The post An Alternative Approach to Positive Pressure Ventilation appeared first on Hayek Medical.
]]>The first use of negative pressure ventilation appeared in 1838. Known as the “tank ventilator”, this allowed a patient to sit inside a box while only a person’s head remained outside open to ambient air. A pressure gauge was fitted to the outside of the box to read the level of negative pressure that was maintained by pumping air in and out through the use of a plunger to facilitate inspiration and expiration.
Fast forward to the invention of the iron lung, designed by Phillip Drinker and Louis Shaw, which was commonly used during the polio epidemic between 1930 and 1960. This cylindrical metal tube created negative pressure around the body of a supine patient, also leaving only the head open to ambient air thus allowing a person with weakened respiratory muscles from the disease to breathe easier. Although effective, the device had several drawbacks. Weighing in over 650 pounds, it was incredibly cumbersome. Access to the patient was through small portholes on the side of the device and made nursing and hygiene incredibly difficult.
The iron lung began to be phased out with the advent of the modern day positive pressure ventilators such as the Bennett and Bird Mark series during the 1950’s. These pioneering models have evolved into the modern ventilators seen in the hospital today with a wide array of mode capabilities and portability for patients needing advanced care. However, ventilating the lung with positive pressure is not a natural method of breathing and can cause overdistention and trauma to the alveoli units within the lung.
Damage caused to the lung by positive pressure was noted in postmortem patients as early as 1967 and was labeled “Respiratory Lung Syndrome”. The overdistention or stretching of alveoli within the lung caused by excessive volume/pressure followed by the subsequent reopening of these collapsed units with each breath can lead to the complication of barotrauma.
Barotrauma occurs when alveoli rupture and air enters into locations of the lung where it is not normally present. This cascading effect may lead to pneumothorax, pneumomediastinum, or subcutaneous emphysema. Lung protective measures and protocols used when initiating mechanical ventilation are the norm in hospitals today and are engineered to help prevent trauma to the lungs from high peak pressures. However, the mortality rate with patients who have prior comorbidities such as asthma, COPD, and interstitial lung disease are still significantly higher.
In 2009, the estimated cost of those requiring mechanical ventilation was $59,770 per patient. A 2019 study by Dexter and Scott noted that “more than 300,000 patients per year receive mechanical ventilation in the United States, and those who experience ventilator associated events developed a high morbidity and mortality risk,”
Complications from mechanical ventilation, whether infectious or noninfectious are proven to lengthen the hospital stay an average of seven to nine days.
Negative pressure is the natural mechanism of breathing in humans and has evolved tremendously since the age of the iron lung. In 1995, Dr. Zamir Hayek introduced the Hayek biphasic cuirass ventilator (BCV) for use in pediatrics and adults. Through the use of a cuirass, which is worn over the thorax, the BCV creates negative pressure within the seal that allows for an easier work of breathing by allowing the rib cage to expand, lower the diaphragm, and allow atelectatic areas of the lung to reinflate. In addition to the negative pressure features of the device, the Hayek BCV also carries the capability to perform high frequency chest wall oscillation (HFCWO) with cough support to aid in secretion clearance.
Use of the BCV has shown success avoiding the need for intubation by increasing Functional Residual Capacity (FRC), improving lung volumes and gas exchange, decreasing airway resistance, increasing cardiac output, and aiding with secretion clearance in a variety of patient populations such as:
· Neuromuscular disease (ALS, MS, MD)
· Pneumonia
· Spinal cord injury
· Congenital heart disease
· Asthma
· COPD
· Cystic Fibrosis
The BCV can be used as a noninvasive standalone unit. It may also work in conjunction with high flow therapy, mask ventilation, or together with mechanically ventilated patients in an effort to shorten ventilatory time.
A study published by Hassinger and colleagues in 2017 noted “a decline in the annual percentage of pediatric ICU admissions requiring intubation by 28% in the 3-year period following the introduction of negative pressure ventilation to their institution.”
While using the BCV, a person may eat, sleep, and talk unencumbered. A patient may use the device throughout the course of a hospital stay from ICU to discharge on a continuous or intermittent schedule and is FDA approved for use at home. Continued use of the BCV at home can decrease frequent recurring admissions and keep patients where they want to be -at home.
Cautions and contraindications of BCV are far less than those associated with positive pressure ventilation using mask ventilation, endotracheal tubes, or tracheostomy tubes. These include:
· Weight greater than 180 kilograms.
· Burns or draining wounds under the shell or seal area.
