AUGUST 2000
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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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CtWE
RESPIRATORY CARE (ISSN 0020-1324, USPS 0489-
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@ 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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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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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
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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,
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For more information, please contact Diane Shearer
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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
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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.
932
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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
REFERENCES
1. Costamini O, Papp KK, Como J, Aucott J, Carlson MD, Aron DC.
Attitudes of faculty, housestaff, and medical students toward clinical
practice guidelines. Acad Med 1999;74:1138-1143.
2. Langley C. Faulkner A. Watkins C, Gray S, Harvey I. Use of guide-
lines in primary care-practitioners' perspectives. Fam Prac I998;15:
105-111.
3. Watkins C, Harvey I, Langley C, Gray S, Faulkner A. General prac-
titioners' use of guidelines in the consultation and their attitudes
towards them. Brit J Gen Practice 1999;49:1 1-15.
4. Stoller JK. Thaggard I. Piquene CA. O'Brien RG. The impact of a
respiratory therapy, consult service on house officers' knowledge of
respiratory care ordering. Respir Care 2000;45:945-952.
5. Lomas J, Anderson GM, Domnick-Pierre K. Vayda E, Enkin MW,
Hannah WJ. Do practice guidelines guide practice? The effect of a
consensus statement on the practice of physicians. N Engl J Med
1989:321:1306-1311.
6. Morris AH, East TD. Wallace CJ. Franklin M. Heerman L. Kinder T.
et al. Standardization of clinical decision making for the conduct of
credible clinical research in complicated medical environments. Proc/
AMIA Annual Fall Symp 1996:418^22.
7. Peterson WL, Cook DJ. Using a practice guideline for safely short-
ening hospital stay for upper gastrointestinal tract hemorrhage. JAMA
1997:278:2186-2187.
8. Clemmer TP, Spuhler VJ. Berwick DM, Nolan TW. Cooperation:
the foundation of improvement. Ann Intern Med 1998:128:1004-
1009.
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
protocol using pulse oximetry to wean mechanically ventilated pa-
tients from toxic oxygen concentrations. Chest 1992;102:1833-1835.
16. Joiner GA, Salisbury D, Bollin GE. Utilizing quality assurance as a
tool for reducing the risk of nosocomial ventilator-associated pneu-
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-
942
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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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-
948
Respiratory Care • August 2(X)0 Vol 45 No 8
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.
REFERENCES
1 . Catterall W, Mackie K, Local anesthetics. In: Hardman JG, Limbird
LE. Goodman and Gilman's The Pharmacological basis of therapeu-
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6. Cooper HA. Methemoglobinemia cau.sed by benzocaine topical spray.
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hemoglobinemia complicating topical anesthesia during broncho-
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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:
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1 1 . Gibson GR, Hunter JB, Rabbe DS Jr, Manoney DL, Ittleman FP.
Methemoglobin produced by high-dose intravenous nitroglycerin.
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12. Trillo RA Jr, Aukburg S. Dapsone-induced methemoglobinemia and
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956
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
958
Respiratory Care • August 2000 Vol 45 No 8
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
Respiratory Care • August 2000 Vol 45 No 8
959
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
972-243-2272
or visiting
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4c
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.
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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
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♦* now \
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Week
September 10-16,
A 2000
If you have ideas for products or special events,
# # contact (972) 406-4684
Respiratory Care • August 2000 Vol 45 No 8
987
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Distributed to U.S. Hospitals by:
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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
postage-paid Product Information card and drop It in any US mailbox.
Your name will automatically be entered In a sweepstakes drawing for the
Grand Prize which Includes round-trip airfare for two to Cincinnati, Ohio
from any domestic US airport, 4 nights, hotel accommodations, and one
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
faxed to (609) 786-4415 or enter Online by requesting product informa-
tion at http://www.pub-serv.com/rs/m120/ Official Sweepstakes rules
may be requested by e-mail at lnfo@aarc.org.
Developing and
Enhancing Pulmonary
Rehabilitation Services
GO
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s-
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<
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3
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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
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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
^ .
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
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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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Sponsored by the AARC, this course is offered on the day preceding the International
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Respiratory Care • August 2000 Vol 45 No 8
1001
Sunday, October 8, 2:00-3:55 pm (Rooms 213,214)
c
_o
'■4-J
o
3
-a
u
S
.2
o
C/5
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
_o
'■C
C3
O
D
•a
W
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a:
E
_a
'^
o
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
Fax: 425.401.1515
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The Responsible
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
1-888-275-4524
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.
