN  USING  PASSY  MUIR  VALVE.  C 
Mna-r  MP.  T  Newlnn  RRT.  E  Nussbaum  MP.  Department  of  Pediatrics, 
Miller  Children's  Hospital,  Long  Beach,  CA. 

BACKGROUND:  The  use  of  the  Passy  Muir  Spealcing  Valve  (PMSV)  has 
been  shown  to  improve  speech,  help  improve  sense  of  smell,  improve 
swallowing,  reduce  the  risk  of  aspiration,  facilitate  secretion  management,  and 
expedite  tracheal  decannulation.  Our  hypothesis  is  that  the  use  of  the  Passy 
Muir  Valve  may  actually  improve  lung  ftmction  and  provide  a  CPAP  effect  in 
the  airway,  which  can  be  measured.  This  may  replace  the  need  for  home 
CPAP  in  some  patients.  METHODS  AND  MEASUREMENTS:  We 
prospectively  evaluated  39  patients,  with  an  a^  range  of  1  month  to  18  years 
(median  36  months,  SEM  10.22  months).  All  tracheostomy  tubes  were  non- 
cuffed  Shiley  or  Bivona.  Five  of  the  39patienls  were  unable  to  use  the  Passy 
Muir  Valve  due  to  an  inadequate  air  leak  around  the  tracheostomy  tube 
resulting  in  distress.  A  Bivona  side  port  adapter  was  placed  on  the 
tracheostomy  tube  and  a  PMSV  was  placed  on  top  of  the  side  port  adapter. 
Oxygen  tubing  was  connected  ftom  the  side  port  adapter  to  a  Novametrix 
Pneumogard  1230A,  (Novametrix,  Wallingford,  CT)  a  pressure  monitoring 
device  with  a  pressure  wave  form  printout.  RESULTS:  The  airway  pressure 
(P„)  generated  at  rest  in  the  patients  who  tolerated  the  PMSV,  was  less  than 
25cm  H2O.  Patients  who  did  not  tolerate  the  PSMV,  hadP.„greaterthan25cm 
H2O  at  rest.  Four  patients  who  did  not  tolerate  the  valve  showed  immediate 
stair  stepping  of  pressures  leading  to  popping  off  of  the  valve.  In  patients 
who  tolerated  the  PMSV,  P,„  mcreased  to  the  range  of  15  to  80cm  H2O  with 
sigh  breaths  and  >  100cm  HjO  with  coughs.  However,  their  P„  returned  to  a 
baseline  ofless  than  25cmH20  usually  within  a  couple  of  breaths.  In  four  of 
the  patients  who  had  documented  bronchomalacia  by  bronchoscope  and  who 
required  CPAP  of  6  -  8cm_s  H2O  to  maintain  oxygen  saturation  m  normal 
range.  The  use  of  PMSV  replaced  the  need  of  a  CPAP  machine. 
CONCLUSION;  The  P,„  generated  with  the  use  of  PMSV  are  measurable,  and 
generally  higher  than  physiologic.  P,w  <  25cm  H2O  at  rest  appears  to  be  safe 
in  the  patients  that  we  studied.  The  CPAP  effect  generated  by  the  use  of 
PMSV  help  eliminate  the  need  of  CPAP  machine  in  some  patients  with 
bronchomalacia. 


OF-00-148 


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992 


Respiratory  Care  •  August  2000  Vol  45  No  8 


Saturday,  October  7, 3:00-4:55  pm  (Rooms  213,214) 


THE  PERFORMANCE  OF  A  NEW  PULSE  OXIMETER  GENERATION  TO  MOTION 
AND  LOW  PERFUSION  SIMULATION  DURING  A  DESATURATION  PROCEDURE 

Chrisioph  Homberger,  PhD.  Haitmui  Gehring,  MD*,  Holgcr  Matz,  ME,  Reiner  Sch%cfer,  MD*. 
Ewald  Konecny.  PhD.  Peter  Schmucker.  MD* 

Institui  fxir  Medizintechnik.  *ICtinik  fur  Anasthesiologie,  Medizinische  Universitat.  L^beck,  Germany 
Introduction:  A  number  of  new  generation  pulse  oximeters  (PO)  were  compared  while  motion 
(1.2)  and  reduced  perfusion  (3)  were  simulated.  Both  artefacts  significantly  impaired  putse 
oxinKter  recordings  and  can  lead  to  abortion  of  measurement  (4.5).  However,  it  seemed  appro- 
priate to  simulate  the  artefacts  either  alone  or  in  combination  in  such  a  way.  that  the  limits  of 
pulse  oximeter  signal  detection  were  challenged  while  the  levels  of  peripheral  arterial  oxygen 
saturation  were  being  altered. 

Methods:  Ten  healthy  volunteers  participated  after  written  infonned  consent  and  approval  by 
the  Ethics  Committee  were  obtained.  The  PO  battery  on  the  left  (test)  hand  consisted  of  a  Datex- 
Ohmeda  3900.  Agilent  Technologies  (formeriy  Hewlett-Packard)  CMS  monitor  software  Rev. 
B.O.  a  Nellcor/Mallinckrodt  N-395,  and  a  Schiller  OX- 1  (identical  to  an  IVY  2000)  incorporating 
Masimo  SETTM  technology.  3  Nellcor/Mallinckrodt  N-3000  served  to  represent  the  established 
generation  of  pulse  oximeters,  one  on  the  test  hand  and  (wo  as  control  monitors  for  the  desaiura- 
tion  procedure  on  the  right  (reference)  hand.  During  four  repeated  desaturation  procedures 
between  75  and  100^  SpO;,  motion,  reduced  perfusion  and  the  combination  of  these  artefacts 
were  simulated.  Before  the  simulation,  an  induced  hypoxemia  without  intervention  served  as 
control.  Motion  was  simulated  using  a  motor-driven  tilt  table  which  moves  the  forearm  and  hand 
of  the  participants.  The  Participants  were  also  asked  to  scratch  and  tap  their  fingers  on  a 
platform.  For  introducing  low  perfusion  without  venous  congestion,  a  balloon  was  inflated  above 
the  brachial  artery  of  the  test  arm.  Balloon  inflation  reduced  finger  perfusion,  as  indicated  by  a 
perfusion  index  measured  on  the  test  and  reference  fingers.  The  Sp02  data  of  the  PO  were 
recorded  continuously  and  the  differences  between  test  and  reference  values  (ASpO;)  were  eval- 
uated and  ordered  with  respect  to  the  established  four  categories  of  interventions. 
Results:  Table  I  shows  the  percentage  of  time  (in  %).  where  the  eriOT  (E)  was  in  the  range -3  < 
A  SpO:  <  3  (E  3)  and  -6  <  ASpO;  <  6  (E  6)  respectively.  Results  are  given  for  the  four  categories 
of  inter\ention.      


Interventions 


N3000 


No  motion,  normal  perfusion 
No  motion,  low  perfusion 
Motion,  normal  perfusion 
Motion,  low  perfusion 


N395  AgUeot       D-O3900      IVY  2000 


99.9 

100 

98.2 

99.8 

95.7 

99.1 

95.4 

98.8 

88.5 

98.2 

90.9 

95.5 

89.7 

95.4 

88.0 

95.8 

78.6 

91.6 

47.5 

73.6 

60.7 

86.9 

45.7 

73.6 

98.3  100  97.7  99.9 

89.9  97.3  93.1  99.4 

84.5  89.3  79.0  91.5 

56.8  79.4  54.9  72.8 


E3    E6 


E3     E6 


ConchisioRs:  The  established  interventions  fialfilled  the  claimed  hierarchy  of  artefact  simulation 
up  to  the  limits  of  PO  signal  extraction.  The  Nellcor  N-395  demonstrates  the  best  performance, 
followed  by  the  D-0  3900  and  the  IVY  2000. 

References:  1.  Barker  SJ  et  al.:  Anesthesiology  1999;  91:A58t;  2.  Russel  GB  et  al.:  Anesthesi- 
ology 1999: 91  :A582;  3.  Russel  GB  et  al.:  Anesthesiology  1999;  91:A584: 4.  MoUer  JT  et  al.: 
Anesthesiology  1993;  78:436-44,  5.  Reich  DL  et  al.:  Anesthesiology  1996;  84:859-64 

OF-00-018 


THE  BUS  AND  PRECISION  OF  A  NEW  GENERATION  OF  PULSE  OXIMETER 

Hartmut  Gehring.  MD.  Christoph  Homberger.  PhD*.  Holger  Matz,  ME*.  Reiner  Sch^fcfer,  MD. 
Ewald  Konecny.  PhD*.  Peter  Schmucker.  MD 

Klinik  fijr  Anasthesiologie.  *Institut  fiir  Medizintechnik.  Medizinische  Universitat.  Lubeck. 
Germany 

Introduction:  A  new  generation  of  pulse  oximeter  (PO)  has  addressed  requirements  for  an 
improved  performance  during  motion  (I)  and  low  perfusion  (2,3)  artefact  simulation.  However, 
the  validation  of  screening  accuracy,  bias  and  precision  against  the  gold  standard  oximetry  has 
yet  to  be  proven. 

Methods:  Nine  healthy  volunteers  participated  after  written  informed  consent  and  approval  by 
the  Ethics  Committee  of  the  Medical  University  of  Luebeck  were  obtained.  A  24  gauge  radial 
artery  cannula  was  placed  in  the  non-dominant  hand  for  arterial  blood  sampling  using  a  dry  hep- 
arinized  2  ml  Monovette"  LH  (Sarstedt,  Germany).  The  reference  oximeters  were  an  OSM-3'*' 
(Radiometer,  Copenhagen)  and  a  270  COnDximeler  (Ciba-Coming).  where  Sa02  samples  were 
measured  in  a  random  fashion.  The  PO  battery  consisted  of  a  Dalex-Ohmcda  3900.  Agilent 
Technologies  (formerly  Hewlett-Packard)  CMS  monitor  software  Rev.  B.O.  a  Nellcor/ 
Mallinckrodt  N-395.  and  a  Schiller  OX- 1  (identical  to  the  IVY  2000)  incorporating  Masimo 
SET™  technology.  3  Nellcor/Mallinckrodt  N-3000s  served  to  represent  the  established  genera- 
lion  of  pulse  oximeter  and  provided  a  control  for  the  desaturation  procedure.  The  SpOi  data  of 
all  devices  were  recorded  continuously  during  a  desaturation  procedure  where  the  monitored 
saturation  was  between  70  and  i00%.  To  allow  stable  conditions  for  all  the  pulse  oximeters, 
plateaus  were  established  at  saturation  steps  of  5%. 

Results:  Table  1  shows  the  bias  (mean  of  differences  between  SaOj  and  Sp02)  and  precision  (± 
lsd)as  well  as  the  Pearson's  correlation  coefficient  rand  the  R'-values  from  the  data  of  the 
tested  PO  battery. 


N  3000     N  3000  (mean)  N  395        Agilent        D-O  3900       l\\  2000 


N 

Mean 

±lsd 


.0.6 

.0.1 

1.4 

1.2 

0.98 

0.98 

0.96 

0.97 

.0.9 

1.2 

-1.5 

0.8 

1.8 

1.6 

1.7 

1.8 

0.97 

0.97 

0.97 

098 

094 

0.94 

0.95 

0% 

Conclusions;  All  PO  tested  in  this  investigation  fulfilled  the  high  standard  of  accuracy  within 

the  nmge  -2  <  A  S^pOj  i  2. 

References:     1.  BaricerSJetal.:  Anesthesiology  I999:91:A58I 

2.  Russel  GB  et  al.:  Anesthesiology  1999;  91:A582 

3.  Russel  OB  et  al.:  Anesthesiology  1999;  91:A584 

OF-00-019 


Cut  Samnury:  Vx  of  Respiroaics  NPPV-HeBox  System  For  COPD  Eiactrbatioa- 

Fimk  Ausian  RRT.  Midiad  Polise  MD.  Temple  University  Hospital,  UMDNJ-Respiraiay 
C»e  Propam  &  Wesi  Jersey  Hospital,  Philadelphia,  Pamqdvania  &  Camden,  New  Jersey. 

A  «3-yearK)ld  man  with  chronic  obsmictivt  pulmonary  disease  (COPD)  was  admincd  to 
the  Emergency  Department  (ED)  complaining  of  severe  dyspnea.  The  respiratory  rate  was 
28  brtaihi'min,  blood  presst«  190/120  mm  Hg,  pulse  144  htoin  and  oral  iemperan«e 
9«.6°  F.  Laboratory  results  revealed  a  hemoglobin  16.5  g/dl,  white  blood  cell  count 
15.2/cmm  and  serum  theophylline  14.8  ug-'ml.  Chest  auscultatioo  revealed  expiiatoty 
wheezes  bilaterally.  Severe  accessory  muscle  use  was  observed-  Artonal  blood  gas  analysis 
(ABGA)  on  oxygon  at  6  L/min  by  nasal  cannula  at  4:00  PM  revealed  pH  7.07,  PaC02  86 
tan,  Pa02  52  icht.  Pbarmocologic  imerventioo  included  intravenous  aminopbylline,  solu- 
medrol  and  three  back-to-back  Albuterol  nebulized  treatments  withou  improvement 
Repeated  ABGA  at  4:30  PM,  pH  7.09,  PaC02  82  torr.  Pa02  56  lorr.  In  view  of  this 
situation,  noninvasive  positive  pressure  ventilation  (NPPV)  using  a  Re^sirooics  S/T-D 
Syston  (Munysvillc,  PA)  was  placed  on  the  patient  using  a  nasal  mask.  The  settings  were 
as  follows.  Inspiratory  Positive  Pressure  (IPAP)  10  cm  H20,  Expiratory  Positive  Pressure 
(EPAP)  3  cm  H2Q,  rate  12  breatfas/min,  oxygen  at  6  Umin.  Repeated  ABGA  at  5:00  PM, 
pH  7. 1 1 ,  PaC02  78  torr.  Pa02  63  torr.  Patient  observation  revealed  a  rate  of  22  breaths/min 
with  moderate  accessory  muscle  use.  NPPV  setting  was  increased  to  IPAP  12  cm  H20, 
EPAP  6  cm  H20.  02  remained  at  6  L/min.  Repeated  ABGA  at  5:30  PM,  pH  7.20,  PaC02  68 
lar,  Pa02  72  torr.  Clinical  observation  revealed  continued  accessory  muscle  use  and 
pitiem  complaining  of  bemg  "unable  to  catch  my  breath".  In  view  of  this  siluaticn,  an  H 
cylinder  of  70%  Helium-30%  Oxygen  (so-called  heliox)  was  introduced  into  the  ffeatment 
plan  via  the  nasal  mask.  He  contimjed  on  6  L/min  oxygen  aid  12  L/min  of  heliox.  (We 
estimated  that  in  a  proportional  relationship.  6  LAnin  equals  44%  02,  diluting  the  helium  to 
56%  but  still  providing  a  less  dense  mixntre,  reduction  in  tuhulance,  and  lessened  work  of 
breathing.)  Repeated  ABGA  at  6:00  PM,  pH  7.38,  PaC02  50  torr,  Pa02  76  torr.  CHiiical 
cteervation  presemed  a  cahncr  patient,  treathing  a  rate  of  18/min  and  verbalized 
Treathing  easier".  He  ranained  oo  NPPV  until  7:00  PM  and  was  changed  to  02,  50% 
Vennii  Mask.  ABGA  was  repealed  at  8:00  PM,  pH  7.37,  PaC02  45  torr,  Pa02  91  torr.  The 
patiem  was  admined  to  the  hospital  and  disdiaiged  six  days  later  without  inciden. 
INKimk»:  This  case  report  describes  a  patient  with  COPD  exaceitation  and  ventilatory 
fiuhire  who  experienced  greaia  tolerance  of  NPPV  and  improved  ABGA  with  the 
mtroduaion  of  heliox.  On  admission,  he  received  aggressive  treatment  without  timely 
response.  In  view  of  ventilatory  allure,  NPPV  was  used,  moderately  improving  ABGA.  In 
light  of  this,  heliox  was  added  as  an  adjimct  to  NPPV.  Within  30  minutes  of  o«tment  die 
patient's  clinical  presentation  improved.  Lessened  accessory  muscle  use  was  noted  and 
patient  verbaUzed  a  greater  degree  of  ccmfbrt  and  toloance  fcr  IPPV.  as  well  as  improving 
ABGA.  It  could  be  inferred  that  helium  with  1/7*  the  density  of  nitrogen  Sdlitaled  a 
rtducticB  in  the  work  of  breathing,  thus  "buying"  time  for  pharmacologic  impact  to  occur. 
Coaclusioa:  Though  fiinher  snidy  is  needed  to  test  the  efSdency  IPPV-Hcliox  method 
before  widespread  use  can  be  seen,  the  outccane  presented  in  this  case  is  encooaging. 
Equipment  and  techniques  that  help  reduce  the  risk  of  invasive  v«entiladoD  arc  important  if 

qialiiy  and  cost  outcomes  are  to  be  assured.  ^, 

*^ '  OF-(X)-040 


LABORATORY  EVALUATION  OF  FOUR  DISPOSABLE  CPAP  VALVES. 

Kristy  M.  Bates*  CRTT.  Robert  S.  Campbell  RRT.  FAARC.  Jay  A.  Johannigman 
MD.  Fred  A.  Luchette  MD,  Kenneth  Davis  Jr.  MD.  Sandra  L.  Miller  MD,  Scott  B. 
Frame  MD,  Richard  D.  Branson  RRT.  Respirator}'  Care  Department*,  The  Uni- 
versity Hospital  and  Division  of  Trauma/Critical  Care,  University  of  Cincinnati 
College  of  Medicine, 

Introduction:  Disposable  CPAP  valves  arc  fixed  or  adjustable  threshold  resistors 
(TR).  An  optimal  TR  will  produce  a  constant  pressure  in  the  face  of  varying  flows. 
We  evaluated  four  commercially  available  CPAP  valves  in  the  laboratory  for  mainte- 
nance of  set  airway  pressure  at  various  constant  flow  rates.  Methods:  Airway 
pressure  generated  with  fixed  CPAP  valves  (5.  10  15.  20  cmH20)  from  two  manufac- 
turers (Caradyne,  Vital  Signs)  were  evaluated  at  constant  flow  rates  of  5.  15,  30,  60, 
and  90  L/min.  Airway  pressure  generated  with  adjustable  CPAP  valves  from  two 
manufacturers  (Mercury.  Interlech)  were  also  tested  at  the  same  flow  rates.  The  mini- 
mum and  maximum  pressure  generated  with  each  adjustable  CPAP  valve  was  mea- 
sured at  60  L/min.  Accuracy  of  labeled  pressure  settings  for  each  adjustable  CPAP 
valve  was  assessed  at  each  flow  rate.  Effect  of  varying  flow  on  pressure  generated 
with  adjustable  CPAP  valves  was  tested  by  adjusting  each  to  a  measured  pressure  of 
10  cmH20  at  60  L/min  and  measuring  the  pressure  maintained  at  all  other  flow  rates. 
Pressure  and  flow  were  measured  with  a  calibration  analyzer  (RT-200).  Results: 
Table  1  reveals  the  pressure  (mean  ±  SD)  measured  at  each  flow  rale  for  each  CPAP 
valve  set  at  10  cmH'G. 


Table  1. 

5LPM 

15LPM 

30LPM 

60LPM 

90LPM 

Caradyne 

10.2  ±0.1 

10.5  ±0.1 

10.6  ±0.1 

10.2  ±0 

9.9  ±0.1 

Vital  Signs 

9.5  ±0.1 

9.8  ±  0.3 

9.8  ±0.1 

9.3  ±0.1 

9.6  ±0.2 

Mercury 

5.0  ±1.2 

6.6  ±1.9 

8.1  ±0.6 

10.0  ±0 

11.4  ±0.9 

Intertech 

4.1  ±0.19 

5.6  ±0.14 

7.3  ±0.37 

10.0  ±0 

11.8±0.1 

Each  fixed  CPAP  valve  provided  pressure  within  10%  of  the  label  pressure  and  were 
unaffected  by  varying  flow  rate.  Each  adjustable  CPAP  valve  provided  significantly 
higher  pressure  than  indicated  by  the  label.  Adjustable  valves  are  poor  TRs  as 
evidenced  by  variability  in  the  pressure  as  flow  is  varied.  Although  adjustable  CPAP 
valves  allow  adjustment  between  0  and  20  cmH^O.  the  minimum/maximum  pressure 
at  60  L/min  was  6.6/31.1  for  the  Mercury  and  5.31/25.9  for  the  Intertech. 
Conclusion:  The  fixed  CPAP  valves  tested  are  accurate  and  reliable  TRs.  The 
adjustable  CPAP  valves  tested  are  noi  accurately  labeled  and  provide  inconsistent 
pressiu^  as  flow  is  varied.  Airway  pressure  should  be  monitored  continuously  during 
clinical  use  of  adjustable  CPAP  valves.  OF-00-071 


Respiratory  Care  •  August  2000  Vol  45  No  8 


993 


Saturday,  October  7, 3:00-4:55  pm  (Rooms  213,214) 


BITE  BLOCKS:  REVIEW  OF  AVAILABLE  EXPERIENCE.  Ed  Hoisineton.  RRT. 
Lucy  Kester.  MBA,  RRT,  James  K.  Stoller,  M.D.,  Cleveland  Clinic  Foundation,  Cleve- 
land, Ohio. 

Introduction:  Because  inadveneni  biting  on  the  endotracheal  tube  with  i^sultant  tube 
occlusion  is  a  common  problem  associated  with  oral  intubation,  devices  called  "bite 
blocks"  have  been  developed  and  have  been  available  since  the  1970's.  Despite  their 
ubiquitous  use.  little  attention  has  been  given  to  the  successes  and  potential  hazards 
associated  with  bite  blocks.  In  the  context  of  reported  past  bite  block-related  complica- 
tions (i.e..  tube  occlusion)  and  a  recent  complication  we  wimessed  (i.e..  cinching  of  the 
pilot  balloon  line),  we  reviewed  the  spectrum  of  available  bite  block  devices  and  report 
experience  regarding  their  use.  Study  Purpose:  To  review  available  bite  block  devices 
and  available  experience  regarding  their  advantages  and  disadvantages.  Methods:  We 
conducted  a  search  of  the  literature  over  the  past  10  years,  consulted  respiratory  therapy 
text  books  and  the  AARC's  Buyer's  Guide,  and  explored  the  internet  for  information 
regarding  the  effectiveness  of  available  bile  blocks  to  prevent  oral  endotracheal  tube 
occlusion  as  well  as  associated  complications  of  their  use.  Results:  Until  recently,  the 
two  most  commonly  used  methods  to  prevent  biting  endotracheal  tube  are  insertion  of 
tongue  depressors  wrapped  with  gauze  or  tape  ( 1 ,  below)  and  the  Guedel  oral  airway  (2, 
below).  Although  the  use  of  gauze  and  tape  has  the  advantage  of  low  expense,  potential 
hazards  include  absorption  of  oral  contaminants  and  bacteria,  and  allergic  reactions  to 
the  tape.  To  our  knowledge,  only  two  commercially  manufactured  bite  blocks  are  cur- 
rently available.  One  device,  equipped  with  a  handle  for  insertion  (3,  below)  is  placed 
between  the  patient's  molars  to  keep  pressure  off  the  endotracheal  tube.  A  second 
device  (4,  below)  wraps  around  the  endotracheal  tube,  thereby  keeping  pressure  off  the 
tube.  Our  recent  experience  with  this  latter  device  suggests  that  caution  should  be  exer- 
cised when  securing  a  wrap-around  device  to  ensure  that  over-tightening  does  not  crimp 
the  endotracheal  tube  or  the  pilot  balloon  line. 


3  Bile  block  w-ithiuiulie 


i.  Wnp-an>und  bice  block 


Conclusions: 

1 .  Use  of  a  bile  block  is  often  essential  for  preventing  occlusion  of  the 
endotracheal  tube  by  the  patientis  biting. 

2.  Our  survey  suggests  that  however  simple,  available  devices  are  few  and  can 
incur  risks,  including  crimping  the  endotracheal  tube  and  the  pilot  balloon  line. 

3.  These  complications  invite  consideration  of  other  devices  designed    OF-00-083 
to  avert  the  current  hazards. 


COMPATIBILITY  OF  THE  RESPIRTECH  PRO  IN  THE  MRI  UNIT 

Mario  Romano.  RCP.  Mercy  General  Hospital,  Medical  Intensive  Care 
Unit,  Sacramento,  CA,  USA 

BACKGROUND:  Because  most  medical  facilities  do  not  have  MRI 

compatible  ventilators,  MRI  studies  on  intubated  patients  are  frequently 
delayed  until  the  patient  is  extubated.  Although  there  are  mechanical 
ventilators  that  are  MRI  compatible,  the  cost  for  purchasing  them  for  MRI 
use  only  is  impractical,  especially  in  light  of  the  limited  number  of 
intubated  patients  needing  an  MRI    This  paper  examines  the  RespirTech 
PRO.  a  single  patient  use  fully  automatic  resuscitator,  and  how  it 
functioned  during  an  MRI  study  in  a  General  Electric  1.5  MRI  unit 

METHODS:  One  clinically  stable  72-year  old  male  patient  in  need  of  an 
MRI  of  his  head  was  placed  on  the  automatic  resuscitator  with  extension 
kit.  The  patient  was  set  in  a  control  mode  of  16  BPM  with  a  ventilating 
pressure  of  25  cm-HaO  and  a  liter  flow  of  40  LPM  at  a  FiOa  of  100%. 
The  patient  was  placed  in  a  General  Electric  1 .5  MRI  unit,  and  the  device 
functioned  vwthout  incident.  No  attraction  to  the  magnet  was  noted. 
Image  artifact  was  minimal  and  was  limited  to  the  patient  tee  area, 
allowing  for  a  clear  picture  of  the  head.  The  patient  tolerated  ventilation 
well,  and  his  vital  signs  are  summarized  in  the  graph  below. 

RESULTS:  Patient  Vital  Signs: 


Tx 

HR 

BP 

OjSat. 

FiOaSet 

Pre  MRI 

85 

98/51 

98% 

100% 

During  MRI 

77 

102/54 

96% 

100% 

DISCUSSION:  No  significant  changes  in  vital  signs  or  O2  saturation  were 
noted  vnth  the  use  of  the  automatic  resuscitator  The  patient  appeared  to 
tolerate  the  procedure  with  no  adverse  affects  No  attraction  to  the  MRI 
magnet  was  noted  and  artifact  was  limited  to  the  patient  tee  area 

CONCLUSIONS:  The  RespirTech  PRO  can  be  a  safe  and  cost  effective 
ventilator  for  use  in  the  MRI  room  vnthout  the  need  to  purchase  capital 
equipment.  More  experience  v»ith  the  use  of  this  automatic  resuscitator  in 
transporting  patients  to  other  areas  of  the  hospital  can  establish  it  as  a 
safe  and  cost  effective  transport 
Supported  by  VORTRAN  Medical  Technology  1,  Inc. 


OF-00-135 


THE  EFFECT  OF  NEBULIZER  OPERATION  ON  MEDICATION 
TEMPERATURE:  COMPARISON  OF  A  NOVEL  PIEZOELECTRIC  NEBULIZER 
WITH  A  TRADITIONAL  ULTRASONIC  NEBULIZER 
James  B.  Fink,  MS,  RRT,  FAARC,  and  Paul  Uster,  PhD 
AeroGen,  Inc.,  Sunnyvale.  CA 

Background:  Ultrasonic  nebulizers  heat  medications  while  generating  aerosols.  The 
effect  of  heat  on  proteins  has  been  well  established,  with  large  variance  between 
molecules.  Proteins  and  liposomes  may  be  aggregated  or  denatured  secondary  to  heat 
ormechanical  methods  of  nebulization.  (Pharmaceutical  Research  1995.12:53-9),  We 
compared  a  novel  piezoelectric  nebulizer  with  a  Siemens  345  UltraSonic  Nebulizer^" 
and  the  effect  of  operation  on  medication  temperature.  While  the  ultrasonic  nebulizer 
applies  high  frequency  vibration  directly  to  the  medication,  the  AeroNeb  uses  an 
aerosol  generator  (AG)  comprised  of  a  dome-shaped,  metallic  plate,  (0.5cm  in  diame- 
ter, perforated  by  precisely  sized  and  tapered  holes  mounted  on  a  ceramic  piezoelectric 
disc,  which  vibrates  when  low  voltage  currents  are  applied.  Methods:  To  determine 
temperature  changes  of  medication  during  use.  we  operated  both  nebulizers  with 
I  OmL  of  solution,  beginning  with  an  ambient  temperature  of  23±  1  "C.  monitored  with  a 
digital  thermistor  placed  in  the  medication  reservoir.  Results:  After  20  minutes  of 
operation,  there  was  a  24*C  increase  in  temperature  in  the  medication  reservoir  with 
the  Siemens  345,  resulting  in  a  maximum  medication  temperature  of  57'C.  In 
contrast,  there  was  no  significant  increase  in  medication  temperature  with  the  AeroNeb 
during  normal  operation.  Conclusions:  Unlike  the  standard  ultrasonic  nebulizer,  the 
novel  piezoelectric  aerosol  generator  did  not  increase  the  temperature  of  the 
medication  during  operation.  Before  nebulizing  proteins  or  liposomes  with  any  ultra- 
sonic nebulizer,  u.sers  should  contact  the  drug  manufacturer  to  determine  the  effect  of 
heat  or  ultrasonic  nebulization  on  drug  efficacy. 


OF-00-138 


ACCURACY  OF  THE  MICRO  PLUS  HANDHELD  SPIROMETER  FOR  THE  MEA- 
SUREMENT OF  FVC,  FEV,  AND  PEER.  David  C.  Shelledv.  PhD.  RRT.  Teny  S. 
LeGrand,  PhD,  RRT,  Stefani  Stevenson,  CRT,  and  Robert  Evans,  CRT.  The  University 
of  Texas  Health  Science  Center  at  San  Antonio,  San  Antonio,  Texas. 
INTRODUCTION:  The  Micro  Plus  (MP)  [Micro  Direct  Inc.,  Uwiston,  ME]  is  a  com- 
pact, battery  operated,  handheld  spirometer  for  the  measurement  of  FEV  | ,  FVC  and 
PEER.  We  compared  the  MP  to  the  SensorMedics  2450  (SM)  10  determine  the  accuracy 
of  the  MP.  METHOD:  Prior  to  data  collection,  the  MP  and  SM  were  caUbrated  accord- 
ing to  factory  recommendations.  We  then  compared  inline  and  separate  measures  at  1 , 
1.5,  2.0, 2.5  and  3.0  L  using  a  calibration  syringe  to  verily  that  placing  the  MP  inline  with 
the  SM  did  not  affect  the  volume  readings.  Fifteen  normal  subjects,  aged  1 8  to  60,  then 
performed  3  FVC  maneuvers  with  the  MP  and  SM  inline.  Mean  values  were  compared 
using  the  t-test  for  dependent  samples.  Pearson-product  moment  correlations  were  cal- 
culated and  regression  equations  were  evaluated  to  determine  the  slope  and  intercepl  of 
the  regression  line.  Means  (SD)  and  ranges  were  calculated  for  the  differences  between 
paired  nssults  between  insuoiments  10  provide  measures  of  bias  and  imprecision.  Limits 
of  agreement  were  then  calculated  as  the  mean  difference  ±  2  SD.  RESULTS:  Mean 
(SD)  values  for  FVC,  FEV,  and  PEER  were: 


FVC 

FEV, 

PEER 

Micro  Plus 

3,99(1.0) 

3.19  (.83) 

5.98  (2.25) 

SeasorMedics  2450 

4.17(1.13) 

3.42  (.91) 

6.23(2.19) 

Thene  were  significant  differences  (p<  0.0001 )  between  the  MP  and  SM  for  FVC.  FEV| 
and  PEER.  Comilation  coefficients  for  FVC.  FEV,  and  PEFR  were  1=0.979.  r=0.9996. 
and  n=0.9888  (p<0.0001 ).  Regre,ssion  equations  were:  FVC  MP  =  0..344  -i-  0.873  SM; 
FEV,  MP  =  0.044-i-0.920SM;PEFRMP  =  0.359+  I.0I7SM.  The  mean  (SD)  differ- 
ence for  the  paired  results  (bias)  for  FVC  was  0. 19  (0.25)  with  a  range  of  -0.89  to  0.5 1 ; 
FHVi  was  0.23  (0.08).  range:  0  1 2  to  0.08;  and  PEFR  was  0.25  (0.34).  range:  - 1 .66  to 
.53.  The  limits  of  agreement  between  the  SM  and  MP  were  -  0.3 1 3  to  -tO.687  for  FVC; 
0.077  to  0.382  for  FEV,  and  -  0.424  to  -(fl.926  for  PEFR.  CONCLUSIONS:  FEV,. 
FVC  and  PEFR  values  obtained  via  the  MP  correlated  significantly  with  SM  values. 
There  were  small,  but  statistically  significant  differences  between  mean  MP  and  SM  val- 
ues and  the  MP  tended  to  underestimate  FVC.  FEV,  and  PEFR.  We  believe  the  MP  can 
be  useful  for  monitoring  and  bedside  evaluation,  however,  it  may  not  be  suitable  as  a 
diagnostic  spirometer. 


OF-00-140 


994 


Respiratory  Care  •  August  2000  Vol  45  No  8 


Saturday,  October  7,  3:00-4:55  pm  (Rooms  213,214) 


PERFORMANCE  OF  NEW  DEMAND  OXYGEN  DELIVERY  SYSTEMS 
IN  A  SIMULATION  OF  LOW  FLOW  OXYGEN  USE 

Peter  Bliss  BM£.  Roben  McCoy  RR I    Vallc>-  Inspired  Produces,  Savage  MN 

Backf^round:  Demand  oxygen  delivei>  systems  (DODS)  are  m  widespread  use  in 
conjunction  with  oxygen  cylinders  or  liquid  oxygen  pntable  devices  via  nasal 
cannula  DODS  are  designed  to  deliver  oxygen  during  all  or  portions  of  inspiration 
to  fn'ovide  a  comparable  FIO2  to  continuous  flow  oxygen  (CFO)  and  to  conserve 
ox>gcn.  I^ach  model  of  device  delivers  oxygen  in  a  differcni  mannCT.  We 
evaluated  the  FIO:  delivery  capabilities  and  ox>-gcn  conservation  of  new  DODS 
compared  to  continuous  flow  oxygen  and  one  currently  available  model 
Methods:  An  apparatus  was  constructed  to  simulate  the  nares,  conducting  airways 
and  an  alveolar  chamber  widt  a  machined  'nose',  flex  tube  (ISO  ml  of  dcadspace) 
and  one  limb  of  a  mechanical  test  lung  (TTL-Michigan  Instruments).  Three 
respiratory  patterns  ( V"r=520  ml,  f=  1 5,20.26/rain,  I  E^  1  ;2.  decelerating  flow 
wave)  were  generated  in  the  "respirating"  limb  of  the  test  lung  as  driven  b>'  a 
linked  ventilator  (7200    Puhtan  Bennett)  The  FlOj  delivery  to  the  alveolar 
chamber  was  measured  at  1 ,2  and  4  L/min  settings  by  a  Ceramatec  model  OM- 
25A  oxy^oi  analyzer.  Oxygen  pulses  from  die  DODS  were  measured  by  a  mass 
flowmeter  (Model  4040  -  TSl).  Devices  tested  were  Mallinckrodt  CR-50, 
Mallinckrodr  Helios,  Victor  02N  Demand  II    The  ratio  of  oxygen  delivery 
(increase  over  21%)  to  CFO  was  calculated  for  each  device. 
ReuiHs:  FiO:  measured  (%)  at  each  resinratoiy  pattern  and  device  setting.  Also, 
the  ratio  or  oxygen  delivery  to  CFO  is  shown  (mean  of  all  settings  md  resptmory 
patterns)  for  each  device. 


Drvict 

Dd. 
Ratio 
Meu 

F101,%                                              1 

lJbg> 

20  bun 

>*bi»i           1 

1 

2 

4 

1 

2 

4 

1 

2 

4 

CFO 

1 

261 

30.6 

37,S 

24.1 

273 

33.5 

23.1 

249 

29.3 

CUM 

1  19 

26  5 

2<8 

336 

25.9 

278 

3U 

25.4 

268 

29.7 

HdiM 

84 

25! 

266 

293 

24  1 

25.9 

28.0 

240 

25.3 

27.7 

02N 

DOMMlU 

91 

25  1 

27.4 

321 

246 

263     296 

24.1 

25.2 

27.8 

All  DODS  triggered  their  oxygen  delivery  as  tnticipa^.  There  is  variability  in 
FIO3  between  devices  at  each  setting  and  with  each  respiratory  pattern     Alrtiough 
these  three  DODS  opcralc  m  a  similar  manner,  there  is  a  difference  of  +  19%  to 
-14%  m  the  amount  of  oxygen  entermg  the  lung,  relative  to  CFO. 
Conciasion:  DODS  settings  must  be  made  to  meet  tfaerqxutic  goals  rather  than 
expected  compahsoos  between  devices  or  to  continuous  62  use. 


OF-00-155 


Postgraduate  Course: 


Win  A  Free  Trip  to  the 

2000  AARC  International 


Respirati^  C 


Cincirmati,  Ohio,  October  7-10 

All  you  have  to  do  is  request  information  from  ttie  advertisers  in  ttiis  Issue. 

How  to  Enter 

To  receive  Information  from  advertisers  in  this  issue,  simply  fill  out  the 
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registration  to  the  46th  International  Respiratory  Congress.  To  enter  you 
must  circle  the  numbers  for  the  product  information  that  you  would  like 
to  receive,  and  provide  all  the  Information  requested.  Cards  may  also  be 
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may  be  requested  by  e-mail  at  lnfo@aarc.org. 


Developing  and 
Enhancing  Pulmonary 
Rehabilitation  Services 


GO 

3 
o 


a 

o' 

s- 

a 

< 

% 
o 

3 
en 


October  6 
Cincinnati  Convention  Center 


If  you  need  training  in  the  administrative  aspects  of  starting  and  operating  out- 
patient pulmonary  rehabilitation  services  in  a  hospital  setting,  then  this  postgraduate 
course  is  designed  especially  for  you.  Just  come  one  day  early  to  the  International 
Respiratory  Congress  and  take  advantage  of  this  opportunity. 

Attendance  is  limited  to  50,  and  you  must  pre-register  by  September  15  —  first 
come,  first  served.  The  course  is  approved  by  the  AARC  for  continuing  education 
credits.  Registration  fee  is  $145  for  AARC  members  and  $245  for  nonmembers.  A 
registration  form  is  provided  in  the  Congress  Program,  or  you  can  call  the  AARC  at 
(972)  243-2272  or  register  online  at  www.aarc.org. 


Respiratory  Care  •  August  2000  Vol  45  No  8 


995 


o 


A^< 


'^HfS^:, 


WPA.Cf  Instrumentation,  Inc. 

7  Fairfield  Place?  West  Caldwell,  NJ  07006 

b  Circle  125  on  product  info  card 


Tel:    973.882.1212 


Sunday,  October  8, 2:00-3:55  pm  (Rooms  200,201) 


"INTRAPULMONARY  PERCUSSIVE  VENTILATION  -  IPV*  -  A  NEW 
METHOD  IN  THE  TREATMENT  OF  LUNG  DISEASE" 


Joaauim  de  Paula  Barrato  Fonseca.  MD,  Ph  D  -  Anibal  de  Oliveira 
Fortuna,  MD  -  Chstiane  Barreto  Fonseca  Antunes  de  Oliveira.  MD  - 
Mariei  Pavoni,  PT.  Unidade  Respiratbria  (Fundafflo-Hospital  Albert 
Sabin)  -  Campinas,  SSo  Paulo,  Brasil. 

BACKGROUND:  The  goal  of  our  presentation  was  to  compare  this 
novel  IPV  technique,  to  traditional  methods  (IPPB  and  CPT  -  Chest 
Physiotherapy),  through  the  objective  analysis  of  60  outpatients 
diagnosed  with  obstructive  pulmonary  diseases,  randomly  divided  in 
three  groups:  20  patients  treated  with  IPV  as  (Group  A);  20  patients 
treated  with  IPPB  as  (Group  B);  and  20  patients  treated  by  CPT  chest 
physiotherapy  with  traditional  extrathoracic  percussion  and  postural 
maneuvering  as  (Group  C).  There  were  tvira  daily  therapeutic  sessions 
for  each  group,  with  data  collection  and  clinical  evaluation, 
documenting  four  (4)  consecutive  days.  All  patients  in  each  of  the 
three  groups,  had  their  spirometric  values  and  Hb02  saturation's 
measured  and  compared  before  and  after  each  session,  this  data 
was  employed  as  a  baseline  for  their  individual  clinical  evaluations. 
Additionally,  sputum  volume  was  measured  after  each  treatment.  In 
the  IPV  group  (A),  all  the  spirometric  parameters  revealed  a  significant 
improvement  over  the  baseline  values  of  (18.6%).  The  IPPB  group  (B) 
demonstrated  spirometric  confirmed  parameter  improvements  of 
(6.4%).  The  CPT  group  (C)  demonstrated  non-remarkable  findings  in 
certain  parameters  (VC,  FEVO  and  average  in  others  (PEF,  PEFjs- 
75%),  with  only  a  sight  improvement  over  the  comparative  baselines 
(5.0%).  Patients  in  the  IPV  group  (A),  had  a  faster  overall 
improvement,  when  compared  with  the  other  two  groups.  The  final 
statistical  analysis  demonstrated  a  significant  improvement  among 
patients  treated  with  the  IPV  technique  in  group  (A),  when  compared 
to  traditional  methods  employed  in  group  (B)  IPPB  and  group  (C)  CPT. 


OF-00-007 


EFFECT  OF  EXTENDING  CIRCUIT  CHANGE  INTERVALS  ON  VENTI- 
LATOR-ASSOCIATED PNEUMONIA  RATES 

Thomas  Smith  BS  RRT.  Virginia  DeFilippo,  MS  RRT.  Patricia  Reagan-Cirincione, 
PhD,  Dorothy  Mazon  RN  MPH    Yale-New  Haven  Hospital,  New  Haven. 

Connecticut 

Background:  Previous  studies  have  suggested  that  changing  ventilator  circuits  at 
seven-day  intervals  vs.  the  current  standard  of  48  hour  intervals  has  no  impact  on 
ventilator  associated  pneumonia  (VAP)  rales.  We  evaluated  the  effect  on  VAP 
rates  of  changing  circuits  from  a  three  time  per  week,  Monday,  Wednesday,  Friday, 
(MWF)  schedule  to  weekly  intervals  at  our  institution. 

Method:  The  study  was  conducted  in  six  intensive  care  units  (ICU).  The  ICUs 
were  arbitrarily  divided  into  two  groups.  The  Pediatric  ICU,  Neurosurgical  ICU, 
and  Surgical  ICU  were  grouped  and  designated  as  Group  I.  Medical  ICU. 
Coronary  Care  Unit,  and  Cardiothoracic  ICU  were  grouped  and  designated  as 
Group  II.  Ventilator  circuits  were  changed  every  seven  days  for  alternating  two- 
month  periods  in  each  group.  Epidemiology  and  Infection  Control  staff  monitored 
the  VAP  rates  for  each  ICU  and  were  blinded  to  the  circuit  change  frequency  dur- 
ing the  study. 

During  the  first  two  month  period,  circuit  change  intervals  in  the  Group  1 
ventilators  were  extended  from  a  three  time  per  week  (MWF)  schedule  to  a  once 
per  week  schedule.  During  that  period.  Group  II  ventilators  had  circuit  change 
interval  of  three  times  per  week,  (MWF).  During  the  second  two  month  period, 
Group  II  ventilators  had  circuit  change  intervals  extended  to  every  seven  days  while 
Group  1  reverted  back  to  the  three  times  per  week  schedule.  During  the  third  two- 
month  period,  the  circuit  change  interval  schedule  of  the  first  two-month  period 
was  repeated.  Epidemiology  and  Infection  Control  staff  collected  data  on  VAP 
rates  in  compliance  with  National  Nosocomial  Infection  Surveillance  (NNIS)  crite- 
ria. One  way  analysis  of  variance  (ANOVA)  was  performed  for  statistical  analysis. 

Results: 


Circuit  Change  Interval 


3  times  per  week 
Total  Ventilator  Days  2279 

Total  VAP  54 

Mean  VAP  Rate  25.42 


once  per  week 

2338 
50 
22.3     p=0.64 


Conclusion:  There  was  no  significant  difference  in  VAP  rates  with  circuit  change 
intervals  extended  to  seven  days  versus  a  three  times  per  week  schedule.  Work  on 
further  extending  the  circuit  change  interval  may  be  indicated.  OF-00-008 


TCAM  WOflK  RESUTS  IN  REOUCTX)*  OF  TIME  ON  Mf  (3W«CAL  VENTIIATION  FOR  PATIENTS  UNDERGOING 

OPEN  HEART  SURGERY. 

pfchad  Mtrdanl  MS.  RRT.  Morton  Plant  Hospita),  Qeamater  a. 

BMXGROUM):   In  1993  a  multidisdplinaty  group  was  hjnrio)  to  improve  the  care  provided  to  patients  eter 
open  he*1  sutgeiy.  The  manager  of  Respi^oiy  Care  Services  led  the  group  »tiidi  consisted  d  cardiac 
suigeons,  aneaheiologcsts.  nurees  and  quality  management  professionals.  Cucroit  practict  was  rwiewed 
and  compared  to  'best  practice'  according  to  available  literature.  The  team  agreed  that  process  changes 
couW  reduce  the  time  patients  were  on  mechanical  ventilation  aher  open  heart  surgery. 
(CTHOO:  M  patients  undergoing  cardiac  surgery  were  rduded  except  patients  who  remained  on 
mech^iicaJ  vertilatjon  for  >24  hours.  Respiratory  therapists  kept  a  log  of  the  time  patients  were  admitted 
to  the  cardiac  surreal  inttraive  care  unit  and  the  time  patients  wre  exlubaled.  Anesthetics/narcotics  were 
modilied.  Nurses  refrained  from  sedating  patients  who  were  waiong  up  so  that  they  could  be  weaned  quiddy. 
Patients  were  weaied  using  the  protocol  approved  by  the  committee.  Mean  ventilator  hours  were  reported 
every  monlh  to  the  committee,  Respiralcry  therapists  were  recognized  periodicady  for  ther  ajccess.  Eadi 
time  ttie  mean  showed  an  iKrease  the  team  analyzed  ttie  root  cause  and  resolved  the  problem.   Utitzation 
of  arterial  blood  gases  and  rentubation  rates  were  tradred. 

RESUTS:  Qwiges  i>  anesthesa  practice,  support  of  cardiac  surgeons  and  iwolvement  of  nurses  resulted 
n  decrease  of  ventilator  hours  from  16.3  to  3.4.  Utization  of  arterial  bkwd  gases  after  open  heart  surgery 
was  reduced  from  6  per  patient  to  2  per  patient  Therapists  on  all  shifts  devrioped  enthusiasm  as  they  saw 
results  and  recerved  recognition  from  hospital  management.  Reintubatioo  rales  improwd  and  the  potential 
of  complicabons  was  reduced.  Total  length  of  slay  decreased  from  1 2  Id  8  days.  Managed  Care  favored  our 
institution  and  volume  inaeased  from  574  per  year  to  883  patients  n  1 998. 

CONaUSION:  Respiratory  therapists  can  make  a  differoice  to  cost  and  patient  care.  Protocols  supported  by 
medico  staff  and  nursing  are  essentia!  but  commitment  to  process  imprwement  by  the  aitire  team  is  most 
■nportanl  Data  collection  and  tradong  provide  visual  feedback  of  success  and  motivates  caregivers. 
n«pl  ntoiy  Can  StnicM  1993  -  2000 
Hduwow  MnVwtfctor-BX  OpwiHowtSiMgwy 


mnt,  OF-00-014 


IS  PASSIVE  EXPIRATORY  FLOW  AND  'HME  DURING 
MECHANICAL  VENTILATION  VALUABLE  IN  ASSESSING 
THE  EFFECTIVENESS  OF  BRONCHODILATOR  THERAPY? 

Christopher  Williamson  RTS.  Samelia  Green  RTS.  and  Timothy  Op't  Holt  EdD,  RRT 
University  of  South  Alabama  Mobile.  Alabama 

PURPOSE:  A  decrease  in  active  expiratory  time  and  increases  in  peak  and  mid- 
expiratory  flows  are  typically  thought  of  as  indicators  of  bronchodilator  (BD) 
effectiveness.  Very  little  is  known  about  changes  in  these  parameters  in  patients 
being  mechanically  ventilated,  since  their  expiration  is  passive,  rather  than  forced 
as  they  are  during  routine  pulmonary  function  studies.  'The  purpose  of  this  study  is 
to  determine  if  these  variables  change  following  BD  therapy  in  patients  with 
chronic  obstructive  pulmonary  disease  (COPD)  who  are  being  mechanically  venti- 
lated. METHODS:  Following  hospital  approval  of  the  project,  seven  patients  with 
COPD  who  were  being  mechanically  ventilated  by  a  Nellcor  Puritan-Bennett  72(X) 
ventilator  and  who  were  receiving  BD  therapy  (2.5  mg  Albuterol  /NS  ±  0.5  mg 
ipratropium  bromide  Q4  hours)  were  studied.  COPD  was  diagnosed  based  on  clini- 
cal history,  physical  findings,  or  pulmonary  function  tests  according  to  the 
standards  of  the  American  Thoracic  Society.  BDs  were  administered  for  30  minutes 
prior  to  suctioning  by  an  in-line  nebulizer  approximately  fifteen  inches  proximal  to 
the  ventilator  circuit  wye.  Each  patient  remained  in  the  Synchronized  Intermittent 
Mandatory  Ventilation  -i-  Pressure  Support  mode  of  ventilation  throughout  the 
study.  For  each  patient,  three  pre-  and  15  minute  post-treatment  flow- volume  loops 
and  flow-time  waveforms  from  mandatory  ventilations  were  printed.  Flows  were 
determined  by  extrapolation  to  the  Y-axis  of  the  loop  followed  by  conversion  to 
L/sec.  Times  were  determined  by  measuring  the  length  of  expiration  along  the  X- 
axis  using  a  dial  caliper  followed  by  conversion  to  seconds.  Changes  in  these 
parameters  were  analyzed  using  a  one-tailed  t  test  (a  =  0.05).  RESULTS:  The 
mean  pre-  and  post-treatment  active  expiratory  times  ±  SO  were  2.28  ±  1.02  sec. 
and  1.78  ±  0.63  sec.  respectively  (p=0.049).  The  mean  pre-  and  post-treatment  peak 
expiratory  flows  ±  SD  were  47.67  ±  1 1.47  L/sec.  and  47.21  ±  12.79  L/sec.  respec- 
tively (p=0.38).  The  mean  pre-  and  post-treatment  mid-expiratory  flows  ±  SD  were 
28.59  ±  3.51  L/sec.  and  28.55  ±  7.59  L/sec.  respectively  (p=0.49). 
CONCLUSIONS:  Changes  in  peak  and  mid-expiratory  flow  on  passive  pre-  and 
post  BD  flow-volume  loops  were  insignificant.  However,  the  active  expiratory  time 
during  passive  expiration  from  a  positive-pressure  breath  decreased  significantly 
following  BD  therapy.  Several  conclusions  may  be  made  that  warrant  further  study: 
1 .  passive  expiratory  flows  from  positive-pressure  tidal  volumes  are  not  sensitive  to 
BD  therapy,  2.  the  dose  of  BD  is  insufficient  to  cause  a  change  in  these  values  in 
the  patients  studied,  3.  the  patients  studied  do  not  respond  to  BD  therapy  due  to  the 
severity  of  their  illness  or  4.  the  numtier  of  patients  studied  was  insufficient  to 
detect  a  change.  Therefore,  this  study  is  still  in  progress  and  more  data  will  be 
obtained.  OF-00-016 


Respiratory  Care  •  August  2(XK)  Vol  45  No  8 


997 


Sunday,  October  8, 2:00-3:55  pm  (Rooms  200,201) 


c 
o 

4— > 

i 

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o 


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PRESSURE  SUPPORT  LEVELS  FOR  SUCCESSFUL  WEANING  FROM  MECHAN- 
ICAL VENTILATION  -  Glen  R.  Coddington.  RCP.  RRT 
Kaiser  Permanente  Orange  County  Medical  Center,  Anaheim,  Ca. 

BACKGROUND:  A  recent  study  (Am  J  Respir  Crit  Care  Med  1998  Dec)  demonstrated  tliat 
T-tube  trials  of  a  few  hours  in  duration  may  serve  as  an  indicator  of  a  patient's  ability  and 
readiness  to  be  weaned  from  mechanical  ventilation.  Another  study  (N  Engl  J  Med  1995 
Feb)  utilized  the  technique  of  placing  the  patient  on  a  Pressure  Support  of  1 8  cmH20  and 
then  reducing  Ihe  pressure  2  to  4  cmH20  per  day  as  tolerated.  Although  both  studies  suggest 
that  these  methods  may  be  somewhat  effective,  they  require  additional  utilization  of  Respira- 
tory staffing  resources,  as  well  as  the  associated  cost  of  materials  and  supplies.  PURPOSE: 
To  identify  and  demonstrate  an  optimal  pressure  support  levels  that  successfully  promote 
weaning  ffom  mechanical  ventilation  without  utilizing  labor  and  time  intense  T-tube  or  Pres- 
sure Support  trials.  METHOD:  A  sample  population  of  100  patients  requiring  invasive 
mechanical  ventilation  were  randomly  selected  and  retrospectively  reviewed  to  evaluate 
what  pressure  support  levels  were  utilized  immediately  prior  to  discontinuing  mechanical 
ventilation.  Mechanical  ventilation  for  all  patients  in  the  study  was  performed  using  the  Puri- 
tan Bennett  720OAE  ventilator.  Neonates  (<6  months)  and  "DNR"  (Do  Not  Resuscitate) 
patients  were  excluded  from  the  study  criteria.  However,  2  pediatric  patients  (ages  15  and 
17)  that  were  cared  for  in  our  adult  Itl^U  were  included  in  the  study.  Unsuccessful  weaning 
was  defined  as  re-institution  of  mechanical  ventilation  within  72  hours  and  was  determined 
by  the  patienti's  clinical  presentation  and  peftinent  invasive  and  non-invasive  data. 
RESULTS: 


Pressure  Support  Level*  At  Termination 
Of  Mechanical  Ventilation 


m 

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M            "         ' 

;-4li" 

(  •  w  II  11  I*  I*  1*  H  IT  II  ti  M  M  u  a  M 

Pnssur*  Support 


EXPERIENCE:  The  QI  tool  developed  by  our  Respiratory  Care  Services  Department 
proved  extremely  useful  for  outcome  analysis  of  ventilator  management.  CONCLUSION: 
There  was  a  96%  success  rate  when  weaning  patients  from  mechanical  ventilation  utilizing  a 
mean  pressure  support  level  of  1 3.2  cmH20  and  this  may  be  a  highly  effective  and  less 
resource  alternative  to  T-tube  and  Pressure  Support  trials.  However,  additional  data  would 
be  helpful  to  better  suggest  which  management  technique  should  be  utilized  for  different 
patient  populations.  With  so  many  variables  involved  with  the  weaning  process,  it  would 
behoove  us  as  bedside  clinicians  to  note  a  conclusion  that  was  reached  in  another  study  (Crit 
Care  Med  1999  Nov)  that  stated:  "The  manner  in  which  the  mode  of  weaning  is  applied  may 
have  a  greater  effect  on  the  likelihood  of  weaning  than  the  mode  itself."  OF-00-028 


PEEP  ENHANCED  UTILIZATION  OF  THE  PASSY-MUIR 
SPEAKING  VALVE 

Susan  Regg.  RRT.  RCP  Drake  Center.  Cincinnati.  Ohio 

Brad  Carr.MA.  CCC-SLP  Drake  Center.  Cincinnati.  Ohio 

Mark  Rinaldi,  RRT.  RCP  Drake  Center  Cincinnati,  Ohio 

Melanie  Bradle,  MA,  CCC-SLP  Drake  Center  Cincinnati,  Ohio 

BACKGROUND:  There  has  been  limited  use  of  the  Passy-Muir  Speaking  Valve  (PMV)  by 
patients  with  ventilator  dependence.  This  study  was  performed  to  determine  if  utilization  of 
Positive  End  Expiratory  Pressure  (PEEP)  with  cuff  deflation  increased  airflow  through  the 
glottis  sufficiently  to  enhance  phonation  with  the  PMV. 

METHOD:  The  data  for  this  study  was  collected  from  a  group  of  patients  that  were  evalu- 
ated by  a  Respiratory  and  Speech  Therapist  to  determine  qualifications.  The  study  require- 
ments included:  Patient  must  be  awake  and  alert  with  stable  vital  signs,  have  functional 
oropharyngeal  muscles,  have  a  tracheostomy  tube  with  an  outer  diameter  not  greater  than 
1 1 .3  mm,  have  a  respiratory  rate  less  than  32  breaths  per  minute,  an  FI02  not  exceeding  50% 
with  associated  oxygen  saturation  not  less  than  90%,  a  PEEP  of  0,  Peak  Inspiratory  Pressures 
(PIP)  less  than  40  cmH20  pressure,  and  patient  must  be  free  of  excessive  secretions,  wheez- 
ing, or  stridor.  Patients  were  then  placed  on  the  following  standardized  ventilator  settings 
using  the  Siemens  Servo  3(X):  Volume  Control  mode  with  tidal  volume  adjusted  to  lOcc  per 
kilogram  Ideal  Body  Weight  (if  the  patient  was  previously  in  a  "weaning  mode",  the 
adjusted  respiratory  rate  was  determined  by  taking  the  patient's  minute  volume  ventilation 
and  dividing  it  by  the  adjusted  tidal  volume)  and  I:E  ratio  not  less  than  1 :2.  Once  the  patient 
was  placed  on  these  standardized  ventilator  settings,  they  were  monitored  for  changes  in 
oxygen  saturation  and  PIPs.  The  patients  were  then  asked  to  perform  speech  tasks,  which 
included  sustained  phonation.  loudness  in  decibels  during  sustained  phonation  and  syllables 
per  breath  during  a  standardized  reading  (The  Grandfather  Passage).  For  the  decibel  reading, 
a  baseline  level  near  the  patient's  mouth  was  recorded,  then  factored  into  loudness  level  dur- 
ing phonation.  During  the  same  session  the  above  protocol  was  repeated  with  incremental 
adjustments  of  PEEP  levels  at  5  cmH20  and  10  cmH20  pressure. 

RESULTS:  The  information  gathered  in  this  study  revealed  that  standardization  of  ventila- 
tor settings  optimized  use  of  the  Passy-Muir  Valve,  especially  with  patients  utilizing  wean- 
ing modes  of  ventilation.  There  were  minimal  changes  in  oxygen  saturation  with  cuff  defla- 
tion, PMV  placement  and  with  the  addition  of  incremental  levels  of  PEEP  using  both  5 
cmH20  and  10  cmH20  pressure.  The  results  indicate  that  there  is  minimal  enhancement  with 
the  use  of  5  cmH20  PEEP.  However,  phonation  was  significantly  enhanced  by  the  use  of  1 0 
cinH20PEEPby  an  average  of  more  than  100%.  often  from  less  than  2  seconds  lo  over  10 
seccmds.  Decibel  levels  on  sustained  phonation  also  increased  significantly,  often  from  an 
inaudible  to  an  audible  level,  and  this  increased  intelligibility.  Syllables  per  breath  measure- 
ments increased  an  average  of  50%.  often  from  a  nonfunctional  to  a  functional  level.  The 
increased  syllables  per  breath  enabled  pallcnLs  to  participate  in  conversation  and  express 
wants  and  needs  without  difficulty. 

CONCLUSION:  The  standardization  of  clinical  pathways  and  utilization  of  10  cmH20 
PEEP  appears  to  enhance  patient  tolerance  and  efficacy.  While  this  study  indicates  that  the 
use  of  PEEP  may  enhance,  or  in  some  ca.scs  enable,  phonation  and  functional 
communication,  there  is  a  need  for  further  investigation  into  methods  to  improve  tolerance 
and  usage  of  the  Passy-Muir  Speaking  Valve. 