· Indwelling lines or tubes directly underneath the foam around the shell.
· The lack of an airway whether natural or artificial.
· Cardiac arrest.
Avoiding the need for positive pressure ventilation and keeping patients as close to their baseline health as possible is a universal goal that all healthcare clinicians strive to achieve. Skyrocketing healthcare costs should drive the healthcare provider to use the earliest and most noninvasive interventions to avoid decompensation of patient populations which are already medically fragile.
Whether in use in an acute care setting or the home, the use of Biphasic Cuirass Ventilation with the Hayek has shown itself to be a novel yet cost effective and reliable approach to ventilation.
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]]>The post What is Spinal Muscular Atrophy? appeared first on Hayek Medical.
]]>Spinal Muscular Atrophy (SMA) is a rare genetic disorder that primarily affects the muscles used for movement. It is a progressive disease that causes muscle weakness and atrophy, leading to difficulties with mobility and everyday tasks. In this blog post, we will delve deeper into the various aspects of SMA, including its causes, symptoms, diagnosis, and treatment options.
SMA is caused by a mutation in the survival motor neuron (SMN1) gene, which is responsible for producing a protein essential for the survival of motor neurons. Motor neurons are nerve cells that control voluntary muscle movement. In individuals with SMA, the decrease in SMN protein leads to the degeneration and death of motor neurons, resulting in muscle weakness.
The severity of SMA can vary widely, ranging from mild to severe. However, common symptoms include muscle weakness, muscle atrophy, and poor muscle tone. Infants with SMA may have difficulty holding their heads up, sitting unsupported, and reaching motor milestones. As the disease progresses, individuals with SMA may experience muscle contractures, scoliosis, and respiratory problems.
There are different types of SMA, classified based on the age of onset and disease progression.
The most severe, also known as Werdnig-Hoffmann disease which typically appears within the first six months of life and can be life-threatening.
Manifests between 6 and 18 months of age and is characterized by the ability to sit unsupported but not walk independently.
Also called Kugelberg-Welander disease, usually begins between 2 and 17 years of age, allowing individuals to walk but experiencing progressive muscle weakness.
Known as adult-onset SMA, presents during adulthood and leads to mild muscle weakness.
Diagnosing SMA typically involves genetic testing to identify mutations in the SMN1 gene. This can be done through a blood test or through the collection of saliva or cheek swab samples. Additionally, electromyography (EMG), muscle biopsy, and other diagnostic procedures may be used to assess the severity of muscle weakness and determine the type of SMA.
Although there is currently no cure for SMA, various treatment options can help manage the symptoms and improve the quality of life for individuals with SMA. One of the most significant developments in SMA treatment is the availability of disease-modifying therapies, such as Spinraza and Zolgensma. These medications work by increasing the production of SMN protein, thereby slowing down the progression of the disease. Physical therapy, respiratory support, and orthopedic interventions are also commonly used to address muscle weakness and related complications.
In recent years, gene therapies like Zolgensma have gained attention for their potential to address the root cause of SMA by replacing or repairing the faulty gene responsible for the disease. These therapies have shown promising results in clinical trials and offer hope for effective treatments in the future.
Supportive care, including mobility aids and assistive devices, is essential in managing SMA symptoms and promoting independence. Regular physical therapy and occupational therapy can help strengthen muscles, improve range of motion, and enhance overall function.
Like many Neuromuscular disorders, SMA can profoundly affect respiratory function, making breathing arduous. This can result in hypercapnea, atelectasis, pneumonia, and compromising overall well-being.
BCV presents an alternative, non-invasive approach to ventilation for SMA patients. This innovative technique employs a cuirass that encloses the anterior chest and abdomen. It operates by generating alternating positive and negative pressure, thereby aiding the weakened respiratory muscles in the inhalation and exhalation process. By facilitating ventilation through BCV, patients experience relief from the respiratory distress caused by SMA.
The cuirass shell creates an air chamber over the chest and abdomen while the Power Unit controls the pressure within the cuirass. The pressure affects the dimensions of the thoracic cavity and thus inflation and deflation of the lungs. Inhalation occurs due to the creation of a negative pressure within the cuirass. The Hayek supports inspiration with the natural expansion of the chest wall and descent of the diaphragm.
In modes that provide ventilation, the Hayek Cuirass ventilator alternates the pressure in the cuirass from negative to positive. This active, positive expiratory phase creates the compression effect on the thorax facilitating lung deflation.
