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AUGUST 2000 




A.j\. ^^ 

Medical Trainee Experience Versus Optimizing Clinical Outcomes 


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

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


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


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



Recommendations of the Fifth Oxygen Consensus Conference 





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190) is published monthly by Daedaius Enterprises Inc, at 
1 1030 Abies Lane. Dallas TX 75229-4593. for the Amer- 
ican Association for Respiratory Care. One volume is 
published per year beginning each January. Subscription 
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The contents of the Journal are indexed in Hospital and 
Health Administration Index. Cumulative Index to Nurs- 
ing and Allied Health Literature. EMBASE/Exerpta Med- 
ica, and RNdex Library Edition. Abridged versions of 
RESPIRATORY CARE are also published in Italian. 
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Periodicals postage paid at Dallas TX and at additional 
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@ Printed on acid-free paper. 
Printed in the United States of America 
Copyright © 2000. by Daedalus Enterprises Inc. 



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 


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 




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 



Recommendations of the Fifth Oxygen Consensus Conference 

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



Introduction of a Single Isomer Beta Agonist 

by Joseph L Rau — Atlanta, Georgia 



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 


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 











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Abstracts from 
Other Journals 


Advertisers Index 
& Help Lines 




of Events 


Preparation Guide 




New Products 

Acute Respiratory Distress Syndrome: 

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

reviewed by Phunsup Wongsurakial — Seattle, Washington 



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 


2000 Abstracts 
Author Index 


Congress Exhibitors 








A Monthly Science Journal 
Established inl 956 

The Official Journal of the 

American Association for 

Respiratory Care 

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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 


Richard D Branson RRT 
University of Cincinnati 
Cincinnati, Ohio 

Charles G Durbin Jr MD 
University of Virginia 
Charlottesville, Virginia 


Dean R Hess PhD RRT FAARC 

Massachusetts General Hospital 
Harvard University 
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James K Stoller MD 

The Cleveland Clinic Foundation 

Cleveland, Ohio 

Alexander B Adams MPH RRT 

Regions Hospital 
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Thomas A Barnes EdD RRT 

Northeastern University 
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Michael J Bishop MD 
University of Washington 
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University Hospitals of Cleveland 
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James B Fink MS RRT FAARC 

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Massachusetts General Hospital 
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Marin H KoUef MD 

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Paris, France 

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Catherine SH Sassoon MD 

University of California Irvine 
Long Beach, California 

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Salt Lake City, Utah 

Arthur S Slutsky MD 

University of Toronto 
Toronto, Ontario, Canada 

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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 


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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; 

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 

Debunking Myths about the Hospitalist Movement — Wachter RM. Am J Med 2000 Jun 

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): 

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. 


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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 

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, 

; 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 


Respiratory Care • August 2000 Vol 45 No 8 

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Techniques for Weaning the Ventilator Patient — Weaning patients from the ventilator, 
both inside and outside the hospital, is a hot topic that concerns practitioners. Learn the pros and 
cons of various techniques for weaning in short-term and long-term situations. Featuring Dean 
Hess, PhD, RRT, and Richard D. Branson, BS, RRT. 90-min. videotape. Item VC88 $49.95 
($99.00 Nonmembers) 

Weaning from Mechanical Ventilation — Covers ventilator weaning approaches, how they 
differ, and the differences in weaning from short- and long-term mechanical ventilation. Also 
teaches the interpretation of measurements used in predicting ability to wean and the main causes 
for weaning failure. Featuring Martin J. Tobin, MD, and David J. Pierson, MD. 90-min. videotape. 
Item VC23 $49.95 ($99.00 Nonmembers) 

Shortening Length of Stay on Ventilators and in Hospitals — Focuses on why patients remain ventilator dependent, and the dis- 
ease-specific factors of ventilatory muscle overload, neurological dysfunction, and gas-exchange difficulties. Maximizing therapy for the 
underlying cardiorespiratory disease is also presented as a component in shortening the patient's length of stay. Also discussed are ventilation 
management complications such as pneumothorax-imposed work from ventilator settings and equipment, aspiration pneumonia, nutrition, 
and fluid. Featuring Neil R. Maclntyre, MD, and Richard D. Branson, BS, RRT. 90-min. videotape. Item VC57 $49.95 ($99.00 

Weaning in the ICU: Predictors and Strategies — Presents predictors and strategies that you may use to wean patients from mechani- 
cal ventilators in the critical care setting. By James K. Stoller, MD. 40-min. audiotape. Item PAD8102 $15.00 ($20.00 Nonmembers) 