OF-00-046 


THE  EFFECT  OF  OPTIMAL  HUMIDITY  ON  VENTILATOR. 
ASSOCIATED  PNEUMONIA  RATES 

Fran  Piedaluc.  RRT  University  of  Colorado  Hospital,  Denver,  Coiorado. 


Introduction:  Controversy  exists  as  to  the  appropriate  temperature  and  humidity 
of  inspired  gas  delivered  lo  mechanically  ventilated  patients  with  artificial  airways. 
Current  AARC  Clinical  Practice  Guidelines  recommends  33±  2°C  with  a  minimum 
of  30  mg/L  of  water  vapor.  A  recent  publication,  Williams  et  al',  provides  evidence 
that  inspired  humidity  must  reach  optimal  level  or  mucosal  dysfunction  will  occur. 
This  optimal  level  is  37°C  with  100%  relative  humidity  and  44  mg/L.  Optimal 
humidity  offers  a  significant  therapeutic  benefit  to  the  patient  of  improved 
mucociliary  clearance.  Because  maximum  mucociliary  transport  defends  the  lung 
against  infection,  the  use  of  optimal  humidity  may  result  in  a  decrease  rate  of  Ven- 
tilator Associated  Pneumonia.  Methods:  Humidification  systems  for  all  mechani- 
cally ventilated  patients  with  artificial  airways  were  set  as  follows:  humidification 
chamber  set  at  37  °C  with  100%  relative  humidity,  heating  wires  in  the  inspiratory 
line  of  the  ventilator  circuit  set  to  maintain  a  temperature  of  39-40°C  at  the  inspira- 
tory side  of  the  circuit  wye.  Temperature  drop  from  circuit  wye  to  patient  airway 
was  estimated  to  be  2-3°.  Delivery  of  inspired  gas  to  patient  airway  inside  of 
patient  estimated  to  be  37°C  and  100%  relative  humidity.  Results:  The  University 
of  Colorado  Hospital  has  monitored  VAP  for  the  past  4  consecutive  years.  For  the 
first  3  years,  the  VAP  yearly  rate  averaged  consistently  15-16%.  The  4th  year,  after 
the  change  to  optimal  humidity,  the  yearly  rate  was  8%.  The  surgical  population 
was  the  group  with  the  largest  decrease.  Conclusion:  The  use  of  optimal  humidity 
coincided  with  a  50%  reduction  in  VAP  rate  at  the  University  of  Colorado  Hospi- 
tal. Further  investigation  of  optimal  humidification  on  patient  outcome  is 
underway. 

L  Williams  R  et  al:  Relationship  between  the  humidity  and  temperature  of  inspired 
gas  and  the  function  of  the  airway  mucosa.  Crit  Care  Med  I996;24(l  1):  1920- 1929. 


20.0 
I «  15.0 

is  10.0 

S.I- 

S>  0.0 


AHNUAL  AVERAOE  UCH  VP  RATE 


14.« 

16.4 

1 

i5.e 

I 

1 

1 

1 

Hh 

1997  19! 

YEAR 


OF-00-039 


VALIDATION  OF  THE  CPX  EXPRESS  GAS  EXCHANGE  MONITOR  DUR- 
ING MECHANICAL  VENTILATION  WITH  CONTINUOUS  BIAS  FLOW. 

Charles  McAnhur  BA  RRTRPFT.  Immanuel-  SlJosephs  Hospital/Mayo  Health  System, 
Mankato,  MN. 

BACKGROUND:  This  study  was  designed  to  evaluate  the  ability  of  a  breath  by  breath 
gas  exchange  monitor  (CPX  Express,  Medical  Graphics.  St.  Paul,  MN.)  to  correct  for 
errors  introduced  by  bias  flow  used  during  mechanical  ventilation. 
METHODS:  A  gas  exchange  validator,  which  simulates  a  known  VO2,  VCO2,  and  VT, 
was  interfaced  with  a  Puritan-Bennett  840  ventilator  (Mallinckrodt,  St.  Louis,  MO.)  via 
a  standard  patient  ventilator  circuit.  The  CPX  Express  sampled  gas  concentrations  at  the 
proximal  end  of  the  patient  circuit  and  expired  flow  as  it  exited  the  ventilator.  The  venti- 
lator was  placed  in  the  CPAP  mode  to  allow  delivery  of  breaths  as  the  validator 
demanded.  Breath  by  breath  measurements  of  VO2,  VCO2.  and  VT  were  made  at  differ- 
ent bias  flow  settings  (set  on  the  ventilator)  with  the  following  validator  settings:  stroke 
volume  1000  ml,  VO2  322  mUmin,  VCO2  299  mL/min,  frequency  10,  duty  cycle  0.5. 
50  breaths  were  collected  at  each  bias  flow  setting. 

RESULTS:  Measures  of  agreement  (bias  ±  precision)  between  the  validator  and  the 
CPX  Express  gas  exchange  monitor  are  presented  below: 


Bias  flow  (L/M) 

V02(%bia.s±lSD) 

VC02(%bias±2SD) 

VT(%biast2SD) 

2 

+4.23  ±  .38 

■H.OO±.39 

-0.76  ±.21 

3 

-0.33  ±  .76 

-3.34  ±.74 

-5.64  ±.14 

6 

-h4.89±1.85 

-3.01  ±2.15 

+  1.53  ±.40 

9 

■^1.95±1.90 

-H  .00  ±2.22 

-2.48  ±  .37 

12 

-1.95  ±1.74 

-1.67  ±1.25 

-4.87  ±.38 

15 

-2.28  ±1.14 

-2.68  ±.34 

-6.21  ±  .45 

18 

-3.91  ±2.44 

-2.34  ±2. 19 

-7.64  ±  .29 

CONCLUSIONS:  The  CPX  Express  gas  exchange  monitor  can  accurately  measure 
breath  by  breath  gas  exchange  during  mechanical  ventilation  with  a  continuous  bias 
flow  in  the  range  studied. 

Partially  funded  by  Medical  Graphics  Coqxiration. 


OF-00-064 


998 


Respiratory  Care  •  August  2000  Vol  45  No  8 


Sunday,  October  8, 2:00-3:55  pm  (Rooms  200,201) 


MECHANICAL  VENTILATION  DURING  BRONCHOSCOPY:  THE  IMPACT 
OF  MODE  VENTILATION. 

Mauro  R  Tucci.MD;  Guilherme  PP  Schettino.  MP:  Rogerio  Souza,  MD;  Marcelo 
BP  Amalo.  MD;  Carlos  RR  Carvalho,  MD.  Experimental  Ventilation  Lab,  Division 
of  Respiratory  Diseases.  HC/InCor-Universily  of  Sao  Paulo  Medical  School,  Brazil. 
Background:  bronchoscopy  is  a  useful  diagnostic  and  therapeutic  procedure  for  crit- 
ically ill  mechanically  ventilated  patients.  However,  the  presence  of  a  flexible  bron- 
choscope (FB)  in  the  ETT  decreases  the  tube  inner  diameter  and  increases  airway 
resistance,  altering  respiratory  mechanics.  Both  volume  (VC)  and  pressure  control 
(PC)  modes  may  be  used  to  ventilate  intubated  patients  during  broncoscopy,  but 
limitation  related  to  control  of  peak  airway  pressure  (PIP)  and  tidal  volume  (Vj) 
occurs.  Pressure  regulated  volume  control  (PRVC,  ServoSOOA)  is  a  new  mode  that 
assure  a  preset  Vj  with  a  demand  flow  pattern  that,  theoretically,  may  be 
advantageously  used  in  this  situation.  Objective:  to  compare  the  performance  of  dif- 
ferent ventilatory  modes  during  broncoscopy  in  a  lung  model.  Method:  Two  endo- 
tracheal tubes  (#7.5  and  8.5)  were  individually  connected  to  the  airway  of  a  low 
compliance  (50ml/cmH2O)  mechanical  lung.  The  ventilator  was  set  to  assure  an 
alveolar  ventilation  (VEalv)  of  5Umin  [VEalv=  VE  n  (150mL  x  RR)J  with  respira- 
tory rates  (RR)  of  12  and  20/min  in  all  tested  modes.  Square  inspiratory  flow  rate  of 
45L/min  and  I:E  ratio  of  1 :2  were  used  for  VC  and  PC  respectively.  The  measure- 
ments were  repeated  before  (control)  and  after  the  FB  (Pentax  1 5P,4.9mm  of  exter- 
nal diameter)  was  inserted.A  VEalv  >4.5L/min,  proximal  peak  inspiratory  pressure 
(PIP)  <45cmH20  and  positive  end  expiratory  pressure  (PEEPi)  <5cmH20  were 
defined  as  optimal  targets  during  control  and  broncoscopy  trials.  Results:  all  tested 
modes  settings  achieved  the  target  parameters  during  control  measurements.  Table 
presents  results  recorded  during  broncoscopy  simulation. 


Mode   RR 


VEalv  (1/min) 


#7.5 


#8.5 


#7.5 


PIP  (cmH;0)  PEEPi  (cmH;0) 


VC 


12 4^±0.2 


#8.5 


#7.5 


20      4.4±0.2 


4.6±0.2     50.6*±4.7      23.6±3.0 


#8.5 


PC 


12      1.9*±0.1 


4.7±0.2     50.2*±5.2      22.0±1.8    2.0±0.1 


20     0.4*±0.1 


3.8*±0.2      11.9±0.4       11.8±0.8 


2.6*±0.2     9.7  ±0.3 


PRVC     12      4.7±0.2 


9.7±0.7 


20      4.7±0.2 


4.9±0.3      28.1±2.2       14.6±0.9     1.6+00 


5.0±0.2      34.8±2.8       14.8±0.8    4.0+0.1 


Mean±SD  of  12  consecutive  breaths;  *  represents  parameters  outside  of  the  defined 
target  levels.  Conclusion:  the  presence  of  the  FB  resulted  in  low  VEalv  and  high  PIP 
during  the  use  of  PC  and  VC  respectively,  PRVC  was  able  to  maintain  target  venti- 
latory levels  during  all  simulated  conditions. 
Funded  by:  FAPESP,  Pronex  and  LIM-FMUSP 

OF-00-068 


LABORATORY  EVALUATION  OF  DUAL  CONTROL  MODES  (DCM)  OF 
VENTILATION  OF  THREE  ADULT  VENTILATORS. 

Gary  Banks*  RRT.  Robert  S.  Campbell  RRT,  FAARC,  Jay  A.  Johannigman  MD, 
Fred  A.  Luchette  MD,  Kenneth  Davis  Jr.  MD,  Sandra  L.  Miller  MD,  Scott  B.  Frame 
MD,  Richard  D.  Branson  RRT.  Respiratory  Care  Department*,  University  Hospi- 
tal and  Division  of  Trauma/Critical  Care,  University  of  Cincinnati  College  of 
Medicine. 

Introdnction:  DCMs  are  designed  to  combine  the  benefits  of  pressure  control  (PC) 
and  volume  control  (VC)  ventilation.  We  evaluated  DCMs  of  3  vents  in  the  lab  with 
respect  to  tidal  volume  (Vt)  and  pressure  delivery  at  different  and  varying  combina- 
tions of  lung  impedance  (LI).  Function  of  DCMs  was  compared  to  that  of  PC  and  VC 
for  and  between  each  vent.  Methods:  Each  vent  (Drager  Evita',  Hamilton  Gahleo, 
Siemens  300)  was  set  to  ventilate  one  side  of  a  two-chambered  test  lung  (TTL)  at  all 
combinations  of  resistance  (R)  and  compliance  (C)  characteristics:  RIO  and  20 
cmH20/Usec,  C  20  and  40  ml/cmH20.  Consuuit  settings  included:  PEEP  -  5  cmH20, 
inspiratory  time  -  1 .0  sec,  2 1  %  O2,  and  a  rate  -  1 5.  Vt  was  set  to  500  ml  during  DCM 
and  VC.  During  PC,  inspiratory  pressure  was  adjusted  to  an  exhaled  Vj  of  500  ml. 
Exhaled  Vj  was  measured  proximally  using  a  variable  orifice  flow  uansducer 
(Bicore)  and  used  as  the  standard  from  which  to  compare  Vj  delivered  and  measured 
by  each  vent.  Time  to  stabilization  (Ts)  of  vent  output  was  measured  with  each  vent 
as  the  time  elapsed  from  initiation  of  DCM  to  delivery  of  Vt  within  10%  of  set  value. 
DCM  response  to  changing  LI  conditions  was  assessed  by  changing  C  and  R  acutely 
from  C40/R10  to  C20/R20  and  visa  versa.  Vt  and  pressure  delivery  to  the  lung  in 
response  to  die  changed  LI  and  Ts  (Vt  within  1 0%  of  set)  widi  each  DCM  were 
recorded  and  compared  to  die  Vt  and  pressure  delivery  measured  widi  PC  and  VC. 
Results:  Ts  from  DCM  initiahzation  varied  between  each  vent  (300  =  22.5  sec.  E'  = 
17.4  sec,  Galileo  =  60.5  sec).  Each  DCM  responded  to  changed  LI  with  appropriate 
pressure  changes  to  maintain  the  target  Vt.  Ts  varied  between  vents  (300  =  29  sec.  Ej 
=  26  sec,  Galileo  =  42  sec)  and  was  determined  by  the  max  pressure  change  per 
breath  allowed  by  each  DCM  algorithm.  The  first  Vt  delivered  after  each  change  in 
LI  are  as  follows  (low/high):  300  =  220/745,  E'  =  240/880,  Galileo  =  270/900.  Each 
vent  performed  similarly  in  PC  and  VC  during  changing  LI.  During  PC,  Vt  changed 
fitim  500  to  263  and  963  ml  following  respective  increased  and  decreased  LI.  During 
VC,  PIP  changed  from  33  to  19  cmH20  and  visa  versa  while  maintaining  Vt  delivery 
of  500  ml.  Actual  Vt  delivery  during  DCM  was  within  10%  of  set  Vt  at  each  lung 
condition  wiUi  a  mean  difference  of:  300  =  -3%.  E'  =  -7%,  Galileo  =  +5%.  Mean  vent 
measured  Vt  was  within  1 0%  of  actual  Vt  delivered  to  test  lung  (300  =  -8.2%,  E'  = 
+7.2%,  Galileo  =  -5.6%).  Conclusion:  Although  there  are  subtle  differences 
between  each  DCM  tested,  all  function  acceptably  and  are  monitored  appropriately. 

OF-00-070 


DIAGNOSIS  OF  VENTILATOR  ASSOCIATED  PNEUMONIA  (VAP):  BRON- 
CHOSCOPIC  BAL  VS.  BLIND,  MINI-BAL  USING  THE  COMBICATH™. 

Sandra  L.  Miller  MP  Robert  S.  Campbell  RRT,  FAARC,  Jay  A.  Johannigman  MD, 
Emily  A.  Montgomery  BS,  Fred  A.  Luchette  MD,  Joseph  S.  Solomkin  MD,  Donald 
C.  Mann  MD,  Richard  D.  Branson  BA,  RRT.  Division  of  Trauma/Critical  Care, 
University  of  Cincinnati  College  of  Medicine. 

Introduction:  Diagnosis  of  VAP  is  difficult.  CIX:  has  defined  VAP  clinically  by 
CXR.  WBC,  temp,  and  sputum  characteristics.  Combicadi™  provides  a  way  of 
blindly  obtaining  a  protected  alveolar  lavage  (PAL)  specimen.  We  determined  the 
Sensitivity  and  Specificity  (SS)  of  PAL  specimens  from  die  CombiCaih^"  to  BAL 
specimens  obtained  bronchoscopicaliy  in  pts  with  CDC  defined  VAP.  Methods: 
Forty-five  pts  were  studied.  BAL  specimens  were  bronchoscopicaliy  obtained  from 
each  lung.  A  uained  Respiratory  Care  Practitioner  used  die  CombiCath™  to  blindly 
obtain  PAL  specimens.  F1O2  of  1 .0  was  used  during  all  procedures.  Volume  of  lavage 
fluid  administered  and  returned  was  recorded.  Specimens  were  prepared  identically 
and  microorganisms  were  identified  using  standard  lab  mediods.  Threshold  for  infec- 
tion was  >10'  CFU/ml  for  boUl  techniques.  Data  collecuon  included:  age,  gender, 
diagnosis  and  APACHE  11,  area  of  infiltration  on  CXR,  ICU  days,  hosp  days,  and 
vent  days.  Baseline  vital  signs  and  O2  sat  (Sp02)  were  recorded  and  any  changes 
noted  during/after  each  procedure.  Change  in  MAP  or  HR  >  20%  or  a  decrease  in 
SpOi  >  5%  was  considered  a  complication.  Antibiotic  use  wiUlin  48hrs  of  sampling 
was  noted.  Results:  Table  1  reveals  outcome  variables  based  on  culture  results.  Cul- 
ture results  were  in  agreement  in  40/45  pts  (32  NEG,  8  POS).  In  five  cases,  BAL  was 
POS  and  PAL  NEG.  SS  of  PAL  compared  to  BAL  is  73%  and  100%.  Lavage  admin- 
istered/returned during  BAL  and  PAL  was  83/16  ml  and  20/2  ml,  respectively.  Com- 
plications were  noted  during  21  BAL  procedures  (19  HR,  13  MAP,  5  Sp02)  and  6 
PAL  procedures  (5  HR,  3  MAP).  Vent  settings  were  altered  during  BAL  on  33  occa- 
sions and  none  during  PAL.  Fourteen  pts  received  antibiotics  wiUiin  48  hr  of 
sampling,  of  which  five  had  POS  cultures.  CXR  involvement  was  bilateral  in  24  pts, 
R  side  only  in  15,  and  L  side  only  in  6.  Time  for  each  procedure  was  16  min  for  PAL 
and  52  min  for  BAL.  Discussion:  CombiCathTw  may  be  useful  in  identifying  pts  with 
VAP.  Confirmed  VAP  was  not  associated  with  increased  hosp  or  ICU  lengtfi  of  stay, 
vent  days,  or  mortality.  Trained  bedside  clinicians  may  perform  PAL  widi  a  lower 
complication  rate  compared  to  BAL.  Conclusion:  The  CombiCadi™  provides  a  safe 
and  accurate  alternative  to  bronchoscopic  BAL  for  diagnosing  VAP. 
Table  1.  Outcome  variables  relative  to  culture  results. 


Variable  Hosp  days  ICU  days     Vent  days      APACHE  II  Deadi 

Culture  +  (13)         25.4±8.6  23.6±8.2     15.7±6.l      18.1  ±7.9        0 

Culture-(32)  28.1  ±9.8  21.4±8.7     15.1  ±8.1      18.4±6.3        5 

OF-00-069 


LABORATORY  EVALUATION  OF  THE  VENT  F2  BREATHING  CIRCUIT. 

Paul  Austin*  CRNA  MS  (I  .tCol  US AF  NCI.  Robert  S.  Campbell  RRT.  FAARC,  Jay 
A.  Johannigman  MD,  Sandra  L.  Miller  MD,  Fred  A.  Luchette  MD,  KenneUi  Davis 
Jr.  MD,  Richard  D.  Branson  BA,  RRT.  Division  of  Trauma/Critical  Care  and  Col- 
lege of  Nursing*,  University  of  Cincinnati  College  of  Medicine. 

Introduction:  The  Universal  F2  (King  Systems)  is  a  coaxial  breathing  circuit 
designed  for  use  during  anesdiesia.  A  recent  modification  of  this  circuit  (Vent  F2) 
allows  its  use  with  an  ICU  ventilator.  We  evaluated  a  60"  version  of  die  Vent  F2  in 
die  laboratory  on  a  spontaneous  breadiing  lung  model.  Methods:  A  two-chamber 
test  lung  (TTL)  was  modified  to  simulate  spontaneous  breathing  with  die  addidon  of 
a  lift  bar.  A  Drager  E'  was  used  to  "drive"  die  lung  model  with  two  drive  conditions: 
300  ml  Vt  @  30  L/min  inspiratory  flow  and  500  ml  Vt  @  60  L/min  inspiratory  flow 
using  a  constant  inspiratory  flow  pattern.  Test  lung  was  set  to  a  compliance  of  50 
ml/cmH20  and  resistance  of  5  cmH20/L/sec.  A  T-Bird  ventilator  was  used  to  venti- 
late the  "patient  lung"  via  the  Vent  F2  circuit  in  die  CPAP  mode  widi  die  following 
combinations  of  PEEP/Pressure  Support:  0/0, 0/10,  5/0,  and  5/10.  Measurements 
included  peak  inspiratory  and  expiratory  flow  rate,  imposed  work  of  breadiing 
(WOBi),  Vt,  and  peak  negative  pressure  (PNP)  during  inspiration.  Measurements 
were  repeated  widi  a  60"  two-limb  breadiing  circuit  (Hudson)  for  comparison.  Resis- 
tance (inspiratory,  expiratory,  and  total)  of  bodi  circuits  was  measured  as  pressure 
drop  across  die  appropriate  portion  of  die  circuit  at  a  constant  flow  of  I  Usee.  Com- 
pliance of  each  circuit  was  measured  by  injecting  known  volumes  from  a  calibrated 
syringe  into  each  circuit  and  measuring  die  internal  pressure.  Pressure  was  measured 
widi  a  calibration  analyzer  (RT-200).  Results:  There  were  no  differences  between 
die  two  breadiing  circuits  widi  respect  to  Vt  delivery,  peak  inspiratory  flow  rate, 
WOBi,  and  PNP  at  any  test  condition.  Peak  expiratory  flow  rate  wiUi  die  Vent  F2 
was  generally  20%  lower  dian  die  conventional  circuit  at  all  test  conditions.  Table  1 
reveals  die  compliance  and  resistance  characteristics  of  each  breadiing  circuit. 


3 

'T3 

O 

t/s 

C 


n 

p 
a 

o' 

i 


O 

I 

T3 


Table  1. 

Resistance  (emHiO/Usec) 

Compliance 

Inspiratory 

Expiratory 

Total 

(cc/cmH20) 

VentF2 

3.1 

3.2 

6.0 

1.33 

Conventional 

0.53 

0.28 

0.94 

1.89 

Conclusion:  The  Vent  F2  coaxial  breadiing  circuit  is  acceptable  for  use  widi  sponta- 
neous breadiing  patients  widi  ICU  ventilators  in  die  post-operative  period.  Future 
studies  should  assess  die  potential  financial  savings,  use  of  die  Vent  F2  widi  various 
humidification  techniques,  and  use  of  the  Vent  F2  in  patients  widi 
obstructive  lung  disease. 


OF-00-072 


Respiratory  Care  •  August  2000  vol  45  No  8 


999 


Sunday,  October  8, 2:00-3:55  pm  (Rooms  200,201) 


I 

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O 

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03 
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C/3 


A  RETROSPECTIVE  COMPARISON  OF  UHFV  vs 
CONVENTIONAL  VENTILATION 

Marie  R.  Milo.  BBA.  RRT.  Vinod  Pun,  MD. 
Providence  Hospital  and  Medical  Centers,  Southfield,  MI 

Background:  High  frequency  ventilation  has  been  used  clinically  for 
approximately  30  years.  It  has  received  scrutiny  regarding  its  application 
and  safety.  The  criteria  for  optimal  use  of  ultrahigh  frequency  ventilation 
(UHFV)  are  still  uncertain.  In  view  of  the  reports  of  high  mortality  in 
aduh  respiratory  distress  syndrome  (ARDS)  ranging  from  40-80%  in 
most  series  we  undertook  a  retrospective  clinical  review  of  patient  data. 
The  objective  was  to  compare  measurements  of  shunt,  Pa02/FI02  ratio 
(P/F),  and  Pa02/PA02  ratio  (a/A)  before  UHFV  (during  conventional 
ventilation)  and  24  and  48  hours  after  the  onset  of  UHFV.  Mortality  and 
incidents  of  complications  were  determined.  Methods:  Fifteen  patients 
(8  women,  7  men)  with  a  mean  age  of  53,5  years  +17.2  were  included  in 
this  analysis.  All  patients  in  this  study  were  placed  on  the  Adult  Star 
1010  ventilatorHemodynamic  profiles  were  performed  and  the  shunts, 
P/F  ratios,  and  a/A  ratios  were  extracted  from  this  data.  Results:  The 
mean  duration  of  conventional  ventilation  prior  to  UHFV  was  24,7  + 
25.5  hrs. 


Pre  UHFV 


Post  24  hrs 


Post  48  hrs 


Pa02/n02  84.6  ±38.0       219.5+ 120.4  •  240.3  +  83.6* 

Qs/Qt  41.6+13.1  22.6±7.8*  25.2+10.5* 

Pa02/PA02        0.16  +  0.11         0.35  +  0.16*  0.35  +  0.13* 
*  p<0.05  compared  to  pre  level 

Mortality  rate  was  15.4%;  only  1  complication  (pneumothorax)  was 
noted.  Conclusions:  Patient  transition  to  UHFV  in  ARDS  has 
historically  been  reviewed  as  late-stage,  and  near-futile  intervention 
which  has  not  served  to  reduce  mortality.  The  current  data  suggests  that 
early  use  of  UHFV  in  ARDS  improves  oxygenation  and  may 
significantly  reduce  mortality  and  morbidity.  Further  study  is  warranted. 

OF-00-074 


PARTIAL  EXPIRATORY  TRACHEAL  GAS  INSUFFLATION  (TGI) 

REDUCES  PAC02  WHILE  SPARING  TGI-AIRWAY  EXPOSURE 

Attwood  J,  McCoy  R,  Virag  R,  Bliss  P.  Methodist  Hospital  Indianapolis,  IN 

Background:  Tracheal  Gas  Insufflation  (TGI)  has  been  shown  to  reduce  minute  venti- 
lation i^quirements  by  flushing  CO2  from  the  anatomical  deadspace.  Recent  research 
has  shown  that  a  low  tidal  volume  strategy  reduces  mortality  in  ARDS.  PaC02  control 
via  other  methods,  such  as  TGI,  may  be  beneficial  when  using  this  strategy.  In  this 
study,  we  investigated  the  effect  of  introducing  TGI  flow  only  in  die  latter  portion  of 
the  expiratory  phase,  when  it  may  be  the  most  beneficial  and  have  the  least  adverse 
affects. 

Methods:  Five  normal  mongrel  dogs  were  intubated,  anesthetized  and  ventilated  to 
produce  normal  blood  gas  measurements,  using  a  tidal  volume  of  approximately  10 
mlTkg  (Mallinckrodt  model  840  ventilator  -  assist  control  mode).  When  blood  gas 
measurements  had  stabilized,  tidal  volume  was  reduced  by  approximately  45%,  to  pro- 
duce PaCOa  measurements  in  the  range  of  70-100  mmHg.  TGI  was  introduced  approx. 
1  cm  above  the  carina  at  4-8  L/min  during  the  latter  portion  of  exhalation  using  a  pha- 
sic controller  (Valley  Inspired  Products).  This  controller  monitors  die  patient  flow  at 
die  inlet  of  the  tracheal  tube  and  gates  TGI  flow  to  start  when  a  threshold  expiratory 
flow  level  is  sensed  and  end  at  the  onset  of  inspiration. 

Results:  Introduction  of  TGI  flow  created  an  average  decrease  in  PaCOi  of  30.5 
mmHg  (33.9%)  when  compared  to  the  values  with  lowered  tidal  volume  and  no  TGI 
(P<.0l  by  paired  t-test).  TGI  was  applied  67.5  (±  6)  %  of  the  total  expiratory  time. 
TGI  flow  rale  was  6.0  (±  2.0)  Ipm.  Mean  PaCOz  results  expressed  as  a  percent  change 
from  the  baseline  (high  tidal  volume,  no  TGI)  values  are  shown  in  the  following  graph: 


l"~ 

n 

r 

1- 

}: 
t 

/ 

k 

■M» 

M«kV1.M«T«  L*«Vt,N«T9l  Lm  VT .  >Nli  TO! 

Conclusion:  Partial  expiratory  TGI  effectively  normalized  PaC02  in  a  reduced  tidal 
volume  sUategy  while  sparing  airway  exposure  to  TGI.  The  independent  controller 
allowed  application  of  TGI  in  Uiis  selective  manner. 
Supported  by  Mallinckrodt.  Inc.  OF-00-079 


Evaluation  of  the  Effects  of  Long-Term  Use  on  Heated  Inspiratory  and  Non- 
Heated  Disposable  Mechanical  Ventilator  Circuits. 

■Jennifer  Keller  RRT.  Frank  Sandusky,  RRT  and  Thomas  Kallstrom,  RRT, 
FAARC 

Background:  In  current  literature,  there  are  numerous  studies  that  discuss  ventila- 
tor circuit  change  intervals.  Current  strategies  promote  longer  intervals  between 
circuit  changes  up  to  and  beyond  seven  days.  All  are  based  on  bacteriological 
surveillance.  Little  is  written  about  the  effect,  on  the  circuit  after  prolonged  use. 
We  sought  to  determine  if  prolonged  use  resulted  in  deleterious  effect  on  the 
disposable  circuit.  Method:  A  PB7200  Ventilator  with  a  Fisher  &  Paykel  MR730 
humidifier  was  utilized  during  the  testing.  The  PB7200,  was  set  at  the  following 
settings:  A/C,  V,.6L,  Peep  5  cm  H20,  Resp.  Rate  16  BPM,  and  humidity  set  at 
37%.  The  Ventilator  was  equipped  with  an  Airlife  non-heated  ventilator  circuit  and 
allowed  to  run  for  30  days.  At  the  end  of  30  days,  the  ventilator  circuit  was  change 
to  an  Isothermal  heated  inspiratory  breadiing  circuit.  A  BIO-TEK  adult  ventilator 
test  lung  was  utilized  for  this  study.  The  test  lung  was  set  with  a  compliance  of  .010 
L/cm  H20  and  an  airway  resistance  adapter  of  Rp20.  We  devised  a  system  to  pre- 
vent condensation  from  entering  the  test  lung,  and  which  could  be  easily  removed 
during  test  measurements.  PIP.  MAP  and  V,,  were  recorded.  A  total  of  seven 
circuits  were  tested.  Three  non-heated  and  four  heated  circuits.  Results:  After  30 
days,  there  was  a  decline  in  peak  inspiratory  pressure  for  both  heated  and  non- 
heated  circuits  of  - 1  cm  H20.  The  test  lung  at  the  end  of  30  days  recorded  an  aver- 
age increase  of  .02  Liters  for  each  delivered  breath.  The  system  compliance  had  an 
average  increase  of  0.4  ml/cm  H20,  with  a  range  of  0.0  to  0.8  ml/cm  H20,  with  no 
difference  between  circuits.  Discussion:  A  significant  increase  in  tubing 
compliance  was  not  observed  in  either  heated  or  non-heated  circuits.  There  was  no 
significant  difference  between  the  initial  delivered  volume  and  that  at  the  end  of  30 
days.  Non  heated  circuits  utilized  two  (2)  liters  of  water  every  24  hours.  However, 
the  heated  wire  circuits  required  one  two  (2)  liter  bag  of  water  ever  two  (2)  days. 
The  cost  savings  may  be  enough  to  justify  the  purchase  of  heated  wire  ventilator 
circuits.  Using  disposable  ventilator  circuits  for  up  to  30  days  does  not  alter  the 
physical  attributes  of  the  circuit  and  is  a  pracfice  that  we  now  feel  can  be  done 
without  change  in  ventilation  of  the  patient. 

OF-00-077 


HIGH  INTERMITTENT  POSITIVE  END-EXPIRATORY  PRESSURE 
(PEEPINT)  SUPPORTS  OXYGENATION  DURING  LOW  TIDAL  VOLUME 
(VT)  VENTILATION  IN  THE  ACUTE  RESPIRATORY  DISTRESS  SYNDROME 
(ARDS). 

RH  Kallet  RRT.  MS.  Siobal  RRT.  EL  Wamecke  RRT.  JA.  Alonso  RRT, .  JA.  Katz  MD. 
JD.  Marks  MD  PhD.  Department  of  Anestiiesia.  San  Francisco  General  Hospital.  94 1 1 0. 

Background:  Low  Vj  ventilation  limits  ventilator-induced  lung  injury  in  ARDS.(  I )  but 
may  potentiate  atelectasis,  especially  during  hypercapnia.(2)  High  levels  of  PEEP  may 
reduce  atelectasis.  Extra-pulmonary  etiologies  of  ARDS  ( ARDSfxp)  are  noted  both  for 
PEEP-responsive  lung  recruinnent  and  PEEP-sensitive  hemodynamic  instability. (3) 
PEEPiNT  raises  set  PEEP  above  baseline  for  2  breaUis  every  3  minutes.  Because  lung 
recruitment  with  PEEP  is  sustained  over  ame.(4)  PEEPn,fr  may  support  arterial  oxygen 
tension  (PaOi)  without  requiring  high  levels  of  set  PEEP  or  high  fiactional  concentrations 
of  inspired  oxygen  (FIO2). 

Case  Summaries:  Four  ARDSexp  patients  (2  with  hemodynamic  instability)  were  venti- 
lated with  a  Drager  E-2  ventilator  at  a  Vj  (mean  ( standard  deviation)  of  5.9  ±  1.3  mL/kg. 
An  FIO2  of  0.93  ±  0. 1  and  PEEP  of  17.5  ±1.9  cm  H2O  were  required  to  maintain  a  Pa02 
of  81  ±  18.7  mm  Hg.  Lower  inflection  point  (LIP)  was  17.8  ±  7.2  cm  H2O.  PEEPINT  was 
set  at  25.5  ±  4. 1  cm  H20.  Over  the  next  24  hours,  set  PEEP  was  decreased  to  1 3.5  ±  4.7 
cm  H2O  while  maintaining  a  Vtof  5.8  ±  1.2  mL/kg  and  a  Pa02  of  72.8  ±  10.8  mm  Hg. 
However,  the  sample  size  was  too  small  for  inferential  statistical  analysis  by  Wilcoxon 
Sign  Rank  Test. 

Conclusion:  By  exploiting  sustained  lung  recruiunent.  PEEPinx  set  above  LIP  may  per- 
mit low  Vt  ventilation  at  a  lower  set  PEEP  and  FIOi.  PEEPmr  may  be  a  particularly  use- 
ful approach  to  low  Vt  ventilation  in  hemodynamically  unstable  ARDSexp  patients. 

1 .  The  ARDS  Network.  Ventilation  with  lower  VT  as  compared  to  ti^ditional  Vt  for 
ALI  and  ARDS.  N  Engl  J  Med.  2000;  342  [in  press]. 

2.  Bendixen  HH.  Medley- Whyte  J.  Impaired  oxygenation  in  surgical  patients  during 
general  anestfiesia  and  controlled  ventilation.  N  Engl  J  Med.  1 963;  269  (19): 
991-996. 

3.  Pelosi  P.  Cadringher  P  Sigh  in  ARDS.  Am  J  Respir  Crit  Care  Med.  1 999;  1 59: 872-880. 

4.  Katz  JA,  Ozanne  GM.  et  al.  Time  course  and  mechanisms  of  lung  volume  increa.se 
with  PEEP  in  acute  respiratory  failure.  Anesthesiology  1981;54:9-16. 

140 
120 
100 

to 
to 

40 

20 

0 


-%02 
-Pa02A=l02 


PiaPEEPim     PEEPW 


PEEPM 
24twt 


OF-00-081 


1000 


Respiratory  Care  •  August  2000  Vol  45  No  8 


Sunday,  October  8, 2:00-3:55  pm  (Rooms  200,201) 


Proxiinal  Wavrfomi  Changes  in  Relation  to  the  Pressure-Volume  Curve  During  Ven- 
tilation with  the  Volumectric  Diffusive  Respirator 
in  a  Mechanical  Model 

Robert  Esiener  RRT.  Parkland  Health  and  Hospital  System.  Dallas.  TX 
T.  Al  West  MD  MPH.  Univeraty  of  Texas  Southwestern  Medical  School,  Dallas.  TX 

Background:  Lung  protective  strategy — targeting  ventilalitHi  to  volumes  generated  ^ 
points  between  the  uf^)er  ainl  lower  inflection  points  on  a  static  pressure-volume  (P-V) 
cune — may  prevent  ventilator-associated  lung  injury.  The  volumetric  diffusive  respiratcM- 
(VDR)  may  also  reduce  the  complications  of  mechanical  ventilation  by  aiding  in  mobiliza- 
tion of  secretions.  Waveform  monitoring  during  ventilation  with  the  VDR  may  provide 
insight  into  the  mechanical  properties  of  the  lung.  We  hypothesize  that  analysis  of  the  oscil- 
latory component  of  the  VDR  w  avefwm  can  be  used  to  select  optimal  pressure  settings  for  a 
lung  protective  strategy.  Methods:  A  static  P-V  curve  was  derived  for  a  modified  Michigan 
lung  model,  and  lower  (P-Acxl)  and  upper  (P-flexu)  inflection  points  calculated.  The  VDR 
was  connected  to  the  model  with  oscillatory  PEEP  held  constant  at  8  cmH20.  Pressure-time 
waveforms  during  an  expiratory  hold  were  obtained  at  different  values  of  demarMl  PEEP 
(PEEPp)  corpssponding  to  different  regions  of  the  P-V  curve.  Likewise,  inspiratory  hold 
waveforms  were  obtained  at  different  values  of  peak  inspiratory  pressure  (PIP).  These 
waveforms  were  then  examined  for  qualitative  differences.  Results:  The  pressure-time 
wavefcHTn  demonstrates  a  noticeable  "trough"  in  mid-cycle  when  the  ccwresponding 
baseline  pressure  (PEEPd  for  end-expiration.  PIP  for  end-inspiration)  falls  between  P-flexL 
and  P-flext .  In  real-time  at  full  sweep  speed  on  the  oscillosct^.  this  trough  translates  into  a 
"bright  zone"  that  is  easily  distinguished  from  the  flat  curves  seen  outside  the  inflection 
points.  Discussion:  In  this  beiKh  model,  oscilloscope  wavefOTm  analysis  made  it  possible  to 
set  the  VDR  for  a  lung-protective  strategy.  In  practice,  this  is  accomplished  by  slowly 
increasing  PEEPd  until  the  distinctive  tmght  zone  on  the  oscilloscqK  is  seen  at  end  expira- 
ticm  ( indicating  PEEPd  >  PAcxl).  then  adjusting  PIP  until  a  comssponding  bright  zone  is 
seen  at  end  inspiration  (PIP  <  Pflexy).  Ventilating  "'between  the  inflection  points'"  may  pre- 
vent iatrogenic  injury  either  from  alveolar  collapse  or  from  overdistension. 


OF-00-082 


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The  Postgraduate  Course  is  presented  by  the  faculty  of  the  Section  of  Respiratory  Therapy  at 
The  Cleveland  Clinic  Foundation,  where  protocols  have  been  in  long-standing  use.  It  will 
describe  the  rationale  for  protocols  and  steps  for  practical  implementation.  Legal  counsel  at 
The  Cleveland  Clinic  also  will  cover  medicolegal  aspects  of  respiratory  care  protocols. 

Sponsored  by  the  AARC,  this  course  is  offered  on  the  day  preceding  the  International 
Respiratory  Congress.  Attendance  is  limited  to  120,  and  you  must  pre-register  by  September 
15  —  first  come,  first  served.  The  course  is  approved  for  continuing  education  credits. 
Registration  fee  is  $130  for  AARC  members  and  $230  for  nonmembers.  A  registration  form 
is  provided  in  the  Congress  Program,  or  you  can  call  the  AARC  at  (972)  243-2272  or  register 
online  at  www.aarc.org. 


Respiratory  Care  •  August  2000  Vol  45  No  8 


1001 


Sunday,  October  8,  2:00-3:55  pm  (Rooms  213,214) 


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RESPIRATORY  CARE  MANAGERS'  VIEWS  ON  BACCALAUREATE  AND 
MASTERS  DEGREE  EDUCATION 

Ellen  A.  Becker.  PhD.  RRT.  Long  Island  University,  Brooklyn,  NY 
PURPOSE:  A  prior  study  indicated  that  many  RTs  without  baccalaureate  degrees  desire  to 
complete  one  and  considered  pursuing  a  degree  through  distance  learning  (DL).  The  same 
RTs  were  uncertain  if  managers  would  value  their  degree  major  and  a  degree  earned  through 
DL.  Less  information  is  known  about  master's  degrees  for  RTs,  thus  managers'  opinions 
were  solicited.  METHODOLOGY;  A  mailed  survey  was  sent  to  1444  members  of  the 
AARC's  Management  Section.  Regarding  baccalaureate  education,  managers  were  asked 
about  their  preferences  for  RTs  with  baccalaureate  degrees,  values  of  different  majors,  and 
values  about  degrees  earned  using  DL.  Attitudes  toward  DL,  content  and  target  audiences 
for  master's  degree  programs,  and  demographic  data  were  also  collected.  RESULTS: 
Twenty-six  percent  of  managers  representing  varied  practice  settings  responded.  For 
baccalaureate  degrees,  advanced  practice  was  valued  highest  followed  by  management, 
teaching,  science,  business,  and  liberal  arts.  For  70%  of  respondents,  hiring  preference  is  for 
RTs  with  baccalaureate  degrees.  If  earned  through  DL,  60%  felt  the  degree  equivalent  to  a 
traditional  degree.  23%  lower.  3%  higher,  and  14%  were  uncertain.  Ofthe  58%  of  managers 
who  hired  RTs  with  pre-professional  degrees  earned  through  DL,  8 1  %  were  satisfied  with 
the  RTs'  knowledge  level  and  87%  would  hire  another  RT  with  pre-professional  DL  prepa- 
ration. Regarding  preference  for  baccalaureate  vs.  associate  degree  pre-professional  prepara- 
tion, 34  %  had  preference.  28%  no  preference,  and  38  %  no  opinion.  Managers  felt  graduate 
degrees  were  valuable  for  managers,  educators,  supervisors,  and  clinical  specialists.  More 
than  50%  of  managers  gave  high  value  ratings  to  advanced  physiology,  evaluating  patient 
programs,  designing  patient  programs,  patient  education,  disease  management,  administra- 
tive issues,  and  computer  skills  for  graduate  content  areas.  Although  95%  of  managers 
would  recommend  graduate  programs  with  some  DL  courses,  only  75%  recommended  pro- 
grams offered  solely  through  DL.  CONCLUSIONS:  Advanced  practice  majors  are  a  viable 
consideration  for  RT  baccalaureate  completion.  The  majority  of  managers  who  hired  RTs 
with  pre-professional  DL  preparation  were  satisfied  although  some  managers  valued  a 
degree  earned  through  DL  less.  While  managers  preferred  hiring  RTs  with  baccalaureate 
degrees,  pre-professional  baccalaureate  preparation  was  not  preferred.  Graduate  degrees  are 
supported  for  managers,  educators,  supervisors,  and  clinical  specialists  and  most  managers 
supported  some  use  of  DL  for  this  degree. 

Managers'  Value  Ratings  of  Baccalaureate  Degree  Majors 


Degree  Major 


HighValue 
n(%  of  total) 


Moderate  Value 
n(%  of  total) 


Low  Value 
n(%  of  total) 


No  Response 
n(%  of  total) 


Advanced  Practice 

Management 

Teaching 

Science 

Business 

Liberal  Arts 

Other 


264(72.7) 
191  (52.6) 
179(49.3) 
169(46.6) 
130(35.8) 
22(6.1) 
18(5.0) 


80(22.0) 
150(41.3) 
147  (40.5) 
152(41.9) 
182  (50.1) 
147  (40.5) 
4(1-1) 


Total  respondents  n  =  363. 

Respondents  were  asked  to  rate  each  of  the  degree  majors. 


1 !  (3.0) 
17(4.7) 
33(9.1) 
34  (9.4) 
43(11.8) 
185(51.0) 
3(0-8) 


8(2.2) 
5(1.4) 
4(1.1) 
8  (2.2) 
8  (2.2) 
9(2.5) 
338(93.1) 


OF-00-011 


Experiences  with  Electronic  Technologies  and  Web  CT  with  a  Respiratory  Ther- 
apy Course. 

Ruben  D  Restrepo.  MD.  RRT.  Lynda  Thomas  Goodfellow,  EdD,  RRT.  Dept.  of  Car- 
diopulmonary Care  Sciences.  Georgia  State  University.  Atlanta,  GA. 
BACKGROUND:  New  and  emerging  technologies  represent  the  state-of-the-art 
among  the  innovative  strategies  for  facilitating  effective  and  efficient  teaching  and 
learning.  Web  CT  is  one  of  the  leading  providers  of  web-based  technology  available 
to  faculty  to  enhance  their  instruction.  It  facilitates  the  creation  of  sophisticated  World 
Wide  Web-based  educational  environments.  The  purpose  ofthe  study  was  lo  evaluate 
student  acceptance  with  the  use  of  lecture  plus  web-based  technology  to  deliver  the 
Neonatal  and  Pediatric  Respiratory  Care  course  (RT  408 1 ).  Two  specific  questions 
were  investigated:  1 )  How  satisfied  were  students  with  the  use  of  lecture  plus  web- 
based  technology  to  deliver  the  course?  and  2)  Would  students  take  a  course  on-line 
based  on  their  experience  with  this  course?.  RT  408 1  is  a  three-hour  credit  course 
offered  during  the  last  semester  of  the  senior  year.  This  was  the  student's  first  experi- 
ence with  web-based  course  material.  METHODS:  From  the  beginning  ofthe  course, 
all  students  had  access  to  the  course  materials  on  Web  CT.  At  the  completion  of  the  7- 
week  course,  students  were  surveyed  regarding  their  satisfaction  with  this  lecture  plus 
web-based  course.  A  questionnaire  produced  for  a  Computer  Science  Department  at 
the  University  of  British  Columbia  was  used  to  answer  the  research  questions.  The 
number  of  "hits"  or  visits  to  the  Web  site  was  also  recorded  for  each  student.  Descrip- 
tive statistics  were  calculated.  RESULTS:  All  28  students  did  access  the  course 
material  through  Web  CT.  The  total  number  of  hits  reported  to  the  Web  site  was 
1739,  with  a  mean  of  58,  and  a  range  of  16-1 14.  Percentages  are  reported  as  follows: 


How  satisfied  were  you  with  the  use  of  Web  CTin  taking  RT  408 1  ?            | 

Not  at  all 

Not  satisfied 

Undecided 

Satisfied 

Very  satisfied 

0% 

11% 

14% 

50% 

25% 

Would  you  take  an  on-line  course  based  on  your  experience  with  RT  4081  ?      | 

Yes 

No 

43% 

57% 

CONCLUSIONS:  Even  though  the  majority  of  the  students  were  satisfied  with  the 
use  of  web-based  technology  to  take  this  course,  factors  probably  associated  with 
learning  styles,  motivation,  and  computer  proficiency  may  explain  why  16  out  ofthe 
28  students  answered  they  would  not  lake  an  on-line  course  based  on  this  experience. 
Future  research  should  focus  on  the  instructor  satisfaction  with  the  use  of  Web  CT 
and  correlation  of  the  numbers  of  hits  to  expected  student  performance  and  learning. 

OF-00-041 


A  RANKING  OF  SELF-ASSESSED  CRITICAL  THINKING  BEHAVIORS  IN 
RESPIRATORY  THERAPY,  Lynda  Thomas  Goodfellow,  Ed.D.,  RRT,  Georgia 
State  Univeisity,  Atlanta,  Georgia 

A  foundational  framework  on  what  comprises  critical  thinking  in 
respiratory  care  has  been  provided  by  Mishoe  (1995).  The  purpose  of  this 
study  was  to  build  upon  this  research  by  ranking  self-assessed  critical  thinking 
behaviors  in  rank  order.  Using  quantitative  survey  research  methodology, 
respiratory  therapists  rated  themselves  on  seven  critical  thinking  skills.  The 
effect  of  personal  variables  on  the  self-assessments  was  also  investigated. 
Mean  scores  for  all  seven  categories  were  relatively  high  (above  4.0)  on  a  six- 
point  scale.  The  percentage  distribution  of  total  item  responses  may  provide  a 
better  insight  into  these  rankings  because  71%  ofthe  respondents  rated  their 
self-assessed  Prioritizing  critical  thinking  behaviors  as  very  well  or  extremely 
well  as  opposed  to  only  49%  ofthe  responses  in  the  Anticipating  critical 
thinking  behaviors  (see  table).  From  analysis  of  bivariate  correlations,  both 
Pearson  and  Spearman's,  and  independent  t-tests  for  dichotomous  variables  at 
(p<  .01),  age  and  educational  level  were  found  to  have  no  effect  on  the  self- 
assessed  behaviors.  The  following  were  statistically  significant  when 
comparing  personal  variables:  Troubleshooting  and  years  of  experience,  p  = 
.000,  Decision  Making  and  years  of  experience,  p  =  .000,  Anticipating  and 
years  of  experience,  p  =  .  000,  Troubleshooting  and  gender,  t  =  4.21,  df  =  946, 
p  =  .000,  female  means  =  4.69,  male  means  =  4.89.  This  ranking  may  suggest 
that  critical  thinking  behaviors  are  difficult  to  teach  in  formal  training 
programs  because  they  are  "individual"  skills  or  abilities.  Experience  may  be 
the  key  to  understanding  these  critical  thinking  behaviors.  Practical 
significance  of  this  study  suggests  that  educators  and  clinicians  should 
consider  learning  strategies  that  incorporate  the  use  of  experience  when 
targeting  novice  practitioners. 

%  of  total  item  response 
Rank    Construct Mean SD        1-2        3-4        i-6 


Prioritizing 
Troubleshooting 
Communicating 
Reflecting 
Decision  making 
Negotiating 
Anticipating 


4.84 
4.77 
4.69 
4.61 
4.58 
4.47 
4.31 


.711       1 


28 


.707 

2 

32 

66 

738 

35 

63 

665 

39 

58 

681 

40 

58 

745 

42 

54 

660 

47 

49 

OF-00-020 

DETERMINING  VENTILATOR  MODES  FOR  PRIORITY  IN  CURRICULUM 
AND  CREDENTIALING.  F.  Herbert  Douce,  MS.  RRT.  Irina  Wvan.  BS  CRT.  The  Ohio 
State  University,  Columbus,  Ohio 

Background:  Educational  programs  are  challenged  to  provide  learning  experiences  for  the 
ever-expanding  scope  of  practice  of  respiratory  care,  including  a  growing  plethora  of  modes 
of  mechanical  ventilation  for  our  adult  patients.  Some  modes  may  have  limited  application 
and  are  available  on  only  one  brand  of  ventilator.  The  purpose  of  this  sludy  was  to 
determine  which  ventilator  modes  should  be  highest  priority  for  curriculum  and  credential- 
ing  for  respiratory  care-  Methods:  We  developed  a  16  item  questionnaire  with  1 3  modes  of 
mechanical  vendlation  identified  in  common  textbooks  and  asked  for  the  frequency  of  their 
use  using  a  5-point  Likert-type  scale.  The  1 3  modes  are:  volume  control  mechanical  ventila- 
tion (VCMV),  pressure  control  mechanical  ventilation  (PCMV).  pressure  control  inverse 
ratio  ventilation  (PCIRV),  assist  control  (AC),  intermittent  mandatory  ventilation  (IMV), 
synchronized  intermittent  mandatory  ventilation  (SIMV).  continuous  positive  airway  pres- 
sure (CPAP),  pressure  support  ventilation  (PSV),  proportional  assist  ventilation  (PAV),  air- 
way pressure  release  ventilation  (APRV).  mandatory  minute  ventilation  (MMV).  volume 
assured  pressure  support  (VAPS),  pressure  regulated  volume  control  (PRVC).  We  defined 
the  scale  as:  1-very  often  (i.e.  daily).  2-often  (i.e.  more  than  once  a  week).  3-someUmes  (i.e. 
less  than  once  a  week).  4-rarely  (i.e.  less  than  once  a  month),  5-never.  The  demographic 
items  were  number  of  ventilator-beds,  and  county  where  the  hospital  is  located.  Of  the  1 99 
acute-care  hospitals  in  Ohio,  we  randomly  selected  and  surveyed  1  (X).  We  mailed  cover  let- 
ter, questionnaire  and  an  addressed,  postage-paid  return  envelope  and  collecled  data  for  30 
days.  We  tabulated  and  described  responses  for  all  respondents,  and  based  upon  their 
county  location,  we  separated  hospitals  as  meQ-opolitan  or  rural,  and  based  upon  the  number 
of  ventilator  beds  as  small  ( I  - 10  ventilator  beds),  medium  ( 1 1  -20  ventilator-beds),  or  large 
(2 1  or  greater).  Using  SPSS  9.0,  we  compared  means  using  one  way  analysis  of  variances 
with  repeated  measures  and  Tukey's  post-hoc  comparison  to  identify  critical  differences 
between  frequencies  for  different  mtxles  of  the  mechanical  ventilation.  To  consider  modes 
used  in  different  locations  and  sizes  of  the  hospitals  we  computed  chi  square  using  Scheffe's 
method.  Results:  Fifty-five  (55%)  hospitals  responded.  The  distribution  of  respondents 
refiect-s  the  disuibution  of  hospitals  in  Ohio  for  location  and  size  aiui  is  presented  in  Table  1 . 
For  all  respondents,  5  modes  were  reponed  as  used 

Rural 

Metropolitan 

Small 

Medium 

Large 

28(51%) 

26(49%) 

18(33%) 

17(31%) 

20(36%) 

often  atKl  very  often;  2  modes  were  used  sometimes,  and  6  mtxlcs  were  rarely  or  never  used. 
There  was  no  statistically  significant  difference  in  the  use  of  any  of  the  1 3  modes  of 
mechanical  ventilation  between  rural  and  metiuptilitan  hospitals.  However,  there  were  sig- 
nificant differences  for  5  out  of  1 3  modes  for  hospitals  based  upon  number  of  ventilator 
beds  with  AC,  SIMV.  PSV,  and  CPAP  being  used  less  often  in  smaller  units  (p<0.0! )  and 
PCIRV  being  used  more  ftiequently  in  larger  units  (p<0,OI ).  Conclusion:  St>me  adult  modes 
of  mechanical  ventilation  are  rarely,  if  ever  used.  Given  limited  instructional  and  clinical 
time,  educational  programs  should  concentrate  on  the  mt>sl  often  used  7  mtxles.  To  assess 
expected  competence  for  adult  mechanical  ventilation,  crcdentialing  examinations  should 
include  the  7  most  often  used  modes.  Children's  hmpitals  and  mtxies  of  neonatal  ventilation 
were  not  considered.;  otherwise  the  respondents  reflect  hospitals  nationwide. 

OF-00-096 

1002 


Respiratory  Care  •  August  2000  Vol  45  No  8 


Sunday,  October  8, 2:00-3:55  pm  (Rooms  213,214) 


RESPIRATORY  THERAPY  STUDENTS'  ATTITUDES  TOWARD  THE 
ELDERLY  AND  PREFERENCES  FOR  WORKING  WITH  ELDERLY 
PATIENTS.  Susan  L.  Perkins.  MAEd,  MA,  RRT,  The  University  of  Alabama  al 
Birmingham.  Birmingham,  Alabama.  Background:  Growing  numbers  of  elderly 
persons,  living  to  advanced  ages,  are  predicted  to  increase  the  need  for  chronic 
health  care  services.  In  general,  health  care  professionals  are  signiflcantly  more 
negative  in  their  attitudes  toward  elderly  patients  than  toward  young  ones  and 
regard  work  with  the  elderly  as  undesirable.  Prior  investigations  have  led  to  con- 
flicting and  somewhat  ambiguous  findings  on  factors  that  influence  health  care 
providers'  work  preferences  in  relation  to  the  elderly.  This  study  was  designed  to 
assess  the  attitudes  toward  the  elderly  of  respiratory  therapy  students  (RTS)  and  to 
investigate  the  relationship  between  these  attitudes  and  their  preferences  for  work- 
ing with  elderly  patients.  Method:  A  set  of  27  semantic  differential  scales  (ASD), 
taken  from  an  instrument  developed  by  Rosencranz  and  McNevin  (1969),  was  uti- 
lized for  the  measurement  of  attitudes.  These  scales  were  chosen  because  of  their 
known  factorial  content.  Work  preferences  were  evaluated  by  items  adapted  from 
the  Wilensky-Barmack  Work  Preference  Questioimaire  (1966).  The  items  from 
this  instrument  asked  for  students'  preferences  in  the  areas  of  1 )  age  of  patient 
population.  2)  diagnostic  category,  and  3)  work  settings.  It  was  hypothesized  that 
the  attitudes  of  RTS  toward  the  elderly  would  be  more  negative  or  neutral  than 
positive,  and  RTS  with  more  positive  attitudes  would  prefer  working  with  elderly 
patients.  Results:  The  hypothesis  predicting  negative  or  neutral  attitudes  was  not 
supported.  Student  attitudes  as  measured  by  the  average  total  score  on  the  ASD 
were  significantly  above  the  theoretically  neutral  score  of  108,  with  mean  (SD) 
127.74  (19.49).  The  second  hypothesis  was  likewise  not  supported.  Analysis  of 
variance  (ANOVA)  revealed  that  there  was  no  relationship  between  total  score  on 
the  ASD  and  student  preferences  for  working  with  elderly  patients.  Conclusion: 
The  results  of  this  study  indicate  that  positive  attitudes  toward  the  elderly  of  RTS 
might  not  assure  adequate  numbers  of  respiratory  therapists  working  with  elderly 
patients  or  in  geriatric  settings.  In  order  to  meet  the  health  care  needs  of  the 
expanding  elderly  population,  ways  must  be  found  to  encourage  RTS  to  work  with 
this  age  group. 


OF-00-098 


The  Effectiveness  of  Standardized  Self-Assessment  Examinations  and 
Graduate/Employer  Eviuations  in  Predicting  Graduate  Pass  Rates  on 
NBRC  Examinations.  Tenv  S.  LeGrand.  PtiD,  RRT  and  David  C.  Shelledy, 
PtiD,  RRT,  University  of  Texas  Healtti  Science  Center,  San  Antonio,  TX. 
Introduction:  Pass  rates  on  the  NBRC  national  tward  examinations 
comprise  an  important  respiratory  care  education  program  outcome  that 
reveals  the  degree  to  which  schools  prepare  respiratory  therapists  to 
perform  competently  in  the  clinical  setting.  Method:  To  define  program 
related  factors  associated  vwth  improved  graduate  outccmes  by 
detennining  if  pass  rates  for  the  certification  self-assessment  examination 
(CRTT-SAE),  the  written  registry  SAE  (WRRT-SAE),  the  clinical  simulation 
SAE  (CSE-SAE),  and  employer/graduate  cognitive  evaluations  correlate 
with  pass  rates  on  the  actual  NBRC  exams,  data  reported  on  the  1996 
accreditation  Report  of  Current  Status  for  all  accredited  respiratory 
therapist  programs  (n=300)  vras  provided  to  the  researchers  in  a  Ijlinded 
fashion  (specific  program  names  and  personnel  could  not  be  identified). 
Correlation  coefficients  were  calculated  for  predictor  variables  for  CRTT, 
WRRT,  and  CSE  performance.  Results:  The  results  show  that  the  CRTT- 
SAE  was  a  moderate  predictor  of  the  CRH  %  pass  rate,  accounting  for 
20.3%  of  the  variance,  and  a  weak  predicta  of  the  WRRT  and  CSE  % 
pass  rates,  predicting  8.4%  and  7.3%  of  the  variance,  respectively.  The 
WRRT-SAE  was  a  very  weak  predictor  of  the  CRTT  %  pass  rate, 
accounting  for  only  2.3%  of  the  variance,  and  did  not  predict  WRRT  or  CSE 
performance  at  all.  There  was  no  relationship  between  CSE-SAE 
perfomiance  and  national  exam  pass  rates,  nadid  employer/graduate 
cognitive  evaluations  demonstrate  correlations.  Conclusion:  There  were 
significant  correlations  between  pass  rates  on  all  NBRC  board  exams  and 
performance  on  the  CRH-SAE,  while  the  WRRT-SAE  was  positively 
correlated  only  vwth  the  CRTT  %  pass  rate.  This  discrepancy  may  be  due 
to  the  fact  that  some  programs  actively  prepare  students  to  take  the 
WRRT-SAE  and  CSE-SAE,  vi^hile  others  use  these  exams  as  Nvake-up 
calls"  to  demonstrate  areas  of  strength  and  weakness,  which  negates  their 
value  as  a  predictor  of  performance  on  registry  level  exams. 

