11 94

November 1994
Volume 39, Number 11

ISSN 0020-1 324-RECACP
RE/PIRATORy
A MONTHLY SCIENCE JOURNAL
39TH YEAR— ESTABLISHED 1956
Controlling Carbon Dioxide Delivery

during Mechanical Ventilation
Clinical Comparison of Two Aerosol

Holding Chambers: ACE vs
Aerochamber
Airway Compromise in Two Patients

with Aplastic Anemia and Coagulation
American Association for Respiratory Core Abnormalities
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1994 Open Forum Abstracts
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RE/PIRATORy C&RE
Monthly Science Joumal. Established 1956. Otiicial Journal of the American Association tor Respiratory Care
EDITORIAL OFFICE
Lane
11031) Atiles
Dallas TX
75229
CONTENTS November 1994
Volume 39, Number 11
1214)243-2272
EDITOR
Pal Brougtier BA RRT
ASSOCIATE EDITOR ORIGINAL CONTRIBUTIONS

Kaye Weber MS RRT
1039 Controlling Carbon Dioxide Delivery during Mechanical Ventilation
ASSISTANT EDITOR by Robert L Chatbum and Susan M Anderson — Cleveland. Ohio
Donna Stephens BBA
MANAGING EDITOR 1047 Clinical Coinparison of Two Aerosol Holding Chambers: ACE vs
Ray Maslerrer BA RRT
Aerochamber
EDITORIAL BOARD by Robert J Perry, Edward G Lcmgenback, and Jonathan S
Dean Hess PhD RRT. Chairman
Thomas A Barnes EdD RRT llowite —Stonv Brook, New York
Richard D Branson RRT
Crystal L Dunievy EdD RRT
G Durbin Jr MD
Charles
Thomas D East PhD TEST YOUR RADIOLOGIC SKILL
Neil R Maclntyrc MD 1051 Airway Compromise in Two Patients with Aplastic Anemia and
Shelley C Mishoe PhD RRT
Joseph L Rau PhD RRT
Coagulation Abnormalities
James K Stoller MD by Loretta D Gleaton and Frederick P Ognibene—Bethesda,
CONSULTING EDITORS Maryland
Frank E Biondo BS RRT
Howard J Birenbaum MD
Robert L Chatbum RRT
Patricia Ann Doorley MS RRT
CORRECTIONS
Donald R Elton MD 1050 Errors in Two CPGs Published in August (Neonatal Time-
Robert R Pluck Jr MS RRT Triggered, Pressure-Limited, Time-Cycled Mechanical Ventilation
Ronald B George MD
James M Hurst MD (Respir Care 1994;39(8):812-816] and Application of Continuous
Charles G Irvin PhD
Positive Airway Pressure to Neonates via Nasal Prongs or
MS Jastremski MD
Robert M
Kacmarek PhD RRT Nasopharyngeal Tube [Respir Care 1994;39(8):817-823]
Hugh S Mathewson MD
Michael McPeck BS RRT
David J Pierson MD
John Shigeoka MD BOOKS, FILMS, TAPES, & SOFTWARE
Jack Wanger MBA RPFT RRT 1057 Lung Function: Assessment and Application in Medicine, 5th edi-
Jeffrey J Ward MEd RRT
tion, by JE Cotes
JOURNAL ASSOCIATES reviewed by Charles G Inin — Denver. Colorado
Stephen M Ayres MD
Reuben M Cliemiaek MD
Donald F Egan MD 1057 Snoring and Obstructive Sleep Apnea, 2nd edition, by David NF
Gareth B Gish MS RRT
George Gregorv' MD Fairbanks MD and Shiro Fujita MD
Ake Grenvik MD reviewed by Timothy R Chappell — Piano, Texas
H Fredenck Helmholz Jr MD
John E Hodgkin MD
William F Miller MD
Thomas L Petty MD LETTERS
Alan K Pierce MD
Henning Pontoppidan MD 1058 Enors in August CPGs
John
Barry
W
Severinghaus
A Shapiro MD
MD by Stephen M Picca —East Meadow, New York
PRODUCTION STAFF
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Steve Bowden Denise Ditzenberger
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RESPIRATORY CARE • NOVEMBER "94 Vol 39 No 1 1021

Abstracts of Pertinent Arlicle
Editorials, Reviews, and Commentaries To Note
Neonatal Sedation: More Art Than Science (commentary) — AR Wolf. Lancet 1994:344:628.
(Pertains to the paper by Jacqz-Aigrain et al abstracted on Page 1022.)
Evolution of Therapy for Cystic Fibrosis— PB Davis. N Engl J Med 1994:331( 10):672. (Pertains to
the paper by Fuchs et al abstracted on Page 1026.)
Multisite Evaluation of a Continuous 3.3 mm Hg, and at pHa values of 7.23-7.57. and the pharmacological effect of the terbu-
Intraarterial Blood Gas Monitoring average bias and precision were 0.01 ± 0.04. taline in the inhaler were measured by scores
System —CP Larson Jr, J Vender. A Seiver. Observed drift per day was — 1.2% for arterial for inhalation technique and clinical response.
Anesthesiology 1994;81(3):543. Po;. 0.3 mm Hg for arterial Pco;. and 0.01 for None of the 3-year-old children used the de-
pH. Bias and precision for samples compared vice efficiently, but 43% of the 4-year-old,
BACKGROUND: We compared the perfor- in two pairs of like-model in vitro blood gas 67% of the 5-year-old. and 80% of the 6-year-
mance of a new. continuous intraarterial blood analyzers were 0.4 ± 4.6% for arterial Pq; old children used the inhaler correctly.
gas (CIABG) monitor with arterial values ob- over the full range, and 0.4 ± 3.7 mm Hg for Although inhaler technique was not perfect in
tained periodically and analyzed by conven- values less than 100 mm Hg, -0.5 ± 1.8 mm the younger age group, 50% of the 3-year-old
tional equipment. METHODS: A CIABG Hg for arterial Pco;. and 0.01 ± 0.01 for pHa. children demonstrated clinical improvement of
monitoring system consisting of a sterile, dis- Although the occasional marked discrepancies asthma symptoms after inhalation. In the older
posable, fiberoptic sensor and a microproces- between one or inore CIABG and in vitro val- age groups, 79%, 92%, and 100% of the 4-, 5-,
sor-controlled monitor with a self-contained ues could sometimes be corrected by flushing and 6-year-old children demonstrated clinical
calibration unit and detachable display panel the arterial catheter or repositioning the sensor, symptoms after in-
improveiTient of asthma
was used. The sensor was inserted through a usually we could not determine the cause of the halation. It is new mode of
concluded that the
20-G radial artery cannula. Light was transmit- discrepancy or which values were the more ac- dry powder delivery system (Bricanyl
ted from the monitor to the sensor tip where it curate. CONCLUSIONS: Over the range of Turbuhaler) can be used in young asthmatic
reacted with fluorescent dyes sensitive to oxy- values and under the clinical conditions stud- children who are 4 years of age and above.
gen or hydrogen ions (analytes). The change in ied, CIABG monitoring provides immediate
the intensity of the photoluminescent radiation blood gas results and trend information with Placebo-Controlled Trial of Midazolam
caused by the analytes was measured every 20 sufficient agreement with in vitro results to be Sedation in Mechanically Ventilated
s and derived blood gas values were displayed. reliable for decision making in most clinical —
Newborn Babies E Jacqz-Aigrain. P Daoud.
Twenty-nine sensors were evaluated in 29 sur- circumstances. Generally, the differences in P Burtin, L Desplanques. F Beaufils. Lancet
gical or intensive care unit patients at one of the values between the two methods of analy- 1994:344:646.
three institutions (Stanford University sis were the result of the combination of the in-
Hospital, Evanston Memorial Hospital, and the herent errors of each method. Additional stud- Although midazolam is used for .sedation of
Palo Alto Veterans .Administration Hospital). ies need to be undertaken to evaluate the per- mechanically ventilated newborn babies, this
The duration of study averaged 6 h (5-8 h) in formance of the CIABG monitor across wider treatment has not been evaluated in a ran-
the operating room, and 46 h (7-121 h) in the ranges of blood gas values, especially for arte- doiTiised trial. We have done a prospective
intensive care unit. A total of 552 values were rial Po; values less than 60 mm Hg and arterial placebo-controlled study of the effects of mi-
compared with those obtained at regular inter- Pco; values greater than 50 mm Hg. dazolam on haemodynamic variables and seda-
vals and analyzed in the hospital blood gas lab- tion as judged by a five-item behavior score.
oratory. Average bias (mean difference be- Assessment of the Ability of Young 46 newborn babies on mechanical ventilation
tween lab value and CIABG). precision (SD of Children To Use a Powder Inhaler Device for respiratory distress syndrome were ran-
difference), and drift (change in the bias with —
(Turbuhaler) A Gorcn, N Noviski, A domly assigned to receive midazolam (n = 24)
time) were determined. RESULTS: At arterial Avital, C Maayan, E Stahl, S Godfrey, C or placebo (n = 22) as a continuous infusion.
oxygen tension (Pq,) values of 32-528 mm Hg. Springer. Pediatr Pulmonol 1994:18:77. Doses of midazolam were calculated to obtain
the average bias was - % meaning1 that the plasma concentrations between 200 and 1000
average CIABG monitor values were 1% The puq»se of the study was to delermine the ng/niL within 24 h of starting treatment and to
lower than those obtained by conventional age at which young asthmatic children could maintain these values throughout the study.
equipment. The precision was 15%. At arterial master the use of a new powder inhaler device Haemodynamic and ventilatory variables were
Pf). values of 32-99 mm Hg, average bias and (Turbuhaler). We studied 59 children with noted every hour, as were complications and
precision were -0.3 ± 8.9 mm Hg. Al arterial asthma between the ages of 3 and 6 years who possible side-effects of treatment. Mean (SD)
carbon dioxide tension (Pco;) values of 24-54 consecutively attended the asthma clinic of the duration of inclusion was 78.7 (30.9) h. I pa-
mm Hg, average bias and precision were 1 .3 ± pediatric department. Efficiency of inhalation tient in the trealnienl group and 7 in the place-
1022 RESPIRATORY CARH • NOVEMBER "94 Vol .V; No

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ABSTRACTS
CAREER bo group were withdrawn because of inade- the questions of pressure limitation with or
quate sedation (p < 0.05). Midazolam gave a without hypercapnia. the pathophysiologic ef-
OPPORTUNITIES significantly better sedative effect than place- fects of hypercapnia, or the concept of ventila-
WITH bo, as estimated

0.05). Heart rate
by the behaviour score (p
and blood pressure were

<
re-
tor-induced parenchymal
Frequently cited references were preferentially
lung injury.
duced by treatment but remained within the included. DATA EXTRACTION: Data were
RESPIRONICS, normal range for gestational age and there was analyzed with particular emphasis on obtaining
no effect on ventilatory indices. The incidence the following variables from the clinical stud-
INC. of complications was similar in the two groups. ies: peak inspiratory pressures, tidal volumes,
No midazolam-related side-effects were noted. minute ventilation, and Pco;- Quantitative as-
Respironics a leader in the
Inc.,
Continuous infusion of midazolam at doses pects of respiratory physiology were used to
development of non-invasive
respiratory care technologies, adapted to gestational age induces effective se- analyze the theoretical effects of permissive
has career opportunities for Cli- dation in newborn babies on mechanical venti- hypercapnia on ventilatory requirements in
nicians, Sales Representatives, lation, with positive effects on haemodynamic normal and injured lungs. DATA SYNTHE-
and Engineers. Positions are variables. The course of the respiratory distress SIS: Extensive animal model data support the
available at our corporate head- syndrome was not influenced by this treatment. hypothesis that ventilator-driven alveolar
quarters located in the rolling Midazolam was given over only a few days overdislention can induce significant
foothills of the Allegheny Moun- and the limited effects on heart rate and blood parenchymal lung injury. The heterogeneous
tains, 20 miles east of Pitts- pressure that we report should not encourage nature of lung injury in adult respiratory dis-
burgh, Pennsylvania. National long-term administration. tress syndrome, with its small physiologic lung
and international opportunities
volume, may render the lung susceptible to this
exist for Sales Representatives.
The Effect of Frequency on Carbon Dioxide type of injury through the use of conventional
Consider a career with an out- Levels during High Frequency Oscillation — tidal volumes (10 to 15 mL/kg). Permissive hy-
standing organization that is V Chan, A Greenough. J Perinat Med percapnia is an approach whereby alveolar
based on teamwork, and a com- 1994;22:I05. overdislention is minimized through either
mitment to its customers and pressure or volume limitation, and the potential
employees. We offer competi- The aim of this study was to assess if, during deleterious consequences of respiratory acido-
tive salaries and benefits pro- high frequency oscillation (HFO), a frequency sis are accepted. Uncontrolled human trials of
grams, educational assistance, of 10 or 15 Hz was associated with lower car- explicit or implicit permissive hypercapnia
profitsharing, and the chance
bon dioxide levels. Twelve infants were re- have demonsttated improved survival in com-
to work with some of the finest
cruited, median gestational age 27 weeks. All parison with models of predictive mortality.
people in the industry.
infants were studied at both frequencies, ap- CONCLUSIONS: Avoidance of alveolar
you are interested, please
If plied in random order and the carbon dioxide overdislention through pressure or volume lim-
forward your resume to: level checked after 30 minutes on each fre- itation has significant support based on animal
quency. Carbon dioxide levels were lower in models and computer simulation. Deleterious
Respironics, inc. 10 of the 12 infants at 10 compared to 15Hz(p effects of the associated hypercarbia in severe
Human Resources < 0.004) and, in the study population, overall lung injury do not appear to be a significant
Department were significantly lower at 10 Hz (p < 0.05). limiting factor in preliminary human clinical
The difference in Paco: levels at the two fre- trials. Although current uncontrolled studies
1001 iVIurry Ridge Drive
quencies, however, was small, thus these re- suggest benefit, controlled trials are urgently
Murrysville, PA 15668-8550 sults suggest the clinician should rely primarily needed to confirm these findings before adop-
Attention: iVlJZ on changes in oscillatory amplitude, rather tion of the treatment can be endorsed.
A representative will be in touch than frequency, to effect changes in carbon

and, if possible, pre-schedule a dioxide levels. Impact of Quality-of-Care Factors on
meeting with you at the AARC Care Unit Mortality
Pediatric Intensive —
National Convention in Las Permissive Hypercapnia in Acute Respiratory MM Pollack, TT Cuerdon. KM Patel. UE
Vegas. Otherwise please stop Failure —A Bidani. AE Tzouanakis, VJ Ruttimann, PR Getson, M Levetown. JAMA
by the Respironics' hospitality Cardenas Jr, JB Zwischenberger. JAMA 1994:272:941.
suite to discuss what opportu- 1994:272:957.
nities we may have for you.A
OBJECTIVE: To determine the importance of
representative of our Human
OBJECTIVE: To evaluate the potential effica- the following care factors previously associat-
Resources Team
be avail-
will
cy of pressure limitation with permissive hy- ed with hospital quality on survival from pedi-
able to take resumes and an-
percapnia in the treatment of acute respiratory atric intensive care: size of the intensive care
swer your questions on Mon-
day, December 12, from 9 A.M. failure/adult respiratory distress syndrome on unit (ICU). medical school teaching status of
to Noon, and from 1 :30 P.M. to the basis of current theories of ventilator-in- the hospital housing the ICU, specialist status
5:30 P.M. and on Tuesday, De- duced lung injury, potential complications of (pediatric intensivist). and unit coordination.
cember 13, from 8:00 A.M. to systemic hypercarbia. and available human DESIGN: After a national survey, consecutive
Noon. Appointments may also outcome studies. DATA SOURCES: Articles case series were collected at 16 sites randomly
be made for Monday evening were identified through MEDLINE, reference selected to represent unique combinations of
and Tuesday afternoon. An citations of published data, and consultation quality-of-care factors. SETTING: Pediatric
Equal Opportunity Employer with authorities in their respective fields. ICUs. PATIENTS: Consecutive admissions to
M/F/D/V.
S TLIDY SELECTION: Animal model experi- each .site. MAIN OUTCOME MEASURE:
mcnlalion and human clinical trials were se- Patient mortality adjusled for physiologic sta-
Icclcd on the basis of whether thcv addressed tus, diagnosis, and other mortalitv risk factors.
RESPIRONICS INC.
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1
ABSTRACTS
RESULTS: There were 5415 pedialric ICU ad- of dying, 1.79: 95% confidence interval [CI|. be associated, or may be negatively associated,
ICU deaths. The ICUs dif-
missions and 248 1.23 to 2.61; p = 0.002). In contrast, the proba- with quality of care in specialized care areas,
fered significantly with respect to descriptive bility of patient .survival after hospitalization in including the pediatric ICU.
variables, including mortality (range. 2.2% to an ICU with a pedialric intensivist was im-
16.4<7r). Analysis of risk-adjusted inortality inproved (relative odds of dying, 0.65; 95% CI, Effect of Aerosolized Recombinant Human
dicated that the hospital teaching .status and the 0.44 to 0.95; p = 0.027 ). Post hoc analysis indi- DNase on Exacerbations of Respiratory
presence of a pediatric intensivist were signifi- cated that the higher severity-adjusted mortali- Symptoms and on Pulmonary Function in
cantly associated with a patient's chance of ty in teaching hospitals may be explained by Patients with Cystic Fibrosis— HJ Fuchs. DS
survival. The probability of patient survival the presence of residents caring for ICU pa- Borowilz. DH Christiansen, EM Morris. ML
after hospitalization in an ICU located in a tients. CONCLUSION: Characteri.stics indica- Nash, BW Ramsey, et al. for the Pulmozyme
teaching hospital was decreased (relative odds tive of the best overall hospital quality may not Study Group. N Engl J Med 1994;331(I0):637.
BACKGROUND; Respiratory disease in pa-

tients with cystic fibrosis is characterized by
airway obstruction caused by the accumulation
of thick, purulent secretions, which results in
PneuViet^
TESTING & TRAINING SYSTEMS
recurrent, symptomatic exacerbations. The
coelasticity of the secretions can be reduced in
vitro by recombinant human deoxyribonucle-
vis-
ase I (rhDNase), a bioengineered copy of the

human enzyme. METHODS: We pert'ormed a
randomized, double-blind, placebo-controlled
study to determine the effects of once daily and
twice-daily administration of rhDNase on ex-
acerbations of respiratory symptoms requiring
parenteral antibiotics and on pulmonary func-
tion. A total of 968 adults and children with
cystic fibrosis were treated for 24 weeks as
RESULTS: One or more exacerba-
outpatients.
tions occurred in27% of the patients given

placebo, 22% of those treated with rhDNase
once daily, and 19% of those treated with
Mech! 1 Ventilators... You've got questions. rhDNase twice daily. As compared with place-
bo, the administration of rhDNase once daily
and twice daily reduced the age-adjusted risk
We've Got Answers! of respiratory exacerbations by

and 37% (p
28%
< 0.01 respectively. The adminis-
),
(p = 0.04)
tration of rhDNase once daily and twice daily

When you deal with of questions come up.
ventilators, plenty
improved forced expiratory volume in one sec-
What kind of vent should we buy? How does this unit com-
ond during the study by a mean (±SD) of 5.8
pare to that one? How do we train people? What's the best way
± 0.7%. and 5.6 ± 0.7%. respectively. None
to test this equipment? How do I document my evaluation,
of the patients had anaphylaxis. Voice alter-
training, and testing? The PneuView System is the answer to
alion and laryngitis were more frequent in the
your questions. more than a vent tester. It's more than
It's a
rhDNase-treated patients than in those receiv-
training tool. PneuView pulls it all together!
ing placebo but were rarely severe and re-
Built around the most respected test lungs in the industry, solved within 21 days of onset. CONCLU-
PneuView lets you simulate a wide variety of patient condi- SIONS: In patients with cystic fibrosis, the ad-
tions. It lets you see what's happening at the patient (test lung), ministration of rhDNase reduced but did not
no matter what kind of ventilator you're using, and lets you eliminate exacerbations of respiratory symp-
document your results. PneuView gives you so much more toms, resulted in slight improvement in pul-
than other simulators, for less than you might expect. monary function, and was well tolerated.
You 'II find the Pneu View System indispensable!

Modeling the Severity of Illness of ICU
APPLICA riONS: Ventilator Testing Patients: A Systems Update —S Lemeshow,
• Cl/tssroow InstructionProduct Evaluation• J-RLe Gall. JAMA 1994;272;I049.
* Product Demonstration • Quality Assurance
OBJECTIVE: To review recent revisions of
For more iiifonmitioii aill: 800-5.50-99.59
systems for estimating the probability of hospi-
tal mortality of adult intensive care unit (ICU)
Michigan patients. Emphasis on comparison of compo-
Instruments nents of systems and potential uses. DATA
SOURCES: Published articles in which the
systems were presented. STUDY SELEC-
4717 Talon Court, S.E. • Grand Rapids, Ml 49512-5409 Phone 616-554-9696 TION: Aculc l>livsiiiloi;v and Chronic Health
• • Fax 616-554-3067

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1026 RESPIRATORY CARH • NOVEMBER "94 Vol .W No 1

Management Tools...
For A Better Respiratory Care Department
m
ABSTRACTS
Evaluation (APACHE HI). Simplified Acute SIONS: All models were based on rigorous re-
Physiology Score (SAPS 111. and Mortality search and reported performance is good. All
Probability Models (MPM II) are the major can be used to assist in assessing prognosis, to
severity systems for ICU patients. DATA EX- compare ICU performance, and to stratify pa-
TRACTION: Information on variables collect- tients for clinical trials. Direct comparison on a
ed in the systems, characteristics of databases common cohort is needed.
from which they were developed, and reported
performance of models were evaluated from Transmission of Mycobacterium tuberculosis
published articles. DATA SYNTHESIS: Associated with Air Travel —CR Driver, SE
APACHE III and SAPS II produce a score and Valway, WM Morgan, IM Onorato, KG
probability of hospital mortality based on Castro. JAMA 1994;272( 13): 10.^1.
worst values of several variables during the

first 24 hours in ICU. The MPM II system has OBJECTIVE: To investigate potential trans-
four models, one ICU admission and one at

at mission of Mycobacterium tuberculosis in air-
24. 48. and 72 hours into the ICU stay. The craft from a crew member with tuberculosis.
SAPS II and MPM II models can be imple- DESIGN: Retrospective cohort study and sur-
mented from published information. The vey. SETTING: A large US airline carrier.
APACHE III score can be calculated from PARTICIPANTS: A total of 212 crew mem-
published information; weights to convert bers and 59 passengers who were exposed to a
score to probability are proprietary. All report- crew member with tuberculosis during a poten-
ed good areas under receiver operating charac- tially infectious period (May through October
teristic curve. Goodness of fit was good for 1992). Comparison volunteer sample of 247
SAPS II and MPM II models and was not re- unexposed crew members. MAIN OUTCOME
poned for APACHE III models. CONCLU- MEASURES: Positive tuberculin skin test
EVERYONE'S CONCERN!
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ABSTRACTS
Changes in cardiac output were independent of with abnormal lungs treated with HBOi. For
lung compliance and concurrent vasoactive clinical reasons, we measured the PaO; of 24
drug support. No consistent ciiange was noted An Announcement Of Importance
patients treated with HBOi. We obtained arte-
in either blood pressure or heart rate. CON-
CLUSIONS: Lung hyperintlation is frequently
rial blood gas values from patients with lung to l{ESPifimYCMMw\mi
dysfunction (a/A < 0.75) prior to, during, and
not achieved by the manual technique.
after HBO;. The pre-HBO: a/A = 0.45 ±0.17 Effective with the November 1994 issue,
Significant changes in cardiac output can occur Williams & Wilkins will be the official advertis-
(mean ± I SD). During HBOi the a/A ranged
and appear to be related to the tidal volume ing sales representative for HSPKAJORY Cut.
from 0.7 to 0.8 depending on chamber pressure
rather than pressure generated.
and returned to the pre-HBOi baseline after Daedalus has selected Williams & Wilkins be-
Oxygen Tension of Patients with
.Arterial HBOi. We conclude the following: ( 1 ) The hy- cause of its international leadership and expe-
rience in medical and health science advertis-
.Abnormal Lungs Treated with Hyperbaric perbaric PjO;S of patients with a/A < 0.75 is
ing sales representation. We believe that this
Oxygen Is Greater Than Predicted LK — greater than expected. (2) However, the PaO: is
experience, coupled with the extra services
Weaver, S Howe. Chest 1994:106:1 134. lower than in patients with normal lung func- offered by Williams h Wilkins and their repu-
tion (a/A > 0.75). Possible explanations in- tation for being "advertiser friendly," will help
The arterial oxygen (O;) tension (Pao,) of pa- you succeed in the promotion of your prod-
clude improvement in ventilation/perfusion
tients with normal gas exchange treated with ucts and services.
matching, reduction of venous admixture,
hyperbaric oxygen (HBO:) can be predicted
and/or extraalveolar uptake of Oi. (3) Your new/ Advertising Representative is
from their pre-HBOi arterial to alveolar O:
Exposures to HBO: treatment pressures Gregory |. Pessagno
tension ratio (a/A) which remains constant up
greater than recommended by existing proto-
National Sales Manager, HSPKATORY On
to a PaO: of 2,000 mm Hg. We observed that (410)528-4218
the a/A could not be used to predict the PaO; of cols may be required in patients with impaired 428 E. Preston St.
patients with impaired gas exchange (reduced transfer of O: across the lung to achieve PaOjS Baltimore, MD 21 202-3993
pre-HBO: a/As) treated with HBOi. Our study similar to patients with normal lung function Fax (410) 528-4452
provides information about the PaO: of patients treated with HBOi.
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1030 RKSPIRATORY CARK NOVEMBER "94 Vol 39 No

For Patients Witti Asthma
Twice-Daily
Sere\^f
(solmeferol xinofoote)
Inhalation Aerosol
Morning and Evening Inhaiation
for Active Days and Restful Nigiits
SEREVENT is indicated for maintenance treatment of asttima and prevention of bronchospasm in

patients 12 years of age and aider with reversibie obstructive airway disease, inciuding patients witti
symptoms of nocturnal asttima, who require regular treatment witt) inhaled, short-acting B2-agonists.
Dosing should be two puffs (42 \jg) of SEREVENT inhalation Aerosol, twice daily, morning and evening,
approximately 12 hours apart.
IMPORTANT: SEREVENT should not be used to relieve acute asthma symptoms.

The most common drug-related adverse events reported in clinical trials were
headache (10%), tremor (3%), and cough (3%).'
Please consult Brief Summary of Prescribing Information on adjacent pages.

BRIEF SUMMARY Drug Interactions: Short-Acting Beta-Agonists: In the two 3-month, repetitive-dose
Serevent® tnals (n=
day, but
1
some
84), the mean
patients used
daily
more
need for additional beta2-agonist use
Eight percent of patients used at least eight inhalations per
was 1 to 1
clinical
V2 inhalations per
(salmeterol xinafoate) day at least on one occasion Six percent used 9 to 12 inhalations at least once. There were 15
Inhalation Aerosol patients (8%) who averaged over four inhalations per day Four of these used an average of 8 to
1 1 inhalations per day In these 1 5 patients there was no observed increase in frequency of car-
diovascular adverse events The safety of concomitant use of more than eight inhalations per day
Bronchodilator Aerosol
of short-acting beta2-agonists with Serevent" (salmeterol xinafoate) Inhalation Aerosol has not
For Oral Inhalation Only
been established. In 1 5 patients who experienced worsening of asthma while receiving Serevent
The following summary Inhalation Aerosol, nebulized albuterol (one dose in most) led to improvement in FEV, and no
is a brief only. Before prescribing, see complete prescribing information
in Serevent' Inhalation Aerosol product labeling increase in occun'ence of cardiovascular adverse events
Monoamine Oxidase Inliibitors and Tricyclic Antidepressants: Salmeterol should be adminis-
CONTRAINDICATIONS: Serevent' Inhalation Aerosol is contraindicated in patients with a history
tered with extreme caution to patients being treated with monoamine oxidase inhibitors or tncycllc
of hypersensitivity to any of the components.
antidepressants because the action of salmeterol on the vascular system may be potentiated by
WARNINGS; 1 Not for Use to Treat Acute Symptoms: Watch for Increased Need for Short-Actino these agents.
Beta ? -Aoonists: Serevent' Inhalation Aerosol should not be used to relieve acute asthma symp- Corticosteroids and Cromoglycate: In clinical trials, inhaled corticosteroids and/or inhaled
toms. If the patient's short-acting, inhaled beta^-agonist becomes less effective, e g , the patient cromolyn sodium did not alter the safety profile of Serevent Inhalation Aerosol when administered
needs more inhalations than usual, medical evaluation must be obtained immediately and concurrently.
increasing use of Serevent Inhalation Aerosol m this situation is inappropriate Serevent Inhalation Methylxanthines: The concurrent use of intravenously or orally administered methylxanthines
Aerosol should not be used more frequently than twice daily (morning and evening) (eg., aminophylline, theophylline) by patients receiving Serevent Inhalation Aerosol has not been
at the recommended dose When prescribing Serevent Inhalation Aerosol, patients must be completely evaluated In one clinical trial, 87 patients receiving Serevent Inhalation Aerosol 42
provided with a short-acting, inhaled betaj-agonist |e g ,
albuterol) for treatment of symptoms meg twice daily concurrently with a theophylline product had adverse event rates similar to those
that occur despite regular twice-daily (morning and evening) use of Serevent in 71 patients receiving Serevent Inhalation Aerosol without theophylline Resting heart rates
Asthma may deteriorate acutely over a period of hours or chronically over several days. In this were slightly higher in the patients on theophylline but were little affected by Serevent Inhalation
setting, increased use of inhaled, short-acting beta2-agonists is a marker of destabilization of Aerosol therapy
asthma and requires re-evaluation of the patient and consideration of alternative treatment regi-
Carcinogenesis, Mutagenesis, Impairment of Fertility: In an 18-month oral carcinogenicity
mens, especially inhaled or systemic corticosteroids. If the patient uses four or more inhalations
study in CD-mice, salmeterol xinafoate caused a dose-related increase in the incidence of
per day of a short-acting bela2-agonist on a regular basis, or if more than one canister (200
smooth muscle hyperplasia, cystic glandular hyperplasia, and leiomyomas of the uterus and a
inhalations per canister) is used in an 8-week period, then the patient should see the pliysician
dose-related increase in the incidence of cysts in the ovaries. A higher incidence of leiomyosarco-
for re-evaluation of treatment
mas was not statistically significant: tumor findings were observed at oral doses of 1 .4 and 10
2 Use With Short-Actinq Beta j -Aoonists, When patients begin treatment with Serevent
mg/kg. which gave 9 and 63 times, respectively, the human exposure based on rodent:human
Inhalation Aerosol, those who have been taking short-acting, inhaled beta2-agonists on a regular
AUC comparisons.
daily basis should be advised to discontinue their regular daily-dosing regimen and should be
Salmeterol caused a dose-related increase in the incidence of mesovarian leiomyomas and
use short-acting, inhaled beta^-agonists only for symptomatic relief if they
clearly instructed to
ovarian cysts in Sprague Dawley rats in a 24-month inhalation/oral carcinogenicity study Tumors
develop asthma symptoms while taking Serevent Inhalation Aerosol (see PRECALITIONS: Drug
were observed in rats receiving doses of 0.68 and 2 58 mg/kg per day (about 55 and 21 5 times
Interactions)
the recommended clinical dose [mg/m^]) These findings in rodents are similar to those reported
3. Serevent Inhalation Aerosol Is Not a Substitute for Oral or Inhaled Corticosteroids: Patients
previously for other beta-adrenergic agonist drugs The relevance of ttiese findings to human use
must be warned not to stop or reduce corticosteroid therapy without medical advice, even if they
IS unknown
feel better when they are lieing treated with Serevent
No significant effects occurred in mice at 2 mg/kg (1 3 times the recommended clinical dose
4- Do Not Exceed Recommended Dose: As with other beta-adrenergic aerosols. Serevent
based on comparisons of the AUCs) and in rats at 0.21 mg/kg (1 5 times the recommended clini-
Inhalation Aerosol should not be used in excess Fatalities have been reported in association with
caldose on a mg/m2 basis).
excessive use of inhaled sympathomimetic drugs Large doses of inhaled or oral salmeterol (12
Salmeterol xinafoate produced no detectable or reproducible increases in microbial and mam-
to20 times the recommended dose) have been associated with clinically significant prolongation
malian gene mutation No blastogenic activity occurred m vitro inhuman lymphocytes or
in vitro.
of theQTq interval, which has the potential for producing ventricular arrhythmias
in vivo in a rat micronucleus No effects on fertility were identified in male and female rats
test.
5. Paradoxical Bronchospasm: As with other inhaled asthma medications, paradoxical
treated orally with salmeterol xinafoate at doses up to 2 mg/kg orally (about 1 60 times the rec-
bronchospasm (which can be life-threatening) has been reported following the use of Serevent
ommended clinical dose on a mg/m^ basis)
Inhalation Aerosol If it occurs, treatment with Serevent Inhalation Aerosol should be discontinued
immediately and alternative therapy instituted Pregnancy: Teratogenic Effects: Pregnancy Category C: No significant effects of maternal
Immediate Hypersensitivity exposure to oral salmeterol xinafoate occurred in the rat at doses up to the equivalent of about
6, fieactions. Immediate hypersensitivity reactions may occur after
1 60 times the recommended clinical dose on a mg/m2 basis Dutch rabbit fetuses exposed to
administration of Serevent Inhalation Aerosol, as demonstrated by rare cases of urticaria, rash,
and bronchospasm. salmeterol xinafoate in ufero exhibited effects charactenstically resulting from beta-adrenoceptor
stimulation; these included precocious eyelid openings, cleft palate, sternebral fusion, limb and
PRECAUTIONS: paw flexures, and delayed ossification of the frontal cranial bones. No significant effects occurred
General: 1 Us e with Spacer The safety and effectiveness of Serevent®
or Other Devices: at 0,6 mg/kg given orally (12 times the recommended clinical dose based on companson of the
Inhalation Aerosol when used with a spacer or other devices have not been adequately studied. AUCs).
2 Cardiovascular and Other Effects: No effect on the cardiovascular system is usually seen New Zealand White rabbits were less sensitive since only delayed ossification of the frontal
after the administration of inhaled salmeterol in recommended doses, but the cardiovascular and bones was seen at 1 mg/kg given orally (approximately 1 .600 times the recommended clinical
central nervous system effects seen with all sympathomimetic drugs (eg , increased blood pres- dose on a mg/m2 basis) Extensive use of other beta-agonists has provided no evidence that
sure, heart rate, excitement) can occur after use of Serevent Inhalation Aerosol and may require these class effects in animals are relevant to use in humans There are no adequate and well-
discontinuation of the drug Salmeterol, like all sympathomimetic amines, should be used with controlled studies with Serevent Inhalation Aerosol in pregnant women. Serevent Inhalation
caution in patients with cardiovascular disorders, especially coronary insufficiency, cardiac Aerosol should be used dunng pregnancy only if the potential benefit justifies the potential risk to
arrtiythmias, and hypertension, in patients with convulsive disorders or thyrotoxicosis; and in the fetus.
patients who are unusually responsive to sympathomimetic amines.
Use in Labor and Delivery: There are no well-controlled human studies that have investigated
As has been described with other beta-adrenergic agonist bronchodilators, clinically significant effects of salmeterol on preterm labor or labor at term. Because of the potential for beta-agonist
changes in systolic and/or diastolic blood pressure, pulse rate, and electrocardiograms have interterence with uterine contractility, use of Serevent Inhalation Aerosol during labor should be
been seen infrequently in individual patients in controlled clinical studies with salmeterol restricted to those patients in whom the benefits clearly outweigh the risks
3. Metabolic Etfi;cts_ Doses of the related beta2-adrenoceptor agonist albuterol, when adminis- Nursing Mothers: Plasma levels of salmeterol after inhaled therapeutic doses are very low (85 to
tered intravenously, have been reported to aggravate pre-existing diabetes mellitus and ketoaci-
200 pg/mL) in humans. In lactating rats dosed with radiolabeled salmeterol. levels of radioactivity
dosis No effects on glucose have been seen with Serevent Inhalation Aerosol at recommended
were similar in plasma and milk. In rats, concentrations of salmeterol in plasma and milk were
doses Administration of beta2-adrenoceptor agonists may cause a decrease in serum potassi-
similar The xinafoate moiety is also transferred to milk in rats at concentrations of about half the
um, possibly through intracellular shunting, which has the potential to increase the likelihood of
corresponding level in plasma. However, since there is no expenence with use of Serevent
arrhythmias The decrease is usually transient, not requiring supplementation
Inhalation Aerosol by nursing mothers, a decision should be made whether to discontinue nursing
Clinically significant changes in blood glucose and/or serum potassium were seen rarely dur-
or to discontinue the drug, taking into account the importance of the drug to the mother Caution
ing clinical studies with long-term administration of Serevent Inhalation Aerosol at recommended should be exercised when salmeterol xinafoate is administered to a nursing woman
doses.
Pediatric Use: The safety and effectiveness of Serevent Inhalation Aerosol in children younger
Information for Patients: See illustrated Patients Instructions for Use. SHAKE WELL BEFORE than 12 years of age have not been established.
USING. Patients should be given the following information:
Not..fgr Use to Treat Acute Sympt oms: Serevent Inhalation Aerosol is not meant to relieve
Geriatric Use: Of the totalnumber of patients who received Serevent Inhalation Aerosol in all
1
clinical studies. 241 were 65 years and older Geriatric patients (65 years and older) with
acute asthmatic symptoms Acute symptoms should be treated with an inhaled, short-acting
reversible obstructive airway disease were evaluated in four well-controlled studies of 3 weeks'
bronchodilator that has been prescribed by a physician for symptom relief.
to 3 months' duration. Two placebo-controlled, crossover studies evaluated twice-daily dosing
2. Dj^Not Exceed Recommended Dose, The bronchodilator action of salmeterol usually lasts
with salmeterol for 21 to 28 days in 45 patients. An additional 75 geriatric patients were treated
for at least 1 2 hours therefore it stiould not be used more often than every 1 2 hours.
with salmeterol for 3 months in two large parallel-group, multicenter studies. These 120 patients
3. !Js_e with Other While using Serevent Inhalation Aerosol, other inhaled medi-
ti/ledications.
cines should be taken only as directed by the physician
experienced increases in AM
and PM peak expiratory flow rate and decreases in diurnal variation
in peak expiratory flow rate similar to responses seen in the total populations of the two latter
4. Use w ith Short-Acting. Inhjiled Bela-Agqnisis: While using Serevent Inhalation Aerosol,
studies The adverse event type and frequency in geriatric patients were not different from those
medical attention should be sought immediately if the short-acting bronchodilator treatment
of the total populations studied
becomes less effective for symptom relief, if more inhalations than usual are needed, or if more
No apparent differences in the efficacy and safety of Serevent Inhalation Aerosol were
Uian the maximum number of inhalations of short-acting bronchodilator treatment prescribed for
observed when genatrc patients were compared with younger patients in clinical trials As with
a 24-hour period are needed. II the patient uses four or more inhalations per day of a short-act-
on a regular basis, or
other bela2-agonists, however, special caution should be observed when using Serevent
ing beta2-agonist if more than one canister (200 inhalations per canister) is
an e-week period, then the patient should see the physician
Inhalation Aerosol in elderly patients who have concomitant cardiovascular disease that could be
used in for re-evaluation of treat-
adversely affected by this class of drug. Based on available data, no adjustment of salmeterol
ment
dosage in geriatric patients is warranted
Patients should be cautioned regarding potential adverse cardiovascular effects, such as palpi-
tations or chest pain, related to the use of additional beta2-agonist ADVERSE REACTIONS: Adverse reactions to salmeterol are similar in nature to reactions to other
5. Use of S y stemic or Inhaled Steroids Serevent Inhalation Aerosol
: does not replace oral or selective beta2-adrenoceptor agonists.e.. tachycardia; palpitations; immediate hypersensitivity
1
inhaled corticosteroids; the dosage of these medicines should not be changed and they should bronchospasm (see WARNINGS); headache; tremor: nervous-
reactions, including urticaria, rash,
not be stopped without consulting the physician, even if the patient feels better ness; and paradoxical bronchospasm (see WARNINGS)
6. Use for Exe rcise-Induced Bronchospasm: When using Serevent Inhalation Aerosol to prevent Two multicenter. 12-week, controlled studies have evaluated twice-daily doses of Serevent'
exercise-induced bronchospasm. the dose should be administered at least 30 to 60 minutes Inhalation Aerosol in patients 1 2 years of age and older with asthma The following table reports
before exercise. the incidence of adverse events in these two studies.
Serevenf^ (salmeterol xinafoate) Inhalation Aerosol

Adverse Experience Incidence In Two Large 12-Week Clinical Trials*
Adverse Event Type

1 994 Annual
Convention
By Tony Dal Nogare, MD
ARDS was originally described in 1967 and has

of the
since undergone much scrutiny. This review of
ARDS discusses the latest developments in risk
factors and treatment. Also covers the 5 diagnostic
American
criteria that must be present to make an accurate
diagnosis of ARDS, including clinical, Association for
radiographic, and physiologic criteria.
Item VT31 - VHS (60 minutes)

Respiratory Care
$35 (nonmember $40).
Add $3.25 for shipping. to be held in
Call (214) 243-2272 or e^
Fax your order to (214) 484-6010 Las Vegas, Nevada,
American Association for Respiratory Care
11030 Abies Ln., Dallas, TX
December
75229-4593
10-13,1994
With the
Information Get acquainted kit for RCPs
Service Card,
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Get the facts on all the • One Minute Asthma
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The computerized
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Information • Astlima Signs Diary sheet (1 /95)
Service Card does it all.
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s .
The lights went off and

stayed off.
On January 17, 1994 at 4:31 care for other patients, but one of the
a. m. , the lights went out at St. Adult Stars was ventilating a young
Johns Hospital in Santa Monica, woman with ARDS. She would not
California. A 6. 8 magnitude earth- have been a good candidate for
"
quake rocked the Los Angeles basin, sustained hand bagging.
shutting down both the hospital' Although natural disasters are the
main and auxiliary power units. exception, brown outs and power
"All of our ventilators stopped outages are occurring with increasing
operating, except for the Adult Stars frequency. Be safe with Infrasonics
. which didn't miss a breath, " said
. . Star ventilators. You' 11 have the
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nator for the hospital. "Not only did operation when the lights go off . .
this free personnel to hand bag and and stay off.
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Now
Learning Objectives for

Positive Pressure Ventilation
in the Home
The National Center for Home Mechanical Ventilation
announces the availability of "Learning Objectives for Positive
Pressure Ventilation in the Home." The 39-page listing of
potential educational objectives allows respiratory care
professionals to customize patient/care giver education based
upon needs The goal of these
of individual patients.
objectives is enhance the education of patients and care
to
givers in the home. Use of educational objectives will
enhance the safety and efficacy of home positive pressure
ventilation. The objectives have been developed with the
input of numerous health care professionals and
professional organizations. The objectives are available
from the National Center for Home Mechanical
Ventilation, 1400 Jackson Street, Room JlOSa,
Denver, CO 80206. Copies are $5.00 each,
which covers the cost of printing and postage.
Original Contributions
Controlling Carbon Dioxide Delivery during

