Research Team: Jason Jubert, BS, NRP, SRT Jessica Straker, NRP, SRT Tuan Nguyen, BS, NRP, SRT Maria Schumann Pereira, BS, NRP, SRT Faculty Advisors: Kelley Buzbee, AAS, RRT-NPS, RCP Conchita Cameron, AAS, RRT How will changes in compliance and resistance affect airway pressures while using EzPAP? The difference between the minimum and the maximum airway pressures tends to decline when lung compliance decreases or resistance increases out of normal ranges. Indicated for lung expansion therapy Treatment and prevention of atelectasis Produces positive airway pressure throughout the breathing cycle via flow meter May be used with nebulizer between patient and device Aids in mobilization of retained secretions Contraindications include: patients who cannot tolerate increased WOB patientswith ICP greater than 20 mmHg recent facial, oral or skull surgery, or trauma, esophageal surgery untreated pnuemothorax unstable hemodynamics acute sinusitis epitastaxis active hemoptysis nausea impaired venous return hyperoxia gastric distention air trapping, auto-PEEP • • • • • • • • Acapella – A small PEP device that helps to mobilize secretions by providing positive expiratory pressure (PEP) therapy and airway vibrations. Atelectasis: an abnormal condition characterized by the collapse of alveoli, preventing respiratory exchange of carbon monoxide and oxygen in a part of the lungs. Barotrauma – Injury caused by increased air or water or pressure Brochioectasis: a disease that involves a dilation of bronchioles that produces a large amount of secretions. Bronchodilator- a drug that relaxes the bronchial passageways and improves the passages of air into the lungs. Cardiac Output – volume of blood pumped per minute by the heart Cystic Fibrosis- An inherited condition in which the exocrine glands produce abnormally viscous mucus, causing chronic respiratory and digestive problems Epistaxis: bleeding from the nose caused by local irritation of mucous membranes • • • Hemodynamics: the study of the physical aspects of blood circulation, including cardiac function and peripheral vascular physiologic characteristics Hemoptysis: coughing up of blood from the respiratory tract Hypercapnia- having abnormally high levels of carbon dioxide circulating in the blood. • Hypoxemia- A lack of oxygen circulating to the tissues. • Inflammation: swelling caused by an infection • • Intracranial pressure- Pressure of the cerebrospinal fluid in the head with sensor inserted through the skull Intrathoracic pressure- pressure in the chest cavity IPPB- Intermittent positive pressure ventilation IS – (incentive spirometry); also referred to as sustained maximal inspiration (SMI), is a component of bronchial hygiene therapy Nebulizer-An apparatus for producing a fine spray or mist. PEP – Positive Expiratory Pressure Pneumothorax: collection of air or gas in the pleural space causing the lung to collapse Prophylactic- a medical treatment that is used to prevent a disease state from occurring. Pulse-rate and strength the heart beats in a minute Pulse ox- amount of oxygen in blood A Lung machine-Series 1101 Breathing simulator (Hans Rudolph, INC 7205 Central Kansas City, MO 64114 U.S.A) was used to simulate the changes in compliance and resistance at the airway. EZ-PAP© model 23-0747 (Smiths Medical ASD, INC 10 Bowman Drive, Keene NH 03431 USA) was attached to the lung machine with a Bacterial Filter model 864-E (Unomedical, INC 5701-S Ware Rd McAllen, Texas 78503 USA) and a 5’Flexible tube (Sims Portex, INC Fort Myers, FL 33905 USA). Small Volume Nebulizer model number 301-20 (E-Value Med www.Trianim.com). A flowmeter model # IMPA1001 (Precision medical, INC 300 Held Drive Northhampton,PA 18067) was attached to the oxygen source was adjusted to deliver 8 lpm.The graph was saved to a floppy disk and then the data was transfer to Excel software (Microsoft ©). Verification procedures were performed to confirm breathing simulator pressures by connecting to Servo-I (Maquet , Inc Wayne, NJ 07470) EZ-PAP© was attached to the lung simulator via the 5’ flex tube; the O2 tubing was attached to the EZ-PAP© and to flowmeter with the 02 flow of 8 lpm. On the simulator, we entered the values for compliance from 10 to 99 ml/cmH20 using as reference the normal range compliance from 50 to 170 ml/cmH20 ( Pilbeam, S., & Cairo, J. M. 2006. Mechanical Ventilation 4 Th Ed. Missouri: Mosby Elsevier) The lung simulator had a limitation on the resistance range between 3 to 200 cmH20/liters per second consequently, we had to start the simulation resistance at 3 cmH20/L/sec and increased until we reached 30 cm/H20/L/sec The study was performed first without the small inline nebulizer; with