OF-OO-1 1 1 


PREDtCTORS  OF  RESPIRATORY  CARE  PROGRAM  OCTCO«S 

DjividL  Vines.  MHS.  RRT,  Terry  S,  LeGrand,  PhD,  RRT  and  David  C. 
SheHedy,  PhD,  RRT.  The  Urwersity  of  Texas  Health  Science  CenlBf,  San 
Artonio.Tx.  PURPOSE:  We  analyzed  the  ab«ity  of  respir*)ry  care  (RC) 
program  students'  entering  GPA  (EGPA),  program  prerequisilB  GPA  (PGPA) 
pre-admission  interview  score  (IS),  general  critical  thinking  ability  (CT)  as 
assessed  by  the  Watson-daser ,  end-of-first-year  competency  exam  (FYEX) 
in-program  GPA  (RCGPA),  and  perfonrance  on  NBRC  certification  and 
written  registry  self-assessment  exams  (CRTTSAE  and  WRRTSAE)  to 
predtot  graduate  outcomes  METHOD:  Records  of  all  graduates  (n=46)  from 
a  bacc^aureate  RC  program  were  reviewed  to  obtain  scores  for  predictor 
variables.  Outcome  measures  included  scores  on  the  NBRC  CRTT  exam, 
and  scores  on  an  end-of-program  written  registry  exam  (WRRT)  and  clinical 
simulalion  exam  (CSE).  Achievement  of  cognitive  (CS),  psychomotor  (PS) 
and  affecttve  (AS)  program  standards  were  assessed  by  surveying 
graduates  and  ernpkjyers.  Pearson  product-moment  correlations  and 
ftxward  step-wise  regression  analyses  were  performed  to  determine  the 
independent  variables  ability  to  predct  specific  outcomes.  RESULTS: 
NBRC  CRTT  exam  scores  were  significantly  con^ated  with  EGPA,  PGPA, 
CT  RCGPA  FYEX.  CRHSAE  and  WRRTSAE.  WRRT  scores  were 
significantly  correlated  with  FYEX,  RCGPA  and  WRRTSAE.  CSE  decision 
making  (DM)  was  significantly  conBlated  with  IS,  FYEX,  RCGPA  and 
CRHSAE.  Graduate  evaluations  for  CS,  PS  and  AS  were  sigiuficanSy 
correlated  with  FYEX,  The  coefficient  of  multiple  correlation,  R^,  indcated 
that  in  combination,  the  independent  variables  accounted  for  the  foflowing 
variances  in  outeome  measures:  66%  in  CRH,  56%  in  WRRT,  14%  in  CSE 
infonradon  gathering,  41%  in  DM,  19%  in  graduate  CS,  27%  in  graduate  PS. 
and  22%  in  graduate  AS.  The  strongest  predictors  of  perfomiance  on  NBRC 
exams  based  on  regresswn  analysis,  were  CT,  EGPA  RCGPA,  FYEX, 
CRTTSAE,  and  WRRTSAE.  CONCLUSKW:  IS,  EGPA  PGPA,  RCGPA 
CT.  FYEX,  CRTTSAE  and  WRRTSAE  may  be  useful  in  predating  graduate 
periformance  on  selecled  program  outeome  measures. 

OF-OO-110 


CHANGES  IN  ATTITUDES  TOWARD  CLASSROOM  AND  CLINICAL 
MISCONDUCT  IN  ALLIED  HEALTH  STUDENTS 

Robert  I..  Wilkins.  Ph.D..  RRT.  Arthur  B.  Marshak,  B.S.,  RRT,  RPFT,  Helen  Hopp 
Marshak,  Ph.D.,  School  of  Allied  Health  Professions,  Loma  Linda  University, 
Loma  Linda,  Ca. 

Introduction;  Educators  in  the  medical  professions  have  sought  to  identify  the 
impact  of  programs  on  their  students  for  many  years.  Students  are  exposed  to  a 
large  variety  of  classroom  and  cUnical  activities  in  respiratory  care  programs.  How 
these  activities  impact  student  perceptions  toward  examples  of  misconduct  is  not 
known.  Objective:  We  sought  to  identify  the  potential  changes  in  the  attitudes  of 
students  towards  specific  examples  of  classroom  and  clinical  misconduct. 
Methods:  As  part  of  a  pilot  smdy,  students  enrolled  in  the  department  of  cardiopul- 
monary sciences  at  Loma  Linda  University  completed  a  survey  pre  and  post 
program  to  identify  potential  changes  in  attitudes  toward  examples  of  10 
inappropriate  classroom  and  13  cUtiical  behaviors.  Each  participant  rated  the  seri- 
ousness of  the  behaviors  on  a  scale  of  one  to  five  (one  =  less  serious;  and  5  =  very 
serious).  Results:  Twenty-one  of  25  (84%)  students  completed  the  survey  both  pre 
and  post  program.  No  significant  changes  in  attitudes  towards  the  10  examples  of 
classroom  behavior  were  identified  over  the  course  of  the  program.  Attitudes 
towards  five  of  the  13  examples  of  clinical  misconduct  were  found  to  change 
significantly  towards  a  lower  score  (less  serious)  over  the  course  of  the  program. 
The  five  behaviors  noted  to  change  were:  parking  in  the  visitoris  parking  lot  [pre- 
program X  =3.38  vs.  post-program  x  =2.67  (p  =  .03)];  not  reporting  false  charting 
[pre-program  x  =  4.95  vs  post=program  x  =  4.57  (p  <  .01)];  taking  hospital  equip- 
ment for  personal  use  [pre-program  x  =  4.7 1  vs  post  program  x  =  4.29  (p  <.01 )]; 
calling  in  sick  inappropriately  [pre-program  x  =  4.48  vs.  post  program  x  =  4.05  (p 
=  .025)];  and  refusing  to  care  for  patients  with  a  highly  contagious  disease  [pre-pro- 
gram X  =  4.67  vs.  post-program  x  =  4.14  (p  =  .05)1  Conclusion:  The  attitudes  of 
allied  health  students  toward  clinical  misconduct  appear  to  be  mote  susceptible  to 
change  especially  in  a  negative  direction  as  compared  to  examples  of  classroom 
misconduct.  This  result  may  be  due  to  modeling  in  the  clinical  setting.  Attitudes 
towards  classroom  conduct  appear  to  be  well  established.  Educators  of  respiratory 
care  students  need  to  be  aware  of  the  fact  that  their  students  are  in  the  early  stages 

of  development  for  attimdes  toward  clinical  conduct. 

OF-00-147 


Respiratory  Care  •  August  2000  Vol  45  No  8 


1003 


Sunday,  October  8, 2:00-3:55  pm  (Rooms  213,214) 


ReUse  of  Medical 

Devices  Has 

Ciiangec, 


c 
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'■C 

C3 
O 
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W 

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a: 

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your  hospital 
can  benefit 


ClearMkdical  ' 

76  136tli  Phice  NE,  Bellevue,  m  98005 

Toll-free:  800.426.1042 

Phone:  425.401.1414 

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Reuse  of 

Healthcare  Devices'' 


BRAIN  BASED  LEARNING  IN  A  POST  PROFESSIONAL  RESPIRATORY  CARE 

PROGRAM  A  COMPARISON  OF  CONVENTIONAL  METHODOLOGY  AND 

BRAIN  BASED  LEARNING  TECHNIQUES 

David  Lope/.,  Ed.S  ,  RRT..  Loma  Linda  Univenit>',  School  of  Allied  Health  Professions. 
Department  of  Cardiopulmonarv'  Sciences.  Loma  Linda,  CA. 

Background:  Neural  plasiicit\'  has  been  shown  to  increase  with  a  rich  learning 
environment:  cxpcnences,  resources,  and  interactions  (clinical  and  group).  Nerve  cell  and 
dendritic  braiKhing  (plasticity)  is  one  of  the  ways  that  the  brain  grows  a  thicker  cerebral 
cortc.\  and  consequently  more  neural  connections.  The  implications  arc  that  the  more 
connections  available  the  easier  it  is  to  process,  retrieve,  and  store  information.  By  way- 
of  neural  networking  the  brain  finds  and  creates  meamng  as  mformation  is  constructed 
and  then  filed  in  the  brain  for  future  use  or  present  leammg.  The  more  an  area  of  the 
cortex  IS  activated  (he  more  neurons  will  create  faster  lines  of  communication  causing  an 
increase  in  memory,  meaning,  and  learning    Recent  advances  m  the  areas  of 
neuroscicnce  and  brain  function  has  improved  die  understanding  of  how  learning  t^es 
place  for  example:  functional  magnetic  resonance  imaging,  PET  (positron  emission 
tomography)  scans,  neural  physiology  (neural  and  humoral  chemical  reactions),  etc.  have 
shown  when  and  where  learning  occurs. 

Methods;  A  (3)  quarter  unit  course  in  Cardiopulmonary  Intensive  Care  was  given  one 
year  to  post -professional  respiratory  care  students  uulizmg  conventional  methodology: 
lecture,  course  and  subject  objectives  followed  by  a  post-test  (final).  The  following  year 
a  second  set  of  student  was  given  ihc  same,  course  and  subject  objectives,  employing 
brain  based  Icaming  strategies  and  the  same  post-test.  These  learning  strategies  included, 
case  studies,  group  discussions,  article  reviews,  patient  rounds,  some  lecuire,  internet 
based  assignments,  student  directed  learning,  and  learning  issues.  Course  evaluations 
were  completed  by  both  groups  that  reflected  both  quantitative  and  qualitative  measures 
that  reflected  the  course  content 

Results:  f  he  post-test  scores  indicated  Uiat  there  was  no  significant  difference  between 
the  conventional  methodology  group  and  those  in  the  brain  based  learning  group 
Outcomes  in  terms  of  total  scores  and  Anal  grades  for  both  groups  were  essentially  the 
same  Qualitative  results  (course  evaluauon  eomments)  showed  an  increased  student 
sausfaction  in  the  brain  based  learning  group  when  compared  to  the  conventional 
methodology  group  Complete  statistics  on  request 

Conclusions:  Brain  based  teaming  techniques  may  be  used  as  an  alternative  way  of 
enhancing  and  improving  respiratory  care  education.  The  concepts  of  integration,  critical 
thinking  and  neurological  networking  can  be  reinforced  utiUzing  brain  baaed  learning. 


OF-00-156 


DOES  AUSCULTATING  THROUGH  THE  PATIENT'S  GOWN 
MAKE  A  DIFFERENCE  IN  THE  PERCEIVED  INTENSITY  OF  THE 
VESICULAR  BREATH  SOUND? 

Robert  L,  Wilkins  Ph.D..  RRT.  Dennis  S.  McCarty,  RRT,  Arthur  B. 
Marshak,  BS,  RRT,  Lennard  Specht.  MD,  James  R.  Dexter,  MD,  School 
of  Allied  Health  Professions,  Loma  Linda  University,  Loma  Linda,  Ca. 

Introduction:  Pulmonary  auscultation  is  a  frequently  used  assessment 
tool  that  helps  evaluate  the  patient's  initial  condition  and  determine  the 
effects  of  therapy.  It  is  recommended  that  chest  auscultation  occur  with 
the  head  of  the  stethoscope  held  directly  against  the  skin.  Some 
clinicians  auscultate  through  a  patient's  gown  either  for  convenience 
sake  or  to  avoid  embarrassment  in  female  patients.  It  is  not  clear  if 
auscultating  through  the  patient's  gown  interferes  with  the  intensity  of 
the  perceived  vesicular  breath  sound.  Objective:  We  sought  to 
determine  if  auscultating  through  the  patient's  gown  and  gown  and  a 
light  robe  decreased  the  perceived  breath  sound  intensity  (BSI).  Meth- 
ods: A  respiratory  therapist  was  trained  using  a  spirometer  to  breathe  at 
consistent  volume  and  inspiratory  flow  prior  to  the  testing.  Fifteen  sub- 
jects (respiratory  therapists  and  physicians)  were  blindfolded  and  asked 
to  rate  the  BSI  on  a  scale  of  one  to  five,  with  five  being  the  loudest,  as 
the  chest  piece  of  the  stethoscope  was  randomly  placed  on  the  skin,  over 
the  gown,  or  over  the  gown  and  robe  at  the  same  position  on  the  chest. 
Results:  Four  of  the  participants  indicated  no  change  in  the  (BSI)  when 
comparing  direct  auscultation  to  auscultation  through  the  clothing.  Five 
participants  perceived  the  BSI  to  decrease  as  clothing  was  added;  and  six 
found  the  BSI  to  increase  as  the  clothing  was  added.  The  differences 
were  not  significantly  different  (p  >  0.05).  Conclusion:  Auscultating 
over  the  patient's  gown  does  not  significantly  diminish  the  clinician's 
perception  of  the  BSI.  Additional  study  of  the  effect  of  clothing  on  the 
qualitative  assessment  of  breath  sounds  is  needed. 

OF-00-157 


1004 


Circle  1 14  on  product  info  card 


RESPIRATORY  CARE  •  AUGUST  2000  VOL  45  NO  8 


This  is  not  Kinetic  Therapy^ 


.,  .-j»^- 


KineticTherapy"  is  ^e  40" 

continuous  lateral  turn  necessary 

to  help  prevent  and  treat 

pulmonary  complications. 


Kinetic 
Ther 


A  360;  cartwheel  can  be  fun  and  energizing,  but  it  does  nothing  for  pulmonary  complications  associated  with 
immobility.  Only  Kinetic  Therapy  s  40;  or  greater  side-to-side  continuous  rotation  has  been  proven  to  help  treat 
and  prevent  the  pulmonary  complications  associated  with  immobility.  In  fact,  new  clinical  studies  confirm  that 
Kinetic  Therapy"  can  help  resolve  atelectasis  and  help  prevent  ARDS'.  As  delivered  by  the  TriaDyne"  II, 
Kinetic  Therapy""  is  so  effective  in  treating  and  preventing  nosocomial  pneumonia  that  it  was  named  a 
Pulmonary  Best  Practice  by  the  Best  Practice  Network'.  Physician  order  is  required. 

To  turn  around  the  prevalence  of  pulmonary  problems  in  your  institution,  order  Kinetic  Therapy""  today! 
Call  I-888-ASK-4  KCI  to  receive  our  clinical  studies  or  to  order  Kinetic  Therapy"  for  your  patient 


'  50+  studies  available  upon  reqiiest.  Results  are  based  on  national  averages  and  may  vary  with  indrvidual  instruitions  and  indivrdual  circumstances. 


The  Best  Practice  Network  includes 
organizations  such  as  the  American 
Association  of  Critical  Care  Nurses 
(AACN).  the  Wound.  Ostomy, 
Continence  Nurses  Society 
(WOCN)  and  the  Society  for 
Critical  Care  Medicine  (SCCM) 


KCI 


Icute  Care   Long  Term  Care   managed  Care   Hnme  Care 


The  QMcal  Advantage' 

1-888-ASK-4  KCI 
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httpi/www.kal  .com 


KCI  USA,  Int,  P.O-  Box  659508.  San  Amonio.  Texas  7826S-9S08.  |.«88-ASK-4  KCI.  In  Caiia<ia.  call  l«)0.668-5«3.  All  tradeimrks.  ngnterKl  trademariu  and  ser<ke  marks  herein  are  property  of  KCI  and  its  aMotes.  All  KCI  produos  are  patented  and/or  covered 
by  pending  pattnn. '  2000  KCI  USA.  Inc  AH  rights  reserved. 


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Visit  AARC  Booths  468,  470, 472, 474  In  Clncinr 


Monday,  October  9, 9:30-1 1 :25  am  (Rooms  200,201) 


CONTINUOUS  ARTERIAL  BLOOD  GAS  MONITORING  ACCURACY  AND 
RELIABILITY  -  THIS  TIME  THROUGH  AN  UMBILICAL  ARTERY 
CATHETER  (UAC).  Patricia  Meyers  RRT  Catherine  Worwa  RCP,  Robert  Trusty 
RRT,  Mark  Mammel  MD.  Infant  Pulmonary  Research  Center,  Childreni's  Hospitals 
and  Clinics,  St.  Paul,  MN 

Introduction:  Arterial  blood  gases  (ABG)  are  a  necessary  diagnostic  parameter  in 
the  management  of  critically  ill  neonates.  Can  an  intravascular  blood  gas  sensor, 
adapted  for  use  through  a  UAC,  be  a  viable  alternative  to  discrete  blood  gas  analy- 
sis? Methods:  We  evaluated  the  Neotrend'''"  (Diametrics  Medical,  Inc)  intravascu- 
lar blood  gas  sensor  in  23  consecutive  neonates  (weight  1.8±1.3  kg.,  gestational  age 
3I±6  weeks)  with  respiratory  failure.  Data  was  collected  to  compare  successful 
placement,  sensor  longevity,  and  bias  and  precision  in  low  (L3-L4)  and  high  (T8- 
Tl  1)  UAC  placement.  The  sensor  is  fiberoptic,  using  fluorescent  technology  for 
the  measurement  of  P02,  and  optical  absorption  to  measure  pH  and  PC02,  with  a 
thermocouple  for  temperature.  The  sensors  were  inserted  via  a  4.0  or  4.5  Fr.  UAC 
and  extended  20  mm  beyond  its  tip,  in  the  descending  aorta.  Results:  Duration  of 
use  was  1  to  304  hrs.  In  high  position,  range  from  3  to  304  hrs,  in  low  position 
from  1  to  91  hrs.  9  sensors  were  used  >72  hrs,  1  in  low  and  8  in  high  position.  9 
sensors  were  placed  in  low  position  with  a  success  rate  of  56%;  18  sensors  were 
placed  in  high  position  with  a  success  rate  of  89%.  ABG's  were  obtained  as  clini- 
cally indicated,  and  analyzed  using  an  ABL  725.  Sensor  measurements  were 
recorded  at  ABG  sampling.  Statistical  analysis  included  determination  of  bias  (B) 
and  precision  (P)  by  Bland-Altman  technique  and  linear  regression  (r). 


ABL 

-  Neotrend 

Combined  Data 

High  Position 

Low  Position     | 

B-P 

r 

B-P 

r 

B-P 

r 

pH 

0.00+0.03 

0.88t 

0.00±0.03 

0.87t 

0.03±0.04 

0.86t 

PC02  (mmHg) 

-3±4 

0.87t 

-2±4 

0.87t 

-4±5 

0.77t 

P02  (mmHg) 

4±14 

0.80t 

4±14 

0.79t 

6±14 

0.88t 

t  ixO.OOOl 

Conclusions:  Neotrend^'^  was  accurate  and  reliable  in  the  neonatal  setting. 
Catheter  placement  in  high  position  increases  the  likelihood  of  successful  sensor 
placement  and  longevity.  We  found  Neotrend^"^  to  be  a  viable  alternative  to 
discrete  blood  gas  measurements  in  critically  ill  neonates.  OF-00-01 2 


UTILIZING  HELIOX  TO  IMPROVE  CARBON  DIOXIDE  ELIMINATION  DURING  fflGH 
FREQUENCY  OSCILLATORY  VENTILATION  IN  A  PEDUTRIC  PATIENT 

Jeffery  Attwood  R|^T.  Ndidiamaka  Musa  MD.  Department  of  Pediatric  Critical  Care,  Clarian 
Health  Partners,  Indianapolis.  Indiana. 

Introduction:  HFOV  is  being  used  successfully  in  the  neonatal  patient  population  and  is  finding 
favor  as  an  alternative  mode  of  ventilation  for  the  pediatric  patient.  A  consequence  of  using  HFOV. 
especially  on  larger  patients,  is  the  inability  to  adequately  purge  carbon  dioxide.  Studies  have  shown 
that  breathing  a  helium-oxygen  mixture  (Heliox)  can  improve  ventilation  and  increase  the  removal  of 
carbon  dioxide.  This  case  report  demonstrates  the  successful  use  of  Heliox  to  reduce  the  PaC02  of  a 
pediatric  patient  being  ventilated  using  a  SensorMedics  3  lOOA  high  frequency  oscillator. 
Case  Study:  A  7  year  old  with  a  history  of  sickle  cell  anemia  was  admitted  for  an  acute  onset  of  chest 
pain  and  shortness  of  breath.  Over  the  next  48  hours  his  respiratory  status  continued  to  deteriorate  and 
ultimately  he  was  intubated  and  placed  on  pressure  regulated  volume  control,  Vt=400ml,  f  =  20.  Fi02 
0.60  and  Peep=10,  PIP  =  40-t-cniH2O.  His  pulmonary  condition  continued  to  worsen  despite  increases 
in  Fi02,  rate,  and  Peep.  PIP  was  60+<:mH2O.  CXR  showed  no  evidence  of  pneumothorax  or  mis- 
positioned  ET  tube.  Patient  was  placed  on  HFOV,  MAP=:30.  Delta  P=58.  Fi02  0.60.  frequency  4  Hz, 
and  Insp.  Time  35%.  Oxygenation  improved  allowing  the  Fi02  and  MAP  to  be  decreased,  however 
PC02  remained  high  (70  -  90  mmHg)  despite  adjustments  to  Delta  P.  frequency,  and  Insp.Time. 
Conventional  ventilation  was  restarted  but  again  P02  decreased  and  patient  was  placed  back  on 
HFOV.  It  was  decided  to  trial  HFOV  with  Heliox  in  an  attempt  to  lower  PC02.  A  cylinder  containing 
79%  Helium  /  21%  Oxygen  was  connected  to  the  medical  air  hose  of  the  HFOV  blender.  Later  this 
set-up  was  modified  to  include  a  secondary  blender  pwwered  by  medical  air  and  Heliox.  which  deliv- 
ered a  controlled  concentration  of  Heliox  to  the  oscillator  blender.  Increasing  the  secondary  blender 
percentage  increased  the  Heliox  delivery.  The  following  chart  illustrates  a  sample  of  ABGis  obtained 
before  and  during  the  24  hours  of  Heliox  therapy. 


Arterial  Blood  Gas 

pH 

PC02 

P02 

HCO-3 

Oscillator 
Blender 

Secondary 
Blender 

Pre  Heliox 

7.31 

77 

91 

39 

407r 

_ 

Heliox  -  15  minutes 

7.64 

30 

43 

33 

40» 

_ 

Heliox  -  30  minutes 

7.56 

36 

63 

33 

607f 

_ 

Off  Heliox-  1  hour 

7.23 

93 

100 

39 

60% 

„ 

Heliox  -  30  minutes 

7.37 

69 

81 

41 

50* 

60% 

Heliox  -  8  hours 

7.50 

42 

69 

36 

50% 

75% 

Heliox  -  22  hours 

7.54 

45 

84 

39 

40% 

70% 

Patient  was  removed  from  Heliox  and  HFOV  and  placed  on  conventional  ventilation  without  dif- 
ficulties. He  was  extubated  after  6  days,  and  discharged  2  weeks  later. 

Discussion:  Heliox  delivered  with  HFOV  was  able  to  drastically  lower  the  PaC02  and  produced 
no  serious  effects  on  machine  function.  More  research  is  required  to  determine  which  patients 
might  benefit  from  this  therapy,  and  to  perfect  the  Heliox  delivery  system.  OF-00-01  *? 


BRONCHODILATOR  USE  IN  THE  FIRST  YEAR  OF  A  BRONCHIOLITIS 
PATHWAY  IN  A  PEDUTRIC  HOSPITAL 

K.  Boyle,  MS,  RRT,  D.  Sittipson,  MPH,  J.  Shaw,  MA,  R.  Baldwin,  MD,  J. 
Robbins,  PhD  Arkansas  Children's  Hospital,  Little  Rock,  AR 

Background:  Bronchiolitis  is  a  common  lower  respiratory  tract  illness,  affecting 
1 0%  of  infants  and  children  less  than  1  year  of  age.  Approximately  1  -2%  of  infants 
with  bronchiolitis  are  hospitalized  each  year.  During  the  hospitalization  inhalation 
drugs  are  typically  used  to  manage  bronchiolitis.  However,  literature  suggests  that 
many  of  these  therapies  are  not  effective.  The  purpose  of  this  study  was  to 
determine  the  number  and  types  of  inhalations  given  to  patients  eligible  for  an  evi- 
dence-based bronchiolitis  guideline.  Methods:  Patients  between  the  ages  of  I 
month  and  12  completed  months  with  first  admission  for  bronchiolitis  were  eligi- 
ble for  the  guideline.  Patients  with  congenital  heart  disease;  bronchopulmonary 
dysplasia;  cystic  fibrosis;  a  ventilator  requirement;  a  PICU  admission;  or  immun- 
odeficiency were  excluded.  The  guideline  recommended  limited  use  of  beta-ago- 
nists, testing  for  RSV,  parenteral  antibiotics,  and  chest  X-rays.  The  Respiratory 
Distress  Assessment  Instrument  (RDAI)  was  used  on  each  patient  admitted  to  the 
hospital  that  physicians  felt  needed  bronchodilators.  Patients  were  treated  first  with 
Albuterol  (0.03  cc/kg),  Racemic  Epinephrine  (0.05  cc/kg),  and  then  a  second  dose 
of  Racemic  Epinephrine  (0. 1  cc/kg).  The  RDAI  was  done  before  and  after  each 
updraft,  a  decrease  of  3  was  considered  a  significant  response.  If  the  infant 
responded  to  one  of  the  drugs  they  were  placed  on  a  PRN  regimen  of  that  drug  and 
the  trial  went  no  further.  If  the  infant  did  not  respond  to  any  of  the  drugs  no 
therapy  was  given  per  the  protocol.  Physicians  were  free  to  take  die  infant  off  the 
pathway  and  treat,  as  they  desired.  Through  retrospective  chart  review,  data  were 
collected  on  a  total  of  177  pathway  eligible  patients.  Results:  Our  population  was 
53.1%  male,  40.7%  African  American,  55.4%  Caucasian  and  2%  Hispanic.  The 
majority  of  health  care  coverage  for  this  population  consisted  of  Medicaid  (59%) 
and  self-pay  (16%),  and  the  mean  age  at  admission  was  around  4  months.  A  total 
of  1,349  inhalations  were  given  of  which  64%  were  albuterol,  26%  were  racemic 
epinephrine,  and  3%  were  ipratropium  bromide.  Experience:  Compared  to  the 
previous  RSV  season,  bronchcxiilator  use  decreased  10%.  Despite  the  pathway, 
when  presented  with  an  infant  who  appeared  ill,  treatment  was  usually  given 
regardless  of  response  to  therapy  or  use  of  an  RDAI  score.  Conclusions:  An 
evidence-based  guideline  had  a  modest,  though  consistent  impact  on  management 
of  infants  with  bronchiolitis.  Although  efficiencies  of  care  were  realized  opportu- 
nity still  exists  to  limit  use  of  ineffective  therapies  and  the  number  of  inhalations 
that  are  given. 

OF-(X)-025 


KINETIC  THERAPY  IMPROVES  OXYGENATION  IN  CHILDREN 
Theresa  Ryan  Schultz.  RRT.  RN.  Richard  Lin,  MD.  Mark  A.  Helfaer,  MD.  The  Children's 
Hospital  of  Philadelphia,  Pediatric  Intensive  Care  Unit.  Philadelphia.  Pennsylvania  19104. 
BACKGROUND:  Critically  ill  patients  often  suffer  complications  of  immobility.  Prolonged 
immobility  can  lead  to  pneumonia,  increased  morbidity,  mortality  and  economic  burden. 
Kinetic  Therapy™  (KT^")  is  a  way  to  redistribute  blood  flow/lung  gas  volume  in  a  way  that 
matching  of  blood  and  gas  will  be  enhanced.  KT™  reduces  atelectasis,  number  of  mechanical 
ventilation  and  ICU  days  compared  with  more  u-aditional  intermittent  turning  of  critically  ill 
adults  I .  To  determine  the  effectiveness  of  KT™  in  children  we  have  undenaken  a  prospective 
cross-over  design,  block-randomized  study.  Children  in  the  Intensive  Care  Unit  weighing  1 5-60 
pounds,  requiring  mechanical  ventilation,  who  have  arterial  access  and  can  safely  be  placed  on  a 
KCi  PediDyne  bed,  are  eligible  for  study.  METHODS:  Informed  consent  is  obtained  for  each 
enrolled  patient.  All  patients  receive  both  KT^"  and  standard  rotation  and  percussion  (S).  each 
for  12-18  hours  prior  to  crossover.  Arterial  blood  gases  are  done  via  l-Stat  once  every  other  hour 
for  the  study  period  (<  3.6  cc  blood  per  patient).  Outcome  variables  monitored  are  Oxygenation 
Index  (01)  Pa02/Fi02  (P/F).  and  A-a  DO;.  RESULTS:  Fourteen  patients  have  been  enrolled  to 
date.  Two  patients  exited  protocol.  Of  the  remaining  twelve  patients,  seven  received  standard 
therapy  first,  five  received  KT™  first.  Based  on  the  experience  of  our  first  study  patient,  the 
evaluation  period  was  extended  to  1 8  hours  of  each  therapy. 


Pt. 

# 

1st  tx. 

OI  after  S 
after  KT™ 

Ol 

P/t"  after  S 
after  KT'-' 

P/F 

A-aDO, 

after  S 

A-aDO> 
after  KT™ 

1 

S 

7.4 

84 
(12th  hour) 

5.1 
(18thhour) 

230 

215 
(12th  hour) 

331.3 
(I8lh  hour) 

1207 

135.3 
(12th  hour) 

80 
1 18th  hour) 

3 

KT™ 

40 

36.3 

60 

66.2 

453,4 

359.7 

4 

KT™ 

20 

15.6 

120 

109.2 

247,8 

244,5 

5 

KT™ 

3.6 

3.6 

276.3 

277.5 

123,5 

1267 

(, 

S 

3.0 

0 

2314 

270 

111 

74.4 

S 

S 

3.2 

1.5 

469 

474 

204 

18.7 

9 

S 

3,3 

3.0 

157,1 

182.9 

139,6 

1.35,6 

ID 

S 

3.0 

1.8 

276,7 

330 

69,9 

58.7 

II 

s 

41 

3.8 

220 

263.3 

83,9 

73.7 

12 

KT™ 

7.2 

5.7 

222.6 

297.5 

141.2 

111 

13 

KT" 

* 

6.1 

* 

245 

* 

125 

14 

S 

24,1 

13.3 

79 

1.35 

581.5 

180 

By  the  Shapiro- Wilk  Test.  Ol  and  A-aD02  were  not  normally  distrihulcd.  Paired  analysis  was 
done  using  Wilcoxon  Signed-Rank  Testing.  There  was  a  significant  difference  in  all  outcome 
variables  at  the  P<O.OI  level.  Two  of  the  ten  patients,  who  received  KT™  first,  deteriorated 
when  they  were  crossed-over  to  standard  therapy  and  were  therefore  relumed  to  KT™.  *One  of 
these  two  patients  was  relumed  to  KT^  prior  to  obtaining  a  blood  gas.  CONCLUSIONS: 
These  preliminary  data  suggest  advantage  of  KT™  over  standard  therapy  in  children.  There  was 
a  greater  difference  noted  in  patients  who  received  standard  therapy  first.  Further  investigatiot) 
is  needed  to  better  understand  this  subgroup  analysis. 

This  study  is  funded  by  KCI  USA  and  Endowed  Chair  Critical  Care  Medicine.     OF-00-030 
1.  RaoofSctal  Chest  115(6);  1658-666/99 


1006 


Respiratory  Care  •  August  2000  Vol  45  No  8 


Monday,  October  9, 9:30-1 1:25  am  (Rooms  200,201) 


ALADDIN"  NCPAP  SYSTEM  WTTH  HELIOX  DECREASED  RESPIRATORY 

DISTRESS  AND  PREVENTED  INTUBATION  IN  AN  INFANT  WITH  RSV 

BRONCHIOLITIS 

Meli.«a  K.  Brown  RRT.  Susan  E.  Duthie  M.D.  Depnitment  of  Critical  Care,  Children's 

Hospital  and  Health  Center,  San  Diego,  California. 

Introduction:  Nasal  Continuous  Positive  Air\ray  Pressuie  (NCPAP)  has  been  available 
in  Neonatal  and  Pediatric  ICUs  for  many  years.  Many  of  the  devices  require  the  infants  to 
expend  a  significant  amount  of  ventilatory  work  to  exhale  against  the  CPAP  flows.  Often 
the  devices  do  not  meet  the  infants  inspiiatory  demand  needs  due  to  inadequate  flow.  The 
ALADDIN"  system  (Hamilton  Medical,  Reno,  NV.)is  designed  for  active  NCPAP 
delivery  through  its  Universal  Generator.  The  ALADDIN"  utilizes  the  Bernoulli  effect 
and  dual  injector  jets  directed  toward  each  nasal  passage  to  maintain  a  constant  NCPAP 
pressure  If  additional  flow  is  needed  by  the  infant  the  Venturi  action  of  the  jets  will 
entrain  additional  flow.  The  infant  can  exhale  without  additional  work  due  to  the  flow 
pressure  stalling  effects  on  the  dual  injector  jets.  Continuous  positive  pressure  is 
maintained  thiwughoul  the  respiratory  cycle  by  a  residual  gas  pressure.  Helium  is  a  low 
density  gas.  When  used  in  combination  with  oxygen  (heliox),  its  ability  to  decrease  work 
of  breathing  in  patient's  with  Respiratory  Syncytial  Virus  (RSV)  bronchiolitis  is  being 
documented  with  increasing  ftequency.  A  small  percentage  of  patients  with  RSV  will  still 
require  intubation  after  heliox  djerapy  is  initiated.  This  case  study  examines  the  benefit  of 
adding  heliox  to  the  improved  NCPAP  system  provided  by  the  ALADDIN".  Case 
Sommary:  The  patient  was  a  previously  healthy  eight  week  old,  5.5  kg  male.  He  had  a 
one  week  history  of  upper  rcs?)itatory  tract  infection  symptoms.  The  mother  reported  the 
child  was  blue  at  home  and  having  periods  of  apnea.  The  infant  was  transported  via 
ambulance  to  an  outlying  fiicility.  The  Children's  Hospital  of  San  Diego  (CHSD) 
transport  team  assessed  the  child  and  found  him  to  be  in  severe  distress  and  near 
respiratory  failure.  He  was  subsequently  transported  to  the  CHSD  PICU.  He  was  placed 
on  the  ALADDIN"  Nasal  CPAP  system  with  aCPAPofS.Thepatienthada  dramatic 
decrease  in  work  of  breathing  as  evidenced  by  decreased  use  of  accessory  muscles, 
decreased  respiratory  rate  and  resolution  of  grunting.  The  patient  still  had  significant 
respiratory  distress  and  tachypnea,  therefore  heliox  (70%  helium,  30%  oxygen)  was 
added  two  hours  later  with  further  clinically  significant  improvement  in  respiratoiy 
status.  CXR  was  consistent  with  bronchiolitis  and  the  patient  was  found  to  be  RSV 
positive.  After  36  hours  the  NCPAP  was  discontinued.  Heliox  therapy  was  maintained  for 
2  additional  days.  The  patient  was  discharged  home  two  days  after  Uk  heliox  was 
discontinued.  DiacuuioD:  The  ALADDIN  with  heliox  had  a  dramatic  effect  on  this 
patient's  work  of  breathing.  Intubation  and  possibly  a  prolonged  ventilated  PICU  course 
was  avoided.  The  benefit  of  NCPAP  in  the  neonatal  population  is  well  documented. 
There  are  many  studies  showing  heliox  can  improve  ventilation  of  infants  with  RSV. 
More  researeh  is  required  to  see  if  active  NCPAP  used  in  combination  with  heliox  will 
decrease  intubation  rates  for  RSV  bronchiolitis. 

OF-00-031 


A  NEW  TOBACCO  INTERVENTION/CESSATION  PROGRAM  FOR 
CHILDREN  AND  TEENS:  STOP  TOBACCO  AND  NICOTINE  DEPENDENCY 
(STAND)  Alisa  G.  French.  MBA.  BS.  RRT  and  Belinda  S.  Huffinan.  RRT.  CPFT 
The  Children's  Medical  Center,  Dayton,  Ohio. 

Background:  Many  studies  have  documented  the  epidemic  increase  of  tobacco  use  in 
children  and  teens.  More  than  3,000  begin  smoking  every  day.  In  response  to  these 
alarming  statistics,  the  Respiratory  Care  Department  of  the  Children's  Medical  Center, 
(CMC),  in  1995  implemented  the  American  Lung  Association's  "Tobacco  Free  Teens" 
program.  This  smoking  cessation  program  was  promoted  as  an  alternative  to  suspension 
for  teens  "caught"  using  tobacco  in  local  school  systems.  From  November  1995  through 
March  1999, 102  teens  completed  the  program.  During  this  time  we  discovered  teens  are 
resistimt  to  changing  their  already  established  negative  behaviors.  Due  to  their  unique 
mind-sets  and  interests,  intervention  techniques  were  needed  to  encourage  teens  to 
choose  positive  attitudes  and  behaviors.  We  felt  tiiese  behaviors  were  necessary  before 
teens  could  be  motivated  to  stop  using  tobacco.  Method:  We  developed  these 
intervention  techniques  and  piloted  a  five-week,  two-hour  session  program,  entitled 
STAND.  This  program  includes  topics  such  as  goal  setting,  problem  solving,  and  stress 
reduction,  secondhand  smoke,  the  onitii  about  tobacco  and  tobacco  advertisement,  and 
quitting  techniques.  The  participants  of  the  program  complete  a  quiz  to  assess  tiieir 
knowledge  and  attittides  pre  and  post  completion  of  program.   The  program  uses  a  lung- 
breath  Carbon  Monoxide  monitoring  system  to  demonstrate  the  levels  inhaled  of 
poisonous  CO,  and  to  provide  positive  feedback.  To  make  die  program  more  appealing 
to  teens  and  encourage  participation  a  race  track  game  board  with  prizes  earned  for 
attendance,  homework  completion,  and  tobacco  free  stams.   Other  program  feanires 
include  graphic  videos,  human  diseased  lung  tissue,  and  other  graphic  visual  aids  selected 
by  a  teen  focus  group.   Results:  A  total  of24  teens  have  completed  the  STAND 
Intervention  and  Cessation  program  since  July  1999.  Of  these  24  teens,  33%  (8  teens) 
reported  tiiey  were  tobacco-free  and  had  smoke-free  verification  wiUi  CO  monitoring. 
Of  the  remaining  1 6  teens,  94%  ( 1 5  teens)  reported  Uiey  had  reduced  tiieir  use.    These 
statistics  verify  that  teen  tobacco  use  is  difficult  to  stop  but  can  be  successfiilly  reduced 
witfi  education.  Moreover,  negative  attitudes  and  beliefs  were  measured  in  19  teens  (Uie 
pilot  group  pre  data  was  not  collected)  and  were  positively  changed  in  89%  (16  teens)  of 
the  teens  stadied.   Experience:  Thiough  pre  and  post  test  analysis,  teens  misconceptions 
and  negative  attimdes  about  tobacco  use  can  be  changed  to  a  positive  outcome  through  an 
intervention  cessation  tobacco  program.  Conclusion:  Our  STAND  intervention  and 
Cessation  program  includes  effective  intervention  techniques  and  tiierefore  offers  an 
advantage  over  the  standard  cessation  programs.  We  will  continue  to  make  this  program 
available  to  teens  as  an  alternative  to  school  suspension  as  our  results  suggest  it  is  a 
valuable  program  leading  to  a  reduction  or  cessation  of  tobacco  use. 

OF-00-033 


RELIABILITY  OF  THE  SINGLE  BREATH  CARBON  MONOXIDE  TEST 
FOR  ASSESSMENT  IN  THE  PEDL\TRIC  POPULATION.  Amanda  Eaton 
CRT,  Katiierine  Smitii  CRT,  Deborah  Cullen  EdD,  RRT,  FAARC,  Simon  Hillier  MD. 
Respiratory  Therapy  Program,  School  of  Allied  Health  Sciences,  Indiana  University 
School  of  Medicine,  Indiana  University.  Indianapolis,  IN. 

Background:  The  majority  of  studies  involving  the  .single  breath  carbon  monoxide 
(CO)  monitor  have  focused  on  the  adult  population  to  determine  smoking  status  as  well 
as  evaluation  of  the  number  of  cigarettes  smoked.  Little  attention  has  been  given  to  the 
clinical  utilization  of  the  CO  monitor  in  pediatrics  to  determine  the  level  of  primary  or 
secondary  cigarette  exposure  or  to  evaluate  CO  exposure.  This  study  focuses  on  the 
reliability  of  die  single  breath  CO  monitor  as  an  assessment  tool  for  pediatrics. 
Method:  The  study  included  fifty-four  children  from  a  large  midwestem  pediatiic  hos- 
pital. All  of  the  children  were  between  the  ages  of  five  and  eighteen  and  cognitively 
could  follow  basic  instructions.  The  subjects  were  conveniently  sampled  from  the  pop- 
ulation of  children  admitted  for  outpatient  day  surgery.  The  patient's  parents  completed 
an  8  item  smoking  questionnaire;  then  two  tests  yielding  two  CO  levels  were  obtained 
from  each  child  using  a  calibrated  Vitalograph  single  breath  CO  monitor.  Pearson's 
correlation  coefficient  (r)  was  utilized  to  quantify  the  reliability  of  the  CO  values. 
Descriptive  analysis  of  the  questionnaire  was  conducted.  Results:  Test  1  resulted  in  a 
mean  CO  level  of  1 .98  and  Test  2  resulted  in  2. 1 7  CO  level.  The  standard  deviation 
(SD)fromTest  I  was  1.35  wiUiaSD  of  2.17  from  Test  2.  Pearson's  r  =  0.87was 
obtained  from  the  test-retest  reliabiHty.  Questionnaire  analysis  resulted  in  high  smok- 
ing behavior  from  parents  in  the  car,  house  and  outside  the  house.  Conclusion:  The 
single  breath  CO  monitor  is  a  reliable  assessment  tool  for  pediatrics  witii  good  test- 
retest  reliability.  This  device  may  provide  an  inexpensive,  noninvasive  measurement 
tool  for  obtaining  CO  levels  in  a  clinical  setting  versus  other  invasive  measurement 
tools  such  as  cotinine  or  carboxyhemoglobin  testing.  This  device  is  also  appropriate 
for  use  in  the  pediatric  population. 


OF-00-054 


SUCCESSFUL  USE  OF  LOW  LUNG  INFLATION  STRATEGY  WITH  HFOV 
IN  A  PREMATURE  INFANT  WITH  AIR  LEAK  SYNDROME:  A  CASE 
REPORT.  Stephen  Dickson.  MS.RRT.  Gwmnett  Medical  Center,  Ruben  D.  ResUepo. 
MD,  RRT,  Georgia  Stale  University,  Atianta,  GA.  BACKGROUND:  Air  Leak 
Syndrome  (ALS)  is  a  well-documented  complication  of  conventional  mechanical  venti- 
lation, occurring  in  20-50%  of  all  newboms.  Several  studies  have  reported  tiiat  HFOV 
significantiy  reduces  the  development  of  air  leak  syndrome  in  infants  with  severe  respi- 
ratory distress  syndrome  (RDS).(IX2)  We  present  the  use  of  low  mean  airway  pressure 
(Paw)  witii  HFOV  to  resolve  ALS  in  a  premanire  patient  wiUi  RDS.  PATIENT:  The 
patient  was  a  27-week  gestation,  825  g  female  deUvered  by  emergency  C-section 
secondary  to  unstable  pre-eclampsia.  She  was  intubated,  treated  with  surfactant  replace- 
ment therapy  and  supported  with  conventional  mechanical  ventilation  (CMV).  At  22 
hours  of  age,  acute  respiratory  acidosis  was  noted,  which  was  not  conrected  despite 
numerous  changes  on  the  ventilator.  Ten  hours  later,  severe  ALS  was  confirmed  by 
CXR  revealing  the  presence  of  a  left  side  pneumothorax,  and  pneumopericardium.  The 
patient  was  then  placed  on  HFOV  using  the  SensorMedics  3 1 OOA.  Initial  settings  were 
Paw=l2,  Delta  P=20,  Ti=  33%.  Fi02=  0.68.  During  die  next  8  hours.  Paw  was  weaned 
to  Paw=10.  The  patient  was  placed  left  side  down.  A  CXR  44  hours  after  Initiation  of 
HFOV  and  dependent  positioning  revealed  a  dramatic  resolution  of  air  leak  and  signifi- 
cant atelectasis,  .\fter  9  days  on  HFOV,  a  CXR  revealed  normal  lung  inflation  and  a  suc- 
cessful switchback  to  conventional  ventilatory  support  (at  Fi02  =.30  and  Paw=  1 1  cm 
H2O)  was  possible.  The  infant  was  exwbated  and  discharged  home  without  evidence  of 
IVH  or  significant  BPD. 


CMV.suf1*canl 

12a)  CMV.«lgl<(3») 


CONCLUSION:  The  use  of  a  lower  airway  pre,ssure  (Paw)  witii  HFOV  provided  sig- 
nificant advantages  in  tills  patient  with  a  severe  air  leak  syndrome.  HFOV  may  be  sug- 
gested not  only  to  prevent  but  also  to  resolve  the  presence  of  air  leak  syndrome  in  neona- 
tal patients  witii  RDS.  (I)  Vamholt  V,  Lasch  P,  Kachel  W,  Diehm  T,  Koelfen  W.  [High 
frequency  oscillatory  ventilation  of  infants  with  severe  respiratory  disorders: 
possibiUties,  risks  and  Umits].  Klin  Padiati- 1994;  206(3):l6l-6.  (2)  Miyahara  K,  Ichihara 
T,  Watanabe  T.  Successful  use  of  HOFV  for  pneumomediastinum.  Ann  Thorac  Cardio- 
vasc  Surg  1999;  5(l):49-51.  OF-00-059 


Respiratory  Care  •  August  2000  Vol  45  No  8 


1007 


Monday,  October  9, 9:30-1 1:25  am  (Rooms  200,201) 


USE  OF  HALOTHANE  IN  A  PEDIATRIC  PATIENT  WITH  STATUS 
ASTHMATICUS:  A  CASE  REPORT. 

R.  D  Restrepo,  MD,  RRT,  Georgia  State  University  (GSU)  and  Children's  Health 
Care  of  Atlanta  at  Egleston  (CHOA),  A.  Ari,  MS,  CRT,  CPFT  (GSU).  Patrick  De 
Meuse.  RRT.  J.  Fortenberry.  MD.  (CHOA).  Atlanta,  GA. 

BACKGROUND:  Asthma  is  the  most  common  chronic  disease  of  childhood  with 
prevalence  in  the  US  of  3%  to  5%.  Acute  asthma  attacks  account  for  an  estimated  1 
to  2  million  emergency  department  visits  each  year  in  the  US.  Despite  our  better 
understanding  of  the  disease  process  and  management,  status  asthmaticus  contin- 
ues to  be  a  life-threatening  event.  The  use  of  volatile  inhaled  anesthetics  has  been 
reported  as  adjunctive  therapy  to  conventional  treatment  of  this  condition.  We 
report  the  use  of  Halothane  in  one  of  our  pediatric  ventilated  patients  admitted  with 
status  asthmaticus.  PATIENT:  This  patient  was  a  1 2  year-old  black  male  admitted 
to  our  PICU  after  failing  to  respond  to  conventional  aerosol  therapy  in  the  ER.  In 
the  PICU,  the  patient  was  placed  on  BiPAP  and  managed  with  continuous  aerosol 
therapy,  and  I.V  corticosteroids  but  quickly  deteriorated  and  required  endotracheal 
intubation  and  mechanical  ventilation.  The  ABG  prior  to  intubation  was:  pH=7.27, 
PaC02=  55,  Pa02=  99,  BE=  -1.5,  FiO2=100%  via  NRB  mask.  Following  mechan- 
ical ventilation  (PCV  rate=20,  PIP=40,  PEEP=  6,  Ti=1.0s,  FiO2=1.0)  the  ABG 
revealed  a  pH=  7.57,  PaC02=  22,  Pa02=  201,  BE=  1.1.  24  hours  later,  the  patient 
developed  severe  respiratory  acidosis  (pH=  6.97,  PaC02=  171,  Pa02=  162,  BE= 
1.7).  Halothane  was  immediately  started  at  2%  in  conjunction  with  mechanical 
ventilation  using  the  Siemens  Servo  900C  anesthesia  ventilator.  Improvement  in 
both  arterial  blood  ga.ses  and  exhaled  tidal  volume  were  noted  thirty  minutes  after 
initiation  of  the  anesthetic  gas.  The  patient  remained  on  Halothane  for  a  total  of  36 
hours  with  concentrations  averaging  0.75%.  The  patient  was  extubated  68  hours 
later  to  BiPAP  16/6,  Fi02=  .30. 


PH 


PaC02        Pa02 


BE 


Sa02     Fi02 


Prior  to  Intubation 

7.27 

55 

99 

-1.5 

96% 

1.0 

PCV 

7.57 

22 

201 

1.1 

99% 

0.8 

Prior  to  Halothane 

6.97 

171 

162 

1.7 

97% 

1.0 

Halothane  2  %r.10niinl 

7.23 

73 

124 

1.5 

97% 

0.4 

Halothane  .5  %(36h) 

7.43 

39 

78 

2.1 

95% 

0.4 

BiPAP 

7.48 

47 

96 

10 

98% 

0.5 

DISCUSSION:  The  use  of  Halothane  in  the  management  of  this  patient  with  sta- 
tus asthmaticus  resulled  in  a  rapid  improvement  of  arterial  blood  gases  without  any 
adverse  effect.  With  appropriate  monitoring.  Halothane  may  be  a  valuable 
therapeutic  modality  for  the  patients  with  status  asthmaticus. 


OF-00-060 


ACHIEVING  ATS  PERFORMANCE  STANDARDS  FOR  SPIROMETRY,  LUNG  VOl^ 

UMKS,  AND  AIRWAY  MECHANICS  IN  PFDIAl  RIC  ASTHMATICS 

BkMishine.  SB.  RRT.  RPFF.  FAARC  Honicky.  RE.  MD,  King,  Kathleen  L.  MSN,PNP 

Michigan  State  University,  East  Lansing,  Michigan 

Background:  Spirometry  i,s  recommended  by  the  NAEPP  for  the  initial  asthma  patient  evalua- 
tion, during  therapeutic  interventions,  and  annually  thereafter  with  a  primary  goal  to  maintain 
nonnai  lung  function.  By  6  years  of  age  most  children  with  coaching  can  reliably  perform 
spirometry  (FVC).  Other  tests  include  lung  volumes  (TGV)  and  airway  mechanics  (Raw)  mea- 
surements. We  asked  the  question  as  to  which  tests  of  lung  ftinction  could  children  reliably  per- 
form and  at  what  level  of  quality  for  the  diagnosis  and  monitoring  of  pediatric  asthma. 
Method:  We  conducted  a  retrospective  analysis  of  7 1  current  asthmatic  patienLs.  ages  4- 1 8  years, 
with  pre  and  post  aerosol  bronchodilatOT  FVC,  TGV  and  Raw  results  derived  from  the 
MedGra|*ics  1085  plethysmogr^rfi.  All  testing  was  performed  by  2  RTs  trained  and  evaluated  to 
be  competent  in  pediatric  testing.  Our  PF  lab  performance  standards  are  described  in  the  1998 
ATS  Management  &  Procedure  Manual  for  PF  Laboratories.  Chapters  6. 8  and  9.  Each  trial  was 
evaluated  fty  conformance  with  ATS  acceptability  and  repnsducibility  criteria.  A  1  -8  fwogressive 
quality  score  (QS)  was  as.signed  to  each  pre  and  post  FVC,  TGV,  and  Raw  result;  i.e.,  within  5% 
reproducibility  for  FVC.  FEV 1 ,  TGV  and  1 0%  reproducibility  for  sGaw.  A  QS  of  1  represents  0 
acceptable  (A)  or  reproducible  (R)  trials.  A  QS  of  8  represents  3  acceptable,  reproducible  trials. 
Results:  A  QS  was  assigned  to  7 1  patients,  both  pre-  and  post-dilator,  1 42  total  results. 


Quality  Score 
Achieved 

Spirometry 
%  of  total 

Age 
Range 

Lung  volumes 
%  of  total 

Age 
Range 

Raw 

%  of  total 

Age 
Range 

1  (OA.OR) 

5.6  » 

6-15 

11.3% 

6-15 

4.2% 

6-15 

2(1  A,  OR) 

.1  % 

8 

42% 

7-13 

0% 

3  (0  A.  >  2  R) 

3.5% 

8-11 

31.7% 

4-14 

2.1  % 

8,9 

4  (2  A. OR) 

1.4% 

9 

.1  % 

14 

0% 

5(1  A,22R) 

2.8% 

9,13 

3.5% 

7-18 

2.1  % 

8,11 

6(3  A. OR) 

8.5% 

7-14 

14% 

14,18 

1.4% 

11 

7  (2  A,  2  2  R) 

2.8% 

4,10 

3.5% 

6-14 

2.1  % 

9.11 

8(3A.22R) 

74.6% 

4-18 

43.7  % 

4-16 

88.9  % 

4-18 

MeanQS:  Raw  7.49,  spirometryy.Ol,  lung  volumes  5.14.  Mean  age:  10 
Conclusion:  In  our  study,  Raw  nltasurcmenLs  achieved  the  highest  quality  scores.  The  splrmn- 
etry  QS  appears  to  be  in  line  with  published  data  for  this  age  group.  Lung  volumes  were  the 
nx>st  difilcull  mcavurcmcnis  for  us  to  obtain  in  this  pediatric  population.  A  lower  QS  did  not 
correlate  with  any  particular  age.  Most  young  children  can  perform  all  of  the  PF  tests  and  some 
adolescents  were  unable  to  do  many  of  the  tests.  Raw  measurements  provided  us  with  useful 
data  on  which  to  make  therapeutic  decisions,  especially  when  archived  and  used  for  longitudi- 
nal patient  care  decision- making.  Raw  is  performed  In  a  shorter  timeframe  than  spirometry, 
requires  \css  patient  coopeniiion  and  efTon,  yields  reliable  results,  has  continuity  with  Raw 
measuremenLs  made  In  the  neonatal  period,  and  offers  a  cost-effective  approach  to  evidence- 
heaaS  uealment  of  the  a.sthmatic  child.  Monitoring  of  the  therapeutic  interventions  by  objective 
measurements  is  csscnlial  lo  achieve  the  NAEPP  goal  of  normal  lung  function.  OF-00-086 


BENCH  EVALUATION  OF  UPPER  AIRWAY  SUCTION  DEVICES 

K.  Boyle,  MS.  RRT,  M.  Avers.  BS.  RRT 
Arkansas  Children's  Hospital,  Little  Rock,  AR 

Background:  Clinical  practice  guidelines  for  bronchiolitis  all  agree  that  suctioning  is  a 
necessary  component  of  treatment  in  infants  with  bronchiolitis.  However,  in  our  institution 
frequent  nasopharyngeal  suctioning  caused  trauma  and  increased  nasal  edema  in  some 
patients.  To  our  knowledge,  there  is  no  literature  on  appropriate  methods  for  frequent  suc- 
tioning of  the  upper  airway.  Other  children's  hospitals  were  surveyed  to  determine  what 
devices  they  were  utilizing  in  infants  with  bronchiolitis.  All  options  offered  have  been 
tried  at  one  time  or  another  in  our  institution.  The  purpose  of  this  bench  study  was  to  deter- 
mine which  device  suctioned  the  greatest  volume  at  a  constant  suction  pressure  of  80 
cmH:0,  which  is  a  moderate  level  of  suction  pressure  for  infants.  Methods:  Suction 
devices  lo  be  evaluated  were:  the  Baby  Booger  Grabber  (BBC)  from  Children's  Medical 
Ventures,  a  small  yankeur  made  by  Argyle  (Y(sm)).  a  large  yankeur  made  by  Baxter  (Y 
(Ig)),  6  Fr,  8  Fr,  and  10  Fr  suction  catheters  from  Medline  and  a  tuberculin  syringe  (TB) 
from  B-D.  We  prepared  honey/water  mixtures  in  two  dilutions  (200-ml  water  to  200-ml 
honey  and  200-ml  water  to  3()0-mI  honey);  we  also  tested  the  devices  with  water.  The  vac- 
uum pressure  was  set  at  80  cmH20.  Continuous  suction  was  used  for  each  device  since 
two  of  them  ( Y{lg)  and  TB)  did  not  have  a  suction  control  port  to  allow  intermittent 
suctioning.  We  allowed  each  device  to  aspirate  the  solution  for  20  seconds.  Three  of  each 
device  was  used  and  the  mean  volume  was  calculated. 
Results:  Volumes  are  in  milliliters. 


Device 

Water 

200  ml  water  lo 
200  ml  Honey 

200  ml  Water  to 
300  ml  Honey 

BBG 

387±  32 

232  ±18 

150  ±8 

Y(sm) 

591  ±40 

238  ±  10 

169  ±6 

Y(lg) 

570  ±  22 

236  ±4 

182±6 

6Fr 

29±5 

5±0 

4±1 

8Fr 

88±4 

16±4 

12±4 

10  Fr 

142  ±  IS 

41  ±2 

21  ±0 

TB 

151  ±24 

99  t  37 

67±6 

Exp«rience:  It  has  been  the  experience  at  our  institution,  that  repeated  nasopharyngeal 
suctioning  with  a  suction  catheter  may  cause  trauma  (increased  bleeding)  or  increased 
edema  in  the  infant  airway.  Since  infants  are  typically  nasal  breathers,  this  may  result  in  an 
increase  in  the  infants'  work  of  breathing.  Clinical  staff  members  do  not  agree  on  the 
appropriate  method  to  suction  the  upper  airway  without  utilizing  nasopharyngeal  suction- 
ing. Tne  Bronchiolitis  Pathway  suction  instructions  should  be  reviewed  and  updated  to 
reflect  suctioning  techniques  that  can  be  utilized  on  a  frequent  basis  (every  30  to  60  min- 
utes the  first  1 2  to  24  hours)  to  maintain  an  open  nasal  airway  for  these  infants. 
Conclusions:  The  devices,  which  aspirated  the  greatest  volumes,  were  the  Y  (Ig).  Y(sm) 
and  BBG.  Y  (Ig)  is  too  large  to  fit  into  the  nare  of  an  infant  and  so  would  not  be  an  appro- 
priate device  for  our  purposes.  The  Y(sm)  and  BBG  suctioned  the  greatest  volume  at  a 
constant  suction  pressure  of  80  cmH20.  Both  devices  are  small  enough  to  fit  into  the  nare 
of  an  infant.  This  study  suggests  that  the  BBG  and  Y{sm)  are  effective  devices  for  use  in 
infants,  allowing  clearance  of  the  upper  airway  without  causing  trauma  or     OF-00-075 
edema  to  the  nasal  conchae  or  nasopnarynx. 


MEASURING  AND  PREDICTING  FRC,  TLC  IN  NONCOOPERATIVE, 
PEDIATRIC  CANDIDATES  FOR  SCOLIOSIS  CORRECTION  SURGERY, 
Chris  Meyer  M.D.,  Alexander  Adams  RRT.  Mary  Stone  RRT,  Cathy  Polley 
RRT,  Caries  Milla  M.D.,  University  of  Minnesota  and  Gillette/Regions  Huspi- 
Uls,  St.  Paul,  MN 

Background:  Pulmonary  function  (PF)  studies  are  difficult  lo  obtain  in  children 
unable  to  cooperate  with  the  instructions.  Most  predicted  PF  values  for  children  are 
based  on  height,  but  in  scoliosis  the  thoracic  curvature  reduces  standing  or  sitting 
height.  Therefore,  armspan  is  often  used  as  a  surrogate  for  height  to  predict  PF  val- 
ues. Children  with  scoliosis,  arm  contractions,  and  an  inability  to  cooperate  present 
an  especially  difficult  problem  with  the  measurement  and  prediction  of  PF  values. 
Methods:  Immediately  prior  to  surgery  for  partial  correction  of  a  thoracic 
curvature,  FRC  and  TLC  were  measured  after  the  patients  were  sedated  and 
intubated.  FRC  was  determined  by  helium  dilution  using  10  large  tidal  breaths  via 
super  syringe  of  a  known  helium  concentration.  TTie  F102  of  the  tidal  breaths  was 
matched  lo  the  ventilator  F102  and  C02/humidity  were  absorbed  from  the  final 
helium  mixture.  Inspiratory  capacity  (IC)  was  determined  by  delivering  a  range  of 
tidal  volumes  (VT)  while  tracking  their  plateau  pressures  (Pplat).  Inspiratory  flow 
was  -set  to  avoid  autoPEEP.  The  VT  that  attained  a  Pplal  of  30-33  cmH20  was  con- 
sidered the  best  estimate  of  IC. 