Weaning and Decannulation: Swallowing Studies and How to Decannulate — Explains the appropriate components of an inter- 
disciplinary care plan for tracheostomized patients. By Mike Harrell, BS, RRT. 40-min. audiotape. Item PAD740 $15.00 ($20.00 

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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- 


Respiratory Care • August 2000 Vol 45 No 8 

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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, to 16) and subscale scores (possible 
range, 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- 

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, 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- 


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 

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): 

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 

Pulmonary Outcome in Extremely Low Birth Weight Infants — 

Fitzgerald DA, Mesiano G, Brosseau L, Davis GM. Pediatrics 2000 

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 

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 

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 


Respiratory Care • August 2000 Vol 45 No 8 

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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 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 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 


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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 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 

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 


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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- 


Respiratory Care • August 2000 Vol 45 No 8 

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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 

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 

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

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

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

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


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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 

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- 

In normal adults, both blood flow and ventilation are distributed prefer- 
entially to the dependent lung zones. In adults with unilateral lung dis-, 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 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, 


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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): 

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 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- 

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 in long-term studies of the safety 
and efficacy of tiotropium. 


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n 1997 VOLUME AT 540/580 
D 1996 VOLUME AT 540/580 
D 1995 VOLUME AT 540/580 


D 1994 VOLUME AT 535/575 
D 1993 VOLUME AT 535/575 
n 1992 VOLUME AT 530/570 
D 1990 VOLUME AT 530/^70 
D 1989 VOLUME AT 530/570 








PO BOX 29686 • DALLAS TX 75229 • FAX [972] 484-2720 


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 

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 


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 


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: 

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 

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 

8. Clemmer TP, Spuhler VJ. Berwick DM, Nolan TW. Cooperation: 
the foundation of improvement. Ann Intern Med 1998:128:1004- 

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: 

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- 

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 

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; 

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 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 

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: 

Respiratory Care • August 2000 Vol 45 No 8 


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 


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- 


Respiratory Care • August 2000 Vol 45 No 8 

Utilization of Long-Term Home Oxygen Therapy 

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


Use Per 
100,000 People 

United States 



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 

Respiratory Care • August 2000 Vol 45 No 8 


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- 


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- 
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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: 

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). 


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 


Respiratory Care • August 2000 Vol 45 No 8 

Impact of a Respiratory Therapy Consult Service 

Table I . Characteristics of Respondents in the Current Survey 


The Cleveland Clinic Foundation 

Mean % Correct for 
All Cases 


of Nebraska 

Mean % Correct for 






% Respondents 


























77.2 ±11.6 
95% CI: 73.6%, 




75.8 ± 12.0 

95% CI: 69.7%. 82.1% 

Table 2. Percent of Correct Responses by Case Study 


The Cleveland Clinic 

Foundation (n = 41) 

Mean (%) ± SD 

University of Nebraska 

in = 17) 

Mean (%) ± SD 

(The Cleveland Clinic 
Mean (%) ± SD 

Foundation — University of Nebraska) 

95% CI (%) p 


84.2 ± 20.0 

92.7 ± 14.7 

-9± 19 




86.6 ± 17.8 

69.1 ± 14.1 

17 ± 17 




67.5 ± 24.2 

72.1 ± 27.8 

-5 ±25 

-19, 10 



77.0 ±21.3 

72.1 ± 17.4 

49 ±20 

-7. 17 



70.8 ± 14.0 

73.5 ± 16.5 

-3± 15 




77.2 ± 11.6 

75.8 ± 12.0 

14 ± 12 

-5.4, 81 


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 ( 

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. 


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 

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 


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. 


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- 


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 

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


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 

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 



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. 


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 
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. 


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 



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. 


Chest radiograph 
Arterial blood gases 

Breath sounds 

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 

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 

Chest radiograph 
Arterial blood gases 

Breath sounds 

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 


Respiratory Care • August 2000 Vol 45 No 8 


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. 


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. 


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: 

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 


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- 

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%. 


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 

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 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- 


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 


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 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. 


1 . Catterall W, Mackie K, Local anesthetics. In: Hardman JG, Limbird 
LE. Goodman and Gilman's The Pharmacological basis of therapeu- 
tics. New York: McGraw-Hill; l996;3.^1-347. 

2. Physician's desk reference, 53rd ed. Montvale, New Jersey: Medical 
Economics, 1999: 734 

3. Physician's desk reference, 53rd ed. Montvale NJ: Medical Econom- 
ics. 1999: 894 

4. Rodriguez LF, Smolik LM, Zbehlik AJ. Benzocaine-induced met- 
hemoglobinemia: report of a severe reaction and review of the lit- 
erature. Ann Pharmacother 1994;28:643-649. 

