Mechanical ventilation is a life-saving technology, but the inevitable decision to wean a patient off of a ventilator requires a skillful combination of proven protocols, reliable technology, and teamwork between RTs and physicians.

By Phyllis Hanlon

For patients unable to breathe on their own, mechanical ventilation can provide life-sustaining oxygen—but potential risks and adverse effects require careful oversight. To reach the end goal of restoring full breathing function to the patient whenever possible, hospitals are developing more effective weaning protocols and manufacturers are creating improved ventilator technology that incorporates useful analytics and interoperability capabilities.

Adverse Effects of Prolonged Ventilation

Patients on long-term ventilation are routinely sedated, often impacting cognitive functioning and prolonging dependence on the device. Jeffrey Davis, BS, RRT, RCT, director, Respiratory Care Services and Pulmonary Function at the Ronald Reagan UCLA Medical Center in Los Angeles, asserted that the industry tends to over-sedate patients. “This has to do with time management. If we could spend time with the patient and explain, keep him apprised of what’s going on, we wouldn’t need sedation and the patient would have less anxiety,” he said.

Davis suggested using non-sedating medications whenever possible, which would allow for earlier weaning. “Personally, I don’t think we extubate the patient quickly enough. We put the patient at risk by leaving the tube in for too long. You need to be aggressive with the patient on a vent because they receive anesthesia,” he asserted. “Once the patient is awake and breathing, you should monitor him closely. Be proactive.”

Duncan Hite, MD, chair, Department of Critical Care Medicine at The Cleveland Clinic, reported that in the last 10 years the medical world has been aware of the use of heavy sedation and the risks it carries. Negative cognitive effects, long-term neurologic issues and even post-traumatic stress disorder could be attributed to sedation drugs.

But the issue of sedation is not a “one-size-fits-all” solution. For instance, an otherwise perfectly calm patient in normal life who is now in the ICU would most likely still be calm. “Keeping this patient on minimal sedation is best,” said Hite. “But a patient that uses alcohol, drugs or is anxious in normal life will be more of a problem in the ICU and will probably require more sedation. It’s impossible for a provider with a high level of certainty to distinguish if there is a lack of respiratory reserves or if someone is just uncomfortable,” Hite explained.

Mobility also impacts a patient’s readiness for weaning. At UCLA’s medical intensive care unit (MICU), a robust early mobilization program is achieving good results, according to Davis. He explained that the program promotes early ambulation, even while patients are still on mechanical ventilation. “It takes a lot of effort [to ambulate the patient] with all of this equipment. But it’s all part of weaning, trying to liberate the patient. This is better for the patient’s mind and body and improves recovery,” he said.

Hite added, “Patients also may experience neuromuscular weakness on two levels. If mechanical ventilation does work well, the muscles in the diaphragm will not be doing any work and they become weaker. When a patient is on a mechanical vent, he should be allowed to do as much work as he can, measured by how fast he is breathing. A machine setting of between 20 and 25 breaths a minute is reasonable.”

Additionally, many patients on mechanical ventilation are lying in bed. “All the muscles are used much less than before their illness,” Hite said. “Between sedation and inactivity, weakness in arms and legs occurs if the patient is on the vent for four to five days.” He noted that in the past ten years or so, some facilities are giving patients on vents physical therapy in spite of the cost of hiring physical therapists work in the ICU. “If you spend more for [physical therapy] on the front end, you’ll spend less in rehab on the back end.”

While ventilator technology has improved dramatically, Davis sees challenges for clinicians who don’t understand the technology. As an example, he cited Maquet’s Neurally Adjusted Ventilatory Assist (NAVA) technology, which is based on neural respiratory output. NAVA captures the electrical activity of the diaphragm and sends it to the ventilator, which works in synchrony with the patient’s breathing, he explained. “[Clinicians] need to know how to use the triggering technology on the NAVA vent or they won’t use it.”

According to Davis, respiratory therapists have a strong academic foundation, hands-on clinical skills, and device-specific training, so they can play an important role in assessing and treating patients on ventilators. At UCLA, RTs have developed trust with physicians and collaborate on timing and appropriateness for patient weaning. “We assess the patient and give the parameters. The physician doesn’t even need to see the patient,” he said.

Customized Protocols

Organizations, such as the American Thoracic Society, have issued guidelines for weaning patients from mechanical ventilation. A number of hospitals have adopted these guidelines, while others have modified them or created their own, specific to patient population. Davis indicated that UCLA follows a couple of different protocols; one is the standard ARDSnet protocol and the other, a rapid cardio-thoracic weaning protocol, which is used in the surgical intensive care unit (ICU), and was developed and implemented in 2010.

Davis explained that when a patient is admitted, he is put on pressure controlled mechanical ventilation, followed by basic initial assessment, including chest x-ray, blood gas analysis, capnography, and pulse oximetry. After assessing hemodynamic and oxygenation status, the nursing staff discontinues sedation.

Once the clinician evaluates neuromuscular strength and temperature and the patient is awake and breathing, the patient is extubated. “This doesn’t require physician approval,” Davis said. “Depending on the patient’s stability, weaning may be done with pulse oximetry monitoring. In some cases, we may just extubate, based on capnography and pulse oximetry readings.”

Davis keeps vent reports to identify areas that need improvement and serve as an aid for risk management. “We can see when something does not go the way we planned,” he noted.

For instance, when a patient extubates himself, the circumstances surrounding the extubation are recorded and evaluated. Davis and his department, concerned they were not achieving the national standards of patient extubation within six hours, recently collected six months of data. “But looking at the data, with the exclusions, we were well within the range of the national average,” he said.

Cleveland Clinic uses spontaneous breathing trials and manipulates the settings on the ventilator so the patient is doing the work of breathing, but is still connected to the vent, reported Hite. “If the patient can breathe for one minute, then we do a more sustained trial, maybe two hours, then discontinuing mechanical ventilation is considered,” he said.

“A patient that can only do a couple of minutes may not be ready for discontinuation,” Hite continued. “They may have some ability but not enough endurance. The process is heavily dependent on patient assessment and rolling over results to spontaneous breathing trial. This approach is not novel to Cleveland Clinic. It’s an approach to weaning that has been slowly refined, available and recommended for more than ten years. Each hospital has its own threshold for SBTs.” 

Enhanced Ventilator Technology

During the last five to 10 years, the scientific community has made great strides in understanding the cause-effect relationships of lung disease and artificial ventilation, according to Edwin Coombs, MA, RRT-NPS, ACCS, FAARC, director of marketing, Intensive Care & Neonatal Care North America, Draeger Medical Inc. “Technology has followed suit with these understandings of therapy options to potentially prevent or limit complications associated with mechanical ventilation. Additionally, improvements to safety and workflow have improved the ICU environment.

“At Draeger, our goal is to build technology that maximizes patient outcomes while reducing complexity and costs through proven technologies,” Coombs said. “The Evita Infinity V500 ventilator provides a comprehensive set of therapy tools to address variations in clinical practice and supports improvements in workflow where a single device can meet the clinical challenges of most patient ventilatory requirements.”

This device features a variety of tools to support weaning, one of which is the SmartCare/PS program. “This feature will continually assess the patient’s readiness for weaning and automatically make appropriate changes based on feedback controls of respiratory rate, tidal volume and ETCO₂,” said Coombs, adding that studies show a significant decrease in ventilation time when using SmartCare/PS.¹

The growing implementation of electronic medical record systems is helping to advance technology as well, and may prevent human error when it comes to data transcription, according to Coombs.

“Having ventilator data available remotely provides access to clinicians with the tools necessary to make decisions, even when not at the bedside. The troubleshooting and data interpretation that can be shared beyond the bedside can create better decision making and lead to a more progressive care plan to advance weaning, intervene in an emergency and improve overall communication amongst caregivers,” he said.

Furthermore, in the last decade the addition of microprocessor control, enhanced monitoring techniques, and safety features represent great strides in ventilator technology, asserted Tom George, clinical marketing manager for CareFusion.

“Devices are more sensitive to interaction with the patient. The vent is good at knowing what the patient is doing and when to self-adjust,” George said. Today’s ventilators also capture and retain important patient clinical data that can be used for tracking and trending purposes.

While these ventilators come with preset parameters, they can also be customized according to need, added Natasha Barany, product manager for CareFusion’s AVEA ventilators. Built-in features that measure negative inspiratory pressure and volumetric CO₂ automatically assess patient condition on a continuous basis, providing the clinician with important information related to weaning readiness. The AVEA ventilator has an esophageal pressure differential measurement tool that looks at advanced parameters to determine why one patient weans and another does not.