Results:  Complete  evaluations  were  obtained  on  four  patients  at  this  time.  Mean 
FRC  and  TLC  were  57.5  ±  7.9%  and  49.2  ±  5.5%  of  predicted,  respectively.  After 
adjustment  for  height  gained  by  the  corrective  surgery  (mean  height  gain  of  6.8 
cm),  the  calculation  of  mean  predicted  FRC  and  TLC  decreased  to  49.9  ±  6.0%  and 
43.0  ±  4.2%. 

Conclusions:  For  these  children  undergoing  a  major  corrective  thoracic  surgery,  a 
restrictive  lung  impairment  is  evident  yet  comparisons  to  predicted  values  based  on 
height  are  questionable.  Repeat  studies  one  year  after  surgery  will  require  evalua- 
tion of  changes  in  actual  FRC,  TLC  values.  Predicted  values  for  these  patients 
should  be  based  on  anthropometric  correlates  other  than  height  or  armspan.  Possi- 
bilities lo  consider  might  be  chest  circumference  or  actual  spine  length. 


OF-(X)-109 


1008 


Respiratory  Care  •  August  2(XX)  Vol  45  No  8 


Monday,  October  9, 9:30-1 1:25  am  (Rooms  200,201) 


ELECTRICAL  STIMl  LATION  FOR  TREATMENT  OF 
DYSPHAGIA  IN  CHILDREN  FAILING  CONVENTIONAL  THERAPY 

Roben  L.  Chutbuni  RRT  FAARC.  Marcy  Freed.  MSP 
Univeriily  Hospitals  of  Cleveland,  OH 
Introduction:  Severe  dysphagia  (swallow  disorder)  leads  to  medical  complications 
such  as  aspiration  pneumonia,  bronchospasm,  dehydration,  malnuuition.  and  asphyxia. 
These  can  cause  death  or  increased  health  care  costs  from  prolonged  length  of  stay, 
readnusstons.  increased  respiratory  support,  tracheotomies,  and  percutaneous 
enterostomal  gastric  (PEG)  tube  placement  for  feeding.  There  is  a  high  failure  rate  with 
conventional  treatments.  We  describe  a  new  treatment  using  electrical  stimulation  (ES) 
to  help  retrain  swallow  muscles.  The  purpose  of  this  study  was  to  determine  the  degree 
of  improvement  in  swallow  function  using  this  technique  in  children  who  failed  conven- 
ticwial  treatment.  Methods:  A  convenience  sample  was  selected  from  referrals  to  our 
hospital  for  dysphagia  treatment.  All  patients  had  failed  piievious  conventional 
treatment,  which  included  Ihemial  stimulation  to  the  oropharynx  and  a  variety  of  stan- 
dard interventions.  The  initial  swallowing  disorder  was  assessed  by  a  modified  barium 
swallow  (MBS)  pRKcdurcusing  various  consistencies  of  food.  Invasive  dilation  of  the 
esophagus  was  pertbmied  if  indicated.  A  swallow  score  was  assigned  by  a  speech 
pathologist  based  on  the  MBS  results  ( 0  =  could  not  swallow  saliva;  6  =  normal  swal- 
low for  all  foods).  Failure  to  swallow  was  confirmed  by  a  radiologist  blinded  to  the 
treatment  prxMocol.  ES  was  administered  by  a  speech  therapist  using  a  modified  battery 
powered  electrical  stimulator  (Rehabilicare  Inc.).  Neuromuscular  electrical  stimulation 
consisted  of  a  rectangular  AC  current  waveform,  frequency  =  80  Hz.  pulse  width  =  300 
microseconds.  Current  intensity  was  set  to  the  palienti's  tolerance  level.  ES  duration  was 
one  hour  per  treatment.  MBS  and  swallow  scoring  were  repeated  when  the  patient 
showed  signs  of  clinical  improvement.  The  change  in  swallow  score  was  evaluated  with 
a  Wilcoxon  signed  rank  test.  Informed  consent  was  obtained.  RESULTS:  Thirty  chil- 
dren were  treated;  median  age  was  3  years  (range  0.5  -18);  57%  females.  Diagnoses: 
40%  neuromuscular.  30%  cerebral  palsy,  30%  CHARGE  syndrome.  Swallow  scores 
improved  significantly  after  treatment  (p  <  0.000 1 ).  Nomial  swallow  function  was 
achieved  by  73%  of  patients.  The  median  number  of  treatments  was  i  i  (range  3-16). 
The  median  duration  of  treatment  was  14  days  (range  3-42). 


30^ 

20  ■ 
10  ■ 
0  ^ 


I 


CONCXUSION:  TtEatment  of  dysphagia  with  electrical  stimulation  and  esophageal 
dilation  (as  needed)  insults  in  significant  improvement  in  swallow  function.  Tliis  treat- 
ment appears  to  offer  better  results  than  conventional  therapy. 

OF-00-116 


DELIVERY  OF  SUB-ATMOSPHERIC  OXYGEN  CONCENTRATIONS  DURING 
MECHANICAL  VENTILATION  OF  CHILDREN  WITH  HEART  DISEASE 

naviri  M  Dolcini  BS  RRT.  Philip  C.  Smith  MD  PhD.  Timothy  R.  Myers  BS  RRT 
Robert  L  Chalburn,  RRT  FAARC,  University  Hospitals  of  Cleveland.  OH 
INTRODUCTION:  The  immediate  survival  of  infants  v»ith  hypoplastic  left  heart  syndrome 
(HLHS)  is  dependent  upon  the  success  in  achieving  several  therapeutic  goals.  One  of 
these  therapeutic  goals  is  to  establish  and  maintain  a  balance  between  systemic  and 
pulmonary  blood  flow  at  or  near  unity.  Because  air-oxygen  blenders  have  a  lower  imit  of 
21%  oxygen  one  technique  to  deliver  sub-almospheric  oxygen  concentrations  is  to  add  a 
measured  flow  of  nitrogen  to  the  inhaled  gas.  But  this  technique  is  imprecise.  Flows  as 
low  as  0  1  Umin  can  change  the  oxygen  concentration  by  2  or  3  percent.  The  purpose  of 
this  study  was  to  evaluate  the  feasibility  of  delivering  sub-atmospheric  oxygen 
concentrations  through  the  ventilator  blender  Specifically,  we  sought  to  Oetemiine  the 
relation  between  blender  reading  and  delivered  oxygen  concentration  when  the  blender 
was  supplied  with  nitrogen  and  air  instead  of  oxygen  and  air,  METHODS;  A  Teledyne  T- 
190  oxygen  analyzer  was  calibrated  vmth  precision  blended  gases  at  5  different  oxygen 
concentrations  (Respir  Care,1999:  441226)  prior  to  use  and  between  each  ventilator 
brand  studied.  Infant  ventilators  (Infant  Star,  Bear  Cub,  and  Bird  VIP)  were  used  for  this 
study  (three  of  each  brand).  All  nine  blenders  on  the  ventilators  were  calibrated  at  21  and 
100%  priof  to  study  implementation,  A  k-tank  of  nitrogen  (50  psi)  was  attached  to  each  air 
inlet  and  air  (50  psi)  was  attached  to  each  oxygen  inlet  of  the  ventilators.  Ventilatore  were 
connected  to  a  test  lung  with  settings  that  created  a  mean  ain«ay  pressure  of  1 1-12 
cmHzO  The  Teledyne  analyzer  vias  placed  in-line  before  the  humidifier.  Ventilator 
blenders  were  adjusted  to  achieve  desired  (ie,  measured)  oxygen  concentrations  of  0- 
21%  RESULTS:  Sub  ambient  oxygen  concentrations  could  be  set  precisely  vflth  all 
ventilators  The  maximum  difference  between  predicted  setting  (from  regression  line 
below)  and  the  actual  setting  on  an  individual  ventilator  viras  5%  for  the  Infant  Star  and  Z% 
for  the  other  ventilators. 


Daslrtd  FI02  (%) 


CONCLUSION:  Delivering  sub-atmospheric  concentrations  of  oxygen  can  be  reliably 
achieved  during  mechanical  ventilation  by  connecting  the  blender  to  nitrogen  and  air 
sources  instead  of  oxygen  and  air.  We  recommend  this  technique  instead  of  using  a 
flowmeter  to  mix  nitrogen  into  the  inspiratory  limb  of  the  ventilator  circuit.     oF-00-1 1 8 


NASOPHARYNGEAL  (NP)  SUCTIONING  AND  ALBUTEROL  IN  BRONCHIOLITICa  . 

Kim  Bennion  BS,  RRT,,  John  W  Salyer  MBA,  RRT.  QCAT  Team  Members 
Respiratory  Care  Service,  Primary  Children's  Medical  Center.  School  of  Medicine, 
University  of  Utah.  Introduction:  Our  hospital  has  a  multi-disciplinary  assessment/care 
team  thai  specializes  in  the  care  of  bronchiolitics.  The  team  Is  called  the  Quality  Care 
Assessment  Team  (QCAT)  and  has  8  specially  trained  RCP's,  They  daily  assess  all 
bronchiolitics  receiving  any  respiratory  interventions.  The  learn  employs  a  standardized 
protocol  for  aerosolized  albuterol,  NP  suctioning  with  a  catheter,  and  a  symptom  based 
respiratory  scoring  system.  The  protocol  includes  an  albuterol  trial  that  can  be 
described  in  the  following  order,  baseline  score,  suction,  repeat  score,  albuterol 
treatment  (tx).  and  repeat  score.  The  score  is  based  on  respiratory  rate,  breath  sounds, 
and  retractions,  each  baing  scored  on  4  levels  (0-4),  Scores  are  classified  as;  0-1 
normal,  2-3  mild  distress.  4-6,  moderate  distress,  7-9  severe  distress.  We  sought  to 
determine  if  intervention  with  NP  suctioning  reduced  the  need  for  further  inlervention 
with  albuterol.  Method*:  Respiratory  scores  were  retrospectively  determined  from 
assessmani  cards  filled  out  by  QCAT  members  during  routine  care.  Data  were 
included  from  patients  with;  (1 )  discharge  diagnoses  of  bronchiolitis,  (2)  an  ordered  (rial 
of  aerosolized  albuterol,  (3)  all  necessary  data  fields  completed.  Cards  were  pulled 
predominanlly  from  cases  in  the  last  two  bronchiolitis  seasons.  An  Improvement  was 
defined  as  a  decrease  In  the  respiratory  score  before  and  after  intervention  (either 
suctioning  or  aerosol  b()  of  >  1 .  Patients  were  classified  according  to  whether  or  not 
their  respiratory  scores  improved,  worsened  or  were  unchanged  after  interventions. 
Proportions  were  tested  for  statistical  significance  using  Chi  square  analyses  with 
significance  established  as  P<  0,05.  Reiuiti:  There  were  166  cards  thai  met  the 
criteria.  The  data  in  the  following  table  have  a  Chi  Square  of  14.6  and  a  P  =  0.006. 


Improved 
after  Tx 

No  change 
after  Tx 

Worsened  after 
Tx 

Improved  after  Sx 

9(5.4) 

70  (42.2) 

9(5  4) 

No  Change  after  Sx 

13(7.8) 

54(32.5) 

5  (3.0) 

Worsened  ^tofSx 

4(2.4) 

2(1.2) 

0(0) 

Data  are  numbers  and  (%)  of  patients. 

Dlscusalon:  Debate  continues  regarding  efficacy  of  respiratory  interventions  in 
bronchiolitis  care.  Our  clinicians  have  long  held  thai  the  appropriate  use  of  suciioning  all 
the  way  Into  the  pharynx  through  both  nares  using  a  catheter,  often  resulted  In 
substantial  improvements  that  obviated  the  need  for  further  u  with  albuterol.  All  our 
suctioning  is  performed  this  way  in  bronchiolitics.  Our  findings  seem  to  support  this 
premise.  Ours  is  a  convenience  sample  (strictly  speaking).  However,  we  felt  that  the 
factors  that  caused  cards  to  be  Incomplete  were  probably  largely  random  and  thus  our 
sample  probably  is  reflecthre  of  bronchiolitics  as  a  whole. 


OF-00-1 27 


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lASIMO  SET*  HAS  MAJOR  ADVANTAGES  FOR  TESTING  OF  INFANT  APNEA 

)an  Villareal.  RRT.  Sudeep  Kukicja.  MD.  Children's  Hospital  of  Orange  Co.,  Orange.  CA 

lackground:  Apoeic  episodes  in  iM-etcnn  infants  demand  investigation,  most  commonly  done 
y  reviewing  recordings  of  multiple  physiologic  variables  from  an  Apnea  Monitoring  System 
\MS).  Pulse  oximerry  (PO)  is  a  common  AMS  parameter  with  shortcomings  in  this  settmg. 
leep  study  researchers"  recently  concluded,  "A  reliable  and  more  accurate  method  of 
*cording  oxygen  saturation  in  these  young  infants  is  needed,  for  use  in  both  neonatal  nurseries 
nd  sleep  studies,  to  aid  in  accurate  clinical  decision-makmg."'  Methods:  Infants  needing 
orkup  for  clinically  significant  apnea  were  enrolled.  The  AMS  montage  included  ECG  Iieart 
te.  impedance  pneumography,  nasal  thermistry.  and  SpO]  percent  and  pulse  rate  (PR).  The 
erformancc  of  a  Masimo  SET  pulse  oximeter  (Masimo  Corp..  Irvmc,  CA)  and  the  Nellcor  PO 
hannel  of  the  EdenTrace  II  Plus  AMS  (Mallinckrodt,  St.  Louis.  MO)  was  assessed.  The 
acings  were  evaluated  for  "true"  desamrations  (SpOj  £  85%)  and  zero-out  date  (a  zero  SpO. 
r  PR  value  or  both).  Suspect  SpO:  ^^  lasting  2  10  seconds  were  compared  (i.e..  clinical 
jservaiions  versus  the  EdenTrace  "motion  annotation"  and  the  Masimo  SET  data  loss). 
esults:  Six  infants  were  randomly  selected  for  study;  birth  weight  of  968  ±  272  gms.  and 
cstational  age  of  27  ±  2  weeks  with  an  equal  gender  mix.  At  lune  of  study,  babies  weighed 
896  ±  127  gms..  bad  an  adjusted  age  of  35  ±  2  weeks,  three  were  on  caffeine  citrate  and  one 
1  supplemental  oxygen.  There  were  73.1  hours  of  AMS  tracings.  48.3  hours  (66%)  were 
semed  quiet  sleep.  Masimo  PO  captured  more  true  desaturations  and  gave  near  continuous 
0  for  all  subjects  {p  <  0.02).  Whereas,  the  EdenTrace  11  Plus  continuously  displayed  "sensors 
K"  and  "recording  data"  in  spue  of  >1.200  epochs  for  39.7  hours  of  "invalid"  PO  dau. 
deed,  observers  were  unaware  of  suspicious  EdenTrace  PO  data  until  recordings  were  played 
ick.  We  confirmed  the  findings  of  Fletcher  et  al'  that  the  majority  of  conventional  PO  data  is 
)rTupt  in  apnea  smdy  recordings  of  infants  during  wakefuhiess  and  active  and  quiet  sleep. 

Categorv 

EdenTrace  11+ 

.Masimo  SET 

SigQificaoce 

Invalid  Data  (hours) 

39.7/73.1(54.3%) 

0.44/73.1(0.6%) 

p<  0.001 

Invalid  Data  (events) 

U08 

34 

p<0.00l 

True  Desaturaiion  Events 

79 

121 

p  <  0.02 

Invalid  DesaiuratiOD  Events 

994 

S 

/7<  0.001 

Zero-Out  Events 

396 

21 

p<0.001 

D 

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1. 

2. 

iscussion  and  Conclusions:  Despite  motion,  Masimo  SET  pulse  oximetry  has  been  shown 
;hly  accurate  in  sick  infants.'  We  have  shown  that  more  reliable,  real-tune  and  continuous 
JO2  monitoring  can  be  accomplished  with  Masuno  SET  in  preterm  infants  undergoing  apne 
sting.  Whereas,  the  Nellcor  component  of  the  EdenTrace  li,?l\is  system  missed  many  true 
saturation  events  and.  by  their  own  admission,  warned  of  "invalid"  PO  data  (>I24  times  ih* 
Masimo  SET)  which  accounted  for  loss  of  over  half  the  pulse  oximetry  data  in  our  random 
mpling  of  preterm  infants.  Use  of  Masimo  SET  should  improve  the  confidence  of  pulse 
imetry  as  a  parameter  in  apnea  testing  systems,  decrease  interpreter's  time  for  sconng  of 
nea  tests  and  reduce  reiesiing  of  subjects  prone  to  motion  during  sleep. 

Fletcher  J.  Page  M.  JefTery  H.  Sleep  states  and  neonatal  pulse  oximetry.  Sleep 

1998.21(3):305-3I0. 

Libetman  R,  Holmes  M,  Taschuk  RD.  Snelting  L.  Accuracy  of  pulse  oximeters  during 

neonatal  motion.  Respiraton  Care  1999;44(l2).i499. 

OF-00-1 3 

i 
I 

1 

Respiratory  Care  •  August  2000  vol  45  No  8 


1009 


STOP  THE 
CONFLICT... 

BETWEEN  PATIEINT  AND  VENTILATOR 


DraRer 


Let  your  patient  cough  or  breathe  unrestricted 
during  controlled  ventilation! 

Drager  has  incorporated  this  idea  in  the  design  of  Evita  ventilators  since  1988 
.  .  .  with  more  than  eight  years  of  experience  combining  spontaneous 
breathing  with  controlled  ventilation. 


The  result: 

The  evolution  of  ventilator 
management  with 
AutoFlow® — an  exclusive 
feature  in  the  E'*  pws  and 
the  Evita^  dura — 
unrestricted  spontaneous 
breathing  during  controlled 
ventilation. 

Circle  119  on  product  Info  card 
Visit  AARC  Booth  122  in  Cincinnati 

Drager  Medical,  Inc. 

1255  Lalces  Parkway  •  BIdg.  100,  Suite  180 

Uwrenceville.  GA  30043-5888 

Tel:  800-4DRAGER  •  Fax;  678-985-1052 


Monday,  October  9, 9:30-1 1:25  am  (Rooms  213,214) 


Presslre-Time  Waveforms  in  Relation  to  the  Static  Pressure- Volume 
Curve  During  High- Frequency  Oscillatory  Ventilation  of  a  Lung  Model 

Dean  Holland  RRT.  Parkland  Health  and  Hospital  System.  Dallas.  TX 
T.  Al  West  MD  MPH,  University  of  Texas  Southwestern  Medical  School.  Dallas,  TX 

Background:  High  frequency  oscillatory  ventilation  (HFOV)  is  an  alternative  mode  of  ven- 
tilation for  treating  patients  suffering  from  adult  respiratory  distress  syndrome  ( ARDS)  and 
who  aa*  failing  conventional  mechanical  ventilation.  The  use  of  an  open-lung  strategy  during 
HFOV — targeting  airway  pressures  between  the  upper  and  lower  points  on  a  pressure- 
volume  (P-V)  curve — mitigates  the  risk  of  iatrogenic  ventilator  associated  lung  injury.  How- 
ever, a  lack  of  real  time  monitoring  options  makes  optimizing  ventilator  settings  at  the  bed- 
side problematic.  We  hypothesize  that  location  on  the  P-V  curve  Is  reflected  in  qualitative 
changes  in  the  shape  of  pressure-time  waveforms  generated  during  HFOV.  Methods:  A 
static  P-V  curve  was  derived  for  a  modified  Michigan  lung  model,  and  lower  (P-flexL)  and 
upper  (P-flexu)  intlection  points  were  calculated  from  a  fitted  logistic  curve.  The  HFOV  was 
connected  to  the  model  with  rate  (4  Hertz),  bias  flow  rate  (30  L/m).  and  fractional  inspiratory 
time  (.5)  held  constant.  Mean  airway  pressure  (MAP)  was  adjusted  to  values  below, 
between,  and  above  the  inflection  points  of  the  P-V  curve.  At  each  MAP  setting,  pressure- 
time  waveforms  were  obtained  from  the  oscilloscope  and  examined.  Results:  Inflection 
points  calculated  from  the  logistic  curve  were  P-flexL  =  1 7.6  cmH20  and  P-nexu=  38.3 
cmH20.  The  pressure-time  waveforms  obtained  at  three  values  of  MAP  are  shown  in  Figure 
I .  The  waveforms  demonstrate  a  "shoulder"  at  the  beginning  of  the  piston  upsuoke  when 
MAP  <  P-flexL  or  MAP  >  P-flexf-  In  contrast,  when  P-flext  <  MAP  <  P-flexu,  the  upstroke 
of  the  waveform  is  smooth.  Conclusions:  In  this  bench  model,  changes  in  MAP  along  the  P- 
V  cun  e  appeared  to  be  associated  with  demonstrable  changes  in  the  shape  of  the  oscillatory 
waveform.  Graphical  waveform  analysis  may  allow  the  clinician  to  select  optimal  HFOV 
settings  for  a  lung  protective  strategy.  Our  early  experience  with  this  method  in  clinical 
application  has  generated  similar  observations. 


OF-00-087 


DETERMINING  THE  EFFECT  OF  FREQUENCY  AND  AMPLITUDE  ON 
THE  TIDAL  VOLUME  DELIVERED  DURING  HIGH  FREQUENCY  OSCIL- 
LATION .  Khaled  A.  Sedeek  MD.  Munevuki  Takeuchi  MD.  Robert  M.  Kacmarek 
PhD  RRT.  Respiratory  Care,  Massachusetts  General  Hospital  and  Hravard  Medical 
School,  Boston  MA. 

Background:  HFC  has  been  shown  advantageous  in  the  management  of  Infant  Respi- 
ratory Distress  Syndrome  and  has  been  proposed  for  use  in  Adult  Respiratory  Distress 
Syndrome.  However,  limited  data  on  the  effect  of  pressure  amplitude  ((P)  and  rate 
(Hz)  on  the  tidal  volumes  delivered  in  adults  is  available.  The  aim  of  this  study  was  lo 
determine  the  tidal  volume  delivered  at  various  rales  and  (P  during  HFO. 
Methods:  In  six  sheep  (29±2  kg)  severe  lung  injury  was  induced  by  repeated  saline 
lung  lavage  until  the  Pa02  decreased  to  less  than  100  mm  Hg  (65±14  mm  Hg)  during 
VC  (Fi02  1.0,  PEEP  5  cmH20,  VT  12  ml/kg  and  RR  15).  After  stabilization  HFO 
was  initiated  at  a  MAP  equal  to  the  point  of  maximum  curvature  (PMC)  on  the  expira- 
tory limb  of  the  P-V  curve  (27(2.4  cmH20)  (S  Goddon:  AJRCCM.  1 59:  A77,  1 999). 
VT  at  all  combinations  of  rates  4,  6, 8,and  lOHz,  and  pressure  amplitudes  of  30, 40, 
50,  and  60  cmH20  with  an  Fi02  of  1 .0  and  an  In.spiratory  time  of  50%  using  the  Sen- 
somedics  adult  HFO  was  measured.  Row  was  measured  by  a  pneumolachometer  cali- 
brated with  a  400  ml/sec  flow  dehvered  by  precision  flowmeter  (Brooks  Instruments), 
Flow  was  ampUfied  and  digitized  using  a  computerized  graphics  program  (WINDAQ; 
Dataq  histruments  Inc.)  at  1000  Hz  and  recorded  by  using  WINDAQ.  Data  was  con- 
tinuously recorded  for  one  minute  and  three  breaths  were  analyzed  at  each  rate  and  (P 
using  the  WINDAQ  playback  system. 

Results:  Results  (see  table):  VT  was  direcUy  proportional  to  AmpUlude  (P<0.000l ) 
and  inversely  proportional  to  the  Frequency  (P<0.0001 ).  At  60  cm  H20  AP  and  4  Hz  a 
1 3 1  —34  ml  VT  (=  4-5  ml/kg)  was  measured.  Two  way  ANOV A  showed  no  interac- 
tion between  Frequency  and  Amphtude  (all  values  are  Mean  ±S.D.). 

AMPLITUDE 

FREQUENCY 

10  Hz 

8  Hz 

6Hz 

4  Hz 

60cmH2O 

35±l 1  ml 

49±14ml 

75±21  ml 

13l±34ml 

50cmH2O 

30±IOml 

43±l2ml 

64±l6ml 

108+30  ml 

40cmH2O 

24±9  ml 

34±llml 

52±l3ml 

87±24  ml 

30cmH2O 

18±6ml 

26±8  ml 

40±10ml 

64±18ml 

Conclusion:  At  low  rates  and  high  AP  in  this  model  VTs  approaching  conventional 
mechanical  ventilation  are  delivered  during  HFO. 

OF-00-088 

THE  EFFECT  OF  BLIND  PROTECTED  SPECIMEN  BRUSH  SAMPLING  ON 

ANTIBIOTICS  USAGE  IN  PATIENTS  WITH  SUSPECTED  VENTILATOR 

ASSOCUTED  PNEUMONIA 

Authors: 

Paul  E.  Marik.  MD.  FCCM;  .loseph  Lvnott  MS,  RRT:  MicheUc  Croxton,  MT(ASCP)SM 

Edward  Pahner,  RRT:  Larry  Miller,  RRT  and  Gary  P.  Zakiga,  MD,  FCCM 

Diviswn  of  Critical  Care  Medicine,  Respiratory  Services  and  Microbwlogy, 

Washington  Hospital  Center,  Washington.  DC 

ABSTRACT 

Background:  The  diagnosis  of  pneumonia  in  ventilated  patients  is  exceedingly  difficult 
Although  culture  of  tracheal  aspirates  have  poor  diagnostic  value  they  are  frequently  used  to 
diagnose  ventilator  associated  pneumonia  (VAP).  Recentiy,  a  number  of  studies  have 
reported  on  the  diagnostic  value  of  "blind"  protected  specimen  brush  (B-PSB)  sampling  in 
the  diagnosis  of  VAP.  B-PSB  can  readily  and  safely  be  performed  by  Respiratory  Care  Prac- 
titioner's (RCP's).  The  aim  of  this  study  was  to  determine  the  cost-effectiveness  of  B-PSB 
sampling  performed  by  RCP's  in  patients  with  suspected  VAP. 

Methods:  During  a  three  month  run  in  period,  patients  in  our  MICU  with  suspected  VAP 
were  treated  based  on  clinical  criteria  and  tracheal-aspirate  culture.  Following  this  mn  in 
period  the  house-staff,  nurses  and  RTs  were  prevented  from  sending  tracheal  aspirates  for 
culture.  All  patients  suspected  of  having  ventilator  associated  pneumonia  underwent  B-PSB 
sampling  with  quantitauve  culture.  The  B-PSB  sampling  was  performed  by  RCP's  who  had 
been  trained  lo  perfonn  the  technique.  A  PSB  with  a  potential  bacterial  pathogen  in  a 
concenttation  >500  CFU/ml  was  regarded  as  positive. 

Results:  During  the  3  month  run  in  period  172  patients  received  mechanical  ventilation  with 
an  average  of  4.9±3.1  ventilator  days/patient  During  this  period  79  patients  were  treated  for 
VAP.  During  the  3  month  study  period  160  patients  received  mechanical  ventilation  with  an 
average  of  5. 1  ±  2.9  ventilator  days  per  patient  (NS).  58  B-PSB  samplings  were  perfomied  in 
50  patients  for  suspected  VAP.  No  complications  related  to  the  procedure  were  reported.  No 
tracheal-aspirates  were  culnired  during  this  time  period.  Eight  patients  had  positive  PSB  cul- 
njres.  Antibiotics  were  changed  in  3  of  these  patients  based  on  the  PSB  results.  Thirty-eight 
courses  of  antibiotics  (in  36  patients)  were  stopped  based  on  negative  PSB  results.  Twelve 
cases  of  VAP  were  suspected  in  6  patients  receiving  antibiotics  for  other  reasons.  No  change 
in  antibiotics  were  made  in  these  cases  based  on  negative  PSB  results.  The  length  of  mechan- 
ical ventilation  was  5.4  ±  3.2  days  in  the  38  culture  negative  patients  in  whom  antibiotics 
were  stopped  compared  to  8.2  -f  4.7  days  in  the  eight  patients  with  PSB  ptjsilive  VAP 
(NS;p=014s).  The  direct  cost  savings,  as  a  result  of  discontinuing  antibiotics  was  $9500. 
There  were  additional  cost  savings  due  to  the  reduced  number  of  culture  specimens  sent  to 
(he  lab  (approximately  $2,000),  with  a  projected  annual  cost  saving  of  $46,0(X). 

Conclusion:  B-PSB  sampling  is  a  simple  and  cost  efficient  diagnostic  test  that  can  safely  be 
performed  by  RCP's.  Furthermore,  this  study  confirms  that  antibiotics  may   OF-00-091 
be  salely  discontinued  in  patients  with  negative  quantitative  culture  results. 


BAG- VALVE-MASK  VENTILATION  DURING  CPR: 
SMALLER  -nOAL  VOLUMES  EVALUATED 

Thomas  A.  Barnes,  Ed.D.,  RRT,  [  i^m  M  Kaiams.  B.S. 

Depanmcnl  ofCaidioputaionary  Sciences,  Nonheaslem  University,  Boston,  MA  021 15 

The  European  Resuscitation  Council  has  rccommeiuied  smaller  tidal  volumes  of  0.5  L  during 
basic  life  support  ventilation  in  order  to  minimize  gastnc  innation.  The  purpose  of  this  study 
was  to  evaluate  the  amount  of  gastric  mllalion  when  tidal  volumes  (V^s)  ofl  .0  and  0.6  L  an: 
delivered  dunng  CPR,  Methods:  A  mechanical  model  of  the  airway  and  lower  esophageal 
sphincter  (LES)  was  designed  to  smdy  gastric  innation.  A  ventilator  delivering  volume- 
controlled  breaths  was  used  lo  simulate  manual  ventilation.  The  breaths  were  delivered  to  a  wye 
connector,  with  one  leg  connected  to  a  Bio-Tek  Instnimcnts  VT- 1  test  lung  and  the  other  leg 
connected  to  a  water  column  pressure  valve  to  mimic  LES.  The  volume  of  gas  passing  through 
LES  was  measured  with  a  Timetet  RT-200  calibration  analyzer.  VtS  of  I.O  L  and  0,6  L  were 
delivered  with  inspiratory  time  (Ti)  of  1 .0,  1 ,5,  and  2.0  s  at  lung  compliance  (Cl)  of  O.  100, 
0.040,  0.020  L  cm  HjO'.  The  effect  of  esophageal  opening  pressures  (EOP)  of 
20,  15,  10,  and  5  cm  HiO  were  also  evaluated.  Results:  Decreasing  Vj  from  1 .0  L  to  0.6  L 
significantly  (PO.OOOl)  reduced  gastric  inflation  at  T,  of  1 .0  and  1 .5  s  al  all  three  C,.s 
Lengthening  Ti  to  1 .5  or  2.0  s  improved  lung  inflation  and  decreased  gastric  inflation,  but 
minimal  improvement  was  observed  when  Cl  was  0,040  and  0.020  L  cm  HjO'    Gastric 
mflation  was  significanlly  (P<0.0001 )  higher  at  C^s  of  0  040,  0.020  L  cm  HjO  .  When  EOP 
was  <10  cm  HiO  with  a  V^  of  0.6  L,  gastric  inflation  was  significantly  (P<0.0001)  higher. 

VQkMW  tB  Stomaea  -  COP  W  cm  H,0 


1SMlM.(10>|   lOWml-llSlI  lOflOmLP.O*)    KOmLllOW     l«8m(.11.ftl     «M«ll(aOl) 

Conclusion:  Smaller  tidal  volumes  reduce  gastric  inflanon  during  bag-valve-mask  ventilation. 
The  use  of  smaller  tidal  volumes  with  bag-valve-maik  venhUtion  is  more  critical  when  the 
EOP  and  Cl  are  decreased.  OF-00-092 


Respiratory  Care  •  August  2000  Vol  45  No  8 


1011 


Monday,  October  9, 9:30-11:25  am  (Rooms  213,214) 


LUNG  RECRUITMENT  MANEUVERS  UTILIZING  AIRWAY  PRESSURE 
RELEASE  VENTILATION 

Lori  Hand,  BSC,  RRT,  CHT;  Maureen  Meade,  MD.  FRCPC,  MSC;  McMaster  Univer- 
sity. Hamilton  Health  Sciences  Corporation,  Hamilton.  Ontario.  Canada 

BACKGROUND:  Patients  with  acute  lung  injury  are  prone  to  further  lung  injury  from 
alveolar  collapse  and  cyclic  lung  reopening.  Lung  recruiunent  maneuvers  (LRMs)  may 
prevent  this  ventilator-induced  lung  injury.  Traditionally.  LRMs  are  conducted  using 
continuous  positive  airway  pressure  (CPAP)  in  the  range  of  30  to  45  cmH20.  for  20  to 
40  seconds.  Newest  generation  mechanical  ventilators  may  not  allow  CPAP  levels  as 
high  as  45  cmH20.  The  purpose  of  this  exercise  was  to  explore  the  use  of  APRV  mode 
for  conducting  LRMs.  METHOD:  We  conducted  LRMs  in  20  patients  using  APRV  as 
follows.  We  set  the  high  pressure  to  the  desired  inflation  pressure  for  the  LRM;  low 
pressure  to  maximum  (not  exceeding  high  pressure);  high  pressure  time  was  maximized 
(30  .sees)  and  low  pressure  time  minimized  (0. 1  sec).  To  initiate  the  LRM  we  switched  to 
iAPRV  mode  and  clocked  the  desired  duration  manually,  then  returning  to  tlie  previous 
mode  of  ventilation.  We  monitored  ventilatory  and  hemodynamic  parameters.  Patients 
were  given  no  additional  sedation  for  the  LRM.  RESULTS  and  EXPERIENCE: 
LRMs  conducted  using  APRV  mode  were  .similar  to  those  using  CPAP  mode  with 
respect  to  hemodynamics  and  gas  exchange  variables.  Respiratory  therapists  performing 
the  LRM  found  the  APRV  procedure  simple  to  perform.  Patients  tolerated  the 
procedure  very  well;  no  LRJVls  were  aborted  due  to  patient  discomfort. 
CONCLUSION:  LRMs  via  APRV  appear  to  be  equal  to  that  deUvered  via  the  CPAP 
mode,  as  pressure  delivered  in  APRV  is  technically  achieved  in  the  same  manner  as 
CPAP  pressure.  This  allows  no  increase  in  manpower  (having  to  change  ventilators) 
when  a  patient  is  ventilated  with  a  newer  generation  ventilator  that  does  not  allow  CPAP 
levels  as  high  as  45  cmH20.  A  more  in  depth  comparison  needs  to  be  followed  out  to 
adequately  assess  this  issue. 


OF-00-093 


EFFECTS  OF  PEAK  PRESSURE  DURING  THE  PRESSURE- VOLUME 
CURVE  MEASUREMENT  IN  AN  ARDS  SHEEP  MODEL 

Munevuki  Takeuchi.  MD.  Khaled  A.  Sedeek,  MD,  Robert  M.  Kacmarek,  PhD 
RRT.  Respiratory  Care,  Massachusetts  General  Hospital  and  Harvard  Medical 
School,  Boston.  MA 

The  use  of  static  PV  curves  have  been  recommended  for  the  proper  setting  of 
mechanical  ventilation.  It  is  well  accepted  that  a  previous  volume  history  must  be 
established  prior  to  measurement  of  the  PV  curve,  however  the  effect  of  the  volume 
history  along  with  the  maximum  pressure  established  during  the  PV  curve  has  not 
been  explored  in  detail.  Methods:  Stable  severe  lung  injury  was  created  by  saline 
lavage  in  6  sheep  (25kg-32kg).  Lavage  was  repeated  until  the  Pa02  <  80  mmHg 
during  volume  ventilation.  VT  12  mL/kg,  PEEP  5  cmH20  and  FI02  1 .0.  After  60 
min  of  stabilization,  hemodynamics  and  blood  gases  were  measured.  After  which  4 
PV  curves  were  sequentially  obtained  with  peak  pressure  (PIP)  of  40.  50.  60  and  40 
cmH20  performed  20  minutes  apart.  In  addition,  the  ventilator  was  adjusted  to 
increase  the  tidal  volume  to  insure  the  same  pressure  for  1  minute  prior  to  the  mea- 
surement. Quasi-static  inflation  and  deflation  limbs  were  obtained  by  the 
supersyringe  technique.  Measured  volume  was  corrected  for  temperature,  humidity, 
gas  compression,  02  consumption  and  C02  production  as  described  by  Gattinoni 
( I ).  Pflex  on  the  inflation  limb,  true  inflection  point  (Pinf-d)  and  point  of  maximal 
curvature  on  the  deflation  limb  (Pmc-d)  were  calculated  by  Venegas's  mathematical 
sigmoidal  equation  (2).  Results:  There  were  no  differences  in  hemodynamics  or 
blood  ga.ses  before  and  after  the  measurements.  In  3  of  6  sheep.  Pflex  at  PIP  40 
could  not  be  determined  mathematically  (therefore  Pflex  at  PIP40  were  excluded 
from  statistics)  but  Pflex  clearly  appeared  when  PIP  was  raised  to  50  or  60. 


PIP40 


PIP50 


P1P60 


PIP40-2 


Pflex 
Pinf-d 
Pmc-d 


19.2  ±1.9 
6.1  ±4.2 
29.1  ±5.8 


22.4  ±1.7 
13.4  +  2.7* 
33.6  ±  5.6  • 


24.0  ±  1.6  # 
16.7  ±2.7* 
36.3  ±  5.0  * 


21.5  ±3.6 
7.8  ±4.8 
3I.7±5.8 


Values  are  mean  ±  SD  (cmH20).  *  p<0.05  vs.  PIP40,  #  p<0.05  vs.  PIP50. 
Conclusion:  Previous  volume  history  and  peak  pressure  during  the  PV  curve 
determination  affected  the  values  for  Pflex,  Pinf-d  and  Pmc-d  in  an  ARDS  sheep 
model.  Furthermore,  if  peak  pressure  is  inadequate,  respiratory  system  mechanics 
maybe  misleading. 

References:  (I )  Gattinoni  L,  et  al.  ICM  13;  19-25.  1987.  (2)  Venegas  JG,  et  al. 
JAP  84:  389-395,  1998.  OF-00-094 


COMPARISON  OF  THE  MEASURED  VS.  CALCULATED  TIDAL 
VOLUME  IN  THE  BENCH  TOP  STUDY  USING  PIPER-IPPB 

Shawan  Huff,  RRT.  Mercy  General  Hospital,  Sacramento,  CA,  USA 
BACKGROUND:  Intermittent  Positive  Pressure  Breathing  (IPPB)  is  a  technique 
used  to  provide  short-term  or  intermittent  mechanical  ventilation  for  the  purpose  of 
augmenting  lung  expansion,  delivering  aerosol  medication,  or  assisting  ventilation 
[1],  To  assess  the  therapeutic  efficacy  of  an  IPPB  treatment,  tidal  volume  may  be 
measured.  This  study  compares  the  measured  tidal  volume  and  the  calculated  tidal 
volume  of  the  Piper-IPPB  device. 

Methods:  The  Piper-IPPB  is  connected  via  a  custom  adapter  to  a  Wrights 
Respiromeler  Mark  14  and  then  to  a  Michigan  Instruments  Inc.  Vent  Aid  TTL. 
Timing  is  accomplished  using  a  Sportline  Alpha  I  410  Splitimer.  A  Timeter  flow 
meter  is  connected  to  a  50-PSI  air  source  and  40  LPM  is  supplied  to  Piper-IPPB 
nebulizer.  The  inspiratory  time  is  controlled  by  adjusting  PIP  and  lung 
compliance.  For  ten  breaths  cycles  both  I-time  and  delivered  tidal  volume  are 
summed  and  averaged.  Fifteen  points  are  collected  and  the  average  tidal  volumes 
obtained.  The  calculated  tidal  volume  is  obtained  using  the  calculation  (I-time  x 
Flow  =  Tidal  Volume).  Flow  =  40  LPM 

Results:  The  average  measured  and  calculated  tidal  volumes  are  summarized 
below. 


I-time  (Seconds) 

Meas.  VI  (L) 

Calc.  Vt  (L) 

%  Difference 

1.0 

.565 

.663 

15% 

1.2 

.707 

.829 

15% 

1.5 

.862 

1.033 

17% 

1.9 

1.157 

1.290 

10% 

2,2 

1.210 

1.451 

17% 

Discussion:  To  assess  the  therapeutic  efficacy  of  an  IPPB  treatment,  tidal  volume 
may  be  measured.  Handheld  spirometers  and  venticomp  bags  are  two  of  the 
volume  measuring  devices  currently  used.  Tidal  volume  can  also  be  calculated 
using  the  calculation  (I-time  x  Flow).  There  is  only  an  approximate  15%  difference 
between  the  measured  tidal  volume  of  the  Piper-IPPB  and  the  calculated  tidal  vol- 
ume.   This  may  be  due  to  inherent  leaks  or  timing  errors. 

Conclusion:  Since  there  is  only  an  approximate  15%  difference  between  the  cal- 
culated and  measured  tidal  volumes.  The  calculated  value  may  be  a  more  efficient 
and  cost  effective  way  to  monitor  patient  tidal  volume  when  giving  iPPB 
treatments.  Further  studies  are  warranted. 
Supported  by  VORTRAN  Medical  Technology  1 ,  Inc. 

1 1 1    Agency  for  Health  Care  Policy  and  Research  { AHCPR).  Health  Technology 
Reports:  intermittent  positive  pressure  breathing  (IPPB)  therapy. 
1991.  Number  I. 


OF-00-105 


PENETRATION  OF  A  DISTALLY  DIRECTED  TGI  WAVE  FRONT  WITH  OPPOS- 
ING (EXPIRATORY)  FLOW.  Chris  Carter  M.D.,  Alexander  Adams  RRT.  Mary  Stone 
RRT,  John  Marini  M.D.  Regioas  Hospital,  St.  Paul.  MN 

Introduction:  Airflow  dynamics  in  the  upper  airway  during  expiration  are  altered  significantly 
by  U^acheal  gas  insufflation  (TGI).  Presumably,  a  cone  of  TGI  flow  emitting  fix)m  the  catheter 
tip  penetrates  distally  to  flush  C02  from  anatomical,  then  mechanical  deadspace.  An  artificial 
airway  model  was  constmcled  to  study  distally  directed  TGI  flow  dynamics  retrograde  to  a 
bias  (expiratory)  flow. 

Methods:  A  #7.0  Mallinckrodi  Hi-Lo  endotracheal  tube  (ETT)  was  inserted  into  a  smooth 
plastic  tube  (14  mm  ID,  60  cm  in  length)  and  TGI  flow  consisting  of  lOOf^  oxygen  was  emit- 
ted from  the  distal  tip  of  the  ETT.  A  bias  flow  of  100%  nitrogen  (representing  expiratory  flow) 
was  delivered  into  the  opposite  end  of  the  tube  to  oppwse  the  TGI  flow.  An  extremely  sensitive 
oxygen  analyzer  ( Ametek,  Pittsburg,  PA)  sampled  02  concentrations  from  a  matrix  of  sites  (in 
a  range  of  depths/distances  from  the  TGI  source)  to  profile  TGI  gas  penetration.  A  range  of 
TGMsias  flows  was  tested.  A  rigid  TGI  catheter  positioned  medially  was  also  tested  in  straight. 
bifurcated  and  cormgated  airway  models. 

Results:  Under  several  tested  conditions,  TGI  distal  penetration  was  significant,  extending  as 
far  as  13  cm  fn>mtheTGI  source.  TGI  gas  commonly  appeared  at  5- 1 0  cm  from  the  source 
despite  high  bias  flows.  A  non-cone  front  was  often  observed  with  TGI  gas  appearing  to 
adhere  to  the  simulated  tracheal  wall,  not  centrally  projected  as  previously  thought  In  the 


Cwlna 


bifurcated  model,  TGI  penetration  extended  further  along  the  lower  bias  flow  limb  (figure  - 
degree  of  shading  =  02  %). 

Conclasioas:  In  this  model,  retrograde  directed  TGI  penetration  (distal  effect  TGI)  was 
marked  and  may  augment  C02  washout  effect.  Although  reUDgrade  TGI  may  induce 
autoPEEP.  the  additional  C02  washout  by  distal  effect  TGI  may  be  a  favorable  tradeoff.  In  the 
bifurc-ated  model,  the  additional  TGI  penemuion  toward  the  lower  bias  flow  limb  suggests  that 
distal  effect  TGI  may  selectively  enhance  C02  washcxit  from  more  slowly  emptying,  higher 
PAC02  alveolar  regions. 


OF-00-106 


1012 


Respiratory  Care  •  August  2000  Vol  45  No  8 


Monday,  October  9, 9:30-1 1:25  am  (Rooms  213,214) 


TRACHEAL  GAS  INSUFFLATION  (TGI)  DURING  LATE  EXHALATION 
REDUCES  PaC02  WHILE  SPARING  TGI  GAS  -  AIRWAY  EXPOSURE 
TIME.  Alexander  B.  Adams  RRT.  Man  Stone  RRT,  Pete  Bliss  BME,  Chris 
Carter  M.D.  Regions  Hospital,  SL  Paul,  MN 

Background:  TGI  reduces  PaC02  by  flushing  the  potentially  rebreathable  alveolar 
gas  from  mechanical  and  anatomical  deadspace  regions  during  exhalation.  There- 
fore, during  inspiration  and  early  expiration  TGI  is  not  effective  and  unnecessarily 
exposes  the  airways  lo  gas  thai  may  be  dry  and  cool.  Carefully  controlled  late  expi- 
ratory TGI  (leTGI)  may  flush  C02  effectively  while  reducing  TGI  gas  -  airway 
exposure  time. 

Methods:  Six  normal  pigs  were  instrumented  and  anesthetized  in  an  oleic  acid  lung 
injury  (OAl)  protocol.  PaC02  was  monitored  continuously  with  an  indwelling 
ABG  catheter  system  (Paratrend  7+.  Diametrics).  After  OAI  was  established,  vol- 
ume control  ventilation  was  set  at  f  =  12. 1;E  =1:2  and  a  tidal  volume  producing 
PaC02  levels  between  60-75  mmHg.  Expiratory  TGI  flow  at  5  Umin  was 
delivered  via  one  channel  of  a  Mattinckrodt  #7  Hi-Lo  lube  positioned  2.5  cm  above 
the  carina.  Using  a  phasic  controller  for  TGI,  ventilator  airflow  was  tracked  and 
TGI  delivery  was  gated  for  either  20, 40,  60,  or  1 00%  (in  random  order)  of  the  lat- 
ter portion  of  expiration. 

Results:  The  figure  displays  mean  PaC02  ±  s.d.  for  baseline  settings  and  the  tested 
leTGI.  PaC02  reduction  from  baseline  was  significant  al  leTGI  of  40%  and  100% 
(p<.01 ).  Of  note  was  the  PaC02  reduction,  although  not  statistically  significant,  at 
only  20%  leTGI. 


r 


TBI   -^o«i 


Conclusions:  Selective  leTGI  caused  reductions  in  PaC02  in  this  model  of  lung 
injury.  While  the  IeTGI%  causing  a  maximal  C02  elimination  may  vary  with  the 
patient's  impedance  condition  and  ventilator  settings  in  use,  leTGI  spares  the  possi- 
ble drying  and  cooling  effects  of  TGI  gas  during  inspiration  and  portions  of  exhala- 
tion. The  use  of  leTGI  should  also  lessen  concern  about  TGI  delivery  causing  pres- 
sure generation  beyond  a  tube  narrowing  or  occlusion. 

OF-00-107 


AN  INCREASE  IN  END  EXPIRATORY  LUNG  VOLUME  DUE  TO  TIDAL 
RECRUITMENT  CAN  BE  SIGNIHCANT  IN  INJURED  LUNGS.  Chris 
Carter  M.D„  Alexander  Adams  RRT.  John  Hotchkiss  M  J).,  Mary  Stone  RRT, 
John  Marini  M.D.,  Regions  Hospital,  SL  Paul,  MN 

Background:  End  expiratory  lung  volume  (EELV)  status  during  mechanical  ventila- 
tion is  dependent  on  ihe  underiying  FRC  (al  ZEEP),  applied  PEEP,  autoPEEP  if  pre- 
sent and  tidal  recruitment.  Tidal  recruitment  (TR)  is  defined  as  an  increase  in  EELV  - 
above  the  EELV  predicted  by  PEEP  alone  -  resulting  from  the  current  ventilatory 
strategy.  TR  may  be  dependent  on  the  status  of  (he  lungs.  PEEP,  1:E.  frequency, 
and/or  tidal  volume.  Our  goal  was  to  delect  and  measure  an  effect  of  lung  injury,  tidal 
excursion  and  the  PEEP  setting  on  TR  in  a  model  of  lung  injury. 
Methods:  In  an  oleic  acid  lung  injury  model,  pressure- volume  (P-V)  curves  and  TR 
determinations  were  made  before  and  after  injury  in  5  pigs  (wt.~  22  kg.).  P-V  curves 
were  generated  by  the  super  syringe  method.  TR  was  measured  by  disconnecting  the 
ventilator  and  tracking  the  drop  in  lung  volume  by  inductance  plethysmography  for 
30  seconds  after  disconnection.  TR  was  measured  under  8  conditions  in  each  animal 
alPEEP  =  0,5,  10,  15cmH20,  PCV  excursions  of  I0cmH2O  (low  excursion)and  30 
cmH20  (high  excursion),  f  =  10/min  and  I:E=1 :2.  AutoPEEP  was  not  detected. 
Results:  TR  was  present  preinjury  but  was  significantly  greater  post  injury  (p<.OI).  A 
PCV  of  30  cmH20  resulted  in  greater  TR  than  PCV  of  10  cmH20  (p=.0005.  see  fig- 
ure). There  was  also  an  association  between  PEEP  and  TR,  pre  and  post  injury,  as 
tested  by  ANOVA  (p<.OI). 

Conclusions:  TR  was  significant  in  this  model  of  lung  injury  and  may  be  of 
importance  during  ventilation  of  injured  lungs  in  ALI/ARDS.  Injury  presence  ,  tidal 
excursion  and  PEEP  were  important  in  generating  TR  but  related  factors  not 
evaluated  in  this  study  such  as  frequency,  I;E,  or  inspiratory  flow  profile  may  be  of 
equal  or  greater  importance. 


Po«tln]ury  -  End  Expiratory  Lung  Volum* 


■s-ioao 

i  ^ 

5 


High  Excursion 
Low  Excursion 


Pressure  (cmH20) 


--00-108 


THE  EFFECT  OF  BI-LEVEL  VENTILATION  ON  OPIOID  UTILIZATION 
IN  A  MEDICAL  INTENSIVE  CARE  UNIT 

John  Saul  RRT.  Ken  Hargett  RRT,  Lisa  Weavind  MD,  Andrew  Shaw  MD,  Mechelle 

Williams  RN  ACNP-CS,  Susannah  Kish  RN  CS  CCRN  CPAN 

The  University  of  Texas  M  D  Anderson  Cancer  Center,  Houston,  Texas 

Introduction:  Opioid  drugs  are  widely  prescribed  for  mechanically  ventilated 
patients  in  the  medical  intensive  care  unit  (MICU),  both  for  analgesia  and  anxiolysis. 
It  has  been  suggested  that  the  need  for  opioids  may  be  related  to  dysynchrony  and 
agitation  while  connected  to  the  ventilator.  A  new  mode  of  ventilation  (BiLevel)  has 
recenUy  been  introduced  that  might  allow  the  patient  to  be  more  comfortable.  The 
current  study  compared  the  use  of  opioid  drugs  in  MICU  patients  before  and  after  the 
introduction  of  the  new  mode. 

Methods:  Data  relating  to  opioid  use  were  collected  in  25  patients  (conventional 
group)  before  the  introduction  of  Bi-Level  and  in  1 2  patients  (BiLevel  group)  after- 
wards. Opioid  usage  was  collected  on  day  1,2.3  and  day  7  after  institution  of 
mechanical  ventilation.  All  opioid  dosages  were  converted  to  an  equivalent 
parenteral  dose  of  morphine  sulfate  for  comparison.  Groups  were  compared  using 
chi  square  or  Mann  Whitney  U  tests  (data  sets  not  ncvmally  distributed). 

Results:  Both  groups  were  similar  in  terms  of  age,  gender,  and  type  of  malignancy. 
Patients  in  both  groups  had  similar  etiologies  for  their  respiraloi7  failure.  Data  shown 
in  the  table  represent  mean  (SE)  values. 


n         Age 

Gender 

Malignancy 

Daily  opioid 

(years) 

(%  male) 

{9c  hematologic) 

dose  (mg) 

Pre  BiLevel 

25       57  (3) 

56 

72 

247  (46) 

Post  BiLevel 

12       52(5) 

67 

67 

147  (55) 

p  value 

.35 

.72 

.74 

.03 

Condusions:  Our  data  suggest  that  BiLevel  mode  of  ventilation  may  be  associated 
with  a  reduced  requirement  for  opioid  drugs  in  critically  ill  cancer  patients.  Further 
studies  examining  the  relationship  of  analgesia  and  sedation  management  related  to 
ventilator  mode  are  waiianted. 

OF-00-114 


EFFECTS  OF  IMPEDANCE  TO  MECHANICAL  VENTILATION  ON  RESISTANCE 
MEASUREMENTS 

Frank  Dennijoii,  MEd,  RRT,  RPFT,  Kitty  Hemlen,  MBA,  RRT,  Rick  H«U.  MS,  RRT,  RPFT 
Arthur  Taft,  PhD,  RRT,  Medical  College  of  Georgia,  Augusta,  GA,  and  Jaaoo  Huater,  RRT 
Medical  Center  of  Central  Georgia,  Macon,  GA. 

Measuirment  of  total  respiraiory  system  resistance  (Rim)  is  a  clinically  useful  tool  for 
assessing  Raw.  However,  it  includes  measuring  resistance  through  the  ventilator  circuit, 
which  changes  (i.e.,  expands)  during  positive  pressure  ventilation.  To  determine  if  the 
ventilator  circuit  contributes  lo  errors  in  resistance  measurement,  we  designed  a  bench  study 
to  evaluate  Rns  measurement  (PIP  -Ppause/Flow)  using  a  mechanical  model  so  that  airways 
and  circuit  resistance  were  fixed  (constant)  at  a  given  flow  rate.  Research  question:  wil 
changes  in  lung  compliance  (CJ  affect  die  accuracy  of  resistance  measurements  as  currently 
practiced?  Medud:  We  used  a  Bird  8400sti  to  ventilate  a  Michigan  Instruments  Trainin) 
Test  Lung  (TTL)  at  a  set  VT  (1.0  L)  using  dry  air,  conventional  circuit,  HME  and  size  1 
ETT.  Rms  was  calculated  ftom  measured  flows.  PIP  and  Ppause,  which  were  made  using  a 
Timeter  RT200.  Alterations  in  lung  impedance  were  created  by  changing  total  Cl  (0.1  to 
0.01  Ucm  H;0)  and  altering  airway  resistance  using  2  Pneuflo  Resistors  (Rp20  and  Rp5)  in 
line  u>  die  TTL.  Measurements  were  repeated  (n  =  10)  at  flows  of  30.  60  and  90  l^min  with 
and  without  the  TTL  in  line  for  comparison.  ANOVA  for  repeated  measures  was  used  f« 
statistical  analysis  of  data.  ResistaiKe  measurements  whh  no  impedance  (None  in  Table)  to 
ventilation  are  accurate  and  set  die  standard  for  comparison. 

Rto  (cm  HiO/Us) 
30  Umin 

RT„(cmH:0/Us) 
60  Umin 

Rna(cmH,04^s) 
90  Umin 

Cu 

Rp20 

Rp5 

Rjj20 

Rp5 

Rp20 

Rp5 

None 

18.1 

II. 1 

30.5 

15.8 

43.5 

21.3 

0.10  Ucm  H:0 

16.2 

9.9 

27.1 

14.6 

38.6 

19.6 

0.07  Ucm  H;0 

15.7 

9.6 

26.8 

14.0 

37.8 

18.9 

0.04  Ucm  HjO 

14.9 

9.1 

24.6 

13.2 

35.3 

17.8 

0.01  UcmHiO 

9.7 

59 

15.9 

7.9 

22.3 

10.2 

Results  clearly  demonstrate  t 
study  (not  shown)  suggest  Ui 
a  result  of  positive  pressure 
time   (flow)   is  reduced.   1 
measurements.  The  clinical  i 
in  airways  (i.e..  inflammatio 
7y  the  decreases  in  die  meas 
there  is  a  decrease  in  C^. 

hat  Km  is  reduced  as  Cl  is  reduced  (P  <  0.001 ).  Oatt  trom  die 
at  this  decrease  in  resistance  is  caused  by  a  reduction  in  flow  as 
expanding  circuit  tubing.  As  the  circuit  expands,  volume  ovet 
hus,   reduction   in   flow   causes  the   reduction   in  the   R™ 
mportance  of  this  bench  study  is  Uial  pathophysiologic  changes 
1  or  obstruction),  which  cause  increased  Raw.  may  be  obscured 
ured  circuit  resistance  included  in  the  Rns  measurements  when 

OF-00-137 

Respiratory  Care  •  August  2000  vol  45  No  8 


1013 


Monday,  October  9, 9:30-1 1:25  am  (Rooms  213,214) 


RELATIONSHIP  OF  RAPID  SHALLOW  MECHANICAL  VENTILATION  PATTERN 
(FREQUENCYmOAL  VOLUME  RATIO:  F/VT)  TO  PHYSIOLOGIC  DEADSPACE 
FRACTION  (VDrtni  EARLY  IN  THE  ACUTE  RESPIRATORY  DISTRESS 
SYNDROME  (ARDS) 

RH  Kallel  RRT.  J-F.  Pittet  MD,  T  Nuckton  MD.  JA  Alonso  RRT,  B  Daniel  RRT,  MA 
Matthay  MD,  University  of  Califbmia,  San  Francisco:  San  Francisco  General 
Hospital.  San  Francisco,  CA  941 10 

Background:  Minute  ventilation  ( V  e)  delivered  with  a  rapid,  shallow  pattern  may 
vrorsen  cartwn  dioxide  (CO2)  gas  exchange  for  4  reasons:  1 .)  as  Vt  decreases 
relative  Vo  increases  because  anatomic  deadspace  is  fixed:'  2.)  at  high  F, 
inspiratory  time  (Ti)  shortens  and  decreases  CO2  diffusion  between  alveolar  and 
atnvay  gases:'  3.)  tissue  resistance  in  ARDS  is  F-dependent  so  that  high  F  may 
result  in  ventilation  inhomogeneity:'  4.)  high  F  decreases  expiratory  time  (Te),  which 
may  cause  dynamic  hyperinflation  and  intrinsic  positive  end-expiratory  pressure 
(PEEPi).'  Therefore,  we  evaluated  the  effect  of  a  rapid  shallow  pattern  (FA^t  )  and 
PEEPi  on  Vo/Vt  and  in  early  ARDS. 

Methods:  Vd/Vt  was  measured  on  Assist/Control  ventilation  In  110  patients  on  Day 
1  of  ARDS.  An  arterial  blood  gas  was  obtained  while  measuring  mean  expired  CO2 
concentration  with  a  Deltatrac  metabolic  monitor.'  Mean  expired  CO2  was  corrected 
for  compressible  volume  dilution.'  Vt  and  V  e  were  corrected  for  compressible 
circuit  loss.  Regression  analysis  was  done  comparing  F,  Vt,  Ti,  PEEPi  and  FA/t  to 
Vd/Vt  Alpha  was  set  at  O.OS. 