BCV’s negative pressure based functionality not only assists in patients respiration, but allows patients to maintain their daily activities and interact with the people around them. Unlike traditional ventilatory methods, BCV permits capable patients to talk, eat, and drink while receiving the essential respiratory support. This pivotal feature dramatically improves their frequency and degree of respiratory compromise, and overall quality of life for SMA patients, fostering a sense of normalcy and independence.
Spinal Muscular Atrophy is a complex genetic disorder that affects the muscles and hampers mobility. It can be challenging for individuals diagnosed with SMA and their families. However, advancements in research and development of disease-modifying therapies provide hope for a brighter future. By raising awareness about SMA and supporting ongoing research efforts, we can strive towards better understanding, diagnosis, and treatment options for this rare disease.
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]]>The post What are the Glenn and Fontan Procedures? appeared first on Hayek Medical.
]]>Medical advancements have revolutionized the way we approach various health conditions, including congenital heart diseases. Among the surgical procedures aimed at addressing these conditions are the Glenn and Fontan procedures. These interventions have proven to be life-changing for patients and their families, providing hope and improved outcomes.
Congenital heart diseases encompass various conditions that affect the heart’s structure and function from birth. Many of these conditions involve abnormalities in the heart’s chambers, valves, or blood vessels, making it difficult for the heart to pump and circulate blood efficiently. In some cases, the heart may not have developed fully or be positioned correctly.
The Glenn and Fontan procedures are typically performed in patients born with single ventricle physiology, a condition that occurs when one of the ventricles, the pumping chambers of the heart, is either underdeveloped or nonfunctional. This results in an imbalance in blood flow, which can lead to complications and impaired oxygenation.
The Glenn procedure, also known as the superior cavopulmonary connection, is typically performed in infants around six to twelve months old. During this surgery, the superior vena cava, responsible for carrying deoxygenated blood from the upper body to the heart, is detached from the right atrium. The surgeon then redirects the blood flow directly to the lungs, bypassing the right ventricle completely.
By bypassing the right ventricle, the Glenn procedure helps improve oxygenation and reduces the workload on the heart. This surgical intervention allows for better circulation and alleviates symptoms like cyanosis, which is characterized by a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood.
Following the Glenn procedure, patients experience improved oxygen saturation levels, reduced respiratory distress, and better overall cardiac function. Though this surgery is a significant milestone in the treatment of congenital heart diseases, it is often a step in a multi-staged surgical approach.
Results of the Glenn Procedure:
– Improved oxygen saturation levels
– Reduced respiratory distress
– Enhanced cardiac function
The Fontan procedure is the subsequent surgery performed after the Glenn procedure, usually between the ages of two and five. It involves rerouting the blood flow from the body directly to the pulmonary arteries, bypassing both ventricles. In this surgery, the inferior vena cava, responsible for carrying deoxygenated blood from the lower body to the heart, is detached from the right atrium and connected directly to the pulmonary arteries.
The purpose of the Fontan procedure is to complete the separation of systemic and pulmonary circulation, allowing deoxygenated blood to flow directly to the lungs for oxygenation. This surgical intervention helps to optimize blood flow, improve overall circulatory function, and reduce symptoms associated with congenital heart diseases.
Similar to the Glenn procedure, the Fontan procedure results in increased oxygen saturation levels, improved cardiac output, and decreased cyanosis. Patients who have undergone the Fontan procedure experience enhanced exercise tolerance and an improved quality of life.
Results of the Fontan Procedure:
– Increased oxygen saturation levels
– Improved cardiac output
– Decreased cyanosis
– Enhanced exercise tolerance and quality of life
In Fontan physiology, the lack of an active ventricular pump to deliver blood is a significant cause of decreased baseline Cardiac Output (CO) and Pulmonary Blood Flow (PBF). Limitations in CO in the Fontan population have primarily been attributed to increased pulmonary vascular resistance, ventricular dysfunction, and decreased afterload.
Due to the absence of the sub-pulmonary ventricle, the diaphragm is considered to be the most important inspiratory muscle for maintenance of venous return in the Fontan population. Respiration acts as a significant source of cardiac output in patients with Fontan physiology, and as such, findings of poor chest wall compliance, respiratory muscle weakness and restrictive lung physiology, which are commonly observed in the Fontan population, have significant impact on the cardiovascular flows of Fontan patients.
In treatment of post-fontan patients, it was found that:
Both the Glenn and Fontan procedures are intricate surgical interventions, with success depending on various factors, including the patient’s overall health, underlying heart conditions, and the surgeon’s expertise. As with any major surgical procedure, there are risks associated with these surgeries, including bleeding, infection, and complications related to anesthesia.
