Home

LSC: Kingwood Undergraduate Research in Respiratory Care, vol 2

1. Vortran Soft showed peak inhaled flow of 5 8 LPM peak exhaled flow of 7 0 LPM peak airway pressure of 0 4 cmH 0O end exhaled pressure of 0 0 cmH O auto PEEP pressure of 0 0 cm H O and tidal volume of 71 ml When going from Vortran Soft to Hard modes there was a 5 change in peak inhaled flow 1 change in peak exhaled flow 25 change in peak airway pressure 10 change in end exhaled pressure no change in auto peep and 1 change in tidal volume Peak Airway Pressure Percent Change Between High and Low Settings 45 E Peak Airway Pressure Percent Change Between High and Low Settings MetaNeb CPEP No Vortran Soft vs Flow vs 20 cmH2O Hard Graph 1 Peak Airway Pressure Change Between High and Low Settings In Graph 1 there was a 45 change in the peak airway pressure between the no flow setting on the MetaNeb and the high flow or 20 cmH 0 setting There was a 25 change in the peak airway pressure between the Vortran soft and hard settings The MetaNeb had a 20 greater change in the peak airway pressure between settings than the Vortran LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol2 no 2 page 39 End Exhaled Pressure Percent Change Between High and Low Settings E End Exhaled Pressure Percent Change Between High and Low MetaNeb CPEP Vortran Soft vs Settings No Flow vs 20 cmH20O Graph 2 End Exha
2. Figure 1 3 CPEP Volume with 20 cmH O CPEP Volume with 20 cmH O displayed peak inhaled flow of 6 0 LPM peak exhaled flow of 6 8 LPM peak airway pressure of 18 2 cmH O end exhaled pressure of 16 0 cmH O auto PEEP pressure of 0 4 cm H O and tidal volume of 64 ml Figure 1 3 showed that the volume did not return to baseline on high flow but maintained 160 ml of functional residual capacity FRC When moving from CPEP with no Flow amp CPEP Volume with 20 cmH O one saw a 7 change in peak inhaled flow 3 change in peak exhaled flow 45 change in peak airway pressure 160 change in peak exhaled pressure 4 change in auto peep 12 5 change in tidal volume and 160 change in functional residual capacity FRC 8 38 6 15 6 68 6 15 0 306 Figure 2 Pressure Baseline During baseline readings one saw peak inhaled flow of 5 4 LPM peak exhaled flow of 6 9 LPM peak airway pressure of 0 3 cmH O end exhaled pressure of 0 0 cmH O auto PEEP pressure of 0 0 cm H20 and tidal volume of 70 ml ressure CMA Figure 2 1 CPEP Pressure with No Flow LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol 2 no 2 page 36 CPEP Pressure with No Flow showed peak inhaled flow of 5 6 LPM peak exhaled flow of 7 0 LPM peak airway pressure of 0 4 cmH O end exhaled pressure of 0 0 cmH O auto PEEP pressure of 0 0 cm H20 and tidal volume of 72 ml ressure cmH to Figure 2 2 CPEP Pressure High Flow on 20
3. Trial One Trial one was performed with 37 46 grams of synthetic secretions with an average viscosity of 4 09cm sec The lung was ventilated using the BiPAP mode for the duration of trial using settings that would maintain inflation see Table 1 BiPAP was also used throughout the duration of the MetaNeb treatment which was performed according to manufacturer s specifications see Table 2 Treatment was administering for 15 minutes and then the lung was suctioned and returned 3 21 grams of synthetic secretions after instilling 5mL of normal saline see Figure 3 Trial Two Trial two was performed by instilling 38 35 grams of synthetic secretions with an average LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol2 no 2 page 9 viscosity of 4 48 cm sec The lung was ventilated with CPAP throughout the trial with settings that achieved lung inflation see Table 4 and was also used during the MetaNeb treatment The parameters of the ventilator during the MetaNeb treatment can be found in Table 5 After the 15 minute MetaNeb treatment the lung was suctioned and 1 45 grams of synthetic secretions were retrieved see Figure 3 Comparison between Trial One and Trial Two These trials were designed to show the effectiveness of the treatment but proved inconclusive most likely because of some major limitations and other factors The time allotted to conduct these trials limited the research to only
4. Great Value Green Food Color amp Egg Dye 0 25 ounce 0z bottle Size 0 25 ounce 0z bottle Distributed by Wal Mart Stores Inc Bentonville AR 72716 1100 24 40 cubic centimeter cc specimen trap Re Order No 8884 724500 Assembled in Mexico LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol 2 no2 page 17 Manufactured for Sherwood Medical St Louis Length 72 inches in MO 63103 Diameter 3 16 inches in 25 McGaw Sterile Water for Irrigation USP Lot No 0501141 Size 1000 milliliter mL Date 2010 01 Expiration Date 08 02 Manufactured by ConMed Corporation 310 Lot no J9K187 Broad St Utica NY 13501 Manufactured by McGaw Inc Irvine CA 92714 29 Precision Weighing Scale 5895 Model M Prove 26 Inline Suction Catheter Serial No 27355093 Ballard Adult Trach Care T Piece Manufactured by Sartorius AG Weender Landstr Size 14 French 4 6 mm 94 108 37075 Goettingen Germany Length 54cm 30 Contractor s Choice 42 Gallon Contractor Clean up Reference 2205 Bags Manufactured by Ballard Medical Products Size 42 gallon x 12 bag box Draper UT Manufactured by Poly America 2000 West Distributed by Kimberly Clark Global Sales Inc Marshall Drive Grand Prairie Texas 75051 Roswell GA 27 Medical Industries America Inc Portable Suction Machine 120 VAC 60 Hz Serial No 55644 Manufactured by Medical Industries America Inc 26378 289 P1 Adel LA 50003
5. amp Denehyl 2002 Medication aerosolized through an intrapulmonary percussive device results in a smaller particle size of 0 2 micrometers with an increased tidal volume and decreased respiratory rate causing greater deposition of the medication in the lungs when compared to small volume nebulizers of 1 89 micrometers Reychler et al 2004 The background research used in this study was based on previous research of similar IPV systems because there was limited resources on the MetaNeb system This investigation was designed to test the MetaNeb s ability to mobilize secretions in deceased animal lungs thus answering the question Can the MetaNeb effectively mobilize secretions The expectations are that the MetaNeb when applied with proper technique at recommended settings will effectively mobilize secretions in all lung regions hours Inclusion criteria contained that the lungs were appropriately sized for intubation fully intact and the lungs could be harvested from pig calf or LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol 2 no 2 page 4 goat also in addition the lungs needed to be obtained or donated within 12 hours of death Exclusion criteria included anything not the size of a pig calf or goat past 12 hours of death and not intact The animal lungs were thoroughly cleaned inside and out with water and soap prior to starting the experiment The excess tissue which w
6. cuff presure Same strategy used to plot the 7 0 tube cuff pressure graph was implied on the 8 0 tube cuff pressure graph using the data from Table 2 When the time frame was separated for 7 0 tube cuff pressures the percent change in the early stage baseline 60 sec was found to be 65 intermediate stage 90 180 sec was a 3 change and in the late stage 210 300 sec there was a 0 change Percent change for the 8 0 ET tube during the early stage was 25 intermediate stage was 4 and in the late stage there was a 0 change Discussion Previous studies suggest that the time it takes for cuff pressures to stabilize is usually underestimated For example Ben et al observed that the size 7 and size 8 ETT cuff pressures 8 0 ET Tube Cuff Presure 5 cuff presure 0 50 100 150 200 250 300 350 Seconds exceeded 30 cm H O after 3 minutes Their research shows that immediately after the insertion of the size 7 ETT the average pressure was below the suggested range At 30 seconds it rose to within the range of cuff pressures and at 3 minutes it continued to rise above the suggested cuff pressures Immediately after inserting the size 9 ETT the average pressure was below normal at 30 seconds it reached suggested range and at 3 minutes it was above normal range Our results are consistent in that measured cuff pressures exceeded 30 cm HO after 3 minutes Cuff pressures were thus less likely to be within the
7. recommended range 20 30 cm H O if measured before three minutes This result suggests that clinicians should wait at least three minutes post LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol2 no 2 page 29 intubation before performing cuff pressure readings to encourage accuracy A limitation of this study is that ETT cuff pressures were not tested on the human trachea but by substitution of corrugated ventilator tubing artificial trachea Our research showed that the volume of air required to inflate the endotracheal tube cuff did not vary as a function of tube size and type But interestingly the volume required to inflate the cuff to a particular pressure was much smaller when the cuff was inflated inside an artificial trachea Also the inner surface of the 5 inch flex hose is corrugated which is not typical of the human or even animal lung Our research as well as Ben et al found that another drawback of these studies was that the inferior border of the ETT cuff was not exposed to positive pressure ventilation It may also be effective to repeat this experiment with the 5 inch flex hose attached to a rubber test lung The rubber test lung could then be bagged to identify the impact of positive pressure ventilation on these cuff pressures Conclusion As this study was conducted it was shown that ETT cuff pressures took an average of three minutes to stabilize Establishing a secure airway via e
8. 10 0 10 MAN manometer MLT minimal leak technique MOV minimal occluding volume LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol2 no 2 page 20 Weight Weight loss for all three trials ranged from 1 40 g to 2 03 g Mean n 3 weight loss for all three trials was 1 73 g SD 0 316069613 with a median of 1 76 g Trial 1 had the most weight loss with a 2 03 g difference from its pre experiment weight Trial 2 had the least amount of weight loss See Table 2 for all recorded weights for each trial Table 2 Trial 1 Trial 2 Trial 3 MAN MLT MOV Weight of Specimen Trap and Sterile Water Before Tracheal 38 40 40 80 37 71 Lavage g Weight of Specimen Trap and Sterile Water Solution After 36 37 39 40 35 95 Tracheal Lavage g Difference in Weight of Specimen Trap and Sterile Water or Solution Before amp After Tracheal Lavage aus Ve EG g Percent Change 5 29 3 43 4 67 Weights of Specimen Trap and Sterile Water Solution Before and After Tracheal Lavage Visible Characteristics of Sterile Water Solution Figure 1 Sterile Water Solution After Tracheal Lavage for Trials 1 3 1 LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol2 no 2 page 21 Table 3 Descriptions of Sterile Water Solution after Tracheal Lavage Trial 1 MAN Trial 2 MLT Trial 3 MOV Cloudy but still translucent Light pink No visible bubbles foam on surface C
9. 28 Suction Connection Tubing Egg whites were used to represent oropharyngeal secretions for this experiment and were colored using green food dye to increase visibility Viscosity of the dyed egg white solution was tested by placing 2 5 milliliters mL of ambient room temperature solution on one end of a single vertical line drawn on a poster board The vertical line was previously marked in one inch in increments up to a total of 22 inches The poster board was raised to a 45 angle to allow the solution to flow from top to bottom and traveled at a rate of 22 inches in 2 6 seconds Due to the bio hazardous nature of the materials used universal precautions were taken Personal protective equipment worn during the experiment included disposable barrier gowns examination gloves and surgical masks with face shields Three cow tracheae were prepared by first removing the visceral pleura and cutting off the lungs two inches above the carina using a disposable surgical scalpel The tracheae were then washed using regular dishwashing detergent and tap water These were rinsed again to remove any detergent residue The distal ends of each trachea were wrapped with paper napkins and taped to reduce diameter Velcro Sticky Back Loop Fastener Tape was attached 3 inches from the end of each trachea Prior to preparation cow tracheae were removed from three calves and kept on ice in a large ice chest for less than 72 hours A r