Mechanical Ventilation
Robert L Chatburn RRT and Susan M Anderson RRT

BACKGROUND: Pediatric cardiac patients are sometimes given carbon dioxide (CO2)
postoperatively to manipulate pulmonary vascular resistance and thus reapportion pul-
monary and peripheral blood flow. We de\ ised a double-blender system for controlling
the delivered CO2 (Fdco:) and oxygen concentrations (Fdo;) and evaluated the utility of
a nomogram to predict blender settings for required gas concentrations. DESCRIP-
TION OF DEVICE: Two Bird 3800 MicroBlenders were connected in series. The first
(a) was supplied by CO2 and air and fed into the second blender (/3), which was also sup-
plied by O2. System equations were derived and a nomogram constructed to predict set-
tings for desired Fdcx): and Fdo: expressed as CO. % and O2 %. EVALUATION METH-
ODS: Values predicted using the nomogram were compared to measured values.
Analyzers were calibrated with standard gases. Blender calibrations were verified. Using
nomogram-derived blender settings. 4 levels of O2 (21. 40. 60, and 80% and 2 levels of
)
CO2 (25 or 30% ). in random order, were analyzed in triplicate. The mean and standard
deviation of differences (predicted - measured values) were used to estimate inaccuracy
intervals that would include 95% of future observations at the 99% confidence level.
EVALUATION RESULTS: The inaccuracy interval (mean difference ± 2.97 standard

CO2 % was 0.06 ± I.IO %. For O2 % the interval was 4.0 ± 2.94 %. CON-
deviations) for
CLUSIONS: The inaccuracy intervals for COi % and O2 % were clinically acceptable.
The nomogram should be an efficient bedside tool for the clinician, expediting system
setup and changes in the gas mixture. [Respir Care 1994;39( 1 1 ): 1039- 1046]
Background of (1 ) a patent ductus arteriosus, (2) adequate interatrial mix-

ing of blood, and (3) a balance between pulmonary (PVR)
Introducing small amounts of carbon dioxide (CO2) in in- and systemic (SVR) vascular resistance as reflected by a
spired gas before and after surgery can help to limit pul- PVRiSVR near unity. Because SVR is normally much
monary blood flow by increasing the pulmonary vascular re- greater than PVR. unequal pulmonary and systemic blood
sistance.' The survival of infants with hypoplastic left heart flow results in systemic hypoperfusion and metabolic acido-
syndrome (HLHS) is critically dependent upon the presence sis in children with HLHS. Jobes et al- have reported that the
most important physiologic variable in preserving an ade-

quate ratio of PVR to SVR is the maintenance of Paco: at or
Mr Chatburn is Instructor, Department of Pediatrics, Case Western
above 40 torr. Undesirable decreases in PacO: may occur dur-
Reserve University, and Director, Pediatric Respiratory Care,
ing induction of general anesthesia and during the transition
Rainbow Babies & Childrens Hospital, and Ms Anderson is a respira-
tory therapist. Pediatric Respiratory Care, Rainbow Babies &
from spontaneous to mechanical ventilation. Body surface
Childrens Hospital —Cleveland Ohio. cooling before bypass decreases the metabolic rate and CO:
production, which may further contribute to reduced PacO:-
A version of this paper will be presented by Ms Anderson during the Attempts to maintain PacO: at the desired level by reducing
RESPIRATORY Care OPEN FORUM at the 1994 AARC Annual tidal volume (Vj), respiratory rate (f), or both often result in
Meeting, to be held in Las Vegas, Nevada, December 10-13, 1994.
arterial desaturation.- It has been hypothesized that desatura-
tion occurs because of decreased functional residual capacity
Reprints: Robert L Chatburn, Director, PediaUic Respiratory Care,
(FRC), closure of small airways, atelectasis, and hypoxemia.-
Rainbow Babies & Childrens Hospital, 1 1 100 Euclid Ave, Cleveland
OH 44106. Maintaining FRC with appropriate Vj and f minimizes these

CONTROLLING CARBON DIOXIDE DELIVERY DURING MECHANICAL VENTILATION
. 1
CM
O
oo
0)
>
3
o
Setting (%)
10 CO2 Blender
a'
I
I
I '
I
'
I
'
M I ' I
'
I
' I ' I ' I I
'
10 5
Delivered CO2 (%)
Example
1 Draw vertical line through desired CO2 (eg, line a, a' at 7%).
2. Draw horizontal line through desired O2 (eg, line b, b' at 48%).
3. Draw line from intersection of first two lines to O2 Blender Setting scale (eg, line c, c' at about 50%). This line should be
parallel to CO2 Blender Setting scale and perpendicular to O2 Blender Scale.
4. Find isopleth closest to intersection of three lines. Read down along isopleth to CO2 Blender Setting scale (eg, 31%).
Fig. 2A. Illustration of the application of a nomogram for predicting oxygen and carbon dioxide concentrations for various settings of the dou-
ble-blender system.
RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 I04I

E
100 -^
90 —
80
^
o^
inspect for outliers and to check that measured values were not value - measured value, so that if the difference is positive we
associated witli the measurement level, as detemiined by a corre- can say that the predicted value overestimates the true value
lation coefficient.'" The hypothesis tliat the correlation coefficient and vice versa). Therefore, the error interval can be interpreted
was not different from zero was tested with Fisher's tiansforma- as an inaccuracy intenxd. The value of k in liquation 3 was se-
tion.'' Outliers were defined using a mcxiified Thompson t tech- lected froin standard tolerance limit tables" to include 95% of
nique^ as any value greater than 1 .9 standard deviations away future observations at the 99% confidence level. This value
from the mean value, based on a sample size of 24 and a 95% was 2.972 for a sample size of 24.
confidence level.
Results
Step 2. The construction of symmetrical enor intervals based on
standard deviations assumes that the data confomi to a nomial or The results of the blender calibration verification procedure
Gaussian distribution. This assumption was confimied using the are shown in Table 1 . Both blender dials tended to overesti-
Kolmogorov-Smimov test. mate the delivered oxygen concentration, particularly at the
higher concentrations. However, they were both within the

Step 3. Predicted values were compared to measured values by manufacturer's specification for maximum eiTor (±3%). With
calculating a statistic, similar to the method proposed by both blenders set at 21%, the measured Ot % was 21.8% and
Altman and Bland.' However, the "limits of agreement" con- CO: % was 0.
'^
the measured
cept proposed by these authors is only a point estimate, which
includes simplifications that may not always apply, particularly Table 1 . Results of Blender Calibration Verification Using Air and
for sample sizes less than 30.'' An alternative is to calculate an Oxygen Inputs (Manufacturer's Error Specification ±3%)
error inteival. '"
The error interval is based on the concept of
tolerance intervals, which are extremely important in evaluat-
ing production and quality in manufacturing and service indus-
tries."'- The error interval takes into account the uncertainty of
estimating sample mean and standard deviation. TTius. the gen-

eral form for an error interval (EI) comparing two values is
El = Xa ± kSDj. [.^1
where Xj is the mean value of the differences between

paired data, SDj is the standard deviation of differences, and
k is a constant whose value depends on the sample size, the
desired proportion of observations to be included in the error

interval, and the desired confidence level.
If the paired data are two measureinents of the same quanti-

ty made by two different measurement systems (neither of
which is assumed to represent the "true" value), then the error
interval can be inteipreted as an agreement inteiyal. An exam-

ple of this would be the comparison of blood gas values from
split samples assayed on two different analyzers. If the paired
data represent the comparison of a measured or estimated
value and a standard or assumed true value, then the error in-
terval can be interpreted as an inaccuracy intenxil. An exam-

ple of this would be the comparison of measured blood gas
values froin a tonometered blood sample with standard (ie,
theoretical) values based on barometric pressure and tonome-

ter-gas concentration.
In the study described here, the measurements made by gas

analyzers were assumed to represent the true gas concentra-
tions because they are u.sed to make clinical decisions. The
nomogram values were considered to be estimates of the true
values. Thus, the error interval was constructed using the dif-
ference between predicted and true values (ie, nomogram
0.75
0.5
0.25
-0.25
0.5
-0.75
-1
8-
)
APPENDIX
Derivation of Blender Equations for Delivering O2-CO2 Mixtures
Assumptions: Fo; of air = 0.2 1 Fco: of . air = 0.0. to carbon dioxide inputs. Using Equation A4, we estimated
that the actual flow of carbon dioxide through the blender
would be SS'/f of the expected flow if oxygen were con-
The equations for both blenders were deri\'ed from basic mass nected, due to carbon dioxide's higher density:
balance equations:
Vcartx,„d,o<,do = (0.85)(Va„). 1A51
(F0..I I V,„,) = (Fo;) (V<,xyEC„l+ (FO;) {V„„ lAl]
V,„, = (V„„,g,„) + (V,i,) |A2J

Substituting this result into Equation A2 and using A2 with
AI yields the equation for the CO2 (a) blender Fq,:
where F is ihe fractional eoncenlration and V is gas flo
_ 0.21(1 -setting)
Gas flow through a constriction is a function of density 0.822 -0.15 (setting)
and viscosity. If the constriction takes the form of an ori-
fice, as in the blenders, the density of the gas plays a domi- where "setting" refers to the Fo; setting of the blender expressed as
nant role in determining the rate of flow. For an ideal ori- a decimal fraction.
fice, across which the pressure difference is kept constant,

the following equations apply:' Substituting this result into Equation Al provides the O2
(P) blender Fq::
Vdensityofga [l-g setting] II -/3 setting] ^^„.„^_,,|)

F^,=
'^- 1.27(0.21
^ -
0.822 -0.15 a setting |A7]
if Gas A is passed through an ideal orifice in a meter cali-
brated for Gas B:

The Fco:S for the two blenders are derived in a similar
density of Gas B
fashion:
now A
ctual of Gas
.V densilv of Gas A
)(no / expected through B meter)
|A41
0.85 a setting -0.1 78
^0.822-0.15 a setting [A8]
The density of oxygen is 32 g/mol and its viscosity is
201 micropoises. The density of carbon dioxide is 44
_ (1-/3 setting) (0.85 g setting - 0. 1 78
g/iTiol with a viscosity of 148 micropoises. The viscosities '*^°'" ' 0.822-0.15 a setting |A9]
of the two gases are not very different to begin with and as-
suming that density dominates flow, we ignored viscous
effects on blender calibration when switching from oxygen A more complete derivation is available upon request.
1046 Ri;SPlRAI()RY CARE • NOVEMBER '44 Vol .V) No I 1

1
Clinical Comparison of Two Aerosol Holding Chambers:

ACE vs Aerochamber
Robert J Perry BS, Edward G Langenback PhD, and Jonathan S Ilowite MD
BACKGROUND: Aerosol holding chambers (HCs) have proven to be an effective
enhancement to the administration of aerosolized medications by metered-dose in-
haler (MDI). Recent bench tests demonstrating different performance characteris-

tics among HCs, which have unknown clinical relevance, suggest the need for pa-
tient studies to confirm the clinical effectiveness of each new HC-MDI combination.
We compared the Aerochamber with the Aerosol Cloud Enhancer (ACE) combined
with albuterol MDI in stable asthmatics. METHODS: Ten subjects were selected
whose FEV| volume exhaled in the first second of a forced exhalation) in-
(the
creased by at least15% following an albuterol aerosol. On separate study days, sub-
jects withheld asthma medications for 8 hours, then inhaled 2 puffs of albuterol
MDI (90 ng/puff) using both HCs. Patients performed FEVi before (pre) and at 30,
60, and 120 minutes after (post) albuterol. Pulse, blood pressure, and incidence of
side effects were recorded. Change in FEVj was expressed using "% possible"
FEVi [%possible = (pre - post FEV,)/(predicted - pre FEV,)]. RESULTS: Mean
(SD) % possible at t = 30, 60, and 120 minutes for ACE were 37.7 (10.1), 35.0 (12.6),
and 25.7(16.2) and for Aerochamber were 28.1 (14.6), 21.8 (20.3), and 25.4 (27.1).
The differences in % possible between ACE and Aerochamber were not statistically
signiHcant at any time period (p > 0.05, paired / test). CONCLUSIONS: Our results
confirm that the ACE- and Aerochamber-MDI combinations function comparably
in adult patients with stable asthma. On average, the difference between HCs was
also not clinically important. [Respir Care I994:39( 1 1 ): 1047-1050.]
Background chodilators, acommon therapy for asthma. A well-designed

HC eliminates most patient-generated errors (ie, poor coordina-
Aerosol holding chambers (HC) have been developed as an tion of MDI actuation and inhalation) that occur in use of
adjunct to metered-dose-inhaler (MDI) delivery of bron- MDI'" and that prevent aerosolized medication from reaching
the lungs. TTie HC should also minimize the deposition of drug
in the mouth and oropharynx' because of propellent evapora-
""
Mr Perry and Dr Lângeiiback ore from the Department of Medicine. tion and particle impaction (ie, with one-way valves^) that re-
Pulmonary Disease/Critical Care Division, State University of New duce the proportion of large nonrespirable particles and be-
York at Stony Brook, Stony Brook, New York. Dr Dowite is Director of cause it encourages slow inhalation of the medication.'''^ This is
Respiratory Care, Winthrop-University Hospital, Mineola, New York. typically achieved through the use of a flow sensor* that acti-
vates an audible warning (whistle) when the patient inhales at

This study was supported in part by Allen & Hanburys, Division of
maximum allowable
or above the manufacturer-determined in-
Glaxo Inc, Research Triangle Park, North Carolina, and by
spiratory flow. Other patient errors, such as failing to inhale the
Diemolding Healthcare Division. Canastota, New York.
medication, are only discouraged by devices that allow visual-
The authors have no fniancial interest in any of the products men- ization of the collapsing reservoir during inhalation."''^ Failure to
tioned in this paper or in any competing product. shake the MDI before use or to perform a sufficient breathhold
of the medication are. to date, not controlled by HC devices.
A version of this paper was presented by Mr Perry during the
The first HCs were well characterized in vitro and in vivo
Respiratory Care Open Forum at the 1993 AARC Annual
before being widely accepted.^'"'- New HC designs, howev-
Meeting, held in Nashville, Tennessee.
er, have been developed and distributed without thorough clin-
ical evaluation. In 1993 alone, we have seen at least two new

Reprints: Robert J Perry, SUNY at Stony Brook, Pulmonary
Disease/Critical Care Division, HSC-T-17 Room 040, Stony Brook HC models being marketed with little, if any, published evi-
NY 11794-8172. dence of clinical effectiveness. In order to receive the Food

I —
COMPARISON OF ACE TO AEROCHAMBER
and Drug Administration approval that allows them to be mar- Then a new MDI was shaken, primed with 2 puffs,''' attached
keted in the United States. HCs are characterized in vitro by to the HC, and placed in the subject's mouth. The HC was
assay of total deposition/dose (etficiency). particle size distri- then charged with 1 puff of aerosol, and the subject inhaled
bution, and amount of aerosolized drug exiting each device slowly from residual volume to total lung capacity, held his
under predetermined sampling conditions. When four HCs breath for 5 seconds, and then exhaled normally. The second
with substantial design differences were compared in this puff was inhaled after a 1 -minute rest. FEV] was measured at
manner using an albuterol MDl aerosol, the data reported in an 30, 60, and 120 minutes after the second puff. In addition,
abstract by Dolovich et al" demonstrated differences among pulse, blood pressure, and incidence of side effects (includ-
the devices. Unfortunately, many of the factors that contiibute ing tremors, nervousness, dizziness, nausea, or headache)
to the clinical effectiveness of various HCs are not known, and were recorded before and after bronchodilator. The albuterol
some that are known may not be taken into account during in- canister was saved for use on the subsequent HC study day.
vitro testing. Therefore, we believe that the clinical equivalen-
cy of a particular device must be directly ascertained in vivo. Table 1. Specifications of Holding Chambers Selected for Study
We selected two HCs. the Aerochamber and the ACE.

Aerochamber ACE
Dolovich et al" reported a 45'y^ difference in efficiency be-
Shape Tube Cone
tween these particular HCs using a 45 L/min sampling Chamber volume (mL) 140 160
flowrate. In our study, the HCs were combined with the same Flow sensor sensitivity* (L/min 156 32
albuterol MDI that was used in the in-vitro study, and our MDI interface Actuator + canister Canister only
suidy consisted of a clinical comparison in asthmatic subjects. Internal valve design Center opening Side opening
The results of this and other in-vivo studies, when compared to

those using in-vitro data, may enable us to determine the clini-
Bronchodilation was assessed by analyzing changes in
cal relevance of bench testing these devices.
FEV I
using an index, % possible FEV], calculated by divid-
ing the difference between baseline and post-albuterol FEV|
Methods
by the difference between the predicted and baseline FEV|
Following informed consent and physical exam, potential

and multiplying by 100% — (pre - post )/( predicted - pre) X
subjects — stable adult asthmatics —were screened to docu-
100%.""' This method of analysis has been reported
most accurate way of comparing ITiVi
to be
were excluded the data.'^

ment reversible airway obstruction. Subjects
if they had an upper respiratory infection; had been hospital-
% possible FEVi was statistically compared between de-
ized for asthma within the past 30 days; had emphysema, vices using a paired Student's / test. '^ Probability values <
chronic bronchitis, significant cardiovascular, hepatic or 0.05 were considered significant. A post-hoc power analysis
renal disease, or a metabolic disorder; were current smokers; was also performed to detemiine how sensitive our study
or were pregnant. The best of 3 trials to perform FEVi was was for detecting a meaningful difference between the two
our measure of reversibility and was made before (pre) and at HCs.
30, 60, and 120 minutes after (post) administration of al-
buterol using a small volume nebulizer (SVN)-compressor Results
combination.* Subjects had not taken any asthma medica-

tions for 8 hours prior to screening or HC study. Of the 12 subjects screened, 2 did not achieve a 15% in-
For the HC study, subjects arrived at the study site at the crease in FEV] after albuterol by SVN, and 10 subjects qual-
same time of day for each of two study days. They received ified for the study and completed the study protocol. Table 2
instruction and were allowed to practice to ensure conect HC describes the characteristics of this group of patients. Mean
technique. Most subjects initially triggered the flow sensor of values for % possible FEVi over time are shown in Figure 1.
the ACE and were instructed to reduce their inspiratory No differences were statistically significant for any time pe-
flowrate so as not to trigger the flow sensor. None triggered riod. The probabilities from the paired t test on ACE vs
the Aerochamber flow sensor. Aerochamber at 30 minutes was 0.068. at 60 minutes 0.056,
Using a randomized crossover study design, we then ad- and at 1 20 minutes 0.962. A post-hoc power analysis .showed
ministered 2 puffs of albuterol by MDI (90^g/puff) using the an 80% chance of detecting a 13% difference between %
ACE or Aerochamber HC. Specifications of the two HCs se- possible FEV|S (for each HC) at the 0.05 level of signifi-
lected for clinical evaluation are given in Table 1. Baseline cance. No patient experienced a significant change in heart
rev was I
performed, and the best of 3 efforts is reported. rale or blood pressure after bronchodilator by any method.
The incidence of side effects was minimal, with 1 patient ex-
*Manufacturers and suppliers are identified in the Product Sources sec- periencing headache and 1 patient experiencing dizziness
tion at the end of the text. both with albuterol by SVN.
1048 RESPIRATORY CARE • NOVEMBER "94 Vol 39 No

Table 2. Mean (SD) Values for Patient Characteristics Prior to Study
Variable
.
InspirEase im the deposition of inetercd-dose aerosols in the human available from four MDl add-on devices (abstract). Am Re\ Respir
Inspiratory tract. Chest 1986:89(4):551-556. Dis 1993;I47:A996.
Newman SP. Millar AB, Lennard-Jones TR. Moren F. Clarke SW. Blake KV. Harman E. Hendeles L. Evaluation of a generic albuterol
ImproveiTient of pressurised aerosol deposition with Nebuhaler spacer metered-dose inhaler: importance of priming the MDl. Ann Allergy
device. Thorax 1 984;39( 2 ):935-94 1
1 1992:68(2): 169- 174.
Lawford P, McKenzie D. Does inspiratory flow rate affect bron- Knudson RJ, Slatin RC. Lebowitz MD. Burrows B. The maximal ex-
chodilator response to an aerosolized ft agonist (absu-act)'.' Thorax piratory flow-volume curve: normal standards, variability, and effects
1981:36:714. of age. Am Rev Respir Dis 1976:1 13(5):587-6(X).
Newman SP, Pavia D. Clarke SW. Simple instructions for using pres- Knudson RJ, Lebowitz MD, Holberg CJ, Burrows B. Changes in the
surized aerosol bronchodilators. J R Soc Med 1980:73( I 0:776-779. normal maximal expiratory flow-volume curve with growth and
Perry RJ, Langenback EG. Bergofsky EH. llowite JS. Differences in aging. Am Rev Respir Dis 1983:127(6):725-734.
aerosol holding chamber flow sensors may alter MDl therapeutic ef- Dompeling E. van Schayck CP, Molema J, Akkermans R, Folgering
fect (abstract). .-Xm Re\ Respir Dis 1993:147(4. Part 2):A996. H, van Grunsven PM, van Weel C. A comparison of six different
Vichyanond P. Chokephaibulkit K, Kerdsomnuig S. Visitsuntom N, ways of expressing the bronchodilating response in asthma and
Tuchinda M. Clinical evaluation of the "Siriraj Spacer" in asthmatic COPD: reproducibility and dependence of prebronchodilator FEV|.
Thai children. Ann Allergy 1992:69(5):433-438. Eur Respir J 1992;5( 81:975-981.
Corr D. Dolovich M. McCormack D. Ruffm R, Obminski G. "Student." The probable error of the mean. Biometrika 1908:6:1.
Newhouse M. Design and characteristics of a portable breath actuated, Blake KV, Hoppe M, Harman E. Hendeles L. Relative amount of al-
particle size selective medical aerosol inhaler. J Aerosol Sci buterol delivered to lung receptors from a metered-dose inhaler and
1982;13:1-7. nebulizer solution: bioassay by histamine bronchoprovocation. Chest
Tobin MJ. Jenouri G. Dania I. Kim C, Watson H, Sackner MA. 1992:101(21:298-299.

Response to bronchodilator drug administration by a new reservoir Crimi N, Palermo F, Cacop;irdo B. Vancheri C, Oliveri R. Palermo B.
aerosol delixen, system and a review of other auxiliary delivery sys- Mistretta A. Bronchodilator eft'ect of Aerochamber and Inspirease in
tems. Am Rev Respir Dis 19S2: 26(4):670-675.
1 comparison with metered dose inhaler. Eur J Respir Dis
Dolovich M, RufUn R, Corr D. Newhouse MT. Clinical evaluation of 1987:71(31:153-157.
a simple demand inhalation MDl aerosol delivery device. Chest Nelson HS, Loffert DT. Comparison of the bronchodilator response to
1983:84(l):36-4i. metered dose inhaler ( MDl ) alone or with the Aerochamber or opti-
Dolovich M. Chambers C, Mazza M. Newhouse MT. Albuterol dose haler (abstract). J Allergy Clin Immunol 1993,91 ; 167.
CORRECTIONS
Errors were made in two Clinical Practice Guidelines printed in the August issue.
In the AARC Guideline: Neonatal Time-Triggered, Pressure-Limited, Time-Cycled Mechanical Ventilation

Section 1 3. 1 states "The Clinical Practice Guideline: Ventilator Circuit Changes, the CDC. and reported experi-
ence suggest that use periods of < 5 days are acceptable when the humidifying device is other than an aerosol
generator." Section 13. 1 should have read "suggest that use periods of > 5 days are acceptable when the humid-
ifying device is other than an aerosol generator." [Error occurred on Page 812.]
In the AARC Guideline: Application of Continuous Positive Airway Pressure to Neonates via Nasal Prongs or
Nasopharyngeal Tube Section 13.2 states "The Clinical Practice Guideline: Ventilator Circuit Changes, the
CDC, and reported experience suggest that use periods of < 5 days are acceptable when the humidifying device
is other than an aerosol generator." Section 13.2 should have read "suggest that use periods of > 5 days are ac-
ceptable when the humidifying device is other than an aerosol generator." j Error occurred on Page 820.]
Clinical Practice Guideline reprints have been coirected. We regret the errors.
1050 RESPIRATORY CARE • NOVEMBER '94 Vol M) No I

1
Test %ur
Patricia A Doorley MS RRT and Charles G Durbin Jr MD. Section Editors Radiologic Skill
Airway Compromise in Two Patients with Aplastic Anemia

and Coagulation Abnormalities
Loretta D Gleaton BA RRT and Frederick P Ognibene MD
Case Summaries low secretions and of "pain in her neck." Her physical exam-
ination was negative for stridor, neck swelling, and tracheal
A 49-year-old Caucasian woman (Patient A), with a his- deviation. A lateral-neck radiograph (Fig. 1) was performed,
tory of aplastic anemia, presented to the Warren G and she was transferred to the medical intensive care unit.
Magnuson Clinical Center of the National Institutes of Another patient, admitted to our center, was a 5 -year-old
1
Health for the administration of anti-thymocyte globulin African- American woman (Patient B) admitted for adminis-
(ATG), cyclosporin A, and glucocorticosteroid therapy. Her tration of ATG, cyclosporin A, and glucocorticosteroids for
physical examination on admission revealed oral mucosal treatment of apla.stic anemia. Physical examination revealed
bleeding, facial ecchymoses. and menorrhagia. Laboratory vaginal and rectal bleeding. Her admission platelet count was
tests revealed a hemoglobin of 8.7 g/dL and a platelet count 3,000/mm' and hemoglobin 6.5 g/dL. Blood culture was pos-
of 3,000/mm\ In addition, blood cultures were positive for itive for Bacteroides fragilis and Clostridium species. Prior
an a-hemolytic streptococcus. On the fourth day after admis- to receiving her immunosuppressive therapy, she was admit-
sion, she continued to have vaginal bleeding with sponta- ted to the medical intensive care unit for placement of a cen-
neous mucosal hemorrhage, oral hematomas, and a new right tral venous catheter necessary for administration of ATG, cy-
periorbital hematoma. She complained of inability to swal- closporin A, glucocorticosteroids, and antibiotics. The right
internal jugular vein was cannulated instead of the femoral

vein because of the femoral vein's proximity to the gastroin-
testinal tract and the uterus, the presumed origins of her bac-
Ms Gleaton is a critical care respiratory therapist and Dr terial infection. One posterior and two anterior approaches
Ognibene is Medical Director, Critical Care Section, Warren G were attempted without adequate blood return. A small
Magnuson Clinical Center of the National Institutes of Health,
hematoma developed in her neck, and local pressure was ap-
Bethesda, Maryland.
plied over the sternocleidomastoid region for approximately
3 minutes. Swelling continued to develop progressing to the
Reprints: Loretta D Gleaton BA RRT, Critical Care Medicine
Department, Warren G Magnuson Clinical Center, National suprasternal notch and then to the contralateral side from the
In.stitutes of Health, 10 Center Drive, MSC 1662, Building 10, clavicle to the angle of the right jaw. An anteroposterior
Room 7D43, Bethesda MD 20892-1662. chest radiograph was performed (Fig. 2).
How would you answer these questions?
What abnormalities are present in both Figures 1 and 2?
What diagnoses should be considered based on Figures 1 and 2';

TEST YOUR RADIOLOGIC SKILL
Fig. 1. Lateral-neck radiograph of Patient A

who complained of dysphagia.
What tiiilher testing would be appropriate to confirm the diagnosis?
What are the appropriate interventions for both of these patients? .
1052 RKSPIRATORY CARL • NOVEMBER "94 Vol 39 No I

Fig. 2. Anteroposterior sitting chest radio-

graph of Patient B after cannulation of the
right-internal-jugular vein.
Answers and Discussion on Next Page
^ J| Learn the
Mechanics of Mechanical Ventilation

Explains how physical and mathematical models are developed and
Noniiorino Respiraiorij applied, how such models are incorporated into ventilator design to
provide estimates of mechanics, and some of the problems that can
Neclionics Durinp develop because of the limitations of the models. Chatburn points out
that lack of consistency among manufacturers in the way in which
NeclianicolVenhlotion compliance and resistance ore measured and temperature
conversions are applied and how the lack of published accuracy and
By Robert L. Chatburn, RRT precision information make data interpretation difficult.
Item VT30 — VHS (60 minutes), $40 (AARC Member $35).

Add $3.25 for shipping.
Call (214) 243-2272 or Fax Your Order to (214) 484-2720 • American Association for Respiratory Care 11 030 • Abies Lane, Dallas, TX 75229-4593
RESPIRATORY CARE • NOVEMBER '94 Vol 39 No II 1053

1
plished by physical examination and assessments of respira-

tory distress and the ability to swallow. Serial lateral-neck
and chest radiographs should be obtained as well.
Oxyhemoglobin saturation by pulse oximetry (SpO:) may be
useful in assessing oxygenation. Supplies for endotracheal
intubation, with or without fiberoptic bronchoscopy, should
be readily available in case an emergency intubation is re-
quired.
Assessments of chest retractions, dyspnea, tachypnea, and
stridor are required to identify impending respiratory failure.
Radiographs are valuable for determining the size and loca-

tion of obstruction. Lateral-neck radiographs offer discrimi-
nating views of the hyoid bone and esophagus.

Anteroposterior chest radiographs reveal tracheal deviation
or compression. Upper airway landinarks inay be obscured
when laryngoscopy is attempted; therefore fiberoptic bron-
Fig. 3, Computerized transaxial tomography scan of Patient A. The choscopy may facilitate a difficult endotracheal intubation.
section is taken through the larynx and shows a 3-cm hematoma (A)
Bronchoscopy may also be used as a diagnostic tool and to
deviating the trachea anteriorly and compressing It to less than half
examine the degree of swelling in the retropharyngeal space,
its normal size. Other structures are labeled to show (B) the trachea,
assessing the trachea's size for evidence of external compres-
(C) a vertebral body, and (D) the hyold bone.
sion.
Patient A was given 50% oxygen via aerosol face mask.

Her rhythm and SpO: were monitored continu-
heart rate and
Answers
ously, and daily lateral-neck and chest radiographs were ob-
tained. Two days after admission to the intensive cai"e unit,
Radiographic Finding: Figure 1 shows a letrophaiyngeal
the patient expectorated a large blood clot. The lateral-neck
mass that impinges on the trachea and bilateral interstitial
radiograph showed improvement with a patent airway (Fig.
reticular infiltrates. Figure 2 reveals a widening of the superi-
4).
or mediastinum with narrowing and displacement of the tra-
Patient B was orally intubated by direct laryngoscopy due
chea toward the left. The extrathoracic airway appears to be
to increasing stridor and dyspnea. The intubation was facili-
compressed.
tated by the use of a short-acting sedative to help relieve anx-
iety and to facilitate visualization of upper airway structures.

Diagnosis: The probable diagnosis in Figure 1 is a
Her course of therapy was further complicated by pneumoni-
hematoma formation in the soft tissues of the neck secondaiy
tis, hepatic and renal dysfunction, and hyperglycemia. The
to bleeding. In Figure 2, the widening of the mediastinum is a
and expired.
patient experienced cai'diac airest
result of soft-tissue swelling due to bleeding.
Discussion
Diagnostic Confirmation: Further testing with computer-
ized transaxial tomography (CTT) scans of the neck should Aplastic anemia is a disease resulting from failure of the
yield a more definite evaluation (Fig. 3). These scans are fre-
bone miirrow to produce adequate numbers of eiythrocytes,
quently used diagnostically because of their fine soft-tissue leukocytes, and thrombocytes. This disorder may be caused
discriininating capabilities. Although examination with oral by drags, chemicals, or viral agents that may directly or indi-
contrast medium is useful in determining esophageal versus rectly damage the bone m;uT0w. leading to pancytopenia. The
tracheal involvement. Patient A's CTT .scan was perfonned main causes of death from aplastic anemia iue hemonhage
with intravenous contrast because of her dysphagia. Figure ?>
and infection. Therefore, the goals of therapy iue manage-
shows soft-tissue fullness posterior to the trachea and withui ment and prevention of bleeding and infectious complica-
the retropharyngeal tissues. tions, pending bone manow reccwery.'
These patients generally require frequent transfusions of
Action and Therapy red cells and platelets. Due to the frequent transfusions and
the common need for parenteral therapies, a central venous
The initial appropriate intervention in a patient with soft- catheter may be indicated. Percutaneous catheters have been
tissue swelling and bleeding into the retropharyngeal space is incriminated as sources of infection and hematoma fonna-
to moniior the [xilient's airway patency. This is accom- tion.' AlteiUion to site selection for peivutaneous catheteri/a-
1054 RHSPIRATORY CARH • NOVEMBER '94 Vol 39 No 1

1 .
Fig. 4. Lateral-neck radiograph of Patient A

after expectoration of a large blood clot. Tfie
appearance of tfie airway fias improved
from Figure 1
tion and platelet transfusion prior to catheterization may re- in the neck after two attempts had been made to cannulate the
may be more likely right internal jugular vein.' Genovesi and Simmons*" reported
duce complications.- Such complications
immunosuppressed patients.- on a patient who had been taking oral anticoagulants and de-
to occur in
The internal jugular vein may be the best route for central veloped bleeding into the retropharyngeal space after a sneez-
venous catheterization. If there is evidence of local bleeding, ing episode. For 3 days, the patient complained of sore throat
good hemostasis can usually be achieved by local compres- and dysphagia and subsequently required a tracheotomy be-
sion. This approach also avoids the pleura and subclavian ar- cause of sudden difficulty breathing.^
The retropharyngeal space lies between the pharynx and
teries, and the right internal jugular vein has an anatomically
As a consequence, this cervical spine and allows the pharynx to move during swal-
direct pathway into the right atrium.
lowing.' Bleeding into and subsequent hematoma formation
site also has a lower risk of pneumothorax and hemothorax.""*
Two previous case reports of upper airway obstruction within the retropharyngeal space can occur easily. Caregivers
secondary to abnormal coagulopathies have been published. must have knowledge of various emergency airway tech-
Knoblanche' reported complications from intemal-jugular- niques to prevent life-threatening emergencies caused by
vein cannulation that precipitated the requirement for endo- masses in this space. Endotracheal intubation via the oral or
hematoma nasal route may be facilitated with the use of a fiberoptic
tracheal intubation. One patient developed a large
1055
RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1
1
bronchoscope. In circumstances in which laryngoscopy is not airway. When positioned properly, the mouth and nasal cavi-
successful, cricothyroidotomy, tracheotomy, and translaryn- ties are sealed, a pharyngeal balloon blocks the oropharynx,
geal intubation may be successful. An esophageal-tracheal and a distal cuff blocks the esophagus. This helps ensure ade-
tube (Combitube. Sheridan Catheter Corp, Argyle NY) may quate ventilation and protection from pulmonary aspiration
'-
be used to stabilize the airway until conditions are better con- of gastric contents.**
trolled and a more definitive method of airway protection can We present just a few of the techniques that may be em-
be established. ployed in managing difficult airways due to obstruction by
The main objective in management of upper airway ob- hematoma. It is important for health-care professionals to
struction is to gain control of the airway by bypassing the ob- recognize impending airway emergencies and to act quickly.
struction.* Oral intubation by laryngoscopy is the most fre- Retropharyngeal hematomas are not uncommon occurrences
quently employed method. This technique allows the clini- in trauma patients with cervical or spinal injuries. The cases
cian to visualize the upper airway structures; however, it also we present are unusual because the threat to the patient's air-
causes the greatest stimulation of airway reflexes. The use of way was secondary to a bleeding disorder. The outcome for
intravenous sedation helps relieve the patient's anxiety and each patient was different, but careful attention to ensuring
maintains lower esophageal tone. Risks associated with oral airway patency was required and appropriate in both cases
endotracheal intubation apply to all patients and include po- for management of upper airway obstruction.
tential injuries to the lip, palate, and teeth.*'"

Blind nasotracheal intubation does not require visualiza- REFERENCES
tion of vocal cords but may cause tissue trauma with a risk of
1. Young NS. Alter PA. Aplastic anemia acquired and inherited.
aspiration from bleeding or rupture of hematoma," and in our
Philadelphia: WB Saunders Co, 1994:3-19.
unit is not recommended in patients with thrombocytopenia
2. Matsumoto T. Simonian S. Kholousy AM. Manual of vascular ac-
or coagulopathy. Fiberoptic bronchoscopy is the most useful cess procedures. Norwalk: Appleton-Century-Crofts, 1987:59-75.
aid for managing difficult airways. The bronchoscope func- 3. Sladen A. Invasive monitoring in the intensive care unit. St Lxiuis:
tions as a stent over which to guide the endotracheal tube CVMosby. 1990:110,115.
4. McGee WT, Mallory DL. Cannulation of the internal and external
through the mouth or nose. In addition, the bronchoscope pro-
jugular veins. In: Kirby RR. Taylor RW. eds. Problems in critical
vides improved visualization of upper airway structures, and
care: vascular cannulation. Philadelphia: JB Lippincott,
may help prevent local tissue damage.**' However, intubation 1988:221,223.
using fiberoptic bronchoscopy is not always an option due to 5. Knoblanche GE. Respiratory obstruction due to haematoma fol-
lowing internal jugular vein cannulation (letter). Anaesth Intensive

the availability of equipment and the expertise required to
Care 1979:3:286.
pyerform it.
6. Genovesi MG, Simmons DH. Airway obstruction due to sponta-
Cricothyroidotomy and tracheotomy may not be practical neous reU'opharyngeal hemorrhage. Chest 1975;68(6):840-842.
solutions for bleeding and edematous neck obstructions be- 7. Kuhn JE, Graziano GP. Airway compromise as a result of retropha-
cause landmarks may be distorted due to the hematoma and ryngeal hematoma following cervical spine injury. J Spinal Disord
1991;4(3):264-269.
swelling. There is also a risk of development of further hemor-
8. Barratt GE, Coulthard SW. Upper airway obsUTJCtion: diagnosis
rhage, incorrect placement of tracheotomy, pneumothorax,
and management options. Contemp Anesth Pract 1987:9:73-96.
and subcutaneous emphysema.** However these techniques are 9. Benumof JL. Management of the difficult adult airway.
recommended as adjuncts for emergency airway management. Anesthesiology 1 99 1 :75( 6): 1 087- 1 1 1 0.
Translaryngeal intubation is a retrograde technique ac- 10. Somerson SJ, Sicilia MR. AANA journal course: update for nur.se
complished by passing a guidewire through the cricothyroid

anesthetists —beyond the laryngoscope: advanced techniques for
difficult airway management. AANA -J 1993 ;6 1 ( 1 ):64-7 1 quiz 7 1 -

;
membrane, and then advancing it cephaladly until it emerges 72.

from the mouth or one of the nares. The proximal and distal 11. Woodmansee VA. Rodriguez A, Mirvis S, Fitzgerald B.
wire ends are pulled tightly, and an endotracheal tube is guid- Genioglossus hemorrhage after blunt facial U-auma. Ann Emerg
ed into the larynx. Application of the Combitube has been de-

Med 1992;21(4):440-444.
12. Klauser R. Roggla G. Pidlich J. Leithner C, Frass M. Massive
scribed as a relatively quick and easy procedure for temporary
upper airway bleeding after thrombolytic therapy: successful air-
airway management. The Combitube is a double-lumen tube way management with the Combitube. Ann Emerg Med
resembling an endotracheal tube and an esophageal obturator 1992:21(41:431-433.
1056 RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1

a
Listing and Reviews of Books and Other Media

Books, Films,
Tapes, & Software
Note to publishers: Send review copies of books, films, tapes, and software to
RESPIRATORY CarE. 1 1030 Abies Lane, Dallas TX 75229-4593.
Lung Function: Assessment and Application pointing part was the superficial way that to summarize the te,sL Although some of the fig-
in Medicine, 5th edition, by JE Cotes DM DSc. flow-volume and volume-time issues were ures are good, others are difficult to interpret
Hardcover, illustrated, 768 pages. Oxford: covered in only 2 pages of a chapter that is 50 In summary, this is the fifth edition of a clas-
Blackwell Scientific Publications, 1993. pages long. Peak flow is given 1 paragraph, sic book on lung function, but it lack-s a certain
$135.00. hardly in line with its current importance, degree of polish. At best, this is a better than av-
when work of breathing got 2 pages and a fig- erage book on lung physiology. Although the
This book purports to describe "the res- ure! Chapter 6 is a description of the practical intended audience Ls wide, 1 think that only
piratory function of the lungs in a variety of measurement of lung mechanics and begins physiologists and pulmonary specialists will
circumstances and indicates how the func- with a table that grades the practical aspects of find it of much use. Given the cost of this book,
tion can be assessed." Thus, it is a combina- many lung function tests on a scale fix)m A to its purchase is probably only justified for the de-
tion pulmonary physiology textbook and D. 1 fail to see why such a subjective evalua- partment reference library.
technical manual for the performance of tion is useful and believe many of the grades
lung-fiinction testing. The author suggests are incoirect. Further, the degree of detail pro- Charles GIrvin PhD
that this book would be useful to scienUsts vided for many of the tests is inadequate. For Direaor
from a variety of disciplines. This is the fifth example, on Page 1 36, we are told to have the Pulmonary Physiology Unit
edition, and the author has attempted to in- subject practice the forced expiratory maneu- National Jewish Center for Immunology &
corporate the many changes in pulmonary ver and then "three technically satisfactory Respiratory Medicine
medicine since the fourth edition ( 1979). blows are recorded." What happens if you Denver, Colorado
The book is organized into 17 chapters. The don't get three? How many do you maximal-
first 4 chapters deal primarily with the topics of ly do? (Answer no more than eight). What is
historical perspective and terminology, equip- meant by satisfactory? The start and end of
ment, and technical issues. In general, the treat- test are not adequately explained. No explana- Snoring and Obstructive Sleep Apnea, 2nd
ment is adequate but disappointing in its lack of tion of back extrapolation is provided, and I edition, by David NF Fairbanks MD and Shiro
synthesis and failure to establish a perspective could not find the term in the index. The Fujita MD. Hardcover, illustrated, 266 pages.
for topics to come. Some of the material seems Ttffeneau index (FEVi/TVC or SVC) is men- New Yoifc Raven Press, 1994. $72.00.
dated — eg, the relative space given to old-fash- tioned, but why some clinical scientists think
ioned strip-chart reconders (2 pages) compared this is a better index is never explained. On the Snoring and Obstructive Sleep Apnea is a
to computer data capture ( 1 paragraph). Many other hand, the discussion of bronchodilator
cond.se well-written review of a complex clini-
of the techniques described just are not used response is good. Again, however, there is a
cal disorder. Edited by two prominent stugeoas
anymore. curious lack of balance where great detail is
in the field provides an extensive review of
The next chapters (5-14) are paired — given to measuring pressure-volume curves
it
operative approaches, but nonsurgical treat-

chapter on basic physiology is followed by a with esophageal balloon, but little space is
ments are also considered in depth. The first
chapter on the technology used to assess a par- given to basic spirometry, a test that we all
chapter, "Snoring: An Overview with Historical
ticular a.spect of that physiology. Thus, there are use.
Perspectives," was actually fun to read. Chapters
paiied chapters on lung mechanics, gas ex- JE Cotes, the author, is best known for
6-12 provided more surgical detail than I (as an
change (V/Q), diflfiisioa control of breathing, his work on the diffusion of gas.
internist) needed, but I do now have a better un-
and exercise. Accordingly, I was not surprised to find that
derstanding of what the surgeons consider when
Rather than attempt an exhaustive evalua- the two chapers on diffusion were better
I refer a patient for possible operation. This will
tion of each pair of chapters (the book is over than the mechanics chapters. Chapter 9, the-
make it easier to discuss possible surgical op-
7(X) pages long), 1 evaluate in detail one chap- oretical basis for this text, is technical at
ter pair of particular interest to me, lung me- times but is a generally well-written discus-
tions with my patients. Chapters 7 and 8 related
to uvulopalatopharyngoplasty are particularly
chanics, and one pair that is the author's par- sion of the measurement of diffusing capac-
timely given the recent explosion of public inter-
ticular expertise, diffusion. Chapter 5 is a ity, which in this book is referred to as trans-
chapter on the mechanical properties of the fer factor —probably a better term. The con- est in this technique, especially laser-assisted
uvulopalatoplasty.
lung. Although the figures are interesting and tent of Chapter 10, the technical aspects of
the chapter has all the right subheadings, the diffusion capacity, is adequate, although I think those who deal with snoring and sleep
content seems superficial. For example, in de- again I find it short on specific detail.
apnea patients as a part of their practice will find
scribing the equal-pressure-point theory, it is Finally, I find the book well referenced but this book a helpftil and informative review. It is
important to clearly explain the concept of ui> the references are difficult to use. They are not easy to read, well edited, and worth including in
stream resistance using the analogy of the wa- found at the end of chapters but rather are col- your reference library.
terfall. This analogy was introduced, albeit lected at the end of the book. In Chapter 6, spe-
briefly, but without a clear example. The au- cific authors are referred to, but I could find no Timothy R ChappeD MD
thor also attempted to explain the choke references. Many of the tables and figures are Pulmonary Medicine
point/wave speed theory, but this was done in only marginally helpftil. In additioa many of the Medical Center of Piano
a confusing way. Perhaps the most disap- tables seem to serve no ital purpose other than Piano, Texas

—
Lcllers on topics of current interest or commenting on material m 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
a.s published may simply reflect the author's
letters
opinion or interpretation of information— not standard practice or the Journal's recommendation. Authors of criticized
material will have the
opportunity lo reply in print. No anonymous letters can be published. Type letter double-spaced, mark it
"For Publication," and mail it to
Letters RE.SPIRATORY CARE Journal, 1 1030 Abies Lane, Dallas TX 75229-459.1.
Errors in August CPGs circuits after intervals greater than 5 days American Association for Respiratory
not less than 5 days. Care. Clinical practice guideline: applica-

The recently published AARC It appears that one or more typographical tion of continuous positive airway pressure
Guideline: Neonatal Time-Triggered, errors are present here. It seems likely that to neonates via nasal prongs or nasopharyn-
Pressure-Limited. Time-Cycled Mechanical practitioners might read one or both of the geal mbe. RespirCare iyy4;.W(8):8l7-823.
Ventilation' states in Section 13.1 "The pediatric Guidelines without referring to the American Association for Respiratory Cai^.
Clinical Practice Guideline: Ventilator Clinical practice guideline: ventilator circuit

ventilator circuit change Guideline. If so.
changes. RespirCare 1994;39(8):797-801.
Circuit Changes . . . suggests that use peri- they may be misled about the recominended
ods of < 5 days are acceptable when the hu- frequency of circuit changes. Because many
midifying device is other than an aerosol institutions are now making the transition
77?^ Editor replies:
generator." Likewise the AARC Guideline: from circuit changes every 24 or 48 hours to
Apphcation of Continuous Positive Airway circuit changes every 5-7 days, it is impor-
Pressure to Neonates via Nasal Prongs or tant to clarify the AARC's recommenda- Our sincere thanks to Dr Picca for point-
Nasopharyngeal Tube- states in Section 13.2 tions.

ing out the errors in the Guidelines. We are
"The Clinical Practice Guideline: Ventilator taking the following steps to minimize the
Circuit Changes . . . suggests that use peri- Stephen M Pieca MD 'damage': ( 1 ) publication of Dr Picca" s let-
ods < 5 days are acceptable when the humid- Nassau County Medical Center ter: (2) publication of a notice of Correction
ifying device is other than an aerosol genera- East Meadow. New York in this issue of the Journal: and (3) correc-
tor." tion of Clinical Practice Guideline reprints.
However, the ventilator circuit change

REFERENCES
Guideline' actually states in Section 12.2.2 Pat Brougher BA RRT
". employing heated Cascade-type
. . circuits Editor, Respiratori Care
American Association for Respiratory
devices (bursting-bubble humidifiers), as
Care. Clinical practice guideline: neonatal
humidifiers, ... or other vapor-phase humid- Project Manager
time-triggered, pressure-limited, time-cy-
ifiers may be changed at an interval of > 5 cled mechanical ventilation. Respir Care AARC Clinical Practice Guidelines
days." That is. it recommends changing the 1 994:39(8 ):8 12-8 16. Dallas, Texas

December 10-13, 1994 • Las Vegas, Nevada
10.58 RESPIRATORY CARE • NOVEMBER 94 Vol 3*^ No

1
Respiratory Care
Open Forum Abstracts
The 1994 RESPIRATORY CARE OPEN FORUM
Each year a highlight of Annual Meeting of the American Association

the
for Respiratory Care, the RESPIRATORY Care Open Forum, provides a
platform for the reporting and discussion of some of the clinical studies,
method and device evaluations, and case reports completed by members
and friends during the previous year. During the 1994 OPEN FORUM in Las
Vegas, Nevada, December more than 175 papers will be presented,
10-13,
clustered into 15 minisymposia. The abstracts of those papers are published
here, sequenced as they will be presented. An index of the authors appears
on Page 1116, with Presenters designated by boldface type.