The Potential of a Fulfilling Life:
However, with advancements in surgical techniques, improved perioperative care, and ongoing research in the field of pediatric cardiology, the outcomes of these surgeries have significantly improved over the years. Many patients who undergo the Glenn and Fontan procedures go on to live fulfilling lives, participating in physical activities and enjoying a relatively normal life despite their underlying heart condition.
The Glenn and Fontan procedures have revolutionized the treatment of congenital heart diseases, specifically in patients with single ventricle physiology. These surgical interventions enhance blood flow, optimize oxygenation, reduce symptoms, and ultimately provide patients with an improved quality of life. As medical advancements continue, countless individuals and families can look forward to a brighter future.
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]]>The post High Frequency Chest Wall Oscillation (HFCWO) appeared first on Hayek Medical.
]]>The problem of clearing the airways of those ill with pulmonary diseases has been a challenge for ages. Typically, coughing to clear obstruction works well for those with normal lung function. However, the immune system and airway mucous clearance mechanisms need to work together to keep our airways clear and free of disease. If one or more of these mechanisms is impaired, then there can be difficulty completely clearing secretions from the airways. This may cause obstruction to our breathing, and respiratory distress. If secretions are not being expelled, We may need intervention to help shake loose the mucous trapped in our lungs when things go wrong. This is where High Frequency Chest Wall Oscillation (HFCWO) may be prescribed.
High-Frequency Oscillation and Compression therapies work through the chest wall itself. Either through manual hand cupping and clapping, or through mechanically transmitted percussive waves, with steady rhythm. This force travels through the airways to shake loose the mucous with shearing forces, to make them easier to cough out. There are handheld percussion devices that can be placed over areas of the chest that the patient can reach. While these devices are helpful, they have their limitations in efficacy. In vest devices, a vest outfitted with several inflatable air pockets applies percussive waves over the lung. However, the necessity of a tight fit to the thorax limits the patient from full expansion of the chest and therefore inhibits maximal alveolar recruitment. Although they are considered helpful in the clearance of sputum and maintenance of clearer airways, the restrictive nature of HFCWC will inhibit lung recruitment as part of their mechanism, limiting the benefits of this mode of therapy[1].
High Frequency Chest Wall Oscillation (HFCWO) occurs when 2 forces are sequentially applied to first compress, then expand the chest wall. The term oscillation refers to both a compression, and expansion motion of a surface to either side of a central point. This motion is distinctive from the mode of therapy of chest wall percussion as that mode depresses only inward, with return to baseline. Only devices that are capable of applying both compression and distension of the chest wall can be truly qualified as a chest wall oscillator. The benefit of this intervention is the ability to more effectively attune the frequency of vibration to the quality of sputum for the patient/disease process. This serves to accelerate the liquefaction of the sputum thus allowing easier expectoration. In HFCWO, the device transmits the oscillating wave throughout the thorax and patients often report it to be more comfortable than chest wall percussion or compression. Contrary to what most manufacturers claim, many vest devices are actually delivering high frequency chest wall compressions, not oscillation. Rather than the pull and push motions against the chest of HFCWO, HFCWC squeezes then relies on the chest wall’s natural rebound to return to the starting point.
External oscillatory effect can be applied to the chest through percussive waves created by chest wall compression or through chest wall oscillation. This transmits to the airways of the patients and creates shearing forces that cause sputum to loosen from the wall of the airways. Hopefully, the loosened sputum will be more affected by the expiratory flow of air in central airways to be expectorated by the patient. These interventions have been used for many years in patients with Cystic Fibrosis, Bronchiectasis and COPD with good effect. However, as pulmonary function worsens in these patients, the capacity for expectoration is compromised by the loss of cough flow.
Indeed, in one study that used vest therapy vs hand cupping and clapping (CCPT) it was noted that tidal volume and pulse oximetry was compromised by post vest therapy [2]. Although the ventilator settings themselves did not change when using vest therapy, the physiologic effects were also evident by the noted increase in mean airway pressure and rapid breathing noted in the patients who used vest therapy compared to those who received CCPT. This makes it clear that even in patients who are actively receiving airway support from positive pressure ventilation, that the restrictive nature of vest therapy on the ability of the chest wall to fully expand is felt and evidenced by measurable changes in the patient’s condition.[3]
BCV (Biphasic Cuirass Ventilation) when applied for secretion clearance support therapy delivers true chest wall oscillation without compromise of FRC (Functional Residual Capacity) . The cuirass covers only the anterior and lateral portions of the thorax and upper abdomen. This allows the patient to sit comfortably in a chair or lie in bed while therapy is administered. As the Biphasic nature of this device does not inhibit chest wall excursion, there is no risk of inducing atelectasis with this intervention, allowing it to be used for more prolonged treatment than chest wall percussors.
