Download Respiratory care : the official journal of the American Association for

September 1990
Volume 35, Number 9
ISSN00989142-RECACP
A MONTHLY SCIENCE JOURNAL
35TH YEAR— ESTABLISHED 1956
Complications of Mechanical
Ventilation in a Children's Hospital
Patterns of Practice
in
Neonatal
and Pediatric Respiratory Care
Effects of Insufflating
and Suction
Flows and Tube and Catheter Size
on Test-Lung Pressures
Mandatory Minute Volume (MMV)
An Overview
Ventilation:
CRCE through
Answer Key
the Journal:
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RESPIRATORY CARE • SEPTEMBER
"90 Vol 35
No
9
861
Abstracts
Articles in Other Journals
Summaries of Pertinent
Reduction of Sputum Pseudomonas
aeruginosa Density by Antibiotics
biotic
Improves Lung Function
g of sputum, a ]0% increase
Cystic
in
Do Broncho-
Fibrosis
More
dilators
and Chest Physiotherapy
than
group achieved better than a 2
log 10 reduction in cfu P. aeruginosa/
a
20%
FVC,
FEV,, and a 30%
increase in
in
increase in FEF25.7S than did those in
Alone WE Regelmann, GR Elliott,
WJ Warwick. CC Clawson. Am Rev
the placebo group. These results
RespirDis 1990; 141:914.
provides significant additional benefit
that
appropriate
evaluated
fibrosis
with
patients
cystic
(CF) and moderate obstructive
lung disease in pulmonary exacerba-
tion
double-blind placebo-
a
in
controlled
determine the
to
trial
of antibiotic-mediated
contribution
reduction in sputum bacterial density
improvement. For the
to clinical
4 days of study,
all
bronchodilating
aerosols
physiotherapy
During
and chest physio-
improvement
antibiotics.
in
showed
mean FVC,
midexpiratory
flowrate (FEF25.75). In 12 of 13
showed no
patients
increases
monas aeruginosa during
12
days. In these
were
stratified
randomized
by
significant
these
first
4
FVC
and
ticarcillin (n = 7) or
(n = 5),
in
addition
to
continued aerosol and chest physiotherapy.
patient
density
had a
of
remaining
the
In
significant
antibiotic
(p
<
0.01
group showed
)
degree of reduction of
and
units
±
Long-Term
the
in
CPAP
nasal
is
Titration
effective in
improving
with
in patients
of Continuous
Positive
Time Relationships by a Noninvasive
in Patients
Sleep Apnea
with Obstruc-
—E
Sforza,
M
E Weitzenblum,
Krieger,
E Lampert,
Apprill,
Am
Ratamaharo.
J
J
Rev
RespirDis 1990:141:866.
Computerized System
—A
Schulze,
H-J Madler, B Gehrhardt P
D
Gmyrek.
Schaller,
Pulmonol
Pediatr
1990;
8:96.
Fifty-four
sleep
obstructive
long-term treatment with nasal con-
tinuous
positive
(CPAP). The
airway pressure
on daytime lung
with postinspiration inspiratory muscle
hemo-
pulmonary
by repeating pulmonary function
to
was
the
(cfu)
of
P.
including
after a
(554
right
log 10 cfu
sputum correlated
heart
±
28 days,
in
mean
the
±
<
The
0.02).
at least
± SEM).
patient
whole from 69.9
torr (p
tests,
catheterization
follow-up period of
increased
group
PaO;
as
±
1.4 to 72.8
yr
I
a
1.4
increase in PgO:
was greater (from 60.4
p<0.01)
±
1.0
to
in
those
who were hypoxemic
prior to
Paco^ decreased
signifi-
treatment.
and/or laryngeal narrowing, or
activity
starting inspiration before expiration
relaxation
the
of continuous positive airway pressure
(CPAP) on both phenomena
infants (birthweight 1,746
in 0.2
kPa increments.
bedside
was
flow-volume
used
for
'responders,'
'appropriate
and FEF25.75. Moreover,
significantly
treatment (n
44.5
±
1.5
= 7),
torr
from 48.5
(p<
±
0.01).
1.3 to
The
in
417g),
23
we
expiration
'premature
analysis
SEPTEMBER
until
16
In
braking
inspiratory
at
line) of the
loop was lengthened
•
computerized
(V/V)
was postponed
CPAP level.' The
segment (rclaxaticm
RESPIRATORY CARE
A
evaluation.
early
decreased and
with significant hypercapnia prior to
patients in the anti-
±
elevated the airway pressure stepwi.se
FVC, FEVi,
with
volume has been
completed. In order to study the effect
degree of improvement in
0.001)
work
with additional respiratory muscle
by retarding early expiratory airflow (V)
effects
and
even dynamically
Infants can defend or
elevate their functional residual capacity
by
significantly
in
with
patients
apnea (OS A) syndrome received
interruption'
862
pulmonary
conclude that
dynamics
tive
dynamics were prospectively evaluated
FVC, FEVi, and
decrea,se
more
p<
and
Airway Pressure by the Pattern of
Breathing: Analysis of Flow- Volume-
cantly only in the subgroup of patients
0.01)
±
0.9 to
Airway Pressure on Daytime Lung
Function and Pulmonary Hemo-
the
(p <
±
change was
resting
We
pressure.
arterial
signifi-
5,024
to
0.001
No
count
of Treatment
Effects
Nasal Continuous Positive
with
patients
significantly
p<
0.6%,
respectively.
observed
90
25
in
OSA.
The degree of
(p<
the
in
with-
cell
and from 49.4
daytime blood gases
66.4 ±2.1,
aeruginosa/g
density
bacterial
total
aeruginosa
P.
sputum.
FEF25.75 than did the placebo group.
P.
lOVmm'
0.02,
the
aeruginosa per gram of sputum and
greater increases in
of improvement correlates with the
±
from 5,347
cantly,
in
rise
greater reductions in logio
colony-forming
aeruginosa
Both the red blood
and the hematocrit decreased
47.1
P.
from
L/min
0.3
calculated
as
difference,
nary exacerbation, and
sputums. Moreover, the degree
±
0.2 to 5.9
patients.
function
days of therapy,
14
next
Pq,
61
in their
an increase
ventilation,
out a change in the alveolar-arterial
the
assigned to the antibiotic group. During
the
±
trial,
aeruginosa and
P.
5.2
alveolar
the patients
trials,
their initial
to receive either parenteral
tobramycin and
placebo
trials,
of Pseudo-
density
the
in
the
therapy in patients with CF, pulmo-
first
and chest
no
but
FEVi, and maximal
the
in
daytime blood gases
in
to be related to
patients received
this time, the patients
significant
therapy
antibiotic
to bronchodilators
We
show
improvement
seemed
an
linear
V/V-
expiratory
'90 Vol 35
No 9
^^>-.^?:A:v:.-
In
more
WE
GOT
TO BE
THE
LEADER
homes
all
over the world,
ventilator
dependent
people depend on LIFECARE
ventilators than any other
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That's right, lifecare leads at
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LIFECARE leads at
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The PLV-100
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It has for many years. Along the
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great part, thanks to
haven't changed the
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leader You wouldn't want us to.
the PLV-100 exceptionally accurate,
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And three power source
options result in
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we
The reason is simple. Advanced
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3
ABSTRACTS
maximum.
time reached a
Elevation of
CPAP beyond this level again
produced
on
airways are
large
likely
which may lead
a rapid, shallow pattern, often combined
with flow acceleration late in expiration
cessation
(recruitment of expiratory muscles). In
measured alveolar deposition and
remaining seven
(non-
infants
side
to premature
effects,
the
We
of treatment.
on pulmonary
function) after aerosolization of 150
lowest
CPAP
Respiratory rate without
'titration trials."
CPAP
±
±
(84
(46
was different between responders
17/min) and
non-responders
approach
This
17/min).
might reduce the
muscle
risk
for
CPAP level
determining the appropriate
of respiratory
pentamidine
Delivery System
Lee.
SW
— AK
MA Johnson,
Newman,
Clarke.
Am
absence of expiratory flow limitation
were
than variable intrathoracic obstruction
Acom
profiles: the
gard
System 22, Respir-
and Respirgard
II,
inspiratory
II
removed.
baffle
was
size
and
greatest
Alveolar
assessment
side effects
with the nebulizer producing the
Rev Respir Dis
I990;141:827.
whereas large airway-related side
were prominent and alveolar
effects
deposition
sition
Nebulizer systems that deposit a high
RESPIRATORY THERAPY
FACULTY POSITION
the
producing the largest droplet
nebulizer
size
illustrates
potential pitfalls in preoperative
with
of patients
tracheo-
malacia. Recordings of airway pressure
and flow during mechanical
are
useful
ventilation
distinguishing
in
fixed
and variable
tion
and may complement
between
intrathoracic obstruc-
of
tests
airway anatomy.
(Acom
22). Values for alveolar depo-
System
proportion of aerosolized pentamidine
lowest with
of major airways. This case
some
II),
SP
present, suggesting a fixed rather
with the
Rational
CA
exter-
high resistance to airflow and
with
a
Talaee,
A
patients
smallest droplet size profile (Respirgard
Simonds,
mainstem bronchi were stented
nally.
Aerosol
N
was encountered. The trachea and
with
of
Toward
Pentamidine:
mainstem bronchi
thoracic inlet to the
systems producing different droplet
least
Targeting
Alveolar
with
disease
AIDS were studied using three nebulizer
deposition
fatigue.
Nine
mg
major airway
labeled
isethionate
""'"Tc-Sn-colloid.
segment
and improve maximal expiratory flow.
Diffuse
responders) these latter signs of excessive
levels applied during the
to resect the unstable
absence of cartilaginous rings from the
airway pressure already occurred
effect
thoracotomy was
right lateral
performed
large
airway-related side effects (eg, cough,
and
A
made.
have
breathlessness,
at the
be
to
marked adverse
with
associated
and adverse airway
effects
were
Bicarbonate Does Not Improve
intermediate using the Respirgard with
Hemodynamics
inspiratory baffle removed, thus indi-
Patients
cating the importance of the baffle valve
osis— DJ Cooper,
in
determining droplet
a
similar
baffle
size.
valve
to
Addition of
the
Acom
Who
JA
Wiggs,
Critically
in
Have
KR
Waliey,
Ann
Russell.
III
Acid-
Lactic
Intern
BR
Med
1990:112:492.
System 22 produced a marked improve-
determine
To
of Allied Health Sciences.
Indiana University School of Medicine.
Indianapolis. Indiana, has position
of a nebulizer that produces an optimal
whether correction of acidemia using
academic
droplet size range offers the advantage
bicarbonate improves hemodynamics
Division
available July
position
grams
in
its
a
wfith
appointment
1,
1990. for an
respiratory therapy pro-
12-month, tenure-track
respiratory therapy
The
programs include a well-established
associate degree program and a reactivated bachelor's degree program
located in a large medical center
complex. Minimum qualifications— a
registered respiratory therapist
master's degree, doctorate
three years of experience
vi/ith
a
preferred;
ment
in droplet size profile. Selection
of enhancing alveolar
active
research productivity are required
Salary and academic rank are commensurate with qualifications and experience
Application
August
1,
1990.
review
will
and continue
suitable candidate
is
identified.
begin
until
ested applicants should submit a letter
of application, a curriculum vitae and
three letters of reference to
Deborah
L
Cullen EdD. RRT, Respiratory Therapy
Programs, CF224, Division of Allied
Health Sciences, Indiana University
Michigan
School of Medicine, 1140
St Indianapolis, IN 46202-51 19. Indiana
University is an equal opportunity,
W
Each patient
The Assessment of Major Airway
nate and equimolar sodium chloride.
The order of the infusions was ran-
a Ventilator-Dependent
domized. Setting: Intensive care unit
Function
in
with
Tracheomalacia
RD Hubmayr, PC
Sheedy,
ES
Edell,
SB
— WF
Pairolero,
PF
Nelson. Chest
of a tertiary care hospital.
acidosis
60-pack-year smoker presented with
<
(bicarbonate
17
Patients:
metabolic
mmol/L
<
10)
and increased
(mean
7.8
mmol/L).
arterial lactate
A
who had
Fourteen patients
and base excess
1990:97:939.
had pulmonary
artery catheters
and
All
1
Mea-
cough, dyspnea, and orthopnea of three
were receiving catecholamines.
months" duration. Spirometry revealed
surements and Main Results: Sodium
a
Inter-
randomized,
sodium bicarbo-
sequentially received
Dunn,
and
lactic acidosis.
Prospective,
blinded, crossover study.
Primary responsibilities of the position
include classroom and clinical teaching
in the associate and bachelor's degree
addition, service
who have
patients
large airway-related side effects.
Patient
In
in
Design:
respiratory
in
of
aerosolized pentamidine while reducing
therapy education and clinical practice
programs.
targeting
Objective:
Study
severe reduction in
flow:
maximal expiratory
CT of the chest and bronchoscopy
bicarbonate (2
over
15
mmol/kg body
min) increased
p<
demonstrated expiratory collapse of a
(7.22
mid-tracheal segment, and a presump-
bicarbonate (12 to
tive
diagnosis of tracheomalacia
was
p<
to
7.36,
0.001),
and
0.001).
18
partial
weight
arterial
pH
serum
mmol/L.
pressure
of
,
affirmative
action
educator, employer
and contractor, M/F
RESPIRATORY CARE
•
SEPTEMBER
"90 Vol 35
No 9
Calibration accuracy
is guaranteed with a
two-year calibration warranty. Such
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The
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The optional MiniCAP Graphic
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S3
The
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S
ABSTRACTS
CO:
blood (Paco.^ ^^^ ^'^
0.001) and decreased
a constant deviation from the sample
plasma ionized calcium (0.95 to 0.87
these measurements of lung function
40
in arterial
torr,
<
p
<
mmol/L, p
0.001).
transiently increased
wedge
14 to 17
bicar-
in
sodium chloride both
bonate and
lary
Sodium
mean over
pressure
p
torr,
<
pulmonary
( 1
<
0.01).
mean
thicomimetic and
patients
Anticholinergic
Agents on the Impedance of the
Respiratory System in Normal Subjects
— G Wesseling, HM Vonk, EFM
and accurate method
(mean pH
normal
of inhalation of 0.2
either
after
bolic
who
patients
ill
was studied
system
of fenoterol
20 healthy
in
in
subjects
a
in
have meta-
frequency spectrum
a
patients.
greater
after
inhalation
Landau,
terol
Healthy
and Adolescents
IL Hudson,
PD
A
in
Xrs
LI
school children, with a
8.8 y;
62
mean age
mean age
girls
and 51
12.6,
8.8,
during the 5
y.
were
symptoms, and none
smoked more than
Static
five
cigarettes/wk
Lung 1990:168:23.
respiratory
system.
dilation
of the central airways.
changes
in
result of
an increase
The
Xfs are supposed to be the
capacitance
in the
—
Pulmonary Disease
HM Thomas III. Am Rev
benefit of
is
"track," that
is,
asthmatic subjects,
pressures
individuals remain at
measured
two-part
RHL
in
pulmonary
with
of
and
1:3, 3:1,
2:2,
in
rehabilita-
'90 Vol 35
No
9
I
we
s
forced
(FEVi)
(I/E)
and we recorded
expiratory
in
vol-
the asthmatic
then performed the same
for patients
(COPD). However, such
and 8
8 asthmatic
eucapnic hypernea while they breathed
ume
chronic obstructive pulmonary
disease
RESPIRATORY CARE • SEPTEMBER
documented
hyperpnea
we performed the
study: First we
at inspiratory to expiratory ratios
group;
well
the constric-
normal subjects during controlled
postchallenge
tion
maximum mouth
(RHL) and
tory heat loss
RespirDis 1990:141:601.
The
in
breathing pattern alone affect respira-
following
maximum
and
J Lafleur,
J Solway.
To determine whether changes
tor response to cold dry gas
of the lungs.
Foster,
Asthma
Rfj can be explained by
in
and dynamic lung
expiratory and inspiratory
patients.
BM Pichurko,
RH Ingram Jr,
The
of the
volumes (other than residual volume),
flows,
COPD
constrictor Response in
Drazen,
structive
tested annually for 5 y. All
benefit
rehabilita-
and the degree of improvement
similar to that of
48 boys
in
a series
Patients
COPD
from intensive pulmonary
JM
and
free of respiratory
nary disease other than
and
mean age
were enrolled
and
COPD.
tory Heat Loss But Not Broncho-
a longitudinal study of lung function
start,
patients
severely impaired with chronic pulmo-
in
girls
non-COPD
of 317 patients with
Breathing Pattern Affects Respira-
Pulmonary Rehabilitation in Lung
Disease Other Than Chronic Ob-
12.6 y at the
tween
increase in ambula-
statistically different be-
Ingenito,
healthy
mean age of
The
extent.
was not
EP
changes
Phelan. Pediatr Pulmonol
twenty-six
same
and ipratropium bromide caused
1990;8:172.
Two hundred
(increase in ambulation
ft
290 ft, p < 0.000 1). Diagnostic
subgroups improved to essentially the
reac-
qualitatively similar changes in Rrs
— ME
Lanigan,
367
of fenoterol
in
than after ipratropium bromide. Feno-
Hibbert,
ambulation distance increased to
±
±
574
Rrs was
The decrease
tance (Xrs).
Children
±219
(SD). At completion of the program,
Inhalation
caused a significant increase
plasma ionized calcium and increases
in
test,
an ambulation distance of 276
of fenoterol and ipratropium bromide
Sodium bicarbonate decreases
Tracking of Lung Function
walk
done
test
On the admission 6-min
32 non-COPD patients had
significant
statistically
in resistance (Rfs)-
these
in
admission and
is
decrease
catecholamines
infused
at
discharge.
tion,
caused
lactate or the cardiovascular response
to
6-min walk
between 4 and 52 Hz. Both agents
and increased blood
acidosis
mg
same pro-
patients in the
assessed by a
tion
of ipratropium bromide
improvement
the
patients with that
is
effects
on the impedance of the respiratory
sodium bicarbonate
does not improve hemodynamics
critically
mg
and 0.02
The
subjects.
Correction of
Conclusions:
using
to
non-COPD
COPD
298
7.13;
cially in
acidemia
is
mechanical parameters, espe-
detect
range 6.90 to 7.20) had no significant
hemodynamic changes
respi-
ratory system by forced oscillations
most
7
the
We compared
gram. Improvement
their
Impedance measurement of the
Occa-
diseases.
patients have been
admitted to our 4-wk inpatient pro-
ft
bicar-
pulmonary
non-COPD
sional
Wouters. Chest 1990:97:1137.
a sensitive
Even
chronic
of
L/min
sodium
severely impaired patients with other
gram.
Effects of Inhalation of /?_-Sympa-
The
bonate compared with that after
infusion.
other healthy
cardiac output
after administration of
acidemic
constant
benefit has not been demonstrated for
of these
have more than
detecting a 0.5
chloride.
in
0.001) and cardiac
the same. These data
sodium
grow
to
relative
indicate that
and
bicarbonate and sodium chloride were
in
healthy individuals
proportion
mean arterial pressure was unchanged.
Hemodynamic responses to sodium
(7%) change
The data
children and adolescents.
capil-
5 to 17 torr,
output (18% and 16%, p
90% power of
time.
measurements
in
normal subjects
8 asthmatic and 8
at fixed target
ventilation (Vp) for tidal
minute
volumes of
867
)
ABSTRACTS
0.2 X forced
0.4 X
the
FVC by
0.6 x
respiratory
target
Our
priately.
capacity
vital
FVC, and
and medical gas analyzer measured the
varying
flowrate
appro-
respectively, at the expiratory
rate
show
results
(FVC),
that
( 1
increasing I/E ratio or tidal volume-
frequency
produced small but
two heat-and-
volume of
0.05)
overall
in
respired
both asthmatic and
FRC
interrupting
volume of the
as assessed by lack of change in slopes
a
of
intercepts
'if
AFEVi
RHL
vs
RHL
in
gas
volume of
per unit
from
resulting
respired
Vj/f
increasing
hyperpnea was
ratios during cold gas
significantly greater in asthmatic than
in
We conclude
nonasthmatic subjects.
that
changes
in
RHL
affect overall
measured
of such changes
in
significantly
(10-
asthmatic persons; and (3)
changing breathing
RHL may
on
nounced
small
airway constrictor
alter
that the effects of
pattern
is
such changes do not
that
in
the
effect
both asthmatic and
nonasthmatic subjects
response
at
maximum
mouth, although the
\5%)\
may
breathing pattern
be more pro-
asthmatic than nonasth-
in
matic subjects, which suggests that the
asthmatic group
may be
1
argon
07c
was
oscillating
possible to
it
HFOV
during
without
measure the
entire respiratory circuit,
These incidence
1
were higher
rates
incidence of Haemophilus
the
gas was
test
product of the
of the
amount of argon
total
equilibrated in the entire respiratory
was
circuit
were
from
isolated
artificial
An
six adults (3%).
airway was established
352
in
the remainder were treated conserva-
the
expiratory flowrate and argon concenthe
from adults (53%). Other organisms
used as a bias flow, and
switched to 100% oxygen. By electrical
tration,
meningitis
population.
children (73%) and in 68 adults (19%);
equilibration,
integration
influenzae
90% oxygen gas mixture
in
initially
after
the
HFOV. To
not affect bronchoconstrictor response
dose-response curves; and the increase
15 y)
from children and 98 blood cultures
convert
to
changes
and
^
(
uous flow. This made
placed
measure
breathing pattern alone did
y.
than
was 10
8/100 000/
children (0-14 y)
in
in adults
expiratory flow to an almost contin-
nonasthmatic subjects of 1 -4 cal/L; (2)
in
incidence
and
in the same
Blood cultures were
obtained from 290 children (60%) and
185 adults (52%). H. influenzae was
isolated from 267 blood cultures (92%)
a rubber balloon for capacitance were
heat loss per unit
in
flowmeter,
hot-wire
statistically signif-
fi.xed
<
(RHL/Ve)
Upstream of the
moisture exchangers for resistance and
at
icant increases (p
gas
end of
the respiratory circuit.
V^
(Vj/O
ratio
and argon concentration,
calculated.
The volume of
tively.
Six children and
Sweden has
two
adults died.
a high incidence of acute
epiglottitis in children,
and the disease
also occurs in adults.
The importance
of H.
the etiology of
influenzae
epiglottitis
in
all
in
age groups
firmed, but in adults
many
con-
is
cases occur
the circuit
without septicaemia. The mortality
the total
currently very low.
was calculated by dividing
amount of argon by the initial
argon concentration. Functional
ual capacity plus the
respiratory circuit
resid-
volume of
the
similarly calcu-
and the difference was estimated
lated
as
was
FRC. The accuracy and reproducof our method were evaluated
ibility
by
using
one-compartment lung
a
is
Influence of Parenteral Nutrition on
Rates of Net Substrate Oxidation
Severe Trauma Patients
in
Jeeva-
DH Young, WR Schiller. Crit
nandam,
Care
—M
Med
1990:18:467.
model. There was a high correlation
between the volume
of the
setting
Optimal
nutritional support should use
able to
model lung and the estimated FRC.
a
adapt to factors that alter the magni-
This method can be used to estimate
guide for administering sufficient but
tude and
site
of
less
FRC
RHL.
in
one-compartment lung
HFOV, and it is poten-
a
(HFOV)
by
Argon Washout Method without
rimetry
Epiglottitis in
Adults
in
Sweden 1981-3
M
Nishimura,
M
Child 1990:65:491.
Taenaka,
I
Nishi-
O
Nylen,
K
Strangert.
indicator
during
residual
in
gas
washout
children and
to
measure
following
criteria: (a)
(FRC)
epiglottis
visualised at
capacity
high-frequency
oscillatory
period
of catabolic
on the
in
rates
the critical
due
illness
to
accidental trauma. Five days of total
parenteral nutrition, providing calories
In a retrospective study of the incidence
method was developed
functional
Troll-
of substrate utilization
to
of acute epiglottitis
modified
B
Arch Dis
Yoshiya. Chest
1990;97:1152.
A
Children and
calo-
indirect
measurements, to determine
the nutritional influence
Acute
fors,
N
Eight
intake.
were evaluated, using
Imanaka,
Takezawa,
caloric
tially useful in clinical situations.