10. It was necessary to allow the adjusted waveforms to populate the screen after each change and before the photograph was taken This took approximately 15 seconds It was understood from here forward that this time frame was necessary after each subsequent change before the photograph of the affected waveform could be taken 2 The MetaNeb was attached to the breathing simulator the frequency set on low on the MetaNeb and the waveforms were then photographed 3 The frequency was then changed to high and the waveforms were photographed 4 The mode on the MetaNeb was then changed to continuous positive expiratory pressure CPEP and the waveforms were photographed 5 The mode was then changed to continuous positive expiratory pressure CPEP low no flow and the waveforms were photographed 6 The mode was then changed to continuous positive expiratory pressure CPEP high 19 cmH O and the waveforms were photographed 7 The mode was then changed from continuous positive expiratory pressure CPEP to aerosol on the MetaNeb with the first setting in this mode being low flow The waveforms were then photographed 8 The aerosol mode was then changed from the low flow setting to the high flow setting reaching approximately 20 cm H O and the waveforms was then photographed The MetaNeb unit is a solely contained unit that can be moved around on wheels It is therefore considered stable enough to be attached to the breathing
11. Secretions The synthetic secretions were prepared using six tablespoons of lime gelatin mix which was mixed with one cup of boiling water left to return to room temperature and stirred occasionally with a fork One cup of corn syrup was then added stirred gently with the fork and the mixture was put in a freezer for 30 minutes The mixture was removed from the freezer stirred with a fork and left sitting at room temperature for an additional 30 minutes Two tablespoons of warm water was added and mixed in with a fork before each test to restore the original viscosity Perform Viscosity Test For the viscosity test the foam poster board was marked in centimeters to determine the length of the board This particular board was 51 centimeters long The board was then propped on top of a table with an incline of 30 and a 2x6 clear plastic wrap was placed at the bottom of the board to catch the secretions A batch of synthetic secretions was mixed and 5cc of the secretions were drawn up in a 30cc syringe At the top of the board the secretions were slowly released from the syringe and the stopwatch was started at the same time The trial was repeated once more to get two trial runs for each lung Protocol of experiment Step 1 the lungs were modified by cutting away any excess tissue in order to find an appropriately sized airway to use an endotracheal tube size 8 Step 2 animal lung was set flat on cardboard that was wrapped in
12. Vortran had a peak airway pressure 0 5 cmH O auto PEEP pressure 0 0 cm H O and tidal volume 72 ml on hard In soft mode there was peak pressure of 0 4 cmH O auto PEEP pressure 0 0 cm H O and tidal volume 71 ml Waveforms in both hard and soft modes were similar to the baseline graphs CONCLUSIONS The MetaNeb on the 20 cmH 0 setting resulted in the most increased functional residual capacity FRC However the Vortran running on 50 psig on both hard and soft settings did not raise the FRC Vibration was seen in both devices Background The MetaNeb Comedica Inc Dallas TX is a form of intrapulmonary percussive ventilation IPV that was introduced in August 2010 and was one of many recently developed devices that incorporate high frequency oscillator ventilation MetaNeb was effectively used for the mobilization of secretions lung expansion therapy and the treatment and prevention of atelectasis by combining continuous lung expansion therapy through the delivery of aerosolized nebulized medication continuous positive pressure ventilation and high frequency positive pressure ventilation Barton 2008 Faram 2009 It required a 50 psi gas source circuits that connect to a power box and pressure limits maintained between 15 20 cm H O The MetaNeb offered three different selections consisting of two modes that could both be used with or without aerosol continuous positive expiratory pressure CPEP and continuous hi
13. adaptation me dicale 29 1 25 34 Wilkins R L Stoller J K amp Kacmarek R M 2009 Egan s Fundamentals of Respiratory Care 9th ed St Louis Missouri Mosby Elsevier Addendum 1 Outfit in gown glove mask and goggles 2 Clean cut lung find airway to intubate 3 At same time perform function test for the MetaNeb LSC Kingwood College Journal of Undergraduate Research in Respirato Waveforms to check for effect of bacterial filter MetaNebO by itself iO i cana AN a bh ith it i Hh LP PIRE PIY EEEE E HEEE iin 07 AKG 2012 i NH wW A A O A OAE ah Aan Aa ala Shalt Naan Ng iH iii HF tit DURA DIANA NIREA UP OT el ete ia il UPeTEE LEAL ENGLES ESSER HA ndergraduate Research in Respiratory Care Vol 2 no Prepare lungs place on cardboard Intubate lung lobe alveolar recruitment Place Lung on BiPAP CPAP LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol2 no 2 page 13 Transport to dental hygiene Pretreatment X ray Added normal saline and massaged into lower lung to mimic forceful cough ar aa 7 AP a Post treatment X ray LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol 2 no2 page 14 Personal Protective Equipment Hospital grade gown glove mask and goggles Kitchen shears MetaNeb Manufacturer Hil Rom Address From Manufacturer Singapore Equipment ma
14. and the Rudolph Breathing Simulator measured 20 4 cm H O The EPAP given by the V60 ventilator was 10 cmH O and the EPAP measured by the Rudolph was 10 2 cmH O The peak inspiratory flow measured was 1 9 L min lower LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol2 no 2 page 33 than what was delivered and the measured tidal volume was 11 L min lower than what was delivered Additional Equipment In addition to the respiratory equipment used for this study a Sony brand Cyber shot digital still camera with a 30X optical zoom was used to capture images of various waveforms The camera was placed on a standard camera tripod to maintain stability Patient Set Parameter The set parameters for the Breathing Simulator used in the entire experiment were based on the manufacturer s recommended mean of the normal values According to these recommendations settings included a set airway resistance of 12 cmH O Ips compliance of 35 ml cmH 0O breath rate of 6 bpm amplitude of 5 cmH O effort slope waveform profiles set at 12 percent inhale 30 to create a 1 2 I E ratio and a set target volume of 3000 ml These parameters are from the breathing simulator manual and represent the parameters that would be found in a normal lung 1 The waveforms on the breathing machine were photographed with the preset parameters without any additional machines attached to it This gave us a baseline to compare future waveforms
15. ata daa M i Tlullallot lee Ug Udit a A se UTM IM TUG UU TMU A UI da T EEI Md NU ad I I Ia a a AATni Photograph 3 MetaNeb on Low Flow MetaNeb on Low Flow had a peak inhaled flow of 47 1 LPM peak exhaled flow of 6 9 LPM peak airway pressure of 1 8 cmH O end exhaled pressure of 1 3 cmH O auto PEEP pressure of 11 4 cm H O and a tidal volume of 59 ml Moving from MetaNeb on Low Flow to high showed an 8 3 change in peak inhaled flow no change in peak exhaled flow and peak airway pressure a 30 change in end exhaled pressure a 16 change in auto peep and no change in tidal volume volume tral Figure 1 Baseline Volanie LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol 2 no2 page 35 The baseline graphs had a peak inhaled flow of 5 4 LPM peak exhaled flow of 6 9 LPM peak airway pressure of 0 3 cmH O end exhaled pressure of 0 0 cmH O auto PEEP pressure of 0 0 cm H O and tidal volume of 70 ml Volume tml CE HH Figure 1 2 CPEP with no Flow During CPEP without flow one saw peak inhaled flow of 5 6 LPM peak exhaled flow of 7 0 LPM peak airway pressure of 0 4 cmH O end exhaled pressure of 0 0 cmH O auto PEEP pressure of 0 0 cm H20 and tidal volume of 72 ml AINT WHN i i ET HII j ji
16. endotracheal tubes cuff mean pressure n 3 was 24 0 cm H 0 SD 2 00 at 30 seconds the mean pressure was 32 67 cm H 0 SD 3 05 at 150 seconds the mean pressure was 33 33 cm H 0 SD 3 05 and at 300 seconds the mean pressure was 34 33 cm SD 3 51 Immediately after submersion the size 8 endotracheal tubes mean pressure n 3 was 22 67 cm H 0 SD 1 15 at 30 seconds the mean pressure was 24 67 cm H 0 SD 1 15 at 150 seconds the mean pressure was 26 67 cm H 0 SD 1 15 and at 300 seconds the mean was calculated to be 28 67 cm H 0 SD 1 15 Conclusion As this study was conducted it was shown that ETT cuff pressure took an average of three minutes to stabilize Background Approximately 900 years have passed to be a cause of concern Irreversible damage to the between the first intubation and the development of a cuffed endotracheal tube Bouvier 1981 The Arabian doctor Avicenna 980 1037 described the first use of orotracheal intubation in dyspnea Bouvier 1981 The history of oral endotracheal intubation actually began in the 18th century At that time obstetricians and lifesavers used breathing tubes Bouvier 1981 Regular oral intubation to keep the respiratory tract clear during narcosis was first applied by Franz Kuhn in 1900 unfortunately the pioneer himself did not live to see his method become a routine procedure In 1928 Ralph M Waters M D and Arthur E Guedel M D introduced an adult endotracheal tube wit
17. from falling below the cuff during ventilation The minimal leak technique was determined to be the least effective cuff management technique CONCLUSION Using a manometer to manage cuff pressure prevented the most simulated secretions from falling below the cuff of a well lubricated ET tube during ventilation Keywords manometer minimal leak technique minimal occluding volume ventilator associated pneumonia lubrication cuff pressure Background When a patient is unable to maintain or protect the upper airway mechanical ventilation is often required The initial airway used for mechanical ventilation is an appropriately sized endotracheal ET tube which consists of a 15 mm adapter polyvinyl chloride PVC tube permanently bonded cuff small filling tube and a pilot balloon Wilkins Stoller amp Kacmarek Fundamentals of Respiratory Care 2009 The purpose of the cuff is to prevent the transfer of secretions from the upper airway into the lower airway and to allow positive pressure ventilation to be administered to the patient Cuff status and pressure are managed and adjusted using the pilot balloon Artificial airway cuff pressure is recommended to be within the range of 20 30 centimeters of water cm H20 Howard 2011 Higher cuff pressures can cause damage to the tracheal tissue such as necrosis stenosis or tracheomalacia Lower cuff pressures can cause secretions from the oral cavity and upper airway to migrate belo
18. of the ongoing requirements of LSC Kingwood Associate in Applied Science Degree includes participation in the creation of this magazine for RSPT 2243 Research in Respiratory Care Students formed teams that designed research projects for application during the semester Some of the requirements of this course were membership in a weekly journal club of current articles from AARC s Journal of Respiratory Care as well as active participation in writing the four papers in our journal based on their independent research Students were also expected to provide peer review of other teams papers The summer 2012 editing board consisted of the following Jovanna Mejia S R T Anna Dunahoe S R T Joyce Bukut SRT Jennifer McMurtrey SRT Shaun Jones SRT Darshane L Miller SRT April Anderson B S S R T Ray Managbanag B S S R T Frederick Johnson B S L C C A S R T Kimberly Gonzalez L V N S R T Ana Vela S R T Juanita Robinson S R T and Stella Ekewenu S R T Jennifer Hua S R T Kim Frie S R T Cynthia Young S R T and Julissa Webb S R T All research this semester was in the form of bench studies Half the class concentrated on exploring the Metaneb IPV machine our program acquired this year One team collected flow volume and pressure graphics on the Metaneb in various modes then compared these graphs to those created by the Vortran IPV machine Another group filled a cadaver cow lung with artificial secretions then att
