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Methods of High-Frequency Assisted Airway Clearance. TSRC Pineywoods District Annual Spring Seminar April 3-4, 2008. David R. Barton, BA, RRT, RCP Educational Coordinator Respiratory Care Services Medical City Dallas Hospital. Objectives.

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methods of high frequency assisted airway clearance

Methods of High-Frequency Assisted Airway Clearance

TSRC Pineywoods District

Annual Spring Seminar

April 3-4, 2008

David R. Barton, BA, RRT, RCP

Educational Coordinator

Respiratory Care Services

Medical City Dallas Hospital

objectives
Objectives
  • Overview of Airway Physiology/HFO device interactions that enhance secretion clearance:
  • Equal Pressure Point
  • Dynamic airway compression with flow limitation
  • Clinical uses of positive airway pressure
  • Oscillatory Clearance Index
objectives3
Objectives
  • Types of High Frequency-Assisted Airway Clearance devices and mechanisms of action:
  • Intrapulmonary Percussive Devices
    • Percussionaire
    • PercussiveNeb
    • MetaNeb
  • High Frequency Chest Wall Compression
    • ThAIRpy Vest
    • Smart Vest
objectives4
Objectives
  • Types of High Frequency-Assisted Airway Clearance devices and mechanisms of action:
  • Oscillatory Positive Expiratory Pressure Devices (Patient Powered)
    • Flutter VRP 1
    • Accapela
  • Evidence supporting use of the various devices
historical perspectives
Historical Perspectives
  • Research on many of these devices has been on-going for more than two decades.
  • Eight lectures on airway clearance techniques were presented at the 17th Annual New Horizons Symposium at the 2001 AARC International Congress and published in Respiratory Care in July, 2002.
historical perspectives7
Historical Perspectives
  • Followed 5 years later with a special Respiratory Care Journal Conference presenting review articles on: Airway Clearance: Physiology, Pharmacology, Techniques and Practice published in Respiratory Care, September and October, 2007.
historical perspectives8
Historical Perspectives
  • Indeed, research continues today.
  • Respiratory Care, March, 2008
    • An article by Alves, et al, relate a bench study on performance characteristics of the Flutter at various inclinations and flows.
historical perspectives9
Historical Perspectives
  • Dean Hess, PhD, RRT pointed out in his forward editorial to the Respiratory Care July, 2002 New Horizons Symposium articles and repeated in the Respiratory Care October, 2007 Journal Conference Summary there remains a dearth of high-level evidence related to airway clearance techniques.
  • Studies are plagued with small sample sizes, crossover designs, surrogate outcome measures and statistical concerns.
historical perspectives10
Historical Perspectives
  • However, Hess remains optimistic about these techniques when he states: “Does lack of evidence mean lack of benefit? Is the lack of evidence due to study methodology, or is there really no benefit from many techniques used to enhance secretion clearance? Although we should not be dogmatic about endorsing a therapy with absence of proof of its benefits, we must also not be dogmatic about abandoning a therapy because of absence of proof of its benefit – absence of proof in NOT proof of absence.”

D Hess, Respiratory Care July, 2007 Vol 47 No 7 pg 757

airway physiology device interactions
Airway Physiology/Device Interactions
  • RTs must have an understanding of the principles of airway physiology/device interactions.
  • We must know how a particular device works.
  • Enables us to make appropriate decisions of which device to use under which circumstances.
airway physiology mechanisms of mucus mobilization
Airway Physiology:Mechanisms of Mucus Mobilization
  • Slug Flow
    • A semi-solid mucus plug is pushed from behind by expiratory air flow.
  • Annular Flow
    • Mucus moves along the lumen of the airway by being pulled along by expiratory air flow or transported by cilia.
  • Mist Flow
    • Aerosolized mucus that is exhaled as suspended droplets.
  • Majority of airway secretion clearance occurs by slug and annular flow
  • Expiratory flow is key to secretion clearance.