Patients fail weaning trials for a variety of reasons, including cardiac instability and high sedation levels, especially in surgical patients. But sometimes clinician availability affects initiation of a weaning trial. For instance, a nurse could stop sedation in preparation for weaning, but a therapist may not be readily available to begin the trial. By the time a clinician is ready to start the process, the patient may have become restless and anxious.

Knowledge is Power

CareFusion’s Knowledge Portal, a decision-support tool, can help to resolve this type of situation by providing the clinician with weaning and sedation analytics to facilitate better patient care. The software application looks at the computerized protocol; when sedation has been tapered and the patient reaches a specified marker, the Knowledge Portal notifies the clinician that the patient is ready to begin a spontaneous breathing trial (SBT). George indicated that this app works with AVEA and ReVel ventilators; clinicians can access the patient data and analytics from any Web-enabled device.

Barany explained that the critical metrics and indicators retained by the Knowledge Portal could help hospitals track trends and create effective ventilator-associated event (VAE) protocols.

“Looking at the data is good for establishing policy. You can see which patients are doing best,” she said. She reported that hospitals that purchase CareFusion products receive access to Knowledge Portal as part of the package. “It’s tied into the hospital information system. They always have access to their data. This is a new way of looking at data and using it to the best benefit,” she said.

Knowledge Portal provides data on a monthly basis and can compare data to the previous month and recognize any changes, saving the hospital time and money. For instance, in the past, data on average ventilator length of stay had to be collected manually. “Someone had to go to the bedside and track the information. In this day and age, hospitals are looking to save money and manpower,” George said.

CareFusion’s Alaris pump also works in conjunction with the ventilator to evaluate sedation levels, George said. “By reducing clinical variability, you can achieve standardized protocols that are more effective and have promising results.”

The industry has seen a trend toward noninvasive ventilation (NIV) during the last five years, according to George. “This is considered a branch of the weaning protocol,” he said. Take the case of a patient with chronic obstructive pulmonary disease; he might fail SBT, but would be a suitable candidate for masked NIV.

Although these automated tools have improved patient care, clinical observation is still key in starting any weaning process. “The patient has to have some resolution in the process that brought him into the hospital in the first place,” said George. Physician and/or therapist oversight, together with enhanced vent technology, can help make that determination.

Team Approach

Successful weaning takes a team approach, according to CareFusion’s George. While the respiratory therapist might initiate the protocol, nurses, physicians, nutritionists, physical therapists and other clinicians should be involved in the process.

“All parties have to agree—using evidence-based practices—on the need to establish protocols. Everyone should buy-in and stick to the protocols,” he said, reiterating the importance of good clinical assessment.

Once protocols are established, they need to be reviewed periodically. “When we develop a protocol, we give it a year, in the absence of any new and important information, and benchmark against hospitals of similar size and acuity,” George said. “We review the literature and constantly fill in any holes regarding sedation, lung protective strategies and other measures.”

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 Phyllis Hanlon is a contributing writer to RT. For further information, contact RTmagazine@nullallied360.com.

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Reference

1. Burns K, Mead M et al. AJRCCM. “Wean Earlier and Automatically with New Technology – A Multicenter Pilot Randomized Controlled Trial.” March 2013, 1-45.

The HAMILTON‐MR1 ventilator is now equipped with a CE-approved Neonatal Option, which means the device can now provide optimal ventilation therapy during MRI procedures for all patient populations, according to Hamilton-Medical.

The MR1 is FDA-approved and available in the US, however, the the Neonatal option is currently available only in the EU and EFTA member states and other countries that recognize CE marking, the company noted.

The HAMILTON-MR1 allows clinicians to take patients from the ICU to the MRI suite and back without having to change anything about the ventilation, even when they are on an advanced mode, the company says. This diminishes the risks for lung de‐recruitment and a patient setback.

The new Neonatal option now also optimizes the HAMILTON‐MR1 for MR‐compatible neonatal ventilation. With tidal volumes as low as 2 ml, safe, and lung‐protective ventilation of even the most fragile patients is guaranteed. The intelligent leak compensation function IntelliTrig automatically adjusts the inspiratory and expiratory trigger sensitivity to potential leaks. This enables optimal synchronization with the neonate’s breathing pattern, Hamilton says.

The company also says the HAMILTON‐MR1 is the first ventilator able to be used at a magnetic field strength of 50 mT, equivalent to 1 m distance for a 3T static magnetic field scanner, without creating any MR image artifacts.

Positioning a medical device too close to the MRI scanner can have fatal consequences. For maximum safety, the HAMILTON‐MR1 continuously monitors the magnetic field with TeslaSpy,an integrated gaussmeter, and gives you an audible and visual signal if you are getting too close.

Maquet Medical Systems USA has signed an exclusive distribution agreement with Flight Medical to distribute the Flight 60 mechanical ventilator, Flight Medical’s flagship product. The two groups will be capable of reaching the majority of market segments in the United States, according to a Maquet Medical Systems news release.

Beginning in the first quarter of 2015, Flight Medical products will be sold in the US by Maquet’s sales representatives along with a select number of legacy Flight Medical distributors.

The Flight 60 ventilator incorporates Flight Medical’s proprietary technology and is designed to provide dependable and affordable mobility. This product is intended to meet the demands of patients across the continuum of care, including those who require acute care, extended care, homecare therapy, or long- or short-term transport. The Flight 60 ventilator aims to provide a cost effective solution for advanced ventilation needs at the bedside and on the move.

Raoul Quintero, president and CEO of Maquet North America, says, “Maquet’s high acuity SERVO ventilation platform has been the industry benchmark for more than 40 years. Our expertise in mechanical ventilation transcends across both our anesthesia and ventilation portfolio which includes numerous products designed for respiratory support.”

Quintero adds, “We have chosen to enter into this relationship with Flight Medical based on their reputation for developing and delivering reliable, easy-to-use and functionally rich ventilators which provide the perfect complement to our existing ventilator product line offering.”

Ron Davidson, Flight Medical CEO, states, “In the last 10 years, over 17,000 of our ventilators have been deployed worldwide for use in home care, long-term care, disaster preparedness, transport and the hospital environment. We’re very proud of the strides we’ve made in the development, manufacturing and marketing of high-end mechanical ventilators, and we are excited to join forces with Maquet, a world leader in the field.”

Source: Maquet Medical Systems USA

[Updated 04.08.15 to correct final paragraph regarding the Carescape R860's availability.]

Last fall, GE Healthcare released its newest critical care ventilator to European markets, the Carescape R860. The ventilator uses advanced lung protection tools and an intuitive touchscreen interface to help improve patient care. Among the functions of the device, Carescape R860 measures patients’ lung volume and potential lung recruitability, the ability of the lung alveoli to open, and titrating the appropriate positive end-expiratory pressure (PEEP) to allow better oxygenation.

Designed with clinician feedback, ultimately, the ventilator was created to improve patient outcomes and increase the ease of use for clinicians by addressing two key objectives: simplify function and mitigate harm. “This is about improving quality of care,” says Matti Lehtonen, general manager, Anesthesia and Respiratory Care, GE Healthcare. “The clinician’s world is not getting any easier. We don’t want to create more stress for [caregivers]. If they are overwhelmed by the device, they may make a mistake. This ventilator isn’t for engineers, it’s designed for clinicians.”

The ventilator, which premiered at the European Society of Intensive Care Medicine annual congress last year and has made rounds across other conferences in the US, Middle East and Europe, has been met with excitement. “The response has been phenomenal,” says Lehtonen. “This is a very special [product] for us,” he adds, emphasizing the amount of time, work, and clinician feedback that has gone into making the ventilator as effective and intuitive as possible.

I had the opportunity to see the device firsthand at the AARC Conference in December, and I was impressed at the simplicity of the touchscreen interface. I’m not a trained RT or ICU clinician, but it was clear from just a few minutes with the device that clinicians would have easy access to all the tools necessary for monitoring and evaluating patient vitals and managing ventilator settings, in just a few swipes of the screen.

Paul Hunsicker, GE’s global product manager, Respiratory Care and Sleep, recounts a clinician’s reaction to the device; he says, “Finally a ventilator that has been designed for a 5-year-old.” The clinician is oversimplifying, of course, because there’s no more complex or nuanced medical device than a mechanical ventilator. But the ability to customize workspaces and analyze waveforms across an entire 72-hour window is providing users the ability to “turn data into information” that can inform clinical decisions, Hunsicker says.