19. on 8 0 mm ET tube Secured ET tube to ramp using Velcro Sticky Back tape Inflated cuff with a 10 milliliter mL disposable syringe until trachea expansion can be seen from the outside of the trachea Attached a manometer to the pilot balloon of the ET tube and adjusted cuff pressure to 120 centimeters of water cm H20 pressure Connected flow inflating anesthesia breathing bag to wall oxygen source and set flowmeter to 15 liters per minute lpm An antimicrobial filter was attached to the end of the resuscitation bag to protect equipment Anesthesia breathing bag was tested for leaks by placing a gloved hand over the open end of the antimicrobial filter and allowing the bag to inflate After testing the bag it and the filter were connected to the ET tube at the patient port 10 Injected 2 5 milliliter mL of room temperature dyed egg white solution into trachea above the cuff using a 10 milliliter mL disposable syringe 11 Pumped anesthesia breathing bag at a rate of 20 times per minute to simulate breathing 12 While manual ventilation took place a specimen trap containing 10 milliliters mL of sterile water was weighed on a calibrated scale The sterile water was then removed from the specimen trap using a 10 milliliter mL disposable syringe The empty specimen trap was connected to an inline suction catheter and a portable suction device After three minutes of manual ventilation the anesthesia breathing bag and f
20. on the MetaNeb and the Vortran Conclusion The purpose of this study was to compare the waveforms created during the three different modes of operation of the MetaNeb and compare them to the waveforms created by the Vortran Percussive Neb to determine if there are similarities between IPV interpulmonary percussive ventilation devices We hypothesized that the waveforms produced during the three different modes of operation of the MetaNeb would be the same as those produced by similar IPV devices We discovered that two of the three MetaNeb modes were actually not comparable to the one mode of the Vortran We were able to compare the no flow and 20 cmH O settings of the CPEP mode on the MetaNeb to the soft and hard settings on the Vortran What we found was that the MetaNeb provided a greater end exhaled pressure than the Vortran as well as higher peak airway pressure The most significant finding of our study was the MetaNeb on the 20 cmH O setting resulting in a sustained functional residual capacity This is significant because it could benefit patients in need of alveolar recruitment This form of air trapping would maintain alveolar expansion while still allowing ventilation on top of this FRC The Vortran on the high setting which is comparable to the MetaNeb 20 cmH O setting did not retain any FRC but returned to baseline However this poor result may be the result of not using the recommende
21. thank Maribeth Stitt RDH Med program director of the LSC Kingwood College dental hygiene department who x rayed the lungs We thank the Garza Meat Processing Plant for donation of the cow lungs Once again LSC Kingwood s Graphic department lead by Shawn Sedoff provided a talented student graphic designer via their annual Design A Thon The student graphic designer Dominic Zotti managed in spite of my rather contradictory instructions to design two wonderful covers for both 2012 volumes based on airway morphology and electron microscope views of the alveoli As always we thank Kenny McCowen program director for his foresight in creating the course and his continued support of this Associate degree research class as it moves closer to a second decade of existence Elizabeth Kelley Bushee AAS RRT NPS REP LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol 2 no 2 page 3 Airway Clearance The Effectiveness of the MetaNebo using Two Cadaver Cow Lungs Jovanna Mejia SRT Anna Dunahoe SRT Joyce Bukut SRT Jennifer McMurtrey SRT Shaun Jones SRT Faculty facilitator Elizabeth Kelley Buzbee A A S R R T N P S R C P Abstract INTRODUCTION The MetaNeb a version of intrapulmonary percussion ventilation is designed to increase the mucociliary clearance improve gas exchange humidify the airway stabilize airway patency and improve the lung mechanics OBJECTIVE To mobilize secretions from all lobes of
22. the lungs with the use of the MetaNeb machine METHODS Artificial secretions were verified for mobility in both trials Conducted two trials one cow cadaver lung was intubated and placed on Bi level Positive airway Pressure mode and 30cc of synthetic secretions was instilled followed by positive pressure to send secretions into the lung The lung was x rayed After 15 minutes on MetaNeb at manufacturer s recommended treatment settings secretions were suctioned into sputum trap and the lung was x rayed The other lung was placed on Continuous Positive airway Pressure mode and metal shavings were added to the secretion Lung was x rayed After 15 minutes on MetaNeb secretions were suctioned and x ray repeated Volumes and weights of secretions obtained with both methods were recorded RESULTS 3 21grams of secretions were removed from the lung on bi level positive airway pressure 1 45 grams were removed on continuous positive airway pressure CONCLUSION Significantly more secretions were removed from the lung during bi level positive airway pressure than from continuous positive airway pressure The total amount of secretions instilled was not recovered possibly due to the evaporation or absorption of the synthetic secretions into the lung tissue Background The MetaNebO was a version of intrapulmonary percussive ventilation IPV The first form of IPV the Percussionaire was generation the MetaNeb device delivers rapid miniburst
23. the cuff pressure is too low To prevent aspiration during positive pressure ventilation pressure must be approximately 27cm H O Aspiration has been shown to occur with intracuff pressures of approximately 20 cm H O Stewart et al 2003 Underinflation of the endotracheal tube cuff is associated with inadequate delivery of prescribed tidal volume and aspiration of secretions When the cuff pressure was maintained at less than 20 cm HO the risk for ventilator associated pneumonia VAP was 4 times higher than when pressure was maintained at higher values Ben Cooper Drummond amp Morello 2012 In the trachea capillary blood flow becomes obstructed when the pressure in an endotracheal tube cuff exceeds the capillary perfusion pressure of the tracheal mucosa Reports suggest that 25 cm HO is a safe pressure although the precise pressure at LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol 2 no 2 page 25 which capillary perfusion is impaired certainly will vary from patient to patient Bouvier 1981 The acceptable cuff pressures range from 25 to 30 mmHg which equates to 20 to 25 cmH O Stewart et al 2003 The precise pressure at which any individual will experience impaired or obstructed tracheal mucosal blood flow will depend upon numerous factors most important their blood pressure Bouvier 1981 Standardized instruments to measure cuff pressures might help decrease the possibility of injur
24. thousandths would provide more accurate results especially when comparing using a manometer and minimal occluding volume Despite manipulation of the tracheae they were too big for the 8 5 mm and 9 0 mm tubes used for the experiment This required cuff pressures to be higher than the normal 20 30 centimeters of water cm H O range in order to ensure a good cuff seal against tracheal wall Using a pressure of 120 cm H O in a human would cause tracheal damage Conclusion This research demonstrated that using a manometer to manage cuff pressure was the most effective technique in preventing oropharyngeal secretions from falling below the cuff of a well lubricated ET tube The minimal leak technique had the most dyed egg white solution fall below the cuff and proved to be the least effective in the prevention of VAP It is suggested that this technique be discontinued in patient care because more proficient methods are available Future studies on this topic should explore how ineffective manometer cleaning in between patients affects the prevalence of VAP when compared to the other techniques using a disposable syringe LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol 2 no 2 page 23 References Blunt M C Young P J Patil A amp Haddock A 2001 Gel Lubrication of the Tracheal Tube Cuff Reduces Pulmonary Aspiration Anesthesiology 95 2 377 381 Deem S amp Treggiari M M 201
25. two trials instead of the ideal three trials Also the two trials that were performed were using two different modes of ventilation These two trials returned different amounts of secretions Figure 4 shows the two trials compared in percentage The researchers found it interesting that BiPAP returned more secretions than CPAP mode This requires further investigated During the first trial it was believed that BiPAP was necessary to maintain cadaver lung inflation however during the second trial it was discovered that CPAP could be used to maintain the same inflation if lung recruitment maneuver was performed prior to placing lungs on CPAP The x rays taken during the two trials did not indicate any change in secretions however the x ray was taken with dental equipment which limited to clarity and quality Another factor that may have affected the trials is evaporation or absorption of the synthetic secretions into the lung tissue researchers believed that the absorption or evaporation could have been changed by heating and humidifying the ventilator circuit Limitations Due to the fact that the lung being used was not a viable lung there was no cilia activity and muscle action which caused may have limited clearance of the airways The lung was not at body temperature it possibly affected the delivered volumes When ventilating the lung positive pressure was used instead of negative pressure to allow the lung to stay inflated when ex
26. 0 New Endotracheal Tubes Designed to Prevent Ventilator Associated Pneumonia Do They Make a Difference Respiratory Care 55 8 1046 1055 Howard W R 2011 Bench Study of a New Device to Display and Maintain Stable Artificial Airway Cuff Pressure Respiratory Care 56 10 1506 1513 O Keefe McCarthy S Santiago C amp Lau G 2008 Ventilator Associated Pneumonia Bundled Strategies An Evidence Based Practice Worldviews on Evidence Based Nursing 193 204 Wilkins R L Stoller J K amp Kacmarek R M 2009 Fundamentals of Respiratory Care Ninth ed D C Shelledy amp L Kester Eds St Louis Missouri USA Mosby Elsevier Bench Study Time Needed for Cuff Pressure Stabilization At Body Temperature After Intubation Kimberly Gonzalez L V N S R T Ana Vela S R T Juanita Robinson S R T and Stella Ekewenu S R T Faculty facilitator Elizabeth Kelley Buzbee A A S R R T N P S R C P Abstract BACKGROUND The purpose of this study is to determine the time it would take for cuff pressure to stabilize once the cuff is subjected to body temperature OBJECTIVE To determine how many minutes for the cuff pressures to increase after intubation METHOD Inflate size 7mm endotracheal tube and size 8mm endotracheal tube with 8 ml of air and place in 37 degree Celsius water bath Check and record cuff pressure immediately at 30 second intervals for 5 minutes RESULTS Immediately after submersion the size 7