Result*:  Both  F/Vt  and  F  showed  as  moderate  positive  con-elation  with  Vd/Vt  (r  = 
.48').  Ti  showed  a  moderate  negative  correlation  vinth  VoA/t  (r  =  -.41').  In  contrast, 
Vt  showed  a  weali  negative  correlation  to  ViWt  (r  =  -.32').  PEEPi  could  be 
measured  in  29  patients  and  was  detected  in  23  patients  (3.09  ±  3.16  cm  H2O). 
PEEPi  correlated  poorly  with  VdA/t  (r  =  .17).  Substituting  Te  as  an  indirect  marker 
for  dynamic  hyperinflation  showed  a  similar  poor  con^elallon  with  Vo/Vt  (r  =  .12). 
Conclusions:  A  rapid  shallow  mechanical  ventilation  pattern  is  associated  with 
Increased  Vd/Vt  with  F  as  the  predominant  factor.  The  moderate  correlation 
between  both  F  and  Ti  with  Vd/Vt  (in  contrast  to  Vt,  Te  and  PEEPi)  suggests  that 
ventilatkm  inhomogeneity  may  be  the  most  important  ventilation-related  factor 
Influencing  deadspace  in  early  ARDS. 

1.  Shapiro  BA.  Clinical  application  of  blood  gases.  St  Louis:  Mosby;  1994  P29-30. 

2.  Fowler  WS.  The  respiratory  deadspace.  Am  J  Physiol.  1948;  154:  405-416. 

3.  Broaeghini  C,  Brandolese  R,  et  al.  Respiratory  i«sisiance  and  intrinsic  PEEP  in  patients 
widi  ARDS.  EurRespirJ  1988;  1:  726-731.. 

4.  Lum  L,  Saville  A,  et  al.  Accuracy  of  physiologic  deadspace  measurement  in  intubated 
pediatric  patients  using  a  metabolic  monitor.  Cril  Care  Med.  1998^16: 760-754. 

{'p<0.05). 

OF-00-141 


EVALUATION  OF  TUBE  COMPENSATION  AND  PRESSURE  SUPPORT  ON 
REDUCING  IMPOSED  WOB  IN  RESPONSE  TO  VARIATIONS  IN 
INSPIRATORY  DRIVE.  Robert  S.  Campbell  RRT.  FAARC.  James  J.  Lawson  RRT. 
Sandra  L.  Miller  MD,  Jay  A.  Johannigman  MD,  Fred  A.  Luchette  MD,  Kenneth  Davis  Jr. 
MD,  Paul  Austin  CRNA  MS  (LtCol  USAF  NC),  Richard  D.  Branson  BA,  RRT.  Division 
of  Trauma/Critical  Care,  University  of  Cincinnati  College  of  Medicine. 
Introduction:  Resistance  (R)  of  artificial  airways  ( AA)  is  recognized  as  a  cause  of 
increa,sed  WOB  in  mechanically  ventilated  pis.  Pressure  support  (PS)  is  commonly  used 
to  reduce  the  WOB  imposed  by  AAs.  Tube  Compensation  (TC)  is  a  newer  feature  of  two 
ventilators  that  may  offer  advantages  over  PS  in  overcoming  imposed  WOB  due  to  the  R 
of  AA.  We  evaluated  the  imposed  WOB  and  ventilator  output  during  TC  and  PS  in  a 
spontaneously  breathing  lung  model  with  varying  inspiratory  flow  demands.  Methods:  A 
two-chamber  test  lung  (TTL)  was  modified  to  simulate  spontaneous  breathing  with  the 
addition  of  a  lift  bar.  A  Hamilton  Galileo  was  used  to  "drive"  the  lung  model  at  a  Vx  of 
500  ml  and  three  inspiratory  flow  demands  (25,  37,  and  50  IVmin)  using  a  constant  inspi- 
ratory flow  pattern  and  5  cmH20  PEEP.  Test  lung  compliance  was  50  m!/cmH20  and  a  6 
or  8  mm  ID  standard  endotracheal  mt>e  provided  resistance.  Two  ventilators  (840  and 
Evita')  with  TC  were  used  to  ventilate  the  patient  lung.  At  each  condition,  vents  were  set 
in  spont  mode  with:  I)  no  PSV  orTC,  2)  100%TC,and3)  lOcmHiOPSV. 
Measurements  included  imposed  WOB,  peak  negative  pressure  (PNP),  peak  inspiratory 
and  expiratory  flow  rate,  peak  airway  pressure,  and  Vj.  Results:  Imposed  WOB  increased 
and  PNP  became  more  negative  as  inspiratory  flow  demand  increased.  As  a  percentage  of 
the  total  WOB  imposed  without  TC  or  PSV,  TC  provides  a  more  consistent  reduction  in 
WOB  at  each  flow  demand  (65%  @  25,  71%  @  37,  and  64%  @  50  L/min)  versus  PSV 
(89%  @  25, 66%  @  37,  and  27%  @  50  Umin).  Figure  1  reveals  the  imposed  WOB 
(mJ/L)  for  each  vent  at  all  flow  demands  at  all  conditions  tested  with  a  6.0  ET  tube. 


PIFR  and  PEFR  increased  as  flow  demand  increased  in  all  conditions,  and  both  were 
highest  with  the  E*.  With  PSV,  Vj  was  highest  at  low  flow  and  was  reduced  as  flow 
demand  increased.  With  TC,  Vj  was  lowest  at  low  flow  and  increased  as  flow  demand 
increased.  Imposed  WOB  was  slightly  lower  on  the  840  in  all  conditions. 
Conclusion:  TC  offers  advantages  over  PSV  in  reducing  imposed  WOB  in  response  to 
varying  inspiratory  flow  demand. 


OF-00-142 


Bench  Test  of  Drager  E4  Ventilator  with  Helium-Oxygen  Mixtures.  .lohn  Newhart  RCP. 
Ci^g  Pedersen  RCP,  Timothy  Mortis  M.D.,  UCSD  Medical  Center,  San  Diego  CA. 
BACKGROUND:  We  have  used  the  Drager  Evita  4  ventilator  to  deliver  helium  oxygen  mix- 
tures (He02)  to  mechanically  ventilated  patients  at  our  institution  for  2  years.  He02  is  used  to 
treat  patients  with  upper  airway  obstruction  by  promoting  laminar  flow  past  the  obscmction 
thus  reducing  the  work  of  breathing.  This  may  also  improve  the  disuibution  of  ventilation. 
Administering  He02  mixtures  through  an  ICU  type  ventilator  requires  an  understanding  of 
how  helium  effects  the  gas  delivery  characteristics  of  the  ventilator.  HeOs  mixtures  of 
80%/20%  have  a  lower  density  than  air  (80/20HeO2-.429g/L  vs.  Air- 1 .293g/L),  affecting  ven- 
tilator function.  The  heat  carrying  capacity  of  He  is  al.so  greater  than  air  causing  hot  wire  flow 
sensors  in  the  ventilator  to  overestimate  derived  volumes.  We  sought  to  determine  He02 
effects  on  ventilator  fiinction  relative  to  accuracy  of  volume  and  F102  delivered.  METHODS: 
Al!  testing  was  done  with  the  ventilator  in  PCV  mode  (open  breathing  system),  adult  range. 
Volumes  were  measured  with  a  Bio  Tek  VTI  (Winooski,  VT)  test  iung.  Oxygen  was 
measured  external  to  the  ventilator  with  an  electrochemical  type  (Mini-Ox  I,  MSA,  Pittsburgh, 
PA)  analyzer.  The  hot  wire  exhalation  flow  sensor  was  removed  due  to  its  incompatibility  in 
measuring  He  mixtures.  RESULTS:  Using  an  80/20  HeOz  mixture  connected  to  the  air  inlet 
of  the  ventilator,  we  found  the  measured  volumes  to  be  coasistent  regardless  of  the  oxygen 
concentration  delivered.  The  ventilator  O2  monitor  was  within  1  %  of  the  external  analyzer. 


CONCLUSION:  The  ventilator  O2  monitor  was  accurate  and  should  be  used  to  attain  the 
desired  Fio;  iastead  of  the  O2  setting  control.  Inspired  volumes  displayed  on  the  ventilator 
when  using  He02  varied  significantiy  from  actual  and  should  not  be  used  for  clinical 
assessment.  Based  on  otir  limited  lab  evaluation  and  clinical  experience,  we  feel  that  80/20 
He02  can  be  safely  used  in  the  Drager  E4  in  adult  mode  using  PCV  when  flow  monitoring  is 
turned  off.  and  the  flow  seasor  is  removed.  Further  testing  will  include  effects  on  volume  con- 
trol mode,  pressure  support,  rise  time,  sensitivity  and  pediatric  mode. 

OF-00-145 


THE  ABDOMINAL  COMPARTMENT  SYNDROME  (ACS)  INFLUENCES 
INTRINSIC  POSITIVE  END-EXPIRATORV  PRESSURE  (PEEP,)  IN  THE  ACUTE 
RESPIRATORY  DISTRESS  SYNDROME  (ARDS) 

RH  fallcl  RRT.  M  Siobal  RRT,  K  Brady  MD,  JD  Marks  PhD  MD.  Department  of 
Anesthesia,  San  Francisco  General  Hospilal.  San  Francisco,  CA  94110 

Background:  Dynamic  hyperinnatton  causes  PEEP,  and  is  directly  proportional  to  minute 
ventilation  ( v  e)  and  airways  resistance,  and  is  inversely  proportional  to  cxpiratoiy  time 
(Tj).  PEEP,  occurs  in  ARDS  partly  because  tissue  resistance  is  late-dcpendenl  (1).  ACS 
causes  high  inua-abdominal  ptessure  that  may  be  uansmitted  to  the  pleural  surface  (2)  thus, 
affecting  measured  PEEP,.  Wc  report  the  efffects  of  increasing  Tj  and  decreasing  v  r  on 
measured  PEEP,  in  a  43  year-old  man  with  ARDS  complicated  by  ACS  and  bronchospasnv 
Case  Summary:  The  patient  was  paralyzed  and  ventilated  in  a  volume  mode  at  7  mlTkg 
with  an  inspiratory  plateau  pressure  -  45  cm  HjO  on  1 5  cm  H,0  set  PEEP.  A  rate  of  32 
produced  a  pH  =  7.29  and  an  arterial  carbon  dioxide  tension  =  63  mm  Hg.  Static  (slat)  and 
dynamic  (dyn)  PEEP,  were  measured  at  a  fixed  inspiratory  time  of  0.75s  as  the  rate  was 
decreased  to  22  (Te;  1.13  10  1.98s;  yt:  14  to  9.3Um).  Compliance  decreased  from  17  to  14 
mL/cm  HjO;  peak  expiratory  flow  rate  (which  reflects  elastic  recoil)  increased  from  65  w  71 
Um.  The  difference  between  PEEP,-dyn  and  PEEP,-stal  (which  reflects  ventilation 
inhomogeneity)  narrowed  from  5.3  to  I  cm  H,0  as  Tj  increased.  Yet,  PEEP,-stat  dill  not 
change  despite  the  fact  that  the  end-expiratory  flow  rate  decreased  from  10  to  0  L/m  and  the 
trapped  volume  (Vttap)  detected  during  die  PEEP,-slat  measuiement  also  decreased. 


l:::gs::t:::U 


■*•  PEEPI-»I« 

-■-    PEEPI-dyn 
-* — Vtrap 


32 


28  26  24 

ResplratOfy  Rat* 


DiKunion:  Our  dau  suggesu  that  in  ARDS  complicated  by  ACS,  PEEP,  may  primarily 
reflect  UBnsmined  intra-abdominal  pressure  rather  than  dynamic  hyperinflation.  Prolonging 
Tg  may  lessen  ventilation  inhomogeneity,  but  paradoxically  may  potentiate  collapse  of 
unstable  alveoli  and  worsen  chest  compliance  (3). 

1.  Broseghini  C.  Brandolese  R.  et  al.  Respiratory  resisQuice  and  intrinsic  PEEP  in  patients 
with  ARDS.  a,r«Mpi>y  1988;  1:726-731, 

2.  Bamea  GE.  Laine  GA.  et  al.  Cardiovascular  response  to  elevation  of  intra-abdominal 
hydrostatic  pressure.  AmJFhyliol.  1985;  248(17):  R208-R2I3. 

3.  Ourevilch  MJ.  Selection  of  I:E  Ratio.  Kacmatek  RM.  Cunenl  Respinuiy  Care 
Techniques.  Chap.  28.  BC  Decker.  1988. 


OF-00-153 


1014 


Respiratory  Care  •  August  2000  Vol  45  No  8 


Monday,  October  9, 9:30-1 1:25  am  (Rooms  213,214) 


INDEPENDE^4T  LUNG  VENTILATION  WITH  CONVENTIONAL  AND  HIGH  FRE- 
QUENCY OSCILLATORY  VENTILATION  Harrison,  Julie  RRT;  Cox.  Timothy  RRT; 
McCloskey,  John  MD  A.I.  DuPont  Hospital  for  Children.  Thomas  Jefferson  Medical 
College.  Wilmington.  De. 

Introduction:  Independent  Lung  Ventilation  (ILV)  has  an  established  role  in  the 
mechanical  ventilation  world,  but  users  must  be  familiar  with  its  complexities  so  it  can  be 
appropriately  applied.  ILV  is  shown  to  be  beneficial  for  bronchopleural  fistula,  unilateral 
lung  disease,  massive  hemoptysis  and  for  thoracic  surgery.  Generally,  ILV  utilizes  two 
like  ventilators,  but  we  present  a  case  summary  utilizing  conventional  mechanical  venti- 
lation and  High  Frequency  Oscillator)'  Ventilation  (HFOV)  to  recruit  the  right  upper  lobe 
of  a  patient  with  a  upper  respiratory  infection  (URI).  Case  Summary:  WF.  a  7-month- 
old,  ex-28  week  pre-mature  baby  with  a  1 2  day  history  of  URI  symptoms  was  placed  on 
antibiotic  therapy  at  home.  On  the  day  13,  the  baby  had  increased  WOB,  nasal  conges- 
tion, cough,  loose  stools,  normal  amount  of  wet  diapers,  no  fever  or  vomiting.  The  baby 
presented  to  the  emergency  room  with  Sa02  in  the  80"s,  RR  80-100,  retracting  and  flar- 
ing. Anterior/posterior  chest  X-ray  showed  RUL  pneumonia.  His  past  medical  history 
revealed  hypoxic  encephalopathy  and  neurologic  damage,  gastro-esophageal  reflux 
(GER).  and  a  fundoplication.  The  patient  was  admitted  with  the  diagnosis  of  right  upper 
lobe  (RUL)  pneumonia  secondary  to  aspiration.  The  baby  was  placed  on  high  flow  02, 
Timentin.  and  a  Beta  Agonist  via  small  volume  nebulizer.  On  Day  2.  the  baby  was  intu- 
bated with  a  3.5  endo-tracheal  tube  (ETT)  for  continued  desaturations  and  placed  on  a 
Bird  VIP  (Thermo- Re spiratorv'  Group,  Palm  Springs.  Ca.).  On  Hospital  Day  3.  both  rigid 
and  flexible  bronchoscopy  showed  increased  secretions  from  the  right  lung;  but 
otherwise  normal  anatomy.  During  Hospital  Days  3,  1 1  attempts  were  made  to  increase 
the  Peak  End  Expiratory  Pressure  (PEEP)  level  from  5  to  6  to  8  to  recruit  RUL.  The  left 
lung  gradually  became  overdistended  while  the  RUL  remained  solidified.  The  PIP's  on 
the  ventilator  were  then  increasing  to  37-39  cmH20.  At  this  point,  WF  was  placed  on  a 
High  Frequency  Oscillatory  Ventilator  (HFOV)  (Thermo-Respiralory  Group,  Palm 
Springs.  Ca.)  starting  at  Mean  Airway  Pressure  (MAP)  20-24,  Amplitude  (AMP)  64-80. 
Frequency  (Hz)  10,  Fractional  Inspired  Oxygen  (Fi02)  .60  The  CXR  was  still  showing 
overdistention  of  the  left  lung  and  consolidation  of  the  RUL,  and  the  patient  was  still  hav- 
ing periods  of  desaturation.  The  patient  was  changed  back  to  conventional  ventilation, 
and  the  decision  was  made  to  initiate  ILV.  The  patient  was  intubated  with  two  3.0  ETTs; 
one  in  the  right  mainstem  for  the  HFOV  and  one  in  the  trachea  for  conventional  ventila- 
tion (CV).  Settings  were  as  follows:  HFOV:  AMP  52.  Hz  10.  MAP  15^I8-»12.  Fi02 
37-.40;  Volume  Cycled:  IMV  mode,  RR  36-»30.  Vi.  80cc,  PEEP  7.  Fi02  .4O-.30,  PIP's 
ranged  from  20  to  mid  30"s  with  MAP's  10-12.7.   The  patient  remained  on  Independent 
Lung  Ventilation  for  3  days,  at  which  time  he  was  then  changed  back  to  conventional 
ventilation  for  12  days.  He  was  then  extubated,  and  within  the  next  10  days,  was  gradu- 
ally weaned  to  room  air  and  discharged.  Discussion:  In  conclusion,  the  decision  to  inde- 
pendently ventilate  each  lung  was  made  to  prevent  barotrauma  to  the  left  lung,  while 
recruiting  the  pneumonic  RUL,  resulting  in  successful  recruitment 
of  the  RUL  and  prevention  of  barotrauma. 


OF-00-160 


STEM  INDUSTRIES  LTD. 

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Phone:  905-51 3-71 70     Fax:  905-474-1 740 

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of  medical  oxygen  fuel  cell  sensors  - 

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Course  speakers  include: 
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Dean  R.  Hess,  PhD,  RRT,  FAARC 
Richard  D.  Branson,  BA,  RRT 
Janice  Thalman,  RRT,  FAARC 
Michael  Gentile,  RRT 
The  AARC  is  sponsoring  this  postgraduate  course  on  the  day  preceding  the  International 
Respiratory  Congress  for  practitioners  wanting  a  fundamental  review  of  mechanical 
ventilation.  Attendance  is  limited  to  120,  and  you  must  pre-register  by  September  15  —  first 
come,  first  served.  The  course  is  approved  for  continuing  education  credits,  and  ventilator 
manufacturers  have  been  invited  to  demonstrate  their  equipment.  Registration  fee  is  $200 
for  AARC  members  and  $300  for  nonmembers.  A  registration  form  is  provided  in  the 
Congress  Program,  or  you  can  call  the  AARC  at  (972)  243-2272  or  register  online  at 
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Respiratory  Care  •  August  2000  Vol  45  No  8 


1015 


At  approximately  lo  lbs.,  the  AeroNOx  makes  light 
worl(  of  transporting  your  patient  on  NO. 

Introducing  the  AeroNOx-  .  .inhaled  nitric  oxide  transport  made 

light   and    easy.   The  AeroNOx   is   a    portable    NO,    NO2    and    O2 

analysis  and  delivery  system  all  in  one!  Quick  connect  fittings  on 

our  regulators  makes  changing  from  bedside  to  transport  tanks     m  M/^ 

quick  and  easy  with  virtually  no  interruption  of  gas  flow  to  your     r  IJ||_!\^0|M^JX 

patient.  The  AeroNOx  can  also  be  purchased  with  optional  bedside 

accessories  so  that  when  you  get  to  where  you  are  going,  you  can 

use  the  AeroNOx  at  the  patient's  bedside  too!  Imagine,  no  more 

hunting  for  equipment,   no   more  lugging  large,  heavy  cylinders 

down  the  hall,  no  more  trying  to  "squeeze"  older,  bulkier  systems 

into  an  ambulance,  elevator  or  plane.  And  best  of  all,  no  more 

need  to  take  your  patient  off  NO  for  transport.  Sound  too  good  to 

be      true?      Contact      your      Pulmonox      representative      for 

more  information  or  to  evaluate  the  AeroNOx  at  your  facility. 


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Phone:  (780)  662-3968 
Fax:  (780)  662-4255 

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5243  -  53  Avenue 
Tofield,  Alberta,  Canada 
ToB  4J0 


At  Pulmonox  Medical  Inc.  ...we  dare  to  go 

yi»«  N^MAn"  has  Gone  ^re 

Come  visit  us  at  the  AARC 

Visit  AARC  Booth  452  in  Cincinnati 


/^t..Ml«    AAO    ^^    n..A«4i..«*    !■««#«    i 


Monday,  October  9, 2:00-3:55  pm  (Rooms  200,201 ) 


NITRIC  OXIDE  (NO)  VU  NASAL  CANNULA 

K.  Boyte.  MS,  RRT.  G.  Lowe.  BS.  RRT.  Richard  James 

Arkansas  Childrens  Hospital,  Little  Rock,  AR 

Background:  The  Cardiology  physicians  requested  that  we  find  a  way  to  safely  deliver 
NO  to  non-intubated  patients.  During  cardiac  catheterization,  it  may  be  desirable  to 
administer  NO  for  a  short  period  of  time  to  determine  if  a  non-intubated  patient  wi!l 
respond  to  the  NO.  We  decided  to  investigate  the  safety  of  delivering  NO  via  NC  since 
we  had  had  reports  of  problems  with  staff  when  delivering  it  through  hoods.  Methods: 
A  NO  delivery  system  was  designed  to  allow  mixture  of  O2  and  NO  through  a  "'wye" 
adapter.  NO  and  Nitrogen  Dioxide  (NO2) 

analyzers  (Drager)  were  adapted  to  fit  into  the  system  for  continuous  monitoring,  and  a 
nasai  cannula  (NC)  was  connected  on  the  outflow  side  of  the  analyzers  (see  diagram 
below): 


l^is  was  a  bench  test;  no  patient  or  animal  was  involved  in  the  study.  NO  tank  concentra- 
tion was  800  ppm.  The  system  ran  for  8  hours  in  an  empty  patient  room.  O2  flow  was  2.5 
1pm,  NO  flow  was  <.l  1pm  (<100ml/min)  with  a  target  NO  concentration  of  40  ppm.  At 
the  time  of  the  study,  this  was  felt  to  be  the  maximal  concentration  that  would  be  utilized 
with  this  method  of  delivery.  Two  environmental  air  sampling  tubes  were  placed  in  the 
room,  one  2  feet  from  the  nasal  prongs  and  one  5  feet  from  the  nasal  prongs.  The  air  sam- 
pling tubes  were  changed  out  at  hour  4  and  replaced  with  2  new  ones  at  the  same  distances. 
NO2  and  NO  readings,  NO  psig,  ppm,  and  flow  were  recorded  at  close  to  30-minute  inter- 
vals. The  air  temperature  of  the  room  was  70  degrees,  and  the  room  underwent  6  air 
exchanges  per  hour.  A  laboratory  accredited  by  die  American  Industrial  Hygiene  Associa- 
tion. Clayton  Environmental  Consultants,  performed  the  air  sampling  mbe  analysis. 
Results:  The  levels  for  nitric  oxide  and  nitrogen  dioxide  were  less  than  the  detection  limit 
of  the  laboratory  (0.3  ppm),  and  did  not  exceed  the  Occupational  Safety  and  Health  Admin- 
istration (OSHA)  Permissible  Exposure  Limit  or  the  American  Conference  of  Governmen- 
tal Industrial  Hygienist  (ACGIH)  threshold  limit  value.  The  NO  tank  psig  went  from  1200 
to  1140overthe8-hourperiod,NO2  levels  read  from  a  low  of  3.0  to  a  maximum  of  3.8. 
Discussion:  In  order  to  assess  the  pulmonary  vascular  response  in  non-intubated  patients. 
NO  was  blended  and  administered  via  NC  to  obtain  an  NO  concentration  of  40  ppm.  The 
results  obtained  indicated  the  NO  and  NO2  were  undetectable  for  this  concentration.  Since 
a  patient  was  not  attached  to  the  system,  and  not  absorbing  the  NO;  the  undetectable  limits 
would  be  further  reduced  with  a  patient  utilizing  the  system  and  absorbing  the  gases.  It  is 
our  belief  that  NO  administered  via  NC  is  a  safe  and  effective  method  of  assessing 
pulmonary  vascular  response  in  OF-00-026 

non- intubated  patients. 


NITRIC  OXIDE  DELIVERY  WITH  THE  AERONOX'.  Khated  Sedeek  MD.  Robert  M 
Kacmarek  PhD  RRT  FAARC.  Dean  Hess  PhD  RRT  FAARC  Respiratory  Care. 
Massachusetts  General  Hospital  and  Harvard  Medical  School,  Boston.  MA 

Background:  Inhaled  NO  Is  FOA  approved  for  treatment  of  hypoxk:  respiratory  failure 
of  the  newborn.  NO  delivery  systems  should  provide  a  constant  [NO]  with  changes  in 
ventilatory  pattern.  We  evaluated  the  Aeronox*  NO  delivery  system  (Pulnronox. 
TofJeld.  Alberta  CA).  Methods.  The  Aeronox*  was  calibrated,  adjusted,  and  connected 
to  the  ventilator  circuit  as  recommended  by  the  manufacturer  NO  was  delivered  into 
the  inspiratory  limb  of  the  ventilator  circuit  near  ttie  ventilator  outlet  Gas  was  sampled 
downstream  from  tfie  point  of  injection  near  the  Y-piece  At  the  same  sample  site,  gas 
was  aspirated  for  analysis  using  a  Sievers  NOA  rapkj-response  analyzer  (Sievers, 
Boulder  CO)  The  output  of  the  Sievers  was  digitized  at  1000  Hz  {VWndaq,  Akron  OH). 
The  Aensnox*  and  Sievers  were  calibrated  simultaneously  with  the  same  gas  mixture 
We  evaluated  3  [NO]  (1.  5.  and  20  ppm).  The  ventilators  were  attached  to  an  infant 
lung  model  (Michigan  Instruments  TTL).  We  evaluated  the  Bird  VIP  ventilator  in  time 
and  volume  controlled  nrodes.  In  the  time  controlled  mode,  we  adjusted  respiratory 
rate  (20,  30.  and  40/min),  inspiratory  time  [0.3.  0  5,  and  O.S  s),  peak  inspiratory 
pressure  (15,  25.  and  35  cm  HjO).  and  fiow  (10  and  15  Umin).  In  the  volume 
controlled  mode,  we  adjusted  respiratory  rate  (20  and  30/min),  bdal  volume  (50  and 
150  mL).  and  ftow  (10  and  20  Umin),  We  also  evaluated  the  Sensormedtcs  HFO 
usmg  a  flow  of  20  L/min  with  adjustments  in  frequency  (5.  10.  and  15  Hz),  mean 
ainvay  pressure  (15,  20,  and  25  cm  H2O),  and  amplitude  (20,  30,  and  40  cm  H^O). 
The  1 00%  O2  setting  on  the  ventilator  was  used  to  evaluate  NO]  production  Results: 
See  figures  for  results  at  20  ppm.  A  bias  was  noted  between  the  [NO]  measured  by 
the  Aeronox*  and  the  Sievers,  but  this  is  too  small  to  be  clinically  important  For  each 
set  of  conditions,  the  fluctuahon  in  delivered  [NO]  as  measured  by  the  rapid  response 
Sievers  NO  analyzer  was  small,  indicating  adequate  mixing  within  the  ventilator  circuit 
and  a  stable  delivered  dose  throughout  inspiratory  phase  The  [NO;]  was  always  <  1 
ppm.  Experience:  Our  only  experience  with  this  devk»  is  in  the  laboratory  setting.  We 
found  It  easy  to  calibrate  and  use  The  only  difficulty  was  in  the  delivery  of  1  ppm 
urKler  some  conditions  because  the  Aeronox^  was  unable  to  be  adjusted  to  a  fk^w  low 
enough  ConduskMis:  Our  evaluation  suggests  that  the  Aeronox'  delivers  a  constant 
[NO]  with  minimal  [NOa]  using  the  ventilators  and  settings  evaluated  In  this  study, 
(study  sponsored  by  INO  Therapeutics,  Clinton  NJl 


OF-00-058 


EVALUATION  OF  THE  INOVENT  FOR  DELIVERY  OF  LOW  DOSE  INHALED  NITRIC 
OXIDE  VIA  NASAL  CANNULA  AT  LOW  FLOWS 

Michael  Tracv.  RRT,  Timothy  f^iyers.  RRT,  Robert  Chatbum.  RRT.FAARC 
Unrversity  Hospitals  of  Oevetand,  Cleveland.  Ohio 

BACKGROUND:  Inhaled  nitric  oxide  (INO)  is  a  selective  pulmonary  vascular  smooth 
muscle  relaxant.  Typically  INO  is  delivered  va  ventilator  circuit.  Previous  work  at  our 
institution  {Resp  Care  1999. 44(10))  demonstrated  low  dose  INO  could  safely  and 
effectively  be  delivered  via  oxytiood.  Work  by  Newhart  et  al  (Resp  Care  1999;  44(10)) 
demonstrated  that  iNO  could  be  delivered  with  the  INOvent  (Datex-Ohmeda,  Madison  Wl) 
adapted  to  a  nasal  cannula  {flow  2-8  Umin,  NO  20-40ppm).  This  method  of  iNO  delivery 
has  been  proposed  for  use  in  a  neonatal/pediatric  setting.  The  purpose  of  this  study  was 
to  determine  the  accuracy  of  iNO  dosages  delivered  via  neonatal  and  pediatric  cannulas 
at  ftovre  below  the  specified  minimum. 

METHODS:  Oxygen  from  a  flowmeter  and  humidifier  was  directed  through  the  INOvent 
injector  module  The  output  side  of  the  injector  module  was  fitted  with  a  six  Inch  sectkw  of 
22  mm  ID  con-ugated  tubing  as  a  mixing  chamber.  An  INOvent  sample  tee  was  attached 
to  the  corrugated  tubing.  This  provided  for  both  gas  sampling  and  output  to  either  a 
neonatal  or  pediatric  cannula  (Salter  Labs.  Arvin,  CA).  After  the  INOvent  was  calibrated 
according  to  the  manufacturer' s  instructions,  it  was  set  to  deliver  1-10  PPM  through  the 
cannula  at  flow  rates  of  0.75  or  1 .5  Umin.  The  delivered  NO  concentrations  analyzed  with 
the  INOvent  were  compared  to  measurements  from  a  reference  analyzer  (Sievers  280 
NOA,  Sievers,  Boulder,  Cdorado).  Measurements  were  made  three  Umes  at  each 
combiriation  of  flow  and  cannula  size 

RESULTS:  Initial  readings  for  all  experiment  conditions  were  extremely  unstable  on  both 
analyzers.  This  problem  was  resolved  after  the  injector  module  was  fixed  in  the  vertk;al 
position  to  the  INOvent  handrail  with  flow  directed  upward.  The  en-or  in  delivered  NO 
concentration  was  similar  for  all  conditions  and  proportional  to  the  setting.  The  actual 
concentration  was  consistently  above  the  set  value.  Representative  data  are  shown  below 
(mean  with  95%  confkjence  inten/als)  for  the  neonatal  cannula  at  1 .5  L/min. 


nOvenI  Setbng  (ppm) 


CONCLUSIONS:  There  is  significant  en-or  (up  to  50%)  in  the  set  NO  concentration  when 
using  flows  below  manufacturer's  spedficatons.  We  recommend  against  using  the 
INOvent  to  deliver  nitric  oxide  to  infants  through  a  nasai  cannula.  OF-00-1 1 9 


RELIABLE  DELIVERY  AND  tWONITORING  OF  INHALED  NITRIC  OXIDE 
SYSTEM  UTILIZING  THE  VDR-3C  PERCUSSIONATOR®  HIGH  FREQUENCY 
TRANSPORT  VENTILATOR  AND  THE  AERONOX™  DELIVERY  SYSTEM 

Dan  Viliareal.  RRT.  and  John  P,  Cleary.  MD  Children's  Hospital  of  Orange  Co.,  Orange.  CA 

Background:  The  mixing  of  Nitric  Oxide  (NO)  gas  in  conventional  mechanical  ventilation  and 
high  frequency  oscillatory  ventilation  has  been  investigated.  However,  adequacy  of  mixing  NO 
in  the  Percussionaior®  Phasitron  (Sandpoint,  ID)  with  its  sliding  vemuri  has  not  been 
examined-  The  purpose  of  this  study  was  to  evaluate  the  mixing  of  NO  gas  utilizing  the  VDR- 
3C  PcrcussicHiatot^  HFV  with  the  Aeronox**"  Nitric  Oxide  Dcliver>'  System  (Tofield,  Alberta, 
Canada)  utilizing  a  range  of  ventilatory  settings.  Secondarily,  we  compared  NO  values 
obtained  using  the  Aeronox'''"  electrochemical  (EC)  analyzer  with  a  "gold  standard"  Sievers 
280  (Boulder.  CO)  chemiluminescence  (CL)  NO  anal>'zer. 

Method:  The  VDR-3C  was  set-up  along  with  the  Aeronox*"  Delivery  System  in  a  manner 
similar  to  that  utilized  during  patient  transport.  A  Vent-Aid  Training  Test  Lung  (Michigan 
Instrument)  was  used  to  provide  2.5ml/cmHiO/kg  static  compliance.  NO  (SOOppm)  was 
instilled  in  the  monitoring  port  of  the  Phasitron,  NO  (EC  and  CL)  and  NO;  (EC)  levels  were 
measured  at  the  following  sites:  1 )  proximal  airway  monitoring  port  of  the  Phasitron;  2)  25cm 
beyond  the  instillation  port  (distal),  and  3)  port  of  the  test  lung-  Ventilator  settings  were  as 
follows:  1 )  Hz  5.  Amp  40,  MAP  25;  2)  Hz  8,  Amp  30.  MAP  20;  and  3)  Hz  1 5.  AMP  20,  MAP 
1 5;  FiO;  was  1 .0.  NO  was  instilled  until  the  desired  NO  dose  of  5ppm.  1  Oppm,  20ppm.  and 
40ppm  was  achieved  at  the  proximal  port  for  each  combination  of  ventilator  settings.  Both 
analyzers  were  calibrated  between  ventilator  and  NO  changes.  NO,  NO;  and  FiO,  values  were 
recorded  5  minutes  afler  ventilatory  changes.  Comparisons  were  made  by  ANOVA. 
Results:  NO  concentrations  were  similar  at  the  three  sampling  ports  with  a  trend  of  an  increase 
in  NO  value  at  distal  ports.  There  was  negligible  difference  of  NO  level  readings  between  the 
EC  and  CL  analyzer. The  t^le  show  results  using  20ppm  NO  and  analyzed  at  the  proximal  and 
distal  airway  ports.  N02  levels  were  below  2.3ppm  across  the  study  conditions. 


HFV  Settings 

Electrochemical 

Chemiluminescence 

Hz 

Amp. 

MAP 

NO 
(proximal) 

NO 

(distal) 

NO 
(proximal) 

NO 
(distal) 

5 

40 

25 

20 

21 

20.9 

209 

8 

30 

20 

20 

21 

20,9 

21.5 

15 

20 

15 

20 

25 

21  2 

24.8 

Coaclusion:  Reliable  delivery  of  nitric  oxide  was  demonstrated  using  the  Aeronox***  Delivery 
System  and  the  VDR-3C  HFV.  The  levels  of  NOj  production  is  below  the  level  of  therapeutic 
concerns.  We  have  utilized  the  VDR-3C  HFV  with  INO  during  transport  of  >  1 0  palienis 
without  complicaticms. 

OF-00-130 


Respiratory  Care  •  August  2000  Vol  45  No  8 


1017 


MONDAY,  October  9,  2:00-3:55  pm  (Rooms  200,201) 


NITRIC  OXIDE  FOR  A  POST-OP  CARDUC  SURGERY  PATIENT:  A  CASE 

REPORT  Suzanne  M  Dumine  BS.  RRT.  Theresa  R.  Schultz  BA,  RRT.  CPFT.  RN, 
Linda  A.  Napoli  BS,  RRT.  RPFT.  Rodolfo  I  Godinez  MD,  PhD  The  Children's 
Ho^jilal  of  Philadelphia.  Philadelphia,  PA 

Background:  A  four  month  old  male  »ilh  Trisomy  2 1  was  referred  lo  our  instilulion 
for  surgical  correction  of  his  cardiac  dcfcct.  Echocardiography  r«sulu  were  complete 
AV  canal  slightly  unbalanced  to  the  right  ventricle,  large  unrcstrictive  VSD  with  bi- 
directional shunting,  large  ASD  with  left  to  right  shunting,  moderate  to  SCTcre 
pulmonary  hypertension  and  tnvial  AV  valve  regurgitation  The  patient  underwent  a 
pulmonary  artery  banding  and  PDA  ligation   He  was  exlubated  six  hours  post  op 
with  supplemental  oxygen  of  one  Ipm  nasal  cannula  with  satorations  in  the  80s. 
TwCTty-four  hours  post  op  the  patient  had  an  acute  desaluration  to  the  40"s  with  a 
slightly  increased  heart  rate.  This  desaturation  episode  was  succcssfiilly  treated  by 
increasing  the  supplemental  oxygen  via  nasal  cannula  However,  thirty  two  hours  post 
op  the  patient's  SpO;  fell  into  the  40' s  and  he  was  noted  to  have  an  increased  work  of 
breathing  at  this  time  The  lungs  on  chest  x-ray  were  described  as  tan  and  lasix 
therapy  was  initiated  The  patient  was  placed  in  a  50%  oxygen  hood,  sedated  to 
decrease  work  of  breathing  and  transfused  with  60  cc  PRBC's  to  increase  oxygen 
carrying  capacity   The  patient  continued  to  deterioralc  despite  these  interventions 
Due  to  the  significant  lability  of  the  oxygen  saturations  which  may  be  caused  by 
decreased  pulmonarv  blood  flow  secondary  lo  elevated  distal  pulmonary  vascular 
resistance,  nitric  oxide  therapy  was  initiated.  Patient  management  otherwise  remained 
constant.  The  patient  was  given  20  ppni  Nitric  Oxide  with  supplemental  (h.  Blood 
gas  results  were  as  follows: 


Pre  Nhiic  Glide 

Post  Nitric  Glide 

PH      7.33 

PH         7.37 

PCOi  49 

PCO.    42 

PaO:    43 

PaOz     62 

HCOj  25 

HCO,    25 

B.E.    -0.9 

B.E.       0.4 

SpOi     75% 

SpOi     91% 

The  nitric  oxide  was  n^aned  lo  2  p|Mn  aver  the  next  twenty  four  hours  and  weaned 
off  within  the  next  32  hours.  The  patient  remained  on  Vi  1pm  nasal  cannula  with 
Sp02's  in  the  80's 

Conclusion:  Nitric  oxide  seemed  to  be  useful  in  improving  the  pulnronary  Uood 
flow  in  a  post  opcrati*'e  5  month  old  cardiac  surger>-  patient. 


OF-00-132 


THE  EFFKC 1  OF  CHANGING  FLOW  RATES  ON  INHALED  NO,  NOj  and  FiOj 
CONCEN  I RA liONS  USING  THE  MANl  AL  VENTILATION  SYSTEM  ON  THE 

DATEX/OHMEDA  INOvgnl*  Sandra  R  Wadlmyer  BA,  RRT.  CPFT.  Lorraine  F,  Hough, 
MEd.  RRT.  CPFT.  The  Children's  HospiUl  of  Philadelphia.  Philadelphia.  PA. 

Background:  The  use  of  the  Datex/Ohmeda  INQvenl  delivery  system  for  inhaled  Nittic  Oxide 
(NO)  therapy  has  become  a  standard  in  our  large  pediatric  insiinilion.  We  were  not  satisfied  with 
the  manufacturer's  suggested  options  when  hand  ventilation  was  required.  We  set  up  a  second 
lank  of  nitric  oxide  with  a  regulator  and  flowmeter  for  use  with  a  flow  inflating  manual 
resuscitator  bag  in  order  to  more  closely  mimic  both  the  FiO;  and  NO  concenualion  our  patients 
were  receiving  on  the  mechanical  ventilator.  However,  this  system  relied  on  the  accuracy  of  the 
oxygen  flowmeter  used  to  titrate  the  NO,  the  bleeding  of  gas  befor.:  connecting  the  patient  to 
avoid  high  nitrogen  dioxide  (NO;)  levels,  the  memory  of  the  caregivers  to  turn  the  tank  off  after 
use  and  the  expense  of  a  stainless  steel  tank  regulator  and  stand-alone  nitric  oxide  lank  at  the 
bedside.  We  found  this  system  awkward  but  functional.  This  evaluation  investigates  the  stability 
and  concentrations  of  NO,  NO:  and  FiO;  delivered  via  a  flow  inflating  manual  resuscitator  bag 
while  varying  flow  rates  on  the  INOvent  manual  delivery  system. 

Methods  and  Materials:  Oxygen  flow  was  titrated  utilizing  an  Ohmeda  pressure  compensated 
oxygen  flowmeter  attached  to  a  50  psi  wall  oxygen  outlet.  The  output  from  the  flowmelcr  was 
attached  to  the  O;  inlet  port  on  the  back  of  the  INOvent  using  an  O,  high  pressure  supply  hose 
Oxygen  Wbing  was  attached  to  the  NO/Oj  outlet  on  the  back  of  the  INOvent  and  used  to  supply 
gas  to  a  flow  mflatmg  manual  resuscitator  bag  (Vital  Signs  Babysafe^*^ '/;  L).  A  sample  tee  was 
placed  in  line  with  the  constant  flow  proximal  to  the  adapter  on  the  manual  resusciUlor  bag.  Gas 
was  sampled  with  inspiratory  sample  line  mbing  attached  lo  the  connector  on  the  Iron!  of  the 
INOvent.  NO,  NO!  and  O;  measurements  were  obtained  at  1  .*>  1pm,  1 2  1pm,  1 0  1pm  and  S  1pm 
This  test  was  repeated  on  four  dift'erent  INOvent  delivery  systems  to  assure  reproducibility. 
Results:  Readings  obtained  are  contained  in  the  chart  below: 


Machine  1 

Machine! 

Machine  3 

Machine  4 

Average 

n,ow 

Oi     1  NO,  ;   NO 

0, 

NOi 

NO 

Oj 

NOi  j   NO 

Oi    i  NO, 

NO 

0,    ;  NO,  ,    NO 

15  ipm 

W.O  i    0.2    '  18,0 

98.0 

0.4 

18.0 

96.0 

0,3    ;  20.0 

98.0  1    0.5 

19.0 

t:ipm 

99.0  i    0.2    i   IS.O 

980 

OJ 

15,0 

97.0 

0.1    1  16.0 

98,0  1    0,5 

15.0 

101pm 

100.0;    0.!     ■   12.0 

99,0 

lOl 

IJ.O 

97.0 

0,1    '■■   14,0 

99.6  i   oT^ 

IJ,5 

98.8      0.2    :   13  1 
98,8  1    0  2    ,    9  8 

81pm 

100.0  r    0.1    1    8.7 

99.0 

0  1 

9.5 

97  0 

0.1    j   110 

990  ;    0.4       10  0 

Diicussion:  Altering  the  flow  appeared  to  result  in  a  predicubie  and  reproducible  change  in 
monitored  values  for  NO,  NO.  and  FiO;.  This  allows  us  to  closely  mimic  the  acmal  NO 
concentration  the  patient  is  receiving  on  the  mechanical  ventilator  when  hand  ventilation  is 
indicated  while  negating  the  need  for  a  second  cumbersome  system  at  the  bedside. 
Conclusion:  Altering  the  flow  rate  on  the  manual  ventilation  system  on  the  Ohmeda  INOvent  i: 
a  viable  option  m  our  clmical  practice.  Further  evaluation  should  be  considered. 


OF-00-133 


METHOD  ANALYSTS  OF  ^aTRlC  OXIDE  WEANING 

RivnandMallov  BS.  RJtT.  Bnan  Glynn  BS  RRT,  William  Bucher  RRT.  Caroline 
Devnreux  BS,  Jay  Greenspan  MD.  Thomas  Jefferson  University  Hospital.  Philadelphia, 
PA. 

BACKGROUND:  At  Thomas  Jeffenon  Univentty  Hosptttl,  the  Neonatal  Intensive  Can 
Hunery's  (volocol  for  Nitric  Oxide  (NO)  diwrapy  is  a  newborn  with  Respiratory  Distress 
SyxKlrcune  (RDS)  who  is  >34  weeks  gesutional  age  with  Persistent  Pulmonary 
Hypertension  of  the  Newborn  (PPHN)  and  an  Oxygen  Index  (OI)  of  >15  but  <25.  infants 
who  meet  these  criterion  are  treated  with  NO  therapy  and  the  method  in  which  the  infant  is 
weaned  ftom  this  therapy  is  central  w  subsequent  need  for  ECMO  (extracorporeal 
incn*rane  oxygenation).  HYPOTHESIS:  We  hypothesize  that  weaning  patients  on  NO 
ev«y  eight  hours:  20-10-5  parts  per  nuilion  (ppm)  is  appropriate.  Alter  24  hours,  if  tfw  01 
is  >15,  the  NO  therapy  is  restarted  at  5ppm  and  a  trial  period  where  the  infant  is 
completely  off  of  the  NO  therapy  is  attempted  every  24  hours.  After  this  period  a 
measured  01  of  IS  is  used  to  determiiK  the  successtiihiess  of  dx  weaning.  METHOE^ 
Nine  patients  were  snulied  using  the  HFOV  3 1  OCA  to  optimize  venblatton  and 
oxygenation.  NO  therapy  w»  started  at  ZOppm  and  reduced  by  50%  every  8  hours.  Our 
results  were  as  follows: 


Meconium  Aspiration  (MAS) 

12h 

YES 

RDS;  Gastroschesis 

24b 

NO 

MAS 

1Mb 

YES 

MAS 

4k 

YES 

MAS 

3k 

YES 

LeftCDH 

C3k 

YES 

RiflilCDH 

4Sk 

YES 

RDS 

a 

DECEASED 

RDS;  pneumoDia 

9.5h 

YES 

CCWCLUSIONS:  The  average  tunc  on  NO  therapy  was  30.3  houn  with  78%  requiring 
ECMO,  1 )%  not  rcquking  ECMO,  and  1 1%  deceased.  We  conclude  that  weanmg  NO 
tlicn9>y  every  8  hours  by  50%  is  too  aggressive.  Further  studies  are  being  investigated  to 
wean  NO  at  a  slower  nie  (5ppm  increments)  after  the  Fi02  is  <60%. 


OF-00-134 


Verification  of  Flow-Inflating  Manual  Bag  Resuscitator  for  Nitric  Oxide  Delivery 

Miller  CC,  Fairbanks  S.  Miller  J  WR 
University  of  British  Columbia,  Department  of  Experimental  Medicine 

Introduction:  Abrupt  interruption  of  inhaled  nitric  oxide  (NO)  delivery  during 
mechanical  ventilation  is  associated  with  a  rapid  deterioration  in  physiological  status 
known  as  "rebound  effect."  Many  routine  procedures,  such  as  bronchial  hygiene 
maneuvers,  changing  out  NO  cylinders,  during  transports,  or  as  a  back-up  during 
break  down  of  NO  delivery  devices  require  that  the  patient  be  removed  from  the  venti- 
lator. During  such  times,  a  manual  bag  resuscitator  is  utilized  to  maintain  ventilation. 
A  system  is  needed  to  provide  a  stable  NO  dosage  during  these  procedures.  The 
purpose  of  this  study  is  to  evaluate  the  Pulmonox  flow-inflating  manual  bag  resuscita- 
tor (INObag).  Method:  The  INObag  was  set-up  according  to  the  attached  test  set-up 
Figure  1 .  NO  was  provided  from  either  one  of  two  AeroNOx  delivery  devices  or  a  Pul- 
monox back-up  cylinder  with  a  fix  flow  rate  of  0.25  LPM.  These  sources  were  isolated 
from  one  another  with  a  three-way  stop-cock.  A  pressure  gauge  was  attached  lo  the 
pressure  port  and  the  INObag  was  attached  to  a  test  lung.  The  suggested  sample  site  on 
the  INObag  was  connected  to  a  rapid  response  chemiluminescencc  NO  analyzer  (280 
NOA,  Sievers.  USA)  or  one  of  two  AeroNOx  delivery  devices  (Pulmonox  Medical 
Corp,  Alberta,  Canada).  Additional  sample  locations  included  a  site  within  the  test 
lung  and  another  within  the  reservoir  of  the  INObag.  A  standard  oxygen  flow  meter 
was  attached  to  the  INObag  delivery  line.  NO  and  nitrogen  dioxide  (NO:)  d^ta  were 
recorded  from  these  various  sites  during  testing  conditions.  A  standard  flow  of  9- 1 0 
LPM  oxygen  was  used  with  0.25  LPM  of  NO  to  attain  a  desired  delivery  dosage  of  20- 
25  parts  per  million  (ppm).  Ventilatory  conditions  were  varied  as  follows:  respiratory 
rate  (RR)  0- 1 50  bpm;  peak  inspiratory  pressure  (PIP)  0-40  cmH20;  positive  end  expi- 
ratory pressure  (PEEP)  of  0-5  cmH20;  and  inspiratory  wave  pattern  spiked  and  square. 
Also,  a  possible  clinical  condition  was  simulated  lo  evaluate  NO2  accumulation  within 
the  device  between  use  if  the  device  was  not  flushed  out  with  a  fresh  gas  flow  as  rec- 
ommended by  the  manufacturer.  Results:  RR.  PIP.  PEEP  and  wave  pattern  had  no  sig- 
nificant effect  on  NO  delivery  (p>0.05)  See  Figures  2-4.  There  was  good  correlation 
between  the  chemiluminescencc  NO  analyzer  and  both  AeroNOx  devices  (r=0.86).  In 
all  simulated  conditions  during  ventilation  the  NO2  remained  below  0.2  ppm.  The 
deadspace  reservoir  showed  a  NO2  concentration  profile  as  shown  in  Figures  5-7.  The 
peak  NO2  at  80,  40  and  20  ppm  NO  and  100%  oxygen  over  an  hour  period  of  time 
without  flushing  was  6.3  ppm  (SD=1.74),  1.3  ppm  (SD=0.42)  and  0.2  ppm  (SD=0.08) 
respectively.  This  was  removed  within  20  s  with  10  LPM  of  fresh  oxygen  gas  flow 
(Figure  8).  Actual  data  is  recorded  ii  Table  1 .  Conclusion:  Use  of  the  INObag  for 
delivery  of  NO  at  20-25  ppm  under  the  clinical  conditions  tested  does  not  pose  any 
increased  risk  to  patients  receiving  NO  therapy  during  mechanical  ventilation.  We  rec- 
ommend that  the  system  be  flushed  for  20  s  before  and  after  each  use  to  ensure  thai 
NO2  is  not  allowed  to  build  up  wilhin  the  systems  dead  space  and  reservoir. 
Funding  provided  by  Pulmonox  Medical  Corporation 

OF-00-144 


1018 


Respiratory  Care  •  August  2000  Vol  45  No  8 


r- 


• 


lus  Performance 


Answering  the 
needs  of  your 
smallest 
patients  ^ 

in  big  ways. 


(fy)  monaghan. 

Monaghan  Medical  Corporation 

PO  Box  2805  •  Plattsburgh,  NY  12901-0299 
Customer  Service  800-833-9653 

™  trademarks. 

©2000  Monaghan  Medical  Corporation. 


AeroOiamher 


••• 


,••    /^/«.r" 


Circle  134  on  product  info  card 
Visit  AARC  Booth)  269  in  Cincinnati 


AeroChambe] 


Face  Seal  Is  Critical  for  Aerosol  Delivery. 

TheAeroC/iainber  Pfus'"  Valved  Holding  Chamber  ('VHC")  with  ComfortSear 
Mask  is  the  only  VHC  specifically  designed  for  the  smaller  facial  features  of 
a  child.  Plus  with  its  improved  design  and  highly  visible  exhalation  valve,  you 
are  assured  of  a  tight  mask  fit  for  exceptional  performance  levels. 

Improved  Aerosol  Suspension  Time  Delivers  Higher  Concentrations. 

The  AeroChamber  Plus™  VHC  with  ComfortSear"  Mask  features  a  superior 
rate  of  drug  delivery.*  The  Plus'  optimal-sized  chamber  and  Flow  Dynamic 
system  can  significantly  enhance  drug  delivery  at  low  tidal  volumes  and  low 
inspiratory  flows. 

The  Only  VHC  Designed  and  Built  for  Children. 

From  its  tamper-resistant  valve  to  the  child-friendly  AeroBear''*^  instructional 
graphics,  the>*eroC/ia/n6er  P/us™  VHC  with  ComfortSeal"  Mask  is  designed 
and  built  for  a  child's  use.  Plus  it  is  durable,  easy  to  clean,  latex  free  and 
offers  a  new  patient  and  family  instructional  video  and  easy-to-read  pictorial 
instructions. 

*  Compared  to  competitive  devices  with  many  tested  drug  formulations 


J 


Monday,  October  9, 2:00-3:55  pm  (Rooms  213,214) 


heuox:  a  mixture  of  60/40  is  effective  in  the  adult  asthmatic 
paubkt. 

Jodene  A.  Brewer  RRT.  Melissa  K.  Brown  RRT.  Shaip  Memorial  Hospital.  San  Diego, 
California;  Children's  Hospital  and  Health  Center,  San  Diego,  Califwrtia. 

Introduction:  Asthma  is  the  cause  of  more  than  three  million  physician  visits  and  200,000 
bospitatizations  a  year.  During  an  asthma  attack  the  lining  of  the  airways  become  swollen 
and  the  airways  pnxhice  a  thick  mucus.  The  muscles  around  the  airways  tighten  and  make 
the  airways  nannwer  causing  bronchoconstriction.  This  bronchoconstriction  leads  to 
ventilation  lo  perfusion  (V/Q)  mismatch.  Heliox  is  a  blend  of  helium  and  oxygen.  Heliox, 
being  a  low-density  gas,  can  allow  fen*  additional  alveolar  ventilation,  resuhing  in  improved 
gas  exchange.  Frequently  this  mixture  ha.s  been  used  at  a  hig^  helium  pcrcaitage  to  oxygen 
percentage  (79/2 1  or  70/30)  suggesting  the  best  possible  results  in  ventilation.  However, 
many  patients  are  not  offered  heliox  therapy,  secondary  to  the  widely  held  belief  that  tower 
concentrations  of  helium  cannot  produce  sufficient  beneficial  effects.  Using  hi^ 
coocentntions  of  helium  limits  the  FiOj  and  many  asthmatic  patients  roquire  more  than 
30%  oxygen.  This  case  study  examines  the  benefit  of  60/40  heliox  in  an  intubated  adult 
asthmatic.  Case  Summary:  The  patient  is  a  25-year-old,  59-kg.  fonale,  with  a  history  of 
asthma  and  a  previous  intubation.  She  had  been  feeling  ill  for  a  couple  of  days,  which 
developed  into  a  sudden  onset  of  shortness  of  breath.  She  called  91 1  and  went  into 
respiratoT>  arrest  while  in  route  to  the  hospital.  The  patient  was  intubated  and  placed  on 
mechanical  ventilation.  Due  to  extreme  bronchial  constriction,  high  peak  pre.ssures  and  low 
tidal  volumes,  the  patient  was  placed  immediately  on  Pressure  Control  Ventilation  (PCV) 
on  a  Servo  900C.  For  1 9  hours  the  patient  was  ventilated  and  had  four  arterial  blood  gases 
drawn  with  unresponsive  respiratory  acidosis.  Whhout  any  ventilator  changes,  the  patient 
was  placed  m  a  heliox  concentration  of  60%  helium  aivj  40%  oxygen  (60/40).  Arterial 
Blood  Gas  results  45  minutes  later  Stowed  an  improved  re^iraKxy  acidosis,  as  well  as  tidal 
volumes  (VT)  increasing  from  440mL  to  670mL.  The  patients  P02  improved  sli^tly.  The 
following  chart  summarizes  the  arterial  blood  gases  pre  and  post  heliox  th^apy: 


Arterial  Blood  Gas 


PCV46A),  l:4l:E,rl6. 
VT-440,40%Fi02 


PCV46/0,  l:4I:E.r.l6, 
VT-^TO.  heliox  (60/40) 


pH        PCO,       POi        HCOj       SaOi 
7.22        72  78  28.5        95.6 


7J1        45 


SI 


22.1        97.9 


Dbeassioa:  60/40helioxnoTmalt2ed  the  blood  gas  values  of  this 

intubated  asthmatic  patient.  The  benefits  of  elevated  heliox  mixtures  for 
patients  with  asthma  are  being  documented  with  increasing  frequency. 
This  case  study  documenis  that  a  60%  helium  and  40%  oxygen  can 
provide  beneficial  effects  white  maintaining  therapeutic  oxygen 
concentrations.  More  reseaa'h  is  required  to  determine  what  the  lowest 
effective  heliox  mixture  is  required  to  inqvove  veittilatioa  and  resfmatory 
acidosis  in  an  asthmatic  patient. 


OF-00-001 


ASSESSING  CHILDCARE  WORKERS  KNOWLEDGE  OF  ASTHMA.  Kasel.Debra 

K..  M.Ed..  RRT  Northern  Kenttickv  University.  Highland  Heights.  KY. 

One  hundred  twenty-six  state  licensed  child  daycare  centers  who  care  for  in&nt  to  school 

aged  children  in  seven  Northern  Kentucky  counties  were  surv^ed  to  answer  the 

following  question:  do  you  accept  children  wi&  a  known  history  of  asthma?  Fifty-four 

daycare  centers  responded  to  the  nirvey,  for  a  respond  rate  of  43%.  The  survey 

questionnaire  included  demographic  infomiation,  seventeen  true/false  questions,  and 

fourteen  yes/no  questions  regarding  the  daycare  worker's  experience  with  asthnta.  All  of 

the  responding  daycare  centers  accept  children  with  a  history  of  asthma.  Twenty  percent 

of  the  respondents  acknowledged  that  they  had  been  involved  in  the  care  of  child  in  an 

asthma  attack  while  at  daycare  on  more  than  one  occasion  in  die  last  six  months.  One 

third  of  the  respondents  were  uniamiliar  witii  peak  flow  meters  and  ^Mcers  'v^le  64% 

were  unsure  bow  to  recc^nize  the  severity  of  an  asthma  attack.  Fifty-nme  percent  of  tiie 

respondents  said  they  did  not  know  enough  about  asthma  to  ensure  the  safety  of  the  child 

during  an  asthma  attack.  An  asthma  workshop  was  held  to  provide  daycare  workers 

mformatkm  on  astfima  and  asthma  treatment.  Workshop  participants  were  given  a 

pre/post  test  The  average  pre-test  score  was  18/36  and  average  post-test  scott  was 

3 1  /36.  In  ctHKlusion,  these  results  verify  th»ie  is  a  lack  of  asthma  education  among  the 

daycare  workers  surveyed  and  that  after  an  education  program  on  asthma  participants 

were  able  to  increase  their  knowledge  on  bow  VO  pcovidt  better  care  for  asthmatic 

children  in  their  daycare  centers. 

OF-00-002 


Evaluation  of  Healthcare  Providers'  Inhaler  Technique 

BaddarS'  RN,  CRTT;  Worthing  E-  M.R.Phann.S,  M.Sc.Clin.Pharm;  Al-Riyami  B'  F.R.C.P. 
Ri.D;  AI-Riyami  K-  B.HTann..M.Phil.  Departments  of  Nursing'.  Hiarmacy%  Medicine'. 

INTRODUCnON 

Inhaled  medications  are  the  cornerstone  of  asthma  management  worldwide.  However,  one 
adult  and  one  pediatric  study  in  Oman  have  confumed  poor  inhaler  technique  amongst 

Sitients.  The  inhaler  technique  of  healthcare  providers  m  Oman  has  not  been  studied, 
biectives: 

1 .  To  assess  the  accuracy  of  inhaler  techniaue  of  the  most  commonly  used  inhaler  device 
(metered  dose  inhaler-MDI)  amongst  healUicare  providers  practicing  in  Oman. 

2.  To  identify  the  most  common  fHX)b!em  steps  or  MDI  technique. 

METHODOLOGY 

Design:  A  one  year  prospective  study  from  December  1998  to  November  1999  using  a  veii)a] 

quesuwnnaire  and  irmalation  demcmsu^tion. 

Setting:  Symposia  on  the  management  of  asthma  held  in  5  regions  of  Oman. 

Subjects:  All  neallh  care  providers  attending  a  symposium  who  agreed  to  particijiate. 

Veital  Questionnaire 

The  verbal  questionnaire  consisted  of  two  questions: 

1 .  Does  participant  counsel  patients  on  the  use  of  the  jMescribed  inhaler? 