Additionally, the cough assist mechanism employed here that is administered for set periods, in cycle with periods of chest wall oscillation. Cough, assisted by the cuirass works by amplifying the natural cough mechanism of our patient. This can enhance the effectiveness of expectoration efforts of those with normal lung function, as well as supporting improved cough efficacy of those with compromised cough force through loss of pulmonary muscle or lung function.
It is in these compromised patients that BCV distinguishes itself from traditional vest style therapies. In addition to HFCWO, BCV offers a recruitment option in Continuous Negative and a NIV option in the biphasic ventilation settings. It naturally enhances chest wall excursion and opens the lung, while vest therapy naturally restricts it. In those patients with already impaired cough strength, there is little reserve left that can allow for any further compromise. Employment of BCV at any stage of disease is optimal as it will not accelerate any deterioration of lung function. It can also support, and possibly improve the lung function of more advanced disease processes. It would seem that utilizing BCV therapy early in any disease process gives the optimal chance of good pulmonary outcomes with no chance of restricting lung function.
[1]: https://www.hillrom.com/content/dam/hillrom-aem/us/en/marketing/knowledge/product-documentation/white-papers/197151-EN-r1_HFCWO-Airflow_Whitepaper_LR.pdf
[2/3]: https://pubmed.ncbi.nlm.nih.gov/28248854/
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]]>The post Neuromuscular Disorders and Biphasic Cuirass Ventilation (BCV) appeared first on Hayek Medical.
]]>Neuromuscular disorders, many of which are progressive, include a wide range of disorders affecting the peripheral nervous system, which consists of the motor and sensory nerves that connect the brain and spinal cord to the rest of the body. Pulmonary muscle weakness is one predominant condition of these disorders.
A common thread in the many different types of neuromuscular disorders is respiratory muscle weakness. In all cases, treatment of the underlying neuromuscular disorder is indicated, if feasible.
The response of respiratory muscle weakness to specific treatments may vary depending on the specific disease entity. For example, respiratory failure due to conditions such as Guillain-Barré syndrome, myasthenia gravis, polymyositis, and multiple sclerosis may be responsive to disease-specific therapy such that respiratory failure resolves as the underlying disorder improves in response to the therapy. In such cases, ventilatory assistance may only be temporary. In contrast, other neuromuscular disorders are not reversible or may progress despite therapy thereby necessitating full-time ventilatory support and adjunctive aids.
Respiratory muscle weakness due to neuromuscular disorder can lead to acute and/or chronic ventilatory failure as well as recurrent aspiration and pneumonia. Management, which is largely supportive, can provide symptomatic relief, improve quality of life, and in some instances, prolong life.
BCV supports respiratory function naturally with extra-thoracic negative pressure support of lung inflation. Instead of positive pressure inflating the lungs with an endotracheal tube or tracheostomy, the cuirass shell works with your diaphragm’s natural breathing motion to draw air into the lungs. Using the various modes of Biphasic Cuirass Ventilation provides a flexible and comfortable support tool than can restore lung function while improving quality of life.
In patients with respiratory muscle weakness who have an ineffective cough, it is suggested that a routine use of adjuncts to assist coughing for secretion clearance is beneficial therapeutic intervention. Such adjuncts can be used in the chronic setting as well during and/or through recovery from acute respiratory illnesses.
When the motor nerve function of the respiratory muscles is affected, cough strength decreases and breathing becomes weak. Decreased cough strength increases the risk of pneumonia and aspiration because an effective cough is needed to keep the airways clear.
BCV provides effective high-frequency chest wall oscillation that generates biphasic changes in transrespiratory pressure without the complications commonly associated with positive-pressure ventilation devices.
This type of gentle, flexible, multi-option support is why we believe that Biphasic Cuirass Ventilation should be a frontline resource for patients suffering with Neuromuscular Disorders.
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]]>The post RSV/Bronchilitis, Breathlessness, and Momma’s Baby appeared first on Hayek Medical.
]]>Headlines from around the country predict what they are referring to as a “Tri-demic”, a triple threat on our health systems of RSV, Covid-19, and the Flu, and point out that the coming season will be bad for all respiratory related illnesses.