Open Forum ABSTRACTS RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1
Initul Negative Inspiratory presslre <p|) To

Maximal Negative inspiratory presslire (PI max)
Ratio Fails To Predkt Swcessful Extlibation
For iNTiiBATED Children. Mohamad F. ElKhanh.
MS. Brenda Baumcisler. MD. Roben L Chaihum, RRT,
PaulG. Smith. IX). Jeffrey LBlumer. PhD. MD. Rain-
bow Babies & Childrens Hospital and Case Wcslem Re-
serve Umversity. Cleveland, OH.
lNTRODLt.TION; In adults success of enluhation can be
predicted by PI/PImax ratio uiden {Pl/Plmax 50.3. Yang
KL. Intensive Care Medicine. 1993; Vol.19. [^,2(»)
Objective; We tested whether the cut-off vaJue of <0.3
for Pl/Plmax could be used m paOents in a pediamc in-
tensive caie unit (PICU). METHODS: Thirty infanLs and
children (0 lo 14 years) mechanicaJly ventiialed m the
PICU. climcally stable and considered ready to be exlu-
baied by the aaending physician were studied. Before the
estubalion trial, a one-way valve that allows exhalaaon
but not inhalationwas insened at the patient airway
opening to determine PI and Plmax. PI and PImaji were
measured as the most negaove deflections produced by
the first and the maximum inhalation effort (in contrast lo
the adull study thai use PImax al 20 sec) during airway
occlusion respectively. Measurements were repealed
three times and mean values were used for data analyses
Failure was defined as reiniubation within 24 hours of
extubauon. Calculations of sensitivity, specificity, posi-
iive and negative predicted values were made to deler-
mme whether the Pl/Plmax index is a good predictor of
successful extubauon. Reslilts: Figure 1 shows that
only 6 (207^) of 30 patienLs had ratios <0.3 and all 6 were
successfully extubated. Of the 24 remaining patients with
ratios >0.3. 16 (67%) were successfully extubated and 8
(33%) were noL In those 24 patients, a cut-otT value for
Pl/Pimax thai discnminates between success and failure
groups could not be identified.
F'^ '
Table 1
Index
: 1
RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 Open Forum ABSTRACTS
LONGTERM PULMONARY STATUS OF DOES RESOLUTION OF RESPIRATORY DISTRESS

INFANTS WHO WERE <750g AT BIRTH Regino SYNDROME IN PRETERM INFANTS SUGGEST
Ykorulc.CRH. Mary McGowan, CRH, VK NORMALIZATION OF LUNG FUNCTION AT
Bhutani, MD, E Sivieri, MS, Newborn Pulmonary DISCHARGE? Mory McGowon. CRH. Regina
Laborotory, Pennsylvania Hospital, Philadelphia,
Ykoruk, CRH, V.nod K Bhutani, M D., Emidio
Sivieri, MS Newborn Pulmonary Laboratory,
Pennsylvania
Pennsylvania Hospital, Philadelphia,
With increasing survival of extremely low Pennsylvania,
birthweight (ELBW) infants, their pulmonary well
being during the first year of life remains an To determine if the clinical diagnosis of broncho-
open quesHon, We followed 28 bobies (BW pulmonary dysplasia (BPD) has an impact on the
GA25±1 6 SD wics) who were functionol residual capocity (FRC) and pulmonary
661 ±60 SDg,
NICU and monitored for mechanics: lung compliance (CL, mL/ cmH.O/kg),
discharged from the
and pulmonary function pulm resistance (RT, cmHp/L/sec), and resistive
their respiratory status
work (WOB g-cm/kg), we studied two groups of
during the first year of life. Two died during
infants prior to discharge Group consisted of 14
(7%) The remainder showed:
I
infancy
infonis with respiratory distress syndrome (RDS);
rehospitalization 7%, pneumonia 7%, upper
GA:32±2 4 SDwks,BW: 773+628 SDg.
I
respiratory infection 44%, otitis media 20%,
Group II consisted of 8 infants with RDS who
1
wheezing 29%, and reactive airway disease also developed BPD GA 27+ 8 SD wks,1
54% The mean values of pulmonary function at BW:889±332 SD g Group was tested at
I
term and at 9 months corrected age (CA) are discharge or term post conceptual age (PCA)
shown with their percentile rank based on 36±2.4 SD wks aher a hospital stay of 4 wks.
healthy non-ventilated very low birthweight Group II was tested ol discharge or term PCA
(VLBW) infants (n=42,BW: 1242+213 SDg, 40± ,8 SD wks aher o hospital stoy of
1 3 wks. 1
GA: 3 1 , 1 ± 1 9SDwksl FRC was measured by the helium dilution

technique (solenoid value switched automatically
{9 mos CA) atend expiration by computerized technique).

Lung mechanics were measured by the leost meon
Mean Value Mean Value
squares technique Pulmonary Function data is
12. 2± 6 55 6± 12,6 shown as meantSD with percentile (%ile} based

13. 5± 52 on previously reported healthy non-ventilated low
22± 13
birth weight PFT data:
76 3147 26 3+ 20,8
1,1+ 7,1 17± 4,2
(TV = tidal volume, mL, CL = lung compliance,

mL/cmHjO, RT = pulm resistance, cmHjO/
l/iec, AP = driving pressure, cmH.O)
The most frequent problem wos reloted to
abnormal airflow function By one year, most
infants had oge appropriate normalized
pulmonary function * and this was associated
with age appropriate neurodevelopmentol status
(90%), Our observations suggest a potential for
an optimum pulmonary outcome with continued
individualized care.
CONCERNS WITH HFV IN NEONATAL TRANSPORT

Roben J. Kopolic. R,R T,. R,N,
San Diego. California

INTRODUCTION The need for transport Frequency
Ventilation (HFV) increases h'ospiials begin HFV programs,
Returning an infant on HFV
ofien noi toleraled. Initially most insUlulions doing HFV
.porl'is
performed Extracorporeal Life Support (ECLSj
.earcti
n option, Wilhrr s acquinng
HFV lo an ECLS c
HFV devices exist but nol all lend themselves lo i
demands of the iransporl selbng METHOD: Three HFV devices
itcd: the Bunnell Life Pulse Jei Ventilator iSall Lake City.
: Infrasonics Infant Star High Frequency Ventilator (San
Diego. CA). J mOOA Oscillatory Ventilator

e and tested tl
chamber and in silu (in the NICU
nenlal
ambulance. between these) RESL'LTS AND EXPERIENCE
id
ind Infrasonics devices are amenable to iranspoi
However, the SensorMedics unit is problematic in thai the ek
ower and gas consumption are extreme, the ngid airway con
i cumbersome, and the size would be prohibitive. Findings c
3 the Bunnell and Infrasonics' HFV devices are:

They have been used successfully
aircraft and rolocraft a
The units operate satisfactorily ii
from ambient lo lO.tKX) feel.

Auscultalory assessment can be thwarted by amb
Changing ihe endotracheal lube (ETT) position c
iL-ally jffccl the delivery of HFV amplitude,
HF\' yas use is greater that with conventional vei

The u^LT should anticipate gas capacity needs pn'
adversely affected ii
ances is nose-io-iail. Subsequently, t

Ithe humidifier's water level sensor
sume the level is low and over fill 1
follow; (a) the front of the Bunnell
.u]dt> iloflt
ler inlet lube should be clamped off in
conditions of extreme and variable axis vibrBlion.
4 Noise level emanating from the Patient Interface Box can
exceed 80 dBA Precautions should be taken lo protect the
infant's ears. e,g,. insulating the Box and ear plugs or
.i A portable power supply is required for continuous opera-
Thc Infrasonics' Infant Star HFV device has unique attributes:

I Given typical settings, gas use of the Infant Star is 1 LPM
HFV mode the consumption can be up to 40 LPM.
How
It least 30 n
use from an AC or 2 1 VDC
3 It contains a standard ventilator, i.e
itonal concerns than Bunnell, e.g.. i ETT.l
Interface Box, sensitive humidifier, or separate controls,
CONCLUSION; Transport of the acutely ill newborn often require;
adaption of bedside NICU techniques to the transport setting. We
reviewed the efficacy of providing HFV dunng neonatal transport.
Air worthiness, battery operation, gas consumption, and predictable
operation in Ihe various modes of transport were addressed
Continuity of neonatal High Frequency Ventilation therapy dunng
transport is possible. OF-94-222
!
Open Forum Abstracts RESPIRATORY CARE • NOVEMBER "94 Vol 39 No 1
IMPACT OF INDIRECT CALORIMETRY ON

THE PHYSICIAN'S NUTKITIONAL ORDERS.
Gaf>' Mdne BS RRT Punian-Bcnncii Corp..
.
Carlsbad. California.
For ihe past six ycar^ at St. Francis Hospital
(Beech Grove. IN), physicians have been exploring

Indirecl Calonmelry (!C). which was insututcd Ui
detect under* and over-feeding. The purpose of this
study was to see how often i( indicated, physicians
adjusted their prescnbed calones when resung

energy expenditure iREEt was reported. (Dunng
study penod of this pro;ect was a pracucing
I
therapist at St. Francis). Methods: All ICs

performed dunng 1991 and 1992 were included
REE was determined with 2900 metabolic can by
collection of Minute Ventilauon, Inspired and
Enbaled gases. All pauents had to be on a FI02
of less than bCisj . Once the test was completed,
REE was reported in the chart As a measure of
compUance. pauents' charts whose prescribed
calones were not within +/- 10% of the REE were
reviewed for the next 72 hours to see if physiaans
changed their calonc prescnpuons to fail within +/-
10% of the REE. Excluded were those pauenus
who died or physically could not be adjusted to
within 10% of REE (i.e.. slow enteral UtraUon)
within 72 hours. In addition, those pauents who
were extubaied dunng the post-REE 72-hour
period were not mcluded if they were switched id
normal oral feedmgs when calonc intake is more
difficult to monitor. Results: In 1991. 60 of 175
testswere excluded. Of the remainmg 15 tesLs. 1
feeding changes were indicated in 74. and feedings

were adjusted to within 10% of REE in 49 cases
(66%). In 1992, 30 of 147 tests were excluded,
changes were indicated in 69 tests,and changes
were made in 56 cases (81%).
Pernal otPby>lcl.D Compllinci|

) 1
RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 Open Forum Abstracts
CLINICAL EVALUATION OF A MATHEMATICAL

MODEL TO PREDICT RESPIRATORY MECHANICS
DURING MECHANICAL VENTILATION
Dean Hess. MEd. RRT, Kevin Foley, RRT. Robert M
Kacmarck. PhD, RRT Departments of Anesthesia and
Respiratory Care, Massachusetts General Hospital and
Harvard Medical School. Boston. MA
Several mathematical models thai describe respiratory
published (1-3) Although ihey have been validated in lung

models, they have not been tested clinically. The purpose of
this project was to collect data on mechanically ventilated
patients to evaluate the validity of these models during
volume-targeted, decclerating-flow mechanical ventilation
METHODS: The study population consisted of 25 patients
(16 males, mean age 61 5±I7 4 yrs). all mechanically
ventilated using the Puritan- Bennett 7200 Patients were
relaxed and breathing m
synchrony with the ventilator at the
time of data collection, Flow (integrated to volume) and
pressure were measured at the proximal airway using a
calibrated lung mechanics analyzer ( Ventrak. Novamelny
End- inspiratory plateau pressure was measured during an
cnd-inspiralory pause, and aulo-PEEP was measured during
an end-expiratory pause using a Braschi valve Resistance
and compliance were calculated using standard methods (41
The values for peak inspiratory pressure (PIP), peak alveolar
pressure (Ppk). mean airway pressure (MAP), and aulo-PEEP
(PEEPi) were calculated using Iheir predictive equations
These values were compared to the actual values measured
by [he lung mechanics analyzer The relationship between the
mathematically predicted values and the actual values were
evaluated using correlation and regression analysis, and bias
lalysis, RESULTS
, 1
Open Forum Abstracts RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1
STABILITY OF ARTERIAL TO END TIDAL CARBON

DIOXIDE DIFFERENCES DURING SHORT TERM
MECHANICAL VENTILATION
JM Gravbeal. CRTT GB Russell. MD . Dcpanmcniof
, PSU CoUcge of Medicine Herehey. Pa. 1 7033
C«pnography for momionng mechanically vcnQlaicd

pauents is scwdard of care during surgery and
the accepted
IS becoming more common in ihc Intensive Care Unit. End-
Uda! carbon dioxide (PetC02) is used clinically as an

positive indicator of endotracheal intubation, a disconnect
aJarm, and as a reflection of the arlcnal panial pressure of
carbon dioxide (PaC02) In normal volunleers. the PaC02
usually e^ccedi PciC02. the P(a ct)C02 is about 4 Hg. mm
Recent studies, m mechanically ventilated ICU palienLs.
demonstrated a larger P(a-el) C02 (8.2 mmHg) and a
significant vanaiion between changes in the PetC02 and
PaC02 {APetC02 and iiPaC02 respectively) (Rcspu^tory
Care 38:923-928.1993), This has also shown in neuro-
intensive care patients (J Neurosurg Anesthesiology 4:245-
249. 1992). To evaluate the influence of ume and changes in
other physiologic variables, we compared the iPeiC02 and
APaC02 in a group of pauents receiving mechanical
ventilation for a shorter penod of ume with conuolled
cardiorespiratory variables. Following insliruuonal approval,
23 surgical patients undergoing craniotomy were studied
intraoperauvely dunng volume controlled vcntilauon. When
clinically indicated (baselme after induction, after cranium
operung prior to dural incision, and at start of closure),
artenaj blood gases (with PaC02) were measured, the
PetC02 was determined from the capnograph (Hewlett
Packard 78520A infrared capnomeier). The P(a-ei)C02 was
evaluated for effects of changes in heart rate (HR), systemic
blood pressures (MAP), central venous pressure (CV'P).
respiratory rate <RR). tidal volume (Vi), positive end-
expiraiory pressure (PEEP), and inspired oxygen fraction
(Fi02) flegression analysis was used to determine the
relationship between PaC02 and Pe[C02 as well as the P(a-
et)C02 and other assessed variables. Student t-test was used
where applicable Correlation coefficients and p values
<0.05 determined significance. The PaC02 was 32,1±4.1
mmHg (range 24 8-16.7), (Values are mean ± s.d.) and
PerC02. 24*4 mmHg (range 16-34). with a P(a-el)C02 of
8,1±3 mmHg (range 3-17 3). Dunng the study penod HR
was 70±16. MAP. 78±I4 mmHg; CVp. 8±5 mmHg. RR.
1 1±2 bpm. TV, 765±221 ml; Fi02. 0,40±0.I3: and PEEP
1.8±1 4 cmH20 There was a significant positive correlation

between P(a-et)C02 and PaC02 (r=0.43. slope=0,31 1.
p<0-0001 ) but poor predictability (r2=0 19). The range of
aPaC02 was -10 to 6,9 mmHg
and APeiC02 was 9 to 7
mmHg Although aPelC02 and APaC02 correlated
staiisucally {p<0 001. r=0 79. slope=0 72. T^=0b2). on
successive measurements 24 % of APetC02 and APaC02
occurred ui opposite direcuons P(a-et)C02 did not change
with ume. Despite a positive correlation between individual

PctC02 and PaC02 pairs, the P(a-et)C02 increassed with
increasing PaC02 and 24% of APetC02 and APaC02
occurred in oppwsiie directions We conclude therefore that
PetC02 does not provide a stable, reliable reflection of
PaC02 dunng mechanical ventilation of relative shon
duration,
OF-94-185
EFFlCAa OF MANUAL CHEST COMPRESSION TEChWIOUE

AND INHALED BRONCHOO LATOR USING BIRO MARK 7 0^ I
PATIENTS WO REQUIRED MECHANICAL VENTILATION DUE

,
Yoshiak
lO. Uasazuni Mizuma. bD. Fumihi to Kasai VD.
Adachi, Id. Showa Univ. School Df
Japan, Shin] ROE.
Juntendo Unn Tokyo. Japan
Introduction
asthmat icus < the forr
of mechanica Unfori the ,
peak inspira equi red to
the patient at r i sk for
tzed bronchodi latofs on
therapy rnay i
have administered I
zed bronchodi
mspi rat ion manua I the Bird Mark
coordinated each t M.th the manual
the stalu
"^
Compare Unl-Vent to any other portable
RESENTING ventilator and you will quickly see why
the Model 750 a class by
THE FIRST is in Itself/
PORTABLE
l/ENTILATOR
THAT
DOESNT \
HAVE TO
APOLOGIZE
FOR BEING
PORTABLE!
"Respiratory Care Magazine,

January 1992, Vol. 37, No. 1.
Blender
CTRL --^
Control, Assist-Control and SIMV operating modes,

optional electronic demand valve - all PEEP compensable! '
> Comprehensive alarm system and automatic continuous system

self-checks for maximum safety! ^m
• Easy-to-operate, logical control groupings, simplify personnel training!
• Operates from internal battery or external power - consumes no gas!
• High-reliability, electronic circuitry is unaffected by changes in altitude!
Formore Information on the Uni-Vent^'^ Model 750, or the name of your local Representative, call Impact today'
IMPACT Instrumentation, Inc., 27 Fairfield Place, P.O. Box 508, West Caldwell, NJ 07006 1-800/969-0750
Visit AARC Qgoth 1 325 in Las Vegas
Sooner or later
weaiiiig liiiii off the vent.
Sowliyiiot make it sooner?

Weaning protocols that use capnography
can help take the guesswork out of
weaning decisions.
Considering tlie time, resources, and quality-of-care
issues involved in weaning ventilated patients, the
implications are clear. When the process of weaning
patients from the ventilator is arbitrary, it creates variability
that can lead to increased costs and reduced efficiency.
There is an alternative. Close, continuous monitoring

of end-tidal COt- as part of a weaning protocol -provides
timely information to help
you gauge your patient's
a ability to be weaned off the

ventilator. Instituting a
protocol that leads to fewer

With the ULTRA CAP monitor,
ABGs and reduced ventilator
the effects of ventilator settings
time per patient can save
can be measured breath to breath,
money, potentially improve
rather than after the 10- to 20-
quality of care, help reduce
miniite waits associated with
MLOS, and make bed
blood gas analysis.
utilization more efficient.
Make the ULTRA CAP monitor a part

of your ventilator weaning process.
Nellcor can help you integrate capnography into a
vital and effective weaning protocol. Take advantage of

our extensive training and support materials, including
our comprehensive collection of institutional weaning
protocols. And you can use the ULTRA CAP'" monitor-
Nellcor's premier capnograph and pulse oximeter-to
implement a protocol of your own.
Because when it comes to weaning patients off the
ventilator, we think you'll agree-the sooner, the better.
lor more information, contact your local representative
or call 1-800-NELLCOR or 510-463-4000. (Call our
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office at +852.529.0363.)
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© Ni-llmr Iruorporntfil I'I'M, All rlRhls rescrvi-d.

1
RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 Open Forum Abstracts

QUANTITATION OF PULMONARY ALVEOLAR CHARACTERIZATION OF ULTRASONIC AEROSOLS
MACROPHAGE PHAGOCYTOSIS USING CONTAINING LIPOSOMES,
FLUORESCENT LIPOSOMES. Nicole C Payne. BS RRT Diane Kachel, BS, and
.
Douglas G Perry PhD, RRT and William J Martin

,
II,
Douglas G Perry, PhD RRT School of Allied Health
MD School ot Allied Health Sciences and Division of Sciences and Division of Pulmonary and Critical Care
Pulmonary and Critical Cafe Medicine, Indiana Uniuer- Medicine, Indiana University School of Medicine,
sity School ot Medicine. Indianapolis IN 46202 Indianapolis IN 46202
A new phagocyte assay based on liposome in- Introductionr Liposomes are artificial vesicles com-
geston by alveolar macrophages (AMs) is presented posed of phospholipid bilayers Liposomes have practi-
Fluorescent liposomes weie formed by aqueous re- cal applications indrug delivery, due to their ability to
consOtuton of phospholipids in the presence of fluor- encapsulate toxic or hydrophobic drugs Liposomes
escein^polystyrene (F-PS) beads The emission spec- are currently being developed as a mode of delivery of
trum of the F-PS/liposomes was similar to that of free therapeutc agents to the lung The direct administra-
F-PS microspheres The amount of fluorescence as a tion of liposomes to the lung would be greatly im-
funcfion of liposome concentraton was calibrated by proved if liposomes could be delivered by aerosoliza-
linear regression Rat AMs were incubated with F-PS/- tion Previous work on the nebulization of liposomes
liposomes for 1 hr At the beginning of incubation, AMs employed pneumatic nebulizers, which were found to
showed no visible interaction with adjacent liposomes, destroy the liposomes by the shear forces created by
and AMs were nonfluorescent After 45 mm, AMs the jet and/or impactor In this study we investigated
could be seen engulfing liposomes, and many AMs the feasibility of using a specially modified ultrasonic
had a fluorescent label v^lhin vacuolar compartments nebulizer to generate liposome-laden aerosols
After 60 mm, AMs were intensely labelled throughout Methods: Liposomes were prepared by aqueous re-
the cytoplasm To determine that the AM uptake of consttution ot phospholipids in the presence of fluor-
fluorescent label was due to bona hde phagocytosis, escem-conjugated polystyrene (F-PS) beads A modi-
dichlorodihydrofluorescein (DHF)-zymosan micro- fied DeVilbiss Aerosonic ultrasonic nebulizer was
spheres were encapsulated in liposomes After 1 hr in- placed in (me with a Mercer cascade impactor Flow
cubation, fluorescence was exclusively seen in AMs, was generated by a downstream vacuum pump and
not free liposomes To establish a tme course of pha- controlled by a high precision Thorpe tube upstream to
gocytosis. AMs were incubatedv^th F-PS/liposomes the nebulizer Aerosol partcle size distnbuton was
for up to 1 hr The number of phagocytosed liposomes quantified by weighing the impacted residue on the
collection stages of the Mercer impactor Mass median
by grid cytometry Phagocytosis was quantified as the diameter (MMD) and geometnc standard deviation (n^)
number of engulfed liposomes per AM (liposomes/- were determined by slope analysis of the cumulative
cell)The number of phagocytosed liposomes per cell weight distribution of liposome-laden aerosols com-
increased monolonically over time, to a maximum of pared to pure aqueous aerosols Liposome morphol-
14 9 ± 6 liposomes/cell at 60 mm (^0 05) To deter- ogy and F-PS entrapment were documented by differ-
mine if the phagocytosis assay could measure a bio-
ential interference contrast and epifluorescence micro-
logic response, AMs were incubated for 18 hr with or scopy Liposome samples obtained before nebuliza-
wnthout lipopolysacchande (LPS) The phagocytic action, after nebulization, and in the final delivered aero-
tvity of LPS-pretieated AMs was significantly greater sol were observed wnth this technique Results: MMD
than control AMs (5 3 ± 1 vs 10 ± 9 liposomes/- for pure aqueous aerosol was 1 4 |jm with n,-^=3 4. m
ceil, p< 05) To determine whether phagocyte activ- contrast, MMD for liposome-laden aerosol was 3 4 tjm
ity could be influenced by liposome compositon, fluor- wnth a(-=2 4 Liposomes pnor to nebulization were mul-
escent liposomes were prepared with or without vitro- tlamellar vesicles (MLVs) with a typical diameter of
nectn (Vn) AMs were incubated for 1 hr with either 5 tjm, liposomes after nebulization were MLVs with a
control or Vn/liposomes AMs significantly engulfed typical diameter of -4 tjm, m contrast, liposomes m
more Vn/liposomes than control (3 7 ± 3 vs 16 5 ± the final delivered aerosol were only -1-2 ym
6 liposomes/cell, p-=^ 05) These findings demon- Conclusions: 1) Liposomes can successfully be incor-
strate that 1 ) liposomes can entrap F-PS microspheres porated m aqueous aerosol by ultrasonic nebulization
and retain their spectroscopic charactenstcs. 2) lipo- 2) Those liposomes that were incorporated in aerosol
somes can be enumerated by fluorometry 3) AMs can partcles were markedly smaller than the onginal lipo-
phagocytose FP-S/liposomes and the fluorophore is somes 3) Liposome-laden aerosols are larger but
and 4) AM phagocytosis
transferred to the cytoplasm, more homogeneous than pure aqueous aerosols Ul-
of liposomes car be measured over tme, is increased trasonic nebulization promises to be a feasible method
v/ith AM actvaton, and can be directly influenced by of aerosol delivery of liposomes lung
to the
liposome composition OF-94-063 OF- 94 -064
ATTENUATION OF LUNG INJURY IN A RABBIT

ACID ASPIRATION MODEL USING GM-1925. A
NOVEL SELECTIN INHIBITOR
Beth PuFault.RiiT ^'^' David Carton, CRTT^'^-
Gerald A. Nystron, HD;; Rene Fitzpatrick, MSIr; -,
Kelley M. Cornell MD and Mark W. Bov/yer MD,
Douglas D. Detinq, KD^; Kerby C. Oberq, HD, PhTH'-*
Department of General Surgery, David Grant
Departnent of Patholoqy, Division of Hunan USAF MC, 60th Medical Group, Travis AFB. CA
Anatony^; Departient or Respiratory Care*^;
Departnent or Surgery, Division of Plastic and , Aspiration Is a major cause of puin
Reconstuctive Surgery'; Departnent of Pediatrics'*.
Lona Linda University, Hedical Center i Children's
Hospital, Lona Linda, California
IKTHODOCTIOB: An inportant factor responsible for

the deiise of prenature neonates is inaturity of
pulnonary structure and function, including
pulnonary cytodifferentiation and surfactant
etabolisi. Epidental groirth factor (EGF) has been
associated vith accelerated developnent of fetal
lung tissue, increased fetal lung phospholipids,
and protection fron both hyaline nenbrane disease
and oxygen toxicity. However, the physiologic role
for EGF has been difficult to denonstrate. The
goal of this study 'Jis to denonstrate the effect
of EGF on rabbit lung developnent through the
introduction of exogenous EGF into the anniotic
fluid of developing fetal rabbits. METHODS:
Pregnant New Zealand vhite rabbit doe? (gestation
day 23-24;tem 31 days) were anesthetized and the
gravid uterus surgically exposed. Four (4) fetuses
per litter underwent agent adninistration via a
continuous infusion nicro-osnotic punp (Alza
Corp). One fetus received vehicle fNaOB/NaCl)
only, another received an anniotic bolus of
retinoic acid (RA: kno^Ti to enhance the expression
of pulnonary EGF Receptors and EGF responsiveness)
and vehicle infusion, the third received EGF (4
ncg/tl/day) in vehicle solution. and the last fetus
received an RA bolus and EGF/venicle infusion.
Following three days of infusion, the pups were
harvested either for norphologic exanination to
detemine lung naturity [phase I) or nechanical
ventilation and subsequent analysis of physiologic
variables to assess lung function (phase II).
KESOLTS: Fetuses treated with EGF showed a
significant increase in lung naturation as
detenined by the percentage of lung volune
available for qas exchange (air space: 41. 5i) in
conparison to controls or vehicle infused fetuses
(33. 8i and 34.11 respectively). This increase
occurred with or without the addition of RA. EGF
infusion also appeared to enhance pulnonary
conpliance (0.32 nl/ca B20/Kg conpared to 0.27 for
controls-15t increase), total lung capacity (TLC:
87.9 nl/Kg conpared to 62.3 for controls-z9i
increase), and deflation stability (56.31 conpared
to 34.51 for controls-38i increase). COMCUJSIONS:
These findings denonstrate that anniotic EGF nay
accelerate lung developnent in fetal rabbits by
increasing airspace. Furthemore, this increase in
air space appears to correlate with inproved lung
conpliance. TLC, and deflation stability in
techanically ventilated prenature pups. These
studies suggest that anniotic delivery of EGF nay
have the potential to enhance lung developnent and
pulnonary function of prenature neonates.
) 1
AN EVALUATION OF THREE FACE SHIELDS RESISTANCE TO FLOW THROUGH THE

FOR VOLUME DELIVERY DURING RESCUE VALVES OF THREE FACE SHIELD CPR
BREATHING BARRIER DEVICES
Mark Simmons MSEd, RPFT, RRT; Dan Deao Mark Simmons MSEd, RPFT, RRT, York
BS, RRT, Laura Moon BS RRT; York Hospital. Hospital, York, PA
York, PA
INTRODUCTION Few published evaluations
INTRODUCTION Due lo the fear of disease have been performed on face shield (FS) CPR
transmission dunng rescue breathing, many barner devices The purpose of this study was
barner devices exist, the newest of these being to determine inspiratory back pressure and flow
the face shiekl (FS) CPR barner devices The resistance of the one way vatves of three FS
purpose of our study was to evaluate the models METHOD The three FS brands
volume delivered to a mannequin (Resusci evaluated were, Kiss of Life (KOL),
Anne. Laerdal Corporation) using three different MicroSHIELD (MICRO) and Res-Cue Key
FS models METHOD Ten rescuers, each (RCK) A continuous flow of air was directed
certfied in BLS, were asked to ventilate a
through each valve at 10 to 60 L/min in
mannequin as they woukJ an aduft dunng
increments of 10 Umin The vatves were held ir
rescue breathing Three devices were tested
the position as they wouW be, when used on a
Kiss of Ufe (KOL), MicroSHIELD (MICRO) and
victim Two devices from each manufacture
Res-Cue Key (RCK) After a penod of practice
were tested Three measurements were made
with each device, the rescuers randomly
at each flow setting for each device, Back
performed mouth to mouth (M-M) and FS
pressure was measured proximal to the valve
breathing with each device for two minutes A
using a Timeter Calibration Analyzer and mean
five minute rest penod was given between each
values reported Resistance was calculated by
senes All volumes were measured ustng a VM-
dividing back pressure by the flow The
90 ventilation monitor (Bear Medical) placed in-
between the mannequins "trachea" and metfiodology was similar to that of others
line
"lungs" Mean VT and SD values were performing back pressure studies to evaluate
resistive pressure through vatves Differences
calculated Differences among the four methods
were evaluated using ANOVA p < 05 was among the three brands were evaluated using
considered significant RESULTS The mean ANOVA p < 05 was considered significant
VT and SD each method of ventilation m L
tor RESULTS At a flow of 50 Umin the mean and
was as M-M 99 i 26, KOL 25 t
follows SD inspiratory back pressures in cm H;0
Oil. MICRO 75 + 22 and RCK 64 + 15 produced by the devices were 7 22 ± 12.
There was a significant difference between the 16,70 1 1.17 and 2 15 lO 15 for KOL, MICRO
volumes obtained among the four methods of and RCK respectively The mean and SD
(ANOVA, p < 001) and significant
ventilation resistance in cm HÔ/Usec was 8 66 i 15,
differenceswere found for each paired 20.04 ± 1 41 and 2 58 + 18 for KOL, MICRO
companson (Scheffe. p < 05) and RCK respectively There was a significant
CONCLUSIONS Only M-M ventilation resulted difference among the mean values for each
in an average VT delivery of at least 0.80 L as brand tested at 50 Umin (ANOVA, p < 001)
recommended by the AHA for rescue breathing and significant differences were found for each
paired companson (Scheffe, p < 05)
CONCLUSIONS The resistance of some of
these vatves may be considered excessive and
only one. RCK, met the ISO standard of back
pressure < 5 cm H,0 at 50 L/min
THE EFFECTS OF CHANGES IN LUNG COMPLIANCE ON THI

FRACTION OF DELIVEEIED OXYGEN {HX>;) AND MINUTE MANUAL VENTILATION DURING
VENTILATION (VEl DELIVERED BY SEVEN DISPOSABLE CARDIOPULMONARY RESUSCITATION
ADULT MANUAL RESUSCrTATORS (DAMRsI Richard Branson. RRT . Kcnnclh Davis Jr, MD. Robert
B..»rll T Ri^.d RRT. Tem Cook. RRT, RN. UC Davis Mcd.eal Johnson. MD. Robert Campbell. RRT. Ted Tabor
Department of Surgery. University of Cincinnati Medical
Seven DAMRs *
Center, Cincinnati. Ohio
compliance ctuingi
DAMR ccted lo a Ttaimnj

Purpose: Ventilatory support during CPR is typically
provided by manual ventilation with a sclf-mOating bag

(SIB) We undertook this study lo determine the
ive rcFwai mea&urcs «ere performed for each DAMF m
cfficieticy of manual ventilation provided the
^cle rale and TTL compliance scningi were randoml
emergency department (ED) to intubated patients dunng
f FD02 Each of ihe seven DAMRs were leslcd by il
CPR Methods Twenty patients amvmg ui the ED
under fuU CPR were entered into the study All patients
te DAMR Each DAMR was tested on a differeni da were manually ventilated with a disposable SIB by a
ossiblc effect of hand fatigue Airway pressure data member of the ED suff {RN, resident. MD. RRT) A
electronic pressure transducer (Pncumogaid 1230^
disposable vanablc onficc pncumotachomclcr and
fi
pressure Up were placed between the SIB and

endotracheal tube Row and pressure signals were
processed by a porUble respiratory monitor (VcnTrak.
;n now R I
;< Umin and 1 1 E ratio of I Novametr«. Waltingford CT) and saved to an IBM
riofmals
compaubic computer Personnel were blinded to the
nanutactureri recomrrrndations Results Data was analyzed u
volume and pressure measurements Tidal volume (V,),
rhree Way ANOVA There wen: iignificam changes in deliver
DAMRs tested peak inspiratory pressure (PIP), frequency (f), and IE
p < 01 ) in oil wvcn DAMRs Five of ihe seven
ratio were calculated on a breath to breath basis and
.ignificant changes in FDO? (P < 01
averaged on a minute lo minute basis Results The
Ventilation was provided by an RN=6. residenl = 8.