the resistance set at 5cmH20/L, we repeated the process and collected graphs with the compliance values set at 10, 20, 30, 40, 50, 60, 80, 90 and 99 ml/cmH20. Then we attached a small inline nebulizer with extra an oxygen flow of 8 lpm and repeated the process with the same compliance values. To obtain the graph for resistance, the lung simulator was set to a normal compliance of 50 ml/cmH20 ; resistance was set to 3cm/H20/L and then increased to these values: 5, 8, 10, 15, 20,25 and 30 cmH20/L. We repeated the process with the small inline nebulizer with extra oxygen flow of 8 lpm; the data was collected and saved to be analyzed. Min Pressure Ez- Pap Without Nebulizer 10.00 (Normal compliance range: 50 - 100 ml/cmH2O) Min Pressure Max Pressure 12.00 Resistance: 5 cmH2O/l/sec Compliance Mean pressure Mean pressure Max Pressure 10 -2.43 0.08 2.59 20 1.71 5.46 9.21 30 1.61 5.54 9.46 40 1.36 5.39 9.43 50 1.07 5.38 9.68 60 -3.87 0.16 4.19 80 0.32 4.37 8.42 90 0.41 4.43 8.44 99 0.36 4.30 8.25 8.00 6.00 4.00 2.00 0.00 -2.00 0 20 40 60 80 100 120 -4.00 -6.00 Figure 1: Changes in pressure to changes in Compliance at resitance of 5 Ez- Pap With Nebulizer Min Pressure Resistance: 5 cmH2O/l/sec Min Pressure Max Pressure 12.00 (Normal compliance range: 50 - 100 ml/cmH2O) Compliance Mean pressure Mean pressure Max Pressure 10 3.77 6.82 9.88 20 3.10 6.62 10.14 30 2.88 6.71 10.53 40 2.46 6.44 10.42 50 2.21 6.39 10.57 60 2.31 6.54 10.77 80 1.74 5.88 10.02 90 1.81 5.91 10.02 99 1.53 5.65 9.78 10.00 8.00 6.00 4.00 2.00 Figure 2: Changes in pressure to changes in Compliance at resistance of 5 0.00 0 20 40 60 80 100 120 Min Pressure Ez- Pap Without Nebulizer 9.00 (Normal resistance range: 0.5 - 2.5 cmH2O/l/sec) Min Pressure Mean pressure Max Pressure 3 0.36 4.70 9.04 5 0.63 4.64 8.66 8 0.88 4.79 8.69 10 1.21 4.44 7.68 15 1.74 4.31 6.87 20 1.26 3.72 6.18 25 2.03 3.92 5.81 30 2.18 3.82 5.47 8.00 7.00 6.00 5.00 4.00 3.00 2.00 1.00 Figure 3: Changes in pressure to changes in Resistance at compliance of 50 0.00 0 Ez- Pap With Nebulizer (Normal resistance range: 0.5 - 2.5 cmH2O/l/sec) Min Pressure Mean pressure 5 10 Min Pressure Compliance 50 ml/cmH2O Resistance Max Pressure 10.00 Compliance 50 ml/cmH2O Resistance Mean pressure 15 20 25 Mean pressure 30 35 Max Pressure 12.00 Max Pressure 3 0.36 4.70 9.04 5 2.14 6.36 10.58 8 1.57 5.68 9.80 10 2.53 6.02 9.51 15 2.71 5.82 8.94 20 3.01 5.71 8.42 25 3.30 5.76 8.22 30 3.49 5.76 8.04 10.00 8.00 6.00 4.00 Figure 4: Changes in pressure to changes in Resistance at compliance of 50 2.00 0.00 0 5 10 15 20 25 30 35 Study limitation: Compliance enter on the lung simulator : 10 to 99 ml/cmH20 ( range allow on the simulator = 3 to 99 ml/cmH20) Normal range compliance from Pilbeam’s: 50 to 170 ml/cmH20 Resistance enter on the lung simulator: 3 to 30 cmH20/liter per second ( range allow on the simulator 3 to 200 cm/H20/ liter per second). Normal range resistance from Egan’s: 0.5 to 2.5 cmH20/liter per second When Ez-Pap is administered without Nebulizer in case of fixed resistance, the changes in compliance violated our Hypothesis. Reasons might be: One oxygen flow (8 Lpm) is not enough to compensate the abrupt change in compliance. Simulator characteristics differ from human lungs Other three cases complied with our Hypothesis. When compliance varied, whether it increased or decreased the mean pressure stayed relatively stable with the nebulizer. Without the nebulizer, we had a severe drop in pressure. When resistance varied with or without the nebulizer and whether it increased or decreased the mean pressure stayed relatively the same. American Lung Association. Airway Clearance Devices: Limited Evidence for What is ‘The Best Method’. Retrieved on February 2, 2009 from http://www.thoracic.org/sections/chapters/thoracicsocietychapters/ca/publications/resources /respiratory-disease-adults/Airway%20Clearance%20Devices.pdf Baker, J., Corbin, M., et al. Effects of EzPap on Physiologic Changes in the Hemodynamics of the Body. Retrieved on January 30, 2009 from www.appskc.lonestar.edu/programs/respcare/ezpap05.ppt Daniel, B.M. Respiratory Abstracts: EzPap? An Alternative in Lung Expansion Therapy. Retrieved on February 2, 2009 from http://www.cardinal.com/mps/focus/respiratory/abstracts/abstracts/ab2001/A00000193.asp Donohue, J.F., Sheth, K., & Schwer, W.A. (2000). EzPap. Management Stategies for the Primary Care Provider. Retrieved on February 3, 2009 from http://www.rtcorner.net/rt_ezpap.htm EZPap Clinical Performances. (n.d.) Retrieved on January 30, 2009 from virtual.yosemite.cc.ca.us Mosby, E. (2006) Mosby’s Medical Dictionary (7th ed.) St. Louis, Missouri. 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