2.  Vkycs  participant  prescribe  inhalen*  for  patients? 
Inhaler  Dgrnonstrdtipn 

Each  participant  was  given  a  placebo  MDI  and  asked  to  demonstrate  one  inhalation  in  front  of 
an  experienced  respiratory  therapist.  The  accuracy  of  inhaler  technique  was  evaluated  accord- 
ing to  a  suuctured  checklist  of  sequential  steps. 

DaU  presenUition  and  analysis:  The  eight  inhaler  steps  were  classified  as  either  'essential'  or 
'jweferred' .  A  value  of  'one'  was  assigned  for  every  step  performed  correctly  and  'zero'  for 
every  step  performed  incorrectly. 

RESULTS 

Onehundredandfifty  healthcare  providers  participated  (107  i^ysicians.  29  nurses.  10  Phar- 
macists and  4  other). 
Verbal  questionnaire: 

148  (99%)  participants  counseled  patients  in  inhaler  technique  of  whom  107  (71%)  also  pre- 
scribed inhaler  devices. 
hihaler  DemonsUation: 

Result  l.Only  23  f  15%)  participants  performed  all  MDI  steps  accurately.  Accuracy  of  "first 
call"  physicians  in  general  practice  and  emergency  medicine  was  only  5%  and  9% 
respectively. 

Result  2.  Tne  most  common  problem  steps  were  a)  shaking  the  canister  before  inhalation  b) 
co-orditiation  of  drug  release  aiKJ  inhalation  c)  holding  breath  after  itthalation. 

CONCLUSIONS 

•  Musi  healthcare  providers  (85%)  piacdang  in  Oman  do  not  demonstrate  accurate  MDI 
technique. 

•  Steps  essentia]  for  drug  delivery  arc  frequently  not  performed  correctly. 

Every  regional  center  should  initiate,  validate  and  audit  training  programs  for  doctors,  nun*es 
and  phairnacisLs  involved  in  the  counseling  of  asthmatic  patients. 

OF-00-017 


USE  OF  AN  EDUCATION,  MANAGMENT  AND  FOLLOW-UP  PROTO- 
COL FOR  EMERGENCY  ROOM  (ER)  ASTHMATIC  PATIENTS 
Chris  Garvev.  RN.  MPA.  GeneAnn  La  Moria,  RRT,  BA,  Stephen  Park,  MD, 
David  Goldschmid,  MD,  Jeff  Clingan,  RN,  MS,  Seton  Medical  Center,  Daly 
City,  CA. 

BACKGROUND:  Emergency  room  and  inpatient  care  accounts  for  a  signifi- 
cant portion  of  total  asthma  care  costs.  Acute  care  management  of  asthma 
may  be  largely  due  to  uncontrolled  disease.  Asthma-related  ER  visits  and 
hospitalizations  may  be  reduced  if  disease  control  is  improved.  The  purposes 
of  this  project  are  to:  (1)  provide  education  and  management  to  ER  patients 
with  moderate  to  severe  asthma  based  on  NIH  "Guidelines  for  the  Diagnosis 
and  Management  of  Asthma- 1997",  (2)  provide  short  term  follow-up  to 
assess  compliance  and  provide  education,  and  (3)  assess  the  impact  of  the 
intervention  and  follow-up  on  ER  and  hospital  revisit  rate.  METHOD:  485 
patients  with  moderate  persistent  to  severe  persistent  asthma  (based  on  self- 
report  of  daily  or  more  frequent  asthma  symptoms)  were  seen  for  ER  care  at 
our  private  community  hospital  between  2/98  and  1/(X).  All  patients  received 
a  standardized  intervention  provided  by  RCPs  based  on  the  1997  NIH  asthma 
guidelines.  The  intervention  includes  education  about  disease  prtKess  and 
control  methods,  trigger  identification  and  control,  use  of  MDI  and  holding 
chamber  with  return  demonstration.  Peak  Flow  Meter  use  with  return  demon- 
stration, importance  of  reporting  of  asthma  symptoms  to  PCP,  follow-up  with 
PCP  and  regular  use  of  "controller"  medication,  and  referral  to  asthma  educa- 
tion class.  Phone  follow-up  within  4  days  of  ER  asthma  visit  includes  assess- 
ment of  presence  of  asthma-related  symptoms,  medication  and  peak  flow 
adherence,  patient  follow-up  with  PCP,  and  education  of  disease  self- 
management  techniques.  Of  all  patients  in  the  sample,  56%  (n=27l)  received 
telephone  follow-up  within  4  days  of  ER  visit.  Forty-four  percent  (n=2l4) 
did  not  answer  3  phone  calls.  Three  months  after  the  initial  ER  asthma  visit 
and  intervention,  respiratory  ER  and  /  or  respiratory  hospitalization  revisit 
rate  was  assessed  by  medical  record  review  of  all  patients.  RESULTS:  For 
the  total  sample,  ER  revisit  rate  for  respiratory  illness  within  3  months  of  ER 
asthma  intervention  decreased  43%  during  the  2  years  of  the  study.  Hospital 
admission  for  respiratory  illness  within  3  months  of  the  ER  asthma  interven- 
tion decreased  10%  during  the  2  years  of  the  study.  Patient  self-report  of 
medication  adherence  averaged  90%,  CONCLUSION:  Patients  demonstrate 
decreased  respiratory  BR  visits  and  respiratory  hospitalizations  after  a 
standardized  asthma  ER  intervention. 

OF-00-044 


1020 


RESPIRATORY  CARE  •  AUGUST  2000  VOL  45  NO  8 


Monday,  October  9, 2:00-3:55  pm  (Rooms  213,214) 


A  Pediatric  Asthma  Fast  Track  (PAFT)  Can  Reduce  The  Number  of 
Patients  Admitted  to  An  Acute  Care  Unit  Thomas  J.  Kallstrora,  KRT, 
FAARC.  Cleveland. 

Bacl(ground:  Asthma  admissions  to  our  acute  care  460  bed 
community/teaching  hospital  have  been  perceived  to  be  a  problem.  One  of 
target.s  for  1999  was  a  20%  or  less  admission  rate  to  the  hospital  from  the 
emergency  department.  Method:  We  addressed  this  problem  in  an  interdisci- 
plinary manner.  We  organized  a  task  force  which  included  nurses,  respiratory 
therapists  (RT),  physicians,  risk  management  and  hospital  administrators. 
Our  goal  was  to  develop  a  process  by  which  we  could  assess  and  treat  expedi- 
tiously and  to  reduce  the  number  of  admissions.  Our  PAFT  was  developed 
using  the  EPR-2  Guidelines  for  the  Diagnosis  and  Management  of  Asthma, 
released  by  the  NIH  in  1997.  Management  of  the  disea.se  was  directed  by  the 
use  of  a  protocols  (algorithms),  an  already  familiar  tool  already  used  on  our 
inpatient  asthma  care  pathway.  Patients  entering  the  PAFT  had  to  be  over  the 
age  of  one,  already  diagnosed  with  asthma,  and  under  the  care  of  a  hospital 
affiliated  physician.  When  the  patient  arrived  at  the  hospital  they  went  imme- 
diately to  the  pediatric  ward,  where  the  PAFT  area  was  located.  This  area  has 
continual  RN/RT  coverage.  Key  to  the  PAFT  protocol  is  assessment, 
therapeutic  intervention,  and  patient  directed  education.  Patients  also  had 
access  to  an  interactive  asthma  education  program  that  was  computer  based. 
Patients  initially  received  Q  20  minute  assessment  and  appropriate  therapy. 
The  intervals  between  interventions  were  extended  if  the  patient  responded.  If 
a  patient  did  not  significantly  improve  within  4  hours  they  were  admitted  to 
the  acute  care  ward  and  then  placed  in  the  pediatric  asthma  pathway.  Results: 
In  a  seven  month  period  ,  41  patients  were  cared  for  in  the  PAFT.  Of  these, 
29  patients  were  discharged  within  3  hours  (71%).  The  average  number  of 
aerosols  was  3.5/patient.  Twelve  were  placed  in  observation  status  (29%)  and 
averaged  6  aerosol  treatments.  Only  1 1  %  of  the  patients  seen  in  the  PAFT 
were  admitted  to  the  acute  care  ward.  For  all  patients,  the  first  assessment 
and  subsequent  aerosol  treatment  was  given  by  1 1  minutes  (from  admission 
to  treatment).  Conclusions:  Using  a  PAFT,  patients  can  be  rapidly  assessed 
and  appropriately  cared  for.  This  can  be  accomplished  with  a  joint  effort 
between  RT,  nurses,  physicians,  and  hospital  administration.  We  have  devel- 
oped a  post  discharge  survey  which  will  be  used  to  track  outcome  indicators. 

OF-00-047 


A  Pediatric  Asthma  Care  Path  (PACP)Can  Reduce  Length  of  Stay 
(LOS).  Thomas  J.  KallsUom.  RRT,  FAARC,  Cleveland. 
Background:  Recent  statistics  released  by  the  National  Institutes  of  Health 
(NIH)  note  the  prevalence  of  pediatric  asthma  has  increa.sed  by  160%  over 
the  last  15  years.  Incidence  of  pediatric  asthmatic  in  our  community  is  high 
as  it  is  throughout  the  country.  Our  risk  management  department  had  noted 
an  increased  number  of  a.sthma  admissions,  readmissions,  and  long  length  of 
stay  at  our  facility  over  the  past  several  years.  There  was  also  considerable 
consternation  between  the  respiratory  therapy  (RT)  and  nursing  staff  regard- 
ing RT  availability  to  provide  aerosolized  bronchodilator  therapy  in  a  timely 
and  consistent  fashion.  A  Team  consisting  of  RT,  nurses,  physicians,  social 
workers  and  pharmacists  were  charged  with  the  task  of  developing  a  protocol 
that  could  address  our  increased  number  of  admissions  and  length  of  stays 
(LOS)  Method:  Our  PACP  was  developed  using  the  EPR-2  Guidelines  for 
the  Diagnosis  and  Management  of  Asthma,  released  by  the  NIH  in  1 997. 
Management  of  the  disease  was  directed  the  use  of  protocols  (algorithms). 
This  pathway  was  a  joint  effort  with  nursing  and  RT  doing  all  of  the  assess- 
ment and  treatments.  Patients  were  scored  with  objective  data  that  allowed 
them  to  provide,  withhold,  or  to  intensify  therapy.  The  PACP  was  designed 
to  decrease  repetitive  and  unnecessary  therapies  and  to  provide  patients  with 
essential  education.  This  we  hoped  would  enable  them  to  better  recognize 
signs  and  symptoms  of  deterioration  and  eventual  treatment  in  hopes  of  pre- 
venting a  trip  to  the  emergency  department.  A  variation  of  this  same  Asthma 
Care  Path  was  developed  at  Rainbow  Babies  and  Children's  Hospital  in 
Cleveland  several  years  previous.  Results:  In  January  of  1999,  nursing  and 
RT  launched  a  new  pathway  for  pediatric  asthma  patients.  The  criteria  was 
limited  to  those  over  the  age  of  one  year  and  who  had  already  been  diagnosed 
with  asthma.  The  average  LOS  for  pediatric  a.sthma  patients  one  year  prior  to 
implementation  of  the  pathway  was  2.26  days/patient.  One  year  into  our  pro- 
gram we  have  seen  the  average  LOS  drop  to  1 .54  days/patient.  This  is  a  35% 
decrease.  Conclusion:  LOS  can  be  positively  influenced  by  a  PACP.  Reduc- 
tion in  LOS  is  only  part  of  what  should  be  measured.  Because  of  the  need  to 
measure  after  discharge  we  have  developed  an  outcomes  measurement  tool 
built  into  a  call-back  survey.  We  hope  to  report  on  this  in  a  future  abstract. 


OF-00-048 


PILOT  OF  A  PEDIATRIC  ASTHMA  ASSESSMENT-BASED,  SCORING 
SYSTEM  AS  A  PREDICTOR  OF  HOSPITAL  LENGTH  OF  STAY. 

Marsha  Rogers  CRT.  Karen  Camasso  MD.  Carolyn  Kercsmar  MD,  Timothy  R.  Myers 
BS.  RRT.  and  Robert  Chatbum  RRT,  FAARC.  Rainbow  Babies  &  Children's  Hospital. 

Cleveland.  OH. 
Introduction:  Asthma  is  a  chronic  inflammatory  disease  of  the  airways  that  affects 
approximately  5  miilion  children.  While  children  represent  1/3  of  the  asthma  population 
in  the  United  States,  they  are  the  fastest  growing  segment  for  prevalence.  Although 
asthma  is  considered  an  ambulatory  sensitive  condition.  Emergency  Department  (ED) 
visits  for  pediatric  asthma  is  common.  ED  visits  and  hospitalization  constitutes  a  failure 
of  ambulatory  or  preventative  care.  Approximately  30-40%  of  our  1600  ED  asthma  visits 
result  in  hospitalization.  All  asthma  patients,  regardless  of  setting,  are  placed  on  an 
assessment-based  care  paths  for  treatment  (ACP).  Patients  requiring  aerosols  more  fre- 
quently than  Q2H  on  admission  are  admitted  to  our  pediatric  intensive  care  unit  (PICU). 
and  those  treated  less  frequently  are  admitted  to  our  Asthma  Care  Unit  (ACU).  Utiliza- 
tion of  our  ACP  has  assisted  in  decreasing  inpatient  length  of  stay  (LOS)  to  1 .9  days  for 
asthma  admissions.  While  this  LOS  for  pediatric  asthma  is  acceptable,  40%  of  our  asth- 
matics have  a  LOS  >  1 .9  days  and  1 69c  require  treatment  intensification  (Respir  Care 
1 998.  43(  1 »  prior  to  discharge  home.  We  theorize  if  these  subsets  could  be  identifled 
earlier  in  their  admission,  that  more  aggressive  care  could  further  shorten  LOS.  Objec- 
tive: To  determine  if  an  assessment-based  pilot  scoring  system  utilized  in  the  ED  prior  to 
admission  for  children  in  status  asthmaticus  is  predictive  of  hospital  (LOS). 
Participants:  All  children,  ages  1-16,  admitted  to  our  hospital  over  3  months  that 
received  at  least  5  or  6  aerosols  in  our  ED  prior  to  admission.  Methodology:  All  ED 
patients  were  treated  using  our  standardized  assessment-based  ACP.  The  ACP  consists 
of  assessment  criteria  (wheeze,  air  exchange,  accessory  muscle  usage,  pulse  oximetry 
and  respiratory  rate)  and  therapy  (02,  albuterol  aerosols,  steroids)  at  prescribed  intervals. 
Treatment  was  discontinued  when  preset  discharge  criteria  were  met.  Patients  were 
observed  for  I  hour  after  their  last  treatment  then  discharged.  Patients  not  meeting 
discharge  criteria  after  6  aerosols  or  1  hour  of  continuous  aerosols  were  admitted.  All 
patients  requiring  admission  were  treated  using  our  inpatient  ACP  (Respir  Care  1998. 
43(  1 )).  Patients  admitted  to  our  PICU  were  treated  with  continuous  and  Q I H  aerosols, 
then  placed  on  the  ACP  when  Q2H  aerosol  frequency  was  achieved.  For  this  study,  a 
weighted,  numerical  scoring  system  based  on  our  standard  ACP  assessment  criteria  was 
piloted.  The  pilot  score  was  assessed  from  each  patient's  fifth  or  sixth  ED  assessment. 
Scores  could  range  from  a  low  of  2  to  a  high  of  1 5.  Results:  A  total  of  95  children  were 
enrolled  in  the  study.  Retrospective  review  of  the  study  data  indicates  that  70  patients 
met  and  completed  all  study  criteria  (study  enrollment,  5  or  6  aerosols  on  ED  ACP,  and 
completion  of  inpatient  ACP).  Student  t-tests  (p<0.05)  were  utilized  to  assess  assessment 
score  significance  to  hospital  LOS. 


Asses-sment  .Score 

>  9  (n=  20) 
5-9  (n=  29) 
<5  (n=2l) 


Avg.  Assessment  Score 

11.2  (±1.4) 
7.2  (±1.3) 
34  (±0.8) 


Hospital  LOS  (SO)  p  value 

2.09  (±0.86)  p=0.0l 

1.58  (±0.55)  p=0.006 

1.29  (±0.48)  p=0.05 


Conclusion:  The  ED  scoring  system  developed  and  piloted  in  this  study  appears  to  be 

have  some  predicted  statistical  value  for  hospital  LOS  for  children  admitted 

with  asthma.  Further  studies  arc  needed  to  validate  this  pilot  data.  OF-00-097 


The  Modified  Borg  Dyspnea  Scale:  Like  pulling  numbers  from  a  hat?  T^ry 
S.  LeGrand.  PhD.  RRT,  Shana  Giles,  David  C.  Shelledy,  PhD,  RRT. 
University  of  Texas  Health  Science  Center,  San  Antonio,  TX 
Ba(*gfound:  The  Borg  scale  Is  often  used  during  asthma,  pulmonary  or 
cardiac  education  programs  to  quantify  patients'  progress  in  learning 
disease  management  The  Borg  scale,  designed  in  1962,  rates  perceived 
exertion  during  exercise.  Itvras  modified  in  1982  to  measure  perceived 
intensity  of  dyspnea  using  a  12-point  scale.  Ck)nflicting  results  have  Ijeen 
reported  in  studies  designed  to  correlate  the  modified  Borg  scale  with 
indices  of  pulmonary  and  physical  function.  For  example,  there  was  no 
significant  difference  t)etween  Borg  scores  beio(&  and  after  a  pulmonary 
rehat)ilitation  program  in  which  there  were  significant  increases  in 
metalwlic  and  physical  function  parameters.  Method:  To  determine  if  the 
modified  Borg  scale  Is  a  valid  tool  to  quantify  outcomes  assoaated  with 
disease  management  education  programs,  Borg  dyspnea  scores  were 
collected  on  asthmatics  (n=43)  who  presented  to  the  emergency 
department  during  acute  asthma  exacerbation.  Subsequently,  scores 
corresponding  to  the  Borg  scale  were  assigned  in  a  blinded  fashion  to 
these  subjects  by  randomly  selecting  cards  from  a  box.  Means  were 
compared  using  a  paired  f-test.  Results:  There  was  no  significant 
difference  between  mean  dyspnea  scores  reported  by  asthmatics  and 
randomly  assigned  scores  (4.21  ±  2.7  vs  4.74  ±  2.9,  p  =  0.38).  Conclusion: 
While  the  modified  Borg  scale  may  be  a  useful  determinant  of  a  patient's 
subjective  level  of  distress  during  a  given  episode  of  dyspnea,  its  use  as  a 
measure  of  the  effectiveness  of  disease  management  education  is 
questionable.  Respiratory  therapists  who  routinely  use  the  Borg  scale 
should  be  aware  of  its  limitations,  and  that  it  may,  in  fact,  be  no  more 
significant  than  "pulling  numbers  from  a  hat."  In  this  study,  the  unreliability 
of  Borg  scores  coupled  with  limitations  shown  in  other  studies 
demonstrates  the  importance  of  utilizing  objective  measures  of  progress, 
such  as  exercise  tolerance,  pulmonary  function  and  standardized 
measures  of  health  related  quality  of  life,  to  detemiine  the  effectiveness  of 
education  in  disease  management  programs. 

OF-OO-112 


RESPIRATORY  CARE  •  AUGUST  2000  VOL  45  NO  8 


1021 


Monday,  October  9, 2:00-3:55  pm  (Rooms  213,214) 


A  COMPARISON  OF  TWO  ASTHMA  EDUCATION  PROGRAMS. 

Stephanie  Monlcath.  CRT  .  Linda  Van  Scoder,  EdD,  RRT,  Respiratory  Therapy 


Program,  School  of  Allied  Health  Sciences,  Indiana  University  School  of  Medicine, 
Indianapolis,  IN,  46202. 

Background: 

Asthma  is  a  disease  that  affects  an  estimated  3-5  million  children  under  the  age  of 
18  and  cost  approximately  3.2  billion  annually  to  treat.  It  is  for  these  reasons  that 
this  study  was  performed.  The  purpose  of  this  study  was  to  compare  the  effective- 
ness of  the  asthma  education  programs  for  two  large  Indiana  hospitals. 
Methods: 

This  study  was  a  descriptive  study  that  used  a  non-experimental  design  format. 
The  study  consisted  of  a  total  of  48  patients,  with  24  randomly  selected  patients 
from  each  hospital.  The  individual  emergency  room  visits  and  hospitalizations 
were  gathered  for  each  patient  during  the  time  frame  of  August  1999  -  February 
2000.  An  indef>endent  t-test  was  used  to  compare  variables  between  the  two 
programs  and  a  dependent  t-test  was  used  to  compare  variables  within  the  same 
program.  The  confidence  interval  (CI)  was  95%  (p(  .05). 
Results: 

The  mean  pre-  and  post-education  ER  visits  and  the  mean  pre-  and  post-education 
hospitalizations  were  calculated  for  each  hospital.  Both  hospitals  had  a  decrease  in 
post-education  ER  visits  and  hospitalizations  {Table  1): 

Table  1     Comparison  of  Resource  Utilization 


Hospital  A 

Hospital  B 

p-value 

Mean  pre-education  ER  visits 

1.583 

0.458 

0.000 

Mean  post-education  ER  visits 

0.250 

0.375 

0.494 

Mean  pre-education  hospitalizations 

1.167 

0.792 

0.031 

Mean  post-education  hospitalizations 

0.042 

0.167 

0.251 

The  mean  change  in  ER  visits  and  hospitalizations  were  also  looked  at  for  each  hos- 
pital. Concerning  the  mean  change  in  ER  visits.  Hospital  A  had  an  average  change 
of  1 .333  and  Hospital  B  had  an  average  change  of  0.083  with  the  p-value  =  0.000. 
Concerning  the  mean  change  in  hospitalizations.  Hospital  A  had  an  average  change 
of  1 . 1 25  and  Hospital  B  had  an  average  change  of  0.792  with  the  p-value  =  0.049. 
Conclusion: 

Both  asthma  education  programs  were  effective  in  decreasing  ER  visits  and  hos- 
pitalizations. Because  patients  in  each  program  had  significantly  different  utiliza- 
tion patterns  prior  to  education,  we  were  unable  to  conclude  which  program  was 
more  effective. 

OF-00-139 


LEVALBUTEROL  &  ALBITTEBm.  SULFATE:  A 
COMPARISON  STUDY 

Marcia  Roberts  Graves  CRTT.  RCP.  BS 
Harris  Methodist  Southwest,  Foit  Worth,  Texas 
Badtgrotind:  Patients  with  severe  onset  of  respiratory  illness 
oftco  go  to  the  Emergency  Dqjartmenl,  (ED)  for  inimediate 
medical  attcniioa  This  study  evaluated  a  comparison  in  the 
clinical  outcomes  of  aerosolized  Levalbuterol  and  Albuterol 
Sulfate  on  that  population  of  patients.  Methods:  Data  was 
collected  on  456  patients  during  a  3-month  study.  All  adult 
patients  presenting  with  onset  of  severe  onset  of  respiratory  illness 
were  included  in  this  study.  Patients  received  aerosolized 
OKdicaUon  with  the  Airlife  sidcstream  high-efficiency  nebulizer. 
It  was  decided  to  target  2  specific  outcomes:  1)  Number  of 
hospital  admissions  for  patients  receiving  each  medication  2} 
Number  and  frequency  of  treatments  for  patients  receiving  eadi 
medication. 

#  Receiving  #  Receiving 

RcsnUs:  Levalbuterol  Albuterol  Sulfate 

I.  25  mg.  S  ml 


ED  patients  treated 

299 

157 

Avg.  #  of  treatments 

in  ED 

3 

5 

Avg.  LOS  in  ED 

1.75  tas. 

2.8  his. 

Hospital  admissions 

29  (10%) 

98(60%) 

Avg.  #  of  treatments 

in  Hospital 

7 

16 

Avg.  LOS  in  Hospital 

2.25  d^ 

3.2  days 

Conclusion:  In  this  study,  patients  treated  with  Levalbuterol 
demonstrated  significant  decrease  in  total  treatment  times  in  both 
the  ED  and  hospital,  hospital  admits,  and  LOS  for  both  the  ED 
and  hospital  as  compared  to  Albuterol  Sulfate.  Levalbuterol 
nebulization  appears  to  make  a  vast  impact  on  both  diaical  and 
financial  outcomes. 


OF-00-149 


Omununtty  Coordinated  Care  in  the  Use  of  Lsoflurane  Augmented  Mechanical  Ventilation 
Treatment  for  Life  Threatening  Asthma-  Cox.  Timothv.  RRT.  Nadkami.  Vinav.  MD.  Culien. 
Edward,  MD,  Christie,  John,  RRT;  Resnik,  Patty  RRT,  Grille,  Angelo  MD,  Muirhead.  Karen  RRT  A.I. 
DuPont  Hospital  for  Children,  Thomas  Jefferson  Medical  College.  Christiana  Care  Health  System, 
Wilmington,  De.  19803 

Introduction:  Major  complications  from  positive-i^-essure  breathing  in  asthmatic  patients  are  common. 
BrorKhodilatory  effects  of  inhalationa!  ane.sthetic  agents,  such  as  Isofliu-ane,  have  long  been  observed  by 
anesthesiologists.  The  timely  use  of  general  anesthesia  to  support  conventional  medical  and  ventilatory 
care  has  been  reported  u.seful  fen-  bronchodilation  and  facilitating  a  rapid  wean  from  the  ventilator.  We 
report  a  case  of  a  pediatric  patient,  status  post  respiratory  arrest  secondary  to  status  aslhmaticus,  treated 
with  mechanical  ventilation  and  isoflurane.  CaseSummary:TF.I4yearold.  70  kg  adolescent,  never 
previously  hospitalized,  had  a  history  of  moderate-severe  asthma  as  a  child.  He  awoke  from  sleep,  at 
approximately  0250.  with  sudden  shortness  of  breath,  stopped  breathing  and  required  CPR  by  family 
nwmbeis  for  approximately  1  minute.  Upon  Medic  arrival,  his  Oxygen  saturation  by  Pulse  Oximeter 
was  50%.  He  was  manually  ventilated  via  ETT  and  transported  to  our  affiliate  tertiary  hospitalis(CCHS) 
ER.  where  he  was  managed  with  an  epinephrine  infusion  and  placed  on  mechanical  ventilation.  ER 
Cpgrse:  A  consulting  pediatric  intensivist,  from  our  institution  met  the  patient  in  the  emergciKy  depart- 
tnenl  (ED).  His  initial  blood  gas  showed  a  severe  respiratory  acidosis  and  hypoxemia:  pH  6^2,  pC02 
267,  p02  87,  HC03  28.  A  right  Pneumothorax  was  identified  and  addressed  with  needle  thoracentesis 
and  placement  of  a  14  French  chest  tube.  The  team  represented  by  the  pediatric  intensivist,  ED  physi- 
cians and  respiratray  care  practitioners  (RCP)  began  titrating  0.5  -1 .0%  Isoflurane  via  the  Siemens 
Servo  900C  anesthesia  ventilator  (Siemens  Medical  Systems,  Danvers.  MA)  with  anesthetic  gas  monitor 
at  0445.  He  demon.strated  that  he  could  tolerate  weaning  from  Isoflurane  by  hand  ventilating  him  for  30 
minutes  with  oxygen  and  continuous  albuterol  aerosols.  He  was  transported  by  to  our  facility's  PICU 
and  was  placed  on  identical  equipment  used  in  the  CCHC-ER.  His  initial  ventilator  settings  included  a 
tidal  volume  of  700  mL  (10  mlAg).  PEEP=5,  Ratc/SIMV  of  10/minute.  Fi02  of  !00%  and  Pres-sure 
support  of  lOcm  H20.   Isoflurane  anesthetic  gas  at  0.5  %  was  initiated  and  titrated  clinically  based  upon 
lung  compliance,  wheezing/aeration,  and  blood  pressure.  Some  pertinent  data  on  his  course  is  summa- 
rized as  follows: 

HOME 

CCHC 

ED 

CCHC 

ED 

Start  of 

Isoflurane 

CCHC 

End  of 

Isoflurane 

CCHC 

THAM 

Trans- 
pon 

TIMH 

0250 

0340 

0420 

0445 

0fi20 

0540 

0550 

0559 

0640 

0650 

0700 

Sa02 

50 

<50 

89 

78 

45 

78 

78 

l(X) 

100 

UK) 

100 

pH 

6.81 

6.72 

6.64 

6.69 

6.67 

6.88 

7.02 

7.15 

PC02 

121 

>200 

259 

210 

267 

144 

95 

76 

PfJ2 

no 

92 

54 

84 

87 

195 

489 

416 

BE 

-10 

-7 

■12 

-13 

-13 

-8 

-6 

-2 

Hmphaicourw: 

Houn)  over  the  nc 
dopamine,  Kelami 
steroids.  He  was  e 
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was  noted  from  hh 
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he  was 
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Jt  a  sustai 
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161 

CHEERS 


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Thanks  to  our  volunteers,  MDA 

is  the  first  voluntary  health 

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Lifetime  Achievement  Award. 


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1-800-572-1717  •  www.nidou5a.org 


1022 


Respiratory  Care  •  August  2(X)0  Vol  45  No  8 


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Syringes  for 
Direct  Blood 

Sampling  from  an 
Arterial  Line 


Medical  Systems 


SIMS,  Ponex,  Pro  Vent,  Needle-Pro,  and  Filier-Pro  are  SIMS  uademarks.  Point-Lok  is  a  trademark  of  Noved  Medical, 


Tuesday,  October  10, 1:30-3:25  pm  (Rooms  200,201) 


CONSCIOUS  SEDATION  PROVIDED  BY  RESPIRATORY  CARE 
PRACTITIONERS  DURING  BRONCHOSCOPY  IN  ADULT  PATIENTS: 
James  T  Shreve  BS.  RRT.  RPFT.  Michael  Uvery,  RRT.  James  P.  Lamberti 
M.D  Inova  Fairfax  Hospital,  Falls  Church,  VA 

OBJECTIVE:  To  evaluate  the  safety  of  conscious  sedation  provided  by 
Respiratory  Care  Practitioners  (RCPs)  during  flexible  bronchoscopy.  We 
studied  460  patients  between  January  1999  and  December  1999. 

METHODS:  RCPs  were  provided  additional  training  and  tested  for 
competence  in  the  insertion  of  intravenous  catheters,  sedative  and  analgesic 
pharmacology,  and  titration  of  analgesics  and  sedatives  prior  to  providing 
conscious  sedation  during  flexible  bronchoscopy.  Baseline  vital  sign 
measurements  were  recorded  to  include  level  of  consciousness  using  a 
modified  Aldrete  Score.  Patiems  were  monitored  during  the  procedure  with 
continuous  ECG,  oxygen  saturation,  plethysmograph  and  non-invasive  blood 
pressure  measurements  every  five  minutes   Post-bronchoscopy  vital  sign 
measurements  were  monitored  until  the  patient  was  stable  (usually  30-60 
minutes  after  the  procedure).  Patients  received  midazolam  (Versed)  and/or 
meperidine  (Demerol)  intravenously  under  direct  physician  supervision.  A 
retrospective  review  was  performed  to  investigate  adverse  reactions  during 
bronchoscopy  with  conscious  sedation  being  provided  by  RCPs. 

RESULTS:  96%  of  the  patients  completed  flexible  bronchoscopy  without  any 
complications  from  conscious  sedation.  1 7  adverse  reactions  to  the  conscious 
sedation  were  noted:  Hypoxia  =  8  patients.  Hypotension  =  3  patients. 
Tachycardia  =  0  patients.  Bradycardia  =  0  patienu.  Reversal  agents  used  =  4 
patients.  Unplanned  admission  to  hospital  =  2  patients,  1  death  not  related. 

CONCLUSION:  RCPs  who  demonstrate  competence  in  airway  skills,  patient 

assessment  and  monitoring  are  excellent  candidates  to  provide  conscious 

sedation   These  practitioners,  with  additional  training  in  inserting  intravenous 

catheters,  sedative  and  analgesic  pharmacology,  can  assist  in  providing  safe 

conscious  sedation  in  accordance  with  physician  direction  to  the  aduk  patient 

population  during  flexible  bronchoscopy. 

*^*^  *  OF-00-004 


THE  IMPACT  OF  A  NURSING  DRIVEN  INTERDISCIPLINARY 
SCREENING  TOOL  IN  IDENTIFYING  THE  NEED  FOR  A 

RESPIRATORY  CARE  CONSULT Craig  Leonard.  MA.  RRT. 

Brian  L.  Smith,  RRT,  Sandra  Gaynor,  DNSC,  RN,  William  T.  Peruzzi, 
MD,  Northwestern  Memorial  Hospital,  Chicago,  Illinois. 

Introduction:  Inadvertent  omission  of  therapeutic  respiratory  care  ser- 
vices can  occur  when  patients  are  admitted  to  the  hospital  for  the 
primary  treatment(s)  of  non-respiratory  related  conditions  and  an  under- 
lying pulmonary  condition  exists.  The  traditional  patient  admission 
process  performed  by  nursing  may  not  be  sufficient  to  identify  all 
patient  conditions  that  would  require  respiratory  care  intervention. 
Through  a  multidisciplinary  task  force,  a  Patient  Profile  Form  (PPF) 
was  established  to  be  used  by  nursing  upon  patient  admission  to  identify 
significant  respiratory  issues  and  trigger  an  appropriate  respiratory  care 
consult.  We  postulated  that  the  incorporation  of  the  PPF  into  the  admit- 
ting process  for  patient  screening  should  result  in  a  more  sensitive  tool 
to  identify  potentially  significant  respiratory  conditions  that  require 
therapeutic  intervention  by  the  respiratory  therapist.    Methods:  An 
interdisciplinary  team  of  healthcare  professionals  including  respiratory 
care  investigated  possible  solutions  for  improving  the  effectiveness  of 
admission  screening  practices  for  patients  at  our  institution.  Each  disci- 
pline identified  important  patient  conditions  that  would  trigger  the  need 
for  a  consult  from  their  respective  service(s).  A  section  on  the  PPF  was 
created  for  each  discipline,  which  highlighted  clinical  conditions  that 
would  require  a  consult  evaluation.  The  PPF  is  required  to  be 
completed  by  the  admitting  nurse  for  all  patient  admissions  to  the  hospi- 
tal Results:  During  the  initial  trial  period  of  the  PPF,  there  were  77 
request  for  respiratory  care  consults.  6  (7.8%)  out  of  the  77  consult 
requests  resulted  from  triggers  for  respiratory  therapy  highlighted  on  the 
PPF.  2  (2.6%)  of  the  6  consults  initiated  from  the  PPF  resulted  in  addi- 
tional respiratory  care  intervention.  The  remaining  4  consults 
recommended  that  further  or  additional  respiratory  care  was  not  neces- 
sary. Conclusions:  We  conclude  that  the  PPF  is  a  valuable  screening 
tool  to  decrease  hospital  errors  through  omission  by  identifying  underly- 
ing pulmonary  conditions  that  may  be  overlooked  upon  routine 
admission  into  the  hospital. 


OF-00-021 


COMPARISON  OF  PHYSICIAN-DIRECTED  VS  RESPIRATORY  CARE  PROTOCOL- 
BASED  TUBERCULIN  SKIN  TESTING 

Sieve  Nivison  BS  RRT.  Virginia  DeFilippo  MS  RRT,  Lynn  Tanoue  MD,  Jeffrey  Topal  MD. 
Yale-New  Haven  Hospital,  New  Haven,  Connecticut 

Purpose:  To  determine  if  tuberculin  skin  testing  performed  by  Respiratory  Care  Practitioners 
(RCP)  is  more  effective  than  the  current  practice  of  testing  performed  by  physicians. 


Background:  Tuberculin  skin  testing  is  an  important  tool  in  identifying  patients  with  latent 
tuberculosis  (TB)  infection.  Given  the  known  efficacy  of  cheinoprophylaxis,  identification  of 
these  individuals  is  important  in  the  prevention  of  future  cases  of  active  TB.  The  current  prac- 
tice at  our  institution  consists  of  the  physician  identifying  a  patient  at  risk  for  TB  infection,  plac- 
ing a  purified  protein  derivative  (PPD)  skin  test,  reading  the  PPD,  and  documenting  the  results  in 
the  medical  record.  A  review  by  Hospital  Epidemiology  and  Infection  Control  over  2  months 
showed  that  of  191  consecutive  patients  meeting  CDC  criteria  for  PPD  testing,  only  1  (0.5%) 
had  a  PPD  placed,  read  and  documented.  A  separate  6  month  review  of  1 14  consecutive  patients 
placed  on  airborne  precautions  for  the  possibility  of  TB  infection  showed  that  only  4  (3.5%)  had 
a  PPD  placed,  read,  and  appropriately  documented. 

Method:  This  study  compared  two  groups  of  patients  over  a  6  week  period.  The  first  group 
consisted  of  patients  admitted  to  adult  wards  in  whom  tuberculin  skin  testing  was  directed  by 
physician  selection.  Consistent  with  current  standard  hospital  practice,  the  physician  determined 
which  patients  would  be  screened,  placed  the  PPD,  interpreted  the  result,  and  made  the  appropri- 
ate documentation.  The  second  group  consisted  of  patients  admitted  to  two  internal  medicine 
wards  where  tuberculin  skin  testing  was  directed  by  a  respiratory  care  protocol.  Physicians  were 
informed  which  patients  in  this  group  met  CDC  criteria  for  PPD  testing.  The  physician  then 
placed  an  order  for  PPD  testing.  Respiratory  Care  Practitioners  trained  in  PPD  testing  then  per- 
formed PPD  placement,  reading,  and  documentation.  Patients  who  were  discharged  or  expired 
before  skin  test  reading  could  be  performed  were  excluded  from  the  study.  Chi-square  was  per- 
formed for  statistical  analysis. 

Rendls: 

«PPDs  %  of  ordered 

I£ad  tests  actually  read 

9  37.5 

26  100% 


Conclusion:  Tuberculin  skin  testing  directed  by  a  respiratory  care  protocol  had  a  higher  com- 
pletion rate  In  comparison  to  traditional  skin  testing  performed  by  physicians. 


#TB  tests 
ordered 

#PPDs 

Physician  -  directed 
skin  testing 

24 

11 

Respiratory  Care  Protocol- 
based  skin  testing 

26 

26 

OF-00-027 


PALM  COMPUTER  IMPROVES  PRODUCTIVITY 
OF  CARE  PATH  MANAGEMENT 

Teresa  A.  Volsko  RRT.  Michael  W.  Konslan  MD,  Robert  L,  Chatburn  RRT,  FAARC 

Rainbow  Babies  and  Children's  Hospital  and  Case  Western  Reserve  University, 

Cleveland,  OH 

The  efficiency  and  quality  of  data  collection  are  integral  components  of  disease 
management  programs.  We  investigated  the  use  of  a  palm  computer,  the  Palm  Mix, 
(Palm  Computing,  Inc.,  Santa  Clara,  CA)  vnth  a  relational  database  for  collecting  clinical 
and  outcome  data  for  patients  hospitalized  for  tnealmeni  of  a  pulmonary  exacerbation  of 
cystic  fibrosis  (CF),  and  who  were  managed  on  a  clinical  care  path.  We  hypothesized 
that  the  use  of  the  Palm  Mix  for  electronic  data  collection  and  transmission  of  linked  data 
vrouki  reduce  the  amount  of  lime  and  expense  incurred  when  compared  with  our  cunent 
paper  based  data  collection  and  computer  entiy  process.  METHODS:  All  patient  and 
outcome  data  were  previously  collected  on  a  paper  copy  of  the  forms  created  In  our  MS 
Access  database.  Our  database  contains  12  related  tables  that  provide  Ihe  framework 
from  which  a  parent  data  collection  form  and  7  subforms  were  built.  A  total  of  2,328 
records  were  collected  and  stored  in  the  database  over  a  three  month  period  (12/1/99  - 
3/1/00).  The  data  recorded  on  the  paper  forms  were  manually  entered  into  the  mirror 
Image  electronic  forms  in  the  database.  A  representative  sample  of  10  patients  (42 
fotms)  was  selected  lor  determining  data  collection  time.  The  time  for  the  CF  Care 
Manager  to  collect  dally  nutrition,  lab.  medication,  nuising,  respiratory,  diagnostic 
testing,  discharge  criteria,  and  co-morbidity,  data  onto  the  paper  fomis  and  hand  enter 
this  infomialion  into  the  MS  Access  database  was  recorded  To  enable  electronic  data 
entry  via  the  Palm  Mix,  Ihe  MS  Access  database  was  linked  to  Palm  based  data 
collection  forms  using  Pendragon  Forms  (Pendragon  Software  Corp.,  LIbertyvllle,  IL). 
Palm  based  data  collection  forms  were  identical  to  the  papec  forms.  The  lime  in  minutes 
(or  Ihe  same  care  manager  to  collect  identical  daily  inlonnation  on  the  Palm  Mix  and 
transfer  it  to  the  MS  Access  database  through  a  Hotsync  maneuver  was  collected  Cost 
was  calculated  as  the  product  of  data  collection  time  and  care  manager's  houriy  salary. 
Data  were  compared  with  unpaired  t-test.  Significance  was  established  as  p<0.05 
RESULTS:  Data  are  displayed  below: 


Number  ol  patients^ 


Data  collection  tlme/patlenl/day  in  minutes 


Data  colleclion  co»l/p«li«nl/dav  in  dollats 


Pipf 


10 


7.8(1.55) 


$2.59(0.51) 


Palm 


10 


5.4  (D.51) 


$1.«2(b.15) 


<  0.001 


<  0.001 


Values  am  mean  l±SD) 

CONCLUSIONS:  Computerized  data  collection  increased  productivity  for  patients  on  the 
Cystic  Fibrosis  Care  Path  Based  on  4,802  patient  days  on  the  CF  care  path  per  year,  we 
estimate  a  time  savings  of  360  hours  per  year  (7  2  hrs/vreek)  In  the  collection  and 
transfer  of  daily  clinical  and  outcomes  data.  This  translates  into  an  estimated  annual  cost 
savings  of  ?7,207  00  at  our  Institution. 


OF-00-043 


1024 


Respiratory  Care  •  August  2000  Vol  45  No  8 


Tuesday,  October  10, 1:30-3:25  pm  (Rooms  200,201) 


IMPLEMENTATION  OF  A  VOLUME-DRIVEN  STAFFING  MATRIX  FOR 
RESPIRATORY  CARE  IMPROVES  STAFFING  WITHOUT  UNFAVORABLE 
IMPACT  TO  BUDGET 

Nabil  MigaU,  MBA.  RRT,  RPSGT.  Elizabeth  Wiseman-Chase,  BA,  RRT,  RH=T,  Brian 
Smith,  BA,  RRT,  Lany  Goldberg,  William  Pemzzi,  MD,  Northwestern  Menxwial  Hospi- 
tal. Chicago,  IL 

Background:  Increases  in  demand  for  respiratory  care  services  present  staffing  challenges 
to  hospital  depanments.  Volume  increases  often  surpass  resources.  Managers  are  faced 
with  the  challenge  of  flexing  staff  to  accommodate  these  demands,  often  relying  on  over- 
time and  agency  staffing.  Historically,  the  use  of  agency  staffing  in  the  Department  of  Res- 
piralor>  Care  (DRC)  at  Northwestern  Memorial  Hospital  (NMH)  had  resulted  in  unfavor- 
able labor  variances  associated  with  lower  productivity  and  premium  labor  rates. 
Additionally,  agencies  are  not  consistent  options  during  periods  of  peak  volume  when 
multiple  institutions  are  requesting  agency  staffing  support.  During  fiscal  year  (FY)  "99, 
the  DRC  experienced  an  unprecedented  increase  in  requests  for  services.  Relative  Value 
Units  (R  VUs)  peribnned  during  peak  months  were  4 1 9,505  and  423,808.  Historic  peak 
volumes  for  FY  ~97  and  FY  '98  ranged  between  213,932  and  332,017  RVUs  (mean  = 
291.224).  A  staffing  alternative  was  implemented  that  was  not  dependent  upon  agency 
staffing  and  that  would  assure  safe  patient  care  without  an  unfavorable  impact  upon  the 
departmental  operating  budget.  Methods:  Evaluation  of  workload  demands  for  the  peak 
months  of  FY  "99  revealed  that  had  each  respiratory  therapist  worked  one  additional  1 2- 
hour  shift  per  payperiod  (84-hours),  the  department  would  have  met  the  requested  demand 
for  patient  care  services.  Through  solicitation  of  feedback  from  the  clinical  staff,  it  was 
detamined  that  ion-calli  would  be  an  acceptable  solution  to  the  workload  [Hoblem.  Man- 
agement then  developed  a  Critical  Volume  IndicatOT  Matrix  (CVIM)  for  the  automatic 
authorization  of  overtime,  on-call,  and  agency  staffing  use  based  on  volume  indicatOTS 
(RVUs)andpatientacuity  (number  of  ventilator  patients).  Results:  DuringFY'OOthe 
CVIM  was  implemented  and  the  following  results  were  obtained:  The  department  was 
able  to  meet  its  service  demands  for  work  volumes  accomplished  during  periods  of  peak 
volume  (473.330  and  475. 1 80  RVUs).  Efficiency  increased  by  using  fewer  agency  staff 
work  hours  (40  vs.  405 1 ),  when  compared  to  the  prior  FY.  RVUs  per  FTE  increased  from 
54,973  (FY  '99)  to  62,540  (FY  ~00).  The  departmental  operating  budget  remained  in  com- 
pliance for  labor  expenses.  ConcluatHis:  We  conclude  that  the  CVIM  is  an  effective 
management  tool  for  flexing  staff  to  volume,  maximizing  productivity  and  maintaining 
con^liance  with  the  departmental  cfpera^g  budget  for  salary  expenses. 

OF-00-078 


EXPERIENCE  WITH  RESPIRATORY  CARE  PROTOCOUS  IN  A  LARGE 
HEALTHCARE  NETWORK.  James  K.  StoUer.  MD,  Lucy  Kester.  MBA.  RRT. 
FAARC>  Cleveland  Clinic  Foundation,  Cleveland,  Ohio. 

Background:  Respiratory  care  protocols  have  been  shown  to  improve  the  allocation  of 
respiratory  care  services  in  lai^e  tertiary  care  medical  centers.  However.  Uttie  attention 
has  been  given  to  evaluating  protocols  in  settings  other  than  teaching  hospitals.  To 
address  questions  regarding  the  use  of  respiratory  protocols  in  smaller  community  hospi- 
tals, we  undertook  a  study  of  protocol  use  throughout  die  Cleveland  Clinic  Health 
System  (CCHS).  The  CCHS  is  a  consortium  that  includes  9  Cleveland  hospitals.  Meth- 
ods: Data  were  collected  during  a  meeting  of  Respiratory  Care  Department 
representatives  from  7  of  the  9  participating  CCHS  hospitals,  where  each  hospital 
[wesented  dieir  experience  with  respiratory  protocols.  Following  the  meeting,  a 
structured  questionnaire  was  distributed  to  each  of  the  CCHS  hospitals  witii  a  request  to 
submit  all  missing  data.  Results:  Table  1  presents  the  findings. 


XO«w 


ntA,Ftb.  1982 


PU.No*.  1fl*7 


CcHichisions:  1 .  Strategies  for  implementing  respiratory  protocols  must  be  customized 
for  the  environment  of  individual  hospitals.  2.  Methods  for  monitoring  the  effectiveness 
of  protocols  vary  among  institutions.  3.  Respiratory  care  protocols  reduce  the  misalloca- 
tion  of  respiratory  care  services  not  only  in  teaching  hospitals,  but  also  in  a  variety  of 
smaller,  community-based  hospitals.  4.  Our  findings  suggest  that  the  efficacy  of  respira- 
tory care  protocols  to  improve  allocation  extends  to  community-based  institutions, 

though  further  study  is  needed. 

OF-00-084 


THE  COST  OF  TRAINING  NEW  RESPIRATORY  THERAPY 
PERSONNEL.  James  K.  StoUer,  MD,  Lucy  Kester,  MBA,  RRT,  FAARC,  Dou- 
glas Orens.  MBA,  RRT.  Cleveland  Clinic  Foundation,  Cleveland,  Ohio. 
Background:  Retention  of  Respiratory  Care  Practitioners  (RCPs)  is  a  desired  institu- 
tional goal  that  reflects  department  loyalty  and  RCPs'  satisfaction.  Cost  considerations 
also  favor  retention  because  training  new  employees  incurs  costs.  Despite  the  widely 
shared  goal  of  minimal  turnover,  neither  the  annual  rate  nor  the  associated  expense  of 
turnover  for  RCPs  has  been  described.  Study  Purpose:  To  establish  the  rate  of  RCP 
turnover  and  the  costs  related  to  training  new  staff  members.  Methods:  The  Cleveland 
Clinic  Health  System  (CCHS)  includes  9  participating  hospitals  (in  Cleveland,  Ohio) 
ranging  from  small  community-based  institutions  to  large  tertiary  care  institutions.  To 
elicit  information  about  annual  turnover  among  RCPs  throughout  die  CCHS,  we  con- 
ducted a  survey  of  key  personnel  in  each  of  the  Cleveland  CCHS  Respiratory  Therapy 
Departments.  To  calculate  the  costs  of  training,  we  reviewed  the  training  schedule  for 
an  RCP  joining  the  Respiratory  Therapy  Section  at  the  Cleveland  Clinic  Hospital. 
Cost  estimates  reflect  the  duration  of  training  by  various  supervisory  RCPs.  their 
respective  wages  (including  benefit  costs),  and  educational  materials  used  in  training. 
Results:  Table  1  presents  the  rate  of  RCP  turnover  (excluding  PRN  stafO  by  participat- 
ing hospital.  Table  2  presents  the  cost  of  training  for  each  RCP  at  the  Cleveland  Clinic 
Foundation  (CCF). 


TwnoTf  lUt—  0*T  Th«  P— 1 1  Yi 


Conclusions:  1 .  The  cost  of  RCP  turnover  is  high  and  is  likely  underestimated  by 
this  analysis.  For  example,  complete  eUmination  of  turnover  would  allow  greater 
allocation  of  RCPs'  attention  to  important  activities  other  than  training/orientation. 
i.e..  patient  care  and  research.  2.  Greater  attention  to  understanding  the  reasons  for 
RCP  turnover  and  its  elimination  is  warranted.  OF-00-085 


PREOPERATIVE  AND  POSTOPERATIVE  INCENTIVE  SPIROMETRY 
TEACHING  IN  THE  GENERAL  SURGERY  PATIENT:  OUTCOME  DIFFER- 
ENCES IN  THE  OCCURRENCE  OF  POSTOPERATIVE  PULMONARY 
COMPLICATIONS.  Rikki  S.  Bminsma  RRT  CPFT.  Karen  W.  Hampton.  RRT. 
St.  Luke's  Hospital,  Jacksonville,  FL. 

Hypothesis:  Research  has  confirmed  the  use  of  an  incentive  spirometry  (IS)  device  after 
undergoing  general  surgery  has  decreased  the  likelihood  of  develq3ing  postoperative 
pulmonary  complications  (i.e.  atelectasis  and  pneumonia).  We  hypothesized  there  is  no 
clear  benefit  of  performing  preoperative  IS  teaching  with  continued  post-op  monitoring 
over  postoperative  IS  instruction  and  monitoring  in  preventing  these  complications. 
Background:  The  time  period  prior  to  surgery  has  often  been  referred  to  as  an  ideal 
"teachable  moment"  for  the  patient  and  family.  Although  the  exact  time  frame  has  not 
been  clearly  identified,  we  believe  the  hour  or  so  just  prior  to  surgery  is  not  the  best  time 
to  "teach"  the  patient.  This  is  often  a  time  when  pre-op  preps  are  occurring,  consents  are 
being  obtained.  p)atients  are  discussing  concerns  with  their  families  or  are  in  prayer.  Sim- 
ply put,  we  feel  the  patient  is  too  overwhelmed  preoperatively  to  comprehend  the  impor- 
tance of  proper  postoperative  IS  use.  However,  this  is  the  time  when  many  patients  in 
our  hospital  are  being  instructed  on  the  technique  and  benefits  of  incentive  spiromeuy. 
Method:  A  retrospective  random  medical  record  review  of  47  patients  was  performed. 
The  criteria  for  inclusion  in  our  study  included  patients  being  admitted  to  general  surgi- 
cal services  between  06/01/99  and  12/31/99  witii  orders  for  incentive  spirometry  instruc- 
tion. Results:  The  following  table  outlines  the  results: 


Pre-op  Instruction 

Post-op  Instruction 

Sample  Size  (Male /Female) 

22(11/11) 

25(10/15) 

Mean  Age  (Range) 

60.2  years  (52  ± 

28) 

60.7  years  (58  ±36) 

m  Smoking  History' 

2 

3 

ffi  Pulmonary  Disease' 

2 

2 

B  Smoking  Hx  &  Pulm  Dx 

2 

1 

Developed  Post-op  Atelectasis' 

3(13.6%) 

3(12%) 

Developed  Post-op  Pneumonia' 

1  (4.5%) 

1(4%) 

Identified  as  a  current  smoker  ot  sometMie  who  has  quit  <  5  years  ago 
■  Fnmi  ftatient/family  interview  and  includes  asthma,  bronchitis  or  emphysema 
'  As  identified  by  positive  chest  roentgenograph  and  a  temperature  <  38°  C 
'  As  identified  by  positive  chest  roentgenograph  and  a  temperature  >  38'  C 

Statistical  analysis  by  chi'  (p=.84)  irxlicates  there  is  no  significant  difference  in  the  likeli- 
hood of  developing  postoperative  pulmonary  complications  between  the  two  groups. 
CfMiduskm:  Results  have  indicated  there  is  no  clear  benefit  of  peoperative  IS  teaching 
with  postoperative  monilmng  when  compared  to  postoperative  teaching  and  mtmitoring 
in  preventing  pulmonary  omiplicauons  after  surgery.  It  was  also  noted  that 
snroking  arxl  pulmonary  histOTy  did  not  influence  the  outcome  of  this  study.  OF-00-095 


RESPIRATORY  CaRE  •  AUGUST  2000  VOL  45  NO  8 


1025 


Tuesday,  October  10, 1:30-3:25  pm  (Rooms  200,201) 


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THE  EFFECTS  OF  A  PULMONARY  VOLUME  EXPANSION 
ASSESSMENT  PROGRAM  ON  THE  MISALLOCATION  OF 
HYPERINFLATION  THERAPIES. 

R  Breeden  RRT.  L  Clavcamp  CRT.  S  Alexander  CRT.  1  Brooks-Bmnn,  DNS, 
RN,  FAAN,  FCCP,  L  Van  Scoder  EdD,  RRT.  Respiratory  Therapy  Program, 
School  of  Allied  Health,  Indiana  University  Medical  Center,  Indianapolis,  IN 
Background:  Many  respiratory  care  treatments  are  being  inappropriately 
ordered.  We  tested  whether  proper  assessment  by  a  respiratory  therapist  would 
change  the  number  of  inappropriately  ordered  intermittent  positive  pressure 
breathing  treatments  (IPPB). 

Methods:  Patients  were  randomly  selected  from  a  list  of  all  cardiothoracic 
patients.  Medical  records  were  reviewed  for  pre  assessment  program  patients  and 
post  assessment  program  patients  to  determine  appropriateness  of  respiratory 
therapy  orders.  Chi  square  was  used  to  determine  the  significance  of  the  nimibers 
of  inappropriate  orders  between  two  groups.  A  t-test  was  used  to  determine  if 
there  was  a  significant  difterence  between  patients  demographics  of  the  groups. 
Results:  There  were  29  pre  group  and  30  post  group  chart  audit  reviews.  The 
demographics  showed  no  statistically  significant  differetKe  for  race,  gender, 
surgery  type,  and  smoking  history  between  the  two  groups.  There  was  a 
statistically  significant  difference  in  age  (pre  group  mean  60.28  (±14. 1 5),  post 
group  mean  49.90  (±1 7.69),  p=.01 6). 

IPPB  Treatment  Orders 


Frequency 

Frequency 

IPPB  Indicated 

10 

6 

IPPB  Ordered 

17 

15 

Original  Number  of  Inappropriate  Orders 

7 

9 

IPPB  Orders  Changed 

0 

13 

This  table  shows  that  in  the  post  group  patients  1 3  of  the  1 5  IPPB  treatments 
were  chained  with  9  of  them  being  ina^ropriate  orders. 
Conclusion:  There  was  a  decrease  in  the  number  of  misallocated  intermittent 
positive  pressure  breathing  treatments  (IPPB)  following  implementation  of  the 
pulmonary  assessment  program. 


OF-00-115 


SEDATED  PROCEDURES  (SP):  EXPANDED  ROLE  FOR  A  RESPIRATORY  CARE 
PRACTITIONER  (RCP).  Jeffrey  W.  Wright  BS.  RRT.  Primary  Children's  Medical  Center 
(PCMC),  Howard  Kadish,  MD,  Associate  Professor  of  Pediatrics  University  of  Utah 
School  Medicine,  Medical  Director  of  the  Rapid  Treatment  Unit.  PCMC,  Salt  Lake  City, 
Utah,  Background:  PCMC  has  adopted  the  philosophy  of  an  "Ouchless  Environ- 
ment". We  recognized  that  there  ware  many  in/oul  patient  procedures  that  are  consid- 
ered to  cause  anxiety  and  discomfort.  PCMC  acknowledged  that  in  the  course  of  treat- 
ment some  patients  would  have  painful  procedures  repeated  numerous  times  as  in  the 
case  of  bone  marrow  aspirates,  bone  biopsies,  and  lumbar  punctures.  Many  of  these 
historically  painful  procedures  were  performed  in  the  OR,  so  certain  medications  could 
be  used  to  reduce  the  pain  and  anxiety  for  the  patient.  Our  Emergency  Department 
(ED)  Physicians  (MD's)  decided  to  use  those  medications  (P'-opofol  and  Ketamine)  In 
the  ED  to  sedate  their  patients  for  particularly  painful  procedures  {i.e.  the  setting  of  a 
fractured  bone)  in  the  spirit  of  the  "Ouchless  Environmenf.  The  ED  then  proposed  a 
plan  to  do  SP  outside  the  OR  in  a  26  bed,  23-hour  Rapid  Treatment  Unit  that  is  adja- 
cent to  the  ED.  ED  sited  potential  benefits  as:  cost  savings  to  the  patient,  a  pa- 
tient/family friendly  environment  {reduced  anxiety  for  the  patient.  Mom  and  Dad  could 
hold  the  child  until  they  fell  asleep),  the  patient's  pain/discomfort  would  be  minimized 
(as  seen  In  the  OR),  and  there  would  be  a  reducttan  of  the  time  required  to  perform  the 
procedure  and  in  recovery  of  the  patient.  Current  Model  of  Care:  The  SPs  are  per- 
formed by  a  team:  ED  MD,  a  RN,  a  RCP,  and  a  Child  Life  Specialist  {CLS}.  The  ED 
MD's,  RN'a,  and  CLS's  rotate  their  staff.  The  RCP  is  the  only  constant  member  of  the 
team  in  our  care  mode).  RoIm:  The  ED  MD  is  in  charge  of  the  patient's  care.  S/he 
completes  tasks  such  as  a  history  and  physical  exam,  explaining  risks,  obtaining  con- 
sent, and  the  administration  of  the  Propofol  and  other  medications.  The  RN  and  RCP, 
through  cross  training,  are  both  responsible  for  obtaining,  preparing,  verifying  doses, 
administering  medication  given  during  the  procedure  {usually  through  a  central  line), 
documenting  medications  given,  and  giving  IV  fluid  if  indicated.  The  RN  and  RCP  are 
responsible  for  cardlo-respiratory  monitoring,  oximetry,  automatic  blood  pressure 
monitoring,  and  the  documentation  of  vital  signs  as  often  as  every  two  minutes.  The 
CLS  role  is  to  give  psycho/social  support  to  patient  and  famlty  before,  during,  and  after 
the  procedure.  They  do  this  by  using  diversionary  activities  for  the  child,  explaining  the 
procedure  in  a  way  the  patient  and  family  will  understand,  and  answering  any  questions 
the  patient  and  family  may  have.  The  RCP  and  RN  may  be  required  to  perform  the 
tame  tasks  as  the  CLS.  The  pnmary  function  of  the  RCP  on  this  team  is  managing  the 
atnvay.  Airway  management  includes:  02  administration,  removal  of  secretions  as 
needed,  monitoring  respiratun  {rate,  depth,  WOB,  and  Sa02),  mask-bag  ventilation  (If 
apnea  occurs),  and  patient  positioning  to  maximize  air  exchange,  Summary;  Current 
care  model  has  achieved  the  stated  goals.  A  typical  patient  having  a  lumbar  puncture 
has  h«d  chargas  decreased  from  approximately  $3000  (when  done  In  O.R.),  down  to 
•niroxknately  $300.  The  time  requirements  for  the  patient  have  been  reduced  to  <  90 
minutM  M«i«n  compared  with  the  OR  (3  to  4  hours)    As  for  the  friendly  environment 
the  fln(flnoi  nr*  wblectlve.  but  the  families  of  the  patients  have  overwhelmingly  gave 
poattfVi  HMd  back,  including  those  familas  who  have  experienced  both  the  old  and  new 
car*  modals.  No  significant  adverse  effects  have  been  reported  during  SPs  using  Pro- 
pofol. Fantanyl,  and  Ketamine  outside  the  OR.  Qp  qq  ^  24 


SELECTION  OF  APPROPRIATE  VENTILATION  PARAMETERS: 
OUTCOMES  ACCORDING  TO  POPULATION 

Katfrl**^  Peakins  RRT.  Robert  L.  Chatbum  RRT.  FAARC,  and  Timothy  R.  Myers  BS.  RRT. 
Rainbow  Bjd)ies  &  Children's  Hospital.  Cleveland,  OH. 