Users can customize their interface and swipe through a number of different workspaces, including a basic view, waveforms and advanced waveforms, split screen, categories, and historical trends. The customization is designed to appeal to all clinicians, in that it can provide an overview for those with basic knowledge of the devices but also allows more experienced users to dig in to the analytics.

One function in particular, the ability to go back and analyze the patient’s waveforms over a 72-hour period, allows clinicians to “recreate the past from a specific point in time,” Hunsicker notes, which can be useful following an adverse event. Clinicians can quickly trace back through patient vitals and use the data to better understand why the event occurred or what led up to it, which in turn can help prevent future occurrences.

The Carescape R860 is available in most countries globally today, with some exceptions. GE Healthcare has filed for FDA approval and is waiting to receive clearance. With the high incidence of ventilator-induced lung injury (which affects about 24% of ventilated patients), as well as the chronic problems of ventilator-associated pneumonia and alarm fatigue in hospitals, odds are the Carescape R860 will be a welcome addition to ICUs and long-term ventilation care facilities across the US.

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Mike Fratantoro is chief editor for RT. Contact him at RTmagazine@nullallied360.com.

The keys to effective ventilator management can be found in procurement, training, and the use of a team approach between RTs, clinicians, and the hospital biotechnology workers who keep the machines up and running.

By Chris Hayhurst

Theresa Bugbee, a biomedical equipment technician at the University of Vermont Medical Center in Burlington, sees each of her hospital’s ventilators at least twice a year for preventive maintenance and scheduled testing. While she’ll occasionally find something in need of repair, it’s relatively rare. More common, in her experience, are the calls from clinicians, or from respiratory therapy technicians, when a problem comes up that requires her attention. But even that is becoming a thing of the past.

“I used to have to deal with a lot of user issues—like there’s a setting that needs to be changed, or a there’s a hole in their circuit, or the humidifier that’s part of the system isn’t heating correctly, so there’s moisture building up that’s causing the ventilator to alarm, when it’s actually the humidifier that’s not working.” The kinds of things, that is, “you’d expect a person who uses that equipment every day should be able to handle.”

Now, Bugbee said, those situations are a lot less frequent—which means she can spend her time where she’s needed the most. “Now, [the clinical team] is much more educated about the technology. They understand how the system works, and they’re willing to do that front-line troubleshooting themselves.”

“Reliable” Technology

In her view, Bugbee said, “ventilation is ventilation is ventilation.” One ventilator might have “different knobology, or different settings, or different PM parts, or a different way to test it, but the principles behind it are the same” as for the next one. When she has a specific question about a certain model, she says, she’ll refer to the service manual, or — if she needs it — tech support, which across the board, with every manufacturer she’s worked with, “is awesome.”

During purchasing, she noted, her department encourages hospital leadership to look at the whole cost of ownership, and to include as factors the availability of product-specific service courses and cooperative support teams. “Once we were replacing gaskets and we needed this tiny little spring, but to get it” — and it didn’t even have a part number — “you had to order the entire assembly for something like $2,500.”

Someone from her team jumped on the phone with tech support, and before long, Bugbee recalled, a box of springs was on its way. “That’s how we do it here. We work closely with support, and I go to their service schools, so if there’s a valve that needs to be replaced, or a pressure meter that has to be recalibrated, I can do the repair on-site. It’s cost-effective,” and it’s also efficient, “so it’s the best thing for our end users — the patients.”

Doing what’s best for patients, in fact, was the primary reason for last September’s AAMI/FDA Summit on Ventilator Technology, where clinicians, manufacturers, HTM professionals, and others discussed the various issues, and potential solutions, surrounding ventilation technology. Patients’ interests were also in mind last October, November, and December in 3 separate FDA Class 1 recalls of 4 different ventilators. In one of those recalls, the FDA pointed to the “potential for damage to their power cord adaptors, which can cause loss of power and complete shut off.” The others involved a software problem and cracks in a circuit board.

That’s not to say that current ventilator technology is in any sort of crisis. “These days, ventilators are very reliable,” said Brad Bonnette, senior project officer in the Health Devices Group at the ECRI Institute. His organization is unaware of any recent reports of ventilator failure that could have been prevented, or of anything—beyond the occasional recall—regarding issues related to safety. “Obviously, ventilators fail. But typically, when they do, they just stop working, they alarm appropriately, and the hospital will just switch it out with another ventilator, and then either send it out for repair or fix it themselves when they have time to do so.”

And don’t be discouraged by the recalls, noted Dan Van Hise, vice president of marketing, Hospital Respiratory Care, at Philips. “The FDA is now classifying almost all mechanical ventilator recalls, whether they’re major or minor, as Class 1, when in the past they would have been classified as Class 2 or Class 3.” Ventilators, in other words, may be making more headlines, but most feel they’re the same as they’ve ever been: critical life-support systems that require careful maintenance, regular testing, open lines of communication with the clinical team, and, on occasion, close collaboration with manufacturers. And yes, ventilator technology is changing, but those changes, in general, are making it easier for biomeds to do their work.

“I look at it as a partnership,” Bugbee said of the 3-way relationship between herself, UVM’s respiratory therapy department, and the manufacturers. “Everyone helps each other where it’s needed.” For example, she said, manufacturers’ recommended test modes don’t always match up with the modes in which clinicians tend to use their vents, which makes communicating with the respiratory therapists key. “If there’s a component that’s starting to fail, I don’t want to miss it because I’m looking in the normal testing mode. I need to test in the mode they’re using.”

Maintenance and Repair

According to Mario Carvajal, president and CEO of South Pacific Biomedical, a company offering hands-on ventilator maintenance and repair classes in Temecula, Calif, it’s a different story for third-party biomed shops. “If you’re an independent biomed and you’re not employed by the hospital, in some cases you can’t call the manufacturer and buy a service manual without enrolling in their training class, and in other cases they won’t even let you take a training class to begin with.”

Along similar lines, he said, the computerized service tools that are increasingly required for work on ventilators are “not always made available” to independent biomeds. “Which means he has no choice but to call in the manufacturer to service the ventilator, even though the hospital has contracted him to take care of the service for them.” Carvajal described manufacturer dislike of third-party servicing as a “growing trend” and “a real challenge for a lot of my customers.”

Nevertheless, Carvajal said, he sees a steady stream of HTM professionals in his classes, where he’ll spend 2 to 4 days on one model of ventilator, covering everything from user control and navigation of the various screens and displays, to testing, troubleshooting, and calibration for that vent. During troubleshooting, he will simulate typical problems by “disconnecting a cable, swapping some tubes around, or introducing something that will cause the ventilator to malfunction.” They discuss error codes, he said, and the tests they can use to isolate specific parts of the vent to determine exactly what failed and how it might be fixed.

“Say you’ve got a popped circuit breaker. Well, that could be bad power at the wall, it could be the power cord, it could be a bad circuit breaker or a bad power supply, it could be all sorts of things. So how do you figure out what’s causing the problem? It’s all about how to get that vent up and running again.”

Third-party biomeds are welcome at Philips’ service schools, according to Van Hise, as are staff HTM professionals from any healthcare facility that uses its ventilators. “And we’ll teach them not only how to support the product and do the preventive maintenance, but also how to do field corrections with our support and parts.” (Service manuals are also available to anyone, he noted: “They’re not secreted in any way.”)

And for those who can’t attend the school, they offer a remote diagnostic service called Respi-Link that allows the company’s own ventilator specialists to connect to its machines via the Internet. “We don’t do it while it’s in the clinical environment,” Van Hise explained. “It’s only with biomeds, and our engineers can see the exact same things that they’re seeing.” The technology allows the Philips technicians to help with troubleshooting, push through software updates, and make other changes as necessary, he said.

In the past, “ventilators were typically not networked devices,” Van Hise noted. Today, though, that’s changed. “Certainly, with our platforms, and I would say throughout the industry, it’s much more common now to have ventilators connected either to the hospital network or to patient monitors, and also to connect them to remote software” on smartphones, for example, “that allow access to the settings and alarms and monitor data” attached to each ventilator. Increasingly, Van Hise said, workers must keep tabs on that data flow to ensure it’s not disrupted by something as simple as a disconnected cable or a poorly seated module.

“Or maybe it’s that ventilator X is connected to a Cerner EMR, and Cerner changes their software and that next-generation version doesn’t work” for that ventilator. Connectivity problems like this are becoming more and more of an issue, and for biomeds, it’s really opening up a whole new can of worms.”