HFOV — H
J
excessive
patients requiring parenteral nutrition
Interruption of
jima,
not
energy expenditure as a
model during
Measurement of Functional Residual Capacity during High-Frequency
Oscillatory Ventilation
patient's
Sweden, 485
356 adulLs
fulfilled
the
red and swollen
laryngoscopy;
match
the
measured basal
energy expenditure and
the
resting
to replace
urinary losses (a) shifted the
initial
RQ from 0.75 ±
(b)
N
0.03 to 0.81
±
0.03,
improved but could not reverse
negative
N
balance, (c) decrea.scd net
(b) stridor or difficulties in swallowing
fat
ventilation
own
norepinephrine and epinephrine excre-
tion
temperature
868
(if
(HFOV) without interrupHFOV. A hot-wire flowmeter
saliva
^
or
water;
and
38 °C. The age
(c)
specific
tion
oxidation,
rates,
and
(e)
(f)
RESPIRATORY CARE • SEPTEMBER
elevated
attained
daily
positive
"90 Vol 35
No 9
.
SIEMENS
.M^L
1989
ZENITH
AWARD
Beware!
High pressures are dangerous.
means
Treating a patient by
tilation
can be
risky.
of
Especially
volume ven-
when
air-
way pressures required to deliver set volumes can increase dramatically with
changing conditions.
Control pressures with Servo
Pressure Controlled ventilation
With a Siemens Servo Ventilator 900C you
instead can use a unique
trols
mode
that con-
pressure at a constant level through-
through adults Instant panel access gives
control at a glance.
out a preset inspiratory time This combined
Pressufe
Pressure contr
Volume contf
with a decelerating flow pattern allows the
opportunity for poorly ventilated lung units
to
expand and reopen.
Explore the Power of Servo
—
(or our new brochure
"Only Servo'"
Siemens offers you the Servo gas delivery
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.
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Standard easy-to-use feature
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No upgrades or options are required And
.
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ISTiJ
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Siemens Life Support Systems
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Original
Contributions
Complications of Mechanical Ventilation
in a Children's Hospital
Multidisciplinary Intensive Care Unit
Patrice
K Benjamin AS RRT, John E Thompson RRT, and P
Pearl
O'Rourke
MD
During a 12-week period, 204 consecutive patients admitted to the multidisciplinary
intensive-care unit of a children's hospital were prospectively studied for
complications of mechanical ventilation. METHOD:
completed a standardized data form at the end of each
patient. Patient age, sex, length of ventilation, diagnosis,
A
respiratory
shift for
therapist
each ventilated
and complications were
noted. Complications were classified as relating to the endotracheal tube (ETT),
management, and were analyzed according
(number per 100 patients or per 100 ventilator days) and to associated
mortality. RESULTS: Patients ranged in age from newborn to 24 years. Sixtythree percent were male. Twenty-one percent of patients were managed by the
medical staff, 11% by the general surgical staff, and 68% by the cardiac surgical
the ventilator, or the patient's medical
to incidence
staff.
Average length of ventilation was 5.2 days. Overall survival rate was 91.7%.
ETT
complications reported as number per 100 patients were: pre-necrosis (13.0 [4/
57 orally intubated patients and 23/147 nasally intubated
patients]),
ETT
retaping
ETT
plugging (1.0), and self-extubation (3.0). Ventilator
complications reported as number per 100 ventilator days were: alarm failures (6.5),
ventilator failures (0.7), and circuit problems (7.0). Medical complications reported
complications (6.0),
number per 100 patients were: massive gastric distension (8.8), right-upper-lobe
pneumothorax (4.4), subcutaneous air (1.5), and pneumoperitoneum
(1.0). ETT and ventilator complications showed no association with mortality. The
large number of cardiac infants less than 24 months of age (n = 101) led us to further
analyze this group for survival rate. We found that the survival rate was 93% for
as
collapse (4.4),
those requiring
<
7 days mechanical ventilation and 89.3% for those requiring
As the study progressed,
days.
>
7
the respiratory therapists independently noted that
both patient and machine increased as did their awareness of
The incidence of alarm failure, circuit problems, and pre-necrosis was
higher among the first 103 patients compared to the 101 patients entered into the
their attentiveness to
complications.
study subsequently. (Respir Care 1990;35:873-878.)
Ms
Benjamin
is
Respiratory Clinical Specialist, Respiratory Care
Department, The Children's Hospital; and
Director, Respiratory Care Department,
,
'
,
and Associate
Massachusetts.
in
^
The
Mr Thompson
is
Children's Hospital,
.....c-uin.
— Boston,
,,
Anesthesia, Harvard Medical School
Dr O'Rourke
is
of Anesthesiology
— SeatUe,
&
Medical Center, and Assistant
and
Pediatrics,
University
of
Washington. She was Associate Director
RESPIRATORY CARE
•
when
this
study was done.
r.^-.j
study
,
results of this
.juhd~
Ms Benjamm
were presented by
Respiratory Care Open Forum during
the 1988
AARC
Director of the Pediatric Intensive
Department, Children's Hospital
Washington
Hospital, Boston,
„,..
Prelimmary
at the
Care Unit and Associate Director of the Respiratory Therapy
Professor
of the Multidisciplinary Intensive Care Unit at the Children's
SEPTEMBER
'90 Vol 35
No 9
Annual Meeting
Reprints:
in
Patrice
Orlando, Florida.
K Benjamin RRT, Respiratory Care
Department, The Children's Hospital, 300 Longwood Ave,
Boston
MA
02115.
873
COMPLICATIONS OF MV
Introduction
into the study.
A
check-off yes/no complications
questionnaire (Fig. 2) was
Mechanical ventilation requiring tracheal intubation
invasive technical therapy that imposes an
is
intimate
between
interface
machine and
results in a
and complications.'
importance of these
the
patient
number of
and the
potential risks
therapi.st
at
the
filled
end of each
out by a respiratory
for the duration
shift
of mechanical ventilation. Therapist compliance in
filling
out the questionnaires was monitored by the
authors and found to be
Although the incidence and
ETT
>
95%.
(tracheostomy
complications
were
tubes
have been reported for the
considered ETTs) included pre-necrosis defined as
adult population," they have not been widely studied
a reddened pre-necrotic or necrotic area around the
risks
in children.
In
ETT; problems during ETT taping such
we
study
this
prospectively
evaluated
incidence of complications in patients
mechanical
ventilation
in
who
the
required
multidisciplinary
the
(ICU) of our children's hospital.
Complications were classified as relating to the
intensive care unit
endotracheal
tube
medical
patient's
(ETT),
the
ventilator,
or
management. The goal was
the
to
identify complications of mechanical ventilation, to
examine the impact of these complications on patient
morbidity and mortality, and to identify ways to
decrease these complications in the future.
ETT
bradycardia, and extubation;
as cyanosis,
plugging defined
as obstruction that required either reintubation or
vigorous instillation of normal saline and suctioning;
and self-extubation.
Ventilator complications included alarm
failure
defined as an alarm that failed to alarm, an alarm
that
was
set outside
alarm that was shut
changed;
off;
problem
a mechanical
be
of department standards, or an
and
venulator failure defined as
that required the ventilator
circuit
complications
including
tubing leaks, humidifier malfunction, and turned-off
humidifiers.
Methods
Medical complications were confirmed radiogra-
and included right-upper-lobe collapse,
pneumothorax (PTX), subcutaneous air, pneumophically
Between March and
May
admitted to the multidisciplinary
who
1988,
ICU
all
patients
of our hospital
required mechanical ventilation were studied.
These patients received routine respiratory manage-
ment including complete
I)
was completed
for
A
and massive
that
tube.
ETT
retaping complications,
patient data sheet
self-extubation
each patient upon entry
distension
gastric
required placement or replacement of a nasogastric
ventilator checks every 3
hours by a respiratory therapist.
(Fig.
peritoneum,
are
reported
and number per
patients
ETT
plugging, and
number
as
100
per
100 ventilator days.
Ventilator complications are reported as
number
per
100 ventilator days. All other data are reported as
number
Name
per 100 patients. Statistical analysis
using the Fisher exact
was done
test.
JCU
Patient No.
ICU Adm. Date
Results
Age
Sex
.Weight
Diagnosis: Admitting
During the 12-week period between March and
May
Chronic
1988, 204 consecutive, mechanically ventilated
patients
Date of Intubation
were entered into the study. The patient ages
ranged from newborn to 24 years (Table
ETT
Oral
Size
Ventilator
-Nasal
length of ventilation
to
Type
ranged from
less
1.
Patient data sheet completed for
upon entry
874
into the study.
each
patient
I ).
The
1
day
53 days, with an average of 5.2 days. There were
a variety of patient diagnoses (Table 2).
Fig.
than
percent of the patients were
staff,
ll't
managed by
by the general surgical
staff,
RESPIRATORY CARE • SEPTEMBER
Twenty-one
the medical
and 68'
'90 Vol 35
t
by
No 9
COMPLICATIONS OF MV
QUESTIONNAIRE
Questions pertaining to events and observations on your
shift.
Name
_
Unit
Shift
Were any
Did any complications
ETT become
Did
If so,
around the ETT?
necrotic areas noted
arise during
plugged?
ETT
no
yes
no
yes
retaping?
no
yes
Complications questionnaire
Fig. 2.
was reintubation or vigorous suctioning required?
no
yes
out by respiratory therapists at
filled
the end of each shift for the duration
Did self-extubation occur?
Was
found
ventilator alarm
Did
ventilator alarm fail?
Did
ventilator fail?
Was
there a
no
yes
How many
no
yes
How many
no
yes
How many
no
yes
off?
problem with the ventilator
How many
of
circuit?
mechanical
times?
times?
times?
no
yes
times?
Was
there massive gastric distension requiring decompression?
Was
there right upper-lobe collapse?
Was
there atelectasis?
Was
there
Was
there subcutaneous air?
Was
there
_
no
yes
pneumothorax?
no
yes
no
yes
no
yes
yes
pneumoperitoneum?
no
yes
no
staff. The overall survival rate
was 91.7%. The incidence of complications that
occurred among the 204 patients in our study are
shown in Table 3.
the cardiac surgical
ETT
Complications
The incidence of
patients; pre-necrosis
pre-necrosis
occurred
orally intubated patients
Table
1
.
Age Data
for
204 Consecutive, Mechanically Ventilated
Patients in a Children's Hospital Multidisciplinary
ICU
the
Age Range
-
30 d
Patients
intubated
nasally
statistical significance,
ventilation
No. of
Newborn
ventilation.
damage was
in
our
study
(no
p = 0.2). Average duration of
for orally intubated patients
enough
up. Complications during
52
of the
15.6% (23/147) of
in
for those nasally intubated.
severe
13.0/100
7% (4/57)
in
patients
was 5 days
and 5.3 days
and
was
to require
ETT
No
tissue
medical follow-
retaping occurred in
ETT
mo - 8 mo
mo - 5 y
6y - 12y
82
6.0/100 patients (1.1/100 ventilator days),
30
plugging
25
ventilator days),
13y- 17y
12
100 patients (0.6/100 ventilator days). There was
1
1
19
18 y
-
24 y
Total:
RESPIRATORY CARE • SEPTEMBER
3
no association
204
'90 Vol 35
occurred
in
1.0/100
patients
(0.2/100
and self-extubation occurred
between
ETT
in
complications
3.0/
and
mortality.
No 9
875
COMPLICATIONS OF MV
Table
2.
Diagnostic Data for 204 Consecutive, Mechanically
Ventilated
disciplinry
Patients
in
a
Children's
Hospital
Multi-
ICU
No. of
Patients
Medical
Upper-airway obstruction
Small airways disease
Bronchiolitis
Bronchopulmonary dysplasia
Alveolar disease
pneumonia
Aspiration pneumonia
Drowning
Neuro/Neuromuscular
Apnea
Status epilepticus
Head trauma
CNS
hypoventilation
Meningitis
Encephalitis
Muscular dystrophy
Other
Cardiac
Pulmonary edema/CHF
Cardiogenic shock
Septic shock/sepsis
Post-CPR
Other
Liver failure
43
Total:
General Surgical
Congenital diaphragmatic hernia
Tracheal-esophageal
fistula
Gastroschesis
Harrington rod/anterior fusion
Liver transplant
Cardiac transplant
Renal transplant
Other thoracic surgery
Other abdominal surgery
22
Total:
Cardiac Surgical
139
ToUl:
Grand
204
Total:
Ventilator Complications
There were 69 alarm
3.
Incidence
of Complications
Mechanically
Ventilated
Hospital Multidisciplinary
Diagnoses
Viral
Table
failures
(6.5/100 ventilator
days), 7 ventilator failures (0.7/100 ventilator days).
in
Patients
ICU
204 Consecutive,
in
a
Children's
COMPLICATIONS OF MV
Overall, ventilator complications were infrequent
and the low frequency of incident
of patients
occurrence.
in
our study and did not contribute to mortality, but
the possibility of these resulting in life-threatening
situations
Discussion
is
obvious; therefore, measures should be
taken to prevent them from occurring.
The
invasive
technical,
patients
a
to
complications.
understand these
number
It
of risks and
important to
is
exposes
intubation
tracheal
requiring
ventilation
of mechanical
nature
potential
and
identify
can be
risks so that patient safety
by improved monitoring and machine
increased
maintenance and by recognition and anticipation of
A number
problems.
of papers
mechanical ventilation complications
unfortunately
have
reported
such information exists
little
'
in adults,'
but
the
in
The main purpose of our study was to report
complications encountered in 204 consecutive,
mechanically-ventilated patients in our multidiscipH-
ICU
The
during a 3-month period.
overall
compares favorably
survival rate in our study (91.7%)
with the survival rates reported in similar adult
series."
'
In 1986, Kanter et
al''
studied the ventilatory
course of postoperative cardiac surgical infants
less
than 24 months of age. They demonstrated a survival
rate of
83%
<
for patients ventilated
for patients ventilated
are comparable
respectively.
^
Kanter
rates
felt
ICU
of
7 days and
93% and 89.3%,
ETT
complications
pediatric
airway
is
recognized as a difficult airway to maintain because
of patient size and lack of patient cooperation.
most commonly anticipated
problem
maintaining good tube position
result in
—a
slight
change
in
in
is
The
that
of
small
the
tube position
right-main-stem intubation or accidental
extubation. This study identified
concern:
potential
skin/tissue
two other
damage in
areas of
nasally
and potential cardiovascular
compromise during ETT retaping. Although neither
contributed to a high morbidity and mortality, closer
attention is indicated. The skin around the nares and
intubated
patients
lips
should be examined frequently.
the
cyanosis and bradycardia
retaping
compares favorably
in 4.4%.
to
may warrant
of the patients.
previous
studies
of
pediatric patients that have reported incidences of
4.5
8%.'*' Baier
and
and
Petersen*' in reviewing the
have noted reported incidence of
literature
PTX
in
adults ranging from 0.5 to 38%. Obviously, the value
of comparing these studies
is
limited because patient
ages and diseases varied. However, in our study,
and other forms of barotrauma did
mortality
— an
association
that
As our study
PTX
correlate with
emphasizes the
air leak.
progressed, the respiratory therapists
independently noted that their attentiveness to both
patient
and machine and
awareness of
their
complications increased. This potentially increased
respiratory therapist vigilance
(ie,
'learning effect')
may explain why the incidence of alarm failure, circuit
problems, and pre-necrosis was higher among the first
103 patients compared to the 101 patients entered
into the study subsequently (Table 4).
Table
4.
Comparison of Incidence of Selected Complications
between the
First
103 Patients and Subsequent 101
Patients Entered into the Study
resources in this population.
In our study, the incidence of
uncooperative child
occurred
84%
high survival rates
these
was low. The instrumented
can
PTX
7 days. These survival rates
our
to
justified the cost of
This
our study,
ominous nature of pulmonary
pediatric literature.
nary
In
We
believe that
noted during
ETT
the use of a cardiac monitor
and an oximeter during the procedure.
Incidence
A
COMPLICATIONS OF MV
group of mechanical ventilation complications
occurred
in
higher standards of care
may
evolve.
3.
DJ, Marsh
Gillespie
III.
We
Clinical
HMM,
outcome of
Divertie
respiratory
Kanter RK, Bove EL, Tobin JR,
Crit
REFERENCES
5.
2.
Streiter
E,
Petty
TL.
Complications of assisted
ventilation
Care
Pollack
Med
MM,
tion. Crit
6.
—
Petersen
in a
New
in
MB, Meadows JA
failure
in
patients
Zimmerman
Care
GW,
after
JJ.
Prolonged
open heart surgery.
1986;14:211-214.
Fields
AL. Holbrook PR. Pneumothorax and
pneumomediastinum during
RM, Lynch JP III. Complications in the ventilated
patient. Clin Chest Med 1988;9:127-128.
Zwillich CW, Pierson DJ, Creach CE, Sutton FD, Schatz
Med
1986;90:364-369.
4.
mechanical ventilation of infants
1.
J
requiring prolonged (24 hours) mechanical ventilation. Chest
encourage other practitioners to pursue data collection
in this special population.
Am
1974;57:161-170.
a predominantly pediatric (non-neonatai)
ICU. a database has been established from which
we hope
prospective study of 354 consecutive episodes.
that
Med
pediatric mechanical
ventila-
1979;7:536-539.
Baier H. Incidence of
medical ICU. Crit Care
Med
pulmonary barotrauma
1983:1 1:67-69.
Orleans
December
AARC
Annual
Meeting
December
878
8-11
RESPIRATORY CARE • SEPTEMBER
"90 Vol 35
No
9
Patterns of Practice in Neonatal
and Pediatric Respiratory Care
W Salyer RRT and Robert L Chatbuin RRT
John
Because
common
information has been available regarding
little
practices in neonatology and pediatrics,
it
has been
difficult to
respiratory care
develop departmental
We
therefore conducted a national survey of current practices,
whether any de facto standards exist in the U.S. METHODS:
A 47-item multiple-choice survey instrument was mailed in 1988 to 689 U.S. hospitals
that included all neonatal and perinatal high-risk centers. RESULTS: Response
standards of care.
hoping to establish
was received from 323 hospitals, for a 47% response rate. Some de facto standards
do seem to exist, notably (1) q 2 h ventilator checks, (2) continuous measurement
of oxygen concentration in oxygen hoods and ventilator circuits, (3) stafFrng ratio
of four ventilator patients to one respiratory care practitioner, and (4) changing
of ventilator circuits q 48 h. CONCLUSION: While we do not claim that such
de facto standards have a scientific basis,
whose
own
we
suggest that respiratory care services
from the de facto standards should investigate why their
and whether they can be justified. (Respir Care 1990:35:879-
practices vary
practices differ
888.)
Introduction
difficult to
determine whether most other
are in fact following whatever
may be more pronounced
Managers of respiratory care departments must
make decisions about what levels of service their
exist.
departments should provide and what are acceptable
pediatrics,
standards of care. Unfortunately, such decisions are
establishing standards for
often difficult because there
specialized kinds of practice, such as
a lack of reported
is
This problem
although
the
In
absence of
may
dations exist,'"* they seldom offer sufficiently detailed
standards
information to help managers decide about standards
of
of care or what equipment
patterns exist,
community
within
standards
or
needed
standards.
guidelines
are
for
practice
Additionally,
voluntary,
such
making
progress
some
has
in
neonatology and
been
made
in
aspects of perinatal
respiratory care.^
consensus on these matters. While some recommen-
is
facilities
recommendations may
common
exist,
we
exist
practice.
official
guidelines,
de facto
simply as identifiable patterns
To determine whether such
and what those patterns are
if
they
surveyed United States hospitals that provide
neonatal and pediatric respiratory care. This paper
it
reports our findings.
Mr
Salyer
Director
is
Mr Chatburn
Educational Coordinator, and
— Pediatric
Respiratory
Care,
Methods
is
Rainbow Babies and
Questionnaire
Childrens Hospital, Cleveland, Ohio.
A
was presented by
Mr
Salyer at the
Respiratory Care Open Forum during
the
1989
version of this paper
Annual Meeting
in
Anaheim,
We
AARC
47 multiple-choice questions, with an answer sheet
California.
scanned by computer. The questionnaire
Appendix) covered those aspects of neonatal and
pediatric respiratory care that we thought would
that could be
(see
W
John
Salyer RRT, Pediatric Respiratory Care.
Rainbow Babies and Childrens Hospital, 2101 Adelbert Rd,
Reprints:
Cleveland
OH
enable us to identify patterns of practice.
44106.
RESPIRATORY CARE
developed a survey instrument consisting of
•
SEPTEMBER
'90 Vol 35
No
9
879
PATTERNS OF PRACTICE
Table
1
.
IN
NEONATAL & PEDIATRIC RESPIRATORY CARE
Demographics of the Hospitals/Departments Responding
Numbers of Neonatal ICU (NICU)
and Pediatric ICU (PICU) Beds
No. of
to the
Survey
PATTERNS OF PRACTICE
District of
listing
Columbia. The two
of 689
NEONATAL & PEDIATRIC RESPIRATORY CARE
efforts resulted in a
we
that
facilities
IN
nearly the entire population of pertinent respiratory
We
care departments.
Who
Does What?— Table
mailed our questionnaire to
689 hospitals, which were in 48 states. Hospitals
were given the option of remaining anonymous, and
they were allowed 2 months in which to return the
the
questionnaire answers.
Table 2 shows whether each of 14 procedures
performed by RCPs, by nurses (RNs), by both
and RNs, or by "others"
Issues
question,
is, if
we
respondents answered
used what
we
call valid
every
response; that
response to a given question was to be expressed
(eg, physicians, laboratory
in
— Table 3
mechanical ventilation are
concerning
summarized
all
is
RCPs
technicians).
Mechanical Ventilation
Treatment of Responses
Because not
2
believe constitutes
Table
3.
These include ventilator-
check frequency, ventilator-Fioj-measurement
frequency,
how
often circuits are changed, use of
airway-pressure monitors, types of circuits employed,
number of respondents who
response was divided by the total number
as a percentage, the
selected that
of respondents to the question.
rounded
some
off to the nearest
total
response rates
Percentages were
whole number;
may be
slightly
therefore,
we determined
the
relationships
between "small" and "large" neonatal and pediatric
and
intensive care units
( 1 )
the frequency of ventilator
checks, (2) the frequency of ventilator-circuit changes,
(3) the types of personnel shift scheduling.
Results
Response to Survey
surveyed departments, 323 responded,
for a response rate of
Demographics
— Table
47%.
1
The demographics of
are
described
in
Table
the responding departments
1,
indicating
bed-size
of
neonatal intensive care units (NICUs) and pediatric
ICUs (PICUs), staff-mixes of registered respiratory
(RRTs) and certified respiratory therapy
therapists
technicians
(CRTTs), numbers of
respiratory care
practitioners (RCPs), presence of supervision, average
numbers of ventilators
in
operation, ratio of ventilator
RCPs, and the distribution of various shift
schedules between hospitals with smaller and larger
patients to
ICUs.
Identification
of Personnel
Performing Various
Respiratory Care Procedures in Responding Hospitals
Percentages of Hospitals
Additionally,
Of the 689
2.
below or
above 100%.
and
Table
Reporting Procedures Performed
by these Persons
PATTERNS OF PRACTICE
Table
IN
NEONATAL & PEDIATRIC RESPIRATORY CARE
Survey Responses Concerning Mechanical Ventilation
3.
Ventilalor-Check Frequency
Distribution of Ventilator Circuit-Change Frequency between
Smaller ICUs
%
Check Frequency
of Respondents
>q4h
44h
q3h
q2h
64
h
17
q
I
8
II
Distribution of Ventilator-Check Frequency
between Smaller ICUs
Larger ICUs
(
>
(
sc
20 Beds) and
20 Beds)
%
Check Frequency
of Small
ICUs
%
of Large
ICUs
Neonatal ICUs
q4h
q3h
q2h
6
9
10
13
65
63
h
19
16
q4h
q3h
q2h
8
6
11
13
63
81
h
18
q
1
Pediatric
q
1
ICUs
Ventilator Fjoi-Measurement Frequency
% of Respondents
Measurement Frequency
Not measured
2
q8h
q4h
8
With
2
ventilator checks
16
Measured continuously
72
Ventilator Circuit-Change Frequency
%
Change Frequency
of Respondents
>q72h
3
q72h
q48h
q24h
67
Type of
9
22
Ventilator Circuits
Circuit
Used
Type
Disposable with heated wire
%
of Respondents
37
Nondisposabic with heated wire
4
Disposable without healed wire
47
Nondisposabic without heated wire
12
(sS
20 Beds) and Larger ICUs (> 20 Beds)
PATTERNS OF PRACTICE
IN
NEONATAL & PEDIATRIC RESPIRATORY CARE
models of ventilators used, and methods of securing
neonatal ventilator circuits to prevent pulling
Table
4.
Policies Related to
Oxygen Therapy and Oxygen Monitoring
on the
Typical Oxygen-Flowrale Ranges with
endotracheal tube.