INTRODUCTION:  In  disease  states  requiring  mcchanica]  ventilation,  the  primary  goal  is  to 
achieve  adequate  gas  exchange  while  preventing  lung  tissue  damage  and  minimal  distuibaDces  to 
the  cardiovascular  system.  The  Respiratory  Care  Practitioner  (RCP)  plays  an  integral  rote  in  the 
successful  management  of  ventiUued  patients.  Past  studies  have  documented  efficiency  and 
ability  of  RCPs  successfully  utilizing  and  in^)lemenling  weamng  protocols  on  mechanically 
ventilaied  [Clients.  The  purpose  of  this  study  was  to  dwcribe  \hc  ability  of  our  RCPs  to  initiate 
mechanical  ventilation  settings  (rale,  PEEP,  lida!  volume.  Fi02,  inspiratory  time,  pressure 
support,  pressure  limit)  and  achieve  adequate  gas  exchange  by  achieving  targeted  anerial  blood 
gas  values  in  neonatal  and  pediatric  populations.  METHODS:  Two  hundred  two  paUcnts 
admitted  to  our  PICU  and  NICU  were  placed  on  nwchanical  ventilators  during  a  three-month 
period  (1-8  to  4-8-00).  RCPs  completed  a  Mechanical  Ventilation  Initiation  Data  Sheet  for  each 
patient  ventilated.  Data  collected  incliukd  age,  weighL  diagnosis,  initial  vcnUIator  settings,  mode 
of  ventilation  and  initial  blood  gas  results  following  ventilation.  Enrolled  patients  that  required 
reintubation  were  excluded  from  data  recollection.  Blood  gas  values  were  analyzed  separately  by 
pH/  PCOi  for  ventilation  and  PCy  SaO:  for  oxygenation.  Ventilation  parameters  were  judged 
aH)ropriate  if  the  first  set  of  blood  gas  values  were  within  acceptable  ranges.  Rc^iratory 
alkalosis  was  ddfined  as  pH  >  7.45  and  PaCOi  <  35  ton.  Respiratory  acidosis  was  defined  as  pH 
<  7.35  and  PaCOj  >  45  torr  (for  PICU  patients,  pH  <  7.25  for  NICU  patients).  Hypoxic  status 
was  defined  as  PaCOj  <  55  torr  (NICU  paUents)  and  SaOi  <  93%  or  SvOj  <  70%  (PICU 
patients).  RESULTS:  The  percentage  of  blood  gas  results  found  to  be  within  acxqpiatole  ranges 
are  shown  in  t^le  below.  Non-percentage  numbers  are  paUents  (by  location)  that  did  not  have 
acid-base  status  or  oxygenation  status  nwasured  by  blood  gas  analysis  (excluded  firom  dw 
percentage  analysis). 

Acid-Base  Status 

alkalolic  fn= 14) 
normal  (n  •'152) 
acidotic  (n''24) 
no  gas  or  capillary  gas 
Oxygenatioo  Status 
hyperoxic  (n=27) 
normal  (n  =123) 
hypoxic  (n=24) 
no  gas  or  capillary  gas 

CONCLUSION:  In  this  stud^,  patioU  pt^nilation  (neonates  versus  pediatrics)  appeared  to  exen 
very  httle  influence  on  therapist  ability  to  initiate  mechanical  vootilation  and  achieve  adequate 

gas  exchange. 

OF-00-121 


Overall 

NICW 

PICV 

7% 

9% 

6% 

MK 

7«K 

S2K 

13K 

I3K 

UK 

12 

5 

7 

Overall 

wu 

PICT 

15% 

35% 

- 

71% 

49% 

88% 

14% 

16% 

12% 

28 

21 

7 

MEASURING  PROCESS  VARIATION  IN  BLOOD  GASES  AND  VENTIUTOR 

MANAGEMENT  IN  AN  NICU.  Kay  lockhart  RRT   John  W.  Salyer,  RRT  MBA, 
FAARC.  Karen  K.  Burton  RN,  RRT.  Respiratory  Care  Service  and  Outcomes  Research 
Service,  Primary  Children's  Medical  Center,  Salt  Lal<e  City.  UT    Introduction;  We 
sought  to  measure  process  variation  in  the  use  of  blood  gases  In  ventilator 
management  by  RCP's  in  our  NICU.  We  suspected  that  there  might  be  important 
deiays  in  responding  to  blood  gas  results.  The  measures  described  below  were  made 
possible  by  the  introduction  of  ventilator  care  plans  in  our  NICU.  These  documents  are 
intended  to  be  prepared  for  all  ventilated  patients  and  act  as  both  physician's  orders 
and  a  plan  of  care  for  ventilator  management.  They  describe  conditions  under  which 
the  patient  should  be  weaned  Design:  Copies  of  ventilator  care  plans  were  gathered 
for  all  ventilated  patients  between  Dec  1999  and  Apr  2000  inclusive  Ail  blood  gas 
results  for  these  patients  were  reviewed  to  determine  those  gases  that  should  have 
resulted  in  a  change  in  ventilator  settings  according  to  the  patients  ventilator  care  plan. 
The  time  between  the  posting  of  the  blood  gas  results  and  subsequent  ventilator 
changes  was  computed  in  minutes  for  each  result.  Standard  descnptive  statistics  were 
computed.  Results  were  further  categorized  into  day  and  night  shift  findings.  Results: 
There  were  600  blood  gases  analyzed  from  39  different  patients.  Mean  (+  1  SD)  time 
from  blood  gas  results  posting  to  subsequent  ventilator  change  was  72  ±  85  minutes, 
with  a  median  of  43  minutes,  and  a  range  of  1  to  845  minutes.  Thirty  five  percent  of 
subsequent  ventilator  changes  occurred  in  less  than  30  minutes,  26%  occurred 
between  30.60  minutes,  12%  between  60-90  minutes,  and  27%  greater  than  90 
minutes.  We  found  no  statistically  significant  differences  in  these  data  between  days 
and  nights  (Mann-Whitney  U  test,  P  =  0.14)  Discussion:  There  is  clearly  considerable 
variation  in  responding  to  blood  gases  thai  should  have  resulted  in  ventilator 
adjustments  in  our  NICU.  We  hypothesized  that  30  minutes  was  a  reasonable  goal  for 
having  responded  to  ail  such  blood  gases.  Using  this  standard  it  is  obvious  that  we 
have  considerable  unwarranted  variation  in  this  process  There  are  a  number  of 
process  "handoff  s"  in  the  use  of  blood  gases  in  our  NICU.  Nurses  initiate  the  process 
of  obtaining  blood  gases.  Capillary  gases  are  drawn  by  phlebotomists  and  arterial  line 
sampling  Is  done  by  the  nursing  staff.  It  is  not  uncommon  for  RCP  s  to  be  unaware  that 
blood  gases  results  have  been  posted  This  could  contribute  significantly  to  delays  in 
ventilator  management   However,  it  is  also  possible  that  RCP's  are  not  responding  as 
quickly  as  they  could.  We  Intend  to  use  continuous  quality  Impravement  methods  to 
further  analyze  this  process  and  to  reduce  unwarranted  variation.  One  possible 
intervention  is  to  make  RCP's  responsible  for  the  entire  process  of  obtaining,  and 
responding  to  blood  gases. 


OF-00-125 


1026 


Respiratory  Care  •  August  2000  Vol  45  No  I 


Tuesday,  October  10. 1:30-3:25  pm  (Rooms  200,201) 


QUALITY  IMPROVEMENT  PROGRAM  IDENTIFIED  FROM  THE  USE  OF 
RESPIRATORY  CARE  PLANS  IN  THE  ICU  SETTING.  John  W.  Salyer.  RRT,  MBA. 

F/VARC,  Key  I  ocKdaft  RRT  -  Karen  K  Bunon  RN,  RRT.  Respiratory  Care  Services  and 
Outcomes  Research  Service,  Pnmary  Chlidren's  Medical  Center.  Salt  Lake  City.  UT. 
Inlroductlon  We  suspected  that  there  were  deficits  in  ventilator  manaflement  in  our 
NICU.  We  souflht  to  improve  measurement  and  standardization  of  ventilator  care  in  the 
NICU  throuflh  the  development  of  ventilator  care  plans.  These  forms  Became  part  of 
the  medical  record  and  served  to  improve  communlcellons  between  all  clinical 
disciplines  involved  in  ventilator  management  and  also  acted  as  physician  orders  Care 
plans  were  to  Be  completed  by  RCP's  in  collaboration  with  MD's  and  NNP's  within  24 
hours  of  patient  admission.  They  contained  such  information  as  ventilator  settings, 
desired  blood  gas  ranges  and  other  weaning  parameters.  Design:  A  prospective  study 
was  conducted  by  collecting  copies  of  all  ventilator  care  plans  on  ventilated  patients 
admitted  to  the  NICU  between  December  1999  and  April  2000.  In  addition,  all  blood  gas 
results  and  ventilator  flow  sheets  were  concurrently  reviewed.  We  randomly  selected  a 
subset  of  these  care  plans  to  analyze.  The  data  gathered  were  entered  into  a  database. 
We  evaluated  how  many  days  the  care  plan  was  followed,  not  followed,  and  the  number 
of  days  the  care  plan  was  not  updated  when  it  should  have,  e.g.  following  surgery  or 
failed  extubation.  We  Identified  over-weaning,  under-weanlng,  and  not  weaning  as 
ways  in  which  the  care  plans  were  not  foilovred  We  further  analyzed  how  many  times 
patients  with  a  care  plan  experienced  a  setback  in  ventilator  management,  e.g.  the 
patient  had  a  subsequent  increase  in  ventilatorv  support  withini  2  hrs  of  following  or  not 
following  the  care  plan.  Results:  There  were  a  total  of  1 85  care  plans  gathered  on  67 
patients   We  reviewed  107  of  these  care  plens.  spanning  435  ventlletor  days,  and 
Involving  39  patients.  Care  plans  were  followed  on  49%  of  ventilator  days  reviewed,  not 
followed  46%  of  ventilator  days,  and  not  properly  updated  on  5%  of  ventilator  days.  Of 
the  patient  days  when  the  care  plan  was  not  followed,  the  distribution  of  types  was,  78% 
overweaned,  19%  not  weaned,  3%  under-weaned.  Among  patients  who  did  not  have 
their  care  plans  followed,  23%  experienced  a  ventilatory  setback.  However,  even 
among  patients  who  did  have  their  care  plans  followed,  there  were  22%  who 
experienced  a  ventilator  setback.  When  pts  were  ovenweaned  it  was  most  often  done 
by  RCP  (57%).  Discussion:  We  found  deficits  in  ventilator  management,  such  that 
nearly  '/i  of  the  time  we  are  not  following  our  care  plans,  with  over-weaning  being  the 
most  prevalent  departure.  However,  our  observation  that  1  In  5  of  patients  experience 
ventilator  set-backs  Irrespective  of  whether  or  not  mo  care  plan  was  followed  suggest 
that  the  care  plans  may  not  be  reflecting  optimal  ventilator  management  guideli.ies. 
Two  possible  problems  are  that  the  care  plans  were  not  updated  often  enough,  or  were 
loo  rest/idrve,  such  as  allowing  only  very  small  changes  In  ventilator  settings.  Thus, 
RCP's  v«ho  were  more  aggressive  In  weaning  than  the  care  plans  allowed,  may  have 
been  using  more  current  information  about  the  pi  than  was  described  by  the  plan. 
Possible  improvement  interventions  include,  updating  care  plans  more  frequently, 
making  vreaning  guidelines  In  the  care  plans  lass  restrictive,  and  requiring  RCP's  to 
follow  the  care  plans  as  written. 

OF-00-126 


SUCCESS  OF  AN  INTERDISCIPLINARY  C.O.P.D.  MANAGEMENT  TEAM: 

Melissa  W.Slobaa,  RRT.RCP,.,  Theresa  Powers,  MSN,  NP-C, 

Donn  Wolfson,  MD,  FCCP  ,  Parma  Community  General  Hospital, 

Parma,  Ohio 

BACKGROUND!  Using  the  aeveland  Health  Quality  Choice  Index 

as  a  benchmark,  it  was  determined  tha,t  mortaljty  and  readdmisslon 

rates  for  C.O.P.D.  were  higher  than  acceptable.  Research 

revealed  dlf f Iclencles  In  D.R.G.  coding,  patient  knowledge 

and  education.  The  C.O.P.D.  Team  core  was  established  consisting 

of  a  Pulmonary  Physician  Champion,  Nurse  Practitioner,  and 

Respiratory  Care  Practitioner.  Secondary  team  members  esked 

to  participate  were  dietary,  psychology  and  social  service. 

METIJOD:  Physician  Champion  communicated  with  medical  staff 

addressing  documentation  necessary  for  proper  coding.  All 

patients  addmltted  with  C.O.P.D  or  related  diagnosis  were 

seen  by  the  Nurse  Practitioner,  Respiratory  Patient  Educator, 

and  Registered  Dietitian.  When  indicated  these  professionals 

consulted  with  attending  physicians  and  made  chenges  In  care 

plans.  All  patients  were  interviewed  post  discharge.  There 

was  a  lOOZ  review  of  all  deaths 

RESULTS  after  ONE  YEAR:  Mortality  had  decreased  from  Itl 

to  0.3X.   Readmlsslon  rates  had  decreased  from  15  to  5X. 

Overall  length  had  decreased  by  0.5  days.  Patient  education 

surveys  demonstrated  an  increase  In  patient  knowledge  from 

72Z  to  95Z.  All  quality  of  life  Indicators  demonstrated 

significant  Improvement. 

CONCLUSION:  Concentrated  attention  and  commitment  from  hosptlal 
administration  down  to  the  team  members  created  the  atmosphere 
required  to  succeed.   Investment  in  a  comparatively  small 
number  of  staff  hours  dedicated  to  the  project  resulted  In 
demonstrable  improvements  In  patient  care,  outcomes,  and 
a  positive  cash  flow  of  $500,000  to  the  institution. 


OF-00-128 


DECREASED  VENTILATOR  LOS  WITH  IMPLEMENTA'nON  OF  DISEASE 
SPECIFIC  VENTILATORy  PROTOCOLS  AND  DECISION  PATHWAYS. 

Albtno  Msrrs.  BS.  R.R.T..  Terry  Miller.  BS,  R.R-T..  Shelly  Jones,  R.R.T.,  Leanne  Keiken, 
RXT..  Robert  Whileside,  BS,  R.R.I.,  Mike  Bccbie,  BS,  R.R.T. 
Mercy  Health  System,  Janesvillc,  WI. 

BackgroQod:  Tbe  most  difficult  and  costly  padeots  are  those  requiring  mechanical 
ventilation  (MV)  and  intensive  care  (ICU)  for  greater  than  24  hours.  Inconsistency  in  the 
management  of  ventilator  dependant  patients  among  respiratory  therapists,  nuiscs  and 
physicians  influences  the  length  of  ICU  stay.  To  study  the  effects  of  disease  specific 
ventilatoiy  pn>tocols,  and  decision  pathways  on  optimizing  padents'  ventilatory  management 
and  hospital  Icngdi  of  stay  (LOSX  we  conducted  die  following  study.  Methods:  An  extensive 
training  program  was  implemented  with  the  assistance  of  Siemens  Clinical  Management 
Program"'  (CMP).  Disease  specific  ventilatory  protocols  and  decision  pathways  ttiat  were 
used  were  denved  tit>m  scientific  evidence  based  practice  and  expert  consensus.  Hducadon 
lectures  and  training  were  provided  for  staff  physicians,  respiialoiy  dierapists  and  ICU  nurses. 
CMP  stressed  the  milizatioo  and  efficient  use  of  mechanicai  ventilation  applying  standard 
ventilatois  and  graphic  waveform  interpretation  as  integrated  in  the  protocols  and  decision 
pathways.  A  data  collection  strategy  was  developed  to  acquire  infoimauon  on  patients 
requiring  mechanical  ventilation  for  greater  dian  24  hours  on  CMP  vs.  off  CMP,  All  patients 
were  assessed  for  outcomes  based  on  severity  of  illness  scoring  (3M  APR-DRG),  morbidity, 
MV  LOS.  tCU  LOS,  hospiul  LOS,  and  cost  of  care.  Results:  During  fiscal  year  (98-99)  a 
total  of  284  padents  were  adroined  to  ICU  requiring  mcchanic3)l  ventilation.  1 56  patients 
required  vcndialory  management  greater  than  24  hours.  1 1 7  padents  were  on  CMP  vs.  39  off 
CMP  protocols.  The  average  severity  of  illness  for  die  patients  on  CMP  was  3.1  /  ofTtTMP 
was  3.5  (APR-DRG).  The  MV  LOS  on  CMP  was  4.8  /off  CMP  was  5.2  (15%  improvement). 
ICU  LOS  on  CMP  was  5.8  /  off  CMP  was  7.2  (21%  improvement).  The  average  bospiul  LOS 
for  patients  on  CMP  was  1 1  /  off  CMP  was  13(16%  hnprovement).  CodcIusIod;  Our  results 
indicated  that  installing  evidenced  based  disease  specific  ventilatory  protocols,  and  decision 
padiways  (CMP)  showed  a  reduction  in  MV  LOS,  ICU  LOS.  hospital  LOS  and  total  cost  of 
care  in  padent  requiring  mechanical  ventilation  greater  than  24  hours. 


AreraxeLOS- 

for  padeati  requlrinti  MV  >  24  hoars. 

Groap 

MVLOS 

ICU  LOS 

Hospital  LOS 

Saverily  Scon 

On  CUP 

4J 

5.8 

11 

3.1 

CWCMP 

il 

7.2 

13 

3.5 

Slwvrimntn 

15 

21 

16 

- 

AvtncB  Coat  of  Care  per  patjenl  -  for  patiesla  reqairinx  MV  >  24  hoan. 

Graap 

MV 

ICU 

Heamll.1 

OnCMP 

S735 

S22012 

X2M1S 

OffCttP 

S854 

S23055 

$31204 

CMSmixaO-rnMO 

Si  19 

S1043 

S2389 

14 

5 

8 

Ealliutad    -  CiV  Savings  +  ICU  Savings -f  Hospital  Savings  "W  <fl>24  hours     4S415.467 
CostSeviaii    L    "»        +        1043       *       2389  J     I  117  J 

OF-00-151 


COST  EFFECTIVENESS  -  PROTOCOLS  FOR 
VENTILATOR  MANAGEMENT 

Gordon  Turner,  MD;  Homer  Engert.  RRT;  Laura  VanHeesL  RRT 
Saint  Mary's  Mercy  Medical  Center,  Grand  Rapids.  ML 

BACKGROUND:  Outcome  improvement  for  mechanically  ventilated  patients  in  a 
14  bed  mixed  critical  care  unit  and  all  patients  in  an  aduh  intermediate  unit  was 
undertaken  in  1998.  We  demonstrated  a  399fr  reduction  in  the  LOS  on  the  ventila- 
tor; however  total  patient  slay  in  the  hospital  and  costs  remained  essentially 
unchanged.  We  continued  to  seek  improvements  and  to  lower  the  overall  cost  of 
care  for  these  patients. 

METHOD:  Our  multi-disciplinary  team  continued  to  refine  our  process  and  we 
implemented  several    Lung  Protection  Strategies:  PCV  or  volume  targeted 
Pressure  Ventilation.  Alveolar  Recruitment.  PEEP  Protocol  and  earlier  Prone  posi- 
tioning. We  analyzed  all  patients  who  spent  time  in  our  critical  care  unit  for  utiliza- 
tion of  resources  and  co.st  of  care,  comparing  fiscal  years  1998  to  1999.  We 
divided  the  patients  into  two  major  groups:  ( 1 )  mechanically  ventilated  and  (2) 
those  who  did  not  require  mechanical  ventilation.  We  analyzed  the  Direct  Variable 
Costs  utilizing  the  hospitalfs  TSI  software  for  both  groups  of  patients. 
Additionally,  we  scrutinized  the  Net  Margins  for  these  cases  to  account  for  any  cost 
shifting  away  from  variable  costs  that  may  have  occurred. 

RESULTS:     Patients  receiving  mechanical  ventilation  had  Direct  Variable  Costs 
that  were  reduced  by  an  average  of  S 1 .427  per  case  representing  a  total  savings  of 
$5 19,(X)0  for  the  year.  Also  the  Net  Margins  increa.sed  by  30%  for  this  same  group 
indicating  the  absence  of  any  cost  shifting.  Variable  Costs  did  not  improve  for 
patients  in  critical  care  who  did  not  require  mechanical  ventilation  and  their  Net 
Margins  declined.  Preliminary  data  for  2(X)0  illustrates  sustained  savings. 

EXPERIENCE:  Our  efforts  which  emphasized  considerable  autonomy  for  the  res- 
piratory therapist  and  the  use  of  consistent  protocols  appears  to  have  resulted  in 
improved  cost  effectiveness  for  patients  who  require  ventilator  support  in  our  hos- 
pital. The  comparison  group  of  patients  who  were  not  impacted  by  the  protocols  or 
focused  improvement  efforts  showed  no  cost  savings  during  this  same  time  peritxi. 

CONCLUSIONS:  Positive  outcomes  can  be  attributed  to  teamwork,  focused  CQI 
efforts  and  greater  involvement  of  the  respiratory  therapist  in  the  management  of 
the  mechanically  ventilated  patient.  The  advantages  of  implementing  strategies  to 
limit  the  time  a  patient  must  spend  on  the  ventilator  and  protect  the  lung  during  that 
time  can  be  demonstrated  through  cost  analysis.  Our  hospital  spent  $5 19,000  less  to 
care  for  364  mechanically  ventilated  patients  in  1999  than  we  would  have  utilizing 
our  historical  (  1998  )  practices  for  this  patient  type.  Cost  improvements  were  seen 
in  the  group  we  targeted  and  not  realized  in  other  patients  in  the  same  unit  during 
the  same  time  period.  OF-00-1 52 


Respiratory  Care  •  August  2000  Vol  45  No  8 


1027 


Tuesday,  October  10, 1:30-3:25  pm  (Rooms  213,214) 


WATER  SELECTION  FOR  LARGE  VOLUME  NEBULIZERS  IN  THE 
LONG  TERM  CARE  SETTING.  WILLIAM  FRENCH.  MA.  RRT.  KATHY 
ERTTER,  MX  (ASCP),  DONNA  PFEIFER,  MT  (ASCP),  LAKELAND  COMMU- 
NITY COLLEGE.  KIRTLAND,  OH 


Inlroduclion:  In  this  area  many  long  term  care  facilities  (LTCF)  use  unheated  large 
volume  jet  nebulizers  (LVN)  filled  with  water  as  the  principal  method  of  providing 
humidification  to  residents  with  tracheostomy  tubes.  Pressure  by  recent  changes  in 
reimbursement,  LTCFs  are  examining  ways  to  save  money.  Thus,  the  question  was 
raised  whether  distilled  water  could  be  used  in  place  of  sterile  water  in  the  LVNs. 
In  order  to  determine  this,  we  decided  to  culture  various  brands  of  commercially 
available  distilled  water  and  compare  these  to  sterile  water.  Methods:  We  obtained 
a  new  unopened  one  gallon  bottle  of  each  of  the  following  brands  of  distilled  water: 
Deer  Park,  Distillata,  and  Tops.  For  comparison,  we  obtained  a  new  unopened  1 
Liter  bottle  of  sterile  from  Baxter  (2F71 14).  A  one  hundred  microliter  sample  from 
each  bottle  was  planted  on  TSA  agar  with  5%  sheep  blood.  The  cultures  were  incu- 
bated at  36  degrees  centigrade  in  a  candle  jar  for  approximately  1 8  hours,  then 
examined.  The  procedure  was  repeated  after  24  hours  on  the  same  water  stored  at 
room  temperature.  Results:  The  first  set  of  cultures  showed  no  growth  on  all  plates 
except  #3  (Tops  distilled  water).  The  growth  pattern  on  this  plate  was  suspicious  of 
contamination  because  most  colonies  grew  outside  of  the  streaked  area. 
Approximately  four  different  colony  types  were  seen.  The  second  set  of  cultures 
showed  no  growth  on  all  four  plates.  Conclusion:  On  the  basis  of  the  negative  cul- 
tures, we  conclude  that  it  is  safe  to  substitute  distilled  water  for  sterile  water  in 
LVNs.  In  addition,  based  on  an  average  cost  of  $0.20/Liter  for  distilled  water  ver- 
sus $  1 .23/Liter  for  sterile  water,  we  calculate  a  savings  of  $  1 .50  to  $2.00  per  day 
per  LVN,  depending  on  nebulizer  flow  rate  and  fluid  output  of  individual  LVNs. 


OF-00-006 


NOCTURNAL  OXYGEN  DESATURATION  OCCURS  IN  COPD 
PATIENTS  RECEIVING  SUPPLEMENTAL  OXYGEN.  Jonathan  B.  Waugh. 
PhD.  RRT.*  Becky  Christian,**  David  Lain,  PhD,  RRT+ 
♦University  of  Alabama  at  Birmingham,  Birmingham,  AL  **  Heartland  Home 
Care,  Kennett,  MO  +  Department  of  Clinical  Programs,  Respironics,  Inc. 

Background:  Supplemental  O2  has  been  shown  to  increase  O2  saturation  in 
patients  with  chronic  obstructive  pulmonary  disease.  Oxygen  has  been  used  to 
reduce  nocturnal  O2  desaturation  in  the  COPD  population.  Our  clinical  experience 
indicated  patients  with  COPD  were  still  at  risk  for  hypoventilation  and  respiratory 
dysfunction  during  sleep  in  spite  of  supplemental  O2  use.  We  measured  nocturnal 
O2  saturation  levels  of  COPD  subjects  receiving  O2  to  document  desaturation 
periods  and  measure  their  significance.  Methods:  23  volunteer  subjects  were 
enrolled  for  analysis  of  data  that  was  routinely  observed  as  part  of  their  normal 
home  care  protocol  for  monitoring  the  utility  of  prescribed  O2  therapy.  Oxygen 
saturation  (Sp02)  was  monitored  using  a  Respironics  920M  pulse  oximeter. 
Results:  Descriptive  data  included  mean  O2  flow  rate  =  2.5  L/min,  mean  patient 
monitoring  period  =  438  min.,  high  Sp02  group  mean  =  98%,  low  Sp02  group 
mean  =  76%,  and  average  Sp02  group  mean  =  93%.  The  group  mean  for  the 
amount  of  time  each  individual  spent  at  their  lowest  Sp022  was  1 9.7  min.  and  the 
average  time  spent  at  saturations  below  88%  (Sp0288Min)  was  73  min.  A 
binomial  test  was  performed  on  a  dichotomous  form  of  the  Sp0288Min  data  that 
yielded  p<0.00 1 .  A  Sp02<88%  for  a  total  of  60  min.  or  longer  constituted  an 
unacceptable  therapeutic  support  event  (equal  to  a  value  of  1,  whereas  Sp02<88% 
for  less  than  60  min.  was  assigned  a  value  of  zero.  Conclusions;  This  group  of 
subjects  with  COPD  were  at  risk  for  nocturnal  desaturation  especially  during 
REM  sleep.  Supplemental  O2  sufficient  for  waking  ventilation  and  maintaining  an 
average  SpO2>90%  was  not  able  to  avert  remarkable  periods  of  nocturnal  desatu- 
ration. Although  supplemental  O2  may  reduce  daily  O2  desaturation  by  some 
degree  in  COPD  patients,  it  may  be  inadequate  to  prevent  serious  nocturnal  desat- 
uration and  sleep  quality  disturbance. 
Sponsored  by  Respironics,  Inc.,  Murrysville,  PA 

OF-00-052 


A  HEAT-MOISTURE  EXCHANGER  WITH  AN  OXYGEN  BLEED-IN  PORT 
CAN  IMPROVE  SHORT-TERM  PORTABILITY  FOR  AMBULATORY  HOME 
OXYGEN  PATIENTS  WITH  A  TRACHEOSTOMY 

Georgelle  Frate-Mikus.  RRT.  James  Slegmaier,  RRT,  RPFT.  Joseph  Lewarski,  RRT 
Hylech  Homecare.  Cleveland,  Ohio 

Background:  Ambulatory  home  oxygen  patients  with  tracheostomies  often  have  diffi- 
culty achieving  adequate  portability.  Typical  high-flow  oxygen  delivery  systems  gener- 
ally require  oxygen  flows  >  6  l/min.  The  LTOTconsensus  recommendation  for  icfeal 
portable  oxygen  suggests  that  systems  weigh  <  10  lbs.  and  provide  4-6  hours  of  portabil- 
ity. Few,  it  any  systems  can  meet  this  requirement  at  such  flows  ("D"  cylinders  operat- 
ing at  6  l/min:  <  (hour;  "E"  cylinder:  -  1.5  hours;  1 .2- liter  liquid  portable  [LOXf:-  1.5 
hours).  Heat-moisture  exchangers  (HME)  with  oxygen  bleed-in  ports  are  available  on  the 
market,  however  no  clinical  cnteria  or  suggested  protocol  is  available  from  the  manufac- 
turers. The  safe  and  effective  application  of  low-flow  oxygen  directly  into  the  trachea  via 
catheter  is  well  noted  in  medical  literature.  Our  hypothesis:  direct  input  of  low-flow  oxy- 
gen into  the  tracheostomy  tube  via  a  HME  would  mimic  transtracheal  oxygen  therapy, 
allowing  a  significant  decrease  in  inspired  oxygen  flow  while  ensuring  adequate 
oxygenation.  Method:  We  developed  a  simple  protocol  using  the  Tracheolife*  HME 
with  oxygen  bleed-in  port  (Mallinckrodt,  Inc^.  A  physician  order  was  obtained  for  each 
trial.  The  patients  were  clinically  evaluated  (RR,  HR,  Sp02,  and  palientis  subjective 
level  of  SOB)  during  all  activities  of  daily  living,  while  on  their  standard  oxygen  deliv- 
ery device  (venturi  tracheostomy  collar)  and  Flu2.  The  patient  was  then  educated  and 
introduced  to  the  HME.  The  oxygen  liter-flow  was  titrated  10  maintain  an  acceptable 
Sp02  (>  90%  during  all  activities,  unless  otherwise  ordered).  The  complete  clinical  eval- 
uation was  repeatedwhile  on  the  HME  with  oxygen.  The  results  of  the  trial  are  noted  in 
the  following  table: 


Patient 

Age 

Pre  FI02  &  Flow* 

02  Bleed-in  w/HME 

Ain  Liter  Flow 

1 

67 

40%  /  6  l/min 

2  l/min 

4  l/min 

2 

2 

40%  /  6  l/min 

1  l/min 

5  l/min 

3 

70 

50%  /  6  l/min 

1  l/min 

5  l/min 

4 

79 

40%/ 6  l/min 

2  l/min 

4  l/min 

5 

68 

35%  /  6  l/min 

2  l/min 

4  I/min 

6 

66 

40%/ 6  l/min 

1  l/min 

5  l/min 

7 

80 

35%  /  6  l/min 

2  l/min 

4  l/min 

8 

70 

50%  /  6  l/min 

3  l/min 

3  l/min 

•Patients  were  using  a  Percent-02-Lock  Mask'ml'n  a  trach  collar  (Salter  Labs,  Inc.) 
Results:  All  8  patients  tolerated  the  HME  with  oxygen  for  ambulation.  There  were  no 
significant  differences  between  pre  &  post  clinical  evaluations.  Mean  HME  oxygen 
bleed-in  was  1.75  l/min.  Mean  decrease  in  flow  was  4.25  l/min  (a  71%4,).  Oxygen  sys- 
tem durations  at  1 .75  l/min  (approximate):  3  hours  with  a  "D"  cylinder;  5  hours  with  an 
**E"  cylinder;  and  7  hours  with  a  1.2  liter  LOX.  Patient  survey  supports  this  new  porta- 
bility translated  into  a  perceived  improved  quality  of  life.  Patients  also  found  the  HME 
less  complex,  easier  to  use,  and  less  cumbersome  as  compared  to  the  traditional 
tracheostomy  collar.  Summary:  Appropriate  use  of  HME's  with  oxygen  ports  may  sig- 
nificantly increase  portability  and  improve  the  quality  of  life  for  select  ambulatory  home 
oxygen  dependent  patients  with  tracheostomies.  Further  study  is  suggested  to  help  stan- 
dardize this  application. 

OF-00-022 


CLINICAL  UTILITY  OF  THE  ST.  GEORGE'S  RESPIRATORY 
QUESTIONNAIRE  TO  EVALUATE  PULMONARY  REHABILITATION. 

Shazia  SaUk  CRT,  Carmesha  N.  Tavlor  CRT,  Deborah  L.  Cullen  EdD,  RRT, 
FAARC.  Respiratory  Therapy  Program,  School  of  Allied  Health  Sciences,  Indiana 
University  School  of  Medicine,  Indianapolis,  Indiana. 

Background:  Pulmonary  rehabilitation  programs  are  developed  to  restore  the 
patient  to  the  highest  possible  level  of  function.  In  order  for  a  patient  to  reach  this 
level  of  independent  function  it  is  important  to  evaluate  the  effectiveness  and  mon- 
itor outcomes  of  pulmonary  rehabilitation  programs.  One  method  of  assessment  is 
via  health-related  quality  of  life  questionnaires.  The  purpose  of  this  study  is  to 
evaluate  the  appropriateness  of  a  hospital-based  community  pulmonary  rehabilita- 
tion program  and  the  utility  of  the  St  George's  Respiratory  Questionnaire  (SGRQ). 
METHODS:  The  St.  George's  Respiratory  Questionnaire  was  used  to  evaluate  the 
health-related  quality  of  life  outcomes  for  a  pulmonary  rehabilitation  program.  The 
questionnaire  was  mailed  to  100  post-pulmonary  graduates  from  a  mid- west  hospi- 
tal-based program  who  had  completed  the  program  in  the  last  2  years.  The 
questionnaire  measured  three  domains:  symptoms,  activities,  and  impacts  as  well 
as  a  total  cumulative  score.  Descriptive  statistics  were  utilized  to  analyze  the 
domain  scores.  RESULTS:  Of  the  100  subjects  60  responded.  The  overall  range 
of  scores  for  all  three  domains  can  range  from  0  to  100.  (A  score  of  zero  indicates 
no  impairment  and  a  score  of  100  indicates  severe  impairment.)  The  activity 
domain  mean  score  was  68.16  ±  0.53  which  indicates  moderately  severe 
impairment  with  physical  activity  and  dyspnea.  The  symptom  domain  mean  score 
was  47.69  ±  2 1 .79,  which  indicates  a  moderate  impairment  with  frequency  of 
cough,  wheeze  and  dyspnea,  and  duration  and  frequency  of  episodes  of  dyspnea 
and  wheeze.  The  impact  domainfs  mean  score  was  34.3 1  ±  20.96,  which  indicates 
a  mild  impairment  with  health  status,  employment,  panic,  and  medication.  CON- 
CLUSION: The  SGRQ  demonstrated  clinical  utility  for  post-rehabilitation  assess- 
ment which  permits  program  modification.  Based  on  the  results  from  the 
participants  of  this  study,  ills  concluded  that  the  program  may  want  to  further 
evaluate  intervention  strategies  for  management  of  pulmonary  activity  and 
dyspnea,  and  consider  implementing  a  phase  II  education  portion  that  would  deal 
with  these  problem  areas  in  their  post-pulmonary  maintenance  sessions. 

OF-00-053 


1028 


Respiratory  Care  •  August  2000  Vol  45  No  8 


Tuesday,  October  10, 1:30-3:25  pm  (Rooms  213,214) 


THE  EFFECTS  OF  INSPIRATORY  MUSCLE  TRAINING  IN  OUTPATIENT 
PULMONARY  REHABILITATION.  Hoberty  PP.  EdD  RRT.  Hastwell  W.  Clan- 
ton  TL.  PhD.  Rittinger  M.  BS  RRT  and  Diaz  PT.  MD.  The  Ohio  Slate  University, 
Columbus.  Ohio.  Background:  Inspiratory  muscle  training  (IMT)  is  a  common 
component  in  outpatient  pulmonary  rehabilitation;  however,  the  physiological  ben- 
efits of  IMT  and  its  contribution  to  the  outcomes  of  rehabilitation  services  have  not 
been  determined.  The  purpose  of  this  study  was  lo  determine  the  effects  of  IMT  on 
breathing  and  general  physical  fiinction.  Method:  The  sample  consisted  of  25 
patients  with  chronic  obstructive  pulmonary  disease  that  were  referred  lo  an  8- 
week  multidisciplinary  outpatient  pulmonary  rehabilitation  program  at  a  compre- 
hensive wellness  center.  These  patients  were  randomly  assigned  either  lo  a  control 
group  ( 10  patients,  7  males  and  3  females)  to  receive  IMT  at  10%  maximal  inspira- 
tory pressure  (MIP)  or  to  a  test  group  (15  patients,  9  males  and  6  females)  to 
receive  IMT  starting  at  40%  MIP  and  increasing  as  tolerated.  Both  groups  used  a 
commercially-available,  single-patient  use,  spring-loaded  threshold  IMT  trainer. 
Instruction  and  practice  were  provided  at  the  beginning  of  rehabilitation.  Training 
was  conducted  on-site  three  days  per  week  and  independently  at  home  on  other 
days.  Patients  kept  a  written  log  of  home  sessions.  Subjects  were  tested  at  the 
beginning  and  at  the  end  of  the  program  using  a  discontinuous  incremental  thresh- 
old loading  test  (DITLT)  which  required  breathing  at  2-minute  intervals  at  6  levels 
of  inspiratory  resistance  beginning  at  30%  of  measured  MIP  and  concluding  at 
80%  or  until  symptom  limited.  Patients  rated  their  perceived  dyspnea  and  breath- 
ing effort  on  a  10-point  modified  BORG  scale  at  each  level  completed.  The  six- 
minute  walk  distance  was  also  determined  pre-  and  post-program.  Independent  t- 
lests  demonstrated  that  the  groups  were  similar  as  to  age,  diagnosis,  and  severity  of 
obstruction.  The  groups  were  not  different  on  pre-program  testing  on  the  DITLT, 
MIP  or  the  six-minute  walk  distance.  Data  were  tabulated  and  an  ANOVA  with 
repeated  measures  was  performed  to  make  pre-  to  post-  comparisons.  Results:  For 
all  25  subjects  combined,  there  were  significant  pre-  to  post-program 
improvements  in  MIP.  maximal  level  completed  during  the  DITLT,  perceived  dys- 
pnea and  exertion  at  the  maximal  level,  and  in  six-minute  walk  distance  (p  <  .05). 
However,  there  was  no  significant  difference  between  the  control  and  test  groups 
on  any  of  these  measures.  Conclusion:  The  results  indicate  that  comprehensive 
pulmonary  rehabilitation  leads  to  improvements  in  breathing  and  physical 
function.  However,  IMT  at  the  conventional  training  level  (>30%  MIP)  does  not 
appear  to  produce  better  outcomes  than  training  at  only  10%  MIP. 
Supported  by  Respironics,  Inc. 


OF-00-062 


THE  DEVELOPMENT  OF  A  COOPERATIVE  OUTCOMES  PROJECT  IN 
PULMONARY  REHABILITATION.  Hoberty  PP.  EdD.  RRT.  The  Ohio  State 
University,  Columbus,  OH,  Moreno  M,  MSN,  RN,  The  Drake  Center.  Cincinnati. 
OH,  and  Horstman  G.  BFA,  RRT.  Marymount  Hospital,  Cleveland.  OH. 
Background:    Quality  outcomes  research  has  been  encouraged  in  health  care 
delivery,  including  pulmonary  rehabilitation.  It  is,  however,  difficult  for  managers 
of  programs  to  obtain  professional  analysis  of  outcomes,  professional 
organizations  lo  obtain  data  that  validates  the  work  of  their  members,  and 
researchers  lo  obtain  a  comprehensive  database  for  research.  This  abstract  reports 
the  development  of  a  unique  statewide,  cooperative  outcomes  project  in  Ohio. 
Methods:  In  1998  the  Ohio  Cardiopulmonary  Rehabilitation  Association 
(OCRA)  charged  the  Pulmonary  Rehabilitation  Representative  to  form  a  commit- 
tee to  gather  and  process  outcomes  in  pulmonary  rehabilitation.  This  followed  a 
previous  OCRA  study  in  cardiac  rehabilitation.  At  approximately  the  same  lime, 
the  Ohio  Society  for  Respiratory  Care  (OSRC)  charged  its  Pulmonary  Rehabilita- 
tion and  Continuing  Care  Committee  to  conduct  an  outcomes  project.  When  faced 
with  the  prospect  of  rival  projects,  the  boards  of  directors  of  both  organizations 
agreed  to  co-endorse  a  single  project.  A  joint  committee  developed  a  lO-question 
survey  instrument  to  determine  which  outcomes  programs  in  the  state  were  gath- 
ering. The  survey  was  mailed  to  67  outpatient  programs  in  Ohio  as  identified  from 
the  program  roster  of  the  American  Association  for  Cardiovascular  and 
Pulmonary  Rehabilitation  and  OSRC  mailing  lists.  Results:  Based  on  44  returns 
(66%)  to  the  questionnaire,  the  joint  committee  developed  a  project  to  gather  10 
patient  and  programs  outcomes  covering  3  general  outcomes  areas  —  clinical, 
behavioral  and  health  status:  1 )  six  minute  walk  distance,  2)  number  of 
hospitalizations.  3)  number  of  emergency  department  visits.  4)  UCSD  Shortness 
of  Breath  Questionnaire®,  5)  Pulmonary  Rehabilitation  Health  Knowledge  Test**, 
6)  smoking  behavior,  7)  program  participation,  8)  maintenance  program  participa- 
tion, 9)  Medical  Outcomes  Study  SF-36*,  and  10)  St.  George's  Respiratory  Ques- 
tionnaire®. To  facilitate  development  of  a  database,  researchers  in  the  Respiratory 
Therapy  Division  of  the  School  of  Allied  Medical  Professions  at  The  Ohio  State 
University  agreed  to  set  up,  tabulate,  and  analyze  outcomes  data  for  December 
1999  to  June  2001.  and  to  produce  program  and  benchmarking  reports.  Conclu- 
sion: To  enact  a  meaningful  comprehensive  outcomes  project,  providers,  profes- 
sional organizations,  and  researchers  joined  in  a  unique  cooperative  project  to 
accomphsh  the  goals  of  each.  This  project  may  serve  as  a  model  for  others  who 
are  developing  multi-purpose  outcome  studies  in  pulmonary  rehabilitation. 


OF-00-063 


pa 


LONGTERh  PATIENT  OUTCOMES  OF  A  PULMONARY  REHABILITATION  PROGRAM 
J«tmlfer  Wlfleamn  RRT,  RCP,  CPFT,  Heliasa  W.  Sloban  BA.  RRT, 
RCP:   Pama  Comaiunlty  General  Hospital,  Parma  Ohio 
BACKGROUND:   A  randOB  selectionof  Pulmonary  Rehabilitation 

tlents  were  tracked  for  three  years  after  coapletlon  of 
the  prograa.   The  aaaple  size  waa  381  of  the  patient  populatioo 
at  the  tlae  the  study  began. 

r«T«OD:  Medical  records  review  and  follow-up  patient  intervlewB 
at  leaat  annually  targeted  6  key  Indicators 

1.  Mortality 

2.  Adalaslon/readBlSBlon  rates  of  surviving  participants 

3.  Percentage  of  participants  still  active  In  Fitness  Club 

4.  PercenUge  of  participants  with  2  or  oore  adalsslons 
In  12  Months. 

5.  Percentage  of  participants  with  one  adalsslon  In  12  aoaths 
f.  percentage  of  participants  with  no  hospital  adalaslons 
RESULTS 

1.  Three  year  Bortallty  rate  was  lOX  with  40t  of  deaths  being 
unrelated  to  Pulnonary  disease. 

2.  Adaisslon  rates  decreased  from   1501  to  5Z 

3.  Continuation  in  exercise  program  Increased  fro»  Ot  to  23X 

4.  Two  or  more  admissions  decreased  froa  52Z  to  OX 

5.  One  admission  per  year  decreased  from  281  to  5Z 

6.  No  admissions  for  one  year  went  from  20Z  to  95Z 
COMCU]SION:  The  longterm  study  deaonstrates  longterm  banmflca 
of  participation  in  a  Pulmonary  RehablllUtlon  Program. 


OF-00-129 


ULTIMATE 

ONLINE 

BUYER'S  GUIDE 

FOR 

RESPIRATORY 

CARE, 


J(^g  on  to  www.aarc.org 

and  select 

"buyer's  Quide. " 


Respiratory  Care  •  August  2000  Vol  45  No  8 


1029 


Open  Forum  Author  Index 


Boldface  type  indicates  presenters. 


A 

Adams,  Alexander  B 987, 1008,  1012, 1013(2) 

Al-Bagaawi,  AM 979 

Albomoz,  MA 984 

Alexander,  S  1026 

Alonso,  JA    1000,  1014 

Al-Riyami,  B 1020 

Al-Riyami,  K    1020 

Amato,  Marcelo  HP   999 

Ari,  Arzu 979,  981,  1008 

Attwood,  Jeffery 1000, 1006 

Austan,  Frank  993 

Austin,  Paul 999,1014 

Ayers,  M 1008 

B 

Baddar,  S 1020 

Baker,  RR 982 

Baldwin,  R   1006 

Banks,  Gary   999 

Barnes,  Thomas  A   1011 

Barreto  Fonseca,  Joaquim  de  Paula 997 

Bates,  Kristy  M 993 

Bates,  Sara-Lou   980 

Batts,  B  989 

Becker,  Ellen  A 1002 

Beebie,  Mike 1027 

Bennett,  Richard  P  979 

Bennion,  Kim 1009 

Bliss,  Peter 995, 1000,1013 

Blonshine,  SB 1008 

Bowe,  Kory 986 

Boyle,  K 1006, 1008,1017 

Boynton,  John  H  Jr 984 

Bradle,  Melanie    998 

Brady,  K  1014 

Branson,  Richard  D  990,  993,  999  (3),  1014 

Breeden,  R    1026 

Brewer,  Jodette  A 1020 

Brooks-Brunn,  J  1026 

Brown,  Melissa  K 989, 1007,  1020 

Bruinsma,  Rikki  S    1025 

Bucher,  William 1018 

Burton,  Karen  K 1026, 1027 

C 

Camasso,  Karen  102 1 

Campbell,  Robert  S   990, 993, 999  (3),  1014 

Campbell,  SL  981 

Carr,  Brad 998 

Carter,  Chris 987,  1012,  1013  (2) 

Carvalho,  Carlos  RR 999 

Castile,  Robert   990 

Chatbum,  Robert  L  ...  .991(4),  1009(2),  1017, 1021, 1024, 1026 

Christian,  Becky 1028 

Christie,  John  1022 


Ciarlariello,  Sue  989 

Clanton,  TL 1029 

Clark,  DM 981 

Claycamp,  L 1026 

Cleary,  John  P 1017 

Clingan,  Jeff 1020 

Coddington,  Glen  R  998 

Cox,  Timothy 1015, 1022 

Croxton,  Michelle 101 1 

CuUen,  Deborah  L  984, 1007,  1028 

CuUen,  Edward 1022 

D 

Daniel,  B 1014 

Davis,  Kenneth  Jr 993,  999  (2),  1014 

De  Meuse,  Patrick 1008 

de  Oliveira,  Cristiane  Barreto  Fonseca  Antunes 997 

Deakins,  Kathleen 991  (2),  1026 

DeFilippo,  Virginia    997,  1024 

DeFiore,  Julie  991 

Dennison,  Frank 982, 1013 

Deshpande,  V  979 

Devereux,  Caroline 1018 

Dexter,  James  R  1004 

Diaz,  PT    1029 

Dickson,  Stephen   1007 

Dilley,  Steven 980 

Dillman,  Christine 980 

Doescher,  Gus 979 

Dolcini,  David  M   1009 

Douce,  F  Herbert   990, 1002 

Draganescu,  JM    984 

Duncan,  Jennifer  L 981 

Durbin,  Charles  G  Jr 985  (2),  986 

Duming,  Suzanne  M 1018 

Duthie,  Susan  E   989,  1007 

E 

Eaton,  Amanda 1007 

Elisan,  Isabelo 985  (2) 

Engert,  Homer   1027 

Enter,  Kathy 1028 

Estetter,  Robert 1001 

Evans,  Robert 994 

F 

Fairbanks,  S 1018 

Fasnacht,  Rebecca 986 

Filbrun,  David 990 

Fink,  James  B 994 

Flucke,  Robert 990 

Fogarty,  Christine 986 

Poland,  Jason 990 

Ford,  Debbie 980 

Fortenberry,  J 990,  1008 

Fortuna,  Anibal  de  Oliveira 997 


1030 


Respiratory  Care  •  August  2000  Vol  45  No  8 


Open  Forum  Author  Index 


Foss,  Scott  A 980 

Frame,  Scott  B 993, 999  (2) 

Frate-Mikus,  Georgette 1028 

Freed,  Marcy 1009 

French,  Alisa  G 1007 

French,  William 1028 

Furlong,  Anna 982 

G 

Garvey,  Chris  1020 

Gassaway,  Daniel  G 984 

Gaynor,  Sandra 1024 

Gehring,  Hartmut  993  (2) 

Giles,  Shana  1021 

Glynn,  Brian 1018 

Godinez,  Rodolfo  I 1018 

Goldberg,  Larry   1025 

Goldschmid,  David 1020 

Gomez,  Ann   985  (2) 

Goodfellow,  Lynda  Thomas 1002  (2) 

Graves,  Marcia  Roberts  1022 

Green,  Samelia 997 

Greenblatt,  JM   984 

Greenspan,  Jay  1018 

Grillo,  Angelo 1022 

H 

Hall,  Rick  982,  1013 

Hampton,  Karen  W 1025 

Hand,  Lori 1012 

Handley,  Dean    980 

Hardy,  Kai^n 985  (2) 

Hargett,  Ken  1013 

Harris,  SS   981 

Harrison,  Julie 1015 

Hastwell,  W 1029 

Hawkins,  Kenneth 984 

Helfaer,  Mark  A  1006 

Helmholz,  Fred 986 

Hemlen,  Kitty 1013 

Hess,  Dean   980,  1017 

Hillier,  Simon 1007 

Hoberty,  PD 1029  (2) 

Hodges,  AL 981 

Hoisington,  Ed   994 

Holland,  Dean 1011 

Holmes,  Mark 982 

Honicky,  RE 1008 

Homberger,  Christoph   993  (2) 

Horstman  G 1029 

Hotchkiss,  John 1013 

Hough,  Lorraine  F   1018 

Hsu,  L  989 

Huff,  Shawan   1012 

Huffman,  Belinda  S   1007 

Huffman,  Phillip 986 

Hunter,  Jason    1013 


I 

Ingalls,  Lori 986 

J 

Jain,  Hitender 984 

James,  Richard 1017 

Johannigman,  Jay  A 993,  999  (3),  1014 

Jones,  Shelley 1027 

K 

Kacmarek,  Robert  M  980,  101 1,  1012,  1017 

Kadish,  Howard   1026 

Kallet,  Rich 987, 1000, 1014  (2) 

Kallstrom,  Thomas  J 1000, 1021  (2) 

Kaneko,  Norihiro   986 

Kasel,  Debra  K 1020 

Katsaros,  Liana  M 1011 

Katz,  JA 1000 

Keiken,  Leanne 1027 

Keller,  Jennifer 1000 

Keppel,  Jean  W 980 

Kercsmar,  Carolyn  1021 

Kester,  Lucy  994, 1025  (2) 

King,  Kathleen  L    1008 

Kish,  Susannah 1013 

Klopf,  Steven   979 

Konecny,  Ewald  993  (2) 

Konstan,  Michael  W 1024 

Korman,  M  984 

Kuehne,  Aleisha 986 

Kukreja,  Sudeep 1009 

L 

La  Moria,  GeneAnn 1020 

Lain,  David 1028 

Lamberti,  James  P 1024 

Lavery,  Michael 1024 

Lawson,  James  J 1014 

LeGrand,  Terry  S 994, 1003  (2),  1021 

Leonard,  Craig 1024 

Lewarski,  Joseph 1028 

Lewis,  MA 981 

Lin,  Richard 1006 

Lockhart,  Kay 1026, 1027 

Lopez,  David 1004 

Lowe,  G 1017 

Luchette,  Fred  A 993,  999  (3),  1014 

Lynott,  Joseph 1011 

M 

Malloy,  Raymond 1018 

Mammel,  Mark 1006 

Mann,  Donald  C 999 

Manning,  Peter 989 

Marek,  Paul  E 1011 

Marini,  John 1012,  1013 


Respiratory  Care  •  August  2000  vol  45  No  8 


1031 


Open  Forum  Author  Index 


Marks,  JD 1000,  1014 

Marra,  Alberto   1027 

Marshak,  Arthur  B 1003,  1004 

Marshak,  Helen  Hopp 1003 

Martin,  James 990 

Matchett,  Stephen 986 

Matthay,  MA    1014 

Matz,  Holger 993  (2) 

Mazon,  Dorothy  997 

McArthur,  Charles  A  998 

McCarty,  Dennis  S .1004 

McCloskey,  John   1015 

McCoy,  Karen    990 

McCoy,  Robert 995,  1000 

McMaster,  J    984 

Meade,  Maureen 1012 

Merchant,  Dilshad   997 

Meyer,  Chris 1008 

Meyers,  Patricia  1006 

Mhanna,  Maroun    990 

Migali,  Nabil 1025 

Milla,  Carlos 1008 

Miller,  CC 1018 

Miller,  JWR   1018 

Miller,  Kenneth 986 

Miller,  Lan^ 101 1 

Miller,  Sandra  L 993,  999  (3),  1014 

Miller,  Ten7 1027 

Milo,  Marie  R 1000 

Mishoe,  SC 982 

Mitchell,  Jolyon  P 979, 980 

Monteath,  Stephanie 1022 

Montgomery,  Emily  A 999 

Moreno,  M   1029 

Morris,  Timothy 1014 

Morton,  Robert  W    980 

Moser,  C  992 

Muirhead,  Karen 1022 

Musa,  Ndidiamaka 1006 

Myers,  Timothy  R  991  (2),  1009,  1017,  1021,  1026 

N 

Nadkami,  Vinay 1022 

Nagel,  Mark  W 979,  980 

Napoli,  Linda  A   1018 

Nelson,  David  P  989 

Newhart,  John 1014 

Newton,  T 992 

Nivison,  Steve 1024 

Novotny,  Terry 990 

Nuckton,T  1014 

Nussbaum,  E 992 

O 

O'Keefe,  Grant 984 

Op't  Holt,  Timothy 997 

Orens,  Douglas 1025 

Ouk,  Sivom 986 


P 

Palmer,  Edward 1011 

Park,  Stephen   1020 

Pavoni,  Marlei 997 

Payne,  Holly 979 

Pearl,  Jeffrey 989 

Pedersen,  Craig 1014 

Peistrup,  Geoff  989 

Perich,  Wanda 986 

Perkins,  Susan  L 1003 

Peruzzi,  WilUam  T 1024,  1025 

Pfeifer,  Donna 1028 

Piedalue,  Fran 998 

Pittet,J-F 1014 

Plevak,  David  986 

Polise,  Michael 993 

Policy,  Cathy 1008 

Powers,  Theresa  1027 

Pringnitz,  James  986 

Puri,  Vinod  1000 

R 

Raake,  Jenni  L   989 

Rau,  JL  979,  981,  989 

Reagan-Cirincione,  Patricia 997 

Regg,  Susan    998 

Reisner,  Cohn 982 

Resnik,  Patty 1022 

Restrepo,  Ruben  D 979,  990, 1002,  1007,  1008 

Rinaldi,  Mark  998 

Rittinger,  M 1029 

Robbins,  J 1006 

Rogers,  Marsha 1021 

Romano,  Mario 994 

Rostow,  Stephanie   985  (2),  986 

Rubins,  C  Garth   989 

Ryckman,  Susan 989 

S 

Salik,  Shazia 1028 

Salyer,  John  W 1009,  1026,  1027 

Sandusky,  Frank 1000 

Saul,  John 1013 

Schafer,  Reiner 993  (2) 

Schettino,  Guilherme  PP  999 

Schmidt,  James  N 980 

Schmucker.  Peter  993  (2) 

Schneiderman,  Norman 979 

Schramm,  Cliff 979 

Schultz,  Theresa  Ryan 1006.  1018 

Schwartz,  Steven  M 989 

Sedeek,  Khaled  A    1011,  1012,  J017 

Shaw,  Andrew   1013 

Shaw,  J  1006 

Shells,  Steven  G 981 

Shelledy,  David  C   987, 994,  1003  (2),  102 1 

Shreve.  James  T 1024 

Simpson,  D 1006 


10.12 


Respiratory  Care  •  August  2000  Vol  45  No  8 


Open  Forum  Author  Index 


Siobal,  Mark 981, 987,  1000,  1014 

Sladek.  David  T  980 

Sloban.  Melissa  W 1027,  1029 

Smith.  Brian  L   1024,  1025 

Smith,  Katherine 1007 

Smith.  Philip  C 1009 

Smith.  Thomas 997 

Soiomkin,  Joseph  S   999 

Souza,  Rogerio 999 

Spainhour.  C 990 

Specht.  Leonard 1004 

Stegmaier.  James  1028 

Stevens.  Anne  Leslie  982 

Stevenson,  Stefani   994 

Stoller,  James  K 994  ,  1025  (2) 

Stone,  Mary  987,  1008,  1012,  1013  (2) 

Super,  Dennis  M 990 

Sweeney,  Dawn  989 

T 

Taft.  Arthur 982,  1013 

Taheer,  M   984 

Takeuchi,  Muneyuki 1011, 1012 

Tanoue,  Lynn   1024 

Taylor,  Carmesha  N 1028 

Terrell,  Bobby 981 

Thomas,  L 990 

Tice,  Jill 990 

Tinkler,  Bethanne 981 

Topal,  Jeffrey   1024 

Tracy,  Michael  991, 1017 

Trusty,  Robert 1006 

Tucci,  Mauro  R 999 

Turner,  Gordon 1027 

U 

Uster,  Paul 994 

Uzark,  Karen 989 

Uzawa,  Yoshihiro 986 

V 

Van  Scoder,  Linda  1022,  1026 

VanHeest,  Laura 1027 

Varekojis,  Sarah  M 990 

Villareal.  Dan 1009, 1017 

Vines,  David  L 987, 1003 

Virag,R 1000 

Volsko,  Teresa  A  991, 1024 

W 

Wadlinger,  Sandra  R   1018 

Ward,  Jeff 986 

Warnecke,  Edna 987,  1000 

Waugh.  Jonathan  B    1028 

Weavind.  Lisa 1013 

Welton.  John  M   984 


West,TAI    1001,  1011 

Whiteside,  Robert 1027 

Wieand,  Frederick  986 

Wiersema,  Kimberly  J 980 

Wilkins,  Robert  L 1003, 1004 

Williams,  Mechelle   1013 

Williamson,  Christopher  997 

Wiseman,  Jennifer 1029 

Wiseman-Chase,  Elizabeth   1025 

Wojciechowski,  William  V  981 

Wolfson,  Donn 1027 

Worthing,  E   1020 

Worwa,  Catherine 1006 

Wright,  Jeffrey  W 1026 

Wyatt.  Irina 1002 

Y 

Yamaguchi,  Yasunari 986 

Z 

Zaioga,  Gary  P  101 1 


Respiratory  Care  •  August  2000  Vol  45  No  8 


1033 


Congress  Exhibitors 


Exhibitors 

at  the  46th  International  Respiratory  Congress 
of  the  American  Association  for  Respiratory  Care 

October  7-10,  2000 
Cincinnati,  Ohio 

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  July  28,  2000  are  listed.) 