MD = 2, RRT = 4 Results for measured vanublcs in
tSD 8 1 below
1068
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Open Forum ABSTRACTS RESPIRATORY CARE . NOVEMBER '94 Vol 39 No 1
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INVASrVt BILEVEL POSmVE AIRWAY

PRESSURE (BLPAP) HOME VENTILATION FOR
CHRONIC RESPIRATORY FAILURE IN
CHILDREN. RW Brown. MD. MPH; EA Gradv.
RRT: CI VanLaanen. RRT; IM Dean. MSN; EA
Hurviiz, MD. VS Nelson. MD; DW Roloff. MD.
Department of Pediatrics, University of
Michigan Medical Center. Ann Arbor, MI.
To assess the utility of chronic outpatient

BLPAP use m children, we reviewed the
records of 105 patients followed in the U of M
Pediatric/Adolescent Home Ventilator Clinic,
32 (30%) of whom used BLPAP as their mode of
home ventilatory
suppon. 15 (47%) of the
BLPAP patients were ventilated via
tracheostomy tube (it), while the remainder
received ventilation via nasal mask (nm). 11
(73%) BLPAP (tt) patients had obstructive
pulmonary disease (OPD) +/• airway anomaly
and 4 (27%) had restrictive respiratory
dysfunction (RRD), including spinal cord
injury, spinal muscular atrophy, and primary
myopathy. The medians and ranges for age at
initiation of BLPAP (AIB). daily ventilatory
duration (DVD), span of BLPAP use, and levels
of inspiratory and expiratory positive airway
pressure (IPAP/EPAP) are presented here:
We conclude: 1) invasive BLPAP can be

included as a venlilaiory suppon option in ihe
outpatient management of pediatric chronic
obslniciive lung disease; 2) BLPAP ventilation
s an effective mode of bolfi invasive and
loninvasive home ventilatory support in
hildrcn with
chronic respiratory failure due
wide range of clinical etiologies; (3) based
D parent interviews, home BLPAP provides
overall improvement in quality of patient aod
family life by allowing fewer respiratory
tions and improved nutritional status,
daytime "energy" and sleep quality.
r.cQ,ii =
1
RESPIRATORY CARE • NOVEMBER "94 Vol 39 No 1 Open Forum ABSTRACTS

SUCCESSFIL ISE OF THE BlPAP' MACHIVE IN 3
VEAR OLD TWINS ELIMINATING THE NEED FOR
TRACHEOTOMY AND OXYGEN THERAPY-KaI.e
Sabaio MS RRT. John McOuiiry. MD, Children's H.ispital
Oakland, Califorrua
Thrtw year old twins were scheduled for uacbeoioniy B(Hh
n*ins suffered severe COj reiennnn and oxygen depnvaiion
when asleep due to a genelic defea. Crouzons. which
results in progressive obstruciiOD of the upper airway due
to excessive dssue growth The rwins were sleep deprived,
had severe night sweats, nionung headaches, and were ofien
agiiated and cranky ihioughoul the day Prior lo
tracheotomy, the twins were evaluated BiPAP" lo

for use of
reduce the severe obstrucove sleep apnea The children
were sedaied in our Pulmonary Function Lah with
chlorohydrate and monitored on and off BiPAP" wiih the
uses of (VCO, mass specffonieiry. Oj/CO, TCM, pulse
owmetery, chest and ahdominat respidace. and EKG
monitor The Iwuis were fust place on (be EPAP/CPAP
mode, however both pnent's exhibited penods of
desaiurations assixiated with bypopnea To eliminate the
desaiurations, the BiPAP" system was placed m the
Sponuneous mode to deliver a pressure support of 8, PEEP
of 4 cmHjO The tables below represent mioal sleep snidy
results prior to BiPAP* and afier 2 weeks of home BiPAP*
Of interest, during the second sleep study, the twins did not
require sedaDon as they readily placed their mask on
themselves and look their naps The twins have been home
for one month on their BiPAP machines and have
completely normalized their sleep paiiems Mom reports no
mght sweats, a deaease in mominf: headaches, ihey are
alen and energetic during the day and are now gauiuig
weighi appropriately
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Open Forum ABSTRACTS RESPIRATORY CARE • NOVEMBER '94 Vol 39 No
VALIDATION OF A NOMOGRAM FOR EFFECT OF PEEP IN CONGENITAL THE CORRELATION BETWEEN FLOW RATE. ET
CONTROLLING C02 DF.LIVERY DURING DIAPHRAGMATIC HERNIA TUBE DIAMETER. POsnTVE PRESSURE. AND TIDAL
MECHANICAL VENTILATION VOLUME IN A NEONATAL MECHANICAL TEST
l.vnneK Bower RRT John H. Arnold MD. .
LUNG Lon J Wen BS. CRCP. Lisa J Schuli BS. CROP
Susan Anderson. RRT. Roben L, Chalbum.RRT. John E. Thompson RRT. Patrice Benjamin Rcaptratory CaxK Services. Mcribârt MolicaJ Center -
Rainbow Babies Hospital, Cleveland. OH. RRT, and Jay M. Wilson MD Fargo. Nonh Dakota
Children's Hospital • Boston, MA Inlnxjuction The cflcct of flow rate on tidal volume
Posloperauve cardiac pediatric patients are
dclivcied. thiDugh very small mfani endotracheal ttjbca. has
sometimes given C02 to manipulate pulmonary Introduction: The high risk congenital not been ajmplctcly studied Hypothesis We hypothesized
vascular resistance, thus affecting pulmonary vs diaphragmatic hernia (CDH) infant that an mcrcaae in flow. Ousjugh very small cndouachcal
pcnpheral blood flow (Ann Thorac Surg continues to be a challenge to ventilate. would dcLvcr a larger uda] volume Evaluation
lut^cs.
1992;54:150), We devised a double blender system

Methods A bench study fomiat was designed lo eshaust-
Little has been published on the u.se of
ivcly sujdy the relationships of PIP. PEEP, flow, and ET
for controlling FiC02 and Fi02, System equations PEEP in these infants post-ECMO. We tube diameter on Udal volume delivered A Scchnst IV l(X)
were denvcd and a nomogram constructed to predict evaluated the effects of PEEP during trials B (time cycled, pressure hmilcd) inlant ventilator set at a
settings for desired FiC02 and Fi02. This study was off of ECMO
on lung compliance (Cdyn). rate of 40 bpm and IT of 35 sec. and Mictugao Insuuments
to assess the agreement of nomogram values with physiologic dead.space (VDAT). PaCOo and TTL sunulator set with an mfaot lung (compLa/Kc of 005
Ucm/H:0. and a lesisUincc of 50 cm H20/tJs) were used
measured gas concentration values. METHODS: Pa02 in CDH infants. Methods: m this study Positive pressures nuigcd from PIPs of 10 to
Two Bu-d 02 blenders were connected in senes. The Patients were sedated, paralyzed, and 30 cm H20, and PEEPs of 2. 4. and 6 cm H20 Rows
first (o) was supplied by C02 and air and fed uito ventilated in the pressure control mode on tested WTie 4, 6. 8. and 10 1pm Tidal volume was measur-
the second blender (P), also supplied by 02. ed usmg Pnucmoview software from a TTL. cahbmled to
the Servo 900C. Standard ventilator
manufacluie's tecommendauons Mallinckrodt brand Lt
setungs were a PIP/PEEP of 30/5 cm H2O
t
Predicted values of FiC02 and Fi02 were compared
sizes lungcd from 2 5 lo 4 ID. each 13 cm length m
to values measured with a Daiex C02 analyzer and and a rale of .10 breaths/min. Cdyn, VDrVT Evaluation Results The results revealed that once the
MiniOX 02 analyzer. The MiniOX was used as a ratios, and arterial blood gases were How to generate desired PIP was met. further
clinical rather than a laboratory standard. Analyzers obtained during routine separations from the
were calibrated with standard gases. Blender ECMO circuit. PEEP levels were lowered
cahbrations were verified with an 02 analyzer from
to 2 cmH20 while maintaining the same
a metabolic carl. Usmg nomogram-denved blender peak inspiratory pressure. Measurements
settings. 8 levels of 02 (20-75%) and 8 levels of were then repeated. Results: Seventeen
C02 (1-9%). inrandom order, were analyzed in CDH infants who required ECMO were
triplicate. The mean and standard deviation of evaluated. There was a significant
differences (predicted-measured values) were used improvement in Cdyn (p=.006), VD/VT
esumaie upper and lower agreement
10 limits.
(p=.011). and Vt/kg (p<.001) when
System equations: decreasing the PEEP from 5 cmH20 to 2
cmH20. The PaCOi also significantly
improved on a lower PEEP (p=.02),
--='4-'^^^S^-^^-- hovever, there was no significant difference
in the Pa02. Discussion: We conclude
_ ^, (l-ppO2)(Q.85FaO2-0.18)
nuu-:-!.^/ , that both VOWT and Cdyn in the CDH
o.82-0.15Fa02 infant significantly improves on low levels
of PEEP. Concurrently, the lowering of the
RESULTS: The agreement interval (mean mean airway pressure does not adversely
difference ± 2 standard deviauons) for predicted affect the Pa02. This suggests that PEEP
minus measured FiC02 was 0, 1 ± 0,8 %. For Fi02 levels greater than 2 cmH20 worsens
near 21% agreement was -0.7 ± 0.2 %. For higher physiologic deadspace and compliance
Fi02s the agreement interval was 4.1 ± 2.2 %. during trials off of potentially ECMO
CONCLUSIONS: The agreement intervals for altering the clinical assessment. Future
FiC02 and Fi02 were clinically acceptable. The studies will be directed to determine whether
nomogram should be an efficient bedside tool for it is the anatomic and/or alveolar deadspace
the clinician, expediting system set-up and changes. that increases with higher PEEP levels.
DYNAMIC COMPUANCE DECREASES INTRAOPERATTVE MEA.SURES OP DYNAMIC

DURING OPEN HEART SURGERY IN COMTI-IANCE 1NCRF.A.SE WITII
CinLDRKN OPEN CIIF.ST VENTII.ATION IN ClIILnREN
B<: Wilson. RRT. F Kern. MO. J Meliones, MD. BC Wibon.RRT .F Kern. MI), J Melmnes.Mn. Ouke
Duke University Medical Center. [)urham, NC UniversilJ M«lic«l Cenur, niirhum, NC
Respiratory dysfunction after surgery for MechanicAl venlilnlion wilh an open chesl occurs
ronf>eniUil heart disease in children can lead to daily in Ihe oprralinf; room for children who
signincanl morbidity and mortality. The effects of undergo repair of complex cardiac anomalies. The
cardiopulmonary bypass (CPB) on respiratory efTect of open versus closed chest mechanical
mechanics have be«n difncull to obtain in the ventilalion on respiralnry mechanics ha>e previously
operating room, until recently. Portable, on-line been dirTicuIl to ohtain in this population. Bedside
devices are now available which allow precise devices are now available which allow precise
measurement of lunf; mechanics. This study measurement o( lung mechanics. This study
investigated the efTect of CPH on airway resistance investigated the effect of intra-operative open versus
and dynamic compliance using a mobile closed chest ventilation on airway resistance and
respiratory mechanics device. MKTIIOn: 23 dynamic compliance using a mobile respiratory
children, who underwent CPB fur surgical mechanics device. MF.TIIOD.S: 16 children who
correction of congenital heart disease were underwent surgical correction of congenital heart
studied. Ages ranged from 1 week to 48 months. disease were studied intraoperatively. Ages ranged
Body weights ranged from 2.9 to 2J.9 Kgs. A from I to .10 months. Body weights ranged from
stand akine respiratory mechanics monitor 2.9 to 14.8 Kgs. A stand alone respiratory
(Ventrak, Novametrix Medical Systems Inc., mechanics monilnr (Ventrak, Novametriv Medical
Wallingford, CT) was placed in-line with a
.Systems Inc.. Wallingford, CII was placed in line
conventional anesthesia ventilator (Draeger IIB, with a conventional anesthesia ventilator (Oraeger
Oraeger, Inc., Chantilly. VA| in the operating
IIB, Draeger, Inc.. Chantilly, VA). Airway
room. PKKP was held constant at 4 cm 1120.
reslstanrr (Bawl and dynamic compliance (Cdyn)
delivered tidal volume wa.s adjusted to ml/kg,
Iti
were measured immediately before aod after mediao
before and after CPB. No changes were made in
slernnloiny. I'Kl.l" was held constant at 4 cm 1120
Row had an open
rate or pattern. All patients
and delivered tidal volume was adjusted to 10
chest via median sternotomy. Airway resistance
ml/kg. No chaoges were made in now rale or
<Raw) and dynamic compliance (Cdyn) were
pattern. Measurements were averaged over a five
measured immediately before and after CPB.
minute study period. ResulLs are listed as the mean
Values were averaged over a five minute study
value +/. standard deviation. .Student's paired t-
peri(»d. Results are listed as the mean value +/
lesLs were used to assess intra-group difference.
standard deviation. Student's paired l-lesi was
A p < O.O.'i was considered signifu-anl. K l-:,Sll| ,TS:
used to assess inlra-grniip differences. A p-value
Mean dynamic compliance and airway resistance
of < 0.05' was considered tignificanl. Ri-SULTS:
with chest closed were .S.2 inl/cm 1120 and 147
In the prt^hypass period, mean dyn.
Dynamic compliance increas.,d 17% wilh
ml/l./sec.
™iplia and a I ml/cm
the chest open (p= .020)-. change* in airway
Il2()and l.t? ml/1120/1. respectively. After
resistance were not signincanl (p = .tS0721.
,
CPB. dynamic complia decreased IS% <:heil Opeii

Cheit ClKinI
(p = .00H6)*, changes in airway resLitanc
Cdyo ."1.2 + 0.7 6.1 t I '•
signifiCRnt (p = .59l2).
Raw 147+11.7 1.17 + in.l
Before CPB After CPB
CONCl.ti.SIONS: This stiiily suggests that dynamic
Mean Cdyn 6.1 + 1.3 5.0 +
compliance increases with open chest mwhanical
Mean Raw 1.17.4 + lO.U 143. 2_t I;
ventilation. Assessmeot of improved compliance in
CONCLUSIONS; Ahnormalilies of lunx
these children li warranted. Due to the increase iii
after CPB are common and cii nlrihute to venliUtory
rnmplianre and tidal volume with chest opening, we
difTirully in the imme<liNte pos CPB period. This 1
ohservetl instances of lung nver-dislention (6/16.

%ltidy suggrsLs that a signinrai
34'*) when conventional tidal volume strategies were
compliance occurs after CPU.
applies!. The improvement in compliance with chest
directed at improving complia
opeing may actually he deliterious if prarti<mers do
warranled. Mobile bedside pii
not identify and attjtist for changes in polmnnary
until were brnericial in dritvli t (he abnnrmalilicn
and dirfTting Ihnr inlervenlio mechanics ntra.operatively.
OF.94-I3I
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maximizes respirable volume, while its clarity
allows you — and your patients — to easily

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: : 1
Open Forum ABSTRACTS RESPIRATORY CARE • NOVEMBER "94 Vol 39 No 1
SYNCHRONIZED ASSISTED VENTI-

LATION OF INFANTS(SAVI)
EXPERIENCE AND EFFICACY;
N.Visveshwra,M. D.
B. Freeman, CBET; W.CaliwagRCP
M. Peck, MSN, Valley Childrens
Hospital, Fresno, CA.
SAVI, using modified
impedance technology was
applied to sick infants
over a three year period.
The respiratory output
signal from a neonatal
monitor was processed
through a ventilation
synchronizer to trigger a
Sechrist 100-IVB ventilator.
On active exhalation the
ventilator cycling ceased.
Survivors 96/110 (87%)
<500g: 2/3 (66%)
<750g: 36/41 (88%)
<lkg: 32/33 (97%)
<2kg: 20/25 (80%)
Of the 110 cases:
Inadequate trigger: 6 (5. 4%)
PIE: 8 (7%) PTx:6 (5%)
IVH <II:6(14%); <IV:3(3%)
Randomized study comparing

SAVI vs. Conventional
Ventilation (CV)+ Exosurf
surfactant on infants with
RDS (a/A<0.22) was then done
Results:
SAVI CMV p
Wt.(g) 914+37 1033+37 NS
a/A admit0.13 0.11 NS
a/A 6hrs 0.2 0.2 NS
01 admitl2.6 13.9 NS
01 6hrs 7.3 13.0 NS
Vent. days 20.6 31.4 <.05
02 days 26.3 43.9 <.05
Ptx. 6% 19% NS
IVH>III 8
Deaths 3/34 12/42 <.05
Charges S4486K $5409K 17%
RT " 45. 9K 54. IK 15%
CONCLUSION: SAVI decreases
mortality, IVH and air leaks
with cost savings. OF-94-1.
A COMPARISON Of TECHNIQUES FOR DETERMINING

RESISTANCE OF TWE REPIRATORY SYSTEM (Rrs) IN
INFANTS AND CHILDREN RECEIVING MECHANICAL
VENTILATION. John Snlvr RS RRT Kaihryn Poll
RRT Respiratory Caie Service, Primary Childrens
.
Medical Center. Sail Lake Cily. Utah,

INTRODUCTION: The Infrasonics Star Calc
Pulmonary Diagnostic System reports total Rrs using
two different formulae: (1) mid-volume (MVRrs) and
least squarcsfLSRRs)- We use the term "respiratory sys
termined using transrcspiratory pressure, not transpul

monary (no esophageal manometry was employed) We
lughl t
s for Rfts reported by these

METHODS: We retrospectively rcvie
pulmonary function let
in our NICU and PICU 1 July 91 and April 94

ileal breaths only and wcr
excluded for (1) airway 1 10%. (2) generally poor
or patient dysynchrony,
(3) if the least squares c<
: test with sigmncance set at < 0.05. We then

Id die dau according to mid-volume R,s. to dc
if differences were more pronounced when Rrj
;her. RESULTS: 84 snjdies were reviewed, of
lb were eacludcd |8for bad quality. 18 for leak >
lone tot correlation coefficient < 0,91, The uble

lists the values of mean, (standard deviations),
ngcl;
All Pts with Pts with Pts with
Age
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USING A CKRririCATION I AIR IC) SATISI^f COMPARISON OF EXAM ITEM CHARACTERISTICS OF

ANNIJAI. CI^RTiniC^llON & i;i)[KJ\'llON CORRELATION COEFHCIENTS GRADUATES IN TWO
RrQUiRr.MnN'i's CALCULTED BY THE POINT-BISERIAL TECHNICIAN PROGRAMS--AK
Scon Pculnicht. RRI' METHOD AND THE HIGH LOW ABILITY Pctcmian-BIack. MPH, RRT. Erwin
Chlldrcirs Mospllal Mcdkal Ctiilcr GROUP METHOD David W. Chane. EdD.
Tech Center. Tampa. FL. JR Black .
RRT Columbus College. Columbus. Georgia

Cincinnati, Oil 4S229 PhD, Veierans' Hospital. Tampa, FL
INim)l>lK:ilON: ikvt.l(i|K.d a format in
I
Inlroduclion: Exam item correlation coefficients

whuh employees of the Respiratory Care INTRODUCTION: The purpose of this
(CC) have been used to refine and revise an
Department could complete mandalory skill original studywas to determine which
exam. Among other criteria, items with low or
check olTs and competency of therapy in two combination of 15 academic, ecorwmic.
negative CC are often evaluated for possible
hours. Previously In a department of 57 Two methods to calculate thtj psychological, and social factors best
revision or deletion.
therapists (HCP's) annual cerlificalions look 3 5
CC method and the
arc the poinl-biserial (PB) describe graduates of two technician
h on average to complete (199 5 h total) In high-low ability group (HLAG)
method. Method: programs.
tabulating compliance in the 2 years prior to the A %-ilcm multiple-choice exam was given to 14 METHOD: The design of the study was
Ccrtincalion Fair, staff compliance was IDOX RT students. The exam items were analyzed by ex post facto or retrospective. The
However this occurred over a period of 3 Scantron 6400 and Form 262-L- With the PB subjects were 333 students at two
months at a lalM)r cost of J30(K) MliHIOI) A method, the Scantron calculated the CC for each postsecondary vocational-technical
Ccrtincalion Fair running continuously for 54 li exam item by: (Mp Mq) x Square root (Np x institutions in west-cenuaJ Florida. All
to accommodate all 3 shifts was used- Set up of Nq) / N x SD, in which Mp |Mq] = Mean total enrollees at one institution over eight
the fair was done by Respiratory Care score of students thai had the item correct
years and all enrollees at a second facility
l-quipment Supervisor and myself at a cost of (incorrect). Np |Nq| = Total number of students
over three years were included. The
J9U In labor Hie fair was slarfcd by myself and that had the item correct [incorrect], N = Total
collected data were analyzed by
2 other supervisors at a cost of |l(>50 in labor
number of student, SD - Standard devialion of
discriminant function analysis.
scores on the whole manual
exam With the
Hie Ccrlincatjon I-air consisted of 12 stations
HLAG method, the students were ranked from
RESULTS: Of the 333 students. 223
liach RCP demonstrated proficiency in set-up indivkduals (70%) completed their
highest to lowest test raw scores. The
and operation of all equipment used in training Discriminant function analysis
performance of the upper 27% of students, high-
Respiratory C:are, profRienty of skills and Cl'lt identified that students most likely to
ability group (HAG), was compared to that of the
rcccrlification RC~P's dcmonsiraied proricienc7 complete the two technician training
lower 27% of students, low-ability group (LAG),
by answering 5 questions involving hands on The CC each exam item was calculated by
for programs (F = 7.9496) (1) tested at the
demonstration, A 25 question test was given 11th grade level or higher in language
subtracting the percent of correct responses in the
with questions covering l-.lectrical/fire safely, LAG from the percent of correct responses in the usage on their first anempt (beta
emergency preparedness, infection control, HAG. Pearson Product-moment correlation (r) wt.=-.56I). (2) were not receiving
charting and billing policies Ki;Sl]I.IS Of 57 and linear regressionwere used to evaluate the financial assistance while a student (beta
RCP's. 47 participated {HZ% compliance) I he overall correlation between these two methods wt. = .36), (3) did not have a history of an
goat was 100% The 10 that did not participate The power table and standard error of estimate emotional handicap (beta wt. = .46), (4)
were followed up and completed the were used to establish the reliability of the were married (beta wt. = -.22). and (5)
requirements Ihe mean time to complete all results. Results; The CC using the PB method were less than thirty years old (range= 18-
requirements in the follow up was 3 5 h. as range from 0.71 to -0.45 (mean = 0.20) and the 56 years) = 39). The
(beta wt. .
compared to 2 h for those using the CC HLAG method range from 1.0 to
using the classification summary by group
-0.5 (mean = 0,18), The Pearson r was 0,80 membership for the graduates (jack -knifed
Ccrtincalion Tair (129 h loial)
where Y intercept: F(X) = 0.83X + 0.02. The
CONCLUSION llic Certifiiation Tair proved to cross-validation or percentage correctly
power of r is >0.99 and the standard error of was accurate at a 94 6% level.
be a valuable tool in alUnving all RCP's to classified)
estimate is 0.18, Conclusions: There was strong
complete their clicckofTs for the year in 2 h. CONCLUSIONS: For the programs
positive correlation between the PB method and
compared to 3 5 h with the follow \ip mcthoil studied, the five correlated factors could
the HLAG method. Since the CC calculated by
be used in the recruiting of individuals
By demonstrating clinical skills In a mock
the PB method is provided during test scoring, it
The ex post
clinical setting, it ensures eonsisiency in the into the uaining programs.
IS Ihe preferred method. The CC with the HLAG
level of clinical prottcicncy demonstrated by the facto design of this study precludes
method is more time-consuming but it is a
Respiratory Care Department, as well as a cost extrapolation of the finding into other
valuable alternative if equipment is not available.
savings programs. of.94-009R
" OF-94-006R
AN EVALUATION OF INTERACTIVE POST-DISCHARGE SURVEY OF AN MDl RESEARCH INSTRUCHON IN

TELECOMMUNICATION TECHNOLOGY PATIENT EDUCATION PROGRAM RESPIRATORY CARE ADVANCED
IN THE EDUCATION OF ASSOCIATE PRACTITIONER PROGRAMS: A SURVEY.
DEGREE RESPIRATORY THERAPY Jaan A. Retharford. RRT. RCP Arthur lones EdD, RRT, Mdnlyn Childcrs,
STUDENTS Randal Robertson PhD RRT, Randal Clirfc. RRT, RCP BS, RRT- University of Texas Medical
Lisa Montiel MAEd RRT Susan PerXins MA ,
IWIichael Mahlmeirter, MS, RRT. RCP Branch, Galveston, TK. According to a 1992
RRT The University of Alabama at Memorial Medical Canter
-
delphi study, 75% of the panelists
Modesto, Calrfomia
Birmingham (UAB), Birmingham. Alabama. considered rest^rch interpretation skills
INTRODUCTION: In order to provide a high miportant to advanced respiratory care
Introductksn The transrtion of hosprtaleed
quality education in the neld of respiratory
pabents from nebuleer therapy to setf-administered practitioners (ARCPs). Considering that
care to residents of rural west central
Metered Dose inhaler (S-MDI) has been descnbed fmdin^;, we sought to descnK^ the status of
Alabama, and to address the problem of a
as therapeubcalty sound and cosl-effectrve research tnlucation among ARCP pmgrams.
shortfall of respiratory care personnel in that
However, Irttle is knovm about the eftectrveness of METHODS: After several educator-
area. Ihe Respiratory Therapy Program at
in-patient S-MDI educabon programs post- rt^stMrchers evaluated face validity and
UAB offers its integrated
discharge We initiated a follow-up phone sun/ey to
tech nicj an/the rapist curriculum at an off-
nâdabihty of the Rt^seaah Education
assess recall of proper MDl and PEFR use in
campus Qui^tionnaire (REQ), an m-house
training site located 60 miles from
patients transitioned to S-MDI MettiodB: We
Birmingham, Comparable classroom instrument, we mailtnl it to all ARCP
attempted to contact every patient transitioned to
instruction is provided at both sites through our S-MDI protocol dunng the first 60 bays of it's protrranis hstcxl by the JRCRTE, The REQ
the use of interactive teleconference implementation 55% (31/56) of the S-MDI patients consists of 32 items to descnK' prO(p-ams,
instruction conducted by program faculty. wore abie to be contacted post-discharge (range of faculty, and research education. To follow
DESCRIPTION OF METHOD Classrooms contact 2 - 18 days post-discharge) Twenty eight up, we contacted 25 randomly-stêcted non-
at both locations are linked by a large of those contacted were ordered for home MDl respt^ndenls by phone six wcvks after
screen, live, voice- activated video hookup. use A senes of questions were asked by one RCP mailout. Data were analy/-ed using Microsoft
The video and audio signals, transmitted by familiar wrth the S-MDI protocol, but not directly
asked Excel spn-adshixH. RESULTS: Including
nberoptic telephone cable, allow lectures to in any patient's care Pabents were
involved
originate at either site and give students at to respond "yes" or "no" to questions, to identify a
phone surveys, M%
(N=180) responded. Of
senes of 4 steps in taking an effective MDl 25 phone contacts, 17 were not available to
both sites equal opportunity to participate In
b-eatment, and to report on PEFR use where survey. Of respondents, 21% have research
discussions A control panel at the podium
show videotapes, applicable ReaulU 93% (26/28) indicated that course's; by pmgram type, 71% of BS and
allows the lecturer to
they felt mstnjctions tor using their MDl were 9.5% of AD. Mean contact hours for research
transparencies, slides, or handwntten notes.
helpful Accuracy m identifying four steps in proper courses = 36. The most common course
Hand-outs and exams are transmitted by
MDl use were as follows shake MDl (96%). breath goals wea' for students to n>ad n'search and
fax machine EVALUATION METHOD: Due
in stow and deep (93%). activate inhaler
at
to Ihe small sample size (n = 35), an interpret statistical results, llie most
beginning of inspiration (93%) hold breath after full
analysis of vanance and a median lest were conimon Reason for not leaihing n-stârch
inspirabon (93%) 19 of those surveyed continued
used to determine if scores on course
to perform PEFR a minimum of QD DIscuMlon & was insufficient time. Ot pmj'.rams without
examinations and Ihe NBRC's Certincation Conclusions These results indicate that the n-seanh courv-s, 69% devote MO (iiiran)
Self -Assessment Examination differed majonty of patients retained MDl instructions conla. hours lo journal studies Oi
I
between students at the two sites recetved as in-patients, but opportunities exist for respvtndenLs, 93% nxjuia' students lo rt^d
RESULTS Analyses revealed that there improvement The use of pnnted handouts could researxh, 26% prxwide a formal to evaluate
were neither practical nor statistically enhance the pabenfs retenbon of instructions,
it, CONCLUSIONS: Formal n^'anh courses
signiHcant differences in the pertormance of given the age of our patient population (mean age
are largely n-slncti\l lo BS programs. But,
the two student groups EXPERIENCE: The 60 5 years, range 19-89 years) Greater emphasis
authors have used Inleradlve should also be placed upon the importance of
K>th AD
and BS progran\s, in general,
teleconference inslfuctlon in the training of regular PEFR monrtonng These results nxjum' students lo road reseanh and leach
respiratory care practitioners for two demonstrate the valuable role RCPs can play m them lo interprx'l it. LIMITAHONS:
consecutive years CONCLUSION: patient education, and the importance of follow-up Ri-spt>n,se rale (64%) may have influencisj
Interactive telecommunication technology is assessment of petient oducation programs post n-sulls; a misworded REQ item nây have
an effective means of assunng the discharge Anecdotely. individuals contacted were taus**d Its mis interpretation.
pleased with the foltow-up call by respiratory care
equivalence of instmctlonal outcomes
potentially enhancing pattent-institotion relations
among multiple traming sites
OF-g-iioi
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1
Open Forum ABSTRACTS RESPIRATORY CARE • NOVEMBER 94 Vol 39 No 1
AN ASSESSMENT OF LEARNING STYLE AND CLINICAL CASE STIJDY EXERCISES FOR

THE EFFECT OF EDUCATION ON STAFF
MYERSBRIGGS PERSONALITY TYPES IN EDUCATION AND MONITORING IN A
UNDERSTANDING OF THE SAFE MEDICAL RESPIRATORY THERAPY CONSULT SERVICE
nFViriri; apt ^SMDAI David L.PqILS BS. RRT. BACCALAUREATE RESPIRATORY CARE
STUDENTS BL Gregg MS RRT Universitv of Lucy Kester. MBA. RRT. Kevin McCarthy. RRT,
Roben L. Chaibum. RRT Rainbow Babies and Chi!-
Kansas Medical Center, Kansas City, Kansas James K SioUcr. MD. Cleveland Clituc Foundaiion,
drens Hospital. Cleveland. OH.
Cleveland, Ohio
INTRODUCTION: Since the miroduction of ihc SMDA lavebeen reported to
Allied \
In an effort to train therapists to use algonlhms,
of 1990. health care facihlics are required lo identify, doc- ed learning styles. An
and to monitor the uniformity of their use in our
ument and report medical device incidents. Wc devel- assessment student learning styles and
of
Respiratory Therapy Consult Service, clinical case
oped an educauonal approach using an algorithm for dc- personality types was undertaken to determine II
studies were corwlrtjcted and dislnbuled every 3 to
termining reportable mcidcnls and performing apjiofiiaie ifthere was a predominant learning style (LS)
4 months (see table) to the clinical staff of the
documenlation- The purpose of this study was to lesi the among baccalaureate respiratory care students at
effecl of the educationprogram on the staffs knowl- KUMC. any Myers Briggs personality types
2) if
Secuon of Respiratory Therapy All Respiratory Care
METHODS: An algorithm (see Figure) was (MB) dominated a particular LS, and 31 if any Pracuiioners (RCPs) were expected to complete
edge level.
con- style/type combination resulted in significantly and return care plans for a set of 4 individual case
developed usiiig the the current hospital policy after
ferring with OUT higher or lovwer grades in RC laboratory courses studies that were developed from actual pauenl data.
Materials/Methods: Fifty lumor RC students were The case studies included information necessary to
given the Learning Style Inventory (LSI) and Myers establish indicauons for aerosol, bronchopulmonary
Briggs Type Indicator (MBTI) at the beginning of hygiene, hypennflauon, oxygen therapy, and pulse
their RC program. The LSI is a 12-item self report oximetry The care plans, which were to be based
instrument with a reliability coefficient of 82
on algonlhms that were formulated for each
The LSI by Kolb was designed to measure an
respiratory care procedure, were then graded by
comparing ihem to -correct" care plans These
Based on the experiential learning theory, Kolb
"correct" plans were predetermined by the consensus
describes four stages of the learning process as
concrete experience (CE), reflective observation of the medical director, manager, supervisors, and
(RO), abstract conceptualization (AC), and active educauon coordinator Corrclauons were examined
expenmentation (AEI The tour LS are between the RCP's grades and their educaUon level,
Accommoi jator (AE/CEI, Diverger (CE/ROl. experience, and type of credcnuals The Uble below
Assimilalo r (RO/ACI, and Converger (AC/AE). A suimnanzes the overall rate of correct responses for the
nonparamt :tric test for significance of difference 5 sets of case studies The trend toward improvement
in overall grades (77 8%± 10 9% to 85 0% + 8 9%)
The expected proportion for each
significant LS. suggests improving performance and farmliarity with
(3)aposttesl LS was 25%. The MBTI is a 94 question survey of
the algonlhms over Ume However, reasons for less-
identical to the an individual's preferences Individuals are scored
Ihan-pcrfect grades include I) first time participation
m four categories: Extraverted/lntroverted, Sensing
and
and
by new department members in laler exercises, 2)
All phases were (Sl/lntuitive (N|, Feeling (F)/ThinkinQ (F),
imperfect performance even by expenenced deparlmeni
adminisured within 60 minutes. Staff and students were Perceiving {P|/Judging (J) Proportions for the
The hypothesis general population are 75:25. S/N 75:25, F/T
members We conclude that I ) admimstenng case
selected at random to enter the study. that E/l
study exercises is a useful method to monitor RCPs"
learning occurred was evaluated with pre and post test 50:50, P/J 50:50 Individual grade averages for
the two lab courses during the lunior year were performance using algonthms, 2) senal use of case
scores using a paired t-tesL RESULTS: Twelve people
grouped according to LS, MB, or both. Groups studies permits identificaUon of poor perforrmng
were enrolled in the study: 4 RRTs. 1 CRTT. 3 students.
were then tested for a significant difference in the individuals and difficull-lo-use algonthms. 3) though
3 OJTs. and 1 noncredenlialed assistant. Post-test scores
proportion of each group above or below a 30 increasing grades over ume suggest improving
(x = 81, SD = 10) increased an average of 19 points
GPA The only lab instructor was an INTP AC/RO performance, imperfect grades suggest the need to
(p=0-0006) compared lo pretest scores (x = 62, SD = 14).
20% Results: There was no significantly dominate LS. continue traiiung in algonlhm use. both for new and
CONCLUSION: Historically greater than of re-
Not surprisingly, there were more concrete sensors veteran department members
portable incidents occur in ICUs where RC staff are fre-
and abstract intuitives (p< 05). There were
quently assigned We conducted an informal phone survey
more intuitive RC students than typically found in
of 13 hospitals revealing only 2 that educated staff regard- 05) There was no
the general population (p<
ing SMDA. Education about the SMDA
is important not
significant difference in lab course GPAs based on
only to comply with the law. but also to protect patients. LS, MB, or both There was no MB dominating any
Oui education progiam yielded only modest improve- LS. 40% of the AE/AC were ESTJs or INTPs 53%
ment perhaps due to the complexity of the topic. We sug- of the AC/RO were ISTJs or ENFPs Conclusions:
gest incorporating an aggressive and ongoing education There is no significant LS or difference in lab
method to assure compliance with the SMDA. course grades based on LS, MB, or both for this
OF-94-121 sample. OF-94-154

1082
Learn the
Mediaims of Mechanical Ventilation

Explains how physical and mathematical models are developed and
Honitoring Respiratory applied, how such models are incorporated into ventilator design to
provide estimates of mechanics, and some of the problems that can
Mechanics During develop because of the limitations of the models. Chotburn points out
that lack of consistency among manufacturers in the way in which
Mechanical Uentilation compliance and resistance are measured and temperature
conversions are applied and how the lack of published accuracy and
By Robert L. Chatburn, RRT precision information make data interpretation difficult.
ItemVT30 — VHS (60 minutes)

$35 ($40 nonmembers)
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1
DELIVERY OF CONTINUOUS ALBUTEROL IN

CONJUNCTION WITH RIBAVIRIN - A CASE STUDY
Linda Allen Napoli. B S RRT. RPFT P/P Spec - . . Lorraine
F Hough. M
Ed RRT. P/P Spec R Godincz,
. . I MD .
PtD . The Childrcns Hospital of Philadelphia.

Philadctfriua. PA
A 4 year old male child presented to the Emcrgencv

Department (ED) with a 3 day history of a "cold" and a
dry cough Vital signs revealed respiratory rale 80/minule,
heart rale 160/nunutc, temperature lOl'V. and SpOj on a
3L nasal cannula of 99% There was significantly
increased work of breathing and breath sounds revealed
coarse rhoiKhi and expiratory wheeze Hypermflalion was
evident on the chest x-rsy This patient had a past medical
history of a diaphragmatic hernia repair at 4 davs of life,
wth extracorporeal membrane oxygenation for 1 1 davs.
mechanical ventilation for 2 months and supplemental
oxygen for 1 year He requu-cs daily treatments (tx) with
albuterol 2 5mg q4°, cromolyn sodium 20mg QID, and
tnamcmotone acetonide by metered dose inhaler (MDI)
TID for his severe residual reactive air%^'sys disease Pnor
to admission, his home treatment regimen had been
escalated to albuterol tx ql°(2 5mg), aerosalizcd atropine
sulfate tnamcmolone acetonide MDI q8 and
4mg qS",
prednisone 2mgA;g BID bv mouth In the ED, the patient
was started on solumedral TV and continuous albuterol at
15mg/hr via a high flow aerosol mask set up with a
HEART™ nebulizer The child was momtored for
unacceptable side cfTects from the albuterol via eonimuous
cardiorespiratory momtonng. pulse oximetry and ql"
physical assessments The patient was diagnosed with
impending respiratory failure due to a respiratory rale >
95% for his age He was found to be positive for
respiratory synclial vims via nasal aspirate The

continuous albuterol was stopped so that Ribavuin could
be admuustered but the palicnl deteriorated significantly
Subse<iuenUy. the recommendation was made lo deliver
both therapies simultaneously Ribavinn (6mg/300cc) was

dcUvcred via a small particle aerosol generator for
12hr/day x 5 days and wyed mto the contmuous albuterol
set up. six inches down from his aerosol mask, at an FiOj
of 30 During the 5 days, his albuterol therapy was slowly
decreased to 5mg/hr Aerosolized atropme sulfate 4mg
04° and cromolyn sodium 20mg QID were started on day
3 By day 7. the contmuous albuterol was disconlmued and
the patient was placed on albuterol tx 5mg q2'' The
atropme sulfate and cromolyn sodium therapies remained
unchanged On day 8, his SpOj on room air was 97% By
day 9, the albuterol tx were decreased to q4 at 2 5mg On
day 10, the patient was discharged on his home regimen
CONCLUSION Ribavirin and contmuous albuierol were
successfully admuustered simultaneously on this child
OF-94-C
PARTICLE SIZE DELIVERY OF MEDICATION

NEBULIZERS Daniel Fisher. BS, RRT Dean Hess, MEd. .
RRT. Rums Williams, BS. RRT. Sharon Pooler. RRT,

Robert M
Kacmarek. PhD. RRT Departments of
Anesthesia and Respiratory Care. Massachusetts General
Hospital and Harvard Medical School, Boston. MA
Nebulizers are commonly used lo administer medications
such as beta agonists Wc conducted this study to evaluate
particle size dehverv from 17 commercially available small
volume nebulizers METHOD Nebulizers were provided
by their manufacturers and evaluated at flows of 6. 8 and
10 L/min Three of each type were evaluated at each flow
Albuterol (0 5 mL of 5%) was added lo the nebulizer cup
and diluted with 2 5 mL saline The nebulizers were
attached lo a ring stand m a vertical position Aerosol was
sampled from ihe outlet of the nebulizer at a flow of 2
L/min to an Iniox (Albuquerque. NM) eleven stage cascade
impactor (stages of 12. 9 52. 7 56. 6. 5. 4. 3. 1,8. L 0.4.
25 The cascade impactor was used according to

*i
manufacturer's specificaltons Albuterolwas washed from

each stage and analyzed spcclropholometrically (Bcckman
DU 30 Spectrophotometer. Irvine. CA) at 278 nm A slock
solution of albuterol (0 05 mg/mL) was prepared from

powdered drug (Sigma. St Louis, MO), and a standard
curve was constructed from serial dilutions Mass median
aerodynamic diameter (MMAD) and geometric standard
deviation ((iSD) were determined, as well as the proportion
of particles 1-5 u- Statistical analysis consisted of repeated
measures ANOVA. with nebulizer brand as the grouping
factor and flow as the repealed measures factor
RESULTS: There was a significant difference in MMAD
between nebulizers (P<0,001) and Rows (P-: 001), and
there was a significant interaction effect (P-0 045) For
GSD. there was a significant difference between nebulizers
(P=0 023). no dilTercncc between flows (P-0 0H5). and a
significant interaction (P<0 001 ) For the proportion of
particles 1-5 w, there was a significant dtffcrcnce between
nebulizers (P=0 034) and between flows (P<0 001 ). bul
there was no intcraclmn (I'-O 21^1 Ihc following data
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"Life and Breath" Video "issues Facing Respiratory

This video uses real-life photos to present a vivid Care — 1994" Video
account of the challenges and rewards inherent in a AARC President Deborah Cullen discusses health
career in respiratory care. "Life and Breath" is great reform, hospital restructuring, research projects, the
for student recruitment or public relations. 6/2 image of the RCP, and other projects the AARC is
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" J . 1
DRUG DELIVERY BY MEDK ATIUN NEBULl/ERS EXHALATION RESISTANCE WHEN USING THE EFFECT Ol- \ lUMIOm' AND SIMULATED PA-
AEROSOL INHALED Sharon Pewler. RRT Dear Hess, .
AEROSOL CHARGING ADAPTER WITH ADULTS TIENT EFR^RTON AEROSOL DEPOSITION
S- David Piper. P.E. Vorlran Medical
Technology.
MEd. RRT. Pums Wiltiams. BS. RRT. Daniel Fisher. BS. .
DURING MECTL^NICAL VENTII j\TION:

RRT. Robert M Kacmarek. PhD. RRT Departmcnis of Inc (VMT), Sacramento, CA Otlo G Raabe. Ph D ,
University of California. Davis, CA. Introduclion:

A LABORAT(::>RY BENCH ?rUDY
Rcspirator> Core an<l Anesthesia. Massachusetts General
Hospital and Harvard Medical School. Boston. MA Placing the Aerosol Charging Adapter (ACA) (VMT
Vanous aspects of mcdtcaiion nebulizer performance (c g.. Model* 100746) between ihe patient wê (PW) and I- Fink. MS, RRT. R. Dh^d MD, ]. Jenne MD,
dead volume, particle size) have been previously reported the Endotracheal Tube (ETT) irwreases Ihe medication M.J.TobinMD
by our group and others However, little uttcnlion has been available for mhalalion by about 7-fold when used with l^\'ision ofPulmonary and Critical Care Med
given 10 the concept oi aerosol inhaled, which is the actual a UiniHEART nebulizer{VMT Modeld 100612) and a 1 lines VA Hnspital and Loyola Ur\iv, of Chicago
amount of drug delivered by a nebulizer to the mouthpiece continuous flow ventilation system. The ACA has pre- Stritch School of Mtxiicine, Hines IL
of the device for a specific breathing pattern (J Aerosol viosly been used with neonates but may increase
Med I99I.4 229) We evaluated uf»-ojo/ inAo/et/ from 17 exhalation resistance when used with aduHs Melhod:
Heated humidificabon wath mechanical ventila-
commercially available nebulizers at 3 flows and 3 solution was perlormed using a Michigan
In-vrlro testing
volumes METHOD The nebulizers were evaluated at Instmments Venl Aid TTL artificial lung, and a Purilan
bon has been shown to decrease delivery of
flows of 6. 8. and 10 L/min and at solution volumes of 3. 4,
Bennett 7200A ventilator with Mode 50 FLOW-BY. aerosol to the lun^ with STnall volume nebulizer.
and 5 mL Three of each nebulizer type were evaluated at
Pressures were measured proximal lo the ETT and at We developed a bench mtxiel to detemTii>e the
each flow and solution volume The solution contained OS the PW using two Dwyer Magnehelic pressure gauges changes in relabve humidity (RH) and
effect of
mL of 5% albuterol solution (2 5 mg) A double-sided test
calibrated at and 10 cm HjO. AuloPEEP indicat- spontaneous effort cffi aerosol delivery to the
lung with lift bar was used to simulate spontaneous ed by the ventilalor{VENT} was also recorded FLOW- lower respiratory tract using metered dose inhalCT
breathmg One side of the test lung was attached to a BY and MiniHEART flows were maintained at 8 and 2
Punian-Bennetl 7200 (rate 2/min. Vj 7 L. sine wave (MDl) in intubated, mechanically ventilated adult
1
L/min respectively- IE ratio was mamlained at 1 2.
(low 30 L/minl, and the other side was attached to the pabents. METHODS: A model consisting of an
compliance at 05 Ucm-HjO. PEEP was set to
nebulizer. Aerosol inhaled was evaluated using a
cm-H20. and a 7 5 mm ETT was used for all lesls
endobacheal hibe (8.0 mm
ID x 26 cm) in a plasbc
modification of a previously described method (Respir
Control values were established by removing Ihe ACA. model of a trachea (16 mm
ID x 100 mm) and
Care 1992.37 1233) The mouthpiece of the nebulizer was
setting FLOW-BY to 10 L/min and repeating Ihe tests. major bronchi (11 mm
ID x 40 mm) was attached
replaced with a slcpdown adapter, and cotton wadding was
The parameters tested were: to a two aimpartment test lung ainnected in par-
placed into the adaptor to trap aerosol The nebulizer was BPM
Respiratory Rate(RR) 14, 24. 30 allel by a metal bar. Inflabtm of one compartment
operated until nebulizalion was complete Albuterol was mL
Tidal Volume(TV) 600. 600. 1000. 1200 simulated spontaneous breaths in the other com-
then extracted from the cotton using 20 mL of 9% saline
The setup included a Purilan Bennen baclena
in-vitro
partmenL A ventilator with wick humidifier was
with gentle agitation by vortex The resulting solution was
filler, humidifier and water traps, all measurements
centnfuged at 5000 G for 10 mm to remove all cotton used with a chamber type MDI adapter
were repeated 3 times in separate runs Results: There
fibers, and absorbance was measured ai 278 nm (Bcckman ( AenziVent) placed in the inspiratory limb 1 5 cm
CA) A
was no measured autoPEEP lor combinations of
DU Spectrophoiomclcr. Irvine. standard curve for proximal to the ET. Twelve puffs of albuterol MDI
parameters which included RR's of 14 and 24 BPM.
albuterol was constructed from the absorbance of serial
AutoPEEP for RR's of 30 BPM are listed below ( lOHO pg) were given at the begirtning of inspira-
dilutions of a stock solution of 005 mg/mL prepared from
(meanistandard deviation): tion during a) a>ntrol, b) pressure support (PS) of
powdered drug (Sigma. St. Louis. MO) The amount of
TV (mL) 600 800 1000 1200 10 cmHÔ and c) spontaneous breaths
drug extracted from the cotton was determined from the
ETTCcmHjO) 0±0 910 1 2 7±0 1 3 8±0 1 Experiments were performed under dry (27° C, <
standard curve The percent of the albuterol placed into the
nebulizer cup that was delivered to the conon wadding PW(cmH20) 0±0 0*0 1,1±0 1 2.1±0,1 10 %
RH) and wet (35° C, llXf'/o RH) conditions
VENT{cmH20) a±0 0±0 a±0 1 OiO
{aerosol inhaled) was calculated Statistical analysis (n=3). Albuterol depositionon filters placed at the
consisted of ANOVA RESULTS Aerosol mhaled v^^ AutoPEEP for the control tests at 30 BPM were:
ends of the main bronchi was measurt?d by spec^
significantly less with a flow of 10 L/min (20 3±6 8% for 6 TV (mL) 600 800 1000 1200
trDpho-tometry(246nm). RESULTS: Under wet
ETTCcmHjO) 0.0±0 0.a±0 O.OIO 1 0±0 1
Umin. 19 6*6 4 forSUmin. 18 1±6 I^/ofor lOL/min.
00±0 0±0 conditions, delivery of albuterol was greater with
P=0 01 Aerosol inhaled was also significanlly less with a
) PW(cmH20) 0±0 1,0±0.1
VENT(cmH20) 0±0 a±0 0,0±0 spontaneous breaths (220 ± 21|ig) tfwi cMitrol
smaller solution volume (17 5±5 8%for3mL, I9 8±6 6% 0.0+0
for 4 mL. and 20 7±6 7% for 5 mL. P-0 000 ) There was 1 Experience: S David Piper, P E. is a Regis (182±21pg)orPS10(172±27pg)(p<0.01) Tlie
a significant difference between nebulizers in aerosol Professional Engir T the State of California, has fraction of albuterol delivered to the lower respira-
.nAo/^<^(P<OOOI) CONCLUSIONS Overall, about 20% been developing and conducting research on tory tract under dry conditions (30 - 35%) was
cup was
or less of the albuterol placed into the nebulizer respiratory products lor over 4 years, and has received greater than wet ( 17 - 20"/..) in all modes (p<0.005).
delivered to the mouthpiece of the device Although patents tor nebulizer and aerosol delivery lechnologies- CONCLUSION: Heated humidity reduced deliv-
aerosol inhaled vâs affected by flow, solution volume, and Otlo G Raabe. Ph D. is a Professor of Environmental ery of albuterol in this model of a ventilated sjxin-
nebulizer brand, the clinical importance of these Engineering at the University of California Conclusion:
taneously breathing patient
difTcrcnccs remains to be determined Wc believe that the The ACA may be used with adults under ordinary
concept of aerosol inhaled is a useful method to respiralory settings at RR"s up to 30 BPM with minimal
characterize aerosol delivery systems which autoPEEP Supported by V A Research Service
autoPEEP, For Ihose conditions in
(supported in pan by Puritan -Bennett Hudson RCI, may not accurately indicate
exists, the ventilator
Marqucst, Professional Medical, SIMS, Inspired Medical)
autoPEEP at the ETT.
OF-94-080 OF-94-140 OF-S
IMPACT OF HUMIDITY ON RESPIR- EVALUATION OF THREE NEBUUZERS FOR FFECTIVENESS OF METERED-DOSE INHALER
ERSUS NEBULIZED DELIVERY OF ALBUTEROL IN
ABLE VOLUME OF MEDICATION DE- LENGTH OF NEBULIZATION TIME NFANTS WITH BRONCHIOLITIS. A
LIVERED VIA VENTILATOR William M Heulitt MD. M Anders RRT,
W. Quinn RPFT RRT Ochsner Stephen F. Wehrman RRT. Warren Sakamoto CRH, G Lowe RRT P Andei .
Ark
Foundation Hospital New Orleans, Wesley Caner CRTT, Anthony de Nectxhea CRTT
Louisiana. Previous reports have Kafiiolani Community College. Honolulu. Hawaii
suggested that continuous flow
nebulization is more successful Introduclion: The length of time ii lakes a small
in delivering medication when votume netxilizer to deliver a standard amount ol
the nebulizer is placed upstream sdubon affects total time spent performing this
from the patient wye. However, therapy and could impact on productivity. Previous
these same studies did not research try Hemstreet et al. published in an abstract
include a humidifier. I sought in Respiratory CareV olume 38, Number 1i suggests
to observe the impact of various
that nebulization beyond "sputter time' (the
humidif ication conditions on spasmodic release of aerosol at l5-30s without
respirable volume of medication visible release of aerosol) is unproducbve A review
delivered by a nebulizer in a
of five respiralory care textbooks suggests operating
ventilator circuit to a test
the nebulizer at six to eight liters per minute We
lung. Method: A Laser particle
compared the length of time it look three different
counter (PC) was adapted to the
brands ol nebulizers to reach 'sputter lime' at two
02 sensor port of a Michigan In-
different flow rates.
struments Training Test Lung
Hethod: Five Baxter •Airlile', Marquest Acorn II.
(TTL) so that a sample could be
and Satter Laboratories model #6911 nebulizers from
aspirated from the TTL into the
two lots were tested using a three ml unit dose of
PC. Three methods were tested
normal saline at six and eight tilers per minute
five times each, data being
respectively. An accurate Puntan Bennett air
collected after the system had
flowmeter was used lor the lesls.
run connected to a ventilator
Results: Results are shown in the table betow
with nebulizer running for three
minutes. Results were converted
from counts of various particle Average Nebulization Time {mm )
sizes into cubic volume of all Flow Baxter Marquest Salter

particles 1-4 microns in size. 6 L/M 6.66 8-91 6.
Summary of results, in milfions 8 L/M 5,47 7.37

of cubic microns(SD): 1) Nebu-
lizer in ventilator position The difference between the Baxter and Marquest
{VP), 120 cm upstream from wye, nebulizers was significant (t= 6 56. p = 0.000; two
with dry gas: .58(.03) 2) Nebu- tails, i-test) The difference between the Baxter and
lizer in VP with gas humidified Salter nebulizers was noi significant
to 34 C at the airway: .52{.03) Experience: Our experience in the clinical setting i:
3)Nebulizer in VP with gas that saving two to three minutes per ireatmeni over
humidified to 34 C in a heated a busy shiH makes a diflerence in practitioner
wire circuit: .51(.02) productivity and ability to complete a workload in a
Respirable volume of medication timely manner.
delivered by the VP with dry gas Conclusion: Use ol a Mow rale ol eight UMin. a
was Significantly higher (p^.05 llme-eHicient nebulizer, and termination ol therapy
by ANOVA) than all other methods at the 'sputter time' could increase a practitioner's
t.-stfd. Conclusion: When using a produaive time Managers shoukJ evaluate the
nebulizer in the VP, bypassing delivery ol small volume nebulizer therapy lo
the humidifer can enhance maximize productivity.
medication delivery. „^_. OF -94 192
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1
PULMONARY DEPOSITION OF SALBUTAMOL DELIVERY OF SALBUTAMOL (S) TO INFANTS

AEROSOL DELIVERED BY METERED DOSE WITH BRONCHO-PULMONARY DYSPLASIA
INHALER (MDI), JET NEBULIZER AND (BPD) BY METERED DOSE INHALER (M) AND
ULTRASONIC NEBUUZER IN JET NEBULIZER (J). TaiJJok, MD;
MECHANICALLY VENTI1j\TED RABBITS. Myrtia B-Dolovich, P£ne Michael TJêwhouse, MD;
TW FJok, MD; Mazan MAI-Essa, MD; Sbari Gray, BScPhm; Geoffrey Coales, MD;
Shelley Monkman. RRT: Myma RDolovich, PEng;
Shelley Monlcman. RRT: Bosco Paes, MD;
Geoffrey Coaics, MD; Barry BowcQ,MScPhm;
Haresb Kirpalani, MD. Dept^f Pediatrics
Haresb M. Kirpalani, MD. aod Medidoe, McMaster Univer^ty, Baniett
Dep( of Pediatrics, MedidDC & Nuclear Medicioe,
Aerosol Lab. Sl Joseph's Hospital, Hamiltoa,
McMaster Uoiversity, Hamiltoa, Ootario, Canada.
Ontario, Canada.
This study was cooduclcd to compare, under
rhis study was conducted to assess the eCOdeocy
fiiodardized experitneatal coaditioas, tbe pulmooary
of aert3S0l depositioa in the lungs of in^ts using
dcpositioQ and distributioo aad tbe fractiooal
a direct method. There is mounting evidence that
depositioQ in tbe veotilator circuit and airway, of
bronchodilaton delivered as aenisols to the
xalbutamol delivered by MDI, Jet nebulizer, and
respiratory tract can Improve the lung functioo
Ultiasooic nebulizer. Salbutamol was cbosen as it is
and clinical state of infants with BPD.
tbe nxist commonly used broncbodilator in infants
suffering from bronchiolitis and BPD. Tecbnetium'99m
We compared the eCGdcncy of M and J (Medic-Aid
Sidestream) in 2 groups of BPD infants:
labelled Salbutamol was administered through a
a Doo-veotilated group, Group 1 (N=9; birth weight
tracbcostooiy (o ventilated rabbits by either an MDI STC+.^2g, post natal age S2+. 31d) and a ventilated
(S puCEs, 100 ug/puff) aided with a spacer placed
group. Group 2 (N=5; birth weight 814+.252g. post
directly betweeo the ETT connection and the patient
natal age S2+.31d). Each received, in random order,
wye (MV15 Aerochamber, TrudcII, Canada)
(Group 1, n=7); or by nebulization (100 ug/kg
cither *^ lechnitium labelled S from either M
(2- lOOug puEb, 5 breaths/puff) or J (lOOug/kg in
in 3 ml techoetium-99m labelled S% albumin).
3ml S% albumin for 5 min); followed 24hr. later by
Nebulization was carried out for 20 mia with a Jet
the other modality. Group 1 received the aertssot
(FX-O-THRU, Hudson, USA) (Group 2 0=11) or
through a £acc mask aided by a ^>accr (Aerocbamber*).
Ultrasonic device (Siemens,Sweden) using either a
standard (Group n=6) or a small (Group 4, n=7)
3,
For Group 2, Mwas discharged into a spacer (MV15
Aerocbamber) placed between the ventilator circuit
reservoir. Lung deposition was estimated by gamma
and the tracheal lube; J was inserted in the
counting of the autopsy lung specimens: mean(sd):
inspiratoiy limb of the circuiL A signiOcantly
greater lung deposition (gamma camera estimate)
as % of amount delivered was actiieved by J in
1 7 a22(ai4) a2Z(ai4) Group
2 11 L13((U1) a48(ai7) a48(ai9)
3 ( 334(L93) a90(a33) a78((U7)
4 7 i29(202) 1QS0-3I) 105{L31)
"Op 4> an other (loupi, p<aiO01
>albutamol was imiformly distributed in the

lungs in group 1 and 2, but showed a
predilection for the right anterior azygous
and the central lung regions in
lobes
ûp 3 and 4. Conclusion: in delivering
Salbutamol to ventilated rabbits, this
Ultrasonic device provides greater lung
deposition but less uniform distribution than
either Jet or MDL Reducing reservoir volume
enhances its efficiency of delivery further,
but also yields differential dc[X)siiion
^
OF-94248
prevent Pneumotach.
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1 1
EV ALUATWN OF FOUR PORTABLE PEAK

Carol Hui RRT MAINTENANCE OF THE RV/TLC RATIO IN
, FLOWMETERS. Rj Sa v MBA.RPFT. DJ Sallons
New Jersey,
l
RESTRICTIVE DISEASE PA Hmper. RPFT. MA
University of Medicine and Dcnlislry of BS,RRT Dcptof Medical Services, The Stamford
True. RRT. RPFT. LB Graf. MSBME, FJ Mflitincz, MD.
Gerry CancUi BS. Ciba-Coming DiagnoBlics Mcdficld. Hospital. Siamford, CT
Dept of Internal Medicine. Division of Pulmooary and
Mass Ted Konopinslci BS. RRT. Univcraily of Ih Introduction : The measurement of peak expuatory
Critical Care Medicme. UMMC. Ann Arbor. Michigan,
Medicine & Dcnlislry of New Jersey (1) Unusual flow (PEF) IS widely accepted u an important mdicaior :
bronchospasm The use of portable

USA
mixed-venous were obuincd from a Ciba-
results the assesimcnt of
Commg M270 CO-oximetcr. Initially .more than 200 peak flowmeierWPFM) has gained increased acceptance i
this regard The National Asthnu Education Program

Id a Dormal population the residual volume
ABG-CO-oximelcr results were identified Ihal met
1
the cntcria of a low Pa02 and high Sa02 (NAEP) has act uandards" lo which these meters should approximately 20-30% of the total lung volume. This ratio
Surpnsingly, these results were consislcnlly being adhere This study was designed to evaiuaie four of the of residual volume to total lung capacity is essenUally the
reported from chtical care patients. A total of newer PFM on the maikci. Personal Besi~(PBl Poekei same regardless of size. A retrospective analysis was
greater than were studied whose abg-CO or
40 pis
Pcak™lPPl The Peak™(Pl and Spu--o-rtow™tSFl. conducted on subjects tested at the University of Michigan
(21 Method Tarpel Hows of ATS wavefomi *24 were
rcsulls consistentlymet this critena AdJilional Pulmonary Laboratory dunng the year^ of 1991 through
produced using a cabbraicd waveform generator. Ten um
pu meeting Ihc above critena continued lo he 1 994 In reviewmg 4.5 2 subject1 tests the RV/TLC rauo
of each brand mcttr were tested ai four fkiw rates, each
included CO-oximetry is routinely performed on ranged from10% lo 80% with the greatest distnbution
flow was repealed five times Readings were taken by a
mixed-venous samples to obtain information necessary
^gleo rfor. Qdevic occumng between 30% and 40% All subject tests were
for cardiac profiles Common among patients were
combinations of one or more of 1) Tylenol cherry
nearest 5 L/M The data obi uicluded m this analysis regardless of their respective
to NAEP guidchnea lor ace respiratory status. The subject population mcluded 2.238
elixir 2) Toul Parenlcral Nutrition (TPN contaming
device vanability males and 2J.14 females, aged 17 to 94. height 51 uiches
greater than 10% lipids) via a tnple lumen catheter.
(31 Resulls
This investigation was undertaken to identify possible to 80 mcbes and weight 60 pounds to 465 pounds. The
target flow 125 6 L/M
causes of unusual mixcd-vcnous results.(2) We subject populauon was divided mto three broad catcgones
compared mixed-vcnous results of twenty-two control based on ethnic backgrounds: Black 634. Caucasian 3,806
patients receiving 650mg cherry Tylenol elixir &/or and Other 72- All fimcUonal residual capaciUes were
TPN via a triple lumen catheter A full spectral scan measured utilizing a Medical Graphics 1 085
on spectrophotometer was performed on Tylenol spiked largci flow 300.3 L/M Plethysmograph. All spirometnc determinations were
venous (in-vilro). and Tylenol mixcd-venous (in-vivol
measured utilizing the Med Soence 3000 and Medical
obtained via triple lumen catheter In a non-controlled
Graphics 1070 systems. Predicted values from Moms and
test, two blood donors mgcsted Tylenol elixir in a
dosage of 650mg Venous samples were dr^wn al 30mm, target flow 5005 L/M
Miller were utilized m the stiwly All procedures were
45min. and 1 Donor venous blood

l/2hr intervals
performed m accordance to ATS standards. From the
containing concentrations of 10%,20%. 30% & 53% 4.512 snidy populauon, 59 subject tests (1,3%) exhibited a
TPN (20%intralipid) tonomelcred to a po2 & pco2 of R V/TLC ratio of less than 20% Twenty one of the 59
40mmHg. were analyzed by CO-oximetry (3) The spectral target flow 719.1 L/M subject tests were clearly identified as Quality Assurance
scan of "normal" blood and that of Tylenol spiked issues while 10 subjects were the restilt of the vanancc of
blood (in vitro) overlay profiles are identical 2.7
the measurement at such small volumes. Only 3 subject
00
Spectral scan overlay profiles of Tylenol blood
(invivo) vs "normal" blood showed a shift in multiple
•• some dau off scale, scale ends at 720 L/M — tests
than
were
50%
identified as having a residual
which could not be attnbuted
volume of less
to methodology or
wave lengths of light above 625 00 nanometers A = ACCURACY = % difference trom target
V = INTER-DEVICE VARLABOJTY ^ % cocfSaert of var. quality assurance issues. This data is supportive of the
The CO-oxuncter results of TPN concentrations of 30%
R = REPRODUClBlLrrY - % wHhin 5% range or 10 L/M theory that the area of apposition establishes a boundary to
& 53% in venous blood were consistent with our initial
findrngs of an abnormally high 02Hb and S02 with a (4) EB, penenge Portable : PFM should be easy to read and which no greater reduction m volume can occur. Tbis
reliable enough lo ensure that readings obtained are useful enables the maintenance of a RV/TLC ratio equal to 20%
relatively low Po2 Results of non-controlled donor
Po2 30min rellecUons of current patient conditions. Many devices even the most severe restnctive ventilatory disease.
blood showed a short term drop in after in
used in the past have not been rcluble for home use
ingestion of Tylenol elixir (4) We concluded ihal
(5) Conclusions There are large variations in ihe products
.
high concentrations of mtrahpids found in TPN

tested as they compare to the standards set by the NAEP.
caused interference in results reported by the
The PB was the most accurate as wcU as ihc easiest lo read.
M270 CO-oximetcr The cause of the resultant shift
Although no PFM lesied completely met NAEP standards
in wave lengths of light seen on spectral scan of
at aU flows, only the SP faded Ihe standards al flow rates
in-vivo Tylenol blood could not be identified
commonly encountered in the assessment of patients with
However, the components of Tylenol are unknown airways disease The PP and P had problems with the high
and would have to be identified and quantified flow tested Clinicians should be aware of specific product
for further study. performance before they recommend PFM for patient use
OF 94-01 5R
A NEW INTERPRETATIVE PARAMETER FOR PATTERNS OF AIRWAY RESPONSIVENESS IN METHACHOLINE PROVOCATION TESTING ; ITS
SPIROMETRY PA Haiper, RFFT. MA True. RRT, ASTHMA PA Harper. RPFT, CM Foss. RRT. RPFT. SAFETY IN A DIVERSE PATIENT POPULATION,
RPFT. LB Graf. MSBME, FJ Martinez, MD Dept of MA True. RRT, RPFT. LB Graf. MS BME. FJ Martinez, LaskowtkiDlVlR.PFT- Unge PA MD,. Stoller JK
.
IntonaJ Medicine, Division of Pulmonary and CnticaJ MD. DcpL of Internal Medicme. Division of Pulmonary MD Kavuru
. M
M.D McCarthy K, RCP T The
,
CareMedicme UMMC, Ann Arbor, Michigan, USA and Cnucal Care Medicme Cleveland Clinic Foundalioo. Cleveland. Ohio. 44I9S.
UMMC. Ann Aibor, MI. USA
As an adjunct to ihe inlcrprelative process w. Melhacholinc Provocation testing (MPT) is a
lacorporaled the FEF25.75 ppd/FVC ppd ral Evidence To date, a positive response to methacholine challenge has and sensitive test that aids ihe chniaan in the
I
safe
suggests the FEF-,5.75 raiher than the FEV, is a more been viewed as an obstructive process characterized by
diagnosis of asthma 0\'cr the last two years we have
soisitive predictor of the presence of morphologic change changes m FVC. FEV, and sGaw The laboratory UMMC noted a significant increase m quenes from outside
Early pCTipheral airway dyslimction can be designates a positive response based on a decrease m
in the lung.
physicians and techmcians regarding patient selection
determined and easily identified utilizing the FEFiS-TS
FEVj >= 20% Although the seventy of obstiucUon has
for MPT and the safet> of the procedure We rc\iewed
been quantified in most laboratoncs based on a change m
ppd/FVC ppd. The dmumshed raUo when coupled with a
FEVj It has been noted that mdjviduals expencnong MPTs done over a 7 month penod m our outpatient
1
reduction in sGAW provides clear evidence of penphcral

cpisoaic bronchospasm may present with a preserved department
auways dysfimction- Of the 672 1 studies reviewed for
F^Vj/FVC raUo Anecdotal cxpenence has suggested that Six hundred and twent>' five patients
spmjmctiy and lung volumes, 103 studies were disallowed
a similar situation can be observed bronchoprovocation m underêni MPT between 5/89 and 9/90 Clinical
&tim the study due to premature cessation of flow and testing. We hypothesized that patients could be divided
indications for testing included cough, dyspnea and
1099 were disallowed due to FVC values above 80% of
into catcgones based on the pattern exhibited with
Data was analyzed from 470 subjects
chest tightness Two hundred sevcnl>' eight of those
predicted- spirometnc measuronents during the chaflenge A
successfully meeting the admission study cntcnon.
tested (44%) had a decrease of > 20% in the FEVl, of
restnctive pattern is defined, for purposes of Ihis study, as
Admission 10 the study required an FVC value of less than one m which the
FEV,/FVC raUo is mamlamed to withm whom 64% were females Twenty nine percent were
80% and good tcmuniil etTon {plateau of 2 sec. or more) 3% of flic baselme value An obstructive pattern is defined currently on or had been on bronchodilaiors (when
Lung volumes were measured utilizmg the Medical as one m which the FE V, /FVC raUo decreased by 4% or possible none x 24 hrs) pnor to testing
Graphics 1085 Plcthysmograph. Spwometnc more as a result of the testing procedure. We Average age was 48 years (range 7 - 90). 62%
dctcrmiiiauons were oblamcd from ihe McdScience 3000
retrospectively examined bronchoprovocation tests were females. 13 4% were mmonlies The lowest FVC
and Medical Graphics 1070 systems Because FEF2S.75 is performed m the pulmonary laboratory spanning a six year
al baseline was 1 23 L (40% of predicted), the lowest
period. The study populaUon was comprised of 1 1
a calculated value, early ccsaaUon of fiow will artificially FEVl at baselme was 96 L (37% of predicted) and
subjects, mcludmg 4 moles and 70 females, age
1 1 7-71
elevate the value thereby reducing the elTcctiveness of the the largest decrease in FEVl was 69% at 5 cumulative
yeBi3, height 61-73 mches,and weight 110-265 pounds
rmio In cases v4icre spirometry is Ihe only data available dose Ufuts (CDU's) There were no scr
Spirometry was performed utiltzmg the Medical Graphics
It IS difTicult to deuamme whether the reductions observed warranting physician intervention
1070 system and the MedScicnce 3000 system
m the FVC are the result of restnciive or obstrwUve
Calibration and spirometnc measurements were performed
disease alone or possibly a combination of both disease in accordance to current ATS guidclmcs Hyper-rcacuve Patienis si
entibca Reduction in FEF;5.75 values establish the responsiveness was associated with a dccbne in ihe FEVj
presence of airway obstruction, while mamlcnance of flow >a 20% Sixtv-thrce subjects wac classified a.s non-
rates with a reduction ui FVC are indicaLve of a reacuve and did not demonstrate a drop of 20% m the
ftamcuve process The FEF25.75 ppd/FVC ppd works FEV| Forty-eight subjects were classified as reactive and
well m dclectmg restrictive and modcralc- severe demonstrated a decline m the FEV, >= 20% Of flicsc 48
otMtnictive panems From spirometry alone we have subjects. 14(29%) preserved the FEVj/FVC raUo to
esUblished that a redo of 40% or less is an extremely
withm 3% of Ihe base line value This group with the
restncuve patlcm not only maintamed then FEV, /FVC lo
good predictor of an increase in RV with a normal or
withm 3% of their baseline, but also rruuniainod their
increased TLC, This usually denotes significant an
FEF25,75/FVCppd, thus exhibiting a prescrvaUon of the
trsppmg and suggests that an associated restrictive
Dow to volume relationship at low lung volumes (FEF25.
highly unlikely With a ratio of 20% or greaia
disorder is 1
75 %prediclcd / FVC % predicted is a new raUo uUlized

the lung volumes may be reduced and flow rates will he
ID the UMMC lab to assist m flie inlcrpietaUon of
incjeued as related to lung volume which is suggestive of
peripheral airways dysfunction ) The 34 rcmaimng
increased elastic recoil The FEF25.75 PPd/FVC ppd reactive subjects (71%) were classified as obstructive
>îh»nr« the mlerpretauon process 10 cases of early This group exhibited greater declines in FVC, FEVj.
limitation lo airflow when Ihe FVC is above 80% FEF25.75. and reF25.7; /TVC ppd ihnn the restnciive
predicted values This is cspeoally true when the group The flow to volume relationship may be nuunuimcd
FEV,/FVC IS normal or borderline The ability lo in the face of significant bronchospasm A prospective
disunguish lung volume utilising this ratio is negated in study of pulmonary mechamca dunng brondiopTOVocation
cues of lung resection, neuromuscular disease and poor testing moy be valuable in identifying the physiology of
this restnctive pattern
lexmmaJ effort.
OF 94-09 OF-94 1
Effectively weaning your patients
from mechanical ventilation is critical
to returning them to productive, healthy
lifestyles. Inefficient ventilation can not
only delay a patient's recovery, but can Using the Peak Expiratory Flow software which automatically antici-
increase hospital costs. The Wave Monitor can help you determine if a pates the natural lung movement and
VM200 provides the information and filter is clogged, assess a response to a works with the patient to decrease
tools you need to make simple adjust- bronchodilator and observe changes in breathing effort and reduce stress. And
ments for superior patient weaning. compliance and resistance through working in any ventilator mode, our
incre;ised or decreased unique Bias Flow decreases ventilator
Tools to peak flows. By making response time and stabilizes baseline
Synchronize Patient appropriate adjust- pressure.
and Ventilator ments on the ventilator you Call today for a complimentary
can lessen the chance for auto- demonstration of the Wave VM200,
For example, the Peak Inspira- PEEP and decrease work to number one for patient weaning.
tory Flow Monitor enables you to

B trigger the ventilator
assess the adequacy of mechanical Also facilitating

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800.451.3111 714.642.3910
and adjust accordingly tive Learning Logic Fax 714. 548. 3091

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1
Open Forum ABSTRACTS RESPIRATORY CARE • NOVEMBER 94 Vol 39 No 1
PRESSURE APPLICATION TIME

AND THE INCIDENCE OF
HEMATOMAS FOLLOWING
ARTERIAL PUNCTURES.
Tom Taylor RRT Sandee Cegielski RRT.
.
Leonard Spechl MD, School of Allied Health

Professions. Victor Valley College and Loma
Linda University, Jerry L Pettis Memorial
Veterans' Medical Center. I 120! Benton
Street. Loma Linda. California 92357
Previously we reported that direct
application of pressure for 10 min to the site
of an artenal puncture compared to the use
of a pressure dressing had a lower incidence
of hematomas The purpose of the present
quality improvement investigation was to
determine if pressure applied to the site of an
arterial puncture could be reduced to the

minimum time required to achieve
hemostasis without increasing the incidence
of hematomas For 12 months our
respiratory care slatTwas instructed to hold
arterial puncture sites for 10 min in the tlrst
group of patients For the next 3 months, we

advised the statT to hold pressure to the
arterial puncture site until hemostasis was
achieved and record this time in the second
group Patients were examined at random
within 24 hours of the arterial puncture A
hematoma was judged to be present if an
area of induration of J 10 mm in diameter
was present We tbund in the first group that
10 of 145 (7%) patients that had pressure
held for 10 min had hematomas In the
second group of patients that had pressure
held only as long as needed to achieve
hemostasis (3 6+ 1 6 min ). 10 of 141 (7%)
developed hematomas (p^ns) We conclude
the lime required to achieve hemostasis
following arterial puncture is usually much
less than 10 min Holding pressure beyond
the lime needed to achieve hemostasis does
not decrease the rate of hematomas
EVALUATION OF LOW FLOW RANGE OF THE

ASTECH PEAK FLOW METER (PFM). Gail Ellison
RS. CPFT. RRT Jim Kccnan BS, RRT, John Salycr
.
BS. RRT. Respiratory Care Service. Primary

Children's Medical Center. Sail Lake City. Utah.
INTRODUCTION: The Aslcch PFM {Center Labs.

Port Wa-shingion. New York) is described by the
manufacturer as a full range device and is graduated
from 30 lo 880 L/m, Wc sought lo test the accuracy
of mcasurcmenis made in ihc low (pediatric) range of
the device. METHODS: 10 PFMs were tested. A
Servo 900 C was configured lo generate How wave
forms m volume control mode of = 40. 80, & 120
Urn. Flow rale was measured with a Timclcr RT 200
scl in the 0-180 L/m range (reported accuracy 1% of
reading). 10 mcasurcmenis were taken on each Asicch
followed by 10 mcasurcmenis on ihc Timclcr. Mean
and SD were computed for each device and then all
PFM's and differences at each level of flow were
tested with Student's t-lcsl, wiih signincance set at
005 RESULTS:
Row in L/m
Mean SD P Value
Timclcr @ 40 L/m 40.2
Aslcch @ 40 L/m
Timclcr @ 80 L/m
Aslcch @ 80 L/m
Timclcr @ 20 L/m
1
Aslcch @ 120 L/m

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1
IDENTIFICATION OF OLDER COMPARISON OF PEFR OF MINI WRJGHTS AND COMPARISON OF TRANSMITTED VS,
ASTHMATICS USING PEAK FLOW ASSESS PEAK FLOWMETERS TO VOLUME REFLECTIVE SP02 VALUES IN PATIENTS
LABILITY DISPLACEMENT SPIROMETRY Gayc BsdgweU RRT, WITH DIGITAL CLUBBING
Pat Wahcn BA RRT RPFT. Vanthiyi G»n MD.
ChUdrcn's Medical Center of Dallu, D&llu, Tcua 75235
DE Abbey. PhD. SF Knulscn. MD. PhD. R
Timnlhv A William,-! AS RRT.
Burchcttc. MS. WF McDonnell. MD. BA Pelcrs.
STUDY PURPOSE: To determine which brand of peak
. .
Children's Hospital Medical Center. Cincinnati,

RRT. Center for Health Research. Loma Linda
flowmeter la the moat accurate as compared to the volume
i
Univcrsily, Loma Linda, CA. USA. displacement spirometer

Idcnlification of asthmatics who present SETTING Clinical, objective, observaliotial study. INTRODUCTION: Pulse oximetry is i
with esscntjally normal spirometry requires a SUBJECT Convenience sampling of 34 children ranging
careful history, and for objective conFir- in age from 4 yean to 17 years, all of whom have
, The I controversy as to
maiion, a bronchial challenge test which is diagnosed reactive airways disease.
whether transmitted (TPO) or reflective pulse
neither inexpensive nor without patient MATERIALS ATOD METHODS: Each patient
performed a pre and post bronchodilator flow-volume oximetry (RPO) is better in patients with digital
discomfort. Peak expiratory flow (PEF)
loop on a P K. Morgan Spiro-Qow volume displacement some caregivers have
lability based on multiple daily measures clubbing. For this reason,
with xpuDmclcr, as part of their outpatient visit. Each subject
may be helpful in identifying patients chosen RPO over TPO in pcdiatnc patients with
The Mini-
was then asked to perfonn the PEFR maneuver on the
increased bronchial reactivity.
digital clubbing This study analyzed the difference
Assess peak flowmeter (x 3 trials), and again on the Mini-
Wright Peak Row Meter was used to compare
Wright's (x 3 txiab) within thirty minulca of Oieu- post between these two methods in a population of
the lability index (PEF max - PEF mm / mean
bronchodtlator apiiomeUy measurement. Every other
PEF) with the National Heart. Lung, and Blood
pedialnc Cyslic Fibrosis patients METHODS: A
subject was asked to use the Mini-Wright's first with the
Institute(NHLBl) Respiratory Symptom Ncllcor N-IO pulse oximeter, verified with die PT-10
Assess second and vice vcraa. Using the student T-test
Questionnaire (RSQ) on self-reported asthma. statistical analysis program, the PEFR'i were compared
The RSQ was admmistercd to all subjects and as follows; Spirometer to Assess. Spirometer to Mini- index finger (DS-lOO transmitted sensor) and from
they were mstructed m
PEF measures. The Wright's, Assess to Mini-Wrighfs.
1cm above Uie right eyebrow (RS-10 refleclive
best of three PEF measures four limes a day RESULTS: PEFR's obtained from the Assess and Mini-
when compared
Wright's were both significantly different sensor. Nellcor Inc.. Hcyward. CA). Three samples
were recorded on a pre -printed diary and
consisted to the volume displacement spirometer (P = <0,05). were obliiined from each site. The patients were
returned after seven days. Subjects
PEFR's obtained from both peak flowmdera when placed into three groups according to the level of
of 1414 male and female non-Hispanic. White,
compared to each other were NOT significanUy different
non-smoking. California residents from an clubbing; control (Nil), mild (N = 19) and severe
(P= >0 05), Comparing the Aascss's values to the Mini-
Adventist Health Study cohort who have been (N =23) as described by Kendig (Disorders of
Wright's also revealed the following trend: The Assess Et. Al.
followed since 1977 with periodic assessment
PEFR was lower than the MW's 55% of the time.
value The Respiratory Tract in Small Children).
of RSQ. A total of 1251 subjects, 771 women The Assess PEFR value was higher Oian the MW's 32% RESULTS: Siudenfs T-Tcst was performed on all
(mean age 65,2 years, range 43-79) and 480 of the time, Tlie two peak flowmeters were actually equal
men (mean age 66.4 years, range 43-80), had 12% of the time
samples on each group TPO = 96.4 SD 75.
Control
accepuble PFTs and PEF measures and RSQ CONCLUSIONS: The Assess peak flowmeter and the RPO 97 2 SD TPO 96.3 SD .74. RPO
1,16- Mild
data. As determined by RSQ, there were 42 Mini-Wnghfs peak flowmeter do not accurately reflect
96 6SD 111 Severe TPO 92.6 SD .98. RPO 94.5
cases of definite asthma in women (5.6%) and PEFR when comftared to a volume displacement
SD 1 .56 The analysis of Oie variance between the
29 cases in men (5,9%). PEF lability in women spirometer. When meter are compared to each other, the
non-asthmatic readings are similar. An Assess peak flowmeter costs our mean differences of RPO and TPO between the
asthmatics was 14.5% (SD 8.0);
hospitalaround $15,00. whereas a Mini-Wright's peak groups was not sutislically significant. The control
women had an index of 10.9% ( SD 6.4); for
flowmeter costs us around $28,00, Both meters have a
men 14.9% (SD 7.5) and 10.0% (SD 5.8) group compared to mild and severe was P = 0.17 and
one year warranty issued by their manufacturer. We
respectively. These differences were P= 13 respectively. Comparison of mild to severe
conclude that it is more cost-effective using the Assess
significant by t-Test {women p=0.001; men p clubbing was P=0 09 CONCLUSIONS: A trend
peak flowmeter rather than the Mini-Wright's in certain of
<0.0001). The sensitivity of PEF lability for
populations suggested that more research be done to
It is
RPO values 2% higher than TPO was observed in the
detection of asthma in women
self-reported determine how each meter ages, how many meters
was 54.8% with a specificity of 69.4%; for
severe group. No statistical evidence that rcncclcd
patients lose, etc This would help understand overall cost
men. 58.6% and 73.4% respectively. These effectiveness. What is most important to remember, SjOZ values read higher than transmitted values in
results suggest that PEF lability can be a however, is that due to the trend of the peak flowmetcra patients with digital clubbing was found Although
simple, cost-effective method to assist in lo be equal only 12% of the time, it is recommended that
this study was limited by patient population, a larger
identifying and following older asthmatic the same brand of peak flowmeter be used when
multi-center study lo include CO-Oximctry may be
subjects. Funding provided by • gruU from the EPA measuring a patient's Peak Expiratory Flow Rate trends.
indicated nF-Od-nifil
OF 94-245 OF-94-24:

December 10-13, 1 994 • Las Vegas, Nevada
1 (W4
B first'jmcfoprocessor sessions. Our outstanding customer service, training,
contiolli-d vcjililator in ]%^fl&oUght it because it (.linical and technical support have helped many of
pro\ ided the ven latest in Ifflmarion technology. More you to log over a million hours on your 7200 fleets -
than a decade later, the 7200 Series Ventilatory System a testimonial to a quality product.
continues to set the standard. We were the first to offer Put all of this together and you'll agree that we're
flow triggering, respiratory mechanics, and PSOL still setting the standard. For more information,
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1 BENNETT.

1
SAFETY AND EFFICACY OF MINI- BHNHFITS A.SSfKlATED WITH A RESPIRATO MULTI-MODALITY PATIENT ASSESSMENT
BRONCHOALVEOLAR LAVAGE (MINI-BAL) RV CARi: A.SShSSMENT-TREATMENT PROTOCOL John Wright MBA BS RRT, Jerry
PERFORMED BY RESPIRATORY PRlXiRAM RESULTS OF A PILOT STUDY Gordon BS RRT, Henri Guidrv BS RRT UCLA .
THERAPISTS FOR THE DIAGNOSIS OF Kevin L.Shrjke MA RRT John E Scaggs BS RRT, . Medical Center, Los Angeles, CA
VENTILATOR-ASSOCIATED PNEUMONIA Kevin R England BA, Joseph Q Henkle MD.
(VAP). and Lanie E Eaglcton MD Introduction: Therapist Driven Protocols and
Kevin R. Bock. OS. RT Rodger Richards. CRTT;
:
other algorithms used as practice guidelines

Mann H. Kollef, M.D. Washington University BACKGROUND: During ihc months of July.
for respiratory therapy usually focus on the
School of Medicine, St, Louis, MO .-\ugust. and September 1993, we implemented a res-
Introduction: The current diagnostic standard
administration of one modality- A
piratory care asscssment-lrealment pilot study on Ihc
VAP is the comprehensive patient assessment protocol for
for the evaluation of suspected orthopedic surgery tloor in our liospii.il The purpose
protected specimen multiple treatment modalities and other
broochoscopically guided ».f Ihc sliidy was to detcmiinc Icasihilily and establish
brush (PSB). We evaluated the safety and cosl-ellci.li\c Ircalmenl pLuis with quality palieni oul-
common interventions is not available. The
accuracy of mini-BAL. performed by respiratory tomes, while maintaining appropnalc Multi-Modality Patrent Assessment Protocol
therapists using a telescoping catheter (BAL communications with physicians and nursing staff.
minimizes the chance of overlooking
Oath, Ballard Medical Products. Draper. Utah) as STUDY DEVELOPMENT & any one type of routine respiratory therapy
non-bronchoscopic technique suspected It also standardizes the
a for IMPLEMENTATION: The study's Task Force intervention.
VAP. Method: Definitions for the presence or developed protocols for oxygen êrapy. aerosolized process of patient assessment,
absence of VAPwere modified from those taken medication therapy, volume expansion therapy, and increasing the consistency of clinical
from the ACCP 1992; 102:5535)and used
(Chest bronchial hygiene therapy using the American application as well as the recommendations
to delermme the individual test's performance Association for Respiratory Care's Clinical Practice by respiratory therapists to physicians. Method
charactenstics (i.e., sensitivity and specificity). Guidelines xs supporting documents. Meetings wen: A patient assessment form (screen) has been
Mmi-BAL was performed by instilling 25 cc of held with the orthopedic surgeons and nursing staff to used as the primary data collecting device at
sterile salme through the BAL-Cath with a synnge inform them of the key components of the pilot pro- the bedside for several years. The assessment
and then respiniting. Safety was assessed by gram. Ten patient evalualors were trained to assess results Vtfere then reviewed by a supervisor, A
comparing patient head rate, mean artenal patients ;ind implement treatment plans. EVALUA-
detailed algorithm (the Multi-Modality Patient
pressure, and artenal oxygen saturation (using TION METHODS: A reference book was established Assessment Protocol) was developed so that
pulse oximetry) at baseline to the worse value that contained the protocols and support material.
supervisors could evaluate the patient
obtamed dunng or withm 5 minutes of the Patient outcomes were evaluated using previously es-
procedure. Quantitative thresholds of > 10^ assessment according to the specific
tablished quality assurance plans. The length of stay,
cfu/mL were required for both the PSB and mim- steps of the algorithm Supervisors were
procedural volume, and cost data were collected.
BAL be supportive of a diagnosis of VAP. given a "pre-test" whereby they evaluated
to EVALUATION RESULTS: More than 50% of the
Results: No complications occurred in the the screens according to the existing
orders received dunng the pilot program were for
performance of 41 mini-BAL procedures. Safety "Respiratory Care Protocol." This allowed the patient technique. This group was then inserviced
profile data is shown in the table below. Twenty- c;u"e evalualnr the tlexibility to initiate one of the ap-
on the use of the algorithm [the Multi-Modality
four PSB samples were obtained for companson proved protocols if indicated. No changes in patient Patient Assesment Protocol). A "post-test" was
with 18 of these paired samples obtained in outcomes were noted and average length of shy then given to determine if consistency had
patients already receiving antibiotics. The remained unchanged during the pilot study compared improved with the use of the Multi-Modality
respective sensitivity and specificity values for
to the base period. Treatment volumes decreased, re- Patient Assessment Protocol. Consistency was
mini-BAL
these 24 paired samples are as follows: sulting in identified cost savings of $5.3 1 8 during the defined as the percentage of similar answers.
100%, 93%; PSB: 57%, 100%. Experience: Our study. Nurses and physicians supported protocol im- Accuracy was defined as the precise choice
experience suggests that respiratory therapists can plementation, and increased communication among of modality according to the protocol.
safely perform mim-BAL m mechanically
caregivers was documented. We believe that profes- Detrimental therapy was the term used to
ventilated patients. Concluîion: Future studies of sionalism of the RCPs was enhanced without comprtv describe assessments that could potentially
nonbroDchoscopic performed
techniques, by mising the ultimate decision- making re.sponsibilities
respiratory therapists, to sample lower airway
harm the patient. Results: Pretest: 37%
of the physician. CONCLUSIONS: The use of respi-
secretions appear warranted based on these
consistency, 46% accurate, 0% detrimental
ratory care protocols is an acceptable method of de-
preliminary demonstrating
data their safety,
therapy. Post-test: 91% consistency, 96%
veloping clinically effective and fiscally responsible
relative accuracy,and cost savmgs ($587 for PSB accuracy, 0% detrimental therapy.
care plans. RCPs at our hospital were able to imple-
versus $95 for mini-BAL). Conclusion: Single modality protocols can
ment care plans that resulted in cost savings without a
Prior value p valui overlook the optimal choice of therapy.
t ^
measured change in patient outcomes. Approval has
41) i-BAL Although RTs avoid harmful choices of
=
been extended from the Executive Committee of the
SaO, (%) 96.0±3,1 0.2568 modality, consistency in choosing the optimal
96.8jL3.2 medical staff to expand hospital-wide. [Respir Care I
Heart rate 99.6jLlO,8 I00.7±10.5 0.6425 994;39(7)7l5-724] modality is significantly improved with the use
of a multi-modality patient assessment protocol.
OF-94-052 OF-94-05
PULMONAHY REHABILITATION REFERRALS VALIDATION OF THE TRIAGE RATING Reductions in Oxygen and O.ximelry Hours
FROM A RESPIRATORY CARE SYSTEM with the ItnplementJtion of Patient Driven
ASSESSMENT/TREATMENT PROGRAM IN THE RESPIRATORY THERAPY CONSULT PnitcKols
JONI D. COLLE B5,RRT,RN
KEVIN L. SHRAKE MA, RRT
SERVICE Richard M Ford BS RRT, Jan E Phillips BS RRT .
Dennis K. Giles RRT. E, Lucy Keslcr, MBA, RRT.