CD Lapin, Resp Care, July 2002 Vol 47 No 7, p 779

airway physiology equal pressure point14
Airway Physiology:Equal Pressure Point
  • The EPP concept is integral to understanding how airflow limitation occurs.
  • Initiated at normal lung volumes the EPP lies at the carina or large bronchi which are reinforced by cartilage and thus resist collapse.
airway physiology equal pressure point15
Airway Physiology:Equal Pressure Point
  • Cough generates supra-maximal, turbulent air flows (flow transients).
  • These flows must speed up through the EPP and creates shear forces that move secretions cephalad.
  • However, the turbulent flows cause faster pressure dissipation creating more potential for airway collapse at the EPP
  • Dynamic airway collapse can also occur in disease states that causes increased compliance (CF, COPD)
  • Even the larger airways may be compressed if frequent coughing has damaged the cartilage.
airway physiology mucus plugging
Airway Physiology:Mucus Plugging
  • In order for cough or expiratory flow to mobilize secretions, it is necessary to get air behind the secretions.
  • Mucus plugs can prevent inspiratory flow from getting behind the site of obstruction, making cough and airway clearance ineffective.
high frequency devices
High-Frequency Devices
  • Anecdotal discoveries made during early research on HFOV found that pulsatile gas flows at 3-30 Hz increased the volume of secretions in the upper airway.
  • Later studies confirmed that the cephalad flow of secretions was accelerated during HFOV.

JB Fink, Resp Care July, 2002 Vol 47 No 7 pg 797

hfo mechanisms of action
HFO: Mechanisms of Action
  • Reduction in mucus viscoelasticity.
  • Shear forces at the air-mucus interface applied at oscillatory frequencies that approximate cilia beat frequency.
    • HFO “resonates” with the cilia, nudging the mucus layer upward.
  • Redistribution of lung volume.

JB Fink, Resp Care July, 2002 Vol 47 No 7 pg 798

hfo mechanisms of action20
HFO: Mechanisms of Action

Normal Exhalation

oscillatory clearance index
Oscillatory Clearance Index
  • OCI was developed by Scherer, et al, in 1995.
  • Described conditions for optimal mucus transport:
    • Expiratory flow in the range of 1-3 L/s.
    • Oscillation frequency between 8-15 Hz.
  • OCI derived to find optimal settings for IPV and HFCO.

TA Scherer, Chest 1998; 113; 1020

oscillatory clearance index23
Oscillatory Clearance Index
  • Using surrogate outcomes of weight of expectorated sputum, PFTs and SpO2 they found:
  • High-frequency airway and chest oscillation was as effective as CPT, was well tolerated and has the potential to reduce health-care costs by permitting self-administration of the modalities.

TA Scherer, Chest 1998; 113; 1020

optimizing the oscillatory clearance index
Optimizing the Oscillatory Clearance Index
  • The higher the frequency,
  • The higher the expiratory flow
  • The lower the inspiratory flow
  • The faster the inward displacement of the airway wall during expiration
  • The slower the outward displacement during the inspiration =
  • Higher OCI
  • Without any bias flow and with equal times of I:E airway wall displacement, the OCI equals zero.

TA Scherer, Chest 1998; 113; 1024

operational characteristics
Operational Characteristics
  • Treatment duration approx 20 min.
  • Impaction pressures of 25-40 psig.
  • Frequency < 100 to 225 cycles/min.
  • Non-oscillatory demand CPAP and intermittent mandatory ventilation (mandatory breath control button).
  • Medication Nebulizer
operational characteristics29
Operational Characteristics
  • Pressure and flow waveforms similar to Percussionaire.
  • Frequency up to 30 Hz.
  • Medication Nebulizer.
operational characteristics31
Operational Characteristics
  • Pressure and Flow waveforms in CHFO mode similar to other IPV devices.
  • Frequency of 230 cycles/min at 45 cmH2O on Higher Setting.
  • Frequency of 190 cycles/min at 38 cmH2O on lower setting.
  • CPEP adjustable from 0-30 cmH2O.
operational characteristics34
Operational Characteristics
  • Pulse frequency adjustable from 5-25 Hz.
  • Pressure in the vest ranges from 28 mm Hg at 5 Hz to 39 mm Hg at 25 Hz.
flutter vrp1 operational characteristics
Flutter VRP1 Operational Characteristics

LA Alves, Resp Care, March 2008, Vol 53 No3 p 319-321

flutter vrp1 operational characteristics38
Flutter VRP1 Operational Characteristics

LA Alves, Resp Care, March 2008, Vol 53 No3 p 321

opep devices acapella
OPEP Devices: Acapella

TA Volsko, Resp Care, Feb, 2003 Vol 48 No 2 pg 127

airway stability with hfo
Airway Stability with HFO
  • Anecdotally, these devices could potentiate dynamic airway compression and shift the EPP peripherally.
  • Non-oscillatory PEP may be an effective way to stent the airways open and promote secretion mobilization with a “huff-effect”.
thank you for your participation

Thank You for your participation!

Discussion

Presentation available at:

www.rtconnection.org

david.barton@HCAHealthcare.com