Exhibit  Hours 

Saturday,  October  7  1 1  AM  to  4  PM 

Sunday,  October  8  1 1  AM  to  4  PM 

Monday,  October  9  11  AM  to  4  PM 

Tuesday,  October  10  1 1  AM  to  3  PM 


Exhibitor 


Booth 


Exhibitor 


Booth 


A 

Advance  Newmagazines 234 

AG  Industries TBA 

Agilent  Technologies TBA 

Alpha  1  Association TBA 

Airborne  Life  Support  Systems/ 

International  Biomedical 328 

Airsep  Corporation TBA 

Allegiance  Healthcare  Corporation Island  333 

Allergy  and  Asthma  Network-Mothers  of  Asthmatics,  Inc  .  TBA 

Allied  Healthcare  Products  Inc 627,629,63 1 

Ambu  Inc 245 

American  Biosystems  Inc 344 

American  College  of  Chest  Physicians TBA 

American  Mobile  Healthcare TBA 

Anerican  Society  of  Electroneurodiagnostic  Technologists .  TBA 

ARC  Medical  Inc 560 

Astra  Zeneca Island  45 1 

AVL  Medical  Instruments Island  255 

B 

B  &  B  Medical  Technologies  Inc 570 

Bay  Corporation 348,350 

Bayer  Diagnostics Island  383 


Bedfont  Scientific  USA 262 

Beta  Biomed  Services  Inc 467 

Bio-logic  Systems  Corporation 258 

Bio-Med  Devices  Inc 322,324.326 

Boehringer  Ingelheim Island  623 

Bunnell  Incorporated 545,547 

C 

Cadwell  Laboratories 242 

California  College  for  Health  Sciences 329 

Caradyne TBA 

Cardiopulmonary  Corporation Island  283 

Committee  on  Accreditation  for  Respiratory  Care TBA 

Comphealth TBA 

Cordigital TBA 

Corpak  Medsystems TBA 

Criticare  Systems  Inc 332 

Cross  Country  Staffmg/TravCorps TBA 

D 

Dale  Medical  Products  Inc 42 1 

Datex-Ohmeda 351,353.355 

Delmar  Publishers 520 

Dey  Lab 423,425,427 


1034 


RESPIRATORY  CARE  •  AUGUST  2000  VOL  45  NO  8 


Congress  Exhibitors 


Exhibitor 


Booth 


Exhibitor 


Booth 


DHD  Healthcare 218,220 

Drager  Medical  Inc Island  122 

E 

Eco  Physics  Inc TB A 

El  Hospital TBA 

F 

Ferraris  Medical  Inc 562,564 

First  Assist,  Inc  Companies TBA 

Fisher  &  Paykel  Healthcare  Inc 523,525.527 

Flotech  Inc TBA 

Focus  Publications TBA 

Forest  Pharmaceuticals  Inc TBA 

Futura  Publishing  Company TBA 

G 

General  Physiotherapy 420 

Glaxo  Wellcome  Inc Island  501 

Goldstein  &  Associates  Inc TBA 

Grass-Telefactor 340,342 

H 

^  Hamilton  Medical  Inc .■ Island  561 

Hans  Rudolph  Inc 236,238 

Harcourt  Health  Sciences 426,428 

Health  Education  Publications  Inc TBA 

Healthcare  Clinical  Consultant TBA 

Hill-Rom 113 

Hollister  Incorporated TBA 

'  Hudson  RCI 212,214 

"  Hy-Tape  Corp TBA 

I 

I  V  League  Medical TBA 

Impact  Instrumentation  Inc 22 1 

Ingmar  Medical 216 

INO  Theraputics  Inc Island  607 

Instrumentation  Industries  Inc 626,628 

Instrumentation  Laboratory 223,225 

Invacare  Corporation Island  261 

I 

I.P.I.  Medical  Products  Inc 323,325 

J 

Jaeger  Inc TBA 

J.H.  Emerson  Company TBA 

K 

KCI 468,470,472,474 

Kendall 549 


Kettering  National  Seminars TBA 

Kimberly-Clark/Ballard  Medical 252,254 

King  Systems  Corporation 227,229 

L 

Lambda  Beta  Honor  Society TBA 

Lemans  Industries  Corporation 568 

Letco  Medical  RHPA TBA 

Life  Medical  Pharmacy TBA 

Lippincott,  Williams  &  Wilkins TBA 

M 

Maersk  Medical  Inc TBA 

Mallinckrodt  Incorporated Island  301 

Masimo  Corporation Island  412 

Maxtec  Inc TBA 

Mayo  Clinic TBA 

MBNA  America 371 

Medical  Education  Technologies TBA 

Medical  Graphics  Corporation Island  361 

MEDIQPRN TBA 

Mediserve  Information  Systems Island  619 

Medline  Industries  Inc TBA 

Merck  Human  Health TBA 

Mercury  Medical 233,235 

Mes  Inc 119 

Micro  Direct/Micro  Medical 521 

MOnaghan  Medical  Corporation Island  269 

Mortara  Instruments  Inc TBA 

MSA  Medical  Instruments 321 

N 

NBRC TBA 

Ndd  Medical  Technologies TBA 

Neotech  Products  Inc TBA 

Newlife  Technologies 528 

Newport  Medical  Instruments Island  1 18 

Nidek  Medical  Products  Inc TBA 

Nihon  Kohden  America  Inc TBA 

Nonin  Medical  Inc TBA 

Nova  Biomedical TBA 

Nova  Health  Systems  Inc 359 

Novametrix  Medical  Systems  Inc Island  475 

O 

Ohmeda  Medical TBA 

Omron  Healthcare  Inc TBA 

Oridion  Medical  Inc 526 

Orlando  Regional  Healthcare  Systems TBA 

Ottawa  University/Kansas  City 346 

Owens-BriGam  Medical  Company 334,336 


RESPIRATORY  CARE  •  AUGUST  2000  VOL  45  NO  8 


1035 


Congress  Exhibitors 


Exhibitor 


Booth 


Exhibitor 


Booth 


P 

Par  Med  Pharmaceutical TEA 

Pari  Respiratory  Equipment  Inc 327 

Pathogenesis  Corporation TEA 

PDS  Instrumentation 522,524 

Percussionaire 121 

PHI  Enterprises  Inc TEA 

Plastimed,  Inc TEA 

Posey  Company TEA 

Praxair  Inc 622,624 

Precision  Medical 429 

Primary  Childrenis  Medical  Center TEA 

Pro-tech  Services  Inc 260 

Pulmonetic  Systems  Inc Island  613 

Pulmonox  Medical  Corporation 452 

Puritan-Eennett  Medical  Gases TEA 

R 

Radiometer  America  Inc 461 ,463 

Resmed Island  569 

Respiratory  Care  Resources TEA 

Respironics Island  533 

RNA  Medical 529 

Ross  Pediatrics TEA 

Rozinn  Electronics  Inc TEA 

RT  Magazine 1 15,1 17 

S 

Salter  Labs 422,424 

Seabury  &  Smith TEA 

Sechrist  Industries  Inc 450 

Sepracor Island  575 

Siemens  Medical  Systems  Inc Island  433 


Signature  Pulications TEA 

SIMS  Portex  Inc/SIMS  ECI  Inc Island  1 12 

SleepNet  Corporation 633,635 

Smooth-Eor  Plastics 241 

Sorenson  Critical  Care TEA 

Stellate  Systems TEA 

Sunrise  Medical 249,25 1 

Superior  Products  Inc 620 

T 

Tee  Time  Inc TEA 

Thayer  Medical  Corporation TEA 

Thermo  Respiratory  Group Island  2 1 3 

TSI  Incorporated 679 

U 

Universal  Hospital  Services TEA 

University  of  Texas/M.D.  Anderson  Cancer  Center TEA 

V 

Vapotherm TEA 

Ventworld.Com  Ey  Amethyst  Research TEA 

Versamed  Inc TEA 

Victor  Medical 237 

Vision  Medical TEA 

Vitalograph  Inc 232 

Vortran  Medical  Technology  1  Inc 320 

W 

Western  Medical 456,458 

Western  Michigan  University TEA 

Westmed  Inc 338 


1036 


RESPIRATORY  CARE  •  AUGUST  2000  VOL  45  NO  8 


News  releases  about  new  products  and  services  will  be  considered  for  publication  in  this  section. 

There  is  no  charge  for  these  listings.  Send  descriptive  release  and  glossy  black  and  white  photographs 

to  RESPIRATORY  CARE,  New  Products  &  Services  Dept,  1  lO.W  Abies  Lane,  Dallas  TX  75229-4593. 

The  Reader  Service  Card  can  be  found  at  the  back  of  the  Journal. 


New  Products 
&  Services 


Calibrators  and  Assessory  Solutions. 
ALKO  Diagnostic  Corporation  has  re- 
cently developed  calibrators  and  assesso- 
ry solutions  for  use  on  Radiometer  ABL' 
50.  500.  and  600  series  analyzers.  Ac- 
cording to  ALKO,  this  new  line  includes: 
cleaning  solution,  salt  bridge  solution,  7.4 
calibration  solution,  6.8  calibration  solu- 
tion, rinse  solution,  and  hypochlorite  so- 
lution. ALKO  is  not  affiliated  with  or 
sponsored  by  Radiometer.  Alko  products 
are  manufactured  by  ALKO  Diagnostic 
and  are  intended  for  use  in  place  of  con- 
sumables distributed  by  the  original 
equipment  manufactuer.  ALKO  says  they 
can  provide  correlation  data  upon  request. 
For  more  information  from  ALKO  Diag- 
nostic Corporation,  circle  number  165  on 
the  reader  service  card  in  this  issue,  or 
send  your  request  electronically  via  "Ad- 
vertisers Online"  at  http://www.aarc.org/ 
buyers_guide/ 


Quest®  Exercise  Stress  system.  Accord- 
ing to  the  company,  this  updated  version 
offers  new  capabilities  in  storage,  report 
editing,  and  network  communication. 
Among  the  product's  new  features, 
Spacelabs  Burdick  mentions  specifically 
the  optional  off-line  storage  of  full-dis- 
closure stress  studies  on  high-density  Zip 
disks;  network  communication  that  al- 
lows for  downloading  of  final  summary 
and  test  report  information;  and  editing 
features  including  on-screen  entry  to  pa- 
tient demographic  fields  and  an  extensive 
comments  field  for  test  observations.  For 
more  information  from  the  Spacelabs 
Burdick,  circle  number  166  on  the  reader 
service  card  in  this  issue,  or  send  your  re- 
quest electronically  via  "Advertisers  On- 
line" at  http://www.aarc.org/buyers_ 
guide/ 


i 

Exercise  Stress  System.  Spacelabs  Bur- 
dick has  introduced  version  3.00  of  its 


Suction  Rej^ulators.  Boehringer  Labora- 
tories Inc  has  announced  the  new  3700 
Series  Suction  Regulators.  The  company 
says  they  are  ideal  for  use  in  the  operating 
room,  intensive  care  unit,  and  at  patient 
bedside  for  intermediate  to  high  levels  of 
suction,  as  well  as  fine  line  vacuum.  The 
company  says  the  device  is  practically  in- 
destructible (made  of  virtually  all  metal) 
and  that  the  screen  can  be  read  at  up  to 
1 80  degrees  field  of  view.  For  more  infor- 
mation from  Boehringer  Laboratories, 
circle  number  167  on  the  reader  service 
card  in  this  issue,  or  send  your  request 
electronically  via  "Advertisers  Online"  at 
http://www.aarc.org/buyers_guide/ 


Patient  Monitor.  The  Electromedical  Di- 
vision of  Siemens  Medical  Systems  Inc 
has  recently  unveiled  its  INFINITY  SC 
6002XL  patient  monitor.  The  company 
describes  the  device  as  a  compact, 
portable  bedside  monitor  ideal  for  every- 
day monitoring  tasks  of  adult,  pediatric, 
and  neonatal  patients  in  multiple  hospital 
settings.  According  to  Simiens,  this  de- 
vice features  a  full  selection  of  commonly 
used  parameters  in  one  package:  ECG, 
respiration,  Spo2.  pulse,  temperature,  and 
invasive  and  noninvasive  blood  pressure. 
For  more  information  from  the  Elec- 
tromedical Division  of  Siemens  Medical 
Systems,  circle  number  168  on  the  reader 
service  card  in  this  issue,  or  send  your  re- 
quest electronically  via  "Advertisers  On- 
line" at  http://www.aarc.org/buyers_ 
guide/ 


Ventilator  With  Graphics  Option. 

Respironics  Inc  announces  the  release  of 
its  new  graphics  option  for  the  Esprit  crit- 
ical care  ventilator.  Respironics  says  the 
new  graphics  option  along  with  the  venti- 
lator's  standard  features  are  designed  to 
provide  clinicians  with  immediate  feed- 
back in  order  to  optimize  ventilator  set- 
tings. According  to  the  company,  the  new 
graphics  features  are  utilized  through  the 
Esprit' s  existing  touch  screen  graphical 
user  interface,  requiring  no  extra  hard- 
ware. Features  include:  rescale,  scrolling 
and  replotting,  and  the  ability  to  choose 
graphics  options  from  the  main  graphics 
screen.  For  more  information  from 
Respironics,  circle  number  169  on  the 
reader  service  card  in  this  issue,  or  send 
your  request  electronically  via  "Advertis- 
ers Online"  at  http://www.aarc.org/ 
buyers_guide/ 


RESPIRATORY  CARE  •  AUGUST  2000  VOL  45  NO  8 


1037 


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  at  $5.50  per  line  and  require 

an  insertion  order.  Deadline  is  the  20th  of  the  month  two  months  preceding  the  month  in  which  you  wish  the  ad  to  run. 

Submit  copy  and  insertion  orders  to  Calendar  of  Events,  RESPIRATORY  CARE.  1 1030  Abies  Lane,  Dallas  TX  75229-4593. 


Calendar 
of  Events 


AARC  &  AFFILIATES 

September  14-15-Pittsburgh, 
Pennsylvania 

The  PSRC  Western  Regional 
Pulmonary  Conference  will  be  held  in 
conjunction  with  The  Greater  Pittsburgh 
Sleep  Professionals  at  the  Sheraton 
Station  Square.  The  conference  features 
education  presentations  on 
management,  critical  care,  sleep 
diagnostics,  pulmonary  rehabihtation, 
the  physician  forum,  and  the  GPSP 
sleep  tract.  Contact:  Debbie  Logan  at 
(800)  545-4663,  ext  112. 

September  20-22 — Rochester, 

Minnesota 

The  Minnesota  Society  for  Respiratory 
Care  host  their  3 1st  Annual  Fall  State 
Conference  —  'Too  Hot  to  Handle." 
Contact:  For  more  information, 
contact  Laurie  Tomaszewski  at  (651) 
232-1922,  Carolyn  Dunow  at 
dunowc@fhpcare.coni,  or  Carl 
Mottram  at  mottram.carl@niayo.edu. 

Septmiber  17-29— Hot  Springs, 

Arkansas 

The  ASRC  will  hold  its  29th  Annual 
State  Meeting  and  Education  Seminar 
at  the  Austin  Hotel  and  Hot  Springs 
Convention  Center.  Speakers  include 
AARC  President  Garry  Kauffman, 
Vijay  Deshpande,  Dr  Mark  Heulitt, 
Dr  Teofilo  Lee-Choing,  Harold 
Davis,  Jeff  Standridge,  Lela  Parish- 
Cooper,  Shelley  Dedman,  James 
Lisenbey,  John  Campbell,  and 
Theresa  Gramlich.  Topics  will 
include  ventilation  in  Y2K,  home 
health,  pulmonary  medicine,  asthma, 
and  patient/practitioner  rights. 
National  vendors  will  present  an 
exhibit  of  the  latest  technology. 
Contact  John  W  Lindsey  at  (870) 
54 1  -7606  or  jlindsey  @ 
ahecpb.uams.edu.  Or  visit  www. 
arksrc.org. 

October  6 — Cincinnati,  Ohio 

The  AARC  is  presenting  three 
postgraduate  courses  immediately  prior 
to  the  annual  Congress.  "Mechanical 
Ventilation"  will  include  lung  injury, 
managing  airway  obstruction,  weaning, 
closed  loop/dual  control  modes,  and 
noninvasive  ventilation.  "Making 
Protocols  Work  in  Your  Institution"  will 
cover  rationale,  legal  aspects,  and  use  in 
the  ICU.  "Developing  and  Enhancing 


Pulmonary  Rehabilitation  Services" 
addresses  staffing,  patient  screening, 
reimbursement,  and  marketing.  All 
courses  are  approved  for  continuing 
education  credits,  and  attendance  space 
is  limited.  Contact:  For  more 
information,  see  the  Congress  Program 
in  the  AARC  Times  July  issue  or  call 
(972)243-2272. 

October  ll-13-Bossier  City, 
Louisiana 

The  LSRC's  second  annual  Fall 
Convention  will  be  held  at  the  Isle  of 
Capri  Hotel  and  Casino  with  numerous 
national  speakers  and  exhibitors.  Ten 
CEUs  will  be  available.  Contact:  For 
more  information  or  booth  reservations, 
call  Shonda  Houston  at  (3 1 8)  226-0555 
or  e-mail  sparta@Isumc.edu. 

November  10-12 — Ithaca,  New  York 

The  NYSSRC  and  the  ALACNY  wiU 
host  the  Northeast  Pulmonary  Teaching 
Conference  at  Cornell  University.  Faculty 
includes  Jim  Fink,  Dean  Hess,  Bob 
Kacmarek,  Neil  Maclntyrc,  David 
Pierson,  and  more.  Sessions  examine 
acute  and  subacute  respiratory  care,  RT 
management,  NIPPY,  pediatrics,  and 
asthma.  Exhibits,  job  fair,  and  family- 
friendly  activities.  Contact:  For  more 
information,  call  Patricia  Kuhl  at  (315) 
422-6142  or  visit  www. 
nepuImonaryconf.com. 

Other  Meetings 

August  13-18 — Hobertus,  Wisconsin 

The  American  Lung  Association  of 
Metropolitan  Chicago  is  looking  for  a 
volunteer  RT  with  a  special  interest 
in  respiratory  care  for  children.  The 
RT  will  volunteer  their  time  and 
provide  structured  asthma  education 
one  hour  a  day  to  children  at  the  18th 
annual  CampACTION  at  YMCA 
Camp  Minikani.  The  RT  will  also 
provide  individual  education  in  the 
cabins.  Up  to  eight  CEU  credits  are 
available.  CampACTION  is  staffed 
24  hours  a  day  by  physicians,  nurses, 
an  RT,  and  a  pharmacist.  Contact:  If 
interested,  call  Evet  Hexamer  at 
(312)  243-2000,  ext  260. 

August  \%-\9-Tampa,  Florida 

The  Alliance  for  Cardiovascular 
Professionals  (ACP)  and  TechEd 
Consultants  are  sponsoring  a 


spirometry  course  at  the  Saddlebrook 
Resort  in  conjunction  with  the  ACP 
annual  meeting.  Tuition  will  be 
discounted  for  ACP  and  FSRC 
members.  Contact:  Call  ACP  at  (540) 
370-0102  or  TechEd  at  (517)  676-7018. 

September  2&-29—TechShop  2000 

If  you  are  a  polysomnographic 
technician  seeking  to  enhance  your 
professional  skills,  you  need 
information  about  TechShop  2000. 
TechShop  2000  is  a  four-day 
introductory  to  intermediate  level, 
hands-on,  intensive  training  for 
polysomnographic  technicians  that 
covers  patient  preparation,  set-up, 
scoring,  troubleshooting,  artifact 
recognition,  and  much  more. 
Beginning  Tuesday,  Sept  26,  and 
ending  with  Keynote  Symposium 
Sept  29,  TechShop  2000  is  taught  at 
one  of  the  world's  premier  sleep 
disorders  centers,  Ohio  Sleep 
Medicine  Institute,  under  the  medical 
direction  of  board-certified  sleep 
specialist  Dr  Helmut  Schmidt.  For  a 
detailed  course  outline,  contact 
Crystal  or  Brian  at  (614)  792-7632  or 
e-mail  sIeepohio@aoI.com. 

Practical  Spirometry  Certification 
Course 

Two-day  hands-on  NIOSH-approved 
course  presented  by  Mayo 
Pulmonary  Services:  Sept  29-30  in 
Chicago  IL;  and  Nov  9-10  in 
Rochester  MN.  NIOSH  approval 
#57.  Approved  by  AAOHN  for  15.6 
contact  hours.  Contact:  For  further 
details,  call  (800)  533-1653. 

March  21-24, 2001— Big  Sky, 
Montana 

The  American  Lung  Association  of 
the  Northern  Rockies  will  host  their 
20th  annual  Big  Sky  Pulmonary  & 
Critical  Care  Medicine  Conference  at 
the  Big  Sky  Ski  Resort.  This 
multidisciplinary  review  and  update 
for  all  health  professionals  interested 
in  pulmonary  and  critical  care 
medicine  will  offer  15  hours  of  CME 
credit.  Contact:  For  more 
information,  call  (406)  442-6556  or 
e-mail  alamtwy@aol.com. 


1038 


Respiratory  Care  •  August  2000  Vol  45  No  8 


American  Association  for  Respiratory  Care 


jase  read  the  eligibility  requirements  for  each  of  the  classifications  in  the 

|ht-hand  column,  then  complete  the  applicable  section.  All  information 
quested  below  must  be  provided,  except  where  indicated  as  optional. 
e  other  side  for  more  information  and  fee  schedule.  Please  sign  and  date 
(plication  on  reverse  side  and  type  or  print  clearly.  Processing  of  applica- 
fi  takes  approximately  15  days. 

Z  Active 
Associate 

□  Foreign 

D  Physician 

n  Industrial 
"  Special 
II  Student 


St  Name  _ 
St  Nome 


cial  Security  No. 
>me  Address 


)te 


-Zip 


one  No. 


rimary  Job  Responsibility  (cbeclr  one  only) 

Z  Technical  Director 

Z  Assistant  Technical  Director 

^  Pulmonary  Function  Specialist 

Z  Instructor/Educator 

~  Supervisor 

H  Staff  Therapist 

~  Staff  Technician 

Z  Rehabilitation/Home  Core 

Z  Medical  Director 

Z  Soles 

Z  Student 

Z  Other,  specify 


rpe  of  Buslnoss 

Z  Hospital 

Z  Skilled  Nursing  Facility 

Z  DME/HME 

Z  Home  Health  Agency 

Z  Educational  Institution 

Z  Manufacturer  or  supplier 

n  Other,  specify 


ite  of  Birth  (optional) 


Sex  (optional) . 


S.  Citizen? 


Yes 


No 


ive  you  ever  been  a  member  of  the  AARC?  __ 
o,  when?  From to 


^ 


Preferred  mailing  address:    D  Home    D  Business 


For  office  use  only 


FOR  ACTIVE  MEMBER 

An  individual  is  eligible  if  he/she  lives  in  the  U.S-  or  its  territories  or  was  an  Active  Member 
prior  to  moving  outside  its  borders  or  territories,  ond  meets  ONE  of  the  follov/ing  criteria:  [1 )  is 
legally  credentioled  as  a  respiratory  core  professional  if  employed  in  a  state  that  mandates 
such,  OR  [2]  is  o  graduate  or  an  accredited  educational  program  in  respiratory  care,  OR  |3j 
holds  a  credential  issued  by  the  NBRC.  An  individuol  who  is  on  AARC  Active  Member  in  good 
stonding  on  December  8,  1994,  will  continue  as  such  provided  his/her  membership  remains  in 
good  standing, 

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 


-Zip 


Phone  No. 


Medical  Director/Medical  Sponsor 


FOR  ASSOCIATE  OR  SPECIAL  MEMBER 

Individuals  who  hold  o  position  related  to  respiratory  core  but  do  not  meet  the  requirements  of 
Active  Member  shall  be  Associate  Members.  They  hove  oil  the  rights  and  benefits  of  the  Asso- 
ciofion  except  to  hold  office,  vote,  or  serve  as  choir  of  a  standing  committee.  The  following  sub- 
classes of  Associate  Membership  ore  available:  Foreign,  Physician,  and  Industrial  (individuals 
whose  primary  occupation  is  directly  or  indirectly  devoted  to  the  manufacture,  sole,  or  distribu- 
tion of  respiratory  core  eauipment  or  supplies}.  Special  Members  ore  those  not  working  in  a 
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 


.Zip 


Phone  No. 


FOR  STUDENT  MEMBER 

Individuals  will  be  classified  as  Student  Members  if  they  meet  all  the  requiremenb  for  Associate 
Membership  and  ore  enrolled  in  on  educotional  program  in  respiratory  core  accredited  by,  or 
in  the  process  of  seeking  occreditotion  from,  on  AARC-recognized  agency. 

SPECIAL  NOTICE  —  Student  Members  do  not  receive  Continuing  Respiratory  Core  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 

City 

State 


-Zip 


Phone  No. 


Length  of  program 

D   1  year 
n  2  years 

Expected  Date  of  Graduation  (REQUIRED 
INFORMATION) 


D  4  years 

n  Other,  specify . 


Month 


Year 


American  Association  for  Respiratory  Care  •  1 1 030  Abies  Lane  •  Dallas,  TX  75229-4593  •  [972]  243-2272  •  Fax  [972]  484-2720       -^ 


American  Association  for  Respiratory  Care 


DemographU  Questions 

We  request  that  you  answer  these  questions  in  order  to  help  us 
design  services  and  programs  to  meet  your  needs. 


Check  file  Highest  Degree  Earned 

O   High  School 

n  RC  Graduate  Technician 

n  Associate  Degree 

n  Bachelor's  Degree 

n  Master's  Degree 

n  Doctorate  Degree 


Number  of  Years  in  Respiratory  Care 

D  a2  years  D   1  1-15  Years 

D  3-5  years  D   1 6  years  or  more 

D  6-10  years 


Job  Status 

a 

Full  Time 

D 

Part  Time 

Credentials 

D 

RRT 

D 

CRT 

D 

Physician 

D 

CRNA 

D 

RN 

Salary 

o 

Less  than  $10,000 

n 

$10,001 -$20,000 

n 

$20,001 -$30,000 

□ 

$30,001 -$40,000 

n  $40,000  or  more 

D  LVN/LPN 

n  CPFT 

n  RPFT 

D  Perinotal/Pediatric 


PLEASE  SIGN 

I  hereby  apply  for  membership  in  the  American  Association  for  Respiratory  Care 
and  hove  enclosed  my  dues.  If  approved  for  membership  in  the  AARC,  I  will  abide 
by  its  bylaws  and  professional  code  of  ethics.  I  authorize  investigation  of  all  state- 
ments contained  herein  and  understand  that  misrepresentations  or  omissions  of 
facts  called  for  is  cause  for  rejection  or  expulsion. 

A  yearly  subscription  to  RESPIRATORY  CARE  journal  ond  AARC  Times  magazine 
includes  an  allocation  of  $1  1 .50  from  my  dues  for  eoch  of  these  publications. 

NOTE:  Contributions  or  gifts  to  the  AARC  are  not  tax  deductible  as  charitable  con- 
tributions 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  that  the  nondeductible  portion 
of  your  dues  —  the  portion  v/bich  is  allocable  to  lobbying  —  is  26%. 


BIgnafurm 
Doto 


Membership  Fees 

Payment  must  accompany  your  application  to  the  AARC.  Fees  are  for  1 2 
montfis.  (NOTE:  Renewal  fees  are  $75.00  Active,  Associate-Industrial  or  Associ- 
ate-Pfiysicion,  or  Special  status;  $90.00  for  Associate-Foreign  status;  and 
$45.00  for  Student  status). 


n  Active 

$  87.50 

D  Associate  (Industrial  or  Physician) 

$  87.50 

D  Associate  (Foreign) 

$102.50 

n  Special 

$  87.50 

n  Student 

$  45.00 

TOTAL 

$ 

Spetialty  Settions 

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  Care  Section 
D  Education  Section 
n  Perinatal-Pediatric  Section 
n  Diagnostics  Section 
n  Continuing  Core- 
Rehabilitation  Section 
n  Management  Section 
n  Transport  Section 
n  Home  Care  Section 
n  Subacute  Care  Section 

TOTAL 

OttAND  TOTAL  =  Membership  Fee 
plus  optional  seetions 


$15.00 

$20.00 

$15.00 

$15.00 

$15.00 

$20.00 

$15.00 

$15.00 

$15.00 

$ 

$ 

D  Total  Amount  Enclosed/Charged       $ 
□  Please  charge  my  dues  (see  belowj 

To  charge  your  dues,  complete  the  following: 
D  MasterCard 
a  Visa 

Cord  Number 


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 


I 


MEl3i)fccH 


For  VOLUNTARY  reporting 

by  health  professionals  of  adverse 

events  and  prtxluct  problems 


Form  Approved:  OMB  No.  0910-0291  Expires:  4/30/96 
See  OMB  statement  on  reverse 
FDA  Use  Only  (Resp  Care) 


THF    FOA    MFDU  AL    PRODUt  TS    REPORTING    PR(>(;RAM 


A.  Patient  information 


1    Patient  identifier 


In  confidence 


2    Age  at  time 
of  event: 

or  


Date 
of  birtti: 


3  Sex 

I     I  female 
I     I  male 


Page 


4   Weigfit 


of 


Triage  unit 
sequence  * 


.  lbs 


kgs 


B.  Adverse  event  or  product  problem 


1    LJ  Adverse  event      and/c 


I     I  Product  problem  (e.g.,  defects/malfunctions) 


2    Outcomes  attributed  to  adverse  event      | — , 

(check  all  that  apply)  U  disability 

I     I  congenital  anomaly 
'I  Q  required  intervention  to  prevent 


□  death 


I     I  life-threatening  permanent  impairment/damage 

I     I  hospitalization  -  initial  or  prolonged        Q  other: 


3  Date  of 
event 


4  Date  of 
ttils  report 


5    Describe  event  or  problem 


6    Relevant  tests/laboratory  data,  including  dates 


7    Other  relevant  history,  including  preexisting  medical  conditions  (eg,  allergies, 
race,  pregnancy,  smoking  and  alcohol  use,  hepatic/renal  dysfunction,  etc.) 


ir 

FDA  Form  3500  1/96) 


Mail  to:     MEdWaTCH  or  FAX  to: 

5600  Fishers  Lane  1-800-FDA-0178 

Rockville,  MD  20852-9787 


C.  Suspect  medication(s) 


1 .  Name  (give  labeled  strength  &  mir/labeler,  if  known) 
#1 


#2 


2    Dose,  frequency  &  route  used 

#1 

#2 


3.  Therapy  dates  (if  unknown,  give  duration) 


Ifom/lo  (or  best  eslimale) 


#1 


4.  Diagnosis  for  use  (indication) 
#1 


6.  Lot  #  (if  known) 

#1 


#2 


7.  Exp.  date  (it  known) 
#1 

#2 


9-  NDC  #  (for  product  problems  only) 


5    Event  abated  after  use 
stopped  or  dose  reduced 

«1  Dyes  Dno   D^gPPy"'' 


#2nyesnho    Di^^Py"'' 


8    Event  reappeared  after 
reintroductlon 

#1  Dyes  Dno  U'^^f 


#2  Dyes  D""    D^g^Py"'' 


10.  Concomitant  medical  products  and  therapy  dates  (exclude  treatment  of  event) 


D.  Suspect  medical  device 


1    Brand  name 


2    Type  of  device 


3.  Manufacturer  name  &  address 


6. 
model  #  _ 

catalog  # 

serial  # 

lot#  


other  # 


4    Operator  of  device 
I    I  health  professional 
I     I  lay  user/patient 
□  other: 


5.   Expiration  date 

(moday/yr) 


7.   If  implanted,  give  date 

(mo/day/yr) 


8.    If  explanted,  give  date 

(mo/day'yr) 


9    Device  available  for  evaluation?                (Do  not  send  to  FDA) 
I     I    yes  EH  ho  Q  returned  to  manufacturer  on 


10.  Concomitant  medical  products  and  therapy  dates  (exclude  treatment  of  event) 


E.    Reporter  (see  confidentiality  section  on  back) 


Name  &  address 


phone  # 


2    Health  professional? 

□   yes       □    no 


3      Occupation 


5      If  you  do  NOT  want  your  identity  disclosed  to 
the  manufacturer,  place  an  "  X  "  in  this  box.      Q 


4   Also  reported  to 

I     I      manufacturer 
I     I      user  facility 
I     I      distributor 


Submission  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  wlien  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 

•  1-800-FDA-7737 

•  1-800-FDA-1088 


•  1-800-822-7967 


to  FAX  report 
to  report  by  modem 
to  report  by  phone  or  for 
more  information 
for  a  VAERS  form 
for  vaccines 


If  your  report  involves  a  serious  adverse  event 
with  a  device  and  it  occurred  in  a  facility  outside  a  doc- 
tor's office,  that  facility  may  be  legally  required  to  report  to 
FDA  and/or  the  manufacturer.  Please  notify  the  person  In 
that  facility  who  would  handle  such  reporting. 

Confidentiality:   The  patient's  identity  Is  held  In  strict 
confidence  by  FDA  and  protected  to  the  fullest  extent  of 
the  law.  The  reporter's  Identity,  Including  the  Identity  of  a 
self-reporter,  may  be  shared  with  the  manufacturer  unless 
requested  otherwise.  However,  FDA  will  not  disclose  the 
reporter's  Identity  in  response  to  a  request  from  the 
public,  pursuant  to  the  Freedom  of  Information  Act. 


The  public  reporting  burden  for  this  collection  of  information 
has  been  estimated  to  average  30  minutes  per  response, 
including  the  time  for  reviewing  instructions,  searching  exist- 
ing data  sources,  gathering  and  maintaining  the  data  needed, 
and  completing  and  reviewing  the  collection  of  information. 
Send  comments  regarding  this  burden  estimate  or  any  other 
aspect  of  this  collection  of  information,  including  suggestions 
for  reducing  this  burden  to: 


DHHS  Reports  Clearance  Office 
Paperworlt  Reduction  Project  (0910-0291) 
IHubert  H.  Humphrey  Building.  Room  531-H 
200  Independence  Avenue.  S.W. 
Wasliington,  DC  20201 


An  agency  may  not  conduct  or  sponsor, 
and  a  person  is  not  required  to  respond  to. 
a  collection  of  information  unless  it  displays 
a  currently  valid  0MB  control  numtier.'* 


Please  do  NOT 
return  this  form 
to  either  of  these 
addresses. 


U.S.  DEPARTMENT  OF  HEALTH  AND  HUMAN  SERVICES 
Public  Health  Service  •  pood  and  Drug  Administration 


FDA  Form  3500-back 


Please  Use  Address  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 


MEcJOfccH 


The  FDA  Medical  Products  Reporting  Program 
Food  and  Drug  Administration 
5600  Fishers  Lane 
Rockville,  MD  20852-9787 


|,,l,lli.,.l..l..l.lMll.ll.l..l>MllMl.l.l.lMllil 


RE/PIRATORyCORE 


Manuscript  Preparation  Guide 


Respiratory  Care  welcomes  original  manuscripts  related  to  the  sci- 
ence and  technology  of  respiratory  care  and  prepared  according  to  the 
following  instructions  and  the  Uniform  Requirements  for  Manuscripts 
Submitted  to  Biomedical  Journals  (available  at  http://www.acpon- 
line.org/joumals/resource/unifreqr.htm).  Manuscripts  are  blinded  and 
reviewed  by  professionals  who  are  experts  in  their  fields.  Authors 
are  responsible  for  obtaining  written  permission  to  publish  previ- 
ously-published figures  and  tables  from  the  original  copyright  hold- 
er. Accepted  manuscripts  are  copyedited  for  clarity,  concision,  and 
consistency  with  RESPIRATORY  Care  format.  Before  publication, 
authors  receive  page  proofs  for  minor  correction.  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  writing  for  any  submission;  contact  the  Editorial  Office. 

Categories  of  Articles 

Research  Article:  A  report  of  an  original  investigation  (a  study). 
Must  include  Title  Page,  Abstract,  Key  Words,  Background, 
Methods,  Results,  Discussion,  Conclusions,  and  References.  May 
also  include  Tables,  Figures  (if  so,  must  include  Figure  Legends), 
Acknowledgments,  and  Appendices. 

Review  Article:  A  comprehensive,  critical  review  of  the  literature 
and  state-of-the-art  summary  of  a  topic  that  has  been  the  subject  of 
at  least  40  published  research  articles.  Must  include;  Title  Page,  Out- 
line, Key  Words,  Introduction,  Review  of  the  Literature,  Summa- 
ry, and  References.  May  also  include;  Tables,  Figures  (if  so,  must 
include  Figure  Legends),  and  Acknowledgments. 

Overview;  A  critical  review  of  a  pertinent  topic  that  has  fewer  than 
40  published  research  articles.  Same  structure  as  Review  Article. 

Update:  A  report  of  subsequent  developments  in  a  topic  that  has 
been  critically  reviewed  in  RESPIRATORY  CARE  or  elsewhere.  Same 
structure  as  a  Review  Article. 


ing  physician  must  either  be  an  author  or  furnish  a  letter 
approving  the  manuscript.  Must  include:  Title  Page,  Abstract,  Intro- 
duction, Case  Summary,  Discussion,  and  References.  May  also 
include;  Tables,  Figures  (if  so,  must  include  Figure  Legends),  and 
Acknowledgments. 

Point-of-View  Paper:  A  paper  expressing  personal  but  substanti- 
ated opinions  on  a  pertinent  topic.  Must  include;  Title  Page,  Text, 
and  References.  May  also  include  Tables  and  Figures  (if  so,  must 
include  Figure  Legends). 

Drug  Capsule:  A  miniature  review  paper  about  a  drug  or  class  of 
drugs  that  includes  discussions  of  pharmacology,  pharmacokinet- 
ics, or  pharmacotherapy. 

Graphics  Corner:  A  brief  case  report  discussing  and  illustrating 
waveforms  for  monitoring  or  diagnosis.  Should  include  Questions, 
Answers,  and  Discussion  sections. 

Kittredge's  Comer:  A  brief  description  of  the  operation  of  respiratory 
care  equipment.  Should  include  information  from  manufacturers  and 
editorial  comments  and  suggestions. 

PFT  Corner:  A  brief,  instructive  case  report  including  pul- 
monary function  testing,  accompanied  by  a  review  of  the  relevant 
physiology  and  appropriate  references  to  the  literature. 

Test  Your  Radiologic  Skill:  A  brief,  instructive  case  report  involv- 
ing pulmonary  medicine  radiography  and  including  one  or  more  radio- 
graphs. May  involve  imaging  techniques  other  than  conventional 
chest  radiography. 

Review  of  a  Book,  Film,  Tape,  or  Software:  A  balanced,  critical 
review  of  a  recent  release.  RESPIRATORY  CARE  does  not  accept  unso- 
licited book  reviews;  please  contact  the  Editor  if  you  have  a  sug- 
gestion for  a  book  review. 


Special  Article:  A  pertinent  paper  not  fitting  one  of  the  other  categories. 
Consult  with  the  Editor  before  writing  or  submitting  such  a  paper. 

Editorial:  A  paper  addressing  an  issue  in  the  practice  or  adminis- 
u-ation  of  respiratory  care.  It  may  present  an  opposing  opinion,  clar- 
ify a  position,  or  bring  a  problem  into  focus. 

Letter:  A  brief,  signed  communication  responding  to  an  item  pub- 
lished in  Respiratory  Care  or  about  other  pertinent  topics.  Tables, 
Figures,  and  References  may  be  included.  The  letter  should  be  marked 
"For  I'ublication." 

Case  Report:  Report  of  an  uncommon  clinical  case  or  a  new  or 
improved  method  of  management  or  treatment.  A  case-manag- 


Preparing  the  Manuscript 

Print  on  one  side  of  white  8.5  xl  1  inch  paper,  with  margins  of  at 
least  1  inch  on  all  sides.  Double-space  the  text  and  number  the  pages. 
Do  not  include  author  names,  author  institutional  affiliations,  or  allu- 
sions to  institutional  affiliations  anywhere  except  on  the  title  page. 
On  the  Abstract  page  include  the  title  but  do  not  include  author  names. 
Begin  each  of  the  following  on  a  new  page;  Title  Page,  Abstract, 
Text,  Acknowledgments,  References,  each  Table,  each  Figure,  and 
each  Appendix.  Use  standard  English  in  the  first  person  and  active 
voice.  Type  all  headings  in  initial-capital  letters  (eg.  Background, 
Methods,  Patients,  Equipment,  Statistical  Analysis,  Results,  Dis- 
cussion). Center  the  main  section  headings  and  place  second-level 
headings  on  the  left  margin. 


Respiratory  Care  Manuscript  Preparation  Guide,  Revised  12/99 


Manuscript  Preparation  Guide 


AbstracL  Please  ensure  that  the  abstract  does  not  contain  any  facts 
or  conclusions  that  do  not  also  appear  in  the  body  text.  Limit  the 
abstract  to  no  more  than  400  words. 

Key  Words.  Research,  Review,  Overview,  and  Special  Articles 
require  Key  Words.  On  the  Abstract  or  Outline  page,  include  a  list 
of  6  to  10  key  words  or  two- word  phrases. 

References.  Assign  reference  numbers  in  the  order  that  articles  are 
cited  in  your  manuscript.  At  the  end  of  your  manuscript,  list  the  cited 
works  in  numerical  order.  Abbreviate  journal  names  as  in  Index  Medi- 
cus.  List  all  authors.  The  following  examples  show  RE.SPIRATORY 
Care's  style  for  references. 

Article  in  a  journal  carrying  pagination  throughout  the  volume: 

Rau  JL,  Harwood  RJ.  Comparison  of  nebulizer  delivery  meth- 
ods through  a  neonatal  endotracheal  tube:  a  bench  study.  Respir 
Care  1992;37(1  0:1233-1 240. 

Article  in  a  publication  that  numbers  each  issue  beginning  with  Page  1 : 

Bunch  D.  Establishing  a  national  database  for  home  care.  AARC 
Times  1991  ;15(Mar):61, 62,64. 

Corporate  author  journal  article: 

American  Association  for  Respiratory  Care.  Criteria  for  estab- 
lishing units  for  chronic  ventilator-dependent  patients  in  hospitals. 
Respir  Care  1988;33(1 1):1044-1046. 

Article  in  joumal  supplement:  (Journals  differ  in  numbering  and  iden- 
tifying supplements.  Supply  information  sufficient  to  allow 
retrieval.) 

Reynolds  HY.  Idiopathic  interstitial  pulmonary  fibrosis.  Chest 
1986;  89(3  Suppl):139S-143S. 

Abstract  in  joumal:  (Abstracts  citations  are  to  be  avoided,  and  those 
more  than  3  years  old  should  not  be  cited.) 

Stevens  DP.  Scavenging  ribavirin  from  an  oxygen  hood  to  reduce 
environmental  exposure  (abstract).  Respir  Care  I990;35(l  1):  1087- 
1088. 

Editorial  in  a  joumal: 

Enright  P.  Can  we  relax  during  spirometry?  (editorial).  Am  Rev 
Respir  Disl993;148(2):274. 

Editorial  with  no  author  given: 

Negative-pressure  ventilation  for  chronic  obstructive  pul- 
monary disease  (editorial).  Lancet  1992;340(8833):  1440- 1441. 

Letter  in  joumal: 

Aelony  Y.  Ethnic  norms  for  pulmonary  function  tests  (letter). 
Chest  I991;99(4):1051. 

Corporate  author  book: 

American  Medical  A.ssociation  Department  of  Drugs.  AMA  drug 
evaluations,  3rd  ed.  Littleton  CO:  Publishing  Sciences  Group;  1977. 


Book:  (For  any  book,  specific  pages  should  be  cited  whenever  ref- 
erence is  made  to  specific  statements  or  other  content.) 

DeRemee  RA.  Clinical  profiles  of  diffuse  interstitial  pul- 
monary disease.  New  York:  Futura;  1990:76-85. 

Chapter  in  book  with  editor(s): 

Pierce  AK.  Acute  respiratory  failure.  In:  GuenterCA,  Welch  MH, 
editors.  Pulmonary  medicine.  Philadelphia:  JB  Lippincott; 
1977:26-42. 

Paper  accepted  but  not  yet  published: 

Hess  D.  New  therapies  for  asthma.  Respir  Care  (year,  in  press). 

Personal  communication  of  unpublished  data  not  yet  accepted  for 
publication:  You  must  obtain  written  permission  to  cite  unpublished 
data  received  via  personal  communication.  Do  not  number  such  ref- 
erences, but  instead  make  parenthetical  reference  in  the  body  text 
of  your  manuscript.  Example:  "Recently,  Jones  found  this  treatment 
effective  in  45  of  83  patients  (Jones  HI,  University  of  the  Cascades, 
1 999,  personal  communication)." 

Tables.  Tables  should  be  consecutively  numbered.  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  non- 
standard abbreviations  and  symbols.  Key  the  footnotes  with  the  fol- 
lowing symbols,  superscripted,  in  the  table  body,  and  in  the  following 
order:  *,  t,  t.  §,  II,  1,  **,  tt.  Do  not  use  horizontal  or  vertical 
rules  or  borders.  Do  not  submit  tables  as  photographs,  reduced  in 
size,  or  on  oversize  paper. 

Figures  (illustrations).  Figures  include  graphs,  line  drawings,  pho- 
tographs, and  radiographs.  Use  only  illustrations  that  clarify  and  aug- 
ment the  text.  Number  figures  consecutively  as  Figure  1 ,  Figure  2, 
etc.  Ail  the  figures  must  be  mentioned  in  the  text.  Every  figure  should 
have  a  legend  (a  title  and/or  description  explaining  the  figure).  Fig- 
ure legends  should  appear  as  separate  paragraphs  at  the  end  of  the 
manuscript  (after  the  References  section),  in  the  same  computer  file 
as  the  manuscript  (not  in  a  separate  file,  as  with  the  tables  and  fig- 
ures). Do  not  create  scanned  versions  of  figures  borrowed  from  other 
publications;  clear  photocopies  are  preferable.  To  include  figures 
previously  published  in  other  publications,  you  must  obtain  permission 
from  the  original  copyright  holder  (see  below).  Figures  must  be  of 
professional  quality  and  a  copy  of  the  article  from  which  the  figure 
came  should  be  available.  If  color  is  essential  to  the  figure,  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  an  identifiable  person.  If  possible, 
submit  radiographs  as  prints  and  full-size  copies  of  film. 

Drugs.  Precisely  identify  all  drugs  and  chemicals  used,  giving  gener- 
ic names,  doses,  and  methods  of  administfation.  Brand  names  may 
be  given  in  parentheses  after  generic  names. 

Commercial  Products.  In  the  text,  parenthetically  identify  com- 
mercial products  only  on  first  mention,  giving  the  manufacturer's 
name,  city,  and  state  or  country.  Example:  "We  performed  spirom- 


Respiratory  Care  Manuscript  Preparation  Guide,  Revised  12/99 


Manuscript  Preparation  Guide 


etry  (1085  System.  Medical  Graphics,  Minneapolis,  Minnesota)." 
Provide  model  numbers  if  available,  and  manufacturer's  suggest- 
ed price,  if  the  study  has  cost  implications. 

Permissions:  You  must  obtain  written  permission  to  use  pictures 
of  identifiable  individuals  or  to  name  individuals  in  the  Acknowl- 
edgments section.  You  must  obtain  written  permission  from  the  orig- 
inal copyright  holder  to  use  figures  and  tables  from  other  publica- 
tions. Copies  of  all  applicable  permissions  must  be  on  file  at 
Respiratory  Care  before  a  manuscript  goes  to  press.  Copyright 
is  most  often  held  by  the  journal  or  book  in  which  the  figure  or  table 
originally  appeared  and  applies  to  the  creativity,  style,  and  form  in 
which  the  facts/data  are  presented  to  the  reader;  the  facts  themselves 
are  not  copyright-protectable.  Therefore,  if  you  were  asking  per- 
mission to  reproduce  a  table  or  figure  directly  from  a  journal  or  book, 
or  with  minor  adaptations,  permission  would  be  necessary.  How- 
ever, if  you  intend  to  extract  some  data  from  text  or  illustrations  and 
present  them  in  an  entirely  new  form,  permission  would  not  be  need- 
ed. Simply  cite  the  source  of  die  data  using  the  following  statement: 
"Figure  adapted  from  data  published  in  ..." 

Ethics.  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  (see 
RespirCare  1997;42(6):635-636)orof  the  institution's  committee 
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  institution's  policy,  a  national  guideline,  or  a  law  on 
the  care  and  use  of  laboratory  animals  was  followed. 

Statistics.  Identify  the  statistical  tests  used  in  analyzing  the  data  and 
give  the  prospectively  determined  level  of  significance  in  the  Meth- 
ods section.  Report  actual  p  values  in  the  Results  section.  Cite  only 
textbook  and  published  article  references  to  support  choices  of  tests. 
As  with  commercial  products  (see  above),  parenthetically  identi- 
fy any  general-use  or  commercial  computer  programs  used. 

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  (Systeme  Internationale) 
units  (units  and  conversion  factors  listed  at  Respir  Care 
1997;42(6):640).  Show  gas  pressures  (including  blood  gas  tensions) 
in  millimeters  of  mercury  (mm  Hg). 


abbreviations.  Do  not  use  abbreviations  in  the  title,  in  section  head- 
ings, and  do  not  use  unusual  abbreviations  in  the  abstract.  Use  an  abbre- 
viation only  if  the  term  occurs  4  or  more  times  in  the  paper.  Define 
all  abbreviations  (ie,  write  out  the  fiill  term  on  first  mention,  followed 
by  the  abbreviation  in  parentheses)  and  thereafter  use  only  the  abbre- 
viation. Standard  units  of  measurement  and  scientific  terms  can  be 
abbreviated  without  explanation  (eg,  L/min,  mm  Hg,  pH,  O2). 
Please  use  the  following  forms:  cm  H2O  (not  cmHiO),  f  (not  bpm), 
L  (not  1),  L/min  (not  LPM,  l/min,  or  1pm),  mL  (not  ml),  mm  Hg 
(not  mmHg),  pH  (not  Ph  or  PH),  p  >  0.001  (not  p>0.001),  s  (not  sec), 
Spo,  (arterial  oxygen  saturation  measured  via  pulse-oximetry). 

Prior  and  Duplicate  Publication.  In  general,  do  not  submit  work 
that  has  been  published  or  accepted  elsewhere,  though  in  special 
instances  the  Editor  may  consider  such  material  if  the  original  pub- 
lisher grants  permission.  Please  consult  the  Editor  before  submit- 
ting such  work. 

Authorship.  All  persons  listed  as  authors  should  have  participat- 
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have  proofread  the  submitted  manuscript,  and  all  should  be  able  to 
publicly  discuss  and  defend  the  paper' s  content.  A  paper  of  corporate 
authorship  must  specify  the  key  persons  responsible  for  the  article. 
Attribution  of  authorship  is  not  based  solely  on  solicitation  of  fund- 
ing, collection  or  analysis  of  data,  provision  of  advice,  or  similar  ser- 
vices. Persons  who  provide  such  ancillary  services  may  be  recog- 
nized in  an  Acknowledgments  section. 

Reviewers:  Please  supply  the  names,  credentials,  affiliations,  address- 
es, and  phone/fax  numbers  of  3  professionals  whom  you  consider 
expert  on  the  topic  of  your  paper.  Your  manuscript  may  be  sent  to 
one  or  more  of  them  for  blind  peer  review. 

Submitting  the  Manuscript 

Submit  three  printed  copies  and  one  (3.5-inch)  computer  diskette. 
The  printed  copies  should  each  include  photocopies  of  all  of  the  Fig- 
ures, Tables,  and  Appendixes.  On  the  diskette,  the  manuscript  should 
be  in  one  file  and  the  tables  in  a  separate  file.  If  soft  copies  of  the  fig- 
ures are  available,  they  should  also  be  in  a  separate  file.  However, 
do  not  create  scanned  versions  of  figures  borrowed  from  other  pub- 
lications; clear  photocopies  are  preferable.  Include  the  completed 
Cover  Letter  and  Checklist  (see  next  page)  and  permission  letters. 
Mail  to  Respiratory  Care,  600  Ninth  Avenue,  Suite  702,  Seat- 
tle WA  98104.  Do  not  fax  manuscripts.  Receipt  will  be  acknowledged. 


Conflict  of  Interest.  On  the  cover  page,  authors  must  disclose  any 
liaison  or  financial  arrangement  they  have  with  a  manufacturer  or 
distributor  whose  product  is  addressed  in  the  manuscript  or  with  the 
manufacturer  or  distributor  of  a  competing  product.  Such  arrange- 
ments do  not  disqualify  a  paper  from  consideration  and  are  not  dis- 
closed to  reviewers.  Reviewers  are  screened  for  possible  conflict 
of  interest. 

Abbreviations  and  Symbols.  Use  standard  abbreviations  and  sym- 
bols, listed  at  Respir  Care  1997,42(6):637-642.  Do  not  create  new 


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Respiratory  Care  Manuscript  Preparation  Guide,  Revised  12/99 


Cover  Letter  &  Checklist 

A  copy  of  this  completed  form  must  accompany  all  manuscripts  submitted  for  publication. 


Title  of  Paper: 


Publication  Category: 


Corresponding  Author: . 
Mailing  Address: 


Reprints:      □  Yes     □  No 


_Phone: 


_FAX: 


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: 


*Second  Author: 


•Third  Author: 


Author  Signature/Date. 


Author  Signature/Date. 


Author  Signature/Date. 


*Fourth  Author: 


Author  Signature/Date, 


Has  this  research  been  presented  in  any  public  forum?       □  Yes    □  No 
If  yes,  where,  when  and  by  whom? 


Has  this  research  received  any  awards?         □  Yes    □  No 
If  yes,  please  describe. 


Has  this  research  received  any  grants  or  other  support,  financial  or  material?      □  Yes    □  No 
If  yes,  please  describe. 


Do  any  of  the  authors  of  this  manuscript  have  a  financial  interest  in  (or  a  commercial  or  consulting  relationship  to)  any  of  the 
products  or  manufacturers  mentioned  in  this  paper  or  any  competing  products  or  manufacturers?        □  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? 

□  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? 


Respiratory  Care  Manuscript  Preparation  Guide,  Revised  12/99 


Notices 


Notices  of  competilions.  scholarships,  fellowships,  examination  dates,  new  educational  programs, 

and  the  like  will  be  li.sted  here  free  of  charge.  Items  for  the  Notices  section  must  reach  the  Journal  60  days 

before  the  desired  month  of  publication  (January  1  for  the  March  issue.  February  1  for  the  April  issue,  etc).  Include  all 

pertinent  information  and  mail  notices  to  RESPIRATORY  CARE  Notices  Depl.  1 1030  Abies  Lane.  Dallas  TX  75229-4593. 


Sciicduitd  P%0'it^^0''i4^  ^<^«ittd4  2000 

Pediatric  Ventilation:  Kids  Are  Different — 

Mark  Heulitt  MD;  Host,  Richard  Branson  RRT— 
Video  July  25;  Audio  August  15 

What  Matters  in  Respiratory  Monitoring: 
What  Goes  and  What  Stays— Dean  Hess  PhD 
RRT  FAARC;  Host,  Richard  Branson  RRT— 
Video  August  22;  Audio  September  26 

Managing  Asthma:  An  Update — ^Patti  Joyner 
RRT  CCM;  Host,  Mari  Jones  MSN  RN  RRT— 
Video  September  19;  Audio  October  17 

Routine  Pulmonary  Function  Testing:  Doing  It 
Right— Carl  D  Mottram  RRT  RPFT;  Host,  David 
Pierson  MD — Video  November  7;  Audio 
December  5 


RESPIRATORY  Care  Journal 

has  been  selected  by  the 

Literature  Selection  Technical 

Review  Confimittee  of  the 
National  Library  of  Medicine  to 

be  indexed  and  included  in 
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which  is  available  online  in  the 
U.S.  and  throughout  the  world. 
All  articles  in  the  Journal  begin- 
ning with  the  January  2000 
issue  will  be  included. 


BM  Helpful  lUeb.Sltes 

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http://www.aarc.org 

—  Current  job  listings 

—  American  Respiratory  Care  Foundation 
fellowships,  grants,  &  awards 

—  Clinical  Practice  Guidelines 

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—  Subject  and  Author  Indexes 

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http://www.aarc.org/keys/ 


The  National  Board  for  Respiratory  Care — 
Examination  Dates  and  Fees  for  2000 


Examination 

Examination  Fees 

CRT 

$190  (new  applicant) 
$150(reapplicant) 

^erinatal/Pediatric 

$250  (new  applicant) 
$220  (reapplicant) 

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$200  (new  applicant) 
$170  (reapplicant) 

RPFT 

$250  (new  applicant) 
$170  (reapplicant) 

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(Written  &  CSE) 

$190  (new  -  written  only) 

$200  (new  -  CSE  only) 

$390  (new  -  both) 

For  information  about  other  services  or  fees,  write  to 

the  National  Board  for  Respiratory  Care, 

8310  Nieman  Road,  Lenexa  KS  66214,  or  call 

(913)  599-4200,  FAX  (913)  541-0156, 

or  e-mail:  nbrc-info@nbrc.org 


RESPIRATORY  CARE  •  AUGUST  2000  VOL  45  NO  8 


1047 


Authors 
in  This  Issue 


Beachey,  Will 976 

Canfreld  Jr,  James 953 

Casaburi,  Richard 957 

Chitkara,  Rajinder  K 953 

Cunningham,  Barbara  A 953 

Daggett,  Matthew 971 

Dunne,  Patrick  J 940 

Hotchkiss,  John  R 974 

Iwasaki,  Dean 971 

Jain,  Prasoon    969 

Kavuru,  Mani  S 967,  969 

Kollef,  Marin  H   938 

Kuschner,  Ware  G    953 

Legere,  Brian  M 967 


Marini,  John  J 974 

O'Brien,  Ralph  G 945 

Oba,  Yuji   972 

Petty,  Thomas  L 957 

Piper,  S  David    971 

Piquette,  Craig  A   945 

Poblete-Coleman,  Lourdes  M  953 

Rau,  Joseph  L 962 

Salzman,  Gary  A    972 

Sarinas,  Priscilla  SA 953 

Smith,  Dorsett  D 975 

Stoller,  James  K  945 

Thaggard,  Irene    945 

Wongsurakiat,  Phunsup    973 


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1048 


RESPIRATORY  CARE  •  AUGUST  2000  VOL  45  NO  8 


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Authors 
in  This  Issue 

Beachey,  Will 

Canfield  Jr,  James 

Casaburi,  Richard 

Chitkara,  Rajinder  K 

Cunningham,  Barbara  A 

Daggett,  Matthew 

Dunne,  Patrick  J 

Hotchkiss,  John  R 

Iwasaki,  Dean 

Jain,  Prasoon    

Kavuru,  Mani  S 

Kollef,  Marin  H    

Kuschner,  Ware  G    

Legere,  Brian  M 


976 

953 

957 

953 

953 

971 

940 

974 

971 

969 

.967,  969 

938 

953 

967 


Marini,  John  J 974 

O'Brien,  Ralph  G  945 

Oba,  Yuji   972 

Petty,  Thomas  L 957 

Piper,  S  David    97 1 

Piquette,  Craig  A    945 

Poblete-Coleman,  Lourdes  M  953 

Rau,  Joseph  L 962 

Salzman,  Gary  A    972 

Sarinas,  Priscilla  SA 953 

Smith,  Dorsett  D 975 

Stoller,  James  K  945 

Thaggard,  Irene    945 

Wongsurakiat,  Phunsup    973 


Adverti: 
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Innovative  Evolution 


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