27. 1 findings were evaluated The same procedure was repeated with the other lung except this lung was kept on CPAP as the secretions were being inserted and metal aluminum pieces were inserted All equipment was kept clean between each experiment per manufacturer s instructions The setup used for the procedure ET tube in line suction catheter sputum trap suction tubing bacteria filter T piece adapter MetaNeb corrugated tubing BiPAP CPAP Results Trial One Viscosity test measured in cm per second to demonstrate how fast A viscosity test was performed on lung one the secretions moved For the calculation of speed at to show that the secretions were mobile Two trials which the secretions traveled the equation distance were performed using 5mL of secretion that traveled divided by time was utilized The mean speed was 51 centimeters cm the mean time for both trials 4 09 cm second SD 0 163 cm sec was 12 45 seconds SD 49 sec The test was Table 1 LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol 2 no2 page 6 Initial settings BiPAP EPA DemHO TRAP 40 cmH RR 20 21 157 mL Table 1 illustrates the initial settings used when the lung was placed on BiPAP Table 2 Ventilator parameters during treatment Airway Clearance CHFO amp Lung Expansion CPEP IPAP cmH 0 36 cmH 0 Respiratory Rate 20 bpm 20 bpm O02 21 21 1218 mL EA 24 4 L min Table 2 shows the ventil
28. 2 no 2 page 37 After moving between CPEP no Flow and CPEP with High Flow with 20 cmH O one saw a 7 change in peak inhaled flow 3 change in peak exhaled flow 45 change in peak airway pressure 160 change in peak exhaled pressure 4 change in auto peep and 12 5 change in tidal volume Vortran olu ae rll Max Toe Min gt Diff sini HHT UA MVE A GA E r AAMU Figure 4 Volume I Baseline During baseline readings before Vortran was attached one saw peak inhaled flow of 5 4 LPM peak exhaled flow of 6 9 LPM peak airway pressure of 0 3 cmH O end exhaled pressure of 0 0 cmH O auto PEEP acco of 0 0 cm mee and tidal volume of 70 ml ae cn sn il i ccc ce IDE pat EE mi i gt N e E ULKI fo TT e e K Ul YT i a ce Figure 4 1 Vortran Hard Volumes st pesenane aS Vortran Hard mode showed peak inhaled flow of 6 1 LPM peak exhaled flow of 7 1 LPM peak airway pressure of 0 5 cmH O end exhaled pressure of 0 1 cmH O auto PEEP pressure of 0 0 cm HO and tidal volume of 72 ml ara o Sr all in dit a a re a Figure 4 2 Vortran Soft Volume Vortran Soft showed peak inhaled flow of 5 8 LPM peak exhaled flow of 7 0 LPM peak airway pressure of 0 4 cmH 0O end exhaled pressure of 0 0 cmH O auto PEEP pressure of 0 0 cm H O and tidal vol
29. Data collected from Word allowing us to create tables to substantiate the research trials were entered in MS Excel to pressure change as time elapsed MS Excel was compute mean range percentage change median utilized to generate graphs exhibiting the change in and standard deviation LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol 2 no 2 page 27 Results Table 1 7 0 ETT Trial 1 Trial 2 Trial 3 Time seconds Pressure cmH 0 Pressure cmH O Pressure cmH O 20 cmH O 26 cmH O 20 cmH O 24 cmH O 20 cmH O 22 cmH O Baseline Immediately after submerging 30 36 cmH O 32 cmH O 30 cmH O 6 36 cmH O 34cmH O 30 cmH O 0 120 36 cmH O 34cmH O 30 cmH O Immediately after submersion it was found that the mean pressure n 3 was 24 0 cm H2O SD 2 00 at 30 seconds the mean pressure was 32 67 cm H2O SD 3 05 at 150 seconds the mean average pressure was 33 33 cm H2O SD 3 05 and at 300 Table 2 8 0 ETT seconds the mean pressure was calculated to be 34 33 cm H2O SD 3 51 The range of pressure was 30 to 38 cm H O The percentage change between the initial cuff pressure and the final cuff pressure of trial 1 was 90 trial 2 was 70 and trial 3 was 55 Trial 1 Trial 2 Trial 3 Time seconds Pressure cmH O Pressure cmH O Pressure cmH O Baseline Immediately after submerging 20 cmH O 22 cmH O 20 cmH O 24 cmH O 20 cmH O 22 cmH O 26 cmH O 28cmH O 26 cmH
30. LONE STA COLLEG N KINGWO OD eat i College Jonfaal he Undergraduate Research in Respirator Care oe kry ar a a ate i T NS A journal for both independent clinical aa research and bench studies in the field qe of respiratory care Pgh _ class of Lone Star College Kingwood ny Associate Degree respiratory care X department Table of contents Editor s COMMENUS 0 ccc ccc ccc cece cence eee encenceeccenceeceeneeneeneeneeeeenuees 3 Airway Clearance The Effectiveness of the MetaNebo using Two Cadaver Cow Lungs Jovanna Mejia SRT Anna Dunahoe SRT Joyce Bukut SRT Jennifer McMurtrey SRT Shaun Jones Addendum to alr way Clearance 274002 hesenacocieiah aiacne idee aenasaiaeseanneiem inal 1 Bench Study Comparison of Cuff Management Techniques in the Prevention of Ventilator Associated Pneumonia Darshane L Miller SRT April Anderson BS SRT Ray Managbanag BS SRT and Frederick Johnson BS LCCA Bench Study Time Needed for Cuff Pressure Stabilization At Body Temperature After Intubation Kimberly Gonzalez L V N S R T Ana Vela S R T Juanita Robinson S R T and Stella BE hs IR tet et cee as ese eee ro en ee eee matte amebe kee aus 25 Waveform Comparisons The MetaNeb and Vortran Jennifer Hua SRT Kim Frie SRT Cynthia Young SRT Julissa Webb LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol 2 no 2 page 2 Editor in chief comments One
31. O 28 cmH O 30cmH O 28 cmH O 28 cmH O 30cmH O 28 cmH O 30 60 90 120 180 210 240 70 2 28 cmH O 30cmH O 28 cmH O 300 28 cmH O The same sequence and time intervals previously used for Table were incorporated to calculate data for Table 2 After submersion the mean pressure n 3 was 22 67 cm H O SD 1 15 at 30cmH O 28 cmH O 30 seconds the mean pressure was 24 67 cm H20 SD 1 15 at 150 seconds the mean pressure was 26 67 cm HO SD 1 15 and at 300 seconds the mean was calculated to be 28 67 cm H O SD 1 15 The range LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol2 no 2 page 28 of pressure was 24 to 30 cm H O The percentage change between the initial cuff pressure and the final The three trials were performed on ETT size 7 0 mm and 8 0 mm at a temperature of 37 degree Celsius a baseline pressure of 20 cmH O and a volume of 8 cc s of air 7 0 ET Tube Cuff Pressure 40 35 30 25 4 20 15 10 0 T T T T T T 0 50 100 150 200 250 300 1 350 Seconds cuff pressure of trial 1 was 40 trial 2 was 50 and trial 3 was 40 Cuff pressures presented for each trial on Table I n 3 were averaged based on 30 second intervals starting immediately after submersion The average plotted on the 7 0 and 8 0 tube cuff pressure graphs in order to demonstrate the cuff pressure changes once the ETT is exposed to body temperature
32. Stainless Combination Square 15 PDI Sterile Lubricating Jelly Size 5 0 grams g 0 17 ounce 0z packets Manufactured by Professional Disposables International Inc Orangeburg NY 10962 16 Parker Flex Tip PFHV High Volume Low Pressure Cuff Tracheal Tube Cuffed Size 8 5 millimeter mm and 9 0 millimeter mm Cat no 86453 Lot no 090300 0686 Date 2010 05 Manufactured by Well Lead Medical Guangzhou China Manufactured for Parker Medical 7275 S Revere Pkwy Suite 804 Englewood CO 80112 17 10 milliliter mL Disposable Syringes Model 10mL Luer Lock Tip Lot no 070823 Manufactured by Exelint International Co 5840 W Centinela Ave Los Angeles CA 90045 18 Posey Cufflator Endotracheal Tube Inflator and Manometer Manufactured by J T Posey Company 5635 Peck Road Arcadia CA 91006 0020 19 Bag and Peep Valve Anesthesia Breathing Bag Lot no 97272 6494 Cat no N7905 Manufactured by Owens Brigam Medical Newland NC Description 0 5 Liter L hyperinflation set hyperinflation elbow with plug 84 inch in star lumen tubing with connectors 20 Precision Medical Flowmeter 0 15LPM Model IMFA Manufactured by Precision Medical 300 Held Drive Northhampton PA 18067 21 MicroGard Microbial Filter Manufactured by CareFusion 22745 Savi Ranch Pkwy Yorba Linda CA 92887 22 Crystal Farms AllWhites 100 Liquid Egg Whites Size 32 ounce 0z carton Manufactured by Crystal Farms a Michael Foods Company 23
33. ached the Metaneb in an attempt to mobilize secretions The other foci of LSC Kingwood College Respiratory Care Department s investigation included bench studies of endotracheal tubes One team measured the time it took for cuff pressures to stabilize at body temperature while another team compared various methods of endotracheal cuff inflation and their ability to prevent material from above the cuff to contaminate the lower airways in a cadaver cow trachea This year found several Kingwood College respiratory care research teams using cadaver cow lung donated by a local meat processing plant Due to the extremely large trachea of the cows and the not quite human anatomy of these lungs the team had their work cut out for them just finding a central airway that would fit the human sized endotracheal tubes The first team to dissect their cow lungs forged the trail for the rest of the teams Isolating appropriate airways and working with fresh tissue that has not been preserved was more time consuming than anyone expected The program facilitator learned that kitchen shears are not only faster than scalpels on lung tissue but safer Although the tissue was from cattle deemed safe for human consumption great efforts were taken to utilize personal protective gear and dispose of the material after This was to my mind one of the most frustrating and yet most enjoyable research classes I ve ever conducted We would like to take this occasion to
34. amining under x ray This allowed the lung to dry out causing the secretions that were inserted in the lung to be absorbed and or evaporated The purpose of the MetaNeb is to mobilize the secretions from the upper airways the cow lung trachea was too large for a human endotracheal tube therefore smaller airways were intubated in both trials the MetaNeb is made to mobilize secretions in the central airways and the area distal to the endotracheal tube that was placed was more peripheral than if the cow lung had been intubated in the tracheal Conclusion The MetaNeb is still a new product that may be an effective means of mobilizing secretions but there is little literature about it and it should be further studied to assess the effectiveness The researchers believed that the MetaNeb would mobilize secretions from all lung regions but the results of these trials do not support this hypothesis Researchers were surprised by the minimal amount of secretions that were returned leading the researchers to believe that the trials were hindered by possible evaporation and absorption of the synthetic secretions it would be interesting to study this further Other possible research stemming from questions that arose in these trials is to study the possible effect that heating and humidifying the ventilator circuit would have on secretion mobilization in patients with secretion buildup References Berney S amp Denehyl L 2002 A com
35. amp was used to simulate a patient s bed set at a 45 angle It was created by covering an illustration board with aluminum foil and taping it to a manila paper covered large cardboard box A 12 inch Stainless Combination Square was used to ensure the ramp was set at a 45 angle Four inch strips of Velcro Sticky Back Hook Fastener Tape were placed 8 inches apart along the top of the ramp LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol 2 no2 page 18 The scale used for this experiment was not calibrated but was zeroed prior to each use by clearing the base plate and pressing the Zero button located in the lower right hand corner Word Statistics Microsoft Excel was used to compile data for this experiment Tables were created using Microsoft Procedure The following steps were taken to test Trial 1 Using a Manometer to Manage Cuff Pressure Trial 1 PANT A 13 14 15 16 17 Attached disposable examination glove on the distal end of cow trachea with rubber band Secured cow trachea to ramp using Velcro Sticky Back tape with proximal end pointing upward Liberally squeezed 1 packet of lubricating jelly onto the outside of the ET tube cuff Inserted lubricated ET tube into the distal end of the calf trachea up to the point where the edge of the trachea was between Parker and Medical on the ET tube 12 cm on 9 0 mm ET tube and 11 5 cm