Looking Forward

Fortunately, thanks to other new and soon-to-arrive advancements in ventilator technology, that can of worms may yet prove manageable. Going forward, Van Hise said, Philips, for one, will be “looking at ways we can make our products more intelligent” and creating “intelligent service plans” around specific devices. Such plans, he explained, would allow “smart messaging” to remind staff that it’s time for preventive maintenance on a specific ventilator, or to warn that if certain actions aren’t taken, a device might fail.

“Probably the biggest change that we’ve seen in ventilators in the last 18 months is around touch-screen interface,” said Paige Krause, global product marketing manager, Life Care Solutions, at GE Healthcare. GE’s latest model is still pending clearance by the FDA for use in the United States, noted Krause, but when it does reach US hospitals, she thinks biomeds will see a noticeable drop in user-issue calls.

“When clinicians look at the screen, they see what they need to see and they’re able to find what they want to find.” The “intuitive” design, Krause added, also makes testing and servicing easier. “You go through that same touch-screen interface, and it only requires one preventive-maintenance session per year.”

Ease of use, and minimal needs when it comes to maintenance and repair, are key factors to consider in any ventilator product, Bonnette noted. His group recently did a study on behalf of a client who asked them to look at both the capital costs and 10-year total cost of ownership for three ventilator models. And what they found, he said, surprised them.

“The total cost of ownership was about the same as the capital cost of each device. And when we broke that down into the operational costs and the maintenance costs, including what you’d pay for PM kits and servicing, it was roughly comparable for all three devices” they researched. Their conclusion? When the time comes to purchase new ventilators, “feel free to look at other factors”—like patient needs and your relationship with vendors—“because you’re not going to see a whole lot of difference in cost.” RT

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Chris Hayhurst is a contributing writer to RT. This article first appeared in 24X7 Magazine. For further information, contact RTmagazine@nullallied360.com.

“With its ease of use, customization capabilities and wireless connectivity, the Lumis series offers important benefits for patients, clinicians, and home medical equipment providers alike,” said Luke Maguire, president of ResMed’s Cardio-Respiratory Care Global Business Unit. “Lumis joins ResMed’s Stellar and Astral lines as a new entry-level option for care providers to efficiently and effectively manage the respiratory stability of their patients.”

The Lumis series comprises the Lumis 100 VPAP S, Lumis 100 VPAP ST and Lumis 150 VPAP ST noninvasive ventilators that support a variety of therapy modes, built-in wireless connectivity, and integrated humidification.

Lumis is compatible with all ResMed Air Solutions accessories, including the popular AirFit mask series, to allow for personalized therapy as well as streamlined home medical equipment inventory management.

Each device features built-in HumidAir heated humidification capabilities and a climate control auto setting, which automatically determines optimal humidification by adjusting to ambient room conditions. Lumis is also compatible with ClimateLineAir Oxy tubing that allows for added oxygen to be heated and humidified, which is useful for patients with COPD.

The Lumis series was designed with connected care capabilities that can improve overall patient care and streamline patient monitoring and therapy management, according to ResMed. Its built-in wireless connectivity means that clinicians and home medical equipment providers have next-day access to a wide range of their patients’ therapy parameters, including blood oxygen saturation when an oximeter is attached. These data, along with therapy statistics and trend data useful for home titration and monitoring, are automatically and securely transmitted to AirView, ResMed’s cloud-based patient management system.

For decades, high-frequency percussive ventilation (HFPV) has found favor with some medical facilities as a viable alternative to conventional ventilation methods.

By Phyllis Hanlon

A 15-year retrospective analysis of International Classification of Diseases, Ninth Revision (ICD-9) indicated that the mortality rate for patients with acute respiratory distress syndrome (ARDS) has decreased by 31%. Increasing use of low tidal volume ventilation and other lung protective strategies could account for the decrease. However, in spite of the lower incidence of mortality, patients who present with ARDS are still at increased risk for a number of adverse effects, one of which is hypoxemia.

Conventional mechanical ventilation approaches may not evoke positive outcomes and, in fact, may cause or exacerbate lung injury. For this reason, high-frequency percussive ventilation (HFPV) has found favor with some medical facilities as a viable alternative to conventional approaches.

HFPV dates back to 1980 when Forrest M. Bird, MD, used this treatment for patients who had suffered burns and/or smoke inhalation with resulting acute respiratory failure. He coined the term “volumetric diffusive respiration” (VDR), which pertains to the ability to percuss the lungs and create “intrapulmonary percussive mixing” with secondary diffusion. VDR increases diffusive oxygen transport into the alveoli and convective carbon dioxide (CO₂) washout from the peripheral airways.

In 2003, researchers in Trieste, Italy outlined the basic principles behind HFPV,¹ a specific mode of high frequency ventilation (HFV). Based on experience, they suggested that HFPV, in combination with conventional mechanical ventilation, could benefit patients with severe respiratory failure. They defined HFPV as “flow-regulated time-cycled ventilation that creates controlled pressure and delivers a series of high frequency subtidal volumes in combination with low frequency breathing cycles.” The authors pointed out that Bird’s VDR is the only system that delivers HFPV.

Nine years later, the same Italian researchers reported findings of a study² that investigated the application of HFPV in patients with acute lung injury/acute respiratory distress syndrome (ALI/ARDS). Thirty-five patients, unresponsive to conventional ventilation after 12 hours, were given HFPV for 12 hours, keeping mean airway pressure consistent. Gas exchange was measured at 12 hours after admission, every four hours during HFPV, one hour at the end of HFPV and 12 hours after HFPV ended. Thirty-five patients on conventional ventilators served as the control.

PaO₂/FiO₂ and the arterial/alveolar oxygen ratio increased during HFPV; a PaO₂/FiO₂ steady state was recorded during the last 12 hours of conventional ventilation. Neither one of these measures changed in the control group. During the first four hours of HFPV, PaCO₂ decreased, but remained unaltered thereafter. The study authors concluded that gas exchange improved, and remained unchanged 12 hours after ending HFPV, in patients who were unresponsive to conventional ventilation.

Moreover, these findings concur with those reported in an article³ published by the American Association of Critical Care Nurses, which stated, “unique gas flow mobilizes significant volumes of pulmonary secretions, further facilitating gas exchange.”

Most recently, University Hospital in Brussels, Belgium issued a retrospective analysis⁴ of critically ill patients with moderate and severe ARDS who were given HFPV. This data analysis evaluated 42 patients, 20 with pneumonia-related ARDS and 22 non-septic ARDS cases, and revealed that within 24 hours HFPV restored normal pH and PaCO₂. Non-septic patients experienced better oxygenation than patients with pneumonia-related ARDS; the latter group also remained on HFPV longer (7.0 vs. 4.9 days; P < 0.05) and also had a higher mortality rate at 30 days than the non-sepsis-related ARDS cases (50% vs. 18%; P = 0.01).

This analysis found that HFPV in moderate and severe ARDS patients resulted in rapid and sustained improvement in oxygenation and ventilation. However, more study is necessary to determine the underlying causes of lower oxygenation improvements and longer ventilator dependency in pneumonia-related ARDS cases versus non-sepsis ARDS patients. RT

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Phyllis Hanlon is a contributing writer to RT. For further information, contact RTmagazine@nullallied360.com.

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References

1. Lucangelo U, Fontanesi L, Antonaglia V et al. “High frequency percussive ventilation (HFPV): Principles and technique.” Minerva Anestesiol 2003;69:841-51.
2. Lucangelo U, Zin WA, Fontanesi L et al. “Early short-term application of high-frequency percussive ventilation improves gas exchange in hypoxemic patients.” Respiration. 2012;84(5):369-76. doi: 10.1159/000334403. Epub 2011 Dec 28.
3. Kunugiyama SK, Schulman CS. “High-frequency percussive ventilation using the VDR-4 ventilator: an effective strategy for patients with refractory hypoxemia.” AACN Adv Crit Care. 2012 Oct-Dec;23(4):370-80. doi. 10.1097/NCI.0b013e31826e9031.
4. Spapen H, Borremans M, Diltoer M et al. “High-frequency percussive ventilation in severe acute respiratory distress syndrome: A single center experience.” J Anaesthesiol Clin Pharmacol. 2014 Jan-Mar; 30(1): 65-70.

Breathe Technologies has announced new research showing that use of its Non-Invasive Open Ventilation (NIOV) System in pulmonary rehabilitation was associated with a notable improvement in mean exercise duration change in patients with chronic respiratory disease. The Breathe NIOV System is an FDA-cleared wearable ventilation system intended for people with respiratory insufficiency. The retrospective case series enrolled seven patients in the test group (with NIOV) and nine in the control group.