Neonatal and Pediatric Nasal Cannulas
Oxygen Therapy and Oxygen Monitoring
Flowrate (L/min)
— Table 4
oxygen flowrates in nasal cannulas,
frequency of Fiq. measurement in hoods, kinds of
noninvasive oxygen monitoring employed in lowTypical
birthweight
delivering
and use of incubators
infants,
oxygen are presented
Table
in
0.10-4,0
38
17
1.0-4.0
4.
Measurement Frequency
— Table 5
q
In
Oxygen Hoods
%
of Respondents
3
shift
q4h
q2h
on heating and humidifying gas delivered
to neonates via resuscitation bags,
7
39
0.25-4.0
for
Heating Gas, Humidifying Gas, and Administering
Policies
of Respondents
0.124-4.0
Frequency of F102 Measurement
Aerosols via Mechanical Ventilation
1
q
methods of aerosol
1
8
8
5
h
76
Continuously
administration during both neonatal and pediatric
mechanical ventilation, and during use of ultrasonic
nebulizers or other
are
shown
in
Table
means
5, as
for
room humidification
are data
on administration
of ribavirin via ventilators.
Most Frequently Used Method of Noninvasive
Oxygen Monitoring in Low-Birthweight Infants
Monitoring Method
Relationships between
We
ICU
Size and Other Data
arbitrarily classified
responding hospitals as
NICUs and PICUs that were either "small"
(^ 20 beds) or "large" (> 20 beds). Findings related
to ICU size are offered in Table 1 (various shift
having
schedules) and in Table 3 (ventilator-check frequency
and
Pulse oximetry
55
Transcutaneous
11
Both above used equally
19
Both above used simultaneously
16
Is the
Incubator Used as an Oxygen-Delivery Device?
ventilator circuit-change frequency).
Response
Yes
Unreported Data
Typographical errors rendered Items 42 and 46
on the survey instrument
invalid,
and therefore the
responses to those items are not reported here.
dealt with the temperature of
oxygen
in
They
hoods and
the temperature of gas delivered via endotracheal
tubes.
Discussion
Credibility of
The
47%
% of Respondents
large
Response
number of responding
hospitals (323,
response) lends our data considerable credibility
%
of Respondents
"
PATTERNS OF PRACTICE
Table
Policies
5.
Do You
IN
NEONATAL & PEDIATRIC RESPIRATORY CARE
Concerning Heating Gas, Humidifying Gas, and Administering Aerosols during Mechanical Ventilation
How
Humidiry Gas to Resuscitation Bags?
Is
Aerosol Administered to Neonates
during Mechanical Ventilation?
Response
% of Respondents
Yes
13
No
87
%
Administration Method
Bagged
in
by hand
Via nebulizer
some
Do You
to
Neonates
via Resuscitation
in circuit,
distance up inspiratory limb
at Patient
24
Y
54
Bags?
How
%
Response
of Respondents
Yes
94
No
6
Is
Aerosol Administered to Pediatric Patients
during Mechanical Ventilation?
in
some
for
Room
%
Response
Humidification?
of Respondents
14
in circuit,
26
distance up inspiratory limb
Via nebulizer in-line
Do You
of Respondents
by hand
Via nebulizer
Use Ultrasonic Nebulizers
%
Administration Method
Bagged
Do You
22
Via nebulizer in-line
Both Heat and Humidify Gas Delivered
of Respondents
at Patient
Y
59
Administer Ribavirin via Volume-Controlled
Ventilators?
Yes
11
No
79
Occasionally
10
Do You Use Any Form
of
Room
Response
Humidification Other than
Ultrasonic Nebulizers?
)
of Respondents
Rarely
17
No
58
Yes
25
Do You
Administer Ribavirin via Pressure-Controlled
Ventilators?
9c
%
Response
of Respondents
of Respondents
Yes
28
Rarely
17
No
59
No
49
Occasionally
12
Yes
33
evidence that our results represent a broad-based
sample
the
is
numbers of
responding
Who
uniform
relatively
facilities
(Table
distribution
on an average day
ventilators in use
method of noninvasive oxygen
primary
of
monitoring
in
Considerable published evidence has suggested that
in
low-birthweight
infants
(Table
4).
is not a safe practice with regard to preventing
hyperoxemia,'' " although at least one paper has
this
1 ).
Does What?
Our
their
as
'
reported otherwise.
findings with regard to
which practitioners
are performing various respiratory care procedures
(Table 2) did not surprise
us,
although
we have
Ratio of Ventilators to
RCPs
little
except intuition with which to analyze these findings.
Also interesting
Pulse Oximetry
practice.
An
alarming finding of the survey was the large
percentage (55%) of
884
is
that
on some
issues there
seems
to be a fairly clear-cut consensus, or standard of
facilities
using pulse oximetry
The
reported by
RCP
ratio of four ventilator patients per
53'/r
of the respondents (Table
recommended standard of
the
1 )
is
the
American Academy
RESPIRATORY CARE • SEPTEMBER
'90 Vol 35
No 9
PATTERNS OF PRACTICE
NEONATAL & PEDIATRIC RESPIRATORY CARE
IN
Smaller and Larger
of Pediatrics^ and seems like a reasonable level of
Even
recently reported survey/
more
patients
ventilator
per
at levels
and
care
except
and 12-hour
their
in
scheduling (eg, 12-hour
Ventilator-Check Frequency
call for
1 ).
a consensus on a
shifts
minimal acceptable frequency of routine ventilator
Our
checks.'^
seem
findings
indicate
to
standard of q 2 hours, which was reported by
of the respondents (Table
in
or combinations of 8-
20 beds
regardless of
64%
for smaller
ICU
and
ICUs (Table
as the threshold
order to look at the data; there
were no important differences
clear
a
ICUs
20 beds,
of 'creative'
use
did smaller
We arbitrarily selected >
of larger
in
Larger ICUs tended to report
shifts).
more such scheduling than
Recently there was a
>
ICUs (^ 20 beds and
larger
respectively),
practitioner.
difference
little
between hospitals with smaller
patterns of practice
of six
respiratory
survey revealed
the
Finally,
94 (30%) of the
so,
responding hospitals reported staffing
or
ICUs
This finding agrees with that of another
staffing.
larger
3).
Continuous Fjo, Measurement
in
practice patterns,
even when different
size,
ICU
size
criteria
were used.
Conclusions
Measuring Fiq. continuously, rather than periodboth ventilator circuits and oxygen hoods
be reached through majority opinion. Simply because
appears to be very widely practiced. Continuous Fiq,
a majority of hospitals practice in a certain fashion
was reported by
72% of our respondents (Table 3), and continuous
measurement in oxygen hoods was reported by 76%
does not necessarily
of respondents (Table 4).
pediatric-perinatal
One must
ically, in
measurement
in ventilator patients
useful
Some de
thirds of facilities reported that they
continues to be
practice. If
48 hours (Table
change
hospitals
little
circuits
less
this issue,
care
facto standards
3).
often,
its
own
rather
than
oxygen concentration
change
in
(3) a staffing ratio of one
While
patients,
there
in
United
the
do seem
to exist,
and
periodic
measurement of
hoods and ventilator
circuits,
RCP to every four ventilator
(4) the changing of ventilator circuits
every 48 hours.
published data to support that
any group has conducted
and has data on
respiratory
notably (1) q 2 hour ventilator checks, (2) the
Changing
ventilator circuits every
some
that practice appropriate.
about patterns of practice in
information
continuous
Two
make
Nevertheless, the findings from our survey contain
States.
Ventilator-Circuit
take care not to assume that truth can
While we
research
are not claiming that these de facto
we do suggest that
own practices
should ask why those
standards have a scientific basis,
they should report their
respiratory care services that find their
findings so that others might benefit.
at variance
from the standards
differences exist,
and how or whether they can be
Ribavirin Administration
justified.
The
administration
of
ribavirin
through
mechanical-ventilator circuits continues to be a point
REFERENCES
of controversy.''' In our survey, a large majority of
responding
facilities
reported that they rarely or never
American College of Chest Physicians, National Heart, Lung,
administer this drug through a ventilator circuit (Table
5).
We
and
recommended
that ribavirin
Blood
Therapy
find this interesting, as a recent report'^ has
Institute.
American Association
be administered only via
National
(report). Respir
Conference on
for Respiratory
Therapy. Adminis-
trative standards for respiratory care services
a
mechanical ventilator
circuit,
in
order that the
(official statement).
aerosol in the ventilator effluvium might be sufficiently
filtered to
reduce the
risk
Joint
of exposing persons in the
•
SEPTEMBER
Commission on Accreditation of Healthcare
JCAHO,
'90 Vol 35
No
and personnel
Respir Care 1983;28:1032-1038.
Organizations. Accreditation manual for hospitals. Chicago:
patient's vicinity to ribavirin aerosols.
RESPIRATORY CARE
Oxygen
Care 1984;29:922-935.
9
1989:233-241.
88S
PATTERNS OF PRACTICE
Management
Health Care
departments
care
in
IN
NEONATAL & PEDIATRIC RESPIRATORY CARE
oxygen measurements
National survey of respiratory
Inc.
children's
AARCTimes
hospitals.
1989;13(ll):63-68.
10.
American Academy of
Pediatrics,
2nd
ed. Elk
Grove
Village IL:
American Academy
II.
DS, Sheridan JF, Bajo KB. 1982 guide
OH:
12.
to centers
Columbus
providing perinatal and neonatal special care.
outcome of
Health.
13.
WA,
14.
Martin RJ. Relationship
of pulse oximetry to arterial oxygen tension
Care
Med
RPA,
WW,
Brockway JM, Eyzaguirre M. Neonatal
reliability. Pediatrics
J.
Of
interest to
AARC
pulse
1989;83:7I7-
RC
managers: Ventilator patient
Section Connection 1989;2:18-19.
Fackler JC, Flannery K, Zipkin
N
in infants. Crit
15.
M, Mcintosh K. Precautions
the use of ribavirin at the Children's Hospital (letter).
Engl J
Med
I990;322:634.
Mahlmeister MJ, Guglielmo BJ,
Harrison
VA, Alexander JR, Rivers
concerned about ribavirin exposure
and transcutaneous
1988;33:809-8
Bignall S, Stebbens
Lissauer T. Pulse oximeter
Smoker
in
1987;15:1102-1105.
DP,
Southall
Hay
monitoring.
Foundation-March of Dimes, 1980.
Walsh MC, Noble LM, Carlo
Rev Respir Dis 1980;122:629-634.
722.
Toward improving the
pregnancy. White Plains NY: The National
Perinatal
in
newborns with cardiopulmo-
Kelleher JF. Pulse oximetry. J Monitor l989;5(l):37-62.
oximetry: Accuracy and
Ross Laboratories, 1982.
Committee on
GA,
oxygen dissociation curves
vivo
In
Am
nary disease.
of Pediatrics. 1988:45-46,244-248.
Easier
HT.
transfused and untransfused
Obstetricians and Gynecologists. Guidelines for perinatal
care.
Wilkinson AR. Phibbs RH, Heilbron DC, Gregory
Versmold
American College of
neonatal and pediatric intensive
in
Arch Dis Child 1987;62:882-888.
care.
arterial
(letter).
We
R.
are
Respir Care
10, 1075.
APPENDIX
Survey Instrument Sent to 689 Hospitals
Please choose the answer that best describes the practice at your hospital Select only one
answer per question. Unless otherwise
stated,
assume these questions
refer to
your practice
in the intensive care units.
1.
Indicate the total
beds
^
a.
2.
your
10
11-20
b.
^
a.
your
in
10
the
intensive care unit
7.
c.
21-30
number of
11-20
Indicate the average
number
of ventilators per day in your
facility:
d.
31-40
e.
>
40
a.
<6
Please
c.
6-10
b.
c.
11-15
d.
16-20
e.
>
20
pediatric intensive care unit
facility:
b.
Indicate
number of neonatal
facility:
Indicate the total
beds
3.
in
21-30
number of FTEs
d.
in
31-40
c.
>
40
the
indicate
mechanical ventilator
your respiratory care
frequency
at
which you change
circuits:
a.
every 24 hours
b.
every 48 hours
c.
every 72 hours
d.
> every 72 hours
department:
^
a.
10
b.
11-20
c.
21-30
d.
31-40
e.
>
40
9.
4.
Of
a.
these
FTEs, approximately what percentage are RRTs?
<25%
b.
26-50%
c.
51-75%
d
Pick the answer which best describes your average overall
What
a.
percentage are
< 25%
b.
76-100%
Which answer
in
a.
26-50%
c.
51-75%
d.
c.
886
best describes the scheduling
1
shifts
2-hour
shifts
patients
to
respiratory
care
2:1
b.
4:1
6:1
d.
8:1
e.
>
8:1
76-100%
method used
your department'
8-hour
ventilated
CRTTs?
1
6.
of
practitioners caring for those patients:
a.
5.
ratio
staff
0.
Indicate the average frequency at
a.
b.
10-hour
d.
Some combination
shifts
c.
of these
which you perform routine
ventilator checks:
e.
every hour
every 3 hours
>
b.
every 2 hours
d.
every 4 hours
every 4 hours
RESPIRATORY CARE • SEPTEMBER
'90 Vol 35
No 9
.
PATTERNS OF PRACTICE
1 1
Indicate
ventilator circuits
you
19.
use:
birthweight infants:
b.
nondisposable with heated wire
c.
disposable without heated wire
d.
nondisposable without heated wire
Which would you say
Pick the answer which best describes your current practice
with regard to noninvasive oxygen monitoring in low-
disposable with heated wire
a.
12.
what type of
NEONATAL & PEDIATRIC RESPIRATORY CARE
IN
most frequently used method
a.
is
transcutaneous oxygen
is
pulse oximetry
monitoring
best describes your current practice
with regard to the measurement of Fjo, in mechanical
b.
most frequently used method
c.
the
two techniques are used
d.
the
two techniques are frequently used simultaneously
fairly
equally
ventilator circuits?
measured continuously
a.
b.
measured intermittently (with each ventilator check)
c.
measured every 4 hours
d.
measured every 8 hours
FiQ,
e.
13.
For questions 20-35, use the code
most) patients
in all (or
is
below
to describe
who
respiratory care personnel
a.
b. nursing personnel
not measured
Which would you
listed
performs these procedures. Select the one best answer:
say best describes your current practice
c.
shared between respiratory care and nursing personnel
d.
others
with regard to the measurement of Fjo, during oxygen
administration by hood?
14.
a.
measured continuously
b.
measured every hour
c.
measured every 2 hours
d.
measured every 4 hours
e.
measured once each
Do
in all (or
most) hoods
20.
Ventilator setup
and operation
21.
Oxygen therapy
via
22.
Blood gas sampling from invasive
23.
Percutaneous blood gas sampling
24.
Blood gas analyses
25.
Transporting blood gases
26.
Transcutaneous Pq, and/or P^q^ monitoring
27.
Pulse oximetry
28.
Administration of aerosolized medications
29.
Postural drainage and percussion
30.
Setup of oxygen equipment on floors
31.
Setup of oxygen equipment
32.
Transport of intubated patients between hospitals
33.
Intubation
34.
Changing tracheostomy tubes
35.
Suctioning intubated patients
hood
lines
shift
you routinely use auxiliary continuous airway pressure
monitors (other than simple disconnect alarms) with timecycled, pressure-limited neonatal ventilators?
a.
15.
yes
Do
b.
you administer
circuits in
a.
16.
no
yes
volume
b.
Do you
ribavirin
via
mechanical ventilator
ventilators?
no
c.
administer
_
rarelv
ribavirin
via
mechanical
ventilator
circuits in pressure-limited ventilators?
a.
17.
yes
b.
no
Which answer
c.
rarely
you use
best describes the techniques
to
in intensive
care units
administer aerosolized bronchodilators to intubated neonatal
patients?
a.
ical ventilator circuit, inserted at the Patient
b.
mechan-
aerosols are predominantly given in-line in the
aerosols
are
predominantly given
mechanical ventilator
or
some
Y
in-line
up the
the
manifold
circuit, inserted at the
significant distance
in
inspiratory side of
36.
the circuit
c.
Do
a.
18.
Which answer
best describes the techniques
you use
37.
mechan-
aerosols are predominantly given in-line in the
ical ventilator circuit, inserted at the Patient
aerosols
are
predominantly given
mechanical ventilator
or
some
yes
b.
no
c.
occasionally
Do
you use any other forms of environmental (room)
in-line
circuit, inserted at
significant distance
a.
in
38.
the
RESPIRATORY CARE • SEPTEMBER
b.
no
c.
occasionally
side of
hand
'90 Vol 35
No
Pick the range which best describes the typical ranges for
flowrates used with neonatal and pediatric nasal oxygen
the manifold
up the inspiratory
aerosols are predominantly bagged in by
yes
Y
the circuit
c.
(room)
humidification?
patients?
b.
ultrasonic nebulizers for environmental
to
administer aerosolized bronchodilators to intubated pediatric
a.
you use
humidification?
aerosols are predominantly bagged in by hand
9
cannulas:
L/min
L/min
a.
0.10-4.0
b.
0.124-4.0
L/min
L/min
c.
1.0-4.0
d.
0.25-4.0
887
1
PATTERNS OF PRACTICE
39.
Do
you use the incubator
itself
IN
NEONATAL & PEDIATRIC RESPIRATORY CARE
as a device to administer
45.
a.
40.
yes
Do
41.
no
b.
occasionally
c.
you humidify gas delivered
yes
a.
Which
ventilator
do you most
frequently use for neonatal
pressure-limited ventilation?
oxygen?
a.
Infant Star
c.
Sechrist
to resuscitation bags?
no
b.
Do you both heat and humidify gas delivered to resuscitation
BEAR Cub
b.
d.
Babybird
e.
others
I
or
11
bags?
yes
a.
42.
43.
46.
no
b.
Which temperature range
you heat
the
a.
30-32
°C
c.
33-35
e.
NTE
Do
best describes the level to
oxygen delivered
via
b.
31-33
d.
35-37
you have supervisors
in the hospital
which
every day on every
best describes the level to
you heat inspired gas delivered to intubated
b. 30-32
a. 28-30 °C
hoods?
(neutral thermal environmental temperature)
Which temperature range
47.
c.
32-34
e.
35-37
Which of
you use
do not
d.
35-37
the statements
below
which
patients?
best describes the
method
to fasten or secure ventilator circuits so that they
pull excessively
on
the endotracheal tube for neonatal
shift?
patients?
a.
44.
yes
Which
volume
888
b.
no
ventilator
do you most frequently use
ventilation?
a.
BEAR
b.
Puritan-Bennett
c.
Siemens Servo
I
or
for pediatric
a.
weights (sandbags, water bags)
b.
taped or pinned to the bed or bedding
c.
manufactured tubing rack or holder
d.
mechanical arm from ventilator
II
d.
Puritan-Bennett
e.
others
MA7200
RESPIRATORY CARE • SEPTEMBER
"90 Vol 35
No
9
The
Effects of Variations in
Flow through
an Insufflating Catheter and Endotracheal-Tube
and Suction-Catheter
Norman
H
Tiffin BSc
The use of
Size
on Test-Lung Pressures
MD
RRT, Michael R Keim RRT, and Timottiy C Frewen
suction
insufflating
catheters that
simultaneously or alternately with suction
deliver
may have
an oxygen flow either
definite benefits.
However,
the potential exists for any inflating flow to cause barotrauma, and this risk has
not been addressed.
MATERIALS & METHOD: We tested a commercially available
single-lumen insufflating suction catheter (VenTech) to determine the factors that
affect the insufflating pressures within a test lung, using a variety of flowrates,
suction-catheter and
endotracheal-tube sizes, and suction pressures.
We
also
attempted to determine the factors that affect the pressure-relief-activation point
on the insufflating catheter.
this
RESULTS: Pressure-relief-valve-activation values in
cm H;0) than clinically acceptable and are
catheter are higher (86-1196
dependent on flowrate but independent of catheter
size.
We
found that the factors
affecting pressures within the test lung include insufflating flowrate
and the
ratio
of the cross-sectional area of the suction catheter to the cross-sectional area of
(SC:ETT) and the length of time the lung is exposed to
volume added to the lung). CONCLUSIONS: Although
our bench study does not allow us to draw specific conclusions applicable to human
the endotracheal tube
the flow
(ie,
the absolute gas
we believe that clinicians should assure an SC:ETT of approximately 0.5
and avoid excessive insufflating flows and prolonged insufflating intervals. (Respir
subjects,
Care 1990:35:889-897.)
Introduction
airway.
of the
However,
complications associated with
Endotraclieal suctioning
in
the intubated patient,
retention that
may
is
a necessary procedure
clinically
this
hypoxemia,' cardiac dysrhythmias,"' alterations
which prevents secretion
systemic and pulmonary blood pressure,
lead to infection or obstruction
hypertension,
and decrease
in
reduce these
is
Critical
this
Home
employed
of topical agents such as atropine' and lidocaine** and
administration of paralyzing agents;^' (2) prophy-
Care Unit. Children's Hospital of Western Ontario when
work was done. Dr Frewen
is
lactic hyperventilation
and/or hyperoxygenation;'""'"
Director, Pediatric Critical
(3) manipulation of catheter size
Mr Keim
sure;" and,
Charge Therapist, Neonatal Intensive Care Unit, St Joseph's
Health Centre
— London, Ontario, Canada.
more
and suction
was supported,
in
part,
by
or adapters to maintain a 'closed' system
VenTech Medical
a
Care
Timothy
Unit,
C Frewen MD,
Children's
Commissioner's
Rd
East,
Hospital
of
Western
Ontario,
RESPIRATORY CARE • SEPTEMBER
N6C
No
flow
of gas
through
the
generation of this concept and,
800
lumen
2V5.
'90 Vol 35
In addition,
catheter
have been
developed. Double-lumen catheters represent the
Director. Pediatric Critical
London, Ontario, Canada
and eliminate
'*
suction catheters that permit inflation of the lung using
Manufacturing, Toronto, Canada.
Reprints:
pres-
recently, (4) use of in-line catheters
the need for ventilator disconnection."
This study
to
(1) administration
Medical Limited,
Care Unit, Children's Hospital of Western Ontario.
is
and include
and was Clinical Research Coordinator, Pediatric
Branch Manager of Aerocare
Sarnia, Ontario,
effects
in
intracranial
functional residual
capacity.* Various strategies have been
Mr Tiffin
important
procedure include
9
more
first
recently, single-
catheters that enable the alternate delivery of
889
EFFECTS OF SUCTIONING
and the application of suction have been
introduced. Although these suction catheters have
gas
shown
been
have
to
important
advantages,
a
new
for
insufflating suction catheter, the
VenTech,*
determine the range of pressures that can be
to
within
generated
a
test
lung
(to
indication of the in-vivo effects)
provide
and the
Protocol
Suction to the catheter was supplied by a wall
the
pulmonary barotrauma does exist.
Cognizant of this new technology and its potential
for pulmonary morbidity, we systematically studied
potential
AND INSUFFLATION
some
factors that
regulator connected by a 6-ft length of
7-mm
I.D.
suction tubing to a
bottle.
The
collection bottle
1500-cc collection
was connected
to the large nipple
on the catheter valve by tubing of the same length
and
size.
Oxygen was supplied by
a
pressure-
compensated flowmeter through standard
oxygen tubing connected
We
affect these pressures.
used a
TTL
'/i-inch
to the small nipple.
lung simulator, which consists
of two lungs of 2-L volume each, connected by a
Materials and
Method
T-piece to simulate the carina. Endotracheal tubes
of various sizes were then attached to the T-piece
Catheter Design
(Fig. 2).
The single-lumen
suction catheter that
we
Negative carinal pressures were measured
studied
allows inflation of the lung with a flow of gas from
the distal tip of the catheter or the application of
suction
manner
a
in
A
catheters.
similar
standard
to
spring-loaded valve activated by
suction
thumb
pressure provides suction, with the default position
of the
valve
permitting
oxygen-supply
lines are
A
size-indexed nipples.
on the valve housing
deforms a
slit
escape (Fig.
in
1).
is
insufflation.
Suction and
connected to the device by
pressure-relief valve located
activated
a rubber disk
when
gas pressure
and allows gas
to
Catheter sizes range from 6-French
(Fr)to I8-French.
The experimental setup for measuring pressures
The 'trachea' (C) is represented by an
Fig. 2.
In
the test lung.
endotracheal tube. (A— test lung, B— T-piece, C—
endotracheal tube, D suction catheter, E— pressure
monitor. F— strip-chart recorder,
oxygen flowmeter,
—
G—
H
— suction system.)
by a strain-gauge manometer and positive pressures
by an electronic pressure monitor. Both manometers
were calibrated against a water column. Pressuretime tracings of positive pressure were recorded on
a strip-chart recorder.