Respiratory distress in anyone is highly relatable. Who hasn’t experienced some shortness of breath following physical exertion? Similiarly, progression from respiratory distress to respiratory failure is that same feeling, but you don’t recover. The work required for each breath is increased, the body generates more carbon dioxide and consumes more oxygen than it’s able to exchange. This is never easy to observe, especially when children or infants are the ones experiencing it. As a caregiver, we have felt similar symptoms and we sympathize very strongly to the distress of the patients in our care.
Included in this seasonal illness prediction for the coming year is a significant increase in the number patients expected to be hospitalized with RSV/Bronchiolitis. Most of us have had this virus with minimal compromising symptoms and resolution in just several days; however, certain young patients are the most vulnerable to this, including patients born prematurely, particularly those with chronic lung disease of prematurity, or patients with neuromuscular weakness.
High flows of humidified air supplemented with oxygen can help many patients, but often the distress is unable to be completely alleviated. The worst patients may be placed on a ventilator, but increasing respiratory support with positive pressure techniques can come with challenges related to the amount of nasal and airway secretions and the potential of lung injury with positive pressure ventilation.
RSV/Bronchiolitis will cause the more seriously ill babies to demonstrate pronounced symptoms of respiratory distress. A scene that many clinicians are able to attest to, is having their heartstrings pulled when they glimpse inside the room and see the stress placed on the parents watching their still new baby clearly having physical difficulty breathing.
Tachypnea or rapid respirations, faster and harder than they have ever seen and retractions, which is when the resistance to breathing is creating places on the baby’s body that suck inward in a very scary way with each breath. Retractions begin to appear at the top and bottom of the sternum, above the clavicles, between each rib and below the ribs. Their baby coughs so hard and sometimes just doesn’t seem to be able to stop. Finally, after several calls to consult with their baby’s clinic, the nurse recommends going to the hospital. They watch as their baby is assessed and cared for. It is hard for them to believe that nothing that is being tried is resolving the tachypnea and retractions. They have been up all night with the baby. Neither they nor the baby have had any rest. Any observers will see the look exchanged between mother and infant, the look that drives a dagger into any parent’s heart as her baby’s eyes and expression says, “Mommy I’m tired and don’t know if I can keep this up.”
Most physicians caring for this type of patient are aware of most of the available non-invasive therapies, but they may be inadequate to help the more severe symptoms and may not immediately relieve distress. At a recent visit to a pediatric hospital, we had the opportunity to meet a respiratory therapist named Matt. :
Matt pointed out how he considers himself fortunate to work at a facility where an alternative non-invasive therapy for the sicker RSV/bronchiolitis patients is available. This therapy is one that is still new to many pediatric ICUs, but one that Matt is very happy is available where he works. Matt related to us the following experience:
I was working in the PICU with several patients with bronchiolitis. All were receiving their standard high flow per protocol for size and O2 requirement, when a Rapid Response was called on one them. SATS had decreased and the retractions had worsened. I arrived with the rest of the team, and prepared to assist with the intubation or placement of a tracheal tube so an invasive ventilator could be started. I knew from some of my experiences with similar children, that when I was able to begin treatment with continuous negative using the noninvasive Biphasic Cuirass Ventilator, that patients would often improve quickly.
As the pediatric intensivist was making final preparations to intubate, I caught their eye and asked,
“Could we just give the cuirass a try before doing this?”
The answer came back, “OK, I’ll give you 5 minutes”.
As the gowned masked and gloved intensivist stood waiting, I brought the BCV to the room, quickly set it and placed it on the patient. The patient’s retractions stopped almost immediately. The pulse oximeter shot up 6 points from the 80s into the mid 90% range. I make some final adjustments to the fit of the cuirass and the settings, which myself and the intensivist decided were working best and when he finally turned away from the patient for a moment; nearly all the members of the rapid response team were either gone or leaving because the patient had so obviously stabilized.
Matt told us, “That is how it nearly always works when we get a chance to use it before they put they tube in.”
Loss of functional residual capacity increases work of breathing and gas exchange. In bronchiolitis with more severe respiratory symptoms that is also the case. Continuous negative gently pulls the lung open as nature intended with negative pressure. This normalizes FRC and can have an effect of acutely decreasing distress just as the baby Matt was taking care experienced. Another thing Matt noted with a big smile was that the baby’s mom thought he was sent from heaven that day for her baby. If you ever met Matt, you would think the same thing every day.
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]]>The post Biphasic Cuirass Ventilation and Secretion Clearance appeared first on Hayek Medical.