5. Ho RT, Nanevicz T, Yee R, Figueredo VM. Benzocaine-induced 
methemoglobinemia — two case reports related to transesophageal 
echocardiography premedication. Cardiovasc Drugs Ther 1998:12: 

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

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

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

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

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

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

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

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

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

15. Guertler AT, Pearce WA. A prospective evaluation of benzocaine- 
associated methemoglobinemia in human beings. Ann Emerg Med 

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

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

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

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

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


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- 

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: 

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 


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. 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. 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- 

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- 

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


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 

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. 


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 


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; 

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. 


Respiratory Care • August 2000 Vol 45 No 8 


Recommendations of the Fifth Oxygen Consensus Conference 


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 


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 


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 



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 


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: 

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 


Respiratory Care • August 2000 Vol 45 No 8 

Introduction of a Single Isomer Beta Agonist 

Albuterol Isomers 






^ I 

" CH, 










D or (S)-albuterol 

L or (R)-albuterol 

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)- intracellular calcium concentration' 
Binds to muscarinic receptors' 
Enhances eosinophil superoxide production with Interleukin-5 

Enhances experimental airway responsiveness' 

S albuterol = dextrorolalory form (S isomer) of albulerol 

Respiratory Care • August 2000 Vol 45 No 8 


Introduction of a Single Isomer Beta Agonist 

45 , 
40 . 

2, 30 

Id 25 

a, 20-^ 


10 -I 




25 . 
20 . 
15 . 


Day (Week 0) 

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


2 3 4 

Time (hours) 

Day 28 (Week 4) 


-♦— Lev0^3(n'«8) 

-A— Rac2J(n=«9) 

-e— RacI25(n=63) 



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- 


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. 


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 

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 


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. 

13. Perrin-Fayolle M. Salbutamol in the treatment of asthma. Lancet 



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. 


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? 



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 

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 


Pulmonary Function in Obesity 

Table I. Pulmonary Function Test Results 





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 





FEV, (L) 
























D,^„ (mUmm Hg/s) 








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. 




Restriction - 





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. 


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- 

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

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

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

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. 


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? 


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; 

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

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 


Peak Expiratory Flow vs Spirometry in a Patient with Asthma 

Table 1 . Pulmonary Function Test Results 








% Predicted 


% 1 









FEV, (L) 














PEF (Lis) 







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. 


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. 



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 

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

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: 

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; 

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: 

Gardner RM, Crapo RO, Jackson BR, Jensen RL. Evaluation of 
accuracy and reproducibility of peak flowmeters at 1 ,400 m. Chest 


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


Letters addressing topics of current interest or material in Respiratory Care will be considered for publication. The Editors may accept or 
decline a letter or edit without changing the author's views. The content of letters as published may simply reflect the author's opinion or 
interpretation of information — not standard practice or the Journal's recommendation. Authors of criticized material will have the opportunity 
to reply In print. No anonymous letters can be published. Type letter double-spaced, mark it "For Publication," and mail it to Respiratory Care, 
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 

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 

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 


Lakewood. Colorado 


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- 

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 


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- 

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 

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 



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 


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 


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; 

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 

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. 


Respiratory Care • 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 

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 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 

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 


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- 


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- 

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 


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- 

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 

• "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 

• Lack of "CVP" for central venous pres- 

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

• 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 

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 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- 


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 

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 

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 


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 


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 


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) 

Mission-SL Joseph's Health System, AshevUte, NC 

Backgnwid: Our facility currently uses a rapd-sequence, patient-<tiven pititocol for tfie 
xt n iiii a l im l o r 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. 


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- 




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. 

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. 


Stage 2 










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. 


Respiratory Care • August 2000 Vol 45 No 8 


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

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. 


Average change 
in PEF (ml) 


Average change 
in PEF (ml) 

Dose 2 

Average total 
in PEF (ml) 

2.50 mg 




0.63 mg 




1.25 mg 




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. 



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 


mean ± S.D 


SAL 1 

pMDl alone 

pMDI with AC+ 

pMDl alone 

pMDl with AC+ 

ED (% label 
claim dose) 

86.0 ± 2.0 


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 


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 


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 & 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 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, 



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 


■ AeroChamber 

S so 

M , iw^-JBLjBL-gaiLJL 


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. 



Respiratory Care • August 2000 Vol 45 No 8 

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


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 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- 


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.) 


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). 

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) 

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. 



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- 

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 


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












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 


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: 






95% Confidence 





















*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 

• the tested VHCs are reasonable for administration of salmeterol. 


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

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 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 

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 



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. 


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 


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




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

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 

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. 