The case series is designed to evaluate the effect of a wearable noninvasive open ventilation system in subjects with chronic respiratory disease in a pulmonary rehabilitation (PR) setting. At the end of the 36 visits, the results of the study showed that the mean change in exercise time was significantly higher in the NIOV group versus the control group despite the fact that patients in this group had more severe chronic lung conditions and poorer pulmonary function values at baseline, according to a Breathe Technologies news release.

In addition, patients in the NIOV group were able to exercise almost 5 minutes longer, on average,

Joanne Scasserra, CRT, RPTF, says, “It is well-established that pulmonary rehabilitation programs have been conclusively linked to positive clinical outcomes in dyspnea reduction, increased exercise capacity and reductions in hospitalization, but improvements in physical activity are currently limited by a lack of solutions that can be utilized to promote PR programs within clinical facilities and at home.”

Scasserra add that the NIOV System can be easily integrated in pulmonary rehabilitation programs in a number of patients, adding, “This technology has the potential to improve the current paradigm of respiratory care, through improved exercise outcomes, increased ambulation and empowerment for patients to more fully engage in daily activities.”

Larry Mastrovich, president and CEO of Breathe Technologies, states, “We are excited to see an ongoing trend of positive study results that continue to reinforce the clinical value of NIOV in improving exercise endurance in patients with chronic respiratory insufficiency who might otherwise be sedentary due to their conditions.”

Source: Breathe Technologies

The US FDA has granted 510(k) clearance for the critical care Life2000 Ventilation System by Breathe Technologies, which is intended to provide continuous or intermittent ventilatory support for the care of individuals who require mechanical ventilation, according to a company announcement.

The Life2000 Ventilation System is indicated for adult patients who require positive pressure ventilation delivered invasively (via ET tube) or noninvasively (via mask). The ventilator is suitable for use in home and institutional settings and is intended to be administered by qualified, trained personnel under the direction of a physician, according to Breathe Technologies.

“We are pleased to announce the FDA clearance of the Breathe Technologies Life2000 Ventilation System,” said Larry Mastrovich, president and CEO of Breathe Technologies. “This clearance underscores our commitment to providing healthcare providers and patients with another therapeutic option for critical care ventilation.”

The company anticipates that the device will be commercially available in the United States in late 2015.

The Flight 60, manufactured by Flight Medical and distributed in the US by Maquet Medical Systems USA, is an innovative, versatile ventilator, combining superior performance and comprehensive capabilities. A wall-air independent ventilation solution, Flight 60 is ideal for pediatric and adult patients in an extensive range of care settings. Its design incorporates flexibility and reliability to meet the challenging clinical demands of patient care both within and outside of the hospital. Key features to support patient care goals include invasive and noninvasive modes including B-Lev (Bi-Phasic ventilation, APRV) and Volume Guarantee, hot swappable battery for up to 12 hours of battery operation, and single and dual-limb patient circuit configurations. 888-627-8383; www.maquetusa.com (See image above.)

Available from Covidien, the Puritan Bennett 980 ventilator’s innovative user interface features a highly customizable display with intuitive screen navigation as well as a unique ventilator assurance feature and an integrated expiratory filtration system. Advanced synchrony tools help clinicians set the ventilator to adapt to their patients’ unique needs and help provide the appropriate level of support throughout the breath. 800-635-5267; www.covidien.com/PB980

GE Healthcare’s Carescape R860 Critical Care Ventilator¹ features built-in advanced lung protection tools and a touchscreen user interface. It was designed with a variety of clinicians and users in mind and monitors and displays patient respiratory history and trends on the screen. The R860 also has lung protection tools, including the INview software suite for measuring lung volume and functional residual capacity (FRC), as well as SpiroDynamics. The ventilator also includes nutrition information right on the touchscreen. 800-345-2700; www3.gehealthcare.com/en

ResMed’s life support ventilators, Astral 100 and Astral 150, offer improved mobility and ease of use for patients with neuromuscular disease, COPD, and other breathing disorders. They offer the best battery-to-weight ratio on the market with an eight-hour internal battery and weight of only 3.2 kg, allowing chronically ill patients who would otherwise be hospitalized to be treated safely away from the hospital. 800-424-0737; www.resmed.com

Dräger’s Evita Infinity V500 critical care ventilator is suitable for all patient ranges: neonatal, pediatric, and adult. It offers new concepts in ventilation, such as APRV with auto-release, configurable SmartCare/PS, and variable PS. It’s standardized nomenclature and customizable interface improves workflow and enhances ICU safety. The V500’s ability to provide invasive, noninvasive, and O₂ therapy offers a comprehensive array of therapy to adapt to the patient’s changing requirements. 800-437-2437; www.draeger.com

The Hamilton-C3 mechanical ventilator from Hamilton Medical is a compact high-end ventilation solution for all patient groups. The Hamilton-C3 features a 12.1-in high-resolution display that shows all relevant patient data at a glance. The C3’s compact design and independence from external power and air supplies allow for maximum mobility throughout the hospital. The integrated high-performance turbine guarantees optimal performance even with noninvasive ventilation. The C3 provides an extensive monitoring package with a 72-hour trend function. 800-426-6331; www.hamilton-medical.com

The TXP-2D from International Biomedical is the only high frequency oscillator designed specifically for neonatal transport. Weighing in at 5 lbs, the TXP-2D effectively delivers up to 600 breaths per minute with a MAP of 30 cm H₂O. When combined with the AeroNOx nitric oxide delivery system, the TXP-2D becomes a unique, effective respiratory tool. 512-873-0033; www.int-bio.com

As part of the Hamilton-G5 ventilator from Hamilton Medical, the integrated cuff pressure controller IntelliCuff continuously monitors and automatically adjusts cuffed tracheal and tracheostomy tubes, providing real-time optimization of cuff pressure. The Protective Ventilation (P/V) Tool provides a repeatable method to assess recruitability and find the best PEEP based on respiratory mechanics, as well as providing an easy and repeatable method for performing recruitment maneuvers. The G5 supports transpulmonary pressure measurement and includes the unique intelligent ventilation mode, Adaptive Support Ventilation (ASV). 800-426-6331; www.hamilton-medical.com

The Babylog VN500 from Dräger is a ventilation system designed to meet the unique challenges of the neonatal patient. The Babylog VN500 offers a wide array of neonatal features to minimize lung injury, improve safety, and improve the environment of care for infants to thrive. Accurate tidal volume delivery as low as 2 cm³, measurement and compensation for ET tube leakage, and volume guarantee options ensure proper ventilation and monitoring of the smallest of patients. In addition to conventional ventilation therapies, the Babylog VN500 can provide noninvasive ventilation and O₂ therapy, which can greatly improve the workflow for clinicians. 800-437-2437; www.draeger.com

With the Carescape R860 NICU Ventilator¹ from GE Healthcare, validated to treat the most vulnerable patients, special color-coding distinguishes this NICU option from other ventilators in a fleet. Specialized ventilation modes are included that help transition neonatal patients off of mechanical ventilation. Modes like Volume Support help support spontaneous breathing and nCPAP, which stimulates the baby to breathe and can help prevent intubation. By precisely tailoring ventilation to serve the sensitive needs of neonates, diagnostic therapy capabilities can be expanded. 800-345-2700; www3.gehealthcare.com/en

Editor Note

1. Carescape R860 and Carescape R860 NICU Ventilator from GE Healthcare are 510(k) pending at the US FDA and not available for sale in the US.

During the American Association for Respiratory Care’s (AARC) Summer Forum in July, Draeger Medical Inc provided 10 ventilators to Respiratory Therapy schools. These state of the art devices were raffled off during the education section meeting, which addressed trends related to contemporary RT education, according to the company.

“Providing the latest technology in mechanical ventilation fosters a greater learning experience in the lab setting for RT students, and better prepares graduates for the workforce,” said Ed Coombs, MA, RRT-NPS, ACCS, FAARC, director of marketing for Intensive Care & Neonatal Care, Draeger Medical Inc.

The company is a proud corporate partner of the AARC and offers leading innovations in respiratory care, including advanced ventilation modes, lung recruitment strategies and unique knowledge-based weaning programs, which will help to maintain cost-effectiveness and improve patient outcomes.

Hospitals face enormous challenges attracting qualified respiratory therapists to meet the increasing demands placed on our health care system today. Institutions of higher learning that offer respiratory care education are on the front lines of training the next generation of dedicated respiratory care professionals. Broad training on modern-day mechanical ventilator products is essential to ensuring a new RT graduate is prepared to enter the workforce.

More information about Draeger is available on the company’s website.