36. ator setting during the treatment while the lung was attached to the MetNeb during CHFO and CPEP The ventilator setting during the treatment was attached to the MetNeb CPEP which was set on lung expansion Figure X rays Lung One Pretreatment X Ray Post treatment X Ray Trial Two Viscosity test meter per second to demonstrate how fast the A viscosity test was performed on lung two secretions moved Speed was derived from the to show that the secretions were mobile and constant equation distance divided by time The mean speed Two trials were performed using 5mL of secretion was 4 48cm second SD 0 278 cm sec that traveled 51cm the mean time for both trials was 11 40 seconds SD 70 sec The test was measured Table 3 LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol2 no 2 page 7 Initial setting CPAP 17 L min 0 21 18 mL 17 0 L min Table 3 illustrates the initial settings used when the lung was placed on CPAP Table 4 Ventilator parameters during treatment Airway Clearance CHFO amp Lung Expansion CPEP Parameters CFO CREP CPAP 25S emH200 Sem Patient Leak 0 s17 L min 17 L min Respiratory Rate O bpm 0 bpm pO 21 We 3387 ml 3387 mL PIP 43 cmH 43 cmH O VE 11 L min 24 4 L min Table 4 shows the ventilator setting during the treatment while the lung was attached to the MetNeb while on CHFO and CPEP Figure 2 X ray Lung Two Pr
37. ause of the similar nature of these two oscillatory modes The MetaNeb baseline waveform and the CPEP low flow setting showed no auto PEEP The MetaNeb CPEP setting with high flow pressure kept at 20 cmH O showed an increase of 160 mL of functional residual capacity One of the more significant findings of this study was the change in the peak airway pressure between settings in the comparable modes of the MetaNeb and the Vortran The MetaNeb showed a 45 change in the peak airway pressure from no flow to 20 cmH O The Vortran showed a 25 change in peak airway pressure between the soft and hard setting This is also the setting where the FRC was noted on the MetaNeb Another notable variance between the MetaNeb and the Vortran was in the end exhaled pressure There was a 160 change in the end exhaled pressure when the MetaNeb was switched from no flow to 20 cmH O The Votran only exhibited a 10 change when it was switched from the soft to hard setting This would show that the MetaNeb has a much greater continuous positive expiratory pressure than the Vortran Limitations Although this study demonstrated that there were similar waveforms produced by the MetaNeb and the Vortran there were also some differences Some of these differences may be attributed to the limitations of our study The manufacturer of the Vortran recommends that it be used with its own 80 psig compressor The 80 psig compressor was
38. ce 2205 Manufactured by Ballard Medical Products Draper UT Distributed by Kimberly Clark Global Sales Inc Roswell GA Sputum trap Sherwood medical Address given St Louis MO 63103 USA Assembled in Mexico Re Order No 8884 724500 074 0490 40cc or ml LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol 2 no 2 page 15 Bench Study Comparison of Cuff Management Techniques in the Prevention of Ventilator Associated Pneumonia Darshane L Miller SRT April Anderson BS SRT Ray Managbanag BS SRT and Frederick Johnson BS LCCA SRT Abstract PURPOSE This research compared current cuff management techniques to determine which was most effective in the prevention of ventilator associated pneumonia OBJECTIVE To determine if using a manometer will prevent the most amount of simulated oronphrynegeal secretions from falling below the cuff of a well lubricated ET tube METHODS Each cuff management technique was performed once using 8 5 mm and 9 0 mm lubricated endotracheal tubes inserted into the tracheae of cow cadavers Dyed egg white solution was placed above the cuff A tracheal lavage was performed after three minutes of manual ventilation to determine the amount of dyed egg white solution that fell below the cuff after ventilation RESULTS Based on volume weight and color changes the trial using a manometer to manage cuff pressure was the most effective technique in preventing simulated secretions
39. cmH O CPEP Pressure High Flow on 20 cmH 0 resulted in a peak inhaled flow of 6 0 LPM peak exhaled flow of 6 8 LPM peak airway pressure of 18 2 cmH O end exhaled pressure of 16 0 cmH O auto PEEP pressure of 0 1 cm H O and tidal volume of 64 ml When going from CPEP Pressure with No Flow to CPEP Pressure High Flow on 20 cmH O a 7 rise in peak inhaled flow 3 change in peak exhaled flow 45 change in peak airway pressure 160 change in peak exhaled pressure 1 change in auto peep and 12 5 change in tidal volume Vol Flow ILEMI Max 5 2 Min G Diff 11 5 in i cL id UTE UreETTTT Y 16 Figure 3 Flow Baseline Baseline graphs showed peak inhaled flow of 5 4 LPM peak exhaled flow of 6 9 LPM peak airway pressure of 0 3 cmH 0O end exhaled pressure of 0 0 cmH O auto PEEP pressure of 0 0 cm H O and tidal volume of 70 ml Figure 3 1 CPEP no Flow CPEP no Flow showed peak inhaled flow of 5 6 LPM peak exhaled flow of 7 0 LPM peak airway pressure of 0 4 cmH 0O end exhaled pressure of 0 0 cmH O auto PEEP pressure of 0 0 cm H3O and tidal volume of 72 mi Figure 3 2 CPEP High Flow with 20 cmH O CPEP High Flow with 20 cmH O showed peak inhaled flow of 6 0 LPM peak exhaled flow of 6 8 LPM peak airway pressure of 18 2 cmH O end exhaled pressure of 16 0 cmH O auto PEEP pressure of 0 4 cm H20 and tidal volume of 64 ml LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol
40. d air into pilot balloon to check for leaks 7 Withdrew air placed into pilot balloon using the same 10ml Luer Lock syringe 8 Removed 10ml Luer Lock syringe from pilot balloon 9 Inserted size 7mm endotracheal tube into 5 inch flex hose 10 Inflated pilot balloon of size 7mm endotracheal tube cuff with 8ml of air 11 Connected the manometer do not detach during each run to the pilot balloon 12 Recorded the pressure 13 Submerged the endotracheal tube cuff completely in water bath 14 Recorded pressure using the manometer immediately after inserting endotracheal tube into bath water 15 Recorded pressures at 30 second intervals until pressures stabilized 16 Repeated and recorded results for steps 1 through 15 for three trial runs The following steps were taken to test Trial 2 Cuff Pressure Stabilization Trial 2 1 Repeated steps 1 through 2 Placed 10ml Luer Lock syringe into pilot balloon of the 8mm endotracheal tube instilled air into pilot balloon to check for leaks 3 Withdrew air placed into pilot balloon using the same 10ml Luer Lock syringe 4 Removed 10ml Luer Lock syringe from pilot balloon 5 Inserted size 8mm endotracheal tube into 5 inch flex hose 6 Inflated pilot balloon of size 8mm endotracheal tube cuff with 8 ml of air 7 Repeated steps 11 through 15 of Trial 1 8 Repeated and recorded results for steps 1 through 7 for three trial runs Statistics Collected data was incorporated on Microsoft pressure for both tube sizes
41. d working pressure Although our hypothesis was not confirmed it can be seen that the newer equipment is an improvement over the older equipment because of the additional FRC References Application for HFCO therapy in airway clearance MetaNeb PowerPoint slides Retrieved from xa yimg com kq groups 18919090 950016353 name MetaNeb 2520Therapy ppt Bocci M Garcia A J Timon B Wolff J R Hargett K amp Thornton C 2006 A case study the use of metaneb to improve secretion removal and reverse atelectasis Respiratory Care Journal Retrieved from _ http www rcjournal com abstracts 2006 id OF 06 113 Barton R D 2008 Method of high frequency assisted airway clearance PowerPoint slides Retrieved from www rtconnection org Faram D J 2009 Combination breathing treatment method Patientdocs Retrieved from http www faq or patent app 200090 188500 Metaneb Retrieved from http www metaneb com index html LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol 2 no 2 page 41 LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol 2 no 2 page 42
42. de in USA serial 10 01911 item C20130 Standard MetaNeb circuit Waveform machine Manufacturer HANS RUDOLPH Inc Series 1101 Breathing Simulator Address from Manufacturer 7200 Wyandotte Kansas City Missouri 64114 USA Scale Company name Santorius Model Name M prove Serial No 27355093 Stock No 3 Syringe 30cc 12cc 3cc Endotracheal Tube Size ID Inner Diameter 8 0 Cuff Diameter 27 5mm Tube OD Outer Diameter MM 9 3mm Reference 112082070 Serial Number 01 04026704300402 Lot No O8LE49 Made by Teleflex Address Research Triangle Park NC Bacterial Filter Guardian Disposable Bacterial Viral Filter Record FH 603003 22mm OD 15 mm ID x 22mm ID 15 mm OD Manufactured By Ventlab Corporation 155 Boyce Drive Mocksville HC 27028 Lot 02452 Self Inflating Manual Resuscitator Portex BiPAP CPAP Manufacturer Phillips Brand name Respironics Model V60 Manufacture address Respironics CA Inc 2271 Cosmos Court Carlsbad CA 92011 Xray machine e Attached to the Wall Intraoral Xray unit By Sirona Model No 4684606 D3302 Serial No 23652 Manufactured 2003 e Arm piece exposure tube Model No 4681263 Serial No 31820 Suction Connector Tubing 72 in length with 3 16 diameter made in Mundelein IL lot 9905081 Date 2004 05 reorder DYND50216 Inline suction catheter Closed suction system for adults AKA Inline suction Size 14 French Length 54cm Referen
43. der to make the Vortran connect to the Rudolph Breathing Simulator a rubber pulmonary function mouth interface was placed on the Vortran patient inhalation port and a six inch section of 22 mm corrugated bore tubing was attached to the rubber mouthpiece and the Rudolph Breathing Simulator See Photograph 1 LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol 2 no 2 page 32 Photograph 1 Vortran Percussive Neb with Connection to Rudolph Breathing Simulator Testing and Calibration MetaNeb The equipment was checked for leaks and proper function before use The MetaNeb was connected to a 50 psig gas source and the knob turned to continuous high frequency oscillation CHFO mode with higher setting selected The selector ring on handset was placed on the three dots indicating high resistance The device was switched to the ON position and the continuous high frequency oscillation CHFO rate was observed for a period of five seconds Continuous high frequency oscillation CHFO was 17 8 pulses in 5 seconds The knob was then turned counter clockwise to full flow to check for leaks in continuous positive expiratory pressure CPEP mode With the selector ring at three dots the patient opening of the handset was occluded and the manometer was observed showing peak pressure between 15 and 30 cmH O indicating no leaks in the MetaNeb Vortran Percussive Neb A function check was also performed on th
44. e Vortran Percussive Neb by occluding the mouthpiece and adjusting the flow until oscillation began According to the manual the Vortran Percussive Neb requires an 80 psig to generate a flow of 60 I min For this study 80 psig was not available therefore a 50 psig was used to perform a function check Series 1101 Breathing Simulator A system leak and calibration was performed on the Series 1101 Rudolph Breathing Simulator by a calibration laboratory AJD on 02 21 2007 and recalibrated on 02 22 2008 According to the manual the unit should be calibrated at least once per year For this study we were unable to calibrate the Rudolph Breathing Simulator therefore a pressure check was conducted to validate the accuracy of the pressure and volumes using the Phillips Respironics V60 mechanical ventilator The Respironics V60 was set in the pressure control PC mode with IPAP 20 cm HO EPAP 10 cm H O peak inspiratory flow 39 L min and tidal volume 184 L min When connected to the Rudolph breathing simulator using a standard bipap circuit the Rudolph Breathing Simulator had a peak pressure of 20 4 cm H O and an end expiratory pressure of 10 2 cmH 0O peak inspiratory of 37 1 cmH O and tidal volume of 173 L min showing that the pressure and volume were very close to accurate thus validating that the pressures and volumes are correct on the Rudolph breathing stimulator As can be seen the Respironics V60 gave an IPAP of 20 cmH 0O