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 

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 

Spurioas Condition 




Failed SpOi 



Failed SpO: 



Failed SpO^ 



Failed PR 1!) 




Failed SpO; 

■'low quality signal" 



Failed SpO; 

■"low quality signal" 



Failed SpOj 

"low quality signal" 

"pulse search" 






(!) 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 

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, - 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. - 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 


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

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 


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 




Tidal Volume (ml) 

605.4±276.0 * 



Peak Flow Rate(ml/sec) 

379.2±227.1 ** 



Flow Rate at 75% TV (niVsec) 




Flow Rate at 50% TV (ml/sec) 




Flow Rate at 25% TV (ml/sec) 




*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 


Lori faig alls. 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 

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. 







• • 



5 '1 


• . . 

■ - ' 


• " 










Kenneth Miller. RRT. MEd: Stephen Matchen, MD; Frederick Wieand, RRT, BA: 
Phillip Huffhian, MD; Wanda Perich, RN. Lehigh Valley Hospital. Allentown, PA, USA, 

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 

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 



Respiratory Care • August 2000 Vol 45 No 8 

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

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 

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. 


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 


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

gatlt g romd: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 


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 



♦* now \ 

to Celebrai 







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 


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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 





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. 





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 ad equat e 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. 


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 


Nmnba Ave. 

of patients Gestage 




1998 surgical j 38 

1999 medical 


1999 surgical | 28 



# Days on 

1.75 days 

Patients req. 
Re-uaubation CompMcarions 

2. 15 days 

3.57 days 


* 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 


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 


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

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 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^. 


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. 



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 



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 



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. 




End Pressure 













Long Release 








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

Shon Release 








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. 



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 


4.0 ±0.02 

3.48 ± 0.08 

9.1 ±0.2 



4,0 ±0.01 

4.04 ± 0.03 




4.0 ±0.08 

4.46 ± 0.09 

5. 7 ±0.6 



4.0 ± 0.03 

5.40 ±0.54 

9.2 ± 0.04 


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 


Respiratory Care • August 2000 Vol 45 No 8 

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

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 


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} 7 5 

OiyteulioB Sana 




hyperoxic ^"27) 



normal (n -123) 




hypoxic fn''24) 




no gas or capilltBygas 



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 


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 (+ 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 



s 8 8 S S « I g ? i § I g « g I S 



: 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. 



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 ** 





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 
° 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 


Respiratory Care • August 2000 Vol 45 No 8 


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

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 
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 



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Respiratory Care • August 2000 Vol 45 No 8 

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


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. 



No motion, normal perfusion 
No motion, low perfusion 
Motion, normal perfusion 
Motion, low perfusion 

N395 AgUeot D-O3900 IVY 2000 

























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 



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. 

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 




























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 


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 


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. 







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 


5.0 ±1.2 

6.6 ±1.9 

8.1 ±0.6 

10.0 ±0 

11.4 ±0.9 


4.1 ±0.19 

5.6 ±0.14 

7.3 ±0.37 

10.0 ±0 


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 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 


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

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 


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. 


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: 






Pre MRI 





During MRI 





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. 


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. 


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: 




Micro Plus 


3.19 (.83) 

5.98 (2.25) 

SeasorMedics 2450 


3.42 (.91) 


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: 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. 



Respiratory Care • August 2000 Vol 45 No 8 

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


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. 



F101,% 1 


20 bun 

>*bi»i 1 






















1 19 

26 5 














24 1 









25 1 




263 296 




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. 


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Attendance is limited to 50, and you must pre-register by September 15 — first 
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registration form is provided in the Congress Program, or you can call the AARC at 
(972) 243-2272 or register online at 

Respiratory Care • August 2000 Vol 45 No 8 





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) 


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. 



Thomas Smith BS RRT. Virginia DeFilippo, MS RRT. Patricia Reagan-Cirincione, 
PhD, Dorothy Mazon RN MPH Yale-New Haven Hospital, New Haven. 


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. 


Circuit Change Interval 

3 times per week 
Total Ventilator Days 2279 

Total VAP 54 

Mean VAP Rate 25.42 

once per week 

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 



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 Opwi HowtSiMgwy 

mnt, OF-00-014 


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 


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


4— > 






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. 

Pressure Support Level* At Termination 
Of Mechanical Ventilation 


^ . 

M " ' 


( • 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 


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 
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. 



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 

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. 

I « 15.0 

is 10.0 


S> 0.0 











1997 19! 




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) 





+4.23 ± .38 


-0.76 ±.21 


-0.33 ± .76 

-3.34 ±.74 

-5.64 ±.14 



-3.01 ±2.15 

+ 1.53 ±.40 



-H .00 ±2.22 

-2.48 ± .37 


-1.95 ±1.74 

-1.67 ±1.25 

-4.87 ±.38 


-2.28 ±1.14 

-2.68 ±.34 

-6.21 ± .45 


-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. 