RT Magazine’s 2015 Product Guide is now available on our enhanced mobile application for tablets and smartphones.

The guide includes more than 75 respiratory care products from 50 of the industry’s leading manufacturers. The guide is organized by product category, including ventilation, aerosol delivery, oxygen therapy, pulse oximetry, and many more.

To access the FREE tablet and mobile apps, download them via iTunes, Google Play, and Amazon for your Android, Apple, and Kindle devices. 

The apps provide the same reliable, engaging material that readers have come to enjoy in our print editions, but now in a highly interactive, easy-to-read mobile version of the magazine.

Updated graphics, design and functions will take advantage of interactive and web-based features to provide users with a more complete reading experience.

Check out the Product Guide in one of the following formats:

Using nutrition software⁸ equipped on GE Healthcare’s newest ventilator, the Carescape R860, The Jewish Hospital – Mercy Health (TJHMH) (Cincinnati) was able to reduce the amount of time ventilated patients remained in the ICU by 28%, which resulted in a cost savings of nearly $9,000 per patient, according to a study conducted by the hospital. That per patient savings could mean a projected annual savings of over $5 million, TJHMH noted.

The hospital’s ICU is the first in the US to use the Carescape R860, which received FDA approval in June 2015, according to GE.

The device’s software allows clinicians to provide a customized assessment of the patient’s nutritional status, through a respiratory care module. This innovative software on GE Healthcare’s ventilators, along with its corresponding respiratory module, provides measured data on ICU patients’ caloric needs, which clinicians can use to find the right nutritional balance for patients, a key to recovery.

The Importance of Nutrition

Nutrition is a vital factor in every person’s health, so when a patient becomes critically ill, every calorie, vitamin, liquid or lack thereof is significant to recovery.^3,4,5 Today, approximately 40-50% of ICU patients are malnourished,³ which can delay the recovery process and increase time spent in the ICU.

Part of this is because ICU care teams have traditionally used manual estimates, one-size-fits-all equations or bulky machines with high training barriers to assess and deliver nutrients to ICU patients. In fact, this approach is accurate only about 30% of the time.^3,4,5

GE Healthcare’s solution was to build automated nutrition assessment software into the ventilator, the machines these patients are already connected to for breathing assistance. The CARESCAPE R860 uses data to measure the patient’s nutritional needs and provides measured calorimetry, not estimates, back to the care team via a touch-screen with swipe controls. The care team can then use this data to customize nutritional support.

 A Growing Need

The admissions rate to hospital intensive care units (ICU) has increased by nearly 50% over the past six years and with it the cost of critical care.¹ With an aging and an increasingly sicker population driving increases in spending on hospital care, if every hospital in the US were able to apply the same technology, care approach and savings as The Jewish Hospital across those of the 5 million patients admitted to the ICU each year who are ventilated² it’s conceivable the country’s healthcare system could reap astounding savings, according to TJHMH’s press release.

“In hospitals, there’s a strong focus on reducing readmission rates. But in the ICU, length of stay is the measure that matters in determining how effectively we’re caring for our patients,” said Pat Davis-Hagens, Mercy Health Central Market president and CEO of The Jewish Hospital. “We’re proud to be the first in the US to use GE Healthcare’s CARESCAPE R860 ventilators and prouder still to be able to get our patients back to their lives as soon as possible. This real-life case study could pave the way for more hospitals to improve care for their sick ICU patients, while potentially reducing costs and length of stay.”

“The ICU is where the most critically ill patients are cared for and we have a duty to focus more advanced innovations on making an impact in this area. This is the gap we designed the CARESCAPE R860 to fill,” said Thierry Leclercq, President and CEO, GE Healthcare Life Care Solutions. “As a ventilator, it provides lung protection tools intended to help clinicians implement lung protection strategies and help caregivers assess when patients may be ready to breathe on their own. In the complex world of ICU nutrition, it provides calculated data that moves us away from the manual estimates traditionally used in care. The Jewish Hospital demonstrated how advanced technology in the hands of today’s skilled care teams can help solve some of our most complex healthcare challenges.”

References

1. Department of Health Policy, George Washington University School of Public Health and Health Sciences, Washington, DC, USA. http://www.ncbi.nlm.nih.gov/pubmed/23672362
2. Society for Critical Care Medicine: http://www.sccm.org/Communications/Pages/CriticalCareStats.aspx.
3. Souba, W. Nutritional support. N Engl J Med 1997; 336: 41.
4. Malone AM. Nutr Clin Pract. 2002; 17: 21-28.
5. Matarese LE, Gottschlich MM (eds). Contemporary Nutrition Support Practice: A Clinical Guide. 1998: 79-98.
6. Reeves MM. Eur J Clin Nutr. 2003; 57: 1530-1535
7. The American Society for the Surgery of Trauma: http://www.aast.org/GeneralInformation/mechanicalventilation.aspx
8. The CARESCAPE R860 nutrition software works in conjunction with a multi-disciplinary clinical program and only as part of the ventilator and the respiratory gas module

Salter Labs has launched a portfolio of medical products designed for use on babies in neonatal ICUs and pediatric care facilities, according to a company announcement. The company recently debuted the products at both the 2015 National Association of Neonatal Nurses meeting and AARC 2015.

The company has also said it received 510(k) clearance from the FDA for the CPAP Cannulaide Securement Device, the only device cleared by the FDA to enhance the CPAP seal in neonatal nasal CPAP therapy, Salter says.

It’s new line of NICU and pediatric respiratory devices include:

• Neonatal nasal CPAP and oxygen securement devices that protect neonates’ skin and enhance the seal created by CPAP cannulas;
• Endotracheal tubes with polyurethane thin cuffs and flexible tips for easier intubation that lessen the chance of airway trauma;
• Divided capnography cannulas with sizes to fit infants and children of all ages;
• High-performance aerosol nebulizers that may reduce treatment time and hospital admissions; and
• Aerosol masks for inhaler therapy designed based on laser-mapping of babies’ faces for a better, softer fit.

“Babies in the NICU and in children’s hospitals deserve products made just for them. I’m thrilled to see Salter develop products just for babies and children that address their special needs; their products have softer and safer materials, a comfortable fit, and help promote effective and compassionate care,” said Michelle Waddell, RN, BS, RNC-NIC, neonatal clinical consultant.

According to an article published in Respiratory Care, appropriate airway humidification reduced inflammatory responses elicited as a consequence of mechanical ventilation. The animal study also found that humidification reduced damage to the cilia and reduced water loss in the airway.

Researchers sought to better define the relationship between airway humidification and mechanical ventilation-induced lung inflammatory responses.

Using a rabbit model (n=40), researchers divided animals into six groups, including control, “dry gas” (mechanical ventilation for 8 h without humidification), and four experimental groups using humidification during MV at 30, 35, 40, and 45°C.

According to results, dry gas group had increased tumor necrosis factor alpha levels in bronchi alveolar lavage fluid (BALF) compared with control animals but the these levels reached baseline when the humidification temperature was increased to 40°C.

In addition, the study reveals that cilia integrity was maintained in the 40°C groups and humidification at 40°C resulted in reduced pathologic injury.

“Pathology and reduced inflammation observed in animals treated at 40°C was similar to that observed in the control animals, suggesting that appropriate humidification reduced inflammatory responses elicited as a consequence of mechanical ventilation, in addition to reducing damage to the cilia and reducing water loss in the airway,” the researchers concluded.

RT magazine’s annual Buyer’s Guide is now available for 2016. Included in the guide are over 200 company manufacturers and distributors of respiratory, emergency medicine, critical care, and sleep products.

Company Index

An alphabetical listing of all the companies with contact information, including toll-free numbers and website addresses.

Product Index

A comprehensive guide, arranged alphabetically by product category, to the companies that provide products and services to the respiratory care profession.

Brand Names

A reference list of the trade names under which companies manufacture or distribute their products, listed alphabetically.

View the 2016 Buyer’s Guide here. 

The new Alveolar Gas Tutor app is designed to help with ventilator management and critical care medicine.

This medical app focuses on simulating the relationship between respiratory variables and their impact on alveolar ventilation and blood gases. The respiratory variables include respiratory rate, tidal volume, dead space and fraction inspired oxygen (FiO₂). The app allows users to see how partial pressure of oxygen and carbon dioxide are affected depending on changes in respiratory variables.