.
David M Bums MD
Me:norial Medical Center James K Sloller, MD. Cleveland Clinic Foundation
Springfield, Illinois
(CCF). Cleveland Ohio
Introduction: Patient Driven Protocols (PDPs).
As pari of Ihe Respiratory Therapy Consult Service
INTRODUCTION: A respiratory care alsoknown as Therapist Diiven Protocols, were
<RTCS) at the Cleveland Clinic Foundation, a
assessment/treatment: program was developed at UCSD to reduce the consumption of
initiated m
our 530 bed teaching system lo rale palienis' scverily of illness lias
used to determine ihe frequency of respiratory
hccn
department resources spent in providing care thai
facility in July 1993. By May 1994, was not medically necessary. PDPs for oxygen
ireatmcnl and patient re-evaluation. This system
Respiratory Care Practitioners (RCPs) us
and oxymctPi' allowed the rcspiraloiA' care practi-

were performing assessments and called Ihe Tnage Rating System (TRS) and rates
on 8 separate axes, assigning up 4 poinis tioncrfRCP) to miii.ik-. hukIiIn. crdisLonlinuc

utilizing physician approved paltents to
protocols on 70% of our patient per axis for a maximum of 32 Triage Pomis, Tnage these sen kvs h.iscd <'n incdiLal si.ili.ippnncd
load. In addition to lowering costs Poinls are ordinalized into 5 Tnage Scores (1-5), guidelines. We e\.ilualed the impact PDPs had on
and improving communication, the where a Triage Score of 1 is assigned to patienis the hours of oxygen and oxymetry utilization and
assessment process has provided an with Ihe highest number of Triage Poinls (i.e , nio-ii the potential to reduce cost. Methods: Patients on
additional mechanism for pulmonary severe illness). Although we have found this raling the pulmonary tloor with request for oxygen
ehabi itati tha system useful over the past 2 years, validation of ihc and/or Continuous Oximeln,' were enixilled in the
improved quality outcomes. METHODS: system is not yel available, To ascertain whether prot(K-ol program RCPs pro\ jded an initial evalu-
Patient assessment sheets were Tnage Ralings correlate with clinical measures of ation to assess the appn>pnalencss ol therapy and
retrospectively audited for
patients' seventy of illness, the current research re-cvaluatn>ns e\ er\ 24 hours lu assess the lieed to
suggested referrals to our pulmonary
examines the association between the TRS (both continue sen leos io deieniiine it there was an\
Triage Poinls and Triage Scores) and clinical Ihc ..I the en
ncide ell I
measures of severily of illness in 98 palienl charge ivci'ids were nbtamed loi a d mnnlh pentKl
itor
RESULTS: Over a nine month period, receiving respiratory care at CCF Between 1/22/92 prior to llie PDP program iuid lor a 4 month penod
650 surgical and 100 medical and 7/14/93, Tnage Points and Scores were assigned after the prt>tocols had been phased in. The nunv
patients were evaluated for their to a convenience sample of 98 patients ordered to
ber of hours of oxygen and oximetry per patient
respiratory needs. Five new receive respiratory care As shown in Ihc table
were detemiined pre and post PDPs. For patients
referrals to pulmonary below, lor both Triage Points and Triage Scores,
in which owgeii or oximetry service was ordered,
rehabilitation were generated significant correlations (Spearman's rho) were
but iic\ci HiiiKikil as, result of the initial cvalua-
I
suit .ng four hom xyge observed with clinical measures, including length of
lioii lorapproprialciK-ss. a dcffcrrcd nx'ord was
EXPERIENCE: The RCPs slay, total hospital charges, charges for rcspiralory
was expanded beyond cask orientation mainlained. Results;
care acliviiics, and numbers of days receiving
to include enhanced patient respiratory care The number of deaths among
assessment skills. When patients did patients in this senes (N = 4) was too small to
not respond to titration from provide meaningful analysis of association with the
oxygen, further intervention was TRS
required from pulmonary
rehabilitation. Consults obtained
directly from the assessment process Wc conclude: I in Ihe current scrics. itic
'
TRS II.l IS
ratings currclaied signincanily with clii
resulted in identification of new
of patient acuiiy. and 2 although further study For oxygen, 1 2.8% of rxxûest were delcrred and
home oxygen patients. In addition,
these patients were provided with needed, these data suggest that the TRS is a v.i
houn. of use per patient deciêascd by 32.8% reduc-
instruction on breathing control and indicator of pnticnls' severity of illness ing total t)xygen houtN hv 1. 762. 1-'or oximetry,
1
self care techniques. I .S,()';; of reqiicsi wlil- d'efcnv.l and hour, of use
CONCLUSIONS: The presence of a [HT paiK-iii (kvuMsi\l I'\ M-i y [I'dik mi: oximetry
.
patient assessment/treatment program hours h> 7,')W (oiulusion krsulis iikiiuilc that
resulted in improved patient signifR-.inl raliKlmns uii Iv aJiu'val in oxygen
outcomes by identifying and reacting
aiuloMTncin houiMliioiigh pioUKi>ldiivctcd ther-
to home oxygen needs that were not
being addressed through traditional apy. W hilc no atKcisi- p.iiieni ris|>oiisc was
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1
TRANSITIONS TO LESS COSTLY MONITORING RESULTS OF PDP

TREATMENT BY UTILIZING PATIENT DRiV IMPLEMFNTATION N.inrv Ti^ml^l BS. RRT
EN PROTOCOLS RCP Jan E. Phillips. RCP. RRT, David M. Burns.
.
Richard M
Ford BS RRT. MD
Jan E Phillips BSRRT David Bums . M MD Introduction; Protocol Driven therapy has been
UCSD Medical Cenler. San Diego CA. UCSD Medical Center since January,
inslituted at
1993. Wilh any new program, careful planning anil
Introduction: Patient Driven Protocols (PDPs) monuoring is essential lo success. The fiscal
allow the respiratory care practitioner (RCP) to ini- impact of protocol dnven therapy has been reported
tiate, modify, or discontinue therapy based on med- and has significant impact on the number and
ical staff approved guidelines, PDPs were intensity of therapies performed. We soughi lo
developed al UCSD to reduce the consumption of create amechanism to deternune if our protocols
department resources spent in providing care that would provide quality care lo our palienis. Method
was not medically necessary The protocols were We selected the high volume service of aerosolized
also structured to make therapy transitions to types bronchodilalor therapy. Monilonng for the success
of respiratory treatments demonstrated to be less of conversion from small volume nebulizer therapy
costly and could eventually be self administered by (SVN) to metered dose inhaler (MDI) device for drug
the patient. We evaluated the impact PDPs had in delivery was accomplished using an algorithm
facil L- ihei
incorporating infonnation from the physical exam.
Methods. The Bronchodilalor PDP incorporated
Daily evaluations were performed for each paiieni
the transition Irom hand held nebuli/er (HHN) to
with orders for bronchodilalor therapy. The
metered dose inhaler (MDI) when the patient
evaluation documents the physical exam, review of
demonstrated the physical and cognitive capabili-
[he lab data, chest xray results. PFT's, secretion
ties to use an MDI. The Secretion Clearance PDP
production, cough effectiveness and respiratory
incorporated the transition from postural drainage
and percussion PD&P) to autogenic drainage
I
hisiory. A plan for therapy is formulated utilizing
ihe algorithm, which provides a lemplale for
(AD) when the palieni uas physically able to per-
consistent decision making and goal oriented
fonn the required breathing patterns associated
therapy. The physician is contacted and the care plan
wilh AD and had a willingness to learn the
is finalized. Selected inrormaiion from tlie evaluaiion
technique Palienis wilh request for aerosol bron-
IS entered into a database managemeni system
chodilators and/or PD&P were enrolled in the pro-
tocol program RCPs provided an initial evaluation
to assess theappropnaleness of therapy and re- each 24 hour reevalualion From this database,
evaluations every 24 hours to assess the patients monitoring is performed for the following: 1)
readiness lor transitions to and/or MDIs

as out- AD Number of patients wiih orders for bronchodilalor
lined in each PDP. Results: For the Bronchodilator therapy. 2) Number of patients meeting MDI
PDP, 498 patients were initially evaluated. 38 conversion cntena as indicated on the protocol
were not started on bronchodilators as there was no algorithm. 3) Number of palienis who were
indication for therapy, 4 were able to start treat-
i 1
convened lo MDI. 4) Documentation of response lo
ment using MDIs rather than HHN, and 136 made MDI therapy, 5) Number of patients who were
MDIs during the coarse of their reslaned on SVN's. Results: A loial of 343 paiients
For the Secretion Clearance PDP. 439 were reviewed. Successful conversion to MDI
patients were initially evaluated. 120 were not therapy, as evidenced by improvement m PFT's or
started on chest physiotherapy as there was no indi- improvenient in breath sounds, was considered an
cation for therapy. 38 made the transition to AD outcome indicator For the year, the average
during the coarse of their treatment. Conclusions: success rate for successful conversion to MDI,
As well as identifying therapy request that may not utilizing the protocol algoriihm. was 98% (213
be medically necessary, PDPs can be structured to patients). Therapy failures occurred at a rate of 2%
facilitate transitions to less costly therapy. The re- (4 patients). Reversion to SVN therapy after
demonstrate substantial numbers of patients
sults conversion to MDI was considered a therapy failure
can make these transitions. The provision of these Conclusion; The rate of success for this protocol
alternative therapies at UCSD require less RCP prompted a change in depanmental policy which
time, fewer supplies, and provide another mecha- makes MDI the method of choice for all patients
nism to reduce department expenses. requiring bronchodilators, who meet the protocol
conversion crilend
OF-94-15
EFFECT OF EXPANDED AUTOMATIC MDI PRELIMINARY EVALUATION OF A PRACimONER-

DRIVEN OXYGEN THERAPY PROTCXXJL— r-rlFHaM
SUBSTITUTION PROTOCOL FOR Mt-'tRRT RandeU Mcrrcn BS RRT. Coniue Une RRT.
BRONCHODILATOR THERAPY EhzAbcih VanCamp RRT. Ivin Nicoletti RRT. David
Cilkui RRT. Mark A Konkle MPA RRT. John G Weg MD
T AlfredsopJlRI . D HauptmanJlRT C FCCP. University of Michigan Medkal Cenier. Ann
Vander^va^f.RRT. D Posi.RRT. P J Fahey.MD Arbor Ml
Loyola Umv Med Ctr, Ma\'wood H, latroductloD: A Continuous Quality Improvement team
studied die oxygen (O^) therapy service at our University
Numerous studies have demonstrated comparable Hospiitl. Using a pulM oximeciy saturaiion (S[02) of 92-
efiTicacy of metered dose lobaler w ith spacer 94% u the urgei range,
ii was found ftom a umple of 454
adult palienison general care floon receiving O2 therapy

(MDI/spacer) to medication nebuluer (MN) id the
thai 37% >94% on O2), 15%
should be decreased (Sp02
admmistratioD of bronchoddalor therapy to adults.
were within target. 18% should be increased (SpOj <92%
infants and children We pre\'ioush' adopted a
on O2). and 30% should be disconiuiued (SpO, ^92% on
protocol that allowed for automatic substitution by air). Methods: A protocol was developed requiring a
respirator,' care s1af1 of MDI/spacer for ordered MN daily Sp02 and allowing respiratory care pracbtioners lo
therapy for adult inpatients who were able to self increase, decrease arid discontinue O2 based on S;02 -
admmister or were mechanicalK ventilated We Target ranges iruluded an SpO^ of 90-92% for COj
administered 6 .496 bronchodilator treatments from

1
retaining COPD 95-97% during the fu^l 72 hr of
paiients;
acute myocardial infarction (AMI) or with unsubte angina
1 1/92-3/93 under thai protocol of which 56 6% were (UA); and 92-94% tor all others, unless ordered by a
deUvered by MN and 43 4% b\ MDI As we physician. The protocol was piloted on three 32-bcd
expanded this protocol we dctermmed changes in general medicine palienl care centers, one of which is
procedure volume, cost and length of stay Our pulmonary. On seven pre-prolocol days (n=126 patients)
and sbi post-protocol days (n=105 patients), all patients
expanded substitution protocol included adults who with O2 ordered had an SpOj obtained. Concurrent records
requned assistance with MDl/spaccr. as well as of the post-protocol patients were also reviewed (466
neonatal and pediatric patients MD[/spaccr use patient-days) for protocol compliance. Results: An
mcreased to 87 9% of the 62.240 treatmeDls given by average of l.S Sp(32 measurements were done per patieni-
the respiratory care department from 1 1/93-3/94 day. CompUance for daily SpO^'s was 95%: 57% of
This program reduced

palieni-days had only 1 SpOj. 24% had 2. 9% had 3. 3%
s-taffing requirements by 7 75
had 4 and 2%
had 5 Sp02's per patient-day. Clinical
fiill lime equivalent (FTF) registry therapists
actioiu dictated by Sp02 measurements before aitd after
representmg $304,990 in annualized salary Supply the protocol was implemented are shown below (target
and medication costs were decreased by $ 1 1 . 1 67 range):
($26,801 annualized) Mean length of stay for Redux
patients with asthma. COPD. pneumoma and
bronchitis was compared for 1 1/92-3/93 and 1 1/93- Pre-prolocol
3/94 and found to be 5 5 and 4 9 days respecliveh (92-94%)
(p=0 22) We conclude that our expanded protocol Post -pro toco I
(92-94%)
for substitution of MDl/s-pacer for MN bronchodilatoi Post-protocol*
therapy decreased labor and suppl>' costs witboul
negatively' impactmg the length of stay
) 1
USING NON-MANDATED INTERVENTIONS WmnN A

VENTILATOR MANAGEMENT AND EVAI.UATION
PRtXlRAM (VENTMANl TO REDUCE AVERAGE
VENTllJ^TOR LENGTH 0¥ STAY (Al.OSv) Jamie
Vnccaro. R R T Oregon Roach. R R f IJnan Clart.
.
.
R R T Donann Miller R R T Herbert i'alnck

Dcparunent of Respiralor> Care ThomiLs JclTerson
Uiiivcr5it\ ilospilal. Philadelphia,
The Venulaior Managemcni and Evalualion ["rogram
,
PA
,
MD .
MARK YOUR
(VenlMan u-as designed lor venulator palienis b\ oiu
I
Dcpanmenl lo ) opiimue respiralorv care services. 2

1
i:ollaboraie care ihrough imcrdisciplmaPr rounds. 3)

provide educatiQiul inscrvices. and 4) collccl and
inlerprcl QA&I dala A tull-timc Respiratorv Therapisl
WHS assigned as Coordinalor for ihis program We were
CALENDARS!
inlcrcstcd
for ihc firî
reviewed a subgroup
m quaniitaimg
year ol VenlMan
iLOSvp' 4U days
ol adull
inlcrvcnlions by the Coordmator
We retrospectively
paUenis wilh ventilator
Tins subgroup ot -13
FUTURE AARC CONVENTIONS
length ol Slav
patients represented only 3 I % ot all ventilator patients m
FY92 but created a large economic burden and high
departmental workload RESULTS Thirteen non-
mandalcd interventions were identified and compiled
from most to least uulized Six most common
December 2-5, 1995
interventions were
lortim I
) structured and ongomg educational
lOO^^'ol. c g ,
I
scheduled inservices
prompting
for Residents, 2)
for feeds within

Orlando, Florida
nutrition support (96%), e g ,
72 hours. 3)optinuzmg equipment (93%), c g . upgrsdmg

and downgrading ventilators. A) stniclurcd physical
assessments (86%). eg paUent/data base acquisition, 5)
.
optimizing wean (86%), e g

and respiratory rate momtonng. and 6) airway
maintenance (54%), e g airway duration, Pip': "stalled"
,
.
patient/ ventilator synchrony
November 3 - 6, 1996
wean, enhance speech Four less com
were promptmg on daily weanmg parameters (26%),
I )
2) expediting hospila! stay (21%), e g mleidisciplinary ,

San Diego, California
discussions with Residents and Departments of Social
Work and Home Care. ?) request for rehabilitation 19%). (
c g bedside OT/PT/Speech. and 4 secretion

.
1
management (19%). e g mucolytic Iherapv Three least

common interventions were changing the wean
modality 12%). 2) homecare educaUon for nurses and
,
I )
December 6 - 9, 1997
New Orleans,
(
family (12%), 3) discharge transport (5%) The ALOSv

for these 43 patients w^ 60 days and the average hospital
(ALOSh) was 88 days In FY91 (Pre-
Louisiana
length of stav
VcnlMan I, there were 48 paUents ( 3 6% of total )
with
ALOSv of 74 days and ALOSh of 95 days

CONCLUSION Non-mandated mtervenlions appear
essential in
proven that
reducmg ALOSv and ALOSh It cannot be
anv smgle one intervention was more
importanl than than another As VentMan interventions
November 7 - 10, 1998
contmue lo be updated, tabulated and analyzed lor
elTectivcness, our slalTtherapisU will mcorporale them Atlanta, Georgia
more commonly Our program serves as a model lor
Respiratory Care Departments in hospitals containing

-open- ICU's
OF-94-24'

lino
1
IHE EFFECT OF PEAS FUKIPFI SEITIIIC OH HE KDMCI OF

»i?rO-PEE?(AP) KEMJDIEW OSIHC TIE 3IIASC8I VM,VE(BV|.
iimiMi t.~lM rbt nn.oF ?EmiSiLv«iiA le.
Cn.FHILUELPBIA.F*. LOWS «. HARMS Ed.D RDT.FIETO)
J.PASCAli Ed.O yOUIGSTOW STATE JJiV. YOMSTMll.Oa.
Ttie BV IS used to leasure AP. It is i device with a one-
way vaive and a port tiat can be opened to Uie
atiosphere. The BV indirectly causes tie exiialation
valve[EV) Ui close for a tiBe feriod based on tlie set PF
and set tidal voluieiWi. Sitll hi^ PF settings tie EV
lay be closed for too short a tiie period to allow
circuitiCTl and lung pressures(P) to equilibrate. Tiis
lay effect tie accuracy of AP leasurejents. In tils
study, PF's were varied froi 10 to 120 L/« in 5 L;i
increients at fiied AF values of 5 and Id ci B20. Tiese
AP levels were cbosen because a study showed 961 of
patients bad 10 ci B20 or less of AP(Respir Care
19Ii;31;1069-71). A Biotek 'VT-KBVTl ventilator tester
was used as tie lung Kdel. Ite BVT linuui lung P was
used to record actual AP. Tie BVT coipliance was set at
0.05 l/oBiO for boti AP values. For S ciH20 A? a 5

ciHiO/1/s resistoriBlwas placed at tie wye witi an
additional B of 20 cil20/l/s in tie eiqjiratory liib of
tie a. For 10 cia20 of AP a 50 ciE20/l/s R replaced tie
20 R. A Purtian-Bcmett 72O0ae witiout buiidifier was
used to record experiiental AP values off tie peaX
pressure digital readout. The 7200 was set for TV of
0.9*l,R« 20/tin,and PF 39 L/i to create 5 ci 820 of AP.
A W of 0.95l,«E16/iin,and PF <2 L/i was set for 10 ci
B20 AP. Budson disposable tubing was used for tie CT.
Tie BV was placed 25 ci troi the wye on the inspiratory
side of the n. lie PF levels were cimged to the desired

levels for leasureient during the eiipiratory pbise so
that when the leasureient was lade tie desired PF was
(Stained. Five Kasureaents were ude at each PF setting
and averaged for both 5 and 10 a B20 AKn=190|. He BVT
iean(SDlwas t.97|0.071aKl 9. 96(0. Ilia B20. Bie 7200
leanlSDIwas 5.*8(0.43)anl 9.37|0.09)ci B20. An

indepenknt t-test(p<0.05) collaring BVT vs. 7200 AP was
perfoned for boti levels of AP. A statistically
significant but clinically irrelevant difference was
found at l»ti AP levels. AJOVA showed no difference in
AP in regard to PP at tie 10 d 820 level. At 5 ci 820
level significant differences were found. He data were
amiqed into ( Sgroups|C)|Gl 10-50,02 55-75,G3BO-10O,G(
105-120 L/1). Tie Sheffe' test sho«d C4 flows caused
tie significant difference in AP due to tie PF. In a lung
Bdel PF does not effect tie accuracy of icastired AP at
10 ci 820 level but at the 5 ci B20 level PF froi 105-
120L/i effect accuracy of AP leasureient.
CLINICAL [MPACT OF P1_IRITAN-BENNF,TT 7200

EXTENDED SELF TEST (EST) UNDER VARYING
CONDITIONS Vincenl Rigei. RRT Dean . Hess. MEd.
RRT. Christopher Hirsch. MPH. RRT. Robert M
Kacmarck. PhD. RRT Respiratory Care and Anesthesia.
Massachusetts General Hospital and Harvard Medical
School, Boston MA
A unique feature of the Puritan-Bennett 7200 venlilalor is
Its ability 10 compensate for (he dynamics of (he patient

circuit based upon an EST In our community, it is
common practice to perform the EST Ijetween padents with

a new circuit and without water in (he humidifier We
conducted (his study to determine whe(her the dynamics of
the circuit change over time, and if there is a best (ime (o
perform (he EST METHODS Six 7200 ventilators were
evaluated under the conditions of SIMV. V, 5 L, 1 2/min,
60% O,. 5 cm H,0 PEEP, peak flow 60 L/min V, and
peak inspiratory pressure (PIP) were recorded from the
7200 digital display, and PEEP was recorded from the
analog display The circuit consisted of 72" of disposable
tubing, a cascade humidifier, in-line water [raps, and a Y-
piece. The Y-piece was connecled to a rubber test lung An
EST was conducled with the circuit cold and dry (time I ),
after adding water to the humidifier (time 2), after 24 hrs

(time 3), and after 104 hrs (time 4) The temperature
delivered from the humidifier was 42 5±0 5 C EST values

recorded were leak (cm H.O), circuit compliance (mL/cm
H,0). and area-volume ratio (A/R) RESULTS
Open Forum ABSTRACTS RESPIRATORY CARE • NOVEMBER "94 Vol 39 No I
ELDCIDATIOH AND TREATMENT OF

PATIENT/VENTILATOR DYSSYNCHRONY
CAUSED BY ADTO-PEEP (PEEP^)
Albert Rlzio, MD. Joe Clirlo, BA
,
RRT, Tom Blackgon. RJ^T. Medical

Center of Delaware.
It has been euggeeted that the use
of extrLnalc PEEP (PEEPj) may
improve patient/ventilator synchrony
In patients with dysaynctirony caused
by PEEPj^. However, a review of the
literature reveals little
documentation eupporting this
treatment. The following case
involves a 60 year old, ventilator
dependant, female with bullous
emphysema, respiratory failure, and
a dya synchronous ventilatory pattern
that waa aucceaBfully reversed
through application of PBEPf The
patient waa maintained on pressure
support ventilation (PSV) of 15
cmHjO Ln the CPAP mode with 5 cmHÔ
of PEEP^. Dalng the Blcore CP-100
monitor, dyaaynchrony, as evidenced
by eaophageal pressure (Pes)
deflections without ventilator
triggering, was documented (Fig. 1).
PEEPji, was determined to be 15 cmR20.
The patient was subsequently treated
with 15 cmH20 of PEEPj; which
significantly Improved
patient/ventilator aynchrony (Fig.
2). Thia case demonstrates that
PEEPe may be used successfully in
the treatment of patient/ventilator
dyaaynchrony caused by PEEPjj.
.^
1

P{-:RF0R\UNCE characteristics of FOLfR F:\PIRATa
RY POSITIVE PRESSURE VALVES.
RusseL T. Reid. RRT, Teresa Cook. RN. RRT TaT>' J. Victra. RRT.
UC Davis Medical Center, Sacramento, California
INTRODUCTION: A companson ot peak expiralory llow ( PEF).
Expiratory airway n^lance (RE), and accuracy of expiratory positive
pressure (EPP) was completed on four EPP valves. METHODS: A
Servo 900C (Siemens-Elema. Solna, Sweden) powered one chamher
of the training test lung (TTL model 1600, Michigan lastmments.
Grand Rapids, MI), simulating spontaneous breatfung on the other
chamber. A 10 mm I.D. endotracheal tube was used Mcusurt'nienLs
were taken using a Stanialc pneumotach (IntriLsonics. Inc San Diegt ,
i.
CA).Paramcleriusedonthe900C»ereViOSUII2..indIE 3 1
Tests were completed at 2 EPP levels 10 and 5 cmH:( ) and 2 TTl.

( 1 I
compliance (Cl) settings (0.2 and 0.4 L/cmH20i. PEF was detined as
maximum How during the exhaled breMh and RE was defined as
iPplat - PEEPtotaiyilow at onset of exhalation. For each \'alve and
condibon, 5 breaths were measured and the mean (SD) was calculat-
ed RESULTS:
(UcmmO
1
HIGH FREQUENCY CHEST WALL

OSCILLATION (HFCWO) IN SPINAL
MUSCULAR ATROPHY; ChinnpciiaA.
Beckerman R; Tulani.- Hospiinl for
Children. New Orlcnns, La.
The purpose of this outpatient evaluation

was to asseis the effects of HFCWO as a
method of airway clearance in a patient
with Spinal Muscular Atrophy (SMA). A
ten year old patient with SMA using
nocturnal negative pressure ventilation
due to chronic respiratory muscle
insufficiency was selected for evaluation.
The patient was clinically stable, but
required daily bronchial drainage therapy
because of a weak cough and secretion
retention. HFCWO was administered
twice per day via the ThAIRapy System
following the manufacturer's
recommended protocol. All HFCWO was
delivered by the patient's family.
Measurements were taken and the
collected data are as follows:
Measured
There comes a time when
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BagEasy'"' Disposîble iM;uiu;il Resiiscitatoi's have away of becoming
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BagEasy's PEEP valve is built in. Otliers say it's because they
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shape for an easy seal. BagEasy comes in adult, cliild, md infant sizes. Find out
what makes it invaluable to vou.
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The First Namk 1\ 1\\(i\ati\i-; Rkspiratory Care
1001 Murry Ridge Drive • Murrysviile, Pennsylvania 15668-8550 USA

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Available December 1994 © Respiruiiics. Inc 1994 Circle 125

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1
COMPARISON Ol A W III A Ihl) WICK HU- M NEW SAFETY FEATURES INCORPORATED WITH
MIDII H M
H'\ S> Ml M lO 111 AriiDWIRH HEATED WIRE HUMIDIFIERS (HWH). SHINJI
AM) SI \\|>\Kl)\i\lll. MORflRfUITS FUKASAWA. BS. RCE. TETSUO M YAGSTOT
1
\SnH \Mt K ni'LIILMlDUIHR. RPT, RCE, RRT. MURAT SABAH, BS.MBA.

A LABORATORY BBNCH STUDY JUNTENDO UNIVERSITY, SCHOOL OF
Ed Bclingon. RRT. J, Fitik. RRT. MEDICINE, TOKYO, JAPAN.
We conducted this study to evaluate
of Pulmoniiry and Critical Care Med the safety features and perfortnance of
i VA Hospital und Loyola Univ of Chicago a new HWH (HPD Medical, San Clemente,
Stritch School of Medicine. Hines IL CA). Performance of the new HWH is
compared to Fisher and Paykel MR-730,
A new heated wick humidificution system whose perfofmance has previously been
(AnaMed) actively humidifies gas by healing a
MET
moist wick within the inspiratory limb of a dispos-
able ventilator circuit. We wanted to determine
how work of breathing, circuit compliance
patient
and operating efficiency compared to standard and
heated wire circuits (Hudson/RCI) used with a
passover wick humidifier (Concha Three-plus, RCI)
. A bench model was developed to compare patient
work of breathing dunng spontaneous breaths, cir-
cuit compliance and lime required to reach 1007f
relative humidity (RH) at set temperatures. METH-
ODS: A model consisting of a two compartment test
lung connected in parallel by a metal bar was
attached to a PB 7200ae (Vent A) so that inflation oi
one compartment simulated a spontaneous breath in
the other compartment. A second PB 7200 ae (Vent
B) was used to ventilate the "patient " model incor-
porating either: a) a wick humidifier with a dispos-
able heated wire circuit, b) a wick humidifier with a
disposable non heated wire circuit, and c) the new
heated wick humidification system. A respiratory
monitoring system (Ventrak) was placed between
the ventilator circuit and test lung to determine pa-
tientwork in Joules/Liter (J/L) during spontaneous
breaths (n=3). Vent A was set lo simulate sponta-
neous breaths with tidal volume of 500 ml. rate of
1 2. peak inspiratory fiow of 40 Umin with Vent B
in CPAP mode at cm H;0 with flow-by set at 10 /
3 L/min. Time required to bring the delivered gas to
> 95'7r RH at 35° C from ambient conditions was
determined by placing a digital hygrometer/
thermometer (Labcrafl) in the inspiratory limb prox-
imal lo the patient connection. Compliance of each
circuit was determined by performing an EST on the
Vent B, RESULTS: The patient work of breathing
was greater with the standard healed wire circuit
(04(U ±.0 2 J/L than either the sLiiidard (0.3X1 ±
1 I
OJ/Ij or wick svsiem III 37^1 ± 01 J/l„ p<0.nO01 ).
The heated wick system reached y5':i RH at 35 C

faster (4,8 ±
minutes) than either circuit with the
.6
wickhumidifier(2l.3 ±2,1 minutes) (p<0,001).
Differences in compliance did not approach signitV
cance. CONCLUSION: The heated wick system
reached desired conditions with less patient work of
breathing than either the standard or heated wire cir-
cuit used with a passover wick type humidifier.
OF-94-162
LABORATORY EVALUATION OF ARTIFICIAL

NOSES
Richard Branson. RRT Kenneth Davis Jr. . MD
Department of Surgery. University of Cmcmnati Medical
Ccmcr. Cincinnau. Ohio
Introduction Artificial noses (AN) are passive

humidiricaiion devices used lo condition inspired gases
during mechanical ventilation. Wc evaluated llie
moisture output, resistance, and dcadspace of 18 AN's

accordmg to the ISO standard (ISO 9360 1992)
Methods A patient model consisiing of a cascade
humidifier, temperature controller. 2 test lungs and a
sencs of tubuig and one way valves to separate
mspiratory and expiratory flows was constructed This
model was venlilaied usmg compressed air (absolute
humidity < 7 mg/L) at 1) V^ = 500 mL and f = 20
b/min. 2) V, = 1000 mL and f = 10 b/min. and 3) V^
= 1000 mL and f = 20 b/mm Dunng ventilation gas
exiting the palicnl model was controLcd to maintain a
temperature of 34±1'C The ventilator used a square
flow waveform and 1 E of 1 3 The model was weighed

and then ventilated for 3 hr and weighed agam to
determine water loss (mg/L) Three of each AN were
tested for three hours at each vcnUlation scUing and the
:sicd)
Mouturr output was dctcrmuicd by Ihe ISO equation

moisture output = 37 6 x (1- water loss with AN/mean
moisture loss without AN) Rcsisunce was dctermmcd
by monitoring pressure drop across each device usmg a
RT 200 calibration analyzer fTimctcr) at a flow of 1 Ui
Results at V, = 1000 mL and f = 10 b/min are shown
below listing the moisture output (mg HjO/L) and
reiisuncc (cm HjO/L/s)
Aqiu + H (27 9. 85). Aqua + FH (28 5 ,

1 .65); Edith
(26.5. 1 47). Edith 500 (21 3. I 73). Edith 1000 (24 6.
2 01); Edith 1500 126 9, 3 52). Rocarc "L" (26 7. 1 59);
Gibeck HVF (30 1, I 95). Hygrobac (30 5. 94). I
Hygrobac "S" l27 1. 2 41j. Hygroslcr l31 3. 2 53),

Intertech 2841 (26 4, I 75). Intcrtech HEPA (2t 4,
1 64). Pill HME (19 9. 1 67), Portex 600 (23 4. 2 84).

Portex 1200 (26 1. 1 23). Viuil Signs HCH (28 1. 2 24);
ViUl Signa HCH/F (27 2. 2 46)
Concluiioni The AARC Conceniui Conference of

Mechanical VentUiton recommends a minimum absolute
humidity of 25 mg Hp/L Several of these devicca are
incapable of meeting (hii standard at a V, of 1000 mL
Several dcvicca are capable of delivcnng 30 mg H,0/L
which meet! the ASTM tUndard for heated humidifiers
None of the devices exceeded the maximum reiistancc of
5 cm HpiUt citablished by ISO Praclitioncn should

be aware of die performance of AN'i pnor to purchase
. ,
RESPIRATORY CARE • NOVEMBER '94 Vol 39 No Open Forum ABSTRACTS
A TWO YEAR EXPERIENCE WITH FACTORS AFFECTING LATEX GLOVE Increased Expiratory Resistance
TEN DAY VENTILATOR CIRCUIT USAGE IN A BLOOD GAS LAB Due to the Normal use of a
(VC) CHANGE OUTS. James A. E)ebbie DiNicoia. Roben ChatbumJ^RT. Rain-
L.
Expiratory Filter- Ryan
Tyra, BS, RRT Jimmy W. , bow Babies & Children's Hospital, Cleveland. OH. Grueber,B HS,RRT University
Norwood, BA, RRT; The Hospital and Clinics. Columbia
University of South Alabama Universal precauuons mandate use of latex gloves
Missouri INTRODUCTION; Normal
Medical Center, Mobile, Al when handling blood samples. In our lab.use of use of expiratory filters on
INTRODUCTION Based on : powder filled gloves appai^nily led to more frequent mechanical ventilators may
available research studies we handwashing, dry irritaied skin, allergy lo powder,
extended our VC change out and higher glove usage compared lo powder free The STAR EXHALATION ISOLATION
interval from every 48 hours hypoallergenic gloves. Powder free gloves arc SYSTEM is regularly used on
to every 10 days. METHODS On : thicker, more durable and can be worn longer with ,
Servo 900C ventilators.
9/1/91 we began changing VC less irritation to the hards This study was to test ihe
HYPOTHESIS: Expiratory filters
every 10 days. Data for VC hypothesis ihai ihe higher cosi of powder free
increase expiratory resistance
cost and nosocomial pneumonia gloves would be offset by their lower rate of usage.
despite normal monitor ing of the
(NP) levels were collected METHODS: Normal usage of powdered gloves
ventilator and the patient.
for the study period 1990- (Kendall brand) and powder free (SafeSkin brand)
METHODS AND MATERIALS; A
1993. NP is defined as per was recorded for 10 days each. The number of
calibrated Servo 900C ventilator
institutional policy, various blood gas assays performed dimng the same period
with the STAR EXHALATION SYSTEM
combinations of clinical, was also recorded. Staff were blinded lo study
and an unmodified patient
radiographic & laboratory results but not glove brand because of obvious
circuit was attached to a
evidence of infection During .
differences between glove types, Average glove
mechanical model of the lung.
the study period there were usage (pairs/blood gas) was compared using a
The ventilator was then measured
no changes in ventilator for inspiratory and expiratory
non-paired l-tesl. Annual glove costs were
protocol. RESULTS For the :
calculated from mean glove usage and projected
resistance without the filter
year prior to 10 day changes blood gas volume, RESULTS: Glove usage {mean
system to get a base-line
S47580 was spent on VC with measurement. A set of filters
± SD) was less for SafeSkm than Kendall (p<0.001.
total NP levels of 120 or were marked and measured for a
see figure below). Skin condition (ie, presence of
10/month. In the 2 years bas The
redness, cracked cuticles and finger pads) appeared
since we have been doing 10 filters were then put on Servo
noticeably improved with SafeSkin. although this
day changes there have been a ventilators in use on patients.
observauon was highly subjective. At 8c/pair, the
total of 234 NP or an average The filters were taken off of
annual cost for Kendall gloves is estimated at
of 9.75/month. Ventilation the patients ventilators
$1,756 (assuming 50.000 blood gases/year). At
levels remained constant randomly from one to sixty seven
4 8«/pair. annual cost for SafeSkin is $5. 160
throughout. The average days and resistance was
CONCLUSIONS: WhUe the cost of the SafeSkin
length of stay on a remeasured. RESULTS: Thirty-
gloves is 500% more per pau- than Kendall, iheu-
ventilator in the ICN was nine filters were measured for
construction allows for longer wear, resulting in less
6.43 days, and for Adult expiratory resistance. The time
than 200% increase in annual glove costs, Ub staff on the ventilator was days to
patients was 4.78 days. In found that because the Safeskin gloves were thicker
1992 $30,865 was spent for 67 days. The least amount of
they could wash theu- hands with gloves on.
VC, and in 1993 $21,014. Our
contribudng to longer use. Improved skin condition
experience shows that 10 day by a filte was 0.85cm
and staff satisfaction might justify the increase in
change outs was a sound H20/L/sec. 'he greatest amount
cost.
economic and patient care e recorded was just
decision. CONCLUSION Our 2 :
under iH20/L/sec. The
year experience has shown a
total savings of $43280 while lidered to be
NP levels have remained
constant.lt is our conclusion r^TTq :
that change outs can be
safely extended to 10 days.
OF-94-057
THE EFFECT OF WEEKLY CIRCUIT CHANGES ON DEVELOPING A PROGRAM FOR Oxide Gas Sterilization on
EfTect of Ethylene
VENTILATOR-ASSOCIATED PNEUMONIA (VAP) MONITORING VENTILATOR-ASSOCIATED Accuracy of BICORE Transducers
RATE Dean Hess. MEd. RRT. Eduard Bums. RKT, NOSOCOMIAL INFECTIONS George Thomas J. Kallstrom.RRT. Roben L, Ch«tbum,RRT.
David Romagnoli. MS. RRT. Roben Kacmarek. PhD. M (ôdhaii.. RRT. Craig Gilliam, BSCIC, Diane Moms.RRT. Rainbow Babies and Children's
RRT Departments of Respiratory Care and Anesthesia. Arkansas Children's Hospital, Little Rock, AR Hospital, Cleveland, OH
Massachusetts General Hospital and Harvard Medical iDtroductloD The purpose of
: this study was to evaluate
School. Boston, MA During an evaluation of heated-wire and describe the perfonnance of a new pneumotachomelci
Frequent changes of the ventilator circuit were once (Neonatal/Infant VarRex Row Transducer. BICORE) and
numidifier^ventilator circuits (HWC), we
thought to be important to prevent nosocomial pneumonia to detcimine the effect of repeated sierilizadon using
m mechanically ventilated patients There is increasing
sought approval to extend our ventilator circuit
ethylene oxide (EtO). This transducer is intended to be a
evidence that the frequency of ventilator circuit changes change interval from 48 hours to 7 days. Our
single use item. However, the manufactuier does stale that
Am presentation to Infection ControldCC) and ICU
does not affect nosocomial pneumonia rate (Dreyfuss.
it can be stcnlized once before use. Method: We
RevRespirDis 1991.143 738) The practice of frequent committees GCUC) emphasized an unproved evaluated 10 new flow transducers. Each was calibrated
circuit changes is costly m terms of both materials and closed system with reduced employee hand with the CP-100 Neonatal Pulmonary Monitor (Bicore)
personnel time We conducted this study to compare VAP contact- We received approval with the before making measurcmenis. A calibrated syringe (Hans
rates and cost reductions with 48 hr versus 7 day circuit condition that an appropriate monitoring Rudolph) set at a volume of 60 mL was used as the
changes METHODS The control group consisted of all
system would be developed without the expense standard. The syringe was pumped al a rale of 30 breaths
adult mechanically ventilated patients for the 6 month l)The number of per minute for approximately one minute. The inspiratory
of obtaining cultures:
period of 11/92-4/93, in which circuits were changed at 48 and expiratory volumes (averages of 10 txeadis) were
ventilator dayfVlCU/month was obtained from
hr intervals On 5/ 1 5/93. the circuit change frequency was recorded from die CP-100 display ATPD)- After
changed to a 7 day interval The study group then consisted
RCS 2)An Epidemiologist
shift report forms;
(al
baseline measurcmenis. each transducer was sterilized

determined ventilator- associated nosocomial
of ventilated patients from 6/93-1 1/93 No changes in
with EtO at a temperature of IZS-UCF for 4 hours
mechanical ventilation practice occurred during this period infections fVAJ) by review of ICU routme
followed by a 4 hour aeration period. The experiment was
Heated cascade humidifiers and unhealed circuits were culture reports and data from ICU rounds; 3)In
repeated until each transducer had been sterilized a total
used VAP were identified using clinical criteria consistent Feb. 1993, mstituted use of HWC
and started
of 4 tunes The transducers were not used on patients
wiih the CDC The cost of circuit changes with 48 hr data collection: 4)retrospectively collected data Inaccuracy was expressed as limits of agreement (mean
versus 7 day circuit changes was calculated from the from previous year; 5) VAl reported to ICC diffcrCTKe, measured minus actual volume, ± 2 SD) for
dislribulion of ventilator days for the control group and the monthly, and to ICUC quarterly. each experimental condition (ie, baseline, and first
study group Patients were suhgrouped per medical versus
through fourth steriUzaiions).
surgical patients, and ICU versus non-ICU patients
VAVIOOO VENTILATOR DAYS Results: The worst case inaccuracy interval for new
RESULTS There were 9858 ventilator days
708 ( 1
1992-48 hr. tubing 1993-HWC probes was -3.9 lo 1.7 mL (inspiraiion. see Figure below).
patients} in the control group and 9 60 ventilator days 1
5.1 CVICU 2.8 Bias increased with sterilization and after the founh time
( 7 5 patients) in the study group The VAP rate for the
1
1
5.6 PICU 3.3 was -43 tnL. Imprecision (SD) increased dramatically
control group was 9 64^ 000 ventilator days SE 98. 95*4
1
rtoi change much
(
after the first sienlizôn but did
CI 7 7-1 6) and the VAP for the study group was 2.2 NICU 1.2
enor observed
1
thereafter Total worst case