Respiratory Care • August 2000 Vol 45 No 8 

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


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) 




PIP (cmH;0) PEEPi (cmH;0) 


12 4^±0.2 



20 4.4±0.2 

4.6±0.2 50.6*±4.7 23.6±3.0 



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 


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 



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 

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. 



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 

Culture-(32) 28.1 ±9.8 21.4±8.7 15.1 ±8.1 18.4±6.3 5 



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. 













Table 1. 

Resistance (emHiO/Usec) 
















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. 


Respiratory Care • August 2000 vol 45 No 8 


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












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. 


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. 




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 

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: 









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, 

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. 



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): 

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 
with PEEP in acute respiratory failure. Anesthesiology 1981;54:9-16. 










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. 



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Respiratory Care • August 2000 Vol 45 No 8 


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










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 

n(% of total) 

Moderate Value 
n(% of total) 

Low Value 
n(% of total) 

No Response 
n(% of total) 

Advanced Practice 





Liberal Arts 


191 (52.6) 

147 (40.5) 
182 (50.1) 
147 (40.5) 

Total respondents n = 363. 

Respondents were asked to rate each of the degree majors. 

1 ! (3.0) 
34 (9.4) 

8 (2.2) 
8 (2.2) 


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 



Very satisfied 






Would you take an on-line course based on your experience with RT 4081 ? | 





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. 


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 

Decision making 


.711 1 






















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 











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. 



Respiratory Care • August 2000 Vol 45 No 8 

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

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. 


The Effectiveness of Standardized Self-Assessment Examinations and 
Graduate/Employer Eviuations in Predicting Graduate Pass Rates on 
NBRC Examinations. Ten v S. LeGrand. PtiD, RR T 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 


Dj ividL 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, 
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, 
CT. FYEX, CRTTSAE and WRRTSAE may be useful in predating graduate 
periformance on selecled program outeome measures. 



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. 


Respiratory Care • August 2000 Vol 45 No 8 


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

ReUse of Medical 

Devices Has 











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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. 



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. 



Circle 1 14 on product info card 


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pulmonary complications. 


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) 


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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) 

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). 


- Neotrend 

Combined Data 

High Position 

Low Position | 














PC02 (mmHg) 







P02 (mmHg) 







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 


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 







Pre Heliox 







Heliox - 15 minutes 







Heliox - 30 minutes 







Off Heliox- 1 hour 







Heliox - 30 minutes 







Heliox - 8 hours 







Heliox - 22 hours 







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 *? 


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. 


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. 



1st tx. 

OI after S 
after KT™ 


P/t" after S 
after KT'-' 



after S 

after KT™ 




(12th hour) 



(12th hour) 

(I8lh hour) 


(12th hour) 

1 18th hour) 
























































































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 


Respiratory Care • August 2000 Vol 45 No 8 

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




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. 


(STAND) Alisa G. French. MBA. BS. RRT and Belinda S. Huffi nan. 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. 


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. 


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. 


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 


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


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 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. 


PaC02 Pa02 


Sa02 Fi02 

Prior to Intubation 














Prior to Halothane 







Halothane 2 %r.10niinl 







Halothane .5 %(36h) 














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. 




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 
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 

% of total 


Lung volumes 
% of total 



% of total 


1 (OA.OR) 

5.6 » 






2(1 A, OR) 

.1 % 





3 (0 A. > 2 R) 





2.1 % 


4 (2 A. OR) 



.1 % 



5(1 A,22R) 





2.1 % 


6(3 A. OR) 







7 (2 A, 2 2 R) 





2.1 % 





43.7 % 


88.9 % 


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 


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. 



200 ml water lo 
200 ml Honey 

200 ml Water to 
300 ml Honey 


387± 32 

232 ±18 

150 ±8 


591 ±40 

238 ± 10 

169 ±6 


570 ± 22 

236 ±4 










10 Fr 

142 ± IS 

41 ±2 

21 ±0 


151 ±24 

99 t 37 


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. 

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. 



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

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


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 ( = 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). 


20 ■ 
10 ■ 


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. 



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 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 


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. 

after Tx 

No change 
after Tx 

Worsened after 

Improved after Sx 


70 (42.2) 

9(5 4) 

No Change after Sx 



5 (3.0) 

Worsened ^tofSx 




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 













)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 
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. 