45. er minute lpm An antimicrobial filter was attached to the end of the resuscitation bag to protect equipment 5 Repeated Steps 9 through 17 of Trial 1 The following steps were taken to test Trial 3 Using Minimal Occluding Volume Technique to Manage Cuff Pressure Trial 3 1 Repeated Steps 1 through 5 of Trial 1 Attached flow inflating resuscitation bag and antimicrobial filter to ET tube at patient port and manually ventilated at a rate of 20 breaths a minute 3 Slowly inflated cuff with a 10 milliliter mL disposable syringe until airflow heard escaping around the cuff during a positive pressure breaths ceased 4 Connected flow inflating anesthesia breathing bag to wall oxygen source and set flowmeter to 4 liters per minute lpm An antimicrobial filter was attached to the end of the resuscitation bag to protect equipment 5 Repeated Steps 9 through 17 of Trial 1 Results Volume Table 1 lists all recorded volumes for each trial Mean volume loss n 3 for all three trials was 0 667 mL SD 1 Trials 1 and 3 each had a volume loss of 1 mL sterile water solution after the tracheal lavage Table 1 Recorded Volumes of Sterile Water Solution Before and After Tracheal Lavage Trial 1 Trial 2 Trial 3 MAN MLT MOV Volume of Instilled Water for 10 10 10 Tracheal Lavage mL Volume of Suctioned Water from 9 10 9 Tracheal Lavage mL Difference in Water Volume Before 0 amp After Tracheal Lavage mL Percent Change
46. er than three minutes for cuff pressures to stabilize Methology To determine the time it will take to stabilize cuff pressures the following materials were used anne j Que a ae Equipment Needed 1 Poly Pro Bath a Serial number 111908C b Model number RS PB 100 c Manufacturer REVSCI 2 Posey 8199 standard cufflator Endotracheal Tube Inflator and Manometer 3 5 inch flex hose trachea substitute 4 Endotracheal Tube Size 7 mm a Lot number 1OOSHV0834K b Manufacturer Well Lead Medical 5 Endotracheal Tube Size 8 mm a Lot number 1003HV0337M b Manufacturer Well Lead Medical 6 Syringe a Model 10 ml Luer Lock Tip b Lot number 070823 c Manufacturer Exelint International 7 76mm glass thermometer measured in Celsius 8 Gallon of distilled water 9 Stopwatch apple I Phone LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol2 no 2 page 26 Procedure The following steps were taken to test trial 1 Cuff Pressure Stabilization Trial 1 1 Filled the water bath with 3 liters distilled water 2 Set temperature on Poly Pro Bath at 37 degree Celsius 3 Covered the water bath maintained for 1 hour 4 Inserted 76mm glass thermometer and checked accuracy of temperature if temperature is off more than 0 5 Celsius recalibrate 5 Instilled 10ml air into 10ml Luer Lock syringe 6 Placed 10ml Luer Lock syringe into pilot balloon of the 7mm endotracheal tube instille
47. etreatment X Ray Post treatment X Ray LIA LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol 2 no2 page amp Figure 3 Secretions m Secretions Secretions removed Secretions removed on BiPaP g on CPaP g Figure 3 demonstrates the amount of secretions that was removed while on BiPAP 3 21grams and CPAP 1 45grams after the 15 minute treatment on MetaNeb While suctioning out the secretion 5mL of normal saline was added to dilute the secretions Figure 4 Percent change between trial one and two Secretions suctioned Negative precent change 1 BiPaP m Secretions suctioned Negative precent change This figure compared secretions removal at different settings The equation was derived from post value subtracted from pre value divided by pre value times 100 The post value was the amount of secretions after suction and pre value was the amount of secretion that was inserted into the lung Discussion and Conclusion In using manufacturer recommended technique and settings the researchers believed the MetaNeb would effectively mobilize secretions in all lung regions When performing the experiment there were some limitations and other factors that should be further investigated to perhaps improve patient care The results of the trials did not support the hypothesis due to unexpected limitations however many questions arose that should be further investigated
48. gh frequency oscillation CHFO Continuous positive expiratory pressure CPEP treatment delivered lung expansion by providing constant airway pressure during both inhalation and exhalation using continuous flow through a venturi and a fixed orifice resistor Bocci Garcia Timon Wolff Hargett amp Thornton 2006 Continuous high frequency oscillation CHFO was an airway clearance therapy which used a systematic method to improve normal mucus clearance and managed atelectasis by delivering aerosolized therapy to relax bronchial smooth muscle to decrease airway resistance and hydrate thickened secretions Continuous high frequency oscillation CHFO was precisely calibrated frequency and I E ratio to generate airway pressure in order to sustain airway ability to prevent early closure of the airway and increase the collapsed lung field Metaneb Continuous high frequency oscillation CHFO was maintained during both inspiration and expiration to form a pressure gradient to the small airways where secretions are trapped This created a faster expiratory airflow that could be controlled to assist in moving the secretions to the upper airways Metaneb Caution should be taken when using MetaNeb The MetaNeb is a single patient use only and entrainment orifices should not be occluded when in use Contraindications of MetaNeb are LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol 2 no 2 page 31 sim
49. h an inflatable rubber cuff that could seal the trachea from gas and water when inflated for anesthetic purposes Bouvier 1981 It was only as late as 1945 that endotracheal intubation became part of hospital practice Bouvier 1981 Today cuffed endotracheal tubes are used in children gt 5 6 years old and adults to seal off the lower airway This seal allows application of positive pressure ventilation to the lungs without extensive gas leaks Bouvier 1981 The seal provided by the cuff helps prevent and minimize aspiration of oropharyngeal or supraglottic secretions into the lungs Bouvier The process of endotracheal intubation has had approximately 1000 years to evolve into a safe practice Bouvier 1981 Unfortunately the pressures used to inflate tracheal tube cuffs continue tracheal mucosa can occur if the cuff pressure is too high Braz Navarro Takata Nascimento 1999 Undetected over inflation of the endotracheal cuff balloon may disrupt the capillary blood supply leading to ischemia inflammation ulceration granulation nerve and vocal damage as well as stenosis at the site of contact between the cuff and trachea Braz et al 1999 Endoscopic studies show a correlation between elevated cuff pressures and tracheal lesions Braz et al 1999 Post operative sore throat is also associated with elevated endotracheal cuff pressure Stewart Secrest Norwood amp Zachary 2003 Patients also can be at risk if
50. hing a calibrated manometer performing the minimal occluding volume technique and performing the minimal leak technique The technique of using a manometer to manage cuff pressure involves inserting a calibrated manometer into the spring loaded end of the pilot balloon The pressure inside of the cuff is displayed on the screen and air can be added or withdrawn to maintain a cuff pressure of 20 30 centimeters of water cm H30 The minimal occluding volume technique involves completely deflating the cuff with a 10 milliliter LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol 2 no2 page 16 mL syringe attached to the pilot balloon until airflow is heard around the cuff during a positive pressure breath Once airflow is heard the cuff is slowly inflated until airflow is no longer heard The minimal leak technique is performed the same way as the minimal occluding volume technique however a small amount of air is removed once no airflow is heard around the cuff Wilkins Stoller amp Kacmarek 2009 Our research will compare the ability of the above cuff pressure management techniques to prevent leakage of oropharyngeal secretions below the cuff of an endotracheal ET tube placed inside the trachea of an animal cadaver Our research will also explore the role cuff lubrication plays in preventing upper airway secretions from entering into the lower airway It is expected that using a manometer will be the m
51. ilar to IPPB such as high intracranial pressure ICP an absolute contraindication of all airway clearance devices Other contraindications included untreated pneumothorax head or neck injury that has not been stabilized and active hemorrhage with hemodynamics instability Application of HFCO Other devices similar to MetaNeb include the Bird IPV which offers the same modes as MetaNeb but is not indicated for lung expansion therapy and is a non disposable and reusable interface circuit The Vortran is another airway clearance device also similar to MetaNeb It is a high frequency intrapulmonary percussive nebulizer that is designed to oscillate at higher frequencies to mobilize mucus from the lungs in patients with retained secretions It offers intrapulmonary percussive aerosol ventilation high frequency oscillation mucus clearance and high aerosol output Faram 2005 Since the MetaNeb only came on the market in 2010 little research is available as to the effectiveness and comparability of this equipment to other IPV intrapulmonary percussive ventilation devices Comedica Inc Dallas TX It would stand to reason that comparable waveforms would indicate a similar function and effectiveness of like equipment The purpose of this study is to compare the waveforms created during the three different modes of operation of the MetaNeb and compare them to the waveforms created by the Vortran Percussive Neb thus observ
52. ilter were removed and the inline suction catheter was connected to the ET tube at the patient port The 10 milliliters mL of sterile water from step 12 was injected into the instillation port of the inline suction catheter Set suction device to 20 millimeters of mercury mmHg and passed entire length of suction catheter down ET tube three times Remaining fluid in glove was extracted by puncturing cutting off glove fingers and or squeezing out the solution into the specimen trap The specimen trap with sterile water and dyed egg white solution was reweighed Volume and color of solution were recorded Double bagged used cow trachea and ET tube for disposal The following steps were taken to test Trial 2 Using Minimal Leak Technique to Manage Cuff Pressure Trial 2 L Repeated steps 1 through 5 of Trial 1 LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol 2 no2 page 19 2 Attached flow inflating anesthesia breathing bag and antimicrobial filter to ET tube at patient port and manually ventilated at a rate of 20 breaths a minute 3 Slowly inflated cuff with a 10 milliliter mL disposable syringe until airflow heard escaping around the cuff during a positive pressure breaths ceased Once a seal was obtained a small amount of air was removed allowing a slight leak at peak inflation pressure 4 Connected flow inflating anesthesia breathing bag to wall oxygen source and set flowmeter to 4 liters p
53. ing any similarities between the IPV intrapulmonary percussive ventilation devices and determining if the devices are truly similar as well as if their therapeutic function is equal Our hypothesis is that the waveforms produced during the three different modes of operation of the MetaNeb will be the same as those produced by similar IPV intrapulmonary percussive ventilation devices specifically the Vortran Percussive Neb Methodology Method This study was performed at Lone Star College Kingwood in the Respiratory Department Laboratory Kingwood Texas US Equipment e MetaNeb Comedica Inc Dallas TX serial number 10 01911 item number C20130 product No PMN3 e Vortran Percussive Neb medical technology Inc Sacramento CA e Series 1101 Breathing stimulator manufacture by Hans Rudolph Inc Kansas City Missouri e Sony brand Cyber shot digital still camera with a 30X optical zoom Description of Use The MetaNeb circuit included a mouthpiece selector ring hand set circuit connector nebulizer orifice indicator adapter size 22 mm x 15 mm occlusion ring and adapter size 22 mm x 22 mm following user manual guide to assemble parts The component of the Vortran Percussive Neb included a nebulizer top mouthpiece nebulizer reservoir with baffle inside main column amplitude dial modulator and gas flow that can support 60 L min The last equipment was the Series 1101 Breathing stimulator In or