Circle 130 on reader service card
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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b
(
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n
a
r
r>
c
IT
0
0
R
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1
0
d
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bj
c
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
h
s
tc
de
of
sa
o>
ap
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
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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
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POSTGRADUATE COURSE:
Mechanical
Ventilation
3
o
c"
3
*
00
o
=r
o'
i
3
O
K)
iNCiNNATi Convention Center
Course speakers include:
Neil R. MacIntyre, MD, FAARC
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
www.aarc.org.
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.
^
PULMOMOI
MmtcAL
Inc.
Phone: (780) 662-3968
Fax: (780) 662-4255
www.pulmonox.com
PO Box 1020
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
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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
mask and continue
was noted from hh
treatments every 4
active with little m
between communi
xl24hou
ne.and v
xlubated
usalbute
right chc
hours H
cmory cw
ty hospi
ITS. the pa
ccuFoniu
succcssf
nilaeroM
'st tube,
s neun>l
the even
al.<imay
Xient was u
mand was
lly 32 hou
>ls at 15m
^y Hospita
>gic status
DfacuBsk
mprovcthc
eaned
transiti<
rs after
g/hr. H
Iday9
ladretu
>n:Coc
carco
mm CO
Hied to I
Lidmissi
sSa02
he was
nrcdto
irdinatio
patient
tinuou
onlinu
jn. aruj
remain
tolerati
lonual
nof iso
withs
s IV infusio
JUS albuterx
placed on 5
cd >95% U
ng room air
and he was
fluranc adn
evere status
isofepin
aerosols
W Oxyg
Jt a sustai
andalbu
jwake. a
inistralio
asthmati
OF
c[^n
anclP
en fan
ned ai
cnilat
ertanc
nguidi
us.
=-00-
e.
/
leak
rosol
inter-
:lines
161
CHEERS
LET'S HEAR IT FOR VOLUNTEERS!
Thanks to our volunteers, MDA
is the first voluntary health
agency to receive the AMA's
Lifetime Achievement Award.
Muscular Dystrophy Association
1-800-572-1717 • www.nidou5a.org
1022
Respiratory Care • August 2(X)0 Vol 45 No 8
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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)
'■4-t
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S
C/5
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-
ed in the reported work and in the shaping of the manuscript, all must
have proofread the submitted manuscript, and all should be able to
publicly discuss and defend the paper' s content. A paper 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
Respiratory Care
Editorial Office:
600 Ninth Avenue, Suite 702
Seattle W A 98104
(206) 223-0558 (voice)
(206) 223-0563 (fax)
rcjoumal @ aarc.org
rcjkk(s>oz.net
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
Index Medicusdinti MEDLINE,
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
American Association for Respiratory Care
http://www.aarc.org
— Current job listings
— American Respiratory Care Foundation
fellowships, grants, & awards
— Clinical Practice Guidelines
National Board for Respiratory Care
http://www.nbrc.org
RESPIRATORY CARE online
http://www.rcjournal.com
— Subject and Author Indexes
— Contact the editorial staff
— Open FORUM; submit your abstract online
Asthma Management
Model System
http://www.nhlbi.nih.gov
Keys to Professional Excellence
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)
CPFT
$200 (new applicant)
$170 (reapplicant)
RPFT
$250 (new applicant)
$170 (reapplicant)
RRT
(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
Advertisers
in This Issue
To advertise in RESPIRATORY Care, contact Tim Goldsbury, 20 Tradewinds Circle, Tequesta FL 33469
at (561) 745-6793, Fax (561) 745-6795, e-mail: goldsbury(S>aarc.org, for rates and media kits. For recruitment/
classified advertising contact Beth Binkley, Marketing Assistant Tor RESPIRATORY CARE, at (972) 243-2272,
Fax (972) 484-6010. Dale Griffiths is the Marketing Director for RESPIRATORY CARE.
Company
Product
Circle #
Phone
Page#
ARC Medical
Bronchtech Inc
Cadwell Laboratories
Clear Medical
Dale Medical Products
DHD Healthcare
Drager Medical
General Biomedical
Hans Rudolph, Inc
Hospitalhub.com
Hy-Tape Coiporation
Impact Instrumentation
IngMar Medical
Instrumentation Industries
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