We
evaluated the catheter by three performance
criteria
— pressure-relief-valve
pressure
Fig.
1.
used
m
The single-lumen
the study.
When
Insufflating
suction catheter
the spring-loaded
thumb valve
is depressed, the insufflating flow is directed to the
environment and suction is applied through the catheter.
pheric)
variables
generation,
pressure
shown
and
generation
in
Table
actuation,
'negative'
across
(ie,
the
positive-
subatmosrange
of
1.
Pressure Relief. Determination of pressure-reliefactivation values under conditions of varying flow
•Suppliers are identified
end of the
890
text.
in
the Product Sources section at the
were determined by connecting the catheter's
tip to
distal
tubing leading to a mercury manometer.
RESPIRATORY CARE • SEPTEMBER
'90 Vol 35
The
No
9
EFFECTS OF SUCTIONING
suction catheter's
vacuum
was connected
nipple
AND INSUFFLATION
to
the suction system and the suction regulator adjusted
to -100 torr [-13.3 kPa]. Oxygen flows were then
introduced into the catheter and the resultant pressurerelief-activation values recorded.
Generated.
Pressure
Positive
was
pressure
-100
set at
Suction
torr [-13.3
regulator
kPa] with the
suction system attached to the catheter.
The
catheter
into the endotracheal tube of
was then introduced
the test lung until the distal tip of the catheter
cm from
1
in
The
the carina.
the lung
positive pressure generated
was measured
at
to-endotracheal-tube-size ratios
and
catheter-size-
(SC:ETTs) shown
(The relationship between the
1.
oxygen
the various
flowrates, endotracheal-tube sizes,
Table
was
in
size of the
suction catheter [SC] and the size of the endotracheal
tube [ETT]
is
expressed as the ratio between the cross-
Representation ofthecross-sectionofthesuction
The hatched area
Fig. 3.
sectional area of the outside of the suction catheter
and the cross-sectional area of the
were not recorded due
[9.81 kPa]
of the
inside
endotracheal tube.) Pressures exceeding 100
catheter within the endotracheal tube.
A represents the area
and area B the lumen
cm H2O
gas escape or entrainment
for
of the
SC when
the
SC:ETT
is
0.5.
to limitations of
the pressure monitor.
Negative Pressure Generated. The catheter was
The
introduced into the endotracheal tube with an oxygen
When
flowrate of 10 L/min.
was
catheter
1
cm
from the
employs the French
the distal tip of the
was
whereas endotracheal tubes are sized according to
the inside diameter in millimeters. Because one Fr
steady-state value
unit
the
various
suction
tracheal-tube sizes,
<
regulator
pressures,
and SC:ETTs shown
-60 cm
H:0
in
Table
A
where
to 0.5
The SC:ETT
is
mm
and the
is
7rr',
w
is
is
3.14 and
radius, the
r is
SC:ETT
closest
approximated by
inversely proportional to the cross-
sectional area of the
ETT(mm)
lumen through which gases can
escape from the lung during insufflation or can be
drawn
=
(A)
1.
recorded due to limitations of the pressure manometer.
[-5.88
for the area of a circle
endo-
kPa] were not
Pressures
equal to approximately 0.33
is
formula
had been reached. Carinal pressures were measured
at
scale for the outside diameter,
negative pressures
carina, the valve
The
when
generated were recorded
a
activated to produce suction.
usual convention for sizing suction catheters
as further
into the lung during suctioning (Fig. 3).
x 2 =
SC
(Fr),
developed in the Appendix.
relationship with
all sizes
We
used
this
of endotracheal tube studied
would fill
ETT. To discover
effects of larger or smaller SC:ETTs, we used
next full size larger and smaller ETT. Figure 4
to determine the suction-catheter size that
Table
1.
Range of Catheter and Endotracheal-Tube
SC:ETT, Pressures, and Rowrates Tested
only
Sizes,
the
the
Suction catheter sizes (Fr)
(mm)
for the different
ETT-SC combina-
tions tested in our study.
3, 4, 5, 6, 7, 8, 9,
10
Our model could
>0.5
SC:ETT
<0.5,
Suction pressures (torr)
^tO, -60, -80, -100, -120,
Oxygen
2, 3, 4, 5, 6, 8, 10, 12,
flowrates (L/min)
of the lumen of a specific
shows SC:ETTs
6.8, 10, 12, 14, 16, 18
Endotracheal tubes
sizes
50%
0.5,
not
simulate
the
in-vivo
conditions of air leak (and thus pressure dissipation)
around a high-volume, low-pressure endotracheal
tube cuff or between tube and tracheal wall with
140
14
an uncuffed tube.
RESPIRATORY CARE • SEPTEMBER
'90 Vol 35
No
9
891
EFFECTS OF SUCTIONING
ETTSize (mm
Fig. 4,
Ratio of
catheter to
thie
ID)
cross-sectional area of
suction
tfie
cross-sectional area of the lumen of the
tfie
endotracheal tube. The centre curve represents the
SC:ETT when the SC in Fr units is twice the numerical
value of the ETT measured in mm (ie,
ETT is 6 mm
then the SC is 12 Fr). The top curve represents the ratio
when the SC is twice the numerical value less one of
the ETT (ie. SC 12 Fr and ETT is 5 mm) and the bottom
curve represents the ratio of SC to twice the ETT plus
1 mm (ie, SC 1 2 Fr and ETT 7 mm). SC = suction catheter
if
(Fr);
ETT
(ETT
2)-1.
=
endotracheal tube size (mm).
=
2) + 1;
-^
SC
ETT
=
•
2;
—*—
—•— SC
SC
(ETT
=
•
Results
Pressure-relief-valve-activation
recorded
a range from 82 to
in
mean of 667 cm H2O
a
1
196
were
values
cm H:0,
[8.04 to 117.28 kPa;
with
mean
65.4 kPa]. Pressure-relief values increased as oxygen
flow increased, but were independent of catheter size
(Figs. 5
&
Positive
6).
and negative pressures generated within
the lung increased as:
1.
SC:ETT
increased.
If
the
SC:ETT was
then the pressure generated within the
1200
CM
1
1000
r
800
^
600
<
test
0.5,
lung
AND INSUFFLATION
EFFECTS OF SUCTIONING
20
O
X
E
o
15
10
en
c
10
5
15
Insufflating Flowrate (L/min)
Fig. 8.
Effect of flowrate
test-lung pressures.
— +— 8
— O— 16
Fr;
Fr;
All
—*—
10
—A—
18
and suction catheter size on
catheters have a
Fr;
— d—
12
Fr;
SC:ETT
— x—
of 0.5.
14
Fr;
Fr.
Discussion
Our
investigation of this catheter reveals that in
all sizes,
model
at
catheters,
which
clinically
and
flowrates, the pressure in our
relief-valve-activation occurs exceeds
acceptable
limits
for
intrapulmonary
pressures.'
Our
study used a lung model that did not account
for secretions.
It is
not
uncommon
in paediatric-size
tubes for secretions to collect on the distal tip of
AND INSUFFLATION
EFFECTS OF SUCTIONING
AND INSUFFLATION
Fig. 10. Positive pressure waveforms
generated with a test-lung com-
L/cm H;0
L/cm H:0
pliance of (A) 0.3
kPa] and
0.04
(B)
[0.41 L/
The higher pressure
kPa].
reflects the higher
when
lung
[3.06 L/
'trachea'
test lung.
pressure
the catheter
and not
SC
=
in
was
B
in
the test
the
in
at the 'carina' in the
14
ETT
Fr;
mm;
= 7.0
insufflating flowrate = 10 L/min.
compliant lung
similar flows. Moreover,
at
flow
insufflating
or the
interrupted
is
withdrawn, the maximal pressure reached
function of the time the lung
(ie,
is
if
catheter
the
is
shown an important
in establishing
between the two
relationship
an inflating pressure. Interestingly, the
be a
literature
does not address the effectiveness of suction
exposed to the flow
catheters,
whether hospital made or commercial, to
will
time determines the absolute volume added to
the lung with a given flow). Certainly, time exposed
remove
secretions,
which
presumably the aim of
is
the procedure.
to the insufflating flow will have positive or negative
Despite the reported problems, insufflating suction
depending on the pressures generated. Previous
catheters appear to have advantages. Preoxygenation
allowed the
methods using a manual resuscitator have been shown
to provide tidal volumes that are too small in the
effects
studies
on
insufflating suction catheters
lung to be exposed to the insufflating flow only for
the length of time
into
and
the airway
suction
was
took to introduce the catheter
it
establish the
Leaving the catheter
has
been
oxygenate when
is
demonstrated to adequately
L
flows of 1-4
Perl
embarrassment
small.
results
CFV
during
It
is
prolonged and the
Some
SC:ETT
investigators"
flowrates
arbitrary
min
'
are
because of the
when
possible that this effect
seen with insufflating catheters
is
kg
•
have shown that cardiac
al
et
increase in intrathoracic pressure
is
•
described as continuous-flow ventilation
(CFV).""^*
'*
airways
'
if
the trachea
may
also be
the
difficulties
oxygen by manual
in
volumes
ventilator
that
to
procedure
is
chose what appear to be
without consideration
for
the use of similar flows in adults and infants.
the
respect
894
As
few authors report on the association of suction-
tt)
endotracheal-tube
si/c
As
The
ventilator
and the
except
negative pressures generated; yet,
in
we have
that
may
do
be due
100%
providing
and the variation
Manipulating the
Fio^s
may
result
in
when
the
washout time
well, the
time the procedure takes.
ventilator
mode have
"
also been
demonstrated to have an effect on preoxygenation.
Double-lumen catheters can be used
oxygen simultaneously with suction
our investigation brings into question
to
higher
finished.""
benefit.
in
may
size
l%3.
the
oxygen-
and the limitations
imposed by the d )uble-lumen
catheters that deliver
is
that alternate flows
in
deliver
apparent
interfere with evacuation of secretions
taneously.'^ This
"
to
— an
However, the proximity of
delivering tip to the suction tip
catheter
size
'"
in ventilators increases the
the insufflating flow
too large.
and
inadvertent continuation of the higher Fjo;
on suction catheter
catheter
in
resuscitator*'
can be delivered.
The
well,
encountered
deliver
consequences of the pulmonary pressures generated.
result of
"^
not produce optimal Pq. values.'" This
to
in position in the large
previously
used and
point at which
be applied."*"""
to
adult'' or too large in the infant"
More
oxygen and suction simul-
not a consideration with catheters
a design
first
proposed by Potter
recent investigations have
RESPIRATORY CARE • SEPTEMBER
shown
90 Vol 35
No
9
EFFECTS OF SUCTIONING
flows
alternating
using
benefits
of oxygen
and
AND INSUFFLATION
with no pressure
may
suction.
Reports of insufflating catheters were limited to
a
more
uses involving large animals or adult
humans
until
initially
the paper published by Graff et al in
1987.'
This
suction
was due presumably
limitation
lumen
to the size of double-
distal
situation
this
The
seen
effects
tages of a single-lumen catheter include the ability
insufflating suction
to reduce the outside diameter of the catheter to enable
lishing a
use in small endotracheal tubes. Graff et
used
al
this
a catheter similar to the catheter evaluated in this
no
paper except that
reported.
A
an
in
catheters of size 5 or 8 Fr
mm.
study,
in
reducing hypoxemia
using
catheters are created by estab-
may have
advantages with adult patients,
in the
earlier study in adults.^*
and
ETT
Conclusions
of either
sizes
These combinations yield a
To minimize
SC:ETT
L/min would
of 4
flow
a
the possibility of barotrauma from
excessive intrapulmonary pressures, the clinician must
be
yield
aware of the
extrinsic
factors
affecting
bench model, we have shown
pressures. In a
dramatically different intrapulmonary pressures for
two
contraindicated.
risks."^
of 0.32 and 0.60, respectively. Based on the findings
these
may be
did not address this issue
hyperoxic state prior to suctioning. Although
Graff and his associates reported the use of suction
of our
et al
flow of 4 L/min oxygen was used based
on the flowrates used
3.0 or 3.5
of intermittent
preterm infant hyperoxia carries clinically important
was
valve
pressure-relief
into
use
Therefore,
retrieved.
in
— possibly
in their paper.
single-lumen suction catheter for neonates. Advan-
its
the secretions in the catheter
airway than that from which they were
Unfortunately, Graff
on the use of
catheters. Graff et al reported
relief,
be expelled back into the lung
these
that
these factors include (1) insufflating flowrates; (2)
ratios.
Graffs study
another
introduces
to constant application during
communicating to
cross-sectional area of the tube
He
question.
ambient; and, to a lesser degree, (3) the length of
advocates the use of intermittent suction as opposed
time the lung
removal of the catheter.
exposed to the flow.
is
Although the ongoing debate over intermittent vs
continuous suction
is
not the focus of this paper,
its
ACKNOWLEDGMENTS
we
application to the type of suction catheter that
investigated needs to be considered. In an editorial
that
appeared
in
this
Pluck
journal.
proponents of continuous suction
as
( 1 )
loss
of
mucus plugs when
stated
for her assistance with
reasons such
cite
suction
The authors thank Mrs Lisa Rawlings
the preparation of the manuscript.
that
is
PRODUCT SOURCES
interrupted,
(2) less evacuation of secretions, leading to
more
Single-Lumen Insufflating Catheter:
frequent passes, and (3) a reduction in the time spent
VenTech Medical Manufacturing, Toronto, Canada
with the airway exposed to negative pressure due
to the secretions blocking the catheter."
damage
that report
Two
Lung
studies
Simulator:
TTL Lung
to the bronchial epithelium using
Simulator, Michigan Instruments,
Grand Rapids Ml
continuous suction''"'" are most often quoted by
advocates of intermittent suctioning.
''^^"
Strain-Gauge Manometer:
Certainly
Bird Products Corp,
insufflating catheters using double- or single-lumen
catheters are not
exempt from
this debate.
one must consider another
insufflating
issue
However,
when
end of the catheter may
of the catheter. This
Electronic Pressure Monitor:
P-7 Scanner, Bird Products Corp, Palm Springs
using
distal
REFERENCES
may
be particularly true for the
in the
neonatal population.
1.
application of oxygen (at a driving pressure
is
CA
not reach the proximal end
small-lumen catheters used
of 50 psi)
CA
suction catheters with a single lumen.
During airway suctioning, material entering the
If the
Palm Springs
allowed under
this condition, especially
RESPIRATORY CARE • SEPTEMBER
'90 Vol 35
No
Boutros
AR.
Arterial blood oxygenation during
and
after
endotracheal suctioning in the apneic patient. Anesthesiology
1970;32:114-118.
9
895
EFFECTS OF SUCTIONING
2.
Pace-Rorida A. Galindii A. Cardiac arrhythmias induced
by negative phase
in
ventilation.
artificial
AND INSUFFLATION
21.
Anesthesiology
Ann
arrhthymias resulting from tracheal suctioning.
4.
22.
Intern
Fanconi
S,
Due
G. Intratracheal suctioning
in sick
preterm
Prevention of intracranial hypertension and cerebral
Respir Care 1987;32:865-869.
23.
987;79:538-
1
Kelly RE, Fun-Sun FY, Artusio JE. Prevention of suction-
induced hypoxemia by simultaneous oxygen insufflation.
542.
Care
Crit
HM.
Shapiro
Med
1987;15:874-875.
and
Intracranial hypertension: Therapeutic
24.
Bitterman H, Keren
anesthetic considerations. Anesthesiology 1975;43:445-453.
6.
MM.
Guthrie
Pardowsky
mechanical
ventilation
(abstract).
Am
7.
Winston SJ, Gravelyn TR,
Rev
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Bedford RF, Persing JA. Pobereskin L, Butler A. Lidocaine
or thiopental for rapid control of intracranial hypertension?
27.
Anesth Analg 1980:59:435-437.
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in
anterior fontanelle
pressure in preterm neonates receiving isoflurane, halothane,
GM.
Chulay M, Graeber
hyperoxygenation
Conforti C.
in
effect of
two preoxygenation techniques
N.
1988;16:55-57.
Ann Emerg Med
techniques.
Ninth National Teaching
units
A comparison of various
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1988;17:232-234.
Baker TO, Baker JP, Koen PA. Endotracheal suctioning
in
hypoxemic
Fisher D,
Limitations
Respir
patients.
31.
of self-inflating
F,
Peters
resuscitators.
KL.
Pediatrics
Hess D. Baran C. Ventilatory volumes using mouth-to-
mouth, mouth-to-mask, and bag-valve techniques. Respir
Care
Care 1986;31:774-779.
Frewen T, Swedlow D.
Increa.se in intracranial
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1982:57:416-
Benson MS, Pierson DJ. Ventilator wash-out volumes:
consideration
in
endotracheal
A
preoxygenation.
suction
Respir Care 1979;24:832-835.
419.
Carlon GC, Fox SJ. Ackerman NJ. Evaluation of a dosedtracheal suction system. Crit Care
Haake R.
R,
Schlichtig
Ulstad
Barotrauma pathophysiology,
N,
Kis.soon
risk factors
Clm
Invest
Med
Prevention
desaturation:
DW.
Merrill EJ, Linden
of suctioning-related
Physiologic
oxygen
Comparison of off-ventilator and on-ventilator
KC, Benson MS,
Craig
Pierson DJ. Prevention of arterial
oxygen desaturation during closed-airway endotracheal tube
in the pediatric
suctioning: Effect of ventilator
1989;12(3):A30.
mode. Respir Care 1984;
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Pierson DJ. Alveolar rupture during mechanical ventilation:
Role of PEEP, peak airway pressure, and distending volume.
GS. Light
arterial
suctioning. Chest 1983;83:621-624.
34.
N, Tiffin N. Frewen T.
Brown SE. Stansbury
RW.
and prevention.
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patient (abstract)
33.
Med 1987;15:522-525.
DR. Henschen RR.
Chest 1987;91:608-613,
Singh
NN. Barrington KJ. Al-Fadley
Finer
1986;77:417-420.
pressure during suctioning. Anesthesiology
17.
Med
Morton R. Oxygen enrichment of bag-valve-mask
1983:28:1563-1568.
16.
Care
during positive-pressure ventilation:
The
J. Tiffin
29.
Newport Beach CA: American Association of
techniques
15.
dog and human. Br J Anaesth 1986;58:544-550.
Campbell TP. Stewart RD. Kaplan RM, DeMichiei RV.
and
Heart Lung
intervention.
suctioning
cat.
Paes B. Neonatal resuscitation. Ontario Respiratory Care
Care Nurses, 1982:309.
Critical
14.
VM.
minimizing hypoxemia during endotracheal suctioning
Institute.
13.
Taylor
Society Update 1988;4:4-7.
EfTicacy of hyperventilation
(abstract). In: Proceedings of the
12
MK.
28.
1988;77;'l5-18.
11.
Chakrabarti
Pasquet EA, Frewen TC, Kissoon N, Gallant
Crit
Analg 1987;66:431-434.
fentanyl or ketamine. Anesth
10.
Whitwam JG.
Prototype volume-controlled neonatal/infant resuscitator.
RH, Thieme RE. Changes
Friesen
A.
Perl
Continuous flow ventilation without respiratory movement
15:1009-1011.
8.
Appl Physiol I982;53:483-
489.
bradycardic responses to endotracheal suctioning by prior
Med
Lehnert BE, Oberdorster G. Slutsky AS. Constant-flow
ventilation of apneic dogs. J
RG. Prevention of
administration of nebulized atropine. Crit Care
Analg 1983;62:33-
37.
25.
Sitrin
Shalstai Y, Gavriely N. Palti T.
tracheal insufflation in the cat. Anesth
adaptor while
Respir Dis 1983;127(4, Part 2):148.
DH,
Respiration maintained by externally applied vibration and
Hazards of
Stephens SJ.
BJ,
endotracheal suctioning through an
maintaining
oxygen desaturation during
endotracheal suctioning of mechanically ventilated patients.
hypoperfusion by muscle paralysis. Pediatrics
5.
RM. Benson MS, Schoene RB. The efficacy of oxygen
Smith
insufflation in preventing arterial
1969:71:1149-1153.
infants:
Lung
1981;10:1028-1036.
Shim C, Fine N, Fernandez R, Williams MH. Cardiac
Med
Heart
during endotracheal suctioning.
insufflation
1968;29:382-383.
3.
Washburn SC, Guthrie MP. Oxygen
Langrehr EA,
35.
Bodai
Bl.
Walton CB, Briggs
S, Goldstein
M. A
clinical
evaluation of an oxygen insufllation/suction catheter. Heart
Respir Care 1988;33:472-486.
18.
19.
Cheney FW. Prevention of hypoxia during
endotracheal suction. Ann Surg 1971;174:24-28.
Demcrs RR, Saklad M. Mechanical aspiration: A reappraisal
Fell
of
20.
its
hazards. Respir Care 1975;20:661-666.
Brandstater B,
Muallcm M.
Atelecta.sis
following tracheal
suction in infants. Anesthesiology 1969;31:468-471.
8%
Lung 1987;16:39-46.
T,
36.
Potter
GJ
.
Device for suction and oxygen administration.
Anesthesiology 1963:24:876.
37.
Graff
M, Do JF,
Hiatt
M, Hegyi
T. Prevention of hypoxia
and hvperoxia during endotracheal suctioning.
Med
Crit
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1987;15:1133-1135.
RESPIRATORY CARE
•
SEPTEMBER
"90 Vol 35
No
9
EFFECTS OF SUCTIONING
38.
Berman IR.Stahl
WM. Prevention of hypoxic complications
AND INSUFFLATION
41.
during endotracheal suctioning. Surgery 1968;63:586-587.
39.
RR. Suctioning
Fluck
(editorial).
40.
Sackner
— Intermittent
or
JF,
Greeneltch
Comparison of tracheobronchial
Gottlief LS.
suction catheters in humans. Chest 1976;69:179-181.
continuous?
42.
Respir Care 1985;30:837-838.
MA, Landa
Jung RC,
Demers RR. Complications
of endotracheal
suctioning
procedures. Respir Care 1982;27:453-457.
MJ.
damage
N, Robinson
Pathogenesis and prevention of tracheobronchial
43.
Klaus
MH,
Fanaroff
AA,
eds.
Care of the high
WB Saunders Co,
Philadelphia:
risk
neonate.
1986:174-178.
with suction procedures. Chest 1973;64:284-290.
APPENDIX
show
Derivation to
that
the area of a suction catheter
approximately one half the area of an endotracheal tube
size
if
The
is
of the suction catheter expressed in French units (Fr)
(2)
miUimeters.
( 1 )
tt
x radiusl
Assumption: Area B =
1^
is
0.7 the radius of circle
A
if
be half the area of circle A.
to
French unit = 3
1
rB
If
Area circle =
B
is
twice the numerical value of the endotracheal tube expressed
in
B must be
radius of circle
the area of circle
the
(mm)
= 0.7
mm.
rA (mm), (See #1)
then,
area A.
rB (Fr) = 0.7 rA
7r{rB)2= 1/2 7r(rA)'.
rB(Fr) =
(rB)- = (rA)2/2.
rB (Fr)
2.1
-
(mm)
x 3,
rA (mm),
2 rA (mm).
rB = rA/1.4.
When
rB = 0.7 rA.
if
area
B
=
Vz
radius of circle
radius of circle
area A, then rB = 0.7 rA.
RESPIRATORY CARE
•
SEPTEMBER
of circle
'90 Vol 35
No
9
B
is
A
is
B
is
expressed in French units and the
expressed in millimeters, twice the area
approximately equal to the area of
circle
A.
897
Reviews, Overviews, & Updates
Mandatory Minute Volume (MMV) Ventilation:
An Overview
C
F Quan MD, George
Stuart
Parides
DO, and
processors to the control
Introduction
now
ventilators
and colleagues described a new
In 1977, Hewlett
concept of providing mechanical ventilation that they
named mandatory minute volume (MMV). With
technique, expired minute ventilation
and
V^)
ventilation (target
If
the patient
guaranteed to the patient.
is
unable to meet
is
this
the patient's spontaneous ventilation.
ventilator
However,
if
the
no contribution from the mechanical
provided. Therefore,
is
MMV
provides a
method of mechanical ventilation in which the
amount of ventilatory support automatically adjusts
spontaneous ventila-
to fluctuations in the level of
tion."