There are two ways Alveolar Gas Tutor can be used, and there are detailed instructions provided with the app. The first involves users entering values for respiratory rate, tidal volume, dead space and FiO₂ and watching the corresponding changes to the partial pressure of oxygen (PAO₂) and carbon dioxide (PACO₂). For the second method, users enter the AaDO₂ value and look at the changes that occur to the partial pressure oxygen and carbon dioxide at the arterial level. This medical app is designed to be user-friendly and clearly displays the content.

Read the full story at www.imedicalapps.com

Maquet Medical Systems USA has launched two new intensive care ventilators, the Servo-U, and a dedicated neonatal intensive care solution, the Servo-n. The devices received clearance from the US FDA in December 2015.

The ventilators are the result of a comprehensive development process that involved collaboration with intensive care experts from around the world.

Servo-U

According to Maquet, the Servo-U represents the “next step” to making protective ventilation more accessible, understandable and easy to implement. The device can be used on neonates through adults and has a completely touch-based interface that helps clinicians manage ventilation.

The Servo-U is equipped with NAVA (Neurally Adjusted Ventilatory Assist) technology and Edi (electrical diaphragmatic) monitoring for enhanced patient-ventilator interaction and greater insight into patient respiratory condition.

The platform is designed to grow with the customer and can be upgraded easily and cost-effectively, according to Maquet.

Servo-n

Servo-n was created to help clinicians provide vulnerable neonatal and infant patients with the support they need while protecting the lungs, brain, and other developing organs, according to Maquet. The device is both sensitive and responsive in conventional modes of ventilation and compensates for variable leakage.

New hot-wire anemometer flow sensor technology works in conjunction with the internal sensor of the Servo-n to trigger, measure, and deliver the desired pressure levels and tidal volumes down to 2 mL. The device also includes both NAVA and noninvasive NAVA modes as standard. The technologies help clinicians match respiratory support to the often irregular breathing patterns of neonates, resulting in less work of breathing, lower peak pressures and FiO₂ requirements, and improved comfort, Maquet reported.

Both the Servo-U and Servo-n are recipients of the 2015 Medical Design Excellence Award’s (MDEA) Gold Award in the “Critical Care and Emergency Medicine Products” category.

“Servo-U and Servo-n are quintessential Maquet products as each boasts our rich heritage in, and company-wide commitment to innovation in ventilation,” Raoul Quintero, president, Americas, Getinge Group, said in a press release. “Both ventilation platforms will allow us to bring additional, user-friendly support tools to clinicians at a time when care practice optimization is more important than ever. A clinician’s ability to tailor ventilation to individual patient needs, through the intuitive user interface and the system’s advanced capabilities like NAVA, is essential within the critical care environment. We believe that once our customers have tried Servo-U and Servo-n, they will never look at mechanical ventilators in the same way again.”

Intubating patients can be a difficult task, and the practice can prove even more challenging in pre-hospital settings. However, video laryngoscopy has been shown to improve intubation success and is becoming more commonly used.

By Phyllis Hanlon

Paramedics face traumatic situations every day that demand quick action, excellent medical skills, and top-notch training to prevent or reduce the risk of serious injury and/or death. When it comes to intubation, the importance of having access to a device that is portable, durable, and efficient, as well as thorough training, could mean the difference between life and death. In 1993, the American Society of Anesthesiologists (ASA) formed the Difficult Airway Task Force and published its first guidelines to facilitate management of the difficult airway and reduce the risk of adverse effects. Ten years later the guidelines were modified, and in 2013 revisions recommended the use of video laryngoscopy.

Tom McGrail, director, clinical services at Ambu, pointed out that while video laryngoscopy translates well to the respiratory therapy environment, emergency personnel have little experience with the tool. “Paramedics don’t intubate every day like anesthesiologists—who have a variety of training available—do,” he said. “[Paramedics] are likely to be called on to intubate the most severely ill patients. You could call them the worst-case scenarios.”

Practice Makes Perfect

McGrail reported that paramedics in the United States, on average, do one intubation a year. “So how do they get experience? It becomes even more important to get them experience in the operating room or emergency room. But this is becoming more difficult due to rules about having [additional] people in the OR. This is creating a bigger chasm between experienced and nonexperienced paramedics,” he said.

So while training on video laryngoscopy is key, a person’s hand-eye coordination may determine how steep a learning curve will be. “If a person is good with a joystick or excels at CAD drawing, he or she might not have a problem,” McGrail said. Given this situation, some emergency systems and departments recognize the need to address proper training and are taking steps to ensure its personnel are thoroughly prepared.

Take the Montgomery County Hospital District (MCHD) and Cypress Creek EMS (CCEMS) in Texas for instance. Together these entities conducted a study¹ on video laryngoscopy using the King Vision video laryngoscope and six Levitan airway training manikins with different anatomies to reflect real live patients.

Jared L. Cosper, BS, Lic-P, director–EMS, MCHD, and one of the study authors, noted that insufficient volume of intubations, rather than training, prevented staff from becoming proficient with laryngoscopy. “Our former medical director worked in a collaborative manner to develop training content with neighboring agencies and the sponsoring agencies, Southeast Texas Regional Advisory Council and Baylor College of Medicine,” he said. “We focused on both traditional direct laryngoscopy as well as video laryngoscopy using the King Vision device, formal classroom training and frequent training through field supervision.”

MCHD considered two options they felt were suitable for the challenging EMS environment and ultimately chose King Vision because the device had a good camera, reasonable initial deployment and ongoing costs, according to Cosper.  “Also, at the time MCHD deployed video laryngoscopy, the options were quite limited, and King systems had an established reputation,” he said. “Our staff felt that while the other device we considered offered a more traditional laryngoscopy technique, the King Vision device offered the best anatomical view.”

Cosper noted that MCHD employees formally practiced the procedure daily for the better part of a year using the best carbon fiber manikins on the market. “They were well prepared but, as always, any skill on a live patient is different from training,” he said. “I believe, despite our training, our staff had a slight learning curve the first time they used the device on a live patient, to which they quickly adjusted and gained comfort with the skill.”

In the last 20 months, since completing the study, MCHD has used video laryngoscopy 450 times, according to Cosper.

A Better View

McGrail explained that the King Vision features a hyperangulated blade, which allows the user to see anatomy you can’t visualize with a regular-shaped blade. “The challenge with direct laryngoscopy is that you can’t see the airway. The advantage of video laryngoscopy, even if it’s just the blade, is that it allows others in the room to see. The key is a better view.”

Additionally, King Vision’s channeled and standard disposable blades offer options for the user. McGrail noted that the first type directs the placement of the blade while the second requires a stylet for tube delivery. He pointed out that a regular shaped blade does not have a channel and cannot “look around the corner.”

Regardless of which laryngoscope a paramedic uses, blood and secretions often obstruct the view. “This is the Achilles heel of video laryngoscopy,” said McGrail. “Regular video laryngoscopy backup suggests having suction for every intubation.” With a channeled blade in the left hand, the paramedic can suction before and during the procedure with the right hand. “The disadvantage is that the channeled blade takes up more space and the mouth opening is limited. Still, when you advance the tube into position and get the blade in, it’s widely preferred by EMS,” he added. Furthermore, the anti-fog coating on the distal lens of the camera wicks away secretions to help keep a better view.

Video laryngoscopy also edges out direct laryngoscopy when it comes to positioning. Users of the latter tool prefer patients situated on a table, but the former can be used on the ground since the device allows the user to “look around the corner,” according to McGrail. “You don’t have to flex the patient’s head or put the patient in a ‘correct’ position.”

Improved Success Rates

Jeff Jarvis, MD, EMS medical director for Williamson County and Marble Falls Area EMS in Central Texas, conducted a study² that analyzed success per attempt, overall success, first-pass success and performed an intention-to-treat analysis to account for protocol violations before direct laryngoscopy and after implementing training with video laryngoscopy. A total of 514 patients with cardiac arrest and other medical issues, but no difference in age, weight, gender or percentage receiving paralytic medications, comprised the direct and the video laryngoscopy groups. Improvements were noted in all measures in the video laryngoscopy group: overall success (64.9% vs. 91.5%, p < 0.01); first-pass success (43.8% vs. 74.2%, p< 0.01); and success per attempt (44.4% vs. 71.2%, p < 0.01).

Jarvis also produced a training video to help EMS systems with historically low intubation success rates in which he emphasizes that the psychomotor skills used for direct laryngoscopy differ from those used for video laryngoscopy. In the video he demonstrated how to hold the device—at the base where the channel joins the blade—unlike the higher grip used for direct laryngoscopy.

Video laryngoscopy has been around for nearly 15 years, dating back to 2001 when Verathon introduced the GlideScope product line; five years later the company acquired Saturn Biomedical Systems and the GlideScope video laryngoscope brand.