]]>Our cardiopulmonary system has a built-in mechanism that upon sensing mucus production in the lungs, reflexively removes them. That built-in mechanism is often sufficient for individuals with normal lungs that may be infected with an acute infection, however, for those with compromised lungs due to chronic illness, it becomes a much greater endeavor to clear secretions. What can help? Innovative thinkers over time have designed mechanical devices to mimic the natural built-in mechanism of secretion removal.
For compromised lungs that are symptomatic for secretion retention, do the following:
We often use the terms mucus and phlegm interchangeably, however, where the types of secretions originate from matter.
Mucus production tissue lines our upper airways and lower airways. Our upper airways include our nose and sinuses all the way down to our epiglottis, while our lower airways from our epiglottis down produce phlegm. When we have a cocktail mix of both sinus drainage, saliva and phlegm, we refer to that as sputum.
The characteristics of sputum samples, which more accurately are obtained via nasotracheal or endotracheal suction, can assist in identifying the type of microorganisms that have invaded our lungs. The goal is to stratify if the infection is viral or bacterial. It’s vital to obtain a good sample. The type of treatment, whether the patient will receive antibiotics or an antiviral, is dependent on the results. Clinicians note the consistency, color, smell (if applicable), and quantity of the sputum produced. By taking these factors into consideration and identifying the invader, clinicians are then able to strategize the best way to remove them from the lungs.
Our normal built-in oscillatory mechanism in our cardiopulmonary secretions is subtle, yet effective, for normal, compliant lungs. We refer to it as cilia. In a paper published in 2017 by Bustamante-Marin and Ostrowski, they describe cilia as “…specialized organelles that provide the force necessary to transport foreign materials in the respiratory tract toward the mouth where they can be swallowed or expectorated. To accomplish this crucial function, the cilia beat in coordinated metachronal waves at a beat frequency that has multiple physiological regulators.” We can imagine the cilia as an assembly line of workers transporting a heavy package from one end to the other. Instead of having one person take the heavy package from point A to point B, the assembly line works together to carry the load little by little. If that isn’t sufficient, the simple action of clearing our throat can create and mimic a beat frequency to assist in oscillating and bringing up those secretions.
For many chronic disease processes, however, the cilia are compromised and unable to function to thin and to mobilize phlegm upward out of the lungs. In order to replicate the beat frequency produced by the metachronal waves, intrathoracic and extrathoracic oscillatory techniques have been developed. Examples of intrathoracic techniques include OPEP, IPPB, PEP, and IPV.
Extrathoracic techniques include high-frequency chest wall compression via air bladder vests or high frequency chest wall oscillators such as via the biphasic cuirass. One of the oldest, yet effective extrathoracic techniques include using a cupped hand for manual chest percussion. For those that choose manual chest percussion, postural drainage and positioning is key in helping secretions to naturally gravitate toward the large airways, making it easier to expectorate.
Once the phlegm is mobilized to the upper airways, it comes in contact with cough receptors located at the carina and lines the trachea, and the cough phase is initiated. The cough phase is made up of deep inspiration, glottic closure, pressure build-up in the lungs, glottic release, expiratory flow generation and it ends with secretion expulsion.
There are various chronic disease processes that impair this function as well, which include neuromuscular disorders and diaphragmatic paralysis. What techniques and mechanical processes have been invented to mimic our natural process? Controlled coughs and huff type cough have been effective techniques for those that do it appropriately. Mechanical support has also been accessible for many, which include intrathoracic assisted cough devices. An extrathoracic method that mimics our natural mechanism of a huff type cough would be via the biphasic cuirass.
Oftentimes, a large collection of phlegm, referred to as mucus plugs, will get plugged in the small airways and close off a functioning lung unit, causing atelectasis, decreasing FRC. Non-invasive ventilation, such as NIPPV, have been used for intrathoracic lung recruitment techniques to assist in restoring that FRC. As previously mentioned, a highly effective extrathoracic technique that mimics, yet again, our natural function is biphasic cuirass using continuous negative extrathoracic pressure. This can safely ventilate and restore any lost FRC from mucus plugs.
We have many options made available to us, the accompanying graphic discusses the spectrum techniques of airway clearance therapies available. We have the choice to use one, two, or three of them. However, taking into consideration our time, efficiency and the space allotted to us, why not use the one highly effective tool that covers the whole spectrum? Biphasic Cuirass Ventilation allows us the opportunity to use one interface to oscillate, expectorate, and ventilate.