^
1977,'
Although
it
MMV
not
is
was
originally described in
Initial
method of
used
frequently
a
mechanical ventilation.
descriptions of
MMV
required modifications of then-existing mechanical
*'
ventilators.'
first
Perhaps
this
need
for modification at
hindered the introduction of
clinical
modes of mechanical ventilation, and its use
may become more prevalent. This overview outlines
as other
**
the possible clinical indications, differences in the
techniques
initiating
arena.
MMV
Clinical Indications
into
the
However, the addition of micro-
MMV can be a useful method of ventilating patients
with fluctuations
Inasmuch
MMV
as the
is
Associate
and Dr Knoper
Dr
is
Professor
Parides
was
a
of
Fellow
Internal
in
Medicine and
Pulmonary Medicine,
Re.search Instructor of Internal
ventilatory drive or effort.^"
in
amount
of ventilatory support with
automatically compensates for changes in the
spontaneous ventilation (Fig.
level of
patients with
1),
acute respiratory failure resulting from drug overdoses
and neuromuscular diseases should be
for this ventilatory technique.
ideal candidates
In addition, patients
with acute respiratory failure from parenchymal lung
disease
who have
variations in ventilatory drive from
periodic sedation also
may
benefit.
There have been
three clinical reports supporting the use of
these indications. In
1
the successful use of
ventilatory
Anesthesiology,
this
ventilation.
gravis.
Dr Quan
and an approach towards
new method of mechanical
utilized,
therapy with
Vg and
target
spontaneous ventilation meets or exceeds the
Vg,
mechanism of newer-model
MMV to be delivered as easily
minute-ventilation
between the
furnishes the difference
level of
allows
spontaneous ventilation, the ventilator
target with
target
minute
predetermined level of expired
a
this
monitored,
is
MD
R Knoper
Steven
It
their
easier
MMV
opinion that
of anticholinesterase
Medicinetransition
for
to provide perioperative
myasthenia
facilitated the
management by allowing
patient's
titration
MMV
support to a patient with
was
MMV
979, Higgs and Bevan" described
smoother
a
medications and an
from mechanical to spontaneous
Division of Respiratory Sciences, University of Arizona College
of Medicine, Tucson, Arizona.
The work was supported
in part
by Shelledy and Mikles," Fevrier and colleagues
by a grant from Ohmeda.
None
breathing. In an unpublished study reviewed in 1988
of the authors had or has any financial interest in any
observed that
MMV
ventilation
10
of the devices reviewed.
failure.
Reprints: Stuart
F Quan
MD,
Associate Professor of Internal
Medicine and Anesthesiology, Division of Respiratory Sciences,
University of Arizona College of Medicine, Tucson
898
AZ
85724.
in
patients
safe
with
There was considerable
amount of spontaneous
patients,
provided
and
in
these
and
acute
efficient
respiratory
variability
in
the
ventilation in several of these
cases
MMV
ventilator to increase or decrease
its
RESPIRATORY CARE • SEPTEMBER
allowed
the
frequency as
'90 Vol 35
No 9
MANDATORY MINUTE VOLUME VENTILATION
required to maintain a stable V^. Four of their patients
had neuromuscular
1988
a
disease. Similarly, as reported in
we found
abstract,
MMV
that
provided
adequate ventilator support and expedited weaning
in
two
patients with acute respiratory failure
drug overdoses.'" Furthermore,
in a recent
from
study using
an experimental canine model of central respiratory
MMV to pressure support
depression, the addition of
ventilation
arterial
(PSV)
more
resulted in a
PSV
Pco- than did using
stable level of
alone.'"
Perhaps the most attractive indication for
is
weaning patients from mechanical
in
Patients
who have been
MMV
ventilation.
ventilator-dependent for short
periods of time (such as those
in
immediate
the
postoperative period and those with uncomplicated
drug overdoses) would seem particularly suitable for
technique.'^
this
anesthesia
dissipated,
or
such cases,
the
as
depressant
effect
of
medications
spontaneous breathing would increase and
simultaneously
ventilatory
In
respiratory
MMV
support
Inasmuch as the
to
would allow mechanical
be
gradually
withdrawn.
would wean themselves,
patients
SIMV«_|_»MMV
Fig. 1. An Illustrative example, using the algorithm
employed by the Ohmeda CPU-1 ventilator, demonstrat-
ing the level of
mechanical ventilation varying according
amount of spontaneous breathing by the patient.
Time IS shown In arbitrary units. In the example, the
patient Is switched from SIMV to MMV at Time = 4.
to the
Mandatory
setting refers to the level of
guaranteed
to the patient
the level of V^
was
during
at least
Vg delivered by
Is
the level of Vg
MMV
Note that when
the ventilator during SIMV. Target
112.5%
of the target, the
amount of mandatory ventilation declined, and when the
Vg was below 100% of the target, the amount of
mandatory ventilation Increased. An accelerated
increase (double Increase) occurred when the V^ fell
below 87.5% of the target.
the Vg had fallen below
If
75%
of the target, the ventilator
to "security" settings.
would have reverted
MANDATORY MINUTE VOLUME VENTILATION
(IMV)
MMV.
or
The 22
patients in the
had a shorter mean weaning time
IMV
the 18 in the
the
MMV
the
blood gas
the
and
1.5 vs 7.5)
(
arterial
ventilator adjustments
(1.0 vs 4.1). If additional studies eventually support
the findings of Davis et
may
ventilation.
Anecdotal reports from
MMV
other investigators also suggest that
weaning technique.'"""
experience with
cases of
MMV
weaning
no data are
review
a
"is
encouraging
that
their
difficult
in
given.'" Forrette et al,'" in a case report,
conjunction
experience
with
PSV
to
using
wean
was weaned
MMV
patient
a
Pneumocystis carinii pneumonia. In
patient
weaning
of
state
a useful
is
prolonged ventilation," but
after
favorable
their
In
and Forster
Suter
techniques,
cite
MMV
increased usage of
al,
reduce the cost of caring for patients weaning
from mechanical
An
in
with
case, the
this
to spontaneous breathing with
a pressure support level of
18-cm H:0, using
ventilation."
become
unsuccessful because of apprehension and dyspnea.
Although the use of
MMV to facilitate interaction
between patient and machine without any
intervention
is
disadvantages.
certain
ventilators offering
ventilation,
clinician
an attractive concept, there also are
current-generation
First,
MMV monitor expiratory minute
which does not necessarily
adequacy of alveolar
A
ventilation.
ventilation target can be achieved
by
reflect the
specified minuteineffective rapid,
condition, but
condition.
during
is
in the first
be insufficient
the second
likely to
The occurrence of
MMV
has been associated with the devel-
opment of lobar atelectasis.'' To
the
in
ineffective ventilation
development of
frequency alarms
alert clinicians
about
rapid, shallow breathing, high-
are
necessary
during
MMV.
Nevertheless, high-frequency alarms indicate to the
clinician only that ineffectual rapid, shallow breathing
MMV may be occurring. They do not alter
MMV algorithm to provide additional ventilator
level
Pco^
mechanical
of
However, Petco^ monitors often can
inaccurate during extended use in an intensive
where there
a large
is
in
amount of
is
considerably
is
lower than the Paco^- and, therefore, using Petco:
as the basis of an algorithm that regulates the level
may
of minute ventilation delivered to the patient
be hazardous. Additionally,
yet
this
MMV
device
is
not
commercially available.
The second
is
possible disadvantage to the use of
that an
automated method of adjusting the
of mechanical
ventilatory
may
support
discourage clinical evaluation of the patient. Although
it
can be argued that
human
intervention
ventilation,"^ this
MMV
reduces the
amount of
and evaluation during mechanical
may
not necessarily benefit patient
With other modes of mechanical ventilation,
a clinician makes an assessment of the patient's status
before changing a ventilation parameter. Inasmuch
care.
as ventilator adjustments occur automatically with
MMV,
a clinician's input
and caregivers might be
contact
probably adequate
the
increased. In such cases, the Petco-
L can be met with a tidal volume
(Vj) of 500 mL and a breathing frequency (0 of
10/min or a Vj of 100 mL and a f of 50/min.
is
device has been
respiratory dead space, the Petco^-Paco- gradient
shallow breathing.' For example, a mandatory minute
Alveolar ventilation
"^
clinical situations
clinical
ventilation of 5
MMV
sampling port and other problems. Furthermore,
MMV.
had been
in
care unit because of inspissation of secretions in the
level
IMV
problem
make adjustments
variations in end-tidal
determine
to
(PetcoO
decreased, and he was eventually extubated. Previous
the patient using
to
Recently, an
ventilation.
tested that monitors
MMV
wean
to the potential
is
amount of mechanical ventilatory support on
basis of a more accurate marker of an alveolar
Subsequently, his pressure support was gradually
attempts to
approach
alternative
of ineffective ventilation
group (33.3 hours). In addition,
group required fewer
measurements
MMV group
(4.8 hours) than
not necessarily required,
more cursory
caregiver-patient
Therefore,
evaluation.
may be
is
lulled into a
reduced, and quality of care could
be adversely affected.
Methods of Delivering
There
is
MMV
no generally accepted standard method
of delivering
MMV.
Currently
(April
1990),
models of ventilators commercially available
United States offer
Ohmeda CPU-
1
MMV
six
in the
as a ventilator modality:
and Advent, Bourns BEAR
5,
PPG
BioMedical Systems IRISA, Engstrom ERICA, and the
Hamilton Veolar.* The
first
five ventilators use various
during
the
support.
900
•Suppliers are identified
end of the
in the
Producl Sourtcs section
at the
text.
RESPIRATORY CARE • SEPTEMBER
'90 Vol 35
No
9
MANDATORY MINUTE VOLUME VENTILATION
modify the amount
mode. Ventilator Vj
Hamilton Veolar
unique
is
microprocessors
amount of
Vy
that
in
is
PSV. All these
ventilation delivered in
all
However, except
PSV
the level of
the level of
in
72
after
s
of "security" ventilation.
CPU-1 and
the
of
the Advent,
two other
conditions trigger entry into "security ventilation."
First, after a
period of apnea (12
CPU-1
with the
s
their
modes
PSV
during
audible apnea alarms are activated, and "security
does not change during
any changes needed
With both
changed
ventilators
Hamilton Veolar,
for the
occur
50%
than
less
is
ventilator-rate adjustments
and user-defined with the Advent), the visual and
of operation. All also permit the use of
MMV.
will again
monitor and control the
to
However,
the target Ve.
the
contrast,
In
constant.
is
by adjusting the level of
use
MMV
of ventilator support in the
when Ve
ventilator rate occurs
algorithms to adjust ventilator frequency and thus
MMV,
ventilation"
and
PSV must
is
to restart the
The apnea alarm must be
started.
made manually.
repetitive
small
when
ventilation"
returns to "security
be
reset
MMV algorithm. Second, the ventilator
volumes
tidal
a series of
This
detected.
is
"inadequate-Vj" function also triggers audible and
Of the
during
5 ventilators that adjust ventilator frequency
MMV,
the
Ohmeda
ventilators
sophisticated algorithms.'^"'
With
have the most
CPU-1, Vp
the
24
below the
time
is
frequency
time
is
is
12.5%
if
Ve
the
Ve
is
Ve.
25%
between 75% and 87.5% of the
Anytime
Ve
the
is
than
less
75% of
if
target
Ve
rate,
which
in
most cases
is
Ve
Ve-
up
rate
is
Ve
A
rate until the average
the lesser of
for the
Advent
is
if
Ve exceeds 112.5%
ventilator expiratory time
is
occur when
Ve
is
is
increased 25%, and
increased 12.5%.
is
ventilator
rate
MMV
it
minimum
will
is
value below
never be reduced.
possible to
"wean" a
2/min
to a ventilator rate of
meet the
target
Ve
by spontaneous breathing.
BEAR 5, the PPG Biomedical Systems
No changes
as the
'90 Vol 35
No
in
the
in
IRISA (marketed
Europe) makes ventilator-rate
MMV
mode on
the basis of a
moving time-averaged Ve. However, with the IRISA,
a 45- to 50-s moving time-averaged Ve is used instead
of the 20-s interval employed by the BEAR 5. In
addition, only 50% of the Ve above the target Ve
decreased by 12.5%
SEPTEMBER
Drager Evita
adjustments
of the target Ve. Reversion to the preset "security"
•
The backVe by
Similar to the algorithm utilized by the Bourns
if
target
when Ve is between 87.5% and 100% of the target
Ve and by 25% when Ve is between 50% and 87.5%
RESPIRATORY CARE
or
IRISA
between 100%- and 106.25% of
the target Ve. Expiratory time
liter
of the target Ve,
between 106.25% and 112.5% of the
Ve, the expiratory time
1
suppressed until
similar in
principle to that of the CPU-1. With the Advent,
however,
is
target Ve.
instead of having the patient
MMV algorithm
venti-
MMV are
during
unique feature of the Bear 5
Therefore, for example,
entirely
Ve
Ve by
below the
falls
called
5
than the target Ve, the
less
back-up
the option to establish a
which the
equal
1).
Advent
is
is
is
this
moving time-averaged
ventilation then
the ventilator Vj.
is
With
established by dividing the target
patient using
The
Ve
exceeds the target
10%. Mechanical
'"
in ventilator rate
the average
the average
the target Ve,
provide a
set to
If
Ventilation.
the basis of a 20-s
the
the ventilator reverts to a preset "security" ventilator
to the target (Fig.
MMV on the Advent.
Bourns BEAR
in the
ventilator reverts to a
in expiratory
is
adjustments
made on
between 87.5% and 100%
is
of the target Ve, and the reduction
available as
lator,
target Ve, the ventilator expiratory
increased.
function
The MMV mode
Augmented Minute
If
shortened, and consequently the ventilator
The reduction
The inadequate-Vj
an option on the CPU-1, but
BEARS
Ve is between 100% and 112.5% of the target Ve,
the expiratory time does not change. However, if Ve
falls
be
is
s.
Ve remains above 112.5% of the target Vp.
can
is
MMV
reset before the
resumed.
algorithm
must be engaged before entering
At each 24-s interval, ventilator
expiratory time is lengthened, and consequently the
ventilator frequency is decreased by 12.5% as long
assessed every
as
must be
visual alarms that
CPU-1
9
901
MANDATORY MINUTE VOLUME VENTILATION
is
recognized as valid by the microprocessor in the
MMV
mode. For example, if the target V^ were 10
L and the patient's actual Vp were 14 L, the IRlSA's
algorithm would make ventilator-rate adjust-
MMV
ments on the basis of a Ve of 12 L. Therefore, if
a spontaneously breathing patient were to suddenly
become
apneic, the average
V^
Vp would fall below the
patient would receive a
and the
mechanical breath more quickly than if all of the
Ve above the target had been recognized as being
target
faster,
valid.
is
being provided to patients with fluctuation
Ve should be a Ve
Pco or pH. If,
ventilatory drive, then the target
that results in an acceptable arterial
however,
MMV
a patient
from mechanical
may need
be
to
is
being used as a method of weaning
set at
hypoventilation
so
ventilation, the target
CPU-1
we
ventilator,
Engstrom ERICA
the
basic concept
the
is
is
called
same
as
by Hewlett and colleagues' except that
a microprocessor, instead of a purely mechanical
system, is used to monitor and control Ve. The ERICA
Ve
continuously compares the target
with expired
between these two variables
equals the amount of one ventilator Vj, a non-
When
the difference
synchronized mechanical breath
which the process
is
delivered, after
repeated.
is
there
recorded the target
who were
Ve during
in
being weaned from mechanical
As shown
ventilation.''
Table
in
Ve were
determining the target
ventilation
(assist/control
mandatory
ventilation
AC
(Patients
who were
and who were not
1,
4, 5,
and
Ve on AC. However,
who were
and
The method of
is
unique
delivering
in the
Hamilton
in that variation in the level
PSV
of
amount of mechanical ventilator
support provided.'^ An 8-breath moving average is
used to alter the
used to determine Ve-
If
PSV
Ve, the amount of
H;0
increments until the
PSV
is
decreased
long as
Ve
in
Ve
the
is
than the target
increased in
is
Ve
is
2-cm
1- to
achieved. Conversely,
2-cm
1- to
less
H:0
increments as
exceeds the target Ve. The amount of
30-cm
H:0
PSV that can be added is
above any concomitant positive end-expiratory
limited to
pressure.
An
additional feature
the ventilator to deliver a
is
the ability to set
minimum amount
of
PSV
ing
in three
Initiation of
Setting the target
Ve
is
the
setting. Logically,
in
was
80^ of
much lower
hypocarbic
or
target
Ve was
weaning was complete
MMV.
spontaneously breath-
Ve on
should not require a target
MMV
lower than the mechanical-ventilation
,
MMV
pre-MMV
807( of their
on IMV, the
initial
target
Ve. However, the target
to be
reduced
Ve; for patients previously
Vp
is
90%
of the
IMV
Ve subsequently may need
in alkalotic
or hypocarbic patients
if
after initiation
MMV.
MMV
MMV
in the
in this
overview, experience to date
Future
most important decision
used. Unfortunately, there are few
data to use as a guide
MMV
component (IMV-Ve) of their Ve. As shown in Table
we found that this assumption was generally correct,
1
with 10 of 11 patients weaning using a target Vg
not less than 90% of their IMV-Ve- As a result of
these observations, for patients previously on AC,
that is
we select an initial target Vp during
of
is
IMV
acid-base
of the six remaining
spontaneous breathing does not occur
with each breath.
MMV
on
the
not less than
Intuitively, patients already
significantly
initial
alkalotic or hypocarbic
Ve
required. In 7 of 10 cases,
MMV
of
intermittent
initially ventilated
either alkalotic
9), a
mode
vs
weaning with
8),
successful using a target
their
the
[AC]
[IMV]) and
status. In all four patients
using
important factors
1,
within 3.5 hours after initiation of
902
for
Ohmeda
21 patients with acute respiratory failure resulting
(Patients 3, 7,
when
stimulus
a
is
necessary to stimulate spontaneous breathing
patients
Veolar
is
Ve
a level that will result in mild
that
spontaneous breathing. Recently, using an
causes
MMV
that described
Veolar
in their
from both lung parenchymal and non-parenchymal
mode in
Extended MMV.'^ Its
Ve.
MMV
being employed to ensure that adequate ventilation
in
The
If
is
MMV
ERICA
MMV.
according to the indication for using
determining the correct
however, the target Vj should
differ
As outlined
suggests
that
ventilating
MMV
patients
may be
a
who have
useful
method of
fluctuations
RESPIRATORY CARE • SEPTEMBER
'90 Vol 35
in
No
9
MANDATORY MINUTE VOLUME VENTILATION
Table
1.
Minute Ventilation,
Volume
Ventilation
Arterial
Blood Gas and
pH
Data, and
Weaning Times
in
21
Patients Placed
on Mandatoi^ Minute
MANDATORY MINUTE VOLUME VENTILATION
REFERENCES
"optimum" rate for the patient and provides a
sufficient amount of PSV so that the patient breathes
at this rate.'" However, no clinical data have been
published regarding how the "optimum" rate is chosen
1.
2.
or the efficacy of this algorithm.
V^
of mechanical ventilation during
imprecise,
is
3.
MMV
4.
regulated
is
and the use of PetcO: may not be more
an
feasible
the
in
arterial
future
MMV
mechanical ventilation during
the
to
Pco;-
are
the
respiratory-muscle fatigue," perhaps
it
first
basis of
8.
will
and
in respiratory support.
Simple mandatory minute volume.
PJ.
AD, Skowronski GA, Oh TE. New
Bersten
generation
Anaesth Intensive Care 1986;14:293-305.
Cameron PD, Oh TE. Newer modes
of
mechanical
Care 1986; 14:258-
ventilatory support. Anaesth Intensive
266.
of
9.
be possible
Higgs BD, Bevan JC. Use of mandatory minute volume
management of a
ventilation in the perioperative
muscle electromyograms
monitor respiratory
Ravenscroft
adjust
sign
ventilation
Ann Chir Gynaecol
ventilation.
Smith BE, Hanning CD. Advances
ventilators.
on the
mode
Norlander O, Jarnberg PO. Control
Anaesthesia 1978;33:246-249.
Further in the future, because
electromyographic changes
to
6.
the possibility that
7.
may be
it
Kokyu To Junkan
JF. Mandatory minute volume.
Br J Anaesth 1986;58:138-150.
Pco^ electrode may soon follow.
intra-arterial
Thus,
(intermittent
1982;196(Suppl):64-67.
5.
has been introduced into clinical use (Continucath,
CA), suggesting
Nunn
mandatory minute
appropriate. Recently, an intra-arterial Pq. electrode
Shiley Inc, Irvine
IMV
Masui 1986;35:662-666.
ventilation).
1983:31:1063-1070.
parameter by which the level
as the
AS, Terry VG. Mandatory minute
Piatt
Hashimoto K. Merits and demerits of
mandatory
Finally, as discussed previously in this overview,
the use of
AM,
Hewlett
volume. Anesthesia 1977;32:163-169.
patient
with myasthenia. Br J Anaesth 1979;51:1181-1184.
(EMG).
If this is feasible, the
MMV
ventilation during
amount of mechanical
for increased
1.
is
ventilation
automatically
made
method of
unique
a
which adjustments are
in
in the level
volume
12.
may be
beneficial in ventilating patients
patients
from
additional
in ventilatory drive
mechanical
studies
are
F,
Baron JF.
mode
et al.
Influence of caloric
during mandatory minute
GC, Knoper SR. Mandatory minute
weaning from
patients
initial levels in
ventilation
Am
(abstract).
Rev Respir Dis
DC, Mikles
Shelledy
II:
Newer modes
SP.
of mechanical
Mandatory minute volume
Management 1988;18:21-28.
Kacmarek RM. Mandatory minute volume
ventilation.
Respir
14.
— Closing
the
loop? Respir Times 1986;1:11-12.
define the role of this ventilatory modality in the
treatment of patients requiring mechanical ventilation.
Ohmeda
respiratory
Chest 1985;87:67-72.
— Optimum
ventilation. Part
However,
needed to more accurately
to
1988;137:A473.
who
or in weaning
ventilation.
ventilation.
SF, Parides
mechanical
13.
have fluctuations
Quan
volume
of ventilatory support
delivered to the patient, without clinician intervention.
MMV
Laaban JP, Lemaire
intake on the respiratory
MMV
summary,
due
hypoventilation
prevents
800.
mechanical ventilatory
support.
In
Pressure support with
supplied by the
ventilation
depression in a canine model. Respir Care 1989;34:795-
1
mechanical
TD, Elkhuizen PHM, Pace NL.
CPU-1
evidence of respiratory-muscle fatigue would
be the signal
East
mandatory minute
For example,
basis of respiratory-muscle function.
EMG
10.
could be regulated on the
15.
Belda FJ, Frasquet J. Badenes R. Barbara
A. Chulia V. Weaning from
PRODUCT SOURCES
S-MVV. Rev Esp
with
results
M, Maruenda
ventilation:
artificial
Anesthesiol
Clinic
Reanim
1982;29:23-33.
16.
Suter
PM.
Weaning
Forster A.
after
prolonged ventilation.
Ventilators:
CPU-1, Ohmeda, Louisville
Acta Anaesthesiol Beig 1982;4:267-273.
CO
CO
17.
Advent, Ohmeda, Louisville
BEAR
5,
Bear Medical Systems Inc, Riverside
CA
PPG BioMcdica! Systems, Lenexa KS
[LRICA, Gambro Inc. Engstrom Div, Lincolnshire
Wi.ssing
DR, Romero MD. George RB. Comparing
newer modes of mechanical
Reno
J
Crit
the
Illness
1987;2:41-49.
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ventilation.
18.
Rodas O, Rodriqucz
IL
controlled
NV
J, Patel
weaning from
D, Venus
B.
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Microprocessor
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Chest
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ACKNOWLEDGMENTS
Davis
S.
Potgieter
volume weaning
in
PD.
l.intt)n
patients
DM
Mandatory minute
with pulmonary physiology.
Anaesth Intensive Care 1989;17:170-174.
We
thank
Ms
Isabella
of the manu.scripl and
reviewing
904
it.
Hewitt
for her help in the preparation
Dr David C l^in
for
his assistance
in
20.
Forrette TL. Billson D.
weaning of an
assist.
Respir
AIDS
Cook EW.
patient by
Ca.se report: Ventilator
MMV
with inspiratory
Management 1987;17:14-18.
RESPIRATORY CARE • SEPTEMBER
'90 Vol 35
No
9
MANDATORY MINUTE VOLUME VENTILATION
21.
Bagley PH,
McAdams SA,
Smith JM. Augmented minute
Med
Chambrin MC, et
ventilation complication. Crit
22.
Chopin C. Fourrier
of weaning
from mechanical
ventilation. Presse
23.