EdenTrace 11+ 

.Masimo SET 


Invalid Data (hours) 



p< 0.001 

Invalid Data (events) 




True Desaturaiion Events 



p < 0.02 

Invalid DesaiuratiOD Events 



/7< 0.001 

Zero-Out Events 











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 


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 



Respiratory Care • August 2000 vol 45 No 8 





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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. 


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.). 



10 Hz 

8 Hz 


4 Hz 


35±l 1 ml 


75±21 ml 






108+30 ml 


24±9 ml 



87±24 ml 



26±8 ml 



Conclusion: At low rates and high AP in this model VTs approaching conventional 
mechanical ventilation are delivered during HFO. 






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 


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. 


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 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 


Monday, October 9, 9:30-11:25 am (Rooms 213,214) 


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. 



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 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. 






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 

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 


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 

I-time (Seconds) 

Meas. VI (L) 

Calc. Vt (L) 

% Difference 





















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. 


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 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 


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. 



Respiratory Care • August 2000 Vol 45 No 8 

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

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. 


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. 


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* 


i ^ 


High Excursion 
Low Excursion 

Pressure (cmH20) 



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 



Daily opioid 


(% male) 

{9c hematologic) 

dose (mg) 

Pre BiLevel 

25 57 (3) 



247 (46) 

Post BiLevel 

12 52(5) 



147 (55) 

p value 





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. 



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 

60 Umin 

90 Umin 










II. 1 





0.10 Ucm H:0 







0.07 Ucm H;0 







0.04 Ucm HjO 







0.01 UcmHiO 







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 


Respiratory Care • August 2000 vol 45 No 8 


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


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. 



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. 


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 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. 



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 L/m and the 
trapped volume (Vttap) detected during die PEEP,-slat measuiement also decreased. 


■*• PEEPI-»I« 

-■- PEEPI-dyn 
-* — Vtrap 


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. 



Respiratory Care • August 2000 Vol 45 No 8 

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

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. 




3575 14th Avenue, Unit 12 

Markham, ON L3R 0H6 CANADA 

Phone: 905-51 3-71 70 Fax: 905-474-1 740 

STEM produces a comprehensive range 

of medical oxygen fuel cell sensors - 

direct replacements for Draeger, 

Teledyne, Ohmeda, MaxTec, etc., 

Price advantageous, position and shock 

insensitive, anaesthetic and gas tolerant, 

backed by a 15 MONTH WARRANTY. 

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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 

Respiratory Care • August 2000 Vol 45 No 8 


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. 




Phone: (780) 662-3968 
Fax: (780) 662-4255 

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 ) 


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 

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. 

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. 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 



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 


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 






























21 2 


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 palienis 
without complicaticms. 


Respiratory Care • August 2000 Vol 45 No 8 


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


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. 



DATEX/OHMEDA INOvgnl* Sandra R Wadlm yer 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 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 3 

Machine 4 



Oi 1 NO, ; NO 





NOi j NO 

Oi i NO, 


0, ; NO, , NO 

15 ipm 

W.O i 0.2 ' 18,0 





0,3 ; 20.0 

98.0 1 0.5 



99.0 i 0.2 i IS.O 





0.1 1 16.0 

98,0 1 0,5 



100.0; 0.! ■ 12.0 





0,1 '■■ 14,0 

99.6 i oT^ 


98.8 0.2 : 13 1 
98,8 1 2 , 9 8 


100.0 r 0.1 1 8.7 





0.1 j 110 

990 ; 0.4 10 

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. 



RivnandMallov BS. RJtT. Bnan Glynn BS RRT, William Bucher RRT. Caroline 
Devnreux BS, Jay Greenspan MD. Thomas Jefferson University Hospital. Philadelphia, 

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) 



RDS; Gastroschesis 





















RDS; pneumoDia 



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%. 


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 
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 



Respiratory Care • August 2000 Vol 45 No 8 



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Monday, October 9, 2:00-3:55 pm (Rooms 213,214) 

heuox: a mixture of 60/40 is effective in the adult asthmatic 

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. 

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 


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. 



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. 


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'. 


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, 

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. 


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. 


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% 

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. 


• Musi healthcare providers (85%) piacdang in Oman do not demonstrate accurate MDI 

• 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. 


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. 




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 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. 


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. 



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. 




Monday, October 9, 2:00-3:55 pm (Rooms 213,214) 


Stephanie Monlcath. CRT . Linda Van Scoder, EdD, RRT, Respiratory Therapy 

Program, School of Allied Health Sciences, Indiana University School of Medicine, 
Indianapolis, IN, 46202. 


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. 

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). 

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 


Mean pre-education ER visits 




Mean post-education ER visits 




Mean pre-education hospitalizations 




Mean post-education hospitalizations 




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. 