Treating respiratory impairment with Biphasic Cuirass Ventilation (BCV) can include control, synchronized, and continuous negative extra-thoracic pressure (CNEP) to move intercostal muscles and diaphragm into a more normal physiological end expiratory position. This supportive negative pressure, which “holds open” opens the chest wall either cyclically or continuously depending on the mode used allows for the true source of most respiratory impairments to be corrected (volume loss). BCV enhances the natural negative trans-pulmonary pressure the body uses to create lung inflation.
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]]>Biphasic Cuirass Ventilation (BCV) or continuous negative pressure cuirass ventilation (CNEP), facilitates normative inspiratory pressure(s) that correct FRC loss by moving the proper anatomy (intercostal muscles and diaphragm) into normal physiological position which “holds open” the chest wall and allows for volume loss, the true source of most respiratory impairments to be corrected.
Treating respiratory impairment with Biphasic Cuirass Ventilation (BCV) can include control, synchronized, and continuous negative extra-thoracic pressure (CNEP) to move intercostal muscles and diaphragm into a more normal physiological end expiratory position. This supportive negative pressure, which “holds open” opens the chest wall either cyclically or continuously depending on the mode used allows for the true source of most respiratory impairments to be corrected (volume loss). BCV enhances the natural negative trans-pulmonary pressure the body uses to create lung inflation.
In a lung with atelectatic collapse, as the FRC is normalized by the application of increased mean negative extra-thoracic pressure, alveoli (air sacs) begin to expand. Collapsed alveoli adjacent to inflated units are pulled open by elastic forces of each surrounding alveoli which immediately begins to restore normal airway pressures, enhancing oxygenation, correcting ventilation and perfusion mismatch and allow for an increased FRC, with a positive side effect of increased overall lung volume(s) and capacities.
According to a study done by the Department of Experimental and Clinical Sciences, University of Brescia:
The number one goal of all respiratory therapy related interventions is to restore normal FRC. The benefits include and are not limited to, increased expiratory flows, reduced compliance, hypoventilation, shunting, and hypoxemia.
BCV corrects the volume limitation in a different but more normative fashion than positive pressure ventilation (i.e. NIPPV, CPAP, or various IPPV modes). External negative pressure creates no internal strain against the cardiopulmonary system and can increase cardiac output. In typical PPV lung inflation, mainly the apices of the lungs are inflated causing them to push against the heart, decreasing left ventricular excursion, and vascular systems creating a tamponade effect. This can severely limit the safe amount of volume/pressure clinicians can use before significantly decreasing venous return and increasing pressures on the heart.
How is BCV different? – BCV creates lung inflation using negative pressure and has the opposite effect on the cardiopulmonary system, and does not create overdistension of lung regions. FRC is always normalized with the use of BCV.
¹Expiratory Flow Limitation Definition, Mechanisms, Methods, and Significance :
Tantucci C. Expiratory flow limitation definition, mechanisms, methods, and significance. Pulm Med. 2013;2013:749860. doi: 10.1155/2013/749860. Epub 2013 Mar 28. PMID: 23606962; PMCID: PMC3625607.
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]]>Functional residual capacity (FRC) is the volume of air present in the lungs at the end of passive expiration. At FRC, the opposing elastic recoil forces of the lungs and chest wall are in equilibrium and there is no exertion by the diaphragm or other respiratory muscles. FRC is the sum of expiratory reserve volume (ERV) and residual volume (RV) and measures approximately 2500 mL in a 70 kg, average-sized male (or approximately 30ml/kg). It cannot be estimated through spirometry, since it includes the residual volume which cannot be directly measured¹.
The purpose of the functional residual capacity is to keep a volume of air in the lungs at end expiration and to facilitate gas exchange, as diffusion of gas happens at the level of the FRC in a normative state which helps move air during speaking, activity, and breathing. There are two reasons why maintenance of gas in the lung at end-expiration (i.e., FRC) is important.
A normal FRC is between 1.7 to 3.5 L, however, FRC can be influenced by several factors.
FRC is increased by:
FRC is decreased by:
●Gender (woman have a 10% lower FRC when compared to men)
●Diaphragmatic muscle tone (individuals with paralyzed diaphragms have lower FRC compared to normal individuals)
●Posture (FRC is greatest when standing > sitting > prone >lateral > supine)
●Certain lung diseases in which elastic recoil is diminished (e.g., ILD, ALS, and kyphoscoliosis)
●Increased abdominal pressure(e.g., obesity, ascites)
¹Barash, Clinical Anesthesia,6th edition, pp. 247–248.
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