54. led Pressure Percent Change Between and Low Setting In Graph 2 there was a 160 change in the end exhaled pressure from the no flow setting on the MetaNeb and the high or 20 cmH 0 setting There was only a 10 change in the end exhaled pressure between the soft and hard settings on the Vortran The MetaNeb had a 150 greater change in end exhaled pressure than the Vortran Discussion The research team hypothesized that the waveforms produced during the three different modes of operation of the Metaneb would be the same as those produced by similar IPV intrapulmonary percussive ventilation devices specifically the Vortran Percussive Neb It was discovered that two of the three settings on the MetaNeb were not truly comparable to either setting on the Vortran The MetaNeb had a mode for delivering aerosol at low or high flow as well as a mode for just delivering low or high flow After attaching the MetaNeb and then the Vortran Percussive devices to the Rudolph lung simulator we found that the MetaNeb on high or low oscillatory settings produced a waveform indicating an elevation in the functional residual capacity The functional residual capacity FRC was elevated to 160 mL on the high setting of the MetaNeb and it never rose on the low setting of the MetaNeb The researchers were able to compare the MetaNeb in the CPEP mode with no flow and 20 cmH 0 to the Vortran soft and hard settings bec
55. loudy Opaque Tan with Greenish Tint Significant amount of visible bubbles foam on surface Cloudy and opaque Pink Slightly visible bubbles foam on surface Discussion Categories used to determine the effectiveness of each cuff management technique were volume weight and visible characteristics of the sterile water solution after tracheal lavage Data collected from the experiment supports the hypothesis that using a manometer is the most effective cuff management technique and prevents the most amount of dyed egg white solution from leaking below the cuff of a well lubricated ET tube The trial that involved using a manometer to manage cuff pressure trial 1 had the least amount of dyed egg white solution fall below the cuff during positive pressure ventilation This was demonstrated in all three categories One milliliter of sterile water solution was lost during the tracheal lavage This was the assumed baseline for each trial due to tracheal tissue absorption of the sterile water solution This absorption also caused a decrease in weight in all three trials The manometer method had the greatest weight loss of the three methods indicating no significant addition of dyed egg white solution to the sterile water for the lavage Contents of the specimen trap after the lavage showed no significant signs of dyed egg white solution The minimal leak technique trial 2 had the most dyed egg white solution fall below the cuff d
56. ndotracheal intubation is a critical clinical skill and lifesaving technique The procedure however can cause complications even long after the endotracheal tube ETT is placed past the vocal cords and secured Tracheal necrosis rupture stenosis laryngeal nerve palsy and tracheo esophageal fistulas are all potential risks when the pressure in ETT cuffs is excessively high References Ben K Cooper J Drummond T amp Morello P 2012 Bench study time frame needed for cuff pressures to stabilize after intubation Kingwood Journal of Undergraduate Reseach in Respiratory Care 2 1 1 5 Bouvier J R 1981 Measuring tracheal tube cuff pressures Tool and technique Heart amp Lung 10 4 686 690 Braz J R Navarro L H Takata I H Nascimento P 1999 Endotracheal tube cuff measurement need for precise measurement Sao Paulo Medical Journal 117 6 243 247 Spiegel J 2010 Endotracheal tube cuffs design and function Anesthesiology News Guide to Airway Management Stewart S Secrest J Norwood B amp Zachary R 2003 A comparison of endotracheal tube cuff pressures using estimation techniques and direct intracuff measurement AANA Journal 71 6 443 447 LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol 2 no 2 page 30 Waveform Comparisons The MetaNeb and Vortran Jennifer Hua Kim Frie Cynthia Young Julissa Webb Abstract BACKGROUND The MetaNeb and Vort
57. not available for our study so 50 psig was used The off label use of the Vortran altered the data collection of the waveforms produced by the Vortran Another limitation may have been the connection of the Vortran to the Randolph Breathing Simulator In order to effectively connect the Vortran to the Randolph a rubber pulmonary function mouth interface had to be connected Being made of rubber it is possible that it absorbed some of the percussiveness therefore altering the data It at 80 LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol2 no 2 page 40 psig and we used a 50 psig It is a recommendation of this team that this study be reproduced in the future using the 80 psig compressor Clinical Significance The results of this study would indicate that using the MetaNeb on the high oscillatory setting on a patient with consolidation such as pneumonia would give that patient a level of functional residual capacity FRC that could be beneficial to that patient In a patient with COPD who does not need an elevated FRC as they already air trap we suggest the MetaNeb on low This particular type of patient could benefit from the percussion of the lower setting without the elevation to their functional residual capacity FRC We were unable to locate any prior studies of this nature to compare our study to It is possible this is the first study comparing waveforms produced by the different settings
58. o CPAP setting 40cmH O This kept the lungs inflated and stationary during the x ray Step 13 x ray of the lung was done Three different density films were used for the x ray this was done in order to obtain which density gave the better observation of the secretions Step 14 researchers resumed BiPAP and transported the lung back to the respiratory department Step 15 lungs were then connected to the MetaNeb at the standard setting for a treatment Times on the MetaNeb were according to the manufacture manual The 15 minute treatment shifted between lung expansion CPEP Continuous Positive Expiratory Pressure for 2 1 2 minutes and then airway clearance CHFO Continuous High Frequency Oscillation for 2 1 2 minutes until 15 minutes was reached While against the manufacture s settings the cuff was kept inflated so inflation was not lost Step 16 promptly after the treatment the lung was suctioned twice with a suction catheter inserted 2 cm past the ET tube 5ml normal saline was administered and a 120mmHg suction pressure was applied Step 17 all synthetic secretions acquired from suctioning was collected in a sputum trap connected to the in line suction catheter Step 18 the synthetic secretions were measured in volume using milliliters cc and weighed with the scale Step 19 repeat steps 10 13 for post treatment assessment Step 20 post x ray of the same area of the lung was performed after secretions were removed Step 2
59. ost effective method of cuff management and that lubricating the cuff will play a key role in preventing VAP Methodology Materials To test the effectiveness of the three cuff management techniques on lubricated endotracheal ET tube cuffs the following materials were used 1 22 inch x 28 inch White Poster Board for Testing of Egg Whites Viscosity 2 CPE Plastic Isolation Gowns disposable Manufactured by Wuhan Vanjoin Light Industrial Products Co Ltd Hubei China 3 Dynarex Ear Loop Procedure Mask w Splash Face Visor disposable Manufactured by Dynarex Corporation 10 Glenshaw Street Orangeburg NY 10962 4 Defender Examination Gloves disposable Manufactured by Digitcare Corp 2999 Overland Ave Los Angeles CA 90064 5 Staples Economy Rubber Bands Size 18 6 Cow Tracheae and Lungs Donated by Garza Processing Market 4519 Theiss Rd 1Humble TX 77338 7 Disposable Surgical Scalpel Manufactured by Med Pro Corporation Shandong China 8 Ultra Concentrated Dawn Dishwashing Liquid Detergent Size 709 milliliter mL bottle Distributed by Procter amp Gamble Cincinnati OH 45202 9 Napkins 10 Scotch Packing Tape Premium Heavy Duty 3770RD Clear Size 1 88 inches x 54 6 yards 11 Velcro Sticky Back Hook amp Loop Fastener General Purpose Tape Black Size inch in x 15 feet ft Roll 12 Wooden Yard Stick 13 Makeshift Aluminum Foil Covered 45 Angle Cardboard Ramp 14 Craftsman 12 inch
60. ould not harm the integrity of the lung was cut away The lungs were then kept flat on a cardboard box covered in plastic The universal precautions were used which included the standard gloves gown goggles and mask After the experiment the lungs were discarded in the proper manner wrapped sealed and double bagged in an industrial grade garbage bag The equipment that was used is stated in the addendum All equipment was calibrated prior to starting the experiment For this study the utilization of the resources available on campus were used which for this case instead of a chest x ray a dental x ray unit ultra oral number three size film Kodak s speed D was used Equipment Calibration Scale Calibration 1 Power on the balance 2 Press calibration button and obtain calibration number after pressing Cal button 3 Power off and restart the balance 4 Place calibration weights located on the side of the machine Allow time to calibrate 6 Confirm 200g A MetaNeb Calibration The MetaNeb was calibrated by performing the Function Test according to the manufacture s manual Because of the added bacteria filter to the circuit which is not mentioned in the manufacture s recommendations a waveform test was performed showing the difference between the manufacture s recommendations versus the circuit with the added bacteria filter the waveform findings showed no major changes between the two tests Preparation of
61. parison of the effects of manual and ventilator hyperinflation on static lung compliance and sputum production in intubated and ventilated intensive care patients Physiotherapy Research International 100 108 Retrieved from http www ncbi nlm nih gov pubmed 12 109234 Cairo J M amp Pilbeam S P 2010 Mosby s Respiratory Care Equipment St Louis Missouri Mosby Elsevier Comedica Incoperated n d MetaNeb Retrieved June 18 2012 from MetaNeb System http www metaneb com Myers T R 2007 October Positive Expiratory Pressure and Oscillatory Positive Expiratory Pressure Therapies Respiratory Care 52 10 1308 1327 Retrieved from http www ingentaconnect com content jrcc rc 2007 0000005 2 000000 1 0 artO0002 Natale J E Pfeifle J amp Homnick D N 1994 June Comparison of intrapulmonary percussive ventilation and chest physiotherapy a pilot study in patients with cystic fibrosis CHEST 105 6 1789 1793 LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol 2 no 2 page 10 Reychler G Keyeux A Cremers C Veriter C Rodenstein O D amp Liistro G 2004 Comparison of Lung Deposition in Two Types of Nebulization Intrapulmonary Percussive Ventilation vs Jet Nebulization CHEST 125 2 502 508 Vienne M Dziri Richez C Bensalah Tolba F Vaillant Ettaiche M Navarre P amp Bougatef A 2009 March Forrest Morton Bird quand l aviation me ne Journal de re