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. 



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 

# Receiving # Receiving 

RcsnUs: Levalbuterol Albuterol Sulfate 

I. 25 mg. S ml 

ED patients treated 



Avg. # of treatments 

in ED 



Avg. LOS in ED 

1.75 tas. 

2.8 his. 

Hospital admissions 

29 (10%) 


Avg. # of treatments 

in Hospital 



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. 


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: 






Start of 



End of 


































































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 

ne.and v 
right chc 
hours H 
cmory cw 
ty hospi 

ITS. the pa 
'st tube, 
s neun>l 
the even 

Xient was u 
mand was 
lly 32 hou 
>ls at 15m 
^y Hospita 
>gic status 

rs after 
g/hr. H 

mm CO 
Hied to I 
he was 

jn. aruj 
nof iso 

s IV infusio 
JUS albuterx 
placed on 5 
cd >95% U 
ng room air 
and he was 
fluranc adn 
evere status 

W Oxyg 
Jt a sustai 
jwake. a 


en fan 
ned ai 









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 • 


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

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 = patients. Bradycardia = 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 



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. 



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. 


«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 


Physician - directed 
skin testing 



Respiratory Care Protocol- 
based skin testing 





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 







5.4 (D.51) 


< 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. 



Respiratory Care • August 2000 Vol 45 No 8 

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


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. 


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. 


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. 


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 

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) 



Mean Age (Range) 

60.2 years (52 ± 


60.7 years (58 ±36) 

m Smoking History' 



ffi Pulmonary Disease' 



B Smoking Hx & Pulm Dx 



Developed Post-op Atelectasis' 



Developed Post-op Pneumonia' 

1 (4.5%) 


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 



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























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 



IPPB Indicated 



IPPB Ordered 



Original Number of Inappropriate Orders 



IPPB Orders Changed 


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. 


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 


Katfr l**^ 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. 

































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. 



Respiratory Care • August 2000 Vol 45 No I 

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


F/VARC, Ke y 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. 



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. 



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. 


for padeati requlrinti MV > 24 hoars. 




Hospital LOS 

Saverily Scon 
















AvtncB Coat of Care per patjenl - for patiesla reqairinx MV > 24 hoan. 














Si 19 






Ealliutad - CiV Savings + ICU Savings -f Hospital Savings "W <fl>24 hours 4S415.467 
CostSeviaii L "» + 1043 * 2389 J I 117 J 



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 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 


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


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. 


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 



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: 



Pre FI02 & Flow* 

02 Bleed-in w/HME 

Ain Liter Flow 



40% / 6 l/min 

2 l/min 

4 l/min 



40% / 6 l/min 

1 l/min 

5 l/min 



50% / 6 l/min 

1 l/min 

5 l/min 



40%/ 6 l/min 

2 l/min 

4 l/min 



35% / 6 l/min 

2 l/min 

4 I/min 



40%/ 6 l/min 

1 l/min 

5 l/min 



35% / 6 l/min 

2 l/min 

4 l/min 



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. 



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 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. 



Respiratory Care • August 2000 Vol 45 No 8 

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

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. 


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. 



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 

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. 








J(^g on to 

and select 

"buyer's Quide. " 

Respiratory Care • August 2000 Vol 45 No 8 


Open Forum Author Index 

Boldface type indicates presenters. 


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 


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 


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 


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 


Eaton, Amanda 1007 

Elisan, Isabelo 985 (2) 

Engert, Homer 1027 

Enter, Kathy 1028 

Estetter, Robert 1001 

Evans, Robert 994 


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 


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 


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 


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 


Ingalls, Lori 986 


Jain, Hitender 984 

James, Richard 1017 

Johannigman, Jay A 993, 999 (3), 1014 

Jones, Shelley 1027 


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 


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 


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 


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 


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'Keefe, Grant 984 

Op't Holt, Timothy 997 

Orens, Douglas 1025 

Ouk, Sivom 986 


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 


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 


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 


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 


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 


Uster, Paul 994 

Uzark, Karen 989 

Uzawa, Yoshihiro 986 


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 


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 


Yamaguchi, Yasunari 986 


Zaioga, Gary P 101 1 

Respiratory Care • August 2000 Vol 45 No 8 


Congress 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 






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 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 


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 


Dale Medical Products Inc 42 1 

Datex-Ohmeda 351,353.355 

Delmar Publishers 520 

Dey Lab 423,425,427 



Congress Exhibitors 





DHD Healthcare 218,220 

Drager Medical Inc Island 122 


Eco Physics Inc TB A 

El Hospital TBA 


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 


General Physiotherapy 420 

Glaxo Wellcome Inc Island 501 

Goldstein & Associates Inc TBA 

Grass-Telefactor 340,342 


^ 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 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.P.I. Medical Products Inc 323,325 