8 62/1000 ventilator days (SE 97, 95% CI 6 7-10 6) By
measured- tniej/true, as %) after four sterilizadons was
([
was no difference in VAP
univariate analysis, there CONCLUSION: Our VAI has decreased since
-24%. Both inspired and expired volumes tended to
between the study group and the control group P=0 ( 5 1 implementing a 7 day circuit change policy with underestimate the true values. Conclusions: Sterilizing
PowerÔ 85) Using logistic regression analysis, the odds HWC. Permanent system for monitormg VAI in these transducers with EtO even once dramabcally
ofVAPwere 77 (P=0 02) for surgical patients. 54
1 1
our hospital has been developed (NNIS System degrades accuracy. If these transducers are to be reused,
(P=0 05) for ICU patients, and 82 (P=0 22) for 7 day - threshold less than 5 VAI/1000 ventilator
other methods of decontaminabon must be evaluated.
circuit changes For the 12 month period of this study, the
cost of materials to change circuits at 48 hr intervals was

$50,725 and the cos! lo change circuits at 7 day intervals — inspiratory volume —
was 1 1 .896 The annual time savings for 7 day circuit
changes was 1335 hrs CONCLUSIONS These results
indicate that ventilator circuits can be changed at 7 day
intervals without a significant change in VAP. and we have
adopted this practice at our large university-affiliated expiratory volume
hospital Weekly ventilator circuit changes can be adopted
with the use of cascade humidifiers and unheated ventilator
circuits Changing circuits at 7 day intervals can result in
important cost savings (supported in part hy Puritan-

Bennett Corporation) 1st 2nd 3rd 41h
OF-94-082
) 1 1
PERSONNEL COSTS ASSOCIATED WITH COSTS ASSOCIATED WITH DRUG COST SAVINGS AND AMORTI/ATKJN PKRIOD
UNIT-DOSE VS. MULTI-DOSE WASTAGE WHEN USING MULTI-DOSE WHEN CONVHR1 INt; FROM DISPOSABLH TO
MEDICATIONS rHEDICATIONS PHRMANENT OXIMETER SENSORS. John Newharl
RCP. David Bums MD, Corbeu Mask RRT MS. Richard
Brian M. Daniel RRT. RCP .
Ford RRT BS
MIchaal J. Mahlmelate r. MS. RRT. RCP
Michael J. Mahlmeister, MS, RRT, RCP
Brian M. Daniel, RRT, RCP U. or CaliforDia Medical Center Introduction: We are a 450 bed teaching hospiial. As
U. of California Medical Center Sao Francisco, California pan of a hospital wide Cost Competitive Swaiegy at
San Francisco. California UCSD. a 29% reduction in operating cost was established
lolroduction: Multiple contribute to
factors
as a target for Respiratory Care Pan of the cost reduction
Introduction: The cosi-elfectiveness of unil- determining the cosl-effcctiveness of unit-dose
(UD) versus multi-dosc (MD) bronchodilator
stragedy within RC included an analysis of maienal
dosG bronchodilaior medicalions (UD) versus resources consumed, particularly those ilems of high
medicalions. We evaluated the contribution of
multi-dose bonles (MO) is usually based upon a volume/high 92-93 disposable
the wastage factor of MD
use. by comparing
cost. In fiscal year
number of supply factors We studied the
the amount of MD
medication administered oximeter sensors cost S85.000 We evaluated the cosi of
contribution of personnel factors to the cost- with the amount of MD
medication purchased utilizing permanent sensors (PS) rather than disposable
effectiveness of UD versus MD. Methods: by Respiratory Care from Pharmacy over a six sensors (DS) Methods: Criteria for evaluation includes:
Twenty one RCPs parlicipated in the study, all month period. Methods: We conducted a The sensor would have to be applicable lo infant through
with previous experience using both UD and MD. retrospective count of all MD
bronchodilator adult All sensors would have to be reasonably easy to
Each RCP was timed prepanng a hand nebulizer treatments (albuterol solulion-Schenng) over a apply and stay attached to ambulatory palienls. The
treatment with a UD ampule (albuterolDey SIX month period Dau was compiled oximeters would have to correlaie closely with anenal
identifying the precise dosage administered blood gasses, have good ariifaci rejeciion. and function on
Laboratories), and a MD bottle (albulerol-
each treatment, so that a total volume of pauents with reduced penpheral perfusion. Sensors were
Schering) + an ampule of normal saline. All RCPs medication use could be calculated for this six lested for a one month period on ICU patients.
were instructed to prepare the treatment at month period. This medication consumption Approximately 30 palienls were uâiled wiih both
their normal therapy pace, not to speed Each was compared to the volume of medication oximeters using DS and oximeters using PS Results:
RCP was timed twice for both UD and MD. and an purchased from Pharmacy for that same time hi a SIX montli period before conversion lo PS we spent
average was obtained for each technique period. Results: A total of 13,639 S35.838 on DS to administer 142.838 hrs of oximetry.
both small volume neb and large volu
Results: The average time to prepare the Subsiiiuiing PS would require a one time start up cost of
treatments were as follows: UD 13.95 seconds purchasing 70 permanent sensors with a 90 day warranty
albuier >l solution SIX month period.
(range 9.87 22 15). MD 32 68 seconds (range Total olume of r ion used for these
ai S75 each initially costing $5,250 This amount can be
18,56 - 52.80) MD treatment preparation took 10,260ml of

amortized over 21.000 hrs of oximetry. In our institution
an average 18,73 seconds longer than UD. thisequaled 28 days. In the six months since we convened
o( albuterol- At amounted tc
20ml/bottli :. this
to PS we administered 130.233 hours of oximiiry costing
Discussion: The additional time necessary to 513 bottles of medication consumed to
$ .250 The operational cost for PS dunng this time
1
prepare a MD treatment represents an added provide therapy. During this six month lime 1
penod included $900 for 12 PS that failed and were no

cost factor Assuming an institutional cost of period. Respiratory Care purchased a total of
1.292 of medication. Discussion
bottles and longer under warranty. $1,2(X) for 16 PS lost $2,475 for .
$24.00/hour (salary + benefits) for an RCP. 33 PS desux)yed. and adhesives at S each x 7075 adhesive
Conclusions: A wastage factor of 779 bottles 1
18.73 seconds equals an additional cost of wraps used = $7,075 Conclusion: After the
can be calculated from the difference between
approximately 12 5 cents per MD treatment medication used versus medication purchased. amortization of the initial 70 PS. the cost of oximeu>
versus UD treatment Conclusions: Over a six At $3.26 per bottle, this represents a wastage went from $250/1000hrs for DS to $80/I000hrs for PS
month period, our staff administered 13,342 MD cost of S2.539 dollars, or approximately 18 for a decrease of 68%
treatments Using the figure of 12.5 cents/MD cents/MD treatment. A variety of factors are
treatment, added personnel costs for MD associated with the failure to consume a full
therapy amounted to $1,667. We believe that bottle of MD

medication, such as bottles left
at the bedside, bottles discarded if opened and

these personnel costs should be considered when
undated or low on volume, or taken home m
evaluating the cost-effectiveness of UD versus
lab coats. This can contribute to medication
MD medications. wastage, and added costs lo the Respiratory
Care department and the institution. Practices
which enhance consumption of the maximum
volume of purchased bronchodilator
medications, which may include the use of UD
in specific clinical situations, should be
explored for their potential cost-savings.
OF-94-11
THE IMPACT OF CHANGING VENTILATOR

EFFECT OF EXTEâ)ING VENTILATOR REDUCTION OF VENTILATOR ASSOCIATED CIRCUITS AT 72 HOURS vs 7 DAYS ON
CIRCUIT CHANGES FROM 2-J TO EVERY 7 PNEUMONIAS (VAP) WITH SEVEN DAY CIRCUIT VENTILATOR ASSOCIATED PNEUMONIA
DAYS CHANGES D Orens MBA. RRT JK Sioller, MD ,
S. Krause. RN. M. Fisher. CRTT J. Fink. MS. RRT .

E>eparmienl of Pulmonan and Cntical Care Medicine
.
Hines VA Hospital. Hines n. Section of Respiraton Therapy

T AJfredson.RRT A Earl.RN. R LtrsooJlN. J
.
Cronm.RRT. D HtuptniMi.RRT. P J Faho.MD and P Cleveland Climc Foundauon

Ventilator circuit change frequency ts established to
Cleveland. Ohio 44195
O'KeefeMD minimize YAP If the frequency of circuit changes can
Loyola Uoiversin,' Medical Center- Maywood, Illinois be safely decreased, the costs associated with the care of
Despite early recommendations thai frequeni changes
ventilated patients could be significantly reduced. This
of venulator mbing lessened the nsk of vcnulator-
In tbeir 1994 drafi sidelines, the CDC states that study was designed to determine whether extending
associaied pneumoma (VAP), more recent studies
veoiiiator circuitii should be routmeh' changed no more ventilator circuit changes from 2 days to 7 days
suggest the value of changing circuits no more than
frequenth than Q48 hours but does not recommend a
significantly impacts VAP. A secondary consideration
even 48 hours or, in a single available smd>, c\cn
maximum We have reccnlty was the reduction in supply and labor costs associated
assess whether less frequent venulator
duration for use altered 7 days To
with extended circuit changes. MEFHODS: All
tubing changes reduced the nsk of VAP at ihe
our pobc> so thai ventilator circuits are changed Q7
ventilated patients in our 6 bed RICH and 8 bed MICU Cleveland Clinic Foundauon, ihe currcni study assesses
days rather than oui pre\ious Q2-3 day c>cle The
were studied prospectively over a three year period lo
mean rale of venlilalor a.ssociated pncumoma (YAP) Ihe rale of VAP in the Medical Intensive Care Uml
determine prevalence of ventilator associated pneumonia
per 1 (KX) days of ventilation was tracked lor two (MICU) before and aflcr changing our policy of tubing
(VAP), During 1991 and 1992 all venulator circuits
changes from e\en 72 hours to 7 days All adull
comparable 7month penods pnor to and affer this were changed every C}48 hours. In December 1992, we
patients admined to ihc MICU were studied for 12
change m procedure ITie mean VAP/l<XMf ventilator began changing ventilau>r circuits on a 07 day basis
months pnor and 12 months alici implementing a new
days was 11 9( 2.958 palienls venlilaled for 13.468 All patients were mechanically ventilated with a
policy of changing venulator tubing every 7 days The
days) from 8/92-2/93 After the mstitution of 7 day Siemens Servo 900C™ or Puritan Bennett 7200A
venulator used was Punian Bennett 7200ae wTth
changes the VAP rate decreased to 4 8 {p=6 01
circuit ventilator equipped with Conchalberm Thite™
Cascade humidifiers and disposable non-heated
1
from 8/93-2/94 ( 2,500 patients ventilated for 12,356 humidifier and Hudson No. 161 3 Ventilator tubing set
wire circuits Vcnulalor circuits ot reservoir chambers
(Hudson RCI) with water traps (I5art No. 5275)) placed
days) Average duration ol ventilation for patients with were changed sooner if gross coniaimnauon with
in both tlie inspiratory and expiratory limb of the
VAP increa-sed from 6 2 to 6 7 days (p=0 19) Circmls sccrcuons and/or blood became apparent Policies
circuit WTien compared to the same time period ( 1
m the NlCt I/IMCI had previoush been changed Q
I
months) in the two previous years. VAP per 1000
regarding delivery hurmdity and icmpcraturc did
. ,
Monday Wednesday and J-ndav Adult circuits were not change over the swdy penod Also, VAP was
ventilatordays decreased in both RICUand MICU
standardly defined using insututional guidelines
changed Q48 hours Healed wire (HW) circuil« were (p<0.01 ) as shown below. Ihe number of ventilated
developed by our infection conuol department who
used pre and posl thangc in NiCU/I'ICU (TV<500 patients and duration of ventilator days did not change
assessed the results over the 24 month study penod
ml ) Non-llW circuits were inilialty used for alt other significantly. In 1993. using seven day circuit changes
Monlhly rates of VAPs were calculated per 100
patJcnLs but were replaced at 48 hours with HW circuits our costs for labor and supplies were reduced by
vcnulator-davs for 12 months before and 12 months
with the 7 day prokMx>l for paticni-s on prolonged (>48 $32,517 over previous years (048 hour circuit changes),
after implemenung the new policy and average rales
hours) ventilation suppbes decreased bv CONCLUSION: This study confirms that the
(, osl for
yvcre rrponed No significant differences in VAP
prolonged use of wick-type bumidifler with standird
t62.949iD7[Donth>(uuiualt/cdtuS107.9l3 with a rates before or affcr our policy change was noted
circuit does not increase the incidence of nosocomial
4 1 % de«;lmc m cncuils purcha.scd/ ventilator day) and pneumonia, even in high risk patienLs. lliese findings Overall, the average rate of VAP/pcr 100 vcnUlalor
labor costs decreased by S 1 5,825^caj We conclude suggest that proposed CIX' recommendations for days y^-as 40 for the 12 month penod before the
that Q7 day ventilator cucuil changes did not increase ventilator circuit changes ^ 48 hours can be extended to
policy change (range \9-i) b}). and the average
rale of VAP and rcniltcd in subsluilial nivings m 7 days using wick humidifiers and standard circuiLs, rate of VAP/pcr HX) vcnulalor days was S9 for the
nrppK'/labor costs with reduction m both VAP and cost. 12 month penod after the policy change (range 28-0 65)
We conclude ( I ) non-hcaied wire circuits on vcnula-
tors uulizing rouunc circuit changes oery 7 days was
not associaiod wnlh higher rates of VAP when com-
panng changes cyery' 72 hour^ (2) Annualized
to circuil
savings associated wilh weekly changes yvcre 57% ($17,911)
Our preliminary cxpcncnce docs not suggest a higher
frequency of VAP when changing vcnttlnlot tubing c\'cry
7 days but further data will emerge from this ongoing study
Year and I'rcquoncy of Vent Circuit Change

1
DOES A PROTECTIVE SHEATH ALLOWING REUSE THE EFFECT OF 7 DAY cmCUIT CHANGES ON
OF DISPOSABLE PULSE OXIMETER PROBES ALTER LX)WER RESPIRATORY TRACT INFECTION RATES IN
SENSITIVITY AND RESPONSE TIME? THE NICU AND Piru John W. Salver BS. RRT.
University
GB Russell. MD Department of Primary Children's Medical Center, and the
fl^ Gravbcal. CRTT
.
Utah
of Utah School of Medicine, Salt Lake City,
Anesthesia, PSU College of Medicine. Hershey. Pa. 17033
Conlinuous momtohng of artenal oxygen saruralion by pulse INTRODUCTION: Thcr
oximetry (Sa02) has gamed widespread use As cost of low

ventilator circuit changes
controls have become more vital, money-saving measures However, there
respiratory tract infections (LRI)
is
have also been developed to reduce the instituiional cost of
littlepublished information regarding this relationship
disposable oxuneter sensors Medical Taping Systems
in neonatal and pediairic populauom Thus we sought
(Glcnmort. PA, 19343) has developed a Probe Shield, frequency of our
to determine whether decreasing the
allowing reuse of disposable sensors A regular disposable PICU had
ventilator circuit changes in the NICU and
probe is laminated increasing longevity For each cUnical
any affect on the incidence of LRI METHODS:
Over a
use, the lammated probe is inserted into a disposable
period of 33 months (June 91 through Feb 94)
the
protective cover. We hypothesized that lamination and circuit changing frequency was decreased from
every 48
covering of disposable Sa02 sensors with Probe Shields will lo 96 hours and finally to weekly
(June 91-Feb 92 every
not alter clinical accuracy and response times in dcsaturaied 48 hours. Mar 92-Mar 93 every 96 hours.
Apnl 93-Feb
humans. After informed consent and uisutuuonal approval, 5 94 weekly). During this iime. all LRI were
identified
normal adult male volunteers were positioned supine and and recorded by the hospital's infection control
nurse
monitored continuously by a 5 lead EKG, RR and systemic A rate of LRI per ventilator day was computed for both
blood pressure. Two Nellcor D25 probes were applied, one
each to the Hrst and second digits of the subject's left hand.
Two Nellcor N200 oxuneters were used Respiratory gases
(carbon dioxide, inspired and expired oxygen, and nitrogen)
were measured by Raman Spectrometry (Rascal D. Ohmeda
Inc.. Louisville. CO, 80027). Each subject breathed a 90%
heUum 10% oxygen mixture to desaturate twice, with Fi02
:
controlled so thai Sa02 went to approximately 70%, Then

each subject breathed 50% oxygen (baJancc helium), with
remm Sa02 to 100% At the end of this first test
of
(comparing two regular Nellcor D25 sensors) one Nellcor
probe was removed, larmnaled and covered with the Probe
Shield, and reattached to the same digit. The second
desaruration followed. Sa02 values were recorded every 10
seconds. Response tunes to 5 % changes in Sa02 were
compared. The oxygen saturation values for each of the
probes and the pre and post -lam mated probe was compared
siaiisucally The difference between the two probes, pre and
post-lammaBon. was calculated- The 95 % confidence
iniervals of the mean differences were calculated for each
subject. A total of 447 Sa02 measurements were made for
each sensor in 5 subjects, Sa02 ranged from 62% to 100%
All subjects desacurated to below 70%. The range of subject
mean difference between control and pre-lammaiion was
0.4-1 7 % and between control and post -lamination was 04-
2,6 % There was no statistical difference between Nellcor
sensor controls and the post-laminaLon Sa02s in 3 subjects
For the Nellcor sensors, differences were slaDstically

significant in 2; m one the laminated probe Sa02 was 0.8 %
higher than the control probe, but in the other the laminated
probe Sa02 was I 3 % lower than the control sensor
Differences are wiihm the error range of the pulse oximeters
The response umes were no different between all probes for
each desaturalion Covcrmg disposable oxygen salurauon

sensor probes with a protective laminate did not result in a
clinically significant difference in Sa02 measurements in
humans dcsaturated to less than 70 %. The response lime to
was also not altered.

desatiiration
This research was funded in part by Medical Taping

Systems. GUnmore. PA 19343
OF-94-184
1
CompansonofWorkof BrealhinE(\VOB)and Aimaj INCIDENCE OF RESPIRATORY COMPLICATIONS

RcMiIante(Ra")in Endotrathcar (ETT) and
REDUCTION OF SELF-EXTUBATION
AND ENDOTRACHEAL TUBE (ETTI UNPLANNED USING COMFIT TRACHEAL TUBE
Tnichcii*(om> (TT) Tube* on a T- Piece- JohoJjnNrrgcr
EXTUBATION IN 16,861 PEDIATRIC ADMISSIONS HOLDER - J McAndrew RRT P Brown
BSCRIT . Sicphtn J Connell BA RRT. Horbcn Paincic
OVER FIFTEEN YEARS Lea Lua, M.D., Mark Carroll.
.
MD. Ocpl of Rcspiraion Care. Thomas JcfTerson Univcr- CRTT,CPFT, Somen/ille Hospital, Somerville.
RRT, Dan Levin. MO.
Luis Toro-Figueroa, M D.,
MA
sn\ Uospilal. Phi/atielp/iia P.l
Children's Medical Center and
The University of
Texas Southwestern Medical Center, Dallas, Texas
liilrDducrion Since T-piece and trach collar Inals are often
75235
BACKGROUND The catastrophic effects of an
the final stq) in weaning a patient from mechanical untimely self or accidental extubation is well
venlilstion, il is of importance lo know standard values lor documented We are a small community hospital
WOB and Raw imposed due lo diHerent ETT and TTs INTRODUCTION; The incidence and types o( ETT
the and the multidiscipline ICU care team consisting of
Although this pnncipa! is the well known outcome of complications over a prolonged period of time m MDs. RNs. RRTs discovered dunng a TQM
documcntaiion ol
large pediatric populations are not well known. We
Pouisilles law. Uierc is surprisingly little
reviewed 15 years of experience in 16. 861 process that self-extubation had reached an
measured values m the literature Wc determined a
admissions, unacceptable level OBJECTFVE To reduce the
graphical set of standard values for WOB and Raw of
various [TIT and TTs over a range of mmuic vcnulations METHODS: Data were collected prosoectively on a number of self-extubalions METHOD
In study
daily basis by the PICU attending from Jan 1, 1977 **l, 59 were
patient's medical records
( Ve( Methods A bench study using a double test lung
setup to simulate a spontaneously brcathmg patient was to July 31, 1992, The data were tabulated and retrospectively received (afterTQM report) and a
performed to examine WOB
and Raw of size 6- 1 E ITs collected monthly. The tabulations were cntcna based policy/procedure was instituted to
and size 6 and 8 TTs over minute ventilations of 5-20 Ipm retrospectively reviewed. reduce the number of vanables (le restraints,
Ichanging both respiratorv rate and Vt and using peak flow RESULTS: 01 16, 861 admissions, 49% were sedation. air\vay management, alamts) between
to maintain an 1 E [alio of 1 2 with ihe Bear 5 vcnUlatorl medical and 51% surgical with an unselected patients In study #2 (after critena instituted),
The Adult Lung Function Anaiszer ALFA. Pulmonary ( mortality rate of 094. There were 7,106 initiations another retrospective study was performed with the
Technologies Industries, Ltd was used lo measure WOB ) of mechanical ventilation and 8,61 same basic results For study #3. the team decided
and Raw The data was then examined and graphed intubations. Of those. 2,520 were
to investigate, research and use commercialK
Results At a Ve of on]> 5 Ipm, the #6 ETT demon- 1,667 nasotracheal and 4,427 not specified. There produced tube holders on the market, as opposed to
strated a three fold mcrease m Raw over the HI 5 ETT and were 1.311 respiratory complications or 15% of all the old stand-by, adhesive tape or cloth trach ties,
a four fold mcrease over the «8 ETT At a Ve of 12 1pm. The r tiplic
thereby removing the last vanable TTie case team
ihc inspiraion cannal pressure necdmg to be generated m unplanned extubations 570 (43%), pneumothorax
deemed the Comfit trach tube holder supenor
the #8 ETT. Ihe 87 5 ETT, and the #7 ETT were -12cm 214 (16%), post extubation croup 200 (15%1,
il:0. -2t)cmJI:0. and -35cmHK5 respectively The «6 TT because heavy dut\', use ui all settings, reliable,
mucous plugging of tube 149 (11%), right
imposed twice the Raw of the «8 TT Graphically, the comfortable, ease of use. enhanced patient care,
bronchus intubation 39 (3%), other 139 (11%)
1*6I) TT proved to be identical lo a »7 5 FTT m WOB and stable and secure All patients in the study were
"Others* occurred less than a few times each and
include cardiorespiratory arrest, bleeding from ETT,
orally intubated according to protocol Our
infectious disease physician advises against
pneumomediastinum, subcutaneous emphysema,
aspiration pneumonia, bradycardia, teeth trauma,
nasotracheal intubations as the complications
pneumopericardium, tracheostomy decannulation, outweigh the advantages RESULTS Given a
tube malposition, nose bleed, left mainstem national average of approximatelv 10% our studies
bronchus intubation, kinked tube Of the unplanned found Study* I sclf-extubation-15% (9/59) Studv
extubations the cause was stated for 59 (10.5%) Ml Selfext{ibation-9% (6/34) Study «3 No self
and included seif-exiuoaiion 14 (25.7%i; during CPT extubations-0% (0/24) after existing policy of using
12 (20.3%). X-ray 7 (11.9%), weighing 5 (8 5%), the Comfit with the cntena in Study U2
retapmg 4 (1.6%) moving patient 3 (5,1%), aerosol CONCLUSION Endo tubes have been a part of
therapy 2 (3.4%), bathing 1(1.7%), stanmg IV 1 intensive care medicine since the late 19th centur>
{1,7%1; or secondary to coughing 6 (10.2%), Accidental extubations are statistically relevant and
secretions 2 (3 4%), or maternal factors 2 (3 4%). with enough senous complications to warrant
CONCLUSIONS: The incidence o( complications of constant vigilance Our cxpenence along with
intubation is relatively high (15%), with unplanned others, that heightened awareness (Hawthorne
Conclusions There are dramatic dilTerences m Ihe WOB extubation (43%) being the most common of these and
effect), patient, family, staff inservice, sedation
and Raw imposed bv the various sizes of endotracheal tubes Of unplanned extubation, the most common causes restraints are key ingredients inreducmg unplanned
which musi be considered wiien inmbaling a patient There are patient self extubation; during CPT. X-ray. and extubations Unfortunately, not enough attention
IS a dramatic dilTerencc m WOB of vanous tracheostomy weighing; and secondary to coughing. has been paid to the actual tube and its secunng
tubes, which is especially important for trachcostomv
device Our experience has been and continues to be
paiienis who are dilTicuii to wean with limited reserve to
WOB and Raw We have initialed a -the proper ENDO TUBE PROTECTOR (ETP),
overcome the imposed
the Comfit, the incidence of self- extubations
study to compare Ihcse bench results lo those in the climcal
decrease significantly
setting to assess tube patcnev
OF-94-242
OF-94-091
TRACHEOSTOMY CURRENT IN THE 1990's INSPIRATORY WORK OF BREATHING AIRWAY RESISTANCE TIIROUCn
CLINICAL PRACTICE IN AN URBAN TEACHING IMPOSED BY THE ENDOTRACHEAL TUBE NEONATAL A PEDIATRIC
HOSPFTAL CL Kasoer RRT. CR Stubbs RRT, JA Barton, AND VENTILATOR DEMAND VALVE DURING ENDOTRACHEAL TUBES
KS Hazel MS. JR Hedges MS, DJ Picrson MD, Harborview PRESSURE SUPPORT & T- PIECE WEANING .
Medical Center. Seattle, WA. Introduction/ Background VALIDATION OF A WEANING PROTOCOL.

Tracheostomy (Trach) is a commonly performed procedure A Sanloro.RRT BG Wilsoo.RRT, J Mclioncs,
.
m hospitals, done for multiple reasons, by several services, Vîrae Hill BSc RRT Military College o( Health
MD. Duke Universilj Medicnl Center,
with pts located throughout the hospital in Ihe absence of a Sciences. DHAHRAN Chnslopher C Miller BA RRT
Durham, NC
defmed institution wide procedure for assessment, and wilh David Dyer BSc RRT. Vicki Foulkrod BA RRT.RCPT &
no recenl literature to descnbc current trach management, Mahmoud Barbara MD King Faisal Specialist
Et Increased work or hreathinft (WOB) can
wc conducted Ihis retrospective study Malenals and Meth-
Hospital and Research Center RIYADH, prolnng the need For renlilalnry .support.
ods Harborview Medical Center is a university operated
Kingdom Saudi Arabia
of Airway resi.slance (Raw) is altered hy
murucipal hospital, and level trauma center, with 320
I
INTRODUCTION The Pressure Supporl (PS) weaning endotracheal tuhe (Ell ) sir* and in.'jpiratory
beds ( 38 ICU. 87 acute care, and 26 rehab) Trach pts arc
dispersed throughout
1
all of these areas We

reviewed Ihe
protocol used by Respiratory Care Department in Ihe flow rale, thereby efTeclinj; the imposed WOB
CSICU al King Faisal Specialist Hospital allows the ,
for Ihe pntient. MeASurementt or Raw thrntif;h

medical records of all pts for the fiscal year 1 992-93 coded
therapist to discontinue ventilator weaning al PS 5 - 10
bv the OA&I
Department as havmg trach status by dx code ndult El I's (uhefi have been puhli.shed.
cm H3O, and progress lo an extubation protocol.
or undcrgomg trach by procedure code We attempted lo However, (he men.'ûred Raw thrnuch sinndard
It is assumed that a PS level of 5 - 10 cm 8,0
answer the following questions How many irachs were I ) neonatal and pediatric ETT's not known. Toi.s
performed on what population'' 2) Who performed/managed overcomes Ihe resistive load imposed by the ETT
determine the relnlinaship, we examined (he
the Irachs"* 3) What post care was given, especially by and the Siemens 900C venlilalor this ossurnplion If
Rnw or neonnlnl ond pedialric ETT's a(
RCP's'' 16.491 pis were admitted m the fiscal year 1992- IS valid we should be able to safely exiubate Irom this
varying Dow mles uîng a bench model.
93, ofwhom 20 were identified as havmg a trach Wc
1
level of ventilatory support which simulates the work of
reviewed the records of 109 pts, (3 were unobtamablc and 8 breathing (WOB) post eidubation
METHODS: ETT si7c 2.0 - 5.5 were sdidied.
were miscoded) These records compnscd 147 admits Re- METHOD: We prospectively studied (9) post Flow ra(cs were vnrird from 3 - 25 LPM
sults0{ Ihc 09 pts. 74% were male and 26% were female
1 operative, cardiac surgical patienis wilh no pre-existing (hrough each (iihe. The Calihra(ion Annly/fr,
Age ranged from 13 lo 83 (mean±SD = 44 5±19 8) 11% lung disease on the day of extubation We measured Scries RT-200 fTimeler Ia';(rumenL<; Corp.
died, 29% were discharged lo home, 39% to subacute care WOBp (patent) using Ihe BiCore CP-100 Pulmonary Lnnca.';(er,PA) was used In measure Raw in
ccnlCTS. 12% to another hospital. 5% to nursing homes, Monitor dunng six stages of PS weanmg, T-Piece cm ll20/L/sec. Three mea.surcmenLs were made
and 5% to other inslituuons Pt dx mcludcd trauma 43%, weaning and alter exiubalion using a mouthpiece (MP) a( each seKinf; and averaced. The calihra(ion
CVA 12%. pncumoma 10% CA 7% and other 26% Pts .
+/or Facemask(FM) connected to Die (low transducer
nnaty7£r was /rroed prior lo each chnnge.
underwent trach for ihc following reasons 21% prolonged Nomial Range WOB= 3-0 6 J/L
20% closed 5% spmal cord inju- RESULTS: Rnw increaiês wi(h decreases in
ventilation. head injuries,
RESULTS: WOB J/L) vs Weaning Condition(
ncs. 22% facial injunes. 3% epiglotitis, 6% other H&N PSMax PS15 PS10 PS5 PSO PSO TP
ETT sire and incren-ses in (low ra(es. See
surgery, 1 6% other intracranial bleeds and 8% other Ad- CPAP 5 5 5 5
(trnph.
mitting services were Gen Surg 29%. Medicine 25%, Ncu-
Mean 0.03 04 13 0,39 0.66 91 67
rojurg 20%. Ncuro 11%. OTO/HNS 5%. Rehab 5% and
other WTviccs 3% Length of stay ranged from to 1 36
SO 0.04 0,07 0,12 0.26 17 0,29 0,19
In all patients, WOBp increased above
I
J/L when
days, (mcanlSD 32 4t30 4, median 24) 63% were Inched
PS was reduced below 5 cm H O & CPAP 5 cm H -O
that admiisionThe procedure was almost always done in
the operating room Services pcrformmg were Cicn Surg
and decreased after exiubalion The gf eatest WOBp
was seen whenboth PS and CPAP were reduced to
(17%), oro/FIN (29%). Neurosurg(14%). OMFS (1%).
Bums Plastics (2%) 47% of those trached were ventilated 0cm H.Op^ 0005 The WOBp at PS 5 cm H;0.
on admission, 63% were ventilated ut some pomt m thcu
CPAP 5 cm HjO was wiihin the normal range of WOBp
hospital iitav. 38% were never on ventilator Of the pt.i wilh (p > 10) There was no diMerence in WOBp between
trochs 2/3 had orders and 85% had progress notes pertain-
T-Piece&PSO, CPAPScmH.O p>0 10 The CP-100
ing to trach marugcmcnl In 36% another service vnu con- monitor displayed post extubation WOB as WOBv
sulted for trach management 100/147 admissions hod RT (ventilator) 07 /-0 01 J/L when the MP wos used
fii<l one on days post trach
notes regarding trach. the When the same measurements were taken using FM
(mcanlSI) 1 2l5 5) 81/147 had notes pertaining to cuff (in 2 jf 9 cases the CP-100 displayed WOBp
) . 58 &
volume K8/M7 had notes rego/dinit cufT pressure C^ oflclu - 86 J/L respectively
UOO Wc determined that many difrcrcnt servicc!i, locations CONCLUSION: The PS level of 5 cm H.O & CPAP
and dx ore involved in pts with trochs We conclude there m of 5 cm H;0 most closely matched the normal range of
a need for access to all Iroch pu by multidisciplinary exper- WOBp +/- 33% The results in this group of patienis
( )
CONCLUSION: Using our nomogram, one ran

tise A natuiol role for RCP's is to coordmotc this expertise validates Ihe use of the weaning prclocol in the CSICU
management We have initialed a predic( impmed Raw For a given ETT size and
and lo facilitate this However more study 15 required lo ovnluate the WOBp
mullidiscipltnarv trach team and plan to study impact
flow.
its In recently exiubaled pationls using both mouth piece &
OF-94-212 face mask lechniquos OF-94-ii9
1
COMPARATIVE EVALUATION OF
ENDOTRACHEAL TUBE RESISTANCE IN
RECENTLY EXTUBATED INFANTS AND
CHILDREN
Tom Malinowskj BS RCP RRT. Ranc^y Scott BS RCP

RRT. Leo Langga BS RCP RRT. Louis Thnh BS RCP
RRT, Mark Rogers BS RCP RRT. Loma Linda
University Children's Hospital. Departincnt of
Respiratory Care, Loma Linda, CA
Introdiirdon: Pediatnc veniilaior managemeni aid
weaning is dependent on airway patency Wc
hypothesize that partial occlusion of pediatric
endotracheal tubes occur more ofên than is recognized,
in spite of adequate humidification and hydration We
sought to compare Ihc patency of endotracheal tubes
extubaicd from mechanically ventilated patients in our
neonatal and pediatnc inlcnsive care units against control
endotracheal tubes Methods: Wc collected fifty (SO)
endotracheal tubes of varying sizes from patients recently
extubated in the NICU and PICU Two evaluations were
performed on the study tube' 1 ) a visual inspection. 2) a
proximal pressure comparison Each Oibe was visually
inspected for obstruction and given a score of through
4 (0 = clear. I = <25%, 2 = <50%. 3 = <7i%. 4 =
complete obstruction) The pressure comparison
introduced continuous flows of 4. 6. 8. 10 and 12 LPM
into the ET tubes and measured proximal pressures to
determine the resistance to flow caused by obstruction
(AR) Flow rates used on the study rubes coincided with
the flow rates used on the mechanical vcnlilalors prior to
extubation Control tubes of matched size and length
were used for comparison against the study tubes
Results: Of the 50 tubes. 16% (8 tubes) had some degree
of visual obstruction ( 4 tubes score of 1 . 2 tubes - score
of 3. and 2 tubes - score of 4) Comparisons were made
of proximal pressure changes between the study tubes
and the post extubation t\
z 30 matched comparisons (:
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1
NITRIC OXIDE (NO) DELIVERY WITH HIGH

FREQUENCY JET VENTILATION (HFJV)
WITH THE BUNNELL LIFE PULSE
Joanna Masi-Lvnch BS. RRT. Kathleen Richards
RRT. John SaJyer BS. RRT. Ronald Day. MD.
Dcpartmeni of Rcspuaiory Care and Dcparunenl of
Pcdialrics. Primary Children's Medical Cenier and
University of Utah. Sail Lake City. Utah,
INTRODUCTION: We sought to lesl ihe uuliiy of a

system for adminislenng and monitoring niiric oxide
concentration [NO] during HFA'. We METHODS:
measured [NO] with an elccuochcmical analyzer in
both a icsl lung (500 mL
ngid flask) and an ETT
adapter during HFJV w.ih conventional vcniilator
(CV) rales of (CPAP). 5 and 10 per minuie. HFJV was
set at a f = 420. PIP = 20 cm HjO. on time 020 sec
and Fi02 3 The CV was scl ai PIP I7 cm H2O. PEEP
3 cm H2O. T[ 0.4 sec.. FiOj 0.3. an. NO
was delivered through IV luh
rigid : HFJV
circuit wiih a plasiic Y-connector between ine siiicom

and the green filter tubing immediaiely distal lo the
pinch valve. (N0| was sampled from a port in the
boilom of the test lung, A 3 mm Hi-Lo jel tube was
inserted through a rubber stopper al the top of the
flask. [NO] was also sampled at the ETT using a side
port sampling adapter. [NO] {mean ± SD) from the icsi
lung and ETT adapter porl were compared using

ANOVA with significant established as a p < 0.05,
Addilionally. we measured [NO] al the ETT adaplcr and
in ihe gas evacuated from a chesi lube in three palienis
during HFJV as well as methemoglobm levels
(HbMET). RESULTS: Results for [NO] are reported ir
parts per million.
IN VrfRO DATA
CVraic n |N0] Test Lung [NO|FT
INVTVODATA
1
Opkn Forum ABSTRACTS RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1
SI i n I
\in, Johmu
r, rXirham. NC
hxlnicdqxircal Membrane (H>pcnalnin (ECMdl
cl> used Ki licut rmnulL-s uith uifili<>a-<ipir3Uir>
(ARDS) patients who may also benefii from

Kilha I rrpinlfd m ihu ronlrul'lnvcrse Ratio VentilaUon (PC-IRVi.
nrgisin The number itT pnliainc palienis ire^lt-J uiih Paiiei ) therapy n»]Uire inline analysis of
|-jE',MO 15 sigiuiicaniK smaller « ith less imprevsn k sur* i* j1
i NO The n types
mus {072. kfi ) Ihc usei'l Ll MO m the pcdiauii f NO analyzer .linically arc Chemilui (CLI
t
It
and electrochemical (EC) Observation of clinical gas

of FX'.MO 1(1 Ileal a -1 >car oM male with Acule ( hesl
analyzers has shown the accuracy of measurement to be
S>Tidromc (ACS) a-^Mviaicd wilh Sickle Cell Hcmoglnhin
(SSIIb)
influenced by the duration of inspiratory pressures We
JR had a hisIinA ol mullipk- liospKal admiviiims evaluated a CL and an EC analyzer to determine if varying
due (ocnmpticalH>n.Na.vMX'iated uithSSHh He prcscnledki duration of inspiratory pressure by changing I.E ratio would
the I.K with a line da> hislur> ol hack & abduminal pain He influence the accuracy of measurements Methods We used a
Ma> jdmilU-d Mith a Sp02 '~>' i>n luum ait and a W^ Puritan Bennett 7200 (Punlan Bennett Carlsbad CA i
hemoglobin o( f> d gm dl I'hj-.ital c\am revoaled moderate ventilator with "Pressure Cycled Ventilation'' sofiware The
respiratno distress with a rcspirat(«> raic of 49, pulse of ventilator was connected to a rubber lest lung via a standard
130. BP of 1 10 fiO and a Icmpctalurc of ^9 1 degrees disposable circuit devoid of a humidifier SOOppm source NO
centigrade Initial C'\R revealed iioair space disease The gas was mixed via a special stainless steel Bird Blender (SSD)
patient was treated wilh supplemental o\>gen\ia nasal (Bird Corporation Palm Springs CA ) wiih Pure Nitrogen
cannula at 2 1 I'M 2-4 hmirs later ;i repeat <'\R re»eakd
LLL itiTilUatc & cltusion Ik «as iranslerred to Diike ventilator The oxygen inlet of the ventilator was connected
liuverîl> Mcduaii enlerlof lunhcrliealmem Wotkupal oxygen. Gas exiling the ventilator was
to cUnical NO-N2-02
DL MC: mcliukd a (
' \ 1 scan w hith re. caled consi.lidation
as set by the ventilator oxygen control and the external SSB
of the left lung, increased opacii\ in the nghl lower lobe and
dial Thus oxygen and NO concentrations can be manipulated
pnihable ikcIuskhi of the left main stem bfimchus The
The No analyzers an API 200 (Advanced Pollution
paUent was intubated appioxiinatel} I7 hour> aUcr
Instrumentation San Diego CA CL type and a Micro Medical
admi«ion to !)l MC
for mechanical * entilation and to
t
(Micro Medical Kent England) EC type were connected to the

circuit twelve inches from the ventilator outlet The tests
Mihn Hing II rpla.

ventilator without changing the results. Data was collected a
iiKludin^; liitih I (ii|UtiK\ i
)-.iill.]iot\ \ inltlaln'n < AK at I.Erabosof 1:3. 12. It, 2 1, 3 1.4 1 At all IE sellings
htvtpital hnur IM) revealed complete upaciflcaunn of hHh the ventilator was set ai a PIP of 50cm H20 1 breaths per 1
lungs The patient was deemed to have a greater than 9(yi min. and 22% oxygen Al each setting change the system wa
chance ol monalit> Uronchi.tscopic removal of secretions allowed to equilibrate fur two minutes. A mean was derived
was not piMsible due to hemtxixnamic instabilil) and \'cno with both devices at each IE
by collecting readings
setting
Artenal f:CMO .las initiated I he patient was suppt'>ncd over one minute Results The following table shows the
withhCM()at lluMsni llKml kg min panided by a ft"
mean readings of each device at each IE ratio, with a
roller nnga
Therapcuuc hronthoscopy was perl ormed twice a da> whili
K!M() was maintained witheMcnsive mucous pluj
support
l:E RATIO 1:3 II
removed dunng each bmnchoscop) The patient shnwed
remarkable improvement bilateral clearing of the C\R &
over U»c bCMO
course LC'MO was discontinued after 106
ECmean 34 7 35 1
hours and mechanical ventilation was discontinued 6 days

after decannulation fmm I (Sfn [ht- piitient was
discharged on hospital d.i> 2H w iih normal neurolngit
function, no supplemental >\\t:Lii. and a normal C\R I
The i;i-SO kejiisin rL(>.>its 1-1 cases of ACS e NO val
treated with RCMO with a loial survival rateof 26T We as compared 1:3 V as 0. (
report the Hrst pedia ordinal regression values for (he successiv
bC\' ofLt levels for Tirm signiricantly increa
aggressive and luxurious bro[Khi>s4.op\ s for NO P< 0001
Conclusion Each instrum
at
obstniction. ECMO should he considcrc similar pattem of increasing values on each IE le
theiap) in patterns with refractory airwa; ugh the mean values for successive levels of IE r
brought on h> severe mucous plugging atistacaUy signincant it remains
s clinically signiHcani
AEROSOL DELIVERY IS AFFECTED BY PREDICTORS OF FAILURE IN NEONATAL HFOV