F,
Med
1987;15:710-71
Care
al.
ventilation:
A new
24.
method
25.
eds.
of
mechanical
Nunn
JF, Lyle
DJR. Bench
testing of the
CPU-1
ventilator,
Br J Anaesth 1986;58:653-662.
1983;12:495-497.
In:
control
Closing the loop. Respir Care 1987;32:440-
444.
CO:-regulated
Chopin C, Chambrin MC. Mangalaboyi J, Fourrier F,
Lestavel P. CO; MV: A new method of weaning from
mechanical ventilation.
Thompson DJ. Computerized
ventilation:
1.
26.
Rouby
JJ.
Le CESAR:
Un nouveau
respirateur remarquable.
Actual Anesth Reanim 1989;8:3-7. Actualits
Kondraske GV, Robinson CJ,
En
Ane.sthesie
Reanimation.
Proceedings of the Eighth Annual Conference of the
27.
Cohen CA, Zagelbaum G, Gross D, Roussos C, Macklem
PT. Clinical manifestations of respiratory muscle
IEEE Engineering in Medicine and Biology Society.
Piscataway NJ: IEEE Engineering in Medicine and Biology
Am J
Med
fatigue.
1982;73:308-316.
Society, 1986:1234-1236.
New
in
Orleans
December
AARC
Annual
Meeting
December
RESPIRATORY CARE
•
SEPTEMBER
'90 Vol 35
No
9
8-11
905
CRCE through
the Journal
For your information, answers to the 50 questions
Jounuil. which appeared
below.
No
in the
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scores will be available from the
A ARC
until
are released in early 1991. Deadline for submission of
credit
The
1.
was August
15, 1990.
correct answers to questions are
e
for
CRCE
through the
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1990
CRCE
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CRCE
Easy To Use
Proven Reliability
Dollars
& Sense
Simply Better
;
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VOLUMES
TO BUY
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THE NEW BIRD.
In the intensive care setting
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So we designed a ventilator that helps you, and your patients,
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•
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ttiat
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classification and characteristics of microbes, requirements for
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Item
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To order,
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800 669-8585
1
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Earns Every Member
to Asthma
of Your Staff One Continuing Education Credit
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•
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•
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•
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•
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and Students
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to
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your hospital
is
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at
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under 75 beds, your registration fee
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2.
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C Band
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Jack Wanger
RCPT RRT and
Charles Irvin PhD, Section Editors
PFT
I
Corner
PFT Comer #37—
A Case of
Joyce
A
25-year-old Korean
B Armstrong
woman was
'Tlat"Spirometry
MA RPFT and John
neck revealed inspiratory
stridor.
Her
admitted to the hospital because of
prescribed medications included theo-
extreme shortness of breath. The
phylline (Slophyllin) 100
patient could not speak English, but
prednisone 15 mg/day. During emer-
through an interpreter she was able to
gency treatment, prior to admission,
account of her
she had responded poorly to inhaled
add
details to a written
medical history that was contained
in
a letter of referral from her physician.
The
patient
had a 7-year history of
Spirometry was performed
pulmonary function laboratory;
shown
are
experienced complete respiratory
shown because an
arrest following
exposure to tear gas
during an antigovemment demonstration; she
consequently required
1
2 days
tid
in
Figure
1
in
the
results
and Table
1.
(Only postbronchodilator data are
albuterol aerosol
treatment had been administered just
prior to spirometry
due to the
her breathing had
difficult.
denied
from the
become
1
.
Admission Spirometry Results
After
Bronchodilator*
FVC
2.51
(71)t
0.60
(19)
FEV,/FVC
PEFR (L/s)
0.24
(27)
0.71
(11)
FEFsQOf (L/s)
0.36
(8)
FEF25.75% (L/S)
0.38
(8)
PIFR
0.72
(18)
FIF5o% (L/s)
0.36
(10)
FEF50/FIF50
1.00
(80)
(L)
FEV,
(L)
(L/s)
patient's
extreme shortness of breath.)
of mechanical ventilation. She reported
that since recovering
Table
and
beta agonist and I.V. steroid therapy.
and a 4-year history of asthma.
During the previous year, she had
rhinitis
mg
MD
Williams
'Albuterol administered.
tValues in parentheses are
'
of predicted
normal.
arrest,
increasingly
She was a nonsmoker and
nocturnal
dyspnea, cough,
sputum production, and chest
pain.
Questions
FLOW
{US)
On admission she appeared cushingoid.
1.
Auscultation at the base of the
How
would you
interpret
admission spirometry (Fig.
Table
Volume
Ms Armstrong
is
(L)
Supervisor, Pulmonary
may
Dr Williams is an
Immunology Fellow National Jewish
Center for Immunology and Respiratory
Fig. 1. Forced flow-volume curves
from admission spirometry (predicted
normal and actual postbroncho-
Medicine, Denver, Colorado.
dilator).
Physiology Unit; and
—
RESPIRATORY CARE
•
SEPTEMBER
2.
'90 Vol 35
No
9
1
the
and
1)?
What
additional diagnostic tests
be indicated?
Answers and Discussion
on next page
909
*
CORNER
PFT
Answers and Discussion
1.
of Spirometry:
Interpretation
Because of the plateaus and reduced
flowrates evident on
and
expiration
inspiration, the spirometry data could
level
of the seventh cervical vertebra
(C7)
(Fig. 2).
procedures were interpreted to indicate
that
during
patient's
this
episode of
intubation (subsequent to her respira-
a fixed airway obstruction. Another
possibility
is
reproducible
a
variable airway obstruction
(ie,
but
vocal
sometimes questi-
to
tory arrest) the tip of the endotracheal
revealing
as
is
such as these. However,
in eight efforts, this patient
severe
interpreted
in cases
Discussion: The results of these two
airflow limitation most likely due to
be
Patient effort
oned
tube
may have caused
tracheal tissue,
erosion
which resulted
Fixed airway
'
obstructing scarring.'
of
in the
enough,
consistently
volume
giving
felt
reproduce
was able
flow-
this
pattern, suggesting that she
good
effort.
was
Also, the interpreter
that the patient
had
under-
fully
stood the instructions for performing
the maneuver.
The
diagnosis of tracheal stenosis
appears to be consistent with
this
young
cords). Lastly, this pattern could reflect
obstructions,
poor patient
characterized by the plateauing of the
woman's
flow-volume loop, both on inspiration
use of bronchoscopic examination in
The flowrates can be
conjunction with a soft-tissue lateral
2.
effort.
Additional
bronchoscopy should be
a
First,
Diagnostic Tests:
performed to investigate the source of
the obstruction. This
a tracheal stenosis
tified.
was done, and
was
clearly iden-
Indeed, attempts to
move
the
and
severe
if
expiration.
markedly reduced;
were
less
than
1
in
this
L/s.
are
case they
The
ratio of
expiratory-to-inspiratory flow at
50%
of the vital capacity (FEF50/FIF50 or
history of intubation.''
roentgenogram
neck
method
for
is
diagnosing
a
The
reliable
tracheal
stenosis."
A
majority of patients with tracheal
may
scope past the lesion were unsuccessful.
E/I
Another diagnostic approach
to
obstruction patterns.'' This differs from
obtain a soft-tissue lateral roentgeno-
obstructive disease in which patients
obstructing lesion and anatomic recon-
gram. This was also done, and the film
have been found to have FEF50/FIF50
struction of the upper airway." This
revealed
marked
tracheal stenosis at the
Fig. 2. Soft-tissue lateral
gram
is
of the neck,
at
50%)
ratios of 0.3
is
and
usually
0.5.
1.0 in
fixed
stenosis
be returned to normal
function by surgical excision of the
patient
was immediately scheduled
for
roentgeno-
showing tracheal
stenosis (seen at the point of the
arrow).
910
RESPIRATORY CARE • SEPTEMBER
'90 Vol 35
No 9
Your Advocate At
Professional Medical Products
snew..
'•••
But not too hot
Our
technologically advanced, adjustable,
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the patient is protected
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But
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continuous temperature feedback."*
This breakthrough system also
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I
|
Reliably precise FIO2 settings
Consistent delivery of aerosol
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i
size distribution
Easy setup — two-step
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A self-cutting
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.
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For a free demonstration, call
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I
^
1-800-845-4560
Professional Medical Products, inc.
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Youradvocate for quality health care products
Circle 139
on reader service card
PFT
surgery.
resection
Successful
of the
Table
CORNER
Spirometry Results 2
2.
and
was performed. Pulmonary
function testing performed two weeks
lesion
trachea
after
Weeks
after
Resection of Tracheal Lesion
re-anastomosis of the
revealed
surgery
improvement
in
remarkable
expiratory and inspi-
FVC
FEV,
Before
After
Bronchodilator
Bronchodilator
2.86
(L)
(L)
FEVi/FVC
FEF50.; (L/s)
PIFR
(L/s)
FIFsQ.? (L/s)
FEF50/FIF50
Albuterol administered.
FLOW
(LVS)
"
fValues
Volume
(L)
Fig. 3. Forced flow-volume curves
from spirometry performed 2 v\/eeks
after resection of tracheal lesion
(predicted normal and pre- and
postbronchodilator).
ratory airflow (Fig. 3
No
significant
and Table
2).
postbronchodilator
change was evident
in
the spirometry.
Eight weeks after surgery, the patient
returned to the hospital
because of
increasing difficulty in breathing.
was
She
too short of breath to perform
spirometry.
A
bronchoscopy showed
that a keloid (scarring) formation
once again
obstructing
the
was
trachea.
Surgery was again performed, followed
this
time by local injections of steroids
and
insertion of a
It
is
Montgomery
T-tube.
anticipated that prolonged splint-
in parentheses are
% of predicted
normal.
e^^-
/"•.
.•-?P;
^^i
I.'.
.tJ^'
'^
v*-
.4^>
NOW, THERE'S
•
K
MORE THAN HOPE
FOR INFANTS WITH
RESPIRATORY
DISTRESS
SYNDROME
4?
^
New, protein-free synthetic
lung surfactant that's as
easy to use as it is efifective
ExOSUrf NEONATAL
(Colfosceril Palmitate, Cetyl Alcohol,
ra
Tyloxapol) For
At
there's
last,
distress
Intratracheal Suspension
more than hope for infants with respiratory
syndrome (RDS). Clinical trials have shown that
protein-free synthetic
EXOSURF
Neonatal dramatically
reduced neonatal morbidity and mortality. In addition to
being effective in both prophylactic and rescue use,
EXOSURF Neonatal was well tolerated.
Widely studied
To
date, in excess of 2,600
EXOSURF
premature infants have received
Neonatal in controlled clinical trials involving
more than 4,400 infants in North America. In addition,
10,000 infants in more than 400 hospitals have received
EXOSURF Neonatal under a treatment IND.
Effective in infants at risk of
developing
RDS
A single,
prophylactic dose of
EXOSURF Neonatal given
immediately following birth
reduced death from RDS by 50%
and one-year mortality by 33% in
neonates weighing 700 to 1100
grams. Two additional prophylactic
doses of EXOSURF Neonatal
reduced one-year mortality by an
additional
30%. EXOSURF
Neonatal reduced the severity
of RDS and the incidence of lung
rupture in these premature infants.
Effective in infants with RDS
In infants weighing 700 to 1350 grams, EXOSURF Neonatal rescue
treatment initiated within 24 hours of birth, reduced death from RDS by
66% and one-year mortality by 44%. Survival to day 28 without bronchopulmonary dysplasia was increased significantly. Pneumothorax, pulmonary interstitial emphysema, and overall pulmonary air leaks were
significantly reduced. Similarly beneficial effects were also observed in
infants with RDS weighing >1350 grams, and chronic lung disease was
significantly
reduced.
Impressive safety profile
adverse events were comparable to
those of placebo, with the exception of apnea. Infants receiving EXOSURF
Neonatal required less ventilatory support, possibly contributing to an
increased incidence of apnea. In both placebo and treated infants, apnea
proved to be a marker for reduced pulmonary air leak and improved
In individual controlled clinical
trials,
survival.
In the treatment IND experience of over 10,000 infants, the reported
incidence of pulmonary bleeding was 4%. It appears to be related to
improvements in pulmonary function in infants whose ductus arteriosus
remains patent. This condition may be prevented by early and aggressive
diagnosis and treatment (unless contraindicated) of patent ductus
arteriosus during the first two days of life (while the ductus arteriosus is
often clinically silent). Additionally, a low incidence (3/1,000) of mucous
plugging of the endotracheal tube was observed.
Please see
full
prescribing information on last
pages
of this
advertisement.
j|i£
ExOSUrf NEONATAL
(Colfosceril Palmitate, Cetyl Alcohol,
ill
L^hJ Tyloxapol) ror intratracheal Suspension
Easy
•
to store
EXOSURF
Neonatal
may be
stored at
room temperature
(15°to30°C[59°to86°F]).
•
Reconstituted suspension may be maintained refrigerated
or at room temperature (2° to SOX [36° to 86°F]) for up
to 12 hours.
Easy to use
•
Key items needed for EXOSURF Neonatal administration are
supplied in one carton: one 10 mL vial of EXOSURF
Neonatal, one 10 mL vial of Sterile Water for Injection,
and five endotracheal tube adapters (2.5 mm, 3.0 mm,
3.5 mm, 4.0 mm, and 4.5 mm).
Easy
•
Each
EXOSURF
mL/kg
2.5
•
to administer
Neonatal dose
is
administered in two
half-doses.
^
EXOSURF
Neonatal is administered via a sideport on
a special endotracheal tube adapter (supplied with
EXOSURF Neonatal) without interrupting mechanical
ventilation.
Easy on the infant
•
To
lungs, the infant
is
EXOSURF
Neonatal in the
simply turned from midline position to
assist the distribution of
the right after the first half-dose and from midline position
to the left after the second half-dose.
A complimentarY
available
videotape on reconstitution and administration of
from your Burroughs Wellcome Co. representative.
Please see
full prescribing information on last pages of
representative for furtfier information.
Copr.
fSj
1990 Burroughs Wellcome Co.
All rigtils
tfiis
reserved.
EXOSURF
advertisement Call your Burrougfis Wellcome
EX112
Co
Neonatal
professional
is
EXOSURF
(COLFOSCERILPALMITATE. CETYL ALCOHOL. TYLOXAPOL)
Neonatal For Intratracheal Suspension
DESCRIPTION: Exosurt Neonatal for Iniratracheal Suspension is a protein-free synthetic lung surlaclanl stored under vacuum
15 a sienie lyophjlized powder Exosurl Neonatal is reconstituted with preservative- tree Sterile Water tor Injection prior to
jdmmislration by iniratracheal mslillalion Each 10 mL vial contains 108 mg collosceril palmitate, commonly known as
3ipalmiloylphosphatidylcholine (DPPC), tormulated with 12 mg cetyl alcohol. 8 mg tyloxapol. and 47 mg sodium chlonde
Sodium hydroxide or hydrochloric acid may have t>een added to adjust pH When reconstituted with 8 mL Sterile Water
6mg/mL cetyl alcohol, and
(or Injection, the Exosurl Neonatal suspension contains 13 5mg/mL colfosceril palmitate,
1 N NaCI
The suspension appears milky white with a pH of 5 to 7 and an osmolality of 185 mOsm/L
1 mg/mL tyloxapol in
1
The chemical names and structural lormuias
ol
the
components
ol Exosurl
cetyt alcohol
coltoscefil palmitate
;i,2-Oipalmiioyt-sn-3-phosphoglycerocholine)
Neonatal are as follows
tyloxapol
(1-hexadecanol)
(formaldehyde polymer with oxirane and
CH,(CH,).«CH,OH
4-(l.l,3.3-tetramethylt)utyl}phenol)
CM.OCtCM.-l-jCH,
Ch,{Ch;>.4CO—
C— m
I.O — P — OCH;CH.N(CHj),
I
o
|R
is
CH,CH,0{CH,CH,OUCH,CH,OH,
m is 6
to 8,
n
is
not
more than
5]
CLINICAL PHARMACOLOGY: Surfactant deficiency is an important factor in the development of the neonatal respiratory
distress syndrome ROS) Thus, surlactant replacement therapy early in the course of RDS should ameliorate the disease
and imprtw symptoms Natural surfactant, a comOination of lipids and apoproteins, exhibits not only surface tension reducing
properties (conferred Dy the lipids), but also rapid spreading and adsorption (conterred by the apoproteins} The major
fraction of the lipid component ol natural surtactant is DPPC. which comprises up to 70% ot natural surtaclant by weight
(
Although DPPC reduces surface tension DPPC alone
,
Exosurl Neonatal, which
is
alcohol
Sodium chloride
is
is ineffective in
RDS because DPPC spreads and adsorbs
protein free, cetyl alcohol acts as the spreading agent for the
Tyloxapol, a polymeric long-chain repeating alcohol,
added
is
DPPC on
poorly In
the air-fluid interface
a nonionic surfactant which acts to disperse both
DPPC and
cetyl
to ad|ust osmolality
Phannaco kinetics: Exosurl Neonatal is administered directly into the trachea Human pharmacokinetic studies ot the aDsorpiion, biotransformation, and excretion ol the components of Exosurf Neonatal have not been performed Nonclinical
studies, however, have shown that DPPC can be absorbed from the alveolus into lung tissue where it can be catabolized
extensively and reutilized for further phospholipid synthesis and secretion In the developing rabbit, 90% ot alveolar
phospholipids are recycled
phatidylcholine
IS
In
premature rabbits, the alveolar
half-lile ot
mlratracheally administered H'-labeled phos-
approximately 12 hours
Animal Studies: In animal models of RDS, treatment with Exosurl Neonatal significantly improved lung volume, compliance
and gas exchange in premature rabbits and lambs The amount and distribution of lung water were not aftected by Exosurf
Neonatal treatment of premature rabbit pups The extent ol lung injury in premature rabbit pups undergoing mechanical
ventilation was reduced significantly by Exosurf Neonatal treatment In premature lambs, neither systemic blood flow nor
flow ihrough the ductus arteriosus were affected by Exosurl Neonatal treatment Survival was significantly better in both
premature rabbits and premature lambs treated with Exosurf Neonatal
CInical Stu(fies: Exosurf Neonatal has been studied in the U S and Canada in controlled clinical trials involving more than
4400 infanis Over 10,000 infants have received Exosurf Neonatal through an open, uncontrolled, North American study
designed
to
provide the drug to premature infants
who might
benefit
and
to obtain additional safely information (Exosurf
Neonatal Treatment IND)
^optr^bctk TreaOnent: The efficacy ot a single dose of Exosurf Neonatal in prophylactic treatment of infants at nsk of developing
respiratory distress syndrome (RDS) was examined in three double-blind, placebo-controlled studies, one involving 215
infants weighing 500 to 700 grams, one involving 385 infants weighing 700 to 1350 grams, and one involving 446 infants
weighing 700 to iiOO grams The infants were intubated and placed on mechanical ventilation, and received 5 mL/kg
Exosurf Neonatal or placebo (air) wilhm 30 minutes of birth
The efficacy of one versus three doses of Exosurf Neonatal in prophylactic treatment of infants at risk ot developing RDS
was examined m a double-blind, placebo-controlled study of 823 infants weighing 700 to 1100 grams The infants were
intubated and placed on mechanical ventilation, and received a first 5 mL/kg dose of Exosurf Neonatal within 30 minutes
Repeat 5 mL/ kg doses of Exosurf Neonatal or place bo(air) were given to all infants who remained on mechanical ventilation
at approximately 12 and 24 hours ol age An initial analysis ol 716 inlants is available
The maior etlicacy parameters Irom these studies are presented
ftMel
m
Table
1
EXOSURF" (COLFOSCERIL PAIMITATE, CETYL ALCOHOL. TYLOXAPOL)
NEONATAL FOR INTRATRACHEAL SUSPENSION
umz
American Association
Respiratory Care
for
36th Annual Convention
and Exhibition
New
Orleans, Louisiana
December 8-11, 1990
Keynote Address
Donald
F.
Egan
,
T
.
Scientific Lecture
Program Committee Special Lecture
25 Symposia
^
^^^^^
97 Open Forum Papers
—
8
•..
_
Open Forum Minisymposia
5 Breakfast Sessions
'-
'—
'
AARC Awards Ceremony
AARC Annual Business
Meetings
;
Specialty Section Business Meetings
National
Sputum Bowl
Exhibit (4 days)
ja%in'
n Up
Social Events (4 nights)
National Volleyball
Tournament
Car Rental Discounts
Continuing Education Credits
Special Airfares
Make plans
to attend the best respiratory care
meeting in1990!
Test Your
Charles
Radiologic Skill
G
Durbin Jr
MD and
Douglas B Eden BS RRT. Section Editors
Left-Sided Subclavian Vein Catheterization
Charles
A
36-year-old white
G
man was
MD and Thomas A Langer MD
Durbin Jr
transferred to our
hospital to be considered for liver transplantation to
presumed hepatic tumor. The patient had a
had stopped
treat a
history of chronic alcohol abuse, but
phase of hepatic transplantation (that period
the native liver
is
removed and
the
donor
being implanted), veno-venous bypass
to return portal
is
when
liver
is
employed
blood to the systemic circulation.
drinking 5 years prior to admission to our hospital.
This
done through a
large catheter placed
Three months prior to
in the right axillary vein at the
time of surgery. For
admission
this
was diagnosed
he
on the
hepatitis
that
non-A non-B
having
as
noted
and malaise. At
jaundice, light-colored stools,
time
he
basis of mildly elevated liver
enzymes,
including alkaline phosphatase, and negative serologic
tests for viral hepatitis.
with bed
change
and
rest
He was
treated conservatively
analgesics. After
6 weeks with no
symptoms, the patient presented
in
CT
scan was
x 12
cm) was
where an abdominal
referring hospital
performed and a large mass (10
cm
to the
Upon admission
revealed
jaundiced, and
in
to
the
compatible with biliary
white blood
cell
this reason, the left
subclavian vein was chosen for
the hyperalimentation catheter insertion
site.
Prior to
insertion of the subclavian catheter, the patient
was
given 2 units of fresh-frozen plasma and 6 units of
platelets to correct his identified clotting
ities.
The
catheter
was then
and a chest radiograph
abnormal-
inserted without difficulty
(Fig.
1)
was obtained
to
confirm correct central placement.
Two
days after catheter placement, the patient
our hospital, physical exampatient
no acute
up revealed elevated
usually
developed acute left-sided weakness, disorientation,
revealed in the region of the porta hepatis.
ination
is
to
distress.
liver
be
thin,
slightly
Laboratory work-
enzymes and
tract obstruction,
bilirubin
an elevated
count (24,000/mm' of blood), and
mild anemia (33'! hematocrit).
After appropriate workup, including family and
social
evaluation,
transplant
Biliary tract
bilateral
To
the
patient
was placed on
to await suitable
list
the
organ availability.
decompression was accomplished with
percutaneous ultrasound-directed catheters.
help correct his chronic malnourished state in
preparation for surgery, a central venous catheter for
hyperalimentation was placed. During the anhepatic
Dr Durbin
Ls
Associate Professor of Anesthesiology and Surgery,
and Dr linger
is
Assi.stani Professor of
Radiology
University
of Virginia Health Sciences Center, Charlottesville, Virginia.
916
Fig. 1. Chest radiograph obtained to confirm correct
placement of a left subclavian catheter In a 36-yearold man.
RESPIRATORY CARE • SEPTEMBER
90 Vol 35
No
9
TEST
YOUR RADIOLOGIC
SKILL
Kenneth Norris
Cancer Hospital
Jr.
one of
is
the nation's most prestigious cancer patient care
and
bilateral loss
Pq: 42
of vision. Arterial blood analysis
and research
PcO: 38 torr [5.1
kPa], and pH 7.44 on room air. He was diagnosed
as having a right-sided embolic stroke and cortical
blindness; concern was raised over the possibility of
a pulmonary embolus. On admission to the surgical
revealed:
torr [5.6 kPa],
intensive care unit, his record, laboratory data,
We
centers.
are a private affiliate
of the University of Southern California,
located
on USC's Health
Campus.
Sciences
At the
Norris
RESPIRATORY CARE
PRACTITIONERS
and
radiographs were reviewed.
we have
achieved an
impressive
position in
Questions
1.
in
Figure
1
structures
could
the
left
subclavian
catheter
be
actions
are
located?
3.
care arena
CHAPTER
TO YOUR
our focus
reveal?
Potential Catheter Locations: In what anatomic
What
Further Actions:
further
the cancer
ANEW
Radiographic Findings: What does the chest
radiograph
2.
BEGIN
because of
on
research,
progressive
cancer
necessary to determine the exact location of the
CAREER.
catheter?
treat-
ments and
supportive
patient care.