62. plastic Both of the test subjects were intubated in a lobe with a smaller airway that could support the size of the endotracheal tube the cuff was inflated to maintain a good seal Step 3 the endotracheal tube was then attached to a Portex self inflating manual resuscitator bag and the lungs were then manually bagged This was done to recruit alveoli Step 4 the lungs were then connected to a Respironics V60 Ventilator to apply BiPAP CPAP and maintained the inflation of lung Step 5 perform viscosity test for secretions Refer to How to Perform Viscosity Test subheading Step 6 the M PROVE top loading balance scale was zeroed the empty syringe and empty sputum trap were weighed This was done to adjust for the weight of the containers in the results Step 7 the synthetic secretions were weighed in the syringe Step 8 then 30cc of synthetic secretions was administered into the airway via syringe Step 9 the lung was placed back on BiPAP and the secretions were manually massaged into the distal airways LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol 2 no2 page 5 Step 10 The BiPAP settings were set at Ipap 40cmH O Epap 12cmH 0 respiratory rate 20 breaths per minute Step 11 the lung was transported to obtain pretreatment x rays This was done in order to see the density of the secretions for the purpose of the post treatment comparison Step 12 researchers then switched from the BiPAP setting t
63. ran are both forms of intrapulmonary percussive ventilation IPV The MetaNeb proposed three methods of operation continuous positive expiratory pressure CPEP for lung expansion continuous high frequency oscillation CHFO for secretion mobilization and aerosol for delivery of medication The Vortran provides high frequency oscillation at two levels soft and hard The aim of this study was to compare the waveforms produced by the MetaNeb and the Vortran METHODS Rudolph Breathing Simulator displayed the waveforms of both devices via pressure volume and flow rates Both devices operated on 50 psig and waveforms of the Rudolph Breathing Simulator alone were collected for baseline graphs All graphs were recorded using digital camera images The MetaNeb was set on oscillation CHFO at both high and low oscillation On continuous positive expiratory pressure CPEP started with no flow and then maintained pressure of 20 cmH 0 The Vortran was set on soft and hard modes RESULT The MetaNeb displayed oscillation waveforms varying slightly between high and low oscillation with 1 8 cmH O peak airway pressure in both modes Auto PEEP of 9 8 cmH 0 on high and 11 8 cmH 0 on low The same mode with no flow had a peak airway pressure of 0 4 cmH O auto PEEP pressure 0 0 cm H O and tidal volume 72 ml When 20 cmH O was added peak airway pressure increased to 18 2 cmH 0 auto PEEP pressure 0 4 cm H O and tidal volume decreased to 64 ml The
64. s of gas mixture at 200 to 300 cycles per minute Natale Pfeifle amp Homnick 1994 introduced in 1979 by Dr Forrest Bird Cairo amp Pilbeam 2010 According to the manufacturer the MetaNeb system was originally designed to increase the mucociliary clearance improve the gas exchange humidify the airway stabilize airway patency and improve the lung mechanics Reychler et al 2004 Theoretically the advantage of IPV had been described as a 2 fold effect in airway clearance Myers 2007 the percussive motion or oscillations reportedly decreased the viscoelastic properties of the mucus and increased expiratory airflow thus making it easier to mobilize secretions up and through the airways by means of short bursts airflow Myers 2007 The MetaNeb is meant to be utilized in three different ways including lung expansion therapy airway clearance and aerosolized medication delivery For the purpose of this research lung hyperinflation is defined as increasing lung volume by increasing the transpulmonary pressure gradient Wilkins Stoller amp Kacmarek 2009 Through a sliding Venturi with added continuous aerosol For the purpose of the study two calf lungs were utilized Both animal lungs were received within 12 hours of death and placed on ice for 72 The technique of lung expansion was used to help mobilize and remove excessive bronchial secretions help with lung expansion and improve oxygenation Berney
65. simulator and requires no additional manipulation during the testing other than changing modes 9 After testing of the MetaNeb was complete the MetaNeb was removed from the breathing simulator 10 The Vortran Percussive Neb was then attached to the breathing simulator was set on the hard setting and the waveforms were photographed 11 The Vortran was then set on the soft setting and the waveforms were photographed This concluded the experiment portion of our study The Vortran was designed to be hand held by patient therefore the Vortran needs to be held by a member of the research team to be attached to the breathing simulator LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol 2 no2 page 34 Results l SEW SOT We TS SS SS A P HS TOTS E E L ete WE tral Max oh Mim ad on sol E T Hy GA HN A hE RCT AONT ei itt a i a d I I I I I i I I I I I I I _ Uo Aa to LPM Max a4 d Min so 4 Diff esc ot MAO A Aa Wu I PEER ai UL t ji dii ALNA ML AM WALA MUU a UULU U L L WA Photograph 2 MetaNeb on High Flow MetaNeb on High Flow had a peak inhaled flow of 43 5 LPM peak exhaled flow of 6 9 LPM peak airway pressure of 1 8 cmH O end exhaled pressure of 1 0 cmH O auto PEEP pressure of 9 8 cm H20 and tidal volume of 59 ml LE LA RAE E e TN v aE AAN NAERAN RRR EEUNA AMWIAMIL L K Ji eee ae A AA NWA nee I EE mme a mo n AA EE APAA
66. t some dyed egg white solution did fall below the cuff of the ET tube Research performed by Blunt et al determined that water soluble lubrication on the cuff of an ET tube reduced the amount of oropharyngeal secretions from falling below the cuff during the first LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol 2 no 2 page 22 48 hours of intubation a key timeframe in the prevention of VAP bacteria colonization Blunt Young Patil amp Haddock 2001 Lubricating the ET tube and using a manometer to manage cuff pressure should significantly reduce the incidence of VAP in a hospital setting when compared to other cuff management techniques Limitations of this study Due to time constraints each trial was performed only once The research should be repeated with a minimum of three runs per trial to provide more conclusive results Some volume of sterile water solution was lost due to absorption into dried tracheal tissue It was assumed that this value is about 1 mL based on the results A test run was not performed to determine how much sterile water solution would be lost and what factors affected the amount of solution lost Another suggestion in correcting this requires the tracheae to be soaked in water until ready to use for the experiment Also the precision of the instrument used to measure volume was to the nearest whole number Repeating the experiment with an instrument that measures to the
67. ume of 71 mi When moving from Vortran Soft to Hard mode one saw 5 rise in peak inhaled flow 1 change in peak exhaled flow 25 change in peak airway pressure 10 change in end exhaled pressure no change in auto peep and 1 change in tidal volume NN od ressure oe 6 36 6 15 J h DT PA ATIA YE PA TP HL A GA pe fg tir NH Wu yr Figure 5 Pressure Baseline LSC Kingwood College Journal of Undergraduate Research in Respiratory Care Vol2 no 2 page 38 Baseline readings showed peak inhaled flow of 5 4 LPM peak exhaled flow of 6 9 LPM peak airway pressure of 0 3 cmH O end exhaled pressure of 0 0 cmH O auto PEEP pressure of 0 0 cm H O and tidal volume of 70 ml SS Ss a AUR aiaia L a afata slid IA A a thy a Tl n Eiane EERROR MOARE EAA AONA MAADAM o Mr ee i i tT l o Sate Be SEES i AA a mi i a AHA TTT Lis i ii tea aL A A Mul sa I Mh tla ee E j os A GA pild mo o oero aaa TROIUEUOLESELEUERO0TEU GLEE a Figure 5 1 Vortran Hard Pressure penae SS peene peee Say SSS 4 Vortran Hard showed peak inhaled flow of 6 1 LPM peak exhaled flow of 7 1 LPM peak airway pressure of 0 5 cmH O end exhaled pressure of 0 1 cmH O auto PEEP pressure of 0 0 cm HO and tidal volume of 72 nL d ATENT i ni if ii F En mo o aly ER RR NAR GASH aAA Hs TE Figure 5 2 Vortran Soft Pressure
68. uring ventilation and was demonstrated in all three categories The volume of the sterile water solution remained the same before and after the tracheal lavage Assuming that about 1 mL of the 10 mL sterile water solution was absorbed by tracheal tissue any additional volume was attributed to dyed egg white solution that managed to fall below the cuff of the ET tube Weight loss post tracheal lavage was considerably less when compared to technique involving using a manometer Dyed egg white solution that managed to fall below the cuff made up the difference in weight 0 63 g Sterile water used for the lavage went from clear and translucent to cloudy opaque and khaki colored The minimal occluding volume technique trial 3 was seen to be less effective than using a manometer but more effective than the minimal leak technique This was demonstrated in only two of the three categories The volume of sterile water lost during the lavage with this technique was the same as the volume lost using a manometer 1 mL Though they were the same it was assumed that some dyed egg white solution did fall below the cuff based on the other categories The weight loss of sterile water solution after the lavage for this technique was not as much as with using a manometer but greater than using the minimal leak technique This along with the change in translucency and the presence of foam on the surface of the solution in the specimen trap indicated tha
69. w the cuff into the lower airway This is the leading contributor to ventilator associated pneumonia VAP Wilkins Stoller amp Kacmarek 2009 Ventilator associated pneumonia VAP accounts for 80 90 of nosocomial pneumonias in intensive care unit ICU patients Deem amp Treggiari 2010 It prolongs the length of hospital stay increases healthcare costs and increases the risk of death within the critically ill adult population O Keefe McCarthy Santiago amp Lau 2008 The risk of ventilator associated pneumonia VAP is greatest during the first five days of intubation but can occur at any time during the intubation period Bacteria contaminated secretions from the oropharynx slide down the longitudinal folds of the inflated cuff created when the cuff pushes against the wall of the trachea into the lower airway Blunt Young Patil amp Haddock 2001 Once in the lower airway the bacteria colonize and signs and symptoms of ventilator associated pneumonia VAP begin to present Current strategies used to prevent ventilator associated pneumonia VAP include hand washing routine suctioning and oral care patient isolation patient positioning lubrication of the endotracheal ET tube cuff with a water based gel and maintaining endotracheal ET tube cuff pressure above 20 centimeters of water cm H20 to prevent oropharyngeal secretions from falling below the cuff Methods used to manage cuff pressure include attac
70. y resulting from endotracheal intubation Braz et al 1999 There are currently four methods for monitoring cuff inflation In the minimal occlusive volume MOV technique air is added to the cuff to create a seal and abolish air leak on inspiration In the minimum leak technique MLT air is removed from the cuff to allow a small leak on inspiration Cuff pressure measurement CPM is performed with a manometer during the inspiratory phase provides objective measurement of intracuff pressure that does not involve cuff deflation A fourth technique the palpation method involves subjective estimation of cuff inflation based on gentle palpation of the pilot balloon Braz et al 1999 In 2012 Ben et al measured cuff pressures as the cuff was heated to 37 degrees The main finding of their research was that cuff pressures did not stabilize at 30 seconds cuff pressures continued to increase up to three minutes Secrest et al 2012 The purpose of this study is to determine the time it would take for the cuff pressures to stabilize once the cuff is subjected to body temperature The cuff pressure should increase as the cuff moves from room temperature to body temperature Gay Lussac s Law states that when volume is constant as the temperature rises the pressure also rises Ben et al 2012 The biological question is how long will it take for the cuff pressure to stabilize after intubation It is anticipated that it will take long

LSC: Kingwood Undergraduate Research in Respiratory Care, vol 2

Contents

Download Pdf Manuals

Related Search

Related Contents