Early clinical trials demonstrated the GlideScope’s ability to provide a superior glottic view when compared with direct laryngoscopy. A 2005 study³ collected data regarding patient demographics and airway characteristics from 728 patients at five Canadian health centers. Both direct laryngoscopy and video laryngoscopy were performed in 133 patients. Findings revealed excellent (C/L 1) or good (C/L 2) laryngeal exposure in 92% and 7% of patients, respectively.

Thirty-five patients had a C/L grade 3 or 4 view with direct laryngoscopy, which improved to a C/L 1 view in 24 patients and a C/L 2 view in three patients. GlideScope achieved successful intubation in 96.3% of patients and provided a comparable or superior view in all cases.

During the last 10 years, GlideScope has added video laryngoscopes for preterm patients and small children to its portfolio and created advanced systems that improve real-time airway views facilitating quicker intubation. Specifically for military and EMS settings, GlideScope created the Ranger, a portable video laryngoscope built to withstand the rigors of extreme field conditions. With blade angulation, a non-glare monitor and anti-fogging mechanism, the Ranger has been awarded US Army “Airworthiness” and US Air Force “Safe-to-Fly” Certifications.

Video and Hands-on Training

Another video laryngoscope that has yielded positive results is the Clarus Video System (CVS), a video-assisted semi-rigid fiberoptic stylet. Researchers from SUNY Upstate Medical University in Syracuse and SUNY University at Buffalo conducted a study⁴ that evaluated the ability of advanced life support (ALS) EMTs to successfully intubate a simulated airway with this system.

Volunteer ALS EMTs watched an eight minute, 22 second video followed by a 10-minute hands-on familiarization period during which the volunteers practiced on a Laerdal Airway Management Trainer manikin situated on the floor to mimic a prehospital scenario. The participants had three attempts with both the CVS and direct laryngoscopy, which were timed from picking up the device to the removal of the stylet from the endotracheal tube. Upon successfully completing the process with one method, the volunteer then attempted the other.

Eighty-one ALS EMTs had a success rate of 95.1% in placing the ETT on the first attempt with direct laryngoscopy and 96.3% with CVS. Median times for total attempts were 15.00 seconds and 14.50 seconds for direct laryngoscopy and CVS, respectively.

Field studies have also shown video laryngoscopy effective in tactical situations. A 2014 study⁵ evaluated the use of video and optical laryngoscopy in a simulated tactical setting, ie, auditory and visual immersion with intubations taking place on the ground and paramedics in full tactical gear. Seven experienced tactical paramedics used each of the laryngoscopes after a one-hour training session on each of four different airway manikins for a total of 84 intubations.

Findings showed the optical and video laryngoscopes had significantly better Cormack-Lehane grades with similar times to ventilation and first-pass success when compared to direct laryngoscopy. Although video laryngoscopy has numerous benefits, no one tool works well under all circumstances, McGrail pointed out. “You have to keep direct laryngoscopy around.” RT

Phyllis Hanlon is a contributing writer to RT. For further information, contact RTmagazine@nullallied360.com.

Reference:

1. Escott MEA, Gleisberg GR, Gillum LS, et al. “Deploying the video laryngoscope into a ground EMS system.” Jems 2014; 34-39. doi: http://www.jems.com/articles/print/volume-39/issue-8/patient-care/deploying-video-laryngoscope-ground-ems.html

2. Jarvis JL, McClure SF, Johns D. “EMS intubation improves with King Vision video laryngoscopy.” Prehosp Emerg Care. 2015 Oct-Dec;19(4):482-9. doi.10.3109/10903127.2015.1005259. Epub 2015 Apr 24.

3. Cooper RM, Pacey JA, Bishop MJ, McCluskey SA. “Early clinical experience with a new videolaryngoscope (GlideScope) in 728 patients.” CanJ. Anaesth. 2005. Feb; 52(2):191-8.

4. Cooney DR, Beaudette C, Clemency BM et al. “Endotracheal intubation with a video-assisted semi-rigid fiberoptic stylet by prehospital providers.” Int J Emerg Med. 2014; 7(1):45. doi: 10.1186/s12245-014-0045-0. eCollection 2014.

5. Yun BJ, Brown CA 3rd, Grazioso CJ, Pozner CN, Raja AS. “Comparison of video, optical and direct laryngoscopy by experienced tactical paramedics.” Prehosp Emerg Care. 2014 Jul-Sep; 18(3):442-5. doi. 10.3109/10903127.2013.864356. EPub 2014 Jan 24.

After successful FDA approval, Hamilton Medical is launching the IntelliCuff pressure controller in the US. Previously available as an option for the ventilator Hamilton-G5, the innovative IntelliCuff technology has now been given its own housing. The ergonomic, handheld device is now available for use with all mechanical ventilators.

The IntelliCuff pressure controller continuously measures and automatically maintains the cuff pressure during mechanical ventilation of adults, pediatrics, and neonates using a cuffed endotracheal tube or tracheostomy.

This handy device ensures an optimal cuff pressure which increases patient safety. It also delivers cost savings and greater efficiency within daily routines in hospitals. It can be used in intensive care units, operating rooms and for inter-hospital transport.

Optimal cuff pressure and patient safety 

The leakage of oral secretions past the endotracheal tube (ETT) is a causative risk factor in the development of ventilator associated pneumonia^1,2 (VAP), and excessive cuff pressure is a risk factor in tracheal injuries.³

Continuously optimized and controlled cuff pressure supports ventilation therapy and protects patients. Hamilton Medical has developed IntelliCuff to make mechanical ventilation more efficient and, above all, safer.

Improved cuff pressure management 

Existing solutions for endotracheal tube cuff pressure management require manual monitoring and adjustment of cuff pressure, which is a critical aspect of the ICU staff workload. It has been shown that up to eight manual adjustments of cuff pressure are required daily to maintain recommended cuff pressure ranges.⁴

The cuff pressure controller of Hamilton Medical permanently maintains and measures the set cuff pressure with two sensors working independently. The device is designed for immediate use; no calibration is required. It operates in a wide but still safe range of desired cuff pressures for various cuffed endotracheal tubes to provide suitable solutions for various clinical situations.

Efficient and reliable support for clinical staff 

In critical situations, clinical staff can increase the cuff pressure for a user-defined period of time to secure the airway and avoid aspiration or unintended extubation; for example, in the event of vomiting, repositioning of the tube, or changes in patient positioning.

Short-duration pressure increases – typical during coughing or retching – are tolerated by the device to maintain the self-sealing functions of high-volume low-pressure cuffs and to avoid needless alarms.

To simplify a safe extubation, the IntelliCuff deflates the cuff on command.

Ergonomic and safe operation 

A large-scale display and convenient interaction buttons make adjusting and verifying settings easy. At all times, the important data is visible supporting an intuitive operation.

IntelliCuff generates an alarm when a leaking cuff or disconnected tubing is detected, as well as in cases of excessive pressure, low battery, or a technical fault. When appropriate, it is also possible to silence some alarms while medical staff remedy the situation.

The IntelliCuff disposable tubing is designed to fit the Luer connector on a variety of cuffed tubes. The shut-off valve prevents loss of cuff pressure in case of an accidental disconnection between the device and the tubing.

References

1. Seegobin RD, van Hasselt GL. Endotracheal cuff pressure and tracheal mucosal blood flow: endoscopic study of effects of four large volume cuffs. Br Med J (Clin Res Ed). 1984 Mar 31;288(6422):965-8.

2. Lorente L, Lecuona M, Jiménez A, Lorenzo L, Roca I, Cabrera J, Llanos C, Mora ML. Continuous endotracheal tube cuff pressure control system protects against ventilatorassociated pneumonia. Crit Care. 2014 Apr 21;18(2):R77.

3. Nseir, Saad, et al. Continuous control of tracheal cuff pressure and microaspiration of gastric contents in critically ill patients. Am J Crit Care 184.9 (2011): 1041-1047.

4. Sole ML, Su X, Talbert S, Penoyer DA, Kalita S, Jimenez E, Ludy JE, Bennett M. Evaluation of an intervention to maintain endotracheal tube cuff pressure within therapeutic range. Am J Crit Care. 2011 Mar;20(2):109-17.

5. Lizy C, Swinnen W, Labeau S, Poelaert J, Vogelaers D, Vandewoude K, Dulhunty J, Blot S. Cuff pressure of endotracheal tubes after changes in body position in critically ill patients treated with mechanical ventilation. Am J Crit Care. 2014 Jan;23(1):e1-8.