Answers and Discussion
on the next Page
Patients
and
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respond very positively
to our unique atmosphere that
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These include pulmonary
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Institute
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Opportunities for Respiratory
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was developed m collaboration
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(213) 224-5483.
20814
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Kenneth Norris
Human
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provide outstanding benefits
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IvID
ra LISC/NORRIS
\JSC c A N
RESPIRATORY CARE • SEPTEMBER
'90 Vol 35
No
9
c;
E R
H
C) S
F
I
T A
I
TEST YOUR RADIOLOGIC SKILL
Answers and Discusssion
catheter indicated a low-pressure venous
and a mean pressure of 12
Radiographic Findings:
subclavian catheter
shadow. This
As
line.
patient
is
is
left
1,
2),
a
in
the
left
side of the heart
an unusual location for a
illustrated
(Fig.
Figure
In
seen to the
left-sided
radiograph from another
a
catheter
into
inserted
vena cava and the
1
is
right atrium.
Also noted
a small left-lower-lobe infiltrate
small
left
aspirate blood from the catheter,
was not
were
in
would have developed from
the
the previous days.
Figure
in
and a possible
pleural effusion.
present,
left
Chest radiograph
usual course of
The
catheter could
if
the catheter
the fluids infused over
Only a small pleural effusion was
was no evidence of the increased
that would have occurred if the
catheter were subserosal or subcutaneous. Because
remaining
the
illustrating the
and there
soft-tissue density
film
Fig. 2.
an extravascular space. Also,
the pleural space, a large pleural effusion
left
different
a
in
in
superior mediastinum and enters the right superior
we were able to
we knew the catheter
out arterial cannuiation. Because
the
subclavian vein usually crosses the midline
waveform
torr [1.6 kPa]. This ruled
catheter
possible
and predictable
was obtained
locations
lie
in
sagittal planes, a lateral chest
(Fig. 3). This
demonstrated that
subclavian catheter.
Potential Catheter Locations:
be introduced inadvertently into any one of the
following locations:
A
venous structure (via
left
Left internal thoracic
(mammary)
subclavian vein)
vein
Accessory hemiazygous vein
Persistent left superior
An
vena cava
arterial structure (via left
subclavian artery)
Descending aorta
Left internal thoracic
An
(mammary)
artery
Fig. 3. Lateral
chest radiograph showing middle-
mediastinal placement of a
extravascular space
Left lung
a 36-year-old
parenchyma
man
left
subclavian catheter
with a persistent
left
in
superior vena
cava.
Left pleural cavity
Mediastinum
the catheter lay in the middle
mammary-vein
mediastinum (ruling
Further Actions: With the occurrence of the stroke,
out
we were quite concerned about
concluded that the catheter was situated
the possibility of aortic
cannuiation. Immediate pressure transduction of the
918
left
or
artery
placement).
We
in a persistent
superior vena cava.
RESPIRATORY CARE • SEPTEMBER
'90 Vol 35
No
9
TEST
Discussion: Although
vena cava
of
which
rises to
4.3%
is
usually present.
superior
overall incidence
The
0.3%.
is
who
in those patients
other congenital heart diseases."
vena cava
left
SKILL
common anomaly
the only
is
vena-cava system,
of the superior
incidence
unknown. The
not
is
this structure,
a persisient
rare,
YOUR RADIOLOGIC
The
right superior
left
superior vena
The
SUPERIOR VENA CAVA
have
RIGHT SUPE
cava usually enters the coronary sinus and thus the
right
atrium,
CORONARY SINUS
and therefore does not create a
HIND THE HEART)
pathological right-to-left shunt. Schematic representation of the relationship
veins of the
between the
normal thorax
is
provided
arteries
in
and
Figure 4;
schematic representation of the relationship between
the arteries
INFERIOR VENA CAVA
and veins of the thorax of someone with
A schematic representation of the
arteries and veins in the thorax
Fig. 5.
relationship
between
with a persistent
was
line
left
inserted.
The
embolic stroke was
patient's
not related to his persistent
malignancy
left
Most
cannulation.
its
someone
superior vena cava.
SUPERIOR VENA CAVA
or
of
resulted
in
superior vena cava
underlying
his
likely,
hypercoagulable
a
state
responsible for the observed cerebral thrombosis and
CORONARY SINUS
infarct.
(BEHIND THE HEART)
lung
No pulmonary
and was thought
persisted,
betvi/een arteries
representation of the relationship
and veins
in
request, he
the normal thorax.
from ascites. At the patient's
was removed from the transplant list and
resulting
atelectasis
A schematic
to be the result of intra-
pulmonary shunting associated with hepatic cirrhosis,
his long history of cigarette abuse, and basilar
INFERIOR VENA CAVA
Fig. 4.
embolus was confirmed by
hypoxemia without dyspnea
Arterial
scan.
discharged from the hospital.
REFERENCES
a persistent
Figure
5.
left
superior vena cava can be seen in
A fluoroscopic examination with radiopaque
dye confirmed that
our patient the persistent
in
Freedom RM, Culham JAG, Moses CAF. Angiocardiodisease. New York: MacMillan
left
graphy of congenital heart
superior vena cava emptied into the coronary sinus,
behind the heart, as
illustrated in
variants of this condition include
inferior
vena cava, the
Figure
5.
&Co,
emptying into the
right superior
may
Adams HL,
Other
enter the
left
infusion
(hyperalimentation)
for
left
4.
•
SEPTEMBER
Weiner
Crit
P,
cause
vessel
'90 Vol 35
No
Care
Ryan JA
Sznajder
Med
Jr,
complications
'
RESPIRATORY CARE
Little,
Brown
Internal jugular vein
I.
Plavnick L, Sveibil F. Bursztein
S.
Unusual complications of subclavian vein catheterization.
and therefore is not recommended. The
catheter was withdrawn and a right subclavian vein
thrombosis'
Boston:
336.
atrium and
hypertonic fluid
may
Abrams angiography.
thrombosis and pulmonary embolism. Chest 1981:80:335-
cause a significant right-to-left shunt.
Use of the coronary sinus
ed.
1983:936.
Bradway W, Biondy RJ, Kaufman JL.
vena cava, or
the right atrium directly. Rarely, the persistent
superior vena cava
Pubhshing, 1984:51.
study
of
1984; 12:538-540.
Abel
RM,
Abbott
in total parenteral
200 consecutive
WM,
et
al.
Catheter
nutrition— A prospective
patients.
N
Engl J
Med
1974;290:757-761.
9
919
Books, Films,
Tapes, & Software
Clinical Atlas of Respiratory Disease,
DM
by Margaret Turner-Warwick
PhD DSc (Hon), Margaret E Hodson
MD MSC, B Cornn MD, and IH Kerr
MA MBBCHIR. Hardcover, illusapproximately 392
trated,
London,
pages.
and Reviews of Books and Other Media
Note to publishers: Send review copies of
Respiratory Care.
Some
will
should not dissuade respiratory care
departments and college
name
from considering
or are totally unavailable in this
country.
few errors and oddities occur
and many of the
in
photographed have a black band across
East Washington Square, Philadelphia
their eyes.
PA
to the reader unfamiliar with
medical
in this text is to
"include as
much
visual
material as possible" to "stimulate a
fascination for lung diseases
by
all
those
involved in the care of patients." This
book from
is
arranged
the United
in the
Kingdom (UK)
manner of
the
more
CT
as highbrow.
It
physicians and
for
other allied health care practitioners.
18.12
Fig.
another
Well-seasoned
mented cases
they were reviewing
Care Therapist
Neurancy Neurosurgical ICU
in
an identifying
— and
should be consi-
well
as
as
diseases.
on chest
sections
the
all
A
edited by Kevin
Clinical
240
pages.
MD
Hardcover,
10 contributors).
trated,
Approach,
R Cooper
(with
illus-
Mount Kisco NY:
seen
Respiratory care practitioners are
these are
usually familiar with disease processes
rarely
Among
the
injuries, respiratory
failure, tuberculosis (helpful to those
who have
Pulmonary Manifestations of Systemic Disease:
Futura Publishing Co, 1990. $48.00.
This text contains sections on
clinically),
if
Critical
21.19),
dered insignificant.
of us
charts tedious, as
to
And
Fig.
volume of docu-
impressive
an
pulmonary physicians and some others
and
RRT
Douglas B Eden BS
Medical
one
to the
however, these are very minor errors
may
find the vast array of photos
is
photo).
21.8,
made
is
pulmonary
book seems appro-
own
copy.
one photo-
that does not exist. Altogether,
basic
yet the
— second
(Section
the respiratory therapist does not exist
UK,
their
University of Virginia
be reminded that the phenomenon of
priate for us as well.
most
prohibit
will
from acquiring
practitioners
Chariottesville, Virginia
Respiratory care practitioners should
in the
clinicians alike, but
cost
lung instead of the right (Section 18.5,
in
was written
book's
left
reference
not quite
and
for students
the
performing a
are
photo, the reference
arrow
MD), though
European
tions (Section 7.15, Fig. 7.32). In
of Medical
Netter
strange
for
will surely
It
serve as a frequently checked resource
procedure without universal precau-
lection
H
may seem
In at least
texts.
Ciba Series (The Ciba Col-
Frank
latter
physicians
graph,
familiar
Illustrations,
The
patients
programs
one copy
at least
their reference libraries.
USA and Canada by JB Lippincott Co,
state that their objective
in the
be unfamiliar to U.S. readers
the text,
The authors
team described
the health care
because they are under a different trade
A
to
75229.
chapter on cystic fibrosis; however, this
Publishing, 1989. (Distributed in the
19105.) $165.00.
TX
medications menti-
orientation.
oned
and software
txxjks. films, tapes,
1030 Abies Lane, Dallas
1
panies the photo to help with anatomic
Gower Medical
England:
Listings
seen
little
of this entity
and asthma (which advo-
cates the concomitant use of aerosol-
that are
less
primary to the lung. They are
conversant with diseases of other
organ
systems
which there are
in
pulmonary problems. This 240-page
volume
is
a review of the respiratory
a primer on lung disease; however, the
ized
beta
pathology that can accompany sys-
book's broad range within the specialty
agonists and, further, suggests increased
temic disease, either as an inconstant
and fundamental simplicity make
use
it
valuable for nearly everyone from the
first
year respiratory care student to
Use of medical
the resident physician.
jargon
is
manages
and the book
minimal,
to
cover just about every
pulmonary disease ever described.
The overly
may
critical
atropine
of aerosolized
and
with
steroids
to
help
reduce the need for oral steroids, an
idea that
may
to the U.S.).
is
the
slowly be finding
The
its
way
strength of this text
generous assortment of case
examples of chest roentgenograms,
CT-scan
and impatient
derivatives
slices,
tomograms,
arterio-
grams, bronchograms, and ventilation/
part of the
The work
sparked
diseases, this
reproduction
is it.
is
The
you're
quality of film
very good, and
fre-
quently an illustrative graph accom-
920
In
I
I
in
many
of the diseases that
have not worked with
school.
therapist
clinically since
the Medical
is
addressed
is
divided into
1 1
chap-
each averaging about 20 pages
of radiographs of various pulmonary
if
work
whom
but one of
to other physicians.
looking for one book with examples
however,
secondary
primarily to pulmonologists but also
length.
frustrating;
spelling
all
College of Virginia, and
my opinion, the authors' objective
was met. found my interest once again
grammar
British
as a
a collaborative
members of
are faculty
ters,
the
It is
by 10 authors,
perfusion scans.
find
syndrome or
complication.
The
diffuse, but
around
a
helpful
to
subject
matter
each chapter
summary
the
is
in
rather
is
organized
outline
uninitiated
that
is
reader.
Mention of the respiratory
Pulmonary involvement accompany-
conspicuously absent from
ing neurologic, cardiac, gastrointesti-
is
RESPIRATORY CARE • SEPTEMBER
'90 Vol 35
No 9
\
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ROXACAPS
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Proven efficacy and safety
Comparable to VENTOLIN"
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Inhalation AerosoP*
Percent
in
Change From Baseline
Mean FEV, After Drug Treatment. Week 12
Each medication was
VENTOLIN ROTACAPS
£
administered tour times daily
for 12 weeks.
albuterol aerosol
30_
all iympatriomimefic amines,
albuterol should be used with caution m
patients with cardiovosculaf disorders,
especioiiv cconorv insufficiency,
hypertension andcordioc OrrhythmKa
"As with
REFERENCE:
Bronsky E Bucho)tzGA,eus5eWW,eial
Comparison ot mhaied albuterol powder
arxj oerosoJ rn asthma J Allergy dm
Immunol 198779 741-7-17
1
120
180
Time (mm)
Adapted trom Bronsky et oi
Venlolin' Inhalation Aerosol
(albuterol,
BRIEF
usp)
SUMMARY
Sronchodilalor Aerosol For Oral Innalalion Only
Tr.^ ',
(.A
j
, J D'let
Summary
d-d Veritonn Rolacaos"
CONTRAINDtCATIONS:
only BetofC orescrtbing. see complete prescribing information in Venlolin^ Inhalation
product labeling
(oi Inhalation
ventolin* inhalation Aerosol and Ventolin Roiacaps* lor Inhalation are contraindicaled
pat en)', Ai'h a 1 ^tofy of hypersensitivity lo any of their
in
components
". rtiihoihe' mhaied beta adrenergic agonists. Ventolin* Inhalation Aerosol and Ventolin Rotacaps* tot
In' ^ .-'
luce paradOKicai Dronchospasm that canbeiife-threatening If it occurs. Ihe preparation should be
Ci'.( .!'' .>•
'nefJialely and alternative therapy instituted
Faiaiihei have been repotted m association with excessive use ot inhaled sympathomimetic drugs The exact cause
IS
unknown
ot deaih
bui cardiac arrest following the unexpected development of a severe acute asthmatic crisis and
:
subsequent hypojiis
is
suspected
may occur afleraCminislration ol albuterol, as demonstraled by rare cases ot
angioedema rash bronchospasm anaphylaxis, ano oropharyngeal edema
The conlenis of Ventolin inhalation Aerosol are under p'essure Do not puncture Do not use or store near heat or
open flame Eipostife to temperatures above I20''f may cause bursting Never throw container into fire or incinerator
Keep Out of reach of children
ifDmediatefiyPe'sensitivity reactions
urticaria
PRECAUTIONS:
Central Although no
on the cardiovascular system is usually seen after the administration
recommended doses cardiovascular and central nervous system (Cf^S) effects seen with all
Sympathomimetic drugs can occur alter use ol mhaied albuterol and may reouire discontinuation of the drug As with
all Sympathomimetic amines albuterol Should be used with caution inpatients with cardiovascular disorders, especially
coronary insufficiency cardiac arrhythmias and hypertension m patients with convulsive disorders hyperthyfoid
ism or diabetes meiiitus and m patients who are unusually responsive to sympathomimetic amines Clinically sigmfi
cant changes m systolic and diastolic blood pressure have been seen m individual patients and could be expected to
occur in some patients atter use o' any beta adrenergic bronchodiialor
Large doses of intravenous albuterol have been reported lo aggravate pre exisiing diabetes metiitus and kelracidoS'S Additionally beia agonists including albuterol given miiavenously may cause a decrease mseium potassium,
possibly through mitaceiiuiar shunimg The decrease is usually transieni. not requiring suppiemanialion Ttie relevance
effect
of inhaled aibuieroi at
oi these observations lo the use of Ventolin* inhalation Aerosol
is
unknown
Although there have been no reports concerning the use ol Ventolin inhjiuiiun Aerosol or Ventolin Rotacaps* (or
Inhalation during labor and delivery it has been reported that high doses ol albuterol admimsiered intravenously inhibit
uterine cof>tractions Although this effect is eitrempiy unlikely as a consequence ot Ventolin use, it should be kept in
lelanneUoiilerPitlaRli:The action oi v^'i'iiri I'naution Aerosol may last up to sm hours and the aclion of Ventolin
Rolicaos tor Inhalation may last tor sii hfjtjf-,, ui longer Therefore they should not be used more IreQuently ihan rec
ommended Do not increase the tf^quencyol doses without medical consultation If the recommended dosage does
not provide relief ot symptoms ur symptoms become worse, seek immediate medical attention While using Ventolin
inhaiatior^ Aerotd orj/e^flMi Rotacaps lor Inhalation, other inhaled drugs should not be used unless prescribed See
package inserts (oi Mfllntd Patient s instructions lor Use
Onit letolMMM: Olher lympathomimetic aerosol bronchodtlato's or epinephrine should not be used concomitantly
wiUlMntOlin Inhalation Aerosol other iympathomimel<c aerosol bronchodiialors should not be used concomilanlly
•WlVlMolin Rotacaps fo* Inhaiahon because they may have additive effects If additional adrenergic drugs are lo be
tdrmmtlertd by any route to the patient uvng Ventolin Inhalation Aerosol, they should be used with caution to avoid
dc(eicr<out cardiovascular effects
Albuterol should be adrrvmstered with extreme caution lo patients
bemg
treated with
anttdepreisjnts because the action of albuterol on the vascular system
Beta receptor biockirtg agents and albuterol inhibit the effect of each other
or tricyclic
m
monoamine oxidase
may be
CardMfMnlt. MilHMttti. Imptlnnml et FtrWHy
doHi corresponding lo til
August 1989
the maximum human inhalational dose (Ventolin Rotacaps* (or Inhalation (albuterol sulfate USP)| In another study
was blocked by the coadministration of propranolol The relevance ot these findings to humans is not known
An 18-month oral study m mice, at doses corresponding to 10,417 limes ihe human inhalational dose, and a lifetime oral
study m hamsters, at doses corresponding lo 1,04? limes the human inhalational dose, showed no evidence ol tumongenicity Studies wilh albuterol showed no evidence ot mutagenesis Oral reproduction studies in rats, at doses corresponding to 1.042 times the human inhalational dose showed no evidence ot impaired (ertility
PTeqaanCY-Teralogenic Ettecis: Pregnancy C3tegoryC: f<\t)u\eto\ has been shown lobe teratogenic m mice when given
in doses corresponding lo 14 times the human aerosol dose and live limes the human inhalational dose (Ventolin
Rotacaps lor Inhalation) There are no adequate and well controlled sludtes in pregnani women Albuterol should he
used during pregnancy only the potential benefit lustifies Ihe potential risk to the fetus A reproduction study m CD l
mice given albuterol subculaneously (0 025. 25. and 2 5 mg/kg, corresponding to 1 4 14, and 140 trmes Ihe maximum
human aerosol dose and to 5, 5, and 52 times the maximum human inhalational dose respectively) showed cleft palale formation in 5 of 111 (4 5^) Ictuses at
25 mg, kg and m 10 of 108 {9 3%) Ictuses ai 2 5 mg kg None was observed
ai 0025 mg/kg Cleli palate also occurred in22ol 72(30 5%) fetuses treated with 2 5 mg kg isoD'oterenol (positive
control) A reproduction study with oral albulerol in Stride Dutch rabOits revealed cranioschrsis m 7o! 19 (37S| letuses
at 50 mq/kq, corresponding to 2 800 limes the maximum human aerosol dose and to 1.042 times Ihe maximum human
inhalational dose of albulerol
Labor and Delivery: Oral albulerol has been shown to delay preterm labor m some reports There are presently no wellcontrolled studies that demonstrate that it will slop preterm iat)oi of prevent labor al term Therefore, cautious use ot
Ventolin Rotacaps lor Inhalation is required m preqnant patients when given lor relief of bronchospasm so as 10 avoid
mterlerence wilh uterine contractility
Nursing Mothers:
iciiy
shown
conli'.i'
It
is
not
'or albuterol
"'
'i-
;
Pcdiairit U\p
'
.
known whether
albuterol
is
excreted
m human
milk
Because
of Ihe potential lor
tumongen-
msome
g
,,.ii)
animal Studies a decision should be made whether to discontinue nursing or to dis
ntu account the importance Ot the drug to the mother
effectiveness have nol been established
m
children below 1? years ot age for either product
ADVERSE REACTIONS:
The adverse reactions to albuterol are similar m nature to reactions to other sympathomi
jgents although ihe incidence ol certain cardiovascular effects is less with albulerol Rare cases of urticaria
angtoedema, lash bronchospasm and oropharyngeal edema have been reported after the use of albulerol In additiort
to the reactions given below by specific dosage form, albulerol like olhci sympathomimetic agents can cause adverse
reactions such as hypertension angina vomitmg, vertigo, CNS stimulation, insomnia unusual taste, and drying or irnlalionof the oropharynx
Tii'iii.
Venlolin* inhalation Aerosol (albuterol. USP): A 13 week double blind study compared albuterol and isoproterenol
aerosols m 147 asthmatic patients The results ol this study showed that the incidence of cardiovascular etiecis was
palpitations less than 10 per 100 with albuterol and less than 15 per 100 with isoproterenol tachycardia 10 per lOO wtlh
both albulerol and isopioleienol, and increased blood pressure, less than S per 100 with both albuterol and isoproier
enol In (he same study both drugs caused tremor or nausea m less Ihan 15 patients per 100, and dizziness or heartburn
m Ics<. than S per 100 patii>nis Nervousness occurred in less Ihan 10 per 100 patients receiving albuterol and less
Ih^n IS per 100 p,)hcnl\ rrccivmo isoproterenol
m
mind
cant dose reUtM) loaease
m USA
it
WARNINGS
1
Printed
this effect
Ventolin RotacapS* for Inhalalton
(albuterol sullate. USP| For Inhalation Only
Ap'usii'
VlfsWBd
Albuterol sulfate like other agents
the irtcidence ol bcnion leiomyomas ot the mesovanum
a
SS5.
m
Venloltn Rotacaps' lor Inhalalion: The results ot clinical Inals in ^72 patients
showed the loHowmg
side effects
CNS Tremors, 6 ol 172 patients (3%) nervousness. 5 of 172 patients (3%) headache 10 of 172 patients (6%). diiimess.
3 ol 172 patients |?%), lightheadedness. 4 of 172 patients (2%), insomnia, 1 ol 172 paiients |<1%). drowsiness. 1 of 172
patients (• 1^)
Nausea burning m stomach indigestion, each m < |% of patients
OfophMryngtal Throat irritation. 3 of 177 patients {2\i dry mouth and voice changes (<i%)
Cariliovaseular lot 17? patients (<!%)
R§spualorr Hoarseness 2ol 17? patients (IV couohing.4ot 172 patients (?\)
Gtslroinlastfnal:
OVERDOSAGE:
information concerning possible overdosage and
its
treatment appears
m the
lull
prescnbmg
inhibitors
poieniiated
m its class
caused a sigmh
two ftv siudy <n the ral at
md 2B00 Itmes the maximum human aerosol dose and lo 42. 246, and 1.04? times
Alien &Hanburys
RB
? 601
March 1969
Research Triangle Park. NC 27709
BOOKS, FILMS. TAPES, & SOFTWARE
hepatic, renal, endocrine, meta-
nal,
and connective
bolic,
accounts for 7 of the
CHOOSE QUALITY
CHOOSE OPTIMUM PERFORMANCE
CHOOSE
tissue diseases
1
The
chapters.
1
other 4 chapters deal with a diversity
infiltrates in the
host,
pulmonary
immuno-compromised
including
of subjects,
malignancies to the
metastatic
on lung
lung, effects of obesity
structure
and function, and drug-induced pulmonary disease. The authors have
attempted to cover
known
is
STERI^VERS
CHOOSE YOUR DECONTAMINATION PROGRAM
WASH ONLY
WASH AND PASTEURIZE
WASH AND CHEMICALLY DISINFECT
reasonably well-
all
pathologic states in which there
likely to b»e lung
involvement.
reference
On
one can find
of the index,
perusal
most systemic disease
to
conditions for which respiratory care
may be
required.
These chapters are brief because the
reader
is
is
little
to
have a working
clinical
medicine. There
assumed
knowledge of
introduction to the individual
— the
diseases
authors limit their
discussions to the
VERS
SYSTEM
STERI •
pulmonary aspects
almost without exception. The docu-
mentation
ally
excellent; chapters gener-
is
Model 520
have more than 50 references, most
The
of them recent.
illustrations are
mainly reproductions of chest radiographs,
are of poor
some of which
quahty.
There
is
a
information
in
wealth
of practical
these terse but
well-
referenced pages. Physicians will be
impressed by the broad scope of the
may
topics covered, but the benefits
be
fully
attainable
collateral reading
on
only
after
some
AEROTHERM
DRYERS
from standard works
internal medicine.