Jaeger Inc TBA 

J.H. Emerson Company TBA 


KCI 468,470,472,474 

Kendall 549 

Kettering National Seminars TBA 

Kimberly-Clark/Ballard Medical 252,254 

King Systems Corporation 227,229 


Lambda Beta Honor Society TBA 

Lemans Industries Corporation 568 

Letco Medical RHPA TBA 

Life Medical Pharmacy TBA 

Lippincott, Williams & Wilkins TBA 


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 


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 



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 


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 



Congress Exhibitors 






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 


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 


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 


Tee Time Inc TEA 

Thayer Medical Corporation TEA 

Thermo Respiratory Group Island 2 1 3 

TSI Incorporated 679 


Universal Hospital Services TEA 

University of Texas/M.D. Anderson Cancer Center TEA 


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 


Western Medical 456,458 

Western Michigan University TEA 

Westmed Inc 338 



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 

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 


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 

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 

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 



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. 

of Events 


September 14-15-Pittsburgh, 

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, 


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 

Septmiber 17-29— Hot Springs, 


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 @ Or visit www. 

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 

October ll-13-Bossier City, 

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 

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. 

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 

Practical Spirometry Certification 

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, 

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 


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 

□ Foreign 

D Physician 

n Industrial 
" Special 
II Student 

St Name _ 
St Nome 

cial Security No. 
>me Address 



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 Home Health Agency 

Z Educational Institution 

Z Manufacturer or supplier 

n Other, specify 

ite of Birth (optional) 

Sex (optional) . 

S. Citizen? 



ive you ever been a member of the AARC? __ 
o, when? From to 


Preferred mailing address: D Home D Business 

For office use only 


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, 


Place of Employment 





Phone No. 

Medical Director/Medical Sponsor 


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. 


Place of Employment 





Phone No. 


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 





Phone No. 

Length of program 

D 1 year 
n 2 years 

Expected Date of Graduation (REQUIRED 

D 4 years 

n Other, specify . 



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 


Full Time 


Part Time 














Less than $10,000 


$10,001 -$20,000 


$20,001 -$30,000 


$30,001 -$40,000 

n $40,000 or more 




D Perinotal/Pediatric 


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%. 


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) 


n Special 

$ 87.50 

n Student 

$ 45.00 



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 


OttAND TOTAL = Membership Fee 
plus optional seetions 












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 /_ 


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 



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) 


A. Patient information 

1 Patient identifier 

In confidence 

2 Age at time 
of event: 


of birtti: 

3 Sex 

I I female 
I I male 


4 Weigfit 


Triage unit 
sequence * 

. lbs 


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 

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.) 


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) 


2 Dose, frequency & route used 



3. Therapy dates (if unknown, give duration) 

Ifom/lo (or best eslimale) 


4. Diagnosis for use (indication) 

6. Lot # (if known) 



7. Exp. date (it known) 


9- NDC # (for product problems only) 

5 Event abated after use 
stopped or dose reduced 

«1 Dyes Dno D^gPPy"'' 

#2nyesnho Di^^Py"'' 

8 Event reappeared after 

#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 

model # _ 

catalog # 

serial # 


other # 

4 Operator of device 
I I health professional 
I I lay user/patient 
□ other: 

5. Expiration date 


7. If implanted, give date 


8. If explanted, give date 


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. 


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 

• 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 

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 











The FDA Medical Products Reporting Program 
Food and Drug Administration 
5600 Fishers Lane 
Rockville, MD 20852-9787 



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- 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 

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 

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- 

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; 

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 @ 


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 



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 


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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 

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What Matters in Respiratory Monitoring: 
What Goes and What Stays— Dean Hess PhD 
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Video August 22; Audio September 26 

Managing Asthma: An Update — ^Patti Joyner 
RRT CCM; Host, Mari Jones MSN RN RRT— 
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Routine Pulmonary Function Testing: Doing It 
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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 

in This Issue 

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in This Issue 

Beachey, Will 

Canfield Jr, James 

Casaburi, Richard 

Chitkara, Rajinder K 

Cunningham, Barbara A 

Daggett, Matthew 

Dunne, Patrick J 

Hotchkiss, John R 

Iwasaki, Dean 

Jain, Prasoon 

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Rau, Joseph L 962 

Salzman, Gary A 972 

Sarinas, Priscilla SA 953 

Smith, Dorsett D 975 

Stoller, James K 945 

Thaggard, Irene 945 

Wongsurakiat, Phunsup 973 

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