1 vnng K Bower RRT, Peter Belit RRT,
AEROSOL GENERATOR POSITION IN HIGH
FREQUENCY OSCILLATOR VENTILATOR Uurcn Pcrlman RRT. John E Thompson RRT.
James C Fackler MD. and Jay M Wilson MD
CIRCUITRY. Children's Hospital • Boston. MA
An oxygenatioo index (01) of greater than 40. is a
Davi d SGanonCRTT .Douglas D Deming MD. Gerald widely accepted indicator for initiating extracorporeal
A Nyslrom MD: Departments of Respiratory Care and life support (ECLS) in neonates on conventional
Pediatrics Loma Linda University Medical Center and ventilation (CV). However, many infants who fail CV
Loma undergo a trial of high frequency oscillatory ventilation
Loma Linda University School of Medicine.
(HFOV) prior to ECLS Unfortunately, Oierc arc no
Linda, CA accepted guidelioiis'to indicate HI=OV failure Wc.
With the increasing use of high frequency therefore, evaluated critena for the use of ECLS in
oscillatory ventilators (HFOV). clinicians have begun neonates treated with HFOV (SensorMedics 3100A)
delivering aerosolized medications through HFOV usmg a high volume strategy Ventdaior and blood gas
circuitry We asked whether the location of the aerosol daU on all potenUal nonsurgical ECLS neonates
treated with HFOV
between 1/92 and 5^4 were
generator in HFOV circuits would affect the volume of
retrospccdvely gathered from a
aerosol delivered to the end of the endotracheal tube Wc
(Ol)
aerosolized a 41 mot phosphorus solution through a (P(a/A)02). were
ygen tension ratio
commercially available aerosol generator (AG) (Hudson calculated Additionally, a ventilation oxygenation
« 1 790. mass median diameter 5 1 \xm) placed into a index (PaCOj x OI=VOI) was developed to include data
HFOV (ScnsorMedics 3100) circuit The baseline on the efficiency of ventilation. Criteria for institution
ventilator senings were; frequency 10 Hz, amplitude 25 of ECLS in Uicsc patients was highly variable and based
cm HjO. mean airway pressure 15 cm HÔ. inspiratory' solely on an individual practitioner's impression ihot
HFOV had failed. The Ol. P(a/A)02. and VOI. were not
lime 33%. and circuit bias flow rate 15 L/m We
calculated prospectively to aid in patient management
positioned the AG's in the inspiratory limb of the
decisions Seventy-four outbom neonates were
ventilator circuit at three different locations: immediately evaluated 40 MAS/PPHN. 26 sepsis, and 8 with oOier
distal to the humidifier (62 cm proximal to the patient diagnoses. Forty-one neonates (55%) responded (R) to
wye), 10 cm proximal to the patient wye. and between HFOV avoiding ECLS (68% MAS. 35% sepsis, 63%
the patient wye and the endotracheal tube We collected other) while 33 (45%) did not respond (NR) requiring
the aerosol sample on a glass filter paper ((ielman) ECLS Seven (5 septic. 2 MAS) of the NR required
emergent cumulation making data acquisition
located in line between the end of" an endotracheal lube
impossible These patients were excluded from further
(3 5. length 15 cm) and an artificial lung (compliance I
analysis There was a slaiistically significant

ml/cmH;0) The AG's were run for 15 min at a driving dilTcrcnce between the R and NR groups with regard lo
now rate of 8 L/min. We removed the filter paper and initial and highest Ol, P(a/A)02. and VOI (p< 001)
placed it in 10 ml of deionizcd water to resuspend the (table). Eighty-seven percent of the patients with an
phosphorus, I wo samples of the resuspendcd phosphorus Ol>60 required ECLS. while only 29% of those widi an
solution were analyzed in duplicate by a OI<60 required ECUS In the latter puUcnts, ECLS was
instituted due lo pcrsistint air leak or cardiac arrest.
spcctruphomeiric iiiclhoiJ Five aerosol izat ion were dune
There were no deaths ui the R group and 6 deaths in the
ateach location with five AG's (25 studies for each
NR group Within die NR group die uiitial and highest
location) Wc calculated the percent of phosphorus mean Ol in nonsurvivors was significantly greater dian
delivered and analyzed the difference between the A(i the lorvivors (36 3 vs 98 5. p=005) Wc conclude: 1)
locations by I -way ANOVA Ol. P(a/A>02 and vol ire all capable of predicting ECLS
Fhc mean amount of phophorus delivered to the filter requirement in HFOV patients often within the first
paper was between I and 5% for hour of HFOV 2) A retrospectively calculated high
mean Ol > 60 waj wsociUcd widi an 86% requirement
Ihc three AG locations. The mean
for ECLS, 3) The fact that 6 desthi occured in Oiia
amount of phosphorus delivered ti
Ol was highest in the non-survivors
scrict and that die
the niter paper increased as the would suggest that delayed initiaUon of ECLS may
distance between the AG and the contribute to morbidity and mortality 4) Based on the
wye decreased, however, pnoT con
m
patient 3
the variability also increased Wc

conclude thai locating the A(i
closer to the patient in Ihc HFOV
circuit increases the amount of aerosol that is delivered
through the endotracheal lube However. Ihc trade-off I
ing the percent of aerosol delivery is increased

nobility in the a It delivered,
1
EARLY VERSUS
1
Index of 1994 OPEN FORUM Authors
Boldface Type Indicates Presenters
Abbey. D 1092, 1094 Buckman, Robert F Jr 1062

Adachi, Mitsuru 1064 Burchette, R 1092, 1094
Adatia. Ian 1114 Bums, David M 1096, 1099 (2), 1 108
Al-Essa, Mazan M 1088 Bums, Edward 1 107
Alfredson, T 1099, 1108 Burton, Karen 1099
Ambrosino, N 1070, 1 104 Cadavid, Mario E 1063
Anders, M 1086 Caldwell, Arthur 1073
Anderson, P 1086 Caliwag, W 1078
Anderson, Susan 1076 Calkin, David 1099
Andruschak, John 1068 Callegari, G 1070, 1104
Antunes, Michael J 1060, 1113 Campbell, Robert 1068, 1111
Arnold. John H 1076 Canelli, Gerry 1090
Austin, Todd M 1072 Cantwell, Patricia 1060
Backes. William 1104 Carlin. Brian W 1070
Badellino, Michael M 1062 Carroll, Mark 1110
Badgwell. Gaye 1094 Carter, Wesley 1086
Bagliani, S 1070, 1 104 Castiglione, R Jr 1102
Ballard, Julie 1078 Cegielski, Sandee 1092
Bandi, V 1084 Chang, David W 1080
Bartlett, Robert H 1063 Channick, Richard 1114
Barton, JA 1110 Chatbum, Robert L 1060 (2), 1061, 1076, 1082, 1 107 (2)
Batch, Kimberly R 1092 Cheng, Ling-Yee 1073
Baumeister, Brenda 1060 Chiang, Ling-Ling 1073
Becker, J 1060 Chiappetta, A 1104
Beckerman. R 1 104 Childers, Marilyn 1080
Belingon, Ed 1106 Chiles, Nina 1064, 1 109
Benjamin. Patrice 1076, 1 1 14 Chow, Jyh-Her 1101
Benson. Michael S 1064 Chu, Chia-Chen 1073
Betit. Peter 1114 (2) Ciarlo, Joe 1 102
Bhutani. Vinod K 1061 (2) Clark, Brian 1 100
Bien, Mauo-Ying 1073 Clark, Randal 1080
Black, JR 1080 Clark, William T 1101
Blackson, Tom 1102 Coates, Geoffrey 1088 (2)
Bliss. David 1063 CoUe, Joni D 1096

Blumer, Jeffrey L 1060 (2) Connell, Stephen J 1064, 1 1 10
Bock, Kevin R 1096 Conrad, Kris 1 104
Boitano, Louie J 1064 Cook, Teresa 1068, 1103
Bonner, Robert A Jr 1064 Cornell, Kelley M 1067
Borisenko. Ludmila 1070 Cronin, J 1 108
Bowen, Barry 1088 Cullen, James A 1060, 1 1 13
Bower, Lynne K 1076, 1114 Curley. Frederick 1099
Bowyer, Mark W 1067 Dallessio, Joseph 1060
Branson, Richard 1068, 1 106 Daniel, Brian M 1107 (2)
Breaux, Charles W Jr 1115 Dashevsky, Yuri 1104

Brega, S 1070. 1 104 Davis, Kenneth Jr 1068, 1 106
Broemcling, L 1060 Day, Ronald 1 1 13 (2)
Brooks, Worth I 102 de Necochea, Anthony 1086
Brosbe, Geri 1072 Dean, JM 1072
Brown, P 1110 Deao, Dan 1068
Brown. RW 1072 Dechcrt, Ronald E 1063
1116 RESPIRATORY CARE • NOVEMBER 94 Vol 39 No 1

1
Open Forum AUTHOR INDEX
DeMaria, F 1070, 1 104 Gregg. BL 1082

Deming. Douglas D 1067. 1 1 14 Grigorieva. Anastassia 1064
Dennison, Frank 1102 Grueber. Ryan 1107
Desai, MH 1060 Guidry. Henri 1096
Desjardins, Steven E 1062 Guntupalli. K 1084
Dethlefsen, Michaela 1111 Haas. Carl F 1099. 1 1 14
Dhand. R 1086 Hadeed, A 1060
DiNicola, Debbie 1107 Hagarty, EM 1072
Dipzinski, F 1070 Hagelgantz. Michael 1 106
Dolovich, Myma B 1088 (2) Hanneman, SK 1062
DuFault. Beth 1067 Hansen. Douglas R 1114
Durbin, Charles G Jr 1063 Harper. PA 1090 (3)
Dyer, David 1110 Harris. Louis N 1101
Eagleton, Lanie E 1096 Hauptman. D 1099, 1 108
Earl, A 1108 Hazel, KS 1110
El Barbary, Mahmoud 1110 Head, C Alvin 1113
El-Khatib, Mohamad F 1060 Hedges, JR 1110
Ellison, Gail 1092 Henkle, Joseph Q 1096
Emberger, John 1110 Hemdon, DN 1060
England, Kevin R 1096 Hess, Dean 1063 (2), 1084 (3), 1086, 1 101 (3), 1 104 (2),
Enright, P 1092, 1094 1107.1113(3)

Fackler, James C 1114 Heulitt, M 1086
Fahey, PJ 1099, 1 108 Hill, Wrae 1110
Fajardo, Erick 1 1 06 Hirsch, Christopher 1099, 1 101 (2)
Ferreira, Carla 1061 Holt, William J 1060, 1113
Fink, J 1072, 1086, 1 106, 1108 Horiuchi, K 1063
Fisher. Daniel 1063, 1084 (3), 1086 Hotta, Toshiro 1102 (2)
Fisher, M 1 108 Hough, Lorraine F 1084, 1111
Fisher, Michael E 1062 Hultman, C 1072
FitzGerald, Cecily 1072 Hunte. Carole 1090
Fitzpatrick. Rene 1067 Hurst, James M 1111
Fok, Tai F 1088 (2) Hurvitz, EA 1072
Foley, Kevin 1063 Irwin, S 1060
Ford. Richard M 1096. 1099. 1 108 Jasper, Edward 1072
Foss, CM 1090 Jenne, J 1086
Foulkrod, Vicki 1110 Jih, Kuen-Shan 1101
Foust, Gregory Neil 1068 Johnson, Robert 1068
Fracchia,C 1070 Johnson, Wayne 1114
Freeman, B 1078 Jones, Arthur 1080
Fukazawa, Shinji 1064, 1106 Kachel, Diane 1067
Fukuoka, Toshio 1 102 (2) Kaemarek. Robert M . . . 1063(2), 1084(3), 1086. 1101 (3), 1 1(M(2), 1 107,
Gallivan, Lorraine E 1064, 1067 1113(3)

Gan, Vanthaya 1094 Kallstrom, Thomas J 1061, 1107
Garton, David 1067, 1078, 1114 Kaplan, Robert 1072
Gay, PC 1070 Kasai, Fumihito 1064
Georgeson, Keith E 1115 Kasper. CL 1110
Giles. Dennis K 1096 Kavuru. M 1090
Gilliam. Craig 1107 Keenan, Jim 1078, 1092, 1099
Godinez, RI 1084 Kehr, W 1062
Goldsberry, David T 1111 Kemper, M 1063
Goodhart, George 1107 Kendall, AG 1070
Gordon, Jerry 1096 Kern, F 1076 (2)
Gradwell, Gary 1072 Kester, Lucy 1082, 1096
Grady, EA 1072 Kirby, Elizabeth A 1063
Graf. LB 1090 (3) Kirpalani. Haresh M 1088 (2)
Gray. Shari 1088 Klein, Linda D 1072
Graybeal, JM 1064, 1109 Knutsen, SF 1092, 1094
Greenspan, Jay S 1060. 1 1 13 Kollef, Marin H 1096
RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 I1I7

Konkle. Mark A 1099, 1 1 14 Milne, Gary 1062

Konopinski. Ted 1090 Mink, Shari L 1063
Konyukov, Yurii 1102 (2) Miyagawa, Tetsuo 1064, 1 106
Kopotic. Robert J 1061 (2) Mizuma, Masazumi 1064
Kratohv il, Joseph 1 104 MIcak, R 1060
Krause, S 1108 Monkman, Shelley 1088 (2)
Kuluz. John 1060 Montiel, Lisa 1080
Kuwayama, Naoto 1102 (2) Moon, Laura 1068
Lane. Connie 1099 Mori, Yoshiaki 1064
Laney Debbie
. 1115 Moras, Diane 1 107
Langbein. WE 1072 Mullarkey, John 1062
Lange, PA 1090 Nadeau, C 1 102
Langga, Leo 1078, 1111 Nagel, Carol A 1092
Langlois, D 1068 Napoli, Linda Allen 1084, 1111
Larson, R 1108 Nelson, VS 1072
Laskowski, DM 1090 Newhart, John 1 108, 1114
Lattin, Chris D 1092 Newhouse, Michael T 1088
Lawrence, G 1072 Newman, Vivienne 1115
Levin, Dan 1110 Nichols, RJ 1060
Limberg. Trina 1072 Nicoletti. Ivan 1099
Lindley. P 1062 Nishimura, Masaji 1101, 1 1 13 (2)
Logan, Debbie 1070 Norwood, Jimmy W 1 107
Lowe, G 1086 Nystrom. Gerald A 1067, 1 1 14
Lu, Chong-Chen 1070 O'Connor. James J 1064
Lua,Lea 1110 O'Keefe. P 1108
Ludington. Susan 1060, 1061 Oberg, Kerby C 1067
MacCallum, Madeleine 1099 Off, David 1 104
Maclntyre. Neil R 1063, 1101 Orens, D 1108
Madsen, Terry 1078 Paes, Bosco 1088
Magro, Donna 1115 Pascale, Pietro J 1101
Mahlmeister, Michael J 1080, 1108 (2) Pataky, Gail 1062
Mahon, Tom 1060 Patrick, Herbert 1064, 1072, 1 100, 1 109, 1110
Malinowski, Tom 1078, 1106, 1111(2) Payne, Nicole C 1067

Martin, William J II 1067 Peck, M 1078
Martinez, FJ 1090 (3) Pellegrini. Richard 1070
Marukawa, Taro 1 102 (2) Perkins, Susan 1080
Masi-Lynch, Joanna 1078, 1113 (2) Perlman, Lauren 1114
Mask, Corbett 1108 Permutt, L 1 102
Mathews, Les 1068 Pemg, Reury Pemg 1070
McAndrew, J 1110 Perry, Douglas G 1067 (3)
McCarthy, Kevin 1082, 1090 Peterman-Black, AK 1080

McCauley, RL 1060 Peters, BA 1094
McConnell, Robert R 1063, 1101 Peters, James A 1092. 1094
McDonnell, WF 1094 Peters, SG 1070
McGee, Tom 1078 Pettinichi, Scott 1080
McGowan, Mary 1061 (2) Phillips, Jan E 1096, 1099 (2)
McLaughlin, Gwenn 1060 Piaggi, G 1070, 1 104
McQuitty, John 1073 Pierson. DJ 1110
Meiler, Rose 1102 Piper, S David 1086
Meliones, J 1076 (2), 1 1 10, 1 1 14 Poll. Kathryn 1078
Merren, Randall 1099 Pooler, Sharon 1084 (2), 1086
Mcssick. WJ 1111 Pope, C 1084
Milisch, Robert A 1104 Post, D 1099
Millard, MW 1072 Potts, David L 1082
Miller, C 1084 Prato, B Stephen 1062
Miller, Christopher C 1110 Prewitt, Lela 1072
Miller, Dorisanne 1064, I 100, 1109 Quinn, William W 1086, 1 102, 1 106
Milligan, Donald 1084 Raahe. Otlo G 1086
1118 RESPIRATORY CARE • NOVEMBER "94 Vol 39 No

1
Randolph. PE 1111 Taft. Art 1 102

Rao, S 1060 Takezawa. Jun 1102 (2)
Reid, Russell T 1068, 1 103 Taylor. Ann 1101

Retherford, Jean A 1080 Taylor. Jerome 1072
Reyes, Ercele 1062 Taylor. Tom 1092
Rho, David 1 104 Tendal. Nancy T 1099
Richards, Kathleen 1113 Thompson. John E 1076, 1 1 14 (2)
Richards, Rodger 1096 Tobin, MJ 1086
Ries, Andrew 1072 Toro-Figueroa, Luis 1110
Riggi, Vincent 1101 Torres, A 1086
Ritz, Ray 1113 (3) Totaro, Lawrence 1 106
Rizzo, Albert 1 102 Trahey, Judy 1063, 1 104
Roach. Gregory 1 100 Trant, Charles A 1114
Robertson, Randal 1080 Trinh, Louis 1 1 1
Robinson, E 1060 True, MA 1090 (3)
Rogers, Mark 1078, 1111 (2) Truwit, Jonathon 1062

Roloff, DW 1072 Tyra, James A 1107
Romagnoli, David 1 1 07 Vaccaro, Jamie 1100
Rosolowski, Bonnie 1061 Vallieu, Dena S 1113
Russell, GB 1064. 1 109 van Stralen, Daved 1111
Sabah, Murat 1 106 VanCamp, Elizabeth 1099
Sabato, Katie 1073, 1115 Vanderwarf, C 1099
Sakamoto, Warren 1086 VanLaanen, CJ 1072
Salkins, DJ 1090 Vierra, Terry J 1 103
Salvi, RJ 1090 Viggiano, RW 1070
Salyer, John W 1078 (3), 1092 (2), 1099, 1109. 1 1 13 (2) Visveshwra, N 1078
Santoro. A 1110 Volsko, Teresa 1084
Scaggs, John E 1096 Wadlinger, Sandra R 1111
Schell, Sheila 1 104 Walsh-Sukys, Michele C 1061
Schleien, Charles 1060 Walters, Pat 1094
Schubert, N 1 102 Wang, Jia-Horng 1073
Schuiz, Lisa J 1076 Wang, Yuh-Lin 1101
Schwartz, A 1 102 Wanger, Jack 1092
Schwartz, Whitney L 1064 Warren, R 1086
Sciurba, Frank C 1092 Weg, John G 1099, 1 1 14
Scott,Randy 1111 Wehrman, Stephen F 1086
Shanks, Thomas 1114 Weir, George 1 109
Shiao, Guang-Ming 1070 Weissman, C 1063
Shimada, Yasuhiro 1 102 (2) Weitzel, Linda 1 109
Shimizu, Kiyokazu 1 102 (2) Wendt, J 1084
Shore, Mary 1 062 Wendt, R 1084
L
Shrake, Kevin 1096 (2) Wert, Lori J 1076
Simmons, Mark 1068 (2) Williams, Purris 1084 (2), 1086, 1 104
Sirgi,C 1084 Williams. Timothy A 1094
Sivieri, Emidio 1061 (2) Wilson, Barbara G 1076 (3), 1 1 10
Skorodin, M 1072 Wilson, Jay M 1076, 1 1 14
Slivka, William A 1092 Wilson, Mark C 1072

Smith, Paul G 1060 Wise, Constance H 1114
Specht, Lennard 1092 Wiswell. Thomas E 1060
Spitzer, Alan R 1060, 1113 Witherspoon. J 1062
Staiano, Amy 1064, 1 109 Woodcock. Brian 1063
Steinberg, Kenneth P 1064 Wright. Jeff 1092
Stoller, James K 1082, 1090, 1096, 1 108 Wright. John 1096
Strong. Kevin 1 104. 1113 Yen. Chih-Chihng 1101
Stubbs.CR 1110 Ykoruk, Regina 1061 (2)
Sullivan. Lynn M 1104 Yuen. Elaine 1109

Swinth. J 1060 Zocchi. L 1070. 1 104
Tabor. Ted 1068

1 :
EXHIBITORS
at the 40th Annual Meeting and Exposition of the
December 10- 13, 1994

Las Vegas, Nevada
Thousands of examples of respiratory care equipment and supplies are displayed,

discussed, and demonstrated in the exhibit booths at the Annual Convention.
The AARC thanks the firms that support the Association by exhibiting.
(Exhibitors confirmed by October 25, 1994, are listed.)
Exhibit Hours
Saturday, December 10 12:00 noon - pm

4:00
Sunday, December 11 11:00 am -4:00 pm
Monday, December 12 11:00 am -4:00 pm
TXiesday, December 13 11:00 am -3:00 pm
Exhibitor Booth Exhibitor Booth

B
Abbey Healthcare Group 113 B & B Medical Technologies, Inc 846

Ackrad Laboratories, Inc 1410 Ballard Medical Products 710, 913, 915
Advance Newsmagazines 1046 Baxter Healthcare Corporation,
Advanced Lifeline Services, Inc 849 I.V. Systems Division 637
Aequitron Medical, Inc 231 Bay Corporation 1331 & 1333
AirSep Corporation 1341 & 1343 BCI International 618 & 620
Allen & Hanburys, Division of Glaxo, Inc 309 Bear Medical Systems, Inc 1119
Allied Healthcare Products, Inc 1225 Becton Dickinson and Company 1414
Ambu 405 & 407 Bellofram 249 & 25
American Biosystems, Inc 1251 Bicore Monitoring Systems, Inc 1219
American College of Chest Physicians 1450 Bio-Med Devices, Inc 626 & 628
American HomePatient 121 Bio-Rad Laboratories 1 301
American Lung Association 1451 Biomedical Sensors/Pfizer

AnaMed International 746 & 748 Hospital Products Group 448 & 450
Anesthesia Associates, Inc 944 Bird Products Corporation 319
Arbor Medical 1424 Bivona Medical Technologies, Inc 1313 & 1315
ARC Medical, Inc 646 & 648 Boehringer Ingelheim
ARTEC, Inc 529 Pharmaceuticals, Inc 619
Asthma and Allergy Foundation Boston Medical Products, Inc 1340
of America 1 447 Breasy Medical Equipment (US), Inc 1319
Automatic Liquid Packaging, Inc 137 & 139 Bunnell Incorporated 850
AVL Scientific Corporation 937 Burdick. Inc 143

1
CONVENTION EXHIBITORS
California College for Health Sciences/California Flotec, Inc 649

College Press 1026 Forest Pharmaceuticals, Inc./
Cardiopulmonary Corporation 1344 UAD Laboratories 239
Center Laboratories 1432 Fukuda Denshi America. Inc 1427
Cemer Corporation 419 Futuremed America, Inc 1307
Chad Therapeutics, Inc 1050
Children's Medical Center of Dallas-TX 224 G
Ciba Corning Diagnostics Corporation 501
Clement Clarke 204 Genentech, Inc 1401 & 1403
CNS, Inc 437 General Physiotherapy, Inc 547
COBE Cardiovascular, Inc 1246 Gibeck, Inc 1400, 1402, 1404, 1406
Consentius Technologies 1245 The Gideons International 1431
Core-M. Inc 1349 GO-MI, Inc 1148
Creative Biomedics 1437 Golden Care, Inc 1207
Criticare Systems. Inc 1007 Goldstein & Associates 1345
Curant Communications, Inc./RT Magazine 1033
Cybermedic 1013 H
D Hamilton Medical, Inc 337

Hans Rudolph, Inc 1302
Dale Medical Products, Inc 345 Health Educator Publications, Inc 200
Data Base Managers 1441 Healthdyne Technologies 1231
DataStar Education Systems HealthScan Products 1327 & 1329
and Services Inc 1 425 Health Way Products, Inc 35
Delmar Publishers, Inc 105 Homedco, Inc 814
DeVilbiss Health Care, Inc 509, 511, 513 Hospitak, Inc 1201 & 1203
Dey Laboratories 920 HR Incorporated 909 & 91
DHD-Diemolding Hudson RCI 1023
Healthcare Division 611, 613, 615 Hy-Tape Surgical Products Corporation 1408
Diametrics Medical, Inc 443
Diamond Software 133 I
Drager, Inc 1336, 1337, 1338, 1339

I-Stat Corporation 948 & 950
E ICN Pharmaceuticals, Inc 1351
Impact Medical Corporation 1325
EdenTec 336 & 338 Indiana University School of Continuing Studies .... 1444
Entech 551 Infrasonics, Inc 737
Epic Medical Equipment IngMar Medical 109
Services, Inc 103 Innovative Medical Marketing 1407
Innovative Medical Systems, Inc 549
Instrumentation Industries, Inc 413&415
Instrumentation Laboratory 901
F.A. Davis Company/Publishers 207 Integrated Health Services Ill
Ferraris Medical, Inc 523 InterMedway 1309 & 1311
Fisher & Paykel Healthcare 630 & 632 International Biomedical, Inc 1426 & 1428
Fisons Pharmaceuticals 1300 Invacare Corporation 301
FloCare Medical 240 IPI Medical Products 500 & 502

1 1
J.B. Lippincott Company 115 NASCO 1438

J.H. Emerson Company 1150 National Board for Respiratory
Johnson Enterprises, Inc 951 Care. Inc 1443 & 1445
Jones Medical 306 National Center for Home
Mechanical Ventilation 1449
K National Safety Technologies. Inc 1429
Nellcor Incorporated 329
Kaiser Permanente 24 Newport Medical
King Systems Corporation 444 & 446 Instruments, Inc 919, 921, 923, 925
Kirk Specialty Systems 650 Nicolet Biomedical. Inc 1241 & 1243
Nidek Medical Products, Inc 1250
L NMC Homecare 232
Nolato Medical 346
Laboratory Data Systems 1346 & 1348 Nonin Medical, Inc 401 & 403
Laerdal Medical 515 NOVA Biomedical 149 & 151
Lambda Beta Society 1446 Nova Health Systems. Inc 1244
LeMans Industries Corporation 246 Nova-VentRx. Inc 1305
LIFECARE International, Inc 219 Novametrix Medical Systems. Inc 1 137
Linear Tonometers, Inc 1419 Nth Systems. Inc 548 & 550
Liquid Carbonic 712 & 714 Nutec Medical Products. Inc 147
M O
Maginnis and Associates 847 Ohmeda 719
Mallinckrodt Medical, Inc 1037 Omni-Tech Medical. Inc 1347
Marquest Medical Products. Inc 608, 610, 612, 614 Omron Healthcare. Inc 1342
Marquette Electronics 1149 & 1151 Ottawa University Kansas City 510
Martell Medical Products, Inc 622 & 624 Oxigraf. Inc 946
MBNA Marketing Systems, Inc 250
Medical Data Electronics 512 & 514 P
Medical Graphics Corporation 1 129
Medical Plastics Laboratory, Inc 449 RK. Morgan Instruments. Inc 1018 & 1020
Medical Taping Systems, Inc 1249 Palco Laboratories 945
MEDIQ/PRN Life Pall Biomedical Products Company 711. 713. 715
Support Services, Inc 525 & 527 PARI Respiratory Equipment. Inc 342
MediServe Information Systems, Inc 1019 Passy-Muir. Inc 1 146
Medisonic USA, Inc 230 Peace Medical. Inc 226 & 228
MedRehab Incoiporated 1411 Pegasus Research Corporation 202
Mercury Medical 236 & 238 PeiTy Baromedical Corporation 1 145 & 1 147
MES, Inc 206 PHI Enterprises, Inc 243
Michigan Instruments, Inc 747 & 749 Phoenix Diagnostics. Inc 1412
Micro Medical Limited 101 PPG Biomedical-Sensors 931 & 933
MMCA/Misty Ox 433 Precision Medical. Inc 949
Monaghan Medical Corporation 813 Presbyterian Hospitals of New Mexico 347
Mosby 214 Primedica 211
MSA 504, 506, 508 Pro-Tech Services 1421
MultiSPIRO, Inc 1423 Professional Medical Products, Inc 810 & 812

1
ProMed Pharmacies 1 044

Pryon Corporation 245 & 247
Pulmo-Dose, Inc 1413 Tamarac Systems Corporation 751
Pulmonary Data Service TECME S.A 451
Instrumentation, Inc 1047 Teledyne Brown Engineering-
Pulmonox Research & Development 1247 Analytical Instruments 927 & 929
Puritan-Bennett Corporation 700 Telefactor Corporation 244
Tenet Information Services, Inc 1030 & 1032
Q 3M Pharmaceuticals 210
Thumbprint Solutions, Inc 131
Quinton Instrument Company 819&918 Total Medical Sales, Inc 1439
Transitional Hospitals Corporation 947
R Transtracheal Systems, Inc 1022 & 1024
Tri-Medical Supply, Inc 248
R. Lewis, Inc 1049
Radiometer America, Inc 1101 U
RCS Health Care Services 851
Res Care, Inc 1440 & 1442 University Hospital Consortium 1430
Resp-I-Care 349 University of Rochester Medical Center-NY 647
Respiflow & Affiliates 1248 University of Texas Medical Branch 340
Respironics, Inc 1 109 University of Virginia Health Sciences Center 350
RFB Technologies 212
RNA Medical 409 & 41 V
Ross Products Division
Abbott Laboratories 1014 Vacumed 1008
Rusch, Inc 201 Vital Signs, Inc 837
Rx Concepts 129 Vitalog Monitoring, Inc 1048
Vitalograph, Inc 1237 & 1239
S Vitaltrends Technology, Inc 651
VORTRAN Medical Technology, Inc 848
S & M Instruments Company 1010 & 1012
Salter Labs 519 & 521 W
Scandipharm, Inc 242
Schiller America, Inc 208 W.B. Saunders Company 218
Sechrist Industries, Inc 423 W.T. Farley, Inc 237
Selco Products Company 127 Warren E. Colhns, Inc 1001
SensorMedics Corporation 625 Washington Hospital Center-DC 1405
Seven Harvest International 348 Wave Energy Systems, Inc 1433
Sherwood Medical 220 & 222 Western Medica 531 & 533
Siemens Medical Systems, Western Michigan University 1448
Electromedical Group 537 Westmed, Inc 141
Smiths Industries Medical Systems, Inc 1213 Williams & Wilkins/Medi-Sim 119
Sontek Medical, Inc 1303
SpaceLabs Medical, Inc 123 & 125 Y
Stackhouse Incorporated 107
Summit Interactive Software 344 Yale New Haven Hospital-CT 1415
Superior Healthcare 1051
Superior Products, Inc 1436 Z
Support Systems International, Inc 225
Synectics Medical, Inc 145 Zymed Medical Instrumentation 1028

1
1995 Call for Abstracts

Respiratory Care • Open Forum
The American Association for Respiratory Care and its sci- Abstract Format and Typing Instructions
ence journal. Respiratory Care, invite submission of brief
abstracts related to any aspect of cardiorespiratory care. The Accepted abstracts will be photographed. First line of abstract
abstracts will be reviewed, and selected authors will be invit- should be the title in all capital letters. Title should explain
ed to present papers at the OPEN FORUM during the AARC content. Follow title with names of all authors (including cre-
Annual Meeting in Oriando. Florida, December 2-5, 1995. dentials), in.stiaitions(s), and location. Underline presenter's
Accepted abstracts will be published in the November 1995 name. Type or electronically print the abstract single spaced
issue of Respiratory Care. Membership in the AARC is in the space provided on the abstract blank. Insert only one
not necessary for participation. letter space between sentences. Text submission on diskette is
encouraged but must be accompanied by a hard copy.

SPECIFICATIONS—READ CAREFULLY! Identifiers will be masked (blinded) for review. Make the ab-
stract all one paragraph. Data may be submitted in table form
An abstract may report ( 1 ) an original study, (2) the evalua- and simple figures may be included provided they fin within
tion of a method or device, or (3) a case or case series. the space allotted. No figures, illustrations, or tables are to be
Topics may be aspects of adult acute care, continuing attached to the abstract form. Provide all author information
care/rehabilitation, perinatology/pediatrics, cardiopulmonary requested at the bottom of abstract form. A cleai" photocopy of
technology, health-care delivery. The abstract may have the abstract may be used. Standard abbreviations may be em-
been presented previously at a local or regional — but not na- ployed without explanation. A new or infrequently used ab-
tional — meeting and should not have been published previ- breviation should be preceded by the spelled-out term the first
ously in a national journal. The abstract will be the only evi- time it is used. Any recurring phrase or expression my be ab-
dence by which the reviewers can decide whether the author breviated if it is first explained. Check the abstract for (1) er-
should be invited to present a paper at the OPEN FORUM. rors in spelling, grammar, facts, and figures; (2) clarity of lan-
Therefore, the abstract must provide all important data, find- guage; and (3) conformance to these specifications. An ab-
ings, and conclusions. Give specific information. Do not stract not may not be reviewed.
prepared as requested
write such general statements as "Results will be presented'" Questions about abstract preparation may be telephoned to
or "Significance will be discussed." the editorial staff of Respiratory Care at (214) 243-2272.
Essential Content Elements Deadline Allowing Revision
An original study abstract must include ( 1 ) Introduction: Authors may choose to submit abstracts early. Abstracts re-
statement of research problem, question, or hypothesis; (2) ceived by March 1 5 will be reviewed and the authors notified
Method: description of research design and conduct in suffi- by April 22. Rejected abstracts will be accompanied by a
cient detail to permit judgment of validity; (3) Results: state- written critique that should in many cases enable authors to
ment of research findings with quantitative data and statisti- revise their abstracts and resubmit them by the fmal deadline
cal analysis; (4) Conclusions: interpretation of the meaning (May 27).
of the results. A method/device evaluation abstract must
include ( 1 ) Introduction: identification of the method or de- Final Deadline
vice and its intended function; (2) Method: description of
the evaluation in sufficient detail to permit judgment of its The mandatory Final Deadline is May 27 (postmark).
objectivity and validity; (3) Results: findings of the evalua- Authors will be notified of acceptance or rejection by letter
tion; (4) Hxperience: summary of the author's practical ex- only — to be inailed by August 15.
perience or a lack of experience; (5) Conclusions: interpre-

tation of the evaluation and experience. Cost comparisons Mailing Instructions
should be included where possible and appropriate. A case
report abstract must report a case that is imcommon or of Mail (Do not fax!) 2 clear copies of the completed abstract
exceptional teaching/learning value and must include ( 1 ) pa- form and a stamped, self-addressed postciud (for notice of
tient data and case summary and (2) significance of case. receipt) to:
Content should reflect results of literature review. The au-
thor(s) should have been actively involved in the case and a Respiratory Care Open Forum
case-managing physician must be a co-author or must ap- 11 030 Abies Lane
prove the report. Dallas, TX 75229-4593

.
1995 Respiratory Care Open Forum

Abstract Form
1 Title must be in all upper

case (capital) letters,
authors' full names and

text in upper and lower
case.
2. Follow title with all
authors' names including

credentials (underline
presenter's name), institu-
tion, and location.
3. Do not justify (ie, do

leave 'ragged' right
margin).
4. Do not use type size less

than 10 points. (See
reduction samples
below.)
5. All text, tables, and

figures must fit into the
rectangle shown.
6. Submit 2 clean copies.

This form may be photo-
copied if multiple
abstracts are to be
submitted.
Mail original &

1 photocopy
(along with postage-paid
postcard) to
Respiratory Care
Open Forum
11030 Abies Lane
Early deadline is
March 15. 1995

(abstract received)
Final deadline is
May 27. 1995

13.9 cm or 5.5"
{abstract postmarked)
Presenter's Name & Credentials
Presenter's Mailing Address This is 14-point type, with

necessary reduction.
Presenter's Voice Phone & Fax This is 1 2-point type, with

necessary reduction.
Corresponding Author's Name & Credentials This is 10-pointtype,

with necessary reduction.
Corresponding Author's Mailing Address
Corresponding Author's Voice Phone & Fax

1
Not-for-profil organizations are offered a free advertisement of up to eight lines to appear, on a space-available basis, in Calendar of Events in
Calendar RE,SP!RAT0RY 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.
of Events 1 1030 Abies Lane, Dallas TX 75229-4593.
AARC & AFFILIATES sents Its annual meetmj: Call (301 ) 897-5700 for infor-
mation.
December 9 in Las Vegas. Nevada. The AARC and its
Board of Medical Advisors present a postgraduate course November 18-22 in Atlanta, Georgia. The Gerontolog-
for medical directors and other physicians the day before ical Society of America presents its annual meeting. Call
the Annual Meeting, The program is approved for 6
(202) 842-1275 for information.
Category I credit hours of the Physician's Recognition
Award of the American Medical Association, Lecture
November 30-December 1 in Washington, District of
topics include ethical dilemmas in the ICU. TB as an
Columbia. The Bureau of Health Professions. Depart-
occupational hazard, cost-effective management of criti-
ment of Health and Human Services, hosts its national
cal illness, and all aspects of providing respiratory care by
conference, "Multiskilling and the Allied Health Work-
protocol. Contact the AARC at (214) 243-2272 or fax
force," at the Key Bridge Marriott, Featured topics
(214) 484-2720 to request that a complete course descrip-
include education and training models; multiskilling and
tion and registration form be sent to your medical director
patient-centered care systems; restrictions to practice;
or other interested physician,
competency assessments; and state initiatives and strate-
December 10-13 in Las Vegas, Nevada. The AARC pre- gies. Registrants receive the white papers written on con-
sents its 40th Annual Convention and Exhibition, "A New ference topics in a pre-conference mailing. For a
Vision," at the Las Vegas Convention Center. For infomia- conference brochure and registration form, fax your
tion, contact the AARC at (214) 243-2272, fax (214) 484- name and address to Lana Phillips, Continuing Education
2720. Coordinator, Allied Health Education Center, Methodist
Hospital, Indianapolis IN, at (3 1 7 929-2 02 or call her at
) 1
February 14-17, 1995 in Reno, Nevada. The NSRC and (317) 929-8925 with questions about registration and
the American Lung Association of Nevada present the 14th hotel reservations. For information on speakers and the
Annual High Sierra Critical Care Conference at the Pepper- program, contact Sherry Makely at (317) 929-3282 or fax
mill Hotel/Casino. The 4-day conference covers critical care (317)929-2102,
topics in adult, pediatric, and neonatal medicine. Contact
Colleen Banghart, American Lung Association of Nevada, February 5-8, 1995 in Breckenridge, Colorado. The
PO Box 7056, Reno NV 89510, American College of Chest Physicians sponsors "Cardio-
pulmonary Wellness and Rehabilitation" at The Village
March 12-15, 1995 in Denver, Colorado. The AARC atBreckenridge Resort, Contact Arlene Karavich,
and the National Jewish Center for Immunology and
American College of Chest Physicians, 3300 Dundee Rd.
Respiratory Medicine announce the call for abstracts for
Northbrook IL 60062-2348, (708) 498-1400,
the 5th International Conference on Pulmonary Rehabil-
itation and Home Ventilation at the Hyatt Regency Hotel,
April 1-7, 1995 in Miami, Florida. The Ventilation
The abstract deadline for poster/oral presentations on
original research/clinical observations is Nov 30, 1994,
Assisted Children's Center (VACC) of the Division of
Pre- and post-conference postgraduate workshop topics

Pediatric Pulmonology in Miami Children's Hospital
include pulmonary rehabilitation, home ventilator care,
hosts its annual VACC Camp for ventilation assisted
respiratory sleep disorders, nicotine dependency treat-

children and their families. The program includes
ment, and transtracheal oxygen. The program is endorsed swimming, field trips, structured games, and campsite
by the American College of Chest Physicians; program entertainment. The campsite, the Leisure Access
chairman is Barry Make MD, Contact the National Center at metro Dade county's AD Barnes Park, is a
Jewish Office of Professional FAlucatit)n at (303) 398- handicapped-accessible urban park located 2 miles
1000, from the hospital. Medical staff and equipment are
available 24 hours-a-day. Contact Cathy Klein,
OTHER MEETINGS VACC Program Coordinator, Division of Pediatric
Pulmonology, Miami Children's Hospital, Suite 203,
November 18-21 in New Orleans, Louisiana. The 3200 SW 60 Court, Miami FL 33 155-4076, (305) 662-
American .Speech-Langiiagc-Hearing Association pre- VACC,
1126 RESPIRATORY CARE • NOVEMBER "94 Vol 39 No 1

Authors
in This Issue
Anderson, Susan M 1039 hvin. Charles G 1057
Chappell, Timothy R 1057 Langenback, Edward G 1047
Chathurn. Robert L 979 Ognibene, Frederick P 1051
Gleaton, Loretta D 1051 Perry, Robert J 1047
Ilowite. Jonathan S 1047 Picca, Stephen M 1058
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J B Lippincott 1033 Sherwood Medical Cover 4

RESPIRATC^RY CARH • NOVHMBKR '94 Vol 39 No

ror raster service,
your reader service card
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RE/PIRATORy CMS
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81 AARC
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Name
82 Respiratory Care
Subscription Information Institution
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113 Automatic Liquid City/State/Zip .
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Peak Flow Meter
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11 94

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November 1994

Volume 39, Number 11

Controlling Carbon Dioxide Delivery

Clinical Comparison of Two Aerosol

Airway Compromise in Two Patients

Even while supported by mechanical ventilation . .

Matthew Sings ' v

Communication is essential to well being and recovery!

Passy-Muir Tracheostomy and Ventilator Speaking Valves

For further information & a free clinical video please contact

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entire line of DHD qualify respiratory care

ODHD DIEMOLDING HEALTHCARE DIVISION

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ASSOCIATE EDITOR ORIGINAL CONTRIBUTIONS

RESPIRATORY CARE • NOVEMBER '94 Vol 39 No 1 1019

^odmbeYm Oxygen Att^,

Maximize your Oxygen Analysis . .

MANUSCRIPT SUBMISSION November 1994

Editorial Office for a copy if you're unable to

QUOTATION. Anyone may, without pen

SUBSCRIPTIONS. Individual subscription rates

CHANGE OF ADDRESS. Six weeks notice is

required to effect a change of address. Note your

ADVERTISING, Display advertising should be

RESPIRATORY CARE • NOVEMBER "94 Vol 39 No 1 1021

Editorials, Reviews, and Commentaries To Note

1022 RESPIRATORY CARH • NOVEMBER "94 Vol .V; No

Sleep Goes A^WJows™

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1026 RESPIRATORY CARH • NOVEMBER "94 Vol .W No 1

worst values of several variables during the