For the
tory care practitioner, the
respira-
book
will
SOLID
CHOOSE
/
DEPENDABLE / RELIABLE
MODEL, and FILTRATION
SIZE,
be quite advanced, requiring a medical
dictionary
and considerable help from
It would be a
basic medical sources.
good textbook
for a didactic course in
the senior year of a respiratory therapy
baccalaureate program,
taught by a
physician.
Hugh S Mathewson
MD
Medical Director
CHOOSE
Respiratory Therapy
University of Kansas
Health Sciences Center
Kansas City, Kansas
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—
new education programs, and
Notices of competitions, scholarships, fellowships, examination dates,
be
listed
for the March issue, February
month of publication (January
information and mail notice to Respiratory Care Notices Dept,
for the
1
1
Notices
the like will
here free of charge. Items for the Notices section must reach the Journal 60 days before the desired
1
Apnl
issue, etc). Include all pertinent
1030 Abies Lane. Dallas
TX
75229.
ARCF Literary Award
Award
• The American Respiratory Care Foundation announces a $1000 Literary
— funded
by Radiometer America Inc
—
for the
RESPIRATORY CARE from October 1989-December 1990. The winner will be announced on December 8,
Annual Meeting, and in the January 1991 issue of Respiratory Care. All case reports will be considered
best case report published in
1990. at the
for the
AARC
award, and no application
is
necessary.
AARC ANNUAL CONVENTION
1
990— New
Orleans, Louisiana,
December 8-11
99 1 —Atlanta. Georgia. December 7-10
1992— San Antonio. Texas, December 12-15
1
SITES
& DATES
1
993- -Nashville, Tennessee, December 11-14
1
994- -Las Vegas, Nevada, December 12-15
1995- -Orlando, Florida, December 2-5
THE NATIONAL BOARD FOR RESPIRATORY CARE
1990 Examination and Fee Schedule
CRTT
Combined
Examination
RRT
Written
$175.00
and Clinical Simulation;
NOVEMBER
EXAMINATION DATE:
Applications Accepted Beginning:
Application Deadline;
10,
1990
Written Registry Only
RRT
1,
1990
Written Registry
September
1,
1990
Clinical Simulation
DECEMBER
1,
1990
June
1,
1990
Advanced
1990
Advanced
Applications Accepted Beginning:
August
Application Deadline:
RPFT
Entry Level
1,
CPFT — new applicant:
CPFT — reapplicant:
RPFF- new applicant:
RPFT— reapplicant:
Applications Accepted Beginning:
Application Deadline:
1,
1990
July
1,
1990
September
1.
1990
Clinical Simulation
CPFT
RPFT
$100.00
$ 80.00
$150.00
$130.00
$ 25.00
Written Registry Examination
DECEMBER
EXAMINATION DATE;
$ 50.00
$100.00
CRTT Recredentialing:
RRT Recredentialing;
Examination
$ 75.00
Only
or reapplicant:
Entry Level
Examination
EXAMINATION DATE:
Only— reapplicant:
July
new
— new applicant:
Examination
$ 25.00
$ 65.00
Recredentialing;
$ 25.00
Recredentialing:
$ 90.00
Membership Renewal
CRTT/RRT/CPFT/RPFT
Fee Schedule
Entry Level
Entry Level
CRTT new applicant:
CRTT — reapplicant:
8.^10
922
$ 75.00
$ 50.00
$ 12.00
Membership Renewal
Combination of CRTT/RRT
and
CPFT/RPFT
Nieman Road • Lenexa, Kansas 66215
$ 18.00
• (91.^) 599-4200
RESPIRATORY CARE
•
SEPTEMBER
'90 Vol 35
No 9
Not-for-profit organizations are offered a free advertisemcnl of
basis, in
Calendar of Events
and require an
Deadline
insertion order
Submit copy and
the ad to run.
Lane. Dallas
Rfspirator^ CARr. Ads
in
TX
the 20th of
is
up
on a space available
to eight lines to appear,
for other
month two months preceding
month you wish
the
Calendar of Events, Rt^PiRATORV Cari
insertion orders to:
Calendar
of Events
meetings are priced at $5 50 per line
11030 Abies
,
75229.
AARC & AFFILIATES
Center, Respiratory Care Dept, 1900 Columbus, Bay City
MI
48708.(517)894-3166.
September 18-19
Conference
M
Honolulu, Hawaii. The Hawaii Society
in
Care presents
for Respiratory
Decade
1717 Palolo Ave. Honolulu HI 96816. (808)
Lexington, Kentucky. The Kentucky Society
in
Care
Respiratory
for
Hilton Hawaiian Village Hotel. Contact Helen
at the
Ono RRT,
October 3-5
17th Annual Respiratory Care
its
— New
presents
Contact Jim Matchuny
547-9532.
Annual
its
"New
Meeting.
Direction," at the Radisson Hotel in Lexington.
Community
Lexington
at
College. (606)
257-1022.
September 20-21
Napa, California. The California Society
in
Care (Chapter
for Respiratory
Napa
10),
October 7-13
Valley College, and
American Lung Association of the Redwood Empire
the
in
for
Cardiopulmonary Care." Topics include heart/lung
transplantation, pressure support/control ventilation, care of the
BPD.
infant with
and post-op cardiac
pre-
oxygenator, and autogenic drainage. Nine
Kate Benscoter
at
September 25-27
Napa
at
Trump
its
October 19
RRT
Ed Mellon
NJ 08244.
Shore Memorial Hospital. Somers Point
(609)
presents
Island,
New York
New York
Niagara
in
Chapter of the
Care hosts the
Neil
1 1
th
New
Falls,
New York
McPeck
State Society for Respiratory
Gary
MD.
CRTT. and Donald
speakers. Contact Emilie
Greenblatt
Walker
Mount
at
5300 Military Rd, Lewiston NY. or
call
MD.
Wilson
Bruce
MD
are
Ratio
St Mary's Hospital,
NY. Speakers
the Future." at the
include John Back
Positive Pressure Ventilation; Michael
Glimpse of the Soviet Health Care System;
MD — New Advances in Transport of the Ventilated
MS — Techniques in Diagnosing Sleep
MS RRT — Pressure Control-Inverse
Karen Larson BS RRT — Entrepreneurial
Mark McCauley
Ventilation;
Management
(716) 298-2142.
York. The Southeastern
in the
Decade Ahead and Respiratory Care Services
Pulmonary
MD —
and the Joint Commission; and John llowite
September 26-28
in
Meeting. "Challenges of a
in
Charleston. Contact
PO
Rehabilitation: What's
Charleston, South Carolina. The South
Carolina Society for Respiratory Care presents
New
Sandy
Box 8500, Florence SC
Decade."
SCSRC
Byrdic.
its
at the
19th
Ken Axton
Annual
RRT
in
Event."
at
Sebasco
BIPAP/CPAP.
Annual
its
Lodge.
pediatric
Topics include
asthma,
surfactant
communication, and case-study workshops,
sleep
therapy,
fibrosis,
ethics,
the
apnea,
AIDS,
as well as other topics
surfactant
Bavarian
Inn
ME 04841. (207) 596-
topics
hemodynamic monitoring, capnography, metabolic
pulmonary
rehabilitation.
and an outdoor steak
frv.
RESPIRATORY CARE
•
Hill
and
'90 Vol 35
No
RPFT RRT,
therapy.
13th
COPD.
ARDS. cystic
home
care,
masquerade
1072 High
(503) 295-0880.
November
2 in Jack.son, Mississippi.
will
be
at the
information, contact
Community
RRT, Bav Medical
SEPTEMBER
its
Resort and
noninvasive monitoring, respiratory muscle function.
MA 02324.
meeting
a.s.sessment.
Special events include a golf outing
Contact Beth
replacement
The
College.
St,
and a
party, golf
Bridgewater
MSRC
mini-seminar on the ABC's of neonate/pediatric
include
ventilation techniques, pediatrics, sleep disorder concerns,
Sturbridge
tournament, walkathon, awards banquet, and vendor reception.
Frankenmuth, Michigan. The Michigan
its Annual Fall Meeting
Motor Lodge. Program
Sheraton
pressure control ventilation, asthma,
Contact Susan Harding
in
the
legislative update. Social events include a
Society for Respiratory Care presents
at
at
mechanical ventilation, lung transplantation, research.
hemodynamics.
8485.
September 26-28
Sturbridge, Massachusetts. The
Conference Center. Topics include cardiopulmonary diagnostics,
for
of interest. Contact Janey Barthelette. Respiratory Care Dept.
Penobscot Bay Medical Center, Rockland
in
1
Massachusetts Society for Respiratory Care presents
Seminar. "The Maine
Fall
and What's on the Horizon. Contact
(516) 444-3180.
at
October 30-November
Annual Meeting.
29501. (803) 661-3629.
Rockland, Maine. The Maine Society
Respiratory Care presents
New
Marriott Hotel
Annual Meeting
September 26-28
Grady
43015.
Daniel Draper
Disorders;
featured
Forms of
RRT — A
Pettett
Infant;
William
New
22nd Annual Symposium. "Into
its
MD — Alternate
York. The Western
Annual Statewide Respiratory Care Sym-
Maclntyre
OH
Ave. Delaware
State Society for Respiratory Care
Marriott Hotel. Uniondale
September 26-28
Ferguson
Director. Respiratory Care.
W Central
Long
in
Chapter of the
653-3729.
posium.
Dan Wine.
(614) 369-8711. ext 3515.
annual Shore Conference
Castle Hotel and Casino. Contact
Times
Columbus, Ohio. The Ohio Society for
its 15th Annual Meeting at the Radisson
in
Memorial Hospital. 561
New Jersey. The New Jersey
Society for Respiratory Care presents
at the
Hotel. Contact
Valley College. (707) 253-3141.
in Atlantic City,
AARC
Respiratory Care hosts
Contact
offered.
Care Week. Turn to the
section in the July issue of
more information.
October 10-12
care, the intravascular
CEUs
U.S.A. Respiratory care practitioners across
RC Week
special
cosponsor the 8th Annual Napa Valley Conference "Current
Concepts
in
the nation celebrate Respiratory
presents a
critical care.
This
Holiday Inn-Medical Center. For more
Donna Lindsey CPFT RRT, Northeast MS
Cunningham Blvd. Booneville MS 38829.
(601) 728-7751. ext 387.
9
923
CALENDAR
November
2 in
Chapter of ihe
presents
"Ventilator Trends
is
PhD RRT
of the U.S. Military
fall
foliage,
Mike
and a
Aiello
at
in
RRT, Box
l.'iO,
New
8-11
TX
the scenic
Hudson River and
the event. Contact
NY
12527. (914) 795-
Glenham
The
AARC
AARC,
1
1030
75229. (214) 243-2272.
OTHER MEETINGS
Tours
complement
Orleans, Louisiana.
Orleans Convention Center. Contact the
the 1990s " Speakers include
MD.
New
in
36th Annual Convention and Exhibition at the
its
Abies Ln, Dallas
topic for the one-
and Norma Braun
Academy,
buffet lunch
presents
The Hotel Thayer,
Academy, West Point NY. The
Robert Kacmarek
December
York. The Hudson Valley
State Society for Respiratory Care
annual educational seminar
its
U.S. Military
day event
New
West Point,
New York
October 10
in
Sandusky, Ohio, The American Lung Association
of Ohio's South Shore and the Sandusky Area Health Education
Center co-sponsor the
5340.
Conference,
North Coast Pulmonary Disease
"RESPIRATORY— A
Lifetime of
CARE"
at the
Radisson Harbour Inn. Contact Carol Adler. (419) 663-5864
or 1-800-231-5864.
November 9
in
Reno, Nevada. The
Respiratory Care and the
present the 9th
the
Annual Respiratory Health Care Conference
Washoe Medical
"Respiratory
Nevada Society for
American Lung Association of Nevada
Illness
Center.
The
Across the
topic of the Conference
Lifespan."
Contact
April 14-21.
at
is
the
Mexican Riviera Cruise. "Each One, Teach One"
theme of
Barbara
is
Garden Grove
CA
spring cruise. Eight
$775 double occupancy,
(800) 462-3628, or write
Rothstein at (702) 829-5864.
IT'S
this year's
earned. Cruise price
is
Dream
Cruises,
CEUs
can be
prepaid. Call
10882 La Dona Ave,
92640.
HERE
The Uniform Reporting Manual,
3rd Edition
The
third ecdition of the
Uniform Reporting Manual represents dramatic changes
— in
the format, the activities covered, and, in many instances, in the time standards. It's an
indispensable guide for managers 'who need to document their work-load units and time
standards. The new third edition is easier for you to use. And, it is no-w ready to ship.
This updated version documents 'work-load units and time standards on: Patient
Assessment Activities, Airway Care. Bronchial Hygiene. Diagnostic Tests, and
Supplemental Oxygen. In addition, there are chapters on Clinical Activities -without Time
Standard and Management Support
Activities.
The manual costs AARC members only $60.
For nonmembers, the cost is $80.
SAVE HALF THE PRICE
or second edition of the Uniform Reporting Manual, you can
get the third edition at half price by sending us the cover of the three-ring binder from
your old edition.
If
you purchased the
first
To
The .VXRC,
order,
I
call
(214) 24.^ 2272
KUO Abies
Lane, Dallas,
TX
7.S229
—
RE/PIRATORy C^RE
and Typists
Instructions for Authors
These Instructions are meant to guide authors and
typisLs,
and in-house manuscript review.
including
Manuscript, a
veterans in those roles, in the production of quality manuscripts. Perfection
not expected, but the well-prepared manuscript has the best chance
is
for
prompt review and
The
Instructions.
Kit
free
is
can
Typists
name
of journal
list
use
from the Journal
the
Model
Kit's
and a copy of these
abbreviations,
office.
early publication.
Preparing the Manuscript
General Concerns
General Requirements
• Double-space
Submissions should (1) be related to respiratory care. (2) be planned
for
and
one of the publication categories below, and (3) be prepared as
indicated in these Instructions.
A
letter
and,
when
have
all
there are
two or more
participated
manuscript, and approved
its
authors, state that
work
the
in
reported,
"We,
all the
more on
authors,
• For
the undersigned,
all
in
research articles, follow formal of
• Meticulously follow
Publication Categories
Evaluation
new
A
Case Report:
A
or.
if
Case
and
description
report of a
clinical
The
case that
uncommon
is
all references, figures, and tables are cited in the text.
• Consider having paper reviewed in-house before submission.
• Have all co-authors proofread and approve manuscript and
or of
author(s) must have been associated
case-managing physician must be one of the authors
Series: Like a Case Report but including a
Review
submission
Article:
Overview:
art
A
comprehensive,
critical
Manuscript Structure
Most kinds of papers have standard
A
critical
A
critically
Review
reviewed (not necessarily
Research
Article.
in this journal).
paper expressing the author's personal opinions on
If
a paper does not
Letter:
A
A
may
consider
one of the foregoing categories
it
as a Special Article.
signed communication about material published
in this
Methods of Evaluation, Results of Evaluation, Discussion), Product
journal
Case Report or Case
(Introduction.
bnef. instructive case report (real or fictional)
by questions for readers
PFT Comer:
Like Blood Gas Corner but involving pulmonary function
Review
(
Like Blood Gas Corner and
PFT Corner
X 5 or 5 ' 7 inch prints of radiographs.
The
a review can discass
it
Review of
May
interested in writing
&
references. Tables
&
may be
tables.
No
&
title),
may be
figures
title
Table
Article: Title page, text
writer's
text,
abstract.
appropriate.
No
name
&
abstract.
affiliation,
included Double-space everything.
page
and
Stmcture: Important Details
Typist's Kit
To di.scu.ss a wnting project, write to Respiratory Care, 1 1030 Abies
Une, Dallas TX 75229 or call 214/243-2272.
Authors are urged to obtain the Respiratory Care Author's & Typist's
The
Literature, State of the Art, Discussion,
include figures
Letter: Title page (provide a
Write "For Publication" on
Author's
Write a Better Case
(introduction, message), references, tables, figure legends.
with an editor.
Editorial Consultation
"How To
Overview, Update, Point of View, or Special
case must be real.
Review of Book, Film, Tape, or Software: Anyone
references.
of Contents optional. Other formats
but involving pulmonary-medicine radiography and including one or
two 4
Acknowledgments page,
Discussion).
Article: Title page. Table of Contents page, continuous text
Introduction. History.
Summary),
testing.
Skill:
Case Summary.
Report," Respir Care 1982:27:29 (Jan 1982)
— with answers and discussion.
data, followed
tables, figure legends.
Series: Title page, abstract page, continuous text
references, tables, figure legends. Also see
involving invasively or noninvasively obtained respiratory care blood
Your Radiologic
Title page, abstract page,
Sources page. Acknowledgments page, references,
or on topics of interest or value to readers.
A
page.
continuous text (Introduction, Description of Device/Method/Technique,
paper thai draws attention to a pertinent concern.
Blood Gas Comer:
Sources
and Model Manuscript, Respir Care I984;29:182 (Feb 1984).
Evaluation of Device/Method/Technique:
fit
Product
Discussion),
Results,
references, tables, figure legends. Please consult
"Writing a Research Paper," Respir Care I985;30:I057 (Dec 1985)
A
pertinent, the editors
IS
Editorial:
Methods,
Acknowledgments page,
a pertinent topic.
Special Article:
the parts
Article: Title page, abstract page, continuous text (Introduction.
&
Materials
report of subsequent developments in a topic that has been
Point of View:
all
listed here.
review of a pertinent topic about which not enough
Update:
However,
parts in a standard order.
papers can vary individually, and not every paper will have
of a pertinent topic that has been the subject of 40
research has been published to merit a
Kit.
sign
letter.
number of cases.
review of the literature and
or more published research papers.
Test
instructions for typing references.
Author:
not an author, must supply a letter approving the manuscript.
state of the
but
Model Manuscript, Respir Care
be sure
device, method, technique, or modification.
exceptional teaching value.
with the case.
A
or
• Structure manuscnpt as specified hereafter.
• Provide all requested information on title page as specified hereafter.
• Proofread manuscript for completeness, clarity, grammar, spelling;
report of an original investigation.
Device/Method/Technique:
of a
evaluation of an old or
W
1984:29:182 (Feb 1984).
read the accompanying
submission for publication."
A
upper right corner and leave margins of
four sides of the page.
General Concerns
Research Article (Study):
including those in references, figure legends,
not justify right margins.
• Number pages
accompanying the manuscript
must specify the intended publication category, be signed by
Do
tables.
— Typist
ALL lines,
Title Page: List
letters,
or
No
professional positions,
authors'
all
and
other
support.
Identify
full
names, degrees, credential
affiliations. List
any
if
desired.
author's
correspondence address,
Name
consulting
sources of grants
or
commercial
relationships that pertain to the paper's topic.
research paper, wnting a case report, convening to and from SI units.
"90 Vol 35
of paper,
telephone number, and reprint address
Kit provides authors with specific guidance about writing a
RESPIRATORY CARE • SEPTEMBER
title
9
925
INSTRUCTIONS FOR AUTHORS & TYPISTS
Number
Abstract Page;
Page
this
less
methods,
as
and
results,
Notes: Although the examples here are printed with single-spaced lines,
double-space references
conclusions drawn.
plea-se
Statistical Analysis: In research articles, identify statistical tests
in article
level
of significance
Methods
in the
numbered
is
as Figure
first
ligure
I.
mentioned
2. etc.
according to the order
5 X 7 to 8 X 10 inches and should be black
remain
legible
if
&
figure
reduced
is
in size for publication.
Corporate Author Journal
American Association
2.
An
testing:
analysis of
Article:
for Respiratory Care. Criteria for establishing
units for chronic ventilator-dependent patients in hospitals. Respir
Care I9XK;3.V|044-1046
to
Final figures
— except proper names.
Article:
paradoxical responses. Respir Care 1988;33:667-671.
white unless color
and numerals must be neat and large enough
Letters
es.sential.
is
which
in
manuscripts. Also, note that words
in
are not capitalized
titles
Shepherd KF. Johnson DC. Bronchodilator
graphs must be
Photographs must be glossy prints
in the text.
and book
Standard Journal
I
&
Figures (illustrations): .Ml photographs, diagrams.
each
and chosen
section. In Results section, report
P values
actual
References
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Book with
JB
Chairman
Editor, Compiler, or
Guenter CA, Welch
9.
MH,
eds.
as 'Author':
Pulmonary medicine
Philadelphia:
Lippincott. 1977.
Chapter
in
Book:
respiratory failure. In: Guenter C.'\,
AK. Acute
Pierce
Welch MH,
Pulmonary medicine. Philadelphia: JB Lippincott 1977:171-
223.
Aficr preparing the manuscript according to these Instructions, perform
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RispiRAioRY Cari.
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Manu.script copy on IBM-compatible or Macintosh disks in addition
place the cited works
list,
York: .Applcton-
American Medical Association Departmcni of Drugs, .AM.>\ drug
Littleton CO: Publishing Sciences Group. 1977.
8.
mail
2, etc
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the reference
The
New
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Lancet 1988:2:905.
(letter).
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•
or incipent
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rest relieve fatigue
Rev Respir Dis 1988:138:516-517.
JF. Applied respiratory physiology.
information, or guide readers to further perUnent literature.
•
Am
with nebulised pentamidine
eds.
to
in
Personal Author Book:
the abbreviation
unless absolutely necessary.
references
papers should
Smith DF, Herd D. Gazzard BG. Reversible bronchoconslriction
6
References:
• Use
full
should be identified as such.)
evaluations, 3rd ed
an abbreviation only
full
cited, abstracts
Rochester DF. Does respiratory muscle
5.
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in
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1988;3.'?:86I-87.1 (Oct 1988).
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Lippard DL. Myers TF. Kahn SE. Accuracy of pulse oximetry
4.
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Chest
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ALL
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pulmonary
interstitial
severely hypoxic infants (abstract). Respir Care 1988:33:886.
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Idiopathic
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1986:89(3. supp I): 1 39s- 43s.
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Is
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926
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1988:33:1050 (Nov 1988)
•
a listed publication category'.'
letter
page complete?
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and
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SI values been provided?
al!
arithmetic been checked?
:ill
;iuihors?
RESPIRATORY CARE • SEPTEMBER
'90 Vol 35
No
9
News
releases about
section.
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is
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be considered for publication
will
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New
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SAFE-T-RACK and
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PORTABLE SPIROMETER.
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RESPIRATORY CARE
•
According
SEPTEMBER
Korotkoff sounds
Instrument
Quinton
Company, Dept RC, 2121 Terry Ave,
Seattle
WA 98121. (800) 426-0337.
'90 Vol 35
No
9
their
For a
free
(press
begins).
is
medical and
copy
call 1-
4 when
Puritan
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927
Authors
in This Issue
Armstrong, Joyce B
909
Mathewson, Hugh S
920
K
873
O'Rourke, P Pearl
873
Chatburn, Robert L
879
Parities,
C
898
916
Quan, Stuart F
920
Salyer,
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Thompson, John E
Keim, Michael
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Tiffin,
Knoper,
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Williams, John
909
MSA
Catalyst Research
865
Professional Medical Products
911
Benjamin, Patrice
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C
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Steven R
Thomas
Langer,
A
George
John
898
W
879
873
Norman H
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864
Indiana University, Indianapolis IN
USC/Norris Cancer
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Hospital, Lx)s Angeles
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RESPIRATORY CARE • SEPTEMBER
'90 Vol 35
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9
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Medical literature reference bibliography available Irom
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ol
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request.
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Circle 148
on reader service card
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NY 13032 USA
(800)847-8000
(315)697-2221
FAX (315) 697-8083
Telex 93-7390
The immediate response.
The effective response.
The correct response.
re.sponse
spans') n.
(ri
1.
something done
in
answer; reply or reaction.
2. a reaction to a stimulus
Over
thirty-five
years ago
Ambu
medicine. The immediate response.
1956 the
identified a
In
manual resuscitator and
first
1955 the
in
need
first
in
the
field
of
emergency
manual suction pump,
1959 a manikin
for training
in
and practic-
ing artificial respiration.
Since then
developing
nicians.
systems
o ^
Ambu
new ones
Today the
has been dedicated to upgrading existing products and
to ensure the effective
Ambu
for training
product
line
response of emergency care tech-
includes state of the art equipment and
and administering emergency resuscitation, anesthesia
and CPR.
i
It's
the innovative response that positioned
emergency care technology
and ensures
So when
it
in
Ambu
on the "cutting edge" of
the 50's, maintained that position into the 90's
well into the future.
life
depends on a
split
second response,
rely
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Ambu
response.
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Hanover, Maryland 21076
Telephone: 1-800-AMBU INC
Telefax:
Circle
1
